hospital_name,last_updated_on,version,location_name,hospital_address,license_number|MA,type_2_npi,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name
Brigham and Women's Hospital,2026-03-27,3.0.0,Brigham and Women's Hospital,75 Francis St Boston MA 02115-6110,2341,1790717650,true,Daniel Morash
"description","code|1","code|1|type","code|2","code|2|type","code|3","code|3|type","code|4","code|4|type","modifiers","setting","drug_unit_of_measurement","drug_type_of_measurement","standard_charge|gross","standard_charge|discounted_cash","payer_name","plan_name","standard_charge|negotiated_dollar","standard_charge|negotiated_percentage","standard_charge|negotiated_algorithm","median_amount","10th_percentile","90th_percentile","count","standard_charge|min","standard_charge|max","standard_charge|methodology","additional_generic_notes"
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","both","","","498.00","373.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","357.56","71.8","","346.79","346.79","346.79","1 through 10","37.73","473.1","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","both","","","498.00","373.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","395.91","79.5","","380.12","255.02","380.12","1 through 10","37.73","473.1","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","both","","","498.00","373.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","265.43","53.3","","380.12","380.12","380.12","1 through 10","37.73","473.1","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","both","","","498.00","373.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","181.77","36.5","","180.16","153.11","180.16","1 through 10","37.73","473.1","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","both","","","498.00","373.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","190.73","38.3","","188.85","183.54","188.85","17","37.73","473.1","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","both","","","498.00","373.50","TRICARE [160005]","HB BWH TRICARE","473.10","95","","46.39","44.07","483.00","1 through 10","37.73","473.1","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","both","","","498.00","373.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.64","42.9","","386.12","386.12","386.12","1 through 10","37.73","473.1","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","outpatient","","","498.00","373.50","AETNA [1001]","HB AMC AETNA HMO","347.60","69.8","","326.99","230.87","376.74","17","39.7","406.97","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","outpatient","","","498.00","373.50","AETNA [1001]","HB AMC AETNA PPO","400.39","80.4","","376.74","376.74","376.74","1 through 10","39.7","406.97","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","outpatient","","","498.00","373.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","406.97","81.72","","386.11","386.11","386.11","1 through 10","39.7","406.97","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","outpatient","","","498.00","373.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","406.97","81.72","","386.11","168.30","386.11","1 through 10","39.7","406.97","percent of total billed charges",""
"12 Lead Ecg Interpretation and Report Only","PX-98500002","CDM","93010","CPT","0985","RC","","","","both","","","40.00","30.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","26.00","65","","24.05","24.05","24.05","1 through 10","8.17","38","percent of total billed charges",""
"12 Lead Ecg Interpretation and Report Only","PX-98500002","CDM","93010","CPT","0985","RC","","","","both","","","40.00","30.00","WELLPOINT [1015]","HB AMC WELLPOINT","29.51","73.78","","64.55","64.55","64.55","1 through 10","8.17","38","percent of total billed charges",""
"12 Lead Ecg Interpretation and Report Only","PX-98500002","CDM","93010","CPT","0985","RC","","","","outpatient","","","40.00","30.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","20.00","50","","19.39","19.39","19.39","1 through 10","20","33","percent of total billed charges",""
"12 Lead Ecg Interpretation and Report Only","PX-98500002","CDM","93010","CPT","0985","RC","","","","outpatient","","","40.00","30.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","21.00","52.5","","38.37","38.37","38.37","1 through 10","20","33","percent of total billed charges",""
"12 Lead Ecg Interpretation and Report Only","PX-98500002","CDM","93010","CPT","0985","RC","","","","outpatient","","","40.00","30.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","32.16","80.4","","18.50","18.50","18.50","1 through 10","20","33","percent of total billed charges",""
"12 Lead Ecg Interpretation and Report Only","PX-98500002","CDM","93010","CPT","0985","RC","","","","outpatient","","","40.00","30.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","32.69","81.72","","29.58","29.58","29.58","1 through 10","20","33","percent of total billed charges",""
"14 Volt Li-Ion Battery Set2465","PX-27000581","CDM","Q0506","HCPCS","0274","RC","","","","both","","","6250.00","4687.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4062.50","65","","4265.63","4265.63","4265.63","1 through 10","986.28","5937.5","percent of total billed charges",""
"14 Volt Li-Ion Battery Set2465","PX-27000581","CDM","Q0506","HCPCS","0274","RC","","","","both","","","6250.00","4687.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4375.00","70","","1260.00","1260.00","1260.00","1 through 10","986.28","5937.5","percent of total billed charges",""
"14 Volt Li-Ion Battery Set2465","PX-27000581","CDM","Q0506","HCPCS","0274","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2393.75","38.3","","684.25","684.25","684.25","1 through 10","986.28","5937.5","percent of total billed charges",""
"14 Volt Li-Ion Battery Set2465","PX-27000581","CDM","Q0506","HCPCS","0274","RC","","","","both","","","6250.00","4687.50","WELLPOINT [1015]","HB AMC WELLPOINT","4611.25","73.78","","1628.60","1628.60","1628.60","1 through 10","986.28","5937.5","percent of total billed charges",""
"14 Volt Li-Ion Battery Set2465","PX-27000581","CDM","Q0506","HCPCS","0274","RC","","","","outpatient","","","6250.00","4687.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3125.00","50","","917.00","917.00","917.00","1 through 10","1666.16","5156.25","percent of total billed charges",""
"14 Volt Li-Ion Battery Set2465","PX-27000581","CDM","Q0506","HCPCS","0274","RC","","","","outpatient","","","6250.00","4687.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3281.25","52.5","","2887.50","2887.50","2887.50","1 through 10","1666.16","5156.25","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","both","","","407.00","305.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","292.23","71.8","","162.99","162.99","162.99","33","83.7","386.65","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","both","","","407.00","305.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","284.90","70","","163.44","163.44","373.29","41","83.7","386.65","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","both","","","407.00","305.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","323.57","79.5","","3751.63","535.94","9647.04","113","83.7","386.65","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","both","","","407.00","305.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","216.93","53.3","","4314.81","714.60","10016.44","104","83.7","386.65","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","both","","","407.00","305.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","264.55","65","","173.55","113.10","173.55","1 through 10","83.7","386.65","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","both","","","407.00","305.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","313.39","77","","177.06","177.06","1026.95","17","83.7","386.65","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","both","","","407.00","305.25","WELLPOINT [1015]","HB AMC WELLPOINT","300.28","73.78","","169.00","157.42","3574.00","540","83.7","386.65","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","outpatient","","","407.00","305.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","246.44","60.55","","540.90","257.57","1352.25","950","163.69","6770.94","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","outpatient","","","407.00","305.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","212.54","52.22","","527.40","310.24","1506.86","1251","163.69","6770.94","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","outpatient","","","407.00","305.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","332.60","81.72","","2177.57","164.80","4355.14","1 through 10","163.69","6770.94","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","both","","","437.00","327.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","113.13","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","113.03","113.03","113.33","1 through 10","104.36","336.49","other","OPPS APC"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","both","","","437.00","327.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.09","95.73","108.09","1 through 10","104.36","336.49","other","OPPS APC"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","both","","","437.00","327.75","MEDICARE [2001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","27","104.36","336.49","other","OPPS APC"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","both","","","437.00","327.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","98.10","83.39","100.26","11","104.36","336.49","other","OPPS APC"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","both","","","437.00","327.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","135.47","31","","131.02","123.91","131.02","1 through 10","104.36","336.49","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","both","","","437.00","327.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","159.51","36.5","","153.49","134.41","158.15","26","104.36","336.49","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","both","","","437.00","327.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","167.37","38.3","","165.78","156.79","165.78","47","104.36","336.49","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","both","","","437.00","327.75","TRICARE [160005]","HB BWH TRICARE","104.36","","APC Price ($109.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","109.85","104.36","109.85","1 through 10","104.36","336.49","other","Tricare OPPS"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","both","","","437.00","327.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.65","107.65","107.65","1 through 10","104.36","336.49","other","OPPS APC"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","both","","","437.00","327.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.65","95.35","108.09","21","104.36","336.49","other","OPPS APC"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","both","","","437.00","327.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.47","42.9","","186.43","186.43","186.43","1 through 10","104.36","336.49","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","both","","","437.00","327.75","WELLPOINT [1015]","HB AMC WELLPOINT","322.42","73.78","","1123.54","1123.54","1123.54","1 through 10","104.36","336.49","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","outpatient","","","437.00","327.75","AETNA [1001]","HB AMC AETNA HMO","305.03","69.8","","558.53","191.68","558.53","1 through 10","149.02","575.66","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","outpatient","","","437.00","327.75","AETNA [1001]","HB AMC AETNA PPO","351.35","80.4","","330.72","330.72","330.72","1 through 10","149.02","575.66","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","outpatient","","","437.00","327.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","149.02","34.1","","333.69","263.83","333.69","1 through 10","149.02","575.66","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","outpatient","","","437.00","327.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","357.12","81.72","","186.43","186.43","186.43","1 through 10","149.02","575.66","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-51000644","CDM","99492","CPT","0510","RC","","","","outpatient","","","437.00","327.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","357.12","81.72","","338.95","338.95","659.51","1 through 10","149.02","575.66","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","113.13","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","113.03","113.03","113.33","1 through 10","104.36","325.16","other","OPPS APC"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.09","95.73","108.09","1 through 10","104.36","325.16","other","OPPS APC"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","325.16","79.5","","333.69","263.83","333.69","1 through 10","104.36","325.16","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","218.00","53.3","","223.87","223.87","223.87","1 through 10","104.36","325.16","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","MEDICARE [2001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","27","104.36","325.16","other","OPPS APC"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","98.10","83.39","100.26","11","104.36","325.16","other","OPPS APC"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","126.79","31","","131.02","123.91","131.02","1 through 10","104.36","325.16","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","149.29","36.5","","153.49","134.41","158.15","26","104.36","325.16","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","156.65","38.3","","165.78","156.79","165.78","47","104.36","325.16","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","TRICARE [160005]","HB BWH TRICARE","104.36","","APC Price ($109.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","109.85","104.36","109.85","1 through 10","104.36","325.16","other","Tricare OPPS"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.65","107.65","107.65","1 through 10","104.36","325.16","other","OPPS APC"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.65","95.35","108.09","21","104.36","325.16","other","OPPS APC"
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","175.46","42.9","","186.43","186.43","186.43","1 through 10","104.36","325.16","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","both","","","409.00","306.75","WELLPOINT [1015]","HB AMC WELLPOINT","301.76","73.78","","1123.54","1123.54","1123.54","1 through 10","104.36","325.16","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","outpatient","","","409.00","306.75","AETNA [1001]","HB AMC AETNA HMO","285.48","69.8","","558.53","191.68","558.53","1 through 10","228.63","575.66","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","outpatient","","","409.00","306.75","AETNA [1001]","HB AMC AETNA PPO","328.84","80.4","","330.72","330.72","330.72","1 through 10","228.63","575.66","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","outpatient","","","409.00","306.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","334.23","81.72","","186.43","186.43","186.43","1 through 10","228.63","575.66","percent of total billed charges",""
"1st Psychiatric Collab Care Mgmt 1st 70 Mins","PX-98301770","CDM","99492","CPT","0983","RC","","","","outpatient","","","409.00","306.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","334.23","81.72","","338.95","338.95","659.51","1 through 10","228.63","575.66","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-51000642","CDM","99494","CPT","0510","RC","","","","both","","","198.00","148.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","61.38","31","","59.33","59.33","59.33","1 through 10","61.38","152.46","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-51000642","CDM","99494","CPT","0510","RC","","","","both","","","198.00","148.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.27","36.5","","65.28","60.86","71.62","124","61.38","152.46","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-51000642","CDM","99494","CPT","0510","RC","","","","both","","","198.00","148.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.83","38.3","","75.07","68.43","75.07","202","61.38","152.46","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-51000642","CDM","99494","CPT","0510","RC","","","","both","","","198.00","148.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","152.46","77","","307.60","307.60","307.60","1 through 10","61.38","152.46","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-51000642","CDM","99494","CPT","0510","RC","","","","both","","","198.00","148.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.94","42.9","","84.42","84.42","84.42","17","61.38","152.46","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-51000642","CDM","99494","CPT","0510","RC","","","","both","","","198.00","148.50","WELLPOINT [1015]","HB AMC WELLPOINT","146.08","73.78","","130.29","130.29","864.29","18","61.38","152.46","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-51000642","CDM","99494","CPT","0510","RC","","","","outpatient","","","198.00","148.50","AETNA [1001]","HB AMC AETNA HMO","138.20","69.8","","993.84","83.65","993.84","16","67.52","161.81","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-51000642","CDM","99494","CPT","0510","RC","","","","outpatient","","","198.00","148.50","AETNA [1001]","HB AMC AETNA PPO","159.19","80.4","","149.76","136.50","149.76","1 through 10","67.52","161.81","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-51000642","CDM","99494","CPT","0510","RC","","","","outpatient","","","198.00","148.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","67.52","34.1","","151.10","96.00","151.11","1 through 10","67.52","161.81","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-51000642","CDM","99494","CPT","0510","RC","","","","outpatient","","","198.00","148.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","161.81","81.72","","84.42","84.42","84.42","1 through 10","67.52","161.81","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-51000642","CDM","99494","CPT","0510","RC","","","","outpatient","","","198.00","148.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","161.81","81.72","","153.48","84.42","153.49","27","67.52","161.81","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-98301772","CDM","99494","CPT","0983","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","151.10","96.00","151.11","1 through 10","54.25","139.13","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-98301772","CDM","99494","CPT","0983","RC","","","","both","","","175.00","131.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.28","53.3","","101.38","96.00","101.38","1 through 10","54.25","139.13","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-98301772","CDM","99494","CPT","0983","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.25","31","","59.33","59.33","59.33","1 through 10","54.25","139.13","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-98301772","CDM","99494","CPT","0983","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","65.28","60.86","71.62","124","54.25","139.13","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-98301772","CDM","99494","CPT","0983","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","75.07","68.43","75.07","202","54.25","139.13","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-98301772","CDM","99494","CPT","0983","RC","","","","both","","","175.00","131.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","134.75","77","","307.60","307.60","307.60","1 through 10","54.25","139.13","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-98301772","CDM","99494","CPT","0983","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","84.42","84.42","84.42","17","54.25","139.13","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-98301772","CDM","99494","CPT","0983","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","130.29","130.29","864.29","18","54.25","139.13","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-98301772","CDM","99494","CPT","0983","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","993.84","83.65","993.84","16","97.83","143.01","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-98301772","CDM","99494","CPT","0983","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA PPO","140.70","80.4","","149.76","136.50","149.76","1 through 10","97.83","143.01","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-98301772","CDM","99494","CPT","0983","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.01","81.72","","84.42","84.42","84.42","1 through 10","97.83","143.01","percent of total billed charges",""
"1st/Sbsq Psych Collab Care Mgmt Ea Addl 30 Mins","PX-98301772","CDM","99494","CPT","0983","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","153.48","84.42","153.49","27","97.83","143.01","percent of total billed charges",""
"3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal","PX-48000480","CDM","93319","CPT","0483","RC","","","","both","","","269.00","201.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","213.86","79.5","","261.00","205.41","261.00","1 through 10","83.39","213.86","percent of total billed charges",""
"3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal","PX-48000480","CDM","93319","CPT","0483","RC","","","","both","","","269.00","201.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","143.38","53.3","","2139.99","2139.99","2139.99","1 through 10","83.39","213.86","percent of total billed charges",""
"3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal","PX-48000480","CDM","93319","CPT","0483","RC","","","","both","","","269.00","201.75","WELLPOINT [1015]","HB AMC WELLPOINT","198.47","73.78","","194.31","194.31","194.31","1 through 10","83.39","213.86","percent of total billed charges",""
"3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal","PX-48000480","CDM","93319","CPT","0483","RC","","","","outpatient","","","269.00","201.75","AETNA [1001]","HB AMC AETNA HMO","187.76","69.8","","176.70","124.76","176.70","1 through 10","134.5","221.93","percent of total billed charges",""
"3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal","PX-48000480","CDM","93319","CPT","0483","RC","","","","outpatient","","","269.00","201.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","141.23","52.5","","150.34","150.34","150.34","1 through 10","134.5","221.93","percent of total billed charges",""
"3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal","PX-48000480","CDM","93319","CPT","0483","RC","","","","outpatient","","","269.00","201.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","141.23","52.5","","138.07","138.07","138.07","1 through 10","134.5","221.93","percent of total billed charges",""
"3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal","PX-48000480","CDM","93319","CPT","0483","RC","","","","outpatient","","","269.00","201.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","219.83","81.72","","208.64","208.64","208.64","1 through 10","134.5","221.93","percent of total billed charges",""
"9vhpv Vacc 2/3 Dose Sched Im Use","PX-63601160","CDM","90651","CPT","0636","RC","","","","both","","","502.64","376.98","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","351.85","70","","216.14","216.14","216.14","1 through 10","155.82","477.51","percent of total billed charges",""
"9vhpv Vacc 2/3 Dose Sched Im Use","PX-63601160","CDM","90651","CPT","0636","RC","","","","both","","","502.64","376.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","183.46","36.5","","187.48","159.34","217.78","1 through 10","155.82","477.51","percent of total billed charges",""
"9vhpv Vacc 2/3 Dose Sched Im Use","PX-63601160","CDM","90651","CPT","0636","RC","","","","both","","","502.64","376.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","192.51","38.3","","196.53","196.53","684.87","74","155.82","477.51","percent of total billed charges",""
"9vhpv Vacc 2/3 Dose Sched Im Use","PX-63601160","CDM","90651","CPT","0636","RC","","","","outpatient","","","502.64","376.98","AETNA [1001]","HB AMC AETNA HMO","350.84","69.8","","392.06","340.29","399.26","1 through 10","235.74","800.97","percent of total billed charges",""
"9vhpv Vacc 2/3 Dose Sched Im Use","PX-63601160","CDM","90651","CPT","0636","RC","","","","outpatient","","","502.64","376.98","AETNA [1001]","HB AMC AETNA PPO","404.12","80.4","","263.38","263.38","263.38","1 through 10","235.74","800.97","percent of total billed charges",""
"9vhpv Vacc 2/3 Dose Sched Im Use","PX-63601160","CDM","90651","CPT","0636","RC","","","","outpatient","","","502.64","376.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","351.35","69.9","","351.97","233.22","408.30","1 through 10","235.74","800.97","percent of total billed charges",""
"9vhpv Vacc 2/3 Dose Sched Im Use","PX-63601160","CDM","90651","CPT","0636","RC","","","","outpatient","","","502.64","376.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","235.74","46.9","","233.22","233.22","408.70","1 through 10","235.74","800.97","percent of total billed charges",""
"9vhpv Vacc 2/3 Dose Sched Im Use","PX-63601160","CDM","90651","CPT","0636","RC","","","","outpatient","","","502.64","376.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","410.76","81.72","","502.64","307.74","793.31","1 through 10","235.74","800.97","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","both","","","500.00","375.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","359.00","71.8","","411.28","205.64","616.92","11","40.8","475","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","both","","","500.00","375.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","328.00","65.6","","328.35","66.05","378.30","1 through 10","40.8","475","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","both","","","500.00","375.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","325.00","65","","1280.40","315.25","1280.40","1 through 10","40.8","475","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","both","","","500.00","375.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","350.00","70","","407.56","237.48","485.00","17","40.8","475","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","both","","","500.00","375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","397.50","79.5","","2034.41","381.70","2034.41","12","40.8","475","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","both","","","500.00","375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","266.50","53.3","","381.70","83.63","630.50","1 through 10","40.8","475","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","both","","","500.00","375.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","325.00","65","","315.25","315.25","395.85","1 through 10","40.8","475","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","both","","","500.00","375.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","325.00","65","","315.25","315.25","315.25","1 through 10","40.8","475","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","both","","","500.00","375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","155.00","31","","174.79","174.79","174.79","1 through 10","40.8","475","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","both","","","500.00","375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","182.50","36.5","","205.64","174.79","349.58","1 through 10","40.8","475","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","both","","","500.00","375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","191.50","38.3","","411.28","411.28","616.92","1 through 10","40.8","475","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","both","","","500.00","375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.50","42.9","","387.71","387.71","387.71","1 through 10","40.8","475","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","both","","","500.00","375.00","WELLPOINT [1015]","HB AMC WELLPOINT","368.90","73.78","","846.08","361.08","846.08","13","40.8","475","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","outpatient","","","500.00","375.00","AETNA [1001]","HB AMC AETNA HMO","349.00","69.8","","328.35","328.35","378.30","1 through 10","40.8","408.6","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","outpatient","","","500.00","375.00","AETNA [1001]","HB AMC AETNA PPO","402.00","80.4","","378.30","378.30","378.30","1 through 10","40.8","408.6","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","outpatient","","","500.00","375.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","402.00","80.4","","378.30","242.50","378.30","1 through 10","40.8","408.6","percent of total billed charges",""
"Ab Hla Class I & II Antigens Qual","PX-30001393","CDM","86828","CPT","0302","RC","","","","outpatient","","","500.00","375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","408.60","81.72","","387.71","228.21","387.77","1 through 10","40.8","408.6","percent of total billed charges",""
"Abatacept Inj 10mg","PX-63600054","CDM","J0129","HCPCS","0636","RC","","","","both","","","96.73","72.55","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.23","","APC Price ($44.11). Final payment is multiplied by 98%.","43.10","42.51","43.60","3475","29.99","104.74","other","OPPS APC"
"Abatacept Injection","PX-63601098","CDM","J0129","HCPCS","0636","RC","","","","both","","","96.73","72.55","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.23","","APC Price ($44.11). Final payment is multiplied by 98%.","43.10","42.51","43.60","3475","29.99","104.74","other","OPPS APC"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1146.50","1145.70","1146.60","14","175.77","1391.62","other","OPPS APC"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","821.70","1095.60","1 through 10","175.77","1391.62","other","OPPS APC"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","407.11","71.8","","2036.25","2036.25","2036.25","1 through 10","175.77","1391.62","percent of total billed charges",""
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","368.55","65","","1843.40","1843.40","1843.40","1 through 10","175.77","1391.62","percent of total billed charges",""
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","396.90","70","","2041.92","2041.92","2041.92","1 through 10","175.77","1391.62","percent of total billed charges",""
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","450.77","79.5","","1497.41","1497.41","1497.41","1 through 10","175.77","1391.62","percent of total billed charges",""
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","302.21","53.3","","1497.41","1497.41","2231.93","1 through 10","175.77","1391.62","percent of total billed charges",""
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1091.14","1091.14","1091.14","1 through 10","175.77","1391.62","other","OPPS APC"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","989.36","1113.41","223","175.77","1391.62","other","OPPS APC"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","206.96","36.5","","899.01","899.01","899.01","23","175.77","1391.62","percent of total billed charges",""
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","217.16","38.3","","2036.25","1108.88","2036.25","56","175.77","1391.62","percent of total billed charges",""
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","969.57","969.57","969.57","1 through 10","175.77","1391.62","other","OPPS APC"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","MOLINA [1014]","HB BWH MOLINA","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2209.01","2209.01","2209.01","1 through 10","175.77","1391.62","other","OPPS APC"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","976.97","3279.42","15","175.77","1391.62","other","OPPS APC"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1096.15","319.83","1113.41","1 through 10","175.77","1391.62","other","OPPS APC"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","both","","","567.00","425.25","WELLPOINT [1015]","HB AMC WELLPOINT","418.33","73.78","","4947.40","4947.40","4947.40","1 through 10","175.77","1391.62","percent of total billed charges",""
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","outpatient","","","567.00","425.25","AETNA [1001]","HB AMC AETNA HMO","395.77","69.8","","1919.97","1355.61","2212.08","17","283.06","2384.07","percent of total billed charges",""
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","outpatient","","","567.00","425.25","AETNA [1001]","HB AMC AETNA PPO","455.87","80.4","","2212.08","2212.08","2212.08","1 through 10","283.06","2384.07","percent of total billed charges",""
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","outpatient","","","567.00","425.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1949.57","1949.57","1949.57","1 through 10","283.06","2384.07","other","Multiple Surgery"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","outpatient","","","567.00","425.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1766.80","1698.26","5300.40","43","283.06","2384.07","other","Multiple Surgery"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","outpatient","","","567.00","425.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1858.18","1858.18","1858.18","12","283.06","2384.07","other","Multiple Surgery"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","outpatient","","","567.00","425.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","2208.50","2208.50","2836.00","1 through 10","283.06","2384.07","other","Multiple Surgery"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","outpatient","","","567.00","425.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3789.50","1949.57","3899.14","1 through 10","283.06","2384.07","other","Multiple Surgery"
"Abdom Paracentesis Dx/Ther W/Imaging Guidance","PX-36000168","CDM","49083","CPT","0983","RC","","","","outpatient","","","567.00","425.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","463.35","81.72","","2267.10","1246.99","2267.10","51","283.06","2384.07","percent of total billed charges",""
"Abdom Paracentesis Dx/Ther W/O Imaging Guidance","PX-36000167","CDM","49082","CPT","0983","RC","","","","both","","","600.00","450.00","MEDICARE [2001]","HB BWH MEDICARE","1192.34","","APC Price ($1,192.34). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","186","1490.43","other","OPPS APC"
"Abdomen Peritoneum Omentum Unlstd","PX-75000344","CDM","49999","CPT","0361","RC","","","","both","","","1374.00","1030.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","425.94","1391.62","other","OPPS APC"
"Abdomen Peritoneum Omentum Unlstd","PX-75000344","CDM","49999","CPT","0361","RC","","","","both","","","1374.00","1030.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","425.94","1391.62","other","OPPS APC"
"Abdomen Peritoneum Omentum Unlstd","PX-75000344","CDM","49999","CPT","0361","RC","","","","both","","","1374.00","1030.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","425.94","1391.62","other","OPPS APC"
"Abdomen Peritoneum Omentum Unlstd","PX-75000344","CDM","49999","CPT","0361","RC","","","","outpatient","","","1374.00","1030.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","687.00","50","","14640.00","14640.00","14640.00","1 through 10","687","8899.59","percent of total billed charges",""
"Abdominal Pain,MAJOR","251","DRG","","","","","","","","inpatient","","","43972.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","28226.27","","Standard inlier is a Case rate ($28,226.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,171, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,006.48) for the length of stay and the standard reimbursement.","28226.26","28226.26","28226.26","1 through 10","4618.59","32942.3","case rate",""
"Abdominal Pain,MINOR","251","DRG","","","","","","","","inpatient","","","46859.02","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","16558.34","","Standard inlier is a Case rate ($16,558.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,100, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,350.32) for the length of stay and the standard reimbursement.","16558.34","16558.34","16558.34","1 through 10","4618.59","32942.3","case rate",""
"Abdominal Pain,MINOR","251","DRG","","","","","","","","inpatient","","","46859.02","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4618.59","","Case rate ($5,106.64). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,536.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5105.39","5105.39","5105.39","1 through 10","4618.59","32942.3","case rate",""
"Abdominal Pain,MODERATE","251","DRG","","","","","","","","inpatient","","","24029.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19019.74","","Standard inlier is a Case rate ($19,019.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,438, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,699.97) for the length of stay and the standard reimbursement.","17337.18","17337.18","17337.18","1 through 10","4618.59","32942.3","case rate",""
"Abdominal Pain,MODERATE","251","DRG","","","","","","","","inpatient","","","24029.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21383.32","","Standard inlier is a Case rate ($21,383.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,438, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,035.18) for the length of stay and the standard reimbursement.","21383.31","21383.31","21383.31","1 through 10","4618.59","32942.3","case rate",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1146.50","1145.70","1146.60","14","906.44","2324.58","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","821.70","1095.60","1 through 10","906.44","2324.58","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2099.43","71.8","","2036.25","2036.25","2036.25","1 through 10","906.44","2324.58","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1900.60","65","","1843.40","1843.40","1843.40","1 through 10","906.44","2324.58","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2046.80","70","","2041.92","2041.92","2041.92","1 through 10","906.44","2324.58","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2324.58","79.5","","1497.41","1497.41","1497.41","1 through 10","906.44","2324.58","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1558.49","53.3","","1497.41","1497.41","2231.93","1 through 10","906.44","2324.58","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1091.14","1091.14","1091.14","1 through 10","906.44","2324.58","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","989.36","1113.41","223","906.44","2324.58","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1067.26","36.5","","899.01","899.01","899.01","23","906.44","2324.58","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1119.89","38.3","","2036.25","1108.88","2036.25","56","906.44","2324.58","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","969.57","969.57","969.57","1 through 10","906.44","2324.58","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","MOLINA [1014]","HB BWH MOLINA","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2209.01","2209.01","2209.01","1 through 10","906.44","2324.58","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","976.97","3279.42","15","906.44","2324.58","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1096.15","319.83","1113.41","1 through 10","906.44","2324.58","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2924.00","2193.00","WELLPOINT [1015]","HB AMC WELLPOINT","2157.33","73.78","","4947.40","4947.40","4947.40","1 through 10","906.44","2324.58","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2924.00","2193.00","AETNA [1001]","HB AMC AETNA HMO","2040.95","69.8","","1919.97","1355.61","2212.08","17","761.55","2389.49","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2924.00","2193.00","AETNA [1001]","HB AMC AETNA PPO","2350.90","80.4","","2212.08","2212.08","2212.08","1 through 10","761.55","2389.49","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2924.00","2193.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1781.82","1749.60","1781.82","51","761.55","2389.49","other","ASC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2924.00","2193.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2018.70","2018.70","2038.73","111","761.55","2389.49","other","ASC "
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2924.00","2193.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1949.57","1949.57","1949.57","1 through 10","761.55","2389.49","other","Multiple Surgery"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2924.00","2193.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1766.80","1698.26","5300.40","43","761.55","2389.49","other","Multiple Surgery"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2924.00","2193.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1858.18","1858.18","1858.18","12","761.55","2389.49","other","Multiple Surgery"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2924.00","2193.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","2208.50","2208.50","2836.00","1 through 10","761.55","2389.49","other","Multiple Surgery"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2924.00","2193.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3789.50","1949.57","3899.14","1 through 10","761.55","2389.49","other","Multiple Surgery"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2924.00","2193.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2389.49","81.72","","2267.10","1246.99","2267.10","51","761.55","2389.49","percent of total billed charges",""
"Abdominal Paracentesis W/O Imaging","PX-75000277","CDM","49082","CPT","0361","RC","","","","both","","","1734.00","1300.50","MEDICARE [2001]","HB BWH MEDICARE","1192.34","","APC Price ($1,192.34). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","537.54","1490.43","other","OPPS APC"
"Ablat Tumor Renal Cryosurg Uni","PX-76001240","CDM","50593","CPT","0761","RC","","","","both","","","14585.00","10938.75","MEDICARE [2001]","HB BWH MEDICARE","12362.70","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","22469.58","22469.58","22469.58","1 through 10","4521.35","15453.37","other","OPPS APC"
"Ablat Tumor Renal Cryosurg Uni","PX-76001240","CDM","50593","CPT","0761","RC","","","","both","","","14585.00","10938.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12115.45","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","12124.58","12116.68","12154.33","1 through 10","4521.35","15453.37","other","OPPS APC"
"Ablate L/R Atrial Fibril W/ Isolate","PX-48000251","CDM","93657","CPT","0481","RC","","","","both","","","10830.00","8122.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8609.85","79.5","","24163.93","5545.06","24795.21","1 through 10","3357.3","8609.85","percent of total billed charges",""
"Ablate L/R Atrial Fibril W/ Isolate","PX-48000251","CDM","93657","CPT","0481","RC","","","","both","","","10830.00","8122.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5772.39","53.3","","5545.06","3378.55","10261.60","1 through 10","3357.3","8609.85","percent of total billed charges",""
"Ablate L/R Atrial Fibril W/ Isolate","PX-48000251","CDM","93657","CPT","0481","RC","","","","both","","","10830.00","8122.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","8339.10","77","","8086.54","8086.54","8086.54","1 through 10","3357.3","8609.85","percent of total billed charges",""
"Ablate L/R Atrial Fibril W/ Isolate","PX-48000251","CDM","93657","CPT","0481","RC","","","","both","","","10830.00","8122.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3952.95","36.5","","3917.25","3917.25","3917.25","1 through 10","3357.3","8609.85","percent of total billed charges",""
"Ablate L/R Atrial Fibril W/ Isolate","PX-48000251","CDM","93657","CPT","0481","RC","","","","both","","","10830.00","8122.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4147.89","38.3","","4106.28","4106.28","4106.28","1 through 10","3357.3","8609.85","percent of total billed charges",""
"Ablate L/R Atrial Fibril W/ Isolate","PX-48000251","CDM","93657","CPT","0481","RC","","","","both","","","10830.00","8122.50","WELLPOINT [1015]","HB AMC WELLPOINT","7990.37","73.78","","7818.74","7818.74","7818.74","1 through 10","3357.3","8609.85","percent of total billed charges",""
"Ablate L/R Atrial Fibril W/ Isolate","PX-48000251","CDM","93657","CPT","0481","RC","","","","outpatient","","","10830.00","8122.50","AETNA [1001]","HB AMC AETNA HMO","7559.34","69.8","","7109.85","5019.96","9631.68","15","5659.76","8850.28","percent of total billed charges",""
"Ablate L/R Atrial Fibril W/ Isolate","PX-48000251","CDM","93657","CPT","0481","RC","","","","outpatient","","","10830.00","8122.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5659.76","52.26","","6498.64","6498.64","6498.64","1 through 10","5659.76","8850.28","percent of total billed charges",""
"Ablate L/R Atrial Fibril W/ Isolate","PX-48000251","CDM","93657","CPT","0481","RC","","","","outpatient","","","10830.00","8122.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8850.28","81.72","","8395.30","4617.73","8395.30","1 through 10","5659.76","8850.28","percent of total billed charges",""
"Ablate L/R Atrial Fibril W/ Isolate","PX-48000251","CDM","93657","CPT","0481","RC","","","","outpatient","","","10830.00","8122.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8850.28","81.72","","8395.30","4617.73","8395.30","1 through 10","5659.76","8850.28","percent of total billed charges",""
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","both","","","3559.00","2669.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","12733.58","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","12722.51","12722.51","12722.51","1 through 10","1103.29","15453.37","other","OPPS APC"
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","both","","","3559.00","2669.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12362.70","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12166.13","12166.13","12166.13","1 through 10","1103.29","15453.37","other","OPPS APC"
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","both","","","3559.00","2669.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2829.41","79.5","","2715.94","2715.94","2715.94","1 through 10","1103.29","15453.37","percent of total billed charges",""
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","both","","","3559.00","2669.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","12362.70","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12116.67","12116.67","12116.67","1 through 10","1103.29","15453.37","other","OPPS APC"
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","both","","","3559.00","2669.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","12362.70","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12126.17","12126.17","12126.17","1 through 10","1103.29","15453.37","other","OPPS APC"
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","both","","","3559.00","2669.25","MEDICARE [2001]","HB BWH MEDICARE","12362.70","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12363.95","12363.95","22469.58","31","1103.29","15453.37","other","OPPS APC"
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","both","","","3559.00","2669.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","12362.70","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11012.59","11012.59","11012.59","1 through 10","1103.29","15453.37","other","OPPS APC"
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","both","","","3559.00","2669.25","TRICARE [160005]","HB BWH TRICARE","11745.75","","APC Price ($12,363.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","12363.95","11745.75","12363.95","1 through 10","1103.29","15453.37","other","Tricare OPPS"
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","both","","","3559.00","2669.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12115.45","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","36366.21","36366.21","36366.21","1 through 10","1103.29","15453.37","other","OPPS APC"
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","both","","","3559.00","2669.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12115.45","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","12116.68","12116.67","12116.68","1 through 10","1103.29","15453.37","other","OPPS APC"
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","both","","","3559.00","2669.25","WELLPOINT [1015]","HB AMC WELLPOINT","2625.83","73.78","","2569.27","2569.27","2569.27","1 through 10","1103.29","15453.37","percent of total billed charges",""
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","outpatient","","","3559.00","2669.25","AETNA [1001]","HB AMC AETNA HMO","2484.18","69.8","","2336.33","2336.33","2336.33","1 through 10","1859.93","11688.78","percent of total billed charges",""
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","outpatient","","","3559.00","2669.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5815.44","","Case rate ($5,815.44). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","13613.95","3451.00","13613.95","1 through 10","1859.93","11688.78","other","ASC "
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","outpatient","","","3559.00","2669.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4136.27","","Case rate ($4,136.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","9596.15","9596.15","9596.15","1 through 10","1859.93","11688.78","other","Multiple Surgery"
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","outpatient","","","3559.00","2669.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4136.27","","Case rate ($4,136.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","10092.50","10092.50","10092.50","1 through 10","1859.93","11688.78","other","Multiple Surgery"
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","outpatient","","","3559.00","2669.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","4136.27","","Case rate ($4,136.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","10588.85","1121.20","10588.85","1 through 10","1859.93","11688.78","other","Multiple Surgery"
"Ablation 1/> Liver Tumor Perq Cryoablation","PX-36000363","CDM","47383","CPT","0361","RC","","","","outpatient","","","3559.00","2669.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2908.41","81.72","","5178.72","3013.56","5178.72","1 through 10","1859.93","11688.78","percent of total billed charges",""
"Ablation Atrioventricular Function","PX-48000168","CDM","93650","CPT","0481","RC","","","","both","","","17026.00","12769.50","MEDICARE [2001]","HB BWH MEDICARE","9010.41","","APC Price ($9,010.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9011.32","9011.32","9011.32","1 through 10","5278.06","13535.67","other","OPPS APC"
"Ablation Bone Tumor Perc W/CT","PX-76000308","CDM","20982","CPT","0761","RC","","","","outpatient","","","12130.00","9097.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6517.81","","Case rate ($6,517.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","15258.19","15258.19","15258.19","1 through 10","5129.63","9912.64","other","ASC "
"Ablation Bone Tumor Rf Perq W/Img Gdn When Done","PX-76002079","CDM","20982","CPT","0761","RC","","","","outpatient","","","12130.00","9097.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6517.81","","Case rate ($6,517.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","15258.19","15258.19","15258.19","1 through 10","5129.63","9912.64","other","ASC "
"Ablation Prostate Cryosurgical|REDUCED SERVICES","PX-76001326","CDM","55873","CPT","0761","RC","","","52","both","","","8143.00","6107.25","MEDICARE [2001]","HB BWH MEDICARE","10980.44","","APC Price ($10,980.44). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5027.26","5027.26","5027.26","1 through 10","10432.47","13725.54","other","OPPS APC"
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","both","","","14676.00","11007.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7135.79","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","7136.58","7129.58","7138.48","1 through 10","4549.56","11667.42","other","OPPS APC"
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","both","","","14676.00","11007.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","6927.95","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6817.79","6817.79","6817.79","1 through 10","4549.56","11667.42","other","OPPS APC"
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","both","","","14676.00","11007.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","10273.20","70","","6790.08","6790.08","6790.08","1 through 10","4549.56","11667.42","percent of total billed charges",""
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","both","","","14676.00","11007.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","8659.94","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","375.00","375.00","375.00","1 through 10","4549.56","11667.42","other","OPPS APC"
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","both","","","14676.00","11007.00","HUMANA [1012]","HB BWH MEDICARE","6927.95","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6200.43","6200.43","6200.43","1 through 10","4549.56","11667.42","other","OPPS APC"
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","both","","","14676.00","11007.00","MEDICARE [2001]","HB BWH MEDICARE","6927.95","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6297.49","20785.95","19","4549.56","11667.42","other","OPPS APC"
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","both","","","14676.00","11007.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5356.74","36.5","","5308.54","5308.54","5308.54","1 through 10","4549.56","11667.42","percent of total billed charges",""
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","both","","","14676.00","11007.00","TRICARE [160005]","HB BWH TRICARE","6582.22","","APC Price ($6,928.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","5982.61","5982.61","5982.61","1 through 10","4549.56","11667.42","other","Tricare OPPS"
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","both","","","14676.00","11007.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6789.39","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20376.24","20376.24","20376.24","1 through 10","4549.56","11667.42","other","OPPS APC"
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","both","","","14676.00","11007.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6789.39","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6797.98","6790.08","6797.98","1 through 10","4549.56","11667.42","other","OPPS APC"
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","both","","","14676.00","11007.00","WELLPOINT [1015]","HB AMC WELLPOINT","10827.95","73.78","","10595.72","10595.72","10595.72","1 through 10","4549.56","11667.42","percent of total billed charges",""
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","outpatient","","","14676.00","11007.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5255.62","","Case rate ($5,255.62). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","10558.54","10558.54","10753.00","1 through 10","4136.27","11993.23","other","ASC"
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","outpatient","","","14676.00","11007.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5255.62","","Case rate ($5,255.62). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","12182.53","12182.53","12303.41","1 through 10","4136.27","11993.23","other","ASC "
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","outpatient","","","14676.00","11007.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4136.27","","Case rate ($4,136.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","9596.15","9596.15","9596.15","1 through 10","4136.27","11993.23","other","Multiple Surgery"
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","outpatient","","","14676.00","11007.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4136.27","","Case rate ($4,136.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","10092.50","10092.50","10092.50","1 through 10","4136.27","11993.23","other","Multiple Surgery"
"Ablation Tumor Liver Radiofreq Perc","PX-75000243","CDM","47382","CPT","0361","RC","","","","outpatient","","","14676.00","11007.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11993.23","81.72","","47853.67","11377.06","47853.67","1 through 10","4136.27","11993.23","percent of total billed charges",""
"Ablt Trurl Prst8 Tis Thrm US Ins Trurl US Trnsdc","PX-76002987","CDM","55882","CPT","0761","RC","","","","both","","","4939.00","3704.25","WELLPOINT [1015]","HB AMC WELLPOINT","3643.99","73.78","","3566.16","3566.16","3566.16","1 through 10","1531.09","19098.22","percent of total billed charges",""
"Abltj 1/+Thyroid Nodule 1 Lobe/Isthmus Perq Rf","PX-76010309","CDM","60660","CPT","0761","RC","","","","both","","","13904.00","10428.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1827.93","11053.68","other","OPPS APC"
"Abltj 1/+Thyroid Nodule 1 Lobe/Isthmus Perq Rf","PX-76010309","CDM","60660","CPT","0761","RC","","","","both","","","13904.00","10428.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5325.23","38.3","","5271.85","5271.85","5271.85","1 through 10","1827.93","11053.68","percent of total billed charges",""
"Abltj 1/+Thyroid Nodule 1 Lobe/Isthmus Perq Rf","PX-76010309","CDM","60660","CPT","0761","RC","","","","both","","","13904.00","10428.00","WELLPOINT [1015]","HB AMC WELLPOINT","10258.37","73.78","","10038.09","10038.09","10038.09","1 through 10","1827.93","11053.68","percent of total billed charges",""
"Abltj 1/+Thyroid Nodule 1 Lobe/Isthmus Perq Rf","PX-76010309","CDM","60660","CPT","0761","RC","","","","outpatient","","","13904.00","10428.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","7260.67","52.22","","7257.90","7257.90","13483.00","1 through 10","5561.6","11470.8","percent of total billed charges",""
"Abltj 1/+Thyroid Nodule 1 Lobe/Isthmus Perq Rf","PX-76010309","CDM","60660","CPT","0761","RC","","","","outpatient","","","13904.00","10428.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11178.82","80.4","","10516.74","10516.74","10516.74","1 through 10","5561.6","11470.8","percent of total billed charges",""
"Abltj 1/+Thyroid Nodule 1 Lobe/Isthmus Perq Rf","PX-76010309","CDM","60660","CPT","0761","RC","","","","outpatient","","","13904.00","10428.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11362.35","81.72","","10778.31","10778.31","10778.31","1 through 10","5561.6","11470.8","percent of total billed charges",""
"Abobotulinum Toxin a Vl 5u","PX-63600072","CDM","J0586","HCPCS","0636","RC","","","","both","","","30.18","22.63","MEDICARE [2001]","HB BWH MEDICARE","8.75","","APC Price ($8.75).","8.63","8.63","8.63","45","8.58","23.24","other","OPPS APC"
"Abobotulinum Toxin a Vl 5u","PX-63600072","CDM","J0586","HCPCS","0636","RC","","","","both","","","30.18","22.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11.02","36.5","","13.96","13.96","13.96","100","8.58","23.24","percent of total billed charges",""
"Abobotulinum Toxin a Vl 5u","PX-63600072","CDM","J0586","HCPCS","0636","RC","","","","both","","","30.18","22.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11.56","38.3","","14.28","14.28","14.28","30","8.58","23.24","percent of total billed charges",""
"Abobotulinum Toxin a Vl 5u","PX-63600072","CDM","J0586","HCPCS","0636","RC","","","","outpatient","","","30.18","22.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21.10","69.9","","25.94","25.30","25.94","204","10.09","24.26","percent of total billed charges",""
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","both","","","4886.00","3664.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1871.34","38.3","","5557.68","1852.56","5557.68","22","1514.66","4719.38","percent of total billed charges",""
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","both","","","4886.00","3664.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3775.88","3775.88","3775.88","1 through 10","1514.66","4719.38","other","OPPS APC"
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","both","","","4886.00","3664.50","WELLPOINT [1015]","HB AMC WELLPOINT","3604.89","73.78","","8265.44","3527.44","8265.44","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4886.00","3664.50","AETNA [1001]","HB AMC AETNA PPO","3928.34","80.4","","3695.64","3695.64","3695.64","1 through 10","2125.14","9843.6","percent of total billed charges",""
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5424.80","5424.80","5524.71","1 through 10","2125.14","9843.6","other","ASC"
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6259.18","6259.18","6321.29","1 through 10","2125.14","9843.6","other","ASC "
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4738.00","4738.00","4738.00","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","24651.60","4930.32","24651.60","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5185.34","2507.93","15556.02","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","10500.81","6162.91","10500.81","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4886.00","3664.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3992.84","81.72","","2083.30","2083.30","2083.30","1 through 10","2125.14","9843.6","percent of total billed charges",""
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","4886.00","3664.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3992.84","81.72","","3787.56","2083.30","11350.00","1 through 10","2125.14","9843.6","percent of total billed charges",""
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","both","","","5977.00","4482.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4751.72","79.5","","11254.00","3060.29","11254.00","1 through 10","1852.87","4751.72","percent of total billed charges",""
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","both","","","5977.00","4482.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3185.74","53.3","","3060.29","3060.29","3060.29","1 through 10","1852.87","4751.72","percent of total billed charges",""
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","both","","","5977.00","4482.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3715.47","3715.47","3715.47","1 through 10","1852.87","4751.72","other","OPPS APC"
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","both","","","5977.00","4482.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1852.87","31","","3581.92","3581.92","3581.92","1 through 10","1852.87","4751.72","percent of total billed charges",""
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","both","","","5977.00","4482.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2181.61","36.5","","6485.73","1837.33","6485.73","1 through 10","1852.87","4751.72","percent of total billed charges",""
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","both","","","5977.00","4482.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2289.19","38.3","","2266.24","2202.48","6798.72","14","1852.87","4751.72","percent of total billed charges",""
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","both","","","5977.00","4482.75","TRICARE [160005]","HB BWH TRICARE","3587.09","","APC Price ($3,775.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","5796.00","5796.00","5796.00","1 through 10","1852.87","4751.72","other","Tricare OPPS"
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","both","","","5977.00","4482.75","WELLPOINT [1015]","HB AMC WELLPOINT","4409.83","73.78","","15907.12","10111.12","15907.12","1 through 10","1852.87","4751.72","percent of total billed charges",""
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","outpatient","","","5977.00","4482.75","AETNA [1001]","HB AMC AETNA HMO","4171.95","69.8","","3923.89","2770.49","3923.89","1 through 10","2125.14","9843.6","percent of total billed charges",""
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","outpatient","","","5977.00","4482.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5524.71","5424.80","5524.71","12","2125.14","9843.6","other","ASC"
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","outpatient","","","5977.00","4482.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6321.29","6259.18","6321.29","33","2125.14","9843.6","other","ASC "
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","outpatient","","","5977.00","4482.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","14790.96","4930.32","24651.60","12","2125.14","9843.6","other","Multiple Surgery"
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","outpatient","","","5977.00","4482.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9988.16","5185.34","9988.16","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","outpatient","","","5977.00","4482.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","5440.36","5227.84","5440.36","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","outpatient","","","5977.00","4482.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4884.40","81.72","","4633.32","4633.32","5796.00","1 through 10","2125.14","9843.6","percent of total billed charges",""
"Abortion With D&C, Aspiration Curettage Or Hysterotomy,MAJOR","543","DRG","","","","","","","","inpatient","","","33324.71","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11639.57","","Case rate ($12,869.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,299.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12866.38","12866.38","12866.38","1 through 10","4506.63","88329.35","case rate",""
"Abortion With D&C, Aspiration Curettage Or Hysterotomy,MINOR","543","DRG","","","","","","","","inpatient","","","19180.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18180.00","","Standard inlier is a Case rate ($18,180). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,223, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,580.50) for the length of stay and the standard reimbursement.","16609.00","16609.00","18180.00","1 through 10","4506.63","88329.35","case rate",""
"Abortion Without D&C","779","TRIS-DRG","","","","","","","","inpatient","","","24985.60","","TRICARE [160005]","HB BWH TRICARE","3352.30","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($5,888.50). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $49,615.51 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($7,851.34), capped at $4,238.16. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $49,615.51 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","4826.00","4826.00","7077.92","1 through 10","3352.3","3352.3","other","Inpatient DRGs"
"Abortion Without D&C, Aspiration Curettage Or Hysterotomy,MAJOR","564","DRG","","","","","","","","inpatient","","","39420.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19284.94","","Standard inlier is a Case rate ($19,284.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,644, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,737.61) for the length of stay and the standard reimbursement.","19284.93","19284.93","19284.93","1 through 10","3938.88","21681.47","case rate",""
"Abortion Without D&C, Aspiration Curettage Or Hysterotomy,MAJOR","564","DRG","","","","","","","","inpatient","","","39420.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21681.47","","Standard inlier is a Case rate ($21,681.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,644, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,077.50) for the length of stay and the standard reimbursement.","19807.89","19807.89","19807.89","1 through 10","3938.88","21681.47","case rate",""
"Abortion Without D&C, Aspiration Curettage Or Hysterotomy,MAJOR","564","DRG","","","","","","","","inpatient","","","39420.84","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8821.35","","Case rate ($9,753.52). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,183.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9751.13","9751.13","9751.13","1 through 10","3938.88","21681.47","case rate",""
"Abortion Without D&C, Aspiration Curettage Or Hysterotomy,MINOR","564","DRG","","","","","","","","inpatient","","","28803.12","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","10326.48","","Standard inlier is a Case rate ($10,326.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $19,679, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,465.91) for the length of stay and the standard reimbursement.","10326.48","10326.48","10326.48","1 through 10","3938.88","21681.47","case rate",""
"Abortion Without D&C, Aspiration Curettage Or Hysterotomy,MINOR","564","DRG","","","","","","","","inpatient","","","28803.12","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","9082.89","9082.89","9082.89","1 through 10","3938.88","21681.47","percent of total billed charges",""
"Abortion Without D&C, Aspiration Curettage Or Hysterotomy,MODERATE","564","DRG","","","","","","","","inpatient","","","27896.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","13812.84","","Standard inlier is a Case rate ($13,812.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,389, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,960.82) for the length of stay and the standard reimbursement.","13812.84","13812.84","13812.84","1 through 10","3938.88","21681.47","case rate",""
"Abortion Without D&C, Aspiration Curettage Or Hysterotomy,MODERATE","564","DRG","","","","","","","","inpatient","","","27896.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","15529.36","","Standard inlier is a Case rate ($15,529.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,389, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,204.26) for the length of stay and the standard reimbursement.","14187.40","14187.40","14187.40","1 through 10","3938.88","21681.47","case rate",""
"Abortion Without D&C, Aspiration Curettage Or Hysterotomy,MODERATE","564","DRG","","","","","","","","inpatient","","","27896.46","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10647.97","","Fee schedule rate ($10,647.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9757.09","9757.09","9757.09","1 through 10","3938.88","21681.47","case rate",""
"Abortion Without D&C, Aspiration Curettage Or Hysterotomy,MODERATE","564","DRG","","","","","","","","inpatient","","","27896.46","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4604.88","","Case rate ($5,091.48). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,521.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5090.23","5090.23","5090.23","1 through 10","3938.88","21681.47","case rate",""
"ABUTMENT TITANIUM 6MM 4 IMPLANT COCHLEAR BIA300 XSEC BAHA FAST SURGERY","SUP-ITM-10092309","CDM","L8614","HCPCS","0278","RC","","","","both","","","7450.63","5587.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3971.19","53.3","","39045.04","39045.04","39045.04","1 through 10","2309.7","47716.66","percent of total billed charges",""
"ABUTMENT TITANIUM 6MM 4 IMPLANT COCHLEAR BIA300 XSEC BAHA FAST SURGERY","SUP-ITM-10092309","CDM","L8614","HCPCS","0278","RC","","","","both","","","7450.63","5587.97","WELLPOINT [1015]","HB AMC WELLPOINT","5497.07","73.78","","36936.51","36936.51","36936.51","1 through 10","2309.7","47716.66","percent of total billed charges",""
"ACETABULAR AUGMENT 15MM SIZE 58 TRABECULAR METAL PARTIAL HEMISPHERE 22","SUP-ITM-10018821","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2057.74","52.26","","1113.10","1113.10","1113.10","1 through 10","1220.63","3130.31","percent of total billed charges",""
"ACETABULAR AUGMENT 15MM SIZE 58 TRABECULAR METAL PARTIAL HEMISPHERE 22","SUP-ITM-10018821","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3130.31","79.5","","1293.60","1148.53","1603.80","1 through 10","1220.63","3130.31","percent of total billed charges",""
"ACETABULAR AUGMENT 15MM SIZE 58 TRABECULAR METAL PARTIAL HEMISPHERE 22","SUP-ITM-10018821","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1437.19","36.5","","1023.42","771.29","2068.67","33","1220.63","3130.31","percent of total billed charges",""
"ACETABULAR AUGMENT 15MM SIZE 58 TRABECULAR METAL PARTIAL HEMISPHERE 22","SUP-ITM-10018821","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1508.06","38.3","","850.52","759.78","1211.25","66","1220.63","3130.31","percent of total billed charges",""
"ACETABULAR AUGMENT 15MM SIZE 58 TRABECULAR METAL PARTIAL HEMISPHERE 22","SUP-ITM-10018821","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1689.19","42.9","","2548.09","2548.09","2548.09","1 through 10","1220.63","3130.31","percent of total billed charges",""
"ACETABULAR AUGMENT 15MM SIZE 58 TRABECULAR METAL PARTIAL HEMISPHERE 22","SUP-ITM-10018821","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1689.19","42.9","","956.46","956.46","956.46","1 through 10","1220.63","3130.31","percent of total billed charges",""
"ACETABULAR AUGMENT 15MM SIZE 58 TRABECULAR METAL PARTIAL HEMISPHERE 22","SUP-ITM-10018821","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","WELLPOINT [1015]","HB AMC WELLPOINT","2905.09","73.78","","2344.73","1619.47","2530.35","16","1220.63","3130.31","percent of total billed charges",""
"ACETABULAR AUGMENT 15MM SIZE 58 TRABECULAR METAL PARTIAL HEMISPHERE 22","SUP-ITM-10018821","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","AETNA [1001]","HB AMC AETNA HMO","2748.38","69.8","","1523.63","988.41","4330.26","39","2057.74","3217.73","percent of total billed charges",""
"ACETABULAR AUGMENT 15MM SIZE 58 TRABECULAR METAL PARTIAL HEMISPHERE 22","SUP-ITM-10018821","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","AETNA [1001]","HB AMC AETNA PPO","3165.75","80.4","","1670.25","1670.25","1670.25","1 through 10","2057.74","3217.73","percent of total billed charges",""
"ACETABULAR AUGMENT 15MM SIZE 58 TRABECULAR METAL PARTIAL HEMISPHERE 22","SUP-ITM-10018821","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2057.74","52.26","","1113.10","1113.10","1113.10","1 through 10","2057.74","3217.73","percent of total billed charges",""
"ACETABULAR AUGMENT 15MM SIZE 58 TRABECULAR METAL PARTIAL HEMISPHERE 22","SUP-ITM-10018821","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3217.73","81.72","","1738.90","1484.65","2716.94","38","2057.74","3217.73","percent of total billed charges",""
"ACETABULAR AUGMENT 62X20MM RESTORATION WEDGE 8","SUP-ITM-10115318","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR AUGMENT 62X20MM RESTORATION WEDGE 8","SUP-ITM-10115318","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3213.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR AUGMENT 62X20MM RESTORATION WEDGE 8","SUP-ITM-10115318","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.51","36.5","","1023.42","771.29","2068.67","33","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR AUGMENT 62X20MM RESTORATION WEDGE 8","SUP-ITM-10115318","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.28","38.3","","850.52","759.78","1211.25","66","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR AUGMENT 62X20MM RESTORATION WEDGE 8","SUP-ITM-10115318","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR AUGMENT 62X20MM RESTORATION WEDGE 8","SUP-ITM-10115318","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","956.46","956.46","956.46","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR AUGMENT 62X20MM RESTORATION WEDGE 8","SUP-ITM-10115318","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","WELLPOINT [1015]","HB AMC WELLPOINT","2982.56","73.78","","2344.73","1619.47","2530.35","16","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR AUGMENT 62X20MM RESTORATION WEDGE 8","SUP-ITM-10115318","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA HMO","2821.67","69.8","","1523.63","988.41","4330.26","39","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR AUGMENT 62X20MM RESTORATION WEDGE 8","SUP-ITM-10115318","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA PPO","3250.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR AUGMENT 62X20MM RESTORATION WEDGE 8","SUP-ITM-10115318","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR AUGMENT 62X20MM RESTORATION WEDGE 8","SUP-ITM-10115318","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.53","81.72","","1738.90","1484.65","2716.94","38","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR CUP 32X53MM STEM LONGEVITY SS WIRE CEMENTED NEUTRAL","SUP-ITM-10080966","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1190.74","52.26","","1113.10","1113.10","1113.10","1 through 10","706.34","1811.41","percent of total billed charges",""
"ACETABULAR CUP 32X53MM STEM LONGEVITY SS WIRE CEMENTED NEUTRAL","SUP-ITM-10080966","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1811.41","79.5","","1293.60","1148.53","1603.80","1 through 10","706.34","1811.41","percent of total billed charges",""
"ACETABULAR CUP 32X53MM STEM LONGEVITY SS WIRE CEMENTED NEUTRAL","SUP-ITM-10080966","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","831.65","36.5","","1023.42","771.29","2068.67","33","706.34","1811.41","percent of total billed charges",""
"ACETABULAR CUP 32X53MM STEM LONGEVITY SS WIRE CEMENTED NEUTRAL","SUP-ITM-10080966","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","872.67","38.3","","850.52","759.78","1211.25","66","706.34","1811.41","percent of total billed charges",""
"ACETABULAR CUP 32X53MM STEM LONGEVITY SS WIRE CEMENTED NEUTRAL","SUP-ITM-10080966","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","977.48","42.9","","2548.09","2548.09","2548.09","1 through 10","706.34","1811.41","percent of total billed charges",""
"ACETABULAR CUP 32X53MM STEM LONGEVITY SS WIRE CEMENTED NEUTRAL","SUP-ITM-10080966","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","977.48","42.9","","956.46","956.46","956.46","1 through 10","706.34","1811.41","percent of total billed charges",""
"ACETABULAR CUP 32X53MM STEM LONGEVITY SS WIRE CEMENTED NEUTRAL","SUP-ITM-10080966","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","WELLPOINT [1015]","HB AMC WELLPOINT","1681.08","73.78","","2344.73","1619.47","2530.35","16","706.34","1811.41","percent of total billed charges",""
"ACETABULAR CUP 32X53MM STEM LONGEVITY SS WIRE CEMENTED NEUTRAL","SUP-ITM-10080966","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2278.50","1708.87","AETNA [1001]","HB AMC AETNA HMO","1590.39","69.8","","1523.63","988.41","4330.26","39","1190.74","1861.99","percent of total billed charges",""
"ACETABULAR CUP 32X53MM STEM LONGEVITY SS WIRE CEMENTED NEUTRAL","SUP-ITM-10080966","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2278.50","1708.87","AETNA [1001]","HB AMC AETNA PPO","1831.91","80.4","","1670.25","1670.25","1670.25","1 through 10","1190.74","1861.99","percent of total billed charges",""
"ACETABULAR CUP 32X53MM STEM LONGEVITY SS WIRE CEMENTED NEUTRAL","SUP-ITM-10080966","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2278.50","1708.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1190.74","52.26","","1113.10","1113.10","1113.10","1 through 10","1190.74","1861.99","percent of total billed charges",""
"ACETABULAR CUP 32X53MM STEM LONGEVITY SS WIRE CEMENTED NEUTRAL","SUP-ITM-10080966","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2278.50","1708.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1861.99","81.72","","1738.90","1484.65","2716.94","38","1190.74","1861.99","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2509.50","1882.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1311.46","52.26","","1113.10","1113.10","1113.10","1 through 10","777.95","1995.05","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2509.50","1882.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1995.05","79.5","","1293.60","1148.53","1603.80","1 through 10","777.95","1995.05","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2509.50","1882.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","915.97","36.5","","1023.42","771.29","2068.67","33","777.95","1995.05","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2509.50","1882.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","961.14","38.3","","850.52","759.78","1211.25","66","777.95","1995.05","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2509.50","1882.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1076.58","42.9","","2548.09","2548.09","2548.09","1 through 10","777.95","1995.05","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2509.50","1882.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1076.58","42.9","","956.46","956.46","956.46","1 through 10","777.95","1995.05","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2509.50","1882.12","WELLPOINT [1015]","HB AMC WELLPOINT","1851.51","73.78","","2344.73","1619.47","2530.35","16","777.95","1995.05","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2509.50","1882.12","AETNA [1001]","HB AMC AETNA HMO","1751.63","69.8","","1523.63","988.41","4330.26","39","1311.46","2050.76","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2509.50","1882.12","AETNA [1001]","HB AMC AETNA PPO","2017.64","80.4","","1670.25","1670.25","1670.25","1 through 10","1311.46","2050.76","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2509.50","1882.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1311.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1311.46","2050.76","percent of total billed charges",""
"ACETABULAR CUP 42X32MM PROSTALAC POLYETHYLENE CEMENTED","SUP-ITM-10119416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2509.50","1882.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2050.76","81.72","","1738.90","1484.65","2716.94","38","1311.46","2050.76","percent of total billed charges",""
"ACETABULAR CUP 48MM SIZE 22 REVISION REGENEREX/RNGLC+ SOLID 08","SUP-ITM-10029401","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR CUP 48MM SIZE 22 REVISION REGENEREX/RNGLC+ SOLID 08","SUP-ITM-10029401","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2504.25","79.5","","1293.60","1148.53","1603.80","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR CUP 48MM SIZE 22 REVISION REGENEREX/RNGLC+ SOLID 08","SUP-ITM-10029401","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1149.75","36.5","","1023.42","771.29","2068.67","33","976.5","2504.25","percent of total billed charges",""
"ACETABULAR CUP 48MM SIZE 22 REVISION REGENEREX/RNGLC+ SOLID 08","SUP-ITM-10029401","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1206.45","38.3","","850.52","759.78","1211.25","66","976.5","2504.25","percent of total billed charges",""
"ACETABULAR CUP 48MM SIZE 22 REVISION REGENEREX/RNGLC+ SOLID 08","SUP-ITM-10029401","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","2548.09","2548.09","2548.09","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR CUP 48MM SIZE 22 REVISION REGENEREX/RNGLC+ SOLID 08","SUP-ITM-10029401","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","956.46","956.46","956.46","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR CUP 48MM SIZE 22 REVISION REGENEREX/RNGLC+ SOLID 08","SUP-ITM-10029401","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","WELLPOINT [1015]","HB AMC WELLPOINT","2324.07","73.78","","2344.73","1619.47","2530.35","16","976.5","2504.25","percent of total billed charges",""
"ACETABULAR CUP 48MM SIZE 22 REVISION REGENEREX/RNGLC+ SOLID 08","SUP-ITM-10029401","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA HMO","2198.70","69.8","","1523.63","988.41","4330.26","39","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR CUP 48MM SIZE 22 REVISION REGENEREX/RNGLC+ SOLID 08","SUP-ITM-10029401","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA PPO","2532.60","80.4","","1670.25","1670.25","1670.25","1 through 10","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR CUP 48MM SIZE 22 REVISION REGENEREX/RNGLC+ SOLID 08","SUP-ITM-10029401","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR CUP 48MM SIZE 22 REVISION REGENEREX/RNGLC+ SOLID 08","SUP-ITM-10029401","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2574.18","81.72","","1738.90","1484.65","2716.94","38","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","both","","","6842.50","5131.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3575.89","52.26","","1113.10","1113.10","1113.10","1 through 10","2121.18","5439.79","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","both","","","6842.50","5131.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5439.79","79.5","","1293.60","1148.53","1603.80","1 through 10","2121.18","5439.79","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","both","","","6842.50","5131.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2497.51","36.5","","1023.42","771.29","2068.67","33","2121.18","5439.79","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","both","","","6842.50","5131.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2620.68","38.3","","850.52","759.78","1211.25","66","2121.18","5439.79","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","both","","","6842.50","5131.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2935.43","42.9","","2548.09","2548.09","2548.09","1 through 10","2121.18","5439.79","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","both","","","6842.50","5131.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2935.43","42.9","","956.46","956.46","956.46","1 through 10","2121.18","5439.79","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","both","","","6842.50","5131.87","WELLPOINT [1015]","HB AMC WELLPOINT","5048.40","73.78","","2344.73","1619.47","2530.35","16","2121.18","5439.79","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6842.50","5131.87","AETNA [1001]","HB AMC AETNA HMO","4776.07","69.8","","1523.63","988.41","4330.26","39","3575.89","5591.69","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6842.50","5131.87","AETNA [1001]","HB AMC AETNA PPO","5501.37","80.4","","1670.25","1670.25","1670.25","1 through 10","3575.89","5591.69","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6842.50","5131.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3575.89","52.26","","1113.10","1113.10","1113.10","1 through 10","3575.89","5591.69","percent of total billed charges",""
"ACETABULAR CUP 56MM BIRMINGHAM RESURFACING COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6842.50","5131.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5591.69","81.72","","1738.90","1484.65","2716.94","38","3575.89","5591.69","percent of total billed charges",""
"ACETABULAR CUP 60MM SIZE 25 REGENEREX RINGLOC PLUS TITANIUM POROUS MULTIHOLE","SUP-ITM-10025572","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR CUP 60MM SIZE 25 REGENEREX RINGLOC PLUS TITANIUM POROUS MULTIHOLE","SUP-ITM-10025572","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3213.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR CUP 60MM SIZE 25 REGENEREX RINGLOC PLUS TITANIUM POROUS MULTIHOLE","SUP-ITM-10025572","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.51","36.5","","1023.42","771.29","2068.67","33","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR CUP 60MM SIZE 25 REGENEREX RINGLOC PLUS TITANIUM POROUS MULTIHOLE","SUP-ITM-10025572","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.28","38.3","","850.52","759.78","1211.25","66","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR CUP 60MM SIZE 25 REGENEREX RINGLOC PLUS TITANIUM POROUS MULTIHOLE","SUP-ITM-10025572","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR CUP 60MM SIZE 25 REGENEREX RINGLOC PLUS TITANIUM POROUS MULTIHOLE","SUP-ITM-10025572","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","956.46","956.46","956.46","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR CUP 60MM SIZE 25 REGENEREX RINGLOC PLUS TITANIUM POROUS MULTIHOLE","SUP-ITM-10025572","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","WELLPOINT [1015]","HB AMC WELLPOINT","2982.56","73.78","","2344.73","1619.47","2530.35","16","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR CUP 60MM SIZE 25 REGENEREX RINGLOC PLUS TITANIUM POROUS MULTIHOLE","SUP-ITM-10025572","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA HMO","2821.67","69.8","","1523.63","988.41","4330.26","39","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR CUP 60MM SIZE 25 REGENEREX RINGLOC PLUS TITANIUM POROUS MULTIHOLE","SUP-ITM-10025572","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA PPO","3250.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR CUP 60MM SIZE 25 REGENEREX RINGLOC PLUS TITANIUM POROUS MULTIHOLE","SUP-ITM-10025572","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR CUP 60MM SIZE 25 REGENEREX RINGLOC PLUS TITANIUM POROUS MULTIHOLE","SUP-ITM-10025572","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.53","81.72","","1738.90","1484.65","2716.94","38","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR INSERT 10DEG SZ P3 32MM SYS 12 CROSSFIRE","SUP-ITM-10011743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","638.36","52.26","","1113.10","1113.10","1113.10","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 10DEG SZ P3 32MM SYS 12 CROSSFIRE","SUP-ITM-10011743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","971.09","79.5","","1293.60","1148.53","1603.80","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 10DEG SZ P3 32MM SYS 12 CROSSFIRE","SUP-ITM-10011743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","445.85","36.5","","1023.42","771.29","2068.67","33","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 10DEG SZ P3 32MM SYS 12 CROSSFIRE","SUP-ITM-10011743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","467.83","38.3","","850.52","759.78","1211.25","66","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 10DEG SZ P3 32MM SYS 12 CROSSFIRE","SUP-ITM-10011743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","524.02","42.9","","2548.09","2548.09","2548.09","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 10DEG SZ P3 32MM SYS 12 CROSSFIRE","SUP-ITM-10011743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","524.02","42.9","","956.46","956.46","956.46","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 10DEG SZ P3 32MM SYS 12 CROSSFIRE","SUP-ITM-10011743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","WELLPOINT [1015]","HB AMC WELLPOINT","901.22","73.78","","2344.73","1619.47","2530.35","16","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 10DEG SZ P3 32MM SYS 12 CROSSFIRE","SUP-ITM-10011743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","AETNA [1001]","HB AMC AETNA HMO","852.61","69.8","","1523.63","988.41","4330.26","39","638.36","998.21","percent of total billed charges",""
"ACETABULAR INSERT 10DEG SZ P3 32MM SYS 12 CROSSFIRE","SUP-ITM-10011743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","AETNA [1001]","HB AMC AETNA PPO","982.09","80.4","","1670.25","1670.25","1670.25","1 through 10","638.36","998.21","percent of total billed charges",""
"ACETABULAR INSERT 10DEG SZ P3 32MM SYS 12 CROSSFIRE","SUP-ITM-10011743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","638.36","52.26","","1113.10","1113.10","1113.10","1 through 10","638.36","998.21","percent of total billed charges",""
"ACETABULAR INSERT 10DEG SZ P3 32MM SYS 12 CROSSFIRE","SUP-ITM-10011743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","998.21","81.72","","1738.90","1484.65","2716.94","38","638.36","998.21","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1280.37","52.26","","1113.10","1113.10","1113.10","1 through 10","759.5","1947.75","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","1293.60","1148.53","1603.80","1 through 10","759.5","1947.75","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","1023.42","771.29","2068.67","33","759.5","1947.75","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","850.52","759.78","1211.25","66","759.5","1947.75","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","2548.09","2548.09","2548.09","1 through 10","759.5","1947.75","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","956.46","956.46","956.46","1 through 10","759.5","1947.75","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","2344.73","1619.47","2530.35","16","759.5","1947.75","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","1523.63","988.41","4330.26","39","1280.37","2002.14","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA PPO","1969.80","80.4","","1670.25","1670.25","1670.25","1 through 10","1280.37","2002.14","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1280.37","52.26","","1113.10","1113.10","1113.10","1 through 10","1280.37","2002.14","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","1738.90","1484.65","2716.94","38","1280.37","2002.14","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3213.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.51","36.5","","1023.42","771.29","2068.67","33","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.28","38.3","","850.52","759.78","1211.25","66","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","956.46","956.46","956.46","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","WELLPOINT [1015]","HB AMC WELLPOINT","2982.56","73.78","","2344.73","1619.47","2530.35","16","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA HMO","2821.67","69.8","","1523.63","988.41","4330.26","39","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA PPO","3250.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.53","81.72","","1738.90","1484.65","2716.94","38","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR INSERT 32MM 0DEG SIZE B TRIDENT POLYETHYLENE","SUP-ITM-10089665","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1006.01","52.26","","1113.10","1113.10","1113.10","1 through 10","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 0DEG SIZE B TRIDENT POLYETHYLENE","SUP-ITM-10089665","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1530.38","79.5","","1293.60","1148.53","1603.80","1 through 10","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 0DEG SIZE B TRIDENT POLYETHYLENE","SUP-ITM-10089665","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","702.63","36.5","","1023.42","771.29","2068.67","33","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 0DEG SIZE B TRIDENT POLYETHYLENE","SUP-ITM-10089665","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","737.28","38.3","","850.52","759.78","1211.25","66","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 0DEG SIZE B TRIDENT POLYETHYLENE","SUP-ITM-10089665","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","2548.09","2548.09","2548.09","1 through 10","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 0DEG SIZE B TRIDENT POLYETHYLENE","SUP-ITM-10089665","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","956.46","956.46","956.46","1 through 10","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 0DEG SIZE B TRIDENT POLYETHYLENE","SUP-ITM-10089665","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","WELLPOINT [1015]","HB AMC WELLPOINT","1420.27","73.78","","2344.73","1619.47","2530.35","16","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 0DEG SIZE B TRIDENT POLYETHYLENE","SUP-ITM-10089665","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA HMO","1343.65","69.8","","1523.63","988.41","4330.26","39","1006.01","1573.11","percent of total billed charges",""
"ACETABULAR INSERT 32MM 0DEG SIZE B TRIDENT POLYETHYLENE","SUP-ITM-10089665","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA PPO","1547.70","80.4","","1670.25","1670.25","1670.25","1 through 10","1006.01","1573.11","percent of total billed charges",""
"ACETABULAR INSERT 32MM 0DEG SIZE B TRIDENT POLYETHYLENE","SUP-ITM-10089665","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1006.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1006.01","1573.11","percent of total billed charges",""
"ACETABULAR INSERT 32MM 0DEG SIZE B TRIDENT POLYETHYLENE","SUP-ITM-10089665","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1573.11","81.72","","1738.90","1484.65","2716.94","38","1006.01","1573.11","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1006.01","52.26","","1113.10","1113.10","1113.10","1 through 10","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1530.38","79.5","","1293.60","1148.53","1603.80","1 through 10","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","702.63","36.5","","1023.42","771.29","2068.67","33","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","737.28","38.3","","850.52","759.78","1211.25","66","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","2548.09","2548.09","2548.09","1 through 10","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","956.46","956.46","956.46","1 through 10","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","WELLPOINT [1015]","HB AMC WELLPOINT","1420.27","73.78","","2344.73","1619.47","2530.35","16","596.75","1530.38","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA HMO","1343.65","69.8","","1523.63","988.41","4330.26","39","1006.01","1573.11","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA PPO","1547.70","80.4","","1670.25","1670.25","1670.25","1 through 10","1006.01","1573.11","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1006.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1006.01","1573.11","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1573.11","81.72","","1738.90","1484.65","2716.94","38","1006.01","1573.11","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1401.09","52.26","","1113.10","1113.10","1113.10","1 through 10","831.11","2131.4","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2131.40","79.5","","1293.60","1148.53","1603.80","1 through 10","831.11","2131.4","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","978.57","36.5","","1023.42","771.29","2068.67","33","831.11","2131.4","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1026.82","38.3","","850.52","759.78","1211.25","66","831.11","2131.4","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.15","42.9","","2548.09","2548.09","2548.09","1 through 10","831.11","2131.4","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.15","42.9","","956.46","956.46","956.46","1 through 10","831.11","2131.4","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","WELLPOINT [1015]","HB AMC WELLPOINT","1978.04","73.78","","2344.73","1619.47","2530.35","16","831.11","2131.4","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2681.00","2010.75","AETNA [1001]","HB AMC AETNA HMO","1871.34","69.8","","1523.63","988.41","4330.26","39","1401.09","2190.91","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2681.00","2010.75","AETNA [1001]","HB AMC AETNA PPO","2155.52","80.4","","1670.25","1670.25","1670.25","1 through 10","1401.09","2190.91","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1401.09","52.26","","1113.10","1113.10","1113.10","1 through 10","1401.09","2190.91","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2681.00","2010.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2190.91","81.72","","1738.90","1484.65","2716.94","38","1401.09","2190.91","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","638.36","52.26","","1113.10","1113.10","1113.10","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","971.09","79.5","","1293.60","1148.53","1603.80","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","445.85","36.5","","1023.42","771.29","2068.67","33","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","467.83","38.3","","850.52","759.78","1211.25","66","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","524.02","42.9","","2548.09","2548.09","2548.09","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","524.02","42.9","","956.46","956.46","956.46","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","WELLPOINT [1015]","HB AMC WELLPOINT","901.22","73.78","","2344.73","1619.47","2530.35","16","378.67","971.09","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","AETNA [1001]","HB AMC AETNA HMO","852.61","69.8","","1523.63","988.41","4330.26","39","638.36","998.21","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","AETNA [1001]","HB AMC AETNA PPO","982.09","80.4","","1670.25","1670.25","1670.25","1 through 10","638.36","998.21","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","638.36","52.26","","1113.10","1113.10","1113.10","1 through 10","638.36","998.21","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","998.21","81.72","","1738.90","1484.65","2716.94","38","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 28X44MM SIZE EE VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114227","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1402.01","52.26","","1113.10","1113.10","1113.10","1 through 10","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X44MM SIZE EE VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114227","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2132.79","79.5","","1293.60","1148.53","1603.80","1 through 10","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X44MM SIZE EE VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114227","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","979.20","36.5","","1023.42","771.29","2068.67","33","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X44MM SIZE EE VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114227","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1027.49","38.3","","850.52","759.78","1211.25","66","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X44MM SIZE EE VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114227","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.90","42.9","","2548.09","2548.09","2548.09","1 through 10","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X44MM SIZE EE VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114227","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.90","42.9","","956.46","956.46","956.46","1 through 10","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X44MM SIZE EE VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114227","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","WELLPOINT [1015]","HB AMC WELLPOINT","1979.33","73.78","","2344.73","1619.47","2530.35","16","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X44MM SIZE EE VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2682.75","2012.06","AETNA [1001]","HB AMC AETNA HMO","1872.56","69.8","","1523.63","988.41","4330.26","39","1402.01","2192.34","percent of total billed charges",""
"ACETABULAR LINER 28X44MM SIZE EE VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2682.75","2012.06","AETNA [1001]","HB AMC AETNA PPO","2156.93","80.4","","1670.25","1670.25","1670.25","1 through 10","1402.01","2192.34","percent of total billed charges",""
"ACETABULAR LINER 28X44MM SIZE EE VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2682.75","2012.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1402.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1402.01","2192.34","percent of total billed charges",""
"ACETABULAR LINER 28X44MM SIZE EE VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL","SUP-ITM-10114227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2682.75","2012.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2192.34","81.72","","1738.90","1484.65","2716.94","38","1402.01","2192.34","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1221.50","916.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","638.36","52.26","","25.34","25.34","25.34","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1221.50","916.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","877.04","71.8","","105.81","105.81","366.90","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1221.50","916.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","855.05","70","","512.90","74.70","612.85","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1221.50","916.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","971.09","79.5","","200.27","182.80","200.27","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1221.50","916.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","651.06","53.3","","37.73","37.73","169.33","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1221.50","916.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","793.98","65","","100.27","8.48","494.52","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1221.50","916.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","793.98","65","","160.19","160.19","160.19","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1221.50","916.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","378.67","31","","28.12","28.12","28.12","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1221.50","916.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","445.85","36.5","","101.66","28.85","502.70","121","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1221.50","916.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","467.83","38.3","","61.58","25.32","328.44","138","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1221.50","916.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","524.02","42.9","","71.66","71.66","71.66","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1221.50","916.12","WELLPOINT [1015]","HB AMC WELLPOINT","901.22","73.78","","74.75","27.97","425.28","93","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1221.50","916.12","AETNA [1001]","HB AMC AETNA HMO","852.61","69.8","","52.67","14.36","414.90","1 through 10","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1221.50","916.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","638.36","52.26","","25.34","25.34","25.34","1 through 10","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1221.50","916.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","982.09","80.4","","478.02","107.84","478.02","1 through 10","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1221.50","916.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","998.21","81.72","","32.74","12.33","122.05","1 through 10","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1221.50","916.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","998.21","81.72","","144.95","32.78","676.91","104","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1402.01","52.26","","1113.10","1113.10","1113.10","1 through 10","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2132.79","79.5","","1293.60","1148.53","1603.80","1 through 10","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","979.20","36.5","","1023.42","771.29","2068.67","33","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1027.49","38.3","","850.52","759.78","1211.25","66","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.90","42.9","","2548.09","2548.09","2548.09","1 through 10","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.90","42.9","","956.46","956.46","956.46","1 through 10","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","WELLPOINT [1015]","HB AMC WELLPOINT","1979.33","73.78","","2344.73","1619.47","2530.35","16","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2682.75","2012.06","AETNA [1001]","HB AMC AETNA HMO","1872.56","69.8","","1523.63","988.41","4330.26","39","1402.01","2192.34","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2682.75","2012.06","AETNA [1001]","HB AMC AETNA PPO","2156.93","80.4","","1670.25","1670.25","1670.25","1 through 10","1402.01","2192.34","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2682.75","2012.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1402.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1402.01","2192.34","percent of total billed charges",""
"ACETABULAR LINER 28X46MM SIZE EF VAVACIT E HIGHLY CROSSLINKED POLYETHYLENE VITAMIN NEUTRAL FF","SUP-ITM-10114228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2682.75","2012.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2192.34","81.72","","1738.90","1484.65","2716.94","38","1402.01","2192.34","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1401.09","52.26","","1113.10","1113.10","1113.10","1 through 10","831.11","2131.4","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2131.40","79.5","","1293.60","1148.53","1603.80","1 through 10","831.11","2131.4","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","978.57","36.5","","1023.42","771.29","2068.67","33","831.11","2131.4","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1026.82","38.3","","850.52","759.78","1211.25","66","831.11","2131.4","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.15","42.9","","2548.09","2548.09","2548.09","1 through 10","831.11","2131.4","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.15","42.9","","956.46","956.46","956.46","1 through 10","831.11","2131.4","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","WELLPOINT [1015]","HB AMC WELLPOINT","1978.04","73.78","","2344.73","1619.47","2530.35","16","831.11","2131.4","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2681.00","2010.75","AETNA [1001]","HB AMC AETNA HMO","1871.34","69.8","","1523.63","988.41","4330.26","39","1401.09","2190.91","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2681.00","2010.75","AETNA [1001]","HB AMC AETNA PPO","2155.52","80.4","","1670.25","1670.25","1670.25","1 through 10","1401.09","2190.91","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1401.09","52.26","","1113.10","1113.10","1113.10","1 through 10","1401.09","2190.91","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2681.00","2010.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2190.91","81.72","","1738.90","1484.65","2716.94","38","1401.09","2190.91","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2508.48","52.26","","1113.10","1113.10","1113.10","1 through 10","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3816.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1752.00","36.5","","1023.42","771.29","2068.67","33","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1838.40","38.3","","850.52","759.78","1211.25","66","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","2548.09","2548.09","2548.09","1 through 10","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","956.46","956.46","956.46","1 through 10","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","WELLPOINT [1015]","HB AMC WELLPOINT","3541.44","73.78","","2344.73","1619.47","2530.35","16","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA HMO","3350.40","69.8","","1523.63","988.41","4330.26","39","2508.48","3922.56","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA PPO","3859.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2508.48","3922.56","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2508.48","52.26","","1113.10","1113.10","1113.10","1 through 10","2508.48","3922.56","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3922.56","81.72","","1738.90","1484.65","2716.94","38","2508.48","3922.56","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","638.36","52.26","","1113.10","1113.10","1113.10","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","971.09","79.5","","1293.60","1148.53","1603.80","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","445.85","36.5","","1023.42","771.29","2068.67","33","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","467.83","38.3","","850.52","759.78","1211.25","66","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","524.02","42.9","","2548.09","2548.09","2548.09","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","524.02","42.9","","956.46","956.46","956.46","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","WELLPOINT [1015]","HB AMC WELLPOINT","901.22","73.78","","2344.73","1619.47","2530.35","16","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","AETNA [1001]","HB AMC AETNA HMO","852.61","69.8","","1523.63","988.41","4330.26","39","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","AETNA [1001]","HB AMC AETNA PPO","982.09","80.4","","1670.25","1670.25","1670.25","1 through 10","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","638.36","52.26","","1113.10","1113.10","1113.10","1 through 10","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","998.21","81.72","","1738.90","1484.65","2716.94","38","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","638.36","52.26","","1113.10","1113.10","1113.10","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","971.09","79.5","","1293.60","1148.53","1603.80","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","445.85","36.5","","1023.42","771.29","2068.67","33","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","467.83","38.3","","850.52","759.78","1211.25","66","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","524.02","42.9","","2548.09","2548.09","2548.09","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","524.02","42.9","","956.46","956.46","956.46","1 through 10","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1221.50","916.12","WELLPOINT [1015]","HB AMC WELLPOINT","901.22","73.78","","2344.73","1619.47","2530.35","16","378.67","971.09","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","AETNA [1001]","HB AMC AETNA HMO","852.61","69.8","","1523.63","988.41","4330.26","39","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","AETNA [1001]","HB AMC AETNA PPO","982.09","80.4","","1670.25","1670.25","1670.25","1 through 10","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","638.36","52.26","","1113.10","1113.10","1113.10","1 through 10","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1221.50","916.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","998.21","81.72","","1738.90","1484.65","2716.94","38","638.36","998.21","percent of total billed charges",""
"ACETABULAR LINER 40MM 3.0 SIZE 25 IMPLANT EPOLY RINGLOC PLUS 3 11","SUP-ITM-10077178","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1335.24","52.26","","1113.10","1113.10","1113.10","1 through 10","792.05","2031.23","percent of total billed charges",""
"ACETABULAR LINER 40MM 3.0 SIZE 25 IMPLANT EPOLY RINGLOC PLUS 3 11","SUP-ITM-10077178","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2031.23","79.5","","1293.60","1148.53","1603.80","1 through 10","792.05","2031.23","percent of total billed charges",""
"ACETABULAR LINER 40MM 3.0 SIZE 25 IMPLANT EPOLY RINGLOC PLUS 3 11","SUP-ITM-10077178","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","932.58","36.5","","1023.42","771.29","2068.67","33","792.05","2031.23","percent of total billed charges",""
"ACETABULAR LINER 40MM 3.0 SIZE 25 IMPLANT EPOLY RINGLOC PLUS 3 11","SUP-ITM-10077178","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","978.57","38.3","","850.52","759.78","1211.25","66","792.05","2031.23","percent of total billed charges",""
"ACETABULAR LINER 40MM 3.0 SIZE 25 IMPLANT EPOLY RINGLOC PLUS 3 11","SUP-ITM-10077178","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1096.10","42.9","","2548.09","2548.09","2548.09","1 through 10","792.05","2031.23","percent of total billed charges",""
"ACETABULAR LINER 40MM 3.0 SIZE 25 IMPLANT EPOLY RINGLOC PLUS 3 11","SUP-ITM-10077178","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1096.10","42.9","","956.46","956.46","956.46","1 through 10","792.05","2031.23","percent of total billed charges",""
"ACETABULAR LINER 40MM 3.0 SIZE 25 IMPLANT EPOLY RINGLOC PLUS 3 11","SUP-ITM-10077178","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","WELLPOINT [1015]","HB AMC WELLPOINT","1885.08","73.78","","2344.73","1619.47","2530.35","16","792.05","2031.23","percent of total billed charges",""
"ACETABULAR LINER 40MM 3.0 SIZE 25 IMPLANT EPOLY RINGLOC PLUS 3 11","SUP-ITM-10077178","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","AETNA [1001]","HB AMC AETNA HMO","1783.39","69.8","","1523.63","988.41","4330.26","39","1335.24","2087.95","percent of total billed charges",""
"ACETABULAR LINER 40MM 3.0 SIZE 25 IMPLANT EPOLY RINGLOC PLUS 3 11","SUP-ITM-10077178","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","AETNA [1001]","HB AMC AETNA PPO","2054.22","80.4","","1670.25","1670.25","1670.25","1 through 10","1335.24","2087.95","percent of total billed charges",""
"ACETABULAR LINER 40MM 3.0 SIZE 25 IMPLANT EPOLY RINGLOC PLUS 3 11","SUP-ITM-10077178","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1335.24","52.26","","1113.10","1113.10","1113.10","1 through 10","1335.24","2087.95","percent of total billed charges",""
"ACETABULAR LINER 40MM 3.0 SIZE 25 IMPLANT EPOLY RINGLOC PLUS 3 11","SUP-ITM-10077178","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2087.95","81.72","","1738.90","1484.65","2716.94","38","1335.24","2087.95","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1857.18","52.26","","1113.10","1113.10","1113.10","1 through 10","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2825.22","79.5","","1293.60","1148.53","1603.80","1 through 10","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1297.11","36.5","","1023.42","771.29","2068.67","33","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1361.08","38.3","","850.52","759.78","1211.25","66","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1524.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1524.55","42.9","","956.46","956.46","956.46","1 through 10","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","WELLPOINT [1015]","HB AMC WELLPOINT","2621.94","73.78","","2344.73","1619.47","2530.35","16","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3553.73","2665.30","AETNA [1001]","HB AMC AETNA HMO","2480.50","69.8","","1523.63","988.41","4330.26","39","1857.18","2904.11","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3553.73","2665.30","AETNA [1001]","HB AMC AETNA PPO","2857.20","80.4","","1670.25","1670.25","1670.25","1 through 10","1857.18","2904.11","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3553.73","2665.30","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1857.18","52.26","","1113.10","1113.10","1113.10","1 through 10","1857.18","2904.11","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3553.73","2665.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2904.11","81.72","","1738.90","1484.65","2716.94","38","1857.18","2904.11","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2508.48","52.26","","1113.10","1113.10","1113.10","1 through 10","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3816.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1752.00","36.5","","1023.42","771.29","2068.67","33","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1838.40","38.3","","850.52","759.78","1211.25","66","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","2548.09","2548.09","2548.09","1 through 10","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","956.46","956.46","956.46","1 through 10","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","WELLPOINT [1015]","HB AMC WELLPOINT","3541.44","73.78","","2344.73","1619.47","2530.35","16","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA HMO","3350.40","69.8","","1523.63","988.41","4330.26","39","2508.48","3922.56","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA PPO","3859.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2508.48","3922.56","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2508.48","52.26","","1113.10","1113.10","1113.10","1 through 10","2508.48","3922.56","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3922.56","81.72","","1738.90","1484.65","2716.94","38","2508.48","3922.56","percent of total billed charges",""
"ACETABULAR LINER 44/58 OR3O DUAL MOBILITY","SUP-ITM-10280249","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2508.48","52.26","","1113.10","1113.10","1113.10","1 through 10","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/58 OR3O DUAL MOBILITY","SUP-ITM-10280249","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3816.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/58 OR3O DUAL MOBILITY","SUP-ITM-10280249","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1752.00","36.5","","1023.42","771.29","2068.67","33","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/58 OR3O DUAL MOBILITY","SUP-ITM-10280249","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1838.40","38.3","","850.52","759.78","1211.25","66","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/58 OR3O DUAL MOBILITY","SUP-ITM-10280249","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","2548.09","2548.09","2548.09","1 through 10","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/58 OR3O DUAL MOBILITY","SUP-ITM-10280249","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","956.46","956.46","956.46","1 through 10","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/58 OR3O DUAL MOBILITY","SUP-ITM-10280249","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","WELLPOINT [1015]","HB AMC WELLPOINT","3541.44","73.78","","2344.73","1619.47","2530.35","16","1488","3816","percent of total billed charges",""
"ACETABULAR LINER 44/58 OR3O DUAL MOBILITY","SUP-ITM-10280249","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA HMO","3350.40","69.8","","1523.63","988.41","4330.26","39","2508.48","3922.56","percent of total billed charges",""
"ACETABULAR LINER 44/58 OR3O DUAL MOBILITY","SUP-ITM-10280249","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA PPO","3859.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2508.48","3922.56","percent of total billed charges",""
"ACETABULAR LINER 44/58 OR3O DUAL MOBILITY","SUP-ITM-10280249","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2508.48","52.26","","1113.10","1113.10","1113.10","1 through 10","2508.48","3922.56","percent of total billed charges",""
"ACETABULAR LINER 44/58 OR3O DUAL MOBILITY","SUP-ITM-10280249","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3922.56","81.72","","1738.90","1484.65","2716.94","38","2508.48","3922.56","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1857.18","52.26","","1113.10","1113.10","1113.10","1 through 10","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2825.22","79.5","","1293.60","1148.53","1603.80","1 through 10","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1297.11","36.5","","1023.42","771.29","2068.67","33","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1361.08","38.3","","850.52","759.78","1211.25","66","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1524.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1524.55","42.9","","956.46","956.46","956.46","1 through 10","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","WELLPOINT [1015]","HB AMC WELLPOINT","2621.94","73.78","","2344.73","1619.47","2530.35","16","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3553.73","2665.30","AETNA [1001]","HB AMC AETNA HMO","2480.50","69.8","","1523.63","988.41","4330.26","39","1857.18","2904.11","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3553.73","2665.30","AETNA [1001]","HB AMC AETNA PPO","2857.20","80.4","","1670.25","1670.25","1670.25","1 through 10","1857.18","2904.11","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3553.73","2665.30","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1857.18","52.26","","1113.10","1113.10","1113.10","1 through 10","1857.18","2904.11","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3553.73","2665.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2904.11","81.72","","1738.90","1484.65","2716.94","38","1857.18","2904.11","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1471.15","52.26","","1113.10","1113.10","1113.10","1 through 10","872.67","2237.96","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2237.96","79.5","","1293.60","1148.53","1603.80","1 through 10","872.67","2237.96","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1027.49","36.5","","1023.42","771.29","2068.67","33","872.67","2237.96","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1078.16","38.3","","850.52","759.78","1211.25","66","872.67","2237.96","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1207.66","42.9","","2548.09","2548.09","2548.09","1 through 10","872.67","2237.96","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1207.66","42.9","","956.46","956.46","956.46","1 through 10","872.67","2237.96","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","WELLPOINT [1015]","HB AMC WELLPOINT","2076.94","73.78","","2344.73","1619.47","2530.35","16","872.67","2237.96","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2815.05","2111.29","AETNA [1001]","HB AMC AETNA HMO","1964.90","69.8","","1523.63","988.41","4330.26","39","1471.15","2300.46","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2815.05","2111.29","AETNA [1001]","HB AMC AETNA PPO","2263.30","80.4","","1670.25","1670.25","1670.25","1 through 10","1471.15","2300.46","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2815.05","2111.29","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1471.15","52.26","","1113.10","1113.10","1113.10","1 through 10","1471.15","2300.46","percent of total billed charges",""
"ACETABULAR LINER 50 52 54X28MM TRILOGY LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED RING","SUP-ITM-10023153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2815.05","2111.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2300.46","81.72","","1738.90","1484.65","2716.94","38","1471.15","2300.46","percent of total billed charges",""
"ACETABULAR LINER 54MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10194228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1857.18","52.26","","1113.10","1113.10","1113.10","1 through 10","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 54MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10194228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2825.22","79.5","","1293.60","1148.53","1603.80","1 through 10","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 54MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10194228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1297.11","36.5","","1023.42","771.29","2068.67","33","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 54MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10194228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1361.08","38.3","","850.52","759.78","1211.25","66","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 54MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10194228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1524.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 54MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10194228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1524.55","42.9","","956.46","956.46","956.46","1 through 10","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 54MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10194228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3553.73","2665.30","WELLPOINT [1015]","HB AMC WELLPOINT","2621.94","73.78","","2344.73","1619.47","2530.35","16","1101.66","2825.22","percent of total billed charges",""
"ACETABULAR LINER 54MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10194228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3553.73","2665.30","AETNA [1001]","HB AMC AETNA HMO","2480.50","69.8","","1523.63","988.41","4330.26","39","1857.18","2904.11","percent of total billed charges",""
"ACETABULAR LINER 54MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10194228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3553.73","2665.30","AETNA [1001]","HB AMC AETNA PPO","2857.20","80.4","","1670.25","1670.25","1670.25","1 through 10","1857.18","2904.11","percent of total billed charges",""
"ACETABULAR LINER 54MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10194228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3553.73","2665.30","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1857.18","52.26","","1113.10","1113.10","1113.10","1 through 10","1857.18","2904.11","percent of total billed charges",""
"ACETABULAR LINER 54MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10194228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3553.73","2665.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2904.11","81.72","","1738.90","1484.65","2716.94","38","1857.18","2904.11","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1402.01","52.26","","1113.10","1113.10","1113.10","1 through 10","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2132.79","79.5","","1293.60","1148.53","1603.80","1 through 10","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","979.20","36.5","","1023.42","771.29","2068.67","33","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1027.49","38.3","","850.52","759.78","1211.25","66","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.90","42.9","","2548.09","2548.09","2548.09","1 through 10","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.90","42.9","","956.46","956.46","956.46","1 through 10","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","both","","","2682.75","2012.06","WELLPOINT [1015]","HB AMC WELLPOINT","1979.33","73.78","","2344.73","1619.47","2530.35","16","831.65","2132.79","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2682.75","2012.06","AETNA [1001]","HB AMC AETNA HMO","1872.56","69.8","","1523.63","988.41","4330.26","39","1402.01","2192.34","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2682.75","2012.06","AETNA [1001]","HB AMC AETNA PPO","2156.93","80.4","","1670.25","1670.25","1670.25","1 through 10","1402.01","2192.34","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2682.75","2012.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1402.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1402.01","2192.34","percent of total billed charges",""
"ACETABULAR LINER 54MMX28 BEARING ACTIVE ARTICULATION E1","SUP-ITM-10194229","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2682.75","2012.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2192.34","81.72","","1738.90","1484.65","2716.94","38","1402.01","2192.34","percent of total billed charges",""
"ACETABULAR LINER 54X47MM PINNACLE DUAL MOBILITY","SUP-ITM-10282793","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2286.38","52.26","","1113.10","1113.10","1113.10","1 through 10","1356.25","3478.13","percent of total billed charges",""
"ACETABULAR LINER 54X47MM PINNACLE DUAL MOBILITY","SUP-ITM-10282793","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3478.13","79.5","","1293.60","1148.53","1603.80","1 through 10","1356.25","3478.13","percent of total billed charges",""
"ACETABULAR LINER 54X47MM PINNACLE DUAL MOBILITY","SUP-ITM-10282793","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1596.88","36.5","","1023.42","771.29","2068.67","33","1356.25","3478.13","percent of total billed charges",""
"ACETABULAR LINER 54X47MM PINNACLE DUAL MOBILITY","SUP-ITM-10282793","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1675.63","38.3","","850.52","759.78","1211.25","66","1356.25","3478.13","percent of total billed charges",""
"ACETABULAR LINER 54X47MM PINNACLE DUAL MOBILITY","SUP-ITM-10282793","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1876.88","42.9","","2548.09","2548.09","2548.09","1 through 10","1356.25","3478.13","percent of total billed charges",""
"ACETABULAR LINER 54X47MM PINNACLE DUAL MOBILITY","SUP-ITM-10282793","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1876.88","42.9","","956.46","956.46","956.46","1 through 10","1356.25","3478.13","percent of total billed charges",""
"ACETABULAR LINER 54X47MM PINNACLE DUAL MOBILITY","SUP-ITM-10282793","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB AMC WELLPOINT","3227.88","73.78","","2344.73","1619.47","2530.35","16","1356.25","3478.13","percent of total billed charges",""
"ACETABULAR LINER 54X47MM PINNACLE DUAL MOBILITY","SUP-ITM-10282793","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","AETNA [1001]","HB AMC AETNA HMO","3053.75","69.8","","1523.63","988.41","4330.26","39","2286.38","3575.25","percent of total billed charges",""
"ACETABULAR LINER 54X47MM PINNACLE DUAL MOBILITY","SUP-ITM-10282793","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","AETNA [1001]","HB AMC AETNA PPO","3517.50","80.4","","1670.25","1670.25","1670.25","1 through 10","2286.38","3575.25","percent of total billed charges",""
"ACETABULAR LINER 54X47MM PINNACLE DUAL MOBILITY","SUP-ITM-10282793","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2286.38","52.26","","1113.10","1113.10","1113.10","1 through 10","2286.38","3575.25","percent of total billed charges",""
"ACETABULAR LINER 54X47MM PINNACLE DUAL MOBILITY","SUP-ITM-10282793","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3575.25","81.72","","1738.90","1484.65","2716.94","38","2286.38","3575.25","percent of total billed charges",""
"ACETABULAR SHELL 25 60MM SIZE RINGLOC POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10101190","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1190.74","52.26","","1113.10","1113.10","1113.10","1 through 10","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 25 60MM SIZE RINGLOC POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10101190","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1811.41","79.5","","1293.60","1148.53","1603.80","1 through 10","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 25 60MM SIZE RINGLOC POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10101190","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","831.65","36.5","","1023.42","771.29","2068.67","33","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 25 60MM SIZE RINGLOC POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10101190","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","872.67","38.3","","850.52","759.78","1211.25","66","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 25 60MM SIZE RINGLOC POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10101190","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","977.48","42.9","","2548.09","2548.09","2548.09","1 through 10","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 25 60MM SIZE RINGLOC POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10101190","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","977.48","42.9","","956.46","956.46","956.46","1 through 10","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 25 60MM SIZE RINGLOC POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10101190","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","WELLPOINT [1015]","HB AMC WELLPOINT","1681.08","73.78","","2344.73","1619.47","2530.35","16","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 25 60MM SIZE RINGLOC POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10101190","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2278.50","1708.87","AETNA [1001]","HB AMC AETNA HMO","1590.39","69.8","","1523.63","988.41","4330.26","39","1190.74","1861.99","percent of total billed charges",""
"ACETABULAR SHELL 25 60MM SIZE RINGLOC POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10101190","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2278.50","1708.87","AETNA [1001]","HB AMC AETNA PPO","1831.91","80.4","","1670.25","1670.25","1670.25","1 through 10","1190.74","1861.99","percent of total billed charges",""
"ACETABULAR SHELL 25 60MM SIZE RINGLOC POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10101190","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2278.50","1708.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1190.74","52.26","","1113.10","1113.10","1113.10","1 through 10","1190.74","1861.99","percent of total billed charges",""
"ACETABULAR SHELL 25 60MM SIZE RINGLOC POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10101190","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2278.50","1708.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1861.99","81.72","","1738.90","1484.65","2716.94","38","1190.74","1861.99","percent of total billed charges",""
"ACETABULAR SHELL 28X43MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10020610","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","1113.10","1113.10","1113.10","1 through 10","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X43MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10020610","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","1293.60","1148.53","1603.80","1 through 10","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X43MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10020610","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","1023.42","771.29","2068.67","33","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X43MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10020610","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","850.52","759.78","1211.25","66","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X43MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10020610","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","2548.09","2548.09","2548.09","1 through 10","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X43MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10020610","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","956.46","956.46","956.46","1 through 10","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X43MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10020610","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","2344.73","1619.47","2530.35","16","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X43MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10020610","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","1523.63","988.41","4330.26","39","914.55","1430.1","percent of total billed charges",""
"ACETABULAR SHELL 28X43MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10020610","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1670.25","1670.25","1670.25","1 through 10","914.55","1430.1","percent of total billed charges",""
"ACETABULAR SHELL 28X43MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10020610","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","1113.10","1113.10","1113.10","1 through 10","914.55","1430.1","percent of total billed charges",""
"ACETABULAR SHELL 28X43MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10020610","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","1738.90","1484.65","2716.94","38","914.55","1430.1","percent of total billed charges",""
"ACETABULAR SHELL 28X50MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122826","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","1113.10","1113.10","1113.10","1 through 10","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X50MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122826","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","1293.60","1148.53","1603.80","1 through 10","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X50MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122826","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","1023.42","771.29","2068.67","33","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X50MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122826","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","850.52","759.78","1211.25","66","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X50MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122826","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","2548.09","2548.09","2548.09","1 through 10","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X50MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122826","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","956.46","956.46","956.46","1 through 10","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X50MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122826","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","2344.73","1619.47","2530.35","16","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X50MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122826","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","1523.63","988.41","4330.26","39","914.55","1430.1","percent of total billed charges",""
"ACETABULAR SHELL 28X50MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122826","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1670.25","1670.25","1670.25","1 through 10","914.55","1430.1","percent of total billed charges",""
"ACETABULAR SHELL 28X50MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122826","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","1113.10","1113.10","1113.10","1 through 10","914.55","1430.1","percent of total billed charges",""
"ACETABULAR SHELL 28X50MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122826","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","1738.90","1484.65","2716.94","38","914.55","1430.1","percent of total billed charges",""
"ACETABULAR SHELL 28X51MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","1113.10","1113.10","1113.10","1 through 10","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X51MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","1293.60","1148.53","1603.80","1 through 10","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X51MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","1023.42","771.29","2068.67","33","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X51MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","850.52","759.78","1211.25","66","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X51MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","2548.09","2548.09","2548.09","1 through 10","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X51MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","956.46","956.46","956.46","1 through 10","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X51MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","2344.73","1619.47","2530.35","16","542.5","1391.25","percent of total billed charges",""
"ACETABULAR SHELL 28X51MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","1523.63","988.41","4330.26","39","914.55","1430.1","percent of total billed charges",""
"ACETABULAR SHELL 28X51MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1670.25","1670.25","1670.25","1 through 10","914.55","1430.1","percent of total billed charges",""
"ACETABULAR SHELL 28X51MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","1113.10","1113.10","1113.10","1 through 10","914.55","1430.1","percent of total billed charges",""
"ACETABULAR SHELL 28X51MM RINGLOC BIPOLAR COBALT ENDO","SUP-ITM-10122827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","1738.90","1484.65","2716.94","38","914.55","1430.1","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1190.74","52.26","","1113.10","1113.10","1113.10","1 through 10","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1811.41","79.5","","1293.60","1148.53","1603.80","1 through 10","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","831.65","36.5","","1023.42","771.29","2068.67","33","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","872.67","38.3","","850.52","759.78","1211.25","66","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","977.48","42.9","","2548.09","2548.09","2548.09","1 through 10","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","977.48","42.9","","956.46","956.46","956.46","1 through 10","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","2278.50","1708.87","WELLPOINT [1015]","HB AMC WELLPOINT","1681.08","73.78","","2344.73","1619.47","2530.35","16","706.34","1811.41","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2278.50","1708.87","AETNA [1001]","HB AMC AETNA HMO","1590.39","69.8","","1523.63","988.41","4330.26","39","1190.74","1861.99","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2278.50","1708.87","AETNA [1001]","HB AMC AETNA PPO","1831.91","80.4","","1670.25","1670.25","1670.25","1 through 10","1190.74","1861.99","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2278.50","1708.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1190.74","52.26","","1113.10","1113.10","1113.10","1 through 10","1190.74","1861.99","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2278.50","1708.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1861.99","81.72","","1738.90","1484.65","2716.94","38","1190.74","1861.99","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2504.25","79.5","","1293.60","1148.53","1603.80","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1149.75","36.5","","1023.42","771.29","2068.67","33","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1206.45","38.3","","850.52","759.78","1211.25","66","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","2548.09","2548.09","2548.09","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","956.46","956.46","956.46","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","WELLPOINT [1015]","HB AMC WELLPOINT","2324.07","73.78","","2344.73","1619.47","2530.35","16","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA HMO","2198.70","69.8","","1523.63","988.41","4330.26","39","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA PPO","2532.60","80.4","","1670.25","1670.25","1670.25","1 through 10","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2574.18","81.72","","1738.90","1484.65","2716.94","38","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2504.25","79.5","","1293.60","1148.53","1603.80","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1149.75","36.5","","1023.42","771.29","2068.67","33","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1206.45","38.3","","850.52","759.78","1211.25","66","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","2548.09","2548.09","2548.09","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","956.46","956.46","956.46","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","WELLPOINT [1015]","HB AMC WELLPOINT","2324.07","73.78","","2344.73","1619.47","2530.35","16","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA HMO","2198.70","69.8","","1523.63","988.41","4330.26","39","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA PPO","2532.60","80.4","","1670.25","1670.25","1670.25","1 through 10","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2574.18","81.72","","1738.90","1484.65","2716.94","38","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1728.50","52.26","","1113.10","1113.10","1113.10","1 through 10","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2629.46","79.5","","1293.60","1148.53","1603.80","1 through 10","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1207.24","36.5","","1023.42","771.29","2068.67","33","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1266.77","38.3","","850.52","759.78","1211.25","66","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1418.92","42.9","","2548.09","2548.09","2548.09","1 through 10","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1418.92","42.9","","956.46","956.46","956.46","1 through 10","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","WELLPOINT [1015]","HB AMC WELLPOINT","2440.27","73.78","","2344.73","1619.47","2530.35","16","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","AETNA [1001]","HB AMC AETNA HMO","2308.64","69.8","","1523.63","988.41","4330.26","39","1728.5","2702.89","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","AETNA [1001]","HB AMC AETNA PPO","2659.23","80.4","","1670.25","1670.25","1670.25","1 through 10","1728.5","2702.89","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1728.50","52.26","","1113.10","1113.10","1113.10","1 through 10","1728.5","2702.89","percent of total billed charges",""
"ACETABULAR SHELL 44MM TRABECULAR METAL TANTALUM MULTIHOLE MODULAR","SUP-ITM-10021810","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2702.89","81.72","","1738.90","1484.65","2716.94","38","1728.5","2702.89","percent of total billed charges",""
"ACETABULAR SHELL 46MM TRABECULAR METAL TANTALUM CLUSTER HOLE MODULAR","SUP-ITM-10200646","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1728.50","52.26","","1113.10","1113.10","1113.10","1 through 10","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 46MM TRABECULAR METAL TANTALUM CLUSTER HOLE MODULAR","SUP-ITM-10200646","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2629.46","79.5","","1293.60","1148.53","1603.80","1 through 10","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 46MM TRABECULAR METAL TANTALUM CLUSTER HOLE MODULAR","SUP-ITM-10200646","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1207.24","36.5","","1023.42","771.29","2068.67","33","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 46MM TRABECULAR METAL TANTALUM CLUSTER HOLE MODULAR","SUP-ITM-10200646","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1266.77","38.3","","850.52","759.78","1211.25","66","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 46MM TRABECULAR METAL TANTALUM CLUSTER HOLE MODULAR","SUP-ITM-10200646","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1418.92","42.9","","2548.09","2548.09","2548.09","1 through 10","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 46MM TRABECULAR METAL TANTALUM CLUSTER HOLE MODULAR","SUP-ITM-10200646","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1418.92","42.9","","956.46","956.46","956.46","1 through 10","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 46MM TRABECULAR METAL TANTALUM CLUSTER HOLE MODULAR","SUP-ITM-10200646","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","WELLPOINT [1015]","HB AMC WELLPOINT","2440.27","73.78","","2344.73","1619.47","2530.35","16","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 46MM TRABECULAR METAL TANTALUM CLUSTER HOLE MODULAR","SUP-ITM-10200646","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","AETNA [1001]","HB AMC AETNA HMO","2308.64","69.8","","1523.63","988.41","4330.26","39","1728.5","2702.89","percent of total billed charges",""
"ACETABULAR SHELL 46MM TRABECULAR METAL TANTALUM CLUSTER HOLE MODULAR","SUP-ITM-10200646","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","AETNA [1001]","HB AMC AETNA PPO","2659.23","80.4","","1670.25","1670.25","1670.25","1 through 10","1728.5","2702.89","percent of total billed charges",""
"ACETABULAR SHELL 46MM TRABECULAR METAL TANTALUM CLUSTER HOLE MODULAR","SUP-ITM-10200646","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1728.50","52.26","","1113.10","1113.10","1113.10","1 through 10","1728.5","2702.89","percent of total billed charges",""
"ACETABULAR SHELL 46MM TRABECULAR METAL TANTALUM CLUSTER HOLE MODULAR","SUP-ITM-10200646","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2702.89","81.72","","1738.90","1484.65","2716.94","38","1728.5","2702.89","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2502.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3806.46","79.5","","1293.60","1148.53","1603.80","1 through 10","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1747.62","36.5","","1023.42","771.29","2068.67","33","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1833.80","38.3","","850.52","759.78","1211.25","66","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2054.05","42.9","","2548.09","2548.09","2548.09","1 through 10","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2054.05","42.9","","956.46","956.46","956.46","1 through 10","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","WELLPOINT [1015]","HB AMC WELLPOINT","3532.59","73.78","","2344.73","1619.47","2530.35","16","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4788.00","3591.00","AETNA [1001]","HB AMC AETNA HMO","3342.02","69.8","","1523.63","988.41","4330.26","39","2502.21","3912.75","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4788.00","3591.00","AETNA [1001]","HB AMC AETNA PPO","3849.55","80.4","","1670.25","1670.25","1670.25","1 through 10","2502.21","3912.75","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4788.00","3591.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2502.21","52.26","","1113.10","1113.10","1113.10","1 through 10","2502.21","3912.75","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4788.00","3591.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3912.75","81.72","","1738.90","1484.65","2716.94","38","2502.21","3912.75","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2502.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3806.46","79.5","","1293.60","1148.53","1603.80","1 through 10","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1747.62","36.5","","1023.42","771.29","2068.67","33","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1833.80","38.3","","850.52","759.78","1211.25","66","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2054.05","42.9","","2548.09","2548.09","2548.09","1 through 10","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2054.05","42.9","","956.46","956.46","956.46","1 through 10","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","WELLPOINT [1015]","HB AMC WELLPOINT","3532.59","73.78","","2344.73","1619.47","2530.35","16","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4788.00","3591.00","AETNA [1001]","HB AMC AETNA HMO","3342.02","69.8","","1523.63","988.41","4330.26","39","2502.21","3912.75","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4788.00","3591.00","AETNA [1001]","HB AMC AETNA PPO","3849.55","80.4","","1670.25","1670.25","1670.25","1 through 10","2502.21","3912.75","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4788.00","3591.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2502.21","52.26","","1113.10","1113.10","1113.10","1 through 10","2502.21","3912.75","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4788.00","3591.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3912.75","81.72","","1738.90","1484.65","2716.94","38","2502.21","3912.75","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1193.5","3060.75","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1193.5","3060.75","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","1023.42","771.29","2068.67","33","1193.5","3060.75","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","850.52","759.78","1211.25","66","1193.5","3060.75","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","2548.09","2548.09","2548.09","1 through 10","1193.5","3060.75","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","956.46","956.46","956.46","1 through 10","1193.5","3060.75","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","2344.73","1619.47","2530.35","16","1193.5","3060.75","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA HMO","2687.30","69.8","","1523.63","988.41","4330.26","39","2012.01","3146.22","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA PPO","3095.40","80.4","","1670.25","1670.25","1670.25","1 through 10","2012.01","3146.22","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","2012.01","3146.22","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","1738.90","1484.65","2716.94","38","2012.01","3146.22","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2502.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3806.46","79.5","","1293.60","1148.53","1603.80","1 through 10","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1747.62","36.5","","1023.42","771.29","2068.67","33","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1833.80","38.3","","850.52","759.78","1211.25","66","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2054.05","42.9","","2548.09","2548.09","2548.09","1 through 10","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2054.05","42.9","","956.46","956.46","956.46","1 through 10","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4788.00","3591.00","WELLPOINT [1015]","HB AMC WELLPOINT","3532.59","73.78","","2344.73","1619.47","2530.35","16","1484.28","3806.46","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4788.00","3591.00","AETNA [1001]","HB AMC AETNA HMO","3342.02","69.8","","1523.63","988.41","4330.26","39","2502.21","3912.75","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4788.00","3591.00","AETNA [1001]","HB AMC AETNA PPO","3849.55","80.4","","1670.25","1670.25","1670.25","1 through 10","2502.21","3912.75","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4788.00","3591.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2502.21","52.26","","1113.10","1113.10","1113.10","1 through 10","2502.21","3912.75","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4788.00","3591.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3912.75","81.72","","1738.90","1484.65","2716.94","38","2502.21","3912.75","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1085","2782.5","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1085","2782.5","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1023.42","771.29","2068.67","33","1085","2782.5","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","850.52","759.78","1211.25","66","1085","2782.5","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1085","2782.5","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","956.46","956.46","956.46","1 through 10","1085","2782.5","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2344.73","1619.47","2530.35","16","1085","2782.5","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1523.63","988.41","4330.26","39","1829.1","2860.2","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1829.1","2860.2","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1829.1","2860.2","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","1738.90","1484.65","2716.94","38","1829.1","2860.2","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2504.25","79.5","","1293.60","1148.53","1603.80","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1149.75","36.5","","1023.42","771.29","2068.67","33","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1206.45","38.3","","850.52","759.78","1211.25","66","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","2548.09","2548.09","2548.09","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","956.46","956.46","956.46","1 through 10","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","WELLPOINT [1015]","HB AMC WELLPOINT","2324.07","73.78","","2344.73","1619.47","2530.35","16","976.5","2504.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA HMO","2198.70","69.8","","1523.63","988.41","4330.26","39","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA PPO","2532.60","80.4","","1670.25","1670.25","1670.25","1 through 10","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2574.18","81.72","","1738.90","1484.65","2716.94","38","1646.19","2574.18","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1250.28","52.26","","1113.10","1113.10","1113.10","1 through 10","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1901.98","79.5","","1293.60","1148.53","1603.80","1 through 10","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","873.24","36.5","","1023.42","771.29","2068.67","33","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","916.30","38.3","","850.52","759.78","1211.25","66","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1026.35","42.9","","2548.09","2548.09","2548.09","1 through 10","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1026.35","42.9","","956.46","956.46","956.46","1 through 10","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","WELLPOINT [1015]","HB AMC WELLPOINT","1765.13","73.78","","2344.73","1619.47","2530.35","16","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2392.43","1794.32","AETNA [1001]","HB AMC AETNA HMO","1669.92","69.8","","1523.63","988.41","4330.26","39","1250.28","1955.09","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2392.43","1794.32","AETNA [1001]","HB AMC AETNA PPO","1923.51","80.4","","1670.25","1670.25","1670.25","1 through 10","1250.28","1955.09","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2392.43","1794.32","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1250.28","52.26","","1113.10","1113.10","1113.10","1 through 10","1250.28","1955.09","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 POROUS PLASMA SPRAY LIMITED HOLE","SUP-ITM-10132605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2392.43","1794.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1955.09","81.72","","1738.90","1484.65","2716.94","38","1250.28","1955.09","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3213.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.51","36.5","","1023.42","771.29","2068.67","33","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.28","38.3","","850.52","759.78","1211.25","66","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","956.46","956.46","956.46","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","WELLPOINT [1015]","HB AMC WELLPOINT","2982.56","73.78","","2344.73","1619.47","2530.35","16","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA HMO","2821.67","69.8","","1523.63","988.41","4330.26","39","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA PPO","3250.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.53","81.72","","1738.90","1484.65","2716.94","38","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR SHELL 62MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER","SUP-ITM-10001711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1250.28","52.26","","1113.10","1113.10","1113.10","1 through 10","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 62MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER","SUP-ITM-10001711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1901.98","79.5","","1293.60","1148.53","1603.80","1 through 10","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 62MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER","SUP-ITM-10001711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","873.24","36.5","","1023.42","771.29","2068.67","33","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 62MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER","SUP-ITM-10001711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","916.30","38.3","","850.52","759.78","1211.25","66","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 62MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER","SUP-ITM-10001711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1026.35","42.9","","2548.09","2548.09","2548.09","1 through 10","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 62MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER","SUP-ITM-10001711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1026.35","42.9","","956.46","956.46","956.46","1 through 10","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 62MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER","SUP-ITM-10001711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2392.43","1794.32","WELLPOINT [1015]","HB AMC WELLPOINT","1765.13","73.78","","2344.73","1619.47","2530.35","16","741.65","1901.98","percent of total billed charges",""
"ACETABULAR SHELL 62MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER","SUP-ITM-10001711","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2392.43","1794.32","AETNA [1001]","HB AMC AETNA HMO","1669.92","69.8","","1523.63","988.41","4330.26","39","1250.28","1955.09","percent of total billed charges",""
"ACETABULAR SHELL 62MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER","SUP-ITM-10001711","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2392.43","1794.32","AETNA [1001]","HB AMC AETNA PPO","1923.51","80.4","","1670.25","1670.25","1670.25","1 through 10","1250.28","1955.09","percent of total billed charges",""
"ACETABULAR SHELL 62MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER","SUP-ITM-10001711","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2392.43","1794.32","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1250.28","52.26","","1113.10","1113.10","1113.10","1 through 10","1250.28","1955.09","percent of total billed charges",""
"ACETABULAR SHELL 62MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER","SUP-ITM-10001711","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2392.43","1794.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1955.09","81.72","","1738.90","1484.65","2716.94","38","1250.28","1955.09","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3213.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.51","36.5","","1023.42","771.29","2068.67","33","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.28","38.3","","850.52","759.78","1211.25","66","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","956.46","956.46","956.46","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","WELLPOINT [1015]","HB AMC WELLPOINT","2982.56","73.78","","2344.73","1619.47","2530.35","16","1253.18","3213.79","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA HMO","2821.67","69.8","","1523.63","988.41","4330.26","39","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA PPO","3250.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.53","81.72","","1738.90","1484.65","2716.94","38","2112.61","3303.53","percent of total billed charges",""
"ACETABULAR SHELL 78MM SIZE VV CONTINUUM TIVANIUM TRABECULAR METAL HEMISPHERE UNIHOLE","SUP-ITM-10201224","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1728.50","52.26","","1113.10","1113.10","1113.10","1 through 10","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 78MM SIZE VV CONTINUUM TIVANIUM TRABECULAR METAL HEMISPHERE UNIHOLE","SUP-ITM-10201224","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2629.46","79.5","","1293.60","1148.53","1603.80","1 through 10","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 78MM SIZE VV CONTINUUM TIVANIUM TRABECULAR METAL HEMISPHERE UNIHOLE","SUP-ITM-10201224","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1207.24","36.5","","1023.42","771.29","2068.67","33","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 78MM SIZE VV CONTINUUM TIVANIUM TRABECULAR METAL HEMISPHERE UNIHOLE","SUP-ITM-10201224","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1266.77","38.3","","850.52","759.78","1211.25","66","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 78MM SIZE VV CONTINUUM TIVANIUM TRABECULAR METAL HEMISPHERE UNIHOLE","SUP-ITM-10201224","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1418.92","42.9","","2548.09","2548.09","2548.09","1 through 10","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 78MM SIZE VV CONTINUUM TIVANIUM TRABECULAR METAL HEMISPHERE UNIHOLE","SUP-ITM-10201224","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1418.92","42.9","","956.46","956.46","956.46","1 through 10","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 78MM SIZE VV CONTINUUM TIVANIUM TRABECULAR METAL HEMISPHERE UNIHOLE","SUP-ITM-10201224","CDM","C1776","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","WELLPOINT [1015]","HB AMC WELLPOINT","2440.27","73.78","","2344.73","1619.47","2530.35","16","1025.33","2629.46","percent of total billed charges",""
"ACETABULAR SHELL 78MM SIZE VV CONTINUUM TIVANIUM TRABECULAR METAL HEMISPHERE UNIHOLE","SUP-ITM-10201224","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","AETNA [1001]","HB AMC AETNA HMO","2308.64","69.8","","1523.63","988.41","4330.26","39","1728.5","2702.89","percent of total billed charges",""
"ACETABULAR SHELL 78MM SIZE VV CONTINUUM TIVANIUM TRABECULAR METAL HEMISPHERE UNIHOLE","SUP-ITM-10201224","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","AETNA [1001]","HB AMC AETNA PPO","2659.23","80.4","","1670.25","1670.25","1670.25","1 through 10","1728.5","2702.89","percent of total billed charges",""
"ACETABULAR SHELL 78MM SIZE VV CONTINUUM TIVANIUM TRABECULAR METAL HEMISPHERE UNIHOLE","SUP-ITM-10201224","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1728.50","52.26","","1113.10","1113.10","1113.10","1 through 10","1728.5","2702.89","percent of total billed charges",""
"ACETABULAR SHELL 78MM SIZE VV CONTINUUM TIVANIUM TRABECULAR METAL HEMISPHERE UNIHOLE","SUP-ITM-10201224","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2702.89","81.72","","1738.90","1484.65","2716.94","38","1728.5","2702.89","percent of total billed charges",""
"ACETABULAR SHELL 80MM POROUS TRABECULAR TANTALUM TIVANIUM REVISION","SUP-ITM-10118051","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2218.24","52.26","","1113.10","1113.10","1113.10","1 through 10","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL 80MM POROUS TRABECULAR TANTALUM TIVANIUM REVISION","SUP-ITM-10118051","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3374.48","79.5","","1293.60","1148.53","1603.80","1 through 10","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL 80MM POROUS TRABECULAR TANTALUM TIVANIUM REVISION","SUP-ITM-10118051","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1549.29","36.5","","1023.42","771.29","2068.67","33","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL 80MM POROUS TRABECULAR TANTALUM TIVANIUM REVISION","SUP-ITM-10118051","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1625.69","38.3","","850.52","759.78","1211.25","66","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL 80MM POROUS TRABECULAR TANTALUM TIVANIUM REVISION","SUP-ITM-10118051","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1820.95","42.9","","2548.09","2548.09","2548.09","1 through 10","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL 80MM POROUS TRABECULAR TANTALUM TIVANIUM REVISION","SUP-ITM-10118051","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1820.95","42.9","","956.46","956.46","956.46","1 through 10","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL 80MM POROUS TRABECULAR TANTALUM TIVANIUM REVISION","SUP-ITM-10118051","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","WELLPOINT [1015]","HB AMC WELLPOINT","3131.69","73.78","","2344.73","1619.47","2530.35","16","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL 80MM POROUS TRABECULAR TANTALUM TIVANIUM REVISION","SUP-ITM-10118051","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4244.63","3183.47","AETNA [1001]","HB AMC AETNA HMO","2962.75","69.8","","1523.63","988.41","4330.26","39","2218.24","3468.71","percent of total billed charges",""
"ACETABULAR SHELL 80MM POROUS TRABECULAR TANTALUM TIVANIUM REVISION","SUP-ITM-10118051","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4244.63","3183.47","AETNA [1001]","HB AMC AETNA PPO","3412.68","80.4","","1670.25","1670.25","1670.25","1 through 10","2218.24","3468.71","percent of total billed charges",""
"ACETABULAR SHELL 80MM POROUS TRABECULAR TANTALUM TIVANIUM REVISION","SUP-ITM-10118051","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4244.63","3183.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2218.24","52.26","","1113.10","1113.10","1113.10","1 through 10","2218.24","3468.71","percent of total billed charges",""
"ACETABULAR SHELL 80MM POROUS TRABECULAR TANTALUM TIVANIUM REVISION","SUP-ITM-10118051","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4244.63","3183.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3468.71","81.72","","1738.90","1484.65","2716.94","38","2218.24","3468.71","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1280.37","52.26","","1113.10","1113.10","1113.10","1 through 10","759.5","1947.75","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","1293.60","1148.53","1603.80","1 through 10","759.5","1947.75","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","1023.42","771.29","2068.67","33","759.5","1947.75","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","850.52","759.78","1211.25","66","759.5","1947.75","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","2548.09","2548.09","2548.09","1 through 10","759.5","1947.75","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","956.46","956.46","956.46","1 through 10","759.5","1947.75","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","2344.73","1619.47","2530.35","16","759.5","1947.75","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","1523.63","988.41","4330.26","39","1280.37","2002.14","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA PPO","1969.80","80.4","","1670.25","1670.25","1670.25","1 through 10","1280.37","2002.14","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1280.37","52.26","","1113.10","1113.10","1113.10","1 through 10","1280.37","2002.14","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","1738.90","1484.65","2716.94","38","1280.37","2002.14","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2218.24","52.26","","1113.10","1113.10","1113.10","1 through 10","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3374.48","79.5","","1293.60","1148.53","1603.80","1 through 10","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1549.29","36.5","","1023.42","771.29","2068.67","33","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1625.69","38.3","","850.52","759.78","1211.25","66","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1820.95","42.9","","2548.09","2548.09","2548.09","1 through 10","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1820.95","42.9","","956.46","956.46","956.46","1 through 10","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","WELLPOINT [1015]","HB AMC WELLPOINT","3131.69","73.78","","2344.73","1619.47","2530.35","16","1315.84","3374.48","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4244.63","3183.47","AETNA [1001]","HB AMC AETNA HMO","2962.75","69.8","","1523.63","988.41","4330.26","39","2218.24","3468.71","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4244.63","3183.47","AETNA [1001]","HB AMC AETNA PPO","3412.68","80.4","","1670.25","1670.25","1670.25","1 through 10","2218.24","3468.71","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4244.63","3183.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2218.24","52.26","","1113.10","1113.10","1113.10","1 through 10","2218.24","3468.71","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4244.63","3183.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3468.71","81.72","","1738.90","1484.65","2716.94","38","2218.24","3468.71","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","350.00","262.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","182.91","52.26","","1113.10","1113.10","1113.10","1 through 10","108.5","278.25","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","278.25","79.5","","1293.60","1148.53","1603.80","1 through 10","108.5","278.25","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.75","36.5","","1023.42","771.29","2068.67","33","108.5","278.25","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","134.05","38.3","","850.52","759.78","1211.25","66","108.5","278.25","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","2548.09","2548.09","2548.09","1 through 10","108.5","278.25","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","956.46","956.46","956.46","1 through 10","108.5","278.25","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","350.00","262.50","WELLPOINT [1015]","HB AMC WELLPOINT","258.23","73.78","","2344.73","1619.47","2530.35","16","108.5","278.25","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA HMO","244.30","69.8","","1523.63","988.41","4330.26","39","182.91","286.02","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA PPO","281.40","80.4","","1670.25","1670.25","1670.25","1 through 10","182.91","286.02","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","182.91","52.26","","1113.10","1113.10","1113.10","1 through 10","182.91","286.02","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","286.02","81.72","","1738.90","1484.65","2716.94","38","182.91","286.02","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0301","RC","","","","both","","","138.00","103.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","109.71","79.5","","105.46","70.75","105.46","11","8.01","131.1","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0301","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.37","36.5","","49.98","42.08","49.98","14","8.01","131.1","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0301","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.85","38.3","","52.39","52.39","157.17","18","8.01","131.1","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0301","RC","","","","both","","","138.00","103.50","TRICARE [160005]","HB BWH TRICARE","131.10","95","","9.35","9.35","9.35","1 through 10","8.01","131.1","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0301","RC","","","","outpatient","","","138.00","103.50","AETNA [1001]","HB AMC AETNA HMO","96.32","69.8","","90.72","64.05","104.52","1 through 10","8.44","112.77","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","112.77","81.72","","107.12","41.17","107.12","1 through 10","8.44","112.77","percent of total billed charges",""
"Acetylcholine Challenge Test","PX-48000489","CDM","93799","CPT","0481","RC","","","","both","","","3668.00","2751.00","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","2916.06","other","OPPS APC"
"Acetylcholine Challenge Test","PX-48000489","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","AETNA [1001]","HB AMC AETNA HMO","2560.26","69.8","","2022.70","2022.70","2022.70","1 through 10","454","3026.1","percent of total billed charges",""
"Acetylcholine Challenge Test","PX-48000489","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2220.97","60.55","","318.03","318.03","2439.77","1 through 10","454","3026.1","percent of total billed charges",""
"Acetylcholine Challenge Test","PX-48000489","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1915.43","52.22","","360.38","360.38","4023.00","1 through 10","454","3026.1","percent of total billed charges",""
"Acetylcholine Challenge Test","PX-48000489","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2017.40","55","","13080.03","13080.03","13080.03","1 through 10","454","3026.1","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","both","","","224.00","168.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","178.08","79.5","","512.34","512.34","512.34","1 through 10","18.03","212.8","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","both","","","224.00","168.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","119.39","53.3","","170.78","114.58","170.78","1 through 10","18.03","212.8","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","both","","","224.00","168.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","81.76","36.5","","80.94","78.55","80.94","1 through 10","18.03","212.8","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","both","","","224.00","168.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","85.79","38.3","","84.85","84.85","254.55","13","18.03","212.8","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","both","","","224.00","168.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.10","42.9","","95.41","95.41","95.41","1 through 10","18.03","212.8","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","both","","","224.00","168.00","WELLPOINT [1015]","HB AMC WELLPOINT","165.27","73.78","","595.56","161.56","595.56","1 through 10","18.03","212.8","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","224.00","168.00","AETNA [1001]","HB AMC AETNA HMO","156.35","69.8","","146.91","146.91","146.91","1 through 10","53.55","184.8","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","224.00","168.00","AETNA [1001]","HB AMC AETNA PPO","180.10","80.4","","113.71","113.71","113.71","1 through 10","53.55","184.8","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","224.00","168.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.00","50","","113.71","92.23","341.13","16","53.55","184.8","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","224.00","168.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","117.60","52.5","","119.35","119.35","358.05","1 through 10","53.55","184.8","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","224.00","168.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","140.00","62.5","","142.14","142.14","142.14","1 through 10","53.55","184.8","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","224.00","168.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","123.20","55","","124.99","124.99","124.99","1 through 10","53.55","184.8","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.05","81.72","","173.47","173.47","173.47","1 through 10","53.55","184.8","percent of total billed charges",""
"Acetylcholine Receptor Blocking Antibody","PX-30003821","CDM","86042","CPT","0302","RC","","","","both","","","224.00","168.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","119.39","53.3","","170.78","170.78","170.78","1 through 10","18.03","212.8","percent of total billed charges",""
"Acetylcholine Receptor Blocking Antibody","PX-30003821","CDM","86042","CPT","0302","RC","","","","both","","","224.00","168.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","81.76","36.5","","78.55","78.55","78.55","1 through 10","18.03","212.8","percent of total billed charges",""
"Acetylcholine Receptor Blocking Antibody","PX-30003821","CDM","86042","CPT","0302","RC","","","","both","","","224.00","168.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","85.79","38.3","","84.85","84.85","84.85","1 through 10","18.03","212.8","percent of total billed charges",""
"Acetylcholine Receptor Blocking Antibody","PX-30003821","CDM","86042","CPT","0302","RC","","","","both","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.10","42.9","","173.47","173.47","173.47","1 through 10","18.03","212.8","percent of total billed charges",""
"Acetylcholine Receptor Blocking Antibody","PX-30003821","CDM","86042","CPT","0302","RC","","","","both","","","224.00","168.00","WELLPOINT [1015]","HB AMC WELLPOINT","165.27","73.78","","595.56","161.56","595.56","1 through 10","18.03","212.8","percent of total billed charges",""
"Acetylcholine Receptor Blocking Antibody","PX-30003821","CDM","86042","CPT","0302","RC","","","","outpatient","","","224.00","168.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.00","50","","113.71","92.23","113.71","1 through 10","53.55","184.8","percent of total billed charges",""
"Acetylcholine Receptor Blocking Antibody","PX-30003821","CDM","86042","CPT","0302","RC","","","","outpatient","","","224.00","168.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","117.60","52.5","","119.35","119.35","119.35","1 through 10","53.55","184.8","percent of total billed charges",""
"Acetylcholine Receptor Blocking Antibody","PX-30003821","CDM","86042","CPT","0302","RC","","","","outpatient","","","224.00","168.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","123.20","55","","124.99","124.99","124.99","1 through 10","53.55","184.8","percent of total billed charges",""
"Acetylcholine Receptor Blocking Antibody","PX-30003821","CDM","86042","CPT","0302","RC","","","","outpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.05","81.72","","173.47","173.47","173.47","1 through 10","53.55","184.8","percent of total billed charges",""
"Acetylcholine Receptor Modulating Antibody","PX-30003822","CDM","86043","CPT","0302","RC","","","","both","","","146.00","109.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.82","53.3","","111.75","111.75","111.75","1 through 10","11.81","138.7","percent of total billed charges",""
"Acetylcholine Receptor Modulating Antibody","PX-30003822","CDM","86043","CPT","0302","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.29","36.5","","51.40","51.40","51.40","1 through 10","11.81","138.7","percent of total billed charges",""
"Acetylcholine Receptor Modulating Antibody","PX-30003822","CDM","86043","CPT","0302","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.92","38.3","","55.52","53.96","166.56","1 through 10","11.81","138.7","percent of total billed charges",""
"Acetylcholine Receptor Modulating Antibody","PX-30003822","CDM","86043","CPT","0302","RC","","","","both","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.63","42.9","","113.51","113.51","113.51","1 through 10","11.81","138.7","percent of total billed charges",""
"Acetylcholine Receptor Modulating Antibody","PX-30003822","CDM","86043","CPT","0302","RC","","","","both","","","146.00","109.50","WELLPOINT [1015]","HB AMC WELLPOINT","107.72","73.78","","389.72","105.72","389.72","1 through 10","11.81","138.7","percent of total billed charges",""
"Acetylcholine Receptor Modulating Antibody","PX-30003822","CDM","86043","CPT","0302","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA PPO","117.38","80.4","","74.41","74.41","74.41","1 through 10","34.76","120.45","percent of total billed charges",""
"Acetylcholine Receptor Modulating Antibody","PX-30003822","CDM","86043","CPT","0302","RC","","","","outpatient","","","146.00","109.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","73.00","50","","74.41","60.35","74.41","1 through 10","34.76","120.45","percent of total billed charges",""
"Acetylcholine Receptor Modulating Antibody","PX-30003822","CDM","86043","CPT","0302","RC","","","","outpatient","","","146.00","109.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","76.65","52.5","","78.10","78.10","78.10","1 through 10","34.76","120.45","percent of total billed charges",""
"Acetylcholine Receptor Modulating Antibody","PX-30003822","CDM","86043","CPT","0302","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","119.31","81.72","","113.51","113.51","113.51","1 through 10","34.76","120.45","percent of total billed charges",""
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1225.00","918.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","584.98","442.65","630.12","1 through 10","379.75","973.88","other","OPPS APC"
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1225.00","918.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","973.88","79.5","","934.96","627.26","934.96","1 through 10","379.75","973.88","percent of total billed charges",""
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1225.00","918.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","522.11","620.04","1 through 10","379.75","973.88","other","OPPS APC"
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1225.00","918.75","HUMANA [1012]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","621.30","618.02","621.30","1 through 10","379.75","973.88","other","OPPS APC"
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1225.00","918.75","MEDICARE [2001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","584.98","630.12","41","379.75","973.88","other","OPPS APC"
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","469.18","38.3","","464.51","451.44","464.51","1 through 10","379.75","973.88","percent of total billed charges",""
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","617.52","573.28","617.92","1 through 10","379.75","973.88","other","OPPS APC"
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1225.00","918.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","273.24","273.24","273.24","1 through 10","379.75","973.88","other","OPPS APC"
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.52","573.29","620.04","1 through 10","379.75","973.88","other","OPPS APC"
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","both","","","1225.00","918.75","WELLPOINT [1015]","HB AMC WELLPOINT","903.81","73.78","","884.47","884.47","884.47","1 through 10","379.75","973.88","percent of total billed charges",""
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","outpatient","","","1225.00","918.75","AETNA [1001]","HB AMC AETNA HMO","855.05","69.8","","804.28","804.28","804.28","1 through 10","640.19","2051.09","percent of total billed charges",""
"Acid Reflux Test Intluminal Prolong","PX-75000317","CDM","91038","CPT","0750","RC","","","","outpatient","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1001.07","81.72","","949.69","949.69","1165.49","1 through 10","640.19","2051.09","percent of total billed charges",""
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","2862.00","2146.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.17","477.17","477.17","1 through 10","598.61","2275.29","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","2862.00","2146.50","MEDICARE [2001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","1890.36","16","598.61","2275.29","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","2862.00","2146.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1044.63","36.5","","1035.08","879.68","1035.08","1 through 10","598.61","2275.29","percent of total billed charges",""
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","2862.00","2146.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1096.15","38.3","","1085.03","1085.03","1085.03","1 through 10","598.61","2275.29","percent of total billed charges",""
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","2862.00","2146.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","617.52","573.28","617.52","1 through 10","598.61","2275.29","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","2862.00","2146.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1860.12","617.92","1860.12","1 through 10","598.61","2275.29","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","2862.00","2146.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","630.12","574.19","630.12","1 through 10","598.61","2275.29","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","outpatient","","","2862.00","2146.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2338.83","81.72","","2218.34","2218.34","2218.34","1 through 10","1045.95","2338.83","percent of total billed charges",""
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","both","","","1384.00","1038.00","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","351.32","1100.28","other","OPPS APC"
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","both","","","1384.00","1038.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","530.07","38.3","","524.72","524.72","524.72","1 through 10","351.32","1100.28","percent of total billed charges",""
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","outpatient","","","1384.00","1038.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1131.00","81.72","","590.08","590.08","590.08","1 through 10","579.66","1131","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","572.00","429.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","454.74","79.5","","336.84","336.84","336.84","1 through 10","177.32","454.74","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","572.00","429.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","304.88","53.3","","225.98","225.98","225.98","1 through 10","177.32","454.74","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","572.00","429.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","208.78","36.5","","135.68","135.68","135.68","1 through 10","177.32","454.74","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","572.00","429.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","219.08","38.3","","167.35","167.35","167.35","1 through 10","177.32","454.74","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","572.00","429.00","WELLPOINT [1015]","HB AMC WELLPOINT","422.02","73.78","","134.12","134.12","134.12","1 through 10","177.32","454.74","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","outpatient","","","572.00","429.00","AETNA [1001]","HB AMC AETNA HMO","399.26","69.8","","289.76","102.29","333.84","1 through 10","228.8","467.44","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","outpatient","","","572.00","429.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","346.35","60.55","","115.49","99.45","115.49","1 through 10","228.8","467.44","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","outpatient","","","572.00","429.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","298.70","52.22","","115.49","99.45","115.49","20","228.8","467.44","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","outpatient","","","572.00","429.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","467.44","81.72","","188.19","188.19","342.14","1 through 10","228.8","467.44","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","137.00","102.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","108.92","79.5","","104.67","70.22","357.30","18","11.81","130.15","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","137.00","102.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","73.02","53.3","","104.67","70.22","104.67","1 through 10","11.81","130.15","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","137.00","102.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","89.05","65","","86.45","86.45","86.45","1 through 10","11.81","130.15","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","137.00","102.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","108.92","79.5","","104.67","104.67","104.67","1 through 10","11.81","130.15","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","137.00","102.75","TRICARE [160005]","HB BWH TRICARE","130.15","95","","14.52","13.79","133.00","1 through 10","11.81","130.15","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","137.00","102.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.77","42.9","","106.32","106.32","106.32","1 through 10","11.81","130.15","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","137.00","102.75","WELLPOINT [1015]","HB AMC WELLPOINT","101.08","73.78","","99.02","99.02","365.02","13","11.81","130.15","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","137.00","102.75","AETNA [1001]","HB AMC AETNA HMO","95.63","69.8","","90.04","63.57","90.04","24","33.7","113.03","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","137.00","102.75","AETNA [1001]","HB AMC AETNA PPO","110.15","80.4","","103.74","103.74","103.74","1 through 10","33.7","113.03","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","137.00","102.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","71.93","52.5","","76.61","76.61","76.61","1 through 10","33.7","113.03","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","137.00","102.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","68.50","50","","69.69","56.53","69.69","31","33.7","113.03","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","137.00","102.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","71.93","52.5","","73.15","70.36","137.92","15","33.7","113.03","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","137.00","102.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","71.93","52.5","","73.15","73.15","73.15","1 through 10","33.7","113.03","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","137.00","102.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","75.35","55","","76.61","62.11","76.61","1 through 10","33.7","113.03","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","137.00","102.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","111.96","81.72","","106.32","58.48","106.32","1 through 10","33.7","113.03","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","137.00","102.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","111.96","81.72","","106.32","58.48","106.32","18","33.7","113.03","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","137.00","102.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","75.35","55","","70.95","70.95","70.95","1 through 10","33.7","113.03","percent of total billed charges",""
"Actinotherapy/Ultraviolet Therapy","PX-76001682","CDM","96900","CPT","0761","RC","","","","both","","","125.00","93.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","48.01","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","48.86","48.86","48.86","84","38.75","99.38","other","OPPS APC"
"Actinotherapy/Ultraviolet Therapy","PX-76001682","CDM","96900","CPT","0761","RC","","","","both","","","125.00","93.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","66.63","53.3","","95.23","95.23","95.23","31","38.75","99.38","percent of total billed charges",""
"Actinotherapy/Ultraviolet Therapy","PX-76001682","CDM","96900","CPT","0761","RC","","","","both","","","125.00","93.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.86","45.86","45.86","52","38.75","99.38","other","OPPS APC"
"Actinotherapy/Ultraviolet Therapy","PX-76001682","CDM","96900","CPT","0761","RC","","","","both","","","125.00","93.75","MEDICARE [2001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.61","46.61","46.61","354","38.75","99.38","other","OPPS APC"
"Actinotherapy/Ultraviolet Therapy","PX-76001682","CDM","96900","CPT","0761","RC","","","","both","","","125.00","93.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","38.75","31","","37.39","37.39","37.39","1 through 10","38.75","99.38","percent of total billed charges",""
"Actinotherapy/Ultraviolet Therapy","PX-76001682","CDM","96900","CPT","0761","RC","","","","both","","","125.00","93.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","47.88","38.3","","47.31","47.31","141.93","238","38.75","99.38","percent of total billed charges",""
"Actinotherapy/Ultraviolet Therapy","PX-76001682","CDM","96900","CPT","0761","RC","","","","both","","","125.00","93.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","45.68","42.89","45.68","46","38.75","99.38","other","OPPS APC"
"Actinotherapy/Ultraviolet Therapy","PX-76001682","CDM","96900","CPT","0761","RC","","","","outpatient","","","125.00","93.75","AETNA [1001]","HB AMC AETNA PPO","100.50","80.4","","63.40","63.40","63.40","55","65.33","254.28","percent of total billed charges",""
"Actinotherapy/Ultraviolet Therapy","PX-76001682","CDM","96900","CPT","0761","RC","","","","outpatient","","","125.00","93.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","102.15","81.72","","96.73","96.73","96.73","1 through 10","65.33","254.28","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","both","","","239.00","179.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","167.30","70","","232.00","102.01","232.00","1 through 10","14.72","227.05","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","both","","","239.00","179.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","190.01","79.5","","182.58","122.50","547.74","16","14.72","227.05","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","both","","","239.00","179.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","127.39","53.3","","367.50","122.50","547.74","14","14.72","227.05","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","both","","","239.00","179.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","184.03","77","","535.92","535.92","535.92","1 through 10","14.72","227.05","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","both","","","239.00","179.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","155.35","65","","150.80","146.25","150.80","1 through 10","14.72","227.05","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","both","","","239.00","179.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","74.09","31","","71.69","71.69","71.69","1 through 10","14.72","227.05","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","both","","","239.00","179.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.24","36.5","","259.62","86.54","605.78","20","14.72","227.05","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","both","","","239.00","179.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.54","38.3","","90.71","88.16","272.13","36","14.72","227.05","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","both","","","239.00","179.25","TRICARE [160005]","HB BWH TRICARE","227.05","95","","17.54","17.54","17.54","1 through 10","14.72","227.05","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","outpatient","","","239.00","179.25","AETNA [1001]","HB AMC AETNA HMO","166.82","69.8","","157.06","110.90","221.80","17","14.72","195.31","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","outpatient","","","239.00","179.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","195.31","81.72","","185.46","102.01","185.46","15","14.72","195.31","percent of total billed charges",""
"Acupuncture W/E-Stim Add 15","PX-94000012","CDM","97814","CPT","0940","RC","","","","both","","","54.00","40.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19.71","36.5","","30.23","30.23","30.23","1 through 10","16.74","51.3","percent of total billed charges",""
"Acupuncture W/E-Stim Add 15","PX-94000012","CDM","97814","CPT","0940","RC","","","","both","","","54.00","40.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20.68","38.3","","45.35","45.35","45.35","38","16.74","51.3","percent of total billed charges",""
"Acupuncture W/E-Stim Add 15","PX-94000012","CDM","97814","CPT","0940","RC","","","","outpatient","","","54.00","40.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","28.35","52.5","","54.00","54.00","54.00","1 through 10","27","44.55","percent of total billed charges",""
"Acupuncture W/E-Stim Add 15","PX-94000012","CDM","97814","CPT","0940","RC","","","","outpatient","","","54.00","40.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","27.00","50","","28.30","28.30","28.30","1 through 10","27","44.55","percent of total billed charges",""
"Acupuncture W/E-Stim Add 15","PX-94000012","CDM","97814","CPT","0940","RC","","","","outpatient","","","54.00","40.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","28.35","52.5","","29.70","29.70","29.70","1 through 10","27","44.55","percent of total billed charges",""
"Acupuncture W/E-Stim Initial","PX-94000011","CDM","97813","CPT","0940","RC","","","","both","","","64.00","48.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.61","28.61","28.61","1 through 10","19.84","60.8","other","OPPS APC"
"Acupuncture W/E-Stim Initial","PX-94000011","CDM","97813","CPT","0940","RC","","","","both","","","64.00","48.00","MEDICARE [2001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","1 through 10","19.84","60.8","other","OPPS APC"
"Acupuncture W/E-Stim Initial","PX-94000011","CDM","97813","CPT","0940","RC","","","","both","","","64.00","48.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.36","36.5","","35.69","35.69","35.69","1 through 10","19.84","60.8","percent of total billed charges",""
"Acupuncture W/E-Stim Initial","PX-94000011","CDM","97813","CPT","0940","RC","","","","both","","","64.00","48.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.51","38.3","","53.54","53.54","53.54","39","19.84","60.8","percent of total billed charges",""
"Acupuncture W/E-Stim Initial","PX-94000011","CDM","97813","CPT","0940","RC","","","","both","","","64.00","48.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","29.08","29.08","29.08","1 through 10","19.84","60.8","other","OPPS APC"
"Acupuncture W/E-Stim Initial","PX-94000011","CDM","97813","CPT","0940","RC","","","","outpatient","","","64.00","48.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","33.60","52.5","","64.00","64.00","64.00","1 through 10","32","129.18","percent of total billed charges",""
"Acupuncture W/E-Stim Initial","PX-94000011","CDM","97813","CPT","0940","RC","","","","outpatient","","","64.00","48.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","32.00","50","","33.54","33.54","33.54","1 through 10","32","129.18","percent of total billed charges",""
"Acupuncture W/E-Stim Initial","PX-94000011","CDM","97813","CPT","0940","RC","","","","outpatient","","","64.00","48.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","33.60","52.5","","35.20","35.20","35.20","1 through 10","32","129.18","percent of total billed charges",""
"Acupuncture W/O E-Stim Add 15min","PX-94000010","CDM","97811","CPT","0940","RC","","","","both","","","49.00","36.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","38.96","79.5","","49.00","49.00","49.00","1 through 10","15.19","46.55","percent of total billed charges",""
"Acupuncture W/O E-Stim Add 15min","PX-94000010","CDM","97811","CPT","0940","RC","","","","both","","","49.00","36.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17.89","36.5","","27.40","23.29","27.40","1 through 10","15.19","46.55","percent of total billed charges",""
"Acupuncture W/O E-Stim Add 15min","PX-94000010","CDM","97811","CPT","0940","RC","","","","both","","","49.00","36.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18.77","38.3","","41.10","41.10","41.10","42","15.19","46.55","percent of total billed charges",""
"Acupuncture W/O E-Stim Add 15min","PX-94000010","CDM","97811","CPT","0940","RC","","","","outpatient","","","49.00","36.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24.50","50","","25.68","25.68","25.68","1 through 10","24.5","40.43","percent of total billed charges",""
"Acupuncture W/O E-Stim Initial","PX-94000009","CDM","97810","CPT","0940","RC","","","","both","","","59.00","44.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46.91","79.5","","59.00","59.00","59.00","1 through 10","18.29","56.05","percent of total billed charges",""
"Acupuncture W/O E-Stim Initial","PX-94000009","CDM","97810","CPT","0940","RC","","","","both","","","59.00","44.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21.54","36.5","","32.76","27.85","32.76","1 through 10","18.29","56.05","percent of total billed charges",""
"Acupuncture W/O E-Stim Initial","PX-94000009","CDM","97810","CPT","0940","RC","","","","both","","","59.00","44.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22.60","38.3","","49.14","49.14","49.14","41","18.29","56.05","percent of total billed charges",""
"Acupuncture W/O E-Stim Initial","PX-94000009","CDM","97810","CPT","0940","RC","","","","outpatient","","","59.00","44.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","29.50","50","","30.92","30.92","30.92","1 through 10","29.5","119.61","percent of total billed charges",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","44978.85","33734.14","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","9413.07","","Case rate ($9,138.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,924.01, add-ons for qualifying new technology services are included. If operating cost exceeds $56,568.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,212.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,986.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,544.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $772.63. The transfer capital threshold is the transfer adjustment factor * $772.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9283.57","9283.57","9283.57","1 through 10","8956.12","14466.2326","other","Inpatient DRG"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","44978.85","33734.14","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9138.90","","Case rate ($9,138.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,924.01, add-ons for qualifying new technology services are included. If operating cost exceeds $56,568.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,212.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,986.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,544.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $772.63. The transfer capital threshold is the transfer adjustment factor * $772.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8899.46","8899.46","8899.46","1 through 10","8956.12","14466.2326","other","Inpatient DRG"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","44978.85","33734.14","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","2116.00","2116.00","2116.00","1 through 10","8956.12","14466.2326","case rate",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","44978.85","33734.14","MEDICARE [2001]","HB BWH MEDICARE","9138.90","","Case rate ($9,138.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,924.01, add-ons for qualifying new technology services are included. If operating cost exceeds $56,568.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,212.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,986.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,544.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $772.63. The transfer capital threshold is the transfer adjustment factor * $772.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11579.37","0.03","11596.26","16","8956.12","14466.2326","other","Inpatient Replacement Plans DRG"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","44978.85","33734.14","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","9138.90","","Case rate ($9,138.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,924.01, add-ons for qualifying new technology services are included. If operating cost exceeds $56,568.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,212.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,986.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,544.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $772.63. The transfer capital threshold is the transfer adjustment factor * $772.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8820.38","8820.38","8820.38","1 through 10","8956.12","14466.2326","other","Inpatient Replacement Plans DRG"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","44978.85","33734.14","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8956.12","","Case rate ($9,138.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,924.01, add-ons for qualifying new technology services are included. If operating cost exceeds $56,568.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,212.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,986.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,544.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $772.63. The transfer capital threshold is the transfer adjustment factor * $772.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8799.62","8799.62","8799.62","1 through 10","8956.12","14466.2326","other","Inpatient DRG"
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","","","","inpatient","","","73659.98","55244.98","MEDICARE [2001]","HB BWH MEDICARE","20587.70","","Case rate ($20,587.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,123.68, add-ons for qualifying new technology services are included. If operating cost exceeds $64,768.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,813.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $18,834.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,743.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,373.47. The transfer capital threshold is the transfer adjustment factor * $1,373.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18866.25","18866.25","18866.25","1 through 10","15631.35","23793.9797","other","Inpatient DRG"
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","","","","inpatient","","","73659.98","55244.98","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","15631.35","","Case rate ($15,950.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,123.68, add-ons for qualifying new technology services are included. If operating cost exceeds $64,768.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,813.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $14,197.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,743.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,373.47. The transfer capital threshold is the transfer adjustment factor * $1,373.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14073.00","14073.00","14073.00","1 through 10","15631.35","23793.9797","other","Inpatient DRG"
"Acute And Subacute Endocarditis With McC","288","MS-DRG","","","","","","","","inpatient","","","136486.81","102365.11","MEDICARE [2001]","HB BWH MEDICARE","32418.33","","Case rate ($32,418.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,097.21, add-ons for qualifying new technology services are included. If operating cost exceeds $75,741.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,617.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $29,860.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,717.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,177.57. The transfer capital threshold is the transfer adjustment factor * $2,177.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","32528.54","32528.54","32528.54","1 through 10","24564.75","41221.0665","other","Inpatient DRG"
"Acute And Subacute Endocarditis With McC","288","MS-DRG","","","","","","","","inpatient","","","136486.81","102365.11","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","24564.75","","Case rate ($25,066.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,097.21, add-ons for qualifying new technology services are included. If operating cost exceeds $75,741.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,617.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $22,508.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,717.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,177.57. The transfer capital threshold is the transfer adjustment factor * $2,177.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","24619.15","24619.15","24619.15","1 through 10","24564.75","41221.0665","other","Inpatient DRG"
"Acute And Subacute Endocarditis,EXTREME","193","DRG","","","","","","","","inpatient","","","160189.30","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","46567.81","","Standard inlier is a Case rate ($46,567.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,859, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,610.58) for the length of stay and the standard reimbursement.","65967.39","65967.39","65967.39","1 through 10","10756.52","175643.04","case rate",""
"Acute And Subacute Endocarditis,EXTREME","193","DRG","","","","","","","","inpatient","","","160189.30","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","14610.86","","Case rate ($16,154.82). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,584.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","250180.47","250180.47","250180.47","1 through 10","10756.52","175643.04","case rate",""
"Acute And Subacute Endocarditis,EXTREME","193","DRG","","","","","","","","inpatient","","","160189.30","","MASSHEALTH [3001]","HB BWH MEDICAID","14610.86","","Case rate ($16,154.82). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,584.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","117.30","117.30","117.30","1 through 10","10756.52","175643.04","case rate",""
"Acute And Subacute Endocarditis,EXTREME","193","DRG","","","","","","","","inpatient","","","160189.30","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14610.86","","Case rate ($16,154.82). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,584.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19412.59","19412.59","19412.59","1 through 10","10756.52","175643.04","case rate",""
"Acute And Subacute Endocarditis,MAJOR","193","DRG","","","","","","","","inpatient","","","67954.06","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14610.86","","Case rate ($16,154.82). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,584.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16150.85","16150.85","16150.85","1 through 10","10756.52","175643.04","case rate",""
"Acute And Subacute Endocarditis,MODERATE","193","DRG","","","","","","","","inpatient","","","23050.59","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","39526.96","","Standard inlier is a Case rate ($39,526.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,987, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,610.52) for the length of stay and the standard reimbursement.","39526.95","39526.95","39526.95","1 through 10","10756.52","175643.04","case rate",""
"Acute Anxiety And Stress Syndromes,MAJOR","756","DRG","","","","","","","","inpatient","","","39689.14","","HEALTH NEW ENGLAND [1034]","HB BWH MEDICAID","15519.04","","Case rate ($17,158.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,588.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18184.04","18184.04","18184.04","1 through 10","954.59","49757.47","case rate",""
"Acute Anxiety And Stress Syndromes,MAJOR","756","DRG","","","","","","","","inpatient","","","39689.14","","MASSHEALTH [3001]","HB BWH MEDICAID","15519.04","","Case rate ($17,158.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,588.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17154.75","17154.75","17154.75","1 through 10","954.59","49757.47","case rate",""
"Acute Anxiety And Stress Syndromes,MAJOR","756","DRG","","","","","","","","inpatient","","","39689.14","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","15519.04","","Case rate ($17,158.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,588.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","954.59","49757.47","case rate",""
"Acute Anxiety And Stress Syndromes,MINOR","756","DRG","","","","","","","","inpatient","","","38276.22","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16824.53","","Fee schedule rate ($16,824.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16334.36","16334.36","16334.36","1 through 10","954.59","49757.47","case rate",""
"Acute Anxiety And Stress Syndromes,MODERATE","756","DRG","","","","","","","","inpatient","","","58603.88","","MASSHEALTH [3001]","HB BWH MEDICAID","10608.01","","Case rate ($11,728.98). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,158.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4926.93","4926.93","4926.93","1 through 10","954.59","49757.47","case rate",""
"Acute Bronchitis And Related Symptoms,EXTREME","145","DRG","","","","","","","","inpatient","","","105245.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","41592.20","","Standard inlier is a Case rate ($41,592.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,417, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,903.67) for the length of stay and the standard reimbursement.","37998.07","37998.07","37998.07","1 through 10","3904.61","45456.22","case rate",""
"Acute Bronchitis And Related Symptoms,MINOR","145","DRG","","","","","","","","inpatient","","","37032.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","14724.86","","Standard inlier is a Case rate ($14,724.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,097, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,090.28) for the length of stay and the standard reimbursement.","14724.85","14724.85","14724.85","1 through 10","3904.61","45456.22","case rate",""
"Acute Bronchitis And Related Symptoms,MINOR","145","DRG","","","","","","","","inpatient","","","37032.85","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","3904.61","","Case rate ($4,317.21). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,747.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4316.15","4316.15","4316.15","1 through 10","3904.61","45456.22","case rate",""
"Acute Bronchitis And Related Symptoms,MODERATE","145","DRG","","","","","","","","inpatient","","","28002.61","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","18822.46","","Standard inlier is a Case rate ($18,822.46). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,671.96) for the length of stay and the standard reimbursement.","18822.46","18822.46","18822.46","1 through 10","3904.61","45456.22","case rate",""
"Acute Bronchitis And Related Symptoms,MODERATE","145","DRG","","","","","","","","inpatient","","","28002.61","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21161.52","","Standard inlier is a Case rate ($21,161.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,003.70) for the length of stay and the standard reimbursement.","15466.30","15466.30","15466.30","1 through 10","3904.61","45456.22","case rate",""
"Acute Bronchitis And Related Symptoms,MODERATE","145","DRG","","","","","","","","inpatient","","","28002.61","","MASSHEALTH [3001]","HB BWH MEDICAID","4778.52","","Case rate ($5,283.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,713.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5282.18","5282.18","5282.18","1 through 10","3904.61","45456.22","case rate",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","both","","","671.00","503.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","469.70","70","","505.52","501.84","505.52","1 through 10","46.39","637.45","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","both","","","671.00","503.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","533.45","79.5","","512.34","512.30","1645.62","16","46.39","637.45","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","both","","","671.00","503.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","357.64","53.3","","548.54","343.73","1537.02","17","46.39","637.45","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","both","","","671.00","503.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","244.92","36.5","","242.82","206.37","242.82","15","46.39","637.45","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","both","","","671.00","503.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","256.99","38.3","","254.54","254.54","763.62","30","46.39","637.45","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","both","","","671.00","503.25","TRICARE [160005]","HB BWH TRICARE","637.45","95","","57.39","57.39","57.39","1 through 10","46.39","637.45","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","outpatient","","","671.00","503.25","AETNA [1001]","HB AMC AETNA HMO","468.36","69.8","","440.73","311.18","507.78","18","46.39","548.34","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","outpatient","","","671.00","503.25","AETNA [1001]","HB AMC AETNA PPO","539.48","80.4","","507.78","507.78","543.66","1 through 10","46.39","548.34","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","outpatient","","","671.00","503.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","548.34","81.72","","520.41","286.24","557.18","21","46.39","548.34","percent of total billed charges",""
"Acute Kidney Injury,EXTREME","469","DRG","","","","","","","","inpatient","","","106736.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","55455.11","","Standard inlier is a Case rate ($55,455.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,771, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,872.19) for the length of stay and the standard reimbursement.","42517.89","42517.89","42517.89","1 through 10","5403.39","64478.37","case rate",""
"Acute Kidney Injury,EXTREME","469","DRG","","","","","","","","inpatient","","","106736.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","62346.49","","Standard inlier is a Case rate ($62,346.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,771, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,849.57) for the length of stay and the standard reimbursement.","56958.90","56958.90","62346.49","1 through 10","5403.39","64478.37","case rate",""
"Acute Kidney Injury,EXTREME","469","DRG","","","","","","","","inpatient","","","106736.21","","MASSHEALTH [3001]","HB BWH MEDICAID","21839.75","","Case rate ($24,147.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,577.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","24141.67","24141.67","24141.67","1 through 10","5403.39","64478.37","case rate",""
"Acute Kidney Injury,EXTREME","469","DRG","","","","","","","","inpatient","","","106736.21","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64478.37","","Fee schedule rate ($64,478.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","64478.37","64478.37","64478.37","1 through 10","5403.39","64478.37","case rate",""
"Acute Kidney Injury,EXTREME","469","DRG","","","","","","","","inpatient","","","106736.21","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","21839.75","","Case rate ($24,147.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,577.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","24141.68","496.29","63317.07","1 through 10","5403.39","64478.37","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","58059.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","29640.53","","Standard inlier is a Case rate ($29,640.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,207.65) for the length of stay and the standard reimbursement.","29640.52","29640.52","29640.52","1 through 10","5403.39","64478.37","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","58059.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","33323.94","","Standard inlier is a Case rate ($33,323.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,730.06) for the length of stay and the standard reimbursement.","33323.94","30444.29","57813.37","1 through 10","5403.39","64478.37","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","58059.43","","HEALTH NEW ENGLAND [1034]","HB BWH MEDICAID","9656.42","","Case rate ($10,676.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,106.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10674.21","10674.21","10674.21","1 through 10","5403.39","64478.37","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","58059.43","","MASSHEALTH [3001]","HB BWH MEDICAID","9656.42","","Case rate ($10,676.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,106.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10674.21","10674.21","24141.67","1 through 10","5403.39","64478.37","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","58059.43","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29284.06","","Fee schedule rate ($29,284.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24891.45","24891.45","24891.45","1 through 10","5403.39","64478.37","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","58059.43","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30748.75","","Fee schedule rate ($30,748.75). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30748.75","30748.75","30748.75","1 through 10","5403.39","64478.37","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","58059.43","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9656.42","","Case rate ($10,676.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,106.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10610.55","1307.28","10674.21","1 through 10","5403.39","64478.37","case rate",""
"Acute Kidney Injury,MODERATE","469","DRG","","","","","","","","inpatient","","","36773.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","18990.64","","Standard inlier is a Case rate ($18,990.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,414, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,695.84) for the length of stay and the standard reimbursement.","18239.38","18239.38","18239.38","1 through 10","5403.39","64478.37","case rate",""
"Acute Kidney Injury,MODERATE","469","DRG","","","","","","","","inpatient","","","36773.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21350.59","","Standard inlier is a Case rate ($21,350.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,414, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,030.54) for the length of stay and the standard reimbursement.","21350.59","21350.59","21350.59","1 through 10","5403.39","64478.37","case rate",""
"Acute Leukemia With Cc","835","MS-DRG","","","","","","","","inpatient","","","106340.49","79755.37","MEDICARE [2001]","HB BWH MEDICARE","19406.74","","Case rate ($19,406.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,284.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,928.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,118.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $17,348.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,904.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,678.36. The transfer capital threshold is the transfer adjustment factor * $1,678.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25458.74","0.03","25496.40","11","19018.61","32232.8669","other","Inpatient Replacement Plans DRG"
"Acute Leukemia With Cc","835","MS-DRG","","","","","","","","inpatient","","","106340.49","79755.37","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19018.61","","Case rate ($19,406.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,284.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,928.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,118.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $17,348.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,904.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,678.36. The transfer capital threshold is the transfer adjustment factor * $1,678.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26996.37","26996.37","26996.37","1 through 10","19018.61","32232.8669","other","Inpatient DRG"
"Acute Leukemia With Cc","835","MS-DRG","","","","","","","","inpatient","","","106340.49","79755.37","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19018.61","","Case rate ($19,406.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,284.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,928.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,118.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $17,348.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,904.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,678.36. The transfer capital threshold is the transfer adjustment factor * $1,678.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19399.45","19399.45","19399.45","1 through 10","19018.61","32232.8669","other","Inpatient DRG"
"Acute Leukemia With Cc","835","MS-DRG","","","","","","","","inpatient","","","106340.49","79755.37","WELLPOINT [1015]","HB AMC WELLPOINT","32232.8669","","Fee schedule rate ($32,671.97).","32232.8669","62993.84","62993.84","1 through 10","19018.61","32232.8669","case rate",""
"Acute Leukemia With McC","834","MS-DRG","","","","","","","","inpatient","","","251048.64","188286.48","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","51973.06","","Case rate ($50,459.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,665.62, add-ons for qualifying new technology services are included. If operating cost exceeds $106,310.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,857.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $45,661.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $60,285.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,417.50. The transfer capital threshold is the transfer adjustment factor * $4,417.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","52029.71","52029.71","52029.71","1 through 10","49450.09","83412.4843","other","Inpatient DRG"
"Acute Leukemia With McC","834","MS-DRG","","","","","","","","inpatient","","","251048.64","188286.48","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","65374.35","","Case rate ($65,374.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,665.62, add-ons for qualifying new technology services are included. If operating cost exceeds $106,310.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,857.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $60,577.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $60,285.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,417.50. The transfer capital threshold is the transfer adjustment factor * $4,417.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","49887.29","49887.29","49887.29","1 through 10","49450.09","83412.4843","other","Inpatient DRG"
"Acute Leukemia With McC","834","MS-DRG","","","","","","","","inpatient","","","251048.64","188286.48","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","99536.74","99536.74","99536.74","1 through 10","49450.09","83412.4843","case rate",""
"Acute Leukemia With McC","834","MS-DRG","","","","","","","","inpatient","","","251048.64","188286.48","MEDICARE [2001]","HB BWH MEDICARE","65374.35","","Case rate ($65,374.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,665.62, add-ons for qualifying new technology services are included. If operating cost exceeds $106,310.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,857.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $60,577.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $60,285.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,417.50. The transfer capital threshold is the transfer adjustment factor * $4,417.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","65440.48","0.03","65537.95","32","49450.09","83412.4843","other","Inpatient DRG"
"Acute Leukemia With McC","834","MS-DRG","","","","","","","","inpatient","","","251048.64","188286.48","MOLINA [1014]","HB BWH MOLINA","49450.09","","Case rate ($50,459.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,665.62, add-ons for qualifying new technology services are included. If operating cost exceeds $106,310.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,857.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $45,661.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $60,285.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,417.50. The transfer capital threshold is the transfer adjustment factor * $4,417.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","50739.89","50739.89","50739.89","1 through 10","49450.09","83412.4843","other","Inpatient DRG"
"Acute Leukemia With McC","834","MS-DRG","","","","","","","","inpatient","","","251048.64","188286.48","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","49450.09","","Case rate ($50,459.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,665.62, add-ons for qualifying new technology services are included. If operating cost exceeds $106,310.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,857.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $45,661.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $60,285.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,417.50. The transfer capital threshold is the transfer adjustment factor * $4,417.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","49608.23","49603.78","71674.57","1 through 10","49450.09","83412.4843","other","Inpatient DRG"
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","","","","inpatient","","","268017.77","201013.33","MEDICARE [2001]","HB BWH MEDICARE","79372.71","","Case rate ($79,372.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $95,471.69, add-ons for qualifying new technology services are included. If operating cost exceeds $141,116.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $9,408.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 15.3. The base transfer operating payment is the transfer adjustment factor * $72,024.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $95,091.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,967.94. The transfer capital threshold is the transfer adjustment factor * $6,967.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","108878.80","108878.80","109041.26","1 through 10","77785.26","135642.41","other","Inpatient Replacement Plans DRG"
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","","","","inpatient","","","268017.77","201013.33","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","77785.26","","Case rate ($79,372.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $95,471.69, add-ons for qualifying new technology services are included. If operating cost exceeds $141,116.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $9,408.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 15.3. The base transfer operating payment is the transfer adjustment factor * $72,024.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $95,091.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,967.94. The transfer capital threshold is the transfer adjustment factor * $6,967.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","137051.13","137051.13","137051.13","1 through 10","77785.26","135642.41","other","Inpatient DRG"
"Acute Leukemia,EXTREME","690","DRG","","","","","","","","inpatient","","","423198.92","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","96482.91","","Standard inlier is a Case rate ($96,482.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $86,676, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,696.33) for the length of stay and the standard reimbursement.","167988.85","167988.85","167988.85","1 through 10","28065.33","357626.52","case rate",""
"Acute Leukemia,EXTREME","690","DRG","","","","","","","","inpatient","","","423198.92","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","108472.79","","Standard inlier is a Case rate ($108,472.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $86,676, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($15,396.81) for the length of stay and the standard reimbursement.","188864.74","188864.74","188864.74","1 through 10","28065.33","357626.52","case rate",""
"Acute Leukemia,EXTREME","690","DRG","","","","","","","","inpatient","","","423198.92","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","108472.79","","Standard inlier is a Case rate ($108,472.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $86,676, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($15,396.81) for the length of stay and the standard reimbursement.","172544.25","172544.25","172544.25","1 through 10","28065.33","357626.52","case rate",""
"Acute Leukemia,EXTREME","690","DRG","","","","","","","","inpatient","","","423198.92","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","227789.02","227789.02","227789.02","1 through 10","28065.33","357626.52","percent of total billed charges",""
"Acute Leukemia,EXTREME","690","DRG","","","","","","","","inpatient","","","423198.92","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","29188.935","","Fee schedule rate ($216,740.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29188.935","216740.72","216740.72","1 through 10","28065.33","357626.52","case rate",""
"Acute Leukemia,EXTREME","690","DRG","","","","","","","","inpatient","","","423198.92","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","30649.23","","Fee schedule rate ($227,584.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30649.23","227584.04","227584.04","1 through 10","28065.33","357626.52","case rate",""
"Acute Leukemia,EXTREME","690","DRG","","","","","","","","inpatient","","","423198.92","","MASSHEALTH [3001]","HB BWH MEDICAID","52904.11","","Case rate ($58,494.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $100,924.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","99536.74","38357.13","158789.02","1 through 10","28065.33","357626.52","case rate",""
"Acute Leukemia,EXTREME","690","DRG","","","","","","","","inpatient","","","423198.92","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","52904.11","","Case rate ($58,494.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $100,924.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","28065.33","357626.52","case rate",""
"Acute Leukemia,EXTREME","690","DRG","","","","","","","","inpatient","","","423198.92","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","214950.13","","Fee schedule rate ($214,950.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","214950.13","214950.13","214950.13","1 through 10","28065.33","357626.52","case rate",""
"Acute Leukemia,EXTREME","690","DRG","","","","","","","","inpatient","","","423198.92","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","225701.17","","Fee schedule rate ($225,701.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","219125.49","219125.49","219125.49","1 through 10","28065.33","357626.52","case rate",""
"Acute Leukemia,EXTREME","690","DRG","","","","","","","","inpatient","","","423198.92","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","52904.11","","Case rate ($58,494.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $100,924.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","120972.34","99536.74","200003.42","1 through 10","28065.33","357626.52","case rate",""
"Acute Leukemia,MAJOR","690","DRG","","","","","","","","inpatient","","","315779.80","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","96482.91","","Standard inlier is a Case rate ($96,482.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $86,676, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,696.33) for the length of stay and the standard reimbursement.","119723.28","119723.28","119723.28","1 through 10","28065.33","357626.52","case rate",""
"Acute Leukemia,MAJOR","690","DRG","","","","","","","","inpatient","","","315779.80","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","108472.79","","Standard inlier is a Case rate ($108,472.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $86,676, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($15,396.81) for the length of stay and the standard reimbursement.","118029.15","99099.25","163209.31","1 through 10","28065.33","357626.52","case rate",""
"Acute Leukemia,MAJOR","690","DRG","","","","","","","","inpatient","","","315779.80","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","","65","","167646.33","167646.33","167646.33","1 through 10","28065.33","357626.52","percent of total billed charges",""
"Acute Leukemia,MAJOR","690","DRG","","","","","","","","inpatient","","","315779.80","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","143993.40","143993.40","143993.40","1 through 10","28065.33","357626.52","percent of total billed charges",""
"Acute Leukemia,MAJOR","690","DRG","","","","","","","","inpatient","","","315779.80","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","29188.935","","Fee schedule rate ($130,323.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29188.935","130323.56","130323.56","1 through 10","28065.33","357626.52","case rate",""
"Acute Leukemia,MODERATE","690","DRG","","","","","","","","inpatient","","","61915.46","","MASSHEALTH [3001]","HB BWH MEDICAID","29377.08","","Case rate ($32,481.42). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $74,911.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","32473.45","32473.45","32473.45","1 through 10","28065.33","357626.52","case rate",""
"Acute Major Eye Infections With Cc/McC","121","MS-DRG","","","","","","","","inpatient","","","46629.02","34971.76","MEDICARE [2001]","HB BWH MEDICARE","10991.58","","Case rate ($10,991.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,154.29, add-ons for qualifying new technology services are included. If operating cost exceeds $58,798.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,376.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $9,675.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,774.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $936.06. The transfer capital threshold is the transfer adjustment factor * $936.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14011.94","14011.94","14011.94","1 through 10","10771.75","17553.8512","other","Inpatient Replacement Plans DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","61321.53","45991.15","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","11261.00","","Case rate ($11,261). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,472.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,117.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,179.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $10,141.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,092.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.56. The transfer capital threshold is the transfer adjustment factor * $739.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8556.35","8556.35","8556.35","1 through 10","8588.69","13910.8838","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","61321.53","45991.15","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8763.97","","Case rate ($8,763.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,472.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,117.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,179.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,644.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,092.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.56. The transfer capital threshold is the transfer adjustment factor * $739.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8505.78","8480.26","10898.00","1 through 10","8588.69","13910.8838","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","61321.53","45991.15","MEDICARE [2001]","HB BWH MEDICARE","11261.00","","Case rate ($11,261). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,472.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,117.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,179.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $10,141.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,092.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.56. The transfer capital threshold is the transfer adjustment factor * $739.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11145.52","0.03","11161.78","53","8588.69","13910.8838","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","61321.53","45991.15","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8588.69","","Case rate ($8,763.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,472.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,117.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,179.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,644.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,092.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.56. The transfer capital threshold is the transfer adjustment factor * $739.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8480.26","8480.26","8540.51","1 through 10","8588.69","13910.8838","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","61321.53","45991.15","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8588.69","","Case rate ($8,763.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,472.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,117.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,179.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,644.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,092.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.56. The transfer capital threshold is the transfer adjustment factor * $739.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8502.29","8472.28","8704.45","1 through 10","8588.69","13910.8838","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","61321.53","45991.15","WELLSENSE [1003]","HB BWH MEDICARE","11261.00","","Case rate ($11,261). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,472.68, add-ons for qualifying new technology services are included. If operating cost exceeds $56,117.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,179.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $10,141.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,092.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.56. The transfer capital threshold is the transfer adjustment factor * $739.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1283.96","1283.96","1283.96","1 through 10","8588.69","13910.8838","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","103956.24","77967.18","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15463.00","","Case rate ($15,012.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,994.81, add-ons for qualifying new technology services are included. If operating cost exceeds $63,639.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,730.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,342.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,614.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.75. The transfer capital threshold is the transfer adjustment factor * $1,290.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15666.41","15647.97","15677.60","1 through 10","14712.37","25126.62","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","103956.24","77967.18","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","19370.67","","Case rate ($19,370.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,994.81, add-ons for qualifying new technology services are included. If operating cost exceeds $63,639.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,730.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $17,700.07 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,614.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.75. The transfer capital threshold is the transfer adjustment factor * $1,290.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15025.75","15025.75","35946.26","1 through 10","14712.37","25126.62","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","103956.24","77967.18","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15012.62","","Case rate ($15,012.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,994.81, add-ons for qualifying new technology services are included. If operating cost exceeds $63,639.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,730.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,342.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,614.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.75. The transfer capital threshold is the transfer adjustment factor * $1,290.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14926.41","14873.48","14981.47","1 through 10","14712.37","25126.62","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","103956.24","77967.18","MEDICARE [2001]","HB BWH MEDICARE","19370.67","","Case rate ($19,370.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,994.81, add-ons for qualifying new technology services are included. If operating cost exceeds $63,639.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,730.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $17,700.07 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,614.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.75. The transfer capital threshold is the transfer adjustment factor * $1,290.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19628.99","0.03","20339.65","80","14712.37","25126.62","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","103956.24","77967.18","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","19370.67","","Case rate ($19,370.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,994.81, add-ons for qualifying new technology services are included. If operating cost exceeds $63,639.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,730.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $17,700.07 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,614.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.75. The transfer capital threshold is the transfer adjustment factor * $1,290.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","115.71","115.71","115.71","1 through 10","14712.37","25126.62","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","103956.24","77967.18","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14712.37","","Case rate ($15,012.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,994.81, add-ons for qualifying new technology services are included. If operating cost exceeds $63,639.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,730.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,342.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,614.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.75. The transfer capital threshold is the transfer adjustment factor * $1,290.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14967.53","14967.53","15008.32","1 through 10","14712.37","25126.62","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","103956.24","77967.18","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14712.37","","Case rate ($15,012.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,994.81, add-ons for qualifying new technology services are included. If operating cost exceeds $63,639.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,730.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,342.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,614.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.75. The transfer capital threshold is the transfer adjustment factor * $1,290.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15223.06","14940.16","23319.29","11","14712.37","25126.62","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","103956.24","77967.18","WELLSENSE [1003]","HB BWH MEDICARE","19370.67","","Case rate ($19,370.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,994.81, add-ons for qualifying new technology services are included. If operating cost exceeds $63,639.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,730.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $17,700.07 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,614.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.75. The transfer capital threshold is the transfer adjustment factor * $1,290.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15328.53","15328.53","15328.53","1 through 10","14712.37","25126.62","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","52236.37","39177.28","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7185.33","","Case rate ($6,976.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,320.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,964.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,022.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,014.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,940.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $581.85. The transfer capital threshold is the transfer adjustment factor * $581.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7068.10","7068.10","7068.10","1 through 10","6836.53","10942.4841","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","52236.37","39177.28","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","6976.05","","Case rate ($6,976.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,320.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,964.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,022.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,014.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,940.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $581.85. The transfer capital threshold is the transfer adjustment factor * $581.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6817.22","6817.22","6817.22","1 through 10","6836.53","10942.4841","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","52236.37","39177.28","MEDICARE [2001]","HB BWH MEDICARE","6976.05","","Case rate ($6,976.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,320.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,964.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,022.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,014.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,940.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $581.85. The transfer capital threshold is the transfer adjustment factor * $581.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","3819.68","728.09","8839.39","1 through 10","6836.53","10942.4841","other","Inpatient Replacement Plans DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","52236.37","39177.28","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","6976.05","","Case rate ($6,976.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,320.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,964.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,022.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,014.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,940.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $581.85. The transfer capital threshold is the transfer adjustment factor * $581.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6738.49","6738.49","6738.49","1 through 10","6836.53","10942.4841","other","Inpatient Replacement Plans DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","52236.37","39177.28","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6836.53","","Case rate ($6,976.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,320.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,964.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,022.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,014.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,940.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $581.85. The transfer capital threshold is the transfer adjustment factor * $581.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6738.62","6738.62","6738.62","1 through 10","6836.53","10942.4841","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","52236.37","39177.28","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6836.53","","Case rate ($6,976.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,320.36, add-ons for qualifying new technology services are included. If operating cost exceeds $53,964.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,022.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,014.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,940.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $581.85. The transfer capital threshold is the transfer adjustment factor * $581.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6745.12","6745.12","9014.62","1 through 10","6836.53","10942.4841","other","Inpatient DRG"
"Acute Myocardial Infarction, Expired With McC","283","MS-DRG","","","","","","","","inpatient","","","101848.44","76386.33","MEDICARE [2001]","HB BWH MEDICARE","23830.39","","Case rate ($23,830.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,131.44, add-ons for qualifying new technology services are included. If operating cost exceeds $67,775.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,034.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $21,856.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,751.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,593.87. The transfer capital threshold is the transfer adjustment factor * $1,593.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23365.27","23330.78","49983.45","1 through 10","18079.93","29508.9414","other","Inpatient DRG"
"Acute Myocardial Infarction, Expired With McC","283","MS-DRG","","","","","","","","inpatient","","","101848.44","76386.33","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","18079.93","","Case rate ($18,448.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,131.44, add-ons for qualifying new technology services are included. If operating cost exceeds $67,775.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,034.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $16,475.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,751.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,593.87. The transfer capital threshold is the transfer adjustment factor * $1,593.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17784.30","17784.30","17784.30","1 through 10","18079.93","29508.9414","other","Inpatient DRG"
"Acute Myocardial Infarction, Expired With McC","283","MS-DRG","","","","","","","","inpatient","","","101848.44","76386.33","WELLPOINT [1015]","HB AMC WELLPOINT","29508.9414","","Fee schedule rate ($31,027.25).","29508.9414","129199.52","129199.52","1 through 10","18079.93","29508.9414","case rate",""
"Acute Myocardial Infarction,EXTREME","190","DRG","","","","","","","","inpatient","","","96954.57","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","49750.16","","Standard inlier is a Case rate ($49,750.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,336, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,062.34) for the length of stay and the standard reimbursement.","45349.08","45349.08","45349.08","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,EXTREME","190","DRG","","","","","","","","inpatient","","","96954.57","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","55932.59","","Standard inlier is a Case rate ($55,932.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,336, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,939.17) for the length of stay and the standard reimbursement.","55932.58","55932.58","55932.58","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,EXTREME","190","DRG","","","","","","","","inpatient","","","96954.57","","MASSHEALTH [3001]","HB BWH MEDICAID","14746.80","","Case rate ($16,305.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,735.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","92341.64","92341.64","92341.64","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MAJOR","190","DRG","","","","","","","","inpatient","","","92228.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","34284.69","","Standard inlier is a Case rate ($34,284.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,309, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,866.92) for the length of stay and the standard reimbursement.","34284.69","34284.69","34284.69","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MAJOR","190","DRG","","","","","","","","inpatient","","","92228.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","38545.24","","Standard inlier is a Case rate ($38,545.24). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,309, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,471.18) for the length of stay and the standard reimbursement.","38545.23","38545.23","38545.23","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MAJOR","190","DRG","","","","","","","","inpatient","","","92228.88","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","19085.7611","","Fee schedule rate ($36,109.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19085.7611","36109.28","36109.28","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MAJOR","190","DRG","","","","","","","","inpatient","","","92228.88","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","20040.6038","","Fee schedule rate ($37,915.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20040.6038","37915.80","37915.80","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MAJOR","190","DRG","","","","","","","","inpatient","","","92228.88","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8779.08","","Case rate ($9,706.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,136.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","460.88","33026.31","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MINOR","190","DRG","","","","","","","","inpatient","","","58315.79","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24556.52","","Standard inlier is a Case rate ($24,556.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,745, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,485.95) for the length of stay and the standard reimbursement.","24556.52","24556.52","24556.52","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MINOR","190","DRG","","","","","","","","inpatient","","","58315.79","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","27608.15","","Standard inlier is a Case rate ($27,608.15). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,745, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,918.75) for the length of stay and the standard reimbursement.","27608.14","25225.85","27608.14","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MINOR","190","DRG","","","","","","","","inpatient","","","58315.79","","MASSHEALTH [3001]","HB BWH MEDICAID","4532.91","","Case rate ($5,011.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,441.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5010.68","5010.68","5010.68","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MINOR","190","DRG","","","","","","","","inpatient","","","58315.79","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23278.64","","Fee schedule rate ($23,278.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23278.64","23278.64","23278.64","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MINOR","190","DRG","","","","","","","","inpatient","","","58315.79","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4532.91","","Case rate ($5,011.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,441.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5010.68","5010.68","5010.68","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MODERATE","190","DRG","","","","","","","","inpatient","","","56085.59","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","26771.88","","Standard inlier is a Case rate ($26,771.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,467, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,800.43) for the length of stay and the standard reimbursement.","26771.87","26771.87","26771.87","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MODERATE","190","DRG","","","","","","","","inpatient","","","56085.59","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","30098.81","","Standard inlier is a Case rate ($30,098.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,467, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,272.28) for the length of stay and the standard reimbursement.","30098.80","30098.80","30098.80","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MODERATE","190","DRG","","","","","","","","inpatient","","","56085.59","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","19085.7611","","Fee schedule rate ($23,948.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19085.7611","23948.36","23948.36","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MODERATE","190","DRG","","","","","","","","inpatient","","","56085.59","","MASSHEALTH [3001]","HB BWH MEDICAID","5992.85","","Case rate ($6,626.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,056.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","617.25","617.25","617.25","1 through 10","4532.91","106916.68","case rate",""
"Acute Myocardial Infarction,MODERATE","190","DRG","","","","","","","","inpatient","","","56085.59","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5992.85","","Case rate ($6,626.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,056.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6624.50","6624.50","6624.50","1 through 10","4532.91","106916.68","case rate",""
"Acyclovir Inj 5mg","PX-63600056","CDM","J0133","HCPCS","0636","RC","","","","both","","","1.57","1.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.60","38.3","","0.03","0.03","0.03","145","0.13","1.21","percent of total billed charges",""
"Acylcarnitines Qn Ea Specimen","PX-30000278","CDM","82017","CPT","0301","RC","","","","both","","","191.00","143.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","151.85","79.5","","145.60","145.60","145.60","1 through 10","11.02","181.45","percent of total billed charges",""
"Acylcarnitines Qn Ea Specimen","PX-30000278","CDM","82017","CPT","0301","RC","","","","both","","","191.00","143.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","69.72","36.5","","58.65","58.65","58.65","1 through 10","11.02","181.45","percent of total billed charges",""
"Acylcarnitines Qn Ea Specimen","PX-30000278","CDM","82017","CPT","0301","RC","","","","both","","","191.00","143.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.15","38.3","","70.30","70.30","70.30","1 through 10","11.02","181.45","percent of total billed charges",""
"Acylcarnitines Qn Ea Specimen","PX-30000278","CDM","82017","CPT","0301","RC","","","","outpatient","","","191.00","143.25","AETNA [1001]","HB AMC AETNA HMO","133.32","69.8","","125.25","88.43","125.25","1 through 10","11.02","156.09","percent of total billed charges",""
"Acylcarnitines Qn Ea Specimen","PX-30000278","CDM","82017","CPT","0301","RC","","","","outpatient","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","156.09","81.72","","81.34","81.34","81.34","1 through 10","11.02","156.09","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","both","","","135.00","101.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","107.33","79.5","","106.25","71.28","106.25","1 through 10","14.12","128.25","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","both","","","135.00","101.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","71.96","53.3","","106.25","71.28","106.25","1 through 10","14.12","128.25","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","49.28","36.5","","50.36","42.80","92.50","13","14.12","128.25","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","51.71","38.3","","52.79","44.55","158.37","30","14.12","128.25","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","outpatient","","","135.00","101.25","AETNA [1001]","HB AMC AETNA HMO","94.23","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","108.54","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","110.32","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Adalimumab Qn With Reflex to Ab, S","PX-30003495","CDM","80299","CPT","0301","RC","","","","both","","","654.00","490.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","519.93","79.5","","106.25","71.28","106.25","1 through 10","14.12","621.3","percent of total billed charges",""
"Adalimumab Qn With Reflex to Ab, S","PX-30003495","CDM","80299","CPT","0301","RC","","","","both","","","654.00","490.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","348.58","53.3","","106.25","71.28","106.25","1 through 10","14.12","621.3","percent of total billed charges",""
"Adalimumab Qn With Reflex to Ab, S","PX-30003495","CDM","80299","CPT","0301","RC","","","","both","","","654.00","490.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","238.71","36.5","","50.36","42.80","92.50","13","14.12","621.3","percent of total billed charges",""
"Adalimumab Qn With Reflex to Ab, S","PX-30003495","CDM","80299","CPT","0301","RC","","","","both","","","654.00","490.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","250.48","38.3","","52.79","44.55","158.37","30","14.12","621.3","percent of total billed charges",""
"Adalimumab Qn With Reflex to Ab, S","PX-30003495","CDM","80299","CPT","0301","RC","","","","outpatient","","","654.00","490.50","AETNA [1001]","HB AMC AETNA HMO","456.49","69.8","","91.40","64.53","105.30","14","14.12","534.45","percent of total billed charges",""
"Adalimumab Qn With Reflex to Ab, S","PX-30003495","CDM","80299","CPT","0301","RC","","","","outpatient","","","654.00","490.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","525.82","80.4","","105.30","105.30","105.30","1 through 10","14.12","534.45","percent of total billed charges",""
"Adalimumab Qn With Reflex to Ab, S","PX-30003495","CDM","80299","CPT","0301","RC","","","","outpatient","","","654.00","490.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","534.45","81.72","","59.36","15.50","59.36","1 through 10","14.12","534.45","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Adamts13 Sequence Analysis","PX-31000625","CDM","81479","CPT","0310","RC","","","","both","","","2526.00","1894.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2008.17","79.5","","0.65","0.65","0.65","1 through 10","783.06","2399.7","percent of total billed charges",""
"Adamts13 Sequence Analysis","PX-31000625","CDM","81479","CPT","0310","RC","","","","both","","","2526.00","1894.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1346.36","53.3","","0.79","0.79","0.79","1 through 10","783.06","2399.7","percent of total billed charges",""
"Adamts13 Sequence Analysis","PX-31000625","CDM","81479","CPT","0310","RC","","","","outpatient","","","2526.00","1894.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1263.00","50","","1.00","1.00","1.00","1 through 10","156.55","2083.95","percent of total billed charges",""
"Adamts13 Sequence Analysis","PX-31000625","CDM","81479","CPT","0310","RC","","","","outpatient","","","2526.00","1894.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1326.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","2083.95","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","429.84","52.26","","1113.10","1113.10","1113.10","1 through 10","254.98","653.89","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","653.89","79.5","","1293.60","1148.53","1603.80","1 through 10","254.98","653.89","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","300.21","36.5","","1023.42","771.29","2068.67","33","254.98","653.89","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","315.02","38.3","","850.52","759.78","1211.25","66","254.98","653.89","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","352.85","42.9","","2548.09","2548.09","2548.09","1 through 10","254.98","653.89","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","352.85","42.9","","956.46","956.46","956.46","1 through 10","254.98","653.89","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","WELLPOINT [1015]","HB AMC WELLPOINT","606.84","73.78","","2344.73","1619.47","2530.35","16","254.98","653.89","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","822.50","616.87","AETNA [1001]","HB AMC AETNA HMO","574.11","69.8","","1523.63","988.41","4330.26","39","429.84","672.15","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","822.50","616.87","AETNA [1001]","HB AMC AETNA PPO","661.29","80.4","","1670.25","1670.25","1670.25","1 through 10","429.84","672.15","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","822.50","616.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","429.84","52.26","","1113.10","1113.10","1113.10","1 through 10","429.84","672.15","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","822.50","616.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","672.15","81.72","","1738.90","1484.65","2716.94","38","429.84","672.15","percent of total billed charges",""
"ADAPTER CONNECTION 1X8 1.3MM 15CM PRECISION M8 POLYURETHANE SILICONE INLINE CONNECTOR","SUP-ITM-10191376","CDM","C1883","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","862.31","36.5","","1073.15","1073.15","1073.15","1 through 10","732.38","1878.19","percent of total billed charges",""
"ADAPTER CONNECTION 1X8 1.3MM 15CM PRECISION M8 POLYURETHANE SILICONE INLINE CONNECTOR","SUP-ITM-10191376","CDM","C1883","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","904.84","38.3","","1808.38","1642.20","1808.38","1 through 10","732.38","1878.19","percent of total billed charges",""
"ADAPTER CONNECTION 1X8 1.3MM 15CM PRECISION M8 POLYURETHANE SILICONE INLINE CONNECTOR","SUP-ITM-10191376","CDM","C1883","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","WELLPOINT [1015]","HB AMC WELLPOINT","1743.05","73.78","","625.38","625.38","625.38","1 through 10","732.38","1878.19","percent of total billed charges",""
"ADAPTER FEMORAL 360 25MM KNEE VANGUARD OFFSET REVISION SYSTEM","SUP-ITM-10117677","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1498.03","52.26","","1113.10","1113.10","1113.10","1 through 10","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 360 25MM KNEE VANGUARD OFFSET REVISION SYSTEM","SUP-ITM-10117677","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2278.87","79.5","","1293.60","1148.53","1603.80","1 through 10","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 360 25MM KNEE VANGUARD OFFSET REVISION SYSTEM","SUP-ITM-10117677","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1046.27","36.5","","1023.42","771.29","2068.67","33","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 360 25MM KNEE VANGUARD OFFSET REVISION SYSTEM","SUP-ITM-10117677","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1097.87","38.3","","850.52","759.78","1211.25","66","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 360 25MM KNEE VANGUARD OFFSET REVISION SYSTEM","SUP-ITM-10117677","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1229.73","42.9","","2548.09","2548.09","2548.09","1 through 10","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 360 25MM KNEE VANGUARD OFFSET REVISION SYSTEM","SUP-ITM-10117677","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1229.73","42.9","","956.46","956.46","956.46","1 through 10","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 360 25MM KNEE VANGUARD OFFSET REVISION SYSTEM","SUP-ITM-10117677","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","WELLPOINT [1015]","HB AMC WELLPOINT","2114.90","73.78","","2344.73","1619.47","2530.35","16","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 360 25MM KNEE VANGUARD OFFSET REVISION SYSTEM","SUP-ITM-10117677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2866.50","2149.87","AETNA [1001]","HB AMC AETNA HMO","2000.82","69.8","","1523.63","988.41","4330.26","39","1498.03","2342.5","percent of total billed charges",""
"ADAPTER FEMORAL 360 25MM KNEE VANGUARD OFFSET REVISION SYSTEM","SUP-ITM-10117677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2866.50","2149.87","AETNA [1001]","HB AMC AETNA PPO","2304.67","80.4","","1670.25","1670.25","1670.25","1 through 10","1498.03","2342.5","percent of total billed charges",""
"ADAPTER FEMORAL 360 25MM KNEE VANGUARD OFFSET REVISION SYSTEM","SUP-ITM-10117677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2866.50","2149.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1498.03","52.26","","1113.10","1113.10","1113.10","1 through 10","1498.03","2342.5","percent of total billed charges",""
"ADAPTER FEMORAL 360 25MM KNEE VANGUARD OFFSET REVISION SYSTEM","SUP-ITM-10117677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2866.50","2149.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2342.50","81.72","","1738.90","1484.65","2716.94","38","1498.03","2342.5","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1227.33","52.26","","1113.10","1113.10","1113.10","1 through 10","728.04","1867.06","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1867.06","79.5","","1293.60","1148.53","1603.80","1 through 10","728.04","1867.06","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","857.20","36.5","","1023.42","771.29","2068.67","33","728.04","1867.06","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","899.48","38.3","","850.52","759.78","1211.25","66","728.04","1867.06","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1007.51","42.9","","2548.09","2548.09","2548.09","1 through 10","728.04","1867.06","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1007.51","42.9","","956.46","956.46","956.46","1 through 10","728.04","1867.06","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","WELLPOINT [1015]","HB AMC WELLPOINT","1732.72","73.78","","2344.73","1619.47","2530.35","16","728.04","1867.06","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2348.50","1761.37","AETNA [1001]","HB AMC AETNA HMO","1639.25","69.8","","1523.63","988.41","4330.26","39","1227.33","1919.19","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2348.50","1761.37","AETNA [1001]","HB AMC AETNA PPO","1888.19","80.4","","1670.25","1670.25","1670.25","1 through 10","1227.33","1919.19","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2348.50","1761.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1227.33","52.26","","1113.10","1113.10","1113.10","1 through 10","1227.33","1919.19","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2348.50","1761.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1919.19","81.72","","1738.90","1484.65","2716.94","38","1227.33","1919.19","percent of total billed charges",""
"ADAPTER FEMORAL 5.0MM KNEE VANGUARD 360 OFFSET REVISION SYSTEM","SUP-ITM-10117678","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1498.03","52.26","","1113.10","1113.10","1113.10","1 through 10","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 5.0MM KNEE VANGUARD 360 OFFSET REVISION SYSTEM","SUP-ITM-10117678","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2278.87","79.5","","1293.60","1148.53","1603.80","1 through 10","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 5.0MM KNEE VANGUARD 360 OFFSET REVISION SYSTEM","SUP-ITM-10117678","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1046.27","36.5","","1023.42","771.29","2068.67","33","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 5.0MM KNEE VANGUARD 360 OFFSET REVISION SYSTEM","SUP-ITM-10117678","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1097.87","38.3","","850.52","759.78","1211.25","66","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 5.0MM KNEE VANGUARD 360 OFFSET REVISION SYSTEM","SUP-ITM-10117678","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1229.73","42.9","","2548.09","2548.09","2548.09","1 through 10","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 5.0MM KNEE VANGUARD 360 OFFSET REVISION SYSTEM","SUP-ITM-10117678","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1229.73","42.9","","956.46","956.46","956.46","1 through 10","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 5.0MM KNEE VANGUARD 360 OFFSET REVISION SYSTEM","SUP-ITM-10117678","CDM","C1776","HCPCS","0278","RC","","","","both","","","2866.50","2149.87","WELLPOINT [1015]","HB AMC WELLPOINT","2114.90","73.78","","2344.73","1619.47","2530.35","16","888.62","2278.87","percent of total billed charges",""
"ADAPTER FEMORAL 5.0MM KNEE VANGUARD 360 OFFSET REVISION SYSTEM","SUP-ITM-10117678","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2866.50","2149.87","AETNA [1001]","HB AMC AETNA HMO","2000.82","69.8","","1523.63","988.41","4330.26","39","1498.03","2342.5","percent of total billed charges",""
"ADAPTER FEMORAL 5.0MM KNEE VANGUARD 360 OFFSET REVISION SYSTEM","SUP-ITM-10117678","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2866.50","2149.87","AETNA [1001]","HB AMC AETNA PPO","2304.67","80.4","","1670.25","1670.25","1670.25","1 through 10","1498.03","2342.5","percent of total billed charges",""
"ADAPTER FEMORAL 5.0MM KNEE VANGUARD 360 OFFSET REVISION SYSTEM","SUP-ITM-10117678","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2866.50","2149.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1498.03","52.26","","1113.10","1113.10","1113.10","1 through 10","1498.03","2342.5","percent of total billed charges",""
"ADAPTER FEMORAL 5.0MM KNEE VANGUARD 360 OFFSET REVISION SYSTEM","SUP-ITM-10117678","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2866.50","2149.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2342.50","81.72","","1738.90","1484.65","2716.94","38","1498.03","2342.5","percent of total billed charges",""
"ADAPTER HEAD 10.5MM FEMORAL IMPLANT HIP VERSYS ENDOPROSTHESIS ALLOY PLUS 14 BX/1","SUP-ITM-10005430","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","310.95","52.26","","1113.10","1113.10","1113.10","1 through 10","184.45","473.03","percent of total billed charges",""
"ADAPTER HEAD 10.5MM FEMORAL IMPLANT HIP VERSYS ENDOPROSTHESIS ALLOY PLUS 14 BX/1","SUP-ITM-10005430","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","473.03","79.5","","1293.60","1148.53","1603.80","1 through 10","184.45","473.03","percent of total billed charges",""
"ADAPTER HEAD 10.5MM FEMORAL IMPLANT HIP VERSYS ENDOPROSTHESIS ALLOY PLUS 14 BX/1","SUP-ITM-10005430","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","217.18","36.5","","1023.42","771.29","2068.67","33","184.45","473.03","percent of total billed charges",""
"ADAPTER HEAD 10.5MM FEMORAL IMPLANT HIP VERSYS ENDOPROSTHESIS ALLOY PLUS 14 BX/1","SUP-ITM-10005430","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","227.89","38.3","","850.52","759.78","1211.25","66","184.45","473.03","percent of total billed charges",""
"ADAPTER HEAD 10.5MM FEMORAL IMPLANT HIP VERSYS ENDOPROSTHESIS ALLOY PLUS 14 BX/1","SUP-ITM-10005430","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.26","42.9","","2548.09","2548.09","2548.09","1 through 10","184.45","473.03","percent of total billed charges",""
"ADAPTER HEAD 10.5MM FEMORAL IMPLANT HIP VERSYS ENDOPROSTHESIS ALLOY PLUS 14 BX/1","SUP-ITM-10005430","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.26","42.9","","956.46","956.46","956.46","1 through 10","184.45","473.03","percent of total billed charges",""
"ADAPTER HEAD 10.5MM FEMORAL IMPLANT HIP VERSYS ENDOPROSTHESIS ALLOY PLUS 14 BX/1","SUP-ITM-10005430","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","WELLPOINT [1015]","HB AMC WELLPOINT","438.99","73.78","","2344.73","1619.47","2530.35","16","184.45","473.03","percent of total billed charges",""
"ADAPTER HEAD 10.5MM FEMORAL IMPLANT HIP VERSYS ENDOPROSTHESIS ALLOY PLUS 14 BX/1","SUP-ITM-10005430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","AETNA [1001]","HB AMC AETNA HMO","415.31","69.8","","1523.63","988.41","4330.26","39","310.95","486.23","percent of total billed charges",""
"ADAPTER HEAD 10.5MM FEMORAL IMPLANT HIP VERSYS ENDOPROSTHESIS ALLOY PLUS 14 BX/1","SUP-ITM-10005430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","AETNA [1001]","HB AMC AETNA PPO","478.38","80.4","","1670.25","1670.25","1670.25","1 through 10","310.95","486.23","percent of total billed charges",""
"ADAPTER HEAD 10.5MM FEMORAL IMPLANT HIP VERSYS ENDOPROSTHESIS ALLOY PLUS 14 BX/1","SUP-ITM-10005430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","310.95","52.26","","1113.10","1113.10","1113.10","1 through 10","310.95","486.23","percent of total billed charges",""
"ADAPTER HEAD 10.5MM FEMORAL IMPLANT HIP VERSYS ENDOPROSTHESIS ALLOY PLUS 14 BX/1","SUP-ITM-10005430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","486.23","81.72","","1738.90","1484.65","2716.94","38","310.95","486.23","percent of total billed charges",""
"ADAPTER HIP PLUS 3.5MM BIOLEX TAPER","SUP-ITM-10196520","CDM","C1776","HCPCS","0278","RC","","","","both","","","828.80","621.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","433.13","52.26","","1113.10","1113.10","1113.10","1 through 10","256.93","658.9","percent of total billed charges",""
"ADAPTER HIP PLUS 3.5MM BIOLEX TAPER","SUP-ITM-10196520","CDM","C1776","HCPCS","0278","RC","","","","both","","","828.80","621.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","658.90","79.5","","1293.60","1148.53","1603.80","1 through 10","256.93","658.9","percent of total billed charges",""
"ADAPTER HIP PLUS 3.5MM BIOLEX TAPER","SUP-ITM-10196520","CDM","C1776","HCPCS","0278","RC","","","","both","","","828.80","621.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","302.51","36.5","","1023.42","771.29","2068.67","33","256.93","658.9","percent of total billed charges",""
"ADAPTER HIP PLUS 3.5MM BIOLEX TAPER","SUP-ITM-10196520","CDM","C1776","HCPCS","0278","RC","","","","both","","","828.80","621.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","317.43","38.3","","850.52","759.78","1211.25","66","256.93","658.9","percent of total billed charges",""
"ADAPTER HIP PLUS 3.5MM BIOLEX TAPER","SUP-ITM-10196520","CDM","C1776","HCPCS","0278","RC","","","","both","","","828.80","621.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","355.56","42.9","","2548.09","2548.09","2548.09","1 through 10","256.93","658.9","percent of total billed charges",""
"ADAPTER HIP PLUS 3.5MM BIOLEX TAPER","SUP-ITM-10196520","CDM","C1776","HCPCS","0278","RC","","","","both","","","828.80","621.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","355.56","42.9","","956.46","956.46","956.46","1 through 10","256.93","658.9","percent of total billed charges",""
"ADAPTER HIP PLUS 3.5MM BIOLEX TAPER","SUP-ITM-10196520","CDM","C1776","HCPCS","0278","RC","","","","both","","","828.80","621.60","WELLPOINT [1015]","HB AMC WELLPOINT","611.49","73.78","","2344.73","1619.47","2530.35","16","256.93","658.9","percent of total billed charges",""
"ADAPTER HIP PLUS 3.5MM BIOLEX TAPER","SUP-ITM-10196520","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","828.80","621.60","AETNA [1001]","HB AMC AETNA HMO","578.50","69.8","","1523.63","988.41","4330.26","39","433.13","677.3","percent of total billed charges",""
"ADAPTER HIP PLUS 3.5MM BIOLEX TAPER","SUP-ITM-10196520","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","828.80","621.60","AETNA [1001]","HB AMC AETNA PPO","666.36","80.4","","1670.25","1670.25","1670.25","1 through 10","433.13","677.3","percent of total billed charges",""
"ADAPTER HIP PLUS 3.5MM BIOLEX TAPER","SUP-ITM-10196520","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","828.80","621.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","433.13","52.26","","1113.10","1113.10","1113.10","1 through 10","433.13","677.3","percent of total billed charges",""
"ADAPTER HIP PLUS 3.5MM BIOLEX TAPER","SUP-ITM-10196520","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","828.80","621.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","677.30","81.72","","1738.90","1484.65","2716.94","38","433.13","677.3","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1737.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2643.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1213.63","36.5","","1023.42","771.29","2068.67","33","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1273.48","38.3","","850.52","759.78","1211.25","66","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","2548.09","2548.09","2548.09","1 through 10","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","956.46","956.46","956.46","1 through 10","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","WELLPOINT [1015]","HB AMC WELLPOINT","2453.19","73.78","","2344.73","1619.47","2530.35","16","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA HMO","2320.85","69.8","","1523.63","988.41","4330.26","39","1737.65","2717.19","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA PPO","2673.30","80.4","","1670.25","1670.25","1670.25","1 through 10","1737.65","2717.19","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1737.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1737.65","2717.19","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2717.19","81.72","","1738.90","1484.65","2716.94","38","1737.65","2717.19","percent of total billed charges",""
"ADAPTER HUMERAL 42MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10136083","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1737.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 42MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10136083","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2643.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 42MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10136083","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1213.63","36.5","","1023.42","771.29","2068.67","33","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 42MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10136083","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1273.48","38.3","","850.52","759.78","1211.25","66","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 42MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10136083","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","2548.09","2548.09","2548.09","1 through 10","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 42MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10136083","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","956.46","956.46","956.46","1 through 10","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 42MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10136083","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","WELLPOINT [1015]","HB AMC WELLPOINT","2453.19","73.78","","2344.73","1619.47","2530.35","16","1030.75","2643.38","percent of total billed charges",""
"ADAPTER HUMERAL 42MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10136083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA HMO","2320.85","69.8","","1523.63","988.41","4330.26","39","1737.65","2717.19","percent of total billed charges",""
"ADAPTER HUMERAL 42MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10136083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA PPO","2673.30","80.4","","1670.25","1670.25","1670.25","1 through 10","1737.65","2717.19","percent of total billed charges",""
"ADAPTER HUMERAL 42MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10136083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1737.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1737.65","2717.19","percent of total billed charges",""
"ADAPTER HUMERAL 42MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10136083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2717.19","81.72","","1738.90","1484.65","2716.94","38","1737.65","2717.19","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","215.10","52.26","","1113.10","1113.10","1113.10","1 through 10","127.6","327.22","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","327.22","79.5","","1293.60","1148.53","1603.80","1 through 10","127.6","327.22","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","150.23","36.5","","1023.42","771.29","2068.67","33","127.6","327.22","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.64","38.3","","850.52","759.78","1211.25","66","127.6","327.22","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.58","42.9","","2548.09","2548.09","2548.09","1 through 10","127.6","327.22","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.58","42.9","","956.46","956.46","956.46","1 through 10","127.6","327.22","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","WELLPOINT [1015]","HB AMC WELLPOINT","303.68","73.78","","2344.73","1619.47","2530.35","16","127.6","327.22","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","411.60","308.70","AETNA [1001]","HB AMC AETNA HMO","287.30","69.8","","1523.63","988.41","4330.26","39","215.1","336.36","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","411.60","308.70","AETNA [1001]","HB AMC AETNA PPO","330.93","80.4","","1670.25","1670.25","1670.25","1 through 10","215.1","336.36","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","411.60","308.70","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","215.10","52.26","","1113.10","1113.10","1113.10","1 through 10","215.1","336.36","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","411.60","308.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","336.36","81.72","","1738.90","1484.65","2716.94","38","215.1","336.36","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","429.84","52.26","","1113.10","1113.10","1113.10","1 through 10","254.98","653.89","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","653.89","79.5","","1293.60","1148.53","1603.80","1 through 10","254.98","653.89","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","300.21","36.5","","1023.42","771.29","2068.67","33","254.98","653.89","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","315.02","38.3","","850.52","759.78","1211.25","66","254.98","653.89","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","352.85","42.9","","2548.09","2548.09","2548.09","1 through 10","254.98","653.89","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","352.85","42.9","","956.46","956.46","956.46","1 through 10","254.98","653.89","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","822.50","616.87","WELLPOINT [1015]","HB AMC WELLPOINT","606.84","73.78","","2344.73","1619.47","2530.35","16","254.98","653.89","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","822.50","616.87","AETNA [1001]","HB AMC AETNA HMO","574.11","69.8","","1523.63","988.41","4330.26","39","429.84","672.15","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","822.50","616.87","AETNA [1001]","HB AMC AETNA PPO","661.29","80.4","","1670.25","1670.25","1670.25","1 through 10","429.84","672.15","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","822.50","616.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","429.84","52.26","","1113.10","1113.10","1113.10","1 through 10","429.84","672.15","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","822.50","616.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","672.15","81.72","","1738.90","1484.65","2716.94","38","429.84","672.15","percent of total billed charges",""
"ADAPTER STACKING KNEE OSSICULAR TITANIUM DIAPHYSEAL SEGMENTAL","SUP-ITM-10122066","CDM","C1776","HCPCS","0278","RC","","","","both","","","859.95","644.96","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","449.41","52.26","","1113.10","1113.10","1113.10","1 through 10","266.58","683.66","percent of total billed charges",""
"ADAPTER STACKING KNEE OSSICULAR TITANIUM DIAPHYSEAL SEGMENTAL","SUP-ITM-10122066","CDM","C1776","HCPCS","0278","RC","","","","both","","","859.95","644.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","683.66","79.5","","1293.60","1148.53","1603.80","1 through 10","266.58","683.66","percent of total billed charges",""
"ADAPTER STACKING KNEE OSSICULAR TITANIUM DIAPHYSEAL SEGMENTAL","SUP-ITM-10122066","CDM","C1776","HCPCS","0278","RC","","","","both","","","859.95","644.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","313.88","36.5","","1023.42","771.29","2068.67","33","266.58","683.66","percent of total billed charges",""
"ADAPTER STACKING KNEE OSSICULAR TITANIUM DIAPHYSEAL SEGMENTAL","SUP-ITM-10122066","CDM","C1776","HCPCS","0278","RC","","","","both","","","859.95","644.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","329.36","38.3","","850.52","759.78","1211.25","66","266.58","683.66","percent of total billed charges",""
"ADAPTER STACKING KNEE OSSICULAR TITANIUM DIAPHYSEAL SEGMENTAL","SUP-ITM-10122066","CDM","C1776","HCPCS","0278","RC","","","","both","","","859.95","644.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","368.92","42.9","","2548.09","2548.09","2548.09","1 through 10","266.58","683.66","percent of total billed charges",""
"ADAPTER STACKING KNEE OSSICULAR TITANIUM DIAPHYSEAL SEGMENTAL","SUP-ITM-10122066","CDM","C1776","HCPCS","0278","RC","","","","both","","","859.95","644.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","368.92","42.9","","956.46","956.46","956.46","1 through 10","266.58","683.66","percent of total billed charges",""
"ADAPTER STACKING KNEE OSSICULAR TITANIUM DIAPHYSEAL SEGMENTAL","SUP-ITM-10122066","CDM","C1776","HCPCS","0278","RC","","","","both","","","859.95","644.96","WELLPOINT [1015]","HB AMC WELLPOINT","634.47","73.78","","2344.73","1619.47","2530.35","16","266.58","683.66","percent of total billed charges",""
"ADAPTER STACKING KNEE OSSICULAR TITANIUM DIAPHYSEAL SEGMENTAL","SUP-ITM-10122066","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","859.95","644.96","AETNA [1001]","HB AMC AETNA HMO","600.25","69.8","","1523.63","988.41","4330.26","39","449.41","702.75","percent of total billed charges",""
"ADAPTER STACKING KNEE OSSICULAR TITANIUM DIAPHYSEAL SEGMENTAL","SUP-ITM-10122066","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","859.95","644.96","AETNA [1001]","HB AMC AETNA PPO","691.40","80.4","","1670.25","1670.25","1670.25","1 through 10","449.41","702.75","percent of total billed charges",""
"ADAPTER STACKING KNEE OSSICULAR TITANIUM DIAPHYSEAL SEGMENTAL","SUP-ITM-10122066","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","859.95","644.96","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","449.41","52.26","","1113.10","1113.10","1113.10","1 through 10","449.41","702.75","percent of total billed charges",""
"ADAPTER STACKING KNEE OSSICULAR TITANIUM DIAPHYSEAL SEGMENTAL","SUP-ITM-10122066","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","859.95","644.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","702.75","81.72","","1738.90","1484.65","2716.94","38","449.41","702.75","percent of total billed charges",""
"ADAPTER STIMULATOR M8 DEEP BRAIN 8 CONTACTS 1.3MMX15CM","SUP-ITM-10241025","CDM","C1883","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1073.15","1073.15","1073.15","1 through 10","1085","2782.5","percent of total billed charges",""
"ADAPTER STIMULATOR M8 DEEP BRAIN 8 CONTACTS 1.3MMX15CM","SUP-ITM-10241025","CDM","C1883","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","1808.38","1642.20","1808.38","1 through 10","1085","2782.5","percent of total billed charges",""
"ADAPTER STIMULATOR M8 DEEP BRAIN 8 CONTACTS 1.3MMX15CM","SUP-ITM-10241025","CDM","C1883","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","625.38","625.38","625.38","1 through 10","1085","2782.5","percent of total billed charges",""
"ADAPTER TAPER 5CM COMPRESS KNEE OSSICULAR AUXILIARY ANTIROTATION SPINDLE","SUP-ITM-10170743","CDM","C1776","HCPCS","0278","RC","","","","both","","","4024.13","3018.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2103.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1247.48","3199.18","percent of total billed charges",""
"ADAPTER TAPER 5CM COMPRESS KNEE OSSICULAR AUXILIARY ANTIROTATION SPINDLE","SUP-ITM-10170743","CDM","C1776","HCPCS","0278","RC","","","","both","","","4024.13","3018.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3199.18","79.5","","1293.60","1148.53","1603.80","1 through 10","1247.48","3199.18","percent of total billed charges",""
"ADAPTER TAPER 5CM COMPRESS KNEE OSSICULAR AUXILIARY ANTIROTATION SPINDLE","SUP-ITM-10170743","CDM","C1776","HCPCS","0278","RC","","","","both","","","4024.13","3018.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1468.81","36.5","","1023.42","771.29","2068.67","33","1247.48","3199.18","percent of total billed charges",""
"ADAPTER TAPER 5CM COMPRESS KNEE OSSICULAR AUXILIARY ANTIROTATION SPINDLE","SUP-ITM-10170743","CDM","C1776","HCPCS","0278","RC","","","","both","","","4024.13","3018.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1541.24","38.3","","850.52","759.78","1211.25","66","1247.48","3199.18","percent of total billed charges",""
"ADAPTER TAPER 5CM COMPRESS KNEE OSSICULAR AUXILIARY ANTIROTATION SPINDLE","SUP-ITM-10170743","CDM","C1776","HCPCS","0278","RC","","","","both","","","4024.13","3018.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.35","42.9","","2548.09","2548.09","2548.09","1 through 10","1247.48","3199.18","percent of total billed charges",""
"ADAPTER TAPER 5CM COMPRESS KNEE OSSICULAR AUXILIARY ANTIROTATION SPINDLE","SUP-ITM-10170743","CDM","C1776","HCPCS","0278","RC","","","","both","","","4024.13","3018.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.35","42.9","","956.46","956.46","956.46","1 through 10","1247.48","3199.18","percent of total billed charges",""
"ADAPTER TAPER 5CM COMPRESS KNEE OSSICULAR AUXILIARY ANTIROTATION SPINDLE","SUP-ITM-10170743","CDM","C1776","HCPCS","0278","RC","","","","both","","","4024.13","3018.10","WELLPOINT [1015]","HB AMC WELLPOINT","2969.00","73.78","","2344.73","1619.47","2530.35","16","1247.48","3199.18","percent of total billed charges",""
"ADAPTER TAPER 5CM COMPRESS KNEE OSSICULAR AUXILIARY ANTIROTATION SPINDLE","SUP-ITM-10170743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4024.13","3018.10","AETNA [1001]","HB AMC AETNA HMO","2808.84","69.8","","1523.63","988.41","4330.26","39","2103.01","3288.52","percent of total billed charges",""
"ADAPTER TAPER 5CM COMPRESS KNEE OSSICULAR AUXILIARY ANTIROTATION SPINDLE","SUP-ITM-10170743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4024.13","3018.10","AETNA [1001]","HB AMC AETNA PPO","3235.40","80.4","","1670.25","1670.25","1670.25","1 through 10","2103.01","3288.52","percent of total billed charges",""
"ADAPTER TAPER 5CM COMPRESS KNEE OSSICULAR AUXILIARY ANTIROTATION SPINDLE","SUP-ITM-10170743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4024.13","3018.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2103.01","52.26","","1113.10","1113.10","1113.10","1 through 10","2103.01","3288.52","percent of total billed charges",""
"ADAPTER TAPER 5CM COMPRESS KNEE OSSICULAR AUXILIARY ANTIROTATION SPINDLE","SUP-ITM-10170743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4024.13","3018.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3288.52","81.72","","1738.90","1484.65","2716.94","38","2103.01","3288.52","percent of total billed charges",""
"Adapter/Extension Lead T1","PX-27000166","CDM","C1883","HCPCS","0278","RC","","","","both","","","1222.10","916.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","446.07","36.5","","1073.15","1073.15","1073.15","1 through 10","378.85","971.57","percent of total billed charges",""
"Adapter/Extension Lead T1","PX-27000166","CDM","C1883","HCPCS","0278","RC","","","","both","","","1222.10","916.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","468.06","38.3","","1808.38","1642.20","1808.38","1 through 10","378.85","971.57","percent of total billed charges",""
"Adapter/Extension Lead T1","PX-27000166","CDM","C1883","HCPCS","0278","RC","","","","both","","","1222.10","916.57","WELLPOINT [1015]","HB AMC WELLPOINT","901.67","73.78","","625.38","625.38","625.38","1 through 10","378.85","971.57","percent of total billed charges",""
"Adapter/Extension Lead T2","PX-27000167","CDM","C1883","HCPCS","0278","RC","","","","both","","","4185.00","3138.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1527.53","36.5","","1073.15","1073.15","1073.15","1 through 10","1297.35","3327.08","percent of total billed charges",""
"Adapter/Extension Lead T2","PX-27000167","CDM","C1883","HCPCS","0278","RC","","","","both","","","4185.00","3138.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1602.86","38.3","","1808.38","1642.20","1808.38","1 through 10","1297.35","3327.08","percent of total billed charges",""
"Adapter/Extension Lead T2","PX-27000167","CDM","C1883","HCPCS","0278","RC","","","","both","","","4185.00","3138.75","WELLPOINT [1015]","HB AMC WELLPOINT","3087.69","73.78","","625.38","625.38","625.38","1 through 10","1297.35","3327.08","percent of total billed charges",""
"Adapter/Extension Lead T3","PX-27000168","CDM","C1883","HCPCS","0278","RC","","","","both","","","7850.00","5887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2865.25","36.5","","1073.15","1073.15","1073.15","1 through 10","2433.5","6240.75","percent of total billed charges",""
"Adapter/Extension Lead T3","PX-27000168","CDM","C1883","HCPCS","0278","RC","","","","both","","","7850.00","5887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3006.55","38.3","","1808.38","1642.20","1808.38","1 through 10","2433.5","6240.75","percent of total billed charges",""
"Adapter/Extension Lead T3","PX-27000168","CDM","C1883","HCPCS","0278","RC","","","","both","","","7850.00","5887.50","WELLPOINT [1015]","HB AMC WELLPOINT","5791.73","73.78","","625.38","625.38","625.38","1 through 10","2433.5","6240.75","percent of total billed charges",""
"Adenosine Challenge Test","PX-48000522","CDM","93799","CPT","0481","RC","","","","both","","","3668.00","2751.00","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","2916.06","other","OPPS APC"
"Adenosine Challenge Test","PX-48000522","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","AETNA [1001]","HB AMC AETNA HMO","2560.26","69.8","","2022.70","2022.70","2022.70","1 through 10","454","3026.1","percent of total billed charges",""
"Adenosine Challenge Test","PX-48000522","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2220.97","60.55","","318.03","318.03","2439.77","1 through 10","454","3026.1","percent of total billed charges",""
"Adenosine Challenge Test","PX-48000522","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1915.43","52.22","","360.38","360.38","4023.00","1 through 10","454","3026.1","percent of total billed charges",""
"Adenosine Challenge Test","PX-48000522","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2017.40","55","","13080.03","13080.03","13080.03","1 through 10","454","3026.1","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"Adhesion Barrier T1","PX-27000080","CDM","C1765","HCPCS","0278","RC","","","","both","","","882.00","661.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","573.30","65","","489.93","489.93","489.93","1 through 10","273.42","701.19","percent of total billed charges",""
"Adj Tiss Xfer Scalp,Extrem 10.1-30 Sqcm","PX-98301642","CDM","14021","CPT","0983","RC","","","","both","","","3212.00","2409.00","FALLON HEALTH [1008]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16224.09","16224.09","16224.09","1 through 10","995.72","2715.13","other","OPPS APC"
"Adj Tiss Xfer Scalp,Extrem 10.1-30 Sqcm","PX-98301642","CDM","14021","CPT","0983","RC","","","","both","","","3212.00","2409.00","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","1990.34","2172.32","1 through 10","995.72","2715.13","other","OPPS APC"
"Adj Tiss Xfer Scalp,Extrem 10.1-30 Sqcm","PX-98301642","CDM","14021","CPT","0983","RC","","","","both","","","3212.00","2409.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1230.20","38.3","","6102.42","6102.42","6102.42","1 through 10","995.72","2715.13","percent of total billed charges",""
"Adj Tiss Xfer Scalp,Extrem 10.1-30 Sqcm","PX-98301642","CDM","14021","CPT","0983","RC","","","","both","","","3212.00","2409.00","WELLPOINT [1015]","HB AMC WELLPOINT","2369.81","73.78","","4158.78","4158.78","4158.78","1 through 10","995.72","2715.13","percent of total billed charges",""
"Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<","PX-98300876","CDM","14040","CPT","0983","RC","","","","both","","","2829.00","2121.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2237.26","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2244.44","2244.44","2244.44","1 through 10","876.99","2715.13","other","OPPS APC"
"Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<","PX-98300876","CDM","14040","CPT","0983","RC","","","","both","","","2829.00","2121.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2137.56","2137.56","2137.56","1 through 10","876.99","2715.13","other","OPPS APC"
"Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<","PX-98300876","CDM","14040","CPT","0983","RC","","","","both","","","2829.00","2121.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1838.85","65","","13148.85","13148.85","13148.85","1 through 10","876.99","2715.13","percent of total billed charges",""
"Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<","PX-98300876","CDM","14040","CPT","0983","RC","","","","both","","","2829.00","2121.75","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","17","876.99","2715.13","other","OPPS APC"
"Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<","PX-98300876","CDM","14040","CPT","0983","RC","","","","both","","","2829.00","2121.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2128.87","2128.87","2128.87","1 through 10","876.99","2715.13","other","OPPS APC"
"Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<","PX-98300876","CDM","14040","CPT","0983","RC","","","","both","","","2829.00","2121.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2134.27","2134.27","2134.27","1 through 10","876.99","2715.13","other","OPPS APC"
"Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<","PX-98300876","CDM","14040","CPT","0983","RC","","","","both","","","2829.00","2121.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2136.38","2133.22","2136.38","1 through 10","876.99","2715.13","other","OPPS APC"
"Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<","PX-98300876","CDM","14040","CPT","0983","RC","","","","outpatient","","","2829.00","2121.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3593.59","3593.59","3593.59","1 through 10","1548.96","5545.35","other","Multiple Surgery"
"Adjt Tis Trns/Reargmt F/C/C/M/N/a/G/H/F 10sqcm/<","PX-98300876","CDM","14040","CPT","0983","RC","","","","outpatient","","","2829.00","2121.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3965.34","1982.67","3965.34","1 through 10","1548.96","5545.35","other","Multiple Surgery"
"Adjt/Reargmt F/C/C/M/N/Ax/G/H/F 10.1-30.0 Sq Cm","PX-98300877","CDM","14041","CPT","0983","RC","","","","both","","","3445.00","2583.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2237.26","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2235.32","2235.32","2235.32","1 through 10","1067.95","2738.78","other","OPPS APC"
"Adjt/Reargmt F/C/C/M/N/Ax/G/H/F 10.1-30.0 Sq Cm","PX-98300877","CDM","14041","CPT","0983","RC","","","","both","","","3445.00","2583.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2137.56","1958.49","2137.56","1 through 10","1067.95","2738.78","other","OPPS APC"
"Adjt/Reargmt F/C/C/M/N/Ax/G/H/F 10.1-30.0 Sq Cm","PX-98300877","CDM","14041","CPT","0983","RC","","","","both","","","3445.00","2583.75","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","6516.96","26","1067.95","2738.78","other","OPPS APC"
"Adjt/Reargmt F/C/C/M/N/Ax/G/H/F 10.1-30.0 Sq Cm","PX-98300877","CDM","14041","CPT","0983","RC","","","","both","","","3445.00","2583.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1257.43","36.5","","18201.66","18201.66","18201.66","1 through 10","1067.95","2738.78","percent of total billed charges",""
"Adjt/Reargmt F/C/C/M/N/Ax/G/H/F 10.1-30.0 Sq Cm","PX-98300877","CDM","14041","CPT","0983","RC","","","","both","","","3445.00","2583.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2129.87","2129.87","2129.87","1 through 10","1067.95","2738.78","other","OPPS APC"
"Adjt/Reargmt F/C/C/M/N/Ax/G/H/F 10.1-30.0 Sq Cm","PX-98300877","CDM","14041","CPT","0983","RC","","","","both","","","3445.00","2583.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2172.32","2136.38","2172.32","1 through 10","1067.95","2738.78","other","OPPS APC"
"Adjt/Reargmt F/C/C/M/N/Ax/G/H/F 10.1-30.0 Sq Cm","PX-98300877","CDM","14041","CPT","0983","RC","","","","outpatient","","","3445.00","2583.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","10780.77","10780.77","10780.77","1 through 10","1548.96","8899.59","other","Multiple Surgery"
"Adjt/Reargmt F/C/C/M/N/Ax/G/H/F 10.1-30.0 Sq Cm","PX-98300877","CDM","14041","CPT","0983","RC","","","","outpatient","","","3445.00","2583.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2815.25","81.72","","4921.91","4921.91","4921.91","1 through 10","1548.96","8899.59","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Admin Hepatitis B Vaccine No Fee","PX-77100011","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","14","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100011","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","1 through 10","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100011","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100011","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","HUMANA [1012]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100011","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","54.79","81","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100011","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.81","53.69","1 through 10","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100011","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","53.69","161.07","1 through 10","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100011","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","53.69","54.79","77","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100012","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","14","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100012","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","1 through 10","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100012","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100012","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","HUMANA [1012]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100012","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","54.79","81","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100012","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.81","53.69","1 through 10","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100012","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","53.69","161.07","1 through 10","13.33","68.49","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100012","CDM","G0010","HCPCS","0771","RC","","","","both","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","53.69","54.79","77","13.33","68.49","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","53.35","56.38","51","13.33","68.49","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.02","51.02","53.91","30","13.33","68.49","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","50.81","50.81","53.69","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","ELDER SERVICES [1037]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","54.79","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","50.81","50.81","50.81","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","HUMANA [1012]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","222.65","11.57","222.65","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","103.70","563","13.33","68.49","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","97.86","50.81","101.62","34","13.33","68.49","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","MOLINA [1014]","HB BWH MOLINA","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","103.70","102.66","154.51","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","53.69","161.07","21","13.33","68.49","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9.66","9.20","9.66","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","51.85","50.81","53.70","336","13.33","68.49","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","WELLPOINT [1015]","HB AMC WELLPOINT","31.73","73.78","","84.00","84.00","84.00","1 through 10","13.33","68.49","percent of total billed charges",""
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","53.35","56.38","51","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.02","51.02","53.91","30","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","50.81","50.81","53.69","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","ELDER SERVICES [1037]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","54.79","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","50.81","50.81","50.81","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","HUMANA [1012]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","222.65","11.57","222.65","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","103.70","563","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","97.86","50.81","101.62","34","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","MOLINA [1014]","HB BWH MOLINA","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","103.70","102.66","154.51","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","53.69","161.07","21","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9.66","9.20","9.66","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","51.85","50.81","53.70","336","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","WELLPOINT [1015]","HB AMC WELLPOINT","31.73","73.78","","84.00","84.00","84.00","1 through 10","13.33","68.49","percent of total billed charges",""
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","53.35","56.38","51","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.02","51.02","53.91","30","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","50.81","50.81","53.69","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","ELDER SERVICES [1037]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","54.79","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","50.81","50.81","50.81","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","HUMANA [1012]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","222.65","11.57","222.65","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","103.70","563","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","97.86","50.81","101.62","34","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","MOLINA [1014]","HB BWH MOLINA","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","103.70","102.66","154.51","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","53.69","161.07","21","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9.66","9.20","9.66","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","51.85","50.81","53.70","336","13.33","68.49","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","43.00","32.25","WELLPOINT [1015]","HB AMC WELLPOINT","31.73","73.78","","84.00","84.00","84.00","1 through 10","13.33","68.49","percent of total billed charges",""
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","48","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","31","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.81","53.69","11","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","161.07","161.07","161.07","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","HUMANA [1012]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","54.79","516","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.81","155.31","26","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","50.81","53.69","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9.66","9.66","9.66","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","50.82","54.79","137","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","48","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","31","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.81","53.69","11","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","161.07","161.07","161.07","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","HUMANA [1012]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","54.79","516","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.81","155.31","26","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","50.81","53.69","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9.66","9.66","9.66","1 through 10","13.33","68.49","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","50.82","54.79","137","13.33","68.49","other","OPPS APC"
"Admn Rsv Monoclonal Antb Seasonal Dose Im Njx","PX-77100075","CDM","96381","CPT","0771","RC","","","","outpatient","","","331.00","248.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.50","50","","316.82","316.82","316.82","1 through 10","62.32","273.08","percent of total billed charges",""
"Admn Rsv Monoclonal Antb Seasonal Dose Im Njx","PX-77100075","CDM","96381","CPT","0771","RC","","","","outpatient","","","331.00","248.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","270.49","81.72","","321.00","321.00","321.00","1 through 10","62.32","273.08","percent of total billed charges",""
"Adrenal And Pituitary Procedures With Cc/McC","614","MS-DRG","","","","","","","","inpatient","","","88796.86","66597.64","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","20984.88","","Case rate ($20,373.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,448.47, add-ons for qualifying new technology services are included. If operating cost exceeds $70,092.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,203.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $18,230.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,068.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,763.65. The transfer capital threshold is the transfer adjustment factor * $1,763.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","21609.37","21609.37","21609.37","1 through 10","19966.2","34332.36","other","Inpatient DRG"
"Adrenal And Pituitary Procedures With Cc/McC","614","MS-DRG","","","","","","","","inpatient","","","88796.86","66597.64","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","20373.67","","Case rate ($20,373.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,448.47, add-ons for qualifying new technology services are included. If operating cost exceeds $70,092.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,203.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $18,230.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,068.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,763.65. The transfer capital threshold is the transfer adjustment factor * $1,763.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20964.10","20737.78","26728.21","1 through 10","19966.2","34332.36","other","Inpatient Replacement Plans DRG"
"Adrenal And Pituitary Procedures With Cc/McC","614","MS-DRG","","","","","","","","inpatient","","","88796.86","66597.64","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","20373.67","","Case rate ($20,373.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,448.47, add-ons for qualifying new technology services are included. If operating cost exceeds $70,092.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,203.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $18,230.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,068.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,763.65. The transfer capital threshold is the transfer adjustment factor * $1,763.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20578.28","20578.28","20578.28","1 through 10","19966.2","34332.36","other","Inpatient DRG"
"Adrenal And Pituitary Procedures With Cc/McC","614","MS-DRG","","","","","","","","inpatient","","","88796.86","66597.64","HUMANA [1012]","HB BWH MEDICARE","20373.67","","Case rate ($20,373.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,448.47, add-ons for qualifying new technology services are included. If operating cost exceeds $70,092.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,203.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $18,230.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,068.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,763.65. The transfer capital threshold is the transfer adjustment factor * $1,763.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20612.83","20612.83","20612.83","1 through 10","19966.2","34332.36","other","Inpatient Replacement Plans DRG"
"Adrenal And Pituitary Procedures With Cc/McC","614","MS-DRG","","","","","","","","inpatient","","","88796.86","66597.64","MEDICARE [2001]","HB BWH MEDICARE","20373.67","","Case rate ($20,373.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,448.47, add-ons for qualifying new technology services are included. If operating cost exceeds $70,092.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,203.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $18,230.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,068.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,763.65. The transfer capital threshold is the transfer adjustment factor * $1,763.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27145.78","0.03","27185.96","30","19966.2","34332.36","other","Inpatient Replacement Plans DRG"
"Adrenal And Pituitary Procedures With Cc/McC","614","MS-DRG","","","","","","","","inpatient","","","88796.86","66597.64","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19966.20","","Case rate ($20,373.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,448.47, add-ons for qualifying new technology services are included. If operating cost exceeds $70,092.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,203.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $18,230.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,068.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,763.65. The transfer capital threshold is the transfer adjustment factor * $1,763.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20550.25","20550.25","20594.12","1 through 10","19966.2","34332.36","other","Inpatient DRG"
"Adrenal And Pituitary Procedures With Cc/McC","614","MS-DRG","","","","","","","","inpatient","","","88796.86","66597.64","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19966.20","","Case rate ($20,373.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,448.47, add-ons for qualifying new technology services are included. If operating cost exceeds $70,092.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,203.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $18,230.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,068.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,763.65. The transfer capital threshold is the transfer adjustment factor * $1,763.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20593.92","20593.92","20593.92","1 through 10","19966.2","34332.36","other","Inpatient DRG"
"Adrenal And Pituitary Procedures Without Cc/McC","615","MS-DRG","","","","","","","","inpatient","","","73258.89","54944.17","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","13144.41","","Case rate ($13,144.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,745.86, add-ons for qualifying new technology services are included. If operating cost exceeds $61,390.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,566.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $11,638.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,366.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.96. The transfer capital threshold is the transfer adjustment factor * $1,125.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13141.24","13141.24","13141.24","1 through 10","12881.52","21918.64","other","Inpatient Replacement Plans DRG"
"Adrenal And Pituitary Procedures Without Cc/McC","615","MS-DRG","","","","","","","","inpatient","","","73258.89","54944.17","MEDICARE [2001]","HB BWH MEDICARE","13144.41","","Case rate ($13,144.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,745.86, add-ons for qualifying new technology services are included. If operating cost exceeds $61,390.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,566.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $11,638.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,366.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.96. The transfer capital threshold is the transfer adjustment factor * $1,125.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","421.02","0.03","17172.13","1 through 10","12881.52","21918.64","other","Inpatient Replacement Plans DRG"
"Adrenal And Pituitary Procedures Without Cc/McC","615","MS-DRG","","","","","","","","inpatient","","","73258.89","54944.17","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12881.52","","Case rate ($13,144.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,745.86, add-ons for qualifying new technology services are included. If operating cost exceeds $61,390.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,566.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $11,638.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,366.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.96. The transfer capital threshold is the transfer adjustment factor * $1,125.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13027.05","13027.05","13027.05","1 through 10","12881.52","21918.64","other","Inpatient DRG"
"Adrenal And Pituitary Procedures Without Cc/McC","615","MS-DRG","","","","","","","","inpatient","","","73258.89","54944.17","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12881.52","","Case rate ($13,144.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,745.86, add-ons for qualifying new technology services are included. If operating cost exceeds $61,390.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,566.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $11,638.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,366.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.96. The transfer capital threshold is the transfer adjustment factor * $1,125.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13082.71","13082.71","13082.71","1 through 10","12881.52","21918.64","other","Inpatient DRG"
"Adrenal Procedures,MINOR","401","DRG","","","","","","","","inpatient","","","67790.93","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","41173.33","","Standard inlier is a Case rate ($41,173.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,665, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,844.80) for the length of stay and the standard reimbursement.","41173.32","41173.32","41173.32","1 through 10","11189.47","376175.48","case rate",""
"Adrenal Procedures,MINOR","401","DRG","","","","","","","","inpatient","","","67790.93","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","46289.92","","Standard inlier is a Case rate ($46,289.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,665, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,570.47) for the length of stay and the standard reimbursement.","46289.91","46289.91","46289.91","1 through 10","11189.47","376175.48","case rate",""
"Adrenal Procedures,MINOR","401","DRG","","","","","","","","inpatient","","","67790.93","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28336.7523","","Fee schedule rate ($28,336.75). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28336.7523","28336.76","28336.76","1 through 10","11189.47","376175.48","case rate",""
"Adrenal Procedures,MINOR","401","DRG","","","","","","","","inpatient","","","67790.93","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","29754.4134","","Fee schedule rate ($29,754.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29754.4134","29754.40","29754.40","1 through 10","11189.47","376175.48","case rate",""
"Adrenal Procedures,MINOR","401","DRG","","","","","","","","inpatient","","","67790.93","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","31170.81","","Fee schedule rate ($31,170.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31170.81","31170.81","31170.81","1 through 10","11189.47","376175.48","case rate",""
"Adrenal Procedures,MINOR","401","DRG","","","","","","","","inpatient","","","67790.93","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","43994.29","","Fee schedule rate ($43,994.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","43994.29","43994.29","43994.29","1 through 10","11189.47","376175.48","case rate",""
"Adrenal Procedures,MINOR","401","DRG","","","","","","","","inpatient","","","67790.93","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46194.73","","Fee schedule rate ($46,194.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","46194.73","46194.73","46194.73","1 through 10","11189.47","376175.48","case rate",""
"Adrenal Procedures,MINOR","401","DRG","","","","","","","","inpatient","","","67790.93","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11189.47","","Case rate ($12,371.89). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,801.89, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12368.85","12368.85","12368.85","1 through 10","11189.47","376175.48","case rate",""
"Adrenal Procedures,MODERATE","401","DRG","","","","","","","","inpatient","","","77894.82","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","88558.42","","Standard inlier is a Case rate ($88,558.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $72,903, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,570.13) for the length of stay and the standard reimbursement.","74521.26","74521.26","74521.26","1 through 10","11189.47","376175.48","case rate",""
"Adrenal Procedures,MODERATE","401","DRG","","","","","","","","inpatient","","","77894.82","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28336.7523","","Fee schedule rate ($42,888.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28336.7523","42888.72","42888.72","1 through 10","11189.47","376175.48","case rate",""
"Adrenal Procedures,MODERATE","401","DRG","","","","","","","","inpatient","","","77894.82","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","29754.4134","","Fee schedule rate ($45,034.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29754.4134","86494.24","86494.24","1 through 10","11189.47","376175.48","case rate",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","both","","","481.00","360.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","336.70","70","","75.80","75.80","75.80","1 through 10","37.85","456.95","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","both","","","481.00","360.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","382.40","79.5","","366.74","246.05","860.19","28","37.85","456.95","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","both","","","481.00","360.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","256.37","53.3","","246.05","246.05","366.74","14","37.85","456.95","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","both","","","481.00","360.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","175.57","36.5","","173.82","147.72","521.46","14","37.85","456.95","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","both","","","481.00","360.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","184.22","38.3","","182.21","153.78","182.21","73","37.85","456.95","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","both","","","481.00","360.75","MOLINA [1014]","HB BWH MOLINA","168.35","35","","76.62","76.62","76.62","1 through 10","37.85","456.95","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","both","","","481.00","360.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","370.37","77","","366.74","366.74","366.74","1 through 10","37.85","456.95","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","both","","","481.00","360.75","TRICARE [160005]","HB BWH TRICARE","456.95","95","","44.21","44.21","44.21","1 through 10","37.85","456.95","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","both","","","481.00","360.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.35","42.9","","372.52","204.90","372.52","1 through 10","37.85","456.95","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","outpatient","","","481.00","360.75","AETNA [1001]","HB AMC AETNA HMO","335.74","69.8","","315.48","222.75","363.48","60","39.83","393.07","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","outpatient","","","481.00","360.75","AETNA [1001]","HB AMC AETNA PPO","386.72","80.4","","363.48","363.48","363.48","1 through 10","39.83","393.07","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","outpatient","","","481.00","360.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","268.88","55.9","","244.18","244.18","244.18","1 through 10","39.83","393.07","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","outpatient","","","481.00","360.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","386.72","80.4","","363.48","363.48","363.48","1 through 10","39.83","393.07","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","outpatient","","","481.00","360.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","393.07","81.72","","372.53","372.53","372.53","1 through 10","39.83","393.07","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","outpatient","","","481.00","360.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","393.07","81.72","","372.52","204.90","372.52","29","39.83","393.07","percent of total billed charges",""
"Aerosol Neb/Mdi/Ippb Demo/Eval","PX-46000007","CDM","94664","CPT","0410","RC","","","","both","","","468.00","351.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","170.82","36.5","","164.35","164.35","164.35","1 through 10","67.25","372.06","percent of total billed charges",""
"Aftercare With Cc/McC","949","MS-DRG","","","","","","","","inpatient","","","17778.80","13334.10","MEDICARE [2001]","HB BWH MEDICARE","11232.41","","Case rate ($11,232.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,444.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,088.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,397.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,895.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,064.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.30. The transfer capital threshold is the transfer adjustment factor * $957.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","50.64","50.64","50.64","1 through 10","11007.76","16283.189","other","Inpatient Replacement Plans DRG"
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","","","","inpatient","","","54421.52","40816.14","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","10652.25","","Case rate ($10,652.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,745.79, add-ons for qualifying new technology services are included. If operating cost exceeds $58,390.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,346.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,366.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,365.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.13. The transfer capital threshold is the transfer adjustment factor * $906.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13550.03","13550.03","13550.03","1 through 10","10439.21","17639.23","other","Inpatient Replacement Plans DRG"
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","","","","inpatient","","","54421.52","40816.14","HUMANA [1012]","HB BWH MEDICARE","10652.25","","Case rate ($10,652.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,745.79, add-ons for qualifying new technology services are included. If operating cost exceeds $58,390.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,346.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,366.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,365.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.13. The transfer capital threshold is the transfer adjustment factor * $906.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26576.26","26576.26","26576.26","1 through 10","10439.21","17639.23","other","Inpatient Replacement Plans DRG"
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","","","","inpatient","","","54421.52","40816.14","MEDICARE [2001]","HB BWH MEDICARE","10652.25","","Case rate ($10,652.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,745.79, add-ons for qualifying new technology services are included. If operating cost exceeds $58,390.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,346.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,366.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,365.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.13. The transfer capital threshold is the transfer adjustment factor * $906.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13702.59","1521.93","13722.66","1 through 10","10439.21","17639.23","other","Inpatient Replacement Plans DRG"
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","","","","inpatient","","","54421.52","40816.14","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10439.21","","Case rate ($10,652.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,745.79, add-ons for qualifying new technology services are included. If operating cost exceeds $58,390.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,346.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,366.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,365.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.13. The transfer capital threshold is the transfer adjustment factor * $906.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10462.38","10462.38","10462.38","1 through 10","10439.21","17639.23","other","Inpatient DRG"
"Aftercare, Musculoskeletal System And Connective Tissue With McC","559","MS-DRG","","","","","","","","inpatient","","","58275.07","43706.30","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","17391.66","","Case rate ($17,391.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,858.71, add-ons for qualifying new technology services are included. If operating cost exceeds $66,503.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,940.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,511.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,478.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,500.61. The transfer capital threshold is the transfer adjustment factor * $1,500.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23414.99","23414.99","23414.99","1 through 10","17043.83","28013.4233","other","Inpatient DRG"
"Aftercare, Musculoskeletal System And Connective Tissue With McC","559","MS-DRG","","","","","","","","inpatient","","","58275.07","43706.30","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","17391.66","","Case rate ($17,391.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,858.71, add-ons for qualifying new technology services are included. If operating cost exceeds $66,503.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,940.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,511.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,478.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,500.61. The transfer capital threshold is the transfer adjustment factor * $1,500.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16920.78","16920.78","16920.78","1 through 10","17043.83","28013.4233","other","Inpatient Replacement Plans DRG"
"Aftercare, Musculoskeletal System And Connective Tissue With McC","559","MS-DRG","","","","","","","","inpatient","","","58275.07","43706.30","MEDICARE [2001]","HB BWH MEDICARE","17391.66","","Case rate ($17,391.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,858.71, add-ons for qualifying new technology services are included. If operating cost exceeds $66,503.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,940.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,511.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,478.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,500.61. The transfer capital threshold is the transfer adjustment factor * $1,500.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22162.49","22162.49","22195.23","1 through 10","17043.83","28013.4233","other","Inpatient Replacement Plans DRG"
"Aftercare, Musculoskeletal System And Connective Tissue With McC","559","MS-DRG","","","","","","","","inpatient","","","58275.07","43706.30","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17043.83","","Case rate ($17,391.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,858.71, add-ons for qualifying new technology services are included. If operating cost exceeds $66,503.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,940.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,511.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,478.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,500.61. The transfer capital threshold is the transfer adjustment factor * $1,500.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13288.13","13288.13","13288.13","1 through 10","17043.83","28013.4233","other","Inpatient DRG"
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/McC","561","MS-DRG","","","","","","","","inpatient","","","21763.01","16322.26","MEDICARE [2001]","HB BWH MEDICARE","7713.09","","Case rate ($7,713.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,207.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,852.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,087.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,686.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,827.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $646.87. The transfer capital threshold is the transfer adjustment factor * $646.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9917.09","9917.09","9917.09","1 through 10","7558.83","12338.4016","other","Inpatient Replacement Plans DRG"
"Agxt Gene, Full Gene Analysis (Agxtz)","PX-31000679","CDM","81479","CPT","0310","RC","","","","both","","","2447.00","1835.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1945.37","79.5","","0.65","0.65","0.65","1 through 10","758.57","2324.65","percent of total billed charges",""
"Agxt Gene, Full Gene Analysis (Agxtz)","PX-31000679","CDM","81479","CPT","0310","RC","","","","both","","","2447.00","1835.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1304.25","53.3","","0.79","0.79","0.79","1 through 10","758.57","2324.65","percent of total billed charges",""
"Agxt Gene, Full Gene Analysis (Agxtz)","PX-31000679","CDM","81479","CPT","0310","RC","","","","outpatient","","","2447.00","1835.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1223.50","50","","1.00","1.00","1.00","1 through 10","156.55","2018.78","percent of total billed charges",""
"Agxt Gene, Full Gene Analysis (Agxtz)","PX-31000679","CDM","81479","CPT","0310","RC","","","","outpatient","","","2447.00","1835.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1284.68","52.5","","1.00","0.53","1.00","1 through 10","156.55","2018.78","percent of total billed charges",""
"Ahugp Atypical Hemolytic Uremic Syndrome Ahus,Tma, C3g Gene Panel, Varie","PX-31001433","CDM","81404","CPT","0310","RC","","","","both","","","7163.00","5372.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5694.59","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","6804.85","percent of total billed charges",""
"Ahus Genetic Panel","PX-31000811","CDM","81479","CPT","0310","RC","","","","both","","","412.00","309.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","327.54","79.5","","0.65","0.65","0.65","1 through 10","127.72","391.4","percent of total billed charges",""
"Ahus Genetic Panel","PX-31000811","CDM","81479","CPT","0310","RC","","","","both","","","412.00","309.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","219.60","53.3","","0.79","0.79","0.79","1 through 10","127.72","391.4","percent of total billed charges",""
"Ahus Genetic Panel","PX-31000811","CDM","81479","CPT","0310","RC","","","","outpatient","","","412.00","309.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","206.00","50","","1.00","1.00","1.00","1 through 10","156.55","339.9","percent of total billed charges",""
"Ahus Genetic Panel","PX-31000811","CDM","81479","CPT","0310","RC","","","","outpatient","","","412.00","309.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","216.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","339.9","percent of total billed charges",""
"Ahus/Ddd Genetic Evaluation","PX-31000810","CDM","81479","CPT","0310","RC","","","","both","","","9318.00","6988.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7407.81","79.5","","0.65","0.65","0.65","1 through 10","2888.58","8852.1","percent of total billed charges",""
"Ahus/Ddd Genetic Evaluation","PX-31000810","CDM","81479","CPT","0310","RC","","","","both","","","9318.00","6988.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4966.49","53.3","","0.79","0.79","0.79","1 through 10","2888.58","8852.1","percent of total billed charges",""
"Ahus/Ddd Genetic Evaluation","PX-31000810","CDM","81479","CPT","0310","RC","","","","outpatient","","","9318.00","6988.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4659.00","50","","1.00","1.00","1.00","1 through 10","156.55","7687.35","percent of total billed charges",""
"Ahus/Ddd Genetic Evaluation","PX-31000810","CDM","81479","CPT","0310","RC","","","","outpatient","","","9318.00","6988.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4891.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","7687.35","percent of total billed charges",""
"Aicd Generator Procedures","245","MS-DRG","","","","","","","","inpatient","","","134836.10","101127.07","MEDICARE [2001]","HB BWH MEDICARE","41998.53","","Case rate ($41,998.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,480.54, add-ons for qualifying new technology services are included. If operating cost exceeds $96,124.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,111.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $37,947.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,100.70 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,671.17. The transfer capital threshold is the transfer adjustment factor * $3,671.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","57889.52","57889.52","57975.70","1 through 10","41158.56","71465.43","other","Inpatient Replacement Plans DRG"
"Aicd Generator Procedures","245","MS-DRG","","","","","","","","inpatient","","","134836.10","101127.07","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","41158.56","","Case rate ($41,998.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,480.54, add-ons for qualifying new technology services are included. If operating cost exceeds $96,124.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,111.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $37,947.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,100.70 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,671.17. The transfer capital threshold is the transfer adjustment factor * $3,671.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","43809.50","43809.50","43809.50","1 through 10","41158.56","71465.43","other","Inpatient DRG"
"Aicd Lead Procedures","265","MS-DRG","","","","","","","","inpatient","","","119401.42","89551.06","MEDICARE [2001]","HB BWH MEDICARE","43215.45","","Case rate ($43,215.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,112.08, add-ons for qualifying new technology services are included. If operating cost exceeds $85,756.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,351.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $39,924.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,732.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,911.42. The transfer capital threshold is the transfer adjustment factor * $2,911.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","42395.45","42395.45","42395.45","1 through 10","32717.74","53832.6152","other","Inpatient DRG"
"Airway Resistance by Oscillometry","PX-46000045","CDM","94728","CPT","0460","RC","","","","both","","","1241.00","930.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","868.70","70","","517.29","517.29","517.29","1 through 10","176.52","986.6","percent of total billed charges",""
"Airway Resistance by Oscillometry","PX-46000045","CDM","94728","CPT","0460","RC","","","","both","","","1241.00","930.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","176.52","986.6","other","OPPS APC"
"Airway Resistance by Oscillometry","PX-46000045","CDM","94728","CPT","0460","RC","","","","both","","","1241.00","930.75","MOLINA [1014]","HB BWH MOLINA","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","368.65","368.65","368.65","1 through 10","176.52","986.6","other","OPPS APC"
"Airway Resistance by Oscillometry","PX-46000045","CDM","94728","CPT","0460","RC","","","","both","","","1241.00","930.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","548.52","548.52","548.52","1 through 10","176.52","986.6","other","OPPS APC"
"Albumin Qn Urine or Other Source","PX-30000282","CDM","82042","CPT","0301","RC","","","","both","","","75.00","56.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59.63","79.5","","172.35","172.35","172.35","1 through 10","5.34","71.25","percent of total billed charges",""
"Albumin Qn Urine or Other Source","PX-30000282","CDM","82042","CPT","0301","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","61.29","81.72","","58.36","58.36","58.36","1 through 10","5.34","61.29","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","68.00","51.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","48.82","71.8","","47.39","47.39","47.39","1 through 10","4.85","64.6","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","68.00","51.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","44.61","65.6","","51.48","51.48","51.48","1 through 10","4.85","64.6","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","68.00","51.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","47.60","70","","66.00","66.00","66.00","1 through 10","4.85","64.6","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","68.00","51.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","54.06","79.5","","51.94","34.85","161.41","18","4.85","64.6","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","68.00","51.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","36.24","53.3","","34.85","34.85","104.55","11","4.85","64.6","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","68.00","51.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24.82","36.5","","24.62","20.92","73.86","18","4.85","64.6","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","68.00","51.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26.04","38.3","","25.81","25.08","77.43","37","4.85","64.6","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","outpatient","","","68.00","51.00","AETNA [1001]","HB AMC AETNA HMO","47.46","69.8","","44.68","31.55","44.68","16","5.11","55.57","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","outpatient","","","68.00","51.00","AETNA [1001]","HB AMC AETNA PPO","54.67","80.4","","51.48","51.48","51.48","1 through 10","5.11","55.57","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","outpatient","","","68.00","51.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","55.57","81.72","","52.76","29.02","52.76","14","5.11","55.57","percent of total billed charges",""
"Albumin Vl","PX-63600245","CDM","P9047","HCPCS","0636","RC","","","","both","","","622.00","466.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","227.03","36.5","","46.48","46.48","46.48","1 through 10","130.19","478.94","percent of total billed charges",""
"Albumin Vl","PX-63600245","CDM","P9047","HCPCS","0636","RC","","","","both","","","622.00","466.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","238.23","38.3","","105.28","57.33","105.28","30","130.19","478.94","percent of total billed charges",""
"Albumin Vl","PX-63600245","CDM","P9047","HCPCS","0636","RC","","","","outpatient","","","622.00","466.50","AETNA [1001]","HB AMC AETNA HMO","434.16","69.8","","114.37","114.37","114.37","1 through 10","88.04","513.15","percent of total billed charges",""
"Albumin Vl","PX-63600245","CDM","P9047","HCPCS","0636","RC","","","","outpatient","","","622.00","466.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","291.72","46.9","","68.04","68.04","68.04","1 through 10","88.04","513.15","percent of total billed charges",""
"Albumin Vl","PX-63600245","CDM","P9047","HCPCS","0636","RC","","","","outpatient","","","622.00","466.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","311.00","50","","209.80","209.80","209.80","1 through 10","88.04","513.15","percent of total billed charges",""
"Albumin Vl 5% 250ml","PX-63600244","CDM","P9045","HCPCS","0636","RC","","","","both","","","1156.00","867.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","66.35","","APC Price ($53.08). Final payment is multiplied by 125%.","52.02","52.02","52.02","1 through 10","50.43","890.12","other","OPPS APC"
"Albumin Vl 5% 250ml","PX-63600244","CDM","P9045","HCPCS","0636","RC","","","","both","","","1156.00","867.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","52.02","","APC Price ($53.08). Final payment is multiplied by 98%.","52.02","52.02","52.02","1 through 10","50.43","890.12","other","OPPS APC"
"Albumin Vl 5% 250ml","PX-63600244","CDM","P9045","HCPCS","0636","RC","","","","outpatient","","","1156.00","867.00","AETNA [1001]","HB AMC AETNA HMO","806.89","69.8","","99.27","99.27","99.27","1 through 10","88.04","953.7","percent of total billed charges",""
"Albumin Vl 5% 250ml","PX-63600244","CDM","P9045","HCPCS","0636","RC","","","","outpatient","","","1156.00","867.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","808.04","69.9","","110.56","110.56","110.56","1 through 10","88.04","953.7","percent of total billed charges",""
"Albumin Vl 5% 250ml","PX-63600244","CDM","P9045","HCPCS","0636","RC","","","","outpatient","","","1156.00","867.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","578.00","50","","52.45","52.45","52.45","1 through 10","88.04","953.7","percent of total billed charges",""
"Albumin Vl 5% 250ml","PX-63600244","CDM","P9045","HCPCS","0636","RC","","","","outpatient","","","1156.00","867.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","929.42","80.4","","114.37","114.37","114.37","1 through 10","88.04","953.7","percent of total billed charges",""
"Alcohol (Etoh) Ablation of Thyroid Nodule","PX-76002939","CDM","60699","CPT","0761","RC","","","","both","","","917.00","687.75","MEDICARE [2001]","HB BWH MEDICARE","6927.95","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6928.65","6928.65","1 through 10","284.27","8659.94","other","OPPS APC"
"Alcohol (Etoh) Ablation of Thyroid Nodule","PX-76002939","CDM","60699","CPT","0761","RC","","","","both","","","917.00","687.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","351.21","38.3","","5123.54","4829.42","5123.54","1 through 10","284.27","8659.94","percent of total billed charges",""
"Alcohol (Etoh) Ablation of Thyroid Nodule","PX-76002939","CDM","60699","CPT","0761","RC","","","","outpatient","","","917.00","687.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","555.24","60.55","","13483.00","13483.00","13483.00","1 through 10","458.5","15696.44","percent of total billed charges",""
"Alcohol (Etoh) Ablation of Thyroid Nodule","PX-76002939","CDM","60699","CPT","0761","RC","","","","outpatient","","","917.00","687.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","478.86","52.22","","13483.00","12302.64","13483.00","1 through 10","458.5","15696.44","percent of total billed charges",""
"Alcohol (Etoh) Ablation of Thyroid Nodule","PX-76002939","CDM","60699","CPT","0761","RC","","","","outpatient","","","917.00","687.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","458.50","50","","13483.00","13483.00","13483.00","1 through 10","458.5","15696.44","percent of total billed charges",""
"Alcohol (Etoh) Ablation of Thyroid Nodule","PX-76002939","CDM","60699","CPT","0761","RC","","","","outpatient","","","917.00","687.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","481.43","52.5","","13483.00","3582.00","13483.00","1 through 10","458.5","15696.44","percent of total billed charges",""
"Alcohol Ablation of Lymphocele","PX-76001909","CDM","38999","CPT","0761","RC","","","","outpatient","","","465.00","348.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","242.82","52.22","","512.50","512.50","512.50","1 through 10","232.5","1234.13","percent of total billed charges",""
"Alcohol Ablation of Lymphocele","PX-76001909","CDM","38999","CPT","0761","RC","","","","outpatient","","","465.00","348.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","232.50","50","","6776.11","6776.11","6776.11","1 through 10","232.5","1234.13","percent of total billed charges",""
"Alcohol Abuse And Dependence,EXTREME","775","DRG","","","","","","","","inpatient","","","73753.38","","MASSHEALTH [3001]","HB BWH MEDICAID","21927.72","","Case rate ($24,244.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,674.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14900.97","14900.97","14900.97","1 through 10","954.59","121310.02","case rate",""
"Alcohol Abuse And Dependence,MAJOR","775","DRG","","","","","","","","inpatient","","","50638.72","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","30304.75","","Fee schedule rate ($30,304.75). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30304.75","30304.75","30304.75","1 through 10","954.59","121310.02","case rate",""
"Alcohol Abuse And Dependence,MAJOR","775","DRG","","","","","","","","inpatient","","","50638.72","","MASSHEALTH [3001]","HB BWH MEDICAID","9273.73","","Case rate ($10,253.70). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,683.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10251.19","914.23","11306.53","1 through 10","954.59","121310.02","case rate",""
"Alcohol Abuse And Dependence,MAJOR","775","DRG","","","","","","","","inpatient","","","50638.72","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","9273.73","","Case rate ($10,253.70). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,683.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","325.64","5615.64","1 through 10","954.59","121310.02","case rate",""
"Alcohol Abuse And Dependence,MAJOR","775","DRG","","","","","","","","inpatient","","","50638.72","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","21742.82","","Fee schedule rate ($21,742.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21109.36","21109.36","21109.36","1 through 10","954.59","121310.02","case rate",""
"Alcohol Abuse And Dependence,MAJOR","775","DRG","","","","","","","","inpatient","","","50638.72","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26859.28","","Fee schedule rate ($26,859.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11053.20","11053.20","11053.20","1 through 10","954.59","121310.02","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","40235.22","","MASSHEALTH [3001]","HB BWH MEDICAID","4853.91","","Case rate ($5,366.84). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,796.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6816.44","2399.34","7092.63","1 through 10","954.59","121310.02","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","40235.22","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","4853.91","","Case rate ($5,366.84). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,796.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","954.59","121310.02","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","40235.22","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15669.32","","Fee schedule rate ($15,669.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15669.32","15669.32","15669.32","1 through 10","954.59","121310.02","case rate",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","66830.40","50122.80","HUMANA [1012]","HB BWH MEDICARE","16298.83","","Case rate ($16,298.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,543.16, add-ons for qualifying new technology services are included. If operating cost exceeds $65,187.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,844.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,514.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,163.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,404.21. The transfer capital threshold is the transfer adjustment factor * $1,404.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16137.23","16137.23","16137.23","1 through 10","15972.85","26874.0528","other","Inpatient Replacement Plans DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","66830.40","50122.80","MEDICARE [2001]","HB BWH MEDICARE","16298.83","","Case rate ($16,298.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,543.16, add-ons for qualifying new technology services are included. If operating cost exceeds $65,187.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,844.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,514.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,163.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,404.21. The transfer capital threshold is the transfer adjustment factor * $1,404.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21272.41","1057.47","21303.81","1 through 10","15972.85","26874.0528","other","Inpatient Replacement Plans DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","66830.40","50122.80","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15972.85","","Case rate ($16,298.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,543.16, add-ons for qualifying new technology services are included. If operating cost exceeds $65,187.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,844.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,514.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,163.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,404.21. The transfer capital threshold is the transfer adjustment factor * $1,404.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16442.16","16113.23","22388.38","1 through 10","15972.85","26874.0528","other","Inpatient DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","66830.40","50122.80","WELLSENSE [1003]","HB BWH MEDICARE","16298.83","","Case rate ($16,298.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,543.16, add-ons for qualifying new technology services are included. If operating cost exceeds $65,187.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,844.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,514.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,163.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,404.21. The transfer capital threshold is the transfer adjustment factor * $1,404.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16606.56","16606.56","16606.56","1 through 10","15972.85","26874.0528","other","Inpatient Replacement Plans DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","44321.29","33240.97","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","8685.81","","Case rate ($8,432.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,074.06, add-ons for qualifying new technology services are included. If operating cost exceeds $55,718.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,150.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,342.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,694.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.35. The transfer capital threshold is the transfer adjustment factor * $710.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","5297.24","5297.24","5297.24","1 through 10","8264.17","13828.18","other","Inpatient DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","44321.29","33240.97","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8432.83","","Case rate ($8,432.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,074.06, add-ons for qualifying new technology services are included. If operating cost exceeds $55,718.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,150.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,342.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,694.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.35. The transfer capital threshold is the transfer adjustment factor * $710.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8195.41","8195.41","8195.41","1 through 10","8264.17","13828.18","other","Inpatient Replacement Plans DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","44321.29","33240.97","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8432.83","","Case rate ($8,432.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,074.06, add-ons for qualifying new technology services are included. If operating cost exceeds $55,718.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,150.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,342.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,694.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.35. The transfer capital threshold is the transfer adjustment factor * $710.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8154.25","8154.25","8218.93","1 through 10","8264.17","13828.18","other","Inpatient DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","44321.29","33240.97","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","6816.44","6816.44","10251.18","1 through 10","8264.17","13828.18","case rate",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","44321.29","33240.97","MEDICARE [2001]","HB BWH MEDICARE","8432.83","","Case rate ($8,432.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,074.06, add-ons for qualifying new technology services are included. If operating cost exceeds $55,718.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,150.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,342.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,694.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.35. The transfer capital threshold is the transfer adjustment factor * $710.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10690.94","10678.68","10694.22","22","8264.17","13828.18","other","Inpatient Replacement Plans DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","44321.29","33240.97","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","8264.17","","Case rate ($8,432.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,074.06, add-ons for qualifying new technology services are included. If operating cost exceeds $55,718.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,150.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,342.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,694.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.35. The transfer capital threshold is the transfer adjustment factor * $710.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7982.80","7982.80","7982.80","1 through 10","8264.17","13828.18","other","Inpatient DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","44321.29","33240.97","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8264.17","","Case rate ($8,432.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,074.06, add-ons for qualifying new technology services are included. If operating cost exceeds $55,718.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,150.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,342.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,694.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.35. The transfer capital threshold is the transfer adjustment factor * $710.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11050.67","8169.83","14355.57","1 through 10","8264.17","13828.18","other","Inpatient DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","44321.29","33240.97","WELLSENSE [1003]","HB BWH MEDICARE","8432.83","","Case rate ($8,432.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,074.06, add-ons for qualifying new technology services are included. If operating cost exceeds $55,718.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,150.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,342.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,694.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $710.35. The transfer capital threshold is the transfer adjustment factor * $710.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8411.90","8411.90","8411.90","1 through 10","8264.17","13828.18","other","Inpatient Replacement Plans DRG"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","","","","inpatient","","","41563.76","31172.82","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","6007.28","","Case rate ($6,007.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,154.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,798.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,936.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,131.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,774.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.39. The transfer capital threshold is the transfer adjustment factor * $496.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5824.18","5824.18","5824.18","1 through 10","5887.13","9418.2931","other","Inpatient DRG"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","","","","inpatient","","","41563.76","31172.82","MEDICARE [2001]","HB BWH MEDICARE","7683.29","","Case rate ($7,683.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,154.16, add-ons for qualifying new technology services are included. If operating cost exceeds $52,798.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,936.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,807.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,774.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.39. The transfer capital threshold is the transfer adjustment factor * $496.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7635.88","7635.88","7635.88","1 through 10","5887.13","9418.2931","other","Inpatient DRG"
"Alcoholic Liver Disease,EXTREME","280","DRG","","","","","","","","inpatient","","","152640.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31868.82","","Standard inlier is a Case rate ($31,868.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,430, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,523.97) for the length of stay and the standard reimbursement.","67026.72","67026.72","67026.72","1 through 10","6285.3","133108.87","case rate",""
"Alcoholic Liver Disease,EXTREME","280","DRG","","","","","","","","inpatient","","","152640.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35829.14","","Standard inlier is a Case rate ($35,829.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,430, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,085.65) for the length of stay and the standard reimbursement.","68844.30","68844.30","68844.30","1 through 10","6285.3","133108.87","case rate",""
"Alcoholic Liver Disease,EXTREME","280","DRG","","","","","","","","inpatient","","","152640.72","","MASSHEALTH [3001]","HB BWH MEDICAID","11172.34","","Case rate ($12,352.94). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,782.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27721.63","27721.63","27721.63","1 through 10","6285.3","133108.87","case rate",""
"Alcoholic Liver Disease,EXTREME","280","DRG","","","","","","","","inpatient","","","152640.72","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11172.34","","Case rate ($12,352.94). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,782.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1348.93","1348.93","1348.93","1 through 10","6285.3","133108.87","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","70185.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31868.82","","Standard inlier is a Case rate ($31,868.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,430, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,523.97) for the length of stay and the standard reimbursement.","31868.82","31868.82","54994.49","1 through 10","6285.3","133108.87","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","70185.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35829.14","","Standard inlier is a Case rate ($35,829.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,430, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,085.65) for the length of stay and the standard reimbursement.","35829.14","35829.14","35829.14","1 through 10","6285.3","133108.87","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","70185.22","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","108273.00","108273.00","108273.00","1 through 10","6285.3","133108.87","percent of total billed charges",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","70185.22","","MASSHEALTH [3001]","HB BWH MEDICAID","11172.34","","Case rate ($12,352.94). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,782.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12349.91","12349.91","12349.91","1 through 10","6285.3","133108.87","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","70185.22","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31254.51","","Fee schedule rate ($31,254.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30343.93","30343.93","30343.93","1 through 10","6285.3","133108.87","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","70185.22","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11172.34","","Case rate ($12,352.94). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,782.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1020.93","304.10","12349.91","1 through 10","6285.3","133108.87","case rate",""
"Alcoholic Liver Disease,MODERATE","280","DRG","","","","","","","","inpatient","","","37181.34","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","23528.56","","Standard inlier is a Case rate ($23,528.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,923, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,339.68) for the length of stay and the standard reimbursement.","23528.55","23528.55","23528.55","1 through 10","6285.3","133108.87","case rate",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","both","","","158.00","118.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","113.44","71.8","","8.56","8.56","8.56","1 through 10","9.52","150.1","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","both","","","158.00","118.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.61","79.5","","120.41","80.78","120.41","23","9.52","150.1","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","both","","","158.00","118.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","84.21","53.3","","80.78","80.78","80.78","1 through 10","9.52","150.1","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","both","","","158.00","118.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.67","36.5","","55.39","48.50","57.07","1 through 10","9.52","150.1","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","both","","","158.00","118.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.51","38.3","","59.82","50.49","59.82","32","9.52","150.1","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","both","","","158.00","118.50","TRICARE [160005]","HB BWH TRICARE","150.10","95","","11.70","11.70","11.70","1 through 10","9.52","150.1","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","both","","","158.00","118.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.78","42.9","","122.31","67.27","122.31","1 through 10","9.52","150.1","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","both","","","158.00","118.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.78","42.9","","67.27","67.27","67.27","1 through 10","9.52","150.1","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","outpatient","","","158.00","118.50","AETNA [1001]","HB AMC AETNA HMO","110.28","69.8","","103.58","73.13","119.34","25","10.01","129.12","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","outpatient","","","158.00","118.50","AETNA [1001]","HB AMC AETNA PPO","127.03","80.4","","119.34","119.34","119.34","1 through 10","10.01","129.12","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","outpatient","","","158.00","118.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","129.12","81.72","","67.27","67.27","67.27","1 through 10","10.01","129.12","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","outpatient","","","158.00","118.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","129.12","81.72","","122.31","67.27","122.31","18","10.01","129.12","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","both","","","500.00","375.00","CHAMPVA [160001]","HB BWH TRICARE","475.00","95","","49.10","49.10","49.10","1 through 10","39.94","475","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","both","","","500.00","375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","397.50","79.5","","381.70","256.08","381.70","14","39.94","475","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","both","","","500.00","375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","266.50","53.3","","256.08","256.08","381.70","12","39.94","475","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","both","","","500.00","375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","182.50","36.5","","180.91","153.75","461.25","30","39.94","475","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","both","","","500.00","375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","191.50","38.3","","189.64","184.30","189.64","84","39.94","475","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","both","","","500.00","375.00","TRICARE [160005]","HB BWH TRICARE","475.00","95","","485.00","46.65","485.00","1 through 10","39.94","475","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","both","","","500.00","375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.50","42.9","","213.25","213.25","213.25","1 through 10","39.94","475","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","both","","","500.00","375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.50","42.9","","213.25","213.25","213.25","1 through 10","39.94","475","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","outpatient","","","500.00","375.00","AETNA [1001]","HB AMC AETNA HMO","349.00","69.8","","328.35","231.83","378.30","25","42.03","408.6","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","outpatient","","","500.00","375.00","AETNA [1001]","HB AMC AETNA PPO","402.00","80.4","","378.30","378.30","378.30","1 through 10","42.03","408.6","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","outpatient","","","500.00","375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","408.60","81.72","","387.71","184.74","387.71","44","42.03","408.6","percent of total billed charges",""
"Alk & Mycn Gene Analysis","PX-31000779","CDM","81479","CPT","0310","RC","","","","both","","","10924.00","8193.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8684.58","79.5","","0.65","0.65","0.65","1 through 10","3386.44","10377.8","percent of total billed charges",""
"Alk & Mycn Gene Analysis","PX-31000779","CDM","81479","CPT","0310","RC","","","","both","","","10924.00","8193.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5822.49","53.3","","0.79","0.79","0.79","1 through 10","3386.44","10377.8","percent of total billed charges",""
"Alk & Mycn Gene Analysis","PX-31000779","CDM","81479","CPT","0310","RC","","","","outpatient","","","10924.00","8193.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5462.00","50","","1.00","1.00","1.00","1 through 10","156.55","9012.3","percent of total billed charges",""
"Alk & Mycn Gene Analysis","PX-31000779","CDM","81479","CPT","0310","RC","","","","outpatient","","","10924.00","8193.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","5735.10","52.5","","1.00","0.53","1.00","1 through 10","156.55","9012.3","percent of total billed charges",""
"Allan-Herndon-Dudley Syndrome: Slc16a2 Gene Sequencing","PX-31000674","CDM","81479","CPT","0310","RC","","","","both","","","2710.00","2032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2154.45","79.5","","0.65","0.65","0.65","1 through 10","840.1","2574.5","percent of total billed charges",""
"Allan-Herndon-Dudley Syndrome: Slc16a2 Gene Sequencing","PX-31000674","CDM","81479","CPT","0310","RC","","","","both","","","2710.00","2032.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1444.43","53.3","","0.79","0.79","0.79","1 through 10","840.1","2574.5","percent of total billed charges",""
"Allan-Herndon-Dudley Syndrome: Slc16a2 Gene Sequencing","PX-31000674","CDM","81479","CPT","0310","RC","","","","outpatient","","","2710.00","2032.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1355.00","50","","1.00","1.00","1.00","1 through 10","156.55","2235.75","percent of total billed charges",""
"Allan-Herndon-Dudley Syndrome: Slc16a2 Gene Sequencing","PX-31000674","CDM","81479","CPT","0310","RC","","","","outpatient","","","2710.00","2032.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1422.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","2235.75","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","both","","","263.00","197.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","209.09","79.5","","200.69","134.64","200.69","12","17.57","249.85","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","both","","","263.00","197.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","96.00","36.5","","95.12","95.12","95.12","1 through 10","17.57","249.85","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","both","","","263.00","197.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.73","38.3","","99.71","99.71","99.71","1 through 10","17.57","249.85","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","both","","","263.00","197.25","WELLPOINT [1015]","HB AMC WELLPOINT","194.04","73.78","","189.85","189.85","189.85","106","17.57","249.85","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","outpatient","","","263.00","197.25","AETNA [1001]","HB AMC AETNA HMO","183.57","69.8","","198.90","172.64","1045.50","27","62.89","214.92","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.92","81.72","","74.05","72.29","203.85","45","62.89","214.92","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Allergic Reactions With McC","915","MS-DRG","","","","","","","","inpatient","","","42564.16","31923.12","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","19649.46","","Case rate ($15,719.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,845.85, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,793.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,986.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,466.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,353.11. The transfer capital threshold is the transfer adjustment factor * $1,353.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","16090.39","16090.39","16090.39","1 through 10","15405.18","26340.58","other","Inpatient DRG"
"Allergic Reactions With McC","915","MS-DRG","","","","","","","","inpatient","","","42564.16","31923.12","MEDICARE [2001]","HB BWH MEDICARE","20288.17","","Case rate ($20,288.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,845.85, add-ons for qualifying new technology services are included. If operating cost exceeds $64,490.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,793.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $18,555.22 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,466.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,353.11. The transfer capital threshold is the transfer adjustment factor * $1,353.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12203.13","12203.13","12203.13","1 through 10","15405.18","26340.58","other","Inpatient DRG"
"Allergic Reactions Without McC","916","MS-DRG","","","","","","","","inpatient","","","42830.07","32122.55","MEDICARE [2001]","HB BWH MEDICARE","8268.12","","Case rate ($8,268.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,696.63, add-ons for qualifying new technology services are included. If operating cost exceeds $53,341.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,976.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,352.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,316.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.14. The transfer capital threshold is the transfer adjustment factor * $536.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1228.51","104.56","8119.17","1 through 10","6328.74","10021.9331","other","Inpatient DRG"
"Allergic Reactions,EXTREME","811","DRG","","","","","","","","inpatient","","","129272.30","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","63531.83","","Standard inlier is a Case rate ($63,531.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $55,591, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,017.82) for the length of stay and the standard reimbursement.","63531.82","63531.82","63531.82","1 through 10","5518.77","254946.65","case rate",""
"Allergic Reactions,MAJOR","811","DRG","","","","","","","","inpatient","","","35820.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32513.11","","Standard inlier is a Case rate ($32,513.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,137, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,614.97) for the length of stay and the standard reimbursement.","32513.11","32513.11","32513.11","1 through 10","5518.77","254946.65","case rate",""
"Allergic Reactions,MAJOR","811","DRG","","","","","","","","inpatient","","","35820.33","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","11297.91","11297.91","11297.91","1 through 10","5518.77","254946.65","percent of total billed charges",""
"Allergic Reactions,MAJOR","811","DRG","","","","","","","","inpatient","","","35820.33","","MASSHEALTH [3001]","HB BWH MEDICAID","9286.29","","Case rate ($10,267.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,697.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10265.08","10265.08","10265.08","1 through 10","5518.77","254946.65","case rate",""
"Allergic Reactions,MAJOR","811","DRG","","","","","","","","inpatient","","","35820.33","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25690.69","","Fee schedule rate ($25,690.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25690.69","25690.69","25690.69","1 through 10","5518.77","254946.65","case rate",""
"Allergic Reactions,MAJOR","811","DRG","","","","","","","","inpatient","","","35820.33","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26975.65","","Fee schedule rate ($26,975.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26975.65","26975.65","26975.65","1 through 10","5518.77","254946.65","case rate",""
"Allg Test Perq & Ic Drug/Biol Immed React W/ I&R","PX-92000133","CDM","95018","CPT","0924","RC","","","","both","","","92.00","69.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","64.40","70","","67.00","67.00","67.00","1 through 10","28.52","73.14","percent of total billed charges",""
"Allg Test Perq & Ic Drug/Biol Immed React W/ I&R","PX-92000133","CDM","95018","CPT","0924","RC","","","","both","","","92.00","69.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","73.14","79.5","","70.04","67.11","70.04","39","28.52","73.14","percent of total billed charges",""
"Allg Test Perq & Ic Drug/Biol Immed React W/ I&R","PX-92000133","CDM","95018","CPT","0924","RC","","","","both","","","92.00","69.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","49.04","53.3","","46.99","46.99","70.04","44","28.52","73.14","percent of total billed charges",""
"Allg Test Perq & Ic Drug/Biol Immed React W/ I&R","PX-92000133","CDM","95018","CPT","0924","RC","","","","both","","","92.00","69.00","HUMANA [1012]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7.79","7.79","7.79","30","28.52","73.14","other","OPPS APC"
"Allg Test Perq & Ic Drug/Biol Immed React W/ I&R","PX-92000133","CDM","95018","CPT","0924","RC","","","","both","","","92.00","69.00","MEDICARE [2001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2.91","2.59","31.07","61","28.52","73.14","other","OPPS APC"
"Allg Test Perq & Ic Drug/Biol Immed React W/ I&R","PX-92000133","CDM","95018","CPT","0924","RC","","","","both","","","92.00","69.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.58","36.5","","33.20","28.21","64.44","94","28.52","73.14","percent of total billed charges",""
"Allg Test Perq & Ic Drug/Biol Immed React W/ I&R","PX-92000133","CDM","95018","CPT","0924","RC","","","","both","","","92.00","69.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35.24","38.3","","34.80","34.80","104.40","149","28.52","73.14","percent of total billed charges",""
"Allg Test Perq & Ic Drug/Biol Immed React W/ I&R","PX-92000133","CDM","95018","CPT","0924","RC","","","","both","","","92.00","69.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","15.23","15.23","15.23","12","28.52","73.14","other","OPPS APC"
"Allg Test Perq & Ic Drug/Biol Immed React W/ I&R","PX-92000133","CDM","95018","CPT","0924","RC","","","","both","","","92.00","69.00","WELLPOINT [1015]","HB AMC WELLPOINT","67.88","73.78","","66.26","66.26","66.26","85","28.52","73.14","percent of total billed charges",""
"Allg Test Perq & Ic Drug/Biol Immed React W/ I&R","PX-92000133","CDM","95018","CPT","0924","RC","","","","outpatient","","","92.00","69.00","AETNA [1001]","HB AMC AETNA HMO","64.22","69.8","","42.54","42.54","60.25","54","48.08","197.92","percent of total billed charges",""
"Allg Test Perq & Ic Drug/Biol Immed React W/ I&R","PX-92000133","CDM","95018","CPT","0924","RC","","","","outpatient","","","92.00","69.00","AETNA [1001]","HB AMC AETNA PPO","73.97","80.4","","93.27","46.64","93.27","22","48.08","197.92","percent of total billed charges",""
"Allg Test Perq & Ic Drug/Biol Immed React W/ I&R","PX-92000133","CDM","95018","CPT","0924","RC","","","","outpatient","","","92.00","69.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","75.18","81.72","","39.14","39.14","39.14","1 through 10","48.08","197.92","percent of total billed charges",""
"Allg Test Perq & Ic Drug/Biol Immed React W/ I&R","PX-92000133","CDM","95018","CPT","0924","RC","","","","outpatient","","","92.00","69.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","75.18","81.72","","71.15","71.15","71.15","43","48.08","197.92","percent of total billed charges",""
"Allg Tstg Perq & Ic Venoms Immed React W/ I&R","PX-92000136","CDM","95017","CPT","0924","RC","","","","both","","","132.00","99.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","104.94","79.5","","96.51","67.58","96.51","27","27.63","104.94","percent of total billed charges",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1113.00","834.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","406.25","36.5","","23.35","23.35","23.35","264","345.03","857.01","percent of total billed charges",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1113.00","834.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","426.28","38.3","","350.11","350.11","350.11","1108","345.03","857.01","percent of total billed charges",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1113.00","834.75","WELLPOINT [1015]","HB AMC WELLPOINT","821.17","73.78","","77.77","77.77","77.77","528","345.03","857.01","percent of total billed charges",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1113.00","834.75","AETNA [1001]","HB AMC AETNA HMO","776.87","69.8","","35.22","35.22","35.22","397","522","894.85","percent of total billed charges",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1113.00","834.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","777.99","69.9","","34.18","34.18","34.18","1057","522","894.85","percent of total billed charges",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1113.00","834.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","522.00","46.9","","34.18","34.18","34.18","528","522","894.85","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","both","","","8563.40","6422.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3125.64","36.5","","23.35","23.35","23.35","264","2654.65","6593.82","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","both","","","8563.40","6422.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3279.78","38.3","","350.11","350.11","350.11","1108","2654.65","6593.82","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","both","","","8563.40","6422.55","WELLPOINT [1015]","HB AMC WELLPOINT","6318.08","73.78","","77.77","77.77","77.77","528","2654.65","6593.82","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","8563.40","6422.55","AETNA [1001]","HB AMC AETNA HMO","5977.25","69.8","","35.22","35.22","35.22","397","4016.23","6884.97","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","8563.40","6422.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5985.82","69.9","","34.18","34.18","34.18","1057","4016.23","6884.97","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","8563.40","6422.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4016.23","46.9","","34.18","34.18","34.18","528","4016.23","6884.97","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9050.00","6787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3303.25","36.5","","23.35","23.35","23.35","264","2805.5","6968.5","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9050.00","6787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3466.15","38.3","","350.11","350.11","350.11","1108","2805.5","6968.5","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9050.00","6787.50","WELLPOINT [1015]","HB AMC WELLPOINT","6677.09","73.78","","77.77","77.77","77.77","528","2805.5","6968.5","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9050.00","6787.50","AETNA [1001]","HB AMC AETNA HMO","6316.90","69.8","","35.22","35.22","35.22","397","4244.45","7276.2","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9050.00","6787.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6325.95","69.9","","34.18","34.18","34.18","1057","4244.45","7276.2","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9050.00","6787.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4244.45","46.9","","34.18","34.18","34.18","528","4244.45","7276.2","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","both","","","10727.50","8045.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3915.54","36.5","","23.35","23.35","23.35","264","3325.53","8260.18","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","both","","","10727.50","8045.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4108.63","38.3","","350.11","350.11","350.11","1108","3325.53","8260.18","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","both","","","10727.50","8045.62","WELLPOINT [1015]","HB AMC WELLPOINT","7914.75","73.78","","77.77","77.77","77.77","528","3325.53","8260.18","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","10727.50","8045.62","AETNA [1001]","HB AMC AETNA HMO","7487.80","69.8","","35.22","35.22","35.22","397","5031.2","8624.91","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","10727.50","8045.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7498.52","69.9","","34.18","34.18","34.18","1057","5031.2","8624.91","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","10727.50","8045.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5031.20","46.9","","34.18","34.18","34.18","528","5031.2","8624.91","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","both","","","12215.00","9161.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4458.48","36.5","","23.35","23.35","23.35","264","3786.65","9405.55","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","both","","","12215.00","9161.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4678.35","38.3","","350.11","350.11","350.11","1108","3786.65","9405.55","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","both","","","12215.00","9161.25","WELLPOINT [1015]","HB AMC WELLPOINT","9012.23","73.78","","77.77","77.77","77.77","528","3786.65","9405.55","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","12215.00","9161.25","AETNA [1001]","HB AMC AETNA HMO","8526.07","69.8","","35.22","35.22","35.22","397","5728.84","9820.86","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","12215.00","9161.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8538.29","69.9","","34.18","34.18","34.18","1057","5728.84","9820.86","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","12215.00","9161.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5728.84","46.9","","34.18","34.18","34.18","528","5728.84","9820.86","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","both","","","483.00","362.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","176.30","36.5","","23.35","23.35","23.35","264","149.73","371.91","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","both","","","483.00","362.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","184.99","38.3","","350.11","350.11","350.11","1108","149.73","371.91","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","both","","","483.00","362.25","WELLPOINT [1015]","HB AMC WELLPOINT","356.36","73.78","","77.77","77.77","77.77","528","149.73","371.91","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","483.00","362.25","AETNA [1001]","HB AMC AETNA HMO","337.13","69.8","","35.22","35.22","35.22","397","226.53","388.33","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","483.00","362.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","337.62","69.9","","34.18","34.18","34.18","1057","226.53","388.33","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","483.00","362.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","226.53","46.9","","34.18","34.18","34.18","528","226.53","388.33","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1998.50","1498.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","729.45","36.5","","23.35","23.35","23.35","264","619.54","1538.85","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1998.50","1498.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","765.43","38.3","","350.11","350.11","350.11","1108","619.54","1538.85","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1998.50","1498.87","WELLPOINT [1015]","HB AMC WELLPOINT","1474.49","73.78","","77.77","77.77","77.77","528","619.54","1538.85","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1998.50","1498.87","AETNA [1001]","HB AMC AETNA HMO","1394.95","69.8","","35.22","35.22","35.22","397","937.3","1606.79","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1998.50","1498.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1396.95","69.9","","34.18","34.18","34.18","1057","937.3","1606.79","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1998.50","1498.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","937.30","46.9","","34.18","34.18","34.18","528","937.3","1606.79","percent of total billed charges",""
"Alloderm 24 Sq Cm Tier1","PX-27001022","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2236.50","1677.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","816.32","36.5","","23.35","23.35","23.35","264","693.32","1722.11","percent of total billed charges",""
"Alloderm 24 Sq Cm Tier1","PX-27001022","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2236.50","1677.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","856.58","38.3","","350.11","350.11","350.11","1108","693.32","1722.11","percent of total billed charges",""
"Alloderm 24 Sq Cm Tier1","PX-27001022","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2236.50","1677.37","WELLPOINT [1015]","HB AMC WELLPOINT","1650.09","73.78","","77.77","77.77","77.77","528","693.32","1722.11","percent of total billed charges",""
"Alloderm 24 Sq Cm Tier1","PX-27001022","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2236.50","1677.37","AETNA [1001]","HB AMC AETNA HMO","1561.08","69.8","","35.22","35.22","35.22","397","1048.92","1798.15","percent of total billed charges",""
"Alloderm 24 Sq Cm Tier1","PX-27001022","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2236.50","1677.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1563.31","69.9","","34.18","34.18","34.18","1057","1048.92","1798.15","percent of total billed charges",""
"Alloderm 24 Sq Cm Tier1","PX-27001022","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2236.50","1677.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1048.92","46.9","","34.18","34.18","34.18","528","1048.92","1798.15","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1480.08","1110.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","540.23","36.5","","23.35","23.35","23.35","264","458.82","1139.66","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1480.08","1110.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","566.87","38.3","","350.11","350.11","350.11","1108","458.82","1139.66","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1480.08","1110.06","WELLPOINT [1015]","HB AMC WELLPOINT","1092.00","73.78","","77.77","77.77","77.77","528","458.82","1139.66","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1480.08","1110.06","AETNA [1001]","HB AMC AETNA HMO","1033.10","69.8","","35.22","35.22","35.22","397","694.16","1189.98","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1480.08","1110.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1034.58","69.9","","34.18","34.18","34.18","1057","694.16","1189.98","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1480.08","1110.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","694.16","46.9","","34.18","34.18","34.18","528","694.16","1189.98","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","both","","","72.34","54.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.40","36.5","","23.35","23.35","23.35","264","22.43","55.7","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","both","","","72.34","54.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27.71","38.3","","350.11","350.11","350.11","1108","22.43","55.7","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","both","","","72.34","54.25","WELLPOINT [1015]","HB AMC WELLPOINT","53.37","73.78","","77.77","77.77","77.77","528","22.43","55.7","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","72.34","54.25","AETNA [1001]","HB AMC AETNA HMO","50.49","69.8","","35.22","35.22","35.22","397","33.93","58.16","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","72.34","54.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","50.57","69.9","","34.18","34.18","34.18","1057","33.93","58.16","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","72.34","54.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33.93","46.9","","34.18","34.18","34.18","528","33.93","58.16","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","both","","","808.50","606.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","295.10","36.5","","23.35","23.35","23.35","264","250.64","622.55","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","both","","","808.50","606.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","309.66","38.3","","350.11","350.11","350.11","1108","250.64","622.55","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","both","","","808.50","606.37","WELLPOINT [1015]","HB AMC WELLPOINT","596.51","73.78","","77.77","77.77","77.77","528","250.64","622.55","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","808.50","606.37","AETNA [1001]","HB AMC AETNA HMO","564.33","69.8","","35.22","35.22","35.22","397","379.19","650.03","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","808.50","606.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","565.14","69.9","","34.18","34.18","34.18","1057","379.19","650.03","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","808.50","606.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","379.19","46.9","","34.18","34.18","34.18","528","379.19","650.03","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2348.50","1761.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","857.20","36.5","","23.35","23.35","23.35","264","728.04","1808.35","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2348.50","1761.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","899.48","38.3","","350.11","350.11","350.11","1108","728.04","1808.35","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2348.50","1761.37","WELLPOINT [1015]","HB AMC WELLPOINT","1732.72","73.78","","77.77","77.77","77.77","528","728.04","1808.35","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2348.50","1761.37","AETNA [1001]","HB AMC AETNA HMO","1639.25","69.8","","35.22","35.22","35.22","397","1101.45","1888.19","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2348.50","1761.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1641.60","69.9","","34.18","34.18","34.18","1057","1101.45","1888.19","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2348.50","1761.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1101.45","46.9","","34.18","34.18","34.18","528","1101.45","1888.19","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1417.50","1063.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","517.39","36.5","","23.35","23.35","23.35","264","439.43","1091.48","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1417.50","1063.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","542.90","38.3","","350.11","350.11","350.11","1108","439.43","1091.48","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1417.50","1063.12","WELLPOINT [1015]","HB AMC WELLPOINT","1045.83","73.78","","77.77","77.77","77.77","528","439.43","1091.48","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1417.50","1063.12","AETNA [1001]","HB AMC AETNA HMO","989.42","69.8","","35.22","35.22","35.22","397","664.81","1139.67","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1417.50","1063.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","990.83","69.9","","34.18","34.18","34.18","1057","664.81","1139.67","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1417.50","1063.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","664.81","46.9","","34.18","34.18","34.18","528","664.81","1139.67","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4140.00","3105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1511.10","36.5","","23.35","23.35","23.35","264","1283.4","3187.8","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4140.00","3105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1585.62","38.3","","350.11","350.11","350.11","1108","1283.4","3187.8","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4140.00","3105.00","WELLPOINT [1015]","HB AMC WELLPOINT","3054.49","73.78","","77.77","77.77","77.77","528","1283.4","3187.8","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4140.00","3105.00","AETNA [1001]","HB AMC AETNA HMO","2889.72","69.8","","35.22","35.22","35.22","397","1941.66","3328.56","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4140.00","3105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2893.86","69.9","","34.18","34.18","34.18","1057","1941.66","3328.56","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4140.00","3105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1941.66","46.9","","34.18","34.18","34.18","528","1941.66","3328.56","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5124.00","3843.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1870.26","36.5","","23.35","23.35","23.35","264","1588.44","3945.48","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5124.00","3843.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1962.49","38.3","","350.11","350.11","350.11","1108","1588.44","3945.48","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5124.00","3843.00","WELLPOINT [1015]","HB AMC WELLPOINT","3780.49","73.78","","77.77","77.77","77.77","528","1588.44","3945.48","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5124.00","3843.00","AETNA [1001]","HB AMC AETNA HMO","3576.55","69.8","","35.22","35.22","35.22","397","2403.16","4119.7","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5124.00","3843.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3581.68","69.9","","34.18","34.18","34.18","1057","2403.16","4119.7","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5124.00","3843.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2403.16","46.9","","34.18","34.18","34.18","528","2403.16","4119.7","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4785.00","3588.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1746.53","36.5","","23.35","23.35","23.35","264","1483.35","3684.45","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4785.00","3588.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1832.66","38.3","","350.11","350.11","350.11","1108","1483.35","3684.45","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4785.00","3588.75","WELLPOINT [1015]","HB AMC WELLPOINT","3530.37","73.78","","77.77","77.77","77.77","528","1483.35","3684.45","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4785.00","3588.75","AETNA [1001]","HB AMC AETNA HMO","3339.93","69.8","","35.22","35.22","35.22","397","2244.17","3847.14","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4785.00","3588.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3344.72","69.9","","34.18","34.18","34.18","1057","2244.17","3847.14","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4785.00","3588.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2244.17","46.9","","34.18","34.18","34.18","528","2244.17","3847.14","percent of total billed charges",""
"Alloderm 72 Sq Cm Tier3","PX-27001021","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5367.50","4025.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1959.14","36.5","","23.35","23.35","23.35","264","1663.93","4132.98","percent of total billed charges",""
"Alloderm 72 Sq Cm Tier3","PX-27001021","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5367.50","4025.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2055.75","38.3","","350.11","350.11","350.11","1108","1663.93","4132.98","percent of total billed charges",""
"Alloderm 72 Sq Cm Tier3","PX-27001021","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5367.50","4025.62","WELLPOINT [1015]","HB AMC WELLPOINT","3960.14","73.78","","77.77","77.77","77.77","528","1663.93","4132.98","percent of total billed charges",""
"Alloderm 72 Sq Cm Tier3","PX-27001021","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5367.50","4025.62","AETNA [1001]","HB AMC AETNA HMO","3746.52","69.8","","35.22","35.22","35.22","397","2517.36","4315.47","percent of total billed charges",""
"Alloderm 72 Sq Cm Tier3","PX-27001021","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5367.50","4025.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3751.88","69.9","","34.18","34.18","34.18","1057","2517.36","4315.47","percent of total billed charges",""
"Alloderm 72 Sq Cm Tier3","PX-27001021","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5367.50","4025.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2517.36","46.9","","34.18","34.18","34.18","528","2517.36","4315.47","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5567.50","4175.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2032.14","36.5","","23.35","23.35","23.35","264","1725.93","4286.98","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5567.50","4175.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2132.35","38.3","","350.11","350.11","350.11","1108","1725.93","4286.98","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5567.50","4175.62","WELLPOINT [1015]","HB AMC WELLPOINT","4107.70","73.78","","77.77","77.77","77.77","528","1725.93","4286.98","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5567.50","4175.62","AETNA [1001]","HB AMC AETNA HMO","3886.12","69.8","","35.22","35.22","35.22","397","2611.16","4476.27","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5567.50","4175.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3891.68","69.9","","34.18","34.18","34.18","1057","2611.16","4476.27","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5567.50","4175.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2611.16","46.9","","34.18","34.18","34.18","528","2611.16","4476.27","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","both","","","877.35","658.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","320.23","36.5","","23.35","23.35","23.35","264","271.98","675.56","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","both","","","877.35","658.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","336.03","38.3","","350.11","350.11","350.11","1108","271.98","675.56","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","both","","","877.35","658.01","WELLPOINT [1015]","HB AMC WELLPOINT","647.31","73.78","","77.77","77.77","77.77","528","271.98","675.56","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","877.35","658.01","AETNA [1001]","HB AMC AETNA HMO","612.39","69.8","","35.22","35.22","35.22","397","411.48","705.39","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","877.35","658.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","613.27","69.9","","34.18","34.18","34.18","1057","411.48","705.39","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","877.35","658.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","411.48","46.9","","34.18","34.18","34.18","528","411.48","705.39","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2555.00","36.5","","23.35","23.35","23.35","264","2170","5390","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2681.00","38.3","","350.11","350.11","350.11","1108","2170","5390","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7000.00","5250.00","WELLPOINT [1015]","HB AMC WELLPOINT","5164.60","73.78","","77.77","77.77","77.77","528","2170","5390","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7000.00","5250.00","AETNA [1001]","HB AMC AETNA HMO","4886.00","69.8","","35.22","35.22","35.22","397","3283","5628","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7000.00","5250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4893.00","69.9","","34.18","34.18","34.18","1057","3283","5628","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7000.00","5250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3283.00","46.9","","34.18","34.18","34.18","528","3283","5628","percent of total billed charges",""
"Alloderm per Sq Cm T1","PX-27000627","CDM","Q4116","HCPCS","0636","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.22","36.5","","23.35","23.35","23.35","264","28.21","70.07","percent of total billed charges",""
"Alloderm per Sq Cm T1","PX-27000627","CDM","Q4116","HCPCS","0636","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.85","38.3","","350.11","350.11","350.11","1108","28.21","70.07","percent of total billed charges",""
"Alloderm per Sq Cm T1","PX-27000627","CDM","Q4116","HCPCS","0636","RC","","","","both","","","91.00","68.25","WELLPOINT [1015]","HB AMC WELLPOINT","67.14","73.78","","77.77","77.77","77.77","528","28.21","70.07","percent of total billed charges",""
"Alloderm per Sq Cm T1","PX-27000627","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA HMO","63.52","69.8","","35.22","35.22","35.22","397","42.68","73.16","percent of total billed charges",""
"Alloderm per Sq Cm T1","PX-27000627","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","91.00","68.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","63.61","69.9","","34.18","34.18","34.18","1057","42.68","73.16","percent of total billed charges",""
"Alloderm per Sq Cm T1","PX-27000627","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","91.00","68.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","42.68","46.9","","34.18","34.18","34.18","528","42.68","73.16","percent of total billed charges",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","","","","inpatient","","","380132.21","285099.16","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","113308.65","","Case rate ($110,008.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $132,351.01, add-ons for qualifying new technology services are included. If operating cost exceeds $177,995.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,110.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.7. The base transfer operating payment is the transfer adjustment factor * $99,958.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $131,971.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $9,670.31. The transfer capital threshold is the transfer adjustment factor * $9,670.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","117022.63","117022.63","214548.54","1 through 10","107808.23","188248.39","other","Inpatient DRG"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","","","","inpatient","","","380132.21","285099.16","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","110008.40","","Case rate ($110,008.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $132,351.01, add-ons for qualifying new technology services are included. If operating cost exceeds $177,995.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,110.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.7. The base transfer operating payment is the transfer adjustment factor * $99,958.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $131,971.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $9,670.31. The transfer capital threshold is the transfer adjustment factor * $9,670.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","152462.84","152462.84","152462.84","1 through 10","107808.23","188248.39","other","Inpatient Replacement Plans DRG"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","","","","inpatient","","","380132.21","285099.16","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","","","Payment is accumulated by days. Day 1 - 45, Case rate ($170,000). Day 46 - 9999, Per diem ($2,750).","599658.49","427372.96","813831.27","1 through 10","107808.23","188248.39","other","Allogenic Unrelated BMT"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","","","","inpatient","","","380132.21","285099.16","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","275221.16","275221.16","275221.16","1 through 10","107808.23","188248.39","case rate",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","","","","inpatient","","","380132.21","285099.16","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","110008.40","","Case rate ($110,008.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $132,351.01, add-ons for qualifying new technology services are included. If operating cost exceeds $177,995.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,110.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.7. The base transfer operating payment is the transfer adjustment factor * $99,958.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $131,971.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $9,670.31. The transfer capital threshold is the transfer adjustment factor * $9,670.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","117222.90","117222.90","117222.90","1 through 10","107808.23","188248.39","other","Inpatient Replacement Plans DRG"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","","","","inpatient","","","380132.21","285099.16","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","110008.40","","Case rate ($110,008.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $132,351.01, add-ons for qualifying new technology services are included. If operating cost exceeds $177,995.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,110.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.7. The base transfer operating payment is the transfer adjustment factor * $99,958.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $131,971.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $9,670.31. The transfer capital threshold is the transfer adjustment factor * $9,670.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","116996.52","116996.52","116996.52","1 through 10","107808.23","188248.39","other","Inpatient Replacement Plans DRG"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","","","","inpatient","","","380132.21","285099.16","MARTIN'S POINT [160007]","HB BWH MEDICARE","110008.40","","Case rate ($110,008.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $132,351.01, add-ons for qualifying new technology services are included. If operating cost exceeds $177,995.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,110.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.7. The base transfer operating payment is the transfer adjustment factor * $99,958.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $131,971.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $9,670.31. The transfer capital threshold is the transfer adjustment factor * $9,670.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","117242.19","117242.19","117242.19","1 through 10","107808.23","188248.39","other","Inpatient Replacement Plans DRG"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","","","","inpatient","","","380132.21","285099.16","MEDICARE [2001]","HB BWH MEDICARE","110008.40","","Case rate ($110,008.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $132,351.01, add-ons for qualifying new technology services are included. If operating cost exceeds $177,995.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,110.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.7. The base transfer operating payment is the transfer adjustment factor * $99,958.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $131,971.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $9,670.31. The transfer capital threshold is the transfer adjustment factor * $9,670.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","154737.43","0.03","154968.48","49","107808.23","188248.39","other","Inpatient Replacement Plans DRG"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","","","","inpatient","","","380132.21","285099.16","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","107808.23","","Case rate ($110,008.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $132,351.01, add-ons for qualifying new technology services are included. If operating cost exceeds $177,995.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,110.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.7. The base transfer operating payment is the transfer adjustment factor * $99,958.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $131,971.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $9,670.31. The transfer capital threshold is the transfer adjustment factor * $9,670.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","116815.24","116815.24","116815.24","1 through 10","107808.23","188248.39","other","Inpatient DRG"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","","","","inpatient","","","380132.21","285099.16","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107808.23","","Case rate ($110,008.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $132,351.01, add-ons for qualifying new technology services are included. If operating cost exceeds $177,995.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,110.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.7. The base transfer operating payment is the transfer adjustment factor * $99,958.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $131,971.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $9,670.31. The transfer capital threshold is the transfer adjustment factor * $9,670.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","163955.43","163955.43","163955.43","1 through 10","107808.23","188248.39","other","Inpatient DRG"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","","","","inpatient","","","380132.21","285099.16","WELLPOINT [1015]","HB AMC WELLPOINT","188248.39","","Fee schedule rate ($188,248.39).","334356.91","184594.97","514679.41","1 through 10","107808.23","188248.39","case rate",""
"Allogeneic Bone Marrow Transplant,EXTREME","007","DRG","","","","","","","","inpatient","","","460443.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","476082.16","","Standard inlier is a Case rate ($476,082.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $381,867, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($67,582.73) for the length of stay and the standard reimbursement.","476082.15","476082.15","476082.15","1 through 10","113764.8","671616.17","case rate",""
"Allogeneic Bone Marrow Transplant,EXTREME","007","DRG","","","","","","","","inpatient","","","460443.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","535244.65","","Standard inlier is a Case rate ($535,244.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $381,867, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($75,973.53) for the length of stay and the standard reimbursement.","686229.83","686229.83","686229.83","1 through 10","113764.8","671616.17","case rate",""
"Allogeneic Bone Marrow Transplant,EXTREME","007","DRG","","","","","","","","inpatient","","","460443.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","535244.65","","Standard inlier is a Case rate ($535,244.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $381,867, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($75,973.53) for the length of stay and the standard reimbursement.","491359.86","315433.90","535244.65","1 through 10","113764.8","671616.17","case rate",""
"Allogeneic Bone Marrow Transplant,EXTREME","007","DRG","","","","","","","","inpatient","","","460443.72","","MASSHEALTH [3001]","HB BWH MEDICAID","248978.67","","Case rate ($275,288.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $317,718.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","275221.15","275221.15","275221.15","1 through 10","113764.8","671616.17","case rate",""
"Allogeneic Bone Marrow Transplant,EXTREME","007","DRG","","","","","","","","inpatient","","","460443.72","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","248978.67","","Case rate ($275,288.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $317,718.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","113764.8","671616.17","case rate",""
"Allogeneic Bone Marrow Transplant,EXTREME","007","DRG","","","","","","","","inpatient","","","460443.72","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","248978.67","","Case rate ($275,288.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $317,718.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","275221.16","275221.16","275221.16","1 through 10","113764.8","671616.17","case rate",""
"Allogeneic Bone Marrow Transplant,MAJOR","007","DRG","","","","","","","","inpatient","","","329915.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","280567.88","","Standard inlier is a Case rate ($280,567.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $229,828, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($39,828.30) for the length of stay and the standard reimbursement.","280567.87","255805.48","315433.90","1 through 10","113764.8","671616.17","case rate",""
"Allogeneic Bone Marrow Transplant,MAJOR","007","DRG","","","","","","","","inpatient","","","329915.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","315433.91","","Standard inlier is a Case rate ($315,433.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $229,828, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($44,773.22) for the length of stay and the standard reimbursement.","315433.90","288176.11","315433.90","17","113764.8","671616.17","case rate",""
"Allogeneic Bone Marrow Transplant,MAJOR","007","DRG","","","","","","","","inpatient","","","329915.32","","MASSHEALTH [3001]","HB BWH MEDICAID","125694.53","","Case rate ($138,976.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $181,406.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","138942.81","138942.81","138942.81","1 through 10","113764.8","671616.17","case rate",""
"Allogeneic Bone Marrow Transplant,MAJOR","007","DRG","","","","","","","","inpatient","","","329915.32","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","125694.53","","Case rate ($138,976.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $181,406.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","76286.00","76286.00","76286.00","1 through 10","113764.8","671616.17","case rate",""
"Allogeneic Bone Marrow Transplant,MAJOR","007","DRG","","","","","","","","inpatient","","","329915.32","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","125694.53","","Case rate ($138,976.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $181,406.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","138942.80","138942.80","138942.80","1 through 10","113764.8","671616.17","case rate",""
"Allogeneic Bone Marrow Transplant,MODERATE","007","DRG","","","","","","","","inpatient","","","304219.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","219462.79","","Standard inlier is a Case rate ($219,462.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $182,311, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($31,154.07) for the length of stay and the standard reimbursement.","219462.79","219462.79","219462.79","1 through 10","113764.8","671616.17","case rate",""
"Allogeneic Bone Marrow Transplant,MODERATE","007","DRG","","","","","","","","inpatient","","","304219.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","246735.32","","Standard inlier is a Case rate ($246,735.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $182,311, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($35,022.03) for the length of stay and the standard reimbursement.","246735.32","246735.32","246735.32","1 through 10","113764.8","671616.17","case rate",""
"ALLOGRAFT BONE 10CC OSTEOAMP FIBER SELECT","SUP-ITM-10269005","CDM","C1889","HCPCS","0278","RC","","","","both","","","4711.50","3533.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3745.64","79.5","","1309.77","674.56","6049.93","26","1460.57","3745.64","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP FIBER SELECT","SUP-ITM-10269005","CDM","C1889","HCPCS","0278","RC","","","","both","","","4711.50","3533.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2511.23","53.3","","1901.83","1901.83","2962.25","1 through 10","1460.57","3745.64","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP FIBER SELECT","SUP-ITM-10269005","CDM","C1889","HCPCS","0278","RC","","","","both","","","4711.50","3533.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1719.70","36.5","","1620.31","1620.31","19908.88","1 through 10","1460.57","3745.64","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP FIBER SELECT","SUP-ITM-10269005","CDM","C1889","HCPCS","0278","RC","","","","both","","","4711.50","3533.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1804.50","38.3","","352.91","352.91","2046.30","1 through 10","1460.57","3745.64","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP FIBER SELECT","SUP-ITM-10269005","CDM","C1889","HCPCS","0278","RC","","","","both","","","4711.50","3533.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2021.23","42.9","","9668.75","9668.75","9668.75","1 through 10","1460.57","3745.64","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP FIBER SELECT","SUP-ITM-10269005","CDM","C1889","HCPCS","0278","RC","","","","both","","","4711.50","3533.62","WELLPOINT [1015]","HB AMC WELLPOINT","3476.14","73.78","","699.88","384.10","3443.31","33","1460.57","3745.64","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP FIBER SELECT","SUP-ITM-10269005","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4711.50","3533.62","AETNA [1001]","HB AMC AETNA HMO","3288.63","69.8","","1421.24","264.50","4933.46","29","2462.23","3850.24","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP FIBER SELECT","SUP-ITM-10269005","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4711.50","3533.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3788.05","80.4","","1022.97","1022.97","3607.50","1 through 10","2462.23","3850.24","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP FIBER SELECT","SUP-ITM-10269005","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4711.50","3533.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3850.24","81.72","","3010.54","693.88","5019.88","35","2462.23","3850.24","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282973","CDM","C1889","HCPCS","0278","RC","","","","both","","","5418.23","4063.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4307.49","79.5","","1309.77","674.56","6049.93","26","1679.65","4307.49","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282973","CDM","C1889","HCPCS","0278","RC","","","","both","","","5418.23","4063.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2887.92","53.3","","1901.83","1901.83","2962.25","1 through 10","1679.65","4307.49","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282973","CDM","C1889","HCPCS","0278","RC","","","","both","","","5418.23","4063.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1977.65","36.5","","1620.31","1620.31","19908.88","1 through 10","1679.65","4307.49","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282973","CDM","C1889","HCPCS","0278","RC","","","","both","","","5418.23","4063.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2075.18","38.3","","352.91","352.91","2046.30","1 through 10","1679.65","4307.49","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282973","CDM","C1889","HCPCS","0278","RC","","","","both","","","5418.23","4063.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2324.42","42.9","","9668.75","9668.75","9668.75","1 through 10","1679.65","4307.49","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282973","CDM","C1889","HCPCS","0278","RC","","","","both","","","5418.23","4063.67","WELLPOINT [1015]","HB AMC WELLPOINT","3997.57","73.78","","699.88","384.10","3443.31","33","1679.65","4307.49","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282973","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5418.23","4063.67","AETNA [1001]","HB AMC AETNA HMO","3781.92","69.8","","1421.24","264.50","4933.46","29","2831.57","4427.78","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282973","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5418.23","4063.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4356.26","80.4","","1022.97","1022.97","3607.50","1 through 10","2831.57","4427.78","percent of total billed charges",""
"ALLOGRAFT BONE 10CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282973","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5418.23","4063.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4427.78","81.72","","3010.54","693.88","5019.88","35","2831.57","4427.78","percent of total billed charges",""
"ALLOGRAFT BONE 15CC OSTEOAMP FIBER SELECT","SUP-ITM-10269006","CDM","C1889","HCPCS","0278","RC","","","","both","","","6361.20","4770.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5057.15","79.5","","1309.77","674.56","6049.93","26","1971.97","5057.15","percent of total billed charges",""
"ALLOGRAFT BONE 15CC OSTEOAMP FIBER SELECT","SUP-ITM-10269006","CDM","C1889","HCPCS","0278","RC","","","","both","","","6361.20","4770.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3390.52","53.3","","1901.83","1901.83","2962.25","1 through 10","1971.97","5057.15","percent of total billed charges",""
"ALLOGRAFT BONE 15CC OSTEOAMP FIBER SELECT","SUP-ITM-10269006","CDM","C1889","HCPCS","0278","RC","","","","both","","","6361.20","4770.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2321.84","36.5","","1620.31","1620.31","19908.88","1 through 10","1971.97","5057.15","percent of total billed charges",""
"ALLOGRAFT BONE 15CC OSTEOAMP FIBER SELECT","SUP-ITM-10269006","CDM","C1889","HCPCS","0278","RC","","","","both","","","6361.20","4770.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2436.34","38.3","","352.91","352.91","2046.30","1 through 10","1971.97","5057.15","percent of total billed charges",""
"ALLOGRAFT BONE 15CC OSTEOAMP FIBER SELECT","SUP-ITM-10269006","CDM","C1889","HCPCS","0278","RC","","","","both","","","6361.20","4770.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2728.95","42.9","","9668.75","9668.75","9668.75","1 through 10","1971.97","5057.15","percent of total billed charges",""
"ALLOGRAFT BONE 15CC OSTEOAMP FIBER SELECT","SUP-ITM-10269006","CDM","C1889","HCPCS","0278","RC","","","","both","","","6361.20","4770.90","WELLPOINT [1015]","HB AMC WELLPOINT","4693.29","73.78","","699.88","384.10","3443.31","33","1971.97","5057.15","percent of total billed charges",""
"ALLOGRAFT BONE 15CC OSTEOAMP FIBER SELECT","SUP-ITM-10269006","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6361.20","4770.90","AETNA [1001]","HB AMC AETNA HMO","4440.12","69.8","","1421.24","264.50","4933.46","29","3324.36","5198.37","percent of total billed charges",""
"ALLOGRAFT BONE 15CC OSTEOAMP FIBER SELECT","SUP-ITM-10269006","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6361.20","4770.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5114.40","80.4","","1022.97","1022.97","3607.50","1 through 10","3324.36","5198.37","percent of total billed charges",""
"ALLOGRAFT BONE 15CC OSTEOAMP FIBER SELECT","SUP-ITM-10269006","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6361.20","4770.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5198.37","81.72","","3010.54","693.88","5019.88","35","3324.36","5198.37","percent of total billed charges",""
"ALLOGRAFT BONE 1CC OSTEOAMP SELECT FIBER","SUP-ITM-10268945","CDM","C1889","HCPCS","0278","RC","","","","both","","","1269.52","952.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1009.27","79.5","","1309.77","674.56","6049.93","26","393.55","1009.27","percent of total billed charges",""
"ALLOGRAFT BONE 1CC OSTEOAMP SELECT FIBER","SUP-ITM-10268945","CDM","C1889","HCPCS","0278","RC","","","","both","","","1269.52","952.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","676.65","53.3","","1901.83","1901.83","2962.25","1 through 10","393.55","1009.27","percent of total billed charges",""
"ALLOGRAFT BONE 1CC OSTEOAMP SELECT FIBER","SUP-ITM-10268945","CDM","C1889","HCPCS","0278","RC","","","","both","","","1269.52","952.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","463.37","36.5","","1620.31","1620.31","19908.88","1 through 10","393.55","1009.27","percent of total billed charges",""
"ALLOGRAFT BONE 1CC OSTEOAMP SELECT FIBER","SUP-ITM-10268945","CDM","C1889","HCPCS","0278","RC","","","","both","","","1269.52","952.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","486.23","38.3","","352.91","352.91","2046.30","1 through 10","393.55","1009.27","percent of total billed charges",""
"ALLOGRAFT BONE 1CC OSTEOAMP SELECT FIBER","SUP-ITM-10268945","CDM","C1889","HCPCS","0278","RC","","","","both","","","1269.52","952.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","544.62","42.9","","9668.75","9668.75","9668.75","1 through 10","393.55","1009.27","percent of total billed charges",""
"ALLOGRAFT BONE 1CC OSTEOAMP SELECT FIBER","SUP-ITM-10268945","CDM","C1889","HCPCS","0278","RC","","","","both","","","1269.52","952.14","WELLPOINT [1015]","HB AMC WELLPOINT","936.65","73.78","","699.88","384.10","3443.31","33","393.55","1009.27","percent of total billed charges",""
"ALLOGRAFT BONE 1CC OSTEOAMP SELECT FIBER","SUP-ITM-10268945","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1269.52","952.14","AETNA [1001]","HB AMC AETNA HMO","886.12","69.8","","1421.24","264.50","4933.46","29","663.45","1037.45","percent of total billed charges",""
"ALLOGRAFT BONE 1CC OSTEOAMP SELECT FIBER","SUP-ITM-10268945","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1269.52","952.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1020.69","80.4","","1022.97","1022.97","3607.50","1 through 10","663.45","1037.45","percent of total billed charges",""
"ALLOGRAFT BONE 1CC OSTEOAMP SELECT FIBER","SUP-ITM-10268945","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1269.52","952.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1037.45","81.72","","3010.54","693.88","5019.88","35","663.45","1037.45","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FIBER","SUP-ITM-10269003","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2253.83","79.5","","1309.77","674.56","6049.93","26","878.85","2253.83","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FIBER","SUP-ITM-10269003","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1511.06","53.3","","1901.83","1901.83","2962.25","1 through 10","878.85","2253.83","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FIBER","SUP-ITM-10269003","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1034.78","36.5","","1620.31","1620.31","19908.88","1 through 10","878.85","2253.83","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FIBER","SUP-ITM-10269003","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1085.81","38.3","","352.91","352.91","2046.30","1 through 10","878.85","2253.83","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FIBER","SUP-ITM-10269003","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","9668.75","9668.75","9668.75","1 through 10","878.85","2253.83","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FIBER","SUP-ITM-10269003","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB AMC WELLPOINT","2091.66","73.78","","699.88","384.10","3443.31","33","878.85","2253.83","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FIBER","SUP-ITM-10269003","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA HMO","1978.83","69.8","","1421.24","264.50","4933.46","29","1481.57","2316.76","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FIBER","SUP-ITM-10269003","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2279.34","80.4","","1022.97","1022.97","3607.50","1 through 10","1481.57","2316.76","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FIBER","SUP-ITM-10269003","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2316.76","81.72","","3010.54","693.88","5019.88","35","1481.57","2316.76","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282971","CDM","C1889","HCPCS","0278","RC","","","","both","","","3263.75","2447.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2594.68","79.5","","1309.77","674.56","6049.93","26","1011.76","2594.68","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282971","CDM","C1889","HCPCS","0278","RC","","","","both","","","3263.75","2447.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1739.58","53.3","","1901.83","1901.83","2962.25","1 through 10","1011.76","2594.68","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282971","CDM","C1889","HCPCS","0278","RC","","","","both","","","3263.75","2447.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1191.27","36.5","","1620.31","1620.31","19908.88","1 through 10","1011.76","2594.68","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282971","CDM","C1889","HCPCS","0278","RC","","","","both","","","3263.75","2447.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1250.02","38.3","","352.91","352.91","2046.30","1 through 10","1011.76","2594.68","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282971","CDM","C1889","HCPCS","0278","RC","","","","both","","","3263.75","2447.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1400.15","42.9","","9668.75","9668.75","9668.75","1 through 10","1011.76","2594.68","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282971","CDM","C1889","HCPCS","0278","RC","","","","both","","","3263.75","2447.81","WELLPOINT [1015]","HB AMC WELLPOINT","2407.99","73.78","","699.88","384.10","3443.31","33","1011.76","2594.68","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282971","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3263.75","2447.81","AETNA [1001]","HB AMC AETNA HMO","2278.10","69.8","","1421.24","264.50","4933.46","29","1705.64","2667.14","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282971","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3263.75","2447.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2624.06","80.4","","1022.97","1022.97","3607.50","1 through 10","1705.64","2667.14","percent of total billed charges",""
"ALLOGRAFT BONE 2.5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282971","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3263.75","2447.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2667.14","81.72","","3010.54","693.88","5019.88","35","1705.64","2667.14","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP FIBER SELECT","SUP-ITM-10269004","CDM","C1889","HCPCS","0278","RC","","","","both","","","4086.95","3065.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3249.13","79.5","","1309.77","674.56","6049.93","26","1266.95","3249.13","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP FIBER SELECT","SUP-ITM-10269004","CDM","C1889","HCPCS","0278","RC","","","","both","","","4086.95","3065.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2178.34","53.3","","1901.83","1901.83","2962.25","1 through 10","1266.95","3249.13","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP FIBER SELECT","SUP-ITM-10269004","CDM","C1889","HCPCS","0278","RC","","","","both","","","4086.95","3065.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1491.74","36.5","","1620.31","1620.31","19908.88","1 through 10","1266.95","3249.13","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP FIBER SELECT","SUP-ITM-10269004","CDM","C1889","HCPCS","0278","RC","","","","both","","","4086.95","3065.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1565.30","38.3","","352.91","352.91","2046.30","1 through 10","1266.95","3249.13","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP FIBER SELECT","SUP-ITM-10269004","CDM","C1889","HCPCS","0278","RC","","","","both","","","4086.95","3065.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.30","42.9","","9668.75","9668.75","9668.75","1 through 10","1266.95","3249.13","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP FIBER SELECT","SUP-ITM-10269004","CDM","C1889","HCPCS","0278","RC","","","","both","","","4086.95","3065.21","WELLPOINT [1015]","HB AMC WELLPOINT","3015.35","73.78","","699.88","384.10","3443.31","33","1266.95","3249.13","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP FIBER SELECT","SUP-ITM-10269004","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4086.95","3065.21","AETNA [1001]","HB AMC AETNA HMO","2852.69","69.8","","1421.24","264.50","4933.46","29","2135.84","3339.86","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP FIBER SELECT","SUP-ITM-10269004","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4086.95","3065.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3285.91","80.4","","1022.97","1022.97","3607.50","1 through 10","2135.84","3339.86","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP FIBER SELECT","SUP-ITM-10269004","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4086.95","3065.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3339.86","81.72","","3010.54","693.88","5019.88","35","2135.84","3339.86","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282972","CDM","C1889","HCPCS","0278","RC","","","","both","","","4028.55","3021.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3202.70","79.5","","1309.77","674.56","6049.93","26","1248.85","3202.7","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282972","CDM","C1889","HCPCS","0278","RC","","","","both","","","4028.55","3021.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2147.22","53.3","","1901.83","1901.83","2962.25","1 through 10","1248.85","3202.7","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282972","CDM","C1889","HCPCS","0278","RC","","","","both","","","4028.55","3021.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1470.42","36.5","","1620.31","1620.31","19908.88","1 through 10","1248.85","3202.7","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282972","CDM","C1889","HCPCS","0278","RC","","","","both","","","4028.55","3021.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1542.93","38.3","","352.91","352.91","2046.30","1 through 10","1248.85","3202.7","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282972","CDM","C1889","HCPCS","0278","RC","","","","both","","","4028.55","3021.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1728.25","42.9","","9668.75","9668.75","9668.75","1 through 10","1248.85","3202.7","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282972","CDM","C1889","HCPCS","0278","RC","","","","both","","","4028.55","3021.41","WELLPOINT [1015]","HB AMC WELLPOINT","2972.26","73.78","","699.88","384.10","3443.31","33","1248.85","3202.7","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282972","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4028.55","3021.41","AETNA [1001]","HB AMC AETNA HMO","2811.93","69.8","","1421.24","264.50","4933.46","29","2105.32","3292.13","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282972","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4028.55","3021.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3238.95","80.4","","1022.97","1022.97","3607.50","1 through 10","2105.32","3292.13","percent of total billed charges",""
"ALLOGRAFT BONE 5CC OSTEOAMP SELECT FLOWABLE","SUP-ITM-10282972","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4028.55","3021.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3292.13","81.72","","3010.54","693.88","5019.88","35","2105.32","3292.13","percent of total billed charges",""
"ALLOGRAFT BONE TIBIA DISTAL LT FRESH OSTEOCHONDRAL","SUP-ITM-10282519","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.80","8675.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9195.61","79.5","","1309.77","674.56","6049.93","26","3585.71","9195.61","percent of total billed charges",""
"ALLOGRAFT BONE TIBIA DISTAL LT FRESH OSTEOCHONDRAL","SUP-ITM-10282519","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.80","8675.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6165.10","53.3","","1901.83","1901.83","2962.25","1 through 10","3585.71","9195.61","percent of total billed charges",""
"ALLOGRAFT BONE TIBIA DISTAL LT FRESH OSTEOCHONDRAL","SUP-ITM-10282519","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.80","8675.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4221.88","36.5","","1620.31","1620.31","19908.88","1 through 10","3585.71","9195.61","percent of total billed charges",""
"ALLOGRAFT BONE TIBIA DISTAL LT FRESH OSTEOCHONDRAL","SUP-ITM-10282519","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.80","8675.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4430.08","38.3","","352.91","352.91","2046.30","1 through 10","3585.71","9195.61","percent of total billed charges",""
"ALLOGRAFT BONE TIBIA DISTAL LT FRESH OSTEOCHONDRAL","SUP-ITM-10282519","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.80","8675.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4962.16","42.9","","9668.75","9668.75","9668.75","1 through 10","3585.71","9195.61","percent of total billed charges",""
"ALLOGRAFT BONE TIBIA DISTAL LT FRESH OSTEOCHONDRAL","SUP-ITM-10282519","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.80","8675.10","WELLPOINT [1015]","HB AMC WELLPOINT","8533.99","73.78","","699.88","384.10","3443.31","33","3585.71","9195.61","percent of total billed charges",""
"ALLOGRAFT BONE TIBIA DISTAL LT FRESH OSTEOCHONDRAL","SUP-ITM-10282519","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11566.80","8675.10","AETNA [1001]","HB AMC AETNA HMO","8073.63","69.8","","1421.24","264.50","4933.46","29","6044.81","9452.39","percent of total billed charges",""
"ALLOGRAFT BONE TIBIA DISTAL LT FRESH OSTEOCHONDRAL","SUP-ITM-10282519","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11566.80","8675.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9299.71","80.4","","1022.97","1022.97","3607.50","1 through 10","6044.81","9452.39","percent of total billed charges",""
"ALLOGRAFT BONE TIBIA DISTAL LT FRESH OSTEOCHONDRAL","SUP-ITM-10282519","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11566.80","8675.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9452.39","81.72","","3010.54","693.88","5019.88","35","6044.81","9452.39","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","9548.38","7161.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7590.96","79.5","","1309.77","674.56","6049.93","26","2960","7590.96","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","9548.38","7161.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5089.29","53.3","","1901.83","1901.83","2962.25","1 through 10","2960","7590.96","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","9548.38","7161.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3485.16","36.5","","1620.31","1620.31","19908.88","1 through 10","2960","7590.96","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","9548.38","7161.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3657.03","38.3","","352.91","352.91","2046.30","1 through 10","2960","7590.96","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","9548.38","7161.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4096.26","42.9","","9668.75","9668.75","9668.75","1 through 10","2960","7590.96","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","9548.38","7161.28","WELLPOINT [1015]","HB AMC WELLPOINT","7044.79","73.78","","699.88","384.10","3443.31","33","2960","7590.96","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9548.38","7161.28","AETNA [1001]","HB AMC AETNA HMO","6664.77","69.8","","1421.24","264.50","4933.46","29","4989.98","7802.94","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9548.38","7161.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7676.90","80.4","","1022.97","1022.97","3607.50","1 through 10","4989.98","7802.94","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9548.38","7161.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7802.94","81.72","","3010.54","693.88","5019.88","35","4989.98","7802.94","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1774.19","1330.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1410.48","79.5","","1309.77","674.56","6049.93","26","550","1410.48","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1774.19","1330.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","945.64","53.3","","1901.83","1901.83","2962.25","1 through 10","550","1410.48","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1774.19","1330.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","647.58","36.5","","1620.31","1620.31","19908.88","1 through 10","550","1410.48","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1774.19","1330.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","679.51","38.3","","352.91","352.91","2046.30","1 through 10","550","1410.48","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1774.19","1330.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","761.13","42.9","","9668.75","9668.75","9668.75","1 through 10","550","1410.48","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1774.19","1330.64","WELLPOINT [1015]","HB AMC WELLPOINT","1309.00","73.78","","699.88","384.10","3443.31","33","550","1410.48","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1774.19","1330.64","AETNA [1001]","HB AMC AETNA HMO","1238.38","69.8","","1421.24","264.50","4933.46","29","927.19","1449.87","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1774.19","1330.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1426.45","80.4","","1022.97","1022.97","3607.50","1 through 10","927.19","1449.87","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1774.19","1330.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1449.87","81.72","","3010.54","693.88","5019.88","35","927.19","1449.87","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2013.08","79.5","","1309.77","674.56","6049.93","26","784.97","2013.08","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.65","53.3","","1901.83","1901.83","2962.25","1 through 10","784.97","2013.08","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.24","36.5","","1620.31","1620.31","19908.88","1 through 10","784.97","2013.08","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.82","38.3","","352.91","352.91","2046.30","1 through 10","784.97","2013.08","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","9668.75","9668.75","9668.75","1 through 10","784.97","2013.08","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","WELLPOINT [1015]","HB AMC WELLPOINT","1868.24","73.78","","699.88","384.10","3443.31","33","784.97","2013.08","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA HMO","1767.45","69.8","","1421.24","264.50","4933.46","29","1323.31","2069.29","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.86","80.4","","1022.97","1022.97","3607.50","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2069.29","81.72","","3010.54","693.88","5019.88","35","1323.31","2069.29","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","5940.88","4455.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4723.00","79.5","","1309.77","674.56","6049.93","26","1841.67","4723","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","5940.88","4455.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3166.49","53.3","","1901.83","1901.83","2962.25","1 through 10","1841.67","4723","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","5940.88","4455.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2168.42","36.5","","1620.31","1620.31","19908.88","1 through 10","1841.67","4723","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","5940.88","4455.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2275.36","38.3","","352.91","352.91","2046.30","1 through 10","1841.67","4723","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","5940.88","4455.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2548.64","42.9","","9668.75","9668.75","9668.75","1 through 10","1841.67","4723","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","5940.88","4455.66","WELLPOINT [1015]","HB AMC WELLPOINT","4383.18","73.78","","699.88","384.10","3443.31","33","1841.67","4723","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5940.88","4455.66","AETNA [1001]","HB AMC AETNA HMO","4146.73","69.8","","1421.24","264.50","4933.46","29","3104.7","4854.89","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5940.88","4455.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4776.47","80.4","","1022.97","1022.97","3607.50","1 through 10","3104.7","4854.89","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5940.88","4455.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4854.89","81.72","","3010.54","693.88","5019.88","35","3104.7","4854.89","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","11974.08","8980.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9519.39","79.5","","1309.77","674.56","6049.93","26","3711.96","9519.39","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","11974.08","8980.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6382.18","53.3","","1901.83","1901.83","2962.25","1 through 10","3711.96","9519.39","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","11974.08","8980.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4370.54","36.5","","1620.31","1620.31","19908.88","1 through 10","3711.96","9519.39","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","11974.08","8980.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4586.07","38.3","","352.91","352.91","2046.30","1 through 10","3711.96","9519.39","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","11974.08","8980.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5136.88","42.9","","9668.75","9668.75","9668.75","1 through 10","3711.96","9519.39","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","11974.08","8980.56","WELLPOINT [1015]","HB AMC WELLPOINT","8834.48","73.78","","699.88","384.10","3443.31","33","3711.96","9519.39","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11974.08","8980.56","AETNA [1001]","HB AMC AETNA HMO","8357.91","69.8","","1421.24","264.50","4933.46","29","6257.65","9785.22","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11974.08","8980.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9627.16","80.4","","1022.97","1022.97","3607.50","1 through 10","6257.65","9785.22","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11974.08","8980.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9785.22","81.72","","3010.54","693.88","5019.88","35","6257.65","9785.22","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","both","","","205.00","153.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","147.19","71.8","","142.88","142.88","142.88","1 through 10","16.43","194.75","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","both","","","205.00","153.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","134.48","65.6","","134.72","17.26","134.72","1 through 10","16.43","194.75","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","both","","","205.00","153.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","162.98","79.5","","156.61","105.07","156.61","31","16.43","194.75","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","both","","","205.00","153.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.27","53.3","","105.07","105.07","156.61","18","16.43","194.75","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.83","36.5","","74.23","63.08","109.53","23","16.43","194.75","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.52","38.3","","77.81","77.81","233.43","70","16.43","194.75","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","both","","","205.00","153.75","TRICARE [160005]","HB BWH TRICARE","194.75","95","","20.21","20.21","20.21","1 through 10","16.43","194.75","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","both","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.95","42.9","","76.05","76.05","76.05","1 through 10","16.43","194.75","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","205.00","153.75","AETNA [1001]","HB AMC AETNA HMO","143.09","69.8","","134.72","95.12","155.22","35","17.3","167.53","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","205.00","153.75","AETNA [1001]","HB AMC AETNA PPO","164.82","80.4","","155.22","155.22","155.22","1 through 10","17.3","167.53","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","205.00","153.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","107.13","52.26","","58.77","58.77","58.77","1 through 10","17.3","167.53","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","205.00","153.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","164.82","80.4","","99.50","99.50","99.50","1 through 10","17.3","167.53","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","167.53","81.72","","87.50","87.50","159.08","1 through 10","17.3","167.53","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","167.53","81.72","","159.08","87.50","159.08","21","17.3","167.53","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","both","","","240.00","180.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","190.80","79.5","","183.37","123.02","183.37","1 through 10","14.17","228","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","both","","","240.00","180.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","127.92","53.3","","183.37","123.02","183.37","1 through 10","14.17","228","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","both","","","240.00","180.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","184.80","77","","538.23","538.23","538.23","1 through 10","14.17","228","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","156.00","65","","108.55","108.55","108.55","1 through 10","14.17","228","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","190.80","79.5","","183.37","183.37","183.37","1 through 10","14.17","228","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.60","36.5","","86.91","73.86","173.82","11","14.17","228","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.92","38.3","","91.10","88.54","91.10","33","14.17","228","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","both","","","240.00","180.00","TRICARE [160005]","HB BWH TRICARE","228.00","95","","16.55","16.55","16.55","1 through 10","14.17","228","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","both","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.96","42.9","","186.26","186.26","186.26","1 through 10","14.17","228","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","outpatient","","","240.00","180.00","AETNA [1001]","HB AMC AETNA HMO","167.52","69.8","","157.74","111.37","181.74","20","14.92","196.13","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","outpatient","","","240.00","180.00","AETNA [1001]","HB AMC AETNA PPO","192.96","80.4","","181.74","181.74","181.74","1 through 10","14.92","196.13","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","outpatient","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","196.13","81.72","","186.26","186.26","186.26","1 through 10","14.92","196.13","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","outpatient","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","196.13","81.72","","102.45","102.45","186.26","11","14.92","196.13","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","both","","","168.00","126.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","133.56","79.5","","128.28","128.28","128.28","14","13.17","159.6","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","both","","","168.00","126.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","89.54","53.3","","128.28","86.06","128.28","1 through 10","13.17","159.6","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","both","","","168.00","126.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","129.36","77","","376.53","376.53","376.53","1 through 10","13.17","159.6","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","both","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","109.20","65","","165.10","165.10","165.10","1 through 10","13.17","159.6","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","both","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","133.56","79.5","","128.28","128.28","128.28","1 through 10","13.17","159.6","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","61.32","36.5","","60.80","51.67","121.60","17","13.17","159.6","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64.34","38.3","","63.73","61.94","63.73","50","13.17","159.6","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","both","","","168.00","126.00","TRICARE [160005]","HB BWH TRICARE","159.60","95","","16.20","15.39","16.20","1 through 10","13.17","159.6","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","both","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.07","42.9","","130.30","130.30","130.30","1 through 10","13.17","159.6","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","outpatient","","","168.00","126.00","AETNA [1001]","HB AMC AETNA HMO","117.26","69.8","","110.35","77.91","155.83","29","13.86","137.29","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","outpatient","","","168.00","126.00","AETNA [1001]","HB AMC AETNA PPO","135.07","80.4","","127.14","127.14","127.14","1 through 10","13.86","137.29","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","137.29","81.72","","130.30","130.30","130.30","1 through 10","13.86","137.29","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","137.29","81.72","","71.67","60.91","130.30","16","13.86","137.29","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","64.00","48.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","45.95","71.8","","133.56","44.52","133.56","17","5.19","60.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","64.00","48.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","44.80","70","","62.00","62.00","62.00","1 through 10","5.19","60.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","64.00","48.00","CHAMPVA [160001]","HB BWH TRICARE","60.80","95","","6.39","6.39","6.39","1 through 10","5.19","60.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","64.00","48.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","50.88","79.5","","48.79","32.74","48.79","144","5.19","60.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","64.00","48.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","34.11","53.3","","32.74","32.74","48.79","95","5.19","60.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","64.00","48.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","41.60","65","","40.30","40.30","53.95","1 through 10","5.19","60.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","64.00","48.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","19.84","31","","19.16","19.16","38.32","1 through 10","5.19","60.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","64.00","48.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.36","36.5","","23.13","19.65","69.39","111","5.19","60.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","64.00","48.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.51","38.3","","24.24","23.56","72.72","343","5.19","60.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","64.00","48.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","49.28","77","","48.79","48.79","48.79","1 through 10","5.19","60.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","64.00","48.00","TRICARE [160005]","HB BWH TRICARE","60.80","95","","6.07","6.07","6.39","13","5.19","60.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","64.00","48.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.46","42.9","","49.56","49.56","49.56","1 through 10","5.19","60.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","64.00","48.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.46","42.9","","27.26","27.26","27.26","1 through 10","5.19","60.8","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","64.00","48.00","AETNA [1001]","HB AMC AETNA HMO","44.67","69.8","","41.97","29.64","48.36","265","5.46","52.3","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","64.00","48.00","AETNA [1001]","HB AMC AETNA PPO","51.46","80.4","","48.36","29.64","48.36","16","5.46","52.3","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","64.00","48.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","33.45","52.26","","4.87","4.87","4.87","1 through 10","5.46","52.3","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","64.00","48.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","51.46","80.4","","48.36","31.00","48.36","1 through 10","5.46","52.3","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","64.00","48.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","52.30","81.72","","27.26","27.26","49.56","1 through 10","5.46","52.3","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","64.00","48.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","52.30","81.72","","49.56","27.26","49.56","119","5.46","52.3","percent of total billed charges",""
"Alteplase Vl 1mg","PX-63600180","CDM","J2997","HCPCS","0636","RC","","","","both","","","189.13","141.85","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","92.56","","APC Price ($94.45). Final payment is multiplied by 98%.","90.02","90.02","90.02","1 through 10","58.63","218.7","other","OPPS APC"
"Alteplase Vl 1mg","PX-63600180","CDM","J2997","HCPCS","0636","RC","","","","outpatient","","","189.13","141.85","AETNA [1001]","HB AMC AETNA HMO","132.01","69.8","","255.35","255.35","255.35","1 through 10","88.7","202.42","percent of total billed charges",""
"Alteration In Consciousness,EXTREME","052","DRG","","","","","","","","inpatient","","","109714.81","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","31280.51","","Standard inlier is a Case rate ($31,280.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,440.01) for the length of stay and the standard reimbursement.","55895.70","55895.70","61175.70","1 through 10","5808.93","81270.7","case rate",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","48305.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","27822.96","","Standard inlier is a Case rate ($27,822.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,949.64) for the length of stay and the standard reimbursement.","31280.50","31280.50","31280.50","1 through 10","5808.93","81270.7","case rate",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","48305.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","31280.51","","Standard inlier is a Case rate ($31,280.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,440.01) for the length of stay and the standard reimbursement.","28577.44","28577.44","28577.44","1 through 10","5808.93","81270.7","case rate",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","48305.46","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10830.1014","","Fee schedule rate ($24,782.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10830.1014","24782.64","24782.64","1 through 10","5808.93","81270.7","case rate",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","48305.46","","MASSHEALTH [3001]","HB BWH MEDICAID","8907.03","","Case rate ($9,848.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,278.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6853.82","6853.82","6853.82","1 through 10","5808.93","81270.7","case rate",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","48305.46","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8907.03","","Case rate ($9,848.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,278.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5031.94","1348.93","9845.83","1 through 10","5808.93","81270.7","case rate",""
"Alteration In Consciousness,MODERATE","052","DRG","","","","","","","","inpatient","","","44337.75","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21403.27","","Standard inlier is a Case rate ($21,403.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,293, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,038.32) for the length of stay and the standard reimbursement.","19512.76","19512.76","19512.76","1 through 10","5808.93","81270.7","case rate",""
"Alteration In Consciousness,MODERATE","052","DRG","","","","","","","","inpatient","","","44337.75","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24063.05","","Standard inlier is a Case rate ($24,063.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,293, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,415.55) for the length of stay and the standard reimbursement.","21983.67","21983.67","21983.67","1 through 10","5808.93","81270.7","case rate",""
"Aluminum","PX-30000296","CDM","82108","CPT","0301","RC","","","","both","","","429.00","321.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","156.59","36.5","","155.17","155.17","155.17","1 through 10","24.97","407.55","percent of total billed charges",""
"Aluminum","PX-30000296","CDM","82108","CPT","0301","RC","","","","outpatient","","","429.00","321.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","350.58","81.72","","182.92","182.92","182.92","1 through 10","26.28","350.58","percent of total billed charges",""
"Ambry Gen Mutyh Gene Seq-Del-Dup","PX-31001163","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Ambry Gen Mutyh Gene Seq-Del-Dup","PX-31001163","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Ambry Gen Mutyh Gene Seq-Del-Dup","PX-31001163","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Ambry Gen Mutyh Gene Seq-Del-Dup","PX-31001163","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Ambulatory Bp Analysis W/Report","PX-48000031","CDM","93788","CPT","0480","RC","","","","both","","","582.00","436.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","462.69","79.5","","443.87","297.79","443.87","1 through 10","180.42","462.69","percent of total billed charges",""
"Ambulatory Bp Analysis W/Report","PX-48000031","CDM","93788","CPT","0480","RC","","","","both","","","582.00","436.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","310.21","53.3","","297.79","297.79","297.79","1 through 10","180.42","462.69","percent of total billed charges",""
"Ambulatory Bp Analysis W/Report","PX-48000031","CDM","93788","CPT","0480","RC","","","","both","","","582.00","436.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","180.42","31","","174.28","174.28","174.28","1 through 10","180.42","462.69","percent of total billed charges",""
"Ambulatory Bp Analysis W/Report","PX-48000031","CDM","93788","CPT","0480","RC","","","","both","","","582.00","436.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","212.43","36.5","","210.37","178.79","210.37","1 through 10","180.42","462.69","percent of total billed charges",""
"Ambulatory Bp Analysis W/Report","PX-48000031","CDM","93788","CPT","0480","RC","","","","both","","","582.00","436.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","222.91","38.3","","220.52","214.32","220.52","43","180.42","462.69","percent of total billed charges",""
"Ambulatory Bp Analysis W/Report","PX-48000031","CDM","93788","CPT","0480","RC","","","","outpatient","","","582.00","436.50","AETNA [1001]","HB AMC AETNA HMO","406.24","69.8","","269.59","269.59","269.59","1 through 10","244.64","475.61","percent of total billed charges",""
"Ambulatory Bp Analysis W/Report","PX-48000031","CDM","93788","CPT","0480","RC","","","","outpatient","","","582.00","436.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","304.15","52.26","","282.26","282.26","282.26","1 through 10","244.64","475.61","percent of total billed charges",""
"Ambulatory Bp Analysis W/Report","PX-48000031","CDM","93788","CPT","0480","RC","","","","outpatient","","","582.00","436.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","475.61","81.72","","450.86","450.86","450.86","1 through 10","244.64","475.61","percent of total billed charges",""
"Ambulatory Bp Analysis W/Report","PX-48000031","CDM","93788","CPT","0480","RC","","","","outpatient","","","582.00","436.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","475.61","81.72","","450.86","247.99","450.86","1 through 10","244.64","475.61","percent of total billed charges",""
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","both","","","646.00","484.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","513.57","79.5","","492.66","330.53","492.66","1 through 10","200.26","513.57","percent of total billed charges",""
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","both","","","646.00","484.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","344.32","53.3","","330.53","330.53","330.53","1 through 10","200.26","513.57","percent of total billed charges",""
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","both","","","646.00","484.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","200.26","31","","193.43","193.43","193.43","1 through 10","200.26","513.57","percent of total billed charges",""
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","both","","","646.00","484.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","235.79","36.5","","233.50","198.44","233.50","1 through 10","200.26","513.57","percent of total billed charges",""
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","both","","","646.00","484.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","247.42","38.3","","244.77","237.88","244.77","43","200.26","513.57","percent of total billed charges",""
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","outpatient","","","646.00","484.50","AETNA [1001]","HB AMC AETNA HMO","450.91","69.8","","299.23","299.23","299.23","1 through 10","244.64","527.91","percent of total billed charges",""
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","outpatient","","","646.00","484.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","337.60","52.26","","282.26","282.26","282.26","1 through 10","244.64","527.91","percent of total billed charges",""
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","outpatient","","","646.00","484.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","527.91","81.72","","500.43","500.43","500.43","1 through 10","244.64","527.91","percent of total billed charges",""
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","outpatient","","","646.00","484.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","527.91","81.72","","500.42","275.25","500.42","1 through 10","244.64","527.91","percent of total billed charges",""
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0921","RC","","","","both","","","646.00","484.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","11","145.42","191.33","other","OPPS APC"
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0921","RC","","","","both","","","646.00","484.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.84","119.28","153.08","1 through 10","145.42","191.33","other","OPPS APC"
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0921","RC","","","","both","","","646.00","484.50","HUMANA [1012]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.02","150.02","150.02","1 through 10","145.42","191.33","other","OPPS APC"
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0921","RC","","","","both","","","646.00","484.50","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","236","145.42","191.33","other","OPPS APC"
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0921","RC","","","","both","","","646.00","484.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","137.03","136.63","150.42","1 through 10","145.42","191.33","other","OPPS APC"
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0921","RC","","","","both","","","646.00","484.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.62","150.02","150.63","1 through 10","145.42","191.33","other","OPPS APC"
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0921","RC","","","","both","","","646.00","484.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.02","150.02","151.02","36","145.42","191.33","other","OPPS APC"
"Amino Acids 6 or More Acids Qn","PX-30000303","CDM","82139","CPT","0301","RC","","","","both","","","193.00","144.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","102.87","53.3","","147.17","147.17","147.17","1 through 10","11.02","183.35","percent of total billed charges",""
"Amino Acids 6 or More Acids Qn","PX-30000303","CDM","82139","CPT","0301","RC","","","","both","","","193.00","144.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.92","38.3","","73.12","71.06","142.12","1 through 10","11.02","183.35","percent of total billed charges",""
"Amino Acids 6 or More Acids Qn","PX-30000303","CDM","82139","CPT","0301","RC","","","","outpatient","","","193.00","144.75","AETNA [1001]","HB AMC AETNA HMO","134.71","69.8","","126.60","89.39","126.60","1 through 10","11.02","157.72","percent of total billed charges",""
"Amino Acids Qn Single","PX-30000300","CDM","82131","CPT","0301","RC","","","","both","","","284.00","213.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","198.80","70","","118.25","118.25","118.25","1 through 10","17.39","269.8","percent of total billed charges",""
"Amino Acids Qn Single","PX-30000300","CDM","82131","CPT","0301","RC","","","","both","","","284.00","213.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","108.77","38.3","","104.50","104.50","104.50","1 through 10","17.39","269.8","percent of total billed charges",""
"Amino Acids Qn Single","PX-30000300","CDM","82131","CPT","0301","RC","","","","outpatient","","","284.00","213.00","AETNA [1001]","HB AMC AETNA HMO","198.23","69.8","","186.18","186.18","186.18","1 through 10","17.39","232.08","percent of total billed charges",""
"Aminolevulinic Acid (Ala)","PX-30000301","CDM","82135","CPT","0301","RC","","","","outpatient","","","274.00","205.50","AETNA [1001]","HB AMC AETNA HMO","191.25","69.8","","127.15","127.15","127.15","1 through 10","16.96","223.91","percent of total billed charges",""
"Aminolevulinic Acid Hcl Top","PX-63601031","CDM","J7308","HCPCS","0278","RC","","","","both","","","581.00","435.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","377.65","65","","913.01","744.45","913.01","1 through 10","180.11","957.98","percent of total billed charges",""
"Aminolevulinic Acid Hcl Top","PX-63601031","CDM","J7308","HCPCS","0278","RC","","","","both","","","581.00","435.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","212.07","36.5","","523.93","445.27","523.93","1 through 10","180.11","957.98","percent of total billed charges",""
"Aminolevulinic Acid Hcl Top","PX-63601031","CDM","J7308","HCPCS","0278","RC","","","","both","","","581.00","435.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","222.52","38.3","","1647.63","549.21","1647.63","11","180.11","957.98","percent of total billed charges",""
"Aminolevulinic Acid Hcl Top","PX-63601031","CDM","J7308","HCPCS","0278","RC","","","","outpatient","","","581.00","435.75","AETNA [1001]","HB AMC AETNA HMO","405.54","69.8","","671.41","671.41","671.41","1 through 10","109.81","898.53","percent of total billed charges",""
"Aminolevulinic Acid Hcl Top","PX-63601031","CDM","J7308","HCPCS","0636","RC","","","","both","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","384.25","","APC Price ($392.09). Final payment is multiplied by 98%.","388.94","388.15","388.94","1 through 10","374.18","490.11","other","OPPS APC"
"Ammonia","PX-30000305","CDM","82140","CPT","0301","RC","","","","both","","","232.00","174.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","184.44","79.5","","118.80","118.80","118.80","1 through 10","14.28","220.4","percent of total billed charges",""
"Ammonia","PX-30000305","CDM","82140","CPT","0301","RC","","","","both","","","232.00","174.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","88.86","38.3","","87.98","85.50","87.98","1 through 10","14.28","220.4","percent of total billed charges",""
"Ammonia","PX-30000305","CDM","82140","CPT","0301","RC","","","","both","","","232.00","174.00","TRICARE [160005]","HB BWH TRICARE","220.40","95","","16.68","16.68","16.68","1 through 10","14.28","220.4","percent of total billed charges",""
"Ammonia","PX-30000305","CDM","82140","CPT","0301","RC","","","","outpatient","","","232.00","174.00","AETNA [1001]","HB AMC AETNA HMO","161.94","69.8","","107.55","107.55","152.33","1 through 10","15.03","189.59","percent of total billed charges",""
"Ammonia","PX-30000305","CDM","82140","CPT","0301","RC","","","","outpatient","","","232.00","174.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","189.59","81.72","","179.87","179.87","179.87","1 through 10","15.03","189.59","percent of total billed charges",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","both","","","1343.00","1007.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1067.69","79.5","","687.46","687.46","687.46","1 through 10","416.33","1292.44","percent of total billed charges",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","both","","","1343.00","1007.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","715.82","53.3","","5208.35","687.46","5208.35","1 through 10","416.33","1292.44","percent of total billed charges",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","both","","","1343.00","1007.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","490.20","36.5","","1456.95","1456.95","2428.25","12","416.33","1292.44","percent of total billed charges",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","both","","","1343.00","1007.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","514.37","38.3","","1527.24","509.08","1979.04","36","416.33","1292.44","percent of total billed charges",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","both","","","1343.00","1007.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","576.15","42.9","","1040.82","1040.82","1040.82","1 through 10","416.33","1292.44","percent of total billed charges",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","both","","","1343.00","1007.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","863.37","863.37","863.37","1 through 10","416.33","1292.44","other","OPPS APC"
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1343.00","1007.25","AETNA [1001]","HB AMC AETNA HMO","937.41","69.8","","881.45","622.36","2031.12","14","558.04","1234.13","percent of total billed charges",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1343.00","1007.25","AETNA [1001]","HB AMC AETNA PPO","1079.77","80.4","","2031.12","2031.12","2031.12","1 through 10","558.04","1234.13","percent of total billed charges",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1343.00","1007.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1305.65","1282.04","1958.48","12","558.04","1234.13","other","ASC"
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1343.00","1007.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1479.23","1479.23","2218.85","29","558.04","1234.13","other","ASC "
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1343.00","1007.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1428.58","1428.58","1428.58","1 through 10","558.04","1234.13","other","Multiple Surgery"
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1343.00","1007.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3733.29","1294.65","3883.95","26","558.04","1234.13","other","Multiple Surgery"
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1343.00","1007.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4084.86","2622.78","6808.10","14","558.04","1234.13","other","Multiple Surgery"
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1343.00","1007.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1428.58","1428.58","1428.58","1 through 10","558.04","1234.13","other","Multiple Surgery"
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1343.00","1007.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1079.77","80.4","","1015.56","1015.56","1015.56","1 through 10","558.04","1234.13","percent of total billed charges",""
"Amniocentesis Diagnostic - 59000","PX-72000002","CDM","59000","CPT","0761","RC","","","","outpatient","","","1343.00","1007.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1097.50","81.72","","1277.63","973.41","1277.63","1 through 10","558.04","1234.13","percent of total billed charges",""
"Amp/Sulbac Vl 1.5gm","PX-63600063","CDM","J0295","HCPCS","0636","RC","","","","both","","","21.93","16.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.00","36.5","","2.81","1.49","16.13","52","5.02","16.89","percent of total billed charges",""
"Amp/Sulbac Vl 1.5gm","PX-63600063","CDM","J0295","HCPCS","0636","RC","","","","both","","","21.93","16.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8.40","38.3","","2.22","1.85","5.15","36","5.02","16.89","percent of total billed charges",""
"Amp/Sulbac Vl 1.5gm","PX-63600063","CDM","J0295","HCPCS","0636","RC","","","","both","","","21.93","16.45","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","16.89","77","","3.67","3.67","3.67","1 through 10","5.02","16.89","percent of total billed charges",""
"Amp/Sulbac Vl 1.5gm","PX-63600063","CDM","J0295","HCPCS","0636","RC","","","","outpatient","","","21.93","16.45","AETNA [1001]","HB AMC AETNA HMO","15.31","69.8","","3.21","3.21","3.21","1 through 10","3.2","17.63","percent of total billed charges",""
"Amp/Sulbac Vl 1.5gm","PX-63600063","CDM","J0295","HCPCS","0636","RC","","","","outpatient","","","21.93","16.45","AETNA [1001]","HB AMC AETNA PPO","17.63","80.4","","2.48","2.48","2.48","1 through 10","3.2","17.63","percent of total billed charges",""
"Amp/Sulbac Vl 1.5gm","PX-63600063","CDM","J0295","HCPCS","0636","RC","","","","outpatient","","","21.93","16.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15.33","69.9","","10.25","3.26","10.29","15","3.2","17.63","percent of total billed charges",""
"Amphetamines Confirmation, Random, Urine","PX-30003697","CDM","G0480","HCPCS","0301","RC","","","","both","","","950.00","712.50","AETNA [1001]","HB AMC AETNA HMO","663.10","69.8","","165.87","111.85","702.73","46","112.14","902.5","percent of total billed charges",""
"Amphetamines Confirmation, Random, Urine","PX-30003697","CDM","G0480","HCPCS","0301","RC","","","","both","","","950.00","712.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","617.50","65","","152.10","152.10","152.10","1 through 10","112.14","902.5","percent of total billed charges",""
"Amphetamines Confirmation, Random, Urine","PX-30003697","CDM","G0480","HCPCS","0301","RC","","","","both","","","950.00","712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","755.25","79.5","","273.09","123.55","816.91","32","112.14","902.5","percent of total billed charges",""
"Amphetamines Confirmation, Random, Urine","PX-30003697","CDM","G0480","HCPCS","0301","RC","","","","both","","","950.00","712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","294.50","31","","320.74","320.74","320.74","1 through 10","112.14","902.5","percent of total billed charges",""
"Amphetamines Confirmation, Random, Urine","PX-30003697","CDM","G0480","HCPCS","0301","RC","","","","both","","","950.00","712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","346.75","36.5","","129.43","87.28","387.17","47","112.14","902.5","percent of total billed charges",""
"Amphetamines Confirmation, Random, Urine","PX-30003697","CDM","G0480","HCPCS","0301","RC","","","","both","","","950.00","712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","363.85","38.3","","168.01","91.49","407.04","67","112.14","902.5","percent of total billed charges",""
"Amphetamines Confirmation, Random, Urine","PX-30003697","CDM","G0480","HCPCS","0301","RC","","","","both","","","950.00","712.50","WELLPOINT [1015]","HB AMC WELLPOINT","700.91","73.78","","352.93","234.00","468.00","21","112.14","902.5","percent of total billed charges",""
"Amphetamines Confirmation, Random, Urine","PX-30003697","CDM","G0480","HCPCS","0301","RC","","","","outpatient","","","950.00","712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","496.47","52.26","","327.89","327.89","327.89","1 through 10","162.72","776.34","percent of total billed charges",""
"Amphetamines Confirmation, Random, Urine","PX-30003697","CDM","G0480","HCPCS","0301","RC","","","","outpatient","","","950.00","712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","776.34","81.72","","102.89","102.89","102.89","1 through 10","162.72","776.34","percent of total billed charges",""
"Amphetamines Confirmation, Random, Urine","PX-30003697","CDM","G0480","HCPCS","0301","RC","","","","outpatient","","","950.00","712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","776.34","81.72","","277.39","152.58","829.78","30","162.72","776.34","percent of total billed charges",""
"Ampicillin Vl 500mg","PX-63600062","CDM","J0290","HCPCS","0636","RC","","","","both","","","8.48","6.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3.10","36.5","","2.93","2.93","2.93","36","2.32","6.53","percent of total billed charges",""
"Ampicillin Vl 500mg","PX-63600062","CDM","J0290","HCPCS","0636","RC","","","","both","","","8.48","6.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3.25","38.3","","2.90","2.90","2.90","12","2.32","6.53","percent of total billed charges",""
"Ampicillin Vl 500mg","PX-63600062","CDM","J0290","HCPCS","0636","RC","","","","outpatient","","","8.48","6.36","AETNA [1001]","HB AMC AETNA HMO","5.92","69.8","","2.04","2.04","5.38","12","1.05","6.82","percent of total billed charges",""
"Ampicillin Vl 500mg","PX-63600062","CDM","J0290","HCPCS","0636","RC","","","","outpatient","","","8.48","6.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5.93","69.9","","365.65","8.94","365.65","46","1.05","6.82","percent of total billed charges",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","","","","inpatient","","","141758.25","106318.69","MEDICARE [2001]","HB BWH MEDICARE","26382.40","","Case rate ($26,382.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,681.79, add-ons for qualifying new technology services are included. If operating cost exceeds $77,326.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,733.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $23,708.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,301.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,293.68. The transfer capital threshold is the transfer adjustment factor * $2,293.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28496.05","19117.12","34662.00","1 through 10","25854.75","43948.0102","other","Inpatient Replacement Plans DRG"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","","","","inpatient","","","141758.25","106318.69","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","25854.75","","Case rate ($26,382.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,681.79, add-ons for qualifying new technology services are included. If operating cost exceeds $77,326.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,733.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $23,708.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,301.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,293.68. The transfer capital threshold is the transfer adjustment factor * $2,293.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26177.35","26177.35","26177.35","1 through 10","25854.75","43948.0102","other","Inpatient DRG"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","","","","inpatient","","","141758.25","106318.69","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","25854.75","","Case rate ($26,382.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,681.79, add-ons for qualifying new technology services are included. If operating cost exceeds $77,326.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,733.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $23,708.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,301.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,293.68. The transfer capital threshold is the transfer adjustment factor * $2,293.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26360.70","26360.70","26360.70","1 through 10","25854.75","43948.0102","other","Inpatient DRG"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","","","","inpatient","","","141758.25","106318.69","WELLPOINT [1015]","HB AMC WELLPOINT","43948.0102","","Fee schedule rate ($44,650.23).","43948.0102","69384.72","69384.72","1 through 10","25854.75","43948.0102","case rate",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC","239","MS-DRG","","","","","","","","inpatient","","","285514.76","214136.07","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","46634.38","","Case rate ($45,276.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,426.09, add-ons for qualifying new technology services are included. If operating cost exceeds $100,070.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,400.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $40,935.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,046.25 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,960.29. The transfer capital threshold is the transfer adjustment factor * $3,960.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","45076.87","45076.87","45076.87","1 through 10","44370.58","77093.51","other","Inpatient DRG"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC","239","MS-DRG","","","","","","","","inpatient","","","285514.76","214136.07","MEDICARE [2001]","HB BWH MEDICARE","58647.47","","Case rate ($58,647.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,426.09, add-ons for qualifying new technology services are included. If operating cost exceeds $100,070.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,400.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $54,307.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,046.25 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,960.29. The transfer capital threshold is the transfer adjustment factor * $3,960.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","59747.89","0.03","233197.56","12","44370.58","77093.51","other","Inpatient DRG"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC","239","MS-DRG","","","","","","","","inpatient","","","285514.76","214136.07","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","44370.58","","Case rate ($45,276.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,426.09, add-ons for qualifying new technology services are included. If operating cost exceeds $100,070.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,400.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $40,935.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,046.25 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,960.29. The transfer capital threshold is the transfer adjustment factor * $3,960.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","39962.11","39962.11","39962.11","1 through 10","44370.58","77093.51","other","Inpatient DRG"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/McC","241","MS-DRG","","","","","","","","inpatient","","","113945.50","85459.12","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12748.32","","Case rate ($13,008.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,582.24, add-ons for qualifying new technology services are included. If operating cost exceeds $61,226.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,554.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,514.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,202.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,113.97. The transfer capital threshold is the transfer adjustment factor * $1,113.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13794.56","13794.56","13794.56","1 through 10","12748.32","21685.24","other","Inpatient DRG"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","","","","inpatient","","","187766.21","140824.66","MEDICARE [2001]","HB BWH MEDICARE","21139.02","","Case rate ($21,139.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,369.79, add-ons for qualifying new technology services are included. If operating cost exceeds $71,014.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,271.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $18,928.01 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,989.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,831.16. The transfer capital threshold is the transfer adjustment factor * $1,831.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","20716.24","35646.56","other","Inpatient Replacement Plans DRG"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","","","","inpatient","","","187766.21","140824.66","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20716.24","","Case rate ($21,139.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,369.79, add-ons for qualifying new technology services are included. If operating cost exceeds $71,014.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,271.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $18,928.01 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,989.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,831.16. The transfer capital threshold is the transfer adjustment factor * $1,831.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26081.91","26081.91","26081.91","1 through 10","20716.24","35646.56","other","Inpatient DRG"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With McC","474","MS-DRG","","","","","","","","inpatient","","","116993.93","87745.45","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","51203.16","","Case rate ($51,203.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $47,521.11, add-ons for qualifying new technology services are included. If operating cost exceeds $93,165.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,894.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $47,369.00 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $47,141.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,454.32. The transfer capital threshold is the transfer adjustment factor * $3,454.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25809.97","25809.97","25809.97","1 through 10","38749.32","67243.99","other","Inpatient DRG"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With McC","474","MS-DRG","","","","","","","","inpatient","","","116993.93","87745.45","MEDICARE [2001]","HB BWH MEDICARE","51203.16","","Case rate ($51,203.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $47,521.11, add-ons for qualifying new technology services are included. If operating cost exceeds $93,165.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,894.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.8. The base transfer operating payment is the transfer adjustment factor * $47,369.00 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $47,141.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,454.32. The transfer capital threshold is the transfer adjustment factor * $3,454.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","53228.19","53228.19","163801.08","1 through 10","38749.32","67243.99","other","Inpatient DRG"
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/McC","476","MS-DRG","","","","","","","","inpatient","","","78483.03","58862.27","MEDICARE [2001]","HB BWH MEDICARE","11145.75","","Case rate ($11,145.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,339.87, add-ons for qualifying new technology services are included. If operating cost exceeds $58,984.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,389.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $9,816.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,960.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $949.66. The transfer capital threshold is the transfer adjustment factor * $949.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13990.24","13990.24","13990.24","1 through 10","10922.84","17552.3421","other","Inpatient Replacement Plans DRG"
"Amputation Of Lower Limb Except Toes,EXTREME","305","DRG","","","","","","","","inpatient","","","169590.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","139782.38","","Standard inlier is a Case rate ($139,782.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $108,333, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($19,840.95) for the length of stay and the standard reimbursement.","127703.27","127703.27","127703.27","1 through 10","11767.51","246465.65","case rate",""
"Amputation Of Lower Limb Except Toes,EXTREME","305","DRG","","","","","","","","inpatient","","","169590.19","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","44647.09","","Case rate ($49,365.03). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $91,795.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,825.52 and the sum of the standard inlier and any outlier amount.","140330.17","140330.17","140330.17","1 through 10","11767.51","246465.65","case rate",""
"Amputation Of Lower Limb Except Toes,MAJOR","305","DRG","","","","","","","","inpatient","","","192622.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","75297.92","","Standard inlier is a Case rate ($75,297.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,729, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,687.91) for the length of stay and the standard reimbursement.","177268.92","177268.92","177268.92","1 through 10","11767.51","246465.65","case rate",""
"Amputation Of Lower Limb Except Toes,MAJOR","305","DRG","","","","","","","","inpatient","","","192622.31","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","40572.065","","Fee schedule rate ($76,355.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40572.065","76355.32","76355.32","1 through 10","11767.51","246465.65","case rate",""
"Amputation Of Lower Limb Except Toes,MAJOR","305","DRG","","","","","","","","inpatient","","","192622.31","","MASSHEALTH [3001]","HB BWH MEDICAID","21903.73","","Case rate ($24,218.33). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,648.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,367.38 and the sum of the standard inlier and any outlier amount.","24212.39","24212.39","24212.39","1 through 10","11767.51","246465.65","case rate",""
"Amputation Of Lower Limb Except Toes,MAJOR","305","DRG","","","","","","","","inpatient","","","192622.31","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","21903.73","","Case rate ($24,218.33). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,648.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,367.38 and the sum of the standard inlier and any outlier amount.","24212.39","1672.21","27050.20","1 through 10","11767.51","246465.65","case rate",""
"Amputation Of Lower Limb Except Toes,MINOR","305","DRG","","","","","","","","inpatient","","","47635.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","37283.54","","Fee schedule rate ($37,283.54). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($4,313.86) multiplied by length of stay and the outlier percent (100%).","37283.54","37283.54","37283.54","1 through 10","11767.51","246465.65","case rate",""
"Amputation Of Lower Limb Except Toes,MINOR","305","DRG","","","","","","","","inpatient","","","47635.21","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11767.51","","Case rate ($13,011.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,441.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13007.81","13007.81","33820.62","1 through 10","11767.51","246465.65","case rate",""
"Amputation Of Lower Limb Except Toes,MODERATE","305","DRG","","","","","","","","inpatient","","","118573.30","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","49715.03","","Standard inlier is a Case rate ($49,715.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,034, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,056.64) for the length of stay and the standard reimbursement.","45418.97","45418.97","45418.97","1 through 10","11767.51","246465.65","case rate",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","111118.90","83339.17","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","22522.18","","Case rate ($22,522.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,918.01, add-ons for qualifying new technology services are included. If operating cost exceeds $66,562.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,945.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $20,637.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,538.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,504.95. The transfer capital threshold is the transfer adjustment factor * $1,504.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","32373.37","32373.37","32373.37","1 through 10","17092.09","29296.38","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","111118.90","83339.17","MEDICARE [2001]","HB BWH MEDICARE","22522.18","","Case rate ($22,522.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,918.01, add-ons for qualifying new technology services are included. If operating cost exceeds $66,562.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,945.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $20,637.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,538.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,504.95. The transfer capital threshold is the transfer adjustment factor * $1,504.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23050.22","23050.22","23084.28","1 through 10","17092.09","29296.38","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With McC","616","MS-DRG","","","","","","","","inpatient","","","233562.86","175172.14","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","33158.04","","Case rate ($32,192.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,675.74, add-ons for qualifying new technology services are included. If operating cost exceeds $84,320.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,246.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $29,006.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,295.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,806.17. The transfer capital threshold is the transfer adjustment factor * $2,806.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","61643.87","61643.87","61643.87","1 through 10","31548.42","54626.63","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With McC","616","MS-DRG","","","","","","","","inpatient","","","233562.86","175172.14","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","32192.27","","Case rate ($32,192.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,675.74, add-ons for qualifying new technology services are included. If operating cost exceeds $84,320.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,246.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $29,006.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,295.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,806.17. The transfer capital threshold is the transfer adjustment factor * $2,806.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","45193.71","45193.71","45193.71","1 through 10","31548.42","54626.63","other","Inpatient Replacement Plans DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With McC","616","MS-DRG","","","","","","","","inpatient","","","233562.86","175172.14","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","32192.27","","Case rate ($32,192.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,675.74, add-ons for qualifying new technology services are included. If operating cost exceeds $84,320.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,246.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $29,006.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,295.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,806.17. The transfer capital threshold is the transfer adjustment factor * $2,806.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27776.54","27776.54","27776.54","1 through 10","31548.42","54626.63","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With McC","616","MS-DRG","","","","","","","","inpatient","","","233562.86","175172.14","MEDICARE [2001]","HB BWH MEDICARE","32192.27","","Case rate ($32,192.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,675.74, add-ons for qualifying new technology services are included. If operating cost exceeds $84,320.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,246.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $29,006.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,295.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,806.17. The transfer capital threshold is the transfer adjustment factor * $2,806.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","45843.37","45843.37","45843.37","1 through 10","31548.42","54626.63","other","Inpatient Replacement Plans DRG"
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","both","","","113.00","84.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","89.84","79.5","","86.57","58.08","86.57","1 through 10","6.35","107.35","percent of total billed charges",""
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","both","","","113.00","84.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.25","36.5","","79.64","34.54","79.64","1 through 10","6.35","107.35","percent of total billed charges",""
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","both","","","113.00","84.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.28","38.3","","43.01","41.80","43.01","18","6.35","107.35","percent of total billed charges",""
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","both","","","113.00","84.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.48","42.9","","48.37","48.37","48.37","1 through 10","6.35","107.35","percent of total billed charges",""
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","outpatient","","","113.00","84.75","AETNA [1001]","HB AMC AETNA HMO","78.87","69.8","","85.80","52.58","85.80","1 through 10","6.68","92.34","percent of total billed charges",""
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","outpatient","","","113.00","84.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","92.34","81.72","","87.93","87.93","87.93","1 through 10","6.68","92.34","percent of total billed charges",""
"Amyotrophic Lateral Sclerosis (Ngs405)","PX-31000926","CDM","81479","CPT","0310","RC","","","","both","","","3238.00","2428.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2574.21","79.5","","0.65","0.65","0.65","1 through 10","1003.78","3076.1","percent of total billed charges",""
"Amyotrophic Lateral Sclerosis (Ngs405)","PX-31000926","CDM","81479","CPT","0310","RC","","","","both","","","3238.00","2428.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1725.85","53.3","","0.79","0.79","0.79","1 through 10","1003.78","3076.1","percent of total billed charges",""
"Amyotrophic Lateral Sclerosis (Ngs405)","PX-31000926","CDM","81479","CPT","0310","RC","","","","outpatient","","","3238.00","2428.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1619.00","50","","1.00","1.00","1.00","1 through 10","156.55","2671.35","percent of total billed charges",""
"Amyotrophic Lateral Sclerosis (Ngs405)","PX-31000926","CDM","81479","CPT","0310","RC","","","","outpatient","","","3238.00","2428.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1699.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","2671.35","percent of total billed charges",""
"Amyotrophic Lateral Sclerosis Advanced Evaluation","PX-31000732","CDM","81479","CPT","0310","RC","","","","both","","","936.00","702.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","744.12","79.5","","0.65","0.65","0.65","1 through 10","290.16","889.2","percent of total billed charges",""
"Amyotrophic Lateral Sclerosis Advanced Evaluation","PX-31000732","CDM","81479","CPT","0310","RC","","","","both","","","936.00","702.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","498.89","53.3","","0.79","0.79","0.79","1 through 10","290.16","889.2","percent of total billed charges",""
"Amyotrophic Lateral Sclerosis Advanced Evaluation","PX-31000732","CDM","81479","CPT","0310","RC","","","","outpatient","","","936.00","702.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","468.00","50","","1.00","1.00","1.00","1 through 10","156.55","772.2","percent of total billed charges",""
"Amyotrophic Lateral Sclerosis Advanced Evaluation","PX-31000732","CDM","81479","CPT","0310","RC","","","","outpatient","","","936.00","702.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","491.40","52.5","","1.00","0.53","1.00","1 through 10","156.55","772.2","percent of total billed charges",""
"Anal And Perineal Procedures,MAJOR","226","DRG","","","","","","","","inpatient","","","119575.38","","MASSHEALTH [3001]","HB BWH MEDICAID","24721.94","","Case rate ($27,334.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $69,764.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8836.54","8836.54","8836.54","1 through 10","7809.21","79839.29","case rate",""
"Anal And Perineal Procedures,MINOR","226","DRG","","","","","","","","inpatient","","","11818.59","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","26247.96","","Standard inlier is a Case rate ($26,247.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,059, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,726.06) for the length of stay and the standard reimbursement.","26247.95","26247.95","26247.95","1 through 10","7809.21","79839.29","case rate",""
"Anal And Perineal Procedures,MINOR","226","DRG","","","","","","","","inpatient","","","11818.59","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7809.21","","Case rate ($8,634.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,064.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8632.31","8632.31","8632.31","1 through 10","7809.21","79839.29","case rate",""
"Anal And Perineal Procedures,MODERATE","226","DRG","","","","","","","","inpatient","","","50915.04","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14296.9864","","Fee schedule rate ($20,570.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14296.9864","19778.16","19778.16","1 through 10","7809.21","79839.29","case rate",""
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","","","","inpatient","","","49132.28","36849.21","MEDICARE [2001]","HB BWH MEDICARE","15874.62","","Case rate ($15,874.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,752.05, add-ons for qualifying new technology services are included. If operating cost exceeds $60,396.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,493.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,441.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,372.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,053.14. The transfer capital threshold is the transfer adjustment factor * $1,053.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15119.66","1931.93","15141.86","1 through 10","12072.47","18998.0599","other","Inpatient DRG"
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","","","","inpatient","","","49132.28","36849.21","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12072.47","","Case rate ($12,318.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,752.05, add-ons for qualifying new technology services are included. If operating cost exceeds $60,396.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,493.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,885.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,372.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,053.14. The transfer capital threshold is the transfer adjustment factor * $1,053.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11502.02","11502.02","11502.02","1 through 10","12072.47","18998.0599","other","Inpatient DRG"
"Anal And Stomal Procedures With McC","347","MS-DRG","","","","","","","","inpatient","","","53207.49","39905.62","MEDICARE [2001]","HB BWH MEDICARE","21320.55","","Case rate ($21,320.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,588.32, add-ons for qualifying new technology services are included. If operating cost exceeds $71,232.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,287.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,093.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,208.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,847.17. The transfer capital threshold is the transfer adjustment factor * $1,847.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","20894.14","35958.28","other","Inpatient Replacement Plans DRG"
"Anal And Stomal Procedures Without Cc/McC","349","MS-DRG","","","","","","","","inpatient","","","42225.48","31669.11","MEDICARE [2001]","HB BWH MEDICARE","8321.55","","Case rate ($8,321.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,940.08, add-ons for qualifying new technology services are included. If operating cost exceeds $55,584.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,140.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $7,241.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,560.25 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $700.54. The transfer capital threshold is the transfer adjustment factor * $700.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10678.87","10678.87","10678.87","1 through 10","8155.12","13293.6619","other","Inpatient Replacement Plans DRG"
"Anal And Stomal Procedures Without Cc/McC","349","TRIS-DRG","","","","","","","","inpatient","","","51972.50","","TRICARE [160005]","HB BWH TRICARE","6993.40","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($12,284.29). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $56,011.29 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($11,167.54), capped at $8,841.43. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $56,011.29 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","11387.64","11387.64","11387.64","1 through 10","6993.4","6993.4","other","Inpatient DRGs"
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","both","","","780.00","585.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","241.8","620.1","other","OPPS APC"
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","both","","","780.00","585.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","241.8","620.1","other","OPPS APC"
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","both","","","780.00","585.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","415.74","53.3","","477.31","477.31","477.31","1 through 10","241.8","620.1","percent of total billed charges",""
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","both","","","780.00","585.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","241.8","620.1","other","OPPS APC"
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","both","","","780.00","585.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","241.8","620.1","other","OPPS APC"
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","284.70","36.5","","1095.87","337.19","1095.87","1 through 10","241.8","620.1","percent of total billed charges",""
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","298.74","38.3","","343.52","323.76","353.46","1 through 10","241.8","620.1","percent of total billed charges",""
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","both","","","780.00","585.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","241.8","620.1","other","Tricare OPPS"
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","both","","","780.00","585.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","241.8","620.1","other","OPPS APC"
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","both","","","780.00","585.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","241.8","620.1","other","OPPS APC"
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","both","","","780.00","585.00","WELLPOINT [1015]","HB AMC WELLPOINT","575.48","73.78","","673.03","673.03","673.03","1 through 10","241.8","620.1","percent of total billed charges",""
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","outpatient","","","780.00","585.00","AETNA [1001]","HB AMC AETNA HMO","544.44","69.8","","612.01","612.01","1224.02","1 through 10","390","700.33","percent of total billed charges",""
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","outpatient","","","780.00","585.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","472.29","60.55","","579.04","568.57","904.00","30","390","700.33","percent of total billed charges",""
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","outpatient","","","780.00","585.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","407.32","52.22","","904.00","656.02","2938.00","26","390","700.33","percent of total billed charges",""
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","outpatient","","","780.00","585.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","390.00","50","","1421.10","875.08","2368.50","15","390","700.33","percent of total billed charges",""
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","outpatient","","","780.00","585.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","409.50","52.5","","2985.00","904.00","2985.00","1 through 10","390","700.33","percent of total billed charges",""
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","outpatient","","","780.00","585.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","637.42","81.72","","722.66","722.66","17449.00","1 through 10","390","700.33","percent of total billed charges",""
"Anal Sphincterotomy","PX-75000453","CDM","46080","CPT","0750","RC","","","","both","","","3765.00","2823.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2006.75","53.3","","4403.52","4403.52","4403.52","1 through 10","1167.15","2993.18","percent of total billed charges",""
"Analy Cytogen Micrarray Copy & Sing","PX-30000217","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2946.27","79.5","","2828.48","1814.97","2828.48","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Analy Cytogen Micrarray Copy & Sing","PX-30000217","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1975.30","53.3","","1814.97","1761.95","1814.97","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Analy Cytogen Micrarray Copy & Sing","PX-30000217","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1352.69","36.5","","1340.56","1340.56","1340.56","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Analy Cytogen Micrarray Copy & Sing","PX-30000217","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1419.40","38.3","","1405.25","1405.25","1405.25","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Analy Cytogen Micrarray Copy & Sing","PX-30000217","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","WELLPOINT [1015]","HB AMC WELLPOINT","2734.29","73.78","","6269.73","2675.73","7188.00","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Analy Cytogen Micrarray Copy & Sing","PX-30000217","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","AETNA [1001]","HB AMC AETNA HMO","2586.79","69.8","","2433.14","2433.14","2433.14","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Analy Cytogen Micrarray Copy & Sing","PX-30000217","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2979.62","80.4","","2803.32","2803.32","2803.32","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Analy Cytogen Micrarray Copy & Sing","PX-30000217","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3028.54","81.72","","2873.04","1533.07","3526.61","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Analy Gene Cyp2c9 Common Variants","PX-30000215","CDM","81227","CPT","0310","RC","","","","both","","","2016.00","1512.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1602.72","79.5","","1538.59","1538.59","1538.59","1 through 10","171.31","1915.2","percent of total billed charges",""
"Analy Gene Serpina1 Common Variants","PX-30000266","CDM","81332","CPT","0310","RC","","","","outpatient","","","844.00","633.00","AETNA [1001]","HB AMC AETNA HMO","589.11","69.8","","391.00","391.00","391.00","1 through 10","154.66","689.72","percent of total billed charges",""
"Analy Gene Ugt1a1 Common Variants","PX-30000270","CDM","81350","CPT","0310","RC","","","","both","","","2361.00","1770.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","904.26","38.3","","895.39","895.39","895.39","1 through 10","229.32","2242.95","percent of total billed charges",""
"Analy Microsatellite Instability","PX-30000254","CDM","81301","CPT","0310","RC","","","","both","","","2896.00","2172.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2302.32","79.5","","2209.90","2209.90","2209.90","1 through 10","341.59","2751.2","percent of total billed charges",""
"Analy Microsatellite Instability","PX-30000254","CDM","81301","CPT","0310","RC","","","","both","","","2896.00","2172.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1543.57","53.3","","1482.62","1482.62","1482.62","1 through 10","341.59","2751.2","percent of total billed charges",""
"Analy Microsatellite Instability","PX-30000254","CDM","81301","CPT","0310","RC","","","","both","","","2896.00","2172.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1109.17","38.3","","1097.93","1097.93","1097.93","1 through 10","341.59","2751.2","percent of total billed charges",""
"Analy Microsatellite Instability","PX-30000254","CDM","81301","CPT","0310","RC","","","","outpatient","","","2896.00","2172.00","AETNA [1001]","HB AMC AETNA HMO","2021.41","69.8","","1901.02","1901.02","1901.02","1 through 10","1022.85","2366.61","percent of total billed charges",""
"Analy Microsatellite Instability","PX-30000254","CDM","81301","CPT","0310","RC","","","","outpatient","","","2896.00","2172.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2366.61","81.72","","2244.72","2244.72","2244.72","1 through 10","1022.85","2366.61","percent of total billed charges",""
"Analys Pump Pain W/O Reprog/Refill","PX-76001483","CDM","62367","CPT","0761","RC","","","","both","","","980.00","735.00","MEDICARE [2001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","356.16","356.16","356.16","1 through 10","303.8","779.1","other","OPPS APC"
"Analysis Chimerism W/Cell Select","PX-30000237","CDM","81268","CPT","0310","RC","","","","both","","","1601.00","1200.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1272.80","79.5","","1222.21","1222.21","1222.21","1 through 10","255.57","1520.95","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","both","","","499.00","374.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","349.30","70","","484.00","212.81","484.00","1 through 10","64.38","474.05","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","both","","","499.00","374.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","396.71","79.5","","380.91","255.55","1142.73","14","64.38","474.05","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","both","","","499.00","374.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","265.97","53.3","","766.65","255.55","1319.02","16","64.38","474.05","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","both","","","499.00","374.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","384.23","77","","1118.04","1118.04","1118.04","1 through 10","64.38","474.05","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","both","","","499.00","374.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","324.35","65","","314.60","304.20","314.60","1 through 10","64.38","474.05","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","both","","","499.00","374.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","182.14","36.5","","541.59","180.53","1263.71","21","64.38","474.05","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","both","","","499.00","374.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","191.12","38.3","","551.76","189.24","919.60","40","64.38","474.05","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","outpatient","","","499.00","374.25","AETNA [1001]","HB AMC AETNA HMO","348.30","69.8","","327.67","231.35","377.52","16","187.67","407.78","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","outpatient","","","499.00","374.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","407.78","81.72","","386.91","212.81","386.91","1 through 10","187.67","407.78","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","both","","","562.00","421.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","446.79","79.5","","428.92","428.92","428.92","1 through 10","71.9","533.9","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","both","","","562.00","421.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","299.55","53.3","","863.28","863.28","863.28","1 through 10","71.9","533.9","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","both","","","562.00","421.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","432.74","77","","1258.95","1258.95","1258.95","1 through 10","71.9","533.9","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","both","","","562.00","421.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","174.22","31","","168.41","168.41","168.41","1 through 10","71.9","533.9","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","both","","","562.00","421.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","215.25","38.3","","621.30","207.10","621.30","1 through 10","71.9","533.9","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","outpatient","","","562.00","421.50","AETNA [1001]","HB AMC AETNA HMO","392.28","69.8","","442.78","368.97","442.78","1 through 10","215.5","459.27","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","outpatient","","","562.00","421.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","459.27","81.72","","435.67","435.67","435.67","1 through 10","215.5","459.27","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","both","","","609.00","456.75","CHAMPVA [160001]","HB BWH TRICARE","578.55","95","","591.00","591.00","591.00","1 through 10","64.05","578.55","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","both","","","609.00","456.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","484.16","79.5","","465.12","312.05","465.12","1 through 10","64.05","578.55","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","both","","","609.00","456.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","324.60","53.3","","312.05","312.05","312.05","1 through 10","64.05","578.55","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","both","","","609.00","456.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","222.29","36.5","","220.44","187.35","220.44","1 through 10","64.05","578.55","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","both","","","609.00","456.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","233.25","38.3","","231.08","224.58","693.24","21","64.05","578.55","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","both","","","609.00","456.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","261.26","42.9","","259.86","259.86","259.86","1 through 10","64.05","578.55","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","609.00","456.75","AETNA [1001]","HB AMC AETNA HMO","425.08","69.8","","282.50","282.50","460.98","1 through 10","230.96","497.67","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","609.00","456.75","AETNA [1001]","HB AMC AETNA PPO","489.64","80.4","","460.98","460.98","460.98","1 through 10","230.96","497.67","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","609.00","456.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","497.67","81.72","","472.45","472.45","472.45","1 through 10","230.96","497.67","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","609.00","456.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","497.67","81.72","","472.45","259.86","605.30","1 through 10","230.96","497.67","percent of total billed charges",""
"Analysis Gene Jak2 V617f Variant","PX-30000238","CDM","81270","CPT","0301","RC","","","","outpatient","","","852.00","639.00","AETNA [1001]","HB AMC AETNA HMO","594.70","69.8","","394.83","394.83","394.83","1 through 10","94.53","696.25","percent of total billed charges",""
"Analysis Gene Jak2 V617f Variant","PX-30000238","CDM","81270","CPT","0301","RC","","","","outpatient","","","852.00","639.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","444.91","52.22","","323.77","323.77","323.77","1 through 10","94.53","696.25","percent of total billed charges",""
"Analysis Gene Mthfr Common Variants","PX-30000244","CDM","81291","CPT","0310","RC","","","","outpatient","","","636.00","477.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","519.74","81.72","","493.23","493.23","493.23","1 through 10","186.62","519.74","percent of total billed charges",""
"Analysis Gene Rearrang Igh Amp Meth","PX-30000230","CDM","81261","CPT","0310","RC","","","","both","","","1487.00","1115.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","792.57","53.3","","1134.85","1134.85","1134.85","1 through 10","194.03","1412.65","percent of total billed charges",""
"Analysis Gene Rearrang Igh Amp Meth","PX-30000230","CDM","81261","CPT","0310","RC","","","","both","","","1487.00","1115.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","542.76","36.5","","914.22","914.22","914.22","1 through 10","194.03","1412.65","percent of total billed charges",""
"Analysis Gene Rearrang Igh Amp Meth","PX-30000230","CDM","81261","CPT","0310","RC","","","","both","","","1487.00","1115.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","569.52","38.3","","547.96","547.96","563.82","1 through 10","194.03","1412.65","percent of total billed charges",""
"Analysis Gene Rearrang Igh Amp Meth","PX-30000230","CDM","81261","CPT","0310","RC","","","","outpatient","","","1487.00","1115.25","AETNA [1001]","HB AMC AETNA HMO","1037.93","69.8","","689.28","689.28","689.28","1 through 10","699.08","1348.54","percent of total billed charges",""
"Analysis Gene Rearrang Igh Amp Meth","PX-30000230","CDM","81261","CPT","0310","RC","","","","outpatient","","","1487.00","1115.25","AETNA [1001]","HB AMC AETNA PPO","1195.55","80.4","","3763.62","3763.62","3763.62","1 through 10","699.08","1348.54","percent of total billed charges",""
"Analysis Gene Rearrang Trg","PX-30000269","CDM","81342","CPT","0301","RC","","","","both","","","1142.00","856.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","907.89","79.5","","871.21","871.21","871.21","1 through 10","197.47","1084.9","percent of total billed charges",""
"Analysis Gene Rearrang Trg","PX-30000269","CDM","81342","CPT","0301","RC","","","","both","","","1142.00","856.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","608.69","53.3","","871.21","871.21","871.21","1 through 10","197.47","1084.9","percent of total billed charges",""
"Analysis Gene Rearrang Trg","PX-30000269","CDM","81342","CPT","0301","RC","","","","both","","","1142.00","856.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","416.83","36.5","","701.84","701.84","701.84","1 through 10","197.47","1084.9","percent of total billed charges",""
"Analysis Gene Rearrang Trg","PX-30000269","CDM","81342","CPT","0301","RC","","","","both","","","1142.00","856.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","437.39","38.3","","432.84","420.66","432.84","1 through 10","197.47","1084.9","percent of total billed charges",""
"Analysis Gene Rearrang Trg","PX-30000269","CDM","81342","CPT","0301","RC","","","","outpatient","","","1142.00","856.50","AETNA [1001]","HB AMC AETNA PPO","918.17","80.4","","2889.27","2889.27","2889.27","1 through 10","207.79","1372.38","percent of total billed charges",""
"Analysis Gene Rearrang Trg","PX-30000269","CDM","81342","CPT","0301","RC","","","","outpatient","","","1142.00","856.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","933.24","81.72","","884.94","884.94","884.94","1 through 10","207.79","1372.38","percent of total billed charges",""
"Analysis Gene Rearrang Trg","PX-30000269","CDM","81342","CPT","0301","RC","","","","outpatient","","","1142.00","856.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","933.24","81.72","","1083.53","1083.53","1083.53","1 through 10","207.79","1372.38","percent of total billed charges",""
"Analysis Gene Str Markers","PX-30000234","CDM","81265","CPT","0310","RC","","","","outpatient","","","1341.00","1005.75","AETNA [1001]","HB AMC AETNA HMO","936.02","69.8","","880.10","880.10","880.10","1 through 10","648.65","1464.7","percent of total billed charges",""
"Analysis Neur W/O Prog Smp/Cpx","PX-92000003","CDM","95970","CPT","0920","RC","","","","both","","","191.00","143.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","151.85","79.5","","145.60","145.60","145.60","1 through 10","59.21","191.33","percent of total billed charges",""
"Analysis Neur W/O Prog Smp/Cpx","PX-92000003","CDM","95970","CPT","0920","RC","","","","both","","","191.00","143.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","59.21","191.33","other","OPPS APC"
"Analysis Neur W/O Prog Smp/Cpx","PX-92000003","CDM","95970","CPT","0920","RC","","","","both","","","191.00","143.25","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","59.21","191.33","other","OPPS APC"
"Analysis Neur W/O Prog Smp/Cpx","PX-92000003","CDM","95970","CPT","0920","RC","","","","both","","","191.00","143.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","69.72","36.5","","69.01","58.65","69.01","1 through 10","59.21","191.33","percent of total billed charges",""
"Analysis Neur W/O Prog Smp/Cpx","PX-92000003","CDM","95970","CPT","0920","RC","","","","both","","","191.00","143.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.15","38.3","","72.34","72.34","72.34","1 through 10","59.21","191.33","percent of total billed charges",""
"Analysis Neur W/O Prog Smp/Cpx","PX-92000003","CDM","95970","CPT","0920","RC","","","","outpatient","","","191.00","143.25","AETNA [1001]","HB AMC AETNA HMO","133.32","69.8","","125.25","88.43","125.25","1 through 10","99.82","545.56","percent of total billed charges",""
"Analysis Neur W/O Prog Smp/Cpx","PX-92000003","CDM","95970","CPT","0920","RC","","","","outpatient","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","156.09","81.72","","147.89","147.89","147.89","1 through 10","99.82","545.56","percent of total billed charges",""
"Analysis Neurostim Smp W/Progam","PX-92000004","CDM","95971","CPT","0920","RC","","","","both","","","439.00","329.25","MEDICARE [2001]","HB BWH MEDICARE","95.90","","APC Price ($95.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.01","109.01","109.01","1 through 10","93.98","349.01","other","OPPS APC"
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","both","","","851.00","638.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","366.81","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","366.69","366.49","366.69","1 through 10","263.81","676.55","other","OPPS APC"
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","both","","","851.00","638.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.46","320.78","350.46","1 through 10","263.81","676.55","other","OPPS APC"
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","both","","","851.00","638.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.46","350.46","354.01","1 through 10","263.81","676.55","other","OPPS APC"
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","both","","","851.00","638.25","MEDICARE [2001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","356.16","356.16","356.16","68","263.81","676.55","other","OPPS APC"
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","both","","","851.00","638.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","349.04","349.04","349.04","1 through 10","263.81","676.55","other","OPPS APC"
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","both","","","851.00","638.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","349.00","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.46","350.46","350.46","1 through 10","263.81","676.55","other","OPPS APC"
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","both","","","851.00","638.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","349.00","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","356.16","326.00","712.20","11","263.81","676.55","other","OPPS APC"
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","outpatient","","","851.00","638.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","320.66","","Case rate ($320.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","644.21","644.21","644.21","1 through 10","320.66","2384.07","other","ASC"
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","outpatient","","","851.00","638.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","320.66","","Case rate ($320.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","750.67","743.29","750.67","1 through 10","320.66","2384.07","other","ASC "
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","366.81","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","367.39","367.29","367.39","12","297.6","763.2","other","OPPS APC"
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.46","350.46","350.46","21","297.6","763.2","other","OPPS APC"
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","763.20","79.5","","732.70","732.70","732.70","1 through 10","297.6","763.2","percent of total billed charges",""
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.46","295.11","350.46","35","297.6","763.2","other","OPPS APC"
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","HUMANA [1012]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","356.16","351.89","356.16","1 through 10","297.6","763.2","other","OPPS APC"
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","MEDICARE [2001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","356.16","326.00","356.16","354","297.6","763.2","other","OPPS APC"
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","297.60","31","","287.68","287.68","287.68","1 through 10","297.6","763.2","percent of total billed charges",""
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","350.40","36.5","","295.13","295.13","347.26","1 through 10","297.6","763.2","percent of total billed charges",""
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","367.68","38.3","","364.02","353.78","364.02","1 through 10","297.6","763.2","percent of total billed charges",""
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","349.04","319.48","349.04","1 through 10","297.6","763.2","other","OPPS APC"
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","MOLINA [1014]","HB BWH MOLINA","349.00","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","706.62","706.62","706.62","1 through 10","297.6","763.2","other","OPPS APC"
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","TRICARE [160005]","HB BWH TRICARE","338.35","","APC Price ($356.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","338.35","309.70","338.35","1 through 10","297.6","763.2","other","Tricare OPPS"
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","349.00","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","356.16","350.46","1068.48","29","297.6","763.2","other","OPPS APC"
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","349.00","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","356.16","319.48","356.16","31","297.6","763.2","other","OPPS APC"
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","both","","","960.00","720.00","WELLPOINT [1015]","HB AMC WELLPOINT","708.29","73.78","","693.13","693.13","693.13","24","297.6","763.2","percent of total billed charges",""
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","outpatient","","","960.00","720.00","AETNA [1001]","HB AMC AETNA PPO","771.84","80.4","","487.84","487.84","487.84","1 through 10","320.66","2547.23","percent of total billed charges",""
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","outpatient","","","960.00","720.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","320.66","","Case rate ($320.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","644.21","644.21","743.29","32","320.66","2547.23","other","ASC"
"Analysis Pump Pain W/Program/Ref","PX-76001486","CDM","62370","CPT","0761","RC","","","","outpatient","","","960.00","720.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","320.66","","Case rate ($320.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","743.29","743.29","750.67","58","320.66","2547.23","other","ASC "
"Analysis Trans Bcr/Abl1 Major Bp","PX-30000196","CDM","81206","CPT","0310","RC","","","","both","","","929.00","696.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","603.85","65","","585.65","585.65","585.65","1 through 10","160.68","882.55","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Major Bp","PX-30000196","CDM","81206","CPT","0310","RC","","","","both","","","929.00","696.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","650.30","70","","163.96","163.96","163.96","1 through 10","160.68","882.55","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Major Bp","PX-30000196","CDM","81206","CPT","0310","RC","","","","both","","","929.00","696.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","738.56","79.5","","709.09","475.73","709.09","1 through 10","160.68","882.55","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Major Bp","PX-30000196","CDM","81206","CPT","0310","RC","","","","both","","","929.00","696.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","339.09","36.5","","285.62","285.62","285.62","1 through 10","160.68","882.55","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Major Bp","PX-30000196","CDM","81206","CPT","0310","RC","","","","both","","","929.00","696.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","355.81","38.3","","352.29","297.33","352.29","1 through 10","160.68","882.55","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Major Bp","PX-30000196","CDM","81206","CPT","0310","RC","","","","outpatient","","","929.00","696.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","759.18","81.72","","720.26","720.26","720.26","1 through 10","283.97","1116.76","percent of total billed charges",""
"Anast a-V Direct Open","PX-76001122","CDM","36821","CPT","0361","RC","","","","both","","","13443.00","10082.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","9410.10","70","","375.00","375.00","375.00","1 through 10","4167.33","10687.19","percent of total billed charges",""
"Anast a-V Direct Open","PX-76001122","CDM","36821","CPT","0361","RC","","","","both","","","13443.00","10082.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7165.12","53.3","","15920.22","15920.22","15920.22","1 through 10","4167.33","10687.19","percent of total billed charges",""
"Anast a-V Direct Open","PX-76001122","CDM","36821","CPT","0361","RC","","","","both","","","13443.00","10082.25","WELLPOINT [1015]","HB AMC WELLPOINT","9918.25","73.78","","23911.85","23911.85","23911.85","1 through 10","4167.33","10687.19","percent of total billed charges",""
"Anast a-V Direct Open","PX-76001122","CDM","36821","CPT","0361","RC","","","","outpatient","","","13443.00","10082.25","AETNA [1001]","HB AMC AETNA HMO","9383.21","69.8","","13458.09","13458.09","13458.09","1 through 10","5377.2","10985.62","percent of total billed charges",""
"Anast a-V Direct Open","PX-76001122","CDM","36821","CPT","0361","RC","","","","outpatient","","","13443.00","10082.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","8139.74","60.55","","6180.41","6180.41","6180.41","1 through 10","5377.2","10985.62","percent of total billed charges",""
"Anast a-V Direct Open","PX-76001122","CDM","36821","CPT","0361","RC","","","","outpatient","","","13443.00","10082.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","7019.93","52.22","","7002.05","7002.05","7002.05","1 through 10","5377.2","10985.62","percent of total billed charges",""
"Anast a-V Direct Open","PX-76001122","CDM","36821","CPT","0361","RC","","","","outpatient","","","13443.00","10082.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10985.62","81.72","","32011.17","32011.17","32011.17","1 through 10","5377.2","10985.62","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.44","435.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","461.45","79.5","","800.18","480.96","1887.97","195","179.94","461.45","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.44","435.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","309.37","53.3","","813.12","216.42","1444.50","81","179.94","461.45","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.44","435.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","179.94","31","","432.60","432.60","432.60","1 through 10","179.94","461.45","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.44","435.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","211.86","36.5","","148.37","54.89","631.39","94","179.94","461.45","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.44","435.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","222.31","38.3","","279.30","91.72","1116.77","266","179.94","461.45","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.44","435.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.01","42.9","","731.00","63.70","731.00","1 through 10","179.94","461.45","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.44","435.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.01","42.9","","384.74","384.74","384.74","1 through 10","179.94","461.45","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.44","435.33","WELLPOINT [1015]","HB AMC WELLPOINT","428.25","73.78","","286.63","119.22","1107.45","105","179.94","461.45","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.44","435.33","AETNA [1001]","HB AMC AETNA HMO","405.15","69.8","","675.31","184.75","1721.50","286","303.34","474.34","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.44","435.33","AETNA [1001]","HB AMC AETNA PPO","466.67","80.4","","1261.44","103.12","1514.10","21","303.34","474.34","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.44","435.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","466.67","80.4","","1365.00","1365.00","1365.00","1 through 10","303.34","474.34","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.44","435.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","474.34","81.72","","5157.68","5157.68","5157.68","1 through 10","303.34","474.34","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.44","435.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","474.34","81.72","","431.26","71.26","1459.57","88","303.34","474.34","percent of total billed charges",""
"ANCHOR PEEK 4.75MM SELF-PUNCHING KNOTLESS ALPHAVENT PC/1EA","SUP-ITM-10329087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1396.50","1047.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1110.22","79.5","","800.18","480.96","1887.97","195","432.92","1110.22","percent of total billed charges",""
"ANCHOR PEEK 4.75MM SELF-PUNCHING KNOTLESS ALPHAVENT PC/1EA","SUP-ITM-10329087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1396.50","1047.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","744.33","53.3","","813.12","216.42","1444.50","81","432.92","1110.22","percent of total billed charges",""
"ANCHOR PEEK 4.75MM SELF-PUNCHING KNOTLESS ALPHAVENT PC/1EA","SUP-ITM-10329087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1396.50","1047.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","432.92","31","","432.60","432.60","432.60","1 through 10","432.92","1110.22","percent of total billed charges",""
"ANCHOR PEEK 4.75MM SELF-PUNCHING KNOTLESS ALPHAVENT PC/1EA","SUP-ITM-10329087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1396.50","1047.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","509.72","36.5","","148.37","54.89","631.39","94","432.92","1110.22","percent of total billed charges",""
"ANCHOR PEEK 4.75MM SELF-PUNCHING KNOTLESS ALPHAVENT PC/1EA","SUP-ITM-10329087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1396.50","1047.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","534.86","38.3","","279.30","91.72","1116.77","266","432.92","1110.22","percent of total billed charges",""
"ANCHOR PEEK 4.75MM SELF-PUNCHING KNOTLESS ALPHAVENT PC/1EA","SUP-ITM-10329087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1396.50","1047.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","599.10","42.9","","731.00","63.70","731.00","1 through 10","432.92","1110.22","percent of total billed charges",""
"ANCHOR PEEK 4.75MM SELF-PUNCHING KNOTLESS ALPHAVENT PC/1EA","SUP-ITM-10329087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1396.50","1047.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","599.10","42.9","","384.74","384.74","384.74","1 through 10","432.92","1110.22","percent of total billed charges",""
"ANCHOR PEEK 4.75MM SELF-PUNCHING KNOTLESS ALPHAVENT PC/1EA","SUP-ITM-10329087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1396.50","1047.37","WELLPOINT [1015]","HB AMC WELLPOINT","1030.34","73.78","","286.63","119.22","1107.45","105","432.92","1110.22","percent of total billed charges",""
"ANCHOR PEEK 4.75MM SELF-PUNCHING KNOTLESS ALPHAVENT PC/1EA","SUP-ITM-10329087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1396.50","1047.37","AETNA [1001]","HB AMC AETNA HMO","974.76","69.8","","675.31","184.75","1721.50","286","729.81","1141.22","percent of total billed charges",""
"ANCHOR PEEK 4.75MM SELF-PUNCHING KNOTLESS ALPHAVENT PC/1EA","SUP-ITM-10329087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1396.50","1047.37","AETNA [1001]","HB AMC AETNA PPO","1122.79","80.4","","1261.44","103.12","1514.10","21","729.81","1141.22","percent of total billed charges",""
"ANCHOR PEEK 4.75MM SELF-PUNCHING KNOTLESS ALPHAVENT PC/1EA","SUP-ITM-10329087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1396.50","1047.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1122.79","80.4","","1365.00","1365.00","1365.00","1 through 10","729.81","1141.22","percent of total billed charges",""
"ANCHOR PEEK 4.75MM SELF-PUNCHING KNOTLESS ALPHAVENT PC/1EA","SUP-ITM-10329087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1396.50","1047.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1141.22","81.72","","5157.68","5157.68","5157.68","1 through 10","729.81","1141.22","percent of total billed charges",""
"ANCHOR PEEK 4.75MM SELF-PUNCHING KNOTLESS ALPHAVENT PC/1EA","SUP-ITM-10329087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1396.50","1047.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1141.22","81.72","","431.26","71.26","1459.57","88","729.81","1141.22","percent of total billed charges",""
"ANCHOR SOFT SP FIBERTAK 2.6 RC FIBER TAPE BLUE-WHITE/BLACK BX/5EA","SUP-ITM-10318078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1645.00","1233.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1307.78","79.5","","800.18","480.96","1887.97","195","509.95","1307.78","percent of total billed charges",""
"ANCHOR SOFT SP FIBERTAK 2.6 RC FIBER TAPE BLUE-WHITE/BLACK BX/5EA","SUP-ITM-10318078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1645.00","1233.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","876.79","53.3","","813.12","216.42","1444.50","81","509.95","1307.78","percent of total billed charges",""
"ANCHOR SOFT SP FIBERTAK 2.6 RC FIBER TAPE BLUE-WHITE/BLACK BX/5EA","SUP-ITM-10318078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1645.00","1233.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","509.95","31","","432.60","432.60","432.60","1 through 10","509.95","1307.78","percent of total billed charges",""
"ANCHOR SOFT SP FIBERTAK 2.6 RC FIBER TAPE BLUE-WHITE/BLACK BX/5EA","SUP-ITM-10318078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1645.00","1233.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","600.43","36.5","","148.37","54.89","631.39","94","509.95","1307.78","percent of total billed charges",""
"ANCHOR SOFT SP FIBERTAK 2.6 RC FIBER TAPE BLUE-WHITE/BLACK BX/5EA","SUP-ITM-10318078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1645.00","1233.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","630.04","38.3","","279.30","91.72","1116.77","266","509.95","1307.78","percent of total billed charges",""
"ANCHOR SOFT SP FIBERTAK 2.6 RC FIBER TAPE BLUE-WHITE/BLACK BX/5EA","SUP-ITM-10318078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1645.00","1233.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","705.71","42.9","","731.00","63.70","731.00","1 through 10","509.95","1307.78","percent of total billed charges",""
"ANCHOR SOFT SP FIBERTAK 2.6 RC FIBER TAPE BLUE-WHITE/BLACK BX/5EA","SUP-ITM-10318078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1645.00","1233.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","705.71","42.9","","384.74","384.74","384.74","1 through 10","509.95","1307.78","percent of total billed charges",""
"ANCHOR SOFT SP FIBERTAK 2.6 RC FIBER TAPE BLUE-WHITE/BLACK BX/5EA","SUP-ITM-10318078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1645.00","1233.75","WELLPOINT [1015]","HB AMC WELLPOINT","1213.68","73.78","","286.63","119.22","1107.45","105","509.95","1307.78","percent of total billed charges",""
"ANCHOR SOFT SP FIBERTAK 2.6 RC FIBER TAPE BLUE-WHITE/BLACK BX/5EA","SUP-ITM-10318078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1645.00","1233.75","AETNA [1001]","HB AMC AETNA HMO","1148.21","69.8","","675.31","184.75","1721.50","286","859.68","1344.29","percent of total billed charges",""
"ANCHOR SOFT SP FIBERTAK 2.6 RC FIBER TAPE BLUE-WHITE/BLACK BX/5EA","SUP-ITM-10318078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1645.00","1233.75","AETNA [1001]","HB AMC AETNA PPO","1322.58","80.4","","1261.44","103.12","1514.10","21","859.68","1344.29","percent of total billed charges",""
"ANCHOR SOFT SP FIBERTAK 2.6 RC FIBER TAPE BLUE-WHITE/BLACK BX/5EA","SUP-ITM-10318078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1645.00","1233.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1322.58","80.4","","1365.00","1365.00","1365.00","1 through 10","859.68","1344.29","percent of total billed charges",""
"ANCHOR SOFT SP FIBERTAK 2.6 RC FIBER TAPE BLUE-WHITE/BLACK BX/5EA","SUP-ITM-10318078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1645.00","1233.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1344.29","81.72","","5157.68","5157.68","5157.68","1 through 10","859.68","1344.29","percent of total billed charges",""
"ANCHOR SOFT SP FIBERTAK 2.6 RC FIBER TAPE BLUE-WHITE/BLACK BX/5EA","SUP-ITM-10318078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1645.00","1233.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1344.29","81.72","","431.26","71.26","1459.57","88","859.68","1344.29","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","765.19","79.5","","800.18","480.96","1887.97","195","298.38","765.19","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","513.01","53.3","","813.12","216.42","1444.50","81","298.38","765.19","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","298.38","31","","432.60","432.60","432.60","1 through 10","298.38","765.19","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","351.31","36.5","","148.37","54.89","631.39","94","298.38","765.19","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","368.64","38.3","","279.30","91.72","1116.77","266","298.38","765.19","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","731.00","63.70","731.00","1 through 10","298.38","765.19","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","384.74","384.74","384.74","1 through 10","298.38","765.19","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","WELLPOINT [1015]","HB AMC WELLPOINT","710.13","73.78","","286.63","119.22","1107.45","105","298.38","765.19","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA HMO","671.83","69.8","","675.31","184.75","1721.50","286","503","786.56","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA PPO","773.85","80.4","","1261.44","103.12","1514.10","21","503","786.56","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","773.85","80.4","","1365.00","1365.00","1365.00","1 through 10","503","786.56","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","786.56","81.72","","5157.68","5157.68","5157.68","1 through 10","503","786.56","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","786.56","81.72","","431.26","71.26","1459.57","88","503","786.56","percent of total billed charges",""
"ANCHOR SURGICAL CLICKX MRI SAFE","SUP-ITM-10174952","CDM","C1883","HCPCS","0278","RC","","","","both","","","1312.50","984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","479.06","36.5","","1073.15","1073.15","1073.15","1 through 10","406.88","1043.44","percent of total billed charges",""
"ANCHOR SURGICAL CLICKX MRI SAFE","SUP-ITM-10174952","CDM","C1883","HCPCS","0278","RC","","","","both","","","1312.50","984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.69","38.3","","1808.38","1642.20","1808.38","1 through 10","406.88","1043.44","percent of total billed charges",""
"ANCHOR SURGICAL CLICKX MRI SAFE","SUP-ITM-10174952","CDM","C1883","HCPCS","0278","RC","","","","both","","","1312.50","984.37","WELLPOINT [1015]","HB AMC WELLPOINT","968.36","73.78","","625.38","625.38","625.38","1 through 10","406.88","1043.44","percent of total billed charges",""
"ANCHOR SUTURE 1.3MM SIZE 4 0 ETHIBOND MICROFIX QUICK PLUS TAPERPOINT DRILL BIT NEEDLE C 1 - DISCONTINUED PER SUPPLIER","SUP-ITM-10011768","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","578.76","79.5","","800.18","480.96","1887.97","195","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE 1.3MM SIZE 4 0 ETHIBOND MICROFIX QUICK PLUS TAPERPOINT DRILL BIT NEEDLE C 1 - DISCONTINUED PER SUPPLIER","SUP-ITM-10011768","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","388.02","53.3","","813.12","216.42","1444.50","81","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE 1.3MM SIZE 4 0 ETHIBOND MICROFIX QUICK PLUS TAPERPOINT DRILL BIT NEEDLE C 1 - DISCONTINUED PER SUPPLIER","SUP-ITM-10011768","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","225.68","31","","432.60","432.60","432.60","1 through 10","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE 1.3MM SIZE 4 0 ETHIBOND MICROFIX QUICK PLUS TAPERPOINT DRILL BIT NEEDLE C 1 - DISCONTINUED PER SUPPLIER","SUP-ITM-10011768","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","265.72","36.5","","148.37","54.89","631.39","94","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE 1.3MM SIZE 4 0 ETHIBOND MICROFIX QUICK PLUS TAPERPOINT DRILL BIT NEEDLE C 1 - DISCONTINUED PER SUPPLIER","SUP-ITM-10011768","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","278.82","38.3","","279.30","91.72","1116.77","266","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE 1.3MM SIZE 4 0 ETHIBOND MICROFIX QUICK PLUS TAPERPOINT DRILL BIT NEEDLE C 1 - DISCONTINUED PER SUPPLIER","SUP-ITM-10011768","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.31","42.9","","731.00","63.70","731.00","1 through 10","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE 1.3MM SIZE 4 0 ETHIBOND MICROFIX QUICK PLUS TAPERPOINT DRILL BIT NEEDLE C 1 - DISCONTINUED PER SUPPLIER","SUP-ITM-10011768","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.31","42.9","","384.74","384.74","384.74","1 through 10","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE 1.3MM SIZE 4 0 ETHIBOND MICROFIX QUICK PLUS TAPERPOINT DRILL BIT NEEDLE C 1 - DISCONTINUED PER SUPPLIER","SUP-ITM-10011768","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","WELLPOINT [1015]","HB AMC WELLPOINT","537.12","73.78","","286.63","119.22","1107.45","105","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE 1.3MM SIZE 4 0 ETHIBOND MICROFIX QUICK PLUS TAPERPOINT DRILL BIT NEEDLE C 1 - DISCONTINUED PER SUPPLIER","SUP-ITM-10011768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","AETNA [1001]","HB AMC AETNA HMO","508.14","69.8","","675.31","184.75","1721.50","286","380.45","594.92","percent of total billed charges",""
"ANCHOR SUTURE 1.3MM SIZE 4 0 ETHIBOND MICROFIX QUICK PLUS TAPERPOINT DRILL BIT NEEDLE C 1 - DISCONTINUED PER SUPPLIER","SUP-ITM-10011768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","AETNA [1001]","HB AMC AETNA PPO","585.31","80.4","","1261.44","103.12","1514.10","21","380.45","594.92","percent of total billed charges",""
"ANCHOR SUTURE 1.3MM SIZE 4 0 ETHIBOND MICROFIX QUICK PLUS TAPERPOINT DRILL BIT NEEDLE C 1 - DISCONTINUED PER SUPPLIER","SUP-ITM-10011768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","585.31","80.4","","1365.00","1365.00","1365.00","1 through 10","380.45","594.92","percent of total billed charges",""
"ANCHOR SUTURE 1.3MM SIZE 4 0 ETHIBOND MICROFIX QUICK PLUS TAPERPOINT DRILL BIT NEEDLE C 1 - DISCONTINUED PER SUPPLIER","SUP-ITM-10011768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","594.92","81.72","","5157.68","5157.68","5157.68","1 through 10","380.45","594.92","percent of total billed charges",""
"ANCHOR SUTURE 1.3MM SIZE 4 0 ETHIBOND MICROFIX QUICK PLUS TAPERPOINT DRILL BIT NEEDLE C 1 - DISCONTINUED PER SUPPLIER","SUP-ITM-10011768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","594.92","81.72","","431.26","71.26","1459.57","88","380.45","594.92","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1224.30","79.5","","800.18","480.96","1887.97","195","477.4","1224.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","820.82","53.3","","813.12","216.42","1444.50","81","477.4","1224.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","477.40","31","","432.60","432.60","432.60","1 through 10","477.4","1224.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","562.10","36.5","","148.37","54.89","631.39","94","477.4","1224.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","589.82","38.3","","279.30","91.72","1116.77","266","477.4","1224.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","660.66","42.9","","731.00","63.70","731.00","1 through 10","477.4","1224.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","660.66","42.9","","384.74","384.74","384.74","1 through 10","477.4","1224.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","WELLPOINT [1015]","HB AMC WELLPOINT","1136.21","73.78","","286.63","119.22","1107.45","105","477.4","1224.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1540.00","1155.00","AETNA [1001]","HB AMC AETNA HMO","1074.92","69.8","","675.31","184.75","1721.50","286","804.8","1258.49","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1540.00","1155.00","AETNA [1001]","HB AMC AETNA PPO","1238.16","80.4","","1261.44","103.12","1514.10","21","804.8","1258.49","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1540.00","1155.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1238.16","80.4","","1365.00","1365.00","1365.00","1 through 10","804.8","1258.49","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1540.00","1155.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1258.49","81.72","","5157.68","5157.68","5157.68","1 through 10","804.8","1258.49","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1540.00","1155.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1258.49","81.72","","431.26","71.26","1459.57","88","804.8","1258.49","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","737.36","79.5","","800.18","480.96","1887.97","195","287.53","737.36","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","494.36","53.3","","813.12","216.42","1444.50","81","287.53","737.36","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","287.53","31","","432.60","432.60","432.60","1 through 10","287.53","737.36","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","338.54","36.5","","148.37","54.89","631.39","94","287.53","737.36","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","355.23","38.3","","279.30","91.72","1116.77","266","287.53","737.36","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","397.90","42.9","","731.00","63.70","731.00","1 through 10","287.53","737.36","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","397.90","42.9","","384.74","384.74","384.74","1 through 10","287.53","737.36","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","WELLPOINT [1015]","HB AMC WELLPOINT","684.31","73.78","","286.63","119.22","1107.45","105","287.53","737.36","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","AETNA [1001]","HB AMC AETNA HMO","647.40","69.8","","675.31","184.75","1721.50","286","484.71","757.95","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","AETNA [1001]","HB AMC AETNA PPO","745.71","80.4","","1261.44","103.12","1514.10","21","484.71","757.95","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","745.71","80.4","","1365.00","1365.00","1365.00","1 through 10","484.71","757.95","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","757.95","81.72","","5157.68","5157.68","5157.68","1 through 10","484.71","757.95","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","757.95","81.72","","431.26","71.26","1459.57","88","484.71","757.95","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","857.50","643.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","681.71","79.5","","800.18","480.96","1887.97","195","265.83","681.71","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","857.50","643.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","457.05","53.3","","813.12","216.42","1444.50","81","265.83","681.71","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","857.50","643.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","265.83","31","","432.60","432.60","432.60","1 through 10","265.83","681.71","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","857.50","643.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","312.99","36.5","","148.37","54.89","631.39","94","265.83","681.71","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","857.50","643.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","328.42","38.3","","279.30","91.72","1116.77","266","265.83","681.71","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","857.50","643.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","367.87","42.9","","731.00","63.70","731.00","1 through 10","265.83","681.71","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","857.50","643.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","367.87","42.9","","384.74","384.74","384.74","1 through 10","265.83","681.71","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","both","","","857.50","643.12","WELLPOINT [1015]","HB AMC WELLPOINT","632.66","73.78","","286.63","119.22","1107.45","105","265.83","681.71","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","AETNA [1001]","HB AMC AETNA HMO","598.54","69.8","","675.31","184.75","1721.50","286","448.13","700.75","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","AETNA [1001]","HB AMC AETNA PPO","689.43","80.4","","1261.44","103.12","1514.10","21","448.13","700.75","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","689.43","80.4","","1365.00","1365.00","1365.00","1 through 10","448.13","700.75","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","700.75","81.72","","5157.68","5157.68","5157.68","1 through 10","448.13","700.75","percent of total billed charges",""
"ANCHOR SUTURE 2 6.5MM ARTHROSCOPY BIOCORKSCREW FIBERWIRE METAL FULL THREAD TRIPLE PLAY BX/5EA","SUP-ITM-10113245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","700.75","81.72","","431.26","71.26","1459.57","88","448.13","700.75","percent of total billed charges",""
"ANCHOR SUTURE 2 7.0X2.7MM SIZE ARTHROSCOPY CORKSCREW FT NEEDLE FIBERWIRE K WIRE MICRO BX/5EA","SUP-ITM-10155831","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","793.01","79.5","","800.18","480.96","1887.97","195","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE 2 7.0X2.7MM SIZE ARTHROSCOPY CORKSCREW FT NEEDLE FIBERWIRE K WIRE MICRO BX/5EA","SUP-ITM-10155831","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","531.67","53.3","","813.12","216.42","1444.50","81","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE 2 7.0X2.7MM SIZE ARTHROSCOPY CORKSCREW FT NEEDLE FIBERWIRE K WIRE MICRO BX/5EA","SUP-ITM-10155831","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","309.23","31","","432.60","432.60","432.60","1 through 10","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE 2 7.0X2.7MM SIZE ARTHROSCOPY CORKSCREW FT NEEDLE FIBERWIRE K WIRE MICRO BX/5EA","SUP-ITM-10155831","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","364.09","36.5","","148.37","54.89","631.39","94","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE 2 7.0X2.7MM SIZE ARTHROSCOPY CORKSCREW FT NEEDLE FIBERWIRE K WIRE MICRO BX/5EA","SUP-ITM-10155831","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","382.04","38.3","","279.30","91.72","1116.77","266","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE 2 7.0X2.7MM SIZE ARTHROSCOPY CORKSCREW FT NEEDLE FIBERWIRE K WIRE MICRO BX/5EA","SUP-ITM-10155831","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.93","42.9","","731.00","63.70","731.00","1 through 10","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE 2 7.0X2.7MM SIZE ARTHROSCOPY CORKSCREW FT NEEDLE FIBERWIRE K WIRE MICRO BX/5EA","SUP-ITM-10155831","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.93","42.9","","384.74","384.74","384.74","1 through 10","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE 2 7.0X2.7MM SIZE ARTHROSCOPY CORKSCREW FT NEEDLE FIBERWIRE K WIRE MICRO BX/5EA","SUP-ITM-10155831","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","WELLPOINT [1015]","HB AMC WELLPOINT","735.96","73.78","","286.63","119.22","1107.45","105","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE 2 7.0X2.7MM SIZE ARTHROSCOPY CORKSCREW FT NEEDLE FIBERWIRE K WIRE MICRO BX/5EA","SUP-ITM-10155831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","AETNA [1001]","HB AMC AETNA HMO","696.26","69.8","","675.31","184.75","1721.50","286","521.29","815.16","percent of total billed charges",""
"ANCHOR SUTURE 2 7.0X2.7MM SIZE ARTHROSCOPY CORKSCREW FT NEEDLE FIBERWIRE K WIRE MICRO BX/5EA","SUP-ITM-10155831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","AETNA [1001]","HB AMC AETNA PPO","801.99","80.4","","1261.44","103.12","1514.10","21","521.29","815.16","percent of total billed charges",""
"ANCHOR SUTURE 2 7.0X2.7MM SIZE ARTHROSCOPY CORKSCREW FT NEEDLE FIBERWIRE K WIRE MICRO BX/5EA","SUP-ITM-10155831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","801.99","80.4","","1365.00","1365.00","1365.00","1 through 10","521.29","815.16","percent of total billed charges",""
"ANCHOR SUTURE 2 7.0X2.7MM SIZE ARTHROSCOPY CORKSCREW FT NEEDLE FIBERWIRE K WIRE MICRO BX/5EA","SUP-ITM-10155831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","815.16","81.72","","5157.68","5157.68","5157.68","1 through 10","521.29","815.16","percent of total billed charges",""
"ANCHOR SUTURE 2 7.0X2.7MM SIZE ARTHROSCOPY CORKSCREW FT NEEDLE FIBERWIRE K WIRE MICRO BX/5EA","SUP-ITM-10155831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","815.16","81.72","","431.26","71.26","1459.57","88","521.29","815.16","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM CS/1BX/1EA","SUP-ITM-10013659","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.96","512.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","542.95","79.5","","800.18","480.96","1887.97","195","211.72","542.95","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM CS/1BX/1EA","SUP-ITM-10013659","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.96","512.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","364.02","53.3","","813.12","216.42","1444.50","81","211.72","542.95","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM CS/1BX/1EA","SUP-ITM-10013659","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.96","512.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","211.72","31","","432.60","432.60","432.60","1 through 10","211.72","542.95","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM CS/1BX/1EA","SUP-ITM-10013659","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.96","512.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","249.28","36.5","","148.37","54.89","631.39","94","211.72","542.95","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM CS/1BX/1EA","SUP-ITM-10013659","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.96","512.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.57","38.3","","279.30","91.72","1116.77","266","211.72","542.95","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM CS/1BX/1EA","SUP-ITM-10013659","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.96","512.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.99","42.9","","731.00","63.70","731.00","1 through 10","211.72","542.95","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM CS/1BX/1EA","SUP-ITM-10013659","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.96","512.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.99","42.9","","384.74","384.74","384.74","1 through 10","211.72","542.95","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM CS/1BX/1EA","SUP-ITM-10013659","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.96","512.22","WELLPOINT [1015]","HB AMC WELLPOINT","503.89","73.78","","286.63","119.22","1107.45","105","211.72","542.95","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM CS/1BX/1EA","SUP-ITM-10013659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.96","512.22","AETNA [1001]","HB AMC AETNA HMO","476.71","69.8","","675.31","184.75","1721.50","286","356.91","558.11","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM CS/1BX/1EA","SUP-ITM-10013659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.96","512.22","AETNA [1001]","HB AMC AETNA PPO","549.10","80.4","","1261.44","103.12","1514.10","21","356.91","558.11","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM CS/1BX/1EA","SUP-ITM-10013659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.96","512.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","549.10","80.4","","1365.00","1365.00","1365.00","1 through 10","356.91","558.11","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM CS/1BX/1EA","SUP-ITM-10013659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.96","512.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","558.11","81.72","","5157.68","5157.68","5157.68","1 through 10","356.91","558.11","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM CS/1BX/1EA","SUP-ITM-10013659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.96","512.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","558.11","81.72","","431.26","71.26","1459.57","88","356.91","558.11","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","623.28","79.5","","800.18","480.96","1887.97","195","243.04","623.28","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","417.87","53.3","","813.12","216.42","1444.50","81","243.04","623.28","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","243.04","31","","432.60","432.60","432.60","1 through 10","243.04","623.28","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","286.16","36.5","","148.37","54.89","631.39","94","243.04","623.28","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","300.27","38.3","","279.30","91.72","1116.77","266","243.04","623.28","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","336.34","42.9","","731.00","63.70","731.00","1 through 10","243.04","623.28","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","336.34","42.9","","384.74","384.74","384.74","1 through 10","243.04","623.28","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","WELLPOINT [1015]","HB AMC WELLPOINT","578.44","73.78","","286.63","119.22","1107.45","105","243.04","623.28","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.00","588.00","AETNA [1001]","HB AMC AETNA HMO","547.23","69.8","","675.31","184.75","1721.50","286","409.72","640.68","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.00","588.00","AETNA [1001]","HB AMC AETNA PPO","630.34","80.4","","1261.44","103.12","1514.10","21","409.72","640.68","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.00","588.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","630.34","80.4","","1365.00","1365.00","1365.00","1 through 10","409.72","640.68","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.00","588.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","640.68","81.72","","5157.68","5157.68","5157.68","1 through 10","409.72","640.68","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.00","588.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","640.68","81.72","","431.26","71.26","1459.57","88","409.72","640.68","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1054.57","79.5","","800.18","480.96","1887.97","195","411.22","1054.57","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","707.02","53.3","","813.12","216.42","1444.50","81","411.22","1054.57","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","411.22","31","","432.60","432.60","432.60","1 through 10","411.22","1054.57","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","484.17","36.5","","148.37","54.89","631.39","94","411.22","1054.57","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","508.05","38.3","","279.30","91.72","1116.77","266","411.22","1054.57","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","569.07","42.9","","731.00","63.70","731.00","1 through 10","411.22","1054.57","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","569.07","42.9","","384.74","384.74","384.74","1 through 10","411.22","1054.57","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","WELLPOINT [1015]","HB AMC WELLPOINT","978.69","73.78","","286.63","119.22","1107.45","105","411.22","1054.57","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.50","994.87","AETNA [1001]","HB AMC AETNA HMO","925.90","69.8","","675.31","184.75","1721.50","286","693.23","1084.02","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.50","994.87","AETNA [1001]","HB AMC AETNA PPO","1066.51","80.4","","1261.44","103.12","1514.10","21","693.23","1084.02","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.50","994.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1066.51","80.4","","1365.00","1365.00","1365.00","1 through 10","693.23","1084.02","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.50","994.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1084.02","81.72","","5157.68","5157.68","5157.68","1 through 10","693.23","1084.02","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.50","994.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1084.02","81.72","","431.26","71.26","1459.57","88","693.23","1084.02","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","765.19","79.5","","800.18","480.96","1887.97","195","298.38","765.19","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","513.01","53.3","","813.12","216.42","1444.50","81","298.38","765.19","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","298.38","31","","432.60","432.60","432.60","1 through 10","298.38","765.19","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","351.31","36.5","","148.37","54.89","631.39","94","298.38","765.19","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","368.64","38.3","","279.30","91.72","1116.77","266","298.38","765.19","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","731.00","63.70","731.00","1 through 10","298.38","765.19","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","384.74","384.74","384.74","1 through 10","298.38","765.19","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","WELLPOINT [1015]","HB AMC WELLPOINT","710.13","73.78","","286.63","119.22","1107.45","105","298.38","765.19","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA HMO","671.83","69.8","","675.31","184.75","1721.50","286","503","786.56","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA PPO","773.85","80.4","","1261.44","103.12","1514.10","21","503","786.56","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","773.85","80.4","","1365.00","1365.00","1365.00","1 through 10","503","786.56","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","786.56","81.72","","5157.68","5157.68","5157.68","1 through 10","503","786.56","percent of total billed charges",""
"ANCHOR SUTURE 2.8MM Q-FIX ALL-SUTURE DOUBLE LOADED #2 MAGNUMWIRE","SUP-ITM-10124152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","786.56","81.72","","431.26","71.26","1459.57","88","503","786.56","percent of total billed charges",""
"ANCHOR SUTURE 21MM LONG BOLT CAP GASKET BX/3EA","SUP-ITM-10151449","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.83","550.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","583.39","79.5","","800.18","480.96","1887.97","195","227.49","583.39","percent of total billed charges",""
"ANCHOR SUTURE 21MM LONG BOLT CAP GASKET BX/3EA","SUP-ITM-10151449","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.83","550.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","391.13","53.3","","813.12","216.42","1444.50","81","227.49","583.39","percent of total billed charges",""
"ANCHOR SUTURE 21MM LONG BOLT CAP GASKET BX/3EA","SUP-ITM-10151449","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.83","550.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","227.49","31","","432.60","432.60","432.60","1 through 10","227.49","583.39","percent of total billed charges",""
"ANCHOR SUTURE 21MM LONG BOLT CAP GASKET BX/3EA","SUP-ITM-10151449","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.83","550.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","267.85","36.5","","148.37","54.89","631.39","94","227.49","583.39","percent of total billed charges",""
"ANCHOR SUTURE 21MM LONG BOLT CAP GASKET BX/3EA","SUP-ITM-10151449","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.83","550.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","281.06","38.3","","279.30","91.72","1116.77","266","227.49","583.39","percent of total billed charges",""
"ANCHOR SUTURE 21MM LONG BOLT CAP GASKET BX/3EA","SUP-ITM-10151449","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.83","550.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","314.81","42.9","","731.00","63.70","731.00","1 through 10","227.49","583.39","percent of total billed charges",""
"ANCHOR SUTURE 21MM LONG BOLT CAP GASKET BX/3EA","SUP-ITM-10151449","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.83","550.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","314.81","42.9","","384.74","384.74","384.74","1 through 10","227.49","583.39","percent of total billed charges",""
"ANCHOR SUTURE 21MM LONG BOLT CAP GASKET BX/3EA","SUP-ITM-10151449","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.83","550.37","WELLPOINT [1015]","HB AMC WELLPOINT","541.42","73.78","","286.63","119.22","1107.45","105","227.49","583.39","percent of total billed charges",""
"ANCHOR SUTURE 21MM LONG BOLT CAP GASKET BX/3EA","SUP-ITM-10151449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.83","550.37","AETNA [1001]","HB AMC AETNA HMO","512.21","69.8","","675.31","184.75","1721.50","286","383.5","599.69","percent of total billed charges",""
"ANCHOR SUTURE 21MM LONG BOLT CAP GASKET BX/3EA","SUP-ITM-10151449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.83","550.37","AETNA [1001]","HB AMC AETNA PPO","590.00","80.4","","1261.44","103.12","1514.10","21","383.5","599.69","percent of total billed charges",""
"ANCHOR SUTURE 21MM LONG BOLT CAP GASKET BX/3EA","SUP-ITM-10151449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.83","550.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","590.00","80.4","","1365.00","1365.00","1365.00","1 through 10","383.5","599.69","percent of total billed charges",""
"ANCHOR SUTURE 21MM LONG BOLT CAP GASKET BX/3EA","SUP-ITM-10151449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.83","550.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","599.69","81.72","","5157.68","5157.68","5157.68","1 through 10","383.5","599.69","percent of total billed charges",""
"ANCHOR SUTURE 21MM LONG BOLT CAP GASKET BX/3EA","SUP-ITM-10151449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.83","550.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","599.69","81.72","","431.26","71.26","1459.57","88","383.5","599.69","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1168.65","79.5","","800.18","480.96","1887.97","195","455.7","1168.65","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","783.51","53.3","","813.12","216.42","1444.50","81","455.7","1168.65","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","455.70","31","","432.60","432.60","432.60","1 through 10","455.7","1168.65","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","536.55","36.5","","148.37","54.89","631.39","94","455.7","1168.65","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","563.01","38.3","","279.30","91.72","1116.77","266","455.7","1168.65","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","731.00","63.70","731.00","1 through 10","455.7","1168.65","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","384.74","384.74","384.74","1 through 10","455.7","1168.65","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB AMC WELLPOINT","1084.57","73.78","","286.63","119.22","1107.45","105","455.7","1168.65","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA HMO","1026.06","69.8","","675.31","184.75","1721.50","286","768.22","1201.28","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA PPO","1181.88","80.4","","1261.44","103.12","1514.10","21","768.22","1201.28","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1181.88","80.4","","1365.00","1365.00","1365.00","1 through 10","768.22","1201.28","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1201.28","81.72","","5157.68","5157.68","5157.68","1 through 10","768.22","1201.28","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1201.28","81.72","","431.26","71.26","1459.57","88","768.22","1201.28","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.00","819.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","868.14","79.5","","800.18","480.96","1887.97","195","338.52","868.14","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.00","819.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","582.04","53.3","","813.12","216.42","1444.50","81","338.52","868.14","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.00","819.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","338.52","31","","432.60","432.60","432.60","1 through 10","338.52","868.14","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.00","819.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","398.58","36.5","","148.37","54.89","631.39","94","338.52","868.14","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.00","819.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","418.24","38.3","","279.30","91.72","1116.77","266","338.52","868.14","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.00","819.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","468.47","42.9","","731.00","63.70","731.00","1 through 10","338.52","868.14","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.00","819.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","468.47","42.9","","384.74","384.74","384.74","1 through 10","338.52","868.14","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.00","819.00","WELLPOINT [1015]","HB AMC WELLPOINT","805.68","73.78","","286.63","119.22","1107.45","105","338.52","868.14","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1092.00","819.00","AETNA [1001]","HB AMC AETNA HMO","762.22","69.8","","675.31","184.75","1721.50","286","570.68","892.38","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1092.00","819.00","AETNA [1001]","HB AMC AETNA PPO","877.97","80.4","","1261.44","103.12","1514.10","21","570.68","892.38","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1092.00","819.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","877.97","80.4","","1365.00","1365.00","1365.00","1 through 10","570.68","892.38","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1092.00","819.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","892.38","81.72","","5157.68","5157.68","5157.68","1 through 10","570.68","892.38","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1092.00","819.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","892.38","81.72","","431.26","71.26","1459.57","88","570.68","892.38","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1775.17","1331.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1411.26","79.5","","800.18","480.96","1887.97","195","550.3","1411.26","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1775.17","1331.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","946.17","53.3","","813.12","216.42","1444.50","81","550.3","1411.26","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1775.17","1331.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","550.30","31","","432.60","432.60","432.60","1 through 10","550.3","1411.26","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1775.17","1331.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","647.94","36.5","","148.37","54.89","631.39","94","550.3","1411.26","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1775.17","1331.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","679.89","38.3","","279.30","91.72","1116.77","266","550.3","1411.26","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1775.17","1331.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","761.55","42.9","","731.00","63.70","731.00","1 through 10","550.3","1411.26","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1775.17","1331.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","761.55","42.9","","384.74","384.74","384.74","1 through 10","550.3","1411.26","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1775.17","1331.38","WELLPOINT [1015]","HB AMC WELLPOINT","1309.72","73.78","","286.63","119.22","1107.45","105","550.3","1411.26","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1775.17","1331.38","AETNA [1001]","HB AMC AETNA HMO","1239.07","69.8","","675.31","184.75","1721.50","286","927.7","1450.67","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1775.17","1331.38","AETNA [1001]","HB AMC AETNA PPO","1427.24","80.4","","1261.44","103.12","1514.10","21","927.7","1450.67","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1775.17","1331.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1427.24","80.4","","1365.00","1365.00","1365.00","1 through 10","927.7","1450.67","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1775.17","1331.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1450.67","81.72","","5157.68","5157.68","5157.68","1 through 10","927.7","1450.67","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1775.17","1331.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1450.67","81.72","","431.26","71.26","1459.57","88","927.7","1450.67","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM SZ 2 WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033415","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","706.87","79.5","","800.18","480.96","1887.97","195","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM SZ 2 WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033415","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","473.91","53.3","","813.12","216.42","1444.50","81","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM SZ 2 WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033415","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","275.63","31","","432.60","432.60","432.60","1 through 10","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM SZ 2 WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033415","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","324.54","36.5","","148.37","54.89","631.39","94","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM SZ 2 WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033415","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","340.54","38.3","","279.30","91.72","1116.77","266","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM SZ 2 WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033415","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","381.44","42.9","","731.00","63.70","731.00","1 through 10","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM SZ 2 WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033415","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","381.44","42.9","","384.74","384.74","384.74","1 through 10","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM SZ 2 WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033415","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","WELLPOINT [1015]","HB AMC WELLPOINT","656.01","73.78","","286.63","119.22","1107.45","105","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM SZ 2 WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.14","666.85","AETNA [1001]","HB AMC AETNA HMO","620.62","69.8","","675.31","184.75","1721.50","286","464.66","726.61","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM SZ 2 WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.14","666.85","AETNA [1001]","HB AMC AETNA PPO","714.87","80.4","","1261.44","103.12","1514.10","21","464.66","726.61","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM SZ 2 WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.14","666.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","714.87","80.4","","1365.00","1365.00","1365.00","1 through 10","464.66","726.61","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM SZ 2 WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.14","666.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","726.61","81.72","","5157.68","5157.68","5157.68","1 through 10","464.66","726.61","percent of total billed charges",""
"ANCHOR SUTURE 3.5MM SZ 2 WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.14","666.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","726.61","81.72","","431.26","71.26","1459.57","88","464.66","726.61","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY SOFT TISSUE FIXATION TWINFIX ULTRA TI TITANIUM SZ 2 ULTRABRAID COBRAID BLUE BLACK","SUP-ITM-10079979","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","528.68","79.5","","800.18","480.96","1887.97","195","206.15","528.68","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY SOFT TISSUE FIXATION TWINFIX ULTRA TI TITANIUM SZ 2 ULTRABRAID COBRAID BLUE BLACK","SUP-ITM-10079979","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","354.45","53.3","","813.12","216.42","1444.50","81","206.15","528.68","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY SOFT TISSUE FIXATION TWINFIX ULTRA TI TITANIUM SZ 2 ULTRABRAID COBRAID BLUE BLACK","SUP-ITM-10079979","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","206.15","31","","432.60","432.60","432.60","1 through 10","206.15","528.68","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY SOFT TISSUE FIXATION TWINFIX ULTRA TI TITANIUM SZ 2 ULTRABRAID COBRAID BLUE BLACK","SUP-ITM-10079979","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","242.73","36.5","","148.37","54.89","631.39","94","206.15","528.68","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY SOFT TISSUE FIXATION TWINFIX ULTRA TI TITANIUM SZ 2 ULTRABRAID COBRAID BLUE BLACK","SUP-ITM-10079979","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","254.70","38.3","","279.30","91.72","1116.77","266","206.15","528.68","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY SOFT TISSUE FIXATION TWINFIX ULTRA TI TITANIUM SZ 2 ULTRABRAID COBRAID BLUE BLACK","SUP-ITM-10079979","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","285.29","42.9","","731.00","63.70","731.00","1 through 10","206.15","528.68","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY SOFT TISSUE FIXATION TWINFIX ULTRA TI TITANIUM SZ 2 ULTRABRAID COBRAID BLUE BLACK","SUP-ITM-10079979","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","285.29","42.9","","384.74","384.74","384.74","1 through 10","206.15","528.68","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY SOFT TISSUE FIXATION TWINFIX ULTRA TI TITANIUM SZ 2 ULTRABRAID COBRAID BLUE BLACK","SUP-ITM-10079979","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","WELLPOINT [1015]","HB AMC WELLPOINT","490.64","73.78","","286.63","119.22","1107.45","105","206.15","528.68","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY SOFT TISSUE FIXATION TWINFIX ULTRA TI TITANIUM SZ 2 ULTRABRAID COBRAID BLUE BLACK","SUP-ITM-10079979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","AETNA [1001]","HB AMC AETNA HMO","464.17","69.8","","675.31","184.75","1721.50","286","347.53","543.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY SOFT TISSUE FIXATION TWINFIX ULTRA TI TITANIUM SZ 2 ULTRABRAID COBRAID BLUE BLACK","SUP-ITM-10079979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","AETNA [1001]","HB AMC AETNA PPO","534.66","80.4","","1261.44","103.12","1514.10","21","347.53","543.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY SOFT TISSUE FIXATION TWINFIX ULTRA TI TITANIUM SZ 2 ULTRABRAID COBRAID BLUE BLACK","SUP-ITM-10079979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","534.66","80.4","","1365.00","1365.00","1365.00","1 through 10","347.53","543.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY SOFT TISSUE FIXATION TWINFIX ULTRA TI TITANIUM SZ 2 ULTRABRAID COBRAID BLUE BLACK","SUP-ITM-10079979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","543.44","81.72","","5157.68","5157.68","5157.68","1 through 10","347.53","543.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY SOFT TISSUE FIXATION TWINFIX ULTRA TI TITANIUM SZ 2 ULTRABRAID COBRAID BLUE BLACK","SUP-ITM-10079979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","543.44","81.72","","431.26","71.26","1459.57","88","347.53","543.44","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.50","1446.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1533.16","79.5","","800.18","480.96","1887.97","195","597.84","1533.16","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.50","1446.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1027.89","53.3","","813.12","216.42","1444.50","81","597.84","1533.16","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.50","1446.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","597.84","31","","432.60","432.60","432.60","1 through 10","597.84","1533.16","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.50","1446.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","703.90","36.5","","148.37","54.89","631.39","94","597.84","1533.16","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.50","1446.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","738.62","38.3","","279.30","91.72","1116.77","266","597.84","1533.16","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.50","1446.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","827.33","42.9","","731.00","63.70","731.00","1 through 10","597.84","1533.16","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.50","1446.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","827.33","42.9","","384.74","384.74","384.74","1 through 10","597.84","1533.16","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1928.50","1446.37","WELLPOINT [1015]","HB AMC WELLPOINT","1422.85","73.78","","286.63","119.22","1107.45","105","597.84","1533.16","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1928.50","1446.37","AETNA [1001]","HB AMC AETNA HMO","1346.09","69.8","","675.31","184.75","1721.50","286","1007.83","1575.97","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1928.50","1446.37","AETNA [1001]","HB AMC AETNA PPO","1550.51","80.4","","1261.44","103.12","1514.10","21","1007.83","1575.97","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1928.50","1446.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1550.51","80.4","","1365.00","1365.00","1365.00","1 through 10","1007.83","1575.97","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1928.50","1446.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1575.97","81.72","","5157.68","5157.68","5157.68","1 through 10","1007.83","1575.97","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1928.50","1446.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1575.97","81.72","","431.26","71.26","1459.57","88","1007.83","1575.97","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1850.66","1387.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1471.27","79.5","","800.18","480.96","1887.97","195","573.7","1471.27","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1850.66","1387.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","986.40","53.3","","813.12","216.42","1444.50","81","573.7","1471.27","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1850.66","1387.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","573.70","31","","432.60","432.60","432.60","1 through 10","573.7","1471.27","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1850.66","1387.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","675.49","36.5","","148.37","54.89","631.39","94","573.7","1471.27","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1850.66","1387.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","708.80","38.3","","279.30","91.72","1116.77","266","573.7","1471.27","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1850.66","1387.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","793.93","42.9","","731.00","63.70","731.00","1 through 10","573.7","1471.27","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1850.66","1387.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","793.93","42.9","","384.74","384.74","384.74","1 through 10","573.7","1471.27","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","both","","","1850.66","1387.99","WELLPOINT [1015]","HB AMC WELLPOINT","1365.42","73.78","","286.63","119.22","1107.45","105","573.7","1471.27","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1850.66","1387.99","AETNA [1001]","HB AMC AETNA HMO","1291.76","69.8","","675.31","184.75","1721.50","286","967.15","1512.36","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1850.66","1387.99","AETNA [1001]","HB AMC AETNA PPO","1487.93","80.4","","1261.44","103.12","1514.10","21","967.15","1512.36","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1850.66","1387.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1487.93","80.4","","1365.00","1365.00","1365.00","1 through 10","967.15","1512.36","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1850.66","1387.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1512.36","81.72","","5157.68","5157.68","5157.68","1 through 10","967.15","1512.36","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM POPLOK ENDOSCOPY KNOTLESS PEEK SUB CORTICAL WING SHOULDER","SUP-ITM-10065023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1850.66","1387.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1512.36","81.72","","431.26","71.26","1459.57","88","967.15","1512.36","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","820.84","79.5","","800.18","480.96","1887.97","195","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","550.32","53.3","","813.12","216.42","1444.50","81","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","320.08","31","","432.60","432.60","432.60","1 through 10","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","376.86","36.5","","148.37","54.89","631.39","94","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","395.45","38.3","","279.30","91.72","1116.77","266","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.94","42.9","","731.00","63.70","731.00","1 through 10","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.94","42.9","","384.74","384.74","384.74","1 through 10","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","WELLPOINT [1015]","HB AMC WELLPOINT","761.78","73.78","","286.63","119.22","1107.45","105","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","AETNA [1001]","HB AMC AETNA HMO","720.69","69.8","","675.31","184.75","1721.50","286","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","AETNA [1001]","HB AMC AETNA PPO","830.13","80.4","","1261.44","103.12","1514.10","21","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","830.13","80.4","","1365.00","1365.00","1365.00","1 through 10","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","843.76","81.72","","5157.68","5157.68","5157.68","1 through 10","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","843.76","81.72","","431.26","71.26","1459.57","88","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4149.90","79.5","","800.18","480.96","1887.97","195","1618.2","4149.9","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2782.26","53.3","","813.12","216.42","1444.50","81","1618.2","4149.9","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1618.20","31","","432.60","432.60","432.60","1 through 10","1618.2","4149.9","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1905.30","36.5","","148.37","54.89","631.39","94","1618.2","4149.9","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1999.26","38.3","","279.30","91.72","1116.77","266","1618.2","4149.9","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2239.38","42.9","","731.00","63.70","731.00","1 through 10","1618.2","4149.9","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2239.38","42.9","","384.74","384.74","384.74","1 through 10","1618.2","4149.9","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","WELLPOINT [1015]","HB AMC WELLPOINT","3851.32","73.78","","286.63","119.22","1107.45","105","1618.2","4149.9","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5220.00","3915.00","AETNA [1001]","HB AMC AETNA HMO","3643.56","69.8","","675.31","184.75","1721.50","286","2727.97","4265.78","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5220.00","3915.00","AETNA [1001]","HB AMC AETNA PPO","4196.88","80.4","","1261.44","103.12","1514.10","21","2727.97","4265.78","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5220.00","3915.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4196.88","80.4","","1365.00","1365.00","1365.00","1 through 10","2727.97","4265.78","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5220.00","3915.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4265.78","81.72","","5157.68","5157.68","5157.68","1 through 10","2727.97","4265.78","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5220.00","3915.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4265.78","81.72","","431.26","71.26","1459.57","88","2727.97","4265.78","percent of total billed charges",""
"ANCHOR SUTURE 5.0X14.2MM SUPER REVO ROTATOR CUFF HI FI TITANIUM POLYESTER SELF DRILLING HIGH STRENGTH","SUP-ITM-10019683","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.25","581.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","616.32","79.5","","800.18","480.96","1887.97","195","240.33","616.32","percent of total billed charges",""
"ANCHOR SUTURE 5.0X14.2MM SUPER REVO ROTATOR CUFF HI FI TITANIUM POLYESTER SELF DRILLING HIGH STRENGTH","SUP-ITM-10019683","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.25","581.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","413.21","53.3","","813.12","216.42","1444.50","81","240.33","616.32","percent of total billed charges",""
"ANCHOR SUTURE 5.0X14.2MM SUPER REVO ROTATOR CUFF HI FI TITANIUM POLYESTER SELF DRILLING HIGH STRENGTH","SUP-ITM-10019683","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.25","581.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","240.33","31","","432.60","432.60","432.60","1 through 10","240.33","616.32","percent of total billed charges",""
"ANCHOR SUTURE 5.0X14.2MM SUPER REVO ROTATOR CUFF HI FI TITANIUM POLYESTER SELF DRILLING HIGH STRENGTH","SUP-ITM-10019683","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.25","581.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","282.97","36.5","","148.37","54.89","631.39","94","240.33","616.32","percent of total billed charges",""
"ANCHOR SUTURE 5.0X14.2MM SUPER REVO ROTATOR CUFF HI FI TITANIUM POLYESTER SELF DRILLING HIGH STRENGTH","SUP-ITM-10019683","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.25","581.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","296.92","38.3","","279.30","91.72","1116.77","266","240.33","616.32","percent of total billed charges",""
"ANCHOR SUTURE 5.0X14.2MM SUPER REVO ROTATOR CUFF HI FI TITANIUM POLYESTER SELF DRILLING HIGH STRENGTH","SUP-ITM-10019683","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.25","581.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","332.58","42.9","","731.00","63.70","731.00","1 through 10","240.33","616.32","percent of total billed charges",""
"ANCHOR SUTURE 5.0X14.2MM SUPER REVO ROTATOR CUFF HI FI TITANIUM POLYESTER SELF DRILLING HIGH STRENGTH","SUP-ITM-10019683","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.25","581.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","332.58","42.9","","384.74","384.74","384.74","1 through 10","240.33","616.32","percent of total billed charges",""
"ANCHOR SUTURE 5.0X14.2MM SUPER REVO ROTATOR CUFF HI FI TITANIUM POLYESTER SELF DRILLING HIGH STRENGTH","SUP-ITM-10019683","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.25","581.44","WELLPOINT [1015]","HB AMC WELLPOINT","571.98","73.78","","286.63","119.22","1107.45","105","240.33","616.32","percent of total billed charges",""
"ANCHOR SUTURE 5.0X14.2MM SUPER REVO ROTATOR CUFF HI FI TITANIUM POLYESTER SELF DRILLING HIGH STRENGTH","SUP-ITM-10019683","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","775.25","581.44","AETNA [1001]","HB AMC AETNA HMO","541.12","69.8","","675.31","184.75","1721.50","286","405.15","633.53","percent of total billed charges",""
"ANCHOR SUTURE 5.0X14.2MM SUPER REVO ROTATOR CUFF HI FI TITANIUM POLYESTER SELF DRILLING HIGH STRENGTH","SUP-ITM-10019683","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","775.25","581.44","AETNA [1001]","HB AMC AETNA PPO","623.30","80.4","","1261.44","103.12","1514.10","21","405.15","633.53","percent of total billed charges",""
"ANCHOR SUTURE 5.0X14.2MM SUPER REVO ROTATOR CUFF HI FI TITANIUM POLYESTER SELF DRILLING HIGH STRENGTH","SUP-ITM-10019683","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","775.25","581.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","623.30","80.4","","1365.00","1365.00","1365.00","1 through 10","405.15","633.53","percent of total billed charges",""
"ANCHOR SUTURE 5.0X14.2MM SUPER REVO ROTATOR CUFF HI FI TITANIUM POLYESTER SELF DRILLING HIGH STRENGTH","SUP-ITM-10019683","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","775.25","581.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","633.53","81.72","","5157.68","5157.68","5157.68","1 through 10","405.15","633.53","percent of total billed charges",""
"ANCHOR SUTURE 5.0X14.2MM SUPER REVO ROTATOR CUFF HI FI TITANIUM POLYESTER SELF DRILLING HIGH STRENGTH","SUP-ITM-10019683","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","775.25","581.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","633.53","81.72","","431.26","71.26","1459.57","88","405.15","633.53","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","876.49","79.5","","800.18","480.96","1887.97","195","341.78","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","587.63","53.3","","813.12","216.42","1444.50","81","341.78","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","341.78","31","","432.60","432.60","432.60","1 through 10","341.78","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","402.41","36.5","","148.37","54.89","631.39","94","341.78","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","422.26","38.3","","279.30","91.72","1116.77","266","341.78","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","472.97","42.9","","731.00","63.70","731.00","1 through 10","341.78","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","472.97","42.9","","384.74","384.74","384.74","1 through 10","341.78","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","WELLPOINT [1015]","HB AMC WELLPOINT","813.42","73.78","","286.63","119.22","1107.45","105","341.78","876.49","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","AETNA [1001]","HB AMC AETNA HMO","769.55","69.8","","675.31","184.75","1721.50","286","576.17","900.96","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","AETNA [1001]","HB AMC AETNA PPO","886.41","80.4","","1261.44","103.12","1514.10","21","576.17","900.96","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","886.41","80.4","","1365.00","1365.00","1365.00","1 through 10","576.17","900.96","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","900.96","81.72","","5157.68","5157.68","5157.68","1 through 10","576.17","900.96","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","900.96","81.72","","431.26","71.26","1459.57","88","576.17","900.96","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1120.00","840.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","890.40","79.5","","800.18","480.96","1887.97","195","347.2","890.4","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1120.00","840.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","596.96","53.3","","813.12","216.42","1444.50","81","347.2","890.4","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1120.00","840.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","347.20","31","","432.60","432.60","432.60","1 through 10","347.2","890.4","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1120.00","840.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","408.80","36.5","","148.37","54.89","631.39","94","347.2","890.4","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1120.00","840.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","428.96","38.3","","279.30","91.72","1116.77","266","347.2","890.4","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1120.00","840.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","480.48","42.9","","731.00","63.70","731.00","1 through 10","347.2","890.4","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1120.00","840.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","480.48","42.9","","384.74","384.74","384.74","1 through 10","347.2","890.4","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1120.00","840.00","WELLPOINT [1015]","HB AMC WELLPOINT","826.34","73.78","","286.63","119.22","1107.45","105","347.2","890.4","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1120.00","840.00","AETNA [1001]","HB AMC AETNA HMO","781.76","69.8","","675.31","184.75","1721.50","286","585.31","915.26","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1120.00","840.00","AETNA [1001]","HB AMC AETNA PPO","900.48","80.4","","1261.44","103.12","1514.10","21","585.31","915.26","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1120.00","840.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","900.48","80.4","","1365.00","1365.00","1365.00","1 through 10","585.31","915.26","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1120.00","840.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","915.26","81.72","","5157.68","5157.68","5157.68","1 through 10","585.31","915.26","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1120.00","840.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","915.26","81.72","","431.26","71.26","1459.57","88","585.31","915.26","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM DUAL CHANNELED THREADED W/OUT NEEDLE ORTHOCORD FASTIN RC","SUP-ITM-10017714","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","800.18","480.96","1887.97","195","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM DUAL CHANNELED THREADED W/OUT NEEDLE ORTHOCORD FASTIN RC","SUP-ITM-10017714","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","813.12","216.42","1444.50","81","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM DUAL CHANNELED THREADED W/OUT NEEDLE ORTHOCORD FASTIN RC","SUP-ITM-10017714","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","260.40","31","","432.60","432.60","432.60","1 through 10","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM DUAL CHANNELED THREADED W/OUT NEEDLE ORTHOCORD FASTIN RC","SUP-ITM-10017714","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","148.37","54.89","631.39","94","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM DUAL CHANNELED THREADED W/OUT NEEDLE ORTHOCORD FASTIN RC","SUP-ITM-10017714","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","279.30","91.72","1116.77","266","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM DUAL CHANNELED THREADED W/OUT NEEDLE ORTHOCORD FASTIN RC","SUP-ITM-10017714","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","731.00","63.70","731.00","1 through 10","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM DUAL CHANNELED THREADED W/OUT NEEDLE ORTHOCORD FASTIN RC","SUP-ITM-10017714","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","384.74","384.74","384.74","1 through 10","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM DUAL CHANNELED THREADED W/OUT NEEDLE ORTHOCORD FASTIN RC","SUP-ITM-10017714","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","286.63","119.22","1107.45","105","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM DUAL CHANNELED THREADED W/OUT NEEDLE ORTHOCORD FASTIN RC","SUP-ITM-10017714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","675.31","184.75","1721.50","286","438.98","686.45","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM DUAL CHANNELED THREADED W/OUT NEEDLE ORTHOCORD FASTIN RC","SUP-ITM-10017714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA PPO","675.36","80.4","","1261.44","103.12","1514.10","21","438.98","686.45","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM DUAL CHANNELED THREADED W/OUT NEEDLE ORTHOCORD FASTIN RC","SUP-ITM-10017714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1365.00","1365.00","1365.00","1 through 10","438.98","686.45","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM DUAL CHANNELED THREADED W/OUT NEEDLE ORTHOCORD FASTIN RC","SUP-ITM-10017714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","686.45","81.72","","5157.68","5157.68","5157.68","1 through 10","438.98","686.45","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM DUAL CHANNELED THREADED W/OUT NEEDLE ORTHOCORD FASTIN RC","SUP-ITM-10017714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","431.26","71.26","1459.57","88","438.98","686.45","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","706.87","79.5","","800.18","480.96","1887.97","195","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","473.91","53.3","","813.12","216.42","1444.50","81","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","275.63","31","","432.60","432.60","432.60","1 through 10","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","324.54","36.5","","148.37","54.89","631.39","94","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","340.54","38.3","","279.30","91.72","1116.77","266","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","381.44","42.9","","731.00","63.70","731.00","1 through 10","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","381.44","42.9","","384.74","384.74","384.74","1 through 10","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.14","666.85","WELLPOINT [1015]","HB AMC WELLPOINT","656.01","73.78","","286.63","119.22","1107.45","105","275.63","706.87","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.14","666.85","AETNA [1001]","HB AMC AETNA HMO","620.62","69.8","","675.31","184.75","1721.50","286","464.66","726.61","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.14","666.85","AETNA [1001]","HB AMC AETNA PPO","714.87","80.4","","1261.44","103.12","1514.10","21","464.66","726.61","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.14","666.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","714.87","80.4","","1365.00","1365.00","1365.00","1 through 10","464.66","726.61","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.14","666.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","726.61","81.72","","5157.68","5157.68","5157.68","1 through 10","464.66","726.61","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM WEDGE II TITANIUM 2 STRAND FORCE FIBER BX/5EA","SUP-ITM-10033416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.14","666.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","726.61","81.72","","431.26","71.26","1459.57","88","464.66","726.61","percent of total billed charges",""
"ANCHOR SUTURE 8.5X3.5MM DX SWIVELOCK SL FORKED EYELET BX/5EA","SUP-ITM-10156089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1182.56","79.5","","800.18","480.96","1887.97","195","461.13","1182.56","percent of total billed charges",""
"ANCHOR SUTURE 8.5X3.5MM DX SWIVELOCK SL FORKED EYELET BX/5EA","SUP-ITM-10156089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","792.84","53.3","","813.12","216.42","1444.50","81","461.13","1182.56","percent of total billed charges",""
"ANCHOR SUTURE 8.5X3.5MM DX SWIVELOCK SL FORKED EYELET BX/5EA","SUP-ITM-10156089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","461.13","31","","432.60","432.60","432.60","1 through 10","461.13","1182.56","percent of total billed charges",""
"ANCHOR SUTURE 8.5X3.5MM DX SWIVELOCK SL FORKED EYELET BX/5EA","SUP-ITM-10156089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","542.94","36.5","","148.37","54.89","631.39","94","461.13","1182.56","percent of total billed charges",""
"ANCHOR SUTURE 8.5X3.5MM DX SWIVELOCK SL FORKED EYELET BX/5EA","SUP-ITM-10156089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","569.71","38.3","","279.30","91.72","1116.77","266","461.13","1182.56","percent of total billed charges",""
"ANCHOR SUTURE 8.5X3.5MM DX SWIVELOCK SL FORKED EYELET BX/5EA","SUP-ITM-10156089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","638.14","42.9","","731.00","63.70","731.00","1 through 10","461.13","1182.56","percent of total billed charges",""
"ANCHOR SUTURE 8.5X3.5MM DX SWIVELOCK SL FORKED EYELET BX/5EA","SUP-ITM-10156089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","638.14","42.9","","384.74","384.74","384.74","1 through 10","461.13","1182.56","percent of total billed charges",""
"ANCHOR SUTURE 8.5X3.5MM DX SWIVELOCK SL FORKED EYELET BX/5EA","SUP-ITM-10156089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","WELLPOINT [1015]","HB AMC WELLPOINT","1097.48","73.78","","286.63","119.22","1107.45","105","461.13","1182.56","percent of total billed charges",""
"ANCHOR SUTURE 8.5X3.5MM DX SWIVELOCK SL FORKED EYELET BX/5EA","SUP-ITM-10156089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","AETNA [1001]","HB AMC AETNA HMO","1038.28","69.8","","675.31","184.75","1721.50","286","777.37","1215.59","percent of total billed charges",""
"ANCHOR SUTURE 8.5X3.5MM DX SWIVELOCK SL FORKED EYELET BX/5EA","SUP-ITM-10156089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","AETNA [1001]","HB AMC AETNA PPO","1195.95","80.4","","1261.44","103.12","1514.10","21","777.37","1215.59","percent of total billed charges",""
"ANCHOR SUTURE 8.5X3.5MM DX SWIVELOCK SL FORKED EYELET BX/5EA","SUP-ITM-10156089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1195.95","80.4","","1365.00","1365.00","1365.00","1 through 10","777.37","1215.59","percent of total billed charges",""
"ANCHOR SUTURE 8.5X3.5MM DX SWIVELOCK SL FORKED EYELET BX/5EA","SUP-ITM-10156089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1215.59","81.72","","5157.68","5157.68","5157.68","1 through 10","777.37","1215.59","percent of total billed charges",""
"ANCHOR SUTURE 8.5X3.5MM DX SWIVELOCK SL FORKED EYELET BX/5EA","SUP-ITM-10156089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1215.59","81.72","","431.26","71.26","1459.57","88","777.37","1215.59","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","865.36","79.5","","800.18","480.96","1887.97","195","337.44","865.36","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","580.17","53.3","","813.12","216.42","1444.50","81","337.44","865.36","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","337.44","31","","432.60","432.60","432.60","1 through 10","337.44","865.36","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","397.30","36.5","","148.37","54.89","631.39","94","337.44","865.36","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","416.90","38.3","","279.30","91.72","1116.77","266","337.44","865.36","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.97","42.9","","731.00","63.70","731.00","1 through 10","337.44","865.36","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.97","42.9","","384.74","384.74","384.74","1 through 10","337.44","865.36","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","WELLPOINT [1015]","HB AMC WELLPOINT","803.10","73.78","","286.63","119.22","1107.45","105","337.44","865.36","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1088.50","816.37","AETNA [1001]","HB AMC AETNA HMO","759.77","69.8","","675.31","184.75","1721.50","286","568.85","889.52","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1088.50","816.37","AETNA [1001]","HB AMC AETNA PPO","875.15","80.4","","1261.44","103.12","1514.10","21","568.85","889.52","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1088.50","816.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","875.15","80.4","","1365.00","1365.00","1365.00","1 through 10","568.85","889.52","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1088.50","816.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","889.52","81.72","","5157.68","5157.68","5157.68","1 through 10","568.85","889.52","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1088.50","816.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","889.52","81.72","","431.26","71.26","1459.57","88","568.85","889.52","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.50","1220.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1293.86","79.5","","800.18","480.96","1887.97","195","504.53","1293.86","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.50","1220.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","867.46","53.3","","813.12","216.42","1444.50","81","504.53","1293.86","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.50","1220.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","504.53","31","","432.60","432.60","432.60","1 through 10","504.53","1293.86","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.50","1220.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","594.04","36.5","","148.37","54.89","631.39","94","504.53","1293.86","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.50","1220.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","623.33","38.3","","279.30","91.72","1116.77","266","504.53","1293.86","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.50","1220.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","698.20","42.9","","731.00","63.70","731.00","1 through 10","504.53","1293.86","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.50","1220.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","698.20","42.9","","384.74","384.74","384.74","1 through 10","504.53","1293.86","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.50","1220.62","WELLPOINT [1015]","HB AMC WELLPOINT","1200.77","73.78","","286.63","119.22","1107.45","105","504.53","1293.86","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1627.50","1220.62","AETNA [1001]","HB AMC AETNA HMO","1136.00","69.8","","675.31","184.75","1721.50","286","850.53","1329.99","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1627.50","1220.62","AETNA [1001]","HB AMC AETNA PPO","1308.51","80.4","","1261.44","103.12","1514.10","21","850.53","1329.99","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1627.50","1220.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1308.51","80.4","","1365.00","1365.00","1365.00","1 through 10","850.53","1329.99","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1627.50","1220.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1329.99","81.72","","5157.68","5157.68","5157.68","1 through 10","850.53","1329.99","percent of total billed charges",""
"ANCHOR SUTURE DX FIBERTAK ST AND NEEDLES BX/5EA","SUP-ITM-10320816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1627.50","1220.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1329.99","81.72","","431.26","71.26","1459.57","88","850.53","1329.99","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","800.18","480.96","1887.97","195","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","813.12","216.42","1444.50","81","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","260.40","31","","432.60","432.60","432.60","1 through 10","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","148.37","54.89","631.39","94","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","279.30","91.72","1116.77","266","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","731.00","63.70","731.00","1 through 10","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","384.74","384.74","384.74","1 through 10","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","286.63","119.22","1107.45","105","260.4","667.8","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","675.31","184.75","1721.50","286","438.98","686.45","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA PPO","675.36","80.4","","1261.44","103.12","1514.10","21","438.98","686.45","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1365.00","1365.00","1365.00","1 through 10","438.98","686.45","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","686.45","81.72","","5157.68","5157.68","5157.68","1 through 10","438.98","686.45","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","431.26","71.26","1459.57","88","438.98","686.45","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","904.31","79.5","","800.18","480.96","1887.97","195","352.63","904.31","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","606.29","53.3","","813.12","216.42","1444.50","81","352.63","904.31","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","352.63","31","","432.60","432.60","432.60","1 through 10","352.63","904.31","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","415.19","36.5","","148.37","54.89","631.39","94","352.63","904.31","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","435.66","38.3","","279.30","91.72","1116.77","266","352.63","904.31","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","487.99","42.9","","731.00","63.70","731.00","1 through 10","352.63","904.31","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","487.99","42.9","","384.74","384.74","384.74","1 through 10","352.63","904.31","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","WELLPOINT [1015]","HB AMC WELLPOINT","839.25","73.78","","286.63","119.22","1107.45","105","352.63","904.31","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.50","853.12","AETNA [1001]","HB AMC AETNA HMO","793.98","69.8","","675.31","184.75","1721.50","286","594.46","929.57","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.50","853.12","AETNA [1001]","HB AMC AETNA PPO","914.55","80.4","","1261.44","103.12","1514.10","21","594.46","929.57","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.50","853.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","914.55","80.4","","1365.00","1365.00","1365.00","1 through 10","594.46","929.57","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.50","853.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","929.57","81.72","","5157.68","5157.68","5157.68","1 through 10","594.46","929.57","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.50","853.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","929.57","81.72","","431.26","71.26","1459.57","88","594.46","929.57","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","954.40","79.5","","800.18","480.96","1887.97","195","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","639.87","53.3","","813.12","216.42","1444.50","81","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","372.16","31","","432.60","432.60","432.60","1 through 10","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","438.18","36.5","","148.37","54.89","631.39","94","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","459.79","38.3","","279.30","91.72","1116.77","266","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","515.01","42.9","","731.00","63.70","731.00","1 through 10","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","515.01","42.9","","384.74","384.74","384.74","1 through 10","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","WELLPOINT [1015]","HB AMC WELLPOINT","885.73","73.78","","286.63","119.22","1107.45","105","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.50","900.37","AETNA [1001]","HB AMC AETNA HMO","837.95","69.8","","675.31","184.75","1721.50","286","627.38","981.05","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.50","900.37","AETNA [1001]","HB AMC AETNA PPO","965.20","80.4","","1261.44","103.12","1514.10","21","627.38","981.05","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.50","900.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","965.20","80.4","","1365.00","1365.00","1365.00","1 through 10","627.38","981.05","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.50","900.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","981.05","81.72","","5157.68","5157.68","5157.68","1 through 10","627.38","981.05","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLEOS 2 MINILOK QUICK PLUS PANACRYL BIO ABSORBABLE BIT","SUP-ITM-10025720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.50","900.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","981.05","81.72","","431.26","71.26","1459.57","88","627.38","981.05","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","1113.00","834.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","884.84","79.5","","800.18","480.96","1887.97","195","345.03","884.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","1113.00","834.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","593.23","53.3","","813.12","216.42","1444.50","81","345.03","884.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","1113.00","834.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","345.03","31","","432.60","432.60","432.60","1 through 10","345.03","884.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","1113.00","834.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","406.25","36.5","","148.37","54.89","631.39","94","345.03","884.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","1113.00","834.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","426.28","38.3","","279.30","91.72","1116.77","266","345.03","884.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","1113.00","834.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","477.48","42.9","","731.00","63.70","731.00","1 through 10","345.03","884.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","1113.00","834.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","477.48","42.9","","384.74","384.74","384.74","1 through 10","345.03","884.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","1113.00","834.75","WELLPOINT [1015]","HB AMC WELLPOINT","821.17","73.78","","286.63","119.22","1107.45","105","345.03","884.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1113.00","834.75","AETNA [1001]","HB AMC AETNA HMO","776.87","69.8","","675.31","184.75","1721.50","286","581.65","909.54","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1113.00","834.75","AETNA [1001]","HB AMC AETNA PPO","894.85","80.4","","1261.44","103.12","1514.10","21","581.65","909.54","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1113.00","834.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","894.85","80.4","","1365.00","1365.00","1365.00","1 through 10","581.65","909.54","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1113.00","834.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","909.54","81.72","","5157.68","5157.68","5157.68","1 through 10","581.65","909.54","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1113.00","834.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","909.54","81.72","","431.26","71.26","1459.57","88","581.65","909.54","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","729.02","79.5","","800.18","480.96","1887.97","195","284.27","729.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","488.76","53.3","","813.12","216.42","1444.50","81","284.27","729.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","284.27","31","","432.60","432.60","432.60","1 through 10","284.27","729.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","334.71","36.5","","148.37","54.89","631.39","94","284.27","729.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","351.21","38.3","","279.30","91.72","1116.77","266","284.27","729.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.39","42.9","","731.00","63.70","731.00","1 through 10","284.27","729.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.39","42.9","","384.74","384.74","384.74","1 through 10","284.27","729.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","WELLPOINT [1015]","HB AMC WELLPOINT","676.56","73.78","","286.63","119.22","1107.45","105","284.27","729.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","917.00","687.75","AETNA [1001]","HB AMC AETNA HMO","640.07","69.8","","675.31","184.75","1721.50","286","479.22","749.37","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","917.00","687.75","AETNA [1001]","HB AMC AETNA PPO","737.27","80.4","","1261.44","103.12","1514.10","21","479.22","749.37","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","917.00","687.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","737.27","80.4","","1365.00","1365.00","1365.00","1 through 10","479.22","749.37","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","917.00","687.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","749.37","81.72","","5157.68","5157.68","5157.68","1 through 10","479.22","749.37","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","917.00","687.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","749.37","81.72","","431.26","71.26","1459.57","88","479.22","749.37","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","520.33","79.5","","800.18","480.96","1887.97","195","202.9","520.33","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","348.85","53.3","","813.12","216.42","1444.50","81","202.9","520.33","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","202.90","31","","432.60","432.60","432.60","1 through 10","202.9","520.33","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","238.89","36.5","","148.37","54.89","631.39","94","202.9","520.33","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","250.67","38.3","","279.30","91.72","1116.77","266","202.9","520.33","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.78","42.9","","731.00","63.70","731.00","1 through 10","202.9","520.33","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.78","42.9","","384.74","384.74","384.74","1 through 10","202.9","520.33","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","WELLPOINT [1015]","HB AMC WELLPOINT","482.89","73.78","","286.63","119.22","1107.45","105","202.9","520.33","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","AETNA [1001]","HB AMC AETNA HMO","456.84","69.8","","675.31","184.75","1721.50","286","342.04","534.86","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","AETNA [1001]","HB AMC AETNA PPO","526.22","80.4","","1261.44","103.12","1514.10","21","342.04","534.86","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","526.22","80.4","","1365.00","1365.00","1365.00","1 through 10","342.04","534.86","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","534.86","81.72","","5157.68","5157.68","5157.68","1 through 10","342.04","534.86","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","534.86","81.72","","431.26","71.26","1459.57","88","342.04","534.86","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.00","519.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","550.94","79.5","","800.18","480.96","1887.97","195","214.83","550.94","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.00","519.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","369.37","53.3","","813.12","216.42","1444.50","81","214.83","550.94","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.00","519.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","214.83","31","","432.60","432.60","432.60","1 through 10","214.83","550.94","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.00","519.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","252.95","36.5","","148.37","54.89","631.39","94","214.83","550.94","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.00","519.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","265.42","38.3","","279.30","91.72","1116.77","266","214.83","550.94","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.00","519.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","297.30","42.9","","731.00","63.70","731.00","1 through 10","214.83","550.94","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.00","519.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","297.30","42.9","","384.74","384.74","384.74","1 through 10","214.83","550.94","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.00","519.75","WELLPOINT [1015]","HB AMC WELLPOINT","511.30","73.78","","286.63","119.22","1107.45","105","214.83","550.94","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","693.00","519.75","AETNA [1001]","HB AMC AETNA HMO","483.71","69.8","","675.31","184.75","1721.50","286","362.16","566.32","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","693.00","519.75","AETNA [1001]","HB AMC AETNA PPO","557.17","80.4","","1261.44","103.12","1514.10","21","362.16","566.32","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","693.00","519.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","557.17","80.4","","1365.00","1365.00","1365.00","1 through 10","362.16","566.32","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","693.00","519.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","566.32","81.72","","5157.68","5157.68","5157.68","1 through 10","362.16","566.32","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","693.00","519.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","566.32","81.72","","431.26","71.26","1459.57","88","362.16","566.32","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","578.76","79.5","","800.18","480.96","1887.97","195","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","388.02","53.3","","813.12","216.42","1444.50","81","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","225.68","31","","432.60","432.60","432.60","1 through 10","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","265.72","36.5","","148.37","54.89","631.39","94","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","278.82","38.3","","279.30","91.72","1116.77","266","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.31","42.9","","731.00","63.70","731.00","1 through 10","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.31","42.9","","384.74","384.74","384.74","1 through 10","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","WELLPOINT [1015]","HB AMC WELLPOINT","537.12","73.78","","286.63","119.22","1107.45","105","225.68","578.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","AETNA [1001]","HB AMC AETNA HMO","508.14","69.8","","675.31","184.75","1721.50","286","380.45","594.92","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","AETNA [1001]","HB AMC AETNA PPO","585.31","80.4","","1261.44","103.12","1514.10","21","380.45","594.92","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","585.31","80.4","","1365.00","1365.00","1365.00","1 through 10","380.45","594.92","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","594.92","81.72","","5157.68","5157.68","5157.68","1 through 10","380.45","594.92","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","594.92","81.72","","431.26","71.26","1459.57","88","380.45","594.92","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1183.00","887.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","940.49","79.5","","800.18","480.96","1887.97","195","366.73","940.49","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1183.00","887.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","630.54","53.3","","813.12","216.42","1444.50","81","366.73","940.49","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1183.00","887.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","366.73","31","","432.60","432.60","432.60","1 through 10","366.73","940.49","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1183.00","887.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","431.80","36.5","","148.37","54.89","631.39","94","366.73","940.49","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1183.00","887.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","453.09","38.3","","279.30","91.72","1116.77","266","366.73","940.49","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1183.00","887.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","507.51","42.9","","731.00","63.70","731.00","1 through 10","366.73","940.49","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1183.00","887.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","507.51","42.9","","384.74","384.74","384.74","1 through 10","366.73","940.49","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1183.00","887.25","WELLPOINT [1015]","HB AMC WELLPOINT","872.82","73.78","","286.63","119.22","1107.45","105","366.73","940.49","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1183.00","887.25","AETNA [1001]","HB AMC AETNA HMO","825.73","69.8","","675.31","184.75","1721.50","286","618.24","966.75","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1183.00","887.25","AETNA [1001]","HB AMC AETNA PPO","951.13","80.4","","1261.44","103.12","1514.10","21","618.24","966.75","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1183.00","887.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","951.13","80.4","","1365.00","1365.00","1365.00","1 through 10","618.24","966.75","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1183.00","887.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","966.75","81.72","","5157.68","5157.68","5157.68","1 through 10","618.24","966.75","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1183.00","887.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","966.75","81.72","","431.26","71.26","1459.57","88","618.24","966.75","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1001.70","79.5","","800.18","480.96","1887.97","195","390.6","1001.7","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","671.58","53.3","","813.12","216.42","1444.50","81","390.6","1001.7","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","390.60","31","","432.60","432.60","432.60","1 through 10","390.6","1001.7","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","459.90","36.5","","148.37","54.89","631.39","94","390.6","1001.7","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","482.58","38.3","","279.30","91.72","1116.77","266","390.6","1001.7","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.54","42.9","","731.00","63.70","731.00","1 through 10","390.6","1001.7","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.54","42.9","","384.74","384.74","384.74","1 through 10","390.6","1001.7","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","WELLPOINT [1015]","HB AMC WELLPOINT","929.63","73.78","","286.63","119.22","1107.45","105","390.6","1001.7","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","AETNA [1001]","HB AMC AETNA HMO","879.48","69.8","","675.31","184.75","1721.50","286","658.48","1029.67","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","AETNA [1001]","HB AMC AETNA PPO","1013.04","80.4","","1261.44","103.12","1514.10","21","658.48","1029.67","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1013.04","80.4","","1365.00","1365.00","1365.00","1 through 10","658.48","1029.67","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1029.67","81.72","","5157.68","5157.68","5157.68","1 through 10","658.48","1029.67","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1029.67","81.72","","431.26","71.26","1459.57","88","658.48","1029.67","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 PRELOADED SMOOTH ENLARGED LOW PROFILE ULTRAFIX RC STITCHPAK BX/1EA","SUP-ITM-10086402","CDM","C1713","HCPCS","0278","RC","","","","both","","","2899.40","2174.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2305.02","79.5","","800.18","480.96","1887.97","195","898.81","2305.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 PRELOADED SMOOTH ENLARGED LOW PROFILE ULTRAFIX RC STITCHPAK BX/1EA","SUP-ITM-10086402","CDM","C1713","HCPCS","0278","RC","","","","both","","","2899.40","2174.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1545.38","53.3","","813.12","216.42","1444.50","81","898.81","2305.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 PRELOADED SMOOTH ENLARGED LOW PROFILE ULTRAFIX RC STITCHPAK BX/1EA","SUP-ITM-10086402","CDM","C1713","HCPCS","0278","RC","","","","both","","","2899.40","2174.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","898.81","31","","432.60","432.60","432.60","1 through 10","898.81","2305.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 PRELOADED SMOOTH ENLARGED LOW PROFILE ULTRAFIX RC STITCHPAK BX/1EA","SUP-ITM-10086402","CDM","C1713","HCPCS","0278","RC","","","","both","","","2899.40","2174.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1058.28","36.5","","148.37","54.89","631.39","94","898.81","2305.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 PRELOADED SMOOTH ENLARGED LOW PROFILE ULTRAFIX RC STITCHPAK BX/1EA","SUP-ITM-10086402","CDM","C1713","HCPCS","0278","RC","","","","both","","","2899.40","2174.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1110.47","38.3","","279.30","91.72","1116.77","266","898.81","2305.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 PRELOADED SMOOTH ENLARGED LOW PROFILE ULTRAFIX RC STITCHPAK BX/1EA","SUP-ITM-10086402","CDM","C1713","HCPCS","0278","RC","","","","both","","","2899.40","2174.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1243.84","42.9","","731.00","63.70","731.00","1 through 10","898.81","2305.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 PRELOADED SMOOTH ENLARGED LOW PROFILE ULTRAFIX RC STITCHPAK BX/1EA","SUP-ITM-10086402","CDM","C1713","HCPCS","0278","RC","","","","both","","","2899.40","2174.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1243.84","42.9","","384.74","384.74","384.74","1 through 10","898.81","2305.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 PRELOADED SMOOTH ENLARGED LOW PROFILE ULTRAFIX RC STITCHPAK BX/1EA","SUP-ITM-10086402","CDM","C1713","HCPCS","0278","RC","","","","both","","","2899.40","2174.55","WELLPOINT [1015]","HB AMC WELLPOINT","2139.18","73.78","","286.63","119.22","1107.45","105","898.81","2305.02","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 PRELOADED SMOOTH ENLARGED LOW PROFILE ULTRAFIX RC STITCHPAK BX/1EA","SUP-ITM-10086402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2899.40","2174.55","AETNA [1001]","HB AMC AETNA HMO","2023.78","69.8","","675.31","184.75","1721.50","286","1515.23","2369.39","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 PRELOADED SMOOTH ENLARGED LOW PROFILE ULTRAFIX RC STITCHPAK BX/1EA","SUP-ITM-10086402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2899.40","2174.55","AETNA [1001]","HB AMC AETNA PPO","2331.12","80.4","","1261.44","103.12","1514.10","21","1515.23","2369.39","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 PRELOADED SMOOTH ENLARGED LOW PROFILE ULTRAFIX RC STITCHPAK BX/1EA","SUP-ITM-10086402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2899.40","2174.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2331.12","80.4","","1365.00","1365.00","1365.00","1 through 10","1515.23","2369.39","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 PRELOADED SMOOTH ENLARGED LOW PROFILE ULTRAFIX RC STITCHPAK BX/1EA","SUP-ITM-10086402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2899.40","2174.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2369.39","81.72","","5157.68","5157.68","5157.68","1 through 10","1515.23","2369.39","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 PRELOADED SMOOTH ENLARGED LOW PROFILE ULTRAFIX RC STITCHPAK BX/1EA","SUP-ITM-10086402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2899.40","2174.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2369.39","81.72","","431.26","71.26","1459.57","88","1515.23","2369.39","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 STITCHPAK ONLY MM","SUP-ITM-10018228","CDM","C1713","HCPCS","0278","RC","","","","both","","","621.53","466.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","494.12","79.5","","800.18","480.96","1887.97","195","192.67","494.12","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 STITCHPAK ONLY MM","SUP-ITM-10018228","CDM","C1713","HCPCS","0278","RC","","","","both","","","621.53","466.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","331.28","53.3","","813.12","216.42","1444.50","81","192.67","494.12","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 STITCHPAK ONLY MM","SUP-ITM-10018228","CDM","C1713","HCPCS","0278","RC","","","","both","","","621.53","466.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","192.67","31","","432.60","432.60","432.60","1 through 10","192.67","494.12","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 STITCHPAK ONLY MM","SUP-ITM-10018228","CDM","C1713","HCPCS","0278","RC","","","","both","","","621.53","466.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","226.86","36.5","","148.37","54.89","631.39","94","192.67","494.12","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 STITCHPAK ONLY MM","SUP-ITM-10018228","CDM","C1713","HCPCS","0278","RC","","","","both","","","621.53","466.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","238.05","38.3","","279.30","91.72","1116.77","266","192.67","494.12","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 STITCHPAK ONLY MM","SUP-ITM-10018228","CDM","C1713","HCPCS","0278","RC","","","","both","","","621.53","466.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.64","42.9","","731.00","63.70","731.00","1 through 10","192.67","494.12","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 STITCHPAK ONLY MM","SUP-ITM-10018228","CDM","C1713","HCPCS","0278","RC","","","","both","","","621.53","466.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.64","42.9","","384.74","384.74","384.74","1 through 10","192.67","494.12","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 STITCHPAK ONLY MM","SUP-ITM-10018228","CDM","C1713","HCPCS","0278","RC","","","","both","","","621.53","466.15","WELLPOINT [1015]","HB AMC WELLPOINT","458.56","73.78","","286.63","119.22","1107.45","105","192.67","494.12","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 STITCHPAK ONLY MM","SUP-ITM-10018228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","621.53","466.15","AETNA [1001]","HB AMC AETNA HMO","433.83","69.8","","675.31","184.75","1721.50","286","324.81","507.91","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 STITCHPAK ONLY MM","SUP-ITM-10018228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","621.53","466.15","AETNA [1001]","HB AMC AETNA PPO","499.71","80.4","","1261.44","103.12","1514.10","21","324.81","507.91","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 STITCHPAK ONLY MM","SUP-ITM-10018228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","621.53","466.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","499.71","80.4","","1365.00","1365.00","1365.00","1 through 10","324.81","507.91","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 STITCHPAK ONLY MM","SUP-ITM-10018228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","621.53","466.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","507.91","81.72","","5157.68","5157.68","5157.68","1 through 10","324.81","507.91","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 STITCHPAK ONLY MM","SUP-ITM-10018228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","621.53","466.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","507.91","81.72","","431.26","71.26","1459.57","88","324.81","507.91","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10139","SUP-ITM-10086403","CDM","C1713","HCPCS","0278","RC","","","","both","","","554.75","416.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","441.03","79.5","","800.18","480.96","1887.97","195","171.97","441.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10139","SUP-ITM-10086403","CDM","C1713","HCPCS","0278","RC","","","","both","","","554.75","416.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","295.68","53.3","","813.12","216.42","1444.50","81","171.97","441.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10139","SUP-ITM-10086403","CDM","C1713","HCPCS","0278","RC","","","","both","","","554.75","416.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","171.97","31","","432.60","432.60","432.60","1 through 10","171.97","441.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10139","SUP-ITM-10086403","CDM","C1713","HCPCS","0278","RC","","","","both","","","554.75","416.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","202.48","36.5","","148.37","54.89","631.39","94","171.97","441.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10139","SUP-ITM-10086403","CDM","C1713","HCPCS","0278","RC","","","","both","","","554.75","416.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","212.47","38.3","","279.30","91.72","1116.77","266","171.97","441.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10139","SUP-ITM-10086403","CDM","C1713","HCPCS","0278","RC","","","","both","","","554.75","416.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","237.99","42.9","","731.00","63.70","731.00","1 through 10","171.97","441.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10139","SUP-ITM-10086403","CDM","C1713","HCPCS","0278","RC","","","","both","","","554.75","416.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","237.99","42.9","","384.74","384.74","384.74","1 through 10","171.97","441.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10139","SUP-ITM-10086403","CDM","C1713","HCPCS","0278","RC","","","","both","","","554.75","416.06","WELLPOINT [1015]","HB AMC WELLPOINT","409.29","73.78","","286.63","119.22","1107.45","105","171.97","441.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10139","SUP-ITM-10086403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","554.75","416.06","AETNA [1001]","HB AMC AETNA HMO","387.22","69.8","","675.31","184.75","1721.50","286","289.91","453.34","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10139","SUP-ITM-10086403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","554.75","416.06","AETNA [1001]","HB AMC AETNA PPO","446.02","80.4","","1261.44","103.12","1514.10","21","289.91","453.34","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10139","SUP-ITM-10086403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","554.75","416.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","446.02","80.4","","1365.00","1365.00","1365.00","1 through 10","289.91","453.34","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10139","SUP-ITM-10086403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","554.75","416.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","453.34","81.72","","5157.68","5157.68","5157.68","1 through 10","289.91","453.34","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10139","SUP-ITM-10086403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","554.75","416.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","453.34","81.72","","431.26","71.26","1459.57","88","289.91","453.34","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10160A","SUP-ITM-10020714","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.64","401.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","425.83","79.5","","800.18","480.96","1887.97","195","166.05","425.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10160A","SUP-ITM-10020714","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.64","401.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","285.50","53.3","","813.12","216.42","1444.50","81","166.05","425.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10160A","SUP-ITM-10020714","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.64","401.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","166.05","31","","432.60","432.60","432.60","1 through 10","166.05","425.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10160A","SUP-ITM-10020714","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.64","401.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","195.51","36.5","","148.37","54.89","631.39","94","166.05","425.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10160A","SUP-ITM-10020714","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.64","401.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","205.15","38.3","","279.30","91.72","1116.77","266","166.05","425.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10160A","SUP-ITM-10020714","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.64","401.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","229.79","42.9","","731.00","63.70","731.00","1 through 10","166.05","425.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10160A","SUP-ITM-10020714","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.64","401.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","229.79","42.9","","384.74","384.74","384.74","1 through 10","166.05","425.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10160A","SUP-ITM-10020714","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.64","401.73","WELLPOINT [1015]","HB AMC WELLPOINT","395.20","73.78","","286.63","119.22","1107.45","105","166.05","425.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10160A","SUP-ITM-10020714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.64","401.73","AETNA [1001]","HB AMC AETNA HMO","373.88","69.8","","675.31","184.75","1721.50","286","279.93","437.73","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10160A","SUP-ITM-10020714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.64","401.73","AETNA [1001]","HB AMC AETNA PPO","430.65","80.4","","1261.44","103.12","1514.10","21","279.93","437.73","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10160A","SUP-ITM-10020714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.64","401.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","430.65","80.4","","1365.00","1365.00","1365.00","1 through 10","279.93","437.73","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10160A","SUP-ITM-10020714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.64","401.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","437.73","81.72","","5157.68","5157.68","5157.68","1 through 10","279.93","437.73","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.9 ULTRAFIX RC ONLY MM 10160A","SUP-ITM-10020714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.64","401.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","437.73","81.72","","431.26","71.26","1459.57","88","279.93","437.73","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 LENGTH0.1MM SHOULDER BIO MINI REVO NUMBER PRELOADED DRIVER 2 HI FI","SUP-ITM-10024460","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.95","739.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","783.83","79.5","","800.18","480.96","1887.97","195","305.64","783.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 LENGTH0.1MM SHOULDER BIO MINI REVO NUMBER PRELOADED DRIVER 2 HI FI","SUP-ITM-10024460","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.95","739.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","525.51","53.3","","813.12","216.42","1444.50","81","305.64","783.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 LENGTH0.1MM SHOULDER BIO MINI REVO NUMBER PRELOADED DRIVER 2 HI FI","SUP-ITM-10024460","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.95","739.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","305.64","31","","432.60","432.60","432.60","1 through 10","305.64","783.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 LENGTH0.1MM SHOULDER BIO MINI REVO NUMBER PRELOADED DRIVER 2 HI FI","SUP-ITM-10024460","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.95","739.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","359.87","36.5","","148.37","54.89","631.39","94","305.64","783.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 LENGTH0.1MM SHOULDER BIO MINI REVO NUMBER PRELOADED DRIVER 2 HI FI","SUP-ITM-10024460","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.95","739.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","377.62","38.3","","279.30","91.72","1116.77","266","305.64","783.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 LENGTH0.1MM SHOULDER BIO MINI REVO NUMBER PRELOADED DRIVER 2 HI FI","SUP-ITM-10024460","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.95","739.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","422.97","42.9","","731.00","63.70","731.00","1 through 10","305.64","783.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 LENGTH0.1MM SHOULDER BIO MINI REVO NUMBER PRELOADED DRIVER 2 HI FI","SUP-ITM-10024460","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.95","739.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","422.97","42.9","","384.74","384.74","384.74","1 through 10","305.64","783.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 LENGTH0.1MM SHOULDER BIO MINI REVO NUMBER PRELOADED DRIVER 2 HI FI","SUP-ITM-10024460","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.95","739.46","WELLPOINT [1015]","HB AMC WELLPOINT","727.43","73.78","","286.63","119.22","1107.45","105","305.64","783.83","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 LENGTH0.1MM SHOULDER BIO MINI REVO NUMBER PRELOADED DRIVER 2 HI FI","SUP-ITM-10024460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","985.95","739.46","AETNA [1001]","HB AMC AETNA HMO","688.19","69.8","","675.31","184.75","1721.50","286","515.26","805.72","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 LENGTH0.1MM SHOULDER BIO MINI REVO NUMBER PRELOADED DRIVER 2 HI FI","SUP-ITM-10024460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","985.95","739.46","AETNA [1001]","HB AMC AETNA PPO","792.70","80.4","","1261.44","103.12","1514.10","21","515.26","805.72","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 LENGTH0.1MM SHOULDER BIO MINI REVO NUMBER PRELOADED DRIVER 2 HI FI","SUP-ITM-10024460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","985.95","739.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","792.70","80.4","","1365.00","1365.00","1365.00","1 through 10","515.26","805.72","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 LENGTH0.1MM SHOULDER BIO MINI REVO NUMBER PRELOADED DRIVER 2 HI FI","SUP-ITM-10024460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","985.95","739.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","805.72","81.72","","5157.68","5157.68","5157.68","1 through 10","515.26","805.72","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 LENGTH0.1MM SHOULDER BIO MINI REVO NUMBER PRELOADED DRIVER 2 HI FI","SUP-ITM-10024460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","985.95","739.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","805.72","81.72","","431.26","71.26","1459.57","88","515.26","805.72","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","820.84","79.5","","800.18","480.96","1887.97","195","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","550.32","53.3","","813.12","216.42","1444.50","81","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","320.08","31","","432.60","432.60","432.60","1 through 10","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","376.86","36.5","","148.37","54.89","631.39","94","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","395.45","38.3","","279.30","91.72","1116.77","266","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.94","42.9","","731.00","63.70","731.00","1 through 10","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.94","42.9","","384.74","384.74","384.74","1 through 10","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","WELLPOINT [1015]","HB AMC WELLPOINT","761.78","73.78","","286.63","119.22","1107.45","105","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","AETNA [1001]","HB AMC AETNA HMO","720.69","69.8","","675.31","184.75","1721.50","286","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","AETNA [1001]","HB AMC AETNA PPO","830.13","80.4","","1261.44","103.12","1514.10","21","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","830.13","80.4","","1365.00","1365.00","1365.00","1 through 10","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","843.76","81.72","","5157.68","5157.68","5157.68","1 through 10","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY ETHIBOND QUICK MICRO","SUP-ITM-10012205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","843.76","81.72","","431.26","71.26","1459.57","88","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY QUICK MICRO SM BONE ORTHOCORD DRILL BIT","SUP-ITM-10030991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","820.84","79.5","","800.18","480.96","1887.97","195","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY QUICK MICRO SM BONE ORTHOCORD DRILL BIT","SUP-ITM-10030991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","550.32","53.3","","813.12","216.42","1444.50","81","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY QUICK MICRO SM BONE ORTHOCORD DRILL BIT","SUP-ITM-10030991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","320.08","31","","432.60","432.60","432.60","1 through 10","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY QUICK MICRO SM BONE ORTHOCORD DRILL BIT","SUP-ITM-10030991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","376.86","36.5","","148.37","54.89","631.39","94","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY QUICK MICRO SM BONE ORTHOCORD DRILL BIT","SUP-ITM-10030991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","395.45","38.3","","279.30","91.72","1116.77","266","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY QUICK MICRO SM BONE ORTHOCORD DRILL BIT","SUP-ITM-10030991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.94","42.9","","731.00","63.70","731.00","1 through 10","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY QUICK MICRO SM BONE ORTHOCORD DRILL BIT","SUP-ITM-10030991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.94","42.9","","384.74","384.74","384.74","1 through 10","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY QUICK MICRO SM BONE ORTHOCORD DRILL BIT","SUP-ITM-10030991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","WELLPOINT [1015]","HB AMC WELLPOINT","761.78","73.78","","286.63","119.22","1107.45","105","320.08","820.84","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY QUICK MICRO SM BONE ORTHOCORD DRILL BIT","SUP-ITM-10030991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","AETNA [1001]","HB AMC AETNA HMO","720.69","69.8","","675.31","184.75","1721.50","286","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY QUICK MICRO SM BONE ORTHOCORD DRILL BIT","SUP-ITM-10030991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","AETNA [1001]","HB AMC AETNA PPO","830.13","80.4","","1261.44","103.12","1514.10","21","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY QUICK MICRO SM BONE ORTHOCORD DRILL BIT","SUP-ITM-10030991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","830.13","80.4","","1365.00","1365.00","1365.00","1 through 10","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY QUICK MICRO SM BONE ORTHOCORD DRILL BIT","SUP-ITM-10030991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","843.76","81.72","","5157.68","5157.68","5157.68","1 through 10","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ARTHROSCOPY QUICK MICRO SM BONE ORTHOCORD DRILL BIT","SUP-ITM-10030991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","843.76","81.72","","431.26","71.26","1459.57","88","539.58","843.76","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ETHIBOND MICROFIX QUICK ORTHOCORD DRILL BIT","SUP-ITM-10030994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","954.40","79.5","","800.18","480.96","1887.97","195","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ETHIBOND MICROFIX QUICK ORTHOCORD DRILL BIT","SUP-ITM-10030994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","639.87","53.3","","813.12","216.42","1444.50","81","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ETHIBOND MICROFIX QUICK ORTHOCORD DRILL BIT","SUP-ITM-10030994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","372.16","31","","432.60","432.60","432.60","1 through 10","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ETHIBOND MICROFIX QUICK ORTHOCORD DRILL BIT","SUP-ITM-10030994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","438.18","36.5","","148.37","54.89","631.39","94","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ETHIBOND MICROFIX QUICK ORTHOCORD DRILL BIT","SUP-ITM-10030994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","459.79","38.3","","279.30","91.72","1116.77","266","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ETHIBOND MICROFIX QUICK ORTHOCORD DRILL BIT","SUP-ITM-10030994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","515.01","42.9","","731.00","63.70","731.00","1 through 10","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ETHIBOND MICROFIX QUICK ORTHOCORD DRILL BIT","SUP-ITM-10030994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","515.01","42.9","","384.74","384.74","384.74","1 through 10","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ETHIBOND MICROFIX QUICK ORTHOCORD DRILL BIT","SUP-ITM-10030994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.50","900.37","WELLPOINT [1015]","HB AMC WELLPOINT","885.73","73.78","","286.63","119.22","1107.45","105","372.16","954.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ETHIBOND MICROFIX QUICK ORTHOCORD DRILL BIT","SUP-ITM-10030994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.50","900.37","AETNA [1001]","HB AMC AETNA HMO","837.95","69.8","","675.31","184.75","1721.50","286","627.38","981.05","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ETHIBOND MICROFIX QUICK ORTHOCORD DRILL BIT","SUP-ITM-10030994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.50","900.37","AETNA [1001]","HB AMC AETNA PPO","965.20","80.4","","1261.44","103.12","1514.10","21","627.38","981.05","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ETHIBOND MICROFIX QUICK ORTHOCORD DRILL BIT","SUP-ITM-10030994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.50","900.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","965.20","80.4","","1365.00","1365.00","1365.00","1 through 10","627.38","981.05","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ETHIBOND MICROFIX QUICK ORTHOCORD DRILL BIT","SUP-ITM-10030994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.50","900.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","981.05","81.72","","5157.68","5157.68","5157.68","1 through 10","627.38","981.05","percent of total billed charges",""
"ANCHOR SUTURE SIZE 3 0 NEEDLEV4 LENGTH1.3MM ETHIBOND MICROFIX QUICK ORTHOCORD DRILL BIT","SUP-ITM-10030994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.50","900.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","981.05","81.72","","431.26","71.26","1459.57","88","627.38","981.05","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 ARTHROSCOPY BIOKNOTLESS BR PLUS BIO ABSOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007173","CDM","C1713","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1163.09","79.5","","800.18","480.96","1887.97","195","453.53","1163.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 ARTHROSCOPY BIOKNOTLESS BR PLUS BIO ABSOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007173","CDM","C1713","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","779.78","53.3","","813.12","216.42","1444.50","81","453.53","1163.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 ARTHROSCOPY BIOKNOTLESS BR PLUS BIO ABSOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007173","CDM","C1713","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","453.53","31","","432.60","432.60","432.60","1 through 10","453.53","1163.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 ARTHROSCOPY BIOKNOTLESS BR PLUS BIO ABSOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007173","CDM","C1713","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","534.00","36.5","","148.37","54.89","631.39","94","453.53","1163.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 ARTHROSCOPY BIOKNOTLESS BR PLUS BIO ABSOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007173","CDM","C1713","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","560.33","38.3","","279.30","91.72","1116.77","266","453.53","1163.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 ARTHROSCOPY BIOKNOTLESS BR PLUS BIO ABSOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007173","CDM","C1713","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","627.63","42.9","","731.00","63.70","731.00","1 through 10","453.53","1163.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 ARTHROSCOPY BIOKNOTLESS BR PLUS BIO ABSOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007173","CDM","C1713","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","627.63","42.9","","384.74","384.74","384.74","1 through 10","453.53","1163.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 ARTHROSCOPY BIOKNOTLESS BR PLUS BIO ABSOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007173","CDM","C1713","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","WELLPOINT [1015]","HB AMC WELLPOINT","1079.40","73.78","","286.63","119.22","1107.45","105","453.53","1163.09","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 ARTHROSCOPY BIOKNOTLESS BR PLUS BIO ABSOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1463.00","1097.25","AETNA [1001]","HB AMC AETNA HMO","1021.17","69.8","","675.31","184.75","1721.50","286","764.56","1195.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 ARTHROSCOPY BIOKNOTLESS BR PLUS BIO ABSOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1463.00","1097.25","AETNA [1001]","HB AMC AETNA PPO","1176.25","80.4","","1261.44","103.12","1514.10","21","764.56","1195.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 ARTHROSCOPY BIOKNOTLESS BR PLUS BIO ABSOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1463.00","1097.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1176.25","80.4","","1365.00","1365.00","1365.00","1 through 10","764.56","1195.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 ARTHROSCOPY BIOKNOTLESS BR PLUS BIO ABSOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1463.00","1097.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1195.56","81.72","","5157.68","5157.68","5157.68","1 through 10","764.56","1195.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 1 ARTHROSCOPY BIOKNOTLESS BR PLUS BIO ABSOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1463.00","1097.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1195.56","81.72","","431.26","71.26","1459.57","88","764.56","1195.56","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 0 5.5MM TWINFIX ULTRA PEEK COBRAID BLUE COBRAID BLACK","SUP-ITM-10079989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1442.00","1081.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1146.39","79.5","","800.18","480.96","1887.97","195","447.02","1146.39","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 0 5.5MM TWINFIX ULTRA PEEK COBRAID BLUE COBRAID BLACK","SUP-ITM-10079989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1442.00","1081.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","768.59","53.3","","813.12","216.42","1444.50","81","447.02","1146.39","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 0 5.5MM TWINFIX ULTRA PEEK COBRAID BLUE COBRAID BLACK","SUP-ITM-10079989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1442.00","1081.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","447.02","31","","432.60","432.60","432.60","1 through 10","447.02","1146.39","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 0 5.5MM TWINFIX ULTRA PEEK COBRAID BLUE COBRAID BLACK","SUP-ITM-10079989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1442.00","1081.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","526.33","36.5","","148.37","54.89","631.39","94","447.02","1146.39","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 0 5.5MM TWINFIX ULTRA PEEK COBRAID BLUE COBRAID BLACK","SUP-ITM-10079989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1442.00","1081.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","552.29","38.3","","279.30","91.72","1116.77","266","447.02","1146.39","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 0 5.5MM TWINFIX ULTRA PEEK COBRAID BLUE COBRAID BLACK","SUP-ITM-10079989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1442.00","1081.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","618.62","42.9","","731.00","63.70","731.00","1 through 10","447.02","1146.39","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 0 5.5MM TWINFIX ULTRA PEEK COBRAID BLUE COBRAID BLACK","SUP-ITM-10079989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1442.00","1081.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","618.62","42.9","","384.74","384.74","384.74","1 through 10","447.02","1146.39","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 0 5.5MM TWINFIX ULTRA PEEK COBRAID BLUE COBRAID BLACK","SUP-ITM-10079989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1442.00","1081.50","WELLPOINT [1015]","HB AMC WELLPOINT","1063.91","73.78","","286.63","119.22","1107.45","105","447.02","1146.39","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 0 5.5MM TWINFIX ULTRA PEEK COBRAID BLUE COBRAID BLACK","SUP-ITM-10079989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1442.00","1081.50","AETNA [1001]","HB AMC AETNA HMO","1006.52","69.8","","675.31","184.75","1721.50","286","753.59","1178.4","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 0 5.5MM TWINFIX ULTRA PEEK COBRAID BLUE COBRAID BLACK","SUP-ITM-10079989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1442.00","1081.50","AETNA [1001]","HB AMC AETNA PPO","1159.37","80.4","","1261.44","103.12","1514.10","21","753.59","1178.4","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 0 5.5MM TWINFIX ULTRA PEEK COBRAID BLUE COBRAID BLACK","SUP-ITM-10079989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1442.00","1081.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1159.37","80.4","","1365.00","1365.00","1365.00","1 through 10","753.59","1178.4","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 0 5.5MM TWINFIX ULTRA PEEK COBRAID BLUE COBRAID BLACK","SUP-ITM-10079989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1442.00","1081.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1178.40","81.72","","5157.68","5157.68","5157.68","1 through 10","753.59","1178.4","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 0 5.5MM TWINFIX ULTRA PEEK COBRAID BLUE COBRAID BLACK","SUP-ITM-10079989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1442.00","1081.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1178.40","81.72","","431.26","71.26","1459.57","88","753.59","1178.4","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","806.93","79.5","","800.18","480.96","1887.97","195","314.65","806.93","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","541.00","53.3","","813.12","216.42","1444.50","81","314.65","806.93","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","314.65","31","","432.60","432.60","432.60","1 through 10","314.65","806.93","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","370.48","36.5","","148.37","54.89","631.39","94","314.65","806.93","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","388.75","38.3","","279.30","91.72","1116.77","266","314.65","806.93","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","435.44","42.9","","731.00","63.70","731.00","1 through 10","314.65","806.93","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","435.44","42.9","","384.74","384.74","384.74","1 through 10","314.65","806.93","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","WELLPOINT [1015]","HB AMC WELLPOINT","748.87","73.78","","286.63","119.22","1107.45","105","314.65","806.93","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","AETNA [1001]","HB AMC AETNA HMO","708.47","69.8","","675.31","184.75","1721.50","286","530.44","829.46","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","AETNA [1001]","HB AMC AETNA PPO","816.06","80.4","","1261.44","103.12","1514.10","21","530.44","829.46","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","816.06","80.4","","1365.00","1365.00","1365.00","1 through 10","530.44","829.46","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","829.46","81.72","","5157.68","5157.68","5157.68","1 through 10","530.44","829.46","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","829.46","81.72","","431.26","71.26","1459.57","88","530.44","829.46","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","800.18","480.96","1887.97","195","434","1113","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","813.12","216.42","1444.50","81","434","1113","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","434.00","31","","432.60","432.60","432.60","1 through 10","434","1113","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","148.37","54.89","631.39","94","434","1113","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","279.30","91.72","1116.77","266","434","1113","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","731.00","63.70","731.00","1 through 10","434","1113","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","384.74","384.74","384.74","1 through 10","434","1113","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","286.63","119.22","1107.45","105","434","1113","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","675.31","184.75","1721.50","286","731.64","1144.08","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA PPO","1125.60","80.4","","1261.44","103.12","1514.10","21","731.64","1144.08","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1365.00","1365.00","1365.00","1 through 10","731.64","1144.08","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1144.08","81.72","","5157.68","5157.68","5157.68","1 through 10","731.64","1144.08","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","431.26","71.26","1459.57","88","731.64","1144.08","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","793.01","79.5","","800.18","480.96","1887.97","195","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","531.67","53.3","","813.12","216.42","1444.50","81","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","309.23","31","","432.60","432.60","432.60","1 through 10","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","364.09","36.5","","148.37","54.89","631.39","94","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","382.04","38.3","","279.30","91.72","1116.77","266","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.93","42.9","","731.00","63.70","731.00","1 through 10","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.93","42.9","","384.74","384.74","384.74","1 through 10","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.50","748.12","WELLPOINT [1015]","HB AMC WELLPOINT","735.96","73.78","","286.63","119.22","1107.45","105","309.23","793.01","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","AETNA [1001]","HB AMC AETNA HMO","696.26","69.8","","675.31","184.75","1721.50","286","521.29","815.16","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","AETNA [1001]","HB AMC AETNA PPO","801.99","80.4","","1261.44","103.12","1514.10","21","521.29","815.16","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","801.99","80.4","","1365.00","1365.00","1365.00","1 through 10","521.29","815.16","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","815.16","81.72","","5157.68","5157.68","5157.68","1 through 10","521.29","815.16","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","815.16","81.72","","431.26","71.26","1459.57","88","521.29","815.16","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 COBRAID BLUE BLACK","SUP-ITM-10078909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1363.43","79.5","","800.18","480.96","1887.97","195","531.65","1363.43","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 COBRAID BLUE BLACK","SUP-ITM-10078909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","914.10","53.3","","813.12","216.42","1444.50","81","531.65","1363.43","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 COBRAID BLUE BLACK","SUP-ITM-10078909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","531.65","31","","432.60","432.60","432.60","1 through 10","531.65","1363.43","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 COBRAID BLUE BLACK","SUP-ITM-10078909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","625.98","36.5","","148.37","54.89","631.39","94","531.65","1363.43","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 COBRAID BLUE BLACK","SUP-ITM-10078909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","656.85","38.3","","279.30","91.72","1116.77","266","531.65","1363.43","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 COBRAID BLUE BLACK","SUP-ITM-10078909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.74","42.9","","731.00","63.70","731.00","1 through 10","531.65","1363.43","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 COBRAID BLUE BLACK","SUP-ITM-10078909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.74","42.9","","384.74","384.74","384.74","1 through 10","531.65","1363.43","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 COBRAID BLUE BLACK","SUP-ITM-10078909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","WELLPOINT [1015]","HB AMC WELLPOINT","1265.33","73.78","","286.63","119.22","1107.45","105","531.65","1363.43","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 COBRAID BLUE BLACK","SUP-ITM-10078909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","AETNA [1001]","HB AMC AETNA HMO","1197.07","69.8","","675.31","184.75","1721.50","286","896.26","1401.5","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 COBRAID BLUE BLACK","SUP-ITM-10078909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","AETNA [1001]","HB AMC AETNA PPO","1378.86","80.4","","1261.44","103.12","1514.10","21","896.26","1401.5","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 COBRAID BLUE BLACK","SUP-ITM-10078909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1378.86","80.4","","1365.00","1365.00","1365.00","1 through 10","896.26","1401.5","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 COBRAID BLUE BLACK","SUP-ITM-10078909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1401.50","81.72","","5157.68","5157.68","5157.68","1 through 10","896.26","1401.5","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 COBRAID BLUE BLACK","SUP-ITM-10078909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1401.50","81.72","","431.26","71.26","1459.57","88","896.26","1401.5","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA COBRAID 3 STRAND WHITE BLUE","SUP-ITM-10078910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1385.69","79.5","","800.18","480.96","1887.97","195","540.33","1385.69","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA COBRAID 3 STRAND WHITE BLUE","SUP-ITM-10078910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","929.02","53.3","","813.12","216.42","1444.50","81","540.33","1385.69","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA COBRAID 3 STRAND WHITE BLUE","SUP-ITM-10078910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","540.33","31","","432.60","432.60","432.60","1 through 10","540.33","1385.69","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA COBRAID 3 STRAND WHITE BLUE","SUP-ITM-10078910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","636.20","36.5","","148.37","54.89","631.39","94","540.33","1385.69","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA COBRAID 3 STRAND WHITE BLUE","SUP-ITM-10078910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","667.57","38.3","","279.30","91.72","1116.77","266","540.33","1385.69","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA COBRAID 3 STRAND WHITE BLUE","SUP-ITM-10078910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","747.75","42.9","","731.00","63.70","731.00","1 through 10","540.33","1385.69","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA COBRAID 3 STRAND WHITE BLUE","SUP-ITM-10078910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","747.75","42.9","","384.74","384.74","384.74","1 through 10","540.33","1385.69","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA COBRAID 3 STRAND WHITE BLUE","SUP-ITM-10078910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","WELLPOINT [1015]","HB AMC WELLPOINT","1285.99","73.78","","286.63","119.22","1107.45","105","540.33","1385.69","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA COBRAID 3 STRAND WHITE BLUE","SUP-ITM-10078910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1743.00","1307.25","AETNA [1001]","HB AMC AETNA HMO","1216.61","69.8","","675.31","184.75","1721.50","286","910.89","1424.38","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA COBRAID 3 STRAND WHITE BLUE","SUP-ITM-10078910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1743.00","1307.25","AETNA [1001]","HB AMC AETNA PPO","1401.37","80.4","","1261.44","103.12","1514.10","21","910.89","1424.38","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA COBRAID 3 STRAND WHITE BLUE","SUP-ITM-10078910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1743.00","1307.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1401.37","80.4","","1365.00","1365.00","1365.00","1 through 10","910.89","1424.38","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA COBRAID 3 STRAND WHITE BLUE","SUP-ITM-10078910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1743.00","1307.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1424.38","81.72","","5157.68","5157.68","5157.68","1 through 10","910.89","1424.38","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM TWINFIX ULTRA HA COBRAID 3 STRAND WHITE BLUE","SUP-ITM-10078910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1743.00","1307.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1424.38","81.72","","431.26","71.26","1459.57","88","910.89","1424.38","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA COBRAID BLUE BLACK","SUP-ITM-10079992","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","800.18","480.96","1887.97","195","271.25","695.63","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA COBRAID BLUE BLACK","SUP-ITM-10079992","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","813.12","216.42","1444.50","81","271.25","695.63","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA COBRAID BLUE BLACK","SUP-ITM-10079992","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.25","31","","432.60","432.60","432.60","1 through 10","271.25","695.63","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA COBRAID BLUE BLACK","SUP-ITM-10079992","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","148.37","54.89","631.39","94","271.25","695.63","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA COBRAID BLUE BLACK","SUP-ITM-10079992","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","279.30","91.72","1116.77","266","271.25","695.63","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA COBRAID BLUE BLACK","SUP-ITM-10079992","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","731.00","63.70","731.00","1 through 10","271.25","695.63","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA COBRAID BLUE BLACK","SUP-ITM-10079992","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","384.74","384.74","384.74","1 through 10","271.25","695.63","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA COBRAID BLUE BLACK","SUP-ITM-10079992","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","286.63","119.22","1107.45","105","271.25","695.63","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA COBRAID BLUE BLACK","SUP-ITM-10079992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","675.31","184.75","1721.50","286","457.28","715.05","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA COBRAID BLUE BLACK","SUP-ITM-10079992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA PPO","703.50","80.4","","1261.44","103.12","1514.10","21","457.28","715.05","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA COBRAID BLUE BLACK","SUP-ITM-10079992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1365.00","1365.00","1365.00","1 through 10","457.28","715.05","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA COBRAID BLUE BLACK","SUP-ITM-10079992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","715.05","81.72","","5157.68","5157.68","5157.68","1 through 10","457.28","715.05","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA COBRAID BLUE BLACK","SUP-ITM-10079992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","431.26","71.26","1459.57","88","457.28","715.05","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 WHITE COBRAID BLUE","SUP-ITM-10078911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1708.00","1281.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1357.86","79.5","","800.18","480.96","1887.97","195","529.48","1357.86","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 WHITE COBRAID BLUE","SUP-ITM-10078911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1708.00","1281.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","910.36","53.3","","813.12","216.42","1444.50","81","529.48","1357.86","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 WHITE COBRAID BLUE","SUP-ITM-10078911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1708.00","1281.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","529.48","31","","432.60","432.60","432.60","1 through 10","529.48","1357.86","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 WHITE COBRAID BLUE","SUP-ITM-10078911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1708.00","1281.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","623.42","36.5","","148.37","54.89","631.39","94","529.48","1357.86","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 WHITE COBRAID BLUE","SUP-ITM-10078911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1708.00","1281.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","654.16","38.3","","279.30","91.72","1116.77","266","529.48","1357.86","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 WHITE COBRAID BLUE","SUP-ITM-10078911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1708.00","1281.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","732.73","42.9","","731.00","63.70","731.00","1 through 10","529.48","1357.86","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 WHITE COBRAID BLUE","SUP-ITM-10078911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1708.00","1281.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","732.73","42.9","","384.74","384.74","384.74","1 through 10","529.48","1357.86","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 WHITE COBRAID BLUE","SUP-ITM-10078911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1708.00","1281.00","WELLPOINT [1015]","HB AMC WELLPOINT","1260.16","73.78","","286.63","119.22","1107.45","105","529.48","1357.86","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 WHITE COBRAID BLUE","SUP-ITM-10078911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1708.00","1281.00","AETNA [1001]","HB AMC AETNA HMO","1192.18","69.8","","675.31","184.75","1721.50","286","892.6","1395.78","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 WHITE COBRAID BLUE","SUP-ITM-10078911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1708.00","1281.00","AETNA [1001]","HB AMC AETNA PPO","1373.23","80.4","","1261.44","103.12","1514.10","21","892.6","1395.78","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 WHITE COBRAID BLUE","SUP-ITM-10078911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1708.00","1281.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1373.23","80.4","","1365.00","1365.00","1365.00","1 through 10","892.6","1395.78","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 WHITE COBRAID BLUE","SUP-ITM-10078911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1708.00","1281.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1395.78","81.72","","5157.68","5157.68","5157.68","1 through 10","892.6","1395.78","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 6.5MM TWINFIX ULTRA HA 2 SUTURE SZ 2 WHITE COBRAID BLUE","SUP-ITM-10078911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1708.00","1281.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1395.78","81.72","","431.26","71.26","1459.57","88","892.6","1395.78","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 BIOABSORBABLE LUPINE LOOP PLUS ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1087.96","79.5","","800.18","480.96","1887.97","195","424.24","1087.96","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 BIOABSORBABLE LUPINE LOOP PLUS ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","729.41","53.3","","813.12","216.42","1444.50","81","424.24","1087.96","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 BIOABSORBABLE LUPINE LOOP PLUS ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","424.24","31","","432.60","432.60","432.60","1 through 10","424.24","1087.96","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 BIOABSORBABLE LUPINE LOOP PLUS ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","499.50","36.5","","148.37","54.89","631.39","94","424.24","1087.96","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 BIOABSORBABLE LUPINE LOOP PLUS ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","524.14","38.3","","279.30","91.72","1116.77","266","424.24","1087.96","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 BIOABSORBABLE LUPINE LOOP PLUS ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","587.09","42.9","","731.00","63.70","731.00","1 through 10","424.24","1087.96","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 BIOABSORBABLE LUPINE LOOP PLUS ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","587.09","42.9","","384.74","384.74","384.74","1 through 10","424.24","1087.96","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 BIOABSORBABLE LUPINE LOOP PLUS ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","WELLPOINT [1015]","HB AMC WELLPOINT","1009.68","73.78","","286.63","119.22","1107.45","105","424.24","1087.96","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 BIOABSORBABLE LUPINE LOOP PLUS ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.50","1026.37","AETNA [1001]","HB AMC AETNA HMO","955.21","69.8","","675.31","184.75","1721.50","286","715.18","1118.34","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 BIOABSORBABLE LUPINE LOOP PLUS ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.50","1026.37","AETNA [1001]","HB AMC AETNA PPO","1100.27","80.4","","1261.44","103.12","1514.10","21","715.18","1118.34","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 BIOABSORBABLE LUPINE LOOP PLUS ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.50","1026.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1100.27","80.4","","1365.00","1365.00","1365.00","1 through 10","715.18","1118.34","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 BIOABSORBABLE LUPINE LOOP PLUS ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.50","1026.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1118.34","81.72","","5157.68","5157.68","5157.68","1 through 10","715.18","1118.34","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 BIOABSORBABLE LUPINE LOOP PLUS ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.50","1026.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1118.34","81.72","","431.26","71.26","1459.57","88","715.18","1118.34","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.00","572.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","606.59","79.5","","800.18","480.96","1887.97","195","236.53","606.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.00","572.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","406.68","53.3","","813.12","216.42","1444.50","81","236.53","606.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.00","572.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","236.53","31","","432.60","432.60","432.60","1 through 10","236.53","606.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.00","572.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","278.50","36.5","","148.37","54.89","631.39","94","236.53","606.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.00","572.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","292.23","38.3","","279.30","91.72","1116.77","266","236.53","606.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.00","572.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","327.33","42.9","","731.00","63.70","731.00","1 through 10","236.53","606.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.00","572.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","327.33","42.9","","384.74","384.74","384.74","1 through 10","236.53","606.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.00","572.25","WELLPOINT [1015]","HB AMC WELLPOINT","562.94","73.78","","286.63","119.22","1107.45","105","236.53","606.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.00","572.25","AETNA [1001]","HB AMC AETNA HMO","532.57","69.8","","675.31","184.75","1721.50","286","398.74","623.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.00","572.25","AETNA [1001]","HB AMC AETNA PPO","613.45","80.4","","1261.44","103.12","1514.10","21","398.74","623.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.00","572.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","613.45","80.4","","1365.00","1365.00","1365.00","1 through 10","398.74","623.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.00","572.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","623.52","81.72","","5157.68","5157.68","5157.68","1 through 10","398.74","623.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.00","572.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","623.52","81.72","","431.26","71.26","1459.57","88","398.74","623.52","percent of total billed charges",""
"Androstenedione","PX-30000312","CDM","82157","CPT","0301","RC","","","","both","","","343.00","257.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","182.82","53.3","","262.07","175.82","262.07","1 through 10","28.69","325.85","percent of total billed charges",""
"Androstenedione","PX-30000312","CDM","82157","CPT","0301","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","125.20","36.5","","124.21","88.88","124.21","1 through 10","28.69","325.85","percent of total billed charges",""
"Androstenedione","PX-30000312","CDM","82157","CPT","0301","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","131.37","38.3","","130.20","126.54","379.62","11","28.69","325.85","percent of total billed charges",""
"Androstenedione","PX-30000312","CDM","82157","CPT","0301","RC","","","","both","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.15","42.9","","266.20","266.20","266.20","1 through 10","28.69","325.85","percent of total billed charges",""
"Androstenedione","PX-30000312","CDM","82157","CPT","0301","RC","","","","outpatient","","","343.00","257.25","AETNA [1001]","HB AMC AETNA HMO","239.41","69.8","","225.44","225.44","259.74","1 through 10","30.18","280.3","percent of total billed charges",""
"Androstenedione","PX-30000312","CDM","82157","CPT","0301","RC","","","","outpatient","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","280.30","81.72","","119.74","116.03","119.74","1 through 10","30.18","280.3","percent of total billed charges",""
"Angina Pectoris","311","MS-DRG","","","","","","","","inpatient","","","41055.40","30791.55","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","6782.64","","Case rate ($6,782.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,087.56, add-ons for qualifying new technology services are included. If operating cost exceeds $53,732.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,004.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,838.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,707.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.79. The transfer capital threshold is the transfer adjustment factor * $564.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6546.96","6546.96","6546.96","1 through 10","6646.99","10538.0453","other","Inpatient DRG"
"Angina Pectoris","311","MS-DRG","","","","","","","","inpatient","","","41055.40","30791.55","MEDICARE [2001]","HB BWH MEDICARE","6782.64","","Case rate ($6,782.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,087.56, add-ons for qualifying new technology services are included. If operating cost exceeds $53,732.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,004.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,838.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,707.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.79. The transfer capital threshold is the transfer adjustment factor * $564.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","728.09","728.09","8522.97","1 through 10","6646.99","10538.0453","other","Inpatient Replacement Plans DRG"
"Angina Pectoris","311","MS-DRG","","","","","","","","inpatient","","","41055.40","30791.55","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","6782.64","","Case rate ($6,782.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,087.56, add-ons for qualifying new technology services are included. If operating cost exceeds $53,732.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,004.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,838.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,707.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.79. The transfer capital threshold is the transfer adjustment factor * $564.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6499.77","6499.77","6499.77","1 through 10","6646.99","10538.0453","other","Inpatient Replacement Plans DRG"
"Angina Pectoris","311","MS-DRG","","","","","","","","inpatient","","","41055.40","30791.55","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6646.99","","Case rate ($6,782.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,087.56, add-ons for qualifying new technology services are included. If operating cost exceeds $53,732.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,004.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,838.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,707.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.79. The transfer capital threshold is the transfer adjustment factor * $564.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6537.17","6537.17","6537.17","1 through 10","6646.99","10538.0453","other","Inpatient DRG"
"Angina Pectoris And Coronary Atherosclerosis,EXTREME","198","DRG","","","","","","","","inpatient","","","93402.35","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","16125.64","","Case rate ($17,829.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,259.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17825.29","17825.29","17825.29","1 through 10","3782.37","274632.31","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MAJOR","198","DRG","","","","","","","","inpatient","","","58025.76","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33702.5956","","Fee schedule rate ($17,524.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33702.5956","16849.16","16849.16","1 through 10","3782.37","274632.31","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MAJOR","198","DRG","","","","","","","","inpatient","","","58025.76","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9154.8131","","Fee schedule rate ($17,524.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9154.8131","16849.16","16849.16","1 through 10","3782.37","274632.31","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MAJOR","198","DRG","","","","","","","","inpatient","","","58025.76","","MASSHEALTH [3001]","HB BWH MEDICAID","4514.63","","Case rate ($4,991.70). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,421.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6997.02","6997.02","6997.02","1 through 10","3782.37","274632.31","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MINOR","198","DRG","","","","","","","","inpatient","","","23410.81","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","14896.26","","Standard inlier is a Case rate ($14,896.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,231, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,114.61) for the length of stay and the standard reimbursement.","13578.48","13578.48","13578.48","1 through 10","3782.37","274632.31","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MINOR","198","DRG","","","","","","","","inpatient","","","23410.81","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","16747.42","","Standard inlier is a Case rate ($16,747.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,231, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,377.16) for the length of stay and the standard reimbursement.","16747.41","15302.21","16747.41","1 through 10","3782.37","274632.31","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MINOR","198","DRG","","","","","","","","inpatient","","","23410.81","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","3782.37","","Case rate ($4,182.06). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,612.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4181.04","4181.04","4181.04","1 through 10","3782.37","274632.31","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MODERATE","198","DRG","","","","","","","","inpatient","","","33124.04","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","17800.49","","Standard inlier is a Case rate ($17,800.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,491, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,526.89) for the length of stay and the standard reimbursement.","16225.79","16225.79","16225.79","1 through 10","3782.37","274632.31","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MODERATE","198","DRG","","","","","","","","inpatient","","","33124.04","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","20012.54","","Standard inlier is a Case rate ($20,012.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,491, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,840.61) for the length of stay and the standard reimbursement.","20012.54","20012.54","20012.54","1 through 10","3782.37","274632.31","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MODERATE","198","DRG","","","","","","","","inpatient","","","33124.04","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33702.5956","","Fee schedule rate ($9,154.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33702.5956","11937.28","11937.28","1 through 10","3782.37","274632.31","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MODERATE","198","DRG","","","","","","","","inpatient","","","33124.04","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9154.8131","","Fee schedule rate ($9,154.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9154.8131","11937.28","11937.28","1 through 10","3782.37","274632.31","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MODERATE","198","DRG","","","","","","","","inpatient","","","33124.04","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35388.7048","","Fee schedule rate ($9,612.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35388.7048","12534.48","12534.48","1 through 10","3782.37","274632.31","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MODERATE","198","DRG","","","","","","","","inpatient","","","33124.04","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","9612.8198","","Fee schedule rate ($9,612.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9612.8198","12534.48","12534.48","1 through 10","3782.37","274632.31","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MODERATE","198","DRG","","","","","","","","inpatient","","","33124.04","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4514.63","","Case rate ($4,991.70). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,421.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4990.47","4990.47","4990.47","1 through 10","3782.37","274632.31","case rate",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","both","","","187.00","140.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","148.67","79.5","","142.45","95.57","142.45","1 through 10","14.31","177.65","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","both","","","187.00","140.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","99.67","53.3","","427.35","95.57","427.35","1 through 10","14.31","177.65","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","both","","","187.00","140.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.26","36.5","","67.51","57.38","67.51","1 through 10","14.31","177.65","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","both","","","187.00","140.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71.62","38.3","","70.77","68.78","212.31","20","14.31","177.65","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","both","","","187.00","140.25","TRICARE [160005]","HB BWH TRICARE","177.65","95","","17.59","17.59","17.59","1 through 10","14.31","177.65","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","outpatient","","","187.00","140.25","AETNA [1001]","HB AMC AETNA HMO","130.53","69.8","","122.54","122.54","141.18","1 through 10","15.06","152.82","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","outpatient","","","187.00","140.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","97.73","52.26","","112.00","112.00","112.00","1 through 10","15.06","152.82","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","outpatient","","","187.00","140.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","152.82","81.72","","181.00","181.00","181.00","1 through 10","15.06","152.82","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","outpatient","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","152.82","81.72","","79.59","79.59","79.59","1 through 10","15.06","152.82","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","outpatient","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","152.82","81.72","","144.69","79.59","144.69","1 through 10","15.06","152.82","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1139.53","52.26","","1113.10","1113.10","1113.10","1 through 10","675.96","1733.5","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1733.50","79.5","","1293.60","1148.53","1603.80","1 through 10","675.96","1733.5","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","795.88","36.5","","1023.42","771.29","2068.67","33","675.96","1733.5","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","835.13","38.3","","850.52","759.78","1211.25","66","675.96","1733.5","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","935.43","42.9","","2548.09","2548.09","2548.09","1 through 10","675.96","1733.5","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","935.43","42.9","","956.46","956.46","956.46","1 through 10","675.96","1733.5","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","WELLPOINT [1015]","HB AMC WELLPOINT","1608.77","73.78","","2344.73","1619.47","2530.35","16","675.96","1733.5","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","AETNA [1001]","HB AMC AETNA HMO","1521.99","69.8","","1523.63","988.41","4330.26","39","1139.53","1781.9","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","AETNA [1001]","HB AMC AETNA PPO","1753.12","80.4","","1670.25","1670.25","1670.25","1 through 10","1139.53","1781.9","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1139.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1139.53","1781.9","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1781.90","81.72","","1738.90","1484.65","2716.94","38","1139.53","1781.9","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","4992.45","3744.34","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2609.05","52.26","","1113.10","1113.10","1113.10","1 through 10","1547.66","3969","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","4992.45","3744.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3969.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1547.66","3969","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","4992.45","3744.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1822.24","36.5","","1023.42","771.29","2068.67","33","1547.66","3969","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","4992.45","3744.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1912.11","38.3","","850.52","759.78","1211.25","66","1547.66","3969","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","4992.45","3744.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2141.76","42.9","","2548.09","2548.09","2548.09","1 through 10","1547.66","3969","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","4992.45","3744.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2141.76","42.9","","956.46","956.46","956.46","1 through 10","1547.66","3969","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","4992.45","3744.34","WELLPOINT [1015]","HB AMC WELLPOINT","3683.43","73.78","","2344.73","1619.47","2530.35","16","1547.66","3969","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4992.45","3744.34","AETNA [1001]","HB AMC AETNA HMO","3484.73","69.8","","1523.63","988.41","4330.26","39","2609.05","4079.83","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4992.45","3744.34","AETNA [1001]","HB AMC AETNA PPO","4013.93","80.4","","1670.25","1670.25","1670.25","1 through 10","2609.05","4079.83","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4992.45","3744.34","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2609.05","52.26","","1113.10","1113.10","1113.10","1 through 10","2609.05","4079.83","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4992.45","3744.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4079.83","81.72","","1738.90","1484.65","2716.94","38","2609.05","4079.83","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","15672.48","11754.36","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8190.44","52.26","","1113.10","1113.10","1113.10","1 through 10","4858.47","12459.62","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","15672.48","11754.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12459.62","79.5","","1293.60","1148.53","1603.80","1 through 10","4858.47","12459.62","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","15672.48","11754.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5720.46","36.5","","1023.42","771.29","2068.67","33","4858.47","12459.62","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","15672.48","11754.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6002.56","38.3","","850.52","759.78","1211.25","66","4858.47","12459.62","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","15672.48","11754.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6723.49","42.9","","2548.09","2548.09","2548.09","1 through 10","4858.47","12459.62","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","15672.48","11754.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6723.49","42.9","","956.46","956.46","956.46","1 through 10","4858.47","12459.62","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","15672.48","11754.36","WELLPOINT [1015]","HB AMC WELLPOINT","11563.16","73.78","","2344.73","1619.47","2530.35","16","4858.47","12459.62","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15672.48","11754.36","AETNA [1001]","HB AMC AETNA HMO","10939.39","69.8","","1523.63","988.41","4330.26","39","8190.44","12807.55","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15672.48","11754.36","AETNA [1001]","HB AMC AETNA PPO","12600.67","80.4","","1670.25","1670.25","1670.25","1 through 10","8190.44","12807.55","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15672.48","11754.36","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8190.44","52.26","","1113.10","1113.10","1113.10","1 through 10","8190.44","12807.55","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15672.48","11754.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12807.55","81.72","","1738.90","1484.65","2716.94","38","8190.44","12807.55","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","7393.41","52.26","","1113.10","1113.10","1113.10","1 through 10","4385.68","11247.14","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11247.14","79.5","","1293.60","1148.53","1603.80","1 through 10","4385.68","11247.14","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5163.78","36.5","","1023.42","771.29","2068.67","33","4385.68","11247.14","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5418.44","38.3","","850.52","759.78","1211.25","66","4385.68","11247.14","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6069.21","42.9","","2548.09","2548.09","2548.09","1 through 10","4385.68","11247.14","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6069.21","42.9","","956.46","956.46","956.46","1 through 10","4385.68","11247.14","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","WELLPOINT [1015]","HB AMC WELLPOINT","10437.91","73.78","","2344.73","1619.47","2530.35","16","4385.68","11247.14","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14147.35","10610.51","AETNA [1001]","HB AMC AETNA HMO","9874.85","69.8","","1523.63","988.41","4330.26","39","7393.41","11561.21","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14147.35","10610.51","AETNA [1001]","HB AMC AETNA PPO","11374.47","80.4","","1670.25","1670.25","1670.25","1 through 10","7393.41","11561.21","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14147.35","10610.51","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","7393.41","52.26","","1113.10","1113.10","1113.10","1 through 10","7393.41","11561.21","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14147.35","10610.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11561.21","81.72","","1738.90","1484.65","2716.94","38","7393.41","11561.21","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2594.71","52.26","","1113.10","1113.10","1113.10","1 through 10","1539.15","3947.18","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3947.18","79.5","","1293.60","1148.53","1603.80","1 through 10","1539.15","3947.18","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1812.23","36.5","","1023.42","771.29","2068.67","33","1539.15","3947.18","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1901.60","38.3","","850.52","759.78","1211.25","66","1539.15","3947.18","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2129.99","42.9","","2548.09","2548.09","2548.09","1 through 10","1539.15","3947.18","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2129.99","42.9","","956.46","956.46","956.46","1 through 10","1539.15","3947.18","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","WELLPOINT [1015]","HB AMC WELLPOINT","3663.18","73.78","","2344.73","1619.47","2530.35","16","1539.15","3947.18","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4965.00","3723.75","AETNA [1001]","HB AMC AETNA HMO","3465.57","69.8","","1523.63","988.41","4330.26","39","2594.71","4057.4","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4965.00","3723.75","AETNA [1001]","HB AMC AETNA PPO","3991.86","80.4","","1670.25","1670.25","1670.25","1 through 10","2594.71","4057.4","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4965.00","3723.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2594.71","52.26","","1113.10","1113.10","1113.10","1 through 10","2594.71","4057.4","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 SULCUS INBONE II POLY PLUS","SUP-ITM-10117057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4965.00","3723.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4057.40","81.72","","1738.90","1484.65","2716.94","38","2594.71","4057.4","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 10MM INBONE II EVERLAST POLYMER 22024310","SUP-ITM-10286107","CDM","C1776","HCPCS","0278","RC","","","","both","","","5385.00","4038.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2814.20","52.26","","1113.10","1113.10","1113.10","1 through 10","1669.35","4281.08","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 10MM INBONE II EVERLAST POLYMER 22024310","SUP-ITM-10286107","CDM","C1776","HCPCS","0278","RC","","","","both","","","5385.00","4038.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4281.08","79.5","","1293.60","1148.53","1603.80","1 through 10","1669.35","4281.08","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 10MM INBONE II EVERLAST POLYMER 22024310","SUP-ITM-10286107","CDM","C1776","HCPCS","0278","RC","","","","both","","","5385.00","4038.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1965.53","36.5","","1023.42","771.29","2068.67","33","1669.35","4281.08","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 10MM INBONE II EVERLAST POLYMER 22024310","SUP-ITM-10286107","CDM","C1776","HCPCS","0278","RC","","","","both","","","5385.00","4038.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2062.46","38.3","","850.52","759.78","1211.25","66","1669.35","4281.08","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 10MM INBONE II EVERLAST POLYMER 22024310","SUP-ITM-10286107","CDM","C1776","HCPCS","0278","RC","","","","both","","","5385.00","4038.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2310.17","42.9","","2548.09","2548.09","2548.09","1 through 10","1669.35","4281.08","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 10MM INBONE II EVERLAST POLYMER 22024310","SUP-ITM-10286107","CDM","C1776","HCPCS","0278","RC","","","","both","","","5385.00","4038.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2310.17","42.9","","956.46","956.46","956.46","1 through 10","1669.35","4281.08","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 10MM INBONE II EVERLAST POLYMER 22024310","SUP-ITM-10286107","CDM","C1776","HCPCS","0278","RC","","","","both","","","5385.00","4038.75","WELLPOINT [1015]","HB AMC WELLPOINT","3973.05","73.78","","2344.73","1619.47","2530.35","16","1669.35","4281.08","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 10MM INBONE II EVERLAST POLYMER 22024310","SUP-ITM-10286107","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5385.00","4038.75","AETNA [1001]","HB AMC AETNA HMO","3758.73","69.8","","1523.63","988.41","4330.26","39","2814.2","4400.62","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 10MM INBONE II EVERLAST POLYMER 22024310","SUP-ITM-10286107","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5385.00","4038.75","AETNA [1001]","HB AMC AETNA PPO","4329.54","80.4","","1670.25","1670.25","1670.25","1 through 10","2814.2","4400.62","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 10MM INBONE II EVERLAST POLYMER 22024310","SUP-ITM-10286107","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5385.00","4038.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2814.20","52.26","","1113.10","1113.10","1113.10","1 through 10","2814.2","4400.62","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 10MM INBONE II EVERLAST POLYMER 22024310","SUP-ITM-10286107","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5385.00","4038.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4400.62","81.72","","1738.90","1484.65","2716.94","38","2814.2","4400.62","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","737.36","79.5","","800.18","480.96","1887.97","195","287.53","737.36","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","494.36","53.3","","813.12","216.42","1444.50","81","287.53","737.36","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","287.53","31","","432.60","432.60","432.60","1 through 10","287.53","737.36","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","338.54","36.5","","148.37","54.89","631.39","94","287.53","737.36","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","355.23","38.3","","279.30","91.72","1116.77","266","287.53","737.36","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","397.90","42.9","","731.00","63.70","731.00","1 through 10","287.53","737.36","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","397.90","42.9","","384.74","384.74","384.74","1 through 10","287.53","737.36","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","WELLPOINT [1015]","HB AMC WELLPOINT","684.31","73.78","","286.63","119.22","1107.45","105","287.53","737.36","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","AETNA [1001]","HB AMC AETNA HMO","647.40","69.8","","675.31","184.75","1721.50","286","484.71","757.95","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","AETNA [1001]","HB AMC AETNA PPO","745.71","80.4","","1261.44","103.12","1514.10","21","484.71","757.95","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","745.71","80.4","","1365.00","1365.00","1365.00","1 through 10","484.71","757.95","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","757.95","81.72","","5157.68","5157.68","5157.68","1 through 10","484.71","757.95","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","757.95","81.72","","431.26","71.26","1459.57","88","484.71","757.95","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1530.38","79.5","","800.18","480.96","1887.97","195","596.75","1530.38","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1026.03","53.3","","813.12","216.42","1444.50","81","596.75","1530.38","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","596.75","31","","432.60","432.60","432.60","1 through 10","596.75","1530.38","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","702.63","36.5","","148.37","54.89","631.39","94","596.75","1530.38","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","737.28","38.3","","279.30","91.72","1116.77","266","596.75","1530.38","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","731.00","63.70","731.00","1 through 10","596.75","1530.38","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","384.74","384.74","384.74","1 through 10","596.75","1530.38","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","WELLPOINT [1015]","HB AMC WELLPOINT","1420.27","73.78","","286.63","119.22","1107.45","105","596.75","1530.38","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA HMO","1343.65","69.8","","675.31","184.75","1721.50","286","1006.01","1573.11","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA PPO","1547.70","80.4","","1261.44","103.12","1514.10","21","1006.01","1573.11","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1547.70","80.4","","1365.00","1365.00","1365.00","1 through 10","1006.01","1573.11","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1573.11","81.72","","5157.68","5157.68","5157.68","1 through 10","1006.01","1573.11","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1573.11","81.72","","431.26","71.26","1459.57","88","1006.01","1573.11","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1655.59","79.5","","800.18","480.96","1887.97","195","645.58","1655.59","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1109.97","53.3","","813.12","216.42","1444.50","81","645.58","1655.59","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","645.58","31","","432.60","432.60","432.60","1 through 10","645.58","1655.59","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","760.11","36.5","","148.37","54.89","631.39","94","645.58","1655.59","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","797.60","38.3","","279.30","91.72","1116.77","266","645.58","1655.59","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","893.39","42.9","","731.00","63.70","731.00","1 through 10","645.58","1655.59","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","893.39","42.9","","384.74","384.74","384.74","1 through 10","645.58","1655.59","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","WELLPOINT [1015]","HB AMC WELLPOINT","1536.47","73.78","","286.63","119.22","1107.45","105","645.58","1655.59","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2082.50","1561.87","AETNA [1001]","HB AMC AETNA HMO","1453.59","69.8","","675.31","184.75","1721.50","286","1088.31","1701.82","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2082.50","1561.87","AETNA [1001]","HB AMC AETNA PPO","1674.33","80.4","","1261.44","103.12","1514.10","21","1088.31","1701.82","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2082.50","1561.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1674.33","80.4","","1365.00","1365.00","1365.00","1 through 10","1088.31","1701.82","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2082.50","1561.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1701.82","81.72","","5157.68","5157.68","5157.68","1 through 10","1088.31","1701.82","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2082.50","1561.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1701.82","81.72","","431.26","71.26","1459.57","88","1088.31","1701.82","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","779.10","79.5","","800.18","480.96","1887.97","195","303.8","779.1","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","522.34","53.3","","813.12","216.42","1444.50","81","303.8","779.1","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","303.80","31","","432.60","432.60","432.60","1 through 10","303.8","779.1","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","357.70","36.5","","148.37","54.89","631.39","94","303.8","779.1","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","375.34","38.3","","279.30","91.72","1116.77","266","303.8","779.1","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.42","42.9","","731.00","63.70","731.00","1 through 10","303.8","779.1","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.42","42.9","","384.74","384.74","384.74","1 through 10","303.8","779.1","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","WELLPOINT [1015]","HB AMC WELLPOINT","723.04","73.78","","286.63","119.22","1107.45","105","303.8","779.1","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","AETNA [1001]","HB AMC AETNA HMO","684.04","69.8","","675.31","184.75","1721.50","286","512.15","800.86","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","AETNA [1001]","HB AMC AETNA PPO","787.92","80.4","","1261.44","103.12","1514.10","21","512.15","800.86","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","787.92","80.4","","1365.00","1365.00","1365.00","1 through 10","512.15","800.86","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","800.86","81.72","","5157.68","5157.68","5157.68","1 through 10","512.15","800.86","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","800.86","81.72","","431.26","71.26","1459.57","88","512.15","800.86","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","834.75","79.5","","800.18","480.96","1887.97","195","325.5","834.75","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","559.65","53.3","","813.12","216.42","1444.50","81","325.5","834.75","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","325.50","31","","432.60","432.60","432.60","1 through 10","325.5","834.75","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","148.37","54.89","631.39","94","325.5","834.75","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","279.30","91.72","1116.77","266","325.5","834.75","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","731.00","63.70","731.00","1 through 10","325.5","834.75","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","384.74","384.74","384.74","1 through 10","325.5","834.75","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB AMC WELLPOINT","774.69","73.78","","286.63","119.22","1107.45","105","325.5","834.75","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA HMO","732.90","69.8","","675.31","184.75","1721.50","286","548.73","858.06","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA PPO","844.20","80.4","","1261.44","103.12","1514.10","21","548.73","858.06","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","844.20","80.4","","1365.00","1365.00","1365.00","1 through 10","548.73","858.06","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","858.06","81.72","","5157.68","5157.68","5157.68","1 through 10","548.73","858.06","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","858.06","81.72","","431.26","71.26","1459.57","88","548.73","858.06","percent of total billed charges",""
"ANKLE PLATE 156MM 12 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076940","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1933.84","79.5","","800.18","480.96","1887.97","195","754.08","1933.84","percent of total billed charges",""
"ANKLE PLATE 156MM 12 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076940","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1296.52","53.3","","813.12","216.42","1444.50","81","754.08","1933.84","percent of total billed charges",""
"ANKLE PLATE 156MM 12 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076940","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","754.08","31","","432.60","432.60","432.60","1 through 10","754.08","1933.84","percent of total billed charges",""
"ANKLE PLATE 156MM 12 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076940","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","887.86","36.5","","148.37","54.89","631.39","94","754.08","1933.84","percent of total billed charges",""
"ANKLE PLATE 156MM 12 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076940","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","931.65","38.3","","279.30","91.72","1116.77","266","754.08","1933.84","percent of total billed charges",""
"ANKLE PLATE 156MM 12 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076940","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1043.54","42.9","","731.00","63.70","731.00","1 through 10","754.08","1933.84","percent of total billed charges",""
"ANKLE PLATE 156MM 12 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076940","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1043.54","42.9","","384.74","384.74","384.74","1 through 10","754.08","1933.84","percent of total billed charges",""
"ANKLE PLATE 156MM 12 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076940","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","WELLPOINT [1015]","HB AMC WELLPOINT","1794.70","73.78","","286.63","119.22","1107.45","105","754.08","1933.84","percent of total billed charges",""
"ANKLE PLATE 156MM 12 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","AETNA [1001]","HB AMC AETNA HMO","1697.89","69.8","","675.31","184.75","1721.50","286","1271.22","1987.84","percent of total billed charges",""
"ANKLE PLATE 156MM 12 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","AETNA [1001]","HB AMC AETNA PPO","1955.73","80.4","","1261.44","103.12","1514.10","21","1271.22","1987.84","percent of total billed charges",""
"ANKLE PLATE 156MM 12 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1955.73","80.4","","1365.00","1365.00","1365.00","1 through 10","1271.22","1987.84","percent of total billed charges",""
"ANKLE PLATE 156MM 12 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1987.84","81.72","","5157.68","5157.68","5157.68","1 through 10","1271.22","1987.84","percent of total billed charges",""
"ANKLE PLATE 156MM 12 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1987.84","81.72","","431.26","71.26","1459.57","88","1271.22","1987.84","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4124.06","79.5","","800.18","480.96","1887.97","195","1608.13","4124.06","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2764.94","53.3","","813.12","216.42","1444.50","81","1608.13","4124.06","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1608.13","31","","432.60","432.60","432.60","1 through 10","1608.13","4124.06","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1893.44","36.5","","148.37","54.89","631.39","94","1608.13","4124.06","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1986.81","38.3","","279.30","91.72","1116.77","266","1608.13","4124.06","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2225.44","42.9","","731.00","63.70","731.00","1 through 10","1608.13","4124.06","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2225.44","42.9","","384.74","384.74","384.74","1 through 10","1608.13","4124.06","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","WELLPOINT [1015]","HB AMC WELLPOINT","3827.34","73.78","","286.63","119.22","1107.45","105","1608.13","4124.06","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5187.50","3890.62","AETNA [1001]","HB AMC AETNA HMO","3620.88","69.8","","675.31","184.75","1721.50","286","2710.99","4239.23","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5187.50","3890.62","AETNA [1001]","HB AMC AETNA PPO","4170.75","80.4","","1261.44","103.12","1514.10","21","2710.99","4239.23","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5187.50","3890.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4170.75","80.4","","1365.00","1365.00","1365.00","1 through 10","2710.99","4239.23","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5187.50","3890.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4239.23","81.72","","5157.68","5157.68","5157.68","1 through 10","2710.99","4239.23","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5187.50","3890.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4239.23","81.72","","431.26","71.26","1459.57","88","2710.99","4239.23","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","626.06","79.5","","800.18","480.96","1887.97","195","244.13","626.06","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","419.74","53.3","","813.12","216.42","1444.50","81","244.13","626.06","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","244.13","31","","432.60","432.60","432.60","1 through 10","244.13","626.06","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","287.44","36.5","","148.37","54.89","631.39","94","244.13","626.06","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","301.61","38.3","","279.30","91.72","1116.77","266","244.13","626.06","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.84","42.9","","731.00","63.70","731.00","1 through 10","244.13","626.06","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.84","42.9","","384.74","384.74","384.74","1 through 10","244.13","626.06","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","WELLPOINT [1015]","HB AMC WELLPOINT","581.02","73.78","","286.63","119.22","1107.45","105","244.13","626.06","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","AETNA [1001]","HB AMC AETNA HMO","549.68","69.8","","675.31","184.75","1721.50","286","411.55","643.55","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","AETNA [1001]","HB AMC AETNA PPO","633.15","80.4","","1261.44","103.12","1514.10","21","411.55","643.55","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","633.15","80.4","","1365.00","1365.00","1365.00","1 through 10","411.55","643.55","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","643.55","81.72","","5157.68","5157.68","5157.68","1 through 10","411.55","643.55","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","643.55","81.72","","431.26","71.26","1459.57","88","411.55","643.55","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1252.13","79.5","","800.18","480.96","1887.97","195","488.25","1252.13","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","839.48","53.3","","813.12","216.42","1444.50","81","488.25","1252.13","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","488.25","31","","432.60","432.60","432.60","1 through 10","488.25","1252.13","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","574.88","36.5","","148.37","54.89","631.39","94","488.25","1252.13","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","603.23","38.3","","279.30","91.72","1116.77","266","488.25","1252.13","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","731.00","63.70","731.00","1 through 10","488.25","1252.13","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","384.74","384.74","384.74","1 through 10","488.25","1252.13","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB AMC WELLPOINT","1162.04","73.78","","286.63","119.22","1107.45","105","488.25","1252.13","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA HMO","1099.35","69.8","","675.31","184.75","1721.50","286","823.1","1287.09","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA PPO","1266.30","80.4","","1261.44","103.12","1514.10","21","823.1","1287.09","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1266.30","80.4","","1365.00","1365.00","1365.00","1 through 10","823.1","1287.09","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1287.09","81.72","","5157.68","5157.68","5157.68","1 through 10","823.1","1287.09","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1287.09","81.72","","431.26","71.26","1459.57","88","823.1","1287.09","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2295.56","79.5","","800.18","480.96","1887.97","195","895.13","2295.56","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1539.04","53.3","","813.12","216.42","1444.50","81","895.13","2295.56","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","895.13","31","","432.60","432.60","432.60","1 through 10","895.13","2295.56","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1053.94","36.5","","148.37","54.89","631.39","94","895.13","2295.56","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1105.91","38.3","","279.30","91.72","1116.77","266","895.13","2295.56","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1238.74","42.9","","731.00","63.70","731.00","1 through 10","895.13","2295.56","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1238.74","42.9","","384.74","384.74","384.74","1 through 10","895.13","2295.56","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","WELLPOINT [1015]","HB AMC WELLPOINT","2130.40","73.78","","286.63","119.22","1107.45","105","895.13","2295.56","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2887.50","2165.62","AETNA [1001]","HB AMC AETNA HMO","2015.48","69.8","","675.31","184.75","1721.50","286","1509.01","2359.67","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2887.50","2165.62","AETNA [1001]","HB AMC AETNA PPO","2321.55","80.4","","1261.44","103.12","1514.10","21","1509.01","2359.67","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2887.50","2165.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2321.55","80.4","","1365.00","1365.00","1365.00","1 through 10","1509.01","2359.67","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2887.50","2165.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2359.67","81.72","","5157.68","5157.68","5157.68","1 through 10","1509.01","2359.67","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2887.50","2165.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2359.67","81.72","","431.26","71.26","1459.57","88","1509.01","2359.67","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","800.18","480.96","1887.97","195","759.5","1947.75","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.85","53.3","","813.12","216.42","1444.50","81","759.5","1947.75","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","759.50","31","","432.60","432.60","432.60","1 through 10","759.5","1947.75","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","148.37","54.89","631.39","94","759.5","1947.75","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","279.30","91.72","1116.77","266","759.5","1947.75","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","731.00","63.70","731.00","1 through 10","759.5","1947.75","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","384.74","384.74","384.74","1 through 10","759.5","1947.75","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","286.63","119.22","1107.45","105","759.5","1947.75","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","675.31","184.75","1721.50","286","1280.37","2002.14","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA PPO","1969.80","80.4","","1261.44","103.12","1514.10","21","1280.37","2002.14","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.80","80.4","","1365.00","1365.00","1365.00","1 through 10","1280.37","2002.14","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2002.14","81.72","","5157.68","5157.68","5157.68","1 through 10","1280.37","2002.14","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","431.26","71.26","1459.57","88","1280.37","2002.14","percent of total billed charges",""
"ANKLE PLATE 8 HOLE SEMI TUBULAR","SUP-ITM-10126197","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1126.91","79.5","","800.18","480.96","1887.97","195","439.43","1126.91","percent of total billed charges",""
"ANKLE PLATE 8 HOLE SEMI TUBULAR","SUP-ITM-10126197","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","755.53","53.3","","813.12","216.42","1444.50","81","439.43","1126.91","percent of total billed charges",""
"ANKLE PLATE 8 HOLE SEMI TUBULAR","SUP-ITM-10126197","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","439.43","31","","432.60","432.60","432.60","1 through 10","439.43","1126.91","percent of total billed charges",""
"ANKLE PLATE 8 HOLE SEMI TUBULAR","SUP-ITM-10126197","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","517.39","36.5","","148.37","54.89","631.39","94","439.43","1126.91","percent of total billed charges",""
"ANKLE PLATE 8 HOLE SEMI TUBULAR","SUP-ITM-10126197","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","542.90","38.3","","279.30","91.72","1116.77","266","439.43","1126.91","percent of total billed charges",""
"ANKLE PLATE 8 HOLE SEMI TUBULAR","SUP-ITM-10126197","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","608.11","42.9","","731.00","63.70","731.00","1 through 10","439.43","1126.91","percent of total billed charges",""
"ANKLE PLATE 8 HOLE SEMI TUBULAR","SUP-ITM-10126197","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","608.11","42.9","","384.74","384.74","384.74","1 through 10","439.43","1126.91","percent of total billed charges",""
"ANKLE PLATE 8 HOLE SEMI TUBULAR","SUP-ITM-10126197","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","WELLPOINT [1015]","HB AMC WELLPOINT","1045.83","73.78","","286.63","119.22","1107.45","105","439.43","1126.91","percent of total billed charges",""
"ANKLE PLATE 8 HOLE SEMI TUBULAR","SUP-ITM-10126197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","AETNA [1001]","HB AMC AETNA HMO","989.42","69.8","","675.31","184.75","1721.50","286","740.79","1158.38","percent of total billed charges",""
"ANKLE PLATE 8 HOLE SEMI TUBULAR","SUP-ITM-10126197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","AETNA [1001]","HB AMC AETNA PPO","1139.67","80.4","","1261.44","103.12","1514.10","21","740.79","1158.38","percent of total billed charges",""
"ANKLE PLATE 8 HOLE SEMI TUBULAR","SUP-ITM-10126197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1139.67","80.4","","1365.00","1365.00","1365.00","1 through 10","740.79","1158.38","percent of total billed charges",""
"ANKLE PLATE 8 HOLE SEMI TUBULAR","SUP-ITM-10126197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1158.38","81.72","","5157.68","5157.68","5157.68","1 through 10","740.79","1158.38","percent of total billed charges",""
"ANKLE PLATE 8 HOLE SEMI TUBULAR","SUP-ITM-10126197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1158.38","81.72","","431.26","71.26","1459.57","88","740.79","1158.38","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","800.18","480.96","1887.97","195","260.4","667.8","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","813.12","216.42","1444.50","81","260.4","667.8","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","260.40","31","","432.60","432.60","432.60","1 through 10","260.4","667.8","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","148.37","54.89","631.39","94","260.4","667.8","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","279.30","91.72","1116.77","266","260.4","667.8","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","731.00","63.70","731.00","1 through 10","260.4","667.8","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","384.74","384.74","384.74","1 through 10","260.4","667.8","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","286.63","119.22","1107.45","105","260.4","667.8","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","675.31","184.75","1721.50","286","438.98","686.45","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA PPO","675.36","80.4","","1261.44","103.12","1514.10","21","438.98","686.45","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1365.00","1365.00","1365.00","1 through 10","438.98","686.45","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","686.45","81.72","","5157.68","5157.68","5157.68","1 through 10","438.98","686.45","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","431.26","71.26","1459.57","88","438.98","686.45","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1321.69","79.5","","800.18","480.96","1887.97","195","515.38","1321.69","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","886.11","53.3","","813.12","216.42","1444.50","81","515.38","1321.69","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","515.38","31","","432.60","432.60","432.60","1 through 10","515.38","1321.69","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","606.81","36.5","","148.37","54.89","631.39","94","515.38","1321.69","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","636.74","38.3","","279.30","91.72","1116.77","266","515.38","1321.69","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.21","42.9","","731.00","63.70","731.00","1 through 10","515.38","1321.69","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.21","42.9","","384.74","384.74","384.74","1 through 10","515.38","1321.69","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","WELLPOINT [1015]","HB AMC WELLPOINT","1226.59","73.78","","286.63","119.22","1107.45","105","515.38","1321.69","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","AETNA [1001]","HB AMC AETNA HMO","1160.43","69.8","","675.31","184.75","1721.50","286","868.82","1358.6","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","AETNA [1001]","HB AMC AETNA PPO","1336.65","80.4","","1261.44","103.12","1514.10","21","868.82","1358.6","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1336.65","80.4","","1365.00","1365.00","1365.00","1 through 10","868.82","1358.6","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1358.60","81.72","","5157.68","5157.68","5157.68","1 through 10","868.82","1358.6","percent of total billed charges",""
"ANKLE PLATE 80MM 6 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1358.60","81.72","","431.26","71.26","1459.57","88","868.82","1358.6","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.50","669.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","709.54","79.5","","800.18","480.96","1887.97","195","276.68","709.54","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.50","669.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","475.70","53.3","","813.12","216.42","1444.50","81","276.68","709.54","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.50","669.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","276.68","31","","432.60","432.60","432.60","1 through 10","276.68","709.54","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.50","669.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","325.76","36.5","","148.37","54.89","631.39","94","276.68","709.54","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.50","669.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","341.83","38.3","","279.30","91.72","1116.77","266","276.68","709.54","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.50","669.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","382.88","42.9","","731.00","63.70","731.00","1 through 10","276.68","709.54","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.50","669.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","382.88","42.9","","384.74","384.74","384.74","1 through 10","276.68","709.54","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.50","669.37","WELLPOINT [1015]","HB AMC WELLPOINT","658.49","73.78","","286.63","119.22","1107.45","105","276.68","709.54","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.50","669.37","AETNA [1001]","HB AMC AETNA HMO","622.97","69.8","","675.31","184.75","1721.50","286","466.42","729.35","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.50","669.37","AETNA [1001]","HB AMC AETNA PPO","717.57","80.4","","1261.44","103.12","1514.10","21","466.42","729.35","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.50","669.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","717.57","80.4","","1365.00","1365.00","1365.00","1 through 10","466.42","729.35","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.50","669.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","729.35","81.72","","5157.68","5157.68","5157.68","1 through 10","466.42","729.35","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.50","669.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","729.35","81.72","","431.26","71.26","1459.57","88","466.42","729.35","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1460.81","79.5","","800.18","480.96","1887.97","195","569.63","1460.81","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","979.39","53.3","","813.12","216.42","1444.50","81","569.63","1460.81","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","569.63","31","","432.60","432.60","432.60","1 through 10","569.63","1460.81","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","670.69","36.5","","148.37","54.89","631.39","94","569.63","1460.81","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","703.76","38.3","","279.30","91.72","1116.77","266","569.63","1460.81","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","788.29","42.9","","731.00","63.70","731.00","1 through 10","569.63","1460.81","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","788.29","42.9","","384.74","384.74","384.74","1 through 10","569.63","1460.81","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","WELLPOINT [1015]","HB AMC WELLPOINT","1355.71","73.78","","286.63","119.22","1107.45","105","569.63","1460.81","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","AETNA [1001]","HB AMC AETNA HMO","1282.58","69.8","","675.31","184.75","1721.50","286","960.28","1501.61","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","AETNA [1001]","HB AMC AETNA PPO","1477.35","80.4","","1261.44","103.12","1514.10","21","960.28","1501.61","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1477.35","80.4","","1365.00","1365.00","1365.00","1 through 10","960.28","1501.61","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1501.61","81.72","","5157.68","5157.68","5157.68","1 through 10","960.28","1501.61","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1501.61","81.72","","431.26","71.26","1459.57","88","960.28","1501.61","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2504.25","79.5","","800.18","480.96","1887.97","195","976.5","2504.25","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1678.95","53.3","","813.12","216.42","1444.50","81","976.5","2504.25","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","976.50","31","","432.60","432.60","432.60","1 through 10","976.5","2504.25","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1149.75","36.5","","148.37","54.89","631.39","94","976.5","2504.25","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1206.45","38.3","","279.30","91.72","1116.77","266","976.5","2504.25","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","731.00","63.70","731.00","1 through 10","976.5","2504.25","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","384.74","384.74","384.74","1 through 10","976.5","2504.25","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","WELLPOINT [1015]","HB AMC WELLPOINT","2324.07","73.78","","286.63","119.22","1107.45","105","976.5","2504.25","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA HMO","2198.70","69.8","","675.31","184.75","1721.50","286","1646.19","2574.18","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA PPO","2532.60","80.4","","1261.44","103.12","1514.10","21","1646.19","2574.18","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2532.60","80.4","","1365.00","1365.00","1365.00","1 through 10","1646.19","2574.18","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2574.18","81.72","","5157.68","5157.68","5157.68","1 through 10","1646.19","2574.18","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2574.18","81.72","","431.26","71.26","1459.57","88","1646.19","2574.18","percent of total billed charges",""
"ANKLE PLATE SM BONE FIBULA LATERAL ORTHOLOC 3DI LEFT","SUP-ITM-10132147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4039.00","3029.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3211.01","79.5","","800.18","480.96","1887.97","195","1252.09","3211.01","percent of total billed charges",""
"ANKLE PLATE SM BONE FIBULA LATERAL ORTHOLOC 3DI LEFT","SUP-ITM-10132147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4039.00","3029.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2152.79","53.3","","813.12","216.42","1444.50","81","1252.09","3211.01","percent of total billed charges",""
"ANKLE PLATE SM BONE FIBULA LATERAL ORTHOLOC 3DI LEFT","SUP-ITM-10132147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4039.00","3029.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1252.09","31","","432.60","432.60","432.60","1 through 10","1252.09","3211.01","percent of total billed charges",""
"ANKLE PLATE SM BONE FIBULA LATERAL ORTHOLOC 3DI LEFT","SUP-ITM-10132147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4039.00","3029.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1474.24","36.5","","148.37","54.89","631.39","94","1252.09","3211.01","percent of total billed charges",""
"ANKLE PLATE SM BONE FIBULA LATERAL ORTHOLOC 3DI LEFT","SUP-ITM-10132147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4039.00","3029.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1546.94","38.3","","279.30","91.72","1116.77","266","1252.09","3211.01","percent of total billed charges",""
"ANKLE PLATE SM BONE FIBULA LATERAL ORTHOLOC 3DI LEFT","SUP-ITM-10132147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4039.00","3029.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1732.73","42.9","","731.00","63.70","731.00","1 through 10","1252.09","3211.01","percent of total billed charges",""
"ANKLE PLATE SM BONE FIBULA LATERAL ORTHOLOC 3DI LEFT","SUP-ITM-10132147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4039.00","3029.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1732.73","42.9","","384.74","384.74","384.74","1 through 10","1252.09","3211.01","percent of total billed charges",""
"ANKLE PLATE SM BONE FIBULA LATERAL ORTHOLOC 3DI LEFT","SUP-ITM-10132147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4039.00","3029.25","WELLPOINT [1015]","HB AMC WELLPOINT","2979.97","73.78","","286.63","119.22","1107.45","105","1252.09","3211.01","percent of total billed charges",""
"ANKLE PLATE SM BONE FIBULA LATERAL ORTHOLOC 3DI LEFT","SUP-ITM-10132147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4039.00","3029.25","AETNA [1001]","HB AMC AETNA HMO","2819.22","69.8","","675.31","184.75","1721.50","286","2110.78","3300.67","percent of total billed charges",""
"ANKLE PLATE SM BONE FIBULA LATERAL ORTHOLOC 3DI LEFT","SUP-ITM-10132147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4039.00","3029.25","AETNA [1001]","HB AMC AETNA PPO","3247.36","80.4","","1261.44","103.12","1514.10","21","2110.78","3300.67","percent of total billed charges",""
"ANKLE PLATE SM BONE FIBULA LATERAL ORTHOLOC 3DI LEFT","SUP-ITM-10132147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4039.00","3029.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3247.36","80.4","","1365.00","1365.00","1365.00","1 through 10","2110.78","3300.67","percent of total billed charges",""
"ANKLE PLATE SM BONE FIBULA LATERAL ORTHOLOC 3DI LEFT","SUP-ITM-10132147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4039.00","3029.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3300.67","81.72","","5157.68","5157.68","5157.68","1 through 10","2110.78","3300.67","percent of total billed charges",""
"ANKLE PLATE SM BONE FIBULA LATERAL ORTHOLOC 3DI LEFT","SUP-ITM-10132147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4039.00","3029.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3300.67","81.72","","431.26","71.26","1459.57","88","2110.78","3300.67","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2147.36","52.26","","1113.10","1113.10","1113.10","1 through 10","1273.79","3266.66","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3266.66","79.5","","1293.60","1148.53","1603.80","1 through 10","1273.79","3266.66","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1499.79","36.5","","1023.42","771.29","2068.67","33","1273.79","3266.66","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1573.75","38.3","","850.52","759.78","1211.25","66","1273.79","3266.66","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1762.76","42.9","","2548.09","2548.09","2548.09","1 through 10","1273.79","3266.66","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1762.76","42.9","","956.46","956.46","956.46","1 through 10","1273.79","3266.66","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","WELLPOINT [1015]","HB AMC WELLPOINT","3031.62","73.78","","2344.73","1619.47","2530.35","16","1273.79","3266.66","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4109.00","3081.75","AETNA [1001]","HB AMC AETNA HMO","2868.08","69.8","","1523.63","988.41","4330.26","39","2147.36","3357.87","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4109.00","3081.75","AETNA [1001]","HB AMC AETNA PPO","3303.64","80.4","","1670.25","1670.25","1670.25","1 through 10","2147.36","3357.87","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4109.00","3081.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2147.36","52.26","","1113.10","1113.10","1113.10","1 through 10","2147.36","3357.87","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4109.00","3081.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3357.87","81.72","","1738.90","1484.65","2716.94","38","2147.36","3357.87","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","2138.50","1603.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1117.58","52.26","","1113.10","1113.10","1113.10","1 through 10","662.94","1700.11","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","2138.50","1603.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1700.11","79.5","","1293.60","1148.53","1603.80","1 through 10","662.94","1700.11","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","2138.50","1603.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","780.55","36.5","","1023.42","771.29","2068.67","33","662.94","1700.11","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","2138.50","1603.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","819.05","38.3","","850.52","759.78","1211.25","66","662.94","1700.11","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","2138.50","1603.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","917.42","42.9","","2548.09","2548.09","2548.09","1 through 10","662.94","1700.11","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","2138.50","1603.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","917.42","42.9","","956.46","956.46","956.46","1 through 10","662.94","1700.11","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","2138.50","1603.87","WELLPOINT [1015]","HB AMC WELLPOINT","1577.79","73.78","","2344.73","1619.47","2530.35","16","662.94","1700.11","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2138.50","1603.87","AETNA [1001]","HB AMC AETNA HMO","1492.67","69.8","","1523.63","988.41","4330.26","39","1117.58","1747.58","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2138.50","1603.87","AETNA [1001]","HB AMC AETNA PPO","1719.35","80.4","","1670.25","1670.25","1670.25","1 through 10","1117.58","1747.58","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2138.50","1603.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1117.58","52.26","","1113.10","1113.10","1113.10","1 through 10","1117.58","1747.58","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2138.50","1603.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1747.58","81.72","","1738.90","1484.65","2716.94","38","1117.58","1747.58","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2002.00","1501.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1046.25","52.26","","1113.10","1113.10","1113.10","1 through 10","620.62","1591.59","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2002.00","1501.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1591.59","79.5","","1293.60","1148.53","1603.80","1 through 10","620.62","1591.59","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2002.00","1501.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","730.73","36.5","","1023.42","771.29","2068.67","33","620.62","1591.59","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2002.00","1501.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","766.77","38.3","","850.52","759.78","1211.25","66","620.62","1591.59","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2002.00","1501.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","858.86","42.9","","2548.09","2548.09","2548.09","1 through 10","620.62","1591.59","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2002.00","1501.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","858.86","42.9","","956.46","956.46","956.46","1 through 10","620.62","1591.59","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2002.00","1501.50","WELLPOINT [1015]","HB AMC WELLPOINT","1477.08","73.78","","2344.73","1619.47","2530.35","16","620.62","1591.59","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2002.00","1501.50","AETNA [1001]","HB AMC AETNA HMO","1397.40","69.8","","1523.63","988.41","4330.26","39","1046.25","1636.03","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2002.00","1501.50","AETNA [1001]","HB AMC AETNA PPO","1609.61","80.4","","1670.25","1670.25","1670.25","1 through 10","1046.25","1636.03","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2002.00","1501.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1046.25","52.26","","1113.10","1113.10","1113.10","1 through 10","1046.25","1636.03","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2002.00","1501.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1636.03","81.72","","1738.90","1484.65","2716.94","38","1046.25","1636.03","percent of total billed charges",""
"Annual Alcohol Misuse Scrnng","PX-51000128","CDM","G0442","HCPCS","0510","RC","","","","both","","","68.00","51.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","36.44","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","36.41","9.72","36.41","1 through 10","21.08","52.36","other","OPPS APC"
"Annual Alcohol Misuse Scrnng","PX-51000128","CDM","G0442","HCPCS","0510","RC","","","","both","","","68.00","51.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.81","34.81","34.81","21","21.08","52.36","other","OPPS APC"
"Annual Alcohol Misuse Scrnng","PX-51000128","CDM","G0442","HCPCS","0510","RC","","","","both","","","68.00","51.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.82","30.82","30.82","1 through 10","21.08","52.36","other","OPPS APC"
"Annual Alcohol Misuse Scrnng","PX-51000128","CDM","G0442","HCPCS","0510","RC","","","","both","","","68.00","51.00","MEDICARE [2001]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","35.38","35.38","62.64","277","21.08","52.36","other","OPPS APC"
"Annual Alcohol Misuse Scrnng","PX-51000128","CDM","G0442","HCPCS","0510","RC","","","","both","","","68.00","51.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9.45","8.03","9.45","26","21.08","52.36","other","OPPS APC"
"Annual Alcohol Misuse Scrnng","PX-51000128","CDM","G0442","HCPCS","0510","RC","","","","both","","","68.00","51.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.67","30.69","34.67","11","21.08","52.36","other","OPPS APC"
"Annual Alcohol Misuse Scrnng","PX-51000128","CDM","G0442","HCPCS","0510","RC","","","","both","","","68.00","51.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","34.67","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","34.67","34.67","34.67","1 through 10","21.08","52.36","other","OPPS APC"
"Annual Alcohol Misuse Scrnng","PX-51000128","CDM","G0442","HCPCS","0510","RC","","","","both","","","68.00","51.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","34.67","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","34.68","9.54","34.68","73","21.08","52.36","other","OPPS APC"
"Annual Depression Screening 15","PX-51000130","CDM","G0444","HCPCS","0510","RC","","","","both","","","68.00","51.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","36.44","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","36.41","9.72","36.41","1 through 10","21.08","64.6","other","OPPS APC"
"Annual Depression Screening 15","PX-51000130","CDM","G0444","HCPCS","0510","RC","","","","both","","","68.00","51.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.81","34.81","34.81","15","21.08","64.6","other","OPPS APC"
"Annual Depression Screening 15","PX-51000130","CDM","G0444","HCPCS","0510","RC","","","","both","","","68.00","51.00","HUMANA [1012]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.67","34.67","34.67","1 through 10","21.08","64.6","other","OPPS APC"
"Annual Depression Screening 15","PX-51000130","CDM","G0444","HCPCS","0510","RC","","","","both","","","68.00","51.00","MEDICARE [2001]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","35.38","35.38","35.38","204","21.08","64.6","other","OPPS APC"
"Annual Depression Screening 15","PX-51000130","CDM","G0444","HCPCS","0510","RC","","","","both","","","68.00","51.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9.45","8.03","9.45","29","21.08","64.6","other","OPPS APC"
"Annual Depression Screening 15","PX-51000130","CDM","G0444","HCPCS","0510","RC","","","","both","","","68.00","51.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.67","7.87","34.67","1 through 10","21.08","64.6","other","OPPS APC"
"Annual Depression Screening 15","PX-51000130","CDM","G0444","HCPCS","0510","RC","","","","both","","","68.00","51.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","34.67","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","34.67","34.67","34.67","1 through 10","21.08","64.6","other","OPPS APC"
"Annual Depression Screening 15","PX-51000130","CDM","G0444","HCPCS","0510","RC","","","","both","","","68.00","51.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","34.67","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","34.68","9.54","34.68","65","21.08","64.6","other","OPPS APC"
"Annual Well Visit Including Ppps Subseq","PX-98301300","CDM","G0439","CPT","0983","RC","","","","both","","","586.00","439.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","465.87","79.5","","683.12","683.12","683.12","1 through 10","137.68","556.7","percent of total billed charges",""
"Annual Well Visit Including Ppps Subseq","PX-98301300","CDM","G0439","CPT","0983","RC","","","","both","","","586.00","439.50","MOLINA [1014]","HB BWH MOLINA","205.10","35","","278.17","278.17","278.17","1 through 10","137.68","556.7","percent of total billed charges",""
"Annual Well Visit Including Ppps Subseq","PX-98301300","CDM","G0439","CPT","0983","RC","","","","outpatient","","","586.00","439.50","AETNA [1001]","HB AMC AETNA HMO","409.03","69.8","","587.64","414.90","587.64","1 through 10","106.12","478.88","percent of total billed charges",""
"Annual Well Visit Including Ppps Subseq","PX-98301300","CDM","G0439","CPT","0983","RC","","","","outpatient","","","586.00","439.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","478.88","81.72","","693.88","381.66","693.88","1 through 10","106.12","478.88","percent of total billed charges",""
"Annual Wellness Visit (PPS) Initial","PX-51000134","CDM","G0438","HCPCS","0510","RC","","","","outpatient","","","1322.00","991.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1080.34","81.72","","563.70","563.70","563.70","1 through 10","106.12","1090.65","percent of total billed charges",""
"Annual Wellness Visit (PPS) Initial","PX-51000138","CDM","G0438","HCPCS","0510","RC","","","","outpatient","","","1322.00","991.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1080.34","81.72","","563.70","563.70","563.70","1 through 10","106.12","1090.65","percent of total billed charges",""
"Annual Wellness Visit (PPS) Subseq","PX-51000135","CDM","G0439","HCPCS","0510","RC","","","","both","","","895.00","671.25","MOLINA [1014]","HB BWH MOLINA","313.25","35","","278.17","278.17","278.17","1 through 10","137.68","850.25","percent of total billed charges",""
"Annual Wellness Visit (PPS) Subseq","PX-51000135","CDM","G0439","HCPCS","0510","RC","","","","outpatient","","","895.00","671.25","AETNA [1001]","HB AMC AETNA HMO","624.71","69.8","","587.64","414.90","587.64","1 through 10","40.19","738.38","percent of total billed charges",""
"Annual Wellness Visit (PPS) Subseq","PX-51000135","CDM","G0439","HCPCS","0510","RC","","","","outpatient","","","895.00","671.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","305.20","34.1","","683.12","683.12","683.12","1 through 10","40.19","738.38","percent of total billed charges",""
"Annual Wellness Visit (PPS) Subseq","PX-51000135","CDM","G0439","HCPCS","0510","RC","","","","outpatient","","","895.00","671.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","731.39","81.72","","693.88","381.66","693.88","1 through 10","40.19","738.38","percent of total billed charges",""
"Annual Wellness Visit (PPS) Subseq","PX-51000139","CDM","G0439","HCPCS","0510","RC","","","","both","","","895.00","671.25","MOLINA [1014]","HB BWH MOLINA","313.25","35","","278.17","278.17","278.17","1 through 10","137.68","850.25","percent of total billed charges",""
"Annual Wellness Visit (PPS) Subseq","PX-51000139","CDM","G0439","HCPCS","0510","RC","","","","outpatient","","","895.00","671.25","AETNA [1001]","HB AMC AETNA HMO","624.71","69.8","","587.64","414.90","587.64","1 through 10","40.19","738.38","percent of total billed charges",""
"Annual Wellness Visit (PPS) Subseq","PX-51000139","CDM","G0439","HCPCS","0510","RC","","","","outpatient","","","895.00","671.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","305.20","34.1","","683.12","683.12","683.12","1 through 10","40.19","738.38","percent of total billed charges",""
"Annual Wellness Visit (PPS) Subseq","PX-51000139","CDM","G0439","HCPCS","0510","RC","","","","outpatient","","","895.00","671.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","731.39","81.72","","693.88","381.66","693.88","1 through 10","40.19","738.38","percent of total billed charges",""
"Anoscopy","PX-75000223","CDM","46600","CPT","0750","RC","","","","both","","","351.00","263.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","187.08","53.3","","267.58","267.58","267.58","1 through 10","108.81","279.05","percent of total billed charges",""
"Anoscopy","PX-75000223","CDM","46600","CPT","0750","RC","","","","both","","","351.00","263.25","WELLPOINT [1015]","HB AMC WELLPOINT","258.97","73.78","","253.13","253.13","253.13","1 through 10","108.81","279.05","percent of total billed charges",""
"Anoscopy","PX-75000223","CDM","46600","CPT","0750","RC","","","","outpatient","","","351.00","263.25","AETNA [1001]","HB AMC AETNA HMO","245.00","69.8","","230.18","230.18","230.18","1 through 10","196.21","700.33","percent of total billed charges",""
"Anoscopy","PX-75000223","CDM","46600","CPT","0750","RC","","","","outpatient","","","351.00","263.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","286.84","81.72","","1947.44","1947.44","1947.44","1 through 10","196.21","700.33","percent of total billed charges",""
"Anoscopy","PX-75000223","CDM","46600","CPT","0761","RC","","","","outpatient","","","351.00","263.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","244.64","244.64","244.64","1 through 10","121.77","183.43","other","ASC"
"Anoscopy","PX-75000223","CDM","46600","CPT","0761","RC","","","","outpatient","","","351.00","263.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","285.06","282.26","285.06","1 through 10","121.77","183.43","other","ASC "
"Anoscopy Dx W/HRA &Chem Agnts Enhancement","PX-75000429","CDM","46601","CPT","0750","RC","","","","both","","","883.00","662.25","MEDICARE [2001]","HB BWH MEDICARE","473.84","","APC Price ($473.84). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","473.88","473.88","473.88","1 through 10","273.73","701.99","other","OPPS APC"
"Anoscopy Dx W/HRA &Chem Agnts Enhancement","PX-75000429","CDM","46601","CPT","0750","RC","","","","outpatient","","","883.00","662.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","244.64","244.64","244.64","1 through 10","121.77","721.59","other","ASC"
"Anoscopy Dx W/HRA &Chem Agnts Enhancement","PX-98302386","CDM","46601","CPT","0983","RC","","","","both","","","600.00","450.00","MEDICARE [2001]","HB BWH MEDICARE","473.84","","APC Price ($473.84). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","473.88","473.88","473.88","1 through 10","186","592.3","other","OPPS APC"
"Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx","PX-75000430","CDM","46607","CPT","0750","RC","","","","both","","","503.00","377.25","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","155.93","1750.11","other","OPPS APC"
"Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx","PX-75000430","CDM","46607","CPT","0750","RC","","","","outpatient","","","503.00","377.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2622.97","2622.97","2622.97","1 through 10","262.87","2384.07","other","ASC "
"Anoscopy Dx W/HRA &Chem Agnts Enhancement W/Bx","PX-98302387","CDM","46607","CPT","0983","RC","","","","both","","","994.00","745.50","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","308.14","1750.11","other","OPPS APC"
"Antegrade Urography Radiological Supvj & Interpj","PX-32000228","CDM","74425","CPT","0320","RC","","","","both","","","1461.00","1095.75","FALLON HEALTH [1008]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.73","419.73","419.73","1 through 10","402.91","1161.5","other","OPPS APC"
"Antegrade Urography Radiological Supvj & Interpj","PX-32000228","CDM","74425","CPT","0320","RC","","","","both","","","1461.00","1095.75","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","402.91","1161.5","other","OPPS APC"
"Antegrade Urography Radiological Supvj & Interpj","PX-32000228","CDM","74425","CPT","0320","RC","","","","both","","","1461.00","1095.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.03","416.03","416.03","1 through 10","402.91","1161.5","other","OPPS APC"
"Antepartum With O.R. Procedure,MAJOR","547","DRG","","","","","","","","inpatient","","","56160.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","43230.21","","Standard inlier is a Case rate ($43,230.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,266, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,136.79) for the length of stay and the standard reimbursement.","43230.21","43230.21","43230.21","1 through 10","7195.76","48602.41","case rate",""
"Antepartum With O.R. Procedure,MAJOR","547","DRG","","","","","","","","inpatient","","","56160.05","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14874.75","","Case rate ($16,446.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,876.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16442.55","16442.55","16442.55","1 through 10","7195.76","48602.41","case rate",""
"Antepartum With O.R. Procedure,MINOR","547","DRG","","","","","","","","inpatient","","","41691.13","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","23394.02","","Standard inlier is a Case rate ($23,394.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,829, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,320.59) for the length of stay and the standard reimbursement.","21372.46","21372.46","23394.02","1 through 10","7195.76","48602.41","case rate",""
"Antepartum With O.R. Procedure,MODERATE","547","DRG","","","","","","","","inpatient","","","71925.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","29093.96","","Standard inlier is a Case rate ($29,093.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,273, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,130.06) for the length of stay and the standard reimbursement.","29093.96","29093.96","29093.96","1 through 10","7195.76","48602.41","case rate",""
"Antepartum With O.R. Procedure,MODERATE","547","DRG","","","","","","","","inpatient","","","71925.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32709.46","","Standard inlier is a Case rate ($32,709.46). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,273, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,642.84) for the length of stay and the standard reimbursement.","32709.45","29882.91","32709.45","1 through 10","7195.76","48602.41","case rate",""
"Antepartum With O.R. Procedure,MODERATE","547","DRG","","","","","","","","inpatient","","","71925.31","","MASSHEALTH [3001]","HB BWH MEDICAID","8891.03","","Case rate ($9,830.57). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,260.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1906.66","1906.66","5967.86","1 through 10","7195.76","48602.41","case rate",""
"Antepartum With O.R. Procedure,MODERATE","547","DRG","","","","","","","","inpatient","","","71925.31","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8891.03","","Case rate ($9,830.57). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,260.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9828.15","9828.15","9828.15","1 through 10","7195.76","48602.41","case rate",""
"Antepartum Without O.R. Procedure,EXTREME","566","DRG","","","","","","","","inpatient","","","79423.58","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38509.78","","Fee schedule rate ($38,509.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38509.78","38509.78","38509.78","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,EXTREME","566","DRG","","","","","","","","inpatient","","","79423.58","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","13073.24","","Case rate ($14,454.71). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,884.71, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14451.16","14451.16","14451.16","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","32269.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","15915.01","","Standard inlier is a Case rate ($15,915.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,024, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,259.23) for the length of stay and the standard reimbursement.","15915.00","15915.00","20471.90","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","32269.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","17892.76","","Standard inlier is a Case rate ($17,892.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,024, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,539.73) for the length of stay and the standard reimbursement.","17892.75","16346.58","33229.81","12","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","32269.65","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","8821.3416","","Fee schedule rate ($17,659.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8821.3416","18499.75","18499.75","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","32269.65","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8401.0452","","Fee schedule rate ($16,817.75). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8401.0452","16817.76","16817.76","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","32269.65","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","8821.3416","","Fee schedule rate ($17,659.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8821.3416","17659.12","18174.51","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","32269.65","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","20748.68","","Fee schedule rate ($20,748.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21022.37","21022.37","21022.37","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","32269.65","","MASSHEALTH [3001]","HB BWH MEDICAID","7341.99","","Case rate ($8,117.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,547.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8115.84","8115.84","8602.78","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","32269.65","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","7341.99","","Case rate ($8,117.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,547.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","32269.65","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17442.56","","Fee schedule rate ($17,442.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17442.56","17442.56","17442.56","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","32269.65","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18314.97","","Fee schedule rate ($18,314.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18314.97","18314.97","18314.97","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","32269.65","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","10501.4004","","Fee schedule rate ($20,748.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10501.4004","20211.82","20211.82","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","32269.65","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7341.99","","Case rate ($8,117.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,547.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3962.94","3.59","8115.84","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MINOR","566","DRG","","","","","","","","inpatient","","","16406.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","8127.29","","Standard inlier is a Case rate ($8,127.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $17,967, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,153.72) for the length of stay and the standard reimbursement.","7408.32","7408.32","9137.26","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MINOR","566","DRG","","","","","","","","inpatient","","","16406.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9137.27","","Standard inlier is a Case rate ($9,137.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $17,967, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,296.96) for the length of stay and the standard reimbursement.","9137.26","9137.26","9137.26","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MINOR","566","DRG","","","","","","","","inpatient","","","16406.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","9137.27","","Standard inlier is a Case rate ($9,137.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $17,967, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,296.96) for the length of stay and the standard reimbursement.","9137.26","8347.68","9137.26","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MINOR","566","DRG","","","","","","","","inpatient","","","16406.10","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8401.0452","","Fee schedule rate ($8,401.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8401.0452","8401.04","8401.04","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MINOR","566","DRG","","","","","","","","inpatient","","","16406.10","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","9241.26","","Fee schedule rate ($9,241.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8885.20","8885.20","9241.28","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MINOR","566","DRG","","","","","","","","inpatient","","","16406.10","","MASSHEALTH [3001]","HB BWH MEDICAID","3720.69","","Case rate ($4,113.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,543.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","48.96","48.96","48.96","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MINOR","566","DRG","","","","","","","","inpatient","","","16406.10","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","3720.69","","Case rate ($4,113.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,543.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2423.35","2423.35","2423.35","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MINOR","566","DRG","","","","","","","","inpatient","","","16406.10","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9855.71","","Fee schedule rate ($9,855.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9855.71","9855.71","9855.71","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MINOR","566","DRG","","","","","","","","inpatient","","","16406.10","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","3720.69","","Case rate ($4,113.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,543.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1125.78","1.54","4112.85","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","24331.24","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","10937.73","","Standard inlier is a Case rate ($10,937.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $20,153, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,552.68) for the length of stay and the standard reimbursement.","10937.72","9970.13","12296.95","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","24331.24","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","12296.95","","Standard inlier is a Case rate ($12,296.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $20,153, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,745.45) for the length of stay and the standard reimbursement.","12296.95","11234.32","22512.84","37","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","24331.24","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8401.0452","","Fee schedule rate ($10,684.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8401.0452","10684.72","10684.72","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","24331.24","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","8821.3416","","Fee schedule rate ($11,219.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8821.3416","11219.28","11219.28","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","24331.24","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","11219.26","","Fee schedule rate ($11,219.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11219.26","11219.26","11219.26","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","24331.24","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","11753.33","","Fee schedule rate ($11,753.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11753.33","11753.33","12333.61","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","24331.24","","MASSHEALTH [3001]","HB BWH MEDICAID","5398.82","","Case rate ($5,969.33). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,399.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5967.86","313.97","5967.86","11","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","24331.24","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","5398.82","","Case rate ($5,969.33). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,399.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","2085.87","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","24331.24","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12233.66","","Fee schedule rate ($12,233.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11877.21","11877.21","12233.66","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","24331.24","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12845.55","","Fee schedule rate ($12,845.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12845.55","12845.55","12845.55","1 through 10","3720.69","254946.65","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","24331.24","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5398.82","","Case rate ($5,969.33). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,399.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5967.86","567.78","5967.86","20","3720.69","254946.65","case rate",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.50","3131.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3319.52","79.5","","800.18","480.96","1887.97","195","1294.41","3319.52","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.50","3131.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2225.54","53.3","","813.12","216.42","1444.50","81","1294.41","3319.52","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.50","3131.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1294.41","31","","432.60","432.60","432.60","1 through 10","1294.41","3319.52","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.50","3131.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1524.06","36.5","","148.37","54.89","631.39","94","1294.41","3319.52","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.50","3131.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1599.22","38.3","","279.30","91.72","1116.77","266","1294.41","3319.52","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.50","3131.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1791.29","42.9","","731.00","63.70","731.00","1 through 10","1294.41","3319.52","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.50","3131.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1791.29","42.9","","384.74","384.74","384.74","1 through 10","1294.41","3319.52","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.50","3131.62","WELLPOINT [1015]","HB AMC WELLPOINT","3080.68","73.78","","286.63","119.22","1107.45","105","1294.41","3319.52","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4175.50","3131.62","AETNA [1001]","HB AMC AETNA HMO","2914.50","69.8","","675.31","184.75","1721.50","286","2182.12","3412.22","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4175.50","3131.62","AETNA [1001]","HB AMC AETNA PPO","3357.10","80.4","","1261.44","103.12","1514.10","21","2182.12","3412.22","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4175.50","3131.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3357.10","80.4","","1365.00","1365.00","1365.00","1 through 10","2182.12","3412.22","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4175.50","3131.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3412.22","81.72","","5157.68","5157.68","5157.68","1 through 10","2182.12","3412.22","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4175.50","3131.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3412.22","81.72","","431.26","71.26","1459.57","88","2182.12","3412.22","percent of total billed charges",""
"ANTHEM DISTAL TIBIA T-PLATE 2.5/3.5MM POLYAXIAL 4 HOLE 76MM SS","SUP-ITM-10325456","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.00","3458.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3665.75","79.5","","800.18","480.96","1887.97","195","1429.41","3665.75","percent of total billed charges",""
"ANTHEM DISTAL TIBIA T-PLATE 2.5/3.5MM POLYAXIAL 4 HOLE 76MM SS","SUP-ITM-10325456","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.00","3458.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2457.66","53.3","","813.12","216.42","1444.50","81","1429.41","3665.75","percent of total billed charges",""
"ANTHEM DISTAL TIBIA T-PLATE 2.5/3.5MM POLYAXIAL 4 HOLE 76MM SS","SUP-ITM-10325456","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.00","3458.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1429.41","31","","432.60","432.60","432.60","1 through 10","1429.41","3665.75","percent of total billed charges",""
"ANTHEM DISTAL TIBIA T-PLATE 2.5/3.5MM POLYAXIAL 4 HOLE 76MM SS","SUP-ITM-10325456","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.00","3458.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1683.02","36.5","","148.37","54.89","631.39","94","1429.41","3665.75","percent of total billed charges",""
"ANTHEM DISTAL TIBIA T-PLATE 2.5/3.5MM POLYAXIAL 4 HOLE 76MM SS","SUP-ITM-10325456","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.00","3458.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1766.01","38.3","","279.30","91.72","1116.77","266","1429.41","3665.75","percent of total billed charges",""
"ANTHEM DISTAL TIBIA T-PLATE 2.5/3.5MM POLYAXIAL 4 HOLE 76MM SS","SUP-ITM-10325456","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.00","3458.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1978.12","42.9","","731.00","63.70","731.00","1 through 10","1429.41","3665.75","percent of total billed charges",""
"ANTHEM DISTAL TIBIA T-PLATE 2.5/3.5MM POLYAXIAL 4 HOLE 76MM SS","SUP-ITM-10325456","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.00","3458.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1978.12","42.9","","384.74","384.74","384.74","1 through 10","1429.41","3665.75","percent of total billed charges",""
"ANTHEM DISTAL TIBIA T-PLATE 2.5/3.5MM POLYAXIAL 4 HOLE 76MM SS","SUP-ITM-10325456","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.00","3458.25","WELLPOINT [1015]","HB AMC WELLPOINT","3402.00","73.78","","286.63","119.22","1107.45","105","1429.41","3665.75","percent of total billed charges",""
"ANTHEM DISTAL TIBIA T-PLATE 2.5/3.5MM POLYAXIAL 4 HOLE 76MM SS","SUP-ITM-10325456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4611.00","3458.25","AETNA [1001]","HB AMC AETNA HMO","3218.48","69.8","","675.31","184.75","1721.50","286","2409.71","3768.11","percent of total billed charges",""
"ANTHEM DISTAL TIBIA T-PLATE 2.5/3.5MM POLYAXIAL 4 HOLE 76MM SS","SUP-ITM-10325456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4611.00","3458.25","AETNA [1001]","HB AMC AETNA PPO","3707.24","80.4","","1261.44","103.12","1514.10","21","2409.71","3768.11","percent of total billed charges",""
"ANTHEM DISTAL TIBIA T-PLATE 2.5/3.5MM POLYAXIAL 4 HOLE 76MM SS","SUP-ITM-10325456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4611.00","3458.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3707.24","80.4","","1365.00","1365.00","1365.00","1 through 10","2409.71","3768.11","percent of total billed charges",""
"ANTHEM DISTAL TIBIA T-PLATE 2.5/3.5MM POLYAXIAL 4 HOLE 76MM SS","SUP-ITM-10325456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4611.00","3458.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3768.11","81.72","","5157.68","5157.68","5157.68","1 through 10","2409.71","3768.11","percent of total billed charges",""
"ANTHEM DISTAL TIBIA T-PLATE 2.5/3.5MM POLYAXIAL 4 HOLE 76MM SS","SUP-ITM-10325456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4611.00","3458.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3768.11","81.72","","431.26","71.26","1459.57","88","2409.71","3768.11","percent of total billed charges",""
"ANTHEM II DOUBLE ROW VOLAR PLATE POLYAXIAL STANDARD LEFT 3 HOLES 49MM SS","SUP-ITM-10325528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3443.94","79.5","","800.18","480.96","1887.97","195","1342.92","3443.94","percent of total billed charges",""
"ANTHEM II DOUBLE ROW VOLAR PLATE POLYAXIAL STANDARD LEFT 3 HOLES 49MM SS","SUP-ITM-10325528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2308.96","53.3","","813.12","216.42","1444.50","81","1342.92","3443.94","percent of total billed charges",""
"ANTHEM II DOUBLE ROW VOLAR PLATE POLYAXIAL STANDARD LEFT 3 HOLES 49MM SS","SUP-ITM-10325528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1342.92","31","","432.60","432.60","432.60","1 through 10","1342.92","3443.94","percent of total billed charges",""
"ANTHEM II DOUBLE ROW VOLAR PLATE POLYAXIAL STANDARD LEFT 3 HOLES 49MM SS","SUP-ITM-10325528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1581.18","36.5","","148.37","54.89","631.39","94","1342.92","3443.94","percent of total billed charges",""
"ANTHEM II DOUBLE ROW VOLAR PLATE POLYAXIAL STANDARD LEFT 3 HOLES 49MM SS","SUP-ITM-10325528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1659.16","38.3","","279.30","91.72","1116.77","266","1342.92","3443.94","percent of total billed charges",""
"ANTHEM II DOUBLE ROW VOLAR PLATE POLYAXIAL STANDARD LEFT 3 HOLES 49MM SS","SUP-ITM-10325528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1858.43","42.9","","731.00","63.70","731.00","1 through 10","1342.92","3443.94","percent of total billed charges",""
"ANTHEM II DOUBLE ROW VOLAR PLATE POLYAXIAL STANDARD LEFT 3 HOLES 49MM SS","SUP-ITM-10325528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1858.43","42.9","","384.74","384.74","384.74","1 through 10","1342.92","3443.94","percent of total billed charges",""
"ANTHEM II DOUBLE ROW VOLAR PLATE POLYAXIAL STANDARD LEFT 3 HOLES 49MM SS","SUP-ITM-10325528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","WELLPOINT [1015]","HB AMC WELLPOINT","3196.15","73.78","","286.63","119.22","1107.45","105","1342.92","3443.94","percent of total billed charges",""
"ANTHEM II DOUBLE ROW VOLAR PLATE POLYAXIAL STANDARD LEFT 3 HOLES 49MM SS","SUP-ITM-10325528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4332.00","3249.00","AETNA [1001]","HB AMC AETNA HMO","3023.74","69.8","","675.31","184.75","1721.50","286","2263.9","3540.11","percent of total billed charges",""
"ANTHEM II DOUBLE ROW VOLAR PLATE POLYAXIAL STANDARD LEFT 3 HOLES 49MM SS","SUP-ITM-10325528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4332.00","3249.00","AETNA [1001]","HB AMC AETNA PPO","3482.93","80.4","","1261.44","103.12","1514.10","21","2263.9","3540.11","percent of total billed charges",""
"ANTHEM II DOUBLE ROW VOLAR PLATE POLYAXIAL STANDARD LEFT 3 HOLES 49MM SS","SUP-ITM-10325528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4332.00","3249.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3482.93","80.4","","1365.00","1365.00","1365.00","1 through 10","2263.9","3540.11","percent of total billed charges",""
"ANTHEM II DOUBLE ROW VOLAR PLATE POLYAXIAL STANDARD LEFT 3 HOLES 49MM SS","SUP-ITM-10325528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4332.00","3249.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3540.11","81.72","","5157.68","5157.68","5157.68","1 through 10","2263.9","3540.11","percent of total billed charges",""
"ANTHEM II DOUBLE ROW VOLAR PLATE POLYAXIAL STANDARD LEFT 3 HOLES 49MM SS","SUP-ITM-10325528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4332.00","3249.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3540.11","81.72","","431.26","71.26","1459.57","88","2263.9","3540.11","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 23 HOLE 331MM","SUP-ITM-10325937","CDM","C1713","HCPCS","0278","RC","","","","both","","","8445.00","6333.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6713.78","79.5","","800.18","480.96","1887.97","195","2617.95","6713.78","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 23 HOLE 331MM","SUP-ITM-10325937","CDM","C1713","HCPCS","0278","RC","","","","both","","","8445.00","6333.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4501.19","53.3","","813.12","216.42","1444.50","81","2617.95","6713.78","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 23 HOLE 331MM","SUP-ITM-10325937","CDM","C1713","HCPCS","0278","RC","","","","both","","","8445.00","6333.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2617.95","31","","432.60","432.60","432.60","1 through 10","2617.95","6713.78","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 23 HOLE 331MM","SUP-ITM-10325937","CDM","C1713","HCPCS","0278","RC","","","","both","","","8445.00","6333.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3082.43","36.5","","148.37","54.89","631.39","94","2617.95","6713.78","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 23 HOLE 331MM","SUP-ITM-10325937","CDM","C1713","HCPCS","0278","RC","","","","both","","","8445.00","6333.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3234.44","38.3","","279.30","91.72","1116.77","266","2617.95","6713.78","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 23 HOLE 331MM","SUP-ITM-10325937","CDM","C1713","HCPCS","0278","RC","","","","both","","","8445.00","6333.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3622.91","42.9","","731.00","63.70","731.00","1 through 10","2617.95","6713.78","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 23 HOLE 331MM","SUP-ITM-10325937","CDM","C1713","HCPCS","0278","RC","","","","both","","","8445.00","6333.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3622.91","42.9","","384.74","384.74","384.74","1 through 10","2617.95","6713.78","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 23 HOLE 331MM","SUP-ITM-10325937","CDM","C1713","HCPCS","0278","RC","","","","both","","","8445.00","6333.75","WELLPOINT [1015]","HB AMC WELLPOINT","6230.72","73.78","","286.63","119.22","1107.45","105","2617.95","6713.78","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 23 HOLE 331MM","SUP-ITM-10325937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8445.00","6333.75","AETNA [1001]","HB AMC AETNA HMO","5894.61","69.8","","675.31","184.75","1721.50","286","4413.36","6901.25","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 23 HOLE 331MM","SUP-ITM-10325937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8445.00","6333.75","AETNA [1001]","HB AMC AETNA PPO","6789.78","80.4","","1261.44","103.12","1514.10","21","4413.36","6901.25","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 23 HOLE 331MM","SUP-ITM-10325937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8445.00","6333.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6789.78","80.4","","1365.00","1365.00","1365.00","1 through 10","4413.36","6901.25","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 23 HOLE 331MM","SUP-ITM-10325937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8445.00","6333.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6901.25","81.72","","5157.68","5157.68","5157.68","1 through 10","4413.36","6901.25","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 23 HOLE 331MM","SUP-ITM-10325937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8445.00","6333.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6901.25","81.72","","431.26","71.26","1459.57","88","4413.36","6901.25","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 26 HOLE 363MM","SUP-ITM-10325938","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6886.69","79.5","","800.18","480.96","1887.97","195","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 26 HOLE 363MM","SUP-ITM-10325938","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4617.11","53.3","","813.12","216.42","1444.50","81","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 26 HOLE 363MM","SUP-ITM-10325938","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2685.38","31","","432.60","432.60","432.60","1 through 10","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 26 HOLE 363MM","SUP-ITM-10325938","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3161.81","36.5","","148.37","54.89","631.39","94","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 26 HOLE 363MM","SUP-ITM-10325938","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3317.74","38.3","","279.30","91.72","1116.77","266","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 26 HOLE 363MM","SUP-ITM-10325938","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3716.21","42.9","","731.00","63.70","731.00","1 through 10","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 26 HOLE 363MM","SUP-ITM-10325938","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3716.21","42.9","","384.74","384.74","384.74","1 through 10","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 26 HOLE 363MM","SUP-ITM-10325938","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","WELLPOINT [1015]","HB AMC WELLPOINT","6391.19","73.78","","286.63","119.22","1107.45","105","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 26 HOLE 363MM","SUP-ITM-10325938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8662.50","6496.87","AETNA [1001]","HB AMC AETNA HMO","6046.43","69.8","","675.31","184.75","1721.50","286","4527.02","7079","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 26 HOLE 363MM","SUP-ITM-10325938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8662.50","6496.87","AETNA [1001]","HB AMC AETNA PPO","6964.65","80.4","","1261.44","103.12","1514.10","21","4527.02","7079","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 26 HOLE 363MM","SUP-ITM-10325938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8662.50","6496.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6964.65","80.4","","1365.00","1365.00","1365.00","1 through 10","4527.02","7079","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 26 HOLE 363MM","SUP-ITM-10325938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8662.50","6496.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7079.00","81.72","","5157.68","5157.68","5157.68","1 through 10","4527.02","7079","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 26 HOLE 363MM","SUP-ITM-10325938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8662.50","6496.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7079.00","81.72","","431.26","71.26","1459.57","88","4527.02","7079","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 29 HOLE 395MM","SUP-ITM-10325939","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7005.94","79.5","","800.18","480.96","1887.97","195","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 29 HOLE 395MM","SUP-ITM-10325939","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4697.06","53.3","","813.12","216.42","1444.50","81","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 29 HOLE 395MM","SUP-ITM-10325939","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2731.88","31","","432.60","432.60","432.60","1 through 10","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 29 HOLE 395MM","SUP-ITM-10325939","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3216.56","36.5","","148.37","54.89","631.39","94","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 29 HOLE 395MM","SUP-ITM-10325939","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3375.19","38.3","","279.30","91.72","1116.77","266","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 29 HOLE 395MM","SUP-ITM-10325939","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3780.56","42.9","","731.00","63.70","731.00","1 through 10","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 29 HOLE 395MM","SUP-ITM-10325939","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3780.56","42.9","","384.74","384.74","384.74","1 through 10","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 29 HOLE 395MM","SUP-ITM-10325939","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","WELLPOINT [1015]","HB AMC WELLPOINT","6501.86","73.78","","286.63","119.22","1107.45","105","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 29 HOLE 395MM","SUP-ITM-10325939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8812.50","6609.37","AETNA [1001]","HB AMC AETNA HMO","6151.13","69.8","","675.31","184.75","1721.50","286","4605.41","7201.58","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 29 HOLE 395MM","SUP-ITM-10325939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8812.50","6609.37","AETNA [1001]","HB AMC AETNA PPO","7085.25","80.4","","1261.44","103.12","1514.10","21","4605.41","7201.58","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 29 HOLE 395MM","SUP-ITM-10325939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8812.50","6609.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7085.25","80.4","","1365.00","1365.00","1365.00","1 through 10","4605.41","7201.58","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 29 HOLE 395MM","SUP-ITM-10325939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8812.50","6609.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7201.58","81.72","","5157.68","5157.68","5157.68","1 through 10","4605.41","7201.58","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE LEFT 29 HOLE 395MM","SUP-ITM-10325939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8812.50","6609.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7201.58","81.72","","431.26","71.26","1459.57","88","4605.41","7201.58","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 14 HOLE 234MM","SUP-ITM-10325945","CDM","C1713","HCPCS","0278","RC","","","","both","","","7920.00","5940.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6296.40","79.5","","800.18","480.96","1887.97","195","2455.2","6296.4","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 14 HOLE 234MM","SUP-ITM-10325945","CDM","C1713","HCPCS","0278","RC","","","","both","","","7920.00","5940.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4221.36","53.3","","813.12","216.42","1444.50","81","2455.2","6296.4","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 14 HOLE 234MM","SUP-ITM-10325945","CDM","C1713","HCPCS","0278","RC","","","","both","","","7920.00","5940.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2455.20","31","","432.60","432.60","432.60","1 through 10","2455.2","6296.4","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 14 HOLE 234MM","SUP-ITM-10325945","CDM","C1713","HCPCS","0278","RC","","","","both","","","7920.00","5940.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2890.80","36.5","","148.37","54.89","631.39","94","2455.2","6296.4","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 14 HOLE 234MM","SUP-ITM-10325945","CDM","C1713","HCPCS","0278","RC","","","","both","","","7920.00","5940.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3033.36","38.3","","279.30","91.72","1116.77","266","2455.2","6296.4","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 14 HOLE 234MM","SUP-ITM-10325945","CDM","C1713","HCPCS","0278","RC","","","","both","","","7920.00","5940.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3397.68","42.9","","731.00","63.70","731.00","1 through 10","2455.2","6296.4","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 14 HOLE 234MM","SUP-ITM-10325945","CDM","C1713","HCPCS","0278","RC","","","","both","","","7920.00","5940.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3397.68","42.9","","384.74","384.74","384.74","1 through 10","2455.2","6296.4","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 14 HOLE 234MM","SUP-ITM-10325945","CDM","C1713","HCPCS","0278","RC","","","","both","","","7920.00","5940.00","WELLPOINT [1015]","HB AMC WELLPOINT","5843.38","73.78","","286.63","119.22","1107.45","105","2455.2","6296.4","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 14 HOLE 234MM","SUP-ITM-10325945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7920.00","5940.00","AETNA [1001]","HB AMC AETNA HMO","5528.16","69.8","","675.31","184.75","1721.50","286","4138.99","6472.22","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 14 HOLE 234MM","SUP-ITM-10325945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7920.00","5940.00","AETNA [1001]","HB AMC AETNA PPO","6367.68","80.4","","1261.44","103.12","1514.10","21","4138.99","6472.22","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 14 HOLE 234MM","SUP-ITM-10325945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7920.00","5940.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6367.68","80.4","","1365.00","1365.00","1365.00","1 through 10","4138.99","6472.22","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 14 HOLE 234MM","SUP-ITM-10325945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7920.00","5940.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6472.22","81.72","","5157.68","5157.68","5157.68","1 through 10","4138.99","6472.22","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 14 HOLE 234MM","SUP-ITM-10325945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7920.00","5940.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6472.22","81.72","","431.26","71.26","1459.57","88","4138.99","6472.22","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 20 HOLE 299MM","SUP-ITM-10325947","CDM","C1713","HCPCS","0278","RC","","","","both","","","8220.00","6165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6534.90","79.5","","800.18","480.96","1887.97","195","2548.2","6534.9","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 20 HOLE 299MM","SUP-ITM-10325947","CDM","C1713","HCPCS","0278","RC","","","","both","","","8220.00","6165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4381.26","53.3","","813.12","216.42","1444.50","81","2548.2","6534.9","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 20 HOLE 299MM","SUP-ITM-10325947","CDM","C1713","HCPCS","0278","RC","","","","both","","","8220.00","6165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2548.20","31","","432.60","432.60","432.60","1 through 10","2548.2","6534.9","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 20 HOLE 299MM","SUP-ITM-10325947","CDM","C1713","HCPCS","0278","RC","","","","both","","","8220.00","6165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3000.30","36.5","","148.37","54.89","631.39","94","2548.2","6534.9","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 20 HOLE 299MM","SUP-ITM-10325947","CDM","C1713","HCPCS","0278","RC","","","","both","","","8220.00","6165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3148.26","38.3","","279.30","91.72","1116.77","266","2548.2","6534.9","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 20 HOLE 299MM","SUP-ITM-10325947","CDM","C1713","HCPCS","0278","RC","","","","both","","","8220.00","6165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3526.38","42.9","","731.00","63.70","731.00","1 through 10","2548.2","6534.9","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 20 HOLE 299MM","SUP-ITM-10325947","CDM","C1713","HCPCS","0278","RC","","","","both","","","8220.00","6165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3526.38","42.9","","384.74","384.74","384.74","1 through 10","2548.2","6534.9","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 20 HOLE 299MM","SUP-ITM-10325947","CDM","C1713","HCPCS","0278","RC","","","","both","","","8220.00","6165.00","WELLPOINT [1015]","HB AMC WELLPOINT","6064.72","73.78","","286.63","119.22","1107.45","105","2548.2","6534.9","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 20 HOLE 299MM","SUP-ITM-10325947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8220.00","6165.00","AETNA [1001]","HB AMC AETNA HMO","5737.56","69.8","","675.31","184.75","1721.50","286","4295.77","6717.38","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 20 HOLE 299MM","SUP-ITM-10325947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8220.00","6165.00","AETNA [1001]","HB AMC AETNA PPO","6608.88","80.4","","1261.44","103.12","1514.10","21","4295.77","6717.38","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 20 HOLE 299MM","SUP-ITM-10325947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8220.00","6165.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6608.88","80.4","","1365.00","1365.00","1365.00","1 through 10","4295.77","6717.38","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 20 HOLE 299MM","SUP-ITM-10325947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8220.00","6165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6717.38","81.72","","5157.68","5157.68","5157.68","1 through 10","4295.77","6717.38","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 20 HOLE 299MM","SUP-ITM-10325947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8220.00","6165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6717.38","81.72","","431.26","71.26","1459.57","88","4295.77","6717.38","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 26 HOLE 363MM","SUP-ITM-10325949","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6886.69","79.5","","800.18","480.96","1887.97","195","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 26 HOLE 363MM","SUP-ITM-10325949","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4617.11","53.3","","813.12","216.42","1444.50","81","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 26 HOLE 363MM","SUP-ITM-10325949","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2685.38","31","","432.60","432.60","432.60","1 through 10","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 26 HOLE 363MM","SUP-ITM-10325949","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3161.81","36.5","","148.37","54.89","631.39","94","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 26 HOLE 363MM","SUP-ITM-10325949","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3317.74","38.3","","279.30","91.72","1116.77","266","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 26 HOLE 363MM","SUP-ITM-10325949","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3716.21","42.9","","731.00","63.70","731.00","1 through 10","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 26 HOLE 363MM","SUP-ITM-10325949","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3716.21","42.9","","384.74","384.74","384.74","1 through 10","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 26 HOLE 363MM","SUP-ITM-10325949","CDM","C1713","HCPCS","0278","RC","","","","both","","","8662.50","6496.87","WELLPOINT [1015]","HB AMC WELLPOINT","6391.19","73.78","","286.63","119.22","1107.45","105","2685.38","6886.69","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 26 HOLE 363MM","SUP-ITM-10325949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8662.50","6496.87","AETNA [1001]","HB AMC AETNA HMO","6046.43","69.8","","675.31","184.75","1721.50","286","4527.02","7079","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 26 HOLE 363MM","SUP-ITM-10325949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8662.50","6496.87","AETNA [1001]","HB AMC AETNA PPO","6964.65","80.4","","1261.44","103.12","1514.10","21","4527.02","7079","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 26 HOLE 363MM","SUP-ITM-10325949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8662.50","6496.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6964.65","80.4","","1365.00","1365.00","1365.00","1 through 10","4527.02","7079","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 26 HOLE 363MM","SUP-ITM-10325949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8662.50","6496.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7079.00","81.72","","5157.68","5157.68","5157.68","1 through 10","4527.02","7079","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 26 HOLE 363MM","SUP-ITM-10325949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8662.50","6496.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7079.00","81.72","","431.26","71.26","1459.57","88","4527.02","7079","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 29 HOLE 395MM","SUP-ITM-10325950","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7005.94","79.5","","800.18","480.96","1887.97","195","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 29 HOLE 395MM","SUP-ITM-10325950","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4697.06","53.3","","813.12","216.42","1444.50","81","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 29 HOLE 395MM","SUP-ITM-10325950","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2731.88","31","","432.60","432.60","432.60","1 through 10","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 29 HOLE 395MM","SUP-ITM-10325950","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3216.56","36.5","","148.37","54.89","631.39","94","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 29 HOLE 395MM","SUP-ITM-10325950","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3375.19","38.3","","279.30","91.72","1116.77","266","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 29 HOLE 395MM","SUP-ITM-10325950","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3780.56","42.9","","731.00","63.70","731.00","1 through 10","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 29 HOLE 395MM","SUP-ITM-10325950","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3780.56","42.9","","384.74","384.74","384.74","1 through 10","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 29 HOLE 395MM","SUP-ITM-10325950","CDM","C1713","HCPCS","0278","RC","","","","both","","","8812.50","6609.37","WELLPOINT [1015]","HB AMC WELLPOINT","6501.86","73.78","","286.63","119.22","1107.45","105","2731.88","7005.94","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 29 HOLE 395MM","SUP-ITM-10325950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8812.50","6609.37","AETNA [1001]","HB AMC AETNA HMO","6151.13","69.8","","675.31","184.75","1721.50","286","4605.41","7201.58","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 29 HOLE 395MM","SUP-ITM-10325950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8812.50","6609.37","AETNA [1001]","HB AMC AETNA PPO","7085.25","80.4","","1261.44","103.12","1514.10","21","4605.41","7201.58","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 29 HOLE 395MM","SUP-ITM-10325950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8812.50","6609.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7085.25","80.4","","1365.00","1365.00","1365.00","1 through 10","4605.41","7201.58","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 29 HOLE 395MM","SUP-ITM-10325950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8812.50","6609.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7201.58","81.72","","5157.68","5157.68","5157.68","1 through 10","4605.41","7201.58","percent of total billed charges",""
"ANTHEM TI LATERAL BROAD DISTAL FEMUR PLATE RIGHT 29 HOLE 395MM","SUP-ITM-10325950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8812.50","6609.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7201.58","81.72","","431.26","71.26","1459.57","88","4605.41","7201.58","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","207.00","155.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","135.79","65.6","","166.14","166.14","166.14","1 through 10","13.35","196.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","207.00","155.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","164.57","79.5","","167.63","112.46","167.63","111","13.35","196.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","207.00","155.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","110.33","53.3","","112.46","112.46","167.63","44","13.35","196.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","207.00","155.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","159.39","77","","164.01","164.01","164.01","1 through 10","13.35","196.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","207.00","155.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","64.17","31","","65.82","65.82","65.82","1 through 10","13.35","196.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","207.00","155.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","75.56","36.5","","79.45","67.52","238.35","91","13.35","196.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","207.00","155.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","79.28","38.3","","83.28","80.94","242.82","207","13.35","196.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","207.00","155.25","TRICARE [160005]","HB BWH TRICARE","196.65","95","","19.77","19.77","20.81","12","13.35","196.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.80","42.9","","170.27","93.66","249.84","1 through 10","13.35","196.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","207.00","155.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.80","42.9","","93.66","93.66","93.66","1 through 10","13.35","196.65","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","outpatient","","","207.00","155.25","AETNA [1001]","HB AMC AETNA HMO","144.49","69.8","","144.20","101.81","166.14","90","13.35","169.16","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","outpatient","","","207.00","155.25","AETNA [1001]","HB AMC AETNA PPO","166.43","80.4","","166.14","111.61","223.22","20","13.35","169.16","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","outpatient","","","207.00","155.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","115.71","55.9","","111.61","111.61","111.61","1 through 10","13.35","169.16","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","outpatient","","","207.00","155.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","108.18","52.26","","49.50","49.50","49.50","1 through 10","13.35","169.16","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","outpatient","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","169.16","81.72","","170.27","93.66","170.27","1 through 10","13.35","169.16","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","outpatient","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","169.16","81.72","","170.27","93.66","170.27","133","13.35","169.16","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Anti-Golimumab Antibody","PX-30003527","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Anti-Phosphatidylserine Antibody","PX-30000793","CDM","86148","CPT","0302","RC","","","","both","","","224.00","168.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","178.08","79.5","","170.78","163.62","293.48","1 through 10","14.19","212.8","percent of total billed charges",""
"Anti-Phosphatidylserine Antibody","PX-30000793","CDM","86148","CPT","0302","RC","","","","both","","","224.00","168.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","119.39","53.3","","114.58","114.58","229.15","1 through 10","14.19","212.8","percent of total billed charges",""
"Anti-Phosphatidylserine Antibody","PX-30000793","CDM","86148","CPT","0302","RC","","","","both","","","224.00","168.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","172.48","77","","167.09","167.09","167.09","1 through 10","14.19","212.8","percent of total billed charges",""
"Anti-Phosphatidylserine Antibody","PX-30000793","CDM","86148","CPT","0302","RC","","","","both","","","224.00","168.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","81.76","36.5","","80.94","68.79","242.82","18","14.19","212.8","percent of total billed charges",""
"Anti-Phosphatidylserine Antibody","PX-30000793","CDM","86148","CPT","0302","RC","","","","both","","","224.00","168.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","85.79","38.3","","84.85","82.46","254.54","30","14.19","212.8","percent of total billed charges",""
"Anti-Phosphatidylserine Antibody","PX-30000793","CDM","86148","CPT","0302","RC","","","","outpatient","","","224.00","168.00","AETNA [1001]","HB AMC AETNA HMO","156.35","69.8","","146.91","103.73","146.91","1 through 10","14.19","183.05","percent of total billed charges",""
"Anti-Phosphatidylserine Antibody","PX-30000793","CDM","86148","CPT","0302","RC","","","","outpatient","","","224.00","168.00","AETNA [1001]","HB AMC AETNA PPO","180.10","80.4","","169.26","169.26","169.26","1 through 10","14.19","183.05","percent of total billed charges",""
"Anti-Phosphatidylserine Antibody","PX-30000793","CDM","86148","CPT","0302","RC","","","","outpatient","","","224.00","168.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","180.10","80.4","","217.00","217.00","217.00","1 through 10","14.19","183.05","percent of total billed charges",""
"Anti-Phosphatidylserine Antibody","PX-30000793","CDM","86148","CPT","0302","RC","","","","outpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.05","81.72","","173.47","95.42","346.94","1 through 10","14.19","183.05","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Antibody Sars-Cov-2","PX-30003647","CDM","86769","CPT","0300","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","74.60","74.60","74.60","1 through 10","41.29","190","percent of total billed charges",""
"Antibody Sars-Cov-2","PX-30003647","CDM","86769","CPT","0300","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","234.60","76.00","234.60","1 through 10","41.29","190","percent of total billed charges",""
"Antibody Sars-Cov-2","PX-30003647","CDM","86769","CPT","0300","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","42.17","42.17","95.60","1 through 10","72.6","258.32","percent of total billed charges",""
"Antibody Sars-Cov-2","PX-30003647","CDM","86769","CPT","0300","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","159.88","152.18","159.88","1 through 10","72.6","258.32","percent of total billed charges",""
"Anticoagulant Poisoning Panel, S/P","PX-30003403","CDM","80377","CPT","0301","RC","","","","both","","","386.00","289.50","WELLPOINT [1015]","HB AMC WELLPOINT","284.79","73.78","","748.00","278.44","748.00","1 through 10","119.66","366.7","percent of total billed charges",""
"Antigbm","PX-30003378","CDM","86021","CPT","0302","RC","","","","both","","","253.00","189.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","177.10","70","","107.73","107.73","107.73","1 through 10","14.75","240.35","percent of total billed charges",""
"Antigbm","PX-30003378","CDM","86021","CPT","0302","RC","","","","both","","","253.00","189.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","201.14","79.5","","129.36","129.36","192.82","1 through 10","14.75","240.35","percent of total billed charges",""
"Antigbm","PX-30003378","CDM","86021","CPT","0302","RC","","","","both","","","253.00","189.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","92.35","36.5","","91.39","91.39","91.39","1 through 10","14.75","240.35","percent of total billed charges",""
"Antigbm","PX-30003378","CDM","86021","CPT","0302","RC","","","","both","","","253.00","189.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.90","38.3","","95.80","95.80","95.80","1 through 10","14.75","240.35","percent of total billed charges",""
"Antigbm","PX-30003378","CDM","86021","CPT","0302","RC","","","","outpatient","","","253.00","189.75","AETNA [1001]","HB AMC AETNA HMO","176.59","69.8","","165.87","117.11","191.10","1 through 10","15.53","206.75","percent of total billed charges",""
"Antigbm","PX-30003378","CDM","86021","CPT","0302","RC","","","","outpatient","","","253.00","189.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","206.75","81.72","","195.85","107.73","195.85","1 through 10","15.53","206.75","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","143.00","107.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","100.10","70","","61.12","61.12","61.12","1 through 10","11.81","135.85","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","143.00","107.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","113.69","79.5","","109.39","73.39","109.39","29","11.81","135.85","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","143.00","107.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","76.22","53.3","","73.39","73.39","109.39","11","11.81","135.85","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","143.00","107.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","110.11","77","","321.09","107.03","321.09","1 through 10","11.81","135.85","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","92.95","65","","90.35","90.35","90.35","1 through 10","11.81","135.85","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","113.69","79.5","","109.39","109.39","109.39","1 through 10","11.81","135.85","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","143.00","107.25","TRICARE [160005]","HB BWH TRICARE","135.85","95","","139.00","14.52","139.00","1 through 10","11.81","135.85","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.35","42.9","","111.12","61.12","111.12","1 through 10","11.81","135.85","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","143.00","107.25","WELLPOINT [1015]","HB AMC WELLPOINT","105.51","73.78","","103.49","103.49","242.49","36","11.81","135.85","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","143.00","107.25","AETNA [1001]","HB AMC AETNA HMO","99.81","69.8","","94.10","66.44","108.42","48","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","143.00","107.25","AETNA [1001]","HB AMC AETNA PPO","114.97","80.4","","108.42","12.40","108.42","1 through 10","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","75.08","52.5","","80.06","80.06","91.05","1 through 10","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","71.50","50","","72.84","69.92","218.52","72","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","75.08","52.5","","76.45","76.45","229.35","30","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","89.38","62.5","","91.05","73.81","91.05","1 through 10","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","75.08","52.5","","61.99","61.99","61.99","1 through 10","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","78.65","55","","80.06","64.91","80.06","13","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","114.97","80.4","","108.42","69.50","108.42","1 through 10","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","116.86","81.72","","139.00","139.00","139.00","1 through 10","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","116.86","81.72","","111.12","61.12","111.12","1 through 10","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","116.86","81.72","","111.12","61.12","111.12","36","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","both","","","143.00","107.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","100.10","70","","61.12","61.12","61.12","1 through 10","11.81","135.85","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","both","","","143.00","107.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","76.22","53.3","","109.39","109.39","109.39","1 through 10","11.81","135.85","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","both","","","143.00","107.25","WELLPOINT [1015]","HB AMC WELLPOINT","105.51","73.78","","242.49","103.49","242.49","1 through 10","11.81","135.85","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","outpatient","","","143.00","107.25","AETNA [1001]","HB AMC AETNA HMO","99.81","69.8","","66.44","66.44","94.10","1 through 10","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","75.08","52.5","","80.06","80.06","80.06","1 through 10","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","71.50","50","","72.84","72.84","72.84","1 through 10","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","78.65","55","","80.06","77.01","80.06","1 through 10","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","outpatient","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","114.97","80.4","","108.42","108.42","108.42","1 through 10","34.67","117.98","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Titer Ea Antb","PX-30003763","CDM","86037","CPT","0302","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","116.86","81.72","","111.12","111.11","111.12","1 through 10","34.67","117.98","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","153.00","114.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","107.10","70","","148.00","148.00","148.00","1 through 10","11.85","145.35","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","78.14","349.44","120","11.85","145.35","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.55","53.3","","116.48","78.14","234.42","77","11.85","145.35","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","153.00","114.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","117.81","77","","341.88","113.96","341.88","1 through 10","11.85","145.35","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","99.45","65","","96.20","96.20","96.20","1 through 10","11.85","145.35","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","116.48","116.48","1 through 10","11.85","145.35","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","47.43","31","","45.73","45.73","45.73","1 through 10","11.85","145.35","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.85","36.5","","55.20","46.47","79.99","95","11.85","145.35","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","57.87","56.24","173.61","366","11.85","145.35","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","153.00","114.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","117.81","77","","148.00","11.85","148.00","1 through 10","11.85","145.35","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","153.00","114.75","TRICARE [160005]","HB BWH TRICARE","145.35","95","","14.57","13.84","14.57","1 through 10","11.85","145.35","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.64","42.9","","118.31","65.08","118.31","1 through 10","11.85","145.35","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","100.20","70.74","115.44","160","12.46","125.03","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA PPO","123.01","80.4","","115.44","77.55","230.88","20","12.46","125.03","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","85.53","55.9","","77.55","77.55","77.55","1 through 10","12.46","125.03","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","123.01","80.4","","74.00","74.00","115.44","1 through 10","12.46","125.03","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","125.03","81.72","","148.00","148.00","148.00","1 through 10","12.46","125.03","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","125.03","81.72","","118.31","65.08","118.31","1 through 10","12.46","125.03","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","118.31","65.08","118.31","141","12.46","125.03","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","both","","","184.00","138.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","146.28","79.5","","140.09","93.98","420.27","26","10.94","174.8","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","both","","","184.00","138.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","98.07","53.3","","93.98","93.98","420.27","24","10.94","174.8","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","both","","","184.00","138.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","141.68","77","","137.06","137.06","137.06","1 through 10","10.94","174.8","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","both","","","184.00","138.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.16","36.5","","66.39","56.43","72.64","20","10.94","174.8","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","both","","","184.00","138.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.47","38.3","","69.60","67.64","208.80","63","10.94","174.8","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","both","","","184.00","138.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","141.68","77","","10.94","10.94","10.94","1 through 10","10.94","174.8","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","both","","","184.00","138.00","TRICARE [160005]","HB BWH TRICARE","174.80","95","","13.45","12.78","13.45","1 through 10","10.94","174.8","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","both","","","184.00","138.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.94","42.9","","142.29","142.29","142.29","1 through 10","10.94","174.8","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","outpatient","","","184.00","138.00","AETNA [1001]","HB AMC AETNA HMO","128.43","69.8","","120.51","85.08","120.51","28","11.5","150.36","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","outpatient","","","184.00","138.00","AETNA [1001]","HB AMC AETNA PPO","147.94","80.4","","93.27","11.49","138.84","1 through 10","11.5","150.36","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","outpatient","","","184.00","138.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","102.86","55.9","","93.27","93.27","93.27","1 through 10","11.5","150.36","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","outpatient","","","184.00","138.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","147.94","80.4","","89.00","89.00","89.00","1 through 10","11.5","150.36","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","outpatient","","","184.00","138.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","150.36","81.72","","142.29","78.27","142.29","33","11.5","150.36","percent of total billed charges",""
"Antistreptolysin O Titer","PX-30000785","CDM","86060","CPT","0302","RC","","","","both","","","122.00","91.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","96.99","79.5","","92.87","92.87","92.87","1 through 10","7.15","115.9","percent of total billed charges",""
"Antistreptolysin O Titer","PX-30000785","CDM","86060","CPT","0302","RC","","","","both","","","122.00","91.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.53","36.5","","37.05","37.05","37.05","1 through 10","7.15","115.9","percent of total billed charges",""
"Antistreptolysin O Titer","PX-30000785","CDM","86060","CPT","0302","RC","","","","both","","","122.00","91.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.73","38.3","","46.14","38.94","134.52","1 through 10","7.15","115.9","percent of total billed charges",""
"Antistreptolysin O Titer","PX-30000785","CDM","86060","CPT","0302","RC","","","","outpatient","","","122.00","91.50","AETNA [1001]","HB AMC AETNA HMO","85.16","69.8","","56.40","56.40","79.89","1 through 10","7.53","99.7","percent of total billed charges",""
"Antistreptolysin O Titer","PX-30000785","CDM","86060","CPT","0302","RC","","","","outpatient","","","122.00","91.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","63.76","52.26","","73.02","73.02","73.02","1 through 10","7.53","99.7","percent of total billed charges",""
"Antistreptolysin O Titer","PX-30000785","CDM","86060","CPT","0302","RC","","","","outpatient","","","122.00","91.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","99.70","81.72","","94.33","51.88","94.33","1 through 10","7.53","99.7","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","both","","","203.00","152.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","142.10","70","","197.00","86.62","197.00","1 through 10","11.61","192.85","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","both","","","203.00","152.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","161.39","79.5","","155.04","104.02","465.12","1 through 10","11.61","192.85","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","both","","","203.00","152.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","108.20","53.3","","312.06","104.02","465.12","1 through 10","11.61","192.85","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","both","","","203.00","152.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","131.95","65","","128.05","122.20","128.05","1 through 10","11.61","192.85","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","both","","","203.00","152.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.10","36.5","","187.35","71.31","514.36","21","11.61","192.85","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","both","","","203.00","152.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.75","38.3","","77.03","77.03","231.09","26","11.61","192.85","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","both","","","203.00","152.25","TRICARE [160005]","HB BWH TRICARE","192.85","95","","13.57","13.57","13.57","1 through 10","11.61","192.85","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","outpatient","","","203.00","152.25","AETNA [1001]","HB AMC AETNA HMO","141.69","69.8","","133.37","94.17","188.34","15","12.22","165.89","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","outpatient","","","203.00","152.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.89","81.72","","157.48","86.62","157.48","1 through 10","12.22","165.89","percent of total billed charges",""
"Antithrombin III Antigen","PX-30001072","CDM","85301","CPT","0305","RC","","","","both","","","193.00","144.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","135.10","70","","134.64","134.64","134.64","1 through 10","10.59","183.35","percent of total billed charges",""
"Antithrombin III Antigen","PX-30001072","CDM","85301","CPT","0305","RC","","","","both","","","193.00","144.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","153.44","79.5","","98.74","98.74","98.74","1 through 10","10.59","183.35","percent of total billed charges",""
"Antithrombin III Antigen","PX-30001072","CDM","85301","CPT","0305","RC","","","","both","","","193.00","144.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","102.87","53.3","","98.74","98.74","98.74","1 through 10","10.59","183.35","percent of total billed charges",""
"Antithrombin III Antigen","PX-30001072","CDM","85301","CPT","0305","RC","","","","both","","","193.00","144.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","125.45","65","","121.55","113.75","121.55","1 through 10","10.59","183.35","percent of total billed charges",""
"Antithrombin III Antigen","PX-30001072","CDM","85301","CPT","0305","RC","","","","both","","","193.00","144.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70.45","36.5","","69.75","59.28","69.75","1 through 10","10.59","183.35","percent of total billed charges",""
"Antithrombin III Antigen","PX-30001072","CDM","85301","CPT","0305","RC","","","","both","","","193.00","144.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.92","38.3","","73.12","73.12","73.12","1 through 10","10.59","183.35","percent of total billed charges",""
"Antithrombin III Antigen","PX-30001072","CDM","85301","CPT","0305","RC","","","","outpatient","","","193.00","144.75","AETNA [1001]","HB AMC AETNA HMO","134.71","69.8","","126.60","89.39","178.78","1 through 10","11.14","157.72","percent of total billed charges",""
"Antithrombin III Antigen","PX-30001072","CDM","85301","CPT","0305","RC","","","","outpatient","","","193.00","144.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","157.72","81.72","","149.49","82.22","149.49","1 through 10","11.14","157.72","percent of total billed charges",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon With McC","268","MS-DRG","","","","","","","","inpatient","","","302434.24","226825.68","HUMANA [1012]","HB BWH MEDICARE","81806.78","","Case rate ($81,806.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $75,907.55, add-ons for qualifying new technology services are included. If operating cost exceeds $121,551.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,974.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $75,892.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $75,527.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,534.36. The transfer capital threshold is the transfer adjustment factor * $5,534.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","58374.73","58374.73","58374.73","1 through 10","61858.35","100620.7516","other","Inpatient DRG"
"Aortic And Heart Assist Procedures Except Pulsation Balloon With McC","268","MS-DRG","","","","","","","","inpatient","","","302434.24","226825.68","MEDICARE [2001]","HB BWH MEDICARE","81806.78","","Case rate ($81,806.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $75,907.55, add-ons for qualifying new technology services are included. If operating cost exceeds $121,551.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,974.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $75,892.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $75,527.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,534.36. The transfer capital threshold is the transfer adjustment factor * $5,534.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","79001.22","78883.65","79001.22","11","61858.35","100620.7516","other","Inpatient DRG"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC","269","MS-DRG","","","","","","","","inpatient","","","143567.81","107675.86","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","40071.45","","Case rate ($38,904.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,755.71, add-ons for qualifying new technology services are included. If operating cost exceeds $92,400.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $35,126.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,375.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,398.23. The transfer capital threshold is the transfer adjustment factor * $3,398.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","39208.59","39208.59","39208.59","1 through 10","38126.23","66152.2","other","Inpatient DRG"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC","269","MS-DRG","","","","","","","","inpatient","","","143567.81","107675.86","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","50377.99","","Case rate ($50,377.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,755.71, add-ons for qualifying new technology services are included. If operating cost exceeds $92,400.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $46,599.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,375.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,398.23. The transfer capital threshold is the transfer adjustment factor * $3,398.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","48548.54","48548.54","48548.54","1 through 10","38126.23","66152.2","other","Inpatient DRG"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC","269","MS-DRG","","","","","","","","inpatient","","","143567.81","107675.86","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","50377.99","","Case rate ($50,377.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,755.71, add-ons for qualifying new technology services are included. If operating cost exceeds $92,400.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $46,599.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,375.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,398.23. The transfer capital threshold is the transfer adjustment factor * $3,398.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","37533.32","37533.32","37533.32","1 through 10","38126.23","66152.2","other","Inpatient DRG"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC","269","MS-DRG","","","","","","","","inpatient","","","143567.81","107675.86","MEDICARE [2001]","HB BWH MEDICARE","50377.99","","Case rate ($50,377.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,755.71, add-ons for qualifying new technology services are included. If operating cost exceeds $92,400.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $46,599.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,375.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,398.23. The transfer capital threshold is the transfer adjustment factor * $3,398.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","49329.43","0.03","49402.79","1 through 10","38126.23","66152.2","other","Inpatient DRG"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC","269","MS-DRG","","","","","","","","inpatient","","","143567.81","107675.86","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","38126.23","","Case rate ($38,904.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,755.71, add-ons for qualifying new technology services are included. If operating cost exceeds $92,400.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,838.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $35,126.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,375.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,398.23. The transfer capital threshold is the transfer adjustment factor * $3,398.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","37306.40","37306.40","37306.40","1 through 10","38126.23","66152.2","other","Inpatient DRG"
"Apheresis for Car-T","PX-76002476","CDM","38225","CPT","0761","RC","","","","both","","","5016.00","3762.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3290.50","65.6","","3292.93","3292.93","3292.93","1 through 10","1554.96","3987.72","percent of total billed charges",""
"Apheresis for Car-T","PX-76002476","CDM","38225","CPT","0761","RC","","","","both","","","5016.00","3762.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3511.20","70","","4063.62","2002.02","4864.00","1 through 10","1554.96","3987.72","percent of total billed charges",""
"Apheresis for Car-T","PX-76002476","CDM","38225","CPT","0761","RC","","","","both","","","5016.00","3762.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3987.72","79.5","","3161.60","3161.60","3161.60","1 through 10","1554.96","3987.72","percent of total billed charges",""
"Apheresis for Car-T","PX-76002476","CDM","38225","CPT","0761","RC","","","","outpatient","","","5016.00","3762.00","AETNA [1001]","HB AMC AETNA HMO","3501.17","69.8","","3292.93","3292.93","3292.93","1 through 10","152","4138.2","percent of total billed charges",""
"Apheresis for Car-T","PX-76002476","CDM","38225","CPT","0761","RC","","","","outpatient","","","5016.00","3762.00","AETNA [1001]","HB AMC AETNA PPO","4032.86","80.4","","3793.92","3793.92","3793.92","1 through 10","152","4138.2","percent of total billed charges",""
"Apheresis for Car-T","PX-76002476","CDM","38225","CPT","0761","RC","","","","outpatient","","","5016.00","3762.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","152.00","","Case rate ($152). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","310.99","305.37","310.99","1 through 10","152","4138.2","other","ASC"
"Apheresis for Car-T","PX-76002476","CDM","38225","CPT","0761","RC","","","","outpatient","","","5016.00","3762.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","152.00","","Case rate ($152). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","355.83","352.34","355.83","14","152","4138.2","other","ASC "
"Apheresis for Car-T","PX-76002476","CDM","38225","CPT","0761","RC","","","","outpatient","","","5016.00","3762.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2508.00","50","","2548.74","2548.74","2548.74","1 through 10","152","4138.2","percent of total billed charges",""
"Apheresis Plasma Pheresis","PX-76001078","CDM","36514","CPT","0761","RC","","","","both","","","6574.00","4930.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2004.94","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","6375.00","2004.00","6375.00","1 through 10","1849.41","5226.33","other","OPPS APC"
"Apheresis Plasma Pheresis","PX-76001078","CDM","36514","CPT","0761","RC","","","","both","","","6574.00","4930.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4601.80","70","","8311.20","8311.20","8311.20","1 through 10","1849.41","5226.33","percent of total billed charges",""
"Apheresis Plasma Pheresis","PX-76001078","CDM","36514","CPT","0761","RC","","","","both","","","6574.00","4930.50","MEDICARE [2001]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1946.74","1946.74","1946.74","1 through 10","1849.41","5226.33","other","OPPS APC"
"Apheresis Plasma Pheresis","PX-76001078","CDM","36514","CPT","0761","RC","","","","both","","","6574.00","4930.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1907.62","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1946.74","1946.74","1946.74","1 through 10","1849.41","5226.33","other","OPPS APC"
"Apheresis Plasma Pheresis","PX-76001078","CDM","36514","CPT","0761","RC","","","","outpatient","","","6574.00","4930.50","AETNA [1001]","HB AMC AETNA HMO","4588.65","69.8","","3047.25","3047.25","3047.25","1 through 10","1426.02","7081.86","percent of total billed charges",""
"Apheresis Plasma Pheresis","PX-76001078","CDM","36514","CPT","0761","RC","","","","outpatient","","","6574.00","4930.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1426.02","","Case rate ($1,426.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3305.51","3305.51","3338.31","15","1426.02","7081.86","other","ASC"
"Apheresis Plasma Pheresis","PX-76001078","CDM","36514","CPT","0761","RC","","","","outpatient","","","6574.00","4930.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1426.02","","Case rate ($1,426.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3305.51","3305.51","3338.31","1 through 10","1426.02","7081.86","other","ASC "
"Apheresis Therapeutic RBC","PX-76001076","CDM","36512","CPT","0761","RC","","","","both","","","5085.00","3813.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2004.94","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2004.10","2003.20","2004.10","1 through 10","1576.35","4042.58","other","OPPS APC"
"Apheresis Therapeutic RBC","PX-76001076","CDM","36512","CPT","0761","RC","","","","both","","","5085.00","3813.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","2433.18","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","1641.10","375.00","1946.74","1 through 10","1576.35","4042.58","other","OPPS APC"
"Apheresis Therapeutic RBC","PX-76001076","CDM","36512","CPT","0761","RC","","","","both","","","5085.00","3813.75","MEDICARE [2001]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1946.74","1602.49","5840.22","54","1576.35","4042.58","other","OPPS APC"
"Apheresis Therapeutic RBC","PX-76001076","CDM","36512","CPT","0761","RC","","","","outpatient","","","5085.00","3813.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1426.02","","Case rate ($1,426.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2864.87","2864.87","2917.64","11","1426.02","7081.86","other","ASC"
"Apheresis Therapeutic RBC","PX-76001076","CDM","36512","CPT","0761","RC","","","","outpatient","","","5085.00","3813.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1426.02","","Case rate ($1,426.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3338.31","3305.51","3338.31","1 through 10","1426.02","7081.86","other","ASC "
"Apheresis Therapeutic Wbc","PX-76001075","CDM","36511","CPT","0761","RC","","","","both","","","4772.00","3579.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1674.59","1674.59","1674.59","1 through 10","1479.32","3793.74","other","OPPS APC"
"Apheresis Therapeutic Wbc","PX-76001075","CDM","36511","CPT","0761","RC","","","","both","","","4772.00","3579.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3340.40","70","","2112.22","2112.22","2112.22","1 through 10","1479.32","3793.74","percent of total billed charges",""
"Apheresis Therapeutic Wbc","PX-76001075","CDM","36511","CPT","0761","RC","","","","both","","","4772.00","3579.00","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1641.10","1641.10","1641.10","1 through 10","1479.32","3793.74","other","OPPS APC"
"Apheresis Therapeutic Wbc","PX-76001075","CDM","36511","CPT","0761","RC","","","","both","","","4772.00","3579.00","MEDICARE [2001]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1946.74","1674.59","1946.74","1 through 10","1479.32","3793.74","other","OPPS APC"
"Apheresis Therapeutic Wbc","PX-76001075","CDM","36511","CPT","0761","RC","","","","both","","","4772.00","3579.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1827.68","38.3","","1809.55","1809.55","1809.55","1 through 10","1479.32","3793.74","percent of total billed charges",""
"Apheresis Therapeutic Wbc","PX-76001075","CDM","36511","CPT","0761","RC","","","","both","","","4772.00","3579.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1907.62","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1641.10","1641.10","1641.10","1 through 10","1479.32","3793.74","other","OPPS APC"
"Apheresis Therapeutic Wbc","PX-76001075","CDM","36511","CPT","0761","RC","","","","outpatient","","","4772.00","3579.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1426.02","","Case rate ($1,426.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2917.64","2864.87","2917.64","1 through 10","1426.02","7081.86","other","ASC"
"Apheresis Therapeutic Wbc","PX-76001075","CDM","36511","CPT","0761","RC","","","","outpatient","","","4772.00","3579.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1426.02","","Case rate ($1,426.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3338.31","3338.31","4628.00","1 through 10","1426.02","7081.86","other","ASC "
"Apheresis Therapeutic Wbc","PX-76001075","CDM","36511","CPT","0761","RC","","","","outpatient","","","4772.00","3579.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3899.68","81.72","","3699.63","3699.62","3699.63","1 through 10","1426.02","7081.86","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","both","","","188.00","141.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","149.46","79.5","","143.24","96.10","286.47","48","15.99","178.6","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","both","","","188.00","141.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.20","53.3","","96.10","96.10","192.19","14","15.99","178.6","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","both","","","188.00","141.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","144.76","77","","140.14","140.14","140.14","1 through 10","15.99","178.6","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.62","36.5","","67.89","57.69","173.07","48","15.99","178.6","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","71.16","71.16","138.32","132","15.99","178.6","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","both","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.65","42.9","","80.03","80.03","80.03","1 through 10","15.99","178.6","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","123.21","87.00","141.96","41","15.99","153.63","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA PPO","151.15","80.4","","141.96","141.96","141.96","1 through 10","15.99","153.63","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","outpatient","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","153.63","81.72","","145.49","80.03","145.49","34","15.99","153.63","percent of total billed charges",""
"Appendectomy With Complex Principal Diagnosis,MODERATE","233","DRG","","","","","","","","inpatient","","","59494.65","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43970.26","","Fee schedule rate ($43,970.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","43970.26","43970.26","43970.26","1 through 10","11149.49","46984.39","case rate",""
"Appendectomy With Complex Principal Diagnosis,MODERATE","233","DRG","","","","","","","","inpatient","","","59507.40","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","46984.39","","Standard inlier is a Case rate ($46,984.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $44,146, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,669.04) for the length of stay and the standard reimbursement.","46984.39","46984.39","46984.39","1 through 10","11149.49","46984.39","case rate",""
"Appendectomy Without Complex Principal Diagnosis,MAJOR","234","DRG","","","","","","","","inpatient","","","70307.76","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","56023.49","","Standard inlier is a Case rate ($56,023.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,399, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,952.07) for the length of stay and the standard reimbursement.","51182.29","51182.29","51182.29","1 through 10","6046.54","56023.49","case rate",""
"Appendectomy Without Complex Principal Diagnosis,MINOR","234","DRG","","","","","","","","inpatient","","","56637.29","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","29502.50","","Standard inlier is a Case rate ($29,502.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,055, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,187.64) for the length of stay and the standard reimbursement.","29502.50","29502.50","29502.50","1 through 10","6046.54","56023.49","case rate",""
"Appendectomy Without Complex Principal Diagnosis,MODERATE","234","DRG","","","","","","","","inpatient","","","48801.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","33893.37","","Standard inlier is a Case rate ($33,893.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,004, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,811.37) for the length of stay and the standard reimbursement.","30895.04","30895.04","30895.04","1 through 10","6046.54","56023.49","case rate",""
"Appendectomy Without Complex Principal Diagnosis,MODERATE","234","DRG","","","","","","","","inpatient","","","48801.19","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32704.67","","Fee schedule rate ($32,704.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32704.67","32704.67","32704.67","1 through 10","6046.54","56023.49","case rate",""
"Appendectomy,MODERATE","225","DRG","","","","","","","","inpatient","","","60290.08","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16504.6093","","Fee schedule rate ($25,106.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16504.6093","25106.96","25106.96","1 through 10","15869.2774","41426.99","case rate",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","","","","inpatient","","","80216.30","60162.22","MEDICARE [2001]","HB BWH MEDICARE","18299.23","","Case rate ($18,299.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,001.01, add-ons for qualifying new technology services are included. If operating cost exceeds $62,645.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,658.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $16,701.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,621.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.93. The transfer capital threshold is the transfer adjustment factor * $1,217.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18117.62","18117.62","18144.30","1 through 10","13903.31","22835.7012","other","Inpatient DRG"
"Appendix Procedures With McC","397","MS-DRG","","","","","","","","inpatient","","","93725.53","70294.15","MEDICARE [2001]","HB BWH MEDICARE","28732.87","","Case rate ($28,732.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,678.75, add-ons for qualifying new technology services are included. If operating cost exceeds $72,323.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,367.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $26,425.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,298.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,927.08. The transfer capital threshold is the transfer adjustment factor * $1,927.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29533.15","29533.15","29533.15","1 through 10","21781.83","37513.71","other","Inpatient DRG"
"Appendix Procedures With McC","397","MS-DRG","","","","","","","","inpatient","","","93725.53","70294.15","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","21781.83","","Case rate ($22,226.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,678.75, add-ons for qualifying new technology services are included. If operating cost exceeds $72,323.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,367.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,919.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,298.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,927.08. The transfer capital threshold is the transfer adjustment factor * $1,927.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22823.48","22823.48","22823.48","1 through 10","21781.83","37513.71","other","Inpatient DRG"
"Appendix Procedures Without Cc/McC","399","MS-DRG","","","","","","","","inpatient","","","60290.08","45217.56","MEDICARE [2001]","HB BWH MEDICARE","10821.92","","Case rate ($10,821.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,950.04, add-ons for qualifying new technology services are included. If operating cost exceeds $58,594.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,361.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $9,520.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,570.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $921.09. The transfer capital threshold is the transfer adjustment factor * $921.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13526.93","13526.93","13526.93","1 through 10","10605.48","16797.7921","other","Inpatient Replacement Plans DRG"
"Appl Cast Hand/Lower Forearm","PX-76000696","CDM","29085","CPT","0761","RC","","","","both","","","466.00","349.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","183.62","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","184.40","184.40","184.40","1 through 10","144.46","370.47","other","OPPS APC"
"Appl Cast Leg Short|BILATERAL PROCEDURE","PX-76000713","CDM","29405","CPT","0510","RC","","","50","both","","","490.00","367.50","MEDICARE [2001]","HB BWH MEDICARE","315.36","","APC Price ($315.36). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","473.09","473.09","1419.27","1 through 10","299.62","394.2","other","OPPS APC"
"Appl of Capsaicin Patch 1 or More","PX-76002971","CDM","17999","CPT","0761","RC","","","","both","","","134.00","100.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4490.63","3878.56","4490.63","1 through 10","41.54","294.93","other","OPPS APC"
"Appl of Capsaicin Patch 1 or More","PX-76002971","CDM","17999","CPT","0761","RC","","","","outpatient","","","134.00","100.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","69.97","52.22","","467.73","465.00","467.73","1 through 10","67","700.33","percent of total billed charges",""
"Appl of Capsaicin Patch 1 or More","PX-98302521","CDM","17999","CPT","0983","RC","","","","both","","","34.00","25.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4490.63","3878.56","4490.63","1 through 10","10.54","294.93","other","OPPS APC"
"Appl of Capsaicin Patch 1 or More","PX-98302521","CDM","17999","CPT","0983","RC","","","","outpatient","","","34.00","25.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","17.75","52.22","","467.73","465.00","467.73","1 through 10","17","700.33","percent of total billed charges",""
"Appl Splint Leg Short","PX-76000720","CDM","29515","CPT","0510","RC","","","","both","","","356.00","267.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","183.62","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.39","187.39","187.39","1 through 10","110.36","274.12","other","OPPS APC"
"Application Topical Fluoride Varnish by Phs/Qhp","PX-51000555","CDM","99188","CPT","0510","RC","","","","both","","","42.00","31.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15.33","36.5","","15.67","15.67","47.01","14","13.02","39.9","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-51000555","CDM","99188","CPT","0510","RC","","","","both","","","42.00","31.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.09","38.3","","16.42","16.42","16.42","26","13.02","39.9","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-51000555","CDM","99188","CPT","0510","RC","","","","outpatient","","","42.00","31.50","AETNA [1001]","HB AMC AETNA HMO","29.32","69.8","","32.76","20.08","32.76","1 through 10","14.32","46.36","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-51000555","CDM","99188","CPT","0510","RC","","","","outpatient","","","42.00","31.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","14.32","34.1","","42.00","42.00","42.00","1 through 10","14.32","46.36","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-51000555","CDM","99188","CPT","0510","RC","","","","outpatient","","","42.00","31.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21.00","50","","22.01","21.13","22.01","1 through 10","14.32","46.36","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-51000555","CDM","99188","CPT","0510","RC","","","","outpatient","","","42.00","31.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22.05","52.5","","23.10","23.10","43.56","1 through 10","14.32","46.36","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-51000555","CDM","99188","CPT","0510","RC","","","","outpatient","","","42.00","31.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","23.10","55","","42.00","23.27","42.00","1 through 10","14.32","46.36","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-51000555","CDM","99188","CPT","0510","RC","","","","outpatient","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34.32","81.72","","33.58","33.57","42.00","1 through 10","14.32","46.36","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-98300843","CDM","99188","CPT","0983","RC","","","","both","","","87.00","65.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.17","79.5","","42.00","42.00","42.00","1 through 10","26.97","82.65","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-98300843","CDM","99188","CPT","0983","RC","","","","both","","","87.00","65.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.37","53.3","","42.00","42.00","42.00","1 through 10","26.97","82.65","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-98300843","CDM","99188","CPT","0983","RC","","","","both","","","87.00","65.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.76","36.5","","15.67","15.67","47.01","14","26.97","82.65","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-98300843","CDM","99188","CPT","0983","RC","","","","both","","","87.00","65.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.32","38.3","","16.42","16.42","16.42","26","26.97","82.65","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-98300843","CDM","99188","CPT","0983","RC","","","","outpatient","","","87.00","65.25","AETNA [1001]","HB AMC AETNA HMO","60.73","69.8","","32.76","20.08","32.76","1 through 10","25.7","71.78","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-98300843","CDM","99188","CPT","0983","RC","","","","outpatient","","","87.00","65.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","43.50","50","","22.01","21.13","22.01","1 through 10","25.7","71.78","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-98300843","CDM","99188","CPT","0983","RC","","","","outpatient","","","87.00","65.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","45.68","52.5","","23.10","23.10","43.56","1 through 10","25.7","71.78","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-98300843","CDM","99188","CPT","0983","RC","","","","outpatient","","","87.00","65.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","47.85","55","","42.00","23.27","42.00","1 through 10","25.7","71.78","percent of total billed charges",""
"Application Topical Fluoride Varnish by Phs/Qhp","PX-98300843","CDM","99188","CPT","0983","RC","","","","outpatient","","","87.00","65.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.10","81.72","","33.58","33.57","42.00","1 through 10","25.7","71.78","percent of total billed charges",""
"Apply Cast Arm Long","PX-76000694","CDM","29065","CPT","0761","RC","","","","outpatient","","","491.00","368.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","235.58","","Case rate ($235.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","603.08","603.08","603.08","1 through 10","210.64","1409.06","other","Multiple Surgery"
"Apply Cast Arm Short","PX-76000695","CDM","29075","CPT","0510","RC","","","","both","","","492.00","369.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","309.05","","APC Price ($315.36). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","293.11","293.11","293.11","1 through 10","152.52","394.2","other","OPPS APC"
"Apply Cast Arm Short","PX-76000695","CDM","29075","CPT","0510","RC","","","","outpatient","","","492.00","369.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","235.58","","Case rate ($235.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","574.82","574.82","574.82","1 through 10","167.77","1409.06","other","Multiple Surgery"
"Apply Cast Arm Short","PX-76000695","CDM","29075","CPT","0510","RC","","","","outpatient","","","492.00","369.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","235.58","","Case rate ($235.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","374.65","374.65","374.65","1 through 10","167.77","1409.06","other","Multiple Surgery"
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","both","","","357.00","267.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","169.73","169.73","169.73","1 through 10","110.67","283.82","other","OPPS APC"
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","both","","","357.00","267.75","MEDICARE [2001]","HB BWH MEDICARE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.39","187.39","187.39","19","110.67","283.82","other","OPPS APC"
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","both","","","357.00","267.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","136.73","38.3","","135.29","135.29","135.29","1 through 10","110.67","283.82","percent of total billed charges",""
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","both","","","357.00","267.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.64","168.33","183.64","1 through 10","110.67","283.82","other","OPPS APC"
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","both","","","357.00","267.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","183.62","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.39","169.22","187.39","1 through 10","110.67","283.82","other","OPPS APC"
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","outpatient","","","357.00","267.75","AETNA [1001]","HB AMC AETNA HMO","249.19","69.8","","269.88","269.88","269.88","1 through 10","134.62","701.53","percent of total billed charges",""
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","outpatient","","","357.00","267.75","AETNA [1001]","HB AMC AETNA PPO","287.03","80.4","","269.88","269.88","269.88","1 through 10","134.62","701.53","percent of total billed charges",""
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","357.00","267.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","192.99","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","192.82","176.96","192.82","13","110.67","283.82","other","OPPS APC"
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","357.00","267.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","184.39","184.39","184.39","1 through 10","110.67","283.82","other","OPPS APC"
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","357.00","267.75","MEDICARE [2001]","HB BWH MEDICARE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.39","171.97","187.39","40","110.67","283.82","other","OPPS APC"
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","357.00","267.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","130.31","36.5","","129.06","129.06","129.06","13","110.67","283.82","percent of total billed charges",""
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","357.00","267.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","136.73","38.3","","135.29","135.29","135.29","11","110.67","283.82","percent of total billed charges",""
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","357.00","267.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.64","183.64","183.64","1 through 10","110.67","283.82","other","OPPS APC"
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","357.00","267.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","183.62","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.39","168.53","281.09","50","110.67","283.82","other","OPPS APC"
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","outpatient","","","357.00","267.75","AETNA [1001]","HB AMC AETNA HMO","249.19","69.8","","165.39","165.39","234.24","1 through 10","134.62","700.33","percent of total billed charges",""
"Apply Multlay Comprs Bl Knee|BILATERAL PROCEDURE","PX-76000726","CDM","29581","CPT","0761","RC","","","50","both","","","357.00","267.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","169.80","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","289.23","289.23","289.23","1 through 10","161.56","206.07","other","OPPS APC"
"Apply Multlay Comprs Bl Knee|BILATERAL PROCEDURE","PX-76000726","CDM","29581","CPT","0761","RC","","","50","both","","","357.00","267.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.90","220.70","276.59","1 through 10","161.56","206.07","other","OPPS APC"
"Apply Multlay Comprs Bl Knee|BILATERAL PROCEDURE","PX-76000726","CDM","29581","CPT","0761","RC","","","50","both","","","357.00","267.75","MEDICARE [2001]","HB BWH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.08","281.08","281.08","37","161.56","206.07","other","OPPS APC"
"Apply Splint Arm Long","PX-76000698","CDM","29105","CPT","0510","RC","","","","outpatient","","","412.00","309.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","140.49","34.1","","314.80","314.80","314.80","1 through 10","134.62","701.53","percent of total billed charges",""
"Apply Splint Arm Long","PX-76000698","CDM","29105","CPT","0510","RC","","","","outpatient","","","412.00","309.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","134.62","","Case rate ($134.62). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","331.17","331.17","331.17","1 through 10","134.62","701.53","other","Multiple Surgery"
"Apply Splint Finger Static","PX-76000701","CDM","29130","CPT","0510","RC","","","","both","","","199.00","149.25","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","61.69","191.33","other","OPPS APC"
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","both","","","718.00","538.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","515.52","71.8","","499.73","499.73","499.73","1 through 10","222.58","570.81","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","both","","","718.00","538.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","466.70","65","","452.40","452.40","452.40","1 through 10","222.58","570.81","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","both","","","718.00","538.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.81","79.5","","547.75","367.49","547.75","1 through 10","222.58","570.81","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","both","","","718.00","538.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","382.69","53.3","","367.49","367.49","367.49","1 through 10","222.58","570.81","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","both","","","718.00","538.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","466.70","65","","452.40","452.40","452.40","1 through 10","222.58","570.81","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","262.07","36.5","","259.61","251.95","259.61","20","222.58","570.81","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.99","38.3","","272.14","272.14","816.42","46","222.58","570.81","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","both","","","718.00","538.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","552.86","77","","524.78","524.78","524.78","1 through 10","222.58","570.81","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","both","","","718.00","538.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","308.02","42.9","","306.03","306.03","306.03","1 through 10","222.58","570.81","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","both","","","718.00","538.50","WELLPOINT [1015]","HB AMC WELLPOINT","529.74","73.78","","518.17","518.17","518.17","1 through 10","222.58","570.81","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","outpatient","","","718.00","538.50","AETNA [1001]","HB AMC AETNA HMO","501.16","69.8","","471.19","332.69","942.38","13","375.23","586.75","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","outpatient","","","718.00","538.50","AETNA [1001]","HB AMC AETNA PPO","577.27","80.4","","542.88","542.88","542.88","1 through 10","375.23","586.75","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","375.23","52.26","","430.68","430.68","430.68","1 through 10","375.23","586.75","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","outpatient","","","718.00","538.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","586.75","81.72","","556.38","556.38","556.38","1 through 10","375.23","586.75","percent of total billed charges",""
"Aqmbf Pet Rest and Pharmacologic Stress","PX-40000171","CDM","78434","CPT","0404","RC","","","","outpatient","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","586.75","81.72","","556.38","306.03","556.38","21","375.23","586.75","percent of total billed charges",""
"Aquaporin-4 Antibody Flow Cytometry Each","PX-30003766","CDM","86053","CPT","0302","RC","","","","both","","","144.00","108.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","76.75","53.3","","73.92","73.92","73.92","1 through 10","36.98","136.8","percent of total billed charges",""
"Aquaporin-4 Antibody Flow Cytometry Each","PX-30003766","CDM","86053","CPT","0302","RC","","","","both","","","144.00","108.00","TRICARE [160005]","HB BWH TRICARE","136.80","95","","43.19","43.19","43.19","1 through 10","36.98","136.8","percent of total billed charges",""
"Aquaporin-4 Antibody Flow Cytometry Each","PX-30003766","CDM","86053","CPT","0302","RC","","","","both","","","144.00","108.00","WELLPOINT [1015]","HB AMC WELLPOINT","106.24","73.78","","244.23","104.23","244.23","1 through 10","36.98","136.8","percent of total billed charges",""
"Aquaporin-4 Antibody Flow Cytometry Each","PX-30003766","CDM","86053","CPT","0302","RC","","","","outpatient","","","144.00","108.00","AETNA [1001]","HB AMC AETNA HMO","100.51","69.8","","94.78","66.92","94.78","1 through 10","34.67","118.8","percent of total billed charges",""
"Aquaporin-4 Antibody Flow Cytometry Each","PX-30003766","CDM","86053","CPT","0302","RC","","","","outpatient","","","144.00","108.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","75.60","52.5","","91.70","91.70","91.70","1 through 10","34.67","118.8","percent of total billed charges",""
"Aquaporin-4 Antibody Flow Cytometry Each","PX-30003766","CDM","86053","CPT","0302","RC","","","","outpatient","","","144.00","108.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","72.00","50","","73.36","70.42","73.36","1 through 10","34.67","118.8","percent of total billed charges",""
"Aquaporin-4 Antibody Flow Cytometry Each","PX-30003766","CDM","86053","CPT","0302","RC","","","","outpatient","","","144.00","108.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","75.60","52.5","","77.00","77.00","77.00","1 through 10","34.67","118.8","percent of total billed charges",""
"Aquaporin-4 Antibody Flow Cytometry Each","PX-30003766","CDM","86053","CPT","0302","RC","","","","outpatient","","","144.00","108.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","79.20","55","","80.64","80.64","80.64","1 through 10","34.67","118.8","percent of total billed charges",""
"Aquaporin-4 Antibody Flow Cytometry Each","PX-30003766","CDM","86053","CPT","0302","RC","","","","outpatient","","","144.00","108.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","117.68","81.72","","61.56","61.56","111.92","1 through 10","34.67","118.8","percent of total billed charges",""
"Aria Reservoir Refill W Imag Guid","PX-48000543","CDM","93799","CPT","0481","RC","","","","both","","","1857.00","1392.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","1476.32","other","OPPS APC"
"Aria Reservoir Refill W Imag Guid","PX-48000543","CDM","93799","CPT","0481","RC","","","","outpatient","","","1857.00","1392.75","AETNA [1001]","HB AMC AETNA HMO","1296.19","69.8","","2022.70","2022.70","2022.70","1 through 10","454","1532.03","percent of total billed charges",""
"Aria Reservoir Refill W Imag Guid","PX-48000543","CDM","93799","CPT","0481","RC","","","","outpatient","","","1857.00","1392.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1124.41","60.55","","318.03","318.03","2439.77","1 through 10","454","1532.03","percent of total billed charges",""
"Aria Reservoir Refill W Imag Guid","PX-48000543","CDM","93799","CPT","0481","RC","","","","outpatient","","","1857.00","1392.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","969.73","52.22","","360.38","360.38","4023.00","1 through 10","454","1532.03","percent of total billed charges",""
"Aria Reservoir Refill W Imag Guid","PX-48000543","CDM","93799","CPT","0481","RC","","","","outpatient","","","1857.00","1392.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1021.35","55","","13080.03","13080.03","13080.03","1 through 10","454","1532.03","percent of total billed charges",""
"Aripirazole Lauroxil 1 Mg","PX-63601349","CDM","J1944","CPT","0636","RC","","","","both","","","12.75","9.56","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3.28","","APC Price ($3.35). Final payment is multiplied by 98%.","3.28","3.21","3.28","1323","3.16","9.82","other","OPPS APC"
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","both","","","235.00","176.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.83","79.5","","179.44","179.44","538.32","1 through 10","18.59","223.25","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","both","","","235.00","176.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","125.26","53.3","","120.38","120.38","120.38","1 through 10","18.59","223.25","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","both","","","235.00","176.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.78","36.5","","85.04","72.28","85.04","1 through 10","18.59","223.25","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","both","","","235.00","176.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","90.01","38.3","","89.15","89.15","89.15","1 through 10","18.59","223.25","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","both","","","235.00","176.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.82","42.9","","182.26","182.26","182.26","1 through 10","18.59","223.25","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","outpatient","","","235.00","176.25","AETNA [1001]","HB AMC AETNA HMO","164.03","69.8","","177.84","154.36","177.84","1 through 10","19.57","192.04","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","outpatient","","","235.00","176.25","AETNA [1001]","HB AMC AETNA PPO","188.94","80.4","","177.84","177.84","177.84","1 through 10","19.57","192.04","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","outpatient","","","235.00","176.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","192.04","81.72","","100.25","100.25","100.25","1 through 10","19.57","192.04","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","outpatient","","","235.00","176.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","192.04","81.72","","182.26","100.25","182.27","1 through 10","19.57","192.04","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","718.00","538.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","360.73","360.73","1 through 10","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","718.00","538.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","438.15","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","350.56","350.56","350.56","1 through 10","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","718.00","538.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.81","79.5","","547.75","547.75","547.75","1 through 10","222.58","570.81","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","718.00","538.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","318.09","318.09","318.09","1 through 10","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","718.00","538.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","466.70","65","","452.40","452.40","452.40","1 through 10","222.58","570.81","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","718.00","538.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","31","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","262.07","36.5","","220.63","60.55","259.61","1 through 10","222.58","570.81","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.99","38.3","","272.14","272.14","272.14","1 through 10","222.58","570.81","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.95","343.55","515.33","21","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","outpatient","","","718.00","538.50","AETNA [1001]","HB AMC AETNA HMO","501.16","69.8","","471.19","471.19","471.19","1 through 10","247.48","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","656.02","655.73","662.53","1 through 10","247.48","700.33","other","ASC "
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","603.85","582.29","603.85","1 through 10","247.48","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","717.69","717.69","717.69","1 through 10","247.48","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","633.55","633.55","633.55","1 through 10","247.48","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","outpatient","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","586.75","81.72","","556.38","556.38","556.38","1 through 10","247.48","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US|BILATERAL PROCEDURE","PX-76002075","CDM","20605","CPT","0761","RC","","","50","both","","","718.00","538.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","541.08","541.08","541.08","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US|BILATERAL PROCEDURE","PX-76002075","CDM","20605","CPT","0761","RC","","","50","both","","","718.00","538.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","484.89","525.83","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US|BILATERAL PROCEDURE","PX-76002075","CDM","20605","CPT","0761","RC","","","50","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","515.31","515.31","515.31","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US|BILATERAL PROCEDURE","PX-76002075","CDM","20605","CPT","0761","RC","","","50","both","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","515.32","515.32","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US|BILATERAL PROCEDURE","PX-76002075","CDM","20605","CPT","0761","RC","","","50","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","984.04","984.04","993.80","1 through 10","424.52","1421.77","other","ASC "
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US|BILATERAL PROCEDURE|MULTIPLE PROCEDURES","PX-76002075","CDM","20605","CPT","0761","RC","","","50|51","both","","","718.00","538.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","525.83","525.83","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US","PX-76002076","CDM","20606","CPT","0761","RC","","","","both","","","378.00","283.50","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","759.32","759.32","759.32","1 through 10","117.18","1027.91","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US","PX-76002076","CDM","20606","CPT","0761","RC","","","","outpatient","","","378.00","283.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1335.35","1335.35","1335.35","1 through 10","197.54","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US","PX-98300794","CDM","20606","CPT","0983","RC","","","","both","","","226.00","169.50","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","759.32","759.32","759.32","1 through 10","70.06","1027.91","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US","PX-98300794","CDM","20606","CPT","0983","RC","","","","outpatient","","","226.00","169.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1335.35","1335.35","1335.35","1 through 10","126.33","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","718.00","538.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","332.63","362.20","1 through 10","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","718.00","538.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","438.15","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","395.00","361.72","395.00","1 through 10","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","718.00","538.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.81","79.5","","544.84","367.49","547.75","1 through 10","222.58","570.81","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","718.00","538.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","382.69","53.3","","547.75","547.75","547.75","1 through 10","222.58","570.81","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","718.00","538.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","290.47","159.04","344.95","1 through 10","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","718.00","538.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","201","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","222.58","31","","215.06","215.06","215.06","1 through 10","222.58","570.81","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","262.07","36.5","","259.61","220.63","519.22","14","222.58","570.81","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.99","38.3","","272.14","264.48","272.14","43","222.58","570.81","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","316.79","343.55","1 through 10","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.56","323.26","517.43","194","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","718.00","538.50","WELLPOINT [1015]","HB AMC WELLPOINT","529.74","73.78","","518.17","518.17","556.80","1 through 10","222.58","570.81","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","outpatient","","","718.00","538.50","AETNA [1001]","HB AMC AETNA HMO","501.16","69.8","","471.19","332.69","471.19","12","247.48","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","717.69","717.69","717.69","1 through 10","247.48","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","827.82","574.15","861.23","1 through 10","247.48","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","603.85","581.58","872.37","1 through 10","247.48","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","633.55","509.77","633.55","1 through 10","247.48","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","outpatient","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","586.75","81.72","","556.38","306.03","556.38","1 through 10","247.48","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","outpatient","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","586.75","81.72","","556.38","306.03","556.38","1 through 10","247.48","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","both","","","198.00","148.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","332.63","362.20","1 through 10","61.38","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","both","","","198.00","148.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","438.15","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","395.00","361.72","395.00","1 through 10","61.38","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","both","","","198.00","148.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","157.41","79.5","","544.84","367.49","547.75","1 through 10","61.38","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","both","","","198.00","148.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","105.53","53.3","","547.75","547.75","547.75","1 through 10","61.38","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","both","","","198.00","148.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","290.47","159.04","344.95","1 through 10","61.38","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","both","","","198.00","148.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","201","61.38","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","both","","","198.00","148.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","61.38","31","","215.06","215.06","215.06","1 through 10","61.38","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","both","","","198.00","148.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.27","36.5","","259.61","220.63","519.22","14","61.38","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","both","","","198.00","148.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.83","38.3","","272.14","264.48","272.14","43","61.38","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","both","","","198.00","148.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","316.79","343.55","1 through 10","61.38","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","both","","","198.00","148.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.56","323.26","517.43","194","61.38","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","both","","","198.00","148.50","WELLPOINT [1015]","HB AMC WELLPOINT","146.08","73.78","","518.17","518.17","556.80","1 through 10","61.38","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","outpatient","","","198.00","148.50","AETNA [1001]","HB AMC AETNA HMO","138.20","69.8","","471.19","332.69","471.19","12","110.68","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","outpatient","","","198.00","148.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","717.69","717.69","717.69","1 through 10","110.68","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","outpatient","","","198.00","148.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","827.82","574.15","861.23","1 through 10","110.68","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","outpatient","","","198.00","148.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","603.85","581.58","872.37","1 through 10","110.68","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","outpatient","","","198.00","148.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","633.55","509.77","633.55","1 through 10","110.68","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","outpatient","","","198.00","148.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","161.81","81.72","","556.38","306.03","556.38","1 through 10","110.68","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-98300795","CDM","20610","CPT","0983","RC","","","","outpatient","","","198.00","148.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","161.81","81.72","","556.38","306.03","556.38","1 through 10","110.68","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","718.00","538.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","541.08","541.08","541.98","13","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.42","517.42","517.42","15","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","718.00","538.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.43","439.82","517.43","14","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","718.00","538.50","HUMANA [1012]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","518.48","518.48","518.48","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","718.00","538.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","484.89","525.83","230","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","515.31","475.19","515.31","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","718.00","538.50","MOLINA [1014]","HB BWH MOLINA","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","525.84","525.84","525.84","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","718.00","538.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","477.13","517.43","14","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","515.32","515.32","39","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","852.86","852.86","868.57","17","424.52","1421.77","other","ASC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","984.04","984.04","993.80","40","424.52","1421.77","other","ASC "
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300795","CDM","20610","CPT","0983","RC","","","50","both","","","198.00","148.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","541.08","541.08","541.98","13","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300795","CDM","20610","CPT","0983","RC","","","50","both","","","198.00","148.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.42","517.42","517.42","15","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300795","CDM","20610","CPT","0983","RC","","","50","both","","","198.00","148.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.43","439.82","517.43","14","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300795","CDM","20610","CPT","0983","RC","","","50","both","","","198.00","148.50","HUMANA [1012]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","518.48","518.48","518.48","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300795","CDM","20610","CPT","0983","RC","","","50","both","","","198.00","148.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","484.89","525.83","230","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300795","CDM","20610","CPT","0983","RC","","","50","both","","","198.00","148.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","515.31","475.19","515.31","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300795","CDM","20610","CPT","0983","RC","","","50","both","","","198.00","148.50","MOLINA [1014]","HB BWH MOLINA","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","525.84","525.84","525.84","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300795","CDM","20610","CPT","0983","RC","","","50","both","","","198.00","148.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","477.13","517.43","14","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300795","CDM","20610","CPT","0983","RC","","","50","both","","","198.00","148.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","515.32","515.32","39","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE|MULTIPLE PROCEDURES","PX-76002077","CDM","20610","CPT","0761","RC","","","50|51","both","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.42","517.42","517.42","1 through 10","302.23","385.5","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE|MULTIPLE PROCEDURES","PX-98300795","CDM","20610","CPT","0983","RC","","","50|51","both","","","198.00","148.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.42","517.42","517.42","1 through 10","302.23","385.5","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","441.00","330.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","350.60","79.5","","336.84","336.84","336.84","1 through 10","136.71","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","441.00","330.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","290.47","290.47","290.47","1 through 10","136.71","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","441.00","330.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","19","136.71","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","441.00","330.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","160.97","36.5","","159.64","159.64","159.64","1 through 10","136.71","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","441.00","330.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","168.90","38.3","","167.35","167.35","167.35","1 through 10","136.71","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","441.00","330.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","323.26","158.40","344.15","1 through 10","136.71","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","outpatient","","","441.00","330.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","578.38","578.38","578.38","1 through 10","230.47","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","outpatient","","","441.00","330.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","360.39","81.72","","342.14","342.14","342.14","1 through 10","230.47","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-98300796","CDM","20611","CPT","0983","RC","","","","both","","","256.00","192.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","203.52","79.5","","336.84","336.84","336.84","1 through 10","79.36","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-98300796","CDM","20611","CPT","0983","RC","","","","both","","","256.00","192.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","290.47","290.47","290.47","1 through 10","79.36","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-98300796","CDM","20611","CPT","0983","RC","","","","both","","","256.00","192.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","19","79.36","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-98300796","CDM","20611","CPT","0983","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","93.44","36.5","","159.64","159.64","159.64","1 through 10","79.36","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-98300796","CDM","20611","CPT","0983","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","98.05","38.3","","167.35","167.35","167.35","1 through 10","79.36","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-98300796","CDM","20611","CPT","0983","RC","","","","both","","","256.00","192.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","323.26","158.40","344.15","1 through 10","79.36","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-98300796","CDM","20611","CPT","0983","RC","","","","outpatient","","","256.00","192.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","578.38","578.38","578.38","1 through 10","143.1","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-98300796","CDM","20611","CPT","0983","RC","","","","outpatient","","","256.00","192.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","209.20","81.72","","342.14","342.14","342.14","1 through 10","143.1","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US|BILATERAL PROCEDURE","PX-76002078","CDM","20611","CPT","0761","RC","","","50","both","","","441.00","330.75","MEDICARE [2001]","HB BWH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","525.83","525.83","1 through 10","302.23","385.5","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US|BILATERAL PROCEDURE","PX-76002078","CDM","20611","CPT","0761","RC","","","50","both","","","441.00","330.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","515.31","515.31","515.31","1 through 10","302.23","385.5","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US|BILATERAL PROCEDURE","PX-76002078","CDM","20611","CPT","0761","RC","","","50","outpatient","","","441.00","330.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","984.04","984.04","984.04","1 through 10","424.52","1421.77","other","ASC "
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US|BILATERAL PROCEDURE","PX-98300796","CDM","20611","CPT","0983","RC","","","50","both","","","256.00","192.00","MEDICARE [2001]","HB BWH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","525.83","525.83","1 through 10","302.23","385.5","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US|BILATERAL PROCEDURE","PX-98300796","CDM","20611","CPT","0983","RC","","","50","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","515.31","515.31","515.31","1 through 10","302.23","385.5","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-76002073","CDM","20600","CPT","0761","RC","","","","both","","","718.00","538.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","360.73","360.73","1 through 10","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-76002073","CDM","20600","CPT","0761","RC","","","","both","","","718.00","538.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.81","79.5","","678.40","367.49","678.40","1 through 10","222.58","570.81","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-76002073","CDM","20600","CPT","0761","RC","","","","both","","","718.00","538.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","382.69","53.3","","367.49","367.49","367.49","1 through 10","222.58","570.81","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-76002073","CDM","20600","CPT","0761","RC","","","","both","","","718.00","538.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","12","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-76002073","CDM","20600","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.99","38.3","","272.14","87.21","272.14","11","222.58","570.81","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-76002073","CDM","20600","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","343.55","343.55","1 through 10","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-76002073","CDM","20600","CPT","0761","RC","","","","both","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","36.97","350.56","1 through 10","222.58","570.81","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-76002073","CDM","20600","CPT","0761","RC","","","","outpatient","","","718.00","538.50","AETNA [1001]","HB AMC AETNA PPO","577.27","80.4","","364.70","364.70","364.70","1 through 10","247.48","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-76002073","CDM","20600","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","882.47","882.47","882.47","1 through 10","247.48","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-76002073","CDM","20600","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","633.55","633.55","633.55","1 through 10","247.48","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-76002073","CDM","20600","CPT","0761","RC","","","","outpatient","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","586.75","81.72","","556.38","556.38","556.38","1 through 10","247.48","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-98300791","CDM","20600","CPT","0983","RC","","","","both","","","156.00","117.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","360.73","360.73","1 through 10","48.36","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-98300791","CDM","20600","CPT","0983","RC","","","","both","","","156.00","117.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.02","79.5","","678.40","367.49","678.40","1 through 10","48.36","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-98300791","CDM","20600","CPT","0983","RC","","","","both","","","156.00","117.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.15","53.3","","367.49","367.49","367.49","1 through 10","48.36","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-98300791","CDM","20600","CPT","0983","RC","","","","both","","","156.00","117.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","12","48.36","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-98300791","CDM","20600","CPT","0983","RC","","","","both","","","156.00","117.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","59.75","38.3","","272.14","87.21","272.14","11","48.36","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-98300791","CDM","20600","CPT","0983","RC","","","","both","","","156.00","117.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","343.55","343.55","1 through 10","48.36","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-98300791","CDM","20600","CPT","0983","RC","","","","both","","","156.00","117.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","36.97","350.56","1 through 10","48.36","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-98300791","CDM","20600","CPT","0983","RC","","","","outpatient","","","156.00","117.00","AETNA [1001]","HB AMC AETNA PPO","125.42","80.4","","364.70","364.70","364.70","1 through 10","87.2","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-98300791","CDM","20600","CPT","0983","RC","","","","outpatient","","","156.00","117.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","882.47","882.47","882.47","1 through 10","87.2","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-98300791","CDM","20600","CPT","0983","RC","","","","outpatient","","","156.00","117.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","633.55","633.55","633.55","1 through 10","87.2","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US","PX-98300791","CDM","20600","CPT","0983","RC","","","","outpatient","","","156.00","117.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","127.48","81.72","","556.38","556.38","556.38","1 through 10","87.2","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002073","CDM","20600","CPT","0761","RC","","","50","both","","","718.00","538.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","541.08","541.08","541.08","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002073","CDM","20600","CPT","0761","RC","","","50","both","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.42","477.13","517.42","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002073","CDM","20600","CPT","0761","RC","","","50","both","","","718.00","538.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.43","517.43","517.43","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002073","CDM","20600","CPT","0761","RC","","","50","both","","","718.00","538.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","484.89","525.83","14","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002073","CDM","20600","CPT","0761","RC","","","50","both","","","718.00","538.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1555.44","1555.44","1555.44","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002073","CDM","20600","CPT","0761","RC","","","50","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","852.86","852.86","852.86","1 through 10","424.52","1421.77","other","ASC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002073","CDM","20600","CPT","0761","RC","","","50","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","993.80","984.04","993.80","1 through 10","424.52","1421.77","other","ASC "
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300791","CDM","20600","CPT","0983","RC","","","50","both","","","156.00","117.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","541.08","541.08","541.08","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300791","CDM","20600","CPT","0983","RC","","","50","both","","","156.00","117.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.42","477.13","517.42","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300791","CDM","20600","CPT","0983","RC","","","50","both","","","156.00","117.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.43","517.43","517.43","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300791","CDM","20600","CPT","0983","RC","","","50","both","","","156.00","117.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","484.89","525.83","14","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Small Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-98300791","CDM","20600","CPT","0983","RC","","","50","both","","","156.00","117.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1555.44","1555.44","1555.44","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","both","","","191.00","143.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","360.73","360.73","1 through 10","59.21","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","both","","","191.00","143.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","438.15","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","350.56","350.56","350.56","1 through 10","59.21","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","both","","","191.00","143.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","151.85","79.5","","547.75","547.75","547.75","1 through 10","59.21","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","both","","","191.00","143.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","318.09","318.09","318.09","1 through 10","59.21","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","both","","","191.00","143.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","124.15","65","","452.40","452.40","452.40","1 through 10","59.21","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","both","","","191.00","143.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","31","59.21","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","both","","","191.00","143.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","69.72","36.5","","220.63","60.55","259.61","1 through 10","59.21","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","both","","","191.00","143.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.15","38.3","","272.14","272.14","272.14","1 through 10","59.21","438.15","percent of total billed charges",""
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","both","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.95","343.55","515.33","21","59.21","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","outpatient","","","191.00","143.25","AETNA [1001]","HB AMC AETNA HMO","133.32","69.8","","471.19","471.19","471.19","1 through 10","105.76","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","outpatient","","","191.00","143.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","603.85","582.29","603.85","1 through 10","105.76","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","outpatient","","","191.00","143.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","717.69","717.69","717.69","1 through 10","105.76","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","outpatient","","","191.00","143.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","633.55","633.55","633.55","1 through 10","105.76","700.33","other","Multiple Surgery"
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US","PX-98300153","CDM","20605","CPT","0983","RC","","","","outpatient","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","156.09","81.72","","556.38","556.38","556.38","1 through 10","105.76","700.33","percent of total billed charges",""
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US|BILATERAL PROCEDURE","PX-98300153","CDM","20605","CPT","0983","RC","","","50","both","","","191.00","143.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","541.08","541.08","541.08","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US|BILATERAL PROCEDURE","PX-98300153","CDM","20605","CPT","0983","RC","","","50","both","","","191.00","143.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","484.89","525.83","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US|BILATERAL PROCEDURE","PX-98300153","CDM","20605","CPT","0983","RC","","","50","both","","","191.00","143.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","515.31","515.31","515.31","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US|BILATERAL PROCEDURE","PX-98300153","CDM","20605","CPT","0983","RC","","","50","both","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","515.32","515.32","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrocentesis Aspir&/Injection Interm Jt/Burs W/O US|BILATERAL PROCEDURE|MULTIPLE PROCEDURES","PX-98300153","CDM","20605","CPT","0983","RC","","","50|51","both","","","191.00","143.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","525.83","525.83","1 through 10","333.03","438.15","other","OPPS APC"
"Arthrosc Aid Rpr Cruciate Lig Ant","PX-76001853","CDM","29888","CPT","0761","RC","","","","outpatient","","","22661.00","16995.75","AETNA [1001]","HB AMC AETNA HMO","15817.38","69.8","","9530.47","9530.47","27109.79","1 through 10","5129.63","18518.57","percent of total billed charges",""
"Arthroscopy Shoulder Rotator Cuff Repair","PX-76002370","CDM","29827","CPT","0761","RC","","","","both","","","7382.00","5536.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8903.33","","APC Price ($9,085.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8330.91","8321.44","8330.91","1 through 10","2288.42","11356.28","other","OPPS APC"
"Arthroscopy Shoulder Rotator Cuff Repair","PX-76002370","CDM","29827","CPT","0761","RC","","","","outpatient","","","7382.00","5536.50","AETNA [1001]","HB AMC AETNA HMO","5152.64","69.8","","35158.64","35158.64","35158.64","1 through 10","3857.83","11593.85","percent of total billed charges",""
"Arthrp Acetblr/Prox Fem Prostc Agrft/Algrft","PX-76002362","CDM","27130","CPT","0761","RC","","","","both","","","48829.00","36621.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16036.09","","APC Price ($16,363.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","14982.02","14084.98","14988.31","1 through 10","14516.11","38819.06","other","OPPS APC"
"Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension","PX-98302528","CDM","25448","CPT","0983","RC","","","","both","","","4047.00","3035.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4043.80","","APC Price ($4,126.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3784.01","3784.01","3784.01","1 through 10","1254.57","5157.91","other","OPPS APC"
"Arthrp Kne Condyle&Platu Medial&Lat Compartments","PX-98301292","CDM","27447","CPT","0761","RC","","","","both","","","6120.00","4590.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16036.09","","APC Price ($16,363.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","14982.42","14974.52","14982.42","14","1897.2","20454.19","other","OPPS APC"
"Arup Udp Glucuronosyltransferase 1a1 Genotyping","PX-31001053","CDM","81350","CPT","0310","RC","","","","both","","","2361.00","1770.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","904.26","38.3","","895.39","895.39","895.39","1 through 10","229.32","2242.95","percent of total billed charges",""
"Asp Cyst Intervert Disc/Paravert","PX-76001459","CDM","62267","CPT","0761","RC","","","","both","","","1430.00","1072.50","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","443.3","1136.85","other","OPPS APC"
"Asp Cyst Intervert Disc/Paravert","PX-76001459","CDM","62267","CPT","0761","RC","","","","both","","","1430.00","1072.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","818.85","1 through 10","443.3","1136.85","other","OPPS APC"
"Asp Cyst Intervert Disc/Paravert","PX-76001459","CDM","62267","CPT","0761","RC","","","","both","","","1430.00","1072.50","WELLPOINT [1015]","HB AMC WELLPOINT","1055.05","73.78","","1032.62","1032.62","1032.62","1 through 10","443.3","1136.85","percent of total billed charges",""
"Asp Cyst Intervert Disc/Paravert","PX-76001459","CDM","62267","CPT","0761","RC","","","","outpatient","","","1430.00","1072.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1168.60","81.72","","1108.77","1108.77","1108.77","1 through 10","579.34","1234.13","percent of total billed charges",""
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0306","RC","","","","both","","","219.00","164.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","153.30","70","","212.00","59.80","212.00","1 through 10","11.74","208.05","percent of total billed charges",""
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0306","RC","","","","both","","","219.00","164.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.11","79.5","","166.84","111.94","395.07","1 through 10","11.74","208.05","percent of total billed charges",""
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0306","RC","","","","both","","","219.00","164.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","142.35","65","","275.60","275.60","275.60","1 through 10","11.74","208.05","percent of total billed charges",""
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0306","RC","","","","both","","","219.00","164.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","79.94","36.5","","79.08","67.20","79.08","1 through 10","11.74","208.05","percent of total billed charges",""
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0306","RC","","","","both","","","219.00","164.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","83.88","38.3","","248.67","82.89","248.67","1 through 10","11.74","208.05","percent of total billed charges",""
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0306","RC","","","","both","","","219.00","164.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.95","42.9","","169.47","93.22","169.47","1 through 10","11.74","208.05","percent of total billed charges",""
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0306","RC","","","","outpatient","","","219.00","164.25","AETNA [1001]","HB AMC AETNA HMO","152.86","69.8","","143.52","126.42","287.04","11","11.81","178.97","percent of total billed charges",""
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0306","RC","","","","outpatient","","","219.00","164.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","178.97","81.72","","169.47","54.35","212.00","1 through 10","11.81","178.97","percent of total billed charges",""
"Aspergillus Antibody","PX-30000881","CDM","86606","CPT","0302","RC","","","","both","","","196.00","147.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","137.20","70","","298.61","298.61","298.61","1 through 10","14.75","186.2","percent of total billed charges",""
"Aspergillus Antibody","PX-30000881","CDM","86606","CPT","0302","RC","","","","both","","","196.00","147.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","155.82","79.5","","149.53","149.53","149.53","1 through 10","14.75","186.2","percent of total billed charges",""
"Aspergillus Antibody","PX-30000881","CDM","86606","CPT","0302","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.54","36.5","","70.87","70.87","70.87","1 through 10","14.75","186.2","percent of total billed charges",""
"Aspergillus Antibody","PX-30000881","CDM","86606","CPT","0302","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.07","38.3","","74.29","74.29","74.29","12","14.75","186.2","percent of total billed charges",""
"Aspergillus Antibody","PX-30000881","CDM","86606","CPT","0302","RC","","","","outpatient","","","196.00","147.00","AETNA [1001]","HB AMC AETNA HMO","136.81","69.8","","128.63","90.82","128.63","1 through 10","15.2","160.17","percent of total billed charges",""
"Aspergillus Antibody","PX-30000881","CDM","86606","CPT","0302","RC","","","","outpatient","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","160.17","81.72","","151.89","151.89","151.89","1 through 10","15.2","160.17","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","684.00","513.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","335.87","335.87","488.93","1 through 10","212.04","593.02","other","OPPS APC"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","684.00","513.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","543.78","79.5","","1445.72","521.78","1445.72","1 through 10","212.04","593.02","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","684.00","513.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","364.57","53.3","","1050.18","350.06","1050.18","1 through 10","212.04","593.02","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","684.00","513.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.16","350.16","350.16","1 through 10","212.04","593.02","other","OPPS APC"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","684.00","513.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","12","212.04","593.02","other","OPPS APC"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","249.66","36.5","","247.30","210.17","247.30","1 through 10","212.04","593.02","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.97","38.3","","259.23","251.94","259.23","1 through 10","212.04","593.02","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","684.00","513.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","435.20","435.20","435.20","1 through 10","212.04","593.02","other","OPPS APC"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","684.00","513.00","WELLPOINT [1015]","HB AMC WELLPOINT","504.66","73.78","","1156.60","493.60","1156.60","1 through 10","212.04","593.02","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","684.00","513.00","AETNA [1001]","HB AMC AETNA HMO","477.43","69.8","","897.70","448.85","897.70","1 through 10","314.08","700.33","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","684.00","513.00","AETNA [1001]","HB AMC AETNA PPO","549.94","80.4","","517.14","517.14","517.14","1 through 10","314.08","700.33","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","684.00","513.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","734.86","721.57","840.82","1 through 10","314.08","700.33","other","ASC"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","684.00","513.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","832.56","832.56","840.82","17","314.08","700.33","other","ASC "
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","684.00","513.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","728.67","728.67","728.67","1 through 10","314.08","700.33","other","Multiple Surgery"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","684.00","513.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","766.36","766.36","766.36","1 through 10","314.08","700.33","other","Multiple Surgery"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","684.00","513.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","558.96","81.72","","530.00","291.52","530.00","1 through 10","314.08","700.33","percent of total billed charges",""
"Aspiration Bladder Insert Suprapubic Catheter","PX-98300901","CDM","51102","CPT","0983","RC","","","","both","","","887.00","665.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2505.46","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2510.28","2510.28","2510.28","1 through 10","274.97","3040.6","other","OPPS APC"
"Aspiration Bladder Insert Suprapubic Catheter","PX-98300901","CDM","51102","CPT","0983","RC","","","","both","","","887.00","665.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2393.81","2393.81","2393.81","1 through 10","274.97","3040.6","other","OPPS APC"
"Aspiration Bladder Insert Suprapubic Catheter","PX-98300901","CDM","51102","CPT","0983","RC","","","","both","","","887.00","665.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2393.81","2432.73","1 through 10","274.97","3040.6","other","OPPS APC"
"Aspiration Bladder Insert Suprapubic Catheter","PX-98300901","CDM","51102","CPT","0983","RC","","","","both","","","887.00","665.25","MEDICARE [2001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","11","274.97","3040.6","other","OPPS APC"
"Aspiration Bladder Insert Suprapubic Catheter","PX-98300901","CDM","51102","CPT","0983","RC","","","","both","","","887.00","665.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","339.72","38.3","","1908.08","1908.08","1908.08","1 through 10","274.97","3040.6","percent of total billed charges",""
"Aspiration Bladder Insert Suprapubic Catheter","PX-98300901","CDM","51102","CPT","0983","RC","","","","both","","","887.00","665.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7158.24","7158.24","7158.24","1 through 10","274.97","3040.6","other","OPPS APC"
"Aspiration Bladder Insert Suprapubic Catheter","PX-98300901","CDM","51102","CPT","0983","RC","","","","both","","","887.00","665.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2391.98","2391.98","2391.98","1 through 10","274.97","3040.6","other","OPPS APC"
"Aspiration Bladder Insert Suprapubic Catheter","PX-98300901","CDM","51102","CPT","0983","RC","","","","outpatient","","","887.00","665.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3632.61","3632.61","3632.61","1 through 10","495.83","2384.07","other","Multiple Surgery"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","5032.00","3774.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2505.46","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2510.28","2510.28","2510.28","1 through 10","1559.92","4000.44","other","OPPS APC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","5032.00","3774.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2393.81","2393.81","2393.81","1 through 10","1559.92","4000.44","other","OPPS APC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","5032.00","3774.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2393.81","2432.73","1 through 10","1559.92","4000.44","other","OPPS APC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","5032.00","3774.00","MEDICARE [2001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","11","1559.92","4000.44","other","OPPS APC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","5032.00","3774.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1927.26","38.3","","1908.08","1908.08","1908.08","1 through 10","1559.92","4000.44","percent of total billed charges",""
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","5032.00","3774.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7158.24","7158.24","7158.24","1 through 10","1559.92","4000.44","other","OPPS APC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","5032.00","3774.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2391.98","2391.98","2391.98","1 through 10","1559.92","4000.44","other","OPPS APC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","outpatient","","","5032.00","3774.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3996.91","3996.91","3996.91","1 through 10","1565.78","4112.15","other","ASC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","outpatient","","","5032.00","3774.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2328.71","2328.71","2328.71","1 through 10","1565.78","4112.15","other","ASC "
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","outpatient","","","5032.00","3774.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3632.61","3632.61","3632.61","1 through 10","1565.78","4112.15","other","Multiple Surgery"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1459.00","1094.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","755.61","421.42","755.61","1 through 10","452.29","1159.91","other","OPPS APC"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1459.00","1094.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1159.91","79.5","","1113.61","1113.61","1113.61","1 through 10","452.29","1159.91","percent of total billed charges",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1459.00","1094.25","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","452.29","1159.91","other","OPPS APC"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1459.00","1094.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","532.54","36.5","","527.80","527.80","527.80","1 through 10","452.29","1159.91","percent of total billed charges",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1459.00","1094.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","558.80","38.3","","553.27","537.70","553.27","1 through 10","452.29","1159.91","percent of total billed charges",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1459.00","1094.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.75","826.35","826.75","1 through 10","452.29","1159.91","other","OPPS APC"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1459.00","1094.25","WELLPOINT [1015]","HB AMC WELLPOINT","1076.45","73.78","","1053.47","1053.47","1053.47","1 through 10","452.29","1159.91","percent of total billed charges",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1459.00","1094.25","AETNA [1001]","HB AMC AETNA HMO","1018.38","69.8","","957.96","957.96","957.96","1 through 10","579.34","1234.13","percent of total billed charges",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1459.00","1094.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1330.98","1330.98","1330.98","1 through 10","579.34","1234.13","other","ASC"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1459.00","1094.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1550.94","767.85","1550.94","1 through 10","579.34","1234.13","other","ASC "
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1459.00","1094.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1680.09","1680.09","1680.09","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1459.00","1094.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1344.07","1344.07","1344.07","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1459.00","1094.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1413.59","1413.59","1413.59","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1459.00","1094.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1192.29","81.72","","1131.15","1131.15","1131.15","1 through 10","579.34","1234.13","percent of total billed charges",""
"Aspiration Cyst Spinal Cord Perc","PX-76001460","CDM","62268","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","874.64","","Case rate ($874.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2047.53","2047.53","2047.53","1 through 10","764.84","2384.07","other","ASC "
"Aspiration Fine Needle W/O Imaging","PX-76000001","CDM","10021","CPT","0761","RC","","","","both","","","528.00","396.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","163.68","593.02","other","OPPS APC"
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","both","","","1954.00","1465.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1553.43","other","OPPS APC"
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","both","","","1954.00","1465.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1553.43","other","OPPS APC"
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","both","","","1954.00","1465.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1041.48","53.3","","477.31","477.31","477.31","1 through 10","333.03","1553.43","percent of total billed charges",""
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","both","","","1954.00","1465.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1553.43","other","OPPS APC"
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","both","","","1954.00","1465.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1553.43","other","OPPS APC"
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","both","","","1954.00","1465.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","713.21","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1553.43","percent of total billed charges",""
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","both","","","1954.00","1465.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","748.38","38.3","","343.52","323.76","353.46","1 through 10","333.03","1553.43","percent of total billed charges",""
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","both","","","1954.00","1465.50","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1553.43","other","Tricare OPPS"
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","both","","","1954.00","1465.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1553.43","other","OPPS APC"
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","both","","","1954.00","1465.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1553.43","other","OPPS APC"
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","both","","","1954.00","1465.50","WELLPOINT [1015]","HB AMC WELLPOINT","1441.66","73.78","","673.03","673.03","673.03","1 through 10","333.03","1553.43","percent of total billed charges",""
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","outpatient","","","1954.00","1465.50","AETNA [1001]","HB AMC AETNA HMO","1363.89","69.8","","612.01","612.01","1224.02","1 through 10","700.33","1612.05","percent of total billed charges",""
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","outpatient","","","1954.00","1465.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1183.15","60.55","","579.04","568.57","904.00","30","700.33","1612.05","percent of total billed charges",""
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","outpatient","","","1954.00","1465.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1020.38","52.22","","904.00","656.02","2938.00","26","700.33","1612.05","percent of total billed charges",""
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","outpatient","","","1954.00","1465.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","977.00","50","","1421.10","875.08","2368.50","15","700.33","1612.05","percent of total billed charges",""
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","outpatient","","","1954.00","1465.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1025.85","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","1612.05","percent of total billed charges",""
"Aspiration of Facet Joint Cyst","PX-76002630","CDM","64999","CPT","0761","RC","","","","outpatient","","","1954.00","1465.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1596.81","81.72","","722.66","722.66","17449.00","1 through 10","700.33","1612.05","percent of total billed charges",""
"Aspiration/Inject Cyst Thyroid","PX-76001413","CDM","60300","CPT","0761","RC","","","","outpatient","","","1459.00","1094.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.70","1535.70","1535.70","1 through 10","579.34","1234.13","other","ASC "
"Assay Neurofilament Light Chain","PX-30003841","CDM","83884","CPT","0302","RC","","","","both","","","1200.00","900.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","954.00","79.5","","916.07","916.07","916.07","1 through 10","372","1140","percent of total billed charges",""
"Assay Neurofilament Light Chain","PX-30003841","CDM","83884","CPT","0302","RC","","","","both","","","1200.00","900.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","639.60","53.3","","1843.77","614.59","1843.77","1 through 10","372","1140","percent of total billed charges",""
"Assay Neurofilament Light Chain","PX-30003841","CDM","83884","CPT","0302","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB AMC WELLPOINT","885.36","73.78","","866.60","866.60","2030.60","1 through 10","372","1140","percent of total billed charges",""
"Assay Neurofilament Light Chain","PX-30003841","CDM","83884","CPT","0302","RC","","","","outpatient","","","1200.00","900.00","AETNA [1001]","HB AMC AETNA HMO","837.60","69.8","","788.03","788.03","788.03","1 through 10","480","990","percent of total billed charges",""
"Assay Neurofilament Light Chain","PX-30003841","CDM","83884","CPT","0302","RC","","","","outpatient","","","1200.00","900.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","726.60","60.55","","726.57","726.57","726.57","17","480","990","percent of total billed charges",""
"Assay Neurofilament Light Chain","PX-30003841","CDM","83884","CPT","0302","RC","","","","outpatient","","","1200.00","900.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","626.64","52.22","","626.59","626.58","626.59","31","480","990","percent of total billed charges",""
"Assay Neurofilament Light Chain","PX-30003841","CDM","83884","CPT","0302","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","980.64","81.72","","930.50","511.81","930.50","1 through 10","480","990","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","470.00","352.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","308.32","65.6","","308.71","308.71","308.71","1 through 10","37.85","446.5","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","470.00","352.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","329.00","70","","456.00","456.00","456.00","1 through 10","37.85","446.5","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","470.00","352.50","CHAMPVA [160001]","HB BWH TRICARE","446.50","95","","46.54","46.54","46.54","1 through 10","37.85","446.5","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","470.00","352.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","373.65","79.5","","358.87","240.77","358.87","72","37.85","446.5","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","470.00","352.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","250.51","53.3","","358.87","240.77","1203.85","41","37.85","446.5","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","470.00","352.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","305.50","65","","287.95","287.95","287.95","1 through 10","37.85","446.5","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","470.00","352.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","145.70","31","","140.90","140.90","140.90","1 through 10","37.85","446.5","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","470.00","352.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","171.55","36.5","","170.09","144.55","850.45","83","37.85","446.5","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","470.00","352.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","180.01","38.3","","178.30","173.28","178.30","253","37.85","446.5","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","470.00","352.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","361.90","77","","358.87","358.87","358.87","1 through 10","37.85","446.5","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","470.00","352.50","TRICARE [160005]","HB BWH TRICARE","446.50","95","","46.54","44.21","46.54","1 through 10","37.85","446.5","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","470.00","352.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.63","42.9","","200.50","200.50","364.53","1 through 10","37.85","446.5","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","470.00","352.50","WELLPOINT [1015]","HB AMC WELLPOINT","346.77","73.78","","339.49","339.49","795.49","37","37.85","446.5","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","AETNA [1001]","HB AMC AETNA HMO","328.06","69.8","","308.71","217.97","355.68","108","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","AETNA [1001]","HB AMC AETNA PPO","377.88","80.4","","355.68","238.94","355.68","12","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","284.59","60.55","","284.64","273.78","306.57","256","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","245.43","52.22","","245.47","245.46","315.19","630","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","246.75","52.5","","298.68","262.66","298.68","13","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","235.00","50","","238.94","229.37","450.07","155","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","246.75","52.5","","250.80","241.22","472.87","96","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","387.75","82.5","","393.98","393.98","393.98","1 through 10","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","293.75","62.5","","393.98","298.68","393.98","1 through 10","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","246.75","52.5","","250.80","250.80","250.80","1 through 10","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","258.50","55","","262.66","252.62","505.24","34","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","377.88","80.4","","355.68","355.68","355.68","1 through 10","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","384.08","81.72","","912.00","912.00","912.00","1 through 10","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","384.08","81.72","","364.53","200.50","364.53","1 through 10","235","387.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","470.00","352.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","384.08","81.72","","364.53","200.50","364.53","77","235","387.75","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","both","","","206.00","154.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","144.20","70","","600.00","600.00","600.00","1 through 10","16.92","195.7","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","both","","","206.00","154.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","163.77","79.5","","157.40","150.80","157.40","1 through 10","16.92","195.7","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","both","","","206.00","154.50","WELLPOINT [1015]","HB AMC WELLPOINT","151.99","73.78","","348.90","148.90","348.90","1 through 10","16.92","195.7","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","outpatient","","","206.00","154.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","108.15","52.5","","131.00","131.00","131.00","1 through 10","50.06","169.95","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","outpatient","","","206.00","154.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","103.00","50","","104.80","100.60","197.40","12","50.06","169.95","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","outpatient","","","206.00","154.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","108.15","52.5","","220.00","220.00","220.00","1 through 10","50.06","169.95","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","outpatient","","","206.00","154.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","128.75","62.5","","131.00","131.00","131.00","1 through 10","50.06","169.95","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","outpatient","","","206.00","154.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","113.30","55","","115.20","115.20","115.20","1 through 10","50.06","169.95","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","outpatient","","","206.00","154.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","168.34","81.72","","159.88","87.94","159.88","1 through 10","50.06","169.95","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","158.00","118.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.61","79.5","","120.41","80.78","120.41","100","13.35","150.1","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","158.00","118.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","84.21","53.3","","80.78","80.78","120.41","56","13.35","150.1","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","158.00","118.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","125.61","79.5","","120.41","120.41","120.41","1 through 10","13.35","150.1","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","158.00","118.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.98","31","","47.28","47.28","47.28","1 through 10","13.35","150.1","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","158.00","118.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.67","36.5","","57.07","48.50","171.21","108","13.35","150.1","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","158.00","118.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.51","38.3","","59.82","59.82","179.46","428","13.35","150.1","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","158.00","118.50","TRICARE [160005]","HB BWH TRICARE","150.10","95","","16.40","16.40","17.26","1 through 10","13.35","150.1","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","158.00","118.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.78","42.9","","67.27","67.27","122.31","1 through 10","13.35","150.1","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","158.00","118.50","AETNA [1001]","HB AMC AETNA HMO","110.28","69.8","","103.58","73.13","103.58","13","13.35","129.12","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","158.00","118.50","AETNA [1001]","HB AMC AETNA PPO","127.03","80.4","","119.34","53.39","119.34","1 through 10","13.35","129.12","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","158.00","118.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","127.03","80.4","","76.50","76.50","76.50","1 through 10","13.35","129.12","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","158.00","118.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","129.12","81.72","","67.27","67.27","153.00","27","13.35","129.12","percent of total billed charges",""
"Assay of Sirolimus","PX-30000035","CDM","80195","CPT","0301","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","100.52","71.8","","97.65","97.65","97.65","1 through 10","7.52","133","percent of total billed charges",""
"Assay of Sirolimus","PX-30000035","CDM","80195","CPT","0301","RC","","","","both","","","140.00","105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.30","79.5","","71.81","71.81","71.81","14","7.52","133","percent of total billed charges",""
"Assay of Sirolimus","PX-30000035","CDM","80195","CPT","0301","RC","","","","both","","","140.00","105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.62","53.3","","71.81","71.81","71.81","1 through 10","7.52","133","percent of total billed charges",""
"Assay of Sirolimus","PX-30000035","CDM","80195","CPT","0301","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.10","36.5","","49.23","43.11","50.73","1 through 10","7.52","133","percent of total billed charges",""
"Assay of Sirolimus","PX-30000035","CDM","80195","CPT","0301","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.62","38.3","","53.18","51.68","53.18","1 through 10","7.52","133","percent of total billed charges",""
"Assay of Sirolimus","PX-30000035","CDM","80195","CPT","0301","RC","","","","both","","","140.00","105.00","TRICARE [160005]","HB BWH TRICARE","133.00","95","","15.71","15.71","15.71","1 through 10","7.52","133","percent of total billed charges",""
"Assay of Sirolimus","PX-30000035","CDM","80195","CPT","0301","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA HMO","97.72","69.8","","92.07","92.07","92.07","1 through 10","7.52","114.41","percent of total billed charges",""
"Assay of Sirolimus","PX-30000035","CDM","80195","CPT","0301","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.41","81.72","","108.72","108.72","108.72","1 through 10","7.52","114.41","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","327.00","245.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","214.51","65.6","","214.61","214.61","214.61","1 through 10","27.38","310.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","327.00","245.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","228.90","70","","187.34","187.34","187.34","1 through 10","27.38","310.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","327.00","245.25","CHAMPVA [160001]","HB BWH TRICARE","310.65","95","","33.67","33.67","33.67","1 through 10","27.38","310.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","327.00","245.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","259.97","79.5","","249.48","167.38","249.48","395","27.38","310.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","327.00","245.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","174.29","53.3","","167.38","167.38","249.48","182","27.38","310.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","327.00","245.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","259.97","79.5","","249.48","249.48","249.48","1 through 10","27.38","310.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","327.00","245.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","101.37","31","","97.95","97.95","97.95","11","27.38","310.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","327.00","245.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","119.36","36.5","","118.24","100.49","301.47","203","27.38","310.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","327.00","245.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","125.24","38.3","","123.95","120.46","123.95","695","27.38","310.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","327.00","245.25","TRICARE [160005]","HB BWH TRICARE","310.65","95","","31.99","31.99","33.67","13","27.38","310.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","327.00","245.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.28","42.9","","253.41","139.38","253.41","17","27.38","310.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","327.00","245.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.28","42.9","","253.41","253.41","253.41","1 through 10","27.38","310.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","327.00","245.25","AETNA [1001]","HB AMC AETNA HMO","228.25","69.8","","214.61","151.53","247.26","443","28.81","267.22","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","327.00","245.25","AETNA [1001]","HB AMC AETNA PPO","262.91","80.4","","247.26","151.53","247.26","59","28.81","267.22","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","327.00","245.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","182.79","55.9","","166.11","166.11","166.11","1 through 10","28.81","267.22","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","327.00","245.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","170.89","52.26","","98.98","98.98","98.98","1 through 10","28.81","267.22","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","327.00","245.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","262.91","80.4","","247.26","158.50","247.26","1 through 10","28.81","267.22","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","327.00","245.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","267.22","81.72","","139.38","139.38","253.41","1 through 10","28.81","267.22","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","327.00","245.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","267.22","81.72","","253.41","139.38","253.41","327","28.81","267.22","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","both","","","270.00","202.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","214.65","79.5","","206.19","138.34","206.19","1 through 10","21.73","256.5","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","98.55","36.5","","83.05","83.05","83.05","1 through 10","21.73","256.5","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","103.41","38.3","","102.44","86.46","102.44","1 through 10","21.73","256.5","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","both","","","270.00","202.50","WELLPOINT [1015]","HB AMC WELLPOINT","199.21","73.78","","195.06","195.06","195.06","1 through 10","21.73","256.5","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","outpatient","","","270.00","202.50","AETNA [1001]","HB AMC AETNA HMO","188.46","69.8","","177.37","125.24","177.37","1 through 10","64.67","222.75","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","outpatient","","","270.00","202.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","141.75","52.5","","171.61","171.61","171.61","1 through 10","64.67","222.75","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","outpatient","","","270.00","202.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","135.00","50","","137.29","137.29","137.29","1 through 10","64.67","222.75","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","outpatient","","","270.00","202.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","141.75","52.5","","144.10","144.10","144.10","1 through 10","64.67","222.75","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","outpatient","","","270.00","202.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","148.50","55","","91.74","91.74","91.74","1 through 10","64.67","222.75","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","outpatient","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","220.64","81.72","","115.20","115.20","115.20","1 through 10","64.67","222.75","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","outpatient","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","220.64","81.72","","115.20","115.20","115.20","1 through 10","64.67","222.75","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","146.33","52.26","","1113.10","1113.10","1113.10","1 through 10","86.8","222.6","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","222.60","79.5","","1293.60","1148.53","1603.80","1 through 10","86.8","222.6","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","102.20","36.5","","1023.42","771.29","2068.67","33","86.8","222.6","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","107.24","38.3","","850.52","759.78","1211.25","66","86.8","222.6","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.12","42.9","","2548.09","2548.09","2548.09","1 through 10","86.8","222.6","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.12","42.9","","956.46","956.46","956.46","1 through 10","86.8","222.6","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","WELLPOINT [1015]","HB AMC WELLPOINT","206.58","73.78","","2344.73","1619.47","2530.35","16","86.8","222.6","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","AETNA [1001]","HB AMC AETNA HMO","195.44","69.8","","1523.63","988.41","4330.26","39","146.33","228.82","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","AETNA [1001]","HB AMC AETNA PPO","225.12","80.4","","1670.25","1670.25","1670.25","1 through 10","146.33","228.82","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","146.33","52.26","","1113.10","1113.10","1113.10","1 through 10","146.33","228.82","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","228.82","81.72","","1738.90","1484.65","2716.94","38","146.33","228.82","percent of total billed charges",""
"ASSEMBLY CABLE 1.8MMX63.5CM BONE PLATE ZIMMER READY COBALT CERCLAGE CRIMP CS/1BX/1EA","SUP-ITM-10024295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1276.24","957.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1014.61","79.5","","800.18","480.96","1887.97","195","395.63","1014.61","percent of total billed charges",""
"ASSEMBLY CABLE 1.8MMX63.5CM BONE PLATE ZIMMER READY COBALT CERCLAGE CRIMP CS/1BX/1EA","SUP-ITM-10024295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1276.24","957.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","680.24","53.3","","813.12","216.42","1444.50","81","395.63","1014.61","percent of total billed charges",""
"ASSEMBLY CABLE 1.8MMX63.5CM BONE PLATE ZIMMER READY COBALT CERCLAGE CRIMP CS/1BX/1EA","SUP-ITM-10024295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1276.24","957.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","395.63","31","","432.60","432.60","432.60","1 through 10","395.63","1014.61","percent of total billed charges",""
"ASSEMBLY CABLE 1.8MMX63.5CM BONE PLATE ZIMMER READY COBALT CERCLAGE CRIMP CS/1BX/1EA","SUP-ITM-10024295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1276.24","957.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","465.83","36.5","","148.37","54.89","631.39","94","395.63","1014.61","percent of total billed charges",""
"ASSEMBLY CABLE 1.8MMX63.5CM BONE PLATE ZIMMER READY COBALT CERCLAGE CRIMP CS/1BX/1EA","SUP-ITM-10024295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1276.24","957.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","488.80","38.3","","279.30","91.72","1116.77","266","395.63","1014.61","percent of total billed charges",""
"ASSEMBLY CABLE 1.8MMX63.5CM BONE PLATE ZIMMER READY COBALT CERCLAGE CRIMP CS/1BX/1EA","SUP-ITM-10024295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1276.24","957.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","547.51","42.9","","731.00","63.70","731.00","1 through 10","395.63","1014.61","percent of total billed charges",""
"ASSEMBLY CABLE 1.8MMX63.5CM BONE PLATE ZIMMER READY COBALT CERCLAGE CRIMP CS/1BX/1EA","SUP-ITM-10024295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1276.24","957.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","547.51","42.9","","384.74","384.74","384.74","1 through 10","395.63","1014.61","percent of total billed charges",""
"ASSEMBLY CABLE 1.8MMX63.5CM BONE PLATE ZIMMER READY COBALT CERCLAGE CRIMP CS/1BX/1EA","SUP-ITM-10024295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1276.24","957.18","WELLPOINT [1015]","HB AMC WELLPOINT","941.61","73.78","","286.63","119.22","1107.45","105","395.63","1014.61","percent of total billed charges",""
"ASSEMBLY CABLE 1.8MMX63.5CM BONE PLATE ZIMMER READY COBALT CERCLAGE CRIMP CS/1BX/1EA","SUP-ITM-10024295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1276.24","957.18","AETNA [1001]","HB AMC AETNA HMO","890.82","69.8","","675.31","184.75","1721.50","286","666.96","1042.94","percent of total billed charges",""
"ASSEMBLY CABLE 1.8MMX63.5CM BONE PLATE ZIMMER READY COBALT CERCLAGE CRIMP CS/1BX/1EA","SUP-ITM-10024295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1276.24","957.18","AETNA [1001]","HB AMC AETNA PPO","1026.10","80.4","","1261.44","103.12","1514.10","21","666.96","1042.94","percent of total billed charges",""
"ASSEMBLY CABLE 1.8MMX63.5CM BONE PLATE ZIMMER READY COBALT CERCLAGE CRIMP CS/1BX/1EA","SUP-ITM-10024295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1276.24","957.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1026.10","80.4","","1365.00","1365.00","1365.00","1 through 10","666.96","1042.94","percent of total billed charges",""
"ASSEMBLY CABLE 1.8MMX63.5CM BONE PLATE ZIMMER READY COBALT CERCLAGE CRIMP CS/1BX/1EA","SUP-ITM-10024295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1276.24","957.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1042.94","81.72","","5157.68","5157.68","5157.68","1 through 10","666.96","1042.94","percent of total billed charges",""
"ASSEMBLY CABLE 1.8MMX63.5CM BONE PLATE ZIMMER READY COBALT CERCLAGE CRIMP CS/1BX/1EA","SUP-ITM-10024295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1276.24","957.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1042.94","81.72","","431.26","71.26","1459.57","88","666.96","1042.94","percent of total billed charges",""
"ASSEMBLY COMPONENT 4.0IN HUMERAL ELBOW COONRAD/MORREY TITANIUM ALLOY REGULAR","SUP-ITM-10017717","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3990.64","52.26","","1113.10","1113.10","1113.10","1 through 10","2367.2","6070.72","percent of total billed charges",""
"ASSEMBLY COMPONENT 4.0IN HUMERAL ELBOW COONRAD/MORREY TITANIUM ALLOY REGULAR","SUP-ITM-10017717","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6070.72","79.5","","1293.60","1148.53","1603.80","1 through 10","2367.2","6070.72","percent of total billed charges",""
"ASSEMBLY COMPONENT 4.0IN HUMERAL ELBOW COONRAD/MORREY TITANIUM ALLOY REGULAR","SUP-ITM-10017717","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2787.19","36.5","","1023.42","771.29","2068.67","33","2367.2","6070.72","percent of total billed charges",""
"ASSEMBLY COMPONENT 4.0IN HUMERAL ELBOW COONRAD/MORREY TITANIUM ALLOY REGULAR","SUP-ITM-10017717","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2924.64","38.3","","850.52","759.78","1211.25","66","2367.2","6070.72","percent of total billed charges",""
"ASSEMBLY COMPONENT 4.0IN HUMERAL ELBOW COONRAD/MORREY TITANIUM ALLOY REGULAR","SUP-ITM-10017717","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3275.90","42.9","","2548.09","2548.09","2548.09","1 through 10","2367.2","6070.72","percent of total billed charges",""
"ASSEMBLY COMPONENT 4.0IN HUMERAL ELBOW COONRAD/MORREY TITANIUM ALLOY REGULAR","SUP-ITM-10017717","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3275.90","42.9","","956.46","956.46","956.46","1 through 10","2367.2","6070.72","percent of total billed charges",""
"ASSEMBLY COMPONENT 4.0IN HUMERAL ELBOW COONRAD/MORREY TITANIUM ALLOY REGULAR","SUP-ITM-10017717","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","WELLPOINT [1015]","HB AMC WELLPOINT","5633.94","73.78","","2344.73","1619.47","2530.35","16","2367.2","6070.72","percent of total billed charges",""
"ASSEMBLY COMPONENT 4.0IN HUMERAL ELBOW COONRAD/MORREY TITANIUM ALLOY REGULAR","SUP-ITM-10017717","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7636.13","5727.10","AETNA [1001]","HB AMC AETNA HMO","5330.02","69.8","","1523.63","988.41","4330.26","39","3990.64","6240.25","percent of total billed charges",""
"ASSEMBLY COMPONENT 4.0IN HUMERAL ELBOW COONRAD/MORREY TITANIUM ALLOY REGULAR","SUP-ITM-10017717","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7636.13","5727.10","AETNA [1001]","HB AMC AETNA PPO","6139.45","80.4","","1670.25","1670.25","1670.25","1 through 10","3990.64","6240.25","percent of total billed charges",""
"ASSEMBLY COMPONENT 4.0IN HUMERAL ELBOW COONRAD/MORREY TITANIUM ALLOY REGULAR","SUP-ITM-10017717","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7636.13","5727.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3990.64","52.26","","1113.10","1113.10","1113.10","1 through 10","3990.64","6240.25","percent of total billed charges",""
"ASSEMBLY COMPONENT 4.0IN HUMERAL ELBOW COONRAD/MORREY TITANIUM ALLOY REGULAR","SUP-ITM-10017717","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7636.13","5727.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6240.25","81.72","","1738.90","1484.65","2716.94","38","3990.64","6240.25","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5432.43","52.26","","1113.10","1113.10","1113.10","1 through 10","3222.45","8264.03","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8264.03","79.5","","1293.60","1148.53","1603.80","1 through 10","3222.45","8264.03","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3794.18","36.5","","1023.42","771.29","2068.67","33","3222.45","8264.03","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3981.29","38.3","","850.52","759.78","1211.25","66","3222.45","8264.03","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4459.46","42.9","","2548.09","2548.09","2548.09","1 through 10","3222.45","8264.03","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4459.46","42.9","","956.46","956.46","956.46","1 through 10","3222.45","8264.03","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","WELLPOINT [1015]","HB AMC WELLPOINT","7669.43","73.78","","2344.73","1619.47","2530.35","16","3222.45","8264.03","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10395.00","7796.25","AETNA [1001]","HB AMC AETNA HMO","7255.71","69.8","","1523.63","988.41","4330.26","39","5432.43","8494.79","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10395.00","7796.25","AETNA [1001]","HB AMC AETNA PPO","8357.58","80.4","","1670.25","1670.25","1670.25","1 through 10","5432.43","8494.79","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10395.00","7796.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5432.43","52.26","","1113.10","1113.10","1113.10","1 through 10","5432.43","8494.79","percent of total billed charges",""
"ASSEMBLY FEMORAL SIZE 5 KNEE LEGION HK COBALT CHROMIUM CEMENTED RIGHT","SUP-ITM-10100575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10395.00","7796.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8494.79","81.72","","1738.90","1484.65","2716.94","38","5432.43","8494.79","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","both","","","1172.50","879.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","932.14","79.5","","1309.77","674.56","6049.93","26","363.48","932.14","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","both","","","1172.50","879.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","624.94","53.3","","1901.83","1901.83","2962.25","1 through 10","363.48","932.14","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","both","","","1172.50","879.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","427.96","36.5","","1620.31","1620.31","19908.88","1 through 10","363.48","932.14","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","both","","","1172.50","879.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","449.07","38.3","","352.91","352.91","2046.30","1 through 10","363.48","932.14","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","both","","","1172.50","879.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","503.00","42.9","","9668.75","9668.75","9668.75","1 through 10","363.48","932.14","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","both","","","1172.50","879.37","WELLPOINT [1015]","HB AMC WELLPOINT","865.07","73.78","","699.88","384.10","3443.31","33","363.48","932.14","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1172.50","879.37","AETNA [1001]","HB AMC AETNA HMO","818.41","69.8","","1421.24","264.50","4933.46","29","612.75","958.17","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1172.50","879.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","942.69","80.4","","1022.97","1022.97","3607.50","1 through 10","612.75","958.17","percent of total billed charges",""
"ASSEMBLY TULIP MODULAR RMM","SUP-ITM-10229356","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1172.50","879.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","958.17","81.72","","3010.54","693.88","5019.88","35","612.75","958.17","percent of total billed charges",""
"Asstd Oocyte Fert More Than 10 Oocy","PX-30000134","CDM","89281","CPT","0300","RC","","","","both","","","4180.00","3135.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3323.10","79.5","","3190.50","2140.51","3190.50","1 through 10","199.41","3971","percent of total billed charges",""
"Asstd Oocyte Fert More Than 10 Oocy","PX-30000134","CDM","89281","CPT","0300","RC","","","","both","","","4180.00","3135.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2227.94","53.3","","3190.50","3190.50","3190.50","1 through 10","199.41","3971","percent of total billed charges",""
"Asstd Oocyte Fert More Than 10 Oocy","PX-30000134","CDM","89281","CPT","0300","RC","","","","both","","","4180.00","3135.00","WELLPOINT [1015]","HB AMC WELLPOINT","3084.00","73.78","","7072.20","3018.20","7072.20","1 through 10","199.41","3971","percent of total billed charges",""
"Asstd Oocyte Fert More Than 10 Oocy","PX-30000134","CDM","89281","CPT","0300","RC","","","","outpatient","","","4180.00","3135.00","AETNA [1001]","HB AMC AETNA HMO","2917.64","69.8","","1937.81","1937.81","1937.81","1 through 10","297.92","3415.9","percent of total billed charges",""
"Asstd Oocyte Fert More Than 10 Oocy","PX-30000134","CDM","89281","CPT","0300","RC","","","","outpatient","","","4180.00","3135.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3415.90","81.72","","3240.77","3240.77","3240.77","1 through 10","297.92","3415.9","percent of total billed charges",""
"Asstd Oocyte Fertilzatn 10 or Less","PX-30000133","CDM","89280","CPT","0300","RC","","","","both","","","2399.00","1799.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1907.21","79.5","","1830.56","1830.56","1830.56","1 through 10","743.69","2279.05","percent of total billed charges",""
"Asstd Oocyte Fertilzatn 10 or Less","PX-30000133","CDM","89280","CPT","0300","RC","","","","both","","","2399.00","1799.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1278.67","53.3","","1228.13","1228.13","1228.13","1 through 10","743.69","2279.05","percent of total billed charges",""
"Asstd Oocyte Fertilzatn 10 or Less","PX-30000133","CDM","89280","CPT","0300","RC","","","","both","","","2399.00","1799.25","WELLPOINT [1015]","HB AMC WELLPOINT","1769.98","73.78","","4057.71","1731.71","4057.71","1 through 10","743.69","2279.05","percent of total billed charges",""
"Asstd Oocyte Fertilzatn 10 or Less","PX-30000133","CDM","89280","CPT","0300","RC","","","","outpatient","","","2399.00","1799.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1960.46","81.72","","1022.74","1022.74","1022.74","1 through 10","265.8","3421.28","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","63.00","47.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","45.23","71.8","","131.40","43.80","131.40","17","5.08","59.85","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","63.00","47.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","44.10","70","","61.00","61.00","61.00","1 through 10","5.08","59.85","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","63.00","47.25","CHAMPVA [160001]","HB BWH TRICARE","59.85","95","","6.24","6.24","6.24","1 through 10","5.08","59.85","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","63.00","47.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","50.09","79.5","","48.01","32.21","48.01","119","5.08","59.85","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","63.00","47.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33.58","53.3","","32.21","32.21","48.01","74","5.08","59.85","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","40.95","65","","39.65","39.65","52.65","1 through 10","5.08","59.85","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","19.53","31","","18.85","18.85","18.85","1 through 10","5.08","59.85","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.00","36.5","","22.75","19.34","58.02","78","5.08","59.85","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.13","38.3","","23.85","23.18","46.36","228","5.08","59.85","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","63.00","47.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","48.51","77","","48.01","48.01","48.01","1 through 10","5.08","59.85","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","63.00","47.25","TRICARE [160005]","HB BWH TRICARE","59.85","95","","6.24","5.93","6.24","11","5.08","59.85","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.03","42.9","","48.76","48.76","48.76","1 through 10","5.08","59.85","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.03","42.9","","26.82","26.82","26.82","1 through 10","5.08","59.85","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","63.00","47.25","AETNA [1001]","HB AMC AETNA HMO","43.97","69.8","","41.30","29.16","47.58","202","5.34","51.48","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","63.00","47.25","AETNA [1001]","HB AMC AETNA PPO","50.65","80.4","","47.58","29.16","47.58","13","5.34","51.48","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","50.65","80.4","","47.58","30.50","47.58","1 through 10","5.34","51.48","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","51.48","81.72","","26.82","26.82","48.76","1 through 10","5.34","51.48","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","51.48","81.72","","48.76","26.82","48.76","90","5.34","51.48","percent of total billed charges",""
"Asthma,EXTREME","141","DRG","","","","","","","","inpatient","","","82754.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","11966.17","","Standard inlier is a Case rate ($38,045.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,235, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,400.85) for the length of stay and the standard reimbursement.","11966.17","34680.27","34680.27","1 through 10","4097.67","58400.05","case rate",""
"Asthma,EXTREME","141","DRG","","","","","","","","inpatient","","","82754.10","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10994.13","","Case rate ($12,155.90). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,585.90, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12152.92","12152.92","12152.92","1 through 10","4097.67","58400.05","case rate",""
"Asthma,MAJOR","141","DRG","","","","","","","","inpatient","","","62041.09","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","18887.90","","Fee schedule rate ($18,887.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2396), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22090.71","22090.71","22090.71","1 through 10","4097.67","58400.05","case rate",""
"Asthma,MAJOR","141","DRG","","","","","","","","inpatient","","","62041.09","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22090.65","","Fee schedule rate ($22,090.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2396), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22090.71","22090.71","22090.71","1 through 10","4097.67","58400.05","case rate",""
"Asthma,MINOR","141","DRG","","","","","","","","inpatient","","","30417.27","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","11966.17","","Standard inlier is a Case rate ($11,966.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $20,953, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,698.67) for the length of stay and the standard reimbursement.","11966.17","10907.60","10907.60","1 through 10","4097.67","58400.05","case rate",""
"Asthma,MINOR","141","DRG","","","","","","","","inpatient","","","30417.27","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","13453.2","","Standard inlier is a Case rate ($13,453.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $20,953, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,909.57) for the length of stay and the standard reimbursement.","13453.2","13453.20","13453.20","1 through 10","4097.67","58400.05","case rate",""
"Asthma,MINOR","141","DRG","","","","","","","","inpatient","","","30417.27","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4097.67","","Case rate ($4,530.68). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,960.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11178.71","11178.71","11178.71","1 through 10","4097.67","58400.05","case rate",""
"Asthma,MODERATE","141","DRG","","","","","","","","inpatient","","","21805.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","13453.2","","Standard inlier is a Case rate ($20,237.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,646, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,872.61) for the length of stay and the standard reimbursement.","13453.2","15178.48","15178.48","1 through 10","4097.67","58400.05","case rate",""
"Asthma,MODERATE","141","DRG","","","","","","","","inpatient","","","21805.72","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5266.31","","Case rate ($5,822.81). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,252.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","900.97","900.97","5821.38","1 through 10","4097.67","58400.05","case rate",""
"Ataxia, Comprehensive Evaluation","PX-31000794","CDM","81479","CPT","0310","RC","","","","both","","","666.00","499.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","529.47","79.5","","0.65","0.65","0.65","1 through 10","206.46","632.7","percent of total billed charges",""
"Ataxia, Comprehensive Evaluation","PX-31000794","CDM","81479","CPT","0310","RC","","","","both","","","666.00","499.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","354.98","53.3","","0.79","0.79","0.79","1 through 10","206.46","632.7","percent of total billed charges",""
"Ataxia, Comprehensive Evaluation","PX-31000794","CDM","81479","CPT","0310","RC","","","","outpatient","","","666.00","499.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","333.00","50","","1.00","1.00","1.00","1 through 10","156.55","549.45","percent of total billed charges",""
"Ataxia, Comprehensive Evaluation","PX-31000794","CDM","81479","CPT","0310","RC","","","","outpatient","","","666.00","499.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","349.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","549.45","percent of total billed charges",""
"Atazanavir","PX-31000672","CDM","80299","CPT","0310","RC","","","","both","","","145.00","108.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","115.28","79.5","","106.25","71.28","106.25","1 through 10","18.27","137.75","percent of total billed charges",""
"Atazanavir","PX-31000672","CDM","80299","CPT","0310","RC","","","","both","","","145.00","108.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.29","53.3","","106.25","71.28","106.25","1 through 10","18.27","137.75","percent of total billed charges",""
"Atazanavir","PX-31000672","CDM","80299","CPT","0310","RC","","","","both","","","145.00","108.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","52.93","36.5","","50.36","42.80","92.50","13","18.27","137.75","percent of total billed charges",""
"Atazanavir","PX-31000672","CDM","80299","CPT","0310","RC","","","","both","","","145.00","108.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.54","38.3","","52.79","44.55","158.37","30","18.27","137.75","percent of total billed charges",""
"Atazanavir","PX-31000672","CDM","80299","CPT","0310","RC","","","","outpatient","","","145.00","108.75","AETNA [1001]","HB AMC AETNA HMO","101.21","69.8","","91.40","64.53","105.30","14","53.62","118.49","percent of total billed charges",""
"Atazanavir","PX-31000672","CDM","80299","CPT","0310","RC","","","","outpatient","","","145.00","108.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","116.58","80.4","","105.30","105.30","105.30","1 through 10","53.62","118.49","percent of total billed charges",""
"Atazanavir","PX-31000672","CDM","80299","CPT","0310","RC","","","","outpatient","","","145.00","108.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","118.49","81.72","","59.36","15.50","59.36","1 through 10","53.62","118.49","percent of total billed charges",""
"Athena, A6520 Amyotrophic Lateral Sclerosos Adv Eval Als 17 Gene Panel","PX-31001305","CDM","81403","CPT","0310","RC","","","","outpatient","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","864.60","81.72","","820.18","820.18","820.18","1 through 10","512.07","1135.28","percent of total billed charges",""
"Athena, Ad134 Mpz Charcot Marie Tooth Type 1b Dna Athena Cmt1b","PX-31001353","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Athena, Ad134 Mpz Charcot Marie Tooth Type 1b Dna Athena Cmt1b","PX-31001353","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"ATHENA, AD146 SCN4A GENE MUTATION SODIUM CHANNEL MYOTONIA CHROMOSOME 17q23.1 q25.3","PX-31001368","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"ATHENA, AD179 EARLY ONSET ALZHEIMER EVALUATION PS1 seq APP DELETION/DUPLICATION PS2 seq","PX-31001348","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"ATHENA, AD179 EARLY ONSET ALZHEIMER EVALUATION PS1 seq APP DELETION/DUPLICATION PS2 seq","PX-31001348","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"ATHENA, AD179 EARLY ONSET ALZHEIMER EVALUATION PS1 seq APP DELETION/DUPLICATION PS2 seq","PX-31001369","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Athena, Ad204 Grn Ftd Dna Sequencing Grn Gene Mutation Ftld Tdp Frontotemporal Dementia Evaluation","PX-31001370","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Athena, Ad205 Mapt Gene Mutation Aphasia Parkinsonism Dementia With Epilepsy Progressive Supranuclear Palsy Chromosome","PX-31001371","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Athena, Ad222 Litaf/Simple Dna Sequencing Charcot Marie Tooth Disease Type 1c Lipopolysaccharide Induced Tumor","PX-31001325","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Athena, Ad223 Cmt2a Charcot Marie Tooth Disease Type 2a Mitofusion 2 Dna Sequencing","PX-31001372","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Athena, Ad229 Cmt2f Hspb1 Hsp27 Dna Sequencing Hspb1 Hsp27 Gene Sequencing Cmtf2 Dna Mutation","PX-31001326","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Athena, Ad235 Anyloidosis Athena Transthyretin Dna Sequencing Amydos 235","PX-31001328","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Athena, Ad405 Facioscapulohumeral Muscular Dystrophy Landouzy Dejerene","PX-31001337","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Athena, Ad421 Notch 3 Gene Athena Cadsil Cadasil","PX-31001379","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Athena, Ad525 Ad520 Complete Tuberous Sclerosis Evaluation","PX-31001349","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Athena, Ad525 Ad520 Complete Tuberous Sclerosis Evaluation","PX-31001349","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Athena, Ad525 Ad520 Complete Tuberous Sclerosis Evaluation","PX-31001373","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Athena, Ad565 Lamin a/C Dna Sequencing Lmna Mutation","PX-31001374","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Athena, Ad643 Complete Als Profile 2012 Amyotrophic Lateral Sclerosis Panel","PX-31001306","CDM","81403","CPT","0310","RC","","","","outpatient","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","864.60","81.72","","820.18","820.18","820.18","1 through 10","512.07","1135.28","percent of total billed charges",""
"Athena, Ad643 Complete Als Profile 2012 Amyotrophic Lateral Sclerosis Panel","PX-31001350","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Athena, Ad643 Complete Als Profile 2012 Amyotrophic Lateral Sclerosis Panel","PX-31001350","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Athena, Ad643 Complete Als Profile 2012 Amyotrophic Lateral Sclerosis Panel","PX-31001375","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Athena, Ad6520 Amyotrophic Lateral Sclerosos Adv Eval Als 17 Gene Panel Ngs Als2 Ang C9orf72","PX-31001367","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Athena, Ad812 Aire Eval Autoimmune Polyglandular Syndrome Evaluation Aire","PX-31001376","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Athena, Ataxia, Comprehensive Evaluation","PX-31001229","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Athena, Ataxia, Comprehensive Evaluation","PX-31001229","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Athena, Ataxia, Comprehensive Evaluation","PX-31001229","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Athena, Ataxia, Comprehensive Evaluation","PX-31001229","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Atherosclerosis With McC","302","MS-DRG","","","","","","","","inpatient","","","80044.19","60033.14","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","11634.20","","Case rate ($11,295.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,519.96, add-ons for qualifying new technology services are included. If operating cost exceeds $59,164.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,403.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,952.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,140.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.85. The transfer capital threshold is the transfer adjustment factor * $962.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11166.50","11166.50","11166.50","1 through 10","11069.43","17555.3603","other","Inpatient DRG"
"Atherosclerosis With McC","302","MS-DRG","","","","","","","","inpatient","","","80044.19","60033.14","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14546.29","","Case rate ($14,546.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,519.96, add-ons for qualifying new technology services are included. If operating cost exceeds $59,164.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,403.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $13,203.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,140.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.85. The transfer capital threshold is the transfer adjustment factor * $962.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","62576.31","62576.31","62576.31","1 through 10","11069.43","17555.3603","other","Inpatient DRG"
"Atherosclerosis With McC","302","MS-DRG","","","","","","","","inpatient","","","80044.19","60033.14","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","11295.34","","Case rate ($11,295.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,519.96, add-ons for qualifying new technology services are included. If operating cost exceeds $59,164.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,403.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,952.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,140.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.85. The transfer capital threshold is the transfer adjustment factor * $962.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6308.17","6308.17","6308.17","1 through 10","11069.43","17555.3603","other","Inpatient DRG"
"Atherosclerosis With McC","302","MS-DRG","","","","","","","","inpatient","","","80044.19","60033.14","MEDICARE [2001]","HB BWH MEDICARE","14546.29","","Case rate ($14,546.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,519.96, add-ons for qualifying new technology services are included. If operating cost exceeds $59,164.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,403.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $13,203.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,140.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.85. The transfer capital threshold is the transfer adjustment factor * $962.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14013.11","13992.61","14013.11","1 through 10","11069.43","17555.3603","other","Inpatient DRG"
"Atherosclerosis With McC","302","MS-DRG","","","","","","","","inpatient","","","80044.19","60033.14","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","11069.43","","Case rate ($11,295.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,519.96, add-ons for qualifying new technology services are included. If operating cost exceeds $59,164.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,403.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,952.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,140.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $962.85. The transfer capital threshold is the transfer adjustment factor * $962.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18.17","18.17","18.17","1 through 10","11069.43","17555.3603","other","Inpatient DRG"
"Atherosclerosis Without McC","303","MS-DRG","","","","","","","","inpatient","","","41509.14","31131.85","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","6716.47","","Case rate ($6,520.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,772.39, add-ons for qualifying new technology services are included. If operating cost exceeds $53,416.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,981.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,599.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,392.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.70. The transfer capital threshold is the transfer adjustment factor * $541.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6590.99","6566.52","6601.56","1 through 10","6390.42","10545","other","Inpatient DRG"
"Atherosclerosis Without McC","303","MS-DRG","","","","","","","","inpatient","","","41509.14","31131.85","HUMANA [1012]","HB BWH MEDICARE","8349.80","","Case rate ($8,349.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,772.39, add-ons for qualifying new technology services are included. If operating cost exceeds $53,416.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,981.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,428.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,392.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.70. The transfer capital threshold is the transfer adjustment factor * $541.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6262.15","6262.15","6262.15","1 through 10","6390.42","10545","other","Inpatient DRG"
"Atherosclerosis Without McC","303","MS-DRG","","","","","","","","inpatient","","","41509.14","31131.85","MEDICARE [2001]","HB BWH MEDICARE","8349.80","","Case rate ($8,349.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,772.39, add-ons for qualifying new technology services are included. If operating cost exceeds $53,416.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,981.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,428.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,392.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.70. The transfer capital threshold is the transfer adjustment factor * $541.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8205.31","728.09","8217.16","28","6390.42","10545","other","Inpatient DRG"
"Atherosclerosis Without McC","303","MS-DRG","","","","","","","","inpatient","","","41509.14","31131.85","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","8349.80","","Case rate ($8,349.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,772.39, add-ons for qualifying new technology services are included. If operating cost exceeds $53,416.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,981.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,428.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,392.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.70. The transfer capital threshold is the transfer adjustment factor * $541.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6260.81","6260.81","6260.81","1 through 10","6390.42","10545","other","Inpatient DRG"
"Atherosclerosis Without McC","303","MS-DRG","","","","","","","","inpatient","","","41509.14","31131.85","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6390.42","","Case rate ($6,520.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,772.39, add-ons for qualifying new technology services are included. If operating cost exceeds $53,416.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,981.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,599.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,392.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.70. The transfer capital threshold is the transfer adjustment factor * $541.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6277.48","6277.48","6277.48","1 through 10","6390.42","10545","other","Inpatient DRG"
"Atherosclerosis Without McC","303","MS-DRG","","","","","","","","inpatient","","","41509.14","31131.85","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6390.42","","Case rate ($6,520.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,772.39, add-ons for qualifying new technology services are included. If operating cost exceeds $53,416.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,981.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,599.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,392.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.70. The transfer capital threshold is the transfer adjustment factor * $541.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6285.47","6285.47","6285.47","1 through 10","6390.42","10545","other","Inpatient DRG"
"Atm Gene Analysis","PX-31000775","CDM","81479","CPT","0310","RC","","","","both","","","2380.00","1785.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1892.10","79.5","","0.65","0.65","0.65","1 through 10","737.8","2261","percent of total billed charges",""
"Atm Gene Analysis","PX-31000775","CDM","81479","CPT","0310","RC","","","","both","","","2380.00","1785.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1268.54","53.3","","0.79","0.79","0.79","1 through 10","737.8","2261","percent of total billed charges",""
"Atm Gene Analysis","PX-31000775","CDM","81479","CPT","0310","RC","","","","outpatient","","","2380.00","1785.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1441.09","60.55","","1.00","1.00","1.00","1 through 10","1151.92","1963.5","percent of total billed charges",""
"Atm Gene Analysis","PX-31000775","CDM","81479","CPT","0310","RC","","","","outpatient","","","2380.00","1785.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1242.84","52.22","","1.00","1.00","1.00","1 through 10","1151.92","1963.5","percent of total billed charges",""
"Atm Gene Analysis","PX-31000775","CDM","81479","CPT","0310","RC","","","","outpatient","","","2380.00","1785.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1190.00","50","","1.00","1.00","1.00","1 through 10","1151.92","1963.5","percent of total billed charges",""
"Atm Gene Analysis","PX-31000775","CDM","81479","CPT","0310","RC","","","","outpatient","","","2380.00","1785.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1249.50","52.5","","1.00","0.53","1.00","1 through 10","1151.92","1963.5","percent of total billed charges",""
"Atomic Absorption Spect","PX-30000319","CDM","82190","CPT","0301","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","91.53","81.72","","87.13","87.13","87.13","1 through 10","5.61","101.51","percent of total billed charges",""
"Atp8b1 Sequence Analysis","PX-31000690","CDM","81479","CPT","0310","RC","","","","both","","","3332.00","2499.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2648.94","79.5","","0.65","0.65","0.65","1 through 10","1032.92","3165.4","percent of total billed charges",""
"Atp8b1 Sequence Analysis","PX-31000690","CDM","81479","CPT","0310","RC","","","","both","","","3332.00","2499.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1775.96","53.3","","0.79","0.79","0.79","1 through 10","1032.92","3165.4","percent of total billed charges",""
"Atp8b1 Sequence Analysis","PX-31000690","CDM","81479","CPT","0310","RC","","","","outpatient","","","3332.00","2499.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1666.00","50","","1.00","1.00","1.00","1 through 10","156.55","2748.9","percent of total billed charges",""
"Atp8b1 Sequence Analysis","PX-31000690","CDM","81479","CPT","0310","RC","","","","outpatient","","","3332.00","2499.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1749.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","2748.9","percent of total billed charges",""
"Atropine Inj 0.01mg","PX-63600065","CDM","J0461","HCPCS","0636","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","0.19","0.19","0.19","100","0.22","0.77","percent of total billed charges",""
"Atropine Inj 0.01mg","PX-63600065","CDM","J0461","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","0.13","0.13","0.13","110","0.22","0.77","percent of total billed charges",""
"Atropine Inj 0.01mg","PX-63600065","CDM","J0461","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","0.26","0.26","0.26","40","0.15","0.8","percent of total billed charges",""
"Atropine Inj 0.01mg","PX-63600065","CDM","J0461","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.70","69.9","","0.72","0.72","0.72","130","0.15","0.8","percent of total billed charges",""
"Atropine Inj 0.01mg","PX-63600065","CDM","J0461","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.47","46.9","","0.12","0.12","0.12","50","0.15","0.8","percent of total billed charges",""
"Atypical Spinal Muscular Atrophy Advanced Sequencing Evaluation","PX-31000787","CDM","81479","CPT","0310","RC","","","","both","","","1662.00","1246.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1321.29","79.5","","0.65","0.65","0.65","1 through 10","515.22","1578.9","percent of total billed charges",""
"Atypical Spinal Muscular Atrophy Advanced Sequencing Evaluation","PX-31000787","CDM","81479","CPT","0310","RC","","","","both","","","1662.00","1246.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","885.85","53.3","","0.79","0.79","0.79","1 through 10","515.22","1578.9","percent of total billed charges",""
"Atypical Spinal Muscular Atrophy Advanced Sequencing Evaluation","PX-31000787","CDM","81479","CPT","0310","RC","","","","outpatient","","","1662.00","1246.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","831.00","50","","1.00","1.00","1.00","1 through 10","156.55","1371.15","percent of total billed charges",""
"Atypical Spinal Muscular Atrophy Advanced Sequencing Evaluation","PX-31000787","CDM","81479","CPT","0310","RC","","","","outpatient","","","1662.00","1246.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","872.55","52.5","","1.00","0.53","1.00","1 through 10","156.55","1371.15","percent of total billed charges",""
"Aud Positional Nystagmus W/Record","PX-47000004","CDM","92542","CPT","0471","RC","","","","both","","","671.00","503.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","145.42","533.45","other","OPPS APC"
"Aud Positional Nystagmus W/Record","PX-47000004","CDM","92542","CPT","0471","RC","","","","both","","","671.00","503.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","533.45","79.5","","512.34","512.34","512.34","1 through 10","145.42","533.45","percent of total billed charges",""
"Aud Positional Nystagmus W/Record","PX-47000004","CDM","92542","CPT","0471","RC","","","","both","","","671.00","503.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","136.63","136.63","136.63","1 through 10","145.42","533.45","other","OPPS APC"
"Aud Positional Nystagmus W/Record","PX-47000004","CDM","92542","CPT","0471","RC","","","","both","","","671.00","503.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.02","150.02","150.02","1 through 10","145.42","533.45","other","OPPS APC"
"Aud Positional Nystagmus W/Record","PX-47000004","CDM","92542","CPT","0471","RC","","","","both","","","671.00","503.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.02","137.44","151.02","1 through 10","145.42","533.45","other","OPPS APC"
"Aud Positional Nystagmus W/Record","PX-47000004","CDM","92542","CPT","0471","RC","","","","outpatient","","","671.00","503.25","AETNA [1001]","HB AMC AETNA HMO","468.36","69.8","","311.18","311.18","311.18","1 through 10","244.64","548.34","percent of total billed charges",""
"Aud Pure Tone Air Only","PX-47000013","CDM","92552","CPT","0471","RC","","","","both","","","204.00","153.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","162.18","79.5","","155.83","104.54","155.83","1 through 10","63.24","191.33","percent of total billed charges",""
"Aud Pure Tone Air Only","PX-47000013","CDM","92552","CPT","0471","RC","","","","both","","","204.00","153.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","108.73","53.3","","155.83","155.83","155.83","1 through 10","63.24","191.33","percent of total billed charges",""
"Aud Pure Tone Air Only","PX-47000013","CDM","92552","CPT","0471","RC","","","","both","","","204.00","153.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.46","36.5","","73.85","62.77","73.85","1 through 10","63.24","191.33","percent of total billed charges",""
"Aud Pure Tone Air Only","PX-47000013","CDM","92552","CPT","0471","RC","","","","both","","","204.00","153.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.13","38.3","","77.42","77.42","77.42","23","63.24","191.33","percent of total billed charges",""
"Aud Pure Tone Air Only","PX-47000013","CDM","92552","CPT","0471","RC","","","","both","","","204.00","153.00","TRICARE [160005]","HB BWH TRICARE","145.42","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","343.43","343.43","343.43","1 through 10","63.24","191.33","other","Tricare OPPS"
"Aud Pure Tone Air Only","PX-47000013","CDM","92552","CPT","0471","RC","","","","outpatient","","","204.00","153.00","AETNA [1001]","HB AMC AETNA PPO","164.02","80.4","","154.44","154.44","154.44","1 through 10","106.61","407.82","percent of total billed charges",""
"Aud Pure Tone Air Only","PX-47000013","CDM","92552","CPT","0471","RC","","","","outpatient","","","204.00","153.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","166.71","81.72","","158.28","87.06","198.00","1 through 10","106.61","407.82","percent of total billed charges",""
"Aud Screen Pure Tone Air Only","PX-47000012","CDM","92551","CPT","0470","RC","","","","both","","","82.00","61.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","65.19","79.5","","43.54","43.54","62.96","23","25.42","77.9","percent of total billed charges",""
"Aud Screen Pure Tone Air Only","PX-47000012","CDM","92551","CPT","0470","RC","","","","both","","","82.00","61.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","43.71","53.3","","43.54","42.24","43.54","1 through 10","25.42","77.9","percent of total billed charges",""
"Aud Screen Pure Tone Air Only","PX-47000012","CDM","92551","CPT","0470","RC","","","","both","","","82.00","61.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","65.19","79.5","","62.96","43.54","62.96","1 through 10","25.42","77.9","percent of total billed charges",""
"Aud Screen Pure Tone Air Only","PX-47000012","CDM","92551","CPT","0470","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29.93","36.5","","22.38","19.02","29.84","89","25.42","77.9","percent of total billed charges",""
"Aud Screen Pure Tone Air Only","PX-47000012","CDM","92551","CPT","0470","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31.41","38.3","","31.28","23.46","42.68","225","25.42","77.9","percent of total billed charges",""
"Aud Screen Pure Tone Air Only","PX-47000012","CDM","92551","CPT","0470","RC","","","","both","","","82.00","61.50","TRICARE [160005]","HB BWH TRICARE","77.90","95","","13.88","13.88","13.88","1 through 10","25.42","77.9","percent of total billed charges",""
"Aud Screen Pure Tone Air Only","PX-47000012","CDM","92551","CPT","0470","RC","","","","both","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.18","42.9","","61.56","61.56","61.56","1 through 10","25.42","77.9","percent of total billed charges",""
"Aud Screen Pure Tone Air Only","PX-47000012","CDM","92551","CPT","0470","RC","","","","both","","","82.00","61.50","WELLPOINT [1015]","HB AMC WELLPOINT","60.50","73.78","","104.23","104.23","104.23","24","25.42","77.9","percent of total billed charges",""
"Aud Screen Pure Tone Air Only","PX-47000012","CDM","92551","CPT","0470","RC","","","","outpatient","","","82.00","61.50","AETNA [1001]","HB AMC AETNA HMO","57.24","69.8","","71.98","66.92","109.20","36","27.58","67.01","percent of total billed charges",""
"Aud Screen Pure Tone Air Only","PX-47000012","CDM","92551","CPT","0470","RC","","","","outpatient","","","82.00","61.50","AETNA [1001]","HB AMC AETNA PPO","65.93","80.4","","171.60","171.60","171.60","1 through 10","27.58","67.01","percent of total billed charges",""
"Aud Screen Pure Tone Air Only","PX-47000012","CDM","92551","CPT","0470","RC","","","","outpatient","","","82.00","61.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","42.85","52.26","","90.50","90.50","90.50","1 through 10","27.58","67.01","percent of total billed charges",""
"Aud Screen Pure Tone Air Only","PX-47000012","CDM","92551","CPT","0470","RC","","","","outpatient","","","82.00","61.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","67.01","81.72","","111.91","111.91","111.91","1 through 10","27.58","67.01","percent of total billed charges",""
"Aud Screen Pure Tone Air Only","PX-47000012","CDM","92551","CPT","0470","RC","","","","outpatient","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","67.01","81.72","","111.91","111.91","140.00","20","27.58","67.01","percent of total billed charges",""
"AUGMENT DISTAL SIZE 3 10MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322122","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 3 10MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322122","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3213.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 3 10MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322122","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.51","36.5","","1023.42","771.29","2068.67","33","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 3 10MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322122","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.28","38.3","","850.52","759.78","1211.25","66","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 3 10MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322122","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 3 10MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322122","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","956.46","956.46","956.46","1 through 10","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 3 10MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322122","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","WELLPOINT [1015]","HB AMC WELLPOINT","2982.56","73.78","","2344.73","1619.47","2530.35","16","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 3 10MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322122","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA HMO","2821.67","69.8","","1523.63","988.41","4330.26","39","2112.61","3303.53","percent of total billed charges",""
"AUGMENT DISTAL SIZE 3 10MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322122","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA PPO","3250.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2112.61","3303.53","percent of total billed charges",""
"AUGMENT DISTAL SIZE 3 10MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322122","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","2112.61","3303.53","percent of total billed charges",""
"AUGMENT DISTAL SIZE 3 10MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322122","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.53","81.72","","1738.90","1484.65","2716.94","38","2112.61","3303.53","percent of total billed charges",""
"AUGMENT DISTAL SIZE 4 5MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 4 5MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3213.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 4 5MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.51","36.5","","1023.42","771.29","2068.67","33","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 4 5MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.28","38.3","","850.52","759.78","1211.25","66","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 4 5MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 4 5MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","956.46","956.46","956.46","1 through 10","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 4 5MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","WELLPOINT [1015]","HB AMC WELLPOINT","2982.56","73.78","","2344.73","1619.47","2530.35","16","1253.18","3213.79","percent of total billed charges",""
"AUGMENT DISTAL SIZE 4 5MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322121","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA HMO","2821.67","69.8","","1523.63","988.41","4330.26","39","2112.61","3303.53","percent of total billed charges",""
"AUGMENT DISTAL SIZE 4 5MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322121","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA PPO","3250.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2112.61","3303.53","percent of total billed charges",""
"AUGMENT DISTAL SIZE 4 5MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322121","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","2112.61","3303.53","percent of total billed charges",""
"AUGMENT DISTAL SIZE 4 5MM TRIATHLON HINGE FEMORAL","SUP-ITM-10322121","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.53","81.72","","1738.90","1484.65","2716.94","38","2112.61","3303.53","percent of total billed charges",""
"AUGMENT TIBIAL SIZE 4 LM/RL 10MM TRIATHLON REVISION","SUP-ITM-10322153","CDM","C1776","HCPCS","0278","RC","","","","both","","","3936.90","2952.67","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2057.42","52.26","","1113.10","1113.10","1113.10","1 through 10","1220.44","3129.84","percent of total billed charges",""
"AUGMENT TIBIAL SIZE 4 LM/RL 10MM TRIATHLON REVISION","SUP-ITM-10322153","CDM","C1776","HCPCS","0278","RC","","","","both","","","3936.90","2952.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3129.84","79.5","","1293.60","1148.53","1603.80","1 through 10","1220.44","3129.84","percent of total billed charges",""
"AUGMENT TIBIAL SIZE 4 LM/RL 10MM TRIATHLON REVISION","SUP-ITM-10322153","CDM","C1776","HCPCS","0278","RC","","","","both","","","3936.90","2952.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1436.97","36.5","","1023.42","771.29","2068.67","33","1220.44","3129.84","percent of total billed charges",""
"AUGMENT TIBIAL SIZE 4 LM/RL 10MM TRIATHLON REVISION","SUP-ITM-10322153","CDM","C1776","HCPCS","0278","RC","","","","both","","","3936.90","2952.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1507.83","38.3","","850.52","759.78","1211.25","66","1220.44","3129.84","percent of total billed charges",""
"AUGMENT TIBIAL SIZE 4 LM/RL 10MM TRIATHLON REVISION","SUP-ITM-10322153","CDM","C1776","HCPCS","0278","RC","","","","both","","","3936.90","2952.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1688.93","42.9","","2548.09","2548.09","2548.09","1 through 10","1220.44","3129.84","percent of total billed charges",""
"AUGMENT TIBIAL SIZE 4 LM/RL 10MM TRIATHLON REVISION","SUP-ITM-10322153","CDM","C1776","HCPCS","0278","RC","","","","both","","","3936.90","2952.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1688.93","42.9","","956.46","956.46","956.46","1 through 10","1220.44","3129.84","percent of total billed charges",""
"AUGMENT TIBIAL SIZE 4 LM/RL 10MM TRIATHLON REVISION","SUP-ITM-10322153","CDM","C1776","HCPCS","0278","RC","","","","both","","","3936.90","2952.67","WELLPOINT [1015]","HB AMC WELLPOINT","2904.64","73.78","","2344.73","1619.47","2530.35","16","1220.44","3129.84","percent of total billed charges",""
"AUGMENT TIBIAL SIZE 4 LM/RL 10MM TRIATHLON REVISION","SUP-ITM-10322153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3936.90","2952.67","AETNA [1001]","HB AMC AETNA HMO","2747.96","69.8","","1523.63","988.41","4330.26","39","2057.42","3217.23","percent of total billed charges",""
"AUGMENT TIBIAL SIZE 4 LM/RL 10MM TRIATHLON REVISION","SUP-ITM-10322153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3936.90","2952.67","AETNA [1001]","HB AMC AETNA PPO","3165.27","80.4","","1670.25","1670.25","1670.25","1 through 10","2057.42","3217.23","percent of total billed charges",""
"AUGMENT TIBIAL SIZE 4 LM/RL 10MM TRIATHLON REVISION","SUP-ITM-10322153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3936.90","2952.67","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2057.42","52.26","","1113.10","1113.10","1113.10","1 through 10","2057.42","3217.23","percent of total billed charges",""
"AUGMENT TIBIAL SIZE 4 LM/RL 10MM TRIATHLON REVISION","SUP-ITM-10322153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3936.90","2952.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3217.23","81.72","","1738.90","1484.65","2716.94","38","2057.42","3217.23","percent of total billed charges",""
"AUTOBAHN EVO ANTEGRADE FEMORAL NAIL 11X360MM GT RIGHT TI STERILE","SUP-ITM-10326084","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4770.00","79.5","","800.18","480.96","1887.97","195","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO ANTEGRADE FEMORAL NAIL 11X360MM GT RIGHT TI STERILE","SUP-ITM-10326084","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3198.00","53.3","","813.12","216.42","1444.50","81","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO ANTEGRADE FEMORAL NAIL 11X360MM GT RIGHT TI STERILE","SUP-ITM-10326084","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1860.00","31","","432.60","432.60","432.60","1 through 10","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO ANTEGRADE FEMORAL NAIL 11X360MM GT RIGHT TI STERILE","SUP-ITM-10326084","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2190.00","36.5","","148.37","54.89","631.39","94","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO ANTEGRADE FEMORAL NAIL 11X360MM GT RIGHT TI STERILE","SUP-ITM-10326084","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2298.00","38.3","","279.30","91.72","1116.77","266","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO ANTEGRADE FEMORAL NAIL 11X360MM GT RIGHT TI STERILE","SUP-ITM-10326084","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2574.00","42.9","","731.00","63.70","731.00","1 through 10","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO ANTEGRADE FEMORAL NAIL 11X360MM GT RIGHT TI STERILE","SUP-ITM-10326084","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2574.00","42.9","","384.74","384.74","384.74","1 through 10","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO ANTEGRADE FEMORAL NAIL 11X360MM GT RIGHT TI STERILE","SUP-ITM-10326084","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB AMC WELLPOINT","4426.80","73.78","","286.63","119.22","1107.45","105","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO ANTEGRADE FEMORAL NAIL 11X360MM GT RIGHT TI STERILE","SUP-ITM-10326084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","AETNA [1001]","HB AMC AETNA HMO","4188.00","69.8","","675.31","184.75","1721.50","286","3135.6","4903.2","percent of total billed charges",""
"AUTOBAHN EVO ANTEGRADE FEMORAL NAIL 11X360MM GT RIGHT TI STERILE","SUP-ITM-10326084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","AETNA [1001]","HB AMC AETNA PPO","4824.00","80.4","","1261.44","103.12","1514.10","21","3135.6","4903.2","percent of total billed charges",""
"AUTOBAHN EVO ANTEGRADE FEMORAL NAIL 11X360MM GT RIGHT TI STERILE","SUP-ITM-10326084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4824.00","80.4","","1365.00","1365.00","1365.00","1 through 10","3135.6","4903.2","percent of total billed charges",""
"AUTOBAHN EVO ANTEGRADE FEMORAL NAIL 11X360MM GT RIGHT TI STERILE","SUP-ITM-10326084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4903.20","81.72","","5157.68","5157.68","5157.68","1 through 10","3135.6","4903.2","percent of total billed charges",""
"AUTOBAHN EVO ANTEGRADE FEMORAL NAIL 11X360MM GT RIGHT TI STERILE","SUP-ITM-10326084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4903.20","81.72","","431.26","71.26","1459.57","88","3135.6","4903.2","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X27.5MM TI","SUP-ITM-10326297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1335.60","79.5","","800.18","480.96","1887.97","195","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X27.5MM TI","SUP-ITM-10326297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","895.44","53.3","","813.12","216.42","1444.50","81","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X27.5MM TI","SUP-ITM-10326297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","520.80","31","","432.60","432.60","432.60","1 through 10","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X27.5MM TI","SUP-ITM-10326297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","613.20","36.5","","148.37","54.89","631.39","94","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X27.5MM TI","SUP-ITM-10326297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","643.44","38.3","","279.30","91.72","1116.77","266","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X27.5MM TI","SUP-ITM-10326297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","720.72","42.9","","731.00","63.70","731.00","1 through 10","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X27.5MM TI","SUP-ITM-10326297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","720.72","42.9","","384.74","384.74","384.74","1 through 10","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X27.5MM TI","SUP-ITM-10326297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","WELLPOINT [1015]","HB AMC WELLPOINT","1239.50","73.78","","286.63","119.22","1107.45","105","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X27.5MM TI","SUP-ITM-10326297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","AETNA [1001]","HB AMC AETNA HMO","1172.64","69.8","","675.31","184.75","1721.50","286","877.97","1372.9","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X27.5MM TI","SUP-ITM-10326297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","AETNA [1001]","HB AMC AETNA PPO","1350.72","80.4","","1261.44","103.12","1514.10","21","877.97","1372.9","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X27.5MM TI","SUP-ITM-10326297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1350.72","80.4","","1365.00","1365.00","1365.00","1 through 10","877.97","1372.9","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X27.5MM TI","SUP-ITM-10326297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1372.90","81.72","","5157.68","5157.68","5157.68","1 through 10","877.97","1372.9","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X27.5MM TI","SUP-ITM-10326297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1372.90","81.72","","431.26","71.26","1459.57","88","877.97","1372.9","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X60MM TI","SUP-ITM-10326321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1335.60","79.5","","800.18","480.96","1887.97","195","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X60MM TI","SUP-ITM-10326321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","895.44","53.3","","813.12","216.42","1444.50","81","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X60MM TI","SUP-ITM-10326321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","520.80","31","","432.60","432.60","432.60","1 through 10","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X60MM TI","SUP-ITM-10326321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","613.20","36.5","","148.37","54.89","631.39","94","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X60MM TI","SUP-ITM-10326321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","643.44","38.3","","279.30","91.72","1116.77","266","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X60MM TI","SUP-ITM-10326321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","720.72","42.9","","731.00","63.70","731.00","1 through 10","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X60MM TI","SUP-ITM-10326321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","720.72","42.9","","384.74","384.74","384.74","1 through 10","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X60MM TI","SUP-ITM-10326321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","WELLPOINT [1015]","HB AMC WELLPOINT","1239.50","73.78","","286.63","119.22","1107.45","105","520.8","1335.6","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X60MM TI","SUP-ITM-10326321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","AETNA [1001]","HB AMC AETNA HMO","1172.64","69.8","","675.31","184.75","1721.50","286","877.97","1372.9","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X60MM TI","SUP-ITM-10326321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","AETNA [1001]","HB AMC AETNA PPO","1350.72","80.4","","1261.44","103.12","1514.10","21","877.97","1372.9","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X60MM TI","SUP-ITM-10326321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1350.72","80.4","","1365.00","1365.00","1365.00","1 through 10","877.97","1372.9","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X60MM TI","SUP-ITM-10326321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1372.90","81.72","","5157.68","5157.68","5157.68","1 through 10","877.97","1372.9","percent of total billed charges",""
"AUTOBAHN EVO HEADLESS LOCKING SCREW 5X60MM TI","SUP-ITM-10326321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1372.90","81.72","","431.26","71.26","1459.57","88","877.97","1372.9","percent of total billed charges",""
"AUTOBAHN EVO LOCKING SCREW 5X25MM TI STERILE","SUP-ITM-10326340","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1001.70","79.5","","800.18","480.96","1887.97","195","390.6","1001.7","percent of total billed charges",""
"AUTOBAHN EVO LOCKING SCREW 5X25MM TI STERILE","SUP-ITM-10326340","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","671.58","53.3","","813.12","216.42","1444.50","81","390.6","1001.7","percent of total billed charges",""
"AUTOBAHN EVO LOCKING SCREW 5X25MM TI STERILE","SUP-ITM-10326340","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","390.60","31","","432.60","432.60","432.60","1 through 10","390.6","1001.7","percent of total billed charges",""
"AUTOBAHN EVO LOCKING SCREW 5X25MM TI STERILE","SUP-ITM-10326340","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","459.90","36.5","","148.37","54.89","631.39","94","390.6","1001.7","percent of total billed charges",""
"AUTOBAHN EVO LOCKING SCREW 5X25MM TI STERILE","SUP-ITM-10326340","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","482.58","38.3","","279.30","91.72","1116.77","266","390.6","1001.7","percent of total billed charges",""
"AUTOBAHN EVO LOCKING SCREW 5X25MM TI STERILE","SUP-ITM-10326340","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.54","42.9","","731.00","63.70","731.00","1 through 10","390.6","1001.7","percent of total billed charges",""
"AUTOBAHN EVO LOCKING SCREW 5X25MM TI STERILE","SUP-ITM-10326340","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.54","42.9","","384.74","384.74","384.74","1 through 10","390.6","1001.7","percent of total billed charges",""
"AUTOBAHN EVO LOCKING SCREW 5X25MM TI STERILE","SUP-ITM-10326340","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","WELLPOINT [1015]","HB AMC WELLPOINT","929.63","73.78","","286.63","119.22","1107.45","105","390.6","1001.7","percent of total billed charges",""
"AUTOBAHN EVO LOCKING SCREW 5X25MM TI STERILE","SUP-ITM-10326340","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","AETNA [1001]","HB AMC AETNA HMO","879.48","69.8","","675.31","184.75","1721.50","286","658.48","1029.67","percent of total billed charges",""
"AUTOBAHN EVO LOCKING SCREW 5X25MM TI STERILE","SUP-ITM-10326340","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","AETNA [1001]","HB AMC AETNA PPO","1013.04","80.4","","1261.44","103.12","1514.10","21","658.48","1029.67","percent of total billed charges",""
"AUTOBAHN EVO LOCKING SCREW 5X25MM TI STERILE","SUP-ITM-10326340","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1013.04","80.4","","1365.00","1365.00","1365.00","1 through 10","658.48","1029.67","percent of total billed charges",""
"AUTOBAHN EVO LOCKING SCREW 5X25MM TI STERILE","SUP-ITM-10326340","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1029.67","81.72","","5157.68","5157.68","5157.68","1 through 10","658.48","1029.67","percent of total billed charges",""
"AUTOBAHN EVO LOCKING SCREW 5X25MM TI STERILE","SUP-ITM-10326340","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1029.67","81.72","","431.26","71.26","1459.57","88","658.48","1029.67","percent of total billed charges",""
"AUTOBAHN EVO RECON LOCKING SCREW 6.5X80MM TI STERILE","SUP-ITM-10326419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1939.00","1454.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1541.51","79.5","","800.18","480.96","1887.97","195","601.09","1541.51","percent of total billed charges",""
"AUTOBAHN EVO RECON LOCKING SCREW 6.5X80MM TI STERILE","SUP-ITM-10326419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1939.00","1454.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1033.49","53.3","","813.12","216.42","1444.50","81","601.09","1541.51","percent of total billed charges",""
"AUTOBAHN EVO RECON LOCKING SCREW 6.5X80MM TI STERILE","SUP-ITM-10326419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1939.00","1454.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","601.09","31","","432.60","432.60","432.60","1 through 10","601.09","1541.51","percent of total billed charges",""
"AUTOBAHN EVO RECON LOCKING SCREW 6.5X80MM TI STERILE","SUP-ITM-10326419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1939.00","1454.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","707.74","36.5","","148.37","54.89","631.39","94","601.09","1541.51","percent of total billed charges",""
"AUTOBAHN EVO RECON LOCKING SCREW 6.5X80MM TI STERILE","SUP-ITM-10326419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1939.00","1454.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","742.64","38.3","","279.30","91.72","1116.77","266","601.09","1541.51","percent of total billed charges",""
"AUTOBAHN EVO RECON LOCKING SCREW 6.5X80MM TI STERILE","SUP-ITM-10326419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1939.00","1454.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","831.83","42.9","","731.00","63.70","731.00","1 through 10","601.09","1541.51","percent of total billed charges",""
"AUTOBAHN EVO RECON LOCKING SCREW 6.5X80MM TI STERILE","SUP-ITM-10326419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1939.00","1454.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","831.83","42.9","","384.74","384.74","384.74","1 through 10","601.09","1541.51","percent of total billed charges",""
"AUTOBAHN EVO RECON LOCKING SCREW 6.5X80MM TI STERILE","SUP-ITM-10326419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1939.00","1454.25","WELLPOINT [1015]","HB AMC WELLPOINT","1430.59","73.78","","286.63","119.22","1107.45","105","601.09","1541.51","percent of total billed charges",""
"AUTOBAHN EVO RECON LOCKING SCREW 6.5X80MM TI STERILE","SUP-ITM-10326419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1939.00","1454.25","AETNA [1001]","HB AMC AETNA HMO","1353.42","69.8","","675.31","184.75","1721.50","286","1013.32","1584.55","percent of total billed charges",""
"AUTOBAHN EVO RECON LOCKING SCREW 6.5X80MM TI STERILE","SUP-ITM-10326419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1939.00","1454.25","AETNA [1001]","HB AMC AETNA PPO","1558.96","80.4","","1261.44","103.12","1514.10","21","1013.32","1584.55","percent of total billed charges",""
"AUTOBAHN EVO RECON LOCKING SCREW 6.5X80MM TI STERILE","SUP-ITM-10326419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1939.00","1454.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1558.96","80.4","","1365.00","1365.00","1365.00","1 through 10","1013.32","1584.55","percent of total billed charges",""
"AUTOBAHN EVO RECON LOCKING SCREW 6.5X80MM TI STERILE","SUP-ITM-10326419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1939.00","1454.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1584.55","81.72","","5157.68","5157.68","5157.68","1 through 10","1013.32","1584.55","percent of total billed charges",""
"AUTOBAHN EVO RECON LOCKING SCREW 6.5X80MM TI STERILE","SUP-ITM-10326419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1939.00","1454.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1584.55","81.72","","431.26","71.26","1459.57","88","1013.32","1584.55","percent of total billed charges",""
"AUTOBAHN EVO RETROGRADE FEMORAL NAIL 12X400MM 5 TI STERILE","SUP-ITM-10326501","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4770.00","79.5","","800.18","480.96","1887.97","195","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO RETROGRADE FEMORAL NAIL 12X400MM 5 TI STERILE","SUP-ITM-10326501","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3198.00","53.3","","813.12","216.42","1444.50","81","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO RETROGRADE FEMORAL NAIL 12X400MM 5 TI STERILE","SUP-ITM-10326501","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1860.00","31","","432.60","432.60","432.60","1 through 10","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO RETROGRADE FEMORAL NAIL 12X400MM 5 TI STERILE","SUP-ITM-10326501","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2190.00","36.5","","148.37","54.89","631.39","94","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO RETROGRADE FEMORAL NAIL 12X400MM 5 TI STERILE","SUP-ITM-10326501","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2298.00","38.3","","279.30","91.72","1116.77","266","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO RETROGRADE FEMORAL NAIL 12X400MM 5 TI STERILE","SUP-ITM-10326501","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2574.00","42.9","","731.00","63.70","731.00","1 through 10","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO RETROGRADE FEMORAL NAIL 12X400MM 5 TI STERILE","SUP-ITM-10326501","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2574.00","42.9","","384.74","384.74","384.74","1 through 10","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO RETROGRADE FEMORAL NAIL 12X400MM 5 TI STERILE","SUP-ITM-10326501","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB AMC WELLPOINT","4426.80","73.78","","286.63","119.22","1107.45","105","1860","4770","percent of total billed charges",""
"AUTOBAHN EVO RETROGRADE FEMORAL NAIL 12X400MM 5 TI STERILE","SUP-ITM-10326501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","AETNA [1001]","HB AMC AETNA HMO","4188.00","69.8","","675.31","184.75","1721.50","286","3135.6","4903.2","percent of total billed charges",""
"AUTOBAHN EVO RETROGRADE FEMORAL NAIL 12X400MM 5 TI STERILE","SUP-ITM-10326501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","AETNA [1001]","HB AMC AETNA PPO","4824.00","80.4","","1261.44","103.12","1514.10","21","3135.6","4903.2","percent of total billed charges",""
"AUTOBAHN EVO RETROGRADE FEMORAL NAIL 12X400MM 5 TI STERILE","SUP-ITM-10326501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4824.00","80.4","","1365.00","1365.00","1365.00","1 through 10","3135.6","4903.2","percent of total billed charges",""
"AUTOBAHN EVO RETROGRADE FEMORAL NAIL 12X400MM 5 TI STERILE","SUP-ITM-10326501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4903.20","81.72","","5157.68","5157.68","5157.68","1 through 10","3135.6","4903.2","percent of total billed charges",""
"AUTOBAHN EVO RETROGRADE FEMORAL NAIL 12X400MM 5 TI STERILE","SUP-ITM-10326501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4903.20","81.72","","431.26","71.26","1459.57","88","3135.6","4903.2","percent of total billed charges",""
"Autologous Bone Marrow Transplant With Cc/McC","016","MS-DRG","","","","","","","","inpatient","","","222660.24","166995.18","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56105.32","","Case rate ($54,471.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $65,495.16, add-ons for qualifying new technology services are included. If operating cost exceeds $111,139.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,211.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 16.1. The base transfer operating payment is the transfer adjustment factor * $49,319.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,115.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,771.38. The transfer capital threshold is the transfer adjustment factor * $4,771.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","3362.67","3362.67","3362.67","1 through 10","53381.76","92882.82","other","Inpatient DRG"
"Autologous Bone Marrow Transplant With Cc/McC","016","MS-DRG","","","","","","","","inpatient","","","222660.24","166995.18","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54471.18","","Case rate ($54,471.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $65,495.16, add-ons for qualifying new technology services are included. If operating cost exceeds $111,139.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,211.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 16.1. The base transfer operating payment is the transfer adjustment factor * $49,319.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,115.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,771.38. The transfer capital threshold is the transfer adjustment factor * $4,771.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","54472.32","54472.32","54472.32","1 through 10","53381.76","92882.82","other","Inpatient Replacement Plans DRG"
"Autologous Bone Marrow Transplant With Cc/McC","016","MS-DRG","","","","","","","","inpatient","","","222660.24","166995.18","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","","","Payment is accumulated by days. Day 1 - 30, Case rate ($105,000). Day 31 - 9999, Per diem ($2,750).","228152.37","210000.00","523356.07","1 through 10","53381.76","92882.82","other","Autologous BMT"
"Autologous Bone Marrow Transplant With Cc/McC","016","MS-DRG","","","","","","","","inpatient","","","222660.24","166995.18","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","68088.98","","Case rate ($54,471.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $65,495.16, add-ons for qualifying new technology services are included. If operating cost exceeds $111,139.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,211.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 16.1. The base transfer operating payment is the transfer adjustment factor * $49,319.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,115.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,771.38. The transfer capital threshold is the transfer adjustment factor * $4,771.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","55307.04","55307.04","55307.04","1 through 10","53381.76","92882.82","other","Inpatient DRG"
"Autologous Bone Marrow Transplant With Cc/McC","016","MS-DRG","","","","","","","","inpatient","","","222660.24","166995.18","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54471.18","","Case rate ($54,471.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $65,495.16, add-ons for qualifying new technology services are included. If operating cost exceeds $111,139.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,211.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 16.1. The base transfer operating payment is the transfer adjustment factor * $49,319.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,115.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,771.38. The transfer capital threshold is the transfer adjustment factor * $4,771.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","54177.53","54177.53","54177.53","1 through 10","53381.76","92882.82","other","Inpatient DRG"
"Autologous Bone Marrow Transplant With Cc/McC","016","MS-DRG","","","","","","","","inpatient","","","222660.24","166995.18","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","176598.66","176598.66","176598.66","1 through 10","53381.76","92882.82","case rate",""
"Autologous Bone Marrow Transplant With Cc/McC","016","MS-DRG","","","","","","","","inpatient","","","222660.24","166995.18","HUMANA [1012]","HB BWH MEDICARE","54471.18","","Case rate ($54,471.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $65,495.16, add-ons for qualifying new technology services are included. If operating cost exceeds $111,139.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,211.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 16.1. The base transfer operating payment is the transfer adjustment factor * $49,319.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,115.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,771.38. The transfer capital threshold is the transfer adjustment factor * $4,771.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","55064.15","55064.15","55064.15","1 through 10","53381.76","92882.82","other","Inpatient Replacement Plans DRG"
"Autologous Bone Marrow Transplant With Cc/McC","016","MS-DRG","","","","","","","","inpatient","","","222660.24","166995.18","MEDICARE [2001]","HB BWH MEDICARE","54471.18","","Case rate ($54,471.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $65,495.16, add-ons for qualifying new technology services are included. If operating cost exceeds $111,139.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,211.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 16.1. The base transfer operating payment is the transfer adjustment factor * $49,319.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,115.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,771.38. The transfer capital threshold is the transfer adjustment factor * $4,771.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","71542.90","71542.90","71542.90","1 through 10","53381.76","92882.82","other","Inpatient Replacement Plans DRG"
"Autologous Bone Marrow Transplant With Cc/McC","016","MS-DRG","","","","","","","","inpatient","","","222660.24","166995.18","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53381.76","","Case rate ($54,471.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $65,495.16, add-ons for qualifying new technology services are included. If operating cost exceeds $111,139.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,211.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 16.1. The base transfer operating payment is the transfer adjustment factor * $49,319.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,115.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,771.38. The transfer capital threshold is the transfer adjustment factor * $4,771.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","77760.28","77760.28","77760.28","1 through 10","53381.76","92882.82","other","Inpatient DRG"
"Autologous Bone Marrow Transplant With Cc/McC","016","MS-DRG","","","","","","","","inpatient","","","222660.24","166995.18","WELLPOINT [1015]","HB AMC WELLPOINT","92882.82","","Fee schedule rate ($92,882.82).","141326.22","141326.22","141326.22","1 through 10","53381.76","92882.82","case rate",""
"Autologous Bone Marrow Transplant With Cc/McC","016","MS-DRG","","","","","","","","inpatient","","","222660.24","166995.18","WELLSENSE [1003]","HB BWH MEDICARE","54471.18","","Case rate ($54,471.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $65,495.16, add-ons for qualifying new technology services are included. If operating cost exceeds $111,139.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,211.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 16.1. The base transfer operating payment is the transfer adjustment factor * $49,319.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,115.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,771.38. The transfer capital threshold is the transfer adjustment factor * $4,771.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","55819.96","55819.96","55819.96","1 through 10","53381.76","92882.82","other","Inpatient Replacement Plans DRG"
"Autologous Bone Marrow Transplant,EXTREME","008","DRG","","","","","","","","inpatient","","","282497.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","240830.49","","Standard inlier is a Case rate ($240,830.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $198,927, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($34,187.34) for the length of stay and the standard reimbursement.","240830.49","240830.49","240830.49","1 through 10","65595.8","347532.44","case rate",""
"Autologous Bone Marrow Transplant,EXTREME","008","DRG","","","","","","","","inpatient","","","282497.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","270758.38","","Standard inlier is a Case rate ($270,758.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $198,927, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($38,431.90) for the length of stay and the standard reimbursement.","247361.15","247361.15","270758.37","1 through 10","65595.8","347532.44","case rate",""
"Autologous Bone Marrow Transplant,EXTREME","008","DRG","","","","","","","","inpatient","","","282497.10","","MASSHEALTH [3001]","HB BWH MEDICAID","159759.89","","Case rate ($176,642.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $219,072.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","44613.73","44613.73","44613.73","1 through 10","65595.8","347532.44","case rate",""
"Autologous Bone Marrow Transplant,EXTREME","008","DRG","","","","","","","","inpatient","","","282497.10","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","159759.89","","Case rate ($176,642.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $219,072.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","87063.08","87063.08","176598.66","1 through 10","65595.8","347532.44","case rate",""
"Autologous Bone Marrow Transplant,MAJOR","008","DRG","","","","","","","","inpatient","","","223560.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","151646.95","","Standard inlier is a Case rate ($151,646.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $129,574, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($21,527.20) for the length of stay and the standard reimbursement.","182311.18","182311.18","182311.18","1 through 10","65595.8","347532.44","case rate",""
"Autologous Bone Marrow Transplant,MAJOR","008","DRG","","","","","","","","inpatient","","","223560.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","170492.04","","Standard inlier is a Case rate ($170,492.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $129,574, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($24,199.93) for the length of stay and the standard reimbursement.","170492.04","155759.20","170492.04","1 through 10","65595.8","347532.44","case rate",""
"Autologous Bone Marrow Transplant,MAJOR","008","DRG","","","","","","","","inpatient","","","223560.36","","HEALTH NEW ENGLAND [1034]","HB BWH MEDICAID","78761.57","","Case rate ($87,084.45). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $129,514.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","87063.08","87063.08","87063.08","1 through 10","65595.8","347532.44","case rate",""
"Autologous Bone Marrow Transplant,MAJOR","008","DRG","","","","","","","","inpatient","","","223560.36","","MASSHEALTH [3001]","HB BWH MEDICAID","78761.57","","Case rate ($87,084.45). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $129,514.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","87063.07","87063.07","87063.07","1 through 10","65595.8","347532.44","case rate",""
"Autologous Bone Marrow Transplant,MAJOR","008","DRG","","","","","","","","inpatient","","","223560.36","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","78761.57","","Case rate ($87,084.45). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $129,514.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","87063.08","87063.08","87063.08","1 through 10","65595.8","347532.44","case rate",""
"Autologous Bone Marrow Transplant,MODERATE","008","DRG","","","","","","","","inpatient","","","171362.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","142647.55","","Standard inlier is a Case rate ($142,647.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $110,315, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,247.64) for the length of stay and the standard reimbursement.","142647.55","142647.55","142647.55","1 through 10","65595.8","347532.44","case rate",""
"Autologous Centrifugation and Separation of Whole Blood for RBC Reinfusi","PX-76002872","CDM","99199","CPT","0761","RC","","","","both","","","2563.00","1922.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2037.59","79.5","","2475.01","315.17","2475.01","1 through 10","794.53","2434.85","percent of total billed charges",""
"Autologous Centrifugation and Separation of Whole Blood for RBC Reinfusi","PX-76002872","CDM","99199","CPT","0761","RC","","","","inpatient","","","2563.00","1922.25","AETNA [1001]","HB AMC AETNA PPO","2037.59","79.5","","12252.89","4048.72","34960.93","4483","1417.34","2037.59","percent of total billed charges",""
"Autologous Centrifugation and Separation of Whole Blood for RBC Reinfusi","PX-76002872","CDM","99199","CPT","0761","RC","","","","inpatient","","","2563.00","1922.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","1417.34","55.3","","23008.10","23008.10","23008.10","248","1417.34","2037.59","percent of total billed charges",""
"Autologous Centrifugation and Separation of Whole Blood for RBC Reinfusi","PX-76002872","CDM","99199","CPT","0761","RC","","","","inpatient","","","2563.00","1922.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2037.59","79.5","","50807.79","50807.79","50807.79","284","1417.34","2037.59","percent of total billed charges",""
"Autologous Centrifugation and Separation of Whole Blood for RBC Reinfusi","PX-76002872","CDM","99199","CPT","0761","RC","","","","outpatient","","","2563.00","1922.25","AETNA [1001]","HB AMC AETNA HMO","1788.97","69.8","","1482.39","1482.39","1482.39","27","1025.2","2114.48","percent of total billed charges",""
"Autologous Centrifugation and Separation of Whole Blood for RBC Reinfusi","PX-76002872","CDM","99199","CPT","0761","RC","","","","outpatient","","","2563.00","1922.25","AETNA [1001]","HB AMC AETNA PPO","2060.65","80.4","","601.53","0.18","1277.78","350","1025.2","2114.48","percent of total billed charges",""
"Autologous Centrifugation and Separation of Whole Blood for RBC Reinfusi","PX-76002872","CDM","99199","CPT","0761","RC","","","","outpatient","","","2563.00","1922.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","1432.72","55.9","","0.18","0.03","6.03","1 through 10","1025.2","2114.48","percent of total billed charges",""
"Autosomal-Recessive Intellectual Disability via the Nrxn1 Gene","PX-31000676","CDM","81479","CPT","0310","RC","","","","both","","","2311.00","1733.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1837.25","79.5","","0.65","0.65","0.65","1 through 10","716.41","2195.45","percent of total billed charges",""
"Autosomal-Recessive Intellectual Disability via the Nrxn1 Gene","PX-31000676","CDM","81479","CPT","0310","RC","","","","both","","","2311.00","1733.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1231.76","53.3","","0.79","0.79","0.79","1 through 10","716.41","2195.45","percent of total billed charges",""
"Autosomal-Recessive Intellectual Disability via the Nrxn1 Gene","PX-31000676","CDM","81479","CPT","0310","RC","","","","outpatient","","","2311.00","1733.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1155.50","50","","1.00","1.00","1.00","1 through 10","156.55","1906.58","percent of total billed charges",""
"Autosomal-Recessive Intellectual Disability via the Nrxn1 Gene","PX-31000676","CDM","81479","CPT","0310","RC","","","","outpatient","","","2311.00","1733.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1213.28","52.5","","1.00","0.53","1.00","1 through 10","156.55","1906.58","percent of total billed charges",""
"Avulsion Nail Plate Single","PX-76000089","CDM","11730","CPT","0761","RC","","","","both","","","513.00","384.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","243.61","36.94","243.71","1 through 10","159.03","407.84","other","OPPS APC"
"Avulsion Nail Plate Single","PX-76000089","CDM","11730","CPT","0761","RC","","","","both","","","513.00","384.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","159.03","407.84","other","OPPS APC"
"Avulsion Nail Plate Single","PX-76000089","CDM","11730","CPT","0761","RC","","","","both","","","513.00","384.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","187.25","36.5","","472.65","472.65","472.65","1 through 10","159.03","407.84","percent of total billed charges",""
"Avulsion Nail Plate Single","PX-76000089","CDM","11730","CPT","0761","RC","","","","both","","","513.00","384.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","196.48","38.3","","194.33","89.54","194.33","1 through 10","159.03","407.84","percent of total billed charges",""
"Avulsion Nail Plate Single","PX-76000089","CDM","11730","CPT","0761","RC","","","","both","","","513.00","384.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.19","231.25","235.97","1 through 10","159.03","407.84","other","OPPS APC"
"Avulsion Nail Plate Single","PX-76000089","CDM","11730","CPT","0761","RC","","","","outpatient","","","513.00","384.75","AETNA [1001]","HB AMC AETNA HMO","358.07","69.8","","694.05","694.05","694.05","1 through 10","176.45","700.33","percent of total billed charges",""
"Avulsion Nail Plate Single","PX-76000089","CDM","11730","CPT","0761","RC","","","","outpatient","","","513.00","384.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","202.69","202.69","202.69","1 through 10","176.45","700.33","other","ASC"
"Avulsion Nail Plate Single","PX-76000089","CDM","11730","CPT","0761","RC","","","","outpatient","","","513.00","384.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","451.71","451.71","451.71","1 through 10","176.45","700.33","other","Multiple Surgery"
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1494.37","52.26","","1113.10","1113.10","1113.10","1 through 10","886.45","2273.3","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2273.30","79.5","","1293.60","1148.53","1603.80","1 through 10","886.45","2273.3","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1043.72","36.5","","1023.42","771.29","2068.67","33","886.45","2273.3","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1095.19","38.3","","850.52","759.78","1211.25","66","886.45","2273.3","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1226.73","42.9","","2548.09","2548.09","2548.09","1 through 10","886.45","2273.3","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1226.73","42.9","","956.46","956.46","956.46","1 through 10","886.45","2273.3","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","WELLPOINT [1015]","HB AMC WELLPOINT","2109.74","73.78","","2344.73","1619.47","2530.35","16","886.45","2273.3","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2859.50","2144.62","AETNA [1001]","HB AMC AETNA HMO","1995.93","69.8","","1523.63","988.41","4330.26","39","1494.37","2336.78","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2859.50","2144.62","AETNA [1001]","HB AMC AETNA PPO","2299.04","80.4","","1670.25","1670.25","1670.25","1 through 10","1494.37","2336.78","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2859.50","2144.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1494.37","52.26","","1113.10","1113.10","1113.10","1 through 10","1494.37","2336.78","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2859.50","2144.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2336.78","81.72","","1738.90","1484.65","2716.94","38","1494.37","2336.78","percent of total billed charges",""
"AXLE SYSTEM ORTHOPEDIC SALVAGE FEMORAL KNEE","SUP-ITM-10118240","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1010.21","52.26","","1113.10","1113.10","1113.10","1 through 10","599.25","1536.77","percent of total billed charges",""
"AXLE SYSTEM ORTHOPEDIC SALVAGE FEMORAL KNEE","SUP-ITM-10118240","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1536.77","79.5","","1293.60","1148.53","1603.80","1 through 10","599.25","1536.77","percent of total billed charges",""
"AXLE SYSTEM ORTHOPEDIC SALVAGE FEMORAL KNEE","SUP-ITM-10118240","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","705.56","36.5","","1023.42","771.29","2068.67","33","599.25","1536.77","percent of total billed charges",""
"AXLE SYSTEM ORTHOPEDIC SALVAGE FEMORAL KNEE","SUP-ITM-10118240","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","740.36","38.3","","850.52","759.78","1211.25","66","599.25","1536.77","percent of total billed charges",""
"AXLE SYSTEM ORTHOPEDIC SALVAGE FEMORAL KNEE","SUP-ITM-10118240","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","829.28","42.9","","2548.09","2548.09","2548.09","1 through 10","599.25","1536.77","percent of total billed charges",""
"AXLE SYSTEM ORTHOPEDIC SALVAGE FEMORAL KNEE","SUP-ITM-10118240","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","829.28","42.9","","956.46","956.46","956.46","1 through 10","599.25","1536.77","percent of total billed charges",""
"AXLE SYSTEM ORTHOPEDIC SALVAGE FEMORAL KNEE","SUP-ITM-10118240","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","WELLPOINT [1015]","HB AMC WELLPOINT","1426.20","73.78","","2344.73","1619.47","2530.35","16","599.25","1536.77","percent of total billed charges",""
"AXLE SYSTEM ORTHOPEDIC SALVAGE FEMORAL KNEE","SUP-ITM-10118240","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1933.05","1449.79","AETNA [1001]","HB AMC AETNA HMO","1349.27","69.8","","1523.63","988.41","4330.26","39","1010.21","1579.69","percent of total billed charges",""
"AXLE SYSTEM ORTHOPEDIC SALVAGE FEMORAL KNEE","SUP-ITM-10118240","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1933.05","1449.79","AETNA [1001]","HB AMC AETNA PPO","1554.17","80.4","","1670.25","1670.25","1670.25","1 through 10","1010.21","1579.69","percent of total billed charges",""
"AXLE SYSTEM ORTHOPEDIC SALVAGE FEMORAL KNEE","SUP-ITM-10118240","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1933.05","1449.79","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1010.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1010.21","1579.69","percent of total billed charges",""
"AXLE SYSTEM ORTHOPEDIC SALVAGE FEMORAL KNEE","SUP-ITM-10118240","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1933.05","1449.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1579.69","81.72","","1738.90","1484.65","2716.94","38","1010.21","1579.69","percent of total billed charges",""
"AXLE TIBIAL IMPLANT KNEE OSS SALVAGE SYSTEM ONC 16A","SUP-ITM-10036215","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1010.21","52.26","","1113.10","1113.10","1113.10","1 through 10","599.25","1536.77","percent of total billed charges",""
"AXLE TIBIAL IMPLANT KNEE OSS SALVAGE SYSTEM ONC 16A","SUP-ITM-10036215","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1536.77","79.5","","1293.60","1148.53","1603.80","1 through 10","599.25","1536.77","percent of total billed charges",""
"AXLE TIBIAL IMPLANT KNEE OSS SALVAGE SYSTEM ONC 16A","SUP-ITM-10036215","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","705.56","36.5","","1023.42","771.29","2068.67","33","599.25","1536.77","percent of total billed charges",""
"AXLE TIBIAL IMPLANT KNEE OSS SALVAGE SYSTEM ONC 16A","SUP-ITM-10036215","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","740.36","38.3","","850.52","759.78","1211.25","66","599.25","1536.77","percent of total billed charges",""
"AXLE TIBIAL IMPLANT KNEE OSS SALVAGE SYSTEM ONC 16A","SUP-ITM-10036215","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","829.28","42.9","","2548.09","2548.09","2548.09","1 through 10","599.25","1536.77","percent of total billed charges",""
"AXLE TIBIAL IMPLANT KNEE OSS SALVAGE SYSTEM ONC 16A","SUP-ITM-10036215","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","829.28","42.9","","956.46","956.46","956.46","1 through 10","599.25","1536.77","percent of total billed charges",""
"AXLE TIBIAL IMPLANT KNEE OSS SALVAGE SYSTEM ONC 16A","SUP-ITM-10036215","CDM","C1776","HCPCS","0278","RC","","","","both","","","1933.05","1449.79","WELLPOINT [1015]","HB AMC WELLPOINT","1426.20","73.78","","2344.73","1619.47","2530.35","16","599.25","1536.77","percent of total billed charges",""
"AXLE TIBIAL IMPLANT KNEE OSS SALVAGE SYSTEM ONC 16A","SUP-ITM-10036215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1933.05","1449.79","AETNA [1001]","HB AMC AETNA HMO","1349.27","69.8","","1523.63","988.41","4330.26","39","1010.21","1579.69","percent of total billed charges",""
"AXLE TIBIAL IMPLANT KNEE OSS SALVAGE SYSTEM ONC 16A","SUP-ITM-10036215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1933.05","1449.79","AETNA [1001]","HB AMC AETNA PPO","1554.17","80.4","","1670.25","1670.25","1670.25","1 through 10","1010.21","1579.69","percent of total billed charges",""
"AXLE TIBIAL IMPLANT KNEE OSS SALVAGE SYSTEM ONC 16A","SUP-ITM-10036215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1933.05","1449.79","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1010.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1010.21","1579.69","percent of total billed charges",""
"AXLE TIBIAL IMPLANT KNEE OSS SALVAGE SYSTEM ONC 16A","SUP-ITM-10036215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1933.05","1449.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1579.69","81.72","","1738.90","1484.65","2716.94","38","1010.21","1579.69","percent of total billed charges",""
"Azithromycin Vl 500mg","PX-63600064","CDM","J0456","HCPCS","0636","RC","","","","outpatient","","","36.69","27.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","25.65","69.9","","5.70","5.70","5.70","1 through 10","5.61","29.5","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","both","","","282.00","211.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","197.40","70","","273.00","171.03","273.00","1 through 10","11.81","267.9","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","both","","","282.00","211.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","224.19","79.5","","214.85","144.14","214.85","13","11.81","267.9","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","both","","","282.00","211.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","150.31","53.3","","214.85","144.14","273.00","1 through 10","11.81","267.9","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","both","","","282.00","211.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","183.30","65","","177.45","177.45","177.45","1 through 10","11.81","267.9","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","both","","","282.00","211.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","87.42","31","","253.08","253.08","333.22","1 through 10","11.81","267.9","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","both","","","282.00","211.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","102.93","36.5","","101.83","86.54","101.83","36","11.81","267.9","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","both","","","282.00","211.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","108.01","38.3","","106.74","103.74","106.74","104","11.81","267.9","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","both","","","282.00","211.50","TRICARE [160005]","HB BWH TRICARE","267.90","95","","43.19","43.19","43.19","1 through 10","11.81","267.9","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","both","","","282.00","211.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.98","42.9","","218.24","120.04","218.24","1 through 10","11.81","267.9","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","outpatient","","","282.00","211.50","AETNA [1001]","HB AMC AETNA HMO","196.84","69.8","","184.82","130.49","212.94","71","11.81","256.97","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","outpatient","","","282.00","211.50","AETNA [1001]","HB AMC AETNA PPO","226.73","80.4","","163.49","143.05","429.15","12","11.81","256.97","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","outpatient","","","282.00","211.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","157.64","55.9","","143.05","143.05","143.05","1 through 10","11.81","256.97","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","outpatient","","","282.00","211.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","230.45","81.72","","218.24","120.04","218.24","1 through 10","11.81","256.97","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","outpatient","","","282.00","211.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","230.45","81.72","","218.24","120.04","218.24","81","11.81","256.97","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","94095.76","70571.82","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","19184.65","","Case rate ($18,625.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,344.46, add-ons for qualifying new technology services are included. If operating cost exceeds $67,988.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,049.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,636.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,964.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,609.48. The transfer capital threshold is the transfer adjustment factor * $1,609.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","18752.88","18752.88","18752.88","1 through 10","18253.35","29757.9429","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","94095.76","70571.82","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","18625.87","","Case rate ($18,625.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,344.46, add-ons for qualifying new technology services are included. If operating cost exceeds $67,988.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,049.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,636.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,964.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,609.48. The transfer capital threshold is the transfer adjustment factor * $1,609.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17980.21","17980.21","17980.21","1 through 10","18253.35","29757.9429","other","Inpatient Replacement Plans DRG"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","94095.76","70571.82","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","70082.34","70082.34","70082.34","1 through 10","18253.35","29757.9429","case rate",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","94095.76","70571.82","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","18625.87","","Case rate ($18,625.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,344.46, add-ons for qualifying new technology services are included. If operating cost exceeds $67,988.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,049.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,636.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,964.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,609.48. The transfer capital threshold is the transfer adjustment factor * $1,609.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17036.48","17036.48","17036.48","1 through 10","18253.35","29757.9429","other","Inpatient Replacement Plans DRG"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","94095.76","70571.82","MEDICARE [2001]","HB BWH MEDICARE","18625.87","","Case rate ($18,625.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,344.46, add-ons for qualifying new technology services are included. If operating cost exceeds $67,988.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,049.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,636.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,964.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,609.48. The transfer capital threshold is the transfer adjustment factor * $1,609.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23525.32","0.03","23560.08","30","18253.35","29757.9429","other","Inpatient Replacement Plans DRG"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","94095.76","70571.82","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","18253.35","","Case rate ($18,625.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,344.46, add-ons for qualifying new technology services are included. If operating cost exceeds $67,988.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,049.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,636.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,964.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,609.48. The transfer capital threshold is the transfer adjustment factor * $1,609.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17867.11","17281.00","17891.72","1 through 10","18253.35","29757.9429","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","94095.76","70571.82","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","18253.35","","Case rate ($18,625.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,344.46, add-ons for qualifying new technology services are included. If operating cost exceeds $67,988.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,049.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,636.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,964.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,609.48. The transfer capital threshold is the transfer adjustment factor * $1,609.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17876.50","17320.11","23897.31","1 through 10","18253.35","29757.9429","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","","","","inpatient","","","157252.57","117939.43","MEDICARE [2001]","HB BWH MEDICARE","44625.46","","Case rate ($44,625.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,419.94, add-ons for qualifying new technology services are included. If operating cost exceeds $87,064.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,447.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,238.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,040.10 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,007.25. The transfer capital threshold is the transfer adjustment factor * $3,007.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","42530.63","0.03","42530.63","13","33782.45","54086.144","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion Without Cc/McC","520","MS-DRG","","","","","","","","inpatient","","","77035.53","57776.65","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14007.35","","Case rate ($14,007.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,784.68, add-ons for qualifying new technology services are included. If operating cost exceeds $62,429.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,642.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,425.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,404.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,202.08. The transfer capital threshold is the transfer adjustment factor * $1,202.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16916.48","16916.48","16916.48","1 through 10","13727.2","21628.4212","other","Inpatient Replacement Plans DRG"
"Back And Neck Procedures Except Spinal Fusion Without Cc/McC","520","MS-DRG","","","","","","","","inpatient","","","77035.53","57776.65","ELDER SERVICES [1037]","HB BWH MEDICARE","14007.35","","Case rate ($14,007.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,784.68, add-ons for qualifying new technology services are included. If operating cost exceeds $62,429.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,642.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,425.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,404.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,202.08. The transfer capital threshold is the transfer adjustment factor * $1,202.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13054.48","13054.48","13054.48","1 through 10","13727.2","21628.4212","other","Inpatient Replacement Plans DRG"
"Back And Neck Procedures Except Spinal Fusion Without Cc/McC","520","MS-DRG","","","","","","","","inpatient","","","77035.53","57776.65","MEDICARE [2001]","HB BWH MEDICARE","14007.35","","Case rate ($14,007.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,784.68, add-ons for qualifying new technology services are included. If operating cost exceeds $62,429.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,642.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,425.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,404.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,202.08. The transfer capital threshold is the transfer adjustment factor * $1,202.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17174.50","17174.50","17199.78","11","13727.2","21628.4212","other","Inpatient Replacement Plans DRG"
"Back And Neck Procedures Except Spinal Fusion Without Cc/McC","520","MS-DRG","","","","","","","","inpatient","","","77035.53","57776.65","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13727.20","","Case rate ($14,007.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,784.68, add-ons for qualifying new technology services are included. If operating cost exceeds $62,429.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,642.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,425.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,404.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,202.08. The transfer capital threshold is the transfer adjustment factor * $1,202.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13054.60","13054.48","13312.95","1 through 10","13727.2","21628.4212","other","Inpatient DRG"
"Baclofen Amp 50mcg/Ml 1ml Trial","PX-63600066","CDM","J0476","HCPCS","0636","RC","","","","outpatient","","","297.50","223.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.53","46.9","","144.82","144.82","144.82","1 through 10","139.53","239.19","percent of total billed charges",""
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","","","","inpatient","","","102015.14","76511.35","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","30914.80","","Case rate ($30,914.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,702.59, add-ons for qualifying new technology services are included. If operating cost exceeds $74,347.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,515.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $28,459.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,322.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.38. The transfer capital threshold is the transfer adjustment factor * $2,075.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21799.12","21799.12","21799.12","1 through 10","23429.43","36176.1452","other","Inpatient DRG"
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","","","","inpatient","","","102015.14","76511.35","MEDICARE [2001]","HB BWH MEDICARE","30914.80","","Case rate ($30,914.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,702.59, add-ons for qualifying new technology services are included. If operating cost exceeds $74,347.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,515.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $28,459.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,322.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.38. The transfer capital threshold is the transfer adjustment factor * $2,075.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28539.24","28539.24","28539.24","1 through 10","23429.43","36176.1452","other","Inpatient DRG"
"Bacterial And Tuberculous Infections Of Nervous System With McC","094","MS-DRG","","","","","","","","inpatient","","","124443.78","93332.83","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","33458.68","","Case rate ($32,484.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,027.13, add-ons for qualifying new technology services are included. If operating cost exceeds $84,671.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,272.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $29,272.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,647.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,831.92. The transfer capital threshold is the transfer adjustment factor * $2,831.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","34412.02","34412.02","34412.02","1 through 10","31834.48","55127.88","other","Inpatient DRG"
"Bacterial And Tuberculous Infections Of Nervous System With McC","094","MS-DRG","","","","","","","","inpatient","","","124443.78","93332.83","MEDICARE [2001]","HB BWH MEDICARE","42045.74","","Case rate ($42,045.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,027.13, add-ons for qualifying new technology services are included. If operating cost exceeds $84,671.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,272.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $38,834.00 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,647.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,831.92. The transfer capital threshold is the transfer adjustment factor * $2,831.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","43293.38","43293.38","43357.72","1 through 10","31834.48","55127.88","other","Inpatient DRG"
"Bacterial And Tuberculous Infections Of Nervous System With McC","094","MS-DRG","","","","","","","","inpatient","","","124443.78","93332.83","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","31834.48","","Case rate ($32,484.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,027.13, add-ons for qualifying new technology services are included. If operating cost exceeds $84,671.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,272.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $29,272.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,647.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,831.92. The transfer capital threshold is the transfer adjustment factor * $2,831.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","32763.49","32763.49","32763.49","1 through 10","31834.48","55127.88","other","Inpatient DRG"
"Bacterial And Tuberculous Infections Of Nervous System With McC","094","MS-DRG","","","","","","","","inpatient","","","124443.78","93332.83","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","31834.48","","Case rate ($32,484.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,027.13, add-ons for qualifying new technology services are included. If operating cost exceeds $84,671.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,272.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.9. The base transfer operating payment is the transfer adjustment factor * $29,272.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,647.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,831.92. The transfer capital threshold is the transfer adjustment factor * $2,831.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","32768.05","32768.05","32768.05","1 through 10","31834.48","55127.88","other","Inpatient DRG"
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/McC","096","MS-DRG","","","","","","","","inpatient","","","66568.06","49926.04","MEDICARE [2001]","HB BWH MEDICARE","23907.58","","Case rate ($23,907.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,702.59, add-ons for qualifying new technology services are included. If operating cost exceeds $74,347.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,515.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $21,452.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,322.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,075.38. The transfer capital threshold is the transfer adjustment factor * $2,075.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","475.42","475.42","475.42","1 through 10","23429.43","36176.1452","other","Inpatient Replacement Plans DRG"
"Bacterial And Tuberculous Infections Of Nervous System,EXTREME","049","DRG","","","","","","","","inpatient","","","126294.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","122249.59","","Standard inlier is a Case rate ($122,249.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $96,207, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,352.31) for the length of stay and the standard reimbursement.","122249.59","122249.59","122249.59","1 through 10","14430.37","191313.32","case rate",""
"Bacterial And Tuberculous Infections Of Nervous System,MAJOR","049","DRG","","","","","","","","inpatient","","","38043.96","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","64963.37","","Fee schedule rate ($64,963.37). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($7,516.56) multiplied by length of stay and the outlier percent (100%).","59216.47","59216.47","59216.47","1 through 10","14430.37","191313.32","case rate",""
"Bacterial And Tuberculous Infections Of Nervous System,MODERATE","049","DRG","","","","","","","","inpatient","","","76643.96","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14430.37","","Case rate ($15,955.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,385.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,629.75 and the sum of the standard inlier and any outlier amount.","15951.34","15951.34","15951.34","1 through 10","14430.37","191313.32","case rate",""
"Bakri Occlusion Catheter","PX-27002385","CDM","C2628","HCPCS","0272","RC","","","","both","","","980.00","735.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","779.10","79.5","","518.94","518.94","518.94","1 through 10","303.8","779.1","percent of total billed charges",""
"Bakri Occlusion Catheter","PX-27002385","CDM","C2628","HCPCS","0272","RC","","","","both","","","980.00","735.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","637.00","65","","429.02","429.02","429.02","1 through 10","303.8","779.1","percent of total billed charges",""
"Bakri Occlusion Catheter","PX-27002385","CDM","C2628","HCPCS","0272","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","357.70","36.5","","4636.13","4636.13","4636.13","1 through 10","303.8","779.1","percent of total billed charges",""
"Bakri Occlusion Catheter","PX-27002385","CDM","C2628","HCPCS","0272","RC","","","","both","","","980.00","735.00","WELLPOINT [1015]","HB AMC WELLPOINT","723.04","73.78","","491.39","491.39","491.39","1 through 10","303.8","779.1","percent of total billed charges",""
"Bakri Occlusion Catheter","PX-27002385","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","800.86","81.72","","290.22","290.22","290.22","1 through 10","512.15","800.86","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","146.33","52.26","","1113.10","1113.10","1113.10","1 through 10","86.8","222.6","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","222.60","79.5","","1293.60","1148.53","1603.80","1 through 10","86.8","222.6","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","102.20","36.5","","1023.42","771.29","2068.67","33","86.8","222.6","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","107.24","38.3","","850.52","759.78","1211.25","66","86.8","222.6","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.12","42.9","","2548.09","2548.09","2548.09","1 through 10","86.8","222.6","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.12","42.9","","956.46","956.46","956.46","1 through 10","86.8","222.6","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","280.00","210.00","WELLPOINT [1015]","HB AMC WELLPOINT","206.58","73.78","","2344.73","1619.47","2530.35","16","86.8","222.6","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","AETNA [1001]","HB AMC AETNA HMO","195.44","69.8","","1523.63","988.41","4330.26","39","146.33","228.82","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","AETNA [1001]","HB AMC AETNA PPO","225.12","80.4","","1670.25","1670.25","1670.25","1 through 10","146.33","228.82","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","146.33","52.26","","1113.10","1113.10","1113.10","1 through 10","146.33","228.82","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","228.82","81.72","","1738.90","1484.65","2716.94","38","146.33","228.82","percent of total billed charges",""
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","both","","","4458.00","3343.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1057.74","3544.11","other","OPPS APC"
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","both","","","4458.00","3343.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","3544.11","other","OPPS APC"
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","both","","","4458.00","3343.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3544.11","other","OPPS APC"
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","both","","","4458.00","3343.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1057.74","3544.11","other","OPPS APC"
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","both","","","4458.00","3343.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1912.48","42.9","","1932.92","1932.92","1932.92","1 through 10","1057.74","3544.11","percent of total billed charges",""
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","both","","","4458.00","3343.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1057.74","3544.11","other","OPPS APC"
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","both","","","4458.00","3343.50","WELLPOINT [1015]","HB AMC WELLPOINT","3289.11","73.78","","2222.33","2222.33","2222.33","1 through 10","1057.74","3544.11","percent of total billed charges",""
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","outpatient","","","4458.00","3343.50","AETNA [1001]","HB AMC AETNA HMO","3111.68","69.8","","2238.60","2238.60","2238.60","1 through 10","2229","8899.59","percent of total billed charges",""
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","outpatient","","","4458.00","3343.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2699.32","60.55","","3144.00","2870.00","3286.00","1 through 10","2229","8899.59","percent of total billed charges",""
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","outpatient","","","4458.00","3343.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2329.75","52.26","","1775.96","1775.96","1775.96","1 through 10","2229","8899.59","percent of total billed charges",""
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","outpatient","","","4458.00","3343.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2327.97","52.22","","3286.00","2018.70","5898.00","1 through 10","2229","8899.59","percent of total billed charges",""
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","outpatient","","","4458.00","3343.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2340.45","52.5","","8340.00","8340.00","8340.00","1 through 10","2229","8899.59","percent of total billed charges",""
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","outpatient","","","4458.00","3343.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3643.08","81.72","","2294.28","682.69","2294.28","1 through 10","2229","8899.59","percent of total billed charges",""
"BALLOON INTRAGASTRIC ORBERA MANAGED WEIGHT LOSS CATHETER SYSTEM NON","SUP-ITM-10156095","CDM","C1889","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","1309.77","674.56","6049.93","26","1534.5","3935.25","percent of total billed charges",""
"BALLOON INTRAGASTRIC ORBERA MANAGED WEIGHT LOSS CATHETER SYSTEM NON","SUP-ITM-10156095","CDM","C1889","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2638.35","53.3","","1901.83","1901.83","2962.25","1 through 10","1534.5","3935.25","percent of total billed charges",""
"BALLOON INTRAGASTRIC ORBERA MANAGED WEIGHT LOSS CATHETER SYSTEM NON","SUP-ITM-10156095","CDM","C1889","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","1620.31","1620.31","19908.88","1 through 10","1534.5","3935.25","percent of total billed charges",""
"BALLOON INTRAGASTRIC ORBERA MANAGED WEIGHT LOSS CATHETER SYSTEM NON","SUP-ITM-10156095","CDM","C1889","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","352.91","352.91","2046.30","1 through 10","1534.5","3935.25","percent of total billed charges",""
"BALLOON INTRAGASTRIC ORBERA MANAGED WEIGHT LOSS CATHETER SYSTEM NON","SUP-ITM-10156095","CDM","C1889","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","9668.75","9668.75","9668.75","1 through 10","1534.5","3935.25","percent of total billed charges",""
"BALLOON INTRAGASTRIC ORBERA MANAGED WEIGHT LOSS CATHETER SYSTEM NON","SUP-ITM-10156095","CDM","C1889","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","699.88","384.10","3443.31","33","1534.5","3935.25","percent of total billed charges",""
"BALLOON INTRAGASTRIC ORBERA MANAGED WEIGHT LOSS CATHETER SYSTEM NON","SUP-ITM-10156095","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","1421.24","264.50","4933.46","29","2586.87","4045.14","percent of total billed charges",""
"BALLOON INTRAGASTRIC ORBERA MANAGED WEIGHT LOSS CATHETER SYSTEM NON","SUP-ITM-10156095","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3979.80","80.4","","1022.97","1022.97","3607.50","1 through 10","2586.87","4045.14","percent of total billed charges",""
"BALLOON INTRAGASTRIC ORBERA MANAGED WEIGHT LOSS CATHETER SYSTEM NON","SUP-ITM-10156095","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","3010.54","693.88","5019.88","35","2586.87","4045.14","percent of total billed charges",""
"BAND ANNULOPLAST 34MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012163","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3199.88","79.5","","1309.77","674.56","6049.93","26","1247.75","3199.88","percent of total billed charges",""
"BAND ANNULOPLAST 34MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012163","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2145.33","53.3","","1901.83","1901.83","2962.25","1 through 10","1247.75","3199.88","percent of total billed charges",""
"BAND ANNULOPLAST 34MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012163","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1469.13","36.5","","1620.31","1620.31","19908.88","1 through 10","1247.75","3199.88","percent of total billed charges",""
"BAND ANNULOPLAST 34MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012163","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1541.58","38.3","","352.91","352.91","2046.30","1 through 10","1247.75","3199.88","percent of total billed charges",""
"BAND ANNULOPLAST 34MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012163","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.73","42.9","","9668.75","9668.75","9668.75","1 through 10","1247.75","3199.88","percent of total billed charges",""
"BAND ANNULOPLAST 34MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012163","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","WELLPOINT [1015]","HB AMC WELLPOINT","2969.65","73.78","","699.88","384.10","3443.31","33","1247.75","3199.88","percent of total billed charges",""
"BAND ANNULOPLAST 34MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012163","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","AETNA [1001]","HB AMC AETNA HMO","2809.45","69.8","","1421.24","264.50","4933.46","29","2103.47","3289.23","percent of total billed charges",""
"BAND ANNULOPLAST 34MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012163","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3236.10","80.4","","1022.97","1022.97","3607.50","1 through 10","2103.47","3289.23","percent of total billed charges",""
"BAND ANNULOPLAST 34MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012163","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3289.23","81.72","","3010.54","693.88","5019.88","35","2103.47","3289.23","percent of total billed charges",""
"BAND ANNULOPLASTY 30MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012155","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3199.88","79.5","","1309.77","674.56","6049.93","26","1247.75","3199.88","percent of total billed charges",""
"BAND ANNULOPLASTY 30MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012155","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2145.33","53.3","","1901.83","1901.83","2962.25","1 through 10","1247.75","3199.88","percent of total billed charges",""
"BAND ANNULOPLASTY 30MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012155","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1469.13","36.5","","1620.31","1620.31","19908.88","1 through 10","1247.75","3199.88","percent of total billed charges",""
"BAND ANNULOPLASTY 30MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012155","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1541.58","38.3","","352.91","352.91","2046.30","1 through 10","1247.75","3199.88","percent of total billed charges",""
"BAND ANNULOPLASTY 30MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012155","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.73","42.9","","9668.75","9668.75","9668.75","1 through 10","1247.75","3199.88","percent of total billed charges",""
"BAND ANNULOPLASTY 30MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012155","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","WELLPOINT [1015]","HB AMC WELLPOINT","2969.65","73.78","","699.88","384.10","3443.31","33","1247.75","3199.88","percent of total billed charges",""
"BAND ANNULOPLASTY 30MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012155","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","AETNA [1001]","HB AMC AETNA HMO","2809.45","69.8","","1421.24","264.50","4933.46","29","2103.47","3289.23","percent of total billed charges",""
"BAND ANNULOPLASTY 30MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012155","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3236.10","80.4","","1022.97","1022.97","3607.50","1 through 10","2103.47","3289.23","percent of total billed charges",""
"BAND ANNULOPLASTY 30MM COLVIN-GALLOWAY FUTURE SEMIRIGID METAL ALLOY FLEXIBLE LOW PROFILE","SUP-ITM-10012155","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3289.23","81.72","","3010.54","693.88","5019.88","35","2103.47","3289.23","percent of total billed charges",""
"BAND TENSION 70MM .062IN PIN BONE SS TROCAR POINT EYELET LOW PROFILE","SUP-ITM-10088501","CDM","C1889","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","150.26","79.5","","1309.77","674.56","6049.93","26","58.59","150.26","percent of total billed charges",""
"BAND TENSION 70MM .062IN PIN BONE SS TROCAR POINT EYELET LOW PROFILE","SUP-ITM-10088501","CDM","C1889","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.74","53.3","","1901.83","1901.83","2962.25","1 through 10","58.59","150.26","percent of total billed charges",""
"BAND TENSION 70MM .062IN PIN BONE SS TROCAR POINT EYELET LOW PROFILE","SUP-ITM-10088501","CDM","C1889","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.99","36.5","","1620.31","1620.31","19908.88","1 through 10","58.59","150.26","percent of total billed charges",""
"BAND TENSION 70MM .062IN PIN BONE SS TROCAR POINT EYELET LOW PROFILE","SUP-ITM-10088501","CDM","C1889","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.39","38.3","","352.91","352.91","2046.30","1 through 10","58.59","150.26","percent of total billed charges",""
"BAND TENSION 70MM .062IN PIN BONE SS TROCAR POINT EYELET LOW PROFILE","SUP-ITM-10088501","CDM","C1889","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","9668.75","9668.75","9668.75","1 through 10","58.59","150.26","percent of total billed charges",""
"BAND TENSION 70MM .062IN PIN BONE SS TROCAR POINT EYELET LOW PROFILE","SUP-ITM-10088501","CDM","C1889","HCPCS","0278","RC","","","","both","","","189.00","141.75","WELLPOINT [1015]","HB AMC WELLPOINT","139.44","73.78","","699.88","384.10","3443.31","33","58.59","150.26","percent of total billed charges",""
"BAND TENSION 70MM .062IN PIN BONE SS TROCAR POINT EYELET LOW PROFILE","SUP-ITM-10088501","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA HMO","131.92","69.8","","1421.24","264.50","4933.46","29","98.77","154.45","percent of total billed charges",""
"BAND TENSION 70MM .062IN PIN BONE SS TROCAR POINT EYELET LOW PROFILE","SUP-ITM-10088501","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","151.96","80.4","","1022.97","1022.97","3607.50","1 through 10","98.77","154.45","percent of total billed charges",""
"BAND TENSION 70MM .062IN PIN BONE SS TROCAR POINT EYELET LOW PROFILE","SUP-ITM-10088501","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","154.45","81.72","","3010.54","693.88","5019.88","35","98.77","154.45","percent of total billed charges",""
"BAR SPINE 4MM SHORT SYNAPSE TITANIUM TRANSVERSE","SUP-ITM-10077236","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.46","79.5","","1309.77","674.56","6049.93","26","157.33","403.46","percent of total billed charges",""
"BAR SPINE 4MM SHORT SYNAPSE TITANIUM TRANSVERSE","SUP-ITM-10077236","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.50","53.3","","1901.83","1901.83","2962.25","1 through 10","157.33","403.46","percent of total billed charges",""
"BAR SPINE 4MM SHORT SYNAPSE TITANIUM TRANSVERSE","SUP-ITM-10077236","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.24","36.5","","1620.31","1620.31","19908.88","1 through 10","157.33","403.46","percent of total billed charges",""
"BAR SPINE 4MM SHORT SYNAPSE TITANIUM TRANSVERSE","SUP-ITM-10077236","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.37","38.3","","352.91","352.91","2046.30","1 through 10","157.33","403.46","percent of total billed charges",""
"BAR SPINE 4MM SHORT SYNAPSE TITANIUM TRANSVERSE","SUP-ITM-10077236","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.72","42.9","","9668.75","9668.75","9668.75","1 through 10","157.33","403.46","percent of total billed charges",""
"BAR SPINE 4MM SHORT SYNAPSE TITANIUM TRANSVERSE","SUP-ITM-10077236","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","WELLPOINT [1015]","HB AMC WELLPOINT","374.43","73.78","","699.88","384.10","3443.31","33","157.33","403.46","percent of total billed charges",""
"BAR SPINE 4MM SHORT SYNAPSE TITANIUM TRANSVERSE","SUP-ITM-10077236","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","AETNA [1001]","HB AMC AETNA HMO","354.24","69.8","","1421.24","264.50","4933.46","29","265.22","414.73","percent of total billed charges",""
"BAR SPINE 4MM SHORT SYNAPSE TITANIUM TRANSVERSE","SUP-ITM-10077236","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","408.03","80.4","","1022.97","1022.97","3607.50","1 through 10","265.22","414.73","percent of total billed charges",""
"BAR SPINE 4MM SHORT SYNAPSE TITANIUM TRANSVERSE","SUP-ITM-10077236","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","414.73","81.72","","3010.54","693.88","5019.88","35","265.22","414.73","percent of total billed charges",""
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","both","","","6606.00","4954.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","5251.77","other","OPPS APC"
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","both","","","6606.00","4954.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","5251.77","other","OPPS APC"
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","both","","","6606.00","4954.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5251.77","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","5251.77","percent of total billed charges",""
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","both","","","6606.00","4954.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","5251.77","other","OPPS APC"
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","both","","","6606.00","4954.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","5251.77","other","OPPS APC"
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","both","","","6606.00","4954.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2411.19","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","5251.77","percent of total billed charges",""
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","both","","","6606.00","4954.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2530.10","38.3","","2723.31","1555.62","2741.61","12","1057.74","5251.77","percent of total billed charges",""
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","both","","","6606.00","4954.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","5251.77","other","OPPS APC"
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","both","","","6606.00","4954.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","5251.77","other","OPPS APC"
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","both","","","6606.00","4954.50","WELLPOINT [1015]","HB AMC WELLPOINT","4873.91","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","5251.77","percent of total billed charges",""
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","outpatient","","","6606.00","4954.50","AETNA [1001]","HB AMC AETNA PPO","5311.22","80.4","","1163.76","1163.76","1163.76","1 through 10","2384.07","5449.95","percent of total billed charges",""
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","outpatient","","","6606.00","4954.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3999.93","60.55","","1781.82","1492.00","4331.00","1 through 10","2384.07","5449.95","percent of total billed charges",""
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","outpatient","","","6606.00","4954.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3449.65","52.22","","3144.00","1492.00","3610.00","13","2384.07","5449.95","percent of total billed charges",""
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","outpatient","","","6606.00","4954.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","3468.15","52.5","","1182.28","1182.28","1182.28","1 through 10","2384.07","5449.95","percent of total billed charges",""
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","outpatient","","","6606.00","4954.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3303.00","50","","3610.00","2269.44","3610.00","1 through 10","2384.07","5449.95","percent of total billed charges",""
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","outpatient","","","6606.00","4954.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3468.15","52.5","","3610.00","2382.05","4331.00","1 through 10","2384.07","5449.95","percent of total billed charges",""
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","outpatient","","","6606.00","4954.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","3633.30","55","","4810.75","3363.17","4810.75","1 through 10","2384.07","5449.95","percent of total billed charges",""
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","outpatient","","","6606.00","4954.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5398.42","81.72","","8894.69","8894.69","8894.69","1 through 10","2384.07","5449.95","percent of total billed charges",""
"Bariatric Endoscopic Antral Myotomy (Beam)","PX-75000529","CDM","43999","CPT","0750","RC","","","","outpatient","","","6606.00","4954.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5398.42","81.72","","2885.83","2132.00","3462.21","1 through 10","2384.07","5449.95","percent of total billed charges",""
"BARRIER ADHESION 3.0X4.0IN INTERCEED ABSORBABLE GYNECARE IMPLANTABLE BX/10EA","SUP-ITM-10074846","CDM","C1765","HCPCS","0278","RC","","","","both","","","1016.63","762.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","660.81","65","","489.93","489.93","489.93","1 through 10","315.16","808.22","percent of total billed charges",""
"BARRIER ADHESION 3X5IN SEPRAFILM ABDOMINOPELVIC CAVITY BIORESORBABLE BX/5EA","SUP-ITM-10158034","CDM","C1765","HCPCS","0278","RC","","","","both","","","3289.25","2466.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2138.01","65","","489.93","489.93","489.93","1 through 10","1019.67","2614.95","percent of total billed charges",""
"BARRIER ADHESION 6X5IN SZ 1 SEPRAFILM ABDOMINOPELVIC CAVITY BIORESORBABLE BX/10EA","SUP-ITM-10002948","CDM","C1765","HCPCS","0278","RC","","","","both","","","1150.36","862.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","747.73","65","","489.93","489.93","489.93","1 through 10","356.61","914.54","percent of total billed charges",""
"Bartonella Antibody","PX-30000885","CDM","86611","CPT","0302","RC","","","","both","","","150.00","112.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","105.00","70","","145.00","145.00","145.00","1 through 10","9.98","142.5","percent of total billed charges",""
"Bartonella Antibody","PX-30000885","CDM","86611","CPT","0302","RC","","","","both","","","150.00","112.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","119.25","79.5","","76.56","76.56","76.56","1 through 10","9.98","142.5","percent of total billed charges",""
"Bartonella Antibody","PX-30000885","CDM","86611","CPT","0302","RC","","","","both","","","150.00","112.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","79.95","53.3","","76.56","76.56","76.56","1 through 10","9.98","142.5","percent of total billed charges",""
"Bartonella Antibody","PX-30000885","CDM","86611","CPT","0302","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54.75","36.5","","54.09","54.09","54.09","1 through 10","9.98","142.5","percent of total billed charges",""
"Bartonella Antibody","PX-30000885","CDM","86611","CPT","0302","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.45","38.3","","56.70","56.70","56.70","12","9.98","142.5","percent of total billed charges",""
"Bartonella Antibody","PX-30000885","CDM","86611","CPT","0302","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","122.58","81.72","","115.91","63.76","463.65","1 through 10","10.07","122.58","percent of total billed charges",""
"Basal Ganglia Calcification Dystonia Nextgen Dna Sequencing Panel (20 Genes)","PX-31000805","CDM","81479","CPT","0310","RC","","","","both","","","1922.00","1441.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1527.99","79.5","","0.65","0.65","0.65","1 through 10","595.82","1825.9","percent of total billed charges",""
"Basal Ganglia Calcification Dystonia Nextgen Dna Sequencing Panel (20 Genes)","PX-31000805","CDM","81479","CPT","0310","RC","","","","both","","","1922.00","1441.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1024.43","53.3","","0.79","0.79","0.79","1 through 10","595.82","1825.9","percent of total billed charges",""
"Basal Ganglia Calcification Dystonia Nextgen Dna Sequencing Panel (20 Genes)","PX-31000805","CDM","81479","CPT","0310","RC","","","","outpatient","","","1922.00","1441.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","961.00","50","","1.00","1.00","1.00","1 through 10","156.55","1585.65","percent of total billed charges",""
"Basal Ganglia Calcification Dystonia Nextgen Dna Sequencing Panel (20 Genes)","PX-31000805","CDM","81479","CPT","0310","RC","","","","outpatient","","","1922.00","1441.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1009.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","1585.65","percent of total billed charges",""
"BASE 30X59MM RIM HELICAL MEDPOR EXTENDED RIGHT","SUP-ITM-10020941","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","4016.63","3012.47","AETNA [1001]","HB AMC AETNA HMO","2803.61","69.8","","1013.24","1013.24","1013.24","1 through 10","2008.32","3313.72","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2822.04","52.26","","1113.10","1113.10","1113.10","1 through 10","1674","4293","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4293.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1674","4293","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1971.00","36.5","","1023.42","771.29","2068.67","33","1674","4293","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2068.20","38.3","","850.52","759.78","1211.25","66","1674","4293","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","2548.09","2548.09","2548.09","1 through 10","1674","4293","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","956.46","956.46","956.46","1 through 10","1674","4293","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB AMC WELLPOINT","3984.12","73.78","","2344.73","1619.47","2530.35","16","1674","4293","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA HMO","3769.20","69.8","","1523.63","988.41","4330.26","39","2822.04","4412.88","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA PPO","4341.60","80.4","","1670.25","1670.25","1670.25","1 through 10","2822.04","4412.88","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2822.04","52.26","","1113.10","1113.10","1113.10","1 through 10","2822.04","4412.88","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4412.88","81.72","","1738.90","1484.65","2716.94","38","2822.04","4412.88","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","800.18","480.96","1887.97","195","1193.5","3060.75","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2052.05","53.3","","813.12","216.42","1444.50","81","1193.5","3060.75","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1193.50","31","","432.60","432.60","432.60","1 through 10","1193.5","3060.75","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","148.37","54.89","631.39","94","1193.5","3060.75","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","279.30","91.72","1116.77","266","1193.5","3060.75","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","731.00","63.70","731.00","1 through 10","1193.5","3060.75","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","384.74","384.74","384.74","1 through 10","1193.5","3060.75","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","286.63","119.22","1107.45","105","1193.5","3060.75","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA HMO","2687.30","69.8","","675.31","184.75","1721.50","286","2012.01","3146.22","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA PPO","3095.40","80.4","","1261.44","103.12","1514.10","21","2012.01","3146.22","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3095.40","80.4","","1365.00","1365.00","1365.00","1 through 10","2012.01","3146.22","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3146.22","81.72","","5157.68","5157.68","5157.68","1 through 10","2012.01","3146.22","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","431.26","71.26","1459.57","88","2012.01","3146.22","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2377.83","52.26","","1113.10","1113.10","1113.10","1 through 10","1410.5","3617.25","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3617.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1410.5","3617.25","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1660.75","36.5","","1023.42","771.29","2068.67","33","1410.5","3617.25","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1742.65","38.3","","850.52","759.78","1211.25","66","1410.5","3617.25","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.95","42.9","","2548.09","2548.09","2548.09","1 through 10","1410.5","3617.25","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.95","42.9","","956.46","956.46","956.46","1 through 10","1410.5","3617.25","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","WELLPOINT [1015]","HB AMC WELLPOINT","3356.99","73.78","","2344.73","1619.47","2530.35","16","1410.5","3617.25","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","AETNA [1001]","HB AMC AETNA HMO","3175.90","69.8","","1523.63","988.41","4330.26","39","2377.83","3718.26","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","AETNA [1001]","HB AMC AETNA PPO","3658.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2377.83","3718.26","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2377.83","52.26","","1113.10","1113.10","1113.10","1 through 10","2377.83","3718.26","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3718.26","81.72","","1738.90","1484.65","2716.94","38","2377.83","3718.26","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TRIATHLON REVISION","SUP-ITM-10322132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4959.60","52.26","","1113.10","1113.10","1113.10","1 through 10","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TRIATHLON REVISION","SUP-ITM-10322132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7544.75","79.5","","1293.60","1148.53","1603.80","1 through 10","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TRIATHLON REVISION","SUP-ITM-10322132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3463.94","36.5","","1023.42","771.29","2068.67","33","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TRIATHLON REVISION","SUP-ITM-10322132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3634.77","38.3","","850.52","759.78","1211.25","66","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TRIATHLON REVISION","SUP-ITM-10322132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4071.32","42.9","","2548.09","2548.09","2548.09","1 through 10","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TRIATHLON REVISION","SUP-ITM-10322132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4071.32","42.9","","956.46","956.46","956.46","1 through 10","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TRIATHLON REVISION","SUP-ITM-10322132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","WELLPOINT [1015]","HB AMC WELLPOINT","7001.91","73.78","","2344.73","1619.47","2530.35","16","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TRIATHLON REVISION","SUP-ITM-10322132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9490.25","7117.69","AETNA [1001]","HB AMC AETNA HMO","6624.19","69.8","","1523.63","988.41","4330.26","39","4959.6","7755.43","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TRIATHLON REVISION","SUP-ITM-10322132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9490.25","7117.69","AETNA [1001]","HB AMC AETNA PPO","7630.16","80.4","","1670.25","1670.25","1670.25","1 through 10","4959.6","7755.43","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TRIATHLON REVISION","SUP-ITM-10322132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9490.25","7117.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4959.60","52.26","","1113.10","1113.10","1113.10","1 through 10","4959.6","7755.43","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TRIATHLON REVISION","SUP-ITM-10322132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9490.25","7117.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7755.43","81.72","","1738.90","1484.65","2716.94","38","4959.6","7755.43","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 4 TRIATHLON REVISION","SUP-ITM-10322131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4959.60","52.26","","1113.10","1113.10","1113.10","1 through 10","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 4 TRIATHLON REVISION","SUP-ITM-10322131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7544.75","79.5","","1293.60","1148.53","1603.80","1 through 10","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 4 TRIATHLON REVISION","SUP-ITM-10322131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3463.94","36.5","","1023.42","771.29","2068.67","33","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 4 TRIATHLON REVISION","SUP-ITM-10322131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3634.77","38.3","","850.52","759.78","1211.25","66","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 4 TRIATHLON REVISION","SUP-ITM-10322131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4071.32","42.9","","2548.09","2548.09","2548.09","1 through 10","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 4 TRIATHLON REVISION","SUP-ITM-10322131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4071.32","42.9","","956.46","956.46","956.46","1 through 10","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 4 TRIATHLON REVISION","SUP-ITM-10322131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","WELLPOINT [1015]","HB AMC WELLPOINT","7001.91","73.78","","2344.73","1619.47","2530.35","16","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 4 TRIATHLON REVISION","SUP-ITM-10322131","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9490.25","7117.69","AETNA [1001]","HB AMC AETNA HMO","6624.19","69.8","","1523.63","988.41","4330.26","39","4959.6","7755.43","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 4 TRIATHLON REVISION","SUP-ITM-10322131","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9490.25","7117.69","AETNA [1001]","HB AMC AETNA PPO","7630.16","80.4","","1670.25","1670.25","1670.25","1 through 10","4959.6","7755.43","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 4 TRIATHLON REVISION","SUP-ITM-10322131","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9490.25","7117.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4959.60","52.26","","1113.10","1113.10","1113.10","1 through 10","4959.6","7755.43","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 4 TRIATHLON REVISION","SUP-ITM-10322131","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9490.25","7117.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7755.43","81.72","","1738.90","1484.65","2716.94","38","4959.6","7755.43","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236293","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1085","2782.5","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236293","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1085","2782.5","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236293","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1023.42","771.29","2068.67","33","1085","2782.5","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236293","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","850.52","759.78","1211.25","66","1085","2782.5","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236293","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1085","2782.5","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236293","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","956.46","956.46","956.46","1 through 10","1085","2782.5","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236293","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2344.73","1619.47","2530.35","16","1085","2782.5","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236293","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1523.63","988.41","4330.26","39","1829.1","2860.2","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236293","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1829.1","2860.2","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236293","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1829.1","2860.2","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236293","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","1738.90","1484.65","2716.94","38","1829.1","2860.2","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 TRIATHLON REVISION","SUP-ITM-10322129","CDM","C1713","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7544.75","79.5","","800.18","480.96","1887.97","195","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 TRIATHLON REVISION","SUP-ITM-10322129","CDM","C1713","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5058.30","53.3","","813.12","216.42","1444.50","81","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 TRIATHLON REVISION","SUP-ITM-10322129","CDM","C1713","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2941.98","31","","432.60","432.60","432.60","1 through 10","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 TRIATHLON REVISION","SUP-ITM-10322129","CDM","C1713","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3463.94","36.5","","148.37","54.89","631.39","94","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 TRIATHLON REVISION","SUP-ITM-10322129","CDM","C1713","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3634.77","38.3","","279.30","91.72","1116.77","266","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 TRIATHLON REVISION","SUP-ITM-10322129","CDM","C1713","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4071.32","42.9","","731.00","63.70","731.00","1 through 10","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 TRIATHLON REVISION","SUP-ITM-10322129","CDM","C1713","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4071.32","42.9","","384.74","384.74","384.74","1 through 10","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 TRIATHLON REVISION","SUP-ITM-10322129","CDM","C1713","HCPCS","0278","RC","","","","both","","","9490.25","7117.69","WELLPOINT [1015]","HB AMC WELLPOINT","7001.91","73.78","","286.63","119.22","1107.45","105","2941.98","7544.75","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 TRIATHLON REVISION","SUP-ITM-10322129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9490.25","7117.69","AETNA [1001]","HB AMC AETNA HMO","6624.19","69.8","","675.31","184.75","1721.50","286","4959.6","7755.43","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 TRIATHLON REVISION","SUP-ITM-10322129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9490.25","7117.69","AETNA [1001]","HB AMC AETNA PPO","7630.16","80.4","","1261.44","103.12","1514.10","21","4959.6","7755.43","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 TRIATHLON REVISION","SUP-ITM-10322129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9490.25","7117.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7630.16","80.4","","1365.00","1365.00","1365.00","1 through 10","4959.6","7755.43","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 TRIATHLON REVISION","SUP-ITM-10322129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9490.25","7117.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7755.43","81.72","","5157.68","5157.68","5157.68","1 through 10","4959.6","7755.43","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 6 TRIATHLON REVISION","SUP-ITM-10322129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9490.25","7117.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7755.43","81.72","","431.26","71.26","1459.57","88","4959.6","7755.43","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0300","RC","","","","inpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","115.56","78.61","","60.20","60.20","60.20","1 through 10","81.29","116.87","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","105.55","71.8","","102.67","9.34","102.67","27","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","96.43","65.6","","96.81","68.35","96.81","11","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","95.55","65","","75.50","75.50","112.54","1 through 10","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","102.90","70","","143.00","102.96","143.00","41","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","CHAMPVA [160001]","HB BWH TRICARE","139.65","95","","10.19","10.19","10.19","1 through 10","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.87","79.5","","112.54","75.50","199.58","1191","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.35","53.3","","75.50","75.50","226.50","771","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","113.19","77","","110.11","110.11","110.11","11","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","95.55","65","","92.95","75.79","92.95","18","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","116.87","79.5","","112.54","112.54","112.54","1 through 10","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","95.55","65","","1000.00","143.00","1000.00","1 through 10","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","105.84","72","","102.96","102.96","102.96","1 through 10","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.57","31","","44.19","44.19","132.57","59","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.66","36.5","","53.34","45.33","160.02","1341","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.30","38.3","","55.91","55.91","167.73","4078","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","MOLINA [1014]","HB BWH MOLINA","51.45","35","","16.78","16.78","25.10","23","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","113.19","77","","111.53","8.29","112.54","17","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","TRICARE [160005]","HB BWH TRICARE","139.65","95","","9.68","9.68","143.00","34","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","139.65","95","","8.46","8.46","8.46","1 through 10","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.06","42.9","","114.31","62.88","114.31","58","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","147.00","110.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.06","42.9","","62.88","62.88","188.64","14","8.29","139.65","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA HMO","102.61","69.8","","96.81","68.35","111.54","1678","8.73","120.13","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA PPO","118.19","80.4","","111.54","74.93","111.54","171","8.73","120.13","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","82.17","55.9","","74.93","74.93","74.93","1 through 10","8.73","120.13","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","147.00","110.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","76.82","52.26","","88.49","8.44","88.49","20","8.73","120.13","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","118.19","80.4","","111.54","103.30","111.54","1 through 10","8.73","120.13","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","120.13","81.72","","114.31","105.50","143.00","12","8.73","120.13","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","120.13","81.72","","62.88","62.88","125.76","74","8.73","120.13","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","120.13","81.72","","114.31","62.88","114.31","1121","8.73","120.13","percent of total billed charges",""
"Basilica Procedure","PX-48000496","CDM","93799","CPT","0481","RC","","","","both","","","2530.00","1897.50","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","2011.35","other","OPPS APC"
"Basilica Procedure","PX-48000496","CDM","93799","CPT","0481","RC","","","","outpatient","","","2530.00","1897.50","AETNA [1001]","HB AMC AETNA HMO","1765.94","69.8","","2022.70","2022.70","2022.70","1 through 10","454","2087.25","percent of total billed charges",""
"Basilica Procedure","PX-48000496","CDM","93799","CPT","0481","RC","","","","outpatient","","","2530.00","1897.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1531.92","60.55","","318.03","318.03","2439.77","1 through 10","454","2087.25","percent of total billed charges",""
"Basilica Procedure","PX-48000496","CDM","93799","CPT","0481","RC","","","","outpatient","","","2530.00","1897.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1321.17","52.22","","360.38","360.38","4023.00","1 through 10","454","2087.25","percent of total billed charges",""
"Basilica Procedure","PX-48000496","CDM","93799","CPT","0481","RC","","","","outpatient","","","2530.00","1897.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1391.50","55","","13080.03","13080.03","13080.03","1 through 10","454","2087.25","percent of total billed charges",""
"Basivertebral Nerve Destruction Lumbar Two Bodies","PX-76002685","CDM","64628","CPT","0761","RC","","","","both","","","3576.00","2682.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","15278.58","","APC Price ($15,278.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","14134.53","14134.53","14134.53","1 through 10","1108.56","19098.22","other","OPPS APC"
"Basivertebral Nerve Destruction Lumbar Two Bodies","PX-76002685","CDM","64628","CPT","0761","RC","","","","both","","","3576.00","2682.00","MEDICARE [2001]","HB BWH MEDICARE","15278.58","","APC Price ($15,278.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","15280.12","14364.36","15280.12","1 through 10","1108.56","19098.22","other","OPPS APC"
"Basivertebral Nerve Destruction Lumbar Two Bodies","PX-76002685","CDM","64628","CPT","0761","RC","","","","both","","","3576.00","2682.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1369.61","38.3","","11702.43","11702.43","11702.43","1 through 10","1108.56","19098.22","percent of total billed charges",""
"Basivertebral Nerve Destruction Lumbar Two Bodies","PX-76002685","CDM","64628","CPT","0761","RC","","","","both","","","3576.00","2682.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14973.01","","APC Price ($15,278.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","14982.02","14982.02","14982.02","1 through 10","1108.56","19098.22","other","OPPS APC"
"Basivertebral Nerve Destruction Lumbar Two Bodies","PX-76002685","CDM","64628","CPT","0761","RC","","","","outpatient","","","3576.00","2682.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","13524.18","","Case rate ($13,524.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","27170.08","27170.08","27170.08","1 through 10","1868.82","15696.44","other","ASC"
"Basivertebral Nerve Destruction Lumbar Two Bodies","PX-76002685","CDM","64628","CPT","0761","RC","","","","outpatient","","","3576.00","2682.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","13524.18","","Case rate ($13,524.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","31660.11","31660.11","31660.11","1 through 10","1868.82","15696.44","other","ASC "
"Bc4830 Comprehensive Platelet Disorder Panel","PX-31001331","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Bc4830 Comprehensive Platelet Disorder Panel Bc4830","PX-31001378","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Bcmed, B8665 Comprehensive Cma High Res & Cma Snp Single Nucleotide Polymorphism","PX-31001268","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2946.27","79.5","","2828.48","1814.97","2828.48","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Bcmed, B8665 Comprehensive Cma High Res & Cma Snp Single Nucleotide Polymorphism","PX-31001268","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1975.30","53.3","","1814.97","1761.95","1814.97","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Bcmed, B8665 Comprehensive Cma High Res & Cma Snp Single Nucleotide Polymorphism","PX-31001268","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1352.69","36.5","","1340.56","1340.56","1340.56","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Bcmed, B8665 Comprehensive Cma High Res & Cma Snp Single Nucleotide Polymorphism","PX-31001268","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1419.40","38.3","","1405.25","1405.25","1405.25","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Bcmed, B8665 Comprehensive Cma High Res & Cma Snp Single Nucleotide Polymorphism","PX-31001268","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","WELLPOINT [1015]","HB AMC WELLPOINT","2734.29","73.78","","6269.73","2675.73","7188.00","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Bcmed, B8665 Comprehensive Cma High Res & Cma Snp Single Nucleotide Polymorphism","PX-31001268","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","AETNA [1001]","HB AMC AETNA HMO","2586.79","69.8","","2433.14","2433.14","2433.14","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Bcmed, B8665 Comprehensive Cma High Res & Cma Snp Single Nucleotide Polymorphism","PX-31001268","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2979.62","80.4","","2803.32","2803.32","2803.32","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Bcmed, B8665 Comprehensive Cma High Res & Cma Snp Single Nucleotide Polymorphism","PX-31001268","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3028.54","81.72","","2873.04","1533.07","3526.61","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Bcw 4835 Platelet Function Disorder Panel Bc4835","PX-31001332","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Bcw Weak Rhd Analysis Bc3040","PX-31001172","CDM","81479","CPT","0310","RC","","","","both","","","833.00","624.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","662.24","79.5","","0.65","0.65","0.65","1 through 10","258.23","791.35","percent of total billed charges",""
"Bcw Weak Rhd Analysis Bc3040","PX-31001172","CDM","81479","CPT","0310","RC","","","","both","","","833.00","624.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","443.99","53.3","","0.79","0.79","0.79","1 through 10","258.23","791.35","percent of total billed charges",""
"Bcw Weak Rhd Analysis Bc3040","PX-31001172","CDM","81479","CPT","0310","RC","","","","outpatient","","","833.00","624.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","416.50","50","","1.00","1.00","1.00","1 through 10","156.55","687.23","percent of total billed charges",""
"Bcw Weak Rhd Analysis Bc3040","PX-31001172","CDM","81479","CPT","0310","RC","","","","outpatient","","","833.00","624.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","437.33","52.5","","1.00","0.53","1.00","1 through 10","156.55","687.23","percent of total billed charges",""
"Bcw, Bcw 1402 Factor VIII Inversion Introns 1 and 22 F8 Deficiency Hemophilia a F8122 Bcw1402","PX-31001308","CDM","81403","CPT","0310","RC","","","","outpatient","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","864.60","81.72","","820.18","820.18","820.18","1 through 10","512.07","1135.28","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML 70-150MICROLITER PAPARTICLE 70TO LC HYPERVASCULAR TUMORS ARTERIOVENOUS MALFORMATION","SUP-ITM-10113984","CDM","C1889","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4968.75","79.5","","1309.77","674.56","6049.93","26","1937.5","4968.75","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML 70-150MICROLITER PAPARTICLE 70TO LC HYPERVASCULAR TUMORS ARTERIOVENOUS MALFORMATION","SUP-ITM-10113984","CDM","C1889","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3331.25","53.3","","1901.83","1901.83","2962.25","1 through 10","1937.5","4968.75","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML 70-150MICROLITER PAPARTICLE 70TO LC HYPERVASCULAR TUMORS ARTERIOVENOUS MALFORMATION","SUP-ITM-10113984","CDM","C1889","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.25","36.5","","1620.31","1620.31","19908.88","1 through 10","1937.5","4968.75","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML 70-150MICROLITER PAPARTICLE 70TO LC HYPERVASCULAR TUMORS ARTERIOVENOUS MALFORMATION","SUP-ITM-10113984","CDM","C1889","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2393.75","38.3","","352.91","352.91","2046.30","1 through 10","1937.5","4968.75","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML 70-150MICROLITER PAPARTICLE 70TO LC HYPERVASCULAR TUMORS ARTERIOVENOUS MALFORMATION","SUP-ITM-10113984","CDM","C1889","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.25","42.9","","9668.75","9668.75","9668.75","1 through 10","1937.5","4968.75","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML 70-150MICROLITER PAPARTICLE 70TO LC HYPERVASCULAR TUMORS ARTERIOVENOUS MALFORMATION","SUP-ITM-10113984","CDM","C1889","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","WELLPOINT [1015]","HB AMC WELLPOINT","4611.25","73.78","","699.88","384.10","3443.31","33","1937.5","4968.75","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML 70-150MICROLITER PAPARTICLE 70TO LC HYPERVASCULAR TUMORS ARTERIOVENOUS MALFORMATION","SUP-ITM-10113984","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","AETNA [1001]","HB AMC AETNA HMO","4362.50","69.8","","1421.24","264.50","4933.46","29","3266.25","5107.5","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML 70-150MICROLITER PAPARTICLE 70TO LC HYPERVASCULAR TUMORS ARTERIOVENOUS MALFORMATION","SUP-ITM-10113984","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5025.00","80.4","","1022.97","1022.97","3607.50","1 through 10","3266.25","5107.5","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML 70-150MICROLITER PAPARTICLE 70TO LC HYPERVASCULAR TUMORS ARTERIOVENOUS MALFORMATION","SUP-ITM-10113984","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5107.50","81.72","","3010.54","693.88","5019.88","35","3266.25","5107.5","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML SPHERE 100TO PREFORMED DEFORMABLE BIOCOMPATIBLE SULFONATE MODIFIED LC HYPERV","SUP-ITM-10091745","CDM","C1889","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4054.50","79.5","","1309.77","674.56","6049.93","26","1581","4054.5","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML SPHERE 100TO PREFORMED DEFORMABLE BIOCOMPATIBLE SULFONATE MODIFIED LC HYPERV","SUP-ITM-10091745","CDM","C1889","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2718.30","53.3","","1901.83","1901.83","2962.25","1 through 10","1581","4054.5","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML SPHERE 100TO PREFORMED DEFORMABLE BIOCOMPATIBLE SULFONATE MODIFIED LC HYPERV","SUP-ITM-10091745","CDM","C1889","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1861.50","36.5","","1620.31","1620.31","19908.88","1 through 10","1581","4054.5","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML SPHERE 100TO PREFORMED DEFORMABLE BIOCOMPATIBLE SULFONATE MODIFIED LC HYPERV","SUP-ITM-10091745","CDM","C1889","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1953.30","38.3","","352.91","352.91","2046.30","1 through 10","1581","4054.5","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML SPHERE 100TO PREFORMED DEFORMABLE BIOCOMPATIBLE SULFONATE MODIFIED LC HYPERV","SUP-ITM-10091745","CDM","C1889","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2187.90","42.9","","9668.75","9668.75","9668.75","1 through 10","1581","4054.5","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML SPHERE 100TO PREFORMED DEFORMABLE BIOCOMPATIBLE SULFONATE MODIFIED LC HYPERV","SUP-ITM-10091745","CDM","C1889","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","WELLPOINT [1015]","HB AMC WELLPOINT","3762.78","73.78","","699.88","384.10","3443.31","33","1581","4054.5","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML SPHERE 100TO PREFORMED DEFORMABLE BIOCOMPATIBLE SULFONATE MODIFIED LC HYPERV","SUP-ITM-10091745","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","AETNA [1001]","HB AMC AETNA HMO","3559.80","69.8","","1421.24","264.50","4933.46","29","2665.26","4167.72","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML SPHERE 100TO PREFORMED DEFORMABLE BIOCOMPATIBLE SULFONATE MODIFIED LC HYPERV","SUP-ITM-10091745","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4100.40","80.4","","1022.97","1022.97","3607.50","1 through 10","2665.26","4167.72","percent of total billed charges",""
"BEAD EMBOLIZATION 2ML SPHERE 100TO PREFORMED DEFORMABLE BIOCOMPATIBLE SULFONATE MODIFIED LC HYPERV","SUP-ITM-10091745","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4167.72","81.72","","3010.54","693.88","5019.88","35","2665.26","4167.72","percent of total billed charges",""
"Behav Assmt W/Score & Docd/Stand Instrument","PX-76002087","CDM","96127","CPT","0918","RC","","","","both","","","40.00","30.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","31.80","79.5","","23.00","23.00","23.00","1 through 10","12.4","58.26","percent of total billed charges",""
"Behav Assmt W/Score & Docd/Stand Instrument","PX-76002087","CDM","96127","CPT","0918","RC","","","","both","","","40.00","30.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14.60","36.5","","23.00","23.00","46.00","1 through 10","12.4","58.26","percent of total billed charges",""
"Behav Assmt W/Score & Docd/Stand Instrument","PX-76002087","CDM","96127","CPT","0918","RC","","","","both","","","40.00","30.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17.16","42.9","","10.11","10.11","10.11","1 through 10","12.4","58.26","percent of total billed charges",""
"Behav Assmt W/Score & Docd/Stand Instrument","PX-76002087","CDM","96127","CPT","0918","RC","","","","outpatient","","","40.00","30.00","AETNA [1001]","HB AMC AETNA HMO","27.92","69.8","","10.99","10.99","10.99","1 through 10","20.9","254.28","percent of total billed charges",""
"Behav Assmt W/Score & Docd/Stand Instrument","PX-98300805","CDM","96127","CPT","0983","RC","","","","both","","","24.00","18.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","19.08","79.5","","23.00","23.00","23.00","1 through 10","7.44","58.26","percent of total billed charges",""
"Behav Assmt W/Score & Docd/Stand Instrument","PX-98300805","CDM","96127","CPT","0983","RC","","","","both","","","24.00","18.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.76","36.5","","23.00","23.00","46.00","1 through 10","7.44","58.26","percent of total billed charges",""
"Behav Assmt W/Score & Docd/Stand Instrument","PX-98300805","CDM","96127","CPT","0983","RC","","","","both","","","24.00","18.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.30","42.9","","10.11","10.11","10.11","1 through 10","7.44","58.26","percent of total billed charges",""
"Behav Assmt W/Score & Docd/Stand Instrument","PX-98300805","CDM","96127","CPT","0983","RC","","","","outpatient","","","24.00","18.00","AETNA [1001]","HB AMC AETNA HMO","16.75","69.8","","10.99","10.99","10.99","1 through 10","13.42","254.28","percent of total billed charges",""
"Behavral Qualit Analys Voice","PX-44000061","CDM","92524","CPT","0444","RC","","","","both","","","733.00","549.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","390.69","53.3","","559.56","559.56","559.56","1 through 10","115.31","696.35","percent of total billed charges",""
"Behavral Qualit Analys Voice","PX-44000061","CDM","92524","CPT","0444","RC","","","","both","","","733.00","549.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","115.31","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($117.66). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($91.91). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","117.66","115.91","117.66","1 through 10","115.31","696.35","fee schedule",""
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4.00","","APC Price ($3.89). Final payment is multiplied by 103%.","4.05","3.92","4.05","1200","3.7","11.55","other","OPPS APC"
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3.89","","APC Price ($3.89).","3.83","3.83","3.87","7151","3.7","11.55","other","OPPS APC"
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","10.77","71.8","","11.25","11.23","11.25","3976","3.7","11.55","percent of total billed charges",""
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","9.75","65","","10.84","10.84","10.84","288","3.7","11.55","percent of total billed charges",""
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","10.50","70","","11.02","11.02","11.02","463","3.7","11.55","percent of total billed charges",""
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","4.86","","APC Price ($3.89). Final payment is multiplied by 125%.","3.83","3.83","3.83","313","3.7","11.55","other","OPPS APC"
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3.89","","APC Price ($3.89).","3.83","3.83","3.87","4140","3.7","11.55","other","OPPS APC"
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","MEDICARE [2001]","HB BWH MEDICARE","3.89","","APC Price ($3.89).","3.89","3.89","3.93","107967","3.7","11.55","other","OPPS APC"
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4.65","31","","4.84","4.84","4.84","300","3.7","11.55","percent of total billed charges",""
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5.48","36.5","","5.84","4.97","5.84","8895","3.7","11.55","percent of total billed charges",""
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5.75","38.3","","6.12","5.95","6.12","13362","3.7","11.55","percent of total billed charges",""
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","3.89","","APC Price ($3.89).","3.83","3.81","3.87","2250","3.7","11.55","other","OPPS APC"
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","TRICARE [160005]","HB BWH TRICARE","3.70","","APC Price ($3.89). Final payment is multiplied by 95%.","972.50","972.50","972.50","1 through 10","3.7","11.55","other","Tricare OPPS"
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","3.81","","APC Price ($3.89). Final payment is multiplied by 98%.","3.83","3.75","3.87","7718","3.7","11.55","other","OPPS APC"
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","both","","","15.00","11.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3.81","","APC Price ($3.89). Final payment is multiplied by 98%.","7.66","7.47","7.73","8589","3.7","11.55","other","OPPS APC"
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","outpatient","","","15.00","11.25","AETNA [1001]","HB AMC AETNA HMO","10.47","69.8","","7.49","7.49","10.59","7202","5.24","12.06","percent of total billed charges",""
"Belatacept Vl 1mg","PX-63600053","CDM","J0485","HCPCS","0636","RC","","","","outpatient","","","15.00","11.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10.49","69.9","","10.85","10.84","10.85","1838","5.24","12.06","percent of total billed charges",""
"Belimumab Vl 10mg","PX-63600068","CDM","J0490","HCPCS","0636","RC","","","","both","","","156.95","117.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.65","31","","68.10","68.10","68.10","1 through 10","48.65","127.47","percent of total billed charges",""
"Belimumab Vl 10mg","PX-63600068","CDM","J0490","HCPCS","0636","RC","","","","both","","","156.95","117.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.29","36.5","","71.26","71.26","71.26","192","48.65","127.47","percent of total billed charges",""
"Belimumab Vl 10mg","PX-63600068","CDM","J0490","HCPCS","0636","RC","","","","both","","","156.95","117.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.11","38.3","","165.45","87.06","166.92","884","48.65","127.47","percent of total billed charges",""
"Belimumab Vl 10mg","PX-63600068","CDM","J0490","HCPCS","0636","RC","","","","both","","","156.95","117.71","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","54.95","","APC Price ($56.07). Final payment is multiplied by 98%.","108.18","54.03","164.66","696","48.65","127.47","other","OPPS APC"
"Belimumab Vl 10mg","PX-63600068","CDM","J0490","HCPCS","0636","RC","","","","outpatient","","","156.95","117.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","109.71","69.9","","464.54","153.39","464.54","253","63.23","126.19","percent of total billed charges",""
"Benign Prostatic Hypertrophy Without McC","726","MS-DRG","","","","","","","","inpatient","","","49650.28","37237.71","MEDICARE [2001]","HB BWH MEDICARE","6966.00","","Case rate ($6,966). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,308.27, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,021.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,005.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,928.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.96. The transfer capital threshold is the transfer adjustment factor * $580.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9054.13","9054.13","9067.24","1 through 10","6826.68","11309.41","other","Inpatient Replacement Plans DRG"
"Benign Prostatic Hypertrophy Without McC","726","MS-DRG","","","","","","","","inpatient","","","49650.28","37237.71","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6826.68","","Case rate ($6,966). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,308.27, add-ons for qualifying new technology services are included. If operating cost exceeds $53,952.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,021.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,005.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,928.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.96. The transfer capital threshold is the transfer adjustment factor * $580.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6942.37","6942.37","6942.37","1 through 10","6826.68","11309.41","other","Inpatient DRG"
"Berlotti Pseudoarticulation Joint Inj, Uni W/Img","PX-76002835","CDM","20999","CPT","0761","RC","","","","outpatient","","","331.00","248.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","172.85","52.22","","596.65","596.65","596.65","1 through 10","165.5","8899.59","percent of total billed charges",""
"Berlotti Pseudoarticulation Joint Inj, Uni W/Img","PX-76002835","CDM","20999","CPT","0761","RC","","","","outpatient","","","331.00","248.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","173.78","52.5","","1695.17","1695.17","1695.17","1 through 10","165.5","8899.59","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","both","","","204.00","153.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","142.80","70","","198.00","87.06","198.00","1 through 10","14.19","193.8","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","both","","","204.00","153.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","162.18","79.5","","155.83","104.55","467.48","67","14.19","193.8","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","both","","","204.00","153.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","108.73","53.3","","155.83","104.55","467.48","54","14.19","193.8","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","both","","","204.00","153.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","157.08","77","","457.38","457.38","457.38","1 through 10","14.19","193.8","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","both","","","204.00","153.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","132.60","65","","128.70","128.70","274.30","1 through 10","14.19","193.8","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","both","","","204.00","153.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.46","36.5","","73.86","62.77","516.99","83","14.19","193.8","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","both","","","204.00","153.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.13","38.3","","77.42","77.42","232.26","177","14.19","193.8","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","both","","","204.00","153.00","TRICARE [160005]","HB BWH TRICARE","193.80","95","","61.34","61.34","61.34","1 through 10","14.19","193.8","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","both","","","204.00","153.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","193.80","95","","25.45","25.45","25.45","1 through 10","14.19","193.8","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","both","","","204.00","153.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.52","42.9","","158.28","158.28","158.28","1 through 10","14.19","193.8","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","204.00","153.00","AETNA [1001]","HB AMC AETNA HMO","142.39","69.8","","134.05","94.65","154.44","63","14.19","173.36","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","204.00","153.00","AETNA [1001]","HB AMC AETNA PPO","164.02","80.4","","154.44","103.75","207.50","1 through 10","14.19","173.36","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","204.00","153.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","164.02","80.4","","198.00","198.00","198.00","1 through 10","14.19","173.36","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","204.00","153.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","166.71","81.72","","396.00","396.00","396.00","1 through 10","14.19","173.36","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","204.00","153.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","166.71","81.72","","87.06","87.06","87.06","1 through 10","14.19","173.36","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","204.00","153.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","166.71","81.72","","158.28","87.06","316.56","52","14.19","173.36","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","both","","","196.00","147.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","137.20","70","","136.80","136.80","136.80","1 through 10","15.86","186.2","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","both","","","196.00","147.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","155.82","79.5","","149.53","100.32","149.53","1 through 10","15.86","186.2","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","both","","","196.00","147.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","104.47","53.3","","448.59","149.53","448.59","1 through 10","15.86","186.2","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.54","36.5","","60.23","60.23","60.23","1 through 10","15.86","186.2","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.07","38.3","","222.87","62.70","222.87","1 through 10","15.86","186.2","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","outpatient","","","196.00","147.00","AETNA [1001]","HB AMC AETNA HMO","136.81","69.8","","148.20","90.82","148.20","1 through 10","16.68","160.17","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","outpatient","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","160.17","81.72","","151.89","151.89","151.89","1 through 10","16.68","160.17","percent of total billed charges",""
"Beta-Amyloid 1-42 (Abeta 42)","PX-30003838","CDM","82234","CPT","0301","RC","","","","both","","","424.00","318.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","337.08","79.5","","970.38","970.38","970.38","1 through 10","131.44","402.8","percent of total billed charges",""
"Beta-Amyloid 1-42 (Abeta 42)","PX-30003838","CDM","82234","CPT","0301","RC","","","","outpatient","","","424.00","318.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","265.00","62.5","","267.15","267.15","267.15","1 through 10","169.6","349.8","percent of total billed charges",""
"Betameth Na Phos/Acet Inj 3mg/3mg","PX-63600079","CDM","J0702","HCPCS","0636","RC","","","","both","","","13.69","10.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5.00","36.5","","10.80","10.80","10.80","1 through 10","4.24","15.71","percent of total billed charges",""
"Betameth Na Phos/Acet Inj 3mg/3mg","PX-63600079","CDM","J0702","HCPCS","0636","RC","","","","both","","","13.69","10.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5.24","38.3","","12.41","11.09","39.96","80","4.24","15.71","percent of total billed charges",""
"Betameth Na Phos/Acet Inj 3mg/3mg","PX-63600079","CDM","J0702","HCPCS","0636","RC","","","","outpatient","","","13.69","10.27","AETNA [1001]","HB AMC AETNA HMO","9.56","69.8","","22.90","20.01","26.32","43","6.42","14.81","percent of total billed charges",""
"Betameth Na Phos/Acet Inj 3mg/3mg","PX-63600079","CDM","J0702","HCPCS","0636","RC","","","","outpatient","","","13.69","10.27","AETNA [1001]","HB AMC AETNA PPO","11.01","80.4","","26.57","22.61","26.57","17","6.42","14.81","percent of total billed charges",""
"Betameth Na Phos/Acet Inj 3mg/3mg","PX-63600079","CDM","J0702","HCPCS","0636","RC","","","","outpatient","","","13.69","10.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9.57","69.9","","19.95","15.65","20.57","44","6.42","14.81","percent of total billed charges",""
"Betameth Na Phos/Acet Inj 3mg/3mg","PX-63600079","CDM","J0702","HCPCS","0636","RC","","","","outpatient","","","13.69","10.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6.42","46.9","","19.95","13.45","20.22","18","6.42","14.81","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","both","","","1727.00","1295.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1372.97","other","OPPS APC"
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","both","","","1727.00","1295.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1372.97","other","OPPS APC"
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","both","","","1727.00","1295.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","920.49","53.3","","477.31","477.31","477.31","1 through 10","333.03","1372.97","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","both","","","1727.00","1295.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1372.97","other","OPPS APC"
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","both","","","1727.00","1295.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1372.97","other","OPPS APC"
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","both","","","1727.00","1295.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","630.36","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1372.97","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","both","","","1727.00","1295.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","661.44","38.3","","343.52","323.76","353.46","1 through 10","333.03","1372.97","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","both","","","1727.00","1295.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1372.97","other","Tricare OPPS"
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","both","","","1727.00","1295.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1372.97","other","OPPS APC"
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","both","","","1727.00","1295.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1372.97","other","OPPS APC"
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","both","","","1727.00","1295.25","WELLPOINT [1015]","HB AMC WELLPOINT","1274.18","73.78","","673.03","673.03","673.03","1 through 10","333.03","1372.97","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","outpatient","","","1727.00","1295.25","AETNA [1001]","HB AMC AETNA HMO","1205.45","69.8","","612.01","612.01","1224.02","1 through 10","700.33","1424.78","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","outpatient","","","1727.00","1295.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1045.70","60.55","","579.04","568.57","904.00","30","700.33","1424.78","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","outpatient","","","1727.00","1295.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","901.84","52.22","","904.00","656.02","2938.00","26","700.33","1424.78","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","outpatient","","","1727.00","1295.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","863.50","50","","1421.10","875.08","2368.50","15","700.33","1424.78","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","outpatient","","","1727.00","1295.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","906.68","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","1424.78","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","outpatient","","","1727.00","1295.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1411.30","81.72","","722.66","722.66","17449.00","1 through 10","700.33","1424.78","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","931.74","other","OPPS APC"
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","931.74","other","OPPS APC"
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","624.68","53.3","","477.31","477.31","477.31","1 through 10","333.03","931.74","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","931.74","other","OPPS APC"
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","931.74","other","OPPS APC"
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","427.78","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","931.74","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","448.88","38.3","","343.52","323.76","353.46","1 through 10","333.03","931.74","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","931.74","other","Tricare OPPS"
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","931.74","other","OPPS APC"
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","931.74","other","OPPS APC"
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","WELLPOINT [1015]","HB AMC WELLPOINT","864.70","73.78","","673.03","673.03","673.03","1 through 10","333.03","931.74","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","outpatient","","","1172.00","879.00","AETNA [1001]","HB AMC AETNA HMO","818.06","69.8","","612.01","612.01","1224.02","1 through 10","586","966.9","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","outpatient","","","1172.00","879.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","709.65","60.55","","579.04","568.57","904.00","30","586","966.9","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","outpatient","","","1172.00","879.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","612.02","52.22","","904.00","656.02","2938.00","26","586","966.9","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","outpatient","","","1172.00","879.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","586.00","50","","1421.10","875.08","2368.50","15","586","966.9","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","outpatient","","","1172.00","879.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","615.30","52.5","","2985.00","904.00","2985.00","1 through 10","586","966.9","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","outpatient","","","1172.00","879.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","957.76","81.72","","722.66","722.66","17449.00","1 through 10","586","966.9","percent of total billed charges",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without McC","462","MS-DRG","","","","","","","","inpatient","","","142742.60","107056.95","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","24644.66","","Case rate ($24,644.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $29,589.88, add-ons for qualifying new technology services are included. If operating cost exceeds $75,234.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,580.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $22,124.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,210.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.39. The transfer capital threshold is the transfer adjustment factor * $2,140.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","35242.03","35242.03","35242.03","1 through 10","24151.77","41666.24","other","Inpatient Replacement Plans DRG"
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without McC","462","MS-DRG","","","","","","","","inpatient","","","142742.60","107056.95","MEDICARE [2001]","HB BWH MEDICARE","24644.66","","Case rate ($24,644.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $29,589.88, add-ons for qualifying new technology services are included. If operating cost exceeds $75,234.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,580.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $22,124.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,210.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,140.39. The transfer capital threshold is the transfer adjustment factor * $2,140.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","34090.56","34090.56","34090.56","1 through 10","24151.77","41666.24","other","Inpatient Replacement Plans DRG"
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","both","","","205.00","153.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","162.98","79.5","","105.07","105.07","156.61","12","16.78","194.75","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","both","","","205.00","153.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.27","53.3","","156.61","105.07","315.21","1 through 10","16.78","194.75","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.83","36.5","","63.08","63.08","74.23","1 through 10","16.78","194.75","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.52","38.3","","77.81","77.81","77.81","30","16.78","194.75","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","both","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.95","42.9","","159.08","159.08","159.08","1 through 10","16.78","194.75","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","both","","","205.00","153.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.95","42.9","","87.50","87.50","87.50","1 through 10","16.78","194.75","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","outpatient","","","205.00","153.75","AETNA [1001]","HB AMC AETNA HMO","143.09","69.8","","134.72","95.12","134.72","1 through 10","17.66","167.53","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","outpatient","","","205.00","153.75","AETNA [1001]","HB AMC AETNA PPO","164.82","80.4","","155.22","155.22","155.22","1 through 10","17.66","167.53","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","167.53","81.72","","87.50","87.50","87.50","1 through 10","17.66","167.53","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","167.53","81.72","","159.08","87.50","159.08","21","17.66","167.53","percent of total billed charges",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","","","","inpatient","","","97471.86","73103.89","MEDICARE [2001]","HB BWH MEDICARE","20241.41","","Case rate ($20,241.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,289.24, add-ons for qualifying new technology services are included. If operating cost exceeds $69,933.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,192.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $18,109.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,909.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,751.98. The transfer capital threshold is the transfer adjustment factor * $1,751.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25031.22","25031.22","25031.22","1 through 10","19836.58","31638.2815","other","Inpatient Replacement Plans DRG"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","","","","inpatient","","","97471.86","73103.89","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19836.58","","Case rate ($20,241.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,289.24, add-ons for qualifying new technology services are included. If operating cost exceeds $69,933.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,192.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $18,109.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,909.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,751.98. The transfer capital threshold is the transfer adjustment factor * $1,751.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18987.09","18987.09","18987.09","1 through 10","19836.58","31638.2815","other","Inpatient DRG"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With McC","408","MS-DRG","","","","","","","","inpatient","","","93184.73","69888.55","MEDICARE [2001]","HB BWH MEDICARE","32905.63","","Case rate ($32,905.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,534.47, add-ons for qualifying new technology services are included. If operating cost exceeds $85,178.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,309.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $29,656.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,154.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,869.09. The transfer capital threshold is the transfer adjustment factor * $2,869.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","41555.65","41555.65","41555.65","1 through 10","32247.52","52838.1183","other","Inpatient Replacement Plans DRG"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With McC","408","MS-DRG","","","","","","","","inpatient","","","93184.73","69888.55","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","32247.52","","Case rate ($32,905.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,534.47, add-ons for qualifying new technology services are included. If operating cost exceeds $85,178.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,309.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $29,656.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,154.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,869.09. The transfer capital threshold is the transfer adjustment factor * $2,869.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","132286.40","132286.40","132286.40","1 through 10","32247.52","52838.1183","other","Inpatient DRG"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/McC","410","MS-DRG","","","","","","","","inpatient","","","32321.00","24240.75","MEDICARE [2001]","HB BWH MEDICARE","19176.49","","Case rate ($19,176.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,814.71, add-ons for qualifying new technology services are included. If operating cost exceeds $63,459.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,717.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $17,519.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,434.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,277.56. The transfer capital threshold is the transfer adjustment factor * $1,277.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","14565.74","23407.6501","other","Inpatient DRG"
"Biliary Tract Unlstd Proc","PX-75000343","CDM","47999","CPT","0361","RC","","","","both","","","2451.00","1838.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","759.81","1948.55","other","OPPS APC"
"Biliary Tract Unlstd Proc","PX-75000343","CDM","47999","CPT","0361","RC","","","","both","","","2451.00","1838.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","759.81","1948.55","other","OPPS APC"
"Biliary Tract Unlstd Proc","PX-75000343","CDM","47999","CPT","0361","RC","","","","outpatient","","","2451.00","1838.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1279.91","52.22","","3734.00","1019.30","3734.00","1 through 10","1225.5","9843.6","percent of total billed charges",""
"Biliary-Venous Fistula Embolization","PX-76002515","CDM","47999","CPT","0761","RC","","","","both","","","2882.00","2161.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","893.42","2291.19","other","OPPS APC"
"Biliary-Venous Fistula Embolization","PX-76002515","CDM","47999","CPT","0761","RC","","","","both","","","2882.00","2161.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","893.42","2291.19","other","OPPS APC"
"Biliary-Venous Fistula Embolization","PX-76002515","CDM","47999","CPT","0761","RC","","","","outpatient","","","2882.00","2161.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1504.98","52.22","","3734.00","1019.30","3734.00","1 through 10","1441","9843.6","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","54.57","71.8","","159.39","29.72","159.39","23","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","49.86","65.6","","50.10","50.10","50.10","1 through 10","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","49.40","65","","48.10","48.10","48.10","11","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","53.20","70","","74.00","74.00","159.84","1 through 10","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","60.42","79.5","","58.24","39.07","58.24","67","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","40.51","53.3","","39.07","39.07","58.24","40","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","58.52","77","","120.12","56.98","120.12","1 through 10","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","49.40","65","","48.10","48.10","50.70","1 through 10","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","23.56","31","","22.87","22.87","22.87","1 through 10","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.74","36.5","","27.60","23.46","53.13","70","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.11","38.3","","28.93","28.12","86.79","212","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","MOLINA [1014]","HB BWH MOLINA","26.60","35","","9.96","9.96","9.96","1 through 10","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","58.52","77","","57.72","57.72","57.72","1 through 10","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","TRICARE [160005]","HB BWH TRICARE","72.20","95","","6.05","5.75","6.05","1 through 10","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","72.20","95","","5.02","5.02","5.02","1 through 10","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.60","42.9","","32.54","32.54","59.16","1 through 10","4.92","72.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","76.00","57.00","AETNA [1001]","HB AMC AETNA HMO","53.05","69.8","","50.10","35.37","57.72","111","5.18","62.11","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","76.00","57.00","AETNA [1001]","HB AMC AETNA PPO","61.10","80.4","","57.72","38.78","57.72","11","5.18","62.11","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","76.00","57.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","61.10","80.4","","37.00","37.00","37.00","1 through 10","5.18","62.11","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","62.11","81.72","","32.54","32.54","32.54","1 through 10","5.18","62.11","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","62.11","81.72","","59.16","32.54","59.16","56","5.18","62.11","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","101.00","75.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","72.52","71.8","","211.08","70.36","211.08","17","4.92","95.95","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","101.00","75.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","66.26","65.6","","76.44","66.35","76.44","1 through 10","4.92","95.95","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","101.00","75.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","70.70","70","","98.00","98.00","98.00","1 through 10","4.92","95.95","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","101.00","75.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","80.30","79.5","","77.13","77.13","77.13","25","4.92","95.95","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","101.00","75.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","53.83","53.3","","51.74","49.49","51.74","1 through 10","4.92","95.95","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","101.00","75.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","65.65","65","","63.70","63.05","63.70","1 through 10","4.92","95.95","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","101.00","75.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36.87","36.5","","36.55","31.07","36.55","13","4.92","95.95","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","101.00","75.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38.68","38.3","","38.32","37.24","211.08","59","4.92","95.95","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","101.00","75.75","TRICARE [160005]","HB BWH TRICARE","95.95","95","","5.75","5.75","6.05","1 through 10","4.92","95.95","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","101.00","75.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","95.95","95","","5.02","5.02","5.02","1 through 10","4.92","95.95","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","outpatient","","","101.00","75.75","AETNA [1001]","HB AMC AETNA HMO","70.50","69.8","","66.35","46.84","76.44","41","5.18","82.54","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","outpatient","","","101.00","75.75","AETNA [1001]","HB AMC AETNA PPO","81.20","80.4","","76.44","76.44","76.44","1 through 10","5.18","82.54","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","outpatient","","","101.00","75.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","81.20","80.4","","49.00","49.00","49.00","1 through 10","5.18","82.54","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","outpatient","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","82.54","81.72","","78.34","43.09","78.34","1 through 10","5.18","82.54","percent of total billed charges",""
"BIOENVELOPE ANTIBIOTIC-ELUTING ELUPRO M SINGLE PACK","SUP-ITM-10328995","CDM","C1889","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2768.59","79.5","","1309.77","674.56","6049.93","26","1079.58","2768.59","percent of total billed charges",""
"BIOENVELOPE ANTIBIOTIC-ELUTING ELUPRO M SINGLE PACK","SUP-ITM-10328995","CDM","C1889","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1856.17","53.3","","1901.83","1901.83","2962.25","1 through 10","1079.58","2768.59","percent of total billed charges",""
"BIOENVELOPE ANTIBIOTIC-ELUTING ELUPRO M SINGLE PACK","SUP-ITM-10328995","CDM","C1889","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1271.11","36.5","","1620.31","1620.31","19908.88","1 through 10","1079.58","2768.59","percent of total billed charges",""
"BIOENVELOPE ANTIBIOTIC-ELUTING ELUPRO M SINGLE PACK","SUP-ITM-10328995","CDM","C1889","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1333.80","38.3","","352.91","352.91","2046.30","1 through 10","1079.58","2768.59","percent of total billed charges",""
"BIOENVELOPE ANTIBIOTIC-ELUTING ELUPRO M SINGLE PACK","SUP-ITM-10328995","CDM","C1889","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1493.99","42.9","","9668.75","9668.75","9668.75","1 through 10","1079.58","2768.59","percent of total billed charges",""
"BIOENVELOPE ANTIBIOTIC-ELUTING ELUPRO M SINGLE PACK","SUP-ITM-10328995","CDM","C1889","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","WELLPOINT [1015]","HB AMC WELLPOINT","2569.39","73.78","","699.88","384.10","3443.31","33","1079.58","2768.59","percent of total billed charges",""
"BIOENVELOPE ANTIBIOTIC-ELUTING ELUPRO M SINGLE PACK","SUP-ITM-10328995","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3482.50","2611.87","AETNA [1001]","HB AMC AETNA HMO","2430.79","69.8","","1421.24","264.50","4933.46","29","1819.95","2845.9","percent of total billed charges",""
"BIOENVELOPE ANTIBIOTIC-ELUTING ELUPRO M SINGLE PACK","SUP-ITM-10328995","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3482.50","2611.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2799.93","80.4","","1022.97","1022.97","3607.50","1 through 10","1819.95","2845.9","percent of total billed charges",""
"BIOENVELOPE ANTIBIOTIC-ELUTING ELUPRO M SINGLE PACK","SUP-ITM-10328995","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3482.50","2611.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2845.90","81.72","","3010.54","693.88","5019.88","35","1819.95","2845.9","percent of total billed charges",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","","","","inpatient","","","98977.89","74233.42","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29494.11","","Case rate ($29,494.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,384.84, add-ons for qualifying new technology services are included. If operating cost exceeds $73,029.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,418.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $27,135.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,005.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,978.82. The transfer capital threshold is the transfer adjustment factor * $1,978.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21428.44","21428.44","27536.97","1 through 10","22356.65","35291.8126","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","","","","inpatient","","","98977.89","74233.42","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","22812.91","","Case rate ($22,812.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,384.84, add-ons for qualifying new technology services are included. If operating cost exceeds $73,029.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,418.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,454.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,005.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,978.82. The transfer capital threshold is the transfer adjustment factor * $1,978.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21108.55","21108.55","21108.55","1 through 10","22356.65","35291.8126","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","","","","inpatient","","","98977.89","74233.42","MEDICARE [2001]","HB BWH MEDICARE","29494.11","","Case rate ($29,494.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,384.84, add-ons for qualifying new technology services are included. If operating cost exceeds $73,029.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,418.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $27,135.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,005.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,978.82. The transfer capital threshold is the transfer adjustment factor * $1,978.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27848.41","0.03","48281.65","1 through 10","22356.65","35291.8126","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","","","","inpatient","","","98977.89","74233.42","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","22356.65","","Case rate ($22,812.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,384.84, add-ons for qualifying new technology services are included. If operating cost exceeds $73,029.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,418.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,454.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,005.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,978.82. The transfer capital threshold is the transfer adjustment factor * $1,978.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21234.37","21234.37","21234.37","1 through 10","22356.65","35291.8126","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue With McC","477","MS-DRG","","","","","","","","inpatient","","","154952.22","116214.16","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","32849.85","","Case rate ($31,893.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,315.56, add-ons for qualifying new technology services are included. If operating cost exceeds $83,960.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,219.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,733.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,935.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,779.77. The transfer capital threshold is the transfer adjustment factor * $2,779.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","30944.87","30944.87","30944.87","1 through 10","31255.2","51897.949","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue With McC","477","MS-DRG","","","","","","","","inpatient","","","154952.22","116214.16","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","41278.59","","Case rate ($41,278.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,315.56, add-ons for qualifying new technology services are included. If operating cost exceeds $83,960.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,219.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $38,118.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,935.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,779.77. The transfer capital threshold is the transfer adjustment factor * $2,779.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","31153.79","31153.79","31153.79","1 through 10","31255.2","51897.949","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue With McC","477","MS-DRG","","","","","","","","inpatient","","","154952.22","116214.16","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","41278.59","","Case rate ($41,278.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,315.56, add-ons for qualifying new technology services are included. If operating cost exceeds $83,960.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,219.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $38,118.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,935.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,779.77. The transfer capital threshold is the transfer adjustment factor * $2,779.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27876.25","27876.25","27876.25","1 through 10","31255.2","51897.949","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue With McC","477","MS-DRG","","","","","","","","inpatient","","","154952.22","116214.16","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","41278.59","","Case rate ($41,278.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,315.56, add-ons for qualifying new technology services are included. If operating cost exceeds $83,960.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,219.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $38,118.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,935.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,779.77. The transfer capital threshold is the transfer adjustment factor * $2,779.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29557.17","29557.17","29557.17","1 through 10","31255.2","51897.949","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue With McC","477","MS-DRG","","","","","","","","inpatient","","","154952.22","116214.16","MEDICARE [2001]","HB BWH MEDICARE","41278.59","","Case rate ($41,278.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,315.56, add-ons for qualifying new technology services are included. If operating cost exceeds $83,960.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,219.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $38,118.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,935.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,779.77. The transfer capital threshold is the transfer adjustment factor * $2,779.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","40821.19","38976.49","40881.83","1 through 10","31255.2","51897.949","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue With McC","477","MS-DRG","","","","","","","","inpatient","","","154952.22","116214.16","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","41278.59","","Case rate ($41,278.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,315.56, add-ons for qualifying new technology services are included. If operating cost exceeds $83,960.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,219.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $38,118.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,935.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,779.77. The transfer capital threshold is the transfer adjustment factor * $2,779.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30940.46","30940.46","30940.46","1 through 10","31255.2","51897.949","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue With McC","477","MS-DRG","","","","","","","","inpatient","","","154952.22","116214.16","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","31255.20","","Case rate ($31,893.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,315.56, add-ons for qualifying new technology services are included. If operating cost exceeds $83,960.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,219.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,733.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,935.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,779.77. The transfer capital threshold is the transfer adjustment factor * $2,779.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","31012.81","31012.81","71595.82","1 through 10","31255.2","51897.949","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC","479","MS-DRG","","","","","","","","inpatient","","","44015.06","33011.29","MEDICARE [2001]","HB BWH MEDICARE","17336.91","","Case rate ($17,336.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,792.82, add-ons for qualifying new technology services are included. If operating cost exceeds $66,437.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,935.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,461.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,412.98 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,495.78. The transfer capital threshold is the transfer adjustment factor * $1,495.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21238.19","21238.19","21238.19","1 through 10","16990.17","26798.5978","other","Inpatient Replacement Plans DRG"
"Biopsy Anorectal Wall Rectal Appr","PX-75000172","CDM","45100","CPT","0750","RC","","","","both","","","5043.00","3782.25","MEDICARE [2001]","HB BWH MEDICARE","3256.42","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3256.75","3256.75","3256.75","1 through 10","1563.33","4070.53","other","OPPS APC"
"Biopsy Anorectal Wall Rectal Appr","PX-75000172","CDM","45100","CPT","0750","RC","","","","both","","","5043.00","3782.25","WELLPOINT [1015]","HB AMC WELLPOINT","3720.73","73.78","","6209.13","6209.13","6209.13","1 through 10","1563.33","4070.53","percent of total billed charges",""
"Biopsy Anorectal Wall Rectal Appr","PX-75000172","CDM","45100","CPT","0750","RC","","","","outpatient","","","5043.00","3782.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6188.43","6188.43","6188.43","1 through 10","2101.12","4121.14","other","ASC "
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4098.00","3073.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1979.93","1820.83","1979.93","1 through 10","1270.38","3257.91","other","OPPS APC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4098.00","3073.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","870.07","1893.34","1 through 10","1270.38","3257.91","other","OPPS APC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4098.00","3073.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3257.91","79.5","","7080.64","7080.64","7080.64","1 through 10","1270.38","3257.91","percent of total billed charges",""
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4098.00","3073.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","1270.38","3257.91","other","OPPS APC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4098.00","3073.50","FALLON HEALTH [1008]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1891.15","1891.15","1891.15","1 through 10","1270.38","3257.91","other","OPPS APC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4098.00","3073.50","HUMANA [1012]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1885.65","1885.65","1885.65","1 through 10","1270.38","3257.91","other","OPPS APC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4098.00","3073.50","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","3539.02","36","1270.38","3257.91","other","OPPS APC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4098.00","3073.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1569.53","38.3","","1553.83","1510.12","1553.83","1 through 10","1270.38","3257.91","percent of total billed charges",""
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4098.00","3073.50","MOLINA [1014]","HB BWH MOLINA","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3503.63","3503.63","3503.63","1 through 10","1270.38","3257.91","other","OPPS APC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4098.00","3073.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5665.95","5665.95","5665.95","1 through 10","1270.38","3257.91","other","OPPS APC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4098.00","3073.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1892.75","1885.65","1892.75","1 through 10","1270.38","3257.91","other","OPPS APC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4098.00","3073.50","WELLPOINT [1015]","HB AMC WELLPOINT","3023.50","73.78","","2958.64","2958.64","2958.64","1 through 10","1270.38","3257.91","percent of total billed charges",""
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","outpatient","","","4098.00","3073.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3160.08","3160.08","3218.28","13","1237.95","5545.35","other","ASC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","outpatient","","","4098.00","3073.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","1841.15","3682.30","21","1237.95","5545.35","other","ASC "
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","outpatient","","","4098.00","3073.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","8616.12","8616.12","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","outpatient","","","4098.00","3073.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3020.60","3020.60","3020.60","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","outpatient","","","4098.00","3073.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","3590.06","3590.06","3590.06","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","outpatient","","","4098.00","3073.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3348.89","81.72","","3176.82","3176.82","3176.82","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2303.00","1727.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1988.83","1979.93","1988.83","1 through 10","713.93","2404.92","other","OPPS APC"
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2303.00","1727.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","488.67","1893.34","1 through 10","713.93","2404.92","other","OPPS APC"
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2303.00","1727.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1612.10","70","","4823.28","4823.28","4823.28","1 through 10","713.93","2404.92","percent of total billed charges",""
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2303.00","1727.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1830.89","79.5","","1179.02","1179.02","1179.02","1 through 10","713.93","2404.92","percent of total billed charges",""
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2303.00","1727.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1227.50","53.3","","4340.30","1757.37","4340.30","1 through 10","713.93","2404.92","percent of total billed charges",""
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2303.00","1727.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1894.65","1894.65","1894.65","1 through 10","713.93","2404.92","other","OPPS APC"
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2303.00","1727.25","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","38","713.93","2404.92","other","OPPS APC"
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2303.00","1727.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1885.65","1885.65","1885.65","1 through 10","713.93","2404.92","other","OPPS APC"
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2303.00","1727.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.45","1891.05","1893.45","1 through 10","713.93","2404.92","other","OPPS APC"
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2303.00","1727.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1889.50","1742.49","1924.13","1 through 10","713.93","2404.92","other","OPPS APC"
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","outpatient","","","2303.00","1727.25","AETNA [1001]","HB AMC AETNA HMO","1607.49","69.8","","1511.74","1511.74","1511.74","1 through 10","1203.55","2384.07","percent of total billed charges",""
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","outpatient","","","2303.00","1727.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3160.08","3160.08","3218.28","1 through 10","1203.55","2384.07","other","ASC"
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","outpatient","","","2303.00","1727.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","3646.12","3682.30","17","1203.55","2384.07","other","ASC "
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","outpatient","","","2303.00","1727.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","8616.12","8616.12","1 through 10","1203.55","2384.07","other","Multiple Surgery"
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","outpatient","","","2303.00","1727.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1882.01","81.72","","1785.06","952.62","1785.06","1 through 10","1203.55","2384.07","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","246.04","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","245.83","67.04","245.83","1 through 10","204.6","524.7","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.08","235.08","235.08","1 through 10","204.6","524.7","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","524.70","79.5","","503.68","337.92","503.68","19","204.6","524.7","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","351.78","53.3","","337.92","337.92","503.68","12","204.6","524.7","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.08","235.08","235.08","1 through 10","204.6","524.7","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","ELDER SERVICES [1037]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","213.13","213.13","213.13","1 through 10","204.6","524.7","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","214.87","214.87","214.87","1 through 10","204.6","524.7","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","HUMANA [1012]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.56","235.56","235.56","1 through 10","204.6","524.7","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","MEDICARE [2001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","238.90","217.48","238.90","57","204.6","524.7","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","65.15","65.15","65.15","1 through 10","204.6","524.7","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","204.60","31","","593.28","197.76","593.28","1 through 10","204.6","524.7","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","240.90","36.5","","238.72","202.88","716.16","38","204.6","524.7","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","252.78","38.3","","250.24","250.24","750.72","66","204.6","524.7","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","234.12","234.12","234.12","1 through 10","204.6","524.7","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","235.08","235.08","235.08","1 through 10","204.6","524.7","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","234.12","63.85","238.90","25","204.6","524.7","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","660.00","495.00","WELLPOINT [1015]","HB AMC WELLPOINT","486.95","73.78","","1116.48","476.48","6209.13","1 through 10","204.6","524.7","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","AETNA [1001]","HB AMC AETNA HMO","460.68","69.8","","433.28","305.92","771.42","19","165.93","700.33","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","AETNA [1001]","HB AMC AETNA PPO","530.64","80.4","","499.20","433.28","499.20","1 through 10","165.93","700.33","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","381.21","381.21","566.42","95","165.93","700.33","other","ASC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","344.92","52.26","","439.84","439.84","439.84","1 through 10","165.93","700.33","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","439.84","439.84","621.58","157","165.93","700.33","other","ASC "
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","424.78","424.78","424.78","1 through 10","165.93","700.33","other","Multiple Surgery"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","384.96","384.96","1154.88","50","165.93","700.33","other","Multiple Surgery"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","389.94","1214.61","27","165.93","700.33","other","Multiple Surgery"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","481.20","481.20","481.20","1 through 10","165.93","700.33","other","Multiple Surgery"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","404.87","404.87","1 through 10","165.93","700.33","other","Multiple Surgery"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","424.78","424.78","424.78","1 through 10","165.93","700.33","other","Multiple Surgery"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","530.64","80.4","","499.20","499.20","499.20","1 through 10","165.93","700.33","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","539.35","81.72","","511.62","511.61","511.62","1 through 10","165.93","700.33","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","539.35","81.72","","511.62","281.41","511.62","33","165.93","700.33","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","660.00","495.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","408.19","408.19","408.19","1 through 10","165.93","700.33","other","Multiple Surgery"
"Biopsy Endomyocardial","PX-48000131","CDM","93505","CPT","0481","RC","","","","both","","","13998.00","10498.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3678.04","3423.23","3678.04","1 through 10","2735.48","11128.41","other","OPPS APC"
"Biopsy Endomyocardial","PX-48000131","CDM","93505","CPT","0481","RC","","","","both","","","13998.00","10498.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","9182.69","65.6","","11827.87","11144.10","15617.04","1 through 10","2735.48","11128.41","percent of total billed charges",""
"Biopsy Endomyocardial","PX-48000131","CDM","93505","CPT","0481","RC","","","","both","","","13998.00","10498.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","9098.70","65","","8823.10","8823.10","8823.10","1 through 10","2735.48","11128.41","percent of total billed charges",""
"Biopsy Endomyocardial","PX-48000131","CDM","93505","CPT","0481","RC","","","","both","","","13998.00","10498.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","4671.83","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","395.00","395.00","3671.00","1 through 10","2735.48","11128.41","other","OPPS APC"
"Biopsy Endomyocardial","PX-48000131","CDM","93505","CPT","0481","RC","","","","both","","","13998.00","10498.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3663.09","3097.14","3678.04","11","2735.48","11128.41","other","OPPS APC"
"Biopsy Endomyocardial","PX-48000131","CDM","93505","CPT","0481","RC","","","","both","","","13998.00","10498.50","MEDICARE [2001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3478.89","11213.55","39","2735.48","11128.41","other","OPPS APC"
"Biopsy Endomyocardial","PX-48000131","CDM","93505","CPT","0481","RC","","","","both","","","13998.00","10498.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5361.23","38.3","","5307.43","5307.43","5307.43","1 through 10","2735.48","11128.41","percent of total billed charges",""
"Biopsy Endomyocardial","PX-48000131","CDM","93505","CPT","0481","RC","","","","outpatient","","","13998.00","10498.50","AETNA [1001]","HB AMC AETNA HMO","9770.60","69.8","","9189.60","9189.60","9189.60","1 through 10","2377.37","11439.17","percent of total billed charges",""
"Biopsy Endomyocardial","PX-48000131","CDM","93505","CPT","0481","RC","","","","outpatient","","","13998.00","10498.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2377.37","","Case rate ($2,377.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","5515.50","5515.50","16546.50","13","2377.37","11439.17","other","Multiple Surgery"
"Biopsy Endomyocardial","PX-48000131","CDM","93505","CPT","0481","RC","","","","outpatient","","","13998.00","10498.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11439.17","81.72","","3043.04","3043.04","3043.04","1 through 10","2377.37","11439.17","percent of total billed charges",""
"Biopsy Ext Ear","PX-76001663","CDM","69100","CPT","0761","RC","","","","both","","","635.00","476.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","275.75","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.32","262.32","262.32","1 through 10","196.85","504.83","other","OPPS APC"
"Biopsy Ext Ear","PX-76001663","CDM","69100","CPT","0761","RC","","","","both","","","635.00","476.25","MEDICARE [2001]","HB BWH MEDICARE","275.75","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","275.78","275.78","275.78","1 through 10","196.85","504.83","other","OPPS APC"
"Biopsy Ext Ear","PX-76001663","CDM","69100","CPT","0761","RC","","","","both","","","635.00","476.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","231.78","36.5","","689.31","689.31","689.31","1 through 10","196.85","504.83","percent of total billed charges",""
"Biopsy Ext Ear","PX-76001663","CDM","69100","CPT","0761","RC","","","","both","","","635.00","476.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","243.21","38.3","","722.58","722.58","722.58","1 through 10","196.85","504.83","percent of total billed charges",""
"Biopsy Ext Ear","PX-76001663","CDM","69100","CPT","0761","RC","","","","both","","","635.00","476.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","275.75","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","135.13","135.13","135.13","1 through 10","196.85","504.83","other","OPPS APC"
"Biopsy Ext Ear","PX-76001663","CDM","69100","CPT","0761","RC","","","","both","","","635.00","476.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","270.23","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","270.26","270.26","270.26","1 through 10","196.85","504.83","other","OPPS APC"
"Biopsy Ext Ear","PX-76001663","CDM","69100","CPT","0761","RC","","","","both","","","635.00","476.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","270.23","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","270.27","270.27","270.27","1 through 10","196.85","504.83","other","OPPS APC"
"Biopsy Ext Ear","PX-76001663","CDM","69100","CPT","0761","RC","","","","outpatient","","","635.00","476.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","235.73","","Case rate ($235.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","473.58","473.58","473.58","1 through 10","206.14","1234.13","other","ASC"
"Biopsy Ext Ear","PX-76001663","CDM","69100","CPT","0761","RC","","","","outpatient","","","635.00","476.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","235.73","","Case rate ($235.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","551.84","273.21","551.84","1 through 10","206.14","1234.13","other","ASC "
"Biopsy Ext Ear","PX-76001663","CDM","69100","CPT","0761","RC","","","","outpatient","","","635.00","476.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","206.14","","Case rate ($206.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1508.94","1508.94","1508.94","1 through 10","206.14","1234.13","other","Multiple Surgery"
"Biopsy Eyelid Incis W/Margin","PX-76001635","CDM","67810","CPT","0761","RC","","","","outpatient","","","908.00","681.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","283.52","","Case rate ($283.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","232.39","232.39","232.39","1 through 10","283.52","1234.13","other","Multiple Surgery"
"Biopsy Gingiva","PX-76001988","CDM","41899","CPT","0510","RC","","","","outpatient","","","2928.00","2196.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1772.90","60.55","","481.00","481.00","481.00","1 through 10","700.33","2415.6","percent of total billed charges",""
"Biopsy Gingiva","PX-98302503","CDM","41899","CPT","0983","RC","","","","outpatient","","","496.00","372.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","300.33","60.55","","481.00","481.00","481.00","1 through 10","248","700.33","percent of total billed charges",""
"Biopsy Gland Salivary Incisional","PX-75000058","CDM","42405","CPT","0761","RC","","","","outpatient","","","6473.00","4854.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2551.58","","Case rate ($2,551.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","5973.25","5973.25","5973.25","1 through 10","2008.14","5545.35","other","ASC "
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","both","","","2492.00","1869.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","867.69","866.49","867.69","1 through 10","772.52","1981.14","other","OPPS APC"
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","both","","","2492.00","1869.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1981.14","79.5","","1902.18","1902.18","1902.18","1 through 10","772.52","1981.14","percent of total billed charges",""
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","both","","","2492.00","1869.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","772.52","1981.14","other","OPPS APC"
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","both","","","2492.00","1869.00","MOLINA [1014]","HB BWH MOLINA","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1657.75","1657.75","1657.75","1 through 10","772.52","1981.14","other","OPPS APC"
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","both","","","2492.00","1869.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","818.85","1 through 10","772.52","1981.14","other","OPPS APC"
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","both","","","2492.00","1869.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.75","826.75","826.75","1 through 10","772.52","1981.14","other","OPPS APC"
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","outpatient","","","2492.00","1869.00","AETNA [1001]","HB AMC AETNA HMO","1739.42","69.8","","1636.31","1636.31","1636.31","1 through 10","579.34","2384.07","percent of total billed charges",""
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","outpatient","","","2492.00","1869.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1330.98","1330.98","1330.98","1 through 10","579.34","2384.07","other","ASC"
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","outpatient","","","2492.00","1869.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","767.85","767.85","767.85","1 through 10","579.34","2384.07","other","ASC "
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","outpatient","","","2492.00","1869.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","4032.21","4032.21","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Biopsy Lesion Vulva/ Perineum Add","PX-76001336","CDM","56606","CPT","0761","RC","","","","both","","","201.00","150.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.37","36.5","","13458.21","13458.21","13458.21","1 through 10","62.31","159.8","percent of total billed charges",""
"Biopsy Lesion Vulva/ Perineum Add","PX-76001336","CDM","56606","CPT","0761","RC","","","","both","","","201.00","150.75","WELLPOINT [1015]","HB AMC WELLPOINT","148.30","73.78","","10731.29","10731.29","10731.29","1 through 10","62.31","159.8","percent of total billed charges",""
"Biopsy Lesion Vulva/ Perineum Add","PX-76001336","CDM","56606","CPT","0761","RC","","","","outpatient","","","201.00","150.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","164.26","81.72","","85.74","85.74","85.74","1 through 10","49.68","164.26","percent of total billed charges",""
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","1312.00","984.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1064.97","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1064.64","1064.64","1064.64","1 through 10","406.72","1292.44","other","OPPS APC"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1017.52","1017.52","1017.52","1 through 10","406.72","1292.44","other","OPPS APC"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","1312.00","984.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.04","79.5","","13248.57","671.62","13248.57","1 through 10","406.72","1292.44","percent of total billed charges",""
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","1312.00","984.00","MEDICARE [2001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1034.06","1034.06","1034.06","16","406.72","1292.44","other","OPPS APC"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","1312.00","984.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","478.88","36.5","","474.46","403.22","13458.21","1 through 10","406.72","1292.44","percent of total billed charges",""
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","1312.00","984.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.50","38.3","","966.72","497.35","1492.05","1 through 10","406.72","1292.44","percent of total billed charges",""
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","1312.00","984.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1013.38","1013.38","1013.38","1 through 10","406.72","1292.44","other","OPPS APC"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","1312.00","984.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1013.38","866.87","1020.88","1 through 10","406.72","1292.44","other","OPPS APC"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","1312.00","984.00","WELLPOINT [1015]","HB AMC WELLPOINT","967.99","73.78","","2219.00","947.00","10731.29","1 through 10","406.72","1292.44","percent of total billed charges",""
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","AETNA [1001]","HB AMC AETNA HMO","915.78","69.8","","5732.42","608.02","5732.42","1 through 10","558.04","1234.13","percent of total billed charges",""
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1305.65","652.83","1472.41","1 through 10","558.04","1234.13","other","ASC"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1479.23","1479.23","1493.91","25","558.04","1234.13","other","ASC "
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3883.95","1294.65","6473.25","13","558.04","1234.13","other","Multiple Surgery"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1361.62","1361.62","1361.62","1 through 10","558.04","1234.13","other","Multiple Surgery"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","948.44","948.44","948.44","1 through 10","558.04","1234.13","other","Multiple Surgery"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1072.17","81.72","","1361.62","1361.62","1361.62","1 through 10","558.04","1234.13","percent of total billed charges",""
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1072.17","81.72","","559.30","559.30","559.30","1 through 10","558.04","1234.13","percent of total billed charges",""
"Biopsy Lip","PX-75000001","CDM","40490","CPT","0761","RC","","","","both","","","659.00","494.25","MEDICARE [2001]","HB BWH MEDICARE","275.75","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","275.78","137.89","275.78","1 through 10","204.29","523.91","other","OPPS APC"
"Biopsy Lip","PX-75000001","CDM","40490","CPT","0761","RC","","","","both","","","659.00","494.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","275.75","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.14","36.57","73.14","1 through 10","204.29","523.91","other","OPPS APC"
"Biopsy Lip","PX-75000001","CDM","40490","CPT","0761","RC","","","","both","","","659.00","494.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","252.40","38.3","","749.55","116.52","749.55","1 through 10","204.29","523.91","percent of total billed charges",""
"Biopsy Lip","PX-75000001","CDM","40490","CPT","0761","RC","","","","both","","","659.00","494.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","270.23","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.97","146.97","146.97","1 through 10","204.29","523.91","other","OPPS APC"
"Biopsy Lip","PX-75000001","CDM","40490","CPT","0761","RC","","","","both","","","659.00","494.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","270.23","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","270.26","270.26","270.26","1 through 10","204.29","523.91","other","OPPS APC"
"Biopsy Lip","PX-75000001","CDM","40490","CPT","0761","RC","","","","both","","","659.00","494.25","WELLPOINT [1015]","HB AMC WELLPOINT","486.21","73.78","","697.60","697.60","697.60","1 through 10","204.29","523.91","percent of total billed charges",""
"Biopsy Lip","PX-75000001","CDM","40490","CPT","0761","RC","","","","outpatient","","","659.00","494.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","235.73","","Case rate ($235.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","482.30","473.58","679.31","1 through 10","206.14","1234.13","other","ASC"
"Biopsy Lip","PX-75000001","CDM","40490","CPT","0761","RC","","","","outpatient","","","659.00","494.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","235.73","","Case rate ($235.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","546.42","546.42","546.42","1 through 10","206.14","1234.13","other","ASC "
"Biopsy Lip","PX-75000001","CDM","40490","CPT","0761","RC","","","","outpatient","","","659.00","494.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","206.14","","Case rate ($206.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","597.81","157.64","597.81","1 through 10","206.14","1234.13","other","Multiple Surgery"
"Biopsy Lip","PX-75000001","CDM","40490","CPT","0761","RC","","","","outpatient","","","659.00","494.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","206.14","","Case rate ($206.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","459.69","149.89","478.24","1 through 10","206.14","1234.13","other","Multiple Surgery"
"Biopsy Lip","PX-75000001","CDM","40490","CPT","0761","RC","","","","outpatient","","","659.00","494.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","206.14","","Case rate ($206.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","484.43","157.64","484.43","1 through 10","206.14","1234.13","other","Multiple Surgery"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1986.93","1979.93","3497.42","1 through 10","1203.42","3086.19","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1741.20","1893.34","13","1203.42","3086.19","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2523.30","65","","2447.25","2447.25","2447.25","1 through 10","1203.42","3086.19","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2717.40","70","","3012.00","3012.00","3012.00","1 through 10","1203.42","3086.19","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3086.19","79.5","","6235.41","2963.06","6657.23","14","1203.42","3086.19","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2069.11","53.3","","1987.92","1987.92","2963.06","1 through 10","1203.42","3086.19","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","FALLON HEALTH [1008]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1203.42","3086.19","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","104","1203.42","3086.19","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1416.93","36.5","","1362.93","1193.51","1404.35","1 through 10","1203.42","3086.19","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1486.81","38.3","","1472.12","1472.12","4416.36","15","1203.42","3086.19","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","MOLINA [1014]","HB BWH MOLINA","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3539.02","3539.02","3539.02","1 through 10","1203.42","3086.19","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","TRICARE [160005]","HB BWH TRICARE","1827.93","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1827.92","1827.92","1827.92","1 through 10","1203.42","3086.19","other","Tricare OPPS"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","1827.93","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1924.13","1924.13","1924.13","1 through 10","1203.42","3086.19","other","Tricare OPPS"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5656.95","1886.65","5679.15","14","1203.42","3086.19","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1741.12","1894.70","13","1203.42","3086.19","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","3882.00","2911.50","WELLPOINT [1015]","HB AMC WELLPOINT","2864.14","73.78","","6568.04","2803.04","6568.04","1 through 10","1203.42","3086.19","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","3882.00","2911.50","AETNA [1001]","HB AMC AETNA HMO","2709.64","69.8","","2548.91","1799.67","2936.70","12","1237.95","3172.37","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","3882.00","2911.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3160.08","3160.08","3218.28","28","1237.95","3172.37","other","ASC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","3882.00","2911.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","3646.12","3682.30","49","1237.95","3172.37","other","ASC "
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","3882.00","2911.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","5521.26","2872.04","8616.12","19","1237.95","3172.37","other","Multiple Surgery"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","3882.00","2911.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3020.60","2909.18","5818.36","1 through 10","1237.95","3172.37","other","Multiple Surgery"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","3882.00","2911.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3169.15","3169.15","3169.15","1 through 10","1237.95","3172.37","other","Multiple Surgery"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","3882.00","2911.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3172.37","81.72","","3009.74","3009.74","3009.74","1 through 10","1237.95","3172.37","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","3882.00","2911.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3045.36","3045.36","3045.36","1 through 10","1237.95","3172.37","other","Multiple Surgery"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1985.83","1979.93","6894.20","1 through 10","1031.37","2644.97","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","449.83","1893.34","1 through 10","1031.37","2644.97","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2162.55","65","","6290.70","6290.70","6290.70","1 through 10","1031.37","2644.97","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2644.97","79.5","","5263.45","4070.30","5387.01","32","1031.37","2644.97","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1773.29","53.3","","7802.31","7802.31","7802.31","21","1031.37","2644.97","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1885.64","1734.12","1885.65","1 through 10","1031.37","2644.97","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1897.19","1897.19","1897.19","1 through 10","1031.37","2644.97","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","HUMANA [1012]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1901.04","1885.65","1904.89","1 through 10","1031.37","2644.97","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2162.55","65","","2035.15","2035.15","2035.15","1 through 10","1031.37","2644.97","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","101","1031.37","2644.97","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1214.36","36.5","","3067.92","1167.81","3067.92","1 through 10","1031.37","2644.97","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1274.24","38.3","","3784.11","1225.88","3784.11","1 through 10","1031.37","2644.97","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1891.65","1885.65","1891.65","1 through 10","1031.37","2644.97","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","1827.93","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1924.13","1924.13","1924.13","1 through 10","1031.37","2644.97","other","Tricare OPPS"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5679.15","1887.15","5679.15","12","1031.37","2644.97","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1889.50","1734.12","1924.13","16","1031.37","2644.97","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","3327.00","2495.25","WELLPOINT [1015]","HB AMC WELLPOINT","2454.66","73.78","","5627.76","2401.76","5627.76","1 through 10","1031.37","2644.97","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","3327.00","2495.25","AETNA [1001]","HB AMC AETNA HMO","2322.25","69.8","","2184.00","1542.03","4368.00","16","1237.95","2718.82","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","3327.00","2495.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3218.28","3160.08","3646.12","15","1237.95","2718.82","other","ASC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","3327.00","2495.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1738.69","52.26","","1996.25","1996.25","1996.25","1 through 10","1237.95","2718.82","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","3327.00","2495.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","3646.12","3682.30","33","1237.95","2718.82","other","ASC "
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","3327.00","2495.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1584.58","1584.58","1584.58","1 through 10","1237.95","2718.82","other","Multiple Surgery"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","3327.00","2495.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","2872.04","14360.20","30","1237.95","2718.82","other","Multiple Surgery"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","3327.00","2495.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3020.60","3020.60","9061.80","1 through 10","1237.95","2718.82","other","Multiple Surgery"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","3327.00","2495.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","3590.06","2822.53","3590.06","1 through 10","1237.95","2718.82","other","Multiple Surgery"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","3327.00","2495.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3045.36","3045.36","3045.36","1 through 10","1237.95","2718.82","other","Multiple Surgery"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","3327.00","2495.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2718.82","81.72","","1418.47","1418.47","1418.47","1 through 10","1237.95","2718.82","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","3327.00","2495.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2718.82","81.72","","2578.86","1418.47","2578.86","1 through 10","1237.95","2718.82","percent of total billed charges",""
"Biopsy Mouth Floor","PX-75000029","CDM","41108","CPT","0761","RC","","","","both","","","2233.00","1674.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","98.92","1885.65","1 through 10","98.92","1885.46","other","OPPS APC"
"Biopsy Mouth Floor","PX-75000029","CDM","41108","CPT","0761","RC","","","","outpatient","","","2233.00","1674.75","AETNA [1001]","HB AMC AETNA HMO","1558.63","69.8","","1231.33","1231.33","1231.33","1 through 10","1166.97","1824.81","percent of total billed charges",""
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","both","","","907.00","680.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","622.84","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","622.30","102.04","622.30","1 through 10","281.17","755.88","other","OPPS APC"
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","both","","","907.00","680.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","721.07","79.5","","663.52","454.00","663.52","1 through 10","281.17","755.88","percent of total billed charges",""
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","both","","","907.00","680.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","483.43","53.3","","464.64","454.00","692.56","1 through 10","281.17","755.88","percent of total billed charges",""
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","both","","","907.00","680.25","MEDICARE [2001]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","604.76","453.58","604.76","17","281.17","755.88","other","OPPS APC"
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","both","","","907.00","680.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","99.16","74.37","99.16","17","281.17","755.88","other","OPPS APC"
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","both","","","907.00","680.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","347.38","38.3","","344.08","177.51","1032.24","1 through 10","281.17","755.88","percent of total billed charges",""
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","both","","","907.00","680.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","592.66","97.18","592.66","1 through 10","281.17","755.88","other","OPPS APC"
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","both","","","907.00","680.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","592.61","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","592.66","97.18","592.66","1 through 10","281.17","755.88","other","OPPS APC"
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","both","","","907.00","680.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","389.10","42.9","","1007.30","1007.30","1007.30","1 through 10","281.17","755.88","percent of total billed charges",""
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","both","","","907.00","680.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","592.61","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","442.38","147.68","442.38","1 through 10","281.17","755.88","other","OPPS APC"
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","both","","","907.00","680.25","WELLPOINT [1015]","HB AMC WELLPOINT","669.18","73.78","","993.16","993.16","993.16","1 through 10","281.17","755.88","percent of total billed charges",""
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","both","","","907.00","680.25","WELLSENSE NH [1050]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1790.70","97.18","1790.70","1 through 10","281.17","755.88","other","OPPS APC"
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","outpatient","","","907.00","680.25","AETNA [1001]","HB AMC AETNA HMO","633.09","69.8","","637.65","637.65","637.65","1 through 10","474","1234.13","percent of total billed charges",""
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","outpatient","","","907.00","680.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","557.06","","Case rate ($557.06). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1405.51","1405.51","1405.51","1 through 10","474","1234.13","other","ASC"
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","outpatient","","","907.00","680.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","557.06","","Case rate ($557.06). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1568.77","1568.77","1569.85","15","474","1234.13","other","ASC "
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","outpatient","","","907.00","680.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","487.13","","Case rate ($487.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1130.14","356.84","1130.14","1 through 10","474","1234.13","other","Multiple Surgery"
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","outpatient","","","907.00","680.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","487.13","","Case rate ($487.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1183.73","249.70","1188.60","1 through 10","474","1234.13","other","Multiple Surgery"
"Biopsy Mouth Vestibule","PX-75000010","CDM","40808","CPT","0761","RC","","","","outpatient","","","907.00","680.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","741.20","81.72","","1066.40","1066.40","1066.40","1 through 10","474","1234.13","percent of total billed charges",""
"Biopsy Mucosa Vaginal Extensive","PX-76001347","CDM","57105","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6259.18","6259.18","6259.18","1 through 10","2125.14","5545.35","other","ASC "
"Biopsy Mucosa Vaginal Smp","PX-76001346","CDM","57100","CPT","0761","RC","","","","both","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1017.52","1017.52","1017.52","1 through 10","406.72","1292.44","other","OPPS APC"
"Biopsy Mucosa Vaginal Smp","PX-76001346","CDM","57100","CPT","0761","RC","","","","both","","","1312.00","984.00","MEDICARE [2001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3102.18","1034.06","3102.18","1 through 10","406.72","1292.44","other","OPPS APC"
"Biopsy Mucosa Vaginal Smp","PX-76001346","CDM","57100","CPT","0761","RC","","","","both","","","1312.00","984.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.50","38.3","","497.35","497.35","497.35","1 through 10","406.72","1292.44","percent of total billed charges",""
"Biopsy Mucosa Vaginal Smp","PX-76001346","CDM","57100","CPT","0761","RC","","","","both","","","1312.00","984.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","867.77","867.77","867.77","1 through 10","406.72","1292.44","other","OPPS APC"
"Biopsy Mucosa Vaginal Smp","PX-76001346","CDM","57100","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1282.04","1282.04","1282.04","1 through 10","558.04","2384.07","other","ASC"
"Biopsy Mucosa Vaginal Smp","PX-76001346","CDM","57100","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1479.23","1479.23","1479.23","1 through 10","558.04","2384.07","other","ASC "
"Biopsy Muscle Deep","PX-76000274","CDM","20205","CPT","0761","RC","","","","both","","","4072.00","3054.00","MEDICARE [2001]","HB BWH MEDICARE","3398.51","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6202.54","3398.86","9327.21","1 through 10","1262.32","4248.14","other","OPPS APC"
"Biopsy Muscle Deep","PX-76000274","CDM","20205","CPT","0761","RC","","","","both","","","4072.00","3054.00","WELLPOINT [1015]","HB AMC WELLPOINT","3004.32","73.78","","2136.72","2136.72","2136.72","1 through 10","1262.32","4248.14","percent of total billed charges",""
"Biopsy Muscle Deep","PX-76000274","CDM","20205","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5463.90","5463.90","5463.90","1 through 10","1810","8899.59","other","ASC"
"Biopsy Muscle Deep","PX-76000274","CDM","20205","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6366.84","6366.84","6366.84","1 through 10","1810","8899.59","other","ASC "
"Biopsy Muscle Deep","PX-76000274","CDM","20205","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4965.87","4965.87","4965.87","1 through 10","1810","8899.59","other","Multiple Surgery"
"Biopsy Muscle Deep","PX-76000274","CDM","20205","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1810.00","44.45","","2294.27","2294.27","2294.27","1 through 10","1810","8899.59","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1979.93","1979.93","1988.83","1 through 10","777.48","2404.92","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1741.20","1893.34","1 through 10","777.48","2404.92","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1630.20","65","","4963.40","4963.40","4963.40","1 through 10","777.48","2404.92","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1993.86","79.5","","1913.98","1284.10","6473.06","13","777.48","2404.92","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1336.76","53.3","","5741.98","4067.20","5741.98","117","777.48","2404.92","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","777.48","2404.92","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1901.04","1901.04","1901.04","1 through 10","777.48","2404.92","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1894.65","1894.65","1894.65","1 through 10","777.48","2404.92","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1769.51","1924.13","100","777.48","2404.92","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","915.42","36.5","","770.94","770.94","770.94","1 through 10","777.48","2404.92","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","960.56","38.3","","2852.73","950.91","2852.73","1 through 10","777.48","2404.92","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5679.15","1893.34","9435.75","13","777.48","2404.92","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","559.36","559.36","559.36","1 through 10","777.48","2404.92","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1075.93","42.9","","1106.56","1106.56","1106.56","1 through 10","777.48","2404.92","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.15","1885.65","1924.13","1 through 10","777.48","2404.92","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2508.00","1881.00","WELLPOINT [1015]","HB AMC WELLPOINT","1850.40","73.78","","4097.75","1810.62","4242.62","13","777.48","2404.92","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2508.00","1881.00","AETNA [1001]","HB AMC AETNA HMO","1750.58","69.8","","1646.46","1162.50","1646.46","13","1237.95","2384.07","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2508.00","1881.00","AETNA [1001]","HB AMC AETNA PPO","2016.43","80.4","","1896.96","1896.96","1896.96","1 through 10","1237.95","2384.07","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2508.00","1881.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3160.08","3160.08","3218.28","23","1237.95","2384.07","other","ASC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2508.00","1881.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1310.68","52.26","","1504.92","1504.92","1504.92","1 through 10","1237.95","2384.07","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2508.00","1881.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","3646.12","3682.30","43","1237.95","2384.07","other","ASC "
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2508.00","1881.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3169.15","3169.15","3169.15","1 through 10","1237.95","2384.07","other","Multiple Surgery"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2508.00","1881.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","2872.04","8616.12","17","1237.95","2384.07","other","Multiple Surgery"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2508.00","1881.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3020.60","2909.18","3020.60","1 through 10","1237.95","2384.07","other","Multiple Surgery"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2508.00","1881.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1821.68","1821.68","1821.68","1 through 10","1237.95","2384.07","other","Multiple Surgery"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2508.00","1881.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1626.53","1626.53","1626.53","1 through 10","1237.95","2384.07","other","Multiple Surgery"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2508.00","1881.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2049.54","81.72","","1944.14","1069.35","1944.14","1 through 10","1237.95","2384.07","percent of total billed charges",""
"Biopsy Muscle Superficial","PX-76000273","CDM","20200","CPT","0761","RC","","","","outpatient","","","3993.00","2994.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2417.76","60.55","","3160.08","3160.08","3218.28","1 through 10","1597.2","3263.08","percent of total billed charges",""
"Biopsy Muscle Superficial","PX-76000273","CDM","20200","CPT","0761","RC","","","","outpatient","","","3993.00","2994.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2085.14","52.22","","3682.30","3646.12","3682.30","1 through 10","1597.2","3263.08","percent of total billed charges",""
"Biopsy Nail Unit","PX-76000094","CDM","11755","CPT","0761","RC","","","","both","","","1133.00","849.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","818.85","818.85","818.85","1 through 10","351.23","1044.34","other","OPPS APC"
"Biopsy Nail Unit","PX-76000094","CDM","11755","CPT","0761","RC","","","","both","","","1133.00","849.75","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","351.23","1044.34","other","OPPS APC"
"Biopsy Nail Unit","PX-76000094","CDM","11755","CPT","0761","RC","","","","both","","","1133.00","849.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","433.94","38.3","","1289.13","1252.86","1289.13","13","351.23","1044.34","percent of total billed charges",""
"Biopsy Nail Unit","PX-76000094","CDM","11755","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","AETNA [1001]","HB AMC AETNA HMO","790.83","69.8","","744.02","744.02","744.02","1 through 10","579.34","1234.13","percent of total billed charges",""
"Biopsy Nail Unit","PX-76000094","CDM","11755","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1355.50","1355.50","1355.50","1 through 10","579.34","1234.13","other","ASC"
"Biopsy Nail Unit","PX-76000094","CDM","11755","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.70","1535.70","1535.70","1 through 10","579.34","1234.13","other","ASC "
"Biopsy Oocyte 5 or Less Embryos","PX-30000135","CDM","89290","CPT","0300","RC","","","","both","","","3734.00","2800.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2968.53","79.5","","2849.73","1911.89","2849.73","1 through 10","199.41","3547.3","percent of total billed charges",""
"Biopsy Oocyte 5 or Less Embryos","PX-30000135","CDM","89290","CPT","0300","RC","","","","both","","","3734.00","2800.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1990.22","53.3","","3621.00","2849.73","3621.00","1 through 10","199.41","3547.3","percent of total billed charges",""
"Biopsy Oocyte 5 or Less Embryos","PX-30000135","CDM","89290","CPT","0300","RC","","","","both","","","3734.00","2800.50","WELLPOINT [1015]","HB AMC WELLPOINT","2754.95","73.78","","6316.83","6316.83","6316.83","1 through 10","199.41","3547.3","percent of total billed charges",""
"Biopsy Oocyte 5 or Less Embryos","PX-30000135","CDM","89290","CPT","0300","RC","","","","outpatient","","","3734.00","2800.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3051.42","81.72","","1592.15","1592.15","2894.63","1 through 10","420.84","3051.42","percent of total billed charges",""
"Biopsy Oocyte More Than 5 Embryos","PX-30000136","CDM","89291","CPT","0300","RC","","","","both","","","4064.00","3048.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3230.88","79.5","","3101.57","3101.57","3101.57","1 through 10","199.41","3860.8","percent of total billed charges",""
"Biopsy Oocyte More Than 5 Embryos","PX-30000136","CDM","89291","CPT","0300","RC","","","","both","","","4064.00","3048.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2166.11","53.3","","3101.57","2080.85","3101.57","1 through 10","199.41","3860.8","percent of total billed charges",""
"Biopsy Oocyte More Than 5 Embryos","PX-30000136","CDM","89291","CPT","0300","RC","","","","both","","","4064.00","3048.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1743.46","42.9","","3150.44","3150.44","3150.44","1 through 10","199.41","3860.8","percent of total billed charges",""
"Biopsy Oocyte More Than 5 Embryos","PX-30000136","CDM","89291","CPT","0300","RC","","","","outpatient","","","4064.00","3048.00","AETNA [1001]","HB AMC AETNA HMO","2836.67","69.8","","1883.80","1883.80","1883.80","1 through 10","420.84","3321.1","percent of total billed charges",""
"Biopsy Oocyte More Than 5 Embryos","PX-30000136","CDM","89291","CPT","0300","RC","","","","outpatient","","","4064.00","3048.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3321.10","81.72","","1732.86","1732.86","1732.86","1 through 10","420.84","3321.1","percent of total billed charges",""
"Biopsy Oropharynx","PX-75000064","CDM","42800","CPT","0761","RC","","","","outpatient","","","4242.00","3181.50","AETNA [1001]","HB AMC AETNA HMO","2960.92","69.8","","8329.13","8329.13","8329.13","1 through 10","2008.14","3466.56","percent of total billed charges",""
"Biopsy Oropharynx","PX-75000064","CDM","42800","CPT","0761","RC","","","","outpatient","","","4242.00","3181.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2008.14","","Case rate ($2,008.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2329.44","2329.44","2329.44","1 through 10","2008.14","3466.56","other","Multiple Surgery"
"Biopsy Palate/Uvula","PX-75000047","CDM","42100","CPT","0761","RC","","","","both","","","1937.00","1452.75","MEDICARE [2001]","HB BWH MEDICARE","1758.93","","APC Price ($1,758.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1759.11","1759.11","1759.11","1 through 10","600.47","2198.66","other","OPPS APC"
"Biopsy Palate/Uvula","PX-75000047","CDM","42100","CPT","0761","RC","","","","both","","","1937.00","1452.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","1758.93","","APC Price ($1,758.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","121.32","121.32","121.32","1 through 10","600.47","2198.66","other","OPPS APC"
"Biopsy Palate/Uvula","PX-75000047","CDM","42100","CPT","0761","RC","","","","both","","","1937.00","1452.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","707.01","36.5","","13767.06","3033.61","13767.06","1 through 10","600.47","2198.66","percent of total billed charges",""
"Biopsy Palate/Uvula","PX-75000047","CDM","42100","CPT","0761","RC","","","","outpatient","","","1937.00","1452.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1462.72","","Case rate ($1,462.72). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3320.41","3320.41","3320.41","1 through 10","1012.28","2384.07","other","ASC"
"Biopsy Palate/Uvula","PX-75000047","CDM","42100","CPT","0761","RC","","","","outpatient","","","1937.00","1452.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1462.72","","Case rate ($1,462.72). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3751.91","3732.72","3751.91","1 through 10","1012.28","2384.07","other","ASC "
"Biopsy Penis","PX-76001305","CDM","54100","CPT","0761","RC","","","","both","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","1262.32","3237.24","other","OPPS APC"
"Biopsy Penis","PX-76001305","CDM","54100","CPT","0761","RC","","","","both","","","4072.00","3054.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1262.32","3237.24","other","OPPS APC"
"Biopsy Penis","PX-76001305","CDM","54100","CPT","0761","RC","","","","both","","","4072.00","3054.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1559.58","38.3","","4632.18","4632.18","4632.18","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Biopsy Penis","PX-76001305","CDM","54100","CPT","0761","RC","","","","both","","","4072.00","3054.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1885.65","1885.65","1885.65","1 through 10","1262.32","3237.24","other","OPPS APC"
"Biopsy Penis","PX-76001305","CDM","54100","CPT","0761","RC","","","","both","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.65","1893.15","1893.65","1 through 10","1262.32","3237.24","other","OPPS APC"
"Biopsy Penis","PX-76001305","CDM","54100","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","AETNA [1001]","HB AMC AETNA HMO","2842.26","69.8","","2673.47","2673.47","2673.47","1 through 10","1237.95","3327.64","percent of total billed charges",""
"Biopsy Penis","PX-76001305","CDM","54100","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","3646.12","3646.12","1 through 10","1237.95","3327.64","other","ASC "
"Biopsy Penis","PX-76001305","CDM","54100","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2872.04","2872.04","2872.04","1 through 10","1237.95","3327.64","other","Multiple Surgery"
"Biopsy Penis","PX-76001305","CDM","54100","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3327.64","81.72","","1736.38","1736.38","1736.38","1 through 10","1237.95","3327.64","percent of total billed charges",""
"Biopsy Pleura Needle Perc","PX-76000819","CDM","32400","CPT","0761","RC","","","","both","","","2692.00","2019.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1769.51","1924.13","1 through 10","834.52","2404.92","other","OPPS APC"
"Biopsy Pleura Needle Perc","PX-76000819","CDM","32400","CPT","0761","RC","","","","both","","","2692.00","2019.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1887.65","1887.65","1887.65","1 through 10","834.52","2404.92","other","OPPS APC"
"Biopsy Pleura Needle Perc","PX-76000819","CDM","32400","CPT","0761","RC","","","","outpatient","","","2692.00","2019.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","3646.12","3646.12","1 through 10","1237.95","2384.07","other","ASC "
"Biopsy Pleura Needle Perc","PX-76000819","CDM","32400","CPT","0761","RC","","","","outpatient","","","2692.00","2019.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","8616.12","8616.12","1 through 10","1237.95","2384.07","other","Multiple Surgery"
"Biopsy Pleura Needle Perc","PX-76000819","CDM","32400","CPT","0761","RC","","","","outpatient","","","2692.00","2019.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","8727.54","8727.54","8727.54","1 through 10","1237.95","2384.07","other","Multiple Surgery"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2505.46","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2510.28","2504.28","2510.28","1 through 10","1169.63","3040.6","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2393.81","2393.81","2393.81","19","1169.63","3040.6","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2999.54","79.5","","9682.46","4805.32","25756.15","14","1169.63","3040.6","percent of total billed charges",""
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2011.01","53.3","","8388.62","8388.62","8388.62","1 through 10","1169.63","3040.6","percent of total billed charges",""
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2200.80","2200.80","2200.80","1 through 10","1169.63","3040.6","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","2905.21","77","","6421.80","6421.80","6421.80","1 through 10","1169.63","3040.6","percent of total billed charges",""
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2403.54","2403.54","2403.54","1 through 10","1169.63","3040.6","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","HUMANA [1012]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2398.67","2398.67","2398.67","1 through 10","1169.63","3040.6","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","MEDICARE [2001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2223.03","2432.73","20","1169.63","3040.6","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1445.06","38.3","","1430.67","1430.67","1430.67","1 through 10","1169.63","3040.6","percent of total billed charges",""
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2178.57","2178.57","2178.57","1 through 10","1169.63","3040.6","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2391.48","2186.37","2391.88","1 through 10","1169.63","3040.6","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2388.95","2180.57","2391.98","13","1169.63","3040.6","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3773.00","2829.75","WELLPOINT [1015]","HB AMC WELLPOINT","2783.72","73.78","","6209.13","2724.13","7989.97","1 through 10","1169.63","3040.6","percent of total billed charges",""
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","outpatient","","","3773.00","2829.75","AETNA [1001]","HB AMC AETNA HMO","2633.55","69.8","","5646.18","2477.14","8329.13","1 through 10","1565.78","3083.3","percent of total billed charges",""
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","outpatient","","","3773.00","2829.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","4611.66","4611.66","4611.66","1 through 10","1565.78","3083.3","other","ASC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","outpatient","","","3773.00","2829.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4611.66","4611.66","4611.66","1 through 10","1565.78","3083.3","other","ASC "
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","outpatient","","","3773.00","2829.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3632.61","3632.61","3632.61","1 through 10","1565.78","3083.3","other","Multiple Surgery"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","outpatient","","","3773.00","2829.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","11461.50","3820.50","11461.50","1 through 10","1565.78","3083.3","other","Multiple Surgery"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","outpatient","","","3773.00","2829.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","4008.40","4008.40","4008.40","1 through 10","1565.78","3083.3","other","Multiple Surgery"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","outpatient","","","3773.00","2829.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3083.30","81.72","","2925.00","2925.00","2925.00","1 through 10","1565.78","3083.3","percent of total billed charges",""
"Biopsy Renal Needle Perc","PX-76001222","CDM","50200","CPT","0761","RC","","","","both","","","2664.00","1998.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.35","1892.55","1893.55","1 through 10","825.84","2404.92","other","OPPS APC"
"Biopsy Renal Needle Perc","PX-76001222","CDM","50200","CPT","0761","RC","","","","outpatient","","","2664.00","1998.00","AETNA [1001]","HB AMC AETNA HMO","1859.47","69.8","","1642.74","1234.67","1642.74","1 through 10","1237.95","2384.07","percent of total billed charges",""
"Biopsy Soft Tissue Neck/Thorax","PX-76001981","CDM","21550","CPT","0761","RC","","","","outpatient","","","4216.00","3162.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3682.30","3682.30","3682.30","1 through 10","1237.95","3445.32","other","ASC "
"Biopsy Thyroid Needle Perc","PX-76001412","CDM","60100","CPT","0761","RC","","","","both","","","1459.00","1094.25","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","452.29","1159.91","other","OPPS APC"
"Biopsy Thyroid Needle Perc","PX-76001412","CDM","60100","CPT","0761","RC","","","","both","","","1459.00","1094.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","532.54","36.5","","448.56","448.56","448.56","1 through 10","452.29","1159.91","percent of total billed charges",""
"Biopsy Thyroid Needle Perc","PX-76001412","CDM","60100","CPT","0761","RC","","","","outpatient","","","1459.00","1094.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1355.50","1330.98","1355.50","1 through 10","579.34","1234.13","other","ASC"
"Biopsy Thyroid Needle Perc","PX-76001412","CDM","60100","CPT","0761","RC","","","","outpatient","","","1459.00","1094.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1550.94","767.85","1550.94","1 through 10","579.34","1234.13","other","ASC "
"Biopsy Tongue Anterior 2/3","PX-75000027","CDM","41100","CPT","0761","RC","","","","both","","","1898.00","1423.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","595.08","116.01","595.08","1 through 10","574.53","1508.91","other","OPPS APC"
"Biopsy Tongue Anterior 2/3","PX-75000027","CDM","41100","CPT","0761","RC","","","","both","","","1898.00","1423.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1508.91","79.5","","972.05","476.64","1448.87","1 through 10","574.53","1508.91","percent of total billed charges",""
"Biopsy Tongue Anterior 2/3","PX-75000027","CDM","41100","CPT","0761","RC","","","","both","","","1898.00","1423.50","MEDICARE [2001]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","604.76","604.76","604.76","1 through 10","574.53","1508.91","other","OPPS APC"
"Biopsy Tongue Anterior 2/3","PX-75000027","CDM","41100","CPT","0761","RC","","","","both","","","1898.00","1423.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.34","117.34","117.34","1 through 10","574.53","1508.91","other","OPPS APC"
"Biopsy Tongue Anterior 2/3","PX-75000027","CDM","41100","CPT","0761","RC","","","","both","","","1898.00","1423.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","726.93","38.3","","719.83","187.29","2159.49","1 through 10","574.53","1508.91","percent of total billed charges",""
"Biopsy Tongue Anterior 2/3","PX-75000027","CDM","41100","CPT","0761","RC","","","","both","","","1898.00","1423.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","592.61","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","444.50","86.25","444.50","1 through 10","574.53","1508.91","other","OPPS APC"
"Biopsy Tongue Anterior 2/3","PX-75000027","CDM","41100","CPT","0761","RC","","","","outpatient","","","1898.00","1423.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","557.06","","Case rate ($557.06). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","969.15","969.15","969.15","1 through 10","487.13","2384.07","other","ASC "
"Biopsy Tongue Anterior 2/3","PX-75000027","CDM","41100","CPT","0761","RC","","","","outpatient","","","1898.00","1423.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","487.13","","Case rate ($487.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3390.42","188.25","3390.42","1 through 10","487.13","2384.07","other","Multiple Surgery"
"Biopsy Tongue Anterior 2/3","PX-75000027","CDM","41100","CPT","0761","RC","","","","outpatient","","","1898.00","1423.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","487.13","","Case rate ($487.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1183.73","1183.73","1183.73","1 through 10","487.13","2384.07","other","Multiple Surgery"
"Biopsy Tongue Post 1/3","PX-75000028","CDM","41105","CPT","0761","RC","","","","outpatient","","","4327.00","3245.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2551.58","","Case rate ($2,551.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6254.83","6254.83","6254.83","1 through 10","2008.14","5545.35","other","ASC "
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","both","","","8007.00","6005.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","6418.94","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5997.75","5997.75","5997.75","1 through 10","2482.17","8023.68","other","OPPS APC"
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","both","","","8007.00","6005.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6365.57","79.5","","6105.15","6105.15","6105.15","1 through 10","2482.17","8023.68","percent of total billed charges",""
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","both","","","8007.00","6005.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5204.55","65","","5047.25","5047.25","5047.25","1 through 10","2482.17","8023.68","percent of total billed charges",""
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","both","","","8007.00","6005.25","MEDICARE [2001]","HB BWH MEDICARE","6418.94","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6419.59","5997.75","6419.59","1 through 10","2482.17","8023.68","other","OPPS APC"
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","both","","","8007.00","6005.25","WELLPOINT [1015]","HB AMC WELLPOINT","5907.56","73.78","","5781.04","5781.04","5781.04","1 through 10","2482.17","8023.68","percent of total billed charges",""
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","outpatient","","","8007.00","6005.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5004.80","","Case rate ($5,004.80). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","10239.82","10239.82","10239.82","1 through 10","2384.07","6543.32","other","ASC"
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","outpatient","","","8007.00","6005.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5004.80","","Case rate ($5,004.80). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","11716.24","11601.13","11716.24","1 through 10","2384.07","6543.32","other","ASC "
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","outpatient","","","8007.00","6005.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3938.87","","Case rate ($3,938.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","27414.54","27414.54","27414.54","1 through 10","2384.07","6543.32","other","Multiple Surgery"
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","outpatient","","","8007.00","6005.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6543.32","81.72","","3414.27","3414.27","3414.27","1 through 10","2384.07","6543.32","percent of total billed charges",""
"Biopsy Transcatheter","PX-76001138","CDM","37200","CPT","0761","RC","","","","outpatient","","","8007.00","6005.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6543.32","81.72","","10083.51","10083.51","10083.51","1 through 10","2384.07","6543.32","percent of total billed charges",""
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","both","","","1312.00","984.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1064.97","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","532.82","532.82","532.82","1 through 10","406.72","1292.44","other","OPPS APC"
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","both","","","1312.00","984.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.04","79.5","","1001.06","1001.06","1001.06","1 through 10","406.72","1292.44","percent of total billed charges",""
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","both","","","1312.00","984.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","699.30","53.3","","2033.87","671.62","2033.87","1 through 10","406.72","1292.44","percent of total billed charges",""
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","both","","","1312.00","984.00","MEDICARE [2001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1034.06","1034.06","1034.06","1 through 10","406.72","1292.44","other","OPPS APC"
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","both","","","1312.00","984.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.50","38.3","","497.35","483.36","1492.05","1 through 10","406.72","1292.44","percent of total billed charges",""
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","both","","","1312.00","984.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","859.86","859.86","859.86","1 through 10","406.72","1292.44","other","OPPS APC"
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","both","","","1312.00","984.00","WELLPOINT [1015]","HB AMC WELLPOINT","967.99","73.78","","2219.00","2219.00","2219.00","1 through 10","406.72","1292.44","percent of total billed charges",""
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","AETNA [1001]","HB AMC AETNA HMO","915.78","69.8","","608.02","608.02","5646.18","1 through 10","558.04","2384.07","percent of total billed charges",""
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","AETNA [1001]","HB AMC AETNA PPO","1054.85","80.4","","861.14","861.14","861.14","1 through 10","558.04","2384.07","percent of total billed charges",""
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1305.65","1282.04","1522.19","1 through 10","558.04","2384.07","other","ASC"
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1493.91","1479.23","1493.91","1 through 10","558.04","2384.07","other","ASC "
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1428.58","1272.33","1428.58","1 through 10","558.04","2384.07","other","Multiple Surgery"
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1294.65","1294.65","1294.65","1 through 10","558.04","2384.07","other","Multiple Surgery"
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1072.17","81.72","","1016.84","1016.84","1016.84","1 through 10","558.04","2384.07","percent of total billed charges",""
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1072.17","81.72","","1016.84","1016.84","1016.84","1 through 10","558.04","2384.07","percent of total billed charges",""
"Biopsy/Exc Lymph Node Axil Deep","PX-76001208","CDM","38525","CPT","0361","RC","","","","outpatient","","","7060.00","5295.00","AETNA [1001]","HB AMC AETNA HMO","4927.88","69.8","","10468.20","10468.20","10468.20","1 through 10","2824","5769.43","percent of total billed charges",""
"Biopsy/Exc Lymph Node Cerv Deep","PX-76001207","CDM","38510","CPT","0361","RC","","","","both","","","7060.00","5295.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2703.98","38.3","","23485.80","23485.80","23485.80","1 through 10","2188.6","5612.7","percent of total billed charges",""
"Biopsy/Exc Node Lymph Ndle Super","PX-76001206","CDM","38505","CPT","0761","RC","","","","both","","","2546.00","1909.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.35","1742.02","1893.55","18","789.26","2404.92","other","OPPS APC"
"Biopsy/Exc Node Lymph Ndle Super","PX-76001206","CDM","38505","CPT","0761","RC","","","","outpatient","","","2546.00","1909.50","AETNA [1001]","HB AMC AETNA HMO","1777.11","69.8","","1671.51","1671.51","1671.51","1 through 10","1237.95","2384.07","percent of total billed charges",""
"Biopsy/Exc Node Lymph Ndle Super","PX-76001206","CDM","38505","CPT","0761","RC","","","","outpatient","","","2546.00","1909.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2079.05","1903.82","3045.36","1 through 10","1237.95","2384.07","other","Multiple Surgery"
"Biotinidase Ea Specimen","PX-30000327","CDM","82261","CPT","0301","RC","","","","outpatient","","","178.00","133.50","AETNA [1001]","HB AMC AETNA HMO","124.24","69.8","","117.12","117.12","117.12","1 through 10","11.02","145.46","percent of total billed charges",""
"Biotinidase Ea Specimen","PX-30000327","CDM","82261","CPT","0301","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","145.46","81.72","","138.30","138.30","138.30","1 through 10","11.02","145.46","percent of total billed charges",""
"Birt-Hogg-Dube, Bhd (Flcn Deletion/Duplication Analysis)","PX-31000688","CDM","81479","CPT","0310","RC","","","","both","","","1407.00","1055.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1118.57","79.5","","0.65","0.65","0.65","1 through 10","436.17","1336.65","percent of total billed charges",""
"Birt-Hogg-Dube, Bhd (Flcn Deletion/Duplication Analysis)","PX-31000688","CDM","81479","CPT","0310","RC","","","","both","","","1407.00","1055.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","749.93","53.3","","0.79","0.79","0.79","1 through 10","436.17","1336.65","percent of total billed charges",""
"Birt-Hogg-Dube, Bhd (Flcn Deletion/Duplication Analysis)","PX-31000688","CDM","81479","CPT","0310","RC","","","","outpatient","","","1407.00","1055.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","703.50","50","","1.00","1.00","1.00","1 through 10","156.55","1160.78","percent of total billed charges",""
"Birt-Hogg-Dube, Bhd (Flcn Deletion/Duplication Analysis)","PX-31000688","CDM","81479","CPT","0310","RC","","","","outpatient","","","1407.00","1055.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","738.68","52.5","","1.00","0.53","1.00","1 through 10","156.55","1160.78","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"BLADE BONE 10.35X75MM HELICAL TFN ADVANCED","SUP-ITM-10164410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1285.88","79.5","","800.18","480.96","1887.97","195","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 10.35X75MM HELICAL TFN ADVANCED","SUP-ITM-10164410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","862.11","53.3","","813.12","216.42","1444.50","81","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 10.35X75MM HELICAL TFN ADVANCED","SUP-ITM-10164410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","501.41","31","","432.60","432.60","432.60","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 10.35X75MM HELICAL TFN ADVANCED","SUP-ITM-10164410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","590.37","36.5","","148.37","54.89","631.39","94","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 10.35X75MM HELICAL TFN ADVANCED","SUP-ITM-10164410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","619.49","38.3","","279.30","91.72","1116.77","266","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 10.35X75MM HELICAL TFN ADVANCED","SUP-ITM-10164410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.89","42.9","","731.00","63.70","731.00","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 10.35X75MM HELICAL TFN ADVANCED","SUP-ITM-10164410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.89","42.9","","384.74","384.74","384.74","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 10.35X75MM HELICAL TFN ADVANCED","SUP-ITM-10164410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","WELLPOINT [1015]","HB AMC WELLPOINT","1193.36","73.78","","286.63","119.22","1107.45","105","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 10.35X75MM HELICAL TFN ADVANCED","SUP-ITM-10164410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","AETNA [1001]","HB AMC AETNA HMO","1128.99","69.8","","675.31","184.75","1721.50","286","845.28","1321.79","percent of total billed charges",""
"BLADE BONE 10.35X75MM HELICAL TFN ADVANCED","SUP-ITM-10164410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","AETNA [1001]","HB AMC AETNA PPO","1300.44","80.4","","1261.44","103.12","1514.10","21","845.28","1321.79","percent of total billed charges",""
"BLADE BONE 10.35X75MM HELICAL TFN ADVANCED","SUP-ITM-10164410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1300.44","80.4","","1365.00","1365.00","1365.00","1 through 10","845.28","1321.79","percent of total billed charges",""
"BLADE BONE 10.35X75MM HELICAL TFN ADVANCED","SUP-ITM-10164410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1321.79","81.72","","5157.68","5157.68","5157.68","1 through 10","845.28","1321.79","percent of total billed charges",""
"BLADE BONE 10.35X75MM HELICAL TFN ADVANCED","SUP-ITM-10164410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1321.79","81.72","","431.26","71.26","1459.57","88","845.28","1321.79","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1779.33","1334.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1414.57","79.5","","800.18","480.96","1887.97","195","551.59","1414.57","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1779.33","1334.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","948.38","53.3","","813.12","216.42","1444.50","81","551.59","1414.57","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1779.33","1334.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","551.59","31","","432.60","432.60","432.60","1 through 10","551.59","1414.57","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1779.33","1334.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","649.46","36.5","","148.37","54.89","631.39","94","551.59","1414.57","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1779.33","1334.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","681.48","38.3","","279.30","91.72","1116.77","266","551.59","1414.57","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1779.33","1334.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","763.33","42.9","","731.00","63.70","731.00","1 through 10","551.59","1414.57","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1779.33","1334.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","763.33","42.9","","384.74","384.74","384.74","1 through 10","551.59","1414.57","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1779.33","1334.50","WELLPOINT [1015]","HB AMC WELLPOINT","1312.79","73.78","","286.63","119.22","1107.45","105","551.59","1414.57","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1779.33","1334.50","AETNA [1001]","HB AMC AETNA HMO","1241.97","69.8","","675.31","184.75","1721.50","286","929.88","1454.07","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1779.33","1334.50","AETNA [1001]","HB AMC AETNA PPO","1430.58","80.4","","1261.44","103.12","1514.10","21","929.88","1454.07","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1779.33","1334.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1430.58","80.4","","1365.00","1365.00","1365.00","1 through 10","929.88","1454.07","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1779.33","1334.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1454.07","81.72","","5157.68","5157.68","5157.68","1 through 10","929.88","1454.07","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1779.33","1334.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1454.07","81.72","","431.26","71.26","1459.57","88","929.88","1454.07","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1679.69","1259.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1335.35","79.5","","800.18","480.96","1887.97","195","520.7","1335.35","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1679.69","1259.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","895.27","53.3","","813.12","216.42","1444.50","81","520.7","1335.35","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1679.69","1259.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","520.70","31","","432.60","432.60","432.60","1 through 10","520.7","1335.35","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1679.69","1259.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","613.09","36.5","","148.37","54.89","631.39","94","520.7","1335.35","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1679.69","1259.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","643.32","38.3","","279.30","91.72","1116.77","266","520.7","1335.35","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1679.69","1259.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","720.59","42.9","","731.00","63.70","731.00","1 through 10","520.7","1335.35","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1679.69","1259.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","720.59","42.9","","384.74","384.74","384.74","1 through 10","520.7","1335.35","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1679.69","1259.77","WELLPOINT [1015]","HB AMC WELLPOINT","1239.28","73.78","","286.63","119.22","1107.45","105","520.7","1335.35","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1679.69","1259.77","AETNA [1001]","HB AMC AETNA HMO","1172.42","69.8","","675.31","184.75","1721.50","286","877.81","1372.64","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1679.69","1259.77","AETNA [1001]","HB AMC AETNA PPO","1350.47","80.4","","1261.44","103.12","1514.10","21","877.81","1372.64","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1679.69","1259.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1350.47","80.4","","1365.00","1365.00","1365.00","1 through 10","877.81","1372.64","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1679.69","1259.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1372.64","81.72","","5157.68","5157.68","5157.68","1 through 10","877.81","1372.64","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1679.69","1259.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1372.64","81.72","","431.26","71.26","1459.57","88","877.81","1372.64","percent of total billed charges",""
"BLADE BONE 11X80MM SPIRAL FOR HUMERAL NAIL TI","SUP-ITM-10018911","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.87","1550.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1643.96","79.5","","800.18","480.96","1887.97","195","641.04","1643.96","percent of total billed charges",""
"BLADE BONE 11X80MM SPIRAL FOR HUMERAL NAIL TI","SUP-ITM-10018911","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.87","1550.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1102.17","53.3","","813.12","216.42","1444.50","81","641.04","1643.96","percent of total billed charges",""
"BLADE BONE 11X80MM SPIRAL FOR HUMERAL NAIL TI","SUP-ITM-10018911","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.87","1550.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","641.04","31","","432.60","432.60","432.60","1 through 10","641.04","1643.96","percent of total billed charges",""
"BLADE BONE 11X80MM SPIRAL FOR HUMERAL NAIL TI","SUP-ITM-10018911","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.87","1550.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","754.77","36.5","","148.37","54.89","631.39","94","641.04","1643.96","percent of total billed charges",""
"BLADE BONE 11X80MM SPIRAL FOR HUMERAL NAIL TI","SUP-ITM-10018911","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.87","1550.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","791.99","38.3","","279.30","91.72","1116.77","266","641.04","1643.96","percent of total billed charges",""
"BLADE BONE 11X80MM SPIRAL FOR HUMERAL NAIL TI","SUP-ITM-10018911","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.87","1550.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","887.12","42.9","","731.00","63.70","731.00","1 through 10","641.04","1643.96","percent of total billed charges",""
"BLADE BONE 11X80MM SPIRAL FOR HUMERAL NAIL TI","SUP-ITM-10018911","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.87","1550.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","887.12","42.9","","384.74","384.74","384.74","1 through 10","641.04","1643.96","percent of total billed charges",""
"BLADE BONE 11X80MM SPIRAL FOR HUMERAL NAIL TI","SUP-ITM-10018911","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.87","1550.90","WELLPOINT [1015]","HB AMC WELLPOINT","1525.67","73.78","","286.63","119.22","1107.45","105","641.04","1643.96","percent of total billed charges",""
"BLADE BONE 11X80MM SPIRAL FOR HUMERAL NAIL TI","SUP-ITM-10018911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2067.87","1550.90","AETNA [1001]","HB AMC AETNA HMO","1443.37","69.8","","675.31","184.75","1721.50","286","1080.67","1689.86","percent of total billed charges",""
"BLADE BONE 11X80MM SPIRAL FOR HUMERAL NAIL TI","SUP-ITM-10018911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2067.87","1550.90","AETNA [1001]","HB AMC AETNA PPO","1662.57","80.4","","1261.44","103.12","1514.10","21","1080.67","1689.86","percent of total billed charges",""
"BLADE BONE 11X80MM SPIRAL FOR HUMERAL NAIL TI","SUP-ITM-10018911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2067.87","1550.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1662.57","80.4","","1365.00","1365.00","1365.00","1 through 10","1080.67","1689.86","percent of total billed charges",""
"BLADE BONE 11X80MM SPIRAL FOR HUMERAL NAIL TI","SUP-ITM-10018911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2067.87","1550.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1689.86","81.72","","5157.68","5157.68","5157.68","1 through 10","1080.67","1689.86","percent of total billed charges",""
"BLADE BONE 11X80MM SPIRAL FOR HUMERAL NAIL TI","SUP-ITM-10018911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2067.87","1550.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1689.86","81.72","","431.26","71.26","1459.57","88","1080.67","1689.86","percent of total billed charges",""
"BLADE BONE 120X11MM TROCHANTERIC FIXATION TI HELICAL","SUP-ITM-10009643","CDM","C1713","HCPCS","0278","RC","","","","both","","","1879.75","1409.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1494.40","79.5","","800.18","480.96","1887.97","195","582.72","1494.4","percent of total billed charges",""
"BLADE BONE 120X11MM TROCHANTERIC FIXATION TI HELICAL","SUP-ITM-10009643","CDM","C1713","HCPCS","0278","RC","","","","both","","","1879.75","1409.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1001.91","53.3","","813.12","216.42","1444.50","81","582.72","1494.4","percent of total billed charges",""
"BLADE BONE 120X11MM TROCHANTERIC FIXATION TI HELICAL","SUP-ITM-10009643","CDM","C1713","HCPCS","0278","RC","","","","both","","","1879.75","1409.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","582.72","31","","432.60","432.60","432.60","1 through 10","582.72","1494.4","percent of total billed charges",""
"BLADE BONE 120X11MM TROCHANTERIC FIXATION TI HELICAL","SUP-ITM-10009643","CDM","C1713","HCPCS","0278","RC","","","","both","","","1879.75","1409.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","686.11","36.5","","148.37","54.89","631.39","94","582.72","1494.4","percent of total billed charges",""
"BLADE BONE 120X11MM TROCHANTERIC FIXATION TI HELICAL","SUP-ITM-10009643","CDM","C1713","HCPCS","0278","RC","","","","both","","","1879.75","1409.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","719.94","38.3","","279.30","91.72","1116.77","266","582.72","1494.4","percent of total billed charges",""
"BLADE BONE 120X11MM TROCHANTERIC FIXATION TI HELICAL","SUP-ITM-10009643","CDM","C1713","HCPCS","0278","RC","","","","both","","","1879.75","1409.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","806.41","42.9","","731.00","63.70","731.00","1 through 10","582.72","1494.4","percent of total billed charges",""
"BLADE BONE 120X11MM TROCHANTERIC FIXATION TI HELICAL","SUP-ITM-10009643","CDM","C1713","HCPCS","0278","RC","","","","both","","","1879.75","1409.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","806.41","42.9","","384.74","384.74","384.74","1 through 10","582.72","1494.4","percent of total billed charges",""
"BLADE BONE 120X11MM TROCHANTERIC FIXATION TI HELICAL","SUP-ITM-10009643","CDM","C1713","HCPCS","0278","RC","","","","both","","","1879.75","1409.81","WELLPOINT [1015]","HB AMC WELLPOINT","1386.88","73.78","","286.63","119.22","1107.45","105","582.72","1494.4","percent of total billed charges",""
"BLADE BONE 120X11MM TROCHANTERIC FIXATION TI HELICAL","SUP-ITM-10009643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1879.75","1409.81","AETNA [1001]","HB AMC AETNA HMO","1312.07","69.8","","675.31","184.75","1721.50","286","982.36","1536.13","percent of total billed charges",""
"BLADE BONE 120X11MM TROCHANTERIC FIXATION TI HELICAL","SUP-ITM-10009643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1879.75","1409.81","AETNA [1001]","HB AMC AETNA PPO","1511.32","80.4","","1261.44","103.12","1514.10","21","982.36","1536.13","percent of total billed charges",""
"BLADE BONE 120X11MM TROCHANTERIC FIXATION TI HELICAL","SUP-ITM-10009643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1879.75","1409.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1511.32","80.4","","1365.00","1365.00","1365.00","1 through 10","982.36","1536.13","percent of total billed charges",""
"BLADE BONE 120X11MM TROCHANTERIC FIXATION TI HELICAL","SUP-ITM-10009643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1879.75","1409.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1536.13","81.72","","5157.68","5157.68","5157.68","1 through 10","982.36","1536.13","percent of total billed charges",""
"BLADE BONE 120X11MM TROCHANTERIC FIXATION TI HELICAL","SUP-ITM-10009643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1879.75","1409.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1536.13","81.72","","431.26","71.26","1459.57","88","982.36","1536.13","percent of total billed charges",""
"BLADE BONE 45MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1088.21","79.5","","800.18","480.96","1887.97","195","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 45MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","729.58","53.3","","813.12","216.42","1444.50","81","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 45MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","424.33","31","","432.60","432.60","432.60","1 through 10","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 45MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","499.62","36.5","","148.37","54.89","631.39","94","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 45MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","524.26","38.3","","279.30","91.72","1116.77","266","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 45MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","587.22","42.9","","731.00","63.70","731.00","1 through 10","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 45MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","587.22","42.9","","384.74","384.74","384.74","1 through 10","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 45MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","WELLPOINT [1015]","HB AMC WELLPOINT","1009.92","73.78","","286.63","119.22","1107.45","105","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 45MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","AETNA [1001]","HB AMC AETNA HMO","955.44","69.8","","675.31","184.75","1721.50","286","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 45MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","AETNA [1001]","HB AMC AETNA PPO","1100.53","80.4","","1261.44","103.12","1514.10","21","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 45MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1100.53","80.4","","1365.00","1365.00","1365.00","1 through 10","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 45MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1118.60","81.72","","5157.68","5157.68","5157.68","1 through 10","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 45MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1118.60","81.72","","431.26","71.26","1459.57","88","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 50MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1088.21","79.5","","800.18","480.96","1887.97","195","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 50MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","729.58","53.3","","813.12","216.42","1444.50","81","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 50MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","424.33","31","","432.60","432.60","432.60","1 through 10","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 50MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","499.62","36.5","","148.37","54.89","631.39","94","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 50MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","524.26","38.3","","279.30","91.72","1116.77","266","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 50MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","587.22","42.9","","731.00","63.70","731.00","1 through 10","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 50MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","587.22","42.9","","384.74","384.74","384.74","1 through 10","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 50MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","WELLPOINT [1015]","HB AMC WELLPOINT","1009.92","73.78","","286.63","119.22","1107.45","105","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 50MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","AETNA [1001]","HB AMC AETNA HMO","955.44","69.8","","675.31","184.75","1721.50","286","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 50MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","AETNA [1001]","HB AMC AETNA PPO","1100.53","80.4","","1261.44","103.12","1514.10","21","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 50MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1100.53","80.4","","1365.00","1365.00","1365.00","1 through 10","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 50MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1118.60","81.72","","5157.68","5157.68","5157.68","1 through 10","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 50MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1118.60","81.72","","431.26","71.26","1459.57","88","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 75MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020768","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1088.21","79.5","","800.18","480.96","1887.97","195","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 75MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020768","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","729.58","53.3","","813.12","216.42","1444.50","81","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 75MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020768","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","424.33","31","","432.60","432.60","432.60","1 through 10","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 75MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020768","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","499.62","36.5","","148.37","54.89","631.39","94","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 75MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020768","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","524.26","38.3","","279.30","91.72","1116.77","266","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 75MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020768","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","587.22","42.9","","731.00","63.70","731.00","1 through 10","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 75MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020768","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","587.22","42.9","","384.74","384.74","384.74","1 through 10","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 75MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020768","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.82","1026.61","WELLPOINT [1015]","HB AMC WELLPOINT","1009.92","73.78","","286.63","119.22","1107.45","105","424.33","1088.21","percent of total billed charges",""
"BLADE BONE 75MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","AETNA [1001]","HB AMC AETNA HMO","955.44","69.8","","675.31","184.75","1721.50","286","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 75MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","AETNA [1001]","HB AMC AETNA PPO","1100.53","80.4","","1261.44","103.12","1514.10","21","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 75MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1100.53","80.4","","1365.00","1365.00","1365.00","1 through 10","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 75MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1118.60","81.72","","5157.68","5157.68","5157.68","1 through 10","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 75MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.82","1026.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1118.60","81.72","","431.26","71.26","1459.57","88","715.35","1118.6","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1285.88","79.5","","800.18","480.96","1887.97","195","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","862.11","53.3","","813.12","216.42","1444.50","81","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","501.41","31","","432.60","432.60","432.60","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","590.37","36.5","","148.37","54.89","631.39","94","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","619.49","38.3","","279.30","91.72","1116.77","266","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.89","42.9","","731.00","63.70","731.00","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.89","42.9","","384.74","384.74","384.74","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","WELLPOINT [1015]","HB AMC WELLPOINT","1193.36","73.78","","286.63","119.22","1107.45","105","501.41","1285.88","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","AETNA [1001]","HB AMC AETNA HMO","1128.99","69.8","","675.31","184.75","1721.50","286","845.28","1321.79","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","AETNA [1001]","HB AMC AETNA PPO","1300.44","80.4","","1261.44","103.12","1514.10","21","845.28","1321.79","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1300.44","80.4","","1365.00","1365.00","1365.00","1 through 10","845.28","1321.79","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1321.79","81.72","","5157.68","5157.68","5157.68","1 through 10","845.28","1321.79","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1321.79","81.72","","431.26","71.26","1459.57","88","845.28","1321.79","percent of total billed charges",""
"BLADE BONE 90X11MM TROCHANTERIC FIXATION TITANIUM HELICAL STERILE","SUP-ITM-10011766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1822.49","1366.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1448.88","79.5","","800.18","480.96","1887.97","195","564.97","1448.88","percent of total billed charges",""
"BLADE BONE 90X11MM TROCHANTERIC FIXATION TITANIUM HELICAL STERILE","SUP-ITM-10011766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1822.49","1366.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","971.39","53.3","","813.12","216.42","1444.50","81","564.97","1448.88","percent of total billed charges",""
"BLADE BONE 90X11MM TROCHANTERIC FIXATION TITANIUM HELICAL STERILE","SUP-ITM-10011766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1822.49","1366.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","564.97","31","","432.60","432.60","432.60","1 through 10","564.97","1448.88","percent of total billed charges",""
"BLADE BONE 90X11MM TROCHANTERIC FIXATION TITANIUM HELICAL STERILE","SUP-ITM-10011766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1822.49","1366.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","665.21","36.5","","148.37","54.89","631.39","94","564.97","1448.88","percent of total billed charges",""
"BLADE BONE 90X11MM TROCHANTERIC FIXATION TITANIUM HELICAL STERILE","SUP-ITM-10011766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1822.49","1366.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","698.01","38.3","","279.30","91.72","1116.77","266","564.97","1448.88","percent of total billed charges",""
"BLADE BONE 90X11MM TROCHANTERIC FIXATION TITANIUM HELICAL STERILE","SUP-ITM-10011766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1822.49","1366.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","781.85","42.9","","731.00","63.70","731.00","1 through 10","564.97","1448.88","percent of total billed charges",""
"BLADE BONE 90X11MM TROCHANTERIC FIXATION TITANIUM HELICAL STERILE","SUP-ITM-10011766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1822.49","1366.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","781.85","42.9","","384.74","384.74","384.74","1 through 10","564.97","1448.88","percent of total billed charges",""
"BLADE BONE 90X11MM TROCHANTERIC FIXATION TITANIUM HELICAL STERILE","SUP-ITM-10011766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1822.49","1366.87","WELLPOINT [1015]","HB AMC WELLPOINT","1344.63","73.78","","286.63","119.22","1107.45","105","564.97","1448.88","percent of total billed charges",""
"BLADE BONE 90X11MM TROCHANTERIC FIXATION TITANIUM HELICAL STERILE","SUP-ITM-10011766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1822.49","1366.87","AETNA [1001]","HB AMC AETNA HMO","1272.10","69.8","","675.31","184.75","1721.50","286","952.43","1489.34","percent of total billed charges",""
"BLADE BONE 90X11MM TROCHANTERIC FIXATION TITANIUM HELICAL STERILE","SUP-ITM-10011766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1822.49","1366.87","AETNA [1001]","HB AMC AETNA PPO","1465.28","80.4","","1261.44","103.12","1514.10","21","952.43","1489.34","percent of total billed charges",""
"BLADE BONE 90X11MM TROCHANTERIC FIXATION TITANIUM HELICAL STERILE","SUP-ITM-10011766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1822.49","1366.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1465.28","80.4","","1365.00","1365.00","1365.00","1 through 10","952.43","1489.34","percent of total billed charges",""
"BLADE BONE 90X11MM TROCHANTERIC FIXATION TITANIUM HELICAL STERILE","SUP-ITM-10011766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1822.49","1366.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1489.34","81.72","","5157.68","5157.68","5157.68","1 through 10","952.43","1489.34","percent of total billed charges",""
"BLADE BONE 90X11MM TROCHANTERIC FIXATION TITANIUM HELICAL STERILE","SUP-ITM-10011766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1822.49","1366.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1489.34","81.72","","431.26","71.26","1459.57","88","952.43","1489.34","percent of total billed charges",""
"BLADE HELICAL 10.5X115MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244701","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1285.88","79.5","","800.18","480.96","1887.97","195","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X115MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244701","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","862.11","53.3","","813.12","216.42","1444.50","81","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X115MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244701","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","501.41","31","","432.60","432.60","432.60","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X115MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244701","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","590.37","36.5","","148.37","54.89","631.39","94","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X115MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244701","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","619.49","38.3","","279.30","91.72","1116.77","266","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X115MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244701","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.89","42.9","","731.00","63.70","731.00","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X115MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244701","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.89","42.9","","384.74","384.74","384.74","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X115MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244701","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","WELLPOINT [1015]","HB AMC WELLPOINT","1193.36","73.78","","286.63","119.22","1107.45","105","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X115MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","AETNA [1001]","HB AMC AETNA HMO","1128.99","69.8","","675.31","184.75","1721.50","286","845.28","1321.79","percent of total billed charges",""
"BLADE HELICAL 10.5X115MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","AETNA [1001]","HB AMC AETNA PPO","1300.44","80.4","","1261.44","103.12","1514.10","21","845.28","1321.79","percent of total billed charges",""
"BLADE HELICAL 10.5X115MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1300.44","80.4","","1365.00","1365.00","1365.00","1 through 10","845.28","1321.79","percent of total billed charges",""
"BLADE HELICAL 10.5X115MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1321.79","81.72","","5157.68","5157.68","5157.68","1 through 10","845.28","1321.79","percent of total billed charges",""
"BLADE HELICAL 10.5X115MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1321.79","81.72","","431.26","71.26","1459.57","88","845.28","1321.79","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1285.88","79.5","","800.18","480.96","1887.97","195","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","862.11","53.3","","813.12","216.42","1444.50","81","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","501.41","31","","432.60","432.60","432.60","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","590.37","36.5","","148.37","54.89","631.39","94","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","619.49","38.3","","279.30","91.72","1116.77","266","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.89","42.9","","731.00","63.70","731.00","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.89","42.9","","384.74","384.74","384.74","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","WELLPOINT [1015]","HB AMC WELLPOINT","1193.36","73.78","","286.63","119.22","1107.45","105","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","AETNA [1001]","HB AMC AETNA HMO","1128.99","69.8","","675.31","184.75","1721.50","286","845.28","1321.79","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","AETNA [1001]","HB AMC AETNA PPO","1300.44","80.4","","1261.44","103.12","1514.10","21","845.28","1321.79","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1300.44","80.4","","1365.00","1365.00","1365.00","1 through 10","845.28","1321.79","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1321.79","81.72","","5157.68","5157.68","5157.68","1 through 10","845.28","1321.79","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1321.79","81.72","","431.26","71.26","1459.57","88","845.28","1321.79","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","845.28","52.26","","1113.10","1113.10","1113.10","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1285.88","79.5","","1293.60","1148.53","1603.80","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","590.37","36.5","","1023.42","771.29","2068.67","33","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","619.49","38.3","","850.52","759.78","1211.25","66","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.89","42.9","","2548.09","2548.09","2548.09","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.89","42.9","","956.46","956.46","956.46","1 through 10","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","both","","","1617.46","1213.09","WELLPOINT [1015]","HB AMC WELLPOINT","1193.36","73.78","","2344.73","1619.47","2530.35","16","501.41","1285.88","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","AETNA [1001]","HB AMC AETNA HMO","1128.99","69.8","","1523.63","988.41","4330.26","39","845.28","1321.79","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","AETNA [1001]","HB AMC AETNA PPO","1300.44","80.4","","1670.25","1670.25","1670.25","1 through 10","845.28","1321.79","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","845.28","52.26","","1113.10","1113.10","1113.10","1 through 10","845.28","1321.79","percent of total billed charges",""
"BLADE HELICAL 10.5X90MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1617.46","1213.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1321.79","81.72","","1738.90","1484.65","2716.94","38","845.28","1321.79","percent of total billed charges",""
"BLADE HYSTEROSCOPY 2.9MM TRUCLEAR MORCELLATOR INCISOR PLUS","SUP-ITM-10113777","CDM","C1782","HCPCS","0272","RC","","","","both","","","1995.00","1496.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1586.03","79.5","","3677.25","3677.25","3677.25","1 through 10","618.45","1586.03","percent of total billed charges",""
"BLADE HYSTEROSCOPY 4MM TRUCLEAR MORCELLATOR ROTARY","SUP-ITM-10023173","CDM","C1782","HCPCS","0272","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","3677.25","3677.25","3677.25","1 through 10","482.83","1238.21","percent of total billed charges",""
"BLADE OSTEOTOME 10MM BONE","SUP-ITM-10021009","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.00","372.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","395.12","79.5","","800.18","480.96","1887.97","195","154.07","395.12","percent of total billed charges",""
"BLADE OSTEOTOME 10MM BONE","SUP-ITM-10021009","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.00","372.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","264.90","53.3","","813.12","216.42","1444.50","81","154.07","395.12","percent of total billed charges",""
"BLADE OSTEOTOME 10MM BONE","SUP-ITM-10021009","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.00","372.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","154.07","31","","432.60","432.60","432.60","1 through 10","154.07","395.12","percent of total billed charges",""
"BLADE OSTEOTOME 10MM BONE","SUP-ITM-10021009","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.00","372.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","181.41","36.5","","148.37","54.89","631.39","94","154.07","395.12","percent of total billed charges",""
"BLADE OSTEOTOME 10MM BONE","SUP-ITM-10021009","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.00","372.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","190.35","38.3","","279.30","91.72","1116.77","266","154.07","395.12","percent of total billed charges",""
"BLADE OSTEOTOME 10MM BONE","SUP-ITM-10021009","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.00","372.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.21","42.9","","731.00","63.70","731.00","1 through 10","154.07","395.12","percent of total billed charges",""
"BLADE OSTEOTOME 10MM BONE","SUP-ITM-10021009","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.00","372.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.21","42.9","","384.74","384.74","384.74","1 through 10","154.07","395.12","percent of total billed charges",""
"BLADE OSTEOTOME 10MM BONE","SUP-ITM-10021009","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.00","372.75","WELLPOINT [1015]","HB AMC WELLPOINT","366.69","73.78","","286.63","119.22","1107.45","105","154.07","395.12","percent of total billed charges",""
"BLADE OSTEOTOME 10MM BONE","SUP-ITM-10021009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","497.00","372.75","AETNA [1001]","HB AMC AETNA HMO","346.91","69.8","","675.31","184.75","1721.50","286","259.73","406.15","percent of total billed charges",""
"BLADE OSTEOTOME 10MM BONE","SUP-ITM-10021009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","497.00","372.75","AETNA [1001]","HB AMC AETNA PPO","399.59","80.4","","1261.44","103.12","1514.10","21","259.73","406.15","percent of total billed charges",""
"BLADE OSTEOTOME 10MM BONE","SUP-ITM-10021009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","497.00","372.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","399.59","80.4","","1365.00","1365.00","1365.00","1 through 10","259.73","406.15","percent of total billed charges",""
"BLADE OSTEOTOME 10MM BONE","SUP-ITM-10021009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","497.00","372.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","406.15","81.72","","5157.68","5157.68","5157.68","1 through 10","259.73","406.15","percent of total billed charges",""
"BLADE OSTEOTOME 10MM BONE","SUP-ITM-10021009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","497.00","372.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","406.15","81.72","","431.26","71.26","1459.57","88","259.73","406.15","percent of total billed charges",""
"BLADE RECIPROCATING 4MM MORCELLATOR TRUCLEAR ULTRA HYSTEROSCOPIC","SUP-ITM-10113776","CDM","C1782","HCPCS","0272","RC","","","","both","","","2625.00","1968.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2086.88","79.5","","3677.25","3677.25","3677.25","1 through 10","813.75","2086.88","percent of total billed charges",""
"BLADE SURGICAL 36MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10012087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.94","79.5","","800.18","480.96","1887.97","195","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 36MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10012087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","699.90","53.3","","813.12","216.42","1444.50","81","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 36MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10012087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","407.07","31","","432.60","432.60","432.60","1 through 10","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 36MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10012087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","479.29","36.5","","148.37","54.89","631.39","94","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 36MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10012087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.93","38.3","","279.30","91.72","1116.77","266","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 36MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10012087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.33","42.9","","731.00","63.70","731.00","1 through 10","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 36MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10012087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.33","42.9","","384.74","384.74","384.74","1 through 10","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 36MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10012087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","WELLPOINT [1015]","HB AMC WELLPOINT","968.83","73.78","","286.63","119.22","1107.45","105","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 36MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10012087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","AETNA [1001]","HB AMC AETNA HMO","916.56","69.8","","675.31","184.75","1721.50","286","686.24","1073.09","percent of total billed charges",""
"BLADE SURGICAL 36MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10012087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","AETNA [1001]","HB AMC AETNA PPO","1055.76","80.4","","1261.44","103.12","1514.10","21","686.24","1073.09","percent of total billed charges",""
"BLADE SURGICAL 36MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10012087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1055.76","80.4","","1365.00","1365.00","1365.00","1 through 10","686.24","1073.09","percent of total billed charges",""
"BLADE SURGICAL 36MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10012087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1073.09","81.72","","5157.68","5157.68","5157.68","1 through 10","686.24","1073.09","percent of total billed charges",""
"BLADE SURGICAL 36MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10012087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1073.09","81.72","","431.26","71.26","1459.57","88","686.24","1073.09","percent of total billed charges",""
"BLADE SURGICAL 42MM SPIRAL INTRAMEDULLARY TI HUMERAL","SUP-ITM-10017531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.94","79.5","","800.18","480.96","1887.97","195","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 42MM SPIRAL INTRAMEDULLARY TI HUMERAL","SUP-ITM-10017531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","699.90","53.3","","813.12","216.42","1444.50","81","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 42MM SPIRAL INTRAMEDULLARY TI HUMERAL","SUP-ITM-10017531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","407.07","31","","432.60","432.60","432.60","1 through 10","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 42MM SPIRAL INTRAMEDULLARY TI HUMERAL","SUP-ITM-10017531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","479.29","36.5","","148.37","54.89","631.39","94","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 42MM SPIRAL INTRAMEDULLARY TI HUMERAL","SUP-ITM-10017531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.93","38.3","","279.30","91.72","1116.77","266","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 42MM SPIRAL INTRAMEDULLARY TI HUMERAL","SUP-ITM-10017531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.33","42.9","","731.00","63.70","731.00","1 through 10","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 42MM SPIRAL INTRAMEDULLARY TI HUMERAL","SUP-ITM-10017531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.33","42.9","","384.74","384.74","384.74","1 through 10","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 42MM SPIRAL INTRAMEDULLARY TI HUMERAL","SUP-ITM-10017531","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","WELLPOINT [1015]","HB AMC WELLPOINT","968.83","73.78","","286.63","119.22","1107.45","105","407.07","1043.94","percent of total billed charges",""
"BLADE SURGICAL 42MM SPIRAL INTRAMEDULLARY TI HUMERAL","SUP-ITM-10017531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","AETNA [1001]","HB AMC AETNA HMO","916.56","69.8","","675.31","184.75","1721.50","286","686.24","1073.09","percent of total billed charges",""
"BLADE SURGICAL 42MM SPIRAL INTRAMEDULLARY TI HUMERAL","SUP-ITM-10017531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","AETNA [1001]","HB AMC AETNA PPO","1055.76","80.4","","1261.44","103.12","1514.10","21","686.24","1073.09","percent of total billed charges",""
"BLADE SURGICAL 42MM SPIRAL INTRAMEDULLARY TI HUMERAL","SUP-ITM-10017531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1055.76","80.4","","1365.00","1365.00","1365.00","1 through 10","686.24","1073.09","percent of total billed charges",""
"BLADE SURGICAL 42MM SPIRAL INTRAMEDULLARY TI HUMERAL","SUP-ITM-10017531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1073.09","81.72","","5157.68","5157.68","5157.68","1 through 10","686.24","1073.09","percent of total billed charges",""
"BLADE SURGICAL 42MM SPIRAL INTRAMEDULLARY TI HUMERAL","SUP-ITM-10017531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1073.09","81.72","","431.26","71.26","1459.57","88","686.24","1073.09","percent of total billed charges",""
"Blastomyces Antibody","PX-30000887","CDM","86612","CPT","0302","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","66.47","66.47","66.47","1 through 10","12.64","166.25","percent of total billed charges",""
"BLOCK AUGMENT 10.0MM SIZE 2 TIBIAL NEXGEN TRABECULAR METAL LEFT LATERAL RIGHT MEDIAL","SUP-ITM-10016406","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2469.29","52.26","","1113.10","1113.10","1113.10","1 through 10","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 10.0MM SIZE 2 TIBIAL NEXGEN TRABECULAR METAL LEFT LATERAL RIGHT MEDIAL","SUP-ITM-10016406","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3756.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 10.0MM SIZE 2 TIBIAL NEXGEN TRABECULAR METAL LEFT LATERAL RIGHT MEDIAL","SUP-ITM-10016406","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1724.63","36.5","","1023.42","771.29","2068.67","33","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 10.0MM SIZE 2 TIBIAL NEXGEN TRABECULAR METAL LEFT LATERAL RIGHT MEDIAL","SUP-ITM-10016406","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1809.68","38.3","","850.52","759.78","1211.25","66","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 10.0MM SIZE 2 TIBIAL NEXGEN TRABECULAR METAL LEFT LATERAL RIGHT MEDIAL","SUP-ITM-10016406","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","2548.09","2548.09","2548.09","1 through 10","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 10.0MM SIZE 2 TIBIAL NEXGEN TRABECULAR METAL LEFT LATERAL RIGHT MEDIAL","SUP-ITM-10016406","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","956.46","956.46","956.46","1 through 10","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 10.0MM SIZE 2 TIBIAL NEXGEN TRABECULAR METAL LEFT LATERAL RIGHT MEDIAL","SUP-ITM-10016406","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","WELLPOINT [1015]","HB AMC WELLPOINT","3486.11","73.78","","2344.73","1619.47","2530.35","16","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 10.0MM SIZE 2 TIBIAL NEXGEN TRABECULAR METAL LEFT LATERAL RIGHT MEDIAL","SUP-ITM-10016406","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA HMO","3298.05","69.8","","1523.63","988.41","4330.26","39","2469.29","3861.27","percent of total billed charges",""
"BLOCK AUGMENT 10.0MM SIZE 2 TIBIAL NEXGEN TRABECULAR METAL LEFT LATERAL RIGHT MEDIAL","SUP-ITM-10016406","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA PPO","3798.90","80.4","","1670.25","1670.25","1670.25","1 through 10","2469.29","3861.27","percent of total billed charges",""
"BLOCK AUGMENT 10.0MM SIZE 2 TIBIAL NEXGEN TRABECULAR METAL LEFT LATERAL RIGHT MEDIAL","SUP-ITM-10016406","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2469.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2469.29","3861.27","percent of total billed charges",""
"BLOCK AUGMENT 10.0MM SIZE 2 TIBIAL NEXGEN TRABECULAR METAL LEFT LATERAL RIGHT MEDIAL","SUP-ITM-10016406","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3861.27","81.72","","1738.90","1484.65","2716.94","38","2469.29","3861.27","percent of total billed charges",""
"BLOCK AUGMENT 10MM KNEE FEMORAL NEXGEN TIVANIUM PRECOAT POSTERIOR SIZE E 09","SUP-ITM-10018043","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","896.90","52.26","","1113.10","1113.10","1113.10","1 through 10","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM KNEE FEMORAL NEXGEN TIVANIUM PRECOAT POSTERIOR SIZE E 09","SUP-ITM-10018043","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1364.40","79.5","","1293.60","1148.53","1603.80","1 through 10","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM KNEE FEMORAL NEXGEN TIVANIUM PRECOAT POSTERIOR SIZE E 09","SUP-ITM-10018043","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","626.42","36.5","","1023.42","771.29","2068.67","33","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM KNEE FEMORAL NEXGEN TIVANIUM PRECOAT POSTERIOR SIZE E 09","SUP-ITM-10018043","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","657.32","38.3","","850.52","759.78","1211.25","66","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM KNEE FEMORAL NEXGEN TIVANIUM PRECOAT POSTERIOR SIZE E 09","SUP-ITM-10018043","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","736.26","42.9","","2548.09","2548.09","2548.09","1 through 10","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM KNEE FEMORAL NEXGEN TIVANIUM PRECOAT POSTERIOR SIZE E 09","SUP-ITM-10018043","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","736.26","42.9","","956.46","956.46","956.46","1 through 10","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM KNEE FEMORAL NEXGEN TIVANIUM PRECOAT POSTERIOR SIZE E 09","SUP-ITM-10018043","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","WELLPOINT [1015]","HB AMC WELLPOINT","1266.23","73.78","","2344.73","1619.47","2530.35","16","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM KNEE FEMORAL NEXGEN TIVANIUM PRECOAT POSTERIOR SIZE E 09","SUP-ITM-10018043","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","AETNA [1001]","HB AMC AETNA HMO","1197.93","69.8","","1523.63","988.41","4330.26","39","896.9","1402.5","percent of total billed charges",""
"BLOCK AUGMENT 10MM KNEE FEMORAL NEXGEN TIVANIUM PRECOAT POSTERIOR SIZE E 09","SUP-ITM-10018043","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","AETNA [1001]","HB AMC AETNA PPO","1379.85","80.4","","1670.25","1670.25","1670.25","1 through 10","896.9","1402.5","percent of total billed charges",""
"BLOCK AUGMENT 10MM KNEE FEMORAL NEXGEN TIVANIUM PRECOAT POSTERIOR SIZE E 09","SUP-ITM-10018043","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","896.90","52.26","","1113.10","1113.10","1113.10","1 through 10","896.9","1402.5","percent of total billed charges",""
"BLOCK AUGMENT 10MM KNEE FEMORAL NEXGEN TIVANIUM PRECOAT POSTERIOR SIZE E 09","SUP-ITM-10018043","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1402.50","81.72","","1738.90","1484.65","2716.94","38","896.9","1402.5","percent of total billed charges",""
"BLOCK AUGMENT 10MM SIZE 3 KNEE NEXGEN TIVANIUM HALF PRECOATED TIBIAL 598800310","SUP-ITM-10079068","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","896.90","52.26","","1113.10","1113.10","1113.10","1 through 10","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM SIZE 3 KNEE NEXGEN TIVANIUM HALF PRECOATED TIBIAL 598800310","SUP-ITM-10079068","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1364.40","79.5","","1293.60","1148.53","1603.80","1 through 10","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM SIZE 3 KNEE NEXGEN TIVANIUM HALF PRECOATED TIBIAL 598800310","SUP-ITM-10079068","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","626.42","36.5","","1023.42","771.29","2068.67","33","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM SIZE 3 KNEE NEXGEN TIVANIUM HALF PRECOATED TIBIAL 598800310","SUP-ITM-10079068","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","657.32","38.3","","850.52","759.78","1211.25","66","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM SIZE 3 KNEE NEXGEN TIVANIUM HALF PRECOATED TIBIAL 598800310","SUP-ITM-10079068","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","736.26","42.9","","2548.09","2548.09","2548.09","1 through 10","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM SIZE 3 KNEE NEXGEN TIVANIUM HALF PRECOATED TIBIAL 598800310","SUP-ITM-10079068","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","736.26","42.9","","956.46","956.46","956.46","1 through 10","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM SIZE 3 KNEE NEXGEN TIVANIUM HALF PRECOATED TIBIAL 598800310","SUP-ITM-10079068","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","WELLPOINT [1015]","HB AMC WELLPOINT","1266.23","73.78","","2344.73","1619.47","2530.35","16","532.03","1364.4","percent of total billed charges",""
"BLOCK AUGMENT 10MM SIZE 3 KNEE NEXGEN TIVANIUM HALF PRECOATED TIBIAL 598800310","SUP-ITM-10079068","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","AETNA [1001]","HB AMC AETNA HMO","1197.93","69.8","","1523.63","988.41","4330.26","39","896.9","1402.5","percent of total billed charges",""
"BLOCK AUGMENT 10MM SIZE 3 KNEE NEXGEN TIVANIUM HALF PRECOATED TIBIAL 598800310","SUP-ITM-10079068","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","AETNA [1001]","HB AMC AETNA PPO","1379.85","80.4","","1670.25","1670.25","1670.25","1 through 10","896.9","1402.5","percent of total billed charges",""
"BLOCK AUGMENT 10MM SIZE 3 KNEE NEXGEN TIVANIUM HALF PRECOATED TIBIAL 598800310","SUP-ITM-10079068","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","896.90","52.26","","1113.10","1113.10","1113.10","1 through 10","896.9","1402.5","percent of total billed charges",""
"BLOCK AUGMENT 10MM SIZE 3 KNEE NEXGEN TIVANIUM HALF PRECOATED TIBIAL 598800310","SUP-ITM-10079068","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1402.50","81.72","","1738.90","1484.65","2716.94","38","896.9","1402.5","percent of total billed charges",""
"BLOCK AUGMENT 3 10MM SIZE FU TRABECULAR METAL TIBIAL","SUP-ITM-10017186","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2469.29","52.26","","1113.10","1113.10","1113.10","1 through 10","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 3 10MM SIZE FU TRABECULAR METAL TIBIAL","SUP-ITM-10017186","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3756.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 3 10MM SIZE FU TRABECULAR METAL TIBIAL","SUP-ITM-10017186","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1724.63","36.5","","1023.42","771.29","2068.67","33","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 3 10MM SIZE FU TRABECULAR METAL TIBIAL","SUP-ITM-10017186","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1809.68","38.3","","850.52","759.78","1211.25","66","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 3 10MM SIZE FU TRABECULAR METAL TIBIAL","SUP-ITM-10017186","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","2548.09","2548.09","2548.09","1 through 10","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 3 10MM SIZE FU TRABECULAR METAL TIBIAL","SUP-ITM-10017186","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","956.46","956.46","956.46","1 through 10","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 3 10MM SIZE FU TRABECULAR METAL TIBIAL","SUP-ITM-10017186","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","WELLPOINT [1015]","HB AMC WELLPOINT","3486.11","73.78","","2344.73","1619.47","2530.35","16","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 3 10MM SIZE FU TRABECULAR METAL TIBIAL","SUP-ITM-10017186","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA HMO","3298.05","69.8","","1523.63","988.41","4330.26","39","2469.29","3861.27","percent of total billed charges",""
"BLOCK AUGMENT 3 10MM SIZE FU TRABECULAR METAL TIBIAL","SUP-ITM-10017186","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA PPO","3798.90","80.4","","1670.25","1670.25","1670.25","1 through 10","2469.29","3861.27","percent of total billed charges",""
"BLOCK AUGMENT 3 10MM SIZE FU TRABECULAR METAL TIBIAL","SUP-ITM-10017186","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2469.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2469.29","3861.27","percent of total billed charges",""
"BLOCK AUGMENT 3 10MM SIZE FU TRABECULAR METAL TIBIAL","SUP-ITM-10017186","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3861.27","81.72","","1738.90","1484.65","2716.94","38","2469.29","3861.27","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2469.29","52.26","","1113.10","1113.10","1113.10","1 through 10","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3756.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1724.63","36.5","","1023.42","771.29","2068.67","33","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1809.68","38.3","","850.52","759.78","1211.25","66","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","2548.09","2548.09","2548.09","1 through 10","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","956.46","956.46","956.46","1 through 10","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","WELLPOINT [1015]","HB AMC WELLPOINT","3486.11","73.78","","2344.73","1619.47","2530.35","16","1464.75","3756.38","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA HMO","3298.05","69.8","","1523.63","988.41","4330.26","39","2469.29","3861.27","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA PPO","3798.90","80.4","","1670.25","1670.25","1670.25","1 through 10","2469.29","3861.27","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2469.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2469.29","3861.27","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3861.27","81.72","","1738.90","1484.65","2716.94","38","2469.29","3861.27","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1139.53","52.26","","1113.10","1113.10","1113.10","1 through 10","675.96","1733.5","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1733.50","79.5","","1293.60","1148.53","1603.80","1 through 10","675.96","1733.5","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","795.88","36.5","","1023.42","771.29","2068.67","33","675.96","1733.5","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","835.13","38.3","","850.52","759.78","1211.25","66","675.96","1733.5","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","935.43","42.9","","2548.09","2548.09","2548.09","1 through 10","675.96","1733.5","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","935.43","42.9","","956.46","956.46","956.46","1 through 10","675.96","1733.5","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","WELLPOINT [1015]","HB AMC WELLPOINT","1608.77","73.78","","2344.73","1619.47","2530.35","16","675.96","1733.5","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","AETNA [1001]","HB AMC AETNA HMO","1521.99","69.8","","1523.63","988.41","4330.26","39","1139.53","1781.9","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","AETNA [1001]","HB AMC AETNA PPO","1753.12","80.4","","1670.25","1670.25","1670.25","1 through 10","1139.53","1781.9","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1139.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1139.53","1781.9","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1781.90","81.72","","1738.90","1484.65","2716.94","38","1139.53","1781.9","percent of total billed charges",""
"BLOCK KNEE 65X5MM AUGMENT FEMORAL VANGUARD 360 DISTAL RT LATERAL LT MAIN 10","SUP-ITM-10117697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","896.90","52.26","","1113.10","1113.10","1113.10","1 through 10","532.03","1364.4","percent of total billed charges",""
"BLOCK KNEE 65X5MM AUGMENT FEMORAL VANGUARD 360 DISTAL RT LATERAL LT MAIN 10","SUP-ITM-10117697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1364.40","79.5","","1293.60","1148.53","1603.80","1 through 10","532.03","1364.4","percent of total billed charges",""
"BLOCK KNEE 65X5MM AUGMENT FEMORAL VANGUARD 360 DISTAL RT LATERAL LT MAIN 10","SUP-ITM-10117697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","626.42","36.5","","1023.42","771.29","2068.67","33","532.03","1364.4","percent of total billed charges",""
"BLOCK KNEE 65X5MM AUGMENT FEMORAL VANGUARD 360 DISTAL RT LATERAL LT MAIN 10","SUP-ITM-10117697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","657.32","38.3","","850.52","759.78","1211.25","66","532.03","1364.4","percent of total billed charges",""
"BLOCK KNEE 65X5MM AUGMENT FEMORAL VANGUARD 360 DISTAL RT LATERAL LT MAIN 10","SUP-ITM-10117697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","736.26","42.9","","2548.09","2548.09","2548.09","1 through 10","532.03","1364.4","percent of total billed charges",""
"BLOCK KNEE 65X5MM AUGMENT FEMORAL VANGUARD 360 DISTAL RT LATERAL LT MAIN 10","SUP-ITM-10117697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","736.26","42.9","","956.46","956.46","956.46","1 through 10","532.03","1364.4","percent of total billed charges",""
"BLOCK KNEE 65X5MM AUGMENT FEMORAL VANGUARD 360 DISTAL RT LATERAL LT MAIN 10","SUP-ITM-10117697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","WELLPOINT [1015]","HB AMC WELLPOINT","1266.23","73.78","","2344.73","1619.47","2530.35","16","532.03","1364.4","percent of total billed charges",""
"BLOCK KNEE 65X5MM AUGMENT FEMORAL VANGUARD 360 DISTAL RT LATERAL LT MAIN 10","SUP-ITM-10117697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","AETNA [1001]","HB AMC AETNA HMO","1197.93","69.8","","1523.63","988.41","4330.26","39","896.9","1402.5","percent of total billed charges",""
"BLOCK KNEE 65X5MM AUGMENT FEMORAL VANGUARD 360 DISTAL RT LATERAL LT MAIN 10","SUP-ITM-10117697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","AETNA [1001]","HB AMC AETNA PPO","1379.85","80.4","","1670.25","1670.25","1670.25","1 through 10","896.9","1402.5","percent of total billed charges",""
"BLOCK KNEE 65X5MM AUGMENT FEMORAL VANGUARD 360 DISTAL RT LATERAL LT MAIN 10","SUP-ITM-10117697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","896.90","52.26","","1113.10","1113.10","1113.10","1 through 10","896.9","1402.5","percent of total billed charges",""
"BLOCK KNEE 65X5MM AUGMENT FEMORAL VANGUARD 360 DISTAL RT LATERAL LT MAIN 10","SUP-ITM-10117697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1402.50","81.72","","1738.90","1484.65","2716.94","38","896.9","1402.5","percent of total billed charges",""
"BLOCK ORTHO SIZE 3 10MM PLATE NEXGEN BONE TIBIAL AUGMENT FULL ROTATING HINGE PRECOAT","SUP-ITM-10030062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1196.51","52.26","","1113.10","1113.10","1113.10","1 through 10","709.75","1820.18","percent of total billed charges",""
"BLOCK ORTHO SIZE 3 10MM PLATE NEXGEN BONE TIBIAL AUGMENT FULL ROTATING HINGE PRECOAT","SUP-ITM-10030062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1820.18","79.5","","1293.60","1148.53","1603.80","1 through 10","709.75","1820.18","percent of total billed charges",""
"BLOCK ORTHO SIZE 3 10MM PLATE NEXGEN BONE TIBIAL AUGMENT FULL ROTATING HINGE PRECOAT","SUP-ITM-10030062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","835.68","36.5","","1023.42","771.29","2068.67","33","709.75","1820.18","percent of total billed charges",""
"BLOCK ORTHO SIZE 3 10MM PLATE NEXGEN BONE TIBIAL AUGMENT FULL ROTATING HINGE PRECOAT","SUP-ITM-10030062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","876.89","38.3","","850.52","759.78","1211.25","66","709.75","1820.18","percent of total billed charges",""
"BLOCK ORTHO SIZE 3 10MM PLATE NEXGEN BONE TIBIAL AUGMENT FULL ROTATING HINGE PRECOAT","SUP-ITM-10030062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","982.21","42.9","","2548.09","2548.09","2548.09","1 through 10","709.75","1820.18","percent of total billed charges",""
"BLOCK ORTHO SIZE 3 10MM PLATE NEXGEN BONE TIBIAL AUGMENT FULL ROTATING HINGE PRECOAT","SUP-ITM-10030062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","982.21","42.9","","956.46","956.46","956.46","1 through 10","709.75","1820.18","percent of total billed charges",""
"BLOCK ORTHO SIZE 3 10MM PLATE NEXGEN BONE TIBIAL AUGMENT FULL ROTATING HINGE PRECOAT","SUP-ITM-10030062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","WELLPOINT [1015]","HB AMC WELLPOINT","1689.22","73.78","","2344.73","1619.47","2530.35","16","709.75","1820.18","percent of total billed charges",""
"BLOCK ORTHO SIZE 3 10MM PLATE NEXGEN BONE TIBIAL AUGMENT FULL ROTATING HINGE PRECOAT","SUP-ITM-10030062","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.53","1717.15","AETNA [1001]","HB AMC AETNA HMO","1598.09","69.8","","1523.63","988.41","4330.26","39","1196.51","1871","percent of total billed charges",""
"BLOCK ORTHO SIZE 3 10MM PLATE NEXGEN BONE TIBIAL AUGMENT FULL ROTATING HINGE PRECOAT","SUP-ITM-10030062","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.53","1717.15","AETNA [1001]","HB AMC AETNA PPO","1840.78","80.4","","1670.25","1670.25","1670.25","1 through 10","1196.51","1871","percent of total billed charges",""
"BLOCK ORTHO SIZE 3 10MM PLATE NEXGEN BONE TIBIAL AUGMENT FULL ROTATING HINGE PRECOAT","SUP-ITM-10030062","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.53","1717.15","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1196.51","52.26","","1113.10","1113.10","1113.10","1 through 10","1196.51","1871","percent of total billed charges",""
"BLOCK ORTHO SIZE 3 10MM PLATE NEXGEN BONE TIBIAL AUGMENT FULL ROTATING HINGE PRECOAT","SUP-ITM-10030062","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.53","1717.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1871.00","81.72","","1738.90","1484.65","2716.94","38","1196.51","1871","percent of total billed charges",""
"BLOCK ORTHO SIZE 6 39MM TIBIAL AUGMENT TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10014946","CDM","C1713","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4774.77","79.5","","800.18","480.96","1887.97","195","1861.86","4774.77","percent of total billed charges",""
"BLOCK ORTHO SIZE 6 39MM TIBIAL AUGMENT TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10014946","CDM","C1713","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3201.20","53.3","","813.12","216.42","1444.50","81","1861.86","4774.77","percent of total billed charges",""
"BLOCK ORTHO SIZE 6 39MM TIBIAL AUGMENT TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10014946","CDM","C1713","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1861.86","31","","432.60","432.60","432.60","1 through 10","1861.86","4774.77","percent of total billed charges",""
"BLOCK ORTHO SIZE 6 39MM TIBIAL AUGMENT TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10014946","CDM","C1713","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2192.19","36.5","","148.37","54.89","631.39","94","1861.86","4774.77","percent of total billed charges",""
"BLOCK ORTHO SIZE 6 39MM TIBIAL AUGMENT TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10014946","CDM","C1713","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2300.30","38.3","","279.30","91.72","1116.77","266","1861.86","4774.77","percent of total billed charges",""
"BLOCK ORTHO SIZE 6 39MM TIBIAL AUGMENT TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10014946","CDM","C1713","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2576.57","42.9","","731.00","63.70","731.00","1 through 10","1861.86","4774.77","percent of total billed charges",""
"BLOCK ORTHO SIZE 6 39MM TIBIAL AUGMENT TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10014946","CDM","C1713","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2576.57","42.9","","384.74","384.74","384.74","1 through 10","1861.86","4774.77","percent of total billed charges",""
"BLOCK ORTHO SIZE 6 39MM TIBIAL AUGMENT TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10014946","CDM","C1713","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","WELLPOINT [1015]","HB AMC WELLPOINT","4431.23","73.78","","286.63","119.22","1107.45","105","1861.86","4774.77","percent of total billed charges",""
"BLOCK ORTHO SIZE 6 39MM TIBIAL AUGMENT TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10014946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6006.00","4504.50","AETNA [1001]","HB AMC AETNA HMO","4192.19","69.8","","675.31","184.75","1721.50","286","3138.74","4908.1","percent of total billed charges",""
"BLOCK ORTHO SIZE 6 39MM TIBIAL AUGMENT TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10014946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6006.00","4504.50","AETNA [1001]","HB AMC AETNA PPO","4828.82","80.4","","1261.44","103.12","1514.10","21","3138.74","4908.1","percent of total billed charges",""
"BLOCK ORTHO SIZE 6 39MM TIBIAL AUGMENT TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10014946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6006.00","4504.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4828.82","80.4","","1365.00","1365.00","1365.00","1 through 10","3138.74","4908.1","percent of total billed charges",""
"BLOCK ORTHO SIZE 6 39MM TIBIAL AUGMENT TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10014946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6006.00","4504.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4908.10","81.72","","5157.68","5157.68","5157.68","1 through 10","3138.74","4908.1","percent of total billed charges",""
"BLOCK ORTHO SIZE 6 39MM TIBIAL AUGMENT TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10014946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6006.00","4504.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4908.10","81.72","","431.26","71.26","1459.57","88","3138.74","4908.1","percent of total billed charges",""
"BLOCK PLATE 10MM SIZE 4 BONE TIBIAL KNEE NEXGEN ROTATING HINGE PRECOAT STEMMED","SUP-ITM-10159062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1196.51","52.26","","1113.10","1113.10","1113.10","1 through 10","709.75","1820.18","percent of total billed charges",""
"BLOCK PLATE 10MM SIZE 4 BONE TIBIAL KNEE NEXGEN ROTATING HINGE PRECOAT STEMMED","SUP-ITM-10159062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1820.18","79.5","","1293.60","1148.53","1603.80","1 through 10","709.75","1820.18","percent of total billed charges",""
"BLOCK PLATE 10MM SIZE 4 BONE TIBIAL KNEE NEXGEN ROTATING HINGE PRECOAT STEMMED","SUP-ITM-10159062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","835.68","36.5","","1023.42","771.29","2068.67","33","709.75","1820.18","percent of total billed charges",""
"BLOCK PLATE 10MM SIZE 4 BONE TIBIAL KNEE NEXGEN ROTATING HINGE PRECOAT STEMMED","SUP-ITM-10159062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","876.89","38.3","","850.52","759.78","1211.25","66","709.75","1820.18","percent of total billed charges",""
"BLOCK PLATE 10MM SIZE 4 BONE TIBIAL KNEE NEXGEN ROTATING HINGE PRECOAT STEMMED","SUP-ITM-10159062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","982.21","42.9","","2548.09","2548.09","2548.09","1 through 10","709.75","1820.18","percent of total billed charges",""
"BLOCK PLATE 10MM SIZE 4 BONE TIBIAL KNEE NEXGEN ROTATING HINGE PRECOAT STEMMED","SUP-ITM-10159062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","982.21","42.9","","956.46","956.46","956.46","1 through 10","709.75","1820.18","percent of total billed charges",""
"BLOCK PLATE 10MM SIZE 4 BONE TIBIAL KNEE NEXGEN ROTATING HINGE PRECOAT STEMMED","SUP-ITM-10159062","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","WELLPOINT [1015]","HB AMC WELLPOINT","1689.22","73.78","","2344.73","1619.47","2530.35","16","709.75","1820.18","percent of total billed charges",""
"BLOCK PLATE 10MM SIZE 4 BONE TIBIAL KNEE NEXGEN ROTATING HINGE PRECOAT STEMMED","SUP-ITM-10159062","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.53","1717.15","AETNA [1001]","HB AMC AETNA HMO","1598.09","69.8","","1523.63","988.41","4330.26","39","1196.51","1871","percent of total billed charges",""
"BLOCK PLATE 10MM SIZE 4 BONE TIBIAL KNEE NEXGEN ROTATING HINGE PRECOAT STEMMED","SUP-ITM-10159062","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.53","1717.15","AETNA [1001]","HB AMC AETNA PPO","1840.78","80.4","","1670.25","1670.25","1670.25","1 through 10","1196.51","1871","percent of total billed charges",""
"BLOCK PLATE 10MM SIZE 4 BONE TIBIAL KNEE NEXGEN ROTATING HINGE PRECOAT STEMMED","SUP-ITM-10159062","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.53","1717.15","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1196.51","52.26","","1113.10","1113.10","1113.10","1 through 10","1196.51","1871","percent of total billed charges",""
"BLOCK PLATE 10MM SIZE 4 BONE TIBIAL KNEE NEXGEN ROTATING HINGE PRECOAT STEMMED","SUP-ITM-10159062","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.53","1717.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1871.00","81.72","","1738.90","1484.65","2716.94","38","1196.51","1871","percent of total billed charges",""
"Blood Count Automated Diff Wbc","PX-30001030","CDM","85004","CPT","0305","RC","","","","both","","","109.00","81.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","41.75","38.3","","41.45","41.45","41.45","1 through 10","6.34","103.55","percent of total billed charges",""
"Blood Count Automated Diff Wbc","PX-30001030","CDM","85004","CPT","0305","RC","","","","outpatient","","","109.00","81.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","89.07","81.72","","84.74","84.74","84.74","1 through 10","6.67","89.07","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0300","RC","","","","inpatient","","","125.00","93.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","98.26","78.61","","96.73","96.73","96.73","1 through 10","69.13","99.38","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","89.75","71.8","","86.88","6.85","260.64","106","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","82.00","65.6","","81.92","57.84","94.38","15","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","81.25","65","","78.65","63.89","307.54","104","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","87.50","70","","121.00","52.03","156.09","83","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","CHAMPVA [160001]","HB BWH TRICARE","118.75","95","","9.36","9.36","9.36","1 through 10","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","99.38","79.5","","95.23","63.89","182.46","1468","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","66.63","53.3","","63.89","63.89","191.67","859","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","96.25","77","","100.10","93.17","279.51","38","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","81.25","65","","78.65","78.65","84.50","20","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","99.38","79.5","","95.23","78.65","95.23","1 through 10","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","38.75","31","","37.39","37.39","112.17","52","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","45.63","36.5","","45.13","38.36","131.40","1319","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","47.88","38.3","","47.31","45.98","141.93","3950","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","MOLINA [1014]","HB BWH MOLINA","43.75","35","","15.42","15.42","30.72","30","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","96.25","77","","94.38","10.88","99.22","24","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","TRICARE [160005]","HB BWH TRICARE","118.75","95","","9.36","8.89","9.36","59","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","118.75","95","","7.77","7.77","7.77","1 through 10","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.63","42.9","","96.73","53.20","96.73","87","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","125.00","93.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.63","42.9","","53.20","53.20","53.20","11","7.61","118.75","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","125.00","93.75","AETNA [1001]","HB AMC AETNA HMO","87.25","69.8","","81.92","57.84","94.38","1961","8.01","102.15","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","125.00","93.75","AETNA [1001]","HB AMC AETNA PPO","100.50","80.4","","94.38","63.40","98.02","206","8.01","102.15","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","125.00","93.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","69.88","55.9","","63.40","63.40","126.80","1 through 10","8.01","102.15","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","125.00","93.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","65.33","52.26","","27.85","27.85","74.88","23","8.01","102.15","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","125.00","93.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","100.50","80.4","","94.38","60.50","98.02","16","8.01","102.15","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","125.00","93.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","102.15","81.72","","96.73","96.72","100.11","15","8.01","102.15","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","125.00","93.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","102.15","81.72","","53.20","53.20","96.73","81","8.01","102.15","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","125.00","93.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","102.15","81.72","","96.73","53.20","96.73","1484","8.01","102.15","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0300","RC","","","","inpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","75.47","78.61","","44.38","44.38","44.38","1 through 10","53.09","76.32","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","68.93","71.8","","66.77","66.77","200.31","33","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","62.98","65.6","","62.96","44.45","62.96","1 through 10","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","62.40","65","","60.45","49.10","181.35","25","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","67.20","70","","66.96","39.99","213.90","70","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","CHAMPVA [160001]","HB BWH TRICARE","91.20","95","","7.80","7.80","7.80","1 through 10","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","76.32","79.5","","73.19","49.10","73.31","1375","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","51.17","53.3","","49.10","49.10","147.30","759","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","73.92","77","","71.61","71.61","214.83","14","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","62.40","65","","60.45","60.45","65.65","41","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","76.32","79.5","","73.19","70.12","73.19","1 through 10","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","62.40","65","","93.00","93.00","93.00","1 through 10","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","29.76","31","","28.74","28.74","86.22","49","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","35.04","36.5","","34.69","29.48","101.01","1269","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","36.77","38.3","","36.36","35.34","109.08","4239","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","MOLINA [1014]","HB BWH MOLINA","33.60","35","","12.84","12.68","25.78","17","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","73.92","77","","72.54","9.23","277.43","15","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","TRICARE [160005]","HB BWH TRICARE","91.20","95","","7.41","7.41","7.80","78","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","91.20","95","","6.47","6.47","6.47","1 through 10","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.18","42.9","","74.34","40.89","74.34","62","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","96.00","72.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.18","42.9","","40.89","40.89","81.78","14","6.34","91.2","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","96.00","72.00","AETNA [1001]","HB AMC AETNA HMO","67.01","69.8","","62.96","44.45","72.54","2053","6.67","78.45","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","96.00","72.00","AETNA [1001]","HB AMC AETNA PPO","77.18","80.4","","72.54","48.73","72.54","213","6.67","78.45","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","96.00","72.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","53.66","55.9","","48.73","48.73","48.73","1 through 10","6.67","78.45","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","96.00","72.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","50.17","52.26","","22.68","22.68","57.55","23","6.67","78.45","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","96.00","72.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","77.18","80.4","","72.54","46.50","72.54","21","6.67","78.45","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","96.00","72.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","78.45","81.72","","74.34","74.34","74.34","1 through 10","6.67","78.45","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","78.45","81.72","","51.26","40.89","77.78","52","6.67","78.45","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","78.45","81.72","","74.34","40.89","74.34","1304","6.67","78.45","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","both","","","45.00","33.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","35.78","79.5","","34.63","23.23","34.63","1 through 10","2.32","42.75","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","both","","","45.00","33.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23.99","53.3","","23.23","23.23","34.63","1 through 10","2.32","42.75","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","both","","","45.00","33.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","35.78","79.5","","34.63","34.63","34.63","1 through 10","2.32","42.75","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","both","","","45.00","33.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16.43","36.5","","16.41","13.95","49.23","21","2.32","42.75","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","both","","","45.00","33.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17.24","38.3","","17.20","17.20","17.20","61","2.32","42.75","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","both","","","45.00","33.75","TRICARE [160005]","HB BWH TRICARE","42.75","95","","2.86","2.72","2.86","1 through 10","2.32","42.75","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","45.00","33.75","AETNA [1001]","HB AMC AETNA HMO","31.41","69.8","","29.79","21.03","34.32","1 through 10","2.44","36.77","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","45.00","33.75","AETNA [1001]","HB AMC AETNA PPO","36.18","80.4","","23.06","21.03","23.06","1 through 10","2.44","36.77","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","45.00","33.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","23.52","52.26","","8.24","8.24","8.24","1 through 10","2.44","36.77","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","45.00","33.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","36.77","81.72","","35.17","33.11","35.17","1 through 10","2.44","36.77","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","both","","","41.00","30.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","32.60","79.5","","31.48","31.48","31.48","1 through 10","2.32","38.95","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","both","","","41.00","30.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","21.85","53.3","","21.12","21.12","21.12","1 through 10","2.32","38.95","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","both","","","41.00","30.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14.97","36.5","","14.92","12.68","14.92","16","2.32","38.95","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","both","","","41.00","30.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15.70","38.3","","15.64","15.64","15.64","32","2.32","38.95","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","both","","","41.00","30.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","31.57","77","","5.26","5.26","5.26","1 through 10","2.32","38.95","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","outpatient","","","41.00","30.75","AETNA [1001]","HB AMC AETNA HMO","28.62","69.8","","27.08","19.12","27.08","1 through 10","2.44","33.51","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","outpatient","","","41.00","30.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","33.51","81.72","","31.98","31.98","40.00","1 through 10","2.44","33.51","percent of total billed charges",""
"Blood Count Leukocyte (Wbc) Auto","PX-30001044","CDM","85048","CPT","0305","RC","","","","both","","","40.00","30.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15.32","38.3","","15.25","15.25","15.25","1 through 10","2.49","38","percent of total billed charges",""
"Blood Count Leukocyte (Wbc) Auto","PX-30001044","CDM","85048","CPT","0305","RC","","","","outpatient","","","40.00","30.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","32.69","81.72","","31.18","31.18","31.18","1 through 10","2.61","32.69","percent of total billed charges",""
"Blood Count Platelet Auto","PX-30001045","CDM","85049","CPT","0305","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29.93","36.5","","29.84","29.84","29.84","1 through 10","4.39","77.9","percent of total billed charges",""
"Blood Count Platelet Auto","PX-30001045","CDM","85049","CPT","0305","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31.41","38.3","","31.28","31.28","31.28","1 through 10","4.39","77.9","percent of total billed charges",""
"Blood Count Platelet Auto","PX-30001045","CDM","85049","CPT","0305","RC","","","","outpatient","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","67.01","81.72","","35.18","35.18","35.18","1 through 10","4.61","67.01","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","both","","","73.00","54.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","52.41","71.8","","50.98","50.98","50.98","1 through 10","3.91","69.35","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","both","","","73.00","54.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","51.10","70","","11.63","11.63","11.63","1 through 10","3.91","69.35","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","both","","","73.00","54.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","58.04","79.5","","55.88","37.49","167.64","58","3.91","69.35","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","both","","","73.00","54.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","38.91","53.3","","55.88","37.49","112.47","44","3.91","69.35","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","both","","","73.00","54.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","56.21","77","","164.01","164.01","164.01","1 through 10","3.91","69.35","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","both","","","73.00","54.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.65","36.5","","26.48","22.51","67.53","59","3.91","69.35","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","both","","","73.00","54.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27.96","38.3","","27.76","26.98","79.44","200","3.91","69.35","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","both","","","73.00","54.75","TRICARE [160005]","HB BWH TRICARE","69.35","95","","4.81","4.57","4.81","1 through 10","3.91","69.35","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","both","","","73.00","54.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.32","42.9","","56.76","56.76","56.76","1 through 10","3.91","69.35","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","both","","","73.00","54.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.32","42.9","","31.22","31.22","31.22","1 through 10","3.91","69.35","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","outpatient","","","73.00","54.75","AETNA [1001]","HB AMC AETNA HMO","50.95","69.8","","48.07","33.94","55.38","72","4.12","59.66","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","outpatient","","","73.00","54.75","AETNA [1001]","HB AMC AETNA PPO","58.69","80.4","","55.38","55.38","55.38","1 through 10","4.12","59.66","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","outpatient","","","73.00","54.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","38.15","52.26","","14.44","14.44","43.94","1 through 10","4.12","59.66","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","outpatient","","","73.00","54.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","59.66","81.72","","56.76","56.76","56.76","1 through 10","4.12","59.66","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","outpatient","","","73.00","54.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","59.66","81.72","","56.76","31.22","56.76","55","4.12","59.66","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","both","","","337.00","252.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","241.97","71.8","","234.79","234.79","234.79","1 through 10","19.95","320.15","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","both","","","337.00","252.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","221.07","65.6","","255.06","255.06","255.06","1 through 10","19.95","320.15","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","both","","","337.00","252.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","235.90","70","","327.00","235.44","327.00","1 through 10","19.95","320.15","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","both","","","337.00","252.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","267.92","79.5","","257.35","257.35","567.27","66","19.95","320.15","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","both","","","337.00","252.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","179.62","53.3","","517.98","165.14","517.98","1 through 10","19.95","320.15","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","both","","","337.00","252.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","259.49","77","","251.79","251.79","251.79","1 through 10","19.95","320.15","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","both","","","337.00","252.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.01","36.5","","103.66","103.66","310.98","14","19.95","320.15","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","both","","","337.00","252.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","129.07","38.3","","127.86","127.86","127.86","59","19.95","320.15","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","337.00","252.75","AETNA [1001]","HB AMC AETNA HMO","235.23","69.8","","255.06","207.64","391.84","41","19.95","275.4","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","337.00","252.75","AETNA [1001]","HB AMC AETNA PPO","270.95","80.4","","255.06","255.06","255.06","1 through 10","19.95","275.4","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","337.00","252.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","270.95","80.4","","255.06","255.06","255.06","1 through 10","19.95","275.4","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","337.00","252.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","275.40","81.72","","3435.90","3435.90","3435.90","1 through 10","19.95","275.4","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","337.00","252.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","275.40","81.72","","327.00","327.00","327.00","1 through 10","19.95","275.4","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","337.00","252.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","275.40","81.72","","261.40","143.78","261.40","19","19.95","275.4","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","43.08","71.8","","41.64","41.64","124.92","20","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","39.36","65.6","","39.27","39.27","39.27","1 through 10","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","39.00","65","","37.70","30.62","113.10","21","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","42.00","70","","49.88","24.94","125.28","54","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","47.70","79.5","","45.65","30.62","84.99","51","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","31.98","53.3","","30.62","30.62","108.81","42","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","46.20","77","","44.66","44.66","44.66","1 through 10","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","39.00","65","","38.35","38.35","38.35","1 through 10","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","39.00","65","","58.00","58.00","58.00","1 through 10","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21.90","36.5","","21.63","18.39","64.89","50","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22.98","38.3","","22.68","22.04","66.12","154","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","MOLINA [1014]","HB BWH MOLINA","21.00","35","","11.28","7.52","15.14","11","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","46.20","77","","45.24","5.76","45.24","1 through 10","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","TRICARE [160005]","HB BWH TRICARE","57.00","95","","4.58","4.35","62.35","1 through 10","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","both","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.74","42.9","","46.37","25.50","46.37","1 through 10","3.54","57","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","outpatient","","","60.00","45.00","AETNA [1001]","HB AMC AETNA HMO","41.88","69.8","","38.65","27.72","55.44","112","3.54","49.03","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","outpatient","","","60.00","45.00","AETNA [1001]","HB AMC AETNA PPO","48.24","80.4","","45.24","30.39","45.24","1 through 10","3.54","49.03","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","outpatient","","","60.00","45.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","31.36","52.26","","35.90","35.90","35.90","1 through 10","3.54","49.03","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","outpatient","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","48.24","80.4","","45.24","45.24","45.24","1 through 10","3.54","49.03","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","49.03","81.72","","46.37","25.50","46.37","1 through 10","3.54","49.03","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","49.03","81.72","","46.37","25.50","46.37","52","3.54","49.03","percent of total billed charges",""
"Blood Smear W/O Differential","PX-30001032","CDM","85008","CPT","0305","RC","","","","both","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.17","42.9","","25.94","25.94","25.94","1 through 10","3.36","57.95","percent of total billed charges",""
"Blood Type Antigen Donor Reagent Serum Each","PX-30000077","CDM","86902","CPT","0302","RC","","","","both","","","192.00","144.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","439.96","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","21.98","21.98","21.98","20","3.95","533.93","other","OPPS APC"
"Blood Type Antigen Donor Reagent Serum Each","PX-30000077","CDM","86902","CPT","0302","RC","","","","both","","","192.00","144.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","533.93","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","10.68","10.68","10.68","80","3.95","533.93","other","OPPS APC"
"Blood Type Antigen Donor Reagent Serum Each","PX-30000077","CDM","86902","CPT","0302","RC","","","","both","","","192.00","144.00","MEDICARE [2001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10.95","10.95","23.73","57","3.95","533.93","other","OPPS APC"
"Blood Type Antigen Donor Reagent Serum Each","PX-30000077","CDM","86902","CPT","0302","RC","","","","both","","","192.00","144.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70.08","36.5","","69.38","69.38","69.38","1 through 10","3.95","533.93","percent of total billed charges",""
"Blood Type Antigen Donor Reagent Serum Each","PX-30000077","CDM","86902","CPT","0302","RC","","","","outpatient","","","192.00","144.00","AETNA [1001]","HB AMC AETNA HMO","134.02","69.8","","125.92","88.91","125.92","1 through 10","3.95","1680.97","percent of total billed charges",""
"Blood Type Antigen Donor Reagent Serum Each","PX-30000077","CDM","86902","CPT","0302","RC","","","","outpatient","","","192.00","144.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","156.90","81.72","","148.69","148.69","148.69","17","3.95","1680.97","percent of total billed charges",""
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","221.00","165.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","175.70","79.5","","112.99","112.99","112.99","1 through 10","3.95","533.93","percent of total billed charges",""
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","221.00","165.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","143.65","65","","139.10","139.10","139.10","1 through 10","3.95","533.93","percent of total billed charges",""
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","221.00","165.75","MEDICARE [2001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","71.20","47.47","784.62","20","3.95","533.93","other","OPPS APC"
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","221.00","165.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.51","31","","66.13","66.13","66.13","1 through 10","3.95","533.93","percent of total billed charges",""
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","221.00","165.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.67","36.5","","79.82","79.82","79.82","1 through 10","3.95","533.93","percent of total billed charges",""
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","221.00","165.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.64","38.3","","83.67","81.32","83.68","18","3.95","533.93","percent of total billed charges",""
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","221.00","165.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","418.65","418.65","1 through 10","3.95","533.93","other","OPPS APC"
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","213.60","213.60","213.60","1 through 10","3.95","533.93","other","OPPS APC"
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","outpatient","","","221.00","165.75","AETNA [1001]","HB AMC AETNA HMO","154.26","69.8","","144.88","102.29","144.88","1 through 10","3.95","1680.97","percent of total billed charges",""
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","outpatient","","","221.00","165.75","AETNA [1001]","HB AMC AETNA PPO","177.68","80.4","","166.92","166.92","166.92","1 through 10","3.95","1680.97","percent of total billed charges",""
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","180.60","81.72","","171.07","171.07","171.07","1 through 10","3.95","1680.97","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0300","RC","","","","inpatient","","","103.00","77.25","AETNA [1001]","HB AMC AETNA HMO","71.17","69.1","","47.80","47.80","47.80","1 through 10","56.96","81.89","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","157.65","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","157.52","78.76","157.52","75","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","22.64","150.63","162","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","73.95","71.8","","215.40","71.80","215.40","28","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","67.57","65.6","","67.70","67.70","78.00","1 through 10","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","66.95","65","","65.00","52.80","65.00","1 through 10","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","72.10","70","","100.00","72.00","216.00","31","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","191.33","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","100.00","10.25","153.08","1 through 10","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","CHAMPVA [160001]","HB BWH TRICARE","145.42","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","100.00","100.00","100.00","1 through 10","3.08","191.33","other","Tricare OPPS"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","81.89","79.5","","78.70","52.80","236.10","514","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","54.90","53.3","","78.70","52.80","236.10","242","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.02","126.32","150.02","29","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","ELDER SERVICES [1037]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","98.00","153.08","1 through 10","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","FALLON HEALTH [1008]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","450.06","153.08","450.06","1 through 10","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","451.89","451.89","451.89","1 through 10","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","79.31","77","","231.00","77.00","231.00","17","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","HUMANA [1012]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","152.02","152.02","152.02","1 through 10","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","66.95","65","","65.00","65.00","70.85","21","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","81.89","79.5","","78.70","75.40","78.70","1 through 10","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.12","75.01","150.12","1 through 10","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","139.42","153.08","813","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","31.93","31","","30.90","30.90","92.70","1 through 10","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37.60","36.5","","37.30","31.70","111.90","363","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39.45","38.3","","39.10","38.00","117.30","1134","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.02","150.02","450.06","36","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","MOLINA [1014]","HB BWH MOLINA","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","303.71","273.26","303.71","1 through 10","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","79.31","77","","78.00","78.00","78.00","1 through 10","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","TRICARE [160005]","HB BWH TRICARE","145.42","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","145.43","132.44","153.08","42","3.08","191.33","other","Tricare OPPS"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","145.42","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","306.16","153.08","306.16","1 through 10","3.08","191.33","other","Tricare OPPS"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","450.06","150.02","451.44","116","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","23.00","23.00","23.00","1 through 10","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.19","42.9","","79.94","43.97","100.00","24","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.02","136.64","153.08","172","3.08","191.33","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","103.00","77.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.19","42.9","","43.97","43.97","43.97","1 through 10","3.08","191.33","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","103.00","77.25","AETNA [1001]","HB AMC AETNA HMO","71.89","69.8","","67.70","47.80","78.00","635","3.08","652.72","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","103.00","77.25","AETNA [1001]","HB AMC AETNA PPO","82.81","80.4","","78.00","52.40","78.00","76","3.08","652.72","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","103.00","77.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","53.83","52.26","","219.19","61.88","219.19","1 through 10","3.08","652.72","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","103.00","77.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","82.81","80.4","","78.00","50.00","82.19","18","3.08","652.72","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","103.00","77.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","84.17","81.72","","79.94","79.94","79.94","1 through 10","3.08","652.72","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","84.17","81.72","","43.97","43.97","79.94","21","3.08","652.72","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","84.17","81.72","","79.94","43.97","79.94","551","3.08","652.72","percent of total billed charges",""
"Blueprint Genetics, Uba1 Single Gene Test","PX-31001228","CDM","81479","CPT","0310","RC","","","","both","","","1313.00","984.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.84","79.5","","0.65","0.65","0.65","1 through 10","407.03","1247.35","percent of total billed charges",""
"Blueprint Genetics, Uba1 Single Gene Test","PX-31001228","CDM","81479","CPT","0310","RC","","","","both","","","1313.00","984.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","699.83","53.3","","0.79","0.79","0.79","1 through 10","407.03","1247.35","percent of total billed charges",""
"Blueprint Genetics, Uba1 Single Gene Test","PX-31001228","CDM","81479","CPT","0310","RC","","","","outpatient","","","1313.00","984.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","656.50","50","","1.00","1.00","1.00","1 through 10","156.55","1083.23","percent of total billed charges",""
"Blueprint Genetics, Uba1 Single Gene Test","PX-31001228","CDM","81479","CPT","0310","RC","","","","outpatient","","","1313.00","984.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","689.33","52.5","","1.00","0.53","1.00","1 through 10","156.55","1083.23","percent of total billed charges",""
"Blup Amelogenesis Imperfecta and Dentinogenesis Imperfecta Panel","PX-31000939","CDM","81479","CPT","0310","RC","","","","both","","","1226.00","919.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","974.67","79.5","","0.65","0.65","0.65","1 through 10","380.06","1164.7","percent of total billed charges",""
"Blup Amelogenesis Imperfecta and Dentinogenesis Imperfecta Panel","PX-31000939","CDM","81479","CPT","0310","RC","","","","both","","","1226.00","919.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","653.46","53.3","","0.79","0.79","0.79","1 through 10","380.06","1164.7","percent of total billed charges",""
"Blup Amelogenesis Imperfecta and Dentinogenesis Imperfecta Panel","PX-31000939","CDM","81479","CPT","0310","RC","","","","outpatient","","","1226.00","919.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","613.00","50","","1.00","1.00","1.00","1 through 10","156.55","1011.45","percent of total billed charges",""
"Blup Amelogenesis Imperfecta and Dentinogenesis Imperfecta Panel","PX-31000939","CDM","81479","CPT","0310","RC","","","","outpatient","","","1226.00","919.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","643.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","1011.45","percent of total billed charges",""
"Blup Osteopetrosis and Dense Bone Dysplasia Panel","PX-31001071","CDM","81479","CPT","0310","RC","","","","both","","","1226.00","919.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","974.67","79.5","","0.65","0.65","0.65","1 through 10","380.06","1164.7","percent of total billed charges",""
"Blup Osteopetrosis and Dense Bone Dysplasia Panel","PX-31001071","CDM","81479","CPT","0310","RC","","","","both","","","1226.00","919.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","653.46","53.3","","0.79","0.79","0.79","1 through 10","380.06","1164.7","percent of total billed charges",""
"Blup Osteopetrosis and Dense Bone Dysplasia Panel","PX-31001071","CDM","81479","CPT","0310","RC","","","","outpatient","","","1226.00","919.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","613.00","50","","1.00","1.00","1.00","1 through 10","156.55","1011.45","percent of total billed charges",""
"Blup Osteopetrosis and Dense Bone Dysplasia Panel","PX-31001071","CDM","81479","CPT","0310","RC","","","","outpatient","","","1226.00","919.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","643.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","1011.45","percent of total billed charges",""
"Blupr Gen Leukodys & Leukenceph Panel","PX-31001174","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Blupr Gen Leukodys & Leukenceph Panel","PX-31001174","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Blupr Gen Leukodys & Leukenceph Panel","PX-31001174","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Blupr Gen Leukodys & Leukenceph Panel","PX-31001174","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1062.53","796.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","844.71","79.5","","800.18","480.96","1887.97","195","329.38","844.71","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1062.53","796.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","566.33","53.3","","813.12","216.42","1444.50","81","329.38","844.71","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1062.53","796.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","329.38","31","","432.60","432.60","432.60","1 through 10","329.38","844.71","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1062.53","796.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","387.82","36.5","","148.37","54.89","631.39","94","329.38","844.71","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1062.53","796.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","406.95","38.3","","279.30","91.72","1116.77","266","329.38","844.71","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1062.53","796.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","455.83","42.9","","731.00","63.70","731.00","1 through 10","329.38","844.71","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1062.53","796.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","455.83","42.9","","384.74","384.74","384.74","1 through 10","329.38","844.71","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1062.53","796.90","WELLPOINT [1015]","HB AMC WELLPOINT","783.93","73.78","","286.63","119.22","1107.45","105","329.38","844.71","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1062.53","796.90","AETNA [1001]","HB AMC AETNA HMO","741.65","69.8","","675.31","184.75","1721.50","286","555.28","868.3","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1062.53","796.90","AETNA [1001]","HB AMC AETNA PPO","854.27","80.4","","1261.44","103.12","1514.10","21","555.28","868.3","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1062.53","796.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","854.27","80.4","","1365.00","1365.00","1365.00","1 through 10","555.28","868.3","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1062.53","796.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","868.30","81.72","","5157.68","5157.68","5157.68","1 through 10","555.28","868.3","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1062.53","796.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","868.30","81.72","","431.26","71.26","1459.57","88","555.28","868.3","percent of total billed charges",""
"BOLT BONE 17X19MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025859","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","763.35","79.5","","800.18","480.96","1887.97","195","297.66","763.35","percent of total billed charges",""
"BOLT BONE 17X19MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025859","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","511.78","53.3","","813.12","216.42","1444.50","81","297.66","763.35","percent of total billed charges",""
"BOLT BONE 17X19MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025859","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","297.66","31","","432.60","432.60","432.60","1 through 10","297.66","763.35","percent of total billed charges",""
"BOLT BONE 17X19MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025859","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","350.47","36.5","","148.37","54.89","631.39","94","297.66","763.35","percent of total billed charges",""
"BOLT BONE 17X19MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025859","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","367.75","38.3","","279.30","91.72","1116.77","266","297.66","763.35","percent of total billed charges",""
"BOLT BONE 17X19MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025859","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","411.92","42.9","","731.00","63.70","731.00","1 through 10","297.66","763.35","percent of total billed charges",""
"BOLT BONE 17X19MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025859","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","411.92","42.9","","384.74","384.74","384.74","1 through 10","297.66","763.35","percent of total billed charges",""
"BOLT BONE 17X19MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025859","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","WELLPOINT [1015]","HB AMC WELLPOINT","708.43","73.78","","286.63","119.22","1107.45","105","297.66","763.35","percent of total billed charges",""
"BOLT BONE 17X19MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","AETNA [1001]","HB AMC AETNA HMO","670.21","69.8","","675.31","184.75","1721.50","286","501.8","784.67","percent of total billed charges",""
"BOLT BONE 17X19MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","AETNA [1001]","HB AMC AETNA PPO","771.99","80.4","","1261.44","103.12","1514.10","21","501.8","784.67","percent of total billed charges",""
"BOLT BONE 17X19MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","771.99","80.4","","1365.00","1365.00","1365.00","1 through 10","501.8","784.67","percent of total billed charges",""
"BOLT BONE 17X19MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","784.67","81.72","","5157.68","5157.68","5157.68","1 through 10","501.8","784.67","percent of total billed charges",""
"BOLT BONE 17X19MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","784.67","81.72","","431.26","71.26","1459.57","88","501.8","784.67","percent of total billed charges",""
"BOLT BONE 40MM LONG EXTERNAL FIXATION STANDOFF MRI CONDITIONAL","SUP-ITM-10039235","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.62","139.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","148.36","79.5","","800.18","480.96","1887.97","195","57.85","148.36","percent of total billed charges",""
"BOLT BONE 40MM LONG EXTERNAL FIXATION STANDOFF MRI CONDITIONAL","SUP-ITM-10039235","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.62","139.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","99.47","53.3","","813.12","216.42","1444.50","81","57.85","148.36","percent of total billed charges",""
"BOLT BONE 40MM LONG EXTERNAL FIXATION STANDOFF MRI CONDITIONAL","SUP-ITM-10039235","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.62","139.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","57.85","31","","432.60","432.60","432.60","1 through 10","57.85","148.36","percent of total billed charges",""
"BOLT BONE 40MM LONG EXTERNAL FIXATION STANDOFF MRI CONDITIONAL","SUP-ITM-10039235","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.62","139.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.12","36.5","","148.37","54.89","631.39","94","57.85","148.36","percent of total billed charges",""
"BOLT BONE 40MM LONG EXTERNAL FIXATION STANDOFF MRI CONDITIONAL","SUP-ITM-10039235","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.62","139.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71.48","38.3","","279.30","91.72","1116.77","266","57.85","148.36","percent of total billed charges",""
"BOLT BONE 40MM LONG EXTERNAL FIXATION STANDOFF MRI CONDITIONAL","SUP-ITM-10039235","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.62","139.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.06","42.9","","731.00","63.70","731.00","1 through 10","57.85","148.36","percent of total billed charges",""
"BOLT BONE 40MM LONG EXTERNAL FIXATION STANDOFF MRI CONDITIONAL","SUP-ITM-10039235","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.62","139.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.06","42.9","","384.74","384.74","384.74","1 through 10","57.85","148.36","percent of total billed charges",""
"BOLT BONE 40MM LONG EXTERNAL FIXATION STANDOFF MRI CONDITIONAL","SUP-ITM-10039235","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.62","139.96","WELLPOINT [1015]","HB AMC WELLPOINT","137.69","73.78","","286.63","119.22","1107.45","105","57.85","148.36","percent of total billed charges",""
"BOLT BONE 40MM LONG EXTERNAL FIXATION STANDOFF MRI CONDITIONAL","SUP-ITM-10039235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.62","139.96","AETNA [1001]","HB AMC AETNA HMO","130.26","69.8","","675.31","184.75","1721.50","286","97.53","152.51","percent of total billed charges",""
"BOLT BONE 40MM LONG EXTERNAL FIXATION STANDOFF MRI CONDITIONAL","SUP-ITM-10039235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.62","139.96","AETNA [1001]","HB AMC AETNA PPO","150.04","80.4","","1261.44","103.12","1514.10","21","97.53","152.51","percent of total billed charges",""
"BOLT BONE 40MM LONG EXTERNAL FIXATION STANDOFF MRI CONDITIONAL","SUP-ITM-10039235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.62","139.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","150.04","80.4","","1365.00","1365.00","1365.00","1 through 10","97.53","152.51","percent of total billed charges",""
"BOLT BONE 40MM LONG EXTERNAL FIXATION STANDOFF MRI CONDITIONAL","SUP-ITM-10039235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.62","139.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","152.51","81.72","","5157.68","5157.68","5157.68","1 through 10","97.53","152.51","percent of total billed charges",""
"BOLT BONE 40MM LONG EXTERNAL FIXATION STANDOFF MRI CONDITIONAL","SUP-ITM-10039235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.62","139.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","152.51","81.72","","431.26","71.26","1459.57","88","97.53","152.51","percent of total billed charges",""
"BOLT BONE 9X12MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025857","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","763.35","79.5","","800.18","480.96","1887.97","195","297.66","763.35","percent of total billed charges",""
"BOLT BONE 9X12MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025857","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","511.78","53.3","","813.12","216.42","1444.50","81","297.66","763.35","percent of total billed charges",""
"BOLT BONE 9X12MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025857","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","297.66","31","","432.60","432.60","432.60","1 through 10","297.66","763.35","percent of total billed charges",""
"BOLT BONE 9X12MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025857","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","350.47","36.5","","148.37","54.89","631.39","94","297.66","763.35","percent of total billed charges",""
"BOLT BONE 9X12MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025857","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","367.75","38.3","","279.30","91.72","1116.77","266","297.66","763.35","percent of total billed charges",""
"BOLT BONE 9X12MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025857","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","411.92","42.9","","731.00","63.70","731.00","1 through 10","297.66","763.35","percent of total billed charges",""
"BOLT BONE 9X12MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025857","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","411.92","42.9","","384.74","384.74","384.74","1 through 10","297.66","763.35","percent of total billed charges",""
"BOLT BONE 9X12MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025857","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","WELLPOINT [1015]","HB AMC WELLPOINT","708.43","73.78","","286.63","119.22","1107.45","105","297.66","763.35","percent of total billed charges",""
"BOLT BONE 9X12MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","AETNA [1001]","HB AMC AETNA HMO","670.21","69.8","","675.31","184.75","1721.50","286","501.8","784.67","percent of total billed charges",""
"BOLT BONE 9X12MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","AETNA [1001]","HB AMC AETNA PPO","771.99","80.4","","1261.44","103.12","1514.10","21","501.8","784.67","percent of total billed charges",""
"BOLT BONE 9X12MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","771.99","80.4","","1365.00","1365.00","1365.00","1 through 10","501.8","784.67","percent of total billed charges",""
"BOLT BONE 9X12MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","784.67","81.72","","5157.68","5157.68","5157.68","1 through 10","501.8","784.67","percent of total billed charges",""
"BOLT BONE 9X12MM UNIVERSAL CONICAL THREADED NAIL FEMORAL","SUP-ITM-10025857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","784.67","81.72","","431.26","71.26","1459.57","88","501.8","784.67","percent of total billed charges",""
"BOLT HIP 24MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1288.70","52.26","","1113.10","1113.10","1113.10","1 through 10","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 24MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1960.41","79.5","","1293.60","1148.53","1603.80","1 through 10","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 24MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","900.06","36.5","","1023.42","771.29","2068.67","33","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 24MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","944.45","38.3","","850.52","759.78","1211.25","66","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 24MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1057.88","42.9","","2548.09","2548.09","2548.09","1 through 10","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 24MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1057.88","42.9","","956.46","956.46","956.46","1 through 10","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 24MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","WELLPOINT [1015]","HB AMC WELLPOINT","1819.36","73.78","","2344.73","1619.47","2530.35","16","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 24MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201978","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","AETNA [1001]","HB AMC AETNA HMO","1721.22","69.8","","1523.63","988.41","4330.26","39","1288.7","2015.16","percent of total billed charges",""
"BOLT HIP 24MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201978","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","AETNA [1001]","HB AMC AETNA PPO","1982.61","80.4","","1670.25","1670.25","1670.25","1 through 10","1288.7","2015.16","percent of total billed charges",""
"BOLT HIP 24MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201978","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1288.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1288.7","2015.16","percent of total billed charges",""
"BOLT HIP 24MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201978","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2015.16","81.72","","1738.90","1484.65","2716.94","38","1288.7","2015.16","percent of total billed charges",""
"BOLT HIP 40MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201986","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1288.70","52.26","","1113.10","1113.10","1113.10","1 through 10","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 40MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201986","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1960.41","79.5","","1293.60","1148.53","1603.80","1 through 10","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 40MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201986","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","900.06","36.5","","1023.42","771.29","2068.67","33","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 40MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201986","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","944.45","38.3","","850.52","759.78","1211.25","66","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 40MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201986","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1057.88","42.9","","2548.09","2548.09","2548.09","1 through 10","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 40MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201986","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1057.88","42.9","","956.46","956.46","956.46","1 through 10","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 40MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201986","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","WELLPOINT [1015]","HB AMC WELLPOINT","1819.36","73.78","","2344.73","1619.47","2530.35","16","764.44","1960.41","percent of total billed charges",""
"BOLT HIP 40MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201986","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","AETNA [1001]","HB AMC AETNA HMO","1721.22","69.8","","1523.63","988.41","4330.26","39","1288.7","2015.16","percent of total billed charges",""
"BOLT HIP 40MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201986","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","AETNA [1001]","HB AMC AETNA PPO","1982.61","80.4","","1670.25","1670.25","1670.25","1 through 10","1288.7","2015.16","percent of total billed charges",""
"BOLT HIP 40MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201986","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1288.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1288.7","2015.16","percent of total billed charges",""
"BOLT HIP 40MM ARCOS LATERAL TROCHANTER","SUP-ITM-10201986","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2015.16","81.72","","1738.90","1484.65","2716.94","38","1288.7","2015.16","percent of total billed charges",""
"BOLT INSERTION FOR SOLID TIBIAL NAIL TI","SUP-ITM-10039407","CDM","C1713","HCPCS","0278","RC","","","","both","","","514.71","386.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","409.19","79.5","","800.18","480.96","1887.97","195","159.56","409.19","percent of total billed charges",""
"BOLT INSERTION FOR SOLID TIBIAL NAIL TI","SUP-ITM-10039407","CDM","C1713","HCPCS","0278","RC","","","","both","","","514.71","386.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","274.34","53.3","","813.12","216.42","1444.50","81","159.56","409.19","percent of total billed charges",""
"BOLT INSERTION FOR SOLID TIBIAL NAIL TI","SUP-ITM-10039407","CDM","C1713","HCPCS","0278","RC","","","","both","","","514.71","386.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","159.56","31","","432.60","432.60","432.60","1 through 10","159.56","409.19","percent of total billed charges",""
"BOLT INSERTION FOR SOLID TIBIAL NAIL TI","SUP-ITM-10039407","CDM","C1713","HCPCS","0278","RC","","","","both","","","514.71","386.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","187.87","36.5","","148.37","54.89","631.39","94","159.56","409.19","percent of total billed charges",""
"BOLT INSERTION FOR SOLID TIBIAL NAIL TI","SUP-ITM-10039407","CDM","C1713","HCPCS","0278","RC","","","","both","","","514.71","386.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","197.13","38.3","","279.30","91.72","1116.77","266","159.56","409.19","percent of total billed charges",""
"BOLT INSERTION FOR SOLID TIBIAL NAIL TI","SUP-ITM-10039407","CDM","C1713","HCPCS","0278","RC","","","","both","","","514.71","386.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.81","42.9","","731.00","63.70","731.00","1 through 10","159.56","409.19","percent of total billed charges",""
"BOLT INSERTION FOR SOLID TIBIAL NAIL TI","SUP-ITM-10039407","CDM","C1713","HCPCS","0278","RC","","","","both","","","514.71","386.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.81","42.9","","384.74","384.74","384.74","1 through 10","159.56","409.19","percent of total billed charges",""
"BOLT INSERTION FOR SOLID TIBIAL NAIL TI","SUP-ITM-10039407","CDM","C1713","HCPCS","0278","RC","","","","both","","","514.71","386.03","WELLPOINT [1015]","HB AMC WELLPOINT","379.75","73.78","","286.63","119.22","1107.45","105","159.56","409.19","percent of total billed charges",""
"BOLT INSERTION FOR SOLID TIBIAL NAIL TI","SUP-ITM-10039407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","514.71","386.03","AETNA [1001]","HB AMC AETNA HMO","359.27","69.8","","675.31","184.75","1721.50","286","268.99","420.62","percent of total billed charges",""
"BOLT INSERTION FOR SOLID TIBIAL NAIL TI","SUP-ITM-10039407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","514.71","386.03","AETNA [1001]","HB AMC AETNA PPO","413.83","80.4","","1261.44","103.12","1514.10","21","268.99","420.62","percent of total billed charges",""
"BOLT INSERTION FOR SOLID TIBIAL NAIL TI","SUP-ITM-10039407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","514.71","386.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","413.83","80.4","","1365.00","1365.00","1365.00","1 through 10","268.99","420.62","percent of total billed charges",""
"BOLT INSERTION FOR SOLID TIBIAL NAIL TI","SUP-ITM-10039407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","514.71","386.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","420.62","81.72","","5157.68","5157.68","5157.68","1 through 10","268.99","420.62","percent of total billed charges",""
"BOLT INSERTION FOR SOLID TIBIAL NAIL TI","SUP-ITM-10039407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","514.71","386.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","420.62","81.72","","431.26","71.26","1459.57","88","268.99","420.62","percent of total billed charges",""
"BOLT LOCKING 3.5MM 4.9X50 INTRAMEDULLARY NAIL TI HEX DRIVE","SUP-ITM-10003840","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.25","339.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","360.33","79.5","","800.18","480.96","1887.97","195","140.51","360.33","percent of total billed charges",""
"BOLT LOCKING 3.5MM 4.9X50 INTRAMEDULLARY NAIL TI HEX DRIVE","SUP-ITM-10003840","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.25","339.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","241.58","53.3","","813.12","216.42","1444.50","81","140.51","360.33","percent of total billed charges",""
"BOLT LOCKING 3.5MM 4.9X50 INTRAMEDULLARY NAIL TI HEX DRIVE","SUP-ITM-10003840","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.25","339.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","140.51","31","","432.60","432.60","432.60","1 through 10","140.51","360.33","percent of total billed charges",""
"BOLT LOCKING 3.5MM 4.9X50 INTRAMEDULLARY NAIL TI HEX DRIVE","SUP-ITM-10003840","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.25","339.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","165.44","36.5","","148.37","54.89","631.39","94","140.51","360.33","percent of total billed charges",""
"BOLT LOCKING 3.5MM 4.9X50 INTRAMEDULLARY NAIL TI HEX DRIVE","SUP-ITM-10003840","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.25","339.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","173.59","38.3","","279.30","91.72","1116.77","266","140.51","360.33","percent of total billed charges",""
"BOLT LOCKING 3.5MM 4.9X50 INTRAMEDULLARY NAIL TI HEX DRIVE","SUP-ITM-10003840","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.25","339.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","194.44","42.9","","731.00","63.70","731.00","1 through 10","140.51","360.33","percent of total billed charges",""
"BOLT LOCKING 3.5MM 4.9X50 INTRAMEDULLARY NAIL TI HEX DRIVE","SUP-ITM-10003840","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.25","339.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","194.44","42.9","","384.74","384.74","384.74","1 through 10","140.51","360.33","percent of total billed charges",""
"BOLT LOCKING 3.5MM 4.9X50 INTRAMEDULLARY NAIL TI HEX DRIVE","SUP-ITM-10003840","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.25","339.94","WELLPOINT [1015]","HB AMC WELLPOINT","334.41","73.78","","286.63","119.22","1107.45","105","140.51","360.33","percent of total billed charges",""
"BOLT LOCKING 3.5MM 4.9X50 INTRAMEDULLARY NAIL TI HEX DRIVE","SUP-ITM-10003840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.25","339.94","AETNA [1001]","HB AMC AETNA HMO","316.37","69.8","","675.31","184.75","1721.50","286","236.87","370.4","percent of total billed charges",""
"BOLT LOCKING 3.5MM 4.9X50 INTRAMEDULLARY NAIL TI HEX DRIVE","SUP-ITM-10003840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.25","339.94","AETNA [1001]","HB AMC AETNA PPO","364.41","80.4","","1261.44","103.12","1514.10","21","236.87","370.4","percent of total billed charges",""
"BOLT LOCKING 3.5MM 4.9X50 INTRAMEDULLARY NAIL TI HEX DRIVE","SUP-ITM-10003840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.25","339.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","364.41","80.4","","1365.00","1365.00","1365.00","1 through 10","236.87","370.4","percent of total billed charges",""
"BOLT LOCKING 3.5MM 4.9X50 INTRAMEDULLARY NAIL TI HEX DRIVE","SUP-ITM-10003840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.25","339.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","370.40","81.72","","5157.68","5157.68","5157.68","1 through 10","236.87","370.4","percent of total billed charges",""
"BOLT LOCKING 3.5MM 4.9X50 INTRAMEDULLARY NAIL TI HEX DRIVE","SUP-ITM-10003840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.25","339.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","370.40","81.72","","431.26","71.26","1459.57","88","236.87","370.4","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1304.99","79.5","","800.18","480.96","1887.97","195","508.87","1304.99","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","874.92","53.3","","813.12","216.42","1444.50","81","508.87","1304.99","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","508.87","31","","432.60","432.60","432.60","1 through 10","508.87","1304.99","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","599.15","36.5","","148.37","54.89","631.39","94","508.87","1304.99","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","628.69","38.3","","279.30","91.72","1116.77","266","508.87","1304.99","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","704.20","42.9","","731.00","63.70","731.00","1 through 10","508.87","1304.99","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","704.20","42.9","","384.74","384.74","384.74","1 through 10","508.87","1304.99","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","WELLPOINT [1015]","HB AMC WELLPOINT","1211.10","73.78","","286.63","119.22","1107.45","105","508.87","1304.99","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.50","1231.12","AETNA [1001]","HB AMC AETNA HMO","1145.77","69.8","","675.31","184.75","1721.50","286","857.85","1341.43","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.50","1231.12","AETNA [1001]","HB AMC AETNA PPO","1319.77","80.4","","1261.44","103.12","1514.10","21","857.85","1341.43","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.50","1231.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1319.77","80.4","","1365.00","1365.00","1365.00","1 through 10","857.85","1341.43","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.50","1231.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1341.43","81.72","","5157.68","5157.68","5157.68","1 through 10","857.85","1341.43","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.50","1231.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1341.43","81.72","","431.26","71.26","1459.57","88","857.85","1341.43","percent of total billed charges",""
"BOLT SPINE 8X35MM VANTAGE TITANIUM ANTERIOR LUMBAR","SUP-ITM-10030068","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","1309.77","674.56","6049.93","26","434","1113","percent of total billed charges",""
"BOLT SPINE 8X35MM VANTAGE TITANIUM ANTERIOR LUMBAR","SUP-ITM-10030068","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","1901.83","1901.83","2962.25","1 through 10","434","1113","percent of total billed charges",""
"BOLT SPINE 8X35MM VANTAGE TITANIUM ANTERIOR LUMBAR","SUP-ITM-10030068","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1620.31","1620.31","19908.88","1 through 10","434","1113","percent of total billed charges",""
"BOLT SPINE 8X35MM VANTAGE TITANIUM ANTERIOR LUMBAR","SUP-ITM-10030068","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","352.91","352.91","2046.30","1 through 10","434","1113","percent of total billed charges",""
"BOLT SPINE 8X35MM VANTAGE TITANIUM ANTERIOR LUMBAR","SUP-ITM-10030068","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","9668.75","9668.75","9668.75","1 through 10","434","1113","percent of total billed charges",""
"BOLT SPINE 8X35MM VANTAGE TITANIUM ANTERIOR LUMBAR","SUP-ITM-10030068","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","699.88","384.10","3443.31","33","434","1113","percent of total billed charges",""
"BOLT SPINE 8X35MM VANTAGE TITANIUM ANTERIOR LUMBAR","SUP-ITM-10030068","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1421.24","264.50","4933.46","29","731.64","1144.08","percent of total billed charges",""
"BOLT SPINE 8X35MM VANTAGE TITANIUM ANTERIOR LUMBAR","SUP-ITM-10030068","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1022.97","1022.97","3607.50","1 through 10","731.64","1144.08","percent of total billed charges",""
"BOLT SPINE 8X35MM VANTAGE TITANIUM ANTERIOR LUMBAR","SUP-ITM-10030068","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","3010.54","693.88","5019.88","35","731.64","1144.08","percent of total billed charges",""
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","both","","","455.00","341.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","141.05","438.15","other","OPPS APC"
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","both","","","455.00","341.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","141.05","438.15","other","OPPS APC"
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","both","","","455.00","341.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.52","53.3","","477.31","477.31","477.31","1 through 10","141.05","438.15","percent of total billed charges",""
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","both","","","455.00","341.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","141.05","438.15","other","OPPS APC"
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","both","","","455.00","341.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","141.05","438.15","other","OPPS APC"
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.08","36.5","","1095.87","337.19","1095.87","1 through 10","141.05","438.15","percent of total billed charges",""
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.27","38.3","","343.52","323.76","353.46","1 through 10","141.05","438.15","percent of total billed charges",""
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","both","","","455.00","341.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","141.05","438.15","other","Tricare OPPS"
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","both","","","455.00","341.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","141.05","438.15","other","OPPS APC"
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","both","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","141.05","438.15","other","OPPS APC"
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","both","","","455.00","341.25","WELLPOINT [1015]","HB AMC WELLPOINT","335.70","73.78","","673.03","673.03","673.03","1 through 10","141.05","438.15","percent of total billed charges",""
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","612.01","612.01","1224.02","1 through 10","227.5","700.33","percent of total billed charges",""
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","outpatient","","","455.00","341.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","275.50","60.55","","579.04","568.57","904.00","30","227.5","700.33","percent of total billed charges",""
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","outpatient","","","455.00","341.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","237.60","52.22","","904.00","656.02","2938.00","26","227.5","700.33","percent of total billed charges",""
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","227.50","50","","1421.10","875.08","2368.50","15","227.5","700.33","percent of total billed charges",""
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","238.88","52.5","","2985.00","904.00","2985.00","1 through 10","227.5","700.33","percent of total billed charges",""
"Bone Block (W/ US Guidance)","PX-76002922","CDM","64999","CPT","0761","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.83","81.72","","722.66","722.66","17449.00","1 through 10","227.5","700.33","percent of total billed charges",""
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","both","","","739.00","554.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","229.09","587.51","other","OPPS APC"
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","both","","","739.00","554.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","229.09","587.51","other","OPPS APC"
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","both","","","739.00","554.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","393.89","53.3","","477.31","477.31","477.31","1 through 10","229.09","587.51","percent of total billed charges",""
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","both","","","739.00","554.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","229.09","587.51","other","OPPS APC"
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","both","","","739.00","554.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","229.09","587.51","other","OPPS APC"
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","both","","","739.00","554.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","269.74","36.5","","1095.87","337.19","1095.87","1 through 10","229.09","587.51","percent of total billed charges",""
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","both","","","739.00","554.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","283.04","38.3","","343.52","323.76","353.46","1 through 10","229.09","587.51","percent of total billed charges",""
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","both","","","739.00","554.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","229.09","587.51","other","Tricare OPPS"
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","both","","","739.00","554.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","229.09","587.51","other","OPPS APC"
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","both","","","739.00","554.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","229.09","587.51","other","OPPS APC"
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","both","","","739.00","554.25","WELLPOINT [1015]","HB AMC WELLPOINT","545.23","73.78","","673.03","673.03","673.03","1 through 10","229.09","587.51","percent of total billed charges",""
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","outpatient","","","739.00","554.25","AETNA [1001]","HB AMC AETNA HMO","515.82","69.8","","612.01","612.01","1224.02","1 through 10","369.5","700.33","percent of total billed charges",""
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","outpatient","","","739.00","554.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","447.46","60.55","","579.04","568.57","904.00","30","369.5","700.33","percent of total billed charges",""
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","outpatient","","","739.00","554.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","385.91","52.22","","904.00","656.02","2938.00","26","369.5","700.33","percent of total billed charges",""
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","outpatient","","","739.00","554.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","369.50","50","","1421.10","875.08","2368.50","15","369.5","700.33","percent of total billed charges",""
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","outpatient","","","739.00","554.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","387.98","52.5","","2985.00","904.00","2985.00","1 through 10","369.5","700.33","percent of total billed charges",""
"Bone Block (W/O US Guidance)","PX-76002921","CDM","64999","CPT","0761","RC","","","","outpatient","","","739.00","554.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","603.91","81.72","","722.66","722.66","17449.00","1 through 10","369.5","700.33","percent of total billed charges",""
"Bone Diseases And Arthropathies With McC","553","MS-DRG","","","","","","","","inpatient","","","67087.66","50315.74","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","12204.83","","Case rate ($12,204.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,614.79, add-ons for qualifying new technology services are included. If operating cost exceeds $60,259.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,483.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,781.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,234.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,043.08. The transfer capital threshold is the transfer adjustment factor * $1,043.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11968.19","11968.19","11968.19","1 through 10","11960.73","20305.24","other","Inpatient DRG"
"Bone Diseases And Arthropathies With McC","553","MS-DRG","","","","","","","","inpatient","","","67087.66","50315.74","MEDICARE [2001]","HB BWH MEDICARE","15726.64","","Case rate ($15,726.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,614.79, add-ons for qualifying new technology services are included. If operating cost exceeds $60,259.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,483.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,303.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,234.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,043.08. The transfer capital threshold is the transfer adjustment factor * $1,043.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15697.95","0.03","15697.95","1 through 10","11960.73","20305.24","other","Inpatient DRG"
"Bone Diseases And Arthropathies With McC","553","MS-DRG","","","","","","","","inpatient","","","67087.66","50315.74","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","15726.64","","Case rate ($15,726.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,614.79, add-ons for qualifying new technology services are included. If operating cost exceeds $60,259.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,483.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,303.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,234.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,043.08. The transfer capital threshold is the transfer adjustment factor * $1,043.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11889.84","11889.84","11889.84","1 through 10","11960.73","20305.24","other","Inpatient DRG"
"Bone Diseases And Arthropathies With McC","553","MS-DRG","","","","","","","","inpatient","","","67087.66","50315.74","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","11960.73","","Case rate ($12,204.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,614.79, add-ons for qualifying new technology services are included. If operating cost exceeds $60,259.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,483.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,781.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,234.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,043.08. The transfer capital threshold is the transfer adjustment factor * $1,043.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11889.79","11889.79","11889.79","1 through 10","11960.73","20305.24","other","Inpatient DRG"
"Bone Diseases And Arthropathies Without McC","554","MS-DRG","","","","","","","","inpatient","","","44560.70","33420.52","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7952.09","","Case rate ($7,952.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,495.34, add-ons for qualifying new technology services are included. If operating cost exceeds $55,139.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,108.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,904.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,115.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $667.95. The transfer capital threshold is the transfer adjustment factor * $667.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7794.92","7794.92","7794.92","1 through 10","7793.05","12594.9486","other","Inpatient DRG"
"Bone Diseases And Arthropathies Without McC","554","MS-DRG","","","","","","","","inpatient","","","44560.70","33420.52","MEDICARE [2001]","HB BWH MEDICARE","7952.09","","Case rate ($7,952.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,495.34, add-ons for qualifying new technology services are included. If operating cost exceeds $55,139.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,108.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,904.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,115.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $667.95. The transfer capital threshold is the transfer adjustment factor * $667.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10117.50","0.03","10132.21","19","7793.05","12594.9486","other","Inpatient Replacement Plans DRG"
"Bone Diseases And Arthropathies Without McC","554","MS-DRG","","","","","","","","inpatient","","","44560.70","33420.52","MOLINA [1014]","HB BWH MOLINA","7793.05","","Case rate ($7,952.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,495.34, add-ons for qualifying new technology services are included. If operating cost exceeds $55,139.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,108.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,904.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,115.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $667.95. The transfer capital threshold is the transfer adjustment factor * $667.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15550.39","15550.39","15550.39","1 through 10","7793.05","12594.9486","other","Inpatient DRG"
"Bone Diseases And Arthropathies Without McC","554","MS-DRG","","","","","","","","inpatient","","","44560.70","33420.52","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7793.05","","Case rate ($7,952.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,495.34, add-ons for qualifying new technology services are included. If operating cost exceeds $55,139.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,108.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,904.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,115.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $667.95. The transfer capital threshold is the transfer adjustment factor * $667.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7727.02","7727.02","7727.02","1 through 10","7793.05","12594.9486","other","Inpatient DRG"
"Bone Diseases And Arthropathies Without McC","554","MS-DRG","","","","","","","","inpatient","","","44560.70","33420.52","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7793.05","","Case rate ($7,952.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,495.34, add-ons for qualifying new technology services are included. If operating cost exceeds $55,139.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,108.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,904.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,115.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $667.95. The transfer capital threshold is the transfer adjustment factor * $667.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7753.61","7753.61","7783.33","1 through 10","7793.05","12594.9486","other","Inpatient DRG"
"BONE HEAD 20 43MM SM GRAFT ALLOGRAFT FEMORAL FROZEN","SUP-ITM-10010718","CDM","C1889","HCPCS","0278","RC","","","","both","","","3984.75","2988.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3167.88","79.5","","1309.77","674.56","6049.93","26","1235.27","3167.88","percent of total billed charges",""
"BONE HEAD 20 43MM SM GRAFT ALLOGRAFT FEMORAL FROZEN","SUP-ITM-10010718","CDM","C1889","HCPCS","0278","RC","","","","both","","","3984.75","2988.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2123.87","53.3","","1901.83","1901.83","2962.25","1 through 10","1235.27","3167.88","percent of total billed charges",""
"BONE HEAD 20 43MM SM GRAFT ALLOGRAFT FEMORAL FROZEN","SUP-ITM-10010718","CDM","C1889","HCPCS","0278","RC","","","","both","","","3984.75","2988.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1454.43","36.5","","1620.31","1620.31","19908.88","1 through 10","1235.27","3167.88","percent of total billed charges",""
"BONE HEAD 20 43MM SM GRAFT ALLOGRAFT FEMORAL FROZEN","SUP-ITM-10010718","CDM","C1889","HCPCS","0278","RC","","","","both","","","3984.75","2988.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1526.16","38.3","","352.91","352.91","2046.30","1 through 10","1235.27","3167.88","percent of total billed charges",""
"BONE HEAD 20 43MM SM GRAFT ALLOGRAFT FEMORAL FROZEN","SUP-ITM-10010718","CDM","C1889","HCPCS","0278","RC","","","","both","","","3984.75","2988.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1709.46","42.9","","9668.75","9668.75","9668.75","1 through 10","1235.27","3167.88","percent of total billed charges",""
"BONE HEAD 20 43MM SM GRAFT ALLOGRAFT FEMORAL FROZEN","SUP-ITM-10010718","CDM","C1889","HCPCS","0278","RC","","","","both","","","3984.75","2988.56","WELLPOINT [1015]","HB AMC WELLPOINT","2939.95","73.78","","699.88","384.10","3443.31","33","1235.27","3167.88","percent of total billed charges",""
"BONE HEAD 20 43MM SM GRAFT ALLOGRAFT FEMORAL FROZEN","SUP-ITM-10010718","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3984.75","2988.56","AETNA [1001]","HB AMC AETNA HMO","2781.36","69.8","","1421.24","264.50","4933.46","29","2082.43","3256.34","percent of total billed charges",""
"BONE HEAD 20 43MM SM GRAFT ALLOGRAFT FEMORAL FROZEN","SUP-ITM-10010718","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3984.75","2988.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3203.74","80.4","","1022.97","1022.97","3607.50","1 through 10","2082.43","3256.34","percent of total billed charges",""
"BONE HEAD 20 43MM SM GRAFT ALLOGRAFT FEMORAL FROZEN","SUP-ITM-10010718","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3984.75","2988.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3256.34","81.72","","3010.54","693.88","5019.88","35","2082.43","3256.34","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","10260.00","7695.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5361.88","52.26","","1113.10","1113.10","1113.10","1 through 10","3180.6","8156.7","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","10260.00","7695.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8156.70","79.5","","1293.60","1148.53","1603.80","1 through 10","3180.6","8156.7","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","10260.00","7695.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3744.90","36.5","","1023.42","771.29","2068.67","33","3180.6","8156.7","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","10260.00","7695.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3929.58","38.3","","850.52","759.78","1211.25","66","3180.6","8156.7","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","10260.00","7695.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4401.54","42.9","","2548.09","2548.09","2548.09","1 through 10","3180.6","8156.7","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","10260.00","7695.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4401.54","42.9","","956.46","956.46","956.46","1 through 10","3180.6","8156.7","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","10260.00","7695.00","WELLPOINT [1015]","HB AMC WELLPOINT","7569.83","73.78","","2344.73","1619.47","2530.35","16","3180.6","8156.7","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10260.00","7695.00","AETNA [1001]","HB AMC AETNA HMO","7161.48","69.8","","1523.63","988.41","4330.26","39","5361.88","8384.47","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10260.00","7695.00","AETNA [1001]","HB AMC AETNA PPO","8249.04","80.4","","1670.25","1670.25","1670.25","1 through 10","5361.88","8384.47","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10260.00","7695.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5361.88","52.26","","1113.10","1113.10","1113.10","1 through 10","5361.88","8384.47","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10260.00","7695.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8384.47","81.72","","1738.90","1484.65","2716.94","38","5361.88","8384.47","percent of total billed charges",""
"BONE IMPLANT COATING COBALT 45MM SYSTEM MANIDBULAR TMJ TITANIUM STANDARD RIGHT","SUP-ITM-10126208","CDM","C1713","HCPCS","0278","RC","","","","both","","","16022.50","12016.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12737.89","79.5","","800.18","480.96","1887.97","195","4966.98","12737.89","percent of total billed charges",""
"BONE IMPLANT COATING COBALT 45MM SYSTEM MANIDBULAR TMJ TITANIUM STANDARD RIGHT","SUP-ITM-10126208","CDM","C1713","HCPCS","0278","RC","","","","both","","","16022.50","12016.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8539.99","53.3","","813.12","216.42","1444.50","81","4966.98","12737.89","percent of total billed charges",""
"BONE IMPLANT COATING COBALT 45MM SYSTEM MANIDBULAR TMJ TITANIUM STANDARD RIGHT","SUP-ITM-10126208","CDM","C1713","HCPCS","0278","RC","","","","both","","","16022.50","12016.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4966.98","31","","432.60","432.60","432.60","1 through 10","4966.98","12737.89","percent of total billed charges",""
"BONE IMPLANT COATING COBALT 45MM SYSTEM MANIDBULAR TMJ TITANIUM STANDARD RIGHT","SUP-ITM-10126208","CDM","C1713","HCPCS","0278","RC","","","","both","","","16022.50","12016.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5848.21","36.5","","148.37","54.89","631.39","94","4966.98","12737.89","percent of total billed charges",""
"BONE IMPLANT COATING COBALT 45MM SYSTEM MANIDBULAR TMJ TITANIUM STANDARD RIGHT","SUP-ITM-10126208","CDM","C1713","HCPCS","0278","RC","","","","both","","","16022.50","12016.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6136.62","38.3","","279.30","91.72","1116.77","266","4966.98","12737.89","percent of total billed charges",""
"BONE IMPLANT COATING COBALT 45MM SYSTEM MANIDBULAR TMJ TITANIUM STANDARD RIGHT","SUP-ITM-10126208","CDM","C1713","HCPCS","0278","RC","","","","both","","","16022.50","12016.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6873.65","42.9","","731.00","63.70","731.00","1 through 10","4966.98","12737.89","percent of total billed charges",""
"BONE IMPLANT COATING COBALT 45MM SYSTEM MANIDBULAR TMJ TITANIUM STANDARD RIGHT","SUP-ITM-10126208","CDM","C1713","HCPCS","0278","RC","","","","both","","","16022.50","12016.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6873.65","42.9","","384.74","384.74","384.74","1 through 10","4966.98","12737.89","percent of total billed charges",""
"BONE IMPLANT COATING COBALT 45MM SYSTEM MANIDBULAR TMJ TITANIUM STANDARD RIGHT","SUP-ITM-10126208","CDM","C1713","HCPCS","0278","RC","","","","both","","","16022.50","12016.87","WELLPOINT [1015]","HB AMC WELLPOINT","11821.40","73.78","","286.63","119.22","1107.45","105","4966.98","12737.89","percent of total billed charges",""
"BONE IMPLANT COATING COBALT 45MM SYSTEM MANIDBULAR TMJ TITANIUM STANDARD RIGHT","SUP-ITM-10126208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16022.50","12016.87","AETNA [1001]","HB AMC AETNA HMO","11183.71","69.8","","675.31","184.75","1721.50","286","8373.36","13093.59","percent of total billed charges",""
"BONE IMPLANT COATING COBALT 45MM SYSTEM MANIDBULAR TMJ TITANIUM STANDARD RIGHT","SUP-ITM-10126208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16022.50","12016.87","AETNA [1001]","HB AMC AETNA PPO","12882.09","80.4","","1261.44","103.12","1514.10","21","8373.36","13093.59","percent of total billed charges",""
"BONE IMPLANT COATING COBALT 45MM SYSTEM MANIDBULAR TMJ TITANIUM STANDARD RIGHT","SUP-ITM-10126208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16022.50","12016.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","12882.09","80.4","","1365.00","1365.00","1365.00","1 through 10","8373.36","13093.59","percent of total billed charges",""
"BONE IMPLANT COATING COBALT 45MM SYSTEM MANIDBULAR TMJ TITANIUM STANDARD RIGHT","SUP-ITM-10126208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16022.50","12016.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","13093.59","81.72","","5157.68","5157.68","5157.68","1 through 10","8373.36","13093.59","percent of total billed charges",""
"BONE IMPLANT COATING COBALT 45MM SYSTEM MANIDBULAR TMJ TITANIUM STANDARD RIGHT","SUP-ITM-10126208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16022.50","12016.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13093.59","81.72","","431.26","71.26","1459.57","88","8373.36","13093.59","percent of total billed charges",""
"Bone Marrow Asp|BILATERAL PROCEDURE","PX-76001195","CDM","38220","CPT","0761","RC","","","50","outpatient","","","542.00","406.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2359.44","","Case rate ($2,359.44). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","5523.45","5523.45","5523.45","1 through 10","2359.44","7112.02","other","ASC "
"Bone Marrow Smear Interpretation","PX-30001048","CDM","85097","CPT","0305","RC","","","","both","","","569.00","426.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","373.26","65.6","","193.11","193.11","193.11","1 through 10","176.39","1212.52","percent of total billed charges",""
"Bone Marrow Smear Interpretation","PX-30001048","CDM","85097","CPT","0305","RC","","","","both","","","569.00","426.75","MEDICARE [2001]","HB BWH MEDICARE","970.02","","APC Price ($970.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","970.12","970.12","970.12","1 through 10","176.39","1212.52","other","OPPS APC"
"Bone Marrow Smear Interpretation","PX-30001048","CDM","85097","CPT","0305","RC","","","","outpatient","","","569.00","426.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","464.99","81.72","","322.96","322.96","322.96","1 through 10","265.8","3421.28","percent of total billed charges",""
"Bone Marrow Transplant,EXTREME","003","DRG","","","","","","","","inpatient","","","427549.24","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","229201.00","","Case rate ($229,201). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($412,562), then multiplying the difference by the percent of outlier that is reimbursed (60%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","262209.36","262209.36","394848.29","1 through 10","97603","1070233.4","case rate",""
"Bone Marrow Transplant,EXTREME","003","DRG","","","","","","","","inpatient","","","427549.24","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","266180.00","","Case rate ($266,180). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($585,131), then multiplying the difference by the percent of outlier that is reimbursed (43%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","218827.47","119554.61","456544.70","16","97603","1070233.4","case rate",""
"Bone Marrow Transplant,EXTREME","003","DRG","","","","","","","","inpatient","","","427549.24","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","204119.00","","Case rate ($204,119). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($397,309), then multiplying the difference by the percent of outlier that is reimbursed (61.5%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","621359.04","621359.04","621359.04","1 through 10","97603","1070233.4","case rate",""
"Bone Marrow Transplant,MAJOR","003","DRG","","","","","","","","inpatient","","","322268.34","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","229201.00","","Case rate ($229,201). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($412,562), then multiplying the difference by the percent of outlier that is reimbursed (60%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","221697.86","221697.86","229201.00","1 through 10","97603","1070233.4","case rate",""
"Bone Marrow Transplant,MAJOR","003","DRG","","","","","","","","inpatient","","","322268.34","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","266180.00","","Case rate ($266,180). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($585,131), then multiplying the difference by the percent of outlier that is reimbursed (43%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","119570.51","29933.75","225483.94","22","97603","1070233.4","case rate",""
"Bone Marrow Transplant,MINOR","003","DRG","","","","","","","","inpatient","","","186557.12","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","121834.00","","Case rate ($121,834). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($267,821), then multiplying the difference by the percent of outlier that is reimbursed (43%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","285112.86","285112.86","285112.86","1 through 10","97603","1070233.4","case rate",""
"Bone Marrow Transplant,MODERATE","003","DRG","","","","","","","","inpatient","","","184191.98","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","124480.00","","Case rate ($124,480). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($248,958), then multiplying the difference by the percent of outlier that is reimbursed (60%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","234780.00","234780.00","234780.00","1 through 10","97603","1070233.4","case rate",""
"Bone Marrow Transplant,MODERATE","003","DRG","","","","","","","","inpatient","","","184191.98","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","121834.00","","Case rate ($121,834). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($267,821), then multiplying the difference by the percent of outlier that is reimbursed (43%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","69469.82","33747.02","104448.35","1 through 10","97603","1070233.4","case rate",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3465.38","79.5","","800.18","480.96","1887.97","195","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2323.33","53.3","","813.12","216.42","1444.50","81","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1351.28","31","","432.60","432.60","432.60","1 through 10","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1591.02","36.5","","148.37","54.89","631.39","94","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1669.49","38.3","","279.30","91.72","1116.77","266","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1870.00","42.9","","731.00","63.70","731.00","1 through 10","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1870.00","42.9","","384.74","384.74","384.74","1 through 10","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","WELLPOINT [1015]","HB AMC WELLPOINT","3216.05","73.78","","286.63","119.22","1107.45","105","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","AETNA [1001]","HB AMC AETNA HMO","3042.56","69.8","","675.31","184.75","1721.50","286","2278","3562.15","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","AETNA [1001]","HB AMC AETNA PPO","3504.61","80.4","","1261.44","103.12","1514.10","21","2278","3562.15","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3504.61","80.4","","1365.00","1365.00","1365.00","1 through 10","2278","3562.15","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3562.15","81.72","","5157.68","5157.68","5157.68","1 through 10","2278","3562.15","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3562.15","81.72","","431.26","71.26","1459.57","88","2278","3562.15","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3465.38","79.5","","800.18","480.96","1887.97","195","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2323.33","53.3","","813.12","216.42","1444.50","81","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1351.28","31","","432.60","432.60","432.60","1 through 10","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1591.02","36.5","","148.37","54.89","631.39","94","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1669.49","38.3","","279.30","91.72","1116.77","266","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1870.00","42.9","","731.00","63.70","731.00","1 through 10","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1870.00","42.9","","384.74","384.74","384.74","1 through 10","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","WELLPOINT [1015]","HB AMC WELLPOINT","3216.05","73.78","","286.63","119.22","1107.45","105","1351.28","3465.38","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","AETNA [1001]","HB AMC AETNA HMO","3042.56","69.8","","675.31","184.75","1721.50","286","2278","3562.15","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","AETNA [1001]","HB AMC AETNA PPO","3504.61","80.4","","1261.44","103.12","1514.10","21","2278","3562.15","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3504.61","80.4","","1365.00","1365.00","1365.00","1 through 10","2278","3562.15","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3562.15","81.72","","5157.68","5157.68","5157.68","1 through 10","2278","3562.15","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3562.15","81.72","","431.26","71.26","1459.57","88","2278","3562.15","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.14","537.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","569.33","79.5","","800.18","480.96","1887.97","195","222","569.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.14","537.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","381.70","53.3","","813.12","216.42","1444.50","81","222","569.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.14","537.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","222.00","31","","432.60","432.60","432.60","1 through 10","222","569.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.14","537.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","261.39","36.5","","148.37","54.89","631.39","94","222","569.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.14","537.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.28","38.3","","279.30","91.72","1116.77","266","222","569.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.14","537.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.22","42.9","","731.00","63.70","731.00","1 through 10","222","569.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.14","537.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.22","42.9","","384.74","384.74","384.74","1 through 10","222","569.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.14","537.10","WELLPOINT [1015]","HB AMC WELLPOINT","528.37","73.78","","286.63","119.22","1107.45","105","222","569.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.14","537.10","AETNA [1001]","HB AMC AETNA HMO","499.87","69.8","","675.31","184.75","1721.50","286","374.25","585.23","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.14","537.10","AETNA [1001]","HB AMC AETNA PPO","575.78","80.4","","1261.44","103.12","1514.10","21","374.25","585.23","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.14","537.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","575.78","80.4","","1365.00","1365.00","1365.00","1 through 10","374.25","585.23","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.14","537.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","585.23","81.72","","5157.68","5157.68","5157.68","1 through 10","374.25","585.23","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.14","537.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","585.23","81.72","","431.26","71.26","1459.57","88","374.25","585.23","percent of total billed charges",""
"BONE NAIL 3.5X440MM FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10024654","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.47","646.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","685.66","79.5","","800.18","480.96","1887.97","195","267.37","685.66","percent of total billed charges",""
"BONE NAIL 3.5X440MM FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10024654","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.47","646.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","459.70","53.3","","813.12","216.42","1444.50","81","267.37","685.66","percent of total billed charges",""
"BONE NAIL 3.5X440MM FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10024654","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.47","646.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","267.37","31","","432.60","432.60","432.60","1 through 10","267.37","685.66","percent of total billed charges",""
"BONE NAIL 3.5X440MM FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10024654","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.47","646.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","314.80","36.5","","148.37","54.89","631.39","94","267.37","685.66","percent of total billed charges",""
"BONE NAIL 3.5X440MM FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10024654","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.47","646.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","330.33","38.3","","279.30","91.72","1116.77","266","267.37","685.66","percent of total billed charges",""
"BONE NAIL 3.5X440MM FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10024654","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.47","646.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","370.00","42.9","","731.00","63.70","731.00","1 through 10","267.37","685.66","percent of total billed charges",""
"BONE NAIL 3.5X440MM FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10024654","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.47","646.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","370.00","42.9","","384.74","384.74","384.74","1 through 10","267.37","685.66","percent of total billed charges",""
"BONE NAIL 3.5X440MM FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10024654","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.47","646.85","WELLPOINT [1015]","HB AMC WELLPOINT","636.33","73.78","","286.63","119.22","1107.45","105","267.37","685.66","percent of total billed charges",""
"BONE NAIL 3.5X440MM FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10024654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.47","646.85","AETNA [1001]","HB AMC AETNA HMO","602.00","69.8","","675.31","184.75","1721.50","286","450.73","704.81","percent of total billed charges",""
"BONE NAIL 3.5X440MM FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10024654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.47","646.85","AETNA [1001]","HB AMC AETNA PPO","693.43","80.4","","1261.44","103.12","1514.10","21","450.73","704.81","percent of total billed charges",""
"BONE NAIL 3.5X440MM FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10024654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.47","646.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","693.43","80.4","","1365.00","1365.00","1365.00","1 through 10","450.73","704.81","percent of total billed charges",""
"BONE NAIL 3.5X440MM FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10024654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.47","646.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","704.81","81.72","","5157.68","5157.68","5157.68","1 through 10","450.73","704.81","percent of total billed charges",""
"BONE NAIL 3.5X440MM FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10024654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.47","646.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","704.81","81.72","","431.26","71.26","1459.57","88","450.73","704.81","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","both","","","813.26","609.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","646.54","79.5","","800.18","480.96","1887.97","195","252.11","646.54","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","both","","","813.26","609.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","433.47","53.3","","813.12","216.42","1444.50","81","252.11","646.54","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","both","","","813.26","609.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","252.11","31","","432.60","432.60","432.60","1 through 10","252.11","646.54","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","both","","","813.26","609.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","296.84","36.5","","148.37","54.89","631.39","94","252.11","646.54","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","both","","","813.26","609.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","311.48","38.3","","279.30","91.72","1116.77","266","252.11","646.54","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","both","","","813.26","609.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","348.89","42.9","","731.00","63.70","731.00","1 through 10","252.11","646.54","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","both","","","813.26","609.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","348.89","42.9","","384.74","384.74","384.74","1 through 10","252.11","646.54","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","both","","","813.26","609.94","WELLPOINT [1015]","HB AMC WELLPOINT","600.02","73.78","","286.63","119.22","1107.45","105","252.11","646.54","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","813.26","609.94","AETNA [1001]","HB AMC AETNA HMO","567.66","69.8","","675.31","184.75","1721.50","286","425.01","664.6","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","813.26","609.94","AETNA [1001]","HB AMC AETNA PPO","653.86","80.4","","1261.44","103.12","1514.10","21","425.01","664.6","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","813.26","609.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","653.86","80.4","","1365.00","1365.00","1365.00","1 through 10","425.01","664.6","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","813.26","609.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","664.60","81.72","","5157.68","5157.68","5157.68","1 through 10","425.01","664.6","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","813.26","609.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","664.60","81.72","","431.26","71.26","1459.57","88","425.01","664.6","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.53","577.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","612.57","79.5","","800.18","480.96","1887.97","195","238.86","612.57","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.53","577.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","410.69","53.3","","813.12","216.42","1444.50","81","238.86","612.57","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.53","577.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","238.86","31","","432.60","432.60","432.60","1 through 10","238.86","612.57","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.53","577.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","281.24","36.5","","148.37","54.89","631.39","94","238.86","612.57","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.53","577.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","295.11","38.3","","279.30","91.72","1116.77","266","238.86","612.57","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.53","577.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","330.56","42.9","","731.00","63.70","731.00","1 through 10","238.86","612.57","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.53","577.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","330.56","42.9","","384.74","384.74","384.74","1 through 10","238.86","612.57","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.53","577.90","WELLPOINT [1015]","HB AMC WELLPOINT","568.50","73.78","","286.63","119.22","1107.45","105","238.86","612.57","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.53","577.90","AETNA [1001]","HB AMC AETNA HMO","537.83","69.8","","675.31","184.75","1721.50","286","402.68","629.68","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.53","577.90","AETNA [1001]","HB AMC AETNA PPO","619.51","80.4","","1261.44","103.12","1514.10","21","402.68","629.68","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.53","577.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","619.51","80.4","","1365.00","1365.00","1365.00","1 through 10","402.68","629.68","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.53","577.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","629.68","81.72","","5157.68","5157.68","5157.68","1 through 10","402.68","629.68","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.53","577.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","629.68","81.72","","431.26","71.26","1459.57","88","402.68","629.68","percent of total billed charges",""
"BONE NAIL 4X440MM FEMORAL CANNULATED TI ELASTIC","SUP-ITM-10024457","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.63","693.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","735.08","79.5","","800.18","480.96","1887.97","195","286.64","735.08","percent of total billed charges",""
"BONE NAIL 4X440MM FEMORAL CANNULATED TI ELASTIC","SUP-ITM-10024457","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.63","693.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","492.83","53.3","","813.12","216.42","1444.50","81","286.64","735.08","percent of total billed charges",""
"BONE NAIL 4X440MM FEMORAL CANNULATED TI ELASTIC","SUP-ITM-10024457","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.63","693.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","286.64","31","","432.60","432.60","432.60","1 through 10","286.64","735.08","percent of total billed charges",""
"BONE NAIL 4X440MM FEMORAL CANNULATED TI ELASTIC","SUP-ITM-10024457","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.63","693.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","337.49","36.5","","148.37","54.89","631.39","94","286.64","735.08","percent of total billed charges",""
"BONE NAIL 4X440MM FEMORAL CANNULATED TI ELASTIC","SUP-ITM-10024457","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.63","693.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","354.13","38.3","","279.30","91.72","1116.77","266","286.64","735.08","percent of total billed charges",""
"BONE NAIL 4X440MM FEMORAL CANNULATED TI ELASTIC","SUP-ITM-10024457","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.63","693.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","396.67","42.9","","731.00","63.70","731.00","1 through 10","286.64","735.08","percent of total billed charges",""
"BONE NAIL 4X440MM FEMORAL CANNULATED TI ELASTIC","SUP-ITM-10024457","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.63","693.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","396.67","42.9","","384.74","384.74","384.74","1 through 10","286.64","735.08","percent of total billed charges",""
"BONE NAIL 4X440MM FEMORAL CANNULATED TI ELASTIC","SUP-ITM-10024457","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.63","693.47","WELLPOINT [1015]","HB AMC WELLPOINT","682.19","73.78","","286.63","119.22","1107.45","105","286.64","735.08","percent of total billed charges",""
"BONE NAIL 4X440MM FEMORAL CANNULATED TI ELASTIC","SUP-ITM-10024457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.63","693.47","AETNA [1001]","HB AMC AETNA HMO","645.39","69.8","","675.31","184.75","1721.50","286","483.21","755.61","percent of total billed charges",""
"BONE NAIL 4X440MM FEMORAL CANNULATED TI ELASTIC","SUP-ITM-10024457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.63","693.47","AETNA [1001]","HB AMC AETNA PPO","743.40","80.4","","1261.44","103.12","1514.10","21","483.21","755.61","percent of total billed charges",""
"BONE NAIL 4X440MM FEMORAL CANNULATED TI ELASTIC","SUP-ITM-10024457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.63","693.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","743.40","80.4","","1365.00","1365.00","1365.00","1 through 10","483.21","755.61","percent of total billed charges",""
"BONE NAIL 4X440MM FEMORAL CANNULATED TI ELASTIC","SUP-ITM-10024457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.63","693.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","755.61","81.72","","5157.68","5157.68","5157.68","1 through 10","483.21","755.61","percent of total billed charges",""
"BONE NAIL 4X440MM FEMORAL CANNULATED TI ELASTIC","SUP-ITM-10024457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.63","693.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","755.61","81.72","","431.26","71.26","1459.57","88","483.21","755.61","percent of total billed charges",""
"BONE NAIL 7MMX240 HUMERAL EX TI","SUP-ITM-10026275","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3409.79","79.5","","800.18","480.96","1887.97","195","1329.6","3409.79","percent of total billed charges",""
"BONE NAIL 7MMX240 HUMERAL EX TI","SUP-ITM-10026275","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2286.06","53.3","","813.12","216.42","1444.50","81","1329.6","3409.79","percent of total billed charges",""
"BONE NAIL 7MMX240 HUMERAL EX TI","SUP-ITM-10026275","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1329.60","31","","432.60","432.60","432.60","1 through 10","1329.6","3409.79","percent of total billed charges",""
"BONE NAIL 7MMX240 HUMERAL EX TI","SUP-ITM-10026275","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1565.50","36.5","","148.37","54.89","631.39","94","1329.6","3409.79","percent of total billed charges",""
"BONE NAIL 7MMX240 HUMERAL EX TI","SUP-ITM-10026275","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1642.70","38.3","","279.30","91.72","1116.77","266","1329.6","3409.79","percent of total billed charges",""
"BONE NAIL 7MMX240 HUMERAL EX TI","SUP-ITM-10026275","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1840.00","42.9","","731.00","63.70","731.00","1 through 10","1329.6","3409.79","percent of total billed charges",""
"BONE NAIL 7MMX240 HUMERAL EX TI","SUP-ITM-10026275","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1840.00","42.9","","384.74","384.74","384.74","1 through 10","1329.6","3409.79","percent of total billed charges",""
"BONE NAIL 7MMX240 HUMERAL EX TI","SUP-ITM-10026275","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","WELLPOINT [1015]","HB AMC WELLPOINT","3164.45","73.78","","286.63","119.22","1107.45","105","1329.6","3409.79","percent of total billed charges",""
"BONE NAIL 7MMX240 HUMERAL EX TI","SUP-ITM-10026275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4289.04","3216.78","AETNA [1001]","HB AMC AETNA HMO","2993.75","69.8","","675.31","184.75","1721.50","286","2241.45","3505","percent of total billed charges",""
"BONE NAIL 7MMX240 HUMERAL EX TI","SUP-ITM-10026275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4289.04","3216.78","AETNA [1001]","HB AMC AETNA PPO","3448.39","80.4","","1261.44","103.12","1514.10","21","2241.45","3505","percent of total billed charges",""
"BONE NAIL 7MMX240 HUMERAL EX TI","SUP-ITM-10026275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4289.04","3216.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3448.39","80.4","","1365.00","1365.00","1365.00","1 through 10","2241.45","3505","percent of total billed charges",""
"BONE NAIL 7MMX240 HUMERAL EX TI","SUP-ITM-10026275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4289.04","3216.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3505.00","81.72","","5157.68","5157.68","5157.68","1 through 10","2241.45","3505","percent of total billed charges",""
"BONE NAIL 7MMX240 HUMERAL EX TI","SUP-ITM-10026275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4289.04","3216.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3505.00","81.72","","431.26","71.26","1459.57","88","2241.45","3505","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3104.02","79.5","","800.18","480.96","1887.97","195","1210.37","3104.02","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2081.06","53.3","","813.12","216.42","1444.50","81","1210.37","3104.02","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1210.37","31","","432.60","432.60","432.60","1 through 10","1210.37","3104.02","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1425.12","36.5","","148.37","54.89","631.39","94","1210.37","3104.02","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1495.40","38.3","","279.30","91.72","1116.77","266","1210.37","3104.02","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1675.00","42.9","","731.00","63.70","731.00","1 through 10","1210.37","3104.02","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1675.00","42.9","","384.74","384.74","384.74","1 through 10","1210.37","3104.02","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","WELLPOINT [1015]","HB AMC WELLPOINT","2880.69","73.78","","286.63","119.22","1107.45","105","1210.37","3104.02","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","AETNA [1001]","HB AMC AETNA HMO","2725.29","69.8","","675.31","184.75","1721.50","286","2040.46","3190.7","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","AETNA [1001]","HB AMC AETNA PPO","3139.16","80.4","","1261.44","103.12","1514.10","21","2040.46","3190.7","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3139.16","80.4","","1365.00","1365.00","1365.00","1 through 10","2040.46","3190.7","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3190.70","81.72","","5157.68","5157.68","5157.68","1 through 10","2040.46","3190.7","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3190.70","81.72","","431.26","71.26","1459.57","88","2040.46","3190.7","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3401.84","79.5","","800.18","480.96","1887.97","195","1326.51","3401.84","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2280.73","53.3","","813.12","216.42","1444.50","81","1326.51","3401.84","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1326.51","31","","432.60","432.60","432.60","1 through 10","1326.51","3401.84","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1561.85","36.5","","148.37","54.89","631.39","94","1326.51","3401.84","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1638.88","38.3","","279.30","91.72","1116.77","266","1326.51","3401.84","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1835.71","42.9","","731.00","63.70","731.00","1 through 10","1326.51","3401.84","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1835.71","42.9","","384.74","384.74","384.74","1 through 10","1326.51","3401.84","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","WELLPOINT [1015]","HB AMC WELLPOINT","3157.08","73.78","","286.63","119.22","1107.45","105","1326.51","3401.84","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4279.05","3209.29","AETNA [1001]","HB AMC AETNA HMO","2986.78","69.8","","675.31","184.75","1721.50","286","2236.23","3496.84","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4279.05","3209.29","AETNA [1001]","HB AMC AETNA PPO","3440.36","80.4","","1261.44","103.12","1514.10","21","2236.23","3496.84","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4279.05","3209.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3440.36","80.4","","1365.00","1365.00","1365.00","1 through 10","2236.23","3496.84","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4279.05","3209.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3496.84","81.72","","5157.68","5157.68","5157.68","1 through 10","2236.23","3496.84","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4279.05","3209.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3496.84","81.72","","431.26","71.26","1459.57","88","2236.23","3496.84","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3309.93","79.5","","800.18","480.96","1887.97","195","1290.66","3309.93","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2219.11","53.3","","813.12","216.42","1444.50","81","1290.66","3309.93","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1290.66","31","","432.60","432.60","432.60","1 through 10","1290.66","3309.93","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1519.65","36.5","","148.37","54.89","631.39","94","1290.66","3309.93","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1594.59","38.3","","279.30","91.72","1116.77","266","1290.66","3309.93","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1786.11","42.9","","731.00","63.70","731.00","1 through 10","1290.66","3309.93","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1786.11","42.9","","384.74","384.74","384.74","1 through 10","1290.66","3309.93","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","WELLPOINT [1015]","HB AMC WELLPOINT","3071.78","73.78","","286.63","119.22","1107.45","105","1290.66","3309.93","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","AETNA [1001]","HB AMC AETNA HMO","2906.07","69.8","","675.31","184.75","1721.50","286","2175.81","3402.35","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","AETNA [1001]","HB AMC AETNA PPO","3347.40","80.4","","1261.44","103.12","1514.10","21","2175.81","3402.35","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3347.40","80.4","","1365.00","1365.00","1365.00","1 through 10","2175.81","3402.35","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3402.35","81.72","","5157.68","5157.68","5157.68","1 through 10","2175.81","3402.35","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3402.35","81.72","","431.26","71.26","1459.57","88","2175.81","3402.35","percent of total billed charges",""
"BONE PIN 12MM 1.8 BUTTRESS STAINLESS DISTAL RADIUS PLATE","SUP-ITM-10006545","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.29","119.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","126.64","79.5","","800.18","480.96","1887.97","195","49.38","126.64","percent of total billed charges",""
"BONE PIN 12MM 1.8 BUTTRESS STAINLESS DISTAL RADIUS PLATE","SUP-ITM-10006545","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.29","119.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","84.90","53.3","","813.12","216.42","1444.50","81","49.38","126.64","percent of total billed charges",""
"BONE PIN 12MM 1.8 BUTTRESS STAINLESS DISTAL RADIUS PLATE","SUP-ITM-10006545","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.29","119.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.38","31","","432.60","432.60","432.60","1 through 10","49.38","126.64","percent of total billed charges",""
"BONE PIN 12MM 1.8 BUTTRESS STAINLESS DISTAL RADIUS PLATE","SUP-ITM-10006545","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.29","119.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.14","36.5","","148.37","54.89","631.39","94","49.38","126.64","percent of total billed charges",""
"BONE PIN 12MM 1.8 BUTTRESS STAINLESS DISTAL RADIUS PLATE","SUP-ITM-10006545","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.29","119.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.01","38.3","","279.30","91.72","1116.77","266","49.38","126.64","percent of total billed charges",""
"BONE PIN 12MM 1.8 BUTTRESS STAINLESS DISTAL RADIUS PLATE","SUP-ITM-10006545","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.29","119.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.34","42.9","","731.00","63.70","731.00","1 through 10","49.38","126.64","percent of total billed charges",""
"BONE PIN 12MM 1.8 BUTTRESS STAINLESS DISTAL RADIUS PLATE","SUP-ITM-10006545","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.29","119.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.34","42.9","","384.74","384.74","384.74","1 through 10","49.38","126.64","percent of total billed charges",""
"BONE PIN 12MM 1.8 BUTTRESS STAINLESS DISTAL RADIUS PLATE","SUP-ITM-10006545","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.29","119.47","WELLPOINT [1015]","HB AMC WELLPOINT","117.52","73.78","","286.63","119.22","1107.45","105","49.38","126.64","percent of total billed charges",""
"BONE PIN 12MM 1.8 BUTTRESS STAINLESS DISTAL RADIUS PLATE","SUP-ITM-10006545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.29","119.47","AETNA [1001]","HB AMC AETNA HMO","111.18","69.8","","675.31","184.75","1721.50","286","83.24","130.17","percent of total billed charges",""
"BONE PIN 12MM 1.8 BUTTRESS STAINLESS DISTAL RADIUS PLATE","SUP-ITM-10006545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.29","119.47","AETNA [1001]","HB AMC AETNA PPO","128.07","80.4","","1261.44","103.12","1514.10","21","83.24","130.17","percent of total billed charges",""
"BONE PIN 12MM 1.8 BUTTRESS STAINLESS DISTAL RADIUS PLATE","SUP-ITM-10006545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.29","119.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.07","80.4","","1365.00","1365.00","1365.00","1 through 10","83.24","130.17","percent of total billed charges",""
"BONE PIN 12MM 1.8 BUTTRESS STAINLESS DISTAL RADIUS PLATE","SUP-ITM-10006545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.29","119.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","130.17","81.72","","5157.68","5157.68","5157.68","1 through 10","83.24","130.17","percent of total billed charges",""
"BONE PIN 12MM 1.8 BUTTRESS STAINLESS DISTAL RADIUS PLATE","SUP-ITM-10006545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.29","119.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.17","81.72","","431.26","71.26","1459.57","88","83.24","130.17","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","247.53","79.5","","800.18","480.96","1887.97","195","96.52","247.53","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","165.95","53.3","","813.12","216.42","1444.50","81","96.52","247.53","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","96.52","31","","432.60","432.60","432.60","1 through 10","96.52","247.53","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","113.65","36.5","","148.37","54.89","631.39","94","96.52","247.53","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.25","38.3","","279.30","91.72","1116.77","266","96.52","247.53","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.57","42.9","","731.00","63.70","731.00","1 through 10","96.52","247.53","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.57","42.9","","384.74","384.74","384.74","1 through 10","96.52","247.53","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","WELLPOINT [1015]","HB AMC WELLPOINT","229.72","73.78","","286.63","119.22","1107.45","105","96.52","247.53","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","AETNA [1001]","HB AMC AETNA HMO","217.33","69.8","","675.31","184.75","1721.50","286","162.72","254.44","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","AETNA [1001]","HB AMC AETNA PPO","250.33","80.4","","1261.44","103.12","1514.10","21","162.72","254.44","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","250.33","80.4","","1365.00","1365.00","1365.00","1 through 10","162.72","254.44","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","254.44","81.72","","5157.68","5157.68","5157.68","1 through 10","162.72","254.44","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","254.44","81.72","","431.26","71.26","1459.57","88","162.72","254.44","percent of total billed charges",""
"BONE PIN 2MM LCP THREADED BENDABLE","SUP-ITM-10039162","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","763.35","79.5","","800.18","480.96","1887.97","195","297.66","763.35","percent of total billed charges",""
"BONE PIN 2MM LCP THREADED BENDABLE","SUP-ITM-10039162","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","511.78","53.3","","813.12","216.42","1444.50","81","297.66","763.35","percent of total billed charges",""
"BONE PIN 2MM LCP THREADED BENDABLE","SUP-ITM-10039162","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","297.66","31","","432.60","432.60","432.60","1 through 10","297.66","763.35","percent of total billed charges",""
"BONE PIN 2MM LCP THREADED BENDABLE","SUP-ITM-10039162","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","350.47","36.5","","148.37","54.89","631.39","94","297.66","763.35","percent of total billed charges",""
"BONE PIN 2MM LCP THREADED BENDABLE","SUP-ITM-10039162","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","367.75","38.3","","279.30","91.72","1116.77","266","297.66","763.35","percent of total billed charges",""
"BONE PIN 2MM LCP THREADED BENDABLE","SUP-ITM-10039162","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","411.92","42.9","","731.00","63.70","731.00","1 through 10","297.66","763.35","percent of total billed charges",""
"BONE PIN 2MM LCP THREADED BENDABLE","SUP-ITM-10039162","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","411.92","42.9","","384.74","384.74","384.74","1 through 10","297.66","763.35","percent of total billed charges",""
"BONE PIN 2MM LCP THREADED BENDABLE","SUP-ITM-10039162","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.19","720.14","WELLPOINT [1015]","HB AMC WELLPOINT","708.43","73.78","","286.63","119.22","1107.45","105","297.66","763.35","percent of total billed charges",""
"BONE PIN 2MM LCP THREADED BENDABLE","SUP-ITM-10039162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","AETNA [1001]","HB AMC AETNA HMO","670.21","69.8","","675.31","184.75","1721.50","286","501.8","784.67","percent of total billed charges",""
"BONE PIN 2MM LCP THREADED BENDABLE","SUP-ITM-10039162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","AETNA [1001]","HB AMC AETNA PPO","771.99","80.4","","1261.44","103.12","1514.10","21","501.8","784.67","percent of total billed charges",""
"BONE PIN 2MM LCP THREADED BENDABLE","SUP-ITM-10039162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","771.99","80.4","","1365.00","1365.00","1365.00","1 through 10","501.8","784.67","percent of total billed charges",""
"BONE PIN 2MM LCP THREADED BENDABLE","SUP-ITM-10039162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","784.67","81.72","","5157.68","5157.68","5157.68","1 through 10","501.8","784.67","percent of total billed charges",""
"BONE PIN 2MM LCP THREADED BENDABLE","SUP-ITM-10039162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.19","720.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","784.67","81.72","","431.26","71.26","1459.57","88","501.8","784.67","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","371.66","79.5","","800.18","480.96","1887.97","195","144.93","371.66","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","249.18","53.3","","813.12","216.42","1444.50","81","144.93","371.66","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","144.93","31","","432.60","432.60","432.60","1 through 10","144.93","371.66","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","170.64","36.5","","148.37","54.89","631.39","94","144.93","371.66","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.05","38.3","","279.30","91.72","1116.77","266","144.93","371.66","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.56","42.9","","731.00","63.70","731.00","1 through 10","144.93","371.66","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.56","42.9","","384.74","384.74","384.74","1 through 10","144.93","371.66","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","WELLPOINT [1015]","HB AMC WELLPOINT","344.92","73.78","","286.63","119.22","1107.45","105","144.93","371.66","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","AETNA [1001]","HB AMC AETNA HMO","326.32","69.8","","675.31","184.75","1721.50","286","244.32","382.04","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","AETNA [1001]","HB AMC AETNA PPO","375.87","80.4","","1261.44","103.12","1514.10","21","244.32","382.04","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","375.87","80.4","","1365.00","1365.00","1365.00","1 through 10","244.32","382.04","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","382.04","81.72","","5157.68","5157.68","5157.68","1 through 10","244.32","382.04","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","382.04","81.72","","431.26","71.26","1459.57","88","244.32","382.04","percent of total billed charges",""
"BONE PIN 3X100MM NAVIGATION ORTHOLOCK SS","SUP-ITM-10021800","CDM","C1889","HCPCS","0278","RC","","","","both","","","2885.93","2164.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2294.31","79.5","","1309.77","674.56","6049.93","26","894.64","2294.31","percent of total billed charges",""
"BONE PIN 3X100MM NAVIGATION ORTHOLOCK SS","SUP-ITM-10021800","CDM","C1889","HCPCS","0278","RC","","","","both","","","2885.93","2164.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1538.20","53.3","","1901.83","1901.83","2962.25","1 through 10","894.64","2294.31","percent of total billed charges",""
"BONE PIN 3X100MM NAVIGATION ORTHOLOCK SS","SUP-ITM-10021800","CDM","C1889","HCPCS","0278","RC","","","","both","","","2885.93","2164.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1053.36","36.5","","1620.31","1620.31","19908.88","1 through 10","894.64","2294.31","percent of total billed charges",""
"BONE PIN 3X100MM NAVIGATION ORTHOLOCK SS","SUP-ITM-10021800","CDM","C1889","HCPCS","0278","RC","","","","both","","","2885.93","2164.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1105.31","38.3","","352.91","352.91","2046.30","1 through 10","894.64","2294.31","percent of total billed charges",""
"BONE PIN 3X100MM NAVIGATION ORTHOLOCK SS","SUP-ITM-10021800","CDM","C1889","HCPCS","0278","RC","","","","both","","","2885.93","2164.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1238.06","42.9","","9668.75","9668.75","9668.75","1 through 10","894.64","2294.31","percent of total billed charges",""
"BONE PIN 3X100MM NAVIGATION ORTHOLOCK SS","SUP-ITM-10021800","CDM","C1889","HCPCS","0278","RC","","","","both","","","2885.93","2164.45","WELLPOINT [1015]","HB AMC WELLPOINT","2129.24","73.78","","699.88","384.10","3443.31","33","894.64","2294.31","percent of total billed charges",""
"BONE PIN 3X100MM NAVIGATION ORTHOLOCK SS","SUP-ITM-10021800","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2885.93","2164.45","AETNA [1001]","HB AMC AETNA HMO","2014.38","69.8","","1421.24","264.50","4933.46","29","1508.19","2358.38","percent of total billed charges",""
"BONE PIN 3X100MM NAVIGATION ORTHOLOCK SS","SUP-ITM-10021800","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2885.93","2164.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2320.29","80.4","","1022.97","1022.97","3607.50","1 through 10","1508.19","2358.38","percent of total billed charges",""
"BONE PIN 3X100MM NAVIGATION ORTHOLOCK SS","SUP-ITM-10021800","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2885.93","2164.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2358.38","81.72","","3010.54","693.88","5019.88","35","1508.19","2358.38","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","371.66","79.5","","800.18","480.96","1887.97","195","144.93","371.66","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","249.18","53.3","","813.12","216.42","1444.50","81","144.93","371.66","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","144.93","31","","432.60","432.60","432.60","1 through 10","144.93","371.66","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","170.64","36.5","","148.37","54.89","631.39","94","144.93","371.66","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.05","38.3","","279.30","91.72","1116.77","266","144.93","371.66","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.56","42.9","","731.00","63.70","731.00","1 through 10","144.93","371.66","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.56","42.9","","384.74","384.74","384.74","1 through 10","144.93","371.66","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","WELLPOINT [1015]","HB AMC WELLPOINT","344.92","73.78","","286.63","119.22","1107.45","105","144.93","371.66","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","AETNA [1001]","HB AMC AETNA HMO","326.32","69.8","","675.31","184.75","1721.50","286","244.32","382.04","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","AETNA [1001]","HB AMC AETNA PPO","375.87","80.4","","1261.44","103.12","1514.10","21","244.32","382.04","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","375.87","80.4","","1365.00","1365.00","1365.00","1 through 10","244.32","382.04","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","382.04","81.72","","5157.68","5157.68","5157.68","1 through 10","244.32","382.04","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","382.04","81.72","","431.26","71.26","1459.57","88","244.32","382.04","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.64","177.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","188.13","79.5","","800.18","480.96","1887.97","195","73.36","188.13","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.64","177.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","126.13","53.3","","813.12","216.42","1444.50","81","73.36","188.13","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.64","177.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","73.36","31","","432.60","432.60","432.60","1 through 10","73.36","188.13","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.64","177.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","86.37","36.5","","148.37","54.89","631.39","94","73.36","188.13","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.64","177.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","90.63","38.3","","279.30","91.72","1116.77","266","73.36","188.13","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.64","177.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.52","42.9","","731.00","63.70","731.00","1 through 10","73.36","188.13","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.64","177.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.52","42.9","","384.74","384.74","384.74","1 through 10","73.36","188.13","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.64","177.48","WELLPOINT [1015]","HB AMC WELLPOINT","174.59","73.78","","286.63","119.22","1107.45","105","73.36","188.13","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","236.64","177.48","AETNA [1001]","HB AMC AETNA HMO","165.17","69.8","","675.31","184.75","1721.50","286","123.67","193.38","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","236.64","177.48","AETNA [1001]","HB AMC AETNA PPO","190.26","80.4","","1261.44","103.12","1514.10","21","123.67","193.38","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","236.64","177.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","190.26","80.4","","1365.00","1365.00","1365.00","1 through 10","123.67","193.38","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","236.64","177.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","193.38","81.72","","5157.68","5157.68","5157.68","1 through 10","123.67","193.38","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","236.64","177.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","193.38","81.72","","431.26","71.26","1459.57","88","123.67","193.38","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","221.71","79.5","","800.18","480.96","1887.97","195","86.45","221.71","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","148.64","53.3","","813.12","216.42","1444.50","81","86.45","221.71","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","86.45","31","","432.60","432.60","432.60","1 through 10","86.45","221.71","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","101.79","36.5","","148.37","54.89","631.39","94","86.45","221.71","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","106.81","38.3","","279.30","91.72","1116.77","266","86.45","221.71","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.64","42.9","","731.00","63.70","731.00","1 through 10","86.45","221.71","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.64","42.9","","384.74","384.74","384.74","1 through 10","86.45","221.71","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","WELLPOINT [1015]","HB AMC WELLPOINT","205.76","73.78","","286.63","119.22","1107.45","105","86.45","221.71","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.88","209.16","AETNA [1001]","HB AMC AETNA HMO","194.66","69.8","","675.31","184.75","1721.50","286","145.74","227.9","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.88","209.16","AETNA [1001]","HB AMC AETNA PPO","224.22","80.4","","1261.44","103.12","1514.10","21","145.74","227.9","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.88","209.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","224.22","80.4","","1365.00","1365.00","1365.00","1 through 10","145.74","227.9","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.88","209.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","227.90","81.72","","5157.68","5157.68","5157.68","1 through 10","145.74","227.9","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.88","209.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","227.90","81.72","","431.26","71.26","1459.57","88","145.74","227.9","percent of total billed charges",""
"BONE PLATE .3MMX12 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131067","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","77.39","79.5","","800.18","480.96","1887.97","195","30.18","77.39","percent of total billed charges",""
"BONE PLATE .3MMX12 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131067","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","51.88","53.3","","813.12","216.42","1444.50","81","30.18","77.39","percent of total billed charges",""
"BONE PLATE .3MMX12 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131067","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","30.18","31","","432.60","432.60","432.60","1 through 10","30.18","77.39","percent of total billed charges",""
"BONE PLATE .3MMX12 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131067","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","35.53","36.5","","148.37","54.89","631.39","94","30.18","77.39","percent of total billed charges",""
"BONE PLATE .3MMX12 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131067","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37.28","38.3","","279.30","91.72","1116.77","266","30.18","77.39","percent of total billed charges",""
"BONE PLATE .3MMX12 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131067","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.76","42.9","","731.00","63.70","731.00","1 through 10","30.18","77.39","percent of total billed charges",""
"BONE PLATE .3MMX12 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131067","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.76","42.9","","384.74","384.74","384.74","1 through 10","30.18","77.39","percent of total billed charges",""
"BONE PLATE .3MMX12 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131067","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","WELLPOINT [1015]","HB AMC WELLPOINT","71.82","73.78","","286.63","119.22","1107.45","105","30.18","77.39","percent of total billed charges",""
"BONE PLATE .3MMX12 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.34","73.00","AETNA [1001]","HB AMC AETNA HMO","67.94","69.8","","675.31","184.75","1721.50","286","50.87","79.55","percent of total billed charges",""
"BONE PLATE .3MMX12 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.34","73.00","AETNA [1001]","HB AMC AETNA PPO","78.26","80.4","","1261.44","103.12","1514.10","21","50.87","79.55","percent of total billed charges",""
"BONE PLATE .3MMX12 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.34","73.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","78.26","80.4","","1365.00","1365.00","1365.00","1 through 10","50.87","79.55","percent of total billed charges",""
"BONE PLATE .3MMX12 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.34","73.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","79.55","81.72","","5157.68","5157.68","5157.68","1 through 10","50.87","79.55","percent of total billed charges",""
"BONE PLATE .3MMX12 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.34","73.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","79.55","81.72","","431.26","71.26","1459.57","88","50.87","79.55","percent of total billed charges",""
"BONE PLATE .3X10 16MM 4 HOLE CRANIAL MATRIXNEURO TI FRAME SHAPE RECTANGULAR ULTRA LOW PROFILE THICK","SUP-ITM-10131071","CDM","C1713","HCPCS","0278","RC","","","","both","","","879.66","659.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","699.33","79.5","","800.18","480.96","1887.97","195","272.69","699.33","percent of total billed charges",""
"BONE PLATE .3X10 16MM 4 HOLE CRANIAL MATRIXNEURO TI FRAME SHAPE RECTANGULAR ULTRA LOW PROFILE THICK","SUP-ITM-10131071","CDM","C1713","HCPCS","0278","RC","","","","both","","","879.66","659.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","468.86","53.3","","813.12","216.42","1444.50","81","272.69","699.33","percent of total billed charges",""
"BONE PLATE .3X10 16MM 4 HOLE CRANIAL MATRIXNEURO TI FRAME SHAPE RECTANGULAR ULTRA LOW PROFILE THICK","SUP-ITM-10131071","CDM","C1713","HCPCS","0278","RC","","","","both","","","879.66","659.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","272.69","31","","432.60","432.60","432.60","1 through 10","272.69","699.33","percent of total billed charges",""
"BONE PLATE .3X10 16MM 4 HOLE CRANIAL MATRIXNEURO TI FRAME SHAPE RECTANGULAR ULTRA LOW PROFILE THICK","SUP-ITM-10131071","CDM","C1713","HCPCS","0278","RC","","","","both","","","879.66","659.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","321.08","36.5","","148.37","54.89","631.39","94","272.69","699.33","percent of total billed charges",""
"BONE PLATE .3X10 16MM 4 HOLE CRANIAL MATRIXNEURO TI FRAME SHAPE RECTANGULAR ULTRA LOW PROFILE THICK","SUP-ITM-10131071","CDM","C1713","HCPCS","0278","RC","","","","both","","","879.66","659.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","336.91","38.3","","279.30","91.72","1116.77","266","272.69","699.33","percent of total billed charges",""
"BONE PLATE .3X10 16MM 4 HOLE CRANIAL MATRIXNEURO TI FRAME SHAPE RECTANGULAR ULTRA LOW PROFILE THICK","SUP-ITM-10131071","CDM","C1713","HCPCS","0278","RC","","","","both","","","879.66","659.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","377.37","42.9","","731.00","63.70","731.00","1 through 10","272.69","699.33","percent of total billed charges",""
"BONE PLATE .3X10 16MM 4 HOLE CRANIAL MATRIXNEURO TI FRAME SHAPE RECTANGULAR ULTRA LOW PROFILE THICK","SUP-ITM-10131071","CDM","C1713","HCPCS","0278","RC","","","","both","","","879.66","659.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","377.37","42.9","","384.74","384.74","384.74","1 through 10","272.69","699.33","percent of total billed charges",""
"BONE PLATE .3X10 16MM 4 HOLE CRANIAL MATRIXNEURO TI FRAME SHAPE RECTANGULAR ULTRA LOW PROFILE THICK","SUP-ITM-10131071","CDM","C1713","HCPCS","0278","RC","","","","both","","","879.66","659.74","WELLPOINT [1015]","HB AMC WELLPOINT","649.01","73.78","","286.63","119.22","1107.45","105","272.69","699.33","percent of total billed charges",""
"BONE PLATE .3X10 16MM 4 HOLE CRANIAL MATRIXNEURO TI FRAME SHAPE RECTANGULAR ULTRA LOW PROFILE THICK","SUP-ITM-10131071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","879.66","659.74","AETNA [1001]","HB AMC AETNA HMO","614.00","69.8","","675.31","184.75","1721.50","286","459.71","718.86","percent of total billed charges",""
"BONE PLATE .3X10 16MM 4 HOLE CRANIAL MATRIXNEURO TI FRAME SHAPE RECTANGULAR ULTRA LOW PROFILE THICK","SUP-ITM-10131071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","879.66","659.74","AETNA [1001]","HB AMC AETNA PPO","707.25","80.4","","1261.44","103.12","1514.10","21","459.71","718.86","percent of total billed charges",""
"BONE PLATE .3X10 16MM 4 HOLE CRANIAL MATRIXNEURO TI FRAME SHAPE RECTANGULAR ULTRA LOW PROFILE THICK","SUP-ITM-10131071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","879.66","659.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","707.25","80.4","","1365.00","1365.00","1365.00","1 through 10","459.71","718.86","percent of total billed charges",""
"BONE PLATE .3X10 16MM 4 HOLE CRANIAL MATRIXNEURO TI FRAME SHAPE RECTANGULAR ULTRA LOW PROFILE THICK","SUP-ITM-10131071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","879.66","659.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","718.86","81.72","","5157.68","5157.68","5157.68","1 through 10","459.71","718.86","percent of total billed charges",""
"BONE PLATE .3X10 16MM 4 HOLE CRANIAL MATRIXNEURO TI FRAME SHAPE RECTANGULAR ULTRA LOW PROFILE THICK","SUP-ITM-10131071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","879.66","659.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","718.86","81.72","","431.26","71.26","1459.57","88","459.71","718.86","percent of total billed charges",""
"BONE PLATE .3X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131066","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","55.43","79.5","","800.18","480.96","1887.97","195","21.61","55.43","percent of total billed charges",""
"BONE PLATE .3X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131066","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37.16","53.3","","813.12","216.42","1444.50","81","21.61","55.43","percent of total billed charges",""
"BONE PLATE .3X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131066","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","21.61","31","","432.60","432.60","432.60","1 through 10","21.61","55.43","percent of total billed charges",""
"BONE PLATE .3X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131066","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25.45","36.5","","148.37","54.89","631.39","94","21.61","55.43","percent of total billed charges",""
"BONE PLATE .3X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131066","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26.70","38.3","","279.30","91.72","1116.77","266","21.61","55.43","percent of total billed charges",""
"BONE PLATE .3X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131066","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","29.91","42.9","","731.00","63.70","731.00","1 through 10","21.61","55.43","percent of total billed charges",""
"BONE PLATE .3X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131066","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","29.91","42.9","","384.74","384.74","384.74","1 through 10","21.61","55.43","percent of total billed charges",""
"BONE PLATE .3X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131066","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","WELLPOINT [1015]","HB AMC WELLPOINT","51.44","73.78","","286.63","119.22","1107.45","105","21.61","55.43","percent of total billed charges",""
"BONE PLATE .3X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.72","52.29","AETNA [1001]","HB AMC AETNA HMO","48.66","69.8","","675.31","184.75","1721.50","286","36.44","56.98","percent of total billed charges",""
"BONE PLATE .3X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.72","52.29","AETNA [1001]","HB AMC AETNA PPO","56.05","80.4","","1261.44","103.12","1514.10","21","36.44","56.98","percent of total billed charges",""
"BONE PLATE .3X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.72","52.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","56.05","80.4","","1365.00","1365.00","1365.00","1 through 10","36.44","56.98","percent of total billed charges",""
"BONE PLATE .3X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.72","52.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","56.98","81.72","","5157.68","5157.68","5157.68","1 through 10","36.44","56.98","percent of total billed charges",""
"BONE PLATE .3X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.72","52.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","56.98","81.72","","431.26","71.26","1459.57","88","36.44","56.98","percent of total billed charges",""
"BONE PLATE .4MM 5 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076550","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.52","400.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","424.94","79.5","","800.18","480.96","1887.97","195","165.7","424.94","percent of total billed charges",""
"BONE PLATE .4MM 5 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076550","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.52","400.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","284.90","53.3","","813.12","216.42","1444.50","81","165.7","424.94","percent of total billed charges",""
"BONE PLATE .4MM 5 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076550","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.52","400.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","165.70","31","","432.60","432.60","432.60","1 through 10","165.7","424.94","percent of total billed charges",""
"BONE PLATE .4MM 5 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076550","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.52","400.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","195.10","36.5","","148.37","54.89","631.39","94","165.7","424.94","percent of total billed charges",""
"BONE PLATE .4MM 5 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076550","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.52","400.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","204.72","38.3","","279.30","91.72","1116.77","266","165.7","424.94","percent of total billed charges",""
"BONE PLATE .4MM 5 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076550","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.52","400.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","229.31","42.9","","731.00","63.70","731.00","1 through 10","165.7","424.94","percent of total billed charges",""
"BONE PLATE .4MM 5 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076550","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.52","400.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","229.31","42.9","","384.74","384.74","384.74","1 through 10","165.7","424.94","percent of total billed charges",""
"BONE PLATE .4MM 5 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076550","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.52","400.89","WELLPOINT [1015]","HB AMC WELLPOINT","394.37","73.78","","286.63","119.22","1107.45","105","165.7","424.94","percent of total billed charges",""
"BONE PLATE .4MM 5 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.52","400.89","AETNA [1001]","HB AMC AETNA HMO","373.09","69.8","","675.31","184.75","1721.50","286","279.34","436.81","percent of total billed charges",""
"BONE PLATE .4MM 5 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.52","400.89","AETNA [1001]","HB AMC AETNA PPO","429.75","80.4","","1261.44","103.12","1514.10","21","279.34","436.81","percent of total billed charges",""
"BONE PLATE .4MM 5 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.52","400.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","429.75","80.4","","1365.00","1365.00","1365.00","1 through 10","279.34","436.81","percent of total billed charges",""
"BONE PLATE .4MM 5 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.52","400.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","436.81","81.72","","5157.68","5157.68","5157.68","1 through 10","279.34","436.81","percent of total billed charges",""
"BONE PLATE .4MM 5 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.52","400.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","436.81","81.72","","431.26","71.26","1459.57","88","279.34","436.81","percent of total billed charges",""
"BONE PLATE .4X24MM 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076543","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","77.39","79.5","","800.18","480.96","1887.97","195","30.18","77.39","percent of total billed charges",""
"BONE PLATE .4X24MM 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076543","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","51.88","53.3","","813.12","216.42","1444.50","81","30.18","77.39","percent of total billed charges",""
"BONE PLATE .4X24MM 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076543","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","30.18","31","","432.60","432.60","432.60","1 through 10","30.18","77.39","percent of total billed charges",""
"BONE PLATE .4X24MM 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076543","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","35.53","36.5","","148.37","54.89","631.39","94","30.18","77.39","percent of total billed charges",""
"BONE PLATE .4X24MM 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076543","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37.28","38.3","","279.30","91.72","1116.77","266","30.18","77.39","percent of total billed charges",""
"BONE PLATE .4X24MM 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076543","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.76","42.9","","731.00","63.70","731.00","1 through 10","30.18","77.39","percent of total billed charges",""
"BONE PLATE .4X24MM 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076543","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.76","42.9","","384.74","384.74","384.74","1 through 10","30.18","77.39","percent of total billed charges",""
"BONE PLATE .4X24MM 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076543","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.34","73.00","WELLPOINT [1015]","HB AMC WELLPOINT","71.82","73.78","","286.63","119.22","1107.45","105","30.18","77.39","percent of total billed charges",""
"BONE PLATE .4X24MM 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076543","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.34","73.00","AETNA [1001]","HB AMC AETNA HMO","67.94","69.8","","675.31","184.75","1721.50","286","50.87","79.55","percent of total billed charges",""
"BONE PLATE .4X24MM 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076543","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.34","73.00","AETNA [1001]","HB AMC AETNA PPO","78.26","80.4","","1261.44","103.12","1514.10","21","50.87","79.55","percent of total billed charges",""
"BONE PLATE .4X24MM 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076543","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.34","73.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","78.26","80.4","","1365.00","1365.00","1365.00","1 through 10","50.87","79.55","percent of total billed charges",""
"BONE PLATE .4X24MM 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076543","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.34","73.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","79.55","81.72","","5157.68","5157.68","5157.68","1 through 10","50.87","79.55","percent of total billed charges",""
"BONE PLATE .4X24MM 4 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076543","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.34","73.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","79.55","81.72","","431.26","71.26","1459.57","88","50.87","79.55","percent of total billed charges",""
"BONE PLATE .4X9MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076541","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","120.09","79.5","","800.18","480.96","1887.97","195","46.83","120.09","percent of total billed charges",""
"BONE PLATE .4X9MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076541","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","80.51","53.3","","813.12","216.42","1444.50","81","46.83","120.09","percent of total billed charges",""
"BONE PLATE .4X9MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076541","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","46.83","31","","432.60","432.60","432.60","1 through 10","46.83","120.09","percent of total billed charges",""
"BONE PLATE .4X9MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076541","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.14","36.5","","148.37","54.89","631.39","94","46.83","120.09","percent of total billed charges",""
"BONE PLATE .4X9MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076541","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.86","38.3","","279.30","91.72","1116.77","266","46.83","120.09","percent of total billed charges",""
"BONE PLATE .4X9MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076541","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.80","42.9","","731.00","63.70","731.00","1 through 10","46.83","120.09","percent of total billed charges",""
"BONE PLATE .4X9MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076541","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.80","42.9","","384.74","384.74","384.74","1 through 10","46.83","120.09","percent of total billed charges",""
"BONE PLATE .4X9MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076541","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","WELLPOINT [1015]","HB AMC WELLPOINT","111.45","73.78","","286.63","119.22","1107.45","105","46.83","120.09","percent of total billed charges",""
"BONE PLATE .4X9MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.06","113.29","AETNA [1001]","HB AMC AETNA HMO","105.44","69.8","","675.31","184.75","1721.50","286","78.94","123.45","percent of total billed charges",""
"BONE PLATE .4X9MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.06","113.29","AETNA [1001]","HB AMC AETNA PPO","121.45","80.4","","1261.44","103.12","1514.10","21","78.94","123.45","percent of total billed charges",""
"BONE PLATE .4X9MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.06","113.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","121.45","80.4","","1365.00","1365.00","1365.00","1 through 10","78.94","123.45","percent of total billed charges",""
"BONE PLATE .4X9MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.06","113.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","123.45","81.72","","5157.68","5157.68","5157.68","1 through 10","78.94","123.45","percent of total billed charges",""
"BONE PLATE .4X9MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.06","113.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","123.45","81.72","","431.26","71.26","1459.57","88","78.94","123.45","percent of total billed charges",""
"BONE PLATE .8MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077443","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.25","383.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","406.44","79.5","","800.18","480.96","1887.97","195","158.49","406.44","percent of total billed charges",""
"BONE PLATE .8MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077443","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.25","383.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","272.50","53.3","","813.12","216.42","1444.50","81","158.49","406.44","percent of total billed charges",""
"BONE PLATE .8MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077443","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.25","383.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","158.49","31","","432.60","432.60","432.60","1 through 10","158.49","406.44","percent of total billed charges",""
"BONE PLATE .8MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077443","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.25","383.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","186.61","36.5","","148.37","54.89","631.39","94","158.49","406.44","percent of total billed charges",""
"BONE PLATE .8MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077443","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.25","383.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","195.81","38.3","","279.30","91.72","1116.77","266","158.49","406.44","percent of total billed charges",""
"BONE PLATE .8MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077443","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.25","383.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","219.33","42.9","","731.00","63.70","731.00","1 through 10","158.49","406.44","percent of total billed charges",""
"BONE PLATE .8MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077443","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.25","383.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","219.33","42.9","","384.74","384.74","384.74","1 through 10","158.49","406.44","percent of total billed charges",""
"BONE PLATE .8MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077443","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.25","383.44","WELLPOINT [1015]","HB AMC WELLPOINT","377.20","73.78","","286.63","119.22","1107.45","105","158.49","406.44","percent of total billed charges",""
"BONE PLATE .8MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077443","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.25","383.44","AETNA [1001]","HB AMC AETNA HMO","356.85","69.8","","675.31","184.75","1721.50","286","267.18","417.79","percent of total billed charges",""
"BONE PLATE .8MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077443","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.25","383.44","AETNA [1001]","HB AMC AETNA PPO","411.05","80.4","","1261.44","103.12","1514.10","21","267.18","417.79","percent of total billed charges",""
"BONE PLATE .8MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077443","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.25","383.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","411.05","80.4","","1365.00","1365.00","1365.00","1 through 10","267.18","417.79","percent of total billed charges",""
"BONE PLATE .8MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077443","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.25","383.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","417.79","81.72","","5157.68","5157.68","5157.68","1 through 10","267.18","417.79","percent of total billed charges",""
"BONE PLATE .8MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077443","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.25","383.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","417.79","81.72","","431.26","71.26","1459.57","88","267.18","417.79","percent of total billed charges",""
"BONE PLATE 0.3MM 14X4 HOLE CRANIAL MATRIX NEURO TI FRAME SHAPE ULTRA LOW PROFILE THICK","SUP-ITM-10131069","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","288.69","79.5","","800.18","480.96","1887.97","195","112.57","288.69","percent of total billed charges",""
"BONE PLATE 0.3MM 14X4 HOLE CRANIAL MATRIX NEURO TI FRAME SHAPE ULTRA LOW PROFILE THICK","SUP-ITM-10131069","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","193.55","53.3","","813.12","216.42","1444.50","81","112.57","288.69","percent of total billed charges",""
"BONE PLATE 0.3MM 14X4 HOLE CRANIAL MATRIX NEURO TI FRAME SHAPE ULTRA LOW PROFILE THICK","SUP-ITM-10131069","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","112.57","31","","432.60","432.60","432.60","1 through 10","112.57","288.69","percent of total billed charges",""
"BONE PLATE 0.3MM 14X4 HOLE CRANIAL MATRIX NEURO TI FRAME SHAPE ULTRA LOW PROFILE THICK","SUP-ITM-10131069","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","132.54","36.5","","148.37","54.89","631.39","94","112.57","288.69","percent of total billed charges",""
"BONE PLATE 0.3MM 14X4 HOLE CRANIAL MATRIX NEURO TI FRAME SHAPE ULTRA LOW PROFILE THICK","SUP-ITM-10131069","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","139.08","38.3","","279.30","91.72","1116.77","266","112.57","288.69","percent of total billed charges",""
"BONE PLATE 0.3MM 14X4 HOLE CRANIAL MATRIX NEURO TI FRAME SHAPE ULTRA LOW PROFILE THICK","SUP-ITM-10131069","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.78","42.9","","731.00","63.70","731.00","1 through 10","112.57","288.69","percent of total billed charges",""
"BONE PLATE 0.3MM 14X4 HOLE CRANIAL MATRIX NEURO TI FRAME SHAPE ULTRA LOW PROFILE THICK","SUP-ITM-10131069","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.78","42.9","","384.74","384.74","384.74","1 through 10","112.57","288.69","percent of total billed charges",""
"BONE PLATE 0.3MM 14X4 HOLE CRANIAL MATRIX NEURO TI FRAME SHAPE ULTRA LOW PROFILE THICK","SUP-ITM-10131069","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","WELLPOINT [1015]","HB AMC WELLPOINT","267.92","73.78","","286.63","119.22","1107.45","105","112.57","288.69","percent of total billed charges",""
"BONE PLATE 0.3MM 14X4 HOLE CRANIAL MATRIX NEURO TI FRAME SHAPE ULTRA LOW PROFILE THICK","SUP-ITM-10131069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.13","272.35","AETNA [1001]","HB AMC AETNA HMO","253.46","69.8","","675.31","184.75","1721.50","286","189.77","296.75","percent of total billed charges",""
"BONE PLATE 0.3MM 14X4 HOLE CRANIAL MATRIX NEURO TI FRAME SHAPE ULTRA LOW PROFILE THICK","SUP-ITM-10131069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.13","272.35","AETNA [1001]","HB AMC AETNA PPO","291.96","80.4","","1261.44","103.12","1514.10","21","189.77","296.75","percent of total billed charges",""
"BONE PLATE 0.3MM 14X4 HOLE CRANIAL MATRIX NEURO TI FRAME SHAPE ULTRA LOW PROFILE THICK","SUP-ITM-10131069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.13","272.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","291.96","80.4","","1365.00","1365.00","1365.00","1 through 10","189.77","296.75","percent of total billed charges",""
"BONE PLATE 0.3MM 14X4 HOLE CRANIAL MATRIX NEURO TI FRAME SHAPE ULTRA LOW PROFILE THICK","SUP-ITM-10131069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.13","272.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","296.75","81.72","","5157.68","5157.68","5157.68","1 through 10","189.77","296.75","percent of total billed charges",""
"BONE PLATE 0.3MM 14X4 HOLE CRANIAL MATRIX NEURO TI FRAME SHAPE ULTRA LOW PROFILE THICK","SUP-ITM-10131069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.13","272.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","296.75","81.72","","431.26","71.26","1459.57","88","189.77","296.75","percent of total billed charges",""
"BONE PLATE 0.3MM 9 2 HOLE CRANIAL MATRIX NEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131065","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.43","181.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","191.94","79.5","","800.18","480.96","1887.97","195","74.84","191.94","percent of total billed charges",""
"BONE PLATE 0.3MM 9 2 HOLE CRANIAL MATRIX NEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131065","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.43","181.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","128.68","53.3","","813.12","216.42","1444.50","81","74.84","191.94","percent of total billed charges",""
"BONE PLATE 0.3MM 9 2 HOLE CRANIAL MATRIX NEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131065","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.43","181.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","74.84","31","","432.60","432.60","432.60","1 through 10","74.84","191.94","percent of total billed charges",""
"BONE PLATE 0.3MM 9 2 HOLE CRANIAL MATRIX NEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131065","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.43","181.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","88.12","36.5","","148.37","54.89","631.39","94","74.84","191.94","percent of total billed charges",""
"BONE PLATE 0.3MM 9 2 HOLE CRANIAL MATRIX NEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131065","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.43","181.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","92.47","38.3","","279.30","91.72","1116.77","266","74.84","191.94","percent of total billed charges",""
"BONE PLATE 0.3MM 9 2 HOLE CRANIAL MATRIX NEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131065","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.43","181.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","103.57","42.9","","731.00","63.70","731.00","1 through 10","74.84","191.94","percent of total billed charges",""
"BONE PLATE 0.3MM 9 2 HOLE CRANIAL MATRIX NEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131065","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.43","181.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","103.57","42.9","","384.74","384.74","384.74","1 through 10","74.84","191.94","percent of total billed charges",""
"BONE PLATE 0.3MM 9 2 HOLE CRANIAL MATRIX NEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131065","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.43","181.07","WELLPOINT [1015]","HB AMC WELLPOINT","178.13","73.78","","286.63","119.22","1107.45","105","74.84","191.94","percent of total billed charges",""
"BONE PLATE 0.3MM 9 2 HOLE CRANIAL MATRIX NEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.43","181.07","AETNA [1001]","HB AMC AETNA HMO","168.52","69.8","","675.31","184.75","1721.50","286","126.17","197.3","percent of total billed charges",""
"BONE PLATE 0.3MM 9 2 HOLE CRANIAL MATRIX NEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.43","181.07","AETNA [1001]","HB AMC AETNA PPO","194.11","80.4","","1261.44","103.12","1514.10","21","126.17","197.3","percent of total billed charges",""
"BONE PLATE 0.3MM 9 2 HOLE CRANIAL MATRIX NEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.43","181.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","194.11","80.4","","1365.00","1365.00","1365.00","1 through 10","126.17","197.3","percent of total billed charges",""
"BONE PLATE 0.3MM 9 2 HOLE CRANIAL MATRIX NEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.43","181.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","197.30","81.72","","5157.68","5157.68","5157.68","1 through 10","126.17","197.3","percent of total billed charges",""
"BONE PLATE 0.3MM 9 2 HOLE CRANIAL MATRIX NEURO TI STRAIGHT CENTRE SPACE ULTRA LOW PROFILE THICK","SUP-ITM-10131065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.43","181.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","197.30","81.72","","431.26","71.26","1459.57","88","126.17","197.3","percent of total billed charges",""
"BONE PLATE 0.3MM MED ORBITAL MATRIXMIDFACE TI FLOOR ANATOMIC","SUP-ITM-10116753","CDM","C1776","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1449.80","52.26","","1113.10","1113.10","1113.10","1 through 10","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 0.3MM MED ORBITAL MATRIXMIDFACE TI FLOOR ANATOMIC","SUP-ITM-10116753","CDM","C1776","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2205.50","79.5","","1293.60","1148.53","1603.80","1 through 10","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 0.3MM MED ORBITAL MATRIXMIDFACE TI FLOOR ANATOMIC","SUP-ITM-10116753","CDM","C1776","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1012.59","36.5","","1023.42","771.29","2068.67","33","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 0.3MM MED ORBITAL MATRIXMIDFACE TI FLOOR ANATOMIC","SUP-ITM-10116753","CDM","C1776","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1062.52","38.3","","850.52","759.78","1211.25","66","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 0.3MM MED ORBITAL MATRIXMIDFACE TI FLOOR ANATOMIC","SUP-ITM-10116753","CDM","C1776","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1190.14","42.9","","2548.09","2548.09","2548.09","1 through 10","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 0.3MM MED ORBITAL MATRIXMIDFACE TI FLOOR ANATOMIC","SUP-ITM-10116753","CDM","C1776","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1190.14","42.9","","956.46","956.46","956.46","1 through 10","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 0.3MM MED ORBITAL MATRIXMIDFACE TI FLOOR ANATOMIC","SUP-ITM-10116753","CDM","C1776","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","WELLPOINT [1015]","HB AMC WELLPOINT","2046.81","73.78","","2344.73","1619.47","2530.35","16","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 0.3MM MED ORBITAL MATRIXMIDFACE TI FLOOR ANATOMIC","SUP-ITM-10116753","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","AETNA [1001]","HB AMC AETNA HMO","1936.40","69.8","","1523.63","988.41","4330.26","39","1449.8","2267.08","percent of total billed charges",""
"BONE PLATE 0.3MM MED ORBITAL MATRIXMIDFACE TI FLOOR ANATOMIC","SUP-ITM-10116753","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","AETNA [1001]","HB AMC AETNA PPO","2230.46","80.4","","1670.25","1670.25","1670.25","1 through 10","1449.8","2267.08","percent of total billed charges",""
"BONE PLATE 0.3MM MED ORBITAL MATRIXMIDFACE TI FLOOR ANATOMIC","SUP-ITM-10116753","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1449.80","52.26","","1113.10","1113.10","1113.10","1 through 10","1449.8","2267.08","percent of total billed charges",""
"BONE PLATE 0.3MM MED ORBITAL MATRIXMIDFACE TI FLOOR ANATOMIC","SUP-ITM-10116753","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2267.08","81.72","","1738.90","1484.65","2716.94","38","1449.8","2267.08","percent of total billed charges",""
"BONE PLATE 0.4MM 20 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076552","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.05","432.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","458.75","79.5","","800.18","480.96","1887.97","195","178.89","458.75","percent of total billed charges",""
"BONE PLATE 0.4MM 20 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076552","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.05","432.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","307.57","53.3","","813.12","216.42","1444.50","81","178.89","458.75","percent of total billed charges",""
"BONE PLATE 0.4MM 20 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076552","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.05","432.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","178.89","31","","432.60","432.60","432.60","1 through 10","178.89","458.75","percent of total billed charges",""
"BONE PLATE 0.4MM 20 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076552","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.05","432.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","210.62","36.5","","148.37","54.89","631.39","94","178.89","458.75","percent of total billed charges",""
"BONE PLATE 0.4MM 20 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076552","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.05","432.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","221.01","38.3","","279.30","91.72","1116.77","266","178.89","458.75","percent of total billed charges",""
"BONE PLATE 0.4MM 20 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076552","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.05","432.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.55","42.9","","731.00","63.70","731.00","1 through 10","178.89","458.75","percent of total billed charges",""
"BONE PLATE 0.4MM 20 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076552","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.05","432.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.55","42.9","","384.74","384.74","384.74","1 through 10","178.89","458.75","percent of total billed charges",""
"BONE PLATE 0.4MM 20 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076552","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.05","432.79","WELLPOINT [1015]","HB AMC WELLPOINT","425.75","73.78","","286.63","119.22","1107.45","105","178.89","458.75","percent of total billed charges",""
"BONE PLATE 0.4MM 20 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.05","432.79","AETNA [1001]","HB AMC AETNA HMO","402.78","69.8","","675.31","184.75","1721.50","286","301.57","471.57","percent of total billed charges",""
"BONE PLATE 0.4MM 20 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.05","432.79","AETNA [1001]","HB AMC AETNA PPO","463.95","80.4","","1261.44","103.12","1514.10","21","301.57","471.57","percent of total billed charges",""
"BONE PLATE 0.4MM 20 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.05","432.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","463.95","80.4","","1365.00","1365.00","1365.00","1 through 10","301.57","471.57","percent of total billed charges",""
"BONE PLATE 0.4MM 20 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.05","432.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","471.57","81.72","","5157.68","5157.68","5157.68","1 through 10","301.57","471.57","percent of total billed charges",""
"BONE PLATE 0.4MM 20 HOLE CRANIAL MATRIXNEURO TI ADAPTION RIGID","SUP-ITM-10076552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.05","432.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","471.57","81.72","","431.26","71.26","1459.57","88","301.57","471.57","percent of total billed charges",""
"BONE PLATE 0.4MM CRANIAL MATRIXNEURO TI XSHAPE RIGID","SUP-ITM-10076544","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","295.59","79.5","","800.18","480.96","1887.97","195","115.26","295.59","percent of total billed charges",""
"BONE PLATE 0.4MM CRANIAL MATRIXNEURO TI XSHAPE RIGID","SUP-ITM-10076544","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.17","53.3","","813.12","216.42","1444.50","81","115.26","295.59","percent of total billed charges",""
"BONE PLATE 0.4MM CRANIAL MATRIXNEURO TI XSHAPE RIGID","SUP-ITM-10076544","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.26","31","","432.60","432.60","432.60","1 through 10","115.26","295.59","percent of total billed charges",""
"BONE PLATE 0.4MM CRANIAL MATRIXNEURO TI XSHAPE RIGID","SUP-ITM-10076544","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","135.71","36.5","","148.37","54.89","631.39","94","115.26","295.59","percent of total billed charges",""
"BONE PLATE 0.4MM CRANIAL MATRIXNEURO TI XSHAPE RIGID","SUP-ITM-10076544","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.40","38.3","","279.30","91.72","1116.77","266","115.26","295.59","percent of total billed charges",""
"BONE PLATE 0.4MM CRANIAL MATRIXNEURO TI XSHAPE RIGID","SUP-ITM-10076544","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.51","42.9","","731.00","63.70","731.00","1 through 10","115.26","295.59","percent of total billed charges",""
"BONE PLATE 0.4MM CRANIAL MATRIXNEURO TI XSHAPE RIGID","SUP-ITM-10076544","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.51","42.9","","384.74","384.74","384.74","1 through 10","115.26","295.59","percent of total billed charges",""
"BONE PLATE 0.4MM CRANIAL MATRIXNEURO TI XSHAPE RIGID","SUP-ITM-10076544","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","WELLPOINT [1015]","HB AMC WELLPOINT","274.32","73.78","","286.63","119.22","1107.45","105","115.26","295.59","percent of total billed charges",""
"BONE PLATE 0.4MM CRANIAL MATRIXNEURO TI XSHAPE RIGID","SUP-ITM-10076544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.81","278.86","AETNA [1001]","HB AMC AETNA HMO","259.52","69.8","","675.31","184.75","1721.50","286","194.31","303.84","percent of total billed charges",""
"BONE PLATE 0.4MM CRANIAL MATRIXNEURO TI XSHAPE RIGID","SUP-ITM-10076544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.81","278.86","AETNA [1001]","HB AMC AETNA PPO","298.94","80.4","","1261.44","103.12","1514.10","21","194.31","303.84","percent of total billed charges",""
"BONE PLATE 0.4MM CRANIAL MATRIXNEURO TI XSHAPE RIGID","SUP-ITM-10076544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.81","278.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","298.94","80.4","","1365.00","1365.00","1365.00","1 through 10","194.31","303.84","percent of total billed charges",""
"BONE PLATE 0.4MM CRANIAL MATRIXNEURO TI XSHAPE RIGID","SUP-ITM-10076544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.81","278.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","303.84","81.72","","5157.68","5157.68","5157.68","1 through 10","194.31","303.84","percent of total billed charges",""
"BONE PLATE 0.4MM CRANIAL MATRIXNEURO TI XSHAPE RIGID","SUP-ITM-10076544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.81","278.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","303.84","81.72","","431.26","71.26","1459.57","88","194.31","303.84","percent of total billed charges",""
"BONE PLATE 0.4X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076542","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","55.43","79.5","","800.18","480.96","1887.97","195","21.61","55.43","percent of total billed charges",""
"BONE PLATE 0.4X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076542","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37.16","53.3","","813.12","216.42","1444.50","81","21.61","55.43","percent of total billed charges",""
"BONE PLATE 0.4X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076542","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","21.61","31","","432.60","432.60","432.60","1 through 10","21.61","55.43","percent of total billed charges",""
"BONE PLATE 0.4X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076542","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25.45","36.5","","148.37","54.89","631.39","94","21.61","55.43","percent of total billed charges",""
"BONE PLATE 0.4X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076542","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26.70","38.3","","279.30","91.72","1116.77","266","21.61","55.43","percent of total billed charges",""
"BONE PLATE 0.4X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076542","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","29.91","42.9","","731.00","63.70","731.00","1 through 10","21.61","55.43","percent of total billed charges",""
"BONE PLATE 0.4X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076542","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","29.91","42.9","","384.74","384.74","384.74","1 through 10","21.61","55.43","percent of total billed charges",""
"BONE PLATE 0.4X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076542","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.72","52.29","WELLPOINT [1015]","HB AMC WELLPOINT","51.44","73.78","","286.63","119.22","1107.45","105","21.61","55.43","percent of total billed charges",""
"BONE PLATE 0.4X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076542","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.72","52.29","AETNA [1001]","HB AMC AETNA HMO","48.66","69.8","","675.31","184.75","1721.50","286","36.44","56.98","percent of total billed charges",""
"BONE PLATE 0.4X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076542","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.72","52.29","AETNA [1001]","HB AMC AETNA PPO","56.05","80.4","","1261.44","103.12","1514.10","21","36.44","56.98","percent of total billed charges",""
"BONE PLATE 0.4X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076542","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.72","52.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","56.05","80.4","","1365.00","1365.00","1365.00","1 through 10","36.44","56.98","percent of total billed charges",""
"BONE PLATE 0.4X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076542","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.72","52.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","56.98","81.72","","5157.68","5157.68","5157.68","1 through 10","36.44","56.98","percent of total billed charges",""
"BONE PLATE 0.4X12MM 2 HOLE CRANIAL MATRIXNEURO TI STRAIGHT RIGID","SUP-ITM-10076542","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.72","52.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","56.98","81.72","","431.26","71.26","1459.57","88","36.44","56.98","percent of total billed charges",""
"BONE PLATE 0.4X18MM 6 HOLE CRANIAL MATRIXNEURO TI DOUBLE Y SHAPE RIGID","SUP-ITM-10076548","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","468.83","79.5","","800.18","480.96","1887.97","195","182.81","468.83","percent of total billed charges",""
"BONE PLATE 0.4X18MM 6 HOLE CRANIAL MATRIXNEURO TI DOUBLE Y SHAPE RIGID","SUP-ITM-10076548","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","314.32","53.3","","813.12","216.42","1444.50","81","182.81","468.83","percent of total billed charges",""
"BONE PLATE 0.4X18MM 6 HOLE CRANIAL MATRIXNEURO TI DOUBLE Y SHAPE RIGID","SUP-ITM-10076548","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","182.81","31","","432.60","432.60","432.60","1 through 10","182.81","468.83","percent of total billed charges",""
"BONE PLATE 0.4X18MM 6 HOLE CRANIAL MATRIXNEURO TI DOUBLE Y SHAPE RIGID","SUP-ITM-10076548","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","215.25","36.5","","148.37","54.89","631.39","94","182.81","468.83","percent of total billed charges",""
"BONE PLATE 0.4X18MM 6 HOLE CRANIAL MATRIXNEURO TI DOUBLE Y SHAPE RIGID","SUP-ITM-10076548","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","225.86","38.3","","279.30","91.72","1116.77","266","182.81","468.83","percent of total billed charges",""
"BONE PLATE 0.4X18MM 6 HOLE CRANIAL MATRIXNEURO TI DOUBLE Y SHAPE RIGID","SUP-ITM-10076548","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","252.99","42.9","","731.00","63.70","731.00","1 through 10","182.81","468.83","percent of total billed charges",""
"BONE PLATE 0.4X18MM 6 HOLE CRANIAL MATRIXNEURO TI DOUBLE Y SHAPE RIGID","SUP-ITM-10076548","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","252.99","42.9","","384.74","384.74","384.74","1 through 10","182.81","468.83","percent of total billed charges",""
"BONE PLATE 0.4X18MM 6 HOLE CRANIAL MATRIXNEURO TI DOUBLE Y SHAPE RIGID","SUP-ITM-10076548","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","WELLPOINT [1015]","HB AMC WELLPOINT","435.10","73.78","","286.63","119.22","1107.45","105","182.81","468.83","percent of total billed charges",""
"BONE PLATE 0.4X18MM 6 HOLE CRANIAL MATRIXNEURO TI DOUBLE Y SHAPE RIGID","SUP-ITM-10076548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","589.72","442.29","AETNA [1001]","HB AMC AETNA HMO","411.62","69.8","","675.31","184.75","1721.50","286","308.19","481.92","percent of total billed charges",""
"BONE PLATE 0.4X18MM 6 HOLE CRANIAL MATRIXNEURO TI DOUBLE Y SHAPE RIGID","SUP-ITM-10076548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","589.72","442.29","AETNA [1001]","HB AMC AETNA PPO","474.13","80.4","","1261.44","103.12","1514.10","21","308.19","481.92","percent of total billed charges",""
"BONE PLATE 0.4X18MM 6 HOLE CRANIAL MATRIXNEURO TI DOUBLE Y SHAPE RIGID","SUP-ITM-10076548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","589.72","442.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","474.13","80.4","","1365.00","1365.00","1365.00","1 through 10","308.19","481.92","percent of total billed charges",""
"BONE PLATE 0.4X18MM 6 HOLE CRANIAL MATRIXNEURO TI DOUBLE Y SHAPE RIGID","SUP-ITM-10076548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","589.72","442.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","481.92","81.72","","5157.68","5157.68","5157.68","1 through 10","308.19","481.92","percent of total billed charges",""
"BONE PLATE 0.4X18MM 6 HOLE CRANIAL MATRIXNEURO TI DOUBLE Y SHAPE RIGID","SUP-ITM-10076548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","589.72","442.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","481.92","81.72","","431.26","71.26","1459.57","88","308.19","481.92","percent of total billed charges",""
"BONE PLATE 0.7MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077436","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.39","403.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","427.23","79.5","","800.18","480.96","1887.97","195","166.59","427.23","percent of total billed charges",""
"BONE PLATE 0.7MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077436","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.39","403.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","286.43","53.3","","813.12","216.42","1444.50","81","166.59","427.23","percent of total billed charges",""
"BONE PLATE 0.7MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077436","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.39","403.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","166.59","31","","432.60","432.60","432.60","1 through 10","166.59","427.23","percent of total billed charges",""
"BONE PLATE 0.7MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077436","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.39","403.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","196.15","36.5","","148.37","54.89","631.39","94","166.59","427.23","percent of total billed charges",""
"BONE PLATE 0.7MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077436","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.39","403.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","205.82","38.3","","279.30","91.72","1116.77","266","166.59","427.23","percent of total billed charges",""
"BONE PLATE 0.7MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077436","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.39","403.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","230.54","42.9","","731.00","63.70","731.00","1 through 10","166.59","427.23","percent of total billed charges",""
"BONE PLATE 0.7MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077436","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.39","403.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","230.54","42.9","","384.74","384.74","384.74","1 through 10","166.59","427.23","percent of total billed charges",""
"BONE PLATE 0.7MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077436","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.39","403.04","WELLPOINT [1015]","HB AMC WELLPOINT","396.49","73.78","","286.63","119.22","1107.45","105","166.59","427.23","percent of total billed charges",""
"BONE PLATE 0.7MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","537.39","403.04","AETNA [1001]","HB AMC AETNA HMO","375.10","69.8","","675.31","184.75","1721.50","286","280.84","439.16","percent of total billed charges",""
"BONE PLATE 0.7MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","537.39","403.04","AETNA [1001]","HB AMC AETNA PPO","432.06","80.4","","1261.44","103.12","1514.10","21","280.84","439.16","percent of total billed charges",""
"BONE PLATE 0.7MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","537.39","403.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","432.06","80.4","","1365.00","1365.00","1365.00","1 through 10","280.84","439.16","percent of total billed charges",""
"BONE PLATE 0.7MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","537.39","403.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","439.16","81.72","","5157.68","5157.68","5157.68","1 through 10","280.84","439.16","percent of total billed charges",""
"BONE PLATE 0.7MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","537.39","403.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","439.16","81.72","","431.26","71.26","1459.57","88","280.84","439.16","percent of total billed charges",""
"BONE PLATE 0.7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI T SHAPE","SUP-ITM-10077441","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.97","435.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","461.87","79.5","","800.18","480.96","1887.97","195","180.1","461.87","percent of total billed charges",""
"BONE PLATE 0.7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI T SHAPE","SUP-ITM-10077441","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.97","435.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","309.66","53.3","","813.12","216.42","1444.50","81","180.1","461.87","percent of total billed charges",""
"BONE PLATE 0.7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI T SHAPE","SUP-ITM-10077441","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.97","435.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","180.10","31","","432.60","432.60","432.60","1 through 10","180.1","461.87","percent of total billed charges",""
"BONE PLATE 0.7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI T SHAPE","SUP-ITM-10077441","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.97","435.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","212.05","36.5","","148.37","54.89","631.39","94","180.1","461.87","percent of total billed charges",""
"BONE PLATE 0.7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI T SHAPE","SUP-ITM-10077441","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.97","435.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","222.51","38.3","","279.30","91.72","1116.77","266","180.1","461.87","percent of total billed charges",""
"BONE PLATE 0.7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI T SHAPE","SUP-ITM-10077441","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.97","435.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.24","42.9","","731.00","63.70","731.00","1 through 10","180.1","461.87","percent of total billed charges",""
"BONE PLATE 0.7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI T SHAPE","SUP-ITM-10077441","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.97","435.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.24","42.9","","384.74","384.74","384.74","1 through 10","180.1","461.87","percent of total billed charges",""
"BONE PLATE 0.7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI T SHAPE","SUP-ITM-10077441","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.97","435.73","WELLPOINT [1015]","HB AMC WELLPOINT","428.64","73.78","","286.63","119.22","1107.45","105","180.1","461.87","percent of total billed charges",""
"BONE PLATE 0.7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI T SHAPE","SUP-ITM-10077441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.97","435.73","AETNA [1001]","HB AMC AETNA HMO","405.52","69.8","","675.31","184.75","1721.50","286","303.61","474.77","percent of total billed charges",""
"BONE PLATE 0.7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI T SHAPE","SUP-ITM-10077441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.97","435.73","AETNA [1001]","HB AMC AETNA PPO","467.10","80.4","","1261.44","103.12","1514.10","21","303.61","474.77","percent of total billed charges",""
"BONE PLATE 0.7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI T SHAPE","SUP-ITM-10077441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.97","435.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","467.10","80.4","","1365.00","1365.00","1365.00","1 through 10","303.61","474.77","percent of total billed charges",""
"BONE PLATE 0.7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI T SHAPE","SUP-ITM-10077441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.97","435.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","474.77","81.72","","5157.68","5157.68","5157.68","1 through 10","303.61","474.77","percent of total billed charges",""
"BONE PLATE 0.7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI T SHAPE","SUP-ITM-10077441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.97","435.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","474.77","81.72","","431.26","71.26","1459.57","88","303.61","474.77","percent of total billed charges",""
"BONE PLATE 0.8MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI ADAPTION","SUP-ITM-10077323","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.95","734.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","778.27","79.5","","800.18","480.96","1887.97","195","303.47","778.27","percent of total billed charges",""
"BONE PLATE 0.8MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI ADAPTION","SUP-ITM-10077323","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.95","734.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","521.78","53.3","","813.12","216.42","1444.50","81","303.47","778.27","percent of total billed charges",""
"BONE PLATE 0.8MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI ADAPTION","SUP-ITM-10077323","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.95","734.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","303.47","31","","432.60","432.60","432.60","1 through 10","303.47","778.27","percent of total billed charges",""
"BONE PLATE 0.8MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI ADAPTION","SUP-ITM-10077323","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.95","734.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","357.32","36.5","","148.37","54.89","631.39","94","303.47","778.27","percent of total billed charges",""
"BONE PLATE 0.8MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI ADAPTION","SUP-ITM-10077323","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.95","734.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","374.94","38.3","","279.30","91.72","1116.77","266","303.47","778.27","percent of total billed charges",""
"BONE PLATE 0.8MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI ADAPTION","SUP-ITM-10077323","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.95","734.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","419.97","42.9","","731.00","63.70","731.00","1 through 10","303.47","778.27","percent of total billed charges",""
"BONE PLATE 0.8MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI ADAPTION","SUP-ITM-10077323","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.95","734.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","419.97","42.9","","384.74","384.74","384.74","1 through 10","303.47","778.27","percent of total billed charges",""
"BONE PLATE 0.8MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI ADAPTION","SUP-ITM-10077323","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.95","734.21","WELLPOINT [1015]","HB AMC WELLPOINT","722.27","73.78","","286.63","119.22","1107.45","105","303.47","778.27","percent of total billed charges",""
"BONE PLATE 0.8MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI ADAPTION","SUP-ITM-10077323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.95","734.21","AETNA [1001]","HB AMC AETNA HMO","683.31","69.8","","675.31","184.75","1721.50","286","511.6","800","percent of total billed charges",""
"BONE PLATE 0.8MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI ADAPTION","SUP-ITM-10077323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.95","734.21","AETNA [1001]","HB AMC AETNA PPO","787.08","80.4","","1261.44","103.12","1514.10","21","511.6","800","percent of total billed charges",""
"BONE PLATE 0.8MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI ADAPTION","SUP-ITM-10077323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.95","734.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","787.08","80.4","","1365.00","1365.00","1365.00","1 through 10","511.6","800","percent of total billed charges",""
"BONE PLATE 0.8MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI ADAPTION","SUP-ITM-10077323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.95","734.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","800.00","81.72","","5157.68","5157.68","5157.68","1 through 10","511.6","800","percent of total billed charges",""
"BONE PLATE 0.8MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI ADAPTION","SUP-ITM-10077323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.95","734.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","800.00","81.72","","431.26","71.26","1459.57","88","511.6","800","percent of total billed charges",""
"BONE PLATE 1 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082145","CDM","C1713","HCPCS","0278","RC","","","","both","","","3426.50","2569.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2724.07","79.5","","800.18","480.96","1887.97","195","1062.22","2724.07","percent of total billed charges",""
"BONE PLATE 1 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082145","CDM","C1713","HCPCS","0278","RC","","","","both","","","3426.50","2569.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1826.32","53.3","","813.12","216.42","1444.50","81","1062.22","2724.07","percent of total billed charges",""
"BONE PLATE 1 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082145","CDM","C1713","HCPCS","0278","RC","","","","both","","","3426.50","2569.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1062.22","31","","432.60","432.60","432.60","1 through 10","1062.22","2724.07","percent of total billed charges",""
"BONE PLATE 1 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082145","CDM","C1713","HCPCS","0278","RC","","","","both","","","3426.50","2569.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1250.67","36.5","","148.37","54.89","631.39","94","1062.22","2724.07","percent of total billed charges",""
"BONE PLATE 1 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082145","CDM","C1713","HCPCS","0278","RC","","","","both","","","3426.50","2569.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1312.35","38.3","","279.30","91.72","1116.77","266","1062.22","2724.07","percent of total billed charges",""
"BONE PLATE 1 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082145","CDM","C1713","HCPCS","0278","RC","","","","both","","","3426.50","2569.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1469.97","42.9","","731.00","63.70","731.00","1 through 10","1062.22","2724.07","percent of total billed charges",""
"BONE PLATE 1 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082145","CDM","C1713","HCPCS","0278","RC","","","","both","","","3426.50","2569.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1469.97","42.9","","384.74","384.74","384.74","1 through 10","1062.22","2724.07","percent of total billed charges",""
"BONE PLATE 1 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082145","CDM","C1713","HCPCS","0278","RC","","","","both","","","3426.50","2569.87","WELLPOINT [1015]","HB AMC WELLPOINT","2528.07","73.78","","286.63","119.22","1107.45","105","1062.22","2724.07","percent of total billed charges",""
"BONE PLATE 1 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3426.50","2569.87","AETNA [1001]","HB AMC AETNA HMO","2391.70","69.8","","675.31","184.75","1721.50","286","1790.69","2800.14","percent of total billed charges",""
"BONE PLATE 1 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3426.50","2569.87","AETNA [1001]","HB AMC AETNA PPO","2754.91","80.4","","1261.44","103.12","1514.10","21","1790.69","2800.14","percent of total billed charges",""
"BONE PLATE 1 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3426.50","2569.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2754.91","80.4","","1365.00","1365.00","1365.00","1 through 10","1790.69","2800.14","percent of total billed charges",""
"BONE PLATE 1 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3426.50","2569.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2800.14","81.72","","5157.68","5157.68","5157.68","1 through 10","1790.69","2800.14","percent of total billed charges",""
"BONE PLATE 1 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3426.50","2569.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2800.14","81.72","","431.26","71.26","1459.57","88","1790.69","2800.14","percent of total billed charges",""
"BONE PLATE 1.25MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.55","1315.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1394.87","79.5","","800.18","480.96","1887.97","195","543.91","1394.87","percent of total billed charges",""
"BONE PLATE 1.25MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.55","1315.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","935.18","53.3","","813.12","216.42","1444.50","81","543.91","1394.87","percent of total billed charges",""
"BONE PLATE 1.25MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.55","1315.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","543.91","31","","432.60","432.60","432.60","1 through 10","543.91","1394.87","percent of total billed charges",""
"BONE PLATE 1.25MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.55","1315.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","640.41","36.5","","148.37","54.89","631.39","94","543.91","1394.87","percent of total billed charges",""
"BONE PLATE 1.25MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.55","1315.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","671.99","38.3","","279.30","91.72","1116.77","266","543.91","1394.87","percent of total billed charges",""
"BONE PLATE 1.25MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.55","1315.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","752.70","42.9","","731.00","63.70","731.00","1 through 10","543.91","1394.87","percent of total billed charges",""
"BONE PLATE 1.25MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.55","1315.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","752.70","42.9","","384.74","384.74","384.74","1 through 10","543.91","1394.87","percent of total billed charges",""
"BONE PLATE 1.25MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081087","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.55","1315.91","WELLPOINT [1015]","HB AMC WELLPOINT","1294.51","73.78","","286.63","119.22","1107.45","105","543.91","1394.87","percent of total billed charges",""
"BONE PLATE 1.25MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1754.55","1315.91","AETNA [1001]","HB AMC AETNA HMO","1224.68","69.8","","675.31","184.75","1721.50","286","916.93","1433.82","percent of total billed charges",""
"BONE PLATE 1.25MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1754.55","1315.91","AETNA [1001]","HB AMC AETNA PPO","1410.66","80.4","","1261.44","103.12","1514.10","21","916.93","1433.82","percent of total billed charges",""
"BONE PLATE 1.25MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1754.55","1315.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1410.66","80.4","","1365.00","1365.00","1365.00","1 through 10","916.93","1433.82","percent of total billed charges",""
"BONE PLATE 1.25MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1754.55","1315.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1433.82","81.72","","5157.68","5157.68","5157.68","1 through 10","916.93","1433.82","percent of total billed charges",""
"BONE PLATE 1.25MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1754.55","1315.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1433.82","81.72","","431.26","71.26","1459.57","88","916.93","1433.82","percent of total billed charges",""
"BONE PLATE 1.25MM 3X3 HOLE COMPRESSION MATRIXMANDIBLE TITANIUM ANGLE","SUP-ITM-10081112","CDM","C1713","HCPCS","0278","RC","","","","both","","","1310.12","982.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1041.55","79.5","","800.18","480.96","1887.97","195","406.14","1041.55","percent of total billed charges",""
"BONE PLATE 1.25MM 3X3 HOLE COMPRESSION MATRIXMANDIBLE TITANIUM ANGLE","SUP-ITM-10081112","CDM","C1713","HCPCS","0278","RC","","","","both","","","1310.12","982.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","698.29","53.3","","813.12","216.42","1444.50","81","406.14","1041.55","percent of total billed charges",""
"BONE PLATE 1.25MM 3X3 HOLE COMPRESSION MATRIXMANDIBLE TITANIUM ANGLE","SUP-ITM-10081112","CDM","C1713","HCPCS","0278","RC","","","","both","","","1310.12","982.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","406.14","31","","432.60","432.60","432.60","1 through 10","406.14","1041.55","percent of total billed charges",""
"BONE PLATE 1.25MM 3X3 HOLE COMPRESSION MATRIXMANDIBLE TITANIUM ANGLE","SUP-ITM-10081112","CDM","C1713","HCPCS","0278","RC","","","","both","","","1310.12","982.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","478.19","36.5","","148.37","54.89","631.39","94","406.14","1041.55","percent of total billed charges",""
"BONE PLATE 1.25MM 3X3 HOLE COMPRESSION MATRIXMANDIBLE TITANIUM ANGLE","SUP-ITM-10081112","CDM","C1713","HCPCS","0278","RC","","","","both","","","1310.12","982.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","501.78","38.3","","279.30","91.72","1116.77","266","406.14","1041.55","percent of total billed charges",""
"BONE PLATE 1.25MM 3X3 HOLE COMPRESSION MATRIXMANDIBLE TITANIUM ANGLE","SUP-ITM-10081112","CDM","C1713","HCPCS","0278","RC","","","","both","","","1310.12","982.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","562.04","42.9","","731.00","63.70","731.00","1 through 10","406.14","1041.55","percent of total billed charges",""
"BONE PLATE 1.25MM 3X3 HOLE COMPRESSION MATRIXMANDIBLE TITANIUM ANGLE","SUP-ITM-10081112","CDM","C1713","HCPCS","0278","RC","","","","both","","","1310.12","982.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","562.04","42.9","","384.74","384.74","384.74","1 through 10","406.14","1041.55","percent of total billed charges",""
"BONE PLATE 1.25MM 3X3 HOLE COMPRESSION MATRIXMANDIBLE TITANIUM ANGLE","SUP-ITM-10081112","CDM","C1713","HCPCS","0278","RC","","","","both","","","1310.12","982.59","WELLPOINT [1015]","HB AMC WELLPOINT","966.61","73.78","","286.63","119.22","1107.45","105","406.14","1041.55","percent of total billed charges",""
"BONE PLATE 1.25MM 3X3 HOLE COMPRESSION MATRIXMANDIBLE TITANIUM ANGLE","SUP-ITM-10081112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1310.12","982.59","AETNA [1001]","HB AMC AETNA HMO","914.46","69.8","","675.31","184.75","1721.50","286","684.67","1070.63","percent of total billed charges",""
"BONE PLATE 1.25MM 3X3 HOLE COMPRESSION MATRIXMANDIBLE TITANIUM ANGLE","SUP-ITM-10081112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1310.12","982.59","AETNA [1001]","HB AMC AETNA PPO","1053.34","80.4","","1261.44","103.12","1514.10","21","684.67","1070.63","percent of total billed charges",""
"BONE PLATE 1.25MM 3X3 HOLE COMPRESSION MATRIXMANDIBLE TITANIUM ANGLE","SUP-ITM-10081112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1310.12","982.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1053.34","80.4","","1365.00","1365.00","1365.00","1 through 10","684.67","1070.63","percent of total billed charges",""
"BONE PLATE 1.25MM 3X3 HOLE COMPRESSION MATRIXMANDIBLE TITANIUM ANGLE","SUP-ITM-10081112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1310.12","982.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1070.63","81.72","","5157.68","5157.68","5157.68","1 through 10","684.67","1070.63","percent of total billed charges",""
"BONE PLATE 1.25MM 3X3 HOLE COMPRESSION MATRIXMANDIBLE TITANIUM ANGLE","SUP-ITM-10081112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1310.12","982.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1070.63","81.72","","431.26","71.26","1459.57","88","684.67","1070.63","percent of total billed charges",""
"BONE PLATE 1.3X0.75MM 3 HOLE HEAD 5 STAINLESS LOCKING T SHAPE","SUP-ITM-10164652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.62","811.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","860.68","79.5","","800.18","480.96","1887.97","195","335.61","860.68","percent of total billed charges",""
"BONE PLATE 1.3X0.75MM 3 HOLE HEAD 5 STAINLESS LOCKING T SHAPE","SUP-ITM-10164652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.62","811.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","577.04","53.3","","813.12","216.42","1444.50","81","335.61","860.68","percent of total billed charges",""
"BONE PLATE 1.3X0.75MM 3 HOLE HEAD 5 STAINLESS LOCKING T SHAPE","SUP-ITM-10164652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.62","811.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","335.61","31","","432.60","432.60","432.60","1 through 10","335.61","860.68","percent of total billed charges",""
"BONE PLATE 1.3X0.75MM 3 HOLE HEAD 5 STAINLESS LOCKING T SHAPE","SUP-ITM-10164652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.62","811.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","395.16","36.5","","148.37","54.89","631.39","94","335.61","860.68","percent of total billed charges",""
"BONE PLATE 1.3X0.75MM 3 HOLE HEAD 5 STAINLESS LOCKING T SHAPE","SUP-ITM-10164652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.62","811.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","414.64","38.3","","279.30","91.72","1116.77","266","335.61","860.68","percent of total billed charges",""
"BONE PLATE 1.3X0.75MM 3 HOLE HEAD 5 STAINLESS LOCKING T SHAPE","SUP-ITM-10164652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.62","811.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","464.44","42.9","","731.00","63.70","731.00","1 through 10","335.61","860.68","percent of total billed charges",""
"BONE PLATE 1.3X0.75MM 3 HOLE HEAD 5 STAINLESS LOCKING T SHAPE","SUP-ITM-10164652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.62","811.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","464.44","42.9","","384.74","384.74","384.74","1 through 10","335.61","860.68","percent of total billed charges",""
"BONE PLATE 1.3X0.75MM 3 HOLE HEAD 5 STAINLESS LOCKING T SHAPE","SUP-ITM-10164652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.62","811.96","WELLPOINT [1015]","HB AMC WELLPOINT","798.76","73.78","","286.63","119.22","1107.45","105","335.61","860.68","percent of total billed charges",""
"BONE PLATE 1.3X0.75MM 3 HOLE HEAD 5 STAINLESS LOCKING T SHAPE","SUP-ITM-10164652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1082.62","811.96","AETNA [1001]","HB AMC AETNA HMO","755.67","69.8","","675.31","184.75","1721.50","286","565.78","884.72","percent of total billed charges",""
"BONE PLATE 1.3X0.75MM 3 HOLE HEAD 5 STAINLESS LOCKING T SHAPE","SUP-ITM-10164652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1082.62","811.96","AETNA [1001]","HB AMC AETNA PPO","870.43","80.4","","1261.44","103.12","1514.10","21","565.78","884.72","percent of total billed charges",""
"BONE PLATE 1.3X0.75MM 3 HOLE HEAD 5 STAINLESS LOCKING T SHAPE","SUP-ITM-10164652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1082.62","811.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","870.43","80.4","","1365.00","1365.00","1365.00","1 through 10","565.78","884.72","percent of total billed charges",""
"BONE PLATE 1.3X0.75MM 3 HOLE HEAD 5 STAINLESS LOCKING T SHAPE","SUP-ITM-10164652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1082.62","811.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","884.72","81.72","","5157.68","5157.68","5157.68","1 through 10","565.78","884.72","percent of total billed charges",""
"BONE PLATE 1.3X0.75MM 3 HOLE HEAD 5 STAINLESS LOCKING T SHAPE","SUP-ITM-10164652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1082.62","811.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","884.72","81.72","","431.26","71.26","1459.57","88","565.78","884.72","percent of total billed charges",""
"BONE PLATE 1.3X18 9MM 6 HOLE CRANIAL TI DOUBLE Y SHAPE ARM","SUP-ITM-10012539","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.72","372.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","394.89","79.5","","800.18","480.96","1887.97","195","153.98","394.89","percent of total billed charges",""
"BONE PLATE 1.3X18 9MM 6 HOLE CRANIAL TI DOUBLE Y SHAPE ARM","SUP-ITM-10012539","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.72","372.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","264.75","53.3","","813.12","216.42","1444.50","81","153.98","394.89","percent of total billed charges",""
"BONE PLATE 1.3X18 9MM 6 HOLE CRANIAL TI DOUBLE Y SHAPE ARM","SUP-ITM-10012539","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.72","372.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","153.98","31","","432.60","432.60","432.60","1 through 10","153.98","394.89","percent of total billed charges",""
"BONE PLATE 1.3X18 9MM 6 HOLE CRANIAL TI DOUBLE Y SHAPE ARM","SUP-ITM-10012539","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.72","372.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","181.30","36.5","","148.37","54.89","631.39","94","153.98","394.89","percent of total billed charges",""
"BONE PLATE 1.3X18 9MM 6 HOLE CRANIAL TI DOUBLE Y SHAPE ARM","SUP-ITM-10012539","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.72","372.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","190.24","38.3","","279.30","91.72","1116.77","266","153.98","394.89","percent of total billed charges",""
"BONE PLATE 1.3X18 9MM 6 HOLE CRANIAL TI DOUBLE Y SHAPE ARM","SUP-ITM-10012539","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.72","372.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.09","42.9","","731.00","63.70","731.00","1 through 10","153.98","394.89","percent of total billed charges",""
"BONE PLATE 1.3X18 9MM 6 HOLE CRANIAL TI DOUBLE Y SHAPE ARM","SUP-ITM-10012539","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.72","372.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.09","42.9","","384.74","384.74","384.74","1 through 10","153.98","394.89","percent of total billed charges",""
"BONE PLATE 1.3X18 9MM 6 HOLE CRANIAL TI DOUBLE Y SHAPE ARM","SUP-ITM-10012539","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.72","372.54","WELLPOINT [1015]","HB AMC WELLPOINT","366.48","73.78","","286.63","119.22","1107.45","105","153.98","394.89","percent of total billed charges",""
"BONE PLATE 1.3X18 9MM 6 HOLE CRANIAL TI DOUBLE Y SHAPE ARM","SUP-ITM-10012539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","496.72","372.54","AETNA [1001]","HB AMC AETNA HMO","346.71","69.8","","675.31","184.75","1721.50","286","259.59","405.92","percent of total billed charges",""
"BONE PLATE 1.3X18 9MM 6 HOLE CRANIAL TI DOUBLE Y SHAPE ARM","SUP-ITM-10012539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","496.72","372.54","AETNA [1001]","HB AMC AETNA PPO","399.36","80.4","","1261.44","103.12","1514.10","21","259.59","405.92","percent of total billed charges",""
"BONE PLATE 1.3X18 9MM 6 HOLE CRANIAL TI DOUBLE Y SHAPE ARM","SUP-ITM-10012539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","496.72","372.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","399.36","80.4","","1365.00","1365.00","1365.00","1 through 10","259.59","405.92","percent of total billed charges",""
"BONE PLATE 1.3X18 9MM 6 HOLE CRANIAL TI DOUBLE Y SHAPE ARM","SUP-ITM-10012539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","496.72","372.54","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","405.92","81.72","","5157.68","5157.68","5157.68","1 through 10","259.59","405.92","percent of total billed charges",""
"BONE PLATE 1.3X18 9MM 6 HOLE CRANIAL TI DOUBLE Y SHAPE ARM","SUP-ITM-10012539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","496.72","372.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","405.92","81.72","","431.26","71.26","1459.57","88","259.59","405.92","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","1048.95","786.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","833.92","79.5","","800.18","480.96","1887.97","195","325.17","833.92","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","1048.95","786.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","559.09","53.3","","813.12","216.42","1444.50","81","325.17","833.92","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","1048.95","786.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","325.17","31","","432.60","432.60","432.60","1 through 10","325.17","833.92","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","1048.95","786.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","382.87","36.5","","148.37","54.89","631.39","94","325.17","833.92","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","1048.95","786.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","401.75","38.3","","279.30","91.72","1116.77","266","325.17","833.92","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","1048.95","786.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.00","42.9","","731.00","63.70","731.00","1 through 10","325.17","833.92","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","1048.95","786.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.00","42.9","","384.74","384.74","384.74","1 through 10","325.17","833.92","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","1048.95","786.71","WELLPOINT [1015]","HB AMC WELLPOINT","773.92","73.78","","286.63","119.22","1107.45","105","325.17","833.92","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1048.95","786.71","AETNA [1001]","HB AMC AETNA HMO","732.17","69.8","","675.31","184.75","1721.50","286","548.18","857.2","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1048.95","786.71","AETNA [1001]","HB AMC AETNA PPO","843.36","80.4","","1261.44","103.12","1514.10","21","548.18","857.2","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1048.95","786.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","843.36","80.4","","1365.00","1365.00","1365.00","1 through 10","548.18","857.2","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1048.95","786.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","857.20","81.72","","5157.68","5157.68","5157.68","1 through 10","548.18","857.2","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1048.95","786.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","857.20","81.72","","431.26","71.26","1459.57","88","548.18","857.2","percent of total billed charges",""
"BONE PLATE 1.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.45","2098.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2223.97","79.5","","800.18","480.96","1887.97","195","867.21","2223.97","percent of total billed charges",""
"BONE PLATE 1.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.45","2098.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1491.04","53.3","","813.12","216.42","1444.50","81","867.21","2223.97","percent of total billed charges",""
"BONE PLATE 1.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.45","2098.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","867.21","31","","432.60","432.60","432.60","1 through 10","867.21","2223.97","percent of total billed charges",""
"BONE PLATE 1.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.45","2098.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1021.07","36.5","","148.37","54.89","631.39","94","867.21","2223.97","percent of total billed charges",""
"BONE PLATE 1.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.45","2098.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1071.42","38.3","","279.30","91.72","1116.77","266","867.21","2223.97","percent of total billed charges",""
"BONE PLATE 1.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.45","2098.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.11","42.9","","731.00","63.70","731.00","1 through 10","867.21","2223.97","percent of total billed charges",""
"BONE PLATE 1.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.45","2098.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.11","42.9","","384.74","384.74","384.74","1 through 10","867.21","2223.97","percent of total billed charges",""
"BONE PLATE 1.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.45","2098.09","WELLPOINT [1015]","HB AMC WELLPOINT","2063.96","73.78","","286.63","119.22","1107.45","105","867.21","2223.97","percent of total billed charges",""
"BONE PLATE 1.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2797.45","2098.09","AETNA [1001]","HB AMC AETNA HMO","1952.62","69.8","","675.31","184.75","1721.50","286","1461.95","2286.08","percent of total billed charges",""
"BONE PLATE 1.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2797.45","2098.09","AETNA [1001]","HB AMC AETNA PPO","2249.15","80.4","","1261.44","103.12","1514.10","21","1461.95","2286.08","percent of total billed charges",""
"BONE PLATE 1.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2797.45","2098.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2249.15","80.4","","1365.00","1365.00","1365.00","1 through 10","1461.95","2286.08","percent of total billed charges",""
"BONE PLATE 1.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2797.45","2098.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2286.08","81.72","","5157.68","5157.68","5157.68","1 through 10","1461.95","2286.08","percent of total billed charges",""
"BONE PLATE 1.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2797.45","2098.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2286.08","81.72","","431.26","71.26","1459.57","88","1461.95","2286.08","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","858.62","79.5","","800.18","480.96","1887.97","195","334.81","858.62","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","575.66","53.3","","813.12","216.42","1444.50","81","334.81","858.62","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","334.81","31","","432.60","432.60","432.60","1 through 10","334.81","858.62","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","394.21","36.5","","148.37","54.89","631.39","94","334.81","858.62","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","413.65","38.3","","279.30","91.72","1116.77","266","334.81","858.62","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","463.33","42.9","","731.00","63.70","731.00","1 through 10","334.81","858.62","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","463.33","42.9","","384.74","384.74","384.74","1 through 10","334.81","858.62","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","WELLPOINT [1015]","HB AMC WELLPOINT","796.85","73.78","","286.63","119.22","1107.45","105","334.81","858.62","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.03","810.02","AETNA [1001]","HB AMC AETNA HMO","753.86","69.8","","675.31","184.75","1721.50","286","564.42","882.6","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.03","810.02","AETNA [1001]","HB AMC AETNA PPO","868.34","80.4","","1261.44","103.12","1514.10","21","564.42","882.6","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.03","810.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","868.34","80.4","","1365.00","1365.00","1365.00","1 through 10","564.42","882.6","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.03","810.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","882.60","81.72","","5157.68","5157.68","5157.68","1 through 10","564.42","882.6","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 LCP LOCKING STAINLESS T SHAPE","SUP-ITM-10083678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.03","810.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","882.60","81.72","","431.26","71.26","1459.57","88","564.42","882.6","percent of total billed charges",""
"BONE PLATE 1.5MM 3X3 HOLE COMPRESSION CRANIOMAXILLOFACIAL MATRIXMANDIBLE TITANIUM DISTAL","SUP-ITM-10081104","CDM","C1713","HCPCS","0278","RC","","","","both","","","1318.80","989.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1048.45","79.5","","800.18","480.96","1887.97","195","408.83","1048.45","percent of total billed charges",""
"BONE PLATE 1.5MM 3X3 HOLE COMPRESSION CRANIOMAXILLOFACIAL MATRIXMANDIBLE TITANIUM DISTAL","SUP-ITM-10081104","CDM","C1713","HCPCS","0278","RC","","","","both","","","1318.80","989.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","702.92","53.3","","813.12","216.42","1444.50","81","408.83","1048.45","percent of total billed charges",""
"BONE PLATE 1.5MM 3X3 HOLE COMPRESSION CRANIOMAXILLOFACIAL MATRIXMANDIBLE TITANIUM DISTAL","SUP-ITM-10081104","CDM","C1713","HCPCS","0278","RC","","","","both","","","1318.80","989.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","408.83","31","","432.60","432.60","432.60","1 through 10","408.83","1048.45","percent of total billed charges",""
"BONE PLATE 1.5MM 3X3 HOLE COMPRESSION CRANIOMAXILLOFACIAL MATRIXMANDIBLE TITANIUM DISTAL","SUP-ITM-10081104","CDM","C1713","HCPCS","0278","RC","","","","both","","","1318.80","989.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","481.36","36.5","","148.37","54.89","631.39","94","408.83","1048.45","percent of total billed charges",""
"BONE PLATE 1.5MM 3X3 HOLE COMPRESSION CRANIOMAXILLOFACIAL MATRIXMANDIBLE TITANIUM DISTAL","SUP-ITM-10081104","CDM","C1713","HCPCS","0278","RC","","","","both","","","1318.80","989.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","505.10","38.3","","279.30","91.72","1116.77","266","408.83","1048.45","percent of total billed charges",""
"BONE PLATE 1.5MM 3X3 HOLE COMPRESSION CRANIOMAXILLOFACIAL MATRIXMANDIBLE TITANIUM DISTAL","SUP-ITM-10081104","CDM","C1713","HCPCS","0278","RC","","","","both","","","1318.80","989.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","565.77","42.9","","731.00","63.70","731.00","1 through 10","408.83","1048.45","percent of total billed charges",""
"BONE PLATE 1.5MM 3X3 HOLE COMPRESSION CRANIOMAXILLOFACIAL MATRIXMANDIBLE TITANIUM DISTAL","SUP-ITM-10081104","CDM","C1713","HCPCS","0278","RC","","","","both","","","1318.80","989.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","565.77","42.9","","384.74","384.74","384.74","1 through 10","408.83","1048.45","percent of total billed charges",""
"BONE PLATE 1.5MM 3X3 HOLE COMPRESSION CRANIOMAXILLOFACIAL MATRIXMANDIBLE TITANIUM DISTAL","SUP-ITM-10081104","CDM","C1713","HCPCS","0278","RC","","","","both","","","1318.80","989.10","WELLPOINT [1015]","HB AMC WELLPOINT","973.01","73.78","","286.63","119.22","1107.45","105","408.83","1048.45","percent of total billed charges",""
"BONE PLATE 1.5MM 3X3 HOLE COMPRESSION CRANIOMAXILLOFACIAL MATRIXMANDIBLE TITANIUM DISTAL","SUP-ITM-10081104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1318.80","989.10","AETNA [1001]","HB AMC AETNA HMO","920.52","69.8","","675.31","184.75","1721.50","286","689.2","1077.72","percent of total billed charges",""
"BONE PLATE 1.5MM 3X3 HOLE COMPRESSION CRANIOMAXILLOFACIAL MATRIXMANDIBLE TITANIUM DISTAL","SUP-ITM-10081104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1318.80","989.10","AETNA [1001]","HB AMC AETNA PPO","1060.32","80.4","","1261.44","103.12","1514.10","21","689.2","1077.72","percent of total billed charges",""
"BONE PLATE 1.5MM 3X3 HOLE COMPRESSION CRANIOMAXILLOFACIAL MATRIXMANDIBLE TITANIUM DISTAL","SUP-ITM-10081104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1318.80","989.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1060.32","80.4","","1365.00","1365.00","1365.00","1 through 10","689.2","1077.72","percent of total billed charges",""
"BONE PLATE 1.5MM 3X3 HOLE COMPRESSION CRANIOMAXILLOFACIAL MATRIXMANDIBLE TITANIUM DISTAL","SUP-ITM-10081104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1318.80","989.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1077.72","81.72","","5157.68","5157.68","5157.68","1 through 10","689.2","1077.72","percent of total billed charges",""
"BONE PLATE 1.5MM 3X3 HOLE COMPRESSION CRANIOMAXILLOFACIAL MATRIXMANDIBLE TITANIUM DISTAL","SUP-ITM-10081104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1318.80","989.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1077.72","81.72","","431.26","71.26","1459.57","88","689.2","1077.72","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.71","970.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1028.50","79.5","","800.18","480.96","1887.97","195","401.05","1028.5","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.71","970.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","689.55","53.3","","813.12","216.42","1444.50","81","401.05","1028.5","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.71","970.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","401.05","31","","432.60","432.60","432.60","1 through 10","401.05","1028.5","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.71","970.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","472.20","36.5","","148.37","54.89","631.39","94","401.05","1028.5","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.71","970.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","495.49","38.3","","279.30","91.72","1116.77","266","401.05","1028.5","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.71","970.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","555.00","42.9","","731.00","63.70","731.00","1 through 10","401.05","1028.5","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.71","970.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","555.00","42.9","","384.74","384.74","384.74","1 through 10","401.05","1028.5","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.71","970.28","WELLPOINT [1015]","HB AMC WELLPOINT","954.50","73.78","","286.63","119.22","1107.45","105","401.05","1028.5","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1293.71","970.28","AETNA [1001]","HB AMC AETNA HMO","903.01","69.8","","675.31","184.75","1721.50","286","676.09","1057.22","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1293.71","970.28","AETNA [1001]","HB AMC AETNA PPO","1040.14","80.4","","1261.44","103.12","1514.10","21","676.09","1057.22","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1293.71","970.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1040.14","80.4","","1365.00","1365.00","1365.00","1 through 10","676.09","1057.22","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1293.71","970.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1057.22","81.72","","5157.68","5157.68","5157.68","1 through 10","676.09","1057.22","percent of total billed charges",""
"BONE PLATE 1.5X50.0MM 4 HOLE 9 TI T SHAPE","SUP-ITM-10001773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1293.71","970.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1057.22","81.72","","431.26","71.26","1459.57","88","676.09","1057.22","percent of total billed charges",""
"BONE PLATE 10 HOLE MAXILLOFACIAL MATRIXWAVE MAXILLOMANDIBULAR FIXATION TI TALL","SUP-ITM-10156055","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.65","561.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","595.18","79.5","","800.18","480.96","1887.97","195","232.08","595.18","percent of total billed charges",""
"BONE PLATE 10 HOLE MAXILLOFACIAL MATRIXWAVE MAXILLOMANDIBULAR FIXATION TI TALL","SUP-ITM-10156055","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.65","561.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","399.03","53.3","","813.12","216.42","1444.50","81","232.08","595.18","percent of total billed charges",""
"BONE PLATE 10 HOLE MAXILLOFACIAL MATRIXWAVE MAXILLOMANDIBULAR FIXATION TI TALL","SUP-ITM-10156055","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.65","561.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","232.08","31","","432.60","432.60","432.60","1 through 10","232.08","595.18","percent of total billed charges",""
"BONE PLATE 10 HOLE MAXILLOFACIAL MATRIXWAVE MAXILLOMANDIBULAR FIXATION TI TALL","SUP-ITM-10156055","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.65","561.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","273.26","36.5","","148.37","54.89","631.39","94","232.08","595.18","percent of total billed charges",""
"BONE PLATE 10 HOLE MAXILLOFACIAL MATRIXWAVE MAXILLOMANDIBULAR FIXATION TI TALL","SUP-ITM-10156055","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.65","561.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","286.73","38.3","","279.30","91.72","1116.77","266","232.08","595.18","percent of total billed charges",""
"BONE PLATE 10 HOLE MAXILLOFACIAL MATRIXWAVE MAXILLOMANDIBULAR FIXATION TI TALL","SUP-ITM-10156055","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.65","561.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","321.17","42.9","","731.00","63.70","731.00","1 through 10","232.08","595.18","percent of total billed charges",""
"BONE PLATE 10 HOLE MAXILLOFACIAL MATRIXWAVE MAXILLOMANDIBULAR FIXATION TI TALL","SUP-ITM-10156055","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.65","561.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","321.17","42.9","","384.74","384.74","384.74","1 through 10","232.08","595.18","percent of total billed charges",""
"BONE PLATE 10 HOLE MAXILLOFACIAL MATRIXWAVE MAXILLOMANDIBULAR FIXATION TI TALL","SUP-ITM-10156055","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.65","561.49","WELLPOINT [1015]","HB AMC WELLPOINT","552.35","73.78","","286.63","119.22","1107.45","105","232.08","595.18","percent of total billed charges",""
"BONE PLATE 10 HOLE MAXILLOFACIAL MATRIXWAVE MAXILLOMANDIBULAR FIXATION TI TALL","SUP-ITM-10156055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","748.65","561.49","AETNA [1001]","HB AMC AETNA HMO","522.56","69.8","","675.31","184.75","1721.50","286","391.24","611.8","percent of total billed charges",""
"BONE PLATE 10 HOLE MAXILLOFACIAL MATRIXWAVE MAXILLOMANDIBULAR FIXATION TI TALL","SUP-ITM-10156055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","748.65","561.49","AETNA [1001]","HB AMC AETNA PPO","601.91","80.4","","1261.44","103.12","1514.10","21","391.24","611.8","percent of total billed charges",""
"BONE PLATE 10 HOLE MAXILLOFACIAL MATRIXWAVE MAXILLOMANDIBULAR FIXATION TI TALL","SUP-ITM-10156055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","748.65","561.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","601.91","80.4","","1365.00","1365.00","1365.00","1 through 10","391.24","611.8","percent of total billed charges",""
"BONE PLATE 10 HOLE MAXILLOFACIAL MATRIXWAVE MAXILLOMANDIBULAR FIXATION TI TALL","SUP-ITM-10156055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","748.65","561.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","611.80","81.72","","5157.68","5157.68","5157.68","1 through 10","391.24","611.8","percent of total billed charges",""
"BONE PLATE 10 HOLE MAXILLOFACIAL MATRIXWAVE MAXILLOMANDIBULAR FIXATION TI TALL","SUP-ITM-10156055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","748.65","561.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","611.80","81.72","","431.26","71.26","1459.57","88","391.24","611.8","percent of total billed charges",""
"BONE PLATE 10 HOLE STERNAL TI LOCKINGXSHAPE WIDE","SUP-ITM-10077450","CDM","C1713","HCPCS","0278","RC","","","","both","","","2178.68","1634.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1732.05","79.5","","800.18","480.96","1887.97","195","675.39","1732.05","percent of total billed charges",""
"BONE PLATE 10 HOLE STERNAL TI LOCKINGXSHAPE WIDE","SUP-ITM-10077450","CDM","C1713","HCPCS","0278","RC","","","","both","","","2178.68","1634.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1161.24","53.3","","813.12","216.42","1444.50","81","675.39","1732.05","percent of total billed charges",""
"BONE PLATE 10 HOLE STERNAL TI LOCKINGXSHAPE WIDE","SUP-ITM-10077450","CDM","C1713","HCPCS","0278","RC","","","","both","","","2178.68","1634.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","675.39","31","","432.60","432.60","432.60","1 through 10","675.39","1732.05","percent of total billed charges",""
"BONE PLATE 10 HOLE STERNAL TI LOCKINGXSHAPE WIDE","SUP-ITM-10077450","CDM","C1713","HCPCS","0278","RC","","","","both","","","2178.68","1634.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","795.22","36.5","","148.37","54.89","631.39","94","675.39","1732.05","percent of total billed charges",""
"BONE PLATE 10 HOLE STERNAL TI LOCKINGXSHAPE WIDE","SUP-ITM-10077450","CDM","C1713","HCPCS","0278","RC","","","","both","","","2178.68","1634.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","834.43","38.3","","279.30","91.72","1116.77","266","675.39","1732.05","percent of total billed charges",""
"BONE PLATE 10 HOLE STERNAL TI LOCKINGXSHAPE WIDE","SUP-ITM-10077450","CDM","C1713","HCPCS","0278","RC","","","","both","","","2178.68","1634.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","934.65","42.9","","731.00","63.70","731.00","1 through 10","675.39","1732.05","percent of total billed charges",""
"BONE PLATE 10 HOLE STERNAL TI LOCKINGXSHAPE WIDE","SUP-ITM-10077450","CDM","C1713","HCPCS","0278","RC","","","","both","","","2178.68","1634.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","934.65","42.9","","384.74","384.74","384.74","1 through 10","675.39","1732.05","percent of total billed charges",""
"BONE PLATE 10 HOLE STERNAL TI LOCKINGXSHAPE WIDE","SUP-ITM-10077450","CDM","C1713","HCPCS","0278","RC","","","","both","","","2178.68","1634.01","WELLPOINT [1015]","HB AMC WELLPOINT","1607.43","73.78","","286.63","119.22","1107.45","105","675.39","1732.05","percent of total billed charges",""
"BONE PLATE 10 HOLE STERNAL TI LOCKINGXSHAPE WIDE","SUP-ITM-10077450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2178.68","1634.01","AETNA [1001]","HB AMC AETNA HMO","1520.72","69.8","","675.31","184.75","1721.50","286","1138.58","1780.42","percent of total billed charges",""
"BONE PLATE 10 HOLE STERNAL TI LOCKINGXSHAPE WIDE","SUP-ITM-10077450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2178.68","1634.01","AETNA [1001]","HB AMC AETNA PPO","1751.66","80.4","","1261.44","103.12","1514.10","21","1138.58","1780.42","percent of total billed charges",""
"BONE PLATE 10 HOLE STERNAL TI LOCKINGXSHAPE WIDE","SUP-ITM-10077450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2178.68","1634.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1751.66","80.4","","1365.00","1365.00","1365.00","1 through 10","1138.58","1780.42","percent of total billed charges",""
"BONE PLATE 10 HOLE STERNAL TI LOCKINGXSHAPE WIDE","SUP-ITM-10077450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2178.68","1634.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1780.42","81.72","","5157.68","5157.68","5157.68","1 through 10","1138.58","1780.42","percent of total billed charges",""
"BONE PLATE 10 HOLE STERNAL TI LOCKINGXSHAPE WIDE","SUP-ITM-10077450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2178.68","1634.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1780.42","81.72","","431.26","71.26","1459.57","88","1138.58","1780.42","percent of total billed charges",""
"BONE PLATE 107MM 1/3 TUBULAR 9 HOLE 626679","SUP-ITM-10186971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2285.75","1714.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1817.17","79.5","","800.18","480.96","1887.97","195","708.58","1817.17","percent of total billed charges",""
"BONE PLATE 107MM 1/3 TUBULAR 9 HOLE 626679","SUP-ITM-10186971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2285.75","1714.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1218.30","53.3","","813.12","216.42","1444.50","81","708.58","1817.17","percent of total billed charges",""
"BONE PLATE 107MM 1/3 TUBULAR 9 HOLE 626679","SUP-ITM-10186971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2285.75","1714.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","708.58","31","","432.60","432.60","432.60","1 through 10","708.58","1817.17","percent of total billed charges",""
"BONE PLATE 107MM 1/3 TUBULAR 9 HOLE 626679","SUP-ITM-10186971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2285.75","1714.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","834.30","36.5","","148.37","54.89","631.39","94","708.58","1817.17","percent of total billed charges",""
"BONE PLATE 107MM 1/3 TUBULAR 9 HOLE 626679","SUP-ITM-10186971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2285.75","1714.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","875.44","38.3","","279.30","91.72","1116.77","266","708.58","1817.17","percent of total billed charges",""
"BONE PLATE 107MM 1/3 TUBULAR 9 HOLE 626679","SUP-ITM-10186971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2285.75","1714.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","980.59","42.9","","731.00","63.70","731.00","1 through 10","708.58","1817.17","percent of total billed charges",""
"BONE PLATE 107MM 1/3 TUBULAR 9 HOLE 626679","SUP-ITM-10186971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2285.75","1714.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","980.59","42.9","","384.74","384.74","384.74","1 through 10","708.58","1817.17","percent of total billed charges",""
"BONE PLATE 107MM 1/3 TUBULAR 9 HOLE 626679","SUP-ITM-10186971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2285.75","1714.31","WELLPOINT [1015]","HB AMC WELLPOINT","1686.43","73.78","","286.63","119.22","1107.45","105","708.58","1817.17","percent of total billed charges",""
"BONE PLATE 107MM 1/3 TUBULAR 9 HOLE 626679","SUP-ITM-10186971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2285.75","1714.31","AETNA [1001]","HB AMC AETNA HMO","1595.45","69.8","","675.31","184.75","1721.50","286","1194.53","1867.91","percent of total billed charges",""
"BONE PLATE 107MM 1/3 TUBULAR 9 HOLE 626679","SUP-ITM-10186971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2285.75","1714.31","AETNA [1001]","HB AMC AETNA PPO","1837.74","80.4","","1261.44","103.12","1514.10","21","1194.53","1867.91","percent of total billed charges",""
"BONE PLATE 107MM 1/3 TUBULAR 9 HOLE 626679","SUP-ITM-10186971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2285.75","1714.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1837.74","80.4","","1365.00","1365.00","1365.00","1 through 10","1194.53","1867.91","percent of total billed charges",""
"BONE PLATE 107MM 1/3 TUBULAR 9 HOLE 626679","SUP-ITM-10186971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2285.75","1714.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1867.91","81.72","","5157.68","5157.68","5157.68","1 through 10","1194.53","1867.91","percent of total billed charges",""
"BONE PLATE 107MM 1/3 TUBULAR 9 HOLE 626679","SUP-ITM-10186971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2285.75","1714.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1867.91","81.72","","431.26","71.26","1459.57","88","1194.53","1867.91","percent of total billed charges",""
"BONE PLATE 10X60MM SLOTTED","SUP-ITM-10186098","CDM","C1713","HCPCS","0278","RC","","","","both","","","670.74","503.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","533.24","79.5","","800.18","480.96","1887.97","195","207.93","533.24","percent of total billed charges",""
"BONE PLATE 10X60MM SLOTTED","SUP-ITM-10186098","CDM","C1713","HCPCS","0278","RC","","","","both","","","670.74","503.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","357.50","53.3","","813.12","216.42","1444.50","81","207.93","533.24","percent of total billed charges",""
"BONE PLATE 10X60MM SLOTTED","SUP-ITM-10186098","CDM","C1713","HCPCS","0278","RC","","","","both","","","670.74","503.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","207.93","31","","432.60","432.60","432.60","1 through 10","207.93","533.24","percent of total billed charges",""
"BONE PLATE 10X60MM SLOTTED","SUP-ITM-10186098","CDM","C1713","HCPCS","0278","RC","","","","both","","","670.74","503.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","244.82","36.5","","148.37","54.89","631.39","94","207.93","533.24","percent of total billed charges",""
"BONE PLATE 10X60MM SLOTTED","SUP-ITM-10186098","CDM","C1713","HCPCS","0278","RC","","","","both","","","670.74","503.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","256.89","38.3","","279.30","91.72","1116.77","266","207.93","533.24","percent of total billed charges",""
"BONE PLATE 10X60MM SLOTTED","SUP-ITM-10186098","CDM","C1713","HCPCS","0278","RC","","","","both","","","670.74","503.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","287.75","42.9","","731.00","63.70","731.00","1 through 10","207.93","533.24","percent of total billed charges",""
"BONE PLATE 10X60MM SLOTTED","SUP-ITM-10186098","CDM","C1713","HCPCS","0278","RC","","","","both","","","670.74","503.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","287.75","42.9","","384.74","384.74","384.74","1 through 10","207.93","533.24","percent of total billed charges",""
"BONE PLATE 10X60MM SLOTTED","SUP-ITM-10186098","CDM","C1713","HCPCS","0278","RC","","","","both","","","670.74","503.05","WELLPOINT [1015]","HB AMC WELLPOINT","494.87","73.78","","286.63","119.22","1107.45","105","207.93","533.24","percent of total billed charges",""
"BONE PLATE 10X60MM SLOTTED","SUP-ITM-10186098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","670.74","503.05","AETNA [1001]","HB AMC AETNA HMO","468.18","69.8","","675.31","184.75","1721.50","286","350.53","548.13","percent of total billed charges",""
"BONE PLATE 10X60MM SLOTTED","SUP-ITM-10186098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","670.74","503.05","AETNA [1001]","HB AMC AETNA PPO","539.27","80.4","","1261.44","103.12","1514.10","21","350.53","548.13","percent of total billed charges",""
"BONE PLATE 10X60MM SLOTTED","SUP-ITM-10186098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","670.74","503.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","539.27","80.4","","1365.00","1365.00","1365.00","1 through 10","350.53","548.13","percent of total billed charges",""
"BONE PLATE 10X60MM SLOTTED","SUP-ITM-10186098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","670.74","503.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","548.13","81.72","","5157.68","5157.68","5157.68","1 through 10","350.53","548.13","percent of total billed charges",""
"BONE PLATE 10X60MM SLOTTED","SUP-ITM-10186098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","670.74","503.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","548.13","81.72","","431.26","71.26","1459.57","88","350.53","548.13","percent of total billed charges",""
"BONE PLATE 110MM LARGE HIP DALL MILES GRIP TROCHANTERIC CABLE","SUP-ITM-10074801","CDM","C1713","HCPCS","0278","RC","","","","both","","","3647.00","2735.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2899.37","79.5","","800.18","480.96","1887.97","195","1130.57","2899.37","percent of total billed charges",""
"BONE PLATE 110MM LARGE HIP DALL MILES GRIP TROCHANTERIC CABLE","SUP-ITM-10074801","CDM","C1713","HCPCS","0278","RC","","","","both","","","3647.00","2735.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1943.85","53.3","","813.12","216.42","1444.50","81","1130.57","2899.37","percent of total billed charges",""
"BONE PLATE 110MM LARGE HIP DALL MILES GRIP TROCHANTERIC CABLE","SUP-ITM-10074801","CDM","C1713","HCPCS","0278","RC","","","","both","","","3647.00","2735.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1130.57","31","","432.60","432.60","432.60","1 through 10","1130.57","2899.37","percent of total billed charges",""
"BONE PLATE 110MM LARGE HIP DALL MILES GRIP TROCHANTERIC CABLE","SUP-ITM-10074801","CDM","C1713","HCPCS","0278","RC","","","","both","","","3647.00","2735.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1331.16","36.5","","148.37","54.89","631.39","94","1130.57","2899.37","percent of total billed charges",""
"BONE PLATE 110MM LARGE HIP DALL MILES GRIP TROCHANTERIC CABLE","SUP-ITM-10074801","CDM","C1713","HCPCS","0278","RC","","","","both","","","3647.00","2735.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1396.80","38.3","","279.30","91.72","1116.77","266","1130.57","2899.37","percent of total billed charges",""
"BONE PLATE 110MM LARGE HIP DALL MILES GRIP TROCHANTERIC CABLE","SUP-ITM-10074801","CDM","C1713","HCPCS","0278","RC","","","","both","","","3647.00","2735.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1564.56","42.9","","731.00","63.70","731.00","1 through 10","1130.57","2899.37","percent of total billed charges",""
"BONE PLATE 110MM LARGE HIP DALL MILES GRIP TROCHANTERIC CABLE","SUP-ITM-10074801","CDM","C1713","HCPCS","0278","RC","","","","both","","","3647.00","2735.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1564.56","42.9","","384.74","384.74","384.74","1 through 10","1130.57","2899.37","percent of total billed charges",""
"BONE PLATE 110MM LARGE HIP DALL MILES GRIP TROCHANTERIC CABLE","SUP-ITM-10074801","CDM","C1713","HCPCS","0278","RC","","","","both","","","3647.00","2735.25","WELLPOINT [1015]","HB AMC WELLPOINT","2690.76","73.78","","286.63","119.22","1107.45","105","1130.57","2899.37","percent of total billed charges",""
"BONE PLATE 110MM LARGE HIP DALL MILES GRIP TROCHANTERIC CABLE","SUP-ITM-10074801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3647.00","2735.25","AETNA [1001]","HB AMC AETNA HMO","2545.61","69.8","","675.31","184.75","1721.50","286","1905.92","2980.33","percent of total billed charges",""
"BONE PLATE 110MM LARGE HIP DALL MILES GRIP TROCHANTERIC CABLE","SUP-ITM-10074801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3647.00","2735.25","AETNA [1001]","HB AMC AETNA PPO","2932.19","80.4","","1261.44","103.12","1514.10","21","1905.92","2980.33","percent of total billed charges",""
"BONE PLATE 110MM LARGE HIP DALL MILES GRIP TROCHANTERIC CABLE","SUP-ITM-10074801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3647.00","2735.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2932.19","80.4","","1365.00","1365.00","1365.00","1 through 10","1905.92","2980.33","percent of total billed charges",""
"BONE PLATE 110MM LARGE HIP DALL MILES GRIP TROCHANTERIC CABLE","SUP-ITM-10074801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3647.00","2735.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2980.33","81.72","","5157.68","5157.68","5157.68","1 through 10","1905.92","2980.33","percent of total billed charges",""
"BONE PLATE 110MM LARGE HIP DALL MILES GRIP TROCHANTERIC CABLE","SUP-ITM-10074801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3647.00","2735.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2980.33","81.72","","431.26","71.26","1459.57","88","1905.92","2980.33","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.96","2689.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2850.84","79.5","","800.18","480.96","1887.97","195","1111.65","2850.84","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.96","2689.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1911.32","53.3","","813.12","216.42","1444.50","81","1111.65","2850.84","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.96","2689.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1111.65","31","","432.60","432.60","432.60","1 through 10","1111.65","2850.84","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.96","2689.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1308.88","36.5","","148.37","54.89","631.39","94","1111.65","2850.84","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.96","2689.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1373.42","38.3","","279.30","91.72","1116.77","266","1111.65","2850.84","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.96","2689.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1538.38","42.9","","731.00","63.70","731.00","1 through 10","1111.65","2850.84","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.96","2689.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1538.38","42.9","","384.74","384.74","384.74","1 through 10","1111.65","2850.84","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.96","2689.47","WELLPOINT [1015]","HB AMC WELLPOINT","2645.72","73.78","","286.63","119.22","1107.45","105","1111.65","2850.84","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3585.96","2689.47","AETNA [1001]","HB AMC AETNA HMO","2503.00","69.8","","675.31","184.75","1721.50","286","1874.02","2930.45","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3585.96","2689.47","AETNA [1001]","HB AMC AETNA PPO","2883.11","80.4","","1261.44","103.12","1514.10","21","1874.02","2930.45","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3585.96","2689.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2883.11","80.4","","1365.00","1365.00","1365.00","1 through 10","1874.02","2930.45","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3585.96","2689.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2930.45","81.72","","5157.68","5157.68","5157.68","1 through 10","1874.02","2930.45","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3585.96","2689.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2930.45","81.72","","431.26","71.26","1459.57","88","1874.02","2930.45","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4571.45","3428.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3634.30","79.5","","800.18","480.96","1887.97","195","1417.15","3634.3","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4571.45","3428.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2436.58","53.3","","813.12","216.42","1444.50","81","1417.15","3634.3","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4571.45","3428.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1417.15","31","","432.60","432.60","432.60","1 through 10","1417.15","3634.3","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4571.45","3428.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1668.58","36.5","","148.37","54.89","631.39","94","1417.15","3634.3","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4571.45","3428.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1750.87","38.3","","279.30","91.72","1116.77","266","1417.15","3634.3","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4571.45","3428.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1961.15","42.9","","731.00","63.70","731.00","1 through 10","1417.15","3634.3","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4571.45","3428.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1961.15","42.9","","384.74","384.74","384.74","1 through 10","1417.15","3634.3","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4571.45","3428.59","WELLPOINT [1015]","HB AMC WELLPOINT","3372.82","73.78","","286.63","119.22","1107.45","105","1417.15","3634.3","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4571.45","3428.59","AETNA [1001]","HB AMC AETNA HMO","3190.87","69.8","","675.31","184.75","1721.50","286","2389.04","3735.79","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4571.45","3428.59","AETNA [1001]","HB AMC AETNA PPO","3675.45","80.4","","1261.44","103.12","1514.10","21","2389.04","3735.79","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4571.45","3428.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3675.45","80.4","","1365.00","1365.00","1365.00","1 through 10","2389.04","3735.79","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4571.45","3428.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3735.79","81.72","","5157.68","5157.68","5157.68","1 through 10","2389.04","3735.79","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4571.45","3428.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3735.79","81.72","","431.26","71.26","1459.57","88","2389.04","3735.79","percent of total billed charges",""
"BONE PLATE 12 HOLE STERNAL TI LOCKING ANGELD","SUP-ITM-10077181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3340.65","2505.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2655.82","79.5","","800.18","480.96","1887.97","195","1035.6","2655.82","percent of total billed charges",""
"BONE PLATE 12 HOLE STERNAL TI LOCKING ANGELD","SUP-ITM-10077181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3340.65","2505.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1780.57","53.3","","813.12","216.42","1444.50","81","1035.6","2655.82","percent of total billed charges",""
"BONE PLATE 12 HOLE STERNAL TI LOCKING ANGELD","SUP-ITM-10077181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3340.65","2505.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1035.60","31","","432.60","432.60","432.60","1 through 10","1035.6","2655.82","percent of total billed charges",""
"BONE PLATE 12 HOLE STERNAL TI LOCKING ANGELD","SUP-ITM-10077181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3340.65","2505.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1219.34","36.5","","148.37","54.89","631.39","94","1035.6","2655.82","percent of total billed charges",""
"BONE PLATE 12 HOLE STERNAL TI LOCKING ANGELD","SUP-ITM-10077181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3340.65","2505.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1279.47","38.3","","279.30","91.72","1116.77","266","1035.6","2655.82","percent of total billed charges",""
"BONE PLATE 12 HOLE STERNAL TI LOCKING ANGELD","SUP-ITM-10077181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3340.65","2505.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1433.14","42.9","","731.00","63.70","731.00","1 through 10","1035.6","2655.82","percent of total billed charges",""
"BONE PLATE 12 HOLE STERNAL TI LOCKING ANGELD","SUP-ITM-10077181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3340.65","2505.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1433.14","42.9","","384.74","384.74","384.74","1 through 10","1035.6","2655.82","percent of total billed charges",""
"BONE PLATE 12 HOLE STERNAL TI LOCKING ANGELD","SUP-ITM-10077181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3340.65","2505.49","WELLPOINT [1015]","HB AMC WELLPOINT","2464.73","73.78","","286.63","119.22","1107.45","105","1035.6","2655.82","percent of total billed charges",""
"BONE PLATE 12 HOLE STERNAL TI LOCKING ANGELD","SUP-ITM-10077181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3340.65","2505.49","AETNA [1001]","HB AMC AETNA HMO","2331.77","69.8","","675.31","184.75","1721.50","286","1745.82","2729.98","percent of total billed charges",""
"BONE PLATE 12 HOLE STERNAL TI LOCKING ANGELD","SUP-ITM-10077181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3340.65","2505.49","AETNA [1001]","HB AMC AETNA PPO","2685.88","80.4","","1261.44","103.12","1514.10","21","1745.82","2729.98","percent of total billed charges",""
"BONE PLATE 12 HOLE STERNAL TI LOCKING ANGELD","SUP-ITM-10077181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3340.65","2505.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2685.88","80.4","","1365.00","1365.00","1365.00","1 through 10","1745.82","2729.98","percent of total billed charges",""
"BONE PLATE 12 HOLE STERNAL TI LOCKING ANGELD","SUP-ITM-10077181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3340.65","2505.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2729.98","81.72","","5157.68","5157.68","5157.68","1 through 10","1745.82","2729.98","percent of total billed charges",""
"BONE PLATE 12 HOLE STERNAL TI LOCKING ANGELD","SUP-ITM-10077181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3340.65","2505.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2729.98","81.72","","431.26","71.26","1459.57","88","1745.82","2729.98","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1839.99","1379.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1462.79","79.5","","800.18","480.96","1887.97","195","570.4","1462.79","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1839.99","1379.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","980.71","53.3","","813.12","216.42","1444.50","81","570.4","1462.79","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1839.99","1379.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","570.40","31","","432.60","432.60","432.60","1 through 10","570.4","1462.79","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1839.99","1379.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","671.60","36.5","","148.37","54.89","631.39","94","570.4","1462.79","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1839.99","1379.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","704.72","38.3","","279.30","91.72","1116.77","266","570.4","1462.79","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1839.99","1379.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","789.36","42.9","","731.00","63.70","731.00","1 through 10","570.4","1462.79","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1839.99","1379.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","789.36","42.9","","384.74","384.74","384.74","1 through 10","570.4","1462.79","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1839.99","1379.99","WELLPOINT [1015]","HB AMC WELLPOINT","1357.54","73.78","","286.63","119.22","1107.45","105","570.4","1462.79","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1839.99","1379.99","AETNA [1001]","HB AMC AETNA HMO","1284.31","69.8","","675.31","184.75","1721.50","286","961.58","1503.64","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1839.99","1379.99","AETNA [1001]","HB AMC AETNA PPO","1479.35","80.4","","1261.44","103.12","1514.10","21","961.58","1503.64","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1839.99","1379.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1479.35","80.4","","1365.00","1365.00","1365.00","1 through 10","961.58","1503.64","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1839.99","1379.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1503.64","81.72","","5157.68","5157.68","5157.68","1 through 10","961.58","1503.64","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1839.99","1379.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1503.64","81.72","","431.26","71.26","1459.57","88","961.58","1503.64","percent of total billed charges",""
"BONE PLATE 124.6X3.5MM SMALL 9 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072309","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.98","527.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","558.87","79.5","","800.18","480.96","1887.97","195","217.92","558.87","percent of total billed charges",""
"BONE PLATE 124.6X3.5MM SMALL 9 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072309","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.98","527.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","374.69","53.3","","813.12","216.42","1444.50","81","217.92","558.87","percent of total billed charges",""
"BONE PLATE 124.6X3.5MM SMALL 9 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072309","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.98","527.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","217.92","31","","432.60","432.60","432.60","1 through 10","217.92","558.87","percent of total billed charges",""
"BONE PLATE 124.6X3.5MM SMALL 9 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072309","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.98","527.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","256.59","36.5","","148.37","54.89","631.39","94","217.92","558.87","percent of total billed charges",""
"BONE PLATE 124.6X3.5MM SMALL 9 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072309","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.98","527.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","269.24","38.3","","279.30","91.72","1116.77","266","217.92","558.87","percent of total billed charges",""
"BONE PLATE 124.6X3.5MM SMALL 9 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072309","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.98","527.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","301.58","42.9","","731.00","63.70","731.00","1 through 10","217.92","558.87","percent of total billed charges",""
"BONE PLATE 124.6X3.5MM SMALL 9 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072309","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.98","527.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","301.58","42.9","","384.74","384.74","384.74","1 through 10","217.92","558.87","percent of total billed charges",""
"BONE PLATE 124.6X3.5MM SMALL 9 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072309","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.98","527.23","WELLPOINT [1015]","HB AMC WELLPOINT","518.66","73.78","","286.63","119.22","1107.45","105","217.92","558.87","percent of total billed charges",""
"BONE PLATE 124.6X3.5MM SMALL 9 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.98","527.23","AETNA [1001]","HB AMC AETNA HMO","490.68","69.8","","675.31","184.75","1721.50","286","367.38","574.48","percent of total billed charges",""
"BONE PLATE 124.6X3.5MM SMALL 9 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.98","527.23","AETNA [1001]","HB AMC AETNA PPO","565.20","80.4","","1261.44","103.12","1514.10","21","367.38","574.48","percent of total billed charges",""
"BONE PLATE 124.6X3.5MM SMALL 9 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.98","527.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","565.20","80.4","","1365.00","1365.00","1365.00","1 through 10","367.38","574.48","percent of total billed charges",""
"BONE PLATE 124.6X3.5MM SMALL 9 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.98","527.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","574.48","81.72","","5157.68","5157.68","5157.68","1 through 10","367.38","574.48","percent of total billed charges",""
"BONE PLATE 124.6X3.5MM SMALL 9 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.98","527.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","574.48","81.72","","431.26","71.26","1459.57","88","367.38","574.48","percent of total billed charges",""
"BONE PLATE 125MM 7 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL RADIUS","SUP-ITM-10022653","CDM","C1713","HCPCS","0278","RC","","","","both","","","4480.39","3360.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3561.91","79.5","","800.18","480.96","1887.97","195","1388.92","3561.91","percent of total billed charges",""
"BONE PLATE 125MM 7 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL RADIUS","SUP-ITM-10022653","CDM","C1713","HCPCS","0278","RC","","","","both","","","4480.39","3360.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2388.05","53.3","","813.12","216.42","1444.50","81","1388.92","3561.91","percent of total billed charges",""
"BONE PLATE 125MM 7 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL RADIUS","SUP-ITM-10022653","CDM","C1713","HCPCS","0278","RC","","","","both","","","4480.39","3360.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1388.92","31","","432.60","432.60","432.60","1 through 10","1388.92","3561.91","percent of total billed charges",""
"BONE PLATE 125MM 7 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL RADIUS","SUP-ITM-10022653","CDM","C1713","HCPCS","0278","RC","","","","both","","","4480.39","3360.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1635.34","36.5","","148.37","54.89","631.39","94","1388.92","3561.91","percent of total billed charges",""
"BONE PLATE 125MM 7 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL RADIUS","SUP-ITM-10022653","CDM","C1713","HCPCS","0278","RC","","","","both","","","4480.39","3360.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1715.99","38.3","","279.30","91.72","1116.77","266","1388.92","3561.91","percent of total billed charges",""
"BONE PLATE 125MM 7 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL RADIUS","SUP-ITM-10022653","CDM","C1713","HCPCS","0278","RC","","","","both","","","4480.39","3360.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1922.09","42.9","","731.00","63.70","731.00","1 through 10","1388.92","3561.91","percent of total billed charges",""
"BONE PLATE 125MM 7 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL RADIUS","SUP-ITM-10022653","CDM","C1713","HCPCS","0278","RC","","","","both","","","4480.39","3360.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1922.09","42.9","","384.74","384.74","384.74","1 through 10","1388.92","3561.91","percent of total billed charges",""
"BONE PLATE 125MM 7 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL RADIUS","SUP-ITM-10022653","CDM","C1713","HCPCS","0278","RC","","","","both","","","4480.39","3360.29","WELLPOINT [1015]","HB AMC WELLPOINT","3305.63","73.78","","286.63","119.22","1107.45","105","1388.92","3561.91","percent of total billed charges",""
"BONE PLATE 125MM 7 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL RADIUS","SUP-ITM-10022653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4480.39","3360.29","AETNA [1001]","HB AMC AETNA HMO","3127.31","69.8","","675.31","184.75","1721.50","286","2341.45","3661.37","percent of total billed charges",""
"BONE PLATE 125MM 7 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL RADIUS","SUP-ITM-10022653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4480.39","3360.29","AETNA [1001]","HB AMC AETNA PPO","3602.23","80.4","","1261.44","103.12","1514.10","21","2341.45","3661.37","percent of total billed charges",""
"BONE PLATE 125MM 7 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL RADIUS","SUP-ITM-10022653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4480.39","3360.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3602.23","80.4","","1365.00","1365.00","1365.00","1 through 10","2341.45","3661.37","percent of total billed charges",""
"BONE PLATE 125MM 7 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL RADIUS","SUP-ITM-10022653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4480.39","3360.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3661.37","81.72","","5157.68","5157.68","5157.68","1 through 10","2341.45","3661.37","percent of total billed charges",""
"BONE PLATE 125MM 7 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL RADIUS","SUP-ITM-10022653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4480.39","3360.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3661.37","81.72","","431.26","71.26","1459.57","88","2341.45","3661.37","percent of total billed charges",""
"BONE PLATE 12MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140298","CDM","C1713","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4006.80","79.5","","800.18","480.96","1887.97","195","1562.4","4006.8","percent of total billed charges",""
"BONE PLATE 12MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140298","CDM","C1713","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2686.32","53.3","","813.12","216.42","1444.50","81","1562.4","4006.8","percent of total billed charges",""
"BONE PLATE 12MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140298","CDM","C1713","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1562.40","31","","432.60","432.60","432.60","1 through 10","1562.4","4006.8","percent of total billed charges",""
"BONE PLATE 12MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140298","CDM","C1713","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1839.60","36.5","","148.37","54.89","631.39","94","1562.4","4006.8","percent of total billed charges",""
"BONE PLATE 12MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140298","CDM","C1713","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1930.32","38.3","","279.30","91.72","1116.77","266","1562.4","4006.8","percent of total billed charges",""
"BONE PLATE 12MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140298","CDM","C1713","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2162.16","42.9","","731.00","63.70","731.00","1 through 10","1562.4","4006.8","percent of total billed charges",""
"BONE PLATE 12MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140298","CDM","C1713","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2162.16","42.9","","384.74","384.74","384.74","1 through 10","1562.4","4006.8","percent of total billed charges",""
"BONE PLATE 12MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140298","CDM","C1713","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","WELLPOINT [1015]","HB AMC WELLPOINT","3718.51","73.78","","286.63","119.22","1107.45","105","1562.4","4006.8","percent of total billed charges",""
"BONE PLATE 12MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5040.00","3780.00","AETNA [1001]","HB AMC AETNA HMO","3517.92","69.8","","675.31","184.75","1721.50","286","2633.9","4118.69","percent of total billed charges",""
"BONE PLATE 12MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5040.00","3780.00","AETNA [1001]","HB AMC AETNA PPO","4052.16","80.4","","1261.44","103.12","1514.10","21","2633.9","4118.69","percent of total billed charges",""
"BONE PLATE 12MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5040.00","3780.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4052.16","80.4","","1365.00","1365.00","1365.00","1 through 10","2633.9","4118.69","percent of total billed charges",""
"BONE PLATE 12MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5040.00","3780.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4118.69","81.72","","5157.68","5157.68","5157.68","1 through 10","2633.9","4118.69","percent of total billed charges",""
"BONE PLATE 12MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5040.00","3780.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4118.69","81.72","","431.26","71.26","1459.57","88","2633.9","4118.69","percent of total billed charges",""
"BONE PLATE 13 HOLE STERNAL TI LOCKING STRAIGHT NONPIN","SUP-ITM-10077449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.18","1851.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1963.00","79.5","","800.18","480.96","1887.97","195","765.45","1963","percent of total billed charges",""
"BONE PLATE 13 HOLE STERNAL TI LOCKING STRAIGHT NONPIN","SUP-ITM-10077449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.18","1851.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1316.07","53.3","","813.12","216.42","1444.50","81","765.45","1963","percent of total billed charges",""
"BONE PLATE 13 HOLE STERNAL TI LOCKING STRAIGHT NONPIN","SUP-ITM-10077449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.18","1851.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","765.45","31","","432.60","432.60","432.60","1 through 10","765.45","1963","percent of total billed charges",""
"BONE PLATE 13 HOLE STERNAL TI LOCKING STRAIGHT NONPIN","SUP-ITM-10077449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.18","1851.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","901.25","36.5","","148.37","54.89","631.39","94","765.45","1963","percent of total billed charges",""
"BONE PLATE 13 HOLE STERNAL TI LOCKING STRAIGHT NONPIN","SUP-ITM-10077449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.18","1851.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","945.70","38.3","","279.30","91.72","1116.77","266","765.45","1963","percent of total billed charges",""
"BONE PLATE 13 HOLE STERNAL TI LOCKING STRAIGHT NONPIN","SUP-ITM-10077449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.18","1851.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1059.28","42.9","","731.00","63.70","731.00","1 through 10","765.45","1963","percent of total billed charges",""
"BONE PLATE 13 HOLE STERNAL TI LOCKING STRAIGHT NONPIN","SUP-ITM-10077449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.18","1851.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1059.28","42.9","","384.74","384.74","384.74","1 through 10","765.45","1963","percent of total billed charges",""
"BONE PLATE 13 HOLE STERNAL TI LOCKING STRAIGHT NONPIN","SUP-ITM-10077449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.18","1851.88","WELLPOINT [1015]","HB AMC WELLPOINT","1821.76","73.78","","286.63","119.22","1107.45","105","765.45","1963","percent of total billed charges",""
"BONE PLATE 13 HOLE STERNAL TI LOCKING STRAIGHT NONPIN","SUP-ITM-10077449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2469.18","1851.88","AETNA [1001]","HB AMC AETNA HMO","1723.49","69.8","","675.31","184.75","1721.50","286","1290.39","2017.81","percent of total billed charges",""
"BONE PLATE 13 HOLE STERNAL TI LOCKING STRAIGHT NONPIN","SUP-ITM-10077449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2469.18","1851.88","AETNA [1001]","HB AMC AETNA PPO","1985.22","80.4","","1261.44","103.12","1514.10","21","1290.39","2017.81","percent of total billed charges",""
"BONE PLATE 13 HOLE STERNAL TI LOCKING STRAIGHT NONPIN","SUP-ITM-10077449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2469.18","1851.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1985.22","80.4","","1365.00","1365.00","1365.00","1 through 10","1290.39","2017.81","percent of total billed charges",""
"BONE PLATE 13 HOLE STERNAL TI LOCKING STRAIGHT NONPIN","SUP-ITM-10077449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2469.18","1851.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2017.81","81.72","","5157.68","5157.68","5157.68","1 through 10","1290.39","2017.81","percent of total billed charges",""
"BONE PLATE 13 HOLE STERNAL TI LOCKING STRAIGHT NONPIN","SUP-ITM-10077449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2469.18","1851.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2017.81","81.72","","431.26","71.26","1459.57","88","1290.39","2017.81","percent of total billed charges",""
"BONE PLATE 131MM MD 15 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4389.00","3291.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3489.26","79.5","","800.18","480.96","1887.97","195","1360.59","3489.26","percent of total billed charges",""
"BONE PLATE 131MM MD 15 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4389.00","3291.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2339.34","53.3","","813.12","216.42","1444.50","81","1360.59","3489.26","percent of total billed charges",""
"BONE PLATE 131MM MD 15 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4389.00","3291.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1360.59","31","","432.60","432.60","432.60","1 through 10","1360.59","3489.26","percent of total billed charges",""
"BONE PLATE 131MM MD 15 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4389.00","3291.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1601.99","36.5","","148.37","54.89","631.39","94","1360.59","3489.26","percent of total billed charges",""
"BONE PLATE 131MM MD 15 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4389.00","3291.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1680.99","38.3","","279.30","91.72","1116.77","266","1360.59","3489.26","percent of total billed charges",""
"BONE PLATE 131MM MD 15 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4389.00","3291.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1882.88","42.9","","731.00","63.70","731.00","1 through 10","1360.59","3489.26","percent of total billed charges",""
"BONE PLATE 131MM MD 15 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4389.00","3291.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1882.88","42.9","","384.74","384.74","384.74","1 through 10","1360.59","3489.26","percent of total billed charges",""
"BONE PLATE 131MM MD 15 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4389.00","3291.75","WELLPOINT [1015]","HB AMC WELLPOINT","3238.20","73.78","","286.63","119.22","1107.45","105","1360.59","3489.26","percent of total billed charges",""
"BONE PLATE 131MM MD 15 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4389.00","3291.75","AETNA [1001]","HB AMC AETNA HMO","3063.52","69.8","","675.31","184.75","1721.50","286","2293.69","3586.69","percent of total billed charges",""
"BONE PLATE 131MM MD 15 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4389.00","3291.75","AETNA [1001]","HB AMC AETNA PPO","3528.76","80.4","","1261.44","103.12","1514.10","21","2293.69","3586.69","percent of total billed charges",""
"BONE PLATE 131MM MD 15 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4389.00","3291.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3528.76","80.4","","1365.00","1365.00","1365.00","1 through 10","2293.69","3586.69","percent of total billed charges",""
"BONE PLATE 131MM MD 15 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4389.00","3291.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3586.69","81.72","","5157.68","5157.68","5157.68","1 through 10","2293.69","3586.69","percent of total billed charges",""
"BONE PLATE 131MM MD 15 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4389.00","3291.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3586.69","81.72","","431.26","71.26","1459.57","88","2293.69","3586.69","percent of total billed charges",""
"BONE PLATE 139MM VARIAX COMPRESSION 11 HOLE BROAD","SUP-ITM-10144780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4264.19","3198.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3390.03","79.5","","800.18","480.96","1887.97","195","1321.9","3390.03","percent of total billed charges",""
"BONE PLATE 139MM VARIAX COMPRESSION 11 HOLE BROAD","SUP-ITM-10144780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4264.19","3198.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2272.81","53.3","","813.12","216.42","1444.50","81","1321.9","3390.03","percent of total billed charges",""
"BONE PLATE 139MM VARIAX COMPRESSION 11 HOLE BROAD","SUP-ITM-10144780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4264.19","3198.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1321.90","31","","432.60","432.60","432.60","1 through 10","1321.9","3390.03","percent of total billed charges",""
"BONE PLATE 139MM VARIAX COMPRESSION 11 HOLE BROAD","SUP-ITM-10144780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4264.19","3198.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1556.43","36.5","","148.37","54.89","631.39","94","1321.9","3390.03","percent of total billed charges",""
"BONE PLATE 139MM VARIAX COMPRESSION 11 HOLE BROAD","SUP-ITM-10144780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4264.19","3198.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1633.18","38.3","","279.30","91.72","1116.77","266","1321.9","3390.03","percent of total billed charges",""
"BONE PLATE 139MM VARIAX COMPRESSION 11 HOLE BROAD","SUP-ITM-10144780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4264.19","3198.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1829.34","42.9","","731.00","63.70","731.00","1 through 10","1321.9","3390.03","percent of total billed charges",""
"BONE PLATE 139MM VARIAX COMPRESSION 11 HOLE BROAD","SUP-ITM-10144780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4264.19","3198.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1829.34","42.9","","384.74","384.74","384.74","1 through 10","1321.9","3390.03","percent of total billed charges",""
"BONE PLATE 139MM VARIAX COMPRESSION 11 HOLE BROAD","SUP-ITM-10144780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4264.19","3198.14","WELLPOINT [1015]","HB AMC WELLPOINT","3146.12","73.78","","286.63","119.22","1107.45","105","1321.9","3390.03","percent of total billed charges",""
"BONE PLATE 139MM VARIAX COMPRESSION 11 HOLE BROAD","SUP-ITM-10144780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4264.19","3198.14","AETNA [1001]","HB AMC AETNA HMO","2976.40","69.8","","675.31","184.75","1721.50","286","2228.47","3484.7","percent of total billed charges",""
"BONE PLATE 139MM VARIAX COMPRESSION 11 HOLE BROAD","SUP-ITM-10144780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4264.19","3198.14","AETNA [1001]","HB AMC AETNA PPO","3428.41","80.4","","1261.44","103.12","1514.10","21","2228.47","3484.7","percent of total billed charges",""
"BONE PLATE 139MM VARIAX COMPRESSION 11 HOLE BROAD","SUP-ITM-10144780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4264.19","3198.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3428.41","80.4","","1365.00","1365.00","1365.00","1 through 10","2228.47","3484.7","percent of total billed charges",""
"BONE PLATE 139MM VARIAX COMPRESSION 11 HOLE BROAD","SUP-ITM-10144780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4264.19","3198.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3484.70","81.72","","5157.68","5157.68","5157.68","1 through 10","2228.47","3484.7","percent of total billed charges",""
"BONE PLATE 139MM VARIAX COMPRESSION 11 HOLE BROAD","SUP-ITM-10144780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4264.19","3198.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3484.70","81.72","","431.26","71.26","1459.57","88","2228.47","3484.7","percent of total billed charges",""
"BONE PLATE 140MM 7 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306450","CDM","C1713","HCPCS","0278","RC","","","","both","","","6777.35","5083.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5387.99","79.5","","800.18","480.96","1887.97","195","2100.98","5387.99","percent of total billed charges",""
"BONE PLATE 140MM 7 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306450","CDM","C1713","HCPCS","0278","RC","","","","both","","","6777.35","5083.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3612.33","53.3","","813.12","216.42","1444.50","81","2100.98","5387.99","percent of total billed charges",""
"BONE PLATE 140MM 7 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306450","CDM","C1713","HCPCS","0278","RC","","","","both","","","6777.35","5083.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2100.98","31","","432.60","432.60","432.60","1 through 10","2100.98","5387.99","percent of total billed charges",""
"BONE PLATE 140MM 7 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306450","CDM","C1713","HCPCS","0278","RC","","","","both","","","6777.35","5083.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2473.73","36.5","","148.37","54.89","631.39","94","2100.98","5387.99","percent of total billed charges",""
"BONE PLATE 140MM 7 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306450","CDM","C1713","HCPCS","0278","RC","","","","both","","","6777.35","5083.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2595.73","38.3","","279.30","91.72","1116.77","266","2100.98","5387.99","percent of total billed charges",""
"BONE PLATE 140MM 7 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306450","CDM","C1713","HCPCS","0278","RC","","","","both","","","6777.35","5083.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2907.48","42.9","","731.00","63.70","731.00","1 through 10","2100.98","5387.99","percent of total billed charges",""
"BONE PLATE 140MM 7 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306450","CDM","C1713","HCPCS","0278","RC","","","","both","","","6777.35","5083.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2907.48","42.9","","384.74","384.74","384.74","1 through 10","2100.98","5387.99","percent of total billed charges",""
"BONE PLATE 140MM 7 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306450","CDM","C1713","HCPCS","0278","RC","","","","both","","","6777.35","5083.01","WELLPOINT [1015]","HB AMC WELLPOINT","5000.33","73.78","","286.63","119.22","1107.45","105","2100.98","5387.99","percent of total billed charges",""
"BONE PLATE 140MM 7 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6777.35","5083.01","AETNA [1001]","HB AMC AETNA HMO","4730.59","69.8","","675.31","184.75","1721.50","286","3541.84","5538.45","percent of total billed charges",""
"BONE PLATE 140MM 7 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6777.35","5083.01","AETNA [1001]","HB AMC AETNA PPO","5448.99","80.4","","1261.44","103.12","1514.10","21","3541.84","5538.45","percent of total billed charges",""
"BONE PLATE 140MM 7 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6777.35","5083.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5448.99","80.4","","1365.00","1365.00","1365.00","1 through 10","3541.84","5538.45","percent of total billed charges",""
"BONE PLATE 140MM 7 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6777.35","5083.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5538.45","81.72","","5157.68","5157.68","5157.68","1 through 10","3541.84","5538.45","percent of total billed charges",""
"BONE PLATE 140MM 7 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6777.35","5083.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5538.45","81.72","","431.26","71.26","1459.57","88","3541.84","5538.45","percent of total billed charges",""
"BONE PLATE 142MM 8 HOLE 135DEG COMPRESSION DHS SS STANDARD BARREL","SUP-ITM-10097901","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1755.34","79.5","","800.18","480.96","1887.97","195","684.47","1755.34","percent of total billed charges",""
"BONE PLATE 142MM 8 HOLE 135DEG COMPRESSION DHS SS STANDARD BARREL","SUP-ITM-10097901","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1176.85","53.3","","813.12","216.42","1444.50","81","684.47","1755.34","percent of total billed charges",""
"BONE PLATE 142MM 8 HOLE 135DEG COMPRESSION DHS SS STANDARD BARREL","SUP-ITM-10097901","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","684.47","31","","432.60","432.60","432.60","1 through 10","684.47","1755.34","percent of total billed charges",""
"BONE PLATE 142MM 8 HOLE 135DEG COMPRESSION DHS SS STANDARD BARREL","SUP-ITM-10097901","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","805.91","36.5","","148.37","54.89","631.39","94","684.47","1755.34","percent of total billed charges",""
"BONE PLATE 142MM 8 HOLE 135DEG COMPRESSION DHS SS STANDARD BARREL","SUP-ITM-10097901","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","845.66","38.3","","279.30","91.72","1116.77","266","684.47","1755.34","percent of total billed charges",""
"BONE PLATE 142MM 8 HOLE 135DEG COMPRESSION DHS SS STANDARD BARREL","SUP-ITM-10097901","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","947.22","42.9","","731.00","63.70","731.00","1 through 10","684.47","1755.34","percent of total billed charges",""
"BONE PLATE 142MM 8 HOLE 135DEG COMPRESSION DHS SS STANDARD BARREL","SUP-ITM-10097901","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","947.22","42.9","","384.74","384.74","384.74","1 through 10","684.47","1755.34","percent of total billed charges",""
"BONE PLATE 142MM 8 HOLE 135DEG COMPRESSION DHS SS STANDARD BARREL","SUP-ITM-10097901","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","WELLPOINT [1015]","HB AMC WELLPOINT","1629.05","73.78","","286.63","119.22","1107.45","105","684.47","1755.34","percent of total billed charges",""
"BONE PLATE 142MM 8 HOLE 135DEG COMPRESSION DHS SS STANDARD BARREL","SUP-ITM-10097901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.98","1655.98","AETNA [1001]","HB AMC AETNA HMO","1541.17","69.8","","675.31","184.75","1721.50","286","1153.89","1804.36","percent of total billed charges",""
"BONE PLATE 142MM 8 HOLE 135DEG COMPRESSION DHS SS STANDARD BARREL","SUP-ITM-10097901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.98","1655.98","AETNA [1001]","HB AMC AETNA PPO","1775.22","80.4","","1261.44","103.12","1514.10","21","1153.89","1804.36","percent of total billed charges",""
"BONE PLATE 142MM 8 HOLE 135DEG COMPRESSION DHS SS STANDARD BARREL","SUP-ITM-10097901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.98","1655.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1775.22","80.4","","1365.00","1365.00","1365.00","1 through 10","1153.89","1804.36","percent of total billed charges",""
"BONE PLATE 142MM 8 HOLE 135DEG COMPRESSION DHS SS STANDARD BARREL","SUP-ITM-10097901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.98","1655.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1804.36","81.72","","5157.68","5157.68","5157.68","1 through 10","1153.89","1804.36","percent of total billed charges",""
"BONE PLATE 142MM 8 HOLE 135DEG COMPRESSION DHS SS STANDARD BARREL","SUP-ITM-10097901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.98","1655.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1804.36","81.72","","431.26","71.26","1459.57","88","1153.89","1804.36","percent of total billed charges",""
"BONE PLATE 14X0.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076545","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","288.69","79.5","","800.18","480.96","1887.97","195","112.57","288.69","percent of total billed charges",""
"BONE PLATE 14X0.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076545","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","193.55","53.3","","813.12","216.42","1444.50","81","112.57","288.69","percent of total billed charges",""
"BONE PLATE 14X0.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076545","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","112.57","31","","432.60","432.60","432.60","1 through 10","112.57","288.69","percent of total billed charges",""
"BONE PLATE 14X0.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076545","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","132.54","36.5","","148.37","54.89","631.39","94","112.57","288.69","percent of total billed charges",""
"BONE PLATE 14X0.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076545","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","139.08","38.3","","279.30","91.72","1116.77","266","112.57","288.69","percent of total billed charges",""
"BONE PLATE 14X0.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076545","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.78","42.9","","731.00","63.70","731.00","1 through 10","112.57","288.69","percent of total billed charges",""
"BONE PLATE 14X0.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076545","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.78","42.9","","384.74","384.74","384.74","1 through 10","112.57","288.69","percent of total billed charges",""
"BONE PLATE 14X0.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076545","CDM","C1713","HCPCS","0278","RC","","","","both","","","363.13","272.35","WELLPOINT [1015]","HB AMC WELLPOINT","267.92","73.78","","286.63","119.22","1107.45","105","112.57","288.69","percent of total billed charges",""
"BONE PLATE 14X0.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.13","272.35","AETNA [1001]","HB AMC AETNA HMO","253.46","69.8","","675.31","184.75","1721.50","286","189.77","296.75","percent of total billed charges",""
"BONE PLATE 14X0.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.13","272.35","AETNA [1001]","HB AMC AETNA PPO","291.96","80.4","","1261.44","103.12","1514.10","21","189.77","296.75","percent of total billed charges",""
"BONE PLATE 14X0.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.13","272.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","291.96","80.4","","1365.00","1365.00","1365.00","1 through 10","189.77","296.75","percent of total billed charges",""
"BONE PLATE 14X0.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.13","272.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","296.75","81.72","","5157.68","5157.68","5157.68","1 through 10","189.77","296.75","percent of total billed charges",""
"BONE PLATE 14X0.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","363.13","272.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","296.75","81.72","","431.26","71.26","1459.57","88","189.77","296.75","percent of total billed charges",""
"BONE PLATE 163MM LONG UNIVERSAL 19 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3927.00","2945.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3121.97","79.5","","800.18","480.96","1887.97","195","1217.37","3121.97","percent of total billed charges",""
"BONE PLATE 163MM LONG UNIVERSAL 19 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3927.00","2945.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2093.09","53.3","","813.12","216.42","1444.50","81","1217.37","3121.97","percent of total billed charges",""
"BONE PLATE 163MM LONG UNIVERSAL 19 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3927.00","2945.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1217.37","31","","432.60","432.60","432.60","1 through 10","1217.37","3121.97","percent of total billed charges",""
"BONE PLATE 163MM LONG UNIVERSAL 19 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3927.00","2945.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1433.36","36.5","","148.37","54.89","631.39","94","1217.37","3121.97","percent of total billed charges",""
"BONE PLATE 163MM LONG UNIVERSAL 19 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3927.00","2945.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1504.04","38.3","","279.30","91.72","1116.77","266","1217.37","3121.97","percent of total billed charges",""
"BONE PLATE 163MM LONG UNIVERSAL 19 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3927.00","2945.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1684.68","42.9","","731.00","63.70","731.00","1 through 10","1217.37","3121.97","percent of total billed charges",""
"BONE PLATE 163MM LONG UNIVERSAL 19 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3927.00","2945.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1684.68","42.9","","384.74","384.74","384.74","1 through 10","1217.37","3121.97","percent of total billed charges",""
"BONE PLATE 163MM LONG UNIVERSAL 19 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3927.00","2945.25","WELLPOINT [1015]","HB AMC WELLPOINT","2897.34","73.78","","286.63","119.22","1107.45","105","1217.37","3121.97","percent of total billed charges",""
"BONE PLATE 163MM LONG UNIVERSAL 19 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3927.00","2945.25","AETNA [1001]","HB AMC AETNA HMO","2741.05","69.8","","675.31","184.75","1721.50","286","2052.25","3209.14","percent of total billed charges",""
"BONE PLATE 163MM LONG UNIVERSAL 19 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3927.00","2945.25","AETNA [1001]","HB AMC AETNA PPO","3157.31","80.4","","1261.44","103.12","1514.10","21","2052.25","3209.14","percent of total billed charges",""
"BONE PLATE 163MM LONG UNIVERSAL 19 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3927.00","2945.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3157.31","80.4","","1365.00","1365.00","1365.00","1 through 10","2052.25","3209.14","percent of total billed charges",""
"BONE PLATE 163MM LONG UNIVERSAL 19 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3927.00","2945.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3209.14","81.72","","5157.68","5157.68","5157.68","1 through 10","2052.25","3209.14","percent of total billed charges",""
"BONE PLATE 163MM LONG UNIVERSAL 19 HOLE TRAUMA MEDIAL RT LT EPS","SUP-ITM-10047655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3927.00","2945.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3209.14","81.72","","431.26","71.26","1459.57","88","2052.25","3209.14","percent of total billed charges",""
"BONE PLATE 167MM 1/3 TUBULAR 14 HOLE 626684","SUP-ITM-10185790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.57","2371.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2514.24","79.5","","800.18","480.96","1887.97","195","980.4","2514.24","percent of total billed charges",""
"BONE PLATE 167MM 1/3 TUBULAR 14 HOLE 626684","SUP-ITM-10185790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.57","2371.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1685.65","53.3","","813.12","216.42","1444.50","81","980.4","2514.24","percent of total billed charges",""
"BONE PLATE 167MM 1/3 TUBULAR 14 HOLE 626684","SUP-ITM-10185790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.57","2371.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","980.40","31","","432.60","432.60","432.60","1 through 10","980.4","2514.24","percent of total billed charges",""
"BONE PLATE 167MM 1/3 TUBULAR 14 HOLE 626684","SUP-ITM-10185790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.57","2371.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1154.34","36.5","","148.37","54.89","631.39","94","980.4","2514.24","percent of total billed charges",""
"BONE PLATE 167MM 1/3 TUBULAR 14 HOLE 626684","SUP-ITM-10185790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.57","2371.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1211.26","38.3","","279.30","91.72","1116.77","266","980.4","2514.24","percent of total billed charges",""
"BONE PLATE 167MM 1/3 TUBULAR 14 HOLE 626684","SUP-ITM-10185790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.57","2371.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1356.74","42.9","","731.00","63.70","731.00","1 through 10","980.4","2514.24","percent of total billed charges",""
"BONE PLATE 167MM 1/3 TUBULAR 14 HOLE 626684","SUP-ITM-10185790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.57","2371.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1356.74","42.9","","384.74","384.74","384.74","1 through 10","980.4","2514.24","percent of total billed charges",""
"BONE PLATE 167MM 1/3 TUBULAR 14 HOLE 626684","SUP-ITM-10185790","CDM","C1713","HCPCS","0278","RC","","","","both","","","3162.57","2371.93","WELLPOINT [1015]","HB AMC WELLPOINT","2333.34","73.78","","286.63","119.22","1107.45","105","980.4","2514.24","percent of total billed charges",""
"BONE PLATE 167MM 1/3 TUBULAR 14 HOLE 626684","SUP-ITM-10185790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3162.57","2371.93","AETNA [1001]","HB AMC AETNA HMO","2207.47","69.8","","675.31","184.75","1721.50","286","1652.76","2584.45","percent of total billed charges",""
"BONE PLATE 167MM 1/3 TUBULAR 14 HOLE 626684","SUP-ITM-10185790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3162.57","2371.93","AETNA [1001]","HB AMC AETNA PPO","2542.71","80.4","","1261.44","103.12","1514.10","21","1652.76","2584.45","percent of total billed charges",""
"BONE PLATE 167MM 1/3 TUBULAR 14 HOLE 626684","SUP-ITM-10185790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3162.57","2371.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2542.71","80.4","","1365.00","1365.00","1365.00","1 through 10","1652.76","2584.45","percent of total billed charges",""
"BONE PLATE 167MM 1/3 TUBULAR 14 HOLE 626684","SUP-ITM-10185790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3162.57","2371.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2584.45","81.72","","5157.68","5157.68","5157.68","1 through 10","1652.76","2584.45","percent of total billed charges",""
"BONE PLATE 167MM 1/3 TUBULAR 14 HOLE 626684","SUP-ITM-10185790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3162.57","2371.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2584.45","81.72","","431.26","71.26","1459.57","88","1652.76","2584.45","percent of total billed charges",""
"BONE PLATE 16X.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076546","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","468.83","79.5","","800.18","480.96","1887.97","195","182.81","468.83","percent of total billed charges",""
"BONE PLATE 16X.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076546","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","314.32","53.3","","813.12","216.42","1444.50","81","182.81","468.83","percent of total billed charges",""
"BONE PLATE 16X.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076546","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","182.81","31","","432.60","432.60","432.60","1 through 10","182.81","468.83","percent of total billed charges",""
"BONE PLATE 16X.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076546","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","215.25","36.5","","148.37","54.89","631.39","94","182.81","468.83","percent of total billed charges",""
"BONE PLATE 16X.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076546","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","225.86","38.3","","279.30","91.72","1116.77","266","182.81","468.83","percent of total billed charges",""
"BONE PLATE 16X.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076546","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","252.99","42.9","","731.00","63.70","731.00","1 through 10","182.81","468.83","percent of total billed charges",""
"BONE PLATE 16X.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076546","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","252.99","42.9","","384.74","384.74","384.74","1 through 10","182.81","468.83","percent of total billed charges",""
"BONE PLATE 16X.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076546","CDM","C1713","HCPCS","0278","RC","","","","both","","","589.72","442.29","WELLPOINT [1015]","HB AMC WELLPOINT","435.10","73.78","","286.63","119.22","1107.45","105","182.81","468.83","percent of total billed charges",""
"BONE PLATE 16X.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076546","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","589.72","442.29","AETNA [1001]","HB AMC AETNA HMO","411.62","69.8","","675.31","184.75","1721.50","286","308.19","481.92","percent of total billed charges",""
"BONE PLATE 16X.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076546","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","589.72","442.29","AETNA [1001]","HB AMC AETNA PPO","474.13","80.4","","1261.44","103.12","1514.10","21","308.19","481.92","percent of total billed charges",""
"BONE PLATE 16X.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076546","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","589.72","442.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","474.13","80.4","","1365.00","1365.00","1365.00","1 through 10","308.19","481.92","percent of total billed charges",""
"BONE PLATE 16X.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076546","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","589.72","442.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","481.92","81.72","","5157.68","5157.68","5157.68","1 through 10","308.19","481.92","percent of total billed charges",""
"BONE PLATE 16X.4MM CRANIAL MATRIXNEURO TI SHAPE RIGID","SUP-ITM-10076546","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","589.72","442.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","481.92","81.72","","431.26","71.26","1459.57","88","308.19","481.92","percent of total billed charges",""
"BONE PLATE 178MM SHORT 10 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004202","CDM","C1713","HCPCS","0278","RC","","","","both","","","2613.31","1959.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2077.58","79.5","","800.18","480.96","1887.97","195","810.13","2077.58","percent of total billed charges",""
"BONE PLATE 178MM SHORT 10 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004202","CDM","C1713","HCPCS","0278","RC","","","","both","","","2613.31","1959.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1392.89","53.3","","813.12","216.42","1444.50","81","810.13","2077.58","percent of total billed charges",""
"BONE PLATE 178MM SHORT 10 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004202","CDM","C1713","HCPCS","0278","RC","","","","both","","","2613.31","1959.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","810.13","31","","432.60","432.60","432.60","1 through 10","810.13","2077.58","percent of total billed charges",""
"BONE PLATE 178MM SHORT 10 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004202","CDM","C1713","HCPCS","0278","RC","","","","both","","","2613.31","1959.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","953.86","36.5","","148.37","54.89","631.39","94","810.13","2077.58","percent of total billed charges",""
"BONE PLATE 178MM SHORT 10 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004202","CDM","C1713","HCPCS","0278","RC","","","","both","","","2613.31","1959.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1000.90","38.3","","279.30","91.72","1116.77","266","810.13","2077.58","percent of total billed charges",""
"BONE PLATE 178MM SHORT 10 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004202","CDM","C1713","HCPCS","0278","RC","","","","both","","","2613.31","1959.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1121.11","42.9","","731.00","63.70","731.00","1 through 10","810.13","2077.58","percent of total billed charges",""
"BONE PLATE 178MM SHORT 10 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004202","CDM","C1713","HCPCS","0278","RC","","","","both","","","2613.31","1959.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1121.11","42.9","","384.74","384.74","384.74","1 through 10","810.13","2077.58","percent of total billed charges",""
"BONE PLATE 178MM SHORT 10 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004202","CDM","C1713","HCPCS","0278","RC","","","","both","","","2613.31","1959.98","WELLPOINT [1015]","HB AMC WELLPOINT","1928.10","73.78","","286.63","119.22","1107.45","105","810.13","2077.58","percent of total billed charges",""
"BONE PLATE 178MM SHORT 10 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2613.31","1959.98","AETNA [1001]","HB AMC AETNA HMO","1824.09","69.8","","675.31","184.75","1721.50","286","1365.72","2135.6","percent of total billed charges",""
"BONE PLATE 178MM SHORT 10 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2613.31","1959.98","AETNA [1001]","HB AMC AETNA PPO","2101.10","80.4","","1261.44","103.12","1514.10","21","1365.72","2135.6","percent of total billed charges",""
"BONE PLATE 178MM SHORT 10 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2613.31","1959.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2101.10","80.4","","1365.00","1365.00","1365.00","1 through 10","1365.72","2135.6","percent of total billed charges",""
"BONE PLATE 178MM SHORT 10 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2613.31","1959.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2135.60","81.72","","5157.68","5157.68","5157.68","1 through 10","1365.72","2135.6","percent of total billed charges",""
"BONE PLATE 178MM SHORT 10 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2613.31","1959.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2135.60","81.72","","431.26","71.26","1459.57","88","1365.72","2135.6","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4998.93","3749.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3974.15","79.5","","800.18","480.96","1887.97","195","1549.67","3974.15","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4998.93","3749.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2664.43","53.3","","813.12","216.42","1444.50","81","1549.67","3974.15","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4998.93","3749.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1549.67","31","","432.60","432.60","432.60","1 through 10","1549.67","3974.15","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4998.93","3749.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1824.61","36.5","","148.37","54.89","631.39","94","1549.67","3974.15","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4998.93","3749.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1914.59","38.3","","279.30","91.72","1116.77","266","1549.67","3974.15","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4998.93","3749.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2144.54","42.9","","731.00","63.70","731.00","1 through 10","1549.67","3974.15","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4998.93","3749.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2144.54","42.9","","384.74","384.74","384.74","1 through 10","1549.67","3974.15","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4998.93","3749.20","WELLPOINT [1015]","HB AMC WELLPOINT","3688.21","73.78","","286.63","119.22","1107.45","105","1549.67","3974.15","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4998.93","3749.20","AETNA [1001]","HB AMC AETNA HMO","3489.25","69.8","","675.31","184.75","1721.50","286","2612.44","4085.13","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4998.93","3749.20","AETNA [1001]","HB AMC AETNA PPO","4019.14","80.4","","1261.44","103.12","1514.10","21","2612.44","4085.13","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4998.93","3749.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4019.14","80.4","","1365.00","1365.00","1365.00","1 through 10","2612.44","4085.13","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4998.93","3749.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4085.13","81.72","","5157.68","5157.68","5157.68","1 through 10","2612.44","4085.13","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4998.93","3749.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4085.13","81.72","","431.26","71.26","1459.57","88","2612.44","4085.13","percent of total billed charges",""
"BONE PLATE 184MM 11 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10027819","CDM","C1713","HCPCS","0278","RC","","","","both","","","4170.57","3127.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3315.60","79.5","","800.18","480.96","1887.97","195","1292.88","3315.6","percent of total billed charges",""
"BONE PLATE 184MM 11 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10027819","CDM","C1713","HCPCS","0278","RC","","","","both","","","4170.57","3127.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2222.91","53.3","","813.12","216.42","1444.50","81","1292.88","3315.6","percent of total billed charges",""
"BONE PLATE 184MM 11 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10027819","CDM","C1713","HCPCS","0278","RC","","","","both","","","4170.57","3127.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1292.88","31","","432.60","432.60","432.60","1 through 10","1292.88","3315.6","percent of total billed charges",""
"BONE PLATE 184MM 11 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10027819","CDM","C1713","HCPCS","0278","RC","","","","both","","","4170.57","3127.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1522.26","36.5","","148.37","54.89","631.39","94","1292.88","3315.6","percent of total billed charges",""
"BONE PLATE 184MM 11 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10027819","CDM","C1713","HCPCS","0278","RC","","","","both","","","4170.57","3127.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1597.33","38.3","","279.30","91.72","1116.77","266","1292.88","3315.6","percent of total billed charges",""
"BONE PLATE 184MM 11 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10027819","CDM","C1713","HCPCS","0278","RC","","","","both","","","4170.57","3127.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1789.17","42.9","","731.00","63.70","731.00","1 through 10","1292.88","3315.6","percent of total billed charges",""
"BONE PLATE 184MM 11 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10027819","CDM","C1713","HCPCS","0278","RC","","","","both","","","4170.57","3127.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1789.17","42.9","","384.74","384.74","384.74","1 through 10","1292.88","3315.6","percent of total billed charges",""
"BONE PLATE 184MM 11 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10027819","CDM","C1713","HCPCS","0278","RC","","","","both","","","4170.57","3127.93","WELLPOINT [1015]","HB AMC WELLPOINT","3077.05","73.78","","286.63","119.22","1107.45","105","1292.88","3315.6","percent of total billed charges",""
"BONE PLATE 184MM 11 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10027819","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4170.57","3127.93","AETNA [1001]","HB AMC AETNA HMO","2911.06","69.8","","675.31","184.75","1721.50","286","2179.54","3408.19","percent of total billed charges",""
"BONE PLATE 184MM 11 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10027819","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4170.57","3127.93","AETNA [1001]","HB AMC AETNA PPO","3353.14","80.4","","1261.44","103.12","1514.10","21","2179.54","3408.19","percent of total billed charges",""
"BONE PLATE 184MM 11 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10027819","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4170.57","3127.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3353.14","80.4","","1365.00","1365.00","1365.00","1 through 10","2179.54","3408.19","percent of total billed charges",""
"BONE PLATE 184MM 11 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10027819","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4170.57","3127.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3408.19","81.72","","5157.68","5157.68","5157.68","1 through 10","2179.54","3408.19","percent of total billed charges",""
"BONE PLATE 184MM 11 HOLE LCP STAINLESS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL RADIUS","SUP-ITM-10027819","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4170.57","3127.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3408.19","81.72","","431.26","71.26","1459.57","88","2179.54","3408.19","percent of total billed charges",""
"BONE PLATE 185MM 10 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306448","CDM","C1713","HCPCS","0278","RC","","","","both","","","7175.85","5381.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5704.80","79.5","","800.18","480.96","1887.97","195","2224.51","5704.8","percent of total billed charges",""
"BONE PLATE 185MM 10 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306448","CDM","C1713","HCPCS","0278","RC","","","","both","","","7175.85","5381.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3824.73","53.3","","813.12","216.42","1444.50","81","2224.51","5704.8","percent of total billed charges",""
"BONE PLATE 185MM 10 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306448","CDM","C1713","HCPCS","0278","RC","","","","both","","","7175.85","5381.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2224.51","31","","432.60","432.60","432.60","1 through 10","2224.51","5704.8","percent of total billed charges",""
"BONE PLATE 185MM 10 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306448","CDM","C1713","HCPCS","0278","RC","","","","both","","","7175.85","5381.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2619.19","36.5","","148.37","54.89","631.39","94","2224.51","5704.8","percent of total billed charges",""
"BONE PLATE 185MM 10 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306448","CDM","C1713","HCPCS","0278","RC","","","","both","","","7175.85","5381.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2748.35","38.3","","279.30","91.72","1116.77","266","2224.51","5704.8","percent of total billed charges",""
"BONE PLATE 185MM 10 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306448","CDM","C1713","HCPCS","0278","RC","","","","both","","","7175.85","5381.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3078.44","42.9","","731.00","63.70","731.00","1 through 10","2224.51","5704.8","percent of total billed charges",""
"BONE PLATE 185MM 10 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306448","CDM","C1713","HCPCS","0278","RC","","","","both","","","7175.85","5381.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3078.44","42.9","","384.74","384.74","384.74","1 through 10","2224.51","5704.8","percent of total billed charges",""
"BONE PLATE 185MM 10 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306448","CDM","C1713","HCPCS","0278","RC","","","","both","","","7175.85","5381.89","WELLPOINT [1015]","HB AMC WELLPOINT","5294.34","73.78","","286.63","119.22","1107.45","105","2224.51","5704.8","percent of total billed charges",""
"BONE PLATE 185MM 10 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7175.85","5381.89","AETNA [1001]","HB AMC AETNA HMO","5008.74","69.8","","675.31","184.75","1721.50","286","3750.1","5864.1","percent of total billed charges",""
"BONE PLATE 185MM 10 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7175.85","5381.89","AETNA [1001]","HB AMC AETNA PPO","5769.38","80.4","","1261.44","103.12","1514.10","21","3750.1","5864.1","percent of total billed charges",""
"BONE PLATE 185MM 10 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7175.85","5381.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5769.38","80.4","","1365.00","1365.00","1365.00","1 through 10","3750.1","5864.1","percent of total billed charges",""
"BONE PLATE 185MM 10 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7175.85","5381.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5864.10","81.72","","5157.68","5157.68","5157.68","1 through 10","3750.1","5864.1","percent of total billed charges",""
"BONE PLATE 185MM 10 HOLE STANDARD ORTHOLOC SPS","SUP-ITM-10306448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7175.85","5381.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5864.10","81.72","","431.26","71.26","1459.57","88","3750.1","5864.1","percent of total billed charges",""
"BONE PLATE 199MM VARIAX COMPRESSION 16 HOLE BROAD 629566S","SUP-ITM-10144787","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.36","3791.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4019.01","79.5","","800.18","480.96","1887.97","195","1567.16","4019.01","percent of total billed charges",""
"BONE PLATE 199MM VARIAX COMPRESSION 16 HOLE BROAD 629566S","SUP-ITM-10144787","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.36","3791.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2694.51","53.3","","813.12","216.42","1444.50","81","1567.16","4019.01","percent of total billed charges",""
"BONE PLATE 199MM VARIAX COMPRESSION 16 HOLE BROAD 629566S","SUP-ITM-10144787","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.36","3791.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1567.16","31","","432.60","432.60","432.60","1 through 10","1567.16","4019.01","percent of total billed charges",""
"BONE PLATE 199MM VARIAX COMPRESSION 16 HOLE BROAD 629566S","SUP-ITM-10144787","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.36","3791.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1845.21","36.5","","148.37","54.89","631.39","94","1567.16","4019.01","percent of total billed charges",""
"BONE PLATE 199MM VARIAX COMPRESSION 16 HOLE BROAD 629566S","SUP-ITM-10144787","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.36","3791.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1936.20","38.3","","279.30","91.72","1116.77","266","1567.16","4019.01","percent of total billed charges",""
"BONE PLATE 199MM VARIAX COMPRESSION 16 HOLE BROAD 629566S","SUP-ITM-10144787","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.36","3791.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2168.75","42.9","","731.00","63.70","731.00","1 through 10","1567.16","4019.01","percent of total billed charges",""
"BONE PLATE 199MM VARIAX COMPRESSION 16 HOLE BROAD 629566S","SUP-ITM-10144787","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.36","3791.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2168.75","42.9","","384.74","384.74","384.74","1 through 10","1567.16","4019.01","percent of total billed charges",""
"BONE PLATE 199MM VARIAX COMPRESSION 16 HOLE BROAD 629566S","SUP-ITM-10144787","CDM","C1713","HCPCS","0278","RC","","","","both","","","5055.36","3791.52","WELLPOINT [1015]","HB AMC WELLPOINT","3729.84","73.78","","286.63","119.22","1107.45","105","1567.16","4019.01","percent of total billed charges",""
"BONE PLATE 199MM VARIAX COMPRESSION 16 HOLE BROAD 629566S","SUP-ITM-10144787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5055.36","3791.52","AETNA [1001]","HB AMC AETNA HMO","3528.64","69.8","","675.31","184.75","1721.50","286","2641.93","4131.24","percent of total billed charges",""
"BONE PLATE 199MM VARIAX COMPRESSION 16 HOLE BROAD 629566S","SUP-ITM-10144787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5055.36","3791.52","AETNA [1001]","HB AMC AETNA PPO","4064.51","80.4","","1261.44","103.12","1514.10","21","2641.93","4131.24","percent of total billed charges",""
"BONE PLATE 199MM VARIAX COMPRESSION 16 HOLE BROAD 629566S","SUP-ITM-10144787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5055.36","3791.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4064.51","80.4","","1365.00","1365.00","1365.00","1 through 10","2641.93","4131.24","percent of total billed charges",""
"BONE PLATE 199MM VARIAX COMPRESSION 16 HOLE BROAD 629566S","SUP-ITM-10144787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5055.36","3791.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4131.24","81.72","","5157.68","5157.68","5157.68","1 through 10","2641.93","4131.24","percent of total billed charges",""
"BONE PLATE 199MM VARIAX COMPRESSION 16 HOLE BROAD 629566S","SUP-ITM-10144787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5055.36","3791.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4131.24","81.72","","431.26","71.26","1459.57","88","2641.93","4131.24","percent of total billed charges",""
"BONE PLATE 1MM 100X/4 4 CRANIOFACIAL TI MESH","SUP-ITM-10075882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4315.02","3236.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3430.44","79.5","","800.18","480.96","1887.97","195","1337.66","3430.44","percent of total billed charges",""
"BONE PLATE 1MM 100X/4 4 CRANIOFACIAL TI MESH","SUP-ITM-10075882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4315.02","3236.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2299.91","53.3","","813.12","216.42","1444.50","81","1337.66","3430.44","percent of total billed charges",""
"BONE PLATE 1MM 100X/4 4 CRANIOFACIAL TI MESH","SUP-ITM-10075882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4315.02","3236.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1337.66","31","","432.60","432.60","432.60","1 through 10","1337.66","3430.44","percent of total billed charges",""
"BONE PLATE 1MM 100X/4 4 CRANIOFACIAL TI MESH","SUP-ITM-10075882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4315.02","3236.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1574.98","36.5","","148.37","54.89","631.39","94","1337.66","3430.44","percent of total billed charges",""
"BONE PLATE 1MM 100X/4 4 CRANIOFACIAL TI MESH","SUP-ITM-10075882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4315.02","3236.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1652.65","38.3","","279.30","91.72","1116.77","266","1337.66","3430.44","percent of total billed charges",""
"BONE PLATE 1MM 100X/4 4 CRANIOFACIAL TI MESH","SUP-ITM-10075882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4315.02","3236.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1851.14","42.9","","731.00","63.70","731.00","1 through 10","1337.66","3430.44","percent of total billed charges",""
"BONE PLATE 1MM 100X/4 4 CRANIOFACIAL TI MESH","SUP-ITM-10075882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4315.02","3236.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1851.14","42.9","","384.74","384.74","384.74","1 through 10","1337.66","3430.44","percent of total billed charges",""
"BONE PLATE 1MM 100X/4 4 CRANIOFACIAL TI MESH","SUP-ITM-10075882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4315.02","3236.26","WELLPOINT [1015]","HB AMC WELLPOINT","3183.62","73.78","","286.63","119.22","1107.45","105","1337.66","3430.44","percent of total billed charges",""
"BONE PLATE 1MM 100X/4 4 CRANIOFACIAL TI MESH","SUP-ITM-10075882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4315.02","3236.26","AETNA [1001]","HB AMC AETNA HMO","3011.88","69.8","","675.31","184.75","1721.50","286","2255.03","3526.23","percent of total billed charges",""
"BONE PLATE 1MM 100X/4 4 CRANIOFACIAL TI MESH","SUP-ITM-10075882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4315.02","3236.26","AETNA [1001]","HB AMC AETNA PPO","3469.28","80.4","","1261.44","103.12","1514.10","21","2255.03","3526.23","percent of total billed charges",""
"BONE PLATE 1MM 100X/4 4 CRANIOFACIAL TI MESH","SUP-ITM-10075882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4315.02","3236.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3469.28","80.4","","1365.00","1365.00","1365.00","1 through 10","2255.03","3526.23","percent of total billed charges",""
"BONE PLATE 1MM 100X/4 4 CRANIOFACIAL TI MESH","SUP-ITM-10075882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4315.02","3236.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3526.23","81.72","","5157.68","5157.68","5157.68","1 through 10","2255.03","3526.23","percent of total billed charges",""
"BONE PLATE 1MM 100X/4 4 CRANIOFACIAL TI MESH","SUP-ITM-10075882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4315.02","3236.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3526.23","81.72","","431.26","71.26","1459.57","88","2255.03","3526.23","percent of total billed charges",""
"BONE PLATE 1MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.48","1226.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1300.21","79.5","","800.18","480.96","1887.97","195","507","1300.21","percent of total billed charges",""
"BONE PLATE 1MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.48","1226.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","871.71","53.3","","813.12","216.42","1444.50","81","507","1300.21","percent of total billed charges",""
"BONE PLATE 1MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.48","1226.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","507.00","31","","432.60","432.60","432.60","1 through 10","507","1300.21","percent of total billed charges",""
"BONE PLATE 1MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.48","1226.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","596.95","36.5","","148.37","54.89","631.39","94","507","1300.21","percent of total billed charges",""
"BONE PLATE 1MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.48","1226.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","626.39","38.3","","279.30","91.72","1116.77","266","507","1300.21","percent of total billed charges",""
"BONE PLATE 1MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.48","1226.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.62","42.9","","731.00","63.70","731.00","1 through 10","507","1300.21","percent of total billed charges",""
"BONE PLATE 1MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.48","1226.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.62","42.9","","384.74","384.74","384.74","1 through 10","507","1300.21","percent of total billed charges",""
"BONE PLATE 1MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081121","CDM","C1713","HCPCS","0278","RC","","","","both","","","1635.48","1226.61","WELLPOINT [1015]","HB AMC WELLPOINT","1206.66","73.78","","286.63","119.22","1107.45","105","507","1300.21","percent of total billed charges",""
"BONE PLATE 1MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1635.48","1226.61","AETNA [1001]","HB AMC AETNA HMO","1141.57","69.8","","675.31","184.75","1721.50","286","854.7","1336.51","percent of total billed charges",""
"BONE PLATE 1MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1635.48","1226.61","AETNA [1001]","HB AMC AETNA PPO","1314.93","80.4","","1261.44","103.12","1514.10","21","854.7","1336.51","percent of total billed charges",""
"BONE PLATE 1MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1635.48","1226.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1314.93","80.4","","1365.00","1365.00","1365.00","1 through 10","854.7","1336.51","percent of total billed charges",""
"BONE PLATE 1MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1635.48","1226.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1336.51","81.72","","5157.68","5157.68","5157.68","1 through 10","854.7","1336.51","percent of total billed charges",""
"BONE PLATE 1MM 12 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1635.48","1226.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1336.51","81.72","","431.26","71.26","1459.57","88","854.7","1336.51","percent of total billed charges",""
"BONE PLATE 1MM 20 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.35","908.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","963.02","79.5","","800.18","480.96","1887.97","195","375.52","963.02","percent of total billed charges",""
"BONE PLATE 1MM 20 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.35","908.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","645.65","53.3","","813.12","216.42","1444.50","81","375.52","963.02","percent of total billed charges",""
"BONE PLATE 1MM 20 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.35","908.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","375.52","31","","432.60","432.60","432.60","1 through 10","375.52","963.02","percent of total billed charges",""
"BONE PLATE 1MM 20 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.35","908.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","442.14","36.5","","148.37","54.89","631.39","94","375.52","963.02","percent of total billed charges",""
"BONE PLATE 1MM 20 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.35","908.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","463.95","38.3","","279.30","91.72","1116.77","266","375.52","963.02","percent of total billed charges",""
"BONE PLATE 1MM 20 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.35","908.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","519.67","42.9","","731.00","63.70","731.00","1 through 10","375.52","963.02","percent of total billed charges",""
"BONE PLATE 1MM 20 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.35","908.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","519.67","42.9","","384.74","384.74","384.74","1 through 10","375.52","963.02","percent of total billed charges",""
"BONE PLATE 1MM 20 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.35","908.51","WELLPOINT [1015]","HB AMC WELLPOINT","893.73","73.78","","286.63","119.22","1107.45","105","375.52","963.02","percent of total billed charges",""
"BONE PLATE 1MM 20 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.35","908.51","AETNA [1001]","HB AMC AETNA HMO","845.52","69.8","","675.31","184.75","1721.50","286","633.05","989.92","percent of total billed charges",""
"BONE PLATE 1MM 20 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.35","908.51","AETNA [1001]","HB AMC AETNA PPO","973.93","80.4","","1261.44","103.12","1514.10","21","633.05","989.92","percent of total billed charges",""
"BONE PLATE 1MM 20 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.35","908.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","973.93","80.4","","1365.00","1365.00","1365.00","1 through 10","633.05","989.92","percent of total billed charges",""
"BONE PLATE 1MM 20 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.35","908.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","989.92","81.72","","5157.68","5157.68","5157.68","1 through 10","633.05","989.92","percent of total billed charges",""
"BONE PLATE 1MM 20 HOLE CRANIAL MATRIXMANDIBLE TI ADAPTION","SUP-ITM-10081120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.35","908.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","989.92","81.72","","431.26","71.26","1459.57","88","633.05","989.92","percent of total billed charges",""
"BONE PLATE 1MM 4 HOLE CRANIAL MATRIXMANDIBLE TI SQUARE MALLEABLE","SUP-ITM-10081119","CDM","C1713","HCPCS","0278","RC","","","","both","","","714.63","535.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","568.13","79.5","","800.18","480.96","1887.97","195","221.54","568.13","percent of total billed charges",""
"BONE PLATE 1MM 4 HOLE CRANIAL MATRIXMANDIBLE TI SQUARE MALLEABLE","SUP-ITM-10081119","CDM","C1713","HCPCS","0278","RC","","","","both","","","714.63","535.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","380.90","53.3","","813.12","216.42","1444.50","81","221.54","568.13","percent of total billed charges",""
"BONE PLATE 1MM 4 HOLE CRANIAL MATRIXMANDIBLE TI SQUARE MALLEABLE","SUP-ITM-10081119","CDM","C1713","HCPCS","0278","RC","","","","both","","","714.63","535.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","221.54","31","","432.60","432.60","432.60","1 through 10","221.54","568.13","percent of total billed charges",""
"BONE PLATE 1MM 4 HOLE CRANIAL MATRIXMANDIBLE TI SQUARE MALLEABLE","SUP-ITM-10081119","CDM","C1713","HCPCS","0278","RC","","","","both","","","714.63","535.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","260.84","36.5","","148.37","54.89","631.39","94","221.54","568.13","percent of total billed charges",""
"BONE PLATE 1MM 4 HOLE CRANIAL MATRIXMANDIBLE TI SQUARE MALLEABLE","SUP-ITM-10081119","CDM","C1713","HCPCS","0278","RC","","","","both","","","714.63","535.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","273.70","38.3","","279.30","91.72","1116.77","266","221.54","568.13","percent of total billed charges",""
"BONE PLATE 1MM 4 HOLE CRANIAL MATRIXMANDIBLE TI SQUARE MALLEABLE","SUP-ITM-10081119","CDM","C1713","HCPCS","0278","RC","","","","both","","","714.63","535.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","306.58","42.9","","731.00","63.70","731.00","1 through 10","221.54","568.13","percent of total billed charges",""
"BONE PLATE 1MM 4 HOLE CRANIAL MATRIXMANDIBLE TI SQUARE MALLEABLE","SUP-ITM-10081119","CDM","C1713","HCPCS","0278","RC","","","","both","","","714.63","535.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","306.58","42.9","","384.74","384.74","384.74","1 through 10","221.54","568.13","percent of total billed charges",""
"BONE PLATE 1MM 4 HOLE CRANIAL MATRIXMANDIBLE TI SQUARE MALLEABLE","SUP-ITM-10081119","CDM","C1713","HCPCS","0278","RC","","","","both","","","714.63","535.97","WELLPOINT [1015]","HB AMC WELLPOINT","527.25","73.78","","286.63","119.22","1107.45","105","221.54","568.13","percent of total billed charges",""
"BONE PLATE 1MM 4 HOLE CRANIAL MATRIXMANDIBLE TI SQUARE MALLEABLE","SUP-ITM-10081119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","714.63","535.97","AETNA [1001]","HB AMC AETNA HMO","498.81","69.8","","675.31","184.75","1721.50","286","373.47","584","percent of total billed charges",""
"BONE PLATE 1MM 4 HOLE CRANIAL MATRIXMANDIBLE TI SQUARE MALLEABLE","SUP-ITM-10081119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","714.63","535.97","AETNA [1001]","HB AMC AETNA PPO","574.56","80.4","","1261.44","103.12","1514.10","21","373.47","584","percent of total billed charges",""
"BONE PLATE 1MM 4 HOLE CRANIAL MATRIXMANDIBLE TI SQUARE MALLEABLE","SUP-ITM-10081119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","714.63","535.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","574.56","80.4","","1365.00","1365.00","1365.00","1 through 10","373.47","584","percent of total billed charges",""
"BONE PLATE 1MM 4 HOLE CRANIAL MATRIXMANDIBLE TI SQUARE MALLEABLE","SUP-ITM-10081119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","714.63","535.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","584.00","81.72","","5157.68","5157.68","5157.68","1 through 10","373.47","584","percent of total billed charges",""
"BONE PLATE 1MM 4 HOLE CRANIAL MATRIXMANDIBLE TI SQUARE MALLEABLE","SUP-ITM-10081119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","714.63","535.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","584.00","81.72","","431.26","71.26","1459.57","88","373.47","584","percent of total billed charges",""
"BONE PLATE 1MM 6 HOLE CRANIOMAXILLOFACIAL TI H SHAPE BRIDGE","SUP-ITM-10003798","CDM","C1713","HCPCS","0278","RC","","","","both","","","493.85","370.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","392.61","79.5","","800.18","480.96","1887.97","195","153.09","392.61","percent of total billed charges",""
"BONE PLATE 1MM 6 HOLE CRANIOMAXILLOFACIAL TI H SHAPE BRIDGE","SUP-ITM-10003798","CDM","C1713","HCPCS","0278","RC","","","","both","","","493.85","370.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","263.22","53.3","","813.12","216.42","1444.50","81","153.09","392.61","percent of total billed charges",""
"BONE PLATE 1MM 6 HOLE CRANIOMAXILLOFACIAL TI H SHAPE BRIDGE","SUP-ITM-10003798","CDM","C1713","HCPCS","0278","RC","","","","both","","","493.85","370.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","153.09","31","","432.60","432.60","432.60","1 through 10","153.09","392.61","percent of total billed charges",""
"BONE PLATE 1MM 6 HOLE CRANIOMAXILLOFACIAL TI H SHAPE BRIDGE","SUP-ITM-10003798","CDM","C1713","HCPCS","0278","RC","","","","both","","","493.85","370.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","180.26","36.5","","148.37","54.89","631.39","94","153.09","392.61","percent of total billed charges",""
"BONE PLATE 1MM 6 HOLE CRANIOMAXILLOFACIAL TI H SHAPE BRIDGE","SUP-ITM-10003798","CDM","C1713","HCPCS","0278","RC","","","","both","","","493.85","370.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","189.14","38.3","","279.30","91.72","1116.77","266","153.09","392.61","percent of total billed charges",""
"BONE PLATE 1MM 6 HOLE CRANIOMAXILLOFACIAL TI H SHAPE BRIDGE","SUP-ITM-10003798","CDM","C1713","HCPCS","0278","RC","","","","both","","","493.85","370.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","211.86","42.9","","731.00","63.70","731.00","1 through 10","153.09","392.61","percent of total billed charges",""
"BONE PLATE 1MM 6 HOLE CRANIOMAXILLOFACIAL TI H SHAPE BRIDGE","SUP-ITM-10003798","CDM","C1713","HCPCS","0278","RC","","","","both","","","493.85","370.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","211.86","42.9","","384.74","384.74","384.74","1 through 10","153.09","392.61","percent of total billed charges",""
"BONE PLATE 1MM 6 HOLE CRANIOMAXILLOFACIAL TI H SHAPE BRIDGE","SUP-ITM-10003798","CDM","C1713","HCPCS","0278","RC","","","","both","","","493.85","370.39","WELLPOINT [1015]","HB AMC WELLPOINT","364.36","73.78","","286.63","119.22","1107.45","105","153.09","392.61","percent of total billed charges",""
"BONE PLATE 1MM 6 HOLE CRANIOMAXILLOFACIAL TI H SHAPE BRIDGE","SUP-ITM-10003798","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","493.85","370.39","AETNA [1001]","HB AMC AETNA HMO","344.71","69.8","","675.31","184.75","1721.50","286","258.09","403.57","percent of total billed charges",""
"BONE PLATE 1MM 6 HOLE CRANIOMAXILLOFACIAL TI H SHAPE BRIDGE","SUP-ITM-10003798","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","493.85","370.39","AETNA [1001]","HB AMC AETNA PPO","397.06","80.4","","1261.44","103.12","1514.10","21","258.09","403.57","percent of total billed charges",""
"BONE PLATE 1MM 6 HOLE CRANIOMAXILLOFACIAL TI H SHAPE BRIDGE","SUP-ITM-10003798","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","493.85","370.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","397.06","80.4","","1365.00","1365.00","1365.00","1 through 10","258.09","403.57","percent of total billed charges",""
"BONE PLATE 1MM 6 HOLE CRANIOMAXILLOFACIAL TI H SHAPE BRIDGE","SUP-ITM-10003798","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","493.85","370.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","403.57","81.72","","5157.68","5157.68","5157.68","1 through 10","258.09","403.57","percent of total billed charges",""
"BONE PLATE 1MM 6 HOLE CRANIOMAXILLOFACIAL TI H SHAPE BRIDGE","SUP-ITM-10003798","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","493.85","370.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","403.57","81.72","","431.26","71.26","1459.57","88","258.09","403.57","percent of total billed charges",""
"BONE PLATE 1MM 8 HOLE CRANIAL MATRIXMANDIBLE TI STRUT MALLEABLE","SUP-ITM-10081118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1408.86","1056.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1120.04","79.5","","800.18","480.96","1887.97","195","436.75","1120.04","percent of total billed charges",""
"BONE PLATE 1MM 8 HOLE CRANIAL MATRIXMANDIBLE TI STRUT MALLEABLE","SUP-ITM-10081118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1408.86","1056.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","750.92","53.3","","813.12","216.42","1444.50","81","436.75","1120.04","percent of total billed charges",""
"BONE PLATE 1MM 8 HOLE CRANIAL MATRIXMANDIBLE TI STRUT MALLEABLE","SUP-ITM-10081118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1408.86","1056.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","436.75","31","","432.60","432.60","432.60","1 through 10","436.75","1120.04","percent of total billed charges",""
"BONE PLATE 1MM 8 HOLE CRANIAL MATRIXMANDIBLE TI STRUT MALLEABLE","SUP-ITM-10081118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1408.86","1056.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","514.23","36.5","","148.37","54.89","631.39","94","436.75","1120.04","percent of total billed charges",""
"BONE PLATE 1MM 8 HOLE CRANIAL MATRIXMANDIBLE TI STRUT MALLEABLE","SUP-ITM-10081118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1408.86","1056.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","539.59","38.3","","279.30","91.72","1116.77","266","436.75","1120.04","percent of total billed charges",""
"BONE PLATE 1MM 8 HOLE CRANIAL MATRIXMANDIBLE TI STRUT MALLEABLE","SUP-ITM-10081118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1408.86","1056.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","604.40","42.9","","731.00","63.70","731.00","1 through 10","436.75","1120.04","percent of total billed charges",""
"BONE PLATE 1MM 8 HOLE CRANIAL MATRIXMANDIBLE TI STRUT MALLEABLE","SUP-ITM-10081118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1408.86","1056.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","604.40","42.9","","384.74","384.74","384.74","1 through 10","436.75","1120.04","percent of total billed charges",""
"BONE PLATE 1MM 8 HOLE CRANIAL MATRIXMANDIBLE TI STRUT MALLEABLE","SUP-ITM-10081118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1408.86","1056.64","WELLPOINT [1015]","HB AMC WELLPOINT","1039.46","73.78","","286.63","119.22","1107.45","105","436.75","1120.04","percent of total billed charges",""
"BONE PLATE 1MM 8 HOLE CRANIAL MATRIXMANDIBLE TI STRUT MALLEABLE","SUP-ITM-10081118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1408.86","1056.64","AETNA [1001]","HB AMC AETNA HMO","983.38","69.8","","675.31","184.75","1721.50","286","736.27","1151.32","percent of total billed charges",""
"BONE PLATE 1MM 8 HOLE CRANIAL MATRIXMANDIBLE TI STRUT MALLEABLE","SUP-ITM-10081118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1408.86","1056.64","AETNA [1001]","HB AMC AETNA PPO","1132.72","80.4","","1261.44","103.12","1514.10","21","736.27","1151.32","percent of total billed charges",""
"BONE PLATE 1MM 8 HOLE CRANIAL MATRIXMANDIBLE TI STRUT MALLEABLE","SUP-ITM-10081118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1408.86","1056.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1132.72","80.4","","1365.00","1365.00","1365.00","1 through 10","736.27","1151.32","percent of total billed charges",""
"BONE PLATE 1MM 8 HOLE CRANIAL MATRIXMANDIBLE TI STRUT MALLEABLE","SUP-ITM-10081118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1408.86","1056.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1151.32","81.72","","5157.68","5157.68","5157.68","1 through 10","736.27","1151.32","percent of total billed charges",""
"BONE PLATE 1MM 8 HOLE CRANIAL MATRIXMANDIBLE TI STRUT MALLEABLE","SUP-ITM-10081118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1408.86","1056.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1151.32","81.72","","431.26","71.26","1459.57","88","736.27","1151.32","percent of total billed charges",""
"BONE PLATE 1MM SM 4 HOLE SUBCONDYLAR TI TRAPEZOIDAL MALLEABLE MATRIXMANDIBLE","SUP-ITM-10131191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2363.80","1772.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1879.22","79.5","","800.18","480.96","1887.97","195","732.78","1879.22","percent of total billed charges",""
"BONE PLATE 1MM SM 4 HOLE SUBCONDYLAR TI TRAPEZOIDAL MALLEABLE MATRIXMANDIBLE","SUP-ITM-10131191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2363.80","1772.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1259.91","53.3","","813.12","216.42","1444.50","81","732.78","1879.22","percent of total billed charges",""
"BONE PLATE 1MM SM 4 HOLE SUBCONDYLAR TI TRAPEZOIDAL MALLEABLE MATRIXMANDIBLE","SUP-ITM-10131191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2363.80","1772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","732.78","31","","432.60","432.60","432.60","1 through 10","732.78","1879.22","percent of total billed charges",""
"BONE PLATE 1MM SM 4 HOLE SUBCONDYLAR TI TRAPEZOIDAL MALLEABLE MATRIXMANDIBLE","SUP-ITM-10131191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2363.80","1772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","862.79","36.5","","148.37","54.89","631.39","94","732.78","1879.22","percent of total billed charges",""
"BONE PLATE 1MM SM 4 HOLE SUBCONDYLAR TI TRAPEZOIDAL MALLEABLE MATRIXMANDIBLE","SUP-ITM-10131191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2363.80","1772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","905.34","38.3","","279.30","91.72","1116.77","266","732.78","1879.22","percent of total billed charges",""
"BONE PLATE 1MM SM 4 HOLE SUBCONDYLAR TI TRAPEZOIDAL MALLEABLE MATRIXMANDIBLE","SUP-ITM-10131191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2363.80","1772.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1014.07","42.9","","731.00","63.70","731.00","1 through 10","732.78","1879.22","percent of total billed charges",""
"BONE PLATE 1MM SM 4 HOLE SUBCONDYLAR TI TRAPEZOIDAL MALLEABLE MATRIXMANDIBLE","SUP-ITM-10131191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2363.80","1772.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1014.07","42.9","","384.74","384.74","384.74","1 through 10","732.78","1879.22","percent of total billed charges",""
"BONE PLATE 1MM SM 4 HOLE SUBCONDYLAR TI TRAPEZOIDAL MALLEABLE MATRIXMANDIBLE","SUP-ITM-10131191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2363.80","1772.85","WELLPOINT [1015]","HB AMC WELLPOINT","1744.01","73.78","","286.63","119.22","1107.45","105","732.78","1879.22","percent of total billed charges",""
"BONE PLATE 1MM SM 4 HOLE SUBCONDYLAR TI TRAPEZOIDAL MALLEABLE MATRIXMANDIBLE","SUP-ITM-10131191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2363.80","1772.85","AETNA [1001]","HB AMC AETNA HMO","1649.93","69.8","","675.31","184.75","1721.50","286","1235.32","1931.7","percent of total billed charges",""
"BONE PLATE 1MM SM 4 HOLE SUBCONDYLAR TI TRAPEZOIDAL MALLEABLE MATRIXMANDIBLE","SUP-ITM-10131191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2363.80","1772.85","AETNA [1001]","HB AMC AETNA PPO","1900.50","80.4","","1261.44","103.12","1514.10","21","1235.32","1931.7","percent of total billed charges",""
"BONE PLATE 1MM SM 4 HOLE SUBCONDYLAR TI TRAPEZOIDAL MALLEABLE MATRIXMANDIBLE","SUP-ITM-10131191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2363.80","1772.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1900.50","80.4","","1365.00","1365.00","1365.00","1 through 10","1235.32","1931.7","percent of total billed charges",""
"BONE PLATE 1MM SM 4 HOLE SUBCONDYLAR TI TRAPEZOIDAL MALLEABLE MATRIXMANDIBLE","SUP-ITM-10131191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2363.80","1772.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1931.70","81.72","","5157.68","5157.68","5157.68","1 through 10","1235.32","1931.7","percent of total billed charges",""
"BONE PLATE 1MM SM 4 HOLE SUBCONDYLAR TI TRAPEZOIDAL MALLEABLE MATRIXMANDIBLE","SUP-ITM-10131191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2363.80","1772.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1931.70","81.72","","431.26","71.26","1459.57","88","1235.32","1931.7","percent of total billed charges",""
"BONE PLATE 1XPINK 0.7MM 3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI Y SHAPE","SUP-ITM-10077429","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.11","409.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","434.16","79.5","","800.18","480.96","1887.97","195","169.29","434.16","percent of total billed charges",""
"BONE PLATE 1XPINK 0.7MM 3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI Y SHAPE","SUP-ITM-10077429","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.11","409.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","291.08","53.3","","813.12","216.42","1444.50","81","169.29","434.16","percent of total billed charges",""
"BONE PLATE 1XPINK 0.7MM 3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI Y SHAPE","SUP-ITM-10077429","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.11","409.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","169.29","31","","432.60","432.60","432.60","1 through 10","169.29","434.16","percent of total billed charges",""
"BONE PLATE 1XPINK 0.7MM 3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI Y SHAPE","SUP-ITM-10077429","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.11","409.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","199.33","36.5","","148.37","54.89","631.39","94","169.29","434.16","percent of total billed charges",""
"BONE PLATE 1XPINK 0.7MM 3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI Y SHAPE","SUP-ITM-10077429","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.11","409.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","209.16","38.3","","279.30","91.72","1116.77","266","169.29","434.16","percent of total billed charges",""
"BONE PLATE 1XPINK 0.7MM 3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI Y SHAPE","SUP-ITM-10077429","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.11","409.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.28","42.9","","731.00","63.70","731.00","1 through 10","169.29","434.16","percent of total billed charges",""
"BONE PLATE 1XPINK 0.7MM 3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI Y SHAPE","SUP-ITM-10077429","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.11","409.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.28","42.9","","384.74","384.74","384.74","1 through 10","169.29","434.16","percent of total billed charges",""
"BONE PLATE 1XPINK 0.7MM 3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI Y SHAPE","SUP-ITM-10077429","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.11","409.58","WELLPOINT [1015]","HB AMC WELLPOINT","402.92","73.78","","286.63","119.22","1107.45","105","169.29","434.16","percent of total billed charges",""
"BONE PLATE 1XPINK 0.7MM 3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI Y SHAPE","SUP-ITM-10077429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.11","409.58","AETNA [1001]","HB AMC AETNA HMO","381.18","69.8","","675.31","184.75","1721.50","286","285.4","446.28","percent of total billed charges",""
"BONE PLATE 1XPINK 0.7MM 3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI Y SHAPE","SUP-ITM-10077429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.11","409.58","AETNA [1001]","HB AMC AETNA PPO","439.07","80.4","","1261.44","103.12","1514.10","21","285.4","446.28","percent of total billed charges",""
"BONE PLATE 1XPINK 0.7MM 3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI Y SHAPE","SUP-ITM-10077429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.11","409.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","439.07","80.4","","1365.00","1365.00","1365.00","1 through 10","285.4","446.28","percent of total billed charges",""
"BONE PLATE 1XPINK 0.7MM 3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI Y SHAPE","SUP-ITM-10077429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.11","409.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","446.28","81.72","","5157.68","5157.68","5157.68","1 through 10","285.4","446.28","percent of total billed charges",""
"BONE PLATE 1XPINK 0.7MM 3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI Y SHAPE","SUP-ITM-10077429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.11","409.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","446.28","81.72","","431.26","71.26","1459.57","88","285.4","446.28","percent of total billed charges",""
"BONE PLATE 2 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3545.50","2659.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2818.67","79.5","","800.18","480.96","1887.97","195","1099.11","2818.67","percent of total billed charges",""
"BONE PLATE 2 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3545.50","2659.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1889.75","53.3","","813.12","216.42","1444.50","81","1099.11","2818.67","percent of total billed charges",""
"BONE PLATE 2 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3545.50","2659.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1099.11","31","","432.60","432.60","432.60","1 through 10","1099.11","2818.67","percent of total billed charges",""
"BONE PLATE 2 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3545.50","2659.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1294.11","36.5","","148.37","54.89","631.39","94","1099.11","2818.67","percent of total billed charges",""
"BONE PLATE 2 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3545.50","2659.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1357.93","38.3","","279.30","91.72","1116.77","266","1099.11","2818.67","percent of total billed charges",""
"BONE PLATE 2 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3545.50","2659.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1521.02","42.9","","731.00","63.70","731.00","1 through 10","1099.11","2818.67","percent of total billed charges",""
"BONE PLATE 2 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3545.50","2659.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1521.02","42.9","","384.74","384.74","384.74","1 through 10","1099.11","2818.67","percent of total billed charges",""
"BONE PLATE 2 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3545.50","2659.12","WELLPOINT [1015]","HB AMC WELLPOINT","2615.87","73.78","","286.63","119.22","1107.45","105","1099.11","2818.67","percent of total billed charges",""
"BONE PLATE 2 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3545.50","2659.12","AETNA [1001]","HB AMC AETNA HMO","2474.76","69.8","","675.31","184.75","1721.50","286","1852.88","2897.38","percent of total billed charges",""
"BONE PLATE 2 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3545.50","2659.12","AETNA [1001]","HB AMC AETNA PPO","2850.58","80.4","","1261.44","103.12","1514.10","21","1852.88","2897.38","percent of total billed charges",""
"BONE PLATE 2 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3545.50","2659.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2850.58","80.4","","1365.00","1365.00","1365.00","1 through 10","1852.88","2897.38","percent of total billed charges",""
"BONE PLATE 2 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3545.50","2659.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2897.38","81.72","","5157.68","5157.68","5157.68","1 through 10","1852.88","2897.38","percent of total billed charges",""
"BONE PLATE 2 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3545.50","2659.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2897.38","81.72","","431.26","71.26","1459.57","88","1852.88","2897.38","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","both","","","2658.64","1993.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2113.62","79.5","","800.18","480.96","1887.97","195","824.18","2113.62","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","both","","","2658.64","1993.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1417.06","53.3","","813.12","216.42","1444.50","81","824.18","2113.62","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","both","","","2658.64","1993.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","824.18","31","","432.60","432.60","432.60","1 through 10","824.18","2113.62","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","both","","","2658.64","1993.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","970.40","36.5","","148.37","54.89","631.39","94","824.18","2113.62","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","both","","","2658.64","1993.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1018.26","38.3","","279.30","91.72","1116.77","266","824.18","2113.62","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","both","","","2658.64","1993.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1140.56","42.9","","731.00","63.70","731.00","1 through 10","824.18","2113.62","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","both","","","2658.64","1993.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1140.56","42.9","","384.74","384.74","384.74","1 through 10","824.18","2113.62","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","both","","","2658.64","1993.98","WELLPOINT [1015]","HB AMC WELLPOINT","1961.54","73.78","","286.63","119.22","1107.45","105","824.18","2113.62","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2658.64","1993.98","AETNA [1001]","HB AMC AETNA HMO","1855.73","69.8","","675.31","184.75","1721.50","286","1389.41","2172.64","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2658.64","1993.98","AETNA [1001]","HB AMC AETNA PPO","2137.55","80.4","","1261.44","103.12","1514.10","21","1389.41","2172.64","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2658.64","1993.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2137.55","80.4","","1365.00","1365.00","1365.00","1 through 10","1389.41","2172.64","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2658.64","1993.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2172.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1389.41","2172.64","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2658.64","1993.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2172.64","81.72","","431.26","71.26","1459.57","88","1389.41","2172.64","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","both","","","2735.04","2051.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2174.36","79.5","","800.18","480.96","1887.97","195","847.86","2174.36","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","both","","","2735.04","2051.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1457.78","53.3","","813.12","216.42","1444.50","81","847.86","2174.36","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","both","","","2735.04","2051.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","847.86","31","","432.60","432.60","432.60","1 through 10","847.86","2174.36","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","both","","","2735.04","2051.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","998.29","36.5","","148.37","54.89","631.39","94","847.86","2174.36","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","both","","","2735.04","2051.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1047.52","38.3","","279.30","91.72","1116.77","266","847.86","2174.36","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","both","","","2735.04","2051.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1173.33","42.9","","731.00","63.70","731.00","1 through 10","847.86","2174.36","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","both","","","2735.04","2051.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1173.33","42.9","","384.74","384.74","384.74","1 through 10","847.86","2174.36","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","both","","","2735.04","2051.28","WELLPOINT [1015]","HB AMC WELLPOINT","2017.91","73.78","","286.63","119.22","1107.45","105","847.86","2174.36","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2735.04","2051.28","AETNA [1001]","HB AMC AETNA HMO","1909.06","69.8","","675.31","184.75","1721.50","286","1429.33","2235.07","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2735.04","2051.28","AETNA [1001]","HB AMC AETNA PPO","2198.97","80.4","","1261.44","103.12","1514.10","21","1429.33","2235.07","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2735.04","2051.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2198.97","80.4","","1365.00","1365.00","1365.00","1 through 10","1429.33","2235.07","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2735.04","2051.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2235.07","81.72","","5157.68","5157.68","5157.68","1 through 10","1429.33","2235.07","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2735.04","2051.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2235.07","81.72","","431.26","71.26","1459.57","88","1429.33","2235.07","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2277.91","1708.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1810.94","79.5","","800.18","480.96","1887.97","195","706.15","1810.94","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2277.91","1708.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1214.13","53.3","","813.12","216.42","1444.50","81","706.15","1810.94","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2277.91","1708.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","706.15","31","","432.60","432.60","432.60","1 through 10","706.15","1810.94","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2277.91","1708.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","831.44","36.5","","148.37","54.89","631.39","94","706.15","1810.94","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2277.91","1708.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","872.44","38.3","","279.30","91.72","1116.77","266","706.15","1810.94","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2277.91","1708.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","977.22","42.9","","731.00","63.70","731.00","1 through 10","706.15","1810.94","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2277.91","1708.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","977.22","42.9","","384.74","384.74","384.74","1 through 10","706.15","1810.94","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2277.91","1708.43","WELLPOINT [1015]","HB AMC WELLPOINT","1680.64","73.78","","286.63","119.22","1107.45","105","706.15","1810.94","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2277.91","1708.43","AETNA [1001]","HB AMC AETNA HMO","1589.98","69.8","","675.31","184.75","1721.50","286","1190.44","1861.51","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2277.91","1708.43","AETNA [1001]","HB AMC AETNA PPO","1831.44","80.4","","1261.44","103.12","1514.10","21","1190.44","1861.51","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2277.91","1708.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1831.44","80.4","","1365.00","1365.00","1365.00","1 through 10","1190.44","1861.51","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2277.91","1708.43","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1861.51","81.72","","5157.68","5157.68","5157.68","1 through 10","1190.44","1861.51","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2277.91","1708.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1861.51","81.72","","431.26","71.26","1459.57","88","1190.44","1861.51","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2213.48","79.5","","800.18","480.96","1887.97","195","863.12","2213.48","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1484.01","53.3","","813.12","216.42","1444.50","81","863.12","2213.48","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","863.12","31","","432.60","432.60","432.60","1 through 10","863.12","2213.48","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1016.25","36.5","","148.37","54.89","631.39","94","863.12","2213.48","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1066.37","38.3","","279.30","91.72","1116.77","266","863.12","2213.48","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1194.44","42.9","","731.00","63.70","731.00","1 through 10","863.12","2213.48","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1194.44","42.9","","384.74","384.74","384.74","1 through 10","863.12","2213.48","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","WELLPOINT [1015]","HB AMC WELLPOINT","2054.22","73.78","","286.63","119.22","1107.45","105","863.12","2213.48","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.25","2088.19","AETNA [1001]","HB AMC AETNA HMO","1943.41","69.8","","675.31","184.75","1721.50","286","1455.05","2275.29","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.25","2088.19","AETNA [1001]","HB AMC AETNA PPO","2238.54","80.4","","1261.44","103.12","1514.10","21","1455.05","2275.29","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.25","2088.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2238.54","80.4","","1365.00","1365.00","1365.00","1 through 10","1455.05","2275.29","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.25","2088.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2275.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1455.05","2275.29","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.25","2088.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2275.29","81.72","","431.26","71.26","1459.57","88","1455.05","2275.29","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","both","","","3513.34","2635.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2793.11","79.5","","800.18","480.96","1887.97","195","1089.14","2793.11","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","both","","","3513.34","2635.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1872.61","53.3","","813.12","216.42","1444.50","81","1089.14","2793.11","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","both","","","3513.34","2635.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1089.14","31","","432.60","432.60","432.60","1 through 10","1089.14","2793.11","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","both","","","3513.34","2635.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1282.37","36.5","","148.37","54.89","631.39","94","1089.14","2793.11","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","both","","","3513.34","2635.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1345.61","38.3","","279.30","91.72","1116.77","266","1089.14","2793.11","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","both","","","3513.34","2635.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1507.22","42.9","","731.00","63.70","731.00","1 through 10","1089.14","2793.11","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","both","","","3513.34","2635.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1507.22","42.9","","384.74","384.74","384.74","1 through 10","1089.14","2793.11","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","both","","","3513.34","2635.00","WELLPOINT [1015]","HB AMC WELLPOINT","2592.14","73.78","","286.63","119.22","1107.45","105","1089.14","2793.11","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3513.34","2635.00","AETNA [1001]","HB AMC AETNA HMO","2452.31","69.8","","675.31","184.75","1721.50","286","1836.07","2871.1","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3513.34","2635.00","AETNA [1001]","HB AMC AETNA PPO","2824.73","80.4","","1261.44","103.12","1514.10","21","1836.07","2871.1","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3513.34","2635.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2824.73","80.4","","1365.00","1365.00","1365.00","1 through 10","1836.07","2871.1","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3513.34","2635.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2871.10","81.72","","5157.68","5157.68","5157.68","1 through 10","1836.07","2871.1","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3513.34","2635.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2871.10","81.72","","431.26","71.26","1459.57","88","1836.07","2871.1","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.04","1857.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1968.45","79.5","","800.18","480.96","1887.97","195","767.57","1968.45","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.04","1857.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1319.73","53.3","","813.12","216.42","1444.50","81","767.57","1968.45","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.04","1857.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","767.57","31","","432.60","432.60","432.60","1 through 10","767.57","1968.45","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.04","1857.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","903.75","36.5","","148.37","54.89","631.39","94","767.57","1968.45","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.04","1857.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","948.32","38.3","","279.30","91.72","1116.77","266","767.57","1968.45","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.04","1857.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1062.22","42.9","","731.00","63.70","731.00","1 through 10","767.57","1968.45","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.04","1857.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1062.22","42.9","","384.74","384.74","384.74","1 through 10","767.57","1968.45","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.04","1857.03","WELLPOINT [1015]","HB AMC WELLPOINT","1826.82","73.78","","286.63","119.22","1107.45","105","767.57","1968.45","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2476.04","1857.03","AETNA [1001]","HB AMC AETNA HMO","1728.28","69.8","","675.31","184.75","1721.50","286","1293.98","2023.42","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2476.04","1857.03","AETNA [1001]","HB AMC AETNA PPO","1990.74","80.4","","1261.44","103.12","1514.10","21","1293.98","2023.42","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2476.04","1857.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1990.74","80.4","","1365.00","1365.00","1365.00","1 through 10","1293.98","2023.42","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2476.04","1857.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2023.42","81.72","","5157.68","5157.68","5157.68","1 through 10","1293.98","2023.42","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2476.04","1857.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2023.42","81.72","","431.26","71.26","1459.57","88","1293.98","2023.42","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM 27 LONG 2 HOLE FOOT VA LCP TI VARIABLE ANGLE LOCKING","SUP-ITM-10096302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.26","1775.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1881.97","79.5","","800.18","480.96","1887.97","195","733.85","1881.97","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM 27 LONG 2 HOLE FOOT VA LCP TI VARIABLE ANGLE LOCKING","SUP-ITM-10096302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.26","1775.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1261.75","53.3","","813.12","216.42","1444.50","81","733.85","1881.97","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM 27 LONG 2 HOLE FOOT VA LCP TI VARIABLE ANGLE LOCKING","SUP-ITM-10096302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.26","1775.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","733.85","31","","432.60","432.60","432.60","1 through 10","733.85","1881.97","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM 27 LONG 2 HOLE FOOT VA LCP TI VARIABLE ANGLE LOCKING","SUP-ITM-10096302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.26","1775.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","864.05","36.5","","148.37","54.89","631.39","94","733.85","1881.97","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM 27 LONG 2 HOLE FOOT VA LCP TI VARIABLE ANGLE LOCKING","SUP-ITM-10096302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.26","1775.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","906.66","38.3","","279.30","91.72","1116.77","266","733.85","1881.97","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM 27 LONG 2 HOLE FOOT VA LCP TI VARIABLE ANGLE LOCKING","SUP-ITM-10096302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.26","1775.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1015.55","42.9","","731.00","63.70","731.00","1 through 10","733.85","1881.97","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM 27 LONG 2 HOLE FOOT VA LCP TI VARIABLE ANGLE LOCKING","SUP-ITM-10096302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.26","1775.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1015.55","42.9","","384.74","384.74","384.74","1 through 10","733.85","1881.97","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM 27 LONG 2 HOLE FOOT VA LCP TI VARIABLE ANGLE LOCKING","SUP-ITM-10096302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.26","1775.44","WELLPOINT [1015]","HB AMC WELLPOINT","1746.56","73.78","","286.63","119.22","1107.45","105","733.85","1881.97","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM 27 LONG 2 HOLE FOOT VA LCP TI VARIABLE ANGLE LOCKING","SUP-ITM-10096302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2367.26","1775.44","AETNA [1001]","HB AMC AETNA HMO","1652.35","69.8","","675.31","184.75","1721.50","286","1237.13","1934.52","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM 27 LONG 2 HOLE FOOT VA LCP TI VARIABLE ANGLE LOCKING","SUP-ITM-10096302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2367.26","1775.44","AETNA [1001]","HB AMC AETNA PPO","1903.28","80.4","","1261.44","103.12","1514.10","21","1237.13","1934.52","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM 27 LONG 2 HOLE FOOT VA LCP TI VARIABLE ANGLE LOCKING","SUP-ITM-10096302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2367.26","1775.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1903.28","80.4","","1365.00","1365.00","1365.00","1 through 10","1237.13","1934.52","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM 27 LONG 2 HOLE FOOT VA LCP TI VARIABLE ANGLE LOCKING","SUP-ITM-10096302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2367.26","1775.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1934.52","81.72","","5157.68","5157.68","5157.68","1 through 10","1237.13","1934.52","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM 27 LONG 2 HOLE FOOT VA LCP TI VARIABLE ANGLE LOCKING","SUP-ITM-10096302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2367.26","1775.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1934.52","81.72","","431.26","71.26","1459.57","88","1237.13","1934.52","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING","SUP-ITM-10037372","CDM","C1713","HCPCS","0278","RC","","","","both","","","2359.49","1769.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1875.79","79.5","","800.18","480.96","1887.97","195","731.44","1875.79","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING","SUP-ITM-10037372","CDM","C1713","HCPCS","0278","RC","","","","both","","","2359.49","1769.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1257.61","53.3","","813.12","216.42","1444.50","81","731.44","1875.79","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING","SUP-ITM-10037372","CDM","C1713","HCPCS","0278","RC","","","","both","","","2359.49","1769.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","731.44","31","","432.60","432.60","432.60","1 through 10","731.44","1875.79","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING","SUP-ITM-10037372","CDM","C1713","HCPCS","0278","RC","","","","both","","","2359.49","1769.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","861.21","36.5","","148.37","54.89","631.39","94","731.44","1875.79","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING","SUP-ITM-10037372","CDM","C1713","HCPCS","0278","RC","","","","both","","","2359.49","1769.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","903.68","38.3","","279.30","91.72","1116.77","266","731.44","1875.79","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING","SUP-ITM-10037372","CDM","C1713","HCPCS","0278","RC","","","","both","","","2359.49","1769.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1012.22","42.9","","731.00","63.70","731.00","1 through 10","731.44","1875.79","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING","SUP-ITM-10037372","CDM","C1713","HCPCS","0278","RC","","","","both","","","2359.49","1769.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1012.22","42.9","","384.74","384.74","384.74","1 through 10","731.44","1875.79","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING","SUP-ITM-10037372","CDM","C1713","HCPCS","0278","RC","","","","both","","","2359.49","1769.62","WELLPOINT [1015]","HB AMC WELLPOINT","1740.83","73.78","","286.63","119.22","1107.45","105","731.44","1875.79","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING","SUP-ITM-10037372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2359.49","1769.62","AETNA [1001]","HB AMC AETNA HMO","1646.92","69.8","","675.31","184.75","1721.50","286","1233.07","1928.18","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING","SUP-ITM-10037372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2359.49","1769.62","AETNA [1001]","HB AMC AETNA PPO","1897.03","80.4","","1261.44","103.12","1514.10","21","1233.07","1928.18","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING","SUP-ITM-10037372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2359.49","1769.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1897.03","80.4","","1365.00","1365.00","1365.00","1 through 10","1233.07","1928.18","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING","SUP-ITM-10037372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2359.49","1769.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1928.18","81.72","","5157.68","5157.68","5157.68","1 through 10","1233.07","1928.18","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING","SUP-ITM-10037372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2359.49","1769.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1928.18","81.72","","431.26","71.26","1459.57","88","1233.07","1928.18","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING LCP TI","SUP-ITM-10096268","CDM","C1713","HCPCS","0278","RC","","","","both","","","3483.55","2612.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2769.42","79.5","","800.18","480.96","1887.97","195","1079.9","2769.42","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING LCP TI","SUP-ITM-10096268","CDM","C1713","HCPCS","0278","RC","","","","both","","","3483.55","2612.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1856.73","53.3","","813.12","216.42","1444.50","81","1079.9","2769.42","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING LCP TI","SUP-ITM-10096268","CDM","C1713","HCPCS","0278","RC","","","","both","","","3483.55","2612.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1079.90","31","","432.60","432.60","432.60","1 through 10","1079.9","2769.42","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING LCP TI","SUP-ITM-10096268","CDM","C1713","HCPCS","0278","RC","","","","both","","","3483.55","2612.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1271.50","36.5","","148.37","54.89","631.39","94","1079.9","2769.42","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING LCP TI","SUP-ITM-10096268","CDM","C1713","HCPCS","0278","RC","","","","both","","","3483.55","2612.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1334.20","38.3","","279.30","91.72","1116.77","266","1079.9","2769.42","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING LCP TI","SUP-ITM-10096268","CDM","C1713","HCPCS","0278","RC","","","","both","","","3483.55","2612.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1494.44","42.9","","731.00","63.70","731.00","1 through 10","1079.9","2769.42","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING LCP TI","SUP-ITM-10096268","CDM","C1713","HCPCS","0278","RC","","","","both","","","3483.55","2612.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1494.44","42.9","","384.74","384.74","384.74","1 through 10","1079.9","2769.42","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING LCP TI","SUP-ITM-10096268","CDM","C1713","HCPCS","0278","RC","","","","both","","","3483.55","2612.66","WELLPOINT [1015]","HB AMC WELLPOINT","2570.16","73.78","","286.63","119.22","1107.45","105","1079.9","2769.42","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING LCP TI","SUP-ITM-10096268","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3483.55","2612.66","AETNA [1001]","HB AMC AETNA HMO","2431.52","69.8","","675.31","184.75","1721.50","286","1820.5","2846.76","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING LCP TI","SUP-ITM-10096268","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3483.55","2612.66","AETNA [1001]","HB AMC AETNA PPO","2800.77","80.4","","1261.44","103.12","1514.10","21","1820.5","2846.76","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING LCP TI","SUP-ITM-10096268","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3483.55","2612.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2800.77","80.4","","1365.00","1365.00","1365.00","1 through 10","1820.5","2846.76","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING LCP TI","SUP-ITM-10096268","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3483.55","2612.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2846.76","81.72","","5157.68","5157.68","5157.68","1 through 10","1820.5","2846.76","percent of total billed charges",""
"BONE PLATE 2.4/2.7MM NAVICULAR LOCKING LCP TI","SUP-ITM-10096268","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3483.55","2612.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2846.76","81.72","","431.26","71.26","1459.57","88","1820.5","2846.76","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4457.39","3343.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3543.63","79.5","","800.18","480.96","1887.97","195","1381.79","3543.63","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4457.39","3343.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2375.79","53.3","","813.12","216.42","1444.50","81","1381.79","3543.63","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4457.39","3343.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1381.79","31","","432.60","432.60","432.60","1 through 10","1381.79","3543.63","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4457.39","3343.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1626.95","36.5","","148.37","54.89","631.39","94","1381.79","3543.63","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4457.39","3343.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1707.18","38.3","","279.30","91.72","1116.77","266","1381.79","3543.63","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4457.39","3343.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1912.22","42.9","","731.00","63.70","731.00","1 through 10","1381.79","3543.63","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4457.39","3343.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1912.22","42.9","","384.74","384.74","384.74","1 through 10","1381.79","3543.63","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4457.39","3343.04","WELLPOINT [1015]","HB AMC WELLPOINT","3288.66","73.78","","286.63","119.22","1107.45","105","1381.79","3543.63","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4457.39","3343.04","AETNA [1001]","HB AMC AETNA HMO","3111.26","69.8","","675.31","184.75","1721.50","286","2329.43","3642.58","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4457.39","3343.04","AETNA [1001]","HB AMC AETNA PPO","3583.74","80.4","","1261.44","103.12","1514.10","21","2329.43","3642.58","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4457.39","3343.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3583.74","80.4","","1365.00","1365.00","1365.00","1 through 10","2329.43","3642.58","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4457.39","3343.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3642.58","81.72","","5157.68","5157.68","5157.68","1 through 10","2329.43","3642.58","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4457.39","3343.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3642.58","81.72","","431.26","71.26","1459.57","88","2329.43","3642.58","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 LONG VA LCP TI GENERAL CLOVERLEAF FUSION","SUP-ITM-10096292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.96","2087.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2212.45","79.5","","800.18","480.96","1887.97","195","862.72","2212.45","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 LONG VA LCP TI GENERAL CLOVERLEAF FUSION","SUP-ITM-10096292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.96","2087.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1483.32","53.3","","813.12","216.42","1444.50","81","862.72","2212.45","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 LONG VA LCP TI GENERAL CLOVERLEAF FUSION","SUP-ITM-10096292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.96","2087.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","862.72","31","","432.60","432.60","432.60","1 through 10","862.72","2212.45","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 LONG VA LCP TI GENERAL CLOVERLEAF FUSION","SUP-ITM-10096292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.96","2087.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1015.78","36.5","","148.37","54.89","631.39","94","862.72","2212.45","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 LONG VA LCP TI GENERAL CLOVERLEAF FUSION","SUP-ITM-10096292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.96","2087.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1065.87","38.3","","279.30","91.72","1116.77","266","862.72","2212.45","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 LONG VA LCP TI GENERAL CLOVERLEAF FUSION","SUP-ITM-10096292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.96","2087.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.89","42.9","","731.00","63.70","731.00","1 through 10","862.72","2212.45","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 LONG VA LCP TI GENERAL CLOVERLEAF FUSION","SUP-ITM-10096292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.96","2087.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.89","42.9","","384.74","384.74","384.74","1 through 10","862.72","2212.45","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 LONG VA LCP TI GENERAL CLOVERLEAF FUSION","SUP-ITM-10096292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.96","2087.22","WELLPOINT [1015]","HB AMC WELLPOINT","2053.27","73.78","","286.63","119.22","1107.45","105","862.72","2212.45","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 LONG VA LCP TI GENERAL CLOVERLEAF FUSION","SUP-ITM-10096292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.96","2087.22","AETNA [1001]","HB AMC AETNA HMO","1942.51","69.8","","675.31","184.75","1721.50","286","1454.37","2274.23","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 LONG VA LCP TI GENERAL CLOVERLEAF FUSION","SUP-ITM-10096292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.96","2087.22","AETNA [1001]","HB AMC AETNA PPO","2237.50","80.4","","1261.44","103.12","1514.10","21","1454.37","2274.23","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 LONG VA LCP TI GENERAL CLOVERLEAF FUSION","SUP-ITM-10096292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.96","2087.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2237.50","80.4","","1365.00","1365.00","1365.00","1 through 10","1454.37","2274.23","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 LONG VA LCP TI GENERAL CLOVERLEAF FUSION","SUP-ITM-10096292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.96","2087.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2274.23","81.72","","5157.68","5157.68","5157.68","1 through 10","1454.37","2274.23","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 LONG VA LCP TI GENERAL CLOVERLEAF FUSION","SUP-ITM-10096292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.96","2087.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2274.23","81.72","","431.26","71.26","1459.57","88","1454.37","2274.23","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.02","987.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1047.03","79.5","","800.18","480.96","1887.97","195","408.28","1047.03","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.02","987.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","701.97","53.3","","813.12","216.42","1444.50","81","408.28","1047.03","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.02","987.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","408.28","31","","432.60","432.60","432.60","1 through 10","408.28","1047.03","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.02","987.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","480.71","36.5","","148.37","54.89","631.39","94","408.28","1047.03","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.02","987.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","504.42","38.3","","279.30","91.72","1116.77","266","408.28","1047.03","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.02","987.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","565.00","42.9","","731.00","63.70","731.00","1 through 10","408.28","1047.03","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.02","987.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","565.00","42.9","","384.74","384.74","384.74","1 through 10","408.28","1047.03","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","both","","","1317.02","987.76","WELLPOINT [1015]","HB AMC WELLPOINT","971.70","73.78","","286.63","119.22","1107.45","105","408.28","1047.03","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1317.02","987.76","AETNA [1001]","HB AMC AETNA HMO","919.28","69.8","","675.31","184.75","1721.50","286","688.27","1076.27","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1317.02","987.76","AETNA [1001]","HB AMC AETNA PPO","1058.88","80.4","","1261.44","103.12","1514.10","21","688.27","1076.27","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1317.02","987.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1058.88","80.4","","1365.00","1365.00","1365.00","1 through 10","688.27","1076.27","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1317.02","987.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1076.27","81.72","","5157.68","5157.68","5157.68","1 through 10","688.27","1076.27","percent of total billed charges",""
"BONE PLATE 2.4MMX66 3 HOLE HEAD 10 LCP STAINLESS T SHAPE","SUP-ITM-10038160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1317.02","987.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1076.27","81.72","","431.26","71.26","1459.57","88","688.27","1076.27","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1718.47","1288.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1366.18","79.5","","800.18","480.96","1887.97","195","532.73","1366.18","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1718.47","1288.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","915.94","53.3","","813.12","216.42","1444.50","81","532.73","1366.18","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1718.47","1288.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","532.73","31","","432.60","432.60","432.60","1 through 10","532.73","1366.18","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1718.47","1288.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","627.24","36.5","","148.37","54.89","631.39","94","532.73","1366.18","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1718.47","1288.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","658.17","38.3","","279.30","91.72","1116.77","266","532.73","1366.18","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1718.47","1288.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","737.22","42.9","","731.00","63.70","731.00","1 through 10","532.73","1366.18","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1718.47","1288.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","737.22","42.9","","384.74","384.74","384.74","1 through 10","532.73","1366.18","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1718.47","1288.85","WELLPOINT [1015]","HB AMC WELLPOINT","1267.89","73.78","","286.63","119.22","1107.45","105","532.73","1366.18","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1718.47","1288.85","AETNA [1001]","HB AMC AETNA HMO","1199.49","69.8","","675.31","184.75","1721.50","286","898.07","1404.33","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1718.47","1288.85","AETNA [1001]","HB AMC AETNA PPO","1381.65","80.4","","1261.44","103.12","1514.10","21","898.07","1404.33","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1718.47","1288.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1381.65","80.4","","1365.00","1365.00","1365.00","1 through 10","898.07","1404.33","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1718.47","1288.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1404.33","81.72","","5157.68","5157.68","5157.68","1 through 10","898.07","1404.33","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1718.47","1288.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1404.33","81.72","","431.26","71.26","1459.57","88","898.07","1404.33","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1857.03","1392.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1476.34","79.5","","800.18","480.96","1887.97","195","575.68","1476.34","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1857.03","1392.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","989.80","53.3","","813.12","216.42","1444.50","81","575.68","1476.34","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1857.03","1392.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","575.68","31","","432.60","432.60","432.60","1 through 10","575.68","1476.34","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1857.03","1392.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","677.82","36.5","","148.37","54.89","631.39","94","575.68","1476.34","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1857.03","1392.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","711.24","38.3","","279.30","91.72","1116.77","266","575.68","1476.34","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1857.03","1392.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","796.67","42.9","","731.00","63.70","731.00","1 through 10","575.68","1476.34","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1857.03","1392.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","796.67","42.9","","384.74","384.74","384.74","1 through 10","575.68","1476.34","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1857.03","1392.77","WELLPOINT [1015]","HB AMC WELLPOINT","1370.12","73.78","","286.63","119.22","1107.45","105","575.68","1476.34","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1857.03","1392.77","AETNA [1001]","HB AMC AETNA HMO","1296.21","69.8","","675.31","184.75","1721.50","286","970.48","1517.56","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1857.03","1392.77","AETNA [1001]","HB AMC AETNA PPO","1493.05","80.4","","1261.44","103.12","1514.10","21","970.48","1517.56","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1857.03","1392.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1493.05","80.4","","1365.00","1365.00","1365.00","1 through 10","970.48","1517.56","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1857.03","1392.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1517.56","81.72","","5157.68","5157.68","5157.68","1 through 10","970.48","1517.56","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1857.03","1392.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1517.56","81.72","","431.26","71.26","1459.57","88","970.48","1517.56","percent of total billed charges",""
"BONE PLATE 2.4X111MM 14 HOLE BROAD LOCKING","SUP-ITM-10306469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4249.21","3186.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3378.12","79.5","","800.18","480.96","1887.97","195","1317.26","3378.12","percent of total billed charges",""
"BONE PLATE 2.4X111MM 14 HOLE BROAD LOCKING","SUP-ITM-10306469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4249.21","3186.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2264.83","53.3","","813.12","216.42","1444.50","81","1317.26","3378.12","percent of total billed charges",""
"BONE PLATE 2.4X111MM 14 HOLE BROAD LOCKING","SUP-ITM-10306469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4249.21","3186.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1317.26","31","","432.60","432.60","432.60","1 through 10","1317.26","3378.12","percent of total billed charges",""
"BONE PLATE 2.4X111MM 14 HOLE BROAD LOCKING","SUP-ITM-10306469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4249.21","3186.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1550.96","36.5","","148.37","54.89","631.39","94","1317.26","3378.12","percent of total billed charges",""
"BONE PLATE 2.4X111MM 14 HOLE BROAD LOCKING","SUP-ITM-10306469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4249.21","3186.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1627.45","38.3","","279.30","91.72","1116.77","266","1317.26","3378.12","percent of total billed charges",""
"BONE PLATE 2.4X111MM 14 HOLE BROAD LOCKING","SUP-ITM-10306469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4249.21","3186.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1822.91","42.9","","731.00","63.70","731.00","1 through 10","1317.26","3378.12","percent of total billed charges",""
"BONE PLATE 2.4X111MM 14 HOLE BROAD LOCKING","SUP-ITM-10306469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4249.21","3186.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1822.91","42.9","","384.74","384.74","384.74","1 through 10","1317.26","3378.12","percent of total billed charges",""
"BONE PLATE 2.4X111MM 14 HOLE BROAD LOCKING","SUP-ITM-10306469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4249.21","3186.91","WELLPOINT [1015]","HB AMC WELLPOINT","3135.07","73.78","","286.63","119.22","1107.45","105","1317.26","3378.12","percent of total billed charges",""
"BONE PLATE 2.4X111MM 14 HOLE BROAD LOCKING","SUP-ITM-10306469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4249.21","3186.91","AETNA [1001]","HB AMC AETNA HMO","2965.95","69.8","","675.31","184.75","1721.50","286","2220.64","3472.45","percent of total billed charges",""
"BONE PLATE 2.4X111MM 14 HOLE BROAD LOCKING","SUP-ITM-10306469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4249.21","3186.91","AETNA [1001]","HB AMC AETNA PPO","3416.36","80.4","","1261.44","103.12","1514.10","21","2220.64","3472.45","percent of total billed charges",""
"BONE PLATE 2.4X111MM 14 HOLE BROAD LOCKING","SUP-ITM-10306469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4249.21","3186.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3416.36","80.4","","1365.00","1365.00","1365.00","1 through 10","2220.64","3472.45","percent of total billed charges",""
"BONE PLATE 2.4X111MM 14 HOLE BROAD LOCKING","SUP-ITM-10306469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4249.21","3186.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3472.45","81.72","","5157.68","5157.68","5157.68","1 through 10","2220.64","3472.45","percent of total billed charges",""
"BONE PLATE 2.4X111MM 14 HOLE BROAD LOCKING","SUP-ITM-10306469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4249.21","3186.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3472.45","81.72","","431.26","71.26","1459.57","88","2220.64","3472.45","percent of total billed charges",""
"BONE PLATE 2.4X132MM 20 HOLE PROFILE","SUP-ITM-10306714","CDM","C1713","HCPCS","0278","RC","","","","both","","","2757.86","2068.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2192.50","79.5","","800.18","480.96","1887.97","195","854.94","2192.5","percent of total billed charges",""
"BONE PLATE 2.4X132MM 20 HOLE PROFILE","SUP-ITM-10306714","CDM","C1713","HCPCS","0278","RC","","","","both","","","2757.86","2068.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1469.94","53.3","","813.12","216.42","1444.50","81","854.94","2192.5","percent of total billed charges",""
"BONE PLATE 2.4X132MM 20 HOLE PROFILE","SUP-ITM-10306714","CDM","C1713","HCPCS","0278","RC","","","","both","","","2757.86","2068.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","854.94","31","","432.60","432.60","432.60","1 through 10","854.94","2192.5","percent of total billed charges",""
"BONE PLATE 2.4X132MM 20 HOLE PROFILE","SUP-ITM-10306714","CDM","C1713","HCPCS","0278","RC","","","","both","","","2757.86","2068.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1006.62","36.5","","148.37","54.89","631.39","94","854.94","2192.5","percent of total billed charges",""
"BONE PLATE 2.4X132MM 20 HOLE PROFILE","SUP-ITM-10306714","CDM","C1713","HCPCS","0278","RC","","","","both","","","2757.86","2068.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1056.26","38.3","","279.30","91.72","1116.77","266","854.94","2192.5","percent of total billed charges",""
"BONE PLATE 2.4X132MM 20 HOLE PROFILE","SUP-ITM-10306714","CDM","C1713","HCPCS","0278","RC","","","","both","","","2757.86","2068.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1183.12","42.9","","731.00","63.70","731.00","1 through 10","854.94","2192.5","percent of total billed charges",""
"BONE PLATE 2.4X132MM 20 HOLE PROFILE","SUP-ITM-10306714","CDM","C1713","HCPCS","0278","RC","","","","both","","","2757.86","2068.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1183.12","42.9","","384.74","384.74","384.74","1 through 10","854.94","2192.5","percent of total billed charges",""
"BONE PLATE 2.4X132MM 20 HOLE PROFILE","SUP-ITM-10306714","CDM","C1713","HCPCS","0278","RC","","","","both","","","2757.86","2068.39","WELLPOINT [1015]","HB AMC WELLPOINT","2034.75","73.78","","286.63","119.22","1107.45","105","854.94","2192.5","percent of total billed charges",""
"BONE PLATE 2.4X132MM 20 HOLE PROFILE","SUP-ITM-10306714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2757.86","2068.39","AETNA [1001]","HB AMC AETNA HMO","1924.99","69.8","","675.31","184.75","1721.50","286","1441.26","2253.72","percent of total billed charges",""
"BONE PLATE 2.4X132MM 20 HOLE PROFILE","SUP-ITM-10306714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2757.86","2068.39","AETNA [1001]","HB AMC AETNA PPO","2217.32","80.4","","1261.44","103.12","1514.10","21","1441.26","2253.72","percent of total billed charges",""
"BONE PLATE 2.4X132MM 20 HOLE PROFILE","SUP-ITM-10306714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2757.86","2068.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2217.32","80.4","","1365.00","1365.00","1365.00","1 through 10","1441.26","2253.72","percent of total billed charges",""
"BONE PLATE 2.4X132MM 20 HOLE PROFILE","SUP-ITM-10306714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2757.86","2068.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2253.72","81.72","","5157.68","5157.68","5157.68","1 through 10","1441.26","2253.72","percent of total billed charges",""
"BONE PLATE 2.4X132MM 20 HOLE PROFILE","SUP-ITM-10306714","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2757.86","2068.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2253.72","81.72","","431.26","71.26","1459.57","88","1441.26","2253.72","percent of total billed charges",""
"BONE PLATE 2.4X156MM 20 HOLE BROAD LOCKING","SUP-ITM-10306466","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.90","3285.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3482.82","79.5","","800.18","480.96","1887.97","195","1358.08","3482.82","percent of total billed charges",""
"BONE PLATE 2.4X156MM 20 HOLE BROAD LOCKING","SUP-ITM-10306466","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.90","3285.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2335.02","53.3","","813.12","216.42","1444.50","81","1358.08","3482.82","percent of total billed charges",""
"BONE PLATE 2.4X156MM 20 HOLE BROAD LOCKING","SUP-ITM-10306466","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.90","3285.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1358.08","31","","432.60","432.60","432.60","1 through 10","1358.08","3482.82","percent of total billed charges",""
"BONE PLATE 2.4X156MM 20 HOLE BROAD LOCKING","SUP-ITM-10306466","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.90","3285.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1599.03","36.5","","148.37","54.89","631.39","94","1358.08","3482.82","percent of total billed charges",""
"BONE PLATE 2.4X156MM 20 HOLE BROAD LOCKING","SUP-ITM-10306466","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.90","3285.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1677.88","38.3","","279.30","91.72","1116.77","266","1358.08","3482.82","percent of total billed charges",""
"BONE PLATE 2.4X156MM 20 HOLE BROAD LOCKING","SUP-ITM-10306466","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.90","3285.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1879.41","42.9","","731.00","63.70","731.00","1 through 10","1358.08","3482.82","percent of total billed charges",""
"BONE PLATE 2.4X156MM 20 HOLE BROAD LOCKING","SUP-ITM-10306466","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.90","3285.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1879.41","42.9","","384.74","384.74","384.74","1 through 10","1358.08","3482.82","percent of total billed charges",""
"BONE PLATE 2.4X156MM 20 HOLE BROAD LOCKING","SUP-ITM-10306466","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.90","3285.67","WELLPOINT [1015]","HB AMC WELLPOINT","3232.23","73.78","","286.63","119.22","1107.45","105","1358.08","3482.82","percent of total billed charges",""
"BONE PLATE 2.4X156MM 20 HOLE BROAD LOCKING","SUP-ITM-10306466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4380.90","3285.67","AETNA [1001]","HB AMC AETNA HMO","3057.87","69.8","","675.31","184.75","1721.50","286","2289.46","3580.07","percent of total billed charges",""
"BONE PLATE 2.4X156MM 20 HOLE BROAD LOCKING","SUP-ITM-10306466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4380.90","3285.67","AETNA [1001]","HB AMC AETNA PPO","3522.24","80.4","","1261.44","103.12","1514.10","21","2289.46","3580.07","percent of total billed charges",""
"BONE PLATE 2.4X156MM 20 HOLE BROAD LOCKING","SUP-ITM-10306466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4380.90","3285.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3522.24","80.4","","1365.00","1365.00","1365.00","1 through 10","2289.46","3580.07","percent of total billed charges",""
"BONE PLATE 2.4X156MM 20 HOLE BROAD LOCKING","SUP-ITM-10306466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4380.90","3285.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3580.07","81.72","","5157.68","5157.68","5157.68","1 through 10","2289.46","3580.07","percent of total billed charges",""
"BONE PLATE 2.4X156MM 20 HOLE BROAD LOCKING","SUP-ITM-10306466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4380.90","3285.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3580.07","81.72","","431.26","71.26","1459.57","88","2289.46","3580.07","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","both","","","2505.83","1879.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1992.13","79.5","","800.18","480.96","1887.97","195","776.81","1992.13","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","both","","","2505.83","1879.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1335.61","53.3","","813.12","216.42","1444.50","81","776.81","1992.13","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","both","","","2505.83","1879.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","776.81","31","","432.60","432.60","432.60","1 through 10","776.81","1992.13","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","both","","","2505.83","1879.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","914.63","36.5","","148.37","54.89","631.39","94","776.81","1992.13","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","both","","","2505.83","1879.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","959.73","38.3","","279.30","91.72","1116.77","266","776.81","1992.13","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","both","","","2505.83","1879.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1075.00","42.9","","731.00","63.70","731.00","1 through 10","776.81","1992.13","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","both","","","2505.83","1879.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1075.00","42.9","","384.74","384.74","384.74","1 through 10","776.81","1992.13","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","both","","","2505.83","1879.37","WELLPOINT [1015]","HB AMC WELLPOINT","1848.80","73.78","","286.63","119.22","1107.45","105","776.81","1992.13","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2505.83","1879.37","AETNA [1001]","HB AMC AETNA HMO","1749.07","69.8","","675.31","184.75","1721.50","286","1309.55","2047.76","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2505.83","1879.37","AETNA [1001]","HB AMC AETNA PPO","2014.69","80.4","","1261.44","103.12","1514.10","21","1309.55","2047.76","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2505.83","1879.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2014.69","80.4","","1365.00","1365.00","1365.00","1 through 10","1309.55","2047.76","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2505.83","1879.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2047.76","81.72","","5157.68","5157.68","5157.68","1 through 10","1309.55","2047.76","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2505.83","1879.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2047.76","81.72","","431.26","71.26","1459.57","88","1309.55","2047.76","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2648.28","1986.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2105.38","79.5","","800.18","480.96","1887.97","195","820.97","2105.38","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2648.28","1986.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1411.53","53.3","","813.12","216.42","1444.50","81","820.97","2105.38","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2648.28","1986.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","820.97","31","","432.60","432.60","432.60","1 through 10","820.97","2105.38","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2648.28","1986.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","966.62","36.5","","148.37","54.89","631.39","94","820.97","2105.38","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2648.28","1986.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1014.29","38.3","","279.30","91.72","1116.77","266","820.97","2105.38","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2648.28","1986.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1136.11","42.9","","731.00","63.70","731.00","1 through 10","820.97","2105.38","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2648.28","1986.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1136.11","42.9","","384.74","384.74","384.74","1 through 10","820.97","2105.38","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2648.28","1986.21","WELLPOINT [1015]","HB AMC WELLPOINT","1953.90","73.78","","286.63","119.22","1107.45","105","820.97","2105.38","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2648.28","1986.21","AETNA [1001]","HB AMC AETNA HMO","1848.50","69.8","","675.31","184.75","1721.50","286","1383.99","2164.17","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2648.28","1986.21","AETNA [1001]","HB AMC AETNA PPO","2129.22","80.4","","1261.44","103.12","1514.10","21","1383.99","2164.17","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2648.28","1986.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2129.22","80.4","","1365.00","1365.00","1365.00","1 through 10","1383.99","2164.17","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2648.28","1986.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2164.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1383.99","2164.17","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2648.28","1986.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2164.17","81.72","","431.26","71.26","1459.57","88","1383.99","2164.17","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM VA LCP TITANIUM CLOVERLEAF FUSION STANDARD","SUP-ITM-10096291","CDM","C1713","HCPCS","0278","RC","","","","both","","","2716.91","2037.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2159.94","79.5","","800.18","480.96","1887.97","195","842.24","2159.94","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM VA LCP TITANIUM CLOVERLEAF FUSION STANDARD","SUP-ITM-10096291","CDM","C1713","HCPCS","0278","RC","","","","both","","","2716.91","2037.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1448.11","53.3","","813.12","216.42","1444.50","81","842.24","2159.94","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM VA LCP TITANIUM CLOVERLEAF FUSION STANDARD","SUP-ITM-10096291","CDM","C1713","HCPCS","0278","RC","","","","both","","","2716.91","2037.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","842.24","31","","432.60","432.60","432.60","1 through 10","842.24","2159.94","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM VA LCP TITANIUM CLOVERLEAF FUSION STANDARD","SUP-ITM-10096291","CDM","C1713","HCPCS","0278","RC","","","","both","","","2716.91","2037.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","991.67","36.5","","148.37","54.89","631.39","94","842.24","2159.94","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM VA LCP TITANIUM CLOVERLEAF FUSION STANDARD","SUP-ITM-10096291","CDM","C1713","HCPCS","0278","RC","","","","both","","","2716.91","2037.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1040.58","38.3","","279.30","91.72","1116.77","266","842.24","2159.94","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM VA LCP TITANIUM CLOVERLEAF FUSION STANDARD","SUP-ITM-10096291","CDM","C1713","HCPCS","0278","RC","","","","both","","","2716.91","2037.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1165.55","42.9","","731.00","63.70","731.00","1 through 10","842.24","2159.94","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM VA LCP TITANIUM CLOVERLEAF FUSION STANDARD","SUP-ITM-10096291","CDM","C1713","HCPCS","0278","RC","","","","both","","","2716.91","2037.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1165.55","42.9","","384.74","384.74","384.74","1 through 10","842.24","2159.94","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM VA LCP TITANIUM CLOVERLEAF FUSION STANDARD","SUP-ITM-10096291","CDM","C1713","HCPCS","0278","RC","","","","both","","","2716.91","2037.68","WELLPOINT [1015]","HB AMC WELLPOINT","2004.54","73.78","","286.63","119.22","1107.45","105","842.24","2159.94","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM VA LCP TITANIUM CLOVERLEAF FUSION STANDARD","SUP-ITM-10096291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2716.91","2037.68","AETNA [1001]","HB AMC AETNA HMO","1896.40","69.8","","675.31","184.75","1721.50","286","1419.86","2220.26","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM VA LCP TITANIUM CLOVERLEAF FUSION STANDARD","SUP-ITM-10096291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2716.91","2037.68","AETNA [1001]","HB AMC AETNA PPO","2184.40","80.4","","1261.44","103.12","1514.10","21","1419.86","2220.26","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM VA LCP TITANIUM CLOVERLEAF FUSION STANDARD","SUP-ITM-10096291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2716.91","2037.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2184.40","80.4","","1365.00","1365.00","1365.00","1 through 10","1419.86","2220.26","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM VA LCP TITANIUM CLOVERLEAF FUSION STANDARD","SUP-ITM-10096291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2716.91","2037.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2220.26","81.72","","5157.68","5157.68","5157.68","1 through 10","1419.86","2220.26","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM VA LCP TITANIUM CLOVERLEAF FUSION STANDARD","SUP-ITM-10096291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2716.91","2037.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2220.26","81.72","","431.26","71.26","1459.57","88","1419.86","2220.26","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1815.59","1361.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1443.39","79.5","","800.18","480.96","1887.97","195","562.83","1443.39","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1815.59","1361.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","967.71","53.3","","813.12","216.42","1444.50","81","562.83","1443.39","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1815.59","1361.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","562.83","31","","432.60","432.60","432.60","1 through 10","562.83","1443.39","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1815.59","1361.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","662.69","36.5","","148.37","54.89","631.39","94","562.83","1443.39","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1815.59","1361.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","695.37","38.3","","279.30","91.72","1116.77","266","562.83","1443.39","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1815.59","1361.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","778.89","42.9","","731.00","63.70","731.00","1 through 10","562.83","1443.39","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1815.59","1361.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","778.89","42.9","","384.74","384.74","384.74","1 through 10","562.83","1443.39","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1815.59","1361.69","WELLPOINT [1015]","HB AMC WELLPOINT","1339.54","73.78","","286.63","119.22","1107.45","105","562.83","1443.39","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1815.59","1361.69","AETNA [1001]","HB AMC AETNA HMO","1267.28","69.8","","675.31","184.75","1721.50","286","948.83","1483.7","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1815.59","1361.69","AETNA [1001]","HB AMC AETNA PPO","1459.73","80.4","","1261.44","103.12","1514.10","21","948.83","1483.7","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1815.59","1361.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1459.73","80.4","","1365.00","1365.00","1365.00","1 through 10","948.83","1483.7","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1815.59","1361.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1483.70","81.72","","5157.68","5157.68","5157.68","1 through 10","948.83","1483.7","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1815.59","1361.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1483.70","81.72","","431.26","71.26","1459.57","88","948.83","1483.7","percent of total billed charges",""
"BONE PLATE 2.4X43MM 5 HOLE 3 LCP TI LEFT","SUP-ITM-10010127","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.95","2020.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2141.69","79.5","","800.18","480.96","1887.97","195","835.12","2141.69","percent of total billed charges",""
"BONE PLATE 2.4X43MM 5 HOLE 3 LCP TI LEFT","SUP-ITM-10010127","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.95","2020.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1435.88","53.3","","813.12","216.42","1444.50","81","835.12","2141.69","percent of total billed charges",""
"BONE PLATE 2.4X43MM 5 HOLE 3 LCP TI LEFT","SUP-ITM-10010127","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.95","2020.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","835.12","31","","432.60","432.60","432.60","1 through 10","835.12","2141.69","percent of total billed charges",""
"BONE PLATE 2.4X43MM 5 HOLE 3 LCP TI LEFT","SUP-ITM-10010127","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.95","2020.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","983.29","36.5","","148.37","54.89","631.39","94","835.12","2141.69","percent of total billed charges",""
"BONE PLATE 2.4X43MM 5 HOLE 3 LCP TI LEFT","SUP-ITM-10010127","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.95","2020.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1031.78","38.3","","279.30","91.72","1116.77","266","835.12","2141.69","percent of total billed charges",""
"BONE PLATE 2.4X43MM 5 HOLE 3 LCP TI LEFT","SUP-ITM-10010127","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.95","2020.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1155.70","42.9","","731.00","63.70","731.00","1 through 10","835.12","2141.69","percent of total billed charges",""
"BONE PLATE 2.4X43MM 5 HOLE 3 LCP TI LEFT","SUP-ITM-10010127","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.95","2020.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1155.70","42.9","","384.74","384.74","384.74","1 through 10","835.12","2141.69","percent of total billed charges",""
"BONE PLATE 2.4X43MM 5 HOLE 3 LCP TI LEFT","SUP-ITM-10010127","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.95","2020.46","WELLPOINT [1015]","HB AMC WELLPOINT","1987.60","73.78","","286.63","119.22","1107.45","105","835.12","2141.69","percent of total billed charges",""
"BONE PLATE 2.4X43MM 5 HOLE 3 LCP TI LEFT","SUP-ITM-10010127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2693.95","2020.46","AETNA [1001]","HB AMC AETNA HMO","1880.38","69.8","","675.31","184.75","1721.50","286","1407.86","2201.5","percent of total billed charges",""
"BONE PLATE 2.4X43MM 5 HOLE 3 LCP TI LEFT","SUP-ITM-10010127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2693.95","2020.46","AETNA [1001]","HB AMC AETNA PPO","2165.94","80.4","","1261.44","103.12","1514.10","21","1407.86","2201.5","percent of total billed charges",""
"BONE PLATE 2.4X43MM 5 HOLE 3 LCP TI LEFT","SUP-ITM-10010127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2693.95","2020.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2165.94","80.4","","1365.00","1365.00","1365.00","1 through 10","1407.86","2201.5","percent of total billed charges",""
"BONE PLATE 2.4X43MM 5 HOLE 3 LCP TI LEFT","SUP-ITM-10010127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2693.95","2020.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2201.50","81.72","","5157.68","5157.68","5157.68","1 through 10","1407.86","2201.5","percent of total billed charges",""
"BONE PLATE 2.4X43MM 5 HOLE 3 LCP TI LEFT","SUP-ITM-10010127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2693.95","2020.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2201.50","81.72","","431.26","71.26","1459.57","88","1407.86","2201.5","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2006.17","1504.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1594.91","79.5","","800.18","480.96","1887.97","195","621.91","1594.91","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2006.17","1504.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1069.29","53.3","","813.12","216.42","1444.50","81","621.91","1594.91","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2006.17","1504.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","621.91","31","","432.60","432.60","432.60","1 through 10","621.91","1594.91","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2006.17","1504.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","732.25","36.5","","148.37","54.89","631.39","94","621.91","1594.91","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2006.17","1504.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","768.36","38.3","","279.30","91.72","1116.77","266","621.91","1594.91","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2006.17","1504.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","860.65","42.9","","731.00","63.70","731.00","1 through 10","621.91","1594.91","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2006.17","1504.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","860.65","42.9","","384.74","384.74","384.74","1 through 10","621.91","1594.91","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2006.17","1504.63","WELLPOINT [1015]","HB AMC WELLPOINT","1480.15","73.78","","286.63","119.22","1107.45","105","621.91","1594.91","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2006.17","1504.63","AETNA [1001]","HB AMC AETNA HMO","1400.31","69.8","","675.31","184.75","1721.50","286","1048.42","1639.44","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2006.17","1504.63","AETNA [1001]","HB AMC AETNA PPO","1612.96","80.4","","1261.44","103.12","1514.10","21","1048.42","1639.44","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2006.17","1504.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1612.96","80.4","","1365.00","1365.00","1365.00","1 through 10","1048.42","1639.44","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2006.17","1504.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1639.44","81.72","","5157.68","5157.68","5157.68","1 through 10","1048.42","1639.44","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2006.17","1504.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1639.44","81.72","","431.26","71.26","1459.57","88","1048.42","1639.44","percent of total billed charges",""
"BONE PLATE 2.4X54MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10002254","CDM","C1713","HCPCS","0278","RC","","","","both","","","1794.87","1346.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1426.92","79.5","","800.18","480.96","1887.97","195","556.41","1426.92","percent of total billed charges",""
"BONE PLATE 2.4X54MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10002254","CDM","C1713","HCPCS","0278","RC","","","","both","","","1794.87","1346.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","956.67","53.3","","813.12","216.42","1444.50","81","556.41","1426.92","percent of total billed charges",""
"BONE PLATE 2.4X54MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10002254","CDM","C1713","HCPCS","0278","RC","","","","both","","","1794.87","1346.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","556.41","31","","432.60","432.60","432.60","1 through 10","556.41","1426.92","percent of total billed charges",""
"BONE PLATE 2.4X54MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10002254","CDM","C1713","HCPCS","0278","RC","","","","both","","","1794.87","1346.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","655.13","36.5","","148.37","54.89","631.39","94","556.41","1426.92","percent of total billed charges",""
"BONE PLATE 2.4X54MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10002254","CDM","C1713","HCPCS","0278","RC","","","","both","","","1794.87","1346.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","687.44","38.3","","279.30","91.72","1116.77","266","556.41","1426.92","percent of total billed charges",""
"BONE PLATE 2.4X54MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10002254","CDM","C1713","HCPCS","0278","RC","","","","both","","","1794.87","1346.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","770.00","42.9","","731.00","63.70","731.00","1 through 10","556.41","1426.92","percent of total billed charges",""
"BONE PLATE 2.4X54MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10002254","CDM","C1713","HCPCS","0278","RC","","","","both","","","1794.87","1346.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","770.00","42.9","","384.74","384.74","384.74","1 through 10","556.41","1426.92","percent of total billed charges",""
"BONE PLATE 2.4X54MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10002254","CDM","C1713","HCPCS","0278","RC","","","","both","","","1794.87","1346.15","WELLPOINT [1015]","HB AMC WELLPOINT","1324.26","73.78","","286.63","119.22","1107.45","105","556.41","1426.92","percent of total billed charges",""
"BONE PLATE 2.4X54MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10002254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1794.87","1346.15","AETNA [1001]","HB AMC AETNA HMO","1252.82","69.8","","675.31","184.75","1721.50","286","938","1466.77","percent of total billed charges",""
"BONE PLATE 2.4X54MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10002254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1794.87","1346.15","AETNA [1001]","HB AMC AETNA PPO","1443.08","80.4","","1261.44","103.12","1514.10","21","938","1466.77","percent of total billed charges",""
"BONE PLATE 2.4X54MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10002254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1794.87","1346.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1443.08","80.4","","1365.00","1365.00","1365.00","1 through 10","938","1466.77","percent of total billed charges",""
"BONE PLATE 2.4X54MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10002254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1794.87","1346.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1466.77","81.72","","5157.68","5157.68","5157.68","1 through 10","938","1466.77","percent of total billed charges",""
"BONE PLATE 2.4X54MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10002254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1794.87","1346.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1466.77","81.72","","431.26","71.26","1459.57","88","938","1466.77","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 VA LCP STAINLESS RIM RIGHT","SUP-ITM-10096972","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1870.65","79.5","","800.18","480.96","1887.97","195","729.44","1870.65","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 VA LCP STAINLESS RIM RIGHT","SUP-ITM-10096972","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1254.16","53.3","","813.12","216.42","1444.50","81","729.44","1870.65","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 VA LCP STAINLESS RIM RIGHT","SUP-ITM-10096972","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","729.44","31","","432.60","432.60","432.60","1 through 10","729.44","1870.65","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 VA LCP STAINLESS RIM RIGHT","SUP-ITM-10096972","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","858.85","36.5","","148.37","54.89","631.39","94","729.44","1870.65","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 VA LCP STAINLESS RIM RIGHT","SUP-ITM-10096972","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","901.21","38.3","","279.30","91.72","1116.77","266","729.44","1870.65","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 VA LCP STAINLESS RIM RIGHT","SUP-ITM-10096972","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1009.45","42.9","","731.00","63.70","731.00","1 through 10","729.44","1870.65","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 VA LCP STAINLESS RIM RIGHT","SUP-ITM-10096972","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1009.45","42.9","","384.74","384.74","384.74","1 through 10","729.44","1870.65","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 VA LCP STAINLESS RIM RIGHT","SUP-ITM-10096972","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","WELLPOINT [1015]","HB AMC WELLPOINT","1736.06","73.78","","286.63","119.22","1107.45","105","729.44","1870.65","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 VA LCP STAINLESS RIM RIGHT","SUP-ITM-10096972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2353.02","1764.76","AETNA [1001]","HB AMC AETNA HMO","1642.41","69.8","","675.31","184.75","1721.50","286","1229.69","1922.89","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 VA LCP STAINLESS RIM RIGHT","SUP-ITM-10096972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2353.02","1764.76","AETNA [1001]","HB AMC AETNA PPO","1891.83","80.4","","1261.44","103.12","1514.10","21","1229.69","1922.89","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 VA LCP STAINLESS RIM RIGHT","SUP-ITM-10096972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2353.02","1764.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1891.83","80.4","","1365.00","1365.00","1365.00","1 through 10","1229.69","1922.89","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 VA LCP STAINLESS RIM RIGHT","SUP-ITM-10096972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2353.02","1764.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1922.89","81.72","","5157.68","5157.68","5157.68","1 through 10","1229.69","1922.89","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 VA LCP STAINLESS RIM RIGHT","SUP-ITM-10096972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2353.02","1764.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1922.89","81.72","","431.26","71.26","1459.57","88","1229.69","1922.89","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1630.41","1222.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1296.18","79.5","","800.18","480.96","1887.97","195","505.43","1296.18","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1630.41","1222.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","869.01","53.3","","813.12","216.42","1444.50","81","505.43","1296.18","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1630.41","1222.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","505.43","31","","432.60","432.60","432.60","1 through 10","505.43","1296.18","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1630.41","1222.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","595.10","36.5","","148.37","54.89","631.39","94","505.43","1296.18","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1630.41","1222.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","624.45","38.3","","279.30","91.72","1116.77","266","505.43","1296.18","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1630.41","1222.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","699.45","42.9","","731.00","63.70","731.00","1 through 10","505.43","1296.18","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1630.41","1222.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","699.45","42.9","","384.74","384.74","384.74","1 through 10","505.43","1296.18","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1630.41","1222.81","WELLPOINT [1015]","HB AMC WELLPOINT","1202.92","73.78","","286.63","119.22","1107.45","105","505.43","1296.18","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1630.41","1222.81","AETNA [1001]","HB AMC AETNA HMO","1138.03","69.8","","675.31","184.75","1721.50","286","852.05","1332.37","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1630.41","1222.81","AETNA [1001]","HB AMC AETNA PPO","1310.85","80.4","","1261.44","103.12","1514.10","21","852.05","1332.37","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1630.41","1222.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1310.85","80.4","","1365.00","1365.00","1365.00","1 through 10","852.05","1332.37","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1630.41","1222.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1332.37","81.72","","5157.68","5157.68","5157.68","1 through 10","852.05","1332.37","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1630.41","1222.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1332.37","81.72","","431.26","71.26","1459.57","88","852.05","1332.37","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.82","1355.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1437.22","79.5","","800.18","480.96","1887.97","195","560.42","1437.22","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.82","1355.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","963.57","53.3","","813.12","216.42","1444.50","81","560.42","1437.22","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.82","1355.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","560.42","31","","432.60","432.60","432.60","1 through 10","560.42","1437.22","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.82","1355.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","659.85","36.5","","148.37","54.89","631.39","94","560.42","1437.22","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.82","1355.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","692.40","38.3","","279.30","91.72","1116.77","266","560.42","1437.22","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.82","1355.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","775.55","42.9","","731.00","63.70","731.00","1 through 10","560.42","1437.22","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.82","1355.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","775.55","42.9","","384.74","384.74","384.74","1 through 10","560.42","1437.22","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.82","1355.86","WELLPOINT [1015]","HB AMC WELLPOINT","1333.81","73.78","","286.63","119.22","1107.45","105","560.42","1437.22","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1807.82","1355.86","AETNA [1001]","HB AMC AETNA HMO","1261.86","69.8","","675.31","184.75","1721.50","286","944.77","1477.35","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1807.82","1355.86","AETNA [1001]","HB AMC AETNA PPO","1453.49","80.4","","1261.44","103.12","1514.10","21","944.77","1477.35","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1807.82","1355.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1453.49","80.4","","1365.00","1365.00","1365.00","1 through 10","944.77","1477.35","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1807.82","1355.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1477.35","81.72","","5157.68","5157.68","5157.68","1 through 10","944.77","1477.35","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1807.82","1355.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1477.35","81.72","","431.26","71.26","1459.57","88","944.77","1477.35","percent of total billed charges",""
"BONE PLATE 2.4X61MM 5 HOLE LCP TI LEFT","SUP-ITM-10012805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2853.48","2140.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2268.52","79.5","","800.18","480.96","1887.97","195","884.58","2268.52","percent of total billed charges",""
"BONE PLATE 2.4X61MM 5 HOLE LCP TI LEFT","SUP-ITM-10012805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2853.48","2140.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1520.90","53.3","","813.12","216.42","1444.50","81","884.58","2268.52","percent of total billed charges",""
"BONE PLATE 2.4X61MM 5 HOLE LCP TI LEFT","SUP-ITM-10012805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2853.48","2140.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","884.58","31","","432.60","432.60","432.60","1 through 10","884.58","2268.52","percent of total billed charges",""
"BONE PLATE 2.4X61MM 5 HOLE LCP TI LEFT","SUP-ITM-10012805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2853.48","2140.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1041.52","36.5","","148.37","54.89","631.39","94","884.58","2268.52","percent of total billed charges",""
"BONE PLATE 2.4X61MM 5 HOLE LCP TI LEFT","SUP-ITM-10012805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2853.48","2140.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1092.88","38.3","","279.30","91.72","1116.77","266","884.58","2268.52","percent of total billed charges",""
"BONE PLATE 2.4X61MM 5 HOLE LCP TI LEFT","SUP-ITM-10012805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2853.48","2140.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1224.14","42.9","","731.00","63.70","731.00","1 through 10","884.58","2268.52","percent of total billed charges",""
"BONE PLATE 2.4X61MM 5 HOLE LCP TI LEFT","SUP-ITM-10012805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2853.48","2140.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1224.14","42.9","","384.74","384.74","384.74","1 through 10","884.58","2268.52","percent of total billed charges",""
"BONE PLATE 2.4X61MM 5 HOLE LCP TI LEFT","SUP-ITM-10012805","CDM","C1713","HCPCS","0278","RC","","","","both","","","2853.48","2140.11","WELLPOINT [1015]","HB AMC WELLPOINT","2105.30","73.78","","286.63","119.22","1107.45","105","884.58","2268.52","percent of total billed charges",""
"BONE PLATE 2.4X61MM 5 HOLE LCP TI LEFT","SUP-ITM-10012805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2853.48","2140.11","AETNA [1001]","HB AMC AETNA HMO","1991.73","69.8","","675.31","184.75","1721.50","286","1491.23","2331.86","percent of total billed charges",""
"BONE PLATE 2.4X61MM 5 HOLE LCP TI LEFT","SUP-ITM-10012805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2853.48","2140.11","AETNA [1001]","HB AMC AETNA PPO","2294.20","80.4","","1261.44","103.12","1514.10","21","1491.23","2331.86","percent of total billed charges",""
"BONE PLATE 2.4X61MM 5 HOLE LCP TI LEFT","SUP-ITM-10012805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2853.48","2140.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2294.20","80.4","","1365.00","1365.00","1365.00","1 through 10","1491.23","2331.86","percent of total billed charges",""
"BONE PLATE 2.4X61MM 5 HOLE LCP TI LEFT","SUP-ITM-10012805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2853.48","2140.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2331.86","81.72","","5157.68","5157.68","5157.68","1 through 10","1491.23","2331.86","percent of total billed charges",""
"BONE PLATE 2.4X61MM 5 HOLE LCP TI LEFT","SUP-ITM-10012805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2853.48","2140.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2331.86","81.72","","431.26","71.26","1459.57","88","1491.23","2331.86","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE PROFILE","SUP-ITM-10306715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.36","1852.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1963.14","79.5","","800.18","480.96","1887.97","195","765.5","1963.14","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE PROFILE","SUP-ITM-10306715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.36","1852.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1316.17","53.3","","813.12","216.42","1444.50","81","765.5","1963.14","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE PROFILE","SUP-ITM-10306715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.36","1852.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","765.50","31","","432.60","432.60","432.60","1 through 10","765.5","1963.14","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE PROFILE","SUP-ITM-10306715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.36","1852.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","901.32","36.5","","148.37","54.89","631.39","94","765.5","1963.14","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE PROFILE","SUP-ITM-10306715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.36","1852.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","945.76","38.3","","279.30","91.72","1116.77","266","765.5","1963.14","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE PROFILE","SUP-ITM-10306715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.36","1852.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1059.36","42.9","","731.00","63.70","731.00","1 through 10","765.5","1963.14","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE PROFILE","SUP-ITM-10306715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.36","1852.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1059.36","42.9","","384.74","384.74","384.74","1 through 10","765.5","1963.14","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE PROFILE","SUP-ITM-10306715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.36","1852.02","WELLPOINT [1015]","HB AMC WELLPOINT","1821.89","73.78","","286.63","119.22","1107.45","105","765.5","1963.14","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE PROFILE","SUP-ITM-10306715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2469.36","1852.02","AETNA [1001]","HB AMC AETNA HMO","1723.61","69.8","","675.31","184.75","1721.50","286","1290.49","2017.96","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE PROFILE","SUP-ITM-10306715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2469.36","1852.02","AETNA [1001]","HB AMC AETNA PPO","1985.37","80.4","","1261.44","103.12","1514.10","21","1290.49","2017.96","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE PROFILE","SUP-ITM-10306715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2469.36","1852.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1985.37","80.4","","1365.00","1365.00","1365.00","1 through 10","1290.49","2017.96","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE PROFILE","SUP-ITM-10306715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2469.36","1852.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2017.96","81.72","","5157.68","5157.68","5157.68","1 through 10","1290.49","2017.96","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE PROFILE","SUP-ITM-10306715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2469.36","1852.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2017.96","81.72","","431.26","71.26","1459.57","88","1290.49","2017.96","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2681.95","2011.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2132.15","79.5","","800.18","480.96","1887.97","195","831.4","2132.15","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2681.95","2011.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1429.48","53.3","","813.12","216.42","1444.50","81","831.4","2132.15","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2681.95","2011.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","831.40","31","","432.60","432.60","432.60","1 through 10","831.4","2132.15","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2681.95","2011.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","978.91","36.5","","148.37","54.89","631.39","94","831.4","2132.15","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2681.95","2011.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1027.19","38.3","","279.30","91.72","1116.77","266","831.4","2132.15","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2681.95","2011.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.56","42.9","","731.00","63.70","731.00","1 through 10","831.4","2132.15","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2681.95","2011.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.56","42.9","","384.74","384.74","384.74","1 through 10","831.4","2132.15","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","both","","","2681.95","2011.46","WELLPOINT [1015]","HB AMC WELLPOINT","1978.74","73.78","","286.63","119.22","1107.45","105","831.4","2132.15","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2681.95","2011.46","AETNA [1001]","HB AMC AETNA HMO","1872.00","69.8","","675.31","184.75","1721.50","286","1401.59","2191.69","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2681.95","2011.46","AETNA [1001]","HB AMC AETNA PPO","2156.29","80.4","","1261.44","103.12","1514.10","21","1401.59","2191.69","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2681.95","2011.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2156.29","80.4","","1365.00","1365.00","1365.00","1 through 10","1401.59","2191.69","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2681.95","2011.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2191.69","81.72","","5157.68","5157.68","5157.68","1 through 10","1401.59","2191.69","percent of total billed charges",""
"BONE PLATE 2.4X66MM 10 HOLE SHAFT LC DCP SS CUBOID","SUP-ITM-10038161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2681.95","2011.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2191.69","81.72","","431.26","71.26","1459.57","88","1401.59","2191.69","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1258.74","944.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1000.70","79.5","","800.18","480.96","1887.97","195","390.21","1000.7","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1258.74","944.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","670.91","53.3","","813.12","216.42","1444.50","81","390.21","1000.7","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1258.74","944.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","390.21","31","","432.60","432.60","432.60","1 through 10","390.21","1000.7","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1258.74","944.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","459.44","36.5","","148.37","54.89","631.39","94","390.21","1000.7","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1258.74","944.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","482.10","38.3","","279.30","91.72","1116.77","266","390.21","1000.7","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1258.74","944.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.00","42.9","","731.00","63.70","731.00","1 through 10","390.21","1000.7","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1258.74","944.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.00","42.9","","384.74","384.74","384.74","1 through 10","390.21","1000.7","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1258.74","944.05","WELLPOINT [1015]","HB AMC WELLPOINT","928.70","73.78","","286.63","119.22","1107.45","105","390.21","1000.7","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1258.74","944.05","AETNA [1001]","HB AMC AETNA HMO","878.60","69.8","","675.31","184.75","1721.50","286","657.82","1028.64","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1258.74","944.05","AETNA [1001]","HB AMC AETNA PPO","1012.03","80.4","","1261.44","103.12","1514.10","21","657.82","1028.64","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1258.74","944.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1012.03","80.4","","1365.00","1365.00","1365.00","1 through 10","657.82","1028.64","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1258.74","944.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1028.64","81.72","","5157.68","5157.68","5157.68","1 through 10","657.82","1028.64","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE TI STRAIGHT","SUP-ITM-10006277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1258.74","944.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1028.64","81.72","","431.26","71.26","1459.57","88","657.82","1028.64","percent of total billed charges",""
"BONE PLATE 2.4X76MM 5X10HOLE T-SHAPE NARROW LOCKING","SUP-ITM-10306686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3964.42","2973.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3151.71","79.5","","800.18","480.96","1887.97","195","1228.97","3151.71","percent of total billed charges",""
"BONE PLATE 2.4X76MM 5X10HOLE T-SHAPE NARROW LOCKING","SUP-ITM-10306686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3964.42","2973.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2113.04","53.3","","813.12","216.42","1444.50","81","1228.97","3151.71","percent of total billed charges",""
"BONE PLATE 2.4X76MM 5X10HOLE T-SHAPE NARROW LOCKING","SUP-ITM-10306686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3964.42","2973.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1228.97","31","","432.60","432.60","432.60","1 through 10","1228.97","3151.71","percent of total billed charges",""
"BONE PLATE 2.4X76MM 5X10HOLE T-SHAPE NARROW LOCKING","SUP-ITM-10306686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3964.42","2973.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1447.01","36.5","","148.37","54.89","631.39","94","1228.97","3151.71","percent of total billed charges",""
"BONE PLATE 2.4X76MM 5X10HOLE T-SHAPE NARROW LOCKING","SUP-ITM-10306686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3964.42","2973.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1518.37","38.3","","279.30","91.72","1116.77","266","1228.97","3151.71","percent of total billed charges",""
"BONE PLATE 2.4X76MM 5X10HOLE T-SHAPE NARROW LOCKING","SUP-ITM-10306686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3964.42","2973.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1700.74","42.9","","731.00","63.70","731.00","1 through 10","1228.97","3151.71","percent of total billed charges",""
"BONE PLATE 2.4X76MM 5X10HOLE T-SHAPE NARROW LOCKING","SUP-ITM-10306686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3964.42","2973.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1700.74","42.9","","384.74","384.74","384.74","1 through 10","1228.97","3151.71","percent of total billed charges",""
"BONE PLATE 2.4X76MM 5X10HOLE T-SHAPE NARROW LOCKING","SUP-ITM-10306686","CDM","C1713","HCPCS","0278","RC","","","","both","","","3964.42","2973.31","WELLPOINT [1015]","HB AMC WELLPOINT","2924.95","73.78","","286.63","119.22","1107.45","105","1228.97","3151.71","percent of total billed charges",""
"BONE PLATE 2.4X76MM 5X10HOLE T-SHAPE NARROW LOCKING","SUP-ITM-10306686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3964.42","2973.31","AETNA [1001]","HB AMC AETNA HMO","2767.17","69.8","","675.31","184.75","1721.50","286","2071.81","3239.72","percent of total billed charges",""
"BONE PLATE 2.4X76MM 5X10HOLE T-SHAPE NARROW LOCKING","SUP-ITM-10306686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3964.42","2973.31","AETNA [1001]","HB AMC AETNA PPO","3187.39","80.4","","1261.44","103.12","1514.10","21","2071.81","3239.72","percent of total billed charges",""
"BONE PLATE 2.4X76MM 5X10HOLE T-SHAPE NARROW LOCKING","SUP-ITM-10306686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3964.42","2973.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3187.39","80.4","","1365.00","1365.00","1365.00","1 through 10","2071.81","3239.72","percent of total billed charges",""
"BONE PLATE 2.4X76MM 5X10HOLE T-SHAPE NARROW LOCKING","SUP-ITM-10306686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3964.42","2973.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3239.72","81.72","","5157.68","5157.68","5157.68","1 through 10","2071.81","3239.72","percent of total billed charges",""
"BONE PLATE 2.4X76MM 5X10HOLE T-SHAPE NARROW LOCKING","SUP-ITM-10306686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3964.42","2973.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3239.72","81.72","","431.26","71.26","1459.57","88","2071.81","3239.72","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","2110.08","1582.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1677.51","79.5","","800.18","480.96","1887.97","195","654.12","1677.51","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","2110.08","1582.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1124.67","53.3","","813.12","216.42","1444.50","81","654.12","1677.51","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","2110.08","1582.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","654.12","31","","432.60","432.60","432.60","1 through 10","654.12","1677.51","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","2110.08","1582.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","770.18","36.5","","148.37","54.89","631.39","94","654.12","1677.51","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","2110.08","1582.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","808.16","38.3","","279.30","91.72","1116.77","266","654.12","1677.51","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","2110.08","1582.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","905.22","42.9","","731.00","63.70","731.00","1 through 10","654.12","1677.51","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","2110.08","1582.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","905.22","42.9","","384.74","384.74","384.74","1 through 10","654.12","1677.51","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","2110.08","1582.56","WELLPOINT [1015]","HB AMC WELLPOINT","1556.82","73.78","","286.63","119.22","1107.45","105","654.12","1677.51","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2110.08","1582.56","AETNA [1001]","HB AMC AETNA HMO","1472.84","69.8","","675.31","184.75","1721.50","286","1102.73","1724.36","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2110.08","1582.56","AETNA [1001]","HB AMC AETNA PPO","1696.50","80.4","","1261.44","103.12","1514.10","21","1102.73","1724.36","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2110.08","1582.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1696.50","80.4","","1365.00","1365.00","1365.00","1 through 10","1102.73","1724.36","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2110.08","1582.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1724.36","81.72","","5157.68","5157.68","5157.68","1 through 10","1102.73","1724.36","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2110.08","1582.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1724.36","81.72","","431.26","71.26","1459.57","88","1102.73","1724.36","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1147.37","860.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","912.16","79.5","","800.18","480.96","1887.97","195","355.68","912.16","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1147.37","860.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","611.55","53.3","","813.12","216.42","1444.50","81","355.68","912.16","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1147.37","860.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","355.68","31","","432.60","432.60","432.60","1 through 10","355.68","912.16","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1147.37","860.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","418.79","36.5","","148.37","54.89","631.39","94","355.68","912.16","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1147.37","860.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","439.44","38.3","","279.30","91.72","1116.77","266","355.68","912.16","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1147.37","860.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","492.22","42.9","","731.00","63.70","731.00","1 through 10","355.68","912.16","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1147.37","860.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","492.22","42.9","","384.74","384.74","384.74","1 through 10","355.68","912.16","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1147.37","860.53","WELLPOINT [1015]","HB AMC WELLPOINT","846.53","73.78","","286.63","119.22","1107.45","105","355.68","912.16","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1147.37","860.53","AETNA [1001]","HB AMC AETNA HMO","800.86","69.8","","675.31","184.75","1721.50","286","599.62","937.63","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1147.37","860.53","AETNA [1001]","HB AMC AETNA PPO","922.49","80.4","","1261.44","103.12","1514.10","21","599.62","937.63","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1147.37","860.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","922.49","80.4","","1365.00","1365.00","1365.00","1 through 10","599.62","937.63","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1147.37","860.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","937.63","81.72","","5157.68","5157.68","5157.68","1 through 10","599.62","937.63","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1147.37","860.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","937.63","81.72","","431.26","71.26","1459.57","88","599.62","937.63","percent of total billed charges",""
"BONE PLATE 2.5MM 12 HOLE CRANIAL MATRIXMANDIBLE TI RECONSTRUCTION STRAIGHT","SUP-ITM-10081095","CDM","C1713","HCPCS","0278","RC","","","","both","","","2001.51","1501.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1591.20","79.5","","800.18","480.96","1887.97","195","620.47","1591.2","percent of total billed charges",""
"BONE PLATE 2.5MM 12 HOLE CRANIAL MATRIXMANDIBLE TI RECONSTRUCTION STRAIGHT","SUP-ITM-10081095","CDM","C1713","HCPCS","0278","RC","","","","both","","","2001.51","1501.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1066.80","53.3","","813.12","216.42","1444.50","81","620.47","1591.2","percent of total billed charges",""
"BONE PLATE 2.5MM 12 HOLE CRANIAL MATRIXMANDIBLE TI RECONSTRUCTION STRAIGHT","SUP-ITM-10081095","CDM","C1713","HCPCS","0278","RC","","","","both","","","2001.51","1501.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","620.47","31","","432.60","432.60","432.60","1 through 10","620.47","1591.2","percent of total billed charges",""
"BONE PLATE 2.5MM 12 HOLE CRANIAL MATRIXMANDIBLE TI RECONSTRUCTION STRAIGHT","SUP-ITM-10081095","CDM","C1713","HCPCS","0278","RC","","","","both","","","2001.51","1501.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","730.55","36.5","","148.37","54.89","631.39","94","620.47","1591.2","percent of total billed charges",""
"BONE PLATE 2.5MM 12 HOLE CRANIAL MATRIXMANDIBLE TI RECONSTRUCTION STRAIGHT","SUP-ITM-10081095","CDM","C1713","HCPCS","0278","RC","","","","both","","","2001.51","1501.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","766.58","38.3","","279.30","91.72","1116.77","266","620.47","1591.2","percent of total billed charges",""
"BONE PLATE 2.5MM 12 HOLE CRANIAL MATRIXMANDIBLE TI RECONSTRUCTION STRAIGHT","SUP-ITM-10081095","CDM","C1713","HCPCS","0278","RC","","","","both","","","2001.51","1501.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","858.65","42.9","","731.00","63.70","731.00","1 through 10","620.47","1591.2","percent of total billed charges",""
"BONE PLATE 2.5MM 12 HOLE CRANIAL MATRIXMANDIBLE TI RECONSTRUCTION STRAIGHT","SUP-ITM-10081095","CDM","C1713","HCPCS","0278","RC","","","","both","","","2001.51","1501.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","858.65","42.9","","384.74","384.74","384.74","1 through 10","620.47","1591.2","percent of total billed charges",""
"BONE PLATE 2.5MM 12 HOLE CRANIAL MATRIXMANDIBLE TI RECONSTRUCTION STRAIGHT","SUP-ITM-10081095","CDM","C1713","HCPCS","0278","RC","","","","both","","","2001.51","1501.13","WELLPOINT [1015]","HB AMC WELLPOINT","1476.71","73.78","","286.63","119.22","1107.45","105","620.47","1591.2","percent of total billed charges",""
"BONE PLATE 2.5MM 12 HOLE CRANIAL MATRIXMANDIBLE TI RECONSTRUCTION STRAIGHT","SUP-ITM-10081095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2001.51","1501.13","AETNA [1001]","HB AMC AETNA HMO","1397.05","69.8","","675.31","184.75","1721.50","286","1045.99","1635.63","percent of total billed charges",""
"BONE PLATE 2.5MM 12 HOLE CRANIAL MATRIXMANDIBLE TI RECONSTRUCTION STRAIGHT","SUP-ITM-10081095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2001.51","1501.13","AETNA [1001]","HB AMC AETNA PPO","1609.21","80.4","","1261.44","103.12","1514.10","21","1045.99","1635.63","percent of total billed charges",""
"BONE PLATE 2.5MM 12 HOLE CRANIAL MATRIXMANDIBLE TI RECONSTRUCTION STRAIGHT","SUP-ITM-10081095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2001.51","1501.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1609.21","80.4","","1365.00","1365.00","1365.00","1 through 10","1045.99","1635.63","percent of total billed charges",""
"BONE PLATE 2.5MM 12 HOLE CRANIAL MATRIXMANDIBLE TI RECONSTRUCTION STRAIGHT","SUP-ITM-10081095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2001.51","1501.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1635.63","81.72","","5157.68","5157.68","5157.68","1 through 10","1045.99","1635.63","percent of total billed charges",""
"BONE PLATE 2.5MM 12 HOLE CRANIAL MATRIXMANDIBLE TI RECONSTRUCTION STRAIGHT","SUP-ITM-10081095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2001.51","1501.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1635.63","81.72","","431.26","71.26","1459.57","88","1045.99","1635.63","percent of total billed charges",""
"BONE PLATE 2.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2205.50","79.5","","800.18","480.96","1887.97","195","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 2.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1478.65","53.3","","813.12","216.42","1444.50","81","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 2.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","860.01","31","","432.60","432.60","432.60","1 through 10","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 2.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1012.59","36.5","","148.37","54.89","631.39","94","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 2.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1062.52","38.3","","279.30","91.72","1116.77","266","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 2.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1190.14","42.9","","731.00","63.70","731.00","1 through 10","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 2.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1190.14","42.9","","384.74","384.74","384.74","1 through 10","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 2.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","WELLPOINT [1015]","HB AMC WELLPOINT","2046.81","73.78","","286.63","119.22","1107.45","105","860.01","2205.5","percent of total billed charges",""
"BONE PLATE 2.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","AETNA [1001]","HB AMC AETNA HMO","1936.40","69.8","","675.31","184.75","1721.50","286","1449.8","2267.08","percent of total billed charges",""
"BONE PLATE 2.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","AETNA [1001]","HB AMC AETNA PPO","2230.46","80.4","","1261.44","103.12","1514.10","21","1449.8","2267.08","percent of total billed charges",""
"BONE PLATE 2.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2230.46","80.4","","1365.00","1365.00","1365.00","1 through 10","1449.8","2267.08","percent of total billed charges",""
"BONE PLATE 2.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2267.08","81.72","","5157.68","5157.68","5157.68","1 through 10","1449.8","2267.08","percent of total billed charges",""
"BONE PLATE 2.5MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2267.08","81.72","","431.26","71.26","1459.57","88","1449.8","2267.08","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2739.80","2054.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2178.14","79.5","","800.18","480.96","1887.97","195","849.34","2178.14","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2739.80","2054.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1460.31","53.3","","813.12","216.42","1444.50","81","849.34","2178.14","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2739.80","2054.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","849.34","31","","432.60","432.60","432.60","1 through 10","849.34","2178.14","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2739.80","2054.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1000.03","36.5","","148.37","54.89","631.39","94","849.34","2178.14","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2739.80","2054.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1049.34","38.3","","279.30","91.72","1116.77","266","849.34","2178.14","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2739.80","2054.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1175.37","42.9","","731.00","63.70","731.00","1 through 10","849.34","2178.14","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2739.80","2054.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1175.37","42.9","","384.74","384.74","384.74","1 through 10","849.34","2178.14","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2739.80","2054.85","WELLPOINT [1015]","HB AMC WELLPOINT","2021.42","73.78","","286.63","119.22","1107.45","105","849.34","2178.14","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2739.80","2054.85","AETNA [1001]","HB AMC AETNA HMO","1912.38","69.8","","675.31","184.75","1721.50","286","1431.82","2238.96","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2739.80","2054.85","AETNA [1001]","HB AMC AETNA PPO","2202.80","80.4","","1261.44","103.12","1514.10","21","1431.82","2238.96","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2739.80","2054.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2202.80","80.4","","1365.00","1365.00","1365.00","1 through 10","1431.82","2238.96","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2739.80","2054.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2238.96","81.72","","5157.68","5157.68","5157.68","1 through 10","1431.82","2238.96","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2739.80","2054.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2238.96","81.72","","431.26","71.26","1459.57","88","1431.82","2238.96","percent of total billed charges",""
"BONE PLATE 2.5MM LG CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131194","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4726.04","79.5","","800.18","480.96","1887.97","195","1842.86","4726.04","percent of total billed charges",""
"BONE PLATE 2.5MM LG CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131194","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3168.53","53.3","","813.12","216.42","1444.50","81","1842.86","4726.04","percent of total billed charges",""
"BONE PLATE 2.5MM LG CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131194","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1842.86","31","","432.60","432.60","432.60","1 through 10","1842.86","4726.04","percent of total billed charges",""
"BONE PLATE 2.5MM LG CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131194","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2169.82","36.5","","148.37","54.89","631.39","94","1842.86","4726.04","percent of total billed charges",""
"BONE PLATE 2.5MM LG CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131194","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2276.82","38.3","","279.30","91.72","1116.77","266","1842.86","4726.04","percent of total billed charges",""
"BONE PLATE 2.5MM LG CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131194","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2550.28","42.9","","731.00","63.70","731.00","1 through 10","1842.86","4726.04","percent of total billed charges",""
"BONE PLATE 2.5MM LG CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131194","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2550.28","42.9","","384.74","384.74","384.74","1 through 10","1842.86","4726.04","percent of total billed charges",""
"BONE PLATE 2.5MM LG CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131194","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","WELLPOINT [1015]","HB AMC WELLPOINT","4386.00","73.78","","286.63","119.22","1107.45","105","1842.86","4726.04","percent of total billed charges",""
"BONE PLATE 2.5MM LG CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5944.70","4458.52","AETNA [1001]","HB AMC AETNA HMO","4149.40","69.8","","675.31","184.75","1721.50","286","3106.7","4858.01","percent of total billed charges",""
"BONE PLATE 2.5MM LG CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5944.70","4458.52","AETNA [1001]","HB AMC AETNA PPO","4779.54","80.4","","1261.44","103.12","1514.10","21","3106.7","4858.01","percent of total billed charges",""
"BONE PLATE 2.5MM LG CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5944.70","4458.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4779.54","80.4","","1365.00","1365.00","1365.00","1 through 10","3106.7","4858.01","percent of total billed charges",""
"BONE PLATE 2.5MM LG CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5944.70","4458.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4858.01","81.72","","5157.68","5157.68","5157.68","1 through 10","3106.7","4858.01","percent of total billed charges",""
"BONE PLATE 2.5MM LG CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5944.70","4458.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4858.01","81.72","","431.26","71.26","1459.57","88","3106.7","4858.01","percent of total billed charges",""
"BONE PLATE 2.5MM SM CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10131192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4396.11","79.5","","800.18","480.96","1887.97","195","1714.21","4396.11","percent of total billed charges",""
"BONE PLATE 2.5MM SM CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10131192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2947.33","53.3","","813.12","216.42","1444.50","81","1714.21","4396.11","percent of total billed charges",""
"BONE PLATE 2.5MM SM CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10131192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1714.21","31","","432.60","432.60","432.60","1 through 10","1714.21","4396.11","percent of total billed charges",""
"BONE PLATE 2.5MM SM CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10131192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2018.34","36.5","","148.37","54.89","631.39","94","1714.21","4396.11","percent of total billed charges",""
"BONE PLATE 2.5MM SM CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10131192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2117.88","38.3","","279.30","91.72","1116.77","266","1714.21","4396.11","percent of total billed charges",""
"BONE PLATE 2.5MM SM CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10131192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2372.24","42.9","","731.00","63.70","731.00","1 through 10","1714.21","4396.11","percent of total billed charges",""
"BONE PLATE 2.5MM SM CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10131192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2372.24","42.9","","384.74","384.74","384.74","1 through 10","1714.21","4396.11","percent of total billed charges",""
"BONE PLATE 2.5MM SM CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10131192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","WELLPOINT [1015]","HB AMC WELLPOINT","4079.81","73.78","","286.63","119.22","1107.45","105","1714.21","4396.11","percent of total billed charges",""
"BONE PLATE 2.5MM SM CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10131192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5529.70","4147.27","AETNA [1001]","HB AMC AETNA HMO","3859.73","69.8","","675.31","184.75","1721.50","286","2889.82","4518.87","percent of total billed charges",""
"BONE PLATE 2.5MM SM CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10131192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5529.70","4147.27","AETNA [1001]","HB AMC AETNA PPO","4445.88","80.4","","1261.44","103.12","1514.10","21","2889.82","4518.87","percent of total billed charges",""
"BONE PLATE 2.5MM SM CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10131192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5529.70","4147.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4445.88","80.4","","1365.00","1365.00","1365.00","1 through 10","2889.82","4518.87","percent of total billed charges",""
"BONE PLATE 2.5MM SM CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10131192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5529.70","4147.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4518.87","81.72","","5157.68","5157.68","5157.68","1 through 10","2889.82","4518.87","percent of total billed charges",""
"BONE PLATE 2.5MM SM CRANIAL MATRIXMANDIBLE TI PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10131192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5529.70","4147.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4518.87","81.72","","431.26","71.26","1459.57","88","2889.82","4518.87","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.80","716.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","759.07","79.5","","800.18","480.96","1887.97","195","295.99","759.07","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.80","716.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","508.91","53.3","","813.12","216.42","1444.50","81","295.99","759.07","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.80","716.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","295.99","31","","432.60","432.60","432.60","1 through 10","295.99","759.07","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.80","716.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","348.50","36.5","","148.37","54.89","631.39","94","295.99","759.07","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.80","716.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","365.69","38.3","","279.30","91.72","1116.77","266","295.99","759.07","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.80","716.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.61","42.9","","731.00","63.70","731.00","1 through 10","295.99","759.07","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.80","716.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.61","42.9","","384.74","384.74","384.74","1 through 10","295.99","759.07","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.80","716.10","WELLPOINT [1015]","HB AMC WELLPOINT","704.45","73.78","","286.63","119.22","1107.45","105","295.99","759.07","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.80","716.10","AETNA [1001]","HB AMC AETNA HMO","666.45","69.8","","675.31","184.75","1721.50","286","498.98","780.26","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.80","716.10","AETNA [1001]","HB AMC AETNA PPO","767.66","80.4","","1261.44","103.12","1514.10","21","498.98","780.26","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.80","716.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","767.66","80.4","","1365.00","1365.00","1365.00","1 through 10","498.98","780.26","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.80","716.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","780.26","81.72","","5157.68","5157.68","5157.68","1 through 10","498.98","780.26","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.80","716.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","780.26","81.72","","431.26","71.26","1459.57","88","498.98","780.26","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 150 8 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10144709","CDM","C1713","HCPCS","0278","RC","","","","both","","","5326.23","3994.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4234.35","79.5","","800.18","480.96","1887.97","195","1651.13","4234.35","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 150 8 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10144709","CDM","C1713","HCPCS","0278","RC","","","","both","","","5326.23","3994.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2838.88","53.3","","813.12","216.42","1444.50","81","1651.13","4234.35","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 150 8 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10144709","CDM","C1713","HCPCS","0278","RC","","","","both","","","5326.23","3994.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1651.13","31","","432.60","432.60","432.60","1 through 10","1651.13","4234.35","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 150 8 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10144709","CDM","C1713","HCPCS","0278","RC","","","","both","","","5326.23","3994.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1944.07","36.5","","148.37","54.89","631.39","94","1651.13","4234.35","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 150 8 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10144709","CDM","C1713","HCPCS","0278","RC","","","","both","","","5326.23","3994.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2039.95","38.3","","279.30","91.72","1116.77","266","1651.13","4234.35","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 150 8 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10144709","CDM","C1713","HCPCS","0278","RC","","","","both","","","5326.23","3994.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2284.95","42.9","","731.00","63.70","731.00","1 through 10","1651.13","4234.35","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 150 8 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10144709","CDM","C1713","HCPCS","0278","RC","","","","both","","","5326.23","3994.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2284.95","42.9","","384.74","384.74","384.74","1 through 10","1651.13","4234.35","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 150 8 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10144709","CDM","C1713","HCPCS","0278","RC","","","","both","","","5326.23","3994.67","WELLPOINT [1015]","HB AMC WELLPOINT","3929.69","73.78","","286.63","119.22","1107.45","105","1651.13","4234.35","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 150 8 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10144709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5326.23","3994.67","AETNA [1001]","HB AMC AETNA HMO","3717.71","69.8","","675.31","184.75","1721.50","286","2783.49","4352.6","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 150 8 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10144709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5326.23","3994.67","AETNA [1001]","HB AMC AETNA PPO","4282.29","80.4","","1261.44","103.12","1514.10","21","2783.49","4352.6","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 150 8 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10144709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5326.23","3994.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4282.29","80.4","","1365.00","1365.00","1365.00","1 through 10","2783.49","4352.6","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 150 8 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10144709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5326.23","3994.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4352.60","81.72","","5157.68","5157.68","5157.68","1 through 10","2783.49","4352.6","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 150 8 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10144709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5326.23","3994.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4352.60","81.72","","431.26","71.26","1459.57","88","2783.49","4352.6","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE LCP ULNA OSTEOTOMY","SUP-ITM-10124856","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2597.50","79.5","","800.18","480.96","1887.97","195","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE LCP ULNA OSTEOTOMY","SUP-ITM-10124856","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1741.47","53.3","","813.12","216.42","1444.50","81","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE LCP ULNA OSTEOTOMY","SUP-ITM-10124856","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1012.86","31","","432.60","432.60","432.60","1 through 10","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE LCP ULNA OSTEOTOMY","SUP-ITM-10124856","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1192.56","36.5","","148.37","54.89","631.39","94","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE LCP ULNA OSTEOTOMY","SUP-ITM-10124856","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1251.37","38.3","","279.30","91.72","1116.77","266","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE LCP ULNA OSTEOTOMY","SUP-ITM-10124856","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1401.67","42.9","","731.00","63.70","731.00","1 through 10","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE LCP ULNA OSTEOTOMY","SUP-ITM-10124856","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1401.67","42.9","","384.74","384.74","384.74","1 through 10","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE LCP ULNA OSTEOTOMY","SUP-ITM-10124856","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","WELLPOINT [1015]","HB AMC WELLPOINT","2410.61","73.78","","286.63","119.22","1107.45","105","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE LCP ULNA OSTEOTOMY","SUP-ITM-10124856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.29","2450.47","AETNA [1001]","HB AMC AETNA HMO","2280.57","69.8","","675.31","184.75","1721.50","286","1707.49","2670.03","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE LCP ULNA OSTEOTOMY","SUP-ITM-10124856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.29","2450.47","AETNA [1001]","HB AMC AETNA PPO","2626.90","80.4","","1261.44","103.12","1514.10","21","1707.49","2670.03","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE LCP ULNA OSTEOTOMY","SUP-ITM-10124856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.29","2450.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2626.90","80.4","","1365.00","1365.00","1365.00","1 through 10","1707.49","2670.03","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE LCP ULNA OSTEOTOMY","SUP-ITM-10124856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.29","2450.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2670.03","81.72","","5157.68","5157.68","5157.68","1 through 10","1707.49","2670.03","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE LCP ULNA OSTEOTOMY","SUP-ITM-10124856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.29","2450.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2670.03","81.72","","431.26","71.26","1459.57","88","1707.49","2670.03","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS VARIABLE ANGLE LOCKING T SHAPE DISTAL","SUP-ITM-10125020","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2400.13","79.5","","800.18","480.96","1887.97","195","935.9","2400.13","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS VARIABLE ANGLE LOCKING T SHAPE DISTAL","SUP-ITM-10125020","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1609.14","53.3","","813.12","216.42","1444.50","81","935.9","2400.13","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS VARIABLE ANGLE LOCKING T SHAPE DISTAL","SUP-ITM-10125020","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","935.90","31","","432.60","432.60","432.60","1 through 10","935.9","2400.13","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS VARIABLE ANGLE LOCKING T SHAPE DISTAL","SUP-ITM-10125020","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1101.95","36.5","","148.37","54.89","631.39","94","935.9","2400.13","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS VARIABLE ANGLE LOCKING T SHAPE DISTAL","SUP-ITM-10125020","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1156.29","38.3","","279.30","91.72","1116.77","266","935.9","2400.13","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS VARIABLE ANGLE LOCKING T SHAPE DISTAL","SUP-ITM-10125020","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1295.16","42.9","","731.00","63.70","731.00","1 through 10","935.9","2400.13","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS VARIABLE ANGLE LOCKING T SHAPE DISTAL","SUP-ITM-10125020","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1295.16","42.9","","384.74","384.74","384.74","1 through 10","935.9","2400.13","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS VARIABLE ANGLE LOCKING T SHAPE DISTAL","SUP-ITM-10125020","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","WELLPOINT [1015]","HB AMC WELLPOINT","2227.44","73.78","","286.63","119.22","1107.45","105","935.9","2400.13","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS VARIABLE ANGLE LOCKING T SHAPE DISTAL","SUP-ITM-10125020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3019.03","2264.27","AETNA [1001]","HB AMC AETNA HMO","2107.28","69.8","","675.31","184.75","1721.50","286","1577.75","2467.15","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS VARIABLE ANGLE LOCKING T SHAPE DISTAL","SUP-ITM-10125020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3019.03","2264.27","AETNA [1001]","HB AMC AETNA PPO","2427.30","80.4","","1261.44","103.12","1514.10","21","1577.75","2467.15","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS VARIABLE ANGLE LOCKING T SHAPE DISTAL","SUP-ITM-10125020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3019.03","2264.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2427.30","80.4","","1365.00","1365.00","1365.00","1 through 10","1577.75","2467.15","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS VARIABLE ANGLE LOCKING T SHAPE DISTAL","SUP-ITM-10125020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3019.03","2264.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2467.15","81.72","","5157.68","5157.68","5157.68","1 through 10","1577.75","2467.15","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS VARIABLE ANGLE LOCKING T SHAPE DISTAL","SUP-ITM-10125020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3019.03","2264.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2467.15","81.72","","431.26","71.26","1459.57","88","1577.75","2467.15","percent of total billed charges",""
"BONE PLATE 2.7MM 64 MED CALCANEAL VARIABLE LOCKING RIGHT","SUP-ITM-10164180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2131.12","79.5","","800.18","480.96","1887.97","195","831","2131.12","percent of total billed charges",""
"BONE PLATE 2.7MM 64 MED CALCANEAL VARIABLE LOCKING RIGHT","SUP-ITM-10164180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1428.79","53.3","","813.12","216.42","1444.50","81","831","2131.12","percent of total billed charges",""
"BONE PLATE 2.7MM 64 MED CALCANEAL VARIABLE LOCKING RIGHT","SUP-ITM-10164180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","831.00","31","","432.60","432.60","432.60","1 through 10","831","2131.12","percent of total billed charges",""
"BONE PLATE 2.7MM 64 MED CALCANEAL VARIABLE LOCKING RIGHT","SUP-ITM-10164180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","978.44","36.5","","148.37","54.89","631.39","94","831","2131.12","percent of total billed charges",""
"BONE PLATE 2.7MM 64 MED CALCANEAL VARIABLE LOCKING RIGHT","SUP-ITM-10164180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1026.69","38.3","","279.30","91.72","1116.77","266","831","2131.12","percent of total billed charges",""
"BONE PLATE 2.7MM 64 MED CALCANEAL VARIABLE LOCKING RIGHT","SUP-ITM-10164180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.00","42.9","","731.00","63.70","731.00","1 through 10","831","2131.12","percent of total billed charges",""
"BONE PLATE 2.7MM 64 MED CALCANEAL VARIABLE LOCKING RIGHT","SUP-ITM-10164180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.00","42.9","","384.74","384.74","384.74","1 through 10","831","2131.12","percent of total billed charges",""
"BONE PLATE 2.7MM 64 MED CALCANEAL VARIABLE LOCKING RIGHT","SUP-ITM-10164180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","WELLPOINT [1015]","HB AMC WELLPOINT","1977.78","73.78","","286.63","119.22","1107.45","105","831","2131.12","percent of total billed charges",""
"BONE PLATE 2.7MM 64 MED CALCANEAL VARIABLE LOCKING RIGHT","SUP-ITM-10164180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","AETNA [1001]","HB AMC AETNA HMO","1871.09","69.8","","675.31","184.75","1721.50","286","1400.91","2190.63","percent of total billed charges",""
"BONE PLATE 2.7MM 64 MED CALCANEAL VARIABLE LOCKING RIGHT","SUP-ITM-10164180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","AETNA [1001]","HB AMC AETNA PPO","2155.24","80.4","","1261.44","103.12","1514.10","21","1400.91","2190.63","percent of total billed charges",""
"BONE PLATE 2.7MM 64 MED CALCANEAL VARIABLE LOCKING RIGHT","SUP-ITM-10164180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2155.24","80.4","","1365.00","1365.00","1365.00","1 through 10","1400.91","2190.63","percent of total billed charges",""
"BONE PLATE 2.7MM 64 MED CALCANEAL VARIABLE LOCKING RIGHT","SUP-ITM-10164180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2190.63","81.72","","5157.68","5157.68","5157.68","1 through 10","1400.91","2190.63","percent of total billed charges",""
"BONE PLATE 2.7MM 64 MED CALCANEAL VARIABLE LOCKING RIGHT","SUP-ITM-10164180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2190.63","81.72","","431.26","71.26","1459.57","88","1400.91","2190.63","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5376.72","4032.54","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2809.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1666.78","4274.49","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5376.72","4032.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4274.49","79.5","","1293.60","1148.53","1603.80","1 through 10","1666.78","4274.49","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5376.72","4032.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1962.50","36.5","","1023.42","771.29","2068.67","33","1666.78","4274.49","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5376.72","4032.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2059.28","38.3","","850.52","759.78","1211.25","66","1666.78","4274.49","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5376.72","4032.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2306.61","42.9","","2548.09","2548.09","2548.09","1 through 10","1666.78","4274.49","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5376.72","4032.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2306.61","42.9","","956.46","956.46","956.46","1 through 10","1666.78","4274.49","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5376.72","4032.54","WELLPOINT [1015]","HB AMC WELLPOINT","3966.94","73.78","","2344.73","1619.47","2530.35","16","1666.78","4274.49","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5376.72","4032.54","AETNA [1001]","HB AMC AETNA HMO","3752.95","69.8","","1523.63","988.41","4330.26","39","2809.87","4393.86","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5376.72","4032.54","AETNA [1001]","HB AMC AETNA PPO","4322.88","80.4","","1670.25","1670.25","1670.25","1 through 10","2809.87","4393.86","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5376.72","4032.54","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2809.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2809.87","4393.86","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5376.72","4032.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4393.86","81.72","","1738.90","1484.65","2716.94","38","2809.87","4393.86","percent of total billed charges",""
"BONE PLATE 2.7MM SM PATELLA STAINLESS VARIABLE ANGLE LOCKING ANTERIOR CORE","SUP-ITM-10294351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2554.37","52.26","","1113.10","1113.10","1113.10","1 through 10","1515.22","3885.81","percent of total billed charges",""
"BONE PLATE 2.7MM SM PATELLA STAINLESS VARIABLE ANGLE LOCKING ANTERIOR CORE","SUP-ITM-10294351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3885.81","79.5","","1293.60","1148.53","1603.80","1 through 10","1515.22","3885.81","percent of total billed charges",""
"BONE PLATE 2.7MM SM PATELLA STAINLESS VARIABLE ANGLE LOCKING ANTERIOR CORE","SUP-ITM-10294351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1784.05","36.5","","1023.42","771.29","2068.67","33","1515.22","3885.81","percent of total billed charges",""
"BONE PLATE 2.7MM SM PATELLA STAINLESS VARIABLE ANGLE LOCKING ANTERIOR CORE","SUP-ITM-10294351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1872.03","38.3","","850.52","759.78","1211.25","66","1515.22","3885.81","percent of total billed charges",""
"BONE PLATE 2.7MM SM PATELLA STAINLESS VARIABLE ANGLE LOCKING ANTERIOR CORE","SUP-ITM-10294351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.87","42.9","","2548.09","2548.09","2548.09","1 through 10","1515.22","3885.81","percent of total billed charges",""
"BONE PLATE 2.7MM SM PATELLA STAINLESS VARIABLE ANGLE LOCKING ANTERIOR CORE","SUP-ITM-10294351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.87","42.9","","956.46","956.46","956.46","1 through 10","1515.22","3885.81","percent of total billed charges",""
"BONE PLATE 2.7MM SM PATELLA STAINLESS VARIABLE ANGLE LOCKING ANTERIOR CORE","SUP-ITM-10294351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","WELLPOINT [1015]","HB AMC WELLPOINT","3606.23","73.78","","2344.73","1619.47","2530.35","16","1515.22","3885.81","percent of total billed charges",""
"BONE PLATE 2.7MM SM PATELLA STAINLESS VARIABLE ANGLE LOCKING ANTERIOR CORE","SUP-ITM-10294351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","AETNA [1001]","HB AMC AETNA HMO","3411.69","69.8","","1523.63","988.41","4330.26","39","2554.37","3994.32","percent of total billed charges",""
"BONE PLATE 2.7MM SM PATELLA STAINLESS VARIABLE ANGLE LOCKING ANTERIOR CORE","SUP-ITM-10294351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","AETNA [1001]","HB AMC AETNA PPO","3929.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2554.37","3994.32","percent of total billed charges",""
"BONE PLATE 2.7MM SM PATELLA STAINLESS VARIABLE ANGLE LOCKING ANTERIOR CORE","SUP-ITM-10294351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2554.37","52.26","","1113.10","1113.10","1113.10","1 through 10","2554.37","3994.32","percent of total billed charges",""
"BONE PLATE 2.7MM SM PATELLA STAINLESS VARIABLE ANGLE LOCKING ANTERIOR CORE","SUP-ITM-10294351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3994.32","81.72","","1738.90","1484.65","2716.94","38","2554.37","3994.32","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON 4H RIGHT 116MM","SUP-ITM-10125495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2441.01","79.5","","800.18","480.96","1887.97","195","951.84","2441.01","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON 4H RIGHT 116MM","SUP-ITM-10125495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1636.55","53.3","","813.12","216.42","1444.50","81","951.84","2441.01","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON 4H RIGHT 116MM","SUP-ITM-10125495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","951.84","31","","432.60","432.60","432.60","1 through 10","951.84","2441.01","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON 4H RIGHT 116MM","SUP-ITM-10125495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1120.71","36.5","","148.37","54.89","631.39","94","951.84","2441.01","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON 4H RIGHT 116MM","SUP-ITM-10125495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1175.98","38.3","","279.30","91.72","1116.77","266","951.84","2441.01","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON 4H RIGHT 116MM","SUP-ITM-10125495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1317.22","42.9","","731.00","63.70","731.00","1 through 10","951.84","2441.01","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON 4H RIGHT 116MM","SUP-ITM-10125495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1317.22","42.9","","384.74","384.74","384.74","1 through 10","951.84","2441.01","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON 4H RIGHT 116MM","SUP-ITM-10125495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","WELLPOINT [1015]","HB AMC WELLPOINT","2265.38","73.78","","286.63","119.22","1107.45","105","951.84","2441.01","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON 4H RIGHT 116MM","SUP-ITM-10125495","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3070.45","2302.84","AETNA [1001]","HB AMC AETNA HMO","2143.17","69.8","","675.31","184.75","1721.50","286","1604.62","2509.17","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON 4H RIGHT 116MM","SUP-ITM-10125495","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3070.45","2302.84","AETNA [1001]","HB AMC AETNA PPO","2468.64","80.4","","1261.44","103.12","1514.10","21","1604.62","2509.17","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON 4H RIGHT 116MM","SUP-ITM-10125495","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3070.45","2302.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2468.64","80.4","","1365.00","1365.00","1365.00","1 through 10","1604.62","2509.17","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON 4H RIGHT 116MM","SUP-ITM-10125495","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3070.45","2302.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2509.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1604.62","2509.17","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON 4H RIGHT 116MM","SUP-ITM-10125495","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3070.45","2302.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2509.17","81.72","","431.26","71.26","1459.57","88","1604.62","2509.17","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON PL 8H/RIGHT/169MM","SUP-ITM-10125497","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2597.50","79.5","","800.18","480.96","1887.97","195","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON PL 8H/RIGHT/169MM","SUP-ITM-10125497","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1741.47","53.3","","813.12","216.42","1444.50","81","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON PL 8H/RIGHT/169MM","SUP-ITM-10125497","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1012.86","31","","432.60","432.60","432.60","1 through 10","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON PL 8H/RIGHT/169MM","SUP-ITM-10125497","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1192.56","36.5","","148.37","54.89","631.39","94","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON PL 8H/RIGHT/169MM","SUP-ITM-10125497","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1251.37","38.3","","279.30","91.72","1116.77","266","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON PL 8H/RIGHT/169MM","SUP-ITM-10125497","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1401.67","42.9","","731.00","63.70","731.00","1 through 10","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON PL 8H/RIGHT/169MM","SUP-ITM-10125497","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1401.67","42.9","","384.74","384.74","384.74","1 through 10","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON PL 8H/RIGHT/169MM","SUP-ITM-10125497","CDM","C1713","HCPCS","0278","RC","","","","both","","","3267.29","2450.47","WELLPOINT [1015]","HB AMC WELLPOINT","2410.61","73.78","","286.63","119.22","1107.45","105","1012.86","2597.5","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON PL 8H/RIGHT/169MM","SUP-ITM-10125497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.29","2450.47","AETNA [1001]","HB AMC AETNA HMO","2280.57","69.8","","675.31","184.75","1721.50","286","1707.49","2670.03","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON PL 8H/RIGHT/169MM","SUP-ITM-10125497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.29","2450.47","AETNA [1001]","HB AMC AETNA PPO","2626.90","80.4","","1261.44","103.12","1514.10","21","1707.49","2670.03","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON PL 8H/RIGHT/169MM","SUP-ITM-10125497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.29","2450.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2626.90","80.4","","1365.00","1365.00","1365.00","1 through 10","1707.49","2670.03","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON PL 8H/RIGHT/169MM","SUP-ITM-10125497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.29","2450.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2670.03","81.72","","5157.68","5157.68","5157.68","1 through 10","1707.49","2670.03","percent of total billed charges",""
"BONE PLATE 2.7MM/3.5MM TI VA-LCP OLECRANON PL 8H/RIGHT/169MM","SUP-ITM-10125497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3267.29","2450.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2670.03","81.72","","431.26","71.26","1459.57","88","1707.49","2670.03","percent of total billed charges",""
"BONE PLATE 2.7MMX72 4HOLE BONE TIBIA VA LCP STAINLESS VARIABLE ANGLE T SHAPE DISTAL","SUP-ITM-10125019","CDM","C1713","HCPCS","0278","RC","","","","both","","","2903.15","2177.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2308.00","79.5","","800.18","480.96","1887.97","195","899.98","2308","percent of total billed charges",""
"BONE PLATE 2.7MMX72 4HOLE BONE TIBIA VA LCP STAINLESS VARIABLE ANGLE T SHAPE DISTAL","SUP-ITM-10125019","CDM","C1713","HCPCS","0278","RC","","","","both","","","2903.15","2177.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1547.38","53.3","","813.12","216.42","1444.50","81","899.98","2308","percent of total billed charges",""
"BONE PLATE 2.7MMX72 4HOLE BONE TIBIA VA LCP STAINLESS VARIABLE ANGLE T SHAPE DISTAL","SUP-ITM-10125019","CDM","C1713","HCPCS","0278","RC","","","","both","","","2903.15","2177.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","899.98","31","","432.60","432.60","432.60","1 through 10","899.98","2308","percent of total billed charges",""
"BONE PLATE 2.7MMX72 4HOLE BONE TIBIA VA LCP STAINLESS VARIABLE ANGLE T SHAPE DISTAL","SUP-ITM-10125019","CDM","C1713","HCPCS","0278","RC","","","","both","","","2903.15","2177.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1059.65","36.5","","148.37","54.89","631.39","94","899.98","2308","percent of total billed charges",""
"BONE PLATE 2.7MMX72 4HOLE BONE TIBIA VA LCP STAINLESS VARIABLE ANGLE T SHAPE DISTAL","SUP-ITM-10125019","CDM","C1713","HCPCS","0278","RC","","","","both","","","2903.15","2177.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1111.91","38.3","","279.30","91.72","1116.77","266","899.98","2308","percent of total billed charges",""
"BONE PLATE 2.7MMX72 4HOLE BONE TIBIA VA LCP STAINLESS VARIABLE ANGLE T SHAPE DISTAL","SUP-ITM-10125019","CDM","C1713","HCPCS","0278","RC","","","","both","","","2903.15","2177.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1245.45","42.9","","731.00","63.70","731.00","1 through 10","899.98","2308","percent of total billed charges",""
"BONE PLATE 2.7MMX72 4HOLE BONE TIBIA VA LCP STAINLESS VARIABLE ANGLE T SHAPE DISTAL","SUP-ITM-10125019","CDM","C1713","HCPCS","0278","RC","","","","both","","","2903.15","2177.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1245.45","42.9","","384.74","384.74","384.74","1 through 10","899.98","2308","percent of total billed charges",""
"BONE PLATE 2.7MMX72 4HOLE BONE TIBIA VA LCP STAINLESS VARIABLE ANGLE T SHAPE DISTAL","SUP-ITM-10125019","CDM","C1713","HCPCS","0278","RC","","","","both","","","2903.15","2177.36","WELLPOINT [1015]","HB AMC WELLPOINT","2141.94","73.78","","286.63","119.22","1107.45","105","899.98","2308","percent of total billed charges",""
"BONE PLATE 2.7MMX72 4HOLE BONE TIBIA VA LCP STAINLESS VARIABLE ANGLE T SHAPE DISTAL","SUP-ITM-10125019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2903.15","2177.36","AETNA [1001]","HB AMC AETNA HMO","2026.40","69.8","","675.31","184.75","1721.50","286","1517.19","2372.45","percent of total billed charges",""
"BONE PLATE 2.7MMX72 4HOLE BONE TIBIA VA LCP STAINLESS VARIABLE ANGLE T SHAPE DISTAL","SUP-ITM-10125019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2903.15","2177.36","AETNA [1001]","HB AMC AETNA PPO","2334.13","80.4","","1261.44","103.12","1514.10","21","1517.19","2372.45","percent of total billed charges",""
"BONE PLATE 2.7MMX72 4HOLE BONE TIBIA VA LCP STAINLESS VARIABLE ANGLE T SHAPE DISTAL","SUP-ITM-10125019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2903.15","2177.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2334.13","80.4","","1365.00","1365.00","1365.00","1 through 10","1517.19","2372.45","percent of total billed charges",""
"BONE PLATE 2.7MMX72 4HOLE BONE TIBIA VA LCP STAINLESS VARIABLE ANGLE T SHAPE DISTAL","SUP-ITM-10125019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2903.15","2177.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2372.45","81.72","","5157.68","5157.68","5157.68","1 through 10","1517.19","2372.45","percent of total billed charges",""
"BONE PLATE 2.7MMX72 4HOLE BONE TIBIA VA LCP STAINLESS VARIABLE ANGLE T SHAPE DISTAL","SUP-ITM-10125019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2903.15","2177.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2372.45","81.72","","431.26","71.26","1459.57","88","1517.19","2372.45","percent of total billed charges",""
"BONE PLATE 2.7X125MM 14 HOLE VARIAX LOCKING BROAD","SUP-ITM-10306696","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.79","3102.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3288.75","79.5","","800.18","480.96","1887.97","195","1282.4","3288.75","percent of total billed charges",""
"BONE PLATE 2.7X125MM 14 HOLE VARIAX LOCKING BROAD","SUP-ITM-10306696","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.79","3102.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2204.91","53.3","","813.12","216.42","1444.50","81","1282.4","3288.75","percent of total billed charges",""
"BONE PLATE 2.7X125MM 14 HOLE VARIAX LOCKING BROAD","SUP-ITM-10306696","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.79","3102.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1282.40","31","","432.60","432.60","432.60","1 through 10","1282.4","3288.75","percent of total billed charges",""
"BONE PLATE 2.7X125MM 14 HOLE VARIAX LOCKING BROAD","SUP-ITM-10306696","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.79","3102.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1509.93","36.5","","148.37","54.89","631.39","94","1282.4","3288.75","percent of total billed charges",""
"BONE PLATE 2.7X125MM 14 HOLE VARIAX LOCKING BROAD","SUP-ITM-10306696","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.79","3102.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1584.39","38.3","","279.30","91.72","1116.77","266","1282.4","3288.75","percent of total billed charges",""
"BONE PLATE 2.7X125MM 14 HOLE VARIAX LOCKING BROAD","SUP-ITM-10306696","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.79","3102.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1774.68","42.9","","731.00","63.70","731.00","1 through 10","1282.4","3288.75","percent of total billed charges",""
"BONE PLATE 2.7X125MM 14 HOLE VARIAX LOCKING BROAD","SUP-ITM-10306696","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.79","3102.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1774.68","42.9","","384.74","384.74","384.74","1 through 10","1282.4","3288.75","percent of total billed charges",""
"BONE PLATE 2.7X125MM 14 HOLE VARIAX LOCKING BROAD","SUP-ITM-10306696","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.79","3102.59","WELLPOINT [1015]","HB AMC WELLPOINT","3052.12","73.78","","286.63","119.22","1107.45","105","1282.4","3288.75","percent of total billed charges",""
"BONE PLATE 2.7X125MM 14 HOLE VARIAX LOCKING BROAD","SUP-ITM-10306696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4136.79","3102.59","AETNA [1001]","HB AMC AETNA HMO","2887.48","69.8","","675.31","184.75","1721.50","286","2161.89","3380.58","percent of total billed charges",""
"BONE PLATE 2.7X125MM 14 HOLE VARIAX LOCKING BROAD","SUP-ITM-10306696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4136.79","3102.59","AETNA [1001]","HB AMC AETNA PPO","3325.98","80.4","","1261.44","103.12","1514.10","21","2161.89","3380.58","percent of total billed charges",""
"BONE PLATE 2.7X125MM 14 HOLE VARIAX LOCKING BROAD","SUP-ITM-10306696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4136.79","3102.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3325.98","80.4","","1365.00","1365.00","1365.00","1 through 10","2161.89","3380.58","percent of total billed charges",""
"BONE PLATE 2.7X125MM 14 HOLE VARIAX LOCKING BROAD","SUP-ITM-10306696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4136.79","3102.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3380.58","81.72","","5157.68","5157.68","5157.68","1 through 10","2161.89","3380.58","percent of total billed charges",""
"BONE PLATE 2.7X125MM 14 HOLE VARIAX LOCKING BROAD","SUP-ITM-10306696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4136.79","3102.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3380.58","81.72","","431.26","71.26","1459.57","88","2161.89","3380.58","percent of total billed charges",""
"BONE PLATE 2.7X176MM 20 HOLE BROAD LOCKING","SUP-ITM-10306463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.30","3654.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3873.48","79.5","","800.18","480.96","1887.97","195","1510.41","3873.48","percent of total billed charges",""
"BONE PLATE 2.7X176MM 20 HOLE BROAD LOCKING","SUP-ITM-10306463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.30","3654.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2596.94","53.3","","813.12","216.42","1444.50","81","1510.41","3873.48","percent of total billed charges",""
"BONE PLATE 2.7X176MM 20 HOLE BROAD LOCKING","SUP-ITM-10306463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.30","3654.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1510.41","31","","432.60","432.60","432.60","1 through 10","1510.41","3873.48","percent of total billed charges",""
"BONE PLATE 2.7X176MM 20 HOLE BROAD LOCKING","SUP-ITM-10306463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.30","3654.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1778.39","36.5","","148.37","54.89","631.39","94","1510.41","3873.48","percent of total billed charges",""
"BONE PLATE 2.7X176MM 20 HOLE BROAD LOCKING","SUP-ITM-10306463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.30","3654.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1866.09","38.3","","279.30","91.72","1116.77","266","1510.41","3873.48","percent of total billed charges",""
"BONE PLATE 2.7X176MM 20 HOLE BROAD LOCKING","SUP-ITM-10306463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.30","3654.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2090.22","42.9","","731.00","63.70","731.00","1 through 10","1510.41","3873.48","percent of total billed charges",""
"BONE PLATE 2.7X176MM 20 HOLE BROAD LOCKING","SUP-ITM-10306463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.30","3654.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2090.22","42.9","","384.74","384.74","384.74","1 through 10","1510.41","3873.48","percent of total billed charges",""
"BONE PLATE 2.7X176MM 20 HOLE BROAD LOCKING","SUP-ITM-10306463","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.30","3654.22","WELLPOINT [1015]","HB AMC WELLPOINT","3594.78","73.78","","286.63","119.22","1107.45","105","1510.41","3873.48","percent of total billed charges",""
"BONE PLATE 2.7X176MM 20 HOLE BROAD LOCKING","SUP-ITM-10306463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4872.30","3654.22","AETNA [1001]","HB AMC AETNA HMO","3400.87","69.8","","675.31","184.75","1721.50","286","2546.26","3981.64","percent of total billed charges",""
"BONE PLATE 2.7X176MM 20 HOLE BROAD LOCKING","SUP-ITM-10306463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4872.30","3654.22","AETNA [1001]","HB AMC AETNA PPO","3917.33","80.4","","1261.44","103.12","1514.10","21","2546.26","3981.64","percent of total billed charges",""
"BONE PLATE 2.7X176MM 20 HOLE BROAD LOCKING","SUP-ITM-10306463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4872.30","3654.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3917.33","80.4","","1365.00","1365.00","1365.00","1 through 10","2546.26","3981.64","percent of total billed charges",""
"BONE PLATE 2.7X176MM 20 HOLE BROAD LOCKING","SUP-ITM-10306463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4872.30","3654.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3981.64","81.72","","5157.68","5157.68","5157.68","1 through 10","2546.26","3981.64","percent of total billed charges",""
"BONE PLATE 2.7X176MM 20 HOLE BROAD LOCKING","SUP-ITM-10306463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4872.30","3654.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3981.64","81.72","","431.26","71.26","1459.57","88","2546.26","3981.64","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","302.68","79.5","","800.18","480.96","1887.97","195","118.03","302.68","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","202.93","53.3","","813.12","216.42","1444.50","81","118.03","302.68","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","118.03","31","","432.60","432.60","432.60","1 through 10","118.03","302.68","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","138.97","36.5","","148.37","54.89","631.39","94","118.03","302.68","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","145.82","38.3","","279.30","91.72","1116.77","266","118.03","302.68","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.33","42.9","","731.00","63.70","731.00","1 through 10","118.03","302.68","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.33","42.9","","384.74","384.74","384.74","1 through 10","118.03","302.68","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","WELLPOINT [1015]","HB AMC WELLPOINT","280.90","73.78","","286.63","119.22","1107.45","105","118.03","302.68","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","380.73","285.55","AETNA [1001]","HB AMC AETNA HMO","265.75","69.8","","675.31","184.75","1721.50","286","198.97","311.13","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","380.73","285.55","AETNA [1001]","HB AMC AETNA PPO","306.11","80.4","","1261.44","103.12","1514.10","21","198.97","311.13","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","380.73","285.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","306.11","80.4","","1365.00","1365.00","1365.00","1 through 10","198.97","311.13","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","380.73","285.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","311.13","81.72","","5157.68","5157.68","5157.68","1 through 10","198.97","311.13","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","380.73","285.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","311.13","81.72","","431.26","71.26","1459.57","88","198.97","311.13","percent of total billed charges",""
"BONE PLATE 2.7X3.5 90MM 2HOLE OLECRANON RIGHT VARIABLE ANGLE LOCKING COMPRESSION TI","SUP-ITM-10125494","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2378.20","79.5","","800.18","480.96","1887.97","195","927.35","2378.2","percent of total billed charges",""
"BONE PLATE 2.7X3.5 90MM 2HOLE OLECRANON RIGHT VARIABLE ANGLE LOCKING COMPRESSION TI","SUP-ITM-10125494","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1594.44","53.3","","813.12","216.42","1444.50","81","927.35","2378.2","percent of total billed charges",""
"BONE PLATE 2.7X3.5 90MM 2HOLE OLECRANON RIGHT VARIABLE ANGLE LOCKING COMPRESSION TI","SUP-ITM-10125494","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","927.35","31","","432.60","432.60","432.60","1 through 10","927.35","2378.2","percent of total billed charges",""
"BONE PLATE 2.7X3.5 90MM 2HOLE OLECRANON RIGHT VARIABLE ANGLE LOCKING COMPRESSION TI","SUP-ITM-10125494","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1091.88","36.5","","148.37","54.89","631.39","94","927.35","2378.2","percent of total billed charges",""
"BONE PLATE 2.7X3.5 90MM 2HOLE OLECRANON RIGHT VARIABLE ANGLE LOCKING COMPRESSION TI","SUP-ITM-10125494","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1145.73","38.3","","279.30","91.72","1116.77","266","927.35","2378.2","percent of total billed charges",""
"BONE PLATE 2.7X3.5 90MM 2HOLE OLECRANON RIGHT VARIABLE ANGLE LOCKING COMPRESSION TI","SUP-ITM-10125494","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1283.33","42.9","","731.00","63.70","731.00","1 through 10","927.35","2378.2","percent of total billed charges",""
"BONE PLATE 2.7X3.5 90MM 2HOLE OLECRANON RIGHT VARIABLE ANGLE LOCKING COMPRESSION TI","SUP-ITM-10125494","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1283.33","42.9","","384.74","384.74","384.74","1 through 10","927.35","2378.2","percent of total billed charges",""
"BONE PLATE 2.7X3.5 90MM 2HOLE OLECRANON RIGHT VARIABLE ANGLE LOCKING COMPRESSION TI","SUP-ITM-10125494","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","WELLPOINT [1015]","HB AMC WELLPOINT","2207.09","73.78","","286.63","119.22","1107.45","105","927.35","2378.2","percent of total billed charges",""
"BONE PLATE 2.7X3.5 90MM 2HOLE OLECRANON RIGHT VARIABLE ANGLE LOCKING COMPRESSION TI","SUP-ITM-10125494","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2991.45","2243.59","AETNA [1001]","HB AMC AETNA HMO","2088.03","69.8","","675.31","184.75","1721.50","286","1563.33","2444.61","percent of total billed charges",""
"BONE PLATE 2.7X3.5 90MM 2HOLE OLECRANON RIGHT VARIABLE ANGLE LOCKING COMPRESSION TI","SUP-ITM-10125494","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2991.45","2243.59","AETNA [1001]","HB AMC AETNA PPO","2405.13","80.4","","1261.44","103.12","1514.10","21","1563.33","2444.61","percent of total billed charges",""
"BONE PLATE 2.7X3.5 90MM 2HOLE OLECRANON RIGHT VARIABLE ANGLE LOCKING COMPRESSION TI","SUP-ITM-10125494","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2991.45","2243.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2405.13","80.4","","1365.00","1365.00","1365.00","1 through 10","1563.33","2444.61","percent of total billed charges",""
"BONE PLATE 2.7X3.5 90MM 2HOLE OLECRANON RIGHT VARIABLE ANGLE LOCKING COMPRESSION TI","SUP-ITM-10125494","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2991.45","2243.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2444.61","81.72","","5157.68","5157.68","5157.68","1 through 10","1563.33","2444.61","percent of total billed charges",""
"BONE PLATE 2.7X3.5 90MM 2HOLE OLECRANON RIGHT VARIABLE ANGLE LOCKING COMPRESSION TI","SUP-ITM-10125494","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2991.45","2243.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2444.61","81.72","","431.26","71.26","1459.57","88","1563.33","2444.61","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.71","328.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","347.98","79.5","","800.18","480.96","1887.97","195","135.69","347.98","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.71","328.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","233.30","53.3","","813.12","216.42","1444.50","81","135.69","347.98","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.71","328.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","135.69","31","","432.60","432.60","432.60","1 through 10","135.69","347.98","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.71","328.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","159.76","36.5","","148.37","54.89","631.39","94","135.69","347.98","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.71","328.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","167.64","38.3","","279.30","91.72","1116.77","266","135.69","347.98","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.71","328.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.78","42.9","","731.00","63.70","731.00","1 through 10","135.69","347.98","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.71","328.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.78","42.9","","384.74","384.74","384.74","1 through 10","135.69","347.98","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.71","328.28","WELLPOINT [1015]","HB AMC WELLPOINT","322.94","73.78","","286.63","119.22","1107.45","105","135.69","347.98","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.71","328.28","AETNA [1001]","HB AMC AETNA HMO","305.52","69.8","","675.31","184.75","1721.50","286","228.75","357.7","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.71","328.28","AETNA [1001]","HB AMC AETNA PPO","351.92","80.4","","1261.44","103.12","1514.10","21","228.75","357.7","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.71","328.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","351.92","80.4","","1365.00","1365.00","1365.00","1 through 10","228.75","357.7","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.71","328.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","357.70","81.72","","5157.68","5157.68","5157.68","1 through 10","228.75","357.7","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.71","328.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","357.70","81.72","","431.26","71.26","1459.57","88","228.75","357.7","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.78","144.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","153.26","79.5","","800.18","480.96","1887.97","195","59.76","153.26","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.78","144.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","102.75","53.3","","813.12","216.42","1444.50","81","59.76","153.26","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.78","144.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","59.76","31","","432.60","432.60","432.60","1 through 10","59.76","153.26","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.78","144.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70.36","36.5","","148.37","54.89","631.39","94","59.76","153.26","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.78","144.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.83","38.3","","279.30","91.72","1116.77","266","59.76","153.26","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.78","144.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.70","42.9","","731.00","63.70","731.00","1 through 10","59.76","153.26","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.78","144.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.70","42.9","","384.74","384.74","384.74","1 through 10","59.76","153.26","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.78","144.58","WELLPOINT [1015]","HB AMC WELLPOINT","142.23","73.78","","286.63","119.22","1107.45","105","59.76","153.26","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","192.78","144.58","AETNA [1001]","HB AMC AETNA HMO","134.56","69.8","","675.31","184.75","1721.50","286","100.75","157.54","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","192.78","144.58","AETNA [1001]","HB AMC AETNA PPO","155.00","80.4","","1261.44","103.12","1514.10","21","100.75","157.54","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","192.78","144.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","155.00","80.4","","1365.00","1365.00","1365.00","1 through 10","100.75","157.54","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","192.78","144.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","157.54","81.72","","5157.68","5157.68","5157.68","1 through 10","100.75","157.54","percent of total billed charges",""
"BONE PLATE 2.7X32MM 2 3 HOLE STAINLESS SHAPE RIGHT","SUP-ITM-10004180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","192.78","144.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","157.54","81.72","","431.26","71.26","1459.57","88","100.75","157.54","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.20","160.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","170.29","79.5","","800.18","480.96","1887.97","195","66.4","170.29","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.20","160.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","114.17","53.3","","813.12","216.42","1444.50","81","66.4","170.29","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.20","160.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","66.40","31","","432.60","432.60","432.60","1 through 10","66.4","170.29","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.20","160.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.18","36.5","","148.37","54.89","631.39","94","66.4","170.29","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.20","160.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82.04","38.3","","279.30","91.72","1116.77","266","66.4","170.29","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.20","160.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.89","42.9","","731.00","63.70","731.00","1 through 10","66.4","170.29","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.20","160.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.89","42.9","","384.74","384.74","384.74","1 through 10","66.4","170.29","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.20","160.65","WELLPOINT [1015]","HB AMC WELLPOINT","158.04","73.78","","286.63","119.22","1107.45","105","66.4","170.29","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.20","160.65","AETNA [1001]","HB AMC AETNA HMO","149.51","69.8","","675.31","184.75","1721.50","286","111.94","175.04","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.20","160.65","AETNA [1001]","HB AMC AETNA PPO","172.22","80.4","","1261.44","103.12","1514.10","21","111.94","175.04","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.20","160.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","172.22","80.4","","1365.00","1365.00","1365.00","1 through 10","111.94","175.04","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.20","160.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","175.04","81.72","","5157.68","5157.68","5157.68","1 through 10","111.94","175.04","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.20","160.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","175.04","81.72","","431.26","71.26","1459.57","88","111.94","175.04","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.76","318.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","337.68","79.5","","800.18","480.96","1887.97","195","131.68","337.68","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.76","318.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","226.40","53.3","","813.12","216.42","1444.50","81","131.68","337.68","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.76","318.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","131.68","31","","432.60","432.60","432.60","1 through 10","131.68","337.68","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.76","318.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","155.04","36.5","","148.37","54.89","631.39","94","131.68","337.68","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.76","318.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","162.68","38.3","","279.30","91.72","1116.77","266","131.68","337.68","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.76","318.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","182.22","42.9","","731.00","63.70","731.00","1 through 10","131.68","337.68","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.76","318.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","182.22","42.9","","384.74","384.74","384.74","1 through 10","131.68","337.68","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.76","318.57","WELLPOINT [1015]","HB AMC WELLPOINT","313.39","73.78","","286.63","119.22","1107.45","105","131.68","337.68","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.76","318.57","AETNA [1001]","HB AMC AETNA HMO","296.48","69.8","","675.31","184.75","1721.50","286","221.98","347.11","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.76","318.57","AETNA [1001]","HB AMC AETNA PPO","341.51","80.4","","1261.44","103.12","1514.10","21","221.98","347.11","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.76","318.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","341.51","80.4","","1365.00","1365.00","1365.00","1 through 10","221.98","347.11","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.76","318.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","347.11","81.72","","5157.68","5157.68","5157.68","1 through 10","221.98","347.11","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.76","318.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","347.11","81.72","","431.26","71.26","1459.57","88","221.98","347.11","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","364.45","79.5","","800.18","480.96","1887.97","195","142.11","364.45","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","244.34","53.3","","813.12","216.42","1444.50","81","142.11","364.45","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","142.11","31","","432.60","432.60","432.60","1 through 10","142.11","364.45","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","167.33","36.5","","148.37","54.89","631.39","94","142.11","364.45","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","175.58","38.3","","279.30","91.72","1116.77","266","142.11","364.45","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","196.67","42.9","","731.00","63.70","731.00","1 through 10","142.11","364.45","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","196.67","42.9","","384.74","384.74","384.74","1 through 10","142.11","364.45","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","WELLPOINT [1015]","HB AMC WELLPOINT","338.23","73.78","","286.63","119.22","1107.45","105","142.11","364.45","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","458.43","343.82","AETNA [1001]","HB AMC AETNA HMO","319.98","69.8","","675.31","184.75","1721.50","286","239.58","374.63","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","458.43","343.82","AETNA [1001]","HB AMC AETNA PPO","368.58","80.4","","1261.44","103.12","1514.10","21","239.58","374.63","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","458.43","343.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","368.58","80.4","","1365.00","1365.00","1365.00","1 through 10","239.58","374.63","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","458.43","343.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","374.63","81.72","","5157.68","5157.68","5157.68","1 through 10","239.58","374.63","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","458.43","343.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","374.63","81.72","","431.26","71.26","1459.57","88","239.58","374.63","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1610.98","1208.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1280.73","79.5","","800.18","480.96","1887.97","195","499.4","1280.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1610.98","1208.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","858.65","53.3","","813.12","216.42","1444.50","81","499.4","1280.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1610.98","1208.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","499.40","31","","432.60","432.60","432.60","1 through 10","499.4","1280.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1610.98","1208.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","588.01","36.5","","148.37","54.89","631.39","94","499.4","1280.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1610.98","1208.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","617.01","38.3","","279.30","91.72","1116.77","266","499.4","1280.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1610.98","1208.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","691.11","42.9","","731.00","63.70","731.00","1 through 10","499.4","1280.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1610.98","1208.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","691.11","42.9","","384.74","384.74","384.74","1 through 10","499.4","1280.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1610.98","1208.23","WELLPOINT [1015]","HB AMC WELLPOINT","1188.58","73.78","","286.63","119.22","1107.45","105","499.4","1280.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1610.98","1208.23","AETNA [1001]","HB AMC AETNA HMO","1124.46","69.8","","675.31","184.75","1721.50","286","841.9","1316.49","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1610.98","1208.23","AETNA [1001]","HB AMC AETNA PPO","1295.23","80.4","","1261.44","103.12","1514.10","21","841.9","1316.49","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1610.98","1208.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1295.23","80.4","","1365.00","1365.00","1365.00","1 through 10","841.9","1316.49","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1610.98","1208.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1316.49","81.72","","5157.68","5157.68","5157.68","1 through 10","841.9","1316.49","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1610.98","1208.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1316.49","81.72","","431.26","71.26","1459.57","88","841.9","1316.49","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1039.89","779.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","826.71","79.5","","800.18","480.96","1887.97","195","322.37","826.71","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1039.89","779.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","554.26","53.3","","813.12","216.42","1444.50","81","322.37","826.71","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1039.89","779.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","322.37","31","","432.60","432.60","432.60","1 through 10","322.37","826.71","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1039.89","779.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","379.56","36.5","","148.37","54.89","631.39","94","322.37","826.71","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1039.89","779.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","398.28","38.3","","279.30","91.72","1116.77","266","322.37","826.71","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1039.89","779.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.11","42.9","","731.00","63.70","731.00","1 through 10","322.37","826.71","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1039.89","779.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.11","42.9","","384.74","384.74","384.74","1 through 10","322.37","826.71","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1039.89","779.92","WELLPOINT [1015]","HB AMC WELLPOINT","767.23","73.78","","286.63","119.22","1107.45","105","322.37","826.71","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1039.89","779.92","AETNA [1001]","HB AMC AETNA HMO","725.84","69.8","","675.31","184.75","1721.50","286","543.45","849.8","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1039.89","779.92","AETNA [1001]","HB AMC AETNA PPO","836.07","80.4","","1261.44","103.12","1514.10","21","543.45","849.8","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1039.89","779.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","836.07","80.4","","1365.00","1365.00","1365.00","1 through 10","543.45","849.8","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1039.89","779.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","849.80","81.72","","5157.68","5157.68","5157.68","1 through 10","543.45","849.8","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1039.89","779.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","849.80","81.72","","431.26","71.26","1459.57","88","543.45","849.8","percent of total billed charges",""
"BONE PLATE 2.8MM 12 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2942.70","2207.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2339.45","79.5","","800.18","480.96","1887.97","195","912.24","2339.45","percent of total billed charges",""
"BONE PLATE 2.8MM 12 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2942.70","2207.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1568.46","53.3","","813.12","216.42","1444.50","81","912.24","2339.45","percent of total billed charges",""
"BONE PLATE 2.8MM 12 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2942.70","2207.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","912.24","31","","432.60","432.60","432.60","1 through 10","912.24","2339.45","percent of total billed charges",""
"BONE PLATE 2.8MM 12 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2942.70","2207.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1074.09","36.5","","148.37","54.89","631.39","94","912.24","2339.45","percent of total billed charges",""
"BONE PLATE 2.8MM 12 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2942.70","2207.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1127.05","38.3","","279.30","91.72","1116.77","266","912.24","2339.45","percent of total billed charges",""
"BONE PLATE 2.8MM 12 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2942.70","2207.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1262.42","42.9","","731.00","63.70","731.00","1 through 10","912.24","2339.45","percent of total billed charges",""
"BONE PLATE 2.8MM 12 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2942.70","2207.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1262.42","42.9","","384.74","384.74","384.74","1 through 10","912.24","2339.45","percent of total billed charges",""
"BONE PLATE 2.8MM 12 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2942.70","2207.02","WELLPOINT [1015]","HB AMC WELLPOINT","2171.12","73.78","","286.63","119.22","1107.45","105","912.24","2339.45","percent of total billed charges",""
"BONE PLATE 2.8MM 12 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2942.70","2207.02","AETNA [1001]","HB AMC AETNA HMO","2054.00","69.8","","675.31","184.75","1721.50","286","1537.86","2404.77","percent of total billed charges",""
"BONE PLATE 2.8MM 12 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2942.70","2207.02","AETNA [1001]","HB AMC AETNA PPO","2365.93","80.4","","1261.44","103.12","1514.10","21","1537.86","2404.77","percent of total billed charges",""
"BONE PLATE 2.8MM 12 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2942.70","2207.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2365.93","80.4","","1365.00","1365.00","1365.00","1 through 10","1537.86","2404.77","percent of total billed charges",""
"BONE PLATE 2.8MM 12 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2942.70","2207.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2404.77","81.72","","5157.68","5157.68","5157.68","1 through 10","1537.86","2404.77","percent of total billed charges",""
"BONE PLATE 2.8MM 12 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2942.70","2207.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2404.77","81.72","","431.26","71.26","1459.57","88","1537.86","2404.77","percent of total billed charges",""
"BONE PLATE 2.8MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081085","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.98","3230.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3424.84","79.5","","800.18","480.96","1887.97","195","1335.47","3424.84","percent of total billed charges",""
"BONE PLATE 2.8MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081085","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.98","3230.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2296.15","53.3","","813.12","216.42","1444.50","81","1335.47","3424.84","percent of total billed charges",""
"BONE PLATE 2.8MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081085","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.98","3230.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1335.47","31","","432.60","432.60","432.60","1 through 10","1335.47","3424.84","percent of total billed charges",""
"BONE PLATE 2.8MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081085","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.98","3230.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1572.41","36.5","","148.37","54.89","631.39","94","1335.47","3424.84","percent of total billed charges",""
"BONE PLATE 2.8MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081085","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.98","3230.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1649.96","38.3","","279.30","91.72","1116.77","266","1335.47","3424.84","percent of total billed charges",""
"BONE PLATE 2.8MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081085","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.98","3230.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1848.12","42.9","","731.00","63.70","731.00","1 through 10","1335.47","3424.84","percent of total billed charges",""
"BONE PLATE 2.8MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081085","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.98","3230.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1848.12","42.9","","384.74","384.74","384.74","1 through 10","1335.47","3424.84","percent of total billed charges",""
"BONE PLATE 2.8MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081085","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.98","3230.98","WELLPOINT [1015]","HB AMC WELLPOINT","3178.43","73.78","","286.63","119.22","1107.45","105","1335.47","3424.84","percent of total billed charges",""
"BONE PLATE 2.8MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4307.98","3230.98","AETNA [1001]","HB AMC AETNA HMO","3006.97","69.8","","675.31","184.75","1721.50","286","2251.35","3520.48","percent of total billed charges",""
"BONE PLATE 2.8MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4307.98","3230.98","AETNA [1001]","HB AMC AETNA PPO","3463.62","80.4","","1261.44","103.12","1514.10","21","2251.35","3520.48","percent of total billed charges",""
"BONE PLATE 2.8MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4307.98","3230.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3463.62","80.4","","1365.00","1365.00","1365.00","1 through 10","2251.35","3520.48","percent of total billed charges",""
"BONE PLATE 2.8MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4307.98","3230.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3520.48","81.72","","5157.68","5157.68","5157.68","1 through 10","2251.35","3520.48","percent of total billed charges",""
"BONE PLATE 2.8MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT RECONSTRUCTION","SUP-ITM-10081085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4307.98","3230.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3520.48","81.72","","431.26","71.26","1459.57","88","2251.35","3520.48","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.50","2139.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2267.74","79.5","","800.18","480.96","1887.97","195","884.28","2267.74","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.50","2139.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1520.38","53.3","","813.12","216.42","1444.50","81","884.28","2267.74","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.50","2139.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","884.28","31","","432.60","432.60","432.60","1 through 10","884.28","2267.74","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.50","2139.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1041.16","36.5","","148.37","54.89","631.39","94","884.28","2267.74","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.50","2139.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1092.51","38.3","","279.30","91.72","1116.77","266","884.28","2267.74","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.50","2139.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1223.72","42.9","","731.00","63.70","731.00","1 through 10","884.28","2267.74","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.50","2139.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1223.72","42.9","","384.74","384.74","384.74","1 through 10","884.28","2267.74","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.50","2139.37","WELLPOINT [1015]","HB AMC WELLPOINT","2104.57","73.78","","286.63","119.22","1107.45","105","884.28","2267.74","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2852.50","2139.37","AETNA [1001]","HB AMC AETNA HMO","1991.05","69.8","","675.31","184.75","1721.50","286","1490.72","2331.06","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2852.50","2139.37","AETNA [1001]","HB AMC AETNA PPO","2293.41","80.4","","1261.44","103.12","1514.10","21","1490.72","2331.06","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2852.50","2139.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2293.41","80.4","","1365.00","1365.00","1365.00","1 through 10","1490.72","2331.06","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2852.50","2139.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2331.06","81.72","","5157.68","5157.68","5157.68","1 through 10","1490.72","2331.06","percent of total billed charges",""
"BONE PLATE 2/2.3MM COMPRESSION METACARPAL T-SHAPE 2/4 HOLE GOLD APTUS HAND","SUP-ITM-10021483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2852.50","2139.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2331.06","81.72","","431.26","71.26","1459.57","88","1490.72","2331.06","percent of total billed charges",""
"BONE PLATE 210MM SHORT 12 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10001526","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.01","2212.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2345.26","79.5","","800.18","480.96","1887.97","195","914.5","2345.26","percent of total billed charges",""
"BONE PLATE 210MM SHORT 12 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10001526","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.01","2212.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1572.36","53.3","","813.12","216.42","1444.50","81","914.5","2345.26","percent of total billed charges",""
"BONE PLATE 210MM SHORT 12 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10001526","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.01","2212.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","914.50","31","","432.60","432.60","432.60","1 through 10","914.5","2345.26","percent of total billed charges",""
"BONE PLATE 210MM SHORT 12 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10001526","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.01","2212.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1076.75","36.5","","148.37","54.89","631.39","94","914.5","2345.26","percent of total billed charges",""
"BONE PLATE 210MM SHORT 12 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10001526","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.01","2212.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1129.85","38.3","","279.30","91.72","1116.77","266","914.5","2345.26","percent of total billed charges",""
"BONE PLATE 210MM SHORT 12 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10001526","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.01","2212.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1265.55","42.9","","731.00","63.70","731.00","1 through 10","914.5","2345.26","percent of total billed charges",""
"BONE PLATE 210MM SHORT 12 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10001526","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.01","2212.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1265.55","42.9","","384.74","384.74","384.74","1 through 10","914.5","2345.26","percent of total billed charges",""
"BONE PLATE 210MM SHORT 12 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10001526","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.01","2212.51","WELLPOINT [1015]","HB AMC WELLPOINT","2176.52","73.78","","286.63","119.22","1107.45","105","914.5","2345.26","percent of total billed charges",""
"BONE PLATE 210MM SHORT 12 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10001526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2950.01","2212.51","AETNA [1001]","HB AMC AETNA HMO","2059.11","69.8","","675.31","184.75","1721.50","286","1541.68","2410.75","percent of total billed charges",""
"BONE PLATE 210MM SHORT 12 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10001526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2950.01","2212.51","AETNA [1001]","HB AMC AETNA PPO","2371.81","80.4","","1261.44","103.12","1514.10","21","1541.68","2410.75","percent of total billed charges",""
"BONE PLATE 210MM SHORT 12 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10001526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2950.01","2212.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2371.81","80.4","","1365.00","1365.00","1365.00","1 through 10","1541.68","2410.75","percent of total billed charges",""
"BONE PLATE 210MM SHORT 12 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10001526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2950.01","2212.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2410.75","81.72","","5157.68","5157.68","5157.68","1 through 10","1541.68","2410.75","percent of total billed charges",""
"BONE PLATE 210MM SHORT 12 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10001526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2950.01","2212.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2410.75","81.72","","431.26","71.26","1459.57","88","1541.68","2410.75","percent of total billed charges",""
"BONE PLATE 236MM 9 HOLE DISTAL FEMORAL LCP TM RIGHT","SUP-ITM-10022890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4516.96","3387.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3590.98","79.5","","800.18","480.96","1887.97","195","1400.26","3590.98","percent of total billed charges",""
"BONE PLATE 236MM 9 HOLE DISTAL FEMORAL LCP TM RIGHT","SUP-ITM-10022890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4516.96","3387.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2407.54","53.3","","813.12","216.42","1444.50","81","1400.26","3590.98","percent of total billed charges",""
"BONE PLATE 236MM 9 HOLE DISTAL FEMORAL LCP TM RIGHT","SUP-ITM-10022890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4516.96","3387.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1400.26","31","","432.60","432.60","432.60","1 through 10","1400.26","3590.98","percent of total billed charges",""
"BONE PLATE 236MM 9 HOLE DISTAL FEMORAL LCP TM RIGHT","SUP-ITM-10022890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4516.96","3387.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1648.69","36.5","","148.37","54.89","631.39","94","1400.26","3590.98","percent of total billed charges",""
"BONE PLATE 236MM 9 HOLE DISTAL FEMORAL LCP TM RIGHT","SUP-ITM-10022890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4516.96","3387.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1730.00","38.3","","279.30","91.72","1116.77","266","1400.26","3590.98","percent of total billed charges",""
"BONE PLATE 236MM 9 HOLE DISTAL FEMORAL LCP TM RIGHT","SUP-ITM-10022890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4516.96","3387.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1937.78","42.9","","731.00","63.70","731.00","1 through 10","1400.26","3590.98","percent of total billed charges",""
"BONE PLATE 236MM 9 HOLE DISTAL FEMORAL LCP TM RIGHT","SUP-ITM-10022890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4516.96","3387.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1937.78","42.9","","384.74","384.74","384.74","1 through 10","1400.26","3590.98","percent of total billed charges",""
"BONE PLATE 236MM 9 HOLE DISTAL FEMORAL LCP TM RIGHT","SUP-ITM-10022890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4516.96","3387.72","WELLPOINT [1015]","HB AMC WELLPOINT","3332.61","73.78","","286.63","119.22","1107.45","105","1400.26","3590.98","percent of total billed charges",""
"BONE PLATE 236MM 9 HOLE DISTAL FEMORAL LCP TM RIGHT","SUP-ITM-10022890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4516.96","3387.72","AETNA [1001]","HB AMC AETNA HMO","3152.84","69.8","","675.31","184.75","1721.50","286","2360.56","3691.26","percent of total billed charges",""
"BONE PLATE 236MM 9 HOLE DISTAL FEMORAL LCP TM RIGHT","SUP-ITM-10022890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4516.96","3387.72","AETNA [1001]","HB AMC AETNA PPO","3631.64","80.4","","1261.44","103.12","1514.10","21","2360.56","3691.26","percent of total billed charges",""
"BONE PLATE 236MM 9 HOLE DISTAL FEMORAL LCP TM RIGHT","SUP-ITM-10022890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4516.96","3387.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3631.64","80.4","","1365.00","1365.00","1365.00","1 through 10","2360.56","3691.26","percent of total billed charges",""
"BONE PLATE 236MM 9 HOLE DISTAL FEMORAL LCP TM RIGHT","SUP-ITM-10022890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4516.96","3387.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3691.26","81.72","","5157.68","5157.68","5157.68","1 through 10","2360.56","3691.26","percent of total billed charges",""
"BONE PLATE 236MM 9 HOLE DISTAL FEMORAL LCP TM RIGHT","SUP-ITM-10022890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4516.96","3387.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3691.26","81.72","","431.26","71.26","1459.57","88","2360.56","3691.26","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2309.98","79.5","","800.18","480.96","1887.97","195","900.75","2309.98","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1548.70","53.3","","813.12","216.42","1444.50","81","900.75","2309.98","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","900.75","31","","432.60","432.60","432.60","1 through 10","900.75","2309.98","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1060.55","36.5","","148.37","54.89","631.39","94","900.75","2309.98","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1112.86","38.3","","279.30","91.72","1116.77","266","900.75","2309.98","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1246.52","42.9","","731.00","63.70","731.00","1 through 10","900.75","2309.98","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1246.52","42.9","","384.74","384.74","384.74","1 through 10","900.75","2309.98","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","WELLPOINT [1015]","HB AMC WELLPOINT","2143.77","73.78","","286.63","119.22","1107.45","105","900.75","2309.98","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2905.63","2179.22","AETNA [1001]","HB AMC AETNA HMO","2028.13","69.8","","675.31","184.75","1721.50","286","1518.48","2374.48","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2905.63","2179.22","AETNA [1001]","HB AMC AETNA PPO","2336.13","80.4","","1261.44","103.12","1514.10","21","1518.48","2374.48","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2905.63","2179.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2336.13","80.4","","1365.00","1365.00","1365.00","1 through 10","1518.48","2374.48","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2905.63","2179.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2374.48","81.72","","5157.68","5157.68","5157.68","1 through 10","1518.48","2374.48","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2905.63","2179.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2374.48","81.72","","431.26","71.26","1459.57","88","1518.48","2374.48","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3532.90","2649.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2808.66","79.5","","800.18","480.96","1887.97","195","1095.2","2808.66","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3532.90","2649.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1883.04","53.3","","813.12","216.42","1444.50","81","1095.2","2808.66","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3532.90","2649.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1095.20","31","","432.60","432.60","432.60","1 through 10","1095.2","2808.66","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3532.90","2649.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1289.51","36.5","","148.37","54.89","631.39","94","1095.2","2808.66","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3532.90","2649.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1353.10","38.3","","279.30","91.72","1116.77","266","1095.2","2808.66","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3532.90","2649.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1515.61","42.9","","731.00","63.70","731.00","1 through 10","1095.2","2808.66","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3532.90","2649.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1515.61","42.9","","384.74","384.74","384.74","1 through 10","1095.2","2808.66","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3532.90","2649.67","WELLPOINT [1015]","HB AMC WELLPOINT","2606.57","73.78","","286.63","119.22","1107.45","105","1095.2","2808.66","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3532.90","2649.67","AETNA [1001]","HB AMC AETNA HMO","2465.96","69.8","","675.31","184.75","1721.50","286","1846.29","2887.09","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3532.90","2649.67","AETNA [1001]","HB AMC AETNA PPO","2840.45","80.4","","1261.44","103.12","1514.10","21","1846.29","2887.09","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3532.90","2649.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2840.45","80.4","","1365.00","1365.00","1365.00","1 through 10","1846.29","2887.09","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3532.90","2649.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2887.09","81.72","","5157.68","5157.68","5157.68","1 through 10","1846.29","2887.09","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3532.90","2649.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2887.09","81.72","","431.26","71.26","1459.57","88","1846.29","2887.09","percent of total billed charges",""
"BONE PLATE 250MM STANDARD ORTHOLOC SPS","SUP-ITM-10306447","CDM","C1713","HCPCS","0278","RC","","","","both","","","7375.10","5531.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5863.20","79.5","","800.18","480.96","1887.97","195","2286.28","5863.2","percent of total billed charges",""
"BONE PLATE 250MM STANDARD ORTHOLOC SPS","SUP-ITM-10306447","CDM","C1713","HCPCS","0278","RC","","","","both","","","7375.10","5531.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3930.93","53.3","","813.12","216.42","1444.50","81","2286.28","5863.2","percent of total billed charges",""
"BONE PLATE 250MM STANDARD ORTHOLOC SPS","SUP-ITM-10306447","CDM","C1713","HCPCS","0278","RC","","","","both","","","7375.10","5531.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2286.28","31","","432.60","432.60","432.60","1 through 10","2286.28","5863.2","percent of total billed charges",""
"BONE PLATE 250MM STANDARD ORTHOLOC SPS","SUP-ITM-10306447","CDM","C1713","HCPCS","0278","RC","","","","both","","","7375.10","5531.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2691.91","36.5","","148.37","54.89","631.39","94","2286.28","5863.2","percent of total billed charges",""
"BONE PLATE 250MM STANDARD ORTHOLOC SPS","SUP-ITM-10306447","CDM","C1713","HCPCS","0278","RC","","","","both","","","7375.10","5531.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2824.66","38.3","","279.30","91.72","1116.77","266","2286.28","5863.2","percent of total billed charges",""
"BONE PLATE 250MM STANDARD ORTHOLOC SPS","SUP-ITM-10306447","CDM","C1713","HCPCS","0278","RC","","","","both","","","7375.10","5531.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3163.92","42.9","","731.00","63.70","731.00","1 through 10","2286.28","5863.2","percent of total billed charges",""
"BONE PLATE 250MM STANDARD ORTHOLOC SPS","SUP-ITM-10306447","CDM","C1713","HCPCS","0278","RC","","","","both","","","7375.10","5531.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3163.92","42.9","","384.74","384.74","384.74","1 through 10","2286.28","5863.2","percent of total billed charges",""
"BONE PLATE 250MM STANDARD ORTHOLOC SPS","SUP-ITM-10306447","CDM","C1713","HCPCS","0278","RC","","","","both","","","7375.10","5531.32","WELLPOINT [1015]","HB AMC WELLPOINT","5441.35","73.78","","286.63","119.22","1107.45","105","2286.28","5863.2","percent of total billed charges",""
"BONE PLATE 250MM STANDARD ORTHOLOC SPS","SUP-ITM-10306447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7375.10","5531.32","AETNA [1001]","HB AMC AETNA HMO","5147.82","69.8","","675.31","184.75","1721.50","286","3854.23","6026.93","percent of total billed charges",""
"BONE PLATE 250MM STANDARD ORTHOLOC SPS","SUP-ITM-10306447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7375.10","5531.32","AETNA [1001]","HB AMC AETNA PPO","5929.58","80.4","","1261.44","103.12","1514.10","21","3854.23","6026.93","percent of total billed charges",""
"BONE PLATE 250MM STANDARD ORTHOLOC SPS","SUP-ITM-10306447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7375.10","5531.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5929.58","80.4","","1365.00","1365.00","1365.00","1 through 10","3854.23","6026.93","percent of total billed charges",""
"BONE PLATE 250MM STANDARD ORTHOLOC SPS","SUP-ITM-10306447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7375.10","5531.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6026.93","81.72","","5157.68","5157.68","5157.68","1 through 10","3854.23","6026.93","percent of total billed charges",""
"BONE PLATE 250MM STANDARD ORTHOLOC SPS","SUP-ITM-10306447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7375.10","5531.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6026.93","81.72","","431.26","71.26","1459.57","88","3854.23","6026.93","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","397.57","298.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","316.07","79.5","","800.18","480.96","1887.97","195","123.25","316.07","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","397.57","298.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","211.90","53.3","","813.12","216.42","1444.50","81","123.25","316.07","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","397.57","298.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","123.25","31","","432.60","432.60","432.60","1 through 10","123.25","316.07","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","397.57","298.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","145.11","36.5","","148.37","54.89","631.39","94","123.25","316.07","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","397.57","298.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","152.27","38.3","","279.30","91.72","1116.77","266","123.25","316.07","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","397.57","298.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.56","42.9","","731.00","63.70","731.00","1 through 10","123.25","316.07","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","397.57","298.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.56","42.9","","384.74","384.74","384.74","1 through 10","123.25","316.07","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","both","","","397.57","298.18","WELLPOINT [1015]","HB AMC WELLPOINT","293.33","73.78","","286.63","119.22","1107.45","105","123.25","316.07","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","397.57","298.18","AETNA [1001]","HB AMC AETNA HMO","277.50","69.8","","675.31","184.75","1721.50","286","207.77","324.89","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","397.57","298.18","AETNA [1001]","HB AMC AETNA PPO","319.65","80.4","","1261.44","103.12","1514.10","21","207.77","324.89","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","397.57","298.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","319.65","80.4","","1365.00","1365.00","1365.00","1 through 10","207.77","324.89","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","397.57","298.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","324.89","81.72","","5157.68","5157.68","5157.68","1 through 10","207.77","324.89","percent of total billed charges",""
"BONE PLATE 25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10002175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","397.57","298.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","324.89","81.72","","431.26","71.26","1459.57","88","207.77","324.89","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.60","1496.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1586.50","79.5","","800.18","480.96","1887.97","195","618.64","1586.5","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.60","1496.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1063.65","53.3","","813.12","216.42","1444.50","81","618.64","1586.5","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.60","1496.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","618.64","31","","432.60","432.60","432.60","1 through 10","618.64","1586.5","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.60","1496.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","728.39","36.5","","148.37","54.89","631.39","94","618.64","1586.5","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.60","1496.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","764.31","38.3","","279.30","91.72","1116.77","266","618.64","1586.5","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.60","1496.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","856.11","42.9","","731.00","63.70","731.00","1 through 10","618.64","1586.5","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.60","1496.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","856.11","42.9","","384.74","384.74","384.74","1 through 10","618.64","1586.5","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1995.60","1496.70","WELLPOINT [1015]","HB AMC WELLPOINT","1472.35","73.78","","286.63","119.22","1107.45","105","618.64","1586.5","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1995.60","1496.70","AETNA [1001]","HB AMC AETNA HMO","1392.93","69.8","","675.31","184.75","1721.50","286","1042.9","1630.8","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1995.60","1496.70","AETNA [1001]","HB AMC AETNA PPO","1604.46","80.4","","1261.44","103.12","1514.10","21","1042.9","1630.8","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1995.60","1496.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1604.46","80.4","","1365.00","1365.00","1365.00","1 through 10","1042.9","1630.8","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1995.60","1496.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1630.80","81.72","","5157.68","5157.68","5157.68","1 through 10","1042.9","1630.8","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1995.60","1496.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1630.80","81.72","","431.26","71.26","1459.57","88","1042.9","1630.8","percent of total billed charges",""
"BONE PLATE 274MM SHORT 16 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004203","CDM","C1713","HCPCS","0278","RC","","","","both","","","3146.85","2360.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2501.75","79.5","","800.18","480.96","1887.97","195","975.52","2501.75","percent of total billed charges",""
"BONE PLATE 274MM SHORT 16 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004203","CDM","C1713","HCPCS","0278","RC","","","","both","","","3146.85","2360.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1677.27","53.3","","813.12","216.42","1444.50","81","975.52","2501.75","percent of total billed charges",""
"BONE PLATE 274MM SHORT 16 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004203","CDM","C1713","HCPCS","0278","RC","","","","both","","","3146.85","2360.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","975.52","31","","432.60","432.60","432.60","1 through 10","975.52","2501.75","percent of total billed charges",""
"BONE PLATE 274MM SHORT 16 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004203","CDM","C1713","HCPCS","0278","RC","","","","both","","","3146.85","2360.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1148.60","36.5","","148.37","54.89","631.39","94","975.52","2501.75","percent of total billed charges",""
"BONE PLATE 274MM SHORT 16 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004203","CDM","C1713","HCPCS","0278","RC","","","","both","","","3146.85","2360.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1205.24","38.3","","279.30","91.72","1116.77","266","975.52","2501.75","percent of total billed charges",""
"BONE PLATE 274MM SHORT 16 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004203","CDM","C1713","HCPCS","0278","RC","","","","both","","","3146.85","2360.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1350.00","42.9","","731.00","63.70","731.00","1 through 10","975.52","2501.75","percent of total billed charges",""
"BONE PLATE 274MM SHORT 16 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004203","CDM","C1713","HCPCS","0278","RC","","","","both","","","3146.85","2360.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1350.00","42.9","","384.74","384.74","384.74","1 through 10","975.52","2501.75","percent of total billed charges",""
"BONE PLATE 274MM SHORT 16 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004203","CDM","C1713","HCPCS","0278","RC","","","","both","","","3146.85","2360.14","WELLPOINT [1015]","HB AMC WELLPOINT","2321.75","73.78","","286.63","119.22","1107.45","105","975.52","2501.75","percent of total billed charges",""
"BONE PLATE 274MM SHORT 16 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004203","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3146.85","2360.14","AETNA [1001]","HB AMC AETNA HMO","2196.50","69.8","","675.31","184.75","1721.50","286","1644.54","2571.61","percent of total billed charges",""
"BONE PLATE 274MM SHORT 16 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004203","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3146.85","2360.14","AETNA [1001]","HB AMC AETNA PPO","2530.07","80.4","","1261.44","103.12","1514.10","21","1644.54","2571.61","percent of total billed charges",""
"BONE PLATE 274MM SHORT 16 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004203","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3146.85","2360.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2530.07","80.4","","1365.00","1365.00","1365.00","1 through 10","1644.54","2571.61","percent of total billed charges",""
"BONE PLATE 274MM SHORT 16 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004203","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3146.85","2360.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2571.61","81.72","","5157.68","5157.68","5157.68","1 through 10","1644.54","2571.61","percent of total billed charges",""
"BONE PLATE 274MM SHORT 16 HOLE 95DEG SUPRACONDYLAR COMPRESSION BARREL SS DCS DCP","SUP-ITM-10004203","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3146.85","2360.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2571.61","81.72","","431.26","71.26","1459.57","88","1644.54","2571.61","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2422.95","1817.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1926.25","79.5","","800.18","480.96","1887.97","195","751.11","1926.25","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2422.95","1817.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1291.43","53.3","","813.12","216.42","1444.50","81","751.11","1926.25","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2422.95","1817.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","751.11","31","","432.60","432.60","432.60","1 through 10","751.11","1926.25","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2422.95","1817.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","884.38","36.5","","148.37","54.89","631.39","94","751.11","1926.25","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2422.95","1817.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","927.99","38.3","","279.30","91.72","1116.77","266","751.11","1926.25","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2422.95","1817.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1039.45","42.9","","731.00","63.70","731.00","1 through 10","751.11","1926.25","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2422.95","1817.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1039.45","42.9","","384.74","384.74","384.74","1 through 10","751.11","1926.25","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2422.95","1817.21","WELLPOINT [1015]","HB AMC WELLPOINT","1787.65","73.78","","286.63","119.22","1107.45","105","751.11","1926.25","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2422.95","1817.21","AETNA [1001]","HB AMC AETNA HMO","1691.22","69.8","","675.31","184.75","1721.50","286","1266.23","1980.03","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2422.95","1817.21","AETNA [1001]","HB AMC AETNA PPO","1948.05","80.4","","1261.44","103.12","1514.10","21","1266.23","1980.03","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2422.95","1817.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1948.05","80.4","","1365.00","1365.00","1365.00","1 through 10","1266.23","1980.03","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2422.95","1817.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1980.03","81.72","","5157.68","5157.68","5157.68","1 through 10","1266.23","1980.03","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2422.95","1817.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1980.03","81.72","","431.26","71.26","1459.57","88","1266.23","1980.03","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1226.37","919.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","974.96","79.5","","800.18","480.96","1887.97","195","380.17","974.96","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1226.37","919.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","653.66","53.3","","813.12","216.42","1444.50","81","380.17","974.96","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1226.37","919.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","380.17","31","","432.60","432.60","432.60","1 through 10","380.17","974.96","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1226.37","919.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","447.63","36.5","","148.37","54.89","631.39","94","380.17","974.96","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1226.37","919.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","469.70","38.3","","279.30","91.72","1116.77","266","380.17","974.96","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1226.37","919.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","526.11","42.9","","731.00","63.70","731.00","1 through 10","380.17","974.96","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1226.37","919.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","526.11","42.9","","384.74","384.74","384.74","1 through 10","380.17","974.96","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","1226.37","919.78","WELLPOINT [1015]","HB AMC WELLPOINT","904.82","73.78","","286.63","119.22","1107.45","105","380.17","974.96","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1226.37","919.78","AETNA [1001]","HB AMC AETNA HMO","856.01","69.8","","675.31","184.75","1721.50","286","640.9","1002.19","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1226.37","919.78","AETNA [1001]","HB AMC AETNA PPO","986.00","80.4","","1261.44","103.12","1514.10","21","640.9","1002.19","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1226.37","919.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","986.00","80.4","","1365.00","1365.00","1365.00","1 through 10","640.9","1002.19","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1226.37","919.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1002.19","81.72","","5157.68","5157.68","5157.68","1 through 10","640.9","1002.19","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1226.37","919.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1002.19","81.72","","431.26","71.26","1459.57","88","640.9","1002.19","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.07","1113.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1179.84","79.5","","800.18","480.96","1887.97","195","460.06","1179.84","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.07","1113.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","791.01","53.3","","813.12","216.42","1444.50","81","460.06","1179.84","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.07","1113.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","460.06","31","","432.60","432.60","432.60","1 through 10","460.06","1179.84","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.07","1113.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","541.69","36.5","","148.37","54.89","631.39","94","460.06","1179.84","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.07","1113.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","568.40","38.3","","279.30","91.72","1116.77","266","460.06","1179.84","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.07","1113.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","636.67","42.9","","731.00","63.70","731.00","1 through 10","460.06","1179.84","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.07","1113.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","636.67","42.9","","384.74","384.74","384.74","1 through 10","460.06","1179.84","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.07","1113.05","WELLPOINT [1015]","HB AMC WELLPOINT","1094.95","73.78","","286.63","119.22","1107.45","105","460.06","1179.84","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1484.07","1113.05","AETNA [1001]","HB AMC AETNA HMO","1035.88","69.8","","675.31","184.75","1721.50","286","775.57","1212.78","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1484.07","1113.05","AETNA [1001]","HB AMC AETNA PPO","1193.19","80.4","","1261.44","103.12","1514.10","21","775.57","1212.78","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1484.07","1113.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1193.19","80.4","","1365.00","1365.00","1365.00","1 through 10","775.57","1212.78","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1484.07","1113.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1212.78","81.72","","5157.68","5157.68","5157.68","1 through 10","775.57","1212.78","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1484.07","1113.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1212.78","81.72","","431.26","71.26","1459.57","88","775.57","1212.78","percent of total billed charges",""
"BONE PLATE 2MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081099","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.26","2148.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2277.09","79.5","","800.18","480.96","1887.97","195","887.92","2277.09","percent of total billed charges",""
"BONE PLATE 2MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081099","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.26","2148.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1526.65","53.3","","813.12","216.42","1444.50","81","887.92","2277.09","percent of total billed charges",""
"BONE PLATE 2MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081099","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.26","2148.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","887.92","31","","432.60","432.60","432.60","1 through 10","887.92","2277.09","percent of total billed charges",""
"BONE PLATE 2MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081099","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.26","2148.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1045.45","36.5","","148.37","54.89","631.39","94","887.92","2277.09","percent of total billed charges",""
"BONE PLATE 2MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081099","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.26","2148.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1097.01","38.3","","279.30","91.72","1116.77","266","887.92","2277.09","percent of total billed charges",""
"BONE PLATE 2MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081099","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.26","2148.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1228.77","42.9","","731.00","63.70","731.00","1 through 10","887.92","2277.09","percent of total billed charges",""
"BONE PLATE 2MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081099","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.26","2148.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1228.77","42.9","","384.74","384.74","384.74","1 through 10","887.92","2277.09","percent of total billed charges",""
"BONE PLATE 2MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081099","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.26","2148.19","WELLPOINT [1015]","HB AMC WELLPOINT","2113.25","73.78","","286.63","119.22","1107.45","105","887.92","2277.09","percent of total billed charges",""
"BONE PLATE 2MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2864.26","2148.19","AETNA [1001]","HB AMC AETNA HMO","1999.25","69.8","","675.31","184.75","1721.50","286","1496.86","2340.67","percent of total billed charges",""
"BONE PLATE 2MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2864.26","2148.19","AETNA [1001]","HB AMC AETNA PPO","2302.87","80.4","","1261.44","103.12","1514.10","21","1496.86","2340.67","percent of total billed charges",""
"BONE PLATE 2MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2864.26","2148.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2302.87","80.4","","1365.00","1365.00","1365.00","1 through 10","1496.86","2340.67","percent of total billed charges",""
"BONE PLATE 2MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2864.26","2148.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2340.67","81.72","","5157.68","5157.68","5157.68","1 through 10","1496.86","2340.67","percent of total billed charges",""
"BONE PLATE 2MM 20 HOLE CRANIAL MATRIXMANDIBLE TI STRAIGHT","SUP-ITM-10081099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2864.26","2148.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2340.67","81.72","","431.26","71.26","1459.57","88","1496.86","2340.67","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1521.63","1141.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1209.70","79.5","","800.18","480.96","1887.97","195","471.71","1209.7","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1521.63","1141.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","811.03","53.3","","813.12","216.42","1444.50","81","471.71","1209.7","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1521.63","1141.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","471.71","31","","432.60","432.60","432.60","1 through 10","471.71","1209.7","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1521.63","1141.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","555.39","36.5","","148.37","54.89","631.39","94","471.71","1209.7","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1521.63","1141.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","582.78","38.3","","279.30","91.72","1116.77","266","471.71","1209.7","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1521.63","1141.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","652.78","42.9","","731.00","63.70","731.00","1 through 10","471.71","1209.7","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1521.63","1141.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","652.78","42.9","","384.74","384.74","384.74","1 through 10","471.71","1209.7","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","both","","","1521.63","1141.22","WELLPOINT [1015]","HB AMC WELLPOINT","1122.66","73.78","","286.63","119.22","1107.45","105","471.71","1209.7","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1521.63","1141.22","AETNA [1001]","HB AMC AETNA HMO","1062.10","69.8","","675.31","184.75","1721.50","286","795.2","1243.48","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1521.63","1141.22","AETNA [1001]","HB AMC AETNA PPO","1223.39","80.4","","1261.44","103.12","1514.10","21","795.2","1243.48","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1521.63","1141.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1223.39","80.4","","1365.00","1365.00","1365.00","1 through 10","795.2","1243.48","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1521.63","1141.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1243.48","81.72","","5157.68","5157.68","5157.68","1 through 10","795.2","1243.48","percent of total billed charges",""
"BONE PLATE 2MM 2HOLE 6HOLE BASE LOCKING PHALANGEAL VARIABLE ANGLE","SUP-ITM-10164589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1521.63","1141.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1243.48","81.72","","431.26","71.26","1459.57","88","795.2","1243.48","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","1087.80","815.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","864.80","79.5","","800.18","480.96","1887.97","195","337.22","864.8","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","1087.80","815.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","579.80","53.3","","813.12","216.42","1444.50","81","337.22","864.8","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","1087.80","815.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","337.22","31","","432.60","432.60","432.60","1 through 10","337.22","864.8","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","1087.80","815.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","397.05","36.5","","148.37","54.89","631.39","94","337.22","864.8","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","1087.80","815.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","416.63","38.3","","279.30","91.72","1116.77","266","337.22","864.8","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","1087.80","815.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.67","42.9","","731.00","63.70","731.00","1 through 10","337.22","864.8","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","1087.80","815.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.67","42.9","","384.74","384.74","384.74","1 through 10","337.22","864.8","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","1087.80","815.85","WELLPOINT [1015]","HB AMC WELLPOINT","802.58","73.78","","286.63","119.22","1107.45","105","337.22","864.8","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1087.80","815.85","AETNA [1001]","HB AMC AETNA HMO","759.28","69.8","","675.31","184.75","1721.50","286","568.48","888.95","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1087.80","815.85","AETNA [1001]","HB AMC AETNA PPO","874.59","80.4","","1261.44","103.12","1514.10","21","568.48","888.95","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1087.80","815.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","874.59","80.4","","1365.00","1365.00","1365.00","1 through 10","568.48","888.95","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1087.80","815.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","888.95","81.72","","5157.68","5157.68","5157.68","1 through 10","568.48","888.95","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1087.80","815.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","888.95","81.72","","431.26","71.26","1459.57","88","568.48","888.95","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","781.41","79.5","","800.18","480.96","1887.97","195","304.7","781.41","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","523.89","53.3","","813.12","216.42","1444.50","81","304.7","781.41","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","304.70","31","","432.60","432.60","432.60","1 through 10","304.7","781.41","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","358.76","36.5","","148.37","54.89","631.39","94","304.7","781.41","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","376.45","38.3","","279.30","91.72","1116.77","266","304.7","781.41","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","421.67","42.9","","731.00","63.70","731.00","1 through 10","304.7","781.41","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","421.67","42.9","","384.74","384.74","384.74","1 through 10","304.7","781.41","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","WELLPOINT [1015]","HB AMC WELLPOINT","725.19","73.78","","286.63","119.22","1107.45","105","304.7","781.41","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","982.91","737.18","AETNA [1001]","HB AMC AETNA HMO","686.07","69.8","","675.31","184.75","1721.50","286","513.67","803.23","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","982.91","737.18","AETNA [1001]","HB AMC AETNA PPO","790.26","80.4","","1261.44","103.12","1514.10","21","513.67","803.23","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","982.91","737.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","790.26","80.4","","1365.00","1365.00","1365.00","1 through 10","513.67","803.23","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","982.91","737.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","803.23","81.72","","5157.68","5157.68","5157.68","1 through 10","513.67","803.23","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","982.91","737.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","803.23","81.72","","431.26","71.26","1459.57","88","513.67","803.23","percent of total billed charges",""
"BONE PLATE 2MM CRANIOMAXILLOFACIAL TI FIXATION CONDYLAR HEAD","SUP-ITM-10081128","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.12","501.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","531.16","79.5","","800.18","480.96","1887.97","195","207.12","531.16","percent of total billed charges",""
"BONE PLATE 2MM CRANIOMAXILLOFACIAL TI FIXATION CONDYLAR HEAD","SUP-ITM-10081128","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.12","501.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","356.11","53.3","","813.12","216.42","1444.50","81","207.12","531.16","percent of total billed charges",""
"BONE PLATE 2MM CRANIOMAXILLOFACIAL TI FIXATION CONDYLAR HEAD","SUP-ITM-10081128","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.12","501.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","207.12","31","","432.60","432.60","432.60","1 through 10","207.12","531.16","percent of total billed charges",""
"BONE PLATE 2MM CRANIOMAXILLOFACIAL TI FIXATION CONDYLAR HEAD","SUP-ITM-10081128","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.12","501.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","243.86","36.5","","148.37","54.89","631.39","94","207.12","531.16","percent of total billed charges",""
"BONE PLATE 2MM CRANIOMAXILLOFACIAL TI FIXATION CONDYLAR HEAD","SUP-ITM-10081128","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.12","501.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","255.89","38.3","","279.30","91.72","1116.77","266","207.12","531.16","percent of total billed charges",""
"BONE PLATE 2MM CRANIOMAXILLOFACIAL TI FIXATION CONDYLAR HEAD","SUP-ITM-10081128","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.12","501.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","286.62","42.9","","731.00","63.70","731.00","1 through 10","207.12","531.16","percent of total billed charges",""
"BONE PLATE 2MM CRANIOMAXILLOFACIAL TI FIXATION CONDYLAR HEAD","SUP-ITM-10081128","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.12","501.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","286.62","42.9","","384.74","384.74","384.74","1 through 10","207.12","531.16","percent of total billed charges",""
"BONE PLATE 2MM CRANIOMAXILLOFACIAL TI FIXATION CONDYLAR HEAD","SUP-ITM-10081128","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.12","501.09","WELLPOINT [1015]","HB AMC WELLPOINT","492.94","73.78","","286.63","119.22","1107.45","105","207.12","531.16","percent of total billed charges",""
"BONE PLATE 2MM CRANIOMAXILLOFACIAL TI FIXATION CONDYLAR HEAD","SUP-ITM-10081128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.12","501.09","AETNA [1001]","HB AMC AETNA HMO","466.35","69.8","","675.31","184.75","1721.50","286","349.16","545.99","percent of total billed charges",""
"BONE PLATE 2MM CRANIOMAXILLOFACIAL TI FIXATION CONDYLAR HEAD","SUP-ITM-10081128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.12","501.09","AETNA [1001]","HB AMC AETNA PPO","537.17","80.4","","1261.44","103.12","1514.10","21","349.16","545.99","percent of total billed charges",""
"BONE PLATE 2MM CRANIOMAXILLOFACIAL TI FIXATION CONDYLAR HEAD","SUP-ITM-10081128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.12","501.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","537.17","80.4","","1365.00","1365.00","1365.00","1 through 10","349.16","545.99","percent of total billed charges",""
"BONE PLATE 2MM CRANIOMAXILLOFACIAL TI FIXATION CONDYLAR HEAD","SUP-ITM-10081128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.12","501.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","545.99","81.72","","5157.68","5157.68","5157.68","1 through 10","349.16","545.99","percent of total billed charges",""
"BONE PLATE 2MM CRANIOMAXILLOFACIAL TI FIXATION CONDYLAR HEAD","SUP-ITM-10081128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.12","501.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","545.99","81.72","","431.26","71.26","1459.57","88","349.16","545.99","percent of total billed charges",""
"BONE PLATE 2MM SM RECONSTRUCTION MATRIXMANDIBLE DOUBLE ANGLE","SUP-ITM-10168161","CDM","C1713","HCPCS","0278","RC","","","","both","","","17195.00","12896.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13670.03","79.5","","800.18","480.96","1887.97","195","5330.45","13670.03","percent of total billed charges",""
"BONE PLATE 2MM SM RECONSTRUCTION MATRIXMANDIBLE DOUBLE ANGLE","SUP-ITM-10168161","CDM","C1713","HCPCS","0278","RC","","","","both","","","17195.00","12896.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9164.94","53.3","","813.12","216.42","1444.50","81","5330.45","13670.03","percent of total billed charges",""
"BONE PLATE 2MM SM RECONSTRUCTION MATRIXMANDIBLE DOUBLE ANGLE","SUP-ITM-10168161","CDM","C1713","HCPCS","0278","RC","","","","both","","","17195.00","12896.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","5330.45","31","","432.60","432.60","432.60","1 through 10","5330.45","13670.03","percent of total billed charges",""
"BONE PLATE 2MM SM RECONSTRUCTION MATRIXMANDIBLE DOUBLE ANGLE","SUP-ITM-10168161","CDM","C1713","HCPCS","0278","RC","","","","both","","","17195.00","12896.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6276.18","36.5","","148.37","54.89","631.39","94","5330.45","13670.03","percent of total billed charges",""
"BONE PLATE 2MM SM RECONSTRUCTION MATRIXMANDIBLE DOUBLE ANGLE","SUP-ITM-10168161","CDM","C1713","HCPCS","0278","RC","","","","both","","","17195.00","12896.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6585.69","38.3","","279.30","91.72","1116.77","266","5330.45","13670.03","percent of total billed charges",""
"BONE PLATE 2MM SM RECONSTRUCTION MATRIXMANDIBLE DOUBLE ANGLE","SUP-ITM-10168161","CDM","C1713","HCPCS","0278","RC","","","","both","","","17195.00","12896.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7376.66","42.9","","731.00","63.70","731.00","1 through 10","5330.45","13670.03","percent of total billed charges",""
"BONE PLATE 2MM SM RECONSTRUCTION MATRIXMANDIBLE DOUBLE ANGLE","SUP-ITM-10168161","CDM","C1713","HCPCS","0278","RC","","","","both","","","17195.00","12896.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7376.66","42.9","","384.74","384.74","384.74","1 through 10","5330.45","13670.03","percent of total billed charges",""
"BONE PLATE 2MM SM RECONSTRUCTION MATRIXMANDIBLE DOUBLE ANGLE","SUP-ITM-10168161","CDM","C1713","HCPCS","0278","RC","","","","both","","","17195.00","12896.25","WELLPOINT [1015]","HB AMC WELLPOINT","12686.47","73.78","","286.63","119.22","1107.45","105","5330.45","13670.03","percent of total billed charges",""
"BONE PLATE 2MM SM RECONSTRUCTION MATRIXMANDIBLE DOUBLE ANGLE","SUP-ITM-10168161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17195.00","12896.25","AETNA [1001]","HB AMC AETNA HMO","12002.11","69.8","","675.31","184.75","1721.50","286","8986.11","14051.75","percent of total billed charges",""
"BONE PLATE 2MM SM RECONSTRUCTION MATRIXMANDIBLE DOUBLE ANGLE","SUP-ITM-10168161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17195.00","12896.25","AETNA [1001]","HB AMC AETNA PPO","13824.78","80.4","","1261.44","103.12","1514.10","21","8986.11","14051.75","percent of total billed charges",""
"BONE PLATE 2MM SM RECONSTRUCTION MATRIXMANDIBLE DOUBLE ANGLE","SUP-ITM-10168161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17195.00","12896.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","13824.78","80.4","","1365.00","1365.00","1365.00","1 through 10","8986.11","14051.75","percent of total billed charges",""
"BONE PLATE 2MM SM RECONSTRUCTION MATRIXMANDIBLE DOUBLE ANGLE","SUP-ITM-10168161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17195.00","12896.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","14051.75","81.72","","5157.68","5157.68","5157.68","1 through 10","8986.11","14051.75","percent of total billed charges",""
"BONE PLATE 2MM SM RECONSTRUCTION MATRIXMANDIBLE DOUBLE ANGLE","SUP-ITM-10168161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17195.00","12896.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14051.75","81.72","","431.26","71.26","1459.57","88","8986.11","14051.75","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.87","79.5","","800.18","480.96","1887.97","195","45.57","116.87","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.35","53.3","","813.12","216.42","1444.50","81","45.57","116.87","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.57","31","","432.60","432.60","432.60","1 through 10","45.57","116.87","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.66","36.5","","148.37","54.89","631.39","94","45.57","116.87","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.30","38.3","","279.30","91.72","1116.77","266","45.57","116.87","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.06","42.9","","731.00","63.70","731.00","1 through 10","45.57","116.87","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.06","42.9","","384.74","384.74","384.74","1 through 10","45.57","116.87","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","WELLPOINT [1015]","HB AMC WELLPOINT","108.46","73.78","","286.63","119.22","1107.45","105","45.57","116.87","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA HMO","102.61","69.8","","675.31","184.75","1721.50","286","76.82","120.13","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA PPO","118.19","80.4","","1261.44","103.12","1514.10","21","76.82","120.13","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","118.19","80.4","","1365.00","1365.00","1365.00","1 through 10","76.82","120.13","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","120.13","81.72","","5157.68","5157.68","5157.68","1 through 10","76.82","120.13","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","120.13","81.72","","431.26","71.26","1459.57","88","76.82","120.13","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","627.73","79.5","","800.18","480.96","1887.97","195","244.78","627.73","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","420.86","53.3","","813.12","216.42","1444.50","81","244.78","627.73","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","244.78","31","","432.60","432.60","432.60","1 through 10","244.78","627.73","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","288.20","36.5","","148.37","54.89","631.39","94","244.78","627.73","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","302.42","38.3","","279.30","91.72","1116.77","266","244.78","627.73","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","338.74","42.9","","731.00","63.70","731.00","1 through 10","244.78","627.73","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","338.74","42.9","","384.74","384.74","384.74","1 through 10","244.78","627.73","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","WELLPOINT [1015]","HB AMC WELLPOINT","582.57","73.78","","286.63","119.22","1107.45","105","244.78","627.73","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","789.60","592.20","AETNA [1001]","HB AMC AETNA HMO","551.14","69.8","","675.31","184.75","1721.50","286","412.64","645.26","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","789.60","592.20","AETNA [1001]","HB AMC AETNA PPO","634.84","80.4","","1261.44","103.12","1514.10","21","412.64","645.26","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","789.60","592.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","634.84","80.4","","1365.00","1365.00","1365.00","1 through 10","412.64","645.26","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","789.60","592.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","645.26","81.72","","5157.68","5157.68","5157.68","1 through 10","412.64","645.26","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","789.60","592.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","645.26","81.72","","431.26","71.26","1459.57","88","412.64","645.26","percent of total billed charges",""
"BONE PLATE 2X1.25MM HOLE CRANIAL MATRIXMANDIBLE TI COMPRESSION","SUP-ITM-10081116","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.60","581.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","616.60","79.5","","800.18","480.96","1887.97","195","240.44","616.6","percent of total billed charges",""
"BONE PLATE 2X1.25MM HOLE CRANIAL MATRIXMANDIBLE TI COMPRESSION","SUP-ITM-10081116","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.60","581.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","413.39","53.3","","813.12","216.42","1444.50","81","240.44","616.6","percent of total billed charges",""
"BONE PLATE 2X1.25MM HOLE CRANIAL MATRIXMANDIBLE TI COMPRESSION","SUP-ITM-10081116","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.60","581.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","240.44","31","","432.60","432.60","432.60","1 through 10","240.44","616.6","percent of total billed charges",""
"BONE PLATE 2X1.25MM HOLE CRANIAL MATRIXMANDIBLE TI COMPRESSION","SUP-ITM-10081116","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.60","581.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","283.09","36.5","","148.37","54.89","631.39","94","240.44","616.6","percent of total billed charges",""
"BONE PLATE 2X1.25MM HOLE CRANIAL MATRIXMANDIBLE TI COMPRESSION","SUP-ITM-10081116","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.60","581.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","297.05","38.3","","279.30","91.72","1116.77","266","240.44","616.6","percent of total billed charges",""
"BONE PLATE 2X1.25MM HOLE CRANIAL MATRIXMANDIBLE TI COMPRESSION","SUP-ITM-10081116","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.60","581.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","332.73","42.9","","731.00","63.70","731.00","1 through 10","240.44","616.6","percent of total billed charges",""
"BONE PLATE 2X1.25MM HOLE CRANIAL MATRIXMANDIBLE TI COMPRESSION","SUP-ITM-10081116","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.60","581.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","332.73","42.9","","384.74","384.74","384.74","1 through 10","240.44","616.6","percent of total billed charges",""
"BONE PLATE 2X1.25MM HOLE CRANIAL MATRIXMANDIBLE TI COMPRESSION","SUP-ITM-10081116","CDM","C1713","HCPCS","0278","RC","","","","both","","","775.60","581.70","WELLPOINT [1015]","HB AMC WELLPOINT","572.24","73.78","","286.63","119.22","1107.45","105","240.44","616.6","percent of total billed charges",""
"BONE PLATE 2X1.25MM HOLE CRANIAL MATRIXMANDIBLE TI COMPRESSION","SUP-ITM-10081116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","775.60","581.70","AETNA [1001]","HB AMC AETNA HMO","541.37","69.8","","675.31","184.75","1721.50","286","405.33","633.82","percent of total billed charges",""
"BONE PLATE 2X1.25MM HOLE CRANIAL MATRIXMANDIBLE TI COMPRESSION","SUP-ITM-10081116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","775.60","581.70","AETNA [1001]","HB AMC AETNA PPO","623.58","80.4","","1261.44","103.12","1514.10","21","405.33","633.82","percent of total billed charges",""
"BONE PLATE 2X1.25MM HOLE CRANIAL MATRIXMANDIBLE TI COMPRESSION","SUP-ITM-10081116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","775.60","581.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","623.58","80.4","","1365.00","1365.00","1365.00","1 through 10","405.33","633.82","percent of total billed charges",""
"BONE PLATE 2X1.25MM HOLE CRANIAL MATRIXMANDIBLE TI COMPRESSION","SUP-ITM-10081116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","775.60","581.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","633.82","81.72","","5157.68","5157.68","5157.68","1 through 10","405.33","633.82","percent of total billed charges",""
"BONE PLATE 2X1.25MM HOLE CRANIAL MATRIXMANDIBLE TI COMPRESSION","SUP-ITM-10081116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","775.60","581.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","633.82","81.72","","431.26","71.26","1459.57","88","405.33","633.82","percent of total billed charges",""
"BONE PLATE 2X1.5MM 10 HOLE CRANIAL RAPIDSORB POLYMER STRUT SCALLOPED","SUP-ITM-10029163","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.71","702.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","744.68","79.5","","800.18","480.96","1887.97","195","290.38","744.68","percent of total billed charges",""
"BONE PLATE 2X1.5MM 10 HOLE CRANIAL RAPIDSORB POLYMER STRUT SCALLOPED","SUP-ITM-10029163","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.71","702.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","499.27","53.3","","813.12","216.42","1444.50","81","290.38","744.68","percent of total billed charges",""
"BONE PLATE 2X1.5MM 10 HOLE CRANIAL RAPIDSORB POLYMER STRUT SCALLOPED","SUP-ITM-10029163","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.71","702.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","290.38","31","","432.60","432.60","432.60","1 through 10","290.38","744.68","percent of total billed charges",""
"BONE PLATE 2X1.5MM 10 HOLE CRANIAL RAPIDSORB POLYMER STRUT SCALLOPED","SUP-ITM-10029163","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.71","702.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","341.90","36.5","","148.37","54.89","631.39","94","290.38","744.68","percent of total billed charges",""
"BONE PLATE 2X1.5MM 10 HOLE CRANIAL RAPIDSORB POLYMER STRUT SCALLOPED","SUP-ITM-10029163","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.71","702.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","358.76","38.3","","279.30","91.72","1116.77","266","290.38","744.68","percent of total billed charges",""
"BONE PLATE 2X1.5MM 10 HOLE CRANIAL RAPIDSORB POLYMER STRUT SCALLOPED","SUP-ITM-10029163","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.71","702.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","401.85","42.9","","731.00","63.70","731.00","1 through 10","290.38","744.68","percent of total billed charges",""
"BONE PLATE 2X1.5MM 10 HOLE CRANIAL RAPIDSORB POLYMER STRUT SCALLOPED","SUP-ITM-10029163","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.71","702.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","401.85","42.9","","384.74","384.74","384.74","1 through 10","290.38","744.68","percent of total billed charges",""
"BONE PLATE 2X1.5MM 10 HOLE CRANIAL RAPIDSORB POLYMER STRUT SCALLOPED","SUP-ITM-10029163","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.71","702.53","WELLPOINT [1015]","HB AMC WELLPOINT","691.10","73.78","","286.63","119.22","1107.45","105","290.38","744.68","percent of total billed charges",""
"BONE PLATE 2X1.5MM 10 HOLE CRANIAL RAPIDSORB POLYMER STRUT SCALLOPED","SUP-ITM-10029163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.71","702.53","AETNA [1001]","HB AMC AETNA HMO","653.82","69.8","","675.31","184.75","1721.50","286","489.52","765.48","percent of total billed charges",""
"BONE PLATE 2X1.5MM 10 HOLE CRANIAL RAPIDSORB POLYMER STRUT SCALLOPED","SUP-ITM-10029163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.71","702.53","AETNA [1001]","HB AMC AETNA PPO","753.11","80.4","","1261.44","103.12","1514.10","21","489.52","765.48","percent of total billed charges",""
"BONE PLATE 2X1.5MM 10 HOLE CRANIAL RAPIDSORB POLYMER STRUT SCALLOPED","SUP-ITM-10029163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.71","702.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","753.11","80.4","","1365.00","1365.00","1365.00","1 through 10","489.52","765.48","percent of total billed charges",""
"BONE PLATE 2X1.5MM 10 HOLE CRANIAL RAPIDSORB POLYMER STRUT SCALLOPED","SUP-ITM-10029163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.71","702.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","765.48","81.72","","5157.68","5157.68","5157.68","1 through 10","489.52","765.48","percent of total billed charges",""
"BONE PLATE 2X1.5MM 10 HOLE CRANIAL RAPIDSORB POLYMER STRUT SCALLOPED","SUP-ITM-10029163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.71","702.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","765.48","81.72","","431.26","71.26","1459.57","88","489.52","765.48","percent of total billed charges",""
"BONE PLATE 2X100MM 20 HOLE FRAGMENT MINI STRAIGHT SS","SUP-ITM-10004216","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.36","590.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","625.95","79.5","","800.18","480.96","1887.97","195","244.08","625.95","percent of total billed charges",""
"BONE PLATE 2X100MM 20 HOLE FRAGMENT MINI STRAIGHT SS","SUP-ITM-10004216","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.36","590.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","419.66","53.3","","813.12","216.42","1444.50","81","244.08","625.95","percent of total billed charges",""
"BONE PLATE 2X100MM 20 HOLE FRAGMENT MINI STRAIGHT SS","SUP-ITM-10004216","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.36","590.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","244.08","31","","432.60","432.60","432.60","1 through 10","244.08","625.95","percent of total billed charges",""
"BONE PLATE 2X100MM 20 HOLE FRAGMENT MINI STRAIGHT SS","SUP-ITM-10004216","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.36","590.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","287.39","36.5","","148.37","54.89","631.39","94","244.08","625.95","percent of total billed charges",""
"BONE PLATE 2X100MM 20 HOLE FRAGMENT MINI STRAIGHT SS","SUP-ITM-10004216","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.36","590.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","301.56","38.3","","279.30","91.72","1116.77","266","244.08","625.95","percent of total billed charges",""
"BONE PLATE 2X100MM 20 HOLE FRAGMENT MINI STRAIGHT SS","SUP-ITM-10004216","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.36","590.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.78","42.9","","731.00","63.70","731.00","1 through 10","244.08","625.95","percent of total billed charges",""
"BONE PLATE 2X100MM 20 HOLE FRAGMENT MINI STRAIGHT SS","SUP-ITM-10004216","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.36","590.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.78","42.9","","384.74","384.74","384.74","1 through 10","244.08","625.95","percent of total billed charges",""
"BONE PLATE 2X100MM 20 HOLE FRAGMENT MINI STRAIGHT SS","SUP-ITM-10004216","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.36","590.52","WELLPOINT [1015]","HB AMC WELLPOINT","580.91","73.78","","286.63","119.22","1107.45","105","244.08","625.95","percent of total billed charges",""
"BONE PLATE 2X100MM 20 HOLE FRAGMENT MINI STRAIGHT SS","SUP-ITM-10004216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.36","590.52","AETNA [1001]","HB AMC AETNA HMO","549.58","69.8","","675.31","184.75","1721.50","286","411.47","643.43","percent of total billed charges",""
"BONE PLATE 2X100MM 20 HOLE FRAGMENT MINI STRAIGHT SS","SUP-ITM-10004216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.36","590.52","AETNA [1001]","HB AMC AETNA PPO","633.04","80.4","","1261.44","103.12","1514.10","21","411.47","643.43","percent of total billed charges",""
"BONE PLATE 2X100MM 20 HOLE FRAGMENT MINI STRAIGHT SS","SUP-ITM-10004216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.36","590.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","633.04","80.4","","1365.00","1365.00","1365.00","1 through 10","411.47","643.43","percent of total billed charges",""
"BONE PLATE 2X100MM 20 HOLE FRAGMENT MINI STRAIGHT SS","SUP-ITM-10004216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.36","590.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","643.43","81.72","","5157.68","5157.68","5157.68","1 through 10","411.47","643.43","percent of total billed charges",""
"BONE PLATE 2X100MM 20 HOLE FRAGMENT MINI STRAIGHT SS","SUP-ITM-10004216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.36","590.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","643.43","81.72","","431.26","71.26","1459.57","88","411.47","643.43","percent of total billed charges",""
"BONE PLATE 2X131MM 20 HOLE BROAD LOCKING","SUP-ITM-10306719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4537.75","3403.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3607.51","79.5","","800.18","480.96","1887.97","195","1406.7","3607.51","percent of total billed charges",""
"BONE PLATE 2X131MM 20 HOLE BROAD LOCKING","SUP-ITM-10306719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4537.75","3403.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2418.62","53.3","","813.12","216.42","1444.50","81","1406.7","3607.51","percent of total billed charges",""
"BONE PLATE 2X131MM 20 HOLE BROAD LOCKING","SUP-ITM-10306719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4537.75","3403.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1406.70","31","","432.60","432.60","432.60","1 through 10","1406.7","3607.51","percent of total billed charges",""
"BONE PLATE 2X131MM 20 HOLE BROAD LOCKING","SUP-ITM-10306719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4537.75","3403.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1656.28","36.5","","148.37","54.89","631.39","94","1406.7","3607.51","percent of total billed charges",""
"BONE PLATE 2X131MM 20 HOLE BROAD LOCKING","SUP-ITM-10306719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4537.75","3403.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1737.96","38.3","","279.30","91.72","1116.77","266","1406.7","3607.51","percent of total billed charges",""
"BONE PLATE 2X131MM 20 HOLE BROAD LOCKING","SUP-ITM-10306719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4537.75","3403.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1946.69","42.9","","731.00","63.70","731.00","1 through 10","1406.7","3607.51","percent of total billed charges",""
"BONE PLATE 2X131MM 20 HOLE BROAD LOCKING","SUP-ITM-10306719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4537.75","3403.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1946.69","42.9","","384.74","384.74","384.74","1 through 10","1406.7","3607.51","percent of total billed charges",""
"BONE PLATE 2X131MM 20 HOLE BROAD LOCKING","SUP-ITM-10306719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4537.75","3403.31","WELLPOINT [1015]","HB AMC WELLPOINT","3347.95","73.78","","286.63","119.22","1107.45","105","1406.7","3607.51","percent of total billed charges",""
"BONE PLATE 2X131MM 20 HOLE BROAD LOCKING","SUP-ITM-10306719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4537.75","3403.31","AETNA [1001]","HB AMC AETNA HMO","3167.35","69.8","","675.31","184.75","1721.50","286","2371.43","3708.25","percent of total billed charges",""
"BONE PLATE 2X131MM 20 HOLE BROAD LOCKING","SUP-ITM-10306719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4537.75","3403.31","AETNA [1001]","HB AMC AETNA PPO","3648.35","80.4","","1261.44","103.12","1514.10","21","2371.43","3708.25","percent of total billed charges",""
"BONE PLATE 2X131MM 20 HOLE BROAD LOCKING","SUP-ITM-10306719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4537.75","3403.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3648.35","80.4","","1365.00","1365.00","1365.00","1 through 10","2371.43","3708.25","percent of total billed charges",""
"BONE PLATE 2X131MM 20 HOLE BROAD LOCKING","SUP-ITM-10306719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4537.75","3403.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3708.25","81.72","","5157.68","5157.68","5157.68","1 through 10","2371.43","3708.25","percent of total billed charges",""
"BONE PLATE 2X131MM 20 HOLE BROAD LOCKING","SUP-ITM-10306719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4537.75","3403.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3708.25","81.72","","431.26","71.26","1459.57","88","2371.43","3708.25","percent of total billed charges",""
"BONE PLATE 2X14 24MM 3 HOLE CRANIAL MATRIXNEURO TI STRUT","SUP-ITM-10076554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.24","773.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","819.84","79.5","","800.18","480.96","1887.97","195","319.68","819.84","percent of total billed charges",""
"BONE PLATE 2X14 24MM 3 HOLE CRANIAL MATRIXNEURO TI STRUT","SUP-ITM-10076554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.24","773.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","549.65","53.3","","813.12","216.42","1444.50","81","319.68","819.84","percent of total billed charges",""
"BONE PLATE 2X14 24MM 3 HOLE CRANIAL MATRIXNEURO TI STRUT","SUP-ITM-10076554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.24","773.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","319.68","31","","432.60","432.60","432.60","1 through 10","319.68","819.84","percent of total billed charges",""
"BONE PLATE 2X14 24MM 3 HOLE CRANIAL MATRIXNEURO TI STRUT","SUP-ITM-10076554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.24","773.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","376.40","36.5","","148.37","54.89","631.39","94","319.68","819.84","percent of total billed charges",""
"BONE PLATE 2X14 24MM 3 HOLE CRANIAL MATRIXNEURO TI STRUT","SUP-ITM-10076554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.24","773.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","394.96","38.3","","279.30","91.72","1116.77","266","319.68","819.84","percent of total billed charges",""
"BONE PLATE 2X14 24MM 3 HOLE CRANIAL MATRIXNEURO TI STRUT","SUP-ITM-10076554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.24","773.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.40","42.9","","731.00","63.70","731.00","1 through 10","319.68","819.84","percent of total billed charges",""
"BONE PLATE 2X14 24MM 3 HOLE CRANIAL MATRIXNEURO TI STRUT","SUP-ITM-10076554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.24","773.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.40","42.9","","384.74","384.74","384.74","1 through 10","319.68","819.84","percent of total billed charges",""
"BONE PLATE 2X14 24MM 3 HOLE CRANIAL MATRIXNEURO TI STRUT","SUP-ITM-10076554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.24","773.43","WELLPOINT [1015]","HB AMC WELLPOINT","760.85","73.78","","286.63","119.22","1107.45","105","319.68","819.84","percent of total billed charges",""
"BONE PLATE 2X14 24MM 3 HOLE CRANIAL MATRIXNEURO TI STRUT","SUP-ITM-10076554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1031.24","773.43","AETNA [1001]","HB AMC AETNA HMO","719.81","69.8","","675.31","184.75","1721.50","286","538.93","842.73","percent of total billed charges",""
"BONE PLATE 2X14 24MM 3 HOLE CRANIAL MATRIXNEURO TI STRUT","SUP-ITM-10076554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1031.24","773.43","AETNA [1001]","HB AMC AETNA PPO","829.12","80.4","","1261.44","103.12","1514.10","21","538.93","842.73","percent of total billed charges",""
"BONE PLATE 2X14 24MM 3 HOLE CRANIAL MATRIXNEURO TI STRUT","SUP-ITM-10076554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1031.24","773.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","829.12","80.4","","1365.00","1365.00","1365.00","1 through 10","538.93","842.73","percent of total billed charges",""
"BONE PLATE 2X14 24MM 3 HOLE CRANIAL MATRIXNEURO TI STRUT","SUP-ITM-10076554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1031.24","773.43","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","842.73","81.72","","5157.68","5157.68","5157.68","1 through 10","538.93","842.73","percent of total billed charges",""
"BONE PLATE 2X14 24MM 3 HOLE CRANIAL MATRIXNEURO TI STRUT","SUP-ITM-10076554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1031.24","773.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","842.73","81.72","","431.26","71.26","1459.57","88","538.93","842.73","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","749.81","562.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","596.10","79.5","","800.18","480.96","1887.97","195","232.44","596.1","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","749.81","562.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","399.65","53.3","","813.12","216.42","1444.50","81","232.44","596.1","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","749.81","562.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","232.44","31","","432.60","432.60","432.60","1 through 10","232.44","596.1","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","749.81","562.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","273.68","36.5","","148.37","54.89","631.39","94","232.44","596.1","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","749.81","562.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","287.18","38.3","","279.30","91.72","1116.77","266","232.44","596.1","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","749.81","562.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","321.67","42.9","","731.00","63.70","731.00","1 through 10","232.44","596.1","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","749.81","562.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","321.67","42.9","","384.74","384.74","384.74","1 through 10","232.44","596.1","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","749.81","562.36","WELLPOINT [1015]","HB AMC WELLPOINT","553.21","73.78","","286.63","119.22","1107.45","105","232.44","596.1","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","749.81","562.36","AETNA [1001]","HB AMC AETNA HMO","523.37","69.8","","675.31","184.75","1721.50","286","391.85","612.74","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","749.81","562.36","AETNA [1001]","HB AMC AETNA PPO","602.85","80.4","","1261.44","103.12","1514.10","21","391.85","612.74","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","749.81","562.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","602.85","80.4","","1365.00","1365.00","1365.00","1 through 10","391.85","612.74","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","749.81","562.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","612.74","81.72","","5157.68","5157.68","5157.68","1 through 10","391.85","612.74","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","749.81","562.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","612.74","81.72","","431.26","71.26","1459.57","88","391.85","612.74","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","164.47","123.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","130.75","79.5","","800.18","480.96","1887.97","195","50.99","130.75","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","164.47","123.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","87.66","53.3","","813.12","216.42","1444.50","81","50.99","130.75","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","164.47","123.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","50.99","31","","432.60","432.60","432.60","1 through 10","50.99","130.75","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","164.47","123.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.03","36.5","","148.37","54.89","631.39","94","50.99","130.75","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","164.47","123.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.99","38.3","","279.30","91.72","1116.77","266","50.99","130.75","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","164.47","123.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.56","42.9","","731.00","63.70","731.00","1 through 10","50.99","130.75","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","164.47","123.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.56","42.9","","384.74","384.74","384.74","1 through 10","50.99","130.75","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","164.47","123.35","WELLPOINT [1015]","HB AMC WELLPOINT","121.35","73.78","","286.63","119.22","1107.45","105","50.99","130.75","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","164.47","123.35","AETNA [1001]","HB AMC AETNA HMO","114.80","69.8","","675.31","184.75","1721.50","286","85.95","134.4","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","164.47","123.35","AETNA [1001]","HB AMC AETNA PPO","132.23","80.4","","1261.44","103.12","1514.10","21","85.95","134.4","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","164.47","123.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","132.23","80.4","","1365.00","1365.00","1365.00","1 through 10","85.95","134.4","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","164.47","123.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","134.40","81.72","","5157.68","5157.68","5157.68","1 through 10","85.95","134.4","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","164.47","123.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","134.40","81.72","","431.26","71.26","1459.57","88","85.95","134.4","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.34","827.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","877.16","79.5","","800.18","480.96","1887.97","195","342.04","877.16","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.34","827.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","588.08","53.3","","813.12","216.42","1444.50","81","342.04","877.16","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.34","827.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","342.04","31","","432.60","432.60","432.60","1 through 10","342.04","877.16","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.34","827.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","402.72","36.5","","148.37","54.89","631.39","94","342.04","877.16","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.34","827.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","422.58","38.3","","279.30","91.72","1116.77","266","342.04","877.16","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.34","827.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","473.33","42.9","","731.00","63.70","731.00","1 through 10","342.04","877.16","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.34","827.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","473.33","42.9","","384.74","384.74","384.74","1 through 10","342.04","877.16","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.34","827.50","WELLPOINT [1015]","HB AMC WELLPOINT","814.04","73.78","","286.63","119.22","1107.45","105","342.04","877.16","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1103.34","827.50","AETNA [1001]","HB AMC AETNA HMO","770.13","69.8","","675.31","184.75","1721.50","286","576.61","901.65","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1103.34","827.50","AETNA [1001]","HB AMC AETNA PPO","887.09","80.4","","1261.44","103.12","1514.10","21","576.61","901.65","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1103.34","827.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","887.09","80.4","","1365.00","1365.00","1365.00","1 through 10","576.61","901.65","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1103.34","827.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","901.65","81.72","","5157.68","5157.68","5157.68","1 through 10","576.61","901.65","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1103.34","827.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","901.65","81.72","","431.26","71.26","1459.57","88","576.61","901.65","percent of total billed charges",""
"BONE PLATE 2X3.5 57MM 4 HOLE SYMPHYSIS PUBIC DCP","SUP-ITM-10037370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2457.91","1843.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1954.04","79.5","","800.18","480.96","1887.97","195","761.95","1954.04","percent of total billed charges",""
"BONE PLATE 2X3.5 57MM 4 HOLE SYMPHYSIS PUBIC DCP","SUP-ITM-10037370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2457.91","1843.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1310.07","53.3","","813.12","216.42","1444.50","81","761.95","1954.04","percent of total billed charges",""
"BONE PLATE 2X3.5 57MM 4 HOLE SYMPHYSIS PUBIC DCP","SUP-ITM-10037370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2457.91","1843.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","761.95","31","","432.60","432.60","432.60","1 through 10","761.95","1954.04","percent of total billed charges",""
"BONE PLATE 2X3.5 57MM 4 HOLE SYMPHYSIS PUBIC DCP","SUP-ITM-10037370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2457.91","1843.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","897.14","36.5","","148.37","54.89","631.39","94","761.95","1954.04","percent of total billed charges",""
"BONE PLATE 2X3.5 57MM 4 HOLE SYMPHYSIS PUBIC DCP","SUP-ITM-10037370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2457.91","1843.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","941.38","38.3","","279.30","91.72","1116.77","266","761.95","1954.04","percent of total billed charges",""
"BONE PLATE 2X3.5 57MM 4 HOLE SYMPHYSIS PUBIC DCP","SUP-ITM-10037370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2457.91","1843.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1054.44","42.9","","731.00","63.70","731.00","1 through 10","761.95","1954.04","percent of total billed charges",""
"BONE PLATE 2X3.5 57MM 4 HOLE SYMPHYSIS PUBIC DCP","SUP-ITM-10037370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2457.91","1843.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1054.44","42.9","","384.74","384.74","384.74","1 through 10","761.95","1954.04","percent of total billed charges",""
"BONE PLATE 2X3.5 57MM 4 HOLE SYMPHYSIS PUBIC DCP","SUP-ITM-10037370","CDM","C1713","HCPCS","0278","RC","","","","both","","","2457.91","1843.43","WELLPOINT [1015]","HB AMC WELLPOINT","1813.45","73.78","","286.63","119.22","1107.45","105","761.95","1954.04","percent of total billed charges",""
"BONE PLATE 2X3.5 57MM 4 HOLE SYMPHYSIS PUBIC DCP","SUP-ITM-10037370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2457.91","1843.43","AETNA [1001]","HB AMC AETNA HMO","1715.62","69.8","","675.31","184.75","1721.50","286","1284.5","2008.6","percent of total billed charges",""
"BONE PLATE 2X3.5 57MM 4 HOLE SYMPHYSIS PUBIC DCP","SUP-ITM-10037370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2457.91","1843.43","AETNA [1001]","HB AMC AETNA PPO","1976.16","80.4","","1261.44","103.12","1514.10","21","1284.5","2008.6","percent of total billed charges",""
"BONE PLATE 2X3.5 57MM 4 HOLE SYMPHYSIS PUBIC DCP","SUP-ITM-10037370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2457.91","1843.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1976.16","80.4","","1365.00","1365.00","1365.00","1 through 10","1284.5","2008.6","percent of total billed charges",""
"BONE PLATE 2X3.5 57MM 4 HOLE SYMPHYSIS PUBIC DCP","SUP-ITM-10037370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2457.91","1843.43","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2008.60","81.72","","5157.68","5157.68","5157.68","1 through 10","1284.5","2008.6","percent of total billed charges",""
"BONE PLATE 2X3.5 57MM 4 HOLE SYMPHYSIS PUBIC DCP","SUP-ITM-10037370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2457.91","1843.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2008.60","81.72","","431.26","71.26","1459.57","88","1284.5","2008.6","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 243.16","SUP-ITM-10004186","CDM","C1713","HCPCS","0278","RC","","","","both","","","1152.55","864.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","916.28","79.5","","800.18","480.96","1887.97","195","357.29","916.28","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 243.16","SUP-ITM-10004186","CDM","C1713","HCPCS","0278","RC","","","","both","","","1152.55","864.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","614.31","53.3","","813.12","216.42","1444.50","81","357.29","916.28","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 243.16","SUP-ITM-10004186","CDM","C1713","HCPCS","0278","RC","","","","both","","","1152.55","864.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","357.29","31","","432.60","432.60","432.60","1 through 10","357.29","916.28","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 243.16","SUP-ITM-10004186","CDM","C1713","HCPCS","0278","RC","","","","both","","","1152.55","864.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","420.68","36.5","","148.37","54.89","631.39","94","357.29","916.28","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 243.16","SUP-ITM-10004186","CDM","C1713","HCPCS","0278","RC","","","","both","","","1152.55","864.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","441.43","38.3","","279.30","91.72","1116.77","266","357.29","916.28","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 243.16","SUP-ITM-10004186","CDM","C1713","HCPCS","0278","RC","","","","both","","","1152.55","864.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","494.44","42.9","","731.00","63.70","731.00","1 through 10","357.29","916.28","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 243.16","SUP-ITM-10004186","CDM","C1713","HCPCS","0278","RC","","","","both","","","1152.55","864.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","494.44","42.9","","384.74","384.74","384.74","1 through 10","357.29","916.28","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 243.16","SUP-ITM-10004186","CDM","C1713","HCPCS","0278","RC","","","","both","","","1152.55","864.41","WELLPOINT [1015]","HB AMC WELLPOINT","850.35","73.78","","286.63","119.22","1107.45","105","357.29","916.28","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 243.16","SUP-ITM-10004186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1152.55","864.41","AETNA [1001]","HB AMC AETNA HMO","804.48","69.8","","675.31","184.75","1721.50","286","602.32","941.86","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 243.16","SUP-ITM-10004186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1152.55","864.41","AETNA [1001]","HB AMC AETNA PPO","926.65","80.4","","1261.44","103.12","1514.10","21","602.32","941.86","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 243.16","SUP-ITM-10004186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1152.55","864.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","926.65","80.4","","1365.00","1365.00","1365.00","1 through 10","602.32","941.86","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 243.16","SUP-ITM-10004186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1152.55","864.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","941.86","81.72","","5157.68","5157.68","5157.68","1 through 10","602.32","941.86","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 243.16","SUP-ITM-10004186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1152.55","864.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","941.86","81.72","","431.26","71.26","1459.57","88","602.32","941.86","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.35","962.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1020.26","79.5","","800.18","480.96","1887.97","195","397.84","1020.26","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.35","962.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","684.03","53.3","","813.12","216.42","1444.50","81","397.84","1020.26","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.35","962.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","397.84","31","","432.60","432.60","432.60","1 through 10","397.84","1020.26","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.35","962.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","468.42","36.5","","148.37","54.89","631.39","94","397.84","1020.26","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.35","962.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","491.52","38.3","","279.30","91.72","1116.77","266","397.84","1020.26","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.35","962.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","550.56","42.9","","731.00","63.70","731.00","1 through 10","397.84","1020.26","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.35","962.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","550.56","42.9","","384.74","384.74","384.74","1 through 10","397.84","1020.26","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.35","962.51","WELLPOINT [1015]","HB AMC WELLPOINT","946.86","73.78","","286.63","119.22","1107.45","105","397.84","1020.26","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1283.35","962.51","AETNA [1001]","HB AMC AETNA HMO","895.78","69.8","","675.31","184.75","1721.50","286","670.68","1048.75","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1283.35","962.51","AETNA [1001]","HB AMC AETNA PPO","1031.81","80.4","","1261.44","103.12","1514.10","21","670.68","1048.75","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1283.35","962.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1031.81","80.4","","1365.00","1365.00","1365.00","1 through 10","670.68","1048.75","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1283.35","962.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1048.75","81.72","","5157.68","5157.68","5157.68","1 through 10","670.68","1048.75","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1283.35","962.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1048.75","81.72","","431.26","71.26","1459.57","88","670.68","1048.75","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1288.53","966.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1024.38","79.5","","800.18","480.96","1887.97","195","399.44","1024.38","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1288.53","966.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","686.79","53.3","","813.12","216.42","1444.50","81","399.44","1024.38","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1288.53","966.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","399.44","31","","432.60","432.60","432.60","1 through 10","399.44","1024.38","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1288.53","966.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","470.31","36.5","","148.37","54.89","631.39","94","399.44","1024.38","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1288.53","966.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","493.51","38.3","","279.30","91.72","1116.77","266","399.44","1024.38","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1288.53","966.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","552.78","42.9","","731.00","63.70","731.00","1 through 10","399.44","1024.38","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1288.53","966.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","552.78","42.9","","384.74","384.74","384.74","1 through 10","399.44","1024.38","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1288.53","966.40","WELLPOINT [1015]","HB AMC WELLPOINT","950.68","73.78","","286.63","119.22","1107.45","105","399.44","1024.38","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1288.53","966.40","AETNA [1001]","HB AMC AETNA HMO","899.39","69.8","","675.31","184.75","1721.50","286","673.39","1052.99","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1288.53","966.40","AETNA [1001]","HB AMC AETNA PPO","1035.98","80.4","","1261.44","103.12","1514.10","21","673.39","1052.99","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1288.53","966.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1035.98","80.4","","1365.00","1365.00","1365.00","1 through 10","673.39","1052.99","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1288.53","966.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1052.99","81.72","","5157.68","5157.68","5157.68","1 through 10","673.39","1052.99","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1288.53","966.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1052.99","81.72","","431.26","71.26","1459.57","88","673.39","1052.99","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1698.72","79.5","","800.18","480.96","1887.97","195","662.39","1698.72","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1138.89","53.3","","813.12","216.42","1444.50","81","662.39","1698.72","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","662.39","31","","432.60","432.60","432.60","1 through 10","662.39","1698.72","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","779.91","36.5","","148.37","54.89","631.39","94","662.39","1698.72","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","818.38","38.3","","279.30","91.72","1116.77","266","662.39","1698.72","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","916.67","42.9","","731.00","63.70","731.00","1 through 10","662.39","1698.72","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","916.67","42.9","","384.74","384.74","384.74","1 through 10","662.39","1698.72","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","WELLPOINT [1015]","HB AMC WELLPOINT","1576.49","73.78","","286.63","119.22","1107.45","105","662.39","1698.72","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2136.75","1602.56","AETNA [1001]","HB AMC AETNA HMO","1491.45","69.8","","675.31","184.75","1721.50","286","1116.67","1746.15","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2136.75","1602.56","AETNA [1001]","HB AMC AETNA PPO","1717.95","80.4","","1261.44","103.12","1514.10","21","1116.67","1746.15","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2136.75","1602.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1717.95","80.4","","1365.00","1365.00","1365.00","1 through 10","1116.67","1746.15","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2136.75","1602.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1746.15","81.72","","5157.68","5157.68","5157.68","1 through 10","1116.67","1746.15","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2136.75","1602.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1746.15","81.72","","431.26","71.26","1459.57","88","1116.67","1746.15","percent of total billed charges",""
"BONE PLATE 2X48MM 3 HOLE HD 8 T SHAPE MODULAR HAND TI","SUP-ITM-10006814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.16","823.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","873.04","79.5","","800.18","480.96","1887.97","195","340.43","873.04","percent of total billed charges",""
"BONE PLATE 2X48MM 3 HOLE HD 8 T SHAPE MODULAR HAND TI","SUP-ITM-10006814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.16","823.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","585.32","53.3","","813.12","216.42","1444.50","81","340.43","873.04","percent of total billed charges",""
"BONE PLATE 2X48MM 3 HOLE HD 8 T SHAPE MODULAR HAND TI","SUP-ITM-10006814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.16","823.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","340.43","31","","432.60","432.60","432.60","1 through 10","340.43","873.04","percent of total billed charges",""
"BONE PLATE 2X48MM 3 HOLE HD 8 T SHAPE MODULAR HAND TI","SUP-ITM-10006814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.16","823.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","400.83","36.5","","148.37","54.89","631.39","94","340.43","873.04","percent of total billed charges",""
"BONE PLATE 2X48MM 3 HOLE HD 8 T SHAPE MODULAR HAND TI","SUP-ITM-10006814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.16","823.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","420.60","38.3","","279.30","91.72","1116.77","266","340.43","873.04","percent of total billed charges",""
"BONE PLATE 2X48MM 3 HOLE HD 8 T SHAPE MODULAR HAND TI","SUP-ITM-10006814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.16","823.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","471.11","42.9","","731.00","63.70","731.00","1 through 10","340.43","873.04","percent of total billed charges",""
"BONE PLATE 2X48MM 3 HOLE HD 8 T SHAPE MODULAR HAND TI","SUP-ITM-10006814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.16","823.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","471.11","42.9","","384.74","384.74","384.74","1 through 10","340.43","873.04","percent of total billed charges",""
"BONE PLATE 2X48MM 3 HOLE HD 8 T SHAPE MODULAR HAND TI","SUP-ITM-10006814","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.16","823.62","WELLPOINT [1015]","HB AMC WELLPOINT","810.22","73.78","","286.63","119.22","1107.45","105","340.43","873.04","percent of total billed charges",""
"BONE PLATE 2X48MM 3 HOLE HD 8 T SHAPE MODULAR HAND TI","SUP-ITM-10006814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.16","823.62","AETNA [1001]","HB AMC AETNA HMO","766.52","69.8","","675.31","184.75","1721.50","286","573.9","897.42","percent of total billed charges",""
"BONE PLATE 2X48MM 3 HOLE HD 8 T SHAPE MODULAR HAND TI","SUP-ITM-10006814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.16","823.62","AETNA [1001]","HB AMC AETNA PPO","882.92","80.4","","1261.44","103.12","1514.10","21","573.9","897.42","percent of total billed charges",""
"BONE PLATE 2X48MM 3 HOLE HD 8 T SHAPE MODULAR HAND TI","SUP-ITM-10006814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.16","823.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","882.92","80.4","","1365.00","1365.00","1365.00","1 through 10","573.9","897.42","percent of total billed charges",""
"BONE PLATE 2X48MM 3 HOLE HD 8 T SHAPE MODULAR HAND TI","SUP-ITM-10006814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.16","823.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","897.42","81.72","","5157.68","5157.68","5157.68","1 through 10","573.9","897.42","percent of total billed charges",""
"BONE PLATE 2X48MM 3 HOLE HD 8 T SHAPE MODULAR HAND TI","SUP-ITM-10006814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.16","823.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","897.42","81.72","","431.26","71.26","1459.57","88","573.9","897.42","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.33","811.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","859.66","79.5","","800.18","480.96","1887.97","195","335.21","859.66","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.33","811.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","576.35","53.3","","813.12","216.42","1444.50","81","335.21","859.66","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.33","811.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","335.21","31","","432.60","432.60","432.60","1 through 10","335.21","859.66","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.33","811.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","394.69","36.5","","148.37","54.89","631.39","94","335.21","859.66","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.33","811.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","414.15","38.3","","279.30","91.72","1116.77","266","335.21","859.66","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.33","811.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","463.89","42.9","","731.00","63.70","731.00","1 through 10","335.21","859.66","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.33","811.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","463.89","42.9","","384.74","384.74","384.74","1 through 10","335.21","859.66","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.33","811.00","WELLPOINT [1015]","HB AMC WELLPOINT","797.81","73.78","","286.63","119.22","1107.45","105","335.21","859.66","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1081.33","811.00","AETNA [1001]","HB AMC AETNA HMO","754.77","69.8","","675.31","184.75","1721.50","286","565.1","883.66","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1081.33","811.00","AETNA [1001]","HB AMC AETNA PPO","869.39","80.4","","1261.44","103.12","1514.10","21","565.1","883.66","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1081.33","811.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","869.39","80.4","","1365.00","1365.00","1365.00","1 through 10","565.1","883.66","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1081.33","811.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","883.66","81.72","","5157.68","5157.68","5157.68","1 through 10","565.1","883.66","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1081.33","811.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","883.66","81.72","","431.26","71.26","1459.57","88","565.1","883.66","percent of total billed charges",""
"BONE PLATE 2X50MM 4 HOLE 9 FRAGMENT MINI T SHAPE STAINLESS EA","SUP-ITM-10004217","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1006.88","79.5","","800.18","480.96","1887.97","195","392.62","1006.88","percent of total billed charges",""
"BONE PLATE 2X50MM 4 HOLE 9 FRAGMENT MINI T SHAPE STAINLESS EA","SUP-ITM-10004217","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","675.05","53.3","","813.12","216.42","1444.50","81","392.62","1006.88","percent of total billed charges",""
"BONE PLATE 2X50MM 4 HOLE 9 FRAGMENT MINI T SHAPE STAINLESS EA","SUP-ITM-10004217","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","392.62","31","","432.60","432.60","432.60","1 through 10","392.62","1006.88","percent of total billed charges",""
"BONE PLATE 2X50MM 4 HOLE 9 FRAGMENT MINI T SHAPE STAINLESS EA","SUP-ITM-10004217","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","462.28","36.5","","148.37","54.89","631.39","94","392.62","1006.88","percent of total billed charges",""
"BONE PLATE 2X50MM 4 HOLE 9 FRAGMENT MINI T SHAPE STAINLESS EA","SUP-ITM-10004217","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","485.07","38.3","","279.30","91.72","1116.77","266","392.62","1006.88","percent of total billed charges",""
"BONE PLATE 2X50MM 4 HOLE 9 FRAGMENT MINI T SHAPE STAINLESS EA","SUP-ITM-10004217","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","543.33","42.9","","731.00","63.70","731.00","1 through 10","392.62","1006.88","percent of total billed charges",""
"BONE PLATE 2X50MM 4 HOLE 9 FRAGMENT MINI T SHAPE STAINLESS EA","SUP-ITM-10004217","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","543.33","42.9","","384.74","384.74","384.74","1 through 10","392.62","1006.88","percent of total billed charges",""
"BONE PLATE 2X50MM 4 HOLE 9 FRAGMENT MINI T SHAPE STAINLESS EA","SUP-ITM-10004217","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","WELLPOINT [1015]","HB AMC WELLPOINT","934.43","73.78","","286.63","119.22","1107.45","105","392.62","1006.88","percent of total billed charges",""
"BONE PLATE 2X50MM 4 HOLE 9 FRAGMENT MINI T SHAPE STAINLESS EA","SUP-ITM-10004217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1266.51","949.88","AETNA [1001]","HB AMC AETNA HMO","884.02","69.8","","675.31","184.75","1721.50","286","661.88","1034.99","percent of total billed charges",""
"BONE PLATE 2X50MM 4 HOLE 9 FRAGMENT MINI T SHAPE STAINLESS EA","SUP-ITM-10004217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1266.51","949.88","AETNA [1001]","HB AMC AETNA PPO","1018.27","80.4","","1261.44","103.12","1514.10","21","661.88","1034.99","percent of total billed charges",""
"BONE PLATE 2X50MM 4 HOLE 9 FRAGMENT MINI T SHAPE STAINLESS EA","SUP-ITM-10004217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1266.51","949.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1018.27","80.4","","1365.00","1365.00","1365.00","1 through 10","661.88","1034.99","percent of total billed charges",""
"BONE PLATE 2X50MM 4 HOLE 9 FRAGMENT MINI T SHAPE STAINLESS EA","SUP-ITM-10004217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1266.51","949.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1034.99","81.72","","5157.68","5157.68","5157.68","1 through 10","661.88","1034.99","percent of total billed charges",""
"BONE PLATE 2X50MM 4 HOLE 9 FRAGMENT MINI T SHAPE STAINLESS EA","SUP-ITM-10004217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1266.51","949.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1034.99","81.72","","431.26","71.26","1459.57","88","661.88","1034.99","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1477.60","1108.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1174.69","79.5","","800.18","480.96","1887.97","195","458.06","1174.69","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1477.60","1108.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","787.56","53.3","","813.12","216.42","1444.50","81","458.06","1174.69","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1477.60","1108.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","458.06","31","","432.60","432.60","432.60","1 through 10","458.06","1174.69","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1477.60","1108.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","539.32","36.5","","148.37","54.89","631.39","94","458.06","1174.69","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1477.60","1108.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","565.92","38.3","","279.30","91.72","1116.77","266","458.06","1174.69","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1477.60","1108.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.89","42.9","","731.00","63.70","731.00","1 through 10","458.06","1174.69","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1477.60","1108.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.89","42.9","","384.74","384.74","384.74","1 through 10","458.06","1174.69","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1477.60","1108.20","WELLPOINT [1015]","HB AMC WELLPOINT","1090.17","73.78","","286.63","119.22","1107.45","105","458.06","1174.69","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1477.60","1108.20","AETNA [1001]","HB AMC AETNA HMO","1031.36","69.8","","675.31","184.75","1721.50","286","772.19","1207.49","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1477.60","1108.20","AETNA [1001]","HB AMC AETNA PPO","1187.99","80.4","","1261.44","103.12","1514.10","21","772.19","1207.49","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1477.60","1108.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1187.99","80.4","","1365.00","1365.00","1365.00","1 through 10","772.19","1207.49","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1477.60","1108.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1207.49","81.72","","5157.68","5157.68","5157.68","1 through 10","772.19","1207.49","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1477.60","1108.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1207.49","81.72","","431.26","71.26","1459.57","88","772.19","1207.49","percent of total billed charges",""
"BONE PLATE 2X54MM 10 HOLE PROFILE","SUP-ITM-10306730","CDM","C1713","HCPCS","0278","RC","","","","both","","","2184.56","1638.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1736.73","79.5","","800.18","480.96","1887.97","195","677.21","1736.73","percent of total billed charges",""
"BONE PLATE 2X54MM 10 HOLE PROFILE","SUP-ITM-10306730","CDM","C1713","HCPCS","0278","RC","","","","both","","","2184.56","1638.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1164.37","53.3","","813.12","216.42","1444.50","81","677.21","1736.73","percent of total billed charges",""
"BONE PLATE 2X54MM 10 HOLE PROFILE","SUP-ITM-10306730","CDM","C1713","HCPCS","0278","RC","","","","both","","","2184.56","1638.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","677.21","31","","432.60","432.60","432.60","1 through 10","677.21","1736.73","percent of total billed charges",""
"BONE PLATE 2X54MM 10 HOLE PROFILE","SUP-ITM-10306730","CDM","C1713","HCPCS","0278","RC","","","","both","","","2184.56","1638.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","797.36","36.5","","148.37","54.89","631.39","94","677.21","1736.73","percent of total billed charges",""
"BONE PLATE 2X54MM 10 HOLE PROFILE","SUP-ITM-10306730","CDM","C1713","HCPCS","0278","RC","","","","both","","","2184.56","1638.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","836.69","38.3","","279.30","91.72","1116.77","266","677.21","1736.73","percent of total billed charges",""
"BONE PLATE 2X54MM 10 HOLE PROFILE","SUP-ITM-10306730","CDM","C1713","HCPCS","0278","RC","","","","both","","","2184.56","1638.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","937.18","42.9","","731.00","63.70","731.00","1 through 10","677.21","1736.73","percent of total billed charges",""
"BONE PLATE 2X54MM 10 HOLE PROFILE","SUP-ITM-10306730","CDM","C1713","HCPCS","0278","RC","","","","both","","","2184.56","1638.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","937.18","42.9","","384.74","384.74","384.74","1 through 10","677.21","1736.73","percent of total billed charges",""
"BONE PLATE 2X54MM 10 HOLE PROFILE","SUP-ITM-10306730","CDM","C1713","HCPCS","0278","RC","","","","both","","","2184.56","1638.42","WELLPOINT [1015]","HB AMC WELLPOINT","1611.77","73.78","","286.63","119.22","1107.45","105","677.21","1736.73","percent of total billed charges",""
"BONE PLATE 2X54MM 10 HOLE PROFILE","SUP-ITM-10306730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2184.56","1638.42","AETNA [1001]","HB AMC AETNA HMO","1524.82","69.8","","675.31","184.75","1721.50","286","1141.65","1785.22","percent of total billed charges",""
"BONE PLATE 2X54MM 10 HOLE PROFILE","SUP-ITM-10306730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2184.56","1638.42","AETNA [1001]","HB AMC AETNA PPO","1756.39","80.4","","1261.44","103.12","1514.10","21","1141.65","1785.22","percent of total billed charges",""
"BONE PLATE 2X54MM 10 HOLE PROFILE","SUP-ITM-10306730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2184.56","1638.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1756.39","80.4","","1365.00","1365.00","1365.00","1 through 10","1141.65","1785.22","percent of total billed charges",""
"BONE PLATE 2X54MM 10 HOLE PROFILE","SUP-ITM-10306730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2184.56","1638.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1785.22","81.72","","5157.68","5157.68","5157.68","1 through 10","1141.65","1785.22","percent of total billed charges",""
"BONE PLATE 2X54MM 10 HOLE PROFILE","SUP-ITM-10306730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2184.56","1638.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1785.22","81.72","","431.26","71.26","1459.57","88","1141.65","1785.22","percent of total billed charges",""
"BONE PLATE 2X55MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038140","CDM","C1713","HCPCS","0278","RC","","","","both","","","1377.88","1033.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1095.41","79.5","","800.18","480.96","1887.97","195","427.14","1095.41","percent of total billed charges",""
"BONE PLATE 2X55MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038140","CDM","C1713","HCPCS","0278","RC","","","","both","","","1377.88","1033.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","734.41","53.3","","813.12","216.42","1444.50","81","427.14","1095.41","percent of total billed charges",""
"BONE PLATE 2X55MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038140","CDM","C1713","HCPCS","0278","RC","","","","both","","","1377.88","1033.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","427.14","31","","432.60","432.60","432.60","1 through 10","427.14","1095.41","percent of total billed charges",""
"BONE PLATE 2X55MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038140","CDM","C1713","HCPCS","0278","RC","","","","both","","","1377.88","1033.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","502.93","36.5","","148.37","54.89","631.39","94","427.14","1095.41","percent of total billed charges",""
"BONE PLATE 2X55MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038140","CDM","C1713","HCPCS","0278","RC","","","","both","","","1377.88","1033.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","527.73","38.3","","279.30","91.72","1116.77","266","427.14","1095.41","percent of total billed charges",""
"BONE PLATE 2X55MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038140","CDM","C1713","HCPCS","0278","RC","","","","both","","","1377.88","1033.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","591.11","42.9","","731.00","63.70","731.00","1 through 10","427.14","1095.41","percent of total billed charges",""
"BONE PLATE 2X55MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038140","CDM","C1713","HCPCS","0278","RC","","","","both","","","1377.88","1033.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","591.11","42.9","","384.74","384.74","384.74","1 through 10","427.14","1095.41","percent of total billed charges",""
"BONE PLATE 2X55MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038140","CDM","C1713","HCPCS","0278","RC","","","","both","","","1377.88","1033.41","WELLPOINT [1015]","HB AMC WELLPOINT","1016.60","73.78","","286.63","119.22","1107.45","105","427.14","1095.41","percent of total billed charges",""
"BONE PLATE 2X55MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038140","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1377.88","1033.41","AETNA [1001]","HB AMC AETNA HMO","961.76","69.8","","675.31","184.75","1721.50","286","720.08","1126","percent of total billed charges",""
"BONE PLATE 2X55MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038140","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1377.88","1033.41","AETNA [1001]","HB AMC AETNA PPO","1107.82","80.4","","1261.44","103.12","1514.10","21","720.08","1126","percent of total billed charges",""
"BONE PLATE 2X55MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038140","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1377.88","1033.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1107.82","80.4","","1365.00","1365.00","1365.00","1 through 10","720.08","1126","percent of total billed charges",""
"BONE PLATE 2X55MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038140","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1377.88","1033.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1126.00","81.72","","5157.68","5157.68","5157.68","1 through 10","720.08","1126","percent of total billed charges",""
"BONE PLATE 2X55MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038140","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1377.88","1033.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1126.00","81.72","","431.26","71.26","1459.57","88","720.08","1126","percent of total billed charges",""
"BONE PLATE 2X57MM 10 HOLE NARROW LOCKING","SUP-ITM-10306725","CDM","C1713","HCPCS","0278","RC","","","","both","","","3102.61","2326.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2466.57","79.5","","800.18","480.96","1887.97","195","961.81","2466.57","percent of total billed charges",""
"BONE PLATE 2X57MM 10 HOLE NARROW LOCKING","SUP-ITM-10306725","CDM","C1713","HCPCS","0278","RC","","","","both","","","3102.61","2326.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1653.69","53.3","","813.12","216.42","1444.50","81","961.81","2466.57","percent of total billed charges",""
"BONE PLATE 2X57MM 10 HOLE NARROW LOCKING","SUP-ITM-10306725","CDM","C1713","HCPCS","0278","RC","","","","both","","","3102.61","2326.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","961.81","31","","432.60","432.60","432.60","1 through 10","961.81","2466.57","percent of total billed charges",""
"BONE PLATE 2X57MM 10 HOLE NARROW LOCKING","SUP-ITM-10306725","CDM","C1713","HCPCS","0278","RC","","","","both","","","3102.61","2326.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1132.45","36.5","","148.37","54.89","631.39","94","961.81","2466.57","percent of total billed charges",""
"BONE PLATE 2X57MM 10 HOLE NARROW LOCKING","SUP-ITM-10306725","CDM","C1713","HCPCS","0278","RC","","","","both","","","3102.61","2326.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1188.30","38.3","","279.30","91.72","1116.77","266","961.81","2466.57","percent of total billed charges",""
"BONE PLATE 2X57MM 10 HOLE NARROW LOCKING","SUP-ITM-10306725","CDM","C1713","HCPCS","0278","RC","","","","both","","","3102.61","2326.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1331.02","42.9","","731.00","63.70","731.00","1 through 10","961.81","2466.57","percent of total billed charges",""
"BONE PLATE 2X57MM 10 HOLE NARROW LOCKING","SUP-ITM-10306725","CDM","C1713","HCPCS","0278","RC","","","","both","","","3102.61","2326.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1331.02","42.9","","384.74","384.74","384.74","1 through 10","961.81","2466.57","percent of total billed charges",""
"BONE PLATE 2X57MM 10 HOLE NARROW LOCKING","SUP-ITM-10306725","CDM","C1713","HCPCS","0278","RC","","","","both","","","3102.61","2326.96","WELLPOINT [1015]","HB AMC WELLPOINT","2289.11","73.78","","286.63","119.22","1107.45","105","961.81","2466.57","percent of total billed charges",""
"BONE PLATE 2X57MM 10 HOLE NARROW LOCKING","SUP-ITM-10306725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3102.61","2326.96","AETNA [1001]","HB AMC AETNA HMO","2165.62","69.8","","675.31","184.75","1721.50","286","1621.42","2535.45","percent of total billed charges",""
"BONE PLATE 2X57MM 10 HOLE NARROW LOCKING","SUP-ITM-10306725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3102.61","2326.96","AETNA [1001]","HB AMC AETNA PPO","2494.50","80.4","","1261.44","103.12","1514.10","21","1621.42","2535.45","percent of total billed charges",""
"BONE PLATE 2X57MM 10 HOLE NARROW LOCKING","SUP-ITM-10306725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3102.61","2326.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2494.50","80.4","","1365.00","1365.00","1365.00","1 through 10","1621.42","2535.45","percent of total billed charges",""
"BONE PLATE 2X57MM 10 HOLE NARROW LOCKING","SUP-ITM-10306725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3102.61","2326.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2535.45","81.72","","5157.68","5157.68","5157.68","1 through 10","1621.42","2535.45","percent of total billed charges",""
"BONE PLATE 2X57MM 10 HOLE NARROW LOCKING","SUP-ITM-10306725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3102.61","2326.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2535.45","81.72","","431.26","71.26","1459.57","88","1621.42","2535.45","percent of total billed charges",""
"BONE PLATE 2X67MM 10 HOLE BROAD LOCKING","SUP-ITM-10306720","CDM","C1713","HCPCS","0278","RC","","","","both","","","3387.37","2540.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2692.96","79.5","","800.18","480.96","1887.97","195","1050.08","2692.96","percent of total billed charges",""
"BONE PLATE 2X67MM 10 HOLE BROAD LOCKING","SUP-ITM-10306720","CDM","C1713","HCPCS","0278","RC","","","","both","","","3387.37","2540.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1805.47","53.3","","813.12","216.42","1444.50","81","1050.08","2692.96","percent of total billed charges",""
"BONE PLATE 2X67MM 10 HOLE BROAD LOCKING","SUP-ITM-10306720","CDM","C1713","HCPCS","0278","RC","","","","both","","","3387.37","2540.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1050.08","31","","432.60","432.60","432.60","1 through 10","1050.08","2692.96","percent of total billed charges",""
"BONE PLATE 2X67MM 10 HOLE BROAD LOCKING","SUP-ITM-10306720","CDM","C1713","HCPCS","0278","RC","","","","both","","","3387.37","2540.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1236.39","36.5","","148.37","54.89","631.39","94","1050.08","2692.96","percent of total billed charges",""
"BONE PLATE 2X67MM 10 HOLE BROAD LOCKING","SUP-ITM-10306720","CDM","C1713","HCPCS","0278","RC","","","","both","","","3387.37","2540.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1297.36","38.3","","279.30","91.72","1116.77","266","1050.08","2692.96","percent of total billed charges",""
"BONE PLATE 2X67MM 10 HOLE BROAD LOCKING","SUP-ITM-10306720","CDM","C1713","HCPCS","0278","RC","","","","both","","","3387.37","2540.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1453.18","42.9","","731.00","63.70","731.00","1 through 10","1050.08","2692.96","percent of total billed charges",""
"BONE PLATE 2X67MM 10 HOLE BROAD LOCKING","SUP-ITM-10306720","CDM","C1713","HCPCS","0278","RC","","","","both","","","3387.37","2540.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1453.18","42.9","","384.74","384.74","384.74","1 through 10","1050.08","2692.96","percent of total billed charges",""
"BONE PLATE 2X67MM 10 HOLE BROAD LOCKING","SUP-ITM-10306720","CDM","C1713","HCPCS","0278","RC","","","","both","","","3387.37","2540.53","WELLPOINT [1015]","HB AMC WELLPOINT","2499.20","73.78","","286.63","119.22","1107.45","105","1050.08","2692.96","percent of total billed charges",""
"BONE PLATE 2X67MM 10 HOLE BROAD LOCKING","SUP-ITM-10306720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3387.37","2540.53","AETNA [1001]","HB AMC AETNA HMO","2364.38","69.8","","675.31","184.75","1721.50","286","1770.24","2768.16","percent of total billed charges",""
"BONE PLATE 2X67MM 10 HOLE BROAD LOCKING","SUP-ITM-10306720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3387.37","2540.53","AETNA [1001]","HB AMC AETNA PPO","2723.45","80.4","","1261.44","103.12","1514.10","21","1770.24","2768.16","percent of total billed charges",""
"BONE PLATE 2X67MM 10 HOLE BROAD LOCKING","SUP-ITM-10306720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3387.37","2540.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2723.45","80.4","","1365.00","1365.00","1365.00","1 through 10","1770.24","2768.16","percent of total billed charges",""
"BONE PLATE 2X67MM 10 HOLE BROAD LOCKING","SUP-ITM-10306720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3387.37","2540.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2768.16","81.72","","5157.68","5157.68","5157.68","1 through 10","1770.24","2768.16","percent of total billed charges",""
"BONE PLATE 2X67MM 10 HOLE BROAD LOCKING","SUP-ITM-10306720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3387.37","2540.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2768.16","81.72","","431.26","71.26","1459.57","88","1770.24","2768.16","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.42","462.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","490.05","79.5","","800.18","480.96","1887.97","195","191.09","490.05","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.42","462.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","328.55","53.3","","813.12","216.42","1444.50","81","191.09","490.05","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.42","462.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","191.09","31","","432.60","432.60","432.60","1 through 10","191.09","490.05","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.42","462.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","224.99","36.5","","148.37","54.89","631.39","94","191.09","490.05","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.42","462.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","236.09","38.3","","279.30","91.72","1116.77","266","191.09","490.05","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.42","462.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","264.44","42.9","","731.00","63.70","731.00","1 through 10","191.09","490.05","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.42","462.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","264.44","42.9","","384.74","384.74","384.74","1 through 10","191.09","490.05","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.42","462.31","WELLPOINT [1015]","HB AMC WELLPOINT","454.79","73.78","","286.63","119.22","1107.45","105","191.09","490.05","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.42","462.31","AETNA [1001]","HB AMC AETNA HMO","430.26","69.8","","675.31","184.75","1721.50","286","322.14","503.74","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.42","462.31","AETNA [1001]","HB AMC AETNA PPO","495.60","80.4","","1261.44","103.12","1514.10","21","322.14","503.74","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.42","462.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","495.60","80.4","","1365.00","1365.00","1365.00","1 through 10","322.14","503.74","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.42","462.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","503.74","81.72","","5157.68","5157.68","5157.68","1 through 10","322.14","503.74","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.42","462.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","503.74","81.72","","431.26","71.26","1459.57","88","322.14","503.74","percent of total billed charges",""
"BONE PLATE 3 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3804.50","2853.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3024.58","79.5","","800.18","480.96","1887.97","195","1179.4","3024.58","percent of total billed charges",""
"BONE PLATE 3 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3804.50","2853.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2027.80","53.3","","813.12","216.42","1444.50","81","1179.4","3024.58","percent of total billed charges",""
"BONE PLATE 3 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3804.50","2853.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1179.40","31","","432.60","432.60","432.60","1 through 10","1179.4","3024.58","percent of total billed charges",""
"BONE PLATE 3 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3804.50","2853.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1388.64","36.5","","148.37","54.89","631.39","94","1179.4","3024.58","percent of total billed charges",""
"BONE PLATE 3 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3804.50","2853.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1457.12","38.3","","279.30","91.72","1116.77","266","1179.4","3024.58","percent of total billed charges",""
"BONE PLATE 3 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3804.50","2853.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1632.13","42.9","","731.00","63.70","731.00","1 through 10","1179.4","3024.58","percent of total billed charges",""
"BONE PLATE 3 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3804.50","2853.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1632.13","42.9","","384.74","384.74","384.74","1 through 10","1179.4","3024.58","percent of total billed charges",""
"BONE PLATE 3 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3804.50","2853.37","WELLPOINT [1015]","HB AMC WELLPOINT","2806.96","73.78","","286.63","119.22","1107.45","105","1179.4","3024.58","percent of total billed charges",""
"BONE PLATE 3 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3804.50","2853.37","AETNA [1001]","HB AMC AETNA HMO","2655.54","69.8","","675.31","184.75","1721.50","286","1988.23","3109.04","percent of total billed charges",""
"BONE PLATE 3 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3804.50","2853.37","AETNA [1001]","HB AMC AETNA PPO","3058.82","80.4","","1261.44","103.12","1514.10","21","1988.23","3109.04","percent of total billed charges",""
"BONE PLATE 3 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3804.50","2853.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3058.82","80.4","","1365.00","1365.00","1365.00","1 through 10","1988.23","3109.04","percent of total billed charges",""
"BONE PLATE 3 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3804.50","2853.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3109.04","81.72","","5157.68","5157.68","5157.68","1 through 10","1988.23","3109.04","percent of total billed charges",""
"BONE PLATE 3 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3804.50","2853.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3109.04","81.72","","431.26","71.26","1459.57","88","1988.23","3109.04","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1939.63","79.5","","800.18","480.96","1887.97","195","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1300.40","53.3","","813.12","216.42","1444.50","81","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","756.33","31","","432.60","432.60","432.60","1 through 10","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","890.52","36.5","","148.37","54.89","631.39","94","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","934.44","38.3","","279.30","91.72","1116.77","266","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1046.67","42.9","","731.00","63.70","731.00","1 through 10","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1046.67","42.9","","384.74","384.74","384.74","1 through 10","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","WELLPOINT [1015]","HB AMC WELLPOINT","1800.07","73.78","","286.63","119.22","1107.45","105","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","AETNA [1001]","HB AMC AETNA HMO","1702.97","69.8","","675.31","184.75","1721.50","286","1275.03","1993.79","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","AETNA [1001]","HB AMC AETNA PPO","1961.58","80.4","","1261.44","103.12","1514.10","21","1275.03","1993.79","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1961.58","80.4","","1365.00","1365.00","1365.00","1 through 10","1275.03","1993.79","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1993.79","81.72","","5157.68","5157.68","5157.68","1 through 10","1275.03","1993.79","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1993.79","81.72","","431.26","71.26","1459.57","88","1275.03","1993.79","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.83","1316.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1395.09","79.5","","800.18","480.96","1887.97","195","544","1395.09","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.83","1316.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","935.32","53.3","","813.12","216.42","1444.50","81","544","1395.09","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.83","1316.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","544.00","31","","432.60","432.60","432.60","1 through 10","544","1395.09","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.83","1316.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","640.51","36.5","","148.37","54.89","631.39","94","544","1395.09","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.83","1316.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","672.10","38.3","","279.30","91.72","1116.77","266","544","1395.09","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.83","1316.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","752.82","42.9","","731.00","63.70","731.00","1 through 10","544","1395.09","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.83","1316.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","752.82","42.9","","384.74","384.74","384.74","1 through 10","544","1395.09","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1754.83","1316.12","WELLPOINT [1015]","HB AMC WELLPOINT","1294.71","73.78","","286.63","119.22","1107.45","105","544","1395.09","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1754.83","1316.12","AETNA [1001]","HB AMC AETNA HMO","1224.87","69.8","","675.31","184.75","1721.50","286","917.07","1434.05","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1754.83","1316.12","AETNA [1001]","HB AMC AETNA PPO","1410.88","80.4","","1261.44","103.12","1514.10","21","917.07","1434.05","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1754.83","1316.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1410.88","80.4","","1365.00","1365.00","1365.00","1 through 10","917.07","1434.05","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1754.83","1316.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1434.05","81.72","","5157.68","5157.68","5157.68","1 through 10","917.07","1434.05","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1754.83","1316.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1434.05","81.72","","431.26","71.26","1459.57","88","917.07","1434.05","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5/8 H 8H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074528","CDM","C1713","HCPCS","0278","RC","","","","both","","","1921.89","1441.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1527.90","79.5","","800.18","480.96","1887.97","195","595.79","1527.9","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5/8 H 8H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074528","CDM","C1713","HCPCS","0278","RC","","","","both","","","1921.89","1441.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1024.37","53.3","","813.12","216.42","1444.50","81","595.79","1527.9","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5/8 H 8H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074528","CDM","C1713","HCPCS","0278","RC","","","","both","","","1921.89","1441.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","595.79","31","","432.60","432.60","432.60","1 through 10","595.79","1527.9","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5/8 H 8H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074528","CDM","C1713","HCPCS","0278","RC","","","","both","","","1921.89","1441.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","701.49","36.5","","148.37","54.89","631.39","94","595.79","1527.9","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5/8 H 8H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074528","CDM","C1713","HCPCS","0278","RC","","","","both","","","1921.89","1441.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","736.08","38.3","","279.30","91.72","1116.77","266","595.79","1527.9","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5/8 H 8H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074528","CDM","C1713","HCPCS","0278","RC","","","","both","","","1921.89","1441.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","824.49","42.9","","731.00","63.70","731.00","1 through 10","595.79","1527.9","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5/8 H 8H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074528","CDM","C1713","HCPCS","0278","RC","","","","both","","","1921.89","1441.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","824.49","42.9","","384.74","384.74","384.74","1 through 10","595.79","1527.9","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5/8 H 8H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074528","CDM","C1713","HCPCS","0278","RC","","","","both","","","1921.89","1441.42","WELLPOINT [1015]","HB AMC WELLPOINT","1417.97","73.78","","286.63","119.22","1107.45","105","595.79","1527.9","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5/8 H 8H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1921.89","1441.42","AETNA [1001]","HB AMC AETNA HMO","1341.48","69.8","","675.31","184.75","1721.50","286","1004.38","1570.57","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5/8 H 8H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1921.89","1441.42","AETNA [1001]","HB AMC AETNA PPO","1545.20","80.4","","1261.44","103.12","1514.10","21","1004.38","1570.57","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5/8 H 8H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1921.89","1441.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1545.20","80.4","","1365.00","1365.00","1365.00","1 through 10","1004.38","1570.57","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5/8 H 8H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1921.89","1441.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1570.57","81.72","","5157.68","5157.68","5157.68","1 through 10","1004.38","1570.57","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5/8 H 8H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1921.89","1441.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1570.57","81.72","","431.26","71.26","1459.57","88","1004.38","1570.57","percent of total billed charges",""
"BONE PLATE 3.5MM 43.5 3 HOLE PELVIC SS SPRING 02.100.303S","SUP-ITM-10036524","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.04","945.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1001.73","79.5","","800.18","480.96","1887.97","195","390.61","1001.73","percent of total billed charges",""
"BONE PLATE 3.5MM 43.5 3 HOLE PELVIC SS SPRING 02.100.303S","SUP-ITM-10036524","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.04","945.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","671.60","53.3","","813.12","216.42","1444.50","81","390.61","1001.73","percent of total billed charges",""
"BONE PLATE 3.5MM 43.5 3 HOLE PELVIC SS SPRING 02.100.303S","SUP-ITM-10036524","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.04","945.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","390.61","31","","432.60","432.60","432.60","1 through 10","390.61","1001.73","percent of total billed charges",""
"BONE PLATE 3.5MM 43.5 3 HOLE PELVIC SS SPRING 02.100.303S","SUP-ITM-10036524","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.04","945.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","459.91","36.5","","148.37","54.89","631.39","94","390.61","1001.73","percent of total billed charges",""
"BONE PLATE 3.5MM 43.5 3 HOLE PELVIC SS SPRING 02.100.303S","SUP-ITM-10036524","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.04","945.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","482.60","38.3","","279.30","91.72","1116.77","266","390.61","1001.73","percent of total billed charges",""
"BONE PLATE 3.5MM 43.5 3 HOLE PELVIC SS SPRING 02.100.303S","SUP-ITM-10036524","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.04","945.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.56","42.9","","731.00","63.70","731.00","1 through 10","390.61","1001.73","percent of total billed charges",""
"BONE PLATE 3.5MM 43.5 3 HOLE PELVIC SS SPRING 02.100.303S","SUP-ITM-10036524","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.04","945.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.56","42.9","","384.74","384.74","384.74","1 through 10","390.61","1001.73","percent of total billed charges",""
"BONE PLATE 3.5MM 43.5 3 HOLE PELVIC SS SPRING 02.100.303S","SUP-ITM-10036524","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.04","945.03","WELLPOINT [1015]","HB AMC WELLPOINT","929.66","73.78","","286.63","119.22","1107.45","105","390.61","1001.73","percent of total billed charges",""
"BONE PLATE 3.5MM 43.5 3 HOLE PELVIC SS SPRING 02.100.303S","SUP-ITM-10036524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.04","945.03","AETNA [1001]","HB AMC AETNA HMO","879.51","69.8","","675.31","184.75","1721.50","286","658.5","1029.7","percent of total billed charges",""
"BONE PLATE 3.5MM 43.5 3 HOLE PELVIC SS SPRING 02.100.303S","SUP-ITM-10036524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.04","945.03","AETNA [1001]","HB AMC AETNA PPO","1013.07","80.4","","1261.44","103.12","1514.10","21","658.5","1029.7","percent of total billed charges",""
"BONE PLATE 3.5MM 43.5 3 HOLE PELVIC SS SPRING 02.100.303S","SUP-ITM-10036524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.04","945.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1013.07","80.4","","1365.00","1365.00","1365.00","1 through 10","658.5","1029.7","percent of total billed charges",""
"BONE PLATE 3.5MM 43.5 3 HOLE PELVIC SS SPRING 02.100.303S","SUP-ITM-10036524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.04","945.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1029.70","81.72","","5157.68","5157.68","5157.68","1 through 10","658.5","1029.7","percent of total billed charges",""
"BONE PLATE 3.5MM 43.5 3 HOLE PELVIC SS SPRING 02.100.303S","SUP-ITM-10036524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.04","945.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1029.70","81.72","","431.26","71.26","1459.57","88","658.5","1029.7","percent of total billed charges",""
"BONE PLATE 3.5MM 4HOLE VA-LOCKING PPFX ATTACHMENT SS","SUP-ITM-10297784","CDM","C1713","HCPCS","0278","RC","","","","both","","","2486.12","1864.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1976.47","79.5","","800.18","480.96","1887.97","195","770.7","1976.47","percent of total billed charges",""
"BONE PLATE 3.5MM 4HOLE VA-LOCKING PPFX ATTACHMENT SS","SUP-ITM-10297784","CDM","C1713","HCPCS","0278","RC","","","","both","","","2486.12","1864.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1325.10","53.3","","813.12","216.42","1444.50","81","770.7","1976.47","percent of total billed charges",""
"BONE PLATE 3.5MM 4HOLE VA-LOCKING PPFX ATTACHMENT SS","SUP-ITM-10297784","CDM","C1713","HCPCS","0278","RC","","","","both","","","2486.12","1864.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","770.70","31","","432.60","432.60","432.60","1 through 10","770.7","1976.47","percent of total billed charges",""
"BONE PLATE 3.5MM 4HOLE VA-LOCKING PPFX ATTACHMENT SS","SUP-ITM-10297784","CDM","C1713","HCPCS","0278","RC","","","","both","","","2486.12","1864.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","907.43","36.5","","148.37","54.89","631.39","94","770.7","1976.47","percent of total billed charges",""
"BONE PLATE 3.5MM 4HOLE VA-LOCKING PPFX ATTACHMENT SS","SUP-ITM-10297784","CDM","C1713","HCPCS","0278","RC","","","","both","","","2486.12","1864.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","952.18","38.3","","279.30","91.72","1116.77","266","770.7","1976.47","percent of total billed charges",""
"BONE PLATE 3.5MM 4HOLE VA-LOCKING PPFX ATTACHMENT SS","SUP-ITM-10297784","CDM","C1713","HCPCS","0278","RC","","","","both","","","2486.12","1864.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.55","42.9","","731.00","63.70","731.00","1 through 10","770.7","1976.47","percent of total billed charges",""
"BONE PLATE 3.5MM 4HOLE VA-LOCKING PPFX ATTACHMENT SS","SUP-ITM-10297784","CDM","C1713","HCPCS","0278","RC","","","","both","","","2486.12","1864.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.55","42.9","","384.74","384.74","384.74","1 through 10","770.7","1976.47","percent of total billed charges",""
"BONE PLATE 3.5MM 4HOLE VA-LOCKING PPFX ATTACHMENT SS","SUP-ITM-10297784","CDM","C1713","HCPCS","0278","RC","","","","both","","","2486.12","1864.59","WELLPOINT [1015]","HB AMC WELLPOINT","1834.26","73.78","","286.63","119.22","1107.45","105","770.7","1976.47","percent of total billed charges",""
"BONE PLATE 3.5MM 4HOLE VA-LOCKING PPFX ATTACHMENT SS","SUP-ITM-10297784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2486.12","1864.59","AETNA [1001]","HB AMC AETNA HMO","1735.31","69.8","","675.31","184.75","1721.50","286","1299.25","2031.66","percent of total billed charges",""
"BONE PLATE 3.5MM 4HOLE VA-LOCKING PPFX ATTACHMENT SS","SUP-ITM-10297784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2486.12","1864.59","AETNA [1001]","HB AMC AETNA PPO","1998.84","80.4","","1261.44","103.12","1514.10","21","1299.25","2031.66","percent of total billed charges",""
"BONE PLATE 3.5MM 4HOLE VA-LOCKING PPFX ATTACHMENT SS","SUP-ITM-10297784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2486.12","1864.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1998.84","80.4","","1365.00","1365.00","1365.00","1 through 10","1299.25","2031.66","percent of total billed charges",""
"BONE PLATE 3.5MM 4HOLE VA-LOCKING PPFX ATTACHMENT SS","SUP-ITM-10297784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2486.12","1864.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2031.66","81.72","","5157.68","5157.68","5157.68","1 through 10","1299.25","2031.66","percent of total billed charges",""
"BONE PLATE 3.5MM 4HOLE VA-LOCKING PPFX ATTACHMENT SS","SUP-ITM-10297784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2486.12","1864.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2031.66","81.72","","431.26","71.26","1459.57","88","1299.25","2031.66","percent of total billed charges",""
"BONE PLATE 3.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2979.17","2234.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2368.44","79.5","","800.18","480.96","1887.97","195","923.54","2368.44","percent of total billed charges",""
"BONE PLATE 3.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2979.17","2234.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1587.90","53.3","","813.12","216.42","1444.50","81","923.54","2368.44","percent of total billed charges",""
"BONE PLATE 3.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2979.17","2234.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","923.54","31","","432.60","432.60","432.60","1 through 10","923.54","2368.44","percent of total billed charges",""
"BONE PLATE 3.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2979.17","2234.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1087.40","36.5","","148.37","54.89","631.39","94","923.54","2368.44","percent of total billed charges",""
"BONE PLATE 3.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2979.17","2234.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1141.02","38.3","","279.30","91.72","1116.77","266","923.54","2368.44","percent of total billed charges",""
"BONE PLATE 3.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2979.17","2234.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1278.06","42.9","","731.00","63.70","731.00","1 through 10","923.54","2368.44","percent of total billed charges",""
"BONE PLATE 3.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2979.17","2234.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1278.06","42.9","","384.74","384.74","384.74","1 through 10","923.54","2368.44","percent of total billed charges",""
"BONE PLATE 3.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2979.17","2234.38","WELLPOINT [1015]","HB AMC WELLPOINT","2198.03","73.78","","286.63","119.22","1107.45","105","923.54","2368.44","percent of total billed charges",""
"BONE PLATE 3.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2979.17","2234.38","AETNA [1001]","HB AMC AETNA HMO","2079.46","69.8","","675.31","184.75","1721.50","286","1556.91","2434.58","percent of total billed charges",""
"BONE PLATE 3.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2979.17","2234.38","AETNA [1001]","HB AMC AETNA PPO","2395.25","80.4","","1261.44","103.12","1514.10","21","1556.91","2434.58","percent of total billed charges",""
"BONE PLATE 3.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2979.17","2234.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2395.25","80.4","","1365.00","1365.00","1365.00","1 through 10","1556.91","2434.58","percent of total billed charges",""
"BONE PLATE 3.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2979.17","2234.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2434.58","81.72","","5157.68","5157.68","5157.68","1 through 10","1556.91","2434.58","percent of total billed charges",""
"BONE PLATE 3.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2979.17","2234.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2434.58","81.72","","431.26","71.26","1459.57","88","1556.91","2434.58","percent of total billed charges",""
"BONE PLATE 3.5MM LG RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297805","CDM","C1713","HCPCS","0278","RC","","","","both","","","4595.76","3446.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3653.63","79.5","","800.18","480.96","1887.97","195","1424.69","3653.63","percent of total billed charges",""
"BONE PLATE 3.5MM LG RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297805","CDM","C1713","HCPCS","0278","RC","","","","both","","","4595.76","3446.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2449.54","53.3","","813.12","216.42","1444.50","81","1424.69","3653.63","percent of total billed charges",""
"BONE PLATE 3.5MM LG RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297805","CDM","C1713","HCPCS","0278","RC","","","","both","","","4595.76","3446.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1424.69","31","","432.60","432.60","432.60","1 through 10","1424.69","3653.63","percent of total billed charges",""
"BONE PLATE 3.5MM LG RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297805","CDM","C1713","HCPCS","0278","RC","","","","both","","","4595.76","3446.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1677.45","36.5","","148.37","54.89","631.39","94","1424.69","3653.63","percent of total billed charges",""
"BONE PLATE 3.5MM LG RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297805","CDM","C1713","HCPCS","0278","RC","","","","both","","","4595.76","3446.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1760.18","38.3","","279.30","91.72","1116.77","266","1424.69","3653.63","percent of total billed charges",""
"BONE PLATE 3.5MM LG RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297805","CDM","C1713","HCPCS","0278","RC","","","","both","","","4595.76","3446.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1971.58","42.9","","731.00","63.70","731.00","1 through 10","1424.69","3653.63","percent of total billed charges",""
"BONE PLATE 3.5MM LG RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297805","CDM","C1713","HCPCS","0278","RC","","","","both","","","4595.76","3446.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1971.58","42.9","","384.74","384.74","384.74","1 through 10","1424.69","3653.63","percent of total billed charges",""
"BONE PLATE 3.5MM LG RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297805","CDM","C1713","HCPCS","0278","RC","","","","both","","","4595.76","3446.82","WELLPOINT [1015]","HB AMC WELLPOINT","3390.75","73.78","","286.63","119.22","1107.45","105","1424.69","3653.63","percent of total billed charges",""
"BONE PLATE 3.5MM LG RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4595.76","3446.82","AETNA [1001]","HB AMC AETNA HMO","3207.84","69.8","","675.31","184.75","1721.50","286","2401.74","3755.66","percent of total billed charges",""
"BONE PLATE 3.5MM LG RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4595.76","3446.82","AETNA [1001]","HB AMC AETNA PPO","3694.99","80.4","","1261.44","103.12","1514.10","21","2401.74","3755.66","percent of total billed charges",""
"BONE PLATE 3.5MM LG RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4595.76","3446.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3694.99","80.4","","1365.00","1365.00","1365.00","1 through 10","2401.74","3755.66","percent of total billed charges",""
"BONE PLATE 3.5MM LG RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4595.76","3446.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3755.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2401.74","3755.66","percent of total billed charges",""
"BONE PLATE 3.5MM LG RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4595.76","3446.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3755.66","81.72","","431.26","71.26","1459.57","88","2401.74","3755.66","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","872.83","654.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","693.90","79.5","","800.18","480.96","1887.97","195","270.58","693.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","872.83","654.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","465.22","53.3","","813.12","216.42","1444.50","81","270.58","693.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","872.83","654.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","270.58","31","","432.60","432.60","432.60","1 through 10","270.58","693.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","872.83","654.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","318.58","36.5","","148.37","54.89","631.39","94","270.58","693.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","872.83","654.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","334.29","38.3","","279.30","91.72","1116.77","266","270.58","693.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","872.83","654.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","374.44","42.9","","731.00","63.70","731.00","1 through 10","270.58","693.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","872.83","654.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","374.44","42.9","","384.74","384.74","384.74","1 through 10","270.58","693.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","872.83","654.62","WELLPOINT [1015]","HB AMC WELLPOINT","643.97","73.78","","286.63","119.22","1107.45","105","270.58","693.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","872.83","654.62","AETNA [1001]","HB AMC AETNA HMO","609.24","69.8","","675.31","184.75","1721.50","286","456.14","713.28","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","872.83","654.62","AETNA [1001]","HB AMC AETNA PPO","701.76","80.4","","1261.44","103.12","1514.10","21","456.14","713.28","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","872.83","654.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","701.76","80.4","","1365.00","1365.00","1365.00","1 through 10","456.14","713.28","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","872.83","654.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","713.28","81.72","","5157.68","5157.68","5157.68","1 through 10","456.14","713.28","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","872.83","654.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","713.28","81.72","","431.26","71.26","1459.57","88","456.14","713.28","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","both","","","4513.08","3384.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3587.90","79.5","","800.18","480.96","1887.97","195","1399.05","3587.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","both","","","4513.08","3384.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2405.47","53.3","","813.12","216.42","1444.50","81","1399.05","3587.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","both","","","4513.08","3384.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1399.05","31","","432.60","432.60","432.60","1 through 10","1399.05","3587.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","both","","","4513.08","3384.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1647.27","36.5","","148.37","54.89","631.39","94","1399.05","3587.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","both","","","4513.08","3384.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1728.51","38.3","","279.30","91.72","1116.77","266","1399.05","3587.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","both","","","4513.08","3384.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1936.11","42.9","","731.00","63.70","731.00","1 through 10","1399.05","3587.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","both","","","4513.08","3384.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1936.11","42.9","","384.74","384.74","384.74","1 through 10","1399.05","3587.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","both","","","4513.08","3384.81","WELLPOINT [1015]","HB AMC WELLPOINT","3329.75","73.78","","286.63","119.22","1107.45","105","1399.05","3587.9","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4513.08","3384.81","AETNA [1001]","HB AMC AETNA HMO","3150.13","69.8","","675.31","184.75","1721.50","286","2358.54","3688.09","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4513.08","3384.81","AETNA [1001]","HB AMC AETNA PPO","3628.52","80.4","","1261.44","103.12","1514.10","21","2358.54","3688.09","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4513.08","3384.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3628.52","80.4","","1365.00","1365.00","1365.00","1 through 10","2358.54","3688.09","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4513.08","3384.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3688.09","81.72","","5157.68","5157.68","5157.68","1 through 10","2358.54","3688.09","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4513.08","3384.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3688.09","81.72","","431.26","71.26","1459.57","88","2358.54","3688.09","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","858.62","79.5","","800.18","480.96","1887.97","195","334.81","858.62","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","575.66","53.3","","813.12","216.42","1444.50","81","334.81","858.62","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","334.81","31","","432.60","432.60","432.60","1 through 10","334.81","858.62","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","394.21","36.5","","148.37","54.89","631.39","94","334.81","858.62","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","413.65","38.3","","279.30","91.72","1116.77","266","334.81","858.62","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","463.33","42.9","","731.00","63.70","731.00","1 through 10","334.81","858.62","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","463.33","42.9","","384.74","384.74","384.74","1 through 10","334.81","858.62","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.03","810.02","WELLPOINT [1015]","HB AMC WELLPOINT","796.85","73.78","","286.63","119.22","1107.45","105","334.81","858.62","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.03","810.02","AETNA [1001]","HB AMC AETNA HMO","753.86","69.8","","675.31","184.75","1721.50","286","564.42","882.6","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.03","810.02","AETNA [1001]","HB AMC AETNA PPO","868.34","80.4","","1261.44","103.12","1514.10","21","564.42","882.6","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.03","810.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","868.34","80.4","","1365.00","1365.00","1365.00","1 through 10","564.42","882.6","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.03","810.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","882.60","81.72","","5157.68","5157.68","5157.68","1 through 10","564.42","882.6","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.03","810.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","882.60","81.72","","431.26","71.26","1459.57","88","564.42","882.6","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","916.86","687.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","728.90","79.5","","800.18","480.96","1887.97","195","284.23","728.9","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","916.86","687.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","488.69","53.3","","813.12","216.42","1444.50","81","284.23","728.9","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","916.86","687.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","284.23","31","","432.60","432.60","432.60","1 through 10","284.23","728.9","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","916.86","687.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","334.65","36.5","","148.37","54.89","631.39","94","284.23","728.9","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","916.86","687.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","351.16","38.3","","279.30","91.72","1116.77","266","284.23","728.9","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","916.86","687.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.33","42.9","","731.00","63.70","731.00","1 through 10","284.23","728.9","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","916.86","687.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.33","42.9","","384.74","384.74","384.74","1 through 10","284.23","728.9","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","916.86","687.64","WELLPOINT [1015]","HB AMC WELLPOINT","676.46","73.78","","286.63","119.22","1107.45","105","284.23","728.9","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","916.86","687.64","AETNA [1001]","HB AMC AETNA HMO","639.97","69.8","","675.31","184.75","1721.50","286","479.15","749.26","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","916.86","687.64","AETNA [1001]","HB AMC AETNA PPO","737.16","80.4","","1261.44","103.12","1514.10","21","479.15","749.26","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","916.86","687.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","737.16","80.4","","1365.00","1365.00","1365.00","1 through 10","479.15","749.26","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","916.86","687.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","749.26","81.72","","5157.68","5157.68","5157.68","1 through 10","479.15","749.26","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","916.86","687.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","749.26","81.72","","431.26","71.26","1459.57","88","479.15","749.26","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.52","1084.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1149.98","79.5","","800.18","480.96","1887.97","195","448.42","1149.98","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.52","1084.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","771.00","53.3","","813.12","216.42","1444.50","81","448.42","1149.98","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.52","1084.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","448.42","31","","432.60","432.60","432.60","1 through 10","448.42","1149.98","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.52","1084.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","527.98","36.5","","148.37","54.89","631.39","94","448.42","1149.98","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.52","1084.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","554.02","38.3","","279.30","91.72","1116.77","266","448.42","1149.98","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.52","1084.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","620.56","42.9","","731.00","63.70","731.00","1 through 10","448.42","1149.98","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.52","1084.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","620.56","42.9","","384.74","384.74","384.74","1 through 10","448.42","1149.98","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.52","1084.89","WELLPOINT [1015]","HB AMC WELLPOINT","1067.24","73.78","","286.63","119.22","1107.45","105","448.42","1149.98","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1446.52","1084.89","AETNA [1001]","HB AMC AETNA HMO","1009.67","69.8","","675.31","184.75","1721.50","286","755.95","1182.1","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1446.52","1084.89","AETNA [1001]","HB AMC AETNA PPO","1163.00","80.4","","1261.44","103.12","1514.10","21","755.95","1182.1","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1446.52","1084.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1163.00","80.4","","1365.00","1365.00","1365.00","1 through 10","755.95","1182.1","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1446.52","1084.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1182.10","81.72","","5157.68","5157.68","5157.68","1 through 10","755.95","1182.1","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1446.52","1084.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1182.10","81.72","","431.26","71.26","1459.57","88","755.95","1182.1","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","378.87","79.5","","800.18","480.96","1887.97","195","147.73","378.87","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","254.01","53.3","","813.12","216.42","1444.50","81","147.73","378.87","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","147.73","31","","432.60","432.60","432.60","1 through 10","147.73","378.87","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","173.94","36.5","","148.37","54.89","631.39","94","147.73","378.87","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","182.52","38.3","","279.30","91.72","1116.77","266","147.73","378.87","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.44","42.9","","731.00","63.70","731.00","1 through 10","147.73","378.87","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.44","42.9","","384.74","384.74","384.74","1 through 10","147.73","378.87","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","WELLPOINT [1015]","HB AMC WELLPOINT","351.61","73.78","","286.63","119.22","1107.45","105","147.73","378.87","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.56","357.42","AETNA [1001]","HB AMC AETNA HMO","332.64","69.8","","675.31","184.75","1721.50","286","249.05","389.44","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.56","357.42","AETNA [1001]","HB AMC AETNA PPO","383.15","80.4","","1261.44","103.12","1514.10","21","249.05","389.44","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.56","357.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","383.15","80.4","","1365.00","1365.00","1365.00","1 through 10","249.05","389.44","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.56","357.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","389.44","81.72","","5157.68","5157.68","5157.68","1 through 10","249.05","389.44","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.56","357.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","389.44","81.72","","431.26","71.26","1459.57","88","249.05","389.44","percent of total billed charges",""
"BONE PLATE 3.5X111MM 8 HOLE STRAIGHT TITANIUM LCP","SUP-ITM-10040459","CDM","C1713","HCPCS","0278","RC","","","","both","","","944.06","708.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","750.53","79.5","","800.18","480.96","1887.97","195","292.66","750.53","percent of total billed charges",""
"BONE PLATE 3.5X111MM 8 HOLE STRAIGHT TITANIUM LCP","SUP-ITM-10040459","CDM","C1713","HCPCS","0278","RC","","","","both","","","944.06","708.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","503.18","53.3","","813.12","216.42","1444.50","81","292.66","750.53","percent of total billed charges",""
"BONE PLATE 3.5X111MM 8 HOLE STRAIGHT TITANIUM LCP","SUP-ITM-10040459","CDM","C1713","HCPCS","0278","RC","","","","both","","","944.06","708.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","292.66","31","","432.60","432.60","432.60","1 through 10","292.66","750.53","percent of total billed charges",""
"BONE PLATE 3.5X111MM 8 HOLE STRAIGHT TITANIUM LCP","SUP-ITM-10040459","CDM","C1713","HCPCS","0278","RC","","","","both","","","944.06","708.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","344.58","36.5","","148.37","54.89","631.39","94","292.66","750.53","percent of total billed charges",""
"BONE PLATE 3.5X111MM 8 HOLE STRAIGHT TITANIUM LCP","SUP-ITM-10040459","CDM","C1713","HCPCS","0278","RC","","","","both","","","944.06","708.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","361.57","38.3","","279.30","91.72","1116.77","266","292.66","750.53","percent of total billed charges",""
"BONE PLATE 3.5X111MM 8 HOLE STRAIGHT TITANIUM LCP","SUP-ITM-10040459","CDM","C1713","HCPCS","0278","RC","","","","both","","","944.06","708.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","405.00","42.9","","731.00","63.70","731.00","1 through 10","292.66","750.53","percent of total billed charges",""
"BONE PLATE 3.5X111MM 8 HOLE STRAIGHT TITANIUM LCP","SUP-ITM-10040459","CDM","C1713","HCPCS","0278","RC","","","","both","","","944.06","708.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","405.00","42.9","","384.74","384.74","384.74","1 through 10","292.66","750.53","percent of total billed charges",""
"BONE PLATE 3.5X111MM 8 HOLE STRAIGHT TITANIUM LCP","SUP-ITM-10040459","CDM","C1713","HCPCS","0278","RC","","","","both","","","944.06","708.04","WELLPOINT [1015]","HB AMC WELLPOINT","696.53","73.78","","286.63","119.22","1107.45","105","292.66","750.53","percent of total billed charges",""
"BONE PLATE 3.5X111MM 8 HOLE STRAIGHT TITANIUM LCP","SUP-ITM-10040459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","944.06","708.04","AETNA [1001]","HB AMC AETNA HMO","658.95","69.8","","675.31","184.75","1721.50","286","493.37","771.49","percent of total billed charges",""
"BONE PLATE 3.5X111MM 8 HOLE STRAIGHT TITANIUM LCP","SUP-ITM-10040459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","944.06","708.04","AETNA [1001]","HB AMC AETNA PPO","759.02","80.4","","1261.44","103.12","1514.10","21","493.37","771.49","percent of total billed charges",""
"BONE PLATE 3.5X111MM 8 HOLE STRAIGHT TITANIUM LCP","SUP-ITM-10040459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","944.06","708.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","759.02","80.4","","1365.00","1365.00","1365.00","1 through 10","493.37","771.49","percent of total billed charges",""
"BONE PLATE 3.5X111MM 8 HOLE STRAIGHT TITANIUM LCP","SUP-ITM-10040459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","944.06","708.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","771.49","81.72","","5157.68","5157.68","5157.68","1 through 10","493.37","771.49","percent of total billed charges",""
"BONE PLATE 3.5X111MM 8 HOLE STRAIGHT TITANIUM LCP","SUP-ITM-10040459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","944.06","708.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","771.49","81.72","","431.26","71.26","1459.57","88","493.37","771.49","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.42","715.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","758.76","79.5","","800.18","480.96","1887.97","195","295.87","758.76","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.42","715.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","508.71","53.3","","813.12","216.42","1444.50","81","295.87","758.76","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.42","715.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","295.87","31","","432.60","432.60","432.60","1 through 10","295.87","758.76","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.42","715.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","348.36","36.5","","148.37","54.89","631.39","94","295.87","758.76","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.42","715.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","365.54","38.3","","279.30","91.72","1116.77","266","295.87","758.76","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.42","715.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.45","42.9","","731.00","63.70","731.00","1 through 10","295.87","758.76","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.42","715.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.45","42.9","","384.74","384.74","384.74","1 through 10","295.87","758.76","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.42","715.81","WELLPOINT [1015]","HB AMC WELLPOINT","704.17","73.78","","286.63","119.22","1107.45","105","295.87","758.76","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.42","715.81","AETNA [1001]","HB AMC AETNA HMO","666.19","69.8","","675.31","184.75","1721.50","286","498.78","779.95","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.42","715.81","AETNA [1001]","HB AMC AETNA PPO","767.35","80.4","","1261.44","103.12","1514.10","21","498.78","779.95","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.42","715.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","767.35","80.4","","1365.00","1365.00","1365.00","1 through 10","498.78","779.95","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.42","715.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","779.95","81.72","","5157.68","5157.68","5157.68","1 through 10","498.78","779.95","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.42","715.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","779.95","81.72","","431.26","71.26","1459.57","88","498.78","779.95","percent of total billed charges",""
"BONE PLATE 3.5X124MM 9 HOLE LCP TITANIUM LOCKING COMPRESSION","SUP-ITM-10040460","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.61","736.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","780.38","79.5","","800.18","480.96","1887.97","195","304.3","780.38","percent of total billed charges",""
"BONE PLATE 3.5X124MM 9 HOLE LCP TITANIUM LOCKING COMPRESSION","SUP-ITM-10040460","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.61","736.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","523.20","53.3","","813.12","216.42","1444.50","81","304.3","780.38","percent of total billed charges",""
"BONE PLATE 3.5X124MM 9 HOLE LCP TITANIUM LOCKING COMPRESSION","SUP-ITM-10040460","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.61","736.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","304.30","31","","432.60","432.60","432.60","1 through 10","304.3","780.38","percent of total billed charges",""
"BONE PLATE 3.5X124MM 9 HOLE LCP TITANIUM LOCKING COMPRESSION","SUP-ITM-10040460","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.61","736.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","358.29","36.5","","148.37","54.89","631.39","94","304.3","780.38","percent of total billed charges",""
"BONE PLATE 3.5X124MM 9 HOLE LCP TITANIUM LOCKING COMPRESSION","SUP-ITM-10040460","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.61","736.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","375.96","38.3","","279.30","91.72","1116.77","266","304.3","780.38","percent of total billed charges",""
"BONE PLATE 3.5X124MM 9 HOLE LCP TITANIUM LOCKING COMPRESSION","SUP-ITM-10040460","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.61","736.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","421.11","42.9","","731.00","63.70","731.00","1 through 10","304.3","780.38","percent of total billed charges",""
"BONE PLATE 3.5X124MM 9 HOLE LCP TITANIUM LOCKING COMPRESSION","SUP-ITM-10040460","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.61","736.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","421.11","42.9","","384.74","384.74","384.74","1 through 10","304.3","780.38","percent of total billed charges",""
"BONE PLATE 3.5X124MM 9 HOLE LCP TITANIUM LOCKING COMPRESSION","SUP-ITM-10040460","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.61","736.21","WELLPOINT [1015]","HB AMC WELLPOINT","724.23","73.78","","286.63","119.22","1107.45","105","304.3","780.38","percent of total billed charges",""
"BONE PLATE 3.5X124MM 9 HOLE LCP TITANIUM LOCKING COMPRESSION","SUP-ITM-10040460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.61","736.21","AETNA [1001]","HB AMC AETNA HMO","685.16","69.8","","675.31","184.75","1721.50","286","512.99","802.17","percent of total billed charges",""
"BONE PLATE 3.5X124MM 9 HOLE LCP TITANIUM LOCKING COMPRESSION","SUP-ITM-10040460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.61","736.21","AETNA [1001]","HB AMC AETNA PPO","789.21","80.4","","1261.44","103.12","1514.10","21","512.99","802.17","percent of total billed charges",""
"BONE PLATE 3.5X124MM 9 HOLE LCP TITANIUM LOCKING COMPRESSION","SUP-ITM-10040460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.61","736.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","789.21","80.4","","1365.00","1365.00","1365.00","1 through 10","512.99","802.17","percent of total billed charges",""
"BONE PLATE 3.5X124MM 9 HOLE LCP TITANIUM LOCKING COMPRESSION","SUP-ITM-10040460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.61","736.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","802.17","81.72","","5157.68","5157.68","5157.68","1 through 10","512.99","802.17","percent of total billed charges",""
"BONE PLATE 3.5X124MM 9 HOLE LCP TITANIUM LOCKING COMPRESSION","SUP-ITM-10040460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.61","736.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","802.17","81.72","","431.26","71.26","1459.57","88","512.99","802.17","percent of total billed charges",""
"BONE PLATE 3.5X130MM 10 HOLE RECONSTRUCTION J LOW PROFILE CURVED RIGHT","SUP-ITM-10038118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1341.48","79.5","","800.18","480.96","1887.97","195","523.09","1341.48","percent of total billed charges",""
"BONE PLATE 3.5X130MM 10 HOLE RECONSTRUCTION J LOW PROFILE CURVED RIGHT","SUP-ITM-10038118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","899.38","53.3","","813.12","216.42","1444.50","81","523.09","1341.48","percent of total billed charges",""
"BONE PLATE 3.5X130MM 10 HOLE RECONSTRUCTION J LOW PROFILE CURVED RIGHT","SUP-ITM-10038118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","523.09","31","","432.60","432.60","432.60","1 through 10","523.09","1341.48","percent of total billed charges",""
"BONE PLATE 3.5X130MM 10 HOLE RECONSTRUCTION J LOW PROFILE CURVED RIGHT","SUP-ITM-10038118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","615.90","36.5","","148.37","54.89","631.39","94","523.09","1341.48","percent of total billed charges",""
"BONE PLATE 3.5X130MM 10 HOLE RECONSTRUCTION J LOW PROFILE CURVED RIGHT","SUP-ITM-10038118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","646.27","38.3","","279.30","91.72","1116.77","266","523.09","1341.48","percent of total billed charges",""
"BONE PLATE 3.5X130MM 10 HOLE RECONSTRUCTION J LOW PROFILE CURVED RIGHT","SUP-ITM-10038118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","723.89","42.9","","731.00","63.70","731.00","1 through 10","523.09","1341.48","percent of total billed charges",""
"BONE PLATE 3.5X130MM 10 HOLE RECONSTRUCTION J LOW PROFILE CURVED RIGHT","SUP-ITM-10038118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","723.89","42.9","","384.74","384.74","384.74","1 through 10","523.09","1341.48","percent of total billed charges",""
"BONE PLATE 3.5X130MM 10 HOLE RECONSTRUCTION J LOW PROFILE CURVED RIGHT","SUP-ITM-10038118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","WELLPOINT [1015]","HB AMC WELLPOINT","1244.96","73.78","","286.63","119.22","1107.45","105","523.09","1341.48","percent of total billed charges",""
"BONE PLATE 3.5X130MM 10 HOLE RECONSTRUCTION J LOW PROFILE CURVED RIGHT","SUP-ITM-10038118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1687.39","1265.54","AETNA [1001]","HB AMC AETNA HMO","1177.80","69.8","","675.31","184.75","1721.50","286","881.83","1378.94","percent of total billed charges",""
"BONE PLATE 3.5X130MM 10 HOLE RECONSTRUCTION J LOW PROFILE CURVED RIGHT","SUP-ITM-10038118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1687.39","1265.54","AETNA [1001]","HB AMC AETNA PPO","1356.66","80.4","","1261.44","103.12","1514.10","21","881.83","1378.94","percent of total billed charges",""
"BONE PLATE 3.5X130MM 10 HOLE RECONSTRUCTION J LOW PROFILE CURVED RIGHT","SUP-ITM-10038118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1687.39","1265.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1356.66","80.4","","1365.00","1365.00","1365.00","1 through 10","881.83","1378.94","percent of total billed charges",""
"BONE PLATE 3.5X130MM 10 HOLE RECONSTRUCTION J LOW PROFILE CURVED RIGHT","SUP-ITM-10038118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1687.39","1265.54","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1378.94","81.72","","5157.68","5157.68","5157.68","1 through 10","881.83","1378.94","percent of total billed charges",""
"BONE PLATE 3.5X130MM 10 HOLE RECONSTRUCTION J LOW PROFILE CURVED RIGHT","SUP-ITM-10038118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1687.39","1265.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1378.94","81.72","","431.26","71.26","1459.57","88","881.83","1378.94","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","937.58","703.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","745.38","79.5","","800.18","480.96","1887.97","195","290.65","745.38","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","937.58","703.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","499.73","53.3","","813.12","216.42","1444.50","81","290.65","745.38","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","937.58","703.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","290.65","31","","432.60","432.60","432.60","1 through 10","290.65","745.38","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","937.58","703.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","342.22","36.5","","148.37","54.89","631.39","94","290.65","745.38","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","937.58","703.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","359.09","38.3","","279.30","91.72","1116.77","266","290.65","745.38","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","937.58","703.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","402.22","42.9","","731.00","63.70","731.00","1 through 10","290.65","745.38","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","937.58","703.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","402.22","42.9","","384.74","384.74","384.74","1 through 10","290.65","745.38","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","937.58","703.18","WELLPOINT [1015]","HB AMC WELLPOINT","691.75","73.78","","286.63","119.22","1107.45","105","290.65","745.38","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","937.58","703.18","AETNA [1001]","HB AMC AETNA HMO","654.43","69.8","","675.31","184.75","1721.50","286","489.98","766.19","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","937.58","703.18","AETNA [1001]","HB AMC AETNA PPO","753.81","80.4","","1261.44","103.12","1514.10","21","489.98","766.19","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","937.58","703.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","753.81","80.4","","1365.00","1365.00","1365.00","1 through 10","489.98","766.19","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","937.58","703.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","766.19","81.72","","5157.68","5157.68","5157.68","1 through 10","489.98","766.19","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","937.58","703.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","766.19","81.72","","431.26","71.26","1459.57","88","489.98","766.19","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040461","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.40","758.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","804.06","79.5","","800.18","480.96","1887.97","195","313.53","804.06","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040461","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.40","758.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","539.08","53.3","","813.12","216.42","1444.50","81","313.53","804.06","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040461","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.40","758.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","313.53","31","","432.60","432.60","432.60","1 through 10","313.53","804.06","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040461","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.40","758.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","369.16","36.5","","148.37","54.89","631.39","94","313.53","804.06","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040461","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.40","758.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","387.37","38.3","","279.30","91.72","1116.77","266","313.53","804.06","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040461","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.40","758.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","433.89","42.9","","731.00","63.70","731.00","1 through 10","313.53","804.06","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040461","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.40","758.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","433.89","42.9","","384.74","384.74","384.74","1 through 10","313.53","804.06","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040461","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.40","758.55","WELLPOINT [1015]","HB AMC WELLPOINT","746.21","73.78","","286.63","119.22","1107.45","105","313.53","804.06","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.40","758.55","AETNA [1001]","HB AMC AETNA HMO","705.96","69.8","","675.31","184.75","1721.50","286","528.56","826.52","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.40","758.55","AETNA [1001]","HB AMC AETNA PPO","813.17","80.4","","1261.44","103.12","1514.10","21","528.56","826.52","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.40","758.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","813.17","80.4","","1365.00","1365.00","1365.00","1 through 10","528.56","826.52","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.40","758.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","826.52","81.72","","5157.68","5157.68","5157.68","1 through 10","528.56","826.52","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.40","758.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","826.52","81.72","","431.26","71.26","1459.57","88","528.56","826.52","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","both","","","2394.46","1795.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1903.60","79.5","","800.18","480.96","1887.97","195","742.28","1903.6","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","both","","","2394.46","1795.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1276.25","53.3","","813.12","216.42","1444.50","81","742.28","1903.6","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","both","","","2394.46","1795.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","742.28","31","","432.60","432.60","432.60","1 through 10","742.28","1903.6","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","both","","","2394.46","1795.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","873.98","36.5","","148.37","54.89","631.39","94","742.28","1903.6","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","both","","","2394.46","1795.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","917.08","38.3","","279.30","91.72","1116.77","266","742.28","1903.6","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","both","","","2394.46","1795.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1027.22","42.9","","731.00","63.70","731.00","1 through 10","742.28","1903.6","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","both","","","2394.46","1795.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1027.22","42.9","","384.74","384.74","384.74","1 through 10","742.28","1903.6","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","both","","","2394.46","1795.84","WELLPOINT [1015]","HB AMC WELLPOINT","1766.63","73.78","","286.63","119.22","1107.45","105","742.28","1903.6","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2394.46","1795.84","AETNA [1001]","HB AMC AETNA HMO","1671.33","69.8","","675.31","184.75","1721.50","286","1251.34","1956.75","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2394.46","1795.84","AETNA [1001]","HB AMC AETNA PPO","1925.15","80.4","","1261.44","103.12","1514.10","21","1251.34","1956.75","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2394.46","1795.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1925.15","80.4","","1365.00","1365.00","1365.00","1 through 10","1251.34","1956.75","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2394.46","1795.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1956.75","81.72","","5157.68","5157.68","5157.68","1 through 10","1251.34","1956.75","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2394.46","1795.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1956.75","81.72","","431.26","71.26","1459.57","88","1251.34","1956.75","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.21","1067.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1131.45","79.5","","800.18","480.96","1887.97","195","441.2","1131.45","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.21","1067.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","758.57","53.3","","813.12","216.42","1444.50","81","441.2","1131.45","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.21","1067.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","441.20","31","","432.60","432.60","432.60","1 through 10","441.2","1131.45","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.21","1067.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","519.47","36.5","","148.37","54.89","631.39","94","441.2","1131.45","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.21","1067.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","545.09","38.3","","279.30","91.72","1116.77","266","441.2","1131.45","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.21","1067.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","610.56","42.9","","731.00","63.70","731.00","1 through 10","441.2","1131.45","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.21","1067.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","610.56","42.9","","384.74","384.74","384.74","1 through 10","441.2","1131.45","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.21","1067.41","WELLPOINT [1015]","HB AMC WELLPOINT","1050.04","73.78","","286.63","119.22","1107.45","105","441.2","1131.45","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1423.21","1067.41","AETNA [1001]","HB AMC AETNA HMO","993.40","69.8","","675.31","184.75","1721.50","286","743.77","1163.05","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1423.21","1067.41","AETNA [1001]","HB AMC AETNA PPO","1144.26","80.4","","1261.44","103.12","1514.10","21","743.77","1163.05","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1423.21","1067.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1144.26","80.4","","1365.00","1365.00","1365.00","1 through 10","743.77","1163.05","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1423.21","1067.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1163.05","81.72","","5157.68","5157.68","5157.68","1 through 10","743.77","1163.05","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1423.21","1067.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1163.05","81.72","","431.26","71.26","1459.57","88","743.77","1163.05","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.64","769.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","815.38","79.5","","800.18","480.96","1887.97","195","317.95","815.38","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.64","769.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","546.67","53.3","","813.12","216.42","1444.50","81","317.95","815.38","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.64","769.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","317.95","31","","432.60","432.60","432.60","1 through 10","317.95","815.38","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.64","769.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","374.36","36.5","","148.37","54.89","631.39","94","317.95","815.38","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.64","769.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","392.82","38.3","","279.30","91.72","1116.77","266","317.95","815.38","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.64","769.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","440.00","42.9","","731.00","63.70","731.00","1 through 10","317.95","815.38","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.64","769.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","440.00","42.9","","384.74","384.74","384.74","1 through 10","317.95","815.38","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.64","769.23","WELLPOINT [1015]","HB AMC WELLPOINT","756.72","73.78","","286.63","119.22","1107.45","105","317.95","815.38","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1025.64","769.23","AETNA [1001]","HB AMC AETNA HMO","715.90","69.8","","675.31","184.75","1721.50","286","536","838.15","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1025.64","769.23","AETNA [1001]","HB AMC AETNA PPO","824.61","80.4","","1261.44","103.12","1514.10","21","536","838.15","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1025.64","769.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","824.61","80.4","","1365.00","1365.00","1365.00","1 through 10","536","838.15","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1025.64","769.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","838.15","81.72","","5157.68","5157.68","5157.68","1 through 10","536","838.15","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1025.64","769.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","838.15","81.72","","431.26","71.26","1459.57","88","536","838.15","percent of total billed charges",""
"BONE PLATE 3.5X143MM DISTAL 9 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10018940","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.56","2299.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2437.92","79.5","","800.18","480.96","1887.97","195","950.63","2437.92","percent of total billed charges",""
"BONE PLATE 3.5X143MM DISTAL 9 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10018940","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.56","2299.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1634.48","53.3","","813.12","216.42","1444.50","81","950.63","2437.92","percent of total billed charges",""
"BONE PLATE 3.5X143MM DISTAL 9 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10018940","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.56","2299.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","950.63","31","","432.60","432.60","432.60","1 through 10","950.63","2437.92","percent of total billed charges",""
"BONE PLATE 3.5X143MM DISTAL 9 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10018940","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.56","2299.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1119.29","36.5","","148.37","54.89","631.39","94","950.63","2437.92","percent of total billed charges",""
"BONE PLATE 3.5X143MM DISTAL 9 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10018940","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.56","2299.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1174.49","38.3","","279.30","91.72","1116.77","266","950.63","2437.92","percent of total billed charges",""
"BONE PLATE 3.5X143MM DISTAL 9 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10018940","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.56","2299.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1315.55","42.9","","731.00","63.70","731.00","1 through 10","950.63","2437.92","percent of total billed charges",""
"BONE PLATE 3.5X143MM DISTAL 9 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10018940","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.56","2299.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1315.55","42.9","","384.74","384.74","384.74","1 through 10","950.63","2437.92","percent of total billed charges",""
"BONE PLATE 3.5X143MM DISTAL 9 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10018940","CDM","C1713","HCPCS","0278","RC","","","","both","","","3066.56","2299.92","WELLPOINT [1015]","HB AMC WELLPOINT","2262.51","73.78","","286.63","119.22","1107.45","105","950.63","2437.92","percent of total billed charges",""
"BONE PLATE 3.5X143MM DISTAL 9 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10018940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3066.56","2299.92","AETNA [1001]","HB AMC AETNA HMO","2140.46","69.8","","675.31","184.75","1721.50","286","1602.58","2505.99","percent of total billed charges",""
"BONE PLATE 3.5X143MM DISTAL 9 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10018940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3066.56","2299.92","AETNA [1001]","HB AMC AETNA PPO","2465.51","80.4","","1261.44","103.12","1514.10","21","1602.58","2505.99","percent of total billed charges",""
"BONE PLATE 3.5X143MM DISTAL 9 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10018940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3066.56","2299.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2465.51","80.4","","1365.00","1365.00","1365.00","1 through 10","1602.58","2505.99","percent of total billed charges",""
"BONE PLATE 3.5X143MM DISTAL 9 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10018940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3066.56","2299.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2505.99","81.72","","5157.68","5157.68","5157.68","1 through 10","1602.58","2505.99","percent of total billed charges",""
"BONE PLATE 3.5X143MM DISTAL 9 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10018940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3066.56","2299.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2505.99","81.72","","431.26","71.26","1459.57","88","1602.58","2505.99","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1355.89","79.5","","800.18","480.96","1887.97","195","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","909.04","53.3","","813.12","216.42","1444.50","81","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","528.71","31","","432.60","432.60","432.60","1 through 10","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","622.51","36.5","","148.37","54.89","631.39","94","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","653.21","38.3","","279.30","91.72","1116.77","266","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","731.67","42.9","","731.00","63.70","731.00","1 through 10","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","731.67","42.9","","384.74","384.74","384.74","1 through 10","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","WELLPOINT [1015]","HB AMC WELLPOINT","1258.33","73.78","","286.63","119.22","1107.45","105","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1705.52","1279.14","AETNA [1001]","HB AMC AETNA HMO","1190.45","69.8","","675.31","184.75","1721.50","286","891.3","1393.75","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1705.52","1279.14","AETNA [1001]","HB AMC AETNA PPO","1371.24","80.4","","1261.44","103.12","1514.10","21","891.3","1393.75","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1705.52","1279.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1371.24","80.4","","1365.00","1365.00","1365.00","1 through 10","891.3","1393.75","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1705.52","1279.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1393.75","81.72","","5157.68","5157.68","5157.68","1 through 10","891.3","1393.75","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1705.52","1279.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1393.75","81.72","","431.26","71.26","1459.57","88","891.3","1393.75","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.92","812.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","861.72","79.5","","800.18","480.96","1887.97","195","336.02","861.72","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.92","812.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","577.73","53.3","","813.12","216.42","1444.50","81","336.02","861.72","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.92","812.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","336.02","31","","432.60","432.60","432.60","1 through 10","336.02","861.72","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.92","812.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","395.63","36.5","","148.37","54.89","631.39","94","336.02","861.72","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.92","812.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","415.14","38.3","","279.30","91.72","1116.77","266","336.02","861.72","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.92","812.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","465.00","42.9","","731.00","63.70","731.00","1 through 10","336.02","861.72","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.92","812.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","465.00","42.9","","384.74","384.74","384.74","1 through 10","336.02","861.72","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.92","812.94","WELLPOINT [1015]","HB AMC WELLPOINT","799.72","73.78","","286.63","119.22","1107.45","105","336.02","861.72","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1083.92","812.94","AETNA [1001]","HB AMC AETNA HMO","756.58","69.8","","675.31","184.75","1721.50","286","566.46","885.78","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1083.92","812.94","AETNA [1001]","HB AMC AETNA PPO","871.47","80.4","","1261.44","103.12","1514.10","21","566.46","885.78","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1083.92","812.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","871.47","80.4","","1365.00","1365.00","1365.00","1 through 10","566.46","885.78","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1083.92","812.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","885.78","81.72","","5157.68","5157.68","5157.68","1 through 10","566.46","885.78","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1083.92","812.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","885.78","81.72","","431.26","71.26","1459.57","88","566.46","885.78","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","1037.30","777.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","824.65","79.5","","800.18","480.96","1887.97","195","321.56","824.65","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","1037.30","777.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","552.88","53.3","","813.12","216.42","1444.50","81","321.56","824.65","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","1037.30","777.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","321.56","31","","432.60","432.60","432.60","1 through 10","321.56","824.65","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","1037.30","777.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","378.61","36.5","","148.37","54.89","631.39","94","321.56","824.65","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","1037.30","777.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","397.29","38.3","","279.30","91.72","1116.77","266","321.56","824.65","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","1037.30","777.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","445.00","42.9","","731.00","63.70","731.00","1 through 10","321.56","824.65","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","1037.30","777.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","445.00","42.9","","384.74","384.74","384.74","1 through 10","321.56","824.65","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","1037.30","777.97","WELLPOINT [1015]","HB AMC WELLPOINT","765.32","73.78","","286.63","119.22","1107.45","105","321.56","824.65","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1037.30","777.97","AETNA [1001]","HB AMC AETNA HMO","724.04","69.8","","675.31","184.75","1721.50","286","542.09","847.68","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1037.30","777.97","AETNA [1001]","HB AMC AETNA PPO","833.99","80.4","","1261.44","103.12","1514.10","21","542.09","847.68","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1037.30","777.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","833.99","80.4","","1365.00","1365.00","1365.00","1 through 10","542.09","847.68","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1037.30","777.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","847.68","81.72","","5157.68","5157.68","5157.68","1 through 10","542.09","847.68","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1037.30","777.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","847.68","81.72","","431.26","71.26","1459.57","88","542.09","847.68","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","both","","","2499.35","1874.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1986.98","79.5","","800.18","480.96","1887.97","195","774.8","1986.98","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","both","","","2499.35","1874.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1332.15","53.3","","813.12","216.42","1444.50","81","774.8","1986.98","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","both","","","2499.35","1874.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","774.80","31","","432.60","432.60","432.60","1 through 10","774.8","1986.98","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","both","","","2499.35","1874.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","912.26","36.5","","148.37","54.89","631.39","94","774.8","1986.98","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","both","","","2499.35","1874.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","957.25","38.3","","279.30","91.72","1116.77","266","774.8","1986.98","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","both","","","2499.35","1874.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1072.22","42.9","","731.00","63.70","731.00","1 through 10","774.8","1986.98","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","both","","","2499.35","1874.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1072.22","42.9","","384.74","384.74","384.74","1 through 10","774.8","1986.98","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","both","","","2499.35","1874.51","WELLPOINT [1015]","HB AMC WELLPOINT","1844.02","73.78","","286.63","119.22","1107.45","105","774.8","1986.98","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2499.35","1874.51","AETNA [1001]","HB AMC AETNA HMO","1744.55","69.8","","675.31","184.75","1721.50","286","1306.16","2042.47","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2499.35","1874.51","AETNA [1001]","HB AMC AETNA PPO","2009.48","80.4","","1261.44","103.12","1514.10","21","1306.16","2042.47","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2499.35","1874.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2009.48","80.4","","1365.00","1365.00","1365.00","1 through 10","1306.16","2042.47","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2499.35","1874.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2042.47","81.72","","5157.68","5157.68","5157.68","1 through 10","1306.16","2042.47","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2499.35","1874.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2042.47","81.72","","431.26","71.26","1459.57","88","1306.16","2042.47","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1407.36","79.5","","800.18","480.96","1887.97","195","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","943.55","53.3","","813.12","216.42","1444.50","81","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","548.78","31","","432.60","432.60","432.60","1 through 10","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","646.15","36.5","","148.37","54.89","631.39","94","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","678.01","38.3","","279.30","91.72","1116.77","266","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","759.45","42.9","","731.00","63.70","731.00","1 through 10","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","759.45","42.9","","384.74","384.74","384.74","1 through 10","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","WELLPOINT [1015]","HB AMC WELLPOINT","1306.11","73.78","","286.63","119.22","1107.45","105","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.27","1327.70","AETNA [1001]","HB AMC AETNA HMO","1235.65","69.8","","675.31","184.75","1721.50","286","925.14","1446.66","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.27","1327.70","AETNA [1001]","HB AMC AETNA PPO","1423.30","80.4","","1261.44","103.12","1514.10","21","925.14","1446.66","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.27","1327.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1423.30","80.4","","1365.00","1365.00","1365.00","1 through 10","925.14","1446.66","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.27","1327.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1446.66","81.72","","5157.68","5157.68","5157.68","1 through 10","925.14","1446.66","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.27","1327.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1446.66","81.72","","431.26","71.26","1459.57","88","925.14","1446.66","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1576.02","1182.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1252.94","79.5","","800.18","480.96","1887.97","195","488.57","1252.94","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1576.02","1182.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","840.02","53.3","","813.12","216.42","1444.50","81","488.57","1252.94","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1576.02","1182.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","488.57","31","","432.60","432.60","432.60","1 through 10","488.57","1252.94","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1576.02","1182.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","575.25","36.5","","148.37","54.89","631.39","94","488.57","1252.94","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1576.02","1182.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","603.62","38.3","","279.30","91.72","1116.77","266","488.57","1252.94","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1576.02","1182.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","676.11","42.9","","731.00","63.70","731.00","1 through 10","488.57","1252.94","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1576.02","1182.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","676.11","42.9","","384.74","384.74","384.74","1 through 10","488.57","1252.94","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1576.02","1182.01","WELLPOINT [1015]","HB AMC WELLPOINT","1162.79","73.78","","286.63","119.22","1107.45","105","488.57","1252.94","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1576.02","1182.01","AETNA [1001]","HB AMC AETNA HMO","1100.06","69.8","","675.31","184.75","1721.50","286","823.63","1287.92","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1576.02","1182.01","AETNA [1001]","HB AMC AETNA PPO","1267.12","80.4","","1261.44","103.12","1514.10","21","823.63","1287.92","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1576.02","1182.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1267.12","80.4","","1365.00","1365.00","1365.00","1 through 10","823.63","1287.92","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1576.02","1182.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1287.92","81.72","","5157.68","5157.68","5157.68","1 through 10","823.63","1287.92","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1576.02","1182.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1287.92","81.72","","431.26","71.26","1459.57","88","823.63","1287.92","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1525.76","79.5","","800.18","480.96","1887.97","195","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1022.93","53.3","","813.12","216.42","1444.50","81","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","594.95","31","","432.60","432.60","432.60","1 through 10","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","700.50","36.5","","148.37","54.89","631.39","94","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","735.05","38.3","","279.30","91.72","1116.77","266","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","823.33","42.9","","731.00","63.70","731.00","1 through 10","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","823.33","42.9","","384.74","384.74","384.74","1 through 10","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","WELLPOINT [1015]","HB AMC WELLPOINT","1415.98","73.78","","286.63","119.22","1107.45","105","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1919.19","1439.39","AETNA [1001]","HB AMC AETNA HMO","1339.59","69.8","","675.31","184.75","1721.50","286","1002.97","1568.36","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1919.19","1439.39","AETNA [1001]","HB AMC AETNA PPO","1543.03","80.4","","1261.44","103.12","1514.10","21","1002.97","1568.36","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1919.19","1439.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1543.03","80.4","","1365.00","1365.00","1365.00","1 through 10","1002.97","1568.36","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1919.19","1439.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1568.36","81.72","","5157.68","5157.68","5157.68","1 through 10","1002.97","1568.36","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1919.19","1439.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1568.36","81.72","","431.26","71.26","1459.57","88","1002.97","1568.36","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","both","","","1626.52","1219.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1293.08","79.5","","800.18","480.96","1887.97","195","504.22","1293.08","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","both","","","1626.52","1219.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","866.94","53.3","","813.12","216.42","1444.50","81","504.22","1293.08","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","both","","","1626.52","1219.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","504.22","31","","432.60","432.60","432.60","1 through 10","504.22","1293.08","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","both","","","1626.52","1219.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","593.68","36.5","","148.37","54.89","631.39","94","504.22","1293.08","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","both","","","1626.52","1219.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","622.96","38.3","","279.30","91.72","1116.77","266","504.22","1293.08","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","both","","","1626.52","1219.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","697.78","42.9","","731.00","63.70","731.00","1 through 10","504.22","1293.08","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","both","","","1626.52","1219.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","697.78","42.9","","384.74","384.74","384.74","1 through 10","504.22","1293.08","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","both","","","1626.52","1219.89","WELLPOINT [1015]","HB AMC WELLPOINT","1200.05","73.78","","286.63","119.22","1107.45","105","504.22","1293.08","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1626.52","1219.89","AETNA [1001]","HB AMC AETNA HMO","1135.31","69.8","","675.31","184.75","1721.50","286","850.02","1329.19","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1626.52","1219.89","AETNA [1001]","HB AMC AETNA PPO","1307.72","80.4","","1261.44","103.12","1514.10","21","850.02","1329.19","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1626.52","1219.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1307.72","80.4","","1365.00","1365.00","1365.00","1 through 10","850.02","1329.19","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1626.52","1219.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1329.19","81.72","","5157.68","5157.68","5157.68","1 through 10","850.02","1329.19","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1626.52","1219.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1329.19","81.72","","431.26","71.26","1459.57","88","850.02","1329.19","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1355.89","79.5","","800.18","480.96","1887.97","195","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","909.04","53.3","","813.12","216.42","1444.50","81","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","528.71","31","","432.60","432.60","432.60","1 through 10","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","622.51","36.5","","148.37","54.89","631.39","94","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","653.21","38.3","","279.30","91.72","1116.77","266","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","731.67","42.9","","731.00","63.70","731.00","1 through 10","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","731.67","42.9","","384.74","384.74","384.74","1 through 10","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1705.52","1279.14","WELLPOINT [1015]","HB AMC WELLPOINT","1258.33","73.78","","286.63","119.22","1107.45","105","528.71","1355.89","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1705.52","1279.14","AETNA [1001]","HB AMC AETNA HMO","1190.45","69.8","","675.31","184.75","1721.50","286","891.3","1393.75","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1705.52","1279.14","AETNA [1001]","HB AMC AETNA PPO","1371.24","80.4","","1261.44","103.12","1514.10","21","891.3","1393.75","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1705.52","1279.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1371.24","80.4","","1365.00","1365.00","1365.00","1 through 10","891.3","1393.75","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1705.52","1279.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1393.75","81.72","","5157.68","5157.68","5157.68","1 through 10","891.3","1393.75","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1705.52","1279.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1393.75","81.72","","431.26","71.26","1459.57","88","891.3","1393.75","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.48","1170.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1240.58","79.5","","800.18","480.96","1887.97","195","483.75","1240.58","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.48","1170.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","831.74","53.3","","813.12","216.42","1444.50","81","483.75","1240.58","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.48","1170.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","483.75","31","","432.60","432.60","432.60","1 through 10","483.75","1240.58","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.48","1170.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","569.58","36.5","","148.37","54.89","631.39","94","483.75","1240.58","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.48","1170.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","597.66","38.3","","279.30","91.72","1116.77","266","483.75","1240.58","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.48","1170.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","669.45","42.9","","731.00","63.70","731.00","1 through 10","483.75","1240.58","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.48","1170.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","669.45","42.9","","384.74","384.74","384.74","1 through 10","483.75","1240.58","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.48","1170.36","WELLPOINT [1015]","HB AMC WELLPOINT","1151.32","73.78","","286.63","119.22","1107.45","105","483.75","1240.58","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1560.48","1170.36","AETNA [1001]","HB AMC AETNA HMO","1089.22","69.8","","675.31","184.75","1721.50","286","815.51","1275.22","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1560.48","1170.36","AETNA [1001]","HB AMC AETNA PPO","1254.63","80.4","","1261.44","103.12","1514.10","21","815.51","1275.22","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1560.48","1170.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1254.63","80.4","","1365.00","1365.00","1365.00","1 through 10","815.51","1275.22","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1560.48","1170.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1275.22","81.72","","5157.68","5157.68","5157.68","1 through 10","815.51","1275.22","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1560.48","1170.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1275.22","81.72","","431.26","71.26","1459.57","88","815.51","1275.22","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.85","1253.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1329.12","79.5","","800.18","480.96","1887.97","195","518.27","1329.12","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.85","1253.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","891.10","53.3","","813.12","216.42","1444.50","81","518.27","1329.12","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.85","1253.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","518.27","31","","432.60","432.60","432.60","1 through 10","518.27","1329.12","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.85","1253.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","610.23","36.5","","148.37","54.89","631.39","94","518.27","1329.12","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.85","1253.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","640.32","38.3","","279.30","91.72","1116.77","266","518.27","1329.12","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.85","1253.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","717.22","42.9","","731.00","63.70","731.00","1 through 10","518.27","1329.12","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.85","1253.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","717.22","42.9","","384.74","384.74","384.74","1 through 10","518.27","1329.12","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.85","1253.89","WELLPOINT [1015]","HB AMC WELLPOINT","1233.49","73.78","","286.63","119.22","1107.45","105","518.27","1329.12","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.85","1253.89","AETNA [1001]","HB AMC AETNA HMO","1166.95","69.8","","675.31","184.75","1721.50","286","873.71","1366.24","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.85","1253.89","AETNA [1001]","HB AMC AETNA PPO","1344.17","80.4","","1261.44","103.12","1514.10","21","873.71","1366.24","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.85","1253.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1344.17","80.4","","1365.00","1365.00","1365.00","1 through 10","873.71","1366.24","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.85","1253.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1366.24","81.72","","5157.68","5157.68","5157.68","1 through 10","873.71","1366.24","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.85","1253.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1366.24","81.72","","431.26","71.26","1459.57","88","873.71","1366.24","percent of total billed charges",""
"BONE PLATE 3.5X19.5MM 1 HOLE SS SPRING PELVUS","SUP-ITM-10036522","CDM","C1713","HCPCS","0278","RC","","","","both","","","1091.69","818.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","867.89","79.5","","800.18","480.96","1887.97","195","338.42","867.89","percent of total billed charges",""
"BONE PLATE 3.5X19.5MM 1 HOLE SS SPRING PELVUS","SUP-ITM-10036522","CDM","C1713","HCPCS","0278","RC","","","","both","","","1091.69","818.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","581.87","53.3","","813.12","216.42","1444.50","81","338.42","867.89","percent of total billed charges",""
"BONE PLATE 3.5X19.5MM 1 HOLE SS SPRING PELVUS","SUP-ITM-10036522","CDM","C1713","HCPCS","0278","RC","","","","both","","","1091.69","818.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","338.42","31","","432.60","432.60","432.60","1 through 10","338.42","867.89","percent of total billed charges",""
"BONE PLATE 3.5X19.5MM 1 HOLE SS SPRING PELVUS","SUP-ITM-10036522","CDM","C1713","HCPCS","0278","RC","","","","both","","","1091.69","818.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","398.47","36.5","","148.37","54.89","631.39","94","338.42","867.89","percent of total billed charges",""
"BONE PLATE 3.5X19.5MM 1 HOLE SS SPRING PELVUS","SUP-ITM-10036522","CDM","C1713","HCPCS","0278","RC","","","","both","","","1091.69","818.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","418.12","38.3","","279.30","91.72","1116.77","266","338.42","867.89","percent of total billed charges",""
"BONE PLATE 3.5X19.5MM 1 HOLE SS SPRING PELVUS","SUP-ITM-10036522","CDM","C1713","HCPCS","0278","RC","","","","both","","","1091.69","818.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","468.34","42.9","","731.00","63.70","731.00","1 through 10","338.42","867.89","percent of total billed charges",""
"BONE PLATE 3.5X19.5MM 1 HOLE SS SPRING PELVUS","SUP-ITM-10036522","CDM","C1713","HCPCS","0278","RC","","","","both","","","1091.69","818.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","468.34","42.9","","384.74","384.74","384.74","1 through 10","338.42","867.89","percent of total billed charges",""
"BONE PLATE 3.5X19.5MM 1 HOLE SS SPRING PELVUS","SUP-ITM-10036522","CDM","C1713","HCPCS","0278","RC","","","","both","","","1091.69","818.77","WELLPOINT [1015]","HB AMC WELLPOINT","805.45","73.78","","286.63","119.22","1107.45","105","338.42","867.89","percent of total billed charges",""
"BONE PLATE 3.5X19.5MM 1 HOLE SS SPRING PELVUS","SUP-ITM-10036522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1091.69","818.77","AETNA [1001]","HB AMC AETNA HMO","762.00","69.8","","675.31","184.75","1721.50","286","570.52","892.13","percent of total billed charges",""
"BONE PLATE 3.5X19.5MM 1 HOLE SS SPRING PELVUS","SUP-ITM-10036522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1091.69","818.77","AETNA [1001]","HB AMC AETNA PPO","877.72","80.4","","1261.44","103.12","1514.10","21","570.52","892.13","percent of total billed charges",""
"BONE PLATE 3.5X19.5MM 1 HOLE SS SPRING PELVUS","SUP-ITM-10036522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1091.69","818.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","877.72","80.4","","1365.00","1365.00","1365.00","1 through 10","570.52","892.13","percent of total billed charges",""
"BONE PLATE 3.5X19.5MM 1 HOLE SS SPRING PELVUS","SUP-ITM-10036522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1091.69","818.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","892.13","81.72","","5157.68","5157.68","5157.68","1 through 10","570.52","892.13","percent of total billed charges",""
"BONE PLATE 3.5X19.5MM 1 HOLE SS SPRING PELVUS","SUP-ITM-10036522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1091.69","818.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","892.13","81.72","","431.26","71.26","1459.57","88","570.52","892.13","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","4169.76","3127.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3314.96","79.5","","800.18","480.96","1887.97","195","1292.63","3314.96","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","4169.76","3127.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2222.48","53.3","","813.12","216.42","1444.50","81","1292.63","3314.96","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","4169.76","3127.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1292.63","31","","432.60","432.60","432.60","1 through 10","1292.63","3314.96","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","4169.76","3127.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1521.96","36.5","","148.37","54.89","631.39","94","1292.63","3314.96","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","4169.76","3127.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1597.02","38.3","","279.30","91.72","1116.77","266","1292.63","3314.96","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","4169.76","3127.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1788.83","42.9","","731.00","63.70","731.00","1 through 10","1292.63","3314.96","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","4169.76","3127.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1788.83","42.9","","384.74","384.74","384.74","1 through 10","1292.63","3314.96","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","4169.76","3127.32","WELLPOINT [1015]","HB AMC WELLPOINT","3076.45","73.78","","286.63","119.22","1107.45","105","1292.63","3314.96","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4169.76","3127.32","AETNA [1001]","HB AMC AETNA HMO","2910.49","69.8","","675.31","184.75","1721.50","286","2179.12","3407.53","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4169.76","3127.32","AETNA [1001]","HB AMC AETNA PPO","3352.49","80.4","","1261.44","103.12","1514.10","21","2179.12","3407.53","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4169.76","3127.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3352.49","80.4","","1365.00","1365.00","1365.00","1 through 10","2179.12","3407.53","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4169.76","3127.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3407.53","81.72","","5157.68","5157.68","5157.68","1 through 10","2179.12","3407.53","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4169.76","3127.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3407.53","81.72","","431.26","71.26","1459.57","88","2179.12","3407.53","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE RECONSTRUCTION LOCKING LOW PROFILE TITANIUM","SUP-ITM-10037388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2707.85","2030.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2152.74","79.5","","800.18","480.96","1887.97","195","839.43","2152.74","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE RECONSTRUCTION LOCKING LOW PROFILE TITANIUM","SUP-ITM-10037388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2707.85","2030.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1443.28","53.3","","813.12","216.42","1444.50","81","839.43","2152.74","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE RECONSTRUCTION LOCKING LOW PROFILE TITANIUM","SUP-ITM-10037388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2707.85","2030.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","839.43","31","","432.60","432.60","432.60","1 through 10","839.43","2152.74","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE RECONSTRUCTION LOCKING LOW PROFILE TITANIUM","SUP-ITM-10037388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2707.85","2030.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","988.37","36.5","","148.37","54.89","631.39","94","839.43","2152.74","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE RECONSTRUCTION LOCKING LOW PROFILE TITANIUM","SUP-ITM-10037388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2707.85","2030.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1037.11","38.3","","279.30","91.72","1116.77","266","839.43","2152.74","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE RECONSTRUCTION LOCKING LOW PROFILE TITANIUM","SUP-ITM-10037388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2707.85","2030.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1161.67","42.9","","731.00","63.70","731.00","1 through 10","839.43","2152.74","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE RECONSTRUCTION LOCKING LOW PROFILE TITANIUM","SUP-ITM-10037388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2707.85","2030.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1161.67","42.9","","384.74","384.74","384.74","1 through 10","839.43","2152.74","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE RECONSTRUCTION LOCKING LOW PROFILE TITANIUM","SUP-ITM-10037388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2707.85","2030.89","WELLPOINT [1015]","HB AMC WELLPOINT","1997.85","73.78","","286.63","119.22","1107.45","105","839.43","2152.74","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE RECONSTRUCTION LOCKING LOW PROFILE TITANIUM","SUP-ITM-10037388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2707.85","2030.89","AETNA [1001]","HB AMC AETNA HMO","1890.08","69.8","","675.31","184.75","1721.50","286","1415.12","2212.86","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE RECONSTRUCTION LOCKING LOW PROFILE TITANIUM","SUP-ITM-10037388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2707.85","2030.89","AETNA [1001]","HB AMC AETNA PPO","2177.11","80.4","","1261.44","103.12","1514.10","21","1415.12","2212.86","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE RECONSTRUCTION LOCKING LOW PROFILE TITANIUM","SUP-ITM-10037388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2707.85","2030.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2177.11","80.4","","1365.00","1365.00","1365.00","1 through 10","1415.12","2212.86","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE RECONSTRUCTION LOCKING LOW PROFILE TITANIUM","SUP-ITM-10037388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2707.85","2030.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2212.86","81.72","","5157.68","5157.68","5157.68","1 through 10","1415.12","2212.86","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE RECONSTRUCTION LOCKING LOW PROFILE TITANIUM","SUP-ITM-10037388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2707.85","2030.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2212.86","81.72","","431.26","71.26","1459.57","88","1415.12","2212.86","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1407.36","79.5","","800.18","480.96","1887.97","195","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","943.55","53.3","","813.12","216.42","1444.50","81","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","548.78","31","","432.60","432.60","432.60","1 through 10","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","646.15","36.5","","148.37","54.89","631.39","94","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","678.01","38.3","","279.30","91.72","1116.77","266","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","759.45","42.9","","731.00","63.70","731.00","1 through 10","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","759.45","42.9","","384.74","384.74","384.74","1 through 10","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.27","1327.70","WELLPOINT [1015]","HB AMC WELLPOINT","1306.11","73.78","","286.63","119.22","1107.45","105","548.78","1407.36","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.27","1327.70","AETNA [1001]","HB AMC AETNA HMO","1235.65","69.8","","675.31","184.75","1721.50","286","925.14","1446.66","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.27","1327.70","AETNA [1001]","HB AMC AETNA PPO","1423.30","80.4","","1261.44","103.12","1514.10","21","925.14","1446.66","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.27","1327.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1423.30","80.4","","1365.00","1365.00","1365.00","1 through 10","925.14","1446.66","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.27","1327.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1446.66","81.72","","5157.68","5157.68","5157.68","1 through 10","925.14","1446.66","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.27","1327.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1446.66","81.72","","431.26","71.26","1459.57","88","925.14","1446.66","percent of total billed charges",""
"BONE PLATE 3.5X202MM 15 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1420.74","79.5","","800.18","480.96","1887.97","195","554","1420.74","percent of total billed charges",""
"BONE PLATE 3.5X202MM 15 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","952.52","53.3","","813.12","216.42","1444.50","81","554","1420.74","percent of total billed charges",""
"BONE PLATE 3.5X202MM 15 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","554.00","31","","432.60","432.60","432.60","1 through 10","554","1420.74","percent of total billed charges",""
"BONE PLATE 3.5X202MM 15 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","652.29","36.5","","148.37","54.89","631.39","94","554","1420.74","percent of total billed charges",""
"BONE PLATE 3.5X202MM 15 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","684.46","38.3","","279.30","91.72","1116.77","266","554","1420.74","percent of total billed charges",""
"BONE PLATE 3.5X202MM 15 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","766.67","42.9","","731.00","63.70","731.00","1 through 10","554","1420.74","percent of total billed charges",""
"BONE PLATE 3.5X202MM 15 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","766.67","42.9","","384.74","384.74","384.74","1 through 10","554","1420.74","percent of total billed charges",""
"BONE PLATE 3.5X202MM 15 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040466","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","WELLPOINT [1015]","HB AMC WELLPOINT","1318.52","73.78","","286.63","119.22","1107.45","105","554","1420.74","percent of total billed charges",""
"BONE PLATE 3.5X202MM 15 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.10","1340.32","AETNA [1001]","HB AMC AETNA HMO","1247.40","69.8","","675.31","184.75","1721.50","286","933.94","1460.42","percent of total billed charges",""
"BONE PLATE 3.5X202MM 15 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.10","1340.32","AETNA [1001]","HB AMC AETNA PPO","1436.83","80.4","","1261.44","103.12","1514.10","21","933.94","1460.42","percent of total billed charges",""
"BONE PLATE 3.5X202MM 15 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.10","1340.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1436.83","80.4","","1365.00","1365.00","1365.00","1 through 10","933.94","1460.42","percent of total billed charges",""
"BONE PLATE 3.5X202MM 15 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.10","1340.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1460.42","81.72","","5157.68","5157.68","5157.68","1 through 10","933.94","1460.42","percent of total billed charges",""
"BONE PLATE 3.5X202MM 15 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.10","1340.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1460.42","81.72","","431.26","71.26","1459.57","88","933.94","1460.42","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.77","1365.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1447.51","79.5","","800.18","480.96","1887.97","195","564.44","1447.51","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.77","1365.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","970.47","53.3","","813.12","216.42","1444.50","81","564.44","1447.51","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.77","1365.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","564.44","31","","432.60","432.60","432.60","1 through 10","564.44","1447.51","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.77","1365.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","664.58","36.5","","148.37","54.89","631.39","94","564.44","1447.51","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.77","1365.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","697.35","38.3","","279.30","91.72","1116.77","266","564.44","1447.51","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.77","1365.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","781.11","42.9","","731.00","63.70","731.00","1 through 10","564.44","1447.51","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.77","1365.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","781.11","42.9","","384.74","384.74","384.74","1 through 10","564.44","1447.51","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.77","1365.58","WELLPOINT [1015]","HB AMC WELLPOINT","1343.36","73.78","","286.63","119.22","1107.45","105","564.44","1447.51","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1820.77","1365.58","AETNA [1001]","HB AMC AETNA HMO","1270.90","69.8","","675.31","184.75","1721.50","286","951.53","1487.93","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1820.77","1365.58","AETNA [1001]","HB AMC AETNA PPO","1463.90","80.4","","1261.44","103.12","1514.10","21","951.53","1487.93","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1820.77","1365.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1463.90","80.4","","1365.00","1365.00","1365.00","1 through 10","951.53","1487.93","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1820.77","1365.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1487.93","81.72","","5157.68","5157.68","5157.68","1 through 10","951.53","1487.93","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1820.77","1365.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1487.93","81.72","","431.26","71.26","1459.57","88","951.53","1487.93","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS LEFT","SUP-ITM-10021031","CDM","C1713","HCPCS","0278","RC","","","","both","","","2987.57","2240.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2375.12","79.5","","800.18","480.96","1887.97","195","926.15","2375.12","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS LEFT","SUP-ITM-10021031","CDM","C1713","HCPCS","0278","RC","","","","both","","","2987.57","2240.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1592.37","53.3","","813.12","216.42","1444.50","81","926.15","2375.12","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS LEFT","SUP-ITM-10021031","CDM","C1713","HCPCS","0278","RC","","","","both","","","2987.57","2240.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","926.15","31","","432.60","432.60","432.60","1 through 10","926.15","2375.12","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS LEFT","SUP-ITM-10021031","CDM","C1713","HCPCS","0278","RC","","","","both","","","2987.57","2240.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1090.46","36.5","","148.37","54.89","631.39","94","926.15","2375.12","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS LEFT","SUP-ITM-10021031","CDM","C1713","HCPCS","0278","RC","","","","both","","","2987.57","2240.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1144.24","38.3","","279.30","91.72","1116.77","266","926.15","2375.12","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS LEFT","SUP-ITM-10021031","CDM","C1713","HCPCS","0278","RC","","","","both","","","2987.57","2240.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1281.67","42.9","","731.00","63.70","731.00","1 through 10","926.15","2375.12","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS LEFT","SUP-ITM-10021031","CDM","C1713","HCPCS","0278","RC","","","","both","","","2987.57","2240.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1281.67","42.9","","384.74","384.74","384.74","1 through 10","926.15","2375.12","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS LEFT","SUP-ITM-10021031","CDM","C1713","HCPCS","0278","RC","","","","both","","","2987.57","2240.68","WELLPOINT [1015]","HB AMC WELLPOINT","2204.23","73.78","","286.63","119.22","1107.45","105","926.15","2375.12","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS LEFT","SUP-ITM-10021031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2987.57","2240.68","AETNA [1001]","HB AMC AETNA HMO","2085.32","69.8","","675.31","184.75","1721.50","286","1561.3","2441.44","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS LEFT","SUP-ITM-10021031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2987.57","2240.68","AETNA [1001]","HB AMC AETNA PPO","2402.01","80.4","","1261.44","103.12","1514.10","21","1561.3","2441.44","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS LEFT","SUP-ITM-10021031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2987.57","2240.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2402.01","80.4","","1365.00","1365.00","1365.00","1 through 10","1561.3","2441.44","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS LEFT","SUP-ITM-10021031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2987.57","2240.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2441.44","81.72","","5157.68","5157.68","5157.68","1 through 10","1561.3","2441.44","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS LEFT","SUP-ITM-10021031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2987.57","2240.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2441.44","81.72","","431.26","71.26","1459.57","88","1561.3","2441.44","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10019287","CDM","C1713","HCPCS","0278","RC","","","","both","","","2826.99","2120.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2247.46","79.5","","800.18","480.96","1887.97","195","876.37","2247.46","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10019287","CDM","C1713","HCPCS","0278","RC","","","","both","","","2826.99","2120.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1506.79","53.3","","813.12","216.42","1444.50","81","876.37","2247.46","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10019287","CDM","C1713","HCPCS","0278","RC","","","","both","","","2826.99","2120.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","876.37","31","","432.60","432.60","432.60","1 through 10","876.37","2247.46","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10019287","CDM","C1713","HCPCS","0278","RC","","","","both","","","2826.99","2120.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1031.85","36.5","","148.37","54.89","631.39","94","876.37","2247.46","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10019287","CDM","C1713","HCPCS","0278","RC","","","","both","","","2826.99","2120.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1082.74","38.3","","279.30","91.72","1116.77","266","876.37","2247.46","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10019287","CDM","C1713","HCPCS","0278","RC","","","","both","","","2826.99","2120.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1212.78","42.9","","731.00","63.70","731.00","1 through 10","876.37","2247.46","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10019287","CDM","C1713","HCPCS","0278","RC","","","","both","","","2826.99","2120.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1212.78","42.9","","384.74","384.74","384.74","1 through 10","876.37","2247.46","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10019287","CDM","C1713","HCPCS","0278","RC","","","","both","","","2826.99","2120.24","WELLPOINT [1015]","HB AMC WELLPOINT","2085.75","73.78","","286.63","119.22","1107.45","105","876.37","2247.46","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10019287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2826.99","2120.24","AETNA [1001]","HB AMC AETNA HMO","1973.24","69.8","","675.31","184.75","1721.50","286","1477.38","2310.22","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10019287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2826.99","2120.24","AETNA [1001]","HB AMC AETNA PPO","2272.90","80.4","","1261.44","103.12","1514.10","21","1477.38","2310.22","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10019287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2826.99","2120.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2272.90","80.4","","1365.00","1365.00","1365.00","1 through 10","1477.38","2310.22","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10019287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2826.99","2120.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2310.22","81.72","","5157.68","5157.68","5157.68","1 through 10","1477.38","2310.22","percent of total billed charges",""
"BONE PLATE 3.5X208MM DISTAL 14 HOLE BONE POSTEROLATERAL HUMERUS LCP SS RIGHT","SUP-ITM-10019287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2826.99","2120.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2310.22","81.72","","431.26","71.26","1459.57","88","1477.38","2310.22","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3543.12","2657.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2816.78","79.5","","800.18","480.96","1887.97","195","1098.37","2816.78","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3543.12","2657.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1888.48","53.3","","813.12","216.42","1444.50","81","1098.37","2816.78","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3543.12","2657.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1098.37","31","","432.60","432.60","432.60","1 through 10","1098.37","2816.78","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3543.12","2657.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1293.24","36.5","","148.37","54.89","631.39","94","1098.37","2816.78","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3543.12","2657.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1357.01","38.3","","279.30","91.72","1116.77","266","1098.37","2816.78","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3543.12","2657.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1520.00","42.9","","731.00","63.70","731.00","1 through 10","1098.37","2816.78","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3543.12","2657.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1520.00","42.9","","384.74","384.74","384.74","1 through 10","1098.37","2816.78","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3543.12","2657.34","WELLPOINT [1015]","HB AMC WELLPOINT","2614.11","73.78","","286.63","119.22","1107.45","105","1098.37","2816.78","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3543.12","2657.34","AETNA [1001]","HB AMC AETNA HMO","2473.10","69.8","","675.31","184.75","1721.50","286","1851.63","2895.44","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3543.12","2657.34","AETNA [1001]","HB AMC AETNA PPO","2848.67","80.4","","1261.44","103.12","1514.10","21","1851.63","2895.44","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3543.12","2657.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2848.67","80.4","","1365.00","1365.00","1365.00","1 through 10","1851.63","2895.44","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3543.12","2657.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2895.44","81.72","","5157.68","5157.68","5157.68","1 through 10","1851.63","2895.44","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3543.12","2657.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2895.44","81.72","","431.26","71.26","1459.57","88","1851.63","2895.44","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.38","2161.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2290.70","79.5","","800.18","480.96","1887.97","195","893.23","2290.7","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.38","2161.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1535.78","53.3","","813.12","216.42","1444.50","81","893.23","2290.7","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.38","2161.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","893.23","31","","432.60","432.60","432.60","1 through 10","893.23","2290.7","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.38","2161.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1051.70","36.5","","148.37","54.89","631.39","94","893.23","2290.7","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.38","2161.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1103.57","38.3","","279.30","91.72","1116.77","266","893.23","2290.7","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.38","2161.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1236.11","42.9","","731.00","63.70","731.00","1 through 10","893.23","2290.7","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.38","2161.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1236.11","42.9","","384.74","384.74","384.74","1 through 10","893.23","2290.7","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.38","2161.03","WELLPOINT [1015]","HB AMC WELLPOINT","2125.88","73.78","","286.63","119.22","1107.45","105","893.23","2290.7","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2881.38","2161.03","AETNA [1001]","HB AMC AETNA HMO","2011.20","69.8","","675.31","184.75","1721.50","286","1505.81","2354.66","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2881.38","2161.03","AETNA [1001]","HB AMC AETNA PPO","2316.63","80.4","","1261.44","103.12","1514.10","21","1505.81","2354.66","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2881.38","2161.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2316.63","80.4","","1365.00","1365.00","1365.00","1 through 10","1505.81","2354.66","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2881.38","2161.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2354.66","81.72","","5157.68","5157.68","5157.68","1 through 10","1505.81","2354.66","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2881.38","2161.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2354.66","81.72","","431.26","71.26","1459.57","88","1505.81","2354.66","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","both","","","2011.14","1508.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1598.86","79.5","","800.18","480.96","1887.97","195","623.45","1598.86","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","both","","","2011.14","1508.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1071.94","53.3","","813.12","216.42","1444.50","81","623.45","1598.86","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","both","","","2011.14","1508.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","623.45","31","","432.60","432.60","432.60","1 through 10","623.45","1598.86","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","both","","","2011.14","1508.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","734.07","36.5","","148.37","54.89","631.39","94","623.45","1598.86","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","both","","","2011.14","1508.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","770.27","38.3","","279.30","91.72","1116.77","266","623.45","1598.86","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","both","","","2011.14","1508.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","862.78","42.9","","731.00","63.70","731.00","1 through 10","623.45","1598.86","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","both","","","2011.14","1508.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","862.78","42.9","","384.74","384.74","384.74","1 through 10","623.45","1598.86","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","both","","","2011.14","1508.35","WELLPOINT [1015]","HB AMC WELLPOINT","1483.82","73.78","","286.63","119.22","1107.45","105","623.45","1598.86","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2011.14","1508.35","AETNA [1001]","HB AMC AETNA HMO","1403.78","69.8","","675.31","184.75","1721.50","286","1051.02","1643.5","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2011.14","1508.35","AETNA [1001]","HB AMC AETNA PPO","1616.96","80.4","","1261.44","103.12","1514.10","21","1051.02","1643.5","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2011.14","1508.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1616.96","80.4","","1365.00","1365.00","1365.00","1 through 10","1051.02","1643.5","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2011.14","1508.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1643.50","81.72","","5157.68","5157.68","5157.68","1 through 10","1051.02","1643.5","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2011.14","1508.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1643.50","81.72","","431.26","71.26","1459.57","88","1051.02","1643.5","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","both","","","1756.02","1317.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1396.04","79.5","","800.18","480.96","1887.97","195","544.37","1396.04","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","both","","","1756.02","1317.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","935.96","53.3","","813.12","216.42","1444.50","81","544.37","1396.04","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","both","","","1756.02","1317.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","544.37","31","","432.60","432.60","432.60","1 through 10","544.37","1396.04","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","both","","","1756.02","1317.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","640.95","36.5","","148.37","54.89","631.39","94","544.37","1396.04","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","both","","","1756.02","1317.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","672.56","38.3","","279.30","91.72","1116.77","266","544.37","1396.04","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","both","","","1756.02","1317.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","753.33","42.9","","731.00","63.70","731.00","1 through 10","544.37","1396.04","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","both","","","1756.02","1317.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","753.33","42.9","","384.74","384.74","384.74","1 through 10","544.37","1396.04","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","both","","","1756.02","1317.01","WELLPOINT [1015]","HB AMC WELLPOINT","1295.59","73.78","","286.63","119.22","1107.45","105","544.37","1396.04","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1756.02","1317.01","AETNA [1001]","HB AMC AETNA HMO","1225.70","69.8","","675.31","184.75","1721.50","286","917.7","1435.02","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1756.02","1317.01","AETNA [1001]","HB AMC AETNA PPO","1411.84","80.4","","1261.44","103.12","1514.10","21","917.7","1435.02","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1756.02","1317.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1411.84","80.4","","1365.00","1365.00","1365.00","1 through 10","917.7","1435.02","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1756.02","1317.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1435.02","81.72","","5157.68","5157.68","5157.68","1 through 10","917.7","1435.02","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1756.02","1317.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1435.02","81.72","","431.26","71.26","1459.57","88","917.7","1435.02","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1525.76","79.5","","800.18","480.96","1887.97","195","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1022.93","53.3","","813.12","216.42","1444.50","81","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","594.95","31","","432.60","432.60","432.60","1 through 10","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","700.50","36.5","","148.37","54.89","631.39","94","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","735.05","38.3","","279.30","91.72","1116.77","266","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","823.33","42.9","","731.00","63.70","731.00","1 through 10","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","823.33","42.9","","384.74","384.74","384.74","1 through 10","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1919.19","1439.39","WELLPOINT [1015]","HB AMC WELLPOINT","1415.98","73.78","","286.63","119.22","1107.45","105","594.95","1525.76","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1919.19","1439.39","AETNA [1001]","HB AMC AETNA HMO","1339.59","69.8","","675.31","184.75","1721.50","286","1002.97","1568.36","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1919.19","1439.39","AETNA [1001]","HB AMC AETNA PPO","1543.03","80.4","","1261.44","103.12","1514.10","21","1002.97","1568.36","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1919.19","1439.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1543.03","80.4","","1365.00","1365.00","1365.00","1 through 10","1002.97","1568.36","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1919.19","1439.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1568.36","81.72","","5157.68","5157.68","5157.68","1 through 10","1002.97","1568.36","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1919.19","1439.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1568.36","81.72","","431.26","71.26","1459.57","88","1002.97","1568.36","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2042.22","1531.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1623.56","79.5","","800.18","480.96","1887.97","195","633.09","1623.56","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2042.22","1531.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1088.50","53.3","","813.12","216.42","1444.50","81","633.09","1623.56","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2042.22","1531.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","633.09","31","","432.60","432.60","432.60","1 through 10","633.09","1623.56","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2042.22","1531.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","745.41","36.5","","148.37","54.89","631.39","94","633.09","1623.56","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2042.22","1531.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","782.17","38.3","","279.30","91.72","1116.77","266","633.09","1623.56","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2042.22","1531.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","876.11","42.9","","731.00","63.70","731.00","1 through 10","633.09","1623.56","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2042.22","1531.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","876.11","42.9","","384.74","384.74","384.74","1 through 10","633.09","1623.56","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2042.22","1531.66","WELLPOINT [1015]","HB AMC WELLPOINT","1506.75","73.78","","286.63","119.22","1107.45","105","633.09","1623.56","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2042.22","1531.66","AETNA [1001]","HB AMC AETNA HMO","1425.47","69.8","","675.31","184.75","1721.50","286","1067.26","1668.9","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2042.22","1531.66","AETNA [1001]","HB AMC AETNA PPO","1641.94","80.4","","1261.44","103.12","1514.10","21","1067.26","1668.9","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2042.22","1531.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1641.94","80.4","","1365.00","1365.00","1365.00","1 through 10","1067.26","1668.9","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2042.22","1531.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1668.90","81.72","","5157.68","5157.68","5157.68","1 through 10","1067.26","1668.9","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2042.22","1531.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1668.90","81.72","","431.26","71.26","1459.57","88","1067.26","1668.9","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1939.63","79.5","","800.18","480.96","1887.97","195","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1300.40","53.3","","813.12","216.42","1444.50","81","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","756.33","31","","432.60","432.60","432.60","1 through 10","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","890.52","36.5","","148.37","54.89","631.39","94","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","934.44","38.3","","279.30","91.72","1116.77","266","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1046.67","42.9","","731.00","63.70","731.00","1 through 10","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1046.67","42.9","","384.74","384.74","384.74","1 through 10","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","WELLPOINT [1015]","HB AMC WELLPOINT","1800.07","73.78","","286.63","119.22","1107.45","105","756.33","1939.63","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","AETNA [1001]","HB AMC AETNA HMO","1702.97","69.8","","675.31","184.75","1721.50","286","1275.03","1993.79","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","AETNA [1001]","HB AMC AETNA PPO","1961.58","80.4","","1261.44","103.12","1514.10","21","1275.03","1993.79","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1961.58","80.4","","1365.00","1365.00","1365.00","1 through 10","1275.03","1993.79","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1993.79","81.72","","5157.68","5157.68","5157.68","1 through 10","1275.03","1993.79","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1993.79","81.72","","431.26","71.26","1459.57","88","1275.03","1993.79","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.99","1478.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1566.94","79.5","","800.18","480.96","1887.97","195","611.01","1566.94","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.99","1478.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1050.54","53.3","","813.12","216.42","1444.50","81","611.01","1566.94","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.99","1478.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","611.01","31","","432.60","432.60","432.60","1 through 10","611.01","1566.94","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.99","1478.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","719.41","36.5","","148.37","54.89","631.39","94","611.01","1566.94","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.99","1478.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","754.89","38.3","","279.30","91.72","1116.77","266","611.01","1566.94","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.99","1478.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","845.55","42.9","","731.00","63.70","731.00","1 through 10","611.01","1566.94","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.99","1478.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","845.55","42.9","","384.74","384.74","384.74","1 through 10","611.01","1566.94","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.99","1478.24","WELLPOINT [1015]","HB AMC WELLPOINT","1454.20","73.78","","286.63","119.22","1107.45","105","611.01","1566.94","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1970.99","1478.24","AETNA [1001]","HB AMC AETNA HMO","1375.75","69.8","","675.31","184.75","1721.50","286","1030.04","1610.69","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1970.99","1478.24","AETNA [1001]","HB AMC AETNA PPO","1584.68","80.4","","1261.44","103.12","1514.10","21","1030.04","1610.69","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1970.99","1478.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1584.68","80.4","","1365.00","1365.00","1365.00","1 through 10","1030.04","1610.69","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1970.99","1478.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1610.69","81.72","","5157.68","5157.68","5157.68","1 through 10","1030.04","1610.69","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1970.99","1478.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1610.69","81.72","","431.26","71.26","1459.57","88","1030.04","1610.69","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","both","","","2012.43","1509.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1599.88","79.5","","800.18","480.96","1887.97","195","623.85","1599.88","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","both","","","2012.43","1509.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1072.63","53.3","","813.12","216.42","1444.50","81","623.85","1599.88","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","both","","","2012.43","1509.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","623.85","31","","432.60","432.60","432.60","1 through 10","623.85","1599.88","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","both","","","2012.43","1509.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","734.54","36.5","","148.37","54.89","631.39","94","623.85","1599.88","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","both","","","2012.43","1509.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","770.76","38.3","","279.30","91.72","1116.77","266","623.85","1599.88","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","both","","","2012.43","1509.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","863.33","42.9","","731.00","63.70","731.00","1 through 10","623.85","1599.88","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","both","","","2012.43","1509.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","863.33","42.9","","384.74","384.74","384.74","1 through 10","623.85","1599.88","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","both","","","2012.43","1509.32","WELLPOINT [1015]","HB AMC WELLPOINT","1484.77","73.78","","286.63","119.22","1107.45","105","623.85","1599.88","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2012.43","1509.32","AETNA [1001]","HB AMC AETNA HMO","1404.68","69.8","","675.31","184.75","1721.50","286","1051.7","1644.56","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2012.43","1509.32","AETNA [1001]","HB AMC AETNA PPO","1617.99","80.4","","1261.44","103.12","1514.10","21","1051.7","1644.56","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2012.43","1509.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1617.99","80.4","","1365.00","1365.00","1365.00","1 through 10","1051.7","1644.56","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2012.43","1509.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1644.56","81.72","","5157.68","5157.68","5157.68","1 through 10","1051.7","1644.56","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2012.43","1509.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1644.56","81.72","","431.26","71.26","1459.57","88","1051.7","1644.56","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2264.96","1698.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1800.64","79.5","","800.18","480.96","1887.97","195","702.14","1800.64","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2264.96","1698.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1207.22","53.3","","813.12","216.42","1444.50","81","702.14","1800.64","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2264.96","1698.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","702.14","31","","432.60","432.60","432.60","1 through 10","702.14","1800.64","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2264.96","1698.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","826.71","36.5","","148.37","54.89","631.39","94","702.14","1800.64","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2264.96","1698.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","867.48","38.3","","279.30","91.72","1116.77","266","702.14","1800.64","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2264.96","1698.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","971.67","42.9","","731.00","63.70","731.00","1 through 10","702.14","1800.64","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2264.96","1698.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","971.67","42.9","","384.74","384.74","384.74","1 through 10","702.14","1800.64","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2264.96","1698.72","WELLPOINT [1015]","HB AMC WELLPOINT","1671.09","73.78","","286.63","119.22","1107.45","105","702.14","1800.64","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2264.96","1698.72","AETNA [1001]","HB AMC AETNA HMO","1580.94","69.8","","675.31","184.75","1721.50","286","1183.67","1850.93","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2264.96","1698.72","AETNA [1001]","HB AMC AETNA PPO","1821.03","80.4","","1261.44","103.12","1514.10","21","1183.67","1850.93","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2264.96","1698.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1821.03","80.4","","1365.00","1365.00","1365.00","1 through 10","1183.67","1850.93","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2264.96","1698.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1850.93","81.72","","5157.68","5157.68","5157.68","1 through 10","1183.67","1850.93","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2264.96","1698.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1850.93","81.72","","431.26","71.26","1459.57","88","1183.67","1850.93","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","4466.00","3349.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3550.47","79.5","","800.18","480.96","1887.97","195","1384.46","3550.47","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","4466.00","3349.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2380.38","53.3","","813.12","216.42","1444.50","81","1384.46","3550.47","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","4466.00","3349.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1384.46","31","","432.60","432.60","432.60","1 through 10","1384.46","3550.47","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","4466.00","3349.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1630.09","36.5","","148.37","54.89","631.39","94","1384.46","3550.47","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","4466.00","3349.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1710.48","38.3","","279.30","91.72","1116.77","266","1384.46","3550.47","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","4466.00","3349.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1915.91","42.9","","731.00","63.70","731.00","1 through 10","1384.46","3550.47","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","4466.00","3349.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1915.91","42.9","","384.74","384.74","384.74","1 through 10","1384.46","3550.47","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","4466.00","3349.50","WELLPOINT [1015]","HB AMC WELLPOINT","3295.01","73.78","","286.63","119.22","1107.45","105","1384.46","3550.47","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4466.00","3349.50","AETNA [1001]","HB AMC AETNA HMO","3117.27","69.8","","675.31","184.75","1721.50","286","2333.93","3649.62","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4466.00","3349.50","AETNA [1001]","HB AMC AETNA PPO","3590.66","80.4","","1261.44","103.12","1514.10","21","2333.93","3649.62","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4466.00","3349.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3590.66","80.4","","1365.00","1365.00","1365.00","1 through 10","2333.93","3649.62","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4466.00","3349.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3649.62","81.72","","5157.68","5157.68","5157.68","1 through 10","2333.93","3649.62","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4466.00","3349.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3649.62","81.72","","431.26","71.26","1459.57","88","2333.93","3649.62","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","561.10","79.5","","800.18","480.96","1887.97","195","218.79","561.1","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","376.18","53.3","","813.12","216.42","1444.50","81","218.79","561.1","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","218.79","31","","432.60","432.60","432.60","1 through 10","218.79","561.1","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","257.61","36.5","","148.37","54.89","631.39","94","218.79","561.1","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","270.31","38.3","","279.30","91.72","1116.77","266","218.79","561.1","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","302.78","42.9","","731.00","63.70","731.00","1 through 10","218.79","561.1","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","302.78","42.9","","384.74","384.74","384.74","1 through 10","218.79","561.1","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","WELLPOINT [1015]","HB AMC WELLPOINT","520.72","73.78","","286.63","119.22","1107.45","105","218.79","561.1","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.78","529.33","AETNA [1001]","HB AMC AETNA HMO","492.63","69.8","","675.31","184.75","1721.50","286","368.84","576.76","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.78","529.33","AETNA [1001]","HB AMC AETNA PPO","567.45","80.4","","1261.44","103.12","1514.10","21","368.84","576.76","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.78","529.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","567.45","80.4","","1365.00","1365.00","1365.00","1 through 10","368.84","576.76","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.78","529.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","576.76","81.72","","5157.68","5157.68","5157.68","1 through 10","368.84","576.76","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.78","529.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","576.76","81.72","","431.26","71.26","1459.57","88","368.84","576.76","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.60","271.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","288.27","79.5","","800.18","480.96","1887.97","195","112.41","288.27","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.60","271.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","193.27","53.3","","813.12","216.42","1444.50","81","112.41","288.27","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.60","271.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","112.41","31","","432.60","432.60","432.60","1 through 10","112.41","288.27","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.60","271.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","132.35","36.5","","148.37","54.89","631.39","94","112.41","288.27","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.60","271.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","138.88","38.3","","279.30","91.72","1116.77","266","112.41","288.27","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.60","271.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.56","42.9","","731.00","63.70","731.00","1 through 10","112.41","288.27","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.60","271.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.56","42.9","","384.74","384.74","384.74","1 through 10","112.41","288.27","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.60","271.95","WELLPOINT [1015]","HB AMC WELLPOINT","267.53","73.78","","286.63","119.22","1107.45","105","112.41","288.27","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.60","271.95","AETNA [1001]","HB AMC AETNA HMO","253.09","69.8","","675.31","184.75","1721.50","286","189.49","296.32","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.60","271.95","AETNA [1001]","HB AMC AETNA PPO","291.53","80.4","","1261.44","103.12","1514.10","21","189.49","296.32","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.60","271.95","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","291.53","80.4","","1365.00","1365.00","1365.00","1 through 10","189.49","296.32","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.60","271.95","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","296.32","81.72","","5157.68","5157.68","5157.68","1 through 10","189.49","296.32","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.60","271.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","296.32","81.72","","431.26","71.26","1459.57","88","189.49","296.32","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.26","1640.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1738.87","79.5","","800.18","480.96","1887.97","195","678.05","1738.87","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.26","1640.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1165.81","53.3","","813.12","216.42","1444.50","81","678.05","1738.87","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.26","1640.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","678.05","31","","432.60","432.60","432.60","1 through 10","678.05","1738.87","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.26","1640.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","798.35","36.5","","148.37","54.89","631.39","94","678.05","1738.87","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.26","1640.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","837.72","38.3","","279.30","91.72","1116.77","266","678.05","1738.87","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.26","1640.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","938.33","42.9","","731.00","63.70","731.00","1 through 10","678.05","1738.87","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.26","1640.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","938.33","42.9","","384.74","384.74","384.74","1 through 10","678.05","1738.87","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.26","1640.44","WELLPOINT [1015]","HB AMC WELLPOINT","1613.76","73.78","","286.63","119.22","1107.45","105","678.05","1738.87","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2187.26","1640.44","AETNA [1001]","HB AMC AETNA HMO","1526.71","69.8","","675.31","184.75","1721.50","286","1143.06","1787.43","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2187.26","1640.44","AETNA [1001]","HB AMC AETNA PPO","1758.56","80.4","","1261.44","103.12","1514.10","21","1143.06","1787.43","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2187.26","1640.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1758.56","80.4","","1365.00","1365.00","1365.00","1 through 10","1143.06","1787.43","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2187.26","1640.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1787.43","81.72","","5157.68","5157.68","5157.68","1 through 10","1143.06","1787.43","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2187.26","1640.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1787.43","81.72","","431.26","71.26","1459.57","88","1143.06","1787.43","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2191.14","1643.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1741.96","79.5","","800.18","480.96","1887.97","195","679.25","1741.96","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2191.14","1643.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1167.88","53.3","","813.12","216.42","1444.50","81","679.25","1741.96","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2191.14","1643.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","679.25","31","","432.60","432.60","432.60","1 through 10","679.25","1741.96","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2191.14","1643.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","799.77","36.5","","148.37","54.89","631.39","94","679.25","1741.96","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2191.14","1643.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","839.21","38.3","","279.30","91.72","1116.77","266","679.25","1741.96","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2191.14","1643.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","940.00","42.9","","731.00","63.70","731.00","1 through 10","679.25","1741.96","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2191.14","1643.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","940.00","42.9","","384.74","384.74","384.74","1 through 10","679.25","1741.96","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2191.14","1643.35","WELLPOINT [1015]","HB AMC WELLPOINT","1616.62","73.78","","286.63","119.22","1107.45","105","679.25","1741.96","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2191.14","1643.35","AETNA [1001]","HB AMC AETNA HMO","1529.42","69.8","","675.31","184.75","1721.50","286","1145.09","1790.6","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2191.14","1643.35","AETNA [1001]","HB AMC AETNA PPO","1761.68","80.4","","1261.44","103.12","1514.10","21","1145.09","1790.6","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2191.14","1643.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1761.68","80.4","","1365.00","1365.00","1365.00","1 through 10","1145.09","1790.6","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2191.14","1643.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1790.60","81.72","","5157.68","5157.68","5157.68","1 through 10","1145.09","1790.6","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2191.14","1643.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1790.60","81.72","","431.26","71.26","1459.57","88","1145.09","1790.6","percent of total billed charges",""
"BONE PLATE 3.5X334MM 20 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3622.12","2716.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2879.59","79.5","","800.18","480.96","1887.97","195","1122.86","2879.59","percent of total billed charges",""
"BONE PLATE 3.5X334MM 20 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3622.12","2716.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1930.59","53.3","","813.12","216.42","1444.50","81","1122.86","2879.59","percent of total billed charges",""
"BONE PLATE 3.5X334MM 20 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3622.12","2716.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1122.86","31","","432.60","432.60","432.60","1 through 10","1122.86","2879.59","percent of total billed charges",""
"BONE PLATE 3.5X334MM 20 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3622.12","2716.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1322.07","36.5","","148.37","54.89","631.39","94","1122.86","2879.59","percent of total billed charges",""
"BONE PLATE 3.5X334MM 20 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3622.12","2716.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1387.27","38.3","","279.30","91.72","1116.77","266","1122.86","2879.59","percent of total billed charges",""
"BONE PLATE 3.5X334MM 20 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3622.12","2716.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1553.89","42.9","","731.00","63.70","731.00","1 through 10","1122.86","2879.59","percent of total billed charges",""
"BONE PLATE 3.5X334MM 20 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3622.12","2716.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1553.89","42.9","","384.74","384.74","384.74","1 through 10","1122.86","2879.59","percent of total billed charges",""
"BONE PLATE 3.5X334MM 20 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3622.12","2716.59","WELLPOINT [1015]","HB AMC WELLPOINT","2672.40","73.78","","286.63","119.22","1107.45","105","1122.86","2879.59","percent of total billed charges",""
"BONE PLATE 3.5X334MM 20 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3622.12","2716.59","AETNA [1001]","HB AMC AETNA HMO","2528.24","69.8","","675.31","184.75","1721.50","286","1892.92","2960","percent of total billed charges",""
"BONE PLATE 3.5X334MM 20 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3622.12","2716.59","AETNA [1001]","HB AMC AETNA PPO","2912.18","80.4","","1261.44","103.12","1514.10","21","1892.92","2960","percent of total billed charges",""
"BONE PLATE 3.5X334MM 20 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3622.12","2716.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2912.18","80.4","","1365.00","1365.00","1365.00","1 through 10","1892.92","2960","percent of total billed charges",""
"BONE PLATE 3.5X334MM 20 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3622.12","2716.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2960.00","81.72","","5157.68","5157.68","5157.68","1 through 10","1892.92","2960","percent of total billed charges",""
"BONE PLATE 3.5X334MM 20 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3622.12","2716.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2960.00","81.72","","431.26","71.26","1459.57","88","1892.92","2960","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.67","278.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","295.48","79.5","","800.18","480.96","1887.97","195","115.22","295.48","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.67","278.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.10","53.3","","813.12","216.42","1444.50","81","115.22","295.48","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.67","278.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.22","31","","432.60","432.60","432.60","1 through 10","115.22","295.48","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.67","278.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","135.66","36.5","","148.37","54.89","631.39","94","115.22","295.48","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.67","278.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.35","38.3","","279.30","91.72","1116.77","266","115.22","295.48","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.67","278.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.45","42.9","","731.00","63.70","731.00","1 through 10","115.22","295.48","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.67","278.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.45","42.9","","384.74","384.74","384.74","1 through 10","115.22","295.48","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.67","278.75","WELLPOINT [1015]","HB AMC WELLPOINT","274.22","73.78","","286.63","119.22","1107.45","105","115.22","295.48","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.67","278.75","AETNA [1001]","HB AMC AETNA HMO","259.43","69.8","","675.31","184.75","1721.50","286","194.23","303.73","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.67","278.75","AETNA [1001]","HB AMC AETNA PPO","298.82","80.4","","1261.44","103.12","1514.10","21","194.23","303.73","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.67","278.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","298.82","80.4","","1365.00","1365.00","1365.00","1 through 10","194.23","303.73","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.67","278.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","303.73","81.72","","5157.68","5157.68","5157.68","1 through 10","194.23","303.73","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.67","278.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","303.73","81.72","","431.26","71.26","1459.57","88","194.23","303.73","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.27","550.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","583.74","79.5","","800.18","480.96","1887.97","195","227.62","583.74","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.27","550.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","391.37","53.3","","813.12","216.42","1444.50","81","227.62","583.74","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.27","550.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","227.62","31","","432.60","432.60","432.60","1 through 10","227.62","583.74","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.27","550.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","268.01","36.5","","148.37","54.89","631.39","94","227.62","583.74","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.27","550.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","281.23","38.3","","279.30","91.72","1116.77","266","227.62","583.74","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.27","550.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.00","42.9","","731.00","63.70","731.00","1 through 10","227.62","583.74","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.27","550.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.00","42.9","","384.74","384.74","384.74","1 through 10","227.62","583.74","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.27","550.70","WELLPOINT [1015]","HB AMC WELLPOINT","541.74","73.78","","286.63","119.22","1107.45","105","227.62","583.74","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","734.27","550.70","AETNA [1001]","HB AMC AETNA HMO","512.52","69.8","","675.31","184.75","1721.50","286","383.73","600.05","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","734.27","550.70","AETNA [1001]","HB AMC AETNA PPO","590.35","80.4","","1261.44","103.12","1514.10","21","383.73","600.05","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","734.27","550.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","590.35","80.4","","1365.00","1365.00","1365.00","1 through 10","383.73","600.05","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","734.27","550.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","600.05","81.72","","5157.68","5157.68","5157.68","1 through 10","383.73","600.05","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","734.27","550.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","600.05","81.72","","431.26","71.26","1459.57","88","383.73","600.05","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.52","831.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","881.27","79.5","","800.18","480.96","1887.97","195","343.64","881.27","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.52","831.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","590.84","53.3","","813.12","216.42","1444.50","81","343.64","881.27","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.52","831.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","343.64","31","","432.60","432.60","432.60","1 through 10","343.64","881.27","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.52","831.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","404.61","36.5","","148.37","54.89","631.39","94","343.64","881.27","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.52","831.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","424.56","38.3","","279.30","91.72","1116.77","266","343.64","881.27","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.52","831.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","475.56","42.9","","731.00","63.70","731.00","1 through 10","343.64","881.27","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.52","831.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","475.56","42.9","","384.74","384.74","384.74","1 through 10","343.64","881.27","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1108.52","831.39","WELLPOINT [1015]","HB AMC WELLPOINT","817.87","73.78","","286.63","119.22","1107.45","105","343.64","881.27","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1108.52","831.39","AETNA [1001]","HB AMC AETNA HMO","773.75","69.8","","675.31","184.75","1721.50","286","579.31","905.88","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1108.52","831.39","AETNA [1001]","HB AMC AETNA PPO","891.25","80.4","","1261.44","103.12","1514.10","21","579.31","905.88","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1108.52","831.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","891.25","80.4","","1365.00","1365.00","1365.00","1 through 10","579.31","905.88","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1108.52","831.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","905.88","81.72","","5157.68","5157.68","5157.68","1 through 10","579.31","905.88","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1108.52","831.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","905.88","81.72","","431.26","71.26","1459.57","88","579.31","905.88","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.94","322.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","341.80","79.5","","800.18","480.96","1887.97","195","133.28","341.8","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.94","322.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","229.16","53.3","","813.12","216.42","1444.50","81","133.28","341.8","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.94","322.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","133.28","31","","432.60","432.60","432.60","1 through 10","133.28","341.8","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.94","322.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","156.93","36.5","","148.37","54.89","631.39","94","133.28","341.8","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.94","322.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","164.67","38.3","","279.30","91.72","1116.77","266","133.28","341.8","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.94","322.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","184.44","42.9","","731.00","63.70","731.00","1 through 10","133.28","341.8","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.94","322.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","184.44","42.9","","384.74","384.74","384.74","1 through 10","133.28","341.8","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.94","322.45","WELLPOINT [1015]","HB AMC WELLPOINT","317.21","73.78","","286.63","119.22","1107.45","105","133.28","341.8","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.94","322.45","AETNA [1001]","HB AMC AETNA HMO","300.10","69.8","","675.31","184.75","1721.50","286","224.69","351.35","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.94","322.45","AETNA [1001]","HB AMC AETNA PPO","345.67","80.4","","1261.44","103.12","1514.10","21","224.69","351.35","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.94","322.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","345.67","80.4","","1365.00","1365.00","1365.00","1 through 10","224.69","351.35","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.94","322.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","351.35","81.72","","5157.68","5157.68","5157.68","1 through 10","224.69","351.35","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.94","322.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","351.35","81.72","","431.26","71.26","1459.57","88","224.69","351.35","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","792.54","594.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","630.07","79.5","","800.18","480.96","1887.97","195","245.69","630.07","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","792.54","594.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","422.42","53.3","","813.12","216.42","1444.50","81","245.69","630.07","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","792.54","594.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","245.69","31","","432.60","432.60","432.60","1 through 10","245.69","630.07","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","792.54","594.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","289.28","36.5","","148.37","54.89","631.39","94","245.69","630.07","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","792.54","594.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","303.54","38.3","","279.30","91.72","1116.77","266","245.69","630.07","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","792.54","594.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.00","42.9","","731.00","63.70","731.00","1 through 10","245.69","630.07","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","792.54","594.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.00","42.9","","384.74","384.74","384.74","1 through 10","245.69","630.07","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","792.54","594.40","WELLPOINT [1015]","HB AMC WELLPOINT","584.74","73.78","","286.63","119.22","1107.45","105","245.69","630.07","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","792.54","594.40","AETNA [1001]","HB AMC AETNA HMO","553.19","69.8","","675.31","184.75","1721.50","286","414.18","647.66","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","792.54","594.40","AETNA [1001]","HB AMC AETNA PPO","637.20","80.4","","1261.44","103.12","1514.10","21","414.18","647.66","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","792.54","594.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","637.20","80.4","","1365.00","1365.00","1365.00","1 through 10","414.18","647.66","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","792.54","594.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","647.66","81.72","","5157.68","5157.68","5157.68","1 through 10","414.18","647.66","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","792.54","594.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","647.66","81.72","","431.26","71.26","1459.57","88","414.18","647.66","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.35","574.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","608.45","79.5","","800.18","480.96","1887.97","195","237.26","608.45","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.35","574.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","407.93","53.3","","813.12","216.42","1444.50","81","237.26","608.45","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.35","574.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","237.26","31","","432.60","432.60","432.60","1 through 10","237.26","608.45","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.35","574.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","279.35","36.5","","148.37","54.89","631.39","94","237.26","608.45","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.35","574.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","293.13","38.3","","279.30","91.72","1116.77","266","237.26","608.45","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.35","574.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","328.34","42.9","","731.00","63.70","731.00","1 through 10","237.26","608.45","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.35","574.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","328.34","42.9","","384.74","384.74","384.74","1 through 10","237.26","608.45","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.35","574.01","WELLPOINT [1015]","HB AMC WELLPOINT","564.68","73.78","","286.63","119.22","1107.45","105","237.26","608.45","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.35","574.01","AETNA [1001]","HB AMC AETNA HMO","534.21","69.8","","675.31","184.75","1721.50","286","399.97","625.44","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.35","574.01","AETNA [1001]","HB AMC AETNA PPO","615.34","80.4","","1261.44","103.12","1514.10","21","399.97","625.44","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.35","574.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","615.34","80.4","","1365.00","1365.00","1365.00","1 through 10","399.97","625.44","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.35","574.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","625.44","81.72","","5157.68","5157.68","5157.68","1 through 10","399.97","625.44","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.35","574.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","625.44","81.72","","431.26","71.26","1459.57","88","399.97","625.44","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","890.96","668.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","708.31","79.5","","800.18","480.96","1887.97","195","276.2","708.31","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","890.96","668.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","474.88","53.3","","813.12","216.42","1444.50","81","276.2","708.31","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","890.96","668.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","276.20","31","","432.60","432.60","432.60","1 through 10","276.2","708.31","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","890.96","668.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","325.20","36.5","","148.37","54.89","631.39","94","276.2","708.31","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","890.96","668.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","341.24","38.3","","279.30","91.72","1116.77","266","276.2","708.31","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","890.96","668.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","382.22","42.9","","731.00","63.70","731.00","1 through 10","276.2","708.31","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","890.96","668.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","382.22","42.9","","384.74","384.74","384.74","1 through 10","276.2","708.31","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","890.96","668.22","WELLPOINT [1015]","HB AMC WELLPOINT","657.35","73.78","","286.63","119.22","1107.45","105","276.2","708.31","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","890.96","668.22","AETNA [1001]","HB AMC AETNA HMO","621.89","69.8","","675.31","184.75","1721.50","286","465.62","728.09","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","890.96","668.22","AETNA [1001]","HB AMC AETNA PPO","716.33","80.4","","1261.44","103.12","1514.10","21","465.62","728.09","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","890.96","668.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","716.33","80.4","","1365.00","1365.00","1365.00","1 through 10","465.62","728.09","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","890.96","668.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","728.09","81.72","","5157.68","5157.68","5157.68","1 through 10","465.62","728.09","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","890.96","668.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","728.09","81.72","","431.26","71.26","1459.57","88","465.62","728.09","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.42","656.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.96","79.5","","800.18","480.96","1887.97","195","271.38","695.96","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.42","656.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.60","53.3","","813.12","216.42","1444.50","81","271.38","695.96","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.42","656.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.38","31","","432.60","432.60","432.60","1 through 10","271.38","695.96","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.42","656.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.53","36.5","","148.37","54.89","631.39","94","271.38","695.96","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.42","656.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.29","38.3","","279.30","91.72","1116.77","266","271.38","695.96","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.42","656.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.56","42.9","","731.00","63.70","731.00","1 through 10","271.38","695.96","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.42","656.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.56","42.9","","384.74","384.74","384.74","1 through 10","271.38","695.96","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.42","656.56","WELLPOINT [1015]","HB AMC WELLPOINT","645.88","73.78","","286.63","119.22","1107.45","105","271.38","695.96","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.42","656.56","AETNA [1001]","HB AMC AETNA HMO","611.04","69.8","","675.31","184.75","1721.50","286","457.49","715.39","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.42","656.56","AETNA [1001]","HB AMC AETNA PPO","703.84","80.4","","1261.44","103.12","1514.10","21","457.49","715.39","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.42","656.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.84","80.4","","1365.00","1365.00","1365.00","1 through 10","457.49","715.39","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.42","656.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","715.39","81.72","","5157.68","5157.68","5157.68","1 through 10","457.49","715.39","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.42","656.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.39","81.72","","431.26","71.26","1459.57","88","457.49","715.39","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","651.69","79.5","","800.18","480.96","1887.97","195","254.12","651.69","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","436.92","53.3","","813.12","216.42","1444.50","81","254.12","651.69","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","254.12","31","","432.60","432.60","432.60","1 through 10","254.12","651.69","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","299.21","36.5","","148.37","54.89","631.39","94","254.12","651.69","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","313.96","38.3","","279.30","91.72","1116.77","266","254.12","651.69","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.67","42.9","","731.00","63.70","731.00","1 through 10","254.12","651.69","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.67","42.9","","384.74","384.74","384.74","1 through 10","254.12","651.69","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","WELLPOINT [1015]","HB AMC WELLPOINT","604.80","73.78","","286.63","119.22","1107.45","105","254.12","651.69","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.74","614.80","AETNA [1001]","HB AMC AETNA HMO","572.18","69.8","","675.31","184.75","1721.50","286","428.4","669.89","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.74","614.80","AETNA [1001]","HB AMC AETNA PPO","659.07","80.4","","1261.44","103.12","1514.10","21","428.4","669.89","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.74","614.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","659.07","80.4","","1365.00","1365.00","1365.00","1 through 10","428.4","669.89","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.74","614.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","669.89","81.72","","5157.68","5157.68","5157.68","1 through 10","428.4","669.89","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.74","614.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","669.89","81.72","","431.26","71.26","1459.57","88","428.4","669.89","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","741.26","79.5","","800.18","480.96","1887.97","195","289.04","741.26","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","496.97","53.3","","813.12","216.42","1444.50","81","289.04","741.26","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","289.04","31","","432.60","432.60","432.60","1 through 10","289.04","741.26","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","340.33","36.5","","148.37","54.89","631.39","94","289.04","741.26","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","357.11","38.3","","279.30","91.72","1116.77","266","289.04","741.26","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.00","42.9","","731.00","63.70","731.00","1 through 10","289.04","741.26","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.00","42.9","","384.74","384.74","384.74","1 through 10","289.04","741.26","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","WELLPOINT [1015]","HB AMC WELLPOINT","687.92","73.78","","286.63","119.22","1107.45","105","289.04","741.26","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.40","699.30","AETNA [1001]","HB AMC AETNA HMO","650.82","69.8","","675.31","184.75","1721.50","286","487.27","761.96","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.40","699.30","AETNA [1001]","HB AMC AETNA PPO","749.65","80.4","","1261.44","103.12","1514.10","21","487.27","761.96","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.40","699.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","749.65","80.4","","1365.00","1365.00","1365.00","1 through 10","487.27","761.96","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.40","699.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","761.96","81.72","","5157.68","5157.68","5157.68","1 through 10","487.27","761.96","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.40","699.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","761.96","81.72","","431.26","71.26","1459.57","88","487.27","761.96","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","714.49","79.5","","800.18","480.96","1887.97","195","278.61","714.49","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","479.02","53.3","","813.12","216.42","1444.50","81","278.61","714.49","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","278.61","31","","432.60","432.60","432.60","1 through 10","278.61","714.49","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","328.04","36.5","","148.37","54.89","631.39","94","278.61","714.49","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","344.21","38.3","","279.30","91.72","1116.77","266","278.61","714.49","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.56","42.9","","731.00","63.70","731.00","1 through 10","278.61","714.49","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.56","42.9","","384.74","384.74","384.74","1 through 10","278.61","714.49","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","WELLPOINT [1015]","HB AMC WELLPOINT","663.08","73.78","","286.63","119.22","1107.45","105","278.61","714.49","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","AETNA [1001]","HB AMC AETNA HMO","627.31","69.8","","675.31","184.75","1721.50","286","469.68","734.44","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","AETNA [1001]","HB AMC AETNA PPO","722.58","80.4","","1261.44","103.12","1514.10","21","469.68","734.44","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","722.58","80.4","","1365.00","1365.00","1365.00","1 through 10","469.68","734.44","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","734.44","81.72","","5157.68","5157.68","5157.68","1 through 10","469.68","734.44","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","734.44","81.72","","431.26","71.26","1459.57","88","469.68","734.44","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","1085.21","813.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","862.74","79.5","","800.18","480.96","1887.97","195","336.42","862.74","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","1085.21","813.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","578.42","53.3","","813.12","216.42","1444.50","81","336.42","862.74","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","1085.21","813.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","336.42","31","","432.60","432.60","432.60","1 through 10","336.42","862.74","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","1085.21","813.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","396.10","36.5","","148.37","54.89","631.39","94","336.42","862.74","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","1085.21","813.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","415.64","38.3","","279.30","91.72","1116.77","266","336.42","862.74","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","1085.21","813.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","465.56","42.9","","731.00","63.70","731.00","1 through 10","336.42","862.74","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","1085.21","813.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","465.56","42.9","","384.74","384.74","384.74","1 through 10","336.42","862.74","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","1085.21","813.91","WELLPOINT [1015]","HB AMC WELLPOINT","800.67","73.78","","286.63","119.22","1107.45","105","336.42","862.74","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1085.21","813.91","AETNA [1001]","HB AMC AETNA HMO","757.48","69.8","","675.31","184.75","1721.50","286","567.13","886.83","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1085.21","813.91","AETNA [1001]","HB AMC AETNA PPO","872.51","80.4","","1261.44","103.12","1514.10","21","567.13","886.83","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1085.21","813.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","872.51","80.4","","1365.00","1365.00","1365.00","1 through 10","567.13","886.83","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1085.21","813.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","886.83","81.72","","5157.68","5157.68","5157.68","1 through 10","567.13","886.83","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1085.21","813.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","886.83","81.72","","431.26","71.26","1459.57","88","567.13","886.83","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.28","567.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","601.24","79.5","","800.18","480.96","1887.97","195","234.45","601.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.28","567.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","403.10","53.3","","813.12","216.42","1444.50","81","234.45","601.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.28","567.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","234.45","31","","432.60","432.60","432.60","1 through 10","234.45","601.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.28","567.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","276.04","36.5","","148.37","54.89","631.39","94","234.45","601.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.28","567.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","289.66","38.3","","279.30","91.72","1116.77","266","234.45","601.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.28","567.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","324.44","42.9","","731.00","63.70","731.00","1 through 10","234.45","601.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.28","567.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","324.44","42.9","","384.74","384.74","384.74","1 through 10","234.45","601.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","756.28","567.21","WELLPOINT [1015]","HB AMC WELLPOINT","557.98","73.78","","286.63","119.22","1107.45","105","234.45","601.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","756.28","567.21","AETNA [1001]","HB AMC AETNA HMO","527.88","69.8","","675.31","184.75","1721.50","286","395.23","618.03","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","756.28","567.21","AETNA [1001]","HB AMC AETNA PPO","608.05","80.4","","1261.44","103.12","1514.10","21","395.23","618.03","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","756.28","567.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","608.05","80.4","","1365.00","1365.00","1365.00","1 through 10","395.23","618.03","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","756.28","567.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","618.03","81.72","","5157.68","5157.68","5157.68","1 through 10","395.23","618.03","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","756.28","567.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","618.03","81.72","","431.26","71.26","1459.57","88","395.23","618.03","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040456","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.67","608.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","644.48","79.5","","800.18","480.96","1887.97","195","251.31","644.48","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040456","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.67","608.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","432.09","53.3","","813.12","216.42","1444.50","81","251.31","644.48","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040456","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.67","608.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","251.31","31","","432.60","432.60","432.60","1 through 10","251.31","644.48","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040456","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.67","608.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","295.89","36.5","","148.37","54.89","631.39","94","251.31","644.48","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040456","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.67","608.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","310.49","38.3","","279.30","91.72","1116.77","266","251.31","644.48","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040456","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.67","608.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","347.78","42.9","","731.00","63.70","731.00","1 through 10","251.31","644.48","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040456","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.67","608.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","347.78","42.9","","384.74","384.74","384.74","1 through 10","251.31","644.48","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040456","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.67","608.00","WELLPOINT [1015]","HB AMC WELLPOINT","598.11","73.78","","286.63","119.22","1107.45","105","251.31","644.48","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","810.67","608.00","AETNA [1001]","HB AMC AETNA HMO","565.85","69.8","","675.31","184.75","1721.50","286","423.66","662.48","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","810.67","608.00","AETNA [1001]","HB AMC AETNA PPO","651.78","80.4","","1261.44","103.12","1514.10","21","423.66","662.48","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","810.67","608.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","651.78","80.4","","1365.00","1365.00","1365.00","1 through 10","423.66","662.48","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","810.67","608.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","662.48","81.72","","5157.68","5157.68","5157.68","1 through 10","423.66","662.48","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","810.67","608.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","662.48","81.72","","431.26","71.26","1459.57","88","423.66","662.48","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.46","208.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","221.38","79.5","","800.18","480.96","1887.97","195","86.32","221.38","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.46","208.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","148.42","53.3","","813.12","216.42","1444.50","81","86.32","221.38","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.46","208.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","86.32","31","","432.60","432.60","432.60","1 through 10","86.32","221.38","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.46","208.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","101.64","36.5","","148.37","54.89","631.39","94","86.32","221.38","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.46","208.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","106.65","38.3","","279.30","91.72","1116.77","266","86.32","221.38","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.46","208.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.46","42.9","","731.00","63.70","731.00","1 through 10","86.32","221.38","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.46","208.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.46","42.9","","384.74","384.74","384.74","1 through 10","86.32","221.38","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.46","208.84","WELLPOINT [1015]","HB AMC WELLPOINT","205.45","73.78","","286.63","119.22","1107.45","105","86.32","221.38","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.46","208.84","AETNA [1001]","HB AMC AETNA HMO","194.37","69.8","","675.31","184.75","1721.50","286","145.52","227.56","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.46","208.84","AETNA [1001]","HB AMC AETNA PPO","223.88","80.4","","1261.44","103.12","1514.10","21","145.52","227.56","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.46","208.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","223.88","80.4","","1365.00","1365.00","1365.00","1 through 10","145.52","227.56","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.46","208.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","227.56","81.72","","5157.68","5157.68","5157.68","1 through 10","145.52","227.56","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.46","208.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","227.56","81.72","","431.26","71.26","1459.57","88","145.52","227.56","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.84","730.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","774.20","79.5","","800.18","480.96","1887.97","195","301.89","774.2","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.84","730.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","519.06","53.3","","813.12","216.42","1444.50","81","301.89","774.2","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.84","730.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","301.89","31","","432.60","432.60","432.60","1 through 10","301.89","774.2","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.84","730.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","355.45","36.5","","148.37","54.89","631.39","94","301.89","774.2","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.84","730.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","372.98","38.3","","279.30","91.72","1116.77","266","301.89","774.2","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.84","730.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","417.78","42.9","","731.00","63.70","731.00","1 through 10","301.89","774.2","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.84","730.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","417.78","42.9","","384.74","384.74","384.74","1 through 10","301.89","774.2","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.84","730.38","WELLPOINT [1015]","HB AMC WELLPOINT","718.50","73.78","","286.63","119.22","1107.45","105","301.89","774.2","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","973.84","730.38","AETNA [1001]","HB AMC AETNA HMO","679.74","69.8","","675.31","184.75","1721.50","286","508.93","795.82","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","973.84","730.38","AETNA [1001]","HB AMC AETNA PPO","782.97","80.4","","1261.44","103.12","1514.10","21","508.93","795.82","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","973.84","730.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","782.97","80.4","","1365.00","1365.00","1365.00","1 through 10","508.93","795.82","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","973.84","730.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","795.82","81.72","","5157.68","5157.68","5157.68","1 through 10","508.93","795.82","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","973.84","730.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","795.82","81.72","","431.26","71.26","1459.57","88","508.93","795.82","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.46","630.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","668.17","79.5","","800.18","480.96","1887.97","195","260.54","668.17","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.46","630.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.97","53.3","","813.12","216.42","1444.50","81","260.54","668.17","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.46","630.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","260.54","31","","432.60","432.60","432.60","1 through 10","260.54","668.17","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.46","630.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.77","36.5","","148.37","54.89","631.39","94","260.54","668.17","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.46","630.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.90","38.3","","279.30","91.72","1116.77","266","260.54","668.17","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.46","630.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.56","42.9","","731.00","63.70","731.00","1 through 10","260.54","668.17","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.46","630.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.56","42.9","","384.74","384.74","384.74","1 through 10","260.54","668.17","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.46","630.34","WELLPOINT [1015]","HB AMC WELLPOINT","620.09","73.78","","286.63","119.22","1107.45","105","260.54","668.17","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.46","630.34","AETNA [1001]","HB AMC AETNA HMO","586.64","69.8","","675.31","184.75","1721.50","286","439.22","686.82","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.46","630.34","AETNA [1001]","HB AMC AETNA PPO","675.73","80.4","","1261.44","103.12","1514.10","21","439.22","686.82","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.46","630.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.73","80.4","","1365.00","1365.00","1365.00","1 through 10","439.22","686.82","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.46","630.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","686.82","81.72","","5157.68","5157.68","5157.68","1 through 10","439.22","686.82","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.46","630.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.82","81.72","","431.26","71.26","1459.57","88","439.22","686.82","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.25","787.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","834.95","79.5","","800.18","480.96","1887.97","195","325.58","834.95","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.25","787.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","559.78","53.3","","813.12","216.42","1444.50","81","325.58","834.95","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.25","787.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","325.58","31","","432.60","432.60","432.60","1 through 10","325.58","834.95","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.25","787.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.34","36.5","","148.37","54.89","631.39","94","325.58","834.95","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.25","787.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.25","38.3","","279.30","91.72","1116.77","266","325.58","834.95","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.25","787.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.56","42.9","","731.00","63.70","731.00","1 through 10","325.58","834.95","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.25","787.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.56","42.9","","384.74","384.74","384.74","1 through 10","325.58","834.95","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.25","787.69","WELLPOINT [1015]","HB AMC WELLPOINT","774.87","73.78","","286.63","119.22","1107.45","105","325.58","834.95","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.25","787.69","AETNA [1001]","HB AMC AETNA HMO","733.07","69.8","","675.31","184.75","1721.50","286","548.86","858.26","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.25","787.69","AETNA [1001]","HB AMC AETNA PPO","844.40","80.4","","1261.44","103.12","1514.10","21","548.86","858.26","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.25","787.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","844.40","80.4","","1365.00","1365.00","1365.00","1 through 10","548.86","858.26","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.25","787.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","858.26","81.72","","5157.68","5157.68","5157.68","1 through 10","548.86","858.26","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.25","787.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","858.26","81.72","","431.26","71.26","1459.57","88","548.86","858.26","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1253.56","940.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","996.58","79.5","","800.18","480.96","1887.97","195","388.6","996.58","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1253.56","940.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","668.15","53.3","","813.12","216.42","1444.50","81","388.6","996.58","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1253.56","940.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","388.60","31","","432.60","432.60","432.60","1 through 10","388.6","996.58","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1253.56","940.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","457.55","36.5","","148.37","54.89","631.39","94","388.6","996.58","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1253.56","940.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","480.11","38.3","","279.30","91.72","1116.77","266","388.6","996.58","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1253.56","940.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","537.78","42.9","","731.00","63.70","731.00","1 through 10","388.6","996.58","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1253.56","940.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","537.78","42.9","","384.74","384.74","384.74","1 through 10","388.6","996.58","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1253.56","940.17","WELLPOINT [1015]","HB AMC WELLPOINT","924.88","73.78","","286.63","119.22","1107.45","105","388.6","996.58","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1253.56","940.17","AETNA [1001]","HB AMC AETNA HMO","874.98","69.8","","675.31","184.75","1721.50","286","655.11","1024.41","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1253.56","940.17","AETNA [1001]","HB AMC AETNA PPO","1007.86","80.4","","1261.44","103.12","1514.10","21","655.11","1024.41","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1253.56","940.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1007.86","80.4","","1365.00","1365.00","1365.00","1 through 10","655.11","1024.41","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1253.56","940.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1024.41","81.72","","5157.68","5157.68","5157.68","1 through 10","655.11","1024.41","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1253.56","940.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1024.41","81.72","","431.26","71.26","1459.57","88","655.11","1024.41","percent of total billed charges",""
"BONE PLATE 3.5X85MM 6 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040457","CDM","C1713","HCPCS","0278","RC","","","","both","","","865.06","648.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","687.72","79.5","","800.18","480.96","1887.97","195","268.17","687.72","percent of total billed charges",""
"BONE PLATE 3.5X85MM 6 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040457","CDM","C1713","HCPCS","0278","RC","","","","both","","","865.06","648.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","461.08","53.3","","813.12","216.42","1444.50","81","268.17","687.72","percent of total billed charges",""
"BONE PLATE 3.5X85MM 6 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040457","CDM","C1713","HCPCS","0278","RC","","","","both","","","865.06","648.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","268.17","31","","432.60","432.60","432.60","1 through 10","268.17","687.72","percent of total billed charges",""
"BONE PLATE 3.5X85MM 6 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040457","CDM","C1713","HCPCS","0278","RC","","","","both","","","865.06","648.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","315.75","36.5","","148.37","54.89","631.39","94","268.17","687.72","percent of total billed charges",""
"BONE PLATE 3.5X85MM 6 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040457","CDM","C1713","HCPCS","0278","RC","","","","both","","","865.06","648.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","331.32","38.3","","279.30","91.72","1116.77","266","268.17","687.72","percent of total billed charges",""
"BONE PLATE 3.5X85MM 6 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040457","CDM","C1713","HCPCS","0278","RC","","","","both","","","865.06","648.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","371.11","42.9","","731.00","63.70","731.00","1 through 10","268.17","687.72","percent of total billed charges",""
"BONE PLATE 3.5X85MM 6 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040457","CDM","C1713","HCPCS","0278","RC","","","","both","","","865.06","648.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","371.11","42.9","","384.74","384.74","384.74","1 through 10","268.17","687.72","percent of total billed charges",""
"BONE PLATE 3.5X85MM 6 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040457","CDM","C1713","HCPCS","0278","RC","","","","both","","","865.06","648.79","WELLPOINT [1015]","HB AMC WELLPOINT","638.24","73.78","","286.63","119.22","1107.45","105","268.17","687.72","percent of total billed charges",""
"BONE PLATE 3.5X85MM 6 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","865.06","648.79","AETNA [1001]","HB AMC AETNA HMO","603.81","69.8","","675.31","184.75","1721.50","286","452.08","706.93","percent of total billed charges",""
"BONE PLATE 3.5X85MM 6 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","865.06","648.79","AETNA [1001]","HB AMC AETNA PPO","695.51","80.4","","1261.44","103.12","1514.10","21","452.08","706.93","percent of total billed charges",""
"BONE PLATE 3.5X85MM 6 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","865.06","648.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","695.51","80.4","","1365.00","1365.00","1365.00","1 through 10","452.08","706.93","percent of total billed charges",""
"BONE PLATE 3.5X85MM 6 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","865.06","648.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","706.93","81.72","","5157.68","5157.68","5157.68","1 through 10","452.08","706.93","percent of total billed charges",""
"BONE PLATE 3.5X85MM 6 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","865.06","648.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","706.93","81.72","","431.26","71.26","1459.57","88","452.08","706.93","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.94","79.5","","800.18","480.96","1887.97","195","407.07","1043.94","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","699.90","53.3","","813.12","216.42","1444.50","81","407.07","1043.94","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","407.07","31","","432.60","432.60","432.60","1 through 10","407.07","1043.94","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","479.29","36.5","","148.37","54.89","631.39","94","407.07","1043.94","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.93","38.3","","279.30","91.72","1116.77","266","407.07","1043.94","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.33","42.9","","731.00","63.70","731.00","1 through 10","407.07","1043.94","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.33","42.9","","384.74","384.74","384.74","1 through 10","407.07","1043.94","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1313.13","984.85","WELLPOINT [1015]","HB AMC WELLPOINT","968.83","73.78","","286.63","119.22","1107.45","105","407.07","1043.94","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","AETNA [1001]","HB AMC AETNA HMO","916.56","69.8","","675.31","184.75","1721.50","286","686.24","1073.09","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","AETNA [1001]","HB AMC AETNA PPO","1055.76","80.4","","1261.44","103.12","1514.10","21","686.24","1073.09","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1055.76","80.4","","1365.00","1365.00","1365.00","1 through 10","686.24","1073.09","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1073.09","81.72","","5157.68","5157.68","5157.68","1 through 10","686.24","1073.09","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1313.13","984.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1073.09","81.72","","431.26","71.26","1459.57","88","686.24","1073.09","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","both","","","2031.86","1523.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1615.33","79.5","","800.18","480.96","1887.97","195","629.88","1615.33","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","both","","","2031.86","1523.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1082.98","53.3","","813.12","216.42","1444.50","81","629.88","1615.33","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","both","","","2031.86","1523.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","629.88","31","","432.60","432.60","432.60","1 through 10","629.88","1615.33","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","both","","","2031.86","1523.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","741.63","36.5","","148.37","54.89","631.39","94","629.88","1615.33","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","both","","","2031.86","1523.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","778.20","38.3","","279.30","91.72","1116.77","266","629.88","1615.33","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","both","","","2031.86","1523.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","871.67","42.9","","731.00","63.70","731.00","1 through 10","629.88","1615.33","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","both","","","2031.86","1523.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","871.67","42.9","","384.74","384.74","384.74","1 through 10","629.88","1615.33","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","both","","","2031.86","1523.89","WELLPOINT [1015]","HB AMC WELLPOINT","1499.11","73.78","","286.63","119.22","1107.45","105","629.88","1615.33","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2031.86","1523.89","AETNA [1001]","HB AMC AETNA HMO","1418.24","69.8","","675.31","184.75","1721.50","286","1061.85","1660.44","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2031.86","1523.89","AETNA [1001]","HB AMC AETNA PPO","1633.62","80.4","","1261.44","103.12","1514.10","21","1061.85","1660.44","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2031.86","1523.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1633.62","80.4","","1365.00","1365.00","1365.00","1 through 10","1061.85","1660.44","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2031.86","1523.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1660.44","81.72","","5157.68","5157.68","5157.68","1 through 10","1061.85","1660.44","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2031.86","1523.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1660.44","81.72","","431.26","71.26","1459.57","88","1061.85","1660.44","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","839.07","79.5","","800.18","480.96","1887.97","195","327.18","839.07","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","562.54","53.3","","813.12","216.42","1444.50","81","327.18","839.07","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","327.18","31","","432.60","432.60","432.60","1 through 10","327.18","839.07","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","385.23","36.5","","148.37","54.89","631.39","94","327.18","839.07","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","404.23","38.3","","279.30","91.72","1116.77","266","327.18","839.07","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","452.78","42.9","","731.00","63.70","731.00","1 through 10","327.18","839.07","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","452.78","42.9","","384.74","384.74","384.74","1 through 10","327.18","839.07","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","WELLPOINT [1015]","HB AMC WELLPOINT","778.70","73.78","","286.63","119.22","1107.45","105","327.18","839.07","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1055.43","791.57","AETNA [1001]","HB AMC AETNA HMO","736.69","69.8","","675.31","184.75","1721.50","286","551.57","862.5","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1055.43","791.57","AETNA [1001]","HB AMC AETNA PPO","848.57","80.4","","1261.44","103.12","1514.10","21","551.57","862.5","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1055.43","791.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","848.57","80.4","","1365.00","1365.00","1365.00","1 through 10","551.57","862.5","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1055.43","791.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","862.50","81.72","","5157.68","5157.68","5157.68","1 through 10","551.57","862.5","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1055.43","791.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","862.50","81.72","","431.26","71.26","1459.57","88","551.57","862.5","percent of total billed charges",""
"BONE PLATE 3.5X97MM 8 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028070","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.59","208.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","220.68","79.5","","800.18","480.96","1887.97","195","86.05","220.68","percent of total billed charges",""
"BONE PLATE 3.5X97MM 8 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028070","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.59","208.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.96","53.3","","813.12","216.42","1444.50","81","86.05","220.68","percent of total billed charges",""
"BONE PLATE 3.5X97MM 8 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028070","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.59","208.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","86.05","31","","432.60","432.60","432.60","1 through 10","86.05","220.68","percent of total billed charges",""
"BONE PLATE 3.5X97MM 8 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028070","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.59","208.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","101.32","36.5","","148.37","54.89","631.39","94","86.05","220.68","percent of total billed charges",""
"BONE PLATE 3.5X97MM 8 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028070","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.59","208.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","106.32","38.3","","279.30","91.72","1116.77","266","86.05","220.68","percent of total billed charges",""
"BONE PLATE 3.5X97MM 8 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028070","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.59","208.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.09","42.9","","731.00","63.70","731.00","1 through 10","86.05","220.68","percent of total billed charges",""
"BONE PLATE 3.5X97MM 8 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028070","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.59","208.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.09","42.9","","384.74","384.74","384.74","1 through 10","86.05","220.68","percent of total billed charges",""
"BONE PLATE 3.5X97MM 8 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028070","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.59","208.19","WELLPOINT [1015]","HB AMC WELLPOINT","204.81","73.78","","286.63","119.22","1107.45","105","86.05","220.68","percent of total billed charges",""
"BONE PLATE 3.5X97MM 8 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","277.59","208.19","AETNA [1001]","HB AMC AETNA HMO","193.76","69.8","","675.31","184.75","1721.50","286","145.07","226.85","percent of total billed charges",""
"BONE PLATE 3.5X97MM 8 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","277.59","208.19","AETNA [1001]","HB AMC AETNA PPO","223.18","80.4","","1261.44","103.12","1514.10","21","145.07","226.85","percent of total billed charges",""
"BONE PLATE 3.5X97MM 8 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","277.59","208.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","223.18","80.4","","1365.00","1365.00","1365.00","1 through 10","145.07","226.85","percent of total billed charges",""
"BONE PLATE 3.5X97MM 8 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","277.59","208.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","226.85","81.72","","5157.68","5157.68","5157.68","1 through 10","145.07","226.85","percent of total billed charges",""
"BONE PLATE 3.5X97MM 8 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","277.59","208.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","226.85","81.72","","431.26","71.26","1459.57","88","145.07","226.85","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1314.43","985.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1044.97","79.5","","800.18","480.96","1887.97","195","407.47","1044.97","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1314.43","985.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","700.59","53.3","","813.12","216.42","1444.50","81","407.47","1044.97","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1314.43","985.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","407.47","31","","432.60","432.60","432.60","1 through 10","407.47","1044.97","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1314.43","985.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","479.77","36.5","","148.37","54.89","631.39","94","407.47","1044.97","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1314.43","985.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","503.43","38.3","","279.30","91.72","1116.77","266","407.47","1044.97","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1314.43","985.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.89","42.9","","731.00","63.70","731.00","1 through 10","407.47","1044.97","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1314.43","985.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.89","42.9","","384.74","384.74","384.74","1 through 10","407.47","1044.97","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1314.43","985.82","WELLPOINT [1015]","HB AMC WELLPOINT","969.79","73.78","","286.63","119.22","1107.45","105","407.47","1044.97","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1314.43","985.82","AETNA [1001]","HB AMC AETNA HMO","917.47","69.8","","675.31","184.75","1721.50","286","686.92","1074.15","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1314.43","985.82","AETNA [1001]","HB AMC AETNA PPO","1056.80","80.4","","1261.44","103.12","1514.10","21","686.92","1074.15","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1314.43","985.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1056.80","80.4","","1365.00","1365.00","1365.00","1 through 10","686.92","1074.15","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1314.43","985.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1074.15","81.72","","5157.68","5157.68","5157.68","1 through 10","686.92","1074.15","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1314.43","985.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1074.15","81.72","","431.26","71.26","1459.57","88","686.92","1074.15","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.79","1711.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1814.02","79.5","","800.18","480.96","1887.97","195","707.35","1814.02","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.79","1711.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1216.19","53.3","","813.12","216.42","1444.50","81","707.35","1814.02","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.79","1711.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","707.35","31","","432.60","432.60","432.60","1 through 10","707.35","1814.02","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.79","1711.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","832.85","36.5","","148.37","54.89","631.39","94","707.35","1814.02","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.79","1711.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","873.93","38.3","","279.30","91.72","1116.77","266","707.35","1814.02","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.79","1711.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","978.89","42.9","","731.00","63.70","731.00","1 through 10","707.35","1814.02","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.79","1711.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","978.89","42.9","","384.74","384.74","384.74","1 through 10","707.35","1814.02","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.79","1711.34","WELLPOINT [1015]","HB AMC WELLPOINT","1683.50","73.78","","286.63","119.22","1107.45","105","707.35","1814.02","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2281.79","1711.34","AETNA [1001]","HB AMC AETNA HMO","1592.69","69.8","","675.31","184.75","1721.50","286","1192.46","1864.68","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2281.79","1711.34","AETNA [1001]","HB AMC AETNA PPO","1834.56","80.4","","1261.44","103.12","1514.10","21","1192.46","1864.68","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2281.79","1711.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1834.56","80.4","","1365.00","1365.00","1365.00","1 through 10","1192.46","1864.68","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2281.79","1711.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1864.68","81.72","","5157.68","5157.68","5157.68","1 through 10","1192.46","1864.68","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2281.79","1711.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1864.68","81.72","","431.26","71.26","1459.57","88","1192.46","1864.68","percent of total billed charges",""
"BONE PLATE 30X5MM 3 HOLE 115DEG OSTEOTOMY BIFURCATED SS","SUP-ITM-10037753","CDM","C1713","HCPCS","0278","RC","","","","both","","","1156.44","867.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","919.37","79.5","","800.18","480.96","1887.97","195","358.5","919.37","percent of total billed charges",""
"BONE PLATE 30X5MM 3 HOLE 115DEG OSTEOTOMY BIFURCATED SS","SUP-ITM-10037753","CDM","C1713","HCPCS","0278","RC","","","","both","","","1156.44","867.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","616.38","53.3","","813.12","216.42","1444.50","81","358.5","919.37","percent of total billed charges",""
"BONE PLATE 30X5MM 3 HOLE 115DEG OSTEOTOMY BIFURCATED SS","SUP-ITM-10037753","CDM","C1713","HCPCS","0278","RC","","","","both","","","1156.44","867.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","358.50","31","","432.60","432.60","432.60","1 through 10","358.5","919.37","percent of total billed charges",""
"BONE PLATE 30X5MM 3 HOLE 115DEG OSTEOTOMY BIFURCATED SS","SUP-ITM-10037753","CDM","C1713","HCPCS","0278","RC","","","","both","","","1156.44","867.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","422.10","36.5","","148.37","54.89","631.39","94","358.5","919.37","percent of total billed charges",""
"BONE PLATE 30X5MM 3 HOLE 115DEG OSTEOTOMY BIFURCATED SS","SUP-ITM-10037753","CDM","C1713","HCPCS","0278","RC","","","","both","","","1156.44","867.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","442.92","38.3","","279.30","91.72","1116.77","266","358.5","919.37","percent of total billed charges",""
"BONE PLATE 30X5MM 3 HOLE 115DEG OSTEOTOMY BIFURCATED SS","SUP-ITM-10037753","CDM","C1713","HCPCS","0278","RC","","","","both","","","1156.44","867.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","496.11","42.9","","731.00","63.70","731.00","1 through 10","358.5","919.37","percent of total billed charges",""
"BONE PLATE 30X5MM 3 HOLE 115DEG OSTEOTOMY BIFURCATED SS","SUP-ITM-10037753","CDM","C1713","HCPCS","0278","RC","","","","both","","","1156.44","867.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","496.11","42.9","","384.74","384.74","384.74","1 through 10","358.5","919.37","percent of total billed charges",""
"BONE PLATE 30X5MM 3 HOLE 115DEG OSTEOTOMY BIFURCATED SS","SUP-ITM-10037753","CDM","C1713","HCPCS","0278","RC","","","","both","","","1156.44","867.33","WELLPOINT [1015]","HB AMC WELLPOINT","853.22","73.78","","286.63","119.22","1107.45","105","358.5","919.37","percent of total billed charges",""
"BONE PLATE 30X5MM 3 HOLE 115DEG OSTEOTOMY BIFURCATED SS","SUP-ITM-10037753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1156.44","867.33","AETNA [1001]","HB AMC AETNA HMO","807.20","69.8","","675.31","184.75","1721.50","286","604.36","945.04","percent of total billed charges",""
"BONE PLATE 30X5MM 3 HOLE 115DEG OSTEOTOMY BIFURCATED SS","SUP-ITM-10037753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1156.44","867.33","AETNA [1001]","HB AMC AETNA PPO","929.78","80.4","","1261.44","103.12","1514.10","21","604.36","945.04","percent of total billed charges",""
"BONE PLATE 30X5MM 3 HOLE 115DEG OSTEOTOMY BIFURCATED SS","SUP-ITM-10037753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1156.44","867.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","929.78","80.4","","1365.00","1365.00","1365.00","1 through 10","604.36","945.04","percent of total billed charges",""
"BONE PLATE 30X5MM 3 HOLE 115DEG OSTEOTOMY BIFURCATED SS","SUP-ITM-10037753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1156.44","867.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","945.04","81.72","","5157.68","5157.68","5157.68","1 through 10","604.36","945.04","percent of total billed charges",""
"BONE PLATE 30X5MM 3 HOLE 115DEG OSTEOTOMY BIFURCATED SS","SUP-ITM-10037753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1156.44","867.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","945.04","81.72","","431.26","71.26","1459.57","88","604.36","945.04","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","822.59","79.5","","800.18","480.96","1887.97","195","320.76","822.59","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","551.50","53.3","","813.12","216.42","1444.50","81","320.76","822.59","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","320.76","31","","432.60","432.60","432.60","1 through 10","320.76","822.59","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","377.67","36.5","","148.37","54.89","631.39","94","320.76","822.59","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","396.29","38.3","","279.30","91.72","1116.77","266","320.76","822.59","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","443.89","42.9","","731.00","63.70","731.00","1 through 10","320.76","822.59","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","443.89","42.9","","384.74","384.74","384.74","1 through 10","320.76","822.59","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","WELLPOINT [1015]","HB AMC WELLPOINT","763.41","73.78","","286.63","119.22","1107.45","105","320.76","822.59","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.71","776.03","AETNA [1001]","HB AMC AETNA HMO","722.23","69.8","","675.31","184.75","1721.50","286","540.74","845.57","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.71","776.03","AETNA [1001]","HB AMC AETNA PPO","831.91","80.4","","1261.44","103.12","1514.10","21","540.74","845.57","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.71","776.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","831.91","80.4","","1365.00","1365.00","1365.00","1 through 10","540.74","845.57","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.71","776.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","845.57","81.72","","5157.68","5157.68","5157.68","1 through 10","540.74","845.57","percent of total billed charges",""
"BONE PLATE 31MM 4 HOLE TUBULAR QUARTER WITH COLLAR TITANIUM CS/1BX/1EA","SUP-ITM-10002102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.71","776.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","845.57","81.72","","431.26","71.26","1459.57","88","540.74","845.57","percent of total billed charges",""
"BONE PLATE 338MM SHORT 20 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10001504","CDM","C1713","HCPCS","0278","RC","","","","both","","","4142.71","3107.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3293.45","79.5","","800.18","480.96","1887.97","195","1284.24","3293.45","percent of total billed charges",""
"BONE PLATE 338MM SHORT 20 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10001504","CDM","C1713","HCPCS","0278","RC","","","","both","","","4142.71","3107.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2208.06","53.3","","813.12","216.42","1444.50","81","1284.24","3293.45","percent of total billed charges",""
"BONE PLATE 338MM SHORT 20 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10001504","CDM","C1713","HCPCS","0278","RC","","","","both","","","4142.71","3107.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1284.24","31","","432.60","432.60","432.60","1 through 10","1284.24","3293.45","percent of total billed charges",""
"BONE PLATE 338MM SHORT 20 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10001504","CDM","C1713","HCPCS","0278","RC","","","","both","","","4142.71","3107.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1512.09","36.5","","148.37","54.89","631.39","94","1284.24","3293.45","percent of total billed charges",""
"BONE PLATE 338MM SHORT 20 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10001504","CDM","C1713","HCPCS","0278","RC","","","","both","","","4142.71","3107.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1586.66","38.3","","279.30","91.72","1116.77","266","1284.24","3293.45","percent of total billed charges",""
"BONE PLATE 338MM SHORT 20 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10001504","CDM","C1713","HCPCS","0278","RC","","","","both","","","4142.71","3107.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1777.22","42.9","","731.00","63.70","731.00","1 through 10","1284.24","3293.45","percent of total billed charges",""
"BONE PLATE 338MM SHORT 20 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10001504","CDM","C1713","HCPCS","0278","RC","","","","both","","","4142.71","3107.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1777.22","42.9","","384.74","384.74","384.74","1 through 10","1284.24","3293.45","percent of total billed charges",""
"BONE PLATE 338MM SHORT 20 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10001504","CDM","C1713","HCPCS","0278","RC","","","","both","","","4142.71","3107.03","WELLPOINT [1015]","HB AMC WELLPOINT","3056.49","73.78","","286.63","119.22","1107.45","105","1284.24","3293.45","percent of total billed charges",""
"BONE PLATE 338MM SHORT 20 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10001504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4142.71","3107.03","AETNA [1001]","HB AMC AETNA HMO","2891.61","69.8","","675.31","184.75","1721.50","286","2164.98","3385.42","percent of total billed charges",""
"BONE PLATE 338MM SHORT 20 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10001504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4142.71","3107.03","AETNA [1001]","HB AMC AETNA PPO","3330.74","80.4","","1261.44","103.12","1514.10","21","2164.98","3385.42","percent of total billed charges",""
"BONE PLATE 338MM SHORT 20 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10001504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4142.71","3107.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3330.74","80.4","","1365.00","1365.00","1365.00","1 through 10","2164.98","3385.42","percent of total billed charges",""
"BONE PLATE 338MM SHORT 20 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10001504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4142.71","3107.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3385.42","81.72","","5157.68","5157.68","5157.68","1 through 10","2164.98","3385.42","percent of total billed charges",""
"BONE PLATE 338MM SHORT 20 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10001504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4142.71","3107.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3385.42","81.72","","431.26","71.26","1459.57","88","2164.98","3385.42","percent of total billed charges",""
"BONE PLATE 33MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077366","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","710.85","79.5","","800.18","480.96","1887.97","195","277.19","710.85","percent of total billed charges",""
"BONE PLATE 33MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077366","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","476.58","53.3","","813.12","216.42","1444.50","81","277.19","710.85","percent of total billed charges",""
"BONE PLATE 33MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077366","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","277.19","31","","432.60","432.60","432.60","1 through 10","277.19","710.85","percent of total billed charges",""
"BONE PLATE 33MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077366","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","326.36","36.5","","148.37","54.89","631.39","94","277.19","710.85","percent of total billed charges",""
"BONE PLATE 33MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077366","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","342.46","38.3","","279.30","91.72","1116.77","266","277.19","710.85","percent of total billed charges",""
"BONE PLATE 33MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077366","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","383.59","42.9","","731.00","63.70","731.00","1 through 10","277.19","710.85","percent of total billed charges",""
"BONE PLATE 33MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077366","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","383.59","42.9","","384.74","384.74","384.74","1 through 10","277.19","710.85","percent of total billed charges",""
"BONE PLATE 33MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077366","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","WELLPOINT [1015]","HB AMC WELLPOINT","659.70","73.78","","286.63","119.22","1107.45","105","277.19","710.85","percent of total billed charges",""
"BONE PLATE 33MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","894.15","670.61","AETNA [1001]","HB AMC AETNA HMO","624.12","69.8","","675.31","184.75","1721.50","286","467.28","730.7","percent of total billed charges",""
"BONE PLATE 33MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","894.15","670.61","AETNA [1001]","HB AMC AETNA PPO","718.90","80.4","","1261.44","103.12","1514.10","21","467.28","730.7","percent of total billed charges",""
"BONE PLATE 33MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","894.15","670.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","718.90","80.4","","1365.00","1365.00","1365.00","1 through 10","467.28","730.7","percent of total billed charges",""
"BONE PLATE 33MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","894.15","670.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","730.70","81.72","","5157.68","5157.68","5157.68","1 through 10","467.28","730.7","percent of total billed charges",""
"BONE PLATE 33MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","894.15","670.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","730.70","81.72","","431.26","71.26","1459.57","88","467.28","730.7","percent of total billed charges",""
"BONE PLATE 35MM 1/3 TUBULAR 3 HOLE 626673","SUP-ITM-10186976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.27","1185.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1257.11","79.5","","800.18","480.96","1887.97","195","490.19","1257.11","percent of total billed charges",""
"BONE PLATE 35MM 1/3 TUBULAR 3 HOLE 626673","SUP-ITM-10186976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.27","1185.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","842.82","53.3","","813.12","216.42","1444.50","81","490.19","1257.11","percent of total billed charges",""
"BONE PLATE 35MM 1/3 TUBULAR 3 HOLE 626673","SUP-ITM-10186976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.27","1185.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","490.19","31","","432.60","432.60","432.60","1 through 10","490.19","1257.11","percent of total billed charges",""
"BONE PLATE 35MM 1/3 TUBULAR 3 HOLE 626673","SUP-ITM-10186976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.27","1185.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","577.16","36.5","","148.37","54.89","631.39","94","490.19","1257.11","percent of total billed charges",""
"BONE PLATE 35MM 1/3 TUBULAR 3 HOLE 626673","SUP-ITM-10186976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.27","1185.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","605.63","38.3","","279.30","91.72","1116.77","266","490.19","1257.11","percent of total billed charges",""
"BONE PLATE 35MM 1/3 TUBULAR 3 HOLE 626673","SUP-ITM-10186976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.27","1185.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","678.36","42.9","","731.00","63.70","731.00","1 through 10","490.19","1257.11","percent of total billed charges",""
"BONE PLATE 35MM 1/3 TUBULAR 3 HOLE 626673","SUP-ITM-10186976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.27","1185.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","678.36","42.9","","384.74","384.74","384.74","1 through 10","490.19","1257.11","percent of total billed charges",""
"BONE PLATE 35MM 1/3 TUBULAR 3 HOLE 626673","SUP-ITM-10186976","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.27","1185.95","WELLPOINT [1015]","HB AMC WELLPOINT","1166.66","73.78","","286.63","119.22","1107.45","105","490.19","1257.11","percent of total billed charges",""
"BONE PLATE 35MM 1/3 TUBULAR 3 HOLE 626673","SUP-ITM-10186976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1581.27","1185.95","AETNA [1001]","HB AMC AETNA HMO","1103.73","69.8","","675.31","184.75","1721.50","286","826.37","1292.21","percent of total billed charges",""
"BONE PLATE 35MM 1/3 TUBULAR 3 HOLE 626673","SUP-ITM-10186976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1581.27","1185.95","AETNA [1001]","HB AMC AETNA PPO","1271.34","80.4","","1261.44","103.12","1514.10","21","826.37","1292.21","percent of total billed charges",""
"BONE PLATE 35MM 1/3 TUBULAR 3 HOLE 626673","SUP-ITM-10186976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1581.27","1185.95","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1271.34","80.4","","1365.00","1365.00","1365.00","1 through 10","826.37","1292.21","percent of total billed charges",""
"BONE PLATE 35MM 1/3 TUBULAR 3 HOLE 626673","SUP-ITM-10186976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1581.27","1185.95","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1292.21","81.72","","5157.68","5157.68","5157.68","1 through 10","826.37","1292.21","percent of total billed charges",""
"BONE PLATE 35MM 1/3 TUBULAR 3 HOLE 626673","SUP-ITM-10186976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1581.27","1185.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1292.21","81.72","","431.26","71.26","1459.57","88","826.37","1292.21","percent of total billed charges",""
"BONE PLATE 36X2.4MM 6 HOLE TI STRAIGHT","SUP-ITM-10006276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1139.60","854.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","905.98","79.5","","800.18","480.96","1887.97","195","353.28","905.98","percent of total billed charges",""
"BONE PLATE 36X2.4MM 6 HOLE TI STRAIGHT","SUP-ITM-10006276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1139.60","854.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","607.41","53.3","","813.12","216.42","1444.50","81","353.28","905.98","percent of total billed charges",""
"BONE PLATE 36X2.4MM 6 HOLE TI STRAIGHT","SUP-ITM-10006276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1139.60","854.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","353.28","31","","432.60","432.60","432.60","1 through 10","353.28","905.98","percent of total billed charges",""
"BONE PLATE 36X2.4MM 6 HOLE TI STRAIGHT","SUP-ITM-10006276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1139.60","854.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","415.95","36.5","","148.37","54.89","631.39","94","353.28","905.98","percent of total billed charges",""
"BONE PLATE 36X2.4MM 6 HOLE TI STRAIGHT","SUP-ITM-10006276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1139.60","854.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","436.47","38.3","","279.30","91.72","1116.77","266","353.28","905.98","percent of total billed charges",""
"BONE PLATE 36X2.4MM 6 HOLE TI STRAIGHT","SUP-ITM-10006276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1139.60","854.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","488.89","42.9","","731.00","63.70","731.00","1 through 10","353.28","905.98","percent of total billed charges",""
"BONE PLATE 36X2.4MM 6 HOLE TI STRAIGHT","SUP-ITM-10006276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1139.60","854.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","488.89","42.9","","384.74","384.74","384.74","1 through 10","353.28","905.98","percent of total billed charges",""
"BONE PLATE 36X2.4MM 6 HOLE TI STRAIGHT","SUP-ITM-10006276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1139.60","854.70","WELLPOINT [1015]","HB AMC WELLPOINT","840.80","73.78","","286.63","119.22","1107.45","105","353.28","905.98","percent of total billed charges",""
"BONE PLATE 36X2.4MM 6 HOLE TI STRAIGHT","SUP-ITM-10006276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1139.60","854.70","AETNA [1001]","HB AMC AETNA HMO","795.44","69.8","","675.31","184.75","1721.50","286","595.55","931.28","percent of total billed charges",""
"BONE PLATE 36X2.4MM 6 HOLE TI STRAIGHT","SUP-ITM-10006276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1139.60","854.70","AETNA [1001]","HB AMC AETNA PPO","916.24","80.4","","1261.44","103.12","1514.10","21","595.55","931.28","percent of total billed charges",""
"BONE PLATE 36X2.4MM 6 HOLE TI STRAIGHT","SUP-ITM-10006276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1139.60","854.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","916.24","80.4","","1365.00","1365.00","1365.00","1 through 10","595.55","931.28","percent of total billed charges",""
"BONE PLATE 36X2.4MM 6 HOLE TI STRAIGHT","SUP-ITM-10006276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1139.60","854.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","931.28","81.72","","5157.68","5157.68","5157.68","1 through 10","595.55","931.28","percent of total billed charges",""
"BONE PLATE 36X2.4MM 6 HOLE TI STRAIGHT","SUP-ITM-10006276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1139.60","854.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","931.28","81.72","","431.26","71.26","1459.57","88","595.55","931.28","percent of total billed charges",""
"BONE PLATE 370MM SHORT 22 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005790","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.89","3245.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3440.67","79.5","","800.18","480.96","1887.97","195","1341.65","3440.67","percent of total billed charges",""
"BONE PLATE 370MM SHORT 22 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005790","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.89","3245.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2306.77","53.3","","813.12","216.42","1444.50","81","1341.65","3440.67","percent of total billed charges",""
"BONE PLATE 370MM SHORT 22 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005790","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.89","3245.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1341.65","31","","432.60","432.60","432.60","1 through 10","1341.65","3440.67","percent of total billed charges",""
"BONE PLATE 370MM SHORT 22 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005790","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.89","3245.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1579.68","36.5","","148.37","54.89","631.39","94","1341.65","3440.67","percent of total billed charges",""
"BONE PLATE 370MM SHORT 22 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005790","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.89","3245.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1657.58","38.3","","279.30","91.72","1116.77","266","1341.65","3440.67","percent of total billed charges",""
"BONE PLATE 370MM SHORT 22 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005790","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.89","3245.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1856.66","42.9","","731.00","63.70","731.00","1 through 10","1341.65","3440.67","percent of total billed charges",""
"BONE PLATE 370MM SHORT 22 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005790","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.89","3245.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1856.66","42.9","","384.74","384.74","384.74","1 through 10","1341.65","3440.67","percent of total billed charges",""
"BONE PLATE 370MM SHORT 22 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005790","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.89","3245.92","WELLPOINT [1015]","HB AMC WELLPOINT","3193.12","73.78","","286.63","119.22","1107.45","105","1341.65","3440.67","percent of total billed charges",""
"BONE PLATE 370MM SHORT 22 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4327.89","3245.92","AETNA [1001]","HB AMC AETNA HMO","3020.87","69.8","","675.31","184.75","1721.50","286","2261.76","3536.75","percent of total billed charges",""
"BONE PLATE 370MM SHORT 22 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4327.89","3245.92","AETNA [1001]","HB AMC AETNA PPO","3479.62","80.4","","1261.44","103.12","1514.10","21","2261.76","3536.75","percent of total billed charges",""
"BONE PLATE 370MM SHORT 22 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4327.89","3245.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3479.62","80.4","","1365.00","1365.00","1365.00","1 through 10","2261.76","3536.75","percent of total billed charges",""
"BONE PLATE 370MM SHORT 22 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4327.89","3245.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3536.75","81.72","","5157.68","5157.68","5157.68","1 through 10","2261.76","3536.75","percent of total billed charges",""
"BONE PLATE 370MM SHORT 22 HOLE 95DEG DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4327.89","3245.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3536.75","81.72","","431.26","71.26","1459.57","88","2261.76","3536.75","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.22","306.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","325.33","79.5","","800.18","480.96","1887.97","195","126.86","325.33","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.22","306.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","218.11","53.3","","813.12","216.42","1444.50","81","126.86","325.33","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.22","306.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","126.86","31","","432.60","432.60","432.60","1 through 10","126.86","325.33","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.22","306.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","149.37","36.5","","148.37","54.89","631.39","94","126.86","325.33","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.22","306.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","156.73","38.3","","279.30","91.72","1116.77","266","126.86","325.33","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.22","306.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","175.56","42.9","","731.00","63.70","731.00","1 through 10","126.86","325.33","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.22","306.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","175.56","42.9","","384.74","384.74","384.74","1 through 10","126.86","325.33","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.22","306.91","WELLPOINT [1015]","HB AMC WELLPOINT","301.92","73.78","","286.63","119.22","1107.45","105","126.86","325.33","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.22","306.91","AETNA [1001]","HB AMC AETNA HMO","285.64","69.8","","675.31","184.75","1721.50","286","213.86","334.41","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.22","306.91","AETNA [1001]","HB AMC AETNA PPO","329.01","80.4","","1261.44","103.12","1514.10","21","213.86","334.41","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.22","306.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","329.01","80.4","","1365.00","1365.00","1365.00","1 through 10","213.86","334.41","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.22","306.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","334.41","81.72","","5157.68","5157.68","5157.68","1 through 10","213.86","334.41","percent of total billed charges",""
"BONE PLATE 37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.22","306.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","334.41","81.72","","431.26","71.26","1459.57","88","213.86","334.41","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","both","","","2595.18","1946.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2063.17","79.5","","800.18","480.96","1887.97","195","804.51","2063.17","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","both","","","2595.18","1946.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1383.23","53.3","","813.12","216.42","1444.50","81","804.51","2063.17","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","both","","","2595.18","1946.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","804.51","31","","432.60","432.60","432.60","1 through 10","804.51","2063.17","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","both","","","2595.18","1946.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","947.24","36.5","","148.37","54.89","631.39","94","804.51","2063.17","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","both","","","2595.18","1946.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","993.95","38.3","","279.30","91.72","1116.77","266","804.51","2063.17","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","both","","","2595.18","1946.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1113.33","42.9","","731.00","63.70","731.00","1 through 10","804.51","2063.17","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","both","","","2595.18","1946.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1113.33","42.9","","384.74","384.74","384.74","1 through 10","804.51","2063.17","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","both","","","2595.18","1946.38","WELLPOINT [1015]","HB AMC WELLPOINT","1914.72","73.78","","286.63","119.22","1107.45","105","804.51","2063.17","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2595.18","1946.38","AETNA [1001]","HB AMC AETNA HMO","1811.44","69.8","","675.31","184.75","1721.50","286","1356.24","2120.78","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2595.18","1946.38","AETNA [1001]","HB AMC AETNA PPO","2086.52","80.4","","1261.44","103.12","1514.10","21","1356.24","2120.78","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2595.18","1946.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2086.52","80.4","","1365.00","1365.00","1365.00","1 through 10","1356.24","2120.78","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2595.18","1946.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2120.78","81.72","","5157.68","5157.68","5157.68","1 through 10","1356.24","2120.78","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2595.18","1946.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2120.78","81.72","","431.26","71.26","1459.57","88","1356.24","2120.78","percent of total billed charges",""
"BONE PLATE 3X 1.5 44MM 8 HOLE SS T SHAPE","SUP-ITM-10038130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.57","821.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","870.98","79.5","","800.18","480.96","1887.97","195","339.63","870.98","percent of total billed charges",""
"BONE PLATE 3X 1.5 44MM 8 HOLE SS T SHAPE","SUP-ITM-10038130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.57","821.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","583.94","53.3","","813.12","216.42","1444.50","81","339.63","870.98","percent of total billed charges",""
"BONE PLATE 3X 1.5 44MM 8 HOLE SS T SHAPE","SUP-ITM-10038130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.57","821.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","339.63","31","","432.60","432.60","432.60","1 through 10","339.63","870.98","percent of total billed charges",""
"BONE PLATE 3X 1.5 44MM 8 HOLE SS T SHAPE","SUP-ITM-10038130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.57","821.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","399.88","36.5","","148.37","54.89","631.39","94","339.63","870.98","percent of total billed charges",""
"BONE PLATE 3X 1.5 44MM 8 HOLE SS T SHAPE","SUP-ITM-10038130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.57","821.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","419.60","38.3","","279.30","91.72","1116.77","266","339.63","870.98","percent of total billed charges",""
"BONE PLATE 3X 1.5 44MM 8 HOLE SS T SHAPE","SUP-ITM-10038130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.57","821.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","470.00","42.9","","731.00","63.70","731.00","1 through 10","339.63","870.98","percent of total billed charges",""
"BONE PLATE 3X 1.5 44MM 8 HOLE SS T SHAPE","SUP-ITM-10038130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.57","821.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","470.00","42.9","","384.74","384.74","384.74","1 through 10","339.63","870.98","percent of total billed charges",""
"BONE PLATE 3X 1.5 44MM 8 HOLE SS T SHAPE","SUP-ITM-10038130","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.57","821.68","WELLPOINT [1015]","HB AMC WELLPOINT","808.31","73.78","","286.63","119.22","1107.45","105","339.63","870.98","percent of total billed charges",""
"BONE PLATE 3X 1.5 44MM 8 HOLE SS T SHAPE","SUP-ITM-10038130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.57","821.68","AETNA [1001]","HB AMC AETNA HMO","764.71","69.8","","675.31","184.75","1721.50","286","572.54","895.3","percent of total billed charges",""
"BONE PLATE 3X 1.5 44MM 8 HOLE SS T SHAPE","SUP-ITM-10038130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.57","821.68","AETNA [1001]","HB AMC AETNA PPO","880.84","80.4","","1261.44","103.12","1514.10","21","572.54","895.3","percent of total billed charges",""
"BONE PLATE 3X 1.5 44MM 8 HOLE SS T SHAPE","SUP-ITM-10038130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.57","821.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","880.84","80.4","","1365.00","1365.00","1365.00","1 through 10","572.54","895.3","percent of total billed charges",""
"BONE PLATE 3X 1.5 44MM 8 HOLE SS T SHAPE","SUP-ITM-10038130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.57","821.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","895.30","81.72","","5157.68","5157.68","5157.68","1 through 10","572.54","895.3","percent of total billed charges",""
"BONE PLATE 3X 1.5 44MM 8 HOLE SS T SHAPE","SUP-ITM-10038130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.57","821.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","895.30","81.72","","431.26","71.26","1459.57","88","572.54","895.3","percent of total billed charges",""
"BONE PLATE 3X1.5MM HOLE CRANIAL MATRIXMANDIBLE TI CRESCENT","SUP-ITM-10081106","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.23","1827.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1937.60","79.5","","800.18","480.96","1887.97","195","755.54","1937.6","percent of total billed charges",""
"BONE PLATE 3X1.5MM HOLE CRANIAL MATRIXMANDIBLE TI CRESCENT","SUP-ITM-10081106","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.23","1827.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1299.04","53.3","","813.12","216.42","1444.50","81","755.54","1937.6","percent of total billed charges",""
"BONE PLATE 3X1.5MM HOLE CRANIAL MATRIXMANDIBLE TI CRESCENT","SUP-ITM-10081106","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.23","1827.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","755.54","31","","432.60","432.60","432.60","1 through 10","755.54","1937.6","percent of total billed charges",""
"BONE PLATE 3X1.5MM HOLE CRANIAL MATRIXMANDIBLE TI CRESCENT","SUP-ITM-10081106","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.23","1827.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","889.59","36.5","","148.37","54.89","631.39","94","755.54","1937.6","percent of total billed charges",""
"BONE PLATE 3X1.5MM HOLE CRANIAL MATRIXMANDIBLE TI CRESCENT","SUP-ITM-10081106","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.23","1827.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","933.46","38.3","","279.30","91.72","1116.77","266","755.54","1937.6","percent of total billed charges",""
"BONE PLATE 3X1.5MM HOLE CRANIAL MATRIXMANDIBLE TI CRESCENT","SUP-ITM-10081106","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.23","1827.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1045.57","42.9","","731.00","63.70","731.00","1 through 10","755.54","1937.6","percent of total billed charges",""
"BONE PLATE 3X1.5MM HOLE CRANIAL MATRIXMANDIBLE TI CRESCENT","SUP-ITM-10081106","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.23","1827.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1045.57","42.9","","384.74","384.74","384.74","1 through 10","755.54","1937.6","percent of total billed charges",""
"BONE PLATE 3X1.5MM HOLE CRANIAL MATRIXMANDIBLE TI CRESCENT","SUP-ITM-10081106","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.23","1827.92","WELLPOINT [1015]","HB AMC WELLPOINT","1798.19","73.78","","286.63","119.22","1107.45","105","755.54","1937.6","percent of total billed charges",""
"BONE PLATE 3X1.5MM HOLE CRANIAL MATRIXMANDIBLE TI CRESCENT","SUP-ITM-10081106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2437.23","1827.92","AETNA [1001]","HB AMC AETNA HMO","1701.19","69.8","","675.31","184.75","1721.50","286","1273.7","1991.7","percent of total billed charges",""
"BONE PLATE 3X1.5MM HOLE CRANIAL MATRIXMANDIBLE TI CRESCENT","SUP-ITM-10081106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2437.23","1827.92","AETNA [1001]","HB AMC AETNA PPO","1959.53","80.4","","1261.44","103.12","1514.10","21","1273.7","1991.7","percent of total billed charges",""
"BONE PLATE 3X1.5MM HOLE CRANIAL MATRIXMANDIBLE TI CRESCENT","SUP-ITM-10081106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2437.23","1827.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1959.53","80.4","","1365.00","1365.00","1365.00","1 through 10","1273.7","1991.7","percent of total billed charges",""
"BONE PLATE 3X1.5MM HOLE CRANIAL MATRIXMANDIBLE TI CRESCENT","SUP-ITM-10081106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2437.23","1827.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1991.70","81.72","","5157.68","5157.68","5157.68","1 through 10","1273.7","1991.7","percent of total billed charges",""
"BONE PLATE 3X1.5MM HOLE CRANIAL MATRIXMANDIBLE TI CRESCENT","SUP-ITM-10081106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2437.23","1827.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1991.70","81.72","","431.26","71.26","1459.57","88","1273.7","1991.7","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.67","667.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","707.29","79.5","","800.18","480.96","1887.97","195","275.8","707.29","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.67","667.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","474.19","53.3","","813.12","216.42","1444.50","81","275.8","707.29","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.67","667.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","275.80","31","","432.60","432.60","432.60","1 through 10","275.8","707.29","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.67","667.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","324.73","36.5","","148.37","54.89","631.39","94","275.8","707.29","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.67","667.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","340.74","38.3","","279.30","91.72","1116.77","266","275.8","707.29","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.67","667.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","381.67","42.9","","731.00","63.70","731.00","1 through 10","275.8","707.29","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.67","667.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","381.67","42.9","","384.74","384.74","384.74","1 through 10","275.8","707.29","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.67","667.25","WELLPOINT [1015]","HB AMC WELLPOINT","656.40","73.78","","286.63","119.22","1107.45","105","275.8","707.29","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.67","667.25","AETNA [1001]","HB AMC AETNA HMO","620.99","69.8","","675.31","184.75","1721.50","286","464.94","727.04","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.67","667.25","AETNA [1001]","HB AMC AETNA PPO","715.29","80.4","","1261.44","103.12","1514.10","21","464.94","727.04","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.67","667.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","715.29","80.4","","1365.00","1365.00","1365.00","1 through 10","464.94","727.04","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.67","667.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","727.04","81.72","","5157.68","5157.68","5157.68","1 through 10","464.94","727.04","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.67","667.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","727.04","81.72","","431.26","71.26","1459.57","88","464.94","727.04","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.81","697.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","739.20","79.5","","800.18","480.96","1887.97","195","288.24","739.2","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.81","697.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","495.59","53.3","","813.12","216.42","1444.50","81","288.24","739.2","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.81","697.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","288.24","31","","432.60","432.60","432.60","1 through 10","288.24","739.2","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.81","697.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","339.38","36.5","","148.37","54.89","631.39","94","288.24","739.2","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.81","697.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","356.12","38.3","","279.30","91.72","1116.77","266","288.24","739.2","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.81","697.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","398.89","42.9","","731.00","63.70","731.00","1 through 10","288.24","739.2","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.81","697.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","398.89","42.9","","384.74","384.74","384.74","1 through 10","288.24","739.2","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","929.81","697.36","WELLPOINT [1015]","HB AMC WELLPOINT","686.01","73.78","","286.63","119.22","1107.45","105","288.24","739.2","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","929.81","697.36","AETNA [1001]","HB AMC AETNA HMO","649.01","69.8","","675.31","184.75","1721.50","286","485.92","759.84","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","929.81","697.36","AETNA [1001]","HB AMC AETNA PPO","747.57","80.4","","1261.44","103.12","1514.10","21","485.92","759.84","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","929.81","697.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","747.57","80.4","","1365.00","1365.00","1365.00","1 through 10","485.92","759.84","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","929.81","697.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","759.84","81.72","","5157.68","5157.68","5157.68","1 through 10","485.92","759.84","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","929.81","697.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","759.84","81.72","","431.26","71.26","1459.57","88","485.92","759.84","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.25","728.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","772.14","79.5","","800.18","480.96","1887.97","195","301.09","772.14","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.25","728.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","517.68","53.3","","813.12","216.42","1444.50","81","301.09","772.14","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.25","728.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","301.09","31","","432.60","432.60","432.60","1 through 10","301.09","772.14","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.25","728.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","354.51","36.5","","148.37","54.89","631.39","94","301.09","772.14","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.25","728.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","371.99","38.3","","279.30","91.72","1116.77","266","301.09","772.14","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.25","728.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","416.67","42.9","","731.00","63.70","731.00","1 through 10","301.09","772.14","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.25","728.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","416.67","42.9","","384.74","384.74","384.74","1 through 10","301.09","772.14","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.25","728.44","WELLPOINT [1015]","HB AMC WELLPOINT","716.59","73.78","","286.63","119.22","1107.45","105","301.09","772.14","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","971.25","728.44","AETNA [1001]","HB AMC AETNA HMO","677.93","69.8","","675.31","184.75","1721.50","286","507.58","793.71","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","971.25","728.44","AETNA [1001]","HB AMC AETNA PPO","780.89","80.4","","1261.44","103.12","1514.10","21","507.58","793.71","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","971.25","728.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","780.89","80.4","","1365.00","1365.00","1365.00","1 through 10","507.58","793.71","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","971.25","728.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","793.71","81.72","","5157.68","5157.68","5157.68","1 through 10","507.58","793.71","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","971.25","728.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","793.71","81.72","","431.26","71.26","1459.57","88","507.58","793.71","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1054.13","790.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","838.03","79.5","","800.18","480.96","1887.97","195","326.78","838.03","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1054.13","790.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","561.85","53.3","","813.12","216.42","1444.50","81","326.78","838.03","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1054.13","790.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","326.78","31","","432.60","432.60","432.60","1 through 10","326.78","838.03","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1054.13","790.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","384.76","36.5","","148.37","54.89","631.39","94","326.78","838.03","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1054.13","790.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","403.73","38.3","","279.30","91.72","1116.77","266","326.78","838.03","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1054.13","790.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","452.22","42.9","","731.00","63.70","731.00","1 through 10","326.78","838.03","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1054.13","790.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","452.22","42.9","","384.74","384.74","384.74","1 through 10","326.78","838.03","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1054.13","790.60","WELLPOINT [1015]","HB AMC WELLPOINT","777.74","73.78","","286.63","119.22","1107.45","105","326.78","838.03","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1054.13","790.60","AETNA [1001]","HB AMC AETNA HMO","735.78","69.8","","675.31","184.75","1721.50","286","550.89","861.44","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1054.13","790.60","AETNA [1001]","HB AMC AETNA PPO","847.52","80.4","","1261.44","103.12","1514.10","21","550.89","861.44","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1054.13","790.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","847.52","80.4","","1365.00","1365.00","1365.00","1 through 10","550.89","861.44","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1054.13","790.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","861.44","81.72","","5157.68","5157.68","5157.68","1 through 10","550.89","861.44","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1054.13","790.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","861.44","81.72","","431.26","71.26","1459.57","88","550.89","861.44","percent of total billed charges",""
"BONE PLATE 3XLT 0.8MM 4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077444","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.33","405.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","429.56","79.5","","800.18","480.96","1887.97","195","167.5","429.56","percent of total billed charges",""
"BONE PLATE 3XLT 0.8MM 4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077444","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.33","405.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","288.00","53.3","","813.12","216.42","1444.50","81","167.5","429.56","percent of total billed charges",""
"BONE PLATE 3XLT 0.8MM 4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077444","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.33","405.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","167.50","31","","432.60","432.60","432.60","1 through 10","167.5","429.56","percent of total billed charges",""
"BONE PLATE 3XLT 0.8MM 4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077444","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.33","405.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","197.22","36.5","","148.37","54.89","631.39","94","167.5","429.56","percent of total billed charges",""
"BONE PLATE 3XLT 0.8MM 4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077444","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.33","405.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","206.95","38.3","","279.30","91.72","1116.77","266","167.5","429.56","percent of total billed charges",""
"BONE PLATE 3XLT 0.8MM 4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077444","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.33","405.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.80","42.9","","731.00","63.70","731.00","1 through 10","167.5","429.56","percent of total billed charges",""
"BONE PLATE 3XLT 0.8MM 4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077444","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.33","405.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.80","42.9","","384.74","384.74","384.74","1 through 10","167.5","429.56","percent of total billed charges",""
"BONE PLATE 3XLT 0.8MM 4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077444","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.33","405.25","WELLPOINT [1015]","HB AMC WELLPOINT","398.66","73.78","","286.63","119.22","1107.45","105","167.5","429.56","percent of total billed charges",""
"BONE PLATE 3XLT 0.8MM 4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.33","405.25","AETNA [1001]","HB AMC AETNA HMO","377.15","69.8","","675.31","184.75","1721.50","286","282.38","441.56","percent of total billed charges",""
"BONE PLATE 3XLT 0.8MM 4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.33","405.25","AETNA [1001]","HB AMC AETNA PPO","434.43","80.4","","1261.44","103.12","1514.10","21","282.38","441.56","percent of total billed charges",""
"BONE PLATE 3XLT 0.8MM 4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.33","405.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","434.43","80.4","","1365.00","1365.00","1365.00","1 through 10","282.38","441.56","percent of total billed charges",""
"BONE PLATE 3XLT 0.8MM 4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.33","405.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","441.56","81.72","","5157.68","5157.68","5157.68","1 through 10","282.38","441.56","percent of total billed charges",""
"BONE PLATE 3XLT 0.8MM 4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TI OBLIQUE L SHAPE","SUP-ITM-10077444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.33","405.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","441.56","81.72","","431.26","71.26","1459.57","88","282.38","441.56","percent of total billed charges",""
"BONE PLATE 4 2.4X58MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10021541","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.22","1666.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1766.66","79.5","","800.18","480.96","1887.97","195","688.89","1766.66","percent of total billed charges",""
"BONE PLATE 4 2.4X58MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10021541","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.22","1666.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1184.44","53.3","","813.12","216.42","1444.50","81","688.89","1766.66","percent of total billed charges",""
"BONE PLATE 4 2.4X58MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10021541","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.22","1666.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","688.89","31","","432.60","432.60","432.60","1 through 10","688.89","1766.66","percent of total billed charges",""
"BONE PLATE 4 2.4X58MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10021541","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.22","1666.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","811.11","36.5","","148.37","54.89","631.39","94","688.89","1766.66","percent of total billed charges",""
"BONE PLATE 4 2.4X58MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10021541","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.22","1666.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","851.11","38.3","","279.30","91.72","1116.77","266","688.89","1766.66","percent of total billed charges",""
"BONE PLATE 4 2.4X58MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10021541","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.22","1666.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.33","42.9","","731.00","63.70","731.00","1 through 10","688.89","1766.66","percent of total billed charges",""
"BONE PLATE 4 2.4X58MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10021541","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.22","1666.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.33","42.9","","384.74","384.74","384.74","1 through 10","688.89","1766.66","percent of total billed charges",""
"BONE PLATE 4 2.4X58MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10021541","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.22","1666.66","WELLPOINT [1015]","HB AMC WELLPOINT","1639.55","73.78","","286.63","119.22","1107.45","105","688.89","1766.66","percent of total billed charges",""
"BONE PLATE 4 2.4X58MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10021541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.22","1666.66","AETNA [1001]","HB AMC AETNA HMO","1551.11","69.8","","675.31","184.75","1721.50","286","1161.33","1816","percent of total billed charges",""
"BONE PLATE 4 2.4X58MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10021541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.22","1666.66","AETNA [1001]","HB AMC AETNA PPO","1786.66","80.4","","1261.44","103.12","1514.10","21","1161.33","1816","percent of total billed charges",""
"BONE PLATE 4 2.4X58MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10021541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.22","1666.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1786.66","80.4","","1365.00","1365.00","1365.00","1 through 10","1161.33","1816","percent of total billed charges",""
"BONE PLATE 4 2.4X58MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10021541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.22","1666.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1816.00","81.72","","5157.68","5157.68","5157.68","1 through 10","1161.33","1816","percent of total billed charges",""
"BONE PLATE 4 2.4X58MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10021541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.22","1666.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1816.00","81.72","","431.26","71.26","1459.57","88","1161.33","1816","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2509.82","79.5","","800.18","480.96","1887.97","195","978.67","2509.82","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1682.68","53.3","","813.12","216.42","1444.50","81","978.67","2509.82","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","978.67","31","","432.60","432.60","432.60","1 through 10","978.67","2509.82","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1152.31","36.5","","148.37","54.89","631.39","94","978.67","2509.82","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1209.13","38.3","","279.30","91.72","1116.77","266","978.67","2509.82","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","731.00","63.70","731.00","1 through 10","978.67","2509.82","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","384.74","384.74","384.74","1 through 10","978.67","2509.82","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","WELLPOINT [1015]","HB AMC WELLPOINT","2329.23","73.78","","286.63","119.22","1107.45","105","978.67","2509.82","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA HMO","2203.59","69.8","","675.31","184.75","1721.50","286","1649.85","2579.9","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA PPO","2538.23","80.4","","1261.44","103.12","1514.10","21","1649.85","2579.9","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2538.23","80.4","","1365.00","1365.00","1365.00","1 through 10","1649.85","2579.9","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2579.90","81.72","","5157.68","5157.68","5157.68","1 through 10","1649.85","2579.9","percent of total billed charges",""
"BONE PLATE 4 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2579.90","81.72","","431.26","71.26","1459.57","88","1649.85","2579.9","percent of total billed charges",""
"BONE PLATE 4 HOLE TI TOMOFIX MEDIAL DISTAL FEMUR PL//LEFT","SUP-ITM-10163864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.45","3373.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3576.27","79.5","","800.18","480.96","1887.97","195","1394.52","3576.27","percent of total billed charges",""
"BONE PLATE 4 HOLE TI TOMOFIX MEDIAL DISTAL FEMUR PL//LEFT","SUP-ITM-10163864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.45","3373.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2397.67","53.3","","813.12","216.42","1444.50","81","1394.52","3576.27","percent of total billed charges",""
"BONE PLATE 4 HOLE TI TOMOFIX MEDIAL DISTAL FEMUR PL//LEFT","SUP-ITM-10163864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.45","3373.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1394.52","31","","432.60","432.60","432.60","1 through 10","1394.52","3576.27","percent of total billed charges",""
"BONE PLATE 4 HOLE TI TOMOFIX MEDIAL DISTAL FEMUR PL//LEFT","SUP-ITM-10163864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.45","3373.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1641.93","36.5","","148.37","54.89","631.39","94","1394.52","3576.27","percent of total billed charges",""
"BONE PLATE 4 HOLE TI TOMOFIX MEDIAL DISTAL FEMUR PL//LEFT","SUP-ITM-10163864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.45","3373.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1722.91","38.3","","279.30","91.72","1116.77","266","1394.52","3576.27","percent of total billed charges",""
"BONE PLATE 4 HOLE TI TOMOFIX MEDIAL DISTAL FEMUR PL//LEFT","SUP-ITM-10163864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.45","3373.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1929.84","42.9","","731.00","63.70","731.00","1 through 10","1394.52","3576.27","percent of total billed charges",""
"BONE PLATE 4 HOLE TI TOMOFIX MEDIAL DISTAL FEMUR PL//LEFT","SUP-ITM-10163864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.45","3373.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1929.84","42.9","","384.74","384.74","384.74","1 through 10","1394.52","3576.27","percent of total billed charges",""
"BONE PLATE 4 HOLE TI TOMOFIX MEDIAL DISTAL FEMUR PL//LEFT","SUP-ITM-10163864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.45","3373.84","WELLPOINT [1015]","HB AMC WELLPOINT","3318.96","73.78","","286.63","119.22","1107.45","105","1394.52","3576.27","percent of total billed charges",""
"BONE PLATE 4 HOLE TI TOMOFIX MEDIAL DISTAL FEMUR PL//LEFT","SUP-ITM-10163864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4498.45","3373.84","AETNA [1001]","HB AMC AETNA HMO","3139.92","69.8","","675.31","184.75","1721.50","286","2350.89","3676.13","percent of total billed charges",""
"BONE PLATE 4 HOLE TI TOMOFIX MEDIAL DISTAL FEMUR PL//LEFT","SUP-ITM-10163864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4498.45","3373.84","AETNA [1001]","HB AMC AETNA PPO","3616.75","80.4","","1261.44","103.12","1514.10","21","2350.89","3676.13","percent of total billed charges",""
"BONE PLATE 4 HOLE TI TOMOFIX MEDIAL DISTAL FEMUR PL//LEFT","SUP-ITM-10163864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4498.45","3373.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3616.75","80.4","","1365.00","1365.00","1365.00","1 through 10","2350.89","3676.13","percent of total billed charges",""
"BONE PLATE 4 HOLE TI TOMOFIX MEDIAL DISTAL FEMUR PL//LEFT","SUP-ITM-10163864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4498.45","3373.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3676.13","81.72","","5157.68","5157.68","5157.68","1 through 10","2350.89","3676.13","percent of total billed charges",""
"BONE PLATE 4 HOLE TI TOMOFIX MEDIAL DISTAL FEMUR PL//LEFT","SUP-ITM-10163864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4498.45","3373.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3676.13","81.72","","431.26","71.26","1459.57","88","2350.89","3676.13","percent of total billed charges",""
"BONE PLATE 4 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082151","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3283.35","79.5","","800.18","480.96","1887.97","195","1280.3","3283.35","percent of total billed charges",""
"BONE PLATE 4 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082151","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2201.29","53.3","","813.12","216.42","1444.50","81","1280.3","3283.35","percent of total billed charges",""
"BONE PLATE 4 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082151","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1280.30","31","","432.60","432.60","432.60","1 through 10","1280.3","3283.35","percent of total billed charges",""
"BONE PLATE 4 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082151","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1507.45","36.5","","148.37","54.89","631.39","94","1280.3","3283.35","percent of total billed charges",""
"BONE PLATE 4 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082151","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1581.79","38.3","","279.30","91.72","1116.77","266","1280.3","3283.35","percent of total billed charges",""
"BONE PLATE 4 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082151","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1771.77","42.9","","731.00","63.70","731.00","1 through 10","1280.3","3283.35","percent of total billed charges",""
"BONE PLATE 4 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082151","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1771.77","42.9","","384.74","384.74","384.74","1 through 10","1280.3","3283.35","percent of total billed charges",""
"BONE PLATE 4 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082151","CDM","C1713","HCPCS","0278","RC","","","","both","","","4130.00","3097.50","WELLPOINT [1015]","HB AMC WELLPOINT","3047.11","73.78","","286.63","119.22","1107.45","105","1280.3","3283.35","percent of total billed charges",""
"BONE PLATE 4 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4130.00","3097.50","AETNA [1001]","HB AMC AETNA HMO","2882.74","69.8","","675.31","184.75","1721.50","286","2158.34","3375.04","percent of total billed charges",""
"BONE PLATE 4 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4130.00","3097.50","AETNA [1001]","HB AMC AETNA PPO","3320.52","80.4","","1261.44","103.12","1514.10","21","2158.34","3375.04","percent of total billed charges",""
"BONE PLATE 4 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4130.00","3097.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3320.52","80.4","","1365.00","1365.00","1365.00","1 through 10","2158.34","3375.04","percent of total billed charges",""
"BONE PLATE 4 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4130.00","3097.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3375.04","81.72","","5157.68","5157.68","5157.68","1 through 10","2158.34","3375.04","percent of total billed charges",""
"BONE PLATE 4 SLOT ALPHA MAXLOCK EXTREME IMPLANT","SUP-ITM-10082151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4130.00","3097.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3375.04","81.72","","431.26","71.26","1459.57","88","2158.34","3375.04","percent of total billed charges",""
"BONE PLATE 4.5 3.5X226MM 14 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029061","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2575.87","79.5","","800.18","480.96","1887.97","195","1004.43","2575.87","percent of total billed charges",""
"BONE PLATE 4.5 3.5X226MM 14 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029061","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1726.97","53.3","","813.12","216.42","1444.50","81","1004.43","2575.87","percent of total billed charges",""
"BONE PLATE 4.5 3.5X226MM 14 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029061","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1004.43","31","","432.60","432.60","432.60","1 through 10","1004.43","2575.87","percent of total billed charges",""
"BONE PLATE 4.5 3.5X226MM 14 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029061","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1182.63","36.5","","148.37","54.89","631.39","94","1004.43","2575.87","percent of total billed charges",""
"BONE PLATE 4.5 3.5X226MM 14 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029061","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1240.95","38.3","","279.30","91.72","1116.77","266","1004.43","2575.87","percent of total billed charges",""
"BONE PLATE 4.5 3.5X226MM 14 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029061","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1390.00","42.9","","731.00","63.70","731.00","1 through 10","1004.43","2575.87","percent of total billed charges",""
"BONE PLATE 4.5 3.5X226MM 14 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029061","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1390.00","42.9","","384.74","384.74","384.74","1 through 10","1004.43","2575.87","percent of total billed charges",""
"BONE PLATE 4.5 3.5X226MM 14 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029061","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","WELLPOINT [1015]","HB AMC WELLPOINT","2390.54","73.78","","286.63","119.22","1107.45","105","1004.43","2575.87","percent of total billed charges",""
"BONE PLATE 4.5 3.5X226MM 14 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","AETNA [1001]","HB AMC AETNA HMO","2261.58","69.8","","675.31","184.75","1721.50","286","1693.27","2647.8","percent of total billed charges",""
"BONE PLATE 4.5 3.5X226MM 14 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","AETNA [1001]","HB AMC AETNA PPO","2605.03","80.4","","1261.44","103.12","1514.10","21","1693.27","2647.8","percent of total billed charges",""
"BONE PLATE 4.5 3.5X226MM 14 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2605.03","80.4","","1365.00","1365.00","1365.00","1 through 10","1693.27","2647.8","percent of total billed charges",""
"BONE PLATE 4.5 3.5X226MM 14 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2647.80","81.72","","5157.68","5157.68","5157.68","1 through 10","1693.27","2647.8","percent of total billed charges",""
"BONE PLATE 4.5 3.5X226MM 14 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2647.80","81.72","","431.26","71.26","1459.57","88","1693.27","2647.8","percent of total billed charges",""
"BONE PLATE 4.5-3.5X172MM 11 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029059","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1933.45","79.5","","800.18","480.96","1887.97","195","753.92","1933.45","percent of total billed charges",""
"BONE PLATE 4.5-3.5X172MM 11 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029059","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1296.26","53.3","","813.12","216.42","1444.50","81","753.92","1933.45","percent of total billed charges",""
"BONE PLATE 4.5-3.5X172MM 11 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029059","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","753.92","31","","432.60","432.60","432.60","1 through 10","753.92","1933.45","percent of total billed charges",""
"BONE PLATE 4.5-3.5X172MM 11 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029059","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","887.68","36.5","","148.37","54.89","631.39","94","753.92","1933.45","percent of total billed charges",""
"BONE PLATE 4.5-3.5X172MM 11 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029059","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","931.46","38.3","","279.30","91.72","1116.77","266","753.92","1933.45","percent of total billed charges",""
"BONE PLATE 4.5-3.5X172MM 11 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029059","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1043.33","42.9","","731.00","63.70","731.00","1 through 10","753.92","1933.45","percent of total billed charges",""
"BONE PLATE 4.5-3.5X172MM 11 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029059","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1043.33","42.9","","384.74","384.74","384.74","1 through 10","753.92","1933.45","percent of total billed charges",""
"BONE PLATE 4.5-3.5X172MM 11 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029059","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","WELLPOINT [1015]","HB AMC WELLPOINT","1794.34","73.78","","286.63","119.22","1107.45","105","753.92","1933.45","percent of total billed charges",""
"BONE PLATE 4.5-3.5X172MM 11 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.01","1824.01","AETNA [1001]","HB AMC AETNA HMO","1697.54","69.8","","675.31","184.75","1721.50","286","1270.97","1987.44","percent of total billed charges",""
"BONE PLATE 4.5-3.5X172MM 11 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.01","1824.01","AETNA [1001]","HB AMC AETNA PPO","1955.34","80.4","","1261.44","103.12","1514.10","21","1270.97","1987.44","percent of total billed charges",""
"BONE PLATE 4.5-3.5X172MM 11 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.01","1824.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1955.34","80.4","","1365.00","1365.00","1365.00","1 through 10","1270.97","1987.44","percent of total billed charges",""
"BONE PLATE 4.5-3.5X172MM 11 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.01","1824.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1987.44","81.72","","5157.68","5157.68","5157.68","1 through 10","1270.97","1987.44","percent of total billed charges",""
"BONE PLATE 4.5-3.5X172MM 11 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.01","1824.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1987.44","81.72","","431.26","71.26","1459.57","88","1270.97","1987.44","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.74","3191.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3383.31","79.5","","800.18","480.96","1887.97","195","1319.28","3383.31","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.74","3191.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2268.31","53.3","","813.12","216.42","1444.50","81","1319.28","3383.31","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.74","3191.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1319.28","31","","432.60","432.60","432.60","1 through 10","1319.28","3383.31","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.74","3191.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1553.35","36.5","","148.37","54.89","631.39","94","1319.28","3383.31","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.74","3191.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1629.95","38.3","","279.30","91.72","1116.77","266","1319.28","3383.31","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.74","3191.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1825.71","42.9","","731.00","63.70","731.00","1 through 10","1319.28","3383.31","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.74","3191.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1825.71","42.9","","384.74","384.74","384.74","1 through 10","1319.28","3383.31","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.74","3191.80","WELLPOINT [1015]","HB AMC WELLPOINT","3139.88","73.78","","286.63","119.22","1107.45","105","1319.28","3383.31","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4255.74","3191.80","AETNA [1001]","HB AMC AETNA HMO","2970.51","69.8","","675.31","184.75","1721.50","286","2224.05","3477.79","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4255.74","3191.80","AETNA [1001]","HB AMC AETNA PPO","3421.61","80.4","","1261.44","103.12","1514.10","21","2224.05","3477.79","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4255.74","3191.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3421.61","80.4","","1365.00","1365.00","1365.00","1 through 10","2224.05","3477.79","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4255.74","3191.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3477.79","81.72","","5157.68","5157.68","5157.68","1 through 10","2224.05","3477.79","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4255.74","3191.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3477.79","81.72","","431.26","71.26","1459.57","88","2224.05","3477.79","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","4339.98","3254.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3450.28","79.5","","800.18","480.96","1887.97","195","1345.39","3450.28","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","4339.98","3254.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2313.21","53.3","","813.12","216.42","1444.50","81","1345.39","3450.28","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","4339.98","3254.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1345.39","31","","432.60","432.60","432.60","1 through 10","1345.39","3450.28","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","4339.98","3254.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1584.09","36.5","","148.37","54.89","631.39","94","1345.39","3450.28","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","4339.98","3254.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1662.21","38.3","","279.30","91.72","1116.77","266","1345.39","3450.28","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","4339.98","3254.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1861.85","42.9","","731.00","63.70","731.00","1 through 10","1345.39","3450.28","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","4339.98","3254.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1861.85","42.9","","384.74","384.74","384.74","1 through 10","1345.39","3450.28","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","4339.98","3254.98","WELLPOINT [1015]","HB AMC WELLPOINT","3202.04","73.78","","286.63","119.22","1107.45","105","1345.39","3450.28","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4339.98","3254.98","AETNA [1001]","HB AMC AETNA HMO","3029.31","69.8","","675.31","184.75","1721.50","286","2268.07","3546.63","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4339.98","3254.98","AETNA [1001]","HB AMC AETNA PPO","3489.34","80.4","","1261.44","103.12","1514.10","21","2268.07","3546.63","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4339.98","3254.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3489.34","80.4","","1365.00","1365.00","1365.00","1 through 10","2268.07","3546.63","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4339.98","3254.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3546.63","81.72","","5157.68","5157.68","5157.68","1 through 10","2268.07","3546.63","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4339.98","3254.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3546.63","81.72","","431.26","71.26","1459.57","88","2268.07","3546.63","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.48","3406.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3611.27","79.5","","800.18","480.96","1887.97","195","1408.17","3611.27","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.48","3406.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2421.14","53.3","","813.12","216.42","1444.50","81","1408.17","3611.27","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.48","3406.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1408.17","31","","432.60","432.60","432.60","1 through 10","1408.17","3611.27","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.48","3406.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1658.01","36.5","","148.37","54.89","631.39","94","1408.17","3611.27","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.48","3406.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1739.77","38.3","","279.30","91.72","1116.77","266","1408.17","3611.27","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.48","3406.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.72","42.9","","731.00","63.70","731.00","1 through 10","1408.17","3611.27","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.48","3406.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.72","42.9","","384.74","384.74","384.74","1 through 10","1408.17","3611.27","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.48","3406.86","WELLPOINT [1015]","HB AMC WELLPOINT","3351.44","73.78","","286.63","119.22","1107.45","105","1408.17","3611.27","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.48","3406.86","AETNA [1001]","HB AMC AETNA HMO","3170.65","69.8","","675.31","184.75","1721.50","286","2373.9","3712.11","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.48","3406.86","AETNA [1001]","HB AMC AETNA PPO","3652.15","80.4","","1261.44","103.12","1514.10","21","2373.9","3712.11","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.48","3406.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3652.15","80.4","","1365.00","1365.00","1365.00","1 through 10","2373.9","3712.11","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.48","3406.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3712.11","81.72","","5157.68","5157.68","5157.68","1 through 10","2373.9","3712.11","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.48","3406.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3712.11","81.72","","431.26","71.26","1459.57","88","2373.9","3712.11","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.44","3477.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3685.97","79.5","","800.18","480.96","1887.97","195","1437.3","3685.97","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.44","3477.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2471.22","53.3","","813.12","216.42","1444.50","81","1437.3","3685.97","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.44","3477.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1437.30","31","","432.60","432.60","432.60","1 through 10","1437.3","3685.97","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.44","3477.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1692.30","36.5","","148.37","54.89","631.39","94","1437.3","3685.97","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.44","3477.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1775.76","38.3","","279.30","91.72","1116.77","266","1437.3","3685.97","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.44","3477.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1989.03","42.9","","731.00","63.70","731.00","1 through 10","1437.3","3685.97","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.44","3477.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1989.03","42.9","","384.74","384.74","384.74","1 through 10","1437.3","3685.97","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.44","3477.33","WELLPOINT [1015]","HB AMC WELLPOINT","3420.77","73.78","","286.63","119.22","1107.45","105","1437.3","3685.97","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.44","3477.33","AETNA [1001]","HB AMC AETNA HMO","3236.24","69.8","","675.31","184.75","1721.50","286","2423","3788.9","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.44","3477.33","AETNA [1001]","HB AMC AETNA PPO","3727.70","80.4","","1261.44","103.12","1514.10","21","2423","3788.9","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.44","3477.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3727.70","80.4","","1365.00","1365.00","1365.00","1 through 10","2423","3788.9","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.44","3477.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3788.90","81.72","","5157.68","5157.68","5157.68","1 through 10","2423","3788.9","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.44","3477.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3788.90","81.72","","431.26","71.26","1459.57","88","2423","3788.9","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","5044.68","3783.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4010.52","79.5","","800.18","480.96","1887.97","195","1563.85","4010.52","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","5044.68","3783.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2688.81","53.3","","813.12","216.42","1444.50","81","1563.85","4010.52","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","5044.68","3783.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1563.85","31","","432.60","432.60","432.60","1 through 10","1563.85","4010.52","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","5044.68","3783.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1841.31","36.5","","148.37","54.89","631.39","94","1563.85","4010.52","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","5044.68","3783.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1932.11","38.3","","279.30","91.72","1116.77","266","1563.85","4010.52","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","5044.68","3783.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2164.17","42.9","","731.00","63.70","731.00","1 through 10","1563.85","4010.52","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","5044.68","3783.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2164.17","42.9","","384.74","384.74","384.74","1 through 10","1563.85","4010.52","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","5044.68","3783.51","WELLPOINT [1015]","HB AMC WELLPOINT","3721.96","73.78","","286.63","119.22","1107.45","105","1563.85","4010.52","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5044.68","3783.51","AETNA [1001]","HB AMC AETNA HMO","3521.19","69.8","","675.31","184.75","1721.50","286","2636.35","4122.51","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5044.68","3783.51","AETNA [1001]","HB AMC AETNA PPO","4055.92","80.4","","1261.44","103.12","1514.10","21","2636.35","4122.51","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5044.68","3783.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4055.92","80.4","","1365.00","1365.00","1365.00","1 through 10","2636.35","4122.51","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5044.68","3783.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4122.51","81.72","","5157.68","5157.68","5157.68","1 through 10","2636.35","4122.51","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5044.68","3783.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4122.51","81.72","","431.26","71.26","1459.57","88","2636.35","4122.51","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","5371.92","4028.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4270.68","79.5","","800.18","480.96","1887.97","195","1665.3","4270.68","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","5371.92","4028.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2863.23","53.3","","813.12","216.42","1444.50","81","1665.3","4270.68","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","5371.92","4028.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1665.30","31","","432.60","432.60","432.60","1 through 10","1665.3","4270.68","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","5371.92","4028.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1960.75","36.5","","148.37","54.89","631.39","94","1665.3","4270.68","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","5371.92","4028.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2057.45","38.3","","279.30","91.72","1116.77","266","1665.3","4270.68","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","5371.92","4028.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2304.55","42.9","","731.00","63.70","731.00","1 through 10","1665.3","4270.68","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","5371.92","4028.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2304.55","42.9","","384.74","384.74","384.74","1 through 10","1665.3","4270.68","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","5371.92","4028.94","WELLPOINT [1015]","HB AMC WELLPOINT","3963.40","73.78","","286.63","119.22","1107.45","105","1665.3","4270.68","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5371.92","4028.94","AETNA [1001]","HB AMC AETNA HMO","3749.60","69.8","","675.31","184.75","1721.50","286","2807.37","4389.93","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5371.92","4028.94","AETNA [1001]","HB AMC AETNA PPO","4319.02","80.4","","1261.44","103.12","1514.10","21","2807.37","4389.93","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5371.92","4028.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4319.02","80.4","","1365.00","1365.00","1365.00","1 through 10","2807.37","4389.93","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5371.92","4028.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4389.93","81.72","","5157.68","5157.68","5157.68","1 through 10","2807.37","4389.93","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5371.92","4028.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4389.93","81.72","","431.26","71.26","1459.57","88","2807.37","4389.93","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5200.40","79.5","","800.18","480.96","1887.97","195","2027.83","5200.4","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3486.56","53.3","","813.12","216.42","1444.50","81","2027.83","5200.4","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2027.83","31","","432.60","432.60","432.60","1 through 10","2027.83","5200.4","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2387.60","36.5","","148.37","54.89","631.39","94","2027.83","5200.4","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2505.35","38.3","","279.30","91.72","1116.77","266","2027.83","5200.4","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2806.25","42.9","","731.00","63.70","731.00","1 through 10","2027.83","5200.4","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2806.25","42.9","","384.74","384.74","384.74","1 through 10","2027.83","5200.4","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","WELLPOINT [1015]","HB AMC WELLPOINT","4826.23","73.78","","286.63","119.22","1107.45","105","2027.83","5200.4","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6541.38","4906.03","AETNA [1001]","HB AMC AETNA HMO","4565.88","69.8","","675.31","184.75","1721.50","286","3418.53","5345.62","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6541.38","4906.03","AETNA [1001]","HB AMC AETNA PPO","5259.27","80.4","","1261.44","103.12","1514.10","21","3418.53","5345.62","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6541.38","4906.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5259.27","80.4","","1365.00","1365.00","1365.00","1 through 10","3418.53","5345.62","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6541.38","4906.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5345.62","81.72","","5157.68","5157.68","5157.68","1 through 10","3418.53","5345.62","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6541.38","4906.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5345.62","81.72","","431.26","71.26","1459.57","88","3418.53","5345.62","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","both","","","5911.65","4433.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4699.76","79.5","","800.18","480.96","1887.97","195","1832.61","4699.76","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","both","","","5911.65","4433.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3150.91","53.3","","813.12","216.42","1444.50","81","1832.61","4699.76","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","both","","","5911.65","4433.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1832.61","31","","432.60","432.60","432.60","1 through 10","1832.61","4699.76","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","both","","","5911.65","4433.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2157.75","36.5","","148.37","54.89","631.39","94","1832.61","4699.76","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","both","","","5911.65","4433.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2264.16","38.3","","279.30","91.72","1116.77","266","1832.61","4699.76","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","both","","","5911.65","4433.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2536.10","42.9","","731.00","63.70","731.00","1 through 10","1832.61","4699.76","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","both","","","5911.65","4433.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2536.10","42.9","","384.74","384.74","384.74","1 through 10","1832.61","4699.76","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","both","","","5911.65","4433.74","WELLPOINT [1015]","HB AMC WELLPOINT","4361.62","73.78","","286.63","119.22","1107.45","105","1832.61","4699.76","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5911.65","4433.74","AETNA [1001]","HB AMC AETNA HMO","4126.33","69.8","","675.31","184.75","1721.50","286","3089.43","4831","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5911.65","4433.74","AETNA [1001]","HB AMC AETNA PPO","4752.97","80.4","","1261.44","103.12","1514.10","21","3089.43","4831","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5911.65","4433.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4752.97","80.4","","1365.00","1365.00","1365.00","1 through 10","3089.43","4831","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5911.65","4433.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4831.00","81.72","","5157.68","5157.68","5157.68","1 through 10","3089.43","4831","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5911.65","4433.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4831.00","81.72","","431.26","71.26","1459.57","88","3089.43","4831","percent of total billed charges",""
"BONE PLATE 4.5MM /314 1OLE LCP CONDYLE STAINLESS RIGHT","SUP-ITM-10011596","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.75","3017.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3198.88","79.5","","800.18","480.96","1887.97","195","1247.36","3198.88","percent of total billed charges",""
"BONE PLATE 4.5MM /314 1OLE LCP CONDYLE STAINLESS RIGHT","SUP-ITM-10011596","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.75","3017.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2144.66","53.3","","813.12","216.42","1444.50","81","1247.36","3198.88","percent of total billed charges",""
"BONE PLATE 4.5MM /314 1OLE LCP CONDYLE STAINLESS RIGHT","SUP-ITM-10011596","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.75","3017.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1247.36","31","","432.60","432.60","432.60","1 through 10","1247.36","3198.88","percent of total billed charges",""
"BONE PLATE 4.5MM /314 1OLE LCP CONDYLE STAINLESS RIGHT","SUP-ITM-10011596","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.75","3017.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1468.67","36.5","","148.37","54.89","631.39","94","1247.36","3198.88","percent of total billed charges",""
"BONE PLATE 4.5MM /314 1OLE LCP CONDYLE STAINLESS RIGHT","SUP-ITM-10011596","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.75","3017.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1541.10","38.3","","279.30","91.72","1116.77","266","1247.36","3198.88","percent of total billed charges",""
"BONE PLATE 4.5MM /314 1OLE LCP CONDYLE STAINLESS RIGHT","SUP-ITM-10011596","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.75","3017.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.19","42.9","","731.00","63.70","731.00","1 through 10","1247.36","3198.88","percent of total billed charges",""
"BONE PLATE 4.5MM /314 1OLE LCP CONDYLE STAINLESS RIGHT","SUP-ITM-10011596","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.75","3017.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.19","42.9","","384.74","384.74","384.74","1 through 10","1247.36","3198.88","percent of total billed charges",""
"BONE PLATE 4.5MM /314 1OLE LCP CONDYLE STAINLESS RIGHT","SUP-ITM-10011596","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.75","3017.81","WELLPOINT [1015]","HB AMC WELLPOINT","2968.72","73.78","","286.63","119.22","1107.45","105","1247.36","3198.88","percent of total billed charges",""
"BONE PLATE 4.5MM /314 1OLE LCP CONDYLE STAINLESS RIGHT","SUP-ITM-10011596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4023.75","3017.81","AETNA [1001]","HB AMC AETNA HMO","2808.58","69.8","","675.31","184.75","1721.50","286","2102.81","3288.21","percent of total billed charges",""
"BONE PLATE 4.5MM /314 1OLE LCP CONDYLE STAINLESS RIGHT","SUP-ITM-10011596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4023.75","3017.81","AETNA [1001]","HB AMC AETNA PPO","3235.10","80.4","","1261.44","103.12","1514.10","21","2102.81","3288.21","percent of total billed charges",""
"BONE PLATE 4.5MM /314 1OLE LCP CONDYLE STAINLESS RIGHT","SUP-ITM-10011596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4023.75","3017.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3235.10","80.4","","1365.00","1365.00","1365.00","1 through 10","2102.81","3288.21","percent of total billed charges",""
"BONE PLATE 4.5MM /314 1OLE LCP CONDYLE STAINLESS RIGHT","SUP-ITM-10011596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4023.75","3017.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3288.21","81.72","","5157.68","5157.68","5157.68","1 through 10","2102.81","3288.21","percent of total billed charges",""
"BONE PLATE 4.5MM /314 1OLE LCP CONDYLE STAINLESS RIGHT","SUP-ITM-10011596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4023.75","3017.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3288.21","81.72","","431.26","71.26","1459.57","88","2102.81","3288.21","percent of total billed charges",""
"BONE PLATE 4.5X113MM 6 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037688","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.89","974.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1032.62","79.5","","800.18","480.96","1887.97","195","402.66","1032.62","percent of total billed charges",""
"BONE PLATE 4.5X113MM 6 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037688","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.89","974.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","692.31","53.3","","813.12","216.42","1444.50","81","402.66","1032.62","percent of total billed charges",""
"BONE PLATE 4.5X113MM 6 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037688","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.89","974.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","402.66","31","","432.60","432.60","432.60","1 through 10","402.66","1032.62","percent of total billed charges",""
"BONE PLATE 4.5X113MM 6 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037688","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.89","974.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","474.09","36.5","","148.37","54.89","631.39","94","402.66","1032.62","percent of total billed charges",""
"BONE PLATE 4.5X113MM 6 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037688","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.89","974.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","497.47","38.3","","279.30","91.72","1116.77","266","402.66","1032.62","percent of total billed charges",""
"BONE PLATE 4.5X113MM 6 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037688","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.89","974.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","557.22","42.9","","731.00","63.70","731.00","1 through 10","402.66","1032.62","percent of total billed charges",""
"BONE PLATE 4.5X113MM 6 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037688","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.89","974.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","557.22","42.9","","384.74","384.74","384.74","1 through 10","402.66","1032.62","percent of total billed charges",""
"BONE PLATE 4.5X113MM 6 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037688","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.89","974.17","WELLPOINT [1015]","HB AMC WELLPOINT","958.32","73.78","","286.63","119.22","1107.45","105","402.66","1032.62","percent of total billed charges",""
"BONE PLATE 4.5X113MM 6 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037688","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1298.89","974.17","AETNA [1001]","HB AMC AETNA HMO","906.63","69.8","","675.31","184.75","1721.50","286","678.8","1061.45","percent of total billed charges",""
"BONE PLATE 4.5X113MM 6 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037688","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1298.89","974.17","AETNA [1001]","HB AMC AETNA PPO","1044.31","80.4","","1261.44","103.12","1514.10","21","678.8","1061.45","percent of total billed charges",""
"BONE PLATE 4.5X113MM 6 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037688","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1298.89","974.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1044.31","80.4","","1365.00","1365.00","1365.00","1 through 10","678.8","1061.45","percent of total billed charges",""
"BONE PLATE 4.5X113MM 6 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037688","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1298.89","974.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1061.45","81.72","","5157.68","5157.68","5157.68","1 through 10","678.8","1061.45","percent of total billed charges",""
"BONE PLATE 4.5X113MM 6 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037688","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1298.89","974.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1061.45","81.72","","431.26","71.26","1459.57","88","678.8","1061.45","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1744.37","1308.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1386.77","79.5","","800.18","480.96","1887.97","195","540.75","1386.77","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1744.37","1308.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","929.75","53.3","","813.12","216.42","1444.50","81","540.75","1386.77","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1744.37","1308.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","540.75","31","","432.60","432.60","432.60","1 through 10","540.75","1386.77","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1744.37","1308.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","636.70","36.5","","148.37","54.89","631.39","94","540.75","1386.77","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1744.37","1308.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","668.09","38.3","","279.30","91.72","1116.77","266","540.75","1386.77","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1744.37","1308.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","748.33","42.9","","731.00","63.70","731.00","1 through 10","540.75","1386.77","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1744.37","1308.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","748.33","42.9","","384.74","384.74","384.74","1 through 10","540.75","1386.77","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1744.37","1308.28","WELLPOINT [1015]","HB AMC WELLPOINT","1287.00","73.78","","286.63","119.22","1107.45","105","540.75","1386.77","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1744.37","1308.28","AETNA [1001]","HB AMC AETNA HMO","1217.57","69.8","","675.31","184.75","1721.50","286","911.61","1425.5","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1744.37","1308.28","AETNA [1001]","HB AMC AETNA PPO","1402.47","80.4","","1261.44","103.12","1514.10","21","911.61","1425.5","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1744.37","1308.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1402.47","80.4","","1365.00","1365.00","1365.00","1 through 10","911.61","1425.5","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1744.37","1308.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1425.50","81.72","","5157.68","5157.68","5157.68","1 through 10","911.61","1425.5","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1744.37","1308.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1425.50","81.72","","431.26","71.26","1459.57","88","911.61","1425.5","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","969.81","79.5","","800.18","480.96","1887.97","195","378.17","969.81","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","650.20","53.3","","813.12","216.42","1444.50","81","378.17","969.81","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","378.17","31","","432.60","432.60","432.60","1 through 10","378.17","969.81","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","445.26","36.5","","148.37","54.89","631.39","94","378.17","969.81","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","467.22","38.3","","279.30","91.72","1116.77","266","378.17","969.81","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","523.33","42.9","","731.00","63.70","731.00","1 through 10","378.17","969.81","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","523.33","42.9","","384.74","384.74","384.74","1 through 10","378.17","969.81","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","WELLPOINT [1015]","HB AMC WELLPOINT","900.03","73.78","","286.63","119.22","1107.45","105","378.17","969.81","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.89","914.92","AETNA [1001]","HB AMC AETNA HMO","851.48","69.8","","675.31","184.75","1721.50","286","637.51","996.89","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.89","914.92","AETNA [1001]","HB AMC AETNA PPO","980.79","80.4","","1261.44","103.12","1514.10","21","637.51","996.89","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.89","914.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","980.79","80.4","","1365.00","1365.00","1365.00","1 through 10","637.51","996.89","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.89","914.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","996.89","81.72","","5157.68","5157.68","5157.68","1 through 10","637.51","996.89","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.89","914.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","996.89","81.72","","431.26","71.26","1459.57","88","637.51","996.89","percent of total billed charges",""
"BONE PLATE 4.5X125MM LCP RECONSTRUCTION STAINLESS BROAD PELVIC STRAIGHT 8 HOLE","SUP-ITM-10004225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.84","1178.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1248.82","79.5","","800.18","480.96","1887.97","195","486.96","1248.82","percent of total billed charges",""
"BONE PLATE 4.5X125MM LCP RECONSTRUCTION STAINLESS BROAD PELVIC STRAIGHT 8 HOLE","SUP-ITM-10004225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.84","1178.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","837.26","53.3","","813.12","216.42","1444.50","81","486.96","1248.82","percent of total billed charges",""
"BONE PLATE 4.5X125MM LCP RECONSTRUCTION STAINLESS BROAD PELVIC STRAIGHT 8 HOLE","SUP-ITM-10004225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.84","1178.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","486.96","31","","432.60","432.60","432.60","1 through 10","486.96","1248.82","percent of total billed charges",""
"BONE PLATE 4.5X125MM LCP RECONSTRUCTION STAINLESS BROAD PELVIC STRAIGHT 8 HOLE","SUP-ITM-10004225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.84","1178.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","573.36","36.5","","148.37","54.89","631.39","94","486.96","1248.82","percent of total billed charges",""
"BONE PLATE 4.5X125MM LCP RECONSTRUCTION STAINLESS BROAD PELVIC STRAIGHT 8 HOLE","SUP-ITM-10004225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.84","1178.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","601.63","38.3","","279.30","91.72","1116.77","266","486.96","1248.82","percent of total billed charges",""
"BONE PLATE 4.5X125MM LCP RECONSTRUCTION STAINLESS BROAD PELVIC STRAIGHT 8 HOLE","SUP-ITM-10004225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.84","1178.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","673.89","42.9","","731.00","63.70","731.00","1 through 10","486.96","1248.82","percent of total billed charges",""
"BONE PLATE 4.5X125MM LCP RECONSTRUCTION STAINLESS BROAD PELVIC STRAIGHT 8 HOLE","SUP-ITM-10004225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.84","1178.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","673.89","42.9","","384.74","384.74","384.74","1 through 10","486.96","1248.82","percent of total billed charges",""
"BONE PLATE 4.5X125MM LCP RECONSTRUCTION STAINLESS BROAD PELVIC STRAIGHT 8 HOLE","SUP-ITM-10004225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1570.84","1178.13","WELLPOINT [1015]","HB AMC WELLPOINT","1158.97","73.78","","286.63","119.22","1107.45","105","486.96","1248.82","percent of total billed charges",""
"BONE PLATE 4.5X125MM LCP RECONSTRUCTION STAINLESS BROAD PELVIC STRAIGHT 8 HOLE","SUP-ITM-10004225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1570.84","1178.13","AETNA [1001]","HB AMC AETNA HMO","1096.45","69.8","","675.31","184.75","1721.50","286","820.92","1283.69","percent of total billed charges",""
"BONE PLATE 4.5X125MM LCP RECONSTRUCTION STAINLESS BROAD PELVIC STRAIGHT 8 HOLE","SUP-ITM-10004225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1570.84","1178.13","AETNA [1001]","HB AMC AETNA PPO","1262.96","80.4","","1261.44","103.12","1514.10","21","820.92","1283.69","percent of total billed charges",""
"BONE PLATE 4.5X125MM LCP RECONSTRUCTION STAINLESS BROAD PELVIC STRAIGHT 8 HOLE","SUP-ITM-10004225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1570.84","1178.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1262.96","80.4","","1365.00","1365.00","1365.00","1 through 10","820.92","1283.69","percent of total billed charges",""
"BONE PLATE 4.5X125MM LCP RECONSTRUCTION STAINLESS BROAD PELVIC STRAIGHT 8 HOLE","SUP-ITM-10004225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1570.84","1178.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1283.69","81.72","","5157.68","5157.68","5157.68","1 through 10","820.92","1283.69","percent of total billed charges",""
"BONE PLATE 4.5X125MM LCP RECONSTRUCTION STAINLESS BROAD PELVIC STRAIGHT 8 HOLE","SUP-ITM-10004225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1570.84","1178.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1283.69","81.72","","431.26","71.26","1459.57","88","820.92","1283.69","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP NARROW TITANIUM","SUP-ITM-10040476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1252.27","939.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","995.55","79.5","","800.18","480.96","1887.97","195","388.2","995.55","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP NARROW TITANIUM","SUP-ITM-10040476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1252.27","939.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","667.46","53.3","","813.12","216.42","1444.50","81","388.2","995.55","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP NARROW TITANIUM","SUP-ITM-10040476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1252.27","939.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","388.20","31","","432.60","432.60","432.60","1 through 10","388.2","995.55","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP NARROW TITANIUM","SUP-ITM-10040476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1252.27","939.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","457.08","36.5","","148.37","54.89","631.39","94","388.2","995.55","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP NARROW TITANIUM","SUP-ITM-10040476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1252.27","939.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","479.62","38.3","","279.30","91.72","1116.77","266","388.2","995.55","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP NARROW TITANIUM","SUP-ITM-10040476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1252.27","939.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","537.22","42.9","","731.00","63.70","731.00","1 through 10","388.2","995.55","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP NARROW TITANIUM","SUP-ITM-10040476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1252.27","939.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","537.22","42.9","","384.74","384.74","384.74","1 through 10","388.2","995.55","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP NARROW TITANIUM","SUP-ITM-10040476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1252.27","939.20","WELLPOINT [1015]","HB AMC WELLPOINT","923.92","73.78","","286.63","119.22","1107.45","105","388.2","995.55","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP NARROW TITANIUM","SUP-ITM-10040476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1252.27","939.20","AETNA [1001]","HB AMC AETNA HMO","874.08","69.8","","675.31","184.75","1721.50","286","654.44","1023.36","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP NARROW TITANIUM","SUP-ITM-10040476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1252.27","939.20","AETNA [1001]","HB AMC AETNA PPO","1006.83","80.4","","1261.44","103.12","1514.10","21","654.44","1023.36","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP NARROW TITANIUM","SUP-ITM-10040476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1252.27","939.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1006.83","80.4","","1365.00","1365.00","1365.00","1 through 10","654.44","1023.36","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP NARROW TITANIUM","SUP-ITM-10040476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1252.27","939.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1023.36","81.72","","5157.68","5157.68","5157.68","1 through 10","654.44","1023.36","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP NARROW TITANIUM","SUP-ITM-10040476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1252.27","939.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1023.36","81.72","","431.26","71.26","1459.57","88","654.44","1023.36","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010151","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.29","837.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","887.45","79.5","","800.18","480.96","1887.97","195","346.05","887.45","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010151","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.29","837.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","594.98","53.3","","813.12","216.42","1444.50","81","346.05","887.45","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010151","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.29","837.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","346.05","31","","432.60","432.60","432.60","1 through 10","346.05","887.45","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010151","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.29","837.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","407.45","36.5","","148.37","54.89","631.39","94","346.05","887.45","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010151","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.29","837.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","427.54","38.3","","279.30","91.72","1116.77","266","346.05","887.45","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010151","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.29","837.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","478.89","42.9","","731.00","63.70","731.00","1 through 10","346.05","887.45","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010151","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.29","837.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","478.89","42.9","","384.74","384.74","384.74","1 through 10","346.05","887.45","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010151","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.29","837.22","WELLPOINT [1015]","HB AMC WELLPOINT","823.60","73.78","","286.63","119.22","1107.45","105","346.05","887.45","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.29","837.22","AETNA [1001]","HB AMC AETNA HMO","779.17","69.8","","675.31","184.75","1721.50","286","583.37","912.23","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.29","837.22","AETNA [1001]","HB AMC AETNA PPO","897.50","80.4","","1261.44","103.12","1514.10","21","583.37","912.23","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.29","837.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","897.50","80.4","","1365.00","1365.00","1365.00","1 through 10","583.37","912.23","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.29","837.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","912.23","81.72","","5157.68","5157.68","5157.68","1 through 10","583.37","912.23","percent of total billed charges",""
"BONE PLATE 4.5X134MM 7 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.29","837.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","912.23","81.72","","431.26","71.26","1459.57","88","583.37","912.23","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.32","1512.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1602.97","79.5","","800.18","480.96","1887.97","195","625.06","1602.97","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.32","1512.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1074.70","53.3","","813.12","216.42","1444.50","81","625.06","1602.97","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.32","1512.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","625.06","31","","432.60","432.60","432.60","1 through 10","625.06","1602.97","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.32","1512.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","735.96","36.5","","148.37","54.89","631.39","94","625.06","1602.97","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.32","1512.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","772.25","38.3","","279.30","91.72","1116.77","266","625.06","1602.97","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.32","1512.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","865.00","42.9","","731.00","63.70","731.00","1 through 10","625.06","1602.97","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.32","1512.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","865.00","42.9","","384.74","384.74","384.74","1 through 10","625.06","1602.97","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.32","1512.24","WELLPOINT [1015]","HB AMC WELLPOINT","1487.64","73.78","","286.63","119.22","1107.45","105","625.06","1602.97","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2016.32","1512.24","AETNA [1001]","HB AMC AETNA HMO","1407.39","69.8","","675.31","184.75","1721.50","286","1053.73","1647.74","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2016.32","1512.24","AETNA [1001]","HB AMC AETNA PPO","1621.12","80.4","","1261.44","103.12","1514.10","21","1053.73","1647.74","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2016.32","1512.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1621.12","80.4","","1365.00","1365.00","1365.00","1 through 10","1053.73","1647.74","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2016.32","1512.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1647.74","81.72","","5157.68","5157.68","5157.68","1 through 10","1053.73","1647.74","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2016.32","1512.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1647.74","81.72","","431.26","71.26","1459.57","88","1053.73","1647.74","percent of total billed charges",""
"BONE PLATE 4.5X151MM 8 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037690","CDM","C1713","HCPCS","0278","RC","","","","both","","","1427.09","1070.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1134.54","79.5","","800.18","480.96","1887.97","195","442.4","1134.54","percent of total billed charges",""
"BONE PLATE 4.5X151MM 8 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037690","CDM","C1713","HCPCS","0278","RC","","","","both","","","1427.09","1070.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","760.64","53.3","","813.12","216.42","1444.50","81","442.4","1134.54","percent of total billed charges",""
"BONE PLATE 4.5X151MM 8 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037690","CDM","C1713","HCPCS","0278","RC","","","","both","","","1427.09","1070.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","442.40","31","","432.60","432.60","432.60","1 through 10","442.4","1134.54","percent of total billed charges",""
"BONE PLATE 4.5X151MM 8 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037690","CDM","C1713","HCPCS","0278","RC","","","","both","","","1427.09","1070.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","520.89","36.5","","148.37","54.89","631.39","94","442.4","1134.54","percent of total billed charges",""
"BONE PLATE 4.5X151MM 8 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037690","CDM","C1713","HCPCS","0278","RC","","","","both","","","1427.09","1070.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","546.58","38.3","","279.30","91.72","1116.77","266","442.4","1134.54","percent of total billed charges",""
"BONE PLATE 4.5X151MM 8 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037690","CDM","C1713","HCPCS","0278","RC","","","","both","","","1427.09","1070.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","612.22","42.9","","731.00","63.70","731.00","1 through 10","442.4","1134.54","percent of total billed charges",""
"BONE PLATE 4.5X151MM 8 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037690","CDM","C1713","HCPCS","0278","RC","","","","both","","","1427.09","1070.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","612.22","42.9","","384.74","384.74","384.74","1 through 10","442.4","1134.54","percent of total billed charges",""
"BONE PLATE 4.5X151MM 8 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037690","CDM","C1713","HCPCS","0278","RC","","","","both","","","1427.09","1070.32","WELLPOINT [1015]","HB AMC WELLPOINT","1052.91","73.78","","286.63","119.22","1107.45","105","442.4","1134.54","percent of total billed charges",""
"BONE PLATE 4.5X151MM 8 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1427.09","1070.32","AETNA [1001]","HB AMC AETNA HMO","996.11","69.8","","675.31","184.75","1721.50","286","745.8","1166.22","percent of total billed charges",""
"BONE PLATE 4.5X151MM 8 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1427.09","1070.32","AETNA [1001]","HB AMC AETNA PPO","1147.38","80.4","","1261.44","103.12","1514.10","21","745.8","1166.22","percent of total billed charges",""
"BONE PLATE 4.5X151MM 8 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1427.09","1070.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1147.38","80.4","","1365.00","1365.00","1365.00","1 through 10","745.8","1166.22","percent of total billed charges",""
"BONE PLATE 4.5X151MM 8 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1427.09","1070.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1166.22","81.72","","5157.68","5157.68","5157.68","1 through 10","745.8","1166.22","percent of total billed charges",""
"BONE PLATE 4.5X151MM 8 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1427.09","1070.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1166.22","81.72","","431.26","71.26","1459.57","88","745.8","1166.22","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.64","1022.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1084.09","79.5","","800.18","480.96","1887.97","195","422.73","1084.09","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.64","1022.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","726.82","53.3","","813.12","216.42","1444.50","81","422.73","1084.09","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.64","1022.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","422.73","31","","432.60","432.60","432.60","1 through 10","422.73","1084.09","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.64","1022.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","497.73","36.5","","148.37","54.89","631.39","94","422.73","1084.09","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.64","1022.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","522.27","38.3","","279.30","91.72","1116.77","266","422.73","1084.09","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.64","1022.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.00","42.9","","731.00","63.70","731.00","1 through 10","422.73","1084.09","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.64","1022.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.00","42.9","","384.74","384.74","384.74","1 through 10","422.73","1084.09","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.64","1022.73","WELLPOINT [1015]","HB AMC WELLPOINT","1006.09","73.78","","286.63","119.22","1107.45","105","422.73","1084.09","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1363.64","1022.73","AETNA [1001]","HB AMC AETNA HMO","951.82","69.8","","675.31","184.75","1721.50","286","712.64","1114.37","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1363.64","1022.73","AETNA [1001]","HB AMC AETNA PPO","1096.37","80.4","","1261.44","103.12","1514.10","21","712.64","1114.37","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1363.64","1022.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1096.37","80.4","","1365.00","1365.00","1365.00","1 through 10","712.64","1114.37","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1363.64","1022.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1114.37","81.72","","5157.68","5157.68","5157.68","1 through 10","712.64","1114.37","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1363.64","1022.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1114.37","81.72","","431.26","71.26","1459.57","88","712.64","1114.37","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.94","905.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","959.52","79.5","","800.18","480.96","1887.97","195","374.15","959.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.94","905.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","643.30","53.3","","813.12","216.42","1444.50","81","374.15","959.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.94","905.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","374.15","31","","432.60","432.60","432.60","1 through 10","374.15","959.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.94","905.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","440.53","36.5","","148.37","54.89","631.39","94","374.15","959.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.94","905.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","462.26","38.3","","279.30","91.72","1116.77","266","374.15","959.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.94","905.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","517.78","42.9","","731.00","63.70","731.00","1 through 10","374.15","959.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.94","905.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","517.78","42.9","","384.74","384.74","384.74","1 through 10","374.15","959.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.94","905.20","WELLPOINT [1015]","HB AMC WELLPOINT","890.48","73.78","","286.63","119.22","1107.45","105","374.15","959.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.94","905.20","AETNA [1001]","HB AMC AETNA HMO","842.44","69.8","","675.31","184.75","1721.50","286","630.75","986.31","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.94","905.20","AETNA [1001]","HB AMC AETNA PPO","970.38","80.4","","1261.44","103.12","1514.10","21","630.75","986.31","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.94","905.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","970.38","80.4","","1365.00","1365.00","1365.00","1 through 10","630.75","986.31","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.94","905.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","986.31","81.72","","5157.68","5157.68","5157.68","1 through 10","630.75","986.31","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.94","905.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","986.31","81.72","","431.26","71.26","1459.57","88","630.75","986.31","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.69","1013.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1073.80","79.5","","800.18","480.96","1887.97","195","418.71","1073.8","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.69","1013.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","719.92","53.3","","813.12","216.42","1444.50","81","418.71","1073.8","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.69","1013.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","418.71","31","","432.60","432.60","432.60","1 through 10","418.71","1073.8","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.69","1013.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","493.00","36.5","","148.37","54.89","631.39","94","418.71","1073.8","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.69","1013.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","517.31","38.3","","279.30","91.72","1116.77","266","418.71","1073.8","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.69","1013.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","579.45","42.9","","731.00","63.70","731.00","1 through 10","418.71","1073.8","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.69","1013.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","579.45","42.9","","384.74","384.74","384.74","1 through 10","418.71","1073.8","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.69","1013.02","WELLPOINT [1015]","HB AMC WELLPOINT","996.54","73.78","","286.63","119.22","1107.45","105","418.71","1073.8","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1350.69","1013.02","AETNA [1001]","HB AMC AETNA HMO","942.78","69.8","","675.31","184.75","1721.50","286","705.87","1103.78","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1350.69","1013.02","AETNA [1001]","HB AMC AETNA PPO","1085.95","80.4","","1261.44","103.12","1514.10","21","705.87","1103.78","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1350.69","1013.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1085.95","80.4","","1365.00","1365.00","1365.00","1 through 10","705.87","1103.78","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1350.69","1013.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1103.78","81.72","","5157.68","5157.68","5157.68","1 through 10","705.87","1103.78","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1350.69","1013.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1103.78","81.72","","431.26","71.26","1459.57","88","705.87","1103.78","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4129.76","3097.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3283.16","79.5","","800.18","480.96","1887.97","195","1280.23","3283.16","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4129.76","3097.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2201.16","53.3","","813.12","216.42","1444.50","81","1280.23","3283.16","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4129.76","3097.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1280.23","31","","432.60","432.60","432.60","1 through 10","1280.23","3283.16","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4129.76","3097.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1507.36","36.5","","148.37","54.89","631.39","94","1280.23","3283.16","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4129.76","3097.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1581.70","38.3","","279.30","91.72","1116.77","266","1280.23","3283.16","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4129.76","3097.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1771.67","42.9","","731.00","63.70","731.00","1 through 10","1280.23","3283.16","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4129.76","3097.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1771.67","42.9","","384.74","384.74","384.74","1 through 10","1280.23","3283.16","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4129.76","3097.32","WELLPOINT [1015]","HB AMC WELLPOINT","3046.94","73.78","","286.63","119.22","1107.45","105","1280.23","3283.16","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4129.76","3097.32","AETNA [1001]","HB AMC AETNA HMO","2882.57","69.8","","675.31","184.75","1721.50","286","2158.21","3374.84","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4129.76","3097.32","AETNA [1001]","HB AMC AETNA PPO","3320.33","80.4","","1261.44","103.12","1514.10","21","2158.21","3374.84","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4129.76","3097.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3320.33","80.4","","1365.00","1365.00","1365.00","1 through 10","2158.21","3374.84","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4129.76","3097.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3374.84","81.72","","5157.68","5157.68","5157.68","1 through 10","2158.21","3374.84","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4129.76","3097.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3374.84","81.72","","431.26","71.26","1459.57","88","2158.21","3374.84","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1476.30","1107.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1173.66","79.5","","800.18","480.96","1887.97","195","457.65","1173.66","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1476.30","1107.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","786.87","53.3","","813.12","216.42","1444.50","81","457.65","1173.66","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1476.30","1107.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","457.65","31","","432.60","432.60","432.60","1 through 10","457.65","1173.66","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1476.30","1107.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","538.85","36.5","","148.37","54.89","631.39","94","457.65","1173.66","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1476.30","1107.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","565.42","38.3","","279.30","91.72","1116.77","266","457.65","1173.66","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1476.30","1107.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.33","42.9","","731.00","63.70","731.00","1 through 10","457.65","1173.66","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1476.30","1107.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.33","42.9","","384.74","384.74","384.74","1 through 10","457.65","1173.66","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1476.30","1107.22","WELLPOINT [1015]","HB AMC WELLPOINT","1089.21","73.78","","286.63","119.22","1107.45","105","457.65","1173.66","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1476.30","1107.22","AETNA [1001]","HB AMC AETNA HMO","1030.46","69.8","","675.31","184.75","1721.50","286","771.51","1206.43","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1476.30","1107.22","AETNA [1001]","HB AMC AETNA PPO","1186.95","80.4","","1261.44","103.12","1514.10","21","771.51","1206.43","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1476.30","1107.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1186.95","80.4","","1365.00","1365.00","1365.00","1 through 10","771.51","1206.43","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1476.30","1107.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1206.43","81.72","","5157.68","5157.68","5157.68","1 through 10","771.51","1206.43","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1476.30","1107.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1206.43","81.72","","431.26","71.26","1459.57","88","771.51","1206.43","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1262.63","946.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1003.79","79.5","","800.18","480.96","1887.97","195","391.42","1003.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1262.63","946.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","672.98","53.3","","813.12","216.42","1444.50","81","391.42","1003.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1262.63","946.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","391.42","31","","432.60","432.60","432.60","1 through 10","391.42","1003.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1262.63","946.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","460.86","36.5","","148.37","54.89","631.39","94","391.42","1003.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1262.63","946.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","483.59","38.3","","279.30","91.72","1116.77","266","391.42","1003.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1262.63","946.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","541.67","42.9","","731.00","63.70","731.00","1 through 10","391.42","1003.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1262.63","946.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","541.67","42.9","","384.74","384.74","384.74","1 through 10","391.42","1003.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1262.63","946.97","WELLPOINT [1015]","HB AMC WELLPOINT","931.57","73.78","","286.63","119.22","1107.45","105","391.42","1003.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1262.63","946.97","AETNA [1001]","HB AMC AETNA HMO","881.32","69.8","","675.31","184.75","1721.50","286","659.85","1031.82","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1262.63","946.97","AETNA [1001]","HB AMC AETNA PPO","1015.15","80.4","","1261.44","103.12","1514.10","21","659.85","1031.82","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1262.63","946.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1015.15","80.4","","1365.00","1365.00","1365.00","1 through 10","659.85","1031.82","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1262.63","946.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1031.82","81.72","","5157.68","5157.68","5157.68","1 through 10","659.85","1031.82","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1262.63","946.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1031.82","81.72","","431.26","71.26","1459.57","88","659.85","1031.82","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1465.94","1099.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1165.42","79.5","","800.18","480.96","1887.97","195","454.44","1165.42","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1465.94","1099.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","781.35","53.3","","813.12","216.42","1444.50","81","454.44","1165.42","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1465.94","1099.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","454.44","31","","432.60","432.60","432.60","1 through 10","454.44","1165.42","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1465.94","1099.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","535.07","36.5","","148.37","54.89","631.39","94","454.44","1165.42","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1465.94","1099.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","561.46","38.3","","279.30","91.72","1116.77","266","454.44","1165.42","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1465.94","1099.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","628.89","42.9","","731.00","63.70","731.00","1 through 10","454.44","1165.42","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1465.94","1099.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","628.89","42.9","","384.74","384.74","384.74","1 through 10","454.44","1165.42","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1465.94","1099.45","WELLPOINT [1015]","HB AMC WELLPOINT","1081.57","73.78","","286.63","119.22","1107.45","105","454.44","1165.42","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1465.94","1099.45","AETNA [1001]","HB AMC AETNA HMO","1023.23","69.8","","675.31","184.75","1721.50","286","766.1","1197.97","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1465.94","1099.45","AETNA [1001]","HB AMC AETNA PPO","1178.62","80.4","","1261.44","103.12","1514.10","21","766.1","1197.97","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1465.94","1099.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1178.62","80.4","","1365.00","1365.00","1365.00","1 through 10","766.1","1197.97","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1465.94","1099.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1197.97","81.72","","5157.68","5157.68","5157.68","1 through 10","766.1","1197.97","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1465.94","1099.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1197.97","81.72","","431.26","71.26","1459.57","88","766.1","1197.97","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1587.67","1190.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1262.20","79.5","","800.18","480.96","1887.97","195","492.18","1262.2","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1587.67","1190.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","846.23","53.3","","813.12","216.42","1444.50","81","492.18","1262.2","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1587.67","1190.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","492.18","31","","432.60","432.60","432.60","1 through 10","492.18","1262.2","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1587.67","1190.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","579.50","36.5","","148.37","54.89","631.39","94","492.18","1262.2","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1587.67","1190.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","608.08","38.3","","279.30","91.72","1116.77","266","492.18","1262.2","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1587.67","1190.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","681.11","42.9","","731.00","63.70","731.00","1 through 10","492.18","1262.2","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1587.67","1190.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","681.11","42.9","","384.74","384.74","384.74","1 through 10","492.18","1262.2","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1587.67","1190.75","WELLPOINT [1015]","HB AMC WELLPOINT","1171.38","73.78","","286.63","119.22","1107.45","105","492.18","1262.2","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1587.67","1190.75","AETNA [1001]","HB AMC AETNA HMO","1108.19","69.8","","675.31","184.75","1721.50","286","829.72","1297.44","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1587.67","1190.75","AETNA [1001]","HB AMC AETNA PPO","1276.49","80.4","","1261.44","103.12","1514.10","21","829.72","1297.44","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1587.67","1190.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1276.49","80.4","","1365.00","1365.00","1365.00","1 through 10","829.72","1297.44","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1587.67","1190.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1297.44","81.72","","5157.68","5157.68","5157.68","1 through 10","829.72","1297.44","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1587.67","1190.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1297.44","81.72","","431.26","71.26","1459.57","88","829.72","1297.44","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.41","1028.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1090.27","79.5","","800.18","480.96","1887.97","195","425.14","1090.27","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.41","1028.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","730.96","53.3","","813.12","216.42","1444.50","81","425.14","1090.27","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.41","1028.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","425.14","31","","432.60","432.60","432.60","1 through 10","425.14","1090.27","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.41","1028.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","500.56","36.5","","148.37","54.89","631.39","94","425.14","1090.27","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.41","1028.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","525.25","38.3","","279.30","91.72","1116.77","266","425.14","1090.27","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.41","1028.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","588.33","42.9","","731.00","63.70","731.00","1 through 10","425.14","1090.27","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.41","1028.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","588.33","42.9","","384.74","384.74","384.74","1 through 10","425.14","1090.27","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1371.41","1028.56","WELLPOINT [1015]","HB AMC WELLPOINT","1011.83","73.78","","286.63","119.22","1107.45","105","425.14","1090.27","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1371.41","1028.56","AETNA [1001]","HB AMC AETNA HMO","957.24","69.8","","675.31","184.75","1721.50","286","716.7","1120.72","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1371.41","1028.56","AETNA [1001]","HB AMC AETNA PPO","1102.61","80.4","","1261.44","103.12","1514.10","21","716.7","1120.72","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1371.41","1028.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1102.61","80.4","","1365.00","1365.00","1365.00","1 through 10","716.7","1120.72","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1371.41","1028.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1120.72","81.72","","5157.68","5157.68","5157.68","1 through 10","716.7","1120.72","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1371.41","1028.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1120.72","81.72","","431.26","71.26","1459.57","88","716.7","1120.72","percent of total billed charges",""
"BONE PLATE 4.5X189MM 10 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037692","CDM","C1713","HCPCS","0278","RC","","","","both","","","1603.21","1202.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1274.55","79.5","","800.18","480.96","1887.97","195","497","1274.55","percent of total billed charges",""
"BONE PLATE 4.5X189MM 10 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037692","CDM","C1713","HCPCS","0278","RC","","","","both","","","1603.21","1202.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","854.51","53.3","","813.12","216.42","1444.50","81","497","1274.55","percent of total billed charges",""
"BONE PLATE 4.5X189MM 10 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037692","CDM","C1713","HCPCS","0278","RC","","","","both","","","1603.21","1202.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","497.00","31","","432.60","432.60","432.60","1 through 10","497","1274.55","percent of total billed charges",""
"BONE PLATE 4.5X189MM 10 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037692","CDM","C1713","HCPCS","0278","RC","","","","both","","","1603.21","1202.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","585.17","36.5","","148.37","54.89","631.39","94","497","1274.55","percent of total billed charges",""
"BONE PLATE 4.5X189MM 10 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037692","CDM","C1713","HCPCS","0278","RC","","","","both","","","1603.21","1202.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","614.03","38.3","","279.30","91.72","1116.77","266","497","1274.55","percent of total billed charges",""
"BONE PLATE 4.5X189MM 10 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037692","CDM","C1713","HCPCS","0278","RC","","","","both","","","1603.21","1202.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","687.78","42.9","","731.00","63.70","731.00","1 through 10","497","1274.55","percent of total billed charges",""
"BONE PLATE 4.5X189MM 10 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037692","CDM","C1713","HCPCS","0278","RC","","","","both","","","1603.21","1202.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","687.78","42.9","","384.74","384.74","384.74","1 through 10","497","1274.55","percent of total billed charges",""
"BONE PLATE 4.5X189MM 10 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037692","CDM","C1713","HCPCS","0278","RC","","","","both","","","1603.21","1202.41","WELLPOINT [1015]","HB AMC WELLPOINT","1182.85","73.78","","286.63","119.22","1107.45","105","497","1274.55","percent of total billed charges",""
"BONE PLATE 4.5X189MM 10 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1603.21","1202.41","AETNA [1001]","HB AMC AETNA HMO","1119.04","69.8","","675.31","184.75","1721.50","286","837.84","1310.14","percent of total billed charges",""
"BONE PLATE 4.5X189MM 10 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1603.21","1202.41","AETNA [1001]","HB AMC AETNA PPO","1288.98","80.4","","1261.44","103.12","1514.10","21","837.84","1310.14","percent of total billed charges",""
"BONE PLATE 4.5X189MM 10 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1603.21","1202.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1288.98","80.4","","1365.00","1365.00","1365.00","1 through 10","837.84","1310.14","percent of total billed charges",""
"BONE PLATE 4.5X189MM 10 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1603.21","1202.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1310.14","81.72","","5157.68","5157.68","5157.68","1 through 10","837.84","1310.14","percent of total billed charges",""
"BONE PLATE 4.5X189MM 10 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1603.21","1202.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1310.14","81.72","","431.26","71.26","1459.57","88","837.84","1310.14","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1579.90","1184.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1256.02","79.5","","800.18","480.96","1887.97","195","489.77","1256.02","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1579.90","1184.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","842.09","53.3","","813.12","216.42","1444.50","81","489.77","1256.02","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1579.90","1184.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","489.77","31","","432.60","432.60","432.60","1 through 10","489.77","1256.02","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1579.90","1184.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","576.66","36.5","","148.37","54.89","631.39","94","489.77","1256.02","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1579.90","1184.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","605.10","38.3","","279.30","91.72","1116.77","266","489.77","1256.02","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1579.90","1184.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","677.78","42.9","","731.00","63.70","731.00","1 through 10","489.77","1256.02","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1579.90","1184.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","677.78","42.9","","384.74","384.74","384.74","1 through 10","489.77","1256.02","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","both","","","1579.90","1184.92","WELLPOINT [1015]","HB AMC WELLPOINT","1165.65","73.78","","286.63","119.22","1107.45","105","489.77","1256.02","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1579.90","1184.92","AETNA [1001]","HB AMC AETNA HMO","1102.77","69.8","","675.31","184.75","1721.50","286","825.66","1291.09","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1579.90","1184.92","AETNA [1001]","HB AMC AETNA PPO","1270.24","80.4","","1261.44","103.12","1514.10","21","825.66","1291.09","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1579.90","1184.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1270.24","80.4","","1365.00","1365.00","1365.00","1 through 10","825.66","1291.09","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1579.90","1184.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1291.09","81.72","","5157.68","5157.68","5157.68","1 through 10","825.66","1291.09","percent of total billed charges",""
"BONE PLATE 4.5X196MM 11 HOLE LC DCP SS NARROW","SUP-ITM-10006510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1579.90","1184.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1291.09","81.72","","431.26","71.26","1459.57","88","825.66","1291.09","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1343.53","79.5","","800.18","480.96","1887.97","195","523.89","1343.53","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","900.76","53.3","","813.12","216.42","1444.50","81","523.89","1343.53","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","523.89","31","","432.60","432.60","432.60","1 through 10","523.89","1343.53","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","616.84","36.5","","148.37","54.89","631.39","94","523.89","1343.53","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","647.26","38.3","","279.30","91.72","1116.77","266","523.89","1343.53","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.00","42.9","","731.00","63.70","731.00","1 through 10","523.89","1343.53","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.00","42.9","","384.74","384.74","384.74","1 through 10","523.89","1343.53","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","WELLPOINT [1015]","HB AMC WELLPOINT","1246.87","73.78","","286.63","119.22","1107.45","105","523.89","1343.53","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","AETNA [1001]","HB AMC AETNA HMO","1179.61","69.8","","675.31","184.75","1721.50","286","883.18","1381.05","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","AETNA [1001]","HB AMC AETNA PPO","1358.74","80.4","","1261.44","103.12","1514.10","21","883.18","1381.05","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1358.74","80.4","","1365.00","1365.00","1365.00","1 through 10","883.18","1381.05","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1381.05","81.72","","5157.68","5157.68","5157.68","1 through 10","883.18","1381.05","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1381.05","81.72","","431.26","71.26","1459.57","88","883.18","1381.05","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","4206.16","3154.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3343.90","79.5","","800.18","480.96","1887.97","195","1303.91","3343.9","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","4206.16","3154.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2241.88","53.3","","813.12","216.42","1444.50","81","1303.91","3343.9","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","4206.16","3154.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1303.91","31","","432.60","432.60","432.60","1 through 10","1303.91","3343.9","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","4206.16","3154.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1535.25","36.5","","148.37","54.89","631.39","94","1303.91","3343.9","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","4206.16","3154.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1610.96","38.3","","279.30","91.72","1116.77","266","1303.91","3343.9","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","4206.16","3154.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1804.44","42.9","","731.00","63.70","731.00","1 through 10","1303.91","3343.9","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","4206.16","3154.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1804.44","42.9","","384.74","384.74","384.74","1 through 10","1303.91","3343.9","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","both","","","4206.16","3154.62","WELLPOINT [1015]","HB AMC WELLPOINT","3103.30","73.78","","286.63","119.22","1107.45","105","1303.91","3343.9","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4206.16","3154.62","AETNA [1001]","HB AMC AETNA HMO","2935.90","69.8","","675.31","184.75","1721.50","286","2198.14","3437.27","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4206.16","3154.62","AETNA [1001]","HB AMC AETNA PPO","3381.75","80.4","","1261.44","103.12","1514.10","21","2198.14","3437.27","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4206.16","3154.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3381.75","80.4","","1365.00","1365.00","1365.00","1 through 10","2198.14","3437.27","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4206.16","3154.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3437.27","81.72","","5157.68","5157.68","5157.68","1 through 10","2198.14","3437.27","percent of total billed charges",""
"BONE PLATE 4.5X206MM 8 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4206.16","3154.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3437.27","81.72","","431.26","71.26","1459.57","88","2198.14","3437.27","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.75","1273.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1349.71","79.5","","800.18","480.96","1887.97","195","526.3","1349.71","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.75","1273.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","904.90","53.3","","813.12","216.42","1444.50","81","526.3","1349.71","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.75","1273.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","526.30","31","","432.60","432.60","432.60","1 through 10","526.3","1349.71","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.75","1273.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","619.68","36.5","","148.37","54.89","631.39","94","526.3","1349.71","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.75","1273.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","650.24","38.3","","279.30","91.72","1116.77","266","526.3","1349.71","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.75","1273.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.33","42.9","","731.00","63.70","731.00","1 through 10","526.3","1349.71","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.75","1273.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.33","42.9","","384.74","384.74","384.74","1 through 10","526.3","1349.71","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.75","1273.31","WELLPOINT [1015]","HB AMC WELLPOINT","1252.60","73.78","","286.63","119.22","1107.45","105","526.3","1349.71","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.75","1273.31","AETNA [1001]","HB AMC AETNA HMO","1185.03","69.8","","675.31","184.75","1721.50","286","887.24","1387.4","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.75","1273.31","AETNA [1001]","HB AMC AETNA PPO","1364.99","80.4","","1261.44","103.12","1514.10","21","887.24","1387.4","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.75","1273.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1364.99","80.4","","1365.00","1365.00","1365.00","1 through 10","887.24","1387.4","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.75","1273.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1387.40","81.72","","5157.68","5157.68","5157.68","1 through 10","887.24","1387.4","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.75","1273.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1387.40","81.72","","431.26","71.26","1459.57","88","887.24","1387.4","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1793.58","1345.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1425.90","79.5","","800.18","480.96","1887.97","195","556.01","1425.9","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1793.58","1345.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","955.98","53.3","","813.12","216.42","1444.50","81","556.01","1425.9","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1793.58","1345.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","556.01","31","","432.60","432.60","432.60","1 through 10","556.01","1425.9","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1793.58","1345.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","654.66","36.5","","148.37","54.89","631.39","94","556.01","1425.9","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1793.58","1345.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","686.94","38.3","","279.30","91.72","1116.77","266","556.01","1425.9","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1793.58","1345.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","769.45","42.9","","731.00","63.70","731.00","1 through 10","556.01","1425.9","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1793.58","1345.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","769.45","42.9","","384.74","384.74","384.74","1 through 10","556.01","1425.9","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1793.58","1345.18","WELLPOINT [1015]","HB AMC WELLPOINT","1323.30","73.78","","286.63","119.22","1107.45","105","556.01","1425.9","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1793.58","1345.18","AETNA [1001]","HB AMC AETNA HMO","1251.92","69.8","","675.31","184.75","1721.50","286","937.32","1465.71","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1793.58","1345.18","AETNA [1001]","HB AMC AETNA PPO","1442.04","80.4","","1261.44","103.12","1514.10","21","937.32","1465.71","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1793.58","1345.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1442.04","80.4","","1365.00","1365.00","1365.00","1 through 10","937.32","1465.71","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1793.58","1345.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1465.71","81.72","","5157.68","5157.68","5157.68","1 through 10","937.32","1465.71","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1793.58","1345.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1465.71","81.72","","431.26","71.26","1459.57","88","937.32","1465.71","percent of total billed charges",""
"BONE PLATE 4.5X227MM 12 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037694","CDM","C1713","HCPCS","0278","RC","","","","both","","","1736.60","1302.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1380.60","79.5","","800.18","480.96","1887.97","195","538.35","1380.6","percent of total billed charges",""
"BONE PLATE 4.5X227MM 12 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037694","CDM","C1713","HCPCS","0278","RC","","","","both","","","1736.60","1302.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","925.61","53.3","","813.12","216.42","1444.50","81","538.35","1380.6","percent of total billed charges",""
"BONE PLATE 4.5X227MM 12 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037694","CDM","C1713","HCPCS","0278","RC","","","","both","","","1736.60","1302.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","538.35","31","","432.60","432.60","432.60","1 through 10","538.35","1380.6","percent of total billed charges",""
"BONE PLATE 4.5X227MM 12 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037694","CDM","C1713","HCPCS","0278","RC","","","","both","","","1736.60","1302.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","633.86","36.5","","148.37","54.89","631.39","94","538.35","1380.6","percent of total billed charges",""
"BONE PLATE 4.5X227MM 12 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037694","CDM","C1713","HCPCS","0278","RC","","","","both","","","1736.60","1302.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","665.12","38.3","","279.30","91.72","1116.77","266","538.35","1380.6","percent of total billed charges",""
"BONE PLATE 4.5X227MM 12 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037694","CDM","C1713","HCPCS","0278","RC","","","","both","","","1736.60","1302.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","745.00","42.9","","731.00","63.70","731.00","1 through 10","538.35","1380.6","percent of total billed charges",""
"BONE PLATE 4.5X227MM 12 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037694","CDM","C1713","HCPCS","0278","RC","","","","both","","","1736.60","1302.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","745.00","42.9","","384.74","384.74","384.74","1 through 10","538.35","1380.6","percent of total billed charges",""
"BONE PLATE 4.5X227MM 12 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037694","CDM","C1713","HCPCS","0278","RC","","","","both","","","1736.60","1302.45","WELLPOINT [1015]","HB AMC WELLPOINT","1281.26","73.78","","286.63","119.22","1107.45","105","538.35","1380.6","percent of total billed charges",""
"BONE PLATE 4.5X227MM 12 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037694","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1736.60","1302.45","AETNA [1001]","HB AMC AETNA HMO","1212.15","69.8","","675.31","184.75","1721.50","286","907.55","1419.15","percent of total billed charges",""
"BONE PLATE 4.5X227MM 12 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037694","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1736.60","1302.45","AETNA [1001]","HB AMC AETNA PPO","1396.23","80.4","","1261.44","103.12","1514.10","21","907.55","1419.15","percent of total billed charges",""
"BONE PLATE 4.5X227MM 12 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037694","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1736.60","1302.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1396.23","80.4","","1365.00","1365.00","1365.00","1 through 10","907.55","1419.15","percent of total billed charges",""
"BONE PLATE 4.5X227MM 12 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037694","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1736.60","1302.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1419.15","81.72","","5157.68","5157.68","5157.68","1 through 10","907.55","1419.15","percent of total billed charges",""
"BONE PLATE 4.5X227MM 12 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037694","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1736.60","1302.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1419.15","81.72","","431.26","71.26","1459.57","88","907.55","1419.15","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.29","1479.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1567.97","79.5","","800.18","480.96","1887.97","195","611.41","1567.97","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.29","1479.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1051.23","53.3","","813.12","216.42","1444.50","81","611.41","1567.97","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.29","1479.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","611.41","31","","432.60","432.60","432.60","1 through 10","611.41","1567.97","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.29","1479.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","719.89","36.5","","148.37","54.89","631.39","94","611.41","1567.97","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.29","1479.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","755.39","38.3","","279.30","91.72","1116.77","266","611.41","1567.97","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.29","1479.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.11","42.9","","731.00","63.70","731.00","1 through 10","611.41","1567.97","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.29","1479.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.11","42.9","","384.74","384.74","384.74","1 through 10","611.41","1567.97","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.29","1479.22","WELLPOINT [1015]","HB AMC WELLPOINT","1455.16","73.78","","286.63","119.22","1107.45","105","611.41","1567.97","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1972.29","1479.22","AETNA [1001]","HB AMC AETNA HMO","1376.66","69.8","","675.31","184.75","1721.50","286","1030.72","1611.76","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1972.29","1479.22","AETNA [1001]","HB AMC AETNA PPO","1585.72","80.4","","1261.44","103.12","1514.10","21","1030.72","1611.76","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1972.29","1479.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1585.72","80.4","","1365.00","1365.00","1365.00","1 through 10","1030.72","1611.76","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1972.29","1479.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1611.76","81.72","","5157.68","5157.68","5157.68","1 through 10","1030.72","1611.76","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1972.29","1479.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1611.76","81.72","","431.26","71.26","1459.57","88","1030.72","1611.76","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","4361.56","3271.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3467.44","79.5","","800.18","480.96","1887.97","195","1352.08","3467.44","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","4361.56","3271.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2324.71","53.3","","813.12","216.42","1444.50","81","1352.08","3467.44","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","4361.56","3271.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1352.08","31","","432.60","432.60","432.60","1 through 10","1352.08","3467.44","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","4361.56","3271.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1591.97","36.5","","148.37","54.89","631.39","94","1352.08","3467.44","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","4361.56","3271.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1670.48","38.3","","279.30","91.72","1116.77","266","1352.08","3467.44","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","4361.56","3271.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1871.11","42.9","","731.00","63.70","731.00","1 through 10","1352.08","3467.44","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","4361.56","3271.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1871.11","42.9","","384.74","384.74","384.74","1 through 10","1352.08","3467.44","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","both","","","4361.56","3271.17","WELLPOINT [1015]","HB AMC WELLPOINT","3217.96","73.78","","286.63","119.22","1107.45","105","1352.08","3467.44","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4361.56","3271.17","AETNA [1001]","HB AMC AETNA HMO","3044.37","69.8","","675.31","184.75","1721.50","286","2279.35","3564.27","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4361.56","3271.17","AETNA [1001]","HB AMC AETNA PPO","3506.69","80.4","","1261.44","103.12","1514.10","21","2279.35","3564.27","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4361.56","3271.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3506.69","80.4","","1365.00","1365.00","1365.00","1 through 10","2279.35","3564.27","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4361.56","3271.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3564.27","81.72","","5157.68","5157.68","5157.68","1 through 10","2279.35","3564.27","percent of total billed charges",""
"BONE PLATE 4.5X242MM 10 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4361.56","3271.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3564.27","81.72","","431.26","71.26","1459.57","88","2279.35","3564.27","percent of total billed charges",""
"BONE PLATE 4.5X247MM 13 HOLE LCP SS CURVED BROAD","SUP-ITM-10019474","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.77","1424.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1510.32","79.5","","800.18","480.96","1887.97","195","588.93","1510.32","percent of total billed charges",""
"BONE PLATE 4.5X247MM 13 HOLE LCP SS CURVED BROAD","SUP-ITM-10019474","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.77","1424.83","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1012.58","53.3","","813.12","216.42","1444.50","81","588.93","1510.32","percent of total billed charges",""
"BONE PLATE 4.5X247MM 13 HOLE LCP SS CURVED BROAD","SUP-ITM-10019474","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.77","1424.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","588.93","31","","432.60","432.60","432.60","1 through 10","588.93","1510.32","percent of total billed charges",""
"BONE PLATE 4.5X247MM 13 HOLE LCP SS CURVED BROAD","SUP-ITM-10019474","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.77","1424.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","693.42","36.5","","148.37","54.89","631.39","94","588.93","1510.32","percent of total billed charges",""
"BONE PLATE 4.5X247MM 13 HOLE LCP SS CURVED BROAD","SUP-ITM-10019474","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.77","1424.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","727.61","38.3","","279.30","91.72","1116.77","266","588.93","1510.32","percent of total billed charges",""
"BONE PLATE 4.5X247MM 13 HOLE LCP SS CURVED BROAD","SUP-ITM-10019474","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.77","1424.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","815.00","42.9","","731.00","63.70","731.00","1 through 10","588.93","1510.32","percent of total billed charges",""
"BONE PLATE 4.5X247MM 13 HOLE LCP SS CURVED BROAD","SUP-ITM-10019474","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.77","1424.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","815.00","42.9","","384.74","384.74","384.74","1 through 10","588.93","1510.32","percent of total billed charges",""
"BONE PLATE 4.5X247MM 13 HOLE LCP SS CURVED BROAD","SUP-ITM-10019474","CDM","C1713","HCPCS","0278","RC","","","","both","","","1899.77","1424.83","WELLPOINT [1015]","HB AMC WELLPOINT","1401.65","73.78","","286.63","119.22","1107.45","105","588.93","1510.32","percent of total billed charges",""
"BONE PLATE 4.5X247MM 13 HOLE LCP SS CURVED BROAD","SUP-ITM-10019474","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1899.77","1424.83","AETNA [1001]","HB AMC AETNA HMO","1326.04","69.8","","675.31","184.75","1721.50","286","992.82","1552.49","percent of total billed charges",""
"BONE PLATE 4.5X247MM 13 HOLE LCP SS CURVED BROAD","SUP-ITM-10019474","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1899.77","1424.83","AETNA [1001]","HB AMC AETNA PPO","1527.42","80.4","","1261.44","103.12","1514.10","21","992.82","1552.49","percent of total billed charges",""
"BONE PLATE 4.5X247MM 13 HOLE LCP SS CURVED BROAD","SUP-ITM-10019474","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1899.77","1424.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1527.42","80.4","","1365.00","1365.00","1365.00","1 through 10","992.82","1552.49","percent of total billed charges",""
"BONE PLATE 4.5X247MM 13 HOLE LCP SS CURVED BROAD","SUP-ITM-10019474","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1899.77","1424.83","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1552.49","81.72","","5157.68","5157.68","5157.68","1 through 10","992.82","1552.49","percent of total billed charges",""
"BONE PLATE 4.5X247MM 13 HOLE LCP SS CURVED BROAD","SUP-ITM-10019474","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1899.77","1424.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1552.49","81.72","","431.26","71.26","1459.57","88","992.82","1552.49","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1780.63","1335.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1415.60","79.5","","800.18","480.96","1887.97","195","552","1415.6","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1780.63","1335.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","949.08","53.3","","813.12","216.42","1444.50","81","552","1415.6","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1780.63","1335.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","552.00","31","","432.60","432.60","432.60","1 through 10","552","1415.6","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1780.63","1335.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","649.93","36.5","","148.37","54.89","631.39","94","552","1415.6","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1780.63","1335.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","681.98","38.3","","279.30","91.72","1116.77","266","552","1415.6","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1780.63","1335.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","763.89","42.9","","731.00","63.70","731.00","1 through 10","552","1415.6","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1780.63","1335.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","763.89","42.9","","384.74","384.74","384.74","1 through 10","552","1415.6","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1780.63","1335.47","WELLPOINT [1015]","HB AMC WELLPOINT","1313.75","73.78","","286.63","119.22","1107.45","105","552","1415.6","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1780.63","1335.47","AETNA [1001]","HB AMC AETNA HMO","1242.88","69.8","","675.31","184.75","1721.50","286","930.56","1455.13","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1780.63","1335.47","AETNA [1001]","HB AMC AETNA PPO","1431.63","80.4","","1261.44","103.12","1514.10","21","930.56","1455.13","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1780.63","1335.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1431.63","80.4","","1365.00","1365.00","1365.00","1 through 10","930.56","1455.13","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1780.63","1335.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1455.13","81.72","","5157.68","5157.68","5157.68","1 through 10","930.56","1455.13","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1780.63","1335.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1455.13","81.72","","431.26","71.26","1459.57","88","930.56","1455.13","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1897.18","1422.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1508.26","79.5","","800.18","480.96","1887.97","195","588.13","1508.26","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1897.18","1422.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1011.20","53.3","","813.12","216.42","1444.50","81","588.13","1508.26","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1897.18","1422.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","588.13","31","","432.60","432.60","432.60","1 through 10","588.13","1508.26","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1897.18","1422.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","692.47","36.5","","148.37","54.89","631.39","94","588.13","1508.26","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1897.18","1422.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","726.62","38.3","","279.30","91.72","1116.77","266","588.13","1508.26","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1897.18","1422.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","813.89","42.9","","731.00","63.70","731.00","1 through 10","588.13","1508.26","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1897.18","1422.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","813.89","42.9","","384.74","384.74","384.74","1 through 10","588.13","1508.26","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037696","CDM","C1713","HCPCS","0278","RC","","","","both","","","1897.18","1422.88","WELLPOINT [1015]","HB AMC WELLPOINT","1399.74","73.78","","286.63","119.22","1107.45","105","588.13","1508.26","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1897.18","1422.88","AETNA [1001]","HB AMC AETNA HMO","1324.23","69.8","","675.31","184.75","1721.50","286","991.47","1550.38","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1897.18","1422.88","AETNA [1001]","HB AMC AETNA PPO","1525.33","80.4","","1261.44","103.12","1514.10","21","991.47","1550.38","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1897.18","1422.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1525.33","80.4","","1365.00","1365.00","1365.00","1 through 10","991.47","1550.38","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1897.18","1422.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1550.38","81.72","","5157.68","5157.68","5157.68","1 through 10","991.47","1550.38","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1897.18","1422.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1550.38","81.72","","431.26","71.26","1459.57","88","991.47","1550.38","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2195.03","1646.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1745.05","79.5","","800.18","480.96","1887.97","195","680.46","1745.05","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2195.03","1646.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1169.95","53.3","","813.12","216.42","1444.50","81","680.46","1745.05","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2195.03","1646.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","680.46","31","","432.60","432.60","432.60","1 through 10","680.46","1745.05","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2195.03","1646.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","801.19","36.5","","148.37","54.89","631.39","94","680.46","1745.05","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2195.03","1646.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","840.70","38.3","","279.30","91.72","1116.77","266","680.46","1745.05","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2195.03","1646.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","941.67","42.9","","731.00","63.70","731.00","1 through 10","680.46","1745.05","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2195.03","1646.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","941.67","42.9","","384.74","384.74","384.74","1 through 10","680.46","1745.05","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2195.03","1646.27","WELLPOINT [1015]","HB AMC WELLPOINT","1619.49","73.78","","286.63","119.22","1107.45","105","680.46","1745.05","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2195.03","1646.27","AETNA [1001]","HB AMC AETNA HMO","1532.13","69.8","","675.31","184.75","1721.50","286","1147.12","1793.78","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2195.03","1646.27","AETNA [1001]","HB AMC AETNA PPO","1764.80","80.4","","1261.44","103.12","1514.10","21","1147.12","1793.78","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2195.03","1646.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1764.80","80.4","","1365.00","1365.00","1365.00","1 through 10","1147.12","1793.78","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2195.03","1646.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1793.78","81.72","","5157.68","5157.68","5157.68","1 through 10","1147.12","1793.78","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2195.03","1646.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1793.78","81.72","","431.26","71.26","1459.57","88","1147.12","1793.78","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","4449.62","3337.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3537.45","79.5","","800.18","480.96","1887.97","195","1379.38","3537.45","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","4449.62","3337.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2371.65","53.3","","813.12","216.42","1444.50","81","1379.38","3537.45","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","4449.62","3337.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1379.38","31","","432.60","432.60","432.60","1 through 10","1379.38","3537.45","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","4449.62","3337.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1624.11","36.5","","148.37","54.89","631.39","94","1379.38","3537.45","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","4449.62","3337.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1704.20","38.3","","279.30","91.72","1116.77","266","1379.38","3537.45","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","4449.62","3337.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1908.89","42.9","","731.00","63.70","731.00","1 through 10","1379.38","3537.45","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","4449.62","3337.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1908.89","42.9","","384.74","384.74","384.74","1 through 10","1379.38","3537.45","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","both","","","4449.62","3337.21","WELLPOINT [1015]","HB AMC WELLPOINT","3282.93","73.78","","286.63","119.22","1107.45","105","1379.38","3537.45","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4449.62","3337.21","AETNA [1001]","HB AMC AETNA HMO","3105.83","69.8","","675.31","184.75","1721.50","286","2325.37","3636.23","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4449.62","3337.21","AETNA [1001]","HB AMC AETNA PPO","3577.49","80.4","","1261.44","103.12","1514.10","21","2325.37","3636.23","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4449.62","3337.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3577.49","80.4","","1365.00","1365.00","1365.00","1 through 10","2325.37","3636.23","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4449.62","3337.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3636.23","81.72","","5157.68","5157.68","5157.68","1 through 10","2325.37","3636.23","percent of total billed charges",""
"BONE PLATE 4.5X278MM 12 HOLE CONDYLAR LCP SS RIGHT","SUP-ITM-10011594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4449.62","3337.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3636.23","81.72","","431.26","71.26","1459.57","88","2325.37","3636.23","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2215.75","1661.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1761.52","79.5","","800.18","480.96","1887.97","195","686.88","1761.52","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2215.75","1661.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1180.99","53.3","","813.12","216.42","1444.50","81","686.88","1761.52","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2215.75","1661.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","686.88","31","","432.60","432.60","432.60","1 through 10","686.88","1761.52","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2215.75","1661.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","808.75","36.5","","148.37","54.89","631.39","94","686.88","1761.52","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2215.75","1661.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","848.63","38.3","","279.30","91.72","1116.77","266","686.88","1761.52","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2215.75","1661.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","950.56","42.9","","731.00","63.70","731.00","1 through 10","686.88","1761.52","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2215.75","1661.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","950.56","42.9","","384.74","384.74","384.74","1 through 10","686.88","1761.52","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","both","","","2215.75","1661.81","WELLPOINT [1015]","HB AMC WELLPOINT","1634.78","73.78","","286.63","119.22","1107.45","105","686.88","1761.52","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2215.75","1661.81","AETNA [1001]","HB AMC AETNA HMO","1546.59","69.8","","675.31","184.75","1721.50","286","1157.95","1810.71","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2215.75","1661.81","AETNA [1001]","HB AMC AETNA PPO","1781.46","80.4","","1261.44","103.12","1514.10","21","1157.95","1810.71","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2215.75","1661.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1781.46","80.4","","1365.00","1365.00","1365.00","1 through 10","1157.95","1810.71","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2215.75","1661.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1810.71","81.72","","5157.68","5157.68","5157.68","1 through 10","1157.95","1810.71","percent of total billed charges",""
"BONE PLATE 4.5X282MM 15 HOLE LCP SS CURVED BROAD","SUP-ITM-10029913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2215.75","1661.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1810.71","81.72","","431.26","71.26","1459.57","88","1157.95","1810.71","percent of total billed charges",""
"BONE PLATE 4.5X286MM 16 HOLE NARROW LC DCP SS","SUP-ITM-10020110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.81","1668.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1768.72","79.5","","800.18","480.96","1887.97","195","689.69","1768.72","percent of total billed charges",""
"BONE PLATE 4.5X286MM 16 HOLE NARROW LC DCP SS","SUP-ITM-10020110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.81","1668.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1185.82","53.3","","813.12","216.42","1444.50","81","689.69","1768.72","percent of total billed charges",""
"BONE PLATE 4.5X286MM 16 HOLE NARROW LC DCP SS","SUP-ITM-10020110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.81","1668.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","689.69","31","","432.60","432.60","432.60","1 through 10","689.69","1768.72","percent of total billed charges",""
"BONE PLATE 4.5X286MM 16 HOLE NARROW LC DCP SS","SUP-ITM-10020110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.81","1668.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","812.06","36.5","","148.37","54.89","631.39","94","689.69","1768.72","percent of total billed charges",""
"BONE PLATE 4.5X286MM 16 HOLE NARROW LC DCP SS","SUP-ITM-10020110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.81","1668.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","852.10","38.3","","279.30","91.72","1116.77","266","689.69","1768.72","percent of total billed charges",""
"BONE PLATE 4.5X286MM 16 HOLE NARROW LC DCP SS","SUP-ITM-10020110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.81","1668.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","954.44","42.9","","731.00","63.70","731.00","1 through 10","689.69","1768.72","percent of total billed charges",""
"BONE PLATE 4.5X286MM 16 HOLE NARROW LC DCP SS","SUP-ITM-10020110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.81","1668.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","954.44","42.9","","384.74","384.74","384.74","1 through 10","689.69","1768.72","percent of total billed charges",""
"BONE PLATE 4.5X286MM 16 HOLE NARROW LC DCP SS","SUP-ITM-10020110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.81","1668.61","WELLPOINT [1015]","HB AMC WELLPOINT","1641.46","73.78","","286.63","119.22","1107.45","105","689.69","1768.72","percent of total billed charges",""
"BONE PLATE 4.5X286MM 16 HOLE NARROW LC DCP SS","SUP-ITM-10020110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.81","1668.61","AETNA [1001]","HB AMC AETNA HMO","1552.92","69.8","","675.31","184.75","1721.50","286","1162.69","1818.11","percent of total billed charges",""
"BONE PLATE 4.5X286MM 16 HOLE NARROW LC DCP SS","SUP-ITM-10020110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.81","1668.61","AETNA [1001]","HB AMC AETNA PPO","1788.75","80.4","","1261.44","103.12","1514.10","21","1162.69","1818.11","percent of total billed charges",""
"BONE PLATE 4.5X286MM 16 HOLE NARROW LC DCP SS","SUP-ITM-10020110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.81","1668.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1788.75","80.4","","1365.00","1365.00","1365.00","1 through 10","1162.69","1818.11","percent of total billed charges",""
"BONE PLATE 4.5X286MM 16 HOLE NARROW LC DCP SS","SUP-ITM-10020110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.81","1668.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1818.11","81.72","","5157.68","5157.68","5157.68","1 through 10","1162.69","1818.11","percent of total billed charges",""
"BONE PLATE 4.5X286MM 16 HOLE NARROW LC DCP SS","SUP-ITM-10020110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.81","1668.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1818.11","81.72","","431.26","71.26","1459.57","88","1162.69","1818.11","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","2079.77","1559.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1653.42","79.5","","800.18","480.96","1887.97","195","644.73","1653.42","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","2079.77","1559.83","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1108.52","53.3","","813.12","216.42","1444.50","81","644.73","1653.42","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","2079.77","1559.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","644.73","31","","432.60","432.60","432.60","1 through 10","644.73","1653.42","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","2079.77","1559.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","759.12","36.5","","148.37","54.89","631.39","94","644.73","1653.42","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","2079.77","1559.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","796.55","38.3","","279.30","91.72","1116.77","266","644.73","1653.42","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","2079.77","1559.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","892.22","42.9","","731.00","63.70","731.00","1 through 10","644.73","1653.42","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","2079.77","1559.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","892.22","42.9","","384.74","384.74","384.74","1 through 10","644.73","1653.42","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","2079.77","1559.83","WELLPOINT [1015]","HB AMC WELLPOINT","1534.45","73.78","","286.63","119.22","1107.45","105","644.73","1653.42","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2079.77","1559.83","AETNA [1001]","HB AMC AETNA HMO","1451.68","69.8","","675.31","184.75","1721.50","286","1086.89","1699.59","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2079.77","1559.83","AETNA [1001]","HB AMC AETNA PPO","1672.14","80.4","","1261.44","103.12","1514.10","21","1086.89","1699.59","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2079.77","1559.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1672.14","80.4","","1365.00","1365.00","1365.00","1 through 10","1086.89","1699.59","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2079.77","1559.83","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1699.59","81.72","","5157.68","5157.68","5157.68","1 through 10","1086.89","1699.59","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2079.77","1559.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1699.59","81.72","","431.26","71.26","1459.57","88","1086.89","1699.59","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2667.70","2000.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2120.82","79.5","","800.18","480.96","1887.97","195","826.99","2120.82","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2667.70","2000.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1421.88","53.3","","813.12","216.42","1444.50","81","826.99","2120.82","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2667.70","2000.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","826.99","31","","432.60","432.60","432.60","1 through 10","826.99","2120.82","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2667.70","2000.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","973.71","36.5","","148.37","54.89","631.39","94","826.99","2120.82","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2667.70","2000.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1021.73","38.3","","279.30","91.72","1116.77","266","826.99","2120.82","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2667.70","2000.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1144.44","42.9","","731.00","63.70","731.00","1 through 10","826.99","2120.82","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2667.70","2000.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1144.44","42.9","","384.74","384.74","384.74","1 through 10","826.99","2120.82","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2667.70","2000.77","WELLPOINT [1015]","HB AMC WELLPOINT","1968.23","73.78","","286.63","119.22","1107.45","105","826.99","2120.82","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2667.70","2000.77","AETNA [1001]","HB AMC AETNA HMO","1862.05","69.8","","675.31","184.75","1721.50","286","1394.14","2180.04","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2667.70","2000.77","AETNA [1001]","HB AMC AETNA PPO","2144.83","80.4","","1261.44","103.12","1514.10","21","1394.14","2180.04","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2667.70","2000.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2144.83","80.4","","1365.00","1365.00","1365.00","1 through 10","1394.14","2180.04","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2667.70","2000.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2180.04","81.72","","5157.68","5157.68","5157.68","1 through 10","1394.14","2180.04","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2667.70","2000.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2180.04","81.72","","431.26","71.26","1459.57","88","1394.14","2180.04","percent of total billed charges",""
"BONE PLATE 4.5X303MM 16 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037698","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.97","1520.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1612.24","79.5","","800.18","480.96","1887.97","195","628.67","1612.24","percent of total billed charges",""
"BONE PLATE 4.5X303MM 16 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037698","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.97","1520.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1080.91","53.3","","813.12","216.42","1444.50","81","628.67","1612.24","percent of total billed charges",""
"BONE PLATE 4.5X303MM 16 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037698","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.97","1520.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","628.67","31","","432.60","432.60","432.60","1 through 10","628.67","1612.24","percent of total billed charges",""
"BONE PLATE 4.5X303MM 16 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037698","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.97","1520.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","740.21","36.5","","148.37","54.89","631.39","94","628.67","1612.24","percent of total billed charges",""
"BONE PLATE 4.5X303MM 16 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037698","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.97","1520.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","776.71","38.3","","279.30","91.72","1116.77","266","628.67","1612.24","percent of total billed charges",""
"BONE PLATE 4.5X303MM 16 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037698","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.97","1520.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","870.00","42.9","","731.00","63.70","731.00","1 through 10","628.67","1612.24","percent of total billed charges",""
"BONE PLATE 4.5X303MM 16 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037698","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.97","1520.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","870.00","42.9","","384.74","384.74","384.74","1 through 10","628.67","1612.24","percent of total billed charges",""
"BONE PLATE 4.5X303MM 16 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037698","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.97","1520.98","WELLPOINT [1015]","HB AMC WELLPOINT","1496.24","73.78","","286.63","119.22","1107.45","105","628.67","1612.24","percent of total billed charges",""
"BONE PLATE 4.5X303MM 16 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.97","1520.98","AETNA [1001]","HB AMC AETNA HMO","1415.52","69.8","","675.31","184.75","1721.50","286","1059.82","1657.26","percent of total billed charges",""
"BONE PLATE 4.5X303MM 16 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.97","1520.98","AETNA [1001]","HB AMC AETNA PPO","1630.49","80.4","","1261.44","103.12","1514.10","21","1059.82","1657.26","percent of total billed charges",""
"BONE PLATE 4.5X303MM 16 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.97","1520.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1630.49","80.4","","1365.00","1365.00","1365.00","1 through 10","1059.82","1657.26","percent of total billed charges",""
"BONE PLATE 4.5X303MM 16 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.97","1520.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1657.26","81.72","","5157.68","5157.68","5157.68","1 through 10","1059.82","1657.26","percent of total billed charges",""
"BONE PLATE 4.5X303MM 16 HOLE LCP SS RECONSTRUCTION STRAIGHT","SUP-ITM-10037698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.97","1520.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1657.26","81.72","","431.26","71.26","1459.57","88","1059.82","1657.26","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2540.79","1905.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2019.93","79.5","","800.18","480.96","1887.97","195","787.64","2019.93","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2540.79","1905.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1354.24","53.3","","813.12","216.42","1444.50","81","787.64","2019.93","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2540.79","1905.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","787.64","31","","432.60","432.60","432.60","1 through 10","787.64","2019.93","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2540.79","1905.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","927.39","36.5","","148.37","54.89","631.39","94","787.64","2019.93","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2540.79","1905.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","973.12","38.3","","279.30","91.72","1116.77","266","787.64","2019.93","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2540.79","1905.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1090.00","42.9","","731.00","63.70","731.00","1 through 10","787.64","2019.93","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2540.79","1905.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1090.00","42.9","","384.74","384.74","384.74","1 through 10","787.64","2019.93","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","both","","","2540.79","1905.59","WELLPOINT [1015]","HB AMC WELLPOINT","1874.59","73.78","","286.63","119.22","1107.45","105","787.64","2019.93","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2540.79","1905.59","AETNA [1001]","HB AMC AETNA HMO","1773.47","69.8","","675.31","184.75","1721.50","286","1327.82","2076.33","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2540.79","1905.59","AETNA [1001]","HB AMC AETNA PPO","2042.80","80.4","","1261.44","103.12","1514.10","21","1327.82","2076.33","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2540.79","1905.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2042.80","80.4","","1365.00","1365.00","1365.00","1 through 10","1327.82","2076.33","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2540.79","1905.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2076.33","81.72","","5157.68","5157.68","5157.68","1 through 10","1327.82","2076.33","percent of total billed charges",""
"BONE PLATE 4.5X318MM 17 HOLE LCP SS CURVED BROAD","SUP-ITM-10019475","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2540.79","1905.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2076.33","81.72","","431.26","71.26","1459.57","88","1327.82","2076.33","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE BROAD CURVED LCP SS","SUP-ITM-10012124","CDM","C1713","HCPCS","0278","RC","","","","both","","","2951.31","2213.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2346.29","79.5","","800.18","480.96","1887.97","195","914.91","2346.29","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE BROAD CURVED LCP SS","SUP-ITM-10012124","CDM","C1713","HCPCS","0278","RC","","","","both","","","2951.31","2213.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1573.05","53.3","","813.12","216.42","1444.50","81","914.91","2346.29","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE BROAD CURVED LCP SS","SUP-ITM-10012124","CDM","C1713","HCPCS","0278","RC","","","","both","","","2951.31","2213.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","914.91","31","","432.60","432.60","432.60","1 through 10","914.91","2346.29","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE BROAD CURVED LCP SS","SUP-ITM-10012124","CDM","C1713","HCPCS","0278","RC","","","","both","","","2951.31","2213.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1077.23","36.5","","148.37","54.89","631.39","94","914.91","2346.29","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE BROAD CURVED LCP SS","SUP-ITM-10012124","CDM","C1713","HCPCS","0278","RC","","","","both","","","2951.31","2213.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1130.35","38.3","","279.30","91.72","1116.77","266","914.91","2346.29","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE BROAD CURVED LCP SS","SUP-ITM-10012124","CDM","C1713","HCPCS","0278","RC","","","","both","","","2951.31","2213.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1266.11","42.9","","731.00","63.70","731.00","1 through 10","914.91","2346.29","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE BROAD CURVED LCP SS","SUP-ITM-10012124","CDM","C1713","HCPCS","0278","RC","","","","both","","","2951.31","2213.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1266.11","42.9","","384.74","384.74","384.74","1 through 10","914.91","2346.29","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE BROAD CURVED LCP SS","SUP-ITM-10012124","CDM","C1713","HCPCS","0278","RC","","","","both","","","2951.31","2213.48","WELLPOINT [1015]","HB AMC WELLPOINT","2177.48","73.78","","286.63","119.22","1107.45","105","914.91","2346.29","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE BROAD CURVED LCP SS","SUP-ITM-10012124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2951.31","2213.48","AETNA [1001]","HB AMC AETNA HMO","2060.01","69.8","","675.31","184.75","1721.50","286","1542.35","2411.81","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE BROAD CURVED LCP SS","SUP-ITM-10012124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2951.31","2213.48","AETNA [1001]","HB AMC AETNA PPO","2372.85","80.4","","1261.44","103.12","1514.10","21","1542.35","2411.81","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE BROAD CURVED LCP SS","SUP-ITM-10012124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2951.31","2213.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2372.85","80.4","","1365.00","1365.00","1365.00","1 through 10","1542.35","2411.81","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE BROAD CURVED LCP SS","SUP-ITM-10012124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2951.31","2213.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2411.81","81.72","","5157.68","5157.68","5157.68","1 through 10","1542.35","2411.81","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE BROAD CURVED LCP SS","SUP-ITM-10012124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2951.31","2213.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2411.81","81.72","","431.26","71.26","1459.57","88","1542.35","2411.81","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10012126","CDM","C1713","HCPCS","0278","RC","","","","both","","","2525.25","1893.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2007.57","79.5","","800.18","480.96","1887.97","195","782.83","2007.57","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10012126","CDM","C1713","HCPCS","0278","RC","","","","both","","","2525.25","1893.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1345.96","53.3","","813.12","216.42","1444.50","81","782.83","2007.57","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10012126","CDM","C1713","HCPCS","0278","RC","","","","both","","","2525.25","1893.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","782.83","31","","432.60","432.60","432.60","1 through 10","782.83","2007.57","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10012126","CDM","C1713","HCPCS","0278","RC","","","","both","","","2525.25","1893.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","921.72","36.5","","148.37","54.89","631.39","94","782.83","2007.57","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10012126","CDM","C1713","HCPCS","0278","RC","","","","both","","","2525.25","1893.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","967.17","38.3","","279.30","91.72","1116.77","266","782.83","2007.57","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10012126","CDM","C1713","HCPCS","0278","RC","","","","both","","","2525.25","1893.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1083.33","42.9","","731.00","63.70","731.00","1 through 10","782.83","2007.57","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10012126","CDM","C1713","HCPCS","0278","RC","","","","both","","","2525.25","1893.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1083.33","42.9","","384.74","384.74","384.74","1 through 10","782.83","2007.57","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10012126","CDM","C1713","HCPCS","0278","RC","","","","both","","","2525.25","1893.94","WELLPOINT [1015]","HB AMC WELLPOINT","1863.13","73.78","","286.63","119.22","1107.45","105","782.83","2007.57","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10012126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2525.25","1893.94","AETNA [1001]","HB AMC AETNA HMO","1762.62","69.8","","675.31","184.75","1721.50","286","1319.7","2063.63","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10012126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2525.25","1893.94","AETNA [1001]","HB AMC AETNA PPO","2030.30","80.4","","1261.44","103.12","1514.10","21","1319.7","2063.63","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10012126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2525.25","1893.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2030.30","80.4","","1365.00","1365.00","1365.00","1 through 10","1319.7","2063.63","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10012126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2525.25","1893.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2063.63","81.72","","5157.68","5157.68","5157.68","1 through 10","1319.7","2063.63","percent of total billed charges",""
"BONE PLATE 4.5X332MM 18 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10012126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2525.25","1893.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2063.63","81.72","","431.26","71.26","1459.57","88","1319.7","2063.63","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2768.71","2076.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2201.12","79.5","","800.18","480.96","1887.97","195","858.3","2201.12","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2768.71","2076.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1475.72","53.3","","813.12","216.42","1444.50","81","858.3","2201.12","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2768.71","2076.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","858.30","31","","432.60","432.60","432.60","1 through 10","858.3","2201.12","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2768.71","2076.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1010.58","36.5","","148.37","54.89","631.39","94","858.3","2201.12","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2768.71","2076.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1060.42","38.3","","279.30","91.72","1116.77","266","858.3","2201.12","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2768.71","2076.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1187.78","42.9","","731.00","63.70","731.00","1 through 10","858.3","2201.12","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2768.71","2076.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1187.78","42.9","","384.74","384.74","384.74","1 through 10","858.3","2201.12","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","both","","","2768.71","2076.53","WELLPOINT [1015]","HB AMC WELLPOINT","2042.75","73.78","","286.63","119.22","1107.45","105","858.3","2201.12","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2768.71","2076.53","AETNA [1001]","HB AMC AETNA HMO","1932.56","69.8","","675.31","184.75","1721.50","286","1446.93","2262.59","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2768.71","2076.53","AETNA [1001]","HB AMC AETNA PPO","2226.04","80.4","","1261.44","103.12","1514.10","21","1446.93","2262.59","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2768.71","2076.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2226.04","80.4","","1365.00","1365.00","1365.00","1 through 10","1446.93","2262.59","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2768.71","2076.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2262.59","81.72","","5157.68","5157.68","5157.68","1 through 10","1446.93","2262.59","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LCP SS CURVED BROAD","SUP-ITM-10013601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2768.71","2076.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2262.59","81.72","","431.26","71.26","1459.57","88","1446.93","2262.59","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040521","CDM","C1713","HCPCS","0278","RC","","","","both","","","3045.84","2284.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2421.44","79.5","","800.18","480.96","1887.97","195","944.21","2421.44","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040521","CDM","C1713","HCPCS","0278","RC","","","","both","","","3045.84","2284.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1623.43","53.3","","813.12","216.42","1444.50","81","944.21","2421.44","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040521","CDM","C1713","HCPCS","0278","RC","","","","both","","","3045.84","2284.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","944.21","31","","432.60","432.60","432.60","1 through 10","944.21","2421.44","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040521","CDM","C1713","HCPCS","0278","RC","","","","both","","","3045.84","2284.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1111.73","36.5","","148.37","54.89","631.39","94","944.21","2421.44","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040521","CDM","C1713","HCPCS","0278","RC","","","","both","","","3045.84","2284.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1166.56","38.3","","279.30","91.72","1116.77","266","944.21","2421.44","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040521","CDM","C1713","HCPCS","0278","RC","","","","both","","","3045.84","2284.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1306.67","42.9","","731.00","63.70","731.00","1 through 10","944.21","2421.44","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040521","CDM","C1713","HCPCS","0278","RC","","","","both","","","3045.84","2284.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1306.67","42.9","","384.74","384.74","384.74","1 through 10","944.21","2421.44","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040521","CDM","C1713","HCPCS","0278","RC","","","","both","","","3045.84","2284.38","WELLPOINT [1015]","HB AMC WELLPOINT","2247.22","73.78","","286.63","119.22","1107.45","105","944.21","2421.44","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040521","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3045.84","2284.38","AETNA [1001]","HB AMC AETNA HMO","2126.00","69.8","","675.31","184.75","1721.50","286","1591.76","2489.06","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040521","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3045.84","2284.38","AETNA [1001]","HB AMC AETNA PPO","2448.86","80.4","","1261.44","103.12","1514.10","21","1591.76","2489.06","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040521","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3045.84","2284.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2448.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1591.76","2489.06","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040521","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3045.84","2284.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2489.06","81.72","","5157.68","5157.68","5157.68","1 through 10","1591.76","2489.06","percent of total billed charges",""
"BONE PLATE 4.5X336MM 18 HOLE LOCKING COMPRESSION LCP CURVED BROAD TITANIUM","SUP-ITM-10040521","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3045.84","2284.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2489.06","81.72","","431.26","71.26","1459.57","88","1591.76","2489.06","percent of total billed charges",""
"BONE PLATE 4.5X358MM 20 HOLE LC DCP SS NARROW","SUP-ITM-10037676","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.05","2574.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2729.27","79.5","","800.18","480.96","1887.97","195","1064.25","2729.27","percent of total billed charges",""
"BONE PLATE 4.5X358MM 20 HOLE LC DCP SS NARROW","SUP-ITM-10037676","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.05","2574.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1829.82","53.3","","813.12","216.42","1444.50","81","1064.25","2729.27","percent of total billed charges",""
"BONE PLATE 4.5X358MM 20 HOLE LC DCP SS NARROW","SUP-ITM-10037676","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.05","2574.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1064.25","31","","432.60","432.60","432.60","1 through 10","1064.25","2729.27","percent of total billed charges",""
"BONE PLATE 4.5X358MM 20 HOLE LC DCP SS NARROW","SUP-ITM-10037676","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.05","2574.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1253.06","36.5","","148.37","54.89","631.39","94","1064.25","2729.27","percent of total billed charges",""
"BONE PLATE 4.5X358MM 20 HOLE LC DCP SS NARROW","SUP-ITM-10037676","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.05","2574.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1314.86","38.3","","279.30","91.72","1116.77","266","1064.25","2729.27","percent of total billed charges",""
"BONE PLATE 4.5X358MM 20 HOLE LC DCP SS NARROW","SUP-ITM-10037676","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.05","2574.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1472.78","42.9","","731.00","63.70","731.00","1 through 10","1064.25","2729.27","percent of total billed charges",""
"BONE PLATE 4.5X358MM 20 HOLE LC DCP SS NARROW","SUP-ITM-10037676","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.05","2574.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1472.78","42.9","","384.74","384.74","384.74","1 through 10","1064.25","2729.27","percent of total billed charges",""
"BONE PLATE 4.5X358MM 20 HOLE LC DCP SS NARROW","SUP-ITM-10037676","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.05","2574.79","WELLPOINT [1015]","HB AMC WELLPOINT","2532.90","73.78","","286.63","119.22","1107.45","105","1064.25","2729.27","percent of total billed charges",""
"BONE PLATE 4.5X358MM 20 HOLE LC DCP SS NARROW","SUP-ITM-10037676","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.05","2574.79","AETNA [1001]","HB AMC AETNA HMO","2396.27","69.8","","675.31","184.75","1721.50","286","1794.11","2805.49","percent of total billed charges",""
"BONE PLATE 4.5X358MM 20 HOLE LC DCP SS NARROW","SUP-ITM-10037676","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.05","2574.79","AETNA [1001]","HB AMC AETNA PPO","2760.17","80.4","","1261.44","103.12","1514.10","21","1794.11","2805.49","percent of total billed charges",""
"BONE PLATE 4.5X358MM 20 HOLE LC DCP SS NARROW","SUP-ITM-10037676","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.05","2574.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2760.17","80.4","","1365.00","1365.00","1365.00","1 through 10","1794.11","2805.49","percent of total billed charges",""
"BONE PLATE 4.5X358MM 20 HOLE LC DCP SS NARROW","SUP-ITM-10037676","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.05","2574.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2805.49","81.72","","5157.68","5157.68","5157.68","1 through 10","1794.11","2805.49","percent of total billed charges",""
"BONE PLATE 4.5X358MM 20 HOLE LC DCP SS NARROW","SUP-ITM-10037676","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.05","2574.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2805.49","81.72","","431.26","71.26","1459.57","88","1794.11","2805.49","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10037677","CDM","C1713","HCPCS","0278","RC","","","","both","","","3210.31","2407.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2552.20","79.5","","800.18","480.96","1887.97","195","995.2","2552.2","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10037677","CDM","C1713","HCPCS","0278","RC","","","","both","","","3210.31","2407.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1711.10","53.3","","813.12","216.42","1444.50","81","995.2","2552.2","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10037677","CDM","C1713","HCPCS","0278","RC","","","","both","","","3210.31","2407.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","995.20","31","","432.60","432.60","432.60","1 through 10","995.2","2552.2","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10037677","CDM","C1713","HCPCS","0278","RC","","","","both","","","3210.31","2407.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1171.76","36.5","","148.37","54.89","631.39","94","995.2","2552.2","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10037677","CDM","C1713","HCPCS","0278","RC","","","","both","","","3210.31","2407.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1229.55","38.3","","279.30","91.72","1116.77","266","995.2","2552.2","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10037677","CDM","C1713","HCPCS","0278","RC","","","","both","","","3210.31","2407.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1377.22","42.9","","731.00","63.70","731.00","1 through 10","995.2","2552.2","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10037677","CDM","C1713","HCPCS","0278","RC","","","","both","","","3210.31","2407.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1377.22","42.9","","384.74","384.74","384.74","1 through 10","995.2","2552.2","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10037677","CDM","C1713","HCPCS","0278","RC","","","","both","","","3210.31","2407.73","WELLPOINT [1015]","HB AMC WELLPOINT","2368.57","73.78","","286.63","119.22","1107.45","105","995.2","2552.2","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10037677","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3210.31","2407.73","AETNA [1001]","HB AMC AETNA HMO","2240.80","69.8","","675.31","184.75","1721.50","286","1677.71","2623.47","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10037677","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3210.31","2407.73","AETNA [1001]","HB AMC AETNA PPO","2581.09","80.4","","1261.44","103.12","1514.10","21","1677.71","2623.47","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10037677","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3210.31","2407.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2581.09","80.4","","1365.00","1365.00","1365.00","1 through 10","1677.71","2623.47","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10037677","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3210.31","2407.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2623.47","81.72","","5157.68","5157.68","5157.68","1 through 10","1677.71","2623.47","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE COMPRESSION LCP PELVIC NARROW SS","SUP-ITM-10037677","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3210.31","2407.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2623.47","81.72","","431.26","71.26","1459.57","88","1677.71","2623.47","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE LCP SS BROAD","SUP-ITM-10012410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3258.22","2443.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2590.28","79.5","","800.18","480.96","1887.97","195","1010.05","2590.28","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE LCP SS BROAD","SUP-ITM-10012410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3258.22","2443.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1736.63","53.3","","813.12","216.42","1444.50","81","1010.05","2590.28","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE LCP SS BROAD","SUP-ITM-10012410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3258.22","2443.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1010.05","31","","432.60","432.60","432.60","1 through 10","1010.05","2590.28","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE LCP SS BROAD","SUP-ITM-10012410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3258.22","2443.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1189.25","36.5","","148.37","54.89","631.39","94","1010.05","2590.28","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE LCP SS BROAD","SUP-ITM-10012410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3258.22","2443.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1247.90","38.3","","279.30","91.72","1116.77","266","1010.05","2590.28","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE LCP SS BROAD","SUP-ITM-10012410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3258.22","2443.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1397.78","42.9","","731.00","63.70","731.00","1 through 10","1010.05","2590.28","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE LCP SS BROAD","SUP-ITM-10012410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3258.22","2443.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1397.78","42.9","","384.74","384.74","384.74","1 through 10","1010.05","2590.28","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE LCP SS BROAD","SUP-ITM-10012410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3258.22","2443.66","WELLPOINT [1015]","HB AMC WELLPOINT","2403.91","73.78","","286.63","119.22","1107.45","105","1010.05","2590.28","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE LCP SS BROAD","SUP-ITM-10012410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3258.22","2443.66","AETNA [1001]","HB AMC AETNA HMO","2274.24","69.8","","675.31","184.75","1721.50","286","1702.75","2662.62","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE LCP SS BROAD","SUP-ITM-10012410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3258.22","2443.66","AETNA [1001]","HB AMC AETNA PPO","2619.61","80.4","","1261.44","103.12","1514.10","21","1702.75","2662.62","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE LCP SS BROAD","SUP-ITM-10012410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3258.22","2443.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2619.61","80.4","","1365.00","1365.00","1365.00","1 through 10","1702.75","2662.62","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE LCP SS BROAD","SUP-ITM-10012410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3258.22","2443.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2662.62","81.72","","5157.68","5157.68","5157.68","1 through 10","1702.75","2662.62","percent of total billed charges",""
"BONE PLATE 4.5X368MM 20 HOLE LCP SS BROAD","SUP-ITM-10012410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3258.22","2443.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2662.62","81.72","","431.26","71.26","1459.57","88","1702.75","2662.62","percent of total billed charges",""
"BONE PLATE 4.5X372MM 20 HOLE FEMORAL LCP SS CURVED BROAD","SUP-ITM-10030089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.93","2442.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2589.26","79.5","","800.18","480.96","1887.97","195","1009.65","2589.26","percent of total billed charges",""
"BONE PLATE 4.5X372MM 20 HOLE FEMORAL LCP SS CURVED BROAD","SUP-ITM-10030089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.93","2442.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1735.94","53.3","","813.12","216.42","1444.50","81","1009.65","2589.26","percent of total billed charges",""
"BONE PLATE 4.5X372MM 20 HOLE FEMORAL LCP SS CURVED BROAD","SUP-ITM-10030089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.93","2442.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1009.65","31","","432.60","432.60","432.60","1 through 10","1009.65","2589.26","percent of total billed charges",""
"BONE PLATE 4.5X372MM 20 HOLE FEMORAL LCP SS CURVED BROAD","SUP-ITM-10030089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.93","2442.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1188.78","36.5","","148.37","54.89","631.39","94","1009.65","2589.26","percent of total billed charges",""
"BONE PLATE 4.5X372MM 20 HOLE FEMORAL LCP SS CURVED BROAD","SUP-ITM-10030089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.93","2442.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1247.40","38.3","","279.30","91.72","1116.77","266","1009.65","2589.26","percent of total billed charges",""
"BONE PLATE 4.5X372MM 20 HOLE FEMORAL LCP SS CURVED BROAD","SUP-ITM-10030089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.93","2442.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1397.22","42.9","","731.00","63.70","731.00","1 through 10","1009.65","2589.26","percent of total billed charges",""
"BONE PLATE 4.5X372MM 20 HOLE FEMORAL LCP SS CURVED BROAD","SUP-ITM-10030089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.93","2442.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1397.22","42.9","","384.74","384.74","384.74","1 through 10","1009.65","2589.26","percent of total billed charges",""
"BONE PLATE 4.5X372MM 20 HOLE FEMORAL LCP SS CURVED BROAD","SUP-ITM-10030089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.93","2442.70","WELLPOINT [1015]","HB AMC WELLPOINT","2402.96","73.78","","286.63","119.22","1107.45","105","1009.65","2589.26","percent of total billed charges",""
"BONE PLATE 4.5X372MM 20 HOLE FEMORAL LCP SS CURVED BROAD","SUP-ITM-10030089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3256.93","2442.70","AETNA [1001]","HB AMC AETNA HMO","2273.34","69.8","","675.31","184.75","1721.50","286","1702.07","2661.56","percent of total billed charges",""
"BONE PLATE 4.5X372MM 20 HOLE FEMORAL LCP SS CURVED BROAD","SUP-ITM-10030089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3256.93","2442.70","AETNA [1001]","HB AMC AETNA PPO","2618.57","80.4","","1261.44","103.12","1514.10","21","1702.07","2661.56","percent of total billed charges",""
"BONE PLATE 4.5X372MM 20 HOLE FEMORAL LCP SS CURVED BROAD","SUP-ITM-10030089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3256.93","2442.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2618.57","80.4","","1365.00","1365.00","1365.00","1 through 10","1702.07","2661.56","percent of total billed charges",""
"BONE PLATE 4.5X372MM 20 HOLE FEMORAL LCP SS CURVED BROAD","SUP-ITM-10030089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3256.93","2442.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2661.56","81.72","","5157.68","5157.68","5157.68","1 through 10","1702.07","2661.56","percent of total billed charges",""
"BONE PLATE 4.5X372MM 20 HOLE FEMORAL LCP SS CURVED BROAD","SUP-ITM-10030089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3256.93","2442.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2661.56","81.72","","431.26","71.26","1459.57","88","1702.07","2661.56","percent of total billed charges",""
"BONE PLATE 4.5X39MM 2 HOLE COMPRESSION NARROW LC DCP SS","SUP-ITM-10001808","CDM","C1713","HCPCS","0278","RC","","","","both","","","949.24","711.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","754.65","79.5","","800.18","480.96","1887.97","195","294.26","754.65","percent of total billed charges",""
"BONE PLATE 4.5X39MM 2 HOLE COMPRESSION NARROW LC DCP SS","SUP-ITM-10001808","CDM","C1713","HCPCS","0278","RC","","","","both","","","949.24","711.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","505.94","53.3","","813.12","216.42","1444.50","81","294.26","754.65","percent of total billed charges",""
"BONE PLATE 4.5X39MM 2 HOLE COMPRESSION NARROW LC DCP SS","SUP-ITM-10001808","CDM","C1713","HCPCS","0278","RC","","","","both","","","949.24","711.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","294.26","31","","432.60","432.60","432.60","1 through 10","294.26","754.65","percent of total billed charges",""
"BONE PLATE 4.5X39MM 2 HOLE COMPRESSION NARROW LC DCP SS","SUP-ITM-10001808","CDM","C1713","HCPCS","0278","RC","","","","both","","","949.24","711.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","346.47","36.5","","148.37","54.89","631.39","94","294.26","754.65","percent of total billed charges",""
"BONE PLATE 4.5X39MM 2 HOLE COMPRESSION NARROW LC DCP SS","SUP-ITM-10001808","CDM","C1713","HCPCS","0278","RC","","","","both","","","949.24","711.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","363.56","38.3","","279.30","91.72","1116.77","266","294.26","754.65","percent of total billed charges",""
"BONE PLATE 4.5X39MM 2 HOLE COMPRESSION NARROW LC DCP SS","SUP-ITM-10001808","CDM","C1713","HCPCS","0278","RC","","","","both","","","949.24","711.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","407.22","42.9","","731.00","63.70","731.00","1 through 10","294.26","754.65","percent of total billed charges",""
"BONE PLATE 4.5X39MM 2 HOLE COMPRESSION NARROW LC DCP SS","SUP-ITM-10001808","CDM","C1713","HCPCS","0278","RC","","","","both","","","949.24","711.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","407.22","42.9","","384.74","384.74","384.74","1 through 10","294.26","754.65","percent of total billed charges",""
"BONE PLATE 4.5X39MM 2 HOLE COMPRESSION NARROW LC DCP SS","SUP-ITM-10001808","CDM","C1713","HCPCS","0278","RC","","","","both","","","949.24","711.93","WELLPOINT [1015]","HB AMC WELLPOINT","700.35","73.78","","286.63","119.22","1107.45","105","294.26","754.65","percent of total billed charges",""
"BONE PLATE 4.5X39MM 2 HOLE COMPRESSION NARROW LC DCP SS","SUP-ITM-10001808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","949.24","711.93","AETNA [1001]","HB AMC AETNA HMO","662.57","69.8","","675.31","184.75","1721.50","286","496.07","775.72","percent of total billed charges",""
"BONE PLATE 4.5X39MM 2 HOLE COMPRESSION NARROW LC DCP SS","SUP-ITM-10001808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","949.24","711.93","AETNA [1001]","HB AMC AETNA PPO","763.19","80.4","","1261.44","103.12","1514.10","21","496.07","775.72","percent of total billed charges",""
"BONE PLATE 4.5X39MM 2 HOLE COMPRESSION NARROW LC DCP SS","SUP-ITM-10001808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","949.24","711.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","763.19","80.4","","1365.00","1365.00","1365.00","1 through 10","496.07","775.72","percent of total billed charges",""
"BONE PLATE 4.5X39MM 2 HOLE COMPRESSION NARROW LC DCP SS","SUP-ITM-10001808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","949.24","711.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","775.72","81.72","","5157.68","5157.68","5157.68","1 through 10","496.07","775.72","percent of total billed charges",""
"BONE PLATE 4.5X39MM 2 HOLE COMPRESSION NARROW LC DCP SS","SUP-ITM-10001808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","949.24","711.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","775.72","81.72","","431.26","71.26","1459.57","88","496.07","775.72","percent of total billed charges",""
"BONE PLATE 4.5X404MM 22 HOLE LCP SS BROAD","SUP-ITM-10025211","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.32","2677.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2838.40","79.5","","800.18","480.96","1887.97","195","1106.8","2838.4","percent of total billed charges",""
"BONE PLATE 4.5X404MM 22 HOLE LCP SS BROAD","SUP-ITM-10025211","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.32","2677.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1902.98","53.3","","813.12","216.42","1444.50","81","1106.8","2838.4","percent of total billed charges",""
"BONE PLATE 4.5X404MM 22 HOLE LCP SS BROAD","SUP-ITM-10025211","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.32","2677.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1106.80","31","","432.60","432.60","432.60","1 through 10","1106.8","2838.4","percent of total billed charges",""
"BONE PLATE 4.5X404MM 22 HOLE LCP SS BROAD","SUP-ITM-10025211","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.32","2677.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1303.17","36.5","","148.37","54.89","631.39","94","1106.8","2838.4","percent of total billed charges",""
"BONE PLATE 4.5X404MM 22 HOLE LCP SS BROAD","SUP-ITM-10025211","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.32","2677.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1367.43","38.3","","279.30","91.72","1116.77","266","1106.8","2838.4","percent of total billed charges",""
"BONE PLATE 4.5X404MM 22 HOLE LCP SS BROAD","SUP-ITM-10025211","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.32","2677.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1531.67","42.9","","731.00","63.70","731.00","1 through 10","1106.8","2838.4","percent of total billed charges",""
"BONE PLATE 4.5X404MM 22 HOLE LCP SS BROAD","SUP-ITM-10025211","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.32","2677.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1531.67","42.9","","384.74","384.74","384.74","1 through 10","1106.8","2838.4","percent of total billed charges",""
"BONE PLATE 4.5X404MM 22 HOLE LCP SS BROAD","SUP-ITM-10025211","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.32","2677.74","WELLPOINT [1015]","HB AMC WELLPOINT","2634.18","73.78","","286.63","119.22","1107.45","105","1106.8","2838.4","percent of total billed charges",""
"BONE PLATE 4.5X404MM 22 HOLE LCP SS BROAD","SUP-ITM-10025211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3570.32","2677.74","AETNA [1001]","HB AMC AETNA HMO","2492.08","69.8","","675.31","184.75","1721.50","286","1865.85","2917.67","percent of total billed charges",""
"BONE PLATE 4.5X404MM 22 HOLE LCP SS BROAD","SUP-ITM-10025211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3570.32","2677.74","AETNA [1001]","HB AMC AETNA PPO","2870.54","80.4","","1261.44","103.12","1514.10","21","1865.85","2917.67","percent of total billed charges",""
"BONE PLATE 4.5X404MM 22 HOLE LCP SS BROAD","SUP-ITM-10025211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3570.32","2677.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2870.54","80.4","","1365.00","1365.00","1365.00","1 through 10","1865.85","2917.67","percent of total billed charges",""
"BONE PLATE 4.5X404MM 22 HOLE LCP SS BROAD","SUP-ITM-10025211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3570.32","2677.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2917.67","81.72","","5157.68","5157.68","5157.68","1 through 10","1865.85","2917.67","percent of total billed charges",""
"BONE PLATE 4.5X404MM 22 HOLE LCP SS BROAD","SUP-ITM-10025211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3570.32","2677.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2917.67","81.72","","431.26","71.26","1459.57","88","1865.85","2917.67","percent of total billed charges",""
"BONE PLATE 4.5X408MM 22 HOLE LCP SS CURVED BROAD","SUP-ITM-10030090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3673.92","2755.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2920.77","79.5","","800.18","480.96","1887.97","195","1138.92","2920.77","percent of total billed charges",""
"BONE PLATE 4.5X408MM 22 HOLE LCP SS CURVED BROAD","SUP-ITM-10030090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3673.92","2755.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1958.20","53.3","","813.12","216.42","1444.50","81","1138.92","2920.77","percent of total billed charges",""
"BONE PLATE 4.5X408MM 22 HOLE LCP SS CURVED BROAD","SUP-ITM-10030090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3673.92","2755.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1138.92","31","","432.60","432.60","432.60","1 through 10","1138.92","2920.77","percent of total billed charges",""
"BONE PLATE 4.5X408MM 22 HOLE LCP SS CURVED BROAD","SUP-ITM-10030090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3673.92","2755.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1340.98","36.5","","148.37","54.89","631.39","94","1138.92","2920.77","percent of total billed charges",""
"BONE PLATE 4.5X408MM 22 HOLE LCP SS CURVED BROAD","SUP-ITM-10030090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3673.92","2755.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1407.11","38.3","","279.30","91.72","1116.77","266","1138.92","2920.77","percent of total billed charges",""
"BONE PLATE 4.5X408MM 22 HOLE LCP SS CURVED BROAD","SUP-ITM-10030090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3673.92","2755.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1576.11","42.9","","731.00","63.70","731.00","1 through 10","1138.92","2920.77","percent of total billed charges",""
"BONE PLATE 4.5X408MM 22 HOLE LCP SS CURVED BROAD","SUP-ITM-10030090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3673.92","2755.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1576.11","42.9","","384.74","384.74","384.74","1 through 10","1138.92","2920.77","percent of total billed charges",""
"BONE PLATE 4.5X408MM 22 HOLE LCP SS CURVED BROAD","SUP-ITM-10030090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3673.92","2755.44","WELLPOINT [1015]","HB AMC WELLPOINT","2710.62","73.78","","286.63","119.22","1107.45","105","1138.92","2920.77","percent of total billed charges",""
"BONE PLATE 4.5X408MM 22 HOLE LCP SS CURVED BROAD","SUP-ITM-10030090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3673.92","2755.44","AETNA [1001]","HB AMC AETNA HMO","2564.40","69.8","","675.31","184.75","1721.50","286","1919.99","3002.33","percent of total billed charges",""
"BONE PLATE 4.5X408MM 22 HOLE LCP SS CURVED BROAD","SUP-ITM-10030090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3673.92","2755.44","AETNA [1001]","HB AMC AETNA PPO","2953.83","80.4","","1261.44","103.12","1514.10","21","1919.99","3002.33","percent of total billed charges",""
"BONE PLATE 4.5X408MM 22 HOLE LCP SS CURVED BROAD","SUP-ITM-10030090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3673.92","2755.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2953.83","80.4","","1365.00","1365.00","1365.00","1 through 10","1919.99","3002.33","percent of total billed charges",""
"BONE PLATE 4.5X408MM 22 HOLE LCP SS CURVED BROAD","SUP-ITM-10030090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3673.92","2755.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3002.33","81.72","","5157.68","5157.68","5157.68","1 through 10","1919.99","3002.33","percent of total billed charges",""
"BONE PLATE 4.5X408MM 22 HOLE LCP SS CURVED BROAD","SUP-ITM-10030090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3673.92","2755.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3002.33","81.72","","431.26","71.26","1459.57","88","1919.99","3002.33","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.24","652.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","691.84","79.5","","800.18","480.96","1887.97","195","269.77","691.84","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.24","652.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","463.84","53.3","","813.12","216.42","1444.50","81","269.77","691.84","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.24","652.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","269.77","31","","432.60","432.60","432.60","1 through 10","269.77","691.84","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.24","652.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","317.64","36.5","","148.37","54.89","631.39","94","269.77","691.84","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.24","652.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","333.30","38.3","","279.30","91.72","1116.77","266","269.77","691.84","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.24","652.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","373.33","42.9","","731.00","63.70","731.00","1 through 10","269.77","691.84","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.24","652.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","373.33","42.9","","384.74","384.74","384.74","1 through 10","269.77","691.84","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.24","652.68","WELLPOINT [1015]","HB AMC WELLPOINT","642.06","73.78","","286.63","119.22","1107.45","105","269.77","691.84","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.24","652.68","AETNA [1001]","HB AMC AETNA HMO","607.43","69.8","","675.31","184.75","1721.50","286","454.79","711.16","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.24","652.68","AETNA [1001]","HB AMC AETNA PPO","699.67","80.4","","1261.44","103.12","1514.10","21","454.79","711.16","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.24","652.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","699.67","80.4","","1365.00","1365.00","1365.00","1 through 10","454.79","711.16","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.24","652.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","711.16","81.72","","5157.68","5157.68","5157.68","1 through 10","454.79","711.16","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.24","652.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","711.16","81.72","","431.26","71.26","1459.57","88","454.79","711.16","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1524.22","1143.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1211.75","79.5","","800.18","480.96","1887.97","195","472.51","1211.75","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1524.22","1143.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","812.41","53.3","","813.12","216.42","1444.50","81","472.51","1211.75","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1524.22","1143.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","472.51","31","","432.60","432.60","432.60","1 through 10","472.51","1211.75","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1524.22","1143.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","556.34","36.5","","148.37","54.89","631.39","94","472.51","1211.75","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1524.22","1143.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","583.78","38.3","","279.30","91.72","1116.77","266","472.51","1211.75","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1524.22","1143.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.89","42.9","","731.00","63.70","731.00","1 through 10","472.51","1211.75","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1524.22","1143.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.89","42.9","","384.74","384.74","384.74","1 through 10","472.51","1211.75","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1524.22","1143.16","WELLPOINT [1015]","HB AMC WELLPOINT","1124.57","73.78","","286.63","119.22","1107.45","105","472.51","1211.75","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1524.22","1143.16","AETNA [1001]","HB AMC AETNA HMO","1063.91","69.8","","675.31","184.75","1721.50","286","796.56","1245.59","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1524.22","1143.16","AETNA [1001]","HB AMC AETNA PPO","1225.47","80.4","","1261.44","103.12","1514.10","21","796.56","1245.59","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1524.22","1143.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1225.47","80.4","","1365.00","1365.00","1365.00","1 through 10","796.56","1245.59","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1524.22","1143.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1245.59","81.72","","5157.68","5157.68","5157.68","1 through 10","796.56","1245.59","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1524.22","1143.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1245.59","81.72","","431.26","71.26","1459.57","88","796.56","1245.59","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","995.86","746.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","791.71","79.5","","800.18","480.96","1887.97","195","308.72","791.71","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","995.86","746.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","530.79","53.3","","813.12","216.42","1444.50","81","308.72","791.71","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","995.86","746.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","308.72","31","","432.60","432.60","432.60","1 through 10","308.72","791.71","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","995.86","746.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","363.49","36.5","","148.37","54.89","631.39","94","308.72","791.71","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","995.86","746.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","381.41","38.3","","279.30","91.72","1116.77","266","308.72","791.71","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","995.86","746.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.22","42.9","","731.00","63.70","731.00","1 through 10","308.72","791.71","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","995.86","746.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.22","42.9","","384.74","384.74","384.74","1 through 10","308.72","791.71","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","995.86","746.89","WELLPOINT [1015]","HB AMC WELLPOINT","734.75","73.78","","286.63","119.22","1107.45","105","308.72","791.71","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","995.86","746.89","AETNA [1001]","HB AMC AETNA HMO","695.11","69.8","","675.31","184.75","1721.50","286","520.44","813.82","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","995.86","746.89","AETNA [1001]","HB AMC AETNA PPO","800.67","80.4","","1261.44","103.12","1514.10","21","520.44","813.82","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","995.86","746.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","800.67","80.4","","1365.00","1365.00","1365.00","1 through 10","520.44","813.82","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","995.86","746.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","813.82","81.72","","5157.68","5157.68","5157.68","1 through 10","520.44","813.82","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","995.86","746.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","813.82","81.72","","431.26","71.26","1459.57","88","520.44","813.82","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","931.11","698.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","740.23","79.5","","800.18","480.96","1887.97","195","288.64","740.23","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","931.11","698.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","496.28","53.3","","813.12","216.42","1444.50","81","288.64","740.23","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","931.11","698.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","288.64","31","","432.60","432.60","432.60","1 through 10","288.64","740.23","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","931.11","698.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","339.86","36.5","","148.37","54.89","631.39","94","288.64","740.23","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","931.11","698.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","356.62","38.3","","279.30","91.72","1116.77","266","288.64","740.23","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","931.11","698.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","399.45","42.9","","731.00","63.70","731.00","1 through 10","288.64","740.23","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","931.11","698.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","399.45","42.9","","384.74","384.74","384.74","1 through 10","288.64","740.23","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","931.11","698.33","WELLPOINT [1015]","HB AMC WELLPOINT","686.97","73.78","","286.63","119.22","1107.45","105","288.64","740.23","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","931.11","698.33","AETNA [1001]","HB AMC AETNA HMO","649.91","69.8","","675.31","184.75","1721.50","286","486.6","760.9","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","931.11","698.33","AETNA [1001]","HB AMC AETNA PPO","748.61","80.4","","1261.44","103.12","1514.10","21","486.6","760.9","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","931.11","698.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","748.61","80.4","","1365.00","1365.00","1365.00","1 through 10","486.6","760.9","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","931.11","698.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","760.90","81.72","","5157.68","5157.68","5157.68","1 through 10","486.6","760.9","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","931.11","698.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","760.90","81.72","","431.26","71.26","1459.57","88","486.6","760.9","percent of total billed charges",""
"BONE PLATE 40MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077367","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","710.85","79.5","","800.18","480.96","1887.97","195","277.19","710.85","percent of total billed charges",""
"BONE PLATE 40MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077367","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","476.58","53.3","","813.12","216.42","1444.50","81","277.19","710.85","percent of total billed charges",""
"BONE PLATE 40MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077367","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","277.19","31","","432.60","432.60","432.60","1 through 10","277.19","710.85","percent of total billed charges",""
"BONE PLATE 40MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077367","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","326.36","36.5","","148.37","54.89","631.39","94","277.19","710.85","percent of total billed charges",""
"BONE PLATE 40MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077367","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","342.46","38.3","","279.30","91.72","1116.77","266","277.19","710.85","percent of total billed charges",""
"BONE PLATE 40MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077367","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","383.59","42.9","","731.00","63.70","731.00","1 through 10","277.19","710.85","percent of total billed charges",""
"BONE PLATE 40MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077367","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","383.59","42.9","","384.74","384.74","384.74","1 through 10","277.19","710.85","percent of total billed charges",""
"BONE PLATE 40MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077367","CDM","C1713","HCPCS","0278","RC","","","","both","","","894.15","670.61","WELLPOINT [1015]","HB AMC WELLPOINT","659.70","73.78","","286.63","119.22","1107.45","105","277.19","710.85","percent of total billed charges",""
"BONE PLATE 40MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","894.15","670.61","AETNA [1001]","HB AMC AETNA HMO","624.12","69.8","","675.31","184.75","1721.50","286","467.28","730.7","percent of total billed charges",""
"BONE PLATE 40MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","894.15","670.61","AETNA [1001]","HB AMC AETNA PPO","718.90","80.4","","1261.44","103.12","1514.10","21","467.28","730.7","percent of total billed charges",""
"BONE PLATE 40MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","894.15","670.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","718.90","80.4","","1365.00","1365.00","1365.00","1 through 10","467.28","730.7","percent of total billed charges",""
"BONE PLATE 40MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","894.15","670.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","730.70","81.72","","5157.68","5157.68","5157.68","1 through 10","467.28","730.7","percent of total billed charges",""
"BONE PLATE 40MM SPLIT MATRIXORTHOGNATHIC TI SAGITTAL SLIDER ADJUSTABLE","SUP-ITM-10077367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","894.15","670.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","730.70","81.72","","431.26","71.26","1459.57","88","467.28","730.7","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.98","819.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","868.92","79.5","","800.18","480.96","1887.97","195","338.82","868.92","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.98","819.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","582.56","53.3","","813.12","216.42","1444.50","81","338.82","868.92","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.98","819.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","338.82","31","","432.60","432.60","432.60","1 through 10","338.82","868.92","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.98","819.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","398.94","36.5","","148.37","54.89","631.39","94","338.82","868.92","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.98","819.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","418.61","38.3","","279.30","91.72","1116.77","266","338.82","868.92","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.98","819.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","468.89","42.9","","731.00","63.70","731.00","1 through 10","338.82","868.92","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.98","819.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","468.89","42.9","","384.74","384.74","384.74","1 through 10","338.82","868.92","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","1092.98","819.73","WELLPOINT [1015]","HB AMC WELLPOINT","806.40","73.78","","286.63","119.22","1107.45","105","338.82","868.92","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1092.98","819.73","AETNA [1001]","HB AMC AETNA HMO","762.90","69.8","","675.31","184.75","1721.50","286","571.19","893.18","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1092.98","819.73","AETNA [1001]","HB AMC AETNA PPO","878.76","80.4","","1261.44","103.12","1514.10","21","571.19","893.18","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1092.98","819.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","878.76","80.4","","1365.00","1365.00","1365.00","1 through 10","571.19","893.18","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1092.98","819.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","893.18","81.72","","5157.68","5157.68","5157.68","1 through 10","571.19","893.18","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1092.98","819.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","893.18","81.72","","431.26","71.26","1459.57","88","571.19","893.18","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1201.46","79.5","","800.18","480.96","1887.97","195","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","805.51","53.3","","813.12","216.42","1444.50","81","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","468.49","31","","432.60","432.60","432.60","1 through 10","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","551.61","36.5","","148.37","54.89","631.39","94","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","578.82","38.3","","279.30","91.72","1116.77","266","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","648.33","42.9","","731.00","63.70","731.00","1 through 10","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","648.33","42.9","","384.74","384.74","384.74","1 through 10","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","WELLPOINT [1015]","HB AMC WELLPOINT","1115.02","73.78","","286.63","119.22","1107.45","105","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","AETNA [1001]","HB AMC AETNA HMO","1054.87","69.8","","675.31","184.75","1721.50","286","789.79","1235.01","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","AETNA [1001]","HB AMC AETNA PPO","1215.06","80.4","","1261.44","103.12","1514.10","21","789.79","1235.01","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1215.06","80.4","","1365.00","1365.00","1365.00","1 through 10","789.79","1235.01","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1235.01","81.72","","5157.68","5157.68","5157.68","1 through 10","789.79","1235.01","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1235.01","81.72","","431.26","71.26","1459.57","88","789.79","1235.01","percent of total billed charges",""
"BONE PLATE 46MM SHORT 2 HOLE 135DEG DHS COMPRESSION BARREL SS","SUP-ITM-10018917","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1201.46","79.5","","800.18","480.96","1887.97","195","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM SHORT 2 HOLE 135DEG DHS COMPRESSION BARREL SS","SUP-ITM-10018917","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","805.51","53.3","","813.12","216.42","1444.50","81","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM SHORT 2 HOLE 135DEG DHS COMPRESSION BARREL SS","SUP-ITM-10018917","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","468.49","31","","432.60","432.60","432.60","1 through 10","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM SHORT 2 HOLE 135DEG DHS COMPRESSION BARREL SS","SUP-ITM-10018917","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","551.61","36.5","","148.37","54.89","631.39","94","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM SHORT 2 HOLE 135DEG DHS COMPRESSION BARREL SS","SUP-ITM-10018917","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","578.82","38.3","","279.30","91.72","1116.77","266","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM SHORT 2 HOLE 135DEG DHS COMPRESSION BARREL SS","SUP-ITM-10018917","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","648.33","42.9","","731.00","63.70","731.00","1 through 10","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM SHORT 2 HOLE 135DEG DHS COMPRESSION BARREL SS","SUP-ITM-10018917","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","648.33","42.9","","384.74","384.74","384.74","1 through 10","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM SHORT 2 HOLE 135DEG DHS COMPRESSION BARREL SS","SUP-ITM-10018917","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","WELLPOINT [1015]","HB AMC WELLPOINT","1115.02","73.78","","286.63","119.22","1107.45","105","468.49","1201.46","percent of total billed charges",""
"BONE PLATE 46MM SHORT 2 HOLE 135DEG DHS COMPRESSION BARREL SS","SUP-ITM-10018917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","AETNA [1001]","HB AMC AETNA HMO","1054.87","69.8","","675.31","184.75","1721.50","286","789.79","1235.01","percent of total billed charges",""
"BONE PLATE 46MM SHORT 2 HOLE 135DEG DHS COMPRESSION BARREL SS","SUP-ITM-10018917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","AETNA [1001]","HB AMC AETNA PPO","1215.06","80.4","","1261.44","103.12","1514.10","21","789.79","1235.01","percent of total billed charges",""
"BONE PLATE 46MM SHORT 2 HOLE 135DEG DHS COMPRESSION BARREL SS","SUP-ITM-10018917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1215.06","80.4","","1365.00","1365.00","1365.00","1 through 10","789.79","1235.01","percent of total billed charges",""
"BONE PLATE 46MM SHORT 2 HOLE 135DEG DHS COMPRESSION BARREL SS","SUP-ITM-10018917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1235.01","81.72","","5157.68","5157.68","5157.68","1 through 10","789.79","1235.01","percent of total billed charges",""
"BONE PLATE 46MM SHORT 2 HOLE 135DEG DHS COMPRESSION BARREL SS","SUP-ITM-10018917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1235.01","81.72","","431.26","71.26","1459.57","88","789.79","1235.01","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","920.40","79.5","","800.18","480.96","1887.97","195","358.9","920.4","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","617.07","53.3","","813.12","216.42","1444.50","81","358.9","920.4","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","358.90","31","","432.60","432.60","432.60","1 through 10","358.9","920.4","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","422.57","36.5","","148.37","54.89","631.39","94","358.9","920.4","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","443.41","38.3","","279.30","91.72","1116.77","266","358.9","920.4","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","496.67","42.9","","731.00","63.70","731.00","1 through 10","358.9","920.4","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","496.67","42.9","","384.74","384.74","384.74","1 through 10","358.9","920.4","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","WELLPOINT [1015]","HB AMC WELLPOINT","854.17","73.78","","286.63","119.22","1107.45","105","358.9","920.4","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1157.73","868.30","AETNA [1001]","HB AMC AETNA HMO","808.10","69.8","","675.31","184.75","1721.50","286","605.03","946.1","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1157.73","868.30","AETNA [1001]","HB AMC AETNA PPO","930.81","80.4","","1261.44","103.12","1514.10","21","605.03","946.1","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1157.73","868.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","930.81","80.4","","1365.00","1365.00","1365.00","1 through 10","605.03","946.1","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1157.73","868.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","946.10","81.72","","5157.68","5157.68","5157.68","1 through 10","605.03","946.1","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1157.73","868.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","946.10","81.72","","431.26","71.26","1459.57","88","605.03","946.1","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","822.59","79.5","","800.18","480.96","1887.97","195","320.76","822.59","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","551.50","53.3","","813.12","216.42","1444.50","81","320.76","822.59","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","320.76","31","","432.60","432.60","432.60","1 through 10","320.76","822.59","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","377.67","36.5","","148.37","54.89","631.39","94","320.76","822.59","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","396.29","38.3","","279.30","91.72","1116.77","266","320.76","822.59","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","443.89","42.9","","731.00","63.70","731.00","1 through 10","320.76","822.59","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","443.89","42.9","","384.74","384.74","384.74","1 through 10","320.76","822.59","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.71","776.03","WELLPOINT [1015]","HB AMC WELLPOINT","763.41","73.78","","286.63","119.22","1107.45","105","320.76","822.59","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.71","776.03","AETNA [1001]","HB AMC AETNA HMO","722.23","69.8","","675.31","184.75","1721.50","286","540.74","845.57","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.71","776.03","AETNA [1001]","HB AMC AETNA PPO","831.91","80.4","","1261.44","103.12","1514.10","21","540.74","845.57","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.71","776.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","831.91","80.4","","1365.00","1365.00","1365.00","1 through 10","540.74","845.57","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.71","776.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","845.57","81.72","","5157.68","5157.68","5157.68","1 through 10","540.74","845.57","percent of total billed charges",""
"BONE PLATE 47MM 6 HOLE TI QUARTER TUBULAR COLLAR","SUP-ITM-10027386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.71","776.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","845.57","81.72","","431.26","71.26","1459.57","88","540.74","845.57","percent of total billed charges",""
"BONE PLATE 48MM 3X16 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10076357","CDM","C1713","HCPCS","0278","RC","","","","both","","","6046.35","4534.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4806.85","79.5","","800.18","480.96","1887.97","195","1874.37","4806.85","percent of total billed charges",""
"BONE PLATE 48MM 3X16 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10076357","CDM","C1713","HCPCS","0278","RC","","","","both","","","6046.35","4534.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3222.70","53.3","","813.12","216.42","1444.50","81","1874.37","4806.85","percent of total billed charges",""
"BONE PLATE 48MM 3X16 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10076357","CDM","C1713","HCPCS","0278","RC","","","","both","","","6046.35","4534.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1874.37","31","","432.60","432.60","432.60","1 through 10","1874.37","4806.85","percent of total billed charges",""
"BONE PLATE 48MM 3X16 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10076357","CDM","C1713","HCPCS","0278","RC","","","","both","","","6046.35","4534.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2206.92","36.5","","148.37","54.89","631.39","94","1874.37","4806.85","percent of total billed charges",""
"BONE PLATE 48MM 3X16 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10076357","CDM","C1713","HCPCS","0278","RC","","","","both","","","6046.35","4534.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2315.75","38.3","","279.30","91.72","1116.77","266","1874.37","4806.85","percent of total billed charges",""
"BONE PLATE 48MM 3X16 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10076357","CDM","C1713","HCPCS","0278","RC","","","","both","","","6046.35","4534.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2593.88","42.9","","731.00","63.70","731.00","1 through 10","1874.37","4806.85","percent of total billed charges",""
"BONE PLATE 48MM 3X16 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10076357","CDM","C1713","HCPCS","0278","RC","","","","both","","","6046.35","4534.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2593.88","42.9","","384.74","384.74","384.74","1 through 10","1874.37","4806.85","percent of total billed charges",""
"BONE PLATE 48MM 3X16 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10076357","CDM","C1713","HCPCS","0278","RC","","","","both","","","6046.35","4534.76","WELLPOINT [1015]","HB AMC WELLPOINT","4461.00","73.78","","286.63","119.22","1107.45","105","1874.37","4806.85","percent of total billed charges",""
"BONE PLATE 48MM 3X16 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10076357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6046.35","4534.76","AETNA [1001]","HB AMC AETNA HMO","4220.35","69.8","","675.31","184.75","1721.50","286","3159.82","4941.08","percent of total billed charges",""
"BONE PLATE 48MM 3X16 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10076357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6046.35","4534.76","AETNA [1001]","HB AMC AETNA PPO","4861.27","80.4","","1261.44","103.12","1514.10","21","3159.82","4941.08","percent of total billed charges",""
"BONE PLATE 48MM 3X16 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10076357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6046.35","4534.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4861.27","80.4","","1365.00","1365.00","1365.00","1 through 10","3159.82","4941.08","percent of total billed charges",""
"BONE PLATE 48MM 3X16 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10076357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6046.35","4534.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4941.08","81.72","","5157.68","5157.68","5157.68","1 through 10","3159.82","4941.08","percent of total billed charges",""
"BONE PLATE 48MM 3X16 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10076357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6046.35","4534.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4941.08","81.72","","431.26","71.26","1459.57","88","3159.82","4941.08","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1978.76","1484.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1573.11","79.5","","800.18","480.96","1887.97","195","613.42","1573.11","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1978.76","1484.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1054.68","53.3","","813.12","216.42","1444.50","81","613.42","1573.11","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1978.76","1484.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","613.42","31","","432.60","432.60","432.60","1 through 10","613.42","1573.11","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1978.76","1484.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","722.25","36.5","","148.37","54.89","631.39","94","613.42","1573.11","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1978.76","1484.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","757.87","38.3","","279.30","91.72","1116.77","266","613.42","1573.11","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1978.76","1484.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","848.89","42.9","","731.00","63.70","731.00","1 through 10","613.42","1573.11","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1978.76","1484.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","848.89","42.9","","384.74","384.74","384.74","1 through 10","613.42","1573.11","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","1978.76","1484.07","WELLPOINT [1015]","HB AMC WELLPOINT","1459.93","73.78","","286.63","119.22","1107.45","105","613.42","1573.11","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1978.76","1484.07","AETNA [1001]","HB AMC AETNA HMO","1381.17","69.8","","675.31","184.75","1721.50","286","1034.1","1617.04","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1978.76","1484.07","AETNA [1001]","HB AMC AETNA PPO","1590.92","80.4","","1261.44","103.12","1514.10","21","1034.1","1617.04","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1978.76","1484.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1590.92","80.4","","1365.00","1365.00","1365.00","1 through 10","1034.1","1617.04","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1978.76","1484.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1617.04","81.72","","5157.68","5157.68","5157.68","1 through 10","1034.1","1617.04","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1978.76","1484.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1617.04","81.72","","431.26","71.26","1459.57","88","1034.1","1617.04","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1029.53","79.5","","1309.77","674.56","6049.93","26","401.45","1029.53","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","690.24","53.3","","1901.83","1901.83","2962.25","1 through 10","401.45","1029.53","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","472.68","36.5","","1620.31","1620.31","19908.88","1 through 10","401.45","1029.53","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","495.99","38.3","","352.91","352.91","2046.30","1 through 10","401.45","1029.53","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","555.56","42.9","","9668.75","9668.75","9668.75","1 through 10","401.45","1029.53","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","WELLPOINT [1015]","HB AMC WELLPOINT","955.45","73.78","","699.88","384.10","3443.31","33","401.45","1029.53","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","AETNA [1001]","HB AMC AETNA HMO","903.91","69.8","","1421.24","264.50","4933.46","29","676.77","1058.27","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1041.18","80.4","","1022.97","1022.97","3607.50","1 through 10","676.77","1058.27","percent of total billed charges",""
"BONE PLATE 4MM 27X2 SYSTEM FIXATION MINI TI DOUBLE BEND SPACING","SUP-ITM-10032568","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1058.27","81.72","","3010.54","693.88","5019.88","35","676.77","1058.27","percent of total billed charges",""
"BONE PLATE 4X20 LIGHT BLUE 2.5MM SM HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10081091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4148.19","3111.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3297.81","79.5","","800.18","480.96","1887.97","195","1285.94","3297.81","percent of total billed charges",""
"BONE PLATE 4X20 LIGHT BLUE 2.5MM SM HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10081091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4148.19","3111.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2210.99","53.3","","813.12","216.42","1444.50","81","1285.94","3297.81","percent of total billed charges",""
"BONE PLATE 4X20 LIGHT BLUE 2.5MM SM HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10081091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4148.19","3111.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1285.94","31","","432.60","432.60","432.60","1 through 10","1285.94","3297.81","percent of total billed charges",""
"BONE PLATE 4X20 LIGHT BLUE 2.5MM SM HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10081091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4148.19","3111.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1514.09","36.5","","148.37","54.89","631.39","94","1285.94","3297.81","percent of total billed charges",""
"BONE PLATE 4X20 LIGHT BLUE 2.5MM SM HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10081091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4148.19","3111.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1588.76","38.3","","279.30","91.72","1116.77","266","1285.94","3297.81","percent of total billed charges",""
"BONE PLATE 4X20 LIGHT BLUE 2.5MM SM HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10081091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4148.19","3111.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1779.57","42.9","","731.00","63.70","731.00","1 through 10","1285.94","3297.81","percent of total billed charges",""
"BONE PLATE 4X20 LIGHT BLUE 2.5MM SM HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10081091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4148.19","3111.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1779.57","42.9","","384.74","384.74","384.74","1 through 10","1285.94","3297.81","percent of total billed charges",""
"BONE PLATE 4X20 LIGHT BLUE 2.5MM SM HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10081091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4148.19","3111.14","WELLPOINT [1015]","HB AMC WELLPOINT","3060.53","73.78","","286.63","119.22","1107.45","105","1285.94","3297.81","percent of total billed charges",""
"BONE PLATE 4X20 LIGHT BLUE 2.5MM SM HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10081091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4148.19","3111.14","AETNA [1001]","HB AMC AETNA HMO","2895.44","69.8","","675.31","184.75","1721.50","286","2167.84","3389.9","percent of total billed charges",""
"BONE PLATE 4X20 LIGHT BLUE 2.5MM SM HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10081091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4148.19","3111.14","AETNA [1001]","HB AMC AETNA PPO","3335.14","80.4","","1261.44","103.12","1514.10","21","2167.84","3389.9","percent of total billed charges",""
"BONE PLATE 4X20 LIGHT BLUE 2.5MM SM HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10081091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4148.19","3111.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3335.14","80.4","","1365.00","1365.00","1365.00","1 through 10","2167.84","3389.9","percent of total billed charges",""
"BONE PLATE 4X20 LIGHT BLUE 2.5MM SM HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10081091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4148.19","3111.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3389.90","81.72","","5157.68","5157.68","5157.68","1 through 10","2167.84","3389.9","percent of total billed charges",""
"BONE PLATE 4X20 LIGHT BLUE 2.5MM SM HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10081091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4148.19","3111.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3389.90","81.72","","431.26","71.26","1459.57","88","2167.84","3389.9","percent of total billed charges",""
"BONE PLATE 5 2.4X67MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10023219","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.97","1715.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1818.14","79.5","","800.18","480.96","1887.97","195","708.96","1818.14","percent of total billed charges",""
"BONE PLATE 5 2.4X67MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10023219","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.97","1715.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1218.96","53.3","","813.12","216.42","1444.50","81","708.96","1818.14","percent of total billed charges",""
"BONE PLATE 5 2.4X67MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10023219","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.97","1715.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","708.96","31","","432.60","432.60","432.60","1 through 10","708.96","1818.14","percent of total billed charges",""
"BONE PLATE 5 2.4X67MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10023219","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.97","1715.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","834.74","36.5","","148.37","54.89","631.39","94","708.96","1818.14","percent of total billed charges",""
"BONE PLATE 5 2.4X67MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10023219","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.97","1715.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","875.91","38.3","","279.30","91.72","1116.77","266","708.96","1818.14","percent of total billed charges",""
"BONE PLATE 5 2.4X67MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10023219","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.97","1715.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","981.11","42.9","","731.00","63.70","731.00","1 through 10","708.96","1818.14","percent of total billed charges",""
"BONE PLATE 5 2.4X67MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10023219","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.97","1715.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","981.11","42.9","","384.74","384.74","384.74","1 through 10","708.96","1818.14","percent of total billed charges",""
"BONE PLATE 5 2.4X67MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10023219","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.97","1715.23","WELLPOINT [1015]","HB AMC WELLPOINT","1687.33","73.78","","286.63","119.22","1107.45","105","708.96","1818.14","percent of total billed charges",""
"BONE PLATE 5 2.4X67MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10023219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2286.97","1715.23","AETNA [1001]","HB AMC AETNA HMO","1596.31","69.8","","675.31","184.75","1721.50","286","1195.17","1868.91","percent of total billed charges",""
"BONE PLATE 5 2.4X67MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10023219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2286.97","1715.23","AETNA [1001]","HB AMC AETNA PPO","1838.72","80.4","","1261.44","103.12","1514.10","21","1195.17","1868.91","percent of total billed charges",""
"BONE PLATE 5 2.4X67MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10023219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2286.97","1715.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1838.72","80.4","","1365.00","1365.00","1365.00","1 through 10","1195.17","1868.91","percent of total billed charges",""
"BONE PLATE 5 2.4X67MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10023219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2286.97","1715.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1868.91","81.72","","5157.68","5157.68","5157.68","1 through 10","1195.17","1868.91","percent of total billed charges",""
"BONE PLATE 5 2.4X67MM 9 HOLE LCP STAINLESS COLUMN RIGHT","SUP-ITM-10023219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2286.97","1715.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1868.91","81.72","","431.26","71.26","1459.57","88","1195.17","1868.91","percent of total billed charges",""
"BONE PLATE 50X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE CONDYLAR","SUP-ITM-10002039","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3248.27","79.5","","800.18","480.96","1887.97","195","1266.62","3248.27","percent of total billed charges",""
"BONE PLATE 50X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE CONDYLAR","SUP-ITM-10002039","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2177.77","53.3","","813.12","216.42","1444.50","81","1266.62","3248.27","percent of total billed charges",""
"BONE PLATE 50X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE CONDYLAR","SUP-ITM-10002039","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1266.62","31","","432.60","432.60","432.60","1 through 10","1266.62","3248.27","percent of total billed charges",""
"BONE PLATE 50X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE CONDYLAR","SUP-ITM-10002039","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1491.34","36.5","","148.37","54.89","631.39","94","1266.62","3248.27","percent of total billed charges",""
"BONE PLATE 50X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE CONDYLAR","SUP-ITM-10002039","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1564.89","38.3","","279.30","91.72","1116.77","266","1266.62","3248.27","percent of total billed charges",""
"BONE PLATE 50X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE CONDYLAR","SUP-ITM-10002039","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1752.84","42.9","","731.00","63.70","731.00","1 through 10","1266.62","3248.27","percent of total billed charges",""
"BONE PLATE 50X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE CONDYLAR","SUP-ITM-10002039","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1752.84","42.9","","384.74","384.74","384.74","1 through 10","1266.62","3248.27","percent of total billed charges",""
"BONE PLATE 50X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE CONDYLAR","SUP-ITM-10002039","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","WELLPOINT [1015]","HB AMC WELLPOINT","3014.55","73.78","","286.63","119.22","1107.45","105","1266.62","3248.27","percent of total billed charges",""
"BONE PLATE 50X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE CONDYLAR","SUP-ITM-10002039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.87","3064.40","AETNA [1001]","HB AMC AETNA HMO","2851.94","69.8","","675.31","184.75","1721.50","286","2135.28","3338.97","percent of total billed charges",""
"BONE PLATE 50X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE CONDYLAR","SUP-ITM-10002039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.87","3064.40","AETNA [1001]","HB AMC AETNA PPO","3285.04","80.4","","1261.44","103.12","1514.10","21","2135.28","3338.97","percent of total billed charges",""
"BONE PLATE 50X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE CONDYLAR","SUP-ITM-10002039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.87","3064.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3285.04","80.4","","1365.00","1365.00","1365.00","1 through 10","2135.28","3338.97","percent of total billed charges",""
"BONE PLATE 50X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE CONDYLAR","SUP-ITM-10002039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.87","3064.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3338.97","81.72","","5157.68","5157.68","5157.68","1 through 10","2135.28","3338.97","percent of total billed charges",""
"BONE PLATE 50X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE CONDYLAR","SUP-ITM-10002039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.87","3064.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3338.97","81.72","","431.26","71.26","1459.57","88","2135.28","3338.97","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1936.03","1452.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1539.14","79.5","","800.18","480.96","1887.97","195","600.17","1539.14","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1936.03","1452.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1031.90","53.3","","813.12","216.42","1444.50","81","600.17","1539.14","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1936.03","1452.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","600.17","31","","432.60","432.60","432.60","1 through 10","600.17","1539.14","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1936.03","1452.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","706.65","36.5","","148.37","54.89","631.39","94","600.17","1539.14","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1936.03","1452.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","741.50","38.3","","279.30","91.72","1116.77","266","600.17","1539.14","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1936.03","1452.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","830.56","42.9","","731.00","63.70","731.00","1 through 10","600.17","1539.14","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1936.03","1452.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","830.56","42.9","","384.74","384.74","384.74","1 through 10","600.17","1539.14","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1936.03","1452.02","WELLPOINT [1015]","HB AMC WELLPOINT","1428.40","73.78","","286.63","119.22","1107.45","105","600.17","1539.14","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1936.03","1452.02","AETNA [1001]","HB AMC AETNA HMO","1351.35","69.8","","675.31","184.75","1721.50","286","1011.77","1582.12","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1936.03","1452.02","AETNA [1001]","HB AMC AETNA PPO","1556.57","80.4","","1261.44","103.12","1514.10","21","1011.77","1582.12","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1936.03","1452.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1556.57","80.4","","1365.00","1365.00","1365.00","1 through 10","1011.77","1582.12","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1936.03","1452.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1582.12","81.72","","5157.68","5157.68","5157.68","1 through 10","1011.77","1582.12","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1936.03","1452.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1582.12","81.72","","431.26","71.26","1459.57","88","1011.77","1582.12","percent of total billed charges",""
"BONE PLATE 57MM 5 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040735","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.79","351.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","372.69","79.5","","800.18","480.96","1887.97","195","145.32","372.69","percent of total billed charges",""
"BONE PLATE 57MM 5 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040735","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.79","351.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","249.87","53.3","","813.12","216.42","1444.50","81","145.32","372.69","percent of total billed charges",""
"BONE PLATE 57MM 5 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040735","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.79","351.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","145.32","31","","432.60","432.60","432.60","1 through 10","145.32","372.69","percent of total billed charges",""
"BONE PLATE 57MM 5 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040735","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.79","351.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","171.11","36.5","","148.37","54.89","631.39","94","145.32","372.69","percent of total billed charges",""
"BONE PLATE 57MM 5 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040735","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.79","351.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.55","38.3","","279.30","91.72","1116.77","266","145.32","372.69","percent of total billed charges",""
"BONE PLATE 57MM 5 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040735","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.79","351.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.11","42.9","","731.00","63.70","731.00","1 through 10","145.32","372.69","percent of total billed charges",""
"BONE PLATE 57MM 5 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040735","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.79","351.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.11","42.9","","384.74","384.74","384.74","1 through 10","145.32","372.69","percent of total billed charges",""
"BONE PLATE 57MM 5 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040735","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.79","351.59","WELLPOINT [1015]","HB AMC WELLPOINT","345.87","73.78","","286.63","119.22","1107.45","105","145.32","372.69","percent of total billed charges",""
"BONE PLATE 57MM 5 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.79","351.59","AETNA [1001]","HB AMC AETNA HMO","327.22","69.8","","675.31","184.75","1721.50","286","244.99","383.1","percent of total billed charges",""
"BONE PLATE 57MM 5 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.79","351.59","AETNA [1001]","HB AMC AETNA PPO","376.91","80.4","","1261.44","103.12","1514.10","21","244.99","383.1","percent of total billed charges",""
"BONE PLATE 57MM 5 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.79","351.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","376.91","80.4","","1365.00","1365.00","1365.00","1 through 10","244.99","383.1","percent of total billed charges",""
"BONE PLATE 57MM 5 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.79","351.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","383.10","81.72","","5157.68","5157.68","5157.68","1 through 10","244.99","383.1","percent of total billed charges",""
"BONE PLATE 57MM 5 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.79","351.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","383.10","81.72","","431.26","71.26","1459.57","88","244.99","383.1","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","343.86","79.5","","800.18","480.96","1887.97","195","134.08","343.86","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","230.54","53.3","","813.12","216.42","1444.50","81","134.08","343.86","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","134.08","31","","432.60","432.60","432.60","1 through 10","134.08","343.86","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","157.87","36.5","","148.37","54.89","631.39","94","134.08","343.86","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","165.66","38.3","","279.30","91.72","1116.77","266","134.08","343.86","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","185.56","42.9","","731.00","63.70","731.00","1 through 10","134.08","343.86","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","185.56","42.9","","384.74","384.74","384.74","1 through 10","134.08","343.86","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","WELLPOINT [1015]","HB AMC WELLPOINT","319.12","73.78","","286.63","119.22","1107.45","105","134.08","343.86","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.53","324.40","AETNA [1001]","HB AMC AETNA HMO","301.91","69.8","","675.31","184.75","1721.50","286","226.04","353.46","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.53","324.40","AETNA [1001]","HB AMC AETNA PPO","347.75","80.4","","1261.44","103.12","1514.10","21","226.04","353.46","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.53","324.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","347.75","80.4","","1365.00","1365.00","1365.00","1 through 10","226.04","353.46","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.53","324.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","353.46","81.72","","5157.68","5157.68","5157.68","1 through 10","226.04","353.46","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.53","324.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","353.46","81.72","","431.26","71.26","1459.57","88","226.04","353.46","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.48","781.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","828.77","79.5","","800.18","480.96","1887.97","195","323.17","828.77","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.48","781.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","555.64","53.3","","813.12","216.42","1444.50","81","323.17","828.77","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.48","781.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","323.17","31","","432.60","432.60","432.60","1 through 10","323.17","828.77","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.48","781.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","380.51","36.5","","148.37","54.89","631.39","94","323.17","828.77","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.48","781.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","399.27","38.3","","279.30","91.72","1116.77","266","323.17","828.77","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.48","781.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","447.22","42.9","","731.00","63.70","731.00","1 through 10","323.17","828.77","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.48","781.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","447.22","42.9","","384.74","384.74","384.74","1 through 10","323.17","828.77","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.48","781.86","WELLPOINT [1015]","HB AMC WELLPOINT","769.14","73.78","","286.63","119.22","1107.45","105","323.17","828.77","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.48","781.86","AETNA [1001]","HB AMC AETNA HMO","727.65","69.8","","675.31","184.75","1721.50","286","544.8","851.91","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.48","781.86","AETNA [1001]","HB AMC AETNA PPO","838.15","80.4","","1261.44","103.12","1514.10","21","544.8","851.91","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.48","781.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","838.15","80.4","","1365.00","1365.00","1365.00","1 through 10","544.8","851.91","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.48","781.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","851.91","81.72","","5157.68","5157.68","5157.68","1 through 10","544.8","851.91","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.48","781.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","851.91","81.72","","431.26","71.26","1459.57","88","544.8","851.91","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1478.89","1109.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1175.72","79.5","","800.18","480.96","1887.97","195","458.46","1175.72","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1478.89","1109.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","788.25","53.3","","813.12","216.42","1444.50","81","458.46","1175.72","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1478.89","1109.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","458.46","31","","432.60","432.60","432.60","1 through 10","458.46","1175.72","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1478.89","1109.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","539.79","36.5","","148.37","54.89","631.39","94","458.46","1175.72","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1478.89","1109.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","566.41","38.3","","279.30","91.72","1116.77","266","458.46","1175.72","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1478.89","1109.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","634.44","42.9","","731.00","63.70","731.00","1 through 10","458.46","1175.72","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1478.89","1109.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","634.44","42.9","","384.74","384.74","384.74","1 through 10","458.46","1175.72","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1478.89","1109.17","WELLPOINT [1015]","HB AMC WELLPOINT","1091.13","73.78","","286.63","119.22","1107.45","105","458.46","1175.72","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1478.89","1109.17","AETNA [1001]","HB AMC AETNA HMO","1032.27","69.8","","675.31","184.75","1721.50","286","772.87","1208.55","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1478.89","1109.17","AETNA [1001]","HB AMC AETNA PPO","1189.03","80.4","","1261.44","103.12","1514.10","21","772.87","1208.55","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1478.89","1109.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1189.03","80.4","","1365.00","1365.00","1365.00","1 through 10","772.87","1208.55","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1478.89","1109.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1208.55","81.72","","5157.68","5157.68","5157.68","1 through 10","772.87","1208.55","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1478.89","1109.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1208.55","81.72","","431.26","71.26","1459.57","88","772.87","1208.55","percent of total billed charges",""
"BONE PLATE 5XRT 64MM 20 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10030879","CDM","C1713","HCPCS","0278","RC","","","","both","","","6716.55","5037.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5339.66","79.5","","800.18","480.96","1887.97","195","2082.13","5339.66","percent of total billed charges",""
"BONE PLATE 5XRT 64MM 20 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10030879","CDM","C1713","HCPCS","0278","RC","","","","both","","","6716.55","5037.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3579.92","53.3","","813.12","216.42","1444.50","81","2082.13","5339.66","percent of total billed charges",""
"BONE PLATE 5XRT 64MM 20 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10030879","CDM","C1713","HCPCS","0278","RC","","","","both","","","6716.55","5037.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2082.13","31","","432.60","432.60","432.60","1 through 10","2082.13","5339.66","percent of total billed charges",""
"BONE PLATE 5XRT 64MM 20 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10030879","CDM","C1713","HCPCS","0278","RC","","","","both","","","6716.55","5037.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2451.54","36.5","","148.37","54.89","631.39","94","2082.13","5339.66","percent of total billed charges",""
"BONE PLATE 5XRT 64MM 20 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10030879","CDM","C1713","HCPCS","0278","RC","","","","both","","","6716.55","5037.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2572.44","38.3","","279.30","91.72","1116.77","266","2082.13","5339.66","percent of total billed charges",""
"BONE PLATE 5XRT 64MM 20 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10030879","CDM","C1713","HCPCS","0278","RC","","","","both","","","6716.55","5037.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2881.40","42.9","","731.00","63.70","731.00","1 through 10","2082.13","5339.66","percent of total billed charges",""
"BONE PLATE 5XRT 64MM 20 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10030879","CDM","C1713","HCPCS","0278","RC","","","","both","","","6716.55","5037.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2881.40","42.9","","384.74","384.74","384.74","1 through 10","2082.13","5339.66","percent of total billed charges",""
"BONE PLATE 5XRT 64MM 20 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10030879","CDM","C1713","HCPCS","0278","RC","","","","both","","","6716.55","5037.41","WELLPOINT [1015]","HB AMC WELLPOINT","4955.47","73.78","","286.63","119.22","1107.45","105","2082.13","5339.66","percent of total billed charges",""
"BONE PLATE 5XRT 64MM 20 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10030879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6716.55","5037.41","AETNA [1001]","HB AMC AETNA HMO","4688.15","69.8","","675.31","184.75","1721.50","286","3510.07","5488.76","percent of total billed charges",""
"BONE PLATE 5XRT 64MM 20 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10030879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6716.55","5037.41","AETNA [1001]","HB AMC AETNA PPO","5400.11","80.4","","1261.44","103.12","1514.10","21","3510.07","5488.76","percent of total billed charges",""
"BONE PLATE 5XRT 64MM 20 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10030879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6716.55","5037.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5400.11","80.4","","1365.00","1365.00","1365.00","1 through 10","3510.07","5488.76","percent of total billed charges",""
"BONE PLATE 5XRT 64MM 20 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10030879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6716.55","5037.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5488.76","81.72","","5157.68","5157.68","5157.68","1 through 10","3510.07","5488.76","percent of total billed charges",""
"BONE PLATE 5XRT 64MM 20 HOLE CRANIOMAXILLOFACIAL TI LOCKING RECONSTRUCTION CONDYLAR HEAD","SUP-ITM-10030879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6716.55","5037.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5488.76","81.72","","431.26","71.26","1459.57","88","3510.07","5488.76","percent of total billed charges",""
"BONE PLATE 6 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021581","CDM","C1713","HCPCS","0278","RC","","","","both","","","1351.00","1013.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1074.05","79.5","","800.18","480.96","1887.97","195","418.81","1074.05","percent of total billed charges",""
"BONE PLATE 6 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021581","CDM","C1713","HCPCS","0278","RC","","","","both","","","1351.00","1013.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","720.08","53.3","","813.12","216.42","1444.50","81","418.81","1074.05","percent of total billed charges",""
"BONE PLATE 6 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021581","CDM","C1713","HCPCS","0278","RC","","","","both","","","1351.00","1013.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","418.81","31","","432.60","432.60","432.60","1 through 10","418.81","1074.05","percent of total billed charges",""
"BONE PLATE 6 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021581","CDM","C1713","HCPCS","0278","RC","","","","both","","","1351.00","1013.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","493.12","36.5","","148.37","54.89","631.39","94","418.81","1074.05","percent of total billed charges",""
"BONE PLATE 6 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021581","CDM","C1713","HCPCS","0278","RC","","","","both","","","1351.00","1013.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","517.43","38.3","","279.30","91.72","1116.77","266","418.81","1074.05","percent of total billed charges",""
"BONE PLATE 6 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021581","CDM","C1713","HCPCS","0278","RC","","","","both","","","1351.00","1013.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","579.58","42.9","","731.00","63.70","731.00","1 through 10","418.81","1074.05","percent of total billed charges",""
"BONE PLATE 6 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021581","CDM","C1713","HCPCS","0278","RC","","","","both","","","1351.00","1013.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","579.58","42.9","","384.74","384.74","384.74","1 through 10","418.81","1074.05","percent of total billed charges",""
"BONE PLATE 6 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021581","CDM","C1713","HCPCS","0278","RC","","","","both","","","1351.00","1013.25","WELLPOINT [1015]","HB AMC WELLPOINT","996.77","73.78","","286.63","119.22","1107.45","105","418.81","1074.05","percent of total billed charges",""
"BONE PLATE 6 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021581","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1351.00","1013.25","AETNA [1001]","HB AMC AETNA HMO","943.00","69.8","","675.31","184.75","1721.50","286","706.03","1104.04","percent of total billed charges",""
"BONE PLATE 6 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021581","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1351.00","1013.25","AETNA [1001]","HB AMC AETNA PPO","1086.20","80.4","","1261.44","103.12","1514.10","21","706.03","1104.04","percent of total billed charges",""
"BONE PLATE 6 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021581","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1351.00","1013.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1086.20","80.4","","1365.00","1365.00","1365.00","1 through 10","706.03","1104.04","percent of total billed charges",""
"BONE PLATE 6 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021581","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1351.00","1013.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1104.04","81.72","","5157.68","5157.68","5157.68","1 through 10","706.03","1104.04","percent of total billed charges",""
"BONE PLATE 6 HOLE COMPRESSION METACARPAL STRAIGHT BAR","SUP-ITM-10021581","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1351.00","1013.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1104.04","81.72","","431.26","71.26","1459.57","88","706.03","1104.04","percent of total billed charges",""
"BONE PLATE 6 HOLE STERNAL TI LOCKING STAR SHAPE","SUP-ITM-10026780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.63","1246.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1321.00","79.5","","800.18","480.96","1887.97","195","515.11","1321","percent of total billed charges",""
"BONE PLATE 6 HOLE STERNAL TI LOCKING STAR SHAPE","SUP-ITM-10026780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.63","1246.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","885.65","53.3","","813.12","216.42","1444.50","81","515.11","1321","percent of total billed charges",""
"BONE PLATE 6 HOLE STERNAL TI LOCKING STAR SHAPE","SUP-ITM-10026780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.63","1246.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","515.11","31","","432.60","432.60","432.60","1 through 10","515.11","1321","percent of total billed charges",""
"BONE PLATE 6 HOLE STERNAL TI LOCKING STAR SHAPE","SUP-ITM-10026780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.63","1246.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","606.49","36.5","","148.37","54.89","631.39","94","515.11","1321","percent of total billed charges",""
"BONE PLATE 6 HOLE STERNAL TI LOCKING STAR SHAPE","SUP-ITM-10026780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.63","1246.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","636.40","38.3","","279.30","91.72","1116.77","266","515.11","1321","percent of total billed charges",""
"BONE PLATE 6 HOLE STERNAL TI LOCKING STAR SHAPE","SUP-ITM-10026780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.63","1246.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","712.84","42.9","","731.00","63.70","731.00","1 through 10","515.11","1321","percent of total billed charges",""
"BONE PLATE 6 HOLE STERNAL TI LOCKING STAR SHAPE","SUP-ITM-10026780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.63","1246.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","712.84","42.9","","384.74","384.74","384.74","1 through 10","515.11","1321","percent of total billed charges",""
"BONE PLATE 6 HOLE STERNAL TI LOCKING STAR SHAPE","SUP-ITM-10026780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.63","1246.22","WELLPOINT [1015]","HB AMC WELLPOINT","1225.95","73.78","","286.63","119.22","1107.45","105","515.11","1321","percent of total billed charges",""
"BONE PLATE 6 HOLE STERNAL TI LOCKING STAR SHAPE","SUP-ITM-10026780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1661.63","1246.22","AETNA [1001]","HB AMC AETNA HMO","1159.82","69.8","","675.31","184.75","1721.50","286","868.37","1357.88","percent of total billed charges",""
"BONE PLATE 6 HOLE STERNAL TI LOCKING STAR SHAPE","SUP-ITM-10026780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1661.63","1246.22","AETNA [1001]","HB AMC AETNA PPO","1335.95","80.4","","1261.44","103.12","1514.10","21","868.37","1357.88","percent of total billed charges",""
"BONE PLATE 6 HOLE STERNAL TI LOCKING STAR SHAPE","SUP-ITM-10026780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1661.63","1246.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1335.95","80.4","","1365.00","1365.00","1365.00","1 through 10","868.37","1357.88","percent of total billed charges",""
"BONE PLATE 6 HOLE STERNAL TI LOCKING STAR SHAPE","SUP-ITM-10026780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1661.63","1246.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1357.88","81.72","","5157.68","5157.68","5157.68","1 through 10","868.37","1357.88","percent of total billed charges",""
"BONE PLATE 6 HOLE STERNAL TI LOCKING STAR SHAPE","SUP-ITM-10026780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1661.63","1246.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1357.88","81.72","","431.26","71.26","1459.57","88","868.37","1357.88","percent of total billed charges",""
"BONE PLATE 6 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL RIGHT","SUP-ITM-10144713","CDM","C1713","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3983.28","79.5","","800.18","480.96","1887.97","195","1553.23","3983.28","percent of total billed charges",""
"BONE PLATE 6 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL RIGHT","SUP-ITM-10144713","CDM","C1713","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2670.55","53.3","","813.12","216.42","1444.50","81","1553.23","3983.28","percent of total billed charges",""
"BONE PLATE 6 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL RIGHT","SUP-ITM-10144713","CDM","C1713","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1553.23","31","","432.60","432.60","432.60","1 through 10","1553.23","3983.28","percent of total billed charges",""
"BONE PLATE 6 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL RIGHT","SUP-ITM-10144713","CDM","C1713","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1828.80","36.5","","148.37","54.89","631.39","94","1553.23","3983.28","percent of total billed charges",""
"BONE PLATE 6 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL RIGHT","SUP-ITM-10144713","CDM","C1713","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1918.99","38.3","","279.30","91.72","1116.77","266","1553.23","3983.28","percent of total billed charges",""
"BONE PLATE 6 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL RIGHT","SUP-ITM-10144713","CDM","C1713","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2149.47","42.9","","731.00","63.70","731.00","1 through 10","1553.23","3983.28","percent of total billed charges",""
"BONE PLATE 6 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL RIGHT","SUP-ITM-10144713","CDM","C1713","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2149.47","42.9","","384.74","384.74","384.74","1 through 10","1553.23","3983.28","percent of total billed charges",""
"BONE PLATE 6 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL RIGHT","SUP-ITM-10144713","CDM","C1713","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","WELLPOINT [1015]","HB AMC WELLPOINT","3696.69","73.78","","286.63","119.22","1107.45","105","1553.23","3983.28","percent of total billed charges",""
"BONE PLATE 6 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL RIGHT","SUP-ITM-10144713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5010.42","3757.81","AETNA [1001]","HB AMC AETNA HMO","3497.27","69.8","","675.31","184.75","1721.50","286","2618.45","4094.52","percent of total billed charges",""
"BONE PLATE 6 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL RIGHT","SUP-ITM-10144713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5010.42","3757.81","AETNA [1001]","HB AMC AETNA PPO","4028.38","80.4","","1261.44","103.12","1514.10","21","2618.45","4094.52","percent of total billed charges",""
"BONE PLATE 6 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL RIGHT","SUP-ITM-10144713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5010.42","3757.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4028.38","80.4","","1365.00","1365.00","1365.00","1 through 10","2618.45","4094.52","percent of total billed charges",""
"BONE PLATE 6 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL RIGHT","SUP-ITM-10144713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5010.42","3757.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4094.52","81.72","","5157.68","5157.68","5157.68","1 through 10","2618.45","4094.52","percent of total billed charges",""
"BONE PLATE 6 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL RIGHT","SUP-ITM-10144713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5010.42","3757.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4094.52","81.72","","431.26","71.26","1459.57","88","2618.45","4094.52","percent of total billed charges",""
"BONE PLATE 60X20MM ADULT 4 HOLE 90DEG OSTEOTOMY SS 20MM DISPLACEMENT ANGLED BLADE","SUP-ITM-10001870","CDM","C1713","HCPCS","0278","RC","","","","both","","","3508.16","2631.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2788.99","79.5","","800.18","480.96","1887.97","195","1087.53","2788.99","percent of total billed charges",""
"BONE PLATE 60X20MM ADULT 4 HOLE 90DEG OSTEOTOMY SS 20MM DISPLACEMENT ANGLED BLADE","SUP-ITM-10001870","CDM","C1713","HCPCS","0278","RC","","","","both","","","3508.16","2631.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1869.85","53.3","","813.12","216.42","1444.50","81","1087.53","2788.99","percent of total billed charges",""
"BONE PLATE 60X20MM ADULT 4 HOLE 90DEG OSTEOTOMY SS 20MM DISPLACEMENT ANGLED BLADE","SUP-ITM-10001870","CDM","C1713","HCPCS","0278","RC","","","","both","","","3508.16","2631.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1087.53","31","","432.60","432.60","432.60","1 through 10","1087.53","2788.99","percent of total billed charges",""
"BONE PLATE 60X20MM ADULT 4 HOLE 90DEG OSTEOTOMY SS 20MM DISPLACEMENT ANGLED BLADE","SUP-ITM-10001870","CDM","C1713","HCPCS","0278","RC","","","","both","","","3508.16","2631.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1280.48","36.5","","148.37","54.89","631.39","94","1087.53","2788.99","percent of total billed charges",""
"BONE PLATE 60X20MM ADULT 4 HOLE 90DEG OSTEOTOMY SS 20MM DISPLACEMENT ANGLED BLADE","SUP-ITM-10001870","CDM","C1713","HCPCS","0278","RC","","","","both","","","3508.16","2631.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1343.63","38.3","","279.30","91.72","1116.77","266","1087.53","2788.99","percent of total billed charges",""
"BONE PLATE 60X20MM ADULT 4 HOLE 90DEG OSTEOTOMY SS 20MM DISPLACEMENT ANGLED BLADE","SUP-ITM-10001870","CDM","C1713","HCPCS","0278","RC","","","","both","","","3508.16","2631.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1505.00","42.9","","731.00","63.70","731.00","1 through 10","1087.53","2788.99","percent of total billed charges",""
"BONE PLATE 60X20MM ADULT 4 HOLE 90DEG OSTEOTOMY SS 20MM DISPLACEMENT ANGLED BLADE","SUP-ITM-10001870","CDM","C1713","HCPCS","0278","RC","","","","both","","","3508.16","2631.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1505.00","42.9","","384.74","384.74","384.74","1 through 10","1087.53","2788.99","percent of total billed charges",""
"BONE PLATE 60X20MM ADULT 4 HOLE 90DEG OSTEOTOMY SS 20MM DISPLACEMENT ANGLED BLADE","SUP-ITM-10001870","CDM","C1713","HCPCS","0278","RC","","","","both","","","3508.16","2631.12","WELLPOINT [1015]","HB AMC WELLPOINT","2588.32","73.78","","286.63","119.22","1107.45","105","1087.53","2788.99","percent of total billed charges",""
"BONE PLATE 60X20MM ADULT 4 HOLE 90DEG OSTEOTOMY SS 20MM DISPLACEMENT ANGLED BLADE","SUP-ITM-10001870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3508.16","2631.12","AETNA [1001]","HB AMC AETNA HMO","2448.70","69.8","","675.31","184.75","1721.50","286","1833.36","2866.87","percent of total billed charges",""
"BONE PLATE 60X20MM ADULT 4 HOLE 90DEG OSTEOTOMY SS 20MM DISPLACEMENT ANGLED BLADE","SUP-ITM-10001870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3508.16","2631.12","AETNA [1001]","HB AMC AETNA PPO","2820.56","80.4","","1261.44","103.12","1514.10","21","1833.36","2866.87","percent of total billed charges",""
"BONE PLATE 60X20MM ADULT 4 HOLE 90DEG OSTEOTOMY SS 20MM DISPLACEMENT ANGLED BLADE","SUP-ITM-10001870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3508.16","2631.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2820.56","80.4","","1365.00","1365.00","1365.00","1 through 10","1833.36","2866.87","percent of total billed charges",""
"BONE PLATE 60X20MM ADULT 4 HOLE 90DEG OSTEOTOMY SS 20MM DISPLACEMENT ANGLED BLADE","SUP-ITM-10001870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3508.16","2631.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2866.87","81.72","","5157.68","5157.68","5157.68","1 through 10","1833.36","2866.87","percent of total billed charges",""
"BONE PLATE 60X20MM ADULT 4 HOLE 90DEG OSTEOTOMY SS 20MM DISPLACEMENT ANGLED BLADE","SUP-ITM-10001870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3508.16","2631.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2866.87","81.72","","431.26","71.26","1459.57","88","1833.36","2866.87","percent of total billed charges",""
"BONE PLATE 6MM 4 HOLE DARCO BOW TITANIUM WEDGE OPENING BUNION MEDIAL SPACER","SUP-ITM-10025668","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.00","3084.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3269.84","79.5","","800.18","480.96","1887.97","195","1275.03","3269.84","percent of total billed charges",""
"BONE PLATE 6MM 4 HOLE DARCO BOW TITANIUM WEDGE OPENING BUNION MEDIAL SPACER","SUP-ITM-10025668","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.00","3084.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2192.23","53.3","","813.12","216.42","1444.50","81","1275.03","3269.84","percent of total billed charges",""
"BONE PLATE 6MM 4 HOLE DARCO BOW TITANIUM WEDGE OPENING BUNION MEDIAL SPACER","SUP-ITM-10025668","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.00","3084.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1275.03","31","","432.60","432.60","432.60","1 through 10","1275.03","3269.84","percent of total billed charges",""
"BONE PLATE 6MM 4 HOLE DARCO BOW TITANIUM WEDGE OPENING BUNION MEDIAL SPACER","SUP-ITM-10025668","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.00","3084.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1501.25","36.5","","148.37","54.89","631.39","94","1275.03","3269.84","percent of total billed charges",""
"BONE PLATE 6MM 4 HOLE DARCO BOW TITANIUM WEDGE OPENING BUNION MEDIAL SPACER","SUP-ITM-10025668","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.00","3084.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1575.28","38.3","","279.30","91.72","1116.77","266","1275.03","3269.84","percent of total billed charges",""
"BONE PLATE 6MM 4 HOLE DARCO BOW TITANIUM WEDGE OPENING BUNION MEDIAL SPACER","SUP-ITM-10025668","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.00","3084.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1764.48","42.9","","731.00","63.70","731.00","1 through 10","1275.03","3269.84","percent of total billed charges",""
"BONE PLATE 6MM 4 HOLE DARCO BOW TITANIUM WEDGE OPENING BUNION MEDIAL SPACER","SUP-ITM-10025668","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.00","3084.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1764.48","42.9","","384.74","384.74","384.74","1 through 10","1275.03","3269.84","percent of total billed charges",""
"BONE PLATE 6MM 4 HOLE DARCO BOW TITANIUM WEDGE OPENING BUNION MEDIAL SPACER","SUP-ITM-10025668","CDM","C1713","HCPCS","0278","RC","","","","both","","","4113.00","3084.75","WELLPOINT [1015]","HB AMC WELLPOINT","3034.57","73.78","","286.63","119.22","1107.45","105","1275.03","3269.84","percent of total billed charges",""
"BONE PLATE 6MM 4 HOLE DARCO BOW TITANIUM WEDGE OPENING BUNION MEDIAL SPACER","SUP-ITM-10025668","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4113.00","3084.75","AETNA [1001]","HB AMC AETNA HMO","2870.87","69.8","","675.31","184.75","1721.50","286","2149.45","3361.14","percent of total billed charges",""
"BONE PLATE 6MM 4 HOLE DARCO BOW TITANIUM WEDGE OPENING BUNION MEDIAL SPACER","SUP-ITM-10025668","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4113.00","3084.75","AETNA [1001]","HB AMC AETNA PPO","3306.85","80.4","","1261.44","103.12","1514.10","21","2149.45","3361.14","percent of total billed charges",""
"BONE PLATE 6MM 4 HOLE DARCO BOW TITANIUM WEDGE OPENING BUNION MEDIAL SPACER","SUP-ITM-10025668","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4113.00","3084.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3306.85","80.4","","1365.00","1365.00","1365.00","1 through 10","2149.45","3361.14","percent of total billed charges",""
"BONE PLATE 6MM 4 HOLE DARCO BOW TITANIUM WEDGE OPENING BUNION MEDIAL SPACER","SUP-ITM-10025668","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4113.00","3084.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3361.14","81.72","","5157.68","5157.68","5157.68","1 through 10","2149.45","3361.14","percent of total billed charges",""
"BONE PLATE 6MM 4 HOLE DARCO BOW TITANIUM WEDGE OPENING BUNION MEDIAL SPACER","SUP-ITM-10025668","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4113.00","3084.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3361.14","81.72","","431.26","71.26","1459.57","88","2149.45","3361.14","percent of total billed charges",""
"BONE PLATE 6X24 2.5MM LG HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4621.29","3465.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3673.93","79.5","","800.18","480.96","1887.97","195","1432.6","3673.93","percent of total billed charges",""
"BONE PLATE 6X24 2.5MM LG HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4621.29","3465.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2463.15","53.3","","813.12","216.42","1444.50","81","1432.6","3673.93","percent of total billed charges",""
"BONE PLATE 6X24 2.5MM LG HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4621.29","3465.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1432.60","31","","432.60","432.60","432.60","1 through 10","1432.6","3673.93","percent of total billed charges",""
"BONE PLATE 6X24 2.5MM LG HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4621.29","3465.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1686.77","36.5","","148.37","54.89","631.39","94","1432.6","3673.93","percent of total billed charges",""
"BONE PLATE 6X24 2.5MM LG HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4621.29","3465.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1769.95","38.3","","279.30","91.72","1116.77","266","1432.6","3673.93","percent of total billed charges",""
"BONE PLATE 6X24 2.5MM LG HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4621.29","3465.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1982.53","42.9","","731.00","63.70","731.00","1 through 10","1432.6","3673.93","percent of total billed charges",""
"BONE PLATE 6X24 2.5MM LG HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4621.29","3465.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1982.53","42.9","","384.74","384.74","384.74","1 through 10","1432.6","3673.93","percent of total billed charges",""
"BONE PLATE 6X24 2.5MM LG HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4621.29","3465.97","WELLPOINT [1015]","HB AMC WELLPOINT","3409.59","73.78","","286.63","119.22","1107.45","105","1432.6","3673.93","percent of total billed charges",""
"BONE PLATE 6X24 2.5MM LG HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4621.29","3465.97","AETNA [1001]","HB AMC AETNA HMO","3225.66","69.8","","675.31","184.75","1721.50","286","2415.09","3776.52","percent of total billed charges",""
"BONE PLATE 6X24 2.5MM LG HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4621.29","3465.97","AETNA [1001]","HB AMC AETNA PPO","3715.52","80.4","","1261.44","103.12","1514.10","21","2415.09","3776.52","percent of total billed charges",""
"BONE PLATE 6X24 2.5MM LG HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4621.29","3465.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3715.52","80.4","","1365.00","1365.00","1365.00","1 through 10","2415.09","3776.52","percent of total billed charges",""
"BONE PLATE 6X24 2.5MM LG HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4621.29","3465.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3776.52","81.72","","5157.68","5157.68","5157.68","1 through 10","2415.09","3776.52","percent of total billed charges",""
"BONE PLATE 6X24 2.5MM LG HOLE CRANIAL MATRIXMANDIBLE TI DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4621.29","3465.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3776.52","81.72","","431.26","71.26","1459.57","88","2415.09","3776.52","percent of total billed charges",""
"BONE PLATE 70MM 2.7 LG VA LOCKING CALCANEAL RIGHT","SUP-ITM-10164178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.08","2025.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2146.56","79.5","","800.18","480.96","1887.97","195","837.02","2146.56","percent of total billed charges",""
"BONE PLATE 70MM 2.7 LG VA LOCKING CALCANEAL RIGHT","SUP-ITM-10164178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.08","2025.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1439.14","53.3","","813.12","216.42","1444.50","81","837.02","2146.56","percent of total billed charges",""
"BONE PLATE 70MM 2.7 LG VA LOCKING CALCANEAL RIGHT","SUP-ITM-10164178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.08","2025.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","837.02","31","","432.60","432.60","432.60","1 through 10","837.02","2146.56","percent of total billed charges",""
"BONE PLATE 70MM 2.7 LG VA LOCKING CALCANEAL RIGHT","SUP-ITM-10164178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.08","2025.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","985.53","36.5","","148.37","54.89","631.39","94","837.02","2146.56","percent of total billed charges",""
"BONE PLATE 70MM 2.7 LG VA LOCKING CALCANEAL RIGHT","SUP-ITM-10164178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.08","2025.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1034.13","38.3","","279.30","91.72","1116.77","266","837.02","2146.56","percent of total billed charges",""
"BONE PLATE 70MM 2.7 LG VA LOCKING CALCANEAL RIGHT","SUP-ITM-10164178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.08","2025.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1158.33","42.9","","731.00","63.70","731.00","1 through 10","837.02","2146.56","percent of total billed charges",""
"BONE PLATE 70MM 2.7 LG VA LOCKING CALCANEAL RIGHT","SUP-ITM-10164178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.08","2025.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1158.33","42.9","","384.74","384.74","384.74","1 through 10","837.02","2146.56","percent of total billed charges",""
"BONE PLATE 70MM 2.7 LG VA LOCKING CALCANEAL RIGHT","SUP-ITM-10164178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.08","2025.06","WELLPOINT [1015]","HB AMC WELLPOINT","1992.12","73.78","","286.63","119.22","1107.45","105","837.02","2146.56","percent of total billed charges",""
"BONE PLATE 70MM 2.7 LG VA LOCKING CALCANEAL RIGHT","SUP-ITM-10164178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2700.08","2025.06","AETNA [1001]","HB AMC AETNA HMO","1884.66","69.8","","675.31","184.75","1721.50","286","1411.06","2206.51","percent of total billed charges",""
"BONE PLATE 70MM 2.7 LG VA LOCKING CALCANEAL RIGHT","SUP-ITM-10164178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2700.08","2025.06","AETNA [1001]","HB AMC AETNA PPO","2170.86","80.4","","1261.44","103.12","1514.10","21","1411.06","2206.51","percent of total billed charges",""
"BONE PLATE 70MM 2.7 LG VA LOCKING CALCANEAL RIGHT","SUP-ITM-10164178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2700.08","2025.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2170.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1411.06","2206.51","percent of total billed charges",""
"BONE PLATE 70MM 2.7 LG VA LOCKING CALCANEAL RIGHT","SUP-ITM-10164178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2700.08","2025.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2206.51","81.72","","5157.68","5157.68","5157.68","1 through 10","1411.06","2206.51","percent of total billed charges",""
"BONE PLATE 70MM 2.7 LG VA LOCKING CALCANEAL RIGHT","SUP-ITM-10164178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2700.08","2025.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2206.51","81.72","","431.26","71.26","1459.57","88","1411.06","2206.51","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1942.27","79.5","","800.18","480.96","1887.97","195","757.36","1942.27","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1302.18","53.3","","813.12","216.42","1444.50","81","757.36","1942.27","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","757.36","31","","432.60","432.60","432.60","1 through 10","757.36","1942.27","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","891.74","36.5","","148.37","54.89","631.39","94","757.36","1942.27","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","935.71","38.3","","279.30","91.72","1116.77","266","757.36","1942.27","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1048.09","42.9","","731.00","63.70","731.00","1 through 10","757.36","1942.27","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1048.09","42.9","","384.74","384.74","384.74","1 through 10","757.36","1942.27","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","WELLPOINT [1015]","HB AMC WELLPOINT","1802.53","73.78","","286.63","119.22","1107.45","105","757.36","1942.27","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.11","1832.33","AETNA [1001]","HB AMC AETNA HMO","1705.29","69.8","","675.31","184.75","1721.50","286","1276.77","1996.51","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.11","1832.33","AETNA [1001]","HB AMC AETNA PPO","1964.26","80.4","","1261.44","103.12","1514.10","21","1276.77","1996.51","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.11","1832.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1964.26","80.4","","1365.00","1365.00","1365.00","1 through 10","1276.77","1996.51","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.11","1832.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1996.51","81.72","","5157.68","5157.68","5157.68","1 through 10","1276.77","1996.51","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.11","1832.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1996.51","81.72","","431.26","71.26","1459.57","88","1276.77","1996.51","percent of total billed charges",""
"BONE PLATE 7MM WEDGE OPENING BOW","SUP-ITM-10042377","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3308.39","79.5","","800.18","480.96","1887.97","195","1290.07","3308.39","percent of total billed charges",""
"BONE PLATE 7MM WEDGE OPENING BOW","SUP-ITM-10042377","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2218.08","53.3","","813.12","216.42","1444.50","81","1290.07","3308.39","percent of total billed charges",""
"BONE PLATE 7MM WEDGE OPENING BOW","SUP-ITM-10042377","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1290.07","31","","432.60","432.60","432.60","1 through 10","1290.07","3308.39","percent of total billed charges",""
"BONE PLATE 7MM WEDGE OPENING BOW","SUP-ITM-10042377","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1518.95","36.5","","148.37","54.89","631.39","94","1290.07","3308.39","percent of total billed charges",""
"BONE PLATE 7MM WEDGE OPENING BOW","SUP-ITM-10042377","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1593.85","38.3","","279.30","91.72","1116.77","266","1290.07","3308.39","percent of total billed charges",""
"BONE PLATE 7MM WEDGE OPENING BOW","SUP-ITM-10042377","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1785.28","42.9","","731.00","63.70","731.00","1 through 10","1290.07","3308.39","percent of total billed charges",""
"BONE PLATE 7MM WEDGE OPENING BOW","SUP-ITM-10042377","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1785.28","42.9","","384.74","384.74","384.74","1 through 10","1290.07","3308.39","percent of total billed charges",""
"BONE PLATE 7MM WEDGE OPENING BOW","SUP-ITM-10042377","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","WELLPOINT [1015]","HB AMC WELLPOINT","3070.35","73.78","","286.63","119.22","1107.45","105","1290.07","3308.39","percent of total billed charges",""
"BONE PLATE 7MM WEDGE OPENING BOW","SUP-ITM-10042377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","AETNA [1001]","HB AMC AETNA HMO","2904.73","69.8","","675.31","184.75","1721.50","286","2174.8","3400.78","percent of total billed charges",""
"BONE PLATE 7MM WEDGE OPENING BOW","SUP-ITM-10042377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","AETNA [1001]","HB AMC AETNA PPO","3345.85","80.4","","1261.44","103.12","1514.10","21","2174.8","3400.78","percent of total billed charges",""
"BONE PLATE 7MM WEDGE OPENING BOW","SUP-ITM-10042377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3345.85","80.4","","1365.00","1365.00","1365.00","1 through 10","2174.8","3400.78","percent of total billed charges",""
"BONE PLATE 7MM WEDGE OPENING BOW","SUP-ITM-10042377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3400.78","81.72","","5157.68","5157.68","5157.68","1 through 10","2174.8","3400.78","percent of total billed charges",""
"BONE PLATE 7MM WEDGE OPENING BOW","SUP-ITM-10042377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3400.78","81.72","","431.26","71.26","1459.57","88","2174.8","3400.78","percent of total billed charges",""
"BONE PLATE 7X2.5MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.19","3135.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3323.25","79.5","","800.18","480.96","1887.97","195","1295.86","3323.25","percent of total billed charges",""
"BONE PLATE 7X2.5MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.19","3135.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2228.04","53.3","","813.12","216.42","1444.50","81","1295.86","3323.25","percent of total billed charges",""
"BONE PLATE 7X2.5MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.19","3135.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1295.86","31","","432.60","432.60","432.60","1 through 10","1295.86","3323.25","percent of total billed charges",""
"BONE PLATE 7X2.5MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.19","3135.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1525.77","36.5","","148.37","54.89","631.39","94","1295.86","3323.25","percent of total billed charges",""
"BONE PLATE 7X2.5MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.19","3135.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1601.01","38.3","","279.30","91.72","1116.77","266","1295.86","3323.25","percent of total billed charges",""
"BONE PLATE 7X2.5MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.19","3135.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1793.30","42.9","","731.00","63.70","731.00","1 through 10","1295.86","3323.25","percent of total billed charges",""
"BONE PLATE 7X2.5MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.19","3135.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1793.30","42.9","","384.74","384.74","384.74","1 through 10","1295.86","3323.25","percent of total billed charges",""
"BONE PLATE 7X2.5MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.19","3135.14","WELLPOINT [1015]","HB AMC WELLPOINT","3084.14","73.78","","286.63","119.22","1107.45","105","1295.86","3323.25","percent of total billed charges",""
"BONE PLATE 7X2.5MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4180.19","3135.14","AETNA [1001]","HB AMC AETNA HMO","2917.77","69.8","","675.31","184.75","1721.50","286","2184.57","3416.05","percent of total billed charges",""
"BONE PLATE 7X2.5MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4180.19","3135.14","AETNA [1001]","HB AMC AETNA PPO","3360.87","80.4","","1261.44","103.12","1514.10","21","2184.57","3416.05","percent of total billed charges",""
"BONE PLATE 7X2.5MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4180.19","3135.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3360.87","80.4","","1365.00","1365.00","1365.00","1 through 10","2184.57","3416.05","percent of total billed charges",""
"BONE PLATE 7X2.5MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4180.19","3135.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3416.05","81.72","","5157.68","5157.68","5157.68","1 through 10","2184.57","3416.05","percent of total billed charges",""
"BONE PLATE 7X2.5MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4180.19","3135.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3416.05","81.72","","431.26","71.26","1459.57","88","2184.57","3416.05","percent of total billed charges",""
"BONE PLATE 7X2.8MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081083","CDM","C1713","HCPCS","0278","RC","","","","both","","","4573.15","3429.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3635.65","79.5","","800.18","480.96","1887.97","195","1417.68","3635.65","percent of total billed charges",""
"BONE PLATE 7X2.8MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081083","CDM","C1713","HCPCS","0278","RC","","","","both","","","4573.15","3429.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2437.49","53.3","","813.12","216.42","1444.50","81","1417.68","3635.65","percent of total billed charges",""
"BONE PLATE 7X2.8MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081083","CDM","C1713","HCPCS","0278","RC","","","","both","","","4573.15","3429.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1417.68","31","","432.60","432.60","432.60","1 through 10","1417.68","3635.65","percent of total billed charges",""
"BONE PLATE 7X2.8MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081083","CDM","C1713","HCPCS","0278","RC","","","","both","","","4573.15","3429.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1669.20","36.5","","148.37","54.89","631.39","94","1417.68","3635.65","percent of total billed charges",""
"BONE PLATE 7X2.8MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081083","CDM","C1713","HCPCS","0278","RC","","","","both","","","4573.15","3429.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1751.52","38.3","","279.30","91.72","1116.77","266","1417.68","3635.65","percent of total billed charges",""
"BONE PLATE 7X2.8MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081083","CDM","C1713","HCPCS","0278","RC","","","","both","","","4573.15","3429.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1961.88","42.9","","731.00","63.70","731.00","1 through 10","1417.68","3635.65","percent of total billed charges",""
"BONE PLATE 7X2.8MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081083","CDM","C1713","HCPCS","0278","RC","","","","both","","","4573.15","3429.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1961.88","42.9","","384.74","384.74","384.74","1 through 10","1417.68","3635.65","percent of total billed charges",""
"BONE PLATE 7X2.8MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081083","CDM","C1713","HCPCS","0278","RC","","","","both","","","4573.15","3429.86","WELLPOINT [1015]","HB AMC WELLPOINT","3374.07","73.78","","286.63","119.22","1107.45","105","1417.68","3635.65","percent of total billed charges",""
"BONE PLATE 7X2.8MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4573.15","3429.86","AETNA [1001]","HB AMC AETNA HMO","3192.06","69.8","","675.31","184.75","1721.50","286","2389.93","3737.18","percent of total billed charges",""
"BONE PLATE 7X2.8MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4573.15","3429.86","AETNA [1001]","HB AMC AETNA PPO","3676.81","80.4","","1261.44","103.12","1514.10","21","2389.93","3737.18","percent of total billed charges",""
"BONE PLATE 7X2.8MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4573.15","3429.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3676.81","80.4","","1365.00","1365.00","1365.00","1 through 10","2389.93","3737.18","percent of total billed charges",""
"BONE PLATE 7X2.8MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4573.15","3429.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3737.18","81.72","","5157.68","5157.68","5157.68","1 through 10","2389.93","3737.18","percent of total billed charges",""
"BONE PLATE 7X2.8MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4573.15","3429.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3737.18","81.72","","431.26","71.26","1459.57","88","2389.93","3737.18","percent of total billed charges",""
"BONE PLATE 7X23 H 2.5MM 23H RECONSTRUCTION MATRIXMANDIBLE CUSTOM","SUP-ITM-10168148","CDM","C1713","HCPCS","0278","RC","","","","both","","","15992.50","11994.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12714.04","79.5","","800.18","480.96","1887.97","195","4957.68","12714.04","percent of total billed charges",""
"BONE PLATE 7X23 H 2.5MM 23H RECONSTRUCTION MATRIXMANDIBLE CUSTOM","SUP-ITM-10168148","CDM","C1713","HCPCS","0278","RC","","","","both","","","15992.50","11994.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8524.00","53.3","","813.12","216.42","1444.50","81","4957.68","12714.04","percent of total billed charges",""
"BONE PLATE 7X23 H 2.5MM 23H RECONSTRUCTION MATRIXMANDIBLE CUSTOM","SUP-ITM-10168148","CDM","C1713","HCPCS","0278","RC","","","","both","","","15992.50","11994.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4957.68","31","","432.60","432.60","432.60","1 through 10","4957.68","12714.04","percent of total billed charges",""
"BONE PLATE 7X23 H 2.5MM 23H RECONSTRUCTION MATRIXMANDIBLE CUSTOM","SUP-ITM-10168148","CDM","C1713","HCPCS","0278","RC","","","","both","","","15992.50","11994.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5837.26","36.5","","148.37","54.89","631.39","94","4957.68","12714.04","percent of total billed charges",""
"BONE PLATE 7X23 H 2.5MM 23H RECONSTRUCTION MATRIXMANDIBLE CUSTOM","SUP-ITM-10168148","CDM","C1713","HCPCS","0278","RC","","","","both","","","15992.50","11994.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6125.13","38.3","","279.30","91.72","1116.77","266","4957.68","12714.04","percent of total billed charges",""
"BONE PLATE 7X23 H 2.5MM 23H RECONSTRUCTION MATRIXMANDIBLE CUSTOM","SUP-ITM-10168148","CDM","C1713","HCPCS","0278","RC","","","","both","","","15992.50","11994.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6860.78","42.9","","731.00","63.70","731.00","1 through 10","4957.68","12714.04","percent of total billed charges",""
"BONE PLATE 7X23 H 2.5MM 23H RECONSTRUCTION MATRIXMANDIBLE CUSTOM","SUP-ITM-10168148","CDM","C1713","HCPCS","0278","RC","","","","both","","","15992.50","11994.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6860.78","42.9","","384.74","384.74","384.74","1 through 10","4957.68","12714.04","percent of total billed charges",""
"BONE PLATE 7X23 H 2.5MM 23H RECONSTRUCTION MATRIXMANDIBLE CUSTOM","SUP-ITM-10168148","CDM","C1713","HCPCS","0278","RC","","","","both","","","15992.50","11994.37","WELLPOINT [1015]","HB AMC WELLPOINT","11799.27","73.78","","286.63","119.22","1107.45","105","4957.68","12714.04","percent of total billed charges",""
"BONE PLATE 7X23 H 2.5MM 23H RECONSTRUCTION MATRIXMANDIBLE CUSTOM","SUP-ITM-10168148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15992.50","11994.37","AETNA [1001]","HB AMC AETNA HMO","11162.77","69.8","","675.31","184.75","1721.50","286","8357.68","13069.07","percent of total billed charges",""
"BONE PLATE 7X23 H 2.5MM 23H RECONSTRUCTION MATRIXMANDIBLE CUSTOM","SUP-ITM-10168148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15992.50","11994.37","AETNA [1001]","HB AMC AETNA PPO","12857.97","80.4","","1261.44","103.12","1514.10","21","8357.68","13069.07","percent of total billed charges",""
"BONE PLATE 7X23 H 2.5MM 23H RECONSTRUCTION MATRIXMANDIBLE CUSTOM","SUP-ITM-10168148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15992.50","11994.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","12857.97","80.4","","1365.00","1365.00","1365.00","1 through 10","8357.68","13069.07","percent of total billed charges",""
"BONE PLATE 7X23 H 2.5MM 23H RECONSTRUCTION MATRIXMANDIBLE CUSTOM","SUP-ITM-10168148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15992.50","11994.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","13069.07","81.72","","5157.68","5157.68","5157.68","1 through 10","8357.68","13069.07","percent of total billed charges",""
"BONE PLATE 7X23 H 2.5MM 23H RECONSTRUCTION MATRIXMANDIBLE CUSTOM","SUP-ITM-10168148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15992.50","11994.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13069.07","81.72","","431.26","71.26","1459.57","88","8357.68","13069.07","percent of total billed charges",""
"BONE PLATE 7X23 H 2MM 23H MATRIXMANDIBLE TI LEFT","SUP-ITM-10146456","CDM","C1713","HCPCS","0278","RC","","","","both","","","10870.15","8152.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8641.77","79.5","","800.18","480.96","1887.97","195","3369.75","8641.77","percent of total billed charges",""
"BONE PLATE 7X23 H 2MM 23H MATRIXMANDIBLE TI LEFT","SUP-ITM-10146456","CDM","C1713","HCPCS","0278","RC","","","","both","","","10870.15","8152.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5793.79","53.3","","813.12","216.42","1444.50","81","3369.75","8641.77","percent of total billed charges",""
"BONE PLATE 7X23 H 2MM 23H MATRIXMANDIBLE TI LEFT","SUP-ITM-10146456","CDM","C1713","HCPCS","0278","RC","","","","both","","","10870.15","8152.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3369.75","31","","432.60","432.60","432.60","1 through 10","3369.75","8641.77","percent of total billed charges",""
"BONE PLATE 7X23 H 2MM 23H MATRIXMANDIBLE TI LEFT","SUP-ITM-10146456","CDM","C1713","HCPCS","0278","RC","","","","both","","","10870.15","8152.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3967.60","36.5","","148.37","54.89","631.39","94","3369.75","8641.77","percent of total billed charges",""
"BONE PLATE 7X23 H 2MM 23H MATRIXMANDIBLE TI LEFT","SUP-ITM-10146456","CDM","C1713","HCPCS","0278","RC","","","","both","","","10870.15","8152.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4163.27","38.3","","279.30","91.72","1116.77","266","3369.75","8641.77","percent of total billed charges",""
"BONE PLATE 7X23 H 2MM 23H MATRIXMANDIBLE TI LEFT","SUP-ITM-10146456","CDM","C1713","HCPCS","0278","RC","","","","both","","","10870.15","8152.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4663.29","42.9","","731.00","63.70","731.00","1 through 10","3369.75","8641.77","percent of total billed charges",""
"BONE PLATE 7X23 H 2MM 23H MATRIXMANDIBLE TI LEFT","SUP-ITM-10146456","CDM","C1713","HCPCS","0278","RC","","","","both","","","10870.15","8152.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4663.29","42.9","","384.74","384.74","384.74","1 through 10","3369.75","8641.77","percent of total billed charges",""
"BONE PLATE 7X23 H 2MM 23H MATRIXMANDIBLE TI LEFT","SUP-ITM-10146456","CDM","C1713","HCPCS","0278","RC","","","","both","","","10870.15","8152.61","WELLPOINT [1015]","HB AMC WELLPOINT","8020.00","73.78","","286.63","119.22","1107.45","105","3369.75","8641.77","percent of total billed charges",""
"BONE PLATE 7X23 H 2MM 23H MATRIXMANDIBLE TI LEFT","SUP-ITM-10146456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10870.15","8152.61","AETNA [1001]","HB AMC AETNA HMO","7587.36","69.8","","675.31","184.75","1721.50","286","5680.74","8883.09","percent of total billed charges",""
"BONE PLATE 7X23 H 2MM 23H MATRIXMANDIBLE TI LEFT","SUP-ITM-10146456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10870.15","8152.61","AETNA [1001]","HB AMC AETNA PPO","8739.60","80.4","","1261.44","103.12","1514.10","21","5680.74","8883.09","percent of total billed charges",""
"BONE PLATE 7X23 H 2MM 23H MATRIXMANDIBLE TI LEFT","SUP-ITM-10146456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10870.15","8152.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8739.60","80.4","","1365.00","1365.00","1365.00","1 through 10","5680.74","8883.09","percent of total billed charges",""
"BONE PLATE 7X23 H 2MM 23H MATRIXMANDIBLE TI LEFT","SUP-ITM-10146456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10870.15","8152.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8883.09","81.72","","5157.68","5157.68","5157.68","1 through 10","5680.74","8883.09","percent of total billed charges",""
"BONE PLATE 7X23 H 2MM 23H MATRIXMANDIBLE TI LEFT","SUP-ITM-10146456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10870.15","8152.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8883.09","81.72","","431.26","71.26","1459.57","88","5680.74","8883.09","percent of total billed charges",""
"BONE PLATE 7X2MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3924.55","2943.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3120.02","79.5","","800.18","480.96","1887.97","195","1216.61","3120.02","percent of total billed charges",""
"BONE PLATE 7X2MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3924.55","2943.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2091.79","53.3","","813.12","216.42","1444.50","81","1216.61","3120.02","percent of total billed charges",""
"BONE PLATE 7X2MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3924.55","2943.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1216.61","31","","432.60","432.60","432.60","1 through 10","1216.61","3120.02","percent of total billed charges",""
"BONE PLATE 7X2MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3924.55","2943.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1432.46","36.5","","148.37","54.89","631.39","94","1216.61","3120.02","percent of total billed charges",""
"BONE PLATE 7X2MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3924.55","2943.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1503.10","38.3","","279.30","91.72","1116.77","266","1216.61","3120.02","percent of total billed charges",""
"BONE PLATE 7X2MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3924.55","2943.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.63","42.9","","731.00","63.70","731.00","1 through 10","1216.61","3120.02","percent of total billed charges",""
"BONE PLATE 7X2MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3924.55","2943.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.63","42.9","","384.74","384.74","384.74","1 through 10","1216.61","3120.02","percent of total billed charges",""
"BONE PLATE 7X2MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3924.55","2943.41","WELLPOINT [1015]","HB AMC WELLPOINT","2895.53","73.78","","286.63","119.22","1107.45","105","1216.61","3120.02","percent of total billed charges",""
"BONE PLATE 7X2MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3924.55","2943.41","AETNA [1001]","HB AMC AETNA HMO","2739.34","69.8","","675.31","184.75","1721.50","286","2050.97","3207.14","percent of total billed charges",""
"BONE PLATE 7X2MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3924.55","2943.41","AETNA [1001]","HB AMC AETNA PPO","3155.34","80.4","","1261.44","103.12","1514.10","21","2050.97","3207.14","percent of total billed charges",""
"BONE PLATE 7X2MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3924.55","2943.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3155.34","80.4","","1365.00","1365.00","1365.00","1 through 10","2050.97","3207.14","percent of total billed charges",""
"BONE PLATE 7X2MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3924.55","2943.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3207.14","81.72","","5157.68","5157.68","5157.68","1 through 10","2050.97","3207.14","percent of total billed charges",""
"BONE PLATE 7X2MM 23 HOLE CRANIAL MATRIXMANDIBLE TI ANGLE RECONSTRUCTION RIGHT","SUP-ITM-10081096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3924.55","2943.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3207.14","81.72","","431.26","71.26","1459.57","88","2050.97","3207.14","percent of total billed charges",""
"BONE PLATE 80MM ADULT 130DEG OSTEOTOMY ANGLED BLADE SS STERILE","SUP-ITM-10037848","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3067.98","79.5","","800.18","480.96","1887.97","195","1196.32","3067.98","percent of total billed charges",""
"BONE PLATE 80MM ADULT 130DEG OSTEOTOMY ANGLED BLADE SS STERILE","SUP-ITM-10037848","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2056.90","53.3","","813.12","216.42","1444.50","81","1196.32","3067.98","percent of total billed charges",""
"BONE PLATE 80MM ADULT 130DEG OSTEOTOMY ANGLED BLADE SS STERILE","SUP-ITM-10037848","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1196.32","31","","432.60","432.60","432.60","1 through 10","1196.32","3067.98","percent of total billed charges",""
"BONE PLATE 80MM ADULT 130DEG OSTEOTOMY ANGLED BLADE SS STERILE","SUP-ITM-10037848","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1408.57","36.5","","148.37","54.89","631.39","94","1196.32","3067.98","percent of total billed charges",""
"BONE PLATE 80MM ADULT 130DEG OSTEOTOMY ANGLED BLADE SS STERILE","SUP-ITM-10037848","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1478.04","38.3","","279.30","91.72","1116.77","266","1196.32","3067.98","percent of total billed charges",""
"BONE PLATE 80MM ADULT 130DEG OSTEOTOMY ANGLED BLADE SS STERILE","SUP-ITM-10037848","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1655.55","42.9","","731.00","63.70","731.00","1 through 10","1196.32","3067.98","percent of total billed charges",""
"BONE PLATE 80MM ADULT 130DEG OSTEOTOMY ANGLED BLADE SS STERILE","SUP-ITM-10037848","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1655.55","42.9","","384.74","384.74","384.74","1 through 10","1196.32","3067.98","percent of total billed charges",""
"BONE PLATE 80MM ADULT 130DEG OSTEOTOMY ANGLED BLADE SS STERILE","SUP-ITM-10037848","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","WELLPOINT [1015]","HB AMC WELLPOINT","2847.24","73.78","","286.63","119.22","1107.45","105","1196.32","3067.98","percent of total billed charges",""
"BONE PLATE 80MM ADULT 130DEG OSTEOTOMY ANGLED BLADE SS STERILE","SUP-ITM-10037848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3859.10","2894.32","AETNA [1001]","HB AMC AETNA HMO","2693.65","69.8","","675.31","184.75","1721.50","286","2016.77","3153.66","percent of total billed charges",""
"BONE PLATE 80MM ADULT 130DEG OSTEOTOMY ANGLED BLADE SS STERILE","SUP-ITM-10037848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3859.10","2894.32","AETNA [1001]","HB AMC AETNA PPO","3102.72","80.4","","1261.44","103.12","1514.10","21","2016.77","3153.66","percent of total billed charges",""
"BONE PLATE 80MM ADULT 130DEG OSTEOTOMY ANGLED BLADE SS STERILE","SUP-ITM-10037848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3859.10","2894.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3102.72","80.4","","1365.00","1365.00","1365.00","1 through 10","2016.77","3153.66","percent of total billed charges",""
"BONE PLATE 80MM ADULT 130DEG OSTEOTOMY ANGLED BLADE SS STERILE","SUP-ITM-10037848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3859.10","2894.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3153.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2016.77","3153.66","percent of total billed charges",""
"BONE PLATE 80MM ADULT 130DEG OSTEOTOMY ANGLED BLADE SS STERILE","SUP-ITM-10037848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3859.10","2894.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3153.66","81.72","","431.26","71.26","1459.57","88","2016.77","3153.66","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.86","358.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","379.90","79.5","","800.18","480.96","1887.97","195","148.14","379.9","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.86","358.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","254.70","53.3","","813.12","216.42","1444.50","81","148.14","379.9","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.86","358.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","148.14","31","","432.60","432.60","432.60","1 through 10","148.14","379.9","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.86","358.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","174.42","36.5","","148.37","54.89","631.39","94","148.14","379.9","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.86","358.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","183.02","38.3","","279.30","91.72","1116.77","266","148.14","379.9","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.86","358.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.00","42.9","","731.00","63.70","731.00","1 through 10","148.14","379.9","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.86","358.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.00","42.9","","384.74","384.74","384.74","1 through 10","148.14","379.9","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.86","358.39","WELLPOINT [1015]","HB AMC WELLPOINT","352.57","73.78","","286.63","119.22","1107.45","105","148.14","379.9","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","477.86","358.39","AETNA [1001]","HB AMC AETNA HMO","333.55","69.8","","675.31","184.75","1721.50","286","249.73","390.51","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","477.86","358.39","AETNA [1001]","HB AMC AETNA PPO","384.20","80.4","","1261.44","103.12","1514.10","21","249.73","390.51","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","477.86","358.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","384.20","80.4","","1365.00","1365.00","1365.00","1 through 10","249.73","390.51","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","477.86","358.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","390.51","81.72","","5157.68","5157.68","5157.68","1 through 10","249.73","390.51","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","477.86","358.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","390.51","81.72","","431.26","71.26","1459.57","88","249.73","390.51","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.18","780.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","827.74","79.5","","800.18","480.96","1887.97","195","322.77","827.74","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.18","780.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","554.95","53.3","","813.12","216.42","1444.50","81","322.77","827.74","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.18","780.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","322.77","31","","432.60","432.60","432.60","1 through 10","322.77","827.74","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.18","780.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","380.03","36.5","","148.37","54.89","631.39","94","322.77","827.74","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.18","780.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","398.77","38.3","","279.30","91.72","1116.77","266","322.77","827.74","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.18","780.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.67","42.9","","731.00","63.70","731.00","1 through 10","322.77","827.74","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.18","780.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.67","42.9","","384.74","384.74","384.74","1 through 10","322.77","827.74","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.18","780.88","WELLPOINT [1015]","HB AMC WELLPOINT","768.18","73.78","","286.63","119.22","1107.45","105","322.77","827.74","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.18","780.88","AETNA [1001]","HB AMC AETNA HMO","726.74","69.8","","675.31","184.75","1721.50","286","544.12","850.85","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.18","780.88","AETNA [1001]","HB AMC AETNA PPO","837.11","80.4","","1261.44","103.12","1514.10","21","544.12","850.85","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.18","780.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","837.11","80.4","","1365.00","1365.00","1365.00","1 through 10","544.12","850.85","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.18","780.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","850.85","81.72","","5157.68","5157.68","5157.68","1 through 10","544.12","850.85","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.18","780.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","850.85","81.72","","431.26","71.26","1459.57","88","544.12","850.85","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1355.41","79.5","","800.18","480.96","1887.97","195","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","908.72","53.3","","813.12","216.42","1444.50","81","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","528.53","31","","432.60","432.60","432.60","1 through 10","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","622.30","36.5","","148.37","54.89","631.39","94","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","652.98","38.3","","279.30","91.72","1116.77","266","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","731.41","42.9","","731.00","63.70","731.00","1 through 10","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","731.41","42.9","","384.74","384.74","384.74","1 through 10","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","WELLPOINT [1015]","HB AMC WELLPOINT","1257.89","73.78","","286.63","119.22","1107.45","105","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.92","1278.69","AETNA [1001]","HB AMC AETNA HMO","1190.03","69.8","","675.31","184.75","1721.50","286","890.99","1393.26","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.92","1278.69","AETNA [1001]","HB AMC AETNA PPO","1370.76","80.4","","1261.44","103.12","1514.10","21","890.99","1393.26","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.92","1278.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1370.76","80.4","","1365.00","1365.00","1365.00","1 through 10","890.99","1393.26","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.92","1278.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1393.26","81.72","","5157.68","5157.68","5157.68","1 through 10","890.99","1393.26","percent of total billed charges",""
"BONE PLATE 83MM 1/3 TUBULAR 7 HOLE 626677","SUP-ITM-10186972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.92","1278.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1393.26","81.72","","431.26","71.26","1459.57","88","890.99","1393.26","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.07","589.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","624.93","79.5","","800.18","480.96","1887.97","195","243.68","624.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.07","589.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","418.98","53.3","","813.12","216.42","1444.50","81","243.68","624.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.07","589.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","243.68","31","","432.60","432.60","432.60","1 through 10","243.68","624.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.07","589.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","286.92","36.5","","148.37","54.89","631.39","94","243.68","624.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.07","589.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","301.06","38.3","","279.30","91.72","1116.77","266","243.68","624.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.07","589.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.22","42.9","","731.00","63.70","731.00","1 through 10","243.68","624.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.07","589.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.22","42.9","","384.74","384.74","384.74","1 through 10","243.68","624.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.07","589.55","WELLPOINT [1015]","HB AMC WELLPOINT","579.96","73.78","","286.63","119.22","1107.45","105","243.68","624.93","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.07","589.55","AETNA [1001]","HB AMC AETNA HMO","548.68","69.8","","675.31","184.75","1721.50","286","410.8","642.38","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.07","589.55","AETNA [1001]","HB AMC AETNA PPO","632.00","80.4","","1261.44","103.12","1514.10","21","410.8","642.38","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.07","589.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","632.00","80.4","","1365.00","1365.00","1365.00","1 through 10","410.8","642.38","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.07","589.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","642.38","81.72","","5157.68","5157.68","5157.68","1 through 10","410.8","642.38","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.07","589.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","642.38","81.72","","431.26","71.26","1459.57","88","410.8","642.38","percent of total billed charges",""
"BONE PLATE 9 HOLE HD 3 LCP TI COLUMN RIGHT","SUP-ITM-10023217","CDM","C1713","HCPCS","0278","RC","","","","both","","","2154.88","1616.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1713.13","79.5","","800.18","480.96","1887.97","195","668.01","1713.13","percent of total billed charges",""
"BONE PLATE 9 HOLE HD 3 LCP TI COLUMN RIGHT","SUP-ITM-10023217","CDM","C1713","HCPCS","0278","RC","","","","both","","","2154.88","1616.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1148.55","53.3","","813.12","216.42","1444.50","81","668.01","1713.13","percent of total billed charges",""
"BONE PLATE 9 HOLE HD 3 LCP TI COLUMN RIGHT","SUP-ITM-10023217","CDM","C1713","HCPCS","0278","RC","","","","both","","","2154.88","1616.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","668.01","31","","432.60","432.60","432.60","1 through 10","668.01","1713.13","percent of total billed charges",""
"BONE PLATE 9 HOLE HD 3 LCP TI COLUMN RIGHT","SUP-ITM-10023217","CDM","C1713","HCPCS","0278","RC","","","","both","","","2154.88","1616.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","786.53","36.5","","148.37","54.89","631.39","94","668.01","1713.13","percent of total billed charges",""
"BONE PLATE 9 HOLE HD 3 LCP TI COLUMN RIGHT","SUP-ITM-10023217","CDM","C1713","HCPCS","0278","RC","","","","both","","","2154.88","1616.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","825.32","38.3","","279.30","91.72","1116.77","266","668.01","1713.13","percent of total billed charges",""
"BONE PLATE 9 HOLE HD 3 LCP TI COLUMN RIGHT","SUP-ITM-10023217","CDM","C1713","HCPCS","0278","RC","","","","both","","","2154.88","1616.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","924.44","42.9","","731.00","63.70","731.00","1 through 10","668.01","1713.13","percent of total billed charges",""
"BONE PLATE 9 HOLE HD 3 LCP TI COLUMN RIGHT","SUP-ITM-10023217","CDM","C1713","HCPCS","0278","RC","","","","both","","","2154.88","1616.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","924.44","42.9","","384.74","384.74","384.74","1 through 10","668.01","1713.13","percent of total billed charges",""
"BONE PLATE 9 HOLE HD 3 LCP TI COLUMN RIGHT","SUP-ITM-10023217","CDM","C1713","HCPCS","0278","RC","","","","both","","","2154.88","1616.16","WELLPOINT [1015]","HB AMC WELLPOINT","1589.87","73.78","","286.63","119.22","1107.45","105","668.01","1713.13","percent of total billed charges",""
"BONE PLATE 9 HOLE HD 3 LCP TI COLUMN RIGHT","SUP-ITM-10023217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2154.88","1616.16","AETNA [1001]","HB AMC AETNA HMO","1504.11","69.8","","675.31","184.75","1721.50","286","1126.14","1760.97","percent of total billed charges",""
"BONE PLATE 9 HOLE HD 3 LCP TI COLUMN RIGHT","SUP-ITM-10023217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2154.88","1616.16","AETNA [1001]","HB AMC AETNA PPO","1732.52","80.4","","1261.44","103.12","1514.10","21","1126.14","1760.97","percent of total billed charges",""
"BONE PLATE 9 HOLE HD 3 LCP TI COLUMN RIGHT","SUP-ITM-10023217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2154.88","1616.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1732.52","80.4","","1365.00","1365.00","1365.00","1 through 10","1126.14","1760.97","percent of total billed charges",""
"BONE PLATE 9 HOLE HD 3 LCP TI COLUMN RIGHT","SUP-ITM-10023217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2154.88","1616.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1760.97","81.72","","5157.68","5157.68","5157.68","1 through 10","1126.14","1760.97","percent of total billed charges",""
"BONE PLATE 9 HOLE HD 3 LCP TI COLUMN RIGHT","SUP-ITM-10023217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2154.88","1616.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1760.97","81.72","","431.26","71.26","1459.57","88","1126.14","1760.97","percent of total billed charges",""
"BONE PLATE 93MM 8 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040738","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.46","376.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","399.46","79.5","","800.18","480.96","1887.97","195","155.76","399.46","percent of total billed charges",""
"BONE PLATE 93MM 8 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040738","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.46","376.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","267.81","53.3","","813.12","216.42","1444.50","81","155.76","399.46","percent of total billed charges",""
"BONE PLATE 93MM 8 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040738","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.46","376.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","155.76","31","","432.60","432.60","432.60","1 through 10","155.76","399.46","percent of total billed charges",""
"BONE PLATE 93MM 8 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040738","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.46","376.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","183.40","36.5","","148.37","54.89","631.39","94","155.76","399.46","percent of total billed charges",""
"BONE PLATE 93MM 8 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040738","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.46","376.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","192.44","38.3","","279.30","91.72","1116.77","266","155.76","399.46","percent of total billed charges",""
"BONE PLATE 93MM 8 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040738","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.46","376.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","215.56","42.9","","731.00","63.70","731.00","1 through 10","155.76","399.46","percent of total billed charges",""
"BONE PLATE 93MM 8 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040738","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.46","376.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","215.56","42.9","","384.74","384.74","384.74","1 through 10","155.76","399.46","percent of total billed charges",""
"BONE PLATE 93MM 8 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040738","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.46","376.84","WELLPOINT [1015]","HB AMC WELLPOINT","370.71","73.78","","286.63","119.22","1107.45","105","155.76","399.46","percent of total billed charges",""
"BONE PLATE 93MM 8 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040738","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.46","376.84","AETNA [1001]","HB AMC AETNA HMO","350.72","69.8","","675.31","184.75","1721.50","286","262.59","410.61","percent of total billed charges",""
"BONE PLATE 93MM 8 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040738","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.46","376.84","AETNA [1001]","HB AMC AETNA PPO","403.98","80.4","","1261.44","103.12","1514.10","21","262.59","410.61","percent of total billed charges",""
"BONE PLATE 93MM 8 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040738","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.46","376.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","403.98","80.4","","1365.00","1365.00","1365.00","1 through 10","262.59","410.61","percent of total billed charges",""
"BONE PLATE 93MM 8 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040738","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.46","376.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","410.61","81.72","","5157.68","5157.68","5157.68","1 through 10","262.59","410.61","percent of total billed charges",""
"BONE PLATE 93MM 8 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040738","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.46","376.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","410.61","81.72","","431.26","71.26","1459.57","88","262.59","410.61","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.32","346.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","367.54","79.5","","800.18","480.96","1887.97","195","143.32","367.54","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.32","346.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","246.42","53.3","","813.12","216.42","1444.50","81","143.32","367.54","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.32","346.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","143.32","31","","432.60","432.60","432.60","1 through 10","143.32","367.54","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.32","346.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","168.75","36.5","","148.37","54.89","631.39","94","143.32","367.54","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.32","346.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","177.07","38.3","","279.30","91.72","1116.77","266","143.32","367.54","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.32","346.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.34","42.9","","731.00","63.70","731.00","1 through 10","143.32","367.54","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.32","346.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.34","42.9","","384.74","384.74","384.74","1 through 10","143.32","367.54","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.32","346.74","WELLPOINT [1015]","HB AMC WELLPOINT","341.10","73.78","","286.63","119.22","1107.45","105","143.32","367.54","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.32","346.74","AETNA [1001]","HB AMC AETNA HMO","322.70","69.8","","675.31","184.75","1721.50","286","241.61","377.81","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.32","346.74","AETNA [1001]","HB AMC AETNA PPO","371.71","80.4","","1261.44","103.12","1514.10","21","241.61","377.81","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.32","346.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","371.71","80.4","","1365.00","1365.00","1365.00","1 through 10","241.61","377.81","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.32","346.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","377.81","81.72","","5157.68","5157.68","5157.68","1 through 10","241.61","377.81","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.32","346.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","377.81","81.72","","431.26","71.26","1459.57","88","241.61","377.81","percent of total billed charges",""
"BONE PLATE 94MM UNIVERSAL 11HOLE TRAUMA MEDIAL STANDARD RT LT EPS","SUP-ITM-10047653","CDM","C1713","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3035.71","79.5","","800.18","480.96","1887.97","195","1183.74","3035.71","percent of total billed charges",""
"BONE PLATE 94MM UNIVERSAL 11HOLE TRAUMA MEDIAL STANDARD RT LT EPS","SUP-ITM-10047653","CDM","C1713","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2035.26","53.3","","813.12","216.42","1444.50","81","1183.74","3035.71","percent of total billed charges",""
"BONE PLATE 94MM UNIVERSAL 11HOLE TRAUMA MEDIAL STANDARD RT LT EPS","SUP-ITM-10047653","CDM","C1713","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1183.74","31","","432.60","432.60","432.60","1 through 10","1183.74","3035.71","percent of total billed charges",""
"BONE PLATE 94MM UNIVERSAL 11HOLE TRAUMA MEDIAL STANDARD RT LT EPS","SUP-ITM-10047653","CDM","C1713","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1393.75","36.5","","148.37","54.89","631.39","94","1183.74","3035.71","percent of total billed charges",""
"BONE PLATE 94MM UNIVERSAL 11HOLE TRAUMA MEDIAL STANDARD RT LT EPS","SUP-ITM-10047653","CDM","C1713","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1462.49","38.3","","279.30","91.72","1116.77","266","1183.74","3035.71","percent of total billed charges",""
"BONE PLATE 94MM UNIVERSAL 11HOLE TRAUMA MEDIAL STANDARD RT LT EPS","SUP-ITM-10047653","CDM","C1713","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1638.14","42.9","","731.00","63.70","731.00","1 through 10","1183.74","3035.71","percent of total billed charges",""
"BONE PLATE 94MM UNIVERSAL 11HOLE TRAUMA MEDIAL STANDARD RT LT EPS","SUP-ITM-10047653","CDM","C1713","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1638.14","42.9","","384.74","384.74","384.74","1 through 10","1183.74","3035.71","percent of total billed charges",""
"BONE PLATE 94MM UNIVERSAL 11HOLE TRAUMA MEDIAL STANDARD RT LT EPS","SUP-ITM-10047653","CDM","C1713","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","WELLPOINT [1015]","HB AMC WELLPOINT","2817.29","73.78","","286.63","119.22","1107.45","105","1183.74","3035.71","percent of total billed charges",""
"BONE PLATE 94MM UNIVERSAL 11HOLE TRAUMA MEDIAL STANDARD RT LT EPS","SUP-ITM-10047653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3818.50","2863.87","AETNA [1001]","HB AMC AETNA HMO","2665.31","69.8","","675.31","184.75","1721.50","286","1995.55","3120.48","percent of total billed charges",""
"BONE PLATE 94MM UNIVERSAL 11HOLE TRAUMA MEDIAL STANDARD RT LT EPS","SUP-ITM-10047653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3818.50","2863.87","AETNA [1001]","HB AMC AETNA PPO","3070.07","80.4","","1261.44","103.12","1514.10","21","1995.55","3120.48","percent of total billed charges",""
"BONE PLATE 94MM UNIVERSAL 11HOLE TRAUMA MEDIAL STANDARD RT LT EPS","SUP-ITM-10047653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3818.50","2863.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3070.07","80.4","","1365.00","1365.00","1365.00","1 through 10","1995.55","3120.48","percent of total billed charges",""
"BONE PLATE 94MM UNIVERSAL 11HOLE TRAUMA MEDIAL STANDARD RT LT EPS","SUP-ITM-10047653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3818.50","2863.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3120.48","81.72","","5157.68","5157.68","5157.68","1 through 10","1995.55","3120.48","percent of total billed charges",""
"BONE PLATE 94MM UNIVERSAL 11HOLE TRAUMA MEDIAL STANDARD RT LT EPS","SUP-ITM-10047653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3818.50","2863.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3120.48","81.72","","431.26","71.26","1459.57","88","1995.55","3120.48","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1355.41","79.5","","800.18","480.96","1887.97","195","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","908.72","53.3","","813.12","216.42","1444.50","81","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","528.53","31","","432.60","432.60","432.60","1 through 10","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","622.30","36.5","","148.37","54.89","631.39","94","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","652.98","38.3","","279.30","91.72","1116.77","266","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","731.41","42.9","","731.00","63.70","731.00","1 through 10","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","731.41","42.9","","384.74","384.74","384.74","1 through 10","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.92","1278.69","WELLPOINT [1015]","HB AMC WELLPOINT","1257.89","73.78","","286.63","119.22","1107.45","105","528.53","1355.41","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.92","1278.69","AETNA [1001]","HB AMC AETNA HMO","1190.03","69.8","","675.31","184.75","1721.50","286","890.99","1393.26","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.92","1278.69","AETNA [1001]","HB AMC AETNA PPO","1370.76","80.4","","1261.44","103.12","1514.10","21","890.99","1393.26","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.92","1278.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1370.76","80.4","","1365.00","1365.00","1365.00","1 through 10","890.99","1393.26","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.92","1278.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1393.26","81.72","","5157.68","5157.68","5157.68","1 through 10","890.99","1393.26","percent of total billed charges",""
"BONE PLATE 95MM 1/3 TUBULAR 8 HOLE","SUP-ITM-10171312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.92","1278.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1393.26","81.72","","431.26","71.26","1459.57","88","890.99","1393.26","percent of total billed charges",""
"BONE PLATE 95X60MM 4 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10004155","CDM","C1713","HCPCS","0278","RC","","","","both","","","2957.78","2218.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2351.44","79.5","","800.18","480.96","1887.97","195","916.91","2351.44","percent of total billed charges",""
"BONE PLATE 95X60MM 4 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10004155","CDM","C1713","HCPCS","0278","RC","","","","both","","","2957.78","2218.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1576.50","53.3","","813.12","216.42","1444.50","81","916.91","2351.44","percent of total billed charges",""
"BONE PLATE 95X60MM 4 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10004155","CDM","C1713","HCPCS","0278","RC","","","","both","","","2957.78","2218.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","916.91","31","","432.60","432.60","432.60","1 through 10","916.91","2351.44","percent of total billed charges",""
"BONE PLATE 95X60MM 4 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10004155","CDM","C1713","HCPCS","0278","RC","","","","both","","","2957.78","2218.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1079.59","36.5","","148.37","54.89","631.39","94","916.91","2351.44","percent of total billed charges",""
"BONE PLATE 95X60MM 4 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10004155","CDM","C1713","HCPCS","0278","RC","","","","both","","","2957.78","2218.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1132.83","38.3","","279.30","91.72","1116.77","266","916.91","2351.44","percent of total billed charges",""
"BONE PLATE 95X60MM 4 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10004155","CDM","C1713","HCPCS","0278","RC","","","","both","","","2957.78","2218.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1268.89","42.9","","731.00","63.70","731.00","1 through 10","916.91","2351.44","percent of total billed charges",""
"BONE PLATE 95X60MM 4 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10004155","CDM","C1713","HCPCS","0278","RC","","","","both","","","2957.78","2218.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1268.89","42.9","","384.74","384.74","384.74","1 through 10","916.91","2351.44","percent of total billed charges",""
"BONE PLATE 95X60MM 4 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10004155","CDM","C1713","HCPCS","0278","RC","","","","both","","","2957.78","2218.33","WELLPOINT [1015]","HB AMC WELLPOINT","2182.25","73.78","","286.63","119.22","1107.45","105","916.91","2351.44","percent of total billed charges",""
"BONE PLATE 95X60MM 4 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10004155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2957.78","2218.33","AETNA [1001]","HB AMC AETNA HMO","2064.53","69.8","","675.31","184.75","1721.50","286","1545.74","2417.1","percent of total billed charges",""
"BONE PLATE 95X60MM 4 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10004155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2957.78","2218.33","AETNA [1001]","HB AMC AETNA PPO","2378.06","80.4","","1261.44","103.12","1514.10","21","1545.74","2417.1","percent of total billed charges",""
"BONE PLATE 95X60MM 4 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10004155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2957.78","2218.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2378.06","80.4","","1365.00","1365.00","1365.00","1 through 10","1545.74","2417.1","percent of total billed charges",""
"BONE PLATE 95X60MM 4 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10004155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2957.78","2218.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2417.10","81.72","","5157.68","5157.68","5157.68","1 through 10","1545.74","2417.1","percent of total billed charges",""
"BONE PLATE 95X60MM 4 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10004155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2957.78","2218.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2417.10","81.72","","431.26","71.26","1459.57","88","1545.74","2417.1","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","506.35","379.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","402.55","79.5","","800.18","480.96","1887.97","195","156.97","402.55","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","506.35","379.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","269.88","53.3","","813.12","216.42","1444.50","81","156.97","402.55","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","506.35","379.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","156.97","31","","432.60","432.60","432.60","1 through 10","156.97","402.55","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","506.35","379.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","184.82","36.5","","148.37","54.89","631.39","94","156.97","402.55","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","506.35","379.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","193.93","38.3","","279.30","91.72","1116.77","266","156.97","402.55","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","506.35","379.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.22","42.9","","731.00","63.70","731.00","1 through 10","156.97","402.55","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","506.35","379.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.22","42.9","","384.74","384.74","384.74","1 through 10","156.97","402.55","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","both","","","506.35","379.76","WELLPOINT [1015]","HB AMC WELLPOINT","373.59","73.78","","286.63","119.22","1107.45","105","156.97","402.55","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","506.35","379.76","AETNA [1001]","HB AMC AETNA HMO","353.43","69.8","","675.31","184.75","1721.50","286","264.62","413.79","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","506.35","379.76","AETNA [1001]","HB AMC AETNA PPO","407.11","80.4","","1261.44","103.12","1514.10","21","264.62","413.79","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","506.35","379.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","407.11","80.4","","1365.00","1365.00","1365.00","1 through 10","264.62","413.79","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","506.35","379.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","413.79","81.72","","5157.68","5157.68","5157.68","1 through 10","264.62","413.79","percent of total billed charges",""
"BONE PLATE 97MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR TI","SUP-ITM-10001625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","506.35","379.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","413.79","81.72","","431.26","71.26","1459.57","88","264.62","413.79","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","289.17","216.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","229.89","79.5","","800.18","480.96","1887.97","195","89.64","229.89","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","289.17","216.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","154.13","53.3","","813.12","216.42","1444.50","81","89.64","229.89","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","289.17","216.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","89.64","31","","432.60","432.60","432.60","1 through 10","89.64","229.89","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","289.17","216.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.55","36.5","","148.37","54.89","631.39","94","89.64","229.89","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","289.17","216.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","110.75","38.3","","279.30","91.72","1116.77","266","89.64","229.89","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","289.17","216.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.05","42.9","","731.00","63.70","731.00","1 through 10","89.64","229.89","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","289.17","216.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.05","42.9","","384.74","384.74","384.74","1 through 10","89.64","229.89","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","289.17","216.88","WELLPOINT [1015]","HB AMC WELLPOINT","213.35","73.78","","286.63","119.22","1107.45","105","89.64","229.89","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","289.17","216.88","AETNA [1001]","HB AMC AETNA HMO","201.84","69.8","","675.31","184.75","1721.50","286","151.12","236.31","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","289.17","216.88","AETNA [1001]","HB AMC AETNA PPO","232.49","80.4","","1261.44","103.12","1514.10","21","151.12","236.31","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","289.17","216.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","232.49","80.4","","1365.00","1365.00","1365.00","1 through 10","151.12","236.31","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","289.17","216.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","236.31","81.72","","5157.68","5157.68","5157.68","1 through 10","151.12","236.31","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","289.17","216.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","236.31","81.72","","431.26","71.26","1459.57","88","151.12","236.31","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","651.69","79.5","","800.18","480.96","1887.97","195","254.12","651.69","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","436.92","53.3","","813.12","216.42","1444.50","81","254.12","651.69","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","254.12","31","","432.60","432.60","432.60","1 through 10","254.12","651.69","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","299.21","36.5","","148.37","54.89","631.39","94","254.12","651.69","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","313.96","38.3","","279.30","91.72","1116.77","266","254.12","651.69","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.67","42.9","","731.00","63.70","731.00","1 through 10","254.12","651.69","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.67","42.9","","384.74","384.74","384.74","1 through 10","254.12","651.69","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.74","614.80","WELLPOINT [1015]","HB AMC WELLPOINT","604.80","73.78","","286.63","119.22","1107.45","105","254.12","651.69","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.74","614.80","AETNA [1001]","HB AMC AETNA HMO","572.18","69.8","","675.31","184.75","1721.50","286","428.4","669.89","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.74","614.80","AETNA [1001]","HB AMC AETNA PPO","659.07","80.4","","1261.44","103.12","1514.10","21","428.4","669.89","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.74","614.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","659.07","80.4","","1365.00","1365.00","1365.00","1 through 10","428.4","669.89","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.74","614.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","669.89","81.72","","5157.68","5157.68","5157.68","1 through 10","428.4","669.89","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.74","614.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","669.89","81.72","","431.26","71.26","1459.57","88","428.4","669.89","percent of total billed charges",""
"BONE PLATE C TYPE FOR CMF DISTRACTORTI CONDYLAR HEAD DISTRACTOR","SUP-ITM-10075199","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.10","3781.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4008.47","79.5","","800.18","480.96","1887.97","195","1563.05","4008.47","percent of total billed charges",""
"BONE PLATE C TYPE FOR CMF DISTRACTORTI CONDYLAR HEAD DISTRACTOR","SUP-ITM-10075199","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.10","3781.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2687.44","53.3","","813.12","216.42","1444.50","81","1563.05","4008.47","percent of total billed charges",""
"BONE PLATE C TYPE FOR CMF DISTRACTORTI CONDYLAR HEAD DISTRACTOR","SUP-ITM-10075199","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.10","3781.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1563.05","31","","432.60","432.60","432.60","1 through 10","1563.05","4008.47","percent of total billed charges",""
"BONE PLATE C TYPE FOR CMF DISTRACTORTI CONDYLAR HEAD DISTRACTOR","SUP-ITM-10075199","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.10","3781.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1840.37","36.5","","148.37","54.89","631.39","94","1563.05","4008.47","percent of total billed charges",""
"BONE PLATE C TYPE FOR CMF DISTRACTORTI CONDYLAR HEAD DISTRACTOR","SUP-ITM-10075199","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.10","3781.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1931.12","38.3","","279.30","91.72","1116.77","266","1563.05","4008.47","percent of total billed charges",""
"BONE PLATE C TYPE FOR CMF DISTRACTORTI CONDYLAR HEAD DISTRACTOR","SUP-ITM-10075199","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.10","3781.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2163.06","42.9","","731.00","63.70","731.00","1 through 10","1563.05","4008.47","percent of total billed charges",""
"BONE PLATE C TYPE FOR CMF DISTRACTORTI CONDYLAR HEAD DISTRACTOR","SUP-ITM-10075199","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.10","3781.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2163.06","42.9","","384.74","384.74","384.74","1 through 10","1563.05","4008.47","percent of total billed charges",""
"BONE PLATE C TYPE FOR CMF DISTRACTORTI CONDYLAR HEAD DISTRACTOR","SUP-ITM-10075199","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.10","3781.57","WELLPOINT [1015]","HB AMC WELLPOINT","3720.06","73.78","","286.63","119.22","1107.45","105","1563.05","4008.47","percent of total billed charges",""
"BONE PLATE C TYPE FOR CMF DISTRACTORTI CONDYLAR HEAD DISTRACTOR","SUP-ITM-10075199","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5042.10","3781.57","AETNA [1001]","HB AMC AETNA HMO","3519.39","69.8","","675.31","184.75","1721.50","286","2635","4120.4","percent of total billed charges",""
"BONE PLATE C TYPE FOR CMF DISTRACTORTI CONDYLAR HEAD DISTRACTOR","SUP-ITM-10075199","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5042.10","3781.57","AETNA [1001]","HB AMC AETNA PPO","4053.85","80.4","","1261.44","103.12","1514.10","21","2635","4120.4","percent of total billed charges",""
"BONE PLATE C TYPE FOR CMF DISTRACTORTI CONDYLAR HEAD DISTRACTOR","SUP-ITM-10075199","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5042.10","3781.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4053.85","80.4","","1365.00","1365.00","1365.00","1 through 10","2635","4120.4","percent of total billed charges",""
"BONE PLATE C TYPE FOR CMF DISTRACTORTI CONDYLAR HEAD DISTRACTOR","SUP-ITM-10075199","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5042.10","3781.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4120.40","81.72","","5157.68","5157.68","5157.68","1 through 10","2635","4120.4","percent of total billed charges",""
"BONE PLATE C TYPE FOR CMF DISTRACTORTI CONDYLAR HEAD DISTRACTOR","SUP-ITM-10075199","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5042.10","3781.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4120.40","81.72","","431.26","71.26","1459.57","88","2635","4120.4","percent of total billed charges",""
"BONE PLATE CAST SUPRAPECTINEAL TITANIUM RIGHT","SUP-ITM-10142552","CDM","C1713","HCPCS","0278","RC","","","","both","","","6838.45","5128.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5436.57","79.5","","800.18","480.96","1887.97","195","2119.92","5436.57","percent of total billed charges",""
"BONE PLATE CAST SUPRAPECTINEAL TITANIUM RIGHT","SUP-ITM-10142552","CDM","C1713","HCPCS","0278","RC","","","","both","","","6838.45","5128.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3644.89","53.3","","813.12","216.42","1444.50","81","2119.92","5436.57","percent of total billed charges",""
"BONE PLATE CAST SUPRAPECTINEAL TITANIUM RIGHT","SUP-ITM-10142552","CDM","C1713","HCPCS","0278","RC","","","","both","","","6838.45","5128.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2119.92","31","","432.60","432.60","432.60","1 through 10","2119.92","5436.57","percent of total billed charges",""
"BONE PLATE CAST SUPRAPECTINEAL TITANIUM RIGHT","SUP-ITM-10142552","CDM","C1713","HCPCS","0278","RC","","","","both","","","6838.45","5128.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2496.03","36.5","","148.37","54.89","631.39","94","2119.92","5436.57","percent of total billed charges",""
"BONE PLATE CAST SUPRAPECTINEAL TITANIUM RIGHT","SUP-ITM-10142552","CDM","C1713","HCPCS","0278","RC","","","","both","","","6838.45","5128.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2619.13","38.3","","279.30","91.72","1116.77","266","2119.92","5436.57","percent of total billed charges",""
"BONE PLATE CAST SUPRAPECTINEAL TITANIUM RIGHT","SUP-ITM-10142552","CDM","C1713","HCPCS","0278","RC","","","","both","","","6838.45","5128.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2933.70","42.9","","731.00","63.70","731.00","1 through 10","2119.92","5436.57","percent of total billed charges",""
"BONE PLATE CAST SUPRAPECTINEAL TITANIUM RIGHT","SUP-ITM-10142552","CDM","C1713","HCPCS","0278","RC","","","","both","","","6838.45","5128.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2933.70","42.9","","384.74","384.74","384.74","1 through 10","2119.92","5436.57","percent of total billed charges",""
"BONE PLATE CAST SUPRAPECTINEAL TITANIUM RIGHT","SUP-ITM-10142552","CDM","C1713","HCPCS","0278","RC","","","","both","","","6838.45","5128.84","WELLPOINT [1015]","HB AMC WELLPOINT","5045.41","73.78","","286.63","119.22","1107.45","105","2119.92","5436.57","percent of total billed charges",""
"BONE PLATE CAST SUPRAPECTINEAL TITANIUM RIGHT","SUP-ITM-10142552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6838.45","5128.84","AETNA [1001]","HB AMC AETNA HMO","4773.24","69.8","","675.31","184.75","1721.50","286","3573.77","5588.38","percent of total billed charges",""
"BONE PLATE CAST SUPRAPECTINEAL TITANIUM RIGHT","SUP-ITM-10142552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6838.45","5128.84","AETNA [1001]","HB AMC AETNA PPO","5498.11","80.4","","1261.44","103.12","1514.10","21","3573.77","5588.38","percent of total billed charges",""
"BONE PLATE CAST SUPRAPECTINEAL TITANIUM RIGHT","SUP-ITM-10142552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6838.45","5128.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5498.11","80.4","","1365.00","1365.00","1365.00","1 through 10","3573.77","5588.38","percent of total billed charges",""
"BONE PLATE CAST SUPRAPECTINEAL TITANIUM RIGHT","SUP-ITM-10142552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6838.45","5128.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5588.38","81.72","","5157.68","5157.68","5157.68","1 through 10","3573.77","5588.38","percent of total billed charges",""
"BONE PLATE CAST SUPRAPECTINEAL TITANIUM RIGHT","SUP-ITM-10142552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6838.45","5128.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5588.38","81.72","","431.26","71.26","1459.57","88","3573.77","5588.38","percent of total billed charges",""
"BONE PLATE COMPRESSION 1.5MM 2 HOLE CRANIAL MATRIX TI","SUP-ITM-10081105","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.96","825.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","875.26","79.5","","800.18","480.96","1887.97","195","341.3","875.26","percent of total billed charges",""
"BONE PLATE COMPRESSION 1.5MM 2 HOLE CRANIAL MATRIX TI","SUP-ITM-10081105","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.96","825.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","586.81","53.3","","813.12","216.42","1444.50","81","341.3","875.26","percent of total billed charges",""
"BONE PLATE COMPRESSION 1.5MM 2 HOLE CRANIAL MATRIX TI","SUP-ITM-10081105","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.96","825.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","341.30","31","","432.60","432.60","432.60","1 through 10","341.3","875.26","percent of total billed charges",""
"BONE PLATE COMPRESSION 1.5MM 2 HOLE CRANIAL MATRIX TI","SUP-ITM-10081105","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.96","825.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","401.85","36.5","","148.37","54.89","631.39","94","341.3","875.26","percent of total billed charges",""
"BONE PLATE COMPRESSION 1.5MM 2 HOLE CRANIAL MATRIX TI","SUP-ITM-10081105","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.96","825.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","421.67","38.3","","279.30","91.72","1116.77","266","341.3","875.26","percent of total billed charges",""
"BONE PLATE COMPRESSION 1.5MM 2 HOLE CRANIAL MATRIX TI","SUP-ITM-10081105","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.96","825.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","472.31","42.9","","731.00","63.70","731.00","1 through 10","341.3","875.26","percent of total billed charges",""
"BONE PLATE COMPRESSION 1.5MM 2 HOLE CRANIAL MATRIX TI","SUP-ITM-10081105","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.96","825.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","472.31","42.9","","384.74","384.74","384.74","1 through 10","341.3","875.26","percent of total billed charges",""
"BONE PLATE COMPRESSION 1.5MM 2 HOLE CRANIAL MATRIX TI","SUP-ITM-10081105","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.96","825.72","WELLPOINT [1015]","HB AMC WELLPOINT","812.29","73.78","","286.63","119.22","1107.45","105","341.3","875.26","percent of total billed charges",""
"BONE PLATE COMPRESSION 1.5MM 2 HOLE CRANIAL MATRIX TI","SUP-ITM-10081105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.96","825.72","AETNA [1001]","HB AMC AETNA HMO","768.47","69.8","","675.31","184.75","1721.50","286","575.36","899.7","percent of total billed charges",""
"BONE PLATE COMPRESSION 1.5MM 2 HOLE CRANIAL MATRIX TI","SUP-ITM-10081105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.96","825.72","AETNA [1001]","HB AMC AETNA PPO","885.17","80.4","","1261.44","103.12","1514.10","21","575.36","899.7","percent of total billed charges",""
"BONE PLATE COMPRESSION 1.5MM 2 HOLE CRANIAL MATRIX TI","SUP-ITM-10081105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.96","825.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","885.17","80.4","","1365.00","1365.00","1365.00","1 through 10","575.36","899.7","percent of total billed charges",""
"BONE PLATE COMPRESSION 1.5MM 2 HOLE CRANIAL MATRIX TI","SUP-ITM-10081105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.96","825.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","899.70","81.72","","5157.68","5157.68","5157.68","1 through 10","575.36","899.7","percent of total billed charges",""
"BONE PLATE COMPRESSION 1.5MM 2 HOLE CRANIAL MATRIX TI","SUP-ITM-10081105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.96","825.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","899.70","81.72","","431.26","71.26","1459.57","88","575.36","899.7","percent of total billed charges",""
"BONE PLATE CRANIOPLASTY PEEK CUSTOM","SUP-ITM-10155935","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10440.34","79.5","","800.18","480.96","1887.97","195","4071.08","10440.34","percent of total billed charges",""
"BONE PLATE CRANIOPLASTY PEEK CUSTOM","SUP-ITM-10155935","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6999.62","53.3","","813.12","216.42","1444.50","81","4071.08","10440.34","percent of total billed charges",""
"BONE PLATE CRANIOPLASTY PEEK CUSTOM","SUP-ITM-10155935","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4071.08","31","","432.60","432.60","432.60","1 through 10","4071.08","10440.34","percent of total billed charges",""
"BONE PLATE CRANIOPLASTY PEEK CUSTOM","SUP-ITM-10155935","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4793.36","36.5","","148.37","54.89","631.39","94","4071.08","10440.34","percent of total billed charges",""
"BONE PLATE CRANIOPLASTY PEEK CUSTOM","SUP-ITM-10155935","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5029.75","38.3","","279.30","91.72","1116.77","266","4071.08","10440.34","percent of total billed charges",""
"BONE PLATE CRANIOPLASTY PEEK CUSTOM","SUP-ITM-10155935","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5633.84","42.9","","731.00","63.70","731.00","1 through 10","4071.08","10440.34","percent of total billed charges",""
"BONE PLATE CRANIOPLASTY PEEK CUSTOM","SUP-ITM-10155935","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5633.84","42.9","","384.74","384.74","384.74","1 through 10","4071.08","10440.34","percent of total billed charges",""
"BONE PLATE CRANIOPLASTY PEEK CUSTOM","SUP-ITM-10155935","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","WELLPOINT [1015]","HB AMC WELLPOINT","9689.16","73.78","","286.63","119.22","1107.45","105","4071.08","10440.34","percent of total billed charges",""
"BONE PLATE CRANIOPLASTY PEEK CUSTOM","SUP-ITM-10155935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","AETNA [1001]","HB AMC AETNA HMO","9166.49","69.8","","675.31","184.75","1721.50","286","6863.04","10731.88","percent of total billed charges",""
"BONE PLATE CRANIOPLASTY PEEK CUSTOM","SUP-ITM-10155935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","AETNA [1001]","HB AMC AETNA PPO","10558.53","80.4","","1261.44","103.12","1514.10","21","6863.04","10731.88","percent of total billed charges",""
"BONE PLATE CRANIOPLASTY PEEK CUSTOM","SUP-ITM-10155935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10558.53","80.4","","1365.00","1365.00","1365.00","1 through 10","6863.04","10731.88","percent of total billed charges",""
"BONE PLATE CRANIOPLASTY PEEK CUSTOM","SUP-ITM-10155935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","10731.88","81.72","","5157.68","5157.68","5157.68","1 through 10","6863.04","10731.88","percent of total billed charges",""
"BONE PLATE CRANIOPLASTY PEEK CUSTOM","SUP-ITM-10155935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10731.88","81.72","","431.26","71.26","1459.57","88","6863.04","10731.88","percent of total billed charges",""
"BONE PLATE HOOK 3.5X62MM 3 HOLE LCP SS","SUP-ITM-10096941","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.28","1191.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1263.48","79.5","","800.18","480.96","1887.97","195","492.68","1263.48","percent of total billed charges",""
"BONE PLATE HOOK 3.5X62MM 3 HOLE LCP SS","SUP-ITM-10096941","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.28","1191.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","847.09","53.3","","813.12","216.42","1444.50","81","492.68","1263.48","percent of total billed charges",""
"BONE PLATE HOOK 3.5X62MM 3 HOLE LCP SS","SUP-ITM-10096941","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.28","1191.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","492.68","31","","432.60","432.60","432.60","1 through 10","492.68","1263.48","percent of total billed charges",""
"BONE PLATE HOOK 3.5X62MM 3 HOLE LCP SS","SUP-ITM-10096941","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.28","1191.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","580.09","36.5","","148.37","54.89","631.39","94","492.68","1263.48","percent of total billed charges",""
"BONE PLATE HOOK 3.5X62MM 3 HOLE LCP SS","SUP-ITM-10096941","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.28","1191.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","608.69","38.3","","279.30","91.72","1116.77","266","492.68","1263.48","percent of total billed charges",""
"BONE PLATE HOOK 3.5X62MM 3 HOLE LCP SS","SUP-ITM-10096941","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.28","1191.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","681.80","42.9","","731.00","63.70","731.00","1 through 10","492.68","1263.48","percent of total billed charges",""
"BONE PLATE HOOK 3.5X62MM 3 HOLE LCP SS","SUP-ITM-10096941","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.28","1191.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","681.80","42.9","","384.74","384.74","384.74","1 through 10","492.68","1263.48","percent of total billed charges",""
"BONE PLATE HOOK 3.5X62MM 3 HOLE LCP SS","SUP-ITM-10096941","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.28","1191.96","WELLPOINT [1015]","HB AMC WELLPOINT","1172.57","73.78","","286.63","119.22","1107.45","105","492.68","1263.48","percent of total billed charges",""
"BONE PLATE HOOK 3.5X62MM 3 HOLE LCP SS","SUP-ITM-10096941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.28","1191.96","AETNA [1001]","HB AMC AETNA HMO","1109.32","69.8","","675.31","184.75","1721.50","286","830.56","1298.76","percent of total billed charges",""
"BONE PLATE HOOK 3.5X62MM 3 HOLE LCP SS","SUP-ITM-10096941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.28","1191.96","AETNA [1001]","HB AMC AETNA PPO","1277.78","80.4","","1261.44","103.12","1514.10","21","830.56","1298.76","percent of total billed charges",""
"BONE PLATE HOOK 3.5X62MM 3 HOLE LCP SS","SUP-ITM-10096941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.28","1191.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1277.78","80.4","","1365.00","1365.00","1365.00","1 through 10","830.56","1298.76","percent of total billed charges",""
"BONE PLATE HOOK 3.5X62MM 3 HOLE LCP SS","SUP-ITM-10096941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.28","1191.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1298.76","81.72","","5157.68","5157.68","5157.68","1 through 10","830.56","1298.76","percent of total billed charges",""
"BONE PLATE HOOK 3.5X62MM 3 HOLE LCP SS","SUP-ITM-10096941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.28","1191.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1298.76","81.72","","431.26","71.26","1459.57","88","830.56","1298.76","percent of total billed charges",""
"BONE PLATE LG POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131919","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4130.03","79.5","","800.18","480.96","1887.97","195","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE LG POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131919","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2768.94","53.3","","813.12","216.42","1444.50","81","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE LG POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131919","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1610.45","31","","432.60","432.60","432.60","1 through 10","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE LG POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131919","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1896.18","36.5","","148.37","54.89","631.39","94","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE LG POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131919","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1989.69","38.3","","279.30","91.72","1116.77","266","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE LG POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131919","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2228.66","42.9","","731.00","63.70","731.00","1 through 10","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE LG POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131919","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2228.66","42.9","","384.74","384.74","384.74","1 through 10","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE LG POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131919","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","WELLPOINT [1015]","HB AMC WELLPOINT","3832.87","73.78","","286.63","119.22","1107.45","105","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE LG POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5195.00","3896.25","AETNA [1001]","HB AMC AETNA HMO","3626.11","69.8","","675.31","184.75","1721.50","286","2714.91","4245.35","percent of total billed charges",""
"BONE PLATE LG POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5195.00","3896.25","AETNA [1001]","HB AMC AETNA PPO","4176.78","80.4","","1261.44","103.12","1514.10","21","2714.91","4245.35","percent of total billed charges",""
"BONE PLATE LG POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5195.00","3896.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4176.78","80.4","","1365.00","1365.00","1365.00","1 through 10","2714.91","4245.35","percent of total billed charges",""
"BONE PLATE LG POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5195.00","3896.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4245.35","81.72","","5157.68","5157.68","5157.68","1 through 10","2714.91","4245.35","percent of total billed charges",""
"BONE PLATE LG POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5195.00","3896.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4245.35","81.72","","431.26","71.26","1459.57","88","2714.91","4245.35","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","5032.89","3774.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4001.15","79.5","","800.18","480.96","1887.97","195","1560.2","4001.15","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","5032.89","3774.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2682.53","53.3","","813.12","216.42","1444.50","81","1560.2","4001.15","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","5032.89","3774.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1560.20","31","","432.60","432.60","432.60","1 through 10","1560.2","4001.15","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","5032.89","3774.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1837.00","36.5","","148.37","54.89","631.39","94","1560.2","4001.15","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","5032.89","3774.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1927.60","38.3","","279.30","91.72","1116.77","266","1560.2","4001.15","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","5032.89","3774.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2159.11","42.9","","731.00","63.70","731.00","1 through 10","1560.2","4001.15","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","5032.89","3774.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2159.11","42.9","","384.74","384.74","384.74","1 through 10","1560.2","4001.15","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","5032.89","3774.67","WELLPOINT [1015]","HB AMC WELLPOINT","3713.27","73.78","","286.63","119.22","1107.45","105","1560.2","4001.15","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5032.89","3774.67","AETNA [1001]","HB AMC AETNA HMO","3512.96","69.8","","675.31","184.75","1721.50","286","2630.19","4112.88","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5032.89","3774.67","AETNA [1001]","HB AMC AETNA PPO","4046.44","80.4","","1261.44","103.12","1514.10","21","2630.19","4112.88","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5032.89","3774.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4046.44","80.4","","1365.00","1365.00","1365.00","1 through 10","2630.19","4112.88","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5032.89","3774.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4112.88","81.72","","5157.68","5157.68","5157.68","1 through 10","2630.19","4112.88","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5032.89","3774.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4112.88","81.72","","431.26","71.26","1459.57","88","2630.19","4112.88","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","3451.00","2588.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2743.55","79.5","","800.18","480.96","1887.97","195","1069.81","2743.55","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","3451.00","2588.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1839.38","53.3","","813.12","216.42","1444.50","81","1069.81","2743.55","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","3451.00","2588.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1069.81","31","","432.60","432.60","432.60","1 through 10","1069.81","2743.55","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","3451.00","2588.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1259.62","36.5","","148.37","54.89","631.39","94","1069.81","2743.55","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","3451.00","2588.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1321.73","38.3","","279.30","91.72","1116.77","266","1069.81","2743.55","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","3451.00","2588.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1480.48","42.9","","731.00","63.70","731.00","1 through 10","1069.81","2743.55","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","3451.00","2588.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1480.48","42.9","","384.74","384.74","384.74","1 through 10","1069.81","2743.55","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","3451.00","2588.25","WELLPOINT [1015]","HB AMC WELLPOINT","2546.15","73.78","","286.63","119.22","1107.45","105","1069.81","2743.55","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3451.00","2588.25","AETNA [1001]","HB AMC AETNA HMO","2408.80","69.8","","675.31","184.75","1721.50","286","1803.49","2820.16","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3451.00","2588.25","AETNA [1001]","HB AMC AETNA PPO","2774.60","80.4","","1261.44","103.12","1514.10","21","1803.49","2820.16","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3451.00","2588.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2774.60","80.4","","1365.00","1365.00","1365.00","1 through 10","1803.49","2820.16","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3451.00","2588.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2820.16","81.72","","5157.68","5157.68","5157.68","1 through 10","1803.49","2820.16","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3451.00","2588.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2820.16","81.72","","431.26","71.26","1459.57","88","1803.49","2820.16","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2051.25","1538.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1630.74","79.5","","800.18","480.96","1887.97","195","635.89","1630.74","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2051.25","1538.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1093.32","53.3","","813.12","216.42","1444.50","81","635.89","1630.74","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2051.25","1538.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","635.89","31","","432.60","432.60","432.60","1 through 10","635.89","1630.74","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2051.25","1538.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","748.71","36.5","","148.37","54.89","631.39","94","635.89","1630.74","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2051.25","1538.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","785.63","38.3","","279.30","91.72","1116.77","266","635.89","1630.74","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2051.25","1538.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","879.99","42.9","","731.00","63.70","731.00","1 through 10","635.89","1630.74","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2051.25","1538.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","879.99","42.9","","384.74","384.74","384.74","1 through 10","635.89","1630.74","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2051.25","1538.44","WELLPOINT [1015]","HB AMC WELLPOINT","1513.41","73.78","","286.63","119.22","1107.45","105","635.89","1630.74","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2051.25","1538.44","AETNA [1001]","HB AMC AETNA HMO","1431.77","69.8","","675.31","184.75","1721.50","286","1071.98","1676.28","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2051.25","1538.44","AETNA [1001]","HB AMC AETNA PPO","1649.21","80.4","","1261.44","103.12","1514.10","21","1071.98","1676.28","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2051.25","1538.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1649.21","80.4","","1365.00","1365.00","1365.00","1 through 10","1071.98","1676.28","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2051.25","1538.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1676.28","81.72","","5157.68","5157.68","5157.68","1 through 10","1071.98","1676.28","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2051.25","1538.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1676.28","81.72","","431.26","71.26","1459.57","88","1071.98","1676.28","percent of total billed charges",""
"BONE PLATE PRECONTOURED CURVED 12 HOLE","SUP-ITM-10212021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5073.00","3804.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4033.04","79.5","","800.18","480.96","1887.97","195","1572.63","4033.04","percent of total billed charges",""
"BONE PLATE PRECONTOURED CURVED 12 HOLE","SUP-ITM-10212021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5073.00","3804.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2703.91","53.3","","813.12","216.42","1444.50","81","1572.63","4033.04","percent of total billed charges",""
"BONE PLATE PRECONTOURED CURVED 12 HOLE","SUP-ITM-10212021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5073.00","3804.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1572.63","31","","432.60","432.60","432.60","1 through 10","1572.63","4033.04","percent of total billed charges",""
"BONE PLATE PRECONTOURED CURVED 12 HOLE","SUP-ITM-10212021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5073.00","3804.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1851.65","36.5","","148.37","54.89","631.39","94","1572.63","4033.04","percent of total billed charges",""
"BONE PLATE PRECONTOURED CURVED 12 HOLE","SUP-ITM-10212021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5073.00","3804.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1942.96","38.3","","279.30","91.72","1116.77","266","1572.63","4033.04","percent of total billed charges",""
"BONE PLATE PRECONTOURED CURVED 12 HOLE","SUP-ITM-10212021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5073.00","3804.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2176.32","42.9","","731.00","63.70","731.00","1 through 10","1572.63","4033.04","percent of total billed charges",""
"BONE PLATE PRECONTOURED CURVED 12 HOLE","SUP-ITM-10212021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5073.00","3804.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2176.32","42.9","","384.74","384.74","384.74","1 through 10","1572.63","4033.04","percent of total billed charges",""
"BONE PLATE PRECONTOURED CURVED 12 HOLE","SUP-ITM-10212021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5073.00","3804.75","WELLPOINT [1015]","HB AMC WELLPOINT","3742.86","73.78","","286.63","119.22","1107.45","105","1572.63","4033.04","percent of total billed charges",""
"BONE PLATE PRECONTOURED CURVED 12 HOLE","SUP-ITM-10212021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5073.00","3804.75","AETNA [1001]","HB AMC AETNA HMO","3540.95","69.8","","675.31","184.75","1721.50","286","2651.15","4145.66","percent of total billed charges",""
"BONE PLATE PRECONTOURED CURVED 12 HOLE","SUP-ITM-10212021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5073.00","3804.75","AETNA [1001]","HB AMC AETNA PPO","4078.69","80.4","","1261.44","103.12","1514.10","21","2651.15","4145.66","percent of total billed charges",""
"BONE PLATE PRECONTOURED CURVED 12 HOLE","SUP-ITM-10212021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5073.00","3804.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4078.69","80.4","","1365.00","1365.00","1365.00","1 through 10","2651.15","4145.66","percent of total billed charges",""
"BONE PLATE PRECONTOURED CURVED 12 HOLE","SUP-ITM-10212021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5073.00","3804.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4145.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2651.15","4145.66","percent of total billed charges",""
"BONE PLATE PRECONTOURED CURVED 12 HOLE","SUP-ITM-10212021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5073.00","3804.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4145.66","81.72","","431.26","71.26","1459.57","88","2651.15","4145.66","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4502.50","3376.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3579.49","79.5","","800.18","480.96","1887.97","195","1395.78","3579.49","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4502.50","3376.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2399.83","53.3","","813.12","216.42","1444.50","81","1395.78","3579.49","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4502.50","3376.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1395.78","31","","432.60","432.60","432.60","1 through 10","1395.78","3579.49","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4502.50","3376.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1643.41","36.5","","148.37","54.89","631.39","94","1395.78","3579.49","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4502.50","3376.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1724.46","38.3","","279.30","91.72","1116.77","266","1395.78","3579.49","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4502.50","3376.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1931.57","42.9","","731.00","63.70","731.00","1 through 10","1395.78","3579.49","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4502.50","3376.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1931.57","42.9","","384.74","384.74","384.74","1 through 10","1395.78","3579.49","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4502.50","3376.87","WELLPOINT [1015]","HB AMC WELLPOINT","3321.94","73.78","","286.63","119.22","1107.45","105","1395.78","3579.49","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4502.50","3376.87","AETNA [1001]","HB AMC AETNA HMO","3142.75","69.8","","675.31","184.75","1721.50","286","2353.01","3679.44","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4502.50","3376.87","AETNA [1001]","HB AMC AETNA PPO","3620.01","80.4","","1261.44","103.12","1514.10","21","2353.01","3679.44","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4502.50","3376.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3620.01","80.4","","1365.00","1365.00","1365.00","1 through 10","2353.01","3679.44","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4502.50","3376.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3679.44","81.72","","5157.68","5157.68","5157.68","1 through 10","2353.01","3679.44","percent of total billed charges",""
"BONE PLATE SM FUSION LATERAL TTC LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4502.50","3376.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3679.44","81.72","","431.26","71.26","1459.57","88","2353.01","3679.44","percent of total billed charges",""
"BONE PLATE SM FUSION ORTHOLOC 3DI MEDIAL COLUMN","SUP-ITM-10132295","CDM","C1713","HCPCS","0278","RC","","","","both","","","4347.00","3260.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3455.87","79.5","","800.18","480.96","1887.97","195","1347.57","3455.87","percent of total billed charges",""
"BONE PLATE SM FUSION ORTHOLOC 3DI MEDIAL COLUMN","SUP-ITM-10132295","CDM","C1713","HCPCS","0278","RC","","","","both","","","4347.00","3260.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2316.95","53.3","","813.12","216.42","1444.50","81","1347.57","3455.87","percent of total billed charges",""
"BONE PLATE SM FUSION ORTHOLOC 3DI MEDIAL COLUMN","SUP-ITM-10132295","CDM","C1713","HCPCS","0278","RC","","","","both","","","4347.00","3260.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1347.57","31","","432.60","432.60","432.60","1 through 10","1347.57","3455.87","percent of total billed charges",""
"BONE PLATE SM FUSION ORTHOLOC 3DI MEDIAL COLUMN","SUP-ITM-10132295","CDM","C1713","HCPCS","0278","RC","","","","both","","","4347.00","3260.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1586.66","36.5","","148.37","54.89","631.39","94","1347.57","3455.87","percent of total billed charges",""
"BONE PLATE SM FUSION ORTHOLOC 3DI MEDIAL COLUMN","SUP-ITM-10132295","CDM","C1713","HCPCS","0278","RC","","","","both","","","4347.00","3260.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1664.90","38.3","","279.30","91.72","1116.77","266","1347.57","3455.87","percent of total billed charges",""
"BONE PLATE SM FUSION ORTHOLOC 3DI MEDIAL COLUMN","SUP-ITM-10132295","CDM","C1713","HCPCS","0278","RC","","","","both","","","4347.00","3260.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1864.86","42.9","","731.00","63.70","731.00","1 through 10","1347.57","3455.87","percent of total billed charges",""
"BONE PLATE SM FUSION ORTHOLOC 3DI MEDIAL COLUMN","SUP-ITM-10132295","CDM","C1713","HCPCS","0278","RC","","","","both","","","4347.00","3260.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1864.86","42.9","","384.74","384.74","384.74","1 through 10","1347.57","3455.87","percent of total billed charges",""
"BONE PLATE SM FUSION ORTHOLOC 3DI MEDIAL COLUMN","SUP-ITM-10132295","CDM","C1713","HCPCS","0278","RC","","","","both","","","4347.00","3260.25","WELLPOINT [1015]","HB AMC WELLPOINT","3207.22","73.78","","286.63","119.22","1107.45","105","1347.57","3455.87","percent of total billed charges",""
"BONE PLATE SM FUSION ORTHOLOC 3DI MEDIAL COLUMN","SUP-ITM-10132295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4347.00","3260.25","AETNA [1001]","HB AMC AETNA HMO","3034.21","69.8","","675.31","184.75","1721.50","286","2271.74","3552.37","percent of total billed charges",""
"BONE PLATE SM FUSION ORTHOLOC 3DI MEDIAL COLUMN","SUP-ITM-10132295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4347.00","3260.25","AETNA [1001]","HB AMC AETNA PPO","3494.99","80.4","","1261.44","103.12","1514.10","21","2271.74","3552.37","percent of total billed charges",""
"BONE PLATE SM FUSION ORTHOLOC 3DI MEDIAL COLUMN","SUP-ITM-10132295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4347.00","3260.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3494.99","80.4","","1365.00","1365.00","1365.00","1 through 10","2271.74","3552.37","percent of total billed charges",""
"BONE PLATE SM FUSION ORTHOLOC 3DI MEDIAL COLUMN","SUP-ITM-10132295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4347.00","3260.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3552.37","81.72","","5157.68","5157.68","5157.68","1 through 10","2271.74","3552.37","percent of total billed charges",""
"BONE PLATE SM FUSION ORTHOLOC 3DI MEDIAL COLUMN","SUP-ITM-10132295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4347.00","3260.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3552.37","81.72","","431.26","71.26","1459.57","88","2271.74","3552.37","percent of total billed charges",""
"BONE PLATE SM LATERAL TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4956.00","3717.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3940.02","79.5","","800.18","480.96","1887.97","195","1536.36","3940.02","percent of total billed charges",""
"BONE PLATE SM LATERAL TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4956.00","3717.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2641.55","53.3","","813.12","216.42","1444.50","81","1536.36","3940.02","percent of total billed charges",""
"BONE PLATE SM LATERAL TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4956.00","3717.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1536.36","31","","432.60","432.60","432.60","1 through 10","1536.36","3940.02","percent of total billed charges",""
"BONE PLATE SM LATERAL TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4956.00","3717.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1808.94","36.5","","148.37","54.89","631.39","94","1536.36","3940.02","percent of total billed charges",""
"BONE PLATE SM LATERAL TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4956.00","3717.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1898.15","38.3","","279.30","91.72","1116.77","266","1536.36","3940.02","percent of total billed charges",""
"BONE PLATE SM LATERAL TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4956.00","3717.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2126.12","42.9","","731.00","63.70","731.00","1 through 10","1536.36","3940.02","percent of total billed charges",""
"BONE PLATE SM LATERAL TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4956.00","3717.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2126.12","42.9","","384.74","384.74","384.74","1 through 10","1536.36","3940.02","percent of total billed charges",""
"BONE PLATE SM LATERAL TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4956.00","3717.00","WELLPOINT [1015]","HB AMC WELLPOINT","3656.54","73.78","","286.63","119.22","1107.45","105","1536.36","3940.02","percent of total billed charges",""
"BONE PLATE SM LATERAL TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4956.00","3717.00","AETNA [1001]","HB AMC AETNA HMO","3459.29","69.8","","675.31","184.75","1721.50","286","2590.01","4050.04","percent of total billed charges",""
"BONE PLATE SM LATERAL TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4956.00","3717.00","AETNA [1001]","HB AMC AETNA PPO","3984.62","80.4","","1261.44","103.12","1514.10","21","2590.01","4050.04","percent of total billed charges",""
"BONE PLATE SM LATERAL TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4956.00","3717.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3984.62","80.4","","1365.00","1365.00","1365.00","1 through 10","2590.01","4050.04","percent of total billed charges",""
"BONE PLATE SM LATERAL TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4956.00","3717.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4050.04","81.72","","5157.68","5157.68","5157.68","1 through 10","2590.01","4050.04","percent of total billed charges",""
"BONE PLATE SM LATERAL TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4956.00","3717.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4050.04","81.72","","431.26","71.26","1459.57","88","2590.01","4050.04","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI ANTERIOLATERAL TIBIOTALAR FUSION STRAIGHT LEFT","SUP-ITM-10132173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3593.40","79.5","","800.18","480.96","1887.97","195","1401.2","3593.4","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI ANTERIOLATERAL TIBIOTALAR FUSION STRAIGHT LEFT","SUP-ITM-10132173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2409.16","53.3","","813.12","216.42","1444.50","81","1401.2","3593.4","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI ANTERIOLATERAL TIBIOTALAR FUSION STRAIGHT LEFT","SUP-ITM-10132173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1401.20","31","","432.60","432.60","432.60","1 through 10","1401.2","3593.4","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI ANTERIOLATERAL TIBIOTALAR FUSION STRAIGHT LEFT","SUP-ITM-10132173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1649.80","36.5","","148.37","54.89","631.39","94","1401.2","3593.4","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI ANTERIOLATERAL TIBIOTALAR FUSION STRAIGHT LEFT","SUP-ITM-10132173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1731.16","38.3","","279.30","91.72","1116.77","266","1401.2","3593.4","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI ANTERIOLATERAL TIBIOTALAR FUSION STRAIGHT LEFT","SUP-ITM-10132173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1939.08","42.9","","731.00","63.70","731.00","1 through 10","1401.2","3593.4","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI ANTERIOLATERAL TIBIOTALAR FUSION STRAIGHT LEFT","SUP-ITM-10132173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1939.08","42.9","","384.74","384.74","384.74","1 through 10","1401.2","3593.4","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI ANTERIOLATERAL TIBIOTALAR FUSION STRAIGHT LEFT","SUP-ITM-10132173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","WELLPOINT [1015]","HB AMC WELLPOINT","3334.86","73.78","","286.63","119.22","1107.45","105","1401.2","3593.4","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI ANTERIOLATERAL TIBIOTALAR FUSION STRAIGHT LEFT","SUP-ITM-10132173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","AETNA [1001]","HB AMC AETNA HMO","3154.96","69.8","","675.31","184.75","1721.50","286","2362.15","3693.74","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI ANTERIOLATERAL TIBIOTALAR FUSION STRAIGHT LEFT","SUP-ITM-10132173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","AETNA [1001]","HB AMC AETNA PPO","3634.08","80.4","","1261.44","103.12","1514.10","21","2362.15","3693.74","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI ANTERIOLATERAL TIBIOTALAR FUSION STRAIGHT LEFT","SUP-ITM-10132173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3634.08","80.4","","1365.00","1365.00","1365.00","1 through 10","2362.15","3693.74","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI ANTERIOLATERAL TIBIOTALAR FUSION STRAIGHT LEFT","SUP-ITM-10132173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3693.74","81.72","","5157.68","5157.68","5157.68","1 through 10","2362.15","3693.74","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI ANTERIOLATERAL TIBIOTALAR FUSION STRAIGHT LEFT","SUP-ITM-10132173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3693.74","81.72","","431.26","71.26","1459.57","88","2362.15","3693.74","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION NAVICULAR CUNEIFORM","SUP-ITM-10132298","CDM","C1713","HCPCS","0278","RC","","","","both","","","4128.00","3096.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3281.76","79.5","","800.18","480.96","1887.97","195","1279.68","3281.76","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION NAVICULAR CUNEIFORM","SUP-ITM-10132298","CDM","C1713","HCPCS","0278","RC","","","","both","","","4128.00","3096.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2200.22","53.3","","813.12","216.42","1444.50","81","1279.68","3281.76","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION NAVICULAR CUNEIFORM","SUP-ITM-10132298","CDM","C1713","HCPCS","0278","RC","","","","both","","","4128.00","3096.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1279.68","31","","432.60","432.60","432.60","1 through 10","1279.68","3281.76","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION NAVICULAR CUNEIFORM","SUP-ITM-10132298","CDM","C1713","HCPCS","0278","RC","","","","both","","","4128.00","3096.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1506.72","36.5","","148.37","54.89","631.39","94","1279.68","3281.76","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION NAVICULAR CUNEIFORM","SUP-ITM-10132298","CDM","C1713","HCPCS","0278","RC","","","","both","","","4128.00","3096.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1581.02","38.3","","279.30","91.72","1116.77","266","1279.68","3281.76","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION NAVICULAR CUNEIFORM","SUP-ITM-10132298","CDM","C1713","HCPCS","0278","RC","","","","both","","","4128.00","3096.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1770.91","42.9","","731.00","63.70","731.00","1 through 10","1279.68","3281.76","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION NAVICULAR CUNEIFORM","SUP-ITM-10132298","CDM","C1713","HCPCS","0278","RC","","","","both","","","4128.00","3096.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1770.91","42.9","","384.74","384.74","384.74","1 through 10","1279.68","3281.76","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION NAVICULAR CUNEIFORM","SUP-ITM-10132298","CDM","C1713","HCPCS","0278","RC","","","","both","","","4128.00","3096.00","WELLPOINT [1015]","HB AMC WELLPOINT","3045.64","73.78","","286.63","119.22","1107.45","105","1279.68","3281.76","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION NAVICULAR CUNEIFORM","SUP-ITM-10132298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4128.00","3096.00","AETNA [1001]","HB AMC AETNA HMO","2881.34","69.8","","675.31","184.75","1721.50","286","2157.29","3373.4","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION NAVICULAR CUNEIFORM","SUP-ITM-10132298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4128.00","3096.00","AETNA [1001]","HB AMC AETNA PPO","3318.91","80.4","","1261.44","103.12","1514.10","21","2157.29","3373.4","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION NAVICULAR CUNEIFORM","SUP-ITM-10132298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4128.00","3096.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3318.91","80.4","","1365.00","1365.00","1365.00","1 through 10","2157.29","3373.4","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION NAVICULAR CUNEIFORM","SUP-ITM-10132298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4128.00","3096.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3373.40","81.72","","5157.68","5157.68","5157.68","1 through 10","2157.29","3373.4","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION NAVICULAR CUNEIFORM","SUP-ITM-10132298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4128.00","3096.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3373.40","81.72","","431.26","71.26","1459.57","88","2157.29","3373.4","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL LEFT","SUP-ITM-10132165","CDM","C1713","HCPCS","0278","RC","","","","both","","","5317.50","3988.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4227.41","79.5","","800.18","480.96","1887.97","195","1648.43","4227.41","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL LEFT","SUP-ITM-10132165","CDM","C1713","HCPCS","0278","RC","","","","both","","","5317.50","3988.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2834.23","53.3","","813.12","216.42","1444.50","81","1648.43","4227.41","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL LEFT","SUP-ITM-10132165","CDM","C1713","HCPCS","0278","RC","","","","both","","","5317.50","3988.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1648.43","31","","432.60","432.60","432.60","1 through 10","1648.43","4227.41","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL LEFT","SUP-ITM-10132165","CDM","C1713","HCPCS","0278","RC","","","","both","","","5317.50","3988.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1940.89","36.5","","148.37","54.89","631.39","94","1648.43","4227.41","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL LEFT","SUP-ITM-10132165","CDM","C1713","HCPCS","0278","RC","","","","both","","","5317.50","3988.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2036.60","38.3","","279.30","91.72","1116.77","266","1648.43","4227.41","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL LEFT","SUP-ITM-10132165","CDM","C1713","HCPCS","0278","RC","","","","both","","","5317.50","3988.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2281.21","42.9","","731.00","63.70","731.00","1 through 10","1648.43","4227.41","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL LEFT","SUP-ITM-10132165","CDM","C1713","HCPCS","0278","RC","","","","both","","","5317.50","3988.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2281.21","42.9","","384.74","384.74","384.74","1 through 10","1648.43","4227.41","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL LEFT","SUP-ITM-10132165","CDM","C1713","HCPCS","0278","RC","","","","both","","","5317.50","3988.12","WELLPOINT [1015]","HB AMC WELLPOINT","3923.25","73.78","","286.63","119.22","1107.45","105","1648.43","4227.41","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL LEFT","SUP-ITM-10132165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5317.50","3988.12","AETNA [1001]","HB AMC AETNA HMO","3711.62","69.8","","675.31","184.75","1721.50","286","2778.93","4345.46","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL LEFT","SUP-ITM-10132165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5317.50","3988.12","AETNA [1001]","HB AMC AETNA PPO","4275.27","80.4","","1261.44","103.12","1514.10","21","2778.93","4345.46","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL LEFT","SUP-ITM-10132165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5317.50","3988.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4275.27","80.4","","1365.00","1365.00","1365.00","1 through 10","2778.93","4345.46","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL LEFT","SUP-ITM-10132165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5317.50","3988.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4345.46","81.72","","5157.68","5157.68","5157.68","1 through 10","2778.93","4345.46","percent of total billed charges",""
"BONE PLATE SM ORTHOLOC 3DI FUSION TT ANTEROLATERAL LEFT","SUP-ITM-10132165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5317.50","3988.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4345.46","81.72","","431.26","71.26","1459.57","88","2778.93","4345.46","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3806.06","79.5","","800.18","480.96","1887.97","195","1484.13","3806.06","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2551.74","53.3","","813.12","216.42","1444.50","81","1484.13","3806.06","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1484.13","31","","432.60","432.60","432.60","1 through 10","1484.13","3806.06","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1747.44","36.5","","148.37","54.89","631.39","94","1484.13","3806.06","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1833.61","38.3","","279.30","91.72","1116.77","266","1484.13","3806.06","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2053.84","42.9","","731.00","63.70","731.00","1 through 10","1484.13","3806.06","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2053.84","42.9","","384.74","384.74","384.74","1 through 10","1484.13","3806.06","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","WELLPOINT [1015]","HB AMC WELLPOINT","3532.22","73.78","","286.63","119.22","1107.45","105","1484.13","3806.06","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4787.50","3590.62","AETNA [1001]","HB AMC AETNA HMO","3341.68","69.8","","675.31","184.75","1721.50","286","2501.95","3912.35","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4787.50","3590.62","AETNA [1001]","HB AMC AETNA PPO","3849.15","80.4","","1261.44","103.12","1514.10","21","2501.95","3912.35","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4787.50","3590.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3849.15","80.4","","1365.00","1365.00","1365.00","1 through 10","2501.95","3912.35","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4787.50","3590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3912.35","81.72","","5157.68","5157.68","5157.68","1 through 10","2501.95","3912.35","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TT FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4787.50","3590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3912.35","81.72","","431.26","71.26","1459.57","88","2501.95","3912.35","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131918","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4130.03","79.5","","800.18","480.96","1887.97","195","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131918","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2768.94","53.3","","813.12","216.42","1444.50","81","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131918","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1610.45","31","","432.60","432.60","432.60","1 through 10","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131918","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1896.18","36.5","","148.37","54.89","631.39","94","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131918","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1989.69","38.3","","279.30","91.72","1116.77","266","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131918","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2228.66","42.9","","731.00","63.70","731.00","1 through 10","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131918","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2228.66","42.9","","384.74","384.74","384.74","1 through 10","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131918","CDM","C1713","HCPCS","0278","RC","","","","both","","","5195.00","3896.25","WELLPOINT [1015]","HB AMC WELLPOINT","3832.87","73.78","","286.63","119.22","1107.45","105","1610.45","4130.03","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5195.00","3896.25","AETNA [1001]","HB AMC AETNA HMO","3626.11","69.8","","675.31","184.75","1721.50","286","2714.91","4245.35","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5195.00","3896.25","AETNA [1001]","HB AMC AETNA PPO","4176.78","80.4","","1261.44","103.12","1514.10","21","2714.91","4245.35","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5195.00","3896.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4176.78","80.4","","1365.00","1365.00","1365.00","1 through 10","2714.91","4245.35","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5195.00","3896.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4245.35","81.72","","5157.68","5157.68","5157.68","1 through 10","2714.91","4245.35","percent of total billed charges",""
"BONE PLATE SM POSTERIOR TTC FUSION ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10131918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5195.00","3896.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4245.35","81.72","","431.26","71.26","1459.57","88","2714.91","4245.35","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4072.50","3054.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3237.64","79.5","","800.18","480.96","1887.97","195","1262.48","3237.64","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4072.50","3054.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2170.64","53.3","","813.12","216.42","1444.50","81","1262.48","3237.64","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4072.50","3054.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1262.48","31","","432.60","432.60","432.60","1 through 10","1262.48","3237.64","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4072.50","3054.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1486.46","36.5","","148.37","54.89","631.39","94","1262.48","3237.64","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4072.50","3054.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1559.77","38.3","","279.30","91.72","1116.77","266","1262.48","3237.64","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4072.50","3054.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1747.10","42.9","","731.00","63.70","731.00","1 through 10","1262.48","3237.64","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4072.50","3054.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1747.10","42.9","","384.74","384.74","384.74","1 through 10","1262.48","3237.64","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4072.50","3054.37","WELLPOINT [1015]","HB AMC WELLPOINT","3004.69","73.78","","286.63","119.22","1107.45","105","1262.48","3237.64","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4072.50","3054.37","AETNA [1001]","HB AMC AETNA HMO","2842.61","69.8","","675.31","184.75","1721.50","286","2128.29","3328.05","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4072.50","3054.37","AETNA [1001]","HB AMC AETNA PPO","3274.29","80.4","","1261.44","103.12","1514.10","21","2128.29","3328.05","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4072.50","3054.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3274.29","80.4","","1365.00","1365.00","1365.00","1 through 10","2128.29","3328.05","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4072.50","3054.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3328.05","81.72","","5157.68","5157.68","5157.68","1 through 10","2128.29","3328.05","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4072.50","3054.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3328.05","81.72","","431.26","71.26","1459.57","88","2128.29","3328.05","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","5041.50","3781.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4007.99","79.5","","800.18","480.96","1887.97","195","1562.87","4007.99","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","5041.50","3781.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2687.12","53.3","","813.12","216.42","1444.50","81","1562.87","4007.99","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","5041.50","3781.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1562.87","31","","432.60","432.60","432.60","1 through 10","1562.87","4007.99","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","5041.50","3781.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1840.15","36.5","","148.37","54.89","631.39","94","1562.87","4007.99","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","5041.50","3781.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1930.89","38.3","","279.30","91.72","1116.77","266","1562.87","4007.99","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","5041.50","3781.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2162.80","42.9","","731.00","63.70","731.00","1 through 10","1562.87","4007.99","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","5041.50","3781.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2162.80","42.9","","384.74","384.74","384.74","1 through 10","1562.87","4007.99","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","5041.50","3781.12","WELLPOINT [1015]","HB AMC WELLPOINT","3719.62","73.78","","286.63","119.22","1107.45","105","1562.87","4007.99","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5041.50","3781.12","AETNA [1001]","HB AMC AETNA HMO","3518.97","69.8","","675.31","184.75","1721.50","286","2634.69","4119.91","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5041.50","3781.12","AETNA [1001]","HB AMC AETNA PPO","4053.37","80.4","","1261.44","103.12","1514.10","21","2634.69","4119.91","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5041.50","3781.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4053.37","80.4","","1365.00","1365.00","1365.00","1 through 10","2634.69","4119.91","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5041.50","3781.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4119.91","81.72","","5157.68","5157.68","5157.68","1 through 10","2634.69","4119.91","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5041.50","3781.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4119.91","81.72","","431.26","71.26","1459.57","88","2634.69","4119.91","percent of total billed charges",""
"BONE PLATE UNIVERSAL 6 HOLE ORTHOLOC 3DI STRAIGHT","SUP-ITM-10132379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2121.00","1590.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1686.20","79.5","","800.18","480.96","1887.97","195","657.51","1686.2","percent of total billed charges",""
"BONE PLATE UNIVERSAL 6 HOLE ORTHOLOC 3DI STRAIGHT","SUP-ITM-10132379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2121.00","1590.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1130.49","53.3","","813.12","216.42","1444.50","81","657.51","1686.2","percent of total billed charges",""
"BONE PLATE UNIVERSAL 6 HOLE ORTHOLOC 3DI STRAIGHT","SUP-ITM-10132379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2121.00","1590.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","657.51","31","","432.60","432.60","432.60","1 through 10","657.51","1686.2","percent of total billed charges",""
"BONE PLATE UNIVERSAL 6 HOLE ORTHOLOC 3DI STRAIGHT","SUP-ITM-10132379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2121.00","1590.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","774.17","36.5","","148.37","54.89","631.39","94","657.51","1686.2","percent of total billed charges",""
"BONE PLATE UNIVERSAL 6 HOLE ORTHOLOC 3DI STRAIGHT","SUP-ITM-10132379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2121.00","1590.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","812.34","38.3","","279.30","91.72","1116.77","266","657.51","1686.2","percent of total billed charges",""
"BONE PLATE UNIVERSAL 6 HOLE ORTHOLOC 3DI STRAIGHT","SUP-ITM-10132379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2121.00","1590.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","909.91","42.9","","731.00","63.70","731.00","1 through 10","657.51","1686.2","percent of total billed charges",""
"BONE PLATE UNIVERSAL 6 HOLE ORTHOLOC 3DI STRAIGHT","SUP-ITM-10132379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2121.00","1590.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","909.91","42.9","","384.74","384.74","384.74","1 through 10","657.51","1686.2","percent of total billed charges",""
"BONE PLATE UNIVERSAL 6 HOLE ORTHOLOC 3DI STRAIGHT","SUP-ITM-10132379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2121.00","1590.75","WELLPOINT [1015]","HB AMC WELLPOINT","1564.87","73.78","","286.63","119.22","1107.45","105","657.51","1686.2","percent of total billed charges",""
"BONE PLATE UNIVERSAL 6 HOLE ORTHOLOC 3DI STRAIGHT","SUP-ITM-10132379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2121.00","1590.75","AETNA [1001]","HB AMC AETNA HMO","1480.46","69.8","","675.31","184.75","1721.50","286","1108.43","1733.28","percent of total billed charges",""
"BONE PLATE UNIVERSAL 6 HOLE ORTHOLOC 3DI STRAIGHT","SUP-ITM-10132379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2121.00","1590.75","AETNA [1001]","HB AMC AETNA PPO","1705.28","80.4","","1261.44","103.12","1514.10","21","1108.43","1733.28","percent of total billed charges",""
"BONE PLATE UNIVERSAL 6 HOLE ORTHOLOC 3DI STRAIGHT","SUP-ITM-10132379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2121.00","1590.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1705.28","80.4","","1365.00","1365.00","1365.00","1 through 10","1108.43","1733.28","percent of total billed charges",""
"BONE PLATE UNIVERSAL 6 HOLE ORTHOLOC 3DI STRAIGHT","SUP-ITM-10132379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2121.00","1590.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1733.28","81.72","","5157.68","5157.68","5157.68","1 through 10","1108.43","1733.28","percent of total billed charges",""
"BONE PLATE UNIVERSAL 6 HOLE ORTHOLOC 3DI STRAIGHT","SUP-ITM-10132379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2121.00","1590.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1733.28","81.72","","431.26","71.26","1459.57","88","1108.43","1733.28","percent of total billed charges",""
"BONE PLATE UNIVERSAL ALPHA MAXLOCK EXTREME SLOTLESS TITANIUM IMPLANT","SUP-ITM-10082143","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.00","2446.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2593.29","79.5","","800.18","480.96","1887.97","195","1011.22","2593.29","percent of total billed charges",""
"BONE PLATE UNIVERSAL ALPHA MAXLOCK EXTREME SLOTLESS TITANIUM IMPLANT","SUP-ITM-10082143","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.00","2446.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1738.65","53.3","","813.12","216.42","1444.50","81","1011.22","2593.29","percent of total billed charges",""
"BONE PLATE UNIVERSAL ALPHA MAXLOCK EXTREME SLOTLESS TITANIUM IMPLANT","SUP-ITM-10082143","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.00","2446.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1011.22","31","","432.60","432.60","432.60","1 through 10","1011.22","2593.29","percent of total billed charges",""
"BONE PLATE UNIVERSAL ALPHA MAXLOCK EXTREME SLOTLESS TITANIUM IMPLANT","SUP-ITM-10082143","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.00","2446.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1190.63","36.5","","148.37","54.89","631.39","94","1011.22","2593.29","percent of total billed charges",""
"BONE PLATE UNIVERSAL ALPHA MAXLOCK EXTREME SLOTLESS TITANIUM IMPLANT","SUP-ITM-10082143","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.00","2446.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1249.35","38.3","","279.30","91.72","1116.77","266","1011.22","2593.29","percent of total billed charges",""
"BONE PLATE UNIVERSAL ALPHA MAXLOCK EXTREME SLOTLESS TITANIUM IMPLANT","SUP-ITM-10082143","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.00","2446.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1399.40","42.9","","731.00","63.70","731.00","1 through 10","1011.22","2593.29","percent of total billed charges",""
"BONE PLATE UNIVERSAL ALPHA MAXLOCK EXTREME SLOTLESS TITANIUM IMPLANT","SUP-ITM-10082143","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.00","2446.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1399.40","42.9","","384.74","384.74","384.74","1 through 10","1011.22","2593.29","percent of total billed charges",""
"BONE PLATE UNIVERSAL ALPHA MAXLOCK EXTREME SLOTLESS TITANIUM IMPLANT","SUP-ITM-10082143","CDM","C1713","HCPCS","0278","RC","","","","both","","","3262.00","2446.50","WELLPOINT [1015]","HB AMC WELLPOINT","2406.70","73.78","","286.63","119.22","1107.45","105","1011.22","2593.29","percent of total billed charges",""
"BONE PLATE UNIVERSAL ALPHA MAXLOCK EXTREME SLOTLESS TITANIUM IMPLANT","SUP-ITM-10082143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3262.00","2446.50","AETNA [1001]","HB AMC AETNA HMO","2276.88","69.8","","675.31","184.75","1721.50","286","1704.72","2665.71","percent of total billed charges",""
"BONE PLATE UNIVERSAL ALPHA MAXLOCK EXTREME SLOTLESS TITANIUM IMPLANT","SUP-ITM-10082143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3262.00","2446.50","AETNA [1001]","HB AMC AETNA PPO","2622.65","80.4","","1261.44","103.12","1514.10","21","1704.72","2665.71","percent of total billed charges",""
"BONE PLATE UNIVERSAL ALPHA MAXLOCK EXTREME SLOTLESS TITANIUM IMPLANT","SUP-ITM-10082143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3262.00","2446.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2622.65","80.4","","1365.00","1365.00","1365.00","1 through 10","1704.72","2665.71","percent of total billed charges",""
"BONE PLATE UNIVERSAL ALPHA MAXLOCK EXTREME SLOTLESS TITANIUM IMPLANT","SUP-ITM-10082143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3262.00","2446.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2665.71","81.72","","5157.68","5157.68","5157.68","1 through 10","1704.72","2665.71","percent of total billed charges",""
"BONE PLATE UNIVERSAL ALPHA MAXLOCK EXTREME SLOTLESS TITANIUM IMPLANT","SUP-ITM-10082143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3262.00","2446.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2665.71","81.72","","431.26","71.26","1459.57","88","1704.72","2665.71","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629503S","SUP-ITM-10144743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1843.59","1382.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1465.65","79.5","","800.18","480.96","1887.97","195","571.51","1465.65","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629503S","SUP-ITM-10144743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1843.59","1382.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","982.63","53.3","","813.12","216.42","1444.50","81","571.51","1465.65","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629503S","SUP-ITM-10144743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1843.59","1382.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","571.51","31","","432.60","432.60","432.60","1 through 10","571.51","1465.65","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629503S","SUP-ITM-10144743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1843.59","1382.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","672.91","36.5","","148.37","54.89","631.39","94","571.51","1465.65","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629503S","SUP-ITM-10144743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1843.59","1382.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","706.09","38.3","","279.30","91.72","1116.77","266","571.51","1465.65","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629503S","SUP-ITM-10144743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1843.59","1382.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","790.90","42.9","","731.00","63.70","731.00","1 through 10","571.51","1465.65","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629503S","SUP-ITM-10144743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1843.59","1382.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","790.90","42.9","","384.74","384.74","384.74","1 through 10","571.51","1465.65","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629503S","SUP-ITM-10144743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1843.59","1382.69","WELLPOINT [1015]","HB AMC WELLPOINT","1360.20","73.78","","286.63","119.22","1107.45","105","571.51","1465.65","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629503S","SUP-ITM-10144743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1843.59","1382.69","AETNA [1001]","HB AMC AETNA HMO","1286.83","69.8","","675.31","184.75","1721.50","286","963.46","1506.58","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629503S","SUP-ITM-10144743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1843.59","1382.69","AETNA [1001]","HB AMC AETNA PPO","1482.25","80.4","","1261.44","103.12","1514.10","21","963.46","1506.58","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629503S","SUP-ITM-10144743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1843.59","1382.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1482.25","80.4","","1365.00","1365.00","1365.00","1 through 10","963.46","1506.58","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629503S","SUP-ITM-10144743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1843.59","1382.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1506.58","81.72","","5157.68","5157.68","5157.68","1 through 10","963.46","1506.58","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629503S","SUP-ITM-10144743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1843.59","1382.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1506.58","81.72","","431.26","71.26","1459.57","88","963.46","1506.58","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1942.27","79.5","","800.18","480.96","1887.97","195","757.36","1942.27","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1302.18","53.3","","813.12","216.42","1444.50","81","757.36","1942.27","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","757.36","31","","432.60","432.60","432.60","1 through 10","757.36","1942.27","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","891.74","36.5","","148.37","54.89","631.39","94","757.36","1942.27","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","935.71","38.3","","279.30","91.72","1116.77","266","757.36","1942.27","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1048.09","42.9","","731.00","63.70","731.00","1 through 10","757.36","1942.27","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1048.09","42.9","","384.74","384.74","384.74","1 through 10","757.36","1942.27","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.11","1832.33","WELLPOINT [1015]","HB AMC WELLPOINT","1802.53","73.78","","286.63","119.22","1107.45","105","757.36","1942.27","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.11","1832.33","AETNA [1001]","HB AMC AETNA HMO","1705.29","69.8","","675.31","184.75","1721.50","286","1276.77","1996.51","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.11","1832.33","AETNA [1001]","HB AMC AETNA PPO","1964.26","80.4","","1261.44","103.12","1514.10","21","1276.77","1996.51","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.11","1832.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1964.26","80.4","","1365.00","1365.00","1365.00","1 through 10","1276.77","1996.51","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.11","1832.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1996.51","81.72","","5157.68","5157.68","5157.68","1 through 10","1276.77","1996.51","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.11","1832.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1996.51","81.72","","431.26","71.26","1459.57","88","1276.77","1996.51","percent of total billed charges",""
"BONE POST 4.6X14MM ANKLE IO FIX 60 DEG - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.00","2908.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3083.01","79.5","","800.18","480.96","1887.97","195","1202.18","3083.01","percent of total billed charges",""
"BONE POST 4.6X14MM ANKLE IO FIX 60 DEG - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.00","2908.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2066.97","53.3","","813.12","216.42","1444.50","81","1202.18","3083.01","percent of total billed charges",""
"BONE POST 4.6X14MM ANKLE IO FIX 60 DEG - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.00","2908.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1202.18","31","","432.60","432.60","432.60","1 through 10","1202.18","3083.01","percent of total billed charges",""
"BONE POST 4.6X14MM ANKLE IO FIX 60 DEG - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.00","2908.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1415.47","36.5","","148.37","54.89","631.39","94","1202.18","3083.01","percent of total billed charges",""
"BONE POST 4.6X14MM ANKLE IO FIX 60 DEG - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.00","2908.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1485.27","38.3","","279.30","91.72","1116.77","266","1202.18","3083.01","percent of total billed charges",""
"BONE POST 4.6X14MM ANKLE IO FIX 60 DEG - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.00","2908.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1663.66","42.9","","731.00","63.70","731.00","1 through 10","1202.18","3083.01","percent of total billed charges",""
"BONE POST 4.6X14MM ANKLE IO FIX 60 DEG - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.00","2908.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1663.66","42.9","","384.74","384.74","384.74","1 through 10","1202.18","3083.01","percent of total billed charges",""
"BONE POST 4.6X14MM ANKLE IO FIX 60 DEG - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.00","2908.50","WELLPOINT [1015]","HB AMC WELLPOINT","2861.19","73.78","","286.63","119.22","1107.45","105","1202.18","3083.01","percent of total billed charges",""
"BONE POST 4.6X14MM ANKLE IO FIX 60 DEG - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3878.00","2908.50","AETNA [1001]","HB AMC AETNA HMO","2706.84","69.8","","675.31","184.75","1721.50","286","2026.64","3169.1","percent of total billed charges",""
"BONE POST 4.6X14MM ANKLE IO FIX 60 DEG - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3878.00","2908.50","AETNA [1001]","HB AMC AETNA PPO","3117.91","80.4","","1261.44","103.12","1514.10","21","2026.64","3169.1","percent of total billed charges",""
"BONE POST 4.6X14MM ANKLE IO FIX 60 DEG - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3878.00","2908.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3117.91","80.4","","1365.00","1365.00","1365.00","1 through 10","2026.64","3169.1","percent of total billed charges",""
"BONE POST 4.6X14MM ANKLE IO FIX 60 DEG - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3878.00","2908.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3169.10","81.72","","5157.68","5157.68","5157.68","1 through 10","2026.64","3169.1","percent of total billed charges",""
"BONE POST 4.6X14MM ANKLE IO FIX 60 DEG - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3878.00","2908.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3169.10","81.72","","431.26","71.26","1459.57","88","2026.64","3169.1","percent of total billed charges",""
"BONE RING .25 165MM FIXATOR HYBRID CARBON EXTERNAL","SUP-ITM-10004048","CDM","C1889","HCPCS","0278","RC","","","","both","","","1023.05","767.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","813.32","79.5","","1309.77","674.56","6049.93","26","317.15","813.32","percent of total billed charges",""
"BONE RING .25 165MM FIXATOR HYBRID CARBON EXTERNAL","SUP-ITM-10004048","CDM","C1889","HCPCS","0278","RC","","","","both","","","1023.05","767.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","545.29","53.3","","1901.83","1901.83","2962.25","1 through 10","317.15","813.32","percent of total billed charges",""
"BONE RING .25 165MM FIXATOR HYBRID CARBON EXTERNAL","SUP-ITM-10004048","CDM","C1889","HCPCS","0278","RC","","","","both","","","1023.05","767.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","373.41","36.5","","1620.31","1620.31","19908.88","1 through 10","317.15","813.32","percent of total billed charges",""
"BONE RING .25 165MM FIXATOR HYBRID CARBON EXTERNAL","SUP-ITM-10004048","CDM","C1889","HCPCS","0278","RC","","","","both","","","1023.05","767.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","391.83","38.3","","352.91","352.91","2046.30","1 through 10","317.15","813.32","percent of total billed charges",""
"BONE RING .25 165MM FIXATOR HYBRID CARBON EXTERNAL","SUP-ITM-10004048","CDM","C1889","HCPCS","0278","RC","","","","both","","","1023.05","767.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","438.89","42.9","","9668.75","9668.75","9668.75","1 through 10","317.15","813.32","percent of total billed charges",""
"BONE RING .25 165MM FIXATOR HYBRID CARBON EXTERNAL","SUP-ITM-10004048","CDM","C1889","HCPCS","0278","RC","","","","both","","","1023.05","767.29","WELLPOINT [1015]","HB AMC WELLPOINT","754.81","73.78","","699.88","384.10","3443.31","33","317.15","813.32","percent of total billed charges",""
"BONE RING .25 165MM FIXATOR HYBRID CARBON EXTERNAL","SUP-ITM-10004048","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1023.05","767.29","AETNA [1001]","HB AMC AETNA HMO","714.09","69.8","","1421.24","264.50","4933.46","29","534.65","836.04","percent of total billed charges",""
"BONE RING .25 165MM FIXATOR HYBRID CARBON EXTERNAL","SUP-ITM-10004048","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1023.05","767.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","822.53","80.4","","1022.97","1022.97","3607.50","1 through 10","534.65","836.04","percent of total billed charges",""
"BONE RING .25 165MM FIXATOR HYBRID CARBON EXTERNAL","SUP-ITM-10004048","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1023.05","767.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","836.04","81.72","","3010.54","693.88","5019.88","35","534.65","836.04","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","both","","","1209.53","907.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","961.58","79.5","","1309.77","674.56","6049.93","26","374.95","961.58","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","both","","","1209.53","907.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","644.68","53.3","","1901.83","1901.83","2962.25","1 through 10","374.95","961.58","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","both","","","1209.53","907.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","441.48","36.5","","1620.31","1620.31","19908.88","1 through 10","374.95","961.58","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","both","","","1209.53","907.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","463.25","38.3","","352.91","352.91","2046.30","1 through 10","374.95","961.58","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","both","","","1209.53","907.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","518.89","42.9","","9668.75","9668.75","9668.75","1 through 10","374.95","961.58","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","both","","","1209.53","907.15","WELLPOINT [1015]","HB AMC WELLPOINT","892.39","73.78","","699.88","384.10","3443.31","33","374.95","961.58","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1209.53","907.15","AETNA [1001]","HB AMC AETNA HMO","844.25","69.8","","1421.24","264.50","4933.46","29","632.1","988.43","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1209.53","907.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","972.46","80.4","","1022.97","1022.97","3607.50","1 through 10","632.1","988.43","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1209.53","907.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","988.43","81.72","","3010.54","693.88","5019.88","35","632.1","988.43","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","1270.40","952.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1009.97","79.5","","1309.77","674.56","6049.93","26","393.82","1009.97","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","1270.40","952.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","677.12","53.3","","1901.83","1901.83","2962.25","1 through 10","393.82","1009.97","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","1270.40","952.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","463.70","36.5","","1620.31","1620.31","19908.88","1 through 10","393.82","1009.97","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","1270.40","952.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","486.56","38.3","","352.91","352.91","2046.30","1 through 10","393.82","1009.97","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","1270.40","952.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","545.00","42.9","","9668.75","9668.75","9668.75","1 through 10","393.82","1009.97","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","1270.40","952.80","WELLPOINT [1015]","HB AMC WELLPOINT","937.30","73.78","","699.88","384.10","3443.31","33","393.82","1009.97","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1270.40","952.80","AETNA [1001]","HB AMC AETNA HMO","886.74","69.8","","1421.24","264.50","4933.46","29","663.91","1038.17","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1270.40","952.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1021.40","80.4","","1022.97","1022.97","3607.50","1 through 10","663.91","1038.17","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1270.40","952.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1038.17","81.72","","3010.54","693.88","5019.88","35","663.91","1038.17","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1196.31","79.5","","1309.77","674.56","6049.93","26","466.48","1196.31","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","802.05","53.3","","1901.83","1901.83","2962.25","1 through 10","466.48","1196.31","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","549.25","36.5","","1620.31","1620.31","19908.88","1 through 10","466.48","1196.31","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","576.33","38.3","","352.91","352.91","2046.30","1 through 10","466.48","1196.31","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","645.55","42.9","","9668.75","9668.75","9668.75","1 through 10","466.48","1196.31","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","WELLPOINT [1015]","HB AMC WELLPOINT","1110.23","73.78","","699.88","384.10","3443.31","33","466.48","1196.31","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1504.79","1128.59","AETNA [1001]","HB AMC AETNA HMO","1050.34","69.8","","1421.24","264.50","4933.46","29","786.4","1229.71","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1504.79","1128.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1209.85","80.4","","1022.97","1022.97","3607.50","1 through 10","786.4","1229.71","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1504.79","1128.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1229.71","81.72","","3010.54","693.88","5019.88","35","786.4","1229.71","percent of total billed charges",""
"BONE RING 115MM .75 EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004047","CDM","C1889","HCPCS","0278","RC","","","","both","","","1107.23","830.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","880.25","79.5","","1309.77","674.56","6049.93","26","343.24","880.25","percent of total billed charges",""
"BONE RING 115MM .75 EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004047","CDM","C1889","HCPCS","0278","RC","","","","both","","","1107.23","830.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","590.15","53.3","","1901.83","1901.83","2962.25","1 through 10","343.24","880.25","percent of total billed charges",""
"BONE RING 115MM .75 EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004047","CDM","C1889","HCPCS","0278","RC","","","","both","","","1107.23","830.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","404.14","36.5","","1620.31","1620.31","19908.88","1 through 10","343.24","880.25","percent of total billed charges",""
"BONE RING 115MM .75 EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004047","CDM","C1889","HCPCS","0278","RC","","","","both","","","1107.23","830.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","424.07","38.3","","352.91","352.91","2046.30","1 through 10","343.24","880.25","percent of total billed charges",""
"BONE RING 115MM .75 EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004047","CDM","C1889","HCPCS","0278","RC","","","","both","","","1107.23","830.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","475.00","42.9","","9668.75","9668.75","9668.75","1 through 10","343.24","880.25","percent of total billed charges",""
"BONE RING 115MM .75 EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004047","CDM","C1889","HCPCS","0278","RC","","","","both","","","1107.23","830.42","WELLPOINT [1015]","HB AMC WELLPOINT","816.91","73.78","","699.88","384.10","3443.31","33","343.24","880.25","percent of total billed charges",""
"BONE RING 115MM .75 EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004047","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1107.23","830.42","AETNA [1001]","HB AMC AETNA HMO","772.85","69.8","","1421.24","264.50","4933.46","29","578.64","904.83","percent of total billed charges",""
"BONE RING 115MM .75 EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004047","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1107.23","830.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","890.21","80.4","","1022.97","1022.97","3607.50","1 through 10","578.64","904.83","percent of total billed charges",""
"BONE RING 115MM .75 EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004047","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1107.23","830.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","904.83","81.72","","3010.54","693.88","5019.88","35","578.64","904.83","percent of total billed charges",""
"BONE ROD 4.5X70MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148220","CDM","C1889","HCPCS","0278","RC","","","","both","","","553.00","414.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","439.64","79.5","","1309.77","674.56","6049.93","26","171.43","439.64","percent of total billed charges",""
"BONE ROD 4.5X70MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148220","CDM","C1889","HCPCS","0278","RC","","","","both","","","553.00","414.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","294.75","53.3","","1901.83","1901.83","2962.25","1 through 10","171.43","439.64","percent of total billed charges",""
"BONE ROD 4.5X70MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148220","CDM","C1889","HCPCS","0278","RC","","","","both","","","553.00","414.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","201.85","36.5","","1620.31","1620.31","19908.88","1 through 10","171.43","439.64","percent of total billed charges",""
"BONE ROD 4.5X70MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148220","CDM","C1889","HCPCS","0278","RC","","","","both","","","553.00","414.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","211.80","38.3","","352.91","352.91","2046.30","1 through 10","171.43","439.64","percent of total billed charges",""
"BONE ROD 4.5X70MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148220","CDM","C1889","HCPCS","0278","RC","","","","both","","","553.00","414.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","237.24","42.9","","9668.75","9668.75","9668.75","1 through 10","171.43","439.64","percent of total billed charges",""
"BONE ROD 4.5X70MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148220","CDM","C1889","HCPCS","0278","RC","","","","both","","","553.00","414.75","WELLPOINT [1015]","HB AMC WELLPOINT","408.00","73.78","","699.88","384.10","3443.31","33","171.43","439.64","percent of total billed charges",""
"BONE ROD 4.5X70MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148220","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","553.00","414.75","AETNA [1001]","HB AMC AETNA HMO","385.99","69.8","","1421.24","264.50","4933.46","29","289","451.91","percent of total billed charges",""
"BONE ROD 4.5X70MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148220","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","553.00","414.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","444.61","80.4","","1022.97","1022.97","3607.50","1 through 10","289","451.91","percent of total billed charges",""
"BONE ROD 4.5X70MM XIA VITALLIUM PREBENT PRECUT HEXAGIONAL END","SUP-ITM-10148220","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","553.00","414.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","451.91","81.72","","3010.54","693.88","5019.88","35","289","451.91","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.00","3327.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3527.42","79.5","","800.18","480.96","1887.97","195","1375.47","3527.42","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.00","3327.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2364.92","53.3","","813.12","216.42","1444.50","81","1375.47","3527.42","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.00","3327.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1375.47","31","","432.60","432.60","432.60","1 through 10","1375.47","3527.42","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.00","3327.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1619.51","36.5","","148.37","54.89","631.39","94","1375.47","3527.42","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.00","3327.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1699.37","38.3","","279.30","91.72","1116.77","266","1375.47","3527.42","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.00","3327.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1903.47","42.9","","731.00","63.70","731.00","1 through 10","1375.47","3527.42","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.00","3327.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1903.47","42.9","","384.74","384.74","384.74","1 through 10","1375.47","3527.42","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.00","3327.75","WELLPOINT [1015]","HB AMC WELLPOINT","3273.62","73.78","","286.63","119.22","1107.45","105","1375.47","3527.42","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4437.00","3327.75","AETNA [1001]","HB AMC AETNA HMO","3097.03","69.8","","675.31","184.75","1721.50","286","2318.78","3625.92","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4437.00","3327.75","AETNA [1001]","HB AMC AETNA PPO","3567.35","80.4","","1261.44","103.12","1514.10","21","2318.78","3625.92","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4437.00","3327.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3567.35","80.4","","1365.00","1365.00","1365.00","1 through 10","2318.78","3625.92","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4437.00","3327.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3625.92","81.72","","5157.68","5157.68","5157.68","1 through 10","2318.78","3625.92","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4437.00","3327.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3625.92","81.72","","431.26","71.26","1459.57","88","2318.78","3625.92","percent of total billed charges",""
"BONE ROD HOOK 5.5X95MM SPINE PEDICLE SIDE TIGHT EXPEDIUM TITANIUM RIGHT","SUP-ITM-10045778","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","800.18","480.96","1887.97","195","162.75","417.38","percent of total billed charges",""
"BONE ROD HOOK 5.5X95MM SPINE PEDICLE SIDE TIGHT EXPEDIUM TITANIUM RIGHT","SUP-ITM-10045778","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","813.12","216.42","1444.50","81","162.75","417.38","percent of total billed charges",""
"BONE ROD HOOK 5.5X95MM SPINE PEDICLE SIDE TIGHT EXPEDIUM TITANIUM RIGHT","SUP-ITM-10045778","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.75","31","","432.60","432.60","432.60","1 through 10","162.75","417.38","percent of total billed charges",""
"BONE ROD HOOK 5.5X95MM SPINE PEDICLE SIDE TIGHT EXPEDIUM TITANIUM RIGHT","SUP-ITM-10045778","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","148.37","54.89","631.39","94","162.75","417.38","percent of total billed charges",""
"BONE ROD HOOK 5.5X95MM SPINE PEDICLE SIDE TIGHT EXPEDIUM TITANIUM RIGHT","SUP-ITM-10045778","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","279.30","91.72","1116.77","266","162.75","417.38","percent of total billed charges",""
"BONE ROD HOOK 5.5X95MM SPINE PEDICLE SIDE TIGHT EXPEDIUM TITANIUM RIGHT","SUP-ITM-10045778","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","731.00","63.70","731.00","1 through 10","162.75","417.38","percent of total billed charges",""
"BONE ROD HOOK 5.5X95MM SPINE PEDICLE SIDE TIGHT EXPEDIUM TITANIUM RIGHT","SUP-ITM-10045778","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","384.74","384.74","384.74","1 through 10","162.75","417.38","percent of total billed charges",""
"BONE ROD HOOK 5.5X95MM SPINE PEDICLE SIDE TIGHT EXPEDIUM TITANIUM RIGHT","SUP-ITM-10045778","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","286.63","119.22","1107.45","105","162.75","417.38","percent of total billed charges",""
"BONE ROD HOOK 5.5X95MM SPINE PEDICLE SIDE TIGHT EXPEDIUM TITANIUM RIGHT","SUP-ITM-10045778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","675.31","184.75","1721.50","286","274.37","429.03","percent of total billed charges",""
"BONE ROD HOOK 5.5X95MM SPINE PEDICLE SIDE TIGHT EXPEDIUM TITANIUM RIGHT","SUP-ITM-10045778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA PPO","422.10","80.4","","1261.44","103.12","1514.10","21","274.37","429.03","percent of total billed charges",""
"BONE ROD HOOK 5.5X95MM SPINE PEDICLE SIDE TIGHT EXPEDIUM TITANIUM RIGHT","SUP-ITM-10045778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1365.00","1365.00","1365.00","1 through 10","274.37","429.03","percent of total billed charges",""
"BONE ROD HOOK 5.5X95MM SPINE PEDICLE SIDE TIGHT EXPEDIUM TITANIUM RIGHT","SUP-ITM-10045778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","429.03","81.72","","5157.68","5157.68","5157.68","1 through 10","274.37","429.03","percent of total billed charges",""
"BONE ROD HOOK 5.5X95MM SPINE PEDICLE SIDE TIGHT EXPEDIUM TITANIUM RIGHT","SUP-ITM-10045778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","431.26","71.26","1459.57","88","274.37","429.03","percent of total billed charges",""
"BONE SCREW 12.7X50MM LAG DHS/DCS SS","SUP-ITM-10038209","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","781.41","79.5","","800.18","480.96","1887.97","195","304.7","781.41","percent of total billed charges",""
"BONE SCREW 12.7X50MM LAG DHS/DCS SS","SUP-ITM-10038209","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","523.89","53.3","","813.12","216.42","1444.50","81","304.7","781.41","percent of total billed charges",""
"BONE SCREW 12.7X50MM LAG DHS/DCS SS","SUP-ITM-10038209","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","304.70","31","","432.60","432.60","432.60","1 through 10","304.7","781.41","percent of total billed charges",""
"BONE SCREW 12.7X50MM LAG DHS/DCS SS","SUP-ITM-10038209","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","358.76","36.5","","148.37","54.89","631.39","94","304.7","781.41","percent of total billed charges",""
"BONE SCREW 12.7X50MM LAG DHS/DCS SS","SUP-ITM-10038209","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","376.45","38.3","","279.30","91.72","1116.77","266","304.7","781.41","percent of total billed charges",""
"BONE SCREW 12.7X50MM LAG DHS/DCS SS","SUP-ITM-10038209","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","421.67","42.9","","731.00","63.70","731.00","1 through 10","304.7","781.41","percent of total billed charges",""
"BONE SCREW 12.7X50MM LAG DHS/DCS SS","SUP-ITM-10038209","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","421.67","42.9","","384.74","384.74","384.74","1 through 10","304.7","781.41","percent of total billed charges",""
"BONE SCREW 12.7X50MM LAG DHS/DCS SS","SUP-ITM-10038209","CDM","C1713","HCPCS","0278","RC","","","","both","","","982.91","737.18","WELLPOINT [1015]","HB AMC WELLPOINT","725.19","73.78","","286.63","119.22","1107.45","105","304.7","781.41","percent of total billed charges",""
"BONE SCREW 12.7X50MM LAG DHS/DCS SS","SUP-ITM-10038209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","982.91","737.18","AETNA [1001]","HB AMC AETNA HMO","686.07","69.8","","675.31","184.75","1721.50","286","513.67","803.23","percent of total billed charges",""
"BONE SCREW 12.7X50MM LAG DHS/DCS SS","SUP-ITM-10038209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","982.91","737.18","AETNA [1001]","HB AMC AETNA PPO","790.26","80.4","","1261.44","103.12","1514.10","21","513.67","803.23","percent of total billed charges",""
"BONE SCREW 12.7X50MM LAG DHS/DCS SS","SUP-ITM-10038209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","982.91","737.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","790.26","80.4","","1365.00","1365.00","1365.00","1 through 10","513.67","803.23","percent of total billed charges",""
"BONE SCREW 12.7X50MM LAG DHS/DCS SS","SUP-ITM-10038209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","982.91","737.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","803.23","81.72","","5157.68","5157.68","5157.68","1 through 10","513.67","803.23","percent of total billed charges",""
"BONE SCREW 12.7X50MM LAG DHS/DCS SS","SUP-ITM-10038209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","982.91","737.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","803.23","81.72","","431.26","71.26","1459.57","88","513.67","803.23","percent of total billed charges",""
"BONE SCREW 2.7MM 11 TI VA LOCKING SCR SELF TPNG T8 STARDRIVE RECESS","SUP-ITM-10096231","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","310.92","79.5","","800.18","480.96","1887.97","195","121.24","310.92","percent of total billed charges",""
"BONE SCREW 2.7MM 11 TI VA LOCKING SCR SELF TPNG T8 STARDRIVE RECESS","SUP-ITM-10096231","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","208.45","53.3","","813.12","216.42","1444.50","81","121.24","310.92","percent of total billed charges",""
"BONE SCREW 2.7MM 11 TI VA LOCKING SCR SELF TPNG T8 STARDRIVE RECESS","SUP-ITM-10096231","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","121.24","31","","432.60","432.60","432.60","1 through 10","121.24","310.92","percent of total billed charges",""
"BONE SCREW 2.7MM 11 TI VA LOCKING SCR SELF TPNG T8 STARDRIVE RECESS","SUP-ITM-10096231","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","142.75","36.5","","148.37","54.89","631.39","94","121.24","310.92","percent of total billed charges",""
"BONE SCREW 2.7MM 11 TI VA LOCKING SCR SELF TPNG T8 STARDRIVE RECESS","SUP-ITM-10096231","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","149.79","38.3","","279.30","91.72","1116.77","266","121.24","310.92","percent of total billed charges",""
"BONE SCREW 2.7MM 11 TI VA LOCKING SCR SELF TPNG T8 STARDRIVE RECESS","SUP-ITM-10096231","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.78","42.9","","731.00","63.70","731.00","1 through 10","121.24","310.92","percent of total billed charges",""
"BONE SCREW 2.7MM 11 TI VA LOCKING SCR SELF TPNG T8 STARDRIVE RECESS","SUP-ITM-10096231","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.78","42.9","","384.74","384.74","384.74","1 through 10","121.24","310.92","percent of total billed charges",""
"BONE SCREW 2.7MM 11 TI VA LOCKING SCR SELF TPNG T8 STARDRIVE RECESS","SUP-ITM-10096231","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","WELLPOINT [1015]","HB AMC WELLPOINT","288.55","73.78","","286.63","119.22","1107.45","105","121.24","310.92","percent of total billed charges",""
"BONE SCREW 2.7MM 11 TI VA LOCKING SCR SELF TPNG T8 STARDRIVE RECESS","SUP-ITM-10096231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","391.09","293.32","AETNA [1001]","HB AMC AETNA HMO","272.98","69.8","","675.31","184.75","1721.50","286","204.38","319.6","percent of total billed charges",""
"BONE SCREW 2.7MM 11 TI VA LOCKING SCR SELF TPNG T8 STARDRIVE RECESS","SUP-ITM-10096231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","391.09","293.32","AETNA [1001]","HB AMC AETNA PPO","314.44","80.4","","1261.44","103.12","1514.10","21","204.38","319.6","percent of total billed charges",""
"BONE SCREW 2.7MM 11 TI VA LOCKING SCR SELF TPNG T8 STARDRIVE RECESS","SUP-ITM-10096231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","391.09","293.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","314.44","80.4","","1365.00","1365.00","1365.00","1 through 10","204.38","319.6","percent of total billed charges",""
"BONE SCREW 2.7MM 11 TI VA LOCKING SCR SELF TPNG T8 STARDRIVE RECESS","SUP-ITM-10096231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","391.09","293.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","319.60","81.72","","5157.68","5157.68","5157.68","1 through 10","204.38","319.6","percent of total billed charges",""
"BONE SCREW 2.7MM 11 TI VA LOCKING SCR SELF TPNG T8 STARDRIVE RECESS","SUP-ITM-10096231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","391.09","293.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","319.60","81.72","","431.26","71.26","1459.57","88","204.38","319.6","percent of total billed charges",""
"BONE SCREW 2MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10086697","CDM","C1889","HCPCS","0278","RC","","","","both","","","84.00","63.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","66.78","79.5","","1309.77","674.56","6049.93","26","26.04","66.78","percent of total billed charges",""
"BONE SCREW 2MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10086697","CDM","C1889","HCPCS","0278","RC","","","","both","","","84.00","63.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","44.77","53.3","","1901.83","1901.83","2962.25","1 through 10","26.04","66.78","percent of total billed charges",""
"BONE SCREW 2MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10086697","CDM","C1889","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30.66","36.5","","1620.31","1620.31","19908.88","1 through 10","26.04","66.78","percent of total billed charges",""
"BONE SCREW 2MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10086697","CDM","C1889","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.17","38.3","","352.91","352.91","2046.30","1 through 10","26.04","66.78","percent of total billed charges",""
"BONE SCREW 2MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10086697","CDM","C1889","HCPCS","0278","RC","","","","both","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.04","42.9","","9668.75","9668.75","9668.75","1 through 10","26.04","66.78","percent of total billed charges",""
"BONE SCREW 2MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10086697","CDM","C1889","HCPCS","0278","RC","","","","both","","","84.00","63.00","WELLPOINT [1015]","HB AMC WELLPOINT","61.98","73.78","","699.88","384.10","3443.31","33","26.04","66.78","percent of total billed charges",""
"BONE SCREW 2MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10086697","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","84.00","63.00","AETNA [1001]","HB AMC AETNA HMO","58.63","69.8","","1421.24","264.50","4933.46","29","43.9","68.64","percent of total billed charges",""
"BONE SCREW 2MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10086697","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","67.54","80.4","","1022.97","1022.97","3607.50","1 through 10","43.9","68.64","percent of total billed charges",""
"BONE SCREW 2MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10086697","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","68.64","81.72","","3010.54","693.88","5019.88","35","43.9","68.64","percent of total billed charges",""
"BONE SCREW 2X1.5MM CONICAL EXTRACTION FOR CORTEX","SUP-ITM-10019178","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.21","273.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","289.55","79.5","","800.18","480.96","1887.97","195","112.91","289.55","percent of total billed charges",""
"BONE SCREW 2X1.5MM CONICAL EXTRACTION FOR CORTEX","SUP-ITM-10019178","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.21","273.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","194.12","53.3","","813.12","216.42","1444.50","81","112.91","289.55","percent of total billed charges",""
"BONE SCREW 2X1.5MM CONICAL EXTRACTION FOR CORTEX","SUP-ITM-10019178","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.21","273.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","112.91","31","","432.60","432.60","432.60","1 through 10","112.91","289.55","percent of total billed charges",""
"BONE SCREW 2X1.5MM CONICAL EXTRACTION FOR CORTEX","SUP-ITM-10019178","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.21","273.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","132.94","36.5","","148.37","54.89","631.39","94","112.91","289.55","percent of total billed charges",""
"BONE SCREW 2X1.5MM CONICAL EXTRACTION FOR CORTEX","SUP-ITM-10019178","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.21","273.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","139.49","38.3","","279.30","91.72","1116.77","266","112.91","289.55","percent of total billed charges",""
"BONE SCREW 2X1.5MM CONICAL EXTRACTION FOR CORTEX","SUP-ITM-10019178","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.21","273.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.25","42.9","","731.00","63.70","731.00","1 through 10","112.91","289.55","percent of total billed charges",""
"BONE SCREW 2X1.5MM CONICAL EXTRACTION FOR CORTEX","SUP-ITM-10019178","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.21","273.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.25","42.9","","384.74","384.74","384.74","1 through 10","112.91","289.55","percent of total billed charges",""
"BONE SCREW 2X1.5MM CONICAL EXTRACTION FOR CORTEX","SUP-ITM-10019178","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.21","273.16","WELLPOINT [1015]","HB AMC WELLPOINT","268.71","73.78","","286.63","119.22","1107.45","105","112.91","289.55","percent of total billed charges",""
"BONE SCREW 2X1.5MM CONICAL EXTRACTION FOR CORTEX","SUP-ITM-10019178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.21","273.16","AETNA [1001]","HB AMC AETNA HMO","254.22","69.8","","675.31","184.75","1721.50","286","190.34","297.63","percent of total billed charges",""
"BONE SCREW 2X1.5MM CONICAL EXTRACTION FOR CORTEX","SUP-ITM-10019178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.21","273.16","AETNA [1001]","HB AMC AETNA PPO","292.82","80.4","","1261.44","103.12","1514.10","21","190.34","297.63","percent of total billed charges",""
"BONE SCREW 2X1.5MM CONICAL EXTRACTION FOR CORTEX","SUP-ITM-10019178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.21","273.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","292.82","80.4","","1365.00","1365.00","1365.00","1 through 10","190.34","297.63","percent of total billed charges",""
"BONE SCREW 2X1.5MM CONICAL EXTRACTION FOR CORTEX","SUP-ITM-10019178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.21","273.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","297.63","81.72","","5157.68","5157.68","5157.68","1 through 10","190.34","297.63","percent of total billed charges",""
"BONE SCREW 2X1.5MM CONICAL EXTRACTION FOR CORTEX","SUP-ITM-10019178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.21","273.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","297.63","81.72","","431.26","71.26","1459.57","88","190.34","297.63","percent of total billed charges",""
"BONE SCREW 3MM FIXATION TI NEURO MACHINE LOW PROFILE","SUP-ITM-10076400","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.89","127.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","135.06","79.5","","800.18","480.96","1887.97","195","52.67","135.06","percent of total billed charges",""
"BONE SCREW 3MM FIXATION TI NEURO MACHINE LOW PROFILE","SUP-ITM-10076400","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.89","127.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","90.55","53.3","","813.12","216.42","1444.50","81","52.67","135.06","percent of total billed charges",""
"BONE SCREW 3MM FIXATION TI NEURO MACHINE LOW PROFILE","SUP-ITM-10076400","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.89","127.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","52.67","31","","432.60","432.60","432.60","1 through 10","52.67","135.06","percent of total billed charges",""
"BONE SCREW 3MM FIXATION TI NEURO MACHINE LOW PROFILE","SUP-ITM-10076400","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.89","127.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","62.01","36.5","","148.37","54.89","631.39","94","52.67","135.06","percent of total billed charges",""
"BONE SCREW 3MM FIXATION TI NEURO MACHINE LOW PROFILE","SUP-ITM-10076400","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.89","127.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","65.07","38.3","","279.30","91.72","1116.77","266","52.67","135.06","percent of total billed charges",""
"BONE SCREW 3MM FIXATION TI NEURO MACHINE LOW PROFILE","SUP-ITM-10076400","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.89","127.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.88","42.9","","731.00","63.70","731.00","1 through 10","52.67","135.06","percent of total billed charges",""
"BONE SCREW 3MM FIXATION TI NEURO MACHINE LOW PROFILE","SUP-ITM-10076400","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.89","127.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.88","42.9","","384.74","384.74","384.74","1 through 10","52.67","135.06","percent of total billed charges",""
"BONE SCREW 3MM FIXATION TI NEURO MACHINE LOW PROFILE","SUP-ITM-10076400","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.89","127.42","WELLPOINT [1015]","HB AMC WELLPOINT","125.34","73.78","","286.63","119.22","1107.45","105","52.67","135.06","percent of total billed charges",""
"BONE SCREW 3MM FIXATION TI NEURO MACHINE LOW PROFILE","SUP-ITM-10076400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.89","127.42","AETNA [1001]","HB AMC AETNA HMO","118.58","69.8","","675.31","184.75","1721.50","286","88.78","138.83","percent of total billed charges",""
"BONE SCREW 3MM FIXATION TI NEURO MACHINE LOW PROFILE","SUP-ITM-10076400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.89","127.42","AETNA [1001]","HB AMC AETNA PPO","136.59","80.4","","1261.44","103.12","1514.10","21","88.78","138.83","percent of total billed charges",""
"BONE SCREW 3MM FIXATION TI NEURO MACHINE LOW PROFILE","SUP-ITM-10076400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.89","127.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","136.59","80.4","","1365.00","1365.00","1365.00","1 through 10","88.78","138.83","percent of total billed charges",""
"BONE SCREW 3MM FIXATION TI NEURO MACHINE LOW PROFILE","SUP-ITM-10076400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.89","127.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","138.83","81.72","","5157.68","5157.68","5157.68","1 through 10","88.78","138.83","percent of total billed charges",""
"BONE SCREW 3MM FIXATION TI NEURO MACHINE LOW PROFILE","SUP-ITM-10076400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.89","127.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","138.83","81.72","","431.26","71.26","1459.57","88","88.78","138.83","percent of total billed charges",""
"BONE SCREW 3MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10031065","CDM","C1713","HCPCS","0278","RC","","","","both","","","70.00","52.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","55.65","79.5","","800.18","480.96","1887.97","195","21.7","55.65","percent of total billed charges",""
"BONE SCREW 3MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10031065","CDM","C1713","HCPCS","0278","RC","","","","both","","","70.00","52.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37.31","53.3","","813.12","216.42","1444.50","81","21.7","55.65","percent of total billed charges",""
"BONE SCREW 3MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10031065","CDM","C1713","HCPCS","0278","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","21.70","31","","432.60","432.60","432.60","1 through 10","21.7","55.65","percent of total billed charges",""
"BONE SCREW 3MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10031065","CDM","C1713","HCPCS","0278","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25.55","36.5","","148.37","54.89","631.39","94","21.7","55.65","percent of total billed charges",""
"BONE SCREW 3MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10031065","CDM","C1713","HCPCS","0278","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26.81","38.3","","279.30","91.72","1116.77","266","21.7","55.65","percent of total billed charges",""
"BONE SCREW 3MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10031065","CDM","C1713","HCPCS","0278","RC","","","","both","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.03","42.9","","731.00","63.70","731.00","1 through 10","21.7","55.65","percent of total billed charges",""
"BONE SCREW 3MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10031065","CDM","C1713","HCPCS","0278","RC","","","","both","","","70.00","52.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.03","42.9","","384.74","384.74","384.74","1 through 10","21.7","55.65","percent of total billed charges",""
"BONE SCREW 3MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10031065","CDM","C1713","HCPCS","0278","RC","","","","both","","","70.00","52.50","WELLPOINT [1015]","HB AMC WELLPOINT","51.65","73.78","","286.63","119.22","1107.45","105","21.7","55.65","percent of total billed charges",""
"BONE SCREW 3MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10031065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA HMO","48.86","69.8","","675.31","184.75","1721.50","286","36.58","57.2","percent of total billed charges",""
"BONE SCREW 3MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10031065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA PPO","56.28","80.4","","1261.44","103.12","1514.10","21","36.58","57.2","percent of total billed charges",""
"BONE SCREW 3MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10031065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","70.00","52.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","56.28","80.4","","1365.00","1365.00","1365.00","1 through 10","36.58","57.2","percent of total billed charges",""
"BONE SCREW 3MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10031065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","57.20","81.72","","5157.68","5157.68","5157.68","1 through 10","36.58","57.2","percent of total billed charges",""
"BONE SCREW 3MM SPINE RING END SYNMESH TI LOCKING LOW PROFILE","SUP-ITM-10031065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","57.20","81.72","","431.26","71.26","1459.57","88","36.58","57.2","percent of total billed charges",""
"BONE SCREW 4.9MM LG CONICAL STAINLESS CANNULATED PARTIAL THREAD","SUP-ITM-10018369","CDM","C1713","HCPCS","0278","RC","","","","both","","","212.21","159.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","168.71","79.5","","800.18","480.96","1887.97","195","65.79","168.71","percent of total billed charges",""
"BONE SCREW 4.9MM LG CONICAL STAINLESS CANNULATED PARTIAL THREAD","SUP-ITM-10018369","CDM","C1713","HCPCS","0278","RC","","","","both","","","212.21","159.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","113.11","53.3","","813.12","216.42","1444.50","81","65.79","168.71","percent of total billed charges",""
"BONE SCREW 4.9MM LG CONICAL STAINLESS CANNULATED PARTIAL THREAD","SUP-ITM-10018369","CDM","C1713","HCPCS","0278","RC","","","","both","","","212.21","159.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","65.79","31","","432.60","432.60","432.60","1 through 10","65.79","168.71","percent of total billed charges",""
"BONE SCREW 4.9MM LG CONICAL STAINLESS CANNULATED PARTIAL THREAD","SUP-ITM-10018369","CDM","C1713","HCPCS","0278","RC","","","","both","","","212.21","159.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.46","36.5","","148.37","54.89","631.39","94","65.79","168.71","percent of total billed charges",""
"BONE SCREW 4.9MM LG CONICAL STAINLESS CANNULATED PARTIAL THREAD","SUP-ITM-10018369","CDM","C1713","HCPCS","0278","RC","","","","both","","","212.21","159.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.28","38.3","","279.30","91.72","1116.77","266","65.79","168.71","percent of total billed charges",""
"BONE SCREW 4.9MM LG CONICAL STAINLESS CANNULATED PARTIAL THREAD","SUP-ITM-10018369","CDM","C1713","HCPCS","0278","RC","","","","both","","","212.21","159.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.04","42.9","","731.00","63.70","731.00","1 through 10","65.79","168.71","percent of total billed charges",""
"BONE SCREW 4.9MM LG CONICAL STAINLESS CANNULATED PARTIAL THREAD","SUP-ITM-10018369","CDM","C1713","HCPCS","0278","RC","","","","both","","","212.21","159.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.04","42.9","","384.74","384.74","384.74","1 through 10","65.79","168.71","percent of total billed charges",""
"BONE SCREW 4.9MM LG CONICAL STAINLESS CANNULATED PARTIAL THREAD","SUP-ITM-10018369","CDM","C1713","HCPCS","0278","RC","","","","both","","","212.21","159.16","WELLPOINT [1015]","HB AMC WELLPOINT","156.57","73.78","","286.63","119.22","1107.45","105","65.79","168.71","percent of total billed charges",""
"BONE SCREW 4.9MM LG CONICAL STAINLESS CANNULATED PARTIAL THREAD","SUP-ITM-10018369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","212.21","159.16","AETNA [1001]","HB AMC AETNA HMO","148.12","69.8","","675.31","184.75","1721.50","286","110.9","173.42","percent of total billed charges",""
"BONE SCREW 4.9MM LG CONICAL STAINLESS CANNULATED PARTIAL THREAD","SUP-ITM-10018369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","212.21","159.16","AETNA [1001]","HB AMC AETNA PPO","170.62","80.4","","1261.44","103.12","1514.10","21","110.9","173.42","percent of total billed charges",""
"BONE SCREW 4.9MM LG CONICAL STAINLESS CANNULATED PARTIAL THREAD","SUP-ITM-10018369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","212.21","159.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","170.62","80.4","","1365.00","1365.00","1365.00","1 through 10","110.9","173.42","percent of total billed charges",""
"BONE SCREW 4.9MM LG CONICAL STAINLESS CANNULATED PARTIAL THREAD","SUP-ITM-10018369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","212.21","159.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","173.42","81.72","","5157.68","5157.68","5157.68","1 through 10","110.9","173.42","percent of total billed charges",""
"BONE SCREW 4.9MM LG CONICAL STAINLESS CANNULATED PARTIAL THREAD","SUP-ITM-10018369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","212.21","159.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","173.42","81.72","","431.26","71.26","1459.57","88","110.9","173.42","percent of total billed charges",""
"BONE SCREW 4MM 2.5X80 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040846","CDM","C1713","HCPCS","0278","RC","","","","both","","","422.17","316.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","335.63","79.5","","800.18","480.96","1887.97","195","130.87","335.63","percent of total billed charges",""
"BONE SCREW 4MM 2.5X80 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040846","CDM","C1713","HCPCS","0278","RC","","","","both","","","422.17","316.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","225.02","53.3","","813.12","216.42","1444.50","81","130.87","335.63","percent of total billed charges",""
"BONE SCREW 4MM 2.5X80 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040846","CDM","C1713","HCPCS","0278","RC","","","","both","","","422.17","316.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","130.87","31","","432.60","432.60","432.60","1 through 10","130.87","335.63","percent of total billed charges",""
"BONE SCREW 4MM 2.5X80 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040846","CDM","C1713","HCPCS","0278","RC","","","","both","","","422.17","316.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","154.09","36.5","","148.37","54.89","631.39","94","130.87","335.63","percent of total billed charges",""
"BONE SCREW 4MM 2.5X80 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040846","CDM","C1713","HCPCS","0278","RC","","","","both","","","422.17","316.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","161.69","38.3","","279.30","91.72","1116.77","266","130.87","335.63","percent of total billed charges",""
"BONE SCREW 4MM 2.5X80 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040846","CDM","C1713","HCPCS","0278","RC","","","","both","","","422.17","316.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.11","42.9","","731.00","63.70","731.00","1 through 10","130.87","335.63","percent of total billed charges",""
"BONE SCREW 4MM 2.5X80 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040846","CDM","C1713","HCPCS","0278","RC","","","","both","","","422.17","316.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.11","42.9","","384.74","384.74","384.74","1 through 10","130.87","335.63","percent of total billed charges",""
"BONE SCREW 4MM 2.5X80 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040846","CDM","C1713","HCPCS","0278","RC","","","","both","","","422.17","316.63","WELLPOINT [1015]","HB AMC WELLPOINT","311.48","73.78","","286.63","119.22","1107.45","105","130.87","335.63","percent of total billed charges",""
"BONE SCREW 4MM 2.5X80 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040846","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","422.17","316.63","AETNA [1001]","HB AMC AETNA HMO","294.67","69.8","","675.31","184.75","1721.50","286","220.63","345","percent of total billed charges",""
"BONE SCREW 4MM 2.5X80 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040846","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","422.17","316.63","AETNA [1001]","HB AMC AETNA PPO","339.42","80.4","","1261.44","103.12","1514.10","21","220.63","345","percent of total billed charges",""
"BONE SCREW 4MM 2.5X80 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040846","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","422.17","316.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","339.42","80.4","","1365.00","1365.00","1365.00","1 through 10","220.63","345","percent of total billed charges",""
"BONE SCREW 4MM 2.5X80 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040846","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","422.17","316.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","345.00","81.72","","5157.68","5157.68","5157.68","1 through 10","220.63","345","percent of total billed charges",""
"BONE SCREW 4MM 2.5X80 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040846","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","422.17","316.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","345.00","81.72","","431.26","71.26","1459.57","88","220.63","345","percent of total billed charges",""
"BONE SCREW 4MMX60 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040848","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","374.75","79.5","","800.18","480.96","1887.97","195","146.13","374.75","percent of total billed charges",""
"BONE SCREW 4MMX60 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040848","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","251.25","53.3","","813.12","216.42","1444.50","81","146.13","374.75","percent of total billed charges",""
"BONE SCREW 4MMX60 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040848","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","146.13","31","","432.60","432.60","432.60","1 through 10","146.13","374.75","percent of total billed charges",""
"BONE SCREW 4MMX60 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040848","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","172.05","36.5","","148.37","54.89","631.39","94","146.13","374.75","percent of total billed charges",""
"BONE SCREW 4MMX60 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040848","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","180.54","38.3","","279.30","91.72","1116.77","266","146.13","374.75","percent of total billed charges",""
"BONE SCREW 4MMX60 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040848","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.22","42.9","","731.00","63.70","731.00","1 through 10","146.13","374.75","percent of total billed charges",""
"BONE SCREW 4MMX60 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040848","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.22","42.9","","384.74","384.74","384.74","1 through 10","146.13","374.75","percent of total billed charges",""
"BONE SCREW 4MMX60 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040848","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","WELLPOINT [1015]","HB AMC WELLPOINT","347.78","73.78","","286.63","119.22","1107.45","105","146.13","374.75","percent of total billed charges",""
"BONE SCREW 4MMX60 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.38","353.53","AETNA [1001]","HB AMC AETNA HMO","329.02","69.8","","675.31","184.75","1721.50","286","246.34","385.21","percent of total billed charges",""
"BONE SCREW 4MMX60 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.38","353.53","AETNA [1001]","HB AMC AETNA PPO","378.99","80.4","","1261.44","103.12","1514.10","21","246.34","385.21","percent of total billed charges",""
"BONE SCREW 4MMX60 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.38","353.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","378.99","80.4","","1365.00","1365.00","1365.00","1 through 10","246.34","385.21","percent of total billed charges",""
"BONE SCREW 4MMX60 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.38","353.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","385.21","81.72","","5157.68","5157.68","5157.68","1 through 10","246.34","385.21","percent of total billed charges",""
"BONE SCREW 4MMX60 20 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.38","353.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","385.21","81.72","","431.26","71.26","1459.57","88","246.34","385.21","percent of total billed charges",""
"BONE SCREW 5MMX100 30 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040854","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.16","351.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","372.19","79.5","","800.18","480.96","1887.97","195","145.13","372.19","percent of total billed charges",""
"BONE SCREW 5MMX100 30 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040854","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.16","351.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","249.53","53.3","","813.12","216.42","1444.50","81","145.13","372.19","percent of total billed charges",""
"BONE SCREW 5MMX100 30 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040854","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.16","351.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","145.13","31","","432.60","432.60","432.60","1 through 10","145.13","372.19","percent of total billed charges",""
"BONE SCREW 5MMX100 30 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040854","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.16","351.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","170.88","36.5","","148.37","54.89","631.39","94","145.13","372.19","percent of total billed charges",""
"BONE SCREW 5MMX100 30 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040854","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.16","351.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.31","38.3","","279.30","91.72","1116.77","266","145.13","372.19","percent of total billed charges",""
"BONE SCREW 5MMX100 30 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040854","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.16","351.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.84","42.9","","731.00","63.70","731.00","1 through 10","145.13","372.19","percent of total billed charges",""
"BONE SCREW 5MMX100 30 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040854","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.16","351.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.84","42.9","","384.74","384.74","384.74","1 through 10","145.13","372.19","percent of total billed charges",""
"BONE SCREW 5MMX100 30 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040854","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.16","351.12","WELLPOINT [1015]","HB AMC WELLPOINT","345.41","73.78","","286.63","119.22","1107.45","105","145.13","372.19","percent of total billed charges",""
"BONE SCREW 5MMX100 30 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.16","351.12","AETNA [1001]","HB AMC AETNA HMO","326.78","69.8","","675.31","184.75","1721.50","286","244.66","382.58","percent of total billed charges",""
"BONE SCREW 5MMX100 30 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.16","351.12","AETNA [1001]","HB AMC AETNA PPO","376.40","80.4","","1261.44","103.12","1514.10","21","244.66","382.58","percent of total billed charges",""
"BONE SCREW 5MMX100 30 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.16","351.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","376.40","80.4","","1365.00","1365.00","1365.00","1 through 10","244.66","382.58","percent of total billed charges",""
"BONE SCREW 5MMX100 30 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.16","351.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","382.58","81.72","","5157.68","5157.68","5157.68","1 through 10","244.66","382.58","percent of total billed charges",""
"BONE SCREW 5MMX100 30 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.16","351.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","382.58","81.72","","431.26","71.26","1459.57","88","244.66","382.58","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","326.78","79.5","","800.18","480.96","1887.97","195","127.42","326.78","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","219.08","53.3","","813.12","216.42","1444.50","81","127.42","326.78","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","127.42","31","","432.60","432.60","432.60","1 through 10","127.42","326.78","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","150.03","36.5","","148.37","54.89","631.39","94","127.42","326.78","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.43","38.3","","279.30","91.72","1116.77","266","127.42","326.78","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.34","42.9","","731.00","63.70","731.00","1 through 10","127.42","326.78","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.34","42.9","","384.74","384.74","384.74","1 through 10","127.42","326.78","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","WELLPOINT [1015]","HB AMC WELLPOINT","303.27","73.78","","286.63","119.22","1107.45","105","127.42","326.78","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.04","308.28","AETNA [1001]","HB AMC AETNA HMO","286.91","69.8","","675.31","184.75","1721.50","286","214.81","335.9","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.04","308.28","AETNA [1001]","HB AMC AETNA PPO","330.48","80.4","","1261.44","103.12","1514.10","21","214.81","335.9","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.04","308.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","330.48","80.4","","1365.00","1365.00","1365.00","1 through 10","214.81","335.9","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.04","308.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","335.90","81.72","","5157.68","5157.68","5157.68","1 through 10","214.81","335.9","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.04","308.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","335.90","81.72","","431.26","71.26","1459.57","88","214.81","335.9","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","349.04","79.5","","800.18","480.96","1887.97","195","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","234.01","53.3","","813.12","216.42","1444.50","81","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","136.10","31","","432.60","432.60","432.60","1 through 10","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","160.25","36.5","","148.37","54.89","631.39","94","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","168.15","38.3","","279.30","91.72","1116.77","266","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.35","42.9","","731.00","63.70","731.00","1 through 10","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.35","42.9","","384.74","384.74","384.74","1 through 10","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","WELLPOINT [1015]","HB AMC WELLPOINT","323.92","73.78","","286.63","119.22","1107.45","105","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","AETNA [1001]","HB AMC AETNA HMO","306.45","69.8","","675.31","184.75","1721.50","286","229.44","358.78","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","AETNA [1001]","HB AMC AETNA PPO","352.99","80.4","","1261.44","103.12","1514.10","21","229.44","358.78","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","352.99","80.4","","1365.00","1365.00","1365.00","1 through 10","229.44","358.78","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","358.78","81.72","","5157.68","5157.68","5157.68","1 through 10","229.44","358.78","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","358.78","81.72","","431.26","71.26","1459.57","88","229.44","358.78","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","349.04","79.5","","800.18","480.96","1887.97","195","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","234.01","53.3","","813.12","216.42","1444.50","81","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","136.10","31","","432.60","432.60","432.60","1 through 10","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","160.25","36.5","","148.37","54.89","631.39","94","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","168.15","38.3","","279.30","91.72","1116.77","266","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.35","42.9","","731.00","63.70","731.00","1 through 10","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.35","42.9","","384.74","384.74","384.74","1 through 10","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","WELLPOINT [1015]","HB AMC WELLPOINT","323.92","73.78","","286.63","119.22","1107.45","105","136.1","349.04","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","AETNA [1001]","HB AMC AETNA HMO","306.45","69.8","","675.31","184.75","1721.50","286","229.44","358.78","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","AETNA [1001]","HB AMC AETNA PPO","352.99","80.4","","1261.44","103.12","1514.10","21","229.44","358.78","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","352.99","80.4","","1365.00","1365.00","1365.00","1 through 10","229.44","358.78","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","358.78","81.72","","5157.68","5157.68","5157.68","1 through 10","229.44","358.78","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","358.78","81.72","","431.26","71.26","1459.57","88","229.44","358.78","percent of total billed charges",""
"BONE SCREW 6MM FIXATION TI CONDYLAR HEAD LRP PLATE","SUP-ITM-10075200","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.98","206.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","219.40","79.5","","800.18","480.96","1887.97","195","85.55","219.4","percent of total billed charges",""
"BONE SCREW 6MM FIXATION TI CONDYLAR HEAD LRP PLATE","SUP-ITM-10075200","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.98","206.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.10","53.3","","813.12","216.42","1444.50","81","85.55","219.4","percent of total billed charges",""
"BONE SCREW 6MM FIXATION TI CONDYLAR HEAD LRP PLATE","SUP-ITM-10075200","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.98","206.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.55","31","","432.60","432.60","432.60","1 through 10","85.55","219.4","percent of total billed charges",""
"BONE SCREW 6MM FIXATION TI CONDYLAR HEAD LRP PLATE","SUP-ITM-10075200","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.98","206.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.73","36.5","","148.37","54.89","631.39","94","85.55","219.4","percent of total billed charges",""
"BONE SCREW 6MM FIXATION TI CONDYLAR HEAD LRP PLATE","SUP-ITM-10075200","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.98","206.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.70","38.3","","279.30","91.72","1116.77","266","85.55","219.4","percent of total billed charges",""
"BONE SCREW 6MM FIXATION TI CONDYLAR HEAD LRP PLATE","SUP-ITM-10075200","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.98","206.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.40","42.9","","731.00","63.70","731.00","1 through 10","85.55","219.4","percent of total billed charges",""
"BONE SCREW 6MM FIXATION TI CONDYLAR HEAD LRP PLATE","SUP-ITM-10075200","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.98","206.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.40","42.9","","384.74","384.74","384.74","1 through 10","85.55","219.4","percent of total billed charges",""
"BONE SCREW 6MM FIXATION TI CONDYLAR HEAD LRP PLATE","SUP-ITM-10075200","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.98","206.98","WELLPOINT [1015]","HB AMC WELLPOINT","203.62","73.78","","286.63","119.22","1107.45","105","85.55","219.4","percent of total billed charges",""
"BONE SCREW 6MM FIXATION TI CONDYLAR HEAD LRP PLATE","SUP-ITM-10075200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.98","206.98","AETNA [1001]","HB AMC AETNA HMO","192.63","69.8","","675.31","184.75","1721.50","286","144.23","225.53","percent of total billed charges",""
"BONE SCREW 6MM FIXATION TI CONDYLAR HEAD LRP PLATE","SUP-ITM-10075200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.98","206.98","AETNA [1001]","HB AMC AETNA PPO","221.89","80.4","","1261.44","103.12","1514.10","21","144.23","225.53","percent of total billed charges",""
"BONE SCREW 6MM FIXATION TI CONDYLAR HEAD LRP PLATE","SUP-ITM-10075200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.98","206.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","221.89","80.4","","1365.00","1365.00","1365.00","1 through 10","144.23","225.53","percent of total billed charges",""
"BONE SCREW 6MM FIXATION TI CONDYLAR HEAD LRP PLATE","SUP-ITM-10075200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.98","206.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","225.53","81.72","","5157.68","5157.68","5157.68","1 through 10","144.23","225.53","percent of total billed charges",""
"BONE SCREW 6MM FIXATION TI CONDYLAR HEAD LRP PLATE","SUP-ITM-10075200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.98","206.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","225.53","81.72","","431.26","71.26","1459.57","88","144.23","225.53","percent of total billed charges",""
"BONE SCREW BOLT EXTERNAL FIXATION SCHANZ CLAMPING POST CANNULATED MRI CONDITIONAL","SUP-ITM-10039206","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.80","632.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","670.03","79.5","","800.18","480.96","1887.97","195","261.27","670.03","percent of total billed charges",""
"BONE SCREW BOLT EXTERNAL FIXATION SCHANZ CLAMPING POST CANNULATED MRI CONDITIONAL","SUP-ITM-10039206","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.80","632.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","449.21","53.3","","813.12","216.42","1444.50","81","261.27","670.03","percent of total billed charges",""
"BONE SCREW BOLT EXTERNAL FIXATION SCHANZ CLAMPING POST CANNULATED MRI CONDITIONAL","SUP-ITM-10039206","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.80","632.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","261.27","31","","432.60","432.60","432.60","1 through 10","261.27","670.03","percent of total billed charges",""
"BONE SCREW BOLT EXTERNAL FIXATION SCHANZ CLAMPING POST CANNULATED MRI CONDITIONAL","SUP-ITM-10039206","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.80","632.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","307.62","36.5","","148.37","54.89","631.39","94","261.27","670.03","percent of total billed charges",""
"BONE SCREW BOLT EXTERNAL FIXATION SCHANZ CLAMPING POST CANNULATED MRI CONDITIONAL","SUP-ITM-10039206","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.80","632.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","322.79","38.3","","279.30","91.72","1116.77","266","261.27","670.03","percent of total billed charges",""
"BONE SCREW BOLT EXTERNAL FIXATION SCHANZ CLAMPING POST CANNULATED MRI CONDITIONAL","SUP-ITM-10039206","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.80","632.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","361.56","42.9","","731.00","63.70","731.00","1 through 10","261.27","670.03","percent of total billed charges",""
"BONE SCREW BOLT EXTERNAL FIXATION SCHANZ CLAMPING POST CANNULATED MRI CONDITIONAL","SUP-ITM-10039206","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.80","632.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","361.56","42.9","","384.74","384.74","384.74","1 through 10","261.27","670.03","percent of total billed charges",""
"BONE SCREW BOLT EXTERNAL FIXATION SCHANZ CLAMPING POST CANNULATED MRI CONDITIONAL","SUP-ITM-10039206","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.80","632.10","WELLPOINT [1015]","HB AMC WELLPOINT","621.82","73.78","","286.63","119.22","1107.45","105","261.27","670.03","percent of total billed charges",""
"BONE SCREW BOLT EXTERNAL FIXATION SCHANZ CLAMPING POST CANNULATED MRI CONDITIONAL","SUP-ITM-10039206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","842.80","632.10","AETNA [1001]","HB AMC AETNA HMO","588.27","69.8","","675.31","184.75","1721.50","286","440.45","688.74","percent of total billed charges",""
"BONE SCREW BOLT EXTERNAL FIXATION SCHANZ CLAMPING POST CANNULATED MRI CONDITIONAL","SUP-ITM-10039206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","842.80","632.10","AETNA [1001]","HB AMC AETNA PPO","677.61","80.4","","1261.44","103.12","1514.10","21","440.45","688.74","percent of total billed charges",""
"BONE SCREW BOLT EXTERNAL FIXATION SCHANZ CLAMPING POST CANNULATED MRI CONDITIONAL","SUP-ITM-10039206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","842.80","632.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","677.61","80.4","","1365.00","1365.00","1365.00","1 through 10","440.45","688.74","percent of total billed charges",""
"BONE SCREW BOLT EXTERNAL FIXATION SCHANZ CLAMPING POST CANNULATED MRI CONDITIONAL","SUP-ITM-10039206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","842.80","632.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","688.74","81.72","","5157.68","5157.68","5157.68","1 through 10","440.45","688.74","percent of total billed charges",""
"BONE SCREW BOLT EXTERNAL FIXATION SCHANZ CLAMPING POST CANNULATED MRI CONDITIONAL","SUP-ITM-10039206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","842.80","632.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","688.74","81.72","","431.26","71.26","1459.57","88","440.45","688.74","percent of total billed charges",""
"BONE SCREW BOLT SCHANZ EXTERNAL FIXATION CANNULATED RING MOUNT MRI CONDITIONAL","SUP-ITM-10039205","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.89","538.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.72","79.5","","800.18","480.96","1887.97","195","222.55","570.72","percent of total billed charges",""
"BONE SCREW BOLT SCHANZ EXTERNAL FIXATION CANNULATED RING MOUNT MRI CONDITIONAL","SUP-ITM-10039205","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.89","538.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","382.64","53.3","","813.12","216.42","1444.50","81","222.55","570.72","percent of total billed charges",""
"BONE SCREW BOLT SCHANZ EXTERNAL FIXATION CANNULATED RING MOUNT MRI CONDITIONAL","SUP-ITM-10039205","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.89","538.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","222.55","31","","432.60","432.60","432.60","1 through 10","222.55","570.72","percent of total billed charges",""
"BONE SCREW BOLT SCHANZ EXTERNAL FIXATION CANNULATED RING MOUNT MRI CONDITIONAL","SUP-ITM-10039205","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.89","538.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","262.03","36.5","","148.37","54.89","631.39","94","222.55","570.72","percent of total billed charges",""
"BONE SCREW BOLT SCHANZ EXTERNAL FIXATION CANNULATED RING MOUNT MRI CONDITIONAL","SUP-ITM-10039205","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.89","538.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.95","38.3","","279.30","91.72","1116.77","266","222.55","570.72","percent of total billed charges",""
"BONE SCREW BOLT SCHANZ EXTERNAL FIXATION CANNULATED RING MOUNT MRI CONDITIONAL","SUP-ITM-10039205","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.89","538.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.97","42.9","","731.00","63.70","731.00","1 through 10","222.55","570.72","percent of total billed charges",""
"BONE SCREW BOLT SCHANZ EXTERNAL FIXATION CANNULATED RING MOUNT MRI CONDITIONAL","SUP-ITM-10039205","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.89","538.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.97","42.9","","384.74","384.74","384.74","1 through 10","222.55","570.72","percent of total billed charges",""
"BONE SCREW BOLT SCHANZ EXTERNAL FIXATION CANNULATED RING MOUNT MRI CONDITIONAL","SUP-ITM-10039205","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.89","538.42","WELLPOINT [1015]","HB AMC WELLPOINT","529.66","73.78","","286.63","119.22","1107.45","105","222.55","570.72","percent of total billed charges",""
"BONE SCREW BOLT SCHANZ EXTERNAL FIXATION CANNULATED RING MOUNT MRI CONDITIONAL","SUP-ITM-10039205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","717.89","538.42","AETNA [1001]","HB AMC AETNA HMO","501.09","69.8","","675.31","184.75","1721.50","286","375.17","586.66","percent of total billed charges",""
"BONE SCREW BOLT SCHANZ EXTERNAL FIXATION CANNULATED RING MOUNT MRI CONDITIONAL","SUP-ITM-10039205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","717.89","538.42","AETNA [1001]","HB AMC AETNA PPO","577.18","80.4","","1261.44","103.12","1514.10","21","375.17","586.66","percent of total billed charges",""
"BONE SCREW BOLT SCHANZ EXTERNAL FIXATION CANNULATED RING MOUNT MRI CONDITIONAL","SUP-ITM-10039205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","717.89","538.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","577.18","80.4","","1365.00","1365.00","1365.00","1 through 10","375.17","586.66","percent of total billed charges",""
"BONE SCREW BOLT SCHANZ EXTERNAL FIXATION CANNULATED RING MOUNT MRI CONDITIONAL","SUP-ITM-10039205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","717.89","538.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","586.66","81.72","","5157.68","5157.68","5157.68","1 through 10","375.17","586.66","percent of total billed charges",""
"BONE SCREW BOLT SCHANZ EXTERNAL FIXATION CANNULATED RING MOUNT MRI CONDITIONAL","SUP-ITM-10039205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","717.89","538.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","586.66","81.72","","431.26","71.26","1459.57","88","375.17","586.66","percent of total billed charges",""
"BONE SCREW CANNULATED CONNECTING WITH INTERNAL THREAD FOR PERCUTANIOUS INSERTION HANDLE","SUP-ITM-10038715","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.64","1159.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1228.78","79.5","","800.18","480.96","1887.97","195","479.15","1228.78","percent of total billed charges",""
"BONE SCREW CANNULATED CONNECTING WITH INTERNAL THREAD FOR PERCUTANIOUS INSERTION HANDLE","SUP-ITM-10038715","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.64","1159.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","823.83","53.3","","813.12","216.42","1444.50","81","479.15","1228.78","percent of total billed charges",""
"BONE SCREW CANNULATED CONNECTING WITH INTERNAL THREAD FOR PERCUTANIOUS INSERTION HANDLE","SUP-ITM-10038715","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.64","1159.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","479.15","31","","432.60","432.60","432.60","1 through 10","479.15","1228.78","percent of total billed charges",""
"BONE SCREW CANNULATED CONNECTING WITH INTERNAL THREAD FOR PERCUTANIOUS INSERTION HANDLE","SUP-ITM-10038715","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.64","1159.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","564.16","36.5","","148.37","54.89","631.39","94","479.15","1228.78","percent of total billed charges",""
"BONE SCREW CANNULATED CONNECTING WITH INTERNAL THREAD FOR PERCUTANIOUS INSERTION HANDLE","SUP-ITM-10038715","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.64","1159.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","591.98","38.3","","279.30","91.72","1116.77","266","479.15","1228.78","percent of total billed charges",""
"BONE SCREW CANNULATED CONNECTING WITH INTERNAL THREAD FOR PERCUTANIOUS INSERTION HANDLE","SUP-ITM-10038715","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.64","1159.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","663.08","42.9","","731.00","63.70","731.00","1 through 10","479.15","1228.78","percent of total billed charges",""
"BONE SCREW CANNULATED CONNECTING WITH INTERNAL THREAD FOR PERCUTANIOUS INSERTION HANDLE","SUP-ITM-10038715","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.64","1159.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","663.08","42.9","","384.74","384.74","384.74","1 through 10","479.15","1228.78","percent of total billed charges",""
"BONE SCREW CANNULATED CONNECTING WITH INTERNAL THREAD FOR PERCUTANIOUS INSERTION HANDLE","SUP-ITM-10038715","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.64","1159.23","WELLPOINT [1015]","HB AMC WELLPOINT","1140.37","73.78","","286.63","119.22","1107.45","105","479.15","1228.78","percent of total billed charges",""
"BONE SCREW CANNULATED CONNECTING WITH INTERNAL THREAD FOR PERCUTANIOUS INSERTION HANDLE","SUP-ITM-10038715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1545.64","1159.23","AETNA [1001]","HB AMC AETNA HMO","1078.86","69.8","","675.31","184.75","1721.50","286","807.75","1263.1","percent of total billed charges",""
"BONE SCREW CANNULATED CONNECTING WITH INTERNAL THREAD FOR PERCUTANIOUS INSERTION HANDLE","SUP-ITM-10038715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1545.64","1159.23","AETNA [1001]","HB AMC AETNA PPO","1242.69","80.4","","1261.44","103.12","1514.10","21","807.75","1263.1","percent of total billed charges",""
"BONE SCREW CANNULATED CONNECTING WITH INTERNAL THREAD FOR PERCUTANIOUS INSERTION HANDLE","SUP-ITM-10038715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1545.64","1159.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1242.69","80.4","","1365.00","1365.00","1365.00","1 through 10","807.75","1263.1","percent of total billed charges",""
"BONE SCREW CANNULATED CONNECTING WITH INTERNAL THREAD FOR PERCUTANIOUS INSERTION HANDLE","SUP-ITM-10038715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1545.64","1159.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1263.10","81.72","","5157.68","5157.68","5157.68","1 through 10","807.75","1263.1","percent of total billed charges",""
"BONE SCREW CANNULATED CONNECTING WITH INTERNAL THREAD FOR PERCUTANIOUS INSERTION HANDLE","SUP-ITM-10038715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1545.64","1159.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1263.10","81.72","","431.26","71.26","1459.57","88","807.75","1263.1","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1663.03","1247.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1322.11","79.5","","800.18","480.96","1887.97","195","515.54","1322.11","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1663.03","1247.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","886.39","53.3","","813.12","216.42","1444.50","81","515.54","1322.11","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1663.03","1247.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","515.54","31","","432.60","432.60","432.60","1 through 10","515.54","1322.11","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1663.03","1247.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","607.01","36.5","","148.37","54.89","631.39","94","515.54","1322.11","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1663.03","1247.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","636.94","38.3","","279.30","91.72","1116.77","266","515.54","1322.11","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1663.03","1247.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.44","42.9","","731.00","63.70","731.00","1 through 10","515.54","1322.11","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1663.03","1247.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.44","42.9","","384.74","384.74","384.74","1 through 10","515.54","1322.11","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","both","","","1663.03","1247.27","WELLPOINT [1015]","HB AMC WELLPOINT","1226.98","73.78","","286.63","119.22","1107.45","105","515.54","1322.11","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1663.03","1247.27","AETNA [1001]","HB AMC AETNA HMO","1160.79","69.8","","675.31","184.75","1721.50","286","869.1","1359.03","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1663.03","1247.27","AETNA [1001]","HB AMC AETNA PPO","1337.08","80.4","","1261.44","103.12","1514.10","21","869.1","1359.03","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1663.03","1247.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1337.08","80.4","","1365.00","1365.00","1365.00","1 through 10","869.1","1359.03","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1663.03","1247.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1359.03","81.72","","5157.68","5157.68","5157.68","1 through 10","869.1","1359.03","percent of total billed charges",""
"BONE SCREW CONNECTING CANNULATED STANDARD INSERTION HANDLE","SUP-ITM-10023284","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1663.03","1247.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1359.03","81.72","","431.26","71.26","1459.57","88","869.1","1359.03","percent of total billed charges",""
"BONE SCREW CONNECTING FOR TI SOLID HUMERAL NAIL","SUP-ITM-10027858","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.04","1249.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1324.50","79.5","","800.18","480.96","1887.97","195","516.47","1324.5","percent of total billed charges",""
"BONE SCREW CONNECTING FOR TI SOLID HUMERAL NAIL","SUP-ITM-10027858","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.04","1249.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","888.00","53.3","","813.12","216.42","1444.50","81","516.47","1324.5","percent of total billed charges",""
"BONE SCREW CONNECTING FOR TI SOLID HUMERAL NAIL","SUP-ITM-10027858","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.04","1249.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","516.47","31","","432.60","432.60","432.60","1 through 10","516.47","1324.5","percent of total billed charges",""
"BONE SCREW CONNECTING FOR TI SOLID HUMERAL NAIL","SUP-ITM-10027858","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.04","1249.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","608.10","36.5","","148.37","54.89","631.39","94","516.47","1324.5","percent of total billed charges",""
"BONE SCREW CONNECTING FOR TI SOLID HUMERAL NAIL","SUP-ITM-10027858","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.04","1249.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","638.09","38.3","","279.30","91.72","1116.77","266","516.47","1324.5","percent of total billed charges",""
"BONE SCREW CONNECTING FOR TI SOLID HUMERAL NAIL","SUP-ITM-10027858","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.04","1249.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.73","42.9","","731.00","63.70","731.00","1 through 10","516.47","1324.5","percent of total billed charges",""
"BONE SCREW CONNECTING FOR TI SOLID HUMERAL NAIL","SUP-ITM-10027858","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.04","1249.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.73","42.9","","384.74","384.74","384.74","1 through 10","516.47","1324.5","percent of total billed charges",""
"BONE SCREW CONNECTING FOR TI SOLID HUMERAL NAIL","SUP-ITM-10027858","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.04","1249.53","WELLPOINT [1015]","HB AMC WELLPOINT","1229.20","73.78","","286.63","119.22","1107.45","105","516.47","1324.5","percent of total billed charges",""
"BONE SCREW CONNECTING FOR TI SOLID HUMERAL NAIL","SUP-ITM-10027858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1666.04","1249.53","AETNA [1001]","HB AMC AETNA HMO","1162.90","69.8","","675.31","184.75","1721.50","286","870.67","1361.49","percent of total billed charges",""
"BONE SCREW CONNECTING FOR TI SOLID HUMERAL NAIL","SUP-ITM-10027858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1666.04","1249.53","AETNA [1001]","HB AMC AETNA PPO","1339.50","80.4","","1261.44","103.12","1514.10","21","870.67","1361.49","percent of total billed charges",""
"BONE SCREW CONNECTING FOR TI SOLID HUMERAL NAIL","SUP-ITM-10027858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1666.04","1249.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1339.50","80.4","","1365.00","1365.00","1365.00","1 through 10","870.67","1361.49","percent of total billed charges",""
"BONE SCREW CONNECTING FOR TI SOLID HUMERAL NAIL","SUP-ITM-10027858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1666.04","1249.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1361.49","81.72","","5157.68","5157.68","5157.68","1 through 10","870.67","1361.49","percent of total billed charges",""
"BONE SCREW CONNECTING FOR TI SOLID HUMERAL NAIL","SUP-ITM-10027858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1666.04","1249.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1361.49","81.72","","431.26","71.26","1459.57","88","870.67","1361.49","percent of total billed charges",""
"BONE SCREW CONNECTING INSERTER FOR TI SPIRAL BLADES","SUP-ITM-10039418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3429.90","2572.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2726.77","79.5","","800.18","480.96","1887.97","195","1063.27","2726.77","percent of total billed charges",""
"BONE SCREW CONNECTING INSERTER FOR TI SPIRAL BLADES","SUP-ITM-10039418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3429.90","2572.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1828.14","53.3","","813.12","216.42","1444.50","81","1063.27","2726.77","percent of total billed charges",""
"BONE SCREW CONNECTING INSERTER FOR TI SPIRAL BLADES","SUP-ITM-10039418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3429.90","2572.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1063.27","31","","432.60","432.60","432.60","1 through 10","1063.27","2726.77","percent of total billed charges",""
"BONE SCREW CONNECTING INSERTER FOR TI SPIRAL BLADES","SUP-ITM-10039418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3429.90","2572.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1251.91","36.5","","148.37","54.89","631.39","94","1063.27","2726.77","percent of total billed charges",""
"BONE SCREW CONNECTING INSERTER FOR TI SPIRAL BLADES","SUP-ITM-10039418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3429.90","2572.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1313.65","38.3","","279.30","91.72","1116.77","266","1063.27","2726.77","percent of total billed charges",""
"BONE SCREW CONNECTING INSERTER FOR TI SPIRAL BLADES","SUP-ITM-10039418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3429.90","2572.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1471.43","42.9","","731.00","63.70","731.00","1 through 10","1063.27","2726.77","percent of total billed charges",""
"BONE SCREW CONNECTING INSERTER FOR TI SPIRAL BLADES","SUP-ITM-10039418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3429.90","2572.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1471.43","42.9","","384.74","384.74","384.74","1 through 10","1063.27","2726.77","percent of total billed charges",""
"BONE SCREW CONNECTING INSERTER FOR TI SPIRAL BLADES","SUP-ITM-10039418","CDM","C1713","HCPCS","0278","RC","","","","both","","","3429.90","2572.42","WELLPOINT [1015]","HB AMC WELLPOINT","2530.58","73.78","","286.63","119.22","1107.45","105","1063.27","2726.77","percent of total billed charges",""
"BONE SCREW CONNECTING INSERTER FOR TI SPIRAL BLADES","SUP-ITM-10039418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3429.90","2572.42","AETNA [1001]","HB AMC AETNA HMO","2394.07","69.8","","675.31","184.75","1721.50","286","1792.47","2802.91","percent of total billed charges",""
"BONE SCREW CONNECTING INSERTER FOR TI SPIRAL BLADES","SUP-ITM-10039418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3429.90","2572.42","AETNA [1001]","HB AMC AETNA PPO","2757.64","80.4","","1261.44","103.12","1514.10","21","1792.47","2802.91","percent of total billed charges",""
"BONE SCREW CONNECTING INSERTER FOR TI SPIRAL BLADES","SUP-ITM-10039418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3429.90","2572.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2757.64","80.4","","1365.00","1365.00","1365.00","1 through 10","1792.47","2802.91","percent of total billed charges",""
"BONE SCREW CONNECTING INSERTER FOR TI SPIRAL BLADES","SUP-ITM-10039418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3429.90","2572.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2802.91","81.72","","5157.68","5157.68","5157.68","1 through 10","1792.47","2802.91","percent of total billed charges",""
"BONE SCREW CONNECTING INSERTER FOR TI SPIRAL BLADES","SUP-ITM-10039418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3429.90","2572.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2802.91","81.72","","431.26","71.26","1459.57","88","1792.47","2802.91","percent of total billed charges",""
"BONE SCREW CONNECTION HELICAL BLADE COUPLING TI","SUP-ITM-10015530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3095.79","2321.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2461.15","79.5","","800.18","480.96","1887.97","195","959.69","2461.15","percent of total billed charges",""
"BONE SCREW CONNECTION HELICAL BLADE COUPLING TI","SUP-ITM-10015530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3095.79","2321.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1650.06","53.3","","813.12","216.42","1444.50","81","959.69","2461.15","percent of total billed charges",""
"BONE SCREW CONNECTION HELICAL BLADE COUPLING TI","SUP-ITM-10015530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3095.79","2321.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","959.69","31","","432.60","432.60","432.60","1 through 10","959.69","2461.15","percent of total billed charges",""
"BONE SCREW CONNECTION HELICAL BLADE COUPLING TI","SUP-ITM-10015530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3095.79","2321.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1129.96","36.5","","148.37","54.89","631.39","94","959.69","2461.15","percent of total billed charges",""
"BONE SCREW CONNECTION HELICAL BLADE COUPLING TI","SUP-ITM-10015530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3095.79","2321.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1185.69","38.3","","279.30","91.72","1116.77","266","959.69","2461.15","percent of total billed charges",""
"BONE SCREW CONNECTION HELICAL BLADE COUPLING TI","SUP-ITM-10015530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3095.79","2321.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1328.09","42.9","","731.00","63.70","731.00","1 through 10","959.69","2461.15","percent of total billed charges",""
"BONE SCREW CONNECTION HELICAL BLADE COUPLING TI","SUP-ITM-10015530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3095.79","2321.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1328.09","42.9","","384.74","384.74","384.74","1 through 10","959.69","2461.15","percent of total billed charges",""
"BONE SCREW CONNECTION HELICAL BLADE COUPLING TI","SUP-ITM-10015530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3095.79","2321.84","WELLPOINT [1015]","HB AMC WELLPOINT","2284.07","73.78","","286.63","119.22","1107.45","105","959.69","2461.15","percent of total billed charges",""
"BONE SCREW CONNECTION HELICAL BLADE COUPLING TI","SUP-ITM-10015530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3095.79","2321.84","AETNA [1001]","HB AMC AETNA HMO","2160.86","69.8","","675.31","184.75","1721.50","286","1617.86","2529.88","percent of total billed charges",""
"BONE SCREW CONNECTION HELICAL BLADE COUPLING TI","SUP-ITM-10015530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3095.79","2321.84","AETNA [1001]","HB AMC AETNA PPO","2489.02","80.4","","1261.44","103.12","1514.10","21","1617.86","2529.88","percent of total billed charges",""
"BONE SCREW CONNECTION HELICAL BLADE COUPLING TI","SUP-ITM-10015530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3095.79","2321.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2489.02","80.4","","1365.00","1365.00","1365.00","1 through 10","1617.86","2529.88","percent of total billed charges",""
"BONE SCREW CONNECTION HELICAL BLADE COUPLING TI","SUP-ITM-10015530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3095.79","2321.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2529.88","81.72","","5157.68","5157.68","5157.68","1 through 10","1617.86","2529.88","percent of total billed charges",""
"BONE SCREW CONNECTION HELICAL BLADE COUPLING TI","SUP-ITM-10015530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3095.79","2321.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2529.88","81.72","","431.26","71.26","1459.57","88","1617.86","2529.88","percent of total billed charges",""
"BONE SCREW CRANIOMAXILLOFACIAL SET MATRIXMANDIBLE TI SLOTTED","SUP-ITM-10081126","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.91","310.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","329.06","79.5","","800.18","480.96","1887.97","195","128.31","329.06","percent of total billed charges",""
"BONE SCREW CRANIOMAXILLOFACIAL SET MATRIXMANDIBLE TI SLOTTED","SUP-ITM-10081126","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.91","310.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","220.61","53.3","","813.12","216.42","1444.50","81","128.31","329.06","percent of total billed charges",""
"BONE SCREW CRANIOMAXILLOFACIAL SET MATRIXMANDIBLE TI SLOTTED","SUP-ITM-10081126","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.91","310.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","128.31","31","","432.60","432.60","432.60","1 through 10","128.31","329.06","percent of total billed charges",""
"BONE SCREW CRANIOMAXILLOFACIAL SET MATRIXMANDIBLE TI SLOTTED","SUP-ITM-10081126","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.91","310.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","151.08","36.5","","148.37","54.89","631.39","94","128.31","329.06","percent of total billed charges",""
"BONE SCREW CRANIOMAXILLOFACIAL SET MATRIXMANDIBLE TI SLOTTED","SUP-ITM-10081126","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.91","310.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","158.53","38.3","","279.30","91.72","1116.77","266","128.31","329.06","percent of total billed charges",""
"BONE SCREW CRANIOMAXILLOFACIAL SET MATRIXMANDIBLE TI SLOTTED","SUP-ITM-10081126","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.91","310.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","177.57","42.9","","731.00","63.70","731.00","1 through 10","128.31","329.06","percent of total billed charges",""
"BONE SCREW CRANIOMAXILLOFACIAL SET MATRIXMANDIBLE TI SLOTTED","SUP-ITM-10081126","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.91","310.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","177.57","42.9","","384.74","384.74","384.74","1 through 10","128.31","329.06","percent of total billed charges",""
"BONE SCREW CRANIOMAXILLOFACIAL SET MATRIXMANDIBLE TI SLOTTED","SUP-ITM-10081126","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.91","310.43","WELLPOINT [1015]","HB AMC WELLPOINT","305.38","73.78","","286.63","119.22","1107.45","105","128.31","329.06","percent of total billed charges",""
"BONE SCREW CRANIOMAXILLOFACIAL SET MATRIXMANDIBLE TI SLOTTED","SUP-ITM-10081126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.91","310.43","AETNA [1001]","HB AMC AETNA HMO","288.91","69.8","","675.31","184.75","1721.50","286","216.31","338.25","percent of total billed charges",""
"BONE SCREW CRANIOMAXILLOFACIAL SET MATRIXMANDIBLE TI SLOTTED","SUP-ITM-10081126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.91","310.43","AETNA [1001]","HB AMC AETNA PPO","332.78","80.4","","1261.44","103.12","1514.10","21","216.31","338.25","percent of total billed charges",""
"BONE SCREW CRANIOMAXILLOFACIAL SET MATRIXMANDIBLE TI SLOTTED","SUP-ITM-10081126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.91","310.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","332.78","80.4","","1365.00","1365.00","1365.00","1 through 10","216.31","338.25","percent of total billed charges",""
"BONE SCREW CRANIOMAXILLOFACIAL SET MATRIXMANDIBLE TI SLOTTED","SUP-ITM-10081126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.91","310.43","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","338.25","81.72","","5157.68","5157.68","5157.68","1 through 10","216.31","338.25","percent of total billed charges",""
"BONE SCREW CRANIOMAXILLOFACIAL SET MATRIXMANDIBLE TI SLOTTED","SUP-ITM-10081126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.91","310.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","338.25","81.72","","431.26","71.26","1459.57","88","216.31","338.25","percent of total billed charges",""
"BONE SCREW FEMORAL CANNULATED CONNECTING TI NAIL","SUP-ITM-10027652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.87","759.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","805.23","79.5","","800.18","480.96","1887.97","195","313.99","805.23","percent of total billed charges",""
"BONE SCREW FEMORAL CANNULATED CONNECTING TI NAIL","SUP-ITM-10027652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.87","759.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","539.86","53.3","","813.12","216.42","1444.50","81","313.99","805.23","percent of total billed charges",""
"BONE SCREW FEMORAL CANNULATED CONNECTING TI NAIL","SUP-ITM-10027652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.87","759.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","313.99","31","","432.60","432.60","432.60","1 through 10","313.99","805.23","percent of total billed charges",""
"BONE SCREW FEMORAL CANNULATED CONNECTING TI NAIL","SUP-ITM-10027652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.87","759.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","369.70","36.5","","148.37","54.89","631.39","94","313.99","805.23","percent of total billed charges",""
"BONE SCREW FEMORAL CANNULATED CONNECTING TI NAIL","SUP-ITM-10027652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.87","759.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","387.93","38.3","","279.30","91.72","1116.77","266","313.99","805.23","percent of total billed charges",""
"BONE SCREW FEMORAL CANNULATED CONNECTING TI NAIL","SUP-ITM-10027652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.87","759.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.52","42.9","","731.00","63.70","731.00","1 through 10","313.99","805.23","percent of total billed charges",""
"BONE SCREW FEMORAL CANNULATED CONNECTING TI NAIL","SUP-ITM-10027652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.87","759.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.52","42.9","","384.74","384.74","384.74","1 through 10","313.99","805.23","percent of total billed charges",""
"BONE SCREW FEMORAL CANNULATED CONNECTING TI NAIL","SUP-ITM-10027652","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.87","759.65","WELLPOINT [1015]","HB AMC WELLPOINT","747.30","73.78","","286.63","119.22","1107.45","105","313.99","805.23","percent of total billed charges",""
"BONE SCREW FEMORAL CANNULATED CONNECTING TI NAIL","SUP-ITM-10027652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.87","759.65","AETNA [1001]","HB AMC AETNA HMO","706.98","69.8","","675.31","184.75","1721.50","286","529.33","827.72","percent of total billed charges",""
"BONE SCREW FEMORAL CANNULATED CONNECTING TI NAIL","SUP-ITM-10027652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.87","759.65","AETNA [1001]","HB AMC AETNA PPO","814.35","80.4","","1261.44","103.12","1514.10","21","529.33","827.72","percent of total billed charges",""
"BONE SCREW FEMORAL CANNULATED CONNECTING TI NAIL","SUP-ITM-10027652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.87","759.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","814.35","80.4","","1365.00","1365.00","1365.00","1 through 10","529.33","827.72","percent of total billed charges",""
"BONE SCREW FEMORAL CANNULATED CONNECTING TI NAIL","SUP-ITM-10027652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.87","759.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","827.72","81.72","","5157.68","5157.68","5157.68","1 through 10","529.33","827.72","percent of total billed charges",""
"BONE SCREW FEMORAL CANNULATED CONNECTING TI NAIL","SUP-ITM-10027652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.87","759.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","827.72","81.72","","431.26","71.26","1459.57","88","529.33","827.72","percent of total billed charges",""
"BONE SCREW FEMORAL CONNECTING FOR TI DISTAL NAILS","SUP-ITM-10039411","CDM","C1713","HCPCS","0278","RC","","","","both","","","1675.07","1256.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1331.68","79.5","","800.18","480.96","1887.97","195","519.27","1331.68","percent of total billed charges",""
"BONE SCREW FEMORAL CONNECTING FOR TI DISTAL NAILS","SUP-ITM-10039411","CDM","C1713","HCPCS","0278","RC","","","","both","","","1675.07","1256.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","892.81","53.3","","813.12","216.42","1444.50","81","519.27","1331.68","percent of total billed charges",""
"BONE SCREW FEMORAL CONNECTING FOR TI DISTAL NAILS","SUP-ITM-10039411","CDM","C1713","HCPCS","0278","RC","","","","both","","","1675.07","1256.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","519.27","31","","432.60","432.60","432.60","1 through 10","519.27","1331.68","percent of total billed charges",""
"BONE SCREW FEMORAL CONNECTING FOR TI DISTAL NAILS","SUP-ITM-10039411","CDM","C1713","HCPCS","0278","RC","","","","both","","","1675.07","1256.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","611.40","36.5","","148.37","54.89","631.39","94","519.27","1331.68","percent of total billed charges",""
"BONE SCREW FEMORAL CONNECTING FOR TI DISTAL NAILS","SUP-ITM-10039411","CDM","C1713","HCPCS","0278","RC","","","","both","","","1675.07","1256.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","641.55","38.3","","279.30","91.72","1116.77","266","519.27","1331.68","percent of total billed charges",""
"BONE SCREW FEMORAL CONNECTING FOR TI DISTAL NAILS","SUP-ITM-10039411","CDM","C1713","HCPCS","0278","RC","","","","both","","","1675.07","1256.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","718.61","42.9","","731.00","63.70","731.00","1 through 10","519.27","1331.68","percent of total billed charges",""
"BONE SCREW FEMORAL CONNECTING FOR TI DISTAL NAILS","SUP-ITM-10039411","CDM","C1713","HCPCS","0278","RC","","","","both","","","1675.07","1256.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","718.61","42.9","","384.74","384.74","384.74","1 through 10","519.27","1331.68","percent of total billed charges",""
"BONE SCREW FEMORAL CONNECTING FOR TI DISTAL NAILS","SUP-ITM-10039411","CDM","C1713","HCPCS","0278","RC","","","","both","","","1675.07","1256.30","WELLPOINT [1015]","HB AMC WELLPOINT","1235.87","73.78","","286.63","119.22","1107.45","105","519.27","1331.68","percent of total billed charges",""
"BONE SCREW FEMORAL CONNECTING FOR TI DISTAL NAILS","SUP-ITM-10039411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1675.07","1256.30","AETNA [1001]","HB AMC AETNA HMO","1169.20","69.8","","675.31","184.75","1721.50","286","875.39","1368.87","percent of total billed charges",""
"BONE SCREW FEMORAL CONNECTING FOR TI DISTAL NAILS","SUP-ITM-10039411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1675.07","1256.30","AETNA [1001]","HB AMC AETNA PPO","1346.76","80.4","","1261.44","103.12","1514.10","21","875.39","1368.87","percent of total billed charges",""
"BONE SCREW FEMORAL CONNECTING FOR TI DISTAL NAILS","SUP-ITM-10039411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1675.07","1256.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1346.76","80.4","","1365.00","1365.00","1365.00","1 through 10","875.39","1368.87","percent of total billed charges",""
"BONE SCREW FEMORAL CONNECTING FOR TI DISTAL NAILS","SUP-ITM-10039411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1675.07","1256.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1368.87","81.72","","5157.68","5157.68","5157.68","1 through 10","875.39","1368.87","percent of total billed charges",""
"BONE SCREW FEMORAL CONNECTING FOR TI DISTAL NAILS","SUP-ITM-10039411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1675.07","1256.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1368.87","81.72","","431.26","71.26","1459.57","88","875.39","1368.87","percent of total billed charges",""
"BONE SCREW FIXATION NAIL PERCUTANEOUS CANNULATED CONNECTING TROCH","SUP-ITM-10094986","CDM","C1713","HCPCS","0278","RC","","","","both","","","1717.21","1287.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1365.18","79.5","","800.18","480.96","1887.97","195","532.34","1365.18","percent of total billed charges",""
"BONE SCREW FIXATION NAIL PERCUTANEOUS CANNULATED CONNECTING TROCH","SUP-ITM-10094986","CDM","C1713","HCPCS","0278","RC","","","","both","","","1717.21","1287.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","915.27","53.3","","813.12","216.42","1444.50","81","532.34","1365.18","percent of total billed charges",""
"BONE SCREW FIXATION NAIL PERCUTANEOUS CANNULATED CONNECTING TROCH","SUP-ITM-10094986","CDM","C1713","HCPCS","0278","RC","","","","both","","","1717.21","1287.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","532.34","31","","432.60","432.60","432.60","1 through 10","532.34","1365.18","percent of total billed charges",""
"BONE SCREW FIXATION NAIL PERCUTANEOUS CANNULATED CONNECTING TROCH","SUP-ITM-10094986","CDM","C1713","HCPCS","0278","RC","","","","both","","","1717.21","1287.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","626.78","36.5","","148.37","54.89","631.39","94","532.34","1365.18","percent of total billed charges",""
"BONE SCREW FIXATION NAIL PERCUTANEOUS CANNULATED CONNECTING TROCH","SUP-ITM-10094986","CDM","C1713","HCPCS","0278","RC","","","","both","","","1717.21","1287.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","657.69","38.3","","279.30","91.72","1116.77","266","532.34","1365.18","percent of total billed charges",""
"BONE SCREW FIXATION NAIL PERCUTANEOUS CANNULATED CONNECTING TROCH","SUP-ITM-10094986","CDM","C1713","HCPCS","0278","RC","","","","both","","","1717.21","1287.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","736.68","42.9","","731.00","63.70","731.00","1 through 10","532.34","1365.18","percent of total billed charges",""
"BONE SCREW FIXATION NAIL PERCUTANEOUS CANNULATED CONNECTING TROCH","SUP-ITM-10094986","CDM","C1713","HCPCS","0278","RC","","","","both","","","1717.21","1287.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","736.68","42.9","","384.74","384.74","384.74","1 through 10","532.34","1365.18","percent of total billed charges",""
"BONE SCREW FIXATION NAIL PERCUTANEOUS CANNULATED CONNECTING TROCH","SUP-ITM-10094986","CDM","C1713","HCPCS","0278","RC","","","","both","","","1717.21","1287.91","WELLPOINT [1015]","HB AMC WELLPOINT","1266.96","73.78","","286.63","119.22","1107.45","105","532.34","1365.18","percent of total billed charges",""
"BONE SCREW FIXATION NAIL PERCUTANEOUS CANNULATED CONNECTING TROCH","SUP-ITM-10094986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1717.21","1287.91","AETNA [1001]","HB AMC AETNA HMO","1198.61","69.8","","675.31","184.75","1721.50","286","897.41","1403.3","percent of total billed charges",""
"BONE SCREW FIXATION NAIL PERCUTANEOUS CANNULATED CONNECTING TROCH","SUP-ITM-10094986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1717.21","1287.91","AETNA [1001]","HB AMC AETNA PPO","1380.64","80.4","","1261.44","103.12","1514.10","21","897.41","1403.3","percent of total billed charges",""
"BONE SCREW FIXATION NAIL PERCUTANEOUS CANNULATED CONNECTING TROCH","SUP-ITM-10094986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1717.21","1287.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1380.64","80.4","","1365.00","1365.00","1365.00","1 through 10","897.41","1403.3","percent of total billed charges",""
"BONE SCREW FIXATION NAIL PERCUTANEOUS CANNULATED CONNECTING TROCH","SUP-ITM-10094986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1717.21","1287.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1403.30","81.72","","5157.68","5157.68","5157.68","1 through 10","897.41","1403.3","percent of total billed charges",""
"BONE SCREW FIXATION NAIL PERCUTANEOUS CANNULATED CONNECTING TROCH","SUP-ITM-10094986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1717.21","1287.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1403.30","81.72","","431.26","71.26","1459.57","88","897.41","1403.3","percent of total billed charges",""
"BONE SCREW HUMERAL COUPLING SPIRAL BLADE FOR TI SOLID NAIL","SUP-ITM-10039452","CDM","C1713","HCPCS","0278","RC","","","","both","","","2210.85","1658.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1757.63","79.5","","800.18","480.96","1887.97","195","685.36","1757.63","percent of total billed charges",""
"BONE SCREW HUMERAL COUPLING SPIRAL BLADE FOR TI SOLID NAIL","SUP-ITM-10039452","CDM","C1713","HCPCS","0278","RC","","","","both","","","2210.85","1658.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1178.38","53.3","","813.12","216.42","1444.50","81","685.36","1757.63","percent of total billed charges",""
"BONE SCREW HUMERAL COUPLING SPIRAL BLADE FOR TI SOLID NAIL","SUP-ITM-10039452","CDM","C1713","HCPCS","0278","RC","","","","both","","","2210.85","1658.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","685.36","31","","432.60","432.60","432.60","1 through 10","685.36","1757.63","percent of total billed charges",""
"BONE SCREW HUMERAL COUPLING SPIRAL BLADE FOR TI SOLID NAIL","SUP-ITM-10039452","CDM","C1713","HCPCS","0278","RC","","","","both","","","2210.85","1658.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","806.96","36.5","","148.37","54.89","631.39","94","685.36","1757.63","percent of total billed charges",""
"BONE SCREW HUMERAL COUPLING SPIRAL BLADE FOR TI SOLID NAIL","SUP-ITM-10039452","CDM","C1713","HCPCS","0278","RC","","","","both","","","2210.85","1658.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","846.76","38.3","","279.30","91.72","1116.77","266","685.36","1757.63","percent of total billed charges",""
"BONE SCREW HUMERAL COUPLING SPIRAL BLADE FOR TI SOLID NAIL","SUP-ITM-10039452","CDM","C1713","HCPCS","0278","RC","","","","both","","","2210.85","1658.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","948.45","42.9","","731.00","63.70","731.00","1 through 10","685.36","1757.63","percent of total billed charges",""
"BONE SCREW HUMERAL COUPLING SPIRAL BLADE FOR TI SOLID NAIL","SUP-ITM-10039452","CDM","C1713","HCPCS","0278","RC","","","","both","","","2210.85","1658.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","948.45","42.9","","384.74","384.74","384.74","1 through 10","685.36","1757.63","percent of total billed charges",""
"BONE SCREW HUMERAL COUPLING SPIRAL BLADE FOR TI SOLID NAIL","SUP-ITM-10039452","CDM","C1713","HCPCS","0278","RC","","","","both","","","2210.85","1658.14","WELLPOINT [1015]","HB AMC WELLPOINT","1631.17","73.78","","286.63","119.22","1107.45","105","685.36","1757.63","percent of total billed charges",""
"BONE SCREW HUMERAL COUPLING SPIRAL BLADE FOR TI SOLID NAIL","SUP-ITM-10039452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2210.85","1658.14","AETNA [1001]","HB AMC AETNA HMO","1543.17","69.8","","675.31","184.75","1721.50","286","1155.39","1806.71","percent of total billed charges",""
"BONE SCREW HUMERAL COUPLING SPIRAL BLADE FOR TI SOLID NAIL","SUP-ITM-10039452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2210.85","1658.14","AETNA [1001]","HB AMC AETNA PPO","1777.52","80.4","","1261.44","103.12","1514.10","21","1155.39","1806.71","percent of total billed charges",""
"BONE SCREW HUMERAL COUPLING SPIRAL BLADE FOR TI SOLID NAIL","SUP-ITM-10039452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2210.85","1658.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1777.52","80.4","","1365.00","1365.00","1365.00","1 through 10","1155.39","1806.71","percent of total billed charges",""
"BONE SCREW HUMERAL COUPLING SPIRAL BLADE FOR TI SOLID NAIL","SUP-ITM-10039452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2210.85","1658.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1806.71","81.72","","5157.68","5157.68","5157.68","1 through 10","1155.39","1806.71","percent of total billed charges",""
"BONE SCREW HUMERAL COUPLING SPIRAL BLADE FOR TI SOLID NAIL","SUP-ITM-10039452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2210.85","1658.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1806.71","81.72","","431.26","71.26","1459.57","88","1155.39","1806.71","percent of total billed charges",""
"BONE SCREW L100MMXD10.5 TFN ADVANCED TI CANNULATED FEMORAL","SUP-ITM-10164418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1222.05","79.5","","800.18","480.96","1887.97","195","476.52","1222.05","percent of total billed charges",""
"BONE SCREW L100MMXD10.5 TFN ADVANCED TI CANNULATED FEMORAL","SUP-ITM-10164418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","819.31","53.3","","813.12","216.42","1444.50","81","476.52","1222.05","percent of total billed charges",""
"BONE SCREW L100MMXD10.5 TFN ADVANCED TI CANNULATED FEMORAL","SUP-ITM-10164418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","476.52","31","","432.60","432.60","432.60","1 through 10","476.52","1222.05","percent of total billed charges",""
"BONE SCREW L100MMXD10.5 TFN ADVANCED TI CANNULATED FEMORAL","SUP-ITM-10164418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","561.07","36.5","","148.37","54.89","631.39","94","476.52","1222.05","percent of total billed charges",""
"BONE SCREW L100MMXD10.5 TFN ADVANCED TI CANNULATED FEMORAL","SUP-ITM-10164418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","588.74","38.3","","279.30","91.72","1116.77","266","476.52","1222.05","percent of total billed charges",""
"BONE SCREW L100MMXD10.5 TFN ADVANCED TI CANNULATED FEMORAL","SUP-ITM-10164418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","659.45","42.9","","731.00","63.70","731.00","1 through 10","476.52","1222.05","percent of total billed charges",""
"BONE SCREW L100MMXD10.5 TFN ADVANCED TI CANNULATED FEMORAL","SUP-ITM-10164418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","659.45","42.9","","384.74","384.74","384.74","1 through 10","476.52","1222.05","percent of total billed charges",""
"BONE SCREW L100MMXD10.5 TFN ADVANCED TI CANNULATED FEMORAL","SUP-ITM-10164418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","WELLPOINT [1015]","HB AMC WELLPOINT","1134.12","73.78","","286.63","119.22","1107.45","105","476.52","1222.05","percent of total billed charges",""
"BONE SCREW L100MMXD10.5 TFN ADVANCED TI CANNULATED FEMORAL","SUP-ITM-10164418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","AETNA [1001]","HB AMC AETNA HMO","1072.94","69.8","","675.31","184.75","1721.50","286","803.33","1256.18","percent of total billed charges",""
"BONE SCREW L100MMXD10.5 TFN ADVANCED TI CANNULATED FEMORAL","SUP-ITM-10164418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","AETNA [1001]","HB AMC AETNA PPO","1235.88","80.4","","1261.44","103.12","1514.10","21","803.33","1256.18","percent of total billed charges",""
"BONE SCREW L100MMXD10.5 TFN ADVANCED TI CANNULATED FEMORAL","SUP-ITM-10164418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1235.88","80.4","","1365.00","1365.00","1365.00","1 through 10","803.33","1256.18","percent of total billed charges",""
"BONE SCREW L100MMXD10.5 TFN ADVANCED TI CANNULATED FEMORAL","SUP-ITM-10164418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1256.18","81.72","","5157.68","5157.68","5157.68","1 through 10","803.33","1256.18","percent of total billed charges",""
"BONE SCREW L100MMXD10.5 TFN ADVANCED TI CANNULATED FEMORAL","SUP-ITM-10164418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1256.18","81.72","","431.26","71.26","1459.57","88","803.33","1256.18","percent of total billed charges",""
"BONE SCREW TROCHANTER CONNECTING CANNULATED FIXATION NAIL","SUP-ITM-10014062","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.98","1010.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1070.85","79.5","","800.18","480.96","1887.97","195","417.56","1070.85","percent of total billed charges",""
"BONE SCREW TROCHANTER CONNECTING CANNULATED FIXATION NAIL","SUP-ITM-10014062","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.98","1010.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","717.94","53.3","","813.12","216.42","1444.50","81","417.56","1070.85","percent of total billed charges",""
"BONE SCREW TROCHANTER CONNECTING CANNULATED FIXATION NAIL","SUP-ITM-10014062","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.98","1010.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","417.56","31","","432.60","432.60","432.60","1 through 10","417.56","1070.85","percent of total billed charges",""
"BONE SCREW TROCHANTER CONNECTING CANNULATED FIXATION NAIL","SUP-ITM-10014062","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.98","1010.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","491.65","36.5","","148.37","54.89","631.39","94","417.56","1070.85","percent of total billed charges",""
"BONE SCREW TROCHANTER CONNECTING CANNULATED FIXATION NAIL","SUP-ITM-10014062","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.98","1010.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","515.89","38.3","","279.30","91.72","1116.77","266","417.56","1070.85","percent of total billed charges",""
"BONE SCREW TROCHANTER CONNECTING CANNULATED FIXATION NAIL","SUP-ITM-10014062","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.98","1010.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","577.85","42.9","","731.00","63.70","731.00","1 through 10","417.56","1070.85","percent of total billed charges",""
"BONE SCREW TROCHANTER CONNECTING CANNULATED FIXATION NAIL","SUP-ITM-10014062","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.98","1010.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","577.85","42.9","","384.74","384.74","384.74","1 through 10","417.56","1070.85","percent of total billed charges",""
"BONE SCREW TROCHANTER CONNECTING CANNULATED FIXATION NAIL","SUP-ITM-10014062","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.98","1010.23","WELLPOINT [1015]","HB AMC WELLPOINT","993.80","73.78","","286.63","119.22","1107.45","105","417.56","1070.85","percent of total billed charges",""
"BONE SCREW TROCHANTER CONNECTING CANNULATED FIXATION NAIL","SUP-ITM-10014062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.98","1010.23","AETNA [1001]","HB AMC AETNA HMO","940.19","69.8","","675.31","184.75","1721.50","286","703.93","1100.75","percent of total billed charges",""
"BONE SCREW TROCHANTER CONNECTING CANNULATED FIXATION NAIL","SUP-ITM-10014062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.98","1010.23","AETNA [1001]","HB AMC AETNA PPO","1082.97","80.4","","1261.44","103.12","1514.10","21","703.93","1100.75","percent of total billed charges",""
"BONE SCREW TROCHANTER CONNECTING CANNULATED FIXATION NAIL","SUP-ITM-10014062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.98","1010.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1082.97","80.4","","1365.00","1365.00","1365.00","1 through 10","703.93","1100.75","percent of total billed charges",""
"BONE SCREW TROCHANTER CONNECTING CANNULATED FIXATION NAIL","SUP-ITM-10014062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.98","1010.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1100.75","81.72","","5157.68","5157.68","5157.68","1 through 10","703.93","1100.75","percent of total billed charges",""
"BONE SCREW TROCHANTER CONNECTING CANNULATED FIXATION NAIL","SUP-ITM-10014062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.98","1010.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1100.75","81.72","","431.26","71.26","1459.57","88","703.93","1100.75","percent of total billed charges",""
"BONE SCREW.AXS.S.T.1.7X10MM.5P","SUP-ITM-10328179","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.76","278.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","294.75","79.5","","800.18","480.96","1887.97","195","114.94","294.75","percent of total billed charges",""
"BONE SCREW.AXS.S.T.1.7X10MM.5P","SUP-ITM-10328179","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.76","278.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","197.62","53.3","","813.12","216.42","1444.50","81","114.94","294.75","percent of total billed charges",""
"BONE SCREW.AXS.S.T.1.7X10MM.5P","SUP-ITM-10328179","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.76","278.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","114.94","31","","432.60","432.60","432.60","1 through 10","114.94","294.75","percent of total billed charges",""
"BONE SCREW.AXS.S.T.1.7X10MM.5P","SUP-ITM-10328179","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.76","278.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","135.33","36.5","","148.37","54.89","631.39","94","114.94","294.75","percent of total billed charges",""
"BONE SCREW.AXS.S.T.1.7X10MM.5P","SUP-ITM-10328179","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.76","278.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.00","38.3","","279.30","91.72","1116.77","266","114.94","294.75","percent of total billed charges",""
"BONE SCREW.AXS.S.T.1.7X10MM.5P","SUP-ITM-10328179","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.76","278.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.06","42.9","","731.00","63.70","731.00","1 through 10","114.94","294.75","percent of total billed charges",""
"BONE SCREW.AXS.S.T.1.7X10MM.5P","SUP-ITM-10328179","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.76","278.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.06","42.9","","384.74","384.74","384.74","1 through 10","114.94","294.75","percent of total billed charges",""
"BONE SCREW.AXS.S.T.1.7X10MM.5P","SUP-ITM-10328179","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.76","278.07","WELLPOINT [1015]","HB AMC WELLPOINT","273.55","73.78","","286.63","119.22","1107.45","105","114.94","294.75","percent of total billed charges",""
"BONE SCREW.AXS.S.T.1.7X10MM.5P","SUP-ITM-10328179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","370.76","278.07","AETNA [1001]","HB AMC AETNA HMO","258.79","69.8","","675.31","184.75","1721.50","286","193.76","302.99","percent of total billed charges",""
"BONE SCREW.AXS.S.T.1.7X10MM.5P","SUP-ITM-10328179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","370.76","278.07","AETNA [1001]","HB AMC AETNA PPO","298.09","80.4","","1261.44","103.12","1514.10","21","193.76","302.99","percent of total billed charges",""
"BONE SCREW.AXS.S.T.1.7X10MM.5P","SUP-ITM-10328179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","370.76","278.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","298.09","80.4","","1365.00","1365.00","1365.00","1 through 10","193.76","302.99","percent of total billed charges",""
"BONE SCREW.AXS.S.T.1.7X10MM.5P","SUP-ITM-10328179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","370.76","278.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","302.99","81.72","","5157.68","5157.68","5157.68","1 through 10","193.76","302.99","percent of total billed charges",""
"BONE SCREW.AXS.S.T.1.7X10MM.5P","SUP-ITM-10328179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","370.76","278.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","302.99","81.72","","431.26","71.26","1459.57","88","193.76","302.99","percent of total billed charges",""
"BONE SPACER 13MMXTO 23 27 TISSUE FROZEN FEMORAL RING ALLOGRAFT NARROW ANTEROLATERAL IRRADIATED","SUP-ITM-10010676","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6075.06","79.5","","1309.77","674.56","6049.93","26","2368.89","6075.06","percent of total billed charges",""
"BONE SPACER 13MMXTO 23 27 TISSUE FROZEN FEMORAL RING ALLOGRAFT NARROW ANTEROLATERAL IRRADIATED","SUP-ITM-10010676","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4072.96","53.3","","1901.83","1901.83","2962.25","1 through 10","2368.89","6075.06","percent of total billed charges",""
"BONE SPACER 13MMXTO 23 27 TISSUE FROZEN FEMORAL RING ALLOGRAFT NARROW ANTEROLATERAL IRRADIATED","SUP-ITM-10010676","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2789.18","36.5","","1620.31","1620.31","19908.88","1 through 10","2368.89","6075.06","percent of total billed charges",""
"BONE SPACER 13MMXTO 23 27 TISSUE FROZEN FEMORAL RING ALLOGRAFT NARROW ANTEROLATERAL IRRADIATED","SUP-ITM-10010676","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2926.73","38.3","","352.91","352.91","2046.30","1 through 10","2368.89","6075.06","percent of total billed charges",""
"BONE SPACER 13MMXTO 23 27 TISSUE FROZEN FEMORAL RING ALLOGRAFT NARROW ANTEROLATERAL IRRADIATED","SUP-ITM-10010676","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3278.24","42.9","","9668.75","9668.75","9668.75","1 through 10","2368.89","6075.06","percent of total billed charges",""
"BONE SPACER 13MMXTO 23 27 TISSUE FROZEN FEMORAL RING ALLOGRAFT NARROW ANTEROLATERAL IRRADIATED","SUP-ITM-10010676","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","WELLPOINT [1015]","HB AMC WELLPOINT","5637.96","73.78","","699.88","384.10","3443.31","33","2368.89","6075.06","percent of total billed charges",""
"BONE SPACER 13MMXTO 23 27 TISSUE FROZEN FEMORAL RING ALLOGRAFT NARROW ANTEROLATERAL IRRADIATED","SUP-ITM-10010676","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7641.58","5731.18","AETNA [1001]","HB AMC AETNA HMO","5333.82","69.8","","1421.24","264.50","4933.46","29","3993.49","6244.7","percent of total billed charges",""
"BONE SPACER 13MMXTO 23 27 TISSUE FROZEN FEMORAL RING ALLOGRAFT NARROW ANTEROLATERAL IRRADIATED","SUP-ITM-10010676","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7641.58","5731.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6143.83","80.4","","1022.97","1022.97","3607.50","1 through 10","3993.49","6244.7","percent of total billed charges",""
"BONE SPACER 13MMXTO 23 27 TISSUE FROZEN FEMORAL RING ALLOGRAFT NARROW ANTEROLATERAL IRRADIATED","SUP-ITM-10010676","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7641.58","5731.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6244.70","81.72","","3010.54","693.88","5019.88","35","3993.49","6244.7","percent of total billed charges",""
"BONE SPACER 13X23 TO 27MM SPINE ALLOGRAFT FRA ANTERIOR FREEZE DRIED NARROW","SUP-ITM-10048764","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6075.06","79.5","","1309.77","674.56","6049.93","26","2368.89","6075.06","percent of total billed charges",""
"BONE SPACER 13X23 TO 27MM SPINE ALLOGRAFT FRA ANTERIOR FREEZE DRIED NARROW","SUP-ITM-10048764","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4072.96","53.3","","1901.83","1901.83","2962.25","1 through 10","2368.89","6075.06","percent of total billed charges",""
"BONE SPACER 13X23 TO 27MM SPINE ALLOGRAFT FRA ANTERIOR FREEZE DRIED NARROW","SUP-ITM-10048764","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2789.18","36.5","","1620.31","1620.31","19908.88","1 through 10","2368.89","6075.06","percent of total billed charges",""
"BONE SPACER 13X23 TO 27MM SPINE ALLOGRAFT FRA ANTERIOR FREEZE DRIED NARROW","SUP-ITM-10048764","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2926.73","38.3","","352.91","352.91","2046.30","1 through 10","2368.89","6075.06","percent of total billed charges",""
"BONE SPACER 13X23 TO 27MM SPINE ALLOGRAFT FRA ANTERIOR FREEZE DRIED NARROW","SUP-ITM-10048764","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3278.24","42.9","","9668.75","9668.75","9668.75","1 through 10","2368.89","6075.06","percent of total billed charges",""
"BONE SPACER 13X23 TO 27MM SPINE ALLOGRAFT FRA ANTERIOR FREEZE DRIED NARROW","SUP-ITM-10048764","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","WELLPOINT [1015]","HB AMC WELLPOINT","5637.96","73.78","","699.88","384.10","3443.31","33","2368.89","6075.06","percent of total billed charges",""
"BONE SPACER 13X23 TO 27MM SPINE ALLOGRAFT FRA ANTERIOR FREEZE DRIED NARROW","SUP-ITM-10048764","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7641.58","5731.18","AETNA [1001]","HB AMC AETNA HMO","5333.82","69.8","","1421.24","264.50","4933.46","29","3993.49","6244.7","percent of total billed charges",""
"BONE SPACER 13X23 TO 27MM SPINE ALLOGRAFT FRA ANTERIOR FREEZE DRIED NARROW","SUP-ITM-10048764","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7641.58","5731.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6143.83","80.4","","1022.97","1022.97","3607.50","1 through 10","3993.49","6244.7","percent of total billed charges",""
"BONE SPACER 13X23 TO 27MM SPINE ALLOGRAFT FRA ANTERIOR FREEZE DRIED NARROW","SUP-ITM-10048764","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7641.58","5731.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6244.70","81.72","","3010.54","693.88","5019.88","35","3993.49","6244.7","percent of total billed charges",""
"Boot Pneumatic Prefab Customized to Fit Pt T1","PX-27000533","CDM","L4360","HCPCS","0274","RC","","","","both","","","203.67","152.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.01","38.3","","79.63","79.63","79.63","1 through 10","63.14","519.9","percent of total billed charges",""
"Boot Pneumatic Prefab Customized to Fit Pt T1","PX-27000533","CDM","L4360","HCPCS","0274","RC","","","","outpatient","","","203.67","152.75","AETNA [1001]","HB AMC AETNA HMO","142.16","69.8","","137.88","137.88","137.88","1 through 10","101.84","863.63","percent of total billed charges",""
"Bordetella Antibody","PX-30000889","CDM","86615","CPT","0302","RC","","","","both","","","219.00","164.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","79.94","36.5","","76.74","76.74","76.74","1 through 10","12.93","208.05","percent of total billed charges",""
"Bordetella Antibody","PX-30000889","CDM","86615","CPT","0302","RC","","","","outpatient","","","219.00","164.25","AETNA [1001]","HB AMC AETNA PPO","176.08","80.4","","222.18","222.18","222.18","1 through 10","13.6","178.97","percent of total billed charges",""
"Borrelia Antibody","PX-30000895","CDM","86619","CPT","0302","RC","","","","both","","","229.00","171.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","122.06","53.3","","234.43","234.43","234.43","1 through 10","13.11","217.55","percent of total billed charges",""
"Borrelia Antibody","PX-30000895","CDM","86619","CPT","0302","RC","","","","both","","","229.00","171.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.71","38.3","","86.80","86.80","86.80","1 through 10","13.11","217.55","percent of total billed charges",""
"Borrelia Antibody","PX-30000895","CDM","86619","CPT","0302","RC","","","","outpatient","","","229.00","171.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","187.14","81.72","","177.47","177.47","354.93","1 through 10","13.8","187.14","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"BOX COMPONENT 67.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016619","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 67.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016619","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3213.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 67.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016619","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.51","36.5","","1023.42","771.29","2068.67","33","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 67.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016619","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.28","38.3","","850.52","759.78","1211.25","66","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 67.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016619","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 67.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016619","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","956.46","956.46","956.46","1 through 10","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 67.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016619","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","WELLPOINT [1015]","HB AMC WELLPOINT","2982.56","73.78","","2344.73","1619.47","2530.35","16","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 67.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016619","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA HMO","2821.67","69.8","","1523.63","988.41","4330.26","39","2112.61","3303.53","percent of total billed charges",""
"BOX COMPONENT 67.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016619","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA PPO","3250.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2112.61","3303.53","percent of total billed charges",""
"BOX COMPONENT 67.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016619","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","2112.61","3303.53","percent of total billed charges",""
"BOX COMPONENT 67.5MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED LEFT","SUP-ITM-10016619","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.53","81.72","","1738.90","1484.65","2716.94","38","2112.61","3303.53","percent of total billed charges",""
"BOX COMPONENT 80.0MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED RIGHT","SUP-ITM-10029226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3213.79","79.5","","800.18","480.96","1887.97","195","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 80.0MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED RIGHT","SUP-ITM-10029226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2154.65","53.3","","813.12","216.42","1444.50","81","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 80.0MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED RIGHT","SUP-ITM-10029226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1253.18","31","","432.60","432.60","432.60","1 through 10","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 80.0MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED RIGHT","SUP-ITM-10029226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.51","36.5","","148.37","54.89","631.39","94","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 80.0MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED RIGHT","SUP-ITM-10029226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.28","38.3","","279.30","91.72","1116.77","266","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 80.0MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED RIGHT","SUP-ITM-10029226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","731.00","63.70","731.00","1 through 10","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 80.0MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED RIGHT","SUP-ITM-10029226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","384.74","384.74","384.74","1 through 10","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 80.0MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED RIGHT","SUP-ITM-10029226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","WELLPOINT [1015]","HB AMC WELLPOINT","2982.56","73.78","","286.63","119.22","1107.45","105","1253.18","3213.79","percent of total billed charges",""
"BOX COMPONENT 80.0MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED RIGHT","SUP-ITM-10029226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA HMO","2821.67","69.8","","675.31","184.75","1721.50","286","2112.61","3303.53","percent of total billed charges",""
"BOX COMPONENT 80.0MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED RIGHT","SUP-ITM-10029226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA PPO","3250.17","80.4","","1261.44","103.12","1514.10","21","2112.61","3303.53","percent of total billed charges",""
"BOX COMPONENT 80.0MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED RIGHT","SUP-ITM-10029226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3250.17","80.4","","1365.00","1365.00","1365.00","1 through 10","2112.61","3303.53","percent of total billed charges",""
"BOX COMPONENT 80.0MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED RIGHT","SUP-ITM-10029226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3303.53","81.72","","5157.68","5157.68","5157.68","1 through 10","2112.61","3303.53","percent of total billed charges",""
"BOX COMPONENT 80.0MM FEMORAL KNEE VANGUARD INTERLOK COBALT POSTERIOR STABILIZED OPEN CEMENTED RIGHT","SUP-ITM-10029226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.53","81.72","","431.26","71.26","1459.57","88","2112.61","3303.53","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3565.58","79.5","","800.18","480.96","1887.97","195","1390.35","3565.58","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2390.51","53.3","","813.12","216.42","1444.50","81","1390.35","3565.58","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1390.35","31","","432.60","432.60","432.60","1 through 10","1390.35","3565.58","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1637.03","36.5","","148.37","54.89","631.39","94","1390.35","3565.58","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1717.76","38.3","","279.30","91.72","1116.77","266","1390.35","3565.58","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1924.07","42.9","","731.00","63.70","731.00","1 through 10","1390.35","3565.58","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1924.07","42.9","","384.74","384.74","384.74","1 through 10","1390.35","3565.58","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","WELLPOINT [1015]","HB AMC WELLPOINT","3309.03","73.78","","286.63","119.22","1107.45","105","1390.35","3565.58","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","AETNA [1001]","HB AMC AETNA HMO","3130.53","69.8","","675.31","184.75","1721.50","286","2343.86","3665.14","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","AETNA [1001]","HB AMC AETNA PPO","3605.94","80.4","","1261.44","103.12","1514.10","21","2343.86","3665.14","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3605.94","80.4","","1365.00","1365.00","1365.00","1 through 10","2343.86","3665.14","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3665.14","81.72","","5157.68","5157.68","5157.68","1 through 10","2343.86","3665.14","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3665.14","81.72","","431.26","71.26","1459.57","88","2343.86","3665.14","percent of total billed charges",""
"Brachy N-S Yttrium-90 per Source T1","PX-27000199","CDM","C2616","HCPCS","0278","RC","","","","both","","","4795.00","3596.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3356.50","70","","18772.47","18772.47","18772.47","1 through 10","1486.45","21856.38","percent of total billed charges",""
"Brachy N-S Yttrium-90 per Source T1","PX-27000199","CDM","C2616","HCPCS","0278","RC","","","","both","","","4795.00","3596.25","MEDICARE [2001]","HB BWH MEDICARE","17485.10","","APC Price ($17,485.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","17485.10","17177.01","17485.10","1 through 10","1486.45","21856.38","other","OPPS APC"
"Brachy N-S Yttrium-90 per Source T1","PX-27000199","CDM","C2616","HCPCS","0278","RC","","","","both","","","4795.00","3596.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17135.40","","APC Price ($17,485.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","17205.34","17205.34","17205.34","1 through 10","1486.45","21856.38","other","OPPS APC"
"Brachy N-S Yttrium-90 per Source T1","PX-27000199","CDM","C2616","HCPCS","0278","RC","","","","both","","","4795.00","3596.25","WELLPOINT [1015]","HB AMC WELLPOINT","3537.75","73.78","","34144.63","34144.63","34144.63","1 through 10","1486.45","21856.38","percent of total billed charges",""
"Brachy N-S Yttrium-90 per Source T3","PX-27000975","CDM","C2616","HCPCS","0278","RC","","","","both","","","63000.00","47250.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","44100.00","70","","18772.47","18772.47","18772.47","1 through 10","16610.85","50085","percent of total billed charges",""
"Brachy N-S Yttrium-90 per Source T3","PX-27000975","CDM","C2616","HCPCS","0278","RC","","","","both","","","63000.00","47250.00","MEDICARE [2001]","HB BWH MEDICARE","17485.10","","APC Price ($17,485.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","17485.10","17177.01","17485.10","1 through 10","16610.85","50085","other","OPPS APC"
"Brachy N-S Yttrium-90 per Source T3","PX-27000975","CDM","C2616","HCPCS","0278","RC","","","","both","","","63000.00","47250.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17135.40","","APC Price ($17,485.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","17205.34","17205.34","17205.34","1 through 10","16610.85","50085","other","OPPS APC"
"Brachy N-S Yttrium-90 per Source T3","PX-27000975","CDM","C2616","HCPCS","0278","RC","","","","both","","","63000.00","47250.00","WELLPOINT [1015]","HB AMC WELLPOINT","46481.40","73.78","","34144.63","34144.63","34144.63","1 through 10","16610.85","50085","percent of total billed charges",""
"Brachytx Isodose Pln Cplx W/Dosimetry Cal","PX-33000106","CDM","77318","CPT","0333","RC","","","","both","","","1691.00","1268.25","MEDICARE [2001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","434.73","434.73","434.73","1 through 10","412.99","1344.35","other","OPPS APC"
"Brachytx Isodose Pln Cplx W/Dosimetry Cal","PX-33000106","CDM","77318","CPT","0333","RC","","","","both","","","1691.00","1268.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","647.65","38.3","","641.24","641.24","641.24","1 through 10","412.99","1344.35","percent of total billed charges",""
"Brachytx Isodose Pln Cplx W/Dosimetry Cal","PX-33000106","CDM","77318","CPT","0333","RC","","","","both","","","1691.00","1268.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","426.04","426.04","426.04","1 through 10","412.99","1344.35","other","OPPS APC"
"Brachytx Isodose Pln Cplx W/Dosimetry Cal","PX-33000106","CDM","77318","CPT","0333","RC","","","","outpatient","","","1691.00","1268.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1381.89","81.72","","1311.02","1311.02","1311.02","1 through 10","875.35","2457.5","percent of total billed charges",""
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","957.00","717.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.77","180.05","928.00","1 through 10","296.67","760.82","other","OPPS APC"
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","957.00","717.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","687.13","71.8","","666.30","666.30","666.30","1 through 10","296.67","760.82","percent of total billed charges",""
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","957.00","717.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","669.90","70","","928.00","928.00","928.00","1 through 10","296.67","760.82","percent of total billed charges",""
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","957.00","717.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","760.82","79.5","","730.34","730.34","730.34","1 through 10","296.67","760.82","percent of total billed charges",""
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","957.00","717.75","ELDER SERVICES [1037]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","434.73","434.73","434.73","1 through 10","296.67","760.82","other","OPPS APC"
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","957.00","717.75","HUMANA [1012]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","426.04","426.04","426.04","1 through 10","296.67","760.82","other","OPPS APC"
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","957.00","717.75","MEDICARE [2001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","434.73","434.73","869.46","19","296.67","760.82","other","OPPS APC"
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","957.00","717.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","366.53","38.3","","646.92","362.85","725.70","1 through 10","296.67","760.82","percent of total billed charges",""
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","957.00","717.75","MOLINA [1014]","HB BWH MOLINA","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","434.73","434.73","434.73","1 through 10","296.67","760.82","other","OPPS APC"
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","957.00","717.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","790.40","790.40","790.40","1 through 10","296.67","760.82","other","OPPS APC"
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","957.00","717.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","426.04","395.20","426.04","1 through 10","296.67","760.82","other","OPPS APC"
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","outpatient","","","957.00","717.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","782.06","81.72","","741.84","741.84","741.84","1 through 10","500.13","1588.01","percent of total billed charges",""
"Braf Gene Analysis V600 Variant(S)","PX-30000200","CDM","81210","CPT","0310","RC","","","","both","","","1012.00","759.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","804.54","79.5","","772.05","618.80","772.05","1 through 10","171.89","961.4","percent of total billed charges",""
"Braf Gene Analysis V600 Variant(S)","PX-30000200","CDM","81210","CPT","0310","RC","","","","both","","","1012.00","759.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","369.38","36.5","","310.98","310.98","310.98","1 through 10","171.89","961.4","percent of total billed charges",""
"Braf Gene Analysis V600 Variant(S)","PX-30000200","CDM","81210","CPT","0310","RC","","","","outpatient","","","1012.00","759.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","612.77","60.55","","502.15","502.15","502.15","1 through 10","325.19","1075.2","percent of total billed charges",""
"Braf Gene Analysis V600 Variant(S)","PX-30000200","CDM","81210","CPT","0310","RC","","","","outpatient","","","1012.00","759.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","528.47","52.22","","502.15","502.15","502.15","1 through 10","325.19","1075.2","percent of total billed charges",""
"Braf Gene Analysis V600 Variant(S)","PX-30000200","CDM","81210","CPT","0310","RC","","","","outpatient","","","1012.00","759.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","827.01","81.72","","669.46","431.35","784.21","1 through 10","325.19","1075.2","percent of total billed charges",""
"Brain Mrgfus","PX-76002340","CDM","61715","CPT","0761","RC","","","","both","","","34518.00","25888.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15251.98","","APC Price ($14,807.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","15239.51","15239.51","15300.90","1 through 10","10700.58","27441.81","other","OPPS APC"
"Brain Mrgfus","PX-76002340","CDM","61715","CPT","0761","RC","","","","both","","","34518.00","25888.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14807.74","","APC Price ($14,807.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","14572.29","14572.29","14572.29","1 through 10","10700.58","27441.81","other","OPPS APC"
"Brain Mrgfus","PX-76002340","CDM","61715","CPT","0761","RC","","","","both","","","34518.00","25888.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","27441.81","79.5","","26344.04","26344.04","26344.04","1 through 10","10700.58","27441.81","percent of total billed charges",""
"Brain Mrgfus","PX-76002340","CDM","61715","CPT","0761","RC","","","","both","","","34518.00","25888.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","14807.74","","APC Price ($14,807.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","14601.91","1243.16","14601.91","1 through 10","10700.58","27441.81","other","OPPS APC"
"Brain Mrgfus","PX-76002340","CDM","61715","CPT","0761","RC","","","","both","","","34518.00","25888.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","14807.74","","APC Price ($14,807.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","14514.06","14513.96","14514.06","1 through 10","10700.58","27441.81","other","OPPS APC"
"Brain Mrgfus","PX-76002340","CDM","61715","CPT","0761","RC","","","","both","","","34518.00","25888.50","MEDICARE [2001]","HB BWH MEDICARE","14807.74","","APC Price ($14,807.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","14809.24","14809.24","14809.24","49","10700.58","27441.81","other","OPPS APC"
"Brain Mrgfus","PX-76002340","CDM","61715","CPT","0761","RC","","","","both","","","34518.00","25888.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","14068.78","","APC Price ($14,809.24). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","14809.24","14809.24","14809.24","1 through 10","10700.58","27441.81","other","Tricare OPPS"
"Brain Mrgfus","PX-76002340","CDM","61715","CPT","0761","RC","","","","both","","","34518.00","25888.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14511.59","","APC Price ($14,807.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","14572.29","14513.06","43539.18","1 through 10","10700.58","27441.81","other","OPPS APC"
"Brain Mrgfus","PX-76002340","CDM","61715","CPT","0761","RC","","","","both","","","34518.00","25888.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14511.59","","APC Price ($14,807.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","14530.27","14516.56","14809.24","21","10700.58","27441.81","other","OPPS APC"
"Brain Mrgfus","PX-76002340","CDM","61715","CPT","0761","RC","","","","both","","","34518.00","25888.50","WELLPOINT [1015]","HB AMC WELLPOINT","25467.38","73.78","","24921.39","24921.39","24921.39","1 through 10","10700.58","27441.81","percent of total billed charges",""
"Brain Mrgfus","PX-76002340","CDM","61715","CPT","0761","RC","","","","outpatient","","","34518.00","25888.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","13965.02","","Case rate ($13,965.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","28572.43","28055.73","28572.43","1 through 10","12500.5","28208.11","other","ASC"
"Brain Mrgfus","PX-76002340","CDM","61715","CPT","0761","RC","","","","outpatient","","","34518.00","25888.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","13965.02","","Case rate ($13,965.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","32692.11","32370.92","32692.11","1 through 10","12500.5","28208.11","other","ASC "
"Branchiootorenal (Bor/Bos)Spectrum Disorder Panel","PX-31000745","CDM","81479","CPT","0310","RC","","","","both","","","939.00","704.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","746.51","79.5","","0.65","0.65","0.65","1 through 10","291.09","892.05","percent of total billed charges",""
"Branchiootorenal (Bor/Bos)Spectrum Disorder Panel","PX-31000745","CDM","81479","CPT","0310","RC","","","","both","","","939.00","704.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","500.49","53.3","","0.79","0.79","0.79","1 through 10","291.09","892.05","percent of total billed charges",""
"Branchiootorenal (Bor/Bos)Spectrum Disorder Panel","PX-31000745","CDM","81479","CPT","0310","RC","","","","outpatient","","","939.00","704.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","469.50","50","","1.00","1.00","1.00","1 through 10","156.55","774.68","percent of total billed charges",""
"Branchiootorenal (Bor/Bos)Spectrum Disorder Panel","PX-31000745","CDM","81479","CPT","0310","RC","","","","outpatient","","","939.00","704.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","492.98","52.5","","1.00","0.53","1.00","1 through 10","156.55","774.68","percent of total billed charges",""
"Brca1 Brca2 Gene Alys Full Seq Full Dup/Del Alys","PX-31000943","CDM","81162","CPT","0310","RC","","","","both","","","17199.00","12899.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13673.21","79.5","","13126.37","13126.37","13126.37","1 through 10","1788.38","16339.05","percent of total billed charges",""
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/McC","584","MS-DRG","","","","","","","","inpatient","","","247542.68","185657.01","MEDICARE [2001]","HB BWH MEDICARE","19907.54","","Case rate ($19,907.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,887.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,531.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,162.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $17,805.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,507.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,722.53. The transfer capital threshold is the transfer adjustment factor * $1,722.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","579.50","0.03","24415.40","1 through 10","19509.39","32305.3037","other","Inpatient Replacement Plans DRG"
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/McC","584","MS-DRG","","","","","","","","inpatient","","","247542.68","185657.01","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19509.39","","Case rate ($19,907.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,887.33, add-ons for qualifying new technology services are included. If operating cost exceeds $69,531.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,162.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $17,805.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,507.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,722.53. The transfer capital threshold is the transfer adjustment factor * $1,722.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18513.45","18513.45","18513.45","1 through 10","19509.39","32305.3037","other","Inpatient DRG"
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/McC","584","MS-DRG","","","","","","","","inpatient","","","247542.68","185657.01","WELLPOINT [1015]","HB AMC WELLPOINT","32305.3037","","Fee schedule rate ($33,531.92).","32305.3037","149730.53","149730.53","1 through 10","19509.39","32305.3037","case rate",""
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/McC","584","TRIS-DRG","","","","","","","","inpatient","","","292275.42","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","30220.76","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($53,084.47). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $96,811.47 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($27,939.19), capped at $38,206.76. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $96,811.47 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","49343.37","49343.37","49343.37","1 through 10","30220.76","30220.76","other","Inpatient DRGs"
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/McC","585","MS-DRG","","","","","","","","inpatient","","","260892.14","195669.10","MEDICARE [2001]","HB BWH MEDICARE","17977.30","","Case rate ($17,977.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,563.71, add-ons for qualifying new technology services are included. If operating cost exceeds $67,208.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,992.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $16,045.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,183.86 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,552.27. The transfer capital threshold is the transfer adjustment factor * $1,552.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23680.93","23680.93","23715.94","1 through 10","17617.75","25413.244","other","Inpatient Replacement Plans DRG"
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/McC","585","TRIS-DRG","","","","","","","","inpatient","","","260892.14","","TRICARE [160005]","HB BWH TRICARE","21958.22","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($38,570.85). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $82,297.86 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($27,550.61), capped at $27,760.80. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $82,297.86 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","31824.07","31824.07","31824.07","1 through 10","21958.22","21958.22","other","Inpatient DRGs"
"BREAST EXPANDER 100CC 4.4X7CM TISSUE GENERAL CRESCENT","SUP-ITM-10009196","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3057.97","79.5","","1309.77","674.56","6049.93","26","1192.42","3057.97","percent of total billed charges",""
"BREAST EXPANDER 100CC 4.4X7CM TISSUE GENERAL CRESCENT","SUP-ITM-10009196","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2050.18","53.3","","1901.83","1901.83","2962.25","1 through 10","1192.42","3057.97","percent of total billed charges",""
"BREAST EXPANDER 100CC 4.4X7CM TISSUE GENERAL CRESCENT","SUP-ITM-10009196","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1403.97","36.5","","1620.31","1620.31","19908.88","1 through 10","1192.42","3057.97","percent of total billed charges",""
"BREAST EXPANDER 100CC 4.4X7CM TISSUE GENERAL CRESCENT","SUP-ITM-10009196","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1473.21","38.3","","352.91","352.91","2046.30","1 through 10","1192.42","3057.97","percent of total billed charges",""
"BREAST EXPANDER 100CC 4.4X7CM TISSUE GENERAL CRESCENT","SUP-ITM-10009196","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1650.15","42.9","","9668.75","9668.75","9668.75","1 through 10","1192.42","3057.97","percent of total billed charges",""
"BREAST EXPANDER 100CC 4.4X7CM TISSUE GENERAL CRESCENT","SUP-ITM-10009196","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","WELLPOINT [1015]","HB AMC WELLPOINT","2837.95","73.78","","699.88","384.10","3443.31","33","1192.42","3057.97","percent of total billed charges",""
"BREAST EXPANDER 100CC 4.4X7CM TISSUE GENERAL CRESCENT","SUP-ITM-10009196","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","AETNA [1001]","HB AMC AETNA HMO","2684.86","69.8","","1421.24","264.50","4933.46","29","2010.18","3143.36","percent of total billed charges",""
"BREAST EXPANDER 100CC 4.4X7CM TISSUE GENERAL CRESCENT","SUP-ITM-10009196","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3092.59","80.4","","1022.97","1022.97","3607.50","1 through 10","2010.18","3143.36","percent of total billed charges",""
"BREAST EXPANDER 100CC 4.4X7CM TISSUE GENERAL CRESCENT","SUP-ITM-10009196","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3143.36","81.72","","3010.54","693.88","5019.88","35","2010.18","3143.36","percent of total billed charges",""
"BREAST EXPANDER 250CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10027447","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1574.90","79.5","","1309.77","674.56","6049.93","26","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 250CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10027447","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1055.87","53.3","","1901.83","1901.83","2962.25","1 through 10","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 250CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10027447","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","723.07","36.5","","1620.31","1620.31","19908.88","1 through 10","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 250CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10027447","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","758.72","38.3","","352.91","352.91","2046.30","1 through 10","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 250CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10027447","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","849.85","42.9","","9668.75","9668.75","9668.75","1 through 10","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 250CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10027447","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","WELLPOINT [1015]","HB AMC WELLPOINT","1461.58","73.78","","699.88","384.10","3443.31","33","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 250CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10027447","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1981.00","1485.75","AETNA [1001]","HB AMC AETNA HMO","1382.74","69.8","","1421.24","264.50","4933.46","29","1035.27","1618.87","percent of total billed charges",""
"BREAST EXPANDER 250CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10027447","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1981.00","1485.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1592.72","80.4","","1022.97","1022.97","3607.50","1 through 10","1035.27","1618.87","percent of total billed charges",""
"BREAST EXPANDER 250CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10027447","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1981.00","1485.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1618.87","81.72","","3010.54","693.88","5019.88","35","1035.27","1618.87","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP","SUP-ITM-10239786","CDM","C1889","HCPCS","0278","RC","","","","both","","","4505.00","3378.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3581.48","79.5","","1309.77","674.56","6049.93","26","1396.55","3581.48","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP","SUP-ITM-10239786","CDM","C1889","HCPCS","0278","RC","","","","both","","","4505.00","3378.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2401.17","53.3","","1901.83","1901.83","2962.25","1 through 10","1396.55","3581.48","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP","SUP-ITM-10239786","CDM","C1889","HCPCS","0278","RC","","","","both","","","4505.00","3378.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1644.33","36.5","","1620.31","1620.31","19908.88","1 through 10","1396.55","3581.48","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP","SUP-ITM-10239786","CDM","C1889","HCPCS","0278","RC","","","","both","","","4505.00","3378.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1725.42","38.3","","352.91","352.91","2046.30","1 through 10","1396.55","3581.48","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP","SUP-ITM-10239786","CDM","C1889","HCPCS","0278","RC","","","","both","","","4505.00","3378.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1932.65","42.9","","9668.75","9668.75","9668.75","1 through 10","1396.55","3581.48","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP","SUP-ITM-10239786","CDM","C1889","HCPCS","0278","RC","","","","both","","","4505.00","3378.75","WELLPOINT [1015]","HB AMC WELLPOINT","3323.79","73.78","","699.88","384.10","3443.31","33","1396.55","3581.48","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP","SUP-ITM-10239786","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4505.00","3378.75","AETNA [1001]","HB AMC AETNA HMO","3144.49","69.8","","1421.24","264.50","4933.46","29","2354.31","3681.49","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP","SUP-ITM-10239786","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4505.00","3378.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3622.02","80.4","","1022.97","1022.97","3607.50","1 through 10","2354.31","3681.49","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP","SUP-ITM-10239786","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4505.00","3378.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3681.49","81.72","","3010.54","693.88","5019.88","35","2354.31","3681.49","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP ENHANCED SURFACE INTERNAL PORT","SUP-ITM-10240547","CDM","C1889","HCPCS","0278","RC","","","","both","","","4505.00","3378.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3581.48","79.5","","1309.77","674.56","6049.93","26","1396.55","3581.48","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP ENHANCED SURFACE INTERNAL PORT","SUP-ITM-10240547","CDM","C1889","HCPCS","0278","RC","","","","both","","","4505.00","3378.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2401.17","53.3","","1901.83","1901.83","2962.25","1 through 10","1396.55","3581.48","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP ENHANCED SURFACE INTERNAL PORT","SUP-ITM-10240547","CDM","C1889","HCPCS","0278","RC","","","","both","","","4505.00","3378.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1644.33","36.5","","1620.31","1620.31","19908.88","1 through 10","1396.55","3581.48","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP ENHANCED SURFACE INTERNAL PORT","SUP-ITM-10240547","CDM","C1889","HCPCS","0278","RC","","","","both","","","4505.00","3378.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1725.42","38.3","","352.91","352.91","2046.30","1 through 10","1396.55","3581.48","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP ENHANCED SURFACE INTERNAL PORT","SUP-ITM-10240547","CDM","C1889","HCPCS","0278","RC","","","","both","","","4505.00","3378.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1932.65","42.9","","9668.75","9668.75","9668.75","1 through 10","1396.55","3581.48","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP ENHANCED SURFACE INTERNAL PORT","SUP-ITM-10240547","CDM","C1889","HCPCS","0278","RC","","","","both","","","4505.00","3378.75","WELLPOINT [1015]","HB AMC WELLPOINT","3323.79","73.78","","699.88","384.10","3443.31","33","1396.55","3581.48","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP ENHANCED SURFACE INTERNAL PORT","SUP-ITM-10240547","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4505.00","3378.75","AETNA [1001]","HB AMC AETNA HMO","3144.49","69.8","","1421.24","264.50","4933.46","29","2354.31","3681.49","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP ENHANCED SURFACE INTERNAL PORT","SUP-ITM-10240547","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4505.00","3378.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3622.02","80.4","","1022.97","1022.97","3607.50","1 through 10","2354.31","3681.49","percent of total billed charges",""
"BREAST EXPANDER 450CC 10 X 13CM TISSUE INTEGRA TEARDROP ENHANCED SURFACE INTERNAL PORT","SUP-ITM-10240547","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4505.00","3378.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3681.49","81.72","","3010.54","693.88","5019.88","35","2354.31","3681.49","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","4378.50","3283.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3480.91","79.5","","1309.77","674.56","6049.93","26","1357.34","3480.91","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","4378.50","3283.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2333.74","53.3","","1901.83","1901.83","2962.25","1 through 10","1357.34","3480.91","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","4378.50","3283.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1598.15","36.5","","1620.31","1620.31","19908.88","1 through 10","1357.34","3480.91","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","4378.50","3283.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1676.97","38.3","","352.91","352.91","2046.30","1 through 10","1357.34","3480.91","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","4378.50","3283.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1878.38","42.9","","9668.75","9668.75","9668.75","1 through 10","1357.34","3480.91","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","4378.50","3283.87","WELLPOINT [1015]","HB AMC WELLPOINT","3230.46","73.78","","699.88","384.10","3443.31","33","1357.34","3480.91","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4378.50","3283.87","AETNA [1001]","HB AMC AETNA HMO","3056.19","69.8","","1421.24","264.50","4933.46","29","2288.2","3578.11","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4378.50","3283.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3520.31","80.4","","1022.97","1022.97","3607.50","1 through 10","2288.2","3578.11","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4378.50","3283.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3578.11","81.72","","3010.54","693.88","5019.88","35","2288.2","3578.11","percent of total billed charges",""
"BREAST EXPANDER 550CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10022767","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1574.90","79.5","","1309.77","674.56","6049.93","26","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 550CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10022767","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1055.87","53.3","","1901.83","1901.83","2962.25","1 through 10","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 550CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10022767","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","723.07","36.5","","1620.31","1620.31","19908.88","1 through 10","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 550CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10022767","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","758.72","38.3","","352.91","352.91","2046.30","1 through 10","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 550CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10022767","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","849.85","42.9","","9668.75","9668.75","9668.75","1 through 10","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 550CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10022767","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","WELLPOINT [1015]","HB AMC WELLPOINT","1461.58","73.78","","699.88","384.10","3443.31","33","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 550CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10022767","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1981.00","1485.75","AETNA [1001]","HB AMC AETNA HMO","1382.74","69.8","","1421.24","264.50","4933.46","29","1035.27","1618.87","percent of total billed charges",""
"BREAST EXPANDER 550CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10022767","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1981.00","1485.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1592.72","80.4","","1022.97","1022.97","3607.50","1 through 10","1035.27","1618.87","percent of total billed charges",""
"BREAST EXPANDER 550CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10022767","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1981.00","1485.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1618.87","81.72","","3010.54","693.88","5019.88","35","1035.27","1618.87","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3297.26","79.5","","1309.77","674.56","6049.93","26","1285.73","3297.26","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2210.62","53.3","","1901.83","1901.83","2962.25","1 through 10","1285.73","3297.26","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1513.84","36.5","","1620.31","1620.31","19908.88","1 through 10","1285.73","3297.26","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1588.49","38.3","","352.91","352.91","2046.30","1 through 10","1285.73","3297.26","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1779.28","42.9","","9668.75","9668.75","9668.75","1 through 10","1285.73","3297.26","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","WELLPOINT [1015]","HB AMC WELLPOINT","3060.03","73.78","","699.88","384.10","3443.31","33","1285.73","3297.26","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4147.50","3110.62","AETNA [1001]","HB AMC AETNA HMO","2894.96","69.8","","1421.24","264.50","4933.46","29","2167.48","3389.34","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4147.50","3110.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3334.59","80.4","","1022.97","1022.97","3607.50","1 through 10","2167.48","3389.34","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4147.50","3110.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3389.34","81.72","","3010.54","693.88","5019.88","35","2167.48","3389.34","percent of total billed charges",""
"BREAST EXPANDER 700CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10026897","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1574.90","79.5","","1309.77","674.56","6049.93","26","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 700CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10026897","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1055.87","53.3","","1901.83","1901.83","2962.25","1 through 10","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 700CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10026897","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","723.07","36.5","","1620.31","1620.31","19908.88","1 through 10","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 700CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10026897","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","758.72","38.3","","352.91","352.91","2046.30","1 through 10","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 700CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10026897","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","849.85","42.9","","9668.75","9668.75","9668.75","1 through 10","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 700CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10026897","CDM","C1889","HCPCS","0278","RC","","","","both","","","1981.00","1485.75","WELLPOINT [1015]","HB AMC WELLPOINT","1461.58","73.78","","699.88","384.10","3443.31","33","614.11","1574.9","percent of total billed charges",""
"BREAST EXPANDER 700CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10026897","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1981.00","1485.75","AETNA [1001]","HB AMC AETNA HMO","1382.74","69.8","","1421.24","264.50","4933.46","29","1035.27","1618.87","percent of total billed charges",""
"BREAST EXPANDER 700CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10026897","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1981.00","1485.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1592.72","80.4","","1022.97","1022.97","3607.50","1 through 10","1035.27","1618.87","percent of total billed charges",""
"BREAST EXPANDER 700CC TISSUE SMOOTH RECTANGLE INJECTION DOME REMOTE FILL BOTTOM LOADING BASE REINFORCED DARCON","SUP-ITM-10026897","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1981.00","1485.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1618.87","81.72","","3010.54","693.88","5019.88","35","1035.27","1618.87","percent of total billed charges",""
"BREAST EXPANDER 800CC 6.5X22CM TISSUE GENERAL CURVE TWO STAGE","SUP-ITM-10026915","CDM","C1889","HCPCS","0278","RC","","","","both","","","4212.00","3159.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3348.54","79.5","","1309.77","674.56","6049.93","26","1305.72","3348.54","percent of total billed charges",""
"BREAST EXPANDER 800CC 6.5X22CM TISSUE GENERAL CURVE TWO STAGE","SUP-ITM-10026915","CDM","C1889","HCPCS","0278","RC","","","","both","","","4212.00","3159.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2245.00","53.3","","1901.83","1901.83","2962.25","1 through 10","1305.72","3348.54","percent of total billed charges",""
"BREAST EXPANDER 800CC 6.5X22CM TISSUE GENERAL CURVE TWO STAGE","SUP-ITM-10026915","CDM","C1889","HCPCS","0278","RC","","","","both","","","4212.00","3159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1537.38","36.5","","1620.31","1620.31","19908.88","1 through 10","1305.72","3348.54","percent of total billed charges",""
"BREAST EXPANDER 800CC 6.5X22CM TISSUE GENERAL CURVE TWO STAGE","SUP-ITM-10026915","CDM","C1889","HCPCS","0278","RC","","","","both","","","4212.00","3159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1613.20","38.3","","352.91","352.91","2046.30","1 through 10","1305.72","3348.54","percent of total billed charges",""
"BREAST EXPANDER 800CC 6.5X22CM TISSUE GENERAL CURVE TWO STAGE","SUP-ITM-10026915","CDM","C1889","HCPCS","0278","RC","","","","both","","","4212.00","3159.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1806.95","42.9","","9668.75","9668.75","9668.75","1 through 10","1305.72","3348.54","percent of total billed charges",""
"BREAST EXPANDER 800CC 6.5X22CM TISSUE GENERAL CURVE TWO STAGE","SUP-ITM-10026915","CDM","C1889","HCPCS","0278","RC","","","","both","","","4212.00","3159.00","WELLPOINT [1015]","HB AMC WELLPOINT","3107.61","73.78","","699.88","384.10","3443.31","33","1305.72","3348.54","percent of total billed charges",""
"BREAST EXPANDER 800CC 6.5X22CM TISSUE GENERAL CURVE TWO STAGE","SUP-ITM-10026915","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4212.00","3159.00","AETNA [1001]","HB AMC AETNA HMO","2939.98","69.8","","1421.24","264.50","4933.46","29","2201.19","3442.05","percent of total billed charges",""
"BREAST EXPANDER 800CC 6.5X22CM TISSUE GENERAL CURVE TWO STAGE","SUP-ITM-10026915","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4212.00","3159.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3386.45","80.4","","1022.97","1022.97","3607.50","1 through 10","2201.19","3442.05","percent of total billed charges",""
"BREAST EXPANDER 800CC 6.5X22CM TISSUE GENERAL CURVE TWO STAGE","SUP-ITM-10026915","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4212.00","3159.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3442.05","81.72","","3010.54","693.88","5019.88","35","2201.19","3442.05","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","both","","","1375.50","1031.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","718.84","52.26","","3643.50","3643.50","3643.50","1 through 10","426.41","1093.52","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","both","","","1375.50","1031.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1093.52","79.5","","2867.44","1923.77","8602.29","1 through 10","426.41","1093.52","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","both","","","1375.50","1031.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","733.14","53.3","","5771.31","1397.09","6509.05","16","426.41","1093.52","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","both","","","1375.50","1031.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1093.52","79.5","","5730.95","5730.95","5730.95","1 through 10","426.41","1093.52","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","both","","","1375.50","1031.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","502.06","36.5","","1154.99","1154.99","1318.95","1 through 10","426.41","1093.52","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","both","","","1375.50","1031.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","526.82","38.3","","1424.61","1034.59","4273.83","20","426.41","1093.52","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","both","","","1375.50","1031.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","590.09","42.9","","2912.61","2912.61","2912.61","1 through 10","426.41","1093.52","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","both","","","1375.50","1031.62","WELLPOINT [1015]","HB AMC WELLPOINT","1014.84","73.78","","2712.59","1969.95","2712.59","1 through 10","426.41","1093.52","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","1375.50","1031.62","AETNA [1001]","HB AMC AETNA HMO","960.10","69.8","","4933.30","1741.59","4933.30","1 through 10","718.84","1124.06","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","1375.50","1031.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","718.84","52.26","","3643.50","3643.50","3643.50","1 through 10","718.84","1124.06","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","1375.50","1031.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1124.06","81.72","","2115.21","1602.05","5825.23","1 through 10","718.84","1124.06","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1904.09","52.26","","3643.50","3643.50","3643.50","1 through 10","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2896.58","79.5","","2867.44","1923.77","8602.29","1 through 10","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1941.99","53.3","","5771.31","1397.09","6509.05","16","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2896.58","79.5","","5730.95","5730.95","5730.95","1 through 10","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1329.88","36.5","","1154.99","1154.99","1318.95","1 through 10","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1395.46","38.3","","1424.61","1034.59","4273.83","20","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1563.06","42.9","","2912.61","2912.61","2912.61","1 through 10","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","WELLPOINT [1015]","HB AMC WELLPOINT","2688.17","73.78","","2712.59","1969.95","2712.59","1 through 10","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3643.50","2732.62","AETNA [1001]","HB AMC AETNA HMO","2543.16","69.8","","4933.30","1741.59","4933.30","1 through 10","1904.09","2977.47","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3643.50","2732.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1904.09","52.26","","3643.50","3643.50","3643.50","1 through 10","1904.09","2977.47","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3643.50","2732.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2977.47","81.72","","2115.21","1602.05","5825.23","1 through 10","1904.09","2977.47","percent of total billed charges",""
"BREAST IMPLANT 225CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10016933","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1415.72","52.26","","3643.50","3643.50","3643.50","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 225CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10016933","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2153.66","79.5","","2867.44","1923.77","8602.29","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 225CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10016933","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1443.90","53.3","","5771.31","1397.09","6509.05","16","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 225CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10016933","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2153.66","79.5","","5730.95","5730.95","5730.95","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 225CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10016933","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","988.79","36.5","","1154.99","1154.99","1318.95","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 225CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10016933","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1037.55","38.3","","1424.61","1034.59","4273.83","20","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 225CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10016933","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1162.16","42.9","","2912.61","2912.61","2912.61","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 225CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10016933","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","WELLPOINT [1015]","HB AMC WELLPOINT","1998.70","73.78","","2712.59","1969.95","2712.59","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 225CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10016933","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2709.00","2031.75","AETNA [1001]","HB AMC AETNA HMO","1890.88","69.8","","4933.30","1741.59","4933.30","1 through 10","1415.72","2213.79","percent of total billed charges",""
"BREAST IMPLANT 225CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10016933","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2709.00","2031.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1415.72","52.26","","3643.50","3643.50","3643.50","1 through 10","1415.72","2213.79","percent of total billed charges",""
"BREAST IMPLANT 225CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10016933","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2709.00","2031.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2213.79","81.72","","2115.21","1602.05","5825.23","1 through 10","1415.72","2213.79","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","521.29","52.26","","3643.50","3643.50","3643.50","1 through 10","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","793.01","79.5","","2867.44","1923.77","8602.29","1 through 10","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","531.67","53.3","","5771.31","1397.09","6509.05","16","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","793.01","79.5","","5730.95","5730.95","5730.95","1 through 10","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","364.09","36.5","","1154.99","1154.99","1318.95","1 through 10","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","382.04","38.3","","1424.61","1034.59","4273.83","20","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.93","42.9","","2912.61","2912.61","2912.61","1 through 10","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","WELLPOINT [1015]","HB AMC WELLPOINT","735.96","73.78","","2712.59","1969.95","2712.59","1 through 10","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","AETNA [1001]","HB AMC AETNA HMO","696.26","69.8","","4933.30","1741.59","4933.30","1 through 10","521.29","815.16","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","521.29","52.26","","3643.50","3643.50","3643.50","1 through 10","521.29","815.16","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","815.16","81.72","","2115.21","1602.05","5825.23","1 through 10","521.29","815.16","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1382.80","52.26","","3643.50","3643.50","3643.50","1 through 10","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2103.57","79.5","","2867.44","1923.77","8602.29","1 through 10","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1410.32","53.3","","5771.31","1397.09","6509.05","16","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2103.57","79.5","","5730.95","5730.95","5730.95","1 through 10","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","965.79","36.5","","1154.99","1154.99","1318.95","1 through 10","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1013.42","38.3","","1424.61","1034.59","4273.83","20","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1135.13","42.9","","2912.61","2912.61","2912.61","1 through 10","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","WELLPOINT [1015]","HB AMC WELLPOINT","1952.22","73.78","","2712.59","1969.95","2712.59","1 through 10","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2646.00","1984.50","AETNA [1001]","HB AMC AETNA HMO","1846.91","69.8","","4933.30","1741.59","4933.30","1 through 10","1382.8","2162.31","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2646.00","1984.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1382.80","52.26","","3643.50","3643.50","3643.50","1 through 10","1382.8","2162.31","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2646.00","1984.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2162.31","81.72","","2115.21","1602.05","5825.23","1 through 10","1382.8","2162.31","percent of total billed charges",""
"BREAST IMPLANT 405CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204010","CDM","C1789","HCPCS","0278","RC","","","","both","","","3335.50","2501.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1743.13","52.26","","3643.50","3643.50","3643.50","1 through 10","1034.01","2651.72","percent of total billed charges",""
"BREAST IMPLANT 405CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204010","CDM","C1789","HCPCS","0278","RC","","","","both","","","3335.50","2501.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2651.72","79.5","","2867.44","1923.77","8602.29","1 through 10","1034.01","2651.72","percent of total billed charges",""
"BREAST IMPLANT 405CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204010","CDM","C1789","HCPCS","0278","RC","","","","both","","","3335.50","2501.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1777.82","53.3","","5771.31","1397.09","6509.05","16","1034.01","2651.72","percent of total billed charges",""
"BREAST IMPLANT 405CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204010","CDM","C1789","HCPCS","0278","RC","","","","both","","","3335.50","2501.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2651.72","79.5","","5730.95","5730.95","5730.95","1 through 10","1034.01","2651.72","percent of total billed charges",""
"BREAST IMPLANT 405CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204010","CDM","C1789","HCPCS","0278","RC","","","","both","","","3335.50","2501.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1217.46","36.5","","1154.99","1154.99","1318.95","1 through 10","1034.01","2651.72","percent of total billed charges",""
"BREAST IMPLANT 405CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204010","CDM","C1789","HCPCS","0278","RC","","","","both","","","3335.50","2501.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1277.50","38.3","","1424.61","1034.59","4273.83","20","1034.01","2651.72","percent of total billed charges",""
"BREAST IMPLANT 405CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204010","CDM","C1789","HCPCS","0278","RC","","","","both","","","3335.50","2501.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1430.93","42.9","","2912.61","2912.61","2912.61","1 through 10","1034.01","2651.72","percent of total billed charges",""
"BREAST IMPLANT 405CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204010","CDM","C1789","HCPCS","0278","RC","","","","both","","","3335.50","2501.62","WELLPOINT [1015]","HB AMC WELLPOINT","2460.93","73.78","","2712.59","1969.95","2712.59","1 through 10","1034.01","2651.72","percent of total billed charges",""
"BREAST IMPLANT 405CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204010","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3335.50","2501.62","AETNA [1001]","HB AMC AETNA HMO","2328.18","69.8","","4933.30","1741.59","4933.30","1 through 10","1743.13","2725.77","percent of total billed charges",""
"BREAST IMPLANT 405CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204010","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3335.50","2501.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1743.13","52.26","","3643.50","3643.50","3643.50","1 through 10","1743.13","2725.77","percent of total billed charges",""
"BREAST IMPLANT 405CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204010","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3335.50","2501.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2725.77","81.72","","2115.21","1602.05","5825.23","1 through 10","1743.13","2725.77","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","521.29","52.26","","3643.50","3643.50","3643.50","1 through 10","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","793.01","79.5","","2867.44","1923.77","8602.29","1 through 10","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","531.67","53.3","","5771.31","1397.09","6509.05","16","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","793.01","79.5","","5730.95","5730.95","5730.95","1 through 10","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","364.09","36.5","","1154.99","1154.99","1318.95","1 through 10","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","382.04","38.3","","1424.61","1034.59","4273.83","20","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.93","42.9","","2912.61","2912.61","2912.61","1 through 10","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","both","","","997.50","748.12","WELLPOINT [1015]","HB AMC WELLPOINT","735.96","73.78","","2712.59","1969.95","2712.59","1 through 10","309.23","793.01","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","AETNA [1001]","HB AMC AETNA HMO","696.26","69.8","","4933.30","1741.59","4933.30","1 through 10","521.29","815.16","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","521.29","52.26","","3643.50","3643.50","3643.50","1 through 10","521.29","815.16","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","997.50","748.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","815.16","81.72","","2115.21","1602.05","5825.23","1 through 10","521.29","815.16","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1415.72","52.26","","3643.50","3643.50","3643.50","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2153.66","79.5","","2867.44","1923.77","8602.29","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1443.90","53.3","","5771.31","1397.09","6509.05","16","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2153.66","79.5","","5730.95","5730.95","5730.95","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","988.79","36.5","","1154.99","1154.99","1318.95","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1037.55","38.3","","1424.61","1034.59","4273.83","20","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1162.16","42.9","","2912.61","2912.61","2912.61","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","WELLPOINT [1015]","HB AMC WELLPOINT","1998.70","73.78","","2712.59","1969.95","2712.59","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2709.00","2031.75","AETNA [1001]","HB AMC AETNA HMO","1890.88","69.8","","4933.30","1741.59","4933.30","1 through 10","1415.72","2213.79","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2709.00","2031.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1415.72","52.26","","3643.50","3643.50","3643.50","1 through 10","1415.72","2213.79","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2709.00","2031.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2213.79","81.72","","2115.21","1602.05","5825.23","1 through 10","1415.72","2213.79","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1243.79","52.26","","3643.50","3643.50","3643.50","1 through 10","737.8","1892.1","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1892.10","79.5","","2867.44","1923.77","8602.29","1 through 10","737.8","1892.1","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1268.54","53.3","","5771.31","1397.09","6509.05","16","737.8","1892.1","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1892.10","79.5","","5730.95","5730.95","5730.95","1 through 10","737.8","1892.1","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","868.70","36.5","","1154.99","1154.99","1318.95","1 through 10","737.8","1892.1","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","911.54","38.3","","1424.61","1034.59","4273.83","20","737.8","1892.1","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1021.02","42.9","","2912.61","2912.61","2912.61","1 through 10","737.8","1892.1","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","WELLPOINT [1015]","HB AMC WELLPOINT","1755.96","73.78","","2712.59","1969.95","2712.59","1 through 10","737.8","1892.1","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2380.00","1785.00","AETNA [1001]","HB AMC AETNA HMO","1661.24","69.8","","4933.30","1741.59","4933.30","1 through 10","1243.79","1944.94","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2380.00","1785.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1243.79","52.26","","3643.50","3643.50","3643.50","1 through 10","1243.79","1944.94","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2380.00","1785.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1944.94","81.72","","2115.21","1602.05","5825.23","1 through 10","1243.79","1944.94","percent of total billed charges",""
"BREAST IMPLANT 650CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171777","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1904.09","52.26","","3643.50","3643.50","3643.50","1 through 10","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 650CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171777","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2896.58","79.5","","2867.44","1923.77","8602.29","1 through 10","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 650CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171777","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1941.99","53.3","","5771.31","1397.09","6509.05","16","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 650CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171777","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2896.58","79.5","","5730.95","5730.95","5730.95","1 through 10","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 650CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171777","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1329.88","36.5","","1154.99","1154.99","1318.95","1 through 10","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 650CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171777","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1395.46","38.3","","1424.61","1034.59","4273.83","20","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 650CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171777","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1563.06","42.9","","2912.61","2912.61","2912.61","1 through 10","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 650CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171777","CDM","C1789","HCPCS","0278","RC","","","","both","","","3643.50","2732.62","WELLPOINT [1015]","HB AMC WELLPOINT","2688.17","73.78","","2712.59","1969.95","2712.59","1 through 10","1129.49","2896.58","percent of total billed charges",""
"BREAST IMPLANT 650CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171777","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3643.50","2732.62","AETNA [1001]","HB AMC AETNA HMO","2543.16","69.8","","4933.30","1741.59","4933.30","1 through 10","1904.09","2977.47","percent of total billed charges",""
"BREAST IMPLANT 650CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171777","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3643.50","2732.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1904.09","52.26","","3643.50","3643.50","3643.50","1 through 10","1904.09","2977.47","percent of total billed charges",""
"BREAST IMPLANT 650CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171777","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3643.50","2732.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2977.47","81.72","","2115.21","1602.05","5825.23","1 through 10","1904.09","2977.47","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1382.80","52.26","","3643.50","3643.50","3643.50","1 through 10","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2103.57","79.5","","2867.44","1923.77","8602.29","1 through 10","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1410.32","53.3","","5771.31","1397.09","6509.05","16","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2103.57","79.5","","5730.95","5730.95","5730.95","1 through 10","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","965.79","36.5","","1154.99","1154.99","1318.95","1 through 10","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1013.42","38.3","","1424.61","1034.59","4273.83","20","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1135.13","42.9","","2912.61","2912.61","2912.61","1 through 10","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","both","","","2646.00","1984.50","WELLPOINT [1015]","HB AMC WELLPOINT","1952.22","73.78","","2712.59","1969.95","2712.59","1 through 10","820.26","2103.57","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2646.00","1984.50","AETNA [1001]","HB AMC AETNA HMO","1846.91","69.8","","4933.30","1741.59","4933.30","1 through 10","1382.8","2162.31","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2646.00","1984.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1382.80","52.26","","3643.50","3643.50","3643.50","1 through 10","1382.8","2162.31","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2646.00","1984.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2162.31","81.72","","2115.21","1602.05","5825.23","1 through 10","1382.8","2162.31","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1415.72","52.26","","3643.50","3643.50","3643.50","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2153.66","79.5","","2867.44","1923.77","8602.29","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1443.90","53.3","","5771.31","1397.09","6509.05","16","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2153.66","79.5","","5730.95","5730.95","5730.95","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","988.79","36.5","","1154.99","1154.99","1318.95","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1037.55","38.3","","1424.61","1034.59","4273.83","20","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1162.16","42.9","","2912.61","2912.61","2912.61","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","both","","","2709.00","2031.75","WELLPOINT [1015]","HB AMC WELLPOINT","1998.70","73.78","","2712.59","1969.95","2712.59","1 through 10","839.79","2153.66","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2709.00","2031.75","AETNA [1001]","HB AMC AETNA HMO","1890.88","69.8","","4933.30","1741.59","4933.30","1 through 10","1415.72","2213.79","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2709.00","2031.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1415.72","52.26","","3643.50","3643.50","3643.50","1 through 10","1415.72","2213.79","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2709.00","2031.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2213.79","81.72","","2115.21","1602.05","5825.23","1 through 10","1415.72","2213.79","percent of total billed charges",""
"Breast Procedures Except Mastectomy,MAJOR","363","DRG","","","","","","","","inpatient","","","249549.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","77401.72","","Standard inlier is a Case rate ($77,401.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,837, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,987.64) for the length of stay and the standard reimbursement.","85533.29","77401.71","92027.28","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MAJOR","363","DRG","","","","","","","","inpatient","","","249549.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","87020.39","","Standard inlier is a Case rate ($87,020.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,837, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,351.82) for the length of stay and the standard reimbursement.","87020.38","79500.63","92846.71","12","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MAJOR","363","DRG","","","","","","","","inpatient","","","249549.10","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","20017.1178","","Fee schedule rate ($48,385.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20017.1178","50689.16","50689.16","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MAJOR","363","DRG","","","","","","","","inpatient","","","249549.10","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","19063.3941","","Fee schedule rate ($46,080.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19063.3941","46080.48","46080.48","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MAJOR","363","DRG","","","","","","","","inpatient","","","249549.10","","MASSHEALTH [3001]","HB BWH MEDICAID","23082.65","","Case rate ($25,521.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $67,951.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25515.57","25515.57","25515.57","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MAJOR","363","DRG","","","","","","","","inpatient","","","249549.10","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68286.85","","Fee schedule rate ($68,286.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","66297.17","66297.17","66297.17","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MAJOR","363","DRG","","","","","","","","inpatient","","","249549.10","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71702.32","","Fee schedule rate ($71,702.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","69613.31","69613.31","69613.31","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MAJOR","363","DRG","","","","","","","","inpatient","","","249549.10","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","23082.65","","Case rate ($25,521.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $67,951.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","26931.33","26931.33","26931.33","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MINOR","363","DRG","","","","","","","","inpatient","","","116839.79","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","68560.42","","Standard inlier is a Case rate ($68,560.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,071, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,731.58) for the length of stay and the standard reimbursement.","37247.18","37247.18","37247.18","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MINOR","363","DRG","","","","","","","","inpatient","","","116839.79","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38894.70","","Fee schedule rate ($38,894.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38894.70","38894.70","38894.70","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MODERATE","363","DRG","","","","","","","","inpatient","","","249570.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","60982.19","","Standard inlier is a Case rate ($60,982.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,071, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,656.79) for the length of stay and the standard reimbursement.","66526.25","60982.18","79732.21","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MODERATE","363","DRG","","","","","","","","inpatient","","","249570.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","68560.42","","Standard inlier is a Case rate ($68,560.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,071, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,731.58) for the length of stay and the standard reimbursement.","68560.41","62635.86","86634.39","18","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MODERATE","363","DRG","","","","","","","","inpatient","","","249570.33","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","186802.08","186802.08","186802.08","1 through 10","18329.5638","87020.39","percent of total billed charges",""
"Breast Procedures Except Mastectomy,MODERATE","363","DRG","","","","","","","","inpatient","","","249570.33","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","20017.1178","","Fee schedule rate ($32,680.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20017.1178","34236.47","34236.47","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MODERATE","363","DRG","","","","","","","","inpatient","","","249570.33","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","19063.3941","","Fee schedule rate ($31,123.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19063.3941","31123.68","31123.68","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MODERATE","363","DRG","","","","","","","","inpatient","","","249570.33","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","20017.1178","","Fee schedule rate ($32,680.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20017.1178","46693.40","46693.40","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MODERATE","363","DRG","","","","","","","","inpatient","","","249570.33","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","175948.60","175948.60","175948.60","1 through 10","18329.5638","87020.39","percent of total billed charges",""
"Breast Procedures Except Mastectomy,MODERATE","363","DRG","","","","","","","","inpatient","","","249570.33","","MASSHEALTH [3001]","HB BWH MEDICAID","20402.66","","Case rate ($22,558.64). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,988.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22553.11","22553.11","22553.11","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MODERATE","363","DRG","","","","","","","","inpatient","","","249570.33","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50818.72","","Fee schedule rate ($50,818.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","50818.72","50818.72","50818.72","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MODERATE","363","DRG","","","","","","","","inpatient","","","249570.33","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53360.49","","Fee schedule rate ($53,360.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","53360.49","53360.49","53360.49","1 through 10","18329.5638","87020.39","case rate",""
"Breast Procedures Except Mastectomy,MODERATE","363","DRG","","","","","","","","inpatient","","","249570.33","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","20402.66","","Case rate ($22,558.64). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,988.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","32154.18","29566.52","36226.64","1 through 10","18329.5638","87020.39","case rate",""
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","167.75","185.81","13","170.5","437.25","other","OPPS APC"
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","437.25","79.5","","419.47","281.42","419.47","18","170.5","437.25","percent of total billed charges",""
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","293.15","53.3","","281.42","281.42","419.47","11","170.5","437.25","percent of total billed charges",""
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","154.23","146.45","182.84","1 through 10","170.5","437.25","other","OPPS APC"
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","170.48","185.81","184","170.5","437.25","other","OPPS APC"
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","170.50","31","","164.70","164.70","164.70","1 through 10","170.5","437.25","percent of total billed charges",""
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","200.75","36.5","","192.95","168.96","198.81","19","170.5","437.25","percent of total billed charges",""
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","210.65","38.3","","208.40","208.40","208.40","48","170.5","437.25","percent of total billed charges",""
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.09","167.07","182.49","1 through 10","170.5","437.25","other","OPPS APC"
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","TRICARE [160005]","HB BWH TRICARE","176.52","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","176.52","176.52","176.52","1 through 10","170.5","437.25","other","Tricare OPPS"
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.69","182.09","184.42","1 through 10","170.5","437.25","other","OPPS APC"
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","235.95","42.9","","426.08","426.08","426.08","1 through 10","170.5","437.25","percent of total billed charges",""
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.60","170.48","185.81","34","170.5","437.25","other","OPPS APC"
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","both","","","550.00","412.50","WELLPOINT [1015]","HB AMC WELLPOINT","405.79","73.78","","396.82","396.82","396.82","1 through 10","170.5","437.25","percent of total billed charges",""
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","outpatient","","","550.00","412.50","AETNA [1001]","HB AMC AETNA HMO","383.90","69.8","","360.84","360.84","360.84","1 through 10","287.43","922.47","percent of total billed charges",""
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","outpatient","","","550.00","412.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","287.43","52.26","","360.38","360.38","360.38","1 through 10","287.43","922.47","percent of total billed charges",""
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","outpatient","","","550.00","412.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","442.20","80.4","","415.74","415.74","415.74","1 through 10","287.43","922.47","percent of total billed charges",""
"Breath Hydrogen/Methane Test","PX-75000319","CDM","91065","CPT","0750","RC","","","","outpatient","","","550.00","412.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","449.46","81.72","","426.08","234.36","426.08","28","287.43","922.47","percent of total billed charges",""
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","both","","","4947.00","3710.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4509.37","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4506.24","4505.44","4506.24","1 through 10","1533.57","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","both","","","4947.00","3710.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4308.41","3564.14","4308.41","1 through 10","1533.57","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","both","","","4947.00","3710.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","5472.54","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","4378.47","4378.47","4378.47","1 through 10","1533.57","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","both","","","4947.00","3710.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3932.87","79.5","","15252.67","3775.24","15252.67","1 through 10","1533.57","5472.54","percent of total billed charges",""
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","both","","","4947.00","3710.25","MEDICARE [2001]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4378.47","4087.20","4378.47","66","1533.57","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","both","","","4947.00","3710.25","MOLINA [1014]","HB BWH MOLINA","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8686.88","8686.88","8686.88","1 through 10","1533.57","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","both","","","4947.00","3710.25","TRICARE [160005]","HB BWH TRICARE","4159.55","","APC Price ($4,378.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","4378.47","4378.47","4378.47","1 through 10","1533.57","5472.54","other","Tricare OPPS"
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","both","","","4947.00","3710.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4021.80","4012.86","4021.80","1 through 10","1533.57","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","both","","","4947.00","3710.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4294.41","4014.46","4299.66","11","1533.57","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","both","","","4947.00","3710.25","WELLPOINT [1015]","HB AMC WELLPOINT","3649.90","73.78","","9338.31","2572.99","12110.04","1 through 10","1533.57","5472.54","percent of total billed charges",""
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","outpatient","","","4947.00","3710.25","AETNA [1001]","HB AMC AETNA HMO","3453.01","69.8","","6067.46","2729.66","16377.98","1 through 10","2466.59","15696.44","percent of total billed charges",""
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","outpatient","","","4947.00","3710.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6296.41","3148.21","6412.37","1 through 10","2466.59","15696.44","other","ASC"
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","outpatient","","","4947.00","3710.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7264.84","3632.42","7336.93","38","2466.59","15696.44","other","ASC "
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","outpatient","","","4947.00","3710.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8583.75","8583.75","17167.47","25","2466.59","15696.44","other","Multiple Surgery"
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","outpatient","","","4947.00","3710.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","6881.79","6881.79","6881.79","1 through 10","2466.59","15696.44","other","Multiple Surgery"
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","outpatient","","","4947.00","3710.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","6314.47","6314.47","6314.47","1 through 10","2466.59","15696.44","other","Multiple Surgery"
"Brnchsc Ebus Guided Sampl 1/2 Node Station/Strux","PX-76002179","CDM","31652","CPT","0761","RC","","","","outpatient","","","4947.00","3710.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4042.69","81.72","","3834.72","1857.57","12837.56","1 through 10","2466.59","15696.44","percent of total billed charges",""
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4509.37","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4512.44","4205.73","7693.35","1 through 10","767.25","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4308.41","949.44","7350.50","1 through 10","767.25","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1967.63","79.5","","5666.65","5666.65","5666.65","43","767.25","5472.54","percent of total billed charges",""
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1319.18","53.3","","5982.25","5982.25","5982.25","1 through 10","767.25","5472.54","percent of total billed charges",""
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4300.50","4300.50","4300.50","1 through 10","767.25","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","FALLON HEALTH [1008]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13135.41","13135.41","13135.41","1 through 10","767.25","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1905.75","77","","1848.00","1848.00","1848.00","1 through 10","767.25","5472.54","percent of total billed charges",""
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4299.90","4299.90","4299.90","1 through 10","767.25","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","MEDICARE [2001]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4378.47","4087.20","8220.85","102","767.25","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","903.38","36.5","","2606.40","2606.40","2606.40","1 through 10","767.25","5472.54","percent of total billed charges",""
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","MOLINA [1014]","HB BWH MOLINA","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8669.37","8109.00","8686.88","1 through 10","767.25","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","12878.70","4296.30","24191.49","11","767.25","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1061.78","42.9","","9835.02","9835.02","9835.02","1 through 10","767.25","5472.54","percent of total billed charges",""
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","both","","","2475.00","1856.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4290.91","4005.46","4298.61","1 through 10","767.25","5472.54","other","OPPS APC"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","outpatient","","","2475.00","1856.25","AETNA [1001]","HB AMC AETNA HMO","1727.55","69.8","","5616.70","2739.01","15352.40","1 through 10","1293.44","15696.44","percent of total billed charges",""
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","outpatient","","","2475.00","1856.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3206.19","3148.21","6412.37","14","1293.44","15696.44","other","ASC"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","outpatient","","","2475.00","1856.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7264.84","3632.42","7336.93","32","1293.44","15696.44","other","ASC "
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","outpatient","","","2475.00","1856.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","7153.11","7153.11","7153.11","1 through 10","1293.44","15696.44","other","Multiple Surgery"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","outpatient","","","2475.00","1856.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8583.75","5722.49","17167.47","24","1293.44","15696.44","other","Multiple Surgery"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","outpatient","","","2475.00","1856.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","3576.56","3157.24","3576.56","1 through 10","1293.44","15696.44","other","Multiple Surgery"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","outpatient","","","2475.00","1856.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","6314.47","1496.25","6314.47","1 through 10","1293.44","15696.44","other","Multiple Surgery"
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","outpatient","","","2475.00","1856.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2022.57","81.72","","1918.56","1055.28","5609.12","1 through 10","1293.44","15696.44","percent of total billed charges",""
"Brnchsc W/Cptr-Asst Image-Guided Na","PX-76000788","CDM","31627","CPT","0761","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","294.91","38.3","","1834.77","1581.91","1834.77","1 through 10","238.7","612.15","percent of total billed charges",""
"Brnchsc W/Cptr-Asst Image-Guided Na","PX-76000788","CDM","31627","CPT","0761","RC","","","","both","","","770.00","577.50","WELLPOINT [1015]","HB AMC WELLPOINT","568.11","73.78","","6531.65","2572.99","9338.31","1 through 10","238.7","612.15","percent of total billed charges",""
"Brnchsc W/Cptr-Asst Image-Guided Na","PX-76000788","CDM","31627","CPT","0761","RC","","","","outpatient","","","770.00","577.50","AETNA [1001]","HB AMC AETNA HMO","537.46","69.8","","6067.46","1651.97","6067.46","1 through 10","162.58","629.24","percent of total billed charges",""
"Brnchsc W/Cptr-Asst Image-Guided Na","PX-76000788","CDM","31627","CPT","0761","RC","","","","outpatient","","","770.00","577.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","162.58","","Case rate ($162.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","376.86","376.86","376.86","1 through 10","162.58","629.24","other","ASC"
"Brnchsc W/Cptr-Asst Image-Guided Na","PX-76000788","CDM","31627","CPT","0761","RC","","","","outpatient","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","629.24","81.72","","2223.67","1857.57","2695.18","1 through 10","162.58","629.24","percent of total billed charges",""
"Brnchsc W/Rmv Valve 1st Lobe","PX-76001805","CDM","31648","CPT","0761","RC","","","","both","","","1791.00","1343.25","MEDICARE [2001]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4378.47","4378.47","4378.47","1 through 10","555.21","5472.54","other","OPPS APC"
"Brnchsc W/Rmv Valve 1st Lobe","PX-76001805","CDM","31648","CPT","0761","RC","","","","both","","","1791.00","1343.25","WELLPOINT [1015]","HB AMC WELLPOINT","1321.40","73.78","","1293.20","1293.20","1293.20","1 through 10","555.21","5472.54","percent of total billed charges",""
"Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les","PX-76002181","CDM","31654","CPT","0761","RC","","","","both","","","505.00","378.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","193.42","38.3","","1834.77","1834.77","1834.77","1 through 10","156.55","401.48","percent of total billed charges",""
"Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les","PX-76002181","CDM","31654","CPT","0761","RC","","","","both","","","505.00","378.75","WELLPOINT [1015]","HB AMC WELLPOINT","372.59","73.78","","9338.31","6531.65","9338.31","1 through 10","156.55","401.48","percent of total billed charges",""
"Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les","PX-76002181","CDM","31654","CPT","0761","RC","","","","outpatient","","","505.00","378.75","AETNA [1001]","HB AMC AETNA HMO","352.49","69.8","","3713.08","3303.94","6067.46","1 through 10","112.65","412.69","percent of total billed charges",""
"Brnschsc Tndsc Ebus Dx/Tx Intervention Perph Les","PX-76002181","CDM","31654","CPT","0761","RC","","","","outpatient","","","505.00","378.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","412.69","81.72","","1857.57","1857.57","1857.57","1 through 10","112.65","412.69","percent of total billed charges",""
"Bronchiolitis And Rsv Pneumonia,EXTREME","138","DRG","","","","","","","","inpatient","","","23731.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","49827.74","","Standard inlier is a Case rate ($49,827.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,113, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,072.63) for the length of stay and the standard reimbursement.","45521.94","45521.94","45521.94","1 through 10","5361.12","83134.46","case rate",""
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","40714.39","30535.79","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","12152.92","12152.92","12152.92","1 through 10","9054.46","15212.88","case rate",""
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","40714.39","30535.79","MEDICARE [2001]","HB BWH MEDICARE","9239.24","","Case rate ($9,239.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,044.81, add-ons for qualifying new technology services are included. If operating cost exceeds $56,689.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,221.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,077.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,664.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.48. The transfer capital threshold is the transfer adjustment factor * $781.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11674.84","0.03","11691.89","34","9054.46","15212.88","other","Inpatient Replacement Plans DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","40714.39","30535.79","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9054.46","","Case rate ($9,239.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,044.81, add-ons for qualifying new technology services are included. If operating cost exceeds $56,689.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,221.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,077.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,664.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.48. The transfer capital threshold is the transfer adjustment factor * $781.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8940.45","8940.45","8940.45","1 through 10","9054.46","15212.88","other","Inpatient DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","40714.39","30535.79","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9054.46","","Case rate ($9,239.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,044.81, add-ons for qualifying new technology services are included. If operating cost exceeds $56,689.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,221.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,077.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,664.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $781.48. The transfer capital threshold is the transfer adjustment factor * $781.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8921.69","8914.72","8946.32","1 through 10","9054.46","15212.88","other","Inpatient DRG"
"Bronchitis And Asthma Without Cc/McC","203","MS-DRG","","","","","","","","inpatient","","","31949.44","23962.08","MEDICARE [2001]","HB BWH MEDICARE","8311.93","","Case rate ($8,311.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,737.25, add-ons for qualifying new technology services are included. If operating cost exceeds $53,381.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,979.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $7,392.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,357.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $539.12. The transfer capital threshold is the transfer adjustment factor * $539.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8490.62","8490.62","8490.62","1 through 10","6361.83","10494.88","other","Inpatient DRG"
"Bronchitis And Asthma Without Cc/McC","203","MS-DRG","","","","","","","","inpatient","","","31949.44","23962.08","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6361.83","","Case rate ($6,491.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,737.25, add-ons for qualifying new technology services are included. If operating cost exceeds $53,381.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,979.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,572.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,357.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $539.12. The transfer capital threshold is the transfer adjustment factor * $539.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6499.01","6499.01","6499.01","1 through 10","6361.83","10494.88","other","Inpatient DRG"
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","both","","","3588.00","2691.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2109.14","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2107.30","2107.30","2107.30","1 through 10","1112.28","2852.46","other","OPPS APC"
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","both","","","3588.00","2691.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2015.14","2015.14","2015.14","1 through 10","1112.28","2852.46","other","OPPS APC"
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","both","","","3588.00","2691.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2852.46","79.5","","6563.58","2737.97","6563.58","1 through 10","1112.28","2852.46","percent of total billed charges",""
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","both","","","3588.00","2691.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1816.48","1816.48","1816.48","1 through 10","1112.28","2852.46","other","OPPS APC"
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","both","","","3588.00","2691.00","MEDICARE [2001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2047.91","1852.43","2047.91","13","1112.28","2852.46","other","OPPS APC"
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","both","","","3588.00","2691.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1309.62","36.5","","2294.51","2294.51","2294.51","1 through 10","1112.28","2852.46","percent of total billed charges",""
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","both","","","3588.00","2691.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2009.45","2009.45","2009.45","1 through 10","1112.28","2852.46","other","OPPS APC"
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","both","","","3588.00","2691.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2006.75","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2014.46","2006.96","2014.46","1 through 10","1112.28","2852.46","other","OPPS APC"
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","outpatient","","","3588.00","2691.00","AETNA [1001]","HB AMC AETNA HMO","2504.42","69.8","","5646.18","5646.18","5646.18","1 through 10","1232.36","2932.11","percent of total billed charges",""
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","outpatient","","","3588.00","2691.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3629.66","3629.66","3665.68","1 through 10","1232.36","2932.11","other","ASC "
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","outpatient","","","3588.00","2691.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2932.11","81.72","","3333.50","3333.50","3333.50","1 through 10","1232.36","2932.11","percent of total billed charges",""
"Bronchosc Revise Prev Plcd Stent","PX-76000799","CDM","31638","CPT","0761","RC","","","","both","","","7106.00","5329.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","8466.62","","APC Price ($8,220.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","8460.15","8460.15","8460.15","1 through 10","2202.86","10275.02","other","OPPS APC"
"Bronchosc Revise Prev Plcd Stent","PX-76000799","CDM","31638","CPT","0761","RC","","","","both","","","7106.00","5329.50","MEDICARE [2001]","HB BWH MEDICARE","8220.02","","APC Price ($8,220.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8220.85","7470.02","8220.85","13","2202.86","10275.02","other","OPPS APC"
"Bronchosc Revise Prev Plcd Stent","PX-76000799","CDM","31638","CPT","0761","RC","","","","both","","","7106.00","5329.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3048.47","42.9","","5508.67","5508.67","5508.67","1 through 10","2202.86","10275.02","percent of total billed charges",""
"Bronchosc Revise Prev Plcd Stent","PX-76000799","CDM","31638","CPT","0761","RC","","","","both","","","7106.00","5329.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8055.62","","APC Price ($8,220.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8064.34","8064.34","8064.34","1 through 10","2202.86","10275.02","other","OPPS APC"
"Bronchosc Revise Prev Plcd Stent","PX-76000799","CDM","31638","CPT","0761","RC","","","","outpatient","","","7106.00","5329.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5886.54","","Case rate ($5,886.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","12043.86","12043.86","12043.86","1 through 10","3713.6","5886.54","other","ASC"
"Bronchosc Revise Prev Plcd Stent","PX-76000799","CDM","31638","CPT","0761","RC","","","","outpatient","","","7106.00","5329.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5886.54","","Case rate ($5,886.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","13780.39","13645.00","13780.39","1 through 10","3713.6","5886.54","other","ASC "
"Bronchosc W/Bronch Stent Plmnt","PX-76000797","CDM","31636","CPT","0761","RC","","","","both","","","6967.00","5225.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5538.77","79.5","","5316.97","5316.97","5316.97","1 through 10","2159.77","10275.02","percent of total billed charges",""
"Bronchosc W/Bronch Stent Plmnt","PX-76000797","CDM","31636","CPT","0761","RC","","","","both","","","6967.00","5225.25","MEDICARE [2001]","HB BWH MEDICARE","8220.02","","APC Price ($8,220.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8220.85","8220.85","14940.04","1 through 10","2159.77","10275.02","other","OPPS APC"
"Bronchosc W/Bronch Stent Plmnt","PX-76000797","CDM","31636","CPT","0761","RC","","","","both","","","6967.00","5225.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","8055.62","","APC Price ($8,220.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1553.88","1553.88","1553.88","1 through 10","2159.77","10275.02","other","OPPS APC"
"Bronchosc W/Bronch Stent Plmnt","PX-76000797","CDM","31636","CPT","0761","RC","","","","both","","","6967.00","5225.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2988.84","42.9","","5400.75","5400.75","5400.75","1 through 10","2159.77","10275.02","percent of total billed charges",""
"Bronchosc W/Bronch Stent Plmnt","PX-76000797","CDM","31636","CPT","0761","RC","","","","both","","","6967.00","5225.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8055.62","","APC Price ($8,220.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8064.34","7320.62","8220.85","1 through 10","2159.77","10275.02","other","OPPS APC"
"Bronchosc W/Bronch Stent Plmnt","PX-76000797","CDM","31636","CPT","0761","RC","","","","outpatient","","","6967.00","5225.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5886.54","","Case rate ($5,886.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","12043.86","5913.03","12043.86","1 through 10","3640.95","5886.54","other","ASC"
"Bronchosc W/Bronch Stent Plmnt","PX-76000797","CDM","31636","CPT","0761","RC","","","","outpatient","","","6967.00","5225.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5886.54","","Case rate ($5,886.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","13645.00","13645.00","13645.00","1 through 10","3640.95","5886.54","other","ASC "
"Bronchosc W/Bronch Stent Plmnt","PX-76000797","CDM","31636","CPT","0761","RC","","","","outpatient","","","6967.00","5225.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4632.81","","Case rate ($4,632.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","10748.12","10748.12","10748.12","1 through 10","3640.95","5886.54","other","Multiple Surgery"
"BRONCHOSCOPE THERAPEUTIC 5.6/2.8 5 AMBU ASCOPE HD BX/5EA","SUP-ITM-10317748","CDM","C1601","HCPCS","0272","RC","","","","both","","","1396.50","1047.37","MEDICARE [2001]","HB BWH MEDICARE","","38.40","38.4% of billed.","531.14","531.14","531.14","1 through 10","432.92","1110.22","other","OPPS APC"
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","both","","","3461.00","2595.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","949.44","949.44","949.44","1 through 10","1072.91","2751.5","other","OPPS APC"
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","both","","","3461.00","2595.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1844.71","53.3","","5991.22","5991.22","5991.22","1 through 10","1072.91","2751.5","percent of total billed charges",""
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","both","","","3461.00","2595.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1822.79","1822.79","1822.79","1 through 10","1072.91","2751.5","other","OPPS APC"
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","both","","","3461.00","2595.75","MEDICARE [2001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2047.91","1852.43","2047.91","1 through 10","1072.91","2751.5","other","OPPS APC"
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","both","","","3461.00","2595.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1325.56","38.3","","1834.77","1581.91","1834.77","1 through 10","1072.91","2751.5","percent of total billed charges",""
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","both","","","3461.00","2595.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2006.75","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2006.95","2006.95","2006.95","1 through 10","1072.91","2751.5","other","OPPS APC"
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","both","","","3461.00","2595.75","WELLPOINT [1015]","HB AMC WELLPOINT","2553.53","73.78","","6531.69","2572.99","6531.69","1 through 10","1072.91","2751.5","percent of total billed charges",""
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","outpatient","","","3461.00","2595.75","AETNA [1001]","HB AMC AETNA HMO","2415.78","69.8","","5616.70","2729.66","6067.50","1 through 10","1232.36","2828.33","percent of total billed charges",""
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","outpatient","","","3461.00","2595.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1601.88","1572.91","1601.88","1 through 10","1232.36","2828.33","other","ASC"
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","outpatient","","","3461.00","2595.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1814.83","1814.83","1832.84","18","1232.36","2828.33","other","ASC "
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","outpatient","","","3461.00","2595.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4288.62","4288.62","4288.62","1 through 10","1232.36","2828.33","other","Multiple Surgery"
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","outpatient","","","3461.00","2595.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3006.96","3006.96","3006.96","1 through 10","1232.36","2828.33","other","Multiple Surgery"
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","outpatient","","","3461.00","2595.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1786.92","1786.92","1786.92","1 through 10","1232.36","2828.33","other","Multiple Surgery"
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","outpatient","","","3461.00","2595.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","4303.73","3903.40","4303.73","1 through 10","1232.36","2828.33","other","Multiple Surgery"
"Bronchoscopy Including Brushing","PX-76000784","CDM","31623","CPT","0761","RC","","","","outpatient","","","3461.00","2595.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2828.33","81.72","","2695.18","1857.60","2695.18","1 through 10","1232.36","2828.33","percent of total billed charges",""
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","both","","","5387.00","4040.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4509.37","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","8466.25","4512.44","8476.52","1 through 10","1669.97","5472.54","other","OPPS APC"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","both","","","5387.00","4040.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8089.32","4308.41","8089.32","14","1669.97","5472.54","other","OPPS APC"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","both","","","5387.00","4040.25","CHAMPVA [160001]","HB BWH TRICARE","4159.55","","APC Price ($4,378.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3253.20","3253.20","3253.20","1 through 10","1669.97","5472.54","other","Tricare OPPS"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","both","","","5387.00","4040.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7320.62","6402.33","8067.28","1 through 10","1669.97","5472.54","other","OPPS APC"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","both","","","5387.00","4040.25","HUMANA [1012]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4317.17","4317.17","4317.17","1 through 10","1669.97","5472.54","other","OPPS APC"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","both","","","5387.00","4040.25","MEDICARE [2001]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8220.85","4378.47","8220.85","93","1669.97","5472.54","other","OPPS APC"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","both","","","5387.00","4040.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8060.43","8060.43","8060.43","1 through 10","1669.97","5472.54","other","OPPS APC"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","both","","","5387.00","4040.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","24169.29","4298.30","24169.29","12","1669.97","5472.54","other","OPPS APC"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","both","","","5387.00","4040.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8064.34","4298.81","8077.02","12","1669.97","5472.54","other","OPPS APC"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","both","","","5387.00","4040.25","WELLPOINT [1015]","HB AMC WELLPOINT","3974.53","73.78","","6531.65","2572.99","9338.31","1 through 10","1669.97","5472.54","percent of total billed charges",""
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","outpatient","","","5387.00","4040.25","AETNA [1001]","HB AMC AETNA HMO","3760.13","69.8","","3423.76","2729.66","6067.46","1 through 10","2466.59","5545.35","percent of total billed charges",""
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","outpatient","","","5387.00","4040.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3206.19","3148.21","6412.37","1 through 10","2466.59","5545.35","other","ASC"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","outpatient","","","5387.00","4040.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3668.46","3632.42","7264.84","23","2466.59","5545.35","other","ASC "
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","outpatient","","","5387.00","4040.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8583.75","8583.75","17167.47","21","2466.59","5545.35","other","Multiple Surgery"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","outpatient","","","5387.00","4040.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","18055.44","18055.44","18055.44","1 through 10","2466.59","5545.35","other","Multiple Surgery"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","outpatient","","","5387.00","4040.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","6314.47","3576.56","6314.47","1 through 10","2466.59","5545.35","other","Multiple Surgery"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","outpatient","","","5387.00","4040.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","6067.81","3157.24","6067.81","1 through 10","2466.59","5545.35","other","Multiple Surgery"
"Bronchoscopy W/Asp Bx Transbronch","PX-76000790","CDM","31629","CPT","0761","RC","","","","outpatient","","","5387.00","4040.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4402.26","81.72","","2695.18","1857.57","5609.12","1 through 10","2466.59","5545.35","percent of total billed charges",""
"Bronchoscopy W/Asp Tree Initial","PX-76000803","CDM","31645","CPT","0761","RC","","","","both","","","1176.00","882.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","934.92","79.5","","5271.33","575.70","5271.33","1 through 10","364.56","2559.63","percent of total billed charges",""
"Bronchoscopy W/Asp Tree Initial","PX-76000803","CDM","31645","CPT","0761","RC","","","","both","","","1176.00","882.00","MEDICARE [2001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2047.91","2047.91","2047.91","1 through 10","364.56","2559.63","other","OPPS APC"
"Bronchoscopy W/Asp Tree Initial","PX-76000803","CDM","31645","CPT","0761","RC","","","","both","","","1176.00","882.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","2006.75","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","262.20","262.20","262.20","1 through 10","364.56","2559.63","other","OPPS APC"
"Bronchoscopy W/Asp Tree Initial","PX-76000803","CDM","31645","CPT","0761","RC","","","","both","","","1176.00","882.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","504.50","42.9","","911.32","911.32","911.32","1 through 10","364.56","2559.63","percent of total billed charges",""
"Bronchoscopy W/Asp Tree Initial","PX-76000803","CDM","31645","CPT","0761","RC","","","","both","","","1176.00","882.00","WELLPOINT [1015]","HB AMC WELLPOINT","867.65","73.78","","848.73","848.73","848.73","1 through 10","364.56","2559.63","percent of total billed charges",""
"Bronchoscopy W/Asp Tree Initial","PX-76000803","CDM","31645","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1601.88","705.44","1601.88","1 through 10","614.58","2384.07","other","ASC"
"Bronchoscopy W/Asp Tree Initial","PX-76000803","CDM","31645","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1814.83","1814.83","1832.84","1 through 10","614.58","2384.07","other","ASC "
"Bronchoscopy W/Asp Tree Initial","PX-76000803","CDM","31645","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2748.16","1429.54","2859.08","1 through 10","614.58","2384.07","other","Multiple Surgery"
"Bronchoscopy W/Asp Tree Initial","PX-76000803","CDM","31645","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","961.03","81.72","","911.32","911.32","911.32","1 through 10","614.58","2384.07","percent of total billed charges",""
"Bronchoscopy W/Balloon Occl","PX-76000795","CDM","31634","CPT","0761","RC","","","","both","","","1676.00","1257.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8220.02","","APC Price ($8,220.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8089.32","8089.32","8089.32","1 through 10","519.56","10275.02","other","OPPS APC"
"Bronchoscopy W/Balloon Occl","PX-76000795","CDM","31634","CPT","0761","RC","","","","both","","","1676.00","1257.00","MEDICARE [2001]","HB BWH MEDICARE","8220.02","","APC Price ($8,220.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8220.85","8220.85","8220.85","1 through 10","519.56","10275.02","other","OPPS APC"
"Bronchoscopy W/Balloon Occl","PX-76000795","CDM","31634","CPT","0761","RC","","","","outpatient","","","1676.00","1257.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5886.54","","Case rate ($5,886.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","13780.39","13780.39","13780.39","1 through 10","875.88","5886.54","other","ASC "
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","both","","","3541.00","2655.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2109.14","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4505.44","4505.44","4505.44","1 through 10","1097.71","2815.1","other","OPPS APC"
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","both","","","3541.00","2655.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2815.10","79.5","","6346.37","2702.56","6346.37","1 through 10","1097.71","2815.1","percent of total billed charges",""
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","both","","","3541.00","2655.75","MEDICARE [2001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4378.47","2047.91","4378.47","12","1097.71","2815.1","other","OPPS APC"
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","both","","","3541.00","2655.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2006.75","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4293.90","4293.90","4293.90","1 through 10","1097.71","2815.1","other","OPPS APC"
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","both","","","3541.00","2655.75","WELLPOINT [1015]","HB AMC WELLPOINT","2612.55","73.78","","5990.61","5990.61","5990.61","1 through 10","1097.71","2815.1","percent of total billed charges",""
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","outpatient","","","3541.00","2655.75","AETNA [1001]","HB AMC AETNA HMO","2471.62","69.8","","2324.82","2324.82","2324.82","1 through 10","1232.36","5545.35","percent of total billed charges",""
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","outpatient","","","3541.00","2655.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3203.75","3145.81","3203.75","1 through 10","1232.36","5545.35","other","ASC"
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","outpatient","","","3541.00","2655.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3629.66","1814.83","3665.68","11","1232.36","5545.35","other","ASC "
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","outpatient","","","3541.00","2655.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1786.92","1786.92","1786.92","1 through 10","1232.36","5545.35","other","Multiple Surgery"
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","outpatient","","","3541.00","2655.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4288.62","1429.54","4288.62","1 through 10","1232.36","5545.35","other","Multiple Surgery"
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","outpatient","","","3541.00","2655.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1503.48","1503.48","1503.48","1 through 10","1232.36","5545.35","other","Multiple Surgery"
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","outpatient","","","3541.00","2655.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1577.42","1577.42","1577.42","1 through 10","1232.36","5545.35","other","Multiple Surgery"
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","outpatient","","","3541.00","2655.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2893.71","81.72","","2745.14","2223.67","2745.14","1 through 10","1232.36","5545.35","percent of total billed charges",""
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","both","","","4090.00","3067.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4509.37","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4505.44","4205.73","4505.44","1 through 10","1267.9","5472.54","other","OPPS APC"
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","both","","","4090.00","3067.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4308.41","722.21","4308.41","1 through 10","1267.9","5472.54","other","OPPS APC"
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","both","","","4090.00","3067.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2683.04","65.6","","4505.44","4505.44","4505.44","1 through 10","1267.9","5472.54","percent of total billed charges",""
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","both","","","4090.00","3067.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2658.50","65","","7733.70","7733.70","7733.70","1 through 10","1267.9","5472.54","percent of total billed charges",""
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","both","","","4090.00","3067.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2863.00","70","","4429.07","3966.00","4429.07","1 through 10","1267.9","5472.54","percent of total billed charges",""
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","both","","","4090.00","3067.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","5472.54","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","875.69","875.69","875.69","1 through 10","1267.9","5472.54","other","OPPS APC"
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","both","","","4090.00","3067.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4306.76","4306.76","4306.76","1 through 10","1267.9","5472.54","other","OPPS APC"
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","both","","","4090.00","3067.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2658.50","65","","2577.90","2577.90","2577.90","1 through 10","1267.9","5472.54","percent of total billed charges",""
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","both","","","4090.00","3067.50","MEDICARE [2001]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4378.47","4087.20","4378.47","45","1267.9","5472.54","other","OPPS APC"
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","both","","","4090.00","3067.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4291.90","4291.90","4291.90","1 through 10","1267.9","5472.54","other","OPPS APC"
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","both","","","4090.00","3067.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1754.61","42.9","","4627.84","4627.84","4627.84","1 through 10","1267.9","5472.54","percent of total billed charges",""
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","both","","","4090.00","3067.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4308.41","4297.01","8056.44","1 through 10","1267.9","5472.54","other","OPPS APC"
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","both","","","4090.00","3067.50","WELLPOINT [1015]","HB AMC WELLPOINT","3017.60","73.78","","6531.65","2952.69","6531.65","1 through 10","1267.9","5472.54","percent of total billed charges",""
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","outpatient","","","4090.00","3067.50","AETNA [1001]","HB AMC AETNA HMO","2854.82","69.8","","5616.70","2739.01","6067.46","1 through 10","2137.43","5545.35","percent of total billed charges",""
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","outpatient","","","4090.00","3067.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6412.37","6296.41","7264.84","1 through 10","2137.43","5545.35","other","ASC"
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","outpatient","","","4090.00","3067.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7336.93","4378.47","7336.93","24","2137.43","5545.35","other","ASC "
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","outpatient","","","4090.00","3067.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","17167.47","2861.25","17167.47","1 through 10","2137.43","5545.35","other","Multiple Surgery"
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","outpatient","","","4090.00","3067.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5796.49","5796.49","5796.49","1 through 10","2137.43","5545.35","other","Multiple Surgery"
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","outpatient","","","4090.00","3067.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","5086.01","2472.55","6314.47","1 through 10","2137.43","5545.35","other","Multiple Surgery"
"Bronchoscopy W/Bx Transbronchia Sgl","PX-76000789","CDM","31628","CPT","0761","RC","","","","outpatient","","","4090.00","3067.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3342.35","81.72","","3170.42","2704.81","3170.42","1 through 10","2137.43","5545.35","percent of total billed charges",""
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","both","","","7113.00","5334.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4509.37","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4505.44","4505.44","4505.44","1 through 10","2205.03","5654.84","other","OPPS APC"
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","both","","","7113.00","5334.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5654.84","79.5","","5428.73","5428.73","5428.73","1 through 10","2205.03","5654.84","percent of total billed charges",""
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","both","","","7113.00","5334.75","ELDER SERVICES [1037]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4290.90","4290.90","6816.26","1 through 10","2205.03","5654.84","other","OPPS APC"
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","both","","","7113.00","5334.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4046.33","4046.33","4046.33","1 through 10","2205.03","5654.84","other","OPPS APC"
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","both","","","7113.00","5334.75","MEDICARE [2001]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4378.47","4087.20","4378.47","38","2205.03","5654.84","other","OPPS APC"
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","both","","","7113.00","5334.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2596.25","36.5","","4589.02","4589.02","4589.02","1 through 10","2205.03","5654.84","percent of total billed charges",""
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","both","","","7113.00","5334.75","MOLINA [1014]","HB BWH MOLINA","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8669.37","8669.37","8669.37","1 through 10","2205.03","5654.84","other","OPPS APC"
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","both","","","7113.00","5334.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4308.41","4292.90","4308.41","1 through 10","2205.03","5654.84","other","OPPS APC"
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","both","","","7113.00","5334.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1586.54","943.23","1586.54","1 through 10","2205.03","5654.84","other","OPPS APC"
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","both","","","7113.00","5334.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3051.48","42.9","","5514.26","4917.51","5514.26","1 through 10","2205.03","5654.84","percent of total billed charges",""
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","both","","","7113.00","5334.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4308.42","4308.42","4308.42","1 through 10","2205.03","5654.84","other","OPPS APC"
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","both","","","7113.00","5334.75","WELLPOINT [1015]","HB AMC WELLPOINT","5247.97","73.78","","5135.56","5135.56","5135.56","1 through 10","2205.03","5654.84","percent of total billed charges",""
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","outpatient","","","7113.00","5334.75","AETNA [1001]","HB AMC AETNA HMO","4964.87","69.8","","4669.95","3297.24","8329.13","1 through 10","2466.59","5812.74","percent of total billed charges",""
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","outpatient","","","7113.00","5334.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3206.19","3148.21","6296.41","1 through 10","2466.59","5812.74","other","ASC"
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","outpatient","","","7113.00","5334.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4308.85","3632.42","7336.93","1 through 10","2466.59","5812.74","other","ASC "
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","outpatient","","","7113.00","5334.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2861.25","2750.25","2861.25","1 through 10","2466.59","5812.74","other","Multiple Surgery"
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","outpatient","","","7113.00","5334.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6018.48","2898.25","6018.48","1 through 10","2466.59","5812.74","other","Multiple Surgery"
"Bronchoscopy W/Destruction Tumor","PX-76000801","CDM","31641","CPT","0761","RC","","","","outpatient","","","7113.00","5334.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","7153.11","7153.11","7153.11","1 through 10","2466.59","5812.74","other","Multiple Surgery"
"Bronchoscopy W/Dilation Clsd Fx","PX-76000791","CDM","31630","CPT","0761","RC","","","","both","","","7187.00","5390.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4509.37","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4505.44","4505.44","4523.83","1 through 10","2227.97","5713.67","other","OPPS APC"
"Bronchoscopy W/Dilation Clsd Fx","PX-76000791","CDM","31630","CPT","0761","RC","","","","both","","","7187.00","5390.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4290.90","4290.90","4290.90","1 through 10","2227.97","5713.67","other","OPPS APC"
"Bronchoscopy W/Dilation Clsd Fx","PX-76000791","CDM","31630","CPT","0761","RC","","","","both","","","7187.00","5390.25","ELDER SERVICES [1037]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6970.00","4005.46","6970.00","1 through 10","2227.97","5713.67","other","OPPS APC"
"Bronchoscopy W/Dilation Clsd Fx","PX-76000791","CDM","31630","CPT","0761","RC","","","","both","","","7187.00","5390.25","MEDICARE [2001]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4378.47","4087.20","4378.47","1 through 10","2227.97","5713.67","other","OPPS APC"
"Bronchoscopy W/Dilation Clsd Fx","PX-76000791","CDM","31630","CPT","0761","RC","","","","both","","","7187.00","5390.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1603.10","943.23","3833.50","1 through 10","2227.97","5713.67","other","OPPS APC"
"Bronchoscopy W/Dilation Clsd Fx","PX-76000791","CDM","31630","CPT","0761","RC","","","","both","","","7187.00","5390.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3083.22","42.9","","5571.82","3278.34","5571.83","1 through 10","2227.97","5713.67","percent of total billed charges",""
"Bronchoscopy W/Dilation Clsd Fx","PX-76000791","CDM","31630","CPT","0761","RC","","","","both","","","7187.00","5390.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4308.42","4308.42","4308.42","1 through 10","2227.97","5713.67","other","OPPS APC"
"Bronchoscopy W/Dilation Clsd Fx","PX-76000791","CDM","31630","CPT","0761","RC","","","","both","","","7187.00","5390.25","WELLPOINT [1015]","HB AMC WELLPOINT","5302.57","73.78","","5189.17","5189.17","9159.58","1 through 10","2227.97","5713.67","percent of total billed charges",""
"Bronchoscopy W/Dilation Clsd Fx","PX-76000791","CDM","31630","CPT","0761","RC","","","","outpatient","","","7187.00","5390.25","AETNA [1001]","HB AMC AETNA HMO","5016.53","69.8","","4718.69","4718.69","4718.69","1 through 10","2466.59","5873.22","percent of total billed charges",""
"Bronchoscopy W/Dilation Clsd Fx","PX-76000791","CDM","31630","CPT","0761","RC","","","","outpatient","","","7187.00","5390.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6296.41","6296.41","6412.37","1 through 10","2466.59","5873.22","other","ASC"
"Bronchoscopy W/Dilation Clsd Fx","PX-76000791","CDM","31630","CPT","0761","RC","","","","outpatient","","","7187.00","5390.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7336.93","7264.84","7336.93","1 through 10","2466.59","5873.22","other","ASC "
"Bronchoscopy W/Dilation Clsd Fx","PX-76000791","CDM","31630","CPT","0761","RC","","","","outpatient","","","7187.00","5390.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","5722.49","5500.50","5722.49","1 through 10","2466.59","5873.22","other","Multiple Surgery"
"Bronchoscopy W/Dilation Clsd Fx","PX-76000791","CDM","31630","CPT","0761","RC","","","","outpatient","","","7187.00","5390.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5796.49","5796.49","5796.49","1 through 10","2466.59","5873.22","other","Multiple Surgery"
"Bronchoscopy W/Excise Tumor","PX-76000800","CDM","31640","CPT","0761","RC","","","","outpatient","","","7071.00","5303.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6018.48","6018.48","6018.48","1 through 10","2466.59","5778.42","other","Multiple Surgery"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2109.14","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2116.20","1906.15","7496.58","1 through 10","1047.8","2687.1","other","OPPS APC"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2015.14","949.44","3700.72","1 through 10","1047.8","2687.1","other","OPPS APC"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2197.00","65","","6392.10","6392.10","6392.10","1 through 10","1047.8","2687.1","percent of total billed charges",""
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2366.00","70","","3278.00","3278.00","3278.00","1 through 10","1047.8","2687.1","percent of total billed charges",""
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2687.10","79.5","","6346.37","2579.79","17194.98","1 through 10","1047.8","2687.1","percent of total billed charges",""
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1801.54","53.3","","5982.25","5982.25","5982.25","1 through 10","1047.8","2687.1","percent of total billed charges",""
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2015.14","2015.14","2015.14","1 through 10","1047.8","2687.1","other","OPPS APC"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2197.00","65","","2130.70","2130.70","2130.70","1 through 10","1047.8","2687.1","percent of total billed charges",""
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","MEDICARE [2001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2047.91","2047.91","2047.91","30","1047.8","2687.1","other","OPPS APC"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1233.70","36.5","","1950.03","1222.69","1950.03","1 through 10","1047.8","2687.1","percent of total billed charges",""
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1294.54","38.3","","2060.36","1281.70","2060.36","1 through 10","1047.8","2687.1","percent of total billed charges",""
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1815.38","1815.38","1815.38","1 through 10","1047.8","2687.1","other","OPPS APC"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","TRICARE [160005]","HB BWH TRICARE","1945.52","","APC Price ($2,047.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","5787.11","5787.11","5787.11","1 through 10","1047.8","2687.1","other","Tricare OPPS"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2006.75","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4298.70","4298.70","4298.70","1 through 10","1047.8","2687.1","other","OPPS APC"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","2006.75","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2261.82","753.94","2261.82","1 through 10","1047.8","2687.1","other","OPPS APC"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1450.02","42.9","","2620.43","2620.43","4627.84","1 through 10","1047.8","2687.1","percent of total billed charges",""
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2006.75","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2014.86","1830.21","2014.86","1 through 10","1047.8","2687.1","other","OPPS APC"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","both","","","3380.00","2535.00","WELLPOINT [1015]","HB AMC WELLPOINT","2493.76","73.78","","5718.47","2440.47","9458.68","16","1047.8","2687.1","percent of total billed charges",""
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","outpatient","","","3380.00","2535.00","AETNA [1001]","HB AMC AETNA HMO","2359.24","69.8","","4438.42","2729.66","6067.46","12","1232.36","2762.14","percent of total billed charges",""
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","outpatient","","","3380.00","2535.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1601.88","1572.91","3203.75","27","1232.36","2762.14","other","ASC"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","outpatient","","","3380.00","2535.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1832.84","1814.83","3665.68","82","1232.36","2762.14","other","ASC "
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","outpatient","","","3380.00","2535.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3573.84","1786.92","3573.84","1 through 10","1232.36","2762.14","other","Multiple Surgery"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","outpatient","","","3380.00","2535.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4288.62","2748.16","4288.62","37","1232.36","2762.14","other","Multiple Surgery"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","outpatient","","","3380.00","2535.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3278.00","1448.03","4510.44","1 through 10","1232.36","2762.14","other","Multiple Surgery"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","outpatient","","","3380.00","2535.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","3438.28","1786.92","3438.28","1 through 10","1232.36","2762.14","other","Multiple Surgery"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","outpatient","","","3380.00","2535.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2043.62","828.86","4203.71","1 through 10","1232.36","2762.14","other","Multiple Surgery"
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","outpatient","","","3380.00","2535.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2762.14","81.72","","2620.43","1857.57","2704.81","11","1232.36","2762.14","percent of total billed charges",""
"Bronchoscopy W/Lav Bronch Alveolar|BILATERAL PROCEDURE","PX-76000785","CDM","31624","CPT","0761","RC","","","50","outpatient","","","3380.00","2535.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2348.79","","Case rate ($2,348.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1572.91","1572.91","1572.91","1 through 10","2348.79","7079.91","other","ASC"
"Bronchoscopy W/Lav Bronch Alveolar|BILATERAL PROCEDURE","PX-76000785","CDM","31624","CPT","0761","RC","","","50","outpatient","","","3380.00","2535.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2348.79","","Case rate ($2,348.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3629.66","3629.66","3629.66","1 through 10","2348.79","7079.91","other","ASC "
"Bronchoscopy W/Lung Biopsy Ea Lobe","PX-76000793","CDM","31632","CPT","0761","RC","","","","both","","","370.00","277.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","240.50","65","","700.05","700.05","700.05","1 through 10","114.7","297.48","percent of total billed charges",""
"Bronchoscopy W/Lung Biopsy Ea Lobe","PX-76000793","CDM","31632","CPT","0761","RC","","","","both","","","370.00","277.50","WELLPOINT [1015]","HB AMC WELLPOINT","272.99","73.78","","2572.99","2572.99","2572.99","1 through 10","114.7","297.48","percent of total billed charges",""
"Bronchoscopy W/Place Cath","PX-76000802","CDM","31643","CPT","0761","RC","","","","both","","","3314.00","2485.50","MEDICARE [2001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6143.73","1852.43","6143.73","1 through 10","1027.34","2634.63","other","OPPS APC"
"Bronchoscopy W/Place Cath","PX-76000802","CDM","31643","CPT","0761","RC","","","","outpatient","","","3314.00","2485.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2748.16","2748.16","2748.16","1 through 10","1232.36","2708.2","other","Multiple Surgery"
"Bronchoscopy W/Remove FB","PX-76000796","CDM","31635","CPT","0761","RC","","","","both","","","3501.00","2625.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1349.46","1349.46","1349.46","1 through 10","1085.31","2783.3","other","OPPS APC"
"Bronchoscopy W/Remove FB","PX-76000796","CDM","31635","CPT","0761","RC","","","","both","","","3501.00","2625.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2783.30","79.5","","2671.87","1714.48","2671.87","1 through 10","1085.31","2783.3","percent of total billed charges",""
"Bronchoscopy W/Remove FB","PX-76000796","CDM","31635","CPT","0761","RC","","","","both","","","3501.00","2625.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1833.91","1833.91","1833.91","1 through 10","1085.31","2783.3","other","OPPS APC"
"Bronchoscopy W/Remove FB","PX-76000796","CDM","31635","CPT","0761","RC","","","","both","","","3501.00","2625.75","MEDICARE [2001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4087.20","2047.91","4087.20","1 through 10","1085.31","2783.3","other","OPPS APC"
"Bronchoscopy W/Remove FB","PX-76000796","CDM","31635","CPT","0761","RC","","","","both","","","3501.00","2625.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","2006.75","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","943.23","943.23","943.23","1 through 10","1085.31","2783.3","other","OPPS APC"
"Bronchoscopy W/Remove FB","PX-76000796","CDM","31635","CPT","0761","RC","","","","outpatient","","","3501.00","2625.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3145.81","1572.91","3145.81","1 through 10","1232.36","5545.35","other","ASC"
"Bronchoscopy W/Remove FB","PX-76000796","CDM","31635","CPT","0761","RC","","","","outpatient","","","3501.00","2625.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3629.66","1016.57","3665.68","1 through 10","1232.36","5545.35","other","ASC "
"Bronchoscopy W/Stent Place","PX-76000792","CDM","31631","CPT","0761","RC","","","","both","","","7106.00","5329.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8220.02","","APC Price ($8,220.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4995.70","4995.70","4995.70","1 through 10","2202.86","10275.02","other","OPPS APC"
"Bronchoscopy W/Stent Place","PX-76000792","CDM","31631","CPT","0761","RC","","","","both","","","7106.00","5329.50","MEDICARE [2001]","HB BWH MEDICARE","8220.02","","APC Price ($8,220.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8220.85","8220.85","8220.85","1 through 10","2202.86","10275.02","other","OPPS APC"
"Bronchoscopy W/Stent Place","PX-76000792","CDM","31631","CPT","0761","RC","","","","outpatient","","","7106.00","5329.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5886.54","","Case rate ($5,886.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","11826.06","11826.06","11826.06","1 through 10","3713.6","5886.54","other","ASC"
"Brooke-Spiegler Syndrome (Cyld Full Sequence Analysis Exons 4-20)","PX-31000806","CDM","81479","CPT","0310","RC","","","","both","","","1759.00","1319.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1398.41","79.5","","0.65","0.65","0.65","1 through 10","545.29","1671.05","percent of total billed charges",""
"Brooke-Spiegler Syndrome (Cyld Full Sequence Analysis Exons 4-20)","PX-31000806","CDM","81479","CPT","0310","RC","","","","both","","","1759.00","1319.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","937.55","53.3","","0.79","0.79","0.79","1 through 10","545.29","1671.05","percent of total billed charges",""
"Brooke-Spiegler Syndrome (Cyld Full Sequence Analysis Exons 4-20)","PX-31000806","CDM","81479","CPT","0310","RC","","","","outpatient","","","1759.00","1319.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","879.50","50","","1.00","1.00","1.00","1 through 10","156.55","1451.18","percent of total billed charges",""
"Brooke-Spiegler Syndrome (Cyld Full Sequence Analysis Exons 4-20)","PX-31000806","CDM","81479","CPT","0310","RC","","","","outpatient","","","1759.00","1319.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","923.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","1451.18","percent of total billed charges",""
"Brucella Antibody","PX-30000896","CDM","86622","CPT","0302","RC","","","","both","","","131.00","98.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","91.70","70","","127.00","127.00","127.00","1 through 10","8.75","124.45","percent of total billed charges",""
"Brucella Antibody","PX-30000896","CDM","86622","CPT","0302","RC","","","","both","","","131.00","98.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","47.82","36.5","","47.37","47.37","47.37","1 through 10","8.75","124.45","percent of total billed charges",""
"Brucella Antibody","PX-30000896","CDM","86622","CPT","0302","RC","","","","both","","","131.00","98.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","50.17","38.3","","49.66","49.66","49.66","1 through 10","8.75","124.45","percent of total billed charges",""
"Brucella Antibody","PX-30000896","CDM","86622","CPT","0302","RC","","","","outpatient","","","131.00","98.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","107.05","81.72","","304.57","304.57","304.57","1 through 10","8.97","107.05","percent of total billed charges",""
"Btk Gene Sequencing & Del/Dup","PX-31000734","CDM","81479","CPT","0310","RC","","","","both","","","2081.00","1560.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1654.40","79.5","","0.65","0.65","0.65","1 through 10","645.11","1976.95","percent of total billed charges",""
"Btk Gene Sequencing & Del/Dup","PX-31000734","CDM","81479","CPT","0310","RC","","","","both","","","2081.00","1560.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1109.17","53.3","","0.79","0.79","0.79","1 through 10","645.11","1976.95","percent of total billed charges",""
"Btk Gene Sequencing & Del/Dup","PX-31000734","CDM","81479","CPT","0310","RC","","","","outpatient","","","2081.00","1560.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1040.50","50","","1.00","1.00","1.00","1 through 10","156.55","1716.83","percent of total billed charges",""
"Btk Gene Sequencing & Del/Dup","PX-31000734","CDM","81479","CPT","0310","RC","","","","outpatient","","","2081.00","1560.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1092.53","52.5","","1.00","0.53","1.00","1 through 10","156.55","1716.83","percent of total billed charges",""
"Bulk Agent Synthetic 1ml T1","PX-27000562","CDM","L8606","HCPCS","0278","RC","","","","both","","","1072.65","804.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","410.82","38.3","","1436.93","1436.93","1436.93","1 through 10","332.52","852.76","percent of total billed charges",""
"BUMPER PROSTHESIS 70X10MM KNEE RL/LM AUGMENT FEMORAL DISTAL VANGUARD ORTHOPEDICS","SUP-ITM-10091097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.58","1292.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1370.25","79.5","","800.18","480.96","1887.97","195","534.31","1370.25","percent of total billed charges",""
"BUMPER PROSTHESIS 70X10MM KNEE RL/LM AUGMENT FEMORAL DISTAL VANGUARD ORTHOPEDICS","SUP-ITM-10091097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.58","1292.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","918.67","53.3","","813.12","216.42","1444.50","81","534.31","1370.25","percent of total billed charges",""
"BUMPER PROSTHESIS 70X10MM KNEE RL/LM AUGMENT FEMORAL DISTAL VANGUARD ORTHOPEDICS","SUP-ITM-10091097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.58","1292.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","534.31","31","","432.60","432.60","432.60","1 through 10","534.31","1370.25","percent of total billed charges",""
"BUMPER PROSTHESIS 70X10MM KNEE RL/LM AUGMENT FEMORAL DISTAL VANGUARD ORTHOPEDICS","SUP-ITM-10091097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.58","1292.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","629.11","36.5","","148.37","54.89","631.39","94","534.31","1370.25","percent of total billed charges",""
"BUMPER PROSTHESIS 70X10MM KNEE RL/LM AUGMENT FEMORAL DISTAL VANGUARD ORTHOPEDICS","SUP-ITM-10091097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.58","1292.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","660.13","38.3","","279.30","91.72","1116.77","266","534.31","1370.25","percent of total billed charges",""
"BUMPER PROSTHESIS 70X10MM KNEE RL/LM AUGMENT FEMORAL DISTAL VANGUARD ORTHOPEDICS","SUP-ITM-10091097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.58","1292.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","739.42","42.9","","731.00","63.70","731.00","1 through 10","534.31","1370.25","percent of total billed charges",""
"BUMPER PROSTHESIS 70X10MM KNEE RL/LM AUGMENT FEMORAL DISTAL VANGUARD ORTHOPEDICS","SUP-ITM-10091097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.58","1292.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","739.42","42.9","","384.74","384.74","384.74","1 through 10","534.31","1370.25","percent of total billed charges",""
"BUMPER PROSTHESIS 70X10MM KNEE RL/LM AUGMENT FEMORAL DISTAL VANGUARD ORTHOPEDICS","SUP-ITM-10091097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.58","1292.68","WELLPOINT [1015]","HB AMC WELLPOINT","1271.66","73.78","","286.63","119.22","1107.45","105","534.31","1370.25","percent of total billed charges",""
"BUMPER PROSTHESIS 70X10MM KNEE RL/LM AUGMENT FEMORAL DISTAL VANGUARD ORTHOPEDICS","SUP-ITM-10091097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.58","1292.68","AETNA [1001]","HB AMC AETNA HMO","1203.06","69.8","","675.31","184.75","1721.50","286","900.74","1408.51","percent of total billed charges",""
"BUMPER PROSTHESIS 70X10MM KNEE RL/LM AUGMENT FEMORAL DISTAL VANGUARD ORTHOPEDICS","SUP-ITM-10091097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.58","1292.68","AETNA [1001]","HB AMC AETNA PPO","1385.76","80.4","","1261.44","103.12","1514.10","21","900.74","1408.51","percent of total billed charges",""
"BUMPER PROSTHESIS 70X10MM KNEE RL/LM AUGMENT FEMORAL DISTAL VANGUARD ORTHOPEDICS","SUP-ITM-10091097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.58","1292.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1385.76","80.4","","1365.00","1365.00","1365.00","1 through 10","900.74","1408.51","percent of total billed charges",""
"BUMPER PROSTHESIS 70X10MM KNEE RL/LM AUGMENT FEMORAL DISTAL VANGUARD ORTHOPEDICS","SUP-ITM-10091097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.58","1292.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1408.51","81.72","","5157.68","5157.68","5157.68","1 through 10","900.74","1408.51","percent of total billed charges",""
"BUMPER PROSTHESIS 70X10MM KNEE RL/LM AUGMENT FEMORAL DISTAL VANGUARD ORTHOPEDICS","SUP-ITM-10091097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.58","1292.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1408.51","81.72","","431.26","71.26","1459.57","88","900.74","1408.51","percent of total billed charges",""
"Burns With Skin Graft Except Extensive Third Degree Burns,EXTREME","842","DRG","","","","","","","","inpatient","","","590522.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","301515.30","","Standard inlier is a Case rate ($301,515.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $220,200, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($42,797.59) for the length of stay and the standard reimbursement.","338601.34","338601.34","338601.34","1 through 10","17623.28","402563.27","case rate",""
"Burns With Skin Graft Except Extensive Third Degree Burns,EXTREME","842","DRG","","","","","","","","inpatient","","","590522.55","","MASSHEALTH [3001]","HB BWH MEDICAID","113807.07","","Case rate ($125,833.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $168,263.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $9,018.16 and the sum of the standard inlier and any outlier amount.","27999.44","27999.44","27999.44","1 through 10","17623.28","402563.27","case rate",""
"Burns With Skin Graft Except Extensive Third Degree Burns,EXTREME","842","DRG","","","","","","","","inpatient","","","590522.55","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","308015.48","","Fee schedule rate ($308,015.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","308015.48","308015.48","308015.48","1 through 10","17623.28","402563.27","case rate",""
"Burns With Skin Graft Except Extensive Third Degree Burns,MAJOR","842","DRG","","","","","","","","inpatient","","","331946.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","110599.75","","Standard inlier is a Case rate ($110,599.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $97,654, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($15,700.30) for the length of stay and the standard reimbursement.","120773.30","120773.30","120773.30","1 through 10","17623.28","402563.27","case rate",""
"Burns With Skin Graft Except Extensive Third Degree Burns,MAJOR","842","DRG","","","","","","","","inpatient","","","331946.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","124343.93","","Standard inlier is a Case rate ($124,343.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $97,654, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,649.59) for the length of stay and the standard reimbursement.","124343.92","124343.92","124343.92","1 through 10","17623.28","402563.27","case rate",""
"Burns With Skin Graft Except Extensive Third Degree Burns,MAJOR","842","DRG","","","","","","","","inpatient","","","331946.44","","MASSHEALTH [3001]","HB BWH MEDICAID","39397.92","","Case rate ($43,561.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $85,991.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","34145.07","34145.07","34145.07","1 through 10","17623.28","402563.27","case rate",""
"Burns With Skin Graft Except Extensive Third Degree Burns,MAJOR","842","DRG","","","","","","","","inpatient","","","331946.44","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","39397.92","","Case rate ($43,561.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $85,991.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","17623.28","402563.27","case rate",""
"Burns With Skin Graft Except Extensive Third Degree Burns,MAJOR","842","DRG","","","","","","","","inpatient","","","331946.44","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","39397.92","","Case rate ($43,561.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $85,991.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","43550.48","43550.48","43550.48","1 through 10","17623.28","402563.27","case rate",""
"Burns With Skin Graft Except Extensive Third Degree Burns,MINOR","842","DRG","","","","","","","","inpatient","","","45361.62","","MASSHEALTH [3001]","HB BWH MEDICAID","17623.28","","Case rate ($19,485.57). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,915.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6942.55","6942.55","6942.55","1 through 10","17623.28","402563.27","case rate",""
"Burns With Skin Graft Except Extensive Third Degree Burns,MINOR","842","DRG","","","","","","","","inpatient","","","45361.62","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","17623.28","","Case rate ($19,485.57). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,915.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","86797.14","86797.14","86797.14","1 through 10","17623.28","402563.27","case rate",""
"Burns With Skin Graft Except Extensive Third Degree Burns,MODERATE","842","DRG","","","","","","","","inpatient","","","204712.73","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","58631.00","","Standard inlier is a Case rate ($58,631.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,240, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,323.02) for the length of stay and the standard reimbursement.","58630.99","58630.99","58630.99","1 through 10","17623.28","402563.27","case rate",""
"Burns With Skin Graft Except Extensive Third Degree Burns,MODERATE","842","DRG","","","","","","","","inpatient","","","204712.73","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","22824.47","","Case rate ($25,236.38). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $67,666.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20664.21","20664.21","20664.21","1 through 10","17623.28","402563.27","case rate",""
"Burns With Skin Graft Except Extensive Third Degree Burns,MODERATE","842","DRG","","","","","","","","inpatient","","","204712.73","","MASSHEALTH [3001]","HB BWH MEDICAID","22824.47","","Case rate ($25,236.38). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $67,666.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","35435.73","35435.73","35435.73","1 through 10","17623.28","402563.27","case rate",""
"Burns With Skin Graft Except Extensive Third Degree Burns,MODERATE","842","DRG","","","","","","","","inpatient","","","204712.73","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","22824.47","","Case rate ($25,236.38). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $67,666.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25230.18","1953.84","37395.91","1 through 10","17623.28","402563.27","case rate",""
"Burr Hole Implant Ventricular Cath/Other Device","PX-76001424","CDM","61210","CPT","0761","RC","","","","outpatient","","","10376.00","7782.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5418.35","52.22","","1473.41","1473.41","1473.41","1 through 10","4150.4","8479.27","percent of total billed charges",""
"BUSHING FEMORAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036213","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","814.32","52.26","","1113.10","1113.10","1113.10","1 through 10","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036213","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.77","79.5","","1293.60","1148.53","1603.80","1 through 10","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036213","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.74","36.5","","1023.42","771.29","2068.67","33","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036213","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.79","38.3","","850.52","759.78","1211.25","66","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036213","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.47","42.9","","2548.09","2548.09","2548.09","1 through 10","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036213","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.47","42.9","","956.46","956.46","956.46","1 through 10","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036213","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","WELLPOINT [1015]","HB AMC WELLPOINT","1149.64","73.78","","2344.73","1619.47","2530.35","16","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036213","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1558.20","1168.65","AETNA [1001]","HB AMC AETNA HMO","1087.62","69.8","","1523.63","988.41","4330.26","39","814.32","1273.36","percent of total billed charges",""
"BUSHING FEMORAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036213","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1558.20","1168.65","AETNA [1001]","HB AMC AETNA PPO","1252.79","80.4","","1670.25","1670.25","1670.25","1 through 10","814.32","1273.36","percent of total billed charges",""
"BUSHING FEMORAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036213","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1558.20","1168.65","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","814.32","52.26","","1113.10","1113.10","1113.10","1 through 10","814.32","1273.36","percent of total billed charges",""
"BUSHING FEMORAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036213","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1558.20","1168.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1273.36","81.72","","1738.90","1484.65","2716.94","38","814.32","1273.36","percent of total billed charges",""
"BUSHING FEMORAL KNEE OSS POLY RESURFACING","SUP-ITM-10118237","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","814.32","52.26","","1113.10","1113.10","1113.10","1 through 10","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL KNEE OSS POLY RESURFACING","SUP-ITM-10118237","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.77","79.5","","1293.60","1148.53","1603.80","1 through 10","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL KNEE OSS POLY RESURFACING","SUP-ITM-10118237","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.74","36.5","","1023.42","771.29","2068.67","33","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL KNEE OSS POLY RESURFACING","SUP-ITM-10118237","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.79","38.3","","850.52","759.78","1211.25","66","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL KNEE OSS POLY RESURFACING","SUP-ITM-10118237","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.47","42.9","","2548.09","2548.09","2548.09","1 through 10","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL KNEE OSS POLY RESURFACING","SUP-ITM-10118237","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.47","42.9","","956.46","956.46","956.46","1 through 10","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL KNEE OSS POLY RESURFACING","SUP-ITM-10118237","CDM","C1776","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","WELLPOINT [1015]","HB AMC WELLPOINT","1149.64","73.78","","2344.73","1619.47","2530.35","16","483.04","1238.77","percent of total billed charges",""
"BUSHING FEMORAL KNEE OSS POLY RESURFACING","SUP-ITM-10118237","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1558.20","1168.65","AETNA [1001]","HB AMC AETNA HMO","1087.62","69.8","","1523.63","988.41","4330.26","39","814.32","1273.36","percent of total billed charges",""
"BUSHING FEMORAL KNEE OSS POLY RESURFACING","SUP-ITM-10118237","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1558.20","1168.65","AETNA [1001]","HB AMC AETNA PPO","1252.79","80.4","","1670.25","1670.25","1670.25","1 through 10","814.32","1273.36","percent of total billed charges",""
"BUSHING FEMORAL KNEE OSS POLY RESURFACING","SUP-ITM-10118237","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1558.20","1168.65","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","814.32","52.26","","1113.10","1113.10","1113.10","1 through 10","814.32","1273.36","percent of total billed charges",""
"BUSHING FEMORAL KNEE OSS POLY RESURFACING","SUP-ITM-10118237","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1558.20","1168.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1273.36","81.72","","1738.90","1484.65","2716.94","38","814.32","1273.36","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","477.40","52.26","","1113.10","1113.10","1113.10","1 through 10","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","726.23","79.5","","1293.60","1148.53","1603.80","1 through 10","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","333.43","36.5","","1023.42","771.29","2068.67","33","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","349.87","38.3","","850.52","759.78","1211.25","66","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.89","42.9","","2548.09","2548.09","2548.09","1 through 10","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.89","42.9","","956.46","956.46","956.46","1 through 10","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","WELLPOINT [1015]","HB AMC WELLPOINT","673.98","73.78","","2344.73","1619.47","2530.35","16","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","913.50","685.12","AETNA [1001]","HB AMC AETNA HMO","637.62","69.8","","1523.63","988.41","4330.26","39","477.4","746.51","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","913.50","685.12","AETNA [1001]","HB AMC AETNA PPO","734.45","80.4","","1670.25","1670.25","1670.25","1 through 10","477.4","746.51","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","913.50","685.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","477.40","52.26","","1113.10","1113.10","1113.10","1 through 10","477.4","746.51","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","913.50","685.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","746.51","81.72","","1738.90","1484.65","2716.94","38","477.4","746.51","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","477.40","52.26","","1113.10","1113.10","1113.10","1 through 10","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","726.23","79.5","","1293.60","1148.53","1603.80","1 through 10","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","333.43","36.5","","1023.42","771.29","2068.67","33","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","349.87","38.3","","850.52","759.78","1211.25","66","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.89","42.9","","2548.09","2548.09","2548.09","1 through 10","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.89","42.9","","956.46","956.46","956.46","1 through 10","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","913.50","685.12","WELLPOINT [1015]","HB AMC WELLPOINT","673.98","73.78","","2344.73","1619.47","2530.35","16","283.19","726.23","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","913.50","685.12","AETNA [1001]","HB AMC AETNA HMO","637.62","69.8","","1523.63","988.41","4330.26","39","477.4","746.51","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","913.50","685.12","AETNA [1001]","HB AMC AETNA PPO","734.45","80.4","","1670.25","1670.25","1670.25","1 through 10","477.4","746.51","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","913.50","685.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","477.40","52.26","","1113.10","1113.10","1113.10","1 through 10","477.4","746.51","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","913.50","685.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","746.51","81.72","","1738.90","1484.65","2716.94","38","477.4","746.51","percent of total billed charges",""
"BUSHING TIBIAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036211","CDM","C1776","HCPCS","0278","RC","","","","both","","","779.10","584.32","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","407.16","52.26","","1113.10","1113.10","1113.10","1 through 10","241.52","619.38","percent of total billed charges",""
"BUSHING TIBIAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036211","CDM","C1776","HCPCS","0278","RC","","","","both","","","779.10","584.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","619.38","79.5","","1293.60","1148.53","1603.80","1 through 10","241.52","619.38","percent of total billed charges",""
"BUSHING TIBIAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036211","CDM","C1776","HCPCS","0278","RC","","","","both","","","779.10","584.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","284.37","36.5","","1023.42","771.29","2068.67","33","241.52","619.38","percent of total billed charges",""
"BUSHING TIBIAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036211","CDM","C1776","HCPCS","0278","RC","","","","both","","","779.10","584.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","298.40","38.3","","850.52","759.78","1211.25","66","241.52","619.38","percent of total billed charges",""
"BUSHING TIBIAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036211","CDM","C1776","HCPCS","0278","RC","","","","both","","","779.10","584.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","334.23","42.9","","2548.09","2548.09","2548.09","1 through 10","241.52","619.38","percent of total billed charges",""
"BUSHING TIBIAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036211","CDM","C1776","HCPCS","0278","RC","","","","both","","","779.10","584.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","334.23","42.9","","956.46","956.46","956.46","1 through 10","241.52","619.38","percent of total billed charges",""
"BUSHING TIBIAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036211","CDM","C1776","HCPCS","0278","RC","","","","both","","","779.10","584.32","WELLPOINT [1015]","HB AMC WELLPOINT","574.82","73.78","","2344.73","1619.47","2530.35","16","241.52","619.38","percent of total billed charges",""
"BUSHING TIBIAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036211","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","AETNA [1001]","HB AMC AETNA HMO","543.81","69.8","","1523.63","988.41","4330.26","39","407.16","636.68","percent of total billed charges",""
"BUSHING TIBIAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036211","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","AETNA [1001]","HB AMC AETNA PPO","626.40","80.4","","1670.25","1670.25","1670.25","1 through 10","407.16","636.68","percent of total billed charges",""
"BUSHING TIBIAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036211","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","407.16","52.26","","1113.10","1113.10","1113.10","1 through 10","407.16","636.68","percent of total billed charges",""
"BUSHING TIBIAL IMPLANT KNEE OSS POLYETHYLENE ONC 16B","SUP-ITM-10036211","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","636.68","81.72","","1738.90","1484.65","2716.94","38","407.16","636.68","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.25","3900.19","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2717.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1612.08","4134.2","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.25","3900.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4134.20","79.5","","1293.60","1148.53","1603.80","1 through 10","1612.08","4134.2","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.25","3900.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1898.09","36.5","","1023.42","771.29","2068.67","33","1612.08","4134.2","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.25","3900.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1991.70","38.3","","850.52","759.78","1211.25","66","1612.08","4134.2","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.25","3900.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2230.91","42.9","","2548.09","2548.09","2548.09","1 through 10","1612.08","4134.2","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.25","3900.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2230.91","42.9","","956.46","956.46","956.46","1 through 10","1612.08","4134.2","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.25","3900.19","WELLPOINT [1015]","HB AMC WELLPOINT","3836.74","73.78","","2344.73","1619.47","2530.35","16","1612.08","4134.2","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5200.25","3900.19","AETNA [1001]","HB AMC AETNA HMO","3629.77","69.8","","1523.63","988.41","4330.26","39","2717.65","4249.64","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5200.25","3900.19","AETNA [1001]","HB AMC AETNA PPO","4181.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2717.65","4249.64","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5200.25","3900.19","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2717.65","52.26","","1113.10","1113.10","1113.10","1 through 10","2717.65","4249.64","percent of total billed charges",""
"BUSHINGS AND AXLE STANDARD ASSEMBLY PACK TRIATHLON","SUP-ITM-10322169","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5200.25","3900.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4249.64","81.72","","1738.90","1484.65","2716.94","38","2717.65","4249.64","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.85","371.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","394.20","79.5","","800.18","480.96","1887.97","195","153.71","394.2","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.85","371.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","264.29","53.3","","813.12","216.42","1444.50","81","153.71","394.2","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.85","371.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","153.71","31","","432.60","432.60","432.60","1 through 10","153.71","394.2","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.85","371.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","180.99","36.5","","148.37","54.89","631.39","94","153.71","394.2","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.85","371.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","189.91","38.3","","279.30","91.72","1116.77","266","153.71","394.2","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.85","371.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.72","42.9","","731.00","63.70","731.00","1 through 10","153.71","394.2","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.85","371.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.72","42.9","","384.74","384.74","384.74","1 through 10","153.71","394.2","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.85","371.89","WELLPOINT [1015]","HB AMC WELLPOINT","365.84","73.78","","286.63","119.22","1107.45","105","153.71","394.2","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.85","371.89","AETNA [1001]","HB AMC AETNA HMO","346.10","69.8","","675.31","184.75","1721.50","286","259.13","405.21","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.85","371.89","AETNA [1001]","HB AMC AETNA PPO","398.66","80.4","","1261.44","103.12","1514.10","21","259.13","405.21","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.85","371.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","398.66","80.4","","1365.00","1365.00","1365.00","1 through 10","259.13","405.21","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.85","371.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","405.21","81.72","","5157.68","5157.68","5157.68","1 through 10","259.13","405.21","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.85","371.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","405.21","81.72","","431.26","71.26","1459.57","88","259.13","405.21","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","371.66","79.5","","800.18","480.96","1887.97","195","144.93","371.66","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","249.18","53.3","","813.12","216.42","1444.50","81","144.93","371.66","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","144.93","31","","432.60","432.60","432.60","1 through 10","144.93","371.66","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","170.64","36.5","","148.37","54.89","631.39","94","144.93","371.66","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.05","38.3","","279.30","91.72","1116.77","266","144.93","371.66","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.56","42.9","","731.00","63.70","731.00","1 through 10","144.93","371.66","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.56","42.9","","384.74","384.74","384.74","1 through 10","144.93","371.66","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.50","350.62","WELLPOINT [1015]","HB AMC WELLPOINT","344.92","73.78","","286.63","119.22","1107.45","105","144.93","371.66","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","AETNA [1001]","HB AMC AETNA HMO","326.32","69.8","","675.31","184.75","1721.50","286","244.32","382.04","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","AETNA [1001]","HB AMC AETNA PPO","375.87","80.4","","1261.44","103.12","1514.10","21","244.32","382.04","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","375.87","80.4","","1365.00","1365.00","1365.00","1 through 10","244.32","382.04","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","382.04","81.72","","5157.68","5157.68","5157.68","1 through 10","244.32","382.04","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","382.04","81.72","","431.26","71.26","1459.57","88","244.32","382.04","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","537.76","52.26","","1113.10","1113.10","1113.10","1 through 10","318.99","818.06","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","818.06","79.5","","1293.60","1148.53","1603.80","1 through 10","318.99","818.06","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","375.59","36.5","","1023.42","771.29","2068.67","33","318.99","818.06","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","394.11","38.3","","850.52","759.78","1211.25","66","318.99","818.06","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","441.44","42.9","","2548.09","2548.09","2548.09","1 through 10","318.99","818.06","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","441.44","42.9","","956.46","956.46","956.46","1 through 10","318.99","818.06","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","WELLPOINT [1015]","HB AMC WELLPOINT","759.20","73.78","","2344.73","1619.47","2530.35","16","318.99","818.06","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","AETNA [1001]","HB AMC AETNA HMO","718.24","69.8","","1523.63","988.41","4330.26","39","537.76","840.9","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","AETNA [1001]","HB AMC AETNA PPO","827.32","80.4","","1670.25","1670.25","1670.25","1 through 10","537.76","840.9","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","537.76","52.26","","1113.10","1113.10","1113.10","1 through 10","537.76","840.9","percent of total billed charges",""
"BUTTON PATELLA 40X10MM KNEE VANGUARD UHMWPE 3 PEG SERIES A STANDARD","SUP-ITM-10041427","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","840.90","81.72","","1738.90","1484.65","2716.94","38","537.76","840.9","percent of total billed charges",""
"BUTTON SHOULDER 48MMX44 COMPONENT HEMICAP HUMERAL HEAD TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10094376","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4246.13","52.26","","1113.10","1113.10","1113.10","1 through 10","2518.75","6459.38","percent of total billed charges",""
"BUTTON SHOULDER 48MMX44 COMPONENT HEMICAP HUMERAL HEAD TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10094376","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6459.38","79.5","","1293.60","1148.53","1603.80","1 through 10","2518.75","6459.38","percent of total billed charges",""
"BUTTON SHOULDER 48MMX44 COMPONENT HEMICAP HUMERAL HEAD TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10094376","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2965.63","36.5","","1023.42","771.29","2068.67","33","2518.75","6459.38","percent of total billed charges",""
"BUTTON SHOULDER 48MMX44 COMPONENT HEMICAP HUMERAL HEAD TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10094376","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3111.88","38.3","","850.52","759.78","1211.25","66","2518.75","6459.38","percent of total billed charges",""
"BUTTON SHOULDER 48MMX44 COMPONENT HEMICAP HUMERAL HEAD TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10094376","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3485.63","42.9","","2548.09","2548.09","2548.09","1 through 10","2518.75","6459.38","percent of total billed charges",""
"BUTTON SHOULDER 48MMX44 COMPONENT HEMICAP HUMERAL HEAD TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10094376","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3485.63","42.9","","956.46","956.46","956.46","1 through 10","2518.75","6459.38","percent of total billed charges",""
"BUTTON SHOULDER 48MMX44 COMPONENT HEMICAP HUMERAL HEAD TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10094376","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","WELLPOINT [1015]","HB AMC WELLPOINT","5994.63","73.78","","2344.73","1619.47","2530.35","16","2518.75","6459.38","percent of total billed charges",""
"BUTTON SHOULDER 48MMX44 COMPONENT HEMICAP HUMERAL HEAD TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10094376","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","AETNA [1001]","HB AMC AETNA HMO","5671.25","69.8","","1523.63","988.41","4330.26","39","4246.13","6639.75","percent of total billed charges",""
"BUTTON SHOULDER 48MMX44 COMPONENT HEMICAP HUMERAL HEAD TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10094376","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","AETNA [1001]","HB AMC AETNA PPO","6532.50","80.4","","1670.25","1670.25","1670.25","1 through 10","4246.13","6639.75","percent of total billed charges",""
"BUTTON SHOULDER 48MMX44 COMPONENT HEMICAP HUMERAL HEAD TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10094376","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4246.13","52.26","","1113.10","1113.10","1113.10","1 through 10","4246.13","6639.75","percent of total billed charges",""
"BUTTON SHOULDER 48MMX44 COMPONENT HEMICAP HUMERAL HEAD TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10094376","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6639.75","81.72","","1738.90","1484.65","2716.94","38","4246.13","6639.75","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1210.39","79.5","","800.18","480.96","1887.97","195","471.98","1210.39","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","811.49","53.3","","813.12","216.42","1444.50","81","471.98","1210.39","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","471.98","31","","432.60","432.60","432.60","1 through 10","471.98","1210.39","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","555.71","36.5","","148.37","54.89","631.39","94","471.98","1210.39","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","583.12","38.3","","279.30","91.72","1116.77","266","471.98","1210.39","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.15","42.9","","731.00","63.70","731.00","1 through 10","471.98","1210.39","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.15","42.9","","384.74","384.74","384.74","1 through 10","471.98","1210.39","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","WELLPOINT [1015]","HB AMC WELLPOINT","1123.30","73.78","","286.63","119.22","1107.45","105","471.98","1210.39","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","AETNA [1001]","HB AMC AETNA HMO","1062.71","69.8","","675.31","184.75","1721.50","286","795.66","1244.19","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","AETNA [1001]","HB AMC AETNA PPO","1224.09","80.4","","1261.44","103.12","1514.10","21","795.66","1244.19","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1224.09","80.4","","1365.00","1365.00","1365.00","1 through 10","795.66","1244.19","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1244.19","81.72","","5157.68","5157.68","5157.68","1 through 10","795.66","1244.19","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1244.19","81.72","","431.26","71.26","1459.57","88","795.66","1244.19","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","973.88","79.5","","800.18","480.96","1887.97","195","379.75","973.88","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","652.93","53.3","","813.12","216.42","1444.50","81","379.75","973.88","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","379.75","31","","432.60","432.60","432.60","1 through 10","379.75","973.88","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","447.13","36.5","","148.37","54.89","631.39","94","379.75","973.88","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","469.18","38.3","","279.30","91.72","1116.77","266","379.75","973.88","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","525.53","42.9","","731.00","63.70","731.00","1 through 10","379.75","973.88","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","525.53","42.9","","384.74","384.74","384.74","1 through 10","379.75","973.88","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","WELLPOINT [1015]","HB AMC WELLPOINT","903.81","73.78","","286.63","119.22","1107.45","105","379.75","973.88","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","AETNA [1001]","HB AMC AETNA HMO","855.05","69.8","","675.31","184.75","1721.50","286","640.19","1001.07","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","AETNA [1001]","HB AMC AETNA PPO","984.90","80.4","","1261.44","103.12","1514.10","21","640.19","1001.07","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","984.90","80.4","","1365.00","1365.00","1365.00","1 through 10","640.19","1001.07","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1001.07","81.72","","5157.68","5157.68","5157.68","1 through 10","640.19","1001.07","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1001.07","81.72","","431.26","71.26","1459.57","88","640.19","1001.07","percent of total billed charges",""
"BUTTON TROCHANTERIC 25MM ARCOS HIP","SUP-ITM-10201977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1960.41","79.5","","800.18","480.96","1887.97","195","764.44","1960.41","percent of total billed charges",""
"BUTTON TROCHANTERIC 25MM ARCOS HIP","SUP-ITM-10201977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1314.34","53.3","","813.12","216.42","1444.50","81","764.44","1960.41","percent of total billed charges",""
"BUTTON TROCHANTERIC 25MM ARCOS HIP","SUP-ITM-10201977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","764.44","31","","432.60","432.60","432.60","1 through 10","764.44","1960.41","percent of total billed charges",""
"BUTTON TROCHANTERIC 25MM ARCOS HIP","SUP-ITM-10201977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","900.06","36.5","","148.37","54.89","631.39","94","764.44","1960.41","percent of total billed charges",""
"BUTTON TROCHANTERIC 25MM ARCOS HIP","SUP-ITM-10201977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","944.45","38.3","","279.30","91.72","1116.77","266","764.44","1960.41","percent of total billed charges",""
"BUTTON TROCHANTERIC 25MM ARCOS HIP","SUP-ITM-10201977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1057.88","42.9","","731.00","63.70","731.00","1 through 10","764.44","1960.41","percent of total billed charges",""
"BUTTON TROCHANTERIC 25MM ARCOS HIP","SUP-ITM-10201977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1057.88","42.9","","384.74","384.74","384.74","1 through 10","764.44","1960.41","percent of total billed charges",""
"BUTTON TROCHANTERIC 25MM ARCOS HIP","SUP-ITM-10201977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","WELLPOINT [1015]","HB AMC WELLPOINT","1819.36","73.78","","286.63","119.22","1107.45","105","764.44","1960.41","percent of total billed charges",""
"BUTTON TROCHANTERIC 25MM ARCOS HIP","SUP-ITM-10201977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","AETNA [1001]","HB AMC AETNA HMO","1721.22","69.8","","675.31","184.75","1721.50","286","1288.7","2015.16","percent of total billed charges",""
"BUTTON TROCHANTERIC 25MM ARCOS HIP","SUP-ITM-10201977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","AETNA [1001]","HB AMC AETNA PPO","1982.61","80.4","","1261.44","103.12","1514.10","21","1288.7","2015.16","percent of total billed charges",""
"BUTTON TROCHANTERIC 25MM ARCOS HIP","SUP-ITM-10201977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1982.61","80.4","","1365.00","1365.00","1365.00","1 through 10","1288.7","2015.16","percent of total billed charges",""
"BUTTON TROCHANTERIC 25MM ARCOS HIP","SUP-ITM-10201977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2015.16","81.72","","5157.68","5157.68","5157.68","1 through 10","1288.7","2015.16","percent of total billed charges",""
"BUTTON TROCHANTERIC 25MM ARCOS HIP","SUP-ITM-10201977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2015.16","81.72","","431.26","71.26","1459.57","88","1288.7","2015.16","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh (-Inh) (B)","PX-30002809","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh 5fc Lc-Ms/Ms","PX-30002993","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Bwh 5fc Lc-Ms/Ms","PX-30002993","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Bwh 5fc Lc-Ms/Ms","PX-30002993","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","50.36","42.80","92.50","13","14.12","299.25","percent of total billed charges",""
"Bwh 5fc Lc-Ms/Ms","PX-30002993","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","52.79","44.55","158.37","30","14.12","299.25","percent of total billed charges",""
"Bwh 5fc Lc-Ms/Ms","PX-30002993","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","91.40","64.53","105.30","14","14.12","257.42","percent of total billed charges",""
"Bwh 5fc Lc-Ms/Ms","PX-30002993","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","105.30","105.30","105.30","1 through 10","14.12","257.42","percent of total billed charges",""
"Bwh 5fc Lc-Ms/Ms","PX-30002993","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","59.36","15.50","59.36","1 through 10","14.12","257.42","percent of total billed charges",""
"Bwh Allopurinol","PX-30002988","CDM","80299","CPT","0301","RC","","","","both","","","317.00","237.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","252.02","79.5","","106.25","71.28","106.25","1 through 10","14.12","301.15","percent of total billed charges",""
"Bwh Allopurinol","PX-30002988","CDM","80299","CPT","0301","RC","","","","both","","","317.00","237.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","168.96","53.3","","106.25","71.28","106.25","1 through 10","14.12","301.15","percent of total billed charges",""
"Bwh Allopurinol","PX-30002988","CDM","80299","CPT","0301","RC","","","","both","","","317.00","237.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","115.71","36.5","","50.36","42.80","92.50","13","14.12","301.15","percent of total billed charges",""
"Bwh Allopurinol","PX-30002988","CDM","80299","CPT","0301","RC","","","","both","","","317.00","237.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.41","38.3","","52.79","44.55","158.37","30","14.12","301.15","percent of total billed charges",""
"Bwh Allopurinol","PX-30002988","CDM","80299","CPT","0301","RC","","","","outpatient","","","317.00","237.75","AETNA [1001]","HB AMC AETNA HMO","221.27","69.8","","91.40","64.53","105.30","14","14.12","259.05","percent of total billed charges",""
"Bwh Allopurinol","PX-30002988","CDM","80299","CPT","0301","RC","","","","outpatient","","","317.00","237.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","254.87","80.4","","105.30","105.30","105.30","1 through 10","14.12","259.05","percent of total billed charges",""
"Bwh Allopurinol","PX-30002988","CDM","80299","CPT","0301","RC","","","","outpatient","","","317.00","237.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","259.05","81.72","","59.36","15.50","59.36","1 through 10","14.12","259.05","percent of total billed charges",""
"Bwh Amyotrophic Lat Sclerosis","PX-31000829","CDM","81479","CPT","0310","RC","","","","both","","","691.00","518.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","549.35","79.5","","0.65","0.65","0.65","1 through 10","214.21","656.45","percent of total billed charges",""
"Bwh Amyotrophic Lat Sclerosis","PX-31000829","CDM","81479","CPT","0310","RC","","","","both","","","691.00","518.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","368.30","53.3","","0.79","0.79","0.79","1 through 10","214.21","656.45","percent of total billed charges",""
"Bwh Amyotrophic Lat Sclerosis","PX-31000829","CDM","81479","CPT","0310","RC","","","","outpatient","","","691.00","518.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","345.50","50","","1.00","1.00","1.00","1 through 10","156.55","570.08","percent of total billed charges",""
"Bwh Amyotrophic Lat Sclerosis","PX-31000829","CDM","81479","CPT","0310","RC","","","","outpatient","","","691.00","518.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","362.78","52.5","","1.00","0.53","1.00","1 through 10","156.55","570.08","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Anti-Iga Ab Quant by Ia","PX-30002793","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh App Squaric Acid Extreme Hairloss","PX-76002088","CDM","17999","CPT","0761","RC","","","","both","","","180.00","135.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4490.63","3878.56","4490.63","1 through 10","55.8","294.93","other","OPPS APC"
"Bwh App Squaric Acid Extreme Hairloss","PX-76002088","CDM","17999","CPT","0761","RC","","","","outpatient","","","180.00","135.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","94.00","52.22","","467.73","465.00","467.73","1 through 10","90","700.33","percent of total billed charges",""
"Bwh Baclofen, Qt","PX-30002986","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Bwh Baclofen, Qt","PX-30002986","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Bwh Baclofen, Qt","PX-30002986","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","50.36","42.80","92.50","13","14.12","299.25","percent of total billed charges",""
"Bwh Baclofen, Qt","PX-30002986","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","52.79","44.55","158.37","30","14.12","299.25","percent of total billed charges",""
"Bwh Baclofen, Qt","PX-30002986","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","91.40","64.53","105.30","14","14.12","257.42","percent of total billed charges",""
"Bwh Baclofen, Qt","PX-30002986","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","105.30","105.30","105.30","1 through 10","14.12","257.42","percent of total billed charges",""
"Bwh Baclofen, Qt","PX-30002986","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","59.36","15.50","59.36","1 through 10","14.12","257.42","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh C1 Esterase Inh Functional Assay Quant","PX-30002791","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Cardiac Output via Inert Gas","PX-48000428","CDM","93799","CPT","0480","RC","","","","both","","","3765.00","2823.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","2993.18","other","OPPS APC"
"Bwh Cardiac Output via Inert Gas","PX-48000428","CDM","93799","CPT","0480","RC","","","","outpatient","","","3765.00","2823.75","AETNA [1001]","HB AMC AETNA HMO","2627.97","69.8","","2022.70","2022.70","2022.70","1 through 10","454","3106.13","percent of total billed charges",""
"Bwh Cardiac Output via Inert Gas","PX-48000428","CDM","93799","CPT","0480","RC","","","","outpatient","","","3765.00","2823.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2279.71","60.55","","318.03","318.03","2439.77","1 through 10","454","3106.13","percent of total billed charges",""
"Bwh Cardiac Output via Inert Gas","PX-48000428","CDM","93799","CPT","0480","RC","","","","outpatient","","","3765.00","2823.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1966.08","52.22","","360.38","360.38","4023.00","1 through 10","454","3106.13","percent of total billed charges",""
"Bwh Cardiac Output via Inert Gas","PX-48000428","CDM","93799","CPT","0480","RC","","","","outpatient","","","3765.00","2823.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2070.75","55","","13080.03","13080.03","13080.03","1 through 10","454","3106.13","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Iga Immunoassay","PX-30002804","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Gliadin Igg Immunoassay","PX-30002805","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Celiac Ds Tissue Transglutaminase Immunoassay","PX-30002806","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Clomipramine","PX-30002991","CDM","80299","CPT","0301","RC","","","","both","","","302.00","226.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","240.09","79.5","","106.25","71.28","106.25","1 through 10","14.12","286.9","percent of total billed charges",""
"Bwh Clomipramine","PX-30002991","CDM","80299","CPT","0301","RC","","","","both","","","302.00","226.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","160.97","53.3","","106.25","71.28","106.25","1 through 10","14.12","286.9","percent of total billed charges",""
"Bwh Clomipramine","PX-30002991","CDM","80299","CPT","0301","RC","","","","both","","","302.00","226.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","110.23","36.5","","50.36","42.80","92.50","13","14.12","286.9","percent of total billed charges",""
"Bwh Clomipramine","PX-30002991","CDM","80299","CPT","0301","RC","","","","both","","","302.00","226.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","115.67","38.3","","52.79","44.55","158.37","30","14.12","286.9","percent of total billed charges",""
"Bwh Clomipramine","PX-30002991","CDM","80299","CPT","0301","RC","","","","outpatient","","","302.00","226.50","AETNA [1001]","HB AMC AETNA HMO","210.80","69.8","","91.40","64.53","105.30","14","14.12","246.79","percent of total billed charges",""
"Bwh Clomipramine","PX-30002991","CDM","80299","CPT","0301","RC","","","","outpatient","","","302.00","226.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","242.81","80.4","","105.30","105.30","105.30","1 through 10","14.12","246.79","percent of total billed charges",""
"Bwh Clomipramine","PX-30002991","CDM","80299","CPT","0301","RC","","","","outpatient","","","302.00","226.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","246.79","81.72","","59.36","15.50","59.36","1 through 10","14.12","246.79","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gd1b Immunassay Nos","PX-30002813","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gm1 Asialo Immun Nos","PX-30002812","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Co-Gm1 Immunassay Nos","PX-30002811","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Comprehensive MD/Myopath Ngh","PX-31000833","CDM","81479","CPT","0310","RC","","","","both","","","5619.00","4214.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4467.11","79.5","","0.65","0.65","0.65","1 through 10","1741.89","5338.05","percent of total billed charges",""
"Bwh Comprehensive MD/Myopath Ngh","PX-31000833","CDM","81479","CPT","0310","RC","","","","both","","","5619.00","4214.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2994.93","53.3","","0.79","0.79","0.79","1 through 10","1741.89","5338.05","percent of total billed charges",""
"Bwh Comprehensive MD/Myopath Ngh","PX-31000833","CDM","81479","CPT","0310","RC","","","","outpatient","","","5619.00","4214.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2809.50","50","","1.00","1.00","1.00","1 through 10","156.55","4635.68","percent of total billed charges",""
"Bwh Comprehensive MD/Myopath Ngh","PX-31000833","CDM","81479","CPT","0310","RC","","","","outpatient","","","5619.00","4214.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2949.98","52.5","","1.00","0.53","1.00","1 through 10","156.55","4635.68","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Crh","PX-30002810","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Dau Tquant Gcms","PX-30002997","CDM","80299","CPT","0301","RC","","","","both","","","274.00","205.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","217.83","79.5","","106.25","71.28","106.25","1 through 10","14.12","260.3","percent of total billed charges",""
"Bwh Dau Tquant Gcms","PX-30002997","CDM","80299","CPT","0301","RC","","","","both","","","274.00","205.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","146.04","53.3","","106.25","71.28","106.25","1 through 10","14.12","260.3","percent of total billed charges",""
"Bwh Dau Tquant Gcms","PX-30002997","CDM","80299","CPT","0301","RC","","","","both","","","274.00","205.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.01","36.5","","50.36","42.80","92.50","13","14.12","260.3","percent of total billed charges",""
"Bwh Dau Tquant Gcms","PX-30002997","CDM","80299","CPT","0301","RC","","","","both","","","274.00","205.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","104.94","38.3","","52.79","44.55","158.37","30","14.12","260.3","percent of total billed charges",""
"Bwh Dau Tquant Gcms","PX-30002997","CDM","80299","CPT","0301","RC","","","","outpatient","","","274.00","205.50","AETNA [1001]","HB AMC AETNA HMO","191.25","69.8","","91.40","64.53","105.30","14","14.12","223.91","percent of total billed charges",""
"Bwh Dau Tquant Gcms","PX-30002997","CDM","80299","CPT","0301","RC","","","","outpatient","","","274.00","205.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","220.30","80.4","","105.30","105.30","105.30","1 through 10","14.12","223.91","percent of total billed charges",""
"Bwh Dau Tquant Gcms","PX-30002997","CDM","80299","CPT","0301","RC","","","","outpatient","","","274.00","205.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","223.91","81.72","","59.36","15.50","59.36","1 through 10","14.12","223.91","percent of total billed charges",""
"Bwh Del/Dup Analysis Acgh","PX-31000830","CDM","81479","CPT","0310","RC","","","","both","","","2597.00","1947.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2064.62","79.5","","0.65","0.65","0.65","1 through 10","805.07","2467.15","percent of total billed charges",""
"Bwh Del/Dup Analysis Acgh","PX-31000830","CDM","81479","CPT","0310","RC","","","","both","","","2597.00","1947.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1384.20","53.3","","0.79","0.79","0.79","1 through 10","805.07","2467.15","percent of total billed charges",""
"Bwh Del/Dup Analysis Acgh","PX-31000830","CDM","81479","CPT","0310","RC","","","","outpatient","","","2597.00","1947.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1298.50","50","","1.00","1.00","1.00","1 through 10","156.55","2142.53","percent of total billed charges",""
"Bwh Del/Dup Analysis Acgh","PX-31000830","CDM","81479","CPT","0310","RC","","","","outpatient","","","2597.00","1947.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1363.43","52.5","","1.00","0.53","1.00","1 through 10","156.55","2142.53","percent of total billed charges",""
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","both","","","1445.00","1083.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1148.78","79.5","","1102.59","739.73","1724.08","21","447.95","1372.75","percent of total billed charges",""
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","both","","","1445.00","1083.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","770.19","53.3","","739.73","739.73","2542.33","1 through 10","447.95","1372.75","percent of total billed charges",""
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","both","","","1445.00","1083.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1148.78","79.5","","1102.59","1102.59","1102.59","1 through 10","447.95","1372.75","percent of total billed charges",""
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","both","","","1445.00","1083.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","863.37","863.37","863.37","1 through 10","447.95","1372.75","other","OPPS APC"
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","both","","","1445.00","1083.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","619.91","42.9","","1119.96","1119.96","1119.96","1 through 10","447.95","1372.75","percent of total billed charges",""
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","both","","","1445.00","1083.75","WELLPOINT [1015]","HB AMC WELLPOINT","1066.12","73.78","","1043.04","1043.04","2444.04","13","447.95","1372.75","percent of total billed charges",""
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","outpatient","","","1445.00","1083.75","AETNA [1001]","HB AMC AETNA HMO","1008.61","69.8","","948.48","669.68","1092.78","21","558.04","1234.13","percent of total billed charges",""
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","outpatient","","","1445.00","1083.75","AETNA [1001]","HB AMC AETNA PPO","1161.78","80.4","","1092.78","1092.78","1092.78","1 through 10","558.04","1234.13","percent of total billed charges",""
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","outpatient","","","1445.00","1083.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1401.00","1401.00","1401.00","1 through 10","558.04","1234.13","other","ASC "
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","outpatient","","","1445.00","1083.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1401.00","1401.00","1401.00","1 through 10","558.04","1234.13","other","Multiple Surgery"
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","outpatient","","","1445.00","1083.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1244.43","1244.43","1244.43","1 through 10","558.04","1234.13","other","Multiple Surgery"
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","outpatient","","","1445.00","1083.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1361.62","1361.62","1361.62","1 through 10","558.04","1234.13","other","Multiple Surgery"
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","outpatient","","","1445.00","1083.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 383%, 191.5 procedures at 0%.","2137.29","2137.29","2137.29","1 through 10","558.04","1234.13","other","Multiple Surgery"
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","outpatient","","","1445.00","1083.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1372.78","995.30","1428.58","1 through 10","558.04","1234.13","other","Multiple Surgery"
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","outpatient","","","1445.00","1083.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1180.85","81.72","","1119.96","616.02","1119.96","16","558.04","1234.13","percent of total billed charges",""
"Bwh Embryo Transfer Intrauterine","PX-76001409","CDM","58974","CPT","0761","RC","","","","outpatient","","","1445.00","1083.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1372.78","1372.78","1372.78","1 through 10","558.04","1234.13","other","Multiple Surgery"
"Bwh Fentanyl Quant Lc Ms Ms","PX-30002987","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Bwh Fentanyl Quant Lc Ms Ms","PX-30002987","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Bwh Fentanyl Quant Lc Ms Ms","PX-30002987","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","50.36","42.80","92.50","13","14.12","299.25","percent of total billed charges",""
"Bwh Fentanyl Quant Lc Ms Ms","PX-30002987","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","52.79","44.55","158.37","30","14.12","299.25","percent of total billed charges",""
"Bwh Fentanyl Quant Lc Ms Ms","PX-30002987","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","91.40","64.53","105.30","14","14.12","257.42","percent of total billed charges",""
"Bwh Fentanyl Quant Lc Ms Ms","PX-30002987","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","105.30","105.30","105.30","1 through 10","14.12","257.42","percent of total billed charges",""
"Bwh Fentanyl Quant Lc Ms Ms","PX-30002987","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","59.36","15.50","59.36","1 through 10","14.12","257.42","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Fgf23 Iea","PX-30002786","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Galop 1 Immunassay Nos","PX-30002814","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Galop 2 Immunassay Nos","PX-30002815","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Galop 3 Immunassay Nos","PX-30002816","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Gancyclovir","PX-30002990","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","224.99","79.5","","106.25","71.28","106.25","1 through 10","14.12","268.85","percent of total billed charges",""
"Bwh Gancyclovir","PX-30002990","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","150.84","53.3","","106.25","71.28","106.25","1 through 10","14.12","268.85","percent of total billed charges",""
"Bwh Gancyclovir","PX-30002990","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","103.30","36.5","","50.36","42.80","92.50","13","14.12","268.85","percent of total billed charges",""
"Bwh Gancyclovir","PX-30002990","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","108.39","38.3","","52.79","44.55","158.37","30","14.12","268.85","percent of total billed charges",""
"Bwh Gancyclovir","PX-30002990","CDM","80299","CPT","0301","RC","","","","outpatient","","","283.00","212.25","AETNA [1001]","HB AMC AETNA HMO","197.53","69.8","","91.40","64.53","105.30","14","14.12","231.27","percent of total billed charges",""
"Bwh Gancyclovir","PX-30002990","CDM","80299","CPT","0301","RC","","","","outpatient","","","283.00","212.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","227.53","80.4","","105.30","105.30","105.30","1 through 10","14.12","231.27","percent of total billed charges",""
"Bwh Gancyclovir","PX-30002990","CDM","80299","CPT","0301","RC","","","","outpatient","","","283.00","212.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","231.27","81.72","","59.36","15.50","59.36","1 through 10","14.12","231.27","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Gbm Antibodies Igg Serum","PX-30002788","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Gm-1 Immunoassay","PX-30002808","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","117.03","71.8","","235.44","25.68","340.32","32","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","106.93","65.6","","106.97","106.97","106.97","1 through 10","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","105.95","65","","271.70","83.42","308.10","12","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","114.10","70","","135.88","69.47","158.00","12","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CHAMPVA [160001]","HB BWH TRICARE","154.85","95","","11.70","11.70","11.70","1 through 10","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","129.59","79.5","","124.35","83.42","124.35","1365","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","86.88","53.3","","83.42","83.42","250.26","789","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","125.51","77","","121.66","117.81","121.66","1 through 10","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","105.95","65","","102.70","99.45","210.60","16","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","50.53","31","","48.82","48.82","146.46","72","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","59.50","36.5","","58.93","50.09","171.60","1710","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.43","38.3","","61.78","61.78","185.34","5604","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","MOLINA [1014]","HB BWH MOLINA","57.05","35","","19.26","19.04","19.26","1 through 10","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","125.51","77","","123.24","24.73","259.00","16","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","TRICARE [160005]","HB BWH TRICARE","154.85","95","","11.12","11.12","11.70","60","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.93","42.9","","126.31","69.47","126.31","71","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.93","42.9","","69.47","69.47","126.31","20","9.52","154.85","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","AETNA [1001]","HB AMC AETNA HMO","113.77","69.8","","106.97","75.52","123.24","2010","10.01","133.2","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","AETNA [1001]","HB AMC AETNA PPO","131.05","80.4","","123.24","75.52","123.24","171","10.01","133.2","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","91.12","55.9","","165.58","82.79","165.58","1 through 10","10.01","133.2","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","85.18","52.26","","34.02","34.02","97.77","29","10.01","133.2","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","131.05","80.4","","123.24","79.00","281.24","15","10.01","133.2","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","133.20","81.72","","126.30","117.83","126.31","1 through 10","10.01","133.2","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","133.20","81.72","","69.47","69.47","126.31","68","10.01","133.2","percent of total billed charges",""
"Bwh Hemoglobin Glycosylated A1c","PX-30002822","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","133.20","81.72","","126.31","69.47","126.31","1333","10.01","133.2","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Histone Ab","PX-30002819","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Anca Elisa Igg","PX-30002803","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Asca Elisa Iga","PX-30002801","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Asca Elisa Igg","PX-30002802","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ibd Serology Anca Igg by Ia","PX-30002800","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Il-1o Quant by Ia","PX-30002794","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Insertion of Leadless Pacemaker","PX-48000427","CDM","93799","CPT","0480","RC","","","","both","","","15195.00","11396.25","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","12080.03","other","OPPS APC"
"Bwh Insertion of Leadless Pacemaker","PX-48000427","CDM","93799","CPT","0480","RC","","","","outpatient","","","15195.00","11396.25","AETNA [1001]","HB AMC AETNA HMO","10606.11","69.8","","2022.70","2022.70","2022.70","1 through 10","454","12535.88","percent of total billed charges",""
"Bwh Insertion of Leadless Pacemaker","PX-48000427","CDM","93799","CPT","0480","RC","","","","outpatient","","","15195.00","11396.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","9200.57","60.55","","318.03","318.03","2439.77","1 through 10","454","12535.88","percent of total billed charges",""
"Bwh Insertion of Leadless Pacemaker","PX-48000427","CDM","93799","CPT","0480","RC","","","","outpatient","","","15195.00","11396.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","7934.83","52.22","","360.38","360.38","4023.00","1 through 10","454","12535.88","percent of total billed charges",""
"Bwh Insertion of Leadless Pacemaker","PX-48000427","CDM","93799","CPT","0480","RC","","","","outpatient","","","15195.00","11396.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","8357.25","55","","13080.03","13080.03","13080.03","1 through 10","454","12535.88","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Insulin Growth Factor Binding Protein 3 Serum","PX-30002765","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Interpretation of Outside Films","PX-98300616","CDM","76140","CPT","0983","RC","","","","both","","","265.00","198.75","AETNA [1001]","HB AMC AETNA HMO","184.97","69.8","","179.41","179.41","179.41","1 through 10","82.15","251.75","percent of total billed charges",""
"Bwh Interpretation of Outside Films","PX-98300616","CDM","76140","CPT","0983","RC","","","","both","","","265.00","198.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","92.75","35","","66.25","66.25","66.25","1 through 10","82.15","251.75","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Leptin, Quant,Elisa","PX-30002780","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Madd Panel Gc and Gv","PX-31000831","CDM","81479","CPT","0310","RC","","","","both","","","8561.00","6420.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6806.00","79.5","","0.65","0.65","0.65","1 through 10","2653.91","8132.95","percent of total billed charges",""
"Bwh Madd Panel Gc and Gv","PX-31000831","CDM","81479","CPT","0310","RC","","","","both","","","8561.00","6420.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4563.01","53.3","","0.79","0.79","0.79","1 through 10","2653.91","8132.95","percent of total billed charges",""
"Bwh Madd Panel Gc and Gv","PX-31000831","CDM","81479","CPT","0310","RC","","","","outpatient","","","8561.00","6420.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4280.50","50","","1.00","1.00","1.00","1 through 10","156.55","7062.83","percent of total billed charges",""
"Bwh Madd Panel Gc and Gv","PX-31000831","CDM","81479","CPT","0310","RC","","","","outpatient","","","8561.00","6420.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4494.53","52.5","","1.00","0.53","1.00","1 through 10","156.55","7062.83","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Mannose Binding Lectin","PX-30002798","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Melandcyte Stimulating Horm","PX-30002818","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Methaqualone Urine by Ia/Gc-Ms","PX-30002995","CDM","80299","CPT","0301","RC","","","","both","","","206.00","154.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","163.77","79.5","","106.25","71.28","106.25","1 through 10","14.12","195.7","percent of total billed charges",""
"Bwh Methaqualone Urine by Ia/Gc-Ms","PX-30002995","CDM","80299","CPT","0301","RC","","","","both","","","206.00","154.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.80","53.3","","106.25","71.28","106.25","1 through 10","14.12","195.7","percent of total billed charges",""
"Bwh Methaqualone Urine by Ia/Gc-Ms","PX-30002995","CDM","80299","CPT","0301","RC","","","","both","","","206.00","154.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","75.19","36.5","","50.36","42.80","92.50","13","14.12","195.7","percent of total billed charges",""
"Bwh Methaqualone Urine by Ia/Gc-Ms","PX-30002995","CDM","80299","CPT","0301","RC","","","","both","","","206.00","154.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.90","38.3","","52.79","44.55","158.37","30","14.12","195.7","percent of total billed charges",""
"Bwh Methaqualone Urine by Ia/Gc-Ms","PX-30002995","CDM","80299","CPT","0301","RC","","","","outpatient","","","206.00","154.50","AETNA [1001]","HB AMC AETNA HMO","143.79","69.8","","91.40","64.53","105.30","14","14.12","168.34","percent of total billed charges",""
"Bwh Methaqualone Urine by Ia/Gc-Ms","PX-30002995","CDM","80299","CPT","0301","RC","","","","outpatient","","","206.00","154.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","165.62","80.4","","105.30","105.30","105.30","1 through 10","14.12","168.34","percent of total billed charges",""
"Bwh Methaqualone Urine by Ia/Gc-Ms","PX-30002995","CDM","80299","CPT","0301","RC","","","","outpatient","","","206.00","154.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","168.34","81.72","","59.36","15.50","59.36","1 through 10","14.12","168.34","percent of total billed charges",""
"Bwh Methotrexate","PX-30002998","CDM","80299","CPT","0301","RC","","","","both","","","242.00","181.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","192.39","79.5","","106.25","71.28","106.25","1 through 10","14.12","229.9","percent of total billed charges",""
"Bwh Methotrexate","PX-30002998","CDM","80299","CPT","0301","RC","","","","both","","","242.00","181.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","128.99","53.3","","106.25","71.28","106.25","1 through 10","14.12","229.9","percent of total billed charges",""
"Bwh Methotrexate","PX-30002998","CDM","80299","CPT","0301","RC","","","","both","","","242.00","181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","88.33","36.5","","50.36","42.80","92.50","13","14.12","229.9","percent of total billed charges",""
"Bwh Methotrexate","PX-30002998","CDM","80299","CPT","0301","RC","","","","both","","","242.00","181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","92.69","38.3","","52.79","44.55","158.37","30","14.12","229.9","percent of total billed charges",""
"Bwh Methotrexate","PX-30002998","CDM","80299","CPT","0301","RC","","","","outpatient","","","242.00","181.50","AETNA [1001]","HB AMC AETNA HMO","168.92","69.8","","91.40","64.53","105.30","14","14.12","197.76","percent of total billed charges",""
"Bwh Methotrexate","PX-30002998","CDM","80299","CPT","0301","RC","","","","outpatient","","","242.00","181.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","194.57","80.4","","105.30","105.30","105.30","1 through 10","14.12","197.76","percent of total billed charges",""
"Bwh Methotrexate","PX-30002998","CDM","80299","CPT","0301","RC","","","","outpatient","","","242.00","181.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","197.76","81.72","","59.36","15.50","59.36","1 through 10","14.12","197.76","percent of total billed charges",""
"Bwh Metoprolol (Lopressor)","PX-30002766","CDM","80299","CPT","0300","RC","","","","both","","","252.00","189.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","200.34","79.5","","106.25","71.28","106.25","1 through 10","14.12","239.4","percent of total billed charges",""
"Bwh Metoprolol (Lopressor)","PX-30002766","CDM","80299","CPT","0300","RC","","","","both","","","252.00","189.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","134.32","53.3","","106.25","71.28","106.25","1 through 10","14.12","239.4","percent of total billed charges",""
"Bwh Metoprolol (Lopressor)","PX-30002766","CDM","80299","CPT","0300","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91.98","36.5","","50.36","42.80","92.50","13","14.12","239.4","percent of total billed charges",""
"Bwh Metoprolol (Lopressor)","PX-30002766","CDM","80299","CPT","0300","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.52","38.3","","52.79","44.55","158.37","30","14.12","239.4","percent of total billed charges",""
"Bwh Metoprolol (Lopressor)","PX-30002766","CDM","80299","CPT","0300","RC","","","","outpatient","","","252.00","189.00","AETNA [1001]","HB AMC AETNA HMO","175.90","69.8","","91.40","64.53","105.30","14","14.12","205.93","percent of total billed charges",""
"Bwh Metoprolol (Lopressor)","PX-30002766","CDM","80299","CPT","0300","RC","","","","outpatient","","","252.00","189.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","202.61","80.4","","105.30","105.30","105.30","1 through 10","14.12","205.93","percent of total billed charges",""
"Bwh Metoprolol (Lopressor)","PX-30002766","CDM","80299","CPT","0300","RC","","","","outpatient","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","205.93","81.72","","59.36","15.50","59.36","1 through 10","14.12","205.93","percent of total billed charges",""
"Bwh Myelodysplasia Panel","PX-31000774","CDM","81479","CPT","0310","RC","","","","both","","","12925.00","9693.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10275.38","79.5","","0.65","0.65","0.65","1 through 10","4006.75","12278.75","percent of total billed charges",""
"Bwh Myelodysplasia Panel","PX-31000774","CDM","81479","CPT","0310","RC","","","","both","","","12925.00","9693.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6889.03","53.3","","0.79","0.79","0.79","1 through 10","4006.75","12278.75","percent of total billed charges",""
"Bwh Myelodysplasia Panel","PX-31000774","CDM","81479","CPT","0310","RC","","","","outpatient","","","12925.00","9693.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6462.50","50","","1.00","1.00","1.00","1 through 10","156.55","10663.13","percent of total billed charges",""
"Bwh Myelodysplasia Panel","PX-31000774","CDM","81479","CPT","0310","RC","","","","outpatient","","","12925.00","9693.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6785.63","52.5","","1.00","0.53","1.00","1 through 10","156.55","10663.13","percent of total billed charges",""
"Bwh Nordoxepin Serum Qt","PX-30002764","CDM","80299","CPT","0300","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Bwh Nordoxepin Serum Qt","PX-30002764","CDM","80299","CPT","0300","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Bwh Nordoxepin Serum Qt","PX-30002764","CDM","80299","CPT","0300","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","50.36","42.80","92.50","13","14.12","299.25","percent of total billed charges",""
"Bwh Nordoxepin Serum Qt","PX-30002764","CDM","80299","CPT","0300","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","52.79","44.55","158.37","30","14.12","299.25","percent of total billed charges",""
"Bwh Nordoxepin Serum Qt","PX-30002764","CDM","80299","CPT","0300","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","91.40","64.53","105.30","14","14.12","257.42","percent of total billed charges",""
"Bwh Nordoxepin Serum Qt","PX-30002764","CDM","80299","CPT","0300","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","105.30","105.30","105.30","1 through 10","14.12","257.42","percent of total billed charges",""
"Bwh Nordoxepin Serum Qt","PX-30002764","CDM","80299","CPT","0300","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","59.36","15.50","59.36","1 through 10","14.12","257.42","percent of total billed charges",""
"Bwh Perc Micro Non-Rf Lung Ablation","PX-76002069","CDM","32999","CPT","0761","RC","","","","both","","","2249.00","1686.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1787.96","79.5","","0.89","0.89","0.89","1 through 10","697.19","1787.96","percent of total billed charges",""
"Bwh Perq Cryo Abl Lung","PX-76002095","CDM","32999","CPT","0761","RC","","","","both","","","2973.00","2229.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2363.54","79.5","","0.89","0.89","0.89","1 through 10","697.51","2363.54","percent of total billed charges",""
"Bwh Perq Microwave Abl Lung","PX-76002068","CDM","32999","CPT","0761","RC","","","","both","","","2249.00","1686.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1787.96","79.5","","0.89","0.89","0.89","1 through 10","697.19","1787.96","percent of total billed charges",""
"Bwh Perq Paravalvular Leak Repair","PX-48000430","CDM","93799","CPT","0480","RC","","","","outpatient","","","28914.00","21685.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","15902.70","55","","13080.03","13080.03","13080.03","1 through 10","14457","23854.05","percent of total billed charges",""
"Bwh Perq Paravalvular Leak Repair","PX-48000430","CDM","93799","CPT","0481","RC","","","","both","","","28914.00","21685.50","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","22986.63","other","OPPS APC"
"Bwh Perq Paravalvular Leak Repair","PX-48000430","CDM","93799","CPT","0481","RC","","","","outpatient","","","28914.00","21685.50","AETNA [1001]","HB AMC AETNA HMO","20181.97","69.8","","2022.70","2022.70","2022.70","1 through 10","454","23628.52","percent of total billed charges",""
"Bwh Perq Paravalvular Leak Repair","PX-48000430","CDM","93799","CPT","0481","RC","","","","outpatient","","","28914.00","21685.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","17507.43","60.55","","318.03","318.03","2439.77","1 through 10","454","23628.52","percent of total billed charges",""
"Bwh Perq Paravalvular Leak Repair","PX-48000430","CDM","93799","CPT","0481","RC","","","","outpatient","","","28914.00","21685.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","15098.89","52.22","","360.38","360.38","4023.00","1 through 10","454","23628.52","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Ribosome P Ab by Ia","PX-30002796","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Rifabutin Hplc Multi Analytes","PX-30002992","CDM","80299","CPT","0301","RC","","","","both","","","317.00","237.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","252.02","79.5","","106.25","71.28","106.25","1 through 10","14.12","301.15","percent of total billed charges",""
"Bwh Rifabutin Hplc Multi Analytes","PX-30002992","CDM","80299","CPT","0301","RC","","","","both","","","317.00","237.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","168.96","53.3","","106.25","71.28","106.25","1 through 10","14.12","301.15","percent of total billed charges",""
"Bwh Rifabutin Hplc Multi Analytes","PX-30002992","CDM","80299","CPT","0301","RC","","","","both","","","317.00","237.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","115.71","36.5","","50.36","42.80","92.50","13","14.12","301.15","percent of total billed charges",""
"Bwh Rifabutin Hplc Multi Analytes","PX-30002992","CDM","80299","CPT","0301","RC","","","","both","","","317.00","237.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.41","38.3","","52.79","44.55","158.37","30","14.12","301.15","percent of total billed charges",""
"Bwh Rifabutin Hplc Multi Analytes","PX-30002992","CDM","80299","CPT","0301","RC","","","","outpatient","","","317.00","237.75","AETNA [1001]","HB AMC AETNA HMO","221.27","69.8","","91.40","64.53","105.30","14","14.12","259.05","percent of total billed charges",""
"Bwh Rifabutin Hplc Multi Analytes","PX-30002992","CDM","80299","CPT","0301","RC","","","","outpatient","","","317.00","237.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","254.87","80.4","","105.30","105.30","105.30","1 through 10","14.12","259.05","percent of total billed charges",""
"Bwh Rifabutin Hplc Multi Analytes","PX-30002992","CDM","80299","CPT","0301","RC","","","","outpatient","","","317.00","237.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","259.05","81.72","","59.36","15.50","59.36","1 through 10","14.12","259.05","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Rl Ibd Anti-I2 Elisa","PX-30002785","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Rl Ibd Elisa Each","PX-30002784","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Rna Polymerase III Ab","PX-30002797","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Rufinamide Hplc","PX-30002994","CDM","80299","CPT","0301","RC","","","","both","","","288.00","216.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","228.96","79.5","","106.25","71.28","106.25","1 through 10","14.12","273.6","percent of total billed charges",""
"Bwh Rufinamide Hplc","PX-30002994","CDM","80299","CPT","0301","RC","","","","both","","","288.00","216.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","153.50","53.3","","106.25","71.28","106.25","1 through 10","14.12","273.6","percent of total billed charges",""
"Bwh Rufinamide Hplc","PX-30002994","CDM","80299","CPT","0301","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.12","36.5","","50.36","42.80","92.50","13","14.12","273.6","percent of total billed charges",""
"Bwh Rufinamide Hplc","PX-30002994","CDM","80299","CPT","0301","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","110.30","38.3","","52.79","44.55","158.37","30","14.12","273.6","percent of total billed charges",""
"Bwh Rufinamide Hplc","PX-30002994","CDM","80299","CPT","0301","RC","","","","outpatient","","","288.00","216.00","AETNA [1001]","HB AMC AETNA HMO","201.02","69.8","","91.40","64.53","105.30","14","14.12","235.35","percent of total billed charges",""
"Bwh Rufinamide Hplc","PX-30002994","CDM","80299","CPT","0301","RC","","","","outpatient","","","288.00","216.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","231.55","80.4","","105.30","105.30","105.30","1 through 10","14.12","235.35","percent of total billed charges",""
"Bwh Rufinamide Hplc","PX-30002994","CDM","80299","CPT","0301","RC","","","","outpatient","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","235.35","81.72","","59.36","15.50","59.36","1 through 10","14.12","235.35","percent of total billed charges",""
"Bwh Spastic Paraplegia Ngs","PX-31000832","CDM","81479","CPT","0310","RC","","","","both","","","4254.00","3190.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3381.93","79.5","","0.65","0.65","0.65","1 through 10","1318.74","4041.3","percent of total billed charges",""
"Bwh Spastic Paraplegia Ngs","PX-31000832","CDM","81479","CPT","0310","RC","","","","both","","","4254.00","3190.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2267.38","53.3","","0.79","0.79","0.79","1 through 10","1318.74","4041.3","percent of total billed charges",""
"Bwh Spastic Paraplegia Ngs","PX-31000832","CDM","81479","CPT","0310","RC","","","","outpatient","","","4254.00","3190.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2127.00","50","","1.00","1.00","1.00","1 through 10","156.55","3509.55","percent of total billed charges",""
"Bwh Spastic Paraplegia Ngs","PX-31000832","CDM","81479","CPT","0310","RC","","","","outpatient","","","4254.00","3190.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2233.35","52.5","","1.00","0.53","1.00","1 through 10","156.55","3509.55","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Stachybotrys Iga Quant","PX-30002789","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Streptomycin Level","PX-30002989","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Bwh Streptomycin Level","PX-30002989","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Bwh Streptomycin Level","PX-30002989","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","50.36","42.80","92.50","13","14.12","299.25","percent of total billed charges",""
"Bwh Streptomycin Level","PX-30002989","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","52.79","44.55","158.37","30","14.12","299.25","percent of total billed charges",""
"Bwh Streptomycin Level","PX-30002989","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","91.40","64.53","105.30","14","14.12","257.42","percent of total billed charges",""
"Bwh Streptomycin Level","PX-30002989","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","105.30","105.30","105.30","1 through 10","14.12","257.42","percent of total billed charges",""
"Bwh Streptomycin Level","PX-30002989","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","59.36","15.50","59.36","1 through 10","14.12","257.42","percent of total billed charges",""
"Bwh Subcutaneous Seroma Sclerotherapy","PX-76002089","CDM","17999","CPT","0761","RC","","","","both","","","6239.00","4679.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4490.63","3878.56","4490.63","1 through 10","224.17","4960.01","other","OPPS APC"
"Bwh Subcutaneous Seroma Sclerotherapy","PX-76002089","CDM","17999","CPT","0761","RC","","","","outpatient","","","6239.00","4679.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3258.01","52.22","","467.73","465.00","467.73","1 through 10","700.33","5147.18","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Sulfatide Autoab","PX-30002807","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","245.00","183.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","194.78","79.5","","125.66","125.66","125.66","1 through 10","38.35","232.75","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","245.00","183.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.59","53.3","","125.67","125.66","187.31","1 through 10","38.35","232.75","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.43","36.5","","86.16","75.45","226.35","22","38.35","232.75","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.84","38.3","","93.06","90.44","93.06","97","38.35","232.75","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","245.00","183.75","TRICARE [160005]","HB BWH TRICARE","232.75","95","","41.46","41.46","41.46","1 through 10","38.35","232.75","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","38.35","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($39.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($27.12). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","38.50","26.69","237.46","1 through 10","38.35","232.75","fee schedule",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA HMO","171.01","69.8","","185.64","113.76","316.44","69","122.5","312.61","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA PPO","196.98","80.4","","185.64","185.64","317.50","1 through 10","122.5","312.61","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Throbopoeitin, Immunoassay","PX-30002787","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Transcatheter Mitral Valve Repair","PX-48000429","CDM","93799","CPT","0480","RC","","","","outpatient","","","10374.00","7780.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","5705.70","55","","13080.03","13080.03","13080.03","1 through 10","5187","8558.55","percent of total billed charges",""
"Bwh Transcatheter Mitral Valve Repair","PX-48000429","CDM","93799","CPT","0481","RC","","","","both","","","10374.00","7780.50","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","8247.33","other","OPPS APC"
"Bwh Transcatheter Mitral Valve Repair","PX-48000429","CDM","93799","CPT","0481","RC","","","","outpatient","","","10374.00","7780.50","AETNA [1001]","HB AMC AETNA HMO","7241.05","69.8","","2022.70","2022.70","2022.70","1 through 10","454","8477.63","percent of total billed charges",""
"Bwh Transcatheter Mitral Valve Repair","PX-48000429","CDM","93799","CPT","0481","RC","","","","outpatient","","","10374.00","7780.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","6281.46","60.55","","318.03","318.03","2439.77","1 through 10","454","8477.63","percent of total billed charges",""
"Bwh Transcatheter Mitral Valve Repair","PX-48000429","CDM","93799","CPT","0481","RC","","","","outpatient","","","10374.00","7780.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5417.30","52.22","","360.38","360.38","4023.00","1 through 10","454","8477.63","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Transglutaminase Iga","PX-30002817","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","both","","","3578.00","2683.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","2844.51","other","OPPS APC"
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","both","","","3578.00","2683.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","2844.51","other","OPPS APC"
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","both","","","3578.00","2683.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2844.51","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","2844.51","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","both","","","3578.00","2683.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","2844.51","other","OPPS APC"
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","both","","","3578.00","2683.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","2844.51","other","OPPS APC"
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","both","","","3578.00","2683.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1305.97","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","2844.51","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","both","","","3578.00","2683.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1370.37","38.3","","2723.31","1555.62","2741.61","12","1057.74","2844.51","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","both","","","3578.00","2683.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","2844.51","other","OPPS APC"
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","both","","","3578.00","2683.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","2844.51","other","OPPS APC"
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","both","","","3578.00","2683.50","WELLPOINT [1015]","HB AMC WELLPOINT","2639.85","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","2844.51","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","outpatient","","","3578.00","2683.50","AETNA [1001]","HB AMC AETNA PPO","2876.71","80.4","","1163.76","1163.76","1163.76","1 through 10","1789","2951.85","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","outpatient","","","3578.00","2683.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2166.48","60.55","","1781.82","1492.00","4331.00","1 through 10","1789","2951.85","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","outpatient","","","3578.00","2683.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1868.43","52.22","","3144.00","1492.00","3610.00","13","1789","2951.85","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","outpatient","","","3578.00","2683.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1878.45","52.5","","1182.28","1182.28","1182.28","1 through 10","1789","2951.85","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","outpatient","","","3578.00","2683.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1789.00","50","","3610.00","2269.44","3610.00","1 through 10","1789","2951.85","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","outpatient","","","3578.00","2683.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1878.45","52.5","","3610.00","2382.05","4331.00","1 through 10","1789","2951.85","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","outpatient","","","3578.00","2683.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1967.90","55","","4810.75","3363.17","4810.75","1 through 10","1789","2951.85","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","outpatient","","","3578.00","2683.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2923.94","81.72","","8894.69","8894.69","8894.69","1 through 10","1789","2951.85","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","outpatient","","","3578.00","2683.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2923.94","81.72","","2885.83","2132.00","3462.21","1 through 10","1789","2951.85","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Tryptase Total and Mature Quant Ia","PX-30002778","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Tryptase, Total","PX-30002799","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Unlisted Acta2 Sequencing","PX-31000382","CDM","81479","CPT","0310","RC","","","","both","","","652.00","489.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","518.34","79.5","","0.65","0.65","0.65","1 through 10","202.12","619.4","percent of total billed charges",""
"Bwh Unlisted Acta2 Sequencing","PX-31000382","CDM","81479","CPT","0310","RC","","","","both","","","652.00","489.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","347.52","53.3","","0.79","0.79","0.79","1 through 10","202.12","619.4","percent of total billed charges",""
"Bwh Unlisted Acta2 Sequencing","PX-31000382","CDM","81479","CPT","0310","RC","","","","outpatient","","","652.00","489.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","326.00","50","","1.00","1.00","1.00","1 through 10","156.55","537.9","percent of total billed charges",""
"Bwh Unlisted Acta2 Sequencing","PX-31000382","CDM","81479","CPT","0310","RC","","","","outpatient","","","652.00","489.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","342.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","537.9","percent of total billed charges",""
"Bwh Unlisted Basics Fibrosis Panel (11 Genes)","PX-31000385","CDM","81479","CPT","0310","RC","","","","both","","","3719.00","2789.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2956.61","79.5","","0.65","0.65","0.65","1 through 10","1152.89","3533.05","percent of total billed charges",""
"Bwh Unlisted Basics Fibrosis Panel (11 Genes)","PX-31000385","CDM","81479","CPT","0310","RC","","","","both","","","3719.00","2789.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1982.23","53.3","","0.79","0.79","0.79","1 through 10","1152.89","3533.05","percent of total billed charges",""
"Bwh Unlisted Basics Fibrosis Panel (11 Genes)","PX-31000385","CDM","81479","CPT","0310","RC","","","","outpatient","","","3719.00","2789.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1859.50","50","","1.00","1.00","1.00","1 through 10","156.55","3068.18","percent of total billed charges",""
"Bwh Unlisted Basics Fibrosis Panel (11 Genes)","PX-31000385","CDM","81479","CPT","0310","RC","","","","outpatient","","","3719.00","2789.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1952.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","3068.18","percent of total billed charges",""
"Bwh Unlisted Col3a1 Dna Sequencing","PX-31000383","CDM","81479","CPT","0310","RC","","","","both","","","2048.00","1536.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1628.16","79.5","","0.65","0.65","0.65","1 through 10","634.88","1945.6","percent of total billed charges",""
"Bwh Unlisted Col3a1 Dna Sequencing","PX-31000383","CDM","81479","CPT","0310","RC","","","","both","","","2048.00","1536.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1091.58","53.3","","0.79","0.79","0.79","1 through 10","634.88","1945.6","percent of total billed charges",""
"Bwh Unlisted Col3a1 Dna Sequencing","PX-31000383","CDM","81479","CPT","0310","RC","","","","outpatient","","","2048.00","1536.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1024.00","50","","1.00","1.00","1.00","1 through 10","156.55","1689.6","percent of total billed charges",""
"Bwh Unlisted Col3a1 Dna Sequencing","PX-31000383","CDM","81479","CPT","0310","RC","","","","outpatient","","","2048.00","1536.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1075.20","52.5","","1.00","0.53","1.00","1 through 10","156.55","1689.6","percent of total billed charges",""
"Bwh Unlisted Dld Dna","PX-31000387","CDM","81479","CPT","0310","RC","","","","both","","","163.00","122.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","129.59","79.5","","0.65","0.65","0.65","1 through 10","50.53","154.85","percent of total billed charges",""
"Bwh Unlisted Dld Dna","PX-31000387","CDM","81479","CPT","0310","RC","","","","both","","","163.00","122.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","86.88","53.3","","0.79","0.79","0.79","1 through 10","50.53","154.85","percent of total billed charges",""
"Bwh Unlisted Dld Dna","PX-31000387","CDM","81479","CPT","0310","RC","","","","outpatient","","","163.00","122.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","81.50","50","","1.00","1.00","1.00","1 through 10","78.89","156.55","percent of total billed charges",""
"Bwh Unlisted Dld Dna","PX-31000387","CDM","81479","CPT","0310","RC","","","","outpatient","","","163.00","122.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","85.58","52.5","","1.00","0.53","1.00","1 through 10","78.89","156.55","percent of total billed charges",""
"Bwh Unlisted Glucan CSF","PX-30002336","CDM","87449","CPT","0300","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","102.43","102.43","102.43","1 through 10","11.74","190","percent of total billed charges",""
"Bwh Unlisted Glucan CSF","PX-30002336","CDM","87449","CPT","0300","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","61.50","61.50","61.50","1 through 10","11.74","190","percent of total billed charges",""
"Bwh Unlisted Glucan CSF","PX-30002336","CDM","87449","CPT","0300","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","75.85","75.86","1 through 10","11.74","190","percent of total billed charges",""
"Bwh Unlisted Glucan CSF","PX-30002336","CDM","87449","CPT","0300","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","155.08","155.08","1 through 10","11.74","190","percent of total billed charges",""
"Bwh Unlisted Glucan CSF","PX-30002336","CDM","87449","CPT","0300","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","131.34","92.73","185.46","17","11.81","163.44","percent of total billed charges",""
"Bwh Unlisted Glucan CSF","PX-30002336","CDM","87449","CPT","0300","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","60.38","194.00","1 through 10","11.81","163.44","percent of total billed charges",""
"Bwh Unlisted Infliximab & Infliximab Ab","PX-30002338","CDM","80299","CPT","0305","RC","","","","both","","","231.00","173.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","183.65","79.5","","106.25","71.28","106.25","1 through 10","14.12","219.45","percent of total billed charges",""
"Bwh Unlisted Infliximab & Infliximab Ab","PX-30002338","CDM","80299","CPT","0305","RC","","","","both","","","231.00","173.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","123.12","53.3","","106.25","71.28","106.25","1 through 10","14.12","219.45","percent of total billed charges",""
"Bwh Unlisted Infliximab & Infliximab Ab","PX-30002338","CDM","80299","CPT","0305","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","84.32","36.5","","50.36","42.80","92.50","13","14.12","219.45","percent of total billed charges",""
"Bwh Unlisted Infliximab & Infliximab Ab","PX-30002338","CDM","80299","CPT","0305","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","88.47","38.3","","52.79","44.55","158.37","30","14.12","219.45","percent of total billed charges",""
"Bwh Unlisted Infliximab & Infliximab Ab","PX-30002338","CDM","80299","CPT","0305","RC","","","","outpatient","","","231.00","173.25","AETNA [1001]","HB AMC AETNA HMO","161.24","69.8","","91.40","64.53","105.30","14","14.12","188.77","percent of total billed charges",""
"Bwh Unlisted Infliximab & Infliximab Ab","PX-30002338","CDM","80299","CPT","0305","RC","","","","outpatient","","","231.00","173.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","185.72","80.4","","105.30","105.30","105.30","1 through 10","14.12","188.77","percent of total billed charges",""
"Bwh Unlisted Infliximab & Infliximab Ab","PX-30002338","CDM","80299","CPT","0305","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","188.77","81.72","","59.36","15.50","59.36","1 through 10","14.12","188.77","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Bwh Unlisted Jc Virus Pcr Quant","PX-30002337","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"Bwh Unlisted Red Cell Ag Genotyping Fetal","PX-31000380","CDM","81479","CPT","0310","RC","","","","both","","","318.00","238.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","252.81","79.5","","0.65","0.65","0.65","1 through 10","98.58","302.1","percent of total billed charges",""
"Bwh Unlisted Red Cell Ag Genotyping Fetal","PX-31000380","CDM","81479","CPT","0310","RC","","","","both","","","318.00","238.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","169.49","53.3","","0.79","0.79","0.79","1 through 10","98.58","302.1","percent of total billed charges",""
"Bwh Unlisted Red Cell Ag Genotyping Fetal","PX-31000380","CDM","81479","CPT","0310","RC","","","","outpatient","","","318.00","238.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","159.00","50","","1.00","1.00","1.00","1 through 10","153.91","262.35","percent of total billed charges",""
"Bwh Unlisted Red Cell Ag Genotyping Fetal","PX-31000380","CDM","81479","CPT","0310","RC","","","","outpatient","","","318.00","238.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","166.95","52.5","","1.00","0.53","1.00","1 through 10","153.91","262.35","percent of total billed charges",""
"Bwh Unlisted Transthyretin Dna","PX-31000381","CDM","81479","CPT","0310","RC","","","","both","","","1651.00","1238.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1312.55","79.5","","0.65","0.65","0.65","1 through 10","511.81","1568.45","percent of total billed charges",""
"Bwh Unlisted Transthyretin Dna","PX-31000381","CDM","81479","CPT","0310","RC","","","","both","","","1651.00","1238.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","879.98","53.3","","0.79","0.79","0.79","1 through 10","511.81","1568.45","percent of total billed charges",""
"Bwh Unlisted Transthyretin Dna","PX-31000381","CDM","81479","CPT","0310","RC","","","","outpatient","","","1651.00","1238.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","825.50","50","","1.00","1.00","1.00","1 through 10","156.55","1362.08","percent of total billed charges",""
"Bwh Unlisted Transthyretin Dna","PX-31000381","CDM","81479","CPT","0310","RC","","","","outpatient","","","1651.00","1238.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","866.78","52.5","","1.00","0.53","1.00","1 through 10","156.55","1362.08","percent of total billed charges",""
"Bwh Unlisted Vascular Aneursym Panel","PX-31000379","CDM","81479","CPT","0310","RC","","","","both","","","2962.00","2221.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2354.79","79.5","","0.65","0.65","0.65","1 through 10","918.22","2813.9","percent of total billed charges",""
"Bwh Unlisted Vascular Aneursym Panel","PX-31000379","CDM","81479","CPT","0310","RC","","","","both","","","2962.00","2221.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1578.75","53.3","","0.79","0.79","0.79","1 through 10","918.22","2813.9","percent of total billed charges",""
"Bwh Unlisted Vascular Aneursym Panel","PX-31000379","CDM","81479","CPT","0310","RC","","","","outpatient","","","2962.00","2221.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1481.00","50","","1.00","1.00","1.00","1 through 10","156.55","2443.65","percent of total billed charges",""
"Bwh Unlisted Vascular Aneursym Panel","PX-31000379","CDM","81479","CPT","0310","RC","","","","outpatient","","","2962.00","2221.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1555.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","2443.65","percent of total billed charges",""
"Bwh Unlisted Y Chromosome Microdeletion","PX-31000386","CDM","81479","CPT","0310","RC","","","","both","","","372.00","279.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","295.74","79.5","","0.65","0.65","0.65","1 through 10","115.32","353.4","percent of total billed charges",""
"Bwh Unlisted Y Chromosome Microdeletion","PX-31000386","CDM","81479","CPT","0310","RC","","","","both","","","372.00","279.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.28","53.3","","0.79","0.79","0.79","1 through 10","115.32","353.4","percent of total billed charges",""
"Bwh Unlisted Y Chromosome Microdeletion","PX-31000386","CDM","81479","CPT","0310","RC","","","","outpatient","","","372.00","279.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","186.00","50","","1.00","1.00","1.00","1 through 10","156.55","306.9","percent of total billed charges",""
"Bwh Unlisted Y Chromosome Microdeletion","PX-31000386","CDM","81479","CPT","0310","RC","","","","outpatient","","","372.00","279.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","195.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","306.9","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Vegf-D by Immunoassay","PX-30002783","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Bwh Voriconazole Qt Hplc","PX-30002996","CDM","80299","CPT","0301","RC","","","","both","","","288.00","216.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","228.96","79.5","","106.25","71.28","106.25","1 through 10","14.12","273.6","percent of total billed charges",""
"Bwh Voriconazole Qt Hplc","PX-30002996","CDM","80299","CPT","0301","RC","","","","both","","","288.00","216.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","153.50","53.3","","106.25","71.28","106.25","1 through 10","14.12","273.6","percent of total billed charges",""
"Bwh Voriconazole Qt Hplc","PX-30002996","CDM","80299","CPT","0301","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.12","36.5","","50.36","42.80","92.50","13","14.12","273.6","percent of total billed charges",""
"Bwh Voriconazole Qt Hplc","PX-30002996","CDM","80299","CPT","0301","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","110.30","38.3","","52.79","44.55","158.37","30","14.12","273.6","percent of total billed charges",""
"Bwh Voriconazole Qt Hplc","PX-30002996","CDM","80299","CPT","0301","RC","","","","outpatient","","","288.00","216.00","AETNA [1001]","HB AMC AETNA HMO","201.02","69.8","","91.40","64.53","105.30","14","14.12","235.35","percent of total billed charges",""
"Bwh Voriconazole Qt Hplc","PX-30002996","CDM","80299","CPT","0301","RC","","","","outpatient","","","288.00","216.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","231.55","80.4","","105.30","105.30","105.30","1 through 10","14.12","235.35","percent of total billed charges",""
"Bwh Voriconazole Qt Hplc","PX-30002996","CDM","80299","CPT","0301","RC","","","","outpatient","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","235.35","81.72","","59.36","15.50","59.36","1 through 10","14.12","235.35","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Bwh Vwf Propeptide Ag, Elisa","PX-30002782","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"BWHOR,STANDARD IMPLANT,IMPLANT,NSMOR","SUP-ITM-10335090","CDM","C1813","HCPCS","0278","RC","","","","both","","","32701.50","24526.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12524.67","38.3","","12613.42","12613.42","12613.42","1 through 10","10137.47","25997.69","percent of total billed charges",""
"BWHOR,STANDARD IMPLANT,IMPLANT,NSMOR","SUP-ITM-10335090","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","32701.50","24526.12","AETNA [1001]","HB AMC AETNA HMO","22825.65","69.8","","34275.85","34275.85","50471.26","19","17089.8","26723.67","percent of total billed charges",""
"Bx Breast 1st Lesion MR Imag","PX-76001934","CDM","19085","CPT","0761","RC","","","","both","","","4356.00","3267.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.15","1742.02","3344.48","1 through 10","1350.36","3463.02","other","OPPS APC"
"Bx Breast 1st Lesion MR Imag","PX-76001934","CDM","19085","CPT","0761","RC","","","","outpatient","","","4356.00","3267.00","AETNA [1001]","HB AMC AETNA HMO","3040.49","69.8","","2859.65","2859.65","2859.65","1 through 10","1237.95","4183.73","percent of total billed charges",""
"Bx Breast 1st Lesion MR Imag","PX-76001934","CDM","19085","CPT","0761","RC","","","","outpatient","","","4356.00","3267.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3169.15","3169.15","3169.15","1 through 10","1237.95","4183.73","other","Multiple Surgery"
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","both","","","4004.00","3003.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2134.13","53.3","","2050.22","2050.22","2050.22","1 through 10","1241.24","3183.18","percent of total billed charges",""
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","both","","","4004.00","3003.00","TRICARE [160005]","HB BWH TRICARE","1827.93","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3398.86","3398.86","3398.86","1 through 10","1241.24","3183.18","other","Tricare OPPS"
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","both","","","4004.00","3003.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.55","1741.12","3338.59","14","1241.24","3183.18","other","OPPS APC"
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","outpatient","","","4004.00","3003.00","AETNA [1001]","HB AMC AETNA HMO","2794.79","69.8","","3712.14","2628.79","3712.14","1 through 10","1237.95","4183.73","percent of total billed charges",""
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","outpatient","","","4004.00","3003.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2760.63","2760.63","2760.63","1 through 10","1237.95","4183.73","other","Multiple Surgery"
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","outpatient","","","4004.00","3003.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3020.60","3020.60","3020.60","1 through 10","1237.95","4183.73","other","Multiple Surgery"
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","outpatient","","","4004.00","3003.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","6090.72","3169.15","6338.30","1 through 10","1237.95","4183.73","other","Multiple Surgery"
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","outpatient","","","4004.00","3003.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3272.07","81.72","","2902.90","2902.90","2902.90","1 through 10","1237.95","4183.73","percent of total billed charges",""
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","both","","","3694.00","2770.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.55","1887.65","1893.55","14","1145.14","2936.73","other","OPPS APC"
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","outpatient","","","3694.00","2770.50","AETNA [1001]","HB AMC AETNA HMO","2578.41","69.8","","4850.02","2425.01","4850.02","1 through 10","1237.95","4183.73","percent of total billed charges",""
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","outpatient","","","3694.00","2770.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","6338.30","3045.36","6338.30","1 through 10","1237.95","4183.73","other","Multiple Surgery"
"Bx Breast Add Lesion US Imag","PX-76001933","CDM","19084","CPT","0761","RC","","","","both","","","596.00","447.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","473.82","79.5","","918.07","918.07","918.07","1 through 10","184.76","473.82","percent of total billed charges",""
"Bx Breast Add Lesion US Imag","PX-76001933","CDM","19084","CPT","0761","RC","","","","both","","","596.00","447.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","228.27","38.3","","678.00","678.00","678.00","1 through 10","184.76","473.82","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","263.00","197.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","184.10","70","","255.00","255.00","255.00","1 through 10","20.39","249.85","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","263.00","197.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","209.09","79.5","","200.69","134.64","200.69","13","20.39","249.85","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","263.00","197.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","140.18","53.3","","200.69","134.64","403.92","12","20.39","249.85","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","263.00","197.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","81.53","31","","92.31","92.31","92.31","1 through 10","20.39","249.85","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","263.00","197.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","96.00","36.5","","95.12","92.31","285.36","14","20.39","249.85","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","263.00","197.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.73","38.3","","99.71","99.71","99.71","46","20.39","249.85","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","263.00","197.25","MOLINA [1014]","HB BWH MOLINA","92.05","35","","41.29","41.29","41.29","1 through 10","20.39","249.85","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","263.00","197.25","TRICARE [160005]","HB BWH TRICARE","249.85","95","","25.08","23.83","25.08","1 through 10","20.39","249.85","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.83","42.9","","203.85","112.12","203.85","1 through 10","20.39","249.85","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","outpatient","","","263.00","197.25","AETNA [1001]","HB AMC AETNA HMO","183.57","69.8","","172.64","121.89","198.90","24","21.45","214.92","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","outpatient","","","263.00","197.25","AETNA [1001]","HB AMC AETNA PPO","211.45","80.4","","198.90","198.90","198.90","1 through 10","21.45","214.92","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","214.92","81.72","","203.85","203.85","203.85","1 through 10","21.45","214.92","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.92","81.72","","203.85","112.12","203.85","15","21.45","214.92","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","63.18","71.8","","33.24","4.57","33.24","1 through 10","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","57.20","65","","165.75","55.25","165.75","1 through 10","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","CHAMPVA [160001]","HB BWH TRICARE","83.60","95","","6.24","6.24","6.24","1 through 10","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.96","79.5","","66.90","44.88","66.90","425","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.90","53.3","","44.88","44.88","156.38","291","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","67.76","77","","196.35","65.45","196.35","11","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","69.96","79.5","","66.90","66.90","66.90","1 through 10","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.28","31","","26.27","26.27","26.27","1 through 10","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","32.12","36.5","","31.71","26.95","95.13","305","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.70","38.3","","33.24","32.30","99.72","1078","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","MOLINA [1014]","HB BWH MOLINA","30.80","35","","10.28","10.28","10.28","1 through 10","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","67.76","77","","66.30","66.29","66.30","11","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","TRICARE [160005]","HB BWH TRICARE","83.60","95","","6.24","5.93","85.00","24","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","83.60","95","","5.18","5.18","5.18","1 through 10","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.75","42.9","","67.95","37.37","67.95","30","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","88.00","66.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.75","42.9","","37.37","37.37","37.37","1 through 10","5.08","83.6","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","88.00","66.00","AETNA [1001]","HB AMC AETNA HMO","61.42","69.8","","57.55","40.63","66.30","499","5.34","71.91","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","88.00","66.00","AETNA [1001]","HB AMC AETNA PPO","70.75","80.4","","66.30","44.54","66.30","62","5.34","71.91","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","88.00","66.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","49.19","55.9","","44.54","44.54","44.54","1 through 10","5.34","71.91","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","88.00","66.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.99","52.26","","18.56","18.56","52.60","1 through 10","5.34","71.91","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","88.00","66.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","70.75","80.4","","151.30","42.50","151.30","1 through 10","5.34","71.91","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","88.00","66.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","71.91","81.72","","67.95","67.95","85.00","1 through 10","5.34","71.91","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","88.00","66.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","71.91","81.72","","37.37","37.37","67.95","15","5.34","71.91","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","88.00","66.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.91","81.72","","67.95","37.37","67.95","469","5.34","71.91","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0300","RC","","","","inpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","136.00","78.61","","134.30","134.30","134.30","1 through 10","95.67","137.54","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","124.21","71.8","","120.62","11.42","120.62","1 through 10","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","112.45","65","","443.50","109.20","443.50","1 through 10","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","121.10","70","","362.88","120.96","504.00","1 through 10","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","137.54","79.5","","132.22","88.70","150.00","270","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","92.21","53.3","","88.70","88.70","266.10","147","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","133.21","77","","129.36","129.36","129.36","1 through 10","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","112.45","65","","131.30","89.04","131.30","1 through 10","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","137.54","79.5","","132.22","132.22","132.22","1 through 10","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","53.63","31","","51.91","51.91","51.91","1 through 10","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.15","36.5","","62.66","53.26","159.78","199","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.26","38.3","","65.69","65.69","197.07","608","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","133.21","77","","132.22","114.00","132.22","1 through 10","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","TRICARE [160005]","HB BWH TRICARE","164.35","95","","15.60","14.82","15.60","1 through 10","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.22","42.9","","134.30","73.87","134.30","12","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.22","42.9","","73.87","73.87","73.87","1 through 10","12.69","164.35","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","173.00","129.75","AETNA [1001]","HB AMC AETNA HMO","120.75","69.8","","113.74","80.30","131.04","286","13.35","141.38","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","173.00","129.75","AETNA [1001]","HB AMC AETNA PPO","139.09","80.4","","131.04","88.03","152.31","23","13.35","141.38","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","173.00","129.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","96.71","55.9","","176.06","88.03","176.06","1 through 10","13.35","141.38","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","173.00","129.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","90.41","52.26","","103.96","45.36","103.96","1 through 10","13.35","141.38","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","139.09","80.4","","131.04","84.00","131.04","1 through 10","13.35","141.38","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","141.38","81.72","","155.56","134.30","155.56","1 through 10","13.35","141.38","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","141.38","81.72","","134.30","73.87","134.30","21","13.35","141.38","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","141.38","81.72","","134.30","73.87","134.30","267","13.35","141.38","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","145.04","71.8","","140.73","140.73","140.73","1 through 10","11.76","191.9","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","CHAMPVA [160001]","HB BWH TRICARE","191.90","95","","14.46","14.46","14.46","1 through 10","11.76","191.9","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.59","79.5","","154.25","103.49","154.25","151","11.76","191.9","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","107.67","53.3","","103.49","103.49","462.75","93","11.76","191.9","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","155.54","77","","452.76","150.92","452.76","1 through 10","11.76","191.9","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.73","36.5","","73.11","62.13","73.11","188","11.76","191.9","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.37","38.3","","76.64","74.48","229.91","476","11.76","191.9","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","155.54","77","","611.52","611.52","611.52","1 through 10","11.76","191.9","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","TRICARE [160005]","HB BWH TRICARE","191.90","95","","13.74","13.74","196.00","14","11.76","191.9","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.66","42.9","","156.68","86.18","156.69","12","11.76","191.9","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA HMO","141.00","69.8","","132.69","93.69","152.88","229","12.38","165.07","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA PPO","162.41","80.4","","152.88","102.71","305.76","50","12.38","165.07","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","112.92","55.9","","102.71","102.71","102.71","1 through 10","12.38","165.07","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","162.41","80.4","","152.88","152.88","196.00","1 through 10","12.38","165.07","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","165.07","81.72","","156.68","86.18","156.68","11","12.38","165.07","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.07","81.72","","156.68","86.18","313.36","205","12.38","165.07","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","145.04","71.8","","140.73","140.73","140.73","1 through 10","11.76","191.9","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","CHAMPVA [160001]","HB BWH TRICARE","191.90","95","","14.46","14.46","14.46","1 through 10","11.76","191.9","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.59","79.5","","154.25","103.49","154.25","151","11.76","191.9","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","107.67","53.3","","103.49","103.49","462.75","93","11.76","191.9","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","155.54","77","","452.76","150.92","452.76","1 through 10","11.76","191.9","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.73","36.5","","73.11","62.13","73.11","188","11.76","191.9","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.37","38.3","","76.64","74.48","229.91","476","11.76","191.9","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","155.54","77","","611.52","611.52","611.52","1 through 10","11.76","191.9","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","TRICARE [160005]","HB BWH TRICARE","191.90","95","","13.74","13.74","196.00","14","11.76","191.9","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.66","42.9","","156.68","86.18","156.69","12","11.76","191.9","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA HMO","141.00","69.8","","132.69","93.69","152.88","229","12.38","165.07","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA PPO","162.41","80.4","","152.88","102.71","305.76","50","12.38","165.07","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","112.92","55.9","","102.71","102.71","102.71","1 through 10","12.38","165.07","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","162.41","80.4","","152.88","152.88","196.00","1 through 10","12.38","165.07","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","165.07","81.72","","156.68","86.18","156.68","11","12.38","165.07","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.07","81.72","","156.68","86.18","313.36","205","12.38","165.07","percent of total billed charges",""
"C9orf72 Gene Hexanucleotide Repeat Expansion","PX-31001073","CDM","81479","CPT","0310","RC","","","","both","","","1029.00","771.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","818.06","79.5","","0.65","0.65","0.65","1 through 10","318.99","977.55","percent of total billed charges",""
"C9orf72 Gene Hexanucleotide Repeat Expansion","PX-31001073","CDM","81479","CPT","0310","RC","","","","both","","","1029.00","771.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","548.46","53.3","","0.79","0.79","0.79","1 through 10","318.99","977.55","percent of total billed charges",""
"C9orf72 Gene Hexanucleotide Repeat Expansion","PX-31001073","CDM","81479","CPT","0310","RC","","","","outpatient","","","1029.00","771.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","514.50","50","","1.00","1.00","1.00","1 through 10","156.55","848.93","percent of total billed charges",""
"C9orf72 Gene Hexanucleotide Repeat Expansion","PX-31001073","CDM","81479","CPT","0310","RC","","","","outpatient","","","1029.00","771.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","540.23","52.5","","1.00","0.53","1.00","1 through 10","156.55","848.93","percent of total billed charges",""
"CABLE BONE 1.7X750MM CERCLAGE COBALT ALLOY CRIMP","SUP-ITM-10019202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.97","938.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","994.52","79.5","","800.18","480.96","1887.97","195","387.8","994.52","percent of total billed charges",""
"CABLE BONE 1.7X750MM CERCLAGE COBALT ALLOY CRIMP","SUP-ITM-10019202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.97","938.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","666.77","53.3","","813.12","216.42","1444.50","81","387.8","994.52","percent of total billed charges",""
"CABLE BONE 1.7X750MM CERCLAGE COBALT ALLOY CRIMP","SUP-ITM-10019202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.97","938.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","387.80","31","","432.60","432.60","432.60","1 through 10","387.8","994.52","percent of total billed charges",""
"CABLE BONE 1.7X750MM CERCLAGE COBALT ALLOY CRIMP","SUP-ITM-10019202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.97","938.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","456.60","36.5","","148.37","54.89","631.39","94","387.8","994.52","percent of total billed charges",""
"CABLE BONE 1.7X750MM CERCLAGE COBALT ALLOY CRIMP","SUP-ITM-10019202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.97","938.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","479.12","38.3","","279.30","91.72","1116.77","266","387.8","994.52","percent of total billed charges",""
"CABLE BONE 1.7X750MM CERCLAGE COBALT ALLOY CRIMP","SUP-ITM-10019202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.97","938.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","536.67","42.9","","731.00","63.70","731.00","1 through 10","387.8","994.52","percent of total billed charges",""
"CABLE BONE 1.7X750MM CERCLAGE COBALT ALLOY CRIMP","SUP-ITM-10019202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.97","938.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","536.67","42.9","","384.74","384.74","384.74","1 through 10","387.8","994.52","percent of total billed charges",""
"CABLE BONE 1.7X750MM CERCLAGE COBALT ALLOY CRIMP","SUP-ITM-10019202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.97","938.23","WELLPOINT [1015]","HB AMC WELLPOINT","922.97","73.78","","286.63","119.22","1107.45","105","387.8","994.52","percent of total billed charges",""
"CABLE BONE 1.7X750MM CERCLAGE COBALT ALLOY CRIMP","SUP-ITM-10019202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.97","938.23","AETNA [1001]","HB AMC AETNA HMO","873.18","69.8","","675.31","184.75","1721.50","286","653.76","1022.29","percent of total billed charges",""
"CABLE BONE 1.7X750MM CERCLAGE COBALT ALLOY CRIMP","SUP-ITM-10019202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.97","938.23","AETNA [1001]","HB AMC AETNA PPO","1005.78","80.4","","1261.44","103.12","1514.10","21","653.76","1022.29","percent of total billed charges",""
"CABLE BONE 1.7X750MM CERCLAGE COBALT ALLOY CRIMP","SUP-ITM-10019202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.97","938.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1005.78","80.4","","1365.00","1365.00","1365.00","1 through 10","653.76","1022.29","percent of total billed charges",""
"CABLE BONE 1.7X750MM CERCLAGE COBALT ALLOY CRIMP","SUP-ITM-10019202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.97","938.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1022.29","81.72","","5157.68","5157.68","5157.68","1 through 10","653.76","1022.29","percent of total billed charges",""
"CABLE BONE 1.7X750MM CERCLAGE COBALT ALLOY CRIMP","SUP-ITM-10019202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.97","938.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1022.29","81.72","","431.26","71.26","1459.57","88","653.76","1022.29","percent of total billed charges",""
"CABLE BONE 1.8MMX63.5CM LONG PLATE ZIMMER READY COBALT GREATER TROCHANTER","SUP-ITM-10011198","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.53","812.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","861.41","79.5","","800.18","480.96","1887.97","195","335.89","861.41","percent of total billed charges",""
"CABLE BONE 1.8MMX63.5CM LONG PLATE ZIMMER READY COBALT GREATER TROCHANTER","SUP-ITM-10011198","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.53","812.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","577.52","53.3","","813.12","216.42","1444.50","81","335.89","861.41","percent of total billed charges",""
"CABLE BONE 1.8MMX63.5CM LONG PLATE ZIMMER READY COBALT GREATER TROCHANTER","SUP-ITM-10011198","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.53","812.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","335.89","31","","432.60","432.60","432.60","1 through 10","335.89","861.41","percent of total billed charges",""
"CABLE BONE 1.8MMX63.5CM LONG PLATE ZIMMER READY COBALT GREATER TROCHANTER","SUP-ITM-10011198","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.53","812.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","395.49","36.5","","148.37","54.89","631.39","94","335.89","861.41","percent of total billed charges",""
"CABLE BONE 1.8MMX63.5CM LONG PLATE ZIMMER READY COBALT GREATER TROCHANTER","SUP-ITM-10011198","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.53","812.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","414.99","38.3","","279.30","91.72","1116.77","266","335.89","861.41","percent of total billed charges",""
"CABLE BONE 1.8MMX63.5CM LONG PLATE ZIMMER READY COBALT GREATER TROCHANTER","SUP-ITM-10011198","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.53","812.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","464.83","42.9","","731.00","63.70","731.00","1 through 10","335.89","861.41","percent of total billed charges",""
"CABLE BONE 1.8MMX63.5CM LONG PLATE ZIMMER READY COBALT GREATER TROCHANTER","SUP-ITM-10011198","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.53","812.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","464.83","42.9","","384.74","384.74","384.74","1 through 10","335.89","861.41","percent of total billed charges",""
"CABLE BONE 1.8MMX63.5CM LONG PLATE ZIMMER READY COBALT GREATER TROCHANTER","SUP-ITM-10011198","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.53","812.65","WELLPOINT [1015]","HB AMC WELLPOINT","799.43","73.78","","286.63","119.22","1107.45","105","335.89","861.41","percent of total billed charges",""
"CABLE BONE 1.8MMX63.5CM LONG PLATE ZIMMER READY COBALT GREATER TROCHANTER","SUP-ITM-10011198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1083.53","812.65","AETNA [1001]","HB AMC AETNA HMO","756.30","69.8","","675.31","184.75","1721.50","286","566.25","885.46","percent of total billed charges",""
"CABLE BONE 1.8MMX63.5CM LONG PLATE ZIMMER READY COBALT GREATER TROCHANTER","SUP-ITM-10011198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1083.53","812.65","AETNA [1001]","HB AMC AETNA PPO","871.16","80.4","","1261.44","103.12","1514.10","21","566.25","885.46","percent of total billed charges",""
"CABLE BONE 1.8MMX63.5CM LONG PLATE ZIMMER READY COBALT GREATER TROCHANTER","SUP-ITM-10011198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1083.53","812.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","871.16","80.4","","1365.00","1365.00","1365.00","1 through 10","566.25","885.46","percent of total billed charges",""
"CABLE BONE 1.8MMX63.5CM LONG PLATE ZIMMER READY COBALT GREATER TROCHANTER","SUP-ITM-10011198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1083.53","812.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","885.46","81.72","","5157.68","5157.68","5157.68","1 through 10","566.25","885.46","percent of total billed charges",""
"CABLE BONE 1.8MMX63.5CM LONG PLATE ZIMMER READY COBALT GREATER TROCHANTER","SUP-ITM-10011198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1083.53","812.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","885.46","81.72","","431.26","71.26","1459.57","88","566.25","885.46","percent of total billed charges",""
"CABLE CONNECTOR VERTEX OPEN","SUP-ITM-10081835","CDM","C1889","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","1309.77","674.56","6049.93","26","54.25","139.13","percent of total billed charges",""
"CABLE CONNECTOR VERTEX OPEN","SUP-ITM-10081835","CDM","C1889","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.28","53.3","","1901.83","1901.83","2962.25","1 through 10","54.25","139.13","percent of total billed charges",""
"CABLE CONNECTOR VERTEX OPEN","SUP-ITM-10081835","CDM","C1889","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","1620.31","1620.31","19908.88","1 through 10","54.25","139.13","percent of total billed charges",""
"CABLE CONNECTOR VERTEX OPEN","SUP-ITM-10081835","CDM","C1889","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","352.91","352.91","2046.30","1 through 10","54.25","139.13","percent of total billed charges",""
"CABLE CONNECTOR VERTEX OPEN","SUP-ITM-10081835","CDM","C1889","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","9668.75","9668.75","9668.75","1 through 10","54.25","139.13","percent of total billed charges",""
"CABLE CONNECTOR VERTEX OPEN","SUP-ITM-10081835","CDM","C1889","HCPCS","0278","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","699.88","384.10","3443.31","33","54.25","139.13","percent of total billed charges",""
"CABLE CONNECTOR VERTEX OPEN","SUP-ITM-10081835","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","1421.24","264.50","4933.46","29","91.46","143.01","percent of total billed charges",""
"CABLE CONNECTOR VERTEX OPEN","SUP-ITM-10081835","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","140.70","80.4","","1022.97","1022.97","3607.50","1 through 10","91.46","143.01","percent of total billed charges",""
"CABLE CONNECTOR VERTEX OPEN","SUP-ITM-10081835","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","3010.54","693.88","5019.88","35","91.46","143.01","percent of total billed charges",""
"CABLE FOUR 23X21CM LONG DEVICE REATTACHMENT HIP READY TITANIUM INTEGRAL","SUP-ITM-10011786","CDM","C1713","HCPCS","0278","RC","","","","both","","","5639.88","4229.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4483.70","79.5","","800.18","480.96","1887.97","195","1748.36","4483.7","percent of total billed charges",""
"CABLE FOUR 23X21CM LONG DEVICE REATTACHMENT HIP READY TITANIUM INTEGRAL","SUP-ITM-10011786","CDM","C1713","HCPCS","0278","RC","","","","both","","","5639.88","4229.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3006.06","53.3","","813.12","216.42","1444.50","81","1748.36","4483.7","percent of total billed charges",""
"CABLE FOUR 23X21CM LONG DEVICE REATTACHMENT HIP READY TITANIUM INTEGRAL","SUP-ITM-10011786","CDM","C1713","HCPCS","0278","RC","","","","both","","","5639.88","4229.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1748.36","31","","432.60","432.60","432.60","1 through 10","1748.36","4483.7","percent of total billed charges",""
"CABLE FOUR 23X21CM LONG DEVICE REATTACHMENT HIP READY TITANIUM INTEGRAL","SUP-ITM-10011786","CDM","C1713","HCPCS","0278","RC","","","","both","","","5639.88","4229.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2058.56","36.5","","148.37","54.89","631.39","94","1748.36","4483.7","percent of total billed charges",""
"CABLE FOUR 23X21CM LONG DEVICE REATTACHMENT HIP READY TITANIUM INTEGRAL","SUP-ITM-10011786","CDM","C1713","HCPCS","0278","RC","","","","both","","","5639.88","4229.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2160.07","38.3","","279.30","91.72","1116.77","266","1748.36","4483.7","percent of total billed charges",""
"CABLE FOUR 23X21CM LONG DEVICE REATTACHMENT HIP READY TITANIUM INTEGRAL","SUP-ITM-10011786","CDM","C1713","HCPCS","0278","RC","","","","both","","","5639.88","4229.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2419.51","42.9","","731.00","63.70","731.00","1 through 10","1748.36","4483.7","percent of total billed charges",""
"CABLE FOUR 23X21CM LONG DEVICE REATTACHMENT HIP READY TITANIUM INTEGRAL","SUP-ITM-10011786","CDM","C1713","HCPCS","0278","RC","","","","both","","","5639.88","4229.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2419.51","42.9","","384.74","384.74","384.74","1 through 10","1748.36","4483.7","percent of total billed charges",""
"CABLE FOUR 23X21CM LONG DEVICE REATTACHMENT HIP READY TITANIUM INTEGRAL","SUP-ITM-10011786","CDM","C1713","HCPCS","0278","RC","","","","both","","","5639.88","4229.91","WELLPOINT [1015]","HB AMC WELLPOINT","4161.10","73.78","","286.63","119.22","1107.45","105","1748.36","4483.7","percent of total billed charges",""
"CABLE FOUR 23X21CM LONG DEVICE REATTACHMENT HIP READY TITANIUM INTEGRAL","SUP-ITM-10011786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5639.88","4229.91","AETNA [1001]","HB AMC AETNA HMO","3936.64","69.8","","675.31","184.75","1721.50","286","2947.4","4608.91","percent of total billed charges",""
"CABLE FOUR 23X21CM LONG DEVICE REATTACHMENT HIP READY TITANIUM INTEGRAL","SUP-ITM-10011786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5639.88","4229.91","AETNA [1001]","HB AMC AETNA PPO","4534.46","80.4","","1261.44","103.12","1514.10","21","2947.4","4608.91","percent of total billed charges",""
"CABLE FOUR 23X21CM LONG DEVICE REATTACHMENT HIP READY TITANIUM INTEGRAL","SUP-ITM-10011786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5639.88","4229.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4534.46","80.4","","1365.00","1365.00","1365.00","1 through 10","2947.4","4608.91","percent of total billed charges",""
"CABLE FOUR 23X21CM LONG DEVICE REATTACHMENT HIP READY TITANIUM INTEGRAL","SUP-ITM-10011786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5639.88","4229.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4608.91","81.72","","5157.68","5157.68","5157.68","1 through 10","2947.4","4608.91","percent of total billed charges",""
"CABLE FOUR 23X21CM LONG DEVICE REATTACHMENT HIP READY TITANIUM INTEGRAL","SUP-ITM-10011786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5639.88","4229.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4608.91","81.72","","431.26","71.26","1459.57","88","2947.4","4608.91","percent of total billed charges",""
"CABLE HIP 2.0MM ACCORD COCR PLATE GRIP COBALT","SUP-ITM-10024600","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.00","357.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","378.42","79.5","","800.18","480.96","1887.97","195","147.56","378.42","percent of total billed charges",""
"CABLE HIP 2.0MM ACCORD COCR PLATE GRIP COBALT","SUP-ITM-10024600","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.00","357.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","253.71","53.3","","813.12","216.42","1444.50","81","147.56","378.42","percent of total billed charges",""
"CABLE HIP 2.0MM ACCORD COCR PLATE GRIP COBALT","SUP-ITM-10024600","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.00","357.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","147.56","31","","432.60","432.60","432.60","1 through 10","147.56","378.42","percent of total billed charges",""
"CABLE HIP 2.0MM ACCORD COCR PLATE GRIP COBALT","SUP-ITM-10024600","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.00","357.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","173.74","36.5","","148.37","54.89","631.39","94","147.56","378.42","percent of total billed charges",""
"CABLE HIP 2.0MM ACCORD COCR PLATE GRIP COBALT","SUP-ITM-10024600","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.00","357.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","182.31","38.3","","279.30","91.72","1116.77","266","147.56","378.42","percent of total billed charges",""
"CABLE HIP 2.0MM ACCORD COCR PLATE GRIP COBALT","SUP-ITM-10024600","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.00","357.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.20","42.9","","731.00","63.70","731.00","1 through 10","147.56","378.42","percent of total billed charges",""
"CABLE HIP 2.0MM ACCORD COCR PLATE GRIP COBALT","SUP-ITM-10024600","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.00","357.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.20","42.9","","384.74","384.74","384.74","1 through 10","147.56","378.42","percent of total billed charges",""
"CABLE HIP 2.0MM ACCORD COCR PLATE GRIP COBALT","SUP-ITM-10024600","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.00","357.00","WELLPOINT [1015]","HB AMC WELLPOINT","351.19","73.78","","286.63","119.22","1107.45","105","147.56","378.42","percent of total billed charges",""
"CABLE HIP 2.0MM ACCORD COCR PLATE GRIP COBALT","SUP-ITM-10024600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.00","357.00","AETNA [1001]","HB AMC AETNA HMO","332.25","69.8","","675.31","184.75","1721.50","286","248.76","388.99","percent of total billed charges",""
"CABLE HIP 2.0MM ACCORD COCR PLATE GRIP COBALT","SUP-ITM-10024600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.00","357.00","AETNA [1001]","HB AMC AETNA PPO","382.70","80.4","","1261.44","103.12","1514.10","21","248.76","388.99","percent of total billed charges",""
"CABLE HIP 2.0MM ACCORD COCR PLATE GRIP COBALT","SUP-ITM-10024600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.00","357.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","382.70","80.4","","1365.00","1365.00","1365.00","1 through 10","248.76","388.99","percent of total billed charges",""
"CABLE HIP 2.0MM ACCORD COCR PLATE GRIP COBALT","SUP-ITM-10024600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.00","357.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","388.99","81.72","","5157.68","5157.68","5157.68","1 through 10","248.76","388.99","percent of total billed charges",""
"CABLE HIP 2.0MM ACCORD COCR PLATE GRIP COBALT","SUP-ITM-10024600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.00","357.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","388.99","81.72","","431.26","71.26","1459.57","88","248.76","388.99","percent of total billed charges",""
"CABLE MULTI LEAD TITANIUM","SUP-ITM-10174946","CDM","C1883","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","1073.15","1073.15","1073.15","1 through 10","325.5","834.75","percent of total billed charges",""
"CABLE MULTI LEAD TITANIUM","SUP-ITM-10174946","CDM","C1883","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","1808.38","1642.20","1808.38","1 through 10","325.5","834.75","percent of total billed charges",""
"CABLE MULTI LEAD TITANIUM","SUP-ITM-10174946","CDM","C1883","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB AMC WELLPOINT","774.69","73.78","","625.38","625.38","625.38","1 through 10","325.5","834.75","percent of total billed charges",""
"CABLE OR 8 CONTACT EXTENSION PUSH BUTTON","SUP-ITM-10282134","CDM","C1883","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","1073.15","1073.15","1073.15","1 through 10","162.75","417.38","percent of total billed charges",""
"CABLE OR 8 CONTACT EXTENSION PUSH BUTTON","SUP-ITM-10282134","CDM","C1883","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","1808.38","1642.20","1808.38","1 through 10","162.75","417.38","percent of total billed charges",""
"CABLE OR 8 CONTACT EXTENSION PUSH BUTTON","SUP-ITM-10282134","CDM","C1883","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","625.38","625.38","625.38","1 through 10","162.75","417.38","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1249.68","937.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","993.50","79.5","","800.18","480.96","1887.97","195","387.4","993.5","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1249.68","937.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","666.08","53.3","","813.12","216.42","1444.50","81","387.4","993.5","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1249.68","937.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","387.40","31","","432.60","432.60","432.60","1 through 10","387.4","993.5","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1249.68","937.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","456.13","36.5","","148.37","54.89","631.39","94","387.4","993.5","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1249.68","937.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","478.63","38.3","","279.30","91.72","1116.77","266","387.4","993.5","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1249.68","937.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","536.11","42.9","","731.00","63.70","731.00","1 through 10","387.4","993.5","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1249.68","937.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","536.11","42.9","","384.74","384.74","384.74","1 through 10","387.4","993.5","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1249.68","937.26","WELLPOINT [1015]","HB AMC WELLPOINT","922.01","73.78","","286.63","119.22","1107.45","105","387.4","993.5","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1249.68","937.26","AETNA [1001]","HB AMC AETNA HMO","872.28","69.8","","675.31","184.75","1721.50","286","653.08","1021.24","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1249.68","937.26","AETNA [1001]","HB AMC AETNA PPO","1004.74","80.4","","1261.44","103.12","1514.10","21","653.08","1021.24","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1249.68","937.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1004.74","80.4","","1365.00","1365.00","1365.00","1 through 10","653.08","1021.24","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1249.68","937.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1021.24","81.72","","5157.68","5157.68","5157.68","1 through 10","653.08","1021.24","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1249.68","937.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1021.24","81.72","","431.26","71.26","1459.57","88","653.08","1021.24","percent of total billed charges",""
"CABLE SPINE 1X470MM TI CRIMP SINGLE LEAD","SUP-ITM-10009128","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","1309.77","674.56","6049.93","26","271.25","695.63","percent of total billed charges",""
"CABLE SPINE 1X470MM TI CRIMP SINGLE LEAD","SUP-ITM-10009128","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","1901.83","1901.83","2962.25","1 through 10","271.25","695.63","percent of total billed charges",""
"CABLE SPINE 1X470MM TI CRIMP SINGLE LEAD","SUP-ITM-10009128","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","1620.31","1620.31","19908.88","1 through 10","271.25","695.63","percent of total billed charges",""
"CABLE SPINE 1X470MM TI CRIMP SINGLE LEAD","SUP-ITM-10009128","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","352.91","352.91","2046.30","1 through 10","271.25","695.63","percent of total billed charges",""
"CABLE SPINE 1X470MM TI CRIMP SINGLE LEAD","SUP-ITM-10009128","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","9668.75","9668.75","9668.75","1 through 10","271.25","695.63","percent of total billed charges",""
"CABLE SPINE 1X470MM TI CRIMP SINGLE LEAD","SUP-ITM-10009128","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","699.88","384.10","3443.31","33","271.25","695.63","percent of total billed charges",""
"CABLE SPINE 1X470MM TI CRIMP SINGLE LEAD","SUP-ITM-10009128","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","1421.24","264.50","4933.46","29","457.28","715.05","percent of total billed charges",""
"CABLE SPINE 1X470MM TI CRIMP SINGLE LEAD","SUP-ITM-10009128","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1022.97","1022.97","3607.50","1 through 10","457.28","715.05","percent of total billed charges",""
"CABLE SPINE 1X470MM TI CRIMP SINGLE LEAD","SUP-ITM-10009128","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","3010.54","693.88","5019.88","35","457.28","715.05","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2696.24","79.5","","800.18","480.96","1887.97","195","1051.37","2696.24","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1807.67","53.3","","813.12","216.42","1444.50","81","1051.37","2696.24","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1051.37","31","","432.60","432.60","432.60","1 through 10","1051.37","2696.24","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1237.90","36.5","","148.37","54.89","631.39","94","1051.37","2696.24","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1298.94","38.3","","279.30","91.72","1116.77","266","1051.37","2696.24","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1454.95","42.9","","731.00","63.70","731.00","1 through 10","1051.37","2696.24","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1454.95","42.9","","384.74","384.74","384.74","1 through 10","1051.37","2696.24","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","WELLPOINT [1015]","HB AMC WELLPOINT","2502.25","73.78","","286.63","119.22","1107.45","105","1051.37","2696.24","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3391.50","2543.62","AETNA [1001]","HB AMC AETNA HMO","2367.27","69.8","","675.31","184.75","1721.50","286","1772.4","2771.53","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3391.50","2543.62","AETNA [1001]","HB AMC AETNA PPO","2726.77","80.4","","1261.44","103.12","1514.10","21","1772.4","2771.53","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3391.50","2543.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2726.77","80.4","","1365.00","1365.00","1365.00","1 through 10","1772.4","2771.53","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3391.50","2543.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2771.53","81.72","","5157.68","5157.68","5157.68","1 through 10","1772.4","2771.53","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3391.50","2543.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2771.53","81.72","","431.26","71.26","1459.57","88","1772.4","2771.53","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 20MM SCREW AT2-055","SUP-ITM-10189481","CDM","C1713","HCPCS","0278","RC","","","","both","","","3339.00","2504.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2654.51","79.5","","800.18","480.96","1887.97","195","1035.09","2654.51","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 20MM SCREW AT2-055","SUP-ITM-10189481","CDM","C1713","HCPCS","0278","RC","","","","both","","","3339.00","2504.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1779.69","53.3","","813.12","216.42","1444.50","81","1035.09","2654.51","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 20MM SCREW AT2-055","SUP-ITM-10189481","CDM","C1713","HCPCS","0278","RC","","","","both","","","3339.00","2504.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1035.09","31","","432.60","432.60","432.60","1 through 10","1035.09","2654.51","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 20MM SCREW AT2-055","SUP-ITM-10189481","CDM","C1713","HCPCS","0278","RC","","","","both","","","3339.00","2504.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1218.74","36.5","","148.37","54.89","631.39","94","1035.09","2654.51","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 20MM SCREW AT2-055","SUP-ITM-10189481","CDM","C1713","HCPCS","0278","RC","","","","both","","","3339.00","2504.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1278.84","38.3","","279.30","91.72","1116.77","266","1035.09","2654.51","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 20MM SCREW AT2-055","SUP-ITM-10189481","CDM","C1713","HCPCS","0278","RC","","","","both","","","3339.00","2504.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1432.43","42.9","","731.00","63.70","731.00","1 through 10","1035.09","2654.51","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 20MM SCREW AT2-055","SUP-ITM-10189481","CDM","C1713","HCPCS","0278","RC","","","","both","","","3339.00","2504.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1432.43","42.9","","384.74","384.74","384.74","1 through 10","1035.09","2654.51","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 20MM SCREW AT2-055","SUP-ITM-10189481","CDM","C1713","HCPCS","0278","RC","","","","both","","","3339.00","2504.25","WELLPOINT [1015]","HB AMC WELLPOINT","2463.51","73.78","","286.63","119.22","1107.45","105","1035.09","2654.51","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 20MM SCREW AT2-055","SUP-ITM-10189481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3339.00","2504.25","AETNA [1001]","HB AMC AETNA HMO","2330.62","69.8","","675.31","184.75","1721.50","286","1744.96","2728.63","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 20MM SCREW AT2-055","SUP-ITM-10189481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3339.00","2504.25","AETNA [1001]","HB AMC AETNA PPO","2684.56","80.4","","1261.44","103.12","1514.10","21","1744.96","2728.63","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 20MM SCREW AT2-055","SUP-ITM-10189481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3339.00","2504.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2684.56","80.4","","1365.00","1365.00","1365.00","1 through 10","1744.96","2728.63","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 20MM SCREW AT2-055","SUP-ITM-10189481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3339.00","2504.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2728.63","81.72","","5157.68","5157.68","5157.68","1 through 10","1744.96","2728.63","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 20MM SCREW AT2-055","SUP-ITM-10189481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3339.00","2504.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2728.63","81.72","","431.26","71.26","1459.57","88","1744.96","2728.63","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","both","","","291.00","218.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","231.35","79.5","","221.93","221.93","665.79","1 through 10","23.17","276.45","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","both","","","291.00","218.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","155.10","53.3","","148.90","148.90","148.90","1 through 10","23.17","276.45","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","106.22","36.5","","105.19","89.39","105.19","1 through 10","23.17","276.45","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","111.45","38.3","","110.26","110.26","110.26","1 through 10","23.17","276.45","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","both","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.84","42.9","","225.43","225.43","225.43","1 through 10","23.17","276.45","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","outpatient","","","291.00","218.25","AETNA [1001]","HB AMC AETNA HMO","203.12","69.8","","219.96","219.96","219.96","1 through 10","23.87","237.81","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","outpatient","","","291.00","218.25","AETNA [1001]","HB AMC AETNA PPO","233.96","80.4","","219.96","219.96","219.96","1 through 10","23.87","237.81","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","outpatient","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","237.81","81.72","","124.00","124.00","124.00","1 through 10","23.87","237.81","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","outpatient","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","237.81","81.72","","225.43","124.00","225.44","1 through 10","23.87","237.81","percent of total billed charges",""
"CAGE SPINE 10X25MM CONCORDE X PAC LORDOTIC","SUP-ITM-10307123","CDM","C1821","HCPCS","0278","RC","","","","both","","","11102.50","8326.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8826.49","79.5","","9828.00","9828.00","9828.00","1 through 10","3441.78","10547.38","percent of total billed charges",""
"CAGE SPINE 10X25MM CONCORDE X PAC LORDOTIC","SUP-ITM-10307123","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","11102.50","8326.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9072.96","81.72","","1958.53","1886.75","1958.53","1 through 10","5802.17","9072.96","percent of total billed charges",""
"CAGE SPINE 22-25MM MED SZ 1 0DEG INTEGRATED XRL TITANIUM","SUP-ITM-10134932","CDM","C1821","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7850.63","79.5","","9828.00","9828.00","9828.00","1 through 10","3061.25","9381.25","percent of total billed charges",""
"CAGE SPINE 22-25MM MED SZ 1 0DEG INTEGRATED XRL TITANIUM","SUP-ITM-10134932","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","9875.00","7406.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8069.85","81.72","","1958.53","1886.75","1958.53","1 through 10","5160.68","8069.85","percent of total billed charges",""
"CAGE SPINE 8MM 8DEG TLIF-C UI 28/10","SUP-ITM-10243943","CDM","C1821","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","9828.00","9828.00","9828.00","1 through 10","1550","4750","percent of total billed charges",""
"CAGE SPINE 8MM 8DEG TLIF-C UI 28/10","SUP-ITM-10243943","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","1958.53","1886.75","1958.53","1 through 10","2613","4086","percent of total billed charges",""
"CAGE SPINE 9X11X31MM 15DEGREE TLX IMPLANT","SUP-ITM-10237165","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5962.50","79.5","","1309.77","674.56","6049.93","26","2325","5962.5","percent of total billed charges",""
"CAGE SPINE 9X11X31MM 15DEGREE TLX IMPLANT","SUP-ITM-10237165","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3997.50","53.3","","1901.83","1901.83","2962.25","1 through 10","2325","5962.5","percent of total billed charges",""
"CAGE SPINE 9X11X31MM 15DEGREE TLX IMPLANT","SUP-ITM-10237165","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2737.50","36.5","","1620.31","1620.31","19908.88","1 through 10","2325","5962.5","percent of total billed charges",""
"CAGE SPINE 9X11X31MM 15DEGREE TLX IMPLANT","SUP-ITM-10237165","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2872.50","38.3","","352.91","352.91","2046.30","1 through 10","2325","5962.5","percent of total billed charges",""
"CAGE SPINE 9X11X31MM 15DEGREE TLX IMPLANT","SUP-ITM-10237165","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3217.50","42.9","","9668.75","9668.75","9668.75","1 through 10","2325","5962.5","percent of total billed charges",""
"CAGE SPINE 9X11X31MM 15DEGREE TLX IMPLANT","SUP-ITM-10237165","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","WELLPOINT [1015]","HB AMC WELLPOINT","5533.50","73.78","","699.88","384.10","3443.31","33","2325","5962.5","percent of total billed charges",""
"CAGE SPINE 9X11X31MM 15DEGREE TLX IMPLANT","SUP-ITM-10237165","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","AETNA [1001]","HB AMC AETNA HMO","5235.00","69.8","","1421.24","264.50","4933.46","29","3919.5","6129","percent of total billed charges",""
"CAGE SPINE 9X11X31MM 15DEGREE TLX IMPLANT","SUP-ITM-10237165","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6030.00","80.4","","1022.97","1022.97","3607.50","1 through 10","3919.5","6129","percent of total billed charges",""
"CAGE SPINE 9X11X31MM 15DEGREE TLX IMPLANT","SUP-ITM-10237165","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6129.00","81.72","","3010.54","693.88","5019.88","35","3919.5","6129","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE LEFT","SUP-ITM-10126063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1894.95","52.26","","1113.10","1113.10","1113.10","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE LEFT","SUP-ITM-10126063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2882.67","79.5","","1293.60","1148.53","1603.80","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE LEFT","SUP-ITM-10126063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1323.49","36.5","","1023.42","771.29","2068.67","33","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE LEFT","SUP-ITM-10126063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1388.76","38.3","","850.52","759.78","1211.25","66","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE LEFT","SUP-ITM-10126063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE LEFT","SUP-ITM-10126063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.55","42.9","","956.46","956.46","956.46","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE LEFT","SUP-ITM-10126063","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","WELLPOINT [1015]","HB AMC WELLPOINT","2675.26","73.78","","2344.73","1619.47","2530.35","16","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE LEFT","SUP-ITM-10126063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","AETNA [1001]","HB AMC AETNA HMO","2530.95","69.8","","1523.63","988.41","4330.26","39","1894.95","2963.17","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE LEFT","SUP-ITM-10126063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","AETNA [1001]","HB AMC AETNA PPO","2915.30","80.4","","1670.25","1670.25","1670.25","1 through 10","1894.95","2963.17","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE LEFT","SUP-ITM-10126063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1894.95","52.26","","1113.10","1113.10","1113.10","1 through 10","1894.95","2963.17","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE LEFT","SUP-ITM-10126063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2963.17","81.72","","1738.90","1484.65","2716.94","38","1894.95","2963.17","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE RIGHT","SUP-ITM-10126064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2882.67","79.5","","800.18","480.96","1887.97","195","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE RIGHT","SUP-ITM-10126064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1932.66","53.3","","813.12","216.42","1444.50","81","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE RIGHT","SUP-ITM-10126064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1124.06","31","","432.60","432.60","432.60","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE RIGHT","SUP-ITM-10126064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1323.49","36.5","","148.37","54.89","631.39","94","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE RIGHT","SUP-ITM-10126064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1388.76","38.3","","279.30","91.72","1116.77","266","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE RIGHT","SUP-ITM-10126064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.55","42.9","","731.00","63.70","731.00","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE RIGHT","SUP-ITM-10126064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.55","42.9","","384.74","384.74","384.74","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE RIGHT","SUP-ITM-10126064","CDM","C1713","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","WELLPOINT [1015]","HB AMC WELLPOINT","2675.26","73.78","","286.63","119.22","1107.45","105","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE RIGHT","SUP-ITM-10126064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","AETNA [1001]","HB AMC AETNA HMO","2530.95","69.8","","675.31","184.75","1721.50","286","1894.95","2963.17","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE RIGHT","SUP-ITM-10126064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","AETNA [1001]","HB AMC AETNA PPO","2915.30","80.4","","1261.44","103.12","1514.10","21","1894.95","2963.17","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE RIGHT","SUP-ITM-10126064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2915.30","80.4","","1365.00","1365.00","1365.00","1 through 10","1894.95","2963.17","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE RIGHT","SUP-ITM-10126064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2963.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1894.95","2963.17","percent of total billed charges",""
"CALCANEAL PLATE 3.6CM SM WAVE FRACTURE RIGHT","SUP-ITM-10126064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2963.17","81.72","","431.26","71.26","1459.57","88","1894.95","2963.17","percent of total billed charges",""
"CALCANEAL PLATE 5.8CM MD WAVE FRACTURE LEFT","SUP-ITM-10126061","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1894.95","52.26","","1113.10","1113.10","1113.10","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 5.8CM MD WAVE FRACTURE LEFT","SUP-ITM-10126061","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2882.67","79.5","","1293.60","1148.53","1603.80","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 5.8CM MD WAVE FRACTURE LEFT","SUP-ITM-10126061","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1323.49","36.5","","1023.42","771.29","2068.67","33","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 5.8CM MD WAVE FRACTURE LEFT","SUP-ITM-10126061","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1388.76","38.3","","850.52","759.78","1211.25","66","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 5.8CM MD WAVE FRACTURE LEFT","SUP-ITM-10126061","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 5.8CM MD WAVE FRACTURE LEFT","SUP-ITM-10126061","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.55","42.9","","956.46","956.46","956.46","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 5.8CM MD WAVE FRACTURE LEFT","SUP-ITM-10126061","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","WELLPOINT [1015]","HB AMC WELLPOINT","2675.26","73.78","","2344.73","1619.47","2530.35","16","1124.06","2882.67","percent of total billed charges",""
"CALCANEAL PLATE 5.8CM MD WAVE FRACTURE LEFT","SUP-ITM-10126061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","AETNA [1001]","HB AMC AETNA HMO","2530.95","69.8","","1523.63","988.41","4330.26","39","1894.95","2963.17","percent of total billed charges",""
"CALCANEAL PLATE 5.8CM MD WAVE FRACTURE LEFT","SUP-ITM-10126061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","AETNA [1001]","HB AMC AETNA PPO","2915.30","80.4","","1670.25","1670.25","1670.25","1 through 10","1894.95","2963.17","percent of total billed charges",""
"CALCANEAL PLATE 5.8CM MD WAVE FRACTURE LEFT","SUP-ITM-10126061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1894.95","52.26","","1113.10","1113.10","1113.10","1 through 10","1894.95","2963.17","percent of total billed charges",""
"CALCANEAL PLATE 5.8CM MD WAVE FRACTURE LEFT","SUP-ITM-10126061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2963.17","81.72","","1738.90","1484.65","2716.94","38","1894.95","2963.17","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","2024.40","1518.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1609.40","79.5","","800.18","480.96","1887.97","195","627.56","1609.4","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","2024.40","1518.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1079.01","53.3","","813.12","216.42","1444.50","81","627.56","1609.4","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","2024.40","1518.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","627.56","31","","432.60","432.60","432.60","1 through 10","627.56","1609.4","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","2024.40","1518.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","738.91","36.5","","148.37","54.89","631.39","94","627.56","1609.4","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","2024.40","1518.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","775.35","38.3","","279.30","91.72","1116.77","266","627.56","1609.4","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","2024.40","1518.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","868.47","42.9","","731.00","63.70","731.00","1 through 10","627.56","1609.4","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","2024.40","1518.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","868.47","42.9","","384.74","384.74","384.74","1 through 10","627.56","1609.4","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","2024.40","1518.30","WELLPOINT [1015]","HB AMC WELLPOINT","1493.60","73.78","","286.63","119.22","1107.45","105","627.56","1609.4","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2024.40","1518.30","AETNA [1001]","HB AMC AETNA HMO","1413.03","69.8","","675.31","184.75","1721.50","286","1057.95","1654.34","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2024.40","1518.30","AETNA [1001]","HB AMC AETNA PPO","1627.62","80.4","","1261.44","103.12","1514.10","21","1057.95","1654.34","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2024.40","1518.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1627.62","80.4","","1365.00","1365.00","1365.00","1 through 10","1057.95","1654.34","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2024.40","1518.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1654.34","81.72","","5157.68","5157.68","5157.68","1 through 10","1057.95","1654.34","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2024.40","1518.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1654.34","81.72","","431.26","71.26","1459.57","88","1057.95","1654.34","percent of total billed charges",""
"CALCANEUS PLATE LG LT WAVE","SUP-ITM-10126059","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1894.95","52.26","","1113.10","1113.10","1113.10","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEUS PLATE LG LT WAVE","SUP-ITM-10126059","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2882.67","79.5","","1293.60","1148.53","1603.80","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEUS PLATE LG LT WAVE","SUP-ITM-10126059","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1323.49","36.5","","1023.42","771.29","2068.67","33","1124.06","2882.67","percent of total billed charges",""
"CALCANEUS PLATE LG LT WAVE","SUP-ITM-10126059","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1388.76","38.3","","850.52","759.78","1211.25","66","1124.06","2882.67","percent of total billed charges",""
"CALCANEUS PLATE LG LT WAVE","SUP-ITM-10126059","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEUS PLATE LG LT WAVE","SUP-ITM-10126059","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.55","42.9","","956.46","956.46","956.46","1 through 10","1124.06","2882.67","percent of total billed charges",""
"CALCANEUS PLATE LG LT WAVE","SUP-ITM-10126059","CDM","C1776","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","WELLPOINT [1015]","HB AMC WELLPOINT","2675.26","73.78","","2344.73","1619.47","2530.35","16","1124.06","2882.67","percent of total billed charges",""
"CALCANEUS PLATE LG LT WAVE","SUP-ITM-10126059","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","AETNA [1001]","HB AMC AETNA HMO","2530.95","69.8","","1523.63","988.41","4330.26","39","1894.95","2963.17","percent of total billed charges",""
"CALCANEUS PLATE LG LT WAVE","SUP-ITM-10126059","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","AETNA [1001]","HB AMC AETNA PPO","2915.30","80.4","","1670.25","1670.25","1670.25","1 through 10","1894.95","2963.17","percent of total billed charges",""
"CALCANEUS PLATE LG LT WAVE","SUP-ITM-10126059","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1894.95","52.26","","1113.10","1113.10","1113.10","1 through 10","1894.95","2963.17","percent of total billed charges",""
"CALCANEUS PLATE LG LT WAVE","SUP-ITM-10126059","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2963.17","81.72","","1738.90","1484.65","2716.94","38","1894.95","2963.17","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","both","","","318.00","238.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","252.81","79.5","","162.62","162.62","162.62","1 through 10","26.25","302.1","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","both","","","318.00","238.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","169.49","53.3","","242.40","162.62","242.40","1 through 10","26.25","302.1","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.79","38.3","","120.43","120.43","120.43","1 through 10","26.25","302.1","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","136.42","42.9","","135.43","135.43","135.43","1 through 10","26.25","302.1","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","outpatient","","","318.00","238.50","AETNA [1001]","HB AMC AETNA HMO","221.96","69.8","","240.24","208.52","240.24","1 through 10","27.61","259.87","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","outpatient","","","318.00","238.50","AETNA [1001]","HB AMC AETNA PPO","255.67","80.4","","147.22","147.22","147.22","1 through 10","27.61","259.87","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","outpatient","","","318.00","238.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","166.19","52.26","","94.86","94.86","94.86","1 through 10","27.61","259.87","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","outpatient","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","259.87","81.72","","246.22","246.21","246.22","1 through 10","27.61","259.87","percent of total billed charges",""
"Calcitonin Vl 200iu/Ml 2ml","PX-63600074","CDM","J0630","HCPCS","0636","RC","","","","outpatient","","","197.88","148.41","AETNA [1001]","HB AMC AETNA HMO","138.12","69.8","","2083.67","2083.67","2083.67","1 through 10","92.81","6083.34","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","both","","","235.00","176.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","154.16","65.6","","177.84","177.84","177.84","1 through 10","13.41","223.25","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","both","","","235.00","176.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","152.75","65","","179.44","179.44","179.44","1 through 10","13.41","223.25","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","both","","","235.00","176.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","164.50","70","","164.16","98.04","228.00","1 through 10","13.41","223.25","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","both","","","235.00","176.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.83","79.5","","360.81","120.38","460.74","76","13.41","223.25","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","both","","","235.00","176.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","125.26","53.3","","179.44","120.38","768.60","18","13.41","223.25","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","both","","","235.00","176.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","180.95","77","","175.56","175.56","175.56","1 through 10","13.41","223.25","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","both","","","235.00","176.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.78","36.5","","82.54","72.28","85.04","20","13.41","223.25","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","both","","","235.00","176.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","90.01","38.3","","89.15","89.15","89.15","72","13.41","223.25","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","both","","","235.00","176.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.82","42.9","","182.26","182.26","182.26","1 through 10","13.41","223.25","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","235.00","176.25","AETNA [1001]","HB AMC AETNA HMO","164.03","69.8","","144.76","108.98","177.84","86","14.1","192.04","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","235.00","176.25","AETNA [1001]","HB AMC AETNA PPO","188.94","80.4","","177.84","177.84","238.94","1 through 10","14.1","192.04","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","235.00","176.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","188.94","80.4","","177.84","177.84","177.84","1 through 10","14.1","192.04","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","235.00","176.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","192.04","81.72","","2395.37","2395.37","2395.37","1 through 10","14.1","192.04","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","235.00","176.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","192.04","81.72","","182.26","182.26","182.26","1 through 10","14.1","192.04","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","235.00","176.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","192.04","81.72","","182.26","100.25","364.52","20","14.1","192.04","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","both","","","72.00","54.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","51.70","71.8","","50.26","50.26","50.26","1 through 10","5.91","68.4","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","both","","","72.00","54.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","57.24","79.5","","55.09","36.96","55.09","13","5.91","68.4","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","both","","","72.00","54.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","38.38","53.3","","55.09","36.96","110.88","1 through 10","5.91","68.4","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","both","","","72.00","54.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","55.44","77","","53.90","53.90","53.90","1 through 10","5.91","68.4","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","both","","","72.00","54.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","22.32","31","","21.63","21.63","21.63","1 through 10","5.91","68.4","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","both","","","72.00","54.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.28","36.5","","26.11","22.19","66.57","13","5.91","68.4","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","both","","","72.00","54.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27.58","38.3","","27.37","23.10","50.26","25","5.91","68.4","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","outpatient","","","72.00","54.00","AETNA [1001]","HB AMC AETNA HMO","50.26","69.8","","47.39","33.46","47.39","19","6.23","58.84","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","outpatient","","","72.00","54.00","AETNA [1001]","HB AMC AETNA PPO","57.89","80.4","","54.60","54.60","54.60","1 through 10","6.23","58.84","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","outpatient","","","72.00","54.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","37.63","52.26","","18.65","18.65","18.65","1 through 10","6.23","58.84","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","outpatient","","","72.00","54.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","58.84","81.72","","55.96","55.96","55.96","1 through 10","6.23","58.84","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","outpatient","","","72.00","54.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","58.84","81.72","","55.96","30.78","55.97","1 through 10","6.23","58.84","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","both","","","66.00","49.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","47.39","71.8","","45.95","45.95","45.95","1 through 10","5.06","62.7","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","both","","","66.00","49.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","43.30","65.6","","49.92","49.92","49.92","1 through 10","5.06","62.7","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","both","","","66.00","49.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","52.47","79.5","","50.37","33.79","64.00","36","5.06","62.7","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","both","","","66.00","49.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","35.18","53.3","","50.37","33.79","50.37","14","5.06","62.7","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","both","","","66.00","49.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24.09","36.5","","23.87","20.29","60.87","17","5.06","62.7","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","both","","","66.00","49.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25.28","38.3","","25.02","24.32","72.96","75","5.06","62.7","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","both","","","66.00","49.50","MOLINA [1014]","HB BWH MOLINA","23.10","35","","10.24","10.24","10.24","1 through 10","5.06","62.7","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","both","","","66.00","49.50","TRICARE [160005]","HB BWH TRICARE","62.70","95","","5.91","5.91","5.91","1 through 10","5.06","62.7","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","both","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.31","42.9","","51.16","51.16","51.16","1 through 10","5.06","62.7","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","66.00","49.50","AETNA [1001]","HB AMC AETNA HMO","46.07","69.8","","43.33","30.59","49.92","35","5.33","53.94","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","66.00","49.50","AETNA [1001]","HB AMC AETNA PPO","53.06","80.4","","49.92","49.92","49.92","1 through 10","5.33","53.94","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","66.00","49.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","53.94","81.72","","51.16","51.16","51.16","1 through 10","5.33","53.94","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","53.94","81.72","","51.16","28.14","51.16","41","5.33","53.94","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","both","","","152.00","114.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","120.84","79.5","","115.69","77.62","115.69","1 through 10","12.64","144.4","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","both","","","152.00","114.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.02","53.3","","77.62","77.62","115.69","1 through 10","12.64","144.4","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.48","36.5","","54.83","46.16","54.83","1 through 10","12.64","144.4","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.22","38.3","","57.48","57.48","57.48","19","12.64","144.4","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","both","","","152.00","114.00","TRICARE [160005]","HB BWH TRICARE","144.40","95","","147.00","15.54","147.00","1 through 10","12.64","144.4","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","outpatient","","","152.00","114.00","AETNA [1001]","HB AMC AETNA HMO","106.10","69.8","","99.52","70.27","199.04","15","13.29","124.21","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","outpatient","","","152.00","114.00","AETNA [1001]","HB AMC AETNA PPO","122.21","80.4","","114.66","114.66","114.66","1 through 10","13.29","124.21","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","outpatient","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","124.21","81.72","","117.51","64.64","117.51","1 through 10","13.29","124.21","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","326.00","244.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","259.17","79.5","","248.69","166.85","248.69","53","19.24","309.7","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","326.00","244.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.76","53.3","","166.85","166.85","248.69","24","19.24","309.7","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","326.00","244.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.99","36.5","","117.87","99.22","117.87","46","19.24","309.7","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","326.00","244.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.86","38.3","","123.56","120.08","123.56","183","19.24","309.7","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","326.00","244.50","MOLINA [1014]","HB BWH MOLINA","114.10","35","","38.95","38.95","38.95","1 through 10","19.24","309.7","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","326.00","244.50","TRICARE [160005]","HB BWH TRICARE","309.70","95","","23.65","22.47","23.65","1 through 10","19.24","309.7","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","326.00","244.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","139.85","42.9","","138.95","138.95","252.61","1 through 10","19.24","309.7","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","326.00","244.50","AETNA [1001]","HB AMC AETNA HMO","227.55","69.8","","213.93","151.05","246.48","107","20.24","266.41","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","326.00","244.50","AETNA [1001]","HB AMC AETNA PPO","262.10","80.4","","246.48","165.58","246.48","14","20.24","266.41","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","326.00","244.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","182.23","55.9","","165.58","165.58","165.58","1 through 10","20.24","266.41","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","326.00","244.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","170.37","52.26","","69.08","59.49","69.08","1 through 10","20.24","266.41","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","326.00","244.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","262.10","80.4","","562.48","158.00","562.48","1 through 10","20.24","266.41","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","326.00","244.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","266.41","81.72","","252.61","252.61","252.61","1 through 10","20.24","266.41","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","326.00","244.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","266.41","81.72","","138.95","138.95","252.61","1 through 10","20.24","266.41","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","326.00","244.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","266.41","81.72","","252.61","138.95","252.61","84","20.24","266.41","percent of total billed charges",""
"Canalith Repositioning Proc","PX-98300627","CDM","95992","CPT","0983","RC","","","","both","","","166.00","124.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","88.48","53.3","","218.79","218.79","218.79","1 through 10","36.25","157.7","percent of total billed charges",""
"Canalith Repositioning Proc","PX-98300627","CDM","95992","CPT","0983","RC","","","","both","","","166.00","124.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.58","38.3","","108.70","105.64","108.70","21","36.25","157.7","percent of total billed charges",""
"Canalith Repositioning Proc","PX-98300627","CDM","95992","CPT","0983","RC","","","","both","","","166.00","124.50","TRICARE [160005]","HB BWH TRICARE","157.70","95","","35.14","35.14","35.14","1 through 10","36.25","157.7","percent of total billed charges",""
"Canalith Repositioning Proc","PX-98300627","CDM","95992","CPT","0983","RC","","","","outpatient","","","166.00","124.50","AETNA [1001]","HB AMC AETNA HMO","115.87","69.8","","132.88","132.88","188.21","1 through 10","83","256.17","percent of total billed charges",""
"Canalith Repositioning Procedure","PX-76002066","CDM","95992","CPT","0761","RC","","","","both","","","287.00","215.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","152.97","53.3","","218.79","218.79","218.79","1 through 10","36.25","272.65","percent of total billed charges",""
"Canalith Repositioning Procedure","PX-76002066","CDM","95992","CPT","0761","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","109.92","38.3","","108.70","105.64","108.70","21","36.25","272.65","percent of total billed charges",""
"Canalith Repositioning Procedure","PX-76002066","CDM","95992","CPT","0761","RC","","","","both","","","287.00","215.25","TRICARE [160005]","HB BWH TRICARE","272.65","95","","35.14","35.14","35.14","1 through 10","36.25","272.65","percent of total billed charges",""
"Canalith Repositioning Procedure","PX-76002066","CDM","95992","CPT","0761","RC","","","","outpatient","","","287.00","215.25","AETNA [1001]","HB AMC AETNA HMO","200.33","69.8","","132.88","132.88","188.21","1 through 10","125.52","256.17","percent of total billed charges",""
"Candida Antibody","PX-30000899","CDM","86628","CPT","0302","RC","","","","both","","","206.00","154.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.80","53.3","","105.60","105.60","105.60","1 through 10","11.77","195.7","percent of total billed charges",""
"CANNULA VENTRICULAR 16GA .008 IN 15MM TIP SMARTFLOW","SUP-ITM-10230150","CDM","C1887","HCPCS","0272","RC","","","","both","","","4987.50","3740.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3581.03","71.8","","28.28","27.13","28.28","1 through 10","1546.13","3965.06","percent of total billed charges",""
"CANNULA VENTRICULAR 16GA .008 IN 15MM TIP SMARTFLOW","SUP-ITM-10230150","CDM","C1887","HCPCS","0272","RC","","","","both","","","4987.50","3740.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3491.25","70","","44.63","35.78","44.63","1 through 10","1546.13","3965.06","percent of total billed charges",""
"CANNULA VENTRICULAR 16GA .008 IN 15MM TIP SMARTFLOW","SUP-ITM-10230150","CDM","C1887","HCPCS","0272","RC","","","","both","","","4987.50","3740.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3965.06","79.5","","1342.89","271.64","6954.67","1 through 10","1546.13","3965.06","percent of total billed charges",""
"CANNULA VENTRICULAR 16GA .008 IN 15MM TIP SMARTFLOW","SUP-ITM-10230150","CDM","C1887","HCPCS","0272","RC","","","","both","","","4987.50","3740.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2658.34","53.3","","4550.00","30.49","4550.00","1 through 10","1546.13","3965.06","percent of total billed charges",""
"CANNULA VENTRICULAR 16GA .008 IN 15MM TIP SMARTFLOW","SUP-ITM-10230150","CDM","C1887","HCPCS","0272","RC","","","","both","","","4987.50","3740.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3241.88","65","","42.09","0.04","5453.50","1 through 10","1546.13","3965.06","percent of total billed charges",""
"CANNULA VENTRICULAR 16GA .008 IN 15MM TIP SMARTFLOW","SUP-ITM-10230150","CDM","C1887","HCPCS","0272","RC","","","","both","","","4987.50","3740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1820.44","36.5","","310.94","18.54","1259.30","62","1546.13","3965.06","percent of total billed charges",""
"CANNULA VENTRICULAR 16GA .008 IN 15MM TIP SMARTFLOW","SUP-ITM-10230150","CDM","C1887","HCPCS","0272","RC","","","","both","","","4987.50","3740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1910.21","38.3","","146.86","22.58","1753.45","65","1546.13","3965.06","percent of total billed charges",""
"CANNULA VENTRICULAR 16GA .008 IN 15MM TIP SMARTFLOW","SUP-ITM-10230150","CDM","C1887","HCPCS","0272","RC","","","","both","","","4987.50","3740.62","WELLPOINT [1015]","HB AMC WELLPOINT","3679.78","73.78","","247.29","33.09","909.09","53","1546.13","3965.06","percent of total billed charges",""
"CANNULA VENTRICULAR 16GA .008 IN 15MM TIP SMARTFLOW","SUP-ITM-10230150","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4987.50","3740.62","AETNA [1001]","HB AMC AETNA HMO","3481.28","69.8","","30.69","30.21","30.69","1 through 10","2606.47","4075.79","percent of total billed charges",""
"CANNULA VENTRICULAR 16GA .008 IN 15MM TIP SMARTFLOW","SUP-ITM-10230150","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4987.50","3740.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4009.95","80.4","","82.69","82.69","82.69","1 through 10","2606.47","4075.79","percent of total billed charges",""
"CANNULA VENTRICULAR 16GA .008 IN 15MM TIP SMARTFLOW","SUP-ITM-10230150","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4987.50","3740.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4075.79","81.72","","751.01","74.72","751.01","1 through 10","2606.47","4075.79","percent of total billed charges",""
"CANNULA VENTRICULAR 16GA .008 IN 15MM TIP SMARTFLOW","SUP-ITM-10230150","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4987.50","3740.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4075.79","81.72","","328.92","46.17","2701.97","59","2606.47","4075.79","percent of total billed charges",""
"CAP BONE 10MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026329","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","428.28","79.5","","800.18","480.96","1887.97","195","167","428.28","percent of total billed charges",""
"CAP BONE 10MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026329","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","287.14","53.3","","813.12","216.42","1444.50","81","167","428.28","percent of total billed charges",""
"CAP BONE 10MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026329","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","167.00","31","","432.60","432.60","432.60","1 through 10","167","428.28","percent of total billed charges",""
"CAP BONE 10MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026329","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","196.63","36.5","","148.37","54.89","631.39","94","167","428.28","percent of total billed charges",""
"CAP BONE 10MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026329","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","206.33","38.3","","279.30","91.72","1116.77","266","167","428.28","percent of total billed charges",""
"CAP BONE 10MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026329","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.11","42.9","","731.00","63.70","731.00","1 through 10","167","428.28","percent of total billed charges",""
"CAP BONE 10MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026329","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.11","42.9","","384.74","384.74","384.74","1 through 10","167","428.28","percent of total billed charges",""
"CAP BONE 10MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026329","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","WELLPOINT [1015]","HB AMC WELLPOINT","397.47","73.78","","286.63","119.22","1107.45","105","167","428.28","percent of total billed charges",""
"CAP BONE 10MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","AETNA [1001]","HB AMC AETNA HMO","376.03","69.8","","675.31","184.75","1721.50","286","281.54","440.24","percent of total billed charges",""
"CAP BONE 10MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","AETNA [1001]","HB AMC AETNA PPO","433.13","80.4","","1261.44","103.12","1514.10","21","281.54","440.24","percent of total billed charges",""
"CAP BONE 10MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","433.13","80.4","","1365.00","1365.00","1365.00","1 through 10","281.54","440.24","percent of total billed charges",""
"CAP BONE 10MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","440.24","81.72","","5157.68","5157.68","5157.68","1 through 10","281.54","440.24","percent of total billed charges",""
"CAP BONE 10MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","440.24","81.72","","431.26","71.26","1459.57","88","281.54","440.24","percent of total billed charges",""
"CAP BONE 15MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026330","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","428.28","79.5","","800.18","480.96","1887.97","195","167","428.28","percent of total billed charges",""
"CAP BONE 15MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026330","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","287.14","53.3","","813.12","216.42","1444.50","81","167","428.28","percent of total billed charges",""
"CAP BONE 15MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026330","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","167.00","31","","432.60","432.60","432.60","1 through 10","167","428.28","percent of total billed charges",""
"CAP BONE 15MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026330","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","196.63","36.5","","148.37","54.89","631.39","94","167","428.28","percent of total billed charges",""
"CAP BONE 15MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026330","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","206.33","38.3","","279.30","91.72","1116.77","266","167","428.28","percent of total billed charges",""
"CAP BONE 15MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026330","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.11","42.9","","731.00","63.70","731.00","1 through 10","167","428.28","percent of total billed charges",""
"CAP BONE 15MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026330","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.11","42.9","","384.74","384.74","384.74","1 through 10","167","428.28","percent of total billed charges",""
"CAP BONE 15MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026330","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","WELLPOINT [1015]","HB AMC WELLPOINT","397.47","73.78","","286.63","119.22","1107.45","105","167","428.28","percent of total billed charges",""
"CAP BONE 15MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","AETNA [1001]","HB AMC AETNA HMO","376.03","69.8","","675.31","184.75","1721.50","286","281.54","440.24","percent of total billed charges",""
"CAP BONE 15MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","AETNA [1001]","HB AMC AETNA PPO","433.13","80.4","","1261.44","103.12","1514.10","21","281.54","440.24","percent of total billed charges",""
"CAP BONE 15MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","433.13","80.4","","1365.00","1365.00","1365.00","1 through 10","281.54","440.24","percent of total billed charges",""
"CAP BONE 15MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","440.24","81.72","","5157.68","5157.68","5157.68","1 through 10","281.54","440.24","percent of total billed charges",""
"CAP BONE 15MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10026330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","440.24","81.72","","431.26","71.26","1459.57","88","281.54","440.24","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11.73","79.5","","800.18","480.96","1887.97","195","4.58","11.73","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7.87","53.3","","813.12","216.42","1444.50","81","4.58","11.73","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4.58","31","","432.60","432.60","432.60","1 through 10","4.58","11.73","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5.39","36.5","","148.37","54.89","631.39","94","4.58","11.73","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5.65","38.3","","279.30","91.72","1116.77","266","4.58","11.73","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.33","42.9","","731.00","63.70","731.00","1 through 10","4.58","11.73","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.33","42.9","","384.74","384.74","384.74","1 through 10","4.58","11.73","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","WELLPOINT [1015]","HB AMC WELLPOINT","10.89","73.78","","286.63","119.22","1107.45","105","4.58","11.73","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.76","11.07","AETNA [1001]","HB AMC AETNA HMO","10.30","69.8","","675.31","184.75","1721.50","286","7.71","12.06","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.76","11.07","AETNA [1001]","HB AMC AETNA PPO","11.87","80.4","","1261.44","103.12","1514.10","21","7.71","12.06","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.76","11.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11.87","80.4","","1365.00","1365.00","1365.00","1 through 10","7.71","12.06","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.76","11.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","12.06","81.72","","5157.68","5157.68","5157.68","1 through 10","7.71","12.06","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.76","11.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12.06","81.72","","431.26","71.26","1459.57","88","7.71","12.06","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11.73","79.5","","800.18","480.96","1887.97","195","4.58","11.73","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7.87","53.3","","813.12","216.42","1444.50","81","4.58","11.73","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4.58","31","","432.60","432.60","432.60","1 through 10","4.58","11.73","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5.39","36.5","","148.37","54.89","631.39","94","4.58","11.73","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5.65","38.3","","279.30","91.72","1116.77","266","4.58","11.73","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.33","42.9","","731.00","63.70","731.00","1 through 10","4.58","11.73","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.33","42.9","","384.74","384.74","384.74","1 through 10","4.58","11.73","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.76","11.07","WELLPOINT [1015]","HB AMC WELLPOINT","10.89","73.78","","286.63","119.22","1107.45","105","4.58","11.73","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.76","11.07","AETNA [1001]","HB AMC AETNA HMO","10.30","69.8","","675.31","184.75","1721.50","286","7.71","12.06","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.76","11.07","AETNA [1001]","HB AMC AETNA PPO","11.87","80.4","","1261.44","103.12","1514.10","21","7.71","12.06","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.76","11.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11.87","80.4","","1365.00","1365.00","1365.00","1 through 10","7.71","12.06","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.76","11.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","12.06","81.72","","5157.68","5157.68","5157.68","1 through 10","7.71","12.06","percent of total billed charges",""
"CAP BONE 4MM PROTECTIVE EXTERNAL FIXATION FOR TUBE AND CARBON FIBER ROD BX/10EA","SUP-ITM-10004566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.76","11.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12.06","81.72","","431.26","71.26","1459.57","88","7.71","12.06","percent of total billed charges",""
"CAP BONE 5MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10012089","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","428.28","79.5","","800.18","480.96","1887.97","195","167","428.28","percent of total billed charges",""
"CAP BONE 5MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10012089","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","287.14","53.3","","813.12","216.42","1444.50","81","167","428.28","percent of total billed charges",""
"CAP BONE 5MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10012089","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","167.00","31","","432.60","432.60","432.60","1 through 10","167","428.28","percent of total billed charges",""
"CAP BONE 5MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10012089","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","196.63","36.5","","148.37","54.89","631.39","94","167","428.28","percent of total billed charges",""
"CAP BONE 5MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10012089","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","206.33","38.3","","279.30","91.72","1116.77","266","167","428.28","percent of total billed charges",""
"CAP BONE 5MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10012089","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.11","42.9","","731.00","63.70","731.00","1 through 10","167","428.28","percent of total billed charges",""
"CAP BONE 5MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10012089","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.11","42.9","","384.74","384.74","384.74","1 through 10","167","428.28","percent of total billed charges",""
"CAP BONE 5MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10012089","CDM","C1713","HCPCS","0278","RC","","","","both","","","538.72","404.04","WELLPOINT [1015]","HB AMC WELLPOINT","397.47","73.78","","286.63","119.22","1107.45","105","167","428.28","percent of total billed charges",""
"CAP BONE 5MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10012089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","AETNA [1001]","HB AMC AETNA HMO","376.03","69.8","","675.31","184.75","1721.50","286","281.54","440.24","percent of total billed charges",""
"CAP BONE 5MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10012089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","AETNA [1001]","HB AMC AETNA PPO","433.13","80.4","","1261.44","103.12","1514.10","21","281.54","440.24","percent of total billed charges",""
"CAP BONE 5MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10012089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","433.13","80.4","","1365.00","1365.00","1365.00","1 through 10","281.54","440.24","percent of total billed charges",""
"CAP BONE 5MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10012089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","440.24","81.72","","5157.68","5157.68","5157.68","1 through 10","281.54","440.24","percent of total billed charges",""
"CAP BONE 5MM END NAIL HUMERAL EXTENSION SPIRAL BLADE TI","SUP-ITM-10012089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","538.72","404.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","440.24","81.72","","431.26","71.26","1459.57","88","281.54","440.24","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","both","","","3542.00","2656.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1851.05","52.26","","1113.10","1113.10","1113.10","1 through 10","1098.02","2815.89","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","both","","","3542.00","2656.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2815.89","79.5","","1293.60","1148.53","1603.80","1 through 10","1098.02","2815.89","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","both","","","3542.00","2656.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1292.83","36.5","","1023.42","771.29","2068.67","33","1098.02","2815.89","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","both","","","3542.00","2656.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1356.59","38.3","","850.52","759.78","1211.25","66","1098.02","2815.89","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","both","","","3542.00","2656.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1519.52","42.9","","2548.09","2548.09","2548.09","1 through 10","1098.02","2815.89","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","both","","","3542.00","2656.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1519.52","42.9","","956.46","956.46","956.46","1 through 10","1098.02","2815.89","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","both","","","3542.00","2656.50","WELLPOINT [1015]","HB AMC WELLPOINT","2613.29","73.78","","2344.73","1619.47","2530.35","16","1098.02","2815.89","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3542.00","2656.50","AETNA [1001]","HB AMC AETNA HMO","2472.32","69.8","","1523.63","988.41","4330.26","39","1851.05","2894.52","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3542.00","2656.50","AETNA [1001]","HB AMC AETNA PPO","2847.77","80.4","","1670.25","1670.25","1670.25","1 through 10","1851.05","2894.52","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3542.00","2656.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1851.05","52.26","","1113.10","1113.10","1113.10","1 through 10","1851.05","2894.52","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3542.00","2656.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2894.52","81.72","","1738.90","1484.65","2716.94","38","1851.05","2894.52","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","541.53","79.5","","800.18","480.96","1887.97","195","211.16","541.53","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","363.06","53.3","","813.12","216.42","1444.50","81","211.16","541.53","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","211.16","31","","432.60","432.60","432.60","1 through 10","211.16","541.53","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","248.63","36.5","","148.37","54.89","631.39","94","211.16","541.53","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","260.89","38.3","","279.30","91.72","1116.77","266","211.16","541.53","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.22","42.9","","731.00","63.70","731.00","1 through 10","211.16","541.53","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.22","42.9","","384.74","384.74","384.74","1 through 10","211.16","541.53","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","WELLPOINT [1015]","HB AMC WELLPOINT","502.57","73.78","","286.63","119.22","1107.45","105","211.16","541.53","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.17","510.88","AETNA [1001]","HB AMC AETNA HMO","475.46","69.8","","675.31","184.75","1721.50","286","355.98","556.65","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.17","510.88","AETNA [1001]","HB AMC AETNA PPO","547.66","80.4","","1261.44","103.12","1514.10","21","355.98","556.65","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.17","510.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","547.66","80.4","","1365.00","1365.00","1365.00","1 through 10","355.98","556.65","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.17","510.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","556.65","81.72","","5157.68","5157.68","5157.68","1 through 10","355.98","556.65","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.17","510.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","556.65","81.72","","431.26","71.26","1459.57","88","355.98","556.65","percent of total billed charges",""
"CAP END 0MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296084","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","491.76","79.5","","800.18","480.96","1887.97","195","191.75","491.76","percent of total billed charges",""
"CAP END 0MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296084","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","329.69","53.3","","813.12","216.42","1444.50","81","191.75","491.76","percent of total billed charges",""
"CAP END 0MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296084","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","191.75","31","","432.60","432.60","432.60","1 through 10","191.75","491.76","percent of total billed charges",""
"CAP END 0MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296084","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","225.77","36.5","","148.37","54.89","631.39","94","191.75","491.76","percent of total billed charges",""
"CAP END 0MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296084","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","236.91","38.3","","279.30","91.72","1116.77","266","191.75","491.76","percent of total billed charges",""
"CAP END 0MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296084","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.36","42.9","","731.00","63.70","731.00","1 through 10","191.75","491.76","percent of total billed charges",""
"CAP END 0MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296084","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.36","42.9","","384.74","384.74","384.74","1 through 10","191.75","491.76","percent of total billed charges",""
"CAP END 0MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296084","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","WELLPOINT [1015]","HB AMC WELLPOINT","456.37","73.78","","286.63","119.22","1107.45","105","191.75","491.76","percent of total billed charges",""
"CAP END 0MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","AETNA [1001]","HB AMC AETNA HMO","431.75","69.8","","675.31","184.75","1721.50","286","323.26","505.49","percent of total billed charges",""
"CAP END 0MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","AETNA [1001]","HB AMC AETNA PPO","497.32","80.4","","1261.44","103.12","1514.10","21","323.26","505.49","percent of total billed charges",""
"CAP END 0MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","497.32","80.4","","1365.00","1365.00","1365.00","1 through 10","323.26","505.49","percent of total billed charges",""
"CAP END 0MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","505.49","81.72","","5157.68","5157.68","5157.68","1 through 10","323.26","505.49","percent of total billed charges",""
"CAP END 0MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","505.49","81.72","","431.26","71.26","1459.57","88","323.26","505.49","percent of total billed charges",""
"CAP END 10MM FEMORAL NAIL TITANIUM EXTENSION T40 STARDRIVE RECESS","SUP-ITM-10095904","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.99","312.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","331.51","79.5","","800.18","480.96","1887.97","195","129.27","331.51","percent of total billed charges",""
"CAP END 10MM FEMORAL NAIL TITANIUM EXTENSION T40 STARDRIVE RECESS","SUP-ITM-10095904","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.99","312.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","222.26","53.3","","813.12","216.42","1444.50","81","129.27","331.51","percent of total billed charges",""
"CAP END 10MM FEMORAL NAIL TITANIUM EXTENSION T40 STARDRIVE RECESS","SUP-ITM-10095904","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.99","312.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","129.27","31","","432.60","432.60","432.60","1 through 10","129.27","331.51","percent of total billed charges",""
"CAP END 10MM FEMORAL NAIL TITANIUM EXTENSION T40 STARDRIVE RECESS","SUP-ITM-10095904","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.99","312.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","152.20","36.5","","148.37","54.89","631.39","94","129.27","331.51","percent of total billed charges",""
"CAP END 10MM FEMORAL NAIL TITANIUM EXTENSION T40 STARDRIVE RECESS","SUP-ITM-10095904","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.99","312.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","159.71","38.3","","279.30","91.72","1116.77","266","129.27","331.51","percent of total billed charges",""
"CAP END 10MM FEMORAL NAIL TITANIUM EXTENSION T40 STARDRIVE RECESS","SUP-ITM-10095904","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.99","312.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.89","42.9","","731.00","63.70","731.00","1 through 10","129.27","331.51","percent of total billed charges",""
"CAP END 10MM FEMORAL NAIL TITANIUM EXTENSION T40 STARDRIVE RECESS","SUP-ITM-10095904","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.99","312.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.89","42.9","","384.74","384.74","384.74","1 through 10","129.27","331.51","percent of total billed charges",""
"CAP END 10MM FEMORAL NAIL TITANIUM EXTENSION T40 STARDRIVE RECESS","SUP-ITM-10095904","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.99","312.74","WELLPOINT [1015]","HB AMC WELLPOINT","307.66","73.78","","286.63","119.22","1107.45","105","129.27","331.51","percent of total billed charges",""
"CAP END 10MM FEMORAL NAIL TITANIUM EXTENSION T40 STARDRIVE RECESS","SUP-ITM-10095904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.99","312.74","AETNA [1001]","HB AMC AETNA HMO","291.06","69.8","","675.31","184.75","1721.50","286","217.92","340.76","percent of total billed charges",""
"CAP END 10MM FEMORAL NAIL TITANIUM EXTENSION T40 STARDRIVE RECESS","SUP-ITM-10095904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.99","312.74","AETNA [1001]","HB AMC AETNA PPO","335.26","80.4","","1261.44","103.12","1514.10","21","217.92","340.76","percent of total billed charges",""
"CAP END 10MM FEMORAL NAIL TITANIUM EXTENSION T40 STARDRIVE RECESS","SUP-ITM-10095904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.99","312.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","335.26","80.4","","1365.00","1365.00","1365.00","1 through 10","217.92","340.76","percent of total billed charges",""
"CAP END 10MM FEMORAL NAIL TITANIUM EXTENSION T40 STARDRIVE RECESS","SUP-ITM-10095904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.99","312.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","340.76","81.72","","5157.68","5157.68","5157.68","1 through 10","217.92","340.76","percent of total billed charges",""
"CAP END 10MM FEMORAL NAIL TITANIUM EXTENSION T40 STARDRIVE RECESS","SUP-ITM-10095904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.99","312.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","340.76","81.72","","431.26","71.26","1459.57","88","217.92","340.76","percent of total billed charges",""
"CAP END 10MM TNA COMPATIBLE","SUP-ITM-10310938","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","491.76","79.5","","800.18","480.96","1887.97","195","191.75","491.76","percent of total billed charges",""
"CAP END 10MM TNA COMPATIBLE","SUP-ITM-10310938","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","329.69","53.3","","813.12","216.42","1444.50","81","191.75","491.76","percent of total billed charges",""
"CAP END 10MM TNA COMPATIBLE","SUP-ITM-10310938","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","191.75","31","","432.60","432.60","432.60","1 through 10","191.75","491.76","percent of total billed charges",""
"CAP END 10MM TNA COMPATIBLE","SUP-ITM-10310938","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","225.77","36.5","","148.37","54.89","631.39","94","191.75","491.76","percent of total billed charges",""
"CAP END 10MM TNA COMPATIBLE","SUP-ITM-10310938","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","236.91","38.3","","279.30","91.72","1116.77","266","191.75","491.76","percent of total billed charges",""
"CAP END 10MM TNA COMPATIBLE","SUP-ITM-10310938","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.36","42.9","","731.00","63.70","731.00","1 through 10","191.75","491.76","percent of total billed charges",""
"CAP END 10MM TNA COMPATIBLE","SUP-ITM-10310938","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.36","42.9","","384.74","384.74","384.74","1 through 10","191.75","491.76","percent of total billed charges",""
"CAP END 10MM TNA COMPATIBLE","SUP-ITM-10310938","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","WELLPOINT [1015]","HB AMC WELLPOINT","456.37","73.78","","286.63","119.22","1107.45","105","191.75","491.76","percent of total billed charges",""
"CAP END 10MM TNA COMPATIBLE","SUP-ITM-10310938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","AETNA [1001]","HB AMC AETNA HMO","431.75","69.8","","675.31","184.75","1721.50","286","323.26","505.49","percent of total billed charges",""
"CAP END 10MM TNA COMPATIBLE","SUP-ITM-10310938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","AETNA [1001]","HB AMC AETNA PPO","497.32","80.4","","1261.44","103.12","1514.10","21","323.26","505.49","percent of total billed charges",""
"CAP END 10MM TNA COMPATIBLE","SUP-ITM-10310938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","497.32","80.4","","1365.00","1365.00","1365.00","1 through 10","323.26","505.49","percent of total billed charges",""
"CAP END 10MM TNA COMPATIBLE","SUP-ITM-10310938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","505.49","81.72","","5157.68","5157.68","5157.68","1 through 10","323.26","505.49","percent of total billed charges",""
"CAP END 10MM TNA COMPATIBLE","SUP-ITM-10310938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","505.49","81.72","","431.26","71.26","1459.57","88","323.26","505.49","percent of total billed charges",""
"CAP END 11.5MM 5 NAIL T2 TITANIUM TIBIA PLUS","SUP-ITM-10023094","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","798.35","79.5","","800.18","480.96","1887.97","195","311.31","798.35","percent of total billed charges",""
"CAP END 11.5MM 5 NAIL T2 TITANIUM TIBIA PLUS","SUP-ITM-10023094","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","535.25","53.3","","813.12","216.42","1444.50","81","311.31","798.35","percent of total billed charges",""
"CAP END 11.5MM 5 NAIL T2 TITANIUM TIBIA PLUS","SUP-ITM-10023094","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","311.31","31","","432.60","432.60","432.60","1 through 10","311.31","798.35","percent of total billed charges",""
"CAP END 11.5MM 5 NAIL T2 TITANIUM TIBIA PLUS","SUP-ITM-10023094","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","366.54","36.5","","148.37","54.89","631.39","94","311.31","798.35","percent of total billed charges",""
"CAP END 11.5MM 5 NAIL T2 TITANIUM TIBIA PLUS","SUP-ITM-10023094","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","384.62","38.3","","279.30","91.72","1116.77","266","311.31","798.35","percent of total billed charges",""
"CAP END 11.5MM 5 NAIL T2 TITANIUM TIBIA PLUS","SUP-ITM-10023094","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","430.81","42.9","","731.00","63.70","731.00","1 through 10","311.31","798.35","percent of total billed charges",""
"CAP END 11.5MM 5 NAIL T2 TITANIUM TIBIA PLUS","SUP-ITM-10023094","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","430.81","42.9","","384.74","384.74","384.74","1 through 10","311.31","798.35","percent of total billed charges",""
"CAP END 11.5MM 5 NAIL T2 TITANIUM TIBIA PLUS","SUP-ITM-10023094","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","WELLPOINT [1015]","HB AMC WELLPOINT","740.91","73.78","","286.63","119.22","1107.45","105","311.31","798.35","percent of total billed charges",""
"CAP END 11.5MM 5 NAIL T2 TITANIUM TIBIA PLUS","SUP-ITM-10023094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.22","753.16","AETNA [1001]","HB AMC AETNA HMO","700.95","69.8","","675.31","184.75","1721.50","286","524.81","820.65","percent of total billed charges",""
"CAP END 11.5MM 5 NAIL T2 TITANIUM TIBIA PLUS","SUP-ITM-10023094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.22","753.16","AETNA [1001]","HB AMC AETNA PPO","807.39","80.4","","1261.44","103.12","1514.10","21","524.81","820.65","percent of total billed charges",""
"CAP END 11.5MM 5 NAIL T2 TITANIUM TIBIA PLUS","SUP-ITM-10023094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.22","753.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","807.39","80.4","","1365.00","1365.00","1365.00","1 through 10","524.81","820.65","percent of total billed charges",""
"CAP END 11.5MM 5 NAIL T2 TITANIUM TIBIA PLUS","SUP-ITM-10023094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.22","753.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","820.65","81.72","","5157.68","5157.68","5157.68","1 through 10","524.81","820.65","percent of total billed charges",""
"CAP END 11.5MM 5 NAIL T2 TITANIUM TIBIA PLUS","SUP-ITM-10023094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.22","753.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","820.65","81.72","","431.26","71.26","1459.57","88","524.81","820.65","percent of total billed charges",""
"CAP END 12MM HINDFOOT ARTHODESIS TITANIUM NAIL FX SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10026597","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.84","401.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","425.20","79.5","","800.18","480.96","1887.97","195","165.8","425.2","percent of total billed charges",""
"CAP END 12MM HINDFOOT ARTHODESIS TITANIUM NAIL FX SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10026597","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.84","401.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","285.07","53.3","","813.12","216.42","1444.50","81","165.8","425.2","percent of total billed charges",""
"CAP END 12MM HINDFOOT ARTHODESIS TITANIUM NAIL FX SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10026597","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.84","401.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","165.80","31","","432.60","432.60","432.60","1 through 10","165.8","425.2","percent of total billed charges",""
"CAP END 12MM HINDFOOT ARTHODESIS TITANIUM NAIL FX SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10026597","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.84","401.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","195.22","36.5","","148.37","54.89","631.39","94","165.8","425.2","percent of total billed charges",""
"CAP END 12MM HINDFOOT ARTHODESIS TITANIUM NAIL FX SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10026597","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.84","401.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","204.84","38.3","","279.30","91.72","1116.77","266","165.8","425.2","percent of total billed charges",""
"CAP END 12MM HINDFOOT ARTHODESIS TITANIUM NAIL FX SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10026597","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.84","401.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","229.45","42.9","","731.00","63.70","731.00","1 through 10","165.8","425.2","percent of total billed charges",""
"CAP END 12MM HINDFOOT ARTHODESIS TITANIUM NAIL FX SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10026597","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.84","401.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","229.45","42.9","","384.74","384.74","384.74","1 through 10","165.8","425.2","percent of total billed charges",""
"CAP END 12MM HINDFOOT ARTHODESIS TITANIUM NAIL FX SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10026597","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.84","401.13","WELLPOINT [1015]","HB AMC WELLPOINT","394.60","73.78","","286.63","119.22","1107.45","105","165.8","425.2","percent of total billed charges",""
"CAP END 12MM HINDFOOT ARTHODESIS TITANIUM NAIL FX SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10026597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.84","401.13","AETNA [1001]","HB AMC AETNA HMO","373.32","69.8","","675.31","184.75","1721.50","286","279.51","437.07","percent of total billed charges",""
"CAP END 12MM HINDFOOT ARTHODESIS TITANIUM NAIL FX SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10026597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.84","401.13","AETNA [1001]","HB AMC AETNA PPO","430.01","80.4","","1261.44","103.12","1514.10","21","279.51","437.07","percent of total billed charges",""
"CAP END 12MM HINDFOOT ARTHODESIS TITANIUM NAIL FX SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10026597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.84","401.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","430.01","80.4","","1365.00","1365.00","1365.00","1 through 10","279.51","437.07","percent of total billed charges",""
"CAP END 12MM HINDFOOT ARTHODESIS TITANIUM NAIL FX SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10026597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.84","401.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","437.07","81.72","","5157.68","5157.68","5157.68","1 through 10","279.51","437.07","percent of total billed charges",""
"CAP END 12MM HINDFOOT ARTHODESIS TITANIUM NAIL FX SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10026597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.84","401.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","437.07","81.72","","431.26","71.26","1459.57","88","279.51","437.07","percent of total billed charges",""
"CAP END 3-4MM TI FOR TI ELASTIC NAIL","SUP-ITM-10040836","CDM","C1713","HCPCS","0278","RC","","","","both","","","218.86","164.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","173.99","79.5","","800.18","480.96","1887.97","195","67.85","173.99","percent of total billed charges",""
"CAP END 3-4MM TI FOR TI ELASTIC NAIL","SUP-ITM-10040836","CDM","C1713","HCPCS","0278","RC","","","","both","","","218.86","164.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","116.65","53.3","","813.12","216.42","1444.50","81","67.85","173.99","percent of total billed charges",""
"CAP END 3-4MM TI FOR TI ELASTIC NAIL","SUP-ITM-10040836","CDM","C1713","HCPCS","0278","RC","","","","both","","","218.86","164.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","67.85","31","","432.60","432.60","432.60","1 through 10","67.85","173.99","percent of total billed charges",""
"CAP END 3-4MM TI FOR TI ELASTIC NAIL","SUP-ITM-10040836","CDM","C1713","HCPCS","0278","RC","","","","both","","","218.86","164.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","79.88","36.5","","148.37","54.89","631.39","94","67.85","173.99","percent of total billed charges",""
"CAP END 3-4MM TI FOR TI ELASTIC NAIL","SUP-ITM-10040836","CDM","C1713","HCPCS","0278","RC","","","","both","","","218.86","164.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","83.82","38.3","","279.30","91.72","1116.77","266","67.85","173.99","percent of total billed charges",""
"CAP END 3-4MM TI FOR TI ELASTIC NAIL","SUP-ITM-10040836","CDM","C1713","HCPCS","0278","RC","","","","both","","","218.86","164.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.89","42.9","","731.00","63.70","731.00","1 through 10","67.85","173.99","percent of total billed charges",""
"CAP END 3-4MM TI FOR TI ELASTIC NAIL","SUP-ITM-10040836","CDM","C1713","HCPCS","0278","RC","","","","both","","","218.86","164.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.89","42.9","","384.74","384.74","384.74","1 through 10","67.85","173.99","percent of total billed charges",""
"CAP END 3-4MM TI FOR TI ELASTIC NAIL","SUP-ITM-10040836","CDM","C1713","HCPCS","0278","RC","","","","both","","","218.86","164.14","WELLPOINT [1015]","HB AMC WELLPOINT","161.47","73.78","","286.63","119.22","1107.45","105","67.85","173.99","percent of total billed charges",""
"CAP END 3-4MM TI FOR TI ELASTIC NAIL","SUP-ITM-10040836","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","218.86","164.14","AETNA [1001]","HB AMC AETNA HMO","152.76","69.8","","675.31","184.75","1721.50","286","114.38","178.85","percent of total billed charges",""
"CAP END 3-4MM TI FOR TI ELASTIC NAIL","SUP-ITM-10040836","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","218.86","164.14","AETNA [1001]","HB AMC AETNA PPO","175.96","80.4","","1261.44","103.12","1514.10","21","114.38","178.85","percent of total billed charges",""
"CAP END 3-4MM TI FOR TI ELASTIC NAIL","SUP-ITM-10040836","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","218.86","164.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","175.96","80.4","","1365.00","1365.00","1365.00","1 through 10","114.38","178.85","percent of total billed charges",""
"CAP END 3-4MM TI FOR TI ELASTIC NAIL","SUP-ITM-10040836","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","218.86","164.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","178.85","81.72","","5157.68","5157.68","5157.68","1 through 10","114.38","178.85","percent of total billed charges",""
"CAP END 3-4MM TI FOR TI ELASTIC NAIL","SUP-ITM-10040836","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","218.86","164.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","178.85","81.72","","431.26","71.26","1459.57","88","114.38","178.85","percent of total billed charges",""
"CAP END 5MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296083","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","491.76","79.5","","800.18","480.96","1887.97","195","191.75","491.76","percent of total billed charges",""
"CAP END 5MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296083","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","329.69","53.3","","813.12","216.42","1444.50","81","191.75","491.76","percent of total billed charges",""
"CAP END 5MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296083","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","191.75","31","","432.60","432.60","432.60","1 through 10","191.75","491.76","percent of total billed charges",""
"CAP END 5MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296083","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","225.77","36.5","","148.37","54.89","631.39","94","191.75","491.76","percent of total billed charges",""
"CAP END 5MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296083","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","236.91","38.3","","279.30","91.72","1116.77","266","191.75","491.76","percent of total billed charges",""
"CAP END 5MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296083","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.36","42.9","","731.00","63.70","731.00","1 through 10","191.75","491.76","percent of total billed charges",""
"CAP END 5MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296083","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.36","42.9","","384.74","384.74","384.74","1 through 10","191.75","491.76","percent of total billed charges",""
"CAP END 5MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296083","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.56","463.92","WELLPOINT [1015]","HB AMC WELLPOINT","456.37","73.78","","286.63","119.22","1107.45","105","191.75","491.76","percent of total billed charges",""
"CAP END 5MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","AETNA [1001]","HB AMC AETNA HMO","431.75","69.8","","675.31","184.75","1721.50","286","323.26","505.49","percent of total billed charges",""
"CAP END 5MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","AETNA [1001]","HB AMC AETNA PPO","497.32","80.4","","1261.44","103.12","1514.10","21","323.26","505.49","percent of total billed charges",""
"CAP END 5MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","497.32","80.4","","1365.00","1365.00","1365.00","1 through 10","323.26","505.49","percent of total billed charges",""
"CAP END 5MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","505.49","81.72","","5157.68","5157.68","5157.68","1 through 10","323.26","505.49","percent of total billed charges",""
"CAP END 5MM NAIL FEMORAL RETROGRADE","SUP-ITM-10296083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.56","463.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","505.49","81.72","","431.26","71.26","1459.57","88","323.26","505.49","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","451.97","79.5","","800.18","480.96","1887.97","195","176.24","451.97","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","303.02","53.3","","813.12","216.42","1444.50","81","176.24","451.97","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","176.24","31","","432.60","432.60","432.60","1 through 10","176.24","451.97","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","207.51","36.5","","148.37","54.89","631.39","94","176.24","451.97","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","217.74","38.3","","279.30","91.72","1116.77","266","176.24","451.97","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","243.89","42.9","","731.00","63.70","731.00","1 through 10","176.24","451.97","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","243.89","42.9","","384.74","384.74","384.74","1 through 10","176.24","451.97","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","WELLPOINT [1015]","HB AMC WELLPOINT","419.45","73.78","","286.63","119.22","1107.45","105","176.24","451.97","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.51","426.38","AETNA [1001]","HB AMC AETNA HMO","396.82","69.8","","675.31","184.75","1721.50","286","297.1","464.59","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.51","426.38","AETNA [1001]","HB AMC AETNA PPO","457.08","80.4","","1261.44","103.12","1514.10","21","297.1","464.59","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.51","426.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","457.08","80.4","","1365.00","1365.00","1365.00","1 through 10","297.1","464.59","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.51","426.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","464.59","81.72","","5157.68","5157.68","5157.68","1 through 10","297.1","464.59","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.51","426.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","464.59","81.72","","431.26","71.26","1459.57","88","297.1","464.59","percent of total billed charges",""
"CAP FOR 3 PC INDEX CS 1 ALTO AORTIC BODY IX LIMB EXTENSION","SUP-ITM-10273828","CDM","C1874","HCPCS","0278","RC","","","","both","","","42747.50","32060.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","27785.88","65","","6652.80","6652.80","6652.80","1 through 10","13251.73","33984.26","percent of total billed charges",""
"CAP FOR 3 PC INDEX CS 1 ALTO AORTIC BODY IX LIMB EXTENSION","SUP-ITM-10273828","CDM","C1874","HCPCS","0278","RC","","","","both","","","42747.50","32060.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33984.26","79.5","","2612.61","795.38","2612.61","1 through 10","13251.73","33984.26","percent of total billed charges",""
"CAP FOR 3 PC INDEX CS 1 ALTO AORTIC BODY IX LIMB EXTENSION","SUP-ITM-10273828","CDM","C1874","HCPCS","0278","RC","","","","both","","","42747.50","32060.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22784.42","53.3","","1101.80","1101.80","1101.80","1 through 10","13251.73","33984.26","percent of total billed charges",""
"CAP FOR 3 PC INDEX CS 1 ALTO AORTIC BODY IX LIMB EXTENSION","SUP-ITM-10273828","CDM","C1874","HCPCS","0278","RC","","","","both","","","42747.50","32060.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","27785.88","65","","1820.00","910.00","1820.00","1 through 10","13251.73","33984.26","percent of total billed charges",""
"CAP FOR 3 PC INDEX CS 1 ALTO AORTIC BODY IX LIMB EXTENSION","SUP-ITM-10273828","CDM","C1874","HCPCS","0278","RC","","","","both","","","42747.50","32060.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15602.84","36.5","","1257.80","693.44","2424.50","1 through 10","13251.73","33984.26","percent of total billed charges",""
"CAP FOR 3 PC INDEX CS 1 ALTO AORTIC BODY IX LIMB EXTENSION","SUP-ITM-10273828","CDM","C1874","HCPCS","0278","RC","","","","both","","","42747.50","32060.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16372.29","38.3","","1950.11","547.40","2346.00","1 through 10","13251.73","33984.26","percent of total billed charges",""
"CAP FOR 3 PC INDEX CS 1 ALTO AORTIC BODY IX LIMB EXTENSION","SUP-ITM-10273828","CDM","C1874","HCPCS","0278","RC","","","","both","","","42747.50","32060.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18338.68","42.9","","5096.18","5096.18","5096.18","1 through 10","13251.73","33984.26","percent of total billed charges",""
"CAP FOR 3 PC INDEX CS 1 ALTO AORTIC BODY IX LIMB EXTENSION","SUP-ITM-10273828","CDM","C1874","HCPCS","0278","RC","","","","both","","","42747.50","32060.62","WELLPOINT [1015]","HB AMC WELLPOINT","31539.11","73.78","","1172.59","1172.59","4829.94","1 through 10","13251.73","33984.26","percent of total billed charges",""
"CAP FOR 3 PC INDEX CS 1 ALTO AORTIC BODY IX LIMB EXTENSION","SUP-ITM-10273828","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42747.50","32060.62","AETNA [1001]","HB AMC AETNA HMO","29837.76","69.8","","1806.84","947.80","5091.72","1 through 10","22339.84","34933.26","percent of total billed charges",""
"CAP FOR 3 PC INDEX CS 1 ALTO AORTIC BODY IX LIMB EXTENSION","SUP-ITM-10273828","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42747.50","32060.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34933.26","81.72","","1259.05","615.58","4586.56","1 through 10","22339.84","34933.26","percent of total billed charges",""
"CAP LOCKING 8X3.5MM SCREW NCB TITANIUM ALLOY","SUP-ITM-10023069","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.04","418.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","443.64","79.5","","800.18","480.96","1887.97","195","172.99","443.64","percent of total billed charges",""
"CAP LOCKING 8X3.5MM SCREW NCB TITANIUM ALLOY","SUP-ITM-10023069","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.04","418.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","297.44","53.3","","813.12","216.42","1444.50","81","172.99","443.64","percent of total billed charges",""
"CAP LOCKING 8X3.5MM SCREW NCB TITANIUM ALLOY","SUP-ITM-10023069","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.04","418.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","172.99","31","","432.60","432.60","432.60","1 through 10","172.99","443.64","percent of total billed charges",""
"CAP LOCKING 8X3.5MM SCREW NCB TITANIUM ALLOY","SUP-ITM-10023069","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.04","418.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","203.68","36.5","","148.37","54.89","631.39","94","172.99","443.64","percent of total billed charges",""
"CAP LOCKING 8X3.5MM SCREW NCB TITANIUM ALLOY","SUP-ITM-10023069","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.04","418.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","213.73","38.3","","279.30","91.72","1116.77","266","172.99","443.64","percent of total billed charges",""
"CAP LOCKING 8X3.5MM SCREW NCB TITANIUM ALLOY","SUP-ITM-10023069","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.04","418.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.40","42.9","","731.00","63.70","731.00","1 through 10","172.99","443.64","percent of total billed charges",""
"CAP LOCKING 8X3.5MM SCREW NCB TITANIUM ALLOY","SUP-ITM-10023069","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.04","418.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.40","42.9","","384.74","384.74","384.74","1 through 10","172.99","443.64","percent of total billed charges",""
"CAP LOCKING 8X3.5MM SCREW NCB TITANIUM ALLOY","SUP-ITM-10023069","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.04","418.53","WELLPOINT [1015]","HB AMC WELLPOINT","411.72","73.78","","286.63","119.22","1107.45","105","172.99","443.64","percent of total billed charges",""
"CAP LOCKING 8X3.5MM SCREW NCB TITANIUM ALLOY","SUP-ITM-10023069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.04","418.53","AETNA [1001]","HB AMC AETNA HMO","389.51","69.8","","675.31","184.75","1721.50","286","291.63","456.03","percent of total billed charges",""
"CAP LOCKING 8X3.5MM SCREW NCB TITANIUM ALLOY","SUP-ITM-10023069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.04","418.53","AETNA [1001]","HB AMC AETNA PPO","448.66","80.4","","1261.44","103.12","1514.10","21","291.63","456.03","percent of total billed charges",""
"CAP LOCKING 8X3.5MM SCREW NCB TITANIUM ALLOY","SUP-ITM-10023069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.04","418.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","448.66","80.4","","1365.00","1365.00","1365.00","1 through 10","291.63","456.03","percent of total billed charges",""
"CAP LOCKING 8X3.5MM SCREW NCB TITANIUM ALLOY","SUP-ITM-10023069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.04","418.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","456.03","81.72","","5157.68","5157.68","5157.68","1 through 10","291.63","456.03","percent of total billed charges",""
"CAP LOCKING 8X3.5MM SCREW NCB TITANIUM ALLOY","SUP-ITM-10023069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.04","418.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","456.03","81.72","","431.26","71.26","1459.57","88","291.63","456.03","percent of total billed charges",""
"CAP NAIL 15MM TRIGEN TITANIUM TIBIAL END HEX BX/1EA","SUP-ITM-10016502","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1168.65","79.5","","800.18","480.96","1887.97","195","455.7","1168.65","percent of total billed charges",""
"CAP NAIL 15MM TRIGEN TITANIUM TIBIAL END HEX BX/1EA","SUP-ITM-10016502","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","783.51","53.3","","813.12","216.42","1444.50","81","455.7","1168.65","percent of total billed charges",""
"CAP NAIL 15MM TRIGEN TITANIUM TIBIAL END HEX BX/1EA","SUP-ITM-10016502","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","455.70","31","","432.60","432.60","432.60","1 through 10","455.7","1168.65","percent of total billed charges",""
"CAP NAIL 15MM TRIGEN TITANIUM TIBIAL END HEX BX/1EA","SUP-ITM-10016502","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","536.55","36.5","","148.37","54.89","631.39","94","455.7","1168.65","percent of total billed charges",""
"CAP NAIL 15MM TRIGEN TITANIUM TIBIAL END HEX BX/1EA","SUP-ITM-10016502","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","563.01","38.3","","279.30","91.72","1116.77","266","455.7","1168.65","percent of total billed charges",""
"CAP NAIL 15MM TRIGEN TITANIUM TIBIAL END HEX BX/1EA","SUP-ITM-10016502","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","731.00","63.70","731.00","1 through 10","455.7","1168.65","percent of total billed charges",""
"CAP NAIL 15MM TRIGEN TITANIUM TIBIAL END HEX BX/1EA","SUP-ITM-10016502","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","384.74","384.74","384.74","1 through 10","455.7","1168.65","percent of total billed charges",""
"CAP NAIL 15MM TRIGEN TITANIUM TIBIAL END HEX BX/1EA","SUP-ITM-10016502","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB AMC WELLPOINT","1084.57","73.78","","286.63","119.22","1107.45","105","455.7","1168.65","percent of total billed charges",""
"CAP NAIL 15MM TRIGEN TITANIUM TIBIAL END HEX BX/1EA","SUP-ITM-10016502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA HMO","1026.06","69.8","","675.31","184.75","1721.50","286","768.22","1201.28","percent of total billed charges",""
"CAP NAIL 15MM TRIGEN TITANIUM TIBIAL END HEX BX/1EA","SUP-ITM-10016502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA PPO","1181.88","80.4","","1261.44","103.12","1514.10","21","768.22","1201.28","percent of total billed charges",""
"CAP NAIL 15MM TRIGEN TITANIUM TIBIAL END HEX BX/1EA","SUP-ITM-10016502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1181.88","80.4","","1365.00","1365.00","1365.00","1 through 10","768.22","1201.28","percent of total billed charges",""
"CAP NAIL 15MM TRIGEN TITANIUM TIBIAL END HEX BX/1EA","SUP-ITM-10016502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1201.28","81.72","","5157.68","5157.68","5157.68","1 through 10","768.22","1201.28","percent of total billed charges",""
"CAP NAIL 15MM TRIGEN TITANIUM TIBIAL END HEX BX/1EA","SUP-ITM-10016502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1201.28","81.72","","431.26","71.26","1459.57","88","768.22","1201.28","percent of total billed charges",""
"CAP SPINAL 5.5MM CREO L2 TITANIUM ALLOY REVISION THREADED LOCKING","SUP-ITM-10140458","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","800.18","480.96","1887.97","195","48.83","125.21","percent of total billed charges",""
"CAP SPINAL 5.5MM CREO L2 TITANIUM ALLOY REVISION THREADED LOCKING","SUP-ITM-10140458","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","813.12","216.42","1444.50","81","48.83","125.21","percent of total billed charges",""
"CAP SPINAL 5.5MM CREO L2 TITANIUM ALLOY REVISION THREADED LOCKING","SUP-ITM-10140458","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.83","31","","432.60","432.60","432.60","1 through 10","48.83","125.21","percent of total billed charges",""
"CAP SPINAL 5.5MM CREO L2 TITANIUM ALLOY REVISION THREADED LOCKING","SUP-ITM-10140458","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","148.37","54.89","631.39","94","48.83","125.21","percent of total billed charges",""
"CAP SPINAL 5.5MM CREO L2 TITANIUM ALLOY REVISION THREADED LOCKING","SUP-ITM-10140458","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","279.30","91.72","1116.77","266","48.83","125.21","percent of total billed charges",""
"CAP SPINAL 5.5MM CREO L2 TITANIUM ALLOY REVISION THREADED LOCKING","SUP-ITM-10140458","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","731.00","63.70","731.00","1 through 10","48.83","125.21","percent of total billed charges",""
"CAP SPINAL 5.5MM CREO L2 TITANIUM ALLOY REVISION THREADED LOCKING","SUP-ITM-10140458","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","384.74","384.74","384.74","1 through 10","48.83","125.21","percent of total billed charges",""
"CAP SPINAL 5.5MM CREO L2 TITANIUM ALLOY REVISION THREADED LOCKING","SUP-ITM-10140458","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","286.63","119.22","1107.45","105","48.83","125.21","percent of total billed charges",""
"CAP SPINAL 5.5MM CREO L2 TITANIUM ALLOY REVISION THREADED LOCKING","SUP-ITM-10140458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","675.31","184.75","1721.50","286","82.31","128.71","percent of total billed charges",""
"CAP SPINAL 5.5MM CREO L2 TITANIUM ALLOY REVISION THREADED LOCKING","SUP-ITM-10140458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA PPO","126.63","80.4","","1261.44","103.12","1514.10","21","82.31","128.71","percent of total billed charges",""
"CAP SPINAL 5.5MM CREO L2 TITANIUM ALLOY REVISION THREADED LOCKING","SUP-ITM-10140458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","1365.00","1365.00","1365.00","1 through 10","82.31","128.71","percent of total billed charges",""
"CAP SPINAL 5.5MM CREO L2 TITANIUM ALLOY REVISION THREADED LOCKING","SUP-ITM-10140458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.71","81.72","","5157.68","5157.68","5157.68","1 through 10","82.31","128.71","percent of total billed charges",""
"CAP SPINAL 5.5MM CREO L2 TITANIUM ALLOY REVISION THREADED LOCKING","SUP-ITM-10140458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","431.26","71.26","1459.57","88","82.31","128.71","percent of total billed charges",""
"CAPITATION CASE AAA TREO","SUP-ITM-10282991","CDM","C1874","HCPCS","0278","RC","","","","both","","","41220.00","30915.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","26793.00","65","","6652.80","6652.80","6652.80","1 through 10","12778.2","32769.9","percent of total billed charges",""
"CAPITATION CASE AAA TREO","SUP-ITM-10282991","CDM","C1874","HCPCS","0278","RC","","","","both","","","41220.00","30915.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","32769.90","79.5","","2612.61","795.38","2612.61","1 through 10","12778.2","32769.9","percent of total billed charges",""
"CAPITATION CASE AAA TREO","SUP-ITM-10282991","CDM","C1874","HCPCS","0278","RC","","","","both","","","41220.00","30915.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","21970.26","53.3","","1101.80","1101.80","1101.80","1 through 10","12778.2","32769.9","percent of total billed charges",""
"CAPITATION CASE AAA TREO","SUP-ITM-10282991","CDM","C1874","HCPCS","0278","RC","","","","both","","","41220.00","30915.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","26793.00","65","","1820.00","910.00","1820.00","1 through 10","12778.2","32769.9","percent of total billed charges",""
"CAPITATION CASE AAA TREO","SUP-ITM-10282991","CDM","C1874","HCPCS","0278","RC","","","","both","","","41220.00","30915.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15045.30","36.5","","1257.80","693.44","2424.50","1 through 10","12778.2","32769.9","percent of total billed charges",""
"CAPITATION CASE AAA TREO","SUP-ITM-10282991","CDM","C1874","HCPCS","0278","RC","","","","both","","","41220.00","30915.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15787.26","38.3","","1950.11","547.40","2346.00","1 through 10","12778.2","32769.9","percent of total billed charges",""
"CAPITATION CASE AAA TREO","SUP-ITM-10282991","CDM","C1874","HCPCS","0278","RC","","","","both","","","41220.00","30915.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17683.38","42.9","","5096.18","5096.18","5096.18","1 through 10","12778.2","32769.9","percent of total billed charges",""
"CAPITATION CASE AAA TREO","SUP-ITM-10282991","CDM","C1874","HCPCS","0278","RC","","","","both","","","41220.00","30915.00","WELLPOINT [1015]","HB AMC WELLPOINT","30412.12","73.78","","1172.59","1172.59","4829.94","1 through 10","12778.2","32769.9","percent of total billed charges",""
"CAPITATION CASE AAA TREO","SUP-ITM-10282991","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","41220.00","30915.00","AETNA [1001]","HB AMC AETNA HMO","28771.56","69.8","","1806.84","947.80","5091.72","1 through 10","21541.57","33684.98","percent of total billed charges",""
"CAPITATION CASE AAA TREO","SUP-ITM-10282991","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","41220.00","30915.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","33684.98","81.72","","1259.05","615.58","4586.56","1 through 10","21541.57","33684.98","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 2 PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269179","CDM","C1874","HCPCS","0278","RC","","","","both","","","88437.50","66328.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","57484.38","65","","6652.80","6652.80","6652.80","1 through 10","27415.63","70307.81","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 2 PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269179","CDM","C1874","HCPCS","0278","RC","","","","both","","","88437.50","66328.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","70307.81","79.5","","2612.61","795.38","2612.61","1 through 10","27415.63","70307.81","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 2 PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269179","CDM","C1874","HCPCS","0278","RC","","","","both","","","88437.50","66328.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","47137.19","53.3","","1101.80","1101.80","1101.80","1 through 10","27415.63","70307.81","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 2 PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269179","CDM","C1874","HCPCS","0278","RC","","","","both","","","88437.50","66328.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","57484.38","65","","1820.00","910.00","1820.00","1 through 10","27415.63","70307.81","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 2 PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269179","CDM","C1874","HCPCS","0278","RC","","","","both","","","88437.50","66328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","32279.69","36.5","","1257.80","693.44","2424.50","1 through 10","27415.63","70307.81","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 2 PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269179","CDM","C1874","HCPCS","0278","RC","","","","both","","","88437.50","66328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33871.56","38.3","","1950.11","547.40","2346.00","1 through 10","27415.63","70307.81","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 2 PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269179","CDM","C1874","HCPCS","0278","RC","","","","both","","","88437.50","66328.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37939.69","42.9","","5096.18","5096.18","5096.18","1 through 10","27415.63","70307.81","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 2 PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269179","CDM","C1874","HCPCS","0278","RC","","","","both","","","88437.50","66328.12","WELLPOINT [1015]","HB AMC WELLPOINT","65249.19","73.78","","1172.59","1172.59","4829.94","1 through 10","27415.63","70307.81","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 2 PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269179","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","88437.50","66328.12","AETNA [1001]","HB AMC AETNA HMO","61729.38","69.8","","1806.84","947.80","5091.72","1 through 10","46217.44","72271.13","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 2 PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269179","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","88437.50","66328.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","72271.13","81.72","","1259.05","615.58","4586.56","1 through 10","46217.44","72271.13","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 3+ PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269178","CDM","C1874","HCPCS","0278","RC","","","","both","","","101250.00","75937.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","65812.50","65","","6652.80","6652.80","6652.80","1 through 10","31387.5","80493.75","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 3+ PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269178","CDM","C1874","HCPCS","0278","RC","","","","both","","","101250.00","75937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","80493.75","79.5","","2612.61","795.38","2612.61","1 through 10","31387.5","80493.75","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 3+ PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269178","CDM","C1874","HCPCS","0278","RC","","","","both","","","101250.00","75937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","53966.25","53.3","","1101.80","1101.80","1101.80","1 through 10","31387.5","80493.75","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 3+ PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269178","CDM","C1874","HCPCS","0278","RC","","","","both","","","101250.00","75937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","65812.50","65","","1820.00","910.00","1820.00","1 through 10","31387.5","80493.75","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 3+ PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269178","CDM","C1874","HCPCS","0278","RC","","","","both","","","101250.00","75937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36956.25","36.5","","1257.80","693.44","2424.50","1 through 10","31387.5","80493.75","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 3+ PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269178","CDM","C1874","HCPCS","0278","RC","","","","both","","","101250.00","75937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38778.75","38.3","","1950.11","547.40","2346.00","1 through 10","31387.5","80493.75","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 3+ PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269178","CDM","C1874","HCPCS","0278","RC","","","","both","","","101250.00","75937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43436.25","42.9","","5096.18","5096.18","5096.18","1 through 10","31387.5","80493.75","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 3+ PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269178","CDM","C1874","HCPCS","0278","RC","","","","both","","","101250.00","75937.50","WELLPOINT [1015]","HB AMC WELLPOINT","74702.25","73.78","","1172.59","1172.59","4829.94","1 through 10","31387.5","80493.75","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 3+ PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269178","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","101250.00","75937.50","AETNA [1001]","HB AMC AETNA HMO","70672.50","69.8","","1806.84","947.80","5091.72","1 through 10","52913.25","82741.5","percent of total billed charges",""
"CAPITATION GRAFT STENT TAG 3+ PIECE CASE ALL ACTIVE CONTROL","SUP-ITM-10269178","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","101250.00","75937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","82741.50","81.72","","1259.05","615.58","4586.56","1 through 10","52913.25","82741.5","percent of total billed charges",""
"CAPITATION STENT AAA 2 PIECE","SUP-ITM-10139420","CDM","C1874","HCPCS","0278","RC","","","","both","","","37612.50","28209.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","24448.13","65","","6652.80","6652.80","6652.80","1 through 10","11659.88","29901.94","percent of total billed charges",""
"CAPITATION STENT AAA 2 PIECE","SUP-ITM-10139420","CDM","C1874","HCPCS","0278","RC","","","","both","","","37612.50","28209.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","29901.94","79.5","","2612.61","795.38","2612.61","1 through 10","11659.88","29901.94","percent of total billed charges",""
"CAPITATION STENT AAA 2 PIECE","SUP-ITM-10139420","CDM","C1874","HCPCS","0278","RC","","","","both","","","37612.50","28209.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","20047.46","53.3","","1101.80","1101.80","1101.80","1 through 10","11659.88","29901.94","percent of total billed charges",""
"CAPITATION STENT AAA 2 PIECE","SUP-ITM-10139420","CDM","C1874","HCPCS","0278","RC","","","","both","","","37612.50","28209.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","24448.13","65","","1820.00","910.00","1820.00","1 through 10","11659.88","29901.94","percent of total billed charges",""
"CAPITATION STENT AAA 2 PIECE","SUP-ITM-10139420","CDM","C1874","HCPCS","0278","RC","","","","both","","","37612.50","28209.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13728.56","36.5","","1257.80","693.44","2424.50","1 through 10","11659.88","29901.94","percent of total billed charges",""
"CAPITATION STENT AAA 2 PIECE","SUP-ITM-10139420","CDM","C1874","HCPCS","0278","RC","","","","both","","","37612.50","28209.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14405.59","38.3","","1950.11","547.40","2346.00","1 through 10","11659.88","29901.94","percent of total billed charges",""
"CAPITATION STENT AAA 2 PIECE","SUP-ITM-10139420","CDM","C1874","HCPCS","0278","RC","","","","both","","","37612.50","28209.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16135.76","42.9","","5096.18","5096.18","5096.18","1 through 10","11659.88","29901.94","percent of total billed charges",""
"CAPITATION STENT AAA 2 PIECE","SUP-ITM-10139420","CDM","C1874","HCPCS","0278","RC","","","","both","","","37612.50","28209.37","WELLPOINT [1015]","HB AMC WELLPOINT","27750.50","73.78","","1172.59","1172.59","4829.94","1 through 10","11659.88","29901.94","percent of total billed charges",""
"CAPITATION STENT AAA 2 PIECE","SUP-ITM-10139420","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","37612.50","28209.37","AETNA [1001]","HB AMC AETNA HMO","26253.53","69.8","","1806.84","947.80","5091.72","1 through 10","19656.29","30736.94","percent of total billed charges",""
"CAPITATION STENT AAA 2 PIECE","SUP-ITM-10139420","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","37612.50","28209.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","30736.94","81.72","","1259.05","615.58","4586.56","1 through 10","19656.29","30736.94","percent of total billed charges",""
"CAPITATION STENT AAA 3 PIECE","SUP-ITM-10139421","CDM","C1874","HCPCS","0278","RC","","","","both","","","43222.50","32416.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","28094.63","65","","6652.80","6652.80","6652.80","1 through 10","13398.98","34361.89","percent of total billed charges",""
"CAPITATION STENT AAA 3 PIECE","SUP-ITM-10139421","CDM","C1874","HCPCS","0278","RC","","","","both","","","43222.50","32416.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","34361.89","79.5","","2612.61","795.38","2612.61","1 through 10","13398.98","34361.89","percent of total billed charges",""
"CAPITATION STENT AAA 3 PIECE","SUP-ITM-10139421","CDM","C1874","HCPCS","0278","RC","","","","both","","","43222.50","32416.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23037.59","53.3","","1101.80","1101.80","1101.80","1 through 10","13398.98","34361.89","percent of total billed charges",""
"CAPITATION STENT AAA 3 PIECE","SUP-ITM-10139421","CDM","C1874","HCPCS","0278","RC","","","","both","","","43222.50","32416.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","28094.63","65","","1820.00","910.00","1820.00","1 through 10","13398.98","34361.89","percent of total billed charges",""
"CAPITATION STENT AAA 3 PIECE","SUP-ITM-10139421","CDM","C1874","HCPCS","0278","RC","","","","both","","","43222.50","32416.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15776.21","36.5","","1257.80","693.44","2424.50","1 through 10","13398.98","34361.89","percent of total billed charges",""
"CAPITATION STENT AAA 3 PIECE","SUP-ITM-10139421","CDM","C1874","HCPCS","0278","RC","","","","both","","","43222.50","32416.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16554.22","38.3","","1950.11","547.40","2346.00","1 through 10","13398.98","34361.89","percent of total billed charges",""
"CAPITATION STENT AAA 3 PIECE","SUP-ITM-10139421","CDM","C1874","HCPCS","0278","RC","","","","both","","","43222.50","32416.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18542.45","42.9","","5096.18","5096.18","5096.18","1 through 10","13398.98","34361.89","percent of total billed charges",""
"CAPITATION STENT AAA 3 PIECE","SUP-ITM-10139421","CDM","C1874","HCPCS","0278","RC","","","","both","","","43222.50","32416.87","WELLPOINT [1015]","HB AMC WELLPOINT","31889.56","73.78","","1172.59","1172.59","4829.94","1 through 10","13398.98","34361.89","percent of total billed charges",""
"CAPITATION STENT AAA 3 PIECE","SUP-ITM-10139421","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","43222.50","32416.87","AETNA [1001]","HB AMC AETNA HMO","30169.31","69.8","","1806.84","947.80","5091.72","1 through 10","22588.08","35321.43","percent of total billed charges",""
"CAPITATION STENT AAA 3 PIECE","SUP-ITM-10139421","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","43222.50","32416.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","35321.43","81.72","","1259.05","615.58","4586.56","1 through 10","22588.08","35321.43","percent of total billed charges",""
"CAPITATION STENT AAA 4 PIECE","SUP-ITM-10139422","CDM","C1874","HCPCS","0278","RC","","","","both","","","48832.50","36624.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","31741.13","65","","6652.80","6652.80","6652.80","1 through 10","15138.08","38821.84","percent of total billed charges",""
"CAPITATION STENT AAA 4 PIECE","SUP-ITM-10139422","CDM","C1874","HCPCS","0278","RC","","","","both","","","48832.50","36624.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","38821.84","79.5","","2612.61","795.38","2612.61","1 through 10","15138.08","38821.84","percent of total billed charges",""
"CAPITATION STENT AAA 4 PIECE","SUP-ITM-10139422","CDM","C1874","HCPCS","0278","RC","","","","both","","","48832.50","36624.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","26027.72","53.3","","1101.80","1101.80","1101.80","1 through 10","15138.08","38821.84","percent of total billed charges",""
"CAPITATION STENT AAA 4 PIECE","SUP-ITM-10139422","CDM","C1874","HCPCS","0278","RC","","","","both","","","48832.50","36624.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","31741.13","65","","1820.00","910.00","1820.00","1 through 10","15138.08","38821.84","percent of total billed charges",""
"CAPITATION STENT AAA 4 PIECE","SUP-ITM-10139422","CDM","C1874","HCPCS","0278","RC","","","","both","","","48832.50","36624.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17823.86","36.5","","1257.80","693.44","2424.50","1 through 10","15138.08","38821.84","percent of total billed charges",""
"CAPITATION STENT AAA 4 PIECE","SUP-ITM-10139422","CDM","C1874","HCPCS","0278","RC","","","","both","","","48832.50","36624.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18702.85","38.3","","1950.11","547.40","2346.00","1 through 10","15138.08","38821.84","percent of total billed charges",""
"CAPITATION STENT AAA 4 PIECE","SUP-ITM-10139422","CDM","C1874","HCPCS","0278","RC","","","","both","","","48832.50","36624.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20949.14","42.9","","5096.18","5096.18","5096.18","1 through 10","15138.08","38821.84","percent of total billed charges",""
"CAPITATION STENT AAA 4 PIECE","SUP-ITM-10139422","CDM","C1874","HCPCS","0278","RC","","","","both","","","48832.50","36624.37","WELLPOINT [1015]","HB AMC WELLPOINT","36028.62","73.78","","1172.59","1172.59","4829.94","1 through 10","15138.08","38821.84","percent of total billed charges",""
"CAPITATION STENT AAA 4 PIECE","SUP-ITM-10139422","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","48832.50","36624.37","AETNA [1001]","HB AMC AETNA HMO","34085.09","69.8","","1806.84","947.80","5091.72","1 through 10","25519.86","39905.92","percent of total billed charges",""
"CAPITATION STENT AAA 4 PIECE","SUP-ITM-10139422","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","48832.50","36624.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","39905.92","81.72","","1259.05","615.58","4586.56","1 through 10","25519.86","39905.92","percent of total billed charges",""
"CAPITATION TERUMO MEDICAL TAA PER PROCEDURE CATH LAB","SUP-ITM-10216628","CDM","C1874","HCPCS","0278","RC","","","","both","","","68750.00","51562.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","44687.50","65","","6652.80","6652.80","6652.80","1 through 10","21312.5","54656.25","percent of total billed charges",""
"CAPITATION TERUMO MEDICAL TAA PER PROCEDURE CATH LAB","SUP-ITM-10216628","CDM","C1874","HCPCS","0278","RC","","","","both","","","68750.00","51562.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","54656.25","79.5","","2612.61","795.38","2612.61","1 through 10","21312.5","54656.25","percent of total billed charges",""
"CAPITATION TERUMO MEDICAL TAA PER PROCEDURE CATH LAB","SUP-ITM-10216628","CDM","C1874","HCPCS","0278","RC","","","","both","","","68750.00","51562.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","36643.75","53.3","","1101.80","1101.80","1101.80","1 through 10","21312.5","54656.25","percent of total billed charges",""
"CAPITATION TERUMO MEDICAL TAA PER PROCEDURE CATH LAB","SUP-ITM-10216628","CDM","C1874","HCPCS","0278","RC","","","","both","","","68750.00","51562.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","44687.50","65","","1820.00","910.00","1820.00","1 through 10","21312.5","54656.25","percent of total billed charges",""
"CAPITATION TERUMO MEDICAL TAA PER PROCEDURE CATH LAB","SUP-ITM-10216628","CDM","C1874","HCPCS","0278","RC","","","","both","","","68750.00","51562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25093.75","36.5","","1257.80","693.44","2424.50","1 through 10","21312.5","54656.25","percent of total billed charges",""
"CAPITATION TERUMO MEDICAL TAA PER PROCEDURE CATH LAB","SUP-ITM-10216628","CDM","C1874","HCPCS","0278","RC","","","","both","","","68750.00","51562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26331.25","38.3","","1950.11","547.40","2346.00","1 through 10","21312.5","54656.25","percent of total billed charges",""
"CAPITATION TERUMO MEDICAL TAA PER PROCEDURE CATH LAB","SUP-ITM-10216628","CDM","C1874","HCPCS","0278","RC","","","","both","","","68750.00","51562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","29493.75","42.9","","5096.18","5096.18","5096.18","1 through 10","21312.5","54656.25","percent of total billed charges",""
"CAPITATION TERUMO MEDICAL TAA PER PROCEDURE CATH LAB","SUP-ITM-10216628","CDM","C1874","HCPCS","0278","RC","","","","both","","","68750.00","51562.50","WELLPOINT [1015]","HB AMC WELLPOINT","50723.75","73.78","","1172.59","1172.59","4829.94","1 through 10","21312.5","54656.25","percent of total billed charges",""
"CAPITATION TERUMO MEDICAL TAA PER PROCEDURE CATH LAB","SUP-ITM-10216628","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","68750.00","51562.50","AETNA [1001]","HB AMC AETNA HMO","47987.50","69.8","","1806.84","947.80","5091.72","1 through 10","35928.75","56182.5","percent of total billed charges",""
"CAPITATION TERUMO MEDICAL TAA PER PROCEDURE CATH LAB","SUP-ITM-10216628","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","68750.00","51562.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","56182.50","81.72","","1259.05","615.58","4586.56","1 through 10","35928.75","56182.5","percent of total billed charges",""
"Car T Cell Infusion","PX-98301665","CDM","38999","CPT","0983","RC","","","","outpatient","","","841.00","630.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","439.17","52.22","","512.50","512.50","512.50","1 through 10","420.5","1234.13","percent of total billed charges",""
"Car T Cell Infusion","PX-98301665","CDM","38999","CPT","0983","RC","","","","outpatient","","","841.00","630.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","420.50","50","","6776.11","6776.11","6776.11","1 through 10","420.5","1234.13","percent of total billed charges",""
"Car-T Cryopreservation, Storage, Shipping","PX-36000429","CDM","38226","CPT","0362","RC","","","","both","","","1333.00","999.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","874.45","65.6","","875.36","875.36","875.36","1 through 10","413.23","1059.74","percent of total billed charges",""
"Car-T Cryopreservation, Storage, Shipping","PX-36000429","CDM","38226","CPT","0362","RC","","","","both","","","1333.00","999.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","933.10","70","","1017.59","532.20","1293.00","1 through 10","413.23","1059.74","percent of total billed charges",""
"Car-T Cryopreservation, Storage, Shipping","PX-36000429","CDM","38226","CPT","0362","RC","","","","both","","","1333.00","999.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1059.74","79.5","","840.45","840.45","840.45","1 through 10","413.23","1059.74","percent of total billed charges",""
"Car-T Cryopreservation, Storage, Shipping","PX-36000429","CDM","38226","CPT","0362","RC","","","","outpatient","","","1333.00","999.75","AETNA [1001]","HB AMC AETNA HMO","930.43","69.8","","1750.72","1750.72","1750.72","1 through 10","61.43","1099.73","percent of total billed charges",""
"Car-T Cryopreservation, Storage, Shipping","PX-36000429","CDM","38226","CPT","0362","RC","","","","outpatient","","","1333.00","999.75","AETNA [1001]","HB AMC AETNA PPO","1071.73","80.4","","2017.08","1008.54","2017.08","1 through 10","61.43","1099.73","percent of total billed charges",""
"Car-T Cryopreservation, Storage, Shipping","PX-36000429","CDM","38226","CPT","0362","RC","","","","outpatient","","","1333.00","999.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","61.43","","Case rate ($61.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","123.41","123.41","125.69","1 through 10","61.43","1099.73","other","ASC"
"Car-T Cryopreservation, Storage, Shipping","PX-36000429","CDM","38226","CPT","0362","RC","","","","outpatient","","","1333.00","999.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","61.43","","Case rate ($61.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","143.81","142.39","287.62","15","61.43","1099.73","other","ASC "
"Car-T Cryopreservation, Storage, Shipping","PX-36000429","CDM","38226","CPT","0362","RC","","","","outpatient","","","1333.00","999.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","666.50","50","","677.53","677.53","677.53","1 through 10","61.43","1099.73","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","both","","","191.00","143.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","151.85","79.5","","145.60","145.60","145.60","1 through 10","14.28","181.45","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","both","","","191.00","143.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","101.80","53.3","","145.60","97.68","145.60","1 through 10","14.28","181.45","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","both","","","191.00","143.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","59.21","31","","57.17","57.17","57.17","1 through 10","14.28","181.45","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","both","","","191.00","143.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","69.72","36.5","","58.65","58.65","58.65","1 through 10","14.28","181.45","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","both","","","191.00","143.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.15","38.3","","72.34","72.34","72.34","1 through 10","14.28","181.45","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","outpatient","","","191.00","143.25","AETNA [1001]","HB AMC AETNA HMO","133.32","69.8","","125.25","88.43","125.25","1 through 10","15.03","156.09","percent of total billed charges",""
"Carbon Monoxide (Co-Ox) Qn","PX-30000346","CDM","82375","CPT","0301","RC","","","","both","","","178.00","133.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","141.51","79.5","","198.08","136.15","198.08","46","12.07","169.1","percent of total billed charges",""
"Carbon Monoxide (Co-Ox) Qn","PX-30000346","CDM","82375","CPT","0301","RC","","","","both","","","178.00","133.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.17","38.3","","67.64","67.64","67.64","50","12.07","169.1","percent of total billed charges",""
"Carbon Monoxide (Co-Ox) Qn","PX-30000346","CDM","82375","CPT","0301","RC","","","","outpatient","","","178.00","133.50","AETNA [1001]","HB AMC AETNA HMO","124.24","69.8","","134.94","117.12","134.94","1 through 10","12.71","145.46","percent of total billed charges",""
"Carbon Monoxide (Co-Ox) Qn","PX-30000346","CDM","82375","CPT","0301","RC","","","","outpatient","","","178.00","133.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","145.46","81.72","","2081.05","2081.05","2081.05","1 through 10","12.71","145.46","percent of total billed charges",""
"Carbon Monoxide (Co-Ox) Qn","PX-30000346","CDM","82375","CPT","0301","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","145.46","81.72","","138.30","138.30","138.30","1 through 10","12.71","145.46","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","1122.00","841.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","736.03","65.6","","520.06","520.06","520.06","1 through 10","197.14","891.99","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","1122.00","841.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","785.40","70","","1088.00","848.64","1088.00","1 through 10","197.14","891.99","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","1122.00","841.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","891.99","79.5","","856.26","574.46","856.26","42","197.14","891.99","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","1122.00","841.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","598.03","53.3","","856.26","574.46","2822.30","32","197.14","891.99","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","1122.00","841.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","863.94","77","","2513.28","837.76","2513.28","1 through 10","197.14","891.99","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","1122.00","841.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","729.30","65","","576.64","576.64","576.64","1 through 10","197.14","891.99","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","1122.00","841.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","409.53","36.5","","405.82","344.90","787.72","40","197.14","891.99","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","1122.00","841.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","429.73","38.3","","425.41","425.41","425.41","103","197.14","891.99","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","1122.00","841.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","481.34","42.9","","478.39","478.39","478.39","1 through 10","197.14","891.99","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","1122.00","841.50","AETNA [1001]","HB AMC AETNA HMO","783.16","69.8","","736.58","593.77","736.58","1 through 10","586.36","916.9","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","1122.00","841.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","586.36","52.26","","673.25","673.25","673.25","1 through 10","586.36","916.9","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","1122.00","841.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","902.09","80.4","","544.00","544.00","544.00","1 through 10","586.36","916.9","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","1122.00","841.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","916.90","81.72","","478.39","478.39","478.39","1 through 10","586.36","916.9","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","1122.00","841.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","916.90","81.72","","869.75","478.39","869.75","41","586.36","916.9","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","both","","","227.00","170.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","180.47","79.5","","116.16","116.16","173.14","1 through 10","18.58","215.65","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","both","","","227.00","170.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","120.99","53.3","","173.14","116.16","173.14","1 through 10","18.58","215.65","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","both","","","227.00","170.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","82.86","36.5","","82.06","82.06","82.06","1 through 10","18.58","215.65","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","both","","","227.00","170.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","86.94","38.3","","86.02","86.02","86.02","14","18.58","215.65","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","outpatient","","","227.00","170.25","AETNA [1001]","HB AMC AETNA HMO","158.45","69.8","","148.94","105.16","171.60","16","19.56","185.5","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","outpatient","","","227.00","170.25","AETNA [1001]","HB AMC AETNA PPO","182.51","80.4","","105.16","105.16","105.16","1 through 10","19.56","185.5","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","outpatient","","","227.00","170.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","182.51","80.4","","171.60","171.60","171.60","1 through 10","19.56","185.5","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","outpatient","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","185.50","81.72","","96.73","96.73","96.73","1 through 10","19.56","185.5","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","outpatient","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","185.50","81.72","","96.73","78.17","175.87","1 through 10","19.56","185.5","percent of total billed charges",""
"CARD MEASURING CD HORIZON LEGACY","SUP-ITM-10059458","CDM","C1889","HCPCS","0278","RC","","","","both","","","595.00","446.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","473.03","79.5","","1309.77","674.56","6049.93","26","184.45","473.03","percent of total billed charges",""
"CARD MEASURING CD HORIZON LEGACY","SUP-ITM-10059458","CDM","C1889","HCPCS","0278","RC","","","","both","","","595.00","446.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","317.14","53.3","","1901.83","1901.83","2962.25","1 through 10","184.45","473.03","percent of total billed charges",""
"CARD MEASURING CD HORIZON LEGACY","SUP-ITM-10059458","CDM","C1889","HCPCS","0278","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","217.18","36.5","","1620.31","1620.31","19908.88","1 through 10","184.45","473.03","percent of total billed charges",""
"CARD MEASURING CD HORIZON LEGACY","SUP-ITM-10059458","CDM","C1889","HCPCS","0278","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","227.89","38.3","","352.91","352.91","2046.30","1 through 10","184.45","473.03","percent of total billed charges",""
"CARD MEASURING CD HORIZON LEGACY","SUP-ITM-10059458","CDM","C1889","HCPCS","0278","RC","","","","both","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.26","42.9","","9668.75","9668.75","9668.75","1 through 10","184.45","473.03","percent of total billed charges",""
"CARD MEASURING CD HORIZON LEGACY","SUP-ITM-10059458","CDM","C1889","HCPCS","0278","RC","","","","both","","","595.00","446.25","WELLPOINT [1015]","HB AMC WELLPOINT","438.99","73.78","","699.88","384.10","3443.31","33","184.45","473.03","percent of total billed charges",""
"CARD MEASURING CD HORIZON LEGACY","SUP-ITM-10059458","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","AETNA [1001]","HB AMC AETNA HMO","415.31","69.8","","1421.24","264.50","4933.46","29","310.95","486.23","percent of total billed charges",""
"CARD MEASURING CD HORIZON LEGACY","SUP-ITM-10059458","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","478.38","80.4","","1022.97","1022.97","3607.50","1 through 10","310.95","486.23","percent of total billed charges",""
"CARD MEASURING CD HORIZON LEGACY","SUP-ITM-10059458","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","486.23","81.72","","3010.54","693.88","5019.88","35","310.95","486.23","percent of total billed charges",""
"Cardiac Arrest And Shock,EXTREME","196","DRG","","","","","","","","inpatient","","","185206.72","","MASSHEALTH [3001]","HB BWH MEDICAID","17384.53","","Case rate ($19,221.58). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,651.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,252.56 and the sum of the standard inlier and any outlier amount.","78452.89","78452.89","78452.89","1 through 10","4665.42","274632.31","case rate",""
"Cardiac Arrest And Shock,EXTREME","196","DRG","","","","","","","","inpatient","","","185206.72","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","17384.53","","Case rate ($19,221.58). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,651.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,252.56 and the sum of the standard inlier and any outlier amount.","2781.16","2781.16","2781.16","1 through 10","4665.42","274632.31","case rate",""
"Cardiac Arrest And Shock,EXTREME","196","DRG","","","","","","","","inpatient","","","185206.72","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","17384.53","","Case rate ($19,221.58). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,651.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,252.56 and the sum of the standard inlier and any outlier amount.","2284.20","2284.20","19216.86","1 through 10","4665.42","274632.31","case rate",""
"Cardiac Arrest And Shock,MAJOR","196","DRG","","","","","","","","inpatient","","","39237.36","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14402.1113","","Fee schedule rate ($75,730.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14402.1113","17399.28","17399.28","1 through 10","4665.42","274632.31","case rate",""
"Cardiac Arrest And Shock,MAJOR","196","DRG","","","","","","","","inpatient","","","39237.36","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33702.5956","","Fee schedule rate ($75,730.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33702.5956","17399.28","17399.28","1 through 10","4665.42","274632.31","case rate",""
"Cardiac Arrest And Shock,MAJOR","196","DRG","","","","","","","","inpatient","","","39237.36","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9389.6666","","Fee schedule rate ($75,730.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9389.6666","17399.28","17399.28","1 through 10","4665.42","274632.31","case rate",""
"Cardiac Arrest, Unexplained With McC","296","MS-DRG","","","","","","","","inpatient","","","185206.72","138905.04","MEDICARE [2001]","HB BWH MEDICARE","14627.65","","Case rate ($14,627.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,531.40, add-ons for qualifying new technology services are included. If operating cost exceeds $63,175.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,696.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,991.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,151.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,256.80. The transfer capital threshold is the transfer adjustment factor * $1,256.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19622.53","19622.53","19622.53","1 through 10","14335.1","24465.6","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","36888.33","27666.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7303.69","","Case rate ($7,090.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,458.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,103.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,032.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,119.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,078.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.99. The transfer capital threshold is the transfer adjustment factor * $591.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7211.97","7211.97","7211.97","1 through 10","6949.14","11156.7763","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","36888.33","27666.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","7090.96","","Case rate ($7,090.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,458.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,103.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,032.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,119.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,078.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.99. The transfer capital threshold is the transfer adjustment factor * $591.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6919.88","6919.88","7029.76","1 through 10","6949.14","11156.7763","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","36888.33","27666.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7090.96","","Case rate ($7,090.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,458.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,103.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,032.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,119.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,078.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.99. The transfer capital threshold is the transfer adjustment factor * $591.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6899.31","6899.31","6899.31","1 through 10","6949.14","11156.7763","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","36888.33","27666.25","FALLON HEALTH [1008]","HB BWH MEDICARE","7090.96","","Case rate ($7,090.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,458.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,103.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,032.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,119.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,078.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.99. The transfer capital threshold is the transfer adjustment factor * $591.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6863.97","6863.97","6863.97","1 through 10","6949.14","11156.7763","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","36888.33","27666.25","MEDICARE [2001]","HB BWH MEDICARE","7090.96","","Case rate ($7,090.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,458.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,103.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,032.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,119.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,078.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.99. The transfer capital threshold is the transfer adjustment factor * $591.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8994.00","0.03","9007.04","98","6949.14","11156.7763","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","36888.33","27666.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","7090.96","","Case rate ($7,090.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,458.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,103.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,032.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,119.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,078.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.99. The transfer capital threshold is the transfer adjustment factor * $591.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","166.74","166.74","166.74","1 through 10","6949.14","11156.7763","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","36888.33","27666.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","7090.96","","Case rate ($7,090.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,458.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,103.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,032.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,119.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,078.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.99. The transfer capital threshold is the transfer adjustment factor * $591.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6866.97","6866.97","6877.97","1 through 10","6949.14","11156.7763","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","36888.33","27666.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6949.14","","Case rate ($7,090.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,458.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,103.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,032.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,119.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,078.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.99. The transfer capital threshold is the transfer adjustment factor * $591.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6887.58","6887.58","6896.61","1 through 10","6949.14","11156.7763","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","36888.33","27666.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6949.14","","Case rate ($7,090.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,458.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,103.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,032.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,119.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,078.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.99. The transfer capital threshold is the transfer adjustment factor * $591.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6869.92","6848.93","6904.75","1 through 10","6949.14","11156.7763","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","62052.25","46539.19","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","11703.76","","Case rate ($11,362.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,601.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,245.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,408.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,014.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,221.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $968.81. The transfer capital threshold is the transfer adjustment factor * $968.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11599.69","11599.69","11599.69","1 through 10","11135.61","18198.2369","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","62052.25","46539.19","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14633.92","","Case rate ($14,633.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,601.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,245.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,408.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $13,285.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,221.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $968.81. The transfer capital threshold is the transfer adjustment factor * $968.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11262.86","11102.03","14313.22","1 through 10","11135.61","18198.2369","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","62052.25","46539.19","MARTIN'S POINT [160007]","HB BWH MEDICARE","14633.92","","Case rate ($14,633.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,601.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,245.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,408.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $13,285.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,221.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $968.81. The transfer capital threshold is the transfer adjustment factor * $968.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11014.39","11014.39","11014.39","1 through 10","11135.61","18198.2369","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","62052.25","46539.19","MEDICARE [2001]","HB BWH MEDICARE","14633.92","","Case rate ($14,633.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,601.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,245.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,408.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $13,285.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,221.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $968.81. The transfer capital threshold is the transfer adjustment factor * $968.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14494.84","0.03","14516.09","56","11135.61","18198.2369","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","62052.25","46539.19","MOLINA [1014]","HB BWH MOLINA","11135.61","","Case rate ($11,362.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,601.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,245.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,408.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,014.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,221.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $968.81. The transfer capital threshold is the transfer adjustment factor * $968.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22425.54","22425.54","22425.54","1 through 10","11135.61","18198.2369","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","62052.25","46539.19","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","11135.61","","Case rate ($11,362.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,601.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,245.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,408.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,014.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,221.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $968.81. The transfer capital threshold is the transfer adjustment factor * $968.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10999.44","10999.44","10999.44","1 through 10","11135.61","18198.2369","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","62052.25","46539.19","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11135.61","","Case rate ($11,362.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,601.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,245.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,408.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,014.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,221.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $968.81. The transfer capital threshold is the transfer adjustment factor * $968.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11041.97","11029.81","11045.39","1 through 10","11135.61","18198.2369","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/McC","310","MS-DRG","","","","","","","","inpatient","","","25281.91","18961.43","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","5543.85","","Case rate ($5,543.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,596.30, add-ons for qualifying new technology services are included. If operating cost exceeds $52,240.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,895.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,708.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,216.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.52. The transfer capital threshold is the transfer adjustment factor * $455.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5307.62","5307.62","5307.62","1 through 10","5432.97","8443.4145","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/McC","310","MS-DRG","","","","","","","","inpatient","","","25281.91","18961.43","FALLON HEALTH [1008]","HB BWH MEDICARE","5543.85","","Case rate ($5,543.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,596.30, add-ons for qualifying new technology services are included. If operating cost exceeds $52,240.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,895.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,708.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,216.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.52. The transfer capital threshold is the transfer adjustment factor * $455.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5249.57","5249.57","5249.57","1 through 10","5432.97","8443.4145","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/McC","310","MS-DRG","","","","","","","","inpatient","","","25281.91","18961.43","MEDICARE [2001]","HB BWH MEDICARE","5543.85","","Case rate ($5,543.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,596.30, add-ons for qualifying new technology services are included. If operating cost exceeds $52,240.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,895.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,708.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,216.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.52. The transfer capital threshold is the transfer adjustment factor * $455.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6874.31","219.17","6884.18","12","5432.97","8443.4145","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/McC","310","MS-DRG","","","","","","","","inpatient","","","25281.91","18961.43","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","5543.85","","Case rate ($5,543.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,596.30, add-ons for qualifying new technology services are included. If operating cost exceeds $52,240.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,895.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,708.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,216.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.52. The transfer capital threshold is the transfer adjustment factor * $455.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5254.41","5254.41","5254.41","1 through 10","5432.97","8443.4145","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/McC","310","MS-DRG","","","","","","","","inpatient","","","25281.91","18961.43","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","5432.97","","Case rate ($5,543.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,596.30, add-ons for qualifying new technology services are included. If operating cost exceeds $52,240.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,895.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,708.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,216.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.52. The transfer capital threshold is the transfer adjustment factor * $455.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5249.59","5249.59","5249.59","1 through 10","5432.97","8443.4145","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders,EXTREME","201","DRG","","","","","","","","inpatient","","","166691.40","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","44895.78","","Standard inlier is a Case rate ($44,895.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,562, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,373.23) for the length of stay and the standard reimbursement.","44895.77","44895.77","44895.77","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,EXTREME","201","DRG","","","","","","","","inpatient","","","166691.40","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","50474.95","","Standard inlier is a Case rate ($50,474.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,562, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,164.50) for the length of stay and the standard reimbursement.","48566.77","48566.77","48566.77","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,EXTREME","201","DRG","","","","","","","","inpatient","","","166691.40","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10051.7298","","Fee schedule rate ($53,955.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10051.7298","53955.92","53955.92","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,EXTREME","201","DRG","","","","","","","","inpatient","","","166691.40","","MASSHEALTH [3001]","HB BWH MEDICAID","14332.12","","Case rate ($15,846.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,276.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29909.93","29909.93","29909.93","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,EXTREME","201","DRG","","","","","","","","inpatient","","","166691.40","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14332.12","","Case rate ($15,846.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,276.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","48106.62","48106.62","48106.62","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","59094.29","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","27334.61","","Standard inlier is a Case rate ($27,334.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,905, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,880.31) for the length of stay and the standard reimbursement.","27334.61","27334.61","27334.61","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","59094.29","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","30731.47","","Standard inlier is a Case rate ($30,731.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,905, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,362.08) for the length of stay and the standard reimbursement.","30731.47","30731.47","37417.41","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","59094.29","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10051.7298","","Fee schedule rate ($24,596.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10051.7298","24597.00","24597.00","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","59094.29","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10554.6084","","Fee schedule rate ($25,827.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10554.6084","25827.56","25827.56","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","59094.29","","MASSHEALTH [3001]","HB BWH MEDICAID","8430.66","","Case rate ($9,321.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,751.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9319.26","9319.26","9319.26","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","59094.29","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25596.91","","Fee schedule rate ($25,596.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25596.91","25596.91","25596.91","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","59094.29","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26877.18","","Fee schedule rate ($26,877.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26877.18","26877.18","26877.18","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","59094.29","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8430.66","","Case rate ($9,321.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,751.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9319.26","9319.26","9319.26","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MINOR","201","DRG","","","","","","","","inpatient","","","23803.00","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","14116.85","","Standard inlier is a Case rate ($14,116.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,626, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,003.97) for the length of stay and the standard reimbursement.","12868.02","12868.02","14116.84","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MINOR","201","DRG","","","","","","","","inpatient","","","23803.00","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","15871.14","","Standard inlier is a Case rate ($15,871.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,626, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,252.78) for the length of stay and the standard reimbursement.","14499.65","14499.65","14499.65","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MINOR","201","DRG","","","","","","","","inpatient","","","23803.00","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10051.7298","","Fee schedule rate ($10,051.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10051.7298","10051.72","10051.72","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MINOR","201","DRG","","","","","","","","inpatient","","","23803.00","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14906.31","","Fee schedule rate ($14,906.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14906.31","14906.31","14906.31","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","31313.00","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","18301.77","","Standard inlier is a Case rate ($18,301.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,879, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,598.05) for the length of stay and the standard reimbursement.","18301.77","16682.73","18301.77","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","31313.00","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","20576.12","","Standard inlier is a Case rate ($20,576.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,879, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,920.61) for the length of stay and the standard reimbursement.","20576.12","18798.06","20576.12","17","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","31313.00","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","4905.32","","Case rate ($5,423.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,853.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4803.80","4803.80","4803.80","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","31313.00","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10051.7298","","Fee schedule rate ($14,592.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10051.7298","14592.24","14592.24","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","31313.00","","MASSHEALTH [3001]","HB BWH MEDICAID","4905.32","","Case rate ($5,423.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,853.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5422.34","5422.34","5422.34","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","31313.00","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","4905.32","","Case rate ($5,423.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,853.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","31313.00","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","18388.86","","Fee schedule rate ($18,388.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18388.86","18388.86","18388.86","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","31313.00","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","19308.60","","Fee schedule rate ($19,308.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19308.60","19308.60","19308.60","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","31313.00","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4905.32","","Case rate ($5,423.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,853.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5747.68","5747.68","5747.68","1 through 10","3714.97","89028.34","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,EXTREME","191","DRG","","","","","","","","inpatient","","","197377.94","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16582.8938","","Fee schedule rate ($95,771.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16582.8938","95771.04","95771.04","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,EXTREME","191","DRG","","","","","","","","inpatient","","","197377.94","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21483.5035","","Fee schedule rate ($95,771.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21483.5035","95771.04","95771.04","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MAJOR","191","DRG","","","","","","","","inpatient","","","91091.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","44611.18","","Standard inlier is a Case rate ($44,611.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,339, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,332.83) for the length of stay and the standard reimbursement.","44611.17","44611.17","44611.17","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MAJOR","191","DRG","","","","","","","","inpatient","","","91091.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","50154.98","","Standard inlier is a Case rate ($50,154.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,339, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,119.08) for the length of stay and the standard reimbursement.","50154.98","50154.98","50154.98","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MAJOR","191","DRG","","","","","","","","inpatient","","","91091.72","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","100624.57","100624.57","100624.57","1 through 10","6237.32","158024.11","percent of total billed charges",""
"Cardiac Catheterization For Coronary Artery Disease,MAJOR","191","DRG","","","","","","","","inpatient","","","91091.72","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16582.8938","","Fee schedule rate ($20,320.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16582.8938","38384.00","38384.00","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MAJOR","191","DRG","","","","","","","","inpatient","","","91091.72","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21483.5035","","Fee schedule rate ($20,320.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21483.5035","38384.00","38384.00","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MAJOR","191","DRG","","","","","","","","inpatient","","","91091.72","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","17412.5204","","Fee schedule rate ($21,337.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17412.5204","40304.32","40304.32","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MAJOR","191","DRG","","","","","","","","inpatient","","","91091.72","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22558.303","","Fee schedule rate ($21,337.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22558.303","40304.32","40304.32","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MAJOR","191","DRG","","","","","","","","inpatient","","","91091.72","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44825.14","","Fee schedule rate ($44,825.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","44825.14","44825.14","44825.14","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MAJOR","191","DRG","","","","","","","","inpatient","","","91091.72","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11048.96","","Case rate ($12,216.53). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,646.53, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12213.53","12213.53","12213.53","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MINOR","191","DRG","","","","","","","","inpatient","","","66374.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","29304.18","","Standard inlier is a Case rate ($29,304.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,436, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,159.91) for the length of stay and the standard reimbursement.","29304.18","29304.18","29304.18","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MINOR","191","DRG","","","","","","","","inpatient","","","66374.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32945.80","","Standard inlier is a Case rate ($32,945.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,436, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,676.38) for the length of stay and the standard reimbursement.","32945.79","32945.79","32945.79","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MINOR","191","DRG","","","","","","","","inpatient","","","66374.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32315.28","","Fee schedule rate ($32,315.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32315.28","32315.28","32315.28","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MODERATE","191","DRG","","","","","","","","inpatient","","","84379.92","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","38621.59","","Standard inlier is a Case rate ($38,621.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,362, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,482.01) for the length of stay and the standard reimbursement.","38621.59","38621.59","38621.59","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MODERATE","191","DRG","","","","","","","","inpatient","","","84379.92","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16582.8938","","Fee schedule rate ($20,320.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16582.8938","20440.65","20440.65","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MODERATE","191","DRG","","","","","","","","inpatient","","","84379.92","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21483.5035","","Fee schedule rate ($20,320.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21483.5035","20440.65","20440.65","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MODERATE","191","DRG","","","","","","","","inpatient","","","84379.92","","MASSHEALTH [3001]","HB BWH MEDICAID","7784.08","","Case rate ($8,606.64). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,036.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8604.53","8604.53","8604.53","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Coronary Artery Disease,MODERATE","191","DRG","","","","","","","","inpatient","","","84379.92","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7784.08","","Case rate ($8,606.64). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,036.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8604.53","8604.53","8604.53","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,EXTREME","192","DRG","","","","","","","","inpatient","","","213306.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31435.452","","Standard inlier is a Case rate ($85,244.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $77,937, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,100.96) for the length of stay and the standard reimbursement.","31435.452","99633.00","99633.00","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,EXTREME","192","DRG","","","","","","","","inpatient","","","213306.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35341.92","","Standard inlier is a Case rate ($95,837.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $77,937, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,603.36) for the length of stay and the standard reimbursement.","35341.92","87556.00","282963.44","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,EXTREME","192","DRG","","","","","","","","inpatient","","","213306.51","","MASSHEALTH [3001]","HB BWH MEDICAID","31715.51","","Case rate ($35,066.95). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $77,496.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","35058.34","35058.34","35058.34","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,EXTREME","192","DRG","","","","","","","","inpatient","","","213306.51","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118006.50","","Fee schedule rate ($118,006.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","46581.28","46581.28","46581.28","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,EXTREME","192","DRG","","","","","","","","inpatient","","","213306.51","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","123907.99","","Fee schedule rate ($123,907.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","123907.99","123907.99","123907.99","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,EXTREME","192","DRG","","","","","","","","inpatient","","","213306.51","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","31715.51","","Case rate ($35,066.95). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $77,496.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","35058.34","1118.45","35058.34","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MAJOR","192","DRG","","","","","","","","inpatient","","","134194.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31435.452","","Standard inlier is a Case rate ($54,856.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,307, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,787.25) for the length of stay and the standard reimbursement.","31435.452","50003.97","67651.98","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MAJOR","192","DRG","","","","","","","","inpatient","","","134194.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35341.92","","Standard inlier is a Case rate ($61,673.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,307, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,754.09) for the length of stay and the standard reimbursement.","35341.92","56344.37","61673.83","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MAJOR","192","DRG","","","","","","","","inpatient","","","134194.06","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16582.8938","","Fee schedule rate ($95,771.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16582.8938","29099.48","29099.48","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MAJOR","192","DRG","","","","","","","","inpatient","","","134194.06","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21483.5035","","Fee schedule rate ($95,771.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21483.5035","29099.48","29099.48","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MAJOR","192","DRG","","","","","","","","inpatient","","","134194.06","","HEALTH NEW ENGLAND [1034]","HB BWH MEDICAID","18841.04","","Case rate ($20,832.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,262.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20826.90","20826.90","20826.90","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MAJOR","192","DRG","","","","","","","","inpatient","","","134194.06","","MASSHEALTH [3001]","HB BWH MEDICAID","18841.04","","Case rate ($20,832.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,262.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23118.61","23118.61","23118.61","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MAJOR","192","DRG","","","","","","","","inpatient","","","134194.06","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","123907.99","","Fee schedule rate ($123,907.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","72349.08","72349.08","72349.08","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MAJOR","192","DRG","","","","","","","","inpatient","","","134194.06","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","18841.04","","Case rate ($20,832.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,262.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20826.90","740.47","136434.99","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MINOR","192","DRG","","","","","","","","inpatient","","","64612.04","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35341.92","","Standard inlier is a Case rate ($32,945.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,436, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,676.38) for the length of stay and the standard reimbursement.","35341.92","35341.92","41207.74","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MINOR","192","DRG","","","","","","","","inpatient","","","64612.04","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16582.8938","","Fee schedule rate ($16,582.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16582.8938","16582.88","16582.88","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MINOR","192","DRG","","","","","","","","inpatient","","","64612.04","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21483.5035","","Fee schedule rate ($16,582.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21483.5035","16582.88","16582.88","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MINOR","192","DRG","","","","","","","","inpatient","","","64612.04","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","17412.5204","","Fee schedule rate ($17,412.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17412.5204","17412.52","17412.52","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MINOR","192","DRG","","","","","","","","inpatient","","","64612.04","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22558.303","","Fee schedule rate ($17,412.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22558.303","17412.52","17412.52","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MINOR","192","DRG","","","","","","","","inpatient","","","64612.04","","MASSHEALTH [3001]","HB BWH MEDICAID","6237.32","","Case rate ($6,896.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,326.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7721.85","7721.85","7721.85","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MODERATE","192","DRG","","","","","","","","inpatient","","","87166.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31435.452","","Standard inlier is a Case rate ($34,352.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,362, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,876.56) for the length of stay and the standard reimbursement.","31435.452","39116.43","39116.43","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MODERATE","192","DRG","","","","","","","","inpatient","","","87166.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35341.92","","Standard inlier is a Case rate ($38,621.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,362, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,482.01) for the length of stay and the standard reimbursement.","35341.92","43977.42","43977.42","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MODERATE","192","DRG","","","","","","","","inpatient","","","87166.31","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16582.8938","","Fee schedule rate ($20,320.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16582.8938","20320.40","20320.40","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MODERATE","192","DRG","","","","","","","","inpatient","","","87166.31","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21483.5035","","Fee schedule rate ($20,320.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21483.5035","20320.40","20320.40","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MODERATE","192","DRG","","","","","","","","inpatient","","","87166.31","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","17412.5204","","Fee schedule rate ($21,337.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17412.5204","20513.92","20513.92","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MODERATE","192","DRG","","","","","","","","inpatient","","","87166.31","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22558.303","","Fee schedule rate ($21,337.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22558.303","20513.92","20513.92","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MODERATE","192","DRG","","","","","","","","inpatient","","","87166.31","","MASSHEALTH [3001]","HB BWH MEDICAID","7784.08","","Case rate ($8,606.64). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,036.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12162.46","12162.46","12162.46","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MODERATE","192","DRG","","","","","","","","inpatient","","","87166.31","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","36043.62","","Fee schedule rate ($36,043.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","52949.22","52949.22","52949.22","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MODERATE","192","DRG","","","","","","","","inpatient","","","87166.31","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7784.08","","Case rate ($8,606.64). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,036.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12142.82","12142.82","12142.82","1 through 10","6237.32","158024.11","case rate",""
"Cardiac Congenital And Valvular Disorders With McC","306","MS-DRG","","","","","","","","inpatient","","","86481.50","64861.12","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","19035.61","","Case rate ($19,035.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,684.04, add-ons for qualifying new technology services are included. If operating cost exceeds $63,328.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,708.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $17,387.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,304.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,267.98. The transfer capital threshold is the transfer adjustment factor * $1,267.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16608.50","16608.50","16608.50","1 through 10","14459.36","22597.2634","other","Inpatient DRG"
"Cardiac Congenital And Valvular Disorders With McC","306","MS-DRG","","","","","","","","inpatient","","","86481.50","64861.12","MEDICARE [2001]","HB BWH MEDICARE","19035.61","","Case rate ($19,035.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,684.04, add-ons for qualifying new technology services are included. If operating cost exceeds $63,328.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,708.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $17,387.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,304.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,267.98. The transfer capital threshold is the transfer adjustment factor * $1,267.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17957.77","0.03","17957.77","1 through 10","14459.36","22597.2634","other","Inpatient DRG"
"Cardiac Congenital And Valvular Disorders With McC","306","MS-DRG","","","","","","","","inpatient","","","86481.50","64861.12","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14459.36","","Case rate ($14,754.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,684.04, add-ons for qualifying new technology services are included. If operating cost exceeds $63,328.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,708.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $13,106.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,304.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,267.98. The transfer capital threshold is the transfer adjustment factor * $1,267.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13596.42","13596.42","13596.42","1 through 10","14459.36","22597.2634","other","Inpatient DRG"
"Cardiac Congenital And Valvular Disorders Without McC","307","MS-DRG","","","","","","","","inpatient","","","43554.81","32666.11","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","11191.16","","Case rate ($11,191.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,407.89, add-ons for qualifying new technology services are included. If operating cost exceeds $56,052.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,174.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $10,076.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,028.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $734.81. The transfer capital threshold is the transfer adjustment factor * $734.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8592.31","8592.31","8592.31","1 through 10","8535.96","13980.3024","other","Inpatient DRG"
"Cardiac Congenital And Valvular Disorders Without McC","307","MS-DRG","","","","","","","","inpatient","","","43554.81","32666.11","MEDICARE [2001]","HB BWH MEDICARE","11191.16","","Case rate ($11,191.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,407.89, add-ons for qualifying new technology services are included. If operating cost exceeds $56,052.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,174.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $10,076.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,028.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $734.81. The transfer capital threshold is the transfer adjustment factor * $734.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11199.76","11199.76","11216.10","1 through 10","8535.96","13980.3024","other","Inpatient DRG"
"Cardiac Defibrillator Implant With Cardiac Catheterization And McC","275","MS-DRG","","","","","","","","inpatient","","","336478.27","252358.70","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","67386.82","","Case rate ($65,424.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $78,680.30, add-ons for qualifying new technology services are included. If operating cost exceeds $124,324.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,177.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $59,306.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $78,300.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,737.54. The transfer capital threshold is the transfer adjustment factor * $5,737.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","66432.36","66432.36","66432.36","1 through 10","64115.62","111690.59","other","Inpatient DRG"
"Cardiac Defibrillator Implant With Cardiac Catheterization And McC","275","MS-DRG","","","","","","","","inpatient","","","336478.27","252358.70","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","65424.10","","Case rate ($65,424.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $78,680.30, add-ons for qualifying new technology services are included. If operating cost exceeds $124,324.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,177.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $59,306.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $78,300.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,737.54. The transfer capital threshold is the transfer adjustment factor * $5,737.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","64647.15","64647.15","64647.15","1 through 10","64115.62","111690.59","other","Inpatient Replacement Plans DRG"
"Cardiac Defibrillator Implant With Cardiac Catheterization And McC","275","MS-DRG","","","","","","","","inpatient","","","336478.27","252358.70","MEDICARE [2001]","HB BWH MEDICARE","65424.10","","Case rate ($65,424.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $78,680.30, add-ons for qualifying new technology services are included. If operating cost exceeds $124,324.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,177.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $59,306.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $78,300.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,737.54. The transfer capital threshold is the transfer adjustment factor * $5,737.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","83716.86","83592.24","83716.86","1 through 10","64115.62","111690.59","other","Inpatient Replacement Plans DRG"
"Cardiac Defibrillator Implant With Cardiac Catheterization And McC","275","MS-DRG","","","","","","","","inpatient","","","336478.27","252358.70","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","64115.62","","Case rate ($65,424.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $78,680.30, add-ons for qualifying new technology services are included. If operating cost exceeds $124,324.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,177.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $59,306.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $78,300.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,737.54. The transfer capital threshold is the transfer adjustment factor * $5,737.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","63253.14","63253.14","63253.14","1 through 10","64115.62","111690.59","other","Inpatient DRG"
"Cardiac Defibrillator Implant With McC Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","","","","inpatient","","","232987.15","174740.36","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","71491.53","","Case rate ($71,491.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $66,339.62, add-ons for qualifying new technology services are included. If operating cost exceeds $111,984.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,273.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $66,278.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,959.77 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,833.26. The transfer capital threshold is the transfer adjustment factor * $4,833.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","65741.99","65741.99","212674.73","1 through 10","54069.23","94087.38","other","Inpatient DRG"
"Cardiac Defibrillator Implant With McC Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","","","","inpatient","","","232987.15","174740.36","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","71491.53","","Case rate ($71,491.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $66,339.62, add-ons for qualifying new technology services are included. If operating cost exceeds $111,984.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,273.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $66,278.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,959.77 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,833.26. The transfer capital threshold is the transfer adjustment factor * $4,833.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","657359.80","657359.80","657359.80","1 through 10","54069.23","94087.38","other","Inpatient DRG"
"Cardiac Defibrillator Implant With McC Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","","","","inpatient","","","232987.15","174740.36","MEDICARE [2001]","HB BWH MEDICARE","71491.53","","Case rate ($71,491.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $66,339.62, add-ons for qualifying new technology services are included. If operating cost exceeds $111,984.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,273.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $66,278.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,959.77 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,833.26. The transfer capital threshold is the transfer adjustment factor * $4,833.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","73305.03","0.03","73414.26","18","54069.23","94087.38","other","Inpatient DRG"
"Cardiac Defibrillator Implant With McC Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","","","","inpatient","","","232987.15","174740.36","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","71491.53","","Case rate ($71,491.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $66,339.62, add-ons for qualifying new technology services are included. If operating cost exceeds $111,984.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,273.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $66,278.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,959.77 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,833.26. The transfer capital threshold is the transfer adjustment factor * $4,833.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","55461.55","55461.55","55461.55","1 through 10","54069.23","94087.38","other","Inpatient DRG"
"Cardiac Defibrillator Implant With McC Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","","","","inpatient","","","232987.15","174740.36","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","54069.23","","Case rate ($55,172.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $66,339.62, add-ons for qualifying new technology services are included. If operating cost exceeds $111,984.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,273.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $49,959.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,959.77 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,833.26. The transfer capital threshold is the transfer adjustment factor * $4,833.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","55412.32","55412.32","55558.53","1 through 10","54069.23","94087.38","other","Inpatient DRG"
"Cardiac Defibrillator Implant Without McC","277","MS-DRG","","","","","","","","inpatient","","","176160.23","132120.17","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","42510.30","","Case rate ($42,510.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,096.59, add-ons for qualifying new technology services are included. If operating cost exceeds $96,741.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,156.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $38,414.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,716.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,716.32. The transfer capital threshold is the transfer adjustment factor * $3,716.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","42044.85","42044.85","42044.85","1 through 10","41660.09","72344.18","other","Inpatient Replacement Plans DRG"
"Cardiac Defibrillator Implant Without McC","277","MS-DRG","","","","","","","","inpatient","","","176160.23","132120.17","HUMANA [1012]","HB BWH MEDICARE","42510.30","","Case rate ($42,510.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,096.59, add-ons for qualifying new technology services are included. If operating cost exceeds $96,741.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,156.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $38,414.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,716.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,716.32. The transfer capital threshold is the transfer adjustment factor * $3,716.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35531.78","35531.78","35531.78","1 through 10","41660.09","72344.18","other","Inpatient Replacement Plans DRG"
"Cardiac Defibrillator Implant Without McC","277","MS-DRG","","","","","","","","inpatient","","","176160.23","132120.17","MEDICARE [2001]","HB BWH MEDICARE","42510.30","","Case rate ($42,510.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,096.59, add-ons for qualifying new technology services are included. If operating cost exceeds $96,741.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,156.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $38,414.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,716.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,716.32. The transfer capital threshold is the transfer adjustment factor * $3,716.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","55120.25","27416.22","55202.28","19","41660.09","72344.18","other","Inpatient Replacement Plans DRG"
"Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,MAJOR","177","DRG","","","","","","","","inpatient","","","92722.94","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72387.47","","Fee schedule rate ($72,387.47). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","72387.47","72387.47","72387.47","1 through 10","10072.24","270078.11","case rate",""
"Cardiac Pacemaker And Defibrillator Revision Except Device Replacement,MODERATE","177","DRG","","","","","","","","inpatient","","","65934.73","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","41512.212","","Standard inlier is a Case rate ($61,132.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $53,933, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,677.19) for the length of stay and the standard reimbursement.","41512.212","55849.42","55849.42","1 through 10","10072.24","270078.11","case rate",""
"Cardiac Pacemaker Device Replacement With McC","258","MS-DRG","","","","","","","","inpatient","","","64203.01","48152.26","MEDICARE [2001]","HB BWH MEDICARE","37578.93","","Case rate ($37,578.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,883.92, add-ons for qualifying new technology services are included. If operating cost exceeds $80,528.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,968.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $34,670.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,504.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,528.32. The transfer capital threshold is the transfer adjustment factor * $2,528.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","33352.77","33352.77","33352.77","1 through 10","28461.56","42337.8005","other","Inpatient DRG"
"Cardiac Pacemaker Device Replacement Without McC","259","MS-DRG","","","","","","","","inpatient","","","52771.94","39578.95","MEDICARE [2001]","HB BWH MEDICARE","24319.32","","Case rate ($24,319.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,584.95, add-ons for qualifying new technology services are included. If operating cost exceeds $68,229.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,067.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $22,312.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,205.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,627.10. The transfer capital threshold is the transfer adjustment factor * $1,627.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","21000.08","21000.08","21000.08","1 through 10","18449.13","26525.4507","other","Inpatient DRG"
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","","","","inpatient","","","85844.05","64383.04","MEDICARE [2001]","HB BWH MEDICARE","17625.17","","Case rate ($17,625.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,139.83, add-ons for qualifying new technology services are included. If operating cost exceeds $66,784.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,961.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $15,724.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,759.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,521.21. The transfer capital threshold is the transfer adjustment factor * $1,521.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","9828.22","1137.65","22682.85","1 through 10","17272.67","28636.6816","other","Inpatient Replacement Plans DRG"
"Cardiac Pacemaker Revision Except Device Replacement With McC","260","MS-DRG","","","","","","","","inpatient","","","194505.78","145879.33","MEDICARE [2001]","HB BWH MEDICARE","30052.22","","Case rate ($30,052.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,099.54, add-ons for qualifying new technology services are included. If operating cost exceeds $81,743.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,057.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $27,054.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,719.70 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,617.39. The transfer capital threshold is the transfer adjustment factor * $2,617.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","40434.51","0.03","40494.57","1 through 10","29451.18","50951.86","other","Inpatient Replacement Plans DRG"
"Cardiac Pacemaker Revision Except Device Replacement With McC","260","MS-DRG","","","","","","","","inpatient","","","194505.78","145879.33","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","29451.18","","Case rate ($30,052.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,099.54, add-ons for qualifying new technology services are included. If operating cost exceeds $81,743.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,057.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $27,054.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,719.70 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,617.39. The transfer capital threshold is the transfer adjustment factor * $2,617.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","11150.51","11150.51","11150.51","1 through 10","29451.18","50951.86","other","Inpatient DRG"
"Cardiac Pacemaker Revision Except Device Replacement With McC","260","MS-DRG","","","","","","","","inpatient","","","194505.78","145879.33","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","29451.18","","Case rate ($30,052.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,099.54, add-ons for qualifying new technology services are included. If operating cost exceeds $81,743.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,057.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $27,054.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,719.70 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,617.39. The transfer capital threshold is the transfer adjustment factor * $2,617.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","30738.32","30738.32","30738.32","1 through 10","29451.18","50951.86","other","Inpatient DRG"
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/McC","262","MS-DRG","","","","","","","","inpatient","","","95842.35","71881.76","MEDICARE [2001]","HB BWH MEDICARE","19676.10","","Case rate ($19,676.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,278.12, add-ons for qualifying new technology services are included. If operating cost exceeds $63,922.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,751.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $17,984.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,898.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,311.51. The transfer capital threshold is the transfer adjustment factor * $1,311.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","18171.85","18171.85","18171.85","1 through 10","14943","22905.1198","other","Inpatient DRG"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","708.00","531.00","AETNA [1001]","HB AMC AETNA HMO","494.18","69.8","","465.10","328.39","465.10","68","125.9","569.23","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","708.00","531.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","154.00","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","153.87","153.87","154.47","83","125.9","569.23","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","708.00","531.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","149.51","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.14","147.14","147.14","103","125.9","569.23","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","708.00","531.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","508.34","71.8","","249.26","124.62","249.26","1 through 10","125.9","569.23","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","708.00","531.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","562.86","79.5","","540.67","362.74","540.67","41","125.9","569.23","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","708.00","531.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","377.36","53.3","","362.74","362.74","540.67","27","125.9","569.23","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","708.00","531.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","149.51","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","141.34","141.34","141.34","1 through 10","125.9","569.23","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","708.00","531.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","271.16","38.3","","261.06","261.06","261.06","1 through 10","125.9","569.23","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","708.00","531.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","149.51","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","146.54","141.34","146.54","123","125.9","569.23","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","708.00","531.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","146.52","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.54","146.54","442.32","166","125.9","569.23","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","708.00","531.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","146.52","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.54","146.54","146.54","111","125.9","569.23","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","468.00","351.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","154.00","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","153.87","153.87","154.47","25","125.9","372.06","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","468.00","351.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","149.51","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.14","147.14","147.14","86","125.9","372.06","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","468.00","351.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","372.06","79.5","","357.30","239.71","357.30","38","125.9","372.06","percent of total billed charges",""
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","468.00","351.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","249.44","53.3","","239.71","239.71","357.30","31","125.9","372.06","percent of total billed charges",""
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","468.00","351.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","149.51","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","141.34","141.34","141.34","1 through 10","125.9","372.06","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","468.00","351.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.24","38.3","","172.52","172.52","172.52","12","125.9","372.06","percent of total billed charges",""
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","468.00","351.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","149.51","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","146.54","146.54","146.54","31","125.9","372.06","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","468.00","351.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","146.52","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.54","141.34","146.54","30","125.9","372.06","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","468.00","351.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","146.52","","APC Price ($149.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.54","146.54","146.84","96","125.9","372.06","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","outpatient","","","468.00","351.00","AETNA [1001]","HB AMC AETNA HMO","326.66","69.8","","217.01","217.01","354.12","34","244.58","541.65","percent of total billed charges",""
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","outpatient","","","468.00","351.00","AETNA [1001]","HB AMC AETNA PPO","376.27","80.4","","217.01","217.01","217.01","1 through 10","244.58","541.65","percent of total billed charges",""
"Cardiac Structural And Valvular Disorders,EXTREME","200","DRG","","","","","","","","inpatient","","","89817.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","45322.68","","Standard inlier is a Case rate ($45,322.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,893, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,433.83) for the length of stay and the standard reimbursement.","45322.67","45322.67","45322.67","1 through 10","3897.75","170339.64","case rate",""
"Cardiac Structural And Valvular Disorders,MAJOR","200","DRG","","","","","","","","inpatient","","","56112.87","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32836.72","","Standard inlier is a Case rate ($32,836.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,360, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,660.90) for the length of stay and the standard reimbursement.","32836.71","32836.71","32836.71","1 through 10","3897.75","170339.64","case rate",""
"Cardiac Structural And Valvular Disorders,MAJOR","200","DRG","","","","","","","","inpatient","","","56112.87","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11273.28","","Fee schedule rate ($26,402.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11273.28","26402.96","26402.96","1 through 10","3897.75","170339.64","case rate",""
"Cardiac Structural And Valvular Disorders,MINOR","200","DRG","","","","","","","","inpatient","","","85804.25","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","3897.75","","Case rate ($4,309.64). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,739.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","3897.75","170339.64","case rate",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","","","","inpatient","","","275228.51","206421.38","MEDICARE [2001]","HB BWH MEDICARE","60360.41","","Case rate ($60,360.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $72,584.63, add-ons for qualifying new technology services are included. If operating cost exceeds $118,229.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,731.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $54,689.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $72,204.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,290.87. The transfer capital threshold is the transfer adjustment factor * $5,290.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","76411.48","76411.48","76525.36","1 through 10","59153.2","97456.1689","other","Inpatient Replacement Plans DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","","","","inpatient","","","275228.51","206421.38","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","59153.20","","Case rate ($60,360.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $72,584.63, add-ons for qualifying new technology services are included. If operating cost exceeds $118,229.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,731.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $54,689.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $72,204.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,290.87. The transfer capital threshold is the transfer adjustment factor * $5,290.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","57890.29","57890.29","57890.29","1 through 10","59153.2","97456.1689","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC","216","MS-DRG","","","","","","","","inpatient","","","444211.57","333158.68","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","92308.17","","Case rate ($89,619.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $107,806.88, add-ons for qualifying new technology services are included. If operating cost exceeds $153,451.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $10,311.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $81,367.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $107,427.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $7,871.81. The transfer capital threshold is the transfer adjustment factor * $7,871.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","106190.30","106190.30","106190.30","1 through 10","87827.19","153237.78","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC","216","MS-DRG","","","","","","","","inpatient","","","444211.57","333158.68","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","89619.58","","Case rate ($89,619.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $107,806.88, add-ons for qualifying new technology services are included. If operating cost exceeds $153,451.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $10,311.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $81,367.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $107,427.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $7,871.81. The transfer capital threshold is the transfer adjustment factor * $7,871.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","88048.43","86974.29","320106.82","1 through 10","87827.19","153237.78","other","Inpatient Replacement Plans DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC","216","MS-DRG","","","","","","","","inpatient","","","444211.57","333158.68","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","89619.58","","Case rate ($89,619.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $107,806.88, add-ons for qualifying new technology services are included. If operating cost exceeds $153,451.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $10,311.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $81,367.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $107,427.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $7,871.81. The transfer capital threshold is the transfer adjustment factor * $7,871.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","86239.56","86239.56","86239.56","1 through 10","87827.19","153237.78","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC","216","MS-DRG","","","","","","","","inpatient","","","444211.57","333158.68","MEDICARE [2001]","HB BWH MEDICARE","89619.58","","Case rate ($89,619.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $107,806.88, add-ons for qualifying new technology services are included. If operating cost exceeds $153,451.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $10,311.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $81,367.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $107,427.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $7,871.81. The transfer capital threshold is the transfer adjustment factor * $7,871.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","114056.61","0.03","114226.80","43","87827.19","153237.78","other","Inpatient Replacement Plans DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC","216","MS-DRG","","","","","","","","inpatient","","","444211.57","333158.68","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","87827.19","","Case rate ($89,619.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $107,806.88, add-ons for qualifying new technology services are included. If operating cost exceeds $153,451.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $10,311.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $81,367.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $107,427.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $7,871.81. The transfer capital threshold is the transfer adjustment factor * $7,871.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","86487.73","86401.37","95491.93","1 through 10","87827.19","153237.78","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With McC","216","MS-DRG","","","","","","","","inpatient","","","444211.57","333158.68","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","87827.19","","Case rate ($89,619.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $107,806.88, add-ons for qualifying new technology services are included. If operating cost exceeds $153,451.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $10,311.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 10.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $81,367.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $107,427.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $7,871.81. The transfer capital threshold is the transfer adjustment factor * $7,871.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","83498.55","69301.85","129528.74","1 through 10","87827.19","153237.78","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/McC","218","MS-DRG","","","","","","","","inpatient","","","264930.69","198698.02","MEDICARE [2001]","HB BWH MEDICARE","78224.31","","Case rate ($78,224.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $72,584.63, add-ons for qualifying new technology services are included. If operating cost exceeds $118,229.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,731.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $72,553.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $72,204.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,290.87. The transfer capital threshold is the transfer adjustment factor * $5,290.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","70520.44","70520.44","70520.44","1 through 10","59153.2","89780.8863","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/McC","218","MS-DRG","","","","","","","","inpatient","","","264930.69","198698.02","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","59153.20","","Case rate ($60,360.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $72,584.63, add-ons for qualifying new technology services are included. If operating cost exceeds $118,229.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,731.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $54,689.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $72,204.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,290.87. The transfer capital threshold is the transfer adjustment factor * $5,290.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","53192.63","53192.63","53192.63","1 through 10","59153.2","89780.8863","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","","","","inpatient","","","203028.29","152271.22","MEDICARE [2001]","HB BWH MEDICARE","63514.47","","Case rate ($63,514.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,940.47, add-ons for qualifying new technology services are included. If operating cost exceeds $104,584.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,731.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $58,843.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $58,560.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,291.08. The transfer capital threshold is the transfer adjustment factor * $4,291.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","62721.90","42702.55","62815.31","1 through 10","48045.69","79932.4997","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","","","","inpatient","","","203028.29","152271.22","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","48045.69","","Case rate ($49,026.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,940.47, add-ons for qualifying new technology services are included. If operating cost exceeds $104,584.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,731.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $44,355.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $58,560.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,291.08. The transfer capital threshold is the transfer adjustment factor * $4,291.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","63256.41","63256.41","72730.78","1 through 10","48045.69","79932.4997","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","","","","inpatient","","","203028.29","152271.22","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","48045.69","","Case rate ($49,026.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,940.47, add-ons for qualifying new technology services are included. If operating cost exceeds $104,584.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,731.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $44,355.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $58,560.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,291.08. The transfer capital threshold is the transfer adjustment factor * $4,291.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","47569.75","47569.75","66069.81","1 through 10","48045.69","79932.4997","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC","219","MS-DRG","","","","","","","","inpatient","","","289476.25","217107.19","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","72534.76","","Case rate ($70,422.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,696.91, add-ons for qualifying new technology services are included. If operating cost exceeds $130,341.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,618.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $63,863.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $84,317.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,178.41. The transfer capital threshold is the transfer adjustment factor * $6,178.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","72553.96","70429.20","88601.20","1 through 10","69013.66","120272.89","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC","219","MS-DRG","","","","","","","","inpatient","","","289476.25","217107.19","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","70422.10","","Case rate ($70,422.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,696.91, add-ons for qualifying new technology services are included. If operating cost exceeds $130,341.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,618.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $63,863.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $84,317.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,178.41. The transfer capital threshold is the transfer adjustment factor * $6,178.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","69751.54","56157.60","87452.69","22","69013.66","120272.89","other","Inpatient Replacement Plans DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC","219","MS-DRG","","","","","","","","inpatient","","","289476.25","217107.19","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","70422.10","","Case rate ($70,422.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,696.91, add-ons for qualifying new technology services are included. If operating cost exceeds $130,341.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,618.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $63,863.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $84,317.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,178.41. The transfer capital threshold is the transfer adjustment factor * $6,178.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","91682.95","91682.95","91682.95","1 through 10","69013.66","120272.89","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC","219","MS-DRG","","","","","","","","inpatient","","","289476.25","217107.19","MARTIN'S POINT [160007]","HB BWH MEDICARE","70422.10","","Case rate ($70,422.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,696.91, add-ons for qualifying new technology services are included. If operating cost exceeds $130,341.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,618.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $63,863.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $84,317.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,178.41. The transfer capital threshold is the transfer adjustment factor * $6,178.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","67274.97","67274.97","69320.07","1 through 10","69013.66","120272.89","other","Inpatient Replacement Plans DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC","219","MS-DRG","","","","","","","","inpatient","","","289476.25","217107.19","MEDICARE [2001]","HB BWH MEDICARE","70422.10","","Case rate ($70,422.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,696.91, add-ons for qualifying new technology services are included. If operating cost exceeds $130,341.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,618.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $63,863.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $84,317.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,178.41. The transfer capital threshold is the transfer adjustment factor * $6,178.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","83451.40","0.03","91633.31","129","69013.66","120272.89","other","Inpatient Replacement Plans DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC","219","MS-DRG","","","","","","","","inpatient","","","289476.25","217107.19","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","69013.66","","Case rate ($70,422.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,696.91, add-ons for qualifying new technology services are included. If operating cost exceeds $130,341.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,618.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $63,863.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $84,317.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,178.41. The transfer capital threshold is the transfer adjustment factor * $6,178.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","69307.13","69270.34","189703.68","1 through 10","69013.66","120272.89","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC","219","MS-DRG","","","","","","","","inpatient","","","289476.25","217107.19","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69013.66","","Case rate ($70,422.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,696.91, add-ons for qualifying new technology services are included. If operating cost exceeds $130,341.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,618.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $63,863.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $84,317.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,178.41. The transfer capital threshold is the transfer adjustment factor * $6,178.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","69151.44","59134.31","181397.48","27","69013.66","120272.89","other","Inpatient DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC","219","MS-DRG","","","","","","","","inpatient","","","289476.25","217107.19","WELLPOINT [1015]","HB AMC WELLPOINT","120272.89","","Fee schedule rate ($120,272.89).","236185.90","120397.72","263579.02","1 through 10","69013.66","120272.89","case rate",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With McC","219","MS-DRG","","","","","","","","inpatient","","","289476.25","217107.19","WELLSENSE NH [1050]","HB BWH MEDICARE","70422.10","","Case rate ($70,422.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,696.91, add-ons for qualifying new technology services are included. If operating cost exceeds $130,341.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,618.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $63,863.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $84,317.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,178.41. The transfer capital threshold is the transfer adjustment factor * $6,178.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","69268.85","69268.85","69268.85","1 through 10","69013.66","120272.89","other","Inpatient Replacement Plans DRG"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC","221","MS-DRG","","","","","","","","inpatient","","","111041.90","83281.42","MEDICARE [2001]","HB BWH MEDICARE","46357.07","","Case rate ($46,357.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $55,727.36, add-ons for qualifying new technology services are included. If operating cost exceeds $101,371.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,495.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.9)) / 2. The base transfer operating payment is the transfer adjustment factor * $41,921.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $55,347.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,055.64. The transfer capital threshold is the transfer adjustment factor * $4,055.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","54421.16","54421.16","54421.16","1 through 10","45429.93","69306.9266","other","Inpatient Replacement Plans DRG"
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,EXTREME","162","DRG","","","","","","","","inpatient","","","597046.64","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","300105.08","","Standard inlier is a Case rate ($300,105.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $245,021, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($42,601.73) for the length of stay and the standard reimbursement.","308243.10","308243.10","308243.10","1 through 10","43110.61","530259.56","case rate",""
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,EXTREME","162","DRG","","","","","","","","inpatient","","","597046.64","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","337398.98","","Standard inlier is a Case rate ($337,398.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $245,021, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($47,890.98) for the length of stay and the standard reimbursement.","337398.98","308243.10","378210.82","1 through 10","43110.61","530259.56","case rate",""
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,EXTREME","162","DRG","","","","","","","","inpatient","","","597046.64","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","751646.82","751646.82","751646.82","1 through 10","43110.61","530259.56","percent of total billed charges",""
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,EXTREME","162","DRG","","","","","","","","inpatient","","","597046.64","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","82422.395","","Fee schedule rate ($254,214.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","82422.395","254214.36","254214.36","1 through 10","43110.61","530259.56","case rate",""
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,EXTREME","162","DRG","","","","","","","","inpatient","","","597046.64","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","99342.492","","Fee schedule rate ($254,214.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","99342.492","254214.36","254214.36","1 through 10","43110.61","530259.56","case rate",""
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,EXTREME","162","DRG","","","","","","","","inpatient","","","597046.64","","HEALTH NEW ENGLAND [1034]","HB BWH MEDICAID","84529.37","","Case rate ($93,461.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $135,891.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1997.85","1997.85","1997.85","1 through 10","43110.61","530259.56","case rate",""
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,EXTREME","162","DRG","","","","","","","","inpatient","","","597046.64","","MASSHEALTH [3001]","HB BWH MEDICAID","84529.37","","Case rate ($93,461.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $135,891.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","80857.47","80857.47","80857.47","1 through 10","43110.61","530259.56","case rate",""
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,EXTREME","162","DRG","","","","","","","","inpatient","","","597046.64","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","84529.37","","Case rate ($93,461.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $135,891.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","286432.39","286432.39","286432.39","1 through 10","43110.61","530259.56","case rate",""
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,MAJOR","162","DRG","","","","","","","","inpatient","","","348541.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","205546.46","","Standard inlier is a Case rate ($205,546.46). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $171,490, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($29,178.56) for the length of stay and the standard reimbursement.","205546.45","205546.45","205546.45","1 through 10","43110.61","530259.56","case rate",""
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,MAJOR","162","DRG","","","","","","","","inpatient","","","348541.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231089.62","","Standard inlier is a Case rate ($231,089.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $171,490, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($32,801.25) for the length of stay and the standard reimbursement.","231089.61","231089.61","231089.61","1 through 10","43110.61","530259.56","case rate",""
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,MAJOR","162","DRG","","","","","","","","inpatient","","","348541.65","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","530259.56","","Fee schedule rate ($530,259.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","213785.39","213785.39","213785.39","1 through 10","43110.61","530259.56","case rate",""
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,MAJOR","162","DRG","","","","","","","","inpatient","","","348541.65","","MASSHEALTH [3001]","HB BWH MEDICAID","55458.44","","Case rate ($61,318.84). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $103,748.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","82877.73","82877.73","82877.73","1 through 10","43110.61","530259.56","case rate",""
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,MAJOR","162","DRG","","","","","","","","inpatient","","","348541.65","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","55458.44","","Case rate ($61,318.84). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $103,748.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","43110.61","530259.56","case rate",""
"Cardiac Valve Procedures With Ami Or Complex Principal Diagnosis,MODERATE","162","DRG","","","","","","","","inpatient","","","223278.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","162904.85","","Standard inlier is a Case rate ($162,904.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $138,329, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($23,125.33) for the length of stay and the standard reimbursement.","187363.08","187363.08","187363.08","1 through 10","43110.61","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,EXTREME","163","DRG","","","","","","","","inpatient","","","410088.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","205546.46","","Standard inlier is a Case rate ($205,546.46). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $171,490, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($29,178.56) for the length of stay and the standard reimbursement.","255371.00","255371.00","277488.08","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,EXTREME","163","DRG","","","","","","","","inpatient","","","410088.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231089.62","","Standard inlier is a Case rate ($231,089.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $171,490, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($32,801.25) for the length of stay and the standard reimbursement.","262295.97","262295.97","287105.83","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,EXTREME","163","DRG","","","","","","","","inpatient","","","410088.25","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","321375.20","","Fee schedule rate ($321,375.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","321375.20","321375.20","321375.20","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,EXTREME","163","DRG","","","","","","","","inpatient","","","410088.25","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","337443.96","","Fee schedule rate ($337,443.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","324434.56","324434.56","324434.56","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,EXTREME","163","DRG","","","","","","","","inpatient","","","410088.25","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","353512.72","","Fee schedule rate ($353,512.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","353512.72","353512.72","353512.72","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,EXTREME","163","DRG","","","","","","","","inpatient","","","410088.25","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","208927.08","","Fee schedule rate ($208,927.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","329355.76","329355.76","329355.76","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,EXTREME","163","DRG","","","","","","","","inpatient","","","410088.25","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","219376.86","","Fee schedule rate ($219,376.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","345820.04","345820.04","345820.04","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,EXTREME","163","DRG","","","","","","","","inpatient","","","410088.25","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","55458.44","","Case rate ($61,318.84). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $103,748.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","85295.20","85295.20","85295.20","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,MAJOR","163","DRG","","","","","","","","inpatient","","","265094.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","170006.93","","Standard inlier is a Case rate ($170,006.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $143,852, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($24,133.51) for the length of stay and the standard reimbursement.","154967.51","154967.51","170006.93","11","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,MAJOR","163","DRG","","","","","","","","inpatient","","","265094.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","191133.61","","Standard inlier is a Case rate ($191,133.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $143,852, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($27,129.83) for the length of stay and the standard reimbursement.","191133.61","174617.06","191133.61","45","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,MAJOR","163","DRG","","","","","","","","inpatient","","","265094.05","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","80286.35","","Fee schedule rate ($80,286.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","158527.84","158527.84","158527.84","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,MAJOR","163","DRG","","","","","","","","inpatient","","","265094.05","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","84303.00","","Fee schedule rate ($84,303.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","166454.24","166454.24","324434.56","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,MAJOR","163","DRG","","","","","","","","inpatient","","","265094.05","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","88316.06","","Fee schedule rate ($88,316.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","174380.60","174380.60","174380.60","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,MAJOR","163","DRG","","","","","","","","inpatient","","","265094.05","","MASSHEALTH [3001]","HB BWH MEDICAID","46842.72","","Case rate ($51,792.68). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $94,222.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","51779.96","51779.96","51779.96","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,MAJOR","163","DRG","","","","","","","","inpatient","","","265094.05","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","198140.08","","Fee schedule rate ($198,140.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","168419.06","168419.06","198140.08","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,MAJOR","163","DRG","","","","","","","","inpatient","","","265094.05","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","208044.97","","Fee schedule rate ($208,044.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","208044.97","208044.97","208044.97","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,MODERATE","163","DRG","","","","","","","","inpatient","","","242193.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","134545.03","","Standard inlier is a Case rate ($134,545.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $116,275, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($19,099.48) for the length of stay and the standard reimbursement.","134545.02","134545.02","134545.02","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,MODERATE","163","DRG","","","","","","","","inpatient","","","242193.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","151264.87","","Standard inlier is a Case rate ($151,264.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $116,275, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($21,470.79) for the length of stay and the standard reimbursement.","146821.68","138193.52","174617.06","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,MODERATE","163","DRG","","","","","","","","inpatient","","","242193.19","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","34059.64","","Case rate ($37,658.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,088.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","50273.25","50273.25","50273.25","1 through 10","33600.41","530259.56","case rate",""
"Cardiac Valve Procedures Without Ami Or Complex Principal Diagnosis,MODERATE","163","DRG","","","","","","","","inpatient","","","242193.19","","MASSHEALTH [3001]","HB BWH MEDICAID","34059.64","","Case rate ($37,658.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,088.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25583.71","25583.71","25583.71","1 through 10","33600.41","530259.56","case rate",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","both","","","229.00","171.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","160.30","70","","222.00","97.61","222.00","1 through 10","14.19","217.55","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","both","","","229.00","171.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","182.06","79.5","","174.72","117.22","524.15","88","14.19","217.55","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","both","","","229.00","171.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","122.06","53.3","","174.72","117.22","586.08","70","14.19","217.55","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","both","","","229.00","171.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","176.33","77","","512.82","170.94","512.82","1 through 10","14.19","217.55","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","both","","","229.00","171.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","148.85","65","","144.30","144.30","288.60","1 through 10","14.19","217.55","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","both","","","229.00","171.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.59","36.5","","82.81","70.38","579.64","83","14.19","217.55","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","both","","","229.00","171.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.71","38.3","","86.80","86.80","260.40","222","14.19","217.55","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","both","","","229.00","171.75","TRICARE [160005]","HB BWH TRICARE","217.55","95","","29.14","29.14","61.34","1 through 10","14.19","217.55","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","both","","","229.00","171.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","217.55","95","","25.45","25.45","25.45","1 through 10","14.19","217.55","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","both","","","229.00","171.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.24","42.9","","177.47","177.47","177.47","1 through 10","14.19","217.55","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","229.00","171.75","AETNA [1001]","HB AMC AETNA HMO","159.84","69.8","","150.30","106.12","173.16","77","14.19","187.14","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","229.00","171.75","AETNA [1001]","HB AMC AETNA PPO","184.12","80.4","","173.16","116.33","232.66","1 through 10","14.19","187.14","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","229.00","171.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","184.12","80.4","","222.00","222.00","222.00","1 through 10","14.19","187.14","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","229.00","171.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","187.14","81.72","","444.00","444.00","444.00","1 through 10","14.19","187.14","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","229.00","171.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","187.14","81.72","","97.62","97.62","97.62","1 through 10","14.19","187.14","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","229.00","171.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","187.14","81.72","","177.47","97.62","354.93","68","14.19","187.14","percent of total billed charges",""
"Cardiomyopathy,MAJOR","205","DRG","","","","","","","","inpatient","","","26936.96","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32385.85","","Fee schedule rate ($32,385.85). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($3,747.17) multiplied by length of stay and the outlier percent (100%).","3747.17","3747.17","3747.17","1 through 10","5150.93","43740.99","case rate",""
"Cardiomyopathy,MINOR","205","DRG","","","","","","","","inpatient","","","18976.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","17558.24","","Standard inlier is a Case rate ($17,558.24). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,492.25) for the length of stay and the standard reimbursement.","17558.24","17558.24","17558.24","1 through 10","5150.93","43740.99","case rate",""
"Cardiomyopathy,MODERATE","205","DRG","","","","","","","","inpatient","","","36004.83","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21877.81","","Standard inlier is a Case rate ($21,877.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,780, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,105.37) for the length of stay and the standard reimbursement.","19987.27","19987.27","19987.27","1 through 10","5150.93","43740.99","case rate",""
"Cardiomyopathy,MODERATE","205","DRG","","","","","","","","inpatient","","","36004.83","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6653.14","","Case rate ($7,356.19). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,786.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","7354.38","1 through 10","5150.93","43740.99","case rate",""
"Cardioneural Ablation for Vagal Syncope","PX-48000473","CDM","93799","CPT","0481","RC","","","","both","","","25690.00","19267.50","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","20423.55","other","OPPS APC"
"Cardioneural Ablation for Vagal Syncope","PX-48000473","CDM","93799","CPT","0481","RC","","","","outpatient","","","25690.00","19267.50","AETNA [1001]","HB AMC AETNA HMO","17931.62","69.8","","2022.70","2022.70","2022.70","1 through 10","454","21194.25","percent of total billed charges",""
"Cardioneural Ablation for Vagal Syncope","PX-48000473","CDM","93799","CPT","0481","RC","","","","outpatient","","","25690.00","19267.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","15555.30","60.55","","318.03","318.03","2439.77","1 through 10","454","21194.25","percent of total billed charges",""
"Cardioneural Ablation for Vagal Syncope","PX-48000473","CDM","93799","CPT","0481","RC","","","","outpatient","","","25690.00","19267.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","13415.32","52.22","","360.38","360.38","4023.00","1 through 10","454","21194.25","percent of total billed charges",""
"Cardioneural Ablation for Vagal Syncope","PX-48000473","CDM","93799","CPT","0481","RC","","","","outpatient","","","25690.00","19267.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","14129.50","55","","13080.03","13080.03","13080.03","1 through 10","454","21194.25","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","800.35","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","800.56","799.66","800.56","1 through 10","738.26","2678.36","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","777.04","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","764.69","764.69","777.12","20","738.26","2678.36","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2678.36","79.5","","2571.13","2571.13","2571.13","1 through 10","738.26","2678.36","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1795.68","53.3","","1724.98","1724.98","1724.98","1 through 10","738.26","2678.36","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","777.04","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","764.69","764.69","764.69","1 through 10","738.26","2678.36","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","FALLON HEALTH [1008]","HB BWH MEDICARE","777.04","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2197.76","2197.76","2197.76","1 through 10","738.26","2678.36","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","MEDICARE [2001]","HB BWH MEDICARE","777.04","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","777.12","777.12","1554.24","203","738.26","2678.36","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1229.69","36.5","","1218.59","1218.59","1218.59","1 through 10","738.26","2678.36","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1290.33","38.3","","1277.40","1277.40","1277.40","1 through 10","738.26","2678.36","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","777.04","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","761.58","696.51","761.98","1 through 10","738.26","2678.36","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","TRICARE [160005]","HB BWH TRICARE","738.26","","APC Price ($777.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","738.26","738.26","738.26","1 through 10","738.26","2678.36","other","Tricare OPPS"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","761.50","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2284.74","696.11","4790.16","1 through 10","738.26","2678.36","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","761.50","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","767.08","704.02","769.48","18","738.26","2678.36","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","3369.00","2526.75","WELLPOINT [1015]","HB AMC WELLPOINT","2485.65","73.78","","2432.28","2432.28","3267.00","1 through 10","738.26","2678.36","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","outpatient","","","3369.00","2526.75","AETNA [1001]","HB AMC AETNA HMO","2351.56","69.8","","2211.76","1561.63","2211.76","1 through 10","1209.56","2753.15","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","outpatient","","","3369.00","2526.75","AETNA [1001]","HB AMC AETNA PPO","2708.68","80.4","","2548.26","2548.26","2548.26","1 through 10","1209.56","2753.15","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","outpatient","","","3369.00","2526.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2753.15","81.72","","2611.64","2611.64","2611.64","1 through 10","1209.56","2753.15","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","outpatient","","","3369.00","2526.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2753.15","81.72","","2611.64","1436.50","2611.64","1 through 10","1209.56","2753.15","percent of total billed charges",""
"Cardioverter-Defibrillator Dual Chamber T3","PX-27000032","CDM","C1721","HCPCS","0278","RC","","","","both","","","32716.70","24537.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12530.50","38.3","","12426.00","12426.00","12426.00","1 through 10","10142.18","26009.78","percent of total billed charges",""
"Cardioverter-Defibrillator Dual Chamber T3","PX-27000032","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","32716.70","24537.52","AETNA [1001]","HB AMC AETNA HMO","22836.26","69.8","","16823.45","16823.45","16823.45","1 through 10","17097.75","26736.09","percent of total billed charges",""
"Cardioverter-Defibrillator Dual Chamber T3","PX-27000032","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","32716.70","24537.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","26736.09","81.72","","19865.09","19865.09","19865.09","1 through 10","17097.75","26736.09","percent of total billed charges",""
"Cardioverter-Defibrillator Single Chamber T3","PX-27000033","CDM","C1722","HCPCS","0278","RC","","","","both","","","27692.98","20769.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","22015.92","79.5","","31564.33","31564.33","31564.33","1 through 10","8584.82","22015.92","percent of total billed charges",""
"Cardioverter-Defibrillator Single Chamber T3","PX-27000033","CDM","C1722","HCPCS","0278","RC","","","","both","","","27692.98","20769.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","18000.44","65","","27210.63","27210.63","27210.63","1 through 10","8584.82","22015.92","percent of total billed charges",""
"Cardioverter-Defibrillator Single Chamber T3","PX-27000033","CDM","C1722","HCPCS","0278","RC","","","","both","","","27692.98","20769.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10107.94","36.5","","46844.13","8621.25","46844.13","1 through 10","8584.82","22015.92","percent of total billed charges",""
"Cardioverter-Defibrillator Single Chamber T3","PX-27000033","CDM","C1722","HCPCS","0278","RC","","","","both","","","27692.98","20769.73","WELLPOINT [1015]","HB AMC WELLPOINT","20431.88","73.78","","16551.00","16551.00","16551.00","1 through 10","8584.82","22015.92","percent of total billed charges",""
"Cardioverter-Defibrillator Single Chamber T3","PX-27000033","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","27692.98","20769.73","AETNA [1001]","HB AMC AETNA HMO","19329.70","69.8","","74515.25","24796.25","74515.25","1 through 10","14472.35","22630.7","percent of total billed charges",""
"Cardioverter-Defibrillator Single Chamber T3","PX-27000033","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","27692.98","20769.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","22630.70","81.72","","10077.92","10077.92","10077.92","1 through 10","14472.35","22630.7","percent of total billed charges",""
"Cardioverter-Defibrillator Single Chamber T3","PX-27000033","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","27692.98","20769.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22630.70","81.72","","41468.88","41468.88","41468.88","1 through 10","14472.35","22630.7","percent of total billed charges",""
"Carnitine Total and Free Qn","PX-30000349","CDM","82379","CPT","0301","RC","","","","both","","","186.00","139.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","147.87","79.5","","141.66","141.66","141.66","1 through 10","11.02","176.7","percent of total billed charges",""
"Carnitine Total and Free Qn","PX-30000349","CDM","82379","CPT","0301","RC","","","","both","","","186.00","139.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.89","36.5","","57.06","56.52","57.06","1 through 10","11.02","176.7","percent of total billed charges",""
"Carnitine Total and Free Qn","PX-30000349","CDM","82379","CPT","0301","RC","","","","both","","","186.00","139.50","TRICARE [160005]","HB BWH TRICARE","176.70","95","","19.31","19.31","19.31","1 through 10","11.02","176.7","percent of total billed charges",""
"Carnitine Total and Free Qn","PX-30000349","CDM","82379","CPT","0301","RC","","","","outpatient","","","186.00","139.50","AETNA [1001]","HB AMC AETNA HMO","129.83","69.8","","86.04","86.04","86.04","1 through 10","11.02","152","percent of total billed charges",""
"Carnitine Total and Free Qn","PX-30000349","CDM","82379","CPT","0301","RC","","","","outpatient","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","152.00","81.72","","143.89","79.15","143.89","1 through 10","11.02","152","percent of total billed charges",""
"Carotene","PX-30000350","CDM","82380","CPT","0301","RC","","","","both","","","108.00","81.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","85.86","79.5","","82.64","82.64","82.64","1 through 10","9.04","102.6","percent of total billed charges",""
"Carotene","PX-30000350","CDM","82380","CPT","0301","RC","","","","both","","","108.00","81.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","39.42","36.5","","39.17","39.17","39.17","1 through 10","9.04","102.6","percent of total billed charges",""
"Carotene","PX-30000350","CDM","82380","CPT","0301","RC","","","","both","","","108.00","81.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","41.36","38.3","","41.06","41.06","41.06","1 through 10","9.04","102.6","percent of total billed charges",""
"Carotene","PX-30000350","CDM","82380","CPT","0301","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","88.26","81.72","","83.94","83.94","83.94","1 through 10","9.51","88.26","percent of total billed charges",""
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","","","","inpatient","","","104359.89","78269.92","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","22851.82","","Case rate ($22,186.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,630.44, add-ons for qualifying new technology services are included. If operating cost exceeds $72,274.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,363.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $19,882.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,250.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,923.54. The transfer capital threshold is the transfer adjustment factor * $1,923.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","21532.81","21532.81","21532.81","1 through 10","21742.51","34329.0068","other","Inpatient DRG"
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","","","","inpatient","","","104359.89","78269.92","ELDER SERVICES [1037]","HB BWH MEDICARE","28680.79","","Case rate ($28,680.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,630.44, add-ons for qualifying new technology services are included. If operating cost exceeds $72,274.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,363.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $26,377.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,250.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,923.54. The transfer capital threshold is the transfer adjustment factor * $1,923.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20951.24","20951.24","20951.24","1 through 10","21742.51","34329.0068","other","Inpatient DRG"
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","","","","inpatient","","","104359.89","78269.92","MEDICARE [2001]","HB BWH MEDICARE","28680.79","","Case rate ($28,680.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,630.44, add-ons for qualifying new technology services are included. If operating cost exceeds $72,274.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,363.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $26,377.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,250.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,923.54. The transfer capital threshold is the transfer adjustment factor * $1,923.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27096.25","0.03","27136.37","11","21742.51","34329.0068","other","Inpatient DRG"
"Carotid Artery Stent Procedures With McC","034","MS-DRG","","","","","","","","inpatient","","","119432.85","89574.64","MEDICARE [2001]","HB BWH MEDICARE","46204.76","","Case rate ($46,204.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $42,884.83, add-ons for qualifying new technology services are included. If operating cost exceeds $88,529.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,554.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $42,710.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,504.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,114.59. The transfer capital threshold is the transfer adjustment factor * $3,114.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","46122.77","46122.77","46191.34","1 through 10","34974.99","58684.3717","other","Inpatient DRG"
"Carotid Artery Stent Procedures Without Cc/McC","036","MS-DRG","","","","","","","","inpatient","","","89406.23","67054.67","MEDICARE [2001]","HB BWH MEDICARE","23380.51","","Case rate ($23,380.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,714.15, add-ons for qualifying new technology services are included. If operating cost exceeds $67,358.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $21,437.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,334.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.29. The transfer capital threshold is the transfer adjustment factor * $1,563.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","17740.22","27663.3121","other","Inpatient DRG"
"Carotid Stent Placement for Extravasation","PX-36000467","CDM","37799","CPT","0361","RC","","","","outpatient","","","25281.00","18960.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","13201.74","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","20856.83","percent of total billed charges",""
"Carotid Stent Placement for Extravasation","PX-36000467","CDM","37799","CPT","0361","RC","","","","outpatient","","","25281.00","18960.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","13272.53","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","20856.83","percent of total billed charges",""
"CARPAL PLATE SZ 1 ARTHROPLASTY","SUP-ITM-10139574","CDM","C1776","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5607.83","52.26","","1113.10","1113.10","1113.10","1 through 10","3326.5","8530.85","percent of total billed charges",""
"CARPAL PLATE SZ 1 ARTHROPLASTY","SUP-ITM-10139574","CDM","C1776","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8530.85","79.5","","1293.60","1148.53","1603.80","1 through 10","3326.5","8530.85","percent of total billed charges",""
"CARPAL PLATE SZ 1 ARTHROPLASTY","SUP-ITM-10139574","CDM","C1776","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3916.68","36.5","","1023.42","771.29","2068.67","33","3326.5","8530.85","percent of total billed charges",""
"CARPAL PLATE SZ 1 ARTHROPLASTY","SUP-ITM-10139574","CDM","C1776","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4109.83","38.3","","850.52","759.78","1211.25","66","3326.5","8530.85","percent of total billed charges",""
"CARPAL PLATE SZ 1 ARTHROPLASTY","SUP-ITM-10139574","CDM","C1776","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4603.44","42.9","","2548.09","2548.09","2548.09","1 through 10","3326.5","8530.85","percent of total billed charges",""
"CARPAL PLATE SZ 1 ARTHROPLASTY","SUP-ITM-10139574","CDM","C1776","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4603.44","42.9","","956.46","956.46","956.46","1 through 10","3326.5","8530.85","percent of total billed charges",""
"CARPAL PLATE SZ 1 ARTHROPLASTY","SUP-ITM-10139574","CDM","C1776","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","WELLPOINT [1015]","HB AMC WELLPOINT","7917.06","73.78","","2344.73","1619.47","2530.35","16","3326.5","8530.85","percent of total billed charges",""
"CARPAL PLATE SZ 1 ARTHROPLASTY","SUP-ITM-10139574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10730.63","8047.97","AETNA [1001]","HB AMC AETNA HMO","7489.98","69.8","","1523.63","988.41","4330.26","39","5607.83","8769.07","percent of total billed charges",""
"CARPAL PLATE SZ 1 ARTHROPLASTY","SUP-ITM-10139574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10730.63","8047.97","AETNA [1001]","HB AMC AETNA PPO","8627.43","80.4","","1670.25","1670.25","1670.25","1 through 10","5607.83","8769.07","percent of total billed charges",""
"CARPAL PLATE SZ 1 ARTHROPLASTY","SUP-ITM-10139574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10730.63","8047.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5607.83","52.26","","1113.10","1113.10","1113.10","1 through 10","5607.83","8769.07","percent of total billed charges",""
"CARPAL PLATE SZ 1 ARTHROPLASTY","SUP-ITM-10139574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10730.63","8047.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8769.07","81.72","","1738.90","1484.65","2716.94","38","5607.83","8769.07","percent of total billed charges",""
"CARTRIDGE PLACEMENT 1X5MM FUSION COIL MARKER STERILE POUCH OF 1","SUP-ITM-10268458","CDM","A4648","HCPCS","0278","RC","","","","both","","","427.00","320.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","339.47","79.5","","454.50","151.50","454.50","21","132.37","352.28","percent of total billed charges",""
"CARTRIDGE PLACEMENT 1X5MM FUSION COIL MARKER STERILE POUCH OF 1","SUP-ITM-10268458","CDM","A4648","HCPCS","0278","RC","","","","both","","","427.00","320.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","227.59","53.3","","304.92","207.96","485.88","1 through 10","132.37","352.28","percent of total billed charges",""
"CARTRIDGE PLACEMENT 1X5MM FUSION COIL MARKER STERILE POUCH OF 1","SUP-ITM-10268458","CDM","A4648","HCPCS","0278","RC","","","","both","","","427.00","320.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","155.86","36.5","","183.06","183.06","183.06","1 through 10","132.37","352.28","percent of total billed charges",""
"CARTRIDGE PLACEMENT 1X5MM FUSION COIL MARKER STERILE POUCH OF 1","SUP-ITM-10268458","CDM","A4648","HCPCS","0278","RC","","","","both","","","427.00","320.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","163.54","38.3","","225.81","149.00","234.60","19","132.37","352.28","percent of total billed charges",""
"CARTRIDGE PLACEMENT 1X5MM FUSION COIL MARKER STERILE POUCH OF 1","SUP-ITM-10268458","CDM","A4648","HCPCS","0278","RC","","","","both","","","427.00","320.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","183.18","42.9","","153.88","90.49","192.50","1 through 10","132.37","352.28","percent of total billed charges",""
"CARTRIDGE PLACEMENT 1X5MM FUSION COIL MARKER STERILE POUCH OF 1","SUP-ITM-10268458","CDM","A4648","HCPCS","0278","RC","","","","both","","","427.00","320.25","WELLPOINT [1015]","HB AMC WELLPOINT","315.04","73.78","","335.82","153.22","335.82","1 through 10","132.37","352.28","percent of total billed charges",""
"CARTRIDGE PLACEMENT 1X5MM FUSION COIL MARKER STERILE POUCH OF 1","SUP-ITM-10268458","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","427.00","320.25","AETNA [1001]","HB AMC AETNA HMO","298.05","69.8","","98.37","92.02","150.15","11","213.5","352.28","percent of total billed charges",""
"CARTRIDGE PLACEMENT 1X5MM FUSION COIL MARKER STERILE POUCH OF 1","SUP-ITM-10268458","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","427.00","320.25","AETNA [1001]","HB AMC AETNA PPO","343.31","80.4","","333.06","160.52","333.06","1 through 10","213.5","352.28","percent of total billed charges",""
"CARTRIDGE PLACEMENT 1X5MM FUSION COIL MARKER STERILE POUCH OF 1","SUP-ITM-10268458","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","427.00","320.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","348.94","81.72","","153.88","84.64","170.39","1 through 10","213.5","352.28","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","both","","","322.00","241.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","255.99","79.5","","245.54","164.74","245.54","1 through 10","24.75","305.9","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","both","","","322.00","241.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","171.63","53.3","","736.62","164.74","736.62","1 through 10","24.75","305.9","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","both","","","322.00","241.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","117.53","36.5","","98.90","98.90","98.90","1 through 10","24.75","305.9","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","both","","","322.00","241.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","123.33","38.3","","121.99","102.96","121.99","1 through 10","24.75","305.9","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","outpatient","","","322.00","241.50","AETNA [1001]","HB AMC AETNA HMO","224.76","69.8","","211.22","149.14","243.36","1 through 10","26.04","263.14","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","outpatient","","","322.00","241.50","AETNA [1001]","HB AMC AETNA PPO","258.89","80.4","","243.36","243.36","243.36","1 through 10","26.04","263.14","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","outpatient","","","322.00","241.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","263.14","81.72","","137.19","7.01","249.41","1 through 10","26.04","263.14","percent of total billed charges",""
"Cath Lt Hrt Transpt/ Transap Punc","PX-48000127","CDM","93462","CPT","0481","RC","","","","both","","","5584.00","4188.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4439.28","79.5","","4261.61","4261.61","4261.61","1 through 10","1731.04","7553.42","percent of total billed charges",""
"Cath Lt Hrt Transpt/ Transap Punc","PX-48000127","CDM","93462","CPT","0481","RC","","","","both","","","5584.00","4188.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2038.16","36.5","","2019.80","2019.80","2019.80","1 through 10","1731.04","7553.42","percent of total billed charges",""
"Cath Lt Hrt Transpt/ Transap Punc","PX-48000127","CDM","93462","CPT","0481","RC","","","","both","","","5584.00","4188.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2138.67","38.3","","2057.70","2057.70","2057.70","1 through 10","1731.04","7553.42","percent of total billed charges",""
"Cath Lt Hrt Transpt/ Transap Punc","PX-48000127","CDM","93462","CPT","0481","RC","","","","outpatient","","","5584.00","4188.00","AETNA [1001]","HB AMC AETNA HMO","3897.63","69.8","","4835.89","2588.37","4852.85","1 through 10","2918.2","4563.24","percent of total billed charges",""
"Cath Lt Hrt Transpt/ Transap Punc","PX-48000127","CDM","93462","CPT","0481","RC","","","","outpatient","","","5584.00","4188.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4563.24","81.72","","2380.98","2380.98","2380.98","1 through 10","2918.2","4563.24","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3758.57","3758.57","22448.00","16","3628.7","18402.66","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","15046.20","65","","11852.54","11852.54","11852.54","1 through 10","3628.7","18402.66","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","16203.60","70","","16162.56","16162.56","16162.56","1 through 10","3628.7","18402.66","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","4774.12","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","21623.78","21623.78","21623.78","1 through 10","3628.7","18402.66","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18402.66","79.5","","17666.58","14591.20","17666.58","1 through 10","3628.7","18402.66","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12337.88","53.3","","17666.58","10914.06","17666.58","1 through 10","3628.7","18402.66","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3758.57","3758.57","6582.37","1 through 10","3628.7","18402.66","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","FALLON HEALTH [1008]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11229.87","11229.87","11229.87","1 through 10","3628.7","18402.66","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","17823.96","77","","17284.96","17284.96","17284.96","1 through 10","3628.7","18402.66","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","HUMANA [1012]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3748.29","3748.29","3748.29","1 through 10","3628.7","18402.66","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","MEDICARE [2001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3819.68","3556.47","3819.68","112","3628.7","18402.66","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8865.68","38.3","","8777.17","8777.17","16117.66","1 through 10","3628.7","18402.66","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","MOLINA [1014]","HB BWH MOLINA","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7578.25","7578.25","7580.58","1 through 10","3628.7","18402.66","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","TRICARE [160005]","HB BWH TRICARE","3628.70","","APC Price ($3,819.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3628.70","3628.70","3628.70","1 through 10","3628.7","18402.66","other","Tricare OPPS"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","3628.70","","APC Price ($3,819.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3819.68","3819.68","3819.68","1 through 10","3628.7","18402.66","other","Tricare OPPS"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3743.49","3499.57","3743.69","1 through 10","3628.7","18402.66","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5163.04","5163.04","5163.04","1 through 10","3628.7","18402.66","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9930.49","42.9","","10213.84","10213.84","10213.84","1 through 10","3628.7","18402.66","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","23148.00","17361.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3750.99","3743.29","3819.68","13","3628.7","18402.66","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","outpatient","","","23148.00","17361.00","AETNA [1001]","HB AMC AETNA HMO","16157.30","69.8","","15197.30","15197.30","15197.30","1 through 10","2529.37","18916.55","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","outpatient","","","23148.00","17361.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","28668.94","6475.19","28668.94","1 through 10","2529.37","18916.55","other","Multiple Surgery"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","outpatient","","","23148.00","17361.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","5868.14","5640.50","11281.00","1 through 10","2529.37","18916.55","other","Multiple Surgery"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","outpatient","","","23148.00","17361.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5944.02","5944.02","5944.02","1 through 10","2529.37","18916.55","other","Multiple Surgery"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","outpatient","","","23148.00","17361.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","7335.17","7335.17","7335.17","1 through 10","2529.37","18916.55","other","Multiple Surgery"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","outpatient","","","23148.00","17361.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6171.66","6171.66","6171.66","1 through 10","2529.37","18916.55","other","Multiple Surgery"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","outpatient","","","23148.00","17361.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","6475.19","6475.19","6475.19","1 through 10","2529.37","18916.55","other","Multiple Surgery"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","outpatient","","","23148.00","17361.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","18916.55","81.72","","16732.01","16732.01","16732.01","1 through 10","2529.37","18916.55","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","outpatient","","","23148.00","17361.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","7056.94","7056.94","7056.94","1 through 10","2529.37","18916.55","other","Multiple Surgery"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","outpatient","","","23148.00","17361.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18916.55","81.72","","17944.93","3424.59","17944.93","1 through 10","2529.37","18916.55","percent of total billed charges",""
"Cath Rt/Lt Heart W/ Ventriculograph","PX-48000118","CDM","93453","CPT","0481","RC","","","","both","","","35289.00","26466.75","MEDICARE [2001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3819.68","3819.68","3819.68","1 through 10","3628.7","28054.76","other","OPPS APC"
"Cath TPA Injection Into Hematoma/Seroma/Collection Subcutaneous","PX-76002452","CDM","17999","CPT","0761","RC","","","","both","","","489.00","366.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4490.63","3878.56","4490.63","1 through 10","151.59","388.76","other","OPPS APC"
"Cath TPA Injection Into Hematoma/Seroma/Collection Subcutaneous","PX-76002452","CDM","17999","CPT","0761","RC","","","","outpatient","","","489.00","366.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","255.36","52.22","","467.73","465.00","467.73","1 through 10","244.5","700.33","percent of total billed charges",""
"Cath, Ep, Cool-Tip T3","PX-27001098","CDM","C2630","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2441.63","38.3","","3714.50","3714.50","3714.50","1 through 10","1976.25","5068.13","percent of total billed charges",""
"Cath, Translum Angio, Drug, Nonlaser Tier2","PX-27001144","CDM","C2623","HCPCS","0272","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","3445.53","3445.53","3445.53","1 through 10","1395","3577.5","percent of total billed charges",""
"Cath, Translum Angio, Drug, Nonlaser Tier2","PX-27001144","CDM","C2623","HCPCS","0272","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","5522.88","5522.88","5522.88","1 through 10","1395","3577.5","percent of total billed charges",""
"Cath, Translum Angio, Drug, Nonlaser Tier2","PX-27001144","CDM","C2623","HCPCS","0272","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","3244.16","3126.90","3244.16","1 through 10","1395","3577.5","percent of total billed charges",""
"Cath, Translum Angio, Drug, Nonlaser Tier2","PX-27001144","CDM","C2623","HCPCS","0272","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","11291.52","11291.52","11291.52","1 through 10","2351.7","3677.4","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","both","","","420.00","315.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","333.90","79.5","","961.79","214.90","961.79","38","130.2","333.9","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","both","","","420.00","315.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","223.86","53.3","","215.25","215.25","1108.28","63","130.2","333.9","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","130.20","31","","125.76","125.76","125.76","1 through 10","130.2","333.9","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","153.30","36.5","","387.06","147.33","455.43","21","130.2","333.9","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","160.86","38.3","","477.42","159.14","477.42","94","130.2","333.9","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","both","","","420.00","315.00","WELLPOINT [1015]","HB AMC WELLPOINT","309.88","73.78","","710.01","303.01","710.01","19","130.2","333.9","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","outpatient","","","420.00","315.00","AETNA [1001]","HB AMC AETNA HMO","293.16","69.8","","275.54","194.55","275.54","19","97.65","343.22","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","outpatient","","","420.00","315.00","AETNA [1001]","HB AMC AETNA PPO","337.68","80.4","","426.54","317.46","426.54","1 through 10","97.65","343.22","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","outpatient","","","420.00","315.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","97.65","","Case rate ($97.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","407.00","407.00","407.00","1 through 10","97.65","343.22","other","ASC"
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","343.22","81.72","","325.36","325.36","325.36","1 through 10","97.65","343.22","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","343.22","81.72","","325.36","178.96","325.36","18","97.65","343.22","percent of total billed charges",""
"CATHETER ABLTN 115CMX7FR 1 4MM L 8 SPACING F J BIDIRECTIONAL EZ STEER TECHNOLOGY REDEL 10 PIN CONCTR THERMOCOUPLE AUTO","SUP-ITM-10072986","CDM","C1730","HCPCS","0272","RC","","","","both","","","1781.50","1336.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","931.01","52.26","","1988.81","1988.81","1988.81","1 through 10","552.27","1416.29","percent of total billed charges",""
"CATHETER ABLTN 115CMX7FR 1 4MM L 8 SPACING F J BIDIRECTIONAL EZ STEER TECHNOLOGY REDEL 10 PIN CONCTR THERMOCOUPLE AUTO","SUP-ITM-10072986","CDM","C1730","HCPCS","0272","RC","","","","both","","","1781.50","1336.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1416.29","79.5","","765.06","765.06","765.06","1 through 10","552.27","1416.29","percent of total billed charges",""
"CATHETER ABLTN 115CMX7FR 1 4MM L 8 SPACING F J BIDIRECTIONAL EZ STEER TECHNOLOGY REDEL 10 PIN CONCTR THERMOCOUPLE AUTO","SUP-ITM-10072986","CDM","C1730","HCPCS","0272","RC","","","","both","","","1781.50","1336.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","949.54","53.3","","6427.95","6427.95","6427.95","1 through 10","552.27","1416.29","percent of total billed charges",""
"CATHETER ABLTN 115CMX7FR 1 4MM L 8 SPACING F J BIDIRECTIONAL EZ STEER TECHNOLOGY REDEL 10 PIN CONCTR THERMOCOUPLE AUTO","SUP-ITM-10072986","CDM","C1730","HCPCS","0272","RC","","","","both","","","1781.50","1336.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1157.98","65","","1193.16","1193.16","1193.16","1 through 10","552.27","1416.29","percent of total billed charges",""
"CATHETER ABLTN 115CMX7FR 1 4MM L 8 SPACING F J BIDIRECTIONAL EZ STEER TECHNOLOGY REDEL 10 PIN CONCTR THERMOCOUPLE AUTO","SUP-ITM-10072986","CDM","C1730","HCPCS","0272","RC","","","","both","","","1781.50","1336.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","650.25","36.5","","2053.37","54.83","3398.85","20","552.27","1416.29","percent of total billed charges",""
"CATHETER ABLTN 115CMX7FR 1 4MM L 8 SPACING F J BIDIRECTIONAL EZ STEER TECHNOLOGY REDEL 10 PIN CONCTR THERMOCOUPLE AUTO","SUP-ITM-10072986","CDM","C1730","HCPCS","0272","RC","","","","both","","","1781.50","1336.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","682.31","38.3","","232.75","124.53","2541.50","39","552.27","1416.29","percent of total billed charges",""
"CATHETER ABLTN 115CMX7FR 1 4MM L 8 SPACING F J BIDIRECTIONAL EZ STEER TECHNOLOGY REDEL 10 PIN CONCTR THERMOCOUPLE AUTO","SUP-ITM-10072986","CDM","C1730","HCPCS","0272","RC","","","","both","","","1781.50","1336.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","764.26","42.9","","66.89","66.89","66.89","1 through 10","552.27","1416.29","percent of total billed charges",""
"CATHETER ABLTN 115CMX7FR 1 4MM L 8 SPACING F J BIDIRECTIONAL EZ STEER TECHNOLOGY REDEL 10 PIN CONCTR THERMOCOUPLE AUTO","SUP-ITM-10072986","CDM","C1730","HCPCS","0272","RC","","","","both","","","1781.50","1336.12","WELLPOINT [1015]","HB AMC WELLPOINT","1314.39","73.78","","2392.81","1818.08","6339.98","15","552.27","1416.29","percent of total billed charges",""
"CATHETER ABLTN 115CMX7FR 1 4MM L 8 SPACING F J BIDIRECTIONAL EZ STEER TECHNOLOGY REDEL 10 PIN CONCTR THERMOCOUPLE AUTO","SUP-ITM-10072986","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","1781.50","1336.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","931.01","52.26","","1988.81","1988.81","1988.81","1 through 10","931.01","1455.84","percent of total billed charges",""
"CATHETER ABLTN 115CMX7FR 1 4MM L 8 SPACING F J BIDIRECTIONAL EZ STEER TECHNOLOGY REDEL 10 PIN CONCTR THERMOCOUPLE AUTO","SUP-ITM-10072986","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","1781.50","1336.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1455.84","81.72","","2569.25","132.34","2569.25","1 through 10","931.01","1455.84","percent of total billed charges",""
"CATHETER ABLTN 115CMX7FR 1 4MM L 8 SPACING F J BIDIRECTIONAL EZ STEER TECHNOLOGY REDEL 10 PIN CONCTR THERMOCOUPLE AUTO","SUP-ITM-10072986","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","1781.50","1336.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1455.84","81.72","","727.92","102.34","6154.18","26","931.01","1455.84","percent of total billed charges",""
"CATHETER ACCESS 2.9FR .9MM 125CM .038IN DISTAL","SUP-ITM-10176340","CDM","C1887","HCPCS","0272","RC","","","","both","","","4588.14","3441.10","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3294.28","71.8","","28.28","27.13","28.28","1 through 10","1422.32","3647.57","percent of total billed charges",""
"CATHETER ACCESS 2.9FR .9MM 125CM .038IN DISTAL","SUP-ITM-10176340","CDM","C1887","HCPCS","0272","RC","","","","both","","","4588.14","3441.10","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3211.70","70","","44.63","35.78","44.63","1 through 10","1422.32","3647.57","percent of total billed charges",""
"CATHETER ACCESS 2.9FR .9MM 125CM .038IN DISTAL","SUP-ITM-10176340","CDM","C1887","HCPCS","0272","RC","","","","both","","","4588.14","3441.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3647.57","79.5","","1342.89","271.64","6954.67","1 through 10","1422.32","3647.57","percent of total billed charges",""
"CATHETER ACCESS 2.9FR .9MM 125CM .038IN DISTAL","SUP-ITM-10176340","CDM","C1887","HCPCS","0272","RC","","","","both","","","4588.14","3441.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2445.48","53.3","","4550.00","30.49","4550.00","1 through 10","1422.32","3647.57","percent of total billed charges",""
"CATHETER ACCESS 2.9FR .9MM 125CM .038IN DISTAL","SUP-ITM-10176340","CDM","C1887","HCPCS","0272","RC","","","","both","","","4588.14","3441.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2982.29","65","","42.09","0.04","5453.50","1 through 10","1422.32","3647.57","percent of total billed charges",""
"CATHETER ACCESS 2.9FR .9MM 125CM .038IN DISTAL","SUP-ITM-10176340","CDM","C1887","HCPCS","0272","RC","","","","both","","","4588.14","3441.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1674.67","36.5","","310.94","18.54","1259.30","62","1422.32","3647.57","percent of total billed charges",""
"CATHETER ACCESS 2.9FR .9MM 125CM .038IN DISTAL","SUP-ITM-10176340","CDM","C1887","HCPCS","0272","RC","","","","both","","","4588.14","3441.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1757.26","38.3","","146.86","22.58","1753.45","65","1422.32","3647.57","percent of total billed charges",""
"CATHETER ACCESS 2.9FR .9MM 125CM .038IN DISTAL","SUP-ITM-10176340","CDM","C1887","HCPCS","0272","RC","","","","both","","","4588.14","3441.10","WELLPOINT [1015]","HB AMC WELLPOINT","3385.13","73.78","","247.29","33.09","909.09","53","1422.32","3647.57","percent of total billed charges",""
"CATHETER ACCESS 2.9FR .9MM 125CM .038IN DISTAL","SUP-ITM-10176340","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4588.14","3441.10","AETNA [1001]","HB AMC AETNA HMO","3202.52","69.8","","30.69","30.21","30.69","1 through 10","2397.76","3749.43","percent of total billed charges",""
"CATHETER ACCESS 2.9FR .9MM 125CM .038IN DISTAL","SUP-ITM-10176340","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4588.14","3441.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3688.86","80.4","","82.69","82.69","82.69","1 through 10","2397.76","3749.43","percent of total billed charges",""
"CATHETER ACCESS 2.9FR .9MM 125CM .038IN DISTAL","SUP-ITM-10176340","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4588.14","3441.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3749.43","81.72","","751.01","74.72","751.01","1 through 10","2397.76","3749.43","percent of total billed charges",""
"CATHETER ACCESS 2.9FR .9MM 125CM .038IN DISTAL","SUP-ITM-10176340","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4588.14","3441.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3749.43","81.72","","328.92","46.17","2701.97","59","2397.76","3749.43","percent of total billed charges",""
"CATHETER ACCESS 6FR VASCULAR ELLIPSYS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10240056","CDM","C1887","HCPCS","0272","RC","","","","both","","","22375.00","16781.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","16065.25","71.8","","28.28","27.13","28.28","1 through 10","6936.25","17788.13","percent of total billed charges",""
"CATHETER ACCESS 6FR VASCULAR ELLIPSYS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10240056","CDM","C1887","HCPCS","0272","RC","","","","both","","","22375.00","16781.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","15662.50","70","","44.63","35.78","44.63","1 through 10","6936.25","17788.13","percent of total billed charges",""
"CATHETER ACCESS 6FR VASCULAR ELLIPSYS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10240056","CDM","C1887","HCPCS","0272","RC","","","","both","","","22375.00","16781.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","17788.13","79.5","","1342.89","271.64","6954.67","1 through 10","6936.25","17788.13","percent of total billed charges",""
"CATHETER ACCESS 6FR VASCULAR ELLIPSYS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10240056","CDM","C1887","HCPCS","0272","RC","","","","both","","","22375.00","16781.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11925.88","53.3","","4550.00","30.49","4550.00","1 through 10","6936.25","17788.13","percent of total billed charges",""
"CATHETER ACCESS 6FR VASCULAR ELLIPSYS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10240056","CDM","C1887","HCPCS","0272","RC","","","","both","","","22375.00","16781.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","14543.75","65","","42.09","0.04","5453.50","1 through 10","6936.25","17788.13","percent of total billed charges",""
"CATHETER ACCESS 6FR VASCULAR ELLIPSYS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10240056","CDM","C1887","HCPCS","0272","RC","","","","both","","","22375.00","16781.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8166.88","36.5","","310.94","18.54","1259.30","62","6936.25","17788.13","percent of total billed charges",""
"CATHETER ACCESS 6FR VASCULAR ELLIPSYS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10240056","CDM","C1887","HCPCS","0272","RC","","","","both","","","22375.00","16781.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8569.63","38.3","","146.86","22.58","1753.45","65","6936.25","17788.13","percent of total billed charges",""
"CATHETER ACCESS 6FR VASCULAR ELLIPSYS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10240056","CDM","C1887","HCPCS","0272","RC","","","","both","","","22375.00","16781.25","WELLPOINT [1015]","HB AMC WELLPOINT","16508.28","73.78","","247.29","33.09","909.09","53","6936.25","17788.13","percent of total billed charges",""
"CATHETER ACCESS 6FR VASCULAR ELLIPSYS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10240056","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","22375.00","16781.25","AETNA [1001]","HB AMC AETNA HMO","15617.75","69.8","","30.69","30.21","30.69","1 through 10","11693.18","18284.85","percent of total billed charges",""
"CATHETER ACCESS 6FR VASCULAR ELLIPSYS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10240056","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","22375.00","16781.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","17989.50","80.4","","82.69","82.69","82.69","1 through 10","11693.18","18284.85","percent of total billed charges",""
"CATHETER ACCESS 6FR VASCULAR ELLIPSYS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10240056","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","22375.00","16781.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","18284.85","81.72","","751.01","74.72","751.01","1 through 10","11693.18","18284.85","percent of total billed charges",""
"CATHETER ACCESS 6FR VASCULAR ELLIPSYS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10240056","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","22375.00","16781.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18284.85","81.72","","328.92","46.17","2701.97","59","11693.18","18284.85","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","both","","","463.40","347.55","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","332.72","71.8","","28.28","27.13","28.28","1 through 10","143.65","368.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","both","","","463.40","347.55","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","324.38","70","","44.63","35.78","44.63","1 through 10","143.65","368.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","both","","","463.40","347.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","368.40","79.5","","1342.89","271.64","6954.67","1 through 10","143.65","368.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","both","","","463.40","347.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","246.99","53.3","","4550.00","30.49","4550.00","1 through 10","143.65","368.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","both","","","463.40","347.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","301.21","65","","42.09","0.04","5453.50","1 through 10","143.65","368.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","both","","","463.40","347.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","169.14","36.5","","310.94","18.54","1259.30","62","143.65","368.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","both","","","463.40","347.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","177.48","38.3","","146.86","22.58","1753.45","65","143.65","368.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","both","","","463.40","347.55","WELLPOINT [1015]","HB AMC WELLPOINT","341.90","73.78","","247.29","33.09","909.09","53","143.65","368.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","463.40","347.55","AETNA [1001]","HB AMC AETNA HMO","323.45","69.8","","30.69","30.21","30.69","1 through 10","242.17","378.69","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","463.40","347.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","372.57","80.4","","82.69","82.69","82.69","1 through 10","242.17","378.69","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","463.40","347.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","378.69","81.72","","751.01","74.72","751.01","1 through 10","242.17","378.69","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","463.40","347.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","378.69","81.72","","328.92","46.17","2701.97","59","242.17","378.69","percent of total billed charges",""
"CATHETER ACCU VU 5FR 2MM 70CM .035IN ANGIOGRAPHY OMNI FLUSH SIZING 2 BANDS BX/10EA","SUP-ITM-10147484","CDM","C1887","HCPCS","0272","RC","","","","both","","","88.55","66.41","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","63.58","71.8","","28.28","27.13","28.28","1 through 10","27.45","70.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 2MM 70CM .035IN ANGIOGRAPHY OMNI FLUSH SIZING 2 BANDS BX/10EA","SUP-ITM-10147484","CDM","C1887","HCPCS","0272","RC","","","","both","","","88.55","66.41","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","61.99","70","","44.63","35.78","44.63","1 through 10","27.45","70.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 2MM 70CM .035IN ANGIOGRAPHY OMNI FLUSH SIZING 2 BANDS BX/10EA","SUP-ITM-10147484","CDM","C1887","HCPCS","0272","RC","","","","both","","","88.55","66.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","70.40","79.5","","1342.89","271.64","6954.67","1 through 10","27.45","70.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 2MM 70CM .035IN ANGIOGRAPHY OMNI FLUSH SIZING 2 BANDS BX/10EA","SUP-ITM-10147484","CDM","C1887","HCPCS","0272","RC","","","","both","","","88.55","66.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","47.20","53.3","","4550.00","30.49","4550.00","1 through 10","27.45","70.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 2MM 70CM .035IN ANGIOGRAPHY OMNI FLUSH SIZING 2 BANDS BX/10EA","SUP-ITM-10147484","CDM","C1887","HCPCS","0272","RC","","","","both","","","88.55","66.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","57.56","65","","42.09","0.04","5453.50","1 through 10","27.45","70.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 2MM 70CM .035IN ANGIOGRAPHY OMNI FLUSH SIZING 2 BANDS BX/10EA","SUP-ITM-10147484","CDM","C1887","HCPCS","0272","RC","","","","both","","","88.55","66.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","32.32","36.5","","310.94","18.54","1259.30","62","27.45","70.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 2MM 70CM .035IN ANGIOGRAPHY OMNI FLUSH SIZING 2 BANDS BX/10EA","SUP-ITM-10147484","CDM","C1887","HCPCS","0272","RC","","","","both","","","88.55","66.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.91","38.3","","146.86","22.58","1753.45","65","27.45","70.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 2MM 70CM .035IN ANGIOGRAPHY OMNI FLUSH SIZING 2 BANDS BX/10EA","SUP-ITM-10147484","CDM","C1887","HCPCS","0272","RC","","","","both","","","88.55","66.41","WELLPOINT [1015]","HB AMC WELLPOINT","65.33","73.78","","247.29","33.09","909.09","53","27.45","70.4","percent of total billed charges",""
"CATHETER ACCU VU 5FR 2MM 70CM .035IN ANGIOGRAPHY OMNI FLUSH SIZING 2 BANDS BX/10EA","SUP-ITM-10147484","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","88.55","66.41","AETNA [1001]","HB AMC AETNA HMO","61.81","69.8","","30.69","30.21","30.69","1 through 10","46.28","72.36","percent of total billed charges",""
"CATHETER ACCU VU 5FR 2MM 70CM .035IN ANGIOGRAPHY OMNI FLUSH SIZING 2 BANDS BX/10EA","SUP-ITM-10147484","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","88.55","66.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","71.19","80.4","","82.69","82.69","82.69","1 through 10","46.28","72.36","percent of total billed charges",""
"CATHETER ACCU VU 5FR 2MM 70CM .035IN ANGIOGRAPHY OMNI FLUSH SIZING 2 BANDS BX/10EA","SUP-ITM-10147484","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","88.55","66.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","72.36","81.72","","751.01","74.72","751.01","1 through 10","46.28","72.36","percent of total billed charges",""
"CATHETER ACCU VU 5FR 2MM 70CM .035IN ANGIOGRAPHY OMNI FLUSH SIZING 2 BANDS BX/10EA","SUP-ITM-10147484","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","88.55","66.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","72.36","81.72","","328.92","46.17","2701.97","59","46.28","72.36","percent of total billed charges",""
"CATHETER ACCU-FLO 15CM DRAINAGE STRAIGHT XRAY DETECTABLE STYLET VENTRICULAR","SUP-ITM-10003571","CDM","C1889","HCPCS","0278","RC","","","","both","","","571.69","428.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","454.49","79.5","","1309.77","674.56","6049.93","26","177.22","454.49","percent of total billed charges",""
"CATHETER ACCU-FLO 15CM DRAINAGE STRAIGHT XRAY DETECTABLE STYLET VENTRICULAR","SUP-ITM-10003571","CDM","C1889","HCPCS","0278","RC","","","","both","","","571.69","428.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","304.71","53.3","","1901.83","1901.83","2962.25","1 through 10","177.22","454.49","percent of total billed charges",""
"CATHETER ACCU-FLO 15CM DRAINAGE STRAIGHT XRAY DETECTABLE STYLET VENTRICULAR","SUP-ITM-10003571","CDM","C1889","HCPCS","0278","RC","","","","both","","","571.69","428.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","208.67","36.5","","1620.31","1620.31","19908.88","1 through 10","177.22","454.49","percent of total billed charges",""
"CATHETER ACCU-FLO 15CM DRAINAGE STRAIGHT XRAY DETECTABLE STYLET VENTRICULAR","SUP-ITM-10003571","CDM","C1889","HCPCS","0278","RC","","","","both","","","571.69","428.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","218.96","38.3","","352.91","352.91","2046.30","1 through 10","177.22","454.49","percent of total billed charges",""
"CATHETER ACCU-FLO 15CM DRAINAGE STRAIGHT XRAY DETECTABLE STYLET VENTRICULAR","SUP-ITM-10003571","CDM","C1889","HCPCS","0278","RC","","","","both","","","571.69","428.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","245.26","42.9","","9668.75","9668.75","9668.75","1 through 10","177.22","454.49","percent of total billed charges",""
"CATHETER ACCU-FLO 15CM DRAINAGE STRAIGHT XRAY DETECTABLE STYLET VENTRICULAR","SUP-ITM-10003571","CDM","C1889","HCPCS","0278","RC","","","","both","","","571.69","428.77","WELLPOINT [1015]","HB AMC WELLPOINT","421.79","73.78","","699.88","384.10","3443.31","33","177.22","454.49","percent of total billed charges",""
"CATHETER ACCU-FLO 15CM DRAINAGE STRAIGHT XRAY DETECTABLE STYLET VENTRICULAR","SUP-ITM-10003571","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","571.69","428.77","AETNA [1001]","HB AMC AETNA HMO","399.04","69.8","","1421.24","264.50","4933.46","29","298.77","467.19","percent of total billed charges",""
"CATHETER ACCU-FLO 15CM DRAINAGE STRAIGHT XRAY DETECTABLE STYLET VENTRICULAR","SUP-ITM-10003571","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","571.69","428.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","459.64","80.4","","1022.97","1022.97","3607.50","1 through 10","298.77","467.19","percent of total billed charges",""
"CATHETER ACCU-FLO 15CM DRAINAGE STRAIGHT XRAY DETECTABLE STYLET VENTRICULAR","SUP-ITM-10003571","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","571.69","428.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","467.19","81.72","","3010.54","693.88","5019.88","35","298.77","467.19","percent of total billed charges",""
"CATHETER ACUITY PRO 7FR 50CM GUIDE CS OUTER STRAIGHT","SUP-ITM-10134385","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","294.02","71.8","","28.28","27.13","28.28","1 through 10","126.95","325.55","percent of total billed charges",""
"CATHETER ACUITY PRO 7FR 50CM GUIDE CS OUTER STRAIGHT","SUP-ITM-10134385","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","286.65","70","","44.63","35.78","44.63","1 through 10","126.95","325.55","percent of total billed charges",""
"CATHETER ACUITY PRO 7FR 50CM GUIDE CS OUTER STRAIGHT","SUP-ITM-10134385","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","325.55","79.5","","1342.89","271.64","6954.67","1 through 10","126.95","325.55","percent of total billed charges",""
"CATHETER ACUITY PRO 7FR 50CM GUIDE CS OUTER STRAIGHT","SUP-ITM-10134385","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","218.26","53.3","","4550.00","30.49","4550.00","1 through 10","126.95","325.55","percent of total billed charges",""
"CATHETER ACUITY PRO 7FR 50CM GUIDE CS OUTER STRAIGHT","SUP-ITM-10134385","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","266.18","65","","42.09","0.04","5453.50","1 through 10","126.95","325.55","percent of total billed charges",""
"CATHETER ACUITY PRO 7FR 50CM GUIDE CS OUTER STRAIGHT","SUP-ITM-10134385","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","149.47","36.5","","310.94","18.54","1259.30","62","126.95","325.55","percent of total billed charges",""
"CATHETER ACUITY PRO 7FR 50CM GUIDE CS OUTER STRAIGHT","SUP-ITM-10134385","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","156.84","38.3","","146.86","22.58","1753.45","65","126.95","325.55","percent of total billed charges",""
"CATHETER ACUITY PRO 7FR 50CM GUIDE CS OUTER STRAIGHT","SUP-ITM-10134385","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","WELLPOINT [1015]","HB AMC WELLPOINT","302.13","73.78","","247.29","33.09","909.09","53","126.95","325.55","percent of total billed charges",""
"CATHETER ACUITY PRO 7FR 50CM GUIDE CS OUTER STRAIGHT","SUP-ITM-10134385","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","409.50","307.12","AETNA [1001]","HB AMC AETNA HMO","285.83","69.8","","30.69","30.21","30.69","1 through 10","214","334.64","percent of total billed charges",""
"CATHETER ACUITY PRO 7FR 50CM GUIDE CS OUTER STRAIGHT","SUP-ITM-10134385","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","409.50","307.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","329.24","80.4","","82.69","82.69","82.69","1 through 10","214","334.64","percent of total billed charges",""
"CATHETER ACUITY PRO 7FR 50CM GUIDE CS OUTER STRAIGHT","SUP-ITM-10134385","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","409.50","307.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","334.64","81.72","","751.01","74.72","751.01","1 through 10","214","334.64","percent of total billed charges",""
"CATHETER ACUITY PRO 7FR 50CM GUIDE CS OUTER STRAIGHT","SUP-ITM-10134385","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","409.50","307.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","334.64","81.72","","328.92","46.17","2701.97","59","214","334.64","percent of total billed charges",""
"CATHETER ADVISOR 8FRX110CM MAPPING HD GRID SENSOR ENABLED HIGH DENSITY","SUP-ITM-10212173","CDM","C1732","HCPCS","0272","RC","","","","both","","","6500.00","4875.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4225.00","65","","2222.68","2222.68","2222.68","1 through 10","2015","5167.5","percent of total billed charges",""
"CATHETER ADVISOR 8FRX110CM MAPPING HD GRID SENSOR ENABLED HIGH DENSITY","SUP-ITM-10212173","CDM","C1732","HCPCS","0272","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2372.50","36.5","","4681.38","1275.47","8371.80","20","2015","5167.5","percent of total billed charges",""
"CATHETER ADVISOR 8FRX110CM MAPPING HD GRID SENSOR ENABLED HIGH DENSITY","SUP-ITM-10212173","CDM","C1732","HCPCS","0272","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2489.50","38.3","","1663.12","1287.53","2528.21","1 through 10","2015","5167.5","percent of total billed charges",""
"CATHETER ADVISOR 8FRX110CM MAPPING HD GRID SENSOR ENABLED HIGH DENSITY","SUP-ITM-10212173","CDM","C1732","HCPCS","0272","RC","","","","both","","","6500.00","4875.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2788.50","42.9","","1935.35","1935.35","1935.35","1 through 10","2015","5167.5","percent of total billed charges",""
"CATHETER ADVISOR 8FRX110CM MAPPING HD GRID SENSOR ENABLED HIGH DENSITY","SUP-ITM-10212173","CDM","C1732","HCPCS","0272","RC","","","","both","","","6500.00","4875.00","WELLPOINT [1015]","HB AMC WELLPOINT","4795.70","73.78","","4813.94","2545.82","7082.06","1 through 10","2015","5167.5","percent of total billed charges",""
"CATHETER ADVISOR 8FRX110CM MAPPING HD GRID SENSOR ENABLED HIGH DENSITY","SUP-ITM-10212173","CDM","C1732","HCPCS","0272","RC","","","","outpatient","","","6500.00","4875.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5311.80","81.72","","2733.55","2433.63","5168.92","14","3396.9","5311.8","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","both","","","90.49","67.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","64.97","71.8","","28.28","27.13","28.28","1 through 10","28.05","71.94","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","both","","","90.49","67.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","63.34","70","","44.63","35.78","44.63","1 through 10","28.05","71.94","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","both","","","90.49","67.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","71.94","79.5","","1342.89","271.64","6954.67","1 through 10","28.05","71.94","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","both","","","90.49","67.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.23","53.3","","4550.00","30.49","4550.00","1 through 10","28.05","71.94","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","both","","","90.49","67.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","58.82","65","","42.09","0.04","5453.50","1 through 10","28.05","71.94","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","both","","","90.49","67.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.03","36.5","","310.94","18.54","1259.30","62","28.05","71.94","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","both","","","90.49","67.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.66","38.3","","146.86","22.58","1753.45","65","28.05","71.94","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","both","","","90.49","67.87","WELLPOINT [1015]","HB AMC WELLPOINT","66.76","73.78","","247.29","33.09","909.09","53","28.05","71.94","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","90.49","67.87","AETNA [1001]","HB AMC AETNA HMO","63.16","69.8","","30.69","30.21","30.69","1 through 10","47.29","73.95","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","90.49","67.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","72.75","80.4","","82.69","82.69","82.69","1 through 10","47.29","73.95","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","90.49","67.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","73.95","81.72","","751.01","74.72","751.01","1 through 10","47.29","73.95","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","90.49","67.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","73.95","81.72","","328.92","46.17","2701.97","59","47.29","73.95","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLE BX/5EA","SUP-ITM-10297902","CDM","C1887","HCPCS","0272","RC","","","","both","","","56.91","42.68","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","40.86","71.8","","28.28","27.13","28.28","1 through 10","17.64","45.24","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLE BX/5EA","SUP-ITM-10297902","CDM","C1887","HCPCS","0272","RC","","","","both","","","56.91","42.68","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","39.84","70","","44.63","35.78","44.63","1 through 10","17.64","45.24","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLE BX/5EA","SUP-ITM-10297902","CDM","C1887","HCPCS","0272","RC","","","","both","","","56.91","42.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","45.24","79.5","","1342.89","271.64","6954.67","1 through 10","17.64","45.24","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLE BX/5EA","SUP-ITM-10297902","CDM","C1887","HCPCS","0272","RC","","","","both","","","56.91","42.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","30.33","53.3","","4550.00","30.49","4550.00","1 through 10","17.64","45.24","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLE BX/5EA","SUP-ITM-10297902","CDM","C1887","HCPCS","0272","RC","","","","both","","","56.91","42.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","36.99","65","","42.09","0.04","5453.50","1 through 10","17.64","45.24","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLE BX/5EA","SUP-ITM-10297902","CDM","C1887","HCPCS","0272","RC","","","","both","","","56.91","42.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20.77","36.5","","310.94","18.54","1259.30","62","17.64","45.24","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLE BX/5EA","SUP-ITM-10297902","CDM","C1887","HCPCS","0272","RC","","","","both","","","56.91","42.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21.80","38.3","","146.86","22.58","1753.45","65","17.64","45.24","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLE BX/5EA","SUP-ITM-10297902","CDM","C1887","HCPCS","0272","RC","","","","both","","","56.91","42.68","WELLPOINT [1015]","HB AMC WELLPOINT","41.99","73.78","","247.29","33.09","909.09","53","17.64","45.24","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLE BX/5EA","SUP-ITM-10297902","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","56.91","42.68","AETNA [1001]","HB AMC AETNA HMO","39.72","69.8","","30.69","30.21","30.69","1 through 10","29.74","46.51","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLE BX/5EA","SUP-ITM-10297902","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","56.91","42.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","45.76","80.4","","82.69","82.69","82.69","1 through 10","29.74","46.51","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLE BX/5EA","SUP-ITM-10297902","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","56.91","42.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","46.51","81.72","","751.01","74.72","751.01","1 through 10","29.74","46.51","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLE BX/5EA","SUP-ITM-10297902","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","56.91","42.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","46.51","81.72","","328.92","46.17","2701.97","59","29.74","46.51","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERNSTEIN BX/5EA","SUP-ITM-10333826","CDM","C1887","HCPCS","0272","RC","","","","both","","","149.10","111.82","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","107.05","71.8","","28.28","27.13","28.28","1 through 10","46.22","118.53","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERNSTEIN BX/5EA","SUP-ITM-10333826","CDM","C1887","HCPCS","0272","RC","","","","both","","","149.10","111.82","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","104.37","70","","44.63","35.78","44.63","1 through 10","46.22","118.53","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERNSTEIN BX/5EA","SUP-ITM-10333826","CDM","C1887","HCPCS","0272","RC","","","","both","","","149.10","111.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","118.53","79.5","","1342.89","271.64","6954.67","1 through 10","46.22","118.53","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERNSTEIN BX/5EA","SUP-ITM-10333826","CDM","C1887","HCPCS","0272","RC","","","","both","","","149.10","111.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","79.47","53.3","","4550.00","30.49","4550.00","1 through 10","46.22","118.53","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERNSTEIN BX/5EA","SUP-ITM-10333826","CDM","C1887","HCPCS","0272","RC","","","","both","","","149.10","111.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","96.92","65","","42.09","0.04","5453.50","1 through 10","46.22","118.53","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERNSTEIN BX/5EA","SUP-ITM-10333826","CDM","C1887","HCPCS","0272","RC","","","","both","","","149.10","111.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54.42","36.5","","310.94","18.54","1259.30","62","46.22","118.53","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERNSTEIN BX/5EA","SUP-ITM-10333826","CDM","C1887","HCPCS","0272","RC","","","","both","","","149.10","111.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.11","38.3","","146.86","22.58","1753.45","65","46.22","118.53","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERNSTEIN BX/5EA","SUP-ITM-10333826","CDM","C1887","HCPCS","0272","RC","","","","both","","","149.10","111.82","WELLPOINT [1015]","HB AMC WELLPOINT","110.01","73.78","","247.29","33.09","909.09","53","46.22","118.53","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERNSTEIN BX/5EA","SUP-ITM-10333826","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","149.10","111.82","AETNA [1001]","HB AMC AETNA HMO","104.07","69.8","","30.69","30.21","30.69","1 through 10","77.92","121.84","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERNSTEIN BX/5EA","SUP-ITM-10333826","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","149.10","111.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","119.88","80.4","","82.69","82.69","82.69","1 through 10","77.92","121.84","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERNSTEIN BX/5EA","SUP-ITM-10333826","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","149.10","111.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","121.84","81.72","","751.01","74.72","751.01","1 through 10","77.92","121.84","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX100CM .035IN SOFT-VU BERNSTEIN BX/5EA","SUP-ITM-10333826","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","149.10","111.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","121.84","81.72","","328.92","46.17","2701.97","59","77.92","121.84","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX110CM 155DEG IMPULSE VENTRICULAR PI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10173723","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","19.48","71.8","","28.28","27.13","28.28","1 through 10","8.41","21.57","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX110CM 155DEG IMPULSE VENTRICULAR PI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10173723","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","18.99","70","","44.63","35.78","44.63","1 through 10","8.41","21.57","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX110CM 155DEG IMPULSE VENTRICULAR PI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10173723","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21.57","79.5","","1342.89","271.64","6954.67","1 through 10","8.41","21.57","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX110CM 155DEG IMPULSE VENTRICULAR PI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10173723","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14.46","53.3","","4550.00","30.49","4550.00","1 through 10","8.41","21.57","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX110CM 155DEG IMPULSE VENTRICULAR PI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10173723","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","17.63","65","","42.09","0.04","5453.50","1 through 10","8.41","21.57","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX110CM 155DEG IMPULSE VENTRICULAR PI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10173723","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9.90","36.5","","310.94","18.54","1259.30","62","8.41","21.57","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX110CM 155DEG IMPULSE VENTRICULAR PI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10173723","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10.39","38.3","","146.86","22.58","1753.45","65","8.41","21.57","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX110CM 155DEG IMPULSE VENTRICULAR PI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10173723","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","WELLPOINT [1015]","HB AMC WELLPOINT","20.02","73.78","","247.29","33.09","909.09","53","8.41","21.57","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX110CM 155DEG IMPULSE VENTRICULAR PI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10173723","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","27.13","20.35","AETNA [1001]","HB AMC AETNA HMO","18.94","69.8","","30.69","30.21","30.69","1 through 10","14.18","22.17","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX110CM 155DEG IMPULSE VENTRICULAR PI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10173723","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","27.13","20.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","21.81","80.4","","82.69","82.69","82.69","1 through 10","14.18","22.17","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX110CM 155DEG IMPULSE VENTRICULAR PI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10173723","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","27.13","20.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","22.17","81.72","","751.01","74.72","751.01","1 through 10","14.18","22.17","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FRX110CM 155DEG IMPULSE VENTRICULAR PI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10173723","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","27.13","20.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22.17","81.72","","328.92","46.17","2701.97","59","14.18","22.17","percent of total billed charges",""
"CATHETER ANGIOPLASTY 6.0FR 4.0X200MM 137CM XL 0.014IN ANGIOSCULPT PTA NITINOL OVER WIRE SCORING BALLOON","SUP-ITM-10137052","CDM","C1725","HCPCS","0272","RC","","","","both","","","4020.00","3015.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2886.36","71.8","","175.91","175.91","175.91","1 through 10","1246.2","3195.9","percent of total billed charges",""
"CATHETER ANGIOPLASTY 6.0FR 4.0X200MM 137CM XL 0.014IN ANGIOSCULPT PTA NITINOL OVER WIRE SCORING BALLOON","SUP-ITM-10137052","CDM","C1725","HCPCS","0272","RC","","","","both","","","4020.00","3015.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2613.00","65","","147.88","147.88","1296.75","1 through 10","1246.2","3195.9","percent of total billed charges",""
"CATHETER ANGIOPLASTY 6.0FR 4.0X200MM 137CM XL 0.014IN ANGIOSCULPT PTA NITINOL OVER WIRE SCORING BALLOON","SUP-ITM-10137052","CDM","C1725","HCPCS","0272","RC","","","","both","","","4020.00","3015.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1467.30","36.5","","181.40","177.87","181.40","21","1246.2","3195.9","percent of total billed charges",""
"CATHETER ANGIOPLASTY 6.0FR 4.0X200MM 137CM XL 0.014IN ANGIOSCULPT PTA NITINOL OVER WIRE SCORING BALLOON","SUP-ITM-10137052","CDM","C1725","HCPCS","0272","RC","","","","both","","","4020.00","3015.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1539.66","38.3","","170.15","88.95","424.24","16","1246.2","3195.9","percent of total billed charges",""
"CATHETER ANGIOPLASTY 6.0FR 4.0X200MM 137CM XL 0.014IN ANGIOSCULPT PTA NITINOL OVER WIRE SCORING BALLOON","SUP-ITM-10137052","CDM","C1725","HCPCS","0272","RC","","","","both","","","4020.00","3015.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1724.58","42.9","","699.48","699.48","699.48","12","1246.2","3195.9","percent of total billed charges",""
"CATHETER ANGIOPLASTY 6.0FR 4.0X200MM 137CM XL 0.014IN ANGIOSCULPT PTA NITINOL OVER WIRE SCORING BALLOON","SUP-ITM-10137052","CDM","C1725","HCPCS","0272","RC","","","","both","","","4020.00","3015.00","WELLPOINT [1015]","HB AMC WELLPOINT","2965.96","73.78","","576.52","182.40","651.44","14","1246.2","3195.9","percent of total billed charges",""
"CATHETER ANGIOPLASTY 6.0FR 4.0X200MM 137CM XL 0.014IN ANGIOSCULPT PTA NITINOL OVER WIRE SCORING BALLOON","SUP-ITM-10137052","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4020.00","3015.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3285.14","81.72","","181.86","100.03","402.41","21","2100.85","3285.14","percent of total billed charges",""
"CATHETER ANGIOPTIC 5FR 65CM .038IN DIAGNOSTIC VASCULAR RACKE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008808","CDM","C1887","HCPCS","0272","RC","","","","both","","","52.50","39.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","37.70","71.8","","28.28","27.13","28.28","1 through 10","16.28","41.74","percent of total billed charges",""
"CATHETER ANGIOPTIC 5FR 65CM .038IN DIAGNOSTIC VASCULAR RACKE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008808","CDM","C1887","HCPCS","0272","RC","","","","both","","","52.50","39.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","36.75","70","","44.63","35.78","44.63","1 through 10","16.28","41.74","percent of total billed charges",""
"CATHETER ANGIOPTIC 5FR 65CM .038IN DIAGNOSTIC VASCULAR RACKE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008808","CDM","C1887","HCPCS","0272","RC","","","","both","","","52.50","39.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","41.74","79.5","","1342.89","271.64","6954.67","1 through 10","16.28","41.74","percent of total billed charges",""
"CATHETER ANGIOPTIC 5FR 65CM .038IN DIAGNOSTIC VASCULAR RACKE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008808","CDM","C1887","HCPCS","0272","RC","","","","both","","","52.50","39.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","27.98","53.3","","4550.00","30.49","4550.00","1 through 10","16.28","41.74","percent of total billed charges",""
"CATHETER ANGIOPTIC 5FR 65CM .038IN DIAGNOSTIC VASCULAR RACKE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008808","CDM","C1887","HCPCS","0272","RC","","","","both","","","52.50","39.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","34.13","65","","42.09","0.04","5453.50","1 through 10","16.28","41.74","percent of total billed charges",""
"CATHETER ANGIOPTIC 5FR 65CM .038IN DIAGNOSTIC VASCULAR RACKE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008808","CDM","C1887","HCPCS","0272","RC","","","","both","","","52.50","39.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19.16","36.5","","310.94","18.54","1259.30","62","16.28","41.74","percent of total billed charges",""
"CATHETER ANGIOPTIC 5FR 65CM .038IN DIAGNOSTIC VASCULAR RACKE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008808","CDM","C1887","HCPCS","0272","RC","","","","both","","","52.50","39.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20.11","38.3","","146.86","22.58","1753.45","65","16.28","41.74","percent of total billed charges",""
"CATHETER ANGIOPTIC 5FR 65CM .038IN DIAGNOSTIC VASCULAR RACKE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008808","CDM","C1887","HCPCS","0272","RC","","","","both","","","52.50","39.37","WELLPOINT [1015]","HB AMC WELLPOINT","38.73","73.78","","247.29","33.09","909.09","53","16.28","41.74","percent of total billed charges",""
"CATHETER ANGIOPTIC 5FR 65CM .038IN DIAGNOSTIC VASCULAR RACKE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008808","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","AETNA [1001]","HB AMC AETNA HMO","36.65","69.8","","30.69","30.21","30.69","1 through 10","27.44","42.9","percent of total billed charges",""
"CATHETER ANGIOPTIC 5FR 65CM .038IN DIAGNOSTIC VASCULAR RACKE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008808","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","42.21","80.4","","82.69","82.69","82.69","1 through 10","27.44","42.9","percent of total billed charges",""
"CATHETER ANGIOPTIC 5FR 65CM .038IN DIAGNOSTIC VASCULAR RACKE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008808","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","42.90","81.72","","751.01","74.72","751.01","1 through 10","27.44","42.9","percent of total billed charges",""
"CATHETER ANGIOPTIC 5FR 65CM .038IN DIAGNOSTIC VASCULAR RACKE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008808","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","42.90","81.72","","328.92","46.17","2701.97","59","27.44","42.9","percent of total billed charges",""
"CATHETER ANGIOSCULPT XL 6FR 5MM 200MM 137CM .014IN OTW PTA SCORING BALLOON PERIPHERAL","SUP-ITM-10137053","CDM","C1725","HCPCS","0272","RC","","","","both","","","4020.00","3015.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2886.36","71.8","","175.91","175.91","175.91","1 through 10","1246.2","3195.9","percent of total billed charges",""
"CATHETER ANGIOSCULPT XL 6FR 5MM 200MM 137CM .014IN OTW PTA SCORING BALLOON PERIPHERAL","SUP-ITM-10137053","CDM","C1725","HCPCS","0272","RC","","","","both","","","4020.00","3015.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2613.00","65","","147.88","147.88","1296.75","1 through 10","1246.2","3195.9","percent of total billed charges",""
"CATHETER ANGIOSCULPT XL 6FR 5MM 200MM 137CM .014IN OTW PTA SCORING BALLOON PERIPHERAL","SUP-ITM-10137053","CDM","C1725","HCPCS","0272","RC","","","","both","","","4020.00","3015.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1467.30","36.5","","181.40","177.87","181.40","21","1246.2","3195.9","percent of total billed charges",""
"CATHETER ANGIOSCULPT XL 6FR 5MM 200MM 137CM .014IN OTW PTA SCORING BALLOON PERIPHERAL","SUP-ITM-10137053","CDM","C1725","HCPCS","0272","RC","","","","both","","","4020.00","3015.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1539.66","38.3","","170.15","88.95","424.24","16","1246.2","3195.9","percent of total billed charges",""
"CATHETER ANGIOSCULPT XL 6FR 5MM 200MM 137CM .014IN OTW PTA SCORING BALLOON PERIPHERAL","SUP-ITM-10137053","CDM","C1725","HCPCS","0272","RC","","","","both","","","4020.00","3015.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1724.58","42.9","","699.48","699.48","699.48","12","1246.2","3195.9","percent of total billed charges",""
"CATHETER ANGIOSCULPT XL 6FR 5MM 200MM 137CM .014IN OTW PTA SCORING BALLOON PERIPHERAL","SUP-ITM-10137053","CDM","C1725","HCPCS","0272","RC","","","","both","","","4020.00","3015.00","WELLPOINT [1015]","HB AMC WELLPOINT","2965.96","73.78","","576.52","182.40","651.44","14","1246.2","3195.9","percent of total billed charges",""
"CATHETER ANGIOSCULPT XL 6FR 5MM 200MM 137CM .014IN OTW PTA SCORING BALLOON PERIPHERAL","SUP-ITM-10137053","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4020.00","3015.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3285.14","81.72","","181.86","100.03","402.41","21","2100.85","3285.14","percent of total billed charges",""
"CATHETER ARMADA 4X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094407","CDM","C1725","HCPCS","0272","RC","","","","both","","","252.00","189.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","180.94","71.8","","175.91","175.91","175.91","1 through 10","78.12","200.34","percent of total billed charges",""
"CATHETER ARMADA 4X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094407","CDM","C1725","HCPCS","0272","RC","","","","both","","","252.00","189.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","163.80","65","","147.88","147.88","1296.75","1 through 10","78.12","200.34","percent of total billed charges",""
"CATHETER ARMADA 4X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094407","CDM","C1725","HCPCS","0272","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91.98","36.5","","181.40","177.87","181.40","21","78.12","200.34","percent of total billed charges",""
"CATHETER ARMADA 4X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094407","CDM","C1725","HCPCS","0272","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.52","38.3","","170.15","88.95","424.24","16","78.12","200.34","percent of total billed charges",""
"CATHETER ARMADA 4X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094407","CDM","C1725","HCPCS","0272","RC","","","","both","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.11","42.9","","699.48","699.48","699.48","12","78.12","200.34","percent of total billed charges",""
"CATHETER ARMADA 4X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094407","CDM","C1725","HCPCS","0272","RC","","","","both","","","252.00","189.00","WELLPOINT [1015]","HB AMC WELLPOINT","185.93","73.78","","576.52","182.40","651.44","14","78.12","200.34","percent of total billed charges",""
"CATHETER ARMADA 4X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094407","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","205.93","81.72","","181.86","100.03","402.41","21","131.7","205.93","percent of total billed charges",""
"CATHETER ASAHI 6.5FR PB3.0 100CM .035IN GUIDING SHEATHLESS HYDROPHILIC COATING PTFE S/S EAUCATH RADIAL","SUP-ITM-10287473","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","339.26","71.8","","28.28","27.13","28.28","1 through 10","146.48","375.64","percent of total billed charges",""
"CATHETER ASAHI 6.5FR PB3.0 100CM .035IN GUIDING SHEATHLESS HYDROPHILIC COATING PTFE S/S EAUCATH RADIAL","SUP-ITM-10287473","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","330.75","70","","44.63","35.78","44.63","1 through 10","146.48","375.64","percent of total billed charges",""
"CATHETER ASAHI 6.5FR PB3.0 100CM .035IN GUIDING SHEATHLESS HYDROPHILIC COATING PTFE S/S EAUCATH RADIAL","SUP-ITM-10287473","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","375.64","79.5","","1342.89","271.64","6954.67","1 through 10","146.48","375.64","percent of total billed charges",""
"CATHETER ASAHI 6.5FR PB3.0 100CM .035IN GUIDING SHEATHLESS HYDROPHILIC COATING PTFE S/S EAUCATH RADIAL","SUP-ITM-10287473","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","251.84","53.3","","4550.00","30.49","4550.00","1 through 10","146.48","375.64","percent of total billed charges",""
"CATHETER ASAHI 6.5FR PB3.0 100CM .035IN GUIDING SHEATHLESS HYDROPHILIC COATING PTFE S/S EAUCATH RADIAL","SUP-ITM-10287473","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","307.13","65","","42.09","0.04","5453.50","1 through 10","146.48","375.64","percent of total billed charges",""
"CATHETER ASAHI 6.5FR PB3.0 100CM .035IN GUIDING SHEATHLESS HYDROPHILIC COATING PTFE S/S EAUCATH RADIAL","SUP-ITM-10287473","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","172.46","36.5","","310.94","18.54","1259.30","62","146.48","375.64","percent of total billed charges",""
"CATHETER ASAHI 6.5FR PB3.0 100CM .035IN GUIDING SHEATHLESS HYDROPHILIC COATING PTFE S/S EAUCATH RADIAL","SUP-ITM-10287473","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","180.97","38.3","","146.86","22.58","1753.45","65","146.48","375.64","percent of total billed charges",""
"CATHETER ASAHI 6.5FR PB3.0 100CM .035IN GUIDING SHEATHLESS HYDROPHILIC COATING PTFE S/S EAUCATH RADIAL","SUP-ITM-10287473","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","WELLPOINT [1015]","HB AMC WELLPOINT","348.61","73.78","","247.29","33.09","909.09","53","146.48","375.64","percent of total billed charges",""
"CATHETER ASAHI 6.5FR PB3.0 100CM .035IN GUIDING SHEATHLESS HYDROPHILIC COATING PTFE S/S EAUCATH RADIAL","SUP-ITM-10287473","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","472.50","354.37","AETNA [1001]","HB AMC AETNA HMO","329.81","69.8","","30.69","30.21","30.69","1 through 10","246.93","386.13","percent of total billed charges",""
"CATHETER ASAHI 6.5FR PB3.0 100CM .035IN GUIDING SHEATHLESS HYDROPHILIC COATING PTFE S/S EAUCATH RADIAL","SUP-ITM-10287473","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","472.50","354.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","379.89","80.4","","82.69","82.69","82.69","1 through 10","246.93","386.13","percent of total billed charges",""
"CATHETER ASAHI 6.5FR PB3.0 100CM .035IN GUIDING SHEATHLESS HYDROPHILIC COATING PTFE S/S EAUCATH RADIAL","SUP-ITM-10287473","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","472.50","354.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","386.13","81.72","","751.01","74.72","751.01","1 through 10","246.93","386.13","percent of total billed charges",""
"CATHETER ASAHI 6.5FR PB3.0 100CM .035IN GUIDING SHEATHLESS HYDROPHILIC COATING PTFE S/S EAUCATH RADIAL","SUP-ITM-10287473","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","472.50","354.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","386.13","81.72","","328.92","46.17","2701.97","59","246.93","386.13","percent of total billed charges",""
"CATHETER ATLAS 6.5F 120CM 12MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027010","CDM","C1725","HCPCS","0272","RC","","","","both","","","973.88","730.41","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","699.25","71.8","","175.91","175.91","175.91","1 through 10","301.9","774.23","percent of total billed charges",""
"CATHETER ATLAS 6.5F 120CM 12MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027010","CDM","C1725","HCPCS","0272","RC","","","","both","","","973.88","730.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","633.02","65","","147.88","147.88","1296.75","1 through 10","301.9","774.23","percent of total billed charges",""
"CATHETER ATLAS 6.5F 120CM 12MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027010","CDM","C1725","HCPCS","0272","RC","","","","both","","","973.88","730.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","355.47","36.5","","181.40","177.87","181.40","21","301.9","774.23","percent of total billed charges",""
"CATHETER ATLAS 6.5F 120CM 12MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027010","CDM","C1725","HCPCS","0272","RC","","","","both","","","973.88","730.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","373.00","38.3","","170.15","88.95","424.24","16","301.9","774.23","percent of total billed charges",""
"CATHETER ATLAS 6.5F 120CM 12MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027010","CDM","C1725","HCPCS","0272","RC","","","","both","","","973.88","730.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","417.79","42.9","","699.48","699.48","699.48","12","301.9","774.23","percent of total billed charges",""
"CATHETER ATLAS 6.5F 120CM 12MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027010","CDM","C1725","HCPCS","0272","RC","","","","both","","","973.88","730.41","WELLPOINT [1015]","HB AMC WELLPOINT","718.53","73.78","","576.52","182.40","651.44","14","301.9","774.23","percent of total billed charges",""
"CATHETER ATLAS 6.5F 120CM 12MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027010","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","973.88","730.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","795.85","81.72","","181.86","100.03","402.41","21","508.95","795.85","percent of total billed charges",""
"CATHETER ATLAS 7F 120CM 20MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027014","CDM","C1725","HCPCS","0272","RC","","","","both","","","1102.50","826.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","791.60","71.8","","175.91","175.91","175.91","1 through 10","341.78","876.49","percent of total billed charges",""
"CATHETER ATLAS 7F 120CM 20MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027014","CDM","C1725","HCPCS","0272","RC","","","","both","","","1102.50","826.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","716.63","65","","147.88","147.88","1296.75","1 through 10","341.78","876.49","percent of total billed charges",""
"CATHETER ATLAS 7F 120CM 20MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027014","CDM","C1725","HCPCS","0272","RC","","","","both","","","1102.50","826.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","402.41","36.5","","181.40","177.87","181.40","21","341.78","876.49","percent of total billed charges",""
"CATHETER ATLAS 7F 120CM 20MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027014","CDM","C1725","HCPCS","0272","RC","","","","both","","","1102.50","826.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","422.26","38.3","","170.15","88.95","424.24","16","341.78","876.49","percent of total billed charges",""
"CATHETER ATLAS 7F 120CM 20MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027014","CDM","C1725","HCPCS","0272","RC","","","","both","","","1102.50","826.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","472.97","42.9","","699.48","699.48","699.48","12","341.78","876.49","percent of total billed charges",""
"CATHETER ATLAS 7F 120CM 20MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027014","CDM","C1725","HCPCS","0272","RC","","","","both","","","1102.50","826.87","WELLPOINT [1015]","HB AMC WELLPOINT","813.42","73.78","","576.52","182.40","651.44","14","341.78","876.49","percent of total billed charges",""
"CATHETER ATLAS 7F 120CM 20MM 4CM BALLOON DILATATION PTA","SUP-ITM-10027014","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1102.50","826.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","900.96","81.72","","181.86","100.03","402.41","21","576.17","900.96","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","both","","","1010.63","757.97","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","725.63","71.8","","175.91","175.91","175.91","1 through 10","313.3","803.45","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","both","","","1010.63","757.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","656.91","65","","147.88","147.88","1296.75","1 through 10","313.3","803.45","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","both","","","1010.63","757.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","368.88","36.5","","181.40","177.87","181.40","21","313.3","803.45","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","both","","","1010.63","757.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","387.07","38.3","","170.15","88.95","424.24","16","313.3","803.45","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","both","","","1010.63","757.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","433.56","42.9","","699.48","699.48","699.48","12","313.3","803.45","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","both","","","1010.63","757.97","WELLPOINT [1015]","HB AMC WELLPOINT","745.64","73.78","","576.52","182.40","651.44","14","313.3","803.45","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1010.63","757.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","825.89","81.72","","181.86","100.03","402.41","21","528.16","825.89","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","600.25","70","","556.50","556.50","556.50","1 through 10","265.83","681.71","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","681.71","79.5","","437.97","293.83","444.55","17","265.83","681.71","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","457.05","53.3","","298.25","293.83","444.55","1 through 10","265.83","681.71","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","557.38","65","","361.73","361.73","361.73","1 through 10","265.83","681.71","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","265.83","31","","171.96","171.96","171.96","1 through 10","265.83","681.71","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","312.99","36.5","","207.57","179.06","271.83","1 through 10","265.83","681.71","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","328.42","38.3","","217.59","211.47","220.86","18","265.83","681.71","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","367.87","42.9","","556.50","451.56","556.50","1 through 10","265.83","681.71","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","367.87","42.9","","444.87","444.87","444.87","1 through 10","265.83","681.71","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","WELLPOINT [1015]","HB AMC WELLPOINT","632.66","73.78","","414.31","414.31","420.55","15","265.83","681.71","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","AETNA [1001]","HB AMC AETNA HMO","598.54","69.8","","376.75","270.01","580.53","30","448.13","700.75","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","AETNA [1001]","HB AMC AETNA PPO","689.43","80.4","","440.60","434.07","440.60","1 through 10","448.13","700.75","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","689.43","80.4","","434.07","434.07","440.60","1 through 10","448.13","700.75","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","700.75","81.72","","444.87","248.37","444.87","1 through 10","448.13","700.75","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","700.75","81.72","","444.87","248.37","451.56","20","448.13","700.75","percent of total billed charges",""
"CATHETER ATTAIN 7FR 130CM GUIDING CORONARY SELECT II LEAD DELIVERY SYSTEM","SUP-ITM-10124592","CDM","C1887","HCPCS","0272","RC","","","","both","","","528.50","396.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","379.46","71.8","","28.28","27.13","28.28","1 through 10","163.84","420.16","percent of total billed charges",""
"CATHETER ATTAIN 7FR 130CM GUIDING CORONARY SELECT II LEAD DELIVERY SYSTEM","SUP-ITM-10124592","CDM","C1887","HCPCS","0272","RC","","","","both","","","528.50","396.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","369.95","70","","44.63","35.78","44.63","1 through 10","163.84","420.16","percent of total billed charges",""
"CATHETER ATTAIN 7FR 130CM GUIDING CORONARY SELECT II LEAD DELIVERY SYSTEM","SUP-ITM-10124592","CDM","C1887","HCPCS","0272","RC","","","","both","","","528.50","396.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","420.16","79.5","","1342.89","271.64","6954.67","1 through 10","163.84","420.16","percent of total billed charges",""
"CATHETER ATTAIN 7FR 130CM GUIDING CORONARY SELECT II LEAD DELIVERY SYSTEM","SUP-ITM-10124592","CDM","C1887","HCPCS","0272","RC","","","","both","","","528.50","396.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","281.69","53.3","","4550.00","30.49","4550.00","1 through 10","163.84","420.16","percent of total billed charges",""
"CATHETER ATTAIN 7FR 130CM GUIDING CORONARY SELECT II LEAD DELIVERY SYSTEM","SUP-ITM-10124592","CDM","C1887","HCPCS","0272","RC","","","","both","","","528.50","396.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","343.53","65","","42.09","0.04","5453.50","1 through 10","163.84","420.16","percent of total billed charges",""
"CATHETER ATTAIN 7FR 130CM GUIDING CORONARY SELECT II LEAD DELIVERY SYSTEM","SUP-ITM-10124592","CDM","C1887","HCPCS","0272","RC","","","","both","","","528.50","396.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","192.90","36.5","","310.94","18.54","1259.30","62","163.84","420.16","percent of total billed charges",""
"CATHETER ATTAIN 7FR 130CM GUIDING CORONARY SELECT II LEAD DELIVERY SYSTEM","SUP-ITM-10124592","CDM","C1887","HCPCS","0272","RC","","","","both","","","528.50","396.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","202.42","38.3","","146.86","22.58","1753.45","65","163.84","420.16","percent of total billed charges",""
"CATHETER ATTAIN 7FR 130CM GUIDING CORONARY SELECT II LEAD DELIVERY SYSTEM","SUP-ITM-10124592","CDM","C1887","HCPCS","0272","RC","","","","both","","","528.50","396.37","WELLPOINT [1015]","HB AMC WELLPOINT","389.93","73.78","","247.29","33.09","909.09","53","163.84","420.16","percent of total billed charges",""
"CATHETER ATTAIN 7FR 130CM GUIDING CORONARY SELECT II LEAD DELIVERY SYSTEM","SUP-ITM-10124592","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","528.50","396.37","AETNA [1001]","HB AMC AETNA HMO","368.89","69.8","","30.69","30.21","30.69","1 through 10","276.19","431.89","percent of total billed charges",""
"CATHETER ATTAIN 7FR 130CM GUIDING CORONARY SELECT II LEAD DELIVERY SYSTEM","SUP-ITM-10124592","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","528.50","396.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","424.91","80.4","","82.69","82.69","82.69","1 through 10","276.19","431.89","percent of total billed charges",""
"CATHETER ATTAIN 7FR 130CM GUIDING CORONARY SELECT II LEAD DELIVERY SYSTEM","SUP-ITM-10124592","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","528.50","396.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","431.89","81.72","","751.01","74.72","751.01","1 through 10","276.19","431.89","percent of total billed charges",""
"CATHETER ATTAIN 7FR 130CM GUIDING CORONARY SELECT II LEAD DELIVERY SYSTEM","SUP-ITM-10124592","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","528.50","396.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","431.89","81.72","","328.92","46.17","2701.97","59","276.19","431.89","percent of total billed charges",""
"CATHETER ATTAIN 7FR 45CM GUIDING DEFLECTIVE LEAD DELIVERY SYSTEM 6227DEF02","SUP-ITM-10013881","CDM","C1887","HCPCS","0272","RC","","","","both","","","1631.00","1223.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1171.06","71.8","","28.28","27.13","28.28","1 through 10","505.61","1296.65","percent of total billed charges",""
"CATHETER ATTAIN 7FR 45CM GUIDING DEFLECTIVE LEAD DELIVERY SYSTEM 6227DEF02","SUP-ITM-10013881","CDM","C1887","HCPCS","0272","RC","","","","both","","","1631.00","1223.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1141.70","70","","44.63","35.78","44.63","1 through 10","505.61","1296.65","percent of total billed charges",""
"CATHETER ATTAIN 7FR 45CM GUIDING DEFLECTIVE LEAD DELIVERY SYSTEM 6227DEF02","SUP-ITM-10013881","CDM","C1887","HCPCS","0272","RC","","","","both","","","1631.00","1223.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1296.65","79.5","","1342.89","271.64","6954.67","1 through 10","505.61","1296.65","percent of total billed charges",""
"CATHETER ATTAIN 7FR 45CM GUIDING DEFLECTIVE LEAD DELIVERY SYSTEM 6227DEF02","SUP-ITM-10013881","CDM","C1887","HCPCS","0272","RC","","","","both","","","1631.00","1223.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","869.32","53.3","","4550.00","30.49","4550.00","1 through 10","505.61","1296.65","percent of total billed charges",""
"CATHETER ATTAIN 7FR 45CM GUIDING DEFLECTIVE LEAD DELIVERY SYSTEM 6227DEF02","SUP-ITM-10013881","CDM","C1887","HCPCS","0272","RC","","","","both","","","1631.00","1223.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1060.15","65","","42.09","0.04","5453.50","1 through 10","505.61","1296.65","percent of total billed charges",""
"CATHETER ATTAIN 7FR 45CM GUIDING DEFLECTIVE LEAD DELIVERY SYSTEM 6227DEF02","SUP-ITM-10013881","CDM","C1887","HCPCS","0272","RC","","","","both","","","1631.00","1223.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","595.32","36.5","","310.94","18.54","1259.30","62","505.61","1296.65","percent of total billed charges",""
"CATHETER ATTAIN 7FR 45CM GUIDING DEFLECTIVE LEAD DELIVERY SYSTEM 6227DEF02","SUP-ITM-10013881","CDM","C1887","HCPCS","0272","RC","","","","both","","","1631.00","1223.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","624.67","38.3","","146.86","22.58","1753.45","65","505.61","1296.65","percent of total billed charges",""
"CATHETER ATTAIN 7FR 45CM GUIDING DEFLECTIVE LEAD DELIVERY SYSTEM 6227DEF02","SUP-ITM-10013881","CDM","C1887","HCPCS","0272","RC","","","","both","","","1631.00","1223.25","WELLPOINT [1015]","HB AMC WELLPOINT","1203.35","73.78","","247.29","33.09","909.09","53","505.61","1296.65","percent of total billed charges",""
"CATHETER ATTAIN 7FR 45CM GUIDING DEFLECTIVE LEAD DELIVERY SYSTEM 6227DEF02","SUP-ITM-10013881","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1631.00","1223.25","AETNA [1001]","HB AMC AETNA HMO","1138.44","69.8","","30.69","30.21","30.69","1 through 10","852.36","1332.85","percent of total billed charges",""
"CATHETER ATTAIN 7FR 45CM GUIDING DEFLECTIVE LEAD DELIVERY SYSTEM 6227DEF02","SUP-ITM-10013881","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1631.00","1223.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1311.32","80.4","","82.69","82.69","82.69","1 through 10","852.36","1332.85","percent of total billed charges",""
"CATHETER ATTAIN 7FR 45CM GUIDING DEFLECTIVE LEAD DELIVERY SYSTEM 6227DEF02","SUP-ITM-10013881","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1631.00","1223.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1332.85","81.72","","751.01","74.72","751.01","1 through 10","852.36","1332.85","percent of total billed charges",""
"CATHETER ATTAIN 7FR 45CM GUIDING DEFLECTIVE LEAD DELIVERY SYSTEM 6227DEF02","SUP-ITM-10013881","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1631.00","1223.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1332.85","81.72","","328.92","46.17","2701.97","59","852.36","1332.85","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 6250V GUIDING SUREVALVE STRAIGHT","SUP-ITM-10124603","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","487.52","71.8","","28.28","27.13","28.28","1 through 10","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 6250V GUIDING SUREVALVE STRAIGHT","SUP-ITM-10124603","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","475.30","70","","44.63","35.78","44.63","1 through 10","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 6250V GUIDING SUREVALVE STRAIGHT","SUP-ITM-10124603","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","539.81","79.5","","1342.89","271.64","6954.67","1 through 10","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 6250V GUIDING SUREVALVE STRAIGHT","SUP-ITM-10124603","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","361.91","53.3","","4550.00","30.49","4550.00","1 through 10","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 6250V GUIDING SUREVALVE STRAIGHT","SUP-ITM-10124603","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","441.35","65","","42.09","0.04","5453.50","1 through 10","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 6250V GUIDING SUREVALVE STRAIGHT","SUP-ITM-10124603","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","247.84","36.5","","310.94","18.54","1259.30","62","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 6250V GUIDING SUREVALVE STRAIGHT","SUP-ITM-10124603","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","260.06","38.3","","146.86","22.58","1753.45","65","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 6250V GUIDING SUREVALVE STRAIGHT","SUP-ITM-10124603","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","WELLPOINT [1015]","HB AMC WELLPOINT","500.97","73.78","","247.29","33.09","909.09","53","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 6250V GUIDING SUREVALVE STRAIGHT","SUP-ITM-10124603","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","679.00","509.25","AETNA [1001]","HB AMC AETNA HMO","473.94","69.8","","30.69","30.21","30.69","1 through 10","354.85","554.88","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 6250V GUIDING SUREVALVE STRAIGHT","SUP-ITM-10124603","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","679.00","509.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","545.92","80.4","","82.69","82.69","82.69","1 through 10","354.85","554.88","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 6250V GUIDING SUREVALVE STRAIGHT","SUP-ITM-10124603","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","679.00","509.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","554.88","81.72","","751.01","74.72","751.01","1 through 10","354.85","554.88","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 6250V GUIDING SUREVALVE STRAIGHT","SUP-ITM-10124603","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","679.00","509.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","554.88","81.72","","328.92","46.17","2701.97","59","354.85","554.88","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 9FR 50CM GUIDING OUTER","SUP-ITM-10124594","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","487.52","71.8","","28.28","27.13","28.28","1 through 10","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 9FR 50CM GUIDING OUTER","SUP-ITM-10124594","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","475.30","70","","44.63","35.78","44.63","1 through 10","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 9FR 50CM GUIDING OUTER","SUP-ITM-10124594","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","539.81","79.5","","1342.89","271.64","6954.67","1 through 10","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 9FR 50CM GUIDING OUTER","SUP-ITM-10124594","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","361.91","53.3","","4550.00","30.49","4550.00","1 through 10","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 9FR 50CM GUIDING OUTER","SUP-ITM-10124594","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","441.35","65","","42.09","0.04","5453.50","1 through 10","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 9FR 50CM GUIDING OUTER","SUP-ITM-10124594","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","247.84","36.5","","310.94","18.54","1259.30","62","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 9FR 50CM GUIDING OUTER","SUP-ITM-10124594","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","260.06","38.3","","146.86","22.58","1753.45","65","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 9FR 50CM GUIDING OUTER","SUP-ITM-10124594","CDM","C1887","HCPCS","0272","RC","","","","both","","","679.00","509.25","WELLPOINT [1015]","HB AMC WELLPOINT","500.97","73.78","","247.29","33.09","909.09","53","210.49","539.81","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 9FR 50CM GUIDING OUTER","SUP-ITM-10124594","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","679.00","509.25","AETNA [1001]","HB AMC AETNA HMO","473.94","69.8","","30.69","30.21","30.69","1 through 10","354.85","554.88","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 9FR 50CM GUIDING OUTER","SUP-ITM-10124594","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","679.00","509.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","545.92","80.4","","82.69","82.69","82.69","1 through 10","354.85","554.88","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 9FR 50CM GUIDING OUTER","SUP-ITM-10124594","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","679.00","509.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","554.88","81.72","","751.01","74.72","751.01","1 through 10","354.85","554.88","percent of total billed charges",""
"CATHETER ATTAIN COMMAND 9FR 50CM GUIDING OUTER","SUP-ITM-10124594","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","679.00","509.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","554.88","81.72","","328.92","46.17","2701.97","59","354.85","554.88","percent of total billed charges",""
"CATHETER AVALON ELITE 23FR 31CM .038IN INFUSIONDUAL LUMEN BICAVAL J TIP GUIDEWIRE S/S","SUP-ITM-10115495","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5765.74","79.5","","1309.77","674.56","6049.93","26","2248.28","5765.74","percent of total billed charges",""
"CATHETER AVALON ELITE 23FR 31CM .038IN INFUSIONDUAL LUMEN BICAVAL J TIP GUIDEWIRE S/S","SUP-ITM-10115495","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3865.58","53.3","","1901.83","1901.83","2962.25","1 through 10","2248.28","5765.74","percent of total billed charges",""
"CATHETER AVALON ELITE 23FR 31CM .038IN INFUSIONDUAL LUMEN BICAVAL J TIP GUIDEWIRE S/S","SUP-ITM-10115495","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2647.16","36.5","","1620.31","1620.31","19908.88","1 through 10","2248.28","5765.74","percent of total billed charges",""
"CATHETER AVALON ELITE 23FR 31CM .038IN INFUSIONDUAL LUMEN BICAVAL J TIP GUIDEWIRE S/S","SUP-ITM-10115495","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2777.71","38.3","","352.91","352.91","2046.30","1 through 10","2248.28","5765.74","percent of total billed charges",""
"CATHETER AVALON ELITE 23FR 31CM .038IN INFUSIONDUAL LUMEN BICAVAL J TIP GUIDEWIRE S/S","SUP-ITM-10115495","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3111.32","42.9","","9668.75","9668.75","9668.75","1 through 10","2248.28","5765.74","percent of total billed charges",""
"CATHETER AVALON ELITE 23FR 31CM .038IN INFUSIONDUAL LUMEN BICAVAL J TIP GUIDEWIRE S/S","SUP-ITM-10115495","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","WELLPOINT [1015]","HB AMC WELLPOINT","5350.89","73.78","","699.88","384.10","3443.31","33","2248.28","5765.74","percent of total billed charges",""
"CATHETER AVALON ELITE 23FR 31CM .038IN INFUSIONDUAL LUMEN BICAVAL J TIP GUIDEWIRE S/S","SUP-ITM-10115495","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7252.50","5439.37","AETNA [1001]","HB AMC AETNA HMO","5062.25","69.8","","1421.24","264.50","4933.46","29","3790.16","5926.74","percent of total billed charges",""
"CATHETER AVALON ELITE 23FR 31CM .038IN INFUSIONDUAL LUMEN BICAVAL J TIP GUIDEWIRE S/S","SUP-ITM-10115495","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7252.50","5439.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5831.01","80.4","","1022.97","1022.97","3607.50","1 through 10","3790.16","5926.74","percent of total billed charges",""
"CATHETER AVALON ELITE 23FR 31CM .038IN INFUSIONDUAL LUMEN BICAVAL J TIP GUIDEWIRE S/S","SUP-ITM-10115495","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7252.50","5439.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5926.74","81.72","","3010.54","693.88","5019.88","35","3790.16","5926.74","percent of total billed charges",""
"CATHETER BACTISEAL 1.9MM BARIUM SILICONE EXTRAVENTRICULAR CLEAR DRAINAGE","SUP-ITM-10046641","CDM","C1729","HCPCS","0272","RC","","","","both","","","1078.35","808.76","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","774.26","71.8","","162.24","51.52","162.24","1 through 10","334.29","857.29","percent of total billed charges",""
"CATHETER BACTISEAL 1.9MM BARIUM SILICONE EXTRAVENTRICULAR CLEAR DRAINAGE","SUP-ITM-10046641","CDM","C1729","HCPCS","0272","RC","","","","both","","","1078.35","808.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","393.60","36.5","","94.34","22.19","146.22","26","334.29","857.29","percent of total billed charges",""
"CATHETER BACTISEAL 1.9MM BARIUM SILICONE EXTRAVENTRICULAR CLEAR DRAINAGE","SUP-ITM-10046641","CDM","C1729","HCPCS","0272","RC","","","","both","","","1078.35","808.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","413.01","38.3","","51.52","27.37","51.52","26","334.29","857.29","percent of total billed charges",""
"CATHETER BACTISEAL 1.9MM BARIUM SILICONE EXTRAVENTRICULAR CLEAR DRAINAGE","SUP-ITM-10046641","CDM","C1729","HCPCS","0272","RC","","","","both","","","1078.35","808.76","WELLPOINT [1015]","HB AMC WELLPOINT","795.61","73.78","","207.21","122.12","216.28","14","334.29","857.29","percent of total billed charges",""
"CATHETER BACTISEAL 1.9MM BARIUM SILICONE EXTRAVENTRICULAR CLEAR DRAINAGE","SUP-ITM-10046641","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1078.35","808.76","AETNA [1001]","HB AMC AETNA HMO","752.69","69.8","","155.96","47.39","155.96","1 through 10","563.55","881.23","percent of total billed charges",""
"CATHETER BACTISEAL 1.9MM BARIUM SILICONE EXTRAVENTRICULAR CLEAR DRAINAGE","SUP-ITM-10046641","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1078.35","808.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","881.23","81.72","","57.36","51.76","232.23","35","563.55","881.23","percent of total billed charges",""
"CATHETER BACTISEAL 120CM 1.3X2.5MM SILICONE PERITONEAL BARIUM STRIPE CLEAR","SUP-ITM-10045369","CDM","C1889","HCPCS","0278","RC","","","","both","","","1294.44","970.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1029.08","79.5","","1309.77","674.56","6049.93","26","401.28","1029.08","percent of total billed charges",""
"CATHETER BACTISEAL 120CM 1.3X2.5MM SILICONE PERITONEAL BARIUM STRIPE CLEAR","SUP-ITM-10045369","CDM","C1889","HCPCS","0278","RC","","","","both","","","1294.44","970.83","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","689.94","53.3","","1901.83","1901.83","2962.25","1 through 10","401.28","1029.08","percent of total billed charges",""
"CATHETER BACTISEAL 120CM 1.3X2.5MM SILICONE PERITONEAL BARIUM STRIPE CLEAR","SUP-ITM-10045369","CDM","C1889","HCPCS","0278","RC","","","","both","","","1294.44","970.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","472.47","36.5","","1620.31","1620.31","19908.88","1 through 10","401.28","1029.08","percent of total billed charges",""
"CATHETER BACTISEAL 120CM 1.3X2.5MM SILICONE PERITONEAL BARIUM STRIPE CLEAR","SUP-ITM-10045369","CDM","C1889","HCPCS","0278","RC","","","","both","","","1294.44","970.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","495.77","38.3","","352.91","352.91","2046.30","1 through 10","401.28","1029.08","percent of total billed charges",""
"CATHETER BACTISEAL 120CM 1.3X2.5MM SILICONE PERITONEAL BARIUM STRIPE CLEAR","SUP-ITM-10045369","CDM","C1889","HCPCS","0278","RC","","","","both","","","1294.44","970.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","555.31","42.9","","9668.75","9668.75","9668.75","1 through 10","401.28","1029.08","percent of total billed charges",""
"CATHETER BACTISEAL 120CM 1.3X2.5MM SILICONE PERITONEAL BARIUM STRIPE CLEAR","SUP-ITM-10045369","CDM","C1889","HCPCS","0278","RC","","","","both","","","1294.44","970.83","WELLPOINT [1015]","HB AMC WELLPOINT","955.04","73.78","","699.88","384.10","3443.31","33","401.28","1029.08","percent of total billed charges",""
"CATHETER BACTISEAL 120CM 1.3X2.5MM SILICONE PERITONEAL BARIUM STRIPE CLEAR","SUP-ITM-10045369","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1294.44","970.83","AETNA [1001]","HB AMC AETNA HMO","903.52","69.8","","1421.24","264.50","4933.46","29","676.47","1057.82","percent of total billed charges",""
"CATHETER BACTISEAL 120CM 1.3X2.5MM SILICONE PERITONEAL BARIUM STRIPE CLEAR","SUP-ITM-10045369","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1294.44","970.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1040.73","80.4","","1022.97","1022.97","3607.50","1 through 10","676.47","1057.82","percent of total billed charges",""
"CATHETER BACTISEAL 120CM 1.3X2.5MM SILICONE PERITONEAL BARIUM STRIPE CLEAR","SUP-ITM-10045369","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1294.44","970.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1057.82","81.72","","3010.54","693.88","5019.88","35","676.47","1057.82","percent of total billed charges",""
"CATHETER BACTISEAL 120CM BARIUM SILICONE PERITONEAL","SUP-ITM-10018023","CDM","C1889","HCPCS","0278","RC","","","","both","","","1125.39","844.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","894.69","79.5","","1309.77","674.56","6049.93","26","348.87","894.69","percent of total billed charges",""
"CATHETER BACTISEAL 120CM BARIUM SILICONE PERITONEAL","SUP-ITM-10018023","CDM","C1889","HCPCS","0278","RC","","","","both","","","1125.39","844.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","599.83","53.3","","1901.83","1901.83","2962.25","1 through 10","348.87","894.69","percent of total billed charges",""
"CATHETER BACTISEAL 120CM BARIUM SILICONE PERITONEAL","SUP-ITM-10018023","CDM","C1889","HCPCS","0278","RC","","","","both","","","1125.39","844.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","410.77","36.5","","1620.31","1620.31","19908.88","1 through 10","348.87","894.69","percent of total billed charges",""
"CATHETER BACTISEAL 120CM BARIUM SILICONE PERITONEAL","SUP-ITM-10018023","CDM","C1889","HCPCS","0278","RC","","","","both","","","1125.39","844.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","431.02","38.3","","352.91","352.91","2046.30","1 through 10","348.87","894.69","percent of total billed charges",""
"CATHETER BACTISEAL 120CM BARIUM SILICONE PERITONEAL","SUP-ITM-10018023","CDM","C1889","HCPCS","0278","RC","","","","both","","","1125.39","844.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","482.79","42.9","","9668.75","9668.75","9668.75","1 through 10","348.87","894.69","percent of total billed charges",""
"CATHETER BACTISEAL 120CM BARIUM SILICONE PERITONEAL","SUP-ITM-10018023","CDM","C1889","HCPCS","0278","RC","","","","both","","","1125.39","844.04","WELLPOINT [1015]","HB AMC WELLPOINT","830.31","73.78","","699.88","384.10","3443.31","33","348.87","894.69","percent of total billed charges",""
"CATHETER BACTISEAL 120CM BARIUM SILICONE PERITONEAL","SUP-ITM-10018023","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1125.39","844.04","AETNA [1001]","HB AMC AETNA HMO","785.52","69.8","","1421.24","264.50","4933.46","29","588.13","919.67","percent of total billed charges",""
"CATHETER BACTISEAL 120CM BARIUM SILICONE PERITONEAL","SUP-ITM-10018023","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1125.39","844.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","904.81","80.4","","1022.97","1022.97","3607.50","1 through 10","588.13","919.67","percent of total billed charges",""
"CATHETER BACTISEAL 120CM BARIUM SILICONE PERITONEAL","SUP-ITM-10018023","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1125.39","844.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","919.67","81.72","","3010.54","693.88","5019.88","35","588.13","919.67","percent of total billed charges",""
"CATHETER BACTISEAL 14CM VENTRICULAR BARIUM SILICONE","SUP-ITM-10018022","CDM","C1889","HCPCS","0278","RC","","","","both","","","1125.39","844.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","894.69","79.5","","1309.77","674.56","6049.93","26","348.87","894.69","percent of total billed charges",""
"CATHETER BACTISEAL 14CM VENTRICULAR BARIUM SILICONE","SUP-ITM-10018022","CDM","C1889","HCPCS","0278","RC","","","","both","","","1125.39","844.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","599.83","53.3","","1901.83","1901.83","2962.25","1 through 10","348.87","894.69","percent of total billed charges",""
"CATHETER BACTISEAL 14CM VENTRICULAR BARIUM SILICONE","SUP-ITM-10018022","CDM","C1889","HCPCS","0278","RC","","","","both","","","1125.39","844.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","410.77","36.5","","1620.31","1620.31","19908.88","1 through 10","348.87","894.69","percent of total billed charges",""
"CATHETER BACTISEAL 14CM VENTRICULAR BARIUM SILICONE","SUP-ITM-10018022","CDM","C1889","HCPCS","0278","RC","","","","both","","","1125.39","844.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","431.02","38.3","","352.91","352.91","2046.30","1 through 10","348.87","894.69","percent of total billed charges",""
"CATHETER BACTISEAL 14CM VENTRICULAR BARIUM SILICONE","SUP-ITM-10018022","CDM","C1889","HCPCS","0278","RC","","","","both","","","1125.39","844.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","482.79","42.9","","9668.75","9668.75","9668.75","1 through 10","348.87","894.69","percent of total billed charges",""
"CATHETER BACTISEAL 14CM VENTRICULAR BARIUM SILICONE","SUP-ITM-10018022","CDM","C1889","HCPCS","0278","RC","","","","both","","","1125.39","844.04","WELLPOINT [1015]","HB AMC WELLPOINT","830.31","73.78","","699.88","384.10","3443.31","33","348.87","894.69","percent of total billed charges",""
"CATHETER BACTISEAL 14CM VENTRICULAR BARIUM SILICONE","SUP-ITM-10018022","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1125.39","844.04","AETNA [1001]","HB AMC AETNA HMO","785.52","69.8","","1421.24","264.50","4933.46","29","588.13","919.67","percent of total billed charges",""
"CATHETER BACTISEAL 14CM VENTRICULAR BARIUM SILICONE","SUP-ITM-10018022","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1125.39","844.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","904.81","80.4","","1022.97","1022.97","3607.50","1 through 10","588.13","919.67","percent of total billed charges",""
"CATHETER BACTISEAL 14CM VENTRICULAR BARIUM SILICONE","SUP-ITM-10018022","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1125.39","844.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","919.67","81.72","","3010.54","693.88","5019.88","35","588.13","919.67","percent of total billed charges",""
"CATHETER BACTISEAL 14X120CM LF DRAINAGE BARIUM SILICONE VENTRICULAR PERITONEAL","SUP-ITM-10017304","CDM","C1889","HCPCS","0278","RC","","","","both","","","1978.69","1484.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1573.06","79.5","","1309.77","674.56","6049.93","26","613.39","1573.06","percent of total billed charges",""
"CATHETER BACTISEAL 14X120CM LF DRAINAGE BARIUM SILICONE VENTRICULAR PERITONEAL","SUP-ITM-10017304","CDM","C1889","HCPCS","0278","RC","","","","both","","","1978.69","1484.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1054.64","53.3","","1901.83","1901.83","2962.25","1 through 10","613.39","1573.06","percent of total billed charges",""
"CATHETER BACTISEAL 14X120CM LF DRAINAGE BARIUM SILICONE VENTRICULAR PERITONEAL","SUP-ITM-10017304","CDM","C1889","HCPCS","0278","RC","","","","both","","","1978.69","1484.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","722.22","36.5","","1620.31","1620.31","19908.88","1 through 10","613.39","1573.06","percent of total billed charges",""
"CATHETER BACTISEAL 14X120CM LF DRAINAGE BARIUM SILICONE VENTRICULAR PERITONEAL","SUP-ITM-10017304","CDM","C1889","HCPCS","0278","RC","","","","both","","","1978.69","1484.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","757.84","38.3","","352.91","352.91","2046.30","1 through 10","613.39","1573.06","percent of total billed charges",""
"CATHETER BACTISEAL 14X120CM LF DRAINAGE BARIUM SILICONE VENTRICULAR PERITONEAL","SUP-ITM-10017304","CDM","C1889","HCPCS","0278","RC","","","","both","","","1978.69","1484.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","848.86","42.9","","9668.75","9668.75","9668.75","1 through 10","613.39","1573.06","percent of total billed charges",""
"CATHETER BACTISEAL 14X120CM LF DRAINAGE BARIUM SILICONE VENTRICULAR PERITONEAL","SUP-ITM-10017304","CDM","C1889","HCPCS","0278","RC","","","","both","","","1978.69","1484.02","WELLPOINT [1015]","HB AMC WELLPOINT","1459.88","73.78","","699.88","384.10","3443.31","33","613.39","1573.06","percent of total billed charges",""
"CATHETER BACTISEAL 14X120CM LF DRAINAGE BARIUM SILICONE VENTRICULAR PERITONEAL","SUP-ITM-10017304","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1978.69","1484.02","AETNA [1001]","HB AMC AETNA HMO","1381.13","69.8","","1421.24","264.50","4933.46","29","1034.06","1616.99","percent of total billed charges",""
"CATHETER BACTISEAL 14X120CM LF DRAINAGE BARIUM SILICONE VENTRICULAR PERITONEAL","SUP-ITM-10017304","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1978.69","1484.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1590.87","80.4","","1022.97","1022.97","3607.50","1 through 10","1034.06","1616.99","percent of total billed charges",""
"CATHETER BACTISEAL 14X120CM LF DRAINAGE BARIUM SILICONE VENTRICULAR PERITONEAL","SUP-ITM-10017304","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1978.69","1484.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1616.99","81.72","","3010.54","693.88","5019.88","35","1034.06","1616.99","percent of total billed charges",""
"CATHETER BACTISEAL 15CMX1.5CMX1.3X2.5MM SILICONE VENTRICULAR BARIUM STRIPE ACCU-FLO STYLE HOLE CLEAR","SUP-ITM-10045368","CDM","C1889","HCPCS","0278","RC","","","","both","","","1416.00","1062.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1125.72","79.5","","1309.77","674.56","6049.93","26","438.96","1125.72","percent of total billed charges",""
"CATHETER BACTISEAL 15CMX1.5CMX1.3X2.5MM SILICONE VENTRICULAR BARIUM STRIPE ACCU-FLO STYLE HOLE CLEAR","SUP-ITM-10045368","CDM","C1889","HCPCS","0278","RC","","","","both","","","1416.00","1062.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","754.73","53.3","","1901.83","1901.83","2962.25","1 through 10","438.96","1125.72","percent of total billed charges",""
"CATHETER BACTISEAL 15CMX1.5CMX1.3X2.5MM SILICONE VENTRICULAR BARIUM STRIPE ACCU-FLO STYLE HOLE CLEAR","SUP-ITM-10045368","CDM","C1889","HCPCS","0278","RC","","","","both","","","1416.00","1062.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","516.84","36.5","","1620.31","1620.31","19908.88","1 through 10","438.96","1125.72","percent of total billed charges",""
"CATHETER BACTISEAL 15CMX1.5CMX1.3X2.5MM SILICONE VENTRICULAR BARIUM STRIPE ACCU-FLO STYLE HOLE CLEAR","SUP-ITM-10045368","CDM","C1889","HCPCS","0278","RC","","","","both","","","1416.00","1062.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","542.33","38.3","","352.91","352.91","2046.30","1 through 10","438.96","1125.72","percent of total billed charges",""
"CATHETER BACTISEAL 15CMX1.5CMX1.3X2.5MM SILICONE VENTRICULAR BARIUM STRIPE ACCU-FLO STYLE HOLE CLEAR","SUP-ITM-10045368","CDM","C1889","HCPCS","0278","RC","","","","both","","","1416.00","1062.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","607.46","42.9","","9668.75","9668.75","9668.75","1 through 10","438.96","1125.72","percent of total billed charges",""
"CATHETER BACTISEAL 15CMX1.5CMX1.3X2.5MM SILICONE VENTRICULAR BARIUM STRIPE ACCU-FLO STYLE HOLE CLEAR","SUP-ITM-10045368","CDM","C1889","HCPCS","0278","RC","","","","both","","","1416.00","1062.00","WELLPOINT [1015]","HB AMC WELLPOINT","1044.72","73.78","","699.88","384.10","3443.31","33","438.96","1125.72","percent of total billed charges",""
"CATHETER BACTISEAL 15CMX1.5CMX1.3X2.5MM SILICONE VENTRICULAR BARIUM STRIPE ACCU-FLO STYLE HOLE CLEAR","SUP-ITM-10045368","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1416.00","1062.00","AETNA [1001]","HB AMC AETNA HMO","988.37","69.8","","1421.24","264.50","4933.46","29","740","1157.16","percent of total billed charges",""
"CATHETER BACTISEAL 15CMX1.5CMX1.3X2.5MM SILICONE VENTRICULAR BARIUM STRIPE ACCU-FLO STYLE HOLE CLEAR","SUP-ITM-10045368","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1416.00","1062.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1138.46","80.4","","1022.97","1022.97","3607.50","1 through 10","740","1157.16","percent of total billed charges",""
"CATHETER BACTISEAL 15CMX1.5CMX1.3X2.5MM SILICONE VENTRICULAR BARIUM STRIPE ACCU-FLO STYLE HOLE CLEAR","SUP-ITM-10045368","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1416.00","1062.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1157.16","81.72","","3010.54","693.88","5019.88","35","740","1157.16","percent of total billed charges",""
"CATHETER BALLOON 11FR 24MM 5CM BIB AORTA","SUP-ITM-10194335","CDM","C1725","HCPCS","0272","RC","","","","both","","","3892.70","2919.52","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2794.96","71.8","","175.91","175.91","175.91","1 through 10","1206.74","3094.7","percent of total billed charges",""
"CATHETER BALLOON 11FR 24MM 5CM BIB AORTA","SUP-ITM-10194335","CDM","C1725","HCPCS","0272","RC","","","","both","","","3892.70","2919.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2530.26","65","","147.88","147.88","1296.75","1 through 10","1206.74","3094.7","percent of total billed charges",""
"CATHETER BALLOON 11FR 24MM 5CM BIB AORTA","SUP-ITM-10194335","CDM","C1725","HCPCS","0272","RC","","","","both","","","3892.70","2919.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1420.84","36.5","","181.40","177.87","181.40","21","1206.74","3094.7","percent of total billed charges",""
"CATHETER BALLOON 11FR 24MM 5CM BIB AORTA","SUP-ITM-10194335","CDM","C1725","HCPCS","0272","RC","","","","both","","","3892.70","2919.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1490.90","38.3","","170.15","88.95","424.24","16","1206.74","3094.7","percent of total billed charges",""
"CATHETER BALLOON 11FR 24MM 5CM BIB AORTA","SUP-ITM-10194335","CDM","C1725","HCPCS","0272","RC","","","","both","","","3892.70","2919.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.97","42.9","","699.48","699.48","699.48","12","1206.74","3094.7","percent of total billed charges",""
"CATHETER BALLOON 11FR 24MM 5CM BIB AORTA","SUP-ITM-10194335","CDM","C1725","HCPCS","0272","RC","","","","both","","","3892.70","2919.52","WELLPOINT [1015]","HB AMC WELLPOINT","2872.03","73.78","","576.52","182.40","651.44","14","1206.74","3094.7","percent of total billed charges",""
"CATHETER BALLOON 11FR 24MM 5CM BIB AORTA","SUP-ITM-10194335","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","3892.70","2919.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3181.11","81.72","","181.86","100.03","402.41","21","2034.33","3181.11","percent of total billed charges",""
"CATHETER BALLOON 24FRX8MM 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155563","CDM","C1726","HCPCS","0272","RC","","","","both","","","1102.05","826.54","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","771.44","70","","863.10","863.10","863.10","1 through 10","341.64","876.13","percent of total billed charges",""
"CATHETER BALLOON 24FRX8MM 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155563","CDM","C1726","HCPCS","0272","RC","","","","both","","","1102.05","826.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","876.13","79.5","","447.66","447.66","447.66","1 through 10","341.64","876.13","percent of total billed charges",""
"CATHETER BALLOON 24FRX8MM 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155563","CDM","C1726","HCPCS","0272","RC","","","","both","","","1102.05","826.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","716.33","65","","1020.11","1020.11","1020.11","1 through 10","341.64","876.13","percent of total billed charges",""
"CATHETER BALLOON 24FRX8MM 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155563","CDM","C1726","HCPCS","0272","RC","","","","both","","","1102.05","826.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","341.64","31","","208.83","208.83","208.83","1 through 10","341.64","876.13","percent of total billed charges",""
"CATHETER BALLOON 24FRX8MM 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155563","CDM","C1726","HCPCS","0272","RC","","","","both","","","1102.05","826.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","402.25","36.5","","312.44","214.23","1086.03","20","341.64","876.13","percent of total billed charges",""
"CATHETER BALLOON 24FRX8MM 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155563","CDM","C1726","HCPCS","0272","RC","","","","both","","","1102.05","826.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","422.09","38.3","","264.25","227.63","567.11","31","341.64","876.13","percent of total billed charges",""
"CATHETER BALLOON 24FRX8MM 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155563","CDM","C1726","HCPCS","0272","RC","","","","both","","","1102.05","826.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","472.78","42.9","","79.94","79.94","79.94","1 through 10","341.64","876.13","percent of total billed charges",""
"CATHETER BALLOON 24FRX8MM 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155563","CDM","C1726","HCPCS","0272","RC","","","","both","","","1102.05","826.54","WELLPOINT [1015]","HB AMC WELLPOINT","813.09","73.78","","174.45","74.45","1168.42","1 through 10","341.64","876.13","percent of total billed charges",""
"CATHETER BALLOON 24FRX8MM 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155563","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1102.05","826.54","AETNA [1001]","HB AMC AETNA HMO","769.23","69.8","","655.01","135.40","784.73","1 through 10","575.93","900.6","percent of total billed charges",""
"CATHETER BALLOON 24FRX8MM 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155563","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1102.05","826.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","900.60","81.72","","540.25","46.28","897.42","36","575.93","900.6","percent of total billed charges",""
"CATHETER BALLOON 34FR 100CM OCCLUSION","SUP-ITM-10155558","CDM","C2628","HCPCS","0272","RC","","","","both","","","688.31","516.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","547.21","79.5","","518.94","518.94","518.94","1 through 10","213.38","547.21","percent of total billed charges",""
"CATHETER BALLOON 34FR 100CM OCCLUSION","SUP-ITM-10155558","CDM","C2628","HCPCS","0272","RC","","","","both","","","688.31","516.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","447.40","65","","429.02","429.02","429.02","1 through 10","213.38","547.21","percent of total billed charges",""
"CATHETER BALLOON 34FR 100CM OCCLUSION","SUP-ITM-10155558","CDM","C2628","HCPCS","0272","RC","","","","both","","","688.31","516.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","251.23","36.5","","4636.13","4636.13","4636.13","1 through 10","213.38","547.21","percent of total billed charges",""
"CATHETER BALLOON 34FR 100CM OCCLUSION","SUP-ITM-10155558","CDM","C2628","HCPCS","0272","RC","","","","both","","","688.31","516.23","WELLPOINT [1015]","HB AMC WELLPOINT","507.84","73.78","","491.39","491.39","491.39","1 through 10","213.38","547.21","percent of total billed charges",""
"CATHETER BALLOON 34FR 100CM OCCLUSION","SUP-ITM-10155558","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","688.31","516.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","562.49","81.72","","290.22","290.22","290.22","1 through 10","359.71","562.49","percent of total billed charges",""
"CATHETER BALLOON 5FR 80CM 10MM 2 .035 35 LP LOW PROFILE ADVANCE ENDHOLE BX/1EA","SUP-ITM-10134247","CDM","C1725","HCPCS","0272","RC","","","","both","","","329.21","246.91","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","236.37","71.8","","175.91","175.91","175.91","1 through 10","102.06","261.72","percent of total billed charges",""
"CATHETER BALLOON 5FR 80CM 10MM 2 .035 35 LP LOW PROFILE ADVANCE ENDHOLE BX/1EA","SUP-ITM-10134247","CDM","C1725","HCPCS","0272","RC","","","","both","","","329.21","246.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","213.99","65","","147.88","147.88","1296.75","1 through 10","102.06","261.72","percent of total billed charges",""
"CATHETER BALLOON 5FR 80CM 10MM 2 .035 35 LP LOW PROFILE ADVANCE ENDHOLE BX/1EA","SUP-ITM-10134247","CDM","C1725","HCPCS","0272","RC","","","","both","","","329.21","246.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","120.16","36.5","","181.40","177.87","181.40","21","102.06","261.72","percent of total billed charges",""
"CATHETER BALLOON 5FR 80CM 10MM 2 .035 35 LP LOW PROFILE ADVANCE ENDHOLE BX/1EA","SUP-ITM-10134247","CDM","C1725","HCPCS","0272","RC","","","","both","","","329.21","246.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","126.09","38.3","","170.15","88.95","424.24","16","102.06","261.72","percent of total billed charges",""
"CATHETER BALLOON 5FR 80CM 10MM 2 .035 35 LP LOW PROFILE ADVANCE ENDHOLE BX/1EA","SUP-ITM-10134247","CDM","C1725","HCPCS","0272","RC","","","","both","","","329.21","246.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.23","42.9","","699.48","699.48","699.48","12","102.06","261.72","percent of total billed charges",""
"CATHETER BALLOON 5FR 80CM 10MM 2 .035 35 LP LOW PROFILE ADVANCE ENDHOLE BX/1EA","SUP-ITM-10134247","CDM","C1725","HCPCS","0272","RC","","","","both","","","329.21","246.91","WELLPOINT [1015]","HB AMC WELLPOINT","242.89","73.78","","576.52","182.40","651.44","14","102.06","261.72","percent of total billed charges",""
"CATHETER BALLOON 5FR 80CM 10MM 2 .035 35 LP LOW PROFILE ADVANCE ENDHOLE BX/1EA","SUP-ITM-10134247","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","329.21","246.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","269.03","81.72","","181.86","100.03","402.41","21","172.05","269.03","percent of total billed charges",""
"CATHETER BALLOON 7FR 100CM 11.5MM .038IN STANDARD OCCLUSION NYLON RADIOPAQUE DOUBLE LUMEN LATEX STERILE","SUP-ITM-10000144","CDM","C2628","HCPCS","0272","RC","","","","both","","","660.03","495.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","524.72","79.5","","518.94","518.94","518.94","1 through 10","204.61","524.72","percent of total billed charges",""
"CATHETER BALLOON 7FR 100CM 11.5MM .038IN STANDARD OCCLUSION NYLON RADIOPAQUE DOUBLE LUMEN LATEX STERILE","SUP-ITM-10000144","CDM","C2628","HCPCS","0272","RC","","","","both","","","660.03","495.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","429.02","65","","429.02","429.02","429.02","1 through 10","204.61","524.72","percent of total billed charges",""
"CATHETER BALLOON 7FR 100CM 11.5MM .038IN STANDARD OCCLUSION NYLON RADIOPAQUE DOUBLE LUMEN LATEX STERILE","SUP-ITM-10000144","CDM","C2628","HCPCS","0272","RC","","","","both","","","660.03","495.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","240.91","36.5","","4636.13","4636.13","4636.13","1 through 10","204.61","524.72","percent of total billed charges",""
"CATHETER BALLOON 7FR 100CM 11.5MM .038IN STANDARD OCCLUSION NYLON RADIOPAQUE DOUBLE LUMEN LATEX STERILE","SUP-ITM-10000144","CDM","C2628","HCPCS","0272","RC","","","","both","","","660.03","495.02","WELLPOINT [1015]","HB AMC WELLPOINT","486.97","73.78","","491.39","491.39","491.39","1 through 10","204.61","524.72","percent of total billed charges",""
"CATHETER BALLOON 7FR 100CM 11.5MM .038IN STANDARD OCCLUSION NYLON RADIOPAQUE DOUBLE LUMEN LATEX STERILE","SUP-ITM-10000144","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","660.03","495.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","539.38","81.72","","290.22","290.22","290.22","1 through 10","344.93","539.38","percent of total billed charges",""
"CATHETER BALLOON 8.0FR 16X20MM 120CM 2XL MICRO14 551 DILATOR AIRWAY","SUP-ITM-10012820","CDM","C1725","HCPCS","0272","RC","","","","both","","","910.00","682.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","653.38","71.8","","175.91","175.91","175.91","1 through 10","282.1","723.45","percent of total billed charges",""
"CATHETER BALLOON 8.0FR 16X20MM 120CM 2XL MICRO14 551 DILATOR AIRWAY","SUP-ITM-10012820","CDM","C1725","HCPCS","0272","RC","","","","both","","","910.00","682.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","591.50","65","","147.88","147.88","1296.75","1 through 10","282.1","723.45","percent of total billed charges",""
"CATHETER BALLOON 8.0FR 16X20MM 120CM 2XL MICRO14 551 DILATOR AIRWAY","SUP-ITM-10012820","CDM","C1725","HCPCS","0272","RC","","","","both","","","910.00","682.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","332.15","36.5","","181.40","177.87","181.40","21","282.1","723.45","percent of total billed charges",""
"CATHETER BALLOON 8.0FR 16X20MM 120CM 2XL MICRO14 551 DILATOR AIRWAY","SUP-ITM-10012820","CDM","C1725","HCPCS","0272","RC","","","","both","","","910.00","682.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","348.53","38.3","","170.15","88.95","424.24","16","282.1","723.45","percent of total billed charges",""
"CATHETER BALLOON 8.0FR 16X20MM 120CM 2XL MICRO14 551 DILATOR AIRWAY","SUP-ITM-10012820","CDM","C1725","HCPCS","0272","RC","","","","both","","","910.00","682.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","390.39","42.9","","699.48","699.48","699.48","12","282.1","723.45","percent of total billed charges",""
"CATHETER BALLOON 8.0FR 16X20MM 120CM 2XL MICRO14 551 DILATOR AIRWAY","SUP-ITM-10012820","CDM","C1725","HCPCS","0272","RC","","","","both","","","910.00","682.50","WELLPOINT [1015]","HB AMC WELLPOINT","671.40","73.78","","576.52","182.40","651.44","14","282.1","723.45","percent of total billed charges",""
"CATHETER BALLOON 8.0FR 16X20MM 120CM 2XL MICRO14 551 DILATOR AIRWAY","SUP-ITM-10012820","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","910.00","682.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","743.65","81.72","","181.86","100.03","402.41","21","475.57","743.65","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T1","PX-27000038","CDM","C1726","HCPCS","0272","RC","","","","both","","","729.00","546.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","510.30","70","","863.10","863.10","863.10","1 through 10","225.99","579.56","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T1","PX-27000038","CDM","C1726","HCPCS","0272","RC","","","","both","","","729.00","546.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","579.56","79.5","","447.66","447.66","447.66","1 through 10","225.99","579.56","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T1","PX-27000038","CDM","C1726","HCPCS","0272","RC","","","","both","","","729.00","546.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","473.85","65","","1020.11","1020.11","1020.11","1 through 10","225.99","579.56","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T1","PX-27000038","CDM","C1726","HCPCS","0272","RC","","","","both","","","729.00","546.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","225.99","31","","208.83","208.83","208.83","1 through 10","225.99","579.56","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T1","PX-27000038","CDM","C1726","HCPCS","0272","RC","","","","both","","","729.00","546.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","266.09","36.5","","312.44","214.23","1086.03","20","225.99","579.56","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T1","PX-27000038","CDM","C1726","HCPCS","0272","RC","","","","both","","","729.00","546.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","279.21","38.3","","264.25","227.63","567.11","31","225.99","579.56","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T1","PX-27000038","CDM","C1726","HCPCS","0272","RC","","","","both","","","729.00","546.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.74","42.9","","79.94","79.94","79.94","1 through 10","225.99","579.56","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T1","PX-27000038","CDM","C1726","HCPCS","0272","RC","","","","both","","","729.00","546.75","WELLPOINT [1015]","HB AMC WELLPOINT","537.86","73.78","","174.45","74.45","1168.42","1 through 10","225.99","579.56","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T1","PX-27000038","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","729.00","546.75","AETNA [1001]","HB AMC AETNA HMO","508.84","69.8","","655.01","135.40","784.73","1 through 10","380.98","595.74","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T1","PX-27000038","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","729.00","546.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","595.74","81.72","","540.25","46.28","897.42","36","380.98","595.74","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T3","PX-27000039","CDM","C1726","HCPCS","0272","RC","","","","both","","","6652.88","4989.66","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4657.02","70","","863.10","863.10","863.10","1 through 10","2062.39","5289.04","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T3","PX-27000039","CDM","C1726","HCPCS","0272","RC","","","","both","","","6652.88","4989.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5289.04","79.5","","447.66","447.66","447.66","1 through 10","2062.39","5289.04","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T3","PX-27000039","CDM","C1726","HCPCS","0272","RC","","","","both","","","6652.88","4989.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4324.37","65","","1020.11","1020.11","1020.11","1 through 10","2062.39","5289.04","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T3","PX-27000039","CDM","C1726","HCPCS","0272","RC","","","","both","","","6652.88","4989.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2062.39","31","","208.83","208.83","208.83","1 through 10","2062.39","5289.04","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T3","PX-27000039","CDM","C1726","HCPCS","0272","RC","","","","both","","","6652.88","4989.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2428.30","36.5","","312.44","214.23","1086.03","20","2062.39","5289.04","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T3","PX-27000039","CDM","C1726","HCPCS","0272","RC","","","","both","","","6652.88","4989.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2548.05","38.3","","264.25","227.63","567.11","31","2062.39","5289.04","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T3","PX-27000039","CDM","C1726","HCPCS","0272","RC","","","","both","","","6652.88","4989.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2854.09","42.9","","79.94","79.94","79.94","1 through 10","2062.39","5289.04","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T3","PX-27000039","CDM","C1726","HCPCS","0272","RC","","","","both","","","6652.88","4989.66","WELLPOINT [1015]","HB AMC WELLPOINT","4908.49","73.78","","174.45","74.45","1168.42","1 through 10","2062.39","5289.04","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T3","PX-27000039","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","6652.88","4989.66","AETNA [1001]","HB AMC AETNA HMO","4643.71","69.8","","655.01","135.40","784.73","1 through 10","3476.8","5436.73","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T3","PX-27000039","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","6652.88","4989.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5436.73","81.72","","540.25","46.28","897.42","36","3476.8","5436.73","percent of total billed charges",""
"CATHETER BARIUM PERT AND VENT LG BACT","SUP-ITM-10114916","CDM","C1889","HCPCS","0278","RC","","","","both","","","2492.00","1869.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1981.14","79.5","","1309.77","674.56","6049.93","26","772.52","1981.14","percent of total billed charges",""
"CATHETER BARIUM PERT AND VENT LG BACT","SUP-ITM-10114916","CDM","C1889","HCPCS","0278","RC","","","","both","","","2492.00","1869.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1328.24","53.3","","1901.83","1901.83","2962.25","1 through 10","772.52","1981.14","percent of total billed charges",""
"CATHETER BARIUM PERT AND VENT LG BACT","SUP-ITM-10114916","CDM","C1889","HCPCS","0278","RC","","","","both","","","2492.00","1869.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","909.58","36.5","","1620.31","1620.31","19908.88","1 through 10","772.52","1981.14","percent of total billed charges",""
"CATHETER BARIUM PERT AND VENT LG BACT","SUP-ITM-10114916","CDM","C1889","HCPCS","0278","RC","","","","both","","","2492.00","1869.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","954.44","38.3","","352.91","352.91","2046.30","1 through 10","772.52","1981.14","percent of total billed charges",""
"CATHETER BARIUM PERT AND VENT LG BACT","SUP-ITM-10114916","CDM","C1889","HCPCS","0278","RC","","","","both","","","2492.00","1869.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1069.07","42.9","","9668.75","9668.75","9668.75","1 through 10","772.52","1981.14","percent of total billed charges",""
"CATHETER BARIUM PERT AND VENT LG BACT","SUP-ITM-10114916","CDM","C1889","HCPCS","0278","RC","","","","both","","","2492.00","1869.00","WELLPOINT [1015]","HB AMC WELLPOINT","1838.60","73.78","","699.88","384.10","3443.31","33","772.52","1981.14","percent of total billed charges",""
"CATHETER BARIUM PERT AND VENT LG BACT","SUP-ITM-10114916","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2492.00","1869.00","AETNA [1001]","HB AMC AETNA HMO","1739.42","69.8","","1421.24","264.50","4933.46","29","1302.32","2036.46","percent of total billed charges",""
"CATHETER BARIUM PERT AND VENT LG BACT","SUP-ITM-10114916","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2492.00","1869.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2003.57","80.4","","1022.97","1022.97","3607.50","1 through 10","1302.32","2036.46","percent of total billed charges",""
"CATHETER BARIUM PERT AND VENT LG BACT","SUP-ITM-10114916","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2492.00","1869.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2036.46","81.72","","3010.54","693.88","5019.88","35","1302.32","2036.46","percent of total billed charges",""
"CATHETER BARRX 7.5MM 15.7MM ELECTRODE 2.8MM 135CM EP RFA ABLATION FLEXIBLE DUODECAPOLAR","SUP-ITM-10124342","CDM","C1886","HCPCS","0272","RC","","","","both","","","5109.00","3831.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3668.26","71.8","","4399.55","4399.55","4399.55","1 through 10","1583.79","4061.66","percent of total billed charges",""
"CATHETER BARRX 7.5MM 15.7MM ELECTRODE 2.8MM 135CM EP RFA ABLATION FLEXIBLE DUODECAPOLAR","SUP-ITM-10124342","CDM","C1886","HCPCS","0272","RC","","","","both","","","5109.00","3831.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1864.79","36.5","","1413.19","621.27","1413.19","1 through 10","1583.79","4061.66","percent of total billed charges",""
"CATHETER BARRX 7.5MM 15.7MM ELECTRODE 2.8MM 135CM EP RFA ABLATION FLEXIBLE DUODECAPOLAR","SUP-ITM-10124342","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","5109.00","3831.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4175.07","81.72","","8168.27","2209.17","8168.27","1 through 10","2669.96","4175.07","percent of total billed charges",""
"CATHETER BARRX ENDOSCOPIC SB RFA","SUP-ITM-10268525","CDM","C1886","HCPCS","0272","RC","","","","both","","","4500.00","3375.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3231.00","71.8","","4399.55","4399.55","4399.55","1 through 10","1395","3577.5","percent of total billed charges",""
"CATHETER BARRX ENDOSCOPIC SB RFA","SUP-ITM-10268525","CDM","C1886","HCPCS","0272","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","1413.19","621.27","1413.19","1 through 10","1395","3577.5","percent of total billed charges",""
"CATHETER BARRX ENDOSCOPIC SB RFA","SUP-ITM-10268525","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","8168.27","2209.17","8168.27","1 through 10","2351.7","3677.4","percent of total billed charges",""
"CATHETER BARRX360 4CM ELEC 8CM BAL 18-31MM 4PSI 16ABLATIONS .035-.069IN EXPRESS RFA BALLOON SELF SIZING ENDOSCOPY","SUP-ITM-10157611","CDM","C1886","HCPCS","0272","RC","","","","both","","","6127.50","4595.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","4399.55","71.8","","4399.55","4399.55","4399.55","1 through 10","1899.53","4871.36","percent of total billed charges",""
"CATHETER BARRX360 4CM ELEC 8CM BAL 18-31MM 4PSI 16ABLATIONS .035-.069IN EXPRESS RFA BALLOON SELF SIZING ENDOSCOPY","SUP-ITM-10157611","CDM","C1886","HCPCS","0272","RC","","","","both","","","6127.50","4595.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2236.54","36.5","","1413.19","621.27","1413.19","1 through 10","1899.53","4871.36","percent of total billed charges",""
"CATHETER BARRX360 4CM ELEC 8CM BAL 18-31MM 4PSI 16ABLATIONS .035-.069IN EXPRESS RFA BALLOON SELF SIZING ENDOSCOPY","SUP-ITM-10157611","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","6127.50","4595.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5007.39","81.72","","8168.27","2209.17","8168.27","1 through 10","3202.23","5007.39","percent of total billed charges",""
"CATHETER BARRX90 20MM 13MM ELECTRODE 4MM 160CM SHAFT RFA FOCAL ENDOSCOPIC HALO DISP","SUP-ITM-10024997","CDM","C1886","HCPCS","0272","RC","","","","both","","","4458.00","3343.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3200.84","71.8","","4399.55","4399.55","4399.55","1 through 10","1381.98","3544.11","percent of total billed charges",""
"CATHETER BARRX90 20MM 13MM ELECTRODE 4MM 160CM SHAFT RFA FOCAL ENDOSCOPIC HALO DISP","SUP-ITM-10024997","CDM","C1886","HCPCS","0272","RC","","","","both","","","4458.00","3343.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1627.17","36.5","","1413.19","621.27","1413.19","1 through 10","1381.98","3544.11","percent of total billed charges",""
"CATHETER BARRX90 20MM 13MM ELECTRODE 4MM 160CM SHAFT RFA FOCAL ENDOSCOPIC HALO DISP","SUP-ITM-10024997","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","4458.00","3343.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3643.08","81.72","","8168.27","2209.17","8168.27","1 through 10","2329.75","3643.08","percent of total billed charges",""
"CATHETER BERMAN 7FR 110CM .038IN ANGIOGRAPHY DOUBLE LUMEN POLYURETHANE BALLOON OCCLUSION STROKE CONTROL","SUP-ITM-10000078","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","339.26","71.8","","28.28","27.13","28.28","1 through 10","146.48","375.64","percent of total billed charges",""
"CATHETER BERMAN 7FR 110CM .038IN ANGIOGRAPHY DOUBLE LUMEN POLYURETHANE BALLOON OCCLUSION STROKE CONTROL","SUP-ITM-10000078","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","330.75","70","","44.63","35.78","44.63","1 through 10","146.48","375.64","percent of total billed charges",""
"CATHETER BERMAN 7FR 110CM .038IN ANGIOGRAPHY DOUBLE LUMEN POLYURETHANE BALLOON OCCLUSION STROKE CONTROL","SUP-ITM-10000078","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","375.64","79.5","","1342.89","271.64","6954.67","1 through 10","146.48","375.64","percent of total billed charges",""
"CATHETER BERMAN 7FR 110CM .038IN ANGIOGRAPHY DOUBLE LUMEN POLYURETHANE BALLOON OCCLUSION STROKE CONTROL","SUP-ITM-10000078","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","251.84","53.3","","4550.00","30.49","4550.00","1 through 10","146.48","375.64","percent of total billed charges",""
"CATHETER BERMAN 7FR 110CM .038IN ANGIOGRAPHY DOUBLE LUMEN POLYURETHANE BALLOON OCCLUSION STROKE CONTROL","SUP-ITM-10000078","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","307.13","65","","42.09","0.04","5453.50","1 through 10","146.48","375.64","percent of total billed charges",""
"CATHETER BERMAN 7FR 110CM .038IN ANGIOGRAPHY DOUBLE LUMEN POLYURETHANE BALLOON OCCLUSION STROKE CONTROL","SUP-ITM-10000078","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","172.46","36.5","","310.94","18.54","1259.30","62","146.48","375.64","percent of total billed charges",""
"CATHETER BERMAN 7FR 110CM .038IN ANGIOGRAPHY DOUBLE LUMEN POLYURETHANE BALLOON OCCLUSION STROKE CONTROL","SUP-ITM-10000078","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","180.97","38.3","","146.86","22.58","1753.45","65","146.48","375.64","percent of total billed charges",""
"CATHETER BERMAN 7FR 110CM .038IN ANGIOGRAPHY DOUBLE LUMEN POLYURETHANE BALLOON OCCLUSION STROKE CONTROL","SUP-ITM-10000078","CDM","C1887","HCPCS","0272","RC","","","","both","","","472.50","354.37","WELLPOINT [1015]","HB AMC WELLPOINT","348.61","73.78","","247.29","33.09","909.09","53","146.48","375.64","percent of total billed charges",""
"CATHETER BERMAN 7FR 110CM .038IN ANGIOGRAPHY DOUBLE LUMEN POLYURETHANE BALLOON OCCLUSION STROKE CONTROL","SUP-ITM-10000078","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","472.50","354.37","AETNA [1001]","HB AMC AETNA HMO","329.81","69.8","","30.69","30.21","30.69","1 through 10","246.93","386.13","percent of total billed charges",""
"CATHETER BERMAN 7FR 110CM .038IN ANGIOGRAPHY DOUBLE LUMEN POLYURETHANE BALLOON OCCLUSION STROKE CONTROL","SUP-ITM-10000078","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","472.50","354.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","379.89","80.4","","82.69","82.69","82.69","1 through 10","246.93","386.13","percent of total billed charges",""
"CATHETER BERMAN 7FR 110CM .038IN ANGIOGRAPHY DOUBLE LUMEN POLYURETHANE BALLOON OCCLUSION STROKE CONTROL","SUP-ITM-10000078","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","472.50","354.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","386.13","81.72","","751.01","74.72","751.01","1 through 10","246.93","386.13","percent of total billed charges",""
"CATHETER BERMAN 7FR 110CM .038IN ANGIOGRAPHY DOUBLE LUMEN POLYURETHANE BALLOON OCCLUSION STROKE CONTROL","SUP-ITM-10000078","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","472.50","354.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","386.13","81.72","","328.92","46.17","2701.97","59","246.93","386.13","percent of total billed charges",""
"CATHETER BICAVAL 31CMX27FR DUAL LUMEN .038IN SS NONCOATED SMOOTH VASCULAR ACCESS CONNECTOR","SUP-ITM-10115496","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5765.74","79.5","","1309.77","674.56","6049.93","26","2248.28","5765.74","percent of total billed charges",""
"CATHETER BICAVAL 31CMX27FR DUAL LUMEN .038IN SS NONCOATED SMOOTH VASCULAR ACCESS CONNECTOR","SUP-ITM-10115496","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3865.58","53.3","","1901.83","1901.83","2962.25","1 through 10","2248.28","5765.74","percent of total billed charges",""
"CATHETER BICAVAL 31CMX27FR DUAL LUMEN .038IN SS NONCOATED SMOOTH VASCULAR ACCESS CONNECTOR","SUP-ITM-10115496","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2647.16","36.5","","1620.31","1620.31","19908.88","1 through 10","2248.28","5765.74","percent of total billed charges",""
"CATHETER BICAVAL 31CMX27FR DUAL LUMEN .038IN SS NONCOATED SMOOTH VASCULAR ACCESS CONNECTOR","SUP-ITM-10115496","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2777.71","38.3","","352.91","352.91","2046.30","1 through 10","2248.28","5765.74","percent of total billed charges",""
"CATHETER BICAVAL 31CMX27FR DUAL LUMEN .038IN SS NONCOATED SMOOTH VASCULAR ACCESS CONNECTOR","SUP-ITM-10115496","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3111.32","42.9","","9668.75","9668.75","9668.75","1 through 10","2248.28","5765.74","percent of total billed charges",""
"CATHETER BICAVAL 31CMX27FR DUAL LUMEN .038IN SS NONCOATED SMOOTH VASCULAR ACCESS CONNECTOR","SUP-ITM-10115496","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","WELLPOINT [1015]","HB AMC WELLPOINT","5350.89","73.78","","699.88","384.10","3443.31","33","2248.28","5765.74","percent of total billed charges",""
"CATHETER BICAVAL 31CMX27FR DUAL LUMEN .038IN SS NONCOATED SMOOTH VASCULAR ACCESS CONNECTOR","SUP-ITM-10115496","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7252.50","5439.37","AETNA [1001]","HB AMC AETNA HMO","5062.25","69.8","","1421.24","264.50","4933.46","29","3790.16","5926.74","percent of total billed charges",""
"CATHETER BICAVAL 31CMX27FR DUAL LUMEN .038IN SS NONCOATED SMOOTH VASCULAR ACCESS CONNECTOR","SUP-ITM-10115496","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7252.50","5439.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5831.01","80.4","","1022.97","1022.97","3607.50","1 through 10","3790.16","5926.74","percent of total billed charges",""
"CATHETER BICAVAL 31CMX27FR DUAL LUMEN .038IN SS NONCOATED SMOOTH VASCULAR ACCESS CONNECTOR","SUP-ITM-10115496","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7252.50","5439.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5926.74","81.72","","3010.54","693.88","5019.88","35","3790.16","5926.74","percent of total billed charges",""
"Catheter Bladder Complicated","PX-76001259","CDM","51703","CPT","0761","RC","","","","both","","","747.00","560.25","WELLPOINT [1015]","HB AMC WELLPOINT","551.14","73.78","","539.02","539.02","539.02","1 through 10","176.52","593.87","percent of total billed charges",""
"Catheter Bladder Complicated","PX-76001259","CDM","51703","CPT","0761","RC","","","","outpatient","","","747.00","560.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","610.45","81.72","","7477.84","318.34","7477.84","1 through 10","155.47","610.45","percent of total billed charges",""
"Catheter Bladder Non-Indwelling","PX-76001257","CDM","51701","CPT","0761","RC","","","","both","","","351.00","263.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","108.81","279.05","other","OPPS APC"
"Catheter Bladder Non-Indwelling","PX-76001257","CDM","51701","CPT","0761","RC","","","","both","","","351.00","263.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","279.05","79.5","","267.58","179.52","267.58","1 through 10","108.81","279.05","percent of total billed charges",""
"Catheter Bladder Non-Indwelling","PX-76001257","CDM","51701","CPT","0761","RC","","","","both","","","351.00","263.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","187.08","53.3","","179.52","179.52","267.58","1 through 10","108.81","279.05","percent of total billed charges",""
"Catheter Bladder Non-Indwelling","PX-76001257","CDM","51701","CPT","0761","RC","","","","both","","","351.00","263.25","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","108.81","279.05","other","OPPS APC"
"Catheter Bladder Non-Indwelling","PX-76001257","CDM","51701","CPT","0761","RC","","","","both","","","351.00","263.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","128.12","36.5","","126.82","107.78","126.82","1 through 10","108.81","279.05","percent of total billed charges",""
"Catheter Bladder Non-Indwelling","PX-76001257","CDM","51701","CPT","0761","RC","","","","both","","","351.00","263.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","134.43","38.3","","132.94","129.20","132.94","13","108.81","279.05","percent of total billed charges",""
"Catheter Bladder Non-Indwelling","PX-76001257","CDM","51701","CPT","0761","RC","","","","both","","","351.00","263.25","WELLPOINT [1015]","HB AMC WELLPOINT","258.97","73.78","","253.13","253.13","253.13","1 through 10","108.81","279.05","percent of total billed charges",""
"Catheter Bladder Non-Indwelling","PX-76001257","CDM","51701","CPT","0761","RC","","","","outpatient","","","351.00","263.25","AETNA [1001]","HB AMC AETNA HMO","245.00","69.8","","230.18","230.18","230.18","1 through 10","121.77","407.82","percent of total billed charges",""
"Catheter Bladder Non-Indwelling","PX-76001257","CDM","51701","CPT","0761","RC","","","","outpatient","","","351.00","263.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","244.64","244.64","249.14","16","121.77","407.82","other","ASC"
"Catheter Bladder Non-Indwelling","PX-76001257","CDM","51701","CPT","0761","RC","","","","outpatient","","","351.00","263.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","282.26","282.26","285.06","28","121.77","407.82","other","ASC "
"Catheter Bladder Non-Indwelling","PX-76001257","CDM","51701","CPT","0761","RC","","","","outpatient","","","351.00","263.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","282.20","80.4","","170.00","170.00","170.00","1 through 10","121.77","407.82","percent of total billed charges",""
"Catheter Bladder Non-Indwelling","PX-76001257","CDM","51701","CPT","0761","RC","","","","outpatient","","","351.00","263.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","286.84","81.72","","271.80","271.80","271.80","1 through 10","121.77","407.82","percent of total billed charges",""
"Catheter Bladder Smp","PX-76001258","CDM","51702","CPT","0761","RC","","","","outpatient","","","343.00","257.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","282.26","282.26","285.06","1 through 10","121.77","407.82","other","ASC "
"CATHETER BLAZER II XP 7FR 4MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR ASYMMETRIC4 CURVE","SUP-ITM-10124144","CDM","C1733","HCPCS","0272","RC","","","","both","","","2537.50","1903.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2017.31","79.5","","17511.01","17511.01","17511.01","1 through 10","786.63","2017.31","percent of total billed charges",""
"CATHETER BLAZER II XP 7FR 4MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR ASYMMETRIC4 CURVE","SUP-ITM-10124144","CDM","C1733","HCPCS","0272","RC","","","","both","","","2537.50","1903.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1352.49","53.3","","21125.00","21125.00","21125.00","1 through 10","786.63","2017.31","percent of total billed charges",""
"CATHETER BLAZER II XP 7FR 4MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR ASYMMETRIC4 CURVE","SUP-ITM-10124144","CDM","C1733","HCPCS","0272","RC","","","","both","","","2537.50","1903.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","926.19","36.5","","7879.63","7879.63","7879.63","1 through 10","786.63","2017.31","percent of total billed charges",""
"CATHETER BLAZER II XP 7FR 4MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR ASYMMETRIC4 CURVE","SUP-ITM-10124144","CDM","C1733","HCPCS","0272","RC","","","","both","","","2537.50","1903.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","971.86","38.3","","8259.88","8259.88","16055.00","1 through 10","786.63","2017.31","percent of total billed charges",""
"CATHETER BLAZER II XP 7FR 4MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR ASYMMETRIC4 CURVE","SUP-ITM-10124144","CDM","C1733","HCPCS","0272","RC","","","","both","","","2537.50","1903.12","WELLPOINT [1015]","HB AMC WELLPOINT","1872.17","73.78","","15727.56","15727.56","20473.75","1 through 10","786.63","2017.31","percent of total billed charges",""
"CATHETER BLAZER II XP 7FR 4MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR ASYMMETRIC4 CURVE","SUP-ITM-10124144","CDM","C1733","HCPCS","0272","RC","","","","outpatient","","","2537.50","1903.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2073.65","81.72","","16887.32","9288.66","16887.32","1 through 10","1326.1","2073.65","percent of total billed charges",""
"CATHETER BLAZER II XP 7FR 4MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR ASYMMETRIC4 CURVE","SUP-ITM-10124144","CDM","C1733","HCPCS","0272","RC","","","","outpatient","","","2537.50","1903.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2073.65","81.72","","16887.33","11641.27","21983.50","1 through 10","1326.1","2073.65","percent of total billed charges",""
"CATHETER BLAZER II XP 8FR 8MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR LARGE CURVE","SUP-ITM-10011574","CDM","C1733","HCPCS","0272","RC","","","","both","","","4125.00","3093.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3279.38","79.5","","17511.01","17511.01","17511.01","1 through 10","1278.75","3279.38","percent of total billed charges",""
"CATHETER BLAZER II XP 8FR 8MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR LARGE CURVE","SUP-ITM-10011574","CDM","C1733","HCPCS","0272","RC","","","","both","","","4125.00","3093.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2198.63","53.3","","21125.00","21125.00","21125.00","1 through 10","1278.75","3279.38","percent of total billed charges",""
"CATHETER BLAZER II XP 8FR 8MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR LARGE CURVE","SUP-ITM-10011574","CDM","C1733","HCPCS","0272","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1505.63","36.5","","7879.63","7879.63","7879.63","1 through 10","1278.75","3279.38","percent of total billed charges",""
"CATHETER BLAZER II XP 8FR 8MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR LARGE CURVE","SUP-ITM-10011574","CDM","C1733","HCPCS","0272","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1579.88","38.3","","8259.88","8259.88","16055.00","1 through 10","1278.75","3279.38","percent of total billed charges",""
"CATHETER BLAZER II XP 8FR 8MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR LARGE CURVE","SUP-ITM-10011574","CDM","C1733","HCPCS","0272","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB AMC WELLPOINT","3043.43","73.78","","15727.56","15727.56","20473.75","1 through 10","1278.75","3279.38","percent of total billed charges",""
"CATHETER BLAZER II XP 8FR 8MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR LARGE CURVE","SUP-ITM-10011574","CDM","C1733","HCPCS","0272","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3370.95","81.72","","16887.32","9288.66","16887.32","1 through 10","2155.73","3370.95","percent of total billed charges",""
"CATHETER BLAZER II XP 8FR 8MM TIP 7FR SHAFT TEMPERATURE ABLATION QUADRIPOLAR LARGE CURVE","SUP-ITM-10011574","CDM","C1733","HCPCS","0272","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3370.95","81.72","","16887.33","11641.27","21983.50","1 through 10","2155.73","3370.95","percent of total billed charges",""
"Catheter Brachytherapy Seed Admin T1","PX-27000043","CDM","C1728","HCPCS","0272","RC","","","","both","","","6250.00","4687.50","WELLPOINT [1015]","HB AMC WELLPOINT","4611.25","73.78","","9120.13","9120.13","9120.13","1 through 10","1937.5","4968.75","percent of total billed charges",""
"Catheter Brachytherapy Seed Admin T1","PX-27000043","CDM","C1728","HCPCS","0272","RC","","","","outpatient","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5107.50","81.72","","9792.65","9792.65","9792.65","1 through 10","3266.25","5107.5","percent of total billed charges",""
"CATHETER BRIDGE 20MM 80MM 90CM .035IN OCCLUSION BALLOON","SUP-ITM-10169101","CDM","C2628","HCPCS","0272","RC","","","","both","","","3255.00","2441.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2587.73","79.5","","518.94","518.94","518.94","1 through 10","1009.05","2587.73","percent of total billed charges",""
"CATHETER BRIDGE 20MM 80MM 90CM .035IN OCCLUSION BALLOON","SUP-ITM-10169101","CDM","C2628","HCPCS","0272","RC","","","","both","","","3255.00","2441.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2115.75","65","","429.02","429.02","429.02","1 through 10","1009.05","2587.73","percent of total billed charges",""
"CATHETER BRIDGE 20MM 80MM 90CM .035IN OCCLUSION BALLOON","SUP-ITM-10169101","CDM","C2628","HCPCS","0272","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1188.08","36.5","","4636.13","4636.13","4636.13","1 through 10","1009.05","2587.73","percent of total billed charges",""
"CATHETER BRIDGE 20MM 80MM 90CM .035IN OCCLUSION BALLOON","SUP-ITM-10169101","CDM","C2628","HCPCS","0272","RC","","","","both","","","3255.00","2441.25","WELLPOINT [1015]","HB AMC WELLPOINT","2401.54","73.78","","491.39","491.39","491.39","1 through 10","1009.05","2587.73","percent of total billed charges",""
"CATHETER BRIDGE 20MM 80MM 90CM .035IN OCCLUSION BALLOON","SUP-ITM-10169101","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","3255.00","2441.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2659.99","81.72","","290.22","290.22","290.22","1 through 10","1701.06","2659.99","percent of total billed charges",""
"CATHETER BRONCHIAL 5.0MM ADULT ALAIR THERMOPLASTY MILD HEAT OUTPATIENT","SUP-ITM-10094933","CDM","C1886","HCPCS","0272","RC","","","","both","","","6250.00","4687.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","4487.50","71.8","","4399.55","4399.55","4399.55","1 through 10","1937.5","4968.75","percent of total billed charges",""
"CATHETER BRONCHIAL 5.0MM ADULT ALAIR THERMOPLASTY MILD HEAT OUTPATIENT","SUP-ITM-10094933","CDM","C1886","HCPCS","0272","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.25","36.5","","1413.19","621.27","1413.19","1 through 10","1937.5","4968.75","percent of total billed charges",""
"CATHETER BRONCHIAL 5.0MM ADULT ALAIR THERMOPLASTY MILD HEAT OUTPATIENT","SUP-ITM-10094933","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5107.50","81.72","","8168.27","2209.17","8168.27","1 through 10","3266.25","5107.5","percent of total billed charges",""
"CATHETER BROVIAC 6.6FR 90CM .7ML CENTRAL VENOUS SINGLE LUMEN INGROWTH CUFF STYLET PEEL APART INTRODUCER NEEDLE INJ CAP 2 CONNECTOR","SUP-ITM-10000063","CDM","C1751","HCPCS","0272","RC","","","","both","","","399.00","299.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","279.30","70","","1389.50","602.17","3167.85","27","123.69","317.21","percent of total billed charges",""
"CATHETER BROVIAC 6.6FR 90CM .7ML CENTRAL VENOUS SINGLE LUMEN INGROWTH CUFF STYLET PEEL APART INTRODUCER NEEDLE INJ CAP 2 CONNECTOR","SUP-ITM-10000063","CDM","C1751","HCPCS","0272","RC","","","","both","","","399.00","299.25","WELLPOINT [1015]","HB AMC WELLPOINT","294.38","73.78","","1089.20","218.86","1089.20","1 through 10","123.69","317.21","percent of total billed charges",""
"CATHETER BROVIAC 6.6FR 90CM .7ML CENTRAL VENOUS SINGLE LUMEN INGROWTH CUFF STYLET PEEL APART INTRODUCER NEEDLE INJ CAP 2 CONNECTOR","SUP-ITM-10000063","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","399.00","299.25","AETNA [1001]","HB AMC AETNA HMO","278.50","69.8","","1389.50","940.69","1389.50","1 through 10","208.52","326.06","percent of total billed charges",""
"CATHETER BROVIAC 6.6FR 90CM .7ML CENTRAL VENOUS SINGLE LUMEN INGROWTH CUFF STYLET PEEL APART INTRODUCER NEEDLE INJ CAP 2 CONNECTOR","SUP-ITM-10000063","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","399.00","299.25","AETNA [1001]","HB AMC AETNA PPO","320.80","80.4","","190.26","190.26","190.26","1 through 10","208.52","326.06","percent of total billed charges",""
"CATHETER BROVIAC 6.6FR 90CM .7ML CENTRAL VENOUS SINGLE LUMEN INGROWTH CUFF STYLET PEEL APART INTRODUCER NEEDLE INJ CAP 2 CONNECTOR","SUP-ITM-10000063","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","326.06","81.72","","1110.77","235.00","1169.52","1 through 10","208.52","326.06","percent of total billed charges",""
"CATHETER CANTATA 2.5FR 150CM .57 .021 .035 SUPERSELECTIVE MICRO DOUBLE MARKER","SUP-ITM-10164941","CDM","C1887","HCPCS","0272","RC","","","","both","","","1160.11","870.08","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","832.96","71.8","","28.28","27.13","28.28","1 through 10","359.63","922.29","percent of total billed charges",""
"CATHETER CANTATA 2.5FR 150CM .57 .021 .035 SUPERSELECTIVE MICRO DOUBLE MARKER","SUP-ITM-10164941","CDM","C1887","HCPCS","0272","RC","","","","both","","","1160.11","870.08","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","812.08","70","","44.63","35.78","44.63","1 through 10","359.63","922.29","percent of total billed charges",""
"CATHETER CANTATA 2.5FR 150CM .57 .021 .035 SUPERSELECTIVE MICRO DOUBLE MARKER","SUP-ITM-10164941","CDM","C1887","HCPCS","0272","RC","","","","both","","","1160.11","870.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","922.29","79.5","","1342.89","271.64","6954.67","1 through 10","359.63","922.29","percent of total billed charges",""
"CATHETER CANTATA 2.5FR 150CM .57 .021 .035 SUPERSELECTIVE MICRO DOUBLE MARKER","SUP-ITM-10164941","CDM","C1887","HCPCS","0272","RC","","","","both","","","1160.11","870.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","618.34","53.3","","4550.00","30.49","4550.00","1 through 10","359.63","922.29","percent of total billed charges",""
"CATHETER CANTATA 2.5FR 150CM .57 .021 .035 SUPERSELECTIVE MICRO DOUBLE MARKER","SUP-ITM-10164941","CDM","C1887","HCPCS","0272","RC","","","","both","","","1160.11","870.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","754.07","65","","42.09","0.04","5453.50","1 through 10","359.63","922.29","percent of total billed charges",""
"CATHETER CANTATA 2.5FR 150CM .57 .021 .035 SUPERSELECTIVE MICRO DOUBLE MARKER","SUP-ITM-10164941","CDM","C1887","HCPCS","0272","RC","","","","both","","","1160.11","870.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","423.44","36.5","","310.94","18.54","1259.30","62","359.63","922.29","percent of total billed charges",""
"CATHETER CANTATA 2.5FR 150CM .57 .021 .035 SUPERSELECTIVE MICRO DOUBLE MARKER","SUP-ITM-10164941","CDM","C1887","HCPCS","0272","RC","","","","both","","","1160.11","870.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","444.32","38.3","","146.86","22.58","1753.45","65","359.63","922.29","percent of total billed charges",""
"CATHETER CANTATA 2.5FR 150CM .57 .021 .035 SUPERSELECTIVE MICRO DOUBLE MARKER","SUP-ITM-10164941","CDM","C1887","HCPCS","0272","RC","","","","both","","","1160.11","870.08","WELLPOINT [1015]","HB AMC WELLPOINT","855.93","73.78","","247.29","33.09","909.09","53","359.63","922.29","percent of total billed charges",""
"CATHETER CANTATA 2.5FR 150CM .57 .021 .035 SUPERSELECTIVE MICRO DOUBLE MARKER","SUP-ITM-10164941","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1160.11","870.08","AETNA [1001]","HB AMC AETNA HMO","809.76","69.8","","30.69","30.21","30.69","1 through 10","606.27","948.04","percent of total billed charges",""
"CATHETER CANTATA 2.5FR 150CM .57 .021 .035 SUPERSELECTIVE MICRO DOUBLE MARKER","SUP-ITM-10164941","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1160.11","870.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","932.73","80.4","","82.69","82.69","82.69","1 through 10","606.27","948.04","percent of total billed charges",""
"CATHETER CANTATA 2.5FR 150CM .57 .021 .035 SUPERSELECTIVE MICRO DOUBLE MARKER","SUP-ITM-10164941","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1160.11","870.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","948.04","81.72","","751.01","74.72","751.01","1 through 10","606.27","948.04","percent of total billed charges",""
"CATHETER CANTATA 2.5FR 150CM .57 .021 .035 SUPERSELECTIVE MICRO DOUBLE MARKER","SUP-ITM-10164941","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1160.11","870.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","948.04","81.72","","328.92","46.17","2701.97","59","606.27","948.04","percent of total billed charges",""
"CATHETER CENTRAL 7FR 16CM 2 LUMEN VENOUS ARROW POLYURETHANE FLEXTIP CS/5EA","SUP-ITM-10091244","CDM","C1751","HCPCS","0272","RC","","","","both","","","79.80","59.85","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","55.86","70","","1389.50","602.17","3167.85","27","24.74","63.44","percent of total billed charges",""
"CATHETER CENTRAL 7FR 16CM 2 LUMEN VENOUS ARROW POLYURETHANE FLEXTIP CS/5EA","SUP-ITM-10091244","CDM","C1751","HCPCS","0272","RC","","","","both","","","79.80","59.85","WELLPOINT [1015]","HB AMC WELLPOINT","58.88","73.78","","1089.20","218.86","1089.20","1 through 10","24.74","63.44","percent of total billed charges",""
"CATHETER CENTRAL 7FR 16CM 2 LUMEN VENOUS ARROW POLYURETHANE FLEXTIP CS/5EA","SUP-ITM-10091244","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","79.80","59.85","AETNA [1001]","HB AMC AETNA HMO","55.70","69.8","","1389.50","940.69","1389.50","1 through 10","41.7","65.21","percent of total billed charges",""
"CATHETER CENTRAL 7FR 16CM 2 LUMEN VENOUS ARROW POLYURETHANE FLEXTIP CS/5EA","SUP-ITM-10091244","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","79.80","59.85","AETNA [1001]","HB AMC AETNA PPO","64.16","80.4","","190.26","190.26","190.26","1 through 10","41.7","65.21","percent of total billed charges",""
"CATHETER CENTRAL 7FR 16CM 2 LUMEN VENOUS ARROW POLYURETHANE FLEXTIP CS/5EA","SUP-ITM-10091244","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","79.80","59.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","65.21","81.72","","1110.77","235.00","1169.52","1 through 10","41.7","65.21","percent of total billed charges",""
"CATHETER CENTRAL 7FRX20CM TRIPLE LUMEN VEN NON TUNNELED COMPNT ONLY POLYURET COTD UNCUFD PWR INJ CS/5EA","SUP-ITM-10014262","CDM","C1751","HCPCS","0272","RC","","","","both","","","108.71","81.53","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","76.10","70","","1389.50","602.17","3167.85","27","33.7","86.42","percent of total billed charges",""
"CATHETER CENTRAL 7FRX20CM TRIPLE LUMEN VEN NON TUNNELED COMPNT ONLY POLYURET COTD UNCUFD PWR INJ CS/5EA","SUP-ITM-10014262","CDM","C1751","HCPCS","0272","RC","","","","both","","","108.71","81.53","WELLPOINT [1015]","HB AMC WELLPOINT","80.21","73.78","","1089.20","218.86","1089.20","1 through 10","33.7","86.42","percent of total billed charges",""
"CATHETER CENTRAL 7FRX20CM TRIPLE LUMEN VEN NON TUNNELED COMPNT ONLY POLYURET COTD UNCUFD PWR INJ CS/5EA","SUP-ITM-10014262","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","108.71","81.53","AETNA [1001]","HB AMC AETNA HMO","75.88","69.8","","1389.50","940.69","1389.50","1 through 10","56.81","88.84","percent of total billed charges",""
"CATHETER CENTRAL 7FRX20CM TRIPLE LUMEN VEN NON TUNNELED COMPNT ONLY POLYURET COTD UNCUFD PWR INJ CS/5EA","SUP-ITM-10014262","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","108.71","81.53","AETNA [1001]","HB AMC AETNA PPO","87.40","80.4","","190.26","190.26","190.26","1 through 10","56.81","88.84","percent of total billed charges",""
"CATHETER CENTRAL 7FRX20CM TRIPLE LUMEN VEN NON TUNNELED COMPNT ONLY POLYURET COTD UNCUFD PWR INJ CS/5EA","SUP-ITM-10014262","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","108.71","81.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","88.84","81.72","","1110.77","235.00","1169.52","1 through 10","56.81","88.84","percent of total billed charges",""
"CATHETER CHARGER 5FR 4MM 100MM 135CM .035IN OTW PTA BALLOON DILATATION PERIPHERAL","SUP-ITM-10094633","CDM","C1725","HCPCS","0272","RC","","","","both","","","525.00","393.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","376.95","71.8","","175.91","175.91","175.91","1 through 10","162.75","417.38","percent of total billed charges",""
"CATHETER CHARGER 5FR 4MM 100MM 135CM .035IN OTW PTA BALLOON DILATATION PERIPHERAL","SUP-ITM-10094633","CDM","C1725","HCPCS","0272","RC","","","","both","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","341.25","65","","147.88","147.88","1296.75","1 through 10","162.75","417.38","percent of total billed charges",""
"CATHETER CHARGER 5FR 4MM 100MM 135CM .035IN OTW PTA BALLOON DILATATION PERIPHERAL","SUP-ITM-10094633","CDM","C1725","HCPCS","0272","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","181.40","177.87","181.40","21","162.75","417.38","percent of total billed charges",""
"CATHETER CHARGER 5FR 4MM 100MM 135CM .035IN OTW PTA BALLOON DILATATION PERIPHERAL","SUP-ITM-10094633","CDM","C1725","HCPCS","0272","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","170.15","88.95","424.24","16","162.75","417.38","percent of total billed charges",""
"CATHETER CHARGER 5FR 4MM 100MM 135CM .035IN OTW PTA BALLOON DILATATION PERIPHERAL","SUP-ITM-10094633","CDM","C1725","HCPCS","0272","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","699.48","699.48","699.48","12","162.75","417.38","percent of total billed charges",""
"CATHETER CHARGER 5FR 4MM 100MM 135CM .035IN OTW PTA BALLOON DILATATION PERIPHERAL","SUP-ITM-10094633","CDM","C1725","HCPCS","0272","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","576.52","182.40","651.44","14","162.75","417.38","percent of total billed charges",""
"CATHETER CHARGER 5FR 4MM 100MM 135CM .035IN OTW PTA BALLOON DILATATION PERIPHERAL","SUP-ITM-10094633","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","181.86","100.03","402.41","21","274.37","429.03","percent of total billed charges",""
"CATHETER CHARTIS SINGLE USE DISPOSABLE","SUP-ITM-10232026","CDM","C2628","HCPCS","0272","RC","","","","both","","","3762.50","2821.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2991.19","79.5","","518.94","518.94","518.94","1 through 10","1166.38","2991.19","percent of total billed charges",""
"CATHETER CHARTIS SINGLE USE DISPOSABLE","SUP-ITM-10232026","CDM","C2628","HCPCS","0272","RC","","","","both","","","3762.50","2821.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2445.63","65","","429.02","429.02","429.02","1 through 10","1166.38","2991.19","percent of total billed charges",""
"CATHETER CHARTIS SINGLE USE DISPOSABLE","SUP-ITM-10232026","CDM","C2628","HCPCS","0272","RC","","","","both","","","3762.50","2821.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1373.31","36.5","","4636.13","4636.13","4636.13","1 through 10","1166.38","2991.19","percent of total billed charges",""
"CATHETER CHARTIS SINGLE USE DISPOSABLE","SUP-ITM-10232026","CDM","C2628","HCPCS","0272","RC","","","","both","","","3762.50","2821.87","WELLPOINT [1015]","HB AMC WELLPOINT","2775.97","73.78","","491.39","491.39","491.39","1 through 10","1166.38","2991.19","percent of total billed charges",""
"CATHETER CHARTIS SINGLE USE DISPOSABLE","SUP-ITM-10232026","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","3762.50","2821.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3074.72","81.72","","290.22","290.22","290.22","1 through 10","1966.28","3074.72","percent of total billed charges",""
"CATHETER CODA 9FR 32MM 120CM .035IN BALLOON PERIPHERAL POLYURETHANE EMBOLIZATION","SUP-ITM-10126259","CDM","C2628","HCPCS","0272","RC","","","","both","","","1674.75","1256.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1331.43","79.5","","518.94","518.94","518.94","1 through 10","519.17","1331.43","percent of total billed charges",""
"CATHETER CODA 9FR 32MM 120CM .035IN BALLOON PERIPHERAL POLYURETHANE EMBOLIZATION","SUP-ITM-10126259","CDM","C2628","HCPCS","0272","RC","","","","both","","","1674.75","1256.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1088.59","65","","429.02","429.02","429.02","1 through 10","519.17","1331.43","percent of total billed charges",""
"CATHETER CODA 9FR 32MM 120CM .035IN BALLOON PERIPHERAL POLYURETHANE EMBOLIZATION","SUP-ITM-10126259","CDM","C2628","HCPCS","0272","RC","","","","both","","","1674.75","1256.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","611.28","36.5","","4636.13","4636.13","4636.13","1 through 10","519.17","1331.43","percent of total billed charges",""
"CATHETER CODA 9FR 32MM 120CM .035IN BALLOON PERIPHERAL POLYURETHANE EMBOLIZATION","SUP-ITM-10126259","CDM","C2628","HCPCS","0272","RC","","","","both","","","1674.75","1256.06","WELLPOINT [1015]","HB AMC WELLPOINT","1235.63","73.78","","491.39","491.39","491.39","1 through 10","519.17","1331.43","percent of total billed charges",""
"CATHETER CODA 9FR 32MM 120CM .035IN BALLOON PERIPHERAL POLYURETHANE EMBOLIZATION","SUP-ITM-10126259","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","1674.75","1256.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1368.61","81.72","","290.22","290.22","290.22","1 through 10","875.22","1368.61","percent of total billed charges",""
"CATHETER CONQUEST 6FR 6MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019774","CDM","C1725","HCPCS","0272","RC","","","","both","","","535.50","401.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","384.49","71.8","","175.91","175.91","175.91","1 through 10","166.01","425.72","percent of total billed charges",""
"CATHETER CONQUEST 6FR 6MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019774","CDM","C1725","HCPCS","0272","RC","","","","both","","","535.50","401.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","348.08","65","","147.88","147.88","1296.75","1 through 10","166.01","425.72","percent of total billed charges",""
"CATHETER CONQUEST 6FR 6MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019774","CDM","C1725","HCPCS","0272","RC","","","","both","","","535.50","401.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","195.46","36.5","","181.40","177.87","181.40","21","166.01","425.72","percent of total billed charges",""
"CATHETER CONQUEST 6FR 6MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019774","CDM","C1725","HCPCS","0272","RC","","","","both","","","535.50","401.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","205.10","38.3","","170.15","88.95","424.24","16","166.01","425.72","percent of total billed charges",""
"CATHETER CONQUEST 6FR 6MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019774","CDM","C1725","HCPCS","0272","RC","","","","both","","","535.50","401.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","229.73","42.9","","699.48","699.48","699.48","12","166.01","425.72","percent of total billed charges",""
"CATHETER CONQUEST 6FR 6MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019774","CDM","C1725","HCPCS","0272","RC","","","","both","","","535.50","401.62","WELLPOINT [1015]","HB AMC WELLPOINT","395.09","73.78","","576.52","182.40","651.44","14","166.01","425.72","percent of total billed charges",""
"CATHETER CONQUEST 6FR 6MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019774","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","535.50","401.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","437.61","81.72","","181.86","100.03","402.41","21","279.85","437.61","percent of total billed charges",""
"CATHETER CONQUEST 6FR 8MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019775","CDM","C1725","HCPCS","0272","RC","","","","both","","","535.50","401.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","384.49","71.8","","175.91","175.91","175.91","1 through 10","166.01","425.72","percent of total billed charges",""
"CATHETER CONQUEST 6FR 8MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019775","CDM","C1725","HCPCS","0272","RC","","","","both","","","535.50","401.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","348.08","65","","147.88","147.88","1296.75","1 through 10","166.01","425.72","percent of total billed charges",""
"CATHETER CONQUEST 6FR 8MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019775","CDM","C1725","HCPCS","0272","RC","","","","both","","","535.50","401.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","195.46","36.5","","181.40","177.87","181.40","21","166.01","425.72","percent of total billed charges",""
"CATHETER CONQUEST 6FR 8MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019775","CDM","C1725","HCPCS","0272","RC","","","","both","","","535.50","401.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","205.10","38.3","","170.15","88.95","424.24","16","166.01","425.72","percent of total billed charges",""
"CATHETER CONQUEST 6FR 8MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019775","CDM","C1725","HCPCS","0272","RC","","","","both","","","535.50","401.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","229.73","42.9","","699.48","699.48","699.48","12","166.01","425.72","percent of total billed charges",""
"CATHETER CONQUEST 6FR 8MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019775","CDM","C1725","HCPCS","0272","RC","","","","both","","","535.50","401.62","WELLPOINT [1015]","HB AMC WELLPOINT","395.09","73.78","","576.52","182.40","651.44","14","166.01","425.72","percent of total billed charges",""
"CATHETER CONQUEST 6FR 8MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10019775","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","535.50","401.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","437.61","81.72","","181.86","100.03","402.41","21","279.85","437.61","percent of total billed charges",""
"CATHETER COYOTE 4FR 2MM 150MM 150CM .014IN MONORAIL BALLOON DILATATION","SUP-ITM-10092172","CDM","C1725","HCPCS","0272","RC","","","","both","","","787.50","590.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","565.43","71.8","","175.91","175.91","175.91","1 through 10","244.13","626.06","percent of total billed charges",""
"CATHETER COYOTE 4FR 2MM 150MM 150CM .014IN MONORAIL BALLOON DILATATION","SUP-ITM-10092172","CDM","C1725","HCPCS","0272","RC","","","","both","","","787.50","590.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","511.88","65","","147.88","147.88","1296.75","1 through 10","244.13","626.06","percent of total billed charges",""
"CATHETER COYOTE 4FR 2MM 150MM 150CM .014IN MONORAIL BALLOON DILATATION","SUP-ITM-10092172","CDM","C1725","HCPCS","0272","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","287.44","36.5","","181.40","177.87","181.40","21","244.13","626.06","percent of total billed charges",""
"CATHETER COYOTE 4FR 2MM 150MM 150CM .014IN MONORAIL BALLOON DILATATION","SUP-ITM-10092172","CDM","C1725","HCPCS","0272","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","301.61","38.3","","170.15","88.95","424.24","16","244.13","626.06","percent of total billed charges",""
"CATHETER COYOTE 4FR 2MM 150MM 150CM .014IN MONORAIL BALLOON DILATATION","SUP-ITM-10092172","CDM","C1725","HCPCS","0272","RC","","","","both","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.84","42.9","","699.48","699.48","699.48","12","244.13","626.06","percent of total billed charges",""
"CATHETER COYOTE 4FR 2MM 150MM 150CM .014IN MONORAIL BALLOON DILATATION","SUP-ITM-10092172","CDM","C1725","HCPCS","0272","RC","","","","both","","","787.50","590.62","WELLPOINT [1015]","HB AMC WELLPOINT","581.02","73.78","","576.52","182.40","651.44","14","244.13","626.06","percent of total billed charges",""
"CATHETER COYOTE 4FR 2MM 150MM 150CM .014IN MONORAIL BALLOON DILATATION","SUP-ITM-10092172","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","643.55","81.72","","181.86","100.03","402.41","21","411.55","643.55","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 14FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM LOOP LOCKING LF","SUP-ITM-10000416","CDM","C1729","HCPCS","0272","RC","","","","both","","","230.37","172.78","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","165.41","71.8","","162.24","51.52","162.24","1 through 10","71.41","183.14","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 14FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM LOOP LOCKING LF","SUP-ITM-10000416","CDM","C1729","HCPCS","0272","RC","","","","both","","","230.37","172.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","84.09","36.5","","94.34","22.19","146.22","26","71.41","183.14","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 14FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM LOOP LOCKING LF","SUP-ITM-10000416","CDM","C1729","HCPCS","0272","RC","","","","both","","","230.37","172.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","88.23","38.3","","51.52","27.37","51.52","26","71.41","183.14","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 14FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM LOOP LOCKING LF","SUP-ITM-10000416","CDM","C1729","HCPCS","0272","RC","","","","both","","","230.37","172.78","WELLPOINT [1015]","HB AMC WELLPOINT","169.97","73.78","","207.21","122.12","216.28","14","71.41","183.14","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 14FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM LOOP LOCKING LF","SUP-ITM-10000416","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","230.37","172.78","AETNA [1001]","HB AMC AETNA HMO","160.80","69.8","","155.96","47.39","155.96","1 through 10","120.39","188.26","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 14FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM LOOP LOCKING LF","SUP-ITM-10000416","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","230.37","172.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","188.26","81.72","","57.36","51.76","232.23","35","120.39","188.26","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 8.5FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC PIGTAIL LOCKING LF","SUP-ITM-10000499","CDM","C1729","HCPCS","0272","RC","","","","both","","","230.37","172.78","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","165.41","71.8","","162.24","51.52","162.24","1 through 10","71.41","183.14","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 8.5FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC PIGTAIL LOCKING LF","SUP-ITM-10000499","CDM","C1729","HCPCS","0272","RC","","","","both","","","230.37","172.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","84.09","36.5","","94.34","22.19","146.22","26","71.41","183.14","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 8.5FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC PIGTAIL LOCKING LF","SUP-ITM-10000499","CDM","C1729","HCPCS","0272","RC","","","","both","","","230.37","172.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","88.23","38.3","","51.52","27.37","51.52","26","71.41","183.14","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 8.5FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC PIGTAIL LOCKING LF","SUP-ITM-10000499","CDM","C1729","HCPCS","0272","RC","","","","both","","","230.37","172.78","WELLPOINT [1015]","HB AMC WELLPOINT","169.97","73.78","","207.21","122.12","216.28","14","71.41","183.14","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 8.5FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC PIGTAIL LOCKING LF","SUP-ITM-10000499","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","230.37","172.78","AETNA [1001]","HB AMC AETNA HMO","160.80","69.8","","155.96","47.39","155.96","1 through 10","120.39","188.26","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 8.5FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC PIGTAIL LOCKING LF","SUP-ITM-10000499","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","230.37","172.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","188.26","81.72","","57.36","51.76","232.23","35","120.39","188.26","percent of total billed charges",""
"CATHETER DECAPOLAR RESPONSE CSL 120CM EA REPROCESSED","SUP-ITM-10092453","CDM","C1732","HCPCS","0272","RC","","","","both","","","165.55","124.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","107.61","65","","2222.68","2222.68","2222.68","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER DECAPOLAR RESPONSE CSL 120CM EA REPROCESSED","SUP-ITM-10092453","CDM","C1732","HCPCS","0272","RC","","","","both","","","165.55","124.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.43","36.5","","4681.38","1275.47","8371.80","20","51.32","131.61","percent of total billed charges",""
"CATHETER DECAPOLAR RESPONSE CSL 120CM EA REPROCESSED","SUP-ITM-10092453","CDM","C1732","HCPCS","0272","RC","","","","both","","","165.55","124.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.41","38.3","","1663.12","1287.53","2528.21","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER DECAPOLAR RESPONSE CSL 120CM EA REPROCESSED","SUP-ITM-10092453","CDM","C1732","HCPCS","0272","RC","","","","both","","","165.55","124.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.02","42.9","","1935.35","1935.35","1935.35","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER DECAPOLAR RESPONSE CSL 120CM EA REPROCESSED","SUP-ITM-10092453","CDM","C1732","HCPCS","0272","RC","","","","both","","","165.55","124.16","WELLPOINT [1015]","HB AMC WELLPOINT","122.14","73.78","","4813.94","2545.82","7082.06","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER DECAPOLAR RESPONSE CSL 120CM EA REPROCESSED","SUP-ITM-10092453","CDM","C1732","HCPCS","0272","RC","","","","outpatient","","","165.55","124.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","135.29","81.72","","2733.55","2433.63","5168.92","14","86.52","135.29","percent of total billed charges",""
"CATHETER DELIVERY G-CATH EZ-2 WITH SNOWSHOE SUTURE ANCHORS BX/6EA","SUP-ITM-10137626","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","1309.77","674.56","6049.93","26","271.25","695.63","percent of total billed charges",""
"CATHETER DELIVERY G-CATH EZ-2 WITH SNOWSHOE SUTURE ANCHORS BX/6EA","SUP-ITM-10137626","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","1901.83","1901.83","2962.25","1 through 10","271.25","695.63","percent of total billed charges",""
"CATHETER DELIVERY G-CATH EZ-2 WITH SNOWSHOE SUTURE ANCHORS BX/6EA","SUP-ITM-10137626","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","1620.31","1620.31","19908.88","1 through 10","271.25","695.63","percent of total billed charges",""
"CATHETER DELIVERY G-CATH EZ-2 WITH SNOWSHOE SUTURE ANCHORS BX/6EA","SUP-ITM-10137626","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","352.91","352.91","2046.30","1 through 10","271.25","695.63","percent of total billed charges",""
"CATHETER DELIVERY G-CATH EZ-2 WITH SNOWSHOE SUTURE ANCHORS BX/6EA","SUP-ITM-10137626","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","9668.75","9668.75","9668.75","1 through 10","271.25","695.63","percent of total billed charges",""
"CATHETER DELIVERY G-CATH EZ-2 WITH SNOWSHOE SUTURE ANCHORS BX/6EA","SUP-ITM-10137626","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","699.88","384.10","3443.31","33","271.25","695.63","percent of total billed charges",""
"CATHETER DELIVERY G-CATH EZ-2 WITH SNOWSHOE SUTURE ANCHORS BX/6EA","SUP-ITM-10137626","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","1421.24","264.50","4933.46","29","457.28","715.05","percent of total billed charges",""
"CATHETER DELIVERY G-CATH EZ-2 WITH SNOWSHOE SUTURE ANCHORS BX/6EA","SUP-ITM-10137626","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1022.97","1022.97","3607.50","1 through 10","457.28","715.05","percent of total billed charges",""
"CATHETER DELIVERY G-CATH EZ-2 WITH SNOWSHOE SUTURE ANCHORS BX/6EA","SUP-ITM-10137626","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","3010.54","693.88","5019.88","35","457.28","715.05","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","both","","","4340.00","3255.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2268.08","52.26","","16.24","16.24","54.15","1 through 10","1345.4","3450.3","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","both","","","4340.00","3255.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3116.12","71.8","","86.33","32.67","86.33","1 through 10","1345.4","3450.3","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","both","","","4340.00","3255.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3038.00","70","","113.68","63.00","177.34","40","1345.4","3450.3","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","both","","","4340.00","3255.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3450.30","79.5","","50.70","21.76","168.00","12","1345.4","3450.3","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","both","","","4340.00","3255.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2313.22","53.3","","89.31","89.31","99.75","1 through 10","1345.4","3450.3","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2821.00","65","","94.41","17.06","2275.00","1 through 10","1345.4","3450.3","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1345.40","31","","35.13","35.13","35.13","1 through 10","1345.4","3450.3","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1584.10","36.5","","40.08","12.40","86.17","108","1345.4","3450.3","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1662.22","38.3","","33.25","10.27","68.43","169","1345.4","3450.3","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","both","","","4340.00","3255.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1861.86","42.9","","25.48","14.86","90.88","1 through 10","1345.4","3450.3","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","both","","","4340.00","3255.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1861.86","42.9","","90.88","90.88","90.88","1 through 10","1345.4","3450.3","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","both","","","4340.00","3255.00","WELLPOINT [1015]","HB AMC WELLPOINT","3202.05","73.78","","84.63","19.55","140.02","123","1345.4","3450.3","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4340.00","3255.00","AETNA [1001]","HB AMC AETNA HMO","3029.32","69.8","","76.96","17.77","113.68","14","2268.08","3546.65","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4340.00","3255.00","AETNA [1001]","HB AMC AETNA PPO","3489.36","80.4","","57.31","57.31","57.31","1 through 10","2268.08","3546.65","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4340.00","3255.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2268.08","52.26","","16.24","16.24","54.15","1 through 10","2268.08","3546.65","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3489.36","80.4","","68.25","68.25","87.50","1 through 10","2268.08","3546.65","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","3546.65","81.72","","156.19","156.19","156.19","1 through 10","2268.08","3546.65","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4340.00","3255.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3546.65","81.72","","82.70","12.06","98.97","13","2268.08","3546.65","percent of total billed charges",""
"CATHETER DELIVERY LEADLESS AVEIR DR","SUP-ITM-10320136","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4340.00","3255.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3546.65","81.72","","50.47","25.30","134.30","140","2268.08","3546.65","percent of total billed charges",""
"CATHETER DIAGNOSTIC 4FR 120CM SUPREME QUAD 5MM JSN REPROCESSED","SUP-ITM-10092450","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","86.52","52.26","","1988.81","1988.81","1988.81","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER DIAGNOSTIC 4FR 120CM SUPREME QUAD 5MM JSN REPROCESSED","SUP-ITM-10092450","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","131.61","79.5","","765.06","765.06","765.06","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER DIAGNOSTIC 4FR 120CM SUPREME QUAD 5MM JSN REPROCESSED","SUP-ITM-10092450","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","88.24","53.3","","6427.95","6427.95","6427.95","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER DIAGNOSTIC 4FR 120CM SUPREME QUAD 5MM JSN REPROCESSED","SUP-ITM-10092450","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","107.61","65","","1193.16","1193.16","1193.16","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER DIAGNOSTIC 4FR 120CM SUPREME QUAD 5MM JSN REPROCESSED","SUP-ITM-10092450","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.43","36.5","","2053.37","54.83","3398.85","20","51.32","131.61","percent of total billed charges",""
"CATHETER DIAGNOSTIC 4FR 120CM SUPREME QUAD 5MM JSN REPROCESSED","SUP-ITM-10092450","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.41","38.3","","232.75","124.53","2541.50","39","51.32","131.61","percent of total billed charges",""
"CATHETER DIAGNOSTIC 4FR 120CM SUPREME QUAD 5MM JSN REPROCESSED","SUP-ITM-10092450","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.02","42.9","","66.89","66.89","66.89","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER DIAGNOSTIC 4FR 120CM SUPREME QUAD 5MM JSN REPROCESSED","SUP-ITM-10092450","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","WELLPOINT [1015]","HB AMC WELLPOINT","122.14","73.78","","2392.81","1818.08","6339.98","15","51.32","131.61","percent of total billed charges",""
"CATHETER DIAGNOSTIC 4FR 120CM SUPREME QUAD 5MM JSN REPROCESSED","SUP-ITM-10092450","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","165.55","124.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","86.52","52.26","","1988.81","1988.81","1988.81","1 through 10","86.52","135.29","percent of total billed charges",""
"CATHETER DIAGNOSTIC 4FR 120CM SUPREME QUAD 5MM JSN REPROCESSED","SUP-ITM-10092450","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","165.55","124.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","135.29","81.72","","2569.25","132.34","2569.25","1 through 10","86.52","135.29","percent of total billed charges",""
"CATHETER DIAGNOSTIC 4FR 120CM SUPREME QUAD 5MM JSN REPROCESSED","SUP-ITM-10092450","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","165.55","124.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","135.29","81.72","","727.92","102.34","6154.18","26","86.52","135.29","percent of total billed charges",""
"CATHETER DIALYSIS 47CM PERITONEAL QUINTON TENCKHOFF UNIVERSAL 2 CUFF","SUP-ITM-10237213","CDM","C1750","HCPCS","0278","RC","","","","both","","","161.00","120.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","84.14","52.26","","154.36","154.36","154.36","1 through 10","49.91","128","percent of total billed charges",""
"CATHETER DIALYSIS 47CM PERITONEAL QUINTON TENCKHOFF UNIVERSAL 2 CUFF","SUP-ITM-10237213","CDM","C1750","HCPCS","0278","RC","","","","both","","","161.00","120.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.65","65","","1371.74","196.32","1371.74","1 through 10","49.91","128","percent of total billed charges",""
"CATHETER DIALYSIS 47CM PERITONEAL QUINTON TENCKHOFF UNIVERSAL 2 CUFF","SUP-ITM-10237213","CDM","C1750","HCPCS","0278","RC","","","","both","","","161.00","120.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.70","70","","249.45","107.26","1254.96","14","49.91","128","percent of total billed charges",""
"CATHETER DIALYSIS 47CM PERITONEAL QUINTON TENCKHOFF UNIVERSAL 2 CUFF","SUP-ITM-10237213","CDM","C1750","HCPCS","0278","RC","","","","both","","","161.00","120.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","128.00","79.5","","196.32","85.01","196.32","1 through 10","49.91","128","percent of total billed charges",""
"CATHETER DIALYSIS 47CM PERITONEAL QUINTON TENCKHOFF UNIVERSAL 2 CUFF","SUP-ITM-10237213","CDM","C1750","HCPCS","0278","RC","","","","both","","","161.00","120.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.81","53.3","","1132.95","1132.95","1132.95","1 through 10","49.91","128","percent of total billed charges",""
"CATHETER DIALYSIS 47CM PERITONEAL QUINTON TENCKHOFF UNIVERSAL 2 CUFF","SUP-ITM-10237213","CDM","C1750","HCPCS","0278","RC","","","","both","","","161.00","120.75","WELLPOINT [1015]","HB AMC WELLPOINT","118.79","73.78","","1297.66","185.72","1297.66","1 through 10","49.91","128","percent of total billed charges",""
"CATHETER DIALYSIS 47CM PERITONEAL QUINTON TENCKHOFF UNIVERSAL 2 CUFF","SUP-ITM-10237213","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","161.00","120.75","AETNA [1001]","HB AMC AETNA HMO","112.38","69.8","","76.96","76.96","76.96","1 through 10","84.14","131.57","percent of total billed charges",""
"CATHETER DIALYSIS 47CM PERITONEAL QUINTON TENCKHOFF UNIVERSAL 2 CUFF","SUP-ITM-10237213","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","161.00","120.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","84.14","52.26","","154.36","154.36","154.36","1 through 10","84.14","131.57","percent of total billed charges",""
"CATHETER DIALYSIS 47CM PERITONEAL QUINTON TENCKHOFF UNIVERSAL 2 CUFF","SUP-ITM-10237213","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","161.00","120.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","131.57","81.72","","199.41","199.41","199.41","1 through 10","84.14","131.57","percent of total billed charges",""
"CATHETER DIALYSIS 57CM ARGYLE SILICONE CURL TIP 2 CUFF PERITONEAL","SUP-ITM-10237208","CDM","C1750","HCPCS","0278","RC","","","","both","","","225.96","169.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","118.09","52.26","","154.36","154.36","154.36","1 through 10","70.05","179.64","percent of total billed charges",""
"CATHETER DIALYSIS 57CM ARGYLE SILICONE CURL TIP 2 CUFF PERITONEAL","SUP-ITM-10237208","CDM","C1750","HCPCS","0278","RC","","","","both","","","225.96","169.47","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","146.87","65","","1371.74","196.32","1371.74","1 through 10","70.05","179.64","percent of total billed charges",""
"CATHETER DIALYSIS 57CM ARGYLE SILICONE CURL TIP 2 CUFF PERITONEAL","SUP-ITM-10237208","CDM","C1750","HCPCS","0278","RC","","","","both","","","225.96","169.47","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","158.17","70","","249.45","107.26","1254.96","14","70.05","179.64","percent of total billed charges",""
"CATHETER DIALYSIS 57CM ARGYLE SILICONE CURL TIP 2 CUFF PERITONEAL","SUP-ITM-10237208","CDM","C1750","HCPCS","0278","RC","","","","both","","","225.96","169.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","179.64","79.5","","196.32","85.01","196.32","1 through 10","70.05","179.64","percent of total billed charges",""
"CATHETER DIALYSIS 57CM ARGYLE SILICONE CURL TIP 2 CUFF PERITONEAL","SUP-ITM-10237208","CDM","C1750","HCPCS","0278","RC","","","","both","","","225.96","169.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","120.44","53.3","","1132.95","1132.95","1132.95","1 through 10","70.05","179.64","percent of total billed charges",""
"CATHETER DIALYSIS 57CM ARGYLE SILICONE CURL TIP 2 CUFF PERITONEAL","SUP-ITM-10237208","CDM","C1750","HCPCS","0278","RC","","","","both","","","225.96","169.47","WELLPOINT [1015]","HB AMC WELLPOINT","166.71","73.78","","1297.66","185.72","1297.66","1 through 10","70.05","179.64","percent of total billed charges",""
"CATHETER DIALYSIS 57CM ARGYLE SILICONE CURL TIP 2 CUFF PERITONEAL","SUP-ITM-10237208","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","225.96","169.47","AETNA [1001]","HB AMC AETNA HMO","157.72","69.8","","76.96","76.96","76.96","1 through 10","118.09","184.65","percent of total billed charges",""
"CATHETER DIALYSIS 57CM ARGYLE SILICONE CURL TIP 2 CUFF PERITONEAL","SUP-ITM-10237208","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","225.96","169.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","118.09","52.26","","154.36","154.36","154.36","1 through 10","118.09","184.65","percent of total billed charges",""
"CATHETER DIALYSIS 57CM ARGYLE SILICONE CURL TIP 2 CUFF PERITONEAL","SUP-ITM-10237208","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","225.96","169.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","184.65","81.72","","199.41","199.41","199.41","1 through 10","118.09","184.65","percent of total billed charges",""
"CATHETER DIALYSIS 59CM ARGYLE SILICONE SWAN NECK CURL 2 CUFF PERITONEAL ADOLESCENT","SUP-ITM-10237182","CDM","C1750","HCPCS","0278","RC","","","","both","","","371.25","278.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","194.02","52.26","","154.36","154.36","154.36","1 through 10","115.09","295.14","percent of total billed charges",""
"CATHETER DIALYSIS 59CM ARGYLE SILICONE SWAN NECK CURL 2 CUFF PERITONEAL ADOLESCENT","SUP-ITM-10237182","CDM","C1750","HCPCS","0278","RC","","","","both","","","371.25","278.44","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","241.31","65","","1371.74","196.32","1371.74","1 through 10","115.09","295.14","percent of total billed charges",""
"CATHETER DIALYSIS 59CM ARGYLE SILICONE SWAN NECK CURL 2 CUFF PERITONEAL ADOLESCENT","SUP-ITM-10237182","CDM","C1750","HCPCS","0278","RC","","","","both","","","371.25","278.44","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","259.88","70","","249.45","107.26","1254.96","14","115.09","295.14","percent of total billed charges",""
"CATHETER DIALYSIS 59CM ARGYLE SILICONE SWAN NECK CURL 2 CUFF PERITONEAL ADOLESCENT","SUP-ITM-10237182","CDM","C1750","HCPCS","0278","RC","","","","both","","","371.25","278.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","295.14","79.5","","196.32","85.01","196.32","1 through 10","115.09","295.14","percent of total billed charges",""
"CATHETER DIALYSIS 59CM ARGYLE SILICONE SWAN NECK CURL 2 CUFF PERITONEAL ADOLESCENT","SUP-ITM-10237182","CDM","C1750","HCPCS","0278","RC","","","","both","","","371.25","278.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","197.88","53.3","","1132.95","1132.95","1132.95","1 through 10","115.09","295.14","percent of total billed charges",""
"CATHETER DIALYSIS 59CM ARGYLE SILICONE SWAN NECK CURL 2 CUFF PERITONEAL ADOLESCENT","SUP-ITM-10237182","CDM","C1750","HCPCS","0278","RC","","","","both","","","371.25","278.44","WELLPOINT [1015]","HB AMC WELLPOINT","273.91","73.78","","1297.66","185.72","1297.66","1 through 10","115.09","295.14","percent of total billed charges",""
"CATHETER DIALYSIS 59CM ARGYLE SILICONE SWAN NECK CURL 2 CUFF PERITONEAL ADOLESCENT","SUP-ITM-10237182","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","371.25","278.44","AETNA [1001]","HB AMC AETNA HMO","259.13","69.8","","76.96","76.96","76.96","1 through 10","194.02","303.39","percent of total billed charges",""
"CATHETER DIALYSIS 59CM ARGYLE SILICONE SWAN NECK CURL 2 CUFF PERITONEAL ADOLESCENT","SUP-ITM-10237182","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","371.25","278.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","194.02","52.26","","154.36","154.36","154.36","1 through 10","194.02","303.39","percent of total billed charges",""
"CATHETER DIALYSIS 59CM ARGYLE SILICONE SWAN NECK CURL 2 CUFF PERITONEAL ADOLESCENT","SUP-ITM-10237182","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","371.25","278.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","303.39","81.72","","199.41","199.41","199.41","1 through 10","194.02","303.39","percent of total billed charges",""
"CATHETER DIALYSIS 62.5CM PERITONEAL SWAN NECK CURL 2 RIGHT","SUP-ITM-10215746","CDM","C1750","HCPCS","0278","RC","","","","both","","","867.09","650.32","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","453.14","52.26","","154.36","154.36","154.36","1 through 10","268.8","689.34","percent of total billed charges",""
"CATHETER DIALYSIS 62.5CM PERITONEAL SWAN NECK CURL 2 RIGHT","SUP-ITM-10215746","CDM","C1750","HCPCS","0278","RC","","","","both","","","867.09","650.32","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","563.61","65","","1371.74","196.32","1371.74","1 through 10","268.8","689.34","percent of total billed charges",""
"CATHETER DIALYSIS 62.5CM PERITONEAL SWAN NECK CURL 2 RIGHT","SUP-ITM-10215746","CDM","C1750","HCPCS","0278","RC","","","","both","","","867.09","650.32","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","606.96","70","","249.45","107.26","1254.96","14","268.8","689.34","percent of total billed charges",""
"CATHETER DIALYSIS 62.5CM PERITONEAL SWAN NECK CURL 2 RIGHT","SUP-ITM-10215746","CDM","C1750","HCPCS","0278","RC","","","","both","","","867.09","650.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","689.34","79.5","","196.32","85.01","196.32","1 through 10","268.8","689.34","percent of total billed charges",""
"CATHETER DIALYSIS 62.5CM PERITONEAL SWAN NECK CURL 2 RIGHT","SUP-ITM-10215746","CDM","C1750","HCPCS","0278","RC","","","","both","","","867.09","650.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","462.16","53.3","","1132.95","1132.95","1132.95","1 through 10","268.8","689.34","percent of total billed charges",""
"CATHETER DIALYSIS 62.5CM PERITONEAL SWAN NECK CURL 2 RIGHT","SUP-ITM-10215746","CDM","C1750","HCPCS","0278","RC","","","","both","","","867.09","650.32","WELLPOINT [1015]","HB AMC WELLPOINT","639.74","73.78","","1297.66","185.72","1297.66","1 through 10","268.8","689.34","percent of total billed charges",""
"CATHETER DIALYSIS 62.5CM PERITONEAL SWAN NECK CURL 2 RIGHT","SUP-ITM-10215746","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","867.09","650.32","AETNA [1001]","HB AMC AETNA HMO","605.23","69.8","","76.96","76.96","76.96","1 through 10","453.14","708.59","percent of total billed charges",""
"CATHETER DIALYSIS 62.5CM PERITONEAL SWAN NECK CURL 2 RIGHT","SUP-ITM-10215746","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","867.09","650.32","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","453.14","52.26","","154.36","154.36","154.36","1 through 10","453.14","708.59","percent of total billed charges",""
"CATHETER DIALYSIS 62.5CM PERITONEAL SWAN NECK CURL 2 RIGHT","SUP-ITM-10215746","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","867.09","650.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","708.59","81.72","","199.41","199.41","199.41","1 through 10","453.14","708.59","percent of total billed charges",""
"CATHETER DIALYSIS 7.9FR 42CM PEDIATRIC ARGYLE SWAN NECK CURL MISSOURI 2 CUFF LT PERITONEAL","SUP-ITM-10030686","CDM","C1750","HCPCS","0278","RC","","","","both","","","601.48","451.11","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","314.33","52.26","","154.36","154.36","154.36","1 through 10","186.46","478.18","percent of total billed charges",""
"CATHETER DIALYSIS 7.9FR 42CM PEDIATRIC ARGYLE SWAN NECK CURL MISSOURI 2 CUFF LT PERITONEAL","SUP-ITM-10030686","CDM","C1750","HCPCS","0278","RC","","","","both","","","601.48","451.11","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","390.96","65","","1371.74","196.32","1371.74","1 through 10","186.46","478.18","percent of total billed charges",""
"CATHETER DIALYSIS 7.9FR 42CM PEDIATRIC ARGYLE SWAN NECK CURL MISSOURI 2 CUFF LT PERITONEAL","SUP-ITM-10030686","CDM","C1750","HCPCS","0278","RC","","","","both","","","601.48","451.11","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","421.04","70","","249.45","107.26","1254.96","14","186.46","478.18","percent of total billed charges",""
"CATHETER DIALYSIS 7.9FR 42CM PEDIATRIC ARGYLE SWAN NECK CURL MISSOURI 2 CUFF LT PERITONEAL","SUP-ITM-10030686","CDM","C1750","HCPCS","0278","RC","","","","both","","","601.48","451.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","478.18","79.5","","196.32","85.01","196.32","1 through 10","186.46","478.18","percent of total billed charges",""
"CATHETER DIALYSIS 7.9FR 42CM PEDIATRIC ARGYLE SWAN NECK CURL MISSOURI 2 CUFF LT PERITONEAL","SUP-ITM-10030686","CDM","C1750","HCPCS","0278","RC","","","","both","","","601.48","451.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","320.59","53.3","","1132.95","1132.95","1132.95","1 through 10","186.46","478.18","percent of total billed charges",""
"CATHETER DIALYSIS 7.9FR 42CM PEDIATRIC ARGYLE SWAN NECK CURL MISSOURI 2 CUFF LT PERITONEAL","SUP-ITM-10030686","CDM","C1750","HCPCS","0278","RC","","","","both","","","601.48","451.11","WELLPOINT [1015]","HB AMC WELLPOINT","443.77","73.78","","1297.66","185.72","1297.66","1 through 10","186.46","478.18","percent of total billed charges",""
"CATHETER DIALYSIS 7.9FR 42CM PEDIATRIC ARGYLE SWAN NECK CURL MISSOURI 2 CUFF LT PERITONEAL","SUP-ITM-10030686","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","601.48","451.11","AETNA [1001]","HB AMC AETNA HMO","419.83","69.8","","76.96","76.96","76.96","1 through 10","314.33","491.53","percent of total billed charges",""
"CATHETER DIALYSIS 7.9FR 42CM PEDIATRIC ARGYLE SWAN NECK CURL MISSOURI 2 CUFF LT PERITONEAL","SUP-ITM-10030686","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","601.48","451.11","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","314.33","52.26","","154.36","154.36","154.36","1 through 10","314.33","491.53","percent of total billed charges",""
"CATHETER DIALYSIS 7.9FR 42CM PEDIATRIC ARGYLE SWAN NECK CURL MISSOURI 2 CUFF LT PERITONEAL","SUP-ITM-10030686","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","601.48","451.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","491.53","81.72","","199.41","199.41","199.41","1 through 10","314.33","491.53","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","7081.25","5310.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5629.59","79.5","","1309.77","674.56","6049.93","26","2195.19","5629.59","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","7081.25","5310.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3774.31","53.3","","1901.83","1901.83","2962.25","1 through 10","2195.19","5629.59","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","7081.25","5310.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2584.66","36.5","","1620.31","1620.31","19908.88","1 through 10","2195.19","5629.59","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","7081.25","5310.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2712.12","38.3","","352.91","352.91","2046.30","1 through 10","2195.19","5629.59","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","7081.25","5310.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3037.86","42.9","","9668.75","9668.75","9668.75","1 through 10","2195.19","5629.59","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","7081.25","5310.94","WELLPOINT [1015]","HB AMC WELLPOINT","5224.55","73.78","","699.88","384.10","3443.31","33","2195.19","5629.59","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","7081.25","5310.94","AETNA [1001]","HB AMC AETNA HMO","4942.71","69.8","","1421.24","264.50","4933.46","29","3700.66","5786.8","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","7081.25","5310.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5693.33","80.4","","1022.97","1022.97","3607.50","1 through 10","3700.66","5786.8","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","7081.25","5310.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5786.80","81.72","","3010.54","693.88","5019.88","35","3700.66","5786.8","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","649.25","70","","556.50","556.50","556.50","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","737.36","79.5","","437.97","293.83","444.55","17","287.53","737.36","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","494.36","53.3","","298.25","293.83","444.55","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","602.88","65","","361.73","361.73","361.73","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","287.53","31","","171.96","171.96","171.96","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","338.54","36.5","","207.57","179.06","271.83","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","355.23","38.3","","217.59","211.47","220.86","18","287.53","737.36","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","397.90","42.9","","556.50","451.56","556.50","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","397.90","42.9","","444.87","444.87","444.87","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","WELLPOINT [1015]","HB AMC WELLPOINT","684.31","73.78","","414.31","414.31","420.55","15","287.53","737.36","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","AETNA [1001]","HB AMC AETNA HMO","647.40","69.8","","376.75","270.01","580.53","30","484.71","757.95","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","AETNA [1001]","HB AMC AETNA PPO","745.71","80.4","","440.60","434.07","440.60","1 through 10","484.71","757.95","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","745.71","80.4","","434.07","434.07","440.60","1 through 10","484.71","757.95","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","757.95","81.72","","444.87","248.37","444.87","1 through 10","484.71","757.95","percent of total billed charges",""
"CATHETER DIGNITY 9.5F CT DUAL PORT WITH SILICONE FILLED SUTURE HOLE AND MICROKIT","SUP-ITM-10170052","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","757.95","81.72","","444.87","248.37","451.56","20","484.71","757.95","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","both","","","1270.82","953.11","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","889.57","70","","863.10","863.10","863.10","1 through 10","393.95","1010.3","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","both","","","1270.82","953.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1010.30","79.5","","447.66","447.66","447.66","1 through 10","393.95","1010.3","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","both","","","1270.82","953.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","826.03","65","","1020.11","1020.11","1020.11","1 through 10","393.95","1010.3","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","both","","","1270.82","953.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","393.95","31","","208.83","208.83","208.83","1 through 10","393.95","1010.3","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","both","","","1270.82","953.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","463.85","36.5","","312.44","214.23","1086.03","20","393.95","1010.3","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","both","","","1270.82","953.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","486.72","38.3","","264.25","227.63","567.11","31","393.95","1010.3","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","both","","","1270.82","953.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","545.18","42.9","","79.94","79.94","79.94","1 through 10","393.95","1010.3","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","both","","","1270.82","953.11","WELLPOINT [1015]","HB AMC WELLPOINT","937.61","73.78","","174.45","74.45","1168.42","1 through 10","393.95","1010.3","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1270.82","953.11","AETNA [1001]","HB AMC AETNA HMO","887.03","69.8","","655.01","135.40","784.73","1 through 10","664.13","1038.51","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1270.82","953.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1038.51","81.72","","540.25","46.28","897.42","36","664.13","1038.51","percent of total billed charges",""
"CATHETER DILATATION 18FR 4CM UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10024783","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","825.58","70","","863.10","863.10","863.10","1 through 10","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 18FR 4CM UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10024783","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","937.62","79.5","","447.66","447.66","447.66","1 through 10","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 18FR 4CM UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10024783","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","766.61","65","","1020.11","1020.11","1020.11","1 through 10","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 18FR 4CM UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10024783","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","365.61","31","","208.83","208.83","208.83","1 through 10","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 18FR 4CM UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10024783","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","430.48","36.5","","312.44","214.23","1086.03","20","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 18FR 4CM UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10024783","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","451.71","38.3","","264.25","227.63","567.11","31","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 18FR 4CM UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10024783","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","505.96","42.9","","79.94","79.94","79.94","1 through 10","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 18FR 4CM UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10024783","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","WELLPOINT [1015]","HB AMC WELLPOINT","870.16","73.78","","174.45","74.45","1168.42","1 through 10","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 18FR 4CM UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10024783","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1179.40","884.55","AETNA [1001]","HB AMC AETNA HMO","823.22","69.8","","655.01","135.40","784.73","1 through 10","616.35","963.81","percent of total billed charges",""
"CATHETER DILATATION 18FR 4CM UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10024783","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1179.40","884.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","963.81","81.72","","540.25","46.28","897.42","36","616.35","963.81","percent of total billed charges",""
"CATHETER DILATATION 26 42MM 18FR 104CM LARGE TRI LOBE POLYURETHANE BALLOON","SUP-ITM-10082919","CDM","C1726","HCPCS","0272","RC","","","","both","","","2460.50","1845.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1722.35","70","","863.10","863.10","863.10","1 through 10","762.76","1956.1","percent of total billed charges",""
"CATHETER DILATATION 26 42MM 18FR 104CM LARGE TRI LOBE POLYURETHANE BALLOON","SUP-ITM-10082919","CDM","C1726","HCPCS","0272","RC","","","","both","","","2460.50","1845.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1956.10","79.5","","447.66","447.66","447.66","1 through 10","762.76","1956.1","percent of total billed charges",""
"CATHETER DILATATION 26 42MM 18FR 104CM LARGE TRI LOBE POLYURETHANE BALLOON","SUP-ITM-10082919","CDM","C1726","HCPCS","0272","RC","","","","both","","","2460.50","1845.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1599.33","65","","1020.11","1020.11","1020.11","1 through 10","762.76","1956.1","percent of total billed charges",""
"CATHETER DILATATION 26 42MM 18FR 104CM LARGE TRI LOBE POLYURETHANE BALLOON","SUP-ITM-10082919","CDM","C1726","HCPCS","0272","RC","","","","both","","","2460.50","1845.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","762.76","31","","208.83","208.83","208.83","1 through 10","762.76","1956.1","percent of total billed charges",""
"CATHETER DILATATION 26 42MM 18FR 104CM LARGE TRI LOBE POLYURETHANE BALLOON","SUP-ITM-10082919","CDM","C1726","HCPCS","0272","RC","","","","both","","","2460.50","1845.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","898.08","36.5","","312.44","214.23","1086.03","20","762.76","1956.1","percent of total billed charges",""
"CATHETER DILATATION 26 42MM 18FR 104CM LARGE TRI LOBE POLYURETHANE BALLOON","SUP-ITM-10082919","CDM","C1726","HCPCS","0272","RC","","","","both","","","2460.50","1845.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","942.37","38.3","","264.25","227.63","567.11","31","762.76","1956.1","percent of total billed charges",""
"CATHETER DILATATION 26 42MM 18FR 104CM LARGE TRI LOBE POLYURETHANE BALLOON","SUP-ITM-10082919","CDM","C1726","HCPCS","0272","RC","","","","both","","","2460.50","1845.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1055.55","42.9","","79.94","79.94","79.94","1 through 10","762.76","1956.1","percent of total billed charges",""
"CATHETER DILATATION 26 42MM 18FR 104CM LARGE TRI LOBE POLYURETHANE BALLOON","SUP-ITM-10082919","CDM","C1726","HCPCS","0272","RC","","","","both","","","2460.50","1845.37","WELLPOINT [1015]","HB AMC WELLPOINT","1815.36","73.78","","174.45","74.45","1168.42","1 through 10","762.76","1956.1","percent of total billed charges",""
"CATHETER DILATATION 26 42MM 18FR 104CM LARGE TRI LOBE POLYURETHANE BALLOON","SUP-ITM-10082919","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2460.50","1845.37","AETNA [1001]","HB AMC AETNA HMO","1717.43","69.8","","655.01","135.40","784.73","1 through 10","1285.86","2010.72","percent of total billed charges",""
"CATHETER DILATATION 26 42MM 18FR 104CM LARGE TRI LOBE POLYURETHANE BALLOON","SUP-ITM-10082919","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2460.50","1845.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2010.72","81.72","","540.25","46.28","897.42","36","1285.86","2010.72","percent of total billed charges",""
"CATHETER DILATATION 4MMCM 12FR 5.8 75 UROMAX ULTRA BALLOON HIGH PRESSURE","SUP-ITM-10027247","CDM","C1726","HCPCS","0272","RC","","","","both","","","1074.99","806.24","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","752.49","70","","863.10","863.10","863.10","1 through 10","333.25","854.62","percent of total billed charges",""
"CATHETER DILATATION 4MMCM 12FR 5.8 75 UROMAX ULTRA BALLOON HIGH PRESSURE","SUP-ITM-10027247","CDM","C1726","HCPCS","0272","RC","","","","both","","","1074.99","806.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","854.62","79.5","","447.66","447.66","447.66","1 through 10","333.25","854.62","percent of total billed charges",""
"CATHETER DILATATION 4MMCM 12FR 5.8 75 UROMAX ULTRA BALLOON HIGH PRESSURE","SUP-ITM-10027247","CDM","C1726","HCPCS","0272","RC","","","","both","","","1074.99","806.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","698.74","65","","1020.11","1020.11","1020.11","1 through 10","333.25","854.62","percent of total billed charges",""
"CATHETER DILATATION 4MMCM 12FR 5.8 75 UROMAX ULTRA BALLOON HIGH PRESSURE","SUP-ITM-10027247","CDM","C1726","HCPCS","0272","RC","","","","both","","","1074.99","806.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","333.25","31","","208.83","208.83","208.83","1 through 10","333.25","854.62","percent of total billed charges",""
"CATHETER DILATATION 4MMCM 12FR 5.8 75 UROMAX ULTRA BALLOON HIGH PRESSURE","SUP-ITM-10027247","CDM","C1726","HCPCS","0272","RC","","","","both","","","1074.99","806.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","392.37","36.5","","312.44","214.23","1086.03","20","333.25","854.62","percent of total billed charges",""
"CATHETER DILATATION 4MMCM 12FR 5.8 75 UROMAX ULTRA BALLOON HIGH PRESSURE","SUP-ITM-10027247","CDM","C1726","HCPCS","0272","RC","","","","both","","","1074.99","806.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","411.72","38.3","","264.25","227.63","567.11","31","333.25","854.62","percent of total billed charges",""
"CATHETER DILATATION 4MMCM 12FR 5.8 75 UROMAX ULTRA BALLOON HIGH PRESSURE","SUP-ITM-10027247","CDM","C1726","HCPCS","0272","RC","","","","both","","","1074.99","806.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","461.17","42.9","","79.94","79.94","79.94","1 through 10","333.25","854.62","percent of total billed charges",""
"CATHETER DILATATION 4MMCM 12FR 5.8 75 UROMAX ULTRA BALLOON HIGH PRESSURE","SUP-ITM-10027247","CDM","C1726","HCPCS","0272","RC","","","","both","","","1074.99","806.24","WELLPOINT [1015]","HB AMC WELLPOINT","793.13","73.78","","174.45","74.45","1168.42","1 through 10","333.25","854.62","percent of total billed charges",""
"CATHETER DILATATION 4MMCM 12FR 5.8 75 UROMAX ULTRA BALLOON HIGH PRESSURE","SUP-ITM-10027247","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1074.99","806.24","AETNA [1001]","HB AMC AETNA HMO","750.34","69.8","","655.01","135.40","784.73","1 through 10","561.79","878.48","percent of total billed charges",""
"CATHETER DILATATION 4MMCM 12FR 5.8 75 UROMAX ULTRA BALLOON HIGH PRESSURE","SUP-ITM-10027247","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1074.99","806.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","878.48","81.72","","540.25","46.28","897.42","36","561.79","878.48","percent of total billed charges",""
"CATHETER DILATATION 5MMX10CM 15FR 75 5.8 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10027246","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","825.58","70","","863.10","863.10","863.10","1 through 10","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 5MMX10CM 15FR 75 5.8 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10027246","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","937.62","79.5","","447.66","447.66","447.66","1 through 10","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 5MMX10CM 15FR 75 5.8 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10027246","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","766.61","65","","1020.11","1020.11","1020.11","1 through 10","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 5MMX10CM 15FR 75 5.8 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10027246","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","365.61","31","","208.83","208.83","208.83","1 through 10","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 5MMX10CM 15FR 75 5.8 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10027246","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","430.48","36.5","","312.44","214.23","1086.03","20","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 5MMX10CM 15FR 75 5.8 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10027246","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","451.71","38.3","","264.25","227.63","567.11","31","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 5MMX10CM 15FR 75 5.8 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10027246","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","505.96","42.9","","79.94","79.94","79.94","1 through 10","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 5MMX10CM 15FR 75 5.8 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10027246","CDM","C1726","HCPCS","0272","RC","","","","both","","","1179.40","884.55","WELLPOINT [1015]","HB AMC WELLPOINT","870.16","73.78","","174.45","74.45","1168.42","1 through 10","365.61","937.62","percent of total billed charges",""
"CATHETER DILATATION 5MMX10CM 15FR 75 5.8 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10027246","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1179.40","884.55","AETNA [1001]","HB AMC AETNA HMO","823.22","69.8","","655.01","135.40","784.73","1 through 10","616.35","963.81","percent of total billed charges",""
"CATHETER DILATATION 5MMX10CM 15FR 75 5.8 UROMAX ULTRA HYDROPLUS HIGH PRESSURE URETERAL","SUP-ITM-10027246","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1179.40","884.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","963.81","81.72","","540.25","46.28","897.42","36","616.35","963.81","percent of total billed charges",""
"CATHETER DILATATION 8X30MM ACHALASIA ESOFLIP BX/5EA","SUP-ITM-10213495","CDM","C1726","HCPCS","0272","RC","","","","both","","","1481.20","1110.90","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1036.84","70","","863.10","863.10","863.10","1 through 10","459.17","1177.55","percent of total billed charges",""
"CATHETER DILATATION 8X30MM ACHALASIA ESOFLIP BX/5EA","SUP-ITM-10213495","CDM","C1726","HCPCS","0272","RC","","","","both","","","1481.20","1110.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1177.55","79.5","","447.66","447.66","447.66","1 through 10","459.17","1177.55","percent of total billed charges",""
"CATHETER DILATATION 8X30MM ACHALASIA ESOFLIP BX/5EA","SUP-ITM-10213495","CDM","C1726","HCPCS","0272","RC","","","","both","","","1481.20","1110.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","962.78","65","","1020.11","1020.11","1020.11","1 through 10","459.17","1177.55","percent of total billed charges",""
"CATHETER DILATATION 8X30MM ACHALASIA ESOFLIP BX/5EA","SUP-ITM-10213495","CDM","C1726","HCPCS","0272","RC","","","","both","","","1481.20","1110.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","459.17","31","","208.83","208.83","208.83","1 through 10","459.17","1177.55","percent of total billed charges",""
"CATHETER DILATATION 8X30MM ACHALASIA ESOFLIP BX/5EA","SUP-ITM-10213495","CDM","C1726","HCPCS","0272","RC","","","","both","","","1481.20","1110.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","540.64","36.5","","312.44","214.23","1086.03","20","459.17","1177.55","percent of total billed charges",""
"CATHETER DILATATION 8X30MM ACHALASIA ESOFLIP BX/5EA","SUP-ITM-10213495","CDM","C1726","HCPCS","0272","RC","","","","both","","","1481.20","1110.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","567.30","38.3","","264.25","227.63","567.11","31","459.17","1177.55","percent of total billed charges",""
"CATHETER DILATATION 8X30MM ACHALASIA ESOFLIP BX/5EA","SUP-ITM-10213495","CDM","C1726","HCPCS","0272","RC","","","","both","","","1481.20","1110.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","635.43","42.9","","79.94","79.94","79.94","1 through 10","459.17","1177.55","percent of total billed charges",""
"CATHETER DILATATION 8X30MM ACHALASIA ESOFLIP BX/5EA","SUP-ITM-10213495","CDM","C1726","HCPCS","0272","RC","","","","both","","","1481.20","1110.90","WELLPOINT [1015]","HB AMC WELLPOINT","1092.83","73.78","","174.45","74.45","1168.42","1 through 10","459.17","1177.55","percent of total billed charges",""
"CATHETER DILATATION 8X30MM ACHALASIA ESOFLIP BX/5EA","SUP-ITM-10213495","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1481.20","1110.90","AETNA [1001]","HB AMC AETNA HMO","1033.88","69.8","","655.01","135.40","784.73","1 through 10","774.08","1210.44","percent of total billed charges",""
"CATHETER DILATATION 8X30MM ACHALASIA ESOFLIP BX/5EA","SUP-ITM-10213495","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1481.20","1110.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1210.44","81.72","","540.25","46.28","897.42","36","774.08","1210.44","percent of total billed charges",""
"CATHETER DILATION 24FR 54CM BAKRI LATEX FREE SILICONE POSTPARTUM STERILE 500ML BX/1EA","SUP-ITM-10100596","CDM","C2628","HCPCS","0272","RC","","","","both","","","1367.17","1025.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1086.90","79.5","","518.94","518.94","518.94","1 through 10","423.82","1086.9","percent of total billed charges",""
"CATHETER DILATION 24FR 54CM BAKRI LATEX FREE SILICONE POSTPARTUM STERILE 500ML BX/1EA","SUP-ITM-10100596","CDM","C2628","HCPCS","0272","RC","","","","both","","","1367.17","1025.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","888.66","65","","429.02","429.02","429.02","1 through 10","423.82","1086.9","percent of total billed charges",""
"CATHETER DILATION 24FR 54CM BAKRI LATEX FREE SILICONE POSTPARTUM STERILE 500ML BX/1EA","SUP-ITM-10100596","CDM","C2628","HCPCS","0272","RC","","","","both","","","1367.17","1025.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","499.02","36.5","","4636.13","4636.13","4636.13","1 through 10","423.82","1086.9","percent of total billed charges",""
"CATHETER DILATION 24FR 54CM BAKRI LATEX FREE SILICONE POSTPARTUM STERILE 500ML BX/1EA","SUP-ITM-10100596","CDM","C2628","HCPCS","0272","RC","","","","both","","","1367.17","1025.38","WELLPOINT [1015]","HB AMC WELLPOINT","1008.70","73.78","","491.39","491.39","491.39","1 through 10","423.82","1086.9","percent of total billed charges",""
"CATHETER DILATION 24FR 54CM BAKRI LATEX FREE SILICONE POSTPARTUM STERILE 500ML BX/1EA","SUP-ITM-10100596","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","1367.17","1025.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1117.25","81.72","","290.22","290.22","290.22","1 through 10","714.48","1117.25","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 12FR 16IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003304","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.72","1.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.37","79.5","","19.51","1.19","19.51","1 through 10","0.53","1.37","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 12FR 16IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003304","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.72","1.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1.12","65","","0.94","0.94","0.94","1 through 10","0.53","1.37","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 12FR 16IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003304","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.72","1.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.63","36.5","","12.11","1.56","53.50","35","0.53","1.37","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 12FR 16IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003304","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.72","1.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.66","38.3","","1.65","0.56","14.07","55","0.53","1.37","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 12FR 16IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003304","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.72","1.29","WELLPOINT [1015]","HB AMC WELLPOINT","1.27","73.78","","24.17","1.07","130.81","14","0.53","1.37","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 12FR 16IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003304","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1.72","1.29","AETNA [1001]","HB AMC AETNA HMO","1.20","69.8","","1.83","0.82","15.71","1 through 10","0.9","1.41","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 12FR 16IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003304","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1.72","1.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1.38","80.4","","0.72","0.72","0.72","1 through 10","0.9","1.41","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 12FR 16IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003304","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1.72","1.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1.41","81.72","","10.92","1.37","10.92","1 through 10","0.9","1.41","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 12FR 16IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003304","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1.72","1.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1.41","81.72","","19.84","1.15","26.27","14","0.9","1.41","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 16FR 14IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003306","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.51","1.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.20","79.5","","19.51","1.19","19.51","1 through 10","0.47","1.2","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 16FR 14IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003306","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.51","1.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.98","65","","0.94","0.94","0.94","1 through 10","0.47","1.2","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 16FR 14IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003306","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.51","1.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.55","36.5","","12.11","1.56","53.50","35","0.47","1.2","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 16FR 14IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003306","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.51","1.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.58","38.3","","1.65","0.56","14.07","55","0.47","1.2","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 16FR 14IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003306","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.51","1.13","WELLPOINT [1015]","HB AMC WELLPOINT","1.11","73.78","","24.17","1.07","130.81","14","0.47","1.2","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 16FR 14IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003306","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1.51","1.13","AETNA [1001]","HB AMC AETNA HMO","1.05","69.8","","1.83","0.82","15.71","1 through 10","0.79","1.23","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 16FR 14IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003306","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1.51","1.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1.21","80.4","","0.72","0.72","0.72","1 through 10","0.79","1.23","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 16FR 14IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003306","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1.51","1.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1.23","81.72","","10.92","1.37","10.92","1 through 10","0.79","1.23","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 16FR 14IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003306","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1.51","1.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1.23","81.72","","19.84","1.15","26.27","14","0.79","1.23","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","both","","","774.55","580.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","615.77","79.5","","1309.77","674.56","6049.93","26","240.11","615.77","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","both","","","774.55","580.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","412.84","53.3","","1901.83","1901.83","2962.25","1 through 10","240.11","615.77","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","both","","","774.55","580.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","282.71","36.5","","1620.31","1620.31","19908.88","1 through 10","240.11","615.77","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","both","","","774.55","580.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","296.65","38.3","","352.91","352.91","2046.30","1 through 10","240.11","615.77","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","both","","","774.55","580.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","332.28","42.9","","9668.75","9668.75","9668.75","1 through 10","240.11","615.77","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","both","","","774.55","580.91","WELLPOINT [1015]","HB AMC WELLPOINT","571.46","73.78","","699.88","384.10","3443.31","33","240.11","615.77","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","774.55","580.91","AETNA [1001]","HB AMC AETNA HMO","540.64","69.8","","1421.24","264.50","4933.46","29","404.78","632.96","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","774.55","580.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","622.74","80.4","","1022.97","1022.97","3607.50","1 through 10","404.78","632.96","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","774.55","580.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","632.96","81.72","","3010.54","693.88","5019.88","35","404.78","632.96","percent of total billed charges",""
"CATHETER DRAINAGE 1.5MM SYSTEM ED3 VENTRICULAR CLEAR","SUP-ITM-10013252","CDM","C1889","HCPCS","0278","RC","","","","both","","","480.41","360.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","381.93","79.5","","1309.77","674.56","6049.93","26","148.93","381.93","percent of total billed charges",""
"CATHETER DRAINAGE 1.5MM SYSTEM ED3 VENTRICULAR CLEAR","SUP-ITM-10013252","CDM","C1889","HCPCS","0278","RC","","","","both","","","480.41","360.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","256.06","53.3","","1901.83","1901.83","2962.25","1 through 10","148.93","381.93","percent of total billed charges",""
"CATHETER DRAINAGE 1.5MM SYSTEM ED3 VENTRICULAR CLEAR","SUP-ITM-10013252","CDM","C1889","HCPCS","0278","RC","","","","both","","","480.41","360.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","175.35","36.5","","1620.31","1620.31","19908.88","1 through 10","148.93","381.93","percent of total billed charges",""
"CATHETER DRAINAGE 1.5MM SYSTEM ED3 VENTRICULAR CLEAR","SUP-ITM-10013252","CDM","C1889","HCPCS","0278","RC","","","","both","","","480.41","360.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","184.00","38.3","","352.91","352.91","2046.30","1 through 10","148.93","381.93","percent of total billed charges",""
"CATHETER DRAINAGE 1.5MM SYSTEM ED3 VENTRICULAR CLEAR","SUP-ITM-10013252","CDM","C1889","HCPCS","0278","RC","","","","both","","","480.41","360.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.10","42.9","","9668.75","9668.75","9668.75","1 through 10","148.93","381.93","percent of total billed charges",""
"CATHETER DRAINAGE 1.5MM SYSTEM ED3 VENTRICULAR CLEAR","SUP-ITM-10013252","CDM","C1889","HCPCS","0278","RC","","","","both","","","480.41","360.31","WELLPOINT [1015]","HB AMC WELLPOINT","354.45","73.78","","699.88","384.10","3443.31","33","148.93","381.93","percent of total billed charges",""
"CATHETER DRAINAGE 1.5MM SYSTEM ED3 VENTRICULAR CLEAR","SUP-ITM-10013252","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","480.41","360.31","AETNA [1001]","HB AMC AETNA HMO","335.33","69.8","","1421.24","264.50","4933.46","29","251.06","392.59","percent of total billed charges",""
"CATHETER DRAINAGE 1.5MM SYSTEM ED3 VENTRICULAR CLEAR","SUP-ITM-10013252","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","480.41","360.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","386.25","80.4","","1022.97","1022.97","3607.50","1 through 10","251.06","392.59","percent of total billed charges",""
"CATHETER DRAINAGE 1.5MM SYSTEM ED3 VENTRICULAR CLEAR","SUP-ITM-10013252","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","480.41","360.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","392.59","81.72","","3010.54","693.88","5019.88","35","251.06","392.59","percent of total billed charges",""
"CATHETER DRAINAGE 1.9MM SET EVD BACTISEAL","SUP-ITM-10022907","CDM","C1889","HCPCS","0278","RC","","","","both","","","1163.61","872.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","925.07","79.5","","1309.77","674.56","6049.93","26","360.72","925.07","percent of total billed charges",""
"CATHETER DRAINAGE 1.9MM SET EVD BACTISEAL","SUP-ITM-10022907","CDM","C1889","HCPCS","0278","RC","","","","both","","","1163.61","872.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","620.20","53.3","","1901.83","1901.83","2962.25","1 through 10","360.72","925.07","percent of total billed charges",""
"CATHETER DRAINAGE 1.9MM SET EVD BACTISEAL","SUP-ITM-10022907","CDM","C1889","HCPCS","0278","RC","","","","both","","","1163.61","872.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","424.72","36.5","","1620.31","1620.31","19908.88","1 through 10","360.72","925.07","percent of total billed charges",""
"CATHETER DRAINAGE 1.9MM SET EVD BACTISEAL","SUP-ITM-10022907","CDM","C1889","HCPCS","0278","RC","","","","both","","","1163.61","872.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","445.66","38.3","","352.91","352.91","2046.30","1 through 10","360.72","925.07","percent of total billed charges",""
"CATHETER DRAINAGE 1.9MM SET EVD BACTISEAL","SUP-ITM-10022907","CDM","C1889","HCPCS","0278","RC","","","","both","","","1163.61","872.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","499.19","42.9","","9668.75","9668.75","9668.75","1 through 10","360.72","925.07","percent of total billed charges",""
"CATHETER DRAINAGE 1.9MM SET EVD BACTISEAL","SUP-ITM-10022907","CDM","C1889","HCPCS","0278","RC","","","","both","","","1163.61","872.71","WELLPOINT [1015]","HB AMC WELLPOINT","858.51","73.78","","699.88","384.10","3443.31","33","360.72","925.07","percent of total billed charges",""
"CATHETER DRAINAGE 1.9MM SET EVD BACTISEAL","SUP-ITM-10022907","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1163.61","872.71","AETNA [1001]","HB AMC AETNA HMO","812.20","69.8","","1421.24","264.50","4933.46","29","608.1","950.9","percent of total billed charges",""
"CATHETER DRAINAGE 1.9MM SET EVD BACTISEAL","SUP-ITM-10022907","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1163.61","872.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","935.54","80.4","","1022.97","1022.97","3607.50","1 through 10","608.1","950.9","percent of total billed charges",""
"CATHETER DRAINAGE 1.9MM SET EVD BACTISEAL","SUP-ITM-10022907","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1163.61","872.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","950.90","81.72","","3010.54","693.88","5019.88","35","608.1","950.9","percent of total billed charges",""
"CATHETER DRAINAGE 10FR 45CM .038IN MULTIPURPOSE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC LOOP LOCKING LF","SUP-ITM-10025290","CDM","C1729","HCPCS","0272","RC","","","","both","","","278.32","208.74","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","199.83","71.8","","162.24","51.52","162.24","1 through 10","86.28","221.26","percent of total billed charges",""
"CATHETER DRAINAGE 10FR 45CM .038IN MULTIPURPOSE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC LOOP LOCKING LF","SUP-ITM-10025290","CDM","C1729","HCPCS","0272","RC","","","","both","","","278.32","208.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","101.59","36.5","","94.34","22.19","146.22","26","86.28","221.26","percent of total billed charges",""
"CATHETER DRAINAGE 10FR 45CM .038IN MULTIPURPOSE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC LOOP LOCKING LF","SUP-ITM-10025290","CDM","C1729","HCPCS","0272","RC","","","","both","","","278.32","208.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","106.60","38.3","","51.52","27.37","51.52","26","86.28","221.26","percent of total billed charges",""
"CATHETER DRAINAGE 10FR 45CM .038IN MULTIPURPOSE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC LOOP LOCKING LF","SUP-ITM-10025290","CDM","C1729","HCPCS","0272","RC","","","","both","","","278.32","208.74","WELLPOINT [1015]","HB AMC WELLPOINT","205.34","73.78","","207.21","122.12","216.28","14","86.28","221.26","percent of total billed charges",""
"CATHETER DRAINAGE 10FR 45CM .038IN MULTIPURPOSE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC LOOP LOCKING LF","SUP-ITM-10025290","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","278.32","208.74","AETNA [1001]","HB AMC AETNA HMO","194.27","69.8","","155.96","47.39","155.96","1 through 10","145.45","227.44","percent of total billed charges",""
"CATHETER DRAINAGE 10FR 45CM .038IN MULTIPURPOSE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC LOOP LOCKING LF","SUP-ITM-10025290","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","278.32","208.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","227.44","81.72","","57.36","51.76","232.23","35","145.45","227.44","percent of total billed charges",""
"CATHETER DRAINAGE 12FR 60CM .038IN MULTIPURPOSE ULTRATHANE MAC-LOC LOCKING LOOP","SUP-ITM-10086953","CDM","C1729","HCPCS","0272","RC","","","","both","","","483.18","362.38","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","346.92","71.8","","162.24","51.52","162.24","1 through 10","149.79","384.13","percent of total billed charges",""
"CATHETER DRAINAGE 12FR 60CM .038IN MULTIPURPOSE ULTRATHANE MAC-LOC LOCKING LOOP","SUP-ITM-10086953","CDM","C1729","HCPCS","0272","RC","","","","both","","","483.18","362.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","176.36","36.5","","94.34","22.19","146.22","26","149.79","384.13","percent of total billed charges",""
"CATHETER DRAINAGE 12FR 60CM .038IN MULTIPURPOSE ULTRATHANE MAC-LOC LOCKING LOOP","SUP-ITM-10086953","CDM","C1729","HCPCS","0272","RC","","","","both","","","483.18","362.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","185.06","38.3","","51.52","27.37","51.52","26","149.79","384.13","percent of total billed charges",""
"CATHETER DRAINAGE 12FR 60CM .038IN MULTIPURPOSE ULTRATHANE MAC-LOC LOCKING LOOP","SUP-ITM-10086953","CDM","C1729","HCPCS","0272","RC","","","","both","","","483.18","362.38","WELLPOINT [1015]","HB AMC WELLPOINT","356.49","73.78","","207.21","122.12","216.28","14","149.79","384.13","percent of total billed charges",""
"CATHETER DRAINAGE 12FR 60CM .038IN MULTIPURPOSE ULTRATHANE MAC-LOC LOCKING LOOP","SUP-ITM-10086953","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","483.18","362.38","AETNA [1001]","HB AMC AETNA HMO","337.26","69.8","","155.96","47.39","155.96","1 through 10","252.51","394.85","percent of total billed charges",""
"CATHETER DRAINAGE 12FR 60CM .038IN MULTIPURPOSE ULTRATHANE MAC-LOC LOCKING LOOP","SUP-ITM-10086953","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","483.18","362.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","394.85","81.72","","57.36","51.76","232.23","35","252.51","394.85","percent of total billed charges",""
"CATHETER DRAINAGE 8FRX30CM NEPHROSTOMY MALECOT TWO FLEXIBLE STYLET BAG CONNECTING TUBE","SUP-ITM-10092636","CDM","C1729","HCPCS","0272","RC","","","","both","","","402.47","301.85","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","288.97","71.8","","162.24","51.52","162.24","1 through 10","124.77","319.96","percent of total billed charges",""
"CATHETER DRAINAGE 8FRX30CM NEPHROSTOMY MALECOT TWO FLEXIBLE STYLET BAG CONNECTING TUBE","SUP-ITM-10092636","CDM","C1729","HCPCS","0272","RC","","","","both","","","402.47","301.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","146.90","36.5","","94.34","22.19","146.22","26","124.77","319.96","percent of total billed charges",""
"CATHETER DRAINAGE 8FRX30CM NEPHROSTOMY MALECOT TWO FLEXIBLE STYLET BAG CONNECTING TUBE","SUP-ITM-10092636","CDM","C1729","HCPCS","0272","RC","","","","both","","","402.47","301.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","154.15","38.3","","51.52","27.37","51.52","26","124.77","319.96","percent of total billed charges",""
"CATHETER DRAINAGE 8FRX30CM NEPHROSTOMY MALECOT TWO FLEXIBLE STYLET BAG CONNECTING TUBE","SUP-ITM-10092636","CDM","C1729","HCPCS","0272","RC","","","","both","","","402.47","301.85","WELLPOINT [1015]","HB AMC WELLPOINT","296.94","73.78","","207.21","122.12","216.28","14","124.77","319.96","percent of total billed charges",""
"CATHETER DRAINAGE 8FRX30CM NEPHROSTOMY MALECOT TWO FLEXIBLE STYLET BAG CONNECTING TUBE","SUP-ITM-10092636","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","402.47","301.85","AETNA [1001]","HB AMC AETNA HMO","280.92","69.8","","155.96","47.39","155.96","1 through 10","210.33","328.9","percent of total billed charges",""
"CATHETER DRAINAGE 8FRX30CM NEPHROSTOMY MALECOT TWO FLEXIBLE STYLET BAG CONNECTING TUBE","SUP-ITM-10092636","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","402.47","301.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","328.90","81.72","","57.36","51.76","232.23","35","210.33","328.9","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","both","","","1270.82","953.11","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","912.45","71.8","","28.28","27.13","28.28","1 through 10","393.95","1010.3","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","both","","","1270.82","953.11","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","889.57","70","","44.63","35.78","44.63","1 through 10","393.95","1010.3","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","both","","","1270.82","953.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1010.30","79.5","","1342.89","271.64","6954.67","1 through 10","393.95","1010.3","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","both","","","1270.82","953.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","677.35","53.3","","4550.00","30.49","4550.00","1 through 10","393.95","1010.3","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","both","","","1270.82","953.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","826.03","65","","42.09","0.04","5453.50","1 through 10","393.95","1010.3","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","both","","","1270.82","953.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","463.85","36.5","","310.94","18.54","1259.30","62","393.95","1010.3","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","both","","","1270.82","953.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","486.72","38.3","","146.86","22.58","1753.45","65","393.95","1010.3","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","both","","","1270.82","953.11","WELLPOINT [1015]","HB AMC WELLPOINT","937.61","73.78","","247.29","33.09","909.09","53","393.95","1010.3","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1270.82","953.11","AETNA [1001]","HB AMC AETNA HMO","887.03","69.8","","30.69","30.21","30.69","1 through 10","664.13","1038.51","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1270.82","953.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1021.74","80.4","","82.69","82.69","82.69","1 through 10","664.13","1038.51","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1270.82","953.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1038.51","81.72","","751.01","74.72","751.01","1 through 10","664.13","1038.51","percent of total billed charges",""
"CATHETER DRAINAGE L 12CM 17 OD 24FR NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE PTFE SHEATH","SUP-ITM-10118206","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1270.82","953.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1038.51","81.72","","328.92","46.17","2701.97","59","664.13","1038.51","percent of total billed charges",""
"Catheter Drainage T1","PX-27000044","CDM","C1729","HCPCS","0272","RC","","","","both","","","366.49","274.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","263.14","71.8","","162.24","51.52","162.24","1 through 10","113.61","291.36","percent of total billed charges",""
"Catheter Drainage T1","PX-27000044","CDM","C1729","HCPCS","0272","RC","","","","both","","","366.49","274.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","133.77","36.5","","94.34","22.19","146.22","26","113.61","291.36","percent of total billed charges",""
"Catheter Drainage T1","PX-27000044","CDM","C1729","HCPCS","0272","RC","","","","both","","","366.49","274.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","140.37","38.3","","51.52","27.37","51.52","26","113.61","291.36","percent of total billed charges",""
"Catheter Drainage T1","PX-27000044","CDM","C1729","HCPCS","0272","RC","","","","both","","","366.49","274.87","WELLPOINT [1015]","HB AMC WELLPOINT","270.40","73.78","","207.21","122.12","216.28","14","113.61","291.36","percent of total billed charges",""
"Catheter Drainage T1","PX-27000044","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","366.49","274.87","AETNA [1001]","HB AMC AETNA HMO","255.81","69.8","","155.96","47.39","155.96","1 through 10","191.53","299.5","percent of total billed charges",""
"Catheter Drainage T1","PX-27000044","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","366.49","274.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","299.50","81.72","","57.36","51.76","232.23","35","191.53","299.5","percent of total billed charges",""
"CATHETER DURAFLOW 15.5FR 28CM HEMODIALYSIS STRAIGHT BASIC KIT BX/5EA","SUP-ITM-10026428","CDM","C1750","HCPCS","0278","RC","","","","both","","","875.00","656.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","457.28","52.26","","154.36","154.36","154.36","1 through 10","271.25","695.63","percent of total billed charges",""
"CATHETER DURAFLOW 15.5FR 28CM HEMODIALYSIS STRAIGHT BASIC KIT BX/5EA","SUP-ITM-10026428","CDM","C1750","HCPCS","0278","RC","","","","both","","","875.00","656.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","568.75","65","","1371.74","196.32","1371.74","1 through 10","271.25","695.63","percent of total billed charges",""
"CATHETER DURAFLOW 15.5FR 28CM HEMODIALYSIS STRAIGHT BASIC KIT BX/5EA","SUP-ITM-10026428","CDM","C1750","HCPCS","0278","RC","","","","both","","","875.00","656.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","612.50","70","","249.45","107.26","1254.96","14","271.25","695.63","percent of total billed charges",""
"CATHETER DURAFLOW 15.5FR 28CM HEMODIALYSIS STRAIGHT BASIC KIT BX/5EA","SUP-ITM-10026428","CDM","C1750","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","196.32","85.01","196.32","1 through 10","271.25","695.63","percent of total billed charges",""
"CATHETER DURAFLOW 15.5FR 28CM HEMODIALYSIS STRAIGHT BASIC KIT BX/5EA","SUP-ITM-10026428","CDM","C1750","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","1132.95","1132.95","1132.95","1 through 10","271.25","695.63","percent of total billed charges",""
"CATHETER DURAFLOW 15.5FR 28CM HEMODIALYSIS STRAIGHT BASIC KIT BX/5EA","SUP-ITM-10026428","CDM","C1750","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","1297.66","185.72","1297.66","1 through 10","271.25","695.63","percent of total billed charges",""
"CATHETER DURAFLOW 15.5FR 28CM HEMODIALYSIS STRAIGHT BASIC KIT BX/5EA","SUP-ITM-10026428","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","76.96","76.96","76.96","1 through 10","457.28","715.05","percent of total billed charges",""
"CATHETER DURAFLOW 15.5FR 28CM HEMODIALYSIS STRAIGHT BASIC KIT BX/5EA","SUP-ITM-10026428","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","457.28","52.26","","154.36","154.36","154.36","1 through 10","457.28","715.05","percent of total billed charges",""
"CATHETER DURAFLOW 15.5FR 28CM HEMODIALYSIS STRAIGHT BASIC KIT BX/5EA","SUP-ITM-10026428","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","199.41","199.41","199.41","1 through 10","457.28","715.05","percent of total billed charges",""
"CATHETER DURAMAX 40CM HEMODIALYSIS STRAIGHT BASIC KIT CHRONIC","SUP-ITM-10113720","CDM","C1750","HCPCS","0278","RC","","","","both","","","822.50","616.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","429.84","52.26","","154.36","154.36","154.36","1 through 10","254.98","653.89","percent of total billed charges",""
"CATHETER DURAMAX 40CM HEMODIALYSIS STRAIGHT BASIC KIT CHRONIC","SUP-ITM-10113720","CDM","C1750","HCPCS","0278","RC","","","","both","","","822.50","616.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","534.63","65","","1371.74","196.32","1371.74","1 through 10","254.98","653.89","percent of total billed charges",""
"CATHETER DURAMAX 40CM HEMODIALYSIS STRAIGHT BASIC KIT CHRONIC","SUP-ITM-10113720","CDM","C1750","HCPCS","0278","RC","","","","both","","","822.50","616.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","575.75","70","","249.45","107.26","1254.96","14","254.98","653.89","percent of total billed charges",""
"CATHETER DURAMAX 40CM HEMODIALYSIS STRAIGHT BASIC KIT CHRONIC","SUP-ITM-10113720","CDM","C1750","HCPCS","0278","RC","","","","both","","","822.50","616.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","653.89","79.5","","196.32","85.01","196.32","1 through 10","254.98","653.89","percent of total billed charges",""
"CATHETER DURAMAX 40CM HEMODIALYSIS STRAIGHT BASIC KIT CHRONIC","SUP-ITM-10113720","CDM","C1750","HCPCS","0278","RC","","","","both","","","822.50","616.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","438.39","53.3","","1132.95","1132.95","1132.95","1 through 10","254.98","653.89","percent of total billed charges",""
"CATHETER DURAMAX 40CM HEMODIALYSIS STRAIGHT BASIC KIT CHRONIC","SUP-ITM-10113720","CDM","C1750","HCPCS","0278","RC","","","","both","","","822.50","616.87","WELLPOINT [1015]","HB AMC WELLPOINT","606.84","73.78","","1297.66","185.72","1297.66","1 through 10","254.98","653.89","percent of total billed charges",""
"CATHETER DURAMAX 40CM HEMODIALYSIS STRAIGHT BASIC KIT CHRONIC","SUP-ITM-10113720","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","822.50","616.87","AETNA [1001]","HB AMC AETNA HMO","574.11","69.8","","76.96","76.96","76.96","1 through 10","429.84","672.15","percent of total billed charges",""
"CATHETER DURAMAX 40CM HEMODIALYSIS STRAIGHT BASIC KIT CHRONIC","SUP-ITM-10113720","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","822.50","616.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","429.84","52.26","","154.36","154.36","154.36","1 through 10","429.84","672.15","percent of total billed charges",""
"CATHETER DURAMAX 40CM HEMODIALYSIS STRAIGHT BASIC KIT CHRONIC","SUP-ITM-10113720","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","822.50","616.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","672.15","81.72","","199.41","199.41","199.41","1 through 10","429.84","672.15","percent of total billed charges",""
"CATHETER EAGLE EYE 2.9FR 150CM .014IN LF INTRAVASCULAR PERIPHERAL PLATINUM DIGITAL IMAGING STERILE DISP PC/1EA","SUP-ITM-10092100","CDM","C1753","HCPCS","0272","RC","","","","both","","","2765.00","2073.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1797.25","65","","1660.75","1660.75","1660.75","1 through 10","857.15","2198.18","percent of total billed charges",""
"CATHETER EAGLE EYE 2.9FR 150CM .014IN LF INTRAVASCULAR PERIPHERAL PLATINUM DIGITAL IMAGING STERILE DISP PC/1EA","SUP-ITM-10092100","CDM","C1753","HCPCS","0272","RC","","","","both","","","2765.00","2073.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1009.23","36.5","","1233.70","876.51","1905.76","1 through 10","857.15","2198.18","percent of total billed charges",""
"CATHETER EAGLE EYE 2.9FR 150CM .014IN LF INTRAVASCULAR PERIPHERAL PLATINUM DIGITAL IMAGING STERILE DISP PC/1EA","SUP-ITM-10092100","CDM","C1753","HCPCS","0272","RC","","","","both","","","2765.00","2073.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1059.00","38.3","","1026.38","999.01","1026.38","1 through 10","857.15","2198.18","percent of total billed charges",""
"CATHETER EAGLE EYE 2.9FR 150CM .014IN LF INTRAVASCULAR PERIPHERAL PLATINUM DIGITAL IMAGING STERILE DISP PC/1EA","SUP-ITM-10092100","CDM","C1753","HCPCS","0272","RC","","","","both","","","2765.00","2073.75","WELLPOINT [1015]","HB AMC WELLPOINT","2040.02","73.78","","1902.20","1902.20","1902.20","1 through 10","857.15","2198.18","percent of total billed charges",""
"CATHETER EAGLE EYE 2.9FR 150CM .014IN LF INTRAVASCULAR PERIPHERAL PLATINUM DIGITAL IMAGING STERILE DISP PC/1EA","SUP-ITM-10092100","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","2765.00","2073.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2259.56","81.72","","2098.42","1123.43","2210.34","1 through 10","1444.99","2259.56","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","both","","","1569.40","1177.05","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1098.58","70","","863.10","863.10","863.10","1 through 10","486.51","1247.67","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","both","","","1569.40","1177.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1247.67","79.5","","447.66","447.66","447.66","1 through 10","486.51","1247.67","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","both","","","1569.40","1177.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1020.11","65","","1020.11","1020.11","1020.11","1 through 10","486.51","1247.67","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","both","","","1569.40","1177.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","486.51","31","","208.83","208.83","208.83","1 through 10","486.51","1247.67","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","both","","","1569.40","1177.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","572.83","36.5","","312.44","214.23","1086.03","20","486.51","1247.67","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","both","","","1569.40","1177.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","601.08","38.3","","264.25","227.63","567.11","31","486.51","1247.67","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","both","","","1569.40","1177.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","673.27","42.9","","79.94","79.94","79.94","1 through 10","486.51","1247.67","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","both","","","1569.40","1177.05","WELLPOINT [1015]","HB AMC WELLPOINT","1157.90","73.78","","174.45","74.45","1168.42","1 through 10","486.51","1247.67","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1569.40","1177.05","AETNA [1001]","HB AMC AETNA HMO","1095.44","69.8","","655.01","135.40","784.73","1 through 10","820.17","1282.51","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1569.40","1177.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1282.51","81.72","","540.25","46.28","897.42","36","820.17","1282.51","percent of total billed charges",""
"CATHETER ENROUTE ENFLATE 4X25MM BALLOON RX TRANSCAROTID DILATATION","SUP-ITM-10310260","CDM","C1725","HCPCS","0272","RC","","","","both","","","1186.50","889.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","851.91","71.8","","175.91","175.91","175.91","1 through 10","367.82","943.27","percent of total billed charges",""
"CATHETER ENROUTE ENFLATE 4X25MM BALLOON RX TRANSCAROTID DILATATION","SUP-ITM-10310260","CDM","C1725","HCPCS","0272","RC","","","","both","","","1186.50","889.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","771.23","65","","147.88","147.88","1296.75","1 through 10","367.82","943.27","percent of total billed charges",""
"CATHETER ENROUTE ENFLATE 4X25MM BALLOON RX TRANSCAROTID DILATATION","SUP-ITM-10310260","CDM","C1725","HCPCS","0272","RC","","","","both","","","1186.50","889.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","433.07","36.5","","181.40","177.87","181.40","21","367.82","943.27","percent of total billed charges",""
"CATHETER ENROUTE ENFLATE 4X25MM BALLOON RX TRANSCAROTID DILATATION","SUP-ITM-10310260","CDM","C1725","HCPCS","0272","RC","","","","both","","","1186.50","889.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","454.43","38.3","","170.15","88.95","424.24","16","367.82","943.27","percent of total billed charges",""
"CATHETER ENROUTE ENFLATE 4X25MM BALLOON RX TRANSCAROTID DILATATION","SUP-ITM-10310260","CDM","C1725","HCPCS","0272","RC","","","","both","","","1186.50","889.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","509.01","42.9","","699.48","699.48","699.48","12","367.82","943.27","percent of total billed charges",""
"CATHETER ENROUTE ENFLATE 4X25MM BALLOON RX TRANSCAROTID DILATATION","SUP-ITM-10310260","CDM","C1725","HCPCS","0272","RC","","","","both","","","1186.50","889.87","WELLPOINT [1015]","HB AMC WELLPOINT","875.40","73.78","","576.52","182.40","651.44","14","367.82","943.27","percent of total billed charges",""
"CATHETER ENROUTE ENFLATE 4X25MM BALLOON RX TRANSCAROTID DILATATION","SUP-ITM-10310260","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1186.50","889.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","969.61","81.72","","181.86","100.03","402.41","21","620.06","969.61","percent of total billed charges",""
"CATHETER EPS 5F 2/5MM 120CM JSN X QUAD - REPROCESSED","SUP-ITM-10278810","CDM","C1730","HCPCS","0272","RC","","","","both","","","147.00","110.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","76.82","52.26","","1988.81","1988.81","1988.81","1 through 10","45.57","116.87","percent of total billed charges",""
"CATHETER EPS 5F 2/5MM 120CM JSN X QUAD - REPROCESSED","SUP-ITM-10278810","CDM","C1730","HCPCS","0272","RC","","","","both","","","147.00","110.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.87","79.5","","765.06","765.06","765.06","1 through 10","45.57","116.87","percent of total billed charges",""
"CATHETER EPS 5F 2/5MM 120CM JSN X QUAD - REPROCESSED","SUP-ITM-10278810","CDM","C1730","HCPCS","0272","RC","","","","both","","","147.00","110.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.35","53.3","","6427.95","6427.95","6427.95","1 through 10","45.57","116.87","percent of total billed charges",""
"CATHETER EPS 5F 2/5MM 120CM JSN X QUAD - REPROCESSED","SUP-ITM-10278810","CDM","C1730","HCPCS","0272","RC","","","","both","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","95.55","65","","1193.16","1193.16","1193.16","1 through 10","45.57","116.87","percent of total billed charges",""
"CATHETER EPS 5F 2/5MM 120CM JSN X QUAD - REPROCESSED","SUP-ITM-10278810","CDM","C1730","HCPCS","0272","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.66","36.5","","2053.37","54.83","3398.85","20","45.57","116.87","percent of total billed charges",""
"CATHETER EPS 5F 2/5MM 120CM JSN X QUAD - REPROCESSED","SUP-ITM-10278810","CDM","C1730","HCPCS","0272","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.30","38.3","","232.75","124.53","2541.50","39","45.57","116.87","percent of total billed charges",""
"CATHETER EPS 5F 2/5MM 120CM JSN X QUAD - REPROCESSED","SUP-ITM-10278810","CDM","C1730","HCPCS","0272","RC","","","","both","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.06","42.9","","66.89","66.89","66.89","1 through 10","45.57","116.87","percent of total billed charges",""
"CATHETER EPS 5F 2/5MM 120CM JSN X QUAD - REPROCESSED","SUP-ITM-10278810","CDM","C1730","HCPCS","0272","RC","","","","both","","","147.00","110.25","WELLPOINT [1015]","HB AMC WELLPOINT","108.46","73.78","","2392.81","1818.08","6339.98","15","45.57","116.87","percent of total billed charges",""
"CATHETER EPS 5F 2/5MM 120CM JSN X QUAD - REPROCESSED","SUP-ITM-10278810","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","147.00","110.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","76.82","52.26","","1988.81","1988.81","1988.81","1 through 10","76.82","120.13","percent of total billed charges",""
"CATHETER EPS 5F 2/5MM 120CM JSN X QUAD - REPROCESSED","SUP-ITM-10278810","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","120.13","81.72","","2569.25","132.34","2569.25","1 through 10","76.82","120.13","percent of total billed charges",""
"CATHETER EPS 5F 2/5MM 120CM JSN X QUAD - REPROCESSED","SUP-ITM-10278810","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","120.13","81.72","","727.92","102.34","6154.18","26","76.82","120.13","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","both","","","1232.70","924.52","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","862.89","70","","863.10","863.10","863.10","1 through 10","382.14","980","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","both","","","1232.70","924.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","980.00","79.5","","447.66","447.66","447.66","1 through 10","382.14","980","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","both","","","1232.70","924.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","801.26","65","","1020.11","1020.11","1020.11","1 through 10","382.14","980","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","both","","","1232.70","924.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","382.14","31","","208.83","208.83","208.83","1 through 10","382.14","980","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","both","","","1232.70","924.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","449.94","36.5","","312.44","214.23","1086.03","20","382.14","980","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","both","","","1232.70","924.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","472.12","38.3","","264.25","227.63","567.11","31","382.14","980","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","both","","","1232.70","924.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","528.83","42.9","","79.94","79.94","79.94","1 through 10","382.14","980","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","both","","","1232.70","924.52","WELLPOINT [1015]","HB AMC WELLPOINT","909.49","73.78","","174.45","74.45","1168.42","1 through 10","382.14","980","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1232.70","924.52","AETNA [1001]","HB AMC AETNA HMO","860.42","69.8","","655.01","135.40","784.73","1 through 10","644.21","1007.36","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1232.70","924.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1007.36","81.72","","540.25","46.28","897.42","36","644.21","1007.36","percent of total billed charges",""
"CATHETER EVERCROSS 5FR 5MM 20MM 135CM .035IN OTW BALLOON COMPLIANT PTA PERIPHERAL","SUP-ITM-10042597","CDM","C1725","HCPCS","0272","RC","","","","both","","","234.50","175.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","168.37","71.8","","175.91","175.91","175.91","1 through 10","72.7","186.43","percent of total billed charges",""
"CATHETER EVERCROSS 5FR 5MM 20MM 135CM .035IN OTW BALLOON COMPLIANT PTA PERIPHERAL","SUP-ITM-10042597","CDM","C1725","HCPCS","0272","RC","","","","both","","","234.50","175.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","152.43","65","","147.88","147.88","1296.75","1 through 10","72.7","186.43","percent of total billed charges",""
"CATHETER EVERCROSS 5FR 5MM 20MM 135CM .035IN OTW BALLOON COMPLIANT PTA PERIPHERAL","SUP-ITM-10042597","CDM","C1725","HCPCS","0272","RC","","","","both","","","234.50","175.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.59","36.5","","181.40","177.87","181.40","21","72.7","186.43","percent of total billed charges",""
"CATHETER EVERCROSS 5FR 5MM 20MM 135CM .035IN OTW BALLOON COMPLIANT PTA PERIPHERAL","SUP-ITM-10042597","CDM","C1725","HCPCS","0272","RC","","","","both","","","234.50","175.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.81","38.3","","170.15","88.95","424.24","16","72.7","186.43","percent of total billed charges",""
"CATHETER EVERCROSS 5FR 5MM 20MM 135CM .035IN OTW BALLOON COMPLIANT PTA PERIPHERAL","SUP-ITM-10042597","CDM","C1725","HCPCS","0272","RC","","","","both","","","234.50","175.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.60","42.9","","699.48","699.48","699.48","12","72.7","186.43","percent of total billed charges",""
"CATHETER EVERCROSS 5FR 5MM 20MM 135CM .035IN OTW BALLOON COMPLIANT PTA PERIPHERAL","SUP-ITM-10042597","CDM","C1725","HCPCS","0272","RC","","","","both","","","234.50","175.87","WELLPOINT [1015]","HB AMC WELLPOINT","173.01","73.78","","576.52","182.40","651.44","14","72.7","186.43","percent of total billed charges",""
"CATHETER EVERCROSS 5FR 5MM 20MM 135CM .035IN OTW BALLOON COMPLIANT PTA PERIPHERAL","SUP-ITM-10042597","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","234.50","175.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.63","81.72","","181.86","100.03","402.41","21","122.55","191.63","percent of total billed charges",""
"CATHETER EXODUS 10FR 25CM DRAINAGE MULTIPURPOSE STANDARD LOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10114982","CDM","C1729","HCPCS","0272","RC","","","","both","","","290.50","217.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","208.58","71.8","","162.24","51.52","162.24","1 through 10","90.06","230.95","percent of total billed charges",""
"CATHETER EXODUS 10FR 25CM DRAINAGE MULTIPURPOSE STANDARD LOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10114982","CDM","C1729","HCPCS","0272","RC","","","","both","","","290.50","217.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","106.03","36.5","","94.34","22.19","146.22","26","90.06","230.95","percent of total billed charges",""
"CATHETER EXODUS 10FR 25CM DRAINAGE MULTIPURPOSE STANDARD LOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10114982","CDM","C1729","HCPCS","0272","RC","","","","both","","","290.50","217.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","111.26","38.3","","51.52","27.37","51.52","26","90.06","230.95","percent of total billed charges",""
"CATHETER EXODUS 10FR 25CM DRAINAGE MULTIPURPOSE STANDARD LOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10114982","CDM","C1729","HCPCS","0272","RC","","","","both","","","290.50","217.87","WELLPOINT [1015]","HB AMC WELLPOINT","214.33","73.78","","207.21","122.12","216.28","14","90.06","230.95","percent of total billed charges",""
"CATHETER EXODUS 10FR 25CM DRAINAGE MULTIPURPOSE STANDARD LOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10114982","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","290.50","217.87","AETNA [1001]","HB AMC AETNA HMO","202.77","69.8","","155.96","47.39","155.96","1 through 10","151.82","237.4","percent of total billed charges",""
"CATHETER EXODUS 10FR 25CM DRAINAGE MULTIPURPOSE STANDARD LOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10114982","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","290.50","217.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","237.40","81.72","","57.36","51.76","232.23","35","151.82","237.4","percent of total billed charges",""
"CATHETER EXTRACTOR PRO 7 TO 6FR 9 TO 12MM .035IN BALLOON RX RETRIEVAL TRIPLE LUMEN","SUP-ITM-10210681","CDM","C1773","HCPCS","0272","RC","","","","both","","","522.73","392.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","190.80","36.5","","114.30","97.14","114.30","1 through 10","162.05","415.57","percent of total billed charges",""
"CATHETER EXTRACTOR PRO 7 TO 6FR 9 TO 12MM .035IN BALLOON RX RETRIEVAL TRIPLE LUMEN","SUP-ITM-10210681","CDM","C1773","HCPCS","0272","RC","","","","both","","","522.73","392.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","200.21","38.3","","119.81","116.44","359.43","20","162.05","415.57","percent of total billed charges",""
"CATHETER EXTRACTOR PRO 7 TO 6FR 9 TO 12MM .035IN BALLOON RX RETRIEVAL TRIPLE LUMEN","SUP-ITM-10210681","CDM","C1773","HCPCS","0272","RC","","","","both","","","522.73","392.05","WELLPOINT [1015]","HB AMC WELLPOINT","385.67","73.78","","875.53","228.13","875.53","1 through 10","162.05","415.57","percent of total billed charges",""
"CATHETER EXTRACTOR PRO 7 TO 6FR 9 TO 12MM .035IN BALLOON RX RETRIEVAL TRIPLE LUMEN","SUP-ITM-10210681","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","522.73","392.05","AETNA [1001]","HB AMC AETNA HMO","364.87","69.8","","207.45","207.45","207.45","1 through 10","273.18","427.17","percent of total billed charges",""
"CATHETER EXTRACTOR PRO 7 TO 6FR 9 TO 12MM .035IN BALLOON RX RETRIEVAL TRIPLE LUMEN","SUP-ITM-10210681","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","522.73","392.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","427.17","81.72","","244.96","134.74","244.96","1 through 10","273.18","427.17","percent of total billed charges",""
"CATHETER FIRST CHOICE 8MMX8CM PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY","SUP-ITM-10148187","CDM","C1725","HCPCS","0272","RC","","","","both","","","808.96","606.72","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","580.83","71.8","","175.91","175.91","175.91","1 through 10","250.78","643.12","percent of total billed charges",""
"CATHETER FIRST CHOICE 8MMX8CM PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY","SUP-ITM-10148187","CDM","C1725","HCPCS","0272","RC","","","","both","","","808.96","606.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","525.82","65","","147.88","147.88","1296.75","1 through 10","250.78","643.12","percent of total billed charges",""
"CATHETER FIRST CHOICE 8MMX8CM PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY","SUP-ITM-10148187","CDM","C1725","HCPCS","0272","RC","","","","both","","","808.96","606.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","295.27","36.5","","181.40","177.87","181.40","21","250.78","643.12","percent of total billed charges",""
"CATHETER FIRST CHOICE 8MMX8CM PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY","SUP-ITM-10148187","CDM","C1725","HCPCS","0272","RC","","","","both","","","808.96","606.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","309.83","38.3","","170.15","88.95","424.24","16","250.78","643.12","percent of total billed charges",""
"CATHETER FIRST CHOICE 8MMX8CM PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY","SUP-ITM-10148187","CDM","C1725","HCPCS","0272","RC","","","","both","","","808.96","606.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","347.04","42.9","","699.48","699.48","699.48","12","250.78","643.12","percent of total billed charges",""
"CATHETER FIRST CHOICE 8MMX8CM PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY","SUP-ITM-10148187","CDM","C1725","HCPCS","0272","RC","","","","both","","","808.96","606.72","WELLPOINT [1015]","HB AMC WELLPOINT","596.85","73.78","","576.52","182.40","651.44","14","250.78","643.12","percent of total billed charges",""
"CATHETER FIRST CHOICE 8MMX8CM PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY","SUP-ITM-10148187","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","808.96","606.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","661.08","81.72","","181.86","100.03","402.41","21","422.76","661.08","percent of total billed charges",""
"CATHETER FLEXIMA 10FR 25CM ALL PURPOSE ABCESS DRAINAGE APD LOOP REGULAR METAL STIFFENING CANNULA TROCAR","SUP-ITM-10008852","CDM","C1729","HCPCS","0272","RC","","","","both","","","297.50","223.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","213.61","71.8","","162.24","51.52","162.24","1 through 10","92.23","236.51","percent of total billed charges",""
"CATHETER FLEXIMA 10FR 25CM ALL PURPOSE ABCESS DRAINAGE APD LOOP REGULAR METAL STIFFENING CANNULA TROCAR","SUP-ITM-10008852","CDM","C1729","HCPCS","0272","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.59","36.5","","94.34","22.19","146.22","26","92.23","236.51","percent of total billed charges",""
"CATHETER FLEXIMA 10FR 25CM ALL PURPOSE ABCESS DRAINAGE APD LOOP REGULAR METAL STIFFENING CANNULA TROCAR","SUP-ITM-10008852","CDM","C1729","HCPCS","0272","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.94","38.3","","51.52","27.37","51.52","26","92.23","236.51","percent of total billed charges",""
"CATHETER FLEXIMA 10FR 25CM ALL PURPOSE ABCESS DRAINAGE APD LOOP REGULAR METAL STIFFENING CANNULA TROCAR","SUP-ITM-10008852","CDM","C1729","HCPCS","0272","RC","","","","both","","","297.50","223.12","WELLPOINT [1015]","HB AMC WELLPOINT","219.50","73.78","","207.21","122.12","216.28","14","92.23","236.51","percent of total billed charges",""
"CATHETER FLEXIMA 10FR 25CM ALL PURPOSE ABCESS DRAINAGE APD LOOP REGULAR METAL STIFFENING CANNULA TROCAR","SUP-ITM-10008852","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","297.50","223.12","AETNA [1001]","HB AMC AETNA HMO","207.66","69.8","","155.96","47.39","155.96","1 through 10","155.47","243.12","percent of total billed charges",""
"CATHETER FLEXIMA 10FR 25CM ALL PURPOSE ABCESS DRAINAGE APD LOOP REGULAR METAL STIFFENING CANNULA TROCAR","SUP-ITM-10008852","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","243.12","81.72","","57.36","51.76","232.23","35","155.47","243.12","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","1144.50","858.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","801.15","70","","863.10","863.10","863.10","1 through 10","354.8","909.88","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","1144.50","858.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","909.88","79.5","","447.66","447.66","447.66","1 through 10","354.8","909.88","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","1144.50","858.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","743.93","65","","1020.11","1020.11","1020.11","1 through 10","354.8","909.88","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","1144.50","858.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","354.80","31","","208.83","208.83","208.83","1 through 10","354.8","909.88","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","1144.50","858.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","417.74","36.5","","312.44","214.23","1086.03","20","354.8","909.88","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","1144.50","858.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","438.34","38.3","","264.25","227.63","567.11","31","354.8","909.88","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","1144.50","858.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","490.99","42.9","","79.94","79.94","79.94","1 through 10","354.8","909.88","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","1144.50","858.37","WELLPOINT [1015]","HB AMC WELLPOINT","844.41","73.78","","174.45","74.45","1168.42","1 through 10","354.8","909.88","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1144.50","858.37","AETNA [1001]","HB AMC AETNA HMO","798.86","69.8","","655.01","135.40","784.73","1 through 10","598.12","935.29","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1144.50","858.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","935.29","81.72","","540.25","46.28","897.42","36","598.12","935.29","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.50","133.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","128.16","71.8","","28.28","27.13","28.28","1 through 10","55.34","141.91","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.50","133.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","124.95","70","","44.63","35.78","44.63","1 through 10","55.34","141.91","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.50","133.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","141.91","79.5","","1342.89","271.64","6954.67","1 through 10","55.34","141.91","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.50","133.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.14","53.3","","4550.00","30.49","4550.00","1 through 10","55.34","141.91","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","116.03","65","","42.09","0.04","5453.50","1 through 10","55.34","141.91","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.15","36.5","","310.94","18.54","1259.30","62","55.34","141.91","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.37","38.3","","146.86","22.58","1753.45","65","55.34","141.91","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.50","133.87","WELLPOINT [1015]","HB AMC WELLPOINT","131.70","73.78","","247.29","33.09","909.09","53","55.34","141.91","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","178.50","133.87","AETNA [1001]","HB AMC AETNA HMO","124.59","69.8","","30.69","30.21","30.69","1 through 10","93.28","145.87","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","143.51","80.4","","82.69","82.69","82.69","1 through 10","93.28","145.87","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","145.87","81.72","","751.01","74.72","751.01","1 through 10","93.28","145.87","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","145.87","81.72","","328.92","46.17","2701.97","59","93.28","145.87","percent of total billed charges",""
"CATHETER GOLD PROBE 7FR 2.33MM 300CM ELECTROHEMOSTASIS BIPOLAR STANDARD CONNECTOR SINGLE USE BX/1EA","SUP-ITM-10138924","CDM","C1886","HCPCS","0272","RC","","","","both","","","562.03","421.52","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","403.54","71.8","","4399.55","4399.55","4399.55","1 through 10","174.23","446.81","percent of total billed charges",""
"CATHETER GOLD PROBE 7FR 2.33MM 300CM ELECTROHEMOSTASIS BIPOLAR STANDARD CONNECTOR SINGLE USE BX/1EA","SUP-ITM-10138924","CDM","C1886","HCPCS","0272","RC","","","","both","","","562.03","421.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","205.14","36.5","","1413.19","621.27","1413.19","1 through 10","174.23","446.81","percent of total billed charges",""
"CATHETER GOLD PROBE 7FR 2.33MM 300CM ELECTROHEMOSTASIS BIPOLAR STANDARD CONNECTOR SINGLE USE BX/1EA","SUP-ITM-10138924","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","562.03","421.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","459.29","81.72","","8168.27","2209.17","8168.27","1 through 10","293.72","459.29","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","both","","","1746.50","1309.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1253.99","71.8","","175.91","175.91","175.91","1 through 10","541.42","1388.47","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","both","","","1746.50","1309.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1135.23","65","","147.88","147.88","1296.75","1 through 10","541.42","1388.47","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","both","","","1746.50","1309.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","637.47","36.5","","181.40","177.87","181.40","21","541.42","1388.47","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","both","","","1746.50","1309.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","668.91","38.3","","170.15","88.95","424.24","16","541.42","1388.47","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","both","","","1746.50","1309.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","749.25","42.9","","699.48","699.48","699.48","12","541.42","1388.47","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","both","","","1746.50","1309.87","WELLPOINT [1015]","HB AMC WELLPOINT","1288.57","73.78","","576.52","182.40","651.44","14","541.42","1388.47","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1746.50","1309.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1427.24","81.72","","181.86","100.03","402.41","21","912.72","1427.24","percent of total billed charges",""
"CATHETER GRAFT 6MMX10 120CM .035IN GUIDEWIRE ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135288","CDM","C1874","HCPCS","0278","RC","","","","both","","","7327.50","5495.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4762.88","65","","6652.80","6652.80","6652.80","1 through 10","2271.53","5825.36","percent of total billed charges",""
"CATHETER GRAFT 6MMX10 120CM .035IN GUIDEWIRE ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135288","CDM","C1874","HCPCS","0278","RC","","","","both","","","7327.50","5495.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5825.36","79.5","","2612.61","795.38","2612.61","1 through 10","2271.53","5825.36","percent of total billed charges",""
"CATHETER GRAFT 6MMX10 120CM .035IN GUIDEWIRE ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135288","CDM","C1874","HCPCS","0278","RC","","","","both","","","7327.50","5495.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3905.56","53.3","","1101.80","1101.80","1101.80","1 through 10","2271.53","5825.36","percent of total billed charges",""
"CATHETER GRAFT 6MMX10 120CM .035IN GUIDEWIRE ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135288","CDM","C1874","HCPCS","0278","RC","","","","both","","","7327.50","5495.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4762.88","65","","1820.00","910.00","1820.00","1 through 10","2271.53","5825.36","percent of total billed charges",""
"CATHETER GRAFT 6MMX10 120CM .035IN GUIDEWIRE ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135288","CDM","C1874","HCPCS","0278","RC","","","","both","","","7327.50","5495.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2674.54","36.5","","1257.80","693.44","2424.50","1 through 10","2271.53","5825.36","percent of total billed charges",""
"CATHETER GRAFT 6MMX10 120CM .035IN GUIDEWIRE ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135288","CDM","C1874","HCPCS","0278","RC","","","","both","","","7327.50","5495.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2806.43","38.3","","1950.11","547.40","2346.00","1 through 10","2271.53","5825.36","percent of total billed charges",""
"CATHETER GRAFT 6MMX10 120CM .035IN GUIDEWIRE ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135288","CDM","C1874","HCPCS","0278","RC","","","","both","","","7327.50","5495.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3143.50","42.9","","5096.18","5096.18","5096.18","1 through 10","2271.53","5825.36","percent of total billed charges",""
"CATHETER GRAFT 6MMX10 120CM .035IN GUIDEWIRE ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135288","CDM","C1874","HCPCS","0278","RC","","","","both","","","7327.50","5495.62","WELLPOINT [1015]","HB AMC WELLPOINT","5406.23","73.78","","1172.59","1172.59","4829.94","1 through 10","2271.53","5825.36","percent of total billed charges",""
"CATHETER GRAFT 6MMX10 120CM .035IN GUIDEWIRE ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135288","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7327.50","5495.62","AETNA [1001]","HB AMC AETNA HMO","5114.60","69.8","","1806.84","947.80","5091.72","1 through 10","3829.35","5988.03","percent of total billed charges",""
"CATHETER GRAFT 6MMX10 120CM .035IN GUIDEWIRE ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135288","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7327.50","5495.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5988.03","81.72","","1259.05","615.58","4586.56","1 through 10","3829.35","5988.03","percent of total billed charges",""
"CATHETER GUIDE 7FR 100CM 0.081IN FEMORAL MACH 1 PTFE LINING POLYMER Q4 CURVE ID","SUP-ITM-10007676","CDM","C1887","HCPCS","0272","RC","","","","both","","","157.50","118.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","113.09","71.8","","28.28","27.13","28.28","1 through 10","48.83","125.21","percent of total billed charges",""
"CATHETER GUIDE 7FR 100CM 0.081IN FEMORAL MACH 1 PTFE LINING POLYMER Q4 CURVE ID","SUP-ITM-10007676","CDM","C1887","HCPCS","0272","RC","","","","both","","","157.50","118.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","110.25","70","","44.63","35.78","44.63","1 through 10","48.83","125.21","percent of total billed charges",""
"CATHETER GUIDE 7FR 100CM 0.081IN FEMORAL MACH 1 PTFE LINING POLYMER Q4 CURVE ID","SUP-ITM-10007676","CDM","C1887","HCPCS","0272","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","1342.89","271.64","6954.67","1 through 10","48.83","125.21","percent of total billed charges",""
"CATHETER GUIDE 7FR 100CM 0.081IN FEMORAL MACH 1 PTFE LINING POLYMER Q4 CURVE ID","SUP-ITM-10007676","CDM","C1887","HCPCS","0272","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","4550.00","30.49","4550.00","1 through 10","48.83","125.21","percent of total billed charges",""
"CATHETER GUIDE 7FR 100CM 0.081IN FEMORAL MACH 1 PTFE LINING POLYMER Q4 CURVE ID","SUP-ITM-10007676","CDM","C1887","HCPCS","0272","RC","","","","both","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","102.38","65","","42.09","0.04","5453.50","1 through 10","48.83","125.21","percent of total billed charges",""
"CATHETER GUIDE 7FR 100CM 0.081IN FEMORAL MACH 1 PTFE LINING POLYMER Q4 CURVE ID","SUP-ITM-10007676","CDM","C1887","HCPCS","0272","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","310.94","18.54","1259.30","62","48.83","125.21","percent of total billed charges",""
"CATHETER GUIDE 7FR 100CM 0.081IN FEMORAL MACH 1 PTFE LINING POLYMER Q4 CURVE ID","SUP-ITM-10007676","CDM","C1887","HCPCS","0272","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","146.86","22.58","1753.45","65","48.83","125.21","percent of total billed charges",""
"CATHETER GUIDE 7FR 100CM 0.081IN FEMORAL MACH 1 PTFE LINING POLYMER Q4 CURVE ID","SUP-ITM-10007676","CDM","C1887","HCPCS","0272","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","247.29","33.09","909.09","53","48.83","125.21","percent of total billed charges",""
"CATHETER GUIDE 7FR 100CM 0.081IN FEMORAL MACH 1 PTFE LINING POLYMER Q4 CURVE ID","SUP-ITM-10007676","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","30.69","30.21","30.69","1 through 10","82.31","128.71","percent of total billed charges",""
"CATHETER GUIDE 7FR 100CM 0.081IN FEMORAL MACH 1 PTFE LINING POLYMER Q4 CURVE ID","SUP-ITM-10007676","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","82.69","82.69","82.69","1 through 10","82.31","128.71","percent of total billed charges",""
"CATHETER GUIDE 7FR 100CM 0.081IN FEMORAL MACH 1 PTFE LINING POLYMER Q4 CURVE ID","SUP-ITM-10007676","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.71","81.72","","751.01","74.72","751.01","1 through 10","82.31","128.71","percent of total billed charges",""
"CATHETER GUIDE 7FR 100CM 0.081IN FEMORAL MACH 1 PTFE LINING POLYMER Q4 CURVE ID","SUP-ITM-10007676","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","328.92","46.17","2701.97","59","82.31","128.71","percent of total billed charges",""
"CATHETER GUIDE 7FR 42CM 115DEG VASCULAR SELECTRA 3D-65-42","SUP-ITM-10289578","CDM","C1887","HCPCS","0272","RC","","","","both","","","717.50","538.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","515.17","71.8","","28.28","27.13","28.28","1 through 10","222.43","570.41","percent of total billed charges",""
"CATHETER GUIDE 7FR 42CM 115DEG VASCULAR SELECTRA 3D-65-42","SUP-ITM-10289578","CDM","C1887","HCPCS","0272","RC","","","","both","","","717.50","538.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","502.25","70","","44.63","35.78","44.63","1 through 10","222.43","570.41","percent of total billed charges",""
"CATHETER GUIDE 7FR 42CM 115DEG VASCULAR SELECTRA 3D-65-42","SUP-ITM-10289578","CDM","C1887","HCPCS","0272","RC","","","","both","","","717.50","538.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.41","79.5","","1342.89","271.64","6954.67","1 through 10","222.43","570.41","percent of total billed charges",""
"CATHETER GUIDE 7FR 42CM 115DEG VASCULAR SELECTRA 3D-65-42","SUP-ITM-10289578","CDM","C1887","HCPCS","0272","RC","","","","both","","","717.50","538.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","382.43","53.3","","4550.00","30.49","4550.00","1 through 10","222.43","570.41","percent of total billed charges",""
"CATHETER GUIDE 7FR 42CM 115DEG VASCULAR SELECTRA 3D-65-42","SUP-ITM-10289578","CDM","C1887","HCPCS","0272","RC","","","","both","","","717.50","538.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","466.38","65","","42.09","0.04","5453.50","1 through 10","222.43","570.41","percent of total billed charges",""
"CATHETER GUIDE 7FR 42CM 115DEG VASCULAR SELECTRA 3D-65-42","SUP-ITM-10289578","CDM","C1887","HCPCS","0272","RC","","","","both","","","717.50","538.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","261.89","36.5","","310.94","18.54","1259.30","62","222.43","570.41","percent of total billed charges",""
"CATHETER GUIDE 7FR 42CM 115DEG VASCULAR SELECTRA 3D-65-42","SUP-ITM-10289578","CDM","C1887","HCPCS","0272","RC","","","","both","","","717.50","538.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.80","38.3","","146.86","22.58","1753.45","65","222.43","570.41","percent of total billed charges",""
"CATHETER GUIDE 7FR 42CM 115DEG VASCULAR SELECTRA 3D-65-42","SUP-ITM-10289578","CDM","C1887","HCPCS","0272","RC","","","","both","","","717.50","538.12","WELLPOINT [1015]","HB AMC WELLPOINT","529.37","73.78","","247.29","33.09","909.09","53","222.43","570.41","percent of total billed charges",""
"CATHETER GUIDE 7FR 42CM 115DEG VASCULAR SELECTRA 3D-65-42","SUP-ITM-10289578","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","717.50","538.12","AETNA [1001]","HB AMC AETNA HMO","500.82","69.8","","30.69","30.21","30.69","1 through 10","374.97","586.34","percent of total billed charges",""
"CATHETER GUIDE 7FR 42CM 115DEG VASCULAR SELECTRA 3D-65-42","SUP-ITM-10289578","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","717.50","538.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","576.87","80.4","","82.69","82.69","82.69","1 through 10","374.97","586.34","percent of total billed charges",""
"CATHETER GUIDE 7FR 42CM 115DEG VASCULAR SELECTRA 3D-65-42","SUP-ITM-10289578","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","717.50","538.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","586.34","81.72","","751.01","74.72","751.01","1 through 10","374.97","586.34","percent of total billed charges",""
"CATHETER GUIDE 7FR 42CM 115DEG VASCULAR SELECTRA 3D-65-42","SUP-ITM-10289578","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","717.50","538.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","586.34","81.72","","328.92","46.17","2701.97","59","374.97","586.34","percent of total billed charges",""
"CATHETER GUIDE LG XLONG CPS LOCATOR CPS 3D CRM","SUP-ITM-10317790","CDM","C1887","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1256.50","71.8","","28.28","27.13","28.28","1 through 10","542.5","1391.25","percent of total billed charges",""
"CATHETER GUIDE LG XLONG CPS LOCATOR CPS 3D CRM","SUP-ITM-10317790","CDM","C1887","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1225.00","70","","44.63","35.78","44.63","1 through 10","542.5","1391.25","percent of total billed charges",""
"CATHETER GUIDE LG XLONG CPS LOCATOR CPS 3D CRM","SUP-ITM-10317790","CDM","C1887","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","1342.89","271.64","6954.67","1 through 10","542.5","1391.25","percent of total billed charges",""
"CATHETER GUIDE LG XLONG CPS LOCATOR CPS 3D CRM","SUP-ITM-10317790","CDM","C1887","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","4550.00","30.49","4550.00","1 through 10","542.5","1391.25","percent of total billed charges",""
"CATHETER GUIDE LG XLONG CPS LOCATOR CPS 3D CRM","SUP-ITM-10317790","CDM","C1887","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1137.50","65","","42.09","0.04","5453.50","1 through 10","542.5","1391.25","percent of total billed charges",""
"CATHETER GUIDE LG XLONG CPS LOCATOR CPS 3D CRM","SUP-ITM-10317790","CDM","C1887","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","310.94","18.54","1259.30","62","542.5","1391.25","percent of total billed charges",""
"CATHETER GUIDE LG XLONG CPS LOCATOR CPS 3D CRM","SUP-ITM-10317790","CDM","C1887","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","146.86","22.58","1753.45","65","542.5","1391.25","percent of total billed charges",""
"CATHETER GUIDE LG XLONG CPS LOCATOR CPS 3D CRM","SUP-ITM-10317790","CDM","C1887","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","247.29","33.09","909.09","53","542.5","1391.25","percent of total billed charges",""
"CATHETER GUIDE LG XLONG CPS LOCATOR CPS 3D CRM","SUP-ITM-10317790","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","30.69","30.21","30.69","1 through 10","914.55","1430.1","percent of total billed charges",""
"CATHETER GUIDE LG XLONG CPS LOCATOR CPS 3D CRM","SUP-ITM-10317790","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","82.69","82.69","82.69","1 through 10","914.55","1430.1","percent of total billed charges",""
"CATHETER GUIDE LG XLONG CPS LOCATOR CPS 3D CRM","SUP-ITM-10317790","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1430.10","81.72","","751.01","74.72","751.01","1 through 10","914.55","1430.1","percent of total billed charges",""
"CATHETER GUIDE LG XLONG CPS LOCATOR CPS 3D CRM","SUP-ITM-10317790","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","328.92","46.17","2701.97","59","914.55","1430.1","percent of total billed charges",""
"CATHETER GUIDING 7FRX100CM 2 SIDE HOLE LAUNCHER AMPLATZ LT CORONARY LA7AL20SH","SUP-ITM-10093165","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","100.52","71.8","","28.28","27.13","28.28","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDING 7FRX100CM 2 SIDE HOLE LAUNCHER AMPLATZ LT CORONARY LA7AL20SH","SUP-ITM-10093165","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","98.00","70","","44.63","35.78","44.63","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDING 7FRX100CM 2 SIDE HOLE LAUNCHER AMPLATZ LT CORONARY LA7AL20SH","SUP-ITM-10093165","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.30","79.5","","1342.89","271.64","6954.67","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDING 7FRX100CM 2 SIDE HOLE LAUNCHER AMPLATZ LT CORONARY LA7AL20SH","SUP-ITM-10093165","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.62","53.3","","4550.00","30.49","4550.00","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDING 7FRX100CM 2 SIDE HOLE LAUNCHER AMPLATZ LT CORONARY LA7AL20SH","SUP-ITM-10093165","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","91.00","65","","42.09","0.04","5453.50","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDING 7FRX100CM 2 SIDE HOLE LAUNCHER AMPLATZ LT CORONARY LA7AL20SH","SUP-ITM-10093165","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.10","36.5","","310.94","18.54","1259.30","62","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDING 7FRX100CM 2 SIDE HOLE LAUNCHER AMPLATZ LT CORONARY LA7AL20SH","SUP-ITM-10093165","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.62","38.3","","146.86","22.58","1753.45","65","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDING 7FRX100CM 2 SIDE HOLE LAUNCHER AMPLATZ LT CORONARY LA7AL20SH","SUP-ITM-10093165","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","WELLPOINT [1015]","HB AMC WELLPOINT","103.29","73.78","","247.29","33.09","909.09","53","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDING 7FRX100CM 2 SIDE HOLE LAUNCHER AMPLATZ LT CORONARY LA7AL20SH","SUP-ITM-10093165","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA HMO","97.72","69.8","","30.69","30.21","30.69","1 through 10","73.16","114.41","percent of total billed charges",""
"CATHETER GUIDING 7FRX100CM 2 SIDE HOLE LAUNCHER AMPLATZ LT CORONARY LA7AL20SH","SUP-ITM-10093165","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.56","80.4","","82.69","82.69","82.69","1 through 10","73.16","114.41","percent of total billed charges",""
"CATHETER GUIDING 7FRX100CM 2 SIDE HOLE LAUNCHER AMPLATZ LT CORONARY LA7AL20SH","SUP-ITM-10093165","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.41","81.72","","751.01","74.72","751.01","1 through 10","73.16","114.41","percent of total billed charges",""
"CATHETER GUIDING 7FRX100CM 2 SIDE HOLE LAUNCHER AMPLATZ LT CORONARY LA7AL20SH","SUP-ITM-10093165","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.41","81.72","","328.92","46.17","2701.97","59","73.16","114.41","percent of total billed charges",""
"CATHETER GUIDING 7FRX55CM 0.078IN VASCULAR MULTIPURPOSE AMPLATZ 1 PERIPH W/OUT HYDROPHILIC COATED RADIOPAQUE","SUP-ITM-10008505","CDM","C1887","HCPCS","0272","RC","","","","both","","","324.87","243.65","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","233.26","71.8","","28.28","27.13","28.28","1 through 10","100.71","258.27","percent of total billed charges",""
"CATHETER GUIDING 7FRX55CM 0.078IN VASCULAR MULTIPURPOSE AMPLATZ 1 PERIPH W/OUT HYDROPHILIC COATED RADIOPAQUE","SUP-ITM-10008505","CDM","C1887","HCPCS","0272","RC","","","","both","","","324.87","243.65","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","227.41","70","","44.63","35.78","44.63","1 through 10","100.71","258.27","percent of total billed charges",""
"CATHETER GUIDING 7FRX55CM 0.078IN VASCULAR MULTIPURPOSE AMPLATZ 1 PERIPH W/OUT HYDROPHILIC COATED RADIOPAQUE","SUP-ITM-10008505","CDM","C1887","HCPCS","0272","RC","","","","both","","","324.87","243.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.27","79.5","","1342.89","271.64","6954.67","1 through 10","100.71","258.27","percent of total billed charges",""
"CATHETER GUIDING 7FRX55CM 0.078IN VASCULAR MULTIPURPOSE AMPLATZ 1 PERIPH W/OUT HYDROPHILIC COATED RADIOPAQUE","SUP-ITM-10008505","CDM","C1887","HCPCS","0272","RC","","","","both","","","324.87","243.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.16","53.3","","4550.00","30.49","4550.00","1 through 10","100.71","258.27","percent of total billed charges",""
"CATHETER GUIDING 7FRX55CM 0.078IN VASCULAR MULTIPURPOSE AMPLATZ 1 PERIPH W/OUT HYDROPHILIC COATED RADIOPAQUE","SUP-ITM-10008505","CDM","C1887","HCPCS","0272","RC","","","","both","","","324.87","243.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","211.17","65","","42.09","0.04","5453.50","1 through 10","100.71","258.27","percent of total billed charges",""
"CATHETER GUIDING 7FRX55CM 0.078IN VASCULAR MULTIPURPOSE AMPLATZ 1 PERIPH W/OUT HYDROPHILIC COATED RADIOPAQUE","SUP-ITM-10008505","CDM","C1887","HCPCS","0272","RC","","","","both","","","324.87","243.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.58","36.5","","310.94","18.54","1259.30","62","100.71","258.27","percent of total billed charges",""
"CATHETER GUIDING 7FRX55CM 0.078IN VASCULAR MULTIPURPOSE AMPLATZ 1 PERIPH W/OUT HYDROPHILIC COATED RADIOPAQUE","SUP-ITM-10008505","CDM","C1887","HCPCS","0272","RC","","","","both","","","324.87","243.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.43","38.3","","146.86","22.58","1753.45","65","100.71","258.27","percent of total billed charges",""
"CATHETER GUIDING 7FRX55CM 0.078IN VASCULAR MULTIPURPOSE AMPLATZ 1 PERIPH W/OUT HYDROPHILIC COATED RADIOPAQUE","SUP-ITM-10008505","CDM","C1887","HCPCS","0272","RC","","","","both","","","324.87","243.65","WELLPOINT [1015]","HB AMC WELLPOINT","239.69","73.78","","247.29","33.09","909.09","53","100.71","258.27","percent of total billed charges",""
"CATHETER GUIDING 7FRX55CM 0.078IN VASCULAR MULTIPURPOSE AMPLATZ 1 PERIPH W/OUT HYDROPHILIC COATED RADIOPAQUE","SUP-ITM-10008505","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","324.87","243.65","AETNA [1001]","HB AMC AETNA HMO","226.76","69.8","","30.69","30.21","30.69","1 through 10","169.78","265.48","percent of total billed charges",""
"CATHETER GUIDING 7FRX55CM 0.078IN VASCULAR MULTIPURPOSE AMPLATZ 1 PERIPH W/OUT HYDROPHILIC COATED RADIOPAQUE","SUP-ITM-10008505","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","324.87","243.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","261.20","80.4","","82.69","82.69","82.69","1 through 10","169.78","265.48","percent of total billed charges",""
"CATHETER GUIDING 7FRX55CM 0.078IN VASCULAR MULTIPURPOSE AMPLATZ 1 PERIPH W/OUT HYDROPHILIC COATED RADIOPAQUE","SUP-ITM-10008505","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","324.87","243.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","265.48","81.72","","751.01","74.72","751.01","1 through 10","169.78","265.48","percent of total billed charges",""
"CATHETER GUIDING 7FRX55CM 0.078IN VASCULAR MULTIPURPOSE AMPLATZ 1 PERIPH W/OUT HYDROPHILIC COATED RADIOPAQUE","SUP-ITM-10008505","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","324.87","243.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","265.48","81.72","","328.92","46.17","2701.97","59","169.78","265.48","percent of total billed charges",""
"CATHETER GUIDING CELLO 8FR 3MM 10MM 95CM .102IN DUAL LUMEN POLYURETHANE S/S BRAIDED SILICONE BALLOON MOUNTED","SUP-ITM-10115271","CDM","C1887","HCPCS","0272","RC","","","","both","","","4860.00","3645.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3489.48","71.8","","28.28","27.13","28.28","1 through 10","1506.6","3863.7","percent of total billed charges",""
"CATHETER GUIDING CELLO 8FR 3MM 10MM 95CM .102IN DUAL LUMEN POLYURETHANE S/S BRAIDED SILICONE BALLOON MOUNTED","SUP-ITM-10115271","CDM","C1887","HCPCS","0272","RC","","","","both","","","4860.00","3645.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3402.00","70","","44.63","35.78","44.63","1 through 10","1506.6","3863.7","percent of total billed charges",""
"CATHETER GUIDING CELLO 8FR 3MM 10MM 95CM .102IN DUAL LUMEN POLYURETHANE S/S BRAIDED SILICONE BALLOON MOUNTED","SUP-ITM-10115271","CDM","C1887","HCPCS","0272","RC","","","","both","","","4860.00","3645.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3863.70","79.5","","1342.89","271.64","6954.67","1 through 10","1506.6","3863.7","percent of total billed charges",""
"CATHETER GUIDING CELLO 8FR 3MM 10MM 95CM .102IN DUAL LUMEN POLYURETHANE S/S BRAIDED SILICONE BALLOON MOUNTED","SUP-ITM-10115271","CDM","C1887","HCPCS","0272","RC","","","","both","","","4860.00","3645.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2590.38","53.3","","4550.00","30.49","4550.00","1 through 10","1506.6","3863.7","percent of total billed charges",""
"CATHETER GUIDING CELLO 8FR 3MM 10MM 95CM .102IN DUAL LUMEN POLYURETHANE S/S BRAIDED SILICONE BALLOON MOUNTED","SUP-ITM-10115271","CDM","C1887","HCPCS","0272","RC","","","","both","","","4860.00","3645.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3159.00","65","","42.09","0.04","5453.50","1 through 10","1506.6","3863.7","percent of total billed charges",""
"CATHETER GUIDING CELLO 8FR 3MM 10MM 95CM .102IN DUAL LUMEN POLYURETHANE S/S BRAIDED SILICONE BALLOON MOUNTED","SUP-ITM-10115271","CDM","C1887","HCPCS","0272","RC","","","","both","","","4860.00","3645.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1773.90","36.5","","310.94","18.54","1259.30","62","1506.6","3863.7","percent of total billed charges",""
"CATHETER GUIDING CELLO 8FR 3MM 10MM 95CM .102IN DUAL LUMEN POLYURETHANE S/S BRAIDED SILICONE BALLOON MOUNTED","SUP-ITM-10115271","CDM","C1887","HCPCS","0272","RC","","","","both","","","4860.00","3645.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1861.38","38.3","","146.86","22.58","1753.45","65","1506.6","3863.7","percent of total billed charges",""
"CATHETER GUIDING CELLO 8FR 3MM 10MM 95CM .102IN DUAL LUMEN POLYURETHANE S/S BRAIDED SILICONE BALLOON MOUNTED","SUP-ITM-10115271","CDM","C1887","HCPCS","0272","RC","","","","both","","","4860.00","3645.00","WELLPOINT [1015]","HB AMC WELLPOINT","3585.71","73.78","","247.29","33.09","909.09","53","1506.6","3863.7","percent of total billed charges",""
"CATHETER GUIDING CELLO 8FR 3MM 10MM 95CM .102IN DUAL LUMEN POLYURETHANE S/S BRAIDED SILICONE BALLOON MOUNTED","SUP-ITM-10115271","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4860.00","3645.00","AETNA [1001]","HB AMC AETNA HMO","3392.28","69.8","","30.69","30.21","30.69","1 through 10","2539.84","3971.59","percent of total billed charges",""
"CATHETER GUIDING CELLO 8FR 3MM 10MM 95CM .102IN DUAL LUMEN POLYURETHANE S/S BRAIDED SILICONE BALLOON MOUNTED","SUP-ITM-10115271","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4860.00","3645.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3907.44","80.4","","82.69","82.69","82.69","1 through 10","2539.84","3971.59","percent of total billed charges",""
"CATHETER GUIDING CELLO 8FR 3MM 10MM 95CM .102IN DUAL LUMEN POLYURETHANE S/S BRAIDED SILICONE BALLOON MOUNTED","SUP-ITM-10115271","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4860.00","3645.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3971.59","81.72","","751.01","74.72","751.01","1 through 10","2539.84","3971.59","percent of total billed charges",""
"CATHETER GUIDING CELLO 8FR 3MM 10MM 95CM .102IN DUAL LUMEN POLYURETHANE S/S BRAIDED SILICONE BALLOON MOUNTED","SUP-ITM-10115271","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4860.00","3645.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3971.59","81.72","","328.92","46.17","2701.97","59","2539.84","3971.59","percent of total billed charges",""
"CATHETER GUIDINGFR 3.6X100CM 3.5 SIDE HOLE LAUNCHER CORONARY","SUP-ITM-10092931","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","100.52","71.8","","28.28","27.13","28.28","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDINGFR 3.6X100CM 3.5 SIDE HOLE LAUNCHER CORONARY","SUP-ITM-10092931","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","98.00","70","","44.63","35.78","44.63","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDINGFR 3.6X100CM 3.5 SIDE HOLE LAUNCHER CORONARY","SUP-ITM-10092931","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.30","79.5","","1342.89","271.64","6954.67","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDINGFR 3.6X100CM 3.5 SIDE HOLE LAUNCHER CORONARY","SUP-ITM-10092931","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.62","53.3","","4550.00","30.49","4550.00","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDINGFR 3.6X100CM 3.5 SIDE HOLE LAUNCHER CORONARY","SUP-ITM-10092931","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","91.00","65","","42.09","0.04","5453.50","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDINGFR 3.6X100CM 3.5 SIDE HOLE LAUNCHER CORONARY","SUP-ITM-10092931","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.10","36.5","","310.94","18.54","1259.30","62","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDINGFR 3.6X100CM 3.5 SIDE HOLE LAUNCHER CORONARY","SUP-ITM-10092931","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.62","38.3","","146.86","22.58","1753.45","65","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDINGFR 3.6X100CM 3.5 SIDE HOLE LAUNCHER CORONARY","SUP-ITM-10092931","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","WELLPOINT [1015]","HB AMC WELLPOINT","103.29","73.78","","247.29","33.09","909.09","53","43.4","111.3","percent of total billed charges",""
"CATHETER GUIDINGFR 3.6X100CM 3.5 SIDE HOLE LAUNCHER CORONARY","SUP-ITM-10092931","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA HMO","97.72","69.8","","30.69","30.21","30.69","1 through 10","73.16","114.41","percent of total billed charges",""
"CATHETER GUIDINGFR 3.6X100CM 3.5 SIDE HOLE LAUNCHER CORONARY","SUP-ITM-10092931","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.56","80.4","","82.69","82.69","82.69","1 through 10","73.16","114.41","percent of total billed charges",""
"CATHETER GUIDINGFR 3.6X100CM 3.5 SIDE HOLE LAUNCHER CORONARY","SUP-ITM-10092931","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.41","81.72","","751.01","74.72","751.01","1 through 10","73.16","114.41","percent of total billed charges",""
"CATHETER GUIDINGFR 3.6X100CM 3.5 SIDE HOLE LAUNCHER CORONARY","SUP-ITM-10092931","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.41","81.72","","328.92","46.17","2701.97","59","73.16","114.41","percent of total billed charges",""
"CATHETER HABIB 8FR 180CM ENDOHPB BIPOLAR RF BX/1EA","SUP-ITM-10146438","CDM","C1886","HCPCS","0272","RC","","","","both","","","4928.55","3696.41","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3538.70","71.8","","4399.55","4399.55","4399.55","1 through 10","1527.85","3918.2","percent of total billed charges",""
"CATHETER HABIB 8FR 180CM ENDOHPB BIPOLAR RF BX/1EA","SUP-ITM-10146438","CDM","C1886","HCPCS","0272","RC","","","","both","","","4928.55","3696.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1798.92","36.5","","1413.19","621.27","1413.19","1 through 10","1527.85","3918.2","percent of total billed charges",""
"CATHETER HABIB 8FR 180CM ENDOHPB BIPOLAR RF BX/1EA","SUP-ITM-10146438","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","4928.55","3696.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4027.61","81.72","","8168.27","2209.17","8168.27","1 through 10","2575.66","4027.61","percent of total billed charges",""
"CATHETER HEMODIALYSIS 14.5FR 23CM ADMINISTRATION BASIC KIT DOUBLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE HEMO-SPLIT CS/5EA","SUP-ITM-10328500","CDM","C1750","HCPCS","0278","RC","","","","both","","","1041.60","781.20","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","544.34","52.26","","154.36","154.36","154.36","1 through 10","322.9","828.07","percent of total billed charges",""
"CATHETER HEMODIALYSIS 14.5FR 23CM ADMINISTRATION BASIC KIT DOUBLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE HEMO-SPLIT CS/5EA","SUP-ITM-10328500","CDM","C1750","HCPCS","0278","RC","","","","both","","","1041.60","781.20","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","677.04","65","","1371.74","196.32","1371.74","1 through 10","322.9","828.07","percent of total billed charges",""
"CATHETER HEMODIALYSIS 14.5FR 23CM ADMINISTRATION BASIC KIT DOUBLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE HEMO-SPLIT CS/5EA","SUP-ITM-10328500","CDM","C1750","HCPCS","0278","RC","","","","both","","","1041.60","781.20","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","729.12","70","","249.45","107.26","1254.96","14","322.9","828.07","percent of total billed charges",""
"CATHETER HEMODIALYSIS 14.5FR 23CM ADMINISTRATION BASIC KIT DOUBLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE HEMO-SPLIT CS/5EA","SUP-ITM-10328500","CDM","C1750","HCPCS","0278","RC","","","","both","","","1041.60","781.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","828.07","79.5","","196.32","85.01","196.32","1 through 10","322.9","828.07","percent of total billed charges",""
"CATHETER HEMODIALYSIS 14.5FR 23CM ADMINISTRATION BASIC KIT DOUBLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE HEMO-SPLIT CS/5EA","SUP-ITM-10328500","CDM","C1750","HCPCS","0278","RC","","","","both","","","1041.60","781.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","555.17","53.3","","1132.95","1132.95","1132.95","1 through 10","322.9","828.07","percent of total billed charges",""
"CATHETER HEMODIALYSIS 14.5FR 23CM ADMINISTRATION BASIC KIT DOUBLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE HEMO-SPLIT CS/5EA","SUP-ITM-10328500","CDM","C1750","HCPCS","0278","RC","","","","both","","","1041.60","781.20","WELLPOINT [1015]","HB AMC WELLPOINT","768.49","73.78","","1297.66","185.72","1297.66","1 through 10","322.9","828.07","percent of total billed charges",""
"CATHETER HEMODIALYSIS 14.5FR 23CM ADMINISTRATION BASIC KIT DOUBLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE HEMO-SPLIT CS/5EA","SUP-ITM-10328500","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1041.60","781.20","AETNA [1001]","HB AMC AETNA HMO","727.04","69.8","","76.96","76.96","76.96","1 through 10","544.34","851.2","percent of total billed charges",""
"CATHETER HEMODIALYSIS 14.5FR 23CM ADMINISTRATION BASIC KIT DOUBLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE HEMO-SPLIT CS/5EA","SUP-ITM-10328500","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1041.60","781.20","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","544.34","52.26","","154.36","154.36","154.36","1 through 10","544.34","851.2","percent of total billed charges",""
"CATHETER HEMODIALYSIS 14.5FR 23CM ADMINISTRATION BASIC KIT DOUBLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE HEMO-SPLIT CS/5EA","SUP-ITM-10328500","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1041.60","781.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","851.20","81.72","","199.41","199.41","199.41","1 through 10","544.34","851.2","percent of total billed charges",""
"CATHETER HEMODIALYSIS 23CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078317","CDM","C1750","HCPCS","0278","RC","","","","both","","","1176.00","882.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","614.58","52.26","","154.36","154.36","154.36","1 through 10","364.56","934.92","percent of total billed charges",""
"CATHETER HEMODIALYSIS 23CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078317","CDM","C1750","HCPCS","0278","RC","","","","both","","","1176.00","882.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","764.40","65","","1371.74","196.32","1371.74","1 through 10","364.56","934.92","percent of total billed charges",""
"CATHETER HEMODIALYSIS 23CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078317","CDM","C1750","HCPCS","0278","RC","","","","both","","","1176.00","882.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","823.20","70","","249.45","107.26","1254.96","14","364.56","934.92","percent of total billed charges",""
"CATHETER HEMODIALYSIS 23CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078317","CDM","C1750","HCPCS","0278","RC","","","","both","","","1176.00","882.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","934.92","79.5","","196.32","85.01","196.32","1 through 10","364.56","934.92","percent of total billed charges",""
"CATHETER HEMODIALYSIS 23CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078317","CDM","C1750","HCPCS","0278","RC","","","","both","","","1176.00","882.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","626.81","53.3","","1132.95","1132.95","1132.95","1 through 10","364.56","934.92","percent of total billed charges",""
"CATHETER HEMODIALYSIS 23CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078317","CDM","C1750","HCPCS","0278","RC","","","","both","","","1176.00","882.00","WELLPOINT [1015]","HB AMC WELLPOINT","867.65","73.78","","1297.66","185.72","1297.66","1 through 10","364.56","934.92","percent of total billed charges",""
"CATHETER HEMODIALYSIS 23CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078317","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1176.00","882.00","AETNA [1001]","HB AMC AETNA HMO","820.85","69.8","","76.96","76.96","76.96","1 through 10","614.58","961.03","percent of total billed charges",""
"CATHETER HEMODIALYSIS 23CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078317","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1176.00","882.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","614.58","52.26","","154.36","154.36","154.36","1 through 10","614.58","961.03","percent of total billed charges",""
"CATHETER HEMODIALYSIS 23CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078317","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1176.00","882.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","961.03","81.72","","199.41","199.41","199.41","1 through 10","614.58","961.03","percent of total billed charges",""
"CATHETER HEMODIALYSIS 42CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078316","CDM","C1750","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2633.90","52.26","","154.36","154.36","154.36","1 through 10","1562.4","4006.8","percent of total billed charges",""
"CATHETER HEMODIALYSIS 42CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078316","CDM","C1750","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3276.00","65","","1371.74","196.32","1371.74","1 through 10","1562.4","4006.8","percent of total billed charges",""
"CATHETER HEMODIALYSIS 42CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078316","CDM","C1750","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3528.00","70","","249.45","107.26","1254.96","14","1562.4","4006.8","percent of total billed charges",""
"CATHETER HEMODIALYSIS 42CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078316","CDM","C1750","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4006.80","79.5","","196.32","85.01","196.32","1 through 10","1562.4","4006.8","percent of total billed charges",""
"CATHETER HEMODIALYSIS 42CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078316","CDM","C1750","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2686.32","53.3","","1132.95","1132.95","1132.95","1 through 10","1562.4","4006.8","percent of total billed charges",""
"CATHETER HEMODIALYSIS 42CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078316","CDM","C1750","HCPCS","0278","RC","","","","both","","","5040.00","3780.00","WELLPOINT [1015]","HB AMC WELLPOINT","3718.51","73.78","","1297.66","185.72","1297.66","1 through 10","1562.4","4006.8","percent of total billed charges",""
"CATHETER HEMODIALYSIS 42CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078316","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","5040.00","3780.00","AETNA [1001]","HB AMC AETNA HMO","3517.92","69.8","","76.96","76.96","76.96","1 through 10","2633.9","4118.69","percent of total billed charges",""
"CATHETER HEMODIALYSIS 42CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078316","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","5040.00","3780.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2633.90","52.26","","154.36","154.36","154.36","1 through 10","2633.9","4118.69","percent of total billed charges",""
"CATHETER HEMODIALYSIS 42CM 14.5FR ADMINISTRATION BASIC KIT SINGLE LUMEN POLYURETHANE STRAIGHT SPLIT TIP CUFFED NON COATED CHRONIC ADULT HIGH-FLOW SIDEHOLE EQUISTREAM CS/5EA","SUP-ITM-10078316","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","5040.00","3780.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4118.69","81.72","","199.41","199.41","199.41","1 through 10","2633.9","4118.69","percent of total billed charges",""
"CATHETER HICKMAN 12FR 90CM 1.8ML RED 1.8ML WHITE CENTRAL VENOUS DUAL LUMEN SURECUFF PEEL APART PERCUTANEOUS INTRODUCER BX/1EA","SUP-ITM-10003659","CDM","C1751","HCPCS","0272","RC","","","","both","","","483.00","362.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","338.10","70","","1389.50","602.17","3167.85","27","149.73","383.99","percent of total billed charges",""
"CATHETER HICKMAN 12FR 90CM 1.8ML RED 1.8ML WHITE CENTRAL VENOUS DUAL LUMEN SURECUFF PEEL APART PERCUTANEOUS INTRODUCER BX/1EA","SUP-ITM-10003659","CDM","C1751","HCPCS","0272","RC","","","","both","","","483.00","362.25","WELLPOINT [1015]","HB AMC WELLPOINT","356.36","73.78","","1089.20","218.86","1089.20","1 through 10","149.73","383.99","percent of total billed charges",""
"CATHETER HICKMAN 12FR 90CM 1.8ML RED 1.8ML WHITE CENTRAL VENOUS DUAL LUMEN SURECUFF PEEL APART PERCUTANEOUS INTRODUCER BX/1EA","SUP-ITM-10003659","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","483.00","362.25","AETNA [1001]","HB AMC AETNA HMO","337.13","69.8","","1389.50","940.69","1389.50","1 through 10","252.42","394.71","percent of total billed charges",""
"CATHETER HICKMAN 12FR 90CM 1.8ML RED 1.8ML WHITE CENTRAL VENOUS DUAL LUMEN SURECUFF PEEL APART PERCUTANEOUS INTRODUCER BX/1EA","SUP-ITM-10003659","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","483.00","362.25","AETNA [1001]","HB AMC AETNA PPO","388.33","80.4","","190.26","190.26","190.26","1 through 10","252.42","394.71","percent of total billed charges",""
"CATHETER HICKMAN 12FR 90CM 1.8ML RED 1.8ML WHITE CENTRAL VENOUS DUAL LUMEN SURECUFF PEEL APART PERCUTANEOUS INTRODUCER BX/1EA","SUP-ITM-10003659","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","483.00","362.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","394.71","81.72","","1110.77","235.00","1169.52","1 through 10","252.42","394.71","percent of total billed charges",""
"CATHETER HICKMAN TRIFUSION 12FR 23CM CENTRAL VENOUS STRAIGHT INTERMEDIATE - ACCESS DIV.","SUP-ITM-10018266","CDM","C1751","HCPCS","0272","RC","","","","both","","","1389.50","1042.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","972.65","70","","1389.50","602.17","3167.85","27","430.75","1104.65","percent of total billed charges",""
"CATHETER HICKMAN TRIFUSION 12FR 23CM CENTRAL VENOUS STRAIGHT INTERMEDIATE - ACCESS DIV.","SUP-ITM-10018266","CDM","C1751","HCPCS","0272","RC","","","","both","","","1389.50","1042.12","WELLPOINT [1015]","HB AMC WELLPOINT","1025.17","73.78","","1089.20","218.86","1089.20","1 through 10","430.75","1104.65","percent of total billed charges",""
"CATHETER HICKMAN TRIFUSION 12FR 23CM CENTRAL VENOUS STRAIGHT INTERMEDIATE - ACCESS DIV.","SUP-ITM-10018266","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","1389.50","1042.12","AETNA [1001]","HB AMC AETNA HMO","969.87","69.8","","1389.50","940.69","1389.50","1 through 10","726.15","1135.5","percent of total billed charges",""
"CATHETER HICKMAN TRIFUSION 12FR 23CM CENTRAL VENOUS STRAIGHT INTERMEDIATE - ACCESS DIV.","SUP-ITM-10018266","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","1389.50","1042.12","AETNA [1001]","HB AMC AETNA PPO","1117.16","80.4","","190.26","190.26","190.26","1 through 10","726.15","1135.5","percent of total billed charges",""
"CATHETER HICKMAN TRIFUSION 12FR 23CM CENTRAL VENOUS STRAIGHT INTERMEDIATE - ACCESS DIV.","SUP-ITM-10018266","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","1389.50","1042.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1135.50","81.72","","1110.77","235.00","1169.52","1 through 10","726.15","1135.5","percent of total billed charges",""
"CATHETER HOLTER SS BARIUM STRAIGHT SILICONE CEREBRAL RESERVOIR VENTRICULAR","SUP-ITM-10000084","CDM","C1889","HCPCS","0278","RC","","","","both","","","312.48","234.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","248.42","79.5","","1309.77","674.56","6049.93","26","96.87","248.42","percent of total billed charges",""
"CATHETER HOLTER SS BARIUM STRAIGHT SILICONE CEREBRAL RESERVOIR VENTRICULAR","SUP-ITM-10000084","CDM","C1889","HCPCS","0278","RC","","","","both","","","312.48","234.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","166.55","53.3","","1901.83","1901.83","2962.25","1 through 10","96.87","248.42","percent of total billed charges",""
"CATHETER HOLTER SS BARIUM STRAIGHT SILICONE CEREBRAL RESERVOIR VENTRICULAR","SUP-ITM-10000084","CDM","C1889","HCPCS","0278","RC","","","","both","","","312.48","234.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.06","36.5","","1620.31","1620.31","19908.88","1 through 10","96.87","248.42","percent of total billed charges",""
"CATHETER HOLTER SS BARIUM STRAIGHT SILICONE CEREBRAL RESERVOIR VENTRICULAR","SUP-ITM-10000084","CDM","C1889","HCPCS","0278","RC","","","","both","","","312.48","234.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.68","38.3","","352.91","352.91","2046.30","1 through 10","96.87","248.42","percent of total billed charges",""
"CATHETER HOLTER SS BARIUM STRAIGHT SILICONE CEREBRAL RESERVOIR VENTRICULAR","SUP-ITM-10000084","CDM","C1889","HCPCS","0278","RC","","","","both","","","312.48","234.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.05","42.9","","9668.75","9668.75","9668.75","1 through 10","96.87","248.42","percent of total billed charges",""
"CATHETER HOLTER SS BARIUM STRAIGHT SILICONE CEREBRAL RESERVOIR VENTRICULAR","SUP-ITM-10000084","CDM","C1889","HCPCS","0278","RC","","","","both","","","312.48","234.36","WELLPOINT [1015]","HB AMC WELLPOINT","230.55","73.78","","699.88","384.10","3443.31","33","96.87","248.42","percent of total billed charges",""
"CATHETER HOLTER SS BARIUM STRAIGHT SILICONE CEREBRAL RESERVOIR VENTRICULAR","SUP-ITM-10000084","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","312.48","234.36","AETNA [1001]","HB AMC AETNA HMO","218.11","69.8","","1421.24","264.50","4933.46","29","163.3","255.36","percent of total billed charges",""
"CATHETER HOLTER SS BARIUM STRAIGHT SILICONE CEREBRAL RESERVOIR VENTRICULAR","SUP-ITM-10000084","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","312.48","234.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","251.23","80.4","","1022.97","1022.97","3607.50","1 through 10","163.3","255.36","percent of total billed charges",""
"CATHETER HOLTER SS BARIUM STRAIGHT SILICONE CEREBRAL RESERVOIR VENTRICULAR","SUP-ITM-10000084","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","312.48","234.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","255.36","81.72","","3010.54","693.88","5019.88","35","163.3","255.36","percent of total billed charges",""
"CATHETER HOLTER VENTRICULAR DRAINAGE MARKING","SUP-ITM-10076809","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.00","777.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","823.62","79.5","","1309.77","674.56","6049.93","26","321.16","823.62","percent of total billed charges",""
"CATHETER HOLTER VENTRICULAR DRAINAGE MARKING","SUP-ITM-10076809","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.00","777.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","552.19","53.3","","1901.83","1901.83","2962.25","1 through 10","321.16","823.62","percent of total billed charges",""
"CATHETER HOLTER VENTRICULAR DRAINAGE MARKING","SUP-ITM-10076809","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.00","777.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","378.14","36.5","","1620.31","1620.31","19908.88","1 through 10","321.16","823.62","percent of total billed charges",""
"CATHETER HOLTER VENTRICULAR DRAINAGE MARKING","SUP-ITM-10076809","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.00","777.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","396.79","38.3","","352.91","352.91","2046.30","1 through 10","321.16","823.62","percent of total billed charges",""
"CATHETER HOLTER VENTRICULAR DRAINAGE MARKING","SUP-ITM-10076809","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.00","777.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","444.44","42.9","","9668.75","9668.75","9668.75","1 through 10","321.16","823.62","percent of total billed charges",""
"CATHETER HOLTER VENTRICULAR DRAINAGE MARKING","SUP-ITM-10076809","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.00","777.00","WELLPOINT [1015]","HB AMC WELLPOINT","764.36","73.78","","699.88","384.10","3443.31","33","321.16","823.62","percent of total billed charges",""
"CATHETER HOLTER VENTRICULAR DRAINAGE MARKING","SUP-ITM-10076809","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.00","777.00","AETNA [1001]","HB AMC AETNA HMO","723.13","69.8","","1421.24","264.50","4933.46","29","541.41","846.62","percent of total billed charges",""
"CATHETER HOLTER VENTRICULAR DRAINAGE MARKING","SUP-ITM-10076809","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.00","777.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","832.94","80.4","","1022.97","1022.97","3607.50","1 through 10","541.41","846.62","percent of total billed charges",""
"CATHETER HOLTER VENTRICULAR DRAINAGE MARKING","SUP-ITM-10076809","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.00","777.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","846.62","81.72","","3010.54","693.88","5019.88","35","541.41","846.62","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","863.10","647.32","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","604.17","70","","863.10","863.10","863.10","1 through 10","267.56","686.16","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","863.10","647.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","686.16","79.5","","447.66","447.66","447.66","1 through 10","267.56","686.16","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","863.10","647.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","561.02","65","","1020.11","1020.11","1020.11","1 through 10","267.56","686.16","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","863.10","647.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","267.56","31","","208.83","208.83","208.83","1 through 10","267.56","686.16","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","863.10","647.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","315.03","36.5","","312.44","214.23","1086.03","20","267.56","686.16","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","863.10","647.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","330.57","38.3","","264.25","227.63","567.11","31","267.56","686.16","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","863.10","647.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","370.27","42.9","","79.94","79.94","79.94","1 through 10","267.56","686.16","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","863.10","647.32","WELLPOINT [1015]","HB AMC WELLPOINT","636.80","73.78","","174.45","74.45","1168.42","1 through 10","267.56","686.16","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","863.10","647.32","AETNA [1001]","HB AMC AETNA HMO","602.44","69.8","","655.01","135.40","784.73","1 through 10","451.06","705.33","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","863.10","647.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","705.33","81.72","","540.25","46.28","897.42","36","451.06","705.33","percent of total billed charges",""
"CATHETER IMAGERII 5FR 65CM .038IN SIM1 BRAIDED TORQUE CEREBRAL BX/5EA","SUP-ITM-10012643","CDM","C1887","HCPCS","0272","RC","","","","both","","","46.90","35.17","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","33.67","71.8","","28.28","27.13","28.28","1 through 10","14.54","37.29","percent of total billed charges",""
"CATHETER IMAGERII 5FR 65CM .038IN SIM1 BRAIDED TORQUE CEREBRAL BX/5EA","SUP-ITM-10012643","CDM","C1887","HCPCS","0272","RC","","","","both","","","46.90","35.17","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","32.83","70","","44.63","35.78","44.63","1 through 10","14.54","37.29","percent of total billed charges",""
"CATHETER IMAGERII 5FR 65CM .038IN SIM1 BRAIDED TORQUE CEREBRAL BX/5EA","SUP-ITM-10012643","CDM","C1887","HCPCS","0272","RC","","","","both","","","46.90","35.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","37.29","79.5","","1342.89","271.64","6954.67","1 through 10","14.54","37.29","percent of total billed charges",""
"CATHETER IMAGERII 5FR 65CM .038IN SIM1 BRAIDED TORQUE CEREBRAL BX/5EA","SUP-ITM-10012643","CDM","C1887","HCPCS","0272","RC","","","","both","","","46.90","35.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","25.00","53.3","","4550.00","30.49","4550.00","1 through 10","14.54","37.29","percent of total billed charges",""
"CATHETER IMAGERII 5FR 65CM .038IN SIM1 BRAIDED TORQUE CEREBRAL BX/5EA","SUP-ITM-10012643","CDM","C1887","HCPCS","0272","RC","","","","both","","","46.90","35.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","30.49","65","","42.09","0.04","5453.50","1 through 10","14.54","37.29","percent of total billed charges",""
"CATHETER IMAGERII 5FR 65CM .038IN SIM1 BRAIDED TORQUE CEREBRAL BX/5EA","SUP-ITM-10012643","CDM","C1887","HCPCS","0272","RC","","","","both","","","46.90","35.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17.12","36.5","","310.94","18.54","1259.30","62","14.54","37.29","percent of total billed charges",""
"CATHETER IMAGERII 5FR 65CM .038IN SIM1 BRAIDED TORQUE CEREBRAL BX/5EA","SUP-ITM-10012643","CDM","C1887","HCPCS","0272","RC","","","","both","","","46.90","35.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17.96","38.3","","146.86","22.58","1753.45","65","14.54","37.29","percent of total billed charges",""
"CATHETER IMAGERII 5FR 65CM .038IN SIM1 BRAIDED TORQUE CEREBRAL BX/5EA","SUP-ITM-10012643","CDM","C1887","HCPCS","0272","RC","","","","both","","","46.90","35.17","WELLPOINT [1015]","HB AMC WELLPOINT","34.60","73.78","","247.29","33.09","909.09","53","14.54","37.29","percent of total billed charges",""
"CATHETER IMAGERII 5FR 65CM .038IN SIM1 BRAIDED TORQUE CEREBRAL BX/5EA","SUP-ITM-10012643","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","46.90","35.17","AETNA [1001]","HB AMC AETNA HMO","32.74","69.8","","30.69","30.21","30.69","1 through 10","24.51","38.33","percent of total billed charges",""
"CATHETER IMAGERII 5FR 65CM .038IN SIM1 BRAIDED TORQUE CEREBRAL BX/5EA","SUP-ITM-10012643","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","46.90","35.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","37.71","80.4","","82.69","82.69","82.69","1 through 10","24.51","38.33","percent of total billed charges",""
"CATHETER IMAGERII 5FR 65CM .038IN SIM1 BRAIDED TORQUE CEREBRAL BX/5EA","SUP-ITM-10012643","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","46.90","35.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","38.33","81.72","","751.01","74.72","751.01","1 through 10","24.51","38.33","percent of total billed charges",""
"CATHETER IMAGERII 5FR 65CM .038IN SIM1 BRAIDED TORQUE CEREBRAL BX/5EA","SUP-ITM-10012643","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","46.90","35.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","38.33","81.72","","328.92","46.17","2701.97","59","24.51","38.33","percent of total billed charges",""
"CATHETER IMPULSE 6FR 100CM .056IN DIAGNOSTIC MPA1 CURVE BX/5EA","SUP-ITM-10017454","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","19.48","71.8","","28.28","27.13","28.28","1 through 10","8.41","21.57","percent of total billed charges",""
"CATHETER IMPULSE 6FR 100CM .056IN DIAGNOSTIC MPA1 CURVE BX/5EA","SUP-ITM-10017454","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","18.99","70","","44.63","35.78","44.63","1 through 10","8.41","21.57","percent of total billed charges",""
"CATHETER IMPULSE 6FR 100CM .056IN DIAGNOSTIC MPA1 CURVE BX/5EA","SUP-ITM-10017454","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21.57","79.5","","1342.89","271.64","6954.67","1 through 10","8.41","21.57","percent of total billed charges",""
"CATHETER IMPULSE 6FR 100CM .056IN DIAGNOSTIC MPA1 CURVE BX/5EA","SUP-ITM-10017454","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14.46","53.3","","4550.00","30.49","4550.00","1 through 10","8.41","21.57","percent of total billed charges",""
"CATHETER IMPULSE 6FR 100CM .056IN DIAGNOSTIC MPA1 CURVE BX/5EA","SUP-ITM-10017454","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","17.63","65","","42.09","0.04","5453.50","1 through 10","8.41","21.57","percent of total billed charges",""
"CATHETER IMPULSE 6FR 100CM .056IN DIAGNOSTIC MPA1 CURVE BX/5EA","SUP-ITM-10017454","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9.90","36.5","","310.94","18.54","1259.30","62","8.41","21.57","percent of total billed charges",""
"CATHETER IMPULSE 6FR 100CM .056IN DIAGNOSTIC MPA1 CURVE BX/5EA","SUP-ITM-10017454","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10.39","38.3","","146.86","22.58","1753.45","65","8.41","21.57","percent of total billed charges",""
"CATHETER IMPULSE 6FR 100CM .056IN DIAGNOSTIC MPA1 CURVE BX/5EA","SUP-ITM-10017454","CDM","C1887","HCPCS","0272","RC","","","","both","","","27.13","20.35","WELLPOINT [1015]","HB AMC WELLPOINT","20.02","73.78","","247.29","33.09","909.09","53","8.41","21.57","percent of total billed charges",""
"CATHETER IMPULSE 6FR 100CM .056IN DIAGNOSTIC MPA1 CURVE BX/5EA","SUP-ITM-10017454","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","27.13","20.35","AETNA [1001]","HB AMC AETNA HMO","18.94","69.8","","30.69","30.21","30.69","1 through 10","14.18","22.17","percent of total billed charges",""
"CATHETER IMPULSE 6FR 100CM .056IN DIAGNOSTIC MPA1 CURVE BX/5EA","SUP-ITM-10017454","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","27.13","20.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","21.81","80.4","","82.69","82.69","82.69","1 through 10","14.18","22.17","percent of total billed charges",""
"CATHETER IMPULSE 6FR 100CM .056IN DIAGNOSTIC MPA1 CURVE BX/5EA","SUP-ITM-10017454","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","27.13","20.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","22.17","81.72","","751.01","74.72","751.01","1 through 10","14.18","22.17","percent of total billed charges",""
"CATHETER IMPULSE 6FR 100CM .056IN DIAGNOSTIC MPA1 CURVE BX/5EA","SUP-ITM-10017454","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","27.13","20.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22.17","81.72","","328.92","46.17","2701.97","59","14.18","22.17","percent of total billed charges",""
"CATHETER INFUSION L 130CM 2.8X2.4FR 45DEG .02IN .018IN ID MICRO RADIOPAQUE MARKER TAPERED MAESTRO NYLON HYDROPHILIC BX/1EA","SUP-ITM-10082074","CDM","C1751","HCPCS","0272","RC","","","","both","","","1073.80","805.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","751.66","70","","1389.50","602.17","3167.85","27","332.88","853.67","percent of total billed charges",""
"CATHETER INFUSION L 130CM 2.8X2.4FR 45DEG .02IN .018IN ID MICRO RADIOPAQUE MARKER TAPERED MAESTRO NYLON HYDROPHILIC BX/1EA","SUP-ITM-10082074","CDM","C1751","HCPCS","0272","RC","","","","both","","","1073.80","805.35","WELLPOINT [1015]","HB AMC WELLPOINT","792.25","73.78","","1089.20","218.86","1089.20","1 through 10","332.88","853.67","percent of total billed charges",""
"CATHETER INFUSION L 130CM 2.8X2.4FR 45DEG .02IN .018IN ID MICRO RADIOPAQUE MARKER TAPERED MAESTRO NYLON HYDROPHILIC BX/1EA","SUP-ITM-10082074","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","1073.80","805.35","AETNA [1001]","HB AMC AETNA HMO","749.51","69.8","","1389.50","940.69","1389.50","1 through 10","561.17","877.51","percent of total billed charges",""
"CATHETER INFUSION L 130CM 2.8X2.4FR 45DEG .02IN .018IN ID MICRO RADIOPAQUE MARKER TAPERED MAESTRO NYLON HYDROPHILIC BX/1EA","SUP-ITM-10082074","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","1073.80","805.35","AETNA [1001]","HB AMC AETNA PPO","863.34","80.4","","190.26","190.26","190.26","1 through 10","561.17","877.51","percent of total billed charges",""
"CATHETER INFUSION L 130CM 2.8X2.4FR 45DEG .02IN .018IN ID MICRO RADIOPAQUE MARKER TAPERED MAESTRO NYLON HYDROPHILIC BX/1EA","SUP-ITM-10082074","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","1073.80","805.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","877.51","81.72","","1110.77","235.00","1169.52","1 through 10","561.17","877.51","percent of total billed charges",""
"CATHETER INQUIRY 7FR 110CM 20 POLE MAPPING EP AFOCUS II DOUBLE LOOP 1120-7-4-SM-AF20DL","SUP-ITM-10085452","CDM","C1731","HCPCS","0272","RC","","","","both","","","4818.00","3613.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3830.31","79.5","","4230.00","4230.00","4230.00","1 through 10","1493.58","3830.31","percent of total billed charges",""
"CATHETER INQUIRY 7FR 110CM 20 POLE MAPPING EP AFOCUS II DOUBLE LOOP 1120-7-4-SM-AF20DL","SUP-ITM-10085452","CDM","C1731","HCPCS","0272","RC","","","","both","","","4818.00","3613.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1845.29","38.3","","1995.27","1920.70","1995.27","1 through 10","1493.58","3830.31","percent of total billed charges",""
"CATHETER INQUIRY 7FR 110CM 20 POLE MAPPING EP AFOCUS II DOUBLE LOOP 1120-7-4-SM-AF20DL","SUP-ITM-10085452","CDM","C1731","HCPCS","0272","RC","","","","both","","","4818.00","3613.50","WELLPOINT [1015]","HB AMC WELLPOINT","3554.72","73.78","","3799.18","3799.18","3799.18","1 through 10","1493.58","3830.31","percent of total billed charges",""
"CATHETER INQUIRY 7FR 110CM 20 POLE MAPPING EP AFOCUS II DOUBLE LOOP 1120-7-4-SM-AF20DL","SUP-ITM-10085452","CDM","C1731","HCPCS","0272","RC","","","","outpatient","","","4818.00","3613.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3937.27","81.72","","2243.79","2243.79","2243.79","1 through 10","2517.89","3937.27","percent of total billed charges",""
"CATHETER INQUIRY 7FR 110CM 20 POLE MAPPING EP AFOCUS II DOUBLE LOOP 1120-7-4-SM-AF20DL","SUP-ITM-10085452","CDM","C1731","HCPCS","0272","RC","","","","outpatient","","","4818.00","3613.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3937.27","81.72","","4400.70","4079.34","4400.70","1 through 10","2517.89","3937.27","percent of total billed charges",""
"Catheter Intracardiac Echo T1","PX-27000069","CDM","C1759","HCPCS","0272","RC","","","","both","","","2926.00","2194.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2326.17","79.5","","4917.59","4917.59","4917.59","1 through 10","907.06","2326.17","percent of total billed charges",""
"Catheter Intracardiac Echo T1","PX-27000069","CDM","C1759","HCPCS","0272","RC","","","","both","","","2926.00","2194.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1559.56","53.3","","4139.10","2904.00","4139.10","1 through 10","907.06","2326.17","percent of total billed charges",""
"Catheter Intracardiac Echo T1","PX-27000069","CDM","C1759","HCPCS","0272","RC","","","","both","","","2926.00","2194.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1901.90","65","","2921.37","2921.37","2921.37","1 through 10","907.06","2326.17","percent of total billed charges",""
"Catheter Intracardiac Echo T1","PX-27000069","CDM","C1759","HCPCS","0272","RC","","","","both","","","2926.00","2194.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1067.99","36.5","","2212.82","1626.98","5029.26","11","907.06","2326.17","percent of total billed charges",""
"Catheter Intracardiac Echo T1","PX-27000069","CDM","C1759","HCPCS","0272","RC","","","","both","","","2926.00","2194.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1120.66","38.3","","2150.50","1757.32","3314.56","20","907.06","2326.17","percent of total billed charges",""
"Catheter Intracardiac Echo T1","PX-27000069","CDM","C1759","HCPCS","0272","RC","","","","both","","","2926.00","2194.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1255.25","42.9","","2044.96","2044.96","2044.96","1 through 10","907.06","2326.17","percent of total billed charges",""
"Catheter Intracardiac Echo T1","PX-27000069","CDM","C1759","HCPCS","0272","RC","","","","both","","","2926.00","2194.50","WELLPOINT [1015]","HB AMC WELLPOINT","2158.80","73.78","","4094.75","3346.10","4416.75","16","907.06","2326.17","percent of total billed charges",""
"Catheter Intracardiac Echo T1","PX-27000069","CDM","C1759","HCPCS","0272","RC","","","","outpatient","","","2926.00","2194.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1529.13","52.26","","2781.15","2781.15","2781.15","1 through 10","1529.13","2391.13","percent of total billed charges",""
"Catheter Intracardiac Echo T1","PX-27000069","CDM","C1759","HCPCS","0272","RC","","","","outpatient","","","2926.00","2194.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2391.13","81.72","","3592.84","1819.96","3592.84","1 through 10","1529.13","2391.13","percent of total billed charges",""
"Catheter Intracardiac Echo T1","PX-27000069","CDM","C1759","HCPCS","0272","RC","","","","outpatient","","","2926.00","2194.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2391.13","81.72","","4396.70","3592.84","4742.44","21","1529.13","2391.13","percent of total billed charges",""
"Catheter Intracardiac Echo T3","PX-27000070","CDM","C1759","HCPCS","0272","RC","","","","both","","","6250.00","4687.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4968.75","79.5","","4917.59","4917.59","4917.59","1 through 10","1937.5","4968.75","percent of total billed charges",""
"Catheter Intracardiac Echo T3","PX-27000070","CDM","C1759","HCPCS","0272","RC","","","","both","","","6250.00","4687.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3331.25","53.3","","4139.10","2904.00","4139.10","1 through 10","1937.5","4968.75","percent of total billed charges",""
"Catheter Intracardiac Echo T3","PX-27000070","CDM","C1759","HCPCS","0272","RC","","","","both","","","6250.00","4687.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4062.50","65","","2921.37","2921.37","2921.37","1 through 10","1937.5","4968.75","percent of total billed charges",""
"Catheter Intracardiac Echo T3","PX-27000070","CDM","C1759","HCPCS","0272","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.25","36.5","","2212.82","1626.98","5029.26","11","1937.5","4968.75","percent of total billed charges",""
"Catheter Intracardiac Echo T3","PX-27000070","CDM","C1759","HCPCS","0272","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2393.75","38.3","","2150.50","1757.32","3314.56","20","1937.5","4968.75","percent of total billed charges",""
"Catheter Intracardiac Echo T3","PX-27000070","CDM","C1759","HCPCS","0272","RC","","","","both","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.25","42.9","","2044.96","2044.96","2044.96","1 through 10","1937.5","4968.75","percent of total billed charges",""
"Catheter Intracardiac Echo T3","PX-27000070","CDM","C1759","HCPCS","0272","RC","","","","both","","","6250.00","4687.50","WELLPOINT [1015]","HB AMC WELLPOINT","4611.25","73.78","","4094.75","3346.10","4416.75","16","1937.5","4968.75","percent of total billed charges",""
"Catheter Intracardiac Echo T3","PX-27000070","CDM","C1759","HCPCS","0272","RC","","","","outpatient","","","6250.00","4687.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3266.25","52.26","","2781.15","2781.15","2781.15","1 through 10","3266.25","5107.5","percent of total billed charges",""
"Catheter Intracardiac Echo T3","PX-27000070","CDM","C1759","HCPCS","0272","RC","","","","outpatient","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5107.50","81.72","","3592.84","1819.96","3592.84","1 through 10","3266.25","5107.5","percent of total billed charges",""
"Catheter Intracardiac Echo T3","PX-27000070","CDM","C1759","HCPCS","0272","RC","","","","outpatient","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5107.50","81.72","","4396.70","3592.84","4742.44","21","3266.25","5107.5","percent of total billed charges",""
"Catheter Intravascular Ultrasound T1","PX-27000061","CDM","C1753","HCPCS","0272","RC","","","","both","","","2556.89","1917.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1661.98","65","","1660.75","1660.75","1660.75","1 through 10","792.64","2032.73","percent of total billed charges",""
"Catheter Intravascular Ultrasound T1","PX-27000061","CDM","C1753","HCPCS","0272","RC","","","","both","","","2556.89","1917.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","933.26","36.5","","1233.70","876.51","1905.76","1 through 10","792.64","2032.73","percent of total billed charges",""
"Catheter Intravascular Ultrasound T1","PX-27000061","CDM","C1753","HCPCS","0272","RC","","","","both","","","2556.89","1917.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","979.29","38.3","","1026.38","999.01","1026.38","1 through 10","792.64","2032.73","percent of total billed charges",""
"Catheter Intravascular Ultrasound T1","PX-27000061","CDM","C1753","HCPCS","0272","RC","","","","both","","","2556.89","1917.67","WELLPOINT [1015]","HB AMC WELLPOINT","1886.47","73.78","","1902.20","1902.20","1902.20","1 through 10","792.64","2032.73","percent of total billed charges",""
"Catheter Intravascular Ultrasound T1","PX-27000061","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","2556.89","1917.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2089.49","81.72","","2098.42","1123.43","2210.34","1 through 10","1336.23","2089.49","percent of total billed charges",""
"Catheter Intravascular Ultrasound T3","PX-27000062","CDM","C1753","HCPCS","0272","RC","","","","both","","","6000.00","4500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3900.00","65","","1660.75","1660.75","1660.75","1 through 10","1860","4770","percent of total billed charges",""
"Catheter Intravascular Ultrasound T3","PX-27000062","CDM","C1753","HCPCS","0272","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2190.00","36.5","","1233.70","876.51","1905.76","1 through 10","1860","4770","percent of total billed charges",""
"Catheter Intravascular Ultrasound T3","PX-27000062","CDM","C1753","HCPCS","0272","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2298.00","38.3","","1026.38","999.01","1026.38","1 through 10","1860","4770","percent of total billed charges",""
"Catheter Intravascular Ultrasound T3","PX-27000062","CDM","C1753","HCPCS","0272","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB AMC WELLPOINT","4426.80","73.78","","1902.20","1902.20","1902.20","1 through 10","1860","4770","percent of total billed charges",""
"Catheter Intravascular Ultrasound T3","PX-27000062","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4903.20","81.72","","2098.42","1123.43","2210.34","1 through 10","3135.6","4903.2","percent of total billed charges",""
"CATHETER IV 7FR 6IN 3 LUMEN CVC CONPONENT CS/5EA","SUP-ITM-10009831","CDM","C1751","HCPCS","0272","RC","","","","both","","","114.38","85.78","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","80.07","70","","1389.50","602.17","3167.85","27","35.46","90.93","percent of total billed charges",""
"CATHETER IV 7FR 6IN 3 LUMEN CVC CONPONENT CS/5EA","SUP-ITM-10009831","CDM","C1751","HCPCS","0272","RC","","","","both","","","114.38","85.78","WELLPOINT [1015]","HB AMC WELLPOINT","84.39","73.78","","1089.20","218.86","1089.20","1 through 10","35.46","90.93","percent of total billed charges",""
"CATHETER IV 7FR 6IN 3 LUMEN CVC CONPONENT CS/5EA","SUP-ITM-10009831","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","114.38","85.78","AETNA [1001]","HB AMC AETNA HMO","79.84","69.8","","1389.50","940.69","1389.50","1 through 10","59.77","93.47","percent of total billed charges",""
"CATHETER IV 7FR 6IN 3 LUMEN CVC CONPONENT CS/5EA","SUP-ITM-10009831","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","114.38","85.78","AETNA [1001]","HB AMC AETNA PPO","91.96","80.4","","190.26","190.26","190.26","1 through 10","59.77","93.47","percent of total billed charges",""
"CATHETER IV 7FR 6IN 3 LUMEN CVC CONPONENT CS/5EA","SUP-ITM-10009831","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","114.38","85.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.47","81.72","","1110.77","235.00","1169.52","1 through 10","59.77","93.47","percent of total billed charges",""
"CATHETER IVL 6MM 60MM M5 INTRAVASCULAR LITHOTRIPSY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10237337","CDM","C1725","HCPCS","0272","RC","","","","both","","","6875.00","5156.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","4936.25","71.8","","175.91","175.91","175.91","1 through 10","2131.25","5465.63","percent of total billed charges",""
"CATHETER IVL 6MM 60MM M5 INTRAVASCULAR LITHOTRIPSY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10237337","CDM","C1725","HCPCS","0272","RC","","","","both","","","6875.00","5156.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4468.75","65","","147.88","147.88","1296.75","1 through 10","2131.25","5465.63","percent of total billed charges",""
"CATHETER IVL 6MM 60MM M5 INTRAVASCULAR LITHOTRIPSY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10237337","CDM","C1725","HCPCS","0272","RC","","","","both","","","6875.00","5156.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2509.38","36.5","","181.40","177.87","181.40","21","2131.25","5465.63","percent of total billed charges",""
"CATHETER IVL 6MM 60MM M5 INTRAVASCULAR LITHOTRIPSY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10237337","CDM","C1725","HCPCS","0272","RC","","","","both","","","6875.00","5156.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2633.13","38.3","","170.15","88.95","424.24","16","2131.25","5465.63","percent of total billed charges",""
"CATHETER IVL 6MM 60MM M5 INTRAVASCULAR LITHOTRIPSY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10237337","CDM","C1725","HCPCS","0272","RC","","","","both","","","6875.00","5156.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2949.38","42.9","","699.48","699.48","699.48","12","2131.25","5465.63","percent of total billed charges",""
"CATHETER IVL 6MM 60MM M5 INTRAVASCULAR LITHOTRIPSY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10237337","CDM","C1725","HCPCS","0272","RC","","","","both","","","6875.00","5156.25","WELLPOINT [1015]","HB AMC WELLPOINT","5072.38","73.78","","576.52","182.40","651.44","14","2131.25","5465.63","percent of total billed charges",""
"CATHETER IVL 6MM 60MM M5 INTRAVASCULAR LITHOTRIPSY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10237337","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","6875.00","5156.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5618.25","81.72","","181.86","100.03","402.41","21","3592.88","5618.25","percent of total billed charges",""
"CATHETER IVL E8 3.5X80MM SHOCKWAVE","SUP-ITM-10333817","CDM","C1725","HCPCS","0272","RC","","","","both","","","11750.00","8812.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","8436.50","71.8","","175.91","175.91","175.91","1 through 10","3642.5","9341.25","percent of total billed charges",""
"CATHETER IVL E8 3.5X80MM SHOCKWAVE","SUP-ITM-10333817","CDM","C1725","HCPCS","0272","RC","","","","both","","","11750.00","8812.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7637.50","65","","147.88","147.88","1296.75","1 through 10","3642.5","9341.25","percent of total billed charges",""
"CATHETER IVL E8 3.5X80MM SHOCKWAVE","SUP-ITM-10333817","CDM","C1725","HCPCS","0272","RC","","","","both","","","11750.00","8812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4288.75","36.5","","181.40","177.87","181.40","21","3642.5","9341.25","percent of total billed charges",""
"CATHETER IVL E8 3.5X80MM SHOCKWAVE","SUP-ITM-10333817","CDM","C1725","HCPCS","0272","RC","","","","both","","","11750.00","8812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4500.25","38.3","","170.15","88.95","424.24","16","3642.5","9341.25","percent of total billed charges",""
"CATHETER IVL E8 3.5X80MM SHOCKWAVE","SUP-ITM-10333817","CDM","C1725","HCPCS","0272","RC","","","","both","","","11750.00","8812.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5040.75","42.9","","699.48","699.48","699.48","12","3642.5","9341.25","percent of total billed charges",""
"CATHETER IVL E8 3.5X80MM SHOCKWAVE","SUP-ITM-10333817","CDM","C1725","HCPCS","0272","RC","","","","both","","","11750.00","8812.50","WELLPOINT [1015]","HB AMC WELLPOINT","8669.15","73.78","","576.52","182.40","651.44","14","3642.5","9341.25","percent of total billed charges",""
"CATHETER IVL E8 3.5X80MM SHOCKWAVE","SUP-ITM-10333817","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","11750.00","8812.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9602.10","81.72","","181.86","100.03","402.41","21","6140.55","9602.1","percent of total billed charges",""
"CATHETER JUGULAR 32FR 34CM 3/8IN CONNECTOR DUAL LUMEN","SUP-ITM-10238804","CDM","C1713","HCPCS","0278","RC","","","","both","","","6587.50","4940.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5237.06","79.5","","800.18","480.96","1887.97","195","2042.13","5237.06","percent of total billed charges",""
"CATHETER JUGULAR 32FR 34CM 3/8IN CONNECTOR DUAL LUMEN","SUP-ITM-10238804","CDM","C1713","HCPCS","0278","RC","","","","both","","","6587.50","4940.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3511.14","53.3","","813.12","216.42","1444.50","81","2042.13","5237.06","percent of total billed charges",""
"CATHETER JUGULAR 32FR 34CM 3/8IN CONNECTOR DUAL LUMEN","SUP-ITM-10238804","CDM","C1713","HCPCS","0278","RC","","","","both","","","6587.50","4940.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2042.13","31","","432.60","432.60","432.60","1 through 10","2042.13","5237.06","percent of total billed charges",""
"CATHETER JUGULAR 32FR 34CM 3/8IN CONNECTOR DUAL LUMEN","SUP-ITM-10238804","CDM","C1713","HCPCS","0278","RC","","","","both","","","6587.50","4940.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2404.44","36.5","","148.37","54.89","631.39","94","2042.13","5237.06","percent of total billed charges",""
"CATHETER JUGULAR 32FR 34CM 3/8IN CONNECTOR DUAL LUMEN","SUP-ITM-10238804","CDM","C1713","HCPCS","0278","RC","","","","both","","","6587.50","4940.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2523.01","38.3","","279.30","91.72","1116.77","266","2042.13","5237.06","percent of total billed charges",""
"CATHETER JUGULAR 32FR 34CM 3/8IN CONNECTOR DUAL LUMEN","SUP-ITM-10238804","CDM","C1713","HCPCS","0278","RC","","","","both","","","6587.50","4940.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2826.04","42.9","","731.00","63.70","731.00","1 through 10","2042.13","5237.06","percent of total billed charges",""
"CATHETER JUGULAR 32FR 34CM 3/8IN CONNECTOR DUAL LUMEN","SUP-ITM-10238804","CDM","C1713","HCPCS","0278","RC","","","","both","","","6587.50","4940.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2826.04","42.9","","384.74","384.74","384.74","1 through 10","2042.13","5237.06","percent of total billed charges",""
"CATHETER JUGULAR 32FR 34CM 3/8IN CONNECTOR DUAL LUMEN","SUP-ITM-10238804","CDM","C1713","HCPCS","0278","RC","","","","both","","","6587.50","4940.62","WELLPOINT [1015]","HB AMC WELLPOINT","4860.26","73.78","","286.63","119.22","1107.45","105","2042.13","5237.06","percent of total billed charges",""
"CATHETER JUGULAR 32FR 34CM 3/8IN CONNECTOR DUAL LUMEN","SUP-ITM-10238804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6587.50","4940.62","AETNA [1001]","HB AMC AETNA HMO","4598.08","69.8","","675.31","184.75","1721.50","286","3442.63","5383.31","percent of total billed charges",""
"CATHETER JUGULAR 32FR 34CM 3/8IN CONNECTOR DUAL LUMEN","SUP-ITM-10238804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6587.50","4940.62","AETNA [1001]","HB AMC AETNA PPO","5296.35","80.4","","1261.44","103.12","1514.10","21","3442.63","5383.31","percent of total billed charges",""
"CATHETER JUGULAR 32FR 34CM 3/8IN CONNECTOR DUAL LUMEN","SUP-ITM-10238804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6587.50","4940.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5296.35","80.4","","1365.00","1365.00","1365.00","1 through 10","3442.63","5383.31","percent of total billed charges",""
"CATHETER JUGULAR 32FR 34CM 3/8IN CONNECTOR DUAL LUMEN","SUP-ITM-10238804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6587.50","4940.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5383.31","81.72","","5157.68","5157.68","5157.68","1 through 10","3442.63","5383.31","percent of total billed charges",""
"CATHETER JUGULAR 32FR 34CM 3/8IN CONNECTOR DUAL LUMEN","SUP-ITM-10238804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6587.50","4940.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5383.31","81.72","","431.26","71.26","1459.57","88","3442.63","5383.31","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","206.50","154.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","107.92","52.26","","16.24","16.24","54.15","1 through 10","64.02","164.17","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","206.50","154.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","148.27","71.8","","86.33","32.67","86.33","1 through 10","64.02","164.17","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","206.50","154.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","144.55","70","","113.68","63.00","177.34","40","64.02","164.17","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","206.50","154.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","164.17","79.5","","50.70","21.76","168.00","12","64.02","164.17","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","206.50","154.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","110.06","53.3","","89.31","89.31","99.75","1 through 10","64.02","164.17","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","206.50","154.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","134.23","65","","94.41","17.06","2275.00","1 through 10","64.02","164.17","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","206.50","154.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","64.02","31","","35.13","35.13","35.13","1 through 10","64.02","164.17","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","206.50","154.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","75.37","36.5","","40.08","12.40","86.17","108","64.02","164.17","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","206.50","154.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","79.09","38.3","","33.25","10.27","68.43","169","64.02","164.17","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","206.50","154.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.59","42.9","","25.48","14.86","90.88","1 through 10","64.02","164.17","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","206.50","154.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.59","42.9","","90.88","90.88","90.88","1 through 10","64.02","164.17","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","206.50","154.87","WELLPOINT [1015]","HB AMC WELLPOINT","152.36","73.78","","84.63","19.55","140.02","123","64.02","164.17","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","206.50","154.87","AETNA [1001]","HB AMC AETNA HMO","144.14","69.8","","76.96","17.77","113.68","14","107.92","168.75","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","206.50","154.87","AETNA [1001]","HB AMC AETNA PPO","166.03","80.4","","57.31","57.31","57.31","1 through 10","107.92","168.75","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","206.50","154.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","107.92","52.26","","16.24","16.24","54.15","1 through 10","107.92","168.75","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","206.50","154.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","166.03","80.4","","68.25","68.25","87.50","1 through 10","107.92","168.75","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","206.50","154.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","168.75","81.72","","156.19","156.19","156.19","1 through 10","107.92","168.75","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","206.50","154.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","168.75","81.72","","82.70","12.06","98.97","13","107.92","168.75","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","206.50","154.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","168.75","81.72","","50.47","25.30","134.30","140","107.92","168.75","percent of total billed charges",""
"CATHETER LAUNCHER 6FR 100CM CORONARY GUIDE AMPLATZ LEFT","SUP-ITM-10092789","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","100.52","71.8","","28.28","27.13","28.28","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER LAUNCHER 6FR 100CM CORONARY GUIDE AMPLATZ LEFT","SUP-ITM-10092789","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","98.00","70","","44.63","35.78","44.63","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER LAUNCHER 6FR 100CM CORONARY GUIDE AMPLATZ LEFT","SUP-ITM-10092789","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.30","79.5","","1342.89","271.64","6954.67","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER LAUNCHER 6FR 100CM CORONARY GUIDE AMPLATZ LEFT","SUP-ITM-10092789","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.62","53.3","","4550.00","30.49","4550.00","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER LAUNCHER 6FR 100CM CORONARY GUIDE AMPLATZ LEFT","SUP-ITM-10092789","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","91.00","65","","42.09","0.04","5453.50","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER LAUNCHER 6FR 100CM CORONARY GUIDE AMPLATZ LEFT","SUP-ITM-10092789","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.10","36.5","","310.94","18.54","1259.30","62","43.4","111.3","percent of total billed charges",""
"CATHETER LAUNCHER 6FR 100CM CORONARY GUIDE AMPLATZ LEFT","SUP-ITM-10092789","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.62","38.3","","146.86","22.58","1753.45","65","43.4","111.3","percent of total billed charges",""
"CATHETER LAUNCHER 6FR 100CM CORONARY GUIDE AMPLATZ LEFT","SUP-ITM-10092789","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","WELLPOINT [1015]","HB AMC WELLPOINT","103.29","73.78","","247.29","33.09","909.09","53","43.4","111.3","percent of total billed charges",""
"CATHETER LAUNCHER 6FR 100CM CORONARY GUIDE AMPLATZ LEFT","SUP-ITM-10092789","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA HMO","97.72","69.8","","30.69","30.21","30.69","1 through 10","73.16","114.41","percent of total billed charges",""
"CATHETER LAUNCHER 6FR 100CM CORONARY GUIDE AMPLATZ LEFT","SUP-ITM-10092789","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.56","80.4","","82.69","82.69","82.69","1 through 10","73.16","114.41","percent of total billed charges",""
"CATHETER LAUNCHER 6FR 100CM CORONARY GUIDE AMPLATZ LEFT","SUP-ITM-10092789","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.41","81.72","","751.01","74.72","751.01","1 through 10","73.16","114.41","percent of total billed charges",""
"CATHETER LAUNCHER 6FR 100CM CORONARY GUIDE AMPLATZ LEFT","SUP-ITM-10092789","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.41","81.72","","328.92","46.17","2701.97","59","73.16","114.41","percent of total billed charges",""
"CATHETER LUTONIX 4X40MM 130CM .018IN PTA DRUG COATED BALLOON","SUP-ITM-10236564","CDM","C2623","HCPCS","0272","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","3445.53","3445.53","3445.53","1 through 10","1534.5","3935.25","percent of total billed charges",""
"CATHETER LUTONIX 4X40MM 130CM .018IN PTA DRUG COATED BALLOON","SUP-ITM-10236564","CDM","C2623","HCPCS","0272","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","5522.88","5522.88","5522.88","1 through 10","1534.5","3935.25","percent of total billed charges",""
"CATHETER LUTONIX 4X40MM 130CM .018IN PTA DRUG COATED BALLOON","SUP-ITM-10236564","CDM","C2623","HCPCS","0272","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","3244.16","3126.90","3244.16","1 through 10","1534.5","3935.25","percent of total billed charges",""
"CATHETER LUTONIX 4X40MM 130CM .018IN PTA DRUG COATED BALLOON","SUP-ITM-10236564","CDM","C2623","HCPCS","0272","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","11291.52","11291.52","11291.52","1 through 10","2586.87","4045.14","percent of total billed charges",""
"CATHETER LUTONIX 5FR 5X150MM 130CM .035IN PTA DRUG COATED BALLOON","SUP-ITM-10166740","CDM","C2623","HCPCS","0272","RC","","","","both","","","5100.00","3825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1861.50","36.5","","3445.53","3445.53","3445.53","1 through 10","1581","4054.5","percent of total billed charges",""
"CATHETER LUTONIX 5FR 5X150MM 130CM .035IN PTA DRUG COATED BALLOON","SUP-ITM-10166740","CDM","C2623","HCPCS","0272","RC","","","","both","","","5100.00","3825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1953.30","38.3","","5522.88","5522.88","5522.88","1 through 10","1581","4054.5","percent of total billed charges",""
"CATHETER LUTONIX 5FR 5X150MM 130CM .035IN PTA DRUG COATED BALLOON","SUP-ITM-10166740","CDM","C2623","HCPCS","0272","RC","","","","both","","","5100.00","3825.00","WELLPOINT [1015]","HB AMC WELLPOINT","3762.78","73.78","","3244.16","3126.90","3244.16","1 through 10","1581","4054.5","percent of total billed charges",""
"CATHETER LUTONIX 5FR 5X150MM 130CM .035IN PTA DRUG COATED BALLOON","SUP-ITM-10166740","CDM","C2623","HCPCS","0272","RC","","","","outpatient","","","5100.00","3825.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4167.72","81.72","","11291.52","11291.52","11291.52","1 through 10","2665.26","4167.72","percent of total billed charges",""
"CATHETER LUTONIX 5FR 5X40MM 130CM .035IN PTA DRUG COATED BALLOON","SUP-ITM-10166735","CDM","C2623","HCPCS","0272","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","3445.53","3445.53","3445.53","1 through 10","1302","3339","percent of total billed charges",""
"CATHETER LUTONIX 5FR 5X40MM 130CM .035IN PTA DRUG COATED BALLOON","SUP-ITM-10166735","CDM","C2623","HCPCS","0272","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","5522.88","5522.88","5522.88","1 through 10","1302","3339","percent of total billed charges",""
"CATHETER LUTONIX 5FR 5X40MM 130CM .035IN PTA DRUG COATED BALLOON","SUP-ITM-10166735","CDM","C2623","HCPCS","0272","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","3244.16","3126.90","3244.16","1 through 10","1302","3339","percent of total billed charges",""
"CATHETER LUTONIX 5FR 5X40MM 130CM .035IN PTA DRUG COATED BALLOON","SUP-ITM-10166735","CDM","C2623","HCPCS","0272","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","11291.52","11291.52","11291.52","1 through 10","2194.92","3432.24","percent of total billed charges",""
"CATHETER LUTONIX 6X220MM 130CM .018IN PTA DRUG COATED BALLOON","SUP-ITM-10236553","CDM","C2623","HCPCS","0272","RC","","","","both","","","6375.00","4781.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2326.88","36.5","","3445.53","3445.53","3445.53","1 through 10","1976.25","5068.13","percent of total billed charges",""
"CATHETER LUTONIX 6X220MM 130CM .018IN PTA DRUG COATED BALLOON","SUP-ITM-10236553","CDM","C2623","HCPCS","0272","RC","","","","both","","","6375.00","4781.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2441.63","38.3","","5522.88","5522.88","5522.88","1 through 10","1976.25","5068.13","percent of total billed charges",""
"CATHETER LUTONIX 6X220MM 130CM .018IN PTA DRUG COATED BALLOON","SUP-ITM-10236553","CDM","C2623","HCPCS","0272","RC","","","","both","","","6375.00","4781.25","WELLPOINT [1015]","HB AMC WELLPOINT","4703.48","73.78","","3244.16","3126.90","3244.16","1 through 10","1976.25","5068.13","percent of total billed charges",""
"CATHETER LUTONIX 6X220MM 130CM .018IN PTA DRUG COATED BALLOON","SUP-ITM-10236553","CDM","C2623","HCPCS","0272","RC","","","","outpatient","","","6375.00","4781.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5209.65","81.72","","11291.52","11291.52","11291.52","1 through 10","3331.58","5209.65","percent of total billed charges",""
"CATHETER M5+ 3.5X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304640","CDM","C1725","HCPCS","0272","RC","","","","both","","","8625.00","6468.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","6192.75","71.8","","175.91","175.91","175.91","1 through 10","2673.75","6856.88","percent of total billed charges",""
"CATHETER M5+ 3.5X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304640","CDM","C1725","HCPCS","0272","RC","","","","both","","","8625.00","6468.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5606.25","65","","147.88","147.88","1296.75","1 through 10","2673.75","6856.88","percent of total billed charges",""
"CATHETER M5+ 3.5X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304640","CDM","C1725","HCPCS","0272","RC","","","","both","","","8625.00","6468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3148.13","36.5","","181.40","177.87","181.40","21","2673.75","6856.88","percent of total billed charges",""
"CATHETER M5+ 3.5X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304640","CDM","C1725","HCPCS","0272","RC","","","","both","","","8625.00","6468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3303.38","38.3","","170.15","88.95","424.24","16","2673.75","6856.88","percent of total billed charges",""
"CATHETER M5+ 3.5X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304640","CDM","C1725","HCPCS","0272","RC","","","","both","","","8625.00","6468.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3700.13","42.9","","699.48","699.48","699.48","12","2673.75","6856.88","percent of total billed charges",""
"CATHETER M5+ 3.5X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304640","CDM","C1725","HCPCS","0272","RC","","","","both","","","8625.00","6468.75","WELLPOINT [1015]","HB AMC WELLPOINT","6363.53","73.78","","576.52","182.40","651.44","14","2673.75","6856.88","percent of total billed charges",""
"CATHETER M5+ 3.5X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304640","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","8625.00","6468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7048.35","81.72","","181.86","100.03","402.41","21","4507.43","7048.35","percent of total billed charges",""
"CATHETER M5+ 8.0X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304632","CDM","C1725","HCPCS","0272","RC","","","","both","","","8625.00","6468.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","6192.75","71.8","","175.91","175.91","175.91","1 through 10","2673.75","6856.88","percent of total billed charges",""
"CATHETER M5+ 8.0X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304632","CDM","C1725","HCPCS","0272","RC","","","","both","","","8625.00","6468.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5606.25","65","","147.88","147.88","1296.75","1 through 10","2673.75","6856.88","percent of total billed charges",""
"CATHETER M5+ 8.0X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304632","CDM","C1725","HCPCS","0272","RC","","","","both","","","8625.00","6468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3148.13","36.5","","181.40","177.87","181.40","21","2673.75","6856.88","percent of total billed charges",""
"CATHETER M5+ 8.0X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304632","CDM","C1725","HCPCS","0272","RC","","","","both","","","8625.00","6468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3303.38","38.3","","170.15","88.95","424.24","16","2673.75","6856.88","percent of total billed charges",""
"CATHETER M5+ 8.0X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304632","CDM","C1725","HCPCS","0272","RC","","","","both","","","8625.00","6468.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3700.13","42.9","","699.48","699.48","699.48","12","2673.75","6856.88","percent of total billed charges",""
"CATHETER M5+ 8.0X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304632","CDM","C1725","HCPCS","0272","RC","","","","both","","","8625.00","6468.75","WELLPOINT [1015]","HB AMC WELLPOINT","6363.53","73.78","","576.52","182.40","651.44","14","2673.75","6856.88","percent of total billed charges",""
"CATHETER M5+ 8.0X60MM INTRAVASCULAR LITHOTRIPSY","SUP-ITM-10304632","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","8625.00","6468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7048.35","81.72","","181.86","100.03","402.41","21","4507.43","7048.35","percent of total billed charges",""
"CATHETER MACH1 6FR 55CM RDC TIP GUIDING PERIPHERAL","SUP-ITM-10100370","CDM","C1887","HCPCS","0272","RC","","","","both","","","306.43","229.82","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","220.02","71.8","","28.28","27.13","28.28","1 through 10","94.99","243.61","percent of total billed charges",""
"CATHETER MACH1 6FR 55CM RDC TIP GUIDING PERIPHERAL","SUP-ITM-10100370","CDM","C1887","HCPCS","0272","RC","","","","both","","","306.43","229.82","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","214.50","70","","44.63","35.78","44.63","1 through 10","94.99","243.61","percent of total billed charges",""
"CATHETER MACH1 6FR 55CM RDC TIP GUIDING PERIPHERAL","SUP-ITM-10100370","CDM","C1887","HCPCS","0272","RC","","","","both","","","306.43","229.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","243.61","79.5","","1342.89","271.64","6954.67","1 through 10","94.99","243.61","percent of total billed charges",""
"CATHETER MACH1 6FR 55CM RDC TIP GUIDING PERIPHERAL","SUP-ITM-10100370","CDM","C1887","HCPCS","0272","RC","","","","both","","","306.43","229.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","163.33","53.3","","4550.00","30.49","4550.00","1 through 10","94.99","243.61","percent of total billed charges",""
"CATHETER MACH1 6FR 55CM RDC TIP GUIDING PERIPHERAL","SUP-ITM-10100370","CDM","C1887","HCPCS","0272","RC","","","","both","","","306.43","229.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","199.18","65","","42.09","0.04","5453.50","1 through 10","94.99","243.61","percent of total billed charges",""
"CATHETER MACH1 6FR 55CM RDC TIP GUIDING PERIPHERAL","SUP-ITM-10100370","CDM","C1887","HCPCS","0272","RC","","","","both","","","306.43","229.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","111.85","36.5","","310.94","18.54","1259.30","62","94.99","243.61","percent of total billed charges",""
"CATHETER MACH1 6FR 55CM RDC TIP GUIDING PERIPHERAL","SUP-ITM-10100370","CDM","C1887","HCPCS","0272","RC","","","","both","","","306.43","229.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","117.36","38.3","","146.86","22.58","1753.45","65","94.99","243.61","percent of total billed charges",""
"CATHETER MACH1 6FR 55CM RDC TIP GUIDING PERIPHERAL","SUP-ITM-10100370","CDM","C1887","HCPCS","0272","RC","","","","both","","","306.43","229.82","WELLPOINT [1015]","HB AMC WELLPOINT","226.08","73.78","","247.29","33.09","909.09","53","94.99","243.61","percent of total billed charges",""
"CATHETER MACH1 6FR 55CM RDC TIP GUIDING PERIPHERAL","SUP-ITM-10100370","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","306.43","229.82","AETNA [1001]","HB AMC AETNA HMO","213.89","69.8","","30.69","30.21","30.69","1 through 10","160.14","250.41","percent of total billed charges",""
"CATHETER MACH1 6FR 55CM RDC TIP GUIDING PERIPHERAL","SUP-ITM-10100370","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","306.43","229.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","246.37","80.4","","82.69","82.69","82.69","1 through 10","160.14","250.41","percent of total billed charges",""
"CATHETER MACH1 6FR 55CM RDC TIP GUIDING PERIPHERAL","SUP-ITM-10100370","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","306.43","229.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","250.41","81.72","","751.01","74.72","751.01","1 through 10","160.14","250.41","percent of total billed charges",""
"CATHETER MACH1 6FR 55CM RDC TIP GUIDING PERIPHERAL","SUP-ITM-10100370","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","306.43","229.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","250.41","81.72","","328.92","46.17","2701.97","59","160.14","250.41","percent of total billed charges",""
"CATHETER MAPPING 6F STANDARD 2.5MM 110CM POLARIS PEDX REPROCESSED","SUP-ITM-10092448","CDM","C1732","HCPCS","0272","RC","","","","both","","","459.55","344.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","298.71","65","","2222.68","2222.68","2222.68","1 through 10","142.46","365.34","percent of total billed charges",""
"CATHETER MAPPING 6F STANDARD 2.5MM 110CM POLARIS PEDX REPROCESSED","SUP-ITM-10092448","CDM","C1732","HCPCS","0272","RC","","","","both","","","459.55","344.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","167.74","36.5","","4681.38","1275.47","8371.80","20","142.46","365.34","percent of total billed charges",""
"CATHETER MAPPING 6F STANDARD 2.5MM 110CM POLARIS PEDX REPROCESSED","SUP-ITM-10092448","CDM","C1732","HCPCS","0272","RC","","","","both","","","459.55","344.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","176.01","38.3","","1663.12","1287.53","2528.21","1 through 10","142.46","365.34","percent of total billed charges",""
"CATHETER MAPPING 6F STANDARD 2.5MM 110CM POLARIS PEDX REPROCESSED","SUP-ITM-10092448","CDM","C1732","HCPCS","0272","RC","","","","both","","","459.55","344.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","197.15","42.9","","1935.35","1935.35","1935.35","1 through 10","142.46","365.34","percent of total billed charges",""
"CATHETER MAPPING 6F STANDARD 2.5MM 110CM POLARIS PEDX REPROCESSED","SUP-ITM-10092448","CDM","C1732","HCPCS","0272","RC","","","","both","","","459.55","344.66","WELLPOINT [1015]","HB AMC WELLPOINT","339.06","73.78","","4813.94","2545.82","7082.06","1 through 10","142.46","365.34","percent of total billed charges",""
"CATHETER MAPPING 6F STANDARD 2.5MM 110CM POLARIS PEDX REPROCESSED","SUP-ITM-10092448","CDM","C1732","HCPCS","0272","RC","","","","outpatient","","","459.55","344.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","375.54","81.72","","2733.55","2433.63","5168.92","14","240.16","375.54","percent of total billed charges",""
"CATHETER MARINER 5FR 100CM .038IN ANGIOGRAPHY COBRA 2 HYDROP - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10166019","CDM","C1887","HCPCS","0272","RC","","","","both","","","700.00","525.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","502.60","71.8","","28.28","27.13","28.28","1 through 10","217","556.5","percent of total billed charges",""
"CATHETER MARINER 5FR 100CM .038IN ANGIOGRAPHY COBRA 2 HYDROP - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10166019","CDM","C1887","HCPCS","0272","RC","","","","both","","","700.00","525.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","490.00","70","","44.63","35.78","44.63","1 through 10","217","556.5","percent of total billed charges",""
"CATHETER MARINER 5FR 100CM .038IN ANGIOGRAPHY COBRA 2 HYDROP - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10166019","CDM","C1887","HCPCS","0272","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","1342.89","271.64","6954.67","1 through 10","217","556.5","percent of total billed charges",""
"CATHETER MARINER 5FR 100CM .038IN ANGIOGRAPHY COBRA 2 HYDROP - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10166019","CDM","C1887","HCPCS","0272","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","4550.00","30.49","4550.00","1 through 10","217","556.5","percent of total billed charges",""
"CATHETER MARINER 5FR 100CM .038IN ANGIOGRAPHY COBRA 2 HYDROP - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10166019","CDM","C1887","HCPCS","0272","RC","","","","both","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","455.00","65","","42.09","0.04","5453.50","1 through 10","217","556.5","percent of total billed charges",""
"CATHETER MARINER 5FR 100CM .038IN ANGIOGRAPHY COBRA 2 HYDROP - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10166019","CDM","C1887","HCPCS","0272","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","310.94","18.54","1259.30","62","217","556.5","percent of total billed charges",""
"CATHETER MARINER 5FR 100CM .038IN ANGIOGRAPHY COBRA 2 HYDROP - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10166019","CDM","C1887","HCPCS","0272","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","146.86","22.58","1753.45","65","217","556.5","percent of total billed charges",""
"CATHETER MARINER 5FR 100CM .038IN ANGIOGRAPHY COBRA 2 HYDROP - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10166019","CDM","C1887","HCPCS","0272","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","247.29","33.09","909.09","53","217","556.5","percent of total billed charges",""
"CATHETER MARINER 5FR 100CM .038IN ANGIOGRAPHY COBRA 2 HYDROP - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10166019","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","30.69","30.21","30.69","1 through 10","365.82","572.04","percent of total billed charges",""
"CATHETER MARINER 5FR 100CM .038IN ANGIOGRAPHY COBRA 2 HYDROP - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10166019","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","562.80","80.4","","82.69","82.69","82.69","1 through 10","365.82","572.04","percent of total billed charges",""
"CATHETER MARINER 5FR 100CM .038IN ANGIOGRAPHY COBRA 2 HYDROP - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10166019","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","572.04","81.72","","751.01","74.72","751.01","1 through 10","365.82","572.04","percent of total billed charges",""
"CATHETER MARINER 5FR 100CM .038IN ANGIOGRAPHY COBRA 2 HYDROP - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10166019","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","328.92","46.17","2701.97","59","365.82","572.04","percent of total billed charges",""
"CATHETER MAXI LD 4CMX16MM 80 4ATM NOMINAL 6ATM .035IN PERIPH OTW COMPLIANT BALLOON NON SCRD WIRE COMPAT BURRST RATE Y","SUP-ITM-10009762","CDM","C1725","HCPCS","0272","RC","","","","both","","","1010.63","757.97","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","725.63","71.8","","175.91","175.91","175.91","1 through 10","313.3","803.45","percent of total billed charges",""
"CATHETER MAXI LD 4CMX16MM 80 4ATM NOMINAL 6ATM .035IN PERIPH OTW COMPLIANT BALLOON NON SCRD WIRE COMPAT BURRST RATE Y","SUP-ITM-10009762","CDM","C1725","HCPCS","0272","RC","","","","both","","","1010.63","757.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","656.91","65","","147.88","147.88","1296.75","1 through 10","313.3","803.45","percent of total billed charges",""
"CATHETER MAXI LD 4CMX16MM 80 4ATM NOMINAL 6ATM .035IN PERIPH OTW COMPLIANT BALLOON NON SCRD WIRE COMPAT BURRST RATE Y","SUP-ITM-10009762","CDM","C1725","HCPCS","0272","RC","","","","both","","","1010.63","757.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","368.88","36.5","","181.40","177.87","181.40","21","313.3","803.45","percent of total billed charges",""
"CATHETER MAXI LD 4CMX16MM 80 4ATM NOMINAL 6ATM .035IN PERIPH OTW COMPLIANT BALLOON NON SCRD WIRE COMPAT BURRST RATE Y","SUP-ITM-10009762","CDM","C1725","HCPCS","0272","RC","","","","both","","","1010.63","757.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","387.07","38.3","","170.15","88.95","424.24","16","313.3","803.45","percent of total billed charges",""
"CATHETER MAXI LD 4CMX16MM 80 4ATM NOMINAL 6ATM .035IN PERIPH OTW COMPLIANT BALLOON NON SCRD WIRE COMPAT BURRST RATE Y","SUP-ITM-10009762","CDM","C1725","HCPCS","0272","RC","","","","both","","","1010.63","757.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","433.56","42.9","","699.48","699.48","699.48","12","313.3","803.45","percent of total billed charges",""
"CATHETER MAXI LD 4CMX16MM 80 4ATM NOMINAL 6ATM .035IN PERIPH OTW COMPLIANT BALLOON NON SCRD WIRE COMPAT BURRST RATE Y","SUP-ITM-10009762","CDM","C1725","HCPCS","0272","RC","","","","both","","","1010.63","757.97","WELLPOINT [1015]","HB AMC WELLPOINT","745.64","73.78","","576.52","182.40","651.44","14","313.3","803.45","percent of total billed charges",""
"CATHETER MAXI LD 4CMX16MM 80 4ATM NOMINAL 6ATM .035IN PERIPH OTW COMPLIANT BALLOON NON SCRD WIRE COMPAT BURRST RATE Y","SUP-ITM-10009762","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1010.63","757.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","825.89","81.72","","181.86","100.03","402.41","21","528.16","825.89","percent of total billed charges",""
"CATHETER METACROSS 200CM 6FR 8X20MM ANGIOPLASTY PTA R2P BALLOON BX/1EA","SUP-ITM-10281374","CDM","C1725","HCPCS","0272","RC","","","","both","","","946.75","710.06","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","679.77","71.8","","175.91","175.91","175.91","1 through 10","293.49","752.67","percent of total billed charges",""
"CATHETER METACROSS 200CM 6FR 8X20MM ANGIOPLASTY PTA R2P BALLOON BX/1EA","SUP-ITM-10281374","CDM","C1725","HCPCS","0272","RC","","","","both","","","946.75","710.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","615.39","65","","147.88","147.88","1296.75","1 through 10","293.49","752.67","percent of total billed charges",""
"CATHETER METACROSS 200CM 6FR 8X20MM ANGIOPLASTY PTA R2P BALLOON BX/1EA","SUP-ITM-10281374","CDM","C1725","HCPCS","0272","RC","","","","both","","","946.75","710.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","345.56","36.5","","181.40","177.87","181.40","21","293.49","752.67","percent of total billed charges",""
"CATHETER METACROSS 200CM 6FR 8X20MM ANGIOPLASTY PTA R2P BALLOON BX/1EA","SUP-ITM-10281374","CDM","C1725","HCPCS","0272","RC","","","","both","","","946.75","710.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","362.61","38.3","","170.15","88.95","424.24","16","293.49","752.67","percent of total billed charges",""
"CATHETER METACROSS 200CM 6FR 8X20MM ANGIOPLASTY PTA R2P BALLOON BX/1EA","SUP-ITM-10281374","CDM","C1725","HCPCS","0272","RC","","","","both","","","946.75","710.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","406.16","42.9","","699.48","699.48","699.48","12","293.49","752.67","percent of total billed charges",""
"CATHETER METACROSS 200CM 6FR 8X20MM ANGIOPLASTY PTA R2P BALLOON BX/1EA","SUP-ITM-10281374","CDM","C1725","HCPCS","0272","RC","","","","both","","","946.75","710.06","WELLPOINT [1015]","HB AMC WELLPOINT","698.51","73.78","","576.52","182.40","651.44","14","293.49","752.67","percent of total billed charges",""
"CATHETER METACROSS 200CM 6FR 8X20MM ANGIOPLASTY PTA R2P BALLOON BX/1EA","SUP-ITM-10281374","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","946.75","710.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","773.68","81.72","","181.86","100.03","402.41","21","494.77","773.68","percent of total billed charges",""
"CATHETER MINI TREK 5FR 2X8MM 145CM DILATION BALLOON CORONARY RX COMPLIANT NON SCORED","SUP-ITM-10083751","CDM","C1725","HCPCS","0272","RC","","","","both","","","227.50","170.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","163.35","71.8","","175.91","175.91","175.91","1 through 10","70.53","180.86","percent of total billed charges",""
"CATHETER MINI TREK 5FR 2X8MM 145CM DILATION BALLOON CORONARY RX COMPLIANT NON SCORED","SUP-ITM-10083751","CDM","C1725","HCPCS","0272","RC","","","","both","","","227.50","170.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","147.88","65","","147.88","147.88","1296.75","1 through 10","70.53","180.86","percent of total billed charges",""
"CATHETER MINI TREK 5FR 2X8MM 145CM DILATION BALLOON CORONARY RX COMPLIANT NON SCORED","SUP-ITM-10083751","CDM","C1725","HCPCS","0272","RC","","","","both","","","227.50","170.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.04","36.5","","181.40","177.87","181.40","21","70.53","180.86","percent of total billed charges",""
"CATHETER MINI TREK 5FR 2X8MM 145CM DILATION BALLOON CORONARY RX COMPLIANT NON SCORED","SUP-ITM-10083751","CDM","C1725","HCPCS","0272","RC","","","","both","","","227.50","170.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.13","38.3","","170.15","88.95","424.24","16","70.53","180.86","percent of total billed charges",""
"CATHETER MINI TREK 5FR 2X8MM 145CM DILATION BALLOON CORONARY RX COMPLIANT NON SCORED","SUP-ITM-10083751","CDM","C1725","HCPCS","0272","RC","","","","both","","","227.50","170.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.60","42.9","","699.48","699.48","699.48","12","70.53","180.86","percent of total billed charges",""
"CATHETER MINI TREK 5FR 2X8MM 145CM DILATION BALLOON CORONARY RX COMPLIANT NON SCORED","SUP-ITM-10083751","CDM","C1725","HCPCS","0272","RC","","","","both","","","227.50","170.62","WELLPOINT [1015]","HB AMC WELLPOINT","167.85","73.78","","576.52","182.40","651.44","14","70.53","180.86","percent of total billed charges",""
"CATHETER MINI TREK 5FR 2X8MM 145CM DILATION BALLOON CORONARY RX COMPLIANT NON SCORED","SUP-ITM-10083751","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","227.50","170.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","185.91","81.72","","181.86","100.03","402.41","21","118.89","185.91","percent of total billed charges",""
"CATHETER MINNIE 6FRX.035INX135CM SUPPORT VASCULAR","SUP-ITM-10065040","CDM","C1887","HCPCS","0272","RC","","","","both","","","442.05","331.54","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","317.39","71.8","","28.28","27.13","28.28","1 through 10","137.04","351.43","percent of total billed charges",""
"CATHETER MINNIE 6FRX.035INX135CM SUPPORT VASCULAR","SUP-ITM-10065040","CDM","C1887","HCPCS","0272","RC","","","","both","","","442.05","331.54","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","309.44","70","","44.63","35.78","44.63","1 through 10","137.04","351.43","percent of total billed charges",""
"CATHETER MINNIE 6FRX.035INX135CM SUPPORT VASCULAR","SUP-ITM-10065040","CDM","C1887","HCPCS","0272","RC","","","","both","","","442.05","331.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","351.43","79.5","","1342.89","271.64","6954.67","1 through 10","137.04","351.43","percent of total billed charges",""
"CATHETER MINNIE 6FRX.035INX135CM SUPPORT VASCULAR","SUP-ITM-10065040","CDM","C1887","HCPCS","0272","RC","","","","both","","","442.05","331.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","235.61","53.3","","4550.00","30.49","4550.00","1 through 10","137.04","351.43","percent of total billed charges",""
"CATHETER MINNIE 6FRX.035INX135CM SUPPORT VASCULAR","SUP-ITM-10065040","CDM","C1887","HCPCS","0272","RC","","","","both","","","442.05","331.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","287.33","65","","42.09","0.04","5453.50","1 through 10","137.04","351.43","percent of total billed charges",""
"CATHETER MINNIE 6FRX.035INX135CM SUPPORT VASCULAR","SUP-ITM-10065040","CDM","C1887","HCPCS","0272","RC","","","","both","","","442.05","331.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","161.35","36.5","","310.94","18.54","1259.30","62","137.04","351.43","percent of total billed charges",""
"CATHETER MINNIE 6FRX.035INX135CM SUPPORT VASCULAR","SUP-ITM-10065040","CDM","C1887","HCPCS","0272","RC","","","","both","","","442.05","331.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","169.31","38.3","","146.86","22.58","1753.45","65","137.04","351.43","percent of total billed charges",""
"CATHETER MINNIE 6FRX.035INX135CM SUPPORT VASCULAR","SUP-ITM-10065040","CDM","C1887","HCPCS","0272","RC","","","","both","","","442.05","331.54","WELLPOINT [1015]","HB AMC WELLPOINT","326.14","73.78","","247.29","33.09","909.09","53","137.04","351.43","percent of total billed charges",""
"CATHETER MINNIE 6FRX.035INX135CM SUPPORT VASCULAR","SUP-ITM-10065040","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","442.05","331.54","AETNA [1001]","HB AMC AETNA HMO","308.55","69.8","","30.69","30.21","30.69","1 through 10","231.02","361.24","percent of total billed charges",""
"CATHETER MINNIE 6FRX.035INX135CM SUPPORT VASCULAR","SUP-ITM-10065040","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","442.05","331.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","355.41","80.4","","82.69","82.69","82.69","1 through 10","231.02","361.24","percent of total billed charges",""
"CATHETER MINNIE 6FRX.035INX135CM SUPPORT VASCULAR","SUP-ITM-10065040","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","442.05","331.54","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","361.24","81.72","","751.01","74.72","751.01","1 through 10","231.02","361.24","percent of total billed charges",""
"CATHETER MINNIE 6FRX.035INX135CM SUPPORT VASCULAR","SUP-ITM-10065040","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","442.05","331.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","361.24","81.72","","328.92","46.17","2701.97","59","231.02","361.24","percent of total billed charges",""
"CATHETER MUSTANG 5FR 6MM 20MM 75CM .035IN DILATATION BALLOON HIGH PRESSURE PERIPH","SUP-ITM-10091420","CDM","C1725","HCPCS","0272","RC","","","","both","","","875.00","656.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","628.25","71.8","","175.91","175.91","175.91","1 through 10","271.25","695.63","percent of total billed charges",""
"CATHETER MUSTANG 5FR 6MM 20MM 75CM .035IN DILATATION BALLOON HIGH PRESSURE PERIPH","SUP-ITM-10091420","CDM","C1725","HCPCS","0272","RC","","","","both","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","568.75","65","","147.88","147.88","1296.75","1 through 10","271.25","695.63","percent of total billed charges",""
"CATHETER MUSTANG 5FR 6MM 20MM 75CM .035IN DILATATION BALLOON HIGH PRESSURE PERIPH","SUP-ITM-10091420","CDM","C1725","HCPCS","0272","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","181.40","177.87","181.40","21","271.25","695.63","percent of total billed charges",""
"CATHETER MUSTANG 5FR 6MM 20MM 75CM .035IN DILATATION BALLOON HIGH PRESSURE PERIPH","SUP-ITM-10091420","CDM","C1725","HCPCS","0272","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","170.15","88.95","424.24","16","271.25","695.63","percent of total billed charges",""
"CATHETER MUSTANG 5FR 6MM 20MM 75CM .035IN DILATATION BALLOON HIGH PRESSURE PERIPH","SUP-ITM-10091420","CDM","C1725","HCPCS","0272","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","699.48","699.48","699.48","12","271.25","695.63","percent of total billed charges",""
"CATHETER MUSTANG 5FR 6MM 20MM 75CM .035IN DILATATION BALLOON HIGH PRESSURE PERIPH","SUP-ITM-10091420","CDM","C1725","HCPCS","0272","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","576.52","182.40","651.44","14","271.25","695.63","percent of total billed charges",""
"CATHETER MUSTANG 5FR 6MM 20MM 75CM .035IN DILATATION BALLOON HIGH PRESSURE PERIPH","SUP-ITM-10091420","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","181.86","100.03","402.41","21","457.28","715.05","percent of total billed charges",""
"CATHETER NANOCROSS ELITE 4FR 2MM 40MM 150CM .014IN OTW BALLOON PTA DILATION PERIPHERAL","SUP-ITM-10042663","CDM","C1725","HCPCS","0272","RC","","","","both","","","395.50","296.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","283.97","71.8","","175.91","175.91","175.91","1 through 10","122.61","314.42","percent of total billed charges",""
"CATHETER NANOCROSS ELITE 4FR 2MM 40MM 150CM .014IN OTW BALLOON PTA DILATION PERIPHERAL","SUP-ITM-10042663","CDM","C1725","HCPCS","0272","RC","","","","both","","","395.50","296.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","257.08","65","","147.88","147.88","1296.75","1 through 10","122.61","314.42","percent of total billed charges",""
"CATHETER NANOCROSS ELITE 4FR 2MM 40MM 150CM .014IN OTW BALLOON PTA DILATION PERIPHERAL","SUP-ITM-10042663","CDM","C1725","HCPCS","0272","RC","","","","both","","","395.50","296.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","144.36","36.5","","181.40","177.87","181.40","21","122.61","314.42","percent of total billed charges",""
"CATHETER NANOCROSS ELITE 4FR 2MM 40MM 150CM .014IN OTW BALLOON PTA DILATION PERIPHERAL","SUP-ITM-10042663","CDM","C1725","HCPCS","0272","RC","","","","both","","","395.50","296.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","151.48","38.3","","170.15","88.95","424.24","16","122.61","314.42","percent of total billed charges",""
"CATHETER NANOCROSS ELITE 4FR 2MM 40MM 150CM .014IN OTW BALLOON PTA DILATION PERIPHERAL","SUP-ITM-10042663","CDM","C1725","HCPCS","0272","RC","","","","both","","","395.50","296.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","169.67","42.9","","699.48","699.48","699.48","12","122.61","314.42","percent of total billed charges",""
"CATHETER NANOCROSS ELITE 4FR 2MM 40MM 150CM .014IN OTW BALLOON PTA DILATION PERIPHERAL","SUP-ITM-10042663","CDM","C1725","HCPCS","0272","RC","","","","both","","","395.50","296.62","WELLPOINT [1015]","HB AMC WELLPOINT","291.80","73.78","","576.52","182.40","651.44","14","122.61","314.42","percent of total billed charges",""
"CATHETER NANOCROSS ELITE 4FR 2MM 40MM 150CM .014IN OTW BALLOON PTA DILATION PERIPHERAL","SUP-ITM-10042663","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","395.50","296.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","323.20","81.72","","181.86","100.03","402.41","21","206.69","323.2","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 150CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100041","CDM","C1887","HCPCS","0272","RC","","","","both","","","631.75","473.81","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","453.60","71.8","","28.28","27.13","28.28","1 through 10","195.84","502.24","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 150CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100041","CDM","C1887","HCPCS","0272","RC","","","","both","","","631.75","473.81","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","442.23","70","","44.63","35.78","44.63","1 through 10","195.84","502.24","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 150CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100041","CDM","C1887","HCPCS","0272","RC","","","","both","","","631.75","473.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","502.24","79.5","","1342.89","271.64","6954.67","1 through 10","195.84","502.24","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 150CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100041","CDM","C1887","HCPCS","0272","RC","","","","both","","","631.75","473.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","336.72","53.3","","4550.00","30.49","4550.00","1 through 10","195.84","502.24","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 150CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100041","CDM","C1887","HCPCS","0272","RC","","","","both","","","631.75","473.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","410.64","65","","42.09","0.04","5453.50","1 through 10","195.84","502.24","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 150CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100041","CDM","C1887","HCPCS","0272","RC","","","","both","","","631.75","473.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","230.59","36.5","","310.94","18.54","1259.30","62","195.84","502.24","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 150CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100041","CDM","C1887","HCPCS","0272","RC","","","","both","","","631.75","473.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","241.96","38.3","","146.86","22.58","1753.45","65","195.84","502.24","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 150CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100041","CDM","C1887","HCPCS","0272","RC","","","","both","","","631.75","473.81","WELLPOINT [1015]","HB AMC WELLPOINT","466.11","73.78","","247.29","33.09","909.09","53","195.84","502.24","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 150CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100041","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","631.75","473.81","AETNA [1001]","HB AMC AETNA HMO","440.96","69.8","","30.69","30.21","30.69","1 through 10","330.15","516.27","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 150CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100041","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","631.75","473.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","507.93","80.4","","82.69","82.69","82.69","1 through 10","330.15","516.27","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 150CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100041","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","631.75","473.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","516.27","81.72","","751.01","74.72","751.01","1 through 10","330.15","516.27","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 150CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100041","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","631.75","473.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","516.27","81.72","","328.92","46.17","2701.97","59","330.15","516.27","percent of total billed charges",""
"CATHETER OCCLUDING 120CM BALLOON INTRAVASCULAR IMAGE GUIDED","SUP-ITM-10306398","CDM","C2628","HCPCS","0272","RC","","","","both","","","1190.00","892.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","946.05","79.5","","518.94","518.94","518.94","1 through 10","368.9","946.05","percent of total billed charges",""
"CATHETER OCCLUDING 120CM BALLOON INTRAVASCULAR IMAGE GUIDED","SUP-ITM-10306398","CDM","C2628","HCPCS","0272","RC","","","","both","","","1190.00","892.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","773.50","65","","429.02","429.02","429.02","1 through 10","368.9","946.05","percent of total billed charges",""
"CATHETER OCCLUDING 120CM BALLOON INTRAVASCULAR IMAGE GUIDED","SUP-ITM-10306398","CDM","C2628","HCPCS","0272","RC","","","","both","","","1190.00","892.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","434.35","36.5","","4636.13","4636.13","4636.13","1 through 10","368.9","946.05","percent of total billed charges",""
"CATHETER OCCLUDING 120CM BALLOON INTRAVASCULAR IMAGE GUIDED","SUP-ITM-10306398","CDM","C2628","HCPCS","0272","RC","","","","both","","","1190.00","892.50","WELLPOINT [1015]","HB AMC WELLPOINT","877.98","73.78","","491.39","491.39","491.39","1 through 10","368.9","946.05","percent of total billed charges",""
"CATHETER OCCLUDING 120CM BALLOON INTRAVASCULAR IMAGE GUIDED","SUP-ITM-10306398","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","1190.00","892.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","972.47","81.72","","290.22","290.22","290.22","1 through 10","621.89","972.47","percent of total billed charges",""
"CATHETER OCCLUSION 26FR 5.0X100CM BALLOON PERCUTANEOUS NEPHROLITHOTOMY","SUP-ITM-10155557","CDM","C2628","HCPCS","0272","RC","","","","both","","","688.31","516.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","547.21","79.5","","518.94","518.94","518.94","1 through 10","213.38","547.21","percent of total billed charges",""
"CATHETER OCCLUSION 26FR 5.0X100CM BALLOON PERCUTANEOUS NEPHROLITHOTOMY","SUP-ITM-10155557","CDM","C2628","HCPCS","0272","RC","","","","both","","","688.31","516.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","447.40","65","","429.02","429.02","429.02","1 through 10","213.38","547.21","percent of total billed charges",""
"CATHETER OCCLUSION 26FR 5.0X100CM BALLOON PERCUTANEOUS NEPHROLITHOTOMY","SUP-ITM-10155557","CDM","C2628","HCPCS","0272","RC","","","","both","","","688.31","516.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","251.23","36.5","","4636.13","4636.13","4636.13","1 through 10","213.38","547.21","percent of total billed charges",""
"CATHETER OCCLUSION 26FR 5.0X100CM BALLOON PERCUTANEOUS NEPHROLITHOTOMY","SUP-ITM-10155557","CDM","C2628","HCPCS","0272","RC","","","","both","","","688.31","516.23","WELLPOINT [1015]","HB AMC WELLPOINT","507.84","73.78","","491.39","491.39","491.39","1 through 10","213.38","547.21","percent of total billed charges",""
"CATHETER OCCLUSION 26FR 5.0X100CM BALLOON PERCUTANEOUS NEPHROLITHOTOMY","SUP-ITM-10155557","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","688.31","516.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","562.49","81.72","","290.22","290.22","290.22","1 through 10","359.71","562.49","percent of total billed charges",""
"CATHETER OCCLUSION 7FR 33MM 100CM DOUBLE LUMEN EQUALIZER RUBBER","SUP-ITM-10013971","CDM","C2628","HCPCS","0272","RC","","","","both","","","798.00","598.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","634.41","79.5","","518.94","518.94","518.94","1 through 10","247.38","634.41","percent of total billed charges",""
"CATHETER OCCLUSION 7FR 33MM 100CM DOUBLE LUMEN EQUALIZER RUBBER","SUP-ITM-10013971","CDM","C2628","HCPCS","0272","RC","","","","both","","","798.00","598.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","518.70","65","","429.02","429.02","429.02","1 through 10","247.38","634.41","percent of total billed charges",""
"CATHETER OCCLUSION 7FR 33MM 100CM DOUBLE LUMEN EQUALIZER RUBBER","SUP-ITM-10013971","CDM","C2628","HCPCS","0272","RC","","","","both","","","798.00","598.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","291.27","36.5","","4636.13","4636.13","4636.13","1 through 10","247.38","634.41","percent of total billed charges",""
"CATHETER OCCLUSION 7FR 33MM 100CM DOUBLE LUMEN EQUALIZER RUBBER","SUP-ITM-10013971","CDM","C2628","HCPCS","0272","RC","","","","both","","","798.00","598.50","WELLPOINT [1015]","HB AMC WELLPOINT","588.76","73.78","","491.39","491.39","491.39","1 through 10","247.38","634.41","percent of total billed charges",""
"CATHETER OCCLUSION 7FR 33MM 100CM DOUBLE LUMEN EQUALIZER RUBBER","SUP-ITM-10013971","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","798.00","598.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","652.13","81.72","","290.22","290.22","290.22","1 through 10","417.03","652.13","percent of total billed charges",""
"CATHETER OCCLUSION 9FRX23CM DOUBLE LUMEN IRRIGATION PRUITT AORTIC","SUP-ITM-10139486","CDM","C2628","HCPCS","0272","RC","","","","both","","","1190.00","892.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","946.05","79.5","","518.94","518.94","518.94","1 through 10","368.9","946.05","percent of total billed charges",""
"CATHETER OCCLUSION 9FRX23CM DOUBLE LUMEN IRRIGATION PRUITT AORTIC","SUP-ITM-10139486","CDM","C2628","HCPCS","0272","RC","","","","both","","","1190.00","892.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","773.50","65","","429.02","429.02","429.02","1 through 10","368.9","946.05","percent of total billed charges",""
"CATHETER OCCLUSION 9FRX23CM DOUBLE LUMEN IRRIGATION PRUITT AORTIC","SUP-ITM-10139486","CDM","C2628","HCPCS","0272","RC","","","","both","","","1190.00","892.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","434.35","36.5","","4636.13","4636.13","4636.13","1 through 10","368.9","946.05","percent of total billed charges",""
"CATHETER OCCLUSION 9FRX23CM DOUBLE LUMEN IRRIGATION PRUITT AORTIC","SUP-ITM-10139486","CDM","C2628","HCPCS","0272","RC","","","","both","","","1190.00","892.50","WELLPOINT [1015]","HB AMC WELLPOINT","877.98","73.78","","491.39","491.39","491.39","1 through 10","368.9","946.05","percent of total billed charges",""
"CATHETER OCCLUSION 9FRX23CM DOUBLE LUMEN IRRIGATION PRUITT AORTIC","SUP-ITM-10139486","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","1190.00","892.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","972.47","81.72","","290.22","290.22","290.22","1 through 10","621.89","972.47","percent of total billed charges",""
"Catheter Occlusion T1","PX-27000211","CDM","C2628","HCPCS","0272","RC","","","","both","","","950.53","712.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","755.67","79.5","","518.94","518.94","518.94","1 through 10","294.66","755.67","percent of total billed charges",""
"Catheter Occlusion T1","PX-27000211","CDM","C2628","HCPCS","0272","RC","","","","both","","","950.53","712.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","617.84","65","","429.02","429.02","429.02","1 through 10","294.66","755.67","percent of total billed charges",""
"Catheter Occlusion T1","PX-27000211","CDM","C2628","HCPCS","0272","RC","","","","both","","","950.53","712.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","346.94","36.5","","4636.13","4636.13","4636.13","1 through 10","294.66","755.67","percent of total billed charges",""
"Catheter Occlusion T1","PX-27000211","CDM","C2628","HCPCS","0272","RC","","","","both","","","950.53","712.90","WELLPOINT [1015]","HB AMC WELLPOINT","701.30","73.78","","491.39","491.39","491.39","1 through 10","294.66","755.67","percent of total billed charges",""
"Catheter Occlusion T1","PX-27000211","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","950.53","712.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","776.77","81.72","","290.22","290.22","290.22","1 through 10","496.75","776.77","percent of total billed charges",""
"Catheter Occlusion T3","PX-27000212","CDM","C2628","HCPCS","0272","RC","","","","both","","","5124.53","3843.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4074.00","79.5","","518.94","518.94","518.94","1 through 10","1588.6","4074","percent of total billed charges",""
"Catheter Occlusion T3","PX-27000212","CDM","C2628","HCPCS","0272","RC","","","","both","","","5124.53","3843.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3330.94","65","","429.02","429.02","429.02","1 through 10","1588.6","4074","percent of total billed charges",""
"Catheter Occlusion T3","PX-27000212","CDM","C2628","HCPCS","0272","RC","","","","both","","","5124.53","3843.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1870.45","36.5","","4636.13","4636.13","4636.13","1 through 10","1588.6","4074","percent of total billed charges",""
"Catheter Occlusion T3","PX-27000212","CDM","C2628","HCPCS","0272","RC","","","","both","","","5124.53","3843.40","WELLPOINT [1015]","HB AMC WELLPOINT","3780.88","73.78","","491.39","491.39","491.39","1 through 10","1588.6","4074","percent of total billed charges",""
"Catheter Occlusion T3","PX-27000212","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","5124.53","3843.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4187.77","81.72","","290.22","290.22","290.22","1 through 10","2678.08","4187.77","percent of total billed charges",""
"Catheter Occlusion Tier2","PX-27001092","CDM","C2628","HCPCS","0272","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","518.94","518.94","518.94","1 through 10","1302","3339","percent of total billed charges",""
"Catheter Occlusion Tier2","PX-27001092","CDM","C2628","HCPCS","0272","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2730.00","65","","429.02","429.02","429.02","1 through 10","1302","3339","percent of total billed charges",""
"Catheter Occlusion Tier2","PX-27001092","CDM","C2628","HCPCS","0272","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","4636.13","4636.13","4636.13","1 through 10","1302","3339","percent of total billed charges",""
"Catheter Occlusion Tier2","PX-27001092","CDM","C2628","HCPCS","0272","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","491.39","491.39","491.39","1 through 10","1302","3339","percent of total billed charges",""
"Catheter Occlusion Tier2","PX-27001092","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3432.24","81.72","","290.22","290.22","290.22","1 through 10","2194.92","3432.24","percent of total billed charges",""
"CATHETER OMNI 5FR 80CM .038IN GUIDING VASCULAR SOS PERIPH W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE BX/5EA","SUP-ITM-10000359","CDM","C1887","HCPCS","0272","RC","","","","both","","","49.70","37.27","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","35.68","71.8","","28.28","27.13","28.28","1 through 10","15.41","39.51","percent of total billed charges",""
"CATHETER OMNI 5FR 80CM .038IN GUIDING VASCULAR SOS PERIPH W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE BX/5EA","SUP-ITM-10000359","CDM","C1887","HCPCS","0272","RC","","","","both","","","49.70","37.27","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","34.79","70","","44.63","35.78","44.63","1 through 10","15.41","39.51","percent of total billed charges",""
"CATHETER OMNI 5FR 80CM .038IN GUIDING VASCULAR SOS PERIPH W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE BX/5EA","SUP-ITM-10000359","CDM","C1887","HCPCS","0272","RC","","","","both","","","49.70","37.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","39.51","79.5","","1342.89","271.64","6954.67","1 through 10","15.41","39.51","percent of total billed charges",""
"CATHETER OMNI 5FR 80CM .038IN GUIDING VASCULAR SOS PERIPH W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE BX/5EA","SUP-ITM-10000359","CDM","C1887","HCPCS","0272","RC","","","","both","","","49.70","37.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","26.49","53.3","","4550.00","30.49","4550.00","1 through 10","15.41","39.51","percent of total billed charges",""
"CATHETER OMNI 5FR 80CM .038IN GUIDING VASCULAR SOS PERIPH W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE BX/5EA","SUP-ITM-10000359","CDM","C1887","HCPCS","0272","RC","","","","both","","","49.70","37.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","32.31","65","","42.09","0.04","5453.50","1 through 10","15.41","39.51","percent of total billed charges",""
"CATHETER OMNI 5FR 80CM .038IN GUIDING VASCULAR SOS PERIPH W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE BX/5EA","SUP-ITM-10000359","CDM","C1887","HCPCS","0272","RC","","","","both","","","49.70","37.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","18.14","36.5","","310.94","18.54","1259.30","62","15.41","39.51","percent of total billed charges",""
"CATHETER OMNI 5FR 80CM .038IN GUIDING VASCULAR SOS PERIPH W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE BX/5EA","SUP-ITM-10000359","CDM","C1887","HCPCS","0272","RC","","","","both","","","49.70","37.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","19.04","38.3","","146.86","22.58","1753.45","65","15.41","39.51","percent of total billed charges",""
"CATHETER OMNI 5FR 80CM .038IN GUIDING VASCULAR SOS PERIPH W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE BX/5EA","SUP-ITM-10000359","CDM","C1887","HCPCS","0272","RC","","","","both","","","49.70","37.27","WELLPOINT [1015]","HB AMC WELLPOINT","36.67","73.78","","247.29","33.09","909.09","53","15.41","39.51","percent of total billed charges",""
"CATHETER OMNI 5FR 80CM .038IN GUIDING VASCULAR SOS PERIPH W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE BX/5EA","SUP-ITM-10000359","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","49.70","37.27","AETNA [1001]","HB AMC AETNA HMO","34.69","69.8","","30.69","30.21","30.69","1 through 10","25.97","40.61","percent of total billed charges",""
"CATHETER OMNI 5FR 80CM .038IN GUIDING VASCULAR SOS PERIPH W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE BX/5EA","SUP-ITM-10000359","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","49.70","37.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","39.96","80.4","","82.69","82.69","82.69","1 through 10","25.97","40.61","percent of total billed charges",""
"CATHETER OMNI 5FR 80CM .038IN GUIDING VASCULAR SOS PERIPH W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE BX/5EA","SUP-ITM-10000359","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","49.70","37.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","40.61","81.72","","751.01","74.72","751.01","1 through 10","25.97","40.61","percent of total billed charges",""
"CATHETER OMNI 5FR 80CM .038IN GUIDING VASCULAR SOS PERIPH W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE BX/5EA","SUP-ITM-10000359","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","49.70","37.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","40.61","81.72","","328.92","46.17","2701.97","59","25.97","40.61","percent of total billed charges",""
"CATHETER ONE-STEP 5FR 15CM 19GA CENTESIS STRAIGHT SLIP FIT SELF CLOSING 4HOLE BX/5EA","SUP-ITM-10115660","CDM","C1729","HCPCS","0272","RC","","","","both","","","64.75","48.56","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","46.49","71.8","","162.24","51.52","162.24","1 through 10","20.07","51.48","percent of total billed charges",""
"CATHETER ONE-STEP 5FR 15CM 19GA CENTESIS STRAIGHT SLIP FIT SELF CLOSING 4HOLE BX/5EA","SUP-ITM-10115660","CDM","C1729","HCPCS","0272","RC","","","","both","","","64.75","48.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.63","36.5","","94.34","22.19","146.22","26","20.07","51.48","percent of total billed charges",""
"CATHETER ONE-STEP 5FR 15CM 19GA CENTESIS STRAIGHT SLIP FIT SELF CLOSING 4HOLE BX/5EA","SUP-ITM-10115660","CDM","C1729","HCPCS","0272","RC","","","","both","","","64.75","48.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.80","38.3","","51.52","27.37","51.52","26","20.07","51.48","percent of total billed charges",""
"CATHETER ONE-STEP 5FR 15CM 19GA CENTESIS STRAIGHT SLIP FIT SELF CLOSING 4HOLE BX/5EA","SUP-ITM-10115660","CDM","C1729","HCPCS","0272","RC","","","","both","","","64.75","48.56","WELLPOINT [1015]","HB AMC WELLPOINT","47.77","73.78","","207.21","122.12","216.28","14","20.07","51.48","percent of total billed charges",""
"CATHETER ONE-STEP 5FR 15CM 19GA CENTESIS STRAIGHT SLIP FIT SELF CLOSING 4HOLE BX/5EA","SUP-ITM-10115660","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","64.75","48.56","AETNA [1001]","HB AMC AETNA HMO","45.20","69.8","","155.96","47.39","155.96","1 through 10","33.84","52.91","percent of total billed charges",""
"CATHETER ONE-STEP 5FR 15CM 19GA CENTESIS STRAIGHT SLIP FIT SELF CLOSING 4HOLE BX/5EA","SUP-ITM-10115660","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","64.75","48.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","52.91","81.72","","57.36","51.76","232.23","35","33.84","52.91","percent of total billed charges",""
"CATHETER ONE-STEP 5FR 7CM 19GA CENTESIS STRAIGHT SELF CLOSING 4HOLE BX/5EA","SUP-ITM-10115687","CDM","C1729","HCPCS","0272","RC","","","","both","","","71.75","53.81","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","51.52","71.8","","162.24","51.52","162.24","1 through 10","22.24","57.04","percent of total billed charges",""
"CATHETER ONE-STEP 5FR 7CM 19GA CENTESIS STRAIGHT SELF CLOSING 4HOLE BX/5EA","SUP-ITM-10115687","CDM","C1729","HCPCS","0272","RC","","","","both","","","71.75","53.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.19","36.5","","94.34","22.19","146.22","26","22.24","57.04","percent of total billed charges",""
"CATHETER ONE-STEP 5FR 7CM 19GA CENTESIS STRAIGHT SELF CLOSING 4HOLE BX/5EA","SUP-ITM-10115687","CDM","C1729","HCPCS","0272","RC","","","","both","","","71.75","53.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27.48","38.3","","51.52","27.37","51.52","26","22.24","57.04","percent of total billed charges",""
"CATHETER ONE-STEP 5FR 7CM 19GA CENTESIS STRAIGHT SELF CLOSING 4HOLE BX/5EA","SUP-ITM-10115687","CDM","C1729","HCPCS","0272","RC","","","","both","","","71.75","53.81","WELLPOINT [1015]","HB AMC WELLPOINT","52.94","73.78","","207.21","122.12","216.28","14","22.24","57.04","percent of total billed charges",""
"CATHETER ONE-STEP 5FR 7CM 19GA CENTESIS STRAIGHT SELF CLOSING 4HOLE BX/5EA","SUP-ITM-10115687","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","71.75","53.81","AETNA [1001]","HB AMC AETNA HMO","50.08","69.8","","155.96","47.39","155.96","1 through 10","37.5","58.63","percent of total billed charges",""
"CATHETER ONE-STEP 5FR 7CM 19GA CENTESIS STRAIGHT SELF CLOSING 4HOLE BX/5EA","SUP-ITM-10115687","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","71.75","53.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","58.63","81.72","","57.36","51.76","232.23","35","37.5","58.63","percent of total billed charges",""
"CATHETER OPTA 5FR 5MM 20MM 80CM .035IN PRO OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007016","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","263.87","71.8","","175.91","175.91","175.91","1 through 10","113.93","292.16","percent of total billed charges",""
"CATHETER OPTA 5FR 5MM 20MM 80CM .035IN PRO OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007016","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","238.88","65","","147.88","147.88","1296.75","1 through 10","113.93","292.16","percent of total billed charges",""
"CATHETER OPTA 5FR 5MM 20MM 80CM .035IN PRO OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007016","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","134.14","36.5","","181.40","177.87","181.40","21","113.93","292.16","percent of total billed charges",""
"CATHETER OPTA 5FR 5MM 20MM 80CM .035IN PRO OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007016","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","140.75","38.3","","170.15","88.95","424.24","16","113.93","292.16","percent of total billed charges",""
"CATHETER OPTA 5FR 5MM 20MM 80CM .035IN PRO OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007016","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.66","42.9","","699.48","699.48","699.48","12","113.93","292.16","percent of total billed charges",""
"CATHETER OPTA 5FR 5MM 20MM 80CM .035IN PRO OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007016","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","WELLPOINT [1015]","HB AMC WELLPOINT","271.14","73.78","","576.52","182.40","651.44","14","113.93","292.16","percent of total billed charges",""
"CATHETER OPTA 5FR 5MM 20MM 80CM .035IN PRO OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007016","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","367.50","275.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","300.32","81.72","","181.86","100.03","402.41","21","192.06","300.32","percent of total billed charges",""
"CATHETER OPTA PRO 5FR 6MM 20MM 80CM .035IN OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007018","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","263.87","71.8","","175.91","175.91","175.91","1 through 10","113.93","292.16","percent of total billed charges",""
"CATHETER OPTA PRO 5FR 6MM 20MM 80CM .035IN OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007018","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","238.88","65","","147.88","147.88","1296.75","1 through 10","113.93","292.16","percent of total billed charges",""
"CATHETER OPTA PRO 5FR 6MM 20MM 80CM .035IN OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007018","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","134.14","36.5","","181.40","177.87","181.40","21","113.93","292.16","percent of total billed charges",""
"CATHETER OPTA PRO 5FR 6MM 20MM 80CM .035IN OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007018","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","140.75","38.3","","170.15","88.95","424.24","16","113.93","292.16","percent of total billed charges",""
"CATHETER OPTA PRO 5FR 6MM 20MM 80CM .035IN OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007018","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.66","42.9","","699.48","699.48","699.48","12","113.93","292.16","percent of total billed charges",""
"CATHETER OPTA PRO 5FR 6MM 20MM 80CM .035IN OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007018","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","WELLPOINT [1015]","HB AMC WELLPOINT","271.14","73.78","","576.52","182.40","651.44","14","113.93","292.16","percent of total billed charges",""
"CATHETER OPTA PRO 5FR 6MM 20MM 80CM .035IN OTW PTA NITINOL LOW PROFILE MODERATE PRESSURE PERIPHERAL","SUP-ITM-10007018","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","367.50","275.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","300.32","81.72","","181.86","100.03","402.41","21","192.06","300.32","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 19CM HEPARIN SPORTSPACK EMERALDVENATRAC BX/5EA","SUP-ITM-10267590","CDM","C1750","HCPCS","0278","RC","","","","both","","","1413.40","1060.05","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","738.64","52.26","","154.36","154.36","154.36","1 through 10","438.15","1123.65","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 19CM HEPARIN SPORTSPACK EMERALDVENATRAC BX/5EA","SUP-ITM-10267590","CDM","C1750","HCPCS","0278","RC","","","","both","","","1413.40","1060.05","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","918.71","65","","1371.74","196.32","1371.74","1 through 10","438.15","1123.65","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 19CM HEPARIN SPORTSPACK EMERALDVENATRAC BX/5EA","SUP-ITM-10267590","CDM","C1750","HCPCS","0278","RC","","","","both","","","1413.40","1060.05","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","989.38","70","","249.45","107.26","1254.96","14","438.15","1123.65","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 19CM HEPARIN SPORTSPACK EMERALDVENATRAC BX/5EA","SUP-ITM-10267590","CDM","C1750","HCPCS","0278","RC","","","","both","","","1413.40","1060.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1123.65","79.5","","196.32","85.01","196.32","1 through 10","438.15","1123.65","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 19CM HEPARIN SPORTSPACK EMERALDVENATRAC BX/5EA","SUP-ITM-10267590","CDM","C1750","HCPCS","0278","RC","","","","both","","","1413.40","1060.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","753.34","53.3","","1132.95","1132.95","1132.95","1 through 10","438.15","1123.65","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 19CM HEPARIN SPORTSPACK EMERALDVENATRAC BX/5EA","SUP-ITM-10267590","CDM","C1750","HCPCS","0278","RC","","","","both","","","1413.40","1060.05","WELLPOINT [1015]","HB AMC WELLPOINT","1042.81","73.78","","1297.66","185.72","1297.66","1 through 10","438.15","1123.65","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 19CM HEPARIN SPORTSPACK EMERALDVENATRAC BX/5EA","SUP-ITM-10267590","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1413.40","1060.05","AETNA [1001]","HB AMC AETNA HMO","986.55","69.8","","76.96","76.96","76.96","1 through 10","738.64","1155.03","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 19CM HEPARIN SPORTSPACK EMERALDVENATRAC BX/5EA","SUP-ITM-10267590","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1413.40","1060.05","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","738.64","52.26","","154.36","154.36","154.36","1 through 10","738.64","1155.03","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 19CM HEPARIN SPORTSPACK EMERALDVENATRAC BX/5EA","SUP-ITM-10267590","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1413.40","1060.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1155.03","81.72","","199.41","199.41","199.41","1 through 10","738.64","1155.03","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM CENTRAL VENOUS CARBOTHANE SPORT SLOT HEMODIALYSIS PK/5EA","SUP-ITM-10267325","CDM","C1750","HCPCS","0278","RC","","","","both","","","1200.47","900.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","627.37","52.26","","154.36","154.36","154.36","1 through 10","372.15","954.37","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM CENTRAL VENOUS CARBOTHANE SPORT SLOT HEMODIALYSIS PK/5EA","SUP-ITM-10267325","CDM","C1750","HCPCS","0278","RC","","","","both","","","1200.47","900.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","780.31","65","","1371.74","196.32","1371.74","1 through 10","372.15","954.37","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM CENTRAL VENOUS CARBOTHANE SPORT SLOT HEMODIALYSIS PK/5EA","SUP-ITM-10267325","CDM","C1750","HCPCS","0278","RC","","","","both","","","1200.47","900.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","840.33","70","","249.45","107.26","1254.96","14","372.15","954.37","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM CENTRAL VENOUS CARBOTHANE SPORT SLOT HEMODIALYSIS PK/5EA","SUP-ITM-10267325","CDM","C1750","HCPCS","0278","RC","","","","both","","","1200.47","900.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","954.37","79.5","","196.32","85.01","196.32","1 through 10","372.15","954.37","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM CENTRAL VENOUS CARBOTHANE SPORT SLOT HEMODIALYSIS PK/5EA","SUP-ITM-10267325","CDM","C1750","HCPCS","0278","RC","","","","both","","","1200.47","900.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","639.85","53.3","","1132.95","1132.95","1132.95","1 through 10","372.15","954.37","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM CENTRAL VENOUS CARBOTHANE SPORT SLOT HEMODIALYSIS PK/5EA","SUP-ITM-10267325","CDM","C1750","HCPCS","0278","RC","","","","both","","","1200.47","900.35","WELLPOINT [1015]","HB AMC WELLPOINT","885.71","73.78","","1297.66","185.72","1297.66","1 through 10","372.15","954.37","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM CENTRAL VENOUS CARBOTHANE SPORT SLOT HEMODIALYSIS PK/5EA","SUP-ITM-10267325","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1200.47","900.35","AETNA [1001]","HB AMC AETNA HMO","837.93","69.8","","76.96","76.96","76.96","1 through 10","627.37","981.02","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM CENTRAL VENOUS CARBOTHANE SPORT SLOT HEMODIALYSIS PK/5EA","SUP-ITM-10267325","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1200.47","900.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","627.37","52.26","","154.36","154.36","154.36","1 through 10","627.37","981.02","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM CENTRAL VENOUS CARBOTHANE SPORT SLOT HEMODIALYSIS PK/5EA","SUP-ITM-10267325","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1200.47","900.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","981.02","81.72","","199.41","199.41","199.41","1 through 10","627.37","981.02","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM SPORT PACK HEPARIN TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267591","CDM","C1750","HCPCS","0278","RC","","","","both","","","1413.40","1060.05","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","738.64","52.26","","154.36","154.36","154.36","1 through 10","438.15","1123.65","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM SPORT PACK HEPARIN TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267591","CDM","C1750","HCPCS","0278","RC","","","","both","","","1413.40","1060.05","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","918.71","65","","1371.74","196.32","1371.74","1 through 10","438.15","1123.65","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM SPORT PACK HEPARIN TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267591","CDM","C1750","HCPCS","0278","RC","","","","both","","","1413.40","1060.05","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","989.38","70","","249.45","107.26","1254.96","14","438.15","1123.65","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM SPORT PACK HEPARIN TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267591","CDM","C1750","HCPCS","0278","RC","","","","both","","","1413.40","1060.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1123.65","79.5","","196.32","85.01","196.32","1 through 10","438.15","1123.65","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM SPORT PACK HEPARIN TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267591","CDM","C1750","HCPCS","0278","RC","","","","both","","","1413.40","1060.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","753.34","53.3","","1132.95","1132.95","1132.95","1 through 10","438.15","1123.65","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM SPORT PACK HEPARIN TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267591","CDM","C1750","HCPCS","0278","RC","","","","both","","","1413.40","1060.05","WELLPOINT [1015]","HB AMC WELLPOINT","1042.81","73.78","","1297.66","185.72","1297.66","1 through 10","438.15","1123.65","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM SPORT PACK HEPARIN TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267591","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1413.40","1060.05","AETNA [1001]","HB AMC AETNA HMO","986.55","69.8","","76.96","76.96","76.96","1 through 10","738.64","1155.03","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM SPORT PACK HEPARIN TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267591","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1413.40","1060.05","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","738.64","52.26","","154.36","154.36","154.36","1 through 10","738.64","1155.03","percent of total billed charges",""
"CATHETER PALINDROME 14.5FR 23CM SPORT PACK HEPARIN TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267591","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1413.40","1060.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1155.03","81.72","","199.41","199.41","199.41","1 through 10","738.64","1155.03","percent of total billed charges",""
"CATHETER PERFUSION 20FR 31CM DOUBLE LUMEN BICAVAL TAPERED INTRODUCER TIP INTERNAL JUGULAR VEIN APPROACH AVALON ELITE POLYURETHANE SILICONE","SUP-ITM-10115494","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5765.74","79.5","","1309.77","674.56","6049.93","26","2248.28","5765.74","percent of total billed charges",""
"CATHETER PERFUSION 20FR 31CM DOUBLE LUMEN BICAVAL TAPERED INTRODUCER TIP INTERNAL JUGULAR VEIN APPROACH AVALON ELITE POLYURETHANE SILICONE","SUP-ITM-10115494","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3865.58","53.3","","1901.83","1901.83","2962.25","1 through 10","2248.28","5765.74","percent of total billed charges",""
"CATHETER PERFUSION 20FR 31CM DOUBLE LUMEN BICAVAL TAPERED INTRODUCER TIP INTERNAL JUGULAR VEIN APPROACH AVALON ELITE POLYURETHANE SILICONE","SUP-ITM-10115494","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2647.16","36.5","","1620.31","1620.31","19908.88","1 through 10","2248.28","5765.74","percent of total billed charges",""
"CATHETER PERFUSION 20FR 31CM DOUBLE LUMEN BICAVAL TAPERED INTRODUCER TIP INTERNAL JUGULAR VEIN APPROACH AVALON ELITE POLYURETHANE SILICONE","SUP-ITM-10115494","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2777.71","38.3","","352.91","352.91","2046.30","1 through 10","2248.28","5765.74","percent of total billed charges",""
"CATHETER PERFUSION 20FR 31CM DOUBLE LUMEN BICAVAL TAPERED INTRODUCER TIP INTERNAL JUGULAR VEIN APPROACH AVALON ELITE POLYURETHANE SILICONE","SUP-ITM-10115494","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3111.32","42.9","","9668.75","9668.75","9668.75","1 through 10","2248.28","5765.74","percent of total billed charges",""
"CATHETER PERFUSION 20FR 31CM DOUBLE LUMEN BICAVAL TAPERED INTRODUCER TIP INTERNAL JUGULAR VEIN APPROACH AVALON ELITE POLYURETHANE SILICONE","SUP-ITM-10115494","CDM","C1889","HCPCS","0278","RC","","","","both","","","7252.50","5439.37","WELLPOINT [1015]","HB AMC WELLPOINT","5350.89","73.78","","699.88","384.10","3443.31","33","2248.28","5765.74","percent of total billed charges",""
"CATHETER PERFUSION 20FR 31CM DOUBLE LUMEN BICAVAL TAPERED INTRODUCER TIP INTERNAL JUGULAR VEIN APPROACH AVALON ELITE POLYURETHANE SILICONE","SUP-ITM-10115494","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7252.50","5439.37","AETNA [1001]","HB AMC AETNA HMO","5062.25","69.8","","1421.24","264.50","4933.46","29","3790.16","5926.74","percent of total billed charges",""
"CATHETER PERFUSION 20FR 31CM DOUBLE LUMEN BICAVAL TAPERED INTRODUCER TIP INTERNAL JUGULAR VEIN APPROACH AVALON ELITE POLYURETHANE SILICONE","SUP-ITM-10115494","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7252.50","5439.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5831.01","80.4","","1022.97","1022.97","3607.50","1 through 10","3790.16","5926.74","percent of total billed charges",""
"CATHETER PERFUSION 20FR 31CM DOUBLE LUMEN BICAVAL TAPERED INTRODUCER TIP INTERNAL JUGULAR VEIN APPROACH AVALON ELITE POLYURETHANE SILICONE","SUP-ITM-10115494","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7252.50","5439.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5926.74","81.72","","3010.54","693.88","5019.88","35","3790.16","5926.74","percent of total billed charges",""
"CATHETER PERITONEAL 15FR 62.5CM DOUBLE CUFF ADULT RIGHT COILED SWAN NECK RADIOPAQUE STRIPE DIALYSIS","SUP-ITM-10009255","CDM","C1750","HCPCS","0278","RC","","","","both","","","616.91","462.68","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","322.40","52.26","","154.36","154.36","154.36","1 through 10","191.24","490.44","percent of total billed charges",""
"CATHETER PERITONEAL 15FR 62.5CM DOUBLE CUFF ADULT RIGHT COILED SWAN NECK RADIOPAQUE STRIPE DIALYSIS","SUP-ITM-10009255","CDM","C1750","HCPCS","0278","RC","","","","both","","","616.91","462.68","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","400.99","65","","1371.74","196.32","1371.74","1 through 10","191.24","490.44","percent of total billed charges",""
"CATHETER PERITONEAL 15FR 62.5CM DOUBLE CUFF ADULT RIGHT COILED SWAN NECK RADIOPAQUE STRIPE DIALYSIS","SUP-ITM-10009255","CDM","C1750","HCPCS","0278","RC","","","","both","","","616.91","462.68","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","431.84","70","","249.45","107.26","1254.96","14","191.24","490.44","percent of total billed charges",""
"CATHETER PERITONEAL 15FR 62.5CM DOUBLE CUFF ADULT RIGHT COILED SWAN NECK RADIOPAQUE STRIPE DIALYSIS","SUP-ITM-10009255","CDM","C1750","HCPCS","0278","RC","","","","both","","","616.91","462.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","490.44","79.5","","196.32","85.01","196.32","1 through 10","191.24","490.44","percent of total billed charges",""
"CATHETER PERITONEAL 15FR 62.5CM DOUBLE CUFF ADULT RIGHT COILED SWAN NECK RADIOPAQUE STRIPE DIALYSIS","SUP-ITM-10009255","CDM","C1750","HCPCS","0278","RC","","","","both","","","616.91","462.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","328.81","53.3","","1132.95","1132.95","1132.95","1 through 10","191.24","490.44","percent of total billed charges",""
"CATHETER PERITONEAL 15FR 62.5CM DOUBLE CUFF ADULT RIGHT COILED SWAN NECK RADIOPAQUE STRIPE DIALYSIS","SUP-ITM-10009255","CDM","C1750","HCPCS","0278","RC","","","","both","","","616.91","462.68","WELLPOINT [1015]","HB AMC WELLPOINT","455.16","73.78","","1297.66","185.72","1297.66","1 through 10","191.24","490.44","percent of total billed charges",""
"CATHETER PERITONEAL 15FR 62.5CM DOUBLE CUFF ADULT RIGHT COILED SWAN NECK RADIOPAQUE STRIPE DIALYSIS","SUP-ITM-10009255","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","616.91","462.68","AETNA [1001]","HB AMC AETNA HMO","430.60","69.8","","76.96","76.96","76.96","1 through 10","322.4","504.14","percent of total billed charges",""
"CATHETER PERITONEAL 15FR 62.5CM DOUBLE CUFF ADULT RIGHT COILED SWAN NECK RADIOPAQUE STRIPE DIALYSIS","SUP-ITM-10009255","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","616.91","462.68","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","322.40","52.26","","154.36","154.36","154.36","1 through 10","322.4","504.14","percent of total billed charges",""
"CATHETER PERITONEAL 15FR 62.5CM DOUBLE CUFF ADULT RIGHT COILED SWAN NECK RADIOPAQUE STRIPE DIALYSIS","SUP-ITM-10009255","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","616.91","462.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","504.14","81.72","","199.41","199.41","199.41","1 through 10","322.4","504.14","percent of total billed charges",""
"CATHETER POLARIS X 6FR 105CM 2.5-5-2.5MM SPACING 270DEGREE STANDARD MAPPING DECAPOLAR STEERABLE DIAGNOSTIC","SUP-ITM-10008731","CDM","C1730","HCPCS","0272","RC","","","","both","","","1655.50","1241.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","865.16","52.26","","1988.81","1988.81","1988.81","1 through 10","513.21","1316.12","percent of total billed charges",""
"CATHETER POLARIS X 6FR 105CM 2.5-5-2.5MM SPACING 270DEGREE STANDARD MAPPING DECAPOLAR STEERABLE DIAGNOSTIC","SUP-ITM-10008731","CDM","C1730","HCPCS","0272","RC","","","","both","","","1655.50","1241.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1316.12","79.5","","765.06","765.06","765.06","1 through 10","513.21","1316.12","percent of total billed charges",""
"CATHETER POLARIS X 6FR 105CM 2.5-5-2.5MM SPACING 270DEGREE STANDARD MAPPING DECAPOLAR STEERABLE DIAGNOSTIC","SUP-ITM-10008731","CDM","C1730","HCPCS","0272","RC","","","","both","","","1655.50","1241.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","882.38","53.3","","6427.95","6427.95","6427.95","1 through 10","513.21","1316.12","percent of total billed charges",""
"CATHETER POLARIS X 6FR 105CM 2.5-5-2.5MM SPACING 270DEGREE STANDARD MAPPING DECAPOLAR STEERABLE DIAGNOSTIC","SUP-ITM-10008731","CDM","C1730","HCPCS","0272","RC","","","","both","","","1655.50","1241.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1076.08","65","","1193.16","1193.16","1193.16","1 through 10","513.21","1316.12","percent of total billed charges",""
"CATHETER POLARIS X 6FR 105CM 2.5-5-2.5MM SPACING 270DEGREE STANDARD MAPPING DECAPOLAR STEERABLE DIAGNOSTIC","SUP-ITM-10008731","CDM","C1730","HCPCS","0272","RC","","","","both","","","1655.50","1241.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","604.26","36.5","","2053.37","54.83","3398.85","20","513.21","1316.12","percent of total billed charges",""
"CATHETER POLARIS X 6FR 105CM 2.5-5-2.5MM SPACING 270DEGREE STANDARD MAPPING DECAPOLAR STEERABLE DIAGNOSTIC","SUP-ITM-10008731","CDM","C1730","HCPCS","0272","RC","","","","both","","","1655.50","1241.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","634.06","38.3","","232.75","124.53","2541.50","39","513.21","1316.12","percent of total billed charges",""
"CATHETER POLARIS X 6FR 105CM 2.5-5-2.5MM SPACING 270DEGREE STANDARD MAPPING DECAPOLAR STEERABLE DIAGNOSTIC","SUP-ITM-10008731","CDM","C1730","HCPCS","0272","RC","","","","both","","","1655.50","1241.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","710.21","42.9","","66.89","66.89","66.89","1 through 10","513.21","1316.12","percent of total billed charges",""
"CATHETER POLARIS X 6FR 105CM 2.5-5-2.5MM SPACING 270DEGREE STANDARD MAPPING DECAPOLAR STEERABLE DIAGNOSTIC","SUP-ITM-10008731","CDM","C1730","HCPCS","0272","RC","","","","both","","","1655.50","1241.62","WELLPOINT [1015]","HB AMC WELLPOINT","1221.43","73.78","","2392.81","1818.08","6339.98","15","513.21","1316.12","percent of total billed charges",""
"CATHETER POLARIS X 6FR 105CM 2.5-5-2.5MM SPACING 270DEGREE STANDARD MAPPING DECAPOLAR STEERABLE DIAGNOSTIC","SUP-ITM-10008731","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","1655.50","1241.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","865.16","52.26","","1988.81","1988.81","1988.81","1 through 10","865.16","1352.87","percent of total billed charges",""
"CATHETER POLARIS X 6FR 105CM 2.5-5-2.5MM SPACING 270DEGREE STANDARD MAPPING DECAPOLAR STEERABLE DIAGNOSTIC","SUP-ITM-10008731","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","1655.50","1241.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1352.87","81.72","","2569.25","132.34","2569.25","1 through 10","865.16","1352.87","percent of total billed charges",""
"CATHETER POLARIS X 6FR 105CM 2.5-5-2.5MM SPACING 270DEGREE STANDARD MAPPING DECAPOLAR STEERABLE DIAGNOSTIC","SUP-ITM-10008731","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","1655.50","1241.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1352.87","81.72","","727.92","102.34","6154.18","26","865.16","1352.87","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","649.25","70","","556.50","556.50","556.50","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","737.36","79.5","","437.97","293.83","444.55","17","287.53","737.36","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","494.36","53.3","","298.25","293.83","444.55","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","602.88","65","","361.73","361.73","361.73","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","287.53","31","","171.96","171.96","171.96","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","338.54","36.5","","207.57","179.06","271.83","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","355.23","38.3","","217.59","211.47","220.86","18","287.53","737.36","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","397.90","42.9","","556.50","451.56","556.50","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","397.90","42.9","","444.87","444.87","444.87","1 through 10","287.53","737.36","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","both","","","927.50","695.62","WELLPOINT [1015]","HB AMC WELLPOINT","684.31","73.78","","414.31","414.31","420.55","15","287.53","737.36","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","AETNA [1001]","HB AMC AETNA HMO","647.40","69.8","","376.75","270.01","580.53","30","484.71","757.95","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","AETNA [1001]","HB AMC AETNA PPO","745.71","80.4","","440.60","434.07","440.60","1 through 10","484.71","757.95","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","745.71","80.4","","434.07","434.07","440.60","1 through 10","484.71","757.95","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","757.95","81.72","","444.87","248.37","444.87","1 through 10","484.71","757.95","percent of total billed charges",""
"CATHETER PORT 6.6F DIGNITY CT PLASTIC LOW-PROFILE SHAPED ATTACHABLE POLYURETHANE BX/5EA","SUP-ITM-10050539","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","757.95","81.72","","444.87","248.37","451.56","20","484.71","757.95","percent of total billed charges",""
"CATHETER POWERFLEX PRO 7X100MM 6FR 80CM 12ATM .035IN BALLOON PTA DILATATION MDX COATING","SUP-ITM-10101265","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","263.87","71.8","","175.91","175.91","175.91","1 through 10","113.93","292.16","percent of total billed charges",""
"CATHETER POWERFLEX PRO 7X100MM 6FR 80CM 12ATM .035IN BALLOON PTA DILATATION MDX COATING","SUP-ITM-10101265","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","238.88","65","","147.88","147.88","1296.75","1 through 10","113.93","292.16","percent of total billed charges",""
"CATHETER POWERFLEX PRO 7X100MM 6FR 80CM 12ATM .035IN BALLOON PTA DILATATION MDX COATING","SUP-ITM-10101265","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","134.14","36.5","","181.40","177.87","181.40","21","113.93","292.16","percent of total billed charges",""
"CATHETER POWERFLEX PRO 7X100MM 6FR 80CM 12ATM .035IN BALLOON PTA DILATATION MDX COATING","SUP-ITM-10101265","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","140.75","38.3","","170.15","88.95","424.24","16","113.93","292.16","percent of total billed charges",""
"CATHETER POWERFLEX PRO 7X100MM 6FR 80CM 12ATM .035IN BALLOON PTA DILATATION MDX COATING","SUP-ITM-10101265","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.66","42.9","","699.48","699.48","699.48","12","113.93","292.16","percent of total billed charges",""
"CATHETER POWERFLEX PRO 7X100MM 6FR 80CM 12ATM .035IN BALLOON PTA DILATATION MDX COATING","SUP-ITM-10101265","CDM","C1725","HCPCS","0272","RC","","","","both","","","367.50","275.62","WELLPOINT [1015]","HB AMC WELLPOINT","271.14","73.78","","576.52","182.40","651.44","14","113.93","292.16","percent of total billed charges",""
"CATHETER POWERFLEX PRO 7X100MM 6FR 80CM 12ATM .035IN BALLOON PTA DILATATION MDX COATING","SUP-ITM-10101265","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","367.50","275.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","300.32","81.72","","181.86","100.03","402.41","21","192.06","300.32","percent of total billed charges",""
"CATHETER POWERHICKMAN 9.5FR 5CM CENTRAL VENOUS SURECUFF DUAL LUMEN","SUP-ITM-10146770","CDM","C1750","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","910.89","52.26","","154.36","154.36","154.36","1 through 10","540.33","1385.69","percent of total billed charges",""
"CATHETER POWERHICKMAN 9.5FR 5CM CENTRAL VENOUS SURECUFF DUAL LUMEN","SUP-ITM-10146770","CDM","C1750","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1132.95","65","","1371.74","196.32","1371.74","1 through 10","540.33","1385.69","percent of total billed charges",""
"CATHETER POWERHICKMAN 9.5FR 5CM CENTRAL VENOUS SURECUFF DUAL LUMEN","SUP-ITM-10146770","CDM","C1750","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1220.10","70","","249.45","107.26","1254.96","14","540.33","1385.69","percent of total billed charges",""
"CATHETER POWERHICKMAN 9.5FR 5CM CENTRAL VENOUS SURECUFF DUAL LUMEN","SUP-ITM-10146770","CDM","C1750","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1385.69","79.5","","196.32","85.01","196.32","1 through 10","540.33","1385.69","percent of total billed charges",""
"CATHETER POWERHICKMAN 9.5FR 5CM CENTRAL VENOUS SURECUFF DUAL LUMEN","SUP-ITM-10146770","CDM","C1750","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","929.02","53.3","","1132.95","1132.95","1132.95","1 through 10","540.33","1385.69","percent of total billed charges",""
"CATHETER POWERHICKMAN 9.5FR 5CM CENTRAL VENOUS SURECUFF DUAL LUMEN","SUP-ITM-10146770","CDM","C1750","HCPCS","0278","RC","","","","both","","","1743.00","1307.25","WELLPOINT [1015]","HB AMC WELLPOINT","1285.99","73.78","","1297.66","185.72","1297.66","1 through 10","540.33","1385.69","percent of total billed charges",""
"CATHETER POWERHICKMAN 9.5FR 5CM CENTRAL VENOUS SURECUFF DUAL LUMEN","SUP-ITM-10146770","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1743.00","1307.25","AETNA [1001]","HB AMC AETNA HMO","1216.61","69.8","","76.96","76.96","76.96","1 through 10","910.89","1424.38","percent of total billed charges",""
"CATHETER POWERHICKMAN 9.5FR 5CM CENTRAL VENOUS SURECUFF DUAL LUMEN","SUP-ITM-10146770","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1743.00","1307.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","910.89","52.26","","154.36","154.36","154.36","1 through 10","910.89","1424.38","percent of total billed charges",""
"CATHETER POWERHICKMAN 9.5FR 5CM CENTRAL VENOUS SURECUFF DUAL LUMEN","SUP-ITM-10146770","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1743.00","1307.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1424.38","81.72","","199.41","199.41","199.41","1 through 10","910.89","1424.38","percent of total billed charges",""
"CATHETER PRISTINE 15.5FR 23CM HEMODIALYSIS STANDARD KIT","SUP-ITM-10295001","CDM","C1750","HCPCS","0278","RC","","","","both","","","1836.66","1377.49","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","959.84","52.26","","154.36","154.36","154.36","1 through 10","569.36","1460.14","percent of total billed charges",""
"CATHETER PRISTINE 15.5FR 23CM HEMODIALYSIS STANDARD KIT","SUP-ITM-10295001","CDM","C1750","HCPCS","0278","RC","","","","both","","","1836.66","1377.49","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1193.83","65","","1371.74","196.32","1371.74","1 through 10","569.36","1460.14","percent of total billed charges",""
"CATHETER PRISTINE 15.5FR 23CM HEMODIALYSIS STANDARD KIT","SUP-ITM-10295001","CDM","C1750","HCPCS","0278","RC","","","","both","","","1836.66","1377.49","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1285.66","70","","249.45","107.26","1254.96","14","569.36","1460.14","percent of total billed charges",""
"CATHETER PRISTINE 15.5FR 23CM HEMODIALYSIS STANDARD KIT","SUP-ITM-10295001","CDM","C1750","HCPCS","0278","RC","","","","both","","","1836.66","1377.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1460.14","79.5","","196.32","85.01","196.32","1 through 10","569.36","1460.14","percent of total billed charges",""
"CATHETER PRISTINE 15.5FR 23CM HEMODIALYSIS STANDARD KIT","SUP-ITM-10295001","CDM","C1750","HCPCS","0278","RC","","","","both","","","1836.66","1377.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","978.94","53.3","","1132.95","1132.95","1132.95","1 through 10","569.36","1460.14","percent of total billed charges",""
"CATHETER PRISTINE 15.5FR 23CM HEMODIALYSIS STANDARD KIT","SUP-ITM-10295001","CDM","C1750","HCPCS","0278","RC","","","","both","","","1836.66","1377.49","WELLPOINT [1015]","HB AMC WELLPOINT","1355.09","73.78","","1297.66","185.72","1297.66","1 through 10","569.36","1460.14","percent of total billed charges",""
"CATHETER PRISTINE 15.5FR 23CM HEMODIALYSIS STANDARD KIT","SUP-ITM-10295001","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1836.66","1377.49","AETNA [1001]","HB AMC AETNA HMO","1281.99","69.8","","76.96","76.96","76.96","1 through 10","959.84","1500.92","percent of total billed charges",""
"CATHETER PRISTINE 15.5FR 23CM HEMODIALYSIS STANDARD KIT","SUP-ITM-10295001","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1836.66","1377.49","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","959.84","52.26","","154.36","154.36","154.36","1 through 10","959.84","1500.92","percent of total billed charges",""
"CATHETER PRISTINE 15.5FR 23CM HEMODIALYSIS STANDARD KIT","SUP-ITM-10295001","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1836.66","1377.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1500.92","81.72","","199.41","199.41","199.41","1 through 10","959.84","1500.92","percent of total billed charges",""
"CATHETER PRO XL 7-6FR 12-15MM 200CM .035IN RETRIEVAL BILIARY BALLOON DISTAL INJECTION EXTRACTOR","SUP-ITM-10138959","CDM","C1773","HCPCS","0272","RC","","","","both","","","356.90","267.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","130.27","36.5","","114.30","97.14","114.30","1 through 10","110.64","283.74","percent of total billed charges",""
"CATHETER PRO XL 7-6FR 12-15MM 200CM .035IN RETRIEVAL BILIARY BALLOON DISTAL INJECTION EXTRACTOR","SUP-ITM-10138959","CDM","C1773","HCPCS","0272","RC","","","","both","","","356.90","267.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","136.69","38.3","","119.81","116.44","359.43","20","110.64","283.74","percent of total billed charges",""
"CATHETER PRO XL 7-6FR 12-15MM 200CM .035IN RETRIEVAL BILIARY BALLOON DISTAL INJECTION EXTRACTOR","SUP-ITM-10138959","CDM","C1773","HCPCS","0272","RC","","","","both","","","356.90","267.67","WELLPOINT [1015]","HB AMC WELLPOINT","263.32","73.78","","875.53","228.13","875.53","1 through 10","110.64","283.74","percent of total billed charges",""
"CATHETER PRO XL 7-6FR 12-15MM 200CM .035IN RETRIEVAL BILIARY BALLOON DISTAL INJECTION EXTRACTOR","SUP-ITM-10138959","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","356.90","267.67","AETNA [1001]","HB AMC AETNA HMO","249.12","69.8","","207.45","207.45","207.45","1 through 10","186.52","291.66","percent of total billed charges",""
"CATHETER PRO XL 7-6FR 12-15MM 200CM .035IN RETRIEVAL BILIARY BALLOON DISTAL INJECTION EXTRACTOR","SUP-ITM-10138959","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","356.90","267.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","291.66","81.72","","244.96","134.74","244.96","1 through 10","186.52","291.66","percent of total billed charges",""
"CATHETER QUADRIPOLAR 6FRX120CM SP-5MM JOSEPHSON-1 RESPONSE","SUP-ITM-10093956","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","86.52","52.26","","1988.81","1988.81","1988.81","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER QUADRIPOLAR 6FRX120CM SP-5MM JOSEPHSON-1 RESPONSE","SUP-ITM-10093956","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","131.61","79.5","","765.06","765.06","765.06","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER QUADRIPOLAR 6FRX120CM SP-5MM JOSEPHSON-1 RESPONSE","SUP-ITM-10093956","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","88.24","53.3","","6427.95","6427.95","6427.95","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER QUADRIPOLAR 6FRX120CM SP-5MM JOSEPHSON-1 RESPONSE","SUP-ITM-10093956","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","107.61","65","","1193.16","1193.16","1193.16","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER QUADRIPOLAR 6FRX120CM SP-5MM JOSEPHSON-1 RESPONSE","SUP-ITM-10093956","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.43","36.5","","2053.37","54.83","3398.85","20","51.32","131.61","percent of total billed charges",""
"CATHETER QUADRIPOLAR 6FRX120CM SP-5MM JOSEPHSON-1 RESPONSE","SUP-ITM-10093956","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.41","38.3","","232.75","124.53","2541.50","39","51.32","131.61","percent of total billed charges",""
"CATHETER QUADRIPOLAR 6FRX120CM SP-5MM JOSEPHSON-1 RESPONSE","SUP-ITM-10093956","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.02","42.9","","66.89","66.89","66.89","1 through 10","51.32","131.61","percent of total billed charges",""
"CATHETER QUADRIPOLAR 6FRX120CM SP-5MM JOSEPHSON-1 RESPONSE","SUP-ITM-10093956","CDM","C1730","HCPCS","0272","RC","","","","both","","","165.55","124.16","WELLPOINT [1015]","HB AMC WELLPOINT","122.14","73.78","","2392.81","1818.08","6339.98","15","51.32","131.61","percent of total billed charges",""
"CATHETER QUADRIPOLAR 6FRX120CM SP-5MM JOSEPHSON-1 RESPONSE","SUP-ITM-10093956","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","165.55","124.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","86.52","52.26","","1988.81","1988.81","1988.81","1 through 10","86.52","135.29","percent of total billed charges",""
"CATHETER QUADRIPOLAR 6FRX120CM SP-5MM JOSEPHSON-1 RESPONSE","SUP-ITM-10093956","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","165.55","124.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","135.29","81.72","","2569.25","132.34","2569.25","1 through 10","86.52","135.29","percent of total billed charges",""
"CATHETER QUADRIPOLAR 6FRX120CM SP-5MM JOSEPHSON-1 RESPONSE","SUP-ITM-10093956","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","165.55","124.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","135.29","81.72","","727.92","102.34","6154.18","26","86.52","135.29","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","both","","","612.50","459.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","439.78","71.8","","28.28","27.13","28.28","1 through 10","189.88","486.94","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","both","","","612.50","459.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","428.75","70","","44.63","35.78","44.63","1 through 10","189.88","486.94","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","both","","","612.50","459.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","486.94","79.5","","1342.89","271.64","6954.67","1 through 10","189.88","486.94","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","both","","","612.50","459.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","326.46","53.3","","4550.00","30.49","4550.00","1 through 10","189.88","486.94","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","both","","","612.50","459.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","398.13","65","","42.09","0.04","5453.50","1 through 10","189.88","486.94","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.56","36.5","","310.94","18.54","1259.30","62","189.88","486.94","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.59","38.3","","146.86","22.58","1753.45","65","189.88","486.94","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","both","","","612.50","459.37","WELLPOINT [1015]","HB AMC WELLPOINT","451.90","73.78","","247.29","33.09","909.09","53","189.88","486.94","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","612.50","459.37","AETNA [1001]","HB AMC AETNA HMO","427.53","69.8","","30.69","30.21","30.69","1 through 10","320.09","500.54","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","612.50","459.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","492.45","80.4","","82.69","82.69","82.69","1 through 10","320.09","500.54","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","500.54","81.72","","751.01","74.72","751.01","1 through 10","320.09","500.54","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","500.54","81.72","","328.92","46.17","2701.97","59","320.09","500.54","percent of total billed charges",""
"CATHETER RANGER 4X40MM 135CM GLOBAL DCB OTW PACLITAXEL COATED PTA BALLOON","SUP-ITM-10282349","CDM","C2623","HCPCS","0272","RC","","","","both","","","4357.50","3268.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1590.49","36.5","","3445.53","3445.53","3445.53","1 through 10","1350.83","3464.21","percent of total billed charges",""
"CATHETER RANGER 4X40MM 135CM GLOBAL DCB OTW PACLITAXEL COATED PTA BALLOON","SUP-ITM-10282349","CDM","C2623","HCPCS","0272","RC","","","","both","","","4357.50","3268.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1668.92","38.3","","5522.88","5522.88","5522.88","1 through 10","1350.83","3464.21","percent of total billed charges",""
"CATHETER RANGER 4X40MM 135CM GLOBAL DCB OTW PACLITAXEL COATED PTA BALLOON","SUP-ITM-10282349","CDM","C2623","HCPCS","0272","RC","","","","both","","","4357.50","3268.12","WELLPOINT [1015]","HB AMC WELLPOINT","3214.96","73.78","","3244.16","3126.90","3244.16","1 through 10","1350.83","3464.21","percent of total billed charges",""
"CATHETER RANGER 4X40MM 135CM GLOBAL DCB OTW PACLITAXEL COATED PTA BALLOON","SUP-ITM-10282349","CDM","C2623","HCPCS","0272","RC","","","","outpatient","","","4357.50","3268.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3560.95","81.72","","11291.52","11291.52","11291.52","1 through 10","2277.23","3560.95","percent of total billed charges",""
"CATHETER RANGER 7X200MM 150CM GLOBAL DCB OTW PACLITAXEL COATED PTA BALLOON","SUP-ITM-10282398","CDM","C2623","HCPCS","0272","RC","","","","both","","","4862.50","3646.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1774.81","36.5","","3445.53","3445.53","3445.53","1 through 10","1507.38","3865.69","percent of total billed charges",""
"CATHETER RANGER 7X200MM 150CM GLOBAL DCB OTW PACLITAXEL COATED PTA BALLOON","SUP-ITM-10282398","CDM","C2623","HCPCS","0272","RC","","","","both","","","4862.50","3646.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1862.34","38.3","","5522.88","5522.88","5522.88","1 through 10","1507.38","3865.69","percent of total billed charges",""
"CATHETER RANGER 7X200MM 150CM GLOBAL DCB OTW PACLITAXEL COATED PTA BALLOON","SUP-ITM-10282398","CDM","C2623","HCPCS","0272","RC","","","","both","","","4862.50","3646.87","WELLPOINT [1015]","HB AMC WELLPOINT","3587.55","73.78","","3244.16","3126.90","3244.16","1 through 10","1507.38","3865.69","percent of total billed charges",""
"CATHETER RANGER 7X200MM 150CM GLOBAL DCB OTW PACLITAXEL COATED PTA BALLOON","SUP-ITM-10282398","CDM","C2623","HCPCS","0272","RC","","","","outpatient","","","4862.50","3646.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3973.64","81.72","","11291.52","11291.52","11291.52","1 through 10","2541.14","3973.64","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","both","","","1652.00","1239.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1186.14","71.8","","175.91","175.91","175.91","1 through 10","512.12","1313.34","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","both","","","1652.00","1239.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1073.80","65","","147.88","147.88","1296.75","1 through 10","512.12","1313.34","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","both","","","1652.00","1239.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","602.98","36.5","","181.40","177.87","181.40","21","512.12","1313.34","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","both","","","1652.00","1239.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","632.72","38.3","","170.15","88.95","424.24","16","512.12","1313.34","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","both","","","1652.00","1239.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","708.71","42.9","","699.48","699.48","699.48","12","512.12","1313.34","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","both","","","1652.00","1239.00","WELLPOINT [1015]","HB AMC WELLPOINT","1218.85","73.78","","576.52","182.40","651.44","14","512.12","1313.34","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1652.00","1239.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1350.01","81.72","","181.86","100.03","402.41","21","863.34","1350.01","percent of total billed charges",""
"CATHETER RESPONSE 6FR 120CM JSN-1 CURVE 5MM DIAGNOSTIC SPACING EP QUADRAPOLAR","SUP-ITM-10009789","CDM","C1730","HCPCS","0272","RC","","","","both","","","378.00","283.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","197.54","52.26","","1988.81","1988.81","1988.81","1 through 10","117.18","300.51","percent of total billed charges",""
"CATHETER RESPONSE 6FR 120CM JSN-1 CURVE 5MM DIAGNOSTIC SPACING EP QUADRAPOLAR","SUP-ITM-10009789","CDM","C1730","HCPCS","0272","RC","","","","both","","","378.00","283.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","300.51","79.5","","765.06","765.06","765.06","1 through 10","117.18","300.51","percent of total billed charges",""
"CATHETER RESPONSE 6FR 120CM JSN-1 CURVE 5MM DIAGNOSTIC SPACING EP QUADRAPOLAR","SUP-ITM-10009789","CDM","C1730","HCPCS","0272","RC","","","","both","","","378.00","283.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","201.47","53.3","","6427.95","6427.95","6427.95","1 through 10","117.18","300.51","percent of total billed charges",""
"CATHETER RESPONSE 6FR 120CM JSN-1 CURVE 5MM DIAGNOSTIC SPACING EP QUADRAPOLAR","SUP-ITM-10009789","CDM","C1730","HCPCS","0272","RC","","","","both","","","378.00","283.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","245.70","65","","1193.16","1193.16","1193.16","1 through 10","117.18","300.51","percent of total billed charges",""
"CATHETER RESPONSE 6FR 120CM JSN-1 CURVE 5MM DIAGNOSTIC SPACING EP QUADRAPOLAR","SUP-ITM-10009789","CDM","C1730","HCPCS","0272","RC","","","","both","","","378.00","283.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","137.97","36.5","","2053.37","54.83","3398.85","20","117.18","300.51","percent of total billed charges",""
"CATHETER RESPONSE 6FR 120CM JSN-1 CURVE 5MM DIAGNOSTIC SPACING EP QUADRAPOLAR","SUP-ITM-10009789","CDM","C1730","HCPCS","0272","RC","","","","both","","","378.00","283.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","144.77","38.3","","232.75","124.53","2541.50","39","117.18","300.51","percent of total billed charges",""
"CATHETER RESPONSE 6FR 120CM JSN-1 CURVE 5MM DIAGNOSTIC SPACING EP QUADRAPOLAR","SUP-ITM-10009789","CDM","C1730","HCPCS","0272","RC","","","","both","","","378.00","283.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","162.16","42.9","","66.89","66.89","66.89","1 through 10","117.18","300.51","percent of total billed charges",""
"CATHETER RESPONSE 6FR 120CM JSN-1 CURVE 5MM DIAGNOSTIC SPACING EP QUADRAPOLAR","SUP-ITM-10009789","CDM","C1730","HCPCS","0272","RC","","","","both","","","378.00","283.50","WELLPOINT [1015]","HB AMC WELLPOINT","278.89","73.78","","2392.81","1818.08","6339.98","15","117.18","300.51","percent of total billed charges",""
"CATHETER RESPONSE 6FR 120CM JSN-1 CURVE 5MM DIAGNOSTIC SPACING EP QUADRAPOLAR","SUP-ITM-10009789","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","378.00","283.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","197.54","52.26","","1988.81","1988.81","1988.81","1 through 10","197.54","308.9","percent of total billed charges",""
"CATHETER RESPONSE 6FR 120CM JSN-1 CURVE 5MM DIAGNOSTIC SPACING EP QUADRAPOLAR","SUP-ITM-10009789","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","378.00","283.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","308.90","81.72","","2569.25","132.34","2569.25","1 through 10","197.54","308.9","percent of total billed charges",""
"CATHETER RESPONSE 6FR 120CM JSN-1 CURVE 5MM DIAGNOSTIC SPACING EP QUADRAPOLAR","SUP-ITM-10009789","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","378.00","283.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","308.90","81.72","","727.92","102.34","6154.18","26","197.54","308.9","percent of total billed charges",""
"CATHETER RESPONSE 6FR 2MM 120CM DIAGNOSTIC CSLEP DECAPOLAR","SUP-ITM-10000236","CDM","C1730","HCPCS","0272","RC","","","","both","","","1058.75","794.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","553.30","52.26","","1988.81","1988.81","1988.81","1 through 10","328.21","841.71","percent of total billed charges",""
"CATHETER RESPONSE 6FR 2MM 120CM DIAGNOSTIC CSLEP DECAPOLAR","SUP-ITM-10000236","CDM","C1730","HCPCS","0272","RC","","","","both","","","1058.75","794.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","841.71","79.5","","765.06","765.06","765.06","1 through 10","328.21","841.71","percent of total billed charges",""
"CATHETER RESPONSE 6FR 2MM 120CM DIAGNOSTIC CSLEP DECAPOLAR","SUP-ITM-10000236","CDM","C1730","HCPCS","0272","RC","","","","both","","","1058.75","794.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","564.31","53.3","","6427.95","6427.95","6427.95","1 through 10","328.21","841.71","percent of total billed charges",""
"CATHETER RESPONSE 6FR 2MM 120CM DIAGNOSTIC CSLEP DECAPOLAR","SUP-ITM-10000236","CDM","C1730","HCPCS","0272","RC","","","","both","","","1058.75","794.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","688.19","65","","1193.16","1193.16","1193.16","1 through 10","328.21","841.71","percent of total billed charges",""
"CATHETER RESPONSE 6FR 2MM 120CM DIAGNOSTIC CSLEP DECAPOLAR","SUP-ITM-10000236","CDM","C1730","HCPCS","0272","RC","","","","both","","","1058.75","794.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","386.44","36.5","","2053.37","54.83","3398.85","20","328.21","841.71","percent of total billed charges",""
"CATHETER RESPONSE 6FR 2MM 120CM DIAGNOSTIC CSLEP DECAPOLAR","SUP-ITM-10000236","CDM","C1730","HCPCS","0272","RC","","","","both","","","1058.75","794.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","405.50","38.3","","232.75","124.53","2541.50","39","328.21","841.71","percent of total billed charges",""
"CATHETER RESPONSE 6FR 2MM 120CM DIAGNOSTIC CSLEP DECAPOLAR","SUP-ITM-10000236","CDM","C1730","HCPCS","0272","RC","","","","both","","","1058.75","794.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","454.20","42.9","","66.89","66.89","66.89","1 through 10","328.21","841.71","percent of total billed charges",""
"CATHETER RESPONSE 6FR 2MM 120CM DIAGNOSTIC CSLEP DECAPOLAR","SUP-ITM-10000236","CDM","C1730","HCPCS","0272","RC","","","","both","","","1058.75","794.06","WELLPOINT [1015]","HB AMC WELLPOINT","781.15","73.78","","2392.81","1818.08","6339.98","15","328.21","841.71","percent of total billed charges",""
"CATHETER RESPONSE 6FR 2MM 120CM DIAGNOSTIC CSLEP DECAPOLAR","SUP-ITM-10000236","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","1058.75","794.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","553.30","52.26","","1988.81","1988.81","1988.81","1 through 10","553.3","865.21","percent of total billed charges",""
"CATHETER RESPONSE 6FR 2MM 120CM DIAGNOSTIC CSLEP DECAPOLAR","SUP-ITM-10000236","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","1058.75","794.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","865.21","81.72","","2569.25","132.34","2569.25","1 through 10","553.3","865.21","percent of total billed charges",""
"CATHETER RESPONSE 6FR 2MM 120CM DIAGNOSTIC CSLEP DECAPOLAR","SUP-ITM-10000236","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","1058.75","794.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","865.21","81.72","","727.92","102.34","6154.18","26","553.3","865.21","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","both","","","630.00","472.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","329.24","52.26","","16.24","16.24","54.15","1 through 10","195.3","500.85","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","both","","","630.00","472.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","452.34","71.8","","86.33","32.67","86.33","1 through 10","195.3","500.85","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","both","","","630.00","472.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","441.00","70","","113.68","63.00","177.34","40","195.3","500.85","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","both","","","630.00","472.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","500.85","79.5","","50.70","21.76","168.00","12","195.3","500.85","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","both","","","630.00","472.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","335.79","53.3","","89.31","89.31","99.75","1 through 10","195.3","500.85","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","both","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","409.50","65","","94.41","17.06","2275.00","1 through 10","195.3","500.85","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","195.30","31","","35.13","35.13","35.13","1 through 10","195.3","500.85","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","229.95","36.5","","40.08","12.40","86.17","108","195.3","500.85","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","241.29","38.3","","33.25","10.27","68.43","169","195.3","500.85","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","both","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","270.27","42.9","","25.48","14.86","90.88","1 through 10","195.3","500.85","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","both","","","630.00","472.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","270.27","42.9","","90.88","90.88","90.88","1 through 10","195.3","500.85","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","both","","","630.00","472.50","WELLPOINT [1015]","HB AMC WELLPOINT","464.81","73.78","","84.63","19.55","140.02","123","195.3","500.85","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","630.00","472.50","AETNA [1001]","HB AMC AETNA HMO","439.74","69.8","","76.96","17.77","113.68","14","329.24","514.84","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","630.00","472.50","AETNA [1001]","HB AMC AETNA PPO","506.52","80.4","","57.31","57.31","57.31","1 through 10","329.24","514.84","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","630.00","472.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","329.24","52.26","","16.24","16.24","54.15","1 through 10","329.24","514.84","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","506.52","80.4","","68.25","68.25","87.50","1 through 10","329.24","514.84","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","514.84","81.72","","156.19","156.19","156.19","1 through 10","329.24","514.84","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","514.84","81.72","","82.70","12.06","98.97","13","329.24","514.84","percent of total billed charges",""
"CATHETER RIGHTSITE 5.4FR 2.4MM 43CM DELIVERY HIS SHEATH","SUP-ITM-10191828","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","514.84","81.72","","50.47","25.30","134.30","140","329.24","514.84","percent of total billed charges",""
"CATHETER SELECTSITE HIS-BUNDLE DEFLECTABLE","SUP-ITM-10240825","CDM","C1887","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","975.04","71.8","","28.28","27.13","28.28","1 through 10","420.98","1079.61","percent of total billed charges",""
"CATHETER SELECTSITE HIS-BUNDLE DEFLECTABLE","SUP-ITM-10240825","CDM","C1887","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","950.60","70","","44.63","35.78","44.63","1 through 10","420.98","1079.61","percent of total billed charges",""
"CATHETER SELECTSITE HIS-BUNDLE DEFLECTABLE","SUP-ITM-10240825","CDM","C1887","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1079.61","79.5","","1342.89","271.64","6954.67","1 through 10","420.98","1079.61","percent of total billed charges",""
"CATHETER SELECTSITE HIS-BUNDLE DEFLECTABLE","SUP-ITM-10240825","CDM","C1887","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","723.81","53.3","","4550.00","30.49","4550.00","1 through 10","420.98","1079.61","percent of total billed charges",""
"CATHETER SELECTSITE HIS-BUNDLE DEFLECTABLE","SUP-ITM-10240825","CDM","C1887","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","882.70","65","","42.09","0.04","5453.50","1 through 10","420.98","1079.61","percent of total billed charges",""
"CATHETER SELECTSITE HIS-BUNDLE DEFLECTABLE","SUP-ITM-10240825","CDM","C1887","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","495.67","36.5","","310.94","18.54","1259.30","62","420.98","1079.61","percent of total billed charges",""
"CATHETER SELECTSITE HIS-BUNDLE DEFLECTABLE","SUP-ITM-10240825","CDM","C1887","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","520.11","38.3","","146.86","22.58","1753.45","65","420.98","1079.61","percent of total billed charges",""
"CATHETER SELECTSITE HIS-BUNDLE DEFLECTABLE","SUP-ITM-10240825","CDM","C1887","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","WELLPOINT [1015]","HB AMC WELLPOINT","1001.93","73.78","","247.29","33.09","909.09","53","420.98","1079.61","percent of total billed charges",""
"CATHETER SELECTSITE HIS-BUNDLE DEFLECTABLE","SUP-ITM-10240825","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","AETNA [1001]","HB AMC AETNA HMO","947.88","69.8","","30.69","30.21","30.69","1 through 10","709.69","1109.76","percent of total billed charges",""
"CATHETER SELECTSITE HIS-BUNDLE DEFLECTABLE","SUP-ITM-10240825","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1091.83","80.4","","82.69","82.69","82.69","1 through 10","709.69","1109.76","percent of total billed charges",""
"CATHETER SELECTSITE HIS-BUNDLE DEFLECTABLE","SUP-ITM-10240825","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1109.76","81.72","","751.01","74.72","751.01","1 through 10","709.69","1109.76","percent of total billed charges",""
"CATHETER SELECTSITE HIS-BUNDLE DEFLECTABLE","SUP-ITM-10240825","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1109.76","81.72","","328.92","46.17","2701.97","59","709.69","1109.76","percent of total billed charges",""
"CATHETER SHERPA NX 6FR 100CM ACTIVE GUIDE CORONARY CURVE AMPLATZ LEFT 3","SUP-ITM-10023321","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","100.52","71.8","","28.28","27.13","28.28","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER SHERPA NX 6FR 100CM ACTIVE GUIDE CORONARY CURVE AMPLATZ LEFT 3","SUP-ITM-10023321","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","98.00","70","","44.63","35.78","44.63","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER SHERPA NX 6FR 100CM ACTIVE GUIDE CORONARY CURVE AMPLATZ LEFT 3","SUP-ITM-10023321","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.30","79.5","","1342.89","271.64","6954.67","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER SHERPA NX 6FR 100CM ACTIVE GUIDE CORONARY CURVE AMPLATZ LEFT 3","SUP-ITM-10023321","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.62","53.3","","4550.00","30.49","4550.00","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER SHERPA NX 6FR 100CM ACTIVE GUIDE CORONARY CURVE AMPLATZ LEFT 3","SUP-ITM-10023321","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","91.00","65","","42.09","0.04","5453.50","1 through 10","43.4","111.3","percent of total billed charges",""
"CATHETER SHERPA NX 6FR 100CM ACTIVE GUIDE CORONARY CURVE AMPLATZ LEFT 3","SUP-ITM-10023321","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.10","36.5","","310.94","18.54","1259.30","62","43.4","111.3","percent of total billed charges",""
"CATHETER SHERPA NX 6FR 100CM ACTIVE GUIDE CORONARY CURVE AMPLATZ LEFT 3","SUP-ITM-10023321","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.62","38.3","","146.86","22.58","1753.45","65","43.4","111.3","percent of total billed charges",""
"CATHETER SHERPA NX 6FR 100CM ACTIVE GUIDE CORONARY CURVE AMPLATZ LEFT 3","SUP-ITM-10023321","CDM","C1887","HCPCS","0272","RC","","","","both","","","140.00","105.00","WELLPOINT [1015]","HB AMC WELLPOINT","103.29","73.78","","247.29","33.09","909.09","53","43.4","111.3","percent of total billed charges",""
"CATHETER SHERPA NX 6FR 100CM ACTIVE GUIDE CORONARY CURVE AMPLATZ LEFT 3","SUP-ITM-10023321","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA HMO","97.72","69.8","","30.69","30.21","30.69","1 through 10","73.16","114.41","percent of total billed charges",""
"CATHETER SHERPA NX 6FR 100CM ACTIVE GUIDE CORONARY CURVE AMPLATZ LEFT 3","SUP-ITM-10023321","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.56","80.4","","82.69","82.69","82.69","1 through 10","73.16","114.41","percent of total billed charges",""
"CATHETER SHERPA NX 6FR 100CM ACTIVE GUIDE CORONARY CURVE AMPLATZ LEFT 3","SUP-ITM-10023321","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.41","81.72","","751.01","74.72","751.01","1 through 10","73.16","114.41","percent of total billed charges",""
"CATHETER SHERPA NX 6FR 100CM ACTIVE GUIDE CORONARY CURVE AMPLATZ LEFT 3","SUP-ITM-10023321","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.41","81.72","","328.92","46.17","2701.97","59","73.16","114.41","percent of total billed charges",""
"CATHETER SLALOM 2CMX7MM 135CM DUAL LUMEN .018IN BALLOON DURALYN PTA OTW","SUP-ITM-10007547","CDM","C1725","HCPCS","0272","RC","","","","both","","","790.13","592.60","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","567.31","71.8","","175.91","175.91","175.91","1 through 10","244.94","628.15","percent of total billed charges",""
"CATHETER SLALOM 2CMX7MM 135CM DUAL LUMEN .018IN BALLOON DURALYN PTA OTW","SUP-ITM-10007547","CDM","C1725","HCPCS","0272","RC","","","","both","","","790.13","592.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","513.58","65","","147.88","147.88","1296.75","1 through 10","244.94","628.15","percent of total billed charges",""
"CATHETER SLALOM 2CMX7MM 135CM DUAL LUMEN .018IN BALLOON DURALYN PTA OTW","SUP-ITM-10007547","CDM","C1725","HCPCS","0272","RC","","","","both","","","790.13","592.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","288.40","36.5","","181.40","177.87","181.40","21","244.94","628.15","percent of total billed charges",""
"CATHETER SLALOM 2CMX7MM 135CM DUAL LUMEN .018IN BALLOON DURALYN PTA OTW","SUP-ITM-10007547","CDM","C1725","HCPCS","0272","RC","","","","both","","","790.13","592.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","302.62","38.3","","170.15","88.95","424.24","16","244.94","628.15","percent of total billed charges",""
"CATHETER SLALOM 2CMX7MM 135CM DUAL LUMEN .018IN BALLOON DURALYN PTA OTW","SUP-ITM-10007547","CDM","C1725","HCPCS","0272","RC","","","","both","","","790.13","592.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","338.97","42.9","","699.48","699.48","699.48","12","244.94","628.15","percent of total billed charges",""
"CATHETER SLALOM 2CMX7MM 135CM DUAL LUMEN .018IN BALLOON DURALYN PTA OTW","SUP-ITM-10007547","CDM","C1725","HCPCS","0272","RC","","","","both","","","790.13","592.60","WELLPOINT [1015]","HB AMC WELLPOINT","582.96","73.78","","576.52","182.40","651.44","14","244.94","628.15","percent of total billed charges",""
"CATHETER SLALOM 2CMX7MM 135CM DUAL LUMEN .018IN BALLOON DURALYN PTA OTW","SUP-ITM-10007547","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","790.13","592.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","645.69","81.72","","181.86","100.03","402.41","21","412.92","645.69","percent of total billed charges",""
"CATHETER SLEEK 4FR 3MM 40MM 150CM .014IN OTW PTA DILATATION PERIPHERAL","SUP-ITM-10088693","CDM","C1725","HCPCS","0272","RC","","","","both","","","682.50","511.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","490.04","71.8","","175.91","175.91","175.91","1 through 10","211.58","542.59","percent of total billed charges",""
"CATHETER SLEEK 4FR 3MM 40MM 150CM .014IN OTW PTA DILATATION PERIPHERAL","SUP-ITM-10088693","CDM","C1725","HCPCS","0272","RC","","","","both","","","682.50","511.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","443.63","65","","147.88","147.88","1296.75","1 through 10","211.58","542.59","percent of total billed charges",""
"CATHETER SLEEK 4FR 3MM 40MM 150CM .014IN OTW PTA DILATATION PERIPHERAL","SUP-ITM-10088693","CDM","C1725","HCPCS","0272","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","249.11","36.5","","181.40","177.87","181.40","21","211.58","542.59","percent of total billed charges",""
"CATHETER SLEEK 4FR 3MM 40MM 150CM .014IN OTW PTA DILATATION PERIPHERAL","SUP-ITM-10088693","CDM","C1725","HCPCS","0272","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.40","38.3","","170.15","88.95","424.24","16","211.58","542.59","percent of total billed charges",""
"CATHETER SLEEK 4FR 3MM 40MM 150CM .014IN OTW PTA DILATATION PERIPHERAL","SUP-ITM-10088693","CDM","C1725","HCPCS","0272","RC","","","","both","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.79","42.9","","699.48","699.48","699.48","12","211.58","542.59","percent of total billed charges",""
"CATHETER SLEEK 4FR 3MM 40MM 150CM .014IN OTW PTA DILATATION PERIPHERAL","SUP-ITM-10088693","CDM","C1725","HCPCS","0272","RC","","","","both","","","682.50","511.87","WELLPOINT [1015]","HB AMC WELLPOINT","503.55","73.78","","576.52","182.40","651.44","14","211.58","542.59","percent of total billed charges",""
"CATHETER SLEEK 4FR 3MM 40MM 150CM .014IN OTW PTA DILATATION PERIPHERAL","SUP-ITM-10088693","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","557.74","81.72","","181.86","100.03","402.41","21","356.67","557.74","percent of total billed charges",""
"CATHETER SNARE 6FR 100CM CURVED TIP REPLACEMENT","SUP-ITM-10000504","CDM","C1773","HCPCS","0272","RC","","","","both","","","115.50","86.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","42.16","36.5","","114.30","97.14","114.30","1 through 10","35.81","91.82","percent of total billed charges",""
"CATHETER SNARE 6FR 100CM CURVED TIP REPLACEMENT","SUP-ITM-10000504","CDM","C1773","HCPCS","0272","RC","","","","both","","","115.50","86.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44.24","38.3","","119.81","116.44","359.43","20","35.81","91.82","percent of total billed charges",""
"CATHETER SNARE 6FR 100CM CURVED TIP REPLACEMENT","SUP-ITM-10000504","CDM","C1773","HCPCS","0272","RC","","","","both","","","115.50","86.62","WELLPOINT [1015]","HB AMC WELLPOINT","85.22","73.78","","875.53","228.13","875.53","1 through 10","35.81","91.82","percent of total billed charges",""
"CATHETER SNARE 6FR 100CM CURVED TIP REPLACEMENT","SUP-ITM-10000504","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","115.50","86.62","AETNA [1001]","HB AMC AETNA HMO","80.62","69.8","","207.45","207.45","207.45","1 through 10","60.36","94.39","percent of total billed charges",""
"CATHETER SNARE 6FR 100CM CURVED TIP REPLACEMENT","SUP-ITM-10000504","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","115.50","86.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","94.39","81.72","","244.96","134.74","244.96","1 through 10","60.36","94.39","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.40","43.05","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","41.21","71.8","","28.28","27.13","28.28","1 through 10","17.79","45.63","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.40","43.05","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","40.18","70","","44.63","35.78","44.63","1 through 10","17.79","45.63","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.40","43.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","45.63","79.5","","1342.89","271.64","6954.67","1 through 10","17.79","45.63","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.40","43.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","30.59","53.3","","4550.00","30.49","4550.00","1 through 10","17.79","45.63","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.40","43.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","37.31","65","","42.09","0.04","5453.50","1 through 10","17.79","45.63","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.40","43.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20.95","36.5","","310.94","18.54","1259.30","62","17.79","45.63","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.40","43.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21.98","38.3","","146.86","22.58","1753.45","65","17.79","45.63","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.40","43.05","WELLPOINT [1015]","HB AMC WELLPOINT","42.35","73.78","","247.29","33.09","909.09","53","17.79","45.63","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","57.40","43.05","AETNA [1001]","HB AMC AETNA HMO","40.07","69.8","","30.69","30.21","30.69","1 through 10","30","46.91","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","57.40","43.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","46.15","80.4","","82.69","82.69","82.69","1 through 10","30","46.91","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","57.40","43.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","46.91","81.72","","751.01","74.72","751.01","1 through 10","30","46.91","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","57.40","43.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","46.91","81.72","","328.92","46.17","2701.97","59","30","46.91","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN DIAGNOSTIC VASCULAR STRAIGHT PERIPH GUIDEWIRE W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE TIP BX/10EA","SUP-ITM-10007114","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.45","33.34","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","31.92","71.8","","28.28","27.13","28.28","1 through 10","13.78","35.34","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN DIAGNOSTIC VASCULAR STRAIGHT PERIPH GUIDEWIRE W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE TIP BX/10EA","SUP-ITM-10007114","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.45","33.34","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","31.12","70","","44.63","35.78","44.63","1 through 10","13.78","35.34","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN DIAGNOSTIC VASCULAR STRAIGHT PERIPH GUIDEWIRE W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE TIP BX/10EA","SUP-ITM-10007114","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.45","33.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","35.34","79.5","","1342.89","271.64","6954.67","1 through 10","13.78","35.34","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN DIAGNOSTIC VASCULAR STRAIGHT PERIPH GUIDEWIRE W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE TIP BX/10EA","SUP-ITM-10007114","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.45","33.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23.69","53.3","","4550.00","30.49","4550.00","1 through 10","13.78","35.34","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN DIAGNOSTIC VASCULAR STRAIGHT PERIPH GUIDEWIRE W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE TIP BX/10EA","SUP-ITM-10007114","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.45","33.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","28.89","65","","42.09","0.04","5453.50","1 through 10","13.78","35.34","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN DIAGNOSTIC VASCULAR STRAIGHT PERIPH GUIDEWIRE W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE TIP BX/10EA","SUP-ITM-10007114","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.45","33.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16.22","36.5","","310.94","18.54","1259.30","62","13.78","35.34","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN DIAGNOSTIC VASCULAR STRAIGHT PERIPH GUIDEWIRE W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE TIP BX/10EA","SUP-ITM-10007114","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.45","33.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17.02","38.3","","146.86","22.58","1753.45","65","13.78","35.34","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN DIAGNOSTIC VASCULAR STRAIGHT PERIPH GUIDEWIRE W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE TIP BX/10EA","SUP-ITM-10007114","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.45","33.34","WELLPOINT [1015]","HB AMC WELLPOINT","32.80","73.78","","247.29","33.09","909.09","53","13.78","35.34","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN DIAGNOSTIC VASCULAR STRAIGHT PERIPH GUIDEWIRE W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE TIP BX/10EA","SUP-ITM-10007114","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","44.45","33.34","AETNA [1001]","HB AMC AETNA HMO","31.03","69.8","","30.69","30.21","30.69","1 through 10","23.23","36.32","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN DIAGNOSTIC VASCULAR STRAIGHT PERIPH GUIDEWIRE W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE TIP BX/10EA","SUP-ITM-10007114","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","44.45","33.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","35.74","80.4","","82.69","82.69","82.69","1 through 10","23.23","36.32","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN DIAGNOSTIC VASCULAR STRAIGHT PERIPH GUIDEWIRE W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE TIP BX/10EA","SUP-ITM-10007114","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","44.45","33.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","36.32","81.72","","751.01","74.72","751.01","1 through 10","23.23","36.32","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN DIAGNOSTIC VASCULAR STRAIGHT PERIPH GUIDEWIRE W/OUT HYDROPHILIC COATING ADULT RADIOPAQUE TIP BX/10EA","SUP-ITM-10007114","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","44.45","33.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","36.32","81.72","","328.92","46.17","2701.97","59","23.23","36.32","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .035IN ANGIOGRAPHY SOS OMNI 3 HIGH TORQUE SHAFT VISCERAL BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10009624","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.63","33.47","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","32.04","71.8","","28.28","27.13","28.28","1 through 10","13.84","35.48","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .035IN ANGIOGRAPHY SOS OMNI 3 HIGH TORQUE SHAFT VISCERAL BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10009624","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.63","33.47","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","31.24","70","","44.63","35.78","44.63","1 through 10","13.84","35.48","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .035IN ANGIOGRAPHY SOS OMNI 3 HIGH TORQUE SHAFT VISCERAL BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10009624","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.63","33.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","35.48","79.5","","1342.89","271.64","6954.67","1 through 10","13.84","35.48","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .035IN ANGIOGRAPHY SOS OMNI 3 HIGH TORQUE SHAFT VISCERAL BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10009624","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.63","33.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23.79","53.3","","4550.00","30.49","4550.00","1 through 10","13.84","35.48","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .035IN ANGIOGRAPHY SOS OMNI 3 HIGH TORQUE SHAFT VISCERAL BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10009624","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.63","33.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","29.01","65","","42.09","0.04","5453.50","1 through 10","13.84","35.48","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .035IN ANGIOGRAPHY SOS OMNI 3 HIGH TORQUE SHAFT VISCERAL BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10009624","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.63","33.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16.29","36.5","","310.94","18.54","1259.30","62","13.84","35.48","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .035IN ANGIOGRAPHY SOS OMNI 3 HIGH TORQUE SHAFT VISCERAL BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10009624","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.63","33.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17.09","38.3","","146.86","22.58","1753.45","65","13.84","35.48","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .035IN ANGIOGRAPHY SOS OMNI 3 HIGH TORQUE SHAFT VISCERAL BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10009624","CDM","C1887","HCPCS","0272","RC","","","","both","","","44.63","33.47","WELLPOINT [1015]","HB AMC WELLPOINT","32.93","73.78","","247.29","33.09","909.09","53","13.84","35.48","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .035IN ANGIOGRAPHY SOS OMNI 3 HIGH TORQUE SHAFT VISCERAL BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10009624","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","44.63","33.47","AETNA [1001]","HB AMC AETNA HMO","31.15","69.8","","30.69","30.21","30.69","1 through 10","23.32","36.47","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .035IN ANGIOGRAPHY SOS OMNI 3 HIGH TORQUE SHAFT VISCERAL BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10009624","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","44.63","33.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","35.88","80.4","","82.69","82.69","82.69","1 through 10","23.32","36.47","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .035IN ANGIOGRAPHY SOS OMNI 3 HIGH TORQUE SHAFT VISCERAL BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10009624","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","44.63","33.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","36.47","81.72","","751.01","74.72","751.01","1 through 10","23.32","36.47","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .035IN ANGIOGRAPHY SOS OMNI 3 HIGH TORQUE SHAFT VISCERAL BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10009624","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","44.63","33.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","36.47","81.72","","328.92","46.17","2701.97","59","23.32","36.47","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","6125.00","4593.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4869.38","79.5","","1309.77","674.56","6049.93","26","1898.75","4869.38","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","6125.00","4593.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3264.63","53.3","","1901.83","1901.83","2962.25","1 through 10","1898.75","4869.38","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","6125.00","4593.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2235.63","36.5","","1620.31","1620.31","19908.88","1 through 10","1898.75","4869.38","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","6125.00","4593.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2345.88","38.3","","352.91","352.91","2046.30","1 through 10","1898.75","4869.38","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","6125.00","4593.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2627.63","42.9","","9668.75","9668.75","9668.75","1 through 10","1898.75","4869.38","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","6125.00","4593.75","WELLPOINT [1015]","HB AMC WELLPOINT","4519.03","73.78","","699.88","384.10","3443.31","33","1898.75","4869.38","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","6125.00","4593.75","AETNA [1001]","HB AMC AETNA HMO","4275.25","69.8","","1421.24","264.50","4933.46","29","3200.93","5005.35","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","6125.00","4593.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4924.50","80.4","","1022.97","1022.97","3607.50","1 through 10","3200.93","5005.35","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","6125.00","4593.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5005.35","81.72","","3010.54","693.88","5019.88","35","3200.93","5005.35","percent of total billed charges",""
"CATHETER STENT 7.0MMX10CM 120 VASCULAR VIABAHN EPTFE GRAFT HEPARIN BIOACTIVE SURFACE PERIPHERAL RADIOPAQUE MARKER","SUP-ITM-10135247","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5609.50","65","","6652.80","6652.80","6652.80","1 through 10","2675.3","6860.85","percent of total billed charges",""
"CATHETER STENT 7.0MMX10CM 120 VASCULAR VIABAHN EPTFE GRAFT HEPARIN BIOACTIVE SURFACE PERIPHERAL RADIOPAQUE MARKER","SUP-ITM-10135247","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6860.85","79.5","","2612.61","795.38","2612.61","1 through 10","2675.3","6860.85","percent of total billed charges",""
"CATHETER STENT 7.0MMX10CM 120 VASCULAR VIABAHN EPTFE GRAFT HEPARIN BIOACTIVE SURFACE PERIPHERAL RADIOPAQUE MARKER","SUP-ITM-10135247","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4599.79","53.3","","1101.80","1101.80","1101.80","1 through 10","2675.3","6860.85","percent of total billed charges",""
"CATHETER STENT 7.0MMX10CM 120 VASCULAR VIABAHN EPTFE GRAFT HEPARIN BIOACTIVE SURFACE PERIPHERAL RADIOPAQUE MARKER","SUP-ITM-10135247","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5609.50","65","","1820.00","910.00","1820.00","1 through 10","2675.3","6860.85","percent of total billed charges",""
"CATHETER STENT 7.0MMX10CM 120 VASCULAR VIABAHN EPTFE GRAFT HEPARIN BIOACTIVE SURFACE PERIPHERAL RADIOPAQUE MARKER","SUP-ITM-10135247","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3149.95","36.5","","1257.80","693.44","2424.50","1 through 10","2675.3","6860.85","percent of total billed charges",""
"CATHETER STENT 7.0MMX10CM 120 VASCULAR VIABAHN EPTFE GRAFT HEPARIN BIOACTIVE SURFACE PERIPHERAL RADIOPAQUE MARKER","SUP-ITM-10135247","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3305.29","38.3","","1950.11","547.40","2346.00","1 through 10","2675.3","6860.85","percent of total billed charges",""
"CATHETER STENT 7.0MMX10CM 120 VASCULAR VIABAHN EPTFE GRAFT HEPARIN BIOACTIVE SURFACE PERIPHERAL RADIOPAQUE MARKER","SUP-ITM-10135247","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3702.27","42.9","","5096.18","5096.18","5096.18","1 through 10","2675.3","6860.85","percent of total billed charges",""
"CATHETER STENT 7.0MMX10CM 120 VASCULAR VIABAHN EPTFE GRAFT HEPARIN BIOACTIVE SURFACE PERIPHERAL RADIOPAQUE MARKER","SUP-ITM-10135247","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","WELLPOINT [1015]","HB AMC WELLPOINT","6367.21","73.78","","1172.59","1172.59","4829.94","1 through 10","2675.3","6860.85","percent of total billed charges",""
"CATHETER STENT 7.0MMX10CM 120 VASCULAR VIABAHN EPTFE GRAFT HEPARIN BIOACTIVE SURFACE PERIPHERAL RADIOPAQUE MARKER","SUP-ITM-10135247","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8630.00","6472.50","AETNA [1001]","HB AMC AETNA HMO","6023.74","69.8","","1806.84","947.80","5091.72","1 through 10","4510.04","7052.44","percent of total billed charges",""
"CATHETER STENT 7.0MMX10CM 120 VASCULAR VIABAHN EPTFE GRAFT HEPARIN BIOACTIVE SURFACE PERIPHERAL RADIOPAQUE MARKER","SUP-ITM-10135247","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8630.00","6472.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7052.44","81.72","","1259.05","615.58","4586.56","1 through 10","4510.04","7052.44","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","both","","","9687.50","7265.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6296.88","65","","6652.80","6652.80","6652.80","1 through 10","3003.13","7701.56","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","both","","","9687.50","7265.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7701.56","79.5","","2612.61","795.38","2612.61","1 through 10","3003.13","7701.56","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","both","","","9687.50","7265.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5163.44","53.3","","1101.80","1101.80","1101.80","1 through 10","3003.13","7701.56","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","both","","","9687.50","7265.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6296.88","65","","1820.00","910.00","1820.00","1 through 10","3003.13","7701.56","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","both","","","9687.50","7265.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3535.94","36.5","","1257.80","693.44","2424.50","1 through 10","3003.13","7701.56","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","both","","","9687.50","7265.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3710.31","38.3","","1950.11","547.40","2346.00","1 through 10","3003.13","7701.56","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","both","","","9687.50","7265.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4155.94","42.9","","5096.18","5096.18","5096.18","1 through 10","3003.13","7701.56","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","both","","","9687.50","7265.62","WELLPOINT [1015]","HB AMC WELLPOINT","7147.44","73.78","","1172.59","1172.59","4829.94","1 through 10","3003.13","7701.56","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9687.50","7265.62","AETNA [1001]","HB AMC AETNA HMO","6761.88","69.8","","1806.84","947.80","5091.72","1 through 10","5062.69","7916.63","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9687.50","7265.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7916.63","81.72","","1259.05","615.58","4586.56","1 through 10","5062.69","7916.63","percent of total billed charges",""
"CATHETER STENT 8MMX5.0 110CM 0.035IN GUIDEWIRE GRAFT ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135300","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4073.88","65","","6652.80","6652.80","6652.80","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER STENT 8MMX5.0 110CM 0.035IN GUIDEWIRE GRAFT ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135300","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4982.66","79.5","","2612.61","795.38","2612.61","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER STENT 8MMX5.0 110CM 0.035IN GUIDEWIRE GRAFT ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135300","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3340.58","53.3","","1101.80","1101.80","1101.80","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER STENT 8MMX5.0 110CM 0.035IN GUIDEWIRE GRAFT ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135300","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4073.88","65","","1820.00","910.00","1820.00","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER STENT 8MMX5.0 110CM 0.035IN GUIDEWIRE GRAFT ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135300","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2287.64","36.5","","1257.80","693.44","2424.50","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER STENT 8MMX5.0 110CM 0.035IN GUIDEWIRE GRAFT ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135300","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2400.45","38.3","","1950.11","547.40","2346.00","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER STENT 8MMX5.0 110CM 0.035IN GUIDEWIRE GRAFT ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135300","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2688.76","42.9","","5096.18","5096.18","5096.18","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER STENT 8MMX5.0 110CM 0.035IN GUIDEWIRE GRAFT ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135300","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","WELLPOINT [1015]","HB AMC WELLPOINT","4624.16","73.78","","1172.59","1172.59","4829.94","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER STENT 8MMX5.0 110CM 0.035IN GUIDEWIRE GRAFT ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135300","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6267.50","4700.62","AETNA [1001]","HB AMC AETNA HMO","4374.72","69.8","","1806.84","947.80","5091.72","1 through 10","3275.4","5121.8","percent of total billed charges",""
"CATHETER STENT 8MMX5.0 110CM 0.035IN GUIDEWIRE GRAFT ENDOPROSTHESIS VIABAHN HUB TO TIP DEPLOYMENT","SUP-ITM-10135300","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6267.50","4700.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5121.80","81.72","","1259.05","615.58","4586.56","1 through 10","3275.4","5121.8","percent of total billed charges",""
"CATHETER STERLING MONORAIL 4FR 3MM 20MM 135CM .018IN 14ATM RX SEMI COMPLIANT BALLOON DILATATION PERIPHERAL NON SCORED WIRE COMPAT","SUP-ITM-10018850","CDM","C1725","HCPCS","0272","RC","","","","both","","","612.50","459.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","439.78","71.8","","175.91","175.91","175.91","1 through 10","189.88","486.94","percent of total billed charges",""
"CATHETER STERLING MONORAIL 4FR 3MM 20MM 135CM .018IN 14ATM RX SEMI COMPLIANT BALLOON DILATATION PERIPHERAL NON SCORED WIRE COMPAT","SUP-ITM-10018850","CDM","C1725","HCPCS","0272","RC","","","","both","","","612.50","459.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","398.13","65","","147.88","147.88","1296.75","1 through 10","189.88","486.94","percent of total billed charges",""
"CATHETER STERLING MONORAIL 4FR 3MM 20MM 135CM .018IN 14ATM RX SEMI COMPLIANT BALLOON DILATATION PERIPHERAL NON SCORED WIRE COMPAT","SUP-ITM-10018850","CDM","C1725","HCPCS","0272","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.56","36.5","","181.40","177.87","181.40","21","189.88","486.94","percent of total billed charges",""
"CATHETER STERLING MONORAIL 4FR 3MM 20MM 135CM .018IN 14ATM RX SEMI COMPLIANT BALLOON DILATATION PERIPHERAL NON SCORED WIRE COMPAT","SUP-ITM-10018850","CDM","C1725","HCPCS","0272","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.59","38.3","","170.15","88.95","424.24","16","189.88","486.94","percent of total billed charges",""
"CATHETER STERLING MONORAIL 4FR 3MM 20MM 135CM .018IN 14ATM RX SEMI COMPLIANT BALLOON DILATATION PERIPHERAL NON SCORED WIRE COMPAT","SUP-ITM-10018850","CDM","C1725","HCPCS","0272","RC","","","","both","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","262.76","42.9","","699.48","699.48","699.48","12","189.88","486.94","percent of total billed charges",""
"CATHETER STERLING MONORAIL 4FR 3MM 20MM 135CM .018IN 14ATM RX SEMI COMPLIANT BALLOON DILATATION PERIPHERAL NON SCORED WIRE COMPAT","SUP-ITM-10018850","CDM","C1725","HCPCS","0272","RC","","","","both","","","612.50","459.37","WELLPOINT [1015]","HB AMC WELLPOINT","451.90","73.78","","576.52","182.40","651.44","14","189.88","486.94","percent of total billed charges",""
"CATHETER STERLING MONORAIL 4FR 3MM 20MM 135CM .018IN 14ATM RX SEMI COMPLIANT BALLOON DILATATION PERIPHERAL NON SCORED WIRE COMPAT","SUP-ITM-10018850","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","500.54","81.72","","181.86","100.03","402.41","21","320.09","500.54","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","both","","","29.75","22.31","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","21.36","71.8","","28.28","27.13","28.28","1 through 10","9.22","23.65","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","both","","","29.75","22.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","20.83","70","","44.63","35.78","44.63","1 through 10","9.22","23.65","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","both","","","29.75","22.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","23.65","79.5","","1342.89","271.64","6954.67","1 through 10","9.22","23.65","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","both","","","29.75","22.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","15.86","53.3","","4550.00","30.49","4550.00","1 through 10","9.22","23.65","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","both","","","29.75","22.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","19.34","65","","42.09","0.04","5453.50","1 through 10","9.22","23.65","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","both","","","29.75","22.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10.86","36.5","","310.94","18.54","1259.30","62","9.22","23.65","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","both","","","29.75","22.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11.39","38.3","","146.86","22.58","1753.45","65","9.22","23.65","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","both","","","29.75","22.31","WELLPOINT [1015]","HB AMC WELLPOINT","21.95","73.78","","247.29","33.09","909.09","53","9.22","23.65","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","29.75","22.31","AETNA [1001]","HB AMC AETNA HMO","20.77","69.8","","30.69","30.21","30.69","1 through 10","15.55","24.31","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","29.75","22.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","23.92","80.4","","82.69","82.69","82.69","1 through 10","15.55","24.31","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","29.75","22.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","24.31","81.72","","751.01","74.72","751.01","1 through 10","15.55","24.31","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","29.75","22.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24.31","81.72","","328.92","46.17","2701.97","59","15.55","24.31","percent of total billed charges",""
"CATHETER SUPREME 5FR 5MMX120CM QUADRIPOLAR DIAGNOSTIC JSN CURVE ELECTROPHYSIOLOGY","SUP-ITM-10206863","CDM","C1730","HCPCS","0272","RC","","","","both","","","404.25","303.19","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","211.26","52.26","","1988.81","1988.81","1988.81","1 through 10","125.32","321.38","percent of total billed charges",""
"CATHETER SUPREME 5FR 5MMX120CM QUADRIPOLAR DIAGNOSTIC JSN CURVE ELECTROPHYSIOLOGY","SUP-ITM-10206863","CDM","C1730","HCPCS","0272","RC","","","","both","","","404.25","303.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","321.38","79.5","","765.06","765.06","765.06","1 through 10","125.32","321.38","percent of total billed charges",""
"CATHETER SUPREME 5FR 5MMX120CM QUADRIPOLAR DIAGNOSTIC JSN CURVE ELECTROPHYSIOLOGY","SUP-ITM-10206863","CDM","C1730","HCPCS","0272","RC","","","","both","","","404.25","303.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","215.47","53.3","","6427.95","6427.95","6427.95","1 through 10","125.32","321.38","percent of total billed charges",""
"CATHETER SUPREME 5FR 5MMX120CM QUADRIPOLAR DIAGNOSTIC JSN CURVE ELECTROPHYSIOLOGY","SUP-ITM-10206863","CDM","C1730","HCPCS","0272","RC","","","","both","","","404.25","303.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","262.76","65","","1193.16","1193.16","1193.16","1 through 10","125.32","321.38","percent of total billed charges",""
"CATHETER SUPREME 5FR 5MMX120CM QUADRIPOLAR DIAGNOSTIC JSN CURVE ELECTROPHYSIOLOGY","SUP-ITM-10206863","CDM","C1730","HCPCS","0272","RC","","","","both","","","404.25","303.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","147.55","36.5","","2053.37","54.83","3398.85","20","125.32","321.38","percent of total billed charges",""
"CATHETER SUPREME 5FR 5MMX120CM QUADRIPOLAR DIAGNOSTIC JSN CURVE ELECTROPHYSIOLOGY","SUP-ITM-10206863","CDM","C1730","HCPCS","0272","RC","","","","both","","","404.25","303.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","154.83","38.3","","232.75","124.53","2541.50","39","125.32","321.38","percent of total billed charges",""
"CATHETER SUPREME 5FR 5MMX120CM QUADRIPOLAR DIAGNOSTIC JSN CURVE ELECTROPHYSIOLOGY","SUP-ITM-10206863","CDM","C1730","HCPCS","0272","RC","","","","both","","","404.25","303.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.42","42.9","","66.89","66.89","66.89","1 through 10","125.32","321.38","percent of total billed charges",""
"CATHETER SUPREME 5FR 5MMX120CM QUADRIPOLAR DIAGNOSTIC JSN CURVE ELECTROPHYSIOLOGY","SUP-ITM-10206863","CDM","C1730","HCPCS","0272","RC","","","","both","","","404.25","303.19","WELLPOINT [1015]","HB AMC WELLPOINT","298.26","73.78","","2392.81","1818.08","6339.98","15","125.32","321.38","percent of total billed charges",""
"CATHETER SUPREME 5FR 5MMX120CM QUADRIPOLAR DIAGNOSTIC JSN CURVE ELECTROPHYSIOLOGY","SUP-ITM-10206863","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","404.25","303.19","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","211.26","52.26","","1988.81","1988.81","1988.81","1 through 10","211.26","330.35","percent of total billed charges",""
"CATHETER SUPREME 5FR 5MMX120CM QUADRIPOLAR DIAGNOSTIC JSN CURVE ELECTROPHYSIOLOGY","SUP-ITM-10206863","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","404.25","303.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","330.35","81.72","","2569.25","132.34","2569.25","1 through 10","211.26","330.35","percent of total billed charges",""
"CATHETER SUPREME 5FR 5MMX120CM QUADRIPOLAR DIAGNOSTIC JSN CURVE ELECTROPHYSIOLOGY","SUP-ITM-10206863","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","404.25","303.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","330.35","81.72","","727.92","102.34","6154.18","26","211.26","330.35","percent of total billed charges",""
"CATHETER SWAN-GANZ 7.5FR 110CM THERMODILUTION 5LUMEN HEMODYNAMIC MONITORING CS/5EA","SUP-ITM-10082901","CDM","C1887","HCPCS","0272","RC","","","","both","","","411.46","308.59","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","295.43","71.8","","28.28","27.13","28.28","1 through 10","127.55","327.11","percent of total billed charges",""
"CATHETER SWAN-GANZ 7.5FR 110CM THERMODILUTION 5LUMEN HEMODYNAMIC MONITORING CS/5EA","SUP-ITM-10082901","CDM","C1887","HCPCS","0272","RC","","","","both","","","411.46","308.59","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","288.02","70","","44.63","35.78","44.63","1 through 10","127.55","327.11","percent of total billed charges",""
"CATHETER SWAN-GANZ 7.5FR 110CM THERMODILUTION 5LUMEN HEMODYNAMIC MONITORING CS/5EA","SUP-ITM-10082901","CDM","C1887","HCPCS","0272","RC","","","","both","","","411.46","308.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","327.11","79.5","","1342.89","271.64","6954.67","1 through 10","127.55","327.11","percent of total billed charges",""
"CATHETER SWAN-GANZ 7.5FR 110CM THERMODILUTION 5LUMEN HEMODYNAMIC MONITORING CS/5EA","SUP-ITM-10082901","CDM","C1887","HCPCS","0272","RC","","","","both","","","411.46","308.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","219.31","53.3","","4550.00","30.49","4550.00","1 through 10","127.55","327.11","percent of total billed charges",""
"CATHETER SWAN-GANZ 7.5FR 110CM THERMODILUTION 5LUMEN HEMODYNAMIC MONITORING CS/5EA","SUP-ITM-10082901","CDM","C1887","HCPCS","0272","RC","","","","both","","","411.46","308.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","267.45","65","","42.09","0.04","5453.50","1 through 10","127.55","327.11","percent of total billed charges",""
"CATHETER SWAN-GANZ 7.5FR 110CM THERMODILUTION 5LUMEN HEMODYNAMIC MONITORING CS/5EA","SUP-ITM-10082901","CDM","C1887","HCPCS","0272","RC","","","","both","","","411.46","308.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","150.18","36.5","","310.94","18.54","1259.30","62","127.55","327.11","percent of total billed charges",""
"CATHETER SWAN-GANZ 7.5FR 110CM THERMODILUTION 5LUMEN HEMODYNAMIC MONITORING CS/5EA","SUP-ITM-10082901","CDM","C1887","HCPCS","0272","RC","","","","both","","","411.46","308.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.59","38.3","","146.86","22.58","1753.45","65","127.55","327.11","percent of total billed charges",""
"CATHETER SWAN-GANZ 7.5FR 110CM THERMODILUTION 5LUMEN HEMODYNAMIC MONITORING CS/5EA","SUP-ITM-10082901","CDM","C1887","HCPCS","0272","RC","","","","both","","","411.46","308.59","WELLPOINT [1015]","HB AMC WELLPOINT","303.58","73.78","","247.29","33.09","909.09","53","127.55","327.11","percent of total billed charges",""
"CATHETER SWAN-GANZ 7.5FR 110CM THERMODILUTION 5LUMEN HEMODYNAMIC MONITORING CS/5EA","SUP-ITM-10082901","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","411.46","308.59","AETNA [1001]","HB AMC AETNA HMO","287.20","69.8","","30.69","30.21","30.69","1 through 10","215.03","336.25","percent of total billed charges",""
"CATHETER SWAN-GANZ 7.5FR 110CM THERMODILUTION 5LUMEN HEMODYNAMIC MONITORING CS/5EA","SUP-ITM-10082901","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","411.46","308.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","330.81","80.4","","82.69","82.69","82.69","1 through 10","215.03","336.25","percent of total billed charges",""
"CATHETER SWAN-GANZ 7.5FR 110CM THERMODILUTION 5LUMEN HEMODYNAMIC MONITORING CS/5EA","SUP-ITM-10082901","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","411.46","308.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","336.25","81.72","","751.01","74.72","751.01","1 through 10","215.03","336.25","percent of total billed charges",""
"CATHETER SWAN-GANZ 7.5FR 110CM THERMODILUTION 5LUMEN HEMODYNAMIC MONITORING CS/5EA","SUP-ITM-10082901","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","411.46","308.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","336.25","81.72","","328.92","46.17","2701.97","59","215.03","336.25","percent of total billed charges",""
"CATHETER TEMPO 5FR 100CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10157645","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.75","43.31","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","41.46","71.8","","28.28","27.13","28.28","1 through 10","17.9","45.91","percent of total billed charges",""
"CATHETER TEMPO 5FR 100CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10157645","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.75","43.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","40.43","70","","44.63","35.78","44.63","1 through 10","17.9","45.91","percent of total billed charges",""
"CATHETER TEMPO 5FR 100CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10157645","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.75","43.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","45.91","79.5","","1342.89","271.64","6954.67","1 through 10","17.9","45.91","percent of total billed charges",""
"CATHETER TEMPO 5FR 100CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10157645","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.75","43.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","30.78","53.3","","4550.00","30.49","4550.00","1 through 10","17.9","45.91","percent of total billed charges",""
"CATHETER TEMPO 5FR 100CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10157645","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.75","43.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","37.54","65","","42.09","0.04","5453.50","1 through 10","17.9","45.91","percent of total billed charges",""
"CATHETER TEMPO 5FR 100CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10157645","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.75","43.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21.08","36.5","","310.94","18.54","1259.30","62","17.9","45.91","percent of total billed charges",""
"CATHETER TEMPO 5FR 100CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10157645","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.75","43.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22.12","38.3","","146.86","22.58","1753.45","65","17.9","45.91","percent of total billed charges",""
"CATHETER TEMPO 5FR 100CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10157645","CDM","C1887","HCPCS","0272","RC","","","","both","","","57.75","43.31","WELLPOINT [1015]","HB AMC WELLPOINT","42.61","73.78","","247.29","33.09","909.09","53","17.9","45.91","percent of total billed charges",""
"CATHETER TEMPO 5FR 100CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10157645","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","57.75","43.31","AETNA [1001]","HB AMC AETNA HMO","40.31","69.8","","30.69","30.21","30.69","1 through 10","30.18","47.19","percent of total billed charges",""
"CATHETER TEMPO 5FR 100CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10157645","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","57.75","43.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","46.43","80.4","","82.69","82.69","82.69","1 through 10","30.18","47.19","percent of total billed charges",""
"CATHETER TEMPO 5FR 100CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10157645","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","57.75","43.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","47.19","81.72","","751.01","74.72","751.01","1 through 10","30.18","47.19","percent of total billed charges",""
"CATHETER TEMPO 5FR 100CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10157645","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","57.75","43.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","47.19","81.72","","328.92","46.17","2701.97","59","30.18","47.19","percent of total billed charges",""
"CATHETER TORCON NB 5FR 100CM .038IN DAV ADVANTAGE ANGLED MULTIPURPOSE PERIPHERAL ANGIOGRAPHIC BX/5EA","SUP-ITM-10174966","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.69","63.52","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","60.81","71.8","","28.28","27.13","28.28","1 through 10","26.25","67.33","percent of total billed charges",""
"CATHETER TORCON NB 5FR 100CM .038IN DAV ADVANTAGE ANGLED MULTIPURPOSE PERIPHERAL ANGIOGRAPHIC BX/5EA","SUP-ITM-10174966","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.69","63.52","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","59.28","70","","44.63","35.78","44.63","1 through 10","26.25","67.33","percent of total billed charges",""
"CATHETER TORCON NB 5FR 100CM .038IN DAV ADVANTAGE ANGLED MULTIPURPOSE PERIPHERAL ANGIOGRAPHIC BX/5EA","SUP-ITM-10174966","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.69","63.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","67.33","79.5","","1342.89","271.64","6954.67","1 through 10","26.25","67.33","percent of total billed charges",""
"CATHETER TORCON NB 5FR 100CM .038IN DAV ADVANTAGE ANGLED MULTIPURPOSE PERIPHERAL ANGIOGRAPHIC BX/5EA","SUP-ITM-10174966","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.69","63.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.14","53.3","","4550.00","30.49","4550.00","1 through 10","26.25","67.33","percent of total billed charges",""
"CATHETER TORCON NB 5FR 100CM .038IN DAV ADVANTAGE ANGLED MULTIPURPOSE PERIPHERAL ANGIOGRAPHIC BX/5EA","SUP-ITM-10174966","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.69","63.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.05","65","","42.09","0.04","5453.50","1 through 10","26.25","67.33","percent of total billed charges",""
"CATHETER TORCON NB 5FR 100CM .038IN DAV ADVANTAGE ANGLED MULTIPURPOSE PERIPHERAL ANGIOGRAPHIC BX/5EA","SUP-ITM-10174966","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.69","63.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30.91","36.5","","310.94","18.54","1259.30","62","26.25","67.33","percent of total billed charges",""
"CATHETER TORCON NB 5FR 100CM .038IN DAV ADVANTAGE ANGLED MULTIPURPOSE PERIPHERAL ANGIOGRAPHIC BX/5EA","SUP-ITM-10174966","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.69","63.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.44","38.3","","146.86","22.58","1753.45","65","26.25","67.33","percent of total billed charges",""
"CATHETER TORCON NB 5FR 100CM .038IN DAV ADVANTAGE ANGLED MULTIPURPOSE PERIPHERAL ANGIOGRAPHIC BX/5EA","SUP-ITM-10174966","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.69","63.52","WELLPOINT [1015]","HB AMC WELLPOINT","62.48","73.78","","247.29","33.09","909.09","53","26.25","67.33","percent of total billed charges",""
"CATHETER TORCON NB 5FR 100CM .038IN DAV ADVANTAGE ANGLED MULTIPURPOSE PERIPHERAL ANGIOGRAPHIC BX/5EA","SUP-ITM-10174966","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","84.69","63.52","AETNA [1001]","HB AMC AETNA HMO","59.11","69.8","","30.69","30.21","30.69","1 through 10","44.26","69.21","percent of total billed charges",""
"CATHETER TORCON NB 5FR 100CM .038IN DAV ADVANTAGE ANGLED MULTIPURPOSE PERIPHERAL ANGIOGRAPHIC BX/5EA","SUP-ITM-10174966","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","84.69","63.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","68.09","80.4","","82.69","82.69","82.69","1 through 10","44.26","69.21","percent of total billed charges",""
"CATHETER TORCON NB 5FR 100CM .038IN DAV ADVANTAGE ANGLED MULTIPURPOSE PERIPHERAL ANGIOGRAPHIC BX/5EA","SUP-ITM-10174966","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","84.69","63.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","69.21","81.72","","751.01","74.72","751.01","1 through 10","44.26","69.21","percent of total billed charges",""
"CATHETER TORCON NB 5FR 100CM .038IN DAV ADVANTAGE ANGLED MULTIPURPOSE PERIPHERAL ANGIOGRAPHIC BX/5EA","SUP-ITM-10174966","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","84.69","63.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","69.21","81.72","","328.92","46.17","2701.97","59","44.26","69.21","percent of total billed charges",""
"CATHETER TRAY 7FRX5CM SINGLE LUMEN PICC ARROW FLEX STRAIGHT GUIDEWIRE SCALPEL VESSEL DILATOR CS/25EA","SUP-ITM-10005787","CDM","C1751","HCPCS","0272","RC","","","","both","","","39.34","29.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","27.54","70","","1389.50","602.17","3167.85","27","12.2","31.28","percent of total billed charges",""
"CATHETER TRAY 7FRX5CM SINGLE LUMEN PICC ARROW FLEX STRAIGHT GUIDEWIRE SCALPEL VESSEL DILATOR CS/25EA","SUP-ITM-10005787","CDM","C1751","HCPCS","0272","RC","","","","both","","","39.34","29.50","WELLPOINT [1015]","HB AMC WELLPOINT","29.03","73.78","","1089.20","218.86","1089.20","1 through 10","12.2","31.28","percent of total billed charges",""
"CATHETER TRAY 7FRX5CM SINGLE LUMEN PICC ARROW FLEX STRAIGHT GUIDEWIRE SCALPEL VESSEL DILATOR CS/25EA","SUP-ITM-10005787","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","39.34","29.50","AETNA [1001]","HB AMC AETNA HMO","27.46","69.8","","1389.50","940.69","1389.50","1 through 10","20.56","32.15","percent of total billed charges",""
"CATHETER TRAY 7FRX5CM SINGLE LUMEN PICC ARROW FLEX STRAIGHT GUIDEWIRE SCALPEL VESSEL DILATOR CS/25EA","SUP-ITM-10005787","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","39.34","29.50","AETNA [1001]","HB AMC AETNA PPO","31.63","80.4","","190.26","190.26","190.26","1 through 10","20.56","32.15","percent of total billed charges",""
"CATHETER TRAY 7FRX5CM SINGLE LUMEN PICC ARROW FLEX STRAIGHT GUIDEWIRE SCALPEL VESSEL DILATOR CS/25EA","SUP-ITM-10005787","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","39.34","29.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","32.15","81.72","","1110.77","235.00","1169.52","1 through 10","20.56","32.15","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","323.75","242.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","257.38","79.5","","19.51","1.19","19.51","1 through 10","100.36","257.38","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","323.75","242.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","210.44","65","","0.94","0.94","0.94","1 through 10","100.36","257.38","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","323.75","242.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.17","36.5","","12.11","1.56","53.50","35","100.36","257.38","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","323.75","242.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.00","38.3","","1.65","0.56","14.07","55","100.36","257.38","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","323.75","242.81","WELLPOINT [1015]","HB AMC WELLPOINT","238.86","73.78","","24.17","1.07","130.81","14","100.36","257.38","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","323.75","242.81","AETNA [1001]","HB AMC AETNA HMO","225.98","69.8","","1.83","0.82","15.71","1 through 10","169.19","264.57","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","323.75","242.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","260.30","80.4","","0.72","0.72","0.72","1 through 10","169.19","264.57","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","323.75","242.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","264.57","81.72","","10.92","1.37","10.92","1 through 10","169.19","264.57","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","323.75","242.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","264.57","81.72","","19.84","1.15","26.27","14","169.19","264.57","percent of total billed charges",""
"CATHETER URETERAL 4.8FR 70CM 8 CONE TIP RT BX/10EA","SUP-ITM-10078395","CDM","C1758","HCPCS","0272","RC","","","","both","","","47.39","35.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","37.68","79.5","","19.51","1.19","19.51","1 through 10","14.69","37.68","percent of total billed charges",""
"CATHETER URETERAL 4.8FR 70CM 8 CONE TIP RT BX/10EA","SUP-ITM-10078395","CDM","C1758","HCPCS","0272","RC","","","","both","","","47.39","35.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","30.80","65","","0.94","0.94","0.94","1 through 10","14.69","37.68","percent of total billed charges",""
"CATHETER URETERAL 4.8FR 70CM 8 CONE TIP RT BX/10EA","SUP-ITM-10078395","CDM","C1758","HCPCS","0272","RC","","","","both","","","47.39","35.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17.30","36.5","","12.11","1.56","53.50","35","14.69","37.68","percent of total billed charges",""
"CATHETER URETERAL 4.8FR 70CM 8 CONE TIP RT BX/10EA","SUP-ITM-10078395","CDM","C1758","HCPCS","0272","RC","","","","both","","","47.39","35.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18.15","38.3","","1.65","0.56","14.07","55","14.69","37.68","percent of total billed charges",""
"CATHETER URETERAL 4.8FR 70CM 8 CONE TIP RT BX/10EA","SUP-ITM-10078395","CDM","C1758","HCPCS","0272","RC","","","","both","","","47.39","35.54","WELLPOINT [1015]","HB AMC WELLPOINT","34.96","73.78","","24.17","1.07","130.81","14","14.69","37.68","percent of total billed charges",""
"CATHETER URETERAL 4.8FR 70CM 8 CONE TIP RT BX/10EA","SUP-ITM-10078395","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","47.39","35.54","AETNA [1001]","HB AMC AETNA HMO","33.08","69.8","","1.83","0.82","15.71","1 through 10","24.77","38.73","percent of total billed charges",""
"CATHETER URETERAL 4.8FR 70CM 8 CONE TIP RT BX/10EA","SUP-ITM-10078395","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","47.39","35.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","38.10","80.4","","0.72","0.72","0.72","1 through 10","24.77","38.73","percent of total billed charges",""
"CATHETER URETERAL 4.8FR 70CM 8 CONE TIP RT BX/10EA","SUP-ITM-10078395","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","47.39","35.54","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","38.73","81.72","","10.92","1.37","10.92","1 through 10","24.77","38.73","percent of total billed charges",""
"CATHETER URETERAL 4.8FR 70CM 8 CONE TIP RT BX/10EA","SUP-ITM-10078395","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","47.39","35.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","38.73","81.72","","19.84","1.15","26.27","14","24.77","38.73","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","both","","","49.56","37.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","39.40","79.5","","19.51","1.19","19.51","1 through 10","15.36","39.4","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","both","","","49.56","37.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","32.21","65","","0.94","0.94","0.94","1 through 10","15.36","39.4","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","both","","","49.56","37.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","18.09","36.5","","12.11","1.56","53.50","35","15.36","39.4","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","both","","","49.56","37.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18.98","38.3","","1.65","0.56","14.07","55","15.36","39.4","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","both","","","49.56","37.17","WELLPOINT [1015]","HB AMC WELLPOINT","36.57","73.78","","24.17","1.07","130.81","14","15.36","39.4","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","49.56","37.17","AETNA [1001]","HB AMC AETNA HMO","34.59","69.8","","1.83","0.82","15.71","1 through 10","25.9","40.5","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","49.56","37.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","39.85","80.4","","0.72","0.72","0.72","1 through 10","25.9","40.5","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","49.56","37.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","40.50","81.72","","10.92","1.37","10.92","1 through 10","25.9","40.5","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","49.56","37.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","40.50","81.72","","19.84","1.15","26.27","14","25.9","40.5","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","both","","","46.33","34.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","36.83","79.5","","19.51","1.19","19.51","1 through 10","14.36","36.83","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","both","","","46.33","34.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","30.11","65","","0.94","0.94","0.94","1 through 10","14.36","36.83","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","both","","","46.33","34.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16.91","36.5","","12.11","1.56","53.50","35","14.36","36.83","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","both","","","46.33","34.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17.74","38.3","","1.65","0.56","14.07","55","14.36","36.83","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","both","","","46.33","34.75","WELLPOINT [1015]","HB AMC WELLPOINT","34.18","73.78","","24.17","1.07","130.81","14","14.36","36.83","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","46.33","34.75","AETNA [1001]","HB AMC AETNA HMO","32.34","69.8","","1.83","0.82","15.71","1 through 10","24.21","37.86","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","46.33","34.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","37.25","80.4","","0.72","0.72","0.72","1 through 10","24.21","37.86","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","46.33","34.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","37.86","81.72","","10.92","1.37","10.92","1 through 10","24.21","37.86","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","46.33","34.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","37.86","81.72","","19.84","1.15","26.27","14","24.21","37.86","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","both","","","25.47","19.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20.25","79.5","","19.51","1.19","19.51","1 through 10","7.9","20.25","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","both","","","25.47","19.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","16.56","65","","0.94","0.94","0.94","1 through 10","7.9","20.25","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","both","","","25.47","19.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9.30","36.5","","12.11","1.56","53.50","35","7.9","20.25","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","both","","","25.47","19.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9.76","38.3","","1.65","0.56","14.07","55","7.9","20.25","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","both","","","25.47","19.10","WELLPOINT [1015]","HB AMC WELLPOINT","18.79","73.78","","24.17","1.07","130.81","14","7.9","20.25","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","25.47","19.10","AETNA [1001]","HB AMC AETNA HMO","17.78","69.8","","1.83","0.82","15.71","1 through 10","13.31","20.81","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","25.47","19.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","20.48","80.4","","0.72","0.72","0.72","1 through 10","13.31","20.81","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","25.47","19.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","20.81","81.72","","10.92","1.37","10.92","1 through 10","13.31","20.81","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","25.47","19.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","20.81","81.72","","19.84","1.15","26.27","14","13.31","20.81","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM /.97 .038 OPEN END BX/10EA","SUP-ITM-10025943","CDM","C1758","HCPCS","0272","RC","","","","both","","","40.29","30.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","32.03","79.5","","19.51","1.19","19.51","1 through 10","12.49","32.03","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM /.97 .038 OPEN END BX/10EA","SUP-ITM-10025943","CDM","C1758","HCPCS","0272","RC","","","","both","","","40.29","30.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","26.19","65","","0.94","0.94","0.94","1 through 10","12.49","32.03","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM /.97 .038 OPEN END BX/10EA","SUP-ITM-10025943","CDM","C1758","HCPCS","0272","RC","","","","both","","","40.29","30.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14.71","36.5","","12.11","1.56","53.50","35","12.49","32.03","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM /.97 .038 OPEN END BX/10EA","SUP-ITM-10025943","CDM","C1758","HCPCS","0272","RC","","","","both","","","40.29","30.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15.43","38.3","","1.65","0.56","14.07","55","12.49","32.03","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM /.97 .038 OPEN END BX/10EA","SUP-ITM-10025943","CDM","C1758","HCPCS","0272","RC","","","","both","","","40.29","30.22","WELLPOINT [1015]","HB AMC WELLPOINT","29.73","73.78","","24.17","1.07","130.81","14","12.49","32.03","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM /.97 .038 OPEN END BX/10EA","SUP-ITM-10025943","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","40.29","30.22","AETNA [1001]","HB AMC AETNA HMO","28.12","69.8","","1.83","0.82","15.71","1 through 10","21.06","32.92","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM /.97 .038 OPEN END BX/10EA","SUP-ITM-10025943","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","40.29","30.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","32.39","80.4","","0.72","0.72","0.72","1 through 10","21.06","32.92","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM /.97 .038 OPEN END BX/10EA","SUP-ITM-10025943","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","40.29","30.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","32.92","81.72","","10.92","1.37","10.92","1 through 10","21.06","32.92","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM /.97 .038 OPEN END BX/10EA","SUP-ITM-10025943","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","40.29","30.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","32.92","81.72","","19.84","1.15","26.27","14","21.06","32.92","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","42.10","31.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33.47","79.5","","19.51","1.19","19.51","1 through 10","13.05","33.47","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","42.10","31.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","27.37","65","","0.94","0.94","0.94","1 through 10","13.05","33.47","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","42.10","31.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15.37","36.5","","12.11","1.56","53.50","35","13.05","33.47","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","42.10","31.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.12","38.3","","1.65","0.56","14.07","55","13.05","33.47","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","42.10","31.57","WELLPOINT [1015]","HB AMC WELLPOINT","31.06","73.78","","24.17","1.07","130.81","14","13.05","33.47","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","42.10","31.57","AETNA [1001]","HB AMC AETNA HMO","29.39","69.8","","1.83","0.82","15.71","1 through 10","22","34.4","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","42.10","31.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","33.85","80.4","","0.72","0.72","0.72","1 through 10","22","34.4","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","42.10","31.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","34.40","81.72","","10.92","1.37","10.92","1 through 10","22","34.4","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","42.10","31.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34.40","81.72","","19.84","1.15","26.27","14","22","34.4","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","both","","","325.12","243.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.47","79.5","","19.51","1.19","19.51","1 through 10","100.79","258.47","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","both","","","325.12","243.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","211.33","65","","0.94","0.94","0.94","1 through 10","100.79","258.47","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","both","","","325.12","243.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.67","36.5","","12.11","1.56","53.50","35","100.79","258.47","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","both","","","325.12","243.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.52","38.3","","1.65","0.56","14.07","55","100.79","258.47","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","both","","","325.12","243.84","WELLPOINT [1015]","HB AMC WELLPOINT","239.87","73.78","","24.17","1.07","130.81","14","100.79","258.47","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","325.12","243.84","AETNA [1001]","HB AMC AETNA HMO","226.93","69.8","","1.83","0.82","15.71","1 through 10","169.91","265.69","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","325.12","243.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","261.40","80.4","","0.72","0.72","0.72","1 through 10","169.91","265.69","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","325.12","243.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","265.69","81.72","","10.92","1.37","10.92","1 through 10","169.91","265.69","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","325.12","243.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","265.69","81.72","","19.84","1.15","26.27","14","169.91","265.69","percent of total billed charges",""
"CATHETER UROLOGY 4MMCM 12FR 3 150 2 DILATION PASSPORT BALLOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014249","CDM","C1726","HCPCS","0272","RC","","","","both","","","918.89","689.17","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","643.22","70","","863.10","863.10","863.10","1 through 10","284.86","730.52","percent of total billed charges",""
"CATHETER UROLOGY 4MMCM 12FR 3 150 2 DILATION PASSPORT BALLOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014249","CDM","C1726","HCPCS","0272","RC","","","","both","","","918.89","689.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","730.52","79.5","","447.66","447.66","447.66","1 through 10","284.86","730.52","percent of total billed charges",""
"CATHETER UROLOGY 4MMCM 12FR 3 150 2 DILATION PASSPORT BALLOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014249","CDM","C1726","HCPCS","0272","RC","","","","both","","","918.89","689.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","597.28","65","","1020.11","1020.11","1020.11","1 through 10","284.86","730.52","percent of total billed charges",""
"CATHETER UROLOGY 4MMCM 12FR 3 150 2 DILATION PASSPORT BALLOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014249","CDM","C1726","HCPCS","0272","RC","","","","both","","","918.89","689.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","284.86","31","","208.83","208.83","208.83","1 through 10","284.86","730.52","percent of total billed charges",""
"CATHETER UROLOGY 4MMCM 12FR 3 150 2 DILATION PASSPORT BALLOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014249","CDM","C1726","HCPCS","0272","RC","","","","both","","","918.89","689.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","335.39","36.5","","312.44","214.23","1086.03","20","284.86","730.52","percent of total billed charges",""
"CATHETER UROLOGY 4MMCM 12FR 3 150 2 DILATION PASSPORT BALLOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014249","CDM","C1726","HCPCS","0272","RC","","","","both","","","918.89","689.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","351.93","38.3","","264.25","227.63","567.11","31","284.86","730.52","percent of total billed charges",""
"CATHETER UROLOGY 4MMCM 12FR 3 150 2 DILATION PASSPORT BALLOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014249","CDM","C1726","HCPCS","0272","RC","","","","both","","","918.89","689.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","394.20","42.9","","79.94","79.94","79.94","1 through 10","284.86","730.52","percent of total billed charges",""
"CATHETER UROLOGY 4MMCM 12FR 3 150 2 DILATION PASSPORT BALLOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014249","CDM","C1726","HCPCS","0272","RC","","","","both","","","918.89","689.17","WELLPOINT [1015]","HB AMC WELLPOINT","677.96","73.78","","174.45","74.45","1168.42","1 through 10","284.86","730.52","percent of total billed charges",""
"CATHETER UROLOGY 4MMCM 12FR 3 150 2 DILATION PASSPORT BALLOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014249","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","918.89","689.17","AETNA [1001]","HB AMC AETNA HMO","641.39","69.8","","655.01","135.40","784.73","1 through 10","480.21","750.92","percent of total billed charges",""
"CATHETER UROLOGY 4MMCM 12FR 3 150 2 DILATION PASSPORT BALLOO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014249","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","918.89","689.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","750.92","81.72","","540.25","46.28","897.42","36","480.21","750.92","percent of total billed charges",""
"CATHETER VASCULAR 13FRX38.1CM PEDIATRIC DLP VENTRICULAR STRAIGHT LT HEART PK/20EA","SUP-ITM-10005333","CDM","C1892","HCPCS","0272","RC","","","","both","","","81.32","60.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29.68","36.5","","66.97","66.97","66.97","1 through 10","25.21","64.65","percent of total billed charges",""
"CATHETER VASCULAR 13FRX38.1CM PEDIATRIC DLP VENTRICULAR STRAIGHT LT HEART PK/20EA","SUP-ITM-10005333","CDM","C1892","HCPCS","0272","RC","","","","both","","","81.32","60.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31.15","38.3","","70.21","44.61","70.21","1 through 10","25.21","64.65","percent of total billed charges",""
"CATHETER VASCULAR 13FRX38.1CM PEDIATRIC DLP VENTRICULAR STRAIGHT LT HEART PK/20EA","SUP-ITM-10005333","CDM","C1892","HCPCS","0272","RC","","","","both","","","81.32","60.99","WELLPOINT [1015]","HB AMC WELLPOINT","60.00","73.78","","84.95","84.95","84.95","1 through 10","25.21","64.65","percent of total billed charges",""
"CATHETER VASCULAR 13FRX38.1CM PEDIATRIC DLP VENTRICULAR STRAIGHT LT HEART PK/20EA","SUP-ITM-10005333","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","81.32","60.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","66.45","81.72","","91.21","50.17","91.21","1 through 10","42.5","66.45","percent of total billed charges",""
"CATHETER VASCULAR 13FRX38.1CM PEDIATRIC DLP VENTRICULAR STRAIGHT LT HEART PK/20EA","SUP-ITM-10005333","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","81.32","60.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","66.45","81.72","","50.17","50.17","50.17","1 through 10","42.5","66.45","percent of total billed charges",""
"CATHETER VASCULAR 140CM 7.5FR TRI LUMEN","SUP-ITM-10337413","CDM","C1887","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2462.74","71.8","","28.28","27.13","28.28","1 through 10","1063.3","2726.85","percent of total billed charges",""
"CATHETER VASCULAR 140CM 7.5FR TRI LUMEN","SUP-ITM-10337413","CDM","C1887","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2401.00","70","","44.63","35.78","44.63","1 through 10","1063.3","2726.85","percent of total billed charges",""
"CATHETER VASCULAR 140CM 7.5FR TRI LUMEN","SUP-ITM-10337413","CDM","C1887","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2726.85","79.5","","1342.89","271.64","6954.67","1 through 10","1063.3","2726.85","percent of total billed charges",""
"CATHETER VASCULAR 140CM 7.5FR TRI LUMEN","SUP-ITM-10337413","CDM","C1887","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1828.19","53.3","","4550.00","30.49","4550.00","1 through 10","1063.3","2726.85","percent of total billed charges",""
"CATHETER VASCULAR 140CM 7.5FR TRI LUMEN","SUP-ITM-10337413","CDM","C1887","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2229.50","65","","42.09","0.04","5453.50","1 through 10","1063.3","2726.85","percent of total billed charges",""
"CATHETER VASCULAR 140CM 7.5FR TRI LUMEN","SUP-ITM-10337413","CDM","C1887","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1251.95","36.5","","310.94","18.54","1259.30","62","1063.3","2726.85","percent of total billed charges",""
"CATHETER VASCULAR 140CM 7.5FR TRI LUMEN","SUP-ITM-10337413","CDM","C1887","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1313.69","38.3","","146.86","22.58","1753.45","65","1063.3","2726.85","percent of total billed charges",""
"CATHETER VASCULAR 140CM 7.5FR TRI LUMEN","SUP-ITM-10337413","CDM","C1887","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","WELLPOINT [1015]","HB AMC WELLPOINT","2530.65","73.78","","247.29","33.09","909.09","53","1063.3","2726.85","percent of total billed charges",""
"CATHETER VASCULAR 140CM 7.5FR TRI LUMEN","SUP-ITM-10337413","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3430.00","2572.50","AETNA [1001]","HB AMC AETNA HMO","2394.14","69.8","","30.69","30.21","30.69","1 through 10","1792.52","2803","percent of total billed charges",""
"CATHETER VASCULAR 140CM 7.5FR TRI LUMEN","SUP-ITM-10337413","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3430.00","2572.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2757.72","80.4","","82.69","82.69","82.69","1 through 10","1792.52","2803","percent of total billed charges",""
"CATHETER VASCULAR 140CM 7.5FR TRI LUMEN","SUP-ITM-10337413","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3430.00","2572.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2803.00","81.72","","751.01","74.72","751.01","1 through 10","1792.52","2803","percent of total billed charges",""
"CATHETER VASCULAR 140CM 7.5FR TRI LUMEN","SUP-ITM-10337413","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3430.00","2572.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2803.00","81.72","","328.92","46.17","2701.97","59","1792.52","2803","percent of total billed charges",""
"CATHETER VASCUTRAK 7FR 7MM 40MM 140CM .018IN SHORT RX SEMI COMPLIANT PERIPHERAL STERILE DISP","SUP-ITM-10046815","CDM","C1725","HCPCS","0272","RC","","","","both","","","2187.50","1640.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1570.63","71.8","","175.91","175.91","175.91","1 through 10","678.13","1739.06","percent of total billed charges",""
"CATHETER VASCUTRAK 7FR 7MM 40MM 140CM .018IN SHORT RX SEMI COMPLIANT PERIPHERAL STERILE DISP","SUP-ITM-10046815","CDM","C1725","HCPCS","0272","RC","","","","both","","","2187.50","1640.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1421.88","65","","147.88","147.88","1296.75","1 through 10","678.13","1739.06","percent of total billed charges",""
"CATHETER VASCUTRAK 7FR 7MM 40MM 140CM .018IN SHORT RX SEMI COMPLIANT PERIPHERAL STERILE DISP","SUP-ITM-10046815","CDM","C1725","HCPCS","0272","RC","","","","both","","","2187.50","1640.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","798.44","36.5","","181.40","177.87","181.40","21","678.13","1739.06","percent of total billed charges",""
"CATHETER VASCUTRAK 7FR 7MM 40MM 140CM .018IN SHORT RX SEMI COMPLIANT PERIPHERAL STERILE DISP","SUP-ITM-10046815","CDM","C1725","HCPCS","0272","RC","","","","both","","","2187.50","1640.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","837.81","38.3","","170.15","88.95","424.24","16","678.13","1739.06","percent of total billed charges",""
"CATHETER VASCUTRAK 7FR 7MM 40MM 140CM .018IN SHORT RX SEMI COMPLIANT PERIPHERAL STERILE DISP","SUP-ITM-10046815","CDM","C1725","HCPCS","0272","RC","","","","both","","","2187.50","1640.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","938.44","42.9","","699.48","699.48","699.48","12","678.13","1739.06","percent of total billed charges",""
"CATHETER VASCUTRAK 7FR 7MM 40MM 140CM .018IN SHORT RX SEMI COMPLIANT PERIPHERAL STERILE DISP","SUP-ITM-10046815","CDM","C1725","HCPCS","0272","RC","","","","both","","","2187.50","1640.62","WELLPOINT [1015]","HB AMC WELLPOINT","1613.94","73.78","","576.52","182.40","651.44","14","678.13","1739.06","percent of total billed charges",""
"CATHETER VASCUTRAK 7FR 7MM 40MM 140CM .018IN SHORT RX SEMI COMPLIANT PERIPHERAL STERILE DISP","SUP-ITM-10046815","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","2187.50","1640.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1787.63","81.72","","181.86","100.03","402.41","21","1143.19","1787.63","percent of total billed charges",""
"Catheter Vein Portal Perc","PX-76001072","CDM","36481","CPT","0361","RC","","","","both","","","2705.00","2028.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2150.48","79.5","","1384.94","1384.94","1384.94","1 through 10","838.55","2150.48","percent of total billed charges",""
"Catheter Venous Blood Select Sample","PX-76001073","CDM","36500","CPT","0761","RC","","","","both","","","1328.00","996.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","484.72","36.5","","408.30","408.30","408.30","1 through 10","411.68","1055.76","percent of total billed charges",""
"Catheter Venous Blood Select Sample","PX-76001073","CDM","36500","CPT","0761","RC","","","","both","","","1328.00","996.00","WELLPOINT [1015]","HB AMC WELLPOINT","979.80","73.78","","958.92","958.92","958.92","1 through 10","411.68","1055.76","percent of total billed charges",""
"Catheter Venous Blood Select Sample","PX-76001073","CDM","36500","CPT","0761","RC","","","","outpatient","","","1328.00","996.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1085.24","81.72","","1029.63","1029.63","1029.63","1 through 10","308.5","1085.24","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 5CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082889","CDM","C1889","HCPCS","0278","RC","","","","both","","","331.90","248.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","263.86","79.5","","1309.77","674.56","6049.93","26","102.89","263.86","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 5CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082889","CDM","C1889","HCPCS","0278","RC","","","","both","","","331.90","248.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","176.90","53.3","","1901.83","1901.83","2962.25","1 through 10","102.89","263.86","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 5CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082889","CDM","C1889","HCPCS","0278","RC","","","","both","","","331.90","248.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.14","36.5","","1620.31","1620.31","19908.88","1 through 10","102.89","263.86","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 5CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082889","CDM","C1889","HCPCS","0278","RC","","","","both","","","331.90","248.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.12","38.3","","352.91","352.91","2046.30","1 through 10","102.89","263.86","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 5CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082889","CDM","C1889","HCPCS","0278","RC","","","","both","","","331.90","248.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.39","42.9","","9668.75","9668.75","9668.75","1 through 10","102.89","263.86","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 5CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082889","CDM","C1889","HCPCS","0278","RC","","","","both","","","331.90","248.92","WELLPOINT [1015]","HB AMC WELLPOINT","244.88","73.78","","699.88","384.10","3443.31","33","102.89","263.86","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 5CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082889","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","331.90","248.92","AETNA [1001]","HB AMC AETNA HMO","231.67","69.8","","1421.24","264.50","4933.46","29","173.45","271.23","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 5CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082889","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","331.90","248.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","266.85","80.4","","1022.97","1022.97","3607.50","1 through 10","173.45","271.23","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 5CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082889","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","331.90","248.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","271.23","81.72","","3010.54","693.88","5019.88","35","173.45","271.23","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 8CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082896","CDM","C1889","HCPCS","0278","RC","","","","both","","","332.14","249.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","264.05","79.5","","1309.77","674.56","6049.93","26","102.96","264.05","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 8CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082896","CDM","C1889","HCPCS","0278","RC","","","","both","","","332.14","249.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","177.03","53.3","","1901.83","1901.83","2962.25","1 through 10","102.96","264.05","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 8CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082896","CDM","C1889","HCPCS","0278","RC","","","","both","","","332.14","249.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.23","36.5","","1620.31","1620.31","19908.88","1 through 10","102.96","264.05","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 8CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082896","CDM","C1889","HCPCS","0278","RC","","","","both","","","332.14","249.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.21","38.3","","352.91","352.91","2046.30","1 through 10","102.96","264.05","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 8CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082896","CDM","C1889","HCPCS","0278","RC","","","","both","","","332.14","249.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.49","42.9","","9668.75","9668.75","9668.75","1 through 10","102.96","264.05","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 8CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082896","CDM","C1889","HCPCS","0278","RC","","","","both","","","332.14","249.10","WELLPOINT [1015]","HB AMC WELLPOINT","245.05","73.78","","699.88","384.10","3443.31","33","102.96","264.05","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 8CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082896","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","332.14","249.10","AETNA [1001]","HB AMC AETNA HMO","231.83","69.8","","1421.24","264.50","4933.46","29","173.58","271.42","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 8CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082896","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","332.14","249.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","267.04","80.4","","1022.97","1022.97","3607.50","1 through 10","173.58","271.42","percent of total billed charges",""
"CATHETER VENTRICULAR 1.3X2.5MM 8CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082896","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","332.14","249.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","271.42","81.72","","3010.54","693.88","5019.88","35","173.58","271.42","percent of total billed charges",""
"CATHETER VENTRICULAR 4CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082893","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.78","245.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","260.59","79.5","","1309.77","674.56","6049.93","26","101.61","260.59","percent of total billed charges",""
"CATHETER VENTRICULAR 4CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082893","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.78","245.83","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","174.71","53.3","","1901.83","1901.83","2962.25","1 through 10","101.61","260.59","percent of total billed charges",""
"CATHETER VENTRICULAR 4CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082893","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.78","245.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","119.64","36.5","","1620.31","1620.31","19908.88","1 through 10","101.61","260.59","percent of total billed charges",""
"CATHETER VENTRICULAR 4CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082893","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.78","245.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","125.54","38.3","","352.91","352.91","2046.30","1 through 10","101.61","260.59","percent of total billed charges",""
"CATHETER VENTRICULAR 4CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082893","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.78","245.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.62","42.9","","9668.75","9668.75","9668.75","1 through 10","101.61","260.59","percent of total billed charges",""
"CATHETER VENTRICULAR 4CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082893","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.78","245.83","WELLPOINT [1015]","HB AMC WELLPOINT","241.84","73.78","","699.88","384.10","3443.31","33","101.61","260.59","percent of total billed charges",""
"CATHETER VENTRICULAR 4CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082893","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","327.78","245.83","AETNA [1001]","HB AMC AETNA HMO","228.79","69.8","","1421.24","264.50","4933.46","29","171.3","267.86","percent of total billed charges",""
"CATHETER VENTRICULAR 4CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082893","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","327.78","245.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","263.54","80.4","","1022.97","1022.97","3607.50","1 through 10","171.3","267.86","percent of total billed charges",""
"CATHETER VENTRICULAR 4CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082893","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","327.78","245.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","267.86","81.72","","3010.54","693.88","5019.88","35","171.3","267.86","percent of total billed charges",""
"CATHETER VENTRICULAR 7CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082890","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.81","245.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","260.61","79.5","","1309.77","674.56","6049.93","26","101.62","260.61","percent of total billed charges",""
"CATHETER VENTRICULAR 7CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082890","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.81","245.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","174.72","53.3","","1901.83","1901.83","2962.25","1 through 10","101.62","260.61","percent of total billed charges",""
"CATHETER VENTRICULAR 7CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082890","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.81","245.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","119.65","36.5","","1620.31","1620.31","19908.88","1 through 10","101.62","260.61","percent of total billed charges",""
"CATHETER VENTRICULAR 7CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082890","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.81","245.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","125.55","38.3","","352.91","352.91","2046.30","1 through 10","101.62","260.61","percent of total billed charges",""
"CATHETER VENTRICULAR 7CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082890","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.81","245.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.63","42.9","","9668.75","9668.75","9668.75","1 through 10","101.62","260.61","percent of total billed charges",""
"CATHETER VENTRICULAR 7CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082890","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.81","245.86","WELLPOINT [1015]","HB AMC WELLPOINT","241.86","73.78","","699.88","384.10","3443.31","33","101.62","260.61","percent of total billed charges",""
"CATHETER VENTRICULAR 7CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082890","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","327.81","245.86","AETNA [1001]","HB AMC AETNA HMO","228.81","69.8","","1421.24","264.50","4933.46","29","171.31","267.89","percent of total billed charges",""
"CATHETER VENTRICULAR 7CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082890","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","327.81","245.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","263.56","80.4","","1022.97","1022.97","3607.50","1 through 10","171.31","267.89","percent of total billed charges",""
"CATHETER VENTRICULAR 7CM PS MEDICAL BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082890","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","327.81","245.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","267.89","81.72","","3010.54","693.88","5019.88","35","171.31","267.89","percent of total billed charges",""
"CATHETER VENTRICULAR 9CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082891","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.68","245.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","260.51","79.5","","1309.77","674.56","6049.93","26","101.58","260.51","percent of total billed charges",""
"CATHETER VENTRICULAR 9CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082891","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.68","245.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","174.65","53.3","","1901.83","1901.83","2962.25","1 through 10","101.58","260.51","percent of total billed charges",""
"CATHETER VENTRICULAR 9CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082891","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.68","245.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","119.60","36.5","","1620.31","1620.31","19908.88","1 through 10","101.58","260.51","percent of total billed charges",""
"CATHETER VENTRICULAR 9CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082891","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.68","245.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","125.50","38.3","","352.91","352.91","2046.30","1 through 10","101.58","260.51","percent of total billed charges",""
"CATHETER VENTRICULAR 9CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082891","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.68","245.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.57","42.9","","9668.75","9668.75","9668.75","1 through 10","101.58","260.51","percent of total billed charges",""
"CATHETER VENTRICULAR 9CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082891","CDM","C1889","HCPCS","0278","RC","","","","both","","","327.68","245.76","WELLPOINT [1015]","HB AMC WELLPOINT","241.76","73.78","","699.88","384.10","3443.31","33","101.58","260.51","percent of total billed charges",""
"CATHETER VENTRICULAR 9CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082891","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","327.68","245.76","AETNA [1001]","HB AMC AETNA HMO","228.72","69.8","","1421.24","264.50","4933.46","29","171.25","267.78","percent of total billed charges",""
"CATHETER VENTRICULAR 9CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082891","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","327.68","245.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","263.45","80.4","","1022.97","1022.97","3607.50","1 through 10","171.25","267.78","percent of total billed charges",""
"CATHETER VENTRICULAR 9CM BARIUM IMPREGNATED RT ANGLE STANDARD","SUP-ITM-10082891","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","327.68","245.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","267.78","81.72","","3010.54","693.88","5019.88","35","171.25","267.78","percent of total billed charges",""
"CATHETER VENTRICULAR PERITONEAL BACTISEAL KIT","SUP-ITM-10045370","CDM","C1889","HCPCS","0278","RC","","","","both","","","2332.82","1749.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1854.59","79.5","","1309.77","674.56","6049.93","26","723.17","1854.59","percent of total billed charges",""
"CATHETER VENTRICULAR PERITONEAL BACTISEAL KIT","SUP-ITM-10045370","CDM","C1889","HCPCS","0278","RC","","","","both","","","2332.82","1749.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1243.39","53.3","","1901.83","1901.83","2962.25","1 through 10","723.17","1854.59","percent of total billed charges",""
"CATHETER VENTRICULAR PERITONEAL BACTISEAL KIT","SUP-ITM-10045370","CDM","C1889","HCPCS","0278","RC","","","","both","","","2332.82","1749.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","851.48","36.5","","1620.31","1620.31","19908.88","1 through 10","723.17","1854.59","percent of total billed charges",""
"CATHETER VENTRICULAR PERITONEAL BACTISEAL KIT","SUP-ITM-10045370","CDM","C1889","HCPCS","0278","RC","","","","both","","","2332.82","1749.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","893.47","38.3","","352.91","352.91","2046.30","1 through 10","723.17","1854.59","percent of total billed charges",""
"CATHETER VENTRICULAR PERITONEAL BACTISEAL KIT","SUP-ITM-10045370","CDM","C1889","HCPCS","0278","RC","","","","both","","","2332.82","1749.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1000.78","42.9","","9668.75","9668.75","9668.75","1 through 10","723.17","1854.59","percent of total billed charges",""
"CATHETER VENTRICULAR PERITONEAL BACTISEAL KIT","SUP-ITM-10045370","CDM","C1889","HCPCS","0278","RC","","","","both","","","2332.82","1749.61","WELLPOINT [1015]","HB AMC WELLPOINT","1721.15","73.78","","699.88","384.10","3443.31","33","723.17","1854.59","percent of total billed charges",""
"CATHETER VENTRICULAR PERITONEAL BACTISEAL KIT","SUP-ITM-10045370","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2332.82","1749.61","AETNA [1001]","HB AMC AETNA HMO","1628.31","69.8","","1421.24","264.50","4933.46","29","1219.13","1906.38","percent of total billed charges",""
"CATHETER VENTRICULAR PERITONEAL BACTISEAL KIT","SUP-ITM-10045370","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2332.82","1749.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1875.59","80.4","","1022.97","1022.97","3607.50","1 through 10","1219.13","1906.38","percent of total billed charges",""
"CATHETER VENTRICULAR PERITONEAL BACTISEAL KIT","SUP-ITM-10045370","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2332.82","1749.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1906.38","81.72","","3010.54","693.88","5019.88","35","1219.13","1906.38","percent of total billed charges",""
"CATHETER VIABAHN SX 11MMX5CMX120CM 10FR 35 RO ENDOPROSTHESIS","SUP-ITM-10276278","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4073.88","65","","6652.80","6652.80","6652.80","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER VIABAHN SX 11MMX5CMX120CM 10FR 35 RO ENDOPROSTHESIS","SUP-ITM-10276278","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4982.66","79.5","","2612.61","795.38","2612.61","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER VIABAHN SX 11MMX5CMX120CM 10FR 35 RO ENDOPROSTHESIS","SUP-ITM-10276278","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3340.58","53.3","","1101.80","1101.80","1101.80","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER VIABAHN SX 11MMX5CMX120CM 10FR 35 RO ENDOPROSTHESIS","SUP-ITM-10276278","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4073.88","65","","1820.00","910.00","1820.00","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER VIABAHN SX 11MMX5CMX120CM 10FR 35 RO ENDOPROSTHESIS","SUP-ITM-10276278","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2287.64","36.5","","1257.80","693.44","2424.50","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER VIABAHN SX 11MMX5CMX120CM 10FR 35 RO ENDOPROSTHESIS","SUP-ITM-10276278","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2400.45","38.3","","1950.11","547.40","2346.00","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER VIABAHN SX 11MMX5CMX120CM 10FR 35 RO ENDOPROSTHESIS","SUP-ITM-10276278","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2688.76","42.9","","5096.18","5096.18","5096.18","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER VIABAHN SX 11MMX5CMX120CM 10FR 35 RO ENDOPROSTHESIS","SUP-ITM-10276278","CDM","C1874","HCPCS","0278","RC","","","","both","","","6267.50","4700.62","WELLPOINT [1015]","HB AMC WELLPOINT","4624.16","73.78","","1172.59","1172.59","4829.94","1 through 10","1942.93","4982.66","percent of total billed charges",""
"CATHETER VIABAHN SX 11MMX5CMX120CM 10FR 35 RO ENDOPROSTHESIS","SUP-ITM-10276278","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6267.50","4700.62","AETNA [1001]","HB AMC AETNA HMO","4374.72","69.8","","1806.84","947.80","5091.72","1 through 10","3275.4","5121.8","percent of total billed charges",""
"CATHETER VIABAHN SX 11MMX5CMX120CM 10FR 35 RO ENDOPROSTHESIS","SUP-ITM-10276278","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6267.50","4700.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5121.80","81.72","","1259.05","615.58","4586.56","1 through 10","3275.4","5121.8","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 19MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188099","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.50","5060.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4385.88","65","","6652.80","6652.80","6652.80","1 through 10","2091.73","5364.26","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 19MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188099","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.50","5060.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5364.26","79.5","","2612.61","795.38","2612.61","1 through 10","2091.73","5364.26","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 19MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188099","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.50","5060.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3596.42","53.3","","1101.80","1101.80","1101.80","1 through 10","2091.73","5364.26","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 19MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188099","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.50","5060.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4385.88","65","","1820.00","910.00","1820.00","1 through 10","2091.73","5364.26","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 19MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188099","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.50","5060.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2462.84","36.5","","1257.80","693.44","2424.50","1 through 10","2091.73","5364.26","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 19MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188099","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.50","5060.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2584.29","38.3","","1950.11","547.40","2346.00","1 through 10","2091.73","5364.26","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 19MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188099","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.50","5060.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2894.68","42.9","","5096.18","5096.18","5096.18","1 through 10","2091.73","5364.26","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 19MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188099","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.50","5060.62","WELLPOINT [1015]","HB AMC WELLPOINT","4978.31","73.78","","1172.59","1172.59","4829.94","1 through 10","2091.73","5364.26","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 19MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188099","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6747.50","5060.62","AETNA [1001]","HB AMC AETNA HMO","4709.76","69.8","","1806.84","947.80","5091.72","1 through 10","3526.24","5514.06","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 19MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188099","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6747.50","5060.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5514.06","81.72","","1259.05","615.58","4586.56","1 through 10","3526.24","5514.06","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 79MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188090","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5534.75","65","","6652.80","6652.80","6652.80","1 through 10","2639.65","6769.43","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 79MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188090","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6769.43","79.5","","2612.61","795.38","2612.61","1 through 10","2639.65","6769.43","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 79MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188090","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4538.50","53.3","","1101.80","1101.80","1101.80","1 through 10","2639.65","6769.43","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 79MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188090","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5534.75","65","","1820.00","910.00","1820.00","1 through 10","2639.65","6769.43","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 79MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188090","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3107.98","36.5","","1257.80","693.44","2424.50","1 through 10","2639.65","6769.43","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 79MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188090","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3261.25","38.3","","1950.11","547.40","2346.00","1 through 10","2639.65","6769.43","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 79MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188090","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3652.94","42.9","","5096.18","5096.18","5096.18","1 through 10","2639.65","6769.43","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 79MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188090","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","WELLPOINT [1015]","HB AMC WELLPOINT","6282.37","73.78","","1172.59","1172.59","4829.94","1 through 10","2639.65","6769.43","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 79MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188090","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8515.00","6386.25","AETNA [1001]","HB AMC AETNA HMO","5943.47","69.8","","1806.84","947.80","5091.72","1 through 10","4449.94","6958.46","percent of total billed charges",""
"CATHETER VIABAHN VBX 7MM 79MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188090","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8515.00","6386.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6958.46","81.72","","1259.05","615.58","4586.56","1 through 10","4449.94","6958.46","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 59MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188084","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4907.50","65","","6652.80","6652.80","6652.80","1 through 10","2340.5","6002.25","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 59MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188084","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6002.25","79.5","","2612.61","795.38","2612.61","1 through 10","2340.5","6002.25","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 59MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188084","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4024.15","53.3","","1101.80","1101.80","1101.80","1 through 10","2340.5","6002.25","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 59MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188084","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4907.50","65","","1820.00","910.00","1820.00","1 through 10","2340.5","6002.25","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 59MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188084","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2755.75","36.5","","1257.80","693.44","2424.50","1 through 10","2340.5","6002.25","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 59MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188084","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2891.65","38.3","","1950.11","547.40","2346.00","1 through 10","2340.5","6002.25","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 59MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188084","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3238.95","42.9","","5096.18","5096.18","5096.18","1 through 10","2340.5","6002.25","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 59MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188084","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","WELLPOINT [1015]","HB AMC WELLPOINT","5570.39","73.78","","1172.59","1172.59","4829.94","1 through 10","2340.5","6002.25","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 59MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188084","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7550.00","5662.50","AETNA [1001]","HB AMC AETNA HMO","5269.90","69.8","","1806.84","947.80","5091.72","1 through 10","3945.63","6169.86","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 59MM 135CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188084","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7550.00","5662.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6169.86","81.72","","1259.05","615.58","4586.56","1 through 10","3945.63","6169.86","percent of total billed charges",""
"CATHETER VIEWFLEX 9FR 3.25MM 90CM 4WAY ULTRASOUND XTRA INTRACARDIAC","SUP-ITM-10152644","CDM","C1759","HCPCS","0272","RC","","","","both","","","5500.00","4125.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2874.30","52.26","","2781.15","2781.15","2781.15","1 through 10","1705","4372.5","percent of total billed charges",""
"CATHETER VIEWFLEX 9FR 3.25MM 90CM 4WAY ULTRASOUND XTRA INTRACARDIAC","SUP-ITM-10152644","CDM","C1759","HCPCS","0272","RC","","","","both","","","5500.00","4125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4372.50","79.5","","4917.59","4917.59","4917.59","1 through 10","1705","4372.5","percent of total billed charges",""
"CATHETER VIEWFLEX 9FR 3.25MM 90CM 4WAY ULTRASOUND XTRA INTRACARDIAC","SUP-ITM-10152644","CDM","C1759","HCPCS","0272","RC","","","","both","","","5500.00","4125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2931.50","53.3","","4139.10","2904.00","4139.10","1 through 10","1705","4372.5","percent of total billed charges",""
"CATHETER VIEWFLEX 9FR 3.25MM 90CM 4WAY ULTRASOUND XTRA INTRACARDIAC","SUP-ITM-10152644","CDM","C1759","HCPCS","0272","RC","","","","both","","","5500.00","4125.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3575.00","65","","2921.37","2921.37","2921.37","1 through 10","1705","4372.5","percent of total billed charges",""
"CATHETER VIEWFLEX 9FR 3.25MM 90CM 4WAY ULTRASOUND XTRA INTRACARDIAC","SUP-ITM-10152644","CDM","C1759","HCPCS","0272","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2007.50","36.5","","2212.82","1626.98","5029.26","11","1705","4372.5","percent of total billed charges",""
"CATHETER VIEWFLEX 9FR 3.25MM 90CM 4WAY ULTRASOUND XTRA INTRACARDIAC","SUP-ITM-10152644","CDM","C1759","HCPCS","0272","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2106.50","38.3","","2150.50","1757.32","3314.56","20","1705","4372.5","percent of total billed charges",""
"CATHETER VIEWFLEX 9FR 3.25MM 90CM 4WAY ULTRASOUND XTRA INTRACARDIAC","SUP-ITM-10152644","CDM","C1759","HCPCS","0272","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2359.50","42.9","","2044.96","2044.96","2044.96","1 through 10","1705","4372.5","percent of total billed charges",""
"CATHETER VIEWFLEX 9FR 3.25MM 90CM 4WAY ULTRASOUND XTRA INTRACARDIAC","SUP-ITM-10152644","CDM","C1759","HCPCS","0272","RC","","","","both","","","5500.00","4125.00","WELLPOINT [1015]","HB AMC WELLPOINT","4057.90","73.78","","4094.75","3346.10","4416.75","16","1705","4372.5","percent of total billed charges",""
"CATHETER VIEWFLEX 9FR 3.25MM 90CM 4WAY ULTRASOUND XTRA INTRACARDIAC","SUP-ITM-10152644","CDM","C1759","HCPCS","0272","RC","","","","outpatient","","","5500.00","4125.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2874.30","52.26","","2781.15","2781.15","2781.15","1 through 10","2874.3","4494.6","percent of total billed charges",""
"CATHETER VIEWFLEX 9FR 3.25MM 90CM 4WAY ULTRASOUND XTRA INTRACARDIAC","SUP-ITM-10152644","CDM","C1759","HCPCS","0272","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4494.60","81.72","","3592.84","1819.96","3592.84","1 through 10","2874.3","4494.6","percent of total billed charges",""
"CATHETER VIEWFLEX 9FR 3.25MM 90CM 4WAY ULTRASOUND XTRA INTRACARDIAC","SUP-ITM-10152644","CDM","C1759","HCPCS","0272","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4494.60","81.72","","4396.70","3592.84","4742.44","21","2874.3","4494.6","percent of total billed charges",""
"CATHETER VISIONS 6FR 135CM .018IN PV 018 INTRAVASCULAR PERIPHERAL ULTRASOUND LF IMAGING PC/1EA","SUP-ITM-10008709","CDM","C1753","HCPCS","0272","RC","","","","both","","","2625.00","1968.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1706.25","65","","1660.75","1660.75","1660.75","1 through 10","813.75","2086.88","percent of total billed charges",""
"CATHETER VISIONS 6FR 135CM .018IN PV 018 INTRAVASCULAR PERIPHERAL ULTRASOUND LF IMAGING PC/1EA","SUP-ITM-10008709","CDM","C1753","HCPCS","0272","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","958.13","36.5","","1233.70","876.51","1905.76","1 through 10","813.75","2086.88","percent of total billed charges",""
"CATHETER VISIONS 6FR 135CM .018IN PV 018 INTRAVASCULAR PERIPHERAL ULTRASOUND LF IMAGING PC/1EA","SUP-ITM-10008709","CDM","C1753","HCPCS","0272","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1005.38","38.3","","1026.38","999.01","1026.38","1 through 10","813.75","2086.88","percent of total billed charges",""
"CATHETER VISIONS 6FR 135CM .018IN PV 018 INTRAVASCULAR PERIPHERAL ULTRASOUND LF IMAGING PC/1EA","SUP-ITM-10008709","CDM","C1753","HCPCS","0272","RC","","","","both","","","2625.00","1968.75","WELLPOINT [1015]","HB AMC WELLPOINT","1936.73","73.78","","1902.20","1902.20","1902.20","1 through 10","813.75","2086.88","percent of total billed charges",""
"CATHETER VISIONS 6FR 135CM .018IN PV 018 INTRAVASCULAR PERIPHERAL ULTRASOUND LF IMAGING PC/1EA","SUP-ITM-10008709","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2145.15","81.72","","2098.42","1123.43","2210.34","1 through 10","1371.83","2145.15","percent of total billed charges",""
"CATHETER VISIONS 8.5FR 90CM .035IN LF SONOGRAPHY PERIPHERAL IMAGING STERILE DISP PC/1EA","SUP-ITM-10114026","CDM","C1753","HCPCS","0272","RC","","","","both","","","3307.50","2480.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2149.88","65","","1660.75","1660.75","1660.75","1 through 10","1025.33","2629.46","percent of total billed charges",""
"CATHETER VISIONS 8.5FR 90CM .035IN LF SONOGRAPHY PERIPHERAL IMAGING STERILE DISP PC/1EA","SUP-ITM-10114026","CDM","C1753","HCPCS","0272","RC","","","","both","","","3307.50","2480.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1207.24","36.5","","1233.70","876.51","1905.76","1 through 10","1025.33","2629.46","percent of total billed charges",""
"CATHETER VISIONS 8.5FR 90CM .035IN LF SONOGRAPHY PERIPHERAL IMAGING STERILE DISP PC/1EA","SUP-ITM-10114026","CDM","C1753","HCPCS","0272","RC","","","","both","","","3307.50","2480.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1266.77","38.3","","1026.38","999.01","1026.38","1 through 10","1025.33","2629.46","percent of total billed charges",""
"CATHETER VISIONS 8.5FR 90CM .035IN LF SONOGRAPHY PERIPHERAL IMAGING STERILE DISP PC/1EA","SUP-ITM-10114026","CDM","C1753","HCPCS","0272","RC","","","","both","","","3307.50","2480.62","WELLPOINT [1015]","HB AMC WELLPOINT","2440.27","73.78","","1902.20","1902.20","1902.20","1 through 10","1025.33","2629.46","percent of total billed charges",""
"CATHETER VISIONS 8.5FR 90CM .035IN LF SONOGRAPHY PERIPHERAL IMAGING STERILE DISP PC/1EA","SUP-ITM-10114026","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","3307.50","2480.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2702.89","81.72","","2098.42","1123.43","2210.34","1 through 10","1728.5","2702.89","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .078IN VASCULAR NYLON MULTIPURPOSE A1 GUIDING","SUP-ITM-10081335","CDM","C1887","HCPCS","0272","RC","","","","both","","","202.13","151.60","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","145.13","71.8","","28.28","27.13","28.28","1 through 10","62.66","160.69","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .078IN VASCULAR NYLON MULTIPURPOSE A1 GUIDING","SUP-ITM-10081335","CDM","C1887","HCPCS","0272","RC","","","","both","","","202.13","151.60","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","141.49","70","","44.63","35.78","44.63","1 through 10","62.66","160.69","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .078IN VASCULAR NYLON MULTIPURPOSE A1 GUIDING","SUP-ITM-10081335","CDM","C1887","HCPCS","0272","RC","","","","both","","","202.13","151.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.69","79.5","","1342.89","271.64","6954.67","1 through 10","62.66","160.69","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .078IN VASCULAR NYLON MULTIPURPOSE A1 GUIDING","SUP-ITM-10081335","CDM","C1887","HCPCS","0272","RC","","","","both","","","202.13","151.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","107.74","53.3","","4550.00","30.49","4550.00","1 through 10","62.66","160.69","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .078IN VASCULAR NYLON MULTIPURPOSE A1 GUIDING","SUP-ITM-10081335","CDM","C1887","HCPCS","0272","RC","","","","both","","","202.13","151.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","131.38","65","","42.09","0.04","5453.50","1 through 10","62.66","160.69","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .078IN VASCULAR NYLON MULTIPURPOSE A1 GUIDING","SUP-ITM-10081335","CDM","C1887","HCPCS","0272","RC","","","","both","","","202.13","151.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.78","36.5","","310.94","18.54","1259.30","62","62.66","160.69","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .078IN VASCULAR NYLON MULTIPURPOSE A1 GUIDING","SUP-ITM-10081335","CDM","C1887","HCPCS","0272","RC","","","","both","","","202.13","151.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.42","38.3","","146.86","22.58","1753.45","65","62.66","160.69","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .078IN VASCULAR NYLON MULTIPURPOSE A1 GUIDING","SUP-ITM-10081335","CDM","C1887","HCPCS","0272","RC","","","","both","","","202.13","151.60","WELLPOINT [1015]","HB AMC WELLPOINT","149.13","73.78","","247.29","33.09","909.09","53","62.66","160.69","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .078IN VASCULAR NYLON MULTIPURPOSE A1 GUIDING","SUP-ITM-10081335","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","202.13","151.60","AETNA [1001]","HB AMC AETNA HMO","141.09","69.8","","30.69","30.21","30.69","1 through 10","105.63","165.18","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .078IN VASCULAR NYLON MULTIPURPOSE A1 GUIDING","SUP-ITM-10081335","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","202.13","151.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","162.51","80.4","","82.69","82.69","82.69","1 through 10","105.63","165.18","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .078IN VASCULAR NYLON MULTIPURPOSE A1 GUIDING","SUP-ITM-10081335","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","202.13","151.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","165.18","81.72","","751.01","74.72","751.01","1 through 10","105.63","165.18","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .078IN VASCULAR NYLON MULTIPURPOSE A1 GUIDING","SUP-ITM-10081335","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","202.13","151.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.18","81.72","","328.92","46.17","2701.97","59","105.63","165.18","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 8FR 100CM .088IN VASCULAR PTFE NYLON JUDKINS RIGHT 4 2SIDEHOLE GUIDING","SUP-ITM-10000516","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.19","133.64","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","127.94","71.8","","28.28","27.13","28.28","1 through 10","55.24","141.66","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 8FR 100CM .088IN VASCULAR PTFE NYLON JUDKINS RIGHT 4 2SIDEHOLE GUIDING","SUP-ITM-10000516","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.19","133.64","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","124.73","70","","44.63","35.78","44.63","1 through 10","55.24","141.66","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 8FR 100CM .088IN VASCULAR PTFE NYLON JUDKINS RIGHT 4 2SIDEHOLE GUIDING","SUP-ITM-10000516","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.19","133.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","141.66","79.5","","1342.89","271.64","6954.67","1 through 10","55.24","141.66","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 8FR 100CM .088IN VASCULAR PTFE NYLON JUDKINS RIGHT 4 2SIDEHOLE GUIDING","SUP-ITM-10000516","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.19","133.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","94.98","53.3","","4550.00","30.49","4550.00","1 through 10","55.24","141.66","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 8FR 100CM .088IN VASCULAR PTFE NYLON JUDKINS RIGHT 4 2SIDEHOLE GUIDING","SUP-ITM-10000516","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.19","133.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","115.82","65","","42.09","0.04","5453.50","1 through 10","55.24","141.66","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 8FR 100CM .088IN VASCULAR PTFE NYLON JUDKINS RIGHT 4 2SIDEHOLE GUIDING","SUP-ITM-10000516","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.19","133.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.04","36.5","","310.94","18.54","1259.30","62","55.24","141.66","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 8FR 100CM .088IN VASCULAR PTFE NYLON JUDKINS RIGHT 4 2SIDEHOLE GUIDING","SUP-ITM-10000516","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.19","133.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.25","38.3","","146.86","22.58","1753.45","65","55.24","141.66","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 8FR 100CM .088IN VASCULAR PTFE NYLON JUDKINS RIGHT 4 2SIDEHOLE GUIDING","SUP-ITM-10000516","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.19","133.64","WELLPOINT [1015]","HB AMC WELLPOINT","131.47","73.78","","247.29","33.09","909.09","53","55.24","141.66","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 8FR 100CM .088IN VASCULAR PTFE NYLON JUDKINS RIGHT 4 2SIDEHOLE GUIDING","SUP-ITM-10000516","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","178.19","133.64","AETNA [1001]","HB AMC AETNA HMO","124.38","69.8","","30.69","30.21","30.69","1 through 10","93.12","145.62","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 8FR 100CM .088IN VASCULAR PTFE NYLON JUDKINS RIGHT 4 2SIDEHOLE GUIDING","SUP-ITM-10000516","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","178.19","133.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","143.26","80.4","","82.69","82.69","82.69","1 through 10","93.12","145.62","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 8FR 100CM .088IN VASCULAR PTFE NYLON JUDKINS RIGHT 4 2SIDEHOLE GUIDING","SUP-ITM-10000516","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","178.19","133.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","145.62","81.72","","751.01","74.72","751.01","1 through 10","93.12","145.62","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 8FR 100CM .088IN VASCULAR PTFE NYLON JUDKINS RIGHT 4 2SIDEHOLE GUIDING","SUP-ITM-10000516","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","178.19","133.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","145.62","81.72","","328.92","46.17","2701.97","59","93.12","145.62","percent of total billed charges",""
"CATHETER WOLVERINE 4.00X15MM BALLOON CUTTING MONORAIL","SUP-ITM-10211630","CDM","C1725","HCPCS","0272","RC","","","","both","","","2800.00","2100.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2010.40","71.8","","175.91","175.91","175.91","1 through 10","868","2226","percent of total billed charges",""
"CATHETER WOLVERINE 4.00X15MM BALLOON CUTTING MONORAIL","SUP-ITM-10211630","CDM","C1725","HCPCS","0272","RC","","","","both","","","2800.00","2100.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1820.00","65","","147.88","147.88","1296.75","1 through 10","868","2226","percent of total billed charges",""
"CATHETER WOLVERINE 4.00X15MM BALLOON CUTTING MONORAIL","SUP-ITM-10211630","CDM","C1725","HCPCS","0272","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","181.40","177.87","181.40","21","868","2226","percent of total billed charges",""
"CATHETER WOLVERINE 4.00X15MM BALLOON CUTTING MONORAIL","SUP-ITM-10211630","CDM","C1725","HCPCS","0272","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","170.15","88.95","424.24","16","868","2226","percent of total billed charges",""
"CATHETER WOLVERINE 4.00X15MM BALLOON CUTTING MONORAIL","SUP-ITM-10211630","CDM","C1725","HCPCS","0272","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","699.48","699.48","699.48","12","868","2226","percent of total billed charges",""
"CATHETER WOLVERINE 4.00X15MM BALLOON CUTTING MONORAIL","SUP-ITM-10211630","CDM","C1725","HCPCS","0272","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","576.52","182.40","651.44","14","868","2226","percent of total billed charges",""
"CATHETER WOLVERINE 4.00X15MM BALLOON CUTTING MONORAIL","SUP-ITM-10211630","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","181.86","100.03","402.41","21","1463.28","2288.16","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1024.10","70","","556.50","556.50","556.50","1 through 10","453.53","1163.09","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1163.09","79.5","","437.97","293.83","444.55","17","453.53","1163.09","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","779.78","53.3","","298.25","293.83","444.55","1 through 10","453.53","1163.09","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","950.95","65","","361.73","361.73","361.73","1 through 10","453.53","1163.09","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","453.53","31","","171.96","171.96","171.96","1 through 10","453.53","1163.09","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","534.00","36.5","","207.57","179.06","271.83","1 through 10","453.53","1163.09","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","560.33","38.3","","217.59","211.47","220.86","18","453.53","1163.09","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","627.63","42.9","","556.50","451.56","556.50","1 through 10","453.53","1163.09","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","627.63","42.9","","444.87","444.87","444.87","1 through 10","453.53","1163.09","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","both","","","1463.00","1097.25","WELLPOINT [1015]","HB AMC WELLPOINT","1079.40","73.78","","414.31","414.31","420.55","15","453.53","1163.09","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1463.00","1097.25","AETNA [1001]","HB AMC AETNA HMO","1021.17","69.8","","376.75","270.01","580.53","30","764.56","1195.56","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1463.00","1097.25","AETNA [1001]","HB AMC AETNA PPO","1176.25","80.4","","440.60","434.07","440.60","1 through 10","764.56","1195.56","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1463.00","1097.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1176.25","80.4","","434.07","434.07","440.60","1 through 10","764.56","1195.56","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1463.00","1097.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1195.56","81.72","","444.87","248.37","444.87","1 through 10","764.56","1195.56","percent of total billed charges",""
"CATHETER XPORT DUO 10FR 2LUMEN EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011310","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1463.00","1097.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1195.56","81.72","","444.87","248.37","451.56","20","764.56","1195.56","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 40MM 120CM .035IN PTA BALLOON DILATATION","SUP-ITM-10000412","CDM","C1725","HCPCS","0272","RC","","","","both","","","910.00","682.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","653.38","71.8","","175.91","175.91","175.91","1 through 10","282.1","723.45","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 40MM 120CM .035IN PTA BALLOON DILATATION","SUP-ITM-10000412","CDM","C1725","HCPCS","0272","RC","","","","both","","","910.00","682.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","591.50","65","","147.88","147.88","1296.75","1 through 10","282.1","723.45","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 40MM 120CM .035IN PTA BALLOON DILATATION","SUP-ITM-10000412","CDM","C1725","HCPCS","0272","RC","","","","both","","","910.00","682.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","332.15","36.5","","181.40","177.87","181.40","21","282.1","723.45","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 40MM 120CM .035IN PTA BALLOON DILATATION","SUP-ITM-10000412","CDM","C1725","HCPCS","0272","RC","","","","both","","","910.00","682.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","348.53","38.3","","170.15","88.95","424.24","16","282.1","723.45","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 40MM 120CM .035IN PTA BALLOON DILATATION","SUP-ITM-10000412","CDM","C1725","HCPCS","0272","RC","","","","both","","","910.00","682.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","390.39","42.9","","699.48","699.48","699.48","12","282.1","723.45","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 40MM 120CM .035IN PTA BALLOON DILATATION","SUP-ITM-10000412","CDM","C1725","HCPCS","0272","RC","","","","both","","","910.00","682.50","WELLPOINT [1015]","HB AMC WELLPOINT","671.40","73.78","","576.52","182.40","651.44","14","282.1","723.45","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 40MM 120CM .035IN PTA BALLOON DILATATION","SUP-ITM-10000412","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","910.00","682.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","743.65","81.72","","181.86","100.03","402.41","21","475.57","743.65","percent of total billed charges",""
"CATHETER Z-MED II 9FR 22MM 4CM 100CM .035IN BALLOON DILATATION PTV","SUP-ITM-10013743","CDM","C1726","HCPCS","0272","RC","","","","both","","","2697.56","2023.17","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1888.29","70","","863.10","863.10","863.10","1 through 10","836.24","2144.56","percent of total billed charges",""
"CATHETER Z-MED II 9FR 22MM 4CM 100CM .035IN BALLOON DILATATION PTV","SUP-ITM-10013743","CDM","C1726","HCPCS","0272","RC","","","","both","","","2697.56","2023.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2144.56","79.5","","447.66","447.66","447.66","1 through 10","836.24","2144.56","percent of total billed charges",""
"CATHETER Z-MED II 9FR 22MM 4CM 100CM .035IN BALLOON DILATATION PTV","SUP-ITM-10013743","CDM","C1726","HCPCS","0272","RC","","","","both","","","2697.56","2023.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1753.41","65","","1020.11","1020.11","1020.11","1 through 10","836.24","2144.56","percent of total billed charges",""
"CATHETER Z-MED II 9FR 22MM 4CM 100CM .035IN BALLOON DILATATION PTV","SUP-ITM-10013743","CDM","C1726","HCPCS","0272","RC","","","","both","","","2697.56","2023.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","836.24","31","","208.83","208.83","208.83","1 through 10","836.24","2144.56","percent of total billed charges",""
"CATHETER Z-MED II 9FR 22MM 4CM 100CM .035IN BALLOON DILATATION PTV","SUP-ITM-10013743","CDM","C1726","HCPCS","0272","RC","","","","both","","","2697.56","2023.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","984.61","36.5","","312.44","214.23","1086.03","20","836.24","2144.56","percent of total billed charges",""
"CATHETER Z-MED II 9FR 22MM 4CM 100CM .035IN BALLOON DILATATION PTV","SUP-ITM-10013743","CDM","C1726","HCPCS","0272","RC","","","","both","","","2697.56","2023.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1033.17","38.3","","264.25","227.63","567.11","31","836.24","2144.56","percent of total billed charges",""
"CATHETER Z-MED II 9FR 22MM 4CM 100CM .035IN BALLOON DILATATION PTV","SUP-ITM-10013743","CDM","C1726","HCPCS","0272","RC","","","","both","","","2697.56","2023.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1157.25","42.9","","79.94","79.94","79.94","1 through 10","836.24","2144.56","percent of total billed charges",""
"CATHETER Z-MED II 9FR 22MM 4CM 100CM .035IN BALLOON DILATATION PTV","SUP-ITM-10013743","CDM","C1726","HCPCS","0272","RC","","","","both","","","2697.56","2023.17","WELLPOINT [1015]","HB AMC WELLPOINT","1990.26","73.78","","174.45","74.45","1168.42","1 through 10","836.24","2144.56","percent of total billed charges",""
"CATHETER Z-MED II 9FR 22MM 4CM 100CM .035IN BALLOON DILATATION PTV","SUP-ITM-10013743","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2697.56","2023.17","AETNA [1001]","HB AMC AETNA HMO","1882.90","69.8","","655.01","135.40","784.73","1 through 10","1409.74","2204.45","percent of total billed charges",""
"CATHETER Z-MED II 9FR 22MM 4CM 100CM .035IN BALLOON DILATATION PTV","SUP-ITM-10013743","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2697.56","2023.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2204.45","81.72","","540.25","46.28","897.42","36","1409.74","2204.45","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","524.00","393.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","366.80","70","","643.40","643.40","643.40","1 through 10","162.44","416.58","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","524.00","393.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","416.58","79.5","","399.80","399.80","399.80","1 through 10","162.44","416.58","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","524.00","393.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.26","36.5","","189.48","61.92","189.48","1 through 10","162.44","416.58","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","524.00","393.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","200.69","38.3","","198.63","64.91","198.63","1 through 10","162.44","416.58","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","524.00","393.00","WELLPOINT [1015]","HB AMC WELLPOINT","386.61","73.78","","378.21","378.21","378.21","1 through 10","162.44","416.58","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","524.00","393.00","AETNA [1001]","HB AMC AETNA HMO","365.75","69.8","","456.30","242.82","456.30","1 through 10","176.45","792.78","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","524.00","393.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","412.84","202.69","412.84","1 through 10","176.45","792.78","other","ASC"
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","524.00","393.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","118.09","118.09","582.76","14","176.45","792.78","other","ASC "
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","524.00","393.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","393.48","86.98","409.36","1 through 10","176.45","792.78","other","Multiple Surgery"
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","524.00","393.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","176.45","792.78","other","Multiple Surgery"
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","524.00","393.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","428.21","81.72","","406.09","406.09","406.10","1 through 10","176.45","792.78","percent of total billed charges",""
"Cca Non-Atherosclerotic Stent","PX-76003019","CDM","37799","CPT","0761","RC","","","","outpatient","","","22731.00","17048.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","11870.13","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","18753.08","percent of total billed charges",""
"Cca Non-Atherosclerotic Stent","PX-76003019","CDM","37799","CPT","0761","RC","","","","outpatient","","","22731.00","17048.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11933.78","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","18753.08","percent of total billed charges",""
"Cecostomy Tube Change WO Imaging","PX-76010314","CDM","45399","CPT","0761","RC","","","","both","","","368.00","276.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","134.32","36.5","","2892.24","2892.24","2892.24","1 through 10","114.08","1353.25","percent of total billed charges",""
"Cecostomy Tube Change WO Imaging","PX-76010314","CDM","45399","CPT","0761","RC","","","","both","","","368.00","276.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","140.94","38.3","","2777.42","2083.54","2946.52","1 through 10","114.08","1353.25","percent of total billed charges",""
"Cecostomy Tube Change WO Imaging","PX-76010314","CDM","45399","CPT","0761","RC","","","","both","","","368.00","276.00","TRICARE [160005]","HB BWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","1028.57","1028.57","1 through 10","114.08","1353.25","other","Tricare OPPS"
"Cecostomy Tube Change WO Imaging","PX-76010314","CDM","45399","CPT","0761","RC","","","","both","","","368.00","276.00","WELLPOINT [1015]","HB AMC WELLPOINT","271.51","73.78","","5772.85","5772.85","7754.00","1 through 10","114.08","1353.25","percent of total billed charges",""
"Cecostomy Tube Change WO Imaging","PX-76010314","CDM","45399","CPT","0761","RC","","","","outpatient","","","368.00","276.00","AETNA [1001]","HB AMC AETNA HMO","256.86","69.8","","5249.46","3706.41","5249.46","1 through 10","184","2384.07","percent of total billed charges",""
"Cecostomy Tube Change WO Imaging","PX-76010314","CDM","45399","CPT","0761","RC","","","","outpatient","","","368.00","276.00","AETNA [1001]","HB AMC AETNA PPO","295.87","80.4","","6048.12","6048.12","6048.12","1 through 10","184","2384.07","percent of total billed charges",""
"Cecostomy Tube Change WO Imaging","PX-76010314","CDM","45399","CPT","0761","RC","","","","outpatient","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","222.82","60.55","","1533.28","1533.28","7754.00","1 through 10","184","2384.07","percent of total billed charges",""
"Cecostomy Tube Change WO Imaging","PX-76010314","CDM","45399","CPT","0761","RC","","","","outpatient","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","192.17","52.22","","1974.52","1533.28","7754.00","21","184","2384.07","percent of total billed charges",""
"Cecostomy Tube Change WO Imaging","PX-76010314","CDM","45399","CPT","0761","RC","","","","outpatient","","","368.00","276.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","193.20","52.5","","4063.09","4063.09","4063.09","1 through 10","184","2384.07","percent of total billed charges",""
"Cecostomy Tube Change WO Imaging","PX-76010314","CDM","45399","CPT","0761","RC","","","","outpatient","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","300.73","81.72","","6198.55","6198.55","7754.00","1 through 10","184","2384.07","percent of total billed charges",""
"Cecostomy Tube Change WO Imaging","PX-76010314","CDM","45399","CPT","0761","RC","","","","outpatient","","","368.00","276.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","230.00","62.5","","4691.17","4691.17","4691.17","1 through 10","184","2384.07","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1.30","71.8","","0.86","0.86","0.86","1 through 10","0.56","1.78","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1.19","65.6","","0.93","0.80","1.61","20","0.56","1.78","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1.18","65","","0.83","0.83","0.83","1 through 10","0.56","1.78","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1.27","70","","1.20","0.85","2.24","57","0.56","1.78","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1.39","77","","0.92","0.92","0.92","1 through 10","0.56","1.78","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1.18","65","","0.78","0.77","3.09","1 through 10","0.56","1.78","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.56","31","","0.87","0.87","0.87","1 through 10","0.56","1.78","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.66","36.5","","0.45","0.38","1.34","740","0.56","1.78","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.69","38.3","","0.47","0.47","1.41","1560","0.56","1.78","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1.39","77","","0.83","0.83","0.83","1 through 10","0.56","1.78","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","outpatient","","","1.81","1.36","AETNA [1001]","HB AMC AETNA HMO","1.26","69.8","","0.82","0.57","1.90","980","0.85","1.81","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","outpatient","","","1.81","1.36","AETNA [1001]","HB AMC AETNA PPO","1.46","80.4","","0.93","0.63","2.18","126","0.85","1.81","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","outpatient","","","1.81","1.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.27","69.9","","1.92","0.56","3.87","1019","0.85","1.81","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","outpatient","","","1.81","1.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.85","46.9","","1.21","0.55","2.62","619","0.85","1.81","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","outpatient","","","1.81","1.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1.46","80.4","","0.93","0.93","0.94","34","0.85","1.81","percent of total billed charges",""
"Cefazolin Sodium Injection","PX-63601012","CDM","J0690","HCPCS","0636","RC","","","","outpatient","","","1.81","1.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1.27","69.9","","7.52","7.52","7.52","1 through 10","0.85","1.81","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1.30","71.8","","0.86","0.86","0.86","1 through 10","0.56","1.78","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1.19","65.6","","0.93","0.80","1.61","20","0.56","1.78","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1.18","65","","0.83","0.83","0.83","1 through 10","0.56","1.78","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1.27","70","","1.20","0.85","2.24","57","0.56","1.78","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1.39","77","","0.92","0.92","0.92","1 through 10","0.56","1.78","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1.18","65","","0.78","0.77","3.09","1 through 10","0.56","1.78","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.56","31","","0.87","0.87","0.87","1 through 10","0.56","1.78","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.66","36.5","","0.45","0.38","1.34","740","0.56","1.78","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.69","38.3","","0.47","0.47","1.41","1560","0.56","1.78","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","both","","","1.81","1.36","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1.39","77","","0.83","0.83","0.83","1 through 10","0.56","1.78","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","outpatient","","","1.81","1.36","AETNA [1001]","HB AMC AETNA HMO","1.26","69.8","","0.82","0.57","1.90","980","0.85","1.81","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","outpatient","","","1.81","1.36","AETNA [1001]","HB AMC AETNA PPO","1.46","80.4","","0.93","0.63","2.18","126","0.85","1.81","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","outpatient","","","1.81","1.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.27","69.9","","1.92","0.56","3.87","1019","0.85","1.81","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","outpatient","","","1.81","1.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.85","46.9","","1.21","0.55","2.62","619","0.85","1.81","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","outpatient","","","1.81","1.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1.46","80.4","","0.93","0.93","0.94","34","0.85","1.81","percent of total billed charges",""
"Cefazolin Vl 500mg","PX-63600076","CDM","J0690","HCPCS","0636","RC","","","","outpatient","","","1.81","1.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1.27","69.9","","7.52","7.52","7.52","1 through 10","0.85","1.81","percent of total billed charges",""
"Cefepime Vl 500mg","PX-63600077","CDM","J0692","HCPCS","0636","RC","","","","outpatient","","","8.27","6.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5.78","69.9","","7.52","7.52","7.52","1 through 10","2.64","6.65","percent of total billed charges",""
"Ceftriaxone Sodium Injection","PX-63601021","CDM","J0696","HCPCS","0636","RC","","","","both","","","54.00","40.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19.71","36.5","","1.38","0.28","1.38","40","1.16","41.58","percent of total billed charges",""
"Ceftriaxone Sodium Injection","PX-63601021","CDM","J0696","HCPCS","0636","RC","","","","both","","","54.00","40.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20.68","38.3","","0.91","0.49","1.50","166","1.16","41.58","percent of total billed charges",""
"Ceftriaxone Sodium Injection","PX-63601021","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","54.00","40.50","AETNA [1001]","HB AMC AETNA HMO","37.69","69.8","","0.37","0.37","8.52","11","1.03","43.42","percent of total billed charges",""
"Ceftriaxone Sodium Injection","PX-63601021","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","54.00","40.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","37.75","69.9","","1.18","0.91","1.20","36","1.03","43.42","percent of total billed charges",""
"Ceftriaxone Sodium Injection","PX-63601021","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","54.00","40.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","25.33","46.9","","0.42","0.34","0.78","72","1.03","43.42","percent of total billed charges",""
"Ceftriaxone Sodium Injection","PX-63601021","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","54.00","40.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","37.75","69.9","","0.58","0.58","0.58","1 through 10","1.03","43.42","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600078","CDM","J0696","HCPCS","0636","RC","","","","both","","","6.62","4.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2.42","36.5","","1.38","0.28","1.38","40","1.16","5.1","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600078","CDM","J0696","HCPCS","0636","RC","","","","both","","","6.62","4.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2.54","38.3","","0.91","0.49","1.50","166","1.16","5.1","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600078","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","6.62","4.96","AETNA [1001]","HB AMC AETNA HMO","4.62","69.8","","0.37","0.37","8.52","11","1.03","5.32","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600078","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","6.62","4.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4.63","69.9","","1.18","0.91","1.20","36","1.03","5.32","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600078","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","6.62","4.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3.10","46.9","","0.42","0.34","0.78","72","1.03","5.32","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600078","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","6.62","4.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","4.63","69.9","","0.58","0.58","0.58","1 through 10","1.03","5.32","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600329","CDM","J0696","HCPCS","0636","RC","","","","both","","","6.62","4.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2.42","36.5","","1.38","0.28","1.38","40","1.16","5.1","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600329","CDM","J0696","HCPCS","0636","RC","","","","both","","","6.62","4.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2.54","38.3","","0.91","0.49","1.50","166","1.16","5.1","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600329","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","6.62","4.96","AETNA [1001]","HB AMC AETNA HMO","4.62","69.8","","0.37","0.37","8.52","11","1.03","5.32","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600329","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","6.62","4.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4.63","69.9","","1.18","0.91","1.20","36","1.03","5.32","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600329","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","6.62","4.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3.10","46.9","","0.42","0.34","0.78","72","1.03","5.32","percent of total billed charges",""
"Ceftriaxone Vl 250mg","PX-63600329","CDM","J0696","HCPCS","0636","RC","","","","outpatient","","","6.62","4.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","4.63","69.9","","0.58","0.58","0.58","1 through 10","1.03","5.32","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","both","","","95.00","71.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","68.21","71.8","","66.06","66.06","66.06","1 through 10","5.49","90.25","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","both","","","95.00","71.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","61.75","65","","59.80","59.80","59.80","1 through 10","5.49","90.25","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","both","","","95.00","71.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","66.50","70","","92.00","92.00","92.00","1 through 10","5.49","90.25","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","both","","","95.00","71.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","75.53","79.5","","217.20","48.58","217.22","23","5.49","90.25","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","both","","","95.00","71.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","50.64","53.3","","48.58","48.58","217.20","13","5.49","90.25","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","both","","","95.00","71.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","61.75","65","","59.80","59.80","59.80","1 through 10","5.49","90.25","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","both","","","95.00","71.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","75.53","79.5","","72.40","72.40","72.40","1 through 10","5.49","90.25","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","both","","","95.00","71.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34.68","36.5","","34.32","29.16","102.96","25","5.49","90.25","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","both","","","95.00","71.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","36.39","38.3","","66.06","35.97","66.06","66","5.49","90.25","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","both","","","95.00","71.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.76","42.9","","40.45","40.45","40.45","1 through 10","5.49","90.25","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","outpatient","","","95.00","71.25","AETNA [1001]","HB AMC AETNA HMO","66.31","69.8","","62.28","43.98","124.56","25","5.68","77.63","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","outpatient","","","95.00","71.25","AETNA [1001]","HB AMC AETNA PPO","76.38","80.4","","48.21","48.21","71.76","1 through 10","5.68","77.63","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","outpatient","","","95.00","71.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","77.63","81.72","","73.54","40.45","73.55","27","5.68","77.63","percent of total billed charges",""
"Cell Energetics Ophthalmoplegia Nextgen Dna Sequence Pan (22 Genes)","PX-31000678","CDM","81479","CPT","0310","RC","","","","both","","","2167.00","1625.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1722.77","79.5","","0.65","0.65","0.65","1 through 10","671.77","2058.65","percent of total billed charges",""
"Cell Energetics Ophthalmoplegia Nextgen Dna Sequence Pan (22 Genes)","PX-31000678","CDM","81479","CPT","0310","RC","","","","both","","","2167.00","1625.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1155.01","53.3","","0.79","0.79","0.79","1 through 10","671.77","2058.65","percent of total billed charges",""
"Cell Energetics Ophthalmoplegia Nextgen Dna Sequence Pan (22 Genes)","PX-31000678","CDM","81479","CPT","0310","RC","","","","outpatient","","","2167.00","1625.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1083.50","50","","1.00","1.00","1.00","1 through 10","156.55","1787.78","percent of total billed charges",""
"Cell Energetics Ophthalmoplegia Nextgen Dna Sequence Pan (22 Genes)","PX-31000678","CDM","81479","CPT","0310","RC","","","","outpatient","","","2167.00","1625.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1137.68","52.5","","1.00","0.53","1.00","1 through 10","156.55","1787.78","percent of total billed charges",""
"Cell Func Stm/Detect Biomarker","PX-30000846","CDM","86352","CPT","0302","RC","","","","both","","","742.00","556.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","482.30","65","","1692.60","468.00","1692.60","1 through 10","125.5","704.9","percent of total billed charges",""
"Cell Func Stm/Detect Biomarker","PX-30000846","CDM","86352","CPT","0302","RC","","","","both","","","742.00","556.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","589.89","79.5","","566.65","566.64","566.65","1 through 10","125.5","704.9","percent of total billed charges",""
"Cell Func Stm/Detect Biomarker","PX-30000846","CDM","86352","CPT","0302","RC","","","","both","","","742.00","556.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","395.49","53.3","","380.16","380.16","380.16","1 through 10","125.5","704.9","percent of total billed charges",""
"Cell Func Stm/Detect Biomarker","PX-30000846","CDM","86352","CPT","0302","RC","","","","both","","","742.00","556.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","270.83","36.5","","268.56","228.24","268.56","1 through 10","125.5","704.9","percent of total billed charges",""
"Cell Func Stm/Detect Biomarker","PX-30000846","CDM","86352","CPT","0302","RC","","","","both","","","742.00","556.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","284.19","38.3","","281.52","273.60","844.56","18","125.5","704.9","percent of total billed charges",""
"Cell Func Stm/Detect Biomarker","PX-30000846","CDM","86352","CPT","0302","RC","","","","outpatient","","","742.00","556.50","AETNA [1001]","HB AMC AETNA PPO","596.57","80.4","","754.56","754.56","754.56","1 through 10","125.5","995.57","percent of total billed charges",""
"Cell Func Stm/Detect Biomarker","PX-30000846","CDM","86352","CPT","0302","RC","","","","outpatient","","","742.00","556.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","606.36","81.72","","575.57","575.57","615.92","1 through 10","125.5","995.57","percent of total billed charges",""
"Cellulitis And Other Skin Infections,EXTREME","383","DRG","","","","","","","","inpatient","","","73616.76","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","18349.83","","Case rate ($20,288.89). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,718.89, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9508.67","9508.67","9508.67","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","60011.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","31229.60","","Standard inlier is a Case rate ($31,229.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,249, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,432.78) for the length of stay and the standard reimbursement.","31229.60","31229.60","31229.60","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","60011.33","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11360.1993","","Fee schedule rate ($26,782.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11360.1993","26782.24","26782.24","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","60011.33","","MASSHEALTH [3001]","HB BWH MEDICAID","8602.02","","Case rate ($9,511.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,941.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9508.67","9508.67","9508.67","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","60011.33","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","8602.02","","Case rate ($9,511.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,941.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1020.93","1020.93","1020.93","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","60011.33","","MOLINA [1014]","HB BWH MEDICAID","8602.02","","Case rate ($9,511.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,941.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16465.48","16465.48","16465.48","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","60011.33","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8602.02","","Case rate ($9,511.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,941.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9508.67","325.64","9508.67","14","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","30034.80","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","13622.03","","Standard inlier is a Case rate ($13,622.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,241, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,933.73) for the length of stay and the standard reimbursement.","10216.52","10216.52","12416.97","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","30034.80","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","15314.83","","Standard inlier is a Case rate ($15,314.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,241, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,173.81) for the length of stay and the standard reimbursement.","15314.83","15314.83","53915.02","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","30034.80","","MASSHEALTH [3001]","HB BWH MEDICAID","4470.08","","Case rate ($4,942.44). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,372.44, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1257.07","834.10","4941.22","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","30034.80","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13657.37","","Fee schedule rate ($13,657.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13657.37","13657.37","13657.37","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","30034.80","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4470.08","","Case rate ($4,942.44). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,372.44, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3841.83","3841.83","3841.83","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","39209.09","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11360.1993","","Fee schedule rate ($13,563.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11360.1993","14644.94","14644.94","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","39209.09","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11928.5394","","Fee schedule rate ($14,241.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11928.5394","13658.68","13658.68","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","39209.09","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","14920.05","","Fee schedule rate ($14,920.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17552.48","17552.48","45958.56","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","39209.09","","MASSHEALTH [3001]","HB BWH MEDICAID","5924.31","","Case rate ($6,550.34). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,980.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6548.73","1614.49","9508.67","1 through 10","4470.08","104643.27","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","39209.09","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5924.31","","Case rate ($6,550.34). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,980.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6548.74","287.40","11111.79","20","4470.08","104643.27","case rate",""
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","74544.11","55908.08","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","13745.44","","Case rate ($13,345.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,987.45, add-ons for qualifying new technology services are included. If operating cost exceeds $61,631.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,583.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,821.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,607.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,143.66. The transfer capital threshold is the transfer adjustment factor * $1,143.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11900.34","11900.34","11900.34","1 through 10","13078.19","22263.24","other","Inpatient DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","74544.11","55908.08","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","13345.09","","Case rate ($13,345.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,987.45, add-ons for qualifying new technology services are included. If operating cost exceeds $61,631.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,583.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,821.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,607.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,143.66. The transfer capital threshold is the transfer adjustment factor * $1,143.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13466.29","13466.29","13466.29","1 through 10","13078.19","22263.24","other","Inpatient Replacement Plans DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","74544.11","55908.08","HUMANA [1012]","HB BWH MEDICARE","13345.09","","Case rate ($13,345.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,987.45, add-ons for qualifying new technology services are included. If operating cost exceeds $61,631.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,583.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,821.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,607.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,143.66. The transfer capital threshold is the transfer adjustment factor * $1,143.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13613.72","13613.72","13613.72","1 through 10","13078.19","22263.24","other","Inpatient Replacement Plans DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","74544.11","55908.08","MEDICARE [2001]","HB BWH MEDICARE","13345.09","","Case rate ($13,345.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,987.45, add-ons for qualifying new technology services are included. If operating cost exceeds $61,631.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,583.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,821.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,607.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,143.66. The transfer capital threshold is the transfer adjustment factor * $1,143.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17598.90","986.81","17624.81","25","13078.19","22263.24","other","Inpatient Replacement Plans DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","74544.11","55908.08","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","13078.19","","Case rate ($13,345.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,987.45, add-ons for qualifying new technology services are included. If operating cost exceeds $61,631.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,583.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,821.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,607.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,143.66. The transfer capital threshold is the transfer adjustment factor * $1,143.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13369.48","13369.48","13369.48","1 through 10","13078.19","22263.24","other","Inpatient DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","74544.11","55908.08","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13078.19","","Case rate ($13,345.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,987.45, add-ons for qualifying new technology services are included. If operating cost exceeds $61,631.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,583.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,821.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,607.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,143.66. The transfer capital threshold is the transfer adjustment factor * $1,143.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22034.01","22034.01","22034.01","1 through 10","13078.19","22263.24","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","39177.10","29382.82","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8324.28","","Case rate ($8,324.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,943.38, add-ons for qualifying new technology services are included. If operating cost exceeds $55,587.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,140.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,243.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,563.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $700.78. The transfer capital threshold is the transfer adjustment factor * $700.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8182.85","8182.82","13466.29","1 through 10","8157.79","13641.78","other","Inpatient Replacement Plans DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","39177.10","29382.82","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8324.28","","Case rate ($8,324.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,943.38, add-ons for qualifying new technology services are included. If operating cost exceeds $55,587.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,140.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,243.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,563.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $700.78. The transfer capital threshold is the transfer adjustment factor * $700.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8222.06","8222.06","8222.06","1 through 10","8157.79","13641.78","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","39177.10","29382.82","HUMANA [1012]","HB BWH MEDICARE","8324.28","","Case rate ($8,324.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,943.38, add-ons for qualifying new technology services are included. If operating cost exceeds $55,587.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,140.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,243.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,563.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $700.78. The transfer capital threshold is the transfer adjustment factor * $700.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8150.21","8150.21","8151.42","1 through 10","8157.79","13641.78","other","Inpatient Replacement Plans DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","39177.10","29382.82","MEDICARE [2001]","HB BWH MEDICARE","8324.28","","Case rate ($8,324.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,943.38, add-ons for qualifying new technology services are included. If operating cost exceeds $55,587.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,140.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,243.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,563.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $700.78. The transfer capital threshold is the transfer adjustment factor * $700.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10662.18","0.03","10677.71","50","8157.79","13641.78","other","Inpatient Replacement Plans DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","39177.10","29382.82","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8157.79","","Case rate ($8,324.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,943.38, add-ons for qualifying new technology services are included. If operating cost exceeds $55,587.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,140.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,243.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,563.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $700.78. The transfer capital threshold is the transfer adjustment factor * $700.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8172.95","8172.95","8172.95","1 through 10","8157.79","13641.78","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","39177.10","29382.82","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8157.79","","Case rate ($8,324.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,943.38, add-ons for qualifying new technology services are included. If operating cost exceeds $55,587.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,140.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,243.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,563.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $700.78. The transfer capital threshold is the transfer adjustment factor * $700.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8212.35","8107.59","11778.15","1 through 10","8157.79","13641.78","other","Inpatient DRG"
"CEMENT BONE 10CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339120","CDM","C1713","HCPCS","0278","RC","","","","both","","","7616.90","5712.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6055.44","79.5","","800.18","480.96","1887.97","195","2361.24","6055.44","percent of total billed charges",""
"CEMENT BONE 10CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339120","CDM","C1713","HCPCS","0278","RC","","","","both","","","7616.90","5712.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4059.81","53.3","","813.12","216.42","1444.50","81","2361.24","6055.44","percent of total billed charges",""
"CEMENT BONE 10CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339120","CDM","C1713","HCPCS","0278","RC","","","","both","","","7616.90","5712.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2361.24","31","","432.60","432.60","432.60","1 through 10","2361.24","6055.44","percent of total billed charges",""
"CEMENT BONE 10CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339120","CDM","C1713","HCPCS","0278","RC","","","","both","","","7616.90","5712.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2780.17","36.5","","148.37","54.89","631.39","94","2361.24","6055.44","percent of total billed charges",""
"CEMENT BONE 10CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339120","CDM","C1713","HCPCS","0278","RC","","","","both","","","7616.90","5712.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2917.27","38.3","","279.30","91.72","1116.77","266","2361.24","6055.44","percent of total billed charges",""
"CEMENT BONE 10CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339120","CDM","C1713","HCPCS","0278","RC","","","","both","","","7616.90","5712.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3267.65","42.9","","731.00","63.70","731.00","1 through 10","2361.24","6055.44","percent of total billed charges",""
"CEMENT BONE 10CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339120","CDM","C1713","HCPCS","0278","RC","","","","both","","","7616.90","5712.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3267.65","42.9","","384.74","384.74","384.74","1 through 10","2361.24","6055.44","percent of total billed charges",""
"CEMENT BONE 10CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339120","CDM","C1713","HCPCS","0278","RC","","","","both","","","7616.90","5712.67","WELLPOINT [1015]","HB AMC WELLPOINT","5619.75","73.78","","286.63","119.22","1107.45","105","2361.24","6055.44","percent of total billed charges",""
"CEMENT BONE 10CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7616.90","5712.67","AETNA [1001]","HB AMC AETNA HMO","5316.60","69.8","","675.31","184.75","1721.50","286","3980.59","6224.53","percent of total billed charges",""
"CEMENT BONE 10CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7616.90","5712.67","AETNA [1001]","HB AMC AETNA PPO","6123.99","80.4","","1261.44","103.12","1514.10","21","3980.59","6224.53","percent of total billed charges",""
"CEMENT BONE 10CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7616.90","5712.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6123.99","80.4","","1365.00","1365.00","1365.00","1 through 10","3980.59","6224.53","percent of total billed charges",""
"CEMENT BONE 10CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7616.90","5712.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6224.53","81.72","","5157.68","5157.68","5157.68","1 through 10","3980.59","6224.53","percent of total billed charges",""
"CEMENT BONE 10CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7616.90","5712.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6224.53","81.72","","431.26","71.26","1459.57","88","3980.59","6224.53","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8496.56","79.5","","800.18","480.96","1887.97","195","3313.13","8496.56","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5696.44","53.3","","813.12","216.42","1444.50","81","3313.13","8496.56","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3313.13","31","","432.60","432.60","432.60","1 through 10","3313.13","8496.56","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3900.94","36.5","","148.37","54.89","631.39","94","3313.13","8496.56","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4093.31","38.3","","279.30","91.72","1116.77","266","3313.13","8496.56","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4584.94","42.9","","731.00","63.70","731.00","1 through 10","3313.13","8496.56","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4584.94","42.9","","384.74","384.74","384.74","1 through 10","3313.13","8496.56","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","WELLPOINT [1015]","HB AMC WELLPOINT","7885.24","73.78","","286.63","119.22","1107.45","105","3313.13","8496.56","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10687.50","8015.62","AETNA [1001]","HB AMC AETNA HMO","7459.88","69.8","","675.31","184.75","1721.50","286","5585.29","8733.83","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10687.50","8015.62","AETNA [1001]","HB AMC AETNA PPO","8592.75","80.4","","1261.44","103.12","1514.10","21","5585.29","8733.83","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10687.50","8015.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8592.75","80.4","","1365.00","1365.00","1365.00","1 through 10","5585.29","8733.83","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10687.50","8015.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8733.83","81.72","","5157.68","5157.68","5157.68","1 through 10","5585.29","8733.83","percent of total billed charges",""
"CEMENT BONE 15CC HYDROSET XT","SUP-ITM-10232528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10687.50","8015.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8733.83","81.72","","431.26","71.26","1459.57","88","5585.29","8733.83","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","269.90","79.5","","800.18","480.96","1887.97","195","105.25","269.9","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","180.95","53.3","","813.12","216.42","1444.50","81","105.25","269.9","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","105.25","31","","432.60","432.60","432.60","1 through 10","105.25","269.9","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.92","36.5","","148.37","54.89","631.39","94","105.25","269.9","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","130.03","38.3","","279.30","91.72","1116.77","266","105.25","269.9","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.65","42.9","","731.00","63.70","731.00","1 through 10","105.25","269.9","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.65","42.9","","384.74","384.74","384.74","1 through 10","105.25","269.9","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","WELLPOINT [1015]","HB AMC WELLPOINT","250.48","73.78","","286.63","119.22","1107.45","105","105.25","269.9","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.50","254.62","AETNA [1001]","HB AMC AETNA HMO","236.97","69.8","","675.31","184.75","1721.50","286","177.42","277.44","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.50","254.62","AETNA [1001]","HB AMC AETNA PPO","272.96","80.4","","1261.44","103.12","1514.10","21","177.42","277.44","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.50","254.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","272.96","80.4","","1365.00","1365.00","1365.00","1 through 10","177.42","277.44","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.50","254.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","277.44","81.72","","5157.68","5157.68","5157.68","1 through 10","177.42","277.44","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.50","254.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","277.44","81.72","","431.26","71.26","1459.57","88","177.42","277.44","percent of total billed charges",""
"CEMENT BONE 20GM VERTAPLEX RADIOPAQUE BX/2EA","SUP-ITM-10211911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1426.57","1069.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1134.12","79.5","","800.18","480.96","1887.97","195","442.24","1134.12","percent of total billed charges",""
"CEMENT BONE 20GM VERTAPLEX RADIOPAQUE BX/2EA","SUP-ITM-10211911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1426.57","1069.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","760.36","53.3","","813.12","216.42","1444.50","81","442.24","1134.12","percent of total billed charges",""
"CEMENT BONE 20GM VERTAPLEX RADIOPAQUE BX/2EA","SUP-ITM-10211911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1426.57","1069.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","442.24","31","","432.60","432.60","432.60","1 through 10","442.24","1134.12","percent of total billed charges",""
"CEMENT BONE 20GM VERTAPLEX RADIOPAQUE BX/2EA","SUP-ITM-10211911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1426.57","1069.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","520.70","36.5","","148.37","54.89","631.39","94","442.24","1134.12","percent of total billed charges",""
"CEMENT BONE 20GM VERTAPLEX RADIOPAQUE BX/2EA","SUP-ITM-10211911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1426.57","1069.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","546.38","38.3","","279.30","91.72","1116.77","266","442.24","1134.12","percent of total billed charges",""
"CEMENT BONE 20GM VERTAPLEX RADIOPAQUE BX/2EA","SUP-ITM-10211911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1426.57","1069.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","612.00","42.9","","731.00","63.70","731.00","1 through 10","442.24","1134.12","percent of total billed charges",""
"CEMENT BONE 20GM VERTAPLEX RADIOPAQUE BX/2EA","SUP-ITM-10211911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1426.57","1069.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","612.00","42.9","","384.74","384.74","384.74","1 through 10","442.24","1134.12","percent of total billed charges",""
"CEMENT BONE 20GM VERTAPLEX RADIOPAQUE BX/2EA","SUP-ITM-10211911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1426.57","1069.93","WELLPOINT [1015]","HB AMC WELLPOINT","1052.52","73.78","","286.63","119.22","1107.45","105","442.24","1134.12","percent of total billed charges",""
"CEMENT BONE 20GM VERTAPLEX RADIOPAQUE BX/2EA","SUP-ITM-10211911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1426.57","1069.93","AETNA [1001]","HB AMC AETNA HMO","995.75","69.8","","675.31","184.75","1721.50","286","745.53","1165.79","percent of total billed charges",""
"CEMENT BONE 20GM VERTAPLEX RADIOPAQUE BX/2EA","SUP-ITM-10211911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1426.57","1069.93","AETNA [1001]","HB AMC AETNA PPO","1146.96","80.4","","1261.44","103.12","1514.10","21","745.53","1165.79","percent of total billed charges",""
"CEMENT BONE 20GM VERTAPLEX RADIOPAQUE BX/2EA","SUP-ITM-10211911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1426.57","1069.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1146.96","80.4","","1365.00","1365.00","1365.00","1 through 10","745.53","1165.79","percent of total billed charges",""
"CEMENT BONE 20GM VERTAPLEX RADIOPAQUE BX/2EA","SUP-ITM-10211911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1426.57","1069.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1165.79","81.72","","5157.68","5157.68","5157.68","1 through 10","745.53","1165.79","percent of total billed charges",""
"CEMENT BONE 20GM VERTAPLEX RADIOPAQUE BX/2EA","SUP-ITM-10211911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1426.57","1069.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1165.79","81.72","","431.26","71.26","1459.57","88","745.53","1165.79","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.30","79.5","","800.18","480.96","1887.97","195","43.4","111.3","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.62","53.3","","813.12","216.42","1444.50","81","43.4","111.3","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","43.40","31","","432.60","432.60","432.60","1 through 10","43.4","111.3","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.10","36.5","","148.37","54.89","631.39","94","43.4","111.3","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.62","38.3","","279.30","91.72","1116.77","266","43.4","111.3","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.06","42.9","","731.00","63.70","731.00","1 through 10","43.4","111.3","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.06","42.9","","384.74","384.74","384.74","1 through 10","43.4","111.3","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","WELLPOINT [1015]","HB AMC WELLPOINT","103.29","73.78","","286.63","119.22","1107.45","105","43.4","111.3","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA HMO","97.72","69.8","","675.31","184.75","1721.50","286","73.16","114.41","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA PPO","112.56","80.4","","1261.44","103.12","1514.10","21","73.16","114.41","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.56","80.4","","1365.00","1365.00","1365.00","1 through 10","73.16","114.41","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.41","81.72","","5157.68","5157.68","5157.68","1 through 10","73.16","114.41","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.41","81.72","","431.26","71.26","1459.57","88","73.16","114.41","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","165.56","79.5","","800.18","480.96","1887.97","195","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.00","53.3","","813.12","216.42","1444.50","81","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","64.56","31","","432.60","432.60","432.60","1 through 10","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.01","36.5","","148.37","54.89","631.39","94","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","79.76","38.3","","279.30","91.72","1116.77","266","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.34","42.9","","731.00","63.70","731.00","1 through 10","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.34","42.9","","384.74","384.74","384.74","1 through 10","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","WELLPOINT [1015]","HB AMC WELLPOINT","153.65","73.78","","286.63","119.22","1107.45","105","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","208.25","156.19","AETNA [1001]","HB AMC AETNA HMO","145.36","69.8","","675.31","184.75","1721.50","286","108.83","170.18","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","208.25","156.19","AETNA [1001]","HB AMC AETNA PPO","167.43","80.4","","1261.44","103.12","1514.10","21","108.83","170.18","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","208.25","156.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","167.43","80.4","","1365.00","1365.00","1365.00","1 through 10","108.83","170.18","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","208.25","156.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","170.18","81.72","","5157.68","5157.68","5157.68","1 through 10","108.83","170.18","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","208.25","156.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","170.18","81.72","","431.26","71.26","1459.57","88","108.83","170.18","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","165.56","79.5","","800.18","480.96","1887.97","195","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.00","53.3","","813.12","216.42","1444.50","81","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","64.56","31","","432.60","432.60","432.60","1 through 10","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.01","36.5","","148.37","54.89","631.39","94","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","79.76","38.3","","279.30","91.72","1116.77","266","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.34","42.9","","731.00","63.70","731.00","1 through 10","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.34","42.9","","384.74","384.74","384.74","1 through 10","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","208.25","156.19","WELLPOINT [1015]","HB AMC WELLPOINT","153.65","73.78","","286.63","119.22","1107.45","105","64.56","165.56","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","208.25","156.19","AETNA [1001]","HB AMC AETNA HMO","145.36","69.8","","675.31","184.75","1721.50","286","108.83","170.18","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","208.25","156.19","AETNA [1001]","HB AMC AETNA PPO","167.43","80.4","","1261.44","103.12","1514.10","21","108.83","170.18","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","208.25","156.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","167.43","80.4","","1365.00","1365.00","1365.00","1 through 10","108.83","170.18","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","208.25","156.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","170.18","81.72","","5157.68","5157.68","5157.68","1 through 10","108.83","170.18","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","208.25","156.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","170.18","81.72","","431.26","71.26","1459.57","88","108.83","170.18","percent of total billed charges",""
"CEMENT BONE 40GM COBALT GENTAMICIN HIGH VISCOSITY SOFTPAC 402283","SUP-ITM-10045383","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","800.18","480.96","1887.97","195","271.25","695.63","percent of total billed charges",""
"CEMENT BONE 40GM COBALT GENTAMICIN HIGH VISCOSITY SOFTPAC 402283","SUP-ITM-10045383","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","813.12","216.42","1444.50","81","271.25","695.63","percent of total billed charges",""
"CEMENT BONE 40GM COBALT GENTAMICIN HIGH VISCOSITY SOFTPAC 402283","SUP-ITM-10045383","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.25","31","","432.60","432.60","432.60","1 through 10","271.25","695.63","percent of total billed charges",""
"CEMENT BONE 40GM COBALT GENTAMICIN HIGH VISCOSITY SOFTPAC 402283","SUP-ITM-10045383","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","148.37","54.89","631.39","94","271.25","695.63","percent of total billed charges",""
"CEMENT BONE 40GM COBALT GENTAMICIN HIGH VISCOSITY SOFTPAC 402283","SUP-ITM-10045383","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","279.30","91.72","1116.77","266","271.25","695.63","percent of total billed charges",""
"CEMENT BONE 40GM COBALT GENTAMICIN HIGH VISCOSITY SOFTPAC 402283","SUP-ITM-10045383","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","731.00","63.70","731.00","1 through 10","271.25","695.63","percent of total billed charges",""
"CEMENT BONE 40GM COBALT GENTAMICIN HIGH VISCOSITY SOFTPAC 402283","SUP-ITM-10045383","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","384.74","384.74","384.74","1 through 10","271.25","695.63","percent of total billed charges",""
"CEMENT BONE 40GM COBALT GENTAMICIN HIGH VISCOSITY SOFTPAC 402283","SUP-ITM-10045383","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","286.63","119.22","1107.45","105","271.25","695.63","percent of total billed charges",""
"CEMENT BONE 40GM COBALT GENTAMICIN HIGH VISCOSITY SOFTPAC 402283","SUP-ITM-10045383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","675.31","184.75","1721.50","286","457.28","715.05","percent of total billed charges",""
"CEMENT BONE 40GM COBALT GENTAMICIN HIGH VISCOSITY SOFTPAC 402283","SUP-ITM-10045383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA PPO","703.50","80.4","","1261.44","103.12","1514.10","21","457.28","715.05","percent of total billed charges",""
"CEMENT BONE 40GM COBALT GENTAMICIN HIGH VISCOSITY SOFTPAC 402283","SUP-ITM-10045383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1365.00","1365.00","1365.00","1 through 10","457.28","715.05","percent of total billed charges",""
"CEMENT BONE 40GM COBALT GENTAMICIN HIGH VISCOSITY SOFTPAC 402283","SUP-ITM-10045383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","715.05","81.72","","5157.68","5157.68","5157.68","1 through 10","457.28","715.05","percent of total billed charges",""
"CEMENT BONE 40GM COBALT GENTAMICIN HIGH VISCOSITY SOFTPAC 402283","SUP-ITM-10045383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","431.26","71.26","1459.57","88","457.28","715.05","percent of total billed charges",""
"CEMENT BONE 5CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4752.96","3564.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3778.60","79.5","","800.18","480.96","1887.97","195","1473.42","3778.6","percent of total billed charges",""
"CEMENT BONE 5CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4752.96","3564.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2533.33","53.3","","813.12","216.42","1444.50","81","1473.42","3778.6","percent of total billed charges",""
"CEMENT BONE 5CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4752.96","3564.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1473.42","31","","432.60","432.60","432.60","1 through 10","1473.42","3778.6","percent of total billed charges",""
"CEMENT BONE 5CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4752.96","3564.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1734.83","36.5","","148.37","54.89","631.39","94","1473.42","3778.6","percent of total billed charges",""
"CEMENT BONE 5CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4752.96","3564.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1820.38","38.3","","279.30","91.72","1116.77","266","1473.42","3778.6","percent of total billed charges",""
"CEMENT BONE 5CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4752.96","3564.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2039.02","42.9","","731.00","63.70","731.00","1 through 10","1473.42","3778.6","percent of total billed charges",""
"CEMENT BONE 5CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4752.96","3564.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2039.02","42.9","","384.74","384.74","384.74","1 through 10","1473.42","3778.6","percent of total billed charges",""
"CEMENT BONE 5CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4752.96","3564.72","WELLPOINT [1015]","HB AMC WELLPOINT","3506.73","73.78","","286.63","119.22","1107.45","105","1473.42","3778.6","percent of total billed charges",""
"CEMENT BONE 5CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4752.96","3564.72","AETNA [1001]","HB AMC AETNA HMO","3317.57","69.8","","675.31","184.75","1721.50","286","2483.9","3884.12","percent of total billed charges",""
"CEMENT BONE 5CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4752.96","3564.72","AETNA [1001]","HB AMC AETNA PPO","3821.38","80.4","","1261.44","103.12","1514.10","21","2483.9","3884.12","percent of total billed charges",""
"CEMENT BONE 5CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4752.96","3564.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3821.38","80.4","","1365.00","1365.00","1365.00","1 through 10","2483.9","3884.12","percent of total billed charges",""
"CEMENT BONE 5CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4752.96","3564.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3884.12","81.72","","5157.68","5157.68","5157.68","1 through 10","2483.9","3884.12","percent of total billed charges",""
"CEMENT BONE 5CC INJECTABLE SUBSTITUTE SELF SET HYDROSET CALCIUM PHOSPHATE","SUP-ITM-10339121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4752.96","3564.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3884.12","81.72","","431.26","71.26","1459.57","88","2483.9","3884.12","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.15","747.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","792.73","79.5","","800.18","480.96","1887.97","195","309.12","792.73","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.15","747.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","531.48","53.3","","813.12","216.42","1444.50","81","309.12","792.73","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.15","747.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","309.12","31","","432.60","432.60","432.60","1 through 10","309.12","792.73","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.15","747.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","363.96","36.5","","148.37","54.89","631.39","94","309.12","792.73","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.15","747.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","381.91","38.3","","279.30","91.72","1116.77","266","309.12","792.73","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.15","747.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.78","42.9","","731.00","63.70","731.00","1 through 10","309.12","792.73","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.15","747.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.78","42.9","","384.74","384.74","384.74","1 through 10","309.12","792.73","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","997.15","747.86","WELLPOINT [1015]","HB AMC WELLPOINT","735.70","73.78","","286.63","119.22","1107.45","105","309.12","792.73","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.15","747.86","AETNA [1001]","HB AMC AETNA HMO","696.01","69.8","","675.31","184.75","1721.50","286","521.11","814.87","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.15","747.86","AETNA [1001]","HB AMC AETNA PPO","801.71","80.4","","1261.44","103.12","1514.10","21","521.11","814.87","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.15","747.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","801.71","80.4","","1365.00","1365.00","1365.00","1 through 10","521.11","814.87","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.15","747.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","814.87","81.72","","5157.68","5157.68","5157.68","1 through 10","521.11","814.87","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","997.15","747.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","814.87","81.72","","431.26","71.26","1459.57","88","521.11","814.87","percent of total billed charges",""
"CEMENT BONE KYPHON ACTIVOS 10","SUP-ITM-10133150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.00","777.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","823.62","79.5","","800.18","480.96","1887.97","195","321.16","823.62","percent of total billed charges",""
"CEMENT BONE KYPHON ACTIVOS 10","SUP-ITM-10133150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.00","777.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","552.19","53.3","","813.12","216.42","1444.50","81","321.16","823.62","percent of total billed charges",""
"CEMENT BONE KYPHON ACTIVOS 10","SUP-ITM-10133150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.00","777.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","321.16","31","","432.60","432.60","432.60","1 through 10","321.16","823.62","percent of total billed charges",""
"CEMENT BONE KYPHON ACTIVOS 10","SUP-ITM-10133150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.00","777.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","378.14","36.5","","148.37","54.89","631.39","94","321.16","823.62","percent of total billed charges",""
"CEMENT BONE KYPHON ACTIVOS 10","SUP-ITM-10133150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.00","777.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","396.79","38.3","","279.30","91.72","1116.77","266","321.16","823.62","percent of total billed charges",""
"CEMENT BONE KYPHON ACTIVOS 10","SUP-ITM-10133150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.00","777.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","444.44","42.9","","731.00","63.70","731.00","1 through 10","321.16","823.62","percent of total billed charges",""
"CEMENT BONE KYPHON ACTIVOS 10","SUP-ITM-10133150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.00","777.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","444.44","42.9","","384.74","384.74","384.74","1 through 10","321.16","823.62","percent of total billed charges",""
"CEMENT BONE KYPHON ACTIVOS 10","SUP-ITM-10133150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.00","777.00","WELLPOINT [1015]","HB AMC WELLPOINT","764.36","73.78","","286.63","119.22","1107.45","105","321.16","823.62","percent of total billed charges",""
"CEMENT BONE KYPHON ACTIVOS 10","SUP-ITM-10133150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.00","777.00","AETNA [1001]","HB AMC AETNA HMO","723.13","69.8","","675.31","184.75","1721.50","286","541.41","846.62","percent of total billed charges",""
"CEMENT BONE KYPHON ACTIVOS 10","SUP-ITM-10133150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.00","777.00","AETNA [1001]","HB AMC AETNA PPO","832.94","80.4","","1261.44","103.12","1514.10","21","541.41","846.62","percent of total billed charges",""
"CEMENT BONE KYPHON ACTIVOS 10","SUP-ITM-10133150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.00","777.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","832.94","80.4","","1365.00","1365.00","1365.00","1 through 10","541.41","846.62","percent of total billed charges",""
"CEMENT BONE KYPHON ACTIVOS 10","SUP-ITM-10133150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.00","777.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","846.62","81.72","","5157.68","5157.68","5157.68","1 through 10","541.41","846.62","percent of total billed charges",""
"CEMENT BONE KYPHON ACTIVOS 10","SUP-ITM-10133150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.00","777.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","846.62","81.72","","431.26","71.26","1459.57","88","541.41","846.62","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","155.82","79.5","","800.18","480.96","1887.97","195","60.76","155.82","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","104.47","53.3","","813.12","216.42","1444.50","81","60.76","155.82","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","60.76","31","","432.60","432.60","432.60","1 through 10","60.76","155.82","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.54","36.5","","148.37","54.89","631.39","94","60.76","155.82","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.07","38.3","","279.30","91.72","1116.77","266","60.76","155.82","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.08","42.9","","731.00","63.70","731.00","1 through 10","60.76","155.82","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.08","42.9","","384.74","384.74","384.74","1 through 10","60.76","155.82","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","WELLPOINT [1015]","HB AMC WELLPOINT","144.61","73.78","","286.63","119.22","1107.45","105","60.76","155.82","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","AETNA [1001]","HB AMC AETNA HMO","136.81","69.8","","675.31","184.75","1721.50","286","102.43","160.17","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","AETNA [1001]","HB AMC AETNA PPO","157.58","80.4","","1261.44","103.12","1514.10","21","102.43","160.17","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","157.58","80.4","","1365.00","1365.00","1365.00","1 through 10","102.43","160.17","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","160.17","81.72","","5157.68","5157.68","5157.68","1 through 10","102.43","160.17","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","160.17","81.72","","431.26","71.26","1459.57","88","102.43","160.17","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","686.00","514.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","545.37","79.5","","800.18","480.96","1887.97","195","212.66","545.37","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","686.00","514.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","365.64","53.3","","813.12","216.42","1444.50","81","212.66","545.37","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","686.00","514.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","212.66","31","","432.60","432.60","432.60","1 through 10","212.66","545.37","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","686.00","514.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","250.39","36.5","","148.37","54.89","631.39","94","212.66","545.37","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","686.00","514.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","262.74","38.3","","279.30","91.72","1116.77","266","212.66","545.37","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","686.00","514.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","294.29","42.9","","731.00","63.70","731.00","1 through 10","212.66","545.37","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","686.00","514.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","294.29","42.9","","384.74","384.74","384.74","1 through 10","212.66","545.37","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","686.00","514.50","WELLPOINT [1015]","HB AMC WELLPOINT","506.13","73.78","","286.63","119.22","1107.45","105","212.66","545.37","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","686.00","514.50","AETNA [1001]","HB AMC AETNA HMO","478.83","69.8","","675.31","184.75","1721.50","286","358.5","560.6","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","686.00","514.50","AETNA [1001]","HB AMC AETNA PPO","551.54","80.4","","1261.44","103.12","1514.10","21","358.5","560.6","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","686.00","514.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","551.54","80.4","","1365.00","1365.00","1365.00","1 through 10","358.5","560.6","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","686.00","514.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","560.60","81.72","","5157.68","5157.68","5157.68","1 through 10","358.5","560.6","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","686.00","514.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","560.60","81.72","","431.26","71.26","1459.57","88","358.5","560.6","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","800.18","480.96","1887.97","195","271.25","695.63","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","813.12","216.42","1444.50","81","271.25","695.63","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.25","31","","432.60","432.60","432.60","1 through 10","271.25","695.63","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","148.37","54.89","631.39","94","271.25","695.63","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","279.30","91.72","1116.77","266","271.25","695.63","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","731.00","63.70","731.00","1 through 10","271.25","695.63","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","384.74","384.74","384.74","1 through 10","271.25","695.63","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","286.63","119.22","1107.45","105","271.25","695.63","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","675.31","184.75","1721.50","286","457.28","715.05","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA PPO","703.50","80.4","","1261.44","103.12","1514.10","21","457.28","715.05","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1365.00","1365.00","1365.00","1 through 10","457.28","715.05","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","715.05","81.72","","5157.68","5157.68","5157.68","1 through 10","457.28","715.05","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","431.26","71.26","1459.57","88","457.28","715.05","percent of total billed charges",""
"CEMENT HYDROXYAPATITE 3ML GRAFT BONE HYDROSET NEURO SYNTHETIC INJECTABLE","SUP-ITM-10079852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.03","2591.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2746.75","79.5","","800.18","480.96","1887.97","195","1071.06","2746.75","percent of total billed charges",""
"CEMENT HYDROXYAPATITE 3ML GRAFT BONE HYDROSET NEURO SYNTHETIC INJECTABLE","SUP-ITM-10079852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.03","2591.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1841.53","53.3","","813.12","216.42","1444.50","81","1071.06","2746.75","percent of total billed charges",""
"CEMENT HYDROXYAPATITE 3ML GRAFT BONE HYDROSET NEURO SYNTHETIC INJECTABLE","SUP-ITM-10079852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.03","2591.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1071.06","31","","432.60","432.60","432.60","1 through 10","1071.06","2746.75","percent of total billed charges",""
"CEMENT HYDROXYAPATITE 3ML GRAFT BONE HYDROSET NEURO SYNTHETIC INJECTABLE","SUP-ITM-10079852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.03","2591.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1261.09","36.5","","148.37","54.89","631.39","94","1071.06","2746.75","percent of total billed charges",""
"CEMENT HYDROXYAPATITE 3ML GRAFT BONE HYDROSET NEURO SYNTHETIC INJECTABLE","SUP-ITM-10079852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.03","2591.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1323.28","38.3","","279.30","91.72","1116.77","266","1071.06","2746.75","percent of total billed charges",""
"CEMENT HYDROXYAPATITE 3ML GRAFT BONE HYDROSET NEURO SYNTHETIC INJECTABLE","SUP-ITM-10079852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.03","2591.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1482.21","42.9","","731.00","63.70","731.00","1 through 10","1071.06","2746.75","percent of total billed charges",""
"CEMENT HYDROXYAPATITE 3ML GRAFT BONE HYDROSET NEURO SYNTHETIC INJECTABLE","SUP-ITM-10079852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.03","2591.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1482.21","42.9","","384.74","384.74","384.74","1 through 10","1071.06","2746.75","percent of total billed charges",""
"CEMENT HYDROXYAPATITE 3ML GRAFT BONE HYDROSET NEURO SYNTHETIC INJECTABLE","SUP-ITM-10079852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.03","2591.27","WELLPOINT [1015]","HB AMC WELLPOINT","2549.12","73.78","","286.63","119.22","1107.45","105","1071.06","2746.75","percent of total billed charges",""
"CEMENT HYDROXYAPATITE 3ML GRAFT BONE HYDROSET NEURO SYNTHETIC INJECTABLE","SUP-ITM-10079852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.03","2591.27","AETNA [1001]","HB AMC AETNA HMO","2411.61","69.8","","675.31","184.75","1721.50","286","1805.6","2823.45","percent of total billed charges",""
"CEMENT HYDROXYAPATITE 3ML GRAFT BONE HYDROSET NEURO SYNTHETIC INJECTABLE","SUP-ITM-10079852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.03","2591.27","AETNA [1001]","HB AMC AETNA PPO","2777.84","80.4","","1261.44","103.12","1514.10","21","1805.6","2823.45","percent of total billed charges",""
"CEMENT HYDROXYAPATITE 3ML GRAFT BONE HYDROSET NEURO SYNTHETIC INJECTABLE","SUP-ITM-10079852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.03","2591.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2777.84","80.4","","1365.00","1365.00","1365.00","1 through 10","1805.6","2823.45","percent of total billed charges",""
"CEMENT HYDROXYAPATITE 3ML GRAFT BONE HYDROSET NEURO SYNTHETIC INJECTABLE","SUP-ITM-10079852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.03","2591.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2823.45","81.72","","5157.68","5157.68","5157.68","1 through 10","1805.6","2823.45","percent of total billed charges",""
"CEMENT HYDROXYAPATITE 3ML GRAFT BONE HYDROSET NEURO SYNTHETIC INJECTABLE","SUP-ITM-10079852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.03","2591.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2823.45","81.72","","431.26","71.26","1459.57","88","1805.6","2823.45","percent of total billed charges",""
"Central Motor Evoked Pot Study Limb","PX-92000081","CDM","95939","CPT","0922","RC","","","","both","","","3728.00","2796.00","WELLPOINT [1015]","HB AMC WELLPOINT","2750.52","73.78","","6306.37","2691.37","6306.37","1 through 10","1147.8","2963.76","percent of total billed charges",""
"Centronuclear Myopathy 8 Genes","PX-30003384","CDM","81479","CPT","0310","RC","","","","both","","","2987.00","2240.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2374.67","79.5","","0.65","0.65","0.65","1 through 10","925.97","2837.65","percent of total billed charges",""
"Centronuclear Myopathy 8 Genes","PX-30003384","CDM","81479","CPT","0310","RC","","","","both","","","2987.00","2240.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1592.07","53.3","","0.79","0.79","0.79","1 through 10","925.97","2837.65","percent of total billed charges",""
"Centronuclear Myopathy 8 Genes","PX-30003384","CDM","81479","CPT","0310","RC","","","","outpatient","","","2987.00","2240.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1493.50","50","","1.00","1.00","1.00","1 through 10","156.55","2464.28","percent of total billed charges",""
"Centronuclear Myopathy 8 Genes","PX-30003384","CDM","81479","CPT","0310","RC","","","","outpatient","","","2987.00","2240.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1568.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","2464.28","percent of total billed charges",""
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","both","","","4886.00","3664.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3884.37","79.5","","3728.81","3725.08","7457.62","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","both","","","4886.00","3664.50","MEDICARE [2001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","1 through 10","1514.66","4719.38","other","OPPS APC"
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","both","","","4886.00","3664.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1783.39","36.5","","1767.27","1767.27","1767.27","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","both","","","4886.00","3664.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1871.34","38.3","","1852.56","1800.44","1852.56","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","AETNA [1001]","HB AMC AETNA HMO","3410.43","69.8","","3207.63","3207.63","3207.63","1 through 10","2125.14","3992.84","percent of total billed charges",""
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5424.80","5424.80","5524.71","1 through 10","2125.14","3992.84","other","ASC"
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6259.18","6259.18","6321.29","1 through 10","2125.14","3992.84","other","ASC "
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5440.36","5440.36","5440.36","1 through 10","2125.14","3992.84","other","Multiple Surgery"
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","14790.96","4739.06","14790.96","1 through 10","2125.14","3992.84","other","Multiple Surgery"
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5185.34","5185.34","5185.34","1 through 10","2125.14","3992.84","other","Multiple Surgery"
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2383.67","2383.67","2383.67","1 through 10","2125.14","3992.84","other","Multiple Surgery"
"Cerclage Cervix Vaginal W/Preg","PX-72000014","CDM","59320","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3992.84","81.72","","3787.56","3787.56","3787.56","1 through 10","2125.14","3992.84","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Certolizumab Level","PX-31000869","CDM","80299","CPT","0301","RC","","","","both","","","255.00","191.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","202.73","79.5","","106.25","71.28","106.25","1 through 10","14.12","242.25","percent of total billed charges",""
"Certolizumab Level","PX-31000869","CDM","80299","CPT","0301","RC","","","","both","","","255.00","191.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","135.92","53.3","","106.25","71.28","106.25","1 through 10","14.12","242.25","percent of total billed charges",""
"Certolizumab Level","PX-31000869","CDM","80299","CPT","0301","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","93.08","36.5","","50.36","42.80","92.50","13","14.12","242.25","percent of total billed charges",""
"Certolizumab Level","PX-31000869","CDM","80299","CPT","0301","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","97.67","38.3","","52.79","44.55","158.37","30","14.12","242.25","percent of total billed charges",""
"Certolizumab Level","PX-31000869","CDM","80299","CPT","0301","RC","","","","outpatient","","","255.00","191.25","AETNA [1001]","HB AMC AETNA HMO","177.99","69.8","","91.40","64.53","105.30","14","14.12","208.39","percent of total billed charges",""
"Certolizumab Level","PX-31000869","CDM","80299","CPT","0301","RC","","","","outpatient","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","205.02","80.4","","105.30","105.30","105.30","1 through 10","14.12","208.39","percent of total billed charges",""
"Certolizumab Level","PX-31000869","CDM","80299","CPT","0301","RC","","","","outpatient","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","208.39","81.72","","59.36","15.50","59.36","1 through 10","14.12","208.39","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","both","","","137.00","102.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","108.92","79.5","","104.67","104.67","314.01","16","10.53","130.15","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","both","","","137.00","102.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","73.02","53.3","","104.67","70.22","104.67","1 through 10","10.53","130.15","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","both","","","137.00","102.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","89.05","65","","105.95","105.95","105.95","1 through 10","10.53","130.15","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","both","","","137.00","102.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","108.92","79.5","","104.67","104.67","104.67","1 through 10","10.53","130.15","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","both","","","137.00","102.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.01","36.5","","49.61","42.16","99.22","19","10.53","130.15","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","both","","","137.00","102.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.47","38.3","","52.00","52.00","156.00","56","10.53","130.15","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","both","","","137.00","102.75","TRICARE [160005]","HB BWH TRICARE","130.15","95","","12.94","12.29","12.94","1 through 10","10.53","130.15","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","both","","","137.00","102.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.77","42.9","","106.32","106.32","106.32","1 through 10","10.53","130.15","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","outpatient","","","137.00","102.75","AETNA [1001]","HB AMC AETNA HMO","95.63","69.8","","90.04","63.57","103.74","24","11.07","111.96","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","outpatient","","","137.00","102.75","AETNA [1001]","HB AMC AETNA PPO","110.15","80.4","","103.74","103.74","103.74","1 through 10","11.07","111.96","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","outpatient","","","137.00","102.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","76.58","55.9","","69.69","69.69","69.69","1 through 10","11.07","111.96","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","outpatient","","","137.00","102.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","111.96","81.72","","106.32","58.48","106.32","1 through 10","11.07","111.96","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","outpatient","","","137.00","102.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","111.96","81.72","","106.32","58.48","106.32","23","11.07","111.96","percent of total billed charges",""
"Cervical Carotid Endograft Pseudo/Aneurysm","PX-76003032","CDM","37799","CPT","0761","RC","","","","outpatient","","","17778.00","13333.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","9283.67","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","14666.85","percent of total billed charges",""
"Cervical Carotid Endograft Pseudo/Aneurysm","PX-76003032","CDM","37799","CPT","0761","RC","","","","outpatient","","","17778.00","13333.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","9333.45","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","14666.85","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","12250.00","9187.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9738.75","79.5","","1309.77","674.56","6049.93","26","3797.5","9738.75","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","12250.00","9187.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6529.25","53.3","","1901.83","1901.83","2962.25","1 through 10","3797.5","9738.75","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","12250.00","9187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4471.25","36.5","","1620.31","1620.31","19908.88","1 through 10","3797.5","9738.75","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","12250.00","9187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4691.75","38.3","","352.91","352.91","2046.30","1 through 10","3797.5","9738.75","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","12250.00","9187.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5255.25","42.9","","9668.75","9668.75","9668.75","1 through 10","3797.5","9738.75","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","12250.00","9187.50","WELLPOINT [1015]","HB AMC WELLPOINT","9038.05","73.78","","699.88","384.10","3443.31","33","3797.5","9738.75","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12250.00","9187.50","AETNA [1001]","HB AMC AETNA HMO","8550.50","69.8","","1421.24","264.50","4933.46","29","6401.85","10010.7","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12250.00","9187.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9849.00","80.4","","1022.97","1022.97","3607.50","1 through 10","6401.85","10010.7","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12250.00","9187.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10010.70","81.72","","3010.54","693.88","5019.88","35","6401.85","10010.7","percent of total billed charges",""
"CERVICAL DISC LG 5MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287032","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10533.75","79.5","","1309.77","674.56","6049.93","26","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC LG 5MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287032","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7062.25","53.3","","1901.83","1901.83","2962.25","1 through 10","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC LG 5MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287032","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4836.25","36.5","","1620.31","1620.31","19908.88","1 through 10","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC LG 5MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287032","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5074.75","38.3","","352.91","352.91","2046.30","1 through 10","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC LG 5MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287032","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5684.25","42.9","","9668.75","9668.75","9668.75","1 through 10","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC LG 5MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287032","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","WELLPOINT [1015]","HB AMC WELLPOINT","9775.85","73.78","","699.88","384.10","3443.31","33","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC LG 5MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287032","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13250.00","9937.50","AETNA [1001]","HB AMC AETNA HMO","9248.50","69.8","","1421.24","264.50","4933.46","29","6924.45","10827.9","percent of total billed charges",""
"CERVICAL DISC LG 5MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287032","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13250.00","9937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10653.00","80.4","","1022.97","1022.97","3607.50","1 through 10","6924.45","10827.9","percent of total billed charges",""
"CERVICAL DISC LG 5MM HEIGHT SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287032","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13250.00","9937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10827.90","81.72","","3010.54","693.88","5019.88","35","6924.45","10827.9","percent of total billed charges",""
"CERVICAL DISC MED 5MM HEIGHT 5DEG LORDOSIS SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287026","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10533.75","79.5","","1309.77","674.56","6049.93","26","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC MED 5MM HEIGHT 5DEG LORDOSIS SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287026","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7062.25","53.3","","1901.83","1901.83","2962.25","1 through 10","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC MED 5MM HEIGHT 5DEG LORDOSIS SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287026","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4836.25","36.5","","1620.31","1620.31","19908.88","1 through 10","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC MED 5MM HEIGHT 5DEG LORDOSIS SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287026","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5074.75","38.3","","352.91","352.91","2046.30","1 through 10","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC MED 5MM HEIGHT 5DEG LORDOSIS SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287026","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5684.25","42.9","","9668.75","9668.75","9668.75","1 through 10","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC MED 5MM HEIGHT 5DEG LORDOSIS SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287026","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","WELLPOINT [1015]","HB AMC WELLPOINT","9775.85","73.78","","699.88","384.10","3443.31","33","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC MED 5MM HEIGHT 5DEG LORDOSIS SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287026","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13250.00","9937.50","AETNA [1001]","HB AMC AETNA HMO","9248.50","69.8","","1421.24","264.50","4933.46","29","6924.45","10827.9","percent of total billed charges",""
"CERVICAL DISC MED 5MM HEIGHT 5DEG LORDOSIS SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287026","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13250.00","9937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10653.00","80.4","","1022.97","1022.97","3607.50","1 through 10","6924.45","10827.9","percent of total billed charges",""
"CERVICAL DISC MED 5MM HEIGHT 5DEG LORDOSIS SIMPLIFY PEEK ENDPLATE TITANIUM COATED CERAMIC CORE","SUP-ITM-10287026","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13250.00","9937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10827.90","81.72","","3010.54","693.88","5019.88","35","6924.45","10827.9","percent of total billed charges",""
"CERVICAL DISC SZ 2 HT 5MM SIMPLIFY","SUP-ITM-10322233","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10533.75","79.5","","1309.77","674.56","6049.93","26","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC SZ 2 HT 5MM SIMPLIFY","SUP-ITM-10322233","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7062.25","53.3","","1901.83","1901.83","2962.25","1 through 10","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC SZ 2 HT 5MM SIMPLIFY","SUP-ITM-10322233","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4836.25","36.5","","1620.31","1620.31","19908.88","1 through 10","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC SZ 2 HT 5MM SIMPLIFY","SUP-ITM-10322233","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5074.75","38.3","","352.91","352.91","2046.30","1 through 10","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC SZ 2 HT 5MM SIMPLIFY","SUP-ITM-10322233","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5684.25","42.9","","9668.75","9668.75","9668.75","1 through 10","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC SZ 2 HT 5MM SIMPLIFY","SUP-ITM-10322233","CDM","C1889","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","WELLPOINT [1015]","HB AMC WELLPOINT","9775.85","73.78","","699.88","384.10","3443.31","33","4107.5","10533.75","percent of total billed charges",""
"CERVICAL DISC SZ 2 HT 5MM SIMPLIFY","SUP-ITM-10322233","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13250.00","9937.50","AETNA [1001]","HB AMC AETNA HMO","9248.50","69.8","","1421.24","264.50","4933.46","29","6924.45","10827.9","percent of total billed charges",""
"CERVICAL DISC SZ 2 HT 5MM SIMPLIFY","SUP-ITM-10322233","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13250.00","9937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10653.00","80.4","","1022.97","1022.97","3607.50","1 through 10","6924.45","10827.9","percent of total billed charges",""
"CERVICAL DISC SZ 2 HT 5MM SIMPLIFY","SUP-ITM-10322233","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13250.00","9937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10827.90","81.72","","3010.54","693.88","5019.88","35","6924.45","10827.9","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","800.18","480.96","1887.97","195","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","813.12","216.42","1444.50","81","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","542.50","31","","432.60","432.60","432.60","1 through 10","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","148.37","54.89","631.39","94","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","279.30","91.72","1116.77","266","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","731.00","63.70","731.00","1 through 10","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","384.74","384.74","384.74","1 through 10","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","286.63","119.22","1107.45","105","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","675.31","184.75","1721.50","286","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1261.44","103.12","1514.10","21","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","1365.00","1365.00","1365.00","1 through 10","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1430.10","81.72","","5157.68","5157.68","5157.68","1 through 10","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","431.26","71.26","1459.57","88","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 20MM ONE LEVEL SKYLINE TITANIUM","SUP-ITM-10077487","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","800.18","480.96","1887.97","195","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 20MM ONE LEVEL SKYLINE TITANIUM","SUP-ITM-10077487","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","813.12","216.42","1444.50","81","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 20MM ONE LEVEL SKYLINE TITANIUM","SUP-ITM-10077487","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","542.50","31","","432.60","432.60","432.60","1 through 10","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 20MM ONE LEVEL SKYLINE TITANIUM","SUP-ITM-10077487","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","148.37","54.89","631.39","94","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 20MM ONE LEVEL SKYLINE TITANIUM","SUP-ITM-10077487","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","279.30","91.72","1116.77","266","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 20MM ONE LEVEL SKYLINE TITANIUM","SUP-ITM-10077487","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","731.00","63.70","731.00","1 through 10","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 20MM ONE LEVEL SKYLINE TITANIUM","SUP-ITM-10077487","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","384.74","384.74","384.74","1 through 10","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 20MM ONE LEVEL SKYLINE TITANIUM","SUP-ITM-10077487","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","286.63","119.22","1107.45","105","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 20MM ONE LEVEL SKYLINE TITANIUM","SUP-ITM-10077487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","675.31","184.75","1721.50","286","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 20MM ONE LEVEL SKYLINE TITANIUM","SUP-ITM-10077487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1261.44","103.12","1514.10","21","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 20MM ONE LEVEL SKYLINE TITANIUM","SUP-ITM-10077487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","1365.00","1365.00","1365.00","1 through 10","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 20MM ONE LEVEL SKYLINE TITANIUM","SUP-ITM-10077487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1430.10","81.72","","5157.68","5157.68","5157.68","1 through 10","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 20MM ONE LEVEL SKYLINE TITANIUM","SUP-ITM-10077487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","431.26","71.26","1459.57","88","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","800.18","480.96","1887.97","195","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","813.12","216.42","1444.50","81","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","542.50","31","","432.60","432.60","432.60","1 through 10","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","148.37","54.89","631.39","94","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","279.30","91.72","1116.77","266","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","731.00","63.70","731.00","1 through 10","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","384.74","384.74","384.74","1 through 10","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","286.63","119.22","1107.45","105","542.5","1391.25","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","675.31","184.75","1721.50","286","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1261.44","103.12","1514.10","21","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","1365.00","1365.00","1365.00","1 through 10","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1430.10","81.72","","5157.68","5157.68","5157.68","1 through 10","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","431.26","71.26","1459.57","88","914.55","1430.1","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1641.68","79.5","","800.18","480.96","1887.97","195","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1100.65","53.3","","813.12","216.42","1444.50","81","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","640.15","31","","432.60","432.60","432.60","1 through 10","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","753.73","36.5","","148.37","54.89","631.39","94","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","790.90","38.3","","279.30","91.72","1116.77","266","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.89","42.9","","731.00","63.70","731.00","1 through 10","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.89","42.9","","384.74","384.74","384.74","1 through 10","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","WELLPOINT [1015]","HB AMC WELLPOINT","1523.56","73.78","","286.63","119.22","1107.45","105","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","AETNA [1001]","HB AMC AETNA HMO","1441.37","69.8","","675.31","184.75","1721.50","286","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","AETNA [1001]","HB AMC AETNA PPO","1660.26","80.4","","1261.44","103.12","1514.10","21","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1660.26","80.4","","1365.00","1365.00","1365.00","1 through 10","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1687.52","81.72","","5157.68","5157.68","5157.68","1 through 10","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1687.52","81.72","","431.26","71.26","1459.57","88","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 37X45MM SM TWO LEVEL LOCKING TITANIUM STATURE","SUP-ITM-10006032","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1878.19","79.5","","800.18","480.96","1887.97","195","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 37X45MM SM TWO LEVEL LOCKING TITANIUM STATURE","SUP-ITM-10006032","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1259.21","53.3","","813.12","216.42","1444.50","81","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 37X45MM SM TWO LEVEL LOCKING TITANIUM STATURE","SUP-ITM-10006032","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","732.38","31","","432.60","432.60","432.60","1 through 10","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 37X45MM SM TWO LEVEL LOCKING TITANIUM STATURE","SUP-ITM-10006032","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","862.31","36.5","","148.37","54.89","631.39","94","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 37X45MM SM TWO LEVEL LOCKING TITANIUM STATURE","SUP-ITM-10006032","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","904.84","38.3","","279.30","91.72","1116.77","266","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 37X45MM SM TWO LEVEL LOCKING TITANIUM STATURE","SUP-ITM-10006032","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","731.00","63.70","731.00","1 through 10","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 37X45MM SM TWO LEVEL LOCKING TITANIUM STATURE","SUP-ITM-10006032","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","384.74","384.74","384.74","1 through 10","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 37X45MM SM TWO LEVEL LOCKING TITANIUM STATURE","SUP-ITM-10006032","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","WELLPOINT [1015]","HB AMC WELLPOINT","1743.05","73.78","","286.63","119.22","1107.45","105","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 37X45MM SM TWO LEVEL LOCKING TITANIUM STATURE","SUP-ITM-10006032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA HMO","1649.03","69.8","","675.31","184.75","1721.50","286","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 37X45MM SM TWO LEVEL LOCKING TITANIUM STATURE","SUP-ITM-10006032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA PPO","1899.45","80.4","","1261.44","103.12","1514.10","21","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 37X45MM SM TWO LEVEL LOCKING TITANIUM STATURE","SUP-ITM-10006032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1899.45","80.4","","1365.00","1365.00","1365.00","1 through 10","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 37X45MM SM TWO LEVEL LOCKING TITANIUM STATURE","SUP-ITM-10006032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1930.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 37X45MM SM TWO LEVEL LOCKING TITANIUM STATURE","SUP-ITM-10006032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1930.64","81.72","","431.26","71.26","1459.57","88","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 38MM TWO LEVEL UNI","SUP-ITM-10138062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1641.68","79.5","","800.18","480.96","1887.97","195","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 38MM TWO LEVEL UNI","SUP-ITM-10138062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1100.65","53.3","","813.12","216.42","1444.50","81","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 38MM TWO LEVEL UNI","SUP-ITM-10138062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","640.15","31","","432.60","432.60","432.60","1 through 10","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 38MM TWO LEVEL UNI","SUP-ITM-10138062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","753.73","36.5","","148.37","54.89","631.39","94","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 38MM TWO LEVEL UNI","SUP-ITM-10138062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","790.90","38.3","","279.30","91.72","1116.77","266","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 38MM TWO LEVEL UNI","SUP-ITM-10138062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.89","42.9","","731.00","63.70","731.00","1 through 10","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 38MM TWO LEVEL UNI","SUP-ITM-10138062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.89","42.9","","384.74","384.74","384.74","1 through 10","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 38MM TWO LEVEL UNI","SUP-ITM-10138062","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","WELLPOINT [1015]","HB AMC WELLPOINT","1523.56","73.78","","286.63","119.22","1107.45","105","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 38MM TWO LEVEL UNI","SUP-ITM-10138062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","AETNA [1001]","HB AMC AETNA HMO","1441.37","69.8","","675.31","184.75","1721.50","286","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 38MM TWO LEVEL UNI","SUP-ITM-10138062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","AETNA [1001]","HB AMC AETNA PPO","1660.26","80.4","","1261.44","103.12","1514.10","21","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 38MM TWO LEVEL UNI","SUP-ITM-10138062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1660.26","80.4","","1365.00","1365.00","1365.00","1 through 10","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 38MM TWO LEVEL UNI","SUP-ITM-10138062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1687.52","81.72","","5157.68","5157.68","5157.68","1 through 10","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 38MM TWO LEVEL UNI","SUP-ITM-10138062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1687.52","81.72","","431.26","71.26","1459.57","88","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1641.68","79.5","","800.18","480.96","1887.97","195","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1100.65","53.3","","813.12","216.42","1444.50","81","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","640.15","31","","432.60","432.60","432.60","1 through 10","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","753.73","36.5","","148.37","54.89","631.39","94","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","790.90","38.3","","279.30","91.72","1116.77","266","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.89","42.9","","731.00","63.70","731.00","1 through 10","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.89","42.9","","384.74","384.74","384.74","1 through 10","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","WELLPOINT [1015]","HB AMC WELLPOINT","1523.56","73.78","","286.63","119.22","1107.45","105","640.15","1641.68","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","AETNA [1001]","HB AMC AETNA HMO","1441.37","69.8","","675.31","184.75","1721.50","286","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","AETNA [1001]","HB AMC AETNA PPO","1660.26","80.4","","1261.44","103.12","1514.10","21","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1660.26","80.4","","1365.00","1365.00","1365.00","1 through 10","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1687.52","81.72","","5157.68","5157.68","5157.68","1 through 10","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 4.0X4.5MM 32 LEVEL 2 6 HOLE REFLEX HYBRID TITANIUM LOCKING RING LOW PROFILE","SUP-ITM-10047398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1687.52","81.72","","431.26","71.26","1459.57","88","1079.17","1687.52","percent of total billed charges",""
"CERVICAL PLATE 40X48MM SM TWO LEVEL LOCKING TITANIUM STATURE CS/1BX/1EA","SUP-ITM-10010481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","800.18","480.96","1887.97","195","651","1669.5","percent of total billed charges",""
"CERVICAL PLATE 40X48MM SM TWO LEVEL LOCKING TITANIUM STATURE CS/1BX/1EA","SUP-ITM-10010481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1119.30","53.3","","813.12","216.42","1444.50","81","651","1669.5","percent of total billed charges",""
"CERVICAL PLATE 40X48MM SM TWO LEVEL LOCKING TITANIUM STATURE CS/1BX/1EA","SUP-ITM-10010481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","651.00","31","","432.60","432.60","432.60","1 through 10","651","1669.5","percent of total billed charges",""
"CERVICAL PLATE 40X48MM SM TWO LEVEL LOCKING TITANIUM STATURE CS/1BX/1EA","SUP-ITM-10010481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","148.37","54.89","631.39","94","651","1669.5","percent of total billed charges",""
"CERVICAL PLATE 40X48MM SM TWO LEVEL LOCKING TITANIUM STATURE CS/1BX/1EA","SUP-ITM-10010481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","279.30","91.72","1116.77","266","651","1669.5","percent of total billed charges",""
"CERVICAL PLATE 40X48MM SM TWO LEVEL LOCKING TITANIUM STATURE CS/1BX/1EA","SUP-ITM-10010481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","731.00","63.70","731.00","1 through 10","651","1669.5","percent of total billed charges",""
"CERVICAL PLATE 40X48MM SM TWO LEVEL LOCKING TITANIUM STATURE CS/1BX/1EA","SUP-ITM-10010481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","384.74","384.74","384.74","1 through 10","651","1669.5","percent of total billed charges",""
"CERVICAL PLATE 40X48MM SM TWO LEVEL LOCKING TITANIUM STATURE CS/1BX/1EA","SUP-ITM-10010481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","286.63","119.22","1107.45","105","651","1669.5","percent of total billed charges",""
"CERVICAL PLATE 40X48MM SM TWO LEVEL LOCKING TITANIUM STATURE CS/1BX/1EA","SUP-ITM-10010481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","675.31","184.75","1721.50","286","1097.46","1716.12","percent of total billed charges",""
"CERVICAL PLATE 40X48MM SM TWO LEVEL LOCKING TITANIUM STATURE CS/1BX/1EA","SUP-ITM-10010481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1261.44","103.12","1514.10","21","1097.46","1716.12","percent of total billed charges",""
"CERVICAL PLATE 40X48MM SM TWO LEVEL LOCKING TITANIUM STATURE CS/1BX/1EA","SUP-ITM-10010481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1688.40","80.4","","1365.00","1365.00","1365.00","1 through 10","1097.46","1716.12","percent of total billed charges",""
"CERVICAL PLATE 40X48MM SM TWO LEVEL LOCKING TITANIUM STATURE CS/1BX/1EA","SUP-ITM-10010481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1716.12","81.72","","5157.68","5157.68","5157.68","1 through 10","1097.46","1716.12","percent of total billed charges",""
"CERVICAL PLATE 40X48MM SM TWO LEVEL LOCKING TITANIUM STATURE CS/1BX/1EA","SUP-ITM-10010481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","431.26","71.26","1459.57","88","1097.46","1716.12","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1878.19","79.5","","800.18","480.96","1887.97","195","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1259.21","53.3","","813.12","216.42","1444.50","81","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","732.38","31","","432.60","432.60","432.60","1 through 10","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","862.31","36.5","","148.37","54.89","631.39","94","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","904.84","38.3","","279.30","91.72","1116.77","266","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","731.00","63.70","731.00","1 through 10","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","384.74","384.74","384.74","1 through 10","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","WELLPOINT [1015]","HB AMC WELLPOINT","1743.05","73.78","","286.63","119.22","1107.45","105","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA HMO","1649.03","69.8","","675.31","184.75","1721.50","286","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA PPO","1899.45","80.4","","1261.44","103.12","1514.10","21","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1899.45","80.4","","1365.00","1365.00","1365.00","1 through 10","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1930.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1930.64","81.72","","431.26","71.26","1459.57","88","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 56X48MM SM LEVEL 3 TITANIUM LOCKING STATURE","SUP-ITM-10011528","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1878.19","79.5","","800.18","480.96","1887.97","195","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 56X48MM SM LEVEL 3 TITANIUM LOCKING STATURE","SUP-ITM-10011528","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1259.21","53.3","","813.12","216.42","1444.50","81","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 56X48MM SM LEVEL 3 TITANIUM LOCKING STATURE","SUP-ITM-10011528","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","732.38","31","","432.60","432.60","432.60","1 through 10","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 56X48MM SM LEVEL 3 TITANIUM LOCKING STATURE","SUP-ITM-10011528","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","862.31","36.5","","148.37","54.89","631.39","94","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 56X48MM SM LEVEL 3 TITANIUM LOCKING STATURE","SUP-ITM-10011528","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","904.84","38.3","","279.30","91.72","1116.77","266","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 56X48MM SM LEVEL 3 TITANIUM LOCKING STATURE","SUP-ITM-10011528","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","731.00","63.70","731.00","1 through 10","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 56X48MM SM LEVEL 3 TITANIUM LOCKING STATURE","SUP-ITM-10011528","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","384.74","384.74","384.74","1 through 10","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 56X48MM SM LEVEL 3 TITANIUM LOCKING STATURE","SUP-ITM-10011528","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","WELLPOINT [1015]","HB AMC WELLPOINT","1743.05","73.78","","286.63","119.22","1107.45","105","732.38","1878.19","percent of total billed charges",""
"CERVICAL PLATE 56X48MM SM LEVEL 3 TITANIUM LOCKING STATURE","SUP-ITM-10011528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA HMO","1649.03","69.8","","675.31","184.75","1721.50","286","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 56X48MM SM LEVEL 3 TITANIUM LOCKING STATURE","SUP-ITM-10011528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA PPO","1899.45","80.4","","1261.44","103.12","1514.10","21","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 56X48MM SM LEVEL 3 TITANIUM LOCKING STATURE","SUP-ITM-10011528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1899.45","80.4","","1365.00","1365.00","1365.00","1 through 10","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 56X48MM SM LEVEL 3 TITANIUM LOCKING STATURE","SUP-ITM-10011528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1930.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 56X48MM SM LEVEL 3 TITANIUM LOCKING STATURE","SUP-ITM-10011528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1930.64","81.72","","431.26","71.26","1459.57","88","1234.64","1930.64","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2059.05","79.5","","800.18","480.96","1887.97","195","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1380.47","53.3","","813.12","216.42","1444.50","81","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","802.90","31","","432.60","432.60","432.60","1 through 10","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","945.35","36.5","","148.37","54.89","631.39","94","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","991.97","38.3","","279.30","91.72","1116.77","266","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1111.11","42.9","","731.00","63.70","731.00","1 through 10","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1111.11","42.9","","384.74","384.74","384.74","1 through 10","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","WELLPOINT [1015]","HB AMC WELLPOINT","1910.90","73.78","","286.63","119.22","1107.45","105","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","AETNA [1001]","HB AMC AETNA HMO","1807.82","69.8","","675.31","184.75","1721.50","286","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","AETNA [1001]","HB AMC AETNA PPO","2082.36","80.4","","1261.44","103.12","1514.10","21","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2082.36","80.4","","1365.00","1365.00","1365.00","1 through 10","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2116.55","81.72","","5157.68","5157.68","5157.68","1 through 10","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2116.55","81.72","","431.26","71.26","1459.57","88","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 TITANIUM LOCKING","SUP-ITM-10005380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2059.05","79.5","","800.18","480.96","1887.97","195","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 TITANIUM LOCKING","SUP-ITM-10005380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1380.47","53.3","","813.12","216.42","1444.50","81","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 TITANIUM LOCKING","SUP-ITM-10005380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","802.90","31","","432.60","432.60","432.60","1 through 10","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 TITANIUM LOCKING","SUP-ITM-10005380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","945.35","36.5","","148.37","54.89","631.39","94","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 TITANIUM LOCKING","SUP-ITM-10005380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","991.97","38.3","","279.30","91.72","1116.77","266","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 TITANIUM LOCKING","SUP-ITM-10005380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1111.11","42.9","","731.00","63.70","731.00","1 through 10","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 TITANIUM LOCKING","SUP-ITM-10005380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1111.11","42.9","","384.74","384.74","384.74","1 through 10","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 TITANIUM LOCKING","SUP-ITM-10005380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","WELLPOINT [1015]","HB AMC WELLPOINT","1910.90","73.78","","286.63","119.22","1107.45","105","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 TITANIUM LOCKING","SUP-ITM-10005380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","AETNA [1001]","HB AMC AETNA HMO","1807.82","69.8","","675.31","184.75","1721.50","286","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 TITANIUM LOCKING","SUP-ITM-10005380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","AETNA [1001]","HB AMC AETNA PPO","2082.36","80.4","","1261.44","103.12","1514.10","21","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 TITANIUM LOCKING","SUP-ITM-10005380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2082.36","80.4","","1365.00","1365.00","1365.00","1 through 10","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 TITANIUM LOCKING","SUP-ITM-10005380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2116.55","81.72","","5157.68","5157.68","5157.68","1 through 10","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 TITANIUM LOCKING","SUP-ITM-10005380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2116.55","81.72","","431.26","71.26","1459.57","88","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 96X105MM LEVEL 4 TITANIUM LOCKING PL VARIABLE ANGLE","SUP-ITM-10086690","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2059.05","79.5","","800.18","480.96","1887.97","195","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 96X105MM LEVEL 4 TITANIUM LOCKING PL VARIABLE ANGLE","SUP-ITM-10086690","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1380.47","53.3","","813.12","216.42","1444.50","81","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 96X105MM LEVEL 4 TITANIUM LOCKING PL VARIABLE ANGLE","SUP-ITM-10086690","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","802.90","31","","432.60","432.60","432.60","1 through 10","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 96X105MM LEVEL 4 TITANIUM LOCKING PL VARIABLE ANGLE","SUP-ITM-10086690","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","945.35","36.5","","148.37","54.89","631.39","94","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 96X105MM LEVEL 4 TITANIUM LOCKING PL VARIABLE ANGLE","SUP-ITM-10086690","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","991.97","38.3","","279.30","91.72","1116.77","266","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 96X105MM LEVEL 4 TITANIUM LOCKING PL VARIABLE ANGLE","SUP-ITM-10086690","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1111.11","42.9","","731.00","63.70","731.00","1 through 10","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 96X105MM LEVEL 4 TITANIUM LOCKING PL VARIABLE ANGLE","SUP-ITM-10086690","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1111.11","42.9","","384.74","384.74","384.74","1 through 10","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 96X105MM LEVEL 4 TITANIUM LOCKING PL VARIABLE ANGLE","SUP-ITM-10086690","CDM","C1713","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","WELLPOINT [1015]","HB AMC WELLPOINT","1910.90","73.78","","286.63","119.22","1107.45","105","802.9","2059.05","percent of total billed charges",""
"CERVICAL PLATE 96X105MM LEVEL 4 TITANIUM LOCKING PL VARIABLE ANGLE","SUP-ITM-10086690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","AETNA [1001]","HB AMC AETNA HMO","1807.82","69.8","","675.31","184.75","1721.50","286","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 96X105MM LEVEL 4 TITANIUM LOCKING PL VARIABLE ANGLE","SUP-ITM-10086690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","AETNA [1001]","HB AMC AETNA PPO","2082.36","80.4","","1261.44","103.12","1514.10","21","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 96X105MM LEVEL 4 TITANIUM LOCKING PL VARIABLE ANGLE","SUP-ITM-10086690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2082.36","80.4","","1365.00","1365.00","1365.00","1 through 10","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 96X105MM LEVEL 4 TITANIUM LOCKING PL VARIABLE ANGLE","SUP-ITM-10086690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2116.55","81.72","","5157.68","5157.68","5157.68","1 through 10","1353.53","2116.55","percent of total billed charges",""
"CERVICAL PLATE 96X105MM LEVEL 4 TITANIUM LOCKING PL VARIABLE ANGLE","SUP-ITM-10086690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2116.55","81.72","","431.26","71.26","1459.57","88","1353.53","2116.55","percent of total billed charges",""
"CERVICAL SPACER 12.5X15 5MMDEG GRAFT LORDOTIC FREEZE DRIED ACF CANCELLOUS CORTICAL IMPLANTABLE","SUP-ITM-10048844","CDM","C1889","HCPCS","0278","RC","","","","both","","","3809.86","2857.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3028.84","79.5","","1309.77","674.56","6049.93","26","1181.06","3028.84","percent of total billed charges",""
"CERVICAL SPACER 12.5X15 5MMDEG GRAFT LORDOTIC FREEZE DRIED ACF CANCELLOUS CORTICAL IMPLANTABLE","SUP-ITM-10048844","CDM","C1889","HCPCS","0278","RC","","","","both","","","3809.86","2857.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2030.66","53.3","","1901.83","1901.83","2962.25","1 through 10","1181.06","3028.84","percent of total billed charges",""
"CERVICAL SPACER 12.5X15 5MMDEG GRAFT LORDOTIC FREEZE DRIED ACF CANCELLOUS CORTICAL IMPLANTABLE","SUP-ITM-10048844","CDM","C1889","HCPCS","0278","RC","","","","both","","","3809.86","2857.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1390.60","36.5","","1620.31","1620.31","19908.88","1 through 10","1181.06","3028.84","percent of total billed charges",""
"CERVICAL SPACER 12.5X15 5MMDEG GRAFT LORDOTIC FREEZE DRIED ACF CANCELLOUS CORTICAL IMPLANTABLE","SUP-ITM-10048844","CDM","C1889","HCPCS","0278","RC","","","","both","","","3809.86","2857.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1459.18","38.3","","352.91","352.91","2046.30","1 through 10","1181.06","3028.84","percent of total billed charges",""
"CERVICAL SPACER 12.5X15 5MMDEG GRAFT LORDOTIC FREEZE DRIED ACF CANCELLOUS CORTICAL IMPLANTABLE","SUP-ITM-10048844","CDM","C1889","HCPCS","0278","RC","","","","both","","","3809.86","2857.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1634.43","42.9","","9668.75","9668.75","9668.75","1 through 10","1181.06","3028.84","percent of total billed charges",""
"CERVICAL SPACER 12.5X15 5MMDEG GRAFT LORDOTIC FREEZE DRIED ACF CANCELLOUS CORTICAL IMPLANTABLE","SUP-ITM-10048844","CDM","C1889","HCPCS","0278","RC","","","","both","","","3809.86","2857.39","WELLPOINT [1015]","HB AMC WELLPOINT","2810.91","73.78","","699.88","384.10","3443.31","33","1181.06","3028.84","percent of total billed charges",""
"CERVICAL SPACER 12.5X15 5MMDEG GRAFT LORDOTIC FREEZE DRIED ACF CANCELLOUS CORTICAL IMPLANTABLE","SUP-ITM-10048844","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3809.86","2857.39","AETNA [1001]","HB AMC AETNA HMO","2659.28","69.8","","1421.24","264.50","4933.46","29","1991.03","3113.42","percent of total billed charges",""
"CERVICAL SPACER 12.5X15 5MMDEG GRAFT LORDOTIC FREEZE DRIED ACF CANCELLOUS CORTICAL IMPLANTABLE","SUP-ITM-10048844","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3809.86","2857.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3063.13","80.4","","1022.97","1022.97","3607.50","1 through 10","1991.03","3113.42","percent of total billed charges",""
"CERVICAL SPACER 12.5X15 5MMDEG GRAFT LORDOTIC FREEZE DRIED ACF CANCELLOUS CORTICAL IMPLANTABLE","SUP-ITM-10048844","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3809.86","2857.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3113.42","81.72","","3010.54","693.88","5019.88","35","1991.03","3113.42","percent of total billed charges",""
"CERVICAL SPACER 7.0X14 12MM 5.0DEG ALLOGRAFT WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048830","CDM","C1889","HCPCS","0278","RC","","","","both","","","3078.50","2308.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2447.41","79.5","","1309.77","674.56","6049.93","26","954.34","2447.41","percent of total billed charges",""
"CERVICAL SPACER 7.0X14 12MM 5.0DEG ALLOGRAFT WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048830","CDM","C1889","HCPCS","0278","RC","","","","both","","","3078.50","2308.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1640.84","53.3","","1901.83","1901.83","2962.25","1 through 10","954.34","2447.41","percent of total billed charges",""
"CERVICAL SPACER 7.0X14 12MM 5.0DEG ALLOGRAFT WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048830","CDM","C1889","HCPCS","0278","RC","","","","both","","","3078.50","2308.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1123.65","36.5","","1620.31","1620.31","19908.88","1 through 10","954.34","2447.41","percent of total billed charges",""
"CERVICAL SPACER 7.0X14 12MM 5.0DEG ALLOGRAFT WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048830","CDM","C1889","HCPCS","0278","RC","","","","both","","","3078.50","2308.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1179.07","38.3","","352.91","352.91","2046.30","1 through 10","954.34","2447.41","percent of total billed charges",""
"CERVICAL SPACER 7.0X14 12MM 5.0DEG ALLOGRAFT WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048830","CDM","C1889","HCPCS","0278","RC","","","","both","","","3078.50","2308.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1320.68","42.9","","9668.75","9668.75","9668.75","1 through 10","954.34","2447.41","percent of total billed charges",""
"CERVICAL SPACER 7.0X14 12MM 5.0DEG ALLOGRAFT WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048830","CDM","C1889","HCPCS","0278","RC","","","","both","","","3078.50","2308.87","WELLPOINT [1015]","HB AMC WELLPOINT","2271.32","73.78","","699.88","384.10","3443.31","33","954.34","2447.41","percent of total billed charges",""
"CERVICAL SPACER 7.0X14 12MM 5.0DEG ALLOGRAFT WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048830","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3078.50","2308.87","AETNA [1001]","HB AMC AETNA HMO","2148.79","69.8","","1421.24","264.50","4933.46","29","1608.82","2515.75","percent of total billed charges",""
"CERVICAL SPACER 7.0X14 12MM 5.0DEG ALLOGRAFT WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048830","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3078.50","2308.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2475.11","80.4","","1022.97","1022.97","3607.50","1 through 10","1608.82","2515.75","percent of total billed charges",""
"CERVICAL SPACER 7.0X14 12MM 5.0DEG ALLOGRAFT WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048830","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3078.50","2308.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2515.75","81.72","","3010.54","693.88","5019.88","35","1608.82","2515.75","percent of total billed charges",""
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","122264.49","91698.37","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","28072.10","","Case rate ($27,254.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,731.60, add-ons for qualifying new technology services are included. If operating cost exceeds $78,376.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,810.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $24,504.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $32,351.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,370.60. The transfer capital threshold is the transfer adjustment factor * $2,370.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","27408.67","27408.67","27408.67","1 through 10","26709.38","43721.6452","other","Inpatient DRG"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","122264.49","91698.37","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","27254.47","","Case rate ($27,254.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,731.60, add-ons for qualifying new technology services are included. If operating cost exceeds $78,376.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,810.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $24,504.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $32,351.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,370.60. The transfer capital threshold is the transfer adjustment factor * $2,370.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","33891.25","33891.25","159722.89","1 through 10","26709.38","43721.6452","other","Inpatient Replacement Plans DRG"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","122264.49","91698.37","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","27254.47","","Case rate ($27,254.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,731.60, add-ons for qualifying new technology services are included. If operating cost exceeds $78,376.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,810.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $24,504.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $32,351.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,370.60. The transfer capital threshold is the transfer adjustment factor * $2,370.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26166.16","26166.16","26166.16","1 through 10","26709.38","43721.6452","other","Inpatient DRG"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","122264.49","91698.37","MEDICARE [2001]","HB BWH MEDICARE","27254.47","","Case rate ($27,254.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,731.60, add-ons for qualifying new technology services are included. If operating cost exceeds $78,376.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,810.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $24,504.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $32,351.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,370.60. The transfer capital threshold is the transfer adjustment factor * $2,370.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34433.81","0.03","34484.91","74","26709.38","43721.6452","other","Inpatient Replacement Plans DRG"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","122264.49","91698.37","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","27254.47","","Case rate ($27,254.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,731.60, add-ons for qualifying new technology services are included. If operating cost exceeds $78,376.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,810.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $24,504.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $32,351.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,370.60. The transfer capital threshold is the transfer adjustment factor * $2,370.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26082.40","26082.40","26100.40","1 through 10","26709.38","43721.6452","other","Inpatient Replacement Plans DRG"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","122264.49","91698.37","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","26709.38","","Case rate ($27,254.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,731.60, add-ons for qualifying new technology services are included. If operating cost exceeds $78,376.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,810.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $24,504.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $32,351.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,370.60. The transfer capital threshold is the transfer adjustment factor * $2,370.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26076.86","26076.86","26076.86","1 through 10","26709.38","43721.6452","other","Inpatient DRG"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","122264.49","91698.37","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","26709.38","","Case rate ($27,254.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,731.60, add-ons for qualifying new technology services are included. If operating cost exceeds $78,376.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,810.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $24,504.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $32,351.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,370.60. The transfer capital threshold is the transfer adjustment factor * $2,370.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26129.00","26094.72","26233.41","1 through 10","26709.38","43721.6452","other","Inpatient DRG"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","122264.49","91698.37","WELLPOINT [1015]","HB AMC WELLPOINT","43721.6452","","Fee schedule rate ($46,147.71).","43721.6452","79937.78","79937.78","1 through 10","26709.38","43721.6452","case rate",""
"Cervical Spinal Fusion With McC","471","MS-DRG","","","","","","","","inpatient","","","171589.81","128692.36","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","57546.46","","Case rate ($57,546.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $53,404.84, add-ons for qualifying new technology services are included. If operating cost exceeds $99,049.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,325.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $53,281.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $53,025.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,885.46. The transfer capital threshold is the transfer adjustment factor * $3,885.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","56671.39","56671.39","56671.39","1 through 10","43539.2","73301.5143","other","Inpatient DRG"
"Cervical Spinal Fusion With McC","471","MS-DRG","","","","","","","","inpatient","","","171589.81","128692.36","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","30886.14","30886.14","30886.14","1 through 10","43539.2","73301.5143","case rate",""
"Cervical Spinal Fusion With McC","471","MS-DRG","","","","","","","","inpatient","","","171589.81","128692.36","MEDICARE [2001]","HB BWH MEDICARE","57546.46","","Case rate ($57,546.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $53,404.84, add-ons for qualifying new technology services are included. If operating cost exceeds $99,049.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,325.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $53,281.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $53,025.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,885.46. The transfer capital threshold is the transfer adjustment factor * $3,885.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","57541.76","0.03","57627.40","18","43539.2","73301.5143","other","Inpatient DRG"
"Cervical Spinal Fusion With McC","471","MS-DRG","","","","","","","","inpatient","","","171589.81","128692.36","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43539.20","","Case rate ($44,427.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $53,404.84, add-ons for qualifying new technology services are included. If operating cost exceeds $99,049.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,325.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $40,162.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $53,025.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,885.46. The transfer capital threshold is the transfer adjustment factor * $3,885.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","43514.14","43514.14","43514.14","1 through 10","43539.2","73301.5143","other","Inpatient DRG"
"Cervical Spinal Fusion Without Cc/McC","473","MS-DRG","","","","","","","","inpatient","","","109688.23","82266.17","MEDICARE [2001]","HB BWH MEDICARE","22649.64","","Case rate ($22,649.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,188.28, add-ons for qualifying new technology services are included. If operating cost exceeds $72,832.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,404.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $20,305.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,808.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,964.41. The transfer capital threshold is the transfer adjustment factor * $1,964.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28187.93","0.03","28229.67","1 through 10","22196.65","35726.4334","other","Inpatient Replacement Plans DRG"
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0510","RC","","","","outpatient","","","191.00","143.25","AETNA [1001]","HB AMC AETNA HMO","133.32","69.8","","100.87","71.22","116.22","1 through 10","106.77","153.56","percent of total billed charges",""
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","both","","","191.00","143.25","MEDICARE [2001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","1 through 10","59.21","151.85","other","OPPS APC"
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","both","","","191.00","143.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","69.72","36.5","","69.01","55.58","69.01","1 through 10","59.21","151.85","percent of total billed charges",""
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","both","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","27.95","27.95","27.95","1 through 10","59.21","151.85","other","OPPS APC"
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","both","","","191.00","143.25","WELLPOINT [1015]","HB AMC WELLPOINT","140.92","73.78","","110.93","110.93","110.93","1 through 10","59.21","151.85","percent of total billed charges",""
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","outpatient","","","191.00","143.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","100.28","52.5","","77.20","77.20","77.20","1 through 10","79.11","202.5","percent of total billed charges",""
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","outpatient","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","156.09","81.72","","65.52","65.52","65.52","1 through 10","79.11","202.5","percent of total billed charges",""
"Cervical/Vag Cancer Screening","PX-77000026","CDM","G0101","HCPCS","0770","RC","","","","outpatient","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","156.09","81.72","","65.52","65.52","119.11","1 through 10","79.11","202.5","percent of total billed charges",""
"Cesarean Section With Sterilization With Cc","784","TRIS-DRG","","","","","","","","inpatient","","","45128.31","","TRICARE [160005]","HB BWH TRICARE","6764.67","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($11,882.52). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $55,609.52 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($8,487.52), capped at $8,552.27. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $55,609.52 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","42659.97","42659.97","42659.97","1 through 10","6764.67","6764.67","other","Inpatient DRGs"
"Cesarean Section With Sterilization With McC","783","MS-DRG","","","","","","","","inpatient","","","57122.52","42841.89","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10412.82","10412.82","10412.82","1 through 10","22320.02","28469.41","case rate",""
"Cesarean Section With Sterilization,MAJOR","539","DRG","","","","","","","","inpatient","","","64544.07","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","33815.75","","Standard inlier is a Case rate ($33,815.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,944, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,800.35) for the length of stay and the standard reimbursement.","33815.74","33815.74","33815.74","1 through 10","7994.28","78675.77","case rate",""
"Cesarean Section With Sterilization,MAJOR","539","DRG","","","","","","","","inpatient","","","64544.07","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","38018.02","","Standard inlier is a Case rate ($38,018.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,944, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,396.34) for the length of stay and the standard reimbursement.","38018.01","38018.01","38018.01","1 through 10","7994.28","78675.77","case rate",""
"Cesarean Section With Sterilization,MAJOR","539","DRG","","","","","","","","inpatient","","","64544.07","","MASSHEALTH [3001]","HB BWH MEDICAID","14195.04","","Case rate ($15,695.06). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,125.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15068.66","11596.03","15068.66","1 through 10","7994.28","78675.77","case rate",""
"Cesarean Section With Sterilization,MAJOR","539","DRG","","","","","","","","inpatient","","","64544.07","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14195.04","","Case rate ($15,695.06). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,125.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15691.20","15691.20","15691.20","1 through 10","7994.28","78675.77","case rate",""
"Cesarean Section With Sterilization,MINOR","539","DRG","","","","","","","","inpatient","","","39927.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20714.41","","Standard inlier is a Case rate ($20,714.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,756, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,940.54) for the length of stay and the standard reimbursement.","20714.41","18881.94","20714.41","11","7994.28","78675.77","case rate",""
"Cesarean Section With Sterilization,MINOR","539","DRG","","","","","","","","inpatient","","","39927.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","23288.58","","Standard inlier is a Case rate ($23,288.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,756, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,305.62) for the length of stay and the standard reimbursement.","21276.12","21276.12","23288.58","1 through 10","7994.28","78675.77","case rate",""
"Cesarean Section With Sterilization,MINOR","539","DRG","","","","","","","","inpatient","","","39927.36","","MASSHEALTH [3001]","HB BWH MEDICAID","7994.28","","Case rate ($8,839.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,269.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9081.85","9081.85","9081.85","1 through 10","7994.28","78675.77","case rate",""
"Cesarean Section With Sterilization,MINOR","539","DRG","","","","","","","","inpatient","","","39927.36","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","7994.28","","Case rate ($8,839.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,269.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","651.28","651.28","651.28","1 through 10","7994.28","78675.77","case rate",""
"Cesarean Section With Sterilization,MINOR","539","DRG","","","","","","","","inpatient","","","39927.36","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7994.28","","Case rate ($8,839.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,269.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8836.88","4.60","8836.88","1 through 10","7994.28","78675.77","case rate",""
"Cesarean Section With Sterilization,MODERATE","539","DRG","","","","","","","","inpatient","","","46480.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","23925.87","","Standard inlier is a Case rate ($23,925.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,255, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,396.42) for the length of stay and the standard reimbursement.","23925.87","21809.30","23925.87","1 through 10","7994.28","78675.77","case rate",""
"Cesarean Section With Sterilization,MODERATE","539","DRG","","","","","","","","inpatient","","","46480.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","26899.13","","Standard inlier is a Case rate ($26,899.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,255, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,818.11) for the length of stay and the standard reimbursement.","26899.12","24574.67","26899.13","17","7994.28","78675.77","case rate",""
"Cesarean Section With Sterilization,MODERATE","539","DRG","","","","","","","","inpatient","","","46480.53","","MASSHEALTH [3001]","HB BWH MEDICAID","9419.95","","Case rate ($10,415.37). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,845.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10412.82","9081.85","10412.82","1 through 10","7994.28","78675.77","case rate",""
"Cesarean Section With Sterilization,MODERATE","539","DRG","","","","","","","","inpatient","","","46480.53","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","9419.95","","Case rate ($10,415.37). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,845.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","651.28","651.28","651.28","1 through 10","7994.28","78675.77","case rate",""
"Cesarean Section With Sterilization,MODERATE","539","DRG","","","","","","","","inpatient","","","46480.53","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9419.95","","Case rate ($10,415.37). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,845.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10412.82","5.13","10412.82","1 through 10","7994.28","78675.77","case rate",""
"Cesarean Section Without Sterilization With Cc","772","TRIS-DRG","","","","","","","","inpatient","","","45251.86","","TRICARE [160005]","HB BWH TRICARE","6773.14","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($11,897.40). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $55,624.40 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($6,798.52), capped at $8,562.98. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $55,624.40 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","13677.51","13677.51","13677.51","1 through 10","6773.14","6773.14","other","Inpatient DRGs"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","","","","inpatient","","","46631.12","34973.34","MEDICARE [2001]","HB BWH MEDICARE","10567.40","","Case rate ($10,567.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,643.66, add-ons for qualifying new technology services are included. If operating cost exceeds $58,288.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,338.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,288.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,263.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $898.64. The transfer capital threshold is the transfer adjustment factor * $898.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","10356.05","17493.56","other","Inpatient Replacement Plans DRG"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","","","","inpatient","","","46631.12","34973.34","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10356.05","","Case rate ($10,567.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,643.66, add-ons for qualifying new technology services are included. If operating cost exceeds $58,288.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,338.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,288.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,263.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $898.64. The transfer capital threshold is the transfer adjustment factor * $898.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9751.13","238.90","14811.82","1 through 10","10356.05","17493.56","other","Inpatient DRG"
"Cesarean Section Without Sterilization With McC","771","TRIS-DRG","","","","","","","","inpatient","","","71358.31","","TRICARE [160005]","HB BWH TRICARE","8408.86","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($14,770.64). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $58,497.64 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($6,422.02), capped at $10,630.95. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $58,497.64 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","16853.08","16853.08","16853.08","1 through 10","8408.86","8408.86","other","Inpatient DRGs"
"Cesarean Section Without Sterilization With McC","771","TRIS-DRG","","","","","","","","inpatient","","","71358.31","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","8408.86","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($14,770.64). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $58,497.64 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($6,422.02), capped at $10,630.95. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $58,497.64 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","16853.09","16853.09","16853.09","1 through 10","8408.86","8408.86","other","Inpatient DRGs"
"Cesarean Section Without Sterilization With McC","786","MS-DRG","","","","","","","","inpatient","","","55088.35","41316.26","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15426.75","","Case rate ($15,426.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,493.35, add-ons for qualifying new technology services are included. If operating cost exceeds $64,137.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,767.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,719.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,113.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,327.28. The transfer capital threshold is the transfer adjustment factor * $1,327.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24269.93","24269.93","24269.93","1 through 10","15118.22","24385.5469","other","Inpatient DRG"
"Cesarean Section Without Sterilization With McC","786","MS-DRG","","","","","","","","inpatient","","","55088.35","41316.26","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","15068.66","15068.66","15068.66","1 through 10","15118.22","24385.5469","case rate",""
"Cesarean Section Without Sterilization With McC","786","MS-DRG","","","","","","","","inpatient","","","55088.35","41316.26","MEDICARE [2001]","HB BWH MEDICARE","15426.75","","Case rate ($15,426.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,493.35, add-ons for qualifying new technology services are included. If operating cost exceeds $64,137.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,767.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,719.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,113.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,327.28. The transfer capital threshold is the transfer adjustment factor * $1,327.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","15118.22","24385.5469","other","Inpatient Replacement Plans DRG"
"Cesarean Section Without Sterilization Without Cc/McC","773","TRIS-DRG","","","","","","","","inpatient","","","44217.60","","TRICARE [160005]","HB BWH TRICARE","5771.22","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($10,137.48). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $53,864.48 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($6,991.37), capped at $7,296.30. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $53,864.48 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","10490.41","7942.34","11648.41","1 through 10","5771.22","5771.22","other","Inpatient DRGs"
"Cesarean Section Without Sterilization Without Cc/McC","788","MS-DRG","","","","","","","","inpatient","","","44609.61","33457.21","MEDICARE [2001]","HB BWH MEDICARE","9126.13","","Case rate ($9,126.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,908.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,553.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,211.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,974.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,528.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $771.51. The transfer capital threshold is the transfer adjustment factor * $771.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10959.88","10959.88","10959.88","1 through 10","8943.61","15018.64","other","Inpatient Replacement Plans DRG"
"Cesarean Section Without Sterilization,EXTREME","540","DRG","","","","","","","","inpatient","","","63997.39","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","52589.70","","Standard inlier is a Case rate ($52,589.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,544, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,465.43) for the length of stay and the standard reimbursement.","47937.42","47937.42","52589.70","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,EXTREME","540","DRG","","","","","","","","inpatient","","","63997.39","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","59125.00","","Standard inlier is a Case rate ($59,125.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,544, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,392.30) for the length of stay and the standard reimbursement.","59124.99","54015.78","80472.94","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,EXTREME","540","DRG","","","","","","","","inpatient","","","63997.39","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16457.6386","","Fee schedule rate ($24,764.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16457.6386","55387.40","55387.40","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,EXTREME","540","DRG","","","","","","","","inpatient","","","63997.39","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","17280.9988","","Fee schedule rate ($26,003.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17280.9988","58158.40","58158.40","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,EXTREME","540","DRG","","","","","","","","inpatient","","","63997.39","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","27241.55","","Fee schedule rate ($27,241.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","58579.35","58579.35","58579.35","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,EXTREME","540","DRG","","","","","","","","inpatient","","","63997.39","","MASSHEALTH [3001]","HB BWH MEDICAID","21334.83","","Case rate ($23,589.32). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,019.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23583.53","23583.53","23583.53","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,EXTREME","540","DRG","","","","","","","","inpatient","","","63997.39","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","21334.83","","Case rate ($23,589.32). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,019.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,EXTREME","540","DRG","","","","","","","","inpatient","","","63997.39","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57442.42","","Fee schedule rate ($57,442.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","57442.42","57442.42","57442.42","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,EXTREME","540","DRG","","","","","","","","inpatient","","","63997.39","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","21334.83","","Case rate ($23,589.32). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,019.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23583.53","607.47","23583.53","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","56253.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31296.39","","Standard inlier is a Case rate ($31,296.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,984, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,442.71) for the length of stay and the standard reimbursement.","28527.79","28527.79","35185.57","47","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","56253.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","35185.57","","Standard inlier is a Case rate ($35,185.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,984, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,994.30) for the length of stay and the standard reimbursement.","32145.05","32145.05","32145.05","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","56253.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35185.57","","Standard inlier is a Case rate ($35,185.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,984, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,994.30) for the length of stay and the standard reimbursement.","35185.57","32145.05","35185.57","99","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","56253.60","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","17280.9988","","Fee schedule rate ($19,831.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17280.9988","27241.55","27241.55","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","56253.60","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16457.6386","","Fee schedule rate ($18,886.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16457.6386","24764.76","24764.76","20","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","56253.60","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","17280.9988","","Fee schedule rate ($19,831.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17280.9988","26003.68","78829.68","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","56253.60","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","20775.62","","Fee schedule rate ($20,775.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27241.56","27241.55","27241.56","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","56253.60","","MASSHEALTH [3001]","HB BWH MEDICAID","13631.85","","Case rate ($15,072.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,502.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15068.66","15068.66","15068.66","23","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","56253.60","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","13631.85","","Case rate ($15,072.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,502.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3313.03","3313.03","3313.03","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","56253.60","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26568.79","","Fee schedule rate ($26,568.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26568.79","26568.79","26568.79","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","56253.60","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27897.66","","Fee schedule rate ($27,897.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27897.66","27897.66","27897.66","22","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MAJOR","540","DRG","","","","","","","","inpatient","","","56253.60","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","13631.85","","Case rate ($15,072.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,502.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15068.66","7.00","15068.66","39","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20326.32","","Standard inlier is a Case rate ($20,326.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,454, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,885.44) for the length of stay and the standard reimbursement.","18528.18","18528.18","20326.31","60","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","22852.26","","Standard inlier is a Case rate ($22,852.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,454, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,243.69) for the length of stay and the standard reimbursement.","22852.26","22852.26","22852.26","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22852.26","","Standard inlier is a Case rate ($22,852.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,454, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,243.69) for the length of stay and the standard reimbursement.","22852.26","20877.51","22852.26","150","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","17280.9988","","Fee schedule rate ($17,281.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17280.9988","17406.08","20572.23","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16457.6386","","Fee schedule rate ($16,457.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16457.6386","16457.64","16457.64","47","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","17280.9988","","Fee schedule rate ($17,281.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17280.9988","16614.36","17281.00","25","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","20304.40","","Fee schedule rate ($20,304.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20572.23","20572.23","20572.23","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","18103.62","","Fee schedule rate ($18,103.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18103.62","18103.62","18103.64","12","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","MASSHEALTH [3001]","HB BWH MEDICAID","8215.90","","Case rate ($9,084.09). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,514.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9081.85","9081.85","9081.85","44","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","8215.90","","Case rate ($9,084.09). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,514.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16001.80","","Fee schedule rate ($16,001.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15535.55","13601.53","16001.80","17","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16802.15","","Fee schedule rate ($16,802.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16802.15","16312.63","16802.15","69","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","17280.9988","","Fee schedule rate ($17,281.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17280.9988","17406.08","17406.08","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","20572.2322","","Fee schedule rate ($20,304.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20572.2322","19779.04","19779.04","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","18103.6232","","Fee schedule rate ($18,103.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18103.6232","17406.08","17406.08","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MINOR","540","DRG","","","","","","","","inpatient","","","43952.26","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8215.90","","Case rate ($9,084.09). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,514.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9081.86","5.18","9081.86","42","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24760.27","","Standard inlier is a Case rate ($24,760.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,902, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,514.87) for the length of stay and the standard reimbursement.","24760.26","22569.88","24760.26","81","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","27837.22","","Standard inlier is a Case rate ($27,837.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,902, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,951.26) for the length of stay and the standard reimbursement.","27837.21","25977.46","27837.21","178","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","10490.35","","Case rate ($11,598.88). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,028.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8555.17","8555.17","8555.17","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","17280.9988","","Fee schedule rate ($19,831.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17280.9988","20775.62","20775.62","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16457.6386","","Fee schedule rate ($18,886.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16457.6386","18886.68","18886.68","35","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","17280.9988","","Fee schedule rate ($19,831.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17280.9988","19066.56","19831.56","29","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","23301.22","","Fee schedule rate ($23,301.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23608.58","23608.58","23608.58","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","19831.58","","Fee schedule rate ($19,831.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23738.50","23738.50","23738.50","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","20775.62","","Fee schedule rate ($20,775.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20775.60","19975.12","20775.62","17","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","MASSHEALTH [3001]","HB BWH MEDICAID","10490.35","","Case rate ($11,598.88). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,028.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11596.03","5162.18","11596.03","45","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","10490.35","","Case rate ($11,598.88). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,028.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","10490.35","","Case rate ($11,598.88). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,028.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5931.28","5931.28","5931.28","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","18670.19","","Fee schedule rate ($18,670.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18126.19","15869.66","18670.19","21","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","19604.00","","Fee schedule rate ($19,604.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19604.00","19032.85","19604.00","59","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","20572.2322","","Fee schedule rate ($23,301.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20572.2322","22698.32","22698.32","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","18103.6232","","Fee schedule rate ($20,775.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18103.6232","19975.13","19975.13","1 through 10","8215.9","59125","case rate",""
"Cesarean Section Without Sterilization,MODERATE","540","DRG","","","","","","","","inpatient","","","47318.33","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10490.35","","Case rate ($11,598.88). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,028.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11596.04","5.80","11731.48","67","8215.9","59125","case rate",""
"Ch0055 for Dex Z","PX-31001334","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Ch0060, So Charge Only Test","PX-31001274","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2946.27","79.5","","2828.48","1814.97","2828.48","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Ch0060, So Charge Only Test","PX-31001274","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1975.30","53.3","","1814.97","1761.95","1814.97","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Ch0060, So Charge Only Test","PX-31001274","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1352.69","36.5","","1340.56","1340.56","1340.56","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Ch0060, So Charge Only Test","PX-31001274","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1419.40","38.3","","1405.25","1405.25","1405.25","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Ch0060, So Charge Only Test","PX-31001274","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","WELLPOINT [1015]","HB AMC WELLPOINT","2734.29","73.78","","6269.73","2675.73","7188.00","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Ch0060, So Charge Only Test","PX-31001274","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","AETNA [1001]","HB AMC AETNA HMO","2586.79","69.8","","2433.14","2433.14","2433.14","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Ch0060, So Charge Only Test","PX-31001274","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2979.62","80.4","","2803.32","2803.32","2803.32","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Ch0060, So Charge Only Test","PX-31001274","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3028.54","81.72","","2873.04","1533.07","3526.61","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Ch0147 Charge Only for Maternal Cell Contamination","PX-31001282","CDM","81265","CPT","0310","RC","","","","outpatient","","","1341.00","1005.75","AETNA [1001]","HB AMC AETNA HMO","936.02","69.8","","880.10","880.10","880.10","1 through 10","648.65","1464.7","percent of total billed charges",""
"Change G-TB to G-J TB Perc Fluoro","PX-75000301","CDM","49446","CPT","0361","RC","","","","both","","","3862.00","2896.50","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1197.22","3070.29","other","OPPS APC"
"Change G-TB to G-J TB Perc Fluoro","PX-75000301","CDM","49446","CPT","0361","RC","","","","both","","","3862.00","2896.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.24","2215.24","2215.24","1 through 10","1197.22","3070.29","other","OPPS APC"
"Change G-TB to G-J TB Perc Fluoro","PX-75000301","CDM","49446","CPT","0361","RC","","","","outpatient","","","3862.00","2896.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3932.02","3932.02","3932.02","1 through 10","1335.02","3156.03","other","ASC "
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","both","","","368.00","276.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","114.08","1391.62","other","OPPS APC"
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","both","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","114.08","1391.62","other","OPPS APC"
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","both","","","368.00","276.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","114.08","1391.62","other","OPPS APC"
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","both","","","368.00","276.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","114.08","1391.62","other","OPPS APC"
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","both","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.87","42.9","","1932.92","1932.92","1932.92","1 through 10","114.08","1391.62","percent of total billed charges",""
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","both","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","114.08","1391.62","other","OPPS APC"
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","both","","","368.00","276.00","WELLPOINT [1015]","HB AMC WELLPOINT","271.51","73.78","","2222.33","2222.33","2222.33","1 through 10","114.08","1391.62","percent of total billed charges",""
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","outpatient","","","368.00","276.00","AETNA [1001]","HB AMC AETNA HMO","256.86","69.8","","2238.60","2238.60","2238.60","1 through 10","184","8899.59","percent of total billed charges",""
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","outpatient","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","222.82","60.55","","3144.00","2870.00","3286.00","1 through 10","184","8899.59","percent of total billed charges",""
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","outpatient","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","192.32","52.26","","1775.96","1775.96","1775.96","1 through 10","184","8899.59","percent of total billed charges",""
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","outpatient","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","192.17","52.22","","3286.00","2018.70","5898.00","1 through 10","184","8899.59","percent of total billed charges",""
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","outpatient","","","368.00","276.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","193.20","52.5","","8340.00","8340.00","8340.00","1 through 10","184","8899.59","percent of total billed charges",""
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","outpatient","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","300.73","81.72","","2294.28","682.69","2294.28","1 through 10","184","8899.59","percent of total billed charges",""
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","297.46","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","298.10","298.10","298.10","1 through 10","232.5","596.25","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","750.00","562.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.21","284.21","284.21","1 through 10","232.5","596.25","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","750.00","562.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","284.21","288.83","1 through 10","232.5","596.25","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","750.00","562.50","MEDICARE [2001]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","288.83","288.83","1 through 10","232.5","596.25","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","264.35","264.35","264.35","1 through 10","232.5","596.25","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","750.00","562.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","283.02","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","849.15","849.15","849.15","1 through 10","232.5","596.25","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","283.02","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","288.83","288.83","288.83","1 through 10","232.5","596.25","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","outpatient","","","750.00","562.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","270.73","265.83","531.66","1 through 10","231.42","1120.45","other","ASC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","outpatient","","","750.00","562.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","306.72","306.72","306.72","1 through 10","231.42","1120.45","other","ASC "
"Change Tube Tracheotomy","PX-76000763","CDM","31502","CPT","0761","RC","","","","both","","","515.00","386.25","MEDICARE [2001]","HB BWH MEDICARE","275.75","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","275.78","275.78","275.78","1 through 10","159.65","409.43","other","OPPS APC"
"Change Tube Tracheotomy","PX-76000763","CDM","31502","CPT","0761","RC","","","","outpatient","","","515.00","386.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","206.14","","Case rate ($206.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","229.85","229.85","229.85","1 through 10","206.14","700.33","other","Multiple Surgery"
"Change Tube Ureterostomy","PX-76001242","CDM","50688","CPT","0761","RC","","","","both","","","4707.00","3530.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2505.46","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2503.28","2503.28","2515.59","1 through 10","1459.17","3742.07","other","OPPS APC"
"Change Tube Ureterostomy","PX-76001242","CDM","50688","CPT","0761","RC","","","","both","","","4707.00","3530.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2393.81","2187.46","2393.81","1 through 10","1459.17","3742.07","other","OPPS APC"
"Change Tube Ureterostomy","PX-76001242","CDM","50688","CPT","0761","RC","","","","both","","","4707.00","3530.25","MEDICARE [2001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2223.03","1216.37","2432.73","66","1459.17","3742.07","other","OPPS APC"
"Change Tube Ureterostomy","PX-76001242","CDM","50688","CPT","0761","RC","","","","both","","","4707.00","3530.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1196.91","1095.69","3590.72","14","1459.17","3742.07","other","OPPS APC"
"Change Tube Ureterostomy","PX-76001242","CDM","50688","CPT","0761","RC","","","","both","","","4707.00","3530.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1195.79","1195.79","2391.98","1 through 10","1459.17","3742.07","other","OPPS APC"
"Change Tube Ureterostomy","PX-76001242","CDM","50688","CPT","0761","RC","","","","both","","","4707.00","3530.25","WELLPOINT [1015]","HB AMC WELLPOINT","3472.82","73.78","","3398.64","3398.64","3398.64","1 through 10","1459.17","3742.07","percent of total billed charges",""
"Change Tube Ureterostomy","PX-76001242","CDM","50688","CPT","0761","RC","","","","outpatient","","","4707.00","3530.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4657.42","4611.66","4657.42","1 through 10","1565.78","3846.56","other","ASC "
"Change Tube Ureterostomy","PX-76001242","CDM","50688","CPT","0761","RC","","","","outpatient","","","4707.00","3530.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3846.56","81.72","","3649.26","3649.26","3649.26","1 through 10","1565.78","3846.56","percent of total billed charges",""
"Change Ureteral Stent Percutaneous","PX-76001223","CDM","50382","CPT","0761","RC","","","","both","","","6992.00","5244.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4021.85","4021.85","4021.85","1 through 10","2167.52","5558.64","other","OPPS APC"
"Chek2 Gene, Full Gene Analysis","PX-31001054","CDM","81479","CPT","0310","RC","","","","both","","","2531.00","1898.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2012.15","79.5","","0.65","0.65","0.65","1 through 10","784.61","2404.45","percent of total billed charges",""
"Chek2 Gene, Full Gene Analysis","PX-31001054","CDM","81479","CPT","0310","RC","","","","both","","","2531.00","1898.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.02","53.3","","0.79","0.79","0.79","1 through 10","784.61","2404.45","percent of total billed charges",""
"Chek2 Gene, Full Gene Analysis","PX-31001054","CDM","81479","CPT","0310","RC","","","","outpatient","","","2531.00","1898.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1265.50","50","","1.00","1.00","1.00","1 through 10","156.55","2088.08","percent of total billed charges",""
"Chek2 Gene, Full Gene Analysis","PX-31001054","CDM","81479","CPT","0310","RC","","","","outpatient","","","2531.00","1898.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1328.78","52.5","","1.00","0.53","1.00","1 through 10","156.55","2088.08","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","1714.00","1285.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","393.86","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","387.60","387.60","387.60","1 through 10","374.21","1362.63","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","1714.00","1285.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","393.86","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","387.60","387.60","387.60","1 through 10","374.21","1362.63","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","1714.00","1285.50","MEDICARE [2001]","HB BWH MEDICARE","393.86","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","393.90","393.90","1108.89","31","374.21","1362.63","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","1714.00","1285.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","625.61","36.5","","526.85","526.85","526.85","1 through 10","374.21","1362.63","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","1714.00","1285.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","656.46","38.3","","649.84","649.84","649.84","1 through 10","374.21","1362.63","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","1714.00","1285.50","TRICARE [160005]","HB BWH TRICARE","374.21","","APC Price ($393.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","393.90","393.90","393.90","1 through 10","374.21","1362.63","other","Tricare OPPS"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","1714.00","1285.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","385.98","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","387.60","386.02","387.60","1 through 10","374.21","1362.63","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","1714.00","1285.50","WELLPOINT [1015]","HB AMC WELLPOINT","1264.59","73.78","","1237.36","1237.36","1237.36","1 through 10","374.21","1362.63","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","outpatient","","","1714.00","1285.50","AETNA [1001]","HB AMC AETNA HMO","1196.37","69.8","","794.44","794.44","794.44","1 through 10","430.03","1400.68","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","outpatient","","","1714.00","1285.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","958.13","55.9","","870.89","870.89","870.89","1 through 10","430.03","1400.68","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","outpatient","","","1714.00","1285.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1400.68","81.72","","1328.60","1328.60","1328.60","1 through 10","430.03","1400.68","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","959.00","719.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","361.43","333.65","361.83","1 through 10","297.29","762.41","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","959.00","719.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","930.00","1 through 10","297.29","762.41","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","959.00","719.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","762.41","79.5","","731.91","491.04","731.91","43","297.29","762.41","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","959.00","719.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","511.15","53.3","","491.04","491.04","491.04","1 through 10","297.29","762.41","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","959.00","719.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","297.29","762.41","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","959.00","719.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","223.30","223.30","223.30","1 through 10","297.29","762.41","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","959.00","719.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","115","297.29","762.41","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","959.00","719.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","297.29","31","","287.37","287.37","287.37","1 through 10","297.29","762.41","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","959.00","719.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","350.04","36.5","","346.89","229.02","346.89","19","297.29","762.41","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","959.00","719.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","367.30","38.3","","363.63","353.40","688.08","74","297.29","762.41","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","959.00","719.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","343.55","343.55","1 through 10","297.29","762.41","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","959.00","719.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","175.28","350.56","47","297.29","762.41","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","959.00","719.25","WELLPOINT [1015]","HB AMC WELLPOINT","707.55","73.78","","692.39","692.39","1149.51","28","297.29","762.41","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","AETNA [1001]","HB AMC AETNA HMO","669.38","69.8","","629.61","444.54","725.40","28","247.48","1234.13","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","AETNA [1001]","HB AMC AETNA PPO","771.04","80.4","","487.32","487.32","974.64","1 through 10","247.48","1234.13","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","568.57","568.57","579.04","159","247.48","1234.13","other","ASC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","501.17","52.26","","656.02","575.49","656.02","1 through 10","247.48","1234.13","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","656.02","656.02","662.53","274","247.48","1234.13","other","ASC "
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","633.55","633.55","633.55","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","574.15","574.15","1722.45","88","247.48","1234.13","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1163.16","603.85","1811.55","42","247.48","1234.13","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 383%, 191.5 procedures at 0%.","744.91","744.91","744.91","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","717.69","717.69","717.69","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","633.55","608.80","633.55","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","411.41","42.9","","743.44","743.44","743.44","1 through 10","247.48","1234.13","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","608.80","608.80","608.80","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","783.69","81.72","","408.92","408.92","408.92","1 through 10","247.48","1234.13","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","959.00","719.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","783.69","81.72","","743.44","408.92","930.00","20","247.48","1234.13","percent of total billed charges",""
"Chemdnrvtn/Dest Nerve Neurlytic Fac","PX-76001571","CDM","64612","CPT","0761","RC","","","","both","","","950.00","712.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","360.73","360.73","1 through 10","294.5","755.25","other","OPPS APC"
"Chemdnrvtn/Dest Nerve Neurlytic Fac","PX-76001571","CDM","64612","CPT","0761","RC","","","","both","","","950.00","712.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","665.00","70","","921.00","921.00","921.00","1 through 10","294.5","755.25","percent of total billed charges",""
"Chemdnrvtn/Dest Nerve Neurlytic Fac","PX-76001571","CDM","64612","CPT","0761","RC","","","","both","","","950.00","712.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","506.35","53.3","","724.83","486.29","724.83","1 through 10","294.5","755.25","percent of total billed charges",""
"Chemdnrvtn/Dest Nerve Neurlytic Fac","PX-76001571","CDM","64612","CPT","0761","RC","","","","both","","","950.00","712.50","ELDER SERVICES [1037]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","1 through 10","294.5","755.25","other","OPPS APC"
"Chemdnrvtn/Dest Nerve Neurlytic Fac","PX-76001571","CDM","64612","CPT","0761","RC","","","","both","","","950.00","712.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","294.5","755.25","other","OPPS APC"
"Chemdnrvtn/Dest Nerve Neurlytic Fac","PX-76001571","CDM","64612","CPT","0761","RC","","","","both","","","950.00","712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","346.75","36.5","","343.53","343.53","343.53","1 through 10","294.5","755.25","percent of total billed charges",""
"Chemdnrvtn/Dest Nerve Neurlytic Fac","PX-76001571","CDM","64612","CPT","0761","RC","","","","both","","","950.00","712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","363.85","38.3","","360.11","277.22","360.11","1 through 10","294.5","755.25","percent of total billed charges",""
"Chemdnrvtn/Dest Nerve Neurlytic Fac","PX-76001571","CDM","64612","CPT","0761","RC","","","","both","","","950.00","712.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","345.74","317.45","523.23","1 through 10","294.5","755.25","other","OPPS APC"
"Chemdnrvtn/Dest Nerve Neurlytic Fac","PX-76001571","CDM","64612","CPT","0761","RC","","","","both","","","950.00","712.50","WELLPOINT [1015]","HB AMC WELLPOINT","700.91","73.78","","685.68","685.68","685.68","1 through 10","294.5","755.25","percent of total billed charges",""
"Chemdnrvtn/Dest Nerve Neurlytic Fac","PX-76001571","CDM","64612","CPT","0761","RC","","","","outpatient","","","950.00","712.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","861.23","827.82","861.23","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Chemdnrvtn/Dest Nerve Neurlytic Fac","PX-76001571","CDM","64612","CPT","0761","RC","","","","outpatient","","","950.00","712.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","717.69","717.69","717.69","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Chemdnrvtn/Dest Nerve Neurlytic Fac","PX-76001571","CDM","64612","CPT","0761","RC","","","","outpatient","","","950.00","712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","776.34","81.72","","404.96","404.96","404.96","1 through 10","247.48","1234.13","percent of total billed charges",""
"Chemdnrvtn/Dest Nerve Neurlytic Fac|BILATERAL PROCEDURE","PX-76001571","CDM","64612","CPT","0761","RC","","","50","both","","","950.00","712.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.42","477.13","517.42","1 through 10","333.03","438.15","other","OPPS APC"
"Chemdnrvtn/Dest Nerve Neurlytic Fac|BILATERAL PROCEDURE","PX-76001571","CDM","64612","CPT","0761","RC","","","50","both","","","950.00","712.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.43","344.95","634.38","1 through 10","333.03","438.15","other","OPPS APC"
"Chemdnrvtn/Dest Nerve Neurlytic Fac|BILATERAL PROCEDURE","PX-76001571","CDM","64612","CPT","0761","RC","","","50","both","","","950.00","712.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","484.89","525.83","19","333.03","438.15","other","OPPS APC"
"Chemdnrvtn/Dest Nerve Neurlytic Fac|BILATERAL PROCEDURE","PX-76001571","CDM","64612","CPT","0761","RC","","","50","both","","","950.00","712.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","194.22","194.22","199.71","1 through 10","333.03","438.15","other","OPPS APC"
"Chemdnrvtn/Dest Nerve Neurlytic Fac|BILATERAL PROCEDURE","PX-76001571","CDM","64612","CPT","0761","RC","","","50","both","","","950.00","712.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","475.19","515.32","1 through 10","333.03","438.15","other","OPPS APC"
"Chemdnrvtn/Dest Nerve Neurlytic Fac|BILATERAL PROCEDURE","PX-76001571","CDM","64612","CPT","0761","RC","","","50","both","","","950.00","712.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","191.11","517.43","1 through 10","333.03","438.15","other","OPPS APC"
"Chemdnrvtn/Dest Nerve Neurlytic Fac|BILATERAL PROCEDURE","PX-76001571","CDM","64612","CPT","0761","RC","","","50","outpatient","","","950.00","712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1396.95","852.86","1404.56","24","424.52","2295.49","other","ASC"
"Chemdnrvtn/Dest Nerve Neurlytic Fac|BILATERAL PROCEDURE","PX-76001571","CDM","64612","CPT","0761","RC","","","50","outpatient","","","950.00","712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.74","984.04","1535.74","52","424.52","2295.49","other","ASC "
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","both","","","179.00","134.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","142.31","79.5","","131.20","131.20","131.20","1 through 10","11.02","170.05","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","both","","","179.00","134.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.41","53.3","","91.87","91.87","547.75","1 through 10","11.02","170.05","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.34","36.5","","55.16","55.16","64.90","1 through 10","11.02","170.05","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.56","38.3","","68.04","68.03","204.09","1 through 10","11.02","170.05","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","179.00","134.25","AETNA [1001]","HB AMC AETNA HMO","124.94","69.8","","117.80","117.80","117.80","1 through 10","11.02","146.28","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","179.00","134.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","146.28","81.72","","129.38","129.38","129.38","1 through 10","11.02","146.28","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","179.00","134.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","146.28","81.72","","76.51","76.51","76.51","1 through 10","11.02","146.28","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","179.00","134.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","146.28","81.72","","76.51","53.51","139.10","13","11.02","146.28","percent of total billed charges",""
"Chemo Cns|REDUCED SERVICES","PX-33000086","CDM","96450","CPT","0331","RC","","","52","both","","","2879.00","2159.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","405.68","","APC Price ($393.86). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","202.65","96.51","202.65","1 through 10","374.21","492.33","other","OPPS APC"
"Chemo Intralesional > 7 Lesions","PX-33000004","CDM","96406","CPT","0331","RC","","","","both","","","1607.00","1205.25","MEDICARE [2001]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.21","250.21","500.42","1 through 10","237.7","1277.57","other","OPPS APC"
"Chemo Intralesional > 7 Lesions","PX-33000004","CDM","96406","CPT","0331","RC","","","","both","","","1607.00","1205.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","615.48","38.3","","609.18","609.18","609.18","1 through 10","237.7","1277.57","percent of total billed charges",""
"Chemo Intralesional > 7 Lesions","PX-33000004","CDM","96406","CPT","0331","RC","","","","both","","","1607.00","1205.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","245.21","245.21","245.21","1 through 10","237.7","1277.57","other","OPPS APC"
"Chemo Intralesional > 7 Lesions","PX-33000004","CDM","96406","CPT","0331","RC","","","","outpatient","","","1607.00","1205.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1313.24","81.72","","1245.46","1245.46","1245.46","1 through 10","430.03","1313.24","percent of total billed charges",""
"Chemo Intralesional 1-7 Lesions","PX-33000003","CDM","96405","CPT","0331","RC","","","","both","","","1015.00","761.25","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","1 through 10","80.29","806.93","other","OPPS APC"
"Chemo Intralesional 1-7 Lesions","PX-33000003","CDM","96405","CPT","0331","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","388.75","38.3","","384.74","367.03","747.84","1 through 10","80.29","806.93","percent of total billed charges",""
"Chemo Intralesional 1-7 Lesions","PX-33000003","CDM","96405","CPT","0331","RC","","","","both","","","1015.00","761.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","75.35","75.35","75.35","1 through 10","80.29","806.93","other","OPPS APC"
"Chemo Intralesional 1-7 Lesions","PX-33000003","CDM","96405","CPT","0331","RC","","","","outpatient","","","1015.00","761.25","AETNA [1001]","HB AMC AETNA HMO","708.47","69.8","","666.17","666.17","666.17","1 through 10","137.27","829.46","percent of total billed charges",""
"Chemo Intralesional 1-7 Lesions","PX-33000003","CDM","96405","CPT","0331","RC","","","","outpatient","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","829.46","81.72","","786.61","786.61","786.61","1 through 10","137.27","829.46","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","405.68","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","405.33","405.33","406.13","19","374.21","1765.7","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","393.86","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","387.60","387.60","387.60","30","374.21","1765.7","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1456.98","65.6","","1458.26","1458.26","1458.26","1 through 10","374.21","1765.7","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1765.70","79.5","","1695.20","1137.31","1695.20","19","374.21","1765.7","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1183.79","53.3","","1695.20","1137.31","3411.93","1 through 10","374.21","1765.7","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","393.86","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","387.60","362.24","387.60","35","374.21","1765.7","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","MEDICARE [2001]","HB BWH MEDICARE","393.86","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","393.90","393.90","1108.89","512","374.21","1765.7","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","688.51","31","","1996.77","665.59","1996.77","1 through 10","374.21","1765.7","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","810.67","36.5","","682.82","682.82","803.44","26","374.21","1765.7","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","850.64","38.3","","842.21","818.52","1593.34","57","374.21","1765.7","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","393.86","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","386.02","386.02","1158.06","11","374.21","1765.7","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","TRICARE [160005]","HB BWH TRICARE","374.21","","APC Price ($393.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","393.90","200.90","393.90","1 through 10","374.21","1765.7","other","Tricare OPPS"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","385.98","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","386.02","362.24","724.48","19","374.21","1765.7","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","385.98","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","386.03","362.24","387.60","53","374.21","1765.7","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","2221.00","1665.75","WELLPOINT [1015]","HB AMC WELLPOINT","1638.65","73.78","","1603.65","1603.65","1603.65","23","374.21","1765.7","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","outpatient","","","2221.00","1665.75","AETNA [1001]","HB AMC AETNA HMO","1550.26","69.8","","1369.61","1029.61","1458.26","23","662.53","1954.33","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","outpatient","","","2221.00","1665.75","AETNA [1001]","HB AMC AETNA PPO","1785.68","80.4","","1680.12","1495.73","1680.12","1 through 10","662.53","1954.33","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","outpatient","","","2221.00","1665.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1815.00","81.72","","1721.90","947.11","1721.91","17","662.53","1954.33","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","727.00","545.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","86.97","86.97","86.97","22","80.29","577.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","727.00","545.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","83.17","83.17","83.17","23","80.29","577.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","727.00","545.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","577.97","79.5","","554.84","372.24","554.84","25","80.29","577.97","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","727.00","545.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","387.49","53.3","","1116.72","372.24","1116.72","22","80.29","577.97","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","727.00","545.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","84.51","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","83.17","75.66","83.17","28","80.29","577.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","727.00","545.25","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","230.66","623","80.29","577.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","727.00","545.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","225.37","31","","653.55","653.55","653.55","1 through 10","80.29","577.97","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","727.00","545.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","265.36","36.5","","262.97","223.49","262.97","34","80.29","577.97","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","727.00","545.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","278.44","38.3","","275.66","275.66","275.66","62","80.29","577.97","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","727.00","545.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.83","82.83","82.83","1 through 10","80.29","577.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","727.00","545.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","75.35","150.70","18","80.29","577.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","727.00","545.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","83.17","75.66","83.17","58","80.29","577.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","727.00","545.25","WELLPOINT [1015]","HB AMC WELLPOINT","536.38","73.78","","524.87","524.87","524.87","21","80.29","577.97","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","outpatient","","","727.00","545.25","AETNA [1001]","HB AMC AETNA HMO","507.45","69.8","","448.02","336.99","477.29","66","137.27","594.1","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","outpatient","","","727.00","545.25","AETNA [1001]","HB AMC AETNA PPO","584.51","80.4","","324.11","324.11","324.11","1 through 10","137.27","594.1","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","outpatient","","","727.00","545.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","594.10","81.72","","309.99","309.99","563.58","18","137.27","594.1","percent of total billed charges",""
"Chemodenerv 1 Extrem 1-4 Ea","PX-76001951","CDM","64643","CPT","0761","RC","","","","both","","","2009.00","1506.75","WELLPOINT [1015]","HB AMC WELLPOINT","1482.24","73.78","","1450.29","1450.29","1450.29","1 through 10","622.79","1597.16","percent of total billed charges",""
"Chemodenerv 1 Extrem 1-4 Ea","PX-76001951","CDM","64643","CPT","0761","RC","","","","outpatient","","","2009.00","1506.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1641.75","81.72","","1557.23","1557.23","1557.23","1 through 10","122.3","1641.75","percent of total billed charges",""
"Chemodenerv 1 Extrem 1-4 Ea","PX-98301722","CDM","64643","CPT","0983","RC","","","","both","","","372.00","279.00","WELLPOINT [1015]","HB AMC WELLPOINT","274.46","73.78","","1450.29","1450.29","1450.29","1 through 10","115.32","295.74","percent of total billed charges",""
"Chemodenerv 1 Extrem 1-4 Ea","PX-98301722","CDM","64643","CPT","0983","RC","","","","outpatient","","","372.00","279.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.00","81.72","","1557.23","1557.23","1557.23","1 through 10","207.95","307.12","percent of total billed charges",""
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","both","","","2927.00","2195.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","847.06","847.06","847.06","1 through 10","781.29","2326.97","other","OPPS APC"
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","both","","","2927.00","2195.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","809.25","809.25","1 through 10","781.29","2326.97","other","OPPS APC"
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","both","","","2927.00","2195.25","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","754.77","822.41","27","781.29","2326.97","other","OPPS APC"
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","both","","","2927.00","2195.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1068.36","36.5","","899.65","899.65","899.65","1 through 10","781.29","2326.97","percent of total billed charges",""
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","both","","","2927.00","2195.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","805.96","805.96","805.96","1 through 10","781.29","2326.97","other","OPPS APC"
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","both","","","2927.00","2195.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","805.96","739.67","2417.88","1 through 10","781.29","2326.97","other","OPPS APC"
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","both","","","2927.00","2195.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","806.86","739.67","813.87","1 through 10","781.29","2326.97","other","OPPS APC"
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","both","","","2927.00","2195.25","WELLPOINT [1015]","HB AMC WELLPOINT","2159.54","73.78","","2112.89","2112.89","2112.89","1 through 10","781.29","2326.97","percent of total billed charges",""
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","outpatient","","","2927.00","2195.25","AETNA [1001]","HB AMC AETNA HMO","2043.05","69.8","","1356.56","1356.56","1356.56","1 through 10","598.81","2391.94","percent of total billed charges",""
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","outpatient","","","2927.00","2195.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1401.04","1375.70","1401.04","1 through 10","598.81","2391.94","other","ASC"
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","outpatient","","","2927.00","2195.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1587.30","1587.30","1603.05","13","598.81","2391.94","other","ASC "
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","outpatient","","","2927.00","2195.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1389.24","694.62","1389.24","1 through 10","598.81","2391.94","other","Multiple Surgery"
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","outpatient","","","2927.00","2195.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1461.10","1461.10","2814.40","1 through 10","598.81","2391.94","other","Multiple Surgery"
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","outpatient","","","2927.00","2195.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1532.95","1532.95","1532.95","1 through 10","598.81","2391.94","other","Multiple Surgery"
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","outpatient","","","2927.00","2195.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2353.31","80.4","","2213.64","2213.64","2213.64","1 through 10","598.81","2391.94","percent of total billed charges",""
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","outpatient","","","2927.00","2195.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2391.94","81.72","","2268.70","2268.70","2268.70","1 through 10","598.81","2391.94","percent of total billed charges",""
"Chemodenerv Musc Neck Dyston","PX-76001949","CDM","64616","CPT","0761","RC","","","","both","","","1288.00","966.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1023.96","79.5","","982.96","982.96","982.96","1 through 10","333.03","1023.96","percent of total billed charges",""
"Chemodenerv Musc Neck Dyston","PX-76001949","CDM","64616","CPT","0761","RC","","","","both","","","1288.00","966.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","1 through 10","333.03","1023.96","other","OPPS APC"
"Chemodenerv Musc Neck Dyston","PX-76001949","CDM","64616","CPT","0761","RC","","","","both","","","1288.00","966.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","32","333.03","1023.96","other","OPPS APC"
"Chemodenerv Musc Neck Dyston","PX-76001949","CDM","64616","CPT","0761","RC","","","","both","","","1288.00","966.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","493.30","38.3","","488.36","474.62","488.36","1 through 10","333.03","1023.96","percent of total billed charges",""
"Chemodenerv Musc Neck Dyston","PX-76001949","CDM","64616","CPT","0761","RC","","","","both","","","1288.00","966.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.56","343.55","523.23","24","333.03","1023.96","other","OPPS APC"
"Chemodenerv Musc Neck Dyston","PX-76001949","CDM","64616","CPT","0761","RC","","","","both","","","1288.00","966.00","WELLPOINT [1015]","HB AMC WELLPOINT","950.29","73.78","","929.88","929.88","1119.58","1 through 10","333.03","1023.96","percent of total billed charges",""
"Chemodenerv Musc Neck Dyston","PX-76001949","CDM","64616","CPT","0761","RC","","","","outpatient","","","1288.00","966.00","AETNA [1001]","HB AMC AETNA HMO","899.02","69.8","","845.57","845.57","845.57","1 through 10","247.48","1234.13","percent of total billed charges",""
"Chemodenerv Musc Neck Dyston","PX-76001949","CDM","64616","CPT","0761","RC","","","","outpatient","","","1288.00","966.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","950.33","950.33","950.33","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Chemodenerv Musc Neck Dyston","PX-76001949","CDM","64616","CPT","0761","RC","","","","outpatient","","","1288.00","966.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1052.55","81.72","","998.45","998.45","998.45","1 through 10","247.48","1234.13","percent of total billed charges",""
"Chemodenerv Musc Neck Dyston","PX-98300634","CDM","64616","CPT","0983","RC","","","","both","","","573.00","429.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","455.54","79.5","","982.96","982.96","982.96","1 through 10","177.63","455.54","percent of total billed charges",""
"Chemodenerv Musc Neck Dyston","PX-98300634","CDM","64616","CPT","0983","RC","","","","both","","","573.00","429.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","1 through 10","177.63","455.54","other","OPPS APC"
"Chemodenerv Musc Neck Dyston","PX-98300634","CDM","64616","CPT","0983","RC","","","","both","","","573.00","429.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","32","177.63","455.54","other","OPPS APC"
"Chemodenerv Musc Neck Dyston","PX-98300634","CDM","64616","CPT","0983","RC","","","","both","","","573.00","429.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","219.46","38.3","","488.36","474.62","488.36","1 through 10","177.63","455.54","percent of total billed charges",""
"Chemodenerv Musc Neck Dyston","PX-98300634","CDM","64616","CPT","0983","RC","","","","both","","","573.00","429.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.56","343.55","523.23","24","177.63","455.54","other","OPPS APC"
"Chemodenerv Musc Neck Dyston","PX-98300634","CDM","64616","CPT","0983","RC","","","","both","","","573.00","429.75","WELLPOINT [1015]","HB AMC WELLPOINT","422.76","73.78","","929.88","929.88","1119.58","1 through 10","177.63","455.54","percent of total billed charges",""
"Chemodenerv Musc Neck Dyston","PX-98300634","CDM","64616","CPT","0983","RC","","","","outpatient","","","573.00","429.75","AETNA [1001]","HB AMC AETNA HMO","399.95","69.8","","845.57","845.57","845.57","1 through 10","247.48","1234.13","percent of total billed charges",""
"Chemodenerv Musc Neck Dyston","PX-98300634","CDM","64616","CPT","0983","RC","","","","outpatient","","","573.00","429.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","950.33","950.33","950.33","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Chemodenerv Musc Neck Dyston","PX-98300634","CDM","64616","CPT","0983","RC","","","","outpatient","","","573.00","429.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","468.26","81.72","","998.45","998.45","998.45","1 through 10","247.48","1234.13","percent of total billed charges",""
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-76001949","CDM","64616","CPT","0761","RC","","","50","both","","","1288.00","966.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.42","484.89","2498.00","1 through 10","333.03","438.15","other","OPPS APC"
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-76001949","CDM","64616","CPT","0761","RC","","","50","both","","","1288.00","966.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.43","517.43","517.43","1 through 10","333.03","438.15","other","OPPS APC"
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-76001949","CDM","64616","CPT","0761","RC","","","50","both","","","1288.00","966.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","484.89","525.83","107","333.03","438.15","other","OPPS APC"
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-76001949","CDM","64616","CPT","0761","RC","","","50","both","","","1288.00","966.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1545.93","515.31","1545.93","1 through 10","333.03","438.15","other","OPPS APC"
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-76001949","CDM","64616","CPT","0761","RC","","","50","both","","","1288.00","966.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","475.19","520.06","1 through 10","333.03","438.15","other","OPPS APC"
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-76001949","CDM","64616","CPT","0761","RC","","","50","both","","","1288.00","966.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","523.23","484.20","525.83","1 through 10","333.03","438.15","other","OPPS APC"
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-76001949","CDM","64616","CPT","0761","RC","","","50","outpatient","","","1288.00","966.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","852.86","852.86","868.57","15","424.52","2295.49","other","ASC"
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-76001949","CDM","64616","CPT","0761","RC","","","50","outpatient","","","1288.00","966.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","984.04","984.04","993.80","61","424.52","2295.49","other","ASC "
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-98300634","CDM","64616","CPT","0983","RC","","","50","both","","","573.00","429.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.42","484.89","2498.00","1 through 10","333.03","438.15","other","OPPS APC"
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-98300634","CDM","64616","CPT","0983","RC","","","50","both","","","573.00","429.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.43","517.43","517.43","1 through 10","333.03","438.15","other","OPPS APC"
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-98300634","CDM","64616","CPT","0983","RC","","","50","both","","","573.00","429.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","484.89","525.83","107","333.03","438.15","other","OPPS APC"
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-98300634","CDM","64616","CPT","0983","RC","","","50","both","","","573.00","429.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1545.93","515.31","1545.93","1 through 10","333.03","438.15","other","OPPS APC"
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-98300634","CDM","64616","CPT","0983","RC","","","50","both","","","573.00","429.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","475.19","520.06","1 through 10","333.03","438.15","other","OPPS APC"
"Chemodenerv Musc Neck Dyston|BILATERAL PROCEDURE","PX-98300634","CDM","64616","CPT","0983","RC","","","50","both","","","573.00","429.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","523.23","484.20","525.83","1 through 10","333.03","438.15","other","OPPS APC"
"Chemodenerv Saliv Glands Bilateral","PX-76001570","CDM","64611","CPT","0761","RC","","","","both","","","709.00","531.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","1 through 10","219.79","563.66","other","OPPS APC"
"Chemodenerv Saliv Glands Bilateral","PX-76001570","CDM","64611","CPT","0761","RC","","","","both","","","709.00","531.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","258.79","36.5","","256.62","249.06","256.62","1 through 10","219.79","563.66","percent of total billed charges",""
"Chemodenerv Saliv Glands Bilateral","PX-76001570","CDM","64611","CPT","0761","RC","","","","both","","","709.00","531.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.15","350.15","350.15","1 through 10","219.79","563.66","other","OPPS APC"
"Chemodenerv Saliv Glands Bilateral","PX-76001570","CDM","64611","CPT","0761","RC","","","","outpatient","","","709.00","531.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","331.27","331.26","656.02","1 through 10","247.48","700.33","other","ASC "
"Chemodenerv Trunk Musc 1-5","PX-76001952","CDM","64646","CPT","0761","RC","","","","both","","","2009.00","1506.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1597.16","79.5","","1533.08","1533.08","1533.08","1 through 10","622.79","1597.16","percent of total billed charges",""
"Chemodenerv Trunk Musc 1-5","PX-76001952","CDM","64646","CPT","0761","RC","","","","both","","","2009.00","1506.75","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","754.77","822.41","1 through 10","622.79","1597.16","other","OPPS APC"
"Chemodenerv Trunk Musc 1-5","PX-76001952","CDM","64646","CPT","0761","RC","","","","both","","","2009.00","1506.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1546.93","77","","6760.86","6760.86","6760.86","1 through 10","622.79","1597.16","percent of total billed charges",""
"Chemodenerv Trunk Musc 1-5","PX-76001952","CDM","64646","CPT","0761","RC","","","","outpatient","","","2009.00","1506.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1603.05","1587.30","1603.05","1 through 10","598.81","1641.75","other","ASC "
"Chemodenerv Trunk Musc 1-5","PX-98300632","CDM","64646","CPT","0983","RC","","","","both","","","599.00","449.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","476.21","79.5","","1533.08","1533.08","1533.08","1 through 10","185.69","1027.91","percent of total billed charges",""
"Chemodenerv Trunk Musc 1-5","PX-98300632","CDM","64646","CPT","0983","RC","","","","both","","","599.00","449.25","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","754.77","822.41","1 through 10","185.69","1027.91","other","OPPS APC"
"Chemodenerv Trunk Musc 1-5","PX-98300632","CDM","64646","CPT","0983","RC","","","","both","","","599.00","449.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","461.23","77","","6760.86","6760.86","6760.86","1 through 10","185.69","1027.91","percent of total billed charges",""
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","both","","","932.00","699.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","288.92","740.94","other","OPPS APC"
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","both","","","932.00","699.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","288.92","740.94","other","OPPS APC"
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","both","","","932.00","699.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","496.76","53.3","","477.31","477.31","477.31","1 through 10","288.92","740.94","percent of total billed charges",""
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","both","","","932.00","699.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","288.92","740.94","other","OPPS APC"
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","both","","","932.00","699.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","288.92","740.94","other","OPPS APC"
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","both","","","932.00","699.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","340.18","36.5","","1095.87","337.19","1095.87","1 through 10","288.92","740.94","percent of total billed charges",""
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","both","","","932.00","699.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","356.96","38.3","","343.52","323.76","353.46","1 through 10","288.92","740.94","percent of total billed charges",""
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","both","","","932.00","699.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","288.92","740.94","other","Tricare OPPS"
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","both","","","932.00","699.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","288.92","740.94","other","OPPS APC"
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","both","","","932.00","699.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","288.92","740.94","other","OPPS APC"
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","both","","","932.00","699.00","WELLPOINT [1015]","HB AMC WELLPOINT","687.63","73.78","","673.03","673.03","673.03","1 through 10","288.92","740.94","percent of total billed charges",""
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","outpatient","","","932.00","699.00","AETNA [1001]","HB AMC AETNA HMO","650.54","69.8","","612.01","612.01","1224.02","1 through 10","466","768.9","percent of total billed charges",""
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","outpatient","","","932.00","699.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","564.33","60.55","","579.04","568.57","904.00","30","466","768.9","percent of total billed charges",""
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","outpatient","","","932.00","699.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","486.69","52.22","","904.00","656.02","2938.00","26","466","768.9","percent of total billed charges",""
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","outpatient","","","932.00","699.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","466.00","50","","1421.10","875.08","2368.50","15","466","768.9","percent of total billed charges",""
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","outpatient","","","932.00","699.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","489.30","52.5","","2985.00","904.00","2985.00","1 through 10","466","768.9","percent of total billed charges",""
"Chemodenerv, Hands and Feet","PX-76002099","CDM","64999","CPT","0761","RC","","","","outpatient","","","932.00","699.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","761.63","81.72","","722.66","722.66","17449.00","1 through 10","466","768.9","percent of total billed charges",""
"Chemodenervation 1 Extremity 5 or More Muscles","PX-76001967","CDM","64644","CPT","0761","RC","","","","both","","","2009.00","1506.75","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","754.77","2467.23","12","622.79","1597.16","other","OPPS APC"
"Chemodenervation 1 Extremity 5 or More Muscles","PX-76001967","CDM","64644","CPT","0761","RC","","","","both","","","2009.00","1506.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","733.29","36.5","","617.52","617.52","617.52","1 through 10","622.79","1597.16","percent of total billed charges",""
"Chemodenervation 1 Extremity 5 or More Muscles","PX-76001967","CDM","64644","CPT","0761","RC","","","","both","","","2009.00","1506.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3698.35","805.96","3698.35","1 through 10","622.79","1597.16","other","OPPS APC"
"Chemodenervation 1 Extremity 5 or More Muscles","PX-76001967","CDM","64644","CPT","0761","RC","","","","both","","","2009.00","1506.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","809.25","809.25","809.25","1 through 10","622.79","1597.16","other","OPPS APC"
"Chemodenervation 1 Extremity 5 or More Muscles","PX-76001967","CDM","64644","CPT","0761","RC","","","","outpatient","","","2009.00","1506.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1375.70","1375.70","1401.04","1 through 10","598.81","1641.75","other","ASC"
"Chemodenervation 1 Extremity 5 or More Muscles","PX-76001967","CDM","64644","CPT","0761","RC","","","","outpatient","","","2009.00","1506.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1389.24","1389.24","1389.24","1 through 10","598.81","1641.75","other","Multiple Surgery"
"Chemodenervation 1 Extremity 5 or More Muscles","PX-76001967","CDM","64644","CPT","0761","RC","","","","outpatient","","","2009.00","1506.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1532.95","1532.95","1532.95","1 through 10","598.81","1641.75","other","Multiple Surgery"
"Chemodenervation 1 Extremity 5 or More Muscles","PX-98301678","CDM","64644","CPT","0983","RC","","","","both","","","608.00","456.00","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","754.77","2467.23","12","188.48","1027.91","other","OPPS APC"
"Chemodenervation 1 Extremity 5 or More Muscles","PX-98301678","CDM","64644","CPT","0983","RC","","","","both","","","608.00","456.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","221.92","36.5","","617.52","617.52","617.52","1 through 10","188.48","1027.91","percent of total billed charges",""
"Chemodenervation 1 Extremity 5 or More Muscles","PX-98301678","CDM","64644","CPT","0983","RC","","","","both","","","608.00","456.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3698.35","805.96","3698.35","1 through 10","188.48","1027.91","other","OPPS APC"
"Chemodenervation 1 Extremity 5 or More Muscles","PX-98301678","CDM","64644","CPT","0983","RC","","","","both","","","608.00","456.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","809.25","809.25","809.25","1 through 10","188.48","1027.91","other","OPPS APC"
"Chemodenervation 1 Extremity 5 or More Muscles","PX-98301678","CDM","64644","CPT","0983","RC","","","","outpatient","","","608.00","456.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1389.24","1389.24","1389.24","1 through 10","339.87","1234.13","other","Multiple Surgery"
"Chemodenervation 1 Extremity 5 or More Muscles","PX-98301678","CDM","64644","CPT","0983","RC","","","","outpatient","","","608.00","456.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1532.95","1532.95","1532.95","1 through 10","339.87","1234.13","other","Multiple Surgery"
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","both","","","215.00","161.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","360.73","360.73","1 through 10","66.65","438.15","other","OPPS APC"
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","both","","","215.00","161.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","170.93","79.5","","428.95","428.95","428.95","1 through 10","66.65","438.15","percent of total billed charges",""
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","both","","","215.00","161.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","114.60","53.3","","320.50","320.50","913.54","1 through 10","66.65","438.15","percent of total billed charges",""
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","both","","","215.00","161.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","209.05","344.95","1 through 10","66.65","438.15","other","OPPS APC"
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","both","","","215.00","161.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","13","66.65","438.15","other","OPPS APC"
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","both","","","215.00","161.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.48","36.5","","226.41","192.42","226.41","11","66.65","438.15","percent of total billed charges",""
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","both","","","215.00","161.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82.35","38.3","","237.34","230.66","237.34","51","66.65","438.15","percent of total billed charges",""
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","both","","","215.00","161.25","WELLPOINT [1015]","HB AMC WELLPOINT","158.63","73.78","","451.91","451.91","451.91","1 through 10","66.65","438.15","percent of total billed charges",""
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","outpatient","","","215.00","161.25","AETNA [1001]","HB AMC AETNA HMO","150.07","69.8","","410.94","410.94","1017.94","1 through 10","120.19","1234.13","percent of total billed charges",""
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","outpatient","","","215.00","161.25","AETNA [1001]","HB AMC AETNA PPO","172.86","80.4","","473.46","473.46","473.46","1 through 10","120.19","1234.13","percent of total billed charges",""
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","outpatient","","","215.00","161.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","574.15","551.88","574.15","20","120.19","1234.13","other","Multiple Surgery"
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","outpatient","","","215.00","161.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","603.85","581.58","1163.16","1 through 10","120.19","1234.13","other","Multiple Surgery"
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","outpatient","","","215.00","161.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","279.81","262.12","279.81","1 through 10","120.19","1234.13","other","Multiple Surgery"
"Chemodenervation Eccrine Glands Both Axillae","PX-98301725","CDM","64650","CPT","0983","RC","","","","outpatient","","","215.00","161.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","175.70","81.72","","485.24","485.24","1451.58","1 through 10","120.19","1234.13","percent of total billed charges",""
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","both","","","626.00","469.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","360.73","360.73","1 through 10","194.06","497.67","other","OPPS APC"
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","both","","","626.00","469.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","497.67","79.5","","428.95","428.95","428.95","1 through 10","194.06","497.67","percent of total billed charges",""
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","both","","","626.00","469.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","333.66","53.3","","320.50","320.50","913.54","1 through 10","194.06","497.67","percent of total billed charges",""
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","both","","","626.00","469.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","209.05","344.95","1 through 10","194.06","497.67","other","OPPS APC"
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","both","","","626.00","469.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","13","194.06","497.67","other","OPPS APC"
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.49","36.5","","226.41","192.42","226.41","11","194.06","497.67","percent of total billed charges",""
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.76","38.3","","237.34","230.66","237.34","51","194.06","497.67","percent of total billed charges",""
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","both","","","626.00","469.50","WELLPOINT [1015]","HB AMC WELLPOINT","461.86","73.78","","451.91","451.91","451.91","1 through 10","194.06","497.67","percent of total billed charges",""
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","outpatient","","","626.00","469.50","AETNA [1001]","HB AMC AETNA HMO","436.95","69.8","","410.94","410.94","1017.94","1 through 10","247.48","1234.13","percent of total billed charges",""
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","outpatient","","","626.00","469.50","AETNA [1001]","HB AMC AETNA PPO","503.30","80.4","","473.46","473.46","473.46","1 through 10","247.48","1234.13","percent of total billed charges",""
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","outpatient","","","626.00","469.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","568.57","568.57","579.04","35","247.48","1234.13","other","ASC"
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","outpatient","","","626.00","469.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","656.02","656.02","662.53","75","247.48","1234.13","other","ASC "
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","outpatient","","","626.00","469.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","574.15","551.88","574.15","20","247.48","1234.13","other","Multiple Surgery"
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","outpatient","","","626.00","469.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","603.85","581.58","1163.16","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","outpatient","","","626.00","469.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","279.81","262.12","279.81","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Chemodenervation Eccrine Glnd Both","PX-76001590","CDM","64650","CPT","0761","RC","","","","outpatient","","","626.00","469.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","511.57","81.72","","485.24","485.24","1451.58","1 through 10","247.48","1234.13","percent of total billed charges",""
"Chemodenervation Eccrine Glnd O/A","PX-76001591","CDM","64653","CPT","0761","RC","","","","both","","","411.00","308.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","127.41","438.15","other","OPPS APC"
"Chemodenervation Eccrine Glnd O/A","PX-76001591","CDM","64653","CPT","0761","RC","","","","outpatient","","","411.00","308.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","662.53","331.26","662.53","1 through 10","214.79","1234.13","other","ASC "
"Chemodenervation Internal Anal Sph","PX-75000222","CDM","46505","CPT","0761","RC","","","","both","","","5043.00","3782.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2687.92","53.3","","4403.52","4403.52","4403.52","1 through 10","1330.22","4009.19","percent of total billed charges",""
"Chemodenervation Internal Anal Sph","PX-75000222","CDM","46505","CPT","0761","RC","","","","both","","","5043.00","3782.25","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","1330.22","4009.19","other","OPPS APC"
"Chemodenervation Internal Anal Sph","PX-75000222","CDM","46505","CPT","0761","RC","","","","both","","","5043.00","3782.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1840.70","36.5","","2643.78","2643.78","2643.78","1 through 10","1330.22","4009.19","percent of total billed charges",""
"Chemodenervation Internal Anal Sph","PX-75000222","CDM","46505","CPT","0761","RC","","","","both","","","5043.00","3782.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1931.47","38.3","","1630.47","1630.47","1630.47","1 through 10","1330.22","4009.19","percent of total billed charges",""
"Chemodenervation Internal Anal Sph","PX-75000222","CDM","46505","CPT","0761","RC","","","","outpatient","","","5043.00","3782.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4121.14","81.72","","8085.53","6667.00","8085.53","1 through 10","979.79","5545.35","percent of total billed charges",""
"Chemodenervation Internal Anal Sph|BILATERAL PROCEDURE","PX-75000222","CDM","46505","CPT","0761","RC","","","50","outpatient","","","5043.00","3782.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1680.68","","Case rate ($1,680.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3934.47","3895.82","3934.47","1 through 10","1680.68","10314.36","other","ASC "
"Chemodenervation of Trunk 6 or More Muscles","PX-76001969","CDM","64647","CPT","0761","RC","","","","outpatient","","","2869.00","2151.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1603.05","1603.05","1603.05","1 through 10","598.81","2344.55","other","ASC "
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","both","","","939.00","704.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","291.09","746.51","other","OPPS APC"
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","both","","","939.00","704.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","291.09","746.51","other","OPPS APC"
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","both","","","939.00","704.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","500.49","53.3","","477.31","477.31","477.31","1 through 10","291.09","746.51","percent of total billed charges",""
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","both","","","939.00","704.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","291.09","746.51","other","OPPS APC"
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","both","","","939.00","704.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","291.09","746.51","other","OPPS APC"
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","both","","","939.00","704.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","342.74","36.5","","1095.87","337.19","1095.87","1 through 10","291.09","746.51","percent of total billed charges",""
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","both","","","939.00","704.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","359.64","38.3","","343.52","323.76","353.46","1 through 10","291.09","746.51","percent of total billed charges",""
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","both","","","939.00","704.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","291.09","746.51","other","Tricare OPPS"
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","both","","","939.00","704.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","291.09","746.51","other","OPPS APC"
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","both","","","939.00","704.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","291.09","746.51","other","OPPS APC"
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","both","","","939.00","704.25","WELLPOINT [1015]","HB AMC WELLPOINT","692.79","73.78","","673.03","673.03","673.03","1 through 10","291.09","746.51","percent of total billed charges",""
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","outpatient","","","939.00","704.25","AETNA [1001]","HB AMC AETNA HMO","655.42","69.8","","612.01","612.01","1224.02","1 through 10","469.5","774.68","percent of total billed charges",""
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","outpatient","","","939.00","704.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","568.56","60.55","","579.04","568.57","904.00","30","469.5","774.68","percent of total billed charges",""
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","outpatient","","","939.00","704.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","490.35","52.22","","904.00","656.02","2938.00","26","469.5","774.68","percent of total billed charges",""
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","outpatient","","","939.00","704.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","469.50","50","","1421.10","875.08","2368.50","15","469.5","774.68","percent of total billed charges",""
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","outpatient","","","939.00","704.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","492.98","52.5","","2985.00","904.00","2985.00","1 through 10","469.5","774.68","percent of total billed charges",""
"Chemodenervation Residual Limb","PX-76002980","CDM","64999","CPT","0761","RC","","","","outpatient","","","939.00","704.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","767.35","81.72","","722.66","722.66","17449.00","1 through 10","469.5","774.68","percent of total billed charges",""
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","748.67","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","705.35","374.01","749.55","17","505.3","1295.85","other","OPPS APC"
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","536.49","357.65","715.31","28","505.3","1295.85","other","OPPS APC"
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1141.00","70","","1581.00","1581.00","1581.00","1 through 10","505.3","1295.85","percent of total billed charges",""
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1295.85","79.5","","4792.84","834.77","4792.84","1 through 10","505.3","1295.85","percent of total billed charges",""
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","868.79","53.3","","2596.71","1244.25","2596.71","1 through 10","505.3","1295.85","percent of total billed charges",""
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","357.66","357.66","671.76","1 through 10","505.3","1295.85","other","OPPS APC"
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","HUMANA [1012]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","358.38","358.38","358.38","1 through 10","505.3","1295.85","other","OPPS APC"
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1295.85","79.5","","1244.25","1244.25","1244.25","1 through 10","505.3","1295.85","percent of total billed charges",""
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","363.47","726.94","380","505.3","1295.85","other","OPPS APC"
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","594.95","36.5","","589.71","572.32","589.71","1 through 10","505.3","1295.85","percent of total billed charges",""
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","624.29","38.3","","618.17","589.71","1854.51","12","505.3","1295.85","percent of total billed charges",""
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","712.40","534.30","712.40","1 through 10","505.3","1295.85","other","OPPS APC"
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","712.33","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","712.40","356.20","712.40","1 through 10","505.3","1295.85","other","OPPS APC"
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","699.27","42.9","","719.36","695.17","719.36","1 through 10","505.3","1295.85","percent of total billed charges",""
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","712.33","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","671.77","335.89","720.31","37","505.3","1295.85","other","OPPS APC"
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","both","","","1630.00","1222.50","WELLPOINT [1015]","HB AMC WELLPOINT","1202.61","73.78","","1177.05","1177.05","1177.06","1 through 10","505.3","1295.85","percent of total billed charges",""
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","outpatient","","","1630.00","1222.50","AETNA [1001]","HB AMC AETNA HMO","1137.74","69.8","","1070.34","755.72","1233.18","11","482.89","1332.04","percent of total billed charges",""
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","outpatient","","","1630.00","1222.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","554.70","376.61","1129.82","25","482.89","1332.04","other","ASC"
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","outpatient","","","1630.00","1222.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","851.84","52.26","","978.33","489.16","978.33","1 through 10","482.89","1332.04","percent of total billed charges",""
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","outpatient","","","1630.00","1222.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1280.02","640.01","1292.72","35","482.89","1332.04","other","ASC "
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","outpatient","","","1630.00","1222.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1680.45","560.15","3360.90","16","482.89","1332.04","other","Multiple Surgery"
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","outpatient","","","1630.00","1222.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3534.75","1178.25","3534.75","1 through 10","482.89","1332.04","other","Multiple Surgery"
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","outpatient","","","1630.00","1222.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1236.20","1235.50","1236.20","1 through 10","482.89","1332.04","other","Multiple Surgery"
"Chemosurg/Mohs 1st Stage T/a/L < 5","PX-76000237","CDM","17313","CPT","0761","RC","","","","outpatient","","","1630.00","1222.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1332.04","81.72","","1263.85","695.17","1263.85","1 through 10","482.89","1332.04","percent of total billed charges",""
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","748.67","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","561.02","374.01","748.02","47","561.41","1439.75","other","OPPS APC"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","715.31","357.65","715.31","74","561.41","1439.75","other","OPPS APC"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1267.70","70","","1745.02","74.26","1745.02","1 through 10","561.41","1439.75","percent of total billed charges",""
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","908.58","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","674.51","674.51","674.51","1 through 10","561.41","1439.75","other","OPPS APC"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","CHAMPVA [160001]","HB BWH TRICARE","690.59","","APC Price ($726.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","726.94","726.94","726.94","1 through 10","561.41","1439.75","other","Tricare OPPS"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1439.75","79.5","","1381.97","1381.97","1381.97","13","561.41","1439.75","percent of total billed charges",""
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","965.26","53.3","","1381.97","927.17","2160.58","1 through 10","561.41","1439.75","percent of total billed charges",""
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","586.43","357.65","715.31","1 through 10","561.41","1439.75","other","OPPS APC"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","357.65","357.65","357.65","1 through 10","561.41","1439.75","other","OPPS APC"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","HUMANA [1012]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","716.76","358.38","719.67","1 through 10","561.41","1439.75","other","OPPS APC"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1177.15","65","","1141.40","930.68","2282.80","1 through 10","561.41","1439.75","percent of total billed charges",""
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","356.20","356.20","356.20","1 through 10","561.41","1439.75","other","OPPS APC"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","363.47","726.94","959","561.41","1439.75","other","OPPS APC"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","561.41","31","","1085.20","542.60","1085.20","1 through 10","561.41","1439.75","percent of total billed charges",""
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","661.02","36.5","","654.99","635.67","654.99","11","561.41","1439.75","percent of total billed charges",""
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","693.61","38.3","","686.60","667.28","2059.80","35","561.41","1439.75","percent of total billed charges",""
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","712.40","356.20","712.40","20","561.41","1439.75","other","OPPS APC"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","712.33","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","712.40","356.20","1781.00","35","561.41","1439.75","other","OPPS APC"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","776.92","42.9","","1403.74","772.11","1403.74","1 through 10","561.41","1439.75","percent of total billed charges",""
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","712.33","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","712.40","356.21","717.95","91","561.41","1439.75","other","OPPS APC"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","both","","","1811.00","1358.25","WELLPOINT [1015]","HB AMC WELLPOINT","1336.16","73.78","","1307.34","1307.34","1307.34","14","561.41","1439.75","percent of total billed charges",""
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","outpatient","","","1811.00","1358.25","AETNA [1001]","HB AMC AETNA HMO","1264.08","69.8","","1188.81","1188.81","1369.68","22","482.89","1479.95","percent of total billed charges",""
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","outpatient","","","1811.00","1358.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1109.39","376.61","1129.82","94","482.89","1479.95","other","ASC"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","outpatient","","","1811.00","1358.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","946.43","52.26","","1086.62","543.31","1086.62","1 through 10","482.89","1479.95","percent of total billed charges",""
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","outpatient","","","1811.00","1358.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1280.02","640.01","1292.72","166","482.89","1479.95","other","ASC "
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","outpatient","","","1811.00","1358.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1236.20","700.19","1400.38","1 through 10","482.89","1479.95","other","Multiple Surgery"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","outpatient","","","1811.00","1358.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1120.30","560.15","3360.90","55","482.89","1479.95","other","Multiple Surgery"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","outpatient","","","1811.00","1358.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1178.25","589.13","1767.39","16","482.89","1479.95","other","Multiple Surgery"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","outpatient","","","1811.00","1358.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1400.38","700.19","1400.38","1 through 10","482.89","1479.95","other","Multiple Surgery"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","outpatient","","","1811.00","1358.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1096.16","1096.16","1096.16","1 through 10","482.89","1479.95","other","Multiple Surgery"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","outpatient","","","1811.00","1358.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","745.00","618.10","1236.20","11","482.89","1479.95","other","Multiple Surgery"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","outpatient","","","1811.00","1358.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1456.04","80.4","","1369.68","878.00","1369.68","13","482.89","1479.95","percent of total billed charges",""
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","outpatient","","","1811.00","1358.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1236.20","1236.20","1236.20","1 through 10","482.89","1479.95","other","Multiple Surgery"
"Chemosurg/Mohs 1st Stg H/N/Hf/G <5","PX-76000235","CDM","17311","CPT","0761","RC","","","","outpatient","","","1811.00","1358.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1479.95","81.72","","1403.75","772.11","1756.00","29","482.89","1479.95","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl H/N/Hf/G <5","PX-76000236","CDM","17312","CPT","0761","RC","","","","both","","","966.00","724.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","767.97","79.5","","737.42","494.74","737.42","1 through 10","299.46","767.97","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl H/N/Hf/G <5","PX-76000236","CDM","17312","CPT","0761","RC","","","","both","","","966.00","724.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","514.88","53.3","","494.74","494.74","494.74","1 through 10","299.46","767.97","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl H/N/Hf/G <5","PX-76000236","CDM","17312","CPT","0761","RC","","","","both","","","966.00","724.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","627.90","65","","609.05","496.61","609.05","1 through 10","299.46","767.97","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl H/N/Hf/G <5","PX-76000236","CDM","17312","CPT","0761","RC","","","","both","","","966.00","724.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","299.46","31","","579.06","579.06","579.06","1 through 10","299.46","767.97","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl H/N/Hf/G <5","PX-76000236","CDM","17312","CPT","0761","RC","","","","both","","","966.00","724.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","352.59","36.5","","349.50","349.50","349.50","1 through 10","299.46","767.97","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl H/N/Hf/G <5","PX-76000236","CDM","17312","CPT","0761","RC","","","","both","","","966.00","724.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","369.98","38.3","","366.37","366.37","1099.11","14","299.46","767.97","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl H/N/Hf/G <5","PX-76000236","CDM","17312","CPT","0761","RC","","","","both","","","966.00","724.50","WELLPOINT [1015]","HB AMC WELLPOINT","712.71","73.78","","697.60","697.60","697.60","1 through 10","299.46","767.97","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl H/N/Hf/G <5","PX-76000236","CDM","17312","CPT","0761","RC","","","","outpatient","","","966.00","724.50","AETNA [1001]","HB AMC AETNA HMO","674.27","69.8","","634.35","634.35","1268.70","12","340.41","789.42","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl H/N/Hf/G <5","PX-76000236","CDM","17312","CPT","0761","RC","","","","outpatient","","","966.00","724.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","340.41","","Case rate ($340.41). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","789.07","789.07","789.07","1 through 10","340.41","789.42","other","ASC"
"Chemosurg/Mohs Ea Addl H/N/Hf/G <5","PX-76000236","CDM","17312","CPT","0761","RC","","","","outpatient","","","966.00","724.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","504.83","52.26","","579.82","579.82","579.82","1 through 10","340.41","789.42","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl H/N/Hf/G <5","PX-76000236","CDM","17312","CPT","0761","RC","","","","outpatient","","","966.00","724.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","340.41","","Case rate ($340.41). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","937.00","937.00","937.00","1 through 10","340.41","789.42","other","ASC "
"Chemosurg/Mohs Ea Addl H/N/Hf/G <5","PX-76000236","CDM","17312","CPT","0761","RC","","","","outpatient","","","966.00","724.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","776.66","80.4","","730.86","468.50","730.86","1 through 10","340.41","789.42","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl H/N/Hf/G <5","PX-76000236","CDM","17312","CPT","0761","RC","","","","outpatient","","","966.00","724.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","789.42","81.72","","749.04","412.00","749.04","1 through 10","340.41","789.42","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl Stg T/a/L <5","PX-76000238","CDM","17314","CPT","0761","RC","","","","both","","","1270.00","952.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1009.65","79.5","","969.58","969.58","969.58","1 through 10","393.7","1009.65","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl Stg T/a/L <5","PX-76000238","CDM","17314","CPT","0761","RC","","","","both","","","1270.00","952.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","676.91","53.3","","2786.27","2786.27","2786.27","1 through 10","393.7","1009.65","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl Stg T/a/L <5","PX-76000238","CDM","17314","CPT","0761","RC","","","","both","","","1270.00","952.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","463.55","36.5","","445.98","445.98","445.98","1 through 10","393.7","1009.65","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl Stg T/a/L <5","PX-76000238","CDM","17314","CPT","0761","RC","","","","both","","","1270.00","952.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","486.41","38.3","","481.71","459.54","481.71","1 through 10","393.7","1009.65","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl Stg T/a/L <5","PX-76000238","CDM","17314","CPT","0761","RC","","","","both","","","1270.00","952.50","WELLPOINT [1015]","HB AMC WELLPOINT","937.01","73.78","","917.22","917.22","917.22","1 through 10","393.7","1009.65","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl Stg T/a/L <5","PX-76000238","CDM","17314","CPT","0761","RC","","","","outpatient","","","1270.00","952.50","AETNA [1001]","HB AMC AETNA HMO","886.46","69.8","","834.06","588.90","960.96","1 through 10","315.61","1037.84","percent of total billed charges",""
"Chemosurg/Mohs Ea Addl Stg T/a/L <5","PX-76000238","CDM","17314","CPT","0761","RC","","","","outpatient","","","1270.00","952.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1037.84","81.72","","541.71","541.71","541.71","1 through 10","315.61","1037.84","percent of total billed charges",""
"Chemotherapy Administration Intralesional","PX-98301677","CDM","96405","CPT","0983","RC","","","","both","","","127.00","95.25","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","1 through 10","39.37","105.64","other","OPPS APC"
"Chemotherapy Administration Intralesional","PX-98301677","CDM","96405","CPT","0983","RC","","","","both","","","127.00","95.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48.64","38.3","","384.74","367.03","747.84","1 through 10","39.37","105.64","percent of total billed charges",""
"Chemotherapy Administration Intralesional","PX-98301677","CDM","96405","CPT","0983","RC","","","","both","","","127.00","95.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","75.35","75.35","75.35","1 through 10","39.37","105.64","other","OPPS APC"
"Chemotherapy Administration Intralesional","PX-98301677","CDM","96405","CPT","0983","RC","","","","outpatient","","","127.00","95.25","AETNA [1001]","HB AMC AETNA HMO","88.65","69.8","","666.17","666.17","666.17","1 through 10","70.99","331.08","percent of total billed charges",""
"Chemotherapy Administration Intralesional","PX-98301677","CDM","96405","CPT","0983","RC","","","","outpatient","","","127.00","95.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","103.78","81.72","","786.61","786.61","786.61","1 through 10","70.99","331.08","percent of total billed charges",""
"Chemotherapy For Acute Leukemia,EXTREME","695","DRG","","","","","","","","inpatient","","","286232.76","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","158102.21","","Standard inlier is a Case rate ($158,102.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $134,594, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($22,443.56) for the length of stay and the standard reimbursement.","158102.21","158102.21","164750.99","1 through 10","14330.98","221471.54","case rate",""
"Chemotherapy For Acute Leukemia,EXTREME","695","DRG","","","","","","","","inpatient","","","286232.76","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","177749.50","","Standard inlier is a Case rate ($177,749.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $134,594, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($25,230.06) for the length of stay and the standard reimbursement.","162389.51","162389.51","315875.65","1 through 10","14330.98","221471.54","case rate",""
"Chemotherapy For Acute Leukemia,EXTREME","695","DRG","","","","","","","","inpatient","","","286232.76","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","69183.97","","Case rate ($76,494.77). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $118,924.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","170559.44","170559.44","170559.44","1 through 10","14330.98","221471.54","case rate",""
"Chemotherapy For Acute Leukemia,MAJOR","695","DRG","","","","","","","","inpatient","","","86294.87","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","50953.25","","Standard inlier is a Case rate ($50,953.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $51,271, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,233.12) for the length of stay and the standard reimbursement.","52334.95","50953.24","75492.34","1 through 10","14330.98","221471.54","case rate",""
"Chemotherapy For Acute Leukemia,MAJOR","695","DRG","","","","","","","","inpatient","","","86294.87","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","57285.18","","Standard inlier is a Case rate ($57,285.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $51,271, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,131.16) for the length of stay and the standard reimbursement.","57285.18","57285.18","57285.18","1 through 10","14330.98","221471.54","case rate",""
"Chemotherapy For Acute Leukemia,MAJOR","695","DRG","","","","","","","","inpatient","","","86294.87","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","28749.93","","Case rate ($31,787.98). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $74,217.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","14330.98","221471.54","case rate",""
"Chemotherapy For Acute Leukemia,MAJOR","695","DRG","","","","","","","","inpatient","","","86294.87","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","28749.93","","Case rate ($31,787.98). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $74,217.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31780.18","31780.18","31780.18","1 through 10","14330.98","221471.54","case rate",""
"Chemotherapy For Acute Leukemia,MODERATE","695","DRG","","","","","","","","inpatient","","","41548.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24368.94","","Standard inlier is a Case rate ($24,368.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,597, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,459.32) for the length of stay and the standard reimbursement.","25029.76","25029.76","25029.76","1 through 10","14330.98","221471.54","case rate",""
"Chemotherapy For Acute Leukemia,MODERATE","695","DRG","","","","","","","","inpatient","","","41548.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","27397.26","","Standard inlier is a Case rate ($27,397.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,597, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,888.81) for the length of stay and the standard reimbursement.","27397.26","27397.26","27397.26","1 through 10","14330.98","221471.54","case rate",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With McC","837","MS-DRG","","","","","","","","inpatient","","","133390.24","100042.68","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","55256.46","","Case rate ($44,205.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $53,136.90, add-ons for qualifying new technology services are included. If operating cost exceeds $98,781.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,305.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $39,959.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,757.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,865.82. The transfer capital threshold is the transfer adjustment factor * $3,865.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","38783.28","38783.28","38783.28","1 through 10","43321.07","75254.56","other","Inpatient DRG"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With McC","837","MS-DRG","","","","","","","","inpatient","","","133390.24","100042.68","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","44205.17","","Case rate ($44,205.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $53,136.90, add-ons for qualifying new technology services are included. If operating cost exceeds $98,781.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,305.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $39,959.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,757.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,865.82. The transfer capital threshold is the transfer adjustment factor * $3,865.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","174819.73","174819.73","174819.73","1 through 10","43321.07","75254.56","other","Inpatient Replacement Plans DRG"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With McC","837","MS-DRG","","","","","","","","inpatient","","","133390.24","100042.68","MARTIN'S POINT [160007]","HB BWH MEDICARE","44205.17","","Case rate ($44,205.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $53,136.90, add-ons for qualifying new technology services are included. If operating cost exceeds $98,781.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,305.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $39,959.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,757.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,865.82. The transfer capital threshold is the transfer adjustment factor * $3,865.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","74638.56","74638.56","74638.56","1 through 10","43321.07","75254.56","other","Inpatient Replacement Plans DRG"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With McC","837","MS-DRG","","","","","","","","inpatient","","","133390.24","100042.68","MEDICARE [2001]","HB BWH MEDICARE","44205.17","","Case rate ($44,205.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $53,136.90, add-ons for qualifying new technology services are included. If operating cost exceeds $98,781.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,305.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $39,959.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,757.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,865.82. The transfer capital threshold is the transfer adjustment factor * $3,865.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","59397.24","59308.94","112343.02","34","43321.07","75254.56","other","Inpatient Replacement Plans DRG"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With McC","837","MS-DRG","","","","","","","","inpatient","","","133390.24","100042.68","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","43321.07","","Case rate ($44,205.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $53,136.90, add-ons for qualifying new technology services are included. If operating cost exceeds $98,781.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,305.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $39,959.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,757.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,865.82. The transfer capital threshold is the transfer adjustment factor * $3,865.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","44850.51","44850.51","44850.51","1 through 10","43321.07","75254.56","other","Inpatient DRG"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With McC","837","MS-DRG","","","","","","","","inpatient","","","133390.24","100042.68","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43321.07","","Case rate ($44,205.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $53,136.90, add-ons for qualifying new technology services are included. If operating cost exceeds $98,781.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,305.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $39,959.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,757.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,865.82. The transfer capital threshold is the transfer adjustment factor * $3,865.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","167783.19","167783.19","167783.19","1 through 10","43321.07","75254.56","other","Inpatient DRG"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","","","","inpatient","","","86006.85","64505.14","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","20003.96","","Case rate ($19,421.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,302.03, add-ons for qualifying new technology services are included. If operating cost exceeds $68,946.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,119.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,361.84 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,922.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,679.64. The transfer capital threshold is the transfer adjustment factor * $1,679.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","19299.67","19299.67","19299.67","1 through 10","19032.89","30607.5662","other","Inpatient DRG"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","","","","inpatient","","","86006.85","64505.14","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","25092.41","","Case rate ($25,092.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,302.03, add-ons for qualifying new technology services are included. If operating cost exceeds $68,946.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,119.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $23,032.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,922.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,679.64. The transfer capital threshold is the transfer adjustment factor * $1,679.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18485.73","18485.73","18485.73","1 through 10","19032.89","30607.5662","other","Inpatient DRG"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","","","","inpatient","","","86006.85","64505.14","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","24276.65","","Case rate ($19,421.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,302.03, add-ons for qualifying new technology services are included. If operating cost exceeds $68,946.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,119.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,361.84 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,922.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,679.64. The transfer capital threshold is the transfer adjustment factor * $1,679.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","18752.85","18752.85","18752.85","1 through 10","19032.89","30607.5662","other","Inpatient DRG"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","","","","inpatient","","","86006.85","64505.14","MARTIN'S POINT [160007]","HB BWH MEDICARE","25092.41","","Case rate ($25,092.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,302.03, add-ons for qualifying new technology services are included. If operating cost exceeds $68,946.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,119.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $23,032.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,922.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,679.64. The transfer capital threshold is the transfer adjustment factor * $1,679.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","157397.05","157397.05","157397.05","1 through 10","19032.89","30607.5662","other","Inpatient DRG"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","","","","inpatient","","","86006.85","64505.14","MEDICARE [2001]","HB BWH MEDICARE","25092.41","","Case rate ($25,092.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,302.03, add-ons for qualifying new technology services are included. If operating cost exceeds $68,946.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,119.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $23,032.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,922.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,679.64. The transfer capital threshold is the transfer adjustment factor * $1,679.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24224.81","0.03","24224.81","1 through 10","19032.89","30607.5662","other","Inpatient DRG"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","","","","inpatient","","","86006.85","64505.14","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19032.89","","Case rate ($19,421.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,302.03, add-ons for qualifying new technology services are included. If operating cost exceeds $68,946.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,119.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,361.84 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,922.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,679.64. The transfer capital threshold is the transfer adjustment factor * $1,679.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18430.65","18430.65","18430.65","1 through 10","19032.89","30607.5662","other","Inpatient DRG"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/McC","839","MS-DRG","","","","","","","","inpatient","","","47490.79","35618.09","MEDICARE [2001]","HB BWH MEDICARE","13551.25","","Case rate ($13,551.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,235.62, add-ons for qualifying new technology services are included. If operating cost exceeds $61,880.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,602.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,009.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,855.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.85. The transfer capital threshold is the transfer adjustment factor * $1,161.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16458.32","16458.32","16458.32","1 through 10","13280.23","19665.0821","other","Inpatient Replacement Plans DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","","","","inpatient","","","35357.95","26518.46","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","12682.78","","Case rate ($12,313.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,745.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,389.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,492.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,880.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,365.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,052.65. The transfer capital threshold is the transfer adjustment factor * $1,052.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12154.60","12154.59","12202.61","1 through 10","12067.11","19176.1337","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","","","","inpatient","","","35357.95","26518.46","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12313.38","","Case rate ($12,313.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,745.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,389.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,492.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,880.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,365.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,052.65. The transfer capital threshold is the transfer adjustment factor * $1,052.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11683.90","11683.90","15039.77","1 through 10","12067.11","19176.1337","other","Inpatient Replacement Plans DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","","","","inpatient","","","35357.95","26518.46","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","15391.73","","Case rate ($12,313.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,745.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,389.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,492.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,880.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,365.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,052.65. The transfer capital threshold is the transfer adjustment factor * $1,052.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","11812.05","11812.05","11812.05","1 through 10","12067.11","19176.1337","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","","","","inpatient","","","35357.95","26518.46","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10012.52","10012.52","10012.52","1 through 10","12067.11","19176.1337","case rate",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","","","","inpatient","","","35357.95","26518.46","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","12313.38","","Case rate ($12,313.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,745.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,389.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,492.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,880.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,365.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,052.65. The transfer capital threshold is the transfer adjustment factor * $1,052.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11702.76","11702.76","11702.76","1 through 10","12067.11","19176.1337","other","Inpatient Replacement Plans DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","","","","inpatient","","","35357.95","26518.46","HUMANA [1012]","HB BWH MEDICARE","12313.38","","Case rate ($12,313.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,745.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,389.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,492.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,880.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,365.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,052.65. The transfer capital threshold is the transfer adjustment factor * $1,052.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10661.42","10661.42","10661.42","1 through 10","12067.11","19176.1337","other","Inpatient Replacement Plans DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","","","","inpatient","","","35357.95","26518.46","MEDICARE [2001]","HB BWH MEDICARE","12313.38","","Case rate ($12,313.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,745.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,389.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,492.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,880.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,365.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,052.65. The transfer capital threshold is the transfer adjustment factor * $1,052.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15258.76","0.03","21382.45","66","12067.11","19176.1337","other","Inpatient Replacement Plans DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","","","","inpatient","","","35357.95","26518.46","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12067.11","","Case rate ($12,313.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,745.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,389.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,492.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,880.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,365.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,052.65. The transfer capital threshold is the transfer adjustment factor * $1,052.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11607.01","11575.81","11665.38","1 through 10","12067.11","19176.1337","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","","","","inpatient","","","35357.95","26518.46","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12067.11","","Case rate ($12,313.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,745.47, add-ons for qualifying new technology services are included. If operating cost exceeds $60,389.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,492.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,880.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,365.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,052.65. The transfer capital threshold is the transfer adjustment factor * $1,052.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11575.81","1.38","11622.42","1 through 10","12067.11","19176.1337","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC","846","MS-DRG","","","","","","","","inpatient","","","78430.67","58823.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","24749.78","","Case rate ($24,028.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,848.65, add-ons for qualifying new technology services are included. If operating cost exceeds $74,493.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,526.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $21,562.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,468.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,086.08. The transfer capital threshold is the transfer adjustment factor * $2,086.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","24171.60","24171.60","24171.60","1 through 10","23548.33","40608.92","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC","846","MS-DRG","","","","","","","","inpatient","","","78430.67","58823.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","31072.27","","Case rate ($31,072.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,848.65, add-ons for qualifying new technology services are included. If operating cost exceeds $74,493.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,526.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $28,606.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,468.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,086.08. The transfer capital threshold is the transfer adjustment factor * $2,086.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23205.31","23205.31","23205.31","1 through 10","23548.33","40608.92","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC","846","MS-DRG","","","","","","","","inpatient","","","78430.67","58823.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","30036.14","","Case rate ($24,028.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,848.65, add-ons for qualifying new technology services are included. If operating cost exceeds $74,493.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,526.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $21,562.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,468.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,086.08. The transfer capital threshold is the transfer adjustment factor * $2,086.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","23530.16","23530.16","23530.16","1 through 10","23548.33","40608.92","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC","846","MS-DRG","","","","","","","","inpatient","","","78430.67","58823.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","24028.91","","Case rate ($24,028.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,848.65, add-ons for qualifying new technology services are included. If operating cost exceeds $74,493.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,526.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $21,562.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,468.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,086.08. The transfer capital threshold is the transfer adjustment factor * $2,086.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22989.12","22989.12","22989.12","1 through 10","23548.33","40608.92","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC","846","MS-DRG","","","","","","","","inpatient","","","78430.67","58823.00","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","31350.84","31350.84","31350.84","1 through 10","23548.33","40608.92","case rate",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC","846","MS-DRG","","","","","","","","inpatient","","","78430.67","58823.00","FALLON HEALTH [1008]","HB BWH MEDICARE","31072.27","","Case rate ($31,072.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,848.65, add-ons for qualifying new technology services are included. If operating cost exceeds $74,493.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,526.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $28,606.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,468.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,086.08. The transfer capital threshold is the transfer adjustment factor * $2,086.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23032.57","23032.57","50244.55","1 through 10","23548.33","40608.92","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC","846","MS-DRG","","","","","","","","inpatient","","","78430.67","58823.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","31072.27","","Case rate ($31,072.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,848.65, add-ons for qualifying new technology services are included. If operating cost exceeds $74,493.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,526.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $28,606.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,468.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,086.08. The transfer capital threshold is the transfer adjustment factor * $2,086.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23038.02","23038.02","23038.02","1 through 10","23548.33","40608.92","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC","846","MS-DRG","","","","","","","","inpatient","","","78430.67","58823.00","MEDICARE [2001]","HB BWH MEDICARE","31072.27","","Case rate ($31,072.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,848.65, add-ons for qualifying new technology services are included. If operating cost exceeds $74,493.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,526.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $28,606.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,468.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,086.08. The transfer capital threshold is the transfer adjustment factor * $2,086.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30385.43","0.03","36913.51","44","23548.33","40608.92","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC","846","MS-DRG","","","","","","","","inpatient","","","78430.67","58823.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","31072.27","","Case rate ($31,072.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,848.65, add-ons for qualifying new technology services are included. If operating cost exceeds $74,493.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,526.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $28,606.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,468.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,086.08. The transfer capital threshold is the transfer adjustment factor * $2,086.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25712.91","25712.91","25712.91","1 through 10","23548.33","40608.92","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC","846","MS-DRG","","","","","","","","inpatient","","","78430.67","58823.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","23548.33","","Case rate ($24,028.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,848.65, add-ons for qualifying new technology services are included. If operating cost exceeds $74,493.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,526.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $21,562.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,468.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,086.08. The transfer capital threshold is the transfer adjustment factor * $2,086.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","24801.11","24801.11","24801.11","1 through 10","23548.33","40608.92","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/McC","848","MS-DRG","","","","","","","","inpatient","","","15367.15","11525.36","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","15537.15","15537.15","15537.15","1 through 10","7965.59","12358.0199","case rate",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/McC","848","MS-DRG","","","","","","","","inpatient","","","15367.15","11525.36","MEDICARE [2001]","HB BWH MEDICARE","8128.15","","Case rate ($8,128.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,707.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,351.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,123.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,064.84 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,327.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.48. The transfer capital threshold is the transfer adjustment factor * $683.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9946.86","0.03","9946.86","1 through 10","7965.59","12358.0199","other","Inpatient Replacement Plans DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/McC","848","MS-DRG","","","","","","","","inpatient","","","15367.15","11525.36","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7965.59","","Case rate ($8,128.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,707.29, add-ons for qualifying new technology services are included. If operating cost exceeds $55,351.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,123.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,064.84 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,327.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.48. The transfer capital threshold is the transfer adjustment factor * $683.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10676.39","10676.39","10676.39","1 through 10","7965.59","12358.0199","other","Inpatient DRG"
"Chemotherapy,EXTREME","693","DRG","","","","","","","","inpatient","","","627304.45","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","251007.65","195616.29","895333.58","1 through 10","14981.0796","256020.61","percent of total billed charges",""
"Chemotherapy,EXTREME","693","DRG","","","","","","","","inpatient","","","627304.45","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15580.8522","","Fee schedule rate ($155,162.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15580.8522","149182.32","2399091.65","1 through 10","14981.0796","256020.61","case rate",""
"Chemotherapy,EXTREME","693","DRG","","","","","","","","inpatient","","","627304.45","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","16360.3476","","Fee schedule rate ($162,924.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16360.3476","156639.72","640586.62","1 through 10","14981.0796","256020.61","case rate",""
"Chemotherapy,MAJOR","693","DRG","","","","","","","","inpatient","","","61618.67","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","90217.69","21226.30","593061.43","1 through 10","14981.0796","256020.61","percent of total billed charges",""
"Chemotherapy,MAJOR","693","DRG","","","","","","","","inpatient","","","61618.67","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15580.8522","","Fee schedule rate ($43,830.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15580.8522","43830.36","2184410.37","1 through 10","14981.0796","256020.61","case rate",""
"Chemotherapy,MAJOR","693","DRG","","","","","","","","inpatient","","","61618.67","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","16360.3476","","Fee schedule rate ($46,023.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16360.3476","46023.16","46023.16","1 through 10","14981.0796","256020.61","case rate",""
"Chemotherapy,MAJOR","693","DRG","","","","","","","","inpatient","","","61618.67","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","48214.00","","Fee schedule rate ($48,214.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","48214.00","48214.00","48214.00","1 through 10","14981.0796","256020.61","case rate",""
"Chemotherapy,MINOR","693","DRG","","","","","","","","inpatient","","","21792.78","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15580.8522","","Fee schedule rate ($15,580.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15580.8522","15580.84","15580.84","1 through 10","14981.0796","256020.61","case rate",""
"Chemotherapy,MODERATE","693","DRG","","","","","","","","inpatient","","","23050.11","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","386653.13","386653.13","386653.13","1 through 10","14981.0796","256020.61","percent of total billed charges",""
"Chemotherapy,MODERATE","693","DRG","","","","","","","","inpatient","","","23050.11","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15580.8522","","Fee schedule rate ($20,553.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15580.8522","20553.04","20553.04","1 through 10","14981.0796","256020.61","case rate",""
"Chemotherapy,MODERATE","693","DRG","","","","","","","","inpatient","","","23050.11","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","22608.62","","Fee schedule rate ($22,608.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22608.62","22608.62","22608.62","1 through 10","14981.0796","256020.61","case rate",""
"Chest Pain","313","MS-DRG","","","","","","","","inpatient","","","34754.54","26065.90","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7156.19","","Case rate ($6,947.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,286.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,930.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,019.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,988.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,906.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.35. The transfer capital threshold is the transfer adjustment factor * $579.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6989.06","6989.06","6989.06","1 through 10","6808.8","11278.08","other","Inpatient DRG"
"Chest Pain","313","MS-DRG","","","","","","","","inpatient","","","34754.54","26065.90","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8903.87","","Case rate ($8,903.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,286.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,930.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,019.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $7,944.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,906.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.35. The transfer capital threshold is the transfer adjustment factor * $579.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8558.03","8558.03","8558.03","1 through 10","6808.8","11278.08","other","Inpatient DRG"
"Chest Pain","313","MS-DRG","","","","","","","","inpatient","","","34754.54","26065.90","MEDICARE [2001]","HB BWH MEDICARE","8903.87","","Case rate ($8,903.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,286.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,930.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,019.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $7,944.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,906.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.35. The transfer capital threshold is the transfer adjustment factor * $579.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1305.48","651.14","8698.59","25","6808.8","11278.08","other","Inpatient DRG"
"Chest Pain","313","MS-DRG","","","","","","","","inpatient","","","34754.54","26065.90","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","8903.87","","Case rate ($8,903.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,286.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,930.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,019.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $7,944.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,906.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.35. The transfer capital threshold is the transfer adjustment factor * $579.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","117.92","117.92","117.92","1 through 10","6808.8","11278.08","other","Inpatient DRG"
"Chest Pain","313","MS-DRG","","","","","","","","inpatient","","","34754.54","26065.90","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6808.80","","Case rate ($6,947.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,286.32, add-ons for qualifying new technology services are included. If operating cost exceeds $53,930.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,019.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,988.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,906.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.35. The transfer capital threshold is the transfer adjustment factor * $579.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9642.06","9642.06","9642.06","1 through 10","6808.8","11278.08","other","Inpatient DRG"
"Chest Pain,MAJOR","203","DRG","","","","","","","","inpatient","","","17477.24","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8461.4361","","Fee schedule rate ($15,940.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8461.4361","15940.96","15940.96","1 through 10","3336.85","26302.91","case rate",""
"Chest Pain,MINOR","203","DRG","","","","","","","","inpatient","","","22165.37","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","16965.58","","Standard inlier is a Case rate ($16,965.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,382, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,408.12) for the length of stay and the standard reimbursement.","15499.51","15499.51","15499.51","1 through 10","3336.85","26302.91","case rate",""
"Chest Pain,MINOR","203","DRG","","","","","","","","inpatient","","","22165.37","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","8884.7538","","Fee schedule rate ($8,884.75). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8884.7538","8884.76","8884.76","1 through 10","3336.85","26302.91","case rate",""
"Chest Tube Exchange","PX-76001897","CDM","32999","CPT","0761","RC","","","","both","","","401.00","300.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","318.80","79.5","","0.89","0.89","0.89","1 through 10","124.31","917.68","percent of total billed charges",""
"Chest Tube Injection and Removal","PX-76002859","CDM","32999","CPT","0761","RC","","","","both","","","304.00","228.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","241.68","79.5","","0.89","0.89","0.89","1 through 10","94.24","917.68","percent of total billed charges",""
"Chest Tube Injection Contrast Only","PX-76102094","CDM","32999","CPT","0761","RC","","","","both","","","305.00","228.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","242.48","79.5","","0.89","0.89","0.89","1 through 10","94.55","917.68","percent of total billed charges",""
"Chest Tube Reposition","PX-76001896","CDM","32999","CPT","0761","RC","","","","both","","","1516.00","1137.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1205.22","79.5","","0.89","0.89","0.89","1 through 10","469.96","1205.22","percent of total billed charges",""
"Chicago U Ataxia Repeat Expansion Panel Rfc1 Gene Analysis","PX-31001264","CDM","0378U","CPT","0310","RC","","","","both","","","2660.00","1995.00","WELLPOINT [1015]","HB AMC WELLPOINT","1962.55","73.78","","2580.00","2580.00","2580.00","1 through 10","134.26","2527","percent of total billed charges",""
"Children's Hospital of Philadelphia, Foxl2 Gene Mutation","PX-31001218","CDM","81479","CPT","0310","RC","","","","both","","","718.00","538.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.81","79.5","","0.65","0.65","0.65","1 through 10","222.58","682.1","percent of total billed charges",""
"Children's Hospital of Philadelphia, Foxl2 Gene Mutation","PX-31001218","CDM","81479","CPT","0310","RC","","","","both","","","718.00","538.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","382.69","53.3","","0.79","0.79","0.79","1 through 10","222.58","682.1","percent of total billed charges",""
"Children's Hospital of Philadelphia, Foxl2 Gene Mutation","PX-31001218","CDM","81479","CPT","0310","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","359.00","50","","1.00","1.00","1.00","1 through 10","156.55","592.35","percent of total billed charges",""
"Children's Hospital of Philadelphia, Foxl2 Gene Mutation","PX-31001218","CDM","81479","CPT","0310","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","376.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","592.35","percent of total billed charges",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","","","","inpatient","","","2341833.05","1756374.79","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","406126.84","","Case rate ($394,297.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $474,579.51, add-ons for qualifying new technology services are included. If operating cost exceeds $520,223.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $37,187.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.4. The base transfer operating payment is the transfer adjustment factor * $359,170.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $474,199.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $34,747.41. The transfer capital threshold is the transfer adjustment factor * $34,747.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","415558.31","403018.44","2610759.01","1 through 10","386411.94","676415.38","other","Inpatient DRG"
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","","","","inpatient","","","2341833.05","1756374.79","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","394297.90","","Case rate ($394,297.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $474,579.51, add-ons for qualifying new technology services are included. If operating cost exceeds $520,223.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $37,187.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.4. The base transfer operating payment is the transfer adjustment factor * $359,170.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $474,199.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $34,747.41. The transfer capital threshold is the transfer adjustment factor * $34,747.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","562901.27","426671.82","2715144.78","1 through 10","386411.94","676415.38","other","Inpatient Replacement Plans DRG"
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","","","","inpatient","","","2341833.05","1756374.79","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","","65.6","","633667.07","631636.64","711780.68","1 through 10","386411.94","676415.38","percent of total billed charges",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","","","","inpatient","","","2341833.05","1756374.79","HUMANA [1012]","HB BWH MEDICARE","394297.90","","Case rate ($394,297.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $474,579.51, add-ons for qualifying new technology services are included. If operating cost exceeds $520,223.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $37,187.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.4. The base transfer operating payment is the transfer adjustment factor * $359,170.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $474,199.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $34,747.41. The transfer capital threshold is the transfer adjustment factor * $34,747.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","378817.47","378817.47","378817.47","1 through 10","386411.94","676415.38","other","Inpatient Replacement Plans DRG"
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","","","","inpatient","","","2341833.05","1756374.79","MARTIN'S POINT [160007]","HB BWH MEDICARE","394297.90","","Case rate ($394,297.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $474,579.51, add-ons for qualifying new technology services are included. If operating cost exceeds $520,223.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $37,187.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.4. The base transfer operating payment is the transfer adjustment factor * $359,170.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $474,199.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $34,747.41. The transfer capital threshold is the transfer adjustment factor * $34,747.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","407701.05","407701.05","407701.05","1 through 10","386411.94","676415.38","other","Inpatient Replacement Plans DRG"
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","","","","inpatient","","","2341833.05","1756374.79","MEDICARE [2001]","HB BWH MEDICARE","394297.90","","Case rate ($394,297.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $474,579.51, add-ons for qualifying new technology services are included. If operating cost exceeds $520,223.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $37,187.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.4. The base transfer operating payment is the transfer adjustment factor * $359,170.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $474,199.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $34,747.41. The transfer capital threshold is the transfer adjustment factor * $34,747.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","524449.34","0.01","542874.75","44","386411.94","676415.38","other","Inpatient Replacement Plans DRG"
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","","","","inpatient","","","2341833.05","1756374.79","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","386411.94","","Case rate ($394,297.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $474,579.51, add-ons for qualifying new technology services are included. If operating cost exceeds $520,223.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $37,187.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.4. The base transfer operating payment is the transfer adjustment factor * $359,170.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $474,199.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $34,747.41. The transfer capital threshold is the transfer adjustment factor * $34,747.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","483066.93","483066.93","483066.93","1 through 10","386411.94","676415.38","other","Inpatient DRG"
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","","","","inpatient","","","2341833.05","1756374.79","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","386411.94","","Case rate ($394,297.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $474,579.51, add-ons for qualifying new technology services are included. If operating cost exceeds $520,223.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $37,187.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.4. The base transfer operating payment is the transfer adjustment factor * $359,170.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $474,199.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $34,747.41. The transfer capital threshold is the transfer adjustment factor * $34,747.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","503110.34","496456.61","533149.25","1 through 10","386411.94","676415.38","other","Inpatient DRG"
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,EXTREME","011","DRG","","","","","","","","inpatient","","","2507202.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","","60","","734291.33","734291.33","734291.33","1 through 10","92177.51","184664.61","percent of total billed charges",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,EXTREME","011","DRG","","","","","","","","inpatient","","","2507202.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","60","","773526.39","632909.52","805834.64","1 through 10","92177.51","184664.61","percent of total billed charges",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,MAJOR","011","DRG","","","","","","","","inpatient","","","2273631.90","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","","60","","578882.18","578051.60","777286.56","1 through 10","92177.51","184664.61","percent of total billed charges",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,MAJOR","011","DRG","","","","","","","","inpatient","","","2273631.90","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","","60","","726974.81","726974.81","726974.81","1 through 10","92177.51","184664.61","percent of total billed charges",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,MAJOR","011","DRG","","","","","","","","inpatient","","","2273631.90","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","60","","590005.84","100779.20","710313.09","15","92177.51","184664.61","percent of total billed charges",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,MAJOR","011","DRG","","","","","","","","inpatient","","","2273631.90","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","121543.17","","Case rate ($134,386.87). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $176,816.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1963500.00","1963500.00","1963500.00","1 through 10","92177.51","184664.61","case rate",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,MODERATE","011","DRG","","","","","","","","inpatient","","","2321141.61","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","60","","576922.87","574688.29","581155.92","1 through 10","92177.51","184664.61","percent of total billed charges",""
"Chimerism Analysis Spec 2 X2","PX-31001296","CDM","81268","CPT","0310","RC","","","","both","","","1601.00","1200.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1272.80","79.5","","1222.21","1222.21","1222.21","1 through 10","255.57","1520.95","percent of total billed charges",""
"Chimerism Analysis W/Cell Select Ea Cell Typ","PX-31001297","CDM","81268","CPT","0310","RC","","","","both","","","1601.00","1200.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1272.80","79.5","","1222.21","1222.21","1222.21","1 through 10","255.57","1520.95","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 60 ASEP CANCELLOUS 1.7 FREEZE DRIED 60CC","SUP-ITM-10010583","CDM","C1889","HCPCS","0278","RC","","","","both","","","2980.25","2235.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2369.30","79.5","","1309.77","674.56","6049.93","26","923.88","2369.3","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 60 ASEP CANCELLOUS 1.7 FREEZE DRIED 60CC","SUP-ITM-10010583","CDM","C1889","HCPCS","0278","RC","","","","both","","","2980.25","2235.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1588.47","53.3","","1901.83","1901.83","2962.25","1 through 10","923.88","2369.3","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 60 ASEP CANCELLOUS 1.7 FREEZE DRIED 60CC","SUP-ITM-10010583","CDM","C1889","HCPCS","0278","RC","","","","both","","","2980.25","2235.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1087.79","36.5","","1620.31","1620.31","19908.88","1 through 10","923.88","2369.3","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 60 ASEP CANCELLOUS 1.7 FREEZE DRIED 60CC","SUP-ITM-10010583","CDM","C1889","HCPCS","0278","RC","","","","both","","","2980.25","2235.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1141.44","38.3","","352.91","352.91","2046.30","1 through 10","923.88","2369.3","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 60 ASEP CANCELLOUS 1.7 FREEZE DRIED 60CC","SUP-ITM-10010583","CDM","C1889","HCPCS","0278","RC","","","","both","","","2980.25","2235.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1278.53","42.9","","9668.75","9668.75","9668.75","1 through 10","923.88","2369.3","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 60 ASEP CANCELLOUS 1.7 FREEZE DRIED 60CC","SUP-ITM-10010583","CDM","C1889","HCPCS","0278","RC","","","","both","","","2980.25","2235.19","WELLPOINT [1015]","HB AMC WELLPOINT","2198.83","73.78","","699.88","384.10","3443.31","33","923.88","2369.3","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 60 ASEP CANCELLOUS 1.7 FREEZE DRIED 60CC","SUP-ITM-10010583","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2980.25","2235.19","AETNA [1001]","HB AMC AETNA HMO","2080.21","69.8","","1421.24","264.50","4933.46","29","1557.48","2435.46","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 60 ASEP CANCELLOUS 1.7 FREEZE DRIED 60CC","SUP-ITM-10010583","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2980.25","2235.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2396.12","80.4","","1022.97","1022.97","3607.50","1 through 10","1557.48","2435.46","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 60 ASEP CANCELLOUS 1.7 FREEZE DRIED 60CC","SUP-ITM-10010583","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2980.25","2235.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2435.46","81.72","","3010.54","693.88","5019.88","35","1557.48","2435.46","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 90 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010584","CDM","C1889","HCPCS","0278","RC","","","","both","","","4436.25","3327.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3526.82","79.5","","1309.77","674.56","6049.93","26","1375.24","3526.82","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 90 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010584","CDM","C1889","HCPCS","0278","RC","","","","both","","","4436.25","3327.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2364.52","53.3","","1901.83","1901.83","2962.25","1 through 10","1375.24","3526.82","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 90 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010584","CDM","C1889","HCPCS","0278","RC","","","","both","","","4436.25","3327.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1619.23","36.5","","1620.31","1620.31","19908.88","1 through 10","1375.24","3526.82","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 90 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010584","CDM","C1889","HCPCS","0278","RC","","","","both","","","4436.25","3327.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1699.08","38.3","","352.91","352.91","2046.30","1 through 10","1375.24","3526.82","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 90 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010584","CDM","C1889","HCPCS","0278","RC","","","","both","","","4436.25","3327.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1903.15","42.9","","9668.75","9668.75","9668.75","1 through 10","1375.24","3526.82","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 90 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010584","CDM","C1889","HCPCS","0278","RC","","","","both","","","4436.25","3327.19","WELLPOINT [1015]","HB AMC WELLPOINT","3273.07","73.78","","699.88","384.10","3443.31","33","1375.24","3526.82","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 90 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010584","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4436.25","3327.19","AETNA [1001]","HB AMC AETNA HMO","3096.50","69.8","","1421.24","264.50","4933.46","29","2318.38","3625.3","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 90 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010584","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4436.25","3327.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3566.75","80.4","","1022.97","1022.97","3607.50","1 through 10","2318.38","3625.3","percent of total billed charges",""
"CHIP BONE 1.7 TO 10MM 90 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010584","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4436.25","3327.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3625.30","81.72","","3010.54","693.88","5019.88","35","2318.38","3625.3","percent of total billed charges",""
"CHIP CANCELLOUS 1.0 TO 5.0MM 5 GRAFT ALLOGRAFT MILLED FREEZE DRIED","SUP-ITM-10051877","CDM","C1889","HCPCS","0278","RC","","","","both","","","707.18","530.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","562.21","79.5","","1309.77","674.56","6049.93","26","219.23","562.21","percent of total billed charges",""
"CHIP CANCELLOUS 1.0 TO 5.0MM 5 GRAFT ALLOGRAFT MILLED FREEZE DRIED","SUP-ITM-10051877","CDM","C1889","HCPCS","0278","RC","","","","both","","","707.18","530.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","376.93","53.3","","1901.83","1901.83","2962.25","1 through 10","219.23","562.21","percent of total billed charges",""
"CHIP CANCELLOUS 1.0 TO 5.0MM 5 GRAFT ALLOGRAFT MILLED FREEZE DRIED","SUP-ITM-10051877","CDM","C1889","HCPCS","0278","RC","","","","both","","","707.18","530.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","258.12","36.5","","1620.31","1620.31","19908.88","1 through 10","219.23","562.21","percent of total billed charges",""
"CHIP CANCELLOUS 1.0 TO 5.0MM 5 GRAFT ALLOGRAFT MILLED FREEZE DRIED","SUP-ITM-10051877","CDM","C1889","HCPCS","0278","RC","","","","both","","","707.18","530.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","270.85","38.3","","352.91","352.91","2046.30","1 through 10","219.23","562.21","percent of total billed charges",""
"CHIP CANCELLOUS 1.0 TO 5.0MM 5 GRAFT ALLOGRAFT MILLED FREEZE DRIED","SUP-ITM-10051877","CDM","C1889","HCPCS","0278","RC","","","","both","","","707.18","530.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","303.38","42.9","","9668.75","9668.75","9668.75","1 through 10","219.23","562.21","percent of total billed charges",""
"CHIP CANCELLOUS 1.0 TO 5.0MM 5 GRAFT ALLOGRAFT MILLED FREEZE DRIED","SUP-ITM-10051877","CDM","C1889","HCPCS","0278","RC","","","","both","","","707.18","530.38","WELLPOINT [1015]","HB AMC WELLPOINT","521.76","73.78","","699.88","384.10","3443.31","33","219.23","562.21","percent of total billed charges",""
"CHIP CANCELLOUS 1.0 TO 5.0MM 5 GRAFT ALLOGRAFT MILLED FREEZE DRIED","SUP-ITM-10051877","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","707.18","530.38","AETNA [1001]","HB AMC AETNA HMO","493.61","69.8","","1421.24","264.50","4933.46","29","369.57","577.91","percent of total billed charges",""
"CHIP CANCELLOUS 1.0 TO 5.0MM 5 GRAFT ALLOGRAFT MILLED FREEZE DRIED","SUP-ITM-10051877","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","707.18","530.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","568.57","80.4","","1022.97","1022.97","3607.50","1 through 10","369.57","577.91","percent of total billed charges",""
"CHIP CANCELLOUS 1.0 TO 5.0MM 5 GRAFT ALLOGRAFT MILLED FREEZE DRIED","SUP-ITM-10051877","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","707.18","530.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","577.91","81.72","","3010.54","693.88","5019.88","35","369.57","577.91","percent of total billed charges",""
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","both","","","142.00","106.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","30.94","","APC Price ($30.04). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","29.15","29.15","29.15","1 through 10","29.44","134.9","other","OPPS APC"
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","both","","","142.00","106.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","30.04","","APC Price ($30.04). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","27.87","27.87","27.87","1 through 10","29.44","134.9","other","OPPS APC"
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","both","","","142.00","106.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","112.89","79.5","","81.29","81.29","81.29","46","29.44","134.9","percent of total billed charges",""
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","both","","","142.00","106.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","75.69","53.3","","81.29","81.29","81.29","44","29.44","134.9","percent of total billed charges",""
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","both","","","142.00","106.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","30.04","","APC Price ($30.04). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","24.32","24.32","27.87","1 through 10","29.44","134.9","other","OPPS APC"
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","both","","","142.00","106.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","92.30","65","","89.70","89.70","89.70","1 through 10","29.44","134.9","percent of total billed charges",""
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","both","","","142.00","106.50","MEDICARE [2001]","HB BWH MEDICARE","30.04","","APC Price ($30.04). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.32","28.32","28.32","1 through 10","29.44","134.9","other","OPPS APC"
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","both","","","142.00","106.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.83","36.5","","23.43","23.43","23.43","25","29.44","134.9","percent of total billed charges",""
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","both","","","142.00","106.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.39","38.3","","35.15","35.15","35.15","349","29.44","134.9","percent of total billed charges",""
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","both","","","142.00","106.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.92","42.9","","67.08","67.08","67.08","1 through 10","29.44","134.9","percent of total billed charges",""
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","both","","","142.00","106.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","29.44","","APC Price ($30.04). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","30.05","27.75","30.05","79","29.44","134.9","other","OPPS APC"
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","both","","","142.00","106.50","WELLPOINT [1015]","HB AMC WELLPOINT","104.77","73.78","","23.53","23.53","23.53","35","29.44","134.9","percent of total billed charges",""
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","outpatient","","","142.00","106.50","AETNA [1001]","HB AMC AETNA HMO","99.12","69.8","","66.59","66.59","66.59","47","56.94","132.39","percent of total billed charges",""
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","outpatient","","","142.00","106.50","AETNA [1001]","HB AMC AETNA PPO","114.17","80.4","","66.59","66.59","133.18","12","56.94","132.39","percent of total billed charges",""
"Chiropractic Manip Spinal 1-2 Reg","PX-94000013","CDM","98940","CPT","0940","RC","","","","outpatient","","","142.00","106.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","116.04","81.72","","67.08","67.08","67.08","77","56.94","132.39","percent of total billed charges",""
"Chiropractic Manip Spinal 3","PX-94000014","CDM","98941","CPT","0940","RC","","","","both","","","199.00","149.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","158.21","79.5","","118.56","118.56","118.56","1 through 10","29.44","189.05","percent of total billed charges",""
"Chiropractic Manip Spinal 3","PX-94000014","CDM","98941","CPT","0940","RC","","","","both","","","199.00","149.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","30.04","","APC Price ($30.04). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","24.32","24.32","24.32","1 through 10","29.44","189.05","other","OPPS APC"
"Chiropractic Manip Spinal 3","PX-94000014","CDM","98941","CPT","0940","RC","","","","both","","","199.00","149.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.64","36.5","","36.08","36.08","36.08","13","29.44","189.05","percent of total billed charges",""
"Chiropractic Manip Spinal 3","PX-94000014","CDM","98941","CPT","0940","RC","","","","both","","","199.00","149.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.22","38.3","","54.12","54.12","54.12","71","29.44","189.05","percent of total billed charges",""
"Chiropractic Manip Spinal 3","PX-94000014","CDM","98941","CPT","0940","RC","","","","both","","","199.00","149.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","29.44","","APC Price ($30.04). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","30.05","28.32","30.05","14","29.44","189.05","other","OPPS APC"
"Chiropractic Manip Spinal 3","PX-94000014","CDM","98941","CPT","0940","RC","","","","both","","","199.00","149.25","WELLPOINT [1015]","HB AMC WELLPOINT","146.82","73.78","","34.47","34.47","34.47","1 through 10","29.44","189.05","percent of total billed charges",""
"Chiropractic Manip Spinal 3","PX-94000014","CDM","98941","CPT","0940","RC","","","","outpatient","","","199.00","149.25","AETNA [1001]","HB AMC AETNA HMO","138.90","69.8","","95.38","95.38","95.38","1 through 10","56.94","162.62","percent of total billed charges",""
"Chiropractic Manip Spinal 3","PX-94000014","CDM","98941","CPT","0940","RC","","","","outpatient","","","199.00","149.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","162.62","81.72","","102.76","102.76","102.76","1 through 10","56.94","162.62","percent of total billed charges",""
"Chiropractic Manip Spinal 3","PX-94000014","CDM","98941","CPT","0940","RC","","","","outpatient","","","199.00","149.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","162.62","81.72","","102.76","102.76","102.76","1 through 10","56.94","162.62","percent of total billed charges",""
"Chlamydia Antibody","PX-30000901","CDM","86631","CPT","0302","RC","","","","outpatient","","","166.00","124.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","135.66","81.72","","70.79","70.79","70.79","1 through 10","12.19","135.66","percent of total billed charges",""
"Chlamydia Antibody Igm","PX-30000903","CDM","86632","CPT","0302","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","74.75","74.75","74.75","1 through 10","13.09","143.01","percent of total billed charges",""
"Chloride Blood","PX-30000359","CDM","82435","CPT","0301","RC","","","","both","","","79.00","59.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","51.82","65.6","","60.06","60.06","60.06","1 through 10","4.51","75.05","percent of total billed charges",""
"Chloride Blood","PX-30000359","CDM","82435","CPT","0301","RC","","","","both","","","79.00","59.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","55.30","70","","77.00","77.00","77.00","1 through 10","4.51","75.05","percent of total billed charges",""
"Chloride Blood","PX-30000359","CDM","82435","CPT","0301","RC","","","","both","","","79.00","59.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","62.81","79.5","","56.55","56.55","56.55","1 through 10","4.51","75.05","percent of total billed charges",""
"Chloride Blood","PX-30000359","CDM","82435","CPT","0301","RC","","","","both","","","79.00","59.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","42.11","53.3","","40.66","40.66","40.66","1 through 10","4.51","75.05","percent of total billed charges",""
"Chloride Blood","PX-30000359","CDM","82435","CPT","0301","RC","","","","both","","","79.00","59.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28.84","36.5","","24.41","24.41","24.41","1 through 10","4.51","75.05","percent of total billed charges",""
"Chloride Blood","PX-30000359","CDM","82435","CPT","0301","RC","","","","both","","","79.00","59.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30.26","38.3","","30.11","30.11","30.11","1 through 10","4.51","75.05","percent of total billed charges",""
"Chloride Blood","PX-30000359","CDM","82435","CPT","0301","RC","","","","outpatient","","","79.00","59.25","AETNA [1001]","HB AMC AETNA HMO","55.14","69.8","","52.13","49.13","52.13","1 through 10","4.73","64.56","percent of total billed charges",""
"Chloride Blood","PX-30000359","CDM","82435","CPT","0301","RC","","","","outpatient","","","79.00","59.25","AETNA [1001]","HB AMC AETNA PPO","63.52","80.4","","60.06","60.06","60.06","1 through 10","4.73","64.56","percent of total billed charges",""
"Chloride Blood","PX-30000359","CDM","82435","CPT","0301","RC","","","","outpatient","","","79.00","59.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","63.52","80.4","","60.06","60.06","60.06","1 through 10","4.73","64.56","percent of total billed charges",""
"Chloride Urine","PX-30000360","CDM","82436","CPT","0301","RC","","","","both","","","80.00","60.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","63.60","79.5","","39.00","39.00","39.00","1 through 10","5.19","76","percent of total billed charges",""
"Chloride Urine","PX-30000360","CDM","82436","CPT","0301","RC","","","","both","","","80.00","60.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","42.64","53.3","","65.09","39.39","65.09","1 through 10","5.19","76","percent of total billed charges",""
"Chloride Urine","PX-30000360","CDM","82436","CPT","0301","RC","","","","both","","","80.00","60.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30.64","38.3","","30.50","30.50","59.28","1 through 10","5.19","76","percent of total billed charges",""
"Chloride Urine","PX-30000360","CDM","82436","CPT","0301","RC","","","","outpatient","","","80.00","60.00","AETNA [1001]","HB AMC AETNA HMO","55.84","69.8","","50.44","37.28","74.56","11","5.19","65.38","percent of total billed charges",""
"Chloride Urine","PX-30000360","CDM","82436","CPT","0301","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","65.38","81.72","","62.35","62.35","62.35","1 through 10","5.19","65.38","percent of total billed charges",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","","","","inpatient","","","95116.95","71337.71","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","24847.35","","Case rate ($24,847.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,074.72, add-ons for qualifying new technology services are included. If operating cost exceeds $68,719.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,103.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $22,804.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,694.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,662.99. The transfer capital threshold is the transfer adjustment factor * $1,662.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18313.37","18313.37","18313.37","1 through 10","18847.85","29851.5071","other","Inpatient DRG"
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","","","","inpatient","","","95116.95","71337.71","MEDICARE [2001]","HB BWH MEDICARE","24847.35","","Case rate ($24,847.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,074.72, add-ons for qualifying new technology services are included. If operating cost exceeds $68,719.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,103.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $22,804.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,694.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,662.99. The transfer capital threshold is the transfer adjustment factor * $1,662.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23598.40","0.03","23633.28","1 through 10","18847.85","29851.5071","other","Inpatient DRG"
"Cholecystectomy Except By Laparoscope Without C.D.E. With McC","414","MS-DRG","","","","","","","","inpatient","","","160431.79","120323.84","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","32878.26","","Case rate ($32,878.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,501.52, add-ons for qualifying new technology services are included. If operating cost exceeds $85,145.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,306.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $29,631.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,121.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,866.68. The transfer capital threshold is the transfer adjustment factor * $2,866.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","31735.66","31735.66","31735.66","1 through 10","32220.69","55804.57","other","Inpatient Replacement Plans DRG"
"Cholecystectomy Except By Laparoscope Without C.D.E. With McC","414","MS-DRG","","","","","","","","inpatient","","","160431.79","120323.84","MEDICARE [2001]","HB BWH MEDICARE","32878.26","","Case rate ($32,878.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,501.52, add-ons for qualifying new technology services are included. If operating cost exceeds $85,145.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,306.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $29,631.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,121.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,866.68. The transfer capital threshold is the transfer adjustment factor * $2,866.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","76433.40","76433.40","76433.40","1 through 10","32220.69","55804.57","other","Inpatient Replacement Plans DRG"
"Cholecystectomy Except Laparoscopic,EXTREME","262","DRG","","","","","","","","inpatient","","","168380.01","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","29488.6528","","Fee schedule rate ($112,311.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29488.6528","112311.40","112311.40","1 through 10","28353.5104","185316.1","case rate",""
"Cholecystectomy Except Laparoscopic,MODERATE","262","DRG","","","","","","","","inpatient","","","78767.66","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","42328.72","","Fee schedule rate ($42,328.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42328.72","42328.72","42328.72","1 through 10","28353.5104","185316.1","case rate",""
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","","","","inpatient","","","272244.13","204183.10","MEDICARE [2001]","HB BWH MEDICARE","25271.17","","Case rate ($25,271.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,467.84, add-ons for qualifying new technology services are included. If operating cost exceeds $69,112.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,131.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $23,199.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,088.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,691.79. The transfer capital threshold is the transfer adjustment factor * $1,691.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25408.04","25408.04","25408.04","1 through 10","19167.88","32167.9756","other","Inpatient DRG"
"Cholecystectomy With C.D.E. Without Cc/McC","413","MS-DRG","","","","","","","","inpatient","","","176767.80","132575.85","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15216.55","","Case rate ($15,527.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,614.15, add-ons for qualifying new technology services are included. If operating cost exceeds $64,258.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,776.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,811.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,234.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,336.14. The transfer capital threshold is the transfer adjustment factor * $1,336.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15167.63","15167.63","15167.63","1 through 10","15216.55","26010.07","other","Inpatient DRG"
"Cholecystectomy,MAJOR","263","DRG","","","","","","","","inpatient","","","121132.20","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","54497.82","","Standard inlier is a Case rate ($54,497.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,028, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,736.29) for the length of stay and the standard reimbursement.","49676.74","49676.74","49676.74","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MAJOR","263","DRG","","","","","","","","inpatient","","","121132.20","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","61270.24","","Standard inlier is a Case rate ($61,270.24). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,028, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,696.80) for the length of stay and the standard reimbursement.","55975.65","61270.23","61270.23","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MAJOR","263","DRG","","","","","","","","inpatient","","","121132.20","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","20201.8744","","Fee schedule rate ($39,529.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20201.8744","39529.20","39529.20","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MAJOR","263","DRG","","","","","","","","inpatient","","","121132.20","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","21212.5552","","Fee schedule rate ($41,506.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21212.5552","41506.80","41506.80","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MAJOR","263","DRG","","","","","","","","inpatient","","","121132.20","","MASSHEALTH [3001]","HB BWH MEDICAID","15164.91","","Case rate ($16,767.41). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,197.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16763.30","16763.30","16763.30","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","72814.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","33890.13","","Standard inlier is a Case rate ($33,890.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,003, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,810.91) for the length of stay and the standard reimbursement.","30892.09","30892.09","33890.13","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","72814.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","38101.64","","Standard inlier is a Case rate ($38,101.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,003, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,408.21) for the length of stay and the standard reimbursement.","38101.64","34809.14","38179.62","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","72814.58","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","20201.8744","","Fee schedule rate ($20,201.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20201.8744","20201.88","20201.88","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","72814.58","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","21212.5552","","Fee schedule rate ($21,212.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21212.5552","21212.56","21212.56","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","72814.58","","MASSHEALTH [3001]","HB BWH MEDICAID","8498.06","","Case rate ($9,396.07). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,826.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9393.76","9393.76","42275.99","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","72814.58","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32025.80","","Fee schedule rate ($32,025.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32025.80","32025.80","32025.80","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","72814.58","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8498.06","","Case rate ($9,396.07). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,826.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9393.76","9393.76","9393.76","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","93351.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","42958.55","","Standard inlier is a Case rate ($42,958.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,053, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,098.23) for the length of stay and the standard reimbursement.","42958.55","42958.55","42958.55","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","93351.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","48296.99","","Standard inlier is a Case rate ($48,296.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,053, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,855.36) for the length of stay and the standard reimbursement.","48296.98","44123.46","48296.98","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","93351.25","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","20201.8744","","Fee schedule rate ($27,301.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20201.8744","27301.16","27301.16","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","93351.25","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","21212.5552","","Fee schedule rate ($28,667.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21212.5552","28667.00","28667.00","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","93351.25","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","30031.64","","Fee schedule rate ($30,031.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30031.64","30031.64","30031.64","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","93351.25","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40859.93","","Fee schedule rate ($40,859.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40859.93","40859.93","40859.93","1 through 10","8498.06","148269.86","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","93351.25","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10886.75","","Case rate ($12,037.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,467.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12034.22","12034.22","12034.22","1 through 10","8498.06","148269.86","case rate",""
"Cholecystost Perc Compl Px","PX-75000245","CDM","47490","CPT","0361","RC","","","","both","","","6454.00","4840.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4123.91","4123.91","4123.91","1 through 10","2000.74","5238.18","other","OPPS APC"
"Cholestasis Panel by Massively Parallel Sequencing (Bcm-Mitomengssm)","PX-31000814","CDM","81479","CPT","0310","RC","","","","both","","","856.00","642.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","680.52","79.5","","0.65","0.65","0.65","1 through 10","265.36","813.2","percent of total billed charges",""
"Cholestasis Panel by Massively Parallel Sequencing (Bcm-Mitomengssm)","PX-31000814","CDM","81479","CPT","0310","RC","","","","both","","","856.00","642.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","456.25","53.3","","0.79","0.79","0.79","1 through 10","265.36","813.2","percent of total billed charges",""
"Cholestasis Panel by Massively Parallel Sequencing (Bcm-Mitomengssm)","PX-31000814","CDM","81479","CPT","0310","RC","","","","outpatient","","","856.00","642.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","428.00","50","","1.00","1.00","1.00","1 through 10","156.55","706.2","percent of total billed charges",""
"Cholestasis Panel by Massively Parallel Sequencing (Bcm-Mitomengssm)","PX-31000814","CDM","81479","CPT","0310","RC","","","","outpatient","","","856.00","642.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","449.40","52.5","","1.00","0.53","1.00","1 through 10","156.55","706.2","percent of total billed charges",""
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","both","","","114.00","85.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","90.63","79.5","","87.36","58.61","262.08","23","8.03","108.3","percent of total billed charges",""
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","both","","","114.00","85.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","60.76","53.3","","58.61","58.61","87.36","1 through 10","8.03","108.3","percent of total billed charges",""
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","35.34","31","","34.30","34.30","34.30","1 through 10","8.03","108.3","percent of total billed charges",""
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.61","36.5","","41.40","35.19","41.40","14","8.03","108.3","percent of total billed charges",""
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.66","38.3","","43.40","42.18","43.40","60","8.03","108.3","percent of total billed charges",""
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","both","","","114.00","85.50","TRICARE [160005]","HB BWH TRICARE","108.30","95","","9.38","9.38","9.38","1 through 10","8.03","108.3","percent of total billed charges",""
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.91","42.9","","48.81","48.81","48.81","1 through 10","8.03","108.3","percent of total billed charges",""
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","outpatient","","","114.00","85.50","AETNA [1001]","HB AMC AETNA HMO","79.57","69.8","","75.15","53.06","86.58","18","8.45","93.16","percent of total billed charges",""
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","outpatient","","","114.00","85.50","AETNA [1001]","HB AMC AETNA PPO","91.66","80.4","","86.58","53.06","86.58","1 through 10","8.45","93.16","percent of total billed charges",""
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","outpatient","","","114.00","85.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","59.58","52.26","","68.69","68.69","68.69","1 through 10","8.45","93.16","percent of total billed charges",""
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.16","81.72","","88.73","48.81","88.73","1 through 10","8.45","93.16","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","both","","","106.00","79.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","76.11","71.8","","9.26","9.26","9.26","1 through 10","9.47","100.7","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","both","","","106.00","79.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","74.20","70","","82.40","82.40","82.40","1 through 10","9.47","100.7","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","both","","","106.00","79.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","84.27","79.5","","81.06","54.38","81.06","1 through 10","9.47","100.7","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","both","","","106.00","79.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","56.50","53.3","","54.38","54.38","54.38","1 through 10","9.47","100.7","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","both","","","106.00","79.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","68.90","65","","66.95","66.95","66.95","1 through 10","9.47","100.7","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","both","","","106.00","79.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","32.86","31","","31.83","31.83","31.83","1 through 10","9.47","100.7","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","both","","","106.00","79.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.69","36.5","","115.26","115.26","115.26","1 through 10","9.47","100.7","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","both","","","106.00","79.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.60","38.3","","40.27","39.14","40.27","19","9.47","100.7","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","both","","","106.00","79.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","81.62","77","","81.06","81.06","81.06","1 through 10","9.47","100.7","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","outpatient","","","106.00","79.50","AETNA [1001]","HB AMC AETNA HMO","73.99","69.8","","69.73","49.23","82.34","12","9.47","86.62","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","outpatient","","","106.00","79.50","AETNA [1001]","HB AMC AETNA PPO","85.22","80.4","","80.34","80.34","80.34","1 through 10","9.47","86.62","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","outpatient","","","106.00","79.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","85.22","80.4","","80.34","80.34","80.34","1 through 10","9.47","86.62","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","outpatient","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","86.62","81.72","","82.34","45.29","82.34","20","9.47","86.62","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","both","","","76.00","57.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","60.42","79.5","","58.24","39.07","174.72","22","4.26","72.2","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","both","","","76.00","57.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","40.51","53.3","","39.07","39.07","58.24","12","4.26","72.2","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","23.56","31","","22.87","22.87","22.87","1 through 10","4.26","72.2","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.74","36.5","","26.79","23.46","27.60","14","4.26","72.2","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.11","38.3","","28.93","28.12","28.93","62","4.26","72.2","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","both","","","76.00","57.00","TRICARE [160005]","HB BWH TRICARE","72.20","95","","4.98","4.98","4.98","1 through 10","4.26","72.2","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","both","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.60","42.9","","32.54","32.54","32.54","1 through 10","4.26","72.2","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","outpatient","","","76.00","57.00","AETNA [1001]","HB AMC AETNA HMO","53.05","69.8","","50.10","50.10","57.72","1 through 10","4.48","62.11","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","outpatient","","","76.00","57.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","39.72","52.26","","45.79","45.79","45.79","1 through 10","4.48","62.11","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","outpatient","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","62.11","81.72","","59.16","32.54","59.16","1 through 10","4.48","62.11","percent of total billed charges",""
"Chr5ce, Labcor 511590 Chromosome 5 Cell Count Microarray Chr5ce","PX-31001269","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2946.27","79.5","","2828.48","1814.97","2828.48","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Chr5ce, Labcor 511590 Chromosome 5 Cell Count Microarray Chr5ce","PX-31001269","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1975.30","53.3","","1814.97","1761.95","1814.97","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Chr5ce, Labcor 511590 Chromosome 5 Cell Count Microarray Chr5ce","PX-31001269","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1352.69","36.5","","1340.56","1340.56","1340.56","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Chr5ce, Labcor 511590 Chromosome 5 Cell Count Microarray Chr5ce","PX-31001269","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1419.40","38.3","","1405.25","1405.25","1405.25","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Chr5ce, Labcor 511590 Chromosome 5 Cell Count Microarray Chr5ce","PX-31001269","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","WELLPOINT [1015]","HB AMC WELLPOINT","2734.29","73.78","","6269.73","2675.73","7188.00","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Chr5ce, Labcor 511590 Chromosome 5 Cell Count Microarray Chr5ce","PX-31001269","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","AETNA [1001]","HB AMC AETNA HMO","2586.79","69.8","","2433.14","2433.14","2433.14","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Chr5ce, Labcor 511590 Chromosome 5 Cell Count Microarray Chr5ce","PX-31001269","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2979.62","80.4","","2803.32","2803.32","2803.32","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Chr5ce, Labcor 511590 Chromosome 5 Cell Count Microarray Chr5ce","PX-31001269","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3028.54","81.72","","2873.04","1533.07","3526.61","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Chrom Add Cell Count","PX-31000140","CDM","88285","CPT","0311","RC","","","","both","","","325.00","243.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","213.20","65.6","","213.26","213.26","213.26","1 through 10","26.37","308.75","percent of total billed charges",""
"Chrom Add Cell Count","PX-31000140","CDM","88285","CPT","0311","RC","","","","both","","","325.00","243.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.38","79.5","","247.91","166.32","247.91","1 through 10","26.37","308.75","percent of total billed charges",""
"Chrom Add Cell Count","PX-31000140","CDM","88285","CPT","0311","RC","","","","both","","","325.00","243.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.23","53.3","","154.53","154.53","154.53","1 through 10","26.37","308.75","percent of total billed charges",""
"Chrom Add Cell Count","PX-31000140","CDM","88285","CPT","0311","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.63","36.5","","99.86","99.86","117.50","1 through 10","26.37","308.75","percent of total billed charges",""
"Chrom Add Cell Count","PX-31000140","CDM","88285","CPT","0311","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.48","38.3","","123.17","119.70","359.10","17","26.37","308.75","percent of total billed charges",""
"Chrom Add Cell Count","PX-31000140","CDM","88285","CPT","0311","RC","","","","outpatient","","","325.00","243.75","AETNA [1001]","HB AMC AETNA HMO","226.85","69.8","","213.26","150.57","213.26","1 through 10","77.33","265.59","percent of total billed charges",""
"Chrom Add Cell Count","PX-31000140","CDM","88285","CPT","0311","RC","","","","outpatient","","","325.00","243.75","AETNA [1001]","HB AMC AETNA PPO","261.30","80.4","","245.70","245.70","245.70","1 through 10","77.33","265.59","percent of total billed charges",""
"Chrom Add Cell Count","PX-31000140","CDM","88285","CPT","0311","RC","","","","outpatient","","","325.00","243.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","265.59","81.72","","251.81","138.51","251.81","1 through 10","77.33","265.59","percent of total billed charges",""
"Chrom Add Karyo","PX-31000137","CDM","88280","CPT","0311","RC","","","","both","","","308.00","231.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","202.05","65.6","","202.42","202.42","202.42","1 through 10","32.8","292.6","percent of total billed charges",""
"Chrom Add Karyo","PX-31000137","CDM","88280","CPT","0311","RC","","","","both","","","308.00","231.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","244.86","79.5","","235.31","157.87","235.31","1 through 10","32.8","292.6","percent of total billed charges",""
"Chrom Add Karyo","PX-31000137","CDM","88280","CPT","0311","RC","","","","both","","","308.00","231.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","164.16","53.3","","1246.61","151.00","1246.61","1 through 10","32.8","292.6","percent of total billed charges",""
"Chrom Add Karyo","PX-31000137","CDM","88280","CPT","0311","RC","","","","both","","","308.00","231.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","112.42","36.5","","111.53","94.78","111.53","1 through 10","32.8","292.6","percent of total billed charges",""
"Chrom Add Karyo","PX-31000137","CDM","88280","CPT","0311","RC","","","","both","","","308.00","231.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","117.96","38.3","","116.91","113.62","340.86","18","32.8","292.6","percent of total billed charges",""
"Chrom Add Karyo","PX-31000137","CDM","88280","CPT","0311","RC","","","","both","","","308.00","231.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.13","42.9","","239.02","239.02","239.02","1 through 10","32.8","292.6","percent of total billed charges",""
"Chrom Add Karyo","PX-31000137","CDM","88280","CPT","0311","RC","","","","outpatient","","","308.00","231.00","AETNA [1001]","HB AMC AETNA HMO","214.98","69.8","","202.42","142.92","466.44","1 through 10","95.89","251.7","percent of total billed charges",""
"Chrom Add Karyo","PX-31000137","CDM","88280","CPT","0311","RC","","","","outpatient","","","308.00","231.00","AETNA [1001]","HB AMC AETNA PPO","247.63","80.4","","156.68","156.68","156.68","1 through 10","95.89","251.7","percent of total billed charges",""
"Chrom Add Karyo","PX-31000137","CDM","88280","CPT","0311","RC","","","","outpatient","","","308.00","231.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","251.70","81.72","","239.02","239.02","301.88","1 through 10","95.89","251.7","percent of total billed charges",""
"Chrom Count 15-20/2","PX-31000122","CDM","88262","CPT","0311","RC","","","","both","","","1577.00","1182.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1253.72","79.5","","1203.32","807.31","1203.32","16","122.98","1498.15","percent of total billed charges",""
"Chrom Count 15-20/2","PX-31000122","CDM","88262","CPT","0311","RC","","","","both","","","1577.00","1182.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","840.54","53.3","","807.31","807.31","3063.79","1 through 10","122.98","1498.15","percent of total billed charges",""
"Chrom Count 15-20/2","PX-31000122","CDM","88262","CPT","0311","RC","","","","both","","","1577.00","1182.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","575.61","36.5","","570.32","484.69","2851.60","21","122.98","1498.15","percent of total billed charges",""
"Chrom Count 15-20/2","PX-31000122","CDM","88262","CPT","0311","RC","","","","both","","","1577.00","1182.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","603.99","38.3","","597.84","581.02","1743.06","60","122.98","1498.15","percent of total billed charges",""
"Chrom Count 15-20/2","PX-31000122","CDM","88262","CPT","0311","RC","","","","both","","","1577.00","1182.75","TRICARE [160005]","HB BWH TRICARE","1498.15","95","","143.66","143.66","143.66","1 through 10","122.98","1498.15","percent of total billed charges",""
"Chrom Count 15-20/2","PX-31000122","CDM","88262","CPT","0311","RC","","","","outpatient","","","1577.00","1182.75","AETNA [1001]","HB AMC AETNA HMO","1100.75","69.8","","1035.13","730.86","1192.62","23","440.28","1288.72","percent of total billed charges",""
"Chrom Count 15-20/2","PX-31000122","CDM","88262","CPT","0311","RC","","","","outpatient","","","1577.00","1182.75","AETNA [1001]","HB AMC AETNA PPO","1267.91","80.4","","1192.62","1192.62","1192.62","1 through 10","440.28","1288.72","percent of total billed charges",""
"Chrom Count 15-20/2","PX-31000122","CDM","88262","CPT","0311","RC","","","","outpatient","","","1577.00","1182.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1288.72","81.72","","1222.28","672.30","1222.28","30","440.28","1288.72","percent of total billed charges",""
"Chrom Count 5/1","PX-31000121","CDM","88261","CPT","0311","RC","","","","both","","","3046.00","2284.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1998.18","65.6","","1999.86","1999.86","1999.86","1 through 10","259.05","2893.7","percent of total billed charges",""
"Chrom Count 5/1","PX-31000121","CDM","88261","CPT","0311","RC","","","","outpatient","","","3046.00","2284.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2489.19","81.72","","2930.46","2361.43","2930.46","1 through 10","755.8","2489.19","percent of total billed charges",""
"Chrom Count Amniotic 15/1","PX-31000126","CDM","88267","CPT","0311","RC","","","","both","","","2105.00","1578.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1673.48","79.5","","1606.27","1077.65","1606.27","1 through 10","184.8","1999.75","percent of total billed charges",""
"Chrom Count Amniotic 15/1","PX-31000126","CDM","88267","CPT","0311","RC","","","","both","","","2105.00","1578.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1121.97","53.3","","1421.58","539.09","1421.58","1 through 10","184.8","1999.75","percent of total billed charges",""
"Chrom Count Amniotic 15/1","PX-31000126","CDM","88267","CPT","0311","RC","","","","both","","","2105.00","1578.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","768.33","36.5","","761.29","647.00","761.29","1 through 10","184.8","1999.75","percent of total billed charges",""
"Chrom Count Amniotic 15/1","PX-31000126","CDM","88267","CPT","0311","RC","","","","both","","","2105.00","1578.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","806.22","38.3","","798.03","761.29","798.03","1 through 10","184.8","1999.75","percent of total billed charges",""
"Chrom Count Amniotic 15/1","PX-31000126","CDM","88267","CPT","0311","RC","","","","outpatient","","","2105.00","1578.75","AETNA [1001]","HB AMC AETNA HMO","1469.29","69.8","","1591.98","1381.76","1591.98","1 through 10","635.15","1720.21","percent of total billed charges",""
"Chrom Count Amniotic 15/1","PX-31000126","CDM","88267","CPT","0311","RC","","","","outpatient","","","2105.00","1578.75","AETNA [1001]","HB AMC AETNA PPO","1692.42","80.4","","1069.48","1069.48","1069.48","1 through 10","635.15","1720.21","percent of total billed charges",""
"Chrom Count Amniotic 15/1","PX-31000126","CDM","88267","CPT","0311","RC","","","","outpatient","","","2105.00","1578.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1720.21","81.72","","1631.58","1631.58","1631.58","1 through 10","635.15","1720.21","percent of total billed charges",""
"Chrom Count Amniotic in Situ","PX-31000127","CDM","88269","CPT","0311","RC","","","","both","","","2797.00","2097.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2223.62","79.5","","2134.35","1431.94","2134.35","1 through 10","170.19","2657.15","percent of total billed charges",""
"Chrom Count Amniotic in Situ","PX-31000127","CDM","88269","CPT","0311","RC","","","","both","","","2797.00","2097.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1490.80","53.3","","1369.56","1369.56","1369.56","1 through 10","170.19","2657.15","percent of total billed charges",""
"Chrom Count Amniotic in Situ","PX-31000127","CDM","88269","CPT","0311","RC","","","","both","","","2797.00","2097.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1020.91","36.5","","1011.58","1011.58","1011.58","1 through 10","170.19","2657.15","percent of total billed charges",""
"Chrom Count Amniotic in Situ","PX-31000127","CDM","88269","CPT","0311","RC","","","","both","","","2797.00","2097.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1071.25","38.3","","3091.68","1030.56","3091.68","12","170.19","2657.15","percent of total billed charges",""
"Chrom Count Amniotic in Situ","PX-31000127","CDM","88269","CPT","0311","RC","","","","both","","","2797.00","2097.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1199.91","42.9","","2167.97","2167.97","2167.97","1 through 10","170.19","2657.15","percent of total billed charges",""
"Chrom Count Amniotic in Situ","PX-31000127","CDM","88269","CPT","0311","RC","","","","outpatient","","","2797.00","2097.75","AETNA [1001]","HB AMC AETNA HMO","1952.31","69.8","","1836.02","1258.47","4230.72","1 through 10","587.72","2285.71","percent of total billed charges",""
"Chrom Count Amniotic in Situ","PX-31000127","CDM","88269","CPT","0311","RC","","","","outpatient","","","2797.00","2097.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2285.71","81.72","","2167.97","2044.62","2167.97","1 through 10","587.72","2285.71","percent of total billed charges",""
"Chromium","PX-30000376","CDM","82495","CPT","0301","RC","","","","both","","","242.00","181.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","128.99","53.3","","124.08","124.08","124.08","1 through 10","19.87","229.9","percent of total billed charges",""
"Chromium","PX-30000376","CDM","82495","CPT","0301","RC","","","","both","","","242.00","181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","92.69","38.3","","91.89","89.30","178.60","1 through 10","19.87","229.9","percent of total billed charges",""
"Chromium","PX-30000376","CDM","82495","CPT","0301","RC","","","","outpatient","","","242.00","181.50","AETNA [1001]","HB AMC AETNA HMO","168.92","69.8","","159.10","159.10","159.10","1 through 10","20.91","197.76","percent of total billed charges",""
"Chromium","PX-30000376","CDM","82495","CPT","0301","RC","","","","outpatient","","","242.00","181.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","197.76","81.72","","187.86","103.33","187.86","1 through 10","20.91","197.76","percent of total billed charges",""
"Chronic Kidney Disease,MAJOR","470","DRG","","","","","","","","inpatient","","","73502.42","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","11069.53","","Case rate ($12,239.26). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,669.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","6293.29","55208.99","case rate",""
"Chronic Kidney Disease,MODERATE","470","DRG","","","","","","","","inpatient","","","25926.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18747.22","","Standard inlier is a Case rate ($18,747.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,615, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,661.01) for the length of stay and the standard reimbursement.","18747.21","18747.21","18747.21","1 through 10","6293.29","55208.99","case rate",""
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","43115.23","32336.42","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8069.76","","Case rate ($8,069.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,637, add-ons for qualifying new technology services are included. If operating cost exceeds $55,281.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,118.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,011.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,257.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.33. The transfer capital threshold is the transfer adjustment factor * $678.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7981.43","7981.43","7981.43","1 through 10","7908.36","12964.6781","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","43115.23","32336.42","MEDICARE [2001]","HB BWH MEDICARE","8069.76","","Case rate ($8,069.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,637, add-ons for qualifying new technology services are included. If operating cost exceeds $55,281.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,118.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,011.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,257.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.33. The transfer capital threshold is the transfer adjustment factor * $678.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10406.35","0.03","10421.51","17","7908.36","12964.6781","other","Inpatient Replacement Plans DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","43115.23","32336.42","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","8069.76","","Case rate ($8,069.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,637, add-ons for qualifying new technology services are included. If operating cost exceeds $55,281.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,118.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,011.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,257.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.33. The transfer capital threshold is the transfer adjustment factor * $678.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","141.73","141.73","141.73","1 through 10","7908.36","12964.6781","other","Inpatient Replacement Plans DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","43115.23","32336.42","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","8069.76","","Case rate ($8,069.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,637, add-ons for qualifying new technology services are included. If operating cost exceeds $55,281.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,118.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,011.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,257.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.33. The transfer capital threshold is the transfer adjustment factor * $678.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7940.10","7940.10","7940.10","1 through 10","7908.36","12964.6781","other","Inpatient Replacement Plans DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","43115.23","32336.42","MOLINA [1014]","HB BWH MOLINA","7908.36","","Case rate ($8,069.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,637, add-ons for qualifying new technology services are included. If operating cost exceeds $55,281.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,118.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,011.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,257.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.33. The transfer capital threshold is the transfer adjustment factor * $678.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16158.98","16158.98","16158.98","1 through 10","7908.36","12964.6781","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","43115.23","32336.42","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7908.36","","Case rate ($8,069.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,637, add-ons for qualifying new technology services are included. If operating cost exceeds $55,281.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,118.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,011.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,257.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.33. The transfer capital threshold is the transfer adjustment factor * $678.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7948.50","7948.50","7948.50","1 through 10","7908.36","12964.6781","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","43115.23","32336.42","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7908.36","","Case rate ($8,069.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,637, add-ons for qualifying new technology services are included. If operating cost exceeds $55,281.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,118.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,011.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,257.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $678.33. The transfer capital threshold is the transfer adjustment factor * $678.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7995.24","7987.89","7997.50","1 through 10","7908.36","12964.6781","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","57780.61","43335.46","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10798.92","","Case rate ($10,484.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,543.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,188.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,331.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,213.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,163.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.32. The transfer capital threshold is the transfer adjustment factor * $891.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9557.41","9557.41","9557.41","1 through 10","10274.7","17351.01","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","57780.61","43335.46","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","10484.39","","Case rate ($10,484.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,543.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,188.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,331.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,213.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,163.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.32. The transfer capital threshold is the transfer adjustment factor * $891.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","82080.16","82080.16","82080.16","1 through 10","10274.7","17351.01","other","Inpatient Replacement Plans DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","57780.61","43335.46","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","10484.39","","Case rate ($10,484.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,543.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,188.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,331.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,213.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,163.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.32. The transfer capital threshold is the transfer adjustment factor * $891.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10314.75","10275.80","36258.62","1 through 10","10274.7","17351.01","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","57780.61","43335.46","MEDICARE [2001]","HB BWH MEDICARE","10484.39","","Case rate ($10,484.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,543.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,188.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,331.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,213.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,163.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.32. The transfer capital threshold is the transfer adjustment factor * $891.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13517.50","678.31","13537.31","29","10274.7","17351.01","other","Inpatient Replacement Plans DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","57780.61","43335.46","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10274.70","","Case rate ($10,484.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,543.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,188.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,331.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,213.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,163.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.32. The transfer capital threshold is the transfer adjustment factor * $891.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10312.18","10309.21","10377.08","1 through 10","10274.7","17351.01","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","57780.61","43335.46","WELLSENSE [1003]","HB BWH MEDICARE","10484.39","","Case rate ($10,484.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,543.73, add-ons for qualifying new technology services are included. If operating cost exceeds $58,188.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,331.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,213.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,163.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.32. The transfer capital threshold is the transfer adjustment factor * $891.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10606.42","10606.42","10606.42","1 through 10","10274.7","17351.01","other","Inpatient Replacement Plans DRG"
"Chronic Obstructive Pulmonary Disease Without Cc/McC","192","MS-DRG","","","","","","","","inpatient","","","27472.20","20604.15","MEDICARE [2001]","HB BWH MEDICARE","6236.23","","Case rate ($6,236.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,429.78, add-ons for qualifying new technology services are included. If operating cost exceeds $53,074.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,956.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,339.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,049.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $516.59. The transfer capital threshold is the transfer adjustment factor * $516.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","701.03","701.03","701.03","1 through 10","6111.51","9766.8952","other","Inpatient Replacement Plans DRG"
"Chronic Obstructive Pulmonary Disease Without Cc/McC","192","MS-DRG","","","","","","","","inpatient","","","27472.20","20604.15","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6111.51","","Case rate ($6,236.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,429.78, add-ons for qualifying new technology services are included. If operating cost exceeds $53,074.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,956.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,339.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,049.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $516.59. The transfer capital threshold is the transfer adjustment factor * $516.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6060.99","6060.99","6060.99","1 through 10","6111.51","9766.8952","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease,EXTREME","140","DRG","","","","","","","","inpatient","","","57780.61","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13183.1098","","Fee schedule rate ($40,081.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13183.1098","47154.12","47154.12","1 through 10","5706.12","66134.23","case rate",""
"Chronic Obstructive Pulmonary Disease,EXTREME","140","DRG","","","","","","","","inpatient","","","57780.61","","MASSHEALTH [3001]","HB BWH MEDICAID","11198.61","","Case rate ($12,381.99). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,811.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12378.95","12378.95","12378.95","1 through 10","5706.12","66134.23","case rate",""
"Chronic Obstructive Pulmonary Disease,EXTREME","140","DRG","","","","","","","","inpatient","","","57780.61","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34190.14","","Fee schedule rate ($34,190.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2396), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40224.01","40224.01","40224.01","1 through 10","5706.12","66134.23","case rate",""
"Chronic Obstructive Pulmonary Disease,EXTREME","140","DRG","","","","","","","","inpatient","","","57780.61","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11198.61","","Case rate ($12,381.99). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,811.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12378.95","12378.95","12378.95","1 through 10","5706.12","66134.23","case rate",""
"Chronic Obstructive Pulmonary Disease,MAJOR","140","DRG","","","","","","","","inpatient","","","68523.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","28415.34","","Standard inlier is a Case rate ($28,415.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,301, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,033.32) for the length of stay and the standard reimbursement.","25959.86","25959.86","28415.34","1 through 10","5706.12","66134.23","case rate",""
"Chronic Obstructive Pulmonary Disease,MAJOR","140","DRG","","","","","","","","inpatient","","","68523.50","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13183.1098","","Fee schedule rate ($24,420.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13183.1098","24420.29","24420.29","1 through 10","5706.12","66134.23","case rate",""
"Chronic Obstructive Pulmonary Disease,MAJOR","140","DRG","","","","","","","","inpatient","","","68523.50","","MASSHEALTH [3001]","HB BWH MEDICAID","6950.15","","Case rate ($7,684.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,114.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12378.95","12378.95","12378.95","1 through 10","5706.12","66134.23","case rate",""
"Chronic Obstructive Pulmonary Disease,MAJOR","140","DRG","","","","","","","","inpatient","","","68523.50","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","21594.27","","Fee schedule rate ($21,594.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18355.01","18355.01","18355.01","1 through 10","5706.12","66134.23","case rate",""
"Chronic Obstructive Pulmonary Disease,MODERATE","140","DRG","","","","","","","","inpatient","","","36089.11","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20843.77","","Standard inlier is a Case rate ($20,843.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,856, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,958.90) for the length of stay and the standard reimbursement.","20843.77","20843.77","20843.77","1 through 10","5706.12","66134.23","case rate",""
"Chronic Obstructive Pulmonary Disease,MODERATE","140","DRG","","","","","","","","inpatient","","","36089.11","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","23434.02","","Standard inlier is a Case rate ($23,434.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,856, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,326.26) for the length of stay and the standard reimbursement.","23434.02","23434.02","23434.02","1 through 10","5706.12","66134.23","case rate",""
"Chronic Obstructive Pulmonary Disease,MODERATE","140","DRG","","","","","","","","inpatient","","","36089.11","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21340.61","","Fee schedule rate ($21,340.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30008.59","30008.59","30008.59","1 through 10","5706.12","66134.23","case rate",""
"Chronic Obstructive Pulmonary Disease,MODERATE","140","DRG","","","","","","","","inpatient","","","36089.11","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5706.12","","Case rate ($6,309.09). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,739.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6307.55","6307.55","6307.55","1 through 10","5706.12","66134.23","case rate",""
"Chrpc, Mayo Chrpc Chromosome Analysis Autopsy POC or Stillbirth","PX-31001270","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2946.27","79.5","","2828.48","1814.97","2828.48","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Chrpc, Mayo Chrpc Chromosome Analysis Autopsy POC or Stillbirth","PX-31001270","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1975.30","53.3","","1814.97","1761.95","1814.97","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Chrpc, Mayo Chrpc Chromosome Analysis Autopsy POC or Stillbirth","PX-31001270","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1352.69","36.5","","1340.56","1340.56","1340.56","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Chrpc, Mayo Chrpc Chromosome Analysis Autopsy POC or Stillbirth","PX-31001270","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1419.40","38.3","","1405.25","1405.25","1405.25","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Chrpc, Mayo Chrpc Chromosome Analysis Autopsy POC or Stillbirth","PX-31001270","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","WELLPOINT [1015]","HB AMC WELLPOINT","2734.29","73.78","","6269.73","2675.73","7188.00","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Chrpc, Mayo Chrpc Chromosome Analysis Autopsy POC or Stillbirth","PX-31001270","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","AETNA [1001]","HB AMC AETNA HMO","2586.79","69.8","","2433.14","2433.14","2433.14","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Chrpc, Mayo Chrpc Chromosome Analysis Autopsy POC or Stillbirth","PX-31001270","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2979.62","80.4","","2803.32","2803.32","2803.32","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Chrpc, Mayo Chrpc Chromosome Analysis Autopsy POC or Stillbirth","PX-31001270","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3028.54","81.72","","2873.04","1533.07","3526.61","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Ciprofloxacin Vl 200mg 20ml","PX-63600084","CDM","J0744","HCPCS","0636","RC","","","","both","","","6.80","5.10","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4.76","70","","4.25","4.25","4.25","1 through 10","2.11","5.24","percent of total billed charges",""
"Ciprofloxacin Vl 200mg 20ml","PX-63600084","CDM","J0744","HCPCS","0636","RC","","","","both","","","6.80","5.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2.48","36.5","","1.75","1.35","6.18","22","2.11","5.24","percent of total billed charges",""
"Ciprofloxacin Vl 200mg 20ml","PX-63600084","CDM","J0744","HCPCS","0636","RC","","","","both","","","6.80","5.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2.60","38.3","","4.65","1.66","6.48","50","2.11","5.24","percent of total billed charges",""
"Ciprofloxacin Vl 200mg 20ml","PX-63600084","CDM","J0744","HCPCS","0636","RC","","","","outpatient","","","6.80","5.10","AETNA [1001]","HB AMC AETNA HMO","4.75","69.8","","2.88","2.64","3.90","23","3.19","5.47","percent of total billed charges",""
"Ciprofloxacin Vl 200mg 20ml","PX-63600084","CDM","J0744","HCPCS","0636","RC","","","","outpatient","","","6.80","5.10","AETNA [1001]","HB AMC AETNA PPO","5.47","80.4","","3.32","3.32","3.32","1 through 10","3.19","5.47","percent of total billed charges",""
"Ciprofloxacin Vl 200mg 20ml","PX-63600084","CDM","J0744","HCPCS","0636","RC","","","","outpatient","","","6.80","5.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4.75","69.9","","5.01","2.76","1799.67","23","3.19","5.47","percent of total billed charges",""
"Circulating Tumor Cell Apheresis Research","PX-76002754","CDM","38999","CPT","0761","RC","","","","outpatient","","","5107.00","3830.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2666.88","52.22","","512.50","512.50","512.50","1 through 10","1234.13","4213.28","percent of total billed charges",""
"Circulating Tumor Cell Apheresis Research","PX-76002754","CDM","38999","CPT","0761","RC","","","","outpatient","","","5107.00","3830.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2553.50","50","","6776.11","6776.11","6776.11","1 through 10","1234.13","4213.28","percent of total billed charges",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","153846.64","115384.98","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","21182.20","","Case rate ($20,565.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,679.08, add-ons for qualifying new technology services are included. If operating cost exceeds $70,323.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,220.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $18,404.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,299.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,780.55. The transfer capital threshold is the transfer adjustment factor * $1,780.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","21020.48","21005.86","22470.92","1 through 10","20153.94","34661.3","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","153846.64","115384.98","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","20565.24","","Case rate ($20,565.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,679.08, add-ons for qualifying new technology services are included. If operating cost exceeds $70,323.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,220.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $18,404.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,299.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,780.55. The transfer capital threshold is the transfer adjustment factor * $1,780.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20147.82","20147.82","278568.97","1 through 10","20153.94","34661.3","other","Inpatient Replacement Plans DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","153846.64","115384.98","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","20565.24","","Case rate ($20,565.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,679.08, add-ons for qualifying new technology services are included. If operating cost exceeds $70,323.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,220.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $18,404.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,299.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,780.55. The transfer capital threshold is the transfer adjustment factor * $1,780.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20120.15","19993.87","31197.16","1 through 10","20153.94","34661.3","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","153846.64","115384.98","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","20826.90","20826.90","27770.00","1 through 10","20153.94","34661.3","case rate",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","153846.64","115384.98","HUMANA [1012]","HB BWH MEDICARE","20565.24","","Case rate ($20,565.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,679.08, add-ons for qualifying new technology services are included. If operating cost exceeds $70,323.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,220.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $18,404.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,299.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,780.55. The transfer capital threshold is the transfer adjustment factor * $1,780.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30804.44","30804.44","30804.44","1 through 10","20153.94","34661.3","other","Inpatient Replacement Plans DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","153846.64","115384.98","MEDICARE [2001]","HB BWH MEDICARE","20565.24","","Case rate ($20,565.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,679.08, add-ons for qualifying new technology services are included. If operating cost exceeds $70,323.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,220.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $18,404.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,299.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,780.55. The transfer capital threshold is the transfer adjustment factor * $1,780.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26402.01","0.03","30364.36","107","20153.94","34661.3","other","Inpatient Replacement Plans DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","153846.64","115384.98","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","20565.24","","Case rate ($20,565.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,679.08, add-ons for qualifying new technology services are included. If operating cost exceeds $70,323.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,220.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $18,404.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,299.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,780.55. The transfer capital threshold is the transfer adjustment factor * $1,780.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","141.73","141.73","141.73","1 through 10","20153.94","34661.3","other","Inpatient Replacement Plans DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","153846.64","115384.98","MOLINA [1014]","HB BWH MOLINA","20153.94","","Case rate ($20,565.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,679.08, add-ons for qualifying new technology services are included. If operating cost exceeds $70,323.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,220.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $18,404.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,299.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,780.55. The transfer capital threshold is the transfer adjustment factor * $1,780.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","40400.33","40400.33","40400.33","1 through 10","20153.94","34661.3","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","153846.64","115384.98","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","20153.94","","Case rate ($20,565.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,679.08, add-ons for qualifying new technology services are included. If operating cost exceeds $70,323.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,220.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $18,404.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,299.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,780.55. The transfer capital threshold is the transfer adjustment factor * $1,780.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19987.86","19960.40","20069.93","1 through 10","20153.94","34661.3","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","153846.64","115384.98","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","20153.94","","Case rate ($20,565.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,679.08, add-ons for qualifying new technology services are included. If operating cost exceeds $70,323.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,220.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $18,404.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,299.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,780.55. The transfer capital threshold is the transfer adjustment factor * $1,780.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26642.78","26642.78","26642.78","1 through 10","20153.94","34661.3","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","153846.64","115384.98","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20153.94","","Case rate ($20,565.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,679.08, add-ons for qualifying new technology services are included. If operating cost exceeds $70,323.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,220.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $18,404.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,299.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,780.55. The transfer capital threshold is the transfer adjustment factor * $1,780.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20083.55","19960.38","43352.08","19","20153.94","34661.3","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","153846.64","115384.98","WELLPOINT [1015]","HB AMC WELLPOINT","34661.30","","Fee schedule rate ($34,661.30).","78632.77","33400.91","133190.44","1 through 10","20153.94","34661.3","case rate",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","78384.72","58788.54","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10445.65","","Case rate ($10,141.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,130.84, add-ons for qualifying new technology services are included. If operating cost exceeds $57,775.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,900.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,751.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.07. The transfer capital threshold is the transfer adjustment factor * $861.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10493.77","10493.77","10534.17","1 through 10","9938.58","16444.6627","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","78384.72","58788.54","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","10141.41","","Case rate ($10,141.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,130.84, add-ons for qualifying new technology services are included. If operating cost exceeds $57,775.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,900.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,751.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.07. The transfer capital threshold is the transfer adjustment factor * $861.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10070.30","10070.30","10070.30","1 through 10","9938.58","16444.6627","other","Inpatient Replacement Plans DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","78384.72","58788.54","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","12676.76","","Case rate ($10,141.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,130.84, add-ons for qualifying new technology services are included. If operating cost exceeds $57,775.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,900.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,751.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.07. The transfer capital threshold is the transfer adjustment factor * $861.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","10210.54","10210.54","10210.54","1 through 10","9938.58","16444.6627","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","78384.72","58788.54","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","10141.41","","Case rate ($10,141.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,130.84, add-ons for qualifying new technology services are included. If operating cost exceeds $57,775.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,900.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,751.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.07. The transfer capital threshold is the transfer adjustment factor * $861.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10011.57","10011.57","10066.02","1 through 10","9938.58","16444.6627","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","78384.72","58788.54","MEDICARE [2001]","HB BWH MEDICARE","10141.41","","Case rate ($10,141.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,130.84, add-ons for qualifying new technology services are included. If operating cost exceeds $57,775.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,900.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,751.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.07. The transfer capital threshold is the transfer adjustment factor * $861.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13124.93","0.03","13144.15","64","9938.58","16444.6627","other","Inpatient Replacement Plans DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","78384.72","58788.54","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","10141.41","","Case rate ($10,141.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,130.84, add-ons for qualifying new technology services are included. If operating cost exceeds $57,775.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,900.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,751.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.07. The transfer capital threshold is the transfer adjustment factor * $861.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9979.19","9979.19","10010.21","1 through 10","9938.58","16444.6627","other","Inpatient Replacement Plans DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","78384.72","58788.54","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9938.58","","Case rate ($10,141.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,130.84, add-ons for qualifying new technology services are included. If operating cost exceeds $57,775.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,900.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,751.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.07. The transfer capital threshold is the transfer adjustment factor * $861.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10019.07","10019.07","26547.74","1 through 10","9938.58","16444.6627","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","78384.72","58788.54","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9938.58","","Case rate ($10,141.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,130.84, add-ons for qualifying new technology services are included. If operating cost exceeds $57,775.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,900.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,751.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.07. The transfer capital threshold is the transfer adjustment factor * $861.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10010.36","10005.30","10065.44","1 through 10","9938.58","16444.6627","other","Inpatient DRG"
"Circumcision W/Clamp or Othr Device","PX-76001306","CDM","54150","CPT","0723","RC","","","","both","","","1034.00","775.50","MEDICARE [2001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","1 through 10","320.54","3040.6","other","OPPS APC"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","","","","inpatient","","","54511.96","40883.97","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","10014.62","","Case rate ($10,014.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,978.20, add-ons for qualifying new technology services are included. If operating cost exceeds $57,622.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,290.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,784.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,598.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.88. The transfer capital threshold is the transfer adjustment factor * $849.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9851.02","9851.02","9851.02","1 through 10","9814.33","16144.3518","other","Inpatient DRG"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","","","","inpatient","","","54511.96","40883.97","MEDICARE [2001]","HB BWH MEDICARE","10014.62","","Case rate ($10,014.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,978.20, add-ons for qualifying new technology services are included. If operating cost exceeds $57,622.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,290.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,784.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,598.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.88. The transfer capital threshold is the transfer adjustment factor * $849.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12890.32","0.03","12909.18","1 through 10","9814.33","16144.3518","other","Inpatient Replacement Plans DRG"
"Cirrhosis And Alcoholic Hepatitis With McC","432","MS-DRG","","","","","","","","inpatient","","","105386.73","79040.05","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","18883.99","","Case rate ($18,333.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,993.07, add-ons for qualifying new technology services are included. If operating cost exceeds $67,637.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,023.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,370.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,613.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,583.73. The transfer capital threshold is the transfer adjustment factor * $1,583.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","18756.65","18756.65","18756.65","1 through 10","17967.29","30829.88","other","Inpatient DRG"
"Cirrhosis And Alcoholic Hepatitis With McC","432","MS-DRG","","","","","","","","inpatient","","","105386.73","79040.05","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","18333.97","","Case rate ($18,333.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,993.07, add-ons for qualifying new technology services are included. If operating cost exceeds $67,637.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,023.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,370.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,613.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,583.73. The transfer capital threshold is the transfer adjustment factor * $1,583.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34843.78","34843.78","102267.79","1 through 10","17967.29","30829.88","other","Inpatient DRG"
"Cirrhosis And Alcoholic Hepatitis With McC","432","MS-DRG","","","","","","","","inpatient","","","105386.73","79040.05","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","27721.63","27721.63","27721.63","1 through 10","17967.29","30829.88","case rate",""
"Cirrhosis And Alcoholic Hepatitis With McC","432","MS-DRG","","","","","","","","inpatient","","","105386.73","79040.05","MEDICARE [2001]","HB BWH MEDICARE","18333.97","","Case rate ($18,333.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,993.07, add-ons for qualifying new technology services are included. If operating cost exceeds $67,637.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,023.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,370.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,613.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,583.73. The transfer capital threshold is the transfer adjustment factor * $1,583.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23408.95","0.03","23408.95","16","17967.29","30829.88","other","Inpatient Replacement Plans DRG"
"Cirrhosis And Alcoholic Hepatitis With McC","432","MS-DRG","","","","","","","","inpatient","","","105386.73","79040.05","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17967.29","","Case rate ($18,333.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,993.07, add-ons for qualifying new technology services are included. If operating cost exceeds $67,637.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,023.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,370.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,613.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,583.73. The transfer capital threshold is the transfer adjustment factor * $1,583.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17832.40","17832.40","17832.40","1 through 10","17967.29","30829.88","other","Inpatient DRG"
"Cirrhosis And Alcoholic Hepatitis With McC","432","MS-DRG","","","","","","","","inpatient","","","105386.73","79040.05","WELLPOINT [1015]","HB AMC WELLPOINT","30829.88","","Fee schedule rate ($30,829.88).","90690.13","90690.13","90690.13","1 through 10","17967.29","30829.88","case rate",""
"Citrate","PX-30000377","CDM","82507","CPT","0301","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","126.39","38.3","","105.60","105.60","105.60","1 through 10","27.24","313.5","percent of total billed charges",""
"Citrate","PX-30000377","CDM","82507","CPT","0301","RC","","","","outpatient","","","330.00","247.50","AETNA [1001]","HB AMC AETNA HMO","230.34","69.8","","216.64","216.64","216.64","1 through 10","28.67","269.68","percent of total billed charges",""
"Citrate","PX-30000377","CDM","82507","CPT","0301","RC","","","","outpatient","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","269.68","81.72","","255.81","255.81","255.81","1 through 10","28.67","269.68","percent of total billed charges",""
"CLAMP BONE 1 HOLE 3.5MM OCCIPITAL TI ROD","SUP-ITM-10032554","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","800.18","480.96","1887.97","195","922.25","2365.13","percent of total billed charges",""
"CLAMP BONE 1 HOLE 3.5MM OCCIPITAL TI ROD","SUP-ITM-10032554","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1585.68","53.3","","813.12","216.42","1444.50","81","922.25","2365.13","percent of total billed charges",""
"CLAMP BONE 1 HOLE 3.5MM OCCIPITAL TI ROD","SUP-ITM-10032554","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","922.25","31","","432.60","432.60","432.60","1 through 10","922.25","2365.13","percent of total billed charges",""
"CLAMP BONE 1 HOLE 3.5MM OCCIPITAL TI ROD","SUP-ITM-10032554","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","148.37","54.89","631.39","94","922.25","2365.13","percent of total billed charges",""
"CLAMP BONE 1 HOLE 3.5MM OCCIPITAL TI ROD","SUP-ITM-10032554","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","279.30","91.72","1116.77","266","922.25","2365.13","percent of total billed charges",""
"CLAMP BONE 1 HOLE 3.5MM OCCIPITAL TI ROD","SUP-ITM-10032554","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","731.00","63.70","731.00","1 through 10","922.25","2365.13","percent of total billed charges",""
"CLAMP BONE 1 HOLE 3.5MM OCCIPITAL TI ROD","SUP-ITM-10032554","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","384.74","384.74","384.74","1 through 10","922.25","2365.13","percent of total billed charges",""
"CLAMP BONE 1 HOLE 3.5MM OCCIPITAL TI ROD","SUP-ITM-10032554","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","WELLPOINT [1015]","HB AMC WELLPOINT","2194.96","73.78","","286.63","119.22","1107.45","105","922.25","2365.13","percent of total billed charges",""
"CLAMP BONE 1 HOLE 3.5MM OCCIPITAL TI ROD","SUP-ITM-10032554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","675.31","184.75","1721.50","286","1554.74","2431.17","percent of total billed charges",""
"CLAMP BONE 1 HOLE 3.5MM OCCIPITAL TI ROD","SUP-ITM-10032554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA PPO","2391.90","80.4","","1261.44","103.12","1514.10","21","1554.74","2431.17","percent of total billed charges",""
"CLAMP BONE 1 HOLE 3.5MM OCCIPITAL TI ROD","SUP-ITM-10032554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2391.90","80.4","","1365.00","1365.00","1365.00","1 through 10","1554.74","2431.17","percent of total billed charges",""
"CLAMP BONE 1 HOLE 3.5MM OCCIPITAL TI ROD","SUP-ITM-10032554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2431.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1554.74","2431.17","percent of total billed charges",""
"CLAMP BONE 1 HOLE 3.5MM OCCIPITAL TI ROD","SUP-ITM-10032554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","431.26","71.26","1459.57","88","1554.74","2431.17","percent of total billed charges",""
"CLAMP BONE SPINE FRACTURE WITH POSTERIOR NUT TITANIUM CS/1BX/1EA","SUP-ITM-10005407","CDM","C1889","HCPCS","0278","RC","","","","both","","","1225.00","918.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","973.88","79.5","","1309.77","674.56","6049.93","26","379.75","973.88","percent of total billed charges",""
"CLAMP BONE SPINE FRACTURE WITH POSTERIOR NUT TITANIUM CS/1BX/1EA","SUP-ITM-10005407","CDM","C1889","HCPCS","0278","RC","","","","both","","","1225.00","918.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","652.93","53.3","","1901.83","1901.83","2962.25","1 through 10","379.75","973.88","percent of total billed charges",""
"CLAMP BONE SPINE FRACTURE WITH POSTERIOR NUT TITANIUM CS/1BX/1EA","SUP-ITM-10005407","CDM","C1889","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","447.13","36.5","","1620.31","1620.31","19908.88","1 through 10","379.75","973.88","percent of total billed charges",""
"CLAMP BONE SPINE FRACTURE WITH POSTERIOR NUT TITANIUM CS/1BX/1EA","SUP-ITM-10005407","CDM","C1889","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","469.18","38.3","","352.91","352.91","2046.30","1 through 10","379.75","973.88","percent of total billed charges",""
"CLAMP BONE SPINE FRACTURE WITH POSTERIOR NUT TITANIUM CS/1BX/1EA","SUP-ITM-10005407","CDM","C1889","HCPCS","0278","RC","","","","both","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","525.53","42.9","","9668.75","9668.75","9668.75","1 through 10","379.75","973.88","percent of total billed charges",""
"CLAMP BONE SPINE FRACTURE WITH POSTERIOR NUT TITANIUM CS/1BX/1EA","SUP-ITM-10005407","CDM","C1889","HCPCS","0278","RC","","","","both","","","1225.00","918.75","WELLPOINT [1015]","HB AMC WELLPOINT","903.81","73.78","","699.88","384.10","3443.31","33","379.75","973.88","percent of total billed charges",""
"CLAMP BONE SPINE FRACTURE WITH POSTERIOR NUT TITANIUM CS/1BX/1EA","SUP-ITM-10005407","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","AETNA [1001]","HB AMC AETNA HMO","855.05","69.8","","1421.24","264.50","4933.46","29","640.19","1001.07","percent of total billed charges",""
"CLAMP BONE SPINE FRACTURE WITH POSTERIOR NUT TITANIUM CS/1BX/1EA","SUP-ITM-10005407","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","984.90","80.4","","1022.97","1022.97","3607.50","1 through 10","640.19","1001.07","percent of total billed charges",""
"CLAMP BONE SPINE FRACTURE WITH POSTERIOR NUT TITANIUM CS/1BX/1EA","SUP-ITM-10005407","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1001.07","81.72","","3010.54","693.88","5019.88","35","640.19","1001.07","percent of total billed charges",""
"CLAMP OCCIPITAL TI 1 HOLE","SUP-ITM-10086838","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","1309.77","674.56","6049.93","26","922.25","2365.13","percent of total billed charges",""
"CLAMP OCCIPITAL TI 1 HOLE","SUP-ITM-10086838","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1585.68","53.3","","1901.83","1901.83","2962.25","1 through 10","922.25","2365.13","percent of total billed charges",""
"CLAMP OCCIPITAL TI 1 HOLE","SUP-ITM-10086838","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","1620.31","1620.31","19908.88","1 through 10","922.25","2365.13","percent of total billed charges",""
"CLAMP OCCIPITAL TI 1 HOLE","SUP-ITM-10086838","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","352.91","352.91","2046.30","1 through 10","922.25","2365.13","percent of total billed charges",""
"CLAMP OCCIPITAL TI 1 HOLE","SUP-ITM-10086838","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","9668.75","9668.75","9668.75","1 through 10","922.25","2365.13","percent of total billed charges",""
"CLAMP OCCIPITAL TI 1 HOLE","SUP-ITM-10086838","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","WELLPOINT [1015]","HB AMC WELLPOINT","2194.96","73.78","","699.88","384.10","3443.31","33","922.25","2365.13","percent of total billed charges",""
"CLAMP OCCIPITAL TI 1 HOLE","SUP-ITM-10086838","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","1421.24","264.50","4933.46","29","1554.74","2431.17","percent of total billed charges",""
"CLAMP OCCIPITAL TI 1 HOLE","SUP-ITM-10086838","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2391.90","80.4","","1022.97","1022.97","3607.50","1 through 10","1554.74","2431.17","percent of total billed charges",""
"CLAMP OCCIPITAL TI 1 HOLE","SUP-ITM-10086838","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","3010.54","693.88","5019.88","35","1554.74","2431.17","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.00","2970.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3148.20","79.5","","800.18","480.96","1887.97","195","1227.6","3148.2","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.00","2970.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2110.68","53.3","","813.12","216.42","1444.50","81","1227.6","3148.2","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.00","2970.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1227.60","31","","432.60","432.60","432.60","1 through 10","1227.6","3148.2","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.00","2970.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1445.40","36.5","","148.37","54.89","631.39","94","1227.6","3148.2","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.00","2970.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1516.68","38.3","","279.30","91.72","1116.77","266","1227.6","3148.2","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.00","2970.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.84","42.9","","731.00","63.70","731.00","1 through 10","1227.6","3148.2","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.00","2970.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.84","42.9","","384.74","384.74","384.74","1 through 10","1227.6","3148.2","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.00","2970.00","WELLPOINT [1015]","HB AMC WELLPOINT","2921.69","73.78","","286.63","119.22","1107.45","105","1227.6","3148.2","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3960.00","2970.00","AETNA [1001]","HB AMC AETNA HMO","2764.08","69.8","","675.31","184.75","1721.50","286","2069.5","3236.11","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3960.00","2970.00","AETNA [1001]","HB AMC AETNA PPO","3183.84","80.4","","1261.44","103.12","1514.10","21","2069.5","3236.11","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3960.00","2970.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3183.84","80.4","","1365.00","1365.00","1365.00","1 through 10","2069.5","3236.11","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3960.00","2970.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3236.11","81.72","","5157.68","5157.68","5157.68","1 through 10","2069.5","3236.11","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3960.00","2970.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3236.11","81.72","","431.26","71.26","1459.57","88","2069.5","3236.11","percent of total billed charges",""
"CLAVICLE PLATE 122MM 8 HOLE SHAFT VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MID RT REPROCESSED","SUP-ITM-10144656","CDM","C1713","HCPCS","0278","RC","","","","both","","","5023.80","3767.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3993.92","79.5","","800.18","480.96","1887.97","195","1557.38","3993.92","percent of total billed charges",""
"CLAVICLE PLATE 122MM 8 HOLE SHAFT VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MID RT REPROCESSED","SUP-ITM-10144656","CDM","C1713","HCPCS","0278","RC","","","","both","","","5023.80","3767.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2677.69","53.3","","813.12","216.42","1444.50","81","1557.38","3993.92","percent of total billed charges",""
"CLAVICLE PLATE 122MM 8 HOLE SHAFT VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MID RT REPROCESSED","SUP-ITM-10144656","CDM","C1713","HCPCS","0278","RC","","","","both","","","5023.80","3767.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1557.38","31","","432.60","432.60","432.60","1 through 10","1557.38","3993.92","percent of total billed charges",""
"CLAVICLE PLATE 122MM 8 HOLE SHAFT VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MID RT REPROCESSED","SUP-ITM-10144656","CDM","C1713","HCPCS","0278","RC","","","","both","","","5023.80","3767.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1833.69","36.5","","148.37","54.89","631.39","94","1557.38","3993.92","percent of total billed charges",""
"CLAVICLE PLATE 122MM 8 HOLE SHAFT VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MID RT REPROCESSED","SUP-ITM-10144656","CDM","C1713","HCPCS","0278","RC","","","","both","","","5023.80","3767.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1924.12","38.3","","279.30","91.72","1116.77","266","1557.38","3993.92","percent of total billed charges",""
"CLAVICLE PLATE 122MM 8 HOLE SHAFT VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MID RT REPROCESSED","SUP-ITM-10144656","CDM","C1713","HCPCS","0278","RC","","","","both","","","5023.80","3767.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2155.21","42.9","","731.00","63.70","731.00","1 through 10","1557.38","3993.92","percent of total billed charges",""
"CLAVICLE PLATE 122MM 8 HOLE SHAFT VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MID RT REPROCESSED","SUP-ITM-10144656","CDM","C1713","HCPCS","0278","RC","","","","both","","","5023.80","3767.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2155.21","42.9","","384.74","384.74","384.74","1 through 10","1557.38","3993.92","percent of total billed charges",""
"CLAVICLE PLATE 122MM 8 HOLE SHAFT VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MID RT REPROCESSED","SUP-ITM-10144656","CDM","C1713","HCPCS","0278","RC","","","","both","","","5023.80","3767.85","WELLPOINT [1015]","HB AMC WELLPOINT","3706.56","73.78","","286.63","119.22","1107.45","105","1557.38","3993.92","percent of total billed charges",""
"CLAVICLE PLATE 122MM 8 HOLE SHAFT VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MID RT REPROCESSED","SUP-ITM-10144656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5023.80","3767.85","AETNA [1001]","HB AMC AETNA HMO","3506.61","69.8","","675.31","184.75","1721.50","286","2625.44","4105.45","percent of total billed charges",""
"CLAVICLE PLATE 122MM 8 HOLE SHAFT VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MID RT REPROCESSED","SUP-ITM-10144656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5023.80","3767.85","AETNA [1001]","HB AMC AETNA PPO","4039.14","80.4","","1261.44","103.12","1514.10","21","2625.44","4105.45","percent of total billed charges",""
"CLAVICLE PLATE 122MM 8 HOLE SHAFT VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MID RT REPROCESSED","SUP-ITM-10144656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5023.80","3767.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4039.14","80.4","","1365.00","1365.00","1365.00","1 through 10","2625.44","4105.45","percent of total billed charges",""
"CLAVICLE PLATE 122MM 8 HOLE SHAFT VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MID RT REPROCESSED","SUP-ITM-10144656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5023.80","3767.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4105.45","81.72","","5157.68","5157.68","5157.68","1 through 10","2625.44","4105.45","percent of total billed charges",""
"CLAVICLE PLATE 122MM 8 HOLE SHAFT VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MID RT REPROCESSED","SUP-ITM-10144656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5023.80","3767.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4105.45","81.72","","431.26","71.26","1459.57","88","2625.44","4105.45","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.77","2431.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2577.21","79.5","","800.18","480.96","1887.97","195","1004.95","2577.21","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.77","2431.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1727.86","53.3","","813.12","216.42","1444.50","81","1004.95","2577.21","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.77","2431.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1004.95","31","","432.60","432.60","432.60","1 through 10","1004.95","2577.21","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.77","2431.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1183.25","36.5","","148.37","54.89","631.39","94","1004.95","2577.21","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.77","2431.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1241.60","38.3","","279.30","91.72","1116.77","266","1004.95","2577.21","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.77","2431.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1390.72","42.9","","731.00","63.70","731.00","1 through 10","1004.95","2577.21","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.77","2431.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1390.72","42.9","","384.74","384.74","384.74","1 through 10","1004.95","2577.21","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.77","2431.33","WELLPOINT [1015]","HB AMC WELLPOINT","2391.78","73.78","","286.63","119.22","1107.45","105","1004.95","2577.21","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3241.77","2431.33","AETNA [1001]","HB AMC AETNA HMO","2262.76","69.8","","675.31","184.75","1721.50","286","1694.15","2649.17","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3241.77","2431.33","AETNA [1001]","HB AMC AETNA PPO","2606.38","80.4","","1261.44","103.12","1514.10","21","1694.15","2649.17","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3241.77","2431.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2606.38","80.4","","1365.00","1365.00","1365.00","1 through 10","1694.15","2649.17","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3241.77","2431.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2649.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1694.15","2649.17","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3241.77","2431.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2649.17","81.72","","431.26","71.26","1459.57","88","1694.15","2649.17","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2609.85","79.5","","800.18","480.96","1887.97","195","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1749.75","53.3","","813.12","216.42","1444.50","81","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1017.68","31","","432.60","432.60","432.60","1 through 10","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1198.23","36.5","","148.37","54.89","631.39","94","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1257.32","38.3","","279.30","91.72","1116.77","266","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1408.33","42.9","","731.00","63.70","731.00","1 through 10","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1408.33","42.9","","384.74","384.74","384.74","1 through 10","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","WELLPOINT [1015]","HB AMC WELLPOINT","2422.07","73.78","","286.63","119.22","1107.45","105","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.83","2462.12","AETNA [1001]","HB AMC AETNA HMO","2291.42","69.8","","675.31","184.75","1721.50","286","1715.61","2682.73","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.83","2462.12","AETNA [1001]","HB AMC AETNA PPO","2639.40","80.4","","1261.44","103.12","1514.10","21","1715.61","2682.73","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.83","2462.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2639.40","80.4","","1365.00","1365.00","1365.00","1 through 10","1715.61","2682.73","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.83","2462.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2682.73","81.72","","5157.68","5157.68","5157.68","1 through 10","1715.61","2682.73","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.83","2462.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2682.73","81.72","","431.26","71.26","1459.57","88","1715.61","2682.73","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037955","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2609.85","79.5","","800.18","480.96","1887.97","195","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037955","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1749.75","53.3","","813.12","216.42","1444.50","81","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037955","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1017.68","31","","432.60","432.60","432.60","1 through 10","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037955","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1198.23","36.5","","148.37","54.89","631.39","94","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037955","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1257.32","38.3","","279.30","91.72","1116.77","266","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037955","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1408.33","42.9","","731.00","63.70","731.00","1 through 10","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037955","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1408.33","42.9","","384.74","384.74","384.74","1 through 10","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037955","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.83","2462.12","WELLPOINT [1015]","HB AMC WELLPOINT","2422.07","73.78","","286.63","119.22","1107.45","105","1017.68","2609.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.83","2462.12","AETNA [1001]","HB AMC AETNA HMO","2291.42","69.8","","675.31","184.75","1721.50","286","1715.61","2682.73","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.83","2462.12","AETNA [1001]","HB AMC AETNA PPO","2639.40","80.4","","1261.44","103.12","1514.10","21","1715.61","2682.73","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.83","2462.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2639.40","80.4","","1365.00","1365.00","1365.00","1 through 10","1715.61","2682.73","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.83","2462.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2682.73","81.72","","5157.68","5157.68","5157.68","1 through 10","1715.61","2682.73","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.83","2462.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2682.73","81.72","","431.26","71.26","1459.57","88","1715.61","2682.73","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","3376.07","2532.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2683.98","79.5","","800.18","480.96","1887.97","195","1046.58","2683.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","3376.07","2532.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1799.45","53.3","","813.12","216.42","1444.50","81","1046.58","2683.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","3376.07","2532.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1046.58","31","","432.60","432.60","432.60","1 through 10","1046.58","2683.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","3376.07","2532.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1232.27","36.5","","148.37","54.89","631.39","94","1046.58","2683.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","3376.07","2532.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1293.03","38.3","","279.30","91.72","1116.77","266","1046.58","2683.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","3376.07","2532.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1448.33","42.9","","731.00","63.70","731.00","1 through 10","1046.58","2683.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","3376.07","2532.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1448.33","42.9","","384.74","384.74","384.74","1 through 10","1046.58","2683.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","3376.07","2532.05","WELLPOINT [1015]","HB AMC WELLPOINT","2490.86","73.78","","286.63","119.22","1107.45","105","1046.58","2683.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3376.07","2532.05","AETNA [1001]","HB AMC AETNA HMO","2356.50","69.8","","675.31","184.75","1721.50","286","1764.33","2758.92","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3376.07","2532.05","AETNA [1001]","HB AMC AETNA PPO","2714.36","80.4","","1261.44","103.12","1514.10","21","1764.33","2758.92","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3376.07","2532.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2714.36","80.4","","1365.00","1365.00","1365.00","1 through 10","1764.33","2758.92","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3376.07","2532.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2758.92","81.72","","5157.68","5157.68","5157.68","1 through 10","1764.33","2758.92","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3376.07","2532.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2758.92","81.72","","431.26","71.26","1459.57","88","1764.33","2758.92","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2798.25","79.5","","800.18","480.96","1887.97","195","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1876.06","53.3","","813.12","216.42","1444.50","81","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1091.14","31","","432.60","432.60","432.60","1 through 10","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1284.73","36.5","","148.37","54.89","631.39","94","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1348.09","38.3","","279.30","91.72","1116.77","266","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1510.00","42.9","","731.00","63.70","731.00","1 through 10","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1510.00","42.9","","384.74","384.74","384.74","1 through 10","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","WELLPOINT [1015]","HB AMC WELLPOINT","2596.92","73.78","","286.63","119.22","1107.45","105","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3519.81","2639.86","AETNA [1001]","HB AMC AETNA HMO","2456.83","69.8","","675.31","184.75","1721.50","286","1839.45","2876.39","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3519.81","2639.86","AETNA [1001]","HB AMC AETNA PPO","2829.93","80.4","","1261.44","103.12","1514.10","21","1839.45","2876.39","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3519.81","2639.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2829.93","80.4","","1365.00","1365.00","1365.00","1 through 10","1839.45","2876.39","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3519.81","2639.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2876.39","81.72","","5157.68","5157.68","5157.68","1 through 10","1839.45","2876.39","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3519.81","2639.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2876.39","81.72","","431.26","71.26","1459.57","88","1839.45","2876.39","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2798.25","79.5","","800.18","480.96","1887.97","195","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1876.06","53.3","","813.12","216.42","1444.50","81","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1091.14","31","","432.60","432.60","432.60","1 through 10","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1284.73","36.5","","148.37","54.89","631.39","94","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1348.09","38.3","","279.30","91.72","1116.77","266","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1510.00","42.9","","731.00","63.70","731.00","1 through 10","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1510.00","42.9","","384.74","384.74","384.74","1 through 10","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3519.81","2639.86","WELLPOINT [1015]","HB AMC WELLPOINT","2596.92","73.78","","286.63","119.22","1107.45","105","1091.14","2798.25","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3519.81","2639.86","AETNA [1001]","HB AMC AETNA HMO","2456.83","69.8","","675.31","184.75","1721.50","286","1839.45","2876.39","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3519.81","2639.86","AETNA [1001]","HB AMC AETNA PPO","2829.93","80.4","","1261.44","103.12","1514.10","21","1839.45","2876.39","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3519.81","2639.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2829.93","80.4","","1365.00","1365.00","1365.00","1 through 10","1839.45","2876.39","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3519.81","2639.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2876.39","81.72","","5157.68","5157.68","5157.68","1 through 10","1839.45","2876.39","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3519.81","2639.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2876.39","81.72","","431.26","71.26","1459.57","88","1839.45","2876.39","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.50","3152.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3341.78","79.5","","800.18","480.96","1887.97","195","1303.09","3341.78","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.50","3152.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2240.47","53.3","","813.12","216.42","1444.50","81","1303.09","3341.78","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.50","3152.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1303.09","31","","432.60","432.60","432.60","1 through 10","1303.09","3341.78","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.50","3152.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1534.28","36.5","","148.37","54.89","631.39","94","1303.09","3341.78","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.50","3152.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1609.94","38.3","","279.30","91.72","1116.77","266","1303.09","3341.78","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.50","3152.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1803.30","42.9","","731.00","63.70","731.00","1 through 10","1303.09","3341.78","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.50","3152.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1803.30","42.9","","384.74","384.74","384.74","1 through 10","1303.09","3341.78","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","4203.50","3152.62","WELLPOINT [1015]","HB AMC WELLPOINT","3101.34","73.78","","286.63","119.22","1107.45","105","1303.09","3341.78","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4203.50","3152.62","AETNA [1001]","HB AMC AETNA HMO","2934.04","69.8","","675.31","184.75","1721.50","286","2196.75","3435.1","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4203.50","3152.62","AETNA [1001]","HB AMC AETNA PPO","3379.61","80.4","","1261.44","103.12","1514.10","21","2196.75","3435.1","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4203.50","3152.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3379.61","80.4","","1365.00","1365.00","1365.00","1 through 10","2196.75","3435.1","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4203.50","3152.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3435.10","81.72","","5157.68","5157.68","5157.68","1 through 10","2196.75","3435.1","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4203.50","3152.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3435.10","81.72","","431.26","71.26","1459.57","88","2196.75","3435.1","percent of total billed charges",""
"CLAW FEMORAL 100MM SMALL HIP ARCOS REVISION COBALT TROCHANTERIC MODULAR","SUP-ITM-10122903","CDM","C1776","HCPCS","0278","RC","","","","both","","","3748.50","2811.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1958.97","52.26","","1113.10","1113.10","1113.10","1 through 10","1162.04","2980.06","percent of total billed charges",""
"CLAW FEMORAL 100MM SMALL HIP ARCOS REVISION COBALT TROCHANTERIC MODULAR","SUP-ITM-10122903","CDM","C1776","HCPCS","0278","RC","","","","both","","","3748.50","2811.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2980.06","79.5","","1293.60","1148.53","1603.80","1 through 10","1162.04","2980.06","percent of total billed charges",""
"CLAW FEMORAL 100MM SMALL HIP ARCOS REVISION COBALT TROCHANTERIC MODULAR","SUP-ITM-10122903","CDM","C1776","HCPCS","0278","RC","","","","both","","","3748.50","2811.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1368.20","36.5","","1023.42","771.29","2068.67","33","1162.04","2980.06","percent of total billed charges",""
"CLAW FEMORAL 100MM SMALL HIP ARCOS REVISION COBALT TROCHANTERIC MODULAR","SUP-ITM-10122903","CDM","C1776","HCPCS","0278","RC","","","","both","","","3748.50","2811.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1435.68","38.3","","850.52","759.78","1211.25","66","1162.04","2980.06","percent of total billed charges",""
"CLAW FEMORAL 100MM SMALL HIP ARCOS REVISION COBALT TROCHANTERIC MODULAR","SUP-ITM-10122903","CDM","C1776","HCPCS","0278","RC","","","","both","","","3748.50","2811.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1608.11","42.9","","2548.09","2548.09","2548.09","1 through 10","1162.04","2980.06","percent of total billed charges",""
"CLAW FEMORAL 100MM SMALL HIP ARCOS REVISION COBALT TROCHANTERIC MODULAR","SUP-ITM-10122903","CDM","C1776","HCPCS","0278","RC","","","","both","","","3748.50","2811.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1608.11","42.9","","956.46","956.46","956.46","1 through 10","1162.04","2980.06","percent of total billed charges",""
"CLAW FEMORAL 100MM SMALL HIP ARCOS REVISION COBALT TROCHANTERIC MODULAR","SUP-ITM-10122903","CDM","C1776","HCPCS","0278","RC","","","","both","","","3748.50","2811.37","WELLPOINT [1015]","HB AMC WELLPOINT","2765.64","73.78","","2344.73","1619.47","2530.35","16","1162.04","2980.06","percent of total billed charges",""
"CLAW FEMORAL 100MM SMALL HIP ARCOS REVISION COBALT TROCHANTERIC MODULAR","SUP-ITM-10122903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3748.50","2811.37","AETNA [1001]","HB AMC AETNA HMO","2616.45","69.8","","1523.63","988.41","4330.26","39","1958.97","3063.27","percent of total billed charges",""
"CLAW FEMORAL 100MM SMALL HIP ARCOS REVISION COBALT TROCHANTERIC MODULAR","SUP-ITM-10122903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3748.50","2811.37","AETNA [1001]","HB AMC AETNA PPO","3013.79","80.4","","1670.25","1670.25","1670.25","1 through 10","1958.97","3063.27","percent of total billed charges",""
"CLAW FEMORAL 100MM SMALL HIP ARCOS REVISION COBALT TROCHANTERIC MODULAR","SUP-ITM-10122903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3748.50","2811.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1958.97","52.26","","1113.10","1113.10","1113.10","1 through 10","1958.97","3063.27","percent of total billed charges",""
"CLAW FEMORAL 100MM SMALL HIP ARCOS REVISION COBALT TROCHANTERIC MODULAR","SUP-ITM-10122903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3748.50","2811.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3063.27","81.72","","1738.90","1484.65","2716.94","38","1958.97","3063.27","percent of total billed charges",""
"CLIP ANASTO 0.9MM 40 SMALL VCS VESSEL CLOSURE SYSTEM S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139752","CDM","C1889","HCPCS","0278","RC","","","","both","","","2674.00","2005.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2125.83","79.5","","1309.77","674.56","6049.93","26","828.94","2125.83","percent of total billed charges",""
"CLIP ANASTO 0.9MM 40 SMALL VCS VESSEL CLOSURE SYSTEM S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139752","CDM","C1889","HCPCS","0278","RC","","","","both","","","2674.00","2005.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1425.24","53.3","","1901.83","1901.83","2962.25","1 through 10","828.94","2125.83","percent of total billed charges",""
"CLIP ANASTO 0.9MM 40 SMALL VCS VESSEL CLOSURE SYSTEM S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139752","CDM","C1889","HCPCS","0278","RC","","","","both","","","2674.00","2005.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","976.01","36.5","","1620.31","1620.31","19908.88","1 through 10","828.94","2125.83","percent of total billed charges",""
"CLIP ANASTO 0.9MM 40 SMALL VCS VESSEL CLOSURE SYSTEM S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139752","CDM","C1889","HCPCS","0278","RC","","","","both","","","2674.00","2005.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1024.14","38.3","","352.91","352.91","2046.30","1 through 10","828.94","2125.83","percent of total billed charges",""
"CLIP ANASTO 0.9MM 40 SMALL VCS VESSEL CLOSURE SYSTEM S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139752","CDM","C1889","HCPCS","0278","RC","","","","both","","","2674.00","2005.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1147.15","42.9","","9668.75","9668.75","9668.75","1 through 10","828.94","2125.83","percent of total billed charges",""
"CLIP ANASTO 0.9MM 40 SMALL VCS VESSEL CLOSURE SYSTEM S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139752","CDM","C1889","HCPCS","0278","RC","","","","both","","","2674.00","2005.50","WELLPOINT [1015]","HB AMC WELLPOINT","1972.88","73.78","","699.88","384.10","3443.31","33","828.94","2125.83","percent of total billed charges",""
"CLIP ANASTO 0.9MM 40 SMALL VCS VESSEL CLOSURE SYSTEM S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139752","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2674.00","2005.50","AETNA [1001]","HB AMC AETNA HMO","1866.45","69.8","","1421.24","264.50","4933.46","29","1397.43","2185.19","percent of total billed charges",""
"CLIP ANASTO 0.9MM 40 SMALL VCS VESSEL CLOSURE SYSTEM S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139752","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2674.00","2005.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2149.90","80.4","","1022.97","1022.97","3607.50","1 through 10","1397.43","2185.19","percent of total billed charges",""
"CLIP ANASTO 0.9MM 40 SMALL VCS VESSEL CLOSURE SYSTEM S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139752","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2674.00","2005.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2185.19","81.72","","3010.54","693.88","5019.88","35","1397.43","2185.19","percent of total billed charges",""
"CLIP ANASTO 3.0MM 25 LARGE VCS VESSEL CLOSURE SYSTEM EXTRA S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139476","CDM","C1889","HCPCS","0278","RC","","","","both","","","2705.50","2029.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2150.87","79.5","","1309.77","674.56","6049.93","26","838.71","2150.87","percent of total billed charges",""
"CLIP ANASTO 3.0MM 25 LARGE VCS VESSEL CLOSURE SYSTEM EXTRA S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139476","CDM","C1889","HCPCS","0278","RC","","","","both","","","2705.50","2029.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1442.03","53.3","","1901.83","1901.83","2962.25","1 through 10","838.71","2150.87","percent of total billed charges",""
"CLIP ANASTO 3.0MM 25 LARGE VCS VESSEL CLOSURE SYSTEM EXTRA S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139476","CDM","C1889","HCPCS","0278","RC","","","","both","","","2705.50","2029.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","987.51","36.5","","1620.31","1620.31","19908.88","1 through 10","838.71","2150.87","percent of total billed charges",""
"CLIP ANASTO 3.0MM 25 LARGE VCS VESSEL CLOSURE SYSTEM EXTRA S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139476","CDM","C1889","HCPCS","0278","RC","","","","both","","","2705.50","2029.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1036.21","38.3","","352.91","352.91","2046.30","1 through 10","838.71","2150.87","percent of total billed charges",""
"CLIP ANASTO 3.0MM 25 LARGE VCS VESSEL CLOSURE SYSTEM EXTRA S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139476","CDM","C1889","HCPCS","0278","RC","","","","both","","","2705.50","2029.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1160.66","42.9","","9668.75","9668.75","9668.75","1 through 10","838.71","2150.87","percent of total billed charges",""
"CLIP ANASTO 3.0MM 25 LARGE VCS VESSEL CLOSURE SYSTEM EXTRA S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139476","CDM","C1889","HCPCS","0278","RC","","","","both","","","2705.50","2029.12","WELLPOINT [1015]","HB AMC WELLPOINT","1996.12","73.78","","699.88","384.10","3443.31","33","838.71","2150.87","percent of total billed charges",""
"CLIP ANASTO 3.0MM 25 LARGE VCS VESSEL CLOSURE SYSTEM EXTRA S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2705.50","2029.12","AETNA [1001]","HB AMC AETNA HMO","1888.44","69.8","","1421.24","264.50","4933.46","29","1413.89","2210.93","percent of total billed charges",""
"CLIP ANASTO 3.0MM 25 LARGE VCS VESSEL CLOSURE SYSTEM EXTRA S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2705.50","2029.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2175.22","80.4","","1022.97","1022.97","3607.50","1 through 10","1413.89","2210.93","percent of total billed charges",""
"CLIP ANASTO 3.0MM 25 LARGE VCS VESSEL CLOSURE SYSTEM EXTRA S - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10139476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2705.50","2029.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2210.93","81.72","","3010.54","693.88","5019.88","35","1413.89","2210.93","percent of total billed charges",""
"CLIP ATRICLIP 35MM PROV OPEN ENDED DEVICE","SUP-ITM-10267888","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10931.25","79.5","","1309.77","674.56","6049.93","26","4262.5","10931.25","percent of total billed charges",""
"CLIP ATRICLIP 35MM PROV OPEN ENDED DEVICE","SUP-ITM-10267888","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7328.75","53.3","","1901.83","1901.83","2962.25","1 through 10","4262.5","10931.25","percent of total billed charges",""
"CLIP ATRICLIP 35MM PROV OPEN ENDED DEVICE","SUP-ITM-10267888","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5018.75","36.5","","1620.31","1620.31","19908.88","1 through 10","4262.5","10931.25","percent of total billed charges",""
"CLIP ATRICLIP 35MM PROV OPEN ENDED DEVICE","SUP-ITM-10267888","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5266.25","38.3","","352.91","352.91","2046.30","1 through 10","4262.5","10931.25","percent of total billed charges",""
"CLIP ATRICLIP 35MM PROV OPEN ENDED DEVICE","SUP-ITM-10267888","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5898.75","42.9","","9668.75","9668.75","9668.75","1 through 10","4262.5","10931.25","percent of total billed charges",""
"CLIP ATRICLIP 35MM PROV OPEN ENDED DEVICE","SUP-ITM-10267888","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","WELLPOINT [1015]","HB AMC WELLPOINT","10144.75","73.78","","699.88","384.10","3443.31","33","4262.5","10931.25","percent of total billed charges",""
"CLIP ATRICLIP 35MM PROV OPEN ENDED DEVICE","SUP-ITM-10267888","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13750.00","10312.50","AETNA [1001]","HB AMC AETNA HMO","9597.50","69.8","","1421.24","264.50","4933.46","29","7185.75","11236.5","percent of total billed charges",""
"CLIP ATRICLIP 35MM PROV OPEN ENDED DEVICE","SUP-ITM-10267888","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13750.00","10312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11055.00","80.4","","1022.97","1022.97","3607.50","1 through 10","7185.75","11236.5","percent of total billed charges",""
"CLIP ATRICLIP 35MM PROV OPEN ENDED DEVICE","SUP-ITM-10267888","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13750.00","10312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11236.50","81.72","","3010.54","693.88","5019.88","35","7185.75","11236.5","percent of total billed charges",""
"CLIP ATRICLIP 40MM PROV OPEN ENDED DEVICE","SUP-ITM-10267887","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10931.25","79.5","","1309.77","674.56","6049.93","26","4262.5","10931.25","percent of total billed charges",""
"CLIP ATRICLIP 40MM PROV OPEN ENDED DEVICE","SUP-ITM-10267887","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7328.75","53.3","","1901.83","1901.83","2962.25","1 through 10","4262.5","10931.25","percent of total billed charges",""
"CLIP ATRICLIP 40MM PROV OPEN ENDED DEVICE","SUP-ITM-10267887","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5018.75","36.5","","1620.31","1620.31","19908.88","1 through 10","4262.5","10931.25","percent of total billed charges",""
"CLIP ATRICLIP 40MM PROV OPEN ENDED DEVICE","SUP-ITM-10267887","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5266.25","38.3","","352.91","352.91","2046.30","1 through 10","4262.5","10931.25","percent of total billed charges",""
"CLIP ATRICLIP 40MM PROV OPEN ENDED DEVICE","SUP-ITM-10267887","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5898.75","42.9","","9668.75","9668.75","9668.75","1 through 10","4262.5","10931.25","percent of total billed charges",""
"CLIP ATRICLIP 40MM PROV OPEN ENDED DEVICE","SUP-ITM-10267887","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","WELLPOINT [1015]","HB AMC WELLPOINT","10144.75","73.78","","699.88","384.10","3443.31","33","4262.5","10931.25","percent of total billed charges",""
"CLIP ATRICLIP 40MM PROV OPEN ENDED DEVICE","SUP-ITM-10267887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13750.00","10312.50","AETNA [1001]","HB AMC AETNA HMO","9597.50","69.8","","1421.24","264.50","4933.46","29","7185.75","11236.5","percent of total billed charges",""
"CLIP ATRICLIP 40MM PROV OPEN ENDED DEVICE","SUP-ITM-10267887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13750.00","10312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11055.00","80.4","","1022.97","1022.97","3607.50","1 through 10","7185.75","11236.5","percent of total billed charges",""
"CLIP ATRICLIP 40MM PROV OPEN ENDED DEVICE","SUP-ITM-10267887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13750.00","10312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11236.50","81.72","","3010.54","693.88","5019.88","35","7185.75","11236.5","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3592.43","79.5","","800.18","480.96","1887.97","195","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2408.51","53.3","","813.12","216.42","1444.50","81","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1400.82","31","","432.60","432.60","432.60","1 through 10","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1649.35","36.5","","148.37","54.89","631.39","94","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1730.69","38.3","","279.30","91.72","1116.77","266","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1938.56","42.9","","731.00","63.70","731.00","1 through 10","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1938.56","42.9","","384.74","384.74","384.74","1 through 10","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","WELLPOINT [1015]","HB AMC WELLPOINT","3333.96","73.78","","286.63","119.22","1107.45","105","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4518.78","3389.08","AETNA [1001]","HB AMC AETNA HMO","3154.11","69.8","","675.31","184.75","1721.50","286","2361.51","3692.75","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4518.78","3389.08","AETNA [1001]","HB AMC AETNA PPO","3633.10","80.4","","1261.44","103.12","1514.10","21","2361.51","3692.75","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4518.78","3389.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3633.10","80.4","","1365.00","1365.00","1365.00","1 through 10","2361.51","3692.75","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4518.78","3389.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3692.75","81.72","","5157.68","5157.68","5157.68","1 through 10","2361.51","3692.75","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4518.78","3389.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3692.75","81.72","","431.26","71.26","1459.57","88","2361.51","3692.75","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3592.43","79.5","","800.18","480.96","1887.97","195","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2408.51","53.3","","813.12","216.42","1444.50","81","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1400.82","31","","432.60","432.60","432.60","1 through 10","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1649.35","36.5","","148.37","54.89","631.39","94","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1730.69","38.3","","279.30","91.72","1116.77","266","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1938.56","42.9","","731.00","63.70","731.00","1 through 10","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1938.56","42.9","","384.74","384.74","384.74","1 through 10","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","both","","","4518.78","3389.08","WELLPOINT [1015]","HB AMC WELLPOINT","3333.96","73.78","","286.63","119.22","1107.45","105","1400.82","3592.43","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4518.78","3389.08","AETNA [1001]","HB AMC AETNA HMO","3154.11","69.8","","675.31","184.75","1721.50","286","2361.51","3692.75","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4518.78","3389.08","AETNA [1001]","HB AMC AETNA PPO","3633.10","80.4","","1261.44","103.12","1514.10","21","2361.51","3692.75","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4518.78","3389.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3633.10","80.4","","1365.00","1365.00","1365.00","1 through 10","2361.51","3692.75","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4518.78","3389.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3692.75","81.72","","5157.68","5157.68","5157.68","1 through 10","2361.51","3692.75","percent of total billed charges",""
"CLIP BONE 12X15 13MM EASY SI BICORTICAL","SUP-ITM-10051556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4518.78","3389.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3692.75","81.72","","431.26","71.26","1459.57","88","2361.51","3692.75","percent of total billed charges",""
"CLIP PISTON .6X5.5MM MVP PROSTHESIS","SUP-ITM-10232132","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1622.25","1216.69","AETNA [1001]","HB AMC AETNA HMO","1132.33","69.8","","1013.24","1013.24","1013.24","1 through 10","811.13","1338.36","percent of total billed charges",""
"CLOSED ILIAC CONNECTOR 20MM","SUP-ITM-10245663","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3436.39","79.5","","800.18","480.96","1887.97","195","1339.98","3436.39","percent of total billed charges",""
"CLOSED ILIAC CONNECTOR 20MM","SUP-ITM-10245663","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2303.89","53.3","","813.12","216.42","1444.50","81","1339.98","3436.39","percent of total billed charges",""
"CLOSED ILIAC CONNECTOR 20MM","SUP-ITM-10245663","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1339.98","31","","432.60","432.60","432.60","1 through 10","1339.98","3436.39","percent of total billed charges",""
"CLOSED ILIAC CONNECTOR 20MM","SUP-ITM-10245663","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1577.71","36.5","","148.37","54.89","631.39","94","1339.98","3436.39","percent of total billed charges",""
"CLOSED ILIAC CONNECTOR 20MM","SUP-ITM-10245663","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1655.52","38.3","","279.30","91.72","1116.77","266","1339.98","3436.39","percent of total billed charges",""
"CLOSED ILIAC CONNECTOR 20MM","SUP-ITM-10245663","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1854.35","42.9","","731.00","63.70","731.00","1 through 10","1339.98","3436.39","percent of total billed charges",""
"CLOSED ILIAC CONNECTOR 20MM","SUP-ITM-10245663","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1854.35","42.9","","384.74","384.74","384.74","1 through 10","1339.98","3436.39","percent of total billed charges",""
"CLOSED ILIAC CONNECTOR 20MM","SUP-ITM-10245663","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","WELLPOINT [1015]","HB AMC WELLPOINT","3189.14","73.78","","286.63","119.22","1107.45","105","1339.98","3436.39","percent of total billed charges",""
"CLOSED ILIAC CONNECTOR 20MM","SUP-ITM-10245663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","AETNA [1001]","HB AMC AETNA HMO","3017.11","69.8","","675.31","184.75","1721.50","286","2258.94","3532.35","percent of total billed charges",""
"CLOSED ILIAC CONNECTOR 20MM","SUP-ITM-10245663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","AETNA [1001]","HB AMC AETNA PPO","3475.29","80.4","","1261.44","103.12","1514.10","21","2258.94","3532.35","percent of total billed charges",""
"CLOSED ILIAC CONNECTOR 20MM","SUP-ITM-10245663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3475.29","80.4","","1365.00","1365.00","1365.00","1 through 10","2258.94","3532.35","percent of total billed charges",""
"CLOSED ILIAC CONNECTOR 20MM","SUP-ITM-10245663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3532.35","81.72","","5157.68","5157.68","5157.68","1 through 10","2258.94","3532.35","percent of total billed charges",""
"CLOSED ILIAC CONNECTOR 20MM","SUP-ITM-10245663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3532.35","81.72","","431.26","71.26","1459.57","88","2258.94","3532.35","percent of total billed charges",""
"Closed Tx Nasal Bone Fx W/Mnpj W/Stabilization","PX-76000326","CDM","21320","CPT","0761","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1624.69","38.3","","6360.01","6360.01","6360.01","1 through 10","98.5","3658.77","percent of total billed charges",""
"Closed Tx Nasal Bone Fx W/Mnpj W/Stabilization","PX-98300165","CDM","21320","CPT","0983","RC","","","","both","","","578.00","433.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","221.37","38.3","","6360.01","6360.01","6360.01","1 through 10","98.5","3658.77","percent of total billed charges",""
"Closure Device Vascular T1","PX-27000071","CDM","C1760","HCPCS","0278","RC","","","","both","","","784.42","588.31","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","563.21","71.8","","612.50","612.50","612.50","1 through 10","243.17","623.61","percent of total billed charges",""
"Closure Device Vascular T1","PX-27000071","CDM","C1760","HCPCS","0278","RC","","","","both","","","784.42","588.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","549.09","70","","612.50","612.50","612.50","1 through 10","243.17","623.61","percent of total billed charges",""
"Closure Device Vascular T1","PX-27000071","CDM","C1760","HCPCS","0278","RC","","","","both","","","784.42","588.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","623.61","79.5","","742.96","323.40","1446.12","32","243.17","623.61","percent of total billed charges",""
"Closure Device Vascular T1","PX-27000071","CDM","C1760","HCPCS","0278","RC","","","","both","","","784.42","588.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","418.10","53.3","","323.40","323.40","550.90","13","243.17","623.61","percent of total billed charges",""
"Closure Device Vascular T1","PX-27000071","CDM","C1760","HCPCS","0278","RC","","","","both","","","784.42","588.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","286.31","36.5","","285.08","194.16","582.48","27","243.17","623.61","percent of total billed charges",""
"Closure Device Vascular T1","PX-27000071","CDM","C1760","HCPCS","0278","RC","","","","both","","","784.42","588.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","300.43","38.3","","239.49","233.98","600.08","52","243.17","623.61","percent of total billed charges",""
"Closure Device Vascular T1","PX-27000071","CDM","C1760","HCPCS","0278","RC","","","","both","","","784.42","588.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","336.52","42.9","","278.69","278.69","278.69","1 through 10","243.17","623.61","percent of total billed charges",""
"Closure Device Vascular T1","PX-27000071","CDM","C1760","HCPCS","0278","RC","","","","both","","","784.42","588.31","WELLPOINT [1015]","HB AMC WELLPOINT","578.75","73.78","","456.01","456.01","456.01","33","243.17","623.61","percent of total billed charges",""
"Closure Device Vascular T1","PX-27000071","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","784.42","588.31","AETNA [1001]","HB AMC AETNA HMO","547.53","69.8","","290.33","290.33","1575.00","1 through 10","409.94","641.03","percent of total billed charges",""
"Closure Device Vascular T1","PX-27000071","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","784.42","588.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","409.94","52.26","","487.31","487.31","487.31","1 through 10","409.94","641.03","percent of total billed charges",""
"Closure Device Vascular T1","PX-27000071","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","784.42","588.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","641.03","81.72","","489.63","489.63","489.63","1 through 10","409.94","641.03","percent of total billed charges",""
"Closure Device Vascular T1","PX-27000071","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","784.42","588.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","641.03","81.72","","489.64","489.63","1888.58","19","409.94","641.03","percent of total billed charges",""
"Closure Device Vascular T3","PX-27000072","CDM","C1760","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","4128.50","71.8","","612.50","612.50","612.50","1 through 10","1782.5","4571.25","percent of total billed charges",""
"Closure Device Vascular T3","PX-27000072","CDM","C1760","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4025.00","70","","612.50","612.50","612.50","1 through 10","1782.5","4571.25","percent of total billed charges",""
"Closure Device Vascular T3","PX-27000072","CDM","C1760","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4571.25","79.5","","742.96","323.40","1446.12","32","1782.5","4571.25","percent of total billed charges",""
"Closure Device Vascular T3","PX-27000072","CDM","C1760","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3064.75","53.3","","323.40","323.40","550.90","13","1782.5","4571.25","percent of total billed charges",""
"Closure Device Vascular T3","PX-27000072","CDM","C1760","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2098.75","36.5","","285.08","194.16","582.48","27","1782.5","4571.25","percent of total billed charges",""
"Closure Device Vascular T3","PX-27000072","CDM","C1760","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2202.25","38.3","","239.49","233.98","600.08","52","1782.5","4571.25","percent of total billed charges",""
"Closure Device Vascular T3","PX-27000072","CDM","C1760","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2466.75","42.9","","278.69","278.69","278.69","1 through 10","1782.5","4571.25","percent of total billed charges",""
"Closure Device Vascular T3","PX-27000072","CDM","C1760","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","WELLPOINT [1015]","HB AMC WELLPOINT","4242.35","73.78","","456.01","456.01","456.01","33","1782.5","4571.25","percent of total billed charges",""
"Closure Device Vascular T3","PX-27000072","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","5750.00","4312.50","AETNA [1001]","HB AMC AETNA HMO","4013.50","69.8","","290.33","290.33","1575.00","1 through 10","3004.95","4698.9","percent of total billed charges",""
"Closure Device Vascular T3","PX-27000072","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","5750.00","4312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3004.95","52.26","","487.31","487.31","487.31","1 through 10","3004.95","4698.9","percent of total billed charges",""
"Closure Device Vascular T3","PX-27000072","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","5750.00","4312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4698.90","81.72","","489.63","489.63","489.63","1 through 10","3004.95","4698.9","percent of total billed charges",""
"Closure Device Vascular T3","PX-27000072","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","5750.00","4312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4698.90","81.72","","489.64","489.63","1888.58","19","3004.95","4698.9","percent of total billed charges",""
"Closure of Split Wound Simple - 12020","PX-76000119","CDM","12020","CPT","0761","RC","","","","both","","","1455.00","1091.25","FALLON HEALTH [1008]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","714.40","714.40","714.40","1 through 10","451.05","1156.73","other","OPPS APC"
"Closure of Split Wound Simple - 12020","PX-76000119","CDM","12020","CPT","0761","RC","","","","both","","","1455.00","1091.25","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","726.94","726.94","1 through 10","451.05","1156.73","other","OPPS APC"
"Closure of Split Wound Simple - 12020","PX-76000119","CDM","12020","CPT","0761","RC","","","","outpatient","","","1455.00","1091.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1280.02","1280.02","1280.02","1 through 10","482.89","1234.13","other","ASC "
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","both","","","5553.00","4164.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2959.75","53.3","","27941.76","10680.91","27941.76","1 through 10","1721.43","4414.64","percent of total billed charges",""
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","both","","","5553.00","4164.75","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","1 through 10","1721.43","4414.64","other","OPPS APC"
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","both","","","5553.00","4164.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2026.85","36.5","","2008.61","2008.61","2008.61","1 through 10","1721.43","4414.64","percent of total billed charges",""
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","both","","","5553.00","4164.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2126.80","38.3","","2046.30","2046.30","2046.30","1 through 10","1721.43","4414.64","percent of total billed charges",""
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","outpatient","","","5553.00","4164.75","AETNA [1001]","HB AMC AETNA HMO","3875.99","69.8","","13695.03","13695.03","13695.03","1 through 10","1548.96","5545.35","percent of total billed charges",""
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","outpatient","","","5553.00","4164.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3624.12","3624.12","3624.12","1 through 10","1548.96","5545.35","other","ASC"
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","outpatient","","","5553.00","4164.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4105.92","2052.96","4105.92","1 through 10","1548.96","5545.35","other","ASC "
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","outpatient","","","5553.00","4164.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3593.59","3454.18","3593.59","1 through 10","1548.96","5545.35","other","Multiple Surgery"
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","outpatient","","","5553.00","4164.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4537.91","81.72","","22507.11","12537.79","22507.11","1 through 10","1548.96","5545.35","percent of total billed charges",""
"Clsd Tx Dist Rad Fx W/Manip","PX-98300641","CDM","25605","CPT","0983","RC","","","","both","","","2391.00","1793.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1957.40","","APC Price ($1,900.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1956.50","1956.50","1956.50","1 through 10","741.21","2375.49","other","OPPS APC"
"Clsd Tx Dist Rad Fx W/Manip","PX-98300641","CDM","25605","CPT","0983","RC","","","","both","","","2391.00","1793.25","MEDICARE [2001]","HB BWH MEDICARE","1900.39","","APC Price ($1,900.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1900.58","1900.58","1900.58","1 through 10","741.21","2375.49","other","OPPS APC"
"Clsd Tx Dist Rad Fx W/Manip","PX-98300641","CDM","25605","CPT","0983","RC","","","","outpatient","","","2391.00","1793.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1953.93","81.72","","2614.84","2614.84","2614.84","1 through 10","1182.01","2384.07","percent of total billed charges",""
"Clsd Tx Pelvic Ring Fx W/O Manipulation","PX-76002387","CDM","27197","CPT","0761","RC","","","","both","","","888.00","666.00","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","705.96","other","OPPS APC"
"Clsd Tx Pelvic Ring Fx W/O Manipulation","PX-76002387","CDM","27197","CPT","0761","RC","","","","both","","","888.00","666.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","324.12","36.5","","321.15","321.15","321.15","1 through 10","270.63","705.96","percent of total billed charges",""
"Clsd Tx Pelvic Ring Fx W/O Manipulation","PX-76002387","CDM","27197","CPT","0761","RC","","","","both","","","888.00","666.00","MOLINA [1014]","HB BWH MOLINA","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","565.18","565.18","565.18","1 through 10","270.63","705.96","other","OPPS APC"
"Clsd Tx Pelvic Ring Fx W/O Manipulation","PX-76002387","CDM","27197","CPT","0761","RC","","","","both","","","888.00","666.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","705.96","other","OPPS APC"
"Clsd Tx Pelvic Ring Fx W/O Manipulation","PX-76002387","CDM","27197","CPT","0761","RC","","","","outpatient","","","888.00","666.00","AETNA [1001]","HB AMC AETNA HMO","619.82","69.8","","671.58","671.58","671.58","1 through 10","225.09","5545.35","percent of total billed charges",""
"Clsd Tx Pelvic Ring Fx W/O Manipulation","PX-76002387","CDM","27197","CPT","0761","RC","","","","outpatient","","","888.00","666.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","257.40","","Case rate ($257.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","301.29","301.29","301.29","1 through 10","225.09","5545.35","other","ASC "
"Clsd Tx Pelvic Ring Fx W/O Manipulation","PX-98301323","CDM","27197","CPT","0983","RC","","","","both","","","607.00","455.25","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","188.17","482.57","other","OPPS APC"
"Clsd Tx Pelvic Ring Fx W/O Manipulation","PX-98301323","CDM","27197","CPT","0983","RC","","","","both","","","607.00","455.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","221.56","36.5","","321.15","321.15","321.15","1 through 10","188.17","482.57","percent of total billed charges",""
"Clsd Tx Pelvic Ring Fx W/O Manipulation","PX-98301323","CDM","27197","CPT","0983","RC","","","","both","","","607.00","455.25","MOLINA [1014]","HB BWH MOLINA","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","565.18","565.18","565.18","1 through 10","188.17","482.57","other","OPPS APC"
"Clsd Tx Pelvic Ring Fx W/O Manipulation","PX-98301323","CDM","27197","CPT","0983","RC","","","","both","","","607.00","455.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","188.17","482.57","other","OPPS APC"
"Clsd Tx Pelvic Ring Fx W/O Manipulation","PX-98301323","CDM","27197","CPT","0983","RC","","","","outpatient","","","607.00","455.25","AETNA [1001]","HB AMC AETNA HMO","423.69","69.8","","671.58","671.58","671.58","1 through 10","225.09","5545.35","percent of total billed charges",""
"Clsd Tx Pelvic Ring Fx W/O Manipulation","PX-98301323","CDM","27197","CPT","0983","RC","","","","outpatient","","","607.00","455.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","257.40","","Case rate ($257.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","301.29","301.29","301.29","1 through 10","225.09","5545.35","other","ASC "
"Cltx Vrt Bdy Fx W/O Manj Req&W/Csting/Bracing","PX-98301657","CDM","22310","CPT","0983","RC","","","","both","","","1380.00","1035.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","293.39","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","293.13","293.13","293.13","1 through 10","270.63","1097.1","other","OPPS APC"
"Cltx Vrt Bdy Fx W/O Manj Req&W/Csting/Bracing","PX-98301657","CDM","22310","CPT","0983","RC","","","","both","","","1380.00","1035.00","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1097.1","other","OPPS APC"
"Cltx Vrt Bdy Fx W/O Manj Req&W/Csting/Bracing","PX-98301657","CDM","22310","CPT","0983","RC","","","","both","","","1380.00","1035.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","503.70","36.5","","662.45","662.45","662.45","1 through 10","270.63","1097.1","percent of total billed charges",""
"Cltx Vrt Bdy Fx W/O Manj Req&W/Csting/Bracing","PX-98301657","CDM","22310","CPT","0983","RC","","","","both","","","1380.00","1035.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","1097.1","other","OPPS APC"
"Cmacb, Mayo Chromosomal Microarray Congenital Blood","PX-31001271","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2946.27","79.5","","2828.48","1814.97","2828.48","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Cmacb, Mayo Chromosomal Microarray Congenital Blood","PX-31001271","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1975.30","53.3","","1814.97","1761.95","1814.97","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Cmacb, Mayo Chromosomal Microarray Congenital Blood","PX-31001271","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1352.69","36.5","","1340.56","1340.56","1340.56","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Cmacb, Mayo Chromosomal Microarray Congenital Blood","PX-31001271","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1419.40","38.3","","1405.25","1405.25","1405.25","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Cmacb, Mayo Chromosomal Microarray Congenital Blood","PX-31001271","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","WELLPOINT [1015]","HB AMC WELLPOINT","2734.29","73.78","","6269.73","2675.73","7188.00","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Cmacb, Mayo Chromosomal Microarray Congenital Blood","PX-31001271","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","AETNA [1001]","HB AMC AETNA HMO","2586.79","69.8","","2433.14","2433.14","2433.14","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Cmacb, Mayo Chromosomal Microarray Congenital Blood","PX-31001271","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2979.62","80.4","","2803.32","2803.32","2803.32","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Cmacb, Mayo Chromosomal Microarray Congenital Blood","PX-31001271","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3028.54","81.72","","2873.04","1533.07","3526.61","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Cmapd, Mayo Prenatal Cvs Amniotic Fluid Chromosmome Microarray Products of Conception","PX-31001275","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2946.27","79.5","","2828.48","1814.97","2828.48","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Cmapd, Mayo Prenatal Cvs Amniotic Fluid Chromosmome Microarray Products of Conception","PX-31001275","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1975.30","53.3","","1814.97","1761.95","1814.97","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Cmapd, Mayo Prenatal Cvs Amniotic Fluid Chromosmome Microarray Products of Conception","PX-31001275","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1352.69","36.5","","1340.56","1340.56","1340.56","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Cmapd, Mayo Prenatal Cvs Amniotic Fluid Chromosmome Microarray Products of Conception","PX-31001275","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1419.40","38.3","","1405.25","1405.25","1405.25","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Cmapd, Mayo Prenatal Cvs Amniotic Fluid Chromosmome Microarray Products of Conception","PX-31001275","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","WELLPOINT [1015]","HB AMC WELLPOINT","2734.29","73.78","","6269.73","2675.73","7188.00","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Cmapd, Mayo Prenatal Cvs Amniotic Fluid Chromosmome Microarray Products of Conception","PX-31001275","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","AETNA [1001]","HB AMC AETNA HMO","2586.79","69.8","","2433.14","2433.14","2433.14","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Cmapd, Mayo Prenatal Cvs Amniotic Fluid Chromosmome Microarray Products of Conception","PX-31001275","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2979.62","80.4","","2803.32","2803.32","2803.32","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Cmapd, Mayo Prenatal Cvs Amniotic Fluid Chromosmome Microarray Products of Conception","PX-31001275","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3028.54","81.72","","2873.04","1533.07","3526.61","1 through 10","1793.7","7110.8","percent of total billed charges",""
"CMCP064 MTD CVRD CP STENT 5 22 5.5 11F PC/1EA","SUP-ITM-10260580","CDM","C1874","HCPCS","0278","RC","","","","both","","","21814.00","16360.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","14179.10","65","","6652.80","6652.80","6652.80","1 through 10","6762.34","17342.13","percent of total billed charges",""
"CMCP064 MTD CVRD CP STENT 5 22 5.5 11F PC/1EA","SUP-ITM-10260580","CDM","C1874","HCPCS","0278","RC","","","","both","","","21814.00","16360.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","17342.13","79.5","","2612.61","795.38","2612.61","1 through 10","6762.34","17342.13","percent of total billed charges",""
"CMCP064 MTD CVRD CP STENT 5 22 5.5 11F PC/1EA","SUP-ITM-10260580","CDM","C1874","HCPCS","0278","RC","","","","both","","","21814.00","16360.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11626.86","53.3","","1101.80","1101.80","1101.80","1 through 10","6762.34","17342.13","percent of total billed charges",""
"CMCP064 MTD CVRD CP STENT 5 22 5.5 11F PC/1EA","SUP-ITM-10260580","CDM","C1874","HCPCS","0278","RC","","","","both","","","21814.00","16360.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","14179.10","65","","1820.00","910.00","1820.00","1 through 10","6762.34","17342.13","percent of total billed charges",""
"CMCP064 MTD CVRD CP STENT 5 22 5.5 11F PC/1EA","SUP-ITM-10260580","CDM","C1874","HCPCS","0278","RC","","","","both","","","21814.00","16360.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7962.11","36.5","","1257.80","693.44","2424.50","1 through 10","6762.34","17342.13","percent of total billed charges",""
"CMCP064 MTD CVRD CP STENT 5 22 5.5 11F PC/1EA","SUP-ITM-10260580","CDM","C1874","HCPCS","0278","RC","","","","both","","","21814.00","16360.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8354.76","38.3","","1950.11","547.40","2346.00","1 through 10","6762.34","17342.13","percent of total billed charges",""
"CMCP064 MTD CVRD CP STENT 5 22 5.5 11F PC/1EA","SUP-ITM-10260580","CDM","C1874","HCPCS","0278","RC","","","","both","","","21814.00","16360.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9358.21","42.9","","5096.18","5096.18","5096.18","1 through 10","6762.34","17342.13","percent of total billed charges",""
"CMCP064 MTD CVRD CP STENT 5 22 5.5 11F PC/1EA","SUP-ITM-10260580","CDM","C1874","HCPCS","0278","RC","","","","both","","","21814.00","16360.50","WELLPOINT [1015]","HB AMC WELLPOINT","16094.37","73.78","","1172.59","1172.59","4829.94","1 through 10","6762.34","17342.13","percent of total billed charges",""
"CMCP064 MTD CVRD CP STENT 5 22 5.5 11F PC/1EA","SUP-ITM-10260580","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","21814.00","16360.50","AETNA [1001]","HB AMC AETNA HMO","15226.17","69.8","","1806.84","947.80","5091.72","1 through 10","11400","17826.4","percent of total billed charges",""
"CMCP064 MTD CVRD CP STENT 5 22 5.5 11F PC/1EA","SUP-ITM-10260580","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","21814.00","16360.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","17826.40","81.72","","1259.05","615.58","4586.56","1 through 10","11400","17826.4","percent of total billed charges",""
"Cmt Advanced Evaluation - Dominant","PX-31000683","CDM","81479","CPT","0310","RC","","","","both","","","1017.00","762.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","808.52","79.5","","0.65","0.65","0.65","1 through 10","315.27","966.15","percent of total billed charges",""
"Cmt Advanced Evaluation - Dominant","PX-31000683","CDM","81479","CPT","0310","RC","","","","both","","","1017.00","762.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","542.06","53.3","","0.79","0.79","0.79","1 through 10","315.27","966.15","percent of total billed charges",""
"Cmt Advanced Evaluation - Dominant","PX-31000683","CDM","81479","CPT","0310","RC","","","","outpatient","","","1017.00","762.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","508.50","50","","1.00","1.00","1.00","1 through 10","156.55","839.03","percent of total billed charges",""
"Cmt Advanced Evaluation - Dominant","PX-31000683","CDM","81479","CPT","0310","RC","","","","outpatient","","","1017.00","762.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","533.93","52.5","","1.00","0.53","1.00","1 through 10","156.55","839.03","percent of total billed charges",""
"Coag Fibrinolysis Func Activity Nos","PX-30001094","CDM","85397","CPT","0305","RC","","","","both","","","400.00","300.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","153.20","38.3","","128.04","128.04","128.04","1 through 10","23.65","380","percent of total billed charges",""
"Coag Fibrinolysis Func Activity Nos","PX-30001094","CDM","85397","CPT","0305","RC","","","","outpatient","","","400.00","300.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","326.88","81.72","","51.06","51.06","51.06","1 through 10","23.65","326.88","percent of total billed charges",""
"Coagulation And Platelet Disorders,EXTREME","661","DRG","","","","","","","","inpatient","","","135954.95","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","72065.45","","Standard inlier is a Case rate ($72,065.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $67,689, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,230.13) for the length of stay and the standard reimbursement.","72065.45","72065.45","72065.45","1 through 10","9569.6","169738.08","case rate",""
"Coagulation And Platelet Disorders,EXTREME","661","DRG","","","","","","","","inpatient","","","135954.95","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","81020.99","","Standard inlier is a Case rate ($81,020.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $67,689, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,500.26) for the length of stay and the standard reimbursement.","8563.35","8563.35","8563.35","1 through 10","9569.6","169738.08","case rate",""
"Coagulation And Platelet Disorders,EXTREME","661","DRG","","","","","","","","inpatient","","","135954.95","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18356.5969","","Fee schedule rate ($102,870.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18356.5969","102870.32","102870.32","1 through 10","9569.6","169738.08","case rate",""
"Coagulation And Platelet Disorders,EXTREME","661","DRG","","","","","","","","inpatient","","","135954.95","","MASSHEALTH [3001]","HB BWH MEDICAID","37945.97","","Case rate ($41,955.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $84,385.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $8,579.92 and the sum of the standard inlier and any outlier amount.","41945.50","41945.50","41945.50","1 through 10","9569.6","169738.08","case rate",""
"Coagulation And Platelet Disorders,MAJOR","661","DRG","","","","","","","","inpatient","","","90634.77","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","37832.50","","Standard inlier is a Case rate ($37,832.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,069, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,370.55) for the length of stay and the standard reimbursement.","34485.70","34485.70","37832.50","1 through 10","9569.6","169738.08","case rate",""
"Coagulation And Platelet Disorders,MAJOR","661","DRG","","","","","","","","inpatient","","","90634.77","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","42533.93","","Standard inlier is a Case rate ($42,533.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,069, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,037.34) for the length of stay and the standard reimbursement.","42533.92","42533.92","186577.89","1 through 10","9569.6","169738.08","case rate",""
"Coagulation And Platelet Disorders,MAJOR","661","DRG","","","","","","","","inpatient","","","90634.77","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","49881.96","49881.96","49881.96","1 through 10","9569.6","169738.08","percent of total billed charges",""
"Coagulation And Platelet Disorders,MAJOR","661","DRG","","","","","","","","inpatient","","","90634.77","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18356.5969","","Fee schedule rate ($44,277.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18356.5969","42571.28","42571.28","1 through 10","9569.6","169738.08","case rate",""
"Coagulation And Platelet Disorders,MAJOR","661","DRG","","","","","","","","inpatient","","","90634.77","","MASSHEALTH [3001]","HB BWH MEDICAID","16373.53","","Case rate ($18,103.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,533.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11103.87","11103.87","18099.31","1 through 10","9569.6","169738.08","case rate",""
"Coagulation And Platelet Disorders,MAJOR","661","DRG","","","","","","","","inpatient","","","90634.77","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","65628.66","","Fee schedule rate ($65,628.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","65628.66","65628.66","65628.66","1 through 10","9569.6","169738.08","case rate",""
"Coagulation And Platelet Disorders,MINOR","661","DRG","","","","","","","","inpatient","","","81672.56","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24721.16","","Standard inlier is a Case rate ($24,721.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,747, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,508.96) for the length of stay and the standard reimbursement.","22584.91","22584.91","22584.91","1 through 10","9569.6","169738.08","case rate",""
"Coagulation And Platelet Disorders,MINOR","661","DRG","","","","","","","","inpatient","","","81672.56","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25042.78","","Fee schedule rate ($25,042.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24313.10","24313.10","24313.10","1 through 10","9569.6","169738.08","case rate",""
"Coagulation And Platelet Disorders,MINOR","661","DRG","","","","","","","","inpatient","","","81672.56","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9569.60","","Case rate ($10,580.84). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,010.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10578.24","10578.24","10578.24","1 through 10","9569.6","169738.08","case rate",""
"Coagulation And Platelet Disorders,MODERATE","661","DRG","","","","","","","","inpatient","","","67279.21","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18356.5969","","Fee schedule rate ($24,212.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18356.5969","24212.28","24212.28","1 through 10","9569.6","169738.08","case rate",""
"Coagulation And Platelet Disorders,MODERATE","661","DRG","","","","","","","","inpatient","","","67279.21","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","19274.9602","","Fee schedule rate ($25,423.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19274.9602","25423.60","25423.60","1 through 10","9569.6","169738.08","case rate",""
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","72990.37","54742.78","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","14722.59","","Case rate ($14,293.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,129.49, add-ons for qualifying new technology services are included. If operating cost exceeds $62,773.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,667.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,686.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,749.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,227.35. The transfer capital threshold is the transfer adjustment factor * $1,227.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14811.92","14811.92","14811.92","1 through 10","14007.9","23360.868","other","Inpatient DRG"
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","72990.37","54742.78","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14293.78","","Case rate ($14,293.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,129.49, add-ons for qualifying new technology services are included. If operating cost exceeds $62,773.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,667.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,686.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,749.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,227.35. The transfer capital threshold is the transfer adjustment factor * $1,227.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14205.00","14205.00","14205.00","1 through 10","14007.9","23360.868","other","Inpatient Replacement Plans DRG"
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","72990.37","54742.78","MEDICARE [2001]","HB BWH MEDICARE","14293.78","","Case rate ($14,293.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,129.49, add-ons for qualifying new technology services are included. If operating cost exceeds $62,773.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,667.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,686.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,749.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,227.35. The transfer capital threshold is the transfer adjustment factor * $1,227.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18527.89","0.03","18555.17","53","14007.9","23360.868","other","Inpatient Replacement Plans DRG"
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","72990.37","54742.78","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14007.90","","Case rate ($14,293.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,129.49, add-ons for qualifying new technology services are included. If operating cost exceeds $62,773.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,667.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,686.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,749.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,227.35. The transfer capital threshold is the transfer adjustment factor * $1,227.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14042.45","14042.45","14042.45","1 through 10","14007.9","23360.868","other","Inpatient DRG"
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","72990.37","54742.78","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14007.90","","Case rate ($14,293.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,129.49, add-ons for qualifying new technology services are included. If operating cost exceeds $62,773.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,667.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,686.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,749.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,227.35. The transfer capital threshold is the transfer adjustment factor * $1,227.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14123.78","14108.20","40411.12","1 through 10","14007.9","23360.868","other","Inpatient DRG"
"Coagulation Time Activated (Act)","PX-30001081","CDM","85347","CPT","0305","RC","","","","both","","","75.00","56.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","53.85","71.8","","52.41","52.41","52.41","1 through 10","4.19","71.25","percent of total billed charges",""
"Coagulation Time Activated (Act)","PX-30001081","CDM","85347","CPT","0305","RC","","","","both","","","75.00","56.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","49.20","65.6","","34.89","34.89","34.89","1 through 10","4.19","71.25","percent of total billed charges",""
"Coagulation Time Activated (Act)","PX-30001081","CDM","85347","CPT","0305","RC","","","","both","","","75.00","56.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59.63","79.5","","73.00","38.54","172.36","43","4.19","71.25","percent of total billed charges",""
"Coagulation Time Activated (Act)","PX-30001081","CDM","85347","CPT","0305","RC","","","","both","","","75.00","56.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39.98","53.3","","38.54","23.49","38.55","21","4.19","71.25","percent of total billed charges",""
"Coagulation Time Activated (Act)","PX-30001081","CDM","85347","CPT","0305","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","48.75","65","","47.45","47.45","142.35","1 through 10","4.19","71.25","percent of total billed charges",""
"Coagulation Time Activated (Act)","PX-30001081","CDM","85347","CPT","0305","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.38","36.5","","27.23","26.43","52.85","46","4.19","71.25","percent of total billed charges",""
"Coagulation Time Activated (Act)","PX-30001081","CDM","85347","CPT","0305","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.73","38.3","","28.54","28.54","55.48","60","4.19","71.25","percent of total billed charges",""
"Coagulation Time Activated (Act)","PX-30001081","CDM","85347","CPT","0305","RC","","","","outpatient","","","75.00","56.25","AETNA [1001]","HB AMC AETNA HMO","52.35","69.8","","49.42","34.89","56.94","134","4.39","61.29","percent of total billed charges",""
"Coagulation Time Activated (Act)","PX-30001081","CDM","85347","CPT","0305","RC","","","","outpatient","","","75.00","56.25","AETNA [1001]","HB AMC AETNA PPO","60.30","80.4","","56.94","53.53","74.62","14","4.39","61.29","percent of total billed charges",""
"Coagulation Time Activated (Act)","PX-30001081","CDM","85347","CPT","0305","RC","","","","outpatient","","","75.00","56.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","39.20","52.26","","45.17","45.17","45.17","1 through 10","4.39","61.29","percent of total billed charges",""
"Coagulation Time Activated (Act)","PX-30001081","CDM","85347","CPT","0305","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","61.29","81.72","","58.36","32.10","58.36","1 through 10","4.39","61.29","percent of total billed charges",""
"Coagulation Time Activated (Act)","PX-30001081","CDM","85347","CPT","0305","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","61.29","81.72","","58.36","32.10","116.71","69","4.39","61.29","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","AETNA [1001]","HB AMC AETNA HMO","436.25","69.8","","410.26","289.67","472.68","45","60.9","593.75","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","448.75","71.8","","1305.33","435.11","1305.33","1 through 10","60.9","593.75","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","410.00","65.6","","410.26","410.26","410.26","1 through 10","60.9","593.75","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","406.25","65","","1181.70","393.90","1181.70","1 through 10","60.9","593.75","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","437.50","70","","436.32","260.58","436.32","1 through 10","60.9","593.75","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","496.88","79.5","","476.92","319.97","1430.76","27","60.9","593.75","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","333.13","53.3","","319.97","306.03","1430.76","23","60.9","593.75","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","193.75","31","","187.25","187.25","187.25","1 through 10","60.9","593.75","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.13","36.5","","226.04","190.28","226.04","42","60.9","593.75","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.38","38.3","","236.95","230.28","710.85","80","60.9","593.75","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","625.00","468.75","AETNA [1001]","HB AMC AETNA PPO","502.50","80.4","","472.68","317.54","923.54","1 through 10","205.18","594.32","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","625.00","468.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","326.63","52.26","","205.18","205.18","205.18","1 through 10","205.18","594.32","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","625.00","468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","510.75","81.72","","484.44","266.46","484.44","1 through 10","205.18","594.32","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","625.00","468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","510.75","81.72","","484.44","266.46","484.44","33","205.18","594.32","percent of total billed charges",""
"Coccidioides Antibody","PX-30000905","CDM","86635","CPT","0302","RC","","","","both","","","164.00","123.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","107.58","65.6","","124.02","124.02","124.02","1 through 10","11.24","155.8","percent of total billed charges",""
"Coccidioides Antibody","PX-30000905","CDM","86635","CPT","0302","RC","","","","both","","","164.00","123.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","114.80","70","","114.48","114.48","129.93","1 through 10","11.24","155.8","percent of total billed charges",""
"Coccidioides Antibody","PX-30000905","CDM","86635","CPT","0302","RC","","","","both","","","164.00","123.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","130.38","79.5","","375.40","375.40","375.40","1 through 10","11.24","155.8","percent of total billed charges",""
"Coccidioides Antibody","PX-30000905","CDM","86635","CPT","0302","RC","","","","both","","","164.00","123.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.81","38.3","","62.17","62.17","62.17","1 through 10","11.24","155.8","percent of total billed charges",""
"Coccidioides Antibody","PX-30000905","CDM","86635","CPT","0302","RC","","","","outpatient","","","164.00","123.00","AETNA [1001]","HB AMC AETNA HMO","114.47","69.8","","107.64","107.64","107.64","1 through 10","11.84","134.02","percent of total billed charges",""
"Coccidioides Antibody","PX-30000905","CDM","86635","CPT","0302","RC","","","","outpatient","","","164.00","123.00","AETNA [1001]","HB AMC AETNA PPO","131.86","80.4","","80.86","80.86","80.86","1 through 10","11.84","134.02","percent of total billed charges",""
"Coccidioides Antibody","PX-30000905","CDM","86635","CPT","0302","RC","","","","outpatient","","","164.00","123.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","134.02","81.72","","127.10","69.91","381.35","1 through 10","11.84","134.02","percent of total billed charges",""
"COCHLEAR IMPLANT SYNCHRONY 2 MI1250 FLEX26 S-VECTOR MAGNET","SUP-ITM-10285788","CDM","L8614","HCPCS","0278","RC","","","","both","","","49612.50","37209.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","26443.46","53.3","","39045.04","39045.04","39045.04","1 through 10","15379.88","47716.66","percent of total billed charges",""
"COCHLEAR IMPLANT SYNCHRONY 2 MI1250 FLEX26 S-VECTOR MAGNET","SUP-ITM-10285788","CDM","L8614","HCPCS","0278","RC","","","","both","","","49612.50","37209.37","WELLPOINT [1015]","HB AMC WELLPOINT","36604.10","73.78","","36936.51","36936.51","36936.51","1 through 10","15379.88","47716.66","percent of total billed charges",""
"COCR EUROCONE HEAD 12/14 26MM STANDARD 0 MM","SUP-ITM-10079893","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","731.64","52.26","","1113.10","1113.10","1113.10","1 through 10","434","1113","percent of total billed charges",""
"COCR EUROCONE HEAD 12/14 26MM STANDARD 0 MM","SUP-ITM-10079893","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","1293.60","1148.53","1603.80","1 through 10","434","1113","percent of total billed charges",""
"COCR EUROCONE HEAD 12/14 26MM STANDARD 0 MM","SUP-ITM-10079893","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1023.42","771.29","2068.67","33","434","1113","percent of total billed charges",""
"COCR EUROCONE HEAD 12/14 26MM STANDARD 0 MM","SUP-ITM-10079893","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","850.52","759.78","1211.25","66","434","1113","percent of total billed charges",""
"COCR EUROCONE HEAD 12/14 26MM STANDARD 0 MM","SUP-ITM-10079893","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","2548.09","2548.09","2548.09","1 through 10","434","1113","percent of total billed charges",""
"COCR EUROCONE HEAD 12/14 26MM STANDARD 0 MM","SUP-ITM-10079893","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","956.46","956.46","956.46","1 through 10","434","1113","percent of total billed charges",""
"COCR EUROCONE HEAD 12/14 26MM STANDARD 0 MM","SUP-ITM-10079893","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","2344.73","1619.47","2530.35","16","434","1113","percent of total billed charges",""
"COCR EUROCONE HEAD 12/14 26MM STANDARD 0 MM","SUP-ITM-10079893","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1523.63","988.41","4330.26","39","731.64","1144.08","percent of total billed charges",""
"COCR EUROCONE HEAD 12/14 26MM STANDARD 0 MM","SUP-ITM-10079893","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA PPO","1125.60","80.4","","1670.25","1670.25","1670.25","1 through 10","731.64","1144.08","percent of total billed charges",""
"COCR EUROCONE HEAD 12/14 26MM STANDARD 0 MM","SUP-ITM-10079893","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","731.64","52.26","","1113.10","1113.10","1113.10","1 through 10","731.64","1144.08","percent of total billed charges",""
"COCR EUROCONE HEAD 12/14 26MM STANDARD 0 MM","SUP-ITM-10079893","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","1738.90","1484.65","2716.94","38","731.64","1144.08","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 20CM 7MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090458","CDM","C1889","HCPCS","0278","RC","","","","both","","","5582.50","4186.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4438.09","79.5","","1309.77","674.56","6049.93","26","1730.58","4438.09","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 20CM 7MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090458","CDM","C1889","HCPCS","0278","RC","","","","both","","","5582.50","4186.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2975.47","53.3","","1901.83","1901.83","2962.25","1 through 10","1730.58","4438.09","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 20CM 7MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090458","CDM","C1889","HCPCS","0278","RC","","","","both","","","5582.50","4186.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2037.61","36.5","","1620.31","1620.31","19908.88","1 through 10","1730.58","4438.09","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 20CM 7MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090458","CDM","C1889","HCPCS","0278","RC","","","","both","","","5582.50","4186.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2138.10","38.3","","352.91","352.91","2046.30","1 through 10","1730.58","4438.09","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 20CM 7MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090458","CDM","C1889","HCPCS","0278","RC","","","","both","","","5582.50","4186.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2394.89","42.9","","9668.75","9668.75","9668.75","1 through 10","1730.58","4438.09","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 20CM 7MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090458","CDM","C1889","HCPCS","0278","RC","","","","both","","","5582.50","4186.87","WELLPOINT [1015]","HB AMC WELLPOINT","4118.77","73.78","","699.88","384.10","3443.31","33","1730.58","4438.09","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 20CM 7MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090458","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5582.50","4186.87","AETNA [1001]","HB AMC AETNA HMO","3896.59","69.8","","1421.24","264.50","4933.46","29","2917.41","4562.02","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 20CM 7MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090458","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5582.50","4186.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4488.33","80.4","","1022.97","1022.97","3607.50","1 through 10","2917.41","4562.02","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 20CM 7MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090458","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5582.50","4186.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4562.02","81.72","","3010.54","693.88","5019.88","35","2917.41","4562.02","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 25CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090461","CDM","C1889","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4531.50","79.5","","1309.77","674.56","6049.93","26","1767","4531.5","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 25CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090461","CDM","C1889","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3038.10","53.3","","1901.83","1901.83","2962.25","1 through 10","1767","4531.5","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 25CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090461","CDM","C1889","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2080.50","36.5","","1620.31","1620.31","19908.88","1 through 10","1767","4531.5","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 25CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090461","CDM","C1889","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2183.10","38.3","","352.91","352.91","2046.30","1 through 10","1767","4531.5","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 25CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090461","CDM","C1889","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2445.30","42.9","","9668.75","9668.75","9668.75","1 through 10","1767","4531.5","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 25CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090461","CDM","C1889","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","WELLPOINT [1015]","HB AMC WELLPOINT","4205.46","73.78","","699.88","384.10","3443.31","33","1767","4531.5","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 25CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090461","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5700.00","4275.00","AETNA [1001]","HB AMC AETNA HMO","3978.60","69.8","","1421.24","264.50","4933.46","29","2978.82","4658.04","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 25CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090461","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5700.00","4275.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4582.80","80.4","","1022.97","1022.97","3607.50","1 through 10","2978.82","4658.04","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 25CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090461","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5700.00","4275.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4658.04","81.72","","3010.54","693.88","5019.88","35","2978.82","4658.04","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 30CM 8MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090460","CDM","C1889","HCPCS","0278","RC","","","","both","","","5820.00","4365.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4626.90","79.5","","1309.77","674.56","6049.93","26","1804.2","4626.9","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 30CM 8MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090460","CDM","C1889","HCPCS","0278","RC","","","","both","","","5820.00","4365.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3102.06","53.3","","1901.83","1901.83","2962.25","1 through 10","1804.2","4626.9","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 30CM 8MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090460","CDM","C1889","HCPCS","0278","RC","","","","both","","","5820.00","4365.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2124.30","36.5","","1620.31","1620.31","19908.88","1 through 10","1804.2","4626.9","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 30CM 8MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090460","CDM","C1889","HCPCS","0278","RC","","","","both","","","5820.00","4365.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2229.06","38.3","","352.91","352.91","2046.30","1 through 10","1804.2","4626.9","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 30CM 8MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090460","CDM","C1889","HCPCS","0278","RC","","","","both","","","5820.00","4365.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2496.78","42.9","","9668.75","9668.75","9668.75","1 through 10","1804.2","4626.9","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 30CM 8MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090460","CDM","C1889","HCPCS","0278","RC","","","","both","","","5820.00","4365.00","WELLPOINT [1015]","HB AMC WELLPOINT","4294.00","73.78","","699.88","384.10","3443.31","33","1804.2","4626.9","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 30CM 8MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090460","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5820.00","4365.00","AETNA [1001]","HB AMC AETNA HMO","4062.36","69.8","","1421.24","264.50","4933.46","29","3041.53","4756.1","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 30CM 8MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090460","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5820.00","4365.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4679.28","80.4","","1022.97","1022.97","3607.50","1 through 10","3041.53","4756.1","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 30CM 8MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090460","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5820.00","4365.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4756.10","81.72","","3010.54","693.88","5019.88","35","3041.53","4756.1","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 35CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090462","CDM","C1889","HCPCS","0278","RC","","","","both","","","5877.50","4408.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4672.61","79.5","","1309.77","674.56","6049.93","26","1822.03","4672.61","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 35CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090462","CDM","C1889","HCPCS","0278","RC","","","","both","","","5877.50","4408.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3132.71","53.3","","1901.83","1901.83","2962.25","1 through 10","1822.03","4672.61","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 35CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090462","CDM","C1889","HCPCS","0278","RC","","","","both","","","5877.50","4408.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2145.29","36.5","","1620.31","1620.31","19908.88","1 through 10","1822.03","4672.61","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 35CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090462","CDM","C1889","HCPCS","0278","RC","","","","both","","","5877.50","4408.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2251.08","38.3","","352.91","352.91","2046.30","1 through 10","1822.03","4672.61","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 35CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090462","CDM","C1889","HCPCS","0278","RC","","","","both","","","5877.50","4408.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2521.45","42.9","","9668.75","9668.75","9668.75","1 through 10","1822.03","4672.61","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 35CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090462","CDM","C1889","HCPCS","0278","RC","","","","both","","","5877.50","4408.12","WELLPOINT [1015]","HB AMC WELLPOINT","4336.42","73.78","","699.88","384.10","3443.31","33","1822.03","4672.61","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 35CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090462","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5877.50","4408.12","AETNA [1001]","HB AMC AETNA HMO","4102.50","69.8","","1421.24","264.50","4933.46","29","3071.58","4803.09","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 35CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090462","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5877.50","4408.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4725.51","80.4","","1022.97","1022.97","3607.50","1 through 10","3071.58","4803.09","percent of total billed charges",""
"COIL 400 EMBOLIZATION .51MM 35CM 9MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090462","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5877.50","4408.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4803.09","81.72","","3010.54","693.88","5019.88","35","3071.58","4803.09","percent of total billed charges",""
"COIL 400 EMBOLIZATION 10CM 4MM COMPLEX EXTRA SOFT","SUP-ITM-10137819","CDM","C1889","HCPCS","0278","RC","","","","both","","","6555.00","4916.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5211.23","79.5","","1309.77","674.56","6049.93","26","2032.05","5211.23","percent of total billed charges",""
"COIL 400 EMBOLIZATION 10CM 4MM COMPLEX EXTRA SOFT","SUP-ITM-10137819","CDM","C1889","HCPCS","0278","RC","","","","both","","","6555.00","4916.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3493.82","53.3","","1901.83","1901.83","2962.25","1 through 10","2032.05","5211.23","percent of total billed charges",""
"COIL 400 EMBOLIZATION 10CM 4MM COMPLEX EXTRA SOFT","SUP-ITM-10137819","CDM","C1889","HCPCS","0278","RC","","","","both","","","6555.00","4916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2392.58","36.5","","1620.31","1620.31","19908.88","1 through 10","2032.05","5211.23","percent of total billed charges",""
"COIL 400 EMBOLIZATION 10CM 4MM COMPLEX EXTRA SOFT","SUP-ITM-10137819","CDM","C1889","HCPCS","0278","RC","","","","both","","","6555.00","4916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2510.57","38.3","","352.91","352.91","2046.30","1 through 10","2032.05","5211.23","percent of total billed charges",""
"COIL 400 EMBOLIZATION 10CM 4MM COMPLEX EXTRA SOFT","SUP-ITM-10137819","CDM","C1889","HCPCS","0278","RC","","","","both","","","6555.00","4916.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2812.10","42.9","","9668.75","9668.75","9668.75","1 through 10","2032.05","5211.23","percent of total billed charges",""
"COIL 400 EMBOLIZATION 10CM 4MM COMPLEX EXTRA SOFT","SUP-ITM-10137819","CDM","C1889","HCPCS","0278","RC","","","","both","","","6555.00","4916.25","WELLPOINT [1015]","HB AMC WELLPOINT","4836.28","73.78","","699.88","384.10","3443.31","33","2032.05","5211.23","percent of total billed charges",""
"COIL 400 EMBOLIZATION 10CM 4MM COMPLEX EXTRA SOFT","SUP-ITM-10137819","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6555.00","4916.25","AETNA [1001]","HB AMC AETNA HMO","4575.39","69.8","","1421.24","264.50","4933.46","29","3425.64","5356.75","percent of total billed charges",""
"COIL 400 EMBOLIZATION 10CM 4MM COMPLEX EXTRA SOFT","SUP-ITM-10137819","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6555.00","4916.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5270.22","80.4","","1022.97","1022.97","3607.50","1 through 10","3425.64","5356.75","percent of total billed charges",""
"COIL 400 EMBOLIZATION 10CM 4MM COMPLEX EXTRA SOFT","SUP-ITM-10137819","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6555.00","4916.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5356.75","81.72","","3010.54","693.88","5019.88","35","3425.64","5356.75","percent of total billed charges",""
"COIL 400 EMBOLIZATION 12CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090480","CDM","C1889","HCPCS","0278","RC","","","","both","","","5867.50","4400.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4664.66","79.5","","1309.77","674.56","6049.93","26","1818.93","4664.66","percent of total billed charges",""
"COIL 400 EMBOLIZATION 12CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090480","CDM","C1889","HCPCS","0278","RC","","","","both","","","5867.50","4400.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3127.38","53.3","","1901.83","1901.83","2962.25","1 through 10","1818.93","4664.66","percent of total billed charges",""
"COIL 400 EMBOLIZATION 12CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090480","CDM","C1889","HCPCS","0278","RC","","","","both","","","5867.50","4400.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2141.64","36.5","","1620.31","1620.31","19908.88","1 through 10","1818.93","4664.66","percent of total billed charges",""
"COIL 400 EMBOLIZATION 12CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090480","CDM","C1889","HCPCS","0278","RC","","","","both","","","5867.50","4400.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2247.25","38.3","","352.91","352.91","2046.30","1 through 10","1818.93","4664.66","percent of total billed charges",""
"COIL 400 EMBOLIZATION 12CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090480","CDM","C1889","HCPCS","0278","RC","","","","both","","","5867.50","4400.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2517.16","42.9","","9668.75","9668.75","9668.75","1 through 10","1818.93","4664.66","percent of total billed charges",""
"COIL 400 EMBOLIZATION 12CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090480","CDM","C1889","HCPCS","0278","RC","","","","both","","","5867.50","4400.62","WELLPOINT [1015]","HB AMC WELLPOINT","4329.04","73.78","","699.88","384.10","3443.31","33","1818.93","4664.66","percent of total billed charges",""
"COIL 400 EMBOLIZATION 12CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090480","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5867.50","4400.62","AETNA [1001]","HB AMC AETNA HMO","4095.52","69.8","","1421.24","264.50","4933.46","29","3066.36","4794.92","percent of total billed charges",""
"COIL 400 EMBOLIZATION 12CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090480","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5867.50","4400.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4717.47","80.4","","1022.97","1022.97","3607.50","1 through 10","3066.36","4794.92","percent of total billed charges",""
"COIL 400 EMBOLIZATION 12CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090480","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5867.50","4400.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4794.92","81.72","","3010.54","693.88","5019.88","35","3066.36","4794.92","percent of total billed charges",""
"COIL 400 EMBOLIZATION 13CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090481","CDM","C1889","HCPCS","0278","RC","","","","both","","","5890.00","4417.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4682.55","79.5","","1309.77","674.56","6049.93","26","1825.9","4682.55","percent of total billed charges",""
"COIL 400 EMBOLIZATION 13CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090481","CDM","C1889","HCPCS","0278","RC","","","","both","","","5890.00","4417.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3139.37","53.3","","1901.83","1901.83","2962.25","1 through 10","1825.9","4682.55","percent of total billed charges",""
"COIL 400 EMBOLIZATION 13CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090481","CDM","C1889","HCPCS","0278","RC","","","","both","","","5890.00","4417.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2149.85","36.5","","1620.31","1620.31","19908.88","1 through 10","1825.9","4682.55","percent of total billed charges",""
"COIL 400 EMBOLIZATION 13CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090481","CDM","C1889","HCPCS","0278","RC","","","","both","","","5890.00","4417.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2255.87","38.3","","352.91","352.91","2046.30","1 through 10","1825.9","4682.55","percent of total billed charges",""
"COIL 400 EMBOLIZATION 13CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090481","CDM","C1889","HCPCS","0278","RC","","","","both","","","5890.00","4417.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2526.81","42.9","","9668.75","9668.75","9668.75","1 through 10","1825.9","4682.55","percent of total billed charges",""
"COIL 400 EMBOLIZATION 13CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090481","CDM","C1889","HCPCS","0278","RC","","","","both","","","5890.00","4417.50","WELLPOINT [1015]","HB AMC WELLPOINT","4345.64","73.78","","699.88","384.10","3443.31","33","1825.9","4682.55","percent of total billed charges",""
"COIL 400 EMBOLIZATION 13CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090481","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5890.00","4417.50","AETNA [1001]","HB AMC AETNA HMO","4111.22","69.8","","1421.24","264.50","4933.46","29","3078.11","4813.31","percent of total billed charges",""
"COIL 400 EMBOLIZATION 13CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090481","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5890.00","4417.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4735.56","80.4","","1022.97","1022.97","3607.50","1 through 10","3078.11","4813.31","percent of total billed charges",""
"COIL 400 EMBOLIZATION 13CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090481","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5890.00","4417.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4813.31","81.72","","3010.54","693.88","5019.88","35","3078.11","4813.31","percent of total billed charges",""
"COIL 400 EMBOLIZATION 1CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090492","CDM","C1889","HCPCS","0278","RC","","","","both","","","4887.00","3665.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3885.17","79.5","","1309.77","674.56","6049.93","26","1514.97","3885.17","percent of total billed charges",""
"COIL 400 EMBOLIZATION 1CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090492","CDM","C1889","HCPCS","0278","RC","","","","both","","","4887.00","3665.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2604.77","53.3","","1901.83","1901.83","2962.25","1 through 10","1514.97","3885.17","percent of total billed charges",""
"COIL 400 EMBOLIZATION 1CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090492","CDM","C1889","HCPCS","0278","RC","","","","both","","","4887.00","3665.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1783.76","36.5","","1620.31","1620.31","19908.88","1 through 10","1514.97","3885.17","percent of total billed charges",""
"COIL 400 EMBOLIZATION 1CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090492","CDM","C1889","HCPCS","0278","RC","","","","both","","","4887.00","3665.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1871.72","38.3","","352.91","352.91","2046.30","1 through 10","1514.97","3885.17","percent of total billed charges",""
"COIL 400 EMBOLIZATION 1CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090492","CDM","C1889","HCPCS","0278","RC","","","","both","","","4887.00","3665.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.52","42.9","","9668.75","9668.75","9668.75","1 through 10","1514.97","3885.17","percent of total billed charges",""
"COIL 400 EMBOLIZATION 1CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090492","CDM","C1889","HCPCS","0278","RC","","","","both","","","4887.00","3665.25","WELLPOINT [1015]","HB AMC WELLPOINT","3605.63","73.78","","699.88","384.10","3443.31","33","1514.97","3885.17","percent of total billed charges",""
"COIL 400 EMBOLIZATION 1CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090492","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4887.00","3665.25","AETNA [1001]","HB AMC AETNA HMO","3411.13","69.8","","1421.24","264.50","4933.46","29","2553.95","3993.66","percent of total billed charges",""
"COIL 400 EMBOLIZATION 1CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090492","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4887.00","3665.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3929.15","80.4","","1022.97","1022.97","3607.50","1 through 10","2553.95","3993.66","percent of total billed charges",""
"COIL 400 EMBOLIZATION 1CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090492","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4887.00","3665.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3993.66","81.72","","3010.54","693.88","5019.88","35","2553.95","3993.66","percent of total billed charges",""
"COIL 400 EMBOLIZATION 2CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090493","CDM","C1889","HCPCS","0278","RC","","","","both","","","5187.00","3890.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4123.67","79.5","","1309.77","674.56","6049.93","26","1607.97","4123.67","percent of total billed charges",""
"COIL 400 EMBOLIZATION 2CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090493","CDM","C1889","HCPCS","0278","RC","","","","both","","","5187.00","3890.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2764.67","53.3","","1901.83","1901.83","2962.25","1 through 10","1607.97","4123.67","percent of total billed charges",""
"COIL 400 EMBOLIZATION 2CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090493","CDM","C1889","HCPCS","0278","RC","","","","both","","","5187.00","3890.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1893.26","36.5","","1620.31","1620.31","19908.88","1 through 10","1607.97","4123.67","percent of total billed charges",""
"COIL 400 EMBOLIZATION 2CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090493","CDM","C1889","HCPCS","0278","RC","","","","both","","","5187.00","3890.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1986.62","38.3","","352.91","352.91","2046.30","1 through 10","1607.97","4123.67","percent of total billed charges",""
"COIL 400 EMBOLIZATION 2CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090493","CDM","C1889","HCPCS","0278","RC","","","","both","","","5187.00","3890.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2225.22","42.9","","9668.75","9668.75","9668.75","1 through 10","1607.97","4123.67","percent of total billed charges",""
"COIL 400 EMBOLIZATION 2CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090493","CDM","C1889","HCPCS","0278","RC","","","","both","","","5187.00","3890.25","WELLPOINT [1015]","HB AMC WELLPOINT","3826.97","73.78","","699.88","384.10","3443.31","33","1607.97","4123.67","percent of total billed charges",""
"COIL 400 EMBOLIZATION 2CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090493","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5187.00","3890.25","AETNA [1001]","HB AMC AETNA HMO","3620.53","69.8","","1421.24","264.50","4933.46","29","2710.73","4238.82","percent of total billed charges",""
"COIL 400 EMBOLIZATION 2CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090493","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5187.00","3890.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4170.35","80.4","","1022.97","1022.97","3607.50","1 through 10","2710.73","4238.82","percent of total billed charges",""
"COIL 400 EMBOLIZATION 2CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090493","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5187.00","3890.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4238.82","81.72","","3010.54","693.88","5019.88","35","2710.73","4238.82","percent of total billed charges",""
"COIL 400 EMBOLIZATION 30CM .02IN 10MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090488","CDM","C1889","HCPCS","0278","RC","","","","both","","","6295.00","4721.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5004.53","79.5","","1309.77","674.56","6049.93","26","1951.45","5004.53","percent of total billed charges",""
"COIL 400 EMBOLIZATION 30CM .02IN 10MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090488","CDM","C1889","HCPCS","0278","RC","","","","both","","","6295.00","4721.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3355.24","53.3","","1901.83","1901.83","2962.25","1 through 10","1951.45","5004.53","percent of total billed charges",""
"COIL 400 EMBOLIZATION 30CM .02IN 10MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090488","CDM","C1889","HCPCS","0278","RC","","","","both","","","6295.00","4721.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2297.68","36.5","","1620.31","1620.31","19908.88","1 through 10","1951.45","5004.53","percent of total billed charges",""
"COIL 400 EMBOLIZATION 30CM .02IN 10MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090488","CDM","C1889","HCPCS","0278","RC","","","","both","","","6295.00","4721.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2410.99","38.3","","352.91","352.91","2046.30","1 through 10","1951.45","5004.53","percent of total billed charges",""
"COIL 400 EMBOLIZATION 30CM .02IN 10MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090488","CDM","C1889","HCPCS","0278","RC","","","","both","","","6295.00","4721.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2700.56","42.9","","9668.75","9668.75","9668.75","1 through 10","1951.45","5004.53","percent of total billed charges",""
"COIL 400 EMBOLIZATION 30CM .02IN 10MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090488","CDM","C1889","HCPCS","0278","RC","","","","both","","","6295.00","4721.25","WELLPOINT [1015]","HB AMC WELLPOINT","4644.45","73.78","","699.88","384.10","3443.31","33","1951.45","5004.53","percent of total billed charges",""
"COIL 400 EMBOLIZATION 30CM .02IN 10MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090488","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6295.00","4721.25","AETNA [1001]","HB AMC AETNA HMO","4393.91","69.8","","1421.24","264.50","4933.46","29","3289.77","5144.27","percent of total billed charges",""
"COIL 400 EMBOLIZATION 30CM .02IN 10MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090488","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6295.00","4721.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5061.18","80.4","","1022.97","1022.97","3607.50","1 through 10","3289.77","5144.27","percent of total billed charges",""
"COIL 400 EMBOLIZATION 30CM .02IN 10MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090488","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6295.00","4721.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5144.27","81.72","","3010.54","693.88","5019.88","35","3289.77","5144.27","percent of total billed charges",""
"COIL 400 EMBOLIZATION 35CM .02IN 11MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090489","CDM","C1889","HCPCS","0278","RC","","","","both","","","6412.50","4809.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5097.94","79.5","","1309.77","674.56","6049.93","26","1987.88","5097.94","percent of total billed charges",""
"COIL 400 EMBOLIZATION 35CM .02IN 11MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090489","CDM","C1889","HCPCS","0278","RC","","","","both","","","6412.50","4809.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3417.86","53.3","","1901.83","1901.83","2962.25","1 through 10","1987.88","5097.94","percent of total billed charges",""
"COIL 400 EMBOLIZATION 35CM .02IN 11MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090489","CDM","C1889","HCPCS","0278","RC","","","","both","","","6412.50","4809.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2340.56","36.5","","1620.31","1620.31","19908.88","1 through 10","1987.88","5097.94","percent of total billed charges",""
"COIL 400 EMBOLIZATION 35CM .02IN 11MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090489","CDM","C1889","HCPCS","0278","RC","","","","both","","","6412.50","4809.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2455.99","38.3","","352.91","352.91","2046.30","1 through 10","1987.88","5097.94","percent of total billed charges",""
"COIL 400 EMBOLIZATION 35CM .02IN 11MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090489","CDM","C1889","HCPCS","0278","RC","","","","both","","","6412.50","4809.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2750.96","42.9","","9668.75","9668.75","9668.75","1 through 10","1987.88","5097.94","percent of total billed charges",""
"COIL 400 EMBOLIZATION 35CM .02IN 11MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090489","CDM","C1889","HCPCS","0278","RC","","","","both","","","6412.50","4809.37","WELLPOINT [1015]","HB AMC WELLPOINT","4731.14","73.78","","699.88","384.10","3443.31","33","1987.88","5097.94","percent of total billed charges",""
"COIL 400 EMBOLIZATION 35CM .02IN 11MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090489","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6412.50","4809.37","AETNA [1001]","HB AMC AETNA HMO","4475.93","69.8","","1421.24","264.50","4933.46","29","3351.17","5240.3","percent of total billed charges",""
"COIL 400 EMBOLIZATION 35CM .02IN 11MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090489","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6412.50","4809.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5155.65","80.4","","1022.97","1022.97","3607.50","1 through 10","3351.17","5240.3","percent of total billed charges",""
"COIL 400 EMBOLIZATION 35CM .02IN 11MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090489","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6412.50","4809.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5240.30","81.72","","3010.54","693.88","5019.88","35","3351.17","5240.3","percent of total billed charges",""
"COIL 400 EMBOLIZATION 3CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090494","CDM","C1889","HCPCS","0278","RC","","","","both","","","4572.50","3429.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3635.14","79.5","","1309.77","674.56","6049.93","26","1417.48","3635.14","percent of total billed charges",""
"COIL 400 EMBOLIZATION 3CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090494","CDM","C1889","HCPCS","0278","RC","","","","both","","","4572.50","3429.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2437.14","53.3","","1901.83","1901.83","2962.25","1 through 10","1417.48","3635.14","percent of total billed charges",""
"COIL 400 EMBOLIZATION 3CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090494","CDM","C1889","HCPCS","0278","RC","","","","both","","","4572.50","3429.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1668.96","36.5","","1620.31","1620.31","19908.88","1 through 10","1417.48","3635.14","percent of total billed charges",""
"COIL 400 EMBOLIZATION 3CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090494","CDM","C1889","HCPCS","0278","RC","","","","both","","","4572.50","3429.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1751.27","38.3","","352.91","352.91","2046.30","1 through 10","1417.48","3635.14","percent of total billed charges",""
"COIL 400 EMBOLIZATION 3CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090494","CDM","C1889","HCPCS","0278","RC","","","","both","","","4572.50","3429.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1961.60","42.9","","9668.75","9668.75","9668.75","1 through 10","1417.48","3635.14","percent of total billed charges",""
"COIL 400 EMBOLIZATION 3CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090494","CDM","C1889","HCPCS","0278","RC","","","","both","","","4572.50","3429.37","WELLPOINT [1015]","HB AMC WELLPOINT","3373.59","73.78","","699.88","384.10","3443.31","33","1417.48","3635.14","percent of total billed charges",""
"COIL 400 EMBOLIZATION 3CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090494","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4572.50","3429.37","AETNA [1001]","HB AMC AETNA HMO","3191.61","69.8","","1421.24","264.50","4933.46","29","2389.59","3736.65","percent of total billed charges",""
"COIL 400 EMBOLIZATION 3CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090494","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4572.50","3429.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3676.29","80.4","","1022.97","1022.97","3607.50","1 through 10","2389.59","3736.65","percent of total billed charges",""
"COIL 400 EMBOLIZATION 3CM .02IN 2MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090494","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4572.50","3429.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3736.65","81.72","","3010.54","693.88","5019.88","35","2389.59","3736.65","percent of total billed charges",""
"COIL 400 EMBOLIZATION 40CM .02IN 10MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090464","CDM","C1889","HCPCS","0278","RC","","","","both","","","5937.50","4453.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4720.31","79.5","","1309.77","674.56","6049.93","26","1840.63","4720.31","percent of total billed charges",""
"COIL 400 EMBOLIZATION 40CM .02IN 10MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090464","CDM","C1889","HCPCS","0278","RC","","","","both","","","5937.50","4453.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3164.69","53.3","","1901.83","1901.83","2962.25","1 through 10","1840.63","4720.31","percent of total billed charges",""
"COIL 400 EMBOLIZATION 40CM .02IN 10MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090464","CDM","C1889","HCPCS","0278","RC","","","","both","","","5937.50","4453.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2167.19","36.5","","1620.31","1620.31","19908.88","1 through 10","1840.63","4720.31","percent of total billed charges",""
"COIL 400 EMBOLIZATION 40CM .02IN 10MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090464","CDM","C1889","HCPCS","0278","RC","","","","both","","","5937.50","4453.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2274.06","38.3","","352.91","352.91","2046.30","1 through 10","1840.63","4720.31","percent of total billed charges",""
"COIL 400 EMBOLIZATION 40CM .02IN 10MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090464","CDM","C1889","HCPCS","0278","RC","","","","both","","","5937.50","4453.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2547.19","42.9","","9668.75","9668.75","9668.75","1 through 10","1840.63","4720.31","percent of total billed charges",""
"COIL 400 EMBOLIZATION 40CM .02IN 10MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090464","CDM","C1889","HCPCS","0278","RC","","","","both","","","5937.50","4453.12","WELLPOINT [1015]","HB AMC WELLPOINT","4380.69","73.78","","699.88","384.10","3443.31","33","1840.63","4720.31","percent of total billed charges",""
"COIL 400 EMBOLIZATION 40CM .02IN 10MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090464","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5937.50","4453.12","AETNA [1001]","HB AMC AETNA HMO","4144.38","69.8","","1421.24","264.50","4933.46","29","3102.94","4852.13","percent of total billed charges",""
"COIL 400 EMBOLIZATION 40CM .02IN 10MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090464","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5937.50","4453.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4773.75","80.4","","1022.97","1022.97","3607.50","1 through 10","3102.94","4852.13","percent of total billed charges",""
"COIL 400 EMBOLIZATION 40CM .02IN 10MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090464","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5937.50","4453.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4852.13","81.72","","3010.54","693.88","5019.88","35","3102.94","4852.13","percent of total billed charges",""
"COIL 400 EMBOLIZATION 48CM .02IN 13MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090469","CDM","C1889","HCPCS","0278","RC","","","","both","","","6032.50","4524.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4795.84","79.5","","1309.77","674.56","6049.93","26","1870.08","4795.84","percent of total billed charges",""
"COIL 400 EMBOLIZATION 48CM .02IN 13MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090469","CDM","C1889","HCPCS","0278","RC","","","","both","","","6032.50","4524.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3215.32","53.3","","1901.83","1901.83","2962.25","1 through 10","1870.08","4795.84","percent of total billed charges",""
"COIL 400 EMBOLIZATION 48CM .02IN 13MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090469","CDM","C1889","HCPCS","0278","RC","","","","both","","","6032.50","4524.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2201.86","36.5","","1620.31","1620.31","19908.88","1 through 10","1870.08","4795.84","percent of total billed charges",""
"COIL 400 EMBOLIZATION 48CM .02IN 13MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090469","CDM","C1889","HCPCS","0278","RC","","","","both","","","6032.50","4524.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2310.45","38.3","","352.91","352.91","2046.30","1 through 10","1870.08","4795.84","percent of total billed charges",""
"COIL 400 EMBOLIZATION 48CM .02IN 13MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090469","CDM","C1889","HCPCS","0278","RC","","","","both","","","6032.50","4524.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2587.94","42.9","","9668.75","9668.75","9668.75","1 through 10","1870.08","4795.84","percent of total billed charges",""
"COIL 400 EMBOLIZATION 48CM .02IN 13MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090469","CDM","C1889","HCPCS","0278","RC","","","","both","","","6032.50","4524.37","WELLPOINT [1015]","HB AMC WELLPOINT","4450.78","73.78","","699.88","384.10","3443.31","33","1870.08","4795.84","percent of total billed charges",""
"COIL 400 EMBOLIZATION 48CM .02IN 13MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090469","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6032.50","4524.37","AETNA [1001]","HB AMC AETNA HMO","4210.69","69.8","","1421.24","264.50","4933.46","29","3152.58","4929.76","percent of total billed charges",""
"COIL 400 EMBOLIZATION 48CM .02IN 13MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090469","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6032.50","4524.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4850.13","80.4","","1022.97","1022.97","3607.50","1 through 10","3152.58","4929.76","percent of total billed charges",""
"COIL 400 EMBOLIZATION 48CM .02IN 13MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090469","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6032.50","4524.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4929.76","81.72","","3010.54","693.88","5019.88","35","3152.58","4929.76","percent of total billed charges",""
"COIL 400 EMBOLIZATION 4CM .02IN 4MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086476","CDM","C1889","HCPCS","0278","RC","","","","both","","","4822.50","3616.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3833.89","79.5","","1309.77","674.56","6049.93","26","1494.98","3833.89","percent of total billed charges",""
"COIL 400 EMBOLIZATION 4CM .02IN 4MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086476","CDM","C1889","HCPCS","0278","RC","","","","both","","","4822.50","3616.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2570.39","53.3","","1901.83","1901.83","2962.25","1 through 10","1494.98","3833.89","percent of total billed charges",""
"COIL 400 EMBOLIZATION 4CM .02IN 4MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086476","CDM","C1889","HCPCS","0278","RC","","","","both","","","4822.50","3616.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1760.21","36.5","","1620.31","1620.31","19908.88","1 through 10","1494.98","3833.89","percent of total billed charges",""
"COIL 400 EMBOLIZATION 4CM .02IN 4MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086476","CDM","C1889","HCPCS","0278","RC","","","","both","","","4822.50","3616.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1847.02","38.3","","352.91","352.91","2046.30","1 through 10","1494.98","3833.89","percent of total billed charges",""
"COIL 400 EMBOLIZATION 4CM .02IN 4MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086476","CDM","C1889","HCPCS","0278","RC","","","","both","","","4822.50","3616.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2068.85","42.9","","9668.75","9668.75","9668.75","1 through 10","1494.98","3833.89","percent of total billed charges",""
"COIL 400 EMBOLIZATION 4CM .02IN 4MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086476","CDM","C1889","HCPCS","0278","RC","","","","both","","","4822.50","3616.87","WELLPOINT [1015]","HB AMC WELLPOINT","3558.04","73.78","","699.88","384.10","3443.31","33","1494.98","3833.89","percent of total billed charges",""
"COIL 400 EMBOLIZATION 4CM .02IN 4MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4822.50","3616.87","AETNA [1001]","HB AMC AETNA HMO","3366.11","69.8","","1421.24","264.50","4933.46","29","2520.24","3940.95","percent of total billed charges",""
"COIL 400 EMBOLIZATION 4CM .02IN 4MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4822.50","3616.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3877.29","80.4","","1022.97","1022.97","3607.50","1 through 10","2520.24","3940.95","percent of total billed charges",""
"COIL 400 EMBOLIZATION 4CM .02IN 4MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4822.50","3616.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3940.95","81.72","","3010.54","693.88","5019.88","35","2520.24","3940.95","percent of total billed charges",""
"COIL 400 EMBOLIZATION 50CM .02IN 14MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090470","CDM","C1889","HCPCS","0278","RC","","","","both","","","6057.50","4543.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4815.71","79.5","","1309.77","674.56","6049.93","26","1877.83","4815.71","percent of total billed charges",""
"COIL 400 EMBOLIZATION 50CM .02IN 14MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090470","CDM","C1889","HCPCS","0278","RC","","","","both","","","6057.50","4543.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3228.65","53.3","","1901.83","1901.83","2962.25","1 through 10","1877.83","4815.71","percent of total billed charges",""
"COIL 400 EMBOLIZATION 50CM .02IN 14MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090470","CDM","C1889","HCPCS","0278","RC","","","","both","","","6057.50","4543.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2210.99","36.5","","1620.31","1620.31","19908.88","1 through 10","1877.83","4815.71","percent of total billed charges",""
"COIL 400 EMBOLIZATION 50CM .02IN 14MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090470","CDM","C1889","HCPCS","0278","RC","","","","both","","","6057.50","4543.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2320.02","38.3","","352.91","352.91","2046.30","1 through 10","1877.83","4815.71","percent of total billed charges",""
"COIL 400 EMBOLIZATION 50CM .02IN 14MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090470","CDM","C1889","HCPCS","0278","RC","","","","both","","","6057.50","4543.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2598.67","42.9","","9668.75","9668.75","9668.75","1 through 10","1877.83","4815.71","percent of total billed charges",""
"COIL 400 EMBOLIZATION 50CM .02IN 14MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090470","CDM","C1889","HCPCS","0278","RC","","","","both","","","6057.50","4543.12","WELLPOINT [1015]","HB AMC WELLPOINT","4469.22","73.78","","699.88","384.10","3443.31","33","1877.83","4815.71","percent of total billed charges",""
"COIL 400 EMBOLIZATION 50CM .02IN 14MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090470","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6057.50","4543.12","AETNA [1001]","HB AMC AETNA HMO","4228.14","69.8","","1421.24","264.50","4933.46","29","3165.65","4950.19","percent of total billed charges",""
"COIL 400 EMBOLIZATION 50CM .02IN 14MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090470","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6057.50","4543.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4870.23","80.4","","1022.97","1022.97","3607.50","1 through 10","3165.65","4950.19","percent of total billed charges",""
"COIL 400 EMBOLIZATION 50CM .02IN 14MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090470","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6057.50","4543.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4950.19","81.72","","3010.54","693.88","5019.88","35","3165.65","4950.19","percent of total billed charges",""
"COIL 400 EMBOLIZATION 57CM .02IN 15MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090471","CDM","C1889","HCPCS","0278","RC","","","","both","","","6140.00","4605.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4881.30","79.5","","1309.77","674.56","6049.93","26","1903.4","4881.3","percent of total billed charges",""
"COIL 400 EMBOLIZATION 57CM .02IN 15MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090471","CDM","C1889","HCPCS","0278","RC","","","","both","","","6140.00","4605.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3272.62","53.3","","1901.83","1901.83","2962.25","1 through 10","1903.4","4881.3","percent of total billed charges",""
"COIL 400 EMBOLIZATION 57CM .02IN 15MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090471","CDM","C1889","HCPCS","0278","RC","","","","both","","","6140.00","4605.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2241.10","36.5","","1620.31","1620.31","19908.88","1 through 10","1903.4","4881.3","percent of total billed charges",""
"COIL 400 EMBOLIZATION 57CM .02IN 15MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090471","CDM","C1889","HCPCS","0278","RC","","","","both","","","6140.00","4605.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2351.62","38.3","","352.91","352.91","2046.30","1 through 10","1903.4","4881.3","percent of total billed charges",""
"COIL 400 EMBOLIZATION 57CM .02IN 15MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090471","CDM","C1889","HCPCS","0278","RC","","","","both","","","6140.00","4605.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2634.06","42.9","","9668.75","9668.75","9668.75","1 through 10","1903.4","4881.3","percent of total billed charges",""
"COIL 400 EMBOLIZATION 57CM .02IN 15MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090471","CDM","C1889","HCPCS","0278","RC","","","","both","","","6140.00","4605.00","WELLPOINT [1015]","HB AMC WELLPOINT","4530.09","73.78","","699.88","384.10","3443.31","33","1903.4","4881.3","percent of total billed charges",""
"COIL 400 EMBOLIZATION 57CM .02IN 15MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090471","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6140.00","4605.00","AETNA [1001]","HB AMC AETNA HMO","4285.72","69.8","","1421.24","264.50","4933.46","29","3208.76","5017.61","percent of total billed charges",""
"COIL 400 EMBOLIZATION 57CM .02IN 15MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090471","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6140.00","4605.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4936.56","80.4","","1022.97","1022.97","3607.50","1 through 10","3208.76","5017.61","percent of total billed charges",""
"COIL 400 EMBOLIZATION 57CM .02IN 15MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090471","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6140.00","4605.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5017.61","81.72","","3010.54","693.88","5019.88","35","3208.76","5017.61","percent of total billed charges",""
"COIL 400 EMBOLIZATION 60CM .02IN 16MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090472","CDM","C1889","HCPCS","0278","RC","","","","both","","","6175.00","4631.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4909.13","79.5","","1309.77","674.56","6049.93","26","1914.25","4909.13","percent of total billed charges",""
"COIL 400 EMBOLIZATION 60CM .02IN 16MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090472","CDM","C1889","HCPCS","0278","RC","","","","both","","","6175.00","4631.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3291.28","53.3","","1901.83","1901.83","2962.25","1 through 10","1914.25","4909.13","percent of total billed charges",""
"COIL 400 EMBOLIZATION 60CM .02IN 16MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090472","CDM","C1889","HCPCS","0278","RC","","","","both","","","6175.00","4631.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2253.88","36.5","","1620.31","1620.31","19908.88","1 through 10","1914.25","4909.13","percent of total billed charges",""
"COIL 400 EMBOLIZATION 60CM .02IN 16MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090472","CDM","C1889","HCPCS","0278","RC","","","","both","","","6175.00","4631.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2365.03","38.3","","352.91","352.91","2046.30","1 through 10","1914.25","4909.13","percent of total billed charges",""
"COIL 400 EMBOLIZATION 60CM .02IN 16MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090472","CDM","C1889","HCPCS","0278","RC","","","","both","","","6175.00","4631.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2649.08","42.9","","9668.75","9668.75","9668.75","1 through 10","1914.25","4909.13","percent of total billed charges",""
"COIL 400 EMBOLIZATION 60CM .02IN 16MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090472","CDM","C1889","HCPCS","0278","RC","","","","both","","","6175.00","4631.25","WELLPOINT [1015]","HB AMC WELLPOINT","4555.92","73.78","","699.88","384.10","3443.31","33","1914.25","4909.13","percent of total billed charges",""
"COIL 400 EMBOLIZATION 60CM .02IN 16MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090472","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6175.00","4631.25","AETNA [1001]","HB AMC AETNA HMO","4310.15","69.8","","1421.24","264.50","4933.46","29","3227.06","5046.21","percent of total billed charges",""
"COIL 400 EMBOLIZATION 60CM .02IN 16MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090472","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6175.00","4631.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4964.70","80.4","","1022.97","1022.97","3607.50","1 through 10","3227.06","5046.21","percent of total billed charges",""
"COIL 400 EMBOLIZATION 60CM .02IN 16MM COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090472","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6175.00","4631.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5046.21","81.72","","3010.54","693.88","5019.88","35","3227.06","5046.21","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090477","CDM","C1889","HCPCS","0278","RC","","","","both","","","5725.00","4293.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4551.38","79.5","","1309.77","674.56","6049.93","26","1774.75","4551.38","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090477","CDM","C1889","HCPCS","0278","RC","","","","both","","","5725.00","4293.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3051.43","53.3","","1901.83","1901.83","2962.25","1 through 10","1774.75","4551.38","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090477","CDM","C1889","HCPCS","0278","RC","","","","both","","","5725.00","4293.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2089.63","36.5","","1620.31","1620.31","19908.88","1 through 10","1774.75","4551.38","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090477","CDM","C1889","HCPCS","0278","RC","","","","both","","","5725.00","4293.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2192.68","38.3","","352.91","352.91","2046.30","1 through 10","1774.75","4551.38","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090477","CDM","C1889","HCPCS","0278","RC","","","","both","","","5725.00","4293.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2456.03","42.9","","9668.75","9668.75","9668.75","1 through 10","1774.75","4551.38","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090477","CDM","C1889","HCPCS","0278","RC","","","","both","","","5725.00","4293.75","WELLPOINT [1015]","HB AMC WELLPOINT","4223.91","73.78","","699.88","384.10","3443.31","33","1774.75","4551.38","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090477","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5725.00","4293.75","AETNA [1001]","HB AMC AETNA HMO","3996.05","69.8","","1421.24","264.50","4933.46","29","2991.89","4678.47","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090477","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5725.00","4293.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4602.90","80.4","","1022.97","1022.97","3607.50","1 through 10","2991.89","4678.47","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090477","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5725.00","4293.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4678.47","81.72","","3010.54","693.88","5019.88","35","2991.89","4678.47","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090497","CDM","C1889","HCPCS","0278","RC","","","","both","","","5320.00","3990.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4229.40","79.5","","1309.77","674.56","6049.93","26","1649.2","4229.4","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090497","CDM","C1889","HCPCS","0278","RC","","","","both","","","5320.00","3990.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2835.56","53.3","","1901.83","1901.83","2962.25","1 through 10","1649.2","4229.4","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090497","CDM","C1889","HCPCS","0278","RC","","","","both","","","5320.00","3990.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1941.80","36.5","","1620.31","1620.31","19908.88","1 through 10","1649.2","4229.4","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090497","CDM","C1889","HCPCS","0278","RC","","","","both","","","5320.00","3990.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2037.56","38.3","","352.91","352.91","2046.30","1 through 10","1649.2","4229.4","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090497","CDM","C1889","HCPCS","0278","RC","","","","both","","","5320.00","3990.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2282.28","42.9","","9668.75","9668.75","9668.75","1 through 10","1649.2","4229.4","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090497","CDM","C1889","HCPCS","0278","RC","","","","both","","","5320.00","3990.00","WELLPOINT [1015]","HB AMC WELLPOINT","3925.10","73.78","","699.88","384.10","3443.31","33","1649.2","4229.4","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090497","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5320.00","3990.00","AETNA [1001]","HB AMC AETNA HMO","3713.36","69.8","","1421.24","264.50","4933.46","29","2780.23","4347.5","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090497","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5320.00","3990.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4277.28","80.4","","1022.97","1022.97","3607.50","1 through 10","2780.23","4347.5","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM .02IN 3MM CURVED EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090497","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5320.00","3990.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4347.50","81.72","","3010.54","693.88","5019.88","35","2780.23","4347.5","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM 3MM COMPLEX EXTRA SOFT","SUP-ITM-10137814","CDM","C1889","HCPCS","0278","RC","","","","both","","","5557.50","4168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4418.21","79.5","","1309.77","674.56","6049.93","26","1722.83","4418.21","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM 3MM COMPLEX EXTRA SOFT","SUP-ITM-10137814","CDM","C1889","HCPCS","0278","RC","","","","both","","","5557.50","4168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2962.15","53.3","","1901.83","1901.83","2962.25","1 through 10","1722.83","4418.21","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM 3MM COMPLEX EXTRA SOFT","SUP-ITM-10137814","CDM","C1889","HCPCS","0278","RC","","","","both","","","5557.50","4168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2028.49","36.5","","1620.31","1620.31","19908.88","1 through 10","1722.83","4418.21","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM 3MM COMPLEX EXTRA SOFT","SUP-ITM-10137814","CDM","C1889","HCPCS","0278","RC","","","","both","","","5557.50","4168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2128.52","38.3","","352.91","352.91","2046.30","1 through 10","1722.83","4418.21","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM 3MM COMPLEX EXTRA SOFT","SUP-ITM-10137814","CDM","C1889","HCPCS","0278","RC","","","","both","","","5557.50","4168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2384.17","42.9","","9668.75","9668.75","9668.75","1 through 10","1722.83","4418.21","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM 3MM COMPLEX EXTRA SOFT","SUP-ITM-10137814","CDM","C1889","HCPCS","0278","RC","","","","both","","","5557.50","4168.12","WELLPOINT [1015]","HB AMC WELLPOINT","4100.32","73.78","","699.88","384.10","3443.31","33","1722.83","4418.21","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM 3MM COMPLEX EXTRA SOFT","SUP-ITM-10137814","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5557.50","4168.12","AETNA [1001]","HB AMC AETNA HMO","3879.14","69.8","","1421.24","264.50","4933.46","29","2904.35","4541.59","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM 3MM COMPLEX EXTRA SOFT","SUP-ITM-10137814","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5557.50","4168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4468.23","80.4","","1022.97","1022.97","3607.50","1 through 10","2904.35","4541.59","percent of total billed charges",""
"COIL 400 EMBOLIZATION 6CM 3MM COMPLEX EXTRA SOFT","SUP-ITM-10137814","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5557.50","4168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4541.59","81.72","","3010.54","693.88","5019.88","35","2904.35","4541.59","percent of total billed charges",""
"COIL 400 EMBOLIZATION 8CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090479","CDM","C1889","HCPCS","0278","RC","","","","both","","","5772.50","4329.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4589.14","79.5","","1309.77","674.56","6049.93","26","1789.48","4589.14","percent of total billed charges",""
"COIL 400 EMBOLIZATION 8CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090479","CDM","C1889","HCPCS","0278","RC","","","","both","","","5772.50","4329.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3076.74","53.3","","1901.83","1901.83","2962.25","1 through 10","1789.48","4589.14","percent of total billed charges",""
"COIL 400 EMBOLIZATION 8CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090479","CDM","C1889","HCPCS","0278","RC","","","","both","","","5772.50","4329.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2106.96","36.5","","1620.31","1620.31","19908.88","1 through 10","1789.48","4589.14","percent of total billed charges",""
"COIL 400 EMBOLIZATION 8CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090479","CDM","C1889","HCPCS","0278","RC","","","","both","","","5772.50","4329.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2210.87","38.3","","352.91","352.91","2046.30","1 through 10","1789.48","4589.14","percent of total billed charges",""
"COIL 400 EMBOLIZATION 8CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090479","CDM","C1889","HCPCS","0278","RC","","","","both","","","5772.50","4329.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2476.40","42.9","","9668.75","9668.75","9668.75","1 through 10","1789.48","4589.14","percent of total billed charges",""
"COIL 400 EMBOLIZATION 8CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090479","CDM","C1889","HCPCS","0278","RC","","","","both","","","5772.50","4329.37","WELLPOINT [1015]","HB AMC WELLPOINT","4258.95","73.78","","699.88","384.10","3443.31","33","1789.48","4589.14","percent of total billed charges",""
"COIL 400 EMBOLIZATION 8CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090479","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5772.50","4329.37","AETNA [1001]","HB AMC AETNA HMO","4029.21","69.8","","1421.24","264.50","4933.46","29","3016.71","4717.29","percent of total billed charges",""
"COIL 400 EMBOLIZATION 8CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090479","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5772.50","4329.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4641.09","80.4","","1022.97","1022.97","3607.50","1 through 10","3016.71","4717.29","percent of total billed charges",""
"COIL 400 EMBOLIZATION 8CM .02IN 4MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090479","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5772.50","4329.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4717.29","81.72","","3010.54","693.88","5019.88","35","3016.71","4717.29","percent of total billed charges",""
"COIL 400 EMBOLIZATION 9CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086475","CDM","C1889","HCPCS","0278","RC","","","","both","","","5795.00","4346.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4607.03","79.5","","1309.77","674.56","6049.93","26","1796.45","4607.03","percent of total billed charges",""
"COIL 400 EMBOLIZATION 9CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086475","CDM","C1889","HCPCS","0278","RC","","","","both","","","5795.00","4346.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3088.74","53.3","","1901.83","1901.83","2962.25","1 through 10","1796.45","4607.03","percent of total billed charges",""
"COIL 400 EMBOLIZATION 9CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086475","CDM","C1889","HCPCS","0278","RC","","","","both","","","5795.00","4346.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2115.18","36.5","","1620.31","1620.31","19908.88","1 through 10","1796.45","4607.03","percent of total billed charges",""
"COIL 400 EMBOLIZATION 9CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086475","CDM","C1889","HCPCS","0278","RC","","","","both","","","5795.00","4346.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2219.49","38.3","","352.91","352.91","2046.30","1 through 10","1796.45","4607.03","percent of total billed charges",""
"COIL 400 EMBOLIZATION 9CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086475","CDM","C1889","HCPCS","0278","RC","","","","both","","","5795.00","4346.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2486.06","42.9","","9668.75","9668.75","9668.75","1 through 10","1796.45","4607.03","percent of total billed charges",""
"COIL 400 EMBOLIZATION 9CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086475","CDM","C1889","HCPCS","0278","RC","","","","both","","","5795.00","4346.25","WELLPOINT [1015]","HB AMC WELLPOINT","4275.55","73.78","","699.88","384.10","3443.31","33","1796.45","4607.03","percent of total billed charges",""
"COIL 400 EMBOLIZATION 9CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086475","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5795.00","4346.25","AETNA [1001]","HB AMC AETNA HMO","4044.91","69.8","","1421.24","264.50","4933.46","29","3028.47","4735.67","percent of total billed charges",""
"COIL 400 EMBOLIZATION 9CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086475","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5795.00","4346.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4659.18","80.4","","1022.97","1022.97","3607.50","1 through 10","3028.47","4735.67","percent of total billed charges",""
"COIL 400 EMBOLIZATION 9CM .02IN 5MM COMPLEX SOFT FILL NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10086475","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5795.00","4346.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4735.67","81.72","","3010.54","693.88","5019.88","35","3028.47","4735.67","percent of total billed charges",""
"COIL AXIUM 1.5MM 2CM .0115IN HELICAL SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024381","CDM","C1889","HCPCS","0278","RC","","","","both","","","2236.50","1677.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1778.02","79.5","","1309.77","674.56","6049.93","26","693.32","1778.02","percent of total billed charges",""
"COIL AXIUM 1.5MM 2CM .0115IN HELICAL SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024381","CDM","C1889","HCPCS","0278","RC","","","","both","","","2236.50","1677.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1192.05","53.3","","1901.83","1901.83","2962.25","1 through 10","693.32","1778.02","percent of total billed charges",""
"COIL AXIUM 1.5MM 2CM .0115IN HELICAL SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024381","CDM","C1889","HCPCS","0278","RC","","","","both","","","2236.50","1677.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","816.32","36.5","","1620.31","1620.31","19908.88","1 through 10","693.32","1778.02","percent of total billed charges",""
"COIL AXIUM 1.5MM 2CM .0115IN HELICAL SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024381","CDM","C1889","HCPCS","0278","RC","","","","both","","","2236.50","1677.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","856.58","38.3","","352.91","352.91","2046.30","1 through 10","693.32","1778.02","percent of total billed charges",""
"COIL AXIUM 1.5MM 2CM .0115IN HELICAL SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024381","CDM","C1889","HCPCS","0278","RC","","","","both","","","2236.50","1677.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","959.46","42.9","","9668.75","9668.75","9668.75","1 through 10","693.32","1778.02","percent of total billed charges",""
"COIL AXIUM 1.5MM 2CM .0115IN HELICAL SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024381","CDM","C1889","HCPCS","0278","RC","","","","both","","","2236.50","1677.37","WELLPOINT [1015]","HB AMC WELLPOINT","1650.09","73.78","","699.88","384.10","3443.31","33","693.32","1778.02","percent of total billed charges",""
"COIL AXIUM 1.5MM 2CM .0115IN HELICAL SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024381","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2236.50","1677.37","AETNA [1001]","HB AMC AETNA HMO","1561.08","69.8","","1421.24","264.50","4933.46","29","1168.79","1827.67","percent of total billed charges",""
"COIL AXIUM 1.5MM 2CM .0115IN HELICAL SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024381","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2236.50","1677.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1798.15","80.4","","1022.97","1022.97","3607.50","1 through 10","1168.79","1827.67","percent of total billed charges",""
"COIL AXIUM 1.5MM 2CM .0115IN HELICAL SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024381","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2236.50","1677.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1827.67","81.72","","3010.54","693.88","5019.88","35","1168.79","1827.67","percent of total billed charges",""
"COIL AXIUM 2MM 2CM .0115IN 3D SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024354","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2253.83","79.5","","1309.77","674.56","6049.93","26","878.85","2253.83","percent of total billed charges",""
"COIL AXIUM 2MM 2CM .0115IN 3D SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024354","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1511.06","53.3","","1901.83","1901.83","2962.25","1 through 10","878.85","2253.83","percent of total billed charges",""
"COIL AXIUM 2MM 2CM .0115IN 3D SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024354","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1034.78","36.5","","1620.31","1620.31","19908.88","1 through 10","878.85","2253.83","percent of total billed charges",""
"COIL AXIUM 2MM 2CM .0115IN 3D SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024354","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1085.81","38.3","","352.91","352.91","2046.30","1 through 10","878.85","2253.83","percent of total billed charges",""
"COIL AXIUM 2MM 2CM .0115IN 3D SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024354","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","9668.75","9668.75","9668.75","1 through 10","878.85","2253.83","percent of total billed charges",""
"COIL AXIUM 2MM 2CM .0115IN 3D SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024354","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB AMC WELLPOINT","2091.66","73.78","","699.88","384.10","3443.31","33","878.85","2253.83","percent of total billed charges",""
"COIL AXIUM 2MM 2CM .0115IN 3D SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024354","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA HMO","1978.83","69.8","","1421.24","264.50","4933.46","29","1481.57","2316.76","percent of total billed charges",""
"COIL AXIUM 2MM 2CM .0115IN 3D SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024354","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2279.34","80.4","","1022.97","1022.97","3607.50","1 through 10","1481.57","2316.76","percent of total billed charges",""
"COIL AXIUM 2MM 2CM .0115IN 3D SOFT DETACHABLE STRETCH RESISTANT VASCULAR","SUP-ITM-10024354","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2316.76","81.72","","3010.54","693.88","5019.88","35","1481.57","2316.76","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 10CM .0115IN HELIX DETACHABLE SUPER SOFT","SUP-ITM-10114780","CDM","C1889","HCPCS","0278","RC","","","","both","","","2236.50","1677.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1778.02","79.5","","1309.77","674.56","6049.93","26","693.32","1778.02","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 10CM .0115IN HELIX DETACHABLE SUPER SOFT","SUP-ITM-10114780","CDM","C1889","HCPCS","0278","RC","","","","both","","","2236.50","1677.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1192.05","53.3","","1901.83","1901.83","2962.25","1 through 10","693.32","1778.02","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 10CM .0115IN HELIX DETACHABLE SUPER SOFT","SUP-ITM-10114780","CDM","C1889","HCPCS","0278","RC","","","","both","","","2236.50","1677.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","816.32","36.5","","1620.31","1620.31","19908.88","1 through 10","693.32","1778.02","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 10CM .0115IN HELIX DETACHABLE SUPER SOFT","SUP-ITM-10114780","CDM","C1889","HCPCS","0278","RC","","","","both","","","2236.50","1677.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","856.58","38.3","","352.91","352.91","2046.30","1 through 10","693.32","1778.02","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 10CM .0115IN HELIX DETACHABLE SUPER SOFT","SUP-ITM-10114780","CDM","C1889","HCPCS","0278","RC","","","","both","","","2236.50","1677.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","959.46","42.9","","9668.75","9668.75","9668.75","1 through 10","693.32","1778.02","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 10CM .0115IN HELIX DETACHABLE SUPER SOFT","SUP-ITM-10114780","CDM","C1889","HCPCS","0278","RC","","","","both","","","2236.50","1677.37","WELLPOINT [1015]","HB AMC WELLPOINT","1650.09","73.78","","699.88","384.10","3443.31","33","693.32","1778.02","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 10CM .0115IN HELIX DETACHABLE SUPER SOFT","SUP-ITM-10114780","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2236.50","1677.37","AETNA [1001]","HB AMC AETNA HMO","1561.08","69.8","","1421.24","264.50","4933.46","29","1168.79","1827.67","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 10CM .0115IN HELIX DETACHABLE SUPER SOFT","SUP-ITM-10114780","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2236.50","1677.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1798.15","80.4","","1022.97","1022.97","3607.50","1 through 10","1168.79","1827.67","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 10CM .0115IN HELIX DETACHABLE SUPER SOFT","SUP-ITM-10114780","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2236.50","1677.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1827.67","81.72","","3010.54","693.88","5019.88","35","1168.79","1827.67","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 6CM .0115IN 3D DETACHABLE SUPER SOFT","SUP-ITM-10114783","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2253.83","79.5","","1309.77","674.56","6049.93","26","878.85","2253.83","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 6CM .0115IN 3D DETACHABLE SUPER SOFT","SUP-ITM-10114783","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1511.06","53.3","","1901.83","1901.83","2962.25","1 through 10","878.85","2253.83","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 6CM .0115IN 3D DETACHABLE SUPER SOFT","SUP-ITM-10114783","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1034.78","36.5","","1620.31","1620.31","19908.88","1 through 10","878.85","2253.83","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 6CM .0115IN 3D DETACHABLE SUPER SOFT","SUP-ITM-10114783","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1085.81","38.3","","352.91","352.91","2046.30","1 through 10","878.85","2253.83","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 6CM .0115IN 3D DETACHABLE SUPER SOFT","SUP-ITM-10114783","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","9668.75","9668.75","9668.75","1 through 10","878.85","2253.83","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 6CM .0115IN 3D DETACHABLE SUPER SOFT","SUP-ITM-10114783","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB AMC WELLPOINT","2091.66","73.78","","699.88","384.10","3443.31","33","878.85","2253.83","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 6CM .0115IN 3D DETACHABLE SUPER SOFT","SUP-ITM-10114783","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA HMO","1978.83","69.8","","1421.24","264.50","4933.46","29","1481.57","2316.76","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 6CM .0115IN 3D DETACHABLE SUPER SOFT","SUP-ITM-10114783","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2279.34","80.4","","1022.97","1022.97","3607.50","1 through 10","1481.57","2316.76","percent of total billed charges",""
"COIL AXIUM PRIME 4MM 6CM .0115IN 3D DETACHABLE SUPER SOFT","SUP-ITM-10114783","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2316.76","81.72","","3010.54","693.88","5019.88","35","1481.57","2316.76","percent of total billed charges",""
"COIL AZUR 10MM 26CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076111","CDM","C1889","HCPCS","0278","RC","","","","both","","","2772.00","2079.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2203.74","79.5","","1309.77","674.56","6049.93","26","859.32","2203.74","percent of total billed charges",""
"COIL AZUR 10MM 26CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076111","CDM","C1889","HCPCS","0278","RC","","","","both","","","2772.00","2079.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1477.48","53.3","","1901.83","1901.83","2962.25","1 through 10","859.32","2203.74","percent of total billed charges",""
"COIL AZUR 10MM 26CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076111","CDM","C1889","HCPCS","0278","RC","","","","both","","","2772.00","2079.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1011.78","36.5","","1620.31","1620.31","19908.88","1 through 10","859.32","2203.74","percent of total billed charges",""
"COIL AZUR 10MM 26CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076111","CDM","C1889","HCPCS","0278","RC","","","","both","","","2772.00","2079.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1061.68","38.3","","352.91","352.91","2046.30","1 through 10","859.32","2203.74","percent of total billed charges",""
"COIL AZUR 10MM 26CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076111","CDM","C1889","HCPCS","0278","RC","","","","both","","","2772.00","2079.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1189.19","42.9","","9668.75","9668.75","9668.75","1 through 10","859.32","2203.74","percent of total billed charges",""
"COIL AZUR 10MM 26CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076111","CDM","C1889","HCPCS","0278","RC","","","","both","","","2772.00","2079.00","WELLPOINT [1015]","HB AMC WELLPOINT","2045.18","73.78","","699.88","384.10","3443.31","33","859.32","2203.74","percent of total billed charges",""
"COIL AZUR 10MM 26CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076111","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2772.00","2079.00","AETNA [1001]","HB AMC AETNA HMO","1934.86","69.8","","1421.24","264.50","4933.46","29","1448.65","2265.28","percent of total billed charges",""
"COIL AZUR 10MM 26CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076111","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2772.00","2079.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2228.69","80.4","","1022.97","1022.97","3607.50","1 through 10","1448.65","2265.28","percent of total billed charges",""
"COIL AZUR 10MM 26CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076111","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2772.00","2079.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2265.28","81.72","","3010.54","693.88","5019.88","35","1448.65","2265.28","percent of total billed charges",""
"COIL AZUR 14MM 34CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076112","CDM","C1889","HCPCS","0278","RC","","","","both","","","2922.50","2191.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.39","79.5","","1309.77","674.56","6049.93","26","905.98","2323.39","percent of total billed charges",""
"COIL AZUR 14MM 34CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076112","CDM","C1889","HCPCS","0278","RC","","","","both","","","2922.50","2191.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1557.69","53.3","","1901.83","1901.83","2962.25","1 through 10","905.98","2323.39","percent of total billed charges",""
"COIL AZUR 14MM 34CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076112","CDM","C1889","HCPCS","0278","RC","","","","both","","","2922.50","2191.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1066.71","36.5","","1620.31","1620.31","19908.88","1 through 10","905.98","2323.39","percent of total billed charges",""
"COIL AZUR 14MM 34CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076112","CDM","C1889","HCPCS","0278","RC","","","","both","","","2922.50","2191.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1119.32","38.3","","352.91","352.91","2046.30","1 through 10","905.98","2323.39","percent of total billed charges",""
"COIL AZUR 14MM 34CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076112","CDM","C1889","HCPCS","0278","RC","","","","both","","","2922.50","2191.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1253.75","42.9","","9668.75","9668.75","9668.75","1 through 10","905.98","2323.39","percent of total billed charges",""
"COIL AZUR 14MM 34CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076112","CDM","C1889","HCPCS","0278","RC","","","","both","","","2922.50","2191.87","WELLPOINT [1015]","HB AMC WELLPOINT","2156.22","73.78","","699.88","384.10","3443.31","33","905.98","2323.39","percent of total billed charges",""
"COIL AZUR 14MM 34CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076112","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2922.50","2191.87","AETNA [1001]","HB AMC AETNA HMO","2039.91","69.8","","1421.24","264.50","4933.46","29","1527.3","2388.27","percent of total billed charges",""
"COIL AZUR 14MM 34CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076112","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2922.50","2191.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2349.69","80.4","","1022.97","1022.97","3607.50","1 through 10","1527.3","2388.27","percent of total billed charges",""
"COIL AZUR 14MM 34CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076112","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2922.50","2191.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2388.27","81.72","","3010.54","693.88","5019.88","35","1527.3","2388.27","percent of total billed charges",""
"COIL AZUR 8MM 20CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076110","CDM","C1889","HCPCS","0278","RC","","","","both","","","2630.25","1972.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2091.05","79.5","","1309.77","674.56","6049.93","26","815.38","2091.05","percent of total billed charges",""
"COIL AZUR 8MM 20CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076110","CDM","C1889","HCPCS","0278","RC","","","","both","","","2630.25","1972.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1401.92","53.3","","1901.83","1901.83","2962.25","1 through 10","815.38","2091.05","percent of total billed charges",""
"COIL AZUR 8MM 20CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076110","CDM","C1889","HCPCS","0278","RC","","","","both","","","2630.25","1972.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","960.04","36.5","","1620.31","1620.31","19908.88","1 through 10","815.38","2091.05","percent of total billed charges",""
"COIL AZUR 8MM 20CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076110","CDM","C1889","HCPCS","0278","RC","","","","both","","","2630.25","1972.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1007.39","38.3","","352.91","352.91","2046.30","1 through 10","815.38","2091.05","percent of total billed charges",""
"COIL AZUR 8MM 20CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076110","CDM","C1889","HCPCS","0278","RC","","","","both","","","2630.25","1972.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1128.38","42.9","","9668.75","9668.75","9668.75","1 through 10","815.38","2091.05","percent of total billed charges",""
"COIL AZUR 8MM 20CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076110","CDM","C1889","HCPCS","0278","RC","","","","both","","","2630.25","1972.69","WELLPOINT [1015]","HB AMC WELLPOINT","1940.60","73.78","","699.88","384.10","3443.31","33","815.38","2091.05","percent of total billed charges",""
"COIL AZUR 8MM 20CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076110","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2630.25","1972.69","AETNA [1001]","HB AMC AETNA HMO","1835.91","69.8","","1421.24","264.50","4933.46","29","1374.57","2149.44","percent of total billed charges",""
"COIL AZUR 8MM 20CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076110","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2630.25","1972.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2114.72","80.4","","1022.97","1022.97","3607.50","1 through 10","1374.57","2149.44","percent of total billed charges",""
"COIL AZUR 8MM 20CM .018IN FRAMING EMBOLIZATION NONHYDROGEL BX/1EA","SUP-ITM-10076110","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2630.25","1972.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2149.44","81.72","","3010.54","693.88","5019.88","35","1374.57","2149.44","percent of total billed charges",""
"COIL CONCERTO 2MM 4CM .0165IN NYLON DETACHABLE HELIX EMBOLIZATION","SUP-ITM-10088732","CDM","C1889","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1460.81","79.5","","1309.77","674.56","6049.93","26","569.63","1460.81","percent of total billed charges",""
"COIL CONCERTO 2MM 4CM .0165IN NYLON DETACHABLE HELIX EMBOLIZATION","SUP-ITM-10088732","CDM","C1889","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","979.39","53.3","","1901.83","1901.83","2962.25","1 through 10","569.63","1460.81","percent of total billed charges",""
"COIL CONCERTO 2MM 4CM .0165IN NYLON DETACHABLE HELIX EMBOLIZATION","SUP-ITM-10088732","CDM","C1889","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","670.69","36.5","","1620.31","1620.31","19908.88","1 through 10","569.63","1460.81","percent of total billed charges",""
"COIL CONCERTO 2MM 4CM .0165IN NYLON DETACHABLE HELIX EMBOLIZATION","SUP-ITM-10088732","CDM","C1889","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","703.76","38.3","","352.91","352.91","2046.30","1 through 10","569.63","1460.81","percent of total billed charges",""
"COIL CONCERTO 2MM 4CM .0165IN NYLON DETACHABLE HELIX EMBOLIZATION","SUP-ITM-10088732","CDM","C1889","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","788.29","42.9","","9668.75","9668.75","9668.75","1 through 10","569.63","1460.81","percent of total billed charges",""
"COIL CONCERTO 2MM 4CM .0165IN NYLON DETACHABLE HELIX EMBOLIZATION","SUP-ITM-10088732","CDM","C1889","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","WELLPOINT [1015]","HB AMC WELLPOINT","1355.71","73.78","","699.88","384.10","3443.31","33","569.63","1460.81","percent of total billed charges",""
"COIL CONCERTO 2MM 4CM .0165IN NYLON DETACHABLE HELIX EMBOLIZATION","SUP-ITM-10088732","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","AETNA [1001]","HB AMC AETNA HMO","1282.58","69.8","","1421.24","264.50","4933.46","29","960.28","1501.61","percent of total billed charges",""
"COIL CONCERTO 2MM 4CM .0165IN NYLON DETACHABLE HELIX EMBOLIZATION","SUP-ITM-10088732","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1477.35","80.4","","1022.97","1022.97","3607.50","1 through 10","960.28","1501.61","percent of total billed charges",""
"COIL CONCERTO 2MM 4CM .0165IN NYLON DETACHABLE HELIX EMBOLIZATION","SUP-ITM-10088732","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1501.61","81.72","","3010.54","693.88","5019.88","35","960.28","1501.61","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 10MM 14CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10019836","CDM","C1889","HCPCS","0278","RC","","","","both","","","317.00","237.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","252.02","79.5","","1309.77","674.56","6049.93","26","98.27","252.02","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 10MM 14CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10019836","CDM","C1889","HCPCS","0278","RC","","","","both","","","317.00","237.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","168.96","53.3","","1901.83","1901.83","2962.25","1 through 10","98.27","252.02","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 10MM 14CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10019836","CDM","C1889","HCPCS","0278","RC","","","","both","","","317.00","237.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","115.71","36.5","","1620.31","1620.31","19908.88","1 through 10","98.27","252.02","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 10MM 14CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10019836","CDM","C1889","HCPCS","0278","RC","","","","both","","","317.00","237.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.41","38.3","","352.91","352.91","2046.30","1 through 10","98.27","252.02","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 10MM 14CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10019836","CDM","C1889","HCPCS","0278","RC","","","","both","","","317.00","237.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.99","42.9","","9668.75","9668.75","9668.75","1 through 10","98.27","252.02","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 10MM 14CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10019836","CDM","C1889","HCPCS","0278","RC","","","","both","","","317.00","237.75","WELLPOINT [1015]","HB AMC WELLPOINT","233.88","73.78","","699.88","384.10","3443.31","33","98.27","252.02","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 10MM 14CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10019836","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","317.00","237.75","AETNA [1001]","HB AMC AETNA HMO","221.27","69.8","","1421.24","264.50","4933.46","29","165.66","259.05","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 10MM 14CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10019836","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","317.00","237.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","254.87","80.4","","1022.97","1022.97","3607.50","1 through 10","165.66","259.05","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 10MM 14CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10019836","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","317.00","237.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","259.05","81.72","","3010.54","693.88","5019.88","35","165.66","259.05","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 3MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087168","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","238.74","79.5","","1309.77","674.56","6049.93","26","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 3MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087168","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","160.06","53.3","","1901.83","1901.83","2962.25","1 through 10","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 3MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087168","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","109.61","36.5","","1620.31","1620.31","19908.88","1 through 10","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 3MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087168","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","115.01","38.3","","352.91","352.91","2046.30","1 through 10","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 3MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087168","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","128.83","42.9","","9668.75","9668.75","9668.75","1 through 10","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 3MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087168","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","WELLPOINT [1015]","HB AMC WELLPOINT","221.56","73.78","","699.88","384.10","3443.31","33","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 3MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087168","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","300.30","225.22","AETNA [1001]","HB AMC AETNA HMO","209.61","69.8","","1421.24","264.50","4933.46","29","156.94","245.41","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 3MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087168","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","300.30","225.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","241.44","80.4","","1022.97","1022.97","3607.50","1 through 10","156.94","245.41","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 3MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087168","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","300.30","225.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","245.41","81.72","","3010.54","693.88","5019.88","35","156.94","245.41","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 5MM 2MM MICROCOIL TORNADO PLATINUM","SUP-ITM-10028561","CDM","C1889","HCPCS","0278","RC","","","","both","","","333.03","249.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","264.76","79.5","","1309.77","674.56","6049.93","26","103.24","264.76","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 5MM 2MM MICROCOIL TORNADO PLATINUM","SUP-ITM-10028561","CDM","C1889","HCPCS","0278","RC","","","","both","","","333.03","249.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","177.50","53.3","","1901.83","1901.83","2962.25","1 through 10","103.24","264.76","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 5MM 2MM MICROCOIL TORNADO PLATINUM","SUP-ITM-10028561","CDM","C1889","HCPCS","0278","RC","","","","both","","","333.03","249.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.56","36.5","","1620.31","1620.31","19908.88","1 through 10","103.24","264.76","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 5MM 2MM MICROCOIL TORNADO PLATINUM","SUP-ITM-10028561","CDM","C1889","HCPCS","0278","RC","","","","both","","","333.03","249.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.55","38.3","","352.91","352.91","2046.30","1 through 10","103.24","264.76","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 5MM 2MM MICROCOIL TORNADO PLATINUM","SUP-ITM-10028561","CDM","C1889","HCPCS","0278","RC","","","","both","","","333.03","249.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.87","42.9","","9668.75","9668.75","9668.75","1 through 10","103.24","264.76","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 5MM 2MM MICROCOIL TORNADO PLATINUM","SUP-ITM-10028561","CDM","C1889","HCPCS","0278","RC","","","","both","","","333.03","249.77","WELLPOINT [1015]","HB AMC WELLPOINT","245.71","73.78","","699.88","384.10","3443.31","33","103.24","264.76","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 5MM 2MM MICROCOIL TORNADO PLATINUM","SUP-ITM-10028561","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","333.03","249.77","AETNA [1001]","HB AMC AETNA HMO","232.45","69.8","","1421.24","264.50","4933.46","29","174.04","272.15","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 5MM 2MM MICROCOIL TORNADO PLATINUM","SUP-ITM-10028561","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","333.03","249.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","267.76","80.4","","1022.97","1022.97","3607.50","1 through 10","174.04","272.15","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 5MM 2MM MICROCOIL TORNADO PLATINUM","SUP-ITM-10028561","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","333.03","249.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","272.15","81.72","","3010.54","693.88","5019.88","35","174.04","272.15","percent of total billed charges",""
"COIL EMBOLIZATION 11MMX45CM NEUROVASCULAR COMPLEX STD FRAME PENUMBRA 400 NITINOL","SUP-ITM-10090466","CDM","C1889","HCPCS","0278","RC","","","","both","","","5997.50","4498.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4768.01","79.5","","1309.77","674.56","6049.93","26","1859.23","4768.01","percent of total billed charges",""
"COIL EMBOLIZATION 11MMX45CM NEUROVASCULAR COMPLEX STD FRAME PENUMBRA 400 NITINOL","SUP-ITM-10090466","CDM","C1889","HCPCS","0278","RC","","","","both","","","5997.50","4498.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3196.67","53.3","","1901.83","1901.83","2962.25","1 through 10","1859.23","4768.01","percent of total billed charges",""
"COIL EMBOLIZATION 11MMX45CM NEUROVASCULAR COMPLEX STD FRAME PENUMBRA 400 NITINOL","SUP-ITM-10090466","CDM","C1889","HCPCS","0278","RC","","","","both","","","5997.50","4498.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2189.09","36.5","","1620.31","1620.31","19908.88","1 through 10","1859.23","4768.01","percent of total billed charges",""
"COIL EMBOLIZATION 11MMX45CM NEUROVASCULAR COMPLEX STD FRAME PENUMBRA 400 NITINOL","SUP-ITM-10090466","CDM","C1889","HCPCS","0278","RC","","","","both","","","5997.50","4498.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2297.04","38.3","","352.91","352.91","2046.30","1 through 10","1859.23","4768.01","percent of total billed charges",""
"COIL EMBOLIZATION 11MMX45CM NEUROVASCULAR COMPLEX STD FRAME PENUMBRA 400 NITINOL","SUP-ITM-10090466","CDM","C1889","HCPCS","0278","RC","","","","both","","","5997.50","4498.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2572.93","42.9","","9668.75","9668.75","9668.75","1 through 10","1859.23","4768.01","percent of total billed charges",""
"COIL EMBOLIZATION 11MMX45CM NEUROVASCULAR COMPLEX STD FRAME PENUMBRA 400 NITINOL","SUP-ITM-10090466","CDM","C1889","HCPCS","0278","RC","","","","both","","","5997.50","4498.12","WELLPOINT [1015]","HB AMC WELLPOINT","4424.96","73.78","","699.88","384.10","3443.31","33","1859.23","4768.01","percent of total billed charges",""
"COIL EMBOLIZATION 11MMX45CM NEUROVASCULAR COMPLEX STD FRAME PENUMBRA 400 NITINOL","SUP-ITM-10090466","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5997.50","4498.12","AETNA [1001]","HB AMC AETNA HMO","4186.26","69.8","","1421.24","264.50","4933.46","29","3134.29","4901.16","percent of total billed charges",""
"COIL EMBOLIZATION 11MMX45CM NEUROVASCULAR COMPLEX STD FRAME PENUMBRA 400 NITINOL","SUP-ITM-10090466","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5997.50","4498.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4821.99","80.4","","1022.97","1022.97","3607.50","1 through 10","3134.29","4901.16","percent of total billed charges",""
"COIL EMBOLIZATION 11MMX45CM NEUROVASCULAR COMPLEX STD FRAME PENUMBRA 400 NITINOL","SUP-ITM-10090466","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5997.50","4498.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4901.16","81.72","","3010.54","693.88","5019.88","35","3134.29","4901.16","percent of total billed charges",""
"COIL EMBOLIZATION 12MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164926","CDM","C1889","HCPCS","0278","RC","","","","both","","","396.41","297.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","315.15","79.5","","1309.77","674.56","6049.93","26","122.89","315.15","percent of total billed charges",""
"COIL EMBOLIZATION 12MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164926","CDM","C1889","HCPCS","0278","RC","","","","both","","","396.41","297.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","211.29","53.3","","1901.83","1901.83","2962.25","1 through 10","122.89","315.15","percent of total billed charges",""
"COIL EMBOLIZATION 12MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164926","CDM","C1889","HCPCS","0278","RC","","","","both","","","396.41","297.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","144.69","36.5","","1620.31","1620.31","19908.88","1 through 10","122.89","315.15","percent of total billed charges",""
"COIL EMBOLIZATION 12MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164926","CDM","C1889","HCPCS","0278","RC","","","","both","","","396.41","297.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","151.83","38.3","","352.91","352.91","2046.30","1 through 10","122.89","315.15","percent of total billed charges",""
"COIL EMBOLIZATION 12MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164926","CDM","C1889","HCPCS","0278","RC","","","","both","","","396.41","297.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.06","42.9","","9668.75","9668.75","9668.75","1 through 10","122.89","315.15","percent of total billed charges",""
"COIL EMBOLIZATION 12MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164926","CDM","C1889","HCPCS","0278","RC","","","","both","","","396.41","297.31","WELLPOINT [1015]","HB AMC WELLPOINT","292.47","73.78","","699.88","384.10","3443.31","33","122.89","315.15","percent of total billed charges",""
"COIL EMBOLIZATION 12MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164926","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","396.41","297.31","AETNA [1001]","HB AMC AETNA HMO","276.69","69.8","","1421.24","264.50","4933.46","29","207.16","323.95","percent of total billed charges",""
"COIL EMBOLIZATION 12MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164926","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","396.41","297.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","318.71","80.4","","1022.97","1022.97","3607.50","1 through 10","207.16","323.95","percent of total billed charges",""
"COIL EMBOLIZATION 12MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164926","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","396.41","297.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","323.95","81.72","","3010.54","693.88","5019.88","35","207.16","323.95","percent of total billed charges",""
"COIL EMBOLIZATION 18MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087176","CDM","C1889","HCPCS","0278","RC","","","","both","","","396.41","297.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","315.15","79.5","","1309.77","674.56","6049.93","26","122.89","315.15","percent of total billed charges",""
"COIL EMBOLIZATION 18MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087176","CDM","C1889","HCPCS","0278","RC","","","","both","","","396.41","297.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","211.29","53.3","","1901.83","1901.83","2962.25","1 through 10","122.89","315.15","percent of total billed charges",""
"COIL EMBOLIZATION 18MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087176","CDM","C1889","HCPCS","0278","RC","","","","both","","","396.41","297.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","144.69","36.5","","1620.31","1620.31","19908.88","1 through 10","122.89","315.15","percent of total billed charges",""
"COIL EMBOLIZATION 18MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087176","CDM","C1889","HCPCS","0278","RC","","","","both","","","396.41","297.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","151.83","38.3","","352.91","352.91","2046.30","1 through 10","122.89","315.15","percent of total billed charges",""
"COIL EMBOLIZATION 18MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087176","CDM","C1889","HCPCS","0278","RC","","","","both","","","396.41","297.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.06","42.9","","9668.75","9668.75","9668.75","1 through 10","122.89","315.15","percent of total billed charges",""
"COIL EMBOLIZATION 18MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087176","CDM","C1889","HCPCS","0278","RC","","","","both","","","396.41","297.31","WELLPOINT [1015]","HB AMC WELLPOINT","292.47","73.78","","699.88","384.10","3443.31","33","122.89","315.15","percent of total billed charges",""
"COIL EMBOLIZATION 18MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087176","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","396.41","297.31","AETNA [1001]","HB AMC AETNA HMO","276.69","69.8","","1421.24","264.50","4933.46","29","207.16","323.95","percent of total billed charges",""
"COIL EMBOLIZATION 18MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087176","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","396.41","297.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","318.71","80.4","","1022.97","1022.97","3607.50","1 through 10","207.16","323.95","percent of total billed charges",""
"COIL EMBOLIZATION 18MM 20CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087176","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","396.41","297.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","323.95","81.72","","3010.54","693.88","5019.88","35","207.16","323.95","percent of total billed charges",""
"COIL EMBOLIZATION 20MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10078920","CDM","C1889","HCPCS","0278","RC","","","","both","","","341.01","255.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","271.10","79.5","","1309.77","674.56","6049.93","26","105.71","271.1","percent of total billed charges",""
"COIL EMBOLIZATION 20MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10078920","CDM","C1889","HCPCS","0278","RC","","","","both","","","341.01","255.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","181.76","53.3","","1901.83","1901.83","2962.25","1 through 10","105.71","271.1","percent of total billed charges",""
"COIL EMBOLIZATION 20MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10078920","CDM","C1889","HCPCS","0278","RC","","","","both","","","341.01","255.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","124.47","36.5","","1620.31","1620.31","19908.88","1 through 10","105.71","271.1","percent of total billed charges",""
"COIL EMBOLIZATION 20MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10078920","CDM","C1889","HCPCS","0278","RC","","","","both","","","341.01","255.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","130.61","38.3","","352.91","352.91","2046.30","1 through 10","105.71","271.1","percent of total billed charges",""
"COIL EMBOLIZATION 20MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10078920","CDM","C1889","HCPCS","0278","RC","","","","both","","","341.01","255.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.29","42.9","","9668.75","9668.75","9668.75","1 through 10","105.71","271.1","percent of total billed charges",""
"COIL EMBOLIZATION 20MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10078920","CDM","C1889","HCPCS","0278","RC","","","","both","","","341.01","255.76","WELLPOINT [1015]","HB AMC WELLPOINT","251.60","73.78","","699.88","384.10","3443.31","33","105.71","271.1","percent of total billed charges",""
"COIL EMBOLIZATION 20MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10078920","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","341.01","255.76","AETNA [1001]","HB AMC AETNA HMO","238.02","69.8","","1421.24","264.50","4933.46","29","178.21","278.67","percent of total billed charges",""
"COIL EMBOLIZATION 20MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10078920","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","341.01","255.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","274.17","80.4","","1022.97","1022.97","3607.50","1 through 10","178.21","278.67","percent of total billed charges",""
"COIL EMBOLIZATION 20MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10078920","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","341.01","255.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","278.67","81.72","","3010.54","693.88","5019.88","35","178.21","278.67","percent of total billed charges",""
"COIL EMBOLIZATION 3CM XMM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137811","CDM","C1889","HCPCS","0278","RC","","","","both","","","4810.00","3607.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3823.95","79.5","","1309.77","674.56","6049.93","26","1491.1","3823.95","percent of total billed charges",""
"COIL EMBOLIZATION 3CM XMM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137811","CDM","C1889","HCPCS","0278","RC","","","","both","","","4810.00","3607.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2563.73","53.3","","1901.83","1901.83","2962.25","1 through 10","1491.1","3823.95","percent of total billed charges",""
"COIL EMBOLIZATION 3CM XMM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137811","CDM","C1889","HCPCS","0278","RC","","","","both","","","4810.00","3607.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1755.65","36.5","","1620.31","1620.31","19908.88","1 through 10","1491.1","3823.95","percent of total billed charges",""
"COIL EMBOLIZATION 3CM XMM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137811","CDM","C1889","HCPCS","0278","RC","","","","both","","","4810.00","3607.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1842.23","38.3","","352.91","352.91","2046.30","1 through 10","1491.1","3823.95","percent of total billed charges",""
"COIL EMBOLIZATION 3CM XMM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137811","CDM","C1889","HCPCS","0278","RC","","","","both","","","4810.00","3607.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2063.49","42.9","","9668.75","9668.75","9668.75","1 through 10","1491.1","3823.95","percent of total billed charges",""
"COIL EMBOLIZATION 3CM XMM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137811","CDM","C1889","HCPCS","0278","RC","","","","both","","","4810.00","3607.50","WELLPOINT [1015]","HB AMC WELLPOINT","3548.82","73.78","","699.88","384.10","3443.31","33","1491.1","3823.95","percent of total billed charges",""
"COIL EMBOLIZATION 3CM XMM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137811","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4810.00","3607.50","AETNA [1001]","HB AMC AETNA HMO","3357.38","69.8","","1421.24","264.50","4933.46","29","2513.71","3930.73","percent of total billed charges",""
"COIL EMBOLIZATION 3CM XMM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137811","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4810.00","3607.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3867.24","80.4","","1022.97","1022.97","3607.50","1 through 10","2513.71","3930.73","percent of total billed charges",""
"COIL EMBOLIZATION 3CM XMM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137811","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4810.00","3607.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3930.73","81.72","","3010.54","693.88","5019.88","35","2513.71","3930.73","percent of total billed charges",""
"COIL EMBOLIZATION 3CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137834","CDM","C1889","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3625.20","79.5","","1309.77","674.56","6049.93","26","1413.6","3625.2","percent of total billed charges",""
"COIL EMBOLIZATION 3CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137834","CDM","C1889","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2430.48","53.3","","1901.83","1901.83","2962.25","1 through 10","1413.6","3625.2","percent of total billed charges",""
"COIL EMBOLIZATION 3CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137834","CDM","C1889","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1664.40","36.5","","1620.31","1620.31","19908.88","1 through 10","1413.6","3625.2","percent of total billed charges",""
"COIL EMBOLIZATION 3CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137834","CDM","C1889","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1746.48","38.3","","352.91","352.91","2046.30","1 through 10","1413.6","3625.2","percent of total billed charges",""
"COIL EMBOLIZATION 3CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137834","CDM","C1889","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1956.24","42.9","","9668.75","9668.75","9668.75","1 through 10","1413.6","3625.2","percent of total billed charges",""
"COIL EMBOLIZATION 3CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137834","CDM","C1889","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","WELLPOINT [1015]","HB AMC WELLPOINT","3364.37","73.78","","699.88","384.10","3443.31","33","1413.6","3625.2","percent of total billed charges",""
"COIL EMBOLIZATION 3CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137834","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4560.00","3420.00","AETNA [1001]","HB AMC AETNA HMO","3182.88","69.8","","1421.24","264.50","4933.46","29","2383.06","3726.43","percent of total billed charges",""
"COIL EMBOLIZATION 3CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137834","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4560.00","3420.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3666.24","80.4","","1022.97","1022.97","3607.50","1 through 10","2383.06","3726.43","percent of total billed charges",""
"COIL EMBOLIZATION 3CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137834","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4560.00","3420.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3726.43","81.72","","3010.54","693.88","5019.88","35","2383.06","3726.43","percent of total billed charges",""
"COIL EMBOLIZATION 3MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164923","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","238.74","79.5","","1309.77","674.56","6049.93","26","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION 3MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164923","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","160.06","53.3","","1901.83","1901.83","2962.25","1 through 10","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION 3MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164923","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","109.61","36.5","","1620.31","1620.31","19908.88","1 through 10","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION 3MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164923","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","115.01","38.3","","352.91","352.91","2046.30","1 through 10","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION 3MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164923","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","128.83","42.9","","9668.75","9668.75","9668.75","1 through 10","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION 3MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164923","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","WELLPOINT [1015]","HB AMC WELLPOINT","221.56","73.78","","699.88","384.10","3443.31","33","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION 3MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164923","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","300.30","225.22","AETNA [1001]","HB AMC AETNA HMO","209.61","69.8","","1421.24","264.50","4933.46","29","156.94","245.41","percent of total billed charges",""
"COIL EMBOLIZATION 3MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164923","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","300.30","225.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","241.44","80.4","","1022.97","1022.97","3607.50","1 through 10","156.94","245.41","percent of total billed charges",""
"COIL EMBOLIZATION 3MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10164923","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","300.30","225.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","245.41","81.72","","3010.54","693.88","5019.88","35","156.94","245.41","percent of total billed charges",""
"COIL EMBOLIZATION 4CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137810","CDM","C1889","HCPCS","0278","RC","","","","both","","","5060.00","3795.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4022.70","79.5","","1309.77","674.56","6049.93","26","1568.6","4022.7","percent of total billed charges",""
"COIL EMBOLIZATION 4CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137810","CDM","C1889","HCPCS","0278","RC","","","","both","","","5060.00","3795.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2696.98","53.3","","1901.83","1901.83","2962.25","1 through 10","1568.6","4022.7","percent of total billed charges",""
"COIL EMBOLIZATION 4CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137810","CDM","C1889","HCPCS","0278","RC","","","","both","","","5060.00","3795.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1846.90","36.5","","1620.31","1620.31","19908.88","1 through 10","1568.6","4022.7","percent of total billed charges",""
"COIL EMBOLIZATION 4CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137810","CDM","C1889","HCPCS","0278","RC","","","","both","","","5060.00","3795.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1937.98","38.3","","352.91","352.91","2046.30","1 through 10","1568.6","4022.7","percent of total billed charges",""
"COIL EMBOLIZATION 4CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137810","CDM","C1889","HCPCS","0278","RC","","","","both","","","5060.00","3795.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2170.74","42.9","","9668.75","9668.75","9668.75","1 through 10","1568.6","4022.7","percent of total billed charges",""
"COIL EMBOLIZATION 4CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137810","CDM","C1889","HCPCS","0278","RC","","","","both","","","5060.00","3795.00","WELLPOINT [1015]","HB AMC WELLPOINT","3733.27","73.78","","699.88","384.10","3443.31","33","1568.6","4022.7","percent of total billed charges",""
"COIL EMBOLIZATION 4CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137810","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5060.00","3795.00","AETNA [1001]","HB AMC AETNA HMO","3531.88","69.8","","1421.24","264.50","4933.46","29","2644.36","4135.03","percent of total billed charges",""
"COIL EMBOLIZATION 4CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137810","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5060.00","3795.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4068.24","80.4","","1022.97","1022.97","3607.50","1 through 10","2644.36","4135.03","percent of total billed charges",""
"COIL EMBOLIZATION 4CMX2MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137810","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5060.00","3795.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4135.03","81.72","","3010.54","693.88","5019.88","35","2644.36","4135.03","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX10CM 400 COMPLEX EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090500","CDM","C1889","HCPCS","0278","RC","","","","both","","","6187.50","4640.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4919.06","79.5","","1309.77","674.56","6049.93","26","1918.13","4919.06","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX10CM 400 COMPLEX EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090500","CDM","C1889","HCPCS","0278","RC","","","","both","","","6187.50","4640.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3297.94","53.3","","1901.83","1901.83","2962.25","1 through 10","1918.13","4919.06","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX10CM 400 COMPLEX EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090500","CDM","C1889","HCPCS","0278","RC","","","","both","","","6187.50","4640.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2258.44","36.5","","1620.31","1620.31","19908.88","1 through 10","1918.13","4919.06","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX10CM 400 COMPLEX EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090500","CDM","C1889","HCPCS","0278","RC","","","","both","","","6187.50","4640.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2369.81","38.3","","352.91","352.91","2046.30","1 through 10","1918.13","4919.06","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX10CM 400 COMPLEX EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090500","CDM","C1889","HCPCS","0278","RC","","","","both","","","6187.50","4640.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2654.44","42.9","","9668.75","9668.75","9668.75","1 through 10","1918.13","4919.06","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX10CM 400 COMPLEX EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090500","CDM","C1889","HCPCS","0278","RC","","","","both","","","6187.50","4640.62","WELLPOINT [1015]","HB AMC WELLPOINT","4565.14","73.78","","699.88","384.10","3443.31","33","1918.13","4919.06","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX10CM 400 COMPLEX EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6187.50","4640.62","AETNA [1001]","HB AMC AETNA HMO","4318.88","69.8","","1421.24","264.50","4933.46","29","3233.59","5056.43","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX10CM 400 COMPLEX EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6187.50","4640.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4974.75","80.4","","1022.97","1022.97","3607.50","1 through 10","3233.59","5056.43","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX10CM 400 COMPLEX EXTRA SOFT NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10090500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6187.50","4640.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5056.43","81.72","","3010.54","693.88","5019.88","35","3233.59","5056.43","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX15CM RUBY LP VASCULAR","SUP-ITM-10276422","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2754.68","79.5","","1309.77","674.56","6049.93","26","1074.15","2754.68","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX15CM RUBY LP VASCULAR","SUP-ITM-10276422","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1846.85","53.3","","1901.83","1901.83","2962.25","1 through 10","1074.15","2754.68","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX15CM RUBY LP VASCULAR","SUP-ITM-10276422","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1264.73","36.5","","1620.31","1620.31","19908.88","1 through 10","1074.15","2754.68","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX15CM RUBY LP VASCULAR","SUP-ITM-10276422","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1327.10","38.3","","352.91","352.91","2046.30","1 through 10","1074.15","2754.68","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX15CM RUBY LP VASCULAR","SUP-ITM-10276422","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1486.49","42.9","","9668.75","9668.75","9668.75","1 through 10","1074.15","2754.68","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX15CM RUBY LP VASCULAR","SUP-ITM-10276422","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB AMC WELLPOINT","2556.48","73.78","","699.88","384.10","3443.31","33","1074.15","2754.68","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX15CM RUBY LP VASCULAR","SUP-ITM-10276422","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","AETNA [1001]","HB AMC AETNA HMO","2418.57","69.8","","1421.24","264.50","4933.46","29","1810.81","2831.6","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX15CM RUBY LP VASCULAR","SUP-ITM-10276422","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2785.86","80.4","","1022.97","1022.97","3607.50","1 through 10","1810.81","2831.6","percent of total billed charges",""
"COIL EMBOLIZATION 4MMX15CM RUBY LP VASCULAR","SUP-ITM-10276422","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2831.60","81.72","","3010.54","693.88","5019.88","35","1810.81","2831.6","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX10MM 1.6 .035IN LOOP RADIAL FORCE MR CONDITIONAL MREYE INCONEL SYNTHETIC FIBER","SUP-ITM-10087050","CDM","C1889","HCPCS","0278","RC","","","","both","","","289.31","216.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","230.00","79.5","","1309.77","674.56","6049.93","26","89.69","230","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX10MM 1.6 .035IN LOOP RADIAL FORCE MR CONDITIONAL MREYE INCONEL SYNTHETIC FIBER","SUP-ITM-10087050","CDM","C1889","HCPCS","0278","RC","","","","both","","","289.31","216.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","154.20","53.3","","1901.83","1901.83","2962.25","1 through 10","89.69","230","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX10MM 1.6 .035IN LOOP RADIAL FORCE MR CONDITIONAL MREYE INCONEL SYNTHETIC FIBER","SUP-ITM-10087050","CDM","C1889","HCPCS","0278","RC","","","","both","","","289.31","216.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.60","36.5","","1620.31","1620.31","19908.88","1 through 10","89.69","230","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX10MM 1.6 .035IN LOOP RADIAL FORCE MR CONDITIONAL MREYE INCONEL SYNTHETIC FIBER","SUP-ITM-10087050","CDM","C1889","HCPCS","0278","RC","","","","both","","","289.31","216.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","110.81","38.3","","352.91","352.91","2046.30","1 through 10","89.69","230","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX10MM 1.6 .035IN LOOP RADIAL FORCE MR CONDITIONAL MREYE INCONEL SYNTHETIC FIBER","SUP-ITM-10087050","CDM","C1889","HCPCS","0278","RC","","","","both","","","289.31","216.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.11","42.9","","9668.75","9668.75","9668.75","1 through 10","89.69","230","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX10MM 1.6 .035IN LOOP RADIAL FORCE MR CONDITIONAL MREYE INCONEL SYNTHETIC FIBER","SUP-ITM-10087050","CDM","C1889","HCPCS","0278","RC","","","","both","","","289.31","216.98","WELLPOINT [1015]","HB AMC WELLPOINT","213.45","73.78","","699.88","384.10","3443.31","33","89.69","230","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX10MM 1.6 .035IN LOOP RADIAL FORCE MR CONDITIONAL MREYE INCONEL SYNTHETIC FIBER","SUP-ITM-10087050","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","289.31","216.98","AETNA [1001]","HB AMC AETNA HMO","201.94","69.8","","1421.24","264.50","4933.46","29","151.19","236.42","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX10MM 1.6 .035IN LOOP RADIAL FORCE MR CONDITIONAL MREYE INCONEL SYNTHETIC FIBER","SUP-ITM-10087050","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","289.31","216.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","232.61","80.4","","1022.97","1022.97","3607.50","1 through 10","151.19","236.42","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX10MM 1.6 .035IN LOOP RADIAL FORCE MR CONDITIONAL MREYE INCONEL SYNTHETIC FIBER","SUP-ITM-10087050","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","289.31","216.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","236.42","81.72","","3010.54","693.88","5019.88","35","151.19","236.42","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX3MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137813","CDM","C1889","HCPCS","0278","RC","","","","both","","","5307.50","3980.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4219.46","79.5","","1309.77","674.56","6049.93","26","1645.33","4219.46","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX3MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137813","CDM","C1889","HCPCS","0278","RC","","","","both","","","5307.50","3980.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2828.90","53.3","","1901.83","1901.83","2962.25","1 through 10","1645.33","4219.46","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX3MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137813","CDM","C1889","HCPCS","0278","RC","","","","both","","","5307.50","3980.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1937.24","36.5","","1620.31","1620.31","19908.88","1 through 10","1645.33","4219.46","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX3MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137813","CDM","C1889","HCPCS","0278","RC","","","","both","","","5307.50","3980.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2032.77","38.3","","352.91","352.91","2046.30","1 through 10","1645.33","4219.46","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX3MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137813","CDM","C1889","HCPCS","0278","RC","","","","both","","","5307.50","3980.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2276.92","42.9","","9668.75","9668.75","9668.75","1 through 10","1645.33","4219.46","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX3MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137813","CDM","C1889","HCPCS","0278","RC","","","","both","","","5307.50","3980.62","WELLPOINT [1015]","HB AMC WELLPOINT","3915.87","73.78","","699.88","384.10","3443.31","33","1645.33","4219.46","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX3MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137813","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5307.50","3980.62","AETNA [1001]","HB AMC AETNA HMO","3704.64","69.8","","1421.24","264.50","4933.46","29","2773.7","4337.29","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX3MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137813","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5307.50","3980.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4267.23","80.4","","1022.97","1022.97","3607.50","1 through 10","2773.7","4337.29","percent of total billed charges",""
"COIL EMBOLIZATION 5CMX3MM 400 COMPLEX NITINOL EXTRA SOFT","SUP-ITM-10137813","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5307.50","3980.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4337.29","81.72","","3010.54","693.88","5019.88","35","2773.7","4337.29","percent of total billed charges",""
"COIL EMBOLIZATION 6MM 6.7MM 80MM .018IN VORTX DIAMOND-18 SHAPE PUSHABLE 16 DACRON FIBER BX/5EA","SUP-ITM-10018265","CDM","C1889","HCPCS","0278","RC","","","","both","","","297.50","223.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.51","79.5","","1309.77","674.56","6049.93","26","92.23","236.51","percent of total billed charges",""
"COIL EMBOLIZATION 6MM 6.7MM 80MM .018IN VORTX DIAMOND-18 SHAPE PUSHABLE 16 DACRON FIBER BX/5EA","SUP-ITM-10018265","CDM","C1889","HCPCS","0278","RC","","","","both","","","297.50","223.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.57","53.3","","1901.83","1901.83","2962.25","1 through 10","92.23","236.51","percent of total billed charges",""
"COIL EMBOLIZATION 6MM 6.7MM 80MM .018IN VORTX DIAMOND-18 SHAPE PUSHABLE 16 DACRON FIBER BX/5EA","SUP-ITM-10018265","CDM","C1889","HCPCS","0278","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.59","36.5","","1620.31","1620.31","19908.88","1 through 10","92.23","236.51","percent of total billed charges",""
"COIL EMBOLIZATION 6MM 6.7MM 80MM .018IN VORTX DIAMOND-18 SHAPE PUSHABLE 16 DACRON FIBER BX/5EA","SUP-ITM-10018265","CDM","C1889","HCPCS","0278","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.94","38.3","","352.91","352.91","2046.30","1 through 10","92.23","236.51","percent of total billed charges",""
"COIL EMBOLIZATION 6MM 6.7MM 80MM .018IN VORTX DIAMOND-18 SHAPE PUSHABLE 16 DACRON FIBER BX/5EA","SUP-ITM-10018265","CDM","C1889","HCPCS","0278","RC","","","","both","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.63","42.9","","9668.75","9668.75","9668.75","1 through 10","92.23","236.51","percent of total billed charges",""
"COIL EMBOLIZATION 6MM 6.7MM 80MM .018IN VORTX DIAMOND-18 SHAPE PUSHABLE 16 DACRON FIBER BX/5EA","SUP-ITM-10018265","CDM","C1889","HCPCS","0278","RC","","","","both","","","297.50","223.12","WELLPOINT [1015]","HB AMC WELLPOINT","219.50","73.78","","699.88","384.10","3443.31","33","92.23","236.51","percent of total billed charges",""
"COIL EMBOLIZATION 6MM 6.7MM 80MM .018IN VORTX DIAMOND-18 SHAPE PUSHABLE 16 DACRON FIBER BX/5EA","SUP-ITM-10018265","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","AETNA [1001]","HB AMC AETNA HMO","207.66","69.8","","1421.24","264.50","4933.46","29","155.47","243.12","percent of total billed charges",""
"COIL EMBOLIZATION 6MM 6.7MM 80MM .018IN VORTX DIAMOND-18 SHAPE PUSHABLE 16 DACRON FIBER BX/5EA","SUP-ITM-10018265","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","239.19","80.4","","1022.97","1022.97","3607.50","1 through 10","155.47","243.12","percent of total billed charges",""
"COIL EMBOLIZATION 6MM 6.7MM 80MM .018IN VORTX DIAMOND-18 SHAPE PUSHABLE 16 DACRON FIBER BX/5EA","SUP-ITM-10018265","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","243.12","81.72","","3010.54","693.88","5019.88","35","155.47","243.12","percent of total billed charges",""
"COIL EMBOLIZATION 8MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087174","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","238.74","79.5","","1309.77","674.56","6049.93","26","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION 8MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087174","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","160.06","53.3","","1901.83","1901.83","2962.25","1 through 10","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION 8MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087174","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","109.61","36.5","","1620.31","1620.31","19908.88","1 through 10","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION 8MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087174","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","115.01","38.3","","352.91","352.91","2046.30","1 through 10","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION 8MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087174","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","128.83","42.9","","9668.75","9668.75","9668.75","1 through 10","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION 8MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087174","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.30","225.22","WELLPOINT [1015]","HB AMC WELLPOINT","221.56","73.78","","699.88","384.10","3443.31","33","93.09","238.74","percent of total billed charges",""
"COIL EMBOLIZATION 8MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087174","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","300.30","225.22","AETNA [1001]","HB AMC AETNA HMO","209.61","69.8","","1421.24","264.50","4933.46","29","156.94","245.41","percent of total billed charges",""
"COIL EMBOLIZATION 8MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087174","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","300.30","225.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","241.44","80.4","","1022.97","1022.97","3607.50","1 through 10","156.94","245.41","percent of total billed charges",""
"COIL EMBOLIZATION 8MM 7CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10087174","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","300.30","225.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","245.41","81.72","","3010.54","693.88","5019.88","35","156.94","245.41","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX20CM .035IN AZUR 35D SYSTEM HYDROGEL POLYMER DETACHABLE","SUP-ITM-10091828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3949.50","2962.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3139.85","79.5","","1309.77","674.56","6049.93","26","1224.35","3139.85","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX20CM .035IN AZUR 35D SYSTEM HYDROGEL POLYMER DETACHABLE","SUP-ITM-10091828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3949.50","2962.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2105.08","53.3","","1901.83","1901.83","2962.25","1 through 10","1224.35","3139.85","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX20CM .035IN AZUR 35D SYSTEM HYDROGEL POLYMER DETACHABLE","SUP-ITM-10091828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3949.50","2962.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1441.57","36.5","","1620.31","1620.31","19908.88","1 through 10","1224.35","3139.85","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX20CM .035IN AZUR 35D SYSTEM HYDROGEL POLYMER DETACHABLE","SUP-ITM-10091828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3949.50","2962.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1512.66","38.3","","352.91","352.91","2046.30","1 through 10","1224.35","3139.85","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX20CM .035IN AZUR 35D SYSTEM HYDROGEL POLYMER DETACHABLE","SUP-ITM-10091828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3949.50","2962.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1694.34","42.9","","9668.75","9668.75","9668.75","1 through 10","1224.35","3139.85","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX20CM .035IN AZUR 35D SYSTEM HYDROGEL POLYMER DETACHABLE","SUP-ITM-10091828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3949.50","2962.12","WELLPOINT [1015]","HB AMC WELLPOINT","2913.94","73.78","","699.88","384.10","3443.31","33","1224.35","3139.85","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX20CM .035IN AZUR 35D SYSTEM HYDROGEL POLYMER DETACHABLE","SUP-ITM-10091828","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3949.50","2962.12","AETNA [1001]","HB AMC AETNA HMO","2756.75","69.8","","1421.24","264.50","4933.46","29","2064.01","3227.53","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX20CM .035IN AZUR 35D SYSTEM HYDROGEL POLYMER DETACHABLE","SUP-ITM-10091828","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3949.50","2962.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3175.40","80.4","","1022.97","1022.97","3607.50","1 through 10","2064.01","3227.53","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX20CM .035IN AZUR 35D SYSTEM HYDROGEL POLYMER DETACHABLE","SUP-ITM-10091828","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3949.50","2962.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3227.53","81.72","","3010.54","693.88","5019.88","35","2064.01","3227.53","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX60CM 400 COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10137820","CDM","C1889","HCPCS","0278","RC","","","","both","","","6887.50","5165.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5475.56","79.5","","1309.77","674.56","6049.93","26","2135.13","5475.56","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX60CM 400 COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10137820","CDM","C1889","HCPCS","0278","RC","","","","both","","","6887.50","5165.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3671.04","53.3","","1901.83","1901.83","2962.25","1 through 10","2135.13","5475.56","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX60CM 400 COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10137820","CDM","C1889","HCPCS","0278","RC","","","","both","","","6887.50","5165.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2513.94","36.5","","1620.31","1620.31","19908.88","1 through 10","2135.13","5475.56","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX60CM 400 COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10137820","CDM","C1889","HCPCS","0278","RC","","","","both","","","6887.50","5165.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2637.91","38.3","","352.91","352.91","2046.30","1 through 10","2135.13","5475.56","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX60CM 400 COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10137820","CDM","C1889","HCPCS","0278","RC","","","","both","","","6887.50","5165.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2954.74","42.9","","9668.75","9668.75","9668.75","1 through 10","2135.13","5475.56","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX60CM 400 COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10137820","CDM","C1889","HCPCS","0278","RC","","","","both","","","6887.50","5165.62","WELLPOINT [1015]","HB AMC WELLPOINT","5081.60","73.78","","699.88","384.10","3443.31","33","2135.13","5475.56","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX60CM 400 COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10137820","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6887.50","5165.62","AETNA [1001]","HB AMC AETNA HMO","4807.48","69.8","","1421.24","264.50","4933.46","29","3599.41","5628.47","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX60CM 400 COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10137820","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6887.50","5165.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5537.55","80.4","","1022.97","1022.97","3607.50","1 through 10","3599.41","5628.47","percent of total billed charges",""
"COIL EMBOLIZATION 8MMX60CM 400 COMPLEX STANDARD NITINOL DETACHABLE STRETCH RESISTANT","SUP-ITM-10137820","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6887.50","5165.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5628.47","81.72","","3010.54","693.88","5019.88","35","3599.41","5628.47","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","1088.96","816.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","865.72","79.5","","1309.77","674.56","6049.93","26","337.58","865.72","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","1088.96","816.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","580.42","53.3","","1901.83","1901.83","2962.25","1 through 10","337.58","865.72","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","1088.96","816.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","397.47","36.5","","1620.31","1620.31","19908.88","1 through 10","337.58","865.72","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","1088.96","816.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","417.07","38.3","","352.91","352.91","2046.30","1 through 10","337.58","865.72","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","1088.96","816.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","467.16","42.9","","9668.75","9668.75","9668.75","1 through 10","337.58","865.72","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","1088.96","816.72","WELLPOINT [1015]","HB AMC WELLPOINT","803.43","73.78","","699.88","384.10","3443.31","33","337.58","865.72","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1088.96","816.72","AETNA [1001]","HB AMC AETNA HMO","760.09","69.8","","1421.24","264.50","4933.46","29","569.09","889.9","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1088.96","816.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","875.52","80.4","","1022.97","1022.97","3607.50","1 through 10","569.09","889.9","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1088.96","816.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","889.90","81.72","","3010.54","693.88","5019.88","35","569.09","889.9","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","4642.56","3481.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3690.84","79.5","","1309.77","674.56","6049.93","26","1439.19","3690.84","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","4642.56","3481.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2474.48","53.3","","1901.83","1901.83","2962.25","1 through 10","1439.19","3690.84","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","4642.56","3481.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1694.53","36.5","","1620.31","1620.31","19908.88","1 through 10","1439.19","3690.84","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","4642.56","3481.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1778.10","38.3","","352.91","352.91","2046.30","1 through 10","1439.19","3690.84","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","4642.56","3481.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1991.66","42.9","","9668.75","9668.75","9668.75","1 through 10","1439.19","3690.84","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","4642.56","3481.92","WELLPOINT [1015]","HB AMC WELLPOINT","3425.28","73.78","","699.88","384.10","3443.31","33","1439.19","3690.84","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4642.56","3481.92","AETNA [1001]","HB AMC AETNA HMO","3240.51","69.8","","1421.24","264.50","4933.46","29","2426.2","3793.9","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4642.56","3481.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3732.62","80.4","","1022.97","1022.97","3607.50","1 through 10","2426.2","3793.9","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4642.56","3481.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3793.90","81.72","","3010.54","693.88","5019.88","35","2426.2","3793.9","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","5564.58","4173.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4423.84","79.5","","1309.77","674.56","6049.93","26","1725.02","4423.84","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","5564.58","4173.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2965.92","53.3","","1901.83","1901.83","2962.25","1 through 10","1725.02","4423.84","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","5564.58","4173.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2031.07","36.5","","1620.31","1620.31","19908.88","1 through 10","1725.02","4423.84","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","5564.58","4173.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2131.23","38.3","","352.91","352.91","2046.30","1 through 10","1725.02","4423.84","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","5564.58","4173.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2387.20","42.9","","9668.75","9668.75","9668.75","1 through 10","1725.02","4423.84","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","5564.58","4173.43","WELLPOINT [1015]","HB AMC WELLPOINT","4105.55","73.78","","699.88","384.10","3443.31","33","1725.02","4423.84","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5564.58","4173.43","AETNA [1001]","HB AMC AETNA HMO","3884.08","69.8","","1421.24","264.50","4933.46","29","2908.05","4547.37","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5564.58","4173.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4473.92","80.4","","1022.97","1022.97","3607.50","1 through 10","2908.05","4547.37","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5564.58","4173.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4547.37","81.72","","3010.54","693.88","5019.88","35","2908.05","4547.37","percent of total billed charges",""
"COIL FIBERED 10MMX20CM EMBOLD","SUP-ITM-10307272","CDM","C1889","HCPCS","0278","RC","","","","both","","","3458.00","2593.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2749.11","79.5","","1309.77","674.56","6049.93","26","1071.98","2749.11","percent of total billed charges",""
"COIL FIBERED 10MMX20CM EMBOLD","SUP-ITM-10307272","CDM","C1889","HCPCS","0278","RC","","","","both","","","3458.00","2593.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1843.11","53.3","","1901.83","1901.83","2962.25","1 through 10","1071.98","2749.11","percent of total billed charges",""
"COIL FIBERED 10MMX20CM EMBOLD","SUP-ITM-10307272","CDM","C1889","HCPCS","0278","RC","","","","both","","","3458.00","2593.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1262.17","36.5","","1620.31","1620.31","19908.88","1 through 10","1071.98","2749.11","percent of total billed charges",""
"COIL FIBERED 10MMX20CM EMBOLD","SUP-ITM-10307272","CDM","C1889","HCPCS","0278","RC","","","","both","","","3458.00","2593.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1324.41","38.3","","352.91","352.91","2046.30","1 through 10","1071.98","2749.11","percent of total billed charges",""
"COIL FIBERED 10MMX20CM EMBOLD","SUP-ITM-10307272","CDM","C1889","HCPCS","0278","RC","","","","both","","","3458.00","2593.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1483.48","42.9","","9668.75","9668.75","9668.75","1 through 10","1071.98","2749.11","percent of total billed charges",""
"COIL FIBERED 10MMX20CM EMBOLD","SUP-ITM-10307272","CDM","C1889","HCPCS","0278","RC","","","","both","","","3458.00","2593.50","WELLPOINT [1015]","HB AMC WELLPOINT","2551.31","73.78","","699.88","384.10","3443.31","33","1071.98","2749.11","percent of total billed charges",""
"COIL FIBERED 10MMX20CM EMBOLD","SUP-ITM-10307272","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3458.00","2593.50","AETNA [1001]","HB AMC AETNA HMO","2413.68","69.8","","1421.24","264.50","4933.46","29","1807.15","2825.88","percent of total billed charges",""
"COIL FIBERED 10MMX20CM EMBOLD","SUP-ITM-10307272","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3458.00","2593.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2780.23","80.4","","1022.97","1022.97","3607.50","1 through 10","1807.15","2825.88","percent of total billed charges",""
"COIL FIBERED 10MMX20CM EMBOLD","SUP-ITM-10307272","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3458.00","2593.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2825.88","81.72","","3010.54","693.88","5019.88","35","1807.15","2825.88","percent of total billed charges",""
"COIL INTERLOCK 15MM 40CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090452","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","1309.77","674.56","6049.93","26","922.25","2365.13","percent of total billed charges",""
"COIL INTERLOCK 15MM 40CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090452","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1585.68","53.3","","1901.83","1901.83","2962.25","1 through 10","922.25","2365.13","percent of total billed charges",""
"COIL INTERLOCK 15MM 40CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090452","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","1620.31","1620.31","19908.88","1 through 10","922.25","2365.13","percent of total billed charges",""
"COIL INTERLOCK 15MM 40CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090452","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","352.91","352.91","2046.30","1 through 10","922.25","2365.13","percent of total billed charges",""
"COIL INTERLOCK 15MM 40CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090452","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","9668.75","9668.75","9668.75","1 through 10","922.25","2365.13","percent of total billed charges",""
"COIL INTERLOCK 15MM 40CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090452","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","WELLPOINT [1015]","HB AMC WELLPOINT","2194.96","73.78","","699.88","384.10","3443.31","33","922.25","2365.13","percent of total billed charges",""
"COIL INTERLOCK 15MM 40CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090452","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","1421.24","264.50","4933.46","29","1554.74","2431.17","percent of total billed charges",""
"COIL INTERLOCK 15MM 40CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090452","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2391.90","80.4","","1022.97","1022.97","3607.50","1 through 10","1554.74","2431.17","percent of total billed charges",""
"COIL INTERLOCK 15MM 40CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090452","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","3010.54","693.88","5019.88","35","1554.74","2431.17","percent of total billed charges",""
"COIL INTERLOCK 4MM 8.0CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072505","CDM","C1889","HCPCS","0278","RC","","","","both","","","1312.50","984.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.44","79.5","","1309.77","674.56","6049.93","26","406.88","1043.44","percent of total billed charges",""
"COIL INTERLOCK 4MM 8.0CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072505","CDM","C1889","HCPCS","0278","RC","","","","both","","","1312.50","984.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","699.56","53.3","","1901.83","1901.83","2962.25","1 through 10","406.88","1043.44","percent of total billed charges",""
"COIL INTERLOCK 4MM 8.0CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072505","CDM","C1889","HCPCS","0278","RC","","","","both","","","1312.50","984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","479.06","36.5","","1620.31","1620.31","19908.88","1 through 10","406.88","1043.44","percent of total billed charges",""
"COIL INTERLOCK 4MM 8.0CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072505","CDM","C1889","HCPCS","0278","RC","","","","both","","","1312.50","984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.69","38.3","","352.91","352.91","2046.30","1 through 10","406.88","1043.44","percent of total billed charges",""
"COIL INTERLOCK 4MM 8.0CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072505","CDM","C1889","HCPCS","0278","RC","","","","both","","","1312.50","984.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.06","42.9","","9668.75","9668.75","9668.75","1 through 10","406.88","1043.44","percent of total billed charges",""
"COIL INTERLOCK 4MM 8.0CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072505","CDM","C1889","HCPCS","0278","RC","","","","both","","","1312.50","984.37","WELLPOINT [1015]","HB AMC WELLPOINT","968.36","73.78","","699.88","384.10","3443.31","33","406.88","1043.44","percent of total billed charges",""
"COIL INTERLOCK 4MM 8.0CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072505","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","AETNA [1001]","HB AMC AETNA HMO","916.13","69.8","","1421.24","264.50","4933.46","29","685.91","1072.58","percent of total billed charges",""
"COIL INTERLOCK 4MM 8.0CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072505","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1055.25","80.4","","1022.97","1022.97","3607.50","1 through 10","685.91","1072.58","percent of total billed charges",""
"COIL INTERLOCK 4MM 8.0CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072505","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1072.58","81.72","","3010.54","693.88","5019.88","35","685.91","1072.58","percent of total billed charges",""
"COIL INTERLOCK 8MM 20CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090448","CDM","C1889","HCPCS","0278","RC","","","","both","","","2273.99","1705.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1807.82","79.5","","1309.77","674.56","6049.93","26","704.94","1807.82","percent of total billed charges",""
"COIL INTERLOCK 8MM 20CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090448","CDM","C1889","HCPCS","0278","RC","","","","both","","","2273.99","1705.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1212.04","53.3","","1901.83","1901.83","2962.25","1 through 10","704.94","1807.82","percent of total billed charges",""
"COIL INTERLOCK 8MM 20CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090448","CDM","C1889","HCPCS","0278","RC","","","","both","","","2273.99","1705.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","830.01","36.5","","1620.31","1620.31","19908.88","1 through 10","704.94","1807.82","percent of total billed charges",""
"COIL INTERLOCK 8MM 20CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090448","CDM","C1889","HCPCS","0278","RC","","","","both","","","2273.99","1705.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","870.94","38.3","","352.91","352.91","2046.30","1 through 10","704.94","1807.82","percent of total billed charges",""
"COIL INTERLOCK 8MM 20CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090448","CDM","C1889","HCPCS","0278","RC","","","","both","","","2273.99","1705.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","975.54","42.9","","9668.75","9668.75","9668.75","1 through 10","704.94","1807.82","percent of total billed charges",""
"COIL INTERLOCK 8MM 20CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090448","CDM","C1889","HCPCS","0278","RC","","","","both","","","2273.99","1705.49","WELLPOINT [1015]","HB AMC WELLPOINT","1677.75","73.78","","699.88","384.10","3443.31","33","704.94","1807.82","percent of total billed charges",""
"COIL INTERLOCK 8MM 20CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090448","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2273.99","1705.49","AETNA [1001]","HB AMC AETNA HMO","1587.25","69.8","","1421.24","264.50","4933.46","29","1188.39","1858.3","percent of total billed charges",""
"COIL INTERLOCK 8MM 20CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090448","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2273.99","1705.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1828.29","80.4","","1022.97","1022.97","3607.50","1 through 10","1188.39","1858.3","percent of total billed charges",""
"COIL INTERLOCK 8MM 20CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090448","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2273.99","1705.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1858.30","81.72","","3010.54","693.88","5019.88","35","1188.39","1858.3","percent of total billed charges",""
"COIL J-SOFT 5CM POD PACKING","SUP-ITM-10212684","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2754.68","79.5","","1309.77","674.56","6049.93","26","1074.15","2754.68","percent of total billed charges",""
"COIL J-SOFT 5CM POD PACKING","SUP-ITM-10212684","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1846.85","53.3","","1901.83","1901.83","2962.25","1 through 10","1074.15","2754.68","percent of total billed charges",""
"COIL J-SOFT 5CM POD PACKING","SUP-ITM-10212684","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1264.73","36.5","","1620.31","1620.31","19908.88","1 through 10","1074.15","2754.68","percent of total billed charges",""
"COIL J-SOFT 5CM POD PACKING","SUP-ITM-10212684","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1327.10","38.3","","352.91","352.91","2046.30","1 through 10","1074.15","2754.68","percent of total billed charges",""
"COIL J-SOFT 5CM POD PACKING","SUP-ITM-10212684","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1486.49","42.9","","9668.75","9668.75","9668.75","1 through 10","1074.15","2754.68","percent of total billed charges",""
"COIL J-SOFT 5CM POD PACKING","SUP-ITM-10212684","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB AMC WELLPOINT","2556.48","73.78","","699.88","384.10","3443.31","33","1074.15","2754.68","percent of total billed charges",""
"COIL J-SOFT 5CM POD PACKING","SUP-ITM-10212684","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","AETNA [1001]","HB AMC AETNA HMO","2418.57","69.8","","1421.24","264.50","4933.46","29","1810.81","2831.6","percent of total billed charges",""
"COIL J-SOFT 5CM POD PACKING","SUP-ITM-10212684","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2785.86","80.4","","1022.97","1022.97","3607.50","1 through 10","1810.81","2831.6","percent of total billed charges",""
"COIL J-SOFT 5CM POD PACKING","SUP-ITM-10212684","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2831.60","81.72","","3010.54","693.88","5019.88","35","1810.81","2831.6","percent of total billed charges",""
"COIL PACKING 10MMX60CM RUBY POD","SUP-ITM-10230676","CDM","C1889","HCPCS","0278","RC","","","","both","","","5370.00","4027.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4269.15","79.5","","1309.77","674.56","6049.93","26","1664.7","4269.15","percent of total billed charges",""
"COIL PACKING 10MMX60CM RUBY POD","SUP-ITM-10230676","CDM","C1889","HCPCS","0278","RC","","","","both","","","5370.00","4027.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2862.21","53.3","","1901.83","1901.83","2962.25","1 through 10","1664.7","4269.15","percent of total billed charges",""
"COIL PACKING 10MMX60CM RUBY POD","SUP-ITM-10230676","CDM","C1889","HCPCS","0278","RC","","","","both","","","5370.00","4027.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1960.05","36.5","","1620.31","1620.31","19908.88","1 through 10","1664.7","4269.15","percent of total billed charges",""
"COIL PACKING 10MMX60CM RUBY POD","SUP-ITM-10230676","CDM","C1889","HCPCS","0278","RC","","","","both","","","5370.00","4027.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2056.71","38.3","","352.91","352.91","2046.30","1 through 10","1664.7","4269.15","percent of total billed charges",""
"COIL PACKING 10MMX60CM RUBY POD","SUP-ITM-10230676","CDM","C1889","HCPCS","0278","RC","","","","both","","","5370.00","4027.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2303.73","42.9","","9668.75","9668.75","9668.75","1 through 10","1664.7","4269.15","percent of total billed charges",""
"COIL PACKING 10MMX60CM RUBY POD","SUP-ITM-10230676","CDM","C1889","HCPCS","0278","RC","","","","both","","","5370.00","4027.50","WELLPOINT [1015]","HB AMC WELLPOINT","3961.99","73.78","","699.88","384.10","3443.31","33","1664.7","4269.15","percent of total billed charges",""
"COIL PACKING 10MMX60CM RUBY POD","SUP-ITM-10230676","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5370.00","4027.50","AETNA [1001]","HB AMC AETNA HMO","3748.26","69.8","","1421.24","264.50","4933.46","29","2806.36","4388.36","percent of total billed charges",""
"COIL PACKING 10MMX60CM RUBY POD","SUP-ITM-10230676","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5370.00","4027.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4317.48","80.4","","1022.97","1022.97","3607.50","1 through 10","2806.36","4388.36","percent of total billed charges",""
"COIL PACKING 10MMX60CM RUBY POD","SUP-ITM-10230676","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5370.00","4027.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4388.36","81.72","","3010.54","693.88","5019.88","35","2806.36","4388.36","percent of total billed charges",""
"COIL PACKING 70CM XL","SUP-ITM-10339809","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5962.50","79.5","","1309.77","674.56","6049.93","26","2325","5962.5","percent of total billed charges",""
"COIL PACKING 70CM XL","SUP-ITM-10339809","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3997.50","53.3","","1901.83","1901.83","2962.25","1 through 10","2325","5962.5","percent of total billed charges",""
"COIL PACKING 70CM XL","SUP-ITM-10339809","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2737.50","36.5","","1620.31","1620.31","19908.88","1 through 10","2325","5962.5","percent of total billed charges",""
"COIL PACKING 70CM XL","SUP-ITM-10339809","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2872.50","38.3","","352.91","352.91","2046.30","1 through 10","2325","5962.5","percent of total billed charges",""
"COIL PACKING 70CM XL","SUP-ITM-10339809","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3217.50","42.9","","9668.75","9668.75","9668.75","1 through 10","2325","5962.5","percent of total billed charges",""
"COIL PACKING 70CM XL","SUP-ITM-10339809","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","WELLPOINT [1015]","HB AMC WELLPOINT","5533.50","73.78","","699.88","384.10","3443.31","33","2325","5962.5","percent of total billed charges",""
"COIL PACKING 70CM XL","SUP-ITM-10339809","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","AETNA [1001]","HB AMC AETNA HMO","5235.00","69.8","","1421.24","264.50","4933.46","29","3919.5","6129","percent of total billed charges",""
"COIL PACKING 70CM XL","SUP-ITM-10339809","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6030.00","80.4","","1022.97","1022.97","3607.50","1 through 10","3919.5","6129","percent of total billed charges",""
"COIL PACKING 70CM XL","SUP-ITM-10339809","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6129.00","81.72","","3010.54","693.88","5019.88","35","3919.5","6129","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 3MM 5CM .025IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113756","CDM","C1889","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2198.18","79.5","","1309.77","674.56","6049.93","26","857.15","2198.18","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 3MM 5CM .025IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113756","CDM","C1889","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1473.75","53.3","","1901.83","1901.83","2962.25","1 through 10","857.15","2198.18","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 3MM 5CM .025IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113756","CDM","C1889","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1009.23","36.5","","1620.31","1620.31","19908.88","1 through 10","857.15","2198.18","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 3MM 5CM .025IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113756","CDM","C1889","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1059.00","38.3","","352.91","352.91","2046.30","1 through 10","857.15","2198.18","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 3MM 5CM .025IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113756","CDM","C1889","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1186.19","42.9","","9668.75","9668.75","9668.75","1 through 10","857.15","2198.18","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 3MM 5CM .025IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113756","CDM","C1889","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","WELLPOINT [1015]","HB AMC WELLPOINT","2040.02","73.78","","699.88","384.10","3443.31","33","857.15","2198.18","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 3MM 5CM .025IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113756","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2765.00","2073.75","AETNA [1001]","HB AMC AETNA HMO","1929.97","69.8","","1421.24","264.50","4933.46","29","1444.99","2259.56","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 3MM 5CM .025IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113756","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2765.00","2073.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2223.06","80.4","","1022.97","1022.97","3607.50","1 through 10","1444.99","2259.56","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 3MM 5CM .025IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113756","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2765.00","2073.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2259.56","81.72","","3010.54","693.88","5019.88","35","1444.99","2259.56","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 4MM 10CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113726","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2754.68","79.5","","1309.77","674.56","6049.93","26","1074.15","2754.68","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 4MM 10CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113726","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1846.85","53.3","","1901.83","1901.83","2962.25","1 through 10","1074.15","2754.68","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 4MM 10CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113726","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1264.73","36.5","","1620.31","1620.31","19908.88","1 through 10","1074.15","2754.68","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 4MM 10CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113726","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1327.10","38.3","","352.91","352.91","2046.30","1 through 10","1074.15","2754.68","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 4MM 10CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113726","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1486.49","42.9","","9668.75","9668.75","9668.75","1 through 10","1074.15","2754.68","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 4MM 10CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113726","CDM","C1889","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB AMC WELLPOINT","2556.48","73.78","","699.88","384.10","3443.31","33","1074.15","2754.68","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 4MM 10CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113726","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","AETNA [1001]","HB AMC AETNA HMO","2418.57","69.8","","1421.24","264.50","4933.46","29","1810.81","2831.6","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 4MM 10CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113726","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2785.86","80.4","","1022.97","1022.97","3607.50","1 through 10","1810.81","2831.6","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 4MM 10CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113726","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2831.60","81.72","","3010.54","693.88","5019.88","35","1810.81","2831.6","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 6MM 30CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113761","CDM","C1889","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3589.43","79.5","","1309.77","674.56","6049.93","26","1399.65","3589.43","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 6MM 30CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113761","CDM","C1889","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2406.50","53.3","","1901.83","1901.83","2962.25","1 through 10","1399.65","3589.43","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 6MM 30CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113761","CDM","C1889","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1647.98","36.5","","1620.31","1620.31","19908.88","1 through 10","1399.65","3589.43","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 6MM 30CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113761","CDM","C1889","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1729.25","38.3","","352.91","352.91","2046.30","1 through 10","1399.65","3589.43","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 6MM 30CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113761","CDM","C1889","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1936.94","42.9","","9668.75","9668.75","9668.75","1 through 10","1399.65","3589.43","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 6MM 30CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113761","CDM","C1889","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","WELLPOINT [1015]","HB AMC WELLPOINT","3331.17","73.78","","699.88","384.10","3443.31","33","1399.65","3589.43","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 6MM 30CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113761","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4515.00","3386.25","AETNA [1001]","HB AMC AETNA HMO","3151.47","69.8","","1421.24","264.50","4933.46","29","2359.54","3689.66","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 6MM 30CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113761","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4515.00","3386.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3630.06","80.4","","1022.97","1022.97","3607.50","1 through 10","2359.54","3689.66","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 6MM 30CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX SOFT FILL PERIPH","SUP-ITM-10113761","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4515.00","3386.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3689.66","81.72","","3010.54","693.88","5019.88","35","2359.54","3689.66","percent of total billed charges",""
"COIL RUBY POD 3.25-4MM 30CM .02IN EMBOLIZATION OCCLUSION DEVICE","SUP-ITM-10135709","CDM","C1889","HCPCS","0278","RC","","","","both","","","5370.00","4027.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4269.15","79.5","","1309.77","674.56","6049.93","26","1664.7","4269.15","percent of total billed charges",""
"COIL RUBY POD 3.25-4MM 30CM .02IN EMBOLIZATION OCCLUSION DEVICE","SUP-ITM-10135709","CDM","C1889","HCPCS","0278","RC","","","","both","","","5370.00","4027.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2862.21","53.3","","1901.83","1901.83","2962.25","1 through 10","1664.7","4269.15","percent of total billed charges",""
"COIL RUBY POD 3.25-4MM 30CM .02IN EMBOLIZATION OCCLUSION DEVICE","SUP-ITM-10135709","CDM","C1889","HCPCS","0278","RC","","","","both","","","5370.00","4027.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1960.05","36.5","","1620.31","1620.31","19908.88","1 through 10","1664.7","4269.15","percent of total billed charges",""
"COIL RUBY POD 3.25-4MM 30CM .02IN EMBOLIZATION OCCLUSION DEVICE","SUP-ITM-10135709","CDM","C1889","HCPCS","0278","RC","","","","both","","","5370.00","4027.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2056.71","38.3","","352.91","352.91","2046.30","1 through 10","1664.7","4269.15","percent of total billed charges",""
"COIL RUBY POD 3.25-4MM 30CM .02IN EMBOLIZATION OCCLUSION DEVICE","SUP-ITM-10135709","CDM","C1889","HCPCS","0278","RC","","","","both","","","5370.00","4027.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2303.73","42.9","","9668.75","9668.75","9668.75","1 through 10","1664.7","4269.15","percent of total billed charges",""
"COIL RUBY POD 3.25-4MM 30CM .02IN EMBOLIZATION OCCLUSION DEVICE","SUP-ITM-10135709","CDM","C1889","HCPCS","0278","RC","","","","both","","","5370.00","4027.50","WELLPOINT [1015]","HB AMC WELLPOINT","3961.99","73.78","","699.88","384.10","3443.31","33","1664.7","4269.15","percent of total billed charges",""
"COIL RUBY POD 3.25-4MM 30CM .02IN EMBOLIZATION OCCLUSION DEVICE","SUP-ITM-10135709","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5370.00","4027.50","AETNA [1001]","HB AMC AETNA HMO","3748.26","69.8","","1421.24","264.50","4933.46","29","2806.36","4388.36","percent of total billed charges",""
"COIL RUBY POD 3.25-4MM 30CM .02IN EMBOLIZATION OCCLUSION DEVICE","SUP-ITM-10135709","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5370.00","4027.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4317.48","80.4","","1022.97","1022.97","3607.50","1 through 10","2806.36","4388.36","percent of total billed charges",""
"COIL RUBY POD 3.25-4MM 30CM .02IN EMBOLIZATION OCCLUSION DEVICE","SUP-ITM-10135709","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5370.00","4027.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4388.36","81.72","","3010.54","693.88","5019.88","35","2806.36","4388.36","percent of total billed charges",""
"COIL TARGET 360 NANO 1.5MM 2CM DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10114020","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4969.86","79.5","","1309.77","674.56","6049.93","26","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 NANO 1.5MM 2CM DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10114020","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3332.00","53.3","","1901.83","1901.83","2962.25","1 through 10","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 NANO 1.5MM 2CM DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10114020","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.76","36.5","","1620.31","1620.31","19908.88","1 through 10","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 NANO 1.5MM 2CM DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10114020","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2394.29","38.3","","352.91","352.91","2046.30","1 through 10","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 NANO 1.5MM 2CM DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10114020","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.85","42.9","","9668.75","9668.75","9668.75","1 through 10","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 NANO 1.5MM 2CM DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10114020","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","WELLPOINT [1015]","HB AMC WELLPOINT","4612.28","73.78","","699.88","384.10","3443.31","33","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 NANO 1.5MM 2CM DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10114020","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6251.40","4688.55","AETNA [1001]","HB AMC AETNA HMO","4363.48","69.8","","1421.24","264.50","4933.46","29","3266.98","5108.64","percent of total billed charges",""
"COIL TARGET 360 NANO 1.5MM 2CM DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10114020","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6251.40","4688.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5026.13","80.4","","1022.97","1022.97","3607.50","1 through 10","3266.98","5108.64","percent of total billed charges",""
"COIL TARGET 360 NANO 1.5MM 2CM DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10114020","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6251.40","4688.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5108.64","81.72","","3010.54","693.88","5019.88","35","3266.98","5108.64","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 3CM DETACHABLE EMBOLIZATION","SUP-ITM-10086673","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4969.86","79.5","","1309.77","674.56","6049.93","26","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 3CM DETACHABLE EMBOLIZATION","SUP-ITM-10086673","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3332.00","53.3","","1901.83","1901.83","2962.25","1 through 10","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 3CM DETACHABLE EMBOLIZATION","SUP-ITM-10086673","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.76","36.5","","1620.31","1620.31","19908.88","1 through 10","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 3CM DETACHABLE EMBOLIZATION","SUP-ITM-10086673","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2394.29","38.3","","352.91","352.91","2046.30","1 through 10","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 3CM DETACHABLE EMBOLIZATION","SUP-ITM-10086673","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.85","42.9","","9668.75","9668.75","9668.75","1 through 10","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 3CM DETACHABLE EMBOLIZATION","SUP-ITM-10086673","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","WELLPOINT [1015]","HB AMC WELLPOINT","4612.28","73.78","","699.88","384.10","3443.31","33","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 3CM DETACHABLE EMBOLIZATION","SUP-ITM-10086673","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6251.40","4688.55","AETNA [1001]","HB AMC AETNA HMO","4363.48","69.8","","1421.24","264.50","4933.46","29","3266.98","5108.64","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 3CM DETACHABLE EMBOLIZATION","SUP-ITM-10086673","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6251.40","4688.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5026.13","80.4","","1022.97","1022.97","3607.50","1 through 10","3266.98","5108.64","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 3CM DETACHABLE EMBOLIZATION","SUP-ITM-10086673","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6251.40","4688.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5108.64","81.72","","3010.54","693.88","5019.88","35","3266.98","5108.64","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 4CM DETACHABLE EMBOLIZATION","SUP-ITM-10087764","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4969.86","79.5","","1309.77","674.56","6049.93","26","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 4CM DETACHABLE EMBOLIZATION","SUP-ITM-10087764","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3332.00","53.3","","1901.83","1901.83","2962.25","1 through 10","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 4CM DETACHABLE EMBOLIZATION","SUP-ITM-10087764","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.76","36.5","","1620.31","1620.31","19908.88","1 through 10","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 4CM DETACHABLE EMBOLIZATION","SUP-ITM-10087764","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2394.29","38.3","","352.91","352.91","2046.30","1 through 10","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 4CM DETACHABLE EMBOLIZATION","SUP-ITM-10087764","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.85","42.9","","9668.75","9668.75","9668.75","1 through 10","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 4CM DETACHABLE EMBOLIZATION","SUP-ITM-10087764","CDM","C1889","HCPCS","0278","RC","","","","both","","","6251.40","4688.55","WELLPOINT [1015]","HB AMC WELLPOINT","4612.28","73.78","","699.88","384.10","3443.31","33","1937.93","4969.86","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 4CM DETACHABLE EMBOLIZATION","SUP-ITM-10087764","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6251.40","4688.55","AETNA [1001]","HB AMC AETNA HMO","4363.48","69.8","","1421.24","264.50","4933.46","29","3266.98","5108.64","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 4CM DETACHABLE EMBOLIZATION","SUP-ITM-10087764","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6251.40","4688.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5026.13","80.4","","1022.97","1022.97","3607.50","1 through 10","3266.98","5108.64","percent of total billed charges",""
"COIL TARGET 360 ULTRA 2MM 4CM DETACHABLE EMBOLIZATION","SUP-ITM-10087764","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6251.40","4688.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5108.64","81.72","","3010.54","693.88","5019.88","35","3266.98","5108.64","percent of total billed charges",""
"COIL TARGET HELICAL 2.5MM 3CM ULTRA VASCULAR DETACHABLE","SUP-ITM-10091030","CDM","C1889","HCPCS","0278","RC","","","","both","","","4868.64","3651.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3870.57","79.5","","1309.77","674.56","6049.93","26","1509.28","3870.57","percent of total billed charges",""
"COIL TARGET HELICAL 2.5MM 3CM ULTRA VASCULAR DETACHABLE","SUP-ITM-10091030","CDM","C1889","HCPCS","0278","RC","","","","both","","","4868.64","3651.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2594.99","53.3","","1901.83","1901.83","2962.25","1 through 10","1509.28","3870.57","percent of total billed charges",""
"COIL TARGET HELICAL 2.5MM 3CM ULTRA VASCULAR DETACHABLE","SUP-ITM-10091030","CDM","C1889","HCPCS","0278","RC","","","","both","","","4868.64","3651.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1777.05","36.5","","1620.31","1620.31","19908.88","1 through 10","1509.28","3870.57","percent of total billed charges",""
"COIL TARGET HELICAL 2.5MM 3CM ULTRA VASCULAR DETACHABLE","SUP-ITM-10091030","CDM","C1889","HCPCS","0278","RC","","","","both","","","4868.64","3651.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1864.69","38.3","","352.91","352.91","2046.30","1 through 10","1509.28","3870.57","percent of total billed charges",""
"COIL TARGET HELICAL 2.5MM 3CM ULTRA VASCULAR DETACHABLE","SUP-ITM-10091030","CDM","C1889","HCPCS","0278","RC","","","","both","","","4868.64","3651.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2088.65","42.9","","9668.75","9668.75","9668.75","1 through 10","1509.28","3870.57","percent of total billed charges",""
"COIL TARGET HELICAL 2.5MM 3CM ULTRA VASCULAR DETACHABLE","SUP-ITM-10091030","CDM","C1889","HCPCS","0278","RC","","","","both","","","4868.64","3651.48","WELLPOINT [1015]","HB AMC WELLPOINT","3592.08","73.78","","699.88","384.10","3443.31","33","1509.28","3870.57","percent of total billed charges",""
"COIL TARGET HELICAL 2.5MM 3CM ULTRA VASCULAR DETACHABLE","SUP-ITM-10091030","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4868.64","3651.48","AETNA [1001]","HB AMC AETNA HMO","3398.31","69.8","","1421.24","264.50","4933.46","29","2544.35","3978.65","percent of total billed charges",""
"COIL TARGET HELICAL 2.5MM 3CM ULTRA VASCULAR DETACHABLE","SUP-ITM-10091030","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4868.64","3651.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3914.39","80.4","","1022.97","1022.97","3607.50","1 through 10","2544.35","3978.65","percent of total billed charges",""
"COIL TARGET HELICAL 2.5MM 3CM ULTRA VASCULAR DETACHABLE","SUP-ITM-10091030","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4868.64","3651.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3978.65","81.72","","3010.54","693.88","5019.88","35","2544.35","3978.65","percent of total billed charges",""
"COIL TARGET HELICAL 2MM 1CM NANO DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10086672","CDM","C1889","HCPCS","0278","RC","","","","both","","","4868.64","3651.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3870.57","79.5","","1309.77","674.56","6049.93","26","1509.28","3870.57","percent of total billed charges",""
"COIL TARGET HELICAL 2MM 1CM NANO DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10086672","CDM","C1889","HCPCS","0278","RC","","","","both","","","4868.64","3651.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2594.99","53.3","","1901.83","1901.83","2962.25","1 through 10","1509.28","3870.57","percent of total billed charges",""
"COIL TARGET HELICAL 2MM 1CM NANO DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10086672","CDM","C1889","HCPCS","0278","RC","","","","both","","","4868.64","3651.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1777.05","36.5","","1620.31","1620.31","19908.88","1 through 10","1509.28","3870.57","percent of total billed charges",""
"COIL TARGET HELICAL 2MM 1CM NANO DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10086672","CDM","C1889","HCPCS","0278","RC","","","","both","","","4868.64","3651.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1864.69","38.3","","352.91","352.91","2046.30","1 through 10","1509.28","3870.57","percent of total billed charges",""
"COIL TARGET HELICAL 2MM 1CM NANO DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10086672","CDM","C1889","HCPCS","0278","RC","","","","both","","","4868.64","3651.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2088.65","42.9","","9668.75","9668.75","9668.75","1 through 10","1509.28","3870.57","percent of total billed charges",""
"COIL TARGET HELICAL 2MM 1CM NANO DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10086672","CDM","C1889","HCPCS","0278","RC","","","","both","","","4868.64","3651.48","WELLPOINT [1015]","HB AMC WELLPOINT","3592.08","73.78","","699.88","384.10","3443.31","33","1509.28","3870.57","percent of total billed charges",""
"COIL TARGET HELICAL 2MM 1CM NANO DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10086672","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4868.64","3651.48","AETNA [1001]","HB AMC AETNA HMO","3398.31","69.8","","1421.24","264.50","4933.46","29","2544.35","3978.65","percent of total billed charges",""
"COIL TARGET HELICAL 2MM 1CM NANO DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10086672","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4868.64","3651.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3914.39","80.4","","1022.97","1022.97","3607.50","1 through 10","2544.35","3978.65","percent of total billed charges",""
"COIL TARGET HELICAL 2MM 1CM NANO DETACHABLE ULTRA EMBOLIZATION","SUP-ITM-10086672","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4868.64","3651.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3978.65","81.72","","3010.54","693.88","5019.88","35","2544.35","3978.65","percent of total billed charges",""
"COIL TARGET XL 360 10MM 40CM STANDARD DETACHABLE EMBOLIZATION","SUP-ITM-10117120","CDM","C1889","HCPCS","0278","RC","","","","both","","","8553.70","6415.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6800.19","79.5","","1309.77","674.56","6049.93","26","2651.65","6800.19","percent of total billed charges",""
"COIL TARGET XL 360 10MM 40CM STANDARD DETACHABLE EMBOLIZATION","SUP-ITM-10117120","CDM","C1889","HCPCS","0278","RC","","","","both","","","8553.70","6415.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4559.12","53.3","","1901.83","1901.83","2962.25","1 through 10","2651.65","6800.19","percent of total billed charges",""
"COIL TARGET XL 360 10MM 40CM STANDARD DETACHABLE EMBOLIZATION","SUP-ITM-10117120","CDM","C1889","HCPCS","0278","RC","","","","both","","","8553.70","6415.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3122.10","36.5","","1620.31","1620.31","19908.88","1 through 10","2651.65","6800.19","percent of total billed charges",""
"COIL TARGET XL 360 10MM 40CM STANDARD DETACHABLE EMBOLIZATION","SUP-ITM-10117120","CDM","C1889","HCPCS","0278","RC","","","","both","","","8553.70","6415.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3276.07","38.3","","352.91","352.91","2046.30","1 through 10","2651.65","6800.19","percent of total billed charges",""
"COIL TARGET XL 360 10MM 40CM STANDARD DETACHABLE EMBOLIZATION","SUP-ITM-10117120","CDM","C1889","HCPCS","0278","RC","","","","both","","","8553.70","6415.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3669.54","42.9","","9668.75","9668.75","9668.75","1 through 10","2651.65","6800.19","percent of total billed charges",""
"COIL TARGET XL 360 10MM 40CM STANDARD DETACHABLE EMBOLIZATION","SUP-ITM-10117120","CDM","C1889","HCPCS","0278","RC","","","","both","","","8553.70","6415.27","WELLPOINT [1015]","HB AMC WELLPOINT","6310.92","73.78","","699.88","384.10","3443.31","33","2651.65","6800.19","percent of total billed charges",""
"COIL TARGET XL 360 10MM 40CM STANDARD DETACHABLE EMBOLIZATION","SUP-ITM-10117120","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8553.70","6415.27","AETNA [1001]","HB AMC AETNA HMO","5970.48","69.8","","1421.24","264.50","4933.46","29","4470.16","6990.08","percent of total billed charges",""
"COIL TARGET XL 360 10MM 40CM STANDARD DETACHABLE EMBOLIZATION","SUP-ITM-10117120","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8553.70","6415.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6877.17","80.4","","1022.97","1022.97","3607.50","1 through 10","4470.16","6990.08","percent of total billed charges",""
"COIL TARGET XL 360 10MM 40CM STANDARD DETACHABLE EMBOLIZATION","SUP-ITM-10117120","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8553.70","6415.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6990.08","81.72","","3010.54","693.88","5019.88","35","4470.16","6990.08","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Col4a1 and Col4a2 Gdna Testing","PX-31000756","CDM","81479","CPT","0310","RC","","","","both","","","1332.00","999.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1058.94","79.5","","0.65","0.65","0.65","1 through 10","412.92","1265.4","percent of total billed charges",""
"Col4a1 and Col4a2 Gdna Testing","PX-31000756","CDM","81479","CPT","0310","RC","","","","both","","","1332.00","999.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","709.96","53.3","","0.79","0.79","0.79","1 through 10","412.92","1265.4","percent of total billed charges",""
"Col4a1 and Col4a2 Gdna Testing","PX-31000756","CDM","81479","CPT","0310","RC","","","","outpatient","","","1332.00","999.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","666.00","50","","1.00","1.00","1.00","1 through 10","156.55","1098.9","percent of total billed charges",""
"Col4a1 and Col4a2 Gdna Testing","PX-31000756","CDM","81479","CPT","0310","RC","","","","outpatient","","","1332.00","999.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","699.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","1098.9","percent of total billed charges",""
"Cold Agglutinin Titer","PX-30000797","CDM","86157","CPT","0302","RC","","","","both","","","141.00","105.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","75.15","53.3","","72.34","72.34","72.34","1 through 10","7.9","133.95","percent of total billed charges",""
"Cold Agglutinin Titer","PX-30000797","CDM","86157","CPT","0302","RC","","","","both","","","141.00","105.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.00","38.3","","53.57","52.06","53.57","1 through 10","7.9","133.95","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","both","","","211.00","158.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","151.50","71.8","","147.19","147.19","147.19","1 through 10","13.15","200.45","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","both","","","211.00","158.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","167.75","79.5","","161.34","108.24","161.34","13","13.15","200.45","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","both","","","211.00","158.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","112.46","53.3","","161.34","108.24","324.72","1 through 10","13.15","200.45","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","both","","","211.00","158.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.02","36.5","","76.47","74.21","76.47","13","13.15","200.45","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","both","","","211.00","158.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.81","38.3","","80.16","77.90","240.48","29","13.15","200.45","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","both","","","211.00","158.25","MOLINA [1014]","HB BWH MOLINA","73.85","35","","37.36","37.36","37.36","1 through 10","13.15","200.45","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","both","","","211.00","158.25","TRICARE [160005]","HB BWH TRICARE","200.45","95","","205.00","205.00","205.00","1 through 10","13.15","200.45","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","both","","","211.00","158.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.52","42.9","","90.14","90.14","90.14","1 through 10","13.15","200.45","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","outpatient","","","211.00","158.25","AETNA [1001]","HB AMC AETNA PPO","169.64","80.4","","159.90","159.90","159.90","1 through 10","13.15","172.43","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","outpatient","","","211.00","158.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","110.27","52.26","","126.86","126.86","126.86","1 through 10","13.15","172.43","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","outpatient","","","211.00","158.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","172.43","81.72","","90.14","90.14","90.14","1 through 10","13.15","172.43","percent of total billed charges",""
"COLLAR CERVICAL 13 TO 16CM MD PHILADELPHIA PLASTAZOTE FOAM 2 PC TRACHEAL OPENING MANDIBLE SUPPORT","SUP-ITM-10100529","CDM","L0172","HCPCS","0274","RC","","","","both","","","43.51","32.63","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21.76","50","","22.80","22.80","22.80","1 through 10","13.49","297.02","percent of total billed charges",""
"COLLAR CERVICAL 13 TO 16CM MD PHILADELPHIA PLASTAZOTE FOAM 2 PC TRACHEAL OPENING MANDIBLE SUPPORT","SUP-ITM-10100529","CDM","L0172","HCPCS","0274","RC","","","","both","","","43.51","32.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.66","38.3","","17.01","17.01","17.01","1 through 10","13.49","297.02","percent of total billed charges",""
"COLLAR CERVICAL 13 TO 16CM MD PHILADELPHIA PLASTAZOTE FOAM 2 PC TRACHEAL OPENING MANDIBLE SUPPORT","SUP-ITM-10100529","CDM","L0172","HCPCS","0274","RC","","","","both","","","43.51","32.63","WELLPOINT [1015]","HB AMC WELLPOINT","32.10","73.78","","32.39","32.39","32.39","1 through 10","13.49","297.02","percent of total billed charges",""
"COLLAR CERVICAL 13 TO 16CM MD PHILADELPHIA PLASTAZOTE FOAM 2 PC TRACHEAL OPENING MANDIBLE SUPPORT","SUP-ITM-10100529","CDM","L0172","HCPCS","0274","RC","","","","outpatient","","","43.51","32.63","AETNA [1001]","HB AMC AETNA HMO","30.37","69.8","","26.36","26.36","26.36","1 through 10","21.76","297.02","percent of total billed charges",""
"COLLAR CERVICAL 13 TO 16CM MD PHILADELPHIA PLASTAZOTE FOAM 2 PC TRACHEAL OPENING MANDIBLE SUPPORT","SUP-ITM-10100529","CDM","L0172","HCPCS","0274","RC","","","","outpatient","","","43.51","32.63","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21.76","50","","22.80","22.80","22.80","1 through 10","21.76","297.02","percent of total billed charges",""
"COLLAR CERVICAL 18.5X3.0IN MD SM DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019445","CDM","L0120","HCPCS","0274","RC","","","","both","","","10.71","8.03","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5.36","50","","6.37","6.11","6.37","1 through 10","3.32","62.05","percent of total billed charges",""
"COLLAR CERVICAL 18.5X3.0IN MD SM DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019445","CDM","L0120","HCPCS","0274","RC","","","","both","","","10.71","8.03","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","5.62","52.5","","6.68","6.68","6.68","1 through 10","3.32","62.05","percent of total billed charges",""
"COLLAR CERVICAL 18.5X3.0IN MD SM DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019445","CDM","L0120","HCPCS","0274","RC","","","","both","","","10.71","8.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4.10","38.3","","4.75","4.75","4.75","1 through 10","3.32","62.05","percent of total billed charges",""
"COLLAR CERVICAL 18.5X3.0IN MD SM DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019445","CDM","L0120","HCPCS","0274","RC","","","","both","","","10.71","8.03","WELLPOINT [1015]","HB AMC WELLPOINT","7.90","73.78","","9.05","9.05","9.05","1 through 10","3.32","62.05","percent of total billed charges",""
"COLLAR CERVICAL 18.5X3.0IN MD SM DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019445","CDM","L0120","HCPCS","0274","RC","","","","outpatient","","","10.71","8.03","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5.36","50","","6.37","6.11","6.37","1 through 10","5.36","62.05","percent of total billed charges",""
"COLLAR CERVICAL 18.5X3.0IN MD SM DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019445","CDM","L0120","HCPCS","0274","RC","","","","outpatient","","","10.71","8.03","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","5.62","52.5","","6.68","6.68","6.68","1 through 10","5.36","62.05","percent of total billed charges",""
"COLLAR CERVICAL 18.5X3.0IN MD SM DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019445","CDM","L0120","HCPCS","0274","RC","","","","outpatient","","","10.71","8.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8.61","80.4","","9.48","9.48","9.48","1 through 10","5.36","62.05","percent of total billed charges",""
"COLLAR CERVICAL 22.5X4.5IN MD LG DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019446","CDM","L0120","HCPCS","0274","RC","","","","both","","","11.27","8.45","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5.64","50","","6.37","6.11","6.37","1 through 10","3.49","62.05","percent of total billed charges",""
"COLLAR CERVICAL 22.5X4.5IN MD LG DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019446","CDM","L0120","HCPCS","0274","RC","","","","both","","","11.27","8.45","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","5.92","52.5","","6.68","6.68","6.68","1 through 10","3.49","62.05","percent of total billed charges",""
"COLLAR CERVICAL 22.5X4.5IN MD LG DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019446","CDM","L0120","HCPCS","0274","RC","","","","both","","","11.27","8.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4.32","38.3","","4.75","4.75","4.75","1 through 10","3.49","62.05","percent of total billed charges",""
"COLLAR CERVICAL 22.5X4.5IN MD LG DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019446","CDM","L0120","HCPCS","0274","RC","","","","both","","","11.27","8.45","WELLPOINT [1015]","HB AMC WELLPOINT","8.32","73.78","","9.05","9.05","9.05","1 through 10","3.49","62.05","percent of total billed charges",""
"COLLAR CERVICAL 22.5X4.5IN MD LG DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019446","CDM","L0120","HCPCS","0274","RC","","","","outpatient","","","11.27","8.45","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5.64","50","","6.37","6.11","6.37","1 through 10","5.64","62.05","percent of total billed charges",""
"COLLAR CERVICAL 22.5X4.5IN MD LG DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019446","CDM","L0120","HCPCS","0274","RC","","","","outpatient","","","11.27","8.45","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","5.92","52.5","","6.68","6.68","6.68","1 through 10","5.64","62.05","percent of total billed charges",""
"COLLAR CERVICAL 22.5X4.5IN MD LG DENSITY FOAM COTTON STOCKINETTE COVER FORM FIT","SUP-ITM-10019446","CDM","L0120","HCPCS","0274","RC","","","","outpatient","","","11.27","8.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9.06","80.4","","9.48","9.48","9.48","1 through 10","5.64","62.05","percent of total billed charges",""
"COLLAR FEMORAL 17 TO 19MMX35 KNEE SEGMENTAL TRABECULAR METAL POROUS","SUP-ITM-10046665","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2790.29","52.26","","1113.10","1113.10","1113.10","1 through 10","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 17 TO 19MMX35 KNEE SEGMENTAL TRABECULAR METAL POROUS","SUP-ITM-10046665","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4244.70","79.5","","1293.60","1148.53","1603.80","1 through 10","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 17 TO 19MMX35 KNEE SEGMENTAL TRABECULAR METAL POROUS","SUP-ITM-10046665","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1948.83","36.5","","1023.42","771.29","2068.67","33","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 17 TO 19MMX35 KNEE SEGMENTAL TRABECULAR METAL POROUS","SUP-ITM-10046665","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2044.93","38.3","","850.52","759.78","1211.25","66","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 17 TO 19MMX35 KNEE SEGMENTAL TRABECULAR METAL POROUS","SUP-ITM-10046665","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","2548.09","2548.09","2548.09","1 through 10","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 17 TO 19MMX35 KNEE SEGMENTAL TRABECULAR METAL POROUS","SUP-ITM-10046665","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","956.46","956.46","956.46","1 through 10","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 17 TO 19MMX35 KNEE SEGMENTAL TRABECULAR METAL POROUS","SUP-ITM-10046665","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","WELLPOINT [1015]","HB AMC WELLPOINT","3939.30","73.78","","2344.73","1619.47","2530.35","16","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 17 TO 19MMX35 KNEE SEGMENTAL TRABECULAR METAL POROUS","SUP-ITM-10046665","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA HMO","3726.80","69.8","","1523.63","988.41","4330.26","39","2790.29","4363.24","percent of total billed charges",""
"COLLAR FEMORAL 17 TO 19MMX35 KNEE SEGMENTAL TRABECULAR METAL POROUS","SUP-ITM-10046665","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA PPO","4292.76","80.4","","1670.25","1670.25","1670.25","1 through 10","2790.29","4363.24","percent of total billed charges",""
"COLLAR FEMORAL 17 TO 19MMX35 KNEE SEGMENTAL TRABECULAR METAL POROUS","SUP-ITM-10046665","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2790.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2790.29","4363.24","percent of total billed charges",""
"COLLAR FEMORAL 17 TO 19MMX35 KNEE SEGMENTAL TRABECULAR METAL POROUS","SUP-ITM-10046665","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4363.24","81.72","","1738.90","1484.65","2716.94","38","2790.29","4363.24","percent of total billed charges",""
"COLLAR FEMORAL 9 TO 16MMX25 IMPLANT KNEE SEGMENTAL TRABECULAR METAL","SUP-ITM-10025552","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2790.29","52.26","","1113.10","1113.10","1113.10","1 through 10","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 9 TO 16MMX25 IMPLANT KNEE SEGMENTAL TRABECULAR METAL","SUP-ITM-10025552","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4244.70","79.5","","1293.60","1148.53","1603.80","1 through 10","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 9 TO 16MMX25 IMPLANT KNEE SEGMENTAL TRABECULAR METAL","SUP-ITM-10025552","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1948.83","36.5","","1023.42","771.29","2068.67","33","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 9 TO 16MMX25 IMPLANT KNEE SEGMENTAL TRABECULAR METAL","SUP-ITM-10025552","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2044.93","38.3","","850.52","759.78","1211.25","66","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 9 TO 16MMX25 IMPLANT KNEE SEGMENTAL TRABECULAR METAL","SUP-ITM-10025552","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","2548.09","2548.09","2548.09","1 through 10","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 9 TO 16MMX25 IMPLANT KNEE SEGMENTAL TRABECULAR METAL","SUP-ITM-10025552","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","956.46","956.46","956.46","1 through 10","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 9 TO 16MMX25 IMPLANT KNEE SEGMENTAL TRABECULAR METAL","SUP-ITM-10025552","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","WELLPOINT [1015]","HB AMC WELLPOINT","3939.30","73.78","","2344.73","1619.47","2530.35","16","1655.17","4244.7","percent of total billed charges",""
"COLLAR FEMORAL 9 TO 16MMX25 IMPLANT KNEE SEGMENTAL TRABECULAR METAL","SUP-ITM-10025552","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA HMO","3726.80","69.8","","1523.63","988.41","4330.26","39","2790.29","4363.24","percent of total billed charges",""
"COLLAR FEMORAL 9 TO 16MMX25 IMPLANT KNEE SEGMENTAL TRABECULAR METAL","SUP-ITM-10025552","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA PPO","4292.76","80.4","","1670.25","1670.25","1670.25","1 through 10","2790.29","4363.24","percent of total billed charges",""
"COLLAR FEMORAL 9 TO 16MMX25 IMPLANT KNEE SEGMENTAL TRABECULAR METAL","SUP-ITM-10025552","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2790.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2790.29","4363.24","percent of total billed charges",""
"COLLAR FEMORAL 9 TO 16MMX25 IMPLANT KNEE SEGMENTAL TRABECULAR METAL","SUP-ITM-10025552","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4363.24","81.72","","1738.90","1484.65","2716.94","38","2790.29","4363.24","percent of total billed charges",""
"COLLAR ROD 6MM SPINE DUAL OPENING USS TITANIUM","SUP-ITM-10033188","CDM","C1889","HCPCS","0278","RC","","","","both","","","245.00","183.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","194.78","79.5","","1309.77","674.56","6049.93","26","75.95","194.78","percent of total billed charges",""
"COLLAR ROD 6MM SPINE DUAL OPENING USS TITANIUM","SUP-ITM-10033188","CDM","C1889","HCPCS","0278","RC","","","","both","","","245.00","183.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.59","53.3","","1901.83","1901.83","2962.25","1 through 10","75.95","194.78","percent of total billed charges",""
"COLLAR ROD 6MM SPINE DUAL OPENING USS TITANIUM","SUP-ITM-10033188","CDM","C1889","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.43","36.5","","1620.31","1620.31","19908.88","1 through 10","75.95","194.78","percent of total billed charges",""
"COLLAR ROD 6MM SPINE DUAL OPENING USS TITANIUM","SUP-ITM-10033188","CDM","C1889","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.84","38.3","","352.91","352.91","2046.30","1 through 10","75.95","194.78","percent of total billed charges",""
"COLLAR ROD 6MM SPINE DUAL OPENING USS TITANIUM","SUP-ITM-10033188","CDM","C1889","HCPCS","0278","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.11","42.9","","9668.75","9668.75","9668.75","1 through 10","75.95","194.78","percent of total billed charges",""
"COLLAR ROD 6MM SPINE DUAL OPENING USS TITANIUM","SUP-ITM-10033188","CDM","C1889","HCPCS","0278","RC","","","","both","","","245.00","183.75","WELLPOINT [1015]","HB AMC WELLPOINT","180.76","73.78","","699.88","384.10","3443.31","33","75.95","194.78","percent of total billed charges",""
"COLLAR ROD 6MM SPINE DUAL OPENING USS TITANIUM","SUP-ITM-10033188","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA HMO","171.01","69.8","","1421.24","264.50","4933.46","29","128.04","200.21","percent of total billed charges",""
"COLLAR ROD 6MM SPINE DUAL OPENING USS TITANIUM","SUP-ITM-10033188","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","196.98","80.4","","1022.97","1022.97","3607.50","1 through 10","128.04","200.21","percent of total billed charges",""
"COLLAR ROD 6MM SPINE DUAL OPENING USS TITANIUM","SUP-ITM-10033188","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","200.21","81.72","","3010.54","693.88","5019.88","35","128.04","200.21","percent of total billed charges",""
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","290.00","217.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.02","119.28","150.63","1 through 10","89.9","230.55","other","OPPS APC"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","290.00","217.50","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","89.9","230.55","other","OPPS APC"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","outpatient","","","290.00","217.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","244.64","244.64","244.64","1 through 10","121.77","407.82","other","ASC"
"Collect Finger/Heel/Ear Stick","PX-30000004","CDM","36416","CPT","0300","RC","","","","both","","","16.00","12.00","WELLPOINT [1015]","HB AMC WELLPOINT","11.80","73.78","","11.91","11.91","11.91","1 through 10","4.96","12.72","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3863.00","2897.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1114.11","3746.00","22","1028.57","3071.09","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3863.00","2897.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","981.55","1065.39","19","1028.57","3071.09","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3863.00","2897.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2704.10","70","","2996.80","2682.24","2996.80","1 through 10","1028.57","3071.09","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3863.00","2897.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3071.09","79.5","","2948.10","1977.89","2948.10","32","1028.57","3071.09","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3863.00","2897.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2058.98","53.3","","1977.89","1977.89","5675.19","17","1028.57","3071.09","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3863.00","2897.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1061.06","853.39","1061.06","1 through 10","1028.57","3071.09","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3863.00","2897.25","FALLON HEALTH [1008]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3183.18","3183.18","3183.18","1 through 10","1028.57","3071.09","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3863.00","2897.25","HUMANA [1012]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","977.56","977.56","977.56","1 through 10","1028.57","3071.09","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3863.00","2897.25","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","187","1028.57","3071.09","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3863.00","2897.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1061.06","1061.06","1061.06","1 through 10","1028.57","3071.09","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3863.00","2897.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3183.18","977.56","3183.18","1 through 10","1028.57","3071.09","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3863.00","2897.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.53","1061.06","40","1028.57","3071.09","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","3863.00","2897.25","AETNA [1001]","HB AMC AETNA HMO","2696.37","69.8","","1790.59","1790.59","2536.04","24","744.89","3156.84","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","3863.00","2897.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1711.31","871.41","1742.82","103","744.89","3156.84","other","ASC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","3863.00","2897.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1974.52","997.06","1994.11","208","744.89","3156.84","other","ASC "
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","3863.00","2897.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3105.85","80.4","","2921.88","2921.88","2921.88","1 through 10","744.89","3156.84","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","3863.00","2897.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2078.24","2078.24","2078.24","1 through 10","744.89","3156.84","other","Multiple Surgery"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","3863.00","2897.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3156.84","81.72","","2994.55","1647.12","2994.55","1 through 10","744.89","3156.84","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","3863.00","2897.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3156.84","81.72","","2994.55","1647.12","2994.55","31","744.89","3156.84","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3862.00","2896.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","557.06","1114.11","1 through 10","1028.57","3070.29","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3862.00","2896.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","981.55","1065.39","1 through 10","1028.57","3070.29","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3862.00","2896.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3070.29","79.5","","2947.32","1977.36","2947.32","12","1028.57","3070.29","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3862.00","2896.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2058.45","53.3","","1977.36","1977.36","2947.32","1 through 10","1028.57","3070.29","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3862.00","2896.50","FALLON HEALTH [1008]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3183.18","3183.18","3183.18","1 through 10","1028.57","3070.29","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3862.00","2896.50","HUMANA [1012]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1061.06","977.56","1061.06","1 through 10","1028.57","3070.29","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3862.00","2896.50","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","75","1028.57","3070.29","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3862.00","2896.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","1061.06","3183.18","1 through 10","1028.57","3070.29","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3862.00","2896.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.53","1061.06","19","1028.57","3070.29","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","3862.00","2896.50","AETNA [1001]","HB AMC AETNA HMO","2695.68","69.8","","2535.37","1790.11","2921.10","25","744.89","3156.03","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","3862.00","2896.50","AETNA [1001]","HB AMC AETNA PPO","3105.05","80.4","","2921.10","2921.10","2921.10","1 through 10","744.89","3156.03","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","3862.00","2896.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1711.31","871.41","1742.82","69","744.89","3156.03","other","ASC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","3862.00","2896.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2018.28","52.26","","2317.41","2317.41","2317.41","1 through 10","744.89","3156.03","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","3862.00","2896.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1974.52","997.06","1994.11","153","744.89","3156.03","other","ASC "
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","3862.00","2896.50","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2078.24","2078.24","2078.24","1 through 10","744.89","3156.03","other","Multiple Surgery"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","3862.00","2896.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3156.03","81.72","","2993.75","2993.75","2993.75","1 through 10","744.89","3156.03","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","3862.00","2896.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3156.03","81.72","","2993.75","1646.68","2993.76","20","744.89","3156.03","percent of total billed charges",""
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","both","","","1648.00","1236.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1114.11","1114.11","1 through 10","510.88","1353.25","other","OPPS APC"
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","both","","","1648.00","1236.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","1065.39","1065.39","1 through 10","510.88","1353.25","other","OPPS APC"
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","both","","","1648.00","1236.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1310.16","79.5","","1551.00","1551.00","1551.00","1 through 10","510.88","1353.25","percent of total billed charges",""
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","both","","","1648.00","1236.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","878.38","53.3","","1257.63","1257.63","1257.63","1 through 10","510.88","1353.25","percent of total billed charges",""
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","both","","","1648.00","1236.00","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","1 through 10","510.88","1353.25","other","OPPS APC"
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","both","","","1648.00","1236.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","601.52","36.5","","596.05","596.05","596.05","1 through 10","510.88","1353.25","percent of total billed charges",""
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","both","","","1648.00","1236.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","631.18","38.3","","607.24","607.24","607.24","1 through 10","510.88","1353.25","percent of total billed charges",""
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","both","","","1648.00","1236.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","977.56","977.56","977.56","1 through 10","510.88","1353.25","other","OPPS APC"
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","both","","","1648.00","1236.00","WELLPOINT [1015]","HB AMC WELLPOINT","1215.89","73.78","","1189.71","1189.71","1189.71","1 through 10","510.88","1353.25","percent of total billed charges",""
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","outpatient","","","1648.00","1236.00","AETNA [1001]","HB AMC AETNA HMO","1150.30","69.8","","1081.85","1081.85","1081.85","1 through 10","744.89","2384.07","percent of total billed charges",""
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","outpatient","","","1648.00","1236.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1711.31","871.41","1742.82","1 through 10","744.89","2384.07","other","ASC"
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","outpatient","","","1648.00","1236.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1974.52","1974.52","1994.11","16","744.89","2384.07","other","ASC "
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","outpatient","","","1648.00","1236.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1728.14","1661.10","1728.14","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","outpatient","","","1648.00","1236.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1817.53","1817.53","1817.53","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","outpatient","","","1648.00","1236.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1220.86","953.46","1447.31","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","outpatient","","","1648.00","1236.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1346.75","81.72","","1277.44","702.64","1277.44","1 through 10","744.89","2384.07","percent of total billed charges",""
"Colonoscopy Flex W/Balloon Dilat","PX-75000201","CDM","45386","CPT","0750","RC","","","","both","","","2631.00","1973.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1377.83","1377.83","1377.83","1 through 10","815.61","2091.65","other","OPPS APC"
"Colonoscopy Flex W/Balloon Dilat","PX-75000201","CDM","45386","CPT","0750","RC","","","","both","","","2631.00","1973.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","815.61","31","","788.26","788.26","788.26","1 through 10","815.61","2091.65","percent of total billed charges",""
"Colonoscopy Flex W/Balloon Dilat","PX-75000201","CDM","45386","CPT","0750","RC","","","","both","","","2631.00","1973.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","960.32","36.5","","951.52","951.52","951.52","1 through 10","815.61","2091.65","percent of total billed charges",""
"Colonoscopy Flex W/Balloon Dilat","PX-75000201","CDM","45386","CPT","0750","RC","","","","both","","","2631.00","1973.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1007.67","38.3","","997.44","951.52","997.44","1 through 10","815.61","2091.65","percent of total billed charges",""
"Colonoscopy Flex W/Balloon Dilat","PX-75000201","CDM","45386","CPT","0750","RC","","","","both","","","2631.00","1973.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1378.23","1268.19","1378.23","1 through 10","815.61","2091.65","other","OPPS APC"
"Colonoscopy Flex W/Balloon Dilat","PX-75000201","CDM","45386","CPT","0750","RC","","","","outpatient","","","2631.00","1973.25","AETNA [1001]","HB AMC AETNA HMO","1836.44","69.8","","1219.38","1219.38","1219.38","1 through 10","979.79","2453.74","percent of total billed charges",""
"Colonoscopy Flex W/Balloon Dilat","PX-75000201","CDM","45386","CPT","0750","RC","","","","outpatient","","","2631.00","1973.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2292.44","2250.98","2292.44","1 through 10","979.79","2453.74","other","ASC"
"Colonoscopy Flex W/Balloon Dilat","PX-75000201","CDM","45386","CPT","0750","RC","","","","outpatient","","","2631.00","1973.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2597.20","2597.20","2622.97","1 through 10","979.79","2453.74","other","ASC "
"Colonoscopy Flex W/Balloon Dilat","PX-75000201","CDM","45386","CPT","0750","RC","","","","outpatient","","","2631.00","1973.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4369.86","1136.56","4369.86","1 through 10","979.79","2453.74","other","Multiple Surgery"
"Colonoscopy Flex W/Balloon Dilat","PX-75000201","CDM","45386","CPT","0750","RC","","","","outpatient","","","2631.00","1973.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2390.69","2390.69","2390.69","1 through 10","979.79","2453.74","other","Multiple Surgery"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1442.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","720.42","662.66","1440.84","1 through 10","811.58","2081.31","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","688.91","688.91","1377.83","1 through 10","811.58","2081.31","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2081.31","79.5","","1998.19","1340.59","4378.86","29","811.58","2081.31","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1395.39","53.3","","1340.59","1282.20","1998.19","1 through 10","811.58","2081.31","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1372.23","686.12","1372.23","1 through 10","811.58","2081.31","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","HUMANA [1012]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1380.63","1380.63","1380.63","1 through 10","811.58","2081.31","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","700.11","700.11","1400.23","121","811.58","2081.31","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","811.58","31","","784.55","784.55","784.55","1 through 10","811.58","2081.31","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","955.57","36.5","","947.05","804.86","947.05","1 through 10","811.58","2081.31","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1002.69","38.3","","992.75","992.75","992.75","20","811.58","2081.31","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1372.23","631.10","2556.14","12","811.58","2081.31","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","TRICARE [160005]","HB BWH TRICARE","1330.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1400.23","1400.23","1400.23","1 through 10","811.58","2081.31","other","Tricare OPPS"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1262.19","686.12","4133.49","1 through 10","811.58","2081.31","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1262.20","686.12","1372.23","103","811.58","2081.31","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1123.12","42.9","","1116.40","1116.40","1116.40","1 through 10","811.58","2081.31","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","AETNA [1001]","HB AMC AETNA HMO","1827.36","69.8","","1718.90","1213.64","1718.90","28","979.79","2453.74","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2250.98","1146.22","2292.44","39","979.79","2453.74","other","ASC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2597.20","2597.20","2622.97","127","979.79","2453.74","other","ASC "
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2841.39","1420.70","2841.39","1 through 10","979.79","2453.74","other","Multiple Surgery"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2273.11","2184.93","2273.11","32","979.79","2453.74","other","Multiple Surgery"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2390.69","1994.11","7172.07","35","979.79","2453.74","other","Multiple Surgery"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","2841.39","1420.70","2841.39","1 through 10","979.79","2453.74","other","Multiple Surgery"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2508.26","1254.13","2508.26","28","979.79","2453.74","other","Multiple Surgery"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2139.43","81.72","","2029.68","1116.40","2029.68","18","979.79","2453.74","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1114.11","1114.11","1 through 10","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","1065.39","1065.39","1 through 10","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3086.99","79.5","","2963.84","1988.45","2963.84","15","1028.57","3086.99","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1061.06","1061.06","1061.06","1 through 10","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","FALLON HEALTH [1008]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","541.36","541.36","541.36","1 through 10","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","56","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1417.30","36.5","","1404.72","1193.82","1404.72","51","1028.57","3086.99","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1487.19","38.3","","1472.51","1431.08","1472.51","144","1028.57","3086.99","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1067.06","977.56","1981.07","1 through 10","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","TRICARE [160005]","HB BWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","947.63","1082.71","1 through 10","1028.57","3086.99","other","Tricare OPPS"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.53","1601.33","1 through 10","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1665.81","42.9","","3010.54","3010.54","3010.54","1 through 10","1028.57","3086.99","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.53","1061.06","19","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","AETNA [1001]","HB AMC AETNA HMO","2710.33","69.8","","2549.58","1800.15","2937.48","16","744.89","3173.19","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","AETNA [1001]","HB AMC AETNA PPO","3121.93","80.4","","2937.48","1973.38","2937.48","1 through 10","744.89","3173.19","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1711.31","855.66","1742.82","48","744.89","3173.19","other","ASC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1974.52","987.26","1994.11","111","744.89","3173.19","other","ASC "
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1906.92","849.18","2160.18","1 through 10","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1728.14","864.07","1728.14","135","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1817.53","908.77","1817.53","66","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 383%, 191.5 procedures at 0%.","2852.93","2852.93","2852.93","1 through 10","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","2160.18","2160.18","2852.93","1 through 10","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1832.43","1350.70","1906.92","37","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3173.19","81.72","","1655.91","1655.91","1655.91","1 through 10","744.89","3173.19","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3173.19","81.72","","3010.54","1655.91","3010.54","14","744.89","3173.19","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1832.43","1832.43","1832.43","1 through 10","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flexible With Band Ligation(S)","PX-75000426","CDM","45398","CPT","0750","RC","","","","outpatient","","","3788.00","2841.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1195.35","1195.35","1195.35","1 through 10","979.79","3095.55","other","Multiple Surgery"
"Colonoscopy Flx Ablation Tumor Polyp/Other Les","PX-75000420","CDM","45388","CPT","0750","RC","","","","both","","","2927.00","2195.25","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","907.37","2326.97","other","OPPS APC"
"Colonoscopy Flx Ablation Tumor Polyp/Other Les","PX-75000420","CDM","45388","CPT","0750","RC","","","","outpatient","","","2927.00","2195.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1311.48","1311.48","1311.48","1 through 10","979.79","2453.74","other","ASC "
"Colonoscopy Flx Ablation Tumor Polyp/Other Les","PX-75000420","CDM","45388","CPT","0750","RC","","","","outpatient","","","2927.00","2195.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1254.13","1254.13","1254.13","1 through 10","979.79","2453.74","other","Multiple Surgery"
"Colonoscopy Flx Ablation Tumor Polyp/Other Les","PX-75000420","CDM","45388","CPT","0750","RC","","","","outpatient","","","2927.00","2195.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2391.94","81.72","","2268.70","2268.70","2268.70","1 through 10","979.79","2453.74","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1114.11","1114.11","1 through 10","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","1065.39","1065.39","1 through 10","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3086.99","79.5","","2963.84","1988.45","2963.84","15","1028.57","3086.99","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1061.06","1061.06","1061.06","1 through 10","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","FALLON HEALTH [1008]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","541.36","541.36","541.36","1 through 10","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","56","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1417.30","36.5","","1404.72","1193.82","1404.72","51","1028.57","3086.99","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1487.19","38.3","","1472.51","1431.08","1472.51","144","1028.57","3086.99","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1067.06","977.56","1981.07","1 through 10","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","TRICARE [160005]","HB BWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","947.63","1082.71","1 through 10","1028.57","3086.99","other","Tricare OPPS"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.53","1601.33","1 through 10","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1665.81","42.9","","3010.54","3010.54","3010.54","1 through 10","1028.57","3086.99","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3883.00","2912.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.53","1061.06","19","1028.57","3086.99","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","AETNA [1001]","HB AMC AETNA HMO","2710.33","69.8","","2549.58","1800.15","2937.48","16","744.89","3173.19","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","AETNA [1001]","HB AMC AETNA PPO","3121.93","80.4","","2937.48","1973.38","2937.48","1 through 10","744.89","3173.19","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1711.31","855.66","1742.82","48","744.89","3173.19","other","ASC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1974.52","987.26","1994.11","111","744.89","3173.19","other","ASC "
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1906.92","849.18","2160.18","1 through 10","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1728.14","864.07","1728.14","135","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1817.53","908.77","1817.53","66","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 383%, 191.5 procedures at 0%.","2852.93","2852.93","2852.93","1 through 10","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","2160.18","2160.18","2852.93","1 through 10","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1832.43","1350.70","1906.92","37","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3173.19","81.72","","1655.91","1655.91","1655.91","1 through 10","744.89","3173.19","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3173.19","81.72","","3010.54","1655.91","3010.54","14","744.89","3173.19","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3883.00","2912.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1832.43","1832.43","1832.43","1 through 10","744.89","3173.19","other","Multiple Surgery"
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","both","","","3863.00","2897.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3354.12","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3351.20","3351.20","3351.20","1 through 10","1197.53","4070.53","other","OPPS APC"
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","both","","","3863.00","2897.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3256.42","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3204.64","3015.46","3204.64","1 through 10","1197.53","4070.53","other","OPPS APC"
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","both","","","3863.00","2897.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3071.09","79.5","","2948.10","2948.10","2948.10","1 through 10","1197.53","4070.53","percent of total billed charges",""
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","both","","","3863.00","2897.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3256.42","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3191.61","3191.61","3191.61","1 through 10","1197.53","4070.53","other","OPPS APC"
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","both","","","3863.00","2897.25","MEDICARE [2001]","HB BWH MEDICARE","3256.42","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3256.75","3064.49","3256.75","16","1197.53","4070.53","other","OPPS APC"
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","both","","","3863.00","2897.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1410.00","36.5","","1397.26","1187.48","1397.26","1 through 10","1197.53","4070.53","percent of total billed charges",""
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","both","","","3863.00","2897.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1479.53","38.3","","1464.69","1464.69","1464.69","1 through 10","1197.53","4070.53","percent of total billed charges",""
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","both","","","3863.00","2897.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","3256.42","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3009.20","3009.20","3009.20","1 through 10","1197.53","4070.53","other","OPPS APC"
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","both","","","3863.00","2897.25","TRICARE [160005]","HB BWH TRICARE","3093.92","","APC Price ($3,256.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3256.75","3256.75","3256.75","1 through 10","1197.53","4070.53","other","Tricare OPPS"
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","both","","","3863.00","2897.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3191.30","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3191.62","3003.21","5822.76","1 through 10","1197.53","4070.53","other","OPPS APC"
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","both","","","3863.00","2897.25","WELLPOINT [1015]","HB AMC WELLPOINT","2850.12","73.78","","2788.89","2788.89","2788.89","1 through 10","1197.53","4070.53","percent of total billed charges",""
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","outpatient","","","3863.00","2897.25","AETNA [1001]","HB AMC AETNA HMO","2696.37","69.8","","2536.04","1790.59","2536.04","1 through 10","979.79","3156.84","percent of total billed charges",""
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","outpatient","","","3863.00","2897.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2292.44","2250.98","2292.44","1 through 10","979.79","3156.84","other","ASC"
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","outpatient","","","3863.00","2897.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2622.97","2597.20","2622.97","22","979.79","3156.84","other","ASC "
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","outpatient","","","3863.00","2897.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2273.11","2273.11","2273.11","1 through 10","979.79","3156.84","other","Multiple Surgery"
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","outpatient","","","3863.00","2897.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3156.84","81.72","","2994.55","2994.55","2994.55","1 through 10","979.79","3156.84","percent of total billed charges",""
"Colonoscopy Flx W/Removal of Foreign Body(S)","PX-75000194","CDM","45379","CPT","0750","RC","","","","both","","","2618.00","1963.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1372.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","1372.23","1372.23","1 through 10","811.58","2081.31","other","OPPS APC"
"Colonoscopy Stoma W/Balloon Dilation","PX-75000410","CDM","44405","CPT","0750","RC","","","","outpatient","","","3863.00","2897.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3156.84","81.72","","2994.55","2994.55","2994.55","1 through 10","979.79","3156.84","percent of total billed charges",""
"Colonoscopy Stoma W/Biopsy","PX-75000158","CDM","44389","CPT","0750","RC","","","","both","","","2651.00","1988.25","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","821.81","2107.55","other","OPPS APC"
"Colonoscopy Thru Stoma","PX-75000157","CDM","44388","CPT","0750","RC","","","","both","","","2618.00","1963.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1395.39","53.3","","1340.59","1340.59","1340.59","1 through 10","811.58","2081.31","percent of total billed charges",""
"Colonoscopy Thru Stoma","PX-75000157","CDM","44388","CPT","0750","RC","","","","both","","","2618.00","1963.50","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","997.51","1082.71","1 through 10","811.58","2081.31","other","OPPS APC"
"Colonoscopy Thru Stoma","PX-75000157","CDM","44388","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1994.11","1974.52","1994.11","1 through 10","744.89","2384.07","other","ASC "
"Colonoscopy Thru Stoma","PX-75000157","CDM","44388","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1728.14","1728.14","1728.14","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1442.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1440.84","1440.84","1440.84","11","812.51","2083.7","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1377.83","1267.34","1400.23","1 through 10","812.51","2083.7","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1834.70","70","","1830.24","1830.24","1830.24","1 through 10","812.51","2083.7","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2083.70","79.5","","2000.55","1342.18","2000.55","39","812.51","2083.7","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1396.99","53.3","","2000.55","1342.18","4283.15","17","812.51","2083.7","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1372.23","1372.23","1372.23","1 through 10","812.51","2083.7","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","FALLON HEALTH [1008]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1372.23","1372.23","1372.23","1 through 10","812.51","2083.7","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","HUMANA [1012]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1372.23","1372.23","1372.23","1 through 10","812.51","2083.7","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2083.70","79.5","","1999.84","1999.84","1999.84","1 through 10","812.51","2083.7","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","168","812.51","2083.7","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","956.67","36.5","","948.17","805.81","1759.58","1 through 10","812.51","2083.7","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1003.84","38.3","","993.92","965.96","993.92","59","812.51","2083.7","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1376.23","1372.23","1378.23","1 through 10","812.51","2083.7","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","TRICARE [160005]","HB BWH TRICARE","1330.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1400.23","1400.23","1400.23","1 through 10","812.51","2083.7","other","Tricare OPPS"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1377.83","1372.23","4141.89","1 through 10","812.51","2083.7","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1124.41","42.9","","1117.72","1117.72","2032.07","1 through 10","812.51","2083.7","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2621.00","1965.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","1262.20","1372.23","97","812.51","2083.7","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","AETNA [1001]","HB AMC AETNA HMO","1829.46","69.8","","1720.93","1215.08","1982.76","55","979.79","2384.07","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","AETNA [1001]","HB AMC AETNA PPO","2107.28","80.4","","1332.01","1332.01","1982.76","1 through 10","979.79","2384.07","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2250.98","2250.98","2292.44","106","979.79","2384.07","other","ASC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1369.73","52.26","","2597.20","2597.20","2597.20","1 through 10","979.79","2384.07","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2597.20","2597.20","2622.97","258","979.79","2384.07","other","ASC "
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2841.39","2841.39","2841.39","1 through 10","979.79","2384.07","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2273.11","2273.11","6819.33","83","979.79","2384.07","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2390.69","2390.69","7172.07","36","979.79","2384.07","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 383%, 191.5 procedures at 0%.","3752.60","3752.60","3752.60","1 through 10","979.79","2384.07","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","2841.39","2841.39","2841.39","1 through 10","979.79","2384.07","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2508.26","2031.41","2508.26","37","979.79","2384.07","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2107.28","80.4","","1982.76","1982.76","1982.76","1 through 10","979.79","2384.07","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2141.88","81.72","","1117.72","1117.72","1117.72","1 through 10","979.79","2384.07","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2621.00","1965.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2141.88","81.72","","2032.07","1117.72","2032.07","33","979.79","2384.07","percent of total billed charges",""
"Colonoscopy W/Esd, Colon","PX-75000341","CDM","45399","CPT","0750","RC","","","","both","","","7996.00","5997.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2918.54","36.5","","2892.24","2892.24","2892.24","1 through 10","2478.76","6356.82","percent of total billed charges",""
"Colonoscopy W/Esd, Colon","PX-75000341","CDM","45399","CPT","0750","RC","","","","both","","","7996.00","5997.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3062.47","38.3","","2777.42","2083.54","2946.52","1 through 10","2478.76","6356.82","percent of total billed charges",""
"Colonoscopy W/Esd, Colon","PX-75000341","CDM","45399","CPT","0750","RC","","","","both","","","7996.00","5997.00","TRICARE [160005]","HB BWH TRICARE","4292.20","","APC Price ($4,518.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","1028.57","1028.57","1 through 10","2478.76","6356.82","other","Tricare OPPS"
"Colonoscopy W/Esd, Colon","PX-75000341","CDM","45399","CPT","0750","RC","","","","both","","","7996.00","5997.00","WELLPOINT [1015]","HB AMC WELLPOINT","5899.45","73.78","","5772.85","5772.85","7754.00","1 through 10","2478.76","6356.82","percent of total billed charges",""
"Colonoscopy W/Esd, Colon","PX-75000341","CDM","45399","CPT","0750","RC","","","","outpatient","","","7996.00","5997.00","AETNA [1001]","HB AMC AETNA HMO","5581.21","69.8","","5249.46","3706.41","5249.46","1 through 10","2384.07","6596.7","percent of total billed charges",""
"Colonoscopy W/Esd, Colon","PX-75000341","CDM","45399","CPT","0750","RC","","","","outpatient","","","7996.00","5997.00","AETNA [1001]","HB AMC AETNA PPO","6428.78","80.4","","6048.12","6048.12","6048.12","1 through 10","2384.07","6596.7","percent of total billed charges",""
"Colonoscopy W/Esd, Colon","PX-75000341","CDM","45399","CPT","0750","RC","","","","outpatient","","","7996.00","5997.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4841.58","60.55","","1533.28","1533.28","7754.00","1 through 10","2384.07","6596.7","percent of total billed charges",""
"Colonoscopy W/Esd, Colon","PX-75000341","CDM","45399","CPT","0750","RC","","","","outpatient","","","7996.00","5997.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4175.51","52.22","","1974.52","1533.28","7754.00","21","2384.07","6596.7","percent of total billed charges",""
"Colonoscopy W/Esd, Colon","PX-75000341","CDM","45399","CPT","0750","RC","","","","outpatient","","","7996.00","5997.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4197.90","52.5","","4063.09","4063.09","4063.09","1 through 10","2384.07","6596.7","percent of total billed charges",""
"Colonoscopy W/Esd, Colon","PX-75000341","CDM","45399","CPT","0750","RC","","","","outpatient","","","7996.00","5997.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6534.33","81.72","","6198.55","6198.55","7754.00","1 through 10","2384.07","6596.7","percent of total billed charges",""
"Colonoscopy W/Esd, Colon","PX-75000341","CDM","45399","CPT","0750","RC","","","","outpatient","","","7996.00","5997.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","4997.50","62.5","","4691.17","4691.17","4691.17","1 through 10","2384.07","6596.7","percent of total billed charges",""
"Colonoscopy With Cecostomy Tube Placement","PX-75000460","CDM","44799","CPT","0750","RC","","","","both","","","368.00","276.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","114.08","1391.62","other","OPPS APC"
"Colonoscopy With Cecostomy Tube Placement","PX-75000460","CDM","44799","CPT","0750","RC","","","","both","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","114.08","1391.62","other","OPPS APC"
"Colonoscopy With Cecostomy Tube Placement","PX-75000460","CDM","44799","CPT","0750","RC","","","","both","","","368.00","276.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","114.08","1391.62","other","OPPS APC"
"Colonoscopy With Cecostomy Tube Placement","PX-75000460","CDM","44799","CPT","0750","RC","","","","both","","","368.00","276.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","114.08","1391.62","other","OPPS APC"
"Colonoscopy With Cecostomy Tube Placement","PX-75000460","CDM","44799","CPT","0750","RC","","","","both","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.87","42.9","","1932.92","1932.92","1932.92","1 through 10","114.08","1391.62","percent of total billed charges",""
"Colonoscopy With Cecostomy Tube Placement","PX-75000460","CDM","44799","CPT","0750","RC","","","","both","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","114.08","1391.62","other","OPPS APC"
"Colonoscopy With Cecostomy Tube Placement","PX-75000460","CDM","44799","CPT","0750","RC","","","","both","","","368.00","276.00","WELLPOINT [1015]","HB AMC WELLPOINT","271.51","73.78","","2222.33","2222.33","2222.33","1 through 10","114.08","1391.62","percent of total billed charges",""
"Colonoscopy With Cecostomy Tube Placement","PX-75000460","CDM","44799","CPT","0750","RC","","","","outpatient","","","368.00","276.00","AETNA [1001]","HB AMC AETNA HMO","256.86","69.8","","2238.60","2238.60","2238.60","1 through 10","184","8899.59","percent of total billed charges",""
"Colonoscopy With Cecostomy Tube Placement","PX-75000460","CDM","44799","CPT","0750","RC","","","","outpatient","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","222.82","60.55","","3144.00","2870.00","3286.00","1 through 10","184","8899.59","percent of total billed charges",""
"Colonoscopy With Cecostomy Tube Placement","PX-75000460","CDM","44799","CPT","0750","RC","","","","outpatient","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","192.32","52.26","","1775.96","1775.96","1775.96","1 through 10","184","8899.59","percent of total billed charges",""
"Colonoscopy With Cecostomy Tube Placement","PX-75000460","CDM","44799","CPT","0750","RC","","","","outpatient","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","192.17","52.22","","3286.00","2018.70","5898.00","1 through 10","184","8899.59","percent of total billed charges",""
"Colonoscopy With Cecostomy Tube Placement","PX-75000460","CDM","44799","CPT","0750","RC","","","","outpatient","","","368.00","276.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","193.20","52.5","","8340.00","8340.00","8340.00","1 through 10","184","8899.59","percent of total billed charges",""
"Colonoscopy With Cecostomy Tube Placement","PX-75000460","CDM","44799","CPT","0750","RC","","","","outpatient","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","300.73","81.72","","2294.28","682.69","2294.28","1 through 10","184","8899.59","percent of total billed charges",""
"Colonoscopy With Hybrid Esd","PX-75000478","CDM","45399","CPT","0750","RC","","","","both","","","5997.00","4497.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2188.91","36.5","","2892.24","2892.24","2892.24","1 through 10","1859.07","5647.06","percent of total billed charges",""
"Colonoscopy With Hybrid Esd","PX-75000478","CDM","45399","CPT","0750","RC","","","","both","","","5997.00","4497.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2296.85","38.3","","2777.42","2083.54","2946.52","1 through 10","1859.07","5647.06","percent of total billed charges",""
"Colonoscopy With Hybrid Esd","PX-75000478","CDM","45399","CPT","0750","RC","","","","both","","","5997.00","4497.75","TRICARE [160005]","HB BWH TRICARE","4292.20","","APC Price ($4,518.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","1028.57","1028.57","1 through 10","1859.07","5647.06","other","Tricare OPPS"
"Colonoscopy With Hybrid Esd","PX-75000478","CDM","45399","CPT","0750","RC","","","","both","","","5997.00","4497.75","WELLPOINT [1015]","HB AMC WELLPOINT","4424.59","73.78","","5772.85","5772.85","7754.00","1 through 10","1859.07","5647.06","percent of total billed charges",""
"Colonoscopy With Hybrid Esd","PX-75000478","CDM","45399","CPT","0750","RC","","","","outpatient","","","5997.00","4497.75","AETNA [1001]","HB AMC AETNA HMO","4185.91","69.8","","5249.46","3706.41","5249.46","1 through 10","2384.07","4947.53","percent of total billed charges",""
"Colonoscopy With Hybrid Esd","PX-75000478","CDM","45399","CPT","0750","RC","","","","outpatient","","","5997.00","4497.75","AETNA [1001]","HB AMC AETNA PPO","4821.59","80.4","","6048.12","6048.12","6048.12","1 through 10","2384.07","4947.53","percent of total billed charges",""
"Colonoscopy With Hybrid Esd","PX-75000478","CDM","45399","CPT","0750","RC","","","","outpatient","","","5997.00","4497.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3631.18","60.55","","1533.28","1533.28","7754.00","1 through 10","2384.07","4947.53","percent of total billed charges",""
"Colonoscopy With Hybrid Esd","PX-75000478","CDM","45399","CPT","0750","RC","","","","outpatient","","","5997.00","4497.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3131.63","52.22","","1974.52","1533.28","7754.00","21","2384.07","4947.53","percent of total billed charges",""
"Colonoscopy With Hybrid Esd","PX-75000478","CDM","45399","CPT","0750","RC","","","","outpatient","","","5997.00","4497.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3148.43","52.5","","4063.09","4063.09","4063.09","1 through 10","2384.07","4947.53","percent of total billed charges",""
"Colonoscopy With Hybrid Esd","PX-75000478","CDM","45399","CPT","0750","RC","","","","outpatient","","","5997.00","4497.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4900.75","81.72","","6198.55","6198.55","7754.00","1 through 10","2384.07","4947.53","percent of total billed charges",""
"Colonoscopy With Hybrid Esd","PX-75000478","CDM","45399","CPT","0750","RC","","","","outpatient","","","5997.00","4497.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","3748.13","62.5","","4691.17","4691.17","4691.17","1 through 10","2384.07","4947.53","percent of total billed charges",""
"Colonoscopy With Mucosal Flap Closure","PX-75000496","CDM","45399","CPT","0750","RC","","","","both","","","3206.00","2404.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1170.19","36.5","","2892.24","2892.24","2892.24","1 through 10","993.86","2548.77","percent of total billed charges",""
"Colonoscopy With Mucosal Flap Closure","PX-75000496","CDM","45399","CPT","0750","RC","","","","both","","","3206.00","2404.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1227.90","38.3","","2777.42","2083.54","2946.52","1 through 10","993.86","2548.77","percent of total billed charges",""
"Colonoscopy With Mucosal Flap Closure","PX-75000496","CDM","45399","CPT","0750","RC","","","","both","","","3206.00","2404.50","TRICARE [160005]","HB BWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","1028.57","1028.57","1 through 10","993.86","2548.77","other","Tricare OPPS"
"Colonoscopy With Mucosal Flap Closure","PX-75000496","CDM","45399","CPT","0750","RC","","","","both","","","3206.00","2404.50","WELLPOINT [1015]","HB AMC WELLPOINT","2365.39","73.78","","5772.85","5772.85","7754.00","1 through 10","993.86","2548.77","percent of total billed charges",""
"Colonoscopy With Mucosal Flap Closure","PX-75000496","CDM","45399","CPT","0750","RC","","","","outpatient","","","3206.00","2404.50","AETNA [1001]","HB AMC AETNA HMO","2237.79","69.8","","5249.46","3706.41","5249.46","1 through 10","1603","2644.95","percent of total billed charges",""
"Colonoscopy With Mucosal Flap Closure","PX-75000496","CDM","45399","CPT","0750","RC","","","","outpatient","","","3206.00","2404.50","AETNA [1001]","HB AMC AETNA PPO","2577.62","80.4","","6048.12","6048.12","6048.12","1 through 10","1603","2644.95","percent of total billed charges",""
"Colonoscopy With Mucosal Flap Closure","PX-75000496","CDM","45399","CPT","0750","RC","","","","outpatient","","","3206.00","2404.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1941.23","60.55","","1533.28","1533.28","7754.00","1 through 10","1603","2644.95","percent of total billed charges",""
"Colonoscopy With Mucosal Flap Closure","PX-75000496","CDM","45399","CPT","0750","RC","","","","outpatient","","","3206.00","2404.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1674.17","52.22","","1974.52","1533.28","7754.00","21","1603","2644.95","percent of total billed charges",""
"Colonoscopy With Mucosal Flap Closure","PX-75000496","CDM","45399","CPT","0750","RC","","","","outpatient","","","3206.00","2404.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1683.15","52.5","","4063.09","4063.09","4063.09","1 through 10","1603","2644.95","percent of total billed charges",""
"Colonoscopy With Mucosal Flap Closure","PX-75000496","CDM","45399","CPT","0750","RC","","","","outpatient","","","3206.00","2404.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2619.94","81.72","","6198.55","6198.55","7754.00","1 through 10","1603","2644.95","percent of total billed charges",""
"Colonoscopy With Mucosal Flap Closure","PX-75000496","CDM","45399","CPT","0750","RC","","","","outpatient","","","3206.00","2404.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2003.75","62.5","","4691.17","4691.17","4691.17","1 through 10","1603","2644.95","percent of total billed charges",""
"Colonoscopy With Occluder Fistula Closure","PX-75000522","CDM","45399","CPT","0750","RC","","","","both","","","17249.00","12936.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6295.89","36.5","","2892.24","2892.24","2892.24","1 through 10","1028.57","13712.96","percent of total billed charges",""
"Colonoscopy With Occluder Fistula Closure","PX-75000522","CDM","45399","CPT","0750","RC","","","","both","","","17249.00","12936.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6606.37","38.3","","2777.42","2083.54","2946.52","1 through 10","1028.57","13712.96","percent of total billed charges",""
"Colonoscopy With Occluder Fistula Closure","PX-75000522","CDM","45399","CPT","0750","RC","","","","both","","","17249.00","12936.75","TRICARE [160005]","HB BWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","1028.57","1028.57","1 through 10","1028.57","13712.96","other","Tricare OPPS"
"Colonoscopy With Occluder Fistula Closure","PX-75000522","CDM","45399","CPT","0750","RC","","","","both","","","17249.00","12936.75","WELLPOINT [1015]","HB AMC WELLPOINT","12726.31","73.78","","5772.85","5772.85","7754.00","1 through 10","1028.57","13712.96","percent of total billed charges",""
"Colonoscopy With Occluder Fistula Closure","PX-75000522","CDM","45399","CPT","0750","RC","","","","outpatient","","","17249.00","12936.75","AETNA [1001]","HB AMC AETNA HMO","12039.80","69.8","","5249.46","3706.41","5249.46","1 through 10","2384.07","14230.43","percent of total billed charges",""
"Colonoscopy With Occluder Fistula Closure","PX-75000522","CDM","45399","CPT","0750","RC","","","","outpatient","","","17249.00","12936.75","AETNA [1001]","HB AMC AETNA PPO","13868.20","80.4","","6048.12","6048.12","6048.12","1 through 10","2384.07","14230.43","percent of total billed charges",""
"Colonoscopy With Occluder Fistula Closure","PX-75000522","CDM","45399","CPT","0750","RC","","","","outpatient","","","17249.00","12936.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","10444.27","60.55","","1533.28","1533.28","7754.00","1 through 10","2384.07","14230.43","percent of total billed charges",""
"Colonoscopy With Occluder Fistula Closure","PX-75000522","CDM","45399","CPT","0750","RC","","","","outpatient","","","17249.00","12936.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","9007.43","52.22","","1974.52","1533.28","7754.00","21","2384.07","14230.43","percent of total billed charges",""
"Colonoscopy With Occluder Fistula Closure","PX-75000522","CDM","45399","CPT","0750","RC","","","","outpatient","","","17249.00","12936.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","9055.73","52.5","","4063.09","4063.09","4063.09","1 through 10","2384.07","14230.43","percent of total billed charges",""
"Colonoscopy With Occluder Fistula Closure","PX-75000522","CDM","45399","CPT","0750","RC","","","","outpatient","","","17249.00","12936.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14095.88","81.72","","6198.55","6198.55","7754.00","1 through 10","2384.07","14230.43","percent of total billed charges",""
"Colonoscopy With Occluder Fistula Closure","PX-75000522","CDM","45399","CPT","0750","RC","","","","outpatient","","","17249.00","12936.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","10780.63","62.5","","4691.17","4691.17","4691.17","1 through 10","2384.07","14230.43","percent of total billed charges",""
"Colonoscopy With Ster","PX-75000479","CDM","45399","CPT","0750","RC","","","","both","","","11994.00","8995.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4377.81","36.5","","2892.24","2892.24","2892.24","1 through 10","1028.57","9535.23","percent of total billed charges",""
"Colonoscopy With Ster","PX-75000479","CDM","45399","CPT","0750","RC","","","","both","","","11994.00","8995.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4593.70","38.3","","2777.42","2083.54","2946.52","1 through 10","1028.57","9535.23","percent of total billed charges",""
"Colonoscopy With Ster","PX-75000479","CDM","45399","CPT","0750","RC","","","","both","","","11994.00","8995.50","TRICARE [160005]","HB BWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","1028.57","1028.57","1 through 10","1028.57","9535.23","other","Tricare OPPS"
"Colonoscopy With Ster","PX-75000479","CDM","45399","CPT","0750","RC","","","","both","","","11994.00","8995.50","WELLPOINT [1015]","HB AMC WELLPOINT","8849.17","73.78","","5772.85","5772.85","7754.00","1 through 10","1028.57","9535.23","percent of total billed charges",""
"Colonoscopy With Ster","PX-75000479","CDM","45399","CPT","0750","RC","","","","outpatient","","","11994.00","8995.50","AETNA [1001]","HB AMC AETNA HMO","8371.81","69.8","","5249.46","3706.41","5249.46","1 through 10","2384.07","9895.05","percent of total billed charges",""
"Colonoscopy With Ster","PX-75000479","CDM","45399","CPT","0750","RC","","","","outpatient","","","11994.00","8995.50","AETNA [1001]","HB AMC AETNA PPO","9643.18","80.4","","6048.12","6048.12","6048.12","1 through 10","2384.07","9895.05","percent of total billed charges",""
"Colonoscopy With Ster","PX-75000479","CDM","45399","CPT","0750","RC","","","","outpatient","","","11994.00","8995.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","7262.37","60.55","","1533.28","1533.28","7754.00","1 through 10","2384.07","9895.05","percent of total billed charges",""
"Colonoscopy With Ster","PX-75000479","CDM","45399","CPT","0750","RC","","","","outpatient","","","11994.00","8995.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6263.27","52.22","","1974.52","1533.28","7754.00","21","2384.07","9895.05","percent of total billed charges",""
"Colonoscopy With Ster","PX-75000479","CDM","45399","CPT","0750","RC","","","","outpatient","","","11994.00","8995.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6296.85","52.5","","4063.09","4063.09","4063.09","1 through 10","2384.07","9895.05","percent of total billed charges",""
"Colonoscopy With Ster","PX-75000479","CDM","45399","CPT","0750","RC","","","","outpatient","","","11994.00","8995.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9801.50","81.72","","6198.55","6198.55","7754.00","1 through 10","2384.07","9895.05","percent of total billed charges",""
"Colonoscopy With Ster","PX-75000479","CDM","45399","CPT","0750","RC","","","","outpatient","","","11994.00","8995.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","7496.25","62.5","","4691.17","4691.17","4691.17","1 through 10","2384.07","9895.05","percent of total billed charges",""
"Colonoscopy With Stricturoplasty","PX-75000542","CDM","44799","CPT","0750","RC","","","","both","","","7416.00","5562.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1057.74","5895.72","other","OPPS APC"
"Colonoscopy With Stricturoplasty","PX-75000542","CDM","44799","CPT","0750","RC","","","","both","","","7416.00","5562.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","5895.72","other","OPPS APC"
"Colonoscopy With Stricturoplasty","PX-75000542","CDM","44799","CPT","0750","RC","","","","both","","","7416.00","5562.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","5895.72","other","OPPS APC"
"Colonoscopy With Stricturoplasty","PX-75000542","CDM","44799","CPT","0750","RC","","","","both","","","7416.00","5562.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1057.74","5895.72","other","OPPS APC"
"Colonoscopy With Stricturoplasty","PX-75000542","CDM","44799","CPT","0750","RC","","","","both","","","7416.00","5562.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3181.46","42.9","","1932.92","1932.92","1932.92","1 through 10","1057.74","5895.72","percent of total billed charges",""
"Colonoscopy With Stricturoplasty","PX-75000542","CDM","44799","CPT","0750","RC","","","","both","","","7416.00","5562.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1057.74","5895.72","other","OPPS APC"
"Colonoscopy With Stricturoplasty","PX-75000542","CDM","44799","CPT","0750","RC","","","","both","","","7416.00","5562.00","WELLPOINT [1015]","HB AMC WELLPOINT","5471.52","73.78","","2222.33","2222.33","2222.33","1 through 10","1057.74","5895.72","percent of total billed charges",""
"Colonoscopy With Stricturoplasty","PX-75000542","CDM","44799","CPT","0750","RC","","","","outpatient","","","7416.00","5562.00","AETNA [1001]","HB AMC AETNA HMO","5176.37","69.8","","2238.60","2238.60","2238.60","1 through 10","3708","8899.59","percent of total billed charges",""
"Colonoscopy With Stricturoplasty","PX-75000542","CDM","44799","CPT","0750","RC","","","","outpatient","","","7416.00","5562.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4490.39","60.55","","3144.00","2870.00","3286.00","1 through 10","3708","8899.59","percent of total billed charges",""
"Colonoscopy With Stricturoplasty","PX-75000542","CDM","44799","CPT","0750","RC","","","","outpatient","","","7416.00","5562.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3875.60","52.26","","1775.96","1775.96","1775.96","1 through 10","3708","8899.59","percent of total billed charges",""
"Colonoscopy With Stricturoplasty","PX-75000542","CDM","44799","CPT","0750","RC","","","","outpatient","","","7416.00","5562.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3872.64","52.22","","3286.00","2018.70","5898.00","1 through 10","3708","8899.59","percent of total billed charges",""
"Colonoscopy With Stricturoplasty","PX-75000542","CDM","44799","CPT","0750","RC","","","","outpatient","","","7416.00","5562.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3893.40","52.5","","8340.00","8340.00","8340.00","1 through 10","3708","8899.59","percent of total billed charges",""
"Colonoscopy With Stricturoplasty","PX-75000542","CDM","44799","CPT","0750","RC","","","","outpatient","","","7416.00","5562.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6060.36","81.72","","2294.28","682.69","2294.28","1 through 10","3708","8899.59","percent of total billed charges",""
"Colpocentesis","PX-76001342","CDM","57020","CPT","0761","RC","","","","both","","","8785.00","6588.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3364.66","38.3","","3330.93","3330.93","3330.93","1 through 10","2723.35","7327.17","percent of total billed charges",""
"Colporrhaphy Non-Obstetric","PX-76001355","CDM","57200","CPT","0761","RC","","","","outpatient","","","8785.00","6588.75","AETNA [1001]","HB AMC AETNA PPO","7063.14","80.4","","9669.46","9669.46","9669.46","1 through 10","3514","7179.1","percent of total billed charges",""
"Colposcopy Cervix/Vagina","PX-76001362","CDM","57452","CPT","0761","RC","","","","both","","","660.00","495.00","MEDICARE [2001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","238.90","108.74","238.90","1 through 10","204.6","524.7","other","OPPS APC"
"Colposcopy Cervix/Vagina","PX-76001362","CDM","57452","CPT","0761","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","252.78","38.3","","250.24","250.24","250.24","1 through 10","204.6","524.7","percent of total billed charges",""
"Colposcopy Cervix/Vagina","PX-76001362","CDM","57452","CPT","0761","RC","","","","both","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","234.60","94.30","234.60","1 through 10","204.6","524.7","other","OPPS APC"
"Colposcopy Cervix/Vagina","PX-76001362","CDM","57452","CPT","0761","RC","","","","outpatient","","","660.00","495.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","444.20","222.10","712.25","1 through 10","165.93","700.33","other","ASC "
"Colposcopy Cervix/Vagina","PX-76001362","CDM","57452","CPT","0761","RC","","","","outpatient","","","660.00","495.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","384.96","384.96","384.96","1 through 10","165.93","700.33","other","Multiple Surgery"
"Colposcopy Cervix/Vagina","PX-76001362","CDM","57452","CPT","0761","RC","","","","outpatient","","","660.00","495.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","404.87","404.87","1 through 10","165.93","700.33","other","Multiple Surgery"
"Colposcopy Cervix/Vagina","PX-76001362","CDM","57452","CPT","0761","RC","","","","outpatient","","","660.00","495.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","424.78","424.78","424.78","1 through 10","165.93","700.33","other","Multiple Surgery"
"Colposcopy Entire Vagina","PX-76001360","CDM","57420","CPT","0761","RC","","","","both","","","672.00","504.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","534.24","79.5","","6346.37","513.12","6346.37","1 through 10","208.32","534.24","percent of total billed charges",""
"Colposcopy Entire Vagina","PX-76001360","CDM","57420","CPT","0761","RC","","","","both","","","672.00","504.00","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","361.24","361.24","1 through 10","208.32","534.24","other","OPPS APC"
"Colposcopy Entire Vagina","PX-76001360","CDM","57420","CPT","0761","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","245.28","36.5","","243.20","143.61","243.20","1 through 10","208.32","534.24","percent of total billed charges",""
"Colposcopy Entire Vagina","PX-76001360","CDM","57420","CPT","0761","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","257.38","38.3","","254.93","254.93","254.93","1 through 10","208.32","534.24","percent of total billed charges",""
"Colposcopy Entire Vagina","PX-76001360","CDM","57420","CPT","0761","RC","","","","outpatient","","","672.00","504.00","AETNA [1001]","HB AMC AETNA HMO","469.06","69.8","","441.40","441.40","441.40","1 through 10","273","1234.13","percent of total billed charges",""
"Colposcopy Entire Vagina","PX-76001360","CDM","57420","CPT","0761","RC","","","","outpatient","","","672.00","504.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","627.19","627.19","627.19","1 through 10","273","1234.13","other","ASC"
"Colposcopy Entire Vagina","PX-76001360","CDM","57420","CPT","0761","RC","","","","outpatient","","","672.00","504.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","723.66","723.66","723.66","1 through 10","273","1234.13","other","ASC "
"Colposcopy Entire Vagina","PX-76001360","CDM","57420","CPT","0761","RC","","","","outpatient","","","672.00","504.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","608.79","608.79","608.79","1 through 10","273","1234.13","other","Multiple Surgery"
"Colposcopy Entire Vagina","PX-76001360","CDM","57420","CPT","0761","RC","","","","outpatient","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","549.16","81.72","","521.21","286.68","521.21","1 through 10","273","1234.13","percent of total billed charges",""
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","both","","","571.00","428.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","246.04","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","246.73","245.83","246.73","1 through 10","177.01","453.95","other","OPPS APC"
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","both","","","571.00","428.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.08","107.00","235.08","1 through 10","177.01","453.95","other","OPPS APC"
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","both","","","571.00","428.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","453.95","79.5","","436.00","436.00","436.00","1 through 10","177.01","453.95","percent of total billed charges",""
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","both","","","571.00","428.25","MEDICARE [2001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","238.90","119.45","238.90","27","177.01","453.95","other","OPPS APC"
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","both","","","571.00","428.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","218.69","38.3","","216.61","182.82","216.61","1 through 10","177.01","453.95","percent of total billed charges",""
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","both","","","571.00","428.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","234.12","234.12","234.12","1 through 10","177.01","453.95","other","OPPS APC"
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","both","","","571.00","428.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","117.54","117.06","235.08","1 through 10","177.01","453.95","other","OPPS APC"
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","both","","","571.00","428.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.96","42.9","","442.87","442.87","442.87","1 through 10","177.01","453.95","percent of total billed charges",""
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","both","","","571.00","428.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","238.90","106.57","671.06","1 through 10","177.01","453.95","other","OPPS APC"
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","outpatient","","","571.00","428.25","AETNA [1001]","HB AMC AETNA HMO","398.56","69.8","","375.06","264.81","375.06","1 through 10","165.93","700.33","percent of total billed charges",""
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","outpatient","","","571.00","428.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","388.23","194.12","388.23","1 through 10","165.93","700.33","other","ASC"
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","outpatient","","","571.00","428.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","439.84","222.10","444.20","12","165.93","700.33","other","ASC "
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","outpatient","","","571.00","428.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","555.03","370.02","555.03","1 through 10","165.93","700.33","other","Multiple Surgery"
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","outpatient","","","571.00","428.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","404.87","404.87","1 through 10","165.93","700.33","other","Multiple Surgery"
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","outpatient","","","571.00","428.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","424.78","424.78","424.78","1 through 10","165.93","700.33","other","Multiple Surgery"
"Colposcopy Vulva","PX-76001339","CDM","56820","CPT","0761","RC","","","","outpatient","","","571.00","428.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","466.62","81.72","","442.87","442.87","442.87","1 through 10","165.93","700.33","percent of total billed charges",""
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","both","","","1312.00","984.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","372.04","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","371.71","371.71","371.71","1 through 10","343.18","1043.04","other","OPPS APC"
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","both","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","355.46","103.16","355.46","1 through 10","343.18","1043.04","other","OPPS APC"
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","both","","","1312.00","984.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.04","79.5","","1001.06","671.62","1001.06","1 through 10","343.18","1043.04","percent of total billed charges",""
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","both","","","1312.00","984.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","699.30","53.3","","1001.06","1001.06","1001.06","1 through 10","343.18","1043.04","percent of total billed charges",""
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","both","","","1312.00","984.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","355.46","355.46","355.46","1 through 10","343.18","1043.04","other","OPPS APC"
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","both","","","1312.00","984.00","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","350.13","361.24","22","343.18","1043.04","other","OPPS APC"
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","both","","","1312.00","984.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.50","38.3","","497.35","483.36","497.35","1 through 10","343.18","1043.04","percent of total billed charges",""
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","both","","","1312.00","984.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","354.02","354.02","354.02","1 through 10","343.18","1043.04","other","OPPS APC"
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","both","","","1312.00","984.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","355.46","355.46","355.46","1 through 10","343.18","1043.04","other","OPPS APC"
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","both","","","1312.00","984.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","361.24","343.13","361.24","1 through 10","343.18","1043.04","other","OPPS APC"
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","AETNA [1001]","HB AMC AETNA HMO","915.78","69.8","","861.14","861.14","6847.52","1 through 10","273","1234.13","percent of total billed charges",""
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","AETNA [1001]","HB AMC AETNA PPO","1054.85","80.4","","992.16","992.16","992.16","1 through 10","273","1234.13","percent of total billed charges",""
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","638.74","319.37","638.74","1 through 10","273","1234.13","other","ASC"
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","685.65","52.26","","787.12","787.12","787.12","1 through 10","273","1234.13","percent of total billed charges",""
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","730.84","723.66","730.84","26","273","1234.13","other","ASC "
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","633.36","633.36","1900.08","17","273","1234.13","other","Multiple Surgery"
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1924.65","641.55","1924.65","1 through 10","273","1234.13","other","Multiple Surgery"
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","698.88","671.58","698.88","1 through 10","273","1234.13","other","Multiple Surgery"
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1072.17","81.72","","1016.84","1016.84","1016.84","1 through 10","273","1234.13","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","949.00","711.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","372.04","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","371.71","371.71","371.71","1 through 10","294.19","754.46","other","OPPS APC"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","949.00","711.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","664.30","70","","395.60","395.60","395.60","1 through 10","294.19","754.46","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","949.00","711.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","754.46","79.5","","724.04","485.76","3484.04","17","294.19","754.46","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","949.00","711.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","505.82","53.3","","724.04","485.76","2172.12","12","294.19","754.46","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","949.00","711.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","355.46","355.46","355.46","1 through 10","294.19","754.46","other","OPPS APC"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","949.00","711.75","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","350.13","361.24","19","294.19","754.46","other","OPPS APC"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","949.00","711.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","294.19","31","","852.84","568.56","852.84","1 through 10","294.19","754.46","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","949.00","711.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","346.39","36.5","","343.16","232.75","343.16","11","294.19","754.46","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","949.00","711.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","363.47","38.3","","359.72","349.60","1079.16","48","294.19","754.46","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","949.00","711.75","TRICARE [160005]","HB BWH TRICARE","343.18","","APC Price ($361.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","343.18","343.18","343.18","1 through 10","294.19","754.46","other","Tricare OPPS"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","949.00","711.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","354.02","354.02","354.02","1 through 10","294.19","754.46","other","OPPS APC"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","949.00","711.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","355.46","137.35","361.24","1 through 10","294.19","754.46","other","OPPS APC"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","949.00","711.75","WELLPOINT [1015]","HB AMC WELLPOINT","700.17","73.78","","1604.94","684.94","1604.94","11","294.19","754.46","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","949.00","711.75","AETNA [1001]","HB AMC AETNA HMO","662.40","69.8","","1045.29","439.76","1245.68","19","273","1234.13","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","949.00","711.75","AETNA [1001]","HB AMC AETNA PPO","763.00","80.4","","964.16","717.60","964.16","1 through 10","273","1234.13","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","949.00","711.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","627.19","627.19","638.74","39","273","1234.13","other","ASC"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","949.00","711.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","723.66","723.66","730.84","92","273","1234.13","other","ASC "
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","949.00","711.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","622.44","622.44","622.44","1 through 10","273","1234.13","other","Multiple Surgery"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","949.00","711.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1217.58","633.36","1900.08","44","273","1234.13","other","Multiple Surgery"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","949.00","711.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","666.12","666.12","1998.36","14","273","1234.13","other","Multiple Surgery"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","949.00","711.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1045.59","1045.59","1045.59","1 through 10","273","1234.13","other","Multiple Surgery"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","949.00","711.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","698.88","671.58","698.88","1 through 10","273","1234.13","other","Multiple Surgery"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","949.00","711.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","763.00","80.4","","460.00","460.00","460.00","1 through 10","273","1234.13","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","949.00","711.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","775.52","81.72","","1028.52","1028.52","1028.52","1 through 10","273","1234.13","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","949.00","711.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","775.52","81.72","","735.45","404.52","6667.00","1 through 10","273","1234.13","percent of total billed charges",""
"Colposcopy W/Bx Elect Loop Cervix","PX-76001366","CDM","57460","CPT","0761","RC","","","","both","","","4886.00","3664.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1871.34","38.3","","1800.44","1800.44","1800.44","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Colposcopy W/Bx Elect Loop Cervix","PX-76001366","CDM","57460","CPT","0761","RC","","","","both","","","4886.00","3664.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3707.87","3707.87","3707.87","1 through 10","1514.66","4719.38","other","OPPS APC"
"Colposcopy W/Bx Elect Loop Cervix","PX-76001366","CDM","57460","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","AETNA [1001]","HB AMC AETNA HMO","3410.43","69.8","","11012.08","11012.08","11012.08","1 through 10","2125.14","3992.84","percent of total billed charges",""
"Colposcopy W/Bx Elect Loop Cervix","PX-76001366","CDM","57460","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6321.29","6321.29","6321.29","1 through 10","2125.14","3992.84","other","ASC "
"Colposcopy W/Bx Elect Loop Cervix","PX-76001366","CDM","57460","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5185.34","5185.34","5185.34","1 through 10","2125.14","3992.84","other","Multiple Surgery"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1017.52","1017.52","1017.52","1 through 10","406.72","1292.44","other","OPPS APC"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1312.00","984.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.04","79.5","","1001.06","1001.06","1001.06","1 through 10","406.72","1292.44","percent of total billed charges",""
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1312.00","984.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","699.30","53.3","","3385.66","3385.66","3385.66","1 through 10","406.72","1292.44","percent of total billed charges",""
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1312.00","984.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","753.70","753.70","753.70","1 through 10","406.72","1292.44","other","OPPS APC"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1312.00","984.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1010.24","77","","2938.32","2938.32","2938.32","1 through 10","406.72","1292.44","percent of total billed charges",""
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1312.00","984.00","MEDICARE [2001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1034.06","877.41","1034.06","26","406.72","1292.44","other","OPPS APC"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1312.00","984.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","478.88","36.5","","11776.58","11776.58","11776.58","1 through 10","406.72","1292.44","percent of total billed charges",""
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1312.00","984.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.50","38.3","","497.35","483.36","497.35","1 through 10","406.72","1292.44","percent of total billed charges",""
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1312.00","984.00","TRICARE [160005]","HB BWH TRICARE","982.35","","APC Price ($1,034.06). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1034.06","1034.06","1034.06","1 through 10","406.72","1292.44","other","Tricare OPPS"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1312.00","984.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1013.38","1013.38","1013.38","1 through 10","406.72","1292.44","other","OPPS APC"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1312.00","984.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","865.47","859.86","2285.38","1 through 10","406.72","1292.44","other","OPPS APC"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1312.00","984.00","WELLPOINT [1015]","HB AMC WELLPOINT","967.99","73.78","","2219.00","2219.00","2219.00","1 through 10","406.72","1292.44","percent of total billed charges",""
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","AETNA [1001]","HB AMC AETNA HMO","915.78","69.8","","861.14","608.02","861.14","1 through 10","558.04","1234.13","percent of total billed charges",""
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1305.65","1282.04","1305.65","1 through 10","558.04","1234.13","other","ASC"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1479.23","1479.23","1493.91","1 through 10","558.04","1234.13","other","ASC "
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3733.29","1294.65","3883.95","1 through 10","558.04","1234.13","other","Multiple Surgery"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1361.62","1244.43","1361.62","1 through 10","558.04","1234.13","other","Multiple Surgery"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1054.85","80.4","","864.50","864.50","864.50","1 through 10","558.04","1234.13","percent of total billed charges",""
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1072.17","81.72","","1016.83","559.30","1016.83","1 through 10","558.04","1234.13","percent of total billed charges",""
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","both","","","784.00","588.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","355.46","355.46","355.46","1 through 10","243.04","623.28","other","OPPS APC"
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","both","","","784.00","588.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","417.87","53.3","","2176.84","2176.84","2176.84","1 through 10","243.04","623.28","percent of total billed charges",""
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","both","","","784.00","588.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","355.46","355.46","355.46","1 through 10","243.04","623.28","other","OPPS APC"
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","both","","","784.00","588.00","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","180.62","361.24","19","243.04","623.28","other","OPPS APC"
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","both","","","784.00","588.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","286.16","36.5","","283.48","283.48","283.48","1 through 10","243.04","623.28","percent of total billed charges",""
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","both","","","784.00","588.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","300.27","38.3","","16512.90","297.16","16512.90","1 through 10","243.04","623.28","percent of total billed charges",""
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","both","","","784.00","588.00","TRICARE [160005]","HB BWH TRICARE","343.18","","APC Price ($361.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","180.62","180.62","180.62","1 through 10","243.04","623.28","other","Tricare OPPS"
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","both","","","784.00","588.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","354.02","354.02","354.02","1 through 10","243.04","623.28","other","OPPS APC"
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","both","","","784.00","588.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.13","177.73","350.13","1 through 10","243.04","623.28","other","OPPS APC"
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","both","","","784.00","588.00","WELLPOINT [1015]","HB AMC WELLPOINT","578.44","73.78","","2085.82","2085.82","2085.82","1 through 10","243.04","623.28","percent of total billed charges",""
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","outpatient","","","784.00","588.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","638.74","627.19","638.74","1 through 10","273","700.33","other","ASC"
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","outpatient","","","784.00","588.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","730.84","361.83","730.84","14","273","700.33","other","ASC "
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","outpatient","","","784.00","588.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1900.08","633.36","1900.08","1 through 10","273","700.33","other","Multiple Surgery"
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","outpatient","","","784.00","588.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1998.36","666.12","1998.36","1 through 10","273","700.33","other","Multiple Surgery"
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","outpatient","","","784.00","588.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","640.68","81.72","","607.54","607.54","607.54","1 through 10","273","700.33","percent of total billed charges",""
"Colposcopy W/Bx Vulva","PX-76001340","CDM","56821","CPT","0761","RC","","","","outpatient","","","784.00","588.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","640.68","81.72","","607.54","334.17","607.54","1 through 10","273","700.33","percent of total billed charges",""
"Colposcopy W/Conization Cervix","PX-76001367","CDM","57461","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","AETNA [1001]","HB AMC AETNA HMO","3410.43","69.8","","3207.63","3207.63","3207.63","1 through 10","2125.14","8899.59","percent of total billed charges",""
"Colposcopy W/Conization Cervix","PX-76001367","CDM","57461","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6321.29","6321.29","6321.29","1 through 10","2125.14","8899.59","other","ASC "
"Colposcopy W/Conization Cervix","PX-76001367","CDM","57461","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4930.32","4930.32","4930.32","1 through 10","2125.14","8899.59","other","Multiple Surgery"
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","both","","","712.00","534.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","566.04","79.5","","1629.09","543.03","1629.09","1 through 10","220.72","566.04","percent of total billed charges",""
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","both","","","712.00","534.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","379.50","53.3","","543.03","543.03","543.03","1 through 10","220.72","566.04","percent of total billed charges",""
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","both","","","712.00","534.00","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","350.13","361.24","1 through 10","220.72","566.04","other","OPPS APC"
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","both","","","712.00","534.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","259.88","36.5","","218.73","149.31","257.37","1 through 10","220.72","566.04","percent of total billed charges",""
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","both","","","712.00","534.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","272.70","38.3","","269.79","269.79","269.79","1 through 10","220.72","566.04","percent of total billed charges",""
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","both","","","712.00","534.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","354.02","344.53","693.26","1 through 10","220.72","566.04","other","OPPS APC"
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","both","","","712.00","534.00","WELLPOINT [1015]","HB AMC WELLPOINT","525.31","73.78","","1203.71","513.71","1203.71","1 through 10","220.72","566.04","percent of total billed charges",""
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","outpatient","","","712.00","534.00","AETNA [1001]","HB AMC AETNA HMO","496.98","69.8","","467.13","467.13","565.80","1 through 10","273","1234.13","percent of total billed charges",""
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","outpatient","","","712.00","534.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","627.19","627.19","925.69","12","273","1234.13","other","ASC"
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","outpatient","","","712.00","534.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","723.66","723.66","1016.72","18","273","1234.13","other","ASC "
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","outpatient","","","712.00","534.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","633.36","316.68","1266.72","1 through 10","273","1234.13","other","Multiple Surgery"
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","outpatient","","","712.00","534.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","666.12","666.12","666.12","1 through 10","273","1234.13","other","Multiple Surgery"
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","outpatient","","","712.00","534.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 383%, 191.5 procedures at 0%.","1045.59","1045.59","1045.59","1 through 10","273","1234.13","other","Multiple Surgery"
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","outpatient","","","712.00","534.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","698.88","698.88","698.88","1 through 10","273","1234.13","other","Multiple Surgery"
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","outpatient","","","712.00","534.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","572.45","80.4","","538.20","538.20","538.20","1 through 10","273","1234.13","percent of total billed charges",""
"Colposcopy W/Endocervical Curettage","PX-76001365","CDM","57456","CPT","0761","RC","","","","outpatient","","","712.00","534.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","581.85","81.72","","551.59","303.39","928.11","1 through 10","273","1234.13","percent of total billed charges",""
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","both","","","2705.00","2028.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1441.77","53.3","","1384.94","1384.94","1384.94","1 through 10","838.55","2150.48","percent of total billed charges",""
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","both","","","2705.00","2028.75","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","838.55","2150.48","other","OPPS APC"
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","both","","","2705.00","2028.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","1372.23","1372.23","1 through 10","838.55","2150.48","other","OPPS APC"
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","outpatient","","","2705.00","2028.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2597.20","2597.20","2597.20","1 through 10","979.79","2453.74","other","ASC "
"Colsc Flexible W/Transendoscopic Balloon Dilat","PX-75000419","CDM","45386","CPT","0750","RC","","","","both","","","2631.00","1973.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1377.83","1377.83","1377.83","1 through 10","815.61","2091.65","other","OPPS APC"
"Colsc Flexible W/Transendoscopic Balloon Dilat","PX-75000419","CDM","45386","CPT","0750","RC","","","","both","","","2631.00","1973.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","815.61","31","","788.26","788.26","788.26","1 through 10","815.61","2091.65","percent of total billed charges",""
"Colsc Flexible W/Transendoscopic Balloon Dilat","PX-75000419","CDM","45386","CPT","0750","RC","","","","both","","","2631.00","1973.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","960.32","36.5","","951.52","951.52","951.52","1 through 10","815.61","2091.65","percent of total billed charges",""
"Colsc Flexible W/Transendoscopic Balloon Dilat","PX-75000419","CDM","45386","CPT","0750","RC","","","","both","","","2631.00","1973.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1007.67","38.3","","997.44","951.52","997.44","1 through 10","815.61","2091.65","percent of total billed charges",""
"Colsc Flexible W/Transendoscopic Balloon Dilat","PX-75000419","CDM","45386","CPT","0750","RC","","","","both","","","2631.00","1973.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1378.23","1268.19","1378.23","1 through 10","815.61","2091.65","other","OPPS APC"
"Colsc Flexible W/Transendoscopic Balloon Dilat","PX-75000419","CDM","45386","CPT","0750","RC","","","","outpatient","","","2631.00","1973.25","AETNA [1001]","HB AMC AETNA HMO","1836.44","69.8","","1219.38","1219.38","1219.38","1 through 10","979.79","2453.74","percent of total billed charges",""
"Colsc Flexible W/Transendoscopic Balloon Dilat","PX-75000419","CDM","45386","CPT","0750","RC","","","","outpatient","","","2631.00","1973.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2292.44","2250.98","2292.44","1 through 10","979.79","2453.74","other","ASC"
"Colsc Flexible W/Transendoscopic Balloon Dilat","PX-75000419","CDM","45386","CPT","0750","RC","","","","outpatient","","","2631.00","1973.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2597.20","2597.20","2622.97","1 through 10","979.79","2453.74","other","ASC "
"Colsc Flexible W/Transendoscopic Balloon Dilat","PX-75000419","CDM","45386","CPT","0750","RC","","","","outpatient","","","2631.00","1973.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4369.86","1136.56","4369.86","1 through 10","979.79","2453.74","other","Multiple Surgery"
"Colsc Flexible W/Transendoscopic Balloon Dilat","PX-75000419","CDM","45386","CPT","0750","RC","","","","outpatient","","","2631.00","1973.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2390.69","2390.69","2390.69","1 through 10","979.79","2453.74","other","Multiple Surgery"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1442.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","720.42","662.66","1440.84","1 through 10","811.58","2081.31","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","688.91","688.91","1377.83","1 through 10","811.58","2081.31","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2081.31","79.5","","1998.19","1340.59","4378.86","29","811.58","2081.31","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1395.39","53.3","","1340.59","1282.20","1998.19","1 through 10","811.58","2081.31","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1372.23","686.12","1372.23","1 through 10","811.58","2081.31","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","HUMANA [1012]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1380.63","1380.63","1380.63","1 through 10","811.58","2081.31","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","700.11","700.11","1400.23","121","811.58","2081.31","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","811.58","31","","784.55","784.55","784.55","1 through 10","811.58","2081.31","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","955.57","36.5","","947.05","804.86","947.05","1 through 10","811.58","2081.31","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1002.69","38.3","","992.75","992.75","992.75","20","811.58","2081.31","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1372.23","631.10","2556.14","12","811.58","2081.31","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","TRICARE [160005]","HB BWH TRICARE","1330.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1400.23","1400.23","1400.23","1 through 10","811.58","2081.31","other","Tricare OPPS"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1262.19","686.12","4133.49","1 through 10","811.58","2081.31","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1262.20","686.12","1372.23","103","811.58","2081.31","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2618.00","1963.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1123.12","42.9","","1116.40","1116.40","1116.40","1 through 10","811.58","2081.31","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","AETNA [1001]","HB AMC AETNA HMO","1827.36","69.8","","1718.90","1213.64","1718.90","28","979.79","2453.74","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2250.98","1146.22","2292.44","39","979.79","2453.74","other","ASC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2597.20","2597.20","2622.97","127","979.79","2453.74","other","ASC "
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2841.39","1420.70","2841.39","1 through 10","979.79","2453.74","other","Multiple Surgery"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2273.11","2184.93","2273.11","32","979.79","2453.74","other","Multiple Surgery"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2390.69","1994.11","7172.07","35","979.79","2453.74","other","Multiple Surgery"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","2841.39","1420.70","2841.39","1 through 10","979.79","2453.74","other","Multiple Surgery"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2508.26","1254.13","2508.26","28","979.79","2453.74","other","Multiple Surgery"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2139.43","81.72","","2029.68","1116.40","2029.68","18","979.79","2453.74","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","both","","","10032.00","7524.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7975.44","79.5","","800.18","480.96","1887.97","195","3109.92","7975.44","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","both","","","10032.00","7524.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5347.06","53.3","","813.12","216.42","1444.50","81","3109.92","7975.44","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","both","","","10032.00","7524.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3109.92","31","","432.60","432.60","432.60","1 through 10","3109.92","7975.44","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","both","","","10032.00","7524.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3661.68","36.5","","148.37","54.89","631.39","94","3109.92","7975.44","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","both","","","10032.00","7524.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3842.26","38.3","","279.30","91.72","1116.77","266","3109.92","7975.44","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","both","","","10032.00","7524.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4303.73","42.9","","731.00","63.70","731.00","1 through 10","3109.92","7975.44","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","both","","","10032.00","7524.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4303.73","42.9","","384.74","384.74","384.74","1 through 10","3109.92","7975.44","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","both","","","10032.00","7524.00","WELLPOINT [1015]","HB AMC WELLPOINT","7401.61","73.78","","286.63","119.22","1107.45","105","3109.92","7975.44","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10032.00","7524.00","AETNA [1001]","HB AMC AETNA HMO","7002.34","69.8","","675.31","184.75","1721.50","286","5242.72","8198.15","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10032.00","7524.00","AETNA [1001]","HB AMC AETNA PPO","8065.73","80.4","","1261.44","103.12","1514.10","21","5242.72","8198.15","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10032.00","7524.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8065.73","80.4","","1365.00","1365.00","1365.00","1 through 10","5242.72","8198.15","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10032.00","7524.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8198.15","81.72","","5157.68","5157.68","5157.68","1 through 10","5242.72","8198.15","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10032.00","7524.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8198.15","81.72","","431.26","71.26","1459.57","88","5242.72","8198.15","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","both","","","6153.63","4615.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4892.14","79.5","","800.18","480.96","1887.97","195","1907.63","4892.14","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","both","","","6153.63","4615.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3279.88","53.3","","813.12","216.42","1444.50","81","1907.63","4892.14","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","both","","","6153.63","4615.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1907.63","31","","432.60","432.60","432.60","1 through 10","1907.63","4892.14","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","both","","","6153.63","4615.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2246.07","36.5","","148.37","54.89","631.39","94","1907.63","4892.14","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","both","","","6153.63","4615.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2356.84","38.3","","279.30","91.72","1116.77","266","1907.63","4892.14","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","both","","","6153.63","4615.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2639.91","42.9","","731.00","63.70","731.00","1 through 10","1907.63","4892.14","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","both","","","6153.63","4615.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2639.91","42.9","","384.74","384.74","384.74","1 through 10","1907.63","4892.14","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","both","","","6153.63","4615.22","WELLPOINT [1015]","HB AMC WELLPOINT","4540.15","73.78","","286.63","119.22","1107.45","105","1907.63","4892.14","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6153.63","4615.22","AETNA [1001]","HB AMC AETNA HMO","4295.23","69.8","","675.31","184.75","1721.50","286","3215.89","5028.75","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6153.63","4615.22","AETNA [1001]","HB AMC AETNA PPO","4947.52","80.4","","1261.44","103.12","1514.10","21","3215.89","5028.75","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6153.63","4615.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4947.52","80.4","","1365.00","1365.00","1365.00","1 through 10","3215.89","5028.75","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6153.63","4615.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5028.75","81.72","","5157.68","5157.68","5157.68","1 through 10","3215.89","5028.75","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6153.63","4615.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5028.75","81.72","","431.26","71.26","1459.57","88","3215.89","5028.75","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","both","","","13649.13","10236.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10851.06","79.5","","800.18","480.96","1887.97","195","4231.23","10851.06","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","both","","","13649.13","10236.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7274.99","53.3","","813.12","216.42","1444.50","81","4231.23","10851.06","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","both","","","13649.13","10236.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4231.23","31","","432.60","432.60","432.60","1 through 10","4231.23","10851.06","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","both","","","13649.13","10236.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4981.93","36.5","","148.37","54.89","631.39","94","4231.23","10851.06","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","both","","","13649.13","10236.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5227.62","38.3","","279.30","91.72","1116.77","266","4231.23","10851.06","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","both","","","13649.13","10236.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5855.48","42.9","","731.00","63.70","731.00","1 through 10","4231.23","10851.06","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","both","","","13649.13","10236.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5855.48","42.9","","384.74","384.74","384.74","1 through 10","4231.23","10851.06","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","both","","","13649.13","10236.85","WELLPOINT [1015]","HB AMC WELLPOINT","10070.33","73.78","","286.63","119.22","1107.45","105","4231.23","10851.06","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13649.13","10236.85","AETNA [1001]","HB AMC AETNA HMO","9527.09","69.8","","675.31","184.75","1721.50","286","7133.04","11154.07","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13649.13","10236.85","AETNA [1001]","HB AMC AETNA PPO","10973.90","80.4","","1261.44","103.12","1514.10","21","7133.04","11154.07","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13649.13","10236.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10973.90","80.4","","1365.00","1365.00","1365.00","1 through 10","7133.04","11154.07","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13649.13","10236.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","11154.07","81.72","","5157.68","5157.68","5157.68","1 through 10","7133.04","11154.07","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13649.13","10236.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11154.07","81.72","","431.26","71.26","1459.57","88","7133.04","11154.07","percent of total billed charges",""
"Combined Anterior And Posterior Cervical Spinal Fusion With McC","429","MS-DRG","","","","","","","","inpatient","","","378489.65","283867.24","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","107043.83","","Case rate ($107,043.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $99,316.21, add-ons for qualifying new technology services are included. If operating cost exceeds $144,960.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $9,689.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $99,414.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $98,936.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $7,249.65. The transfer capital threshold is the transfer adjustment factor * $7,249.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","75167.01","75167.01","75167.01","1 through 10","80915.04","125867.9946","other","Inpatient DRG"
"Combined Anterior And Posterior Cervical Spinal Fusion With McC","429","MS-DRG","","","","","","","","inpatient","","","378489.65","283867.24","MEDICARE [2001]","HB BWH MEDICARE","107043.83","","Case rate ($107,043.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $99,316.21, add-ons for qualifying new technology services are included. If operating cost exceeds $144,960.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $9,689.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $99,414.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $98,936.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $7,249.65. The transfer capital threshold is the transfer adjustment factor * $7,249.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","80915.04","125867.9946","other","Inpatient DRG"
"Combined Anterior And Posterior Cervical Spinal Fusion Without McC","430","MS-DRG","","","","","","","","inpatient","","","181511.98","136133.98","MEDICARE [2001]","HB BWH MEDICARE","52987.94","","Case rate ($52,987.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $63,709.61, add-ons for qualifying new technology services are included. If operating cost exceeds $109,354.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,080.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $47,967.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $63,329.77 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,640.55. The transfer capital threshold is the transfer adjustment factor * $4,640.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","51928.18","82555.3155","other","Inpatient Replacement Plans DRG"
"Combined Anterior And Posterior Cervical Spinal Fusion Without McC","430","MS-DRG","","","","","","","","inpatient","","","181511.98","136133.98","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","51928.18","","Case rate ($52,987.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $63,709.61, add-ons for qualifying new technology services are included. If operating cost exceeds $109,354.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,080.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $47,967.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $63,329.77 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,640.55. The transfer capital threshold is the transfer adjustment factor * $4,640.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","49137.27","49137.27","49137.27","1 through 10","51928.18","82555.3155","other","Inpatient DRG"
"Combined Pituitary Hormone Deficiency-4 (Cphd-4) via the Lhx4 Gene","PX-31000802","CDM","81479","CPT","0310","RC","","","","both","","","1017.00","762.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","808.52","79.5","","0.65","0.65","0.65","1 through 10","315.27","966.15","percent of total billed charges",""
"Combined Pituitary Hormone Deficiency-4 (Cphd-4) via the Lhx4 Gene","PX-31000802","CDM","81479","CPT","0310","RC","","","","both","","","1017.00","762.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","542.06","53.3","","0.79","0.79","0.79","1 through 10","315.27","966.15","percent of total billed charges",""
"Combined Pituitary Hormone Deficiency-4 (Cphd-4) via the Lhx4 Gene","PX-31000802","CDM","81479","CPT","0310","RC","","","","outpatient","","","1017.00","762.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","508.50","50","","1.00","1.00","1.00","1 through 10","156.55","839.03","percent of total billed charges",""
"Combined Pituitary Hormone Deficiency-4 (Cphd-4) via the Lhx4 Gene","PX-31000802","CDM","81479","CPT","0310","RC","","","","outpatient","","","1017.00","762.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","533.93","52.5","","1.00","0.53","1.00","1 through 10","156.55","839.03","percent of total billed charges",""
"COMMANDER ULTRA 23MM S3","SUP-ITM-10268993","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","64593.75","79.5","","1309.77","674.56","6049.93","26","25187.5","64593.75","percent of total billed charges",""
"COMMANDER ULTRA 23MM S3","SUP-ITM-10268993","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","43306.25","53.3","","1901.83","1901.83","2962.25","1 through 10","25187.5","64593.75","percent of total billed charges",""
"COMMANDER ULTRA 23MM S3","SUP-ITM-10268993","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29656.25","36.5","","1620.31","1620.31","19908.88","1 through 10","25187.5","64593.75","percent of total billed charges",""
"COMMANDER ULTRA 23MM S3","SUP-ITM-10268993","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31118.75","38.3","","352.91","352.91","2046.30","1 through 10","25187.5","64593.75","percent of total billed charges",""
"COMMANDER ULTRA 23MM S3","SUP-ITM-10268993","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34856.25","42.9","","9668.75","9668.75","9668.75","1 through 10","25187.5","64593.75","percent of total billed charges",""
"COMMANDER ULTRA 23MM S3","SUP-ITM-10268993","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","WELLPOINT [1015]","HB AMC WELLPOINT","59946.25","73.78","","699.88","384.10","3443.31","33","25187.5","64593.75","percent of total billed charges",""
"COMMANDER ULTRA 23MM S3","SUP-ITM-10268993","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","81250.00","60937.50","AETNA [1001]","HB AMC AETNA HMO","56712.50","69.8","","1421.24","264.50","4933.46","29","42461.25","66397.5","percent of total billed charges",""
"COMMANDER ULTRA 23MM S3","SUP-ITM-10268993","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","81250.00","60937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","65325.00","80.4","","1022.97","1022.97","3607.50","1 through 10","42461.25","66397.5","percent of total billed charges",""
"COMMANDER ULTRA 23MM S3","SUP-ITM-10268993","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","81250.00","60937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","66397.50","81.72","","3010.54","693.88","5019.88","35","42461.25","66397.5","percent of total billed charges",""
"Comparative Analysis Using Str Markers","PX-31001284","CDM","81265","CPT","0310","RC","","","","outpatient","","","1341.00","1005.75","AETNA [1001]","HB AMC AETNA HMO","936.02","69.8","","880.10","880.10","880.10","1 through 10","648.65","1464.7","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","214.00","160.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.71","34.71","34.71","1 through 10","66.34","254.35","other","OPPS APC"
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","214.00","160.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","153.65","71.8","","149.34","149.34","149.34","1 through 10","66.34","254.35","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","214.00","160.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","170.13","79.5","","163.70","154.57","163.70","15","66.34","254.35","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","214.00","160.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","114.06","53.3","","553.42","109.82","553.42","1 through 10","66.34","254.35","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","214.00","160.50","HUMANA [1012]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5116.42","5116.42","5116.42","1 through 10","66.34","254.35","other","OPPS APC"
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","214.00","160.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","139.10","65","","270.40","270.40","270.40","1 through 10","66.34","254.35","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","214.00","160.50","MEDICARE [2001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20.71","18.64","45.22","262","66.34","254.35","other","OPPS APC"
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","214.00","160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.11","36.5","","77.59","65.94","77.59","1 through 10","66.34","254.35","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","214.00","160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.96","38.3","","81.33","81.33","158.08","11","66.34","254.35","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","214.00","160.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","99.72","99.72","99.72","1 through 10","66.34","254.35","other","OPPS APC"
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","214.00","160.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.81","42.9","","166.28","166.28","166.28","1 through 10","66.34","254.35","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","214.00","160.50","WELLPOINT [1015]","HB AMC WELLPOINT","157.89","73.78","","154.86","154.86","154.86","1 through 10","66.34","254.35","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","outpatient","","","214.00","160.50","AETNA [1001]","HB AMC AETNA HMO","149.37","69.8","","134.28","97.17","140.82","31","111.84","887.19","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","outpatient","","","214.00","160.50","AETNA [1001]","HB AMC AETNA PPO","172.06","80.4","","162.24","162.24","162.24","1 through 10","111.84","887.19","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","outpatient","","","214.00","160.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","172.06","80.4","","162.24","162.24","162.24","1 through 10","111.84","887.19","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","outpatient","","","214.00","160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.88","81.72","","332.56","332.56","332.56","1 through 10","111.84","887.19","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","145.04","71.8","","140.73","140.73","140.73","1 through 10","11.76","191.9","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","CHAMPVA [160001]","HB BWH TRICARE","191.90","95","","14.46","14.46","14.46","1 through 10","11.76","191.9","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.59","79.5","","154.25","103.49","154.25","151","11.76","191.9","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","107.67","53.3","","103.49","103.49","462.75","93","11.76","191.9","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","155.54","77","","452.76","150.92","452.76","1 through 10","11.76","191.9","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.73","36.5","","73.11","62.13","73.11","188","11.76","191.9","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.37","38.3","","76.64","74.48","229.91","476","11.76","191.9","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","155.54","77","","611.52","611.52","611.52","1 through 10","11.76","191.9","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","TRICARE [160005]","HB BWH TRICARE","191.90","95","","13.74","13.74","196.00","14","11.76","191.9","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.66","42.9","","156.68","86.18","156.69","12","11.76","191.9","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA HMO","141.00","69.8","","132.69","93.69","152.88","229","12.38","165.07","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA PPO","162.41","80.4","","152.88","102.71","305.76","50","12.38","165.07","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","112.92","55.9","","102.71","102.71","102.71","1 through 10","12.38","165.07","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","162.41","80.4","","152.88","152.88","196.00","1 through 10","12.38","165.07","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","165.07","81.72","","156.68","86.18","156.68","11","12.38","165.07","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.07","81.72","","156.68","86.18","313.36","205","12.38","165.07","percent of total billed charges",""
"Complement Functional Activity","PX-30000799","CDM","86161","CPT","0302","RC","","","","both","","","202.00","151.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.59","79.5","","127.40","127.40","127.40","1 through 10","11.76","191.9","percent of total billed charges",""
"Complement Functional Activity","PX-30000799","CDM","86161","CPT","0302","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA PPO","162.41","80.4","","152.88","152.88","152.88","1 through 10","12.38","165.07","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","both","","","244.00","183.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","193.98","79.5","","186.52","125.14","186.52","15","19.91","231.8","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","both","","","244.00","183.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.05","53.3","","186.52","125.14","559.56","1 through 10","19.91","231.8","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","both","","","244.00","183.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","187.88","77","","547.47","182.49","547.47","1 through 10","19.91","231.8","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","both","","","244.00","183.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.06","36.5","","88.40","75.13","265.20","21","19.91","231.8","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","both","","","244.00","183.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.45","38.3","","92.67","92.67","278.01","41","19.91","231.8","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","both","","","244.00","183.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.68","42.9","","189.46","189.46","189.46","1 through 10","19.91","231.8","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","outpatient","","","244.00","183.00","AETNA [1001]","HB AMC AETNA HMO","170.31","69.8","","113.29","113.29","160.45","17","20.95","199.4","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","outpatient","","","244.00","183.00","AETNA [1001]","HB AMC AETNA PPO","196.18","80.4","","184.86","124.19","239.77","1 through 10","20.95","199.4","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","outpatient","","","244.00","183.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","136.40","55.9","","124.19","124.19","124.19","1 through 10","20.95","199.4","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","outpatient","","","244.00","183.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","196.18","80.4","","184.86","118.50","184.86","1 through 10","20.95","199.4","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","outpatient","","","244.00","183.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","199.40","81.72","","104.21","104.21","104.21","1 through 10","20.95","199.4","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","outpatient","","","244.00","183.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","199.40","81.72","","189.46","80.81","378.92","20","20.95","199.4","percent of total billed charges",""
"Complete Ataxix Evaluation","PX-31001307","CDM","81403","CPT","0310","RC","","","","outpatient","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","864.60","81.72","","820.18","820.18","820.18","1 through 10","512.07","1135.28","percent of total billed charges",""
"Complete Ataxix Evaluation","PX-31001330","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Complete Ataxix Evaluation","PX-31001352","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Complete Ataxix Evaluation","PX-31001352","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Complete Ataxix Evaluation","PX-31001377","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","2981.00","2235.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.72","640.72","640.72","1 through 10","618.58","2369.9","other","OPPS APC"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","2981.00","2235.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2369.90","79.5","","1526.45","1526.45","6825.66","11","618.58","2369.9","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","2981.00","2235.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1588.87","53.3","","4579.35","1526.45","6825.66","1 through 10","618.58","2369.9","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","2981.00","2235.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.72","640.72","640.72","1 through 10","618.58","2369.9","other","OPPS APC"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","2981.00","2235.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","597.97","597.97","597.97","1 through 10","618.58","2369.9","other","OPPS APC"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","2981.00","2235.75","MEDICARE [2001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1953.42","651.14","1953.42","29","618.58","2369.9","other","OPPS APC"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","2981.00","2235.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1088.07","36.5","","3235.02","916.45","3235.02","1 through 10","618.58","2369.9","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","2981.00","2235.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1141.72","38.3","","3391.14","1130.38","3391.14","15","618.58","2369.9","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","2981.00","2235.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","638.12","638.12","638.12","1 through 10","618.58","2369.9","other","OPPS APC"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","2981.00","2235.75","TRICARE [160005]","HB BWH TRICARE","618.58","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","651.14","651.14","651.14","1 through 10","618.58","2369.9","other","Tricare OPPS"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","2981.00","2235.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","643.12","641.82","643.12","1 through 10","618.58","2369.9","other","OPPS APC"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","2981.00","2235.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1278.85","42.9","","1271.17","1271.17","1271.17","1 through 10","618.58","2369.9","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","outpatient","","","2981.00","2235.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2436.07","81.72","","1271.17","1271.17","1271.17","1 through 10","1142.94","4543.76","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","outpatient","","","2981.00","2235.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2436.07","81.72","","2311.07","1271.17","2331.09","1 through 10","1142.94","4543.76","percent of total billed charges",""
"Complex Cystometrogram W/Up","PX-76001266","CDM","51727","CPT","0761","RC","","","","both","","","2391.00","1793.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","872.72","36.5","","735.12","735.12","735.12","1 through 10","741.21","1900.85","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","both","","","70.00","52.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","50.26","71.8","","27.37","26.11","50.26","1 through 10","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","both","","","70.00","52.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","55.65","79.5","","35.49","35.49","70.00","1 through 10","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","21.70","31","","21.63","21.63","21.63","12","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25.55","36.5","","26.11","22.19","26.11","422","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26.81","38.3","","27.37","27.37","27.37","484","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","both","","","70.00","52.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","53.90","77","","514.42","514.42","514.42","1 through 10","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","both","","","70.00","52.50","TRICARE [160005]","HB BWH TRICARE","66.50","95","","15.90","15.90","15.90","1 through 10","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","both","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.03","42.9","","55.96","30.78","55.96","1 through 10","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","both","","","70.00","52.50","WELLPOINT [1015]","HB AMC WELLPOINT","51.65","73.78","","52.12","52.12","52.23","88","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA HMO","48.86","69.8","","47.39","33.46","54.60","77","35","57.75","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","outpatient","","","70.00","52.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","42.39","60.55","","70.00","70.00","70.00","1 through 10","35","57.75","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","outpatient","","","70.00","52.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","36.55","52.22","","70.00","70.00","70.00","1 through 10","35","57.75","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","outpatient","","","70.00","52.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","35.00","50","","70.00","27.49","70.00","1 through 10","35","57.75","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","outpatient","","","70.00","52.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","57.20","81.72","","55.96","55.96","55.96","1 through 10","35","57.75","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","57.20","81.72","","30.78","30.78","55.96","11","35","57.75","percent of total billed charges",""
"Complex E/M Visit Add On","PX-98302021","CDM","G2211","HCPCS","0983","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","57.20","81.72","","55.96","30.78","55.96","82","35","57.75","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","both","","","70.00","52.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","50.26","71.8","","27.37","26.11","50.26","1 through 10","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","both","","","70.00","52.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","55.65","79.5","","35.49","35.49","70.00","1 through 10","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","21.70","31","","21.63","21.63","21.63","12","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25.55","36.5","","26.11","22.19","26.11","422","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26.81","38.3","","27.37","27.37","27.37","484","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","both","","","70.00","52.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","53.90","77","","514.42","514.42","514.42","1 through 10","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","both","","","70.00","52.50","TRICARE [160005]","HB BWH TRICARE","66.50","95","","15.90","15.90","15.90","1 through 10","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","both","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.03","42.9","","55.96","30.78","55.96","1 through 10","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","both","","","70.00","52.50","WELLPOINT [1015]","HB AMC WELLPOINT","51.65","73.78","","52.12","52.12","52.23","88","16.4","66.5","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA HMO","48.86","69.8","","47.39","33.46","54.60","77","35","57.75","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","outpatient","","","70.00","52.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","42.39","60.55","","70.00","70.00","70.00","1 through 10","35","57.75","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","outpatient","","","70.00","52.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","36.55","52.22","","70.00","70.00","70.00","1 through 10","35","57.75","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","outpatient","","","70.00","52.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","35.00","50","","70.00","27.49","70.00","1 through 10","35","57.75","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","outpatient","","","70.00","52.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","57.20","81.72","","55.96","55.96","55.96","1 through 10","35","57.75","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","57.20","81.72","","30.78","30.78","55.96","11","35","57.75","percent of total billed charges",""
"Complex E/M Visit Add on Psych","PX-96000060","CDM","G2211","HCPCS","0961","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","57.20","81.72","","55.96","30.78","55.96","82","35","57.75","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","both","","","235.00","176.25","CHAMPVA [160001]","HB BWH TRICARE","223.25","95","","21.67","21.67","21.67","1 through 10","17.62","223.25","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","both","","","235.00","176.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.83","79.5","","179.44","120.38","538.32","47","17.62","223.25","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","both","","","235.00","176.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","125.26","53.3","","120.38","120.38","179.44","20","17.62","223.25","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","both","","","235.00","176.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.85","31","","82.54","82.54","82.54","1 through 10","17.62","223.25","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","both","","","235.00","176.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.78","36.5","","85.04","72.28","163.70","35","17.62","223.25","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","both","","","235.00","176.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","90.01","38.3","","89.15","86.64","89.15","115","17.62","223.25","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","both","","","235.00","176.25","TRICARE [160005]","HB BWH TRICARE","223.25","95","","20.59","20.59","21.67","1 through 10","17.62","223.25","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","both","","","235.00","176.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.82","42.9","","100.25","81.48","182.26","1 through 10","17.62","223.25","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","235.00","176.25","AETNA [1001]","HB AMC AETNA HMO","164.03","69.8","","154.36","108.98","177.84","55","18.54","192.04","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","235.00","176.25","AETNA [1001]","HB AMC AETNA PPO","188.94","80.4","","177.84","108.98","177.84","1 through 10","18.54","192.04","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","235.00","176.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","131.37","55.9","","119.47","119.47","119.47","1 through 10","18.54","192.04","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","235.00","176.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.81","52.26","","141.09","141.09","141.09","1 through 10","18.54","192.04","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","235.00","176.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","192.04","81.72","","100.25","100.25","182.26","1 through 10","18.54","192.04","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","235.00","176.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","192.04","81.72","","182.26","100.25","182.26","52","18.54","192.04","percent of total billed charges",""
"Complex Venous Malf Sclerotherapy","PX-76002096","CDM","37799","CPT","0761","RC","","","","outpatient","","","34447.00","25835.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","17988.22","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","28418.78","percent of total billed charges",""
"Complex Venous Malf Sclerotherapy","PX-76002096","CDM","37799","CPT","0761","RC","","","","outpatient","","","34447.00","25835.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","18084.68","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","28418.78","percent of total billed charges",""
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","","","","inpatient","","","42444.15","31833.11","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","10263.65","","Case rate ($10,263.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,277.99, add-ons for qualifying new technology services are included. If operating cost exceeds $57,922.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,312.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,011.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,898.15 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $871.85. The transfer capital threshold is the transfer adjustment factor * $871.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12941.50","12941.50","12941.50","1 through 10","10058.38","16435.6081","other","Inpatient Replacement Plans DRG"
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","","","","inpatient","","","42444.15","31833.11","MEDICARE [2001]","HB BWH MEDICARE","10263.65","","Case rate ($10,263.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,277.99, add-ons for qualifying new technology services are included. If operating cost exceeds $57,922.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,312.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,011.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,898.15 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $871.85. The transfer capital threshold is the transfer adjustment factor * $871.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1734.70","1197.47","13137.05","1 through 10","10058.38","16435.6081","other","Inpatient Replacement Plans DRG"
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","","","","inpatient","","","42444.15","31833.11","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","10058.38","","Case rate ($10,263.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,277.99, add-ons for qualifying new technology services are included. If operating cost exceeds $57,922.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,312.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,011.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,898.15 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $871.85. The transfer capital threshold is the transfer adjustment factor * $871.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10015.14","10015.14","10015.14","1 through 10","10058.38","16435.6081","other","Inpatient DRG"
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","","","","inpatient","","","42444.15","31833.11","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10058.38","","Case rate ($10,263.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,277.99, add-ons for qualifying new technology services are included. If operating cost exceeds $57,922.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,312.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,011.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,898.15 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $871.85. The transfer capital threshold is the transfer adjustment factor * $871.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10005.00","10005.00","10005.00","1 through 10","10058.38","16435.6081","other","Inpatient DRG"
"Complicated Peptic Ulcer With McC","380","MS-DRG","","","","","","","","inpatient","","","74967.75","56225.81","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","18827.63","","Case rate ($18,279.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,927.18, add-ons for qualifying new technology services are included. If operating cost exceeds $67,571.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,019.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $16,320.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,547.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.90. The transfer capital threshold is the transfer adjustment factor * $1,578.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","18331.40","18331.40","18331.40","1 through 10","17913.67","30735.9","other","Inpatient DRG"
"Complicated Peptic Ulcer With McC","380","MS-DRG","","","","","","","","inpatient","","","74967.75","56225.81","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","18279.25","","Case rate ($18,279.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,927.18, add-ons for qualifying new technology services are included. If operating cost exceeds $67,571.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,019.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $16,320.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,547.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.90. The transfer capital threshold is the transfer adjustment factor * $1,578.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17552.80","17552.80","17552.80","1 through 10","17913.67","30735.9","other","Inpatient Replacement Plans DRG"
"Complicated Peptic Ulcer With McC","380","MS-DRG","","","","","","","","inpatient","","","74967.75","56225.81","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","18279.25","","Case rate ($18,279.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,927.18, add-ons for qualifying new technology services are included. If operating cost exceeds $67,571.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,019.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $16,320.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,547.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.90. The transfer capital threshold is the transfer adjustment factor * $1,578.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17513.48","17513.48","17513.48","1 through 10","17913.67","30735.9","other","Inpatient DRG"
"Complicated Peptic Ulcer With McC","380","MS-DRG","","","","","","","","inpatient","","","74967.75","56225.81","MEDICARE [2001]","HB BWH MEDICARE","18279.25","","Case rate ($18,279.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,927.18, add-ons for qualifying new technology services are included. If operating cost exceeds $67,571.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,019.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $16,320.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,547.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.90. The transfer capital threshold is the transfer adjustment factor * $1,578.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22990.94","22964.17","22998.09","15","17913.67","30735.9","other","Inpatient Replacement Plans DRG"
"Complicated Peptic Ulcer With McC","380","MS-DRG","","","","","","","","inpatient","","","74967.75","56225.81","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","17913.67","","Case rate ($18,279.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,927.18, add-ons for qualifying new technology services are included. If operating cost exceeds $67,571.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,019.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $16,320.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,547.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.90. The transfer capital threshold is the transfer adjustment factor * $1,578.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17406.34","17406.34","17406.34","1 through 10","17913.67","30735.9","other","Inpatient DRG"
"Complicated Peptic Ulcer With McC","380","MS-DRG","","","","","","","","inpatient","","","74967.75","56225.81","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17913.67","","Case rate ($18,279.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,927.18, add-ons for qualifying new technology services are included. If operating cost exceeds $67,571.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,019.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $16,320.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,547.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,578.90. The transfer capital threshold is the transfer adjustment factor * $1,578.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17460.10","17460.10","17460.10","1 through 10","17913.67","30735.9","other","Inpatient DRG"
"Complicated Peptic Ulcer Without Cc/McC","382","MS-DRG","","","","","","","","inpatient","","","30229.07","22671.80","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7529.34","","Case rate ($7,683). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,171.41, add-ons for qualifying new technology services are included. If operating cost exceeds $54,815.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,084.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,658.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,791.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.21. The transfer capital threshold is the transfer adjustment factor * $644.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6994.44","6994.44","6994.44","1 through 10","7529.34","11307.6863","other","Inpatient DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","39821.95","29866.46","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","9808.63","","Case rate ($9,522.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,386.32, add-ons for qualifying new technology services are included. If operating cost exceeds $57,030.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,246.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,336.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,006.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $806.51. The transfer capital threshold is the transfer adjustment factor * $806.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9774.76","9774.76","9774.76","1 through 10","9332.48","15330.9469","other","Inpatient DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","39821.95","29866.46","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9522.94","","Case rate ($9,522.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,386.32, add-ons for qualifying new technology services are included. If operating cost exceeds $57,030.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,246.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,336.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,006.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $806.51. The transfer capital threshold is the transfer adjustment factor * $806.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9395.96","9395.96","9395.96","1 through 10","9332.48","15330.9469","other","Inpatient Replacement Plans DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","39821.95","29866.46","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9522.94","","Case rate ($9,522.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,386.32, add-ons for qualifying new technology services are included. If operating cost exceeds $57,030.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,246.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,336.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,006.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $806.51. The transfer capital threshold is the transfer adjustment factor * $806.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9321.82","9309.32","17266.18","1 through 10","9332.48","15330.9469","other","Inpatient DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","39821.95","29866.46","MEDICARE [2001]","HB BWH MEDICARE","9522.94","","Case rate ($9,522.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,386.32, add-ons for qualifying new technology services are included. If operating cost exceeds $57,030.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,246.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,336.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,006.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $806.51. The transfer capital threshold is the transfer adjustment factor * $806.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12254.88","0.03","12272.81","50","9332.48","15330.9469","other","Inpatient Replacement Plans DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","39821.95","29866.46","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9332.48","","Case rate ($9,522.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,386.32, add-ons for qualifying new technology services are included. If operating cost exceeds $57,030.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,246.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,336.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,006.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $806.51. The transfer capital threshold is the transfer adjustment factor * $806.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16830.61","16593.14","17265.56","1 through 10","9332.48","15330.9469","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","77523.34","58142.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","17593.02","","Case rate ($17,080.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,484.25, add-ons for qualifying new technology services are included. If operating cost exceeds $66,128.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $15,227.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,104.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.17. The transfer capital threshold is the transfer adjustment factor * $1,473.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17362.00","17362.00","17362.00","1 through 10","16738.99","28677.65","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","77523.34","58142.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","22054.55","","Case rate ($22,054.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,484.25, add-ons for qualifying new technology services are included. If operating cost exceeds $66,128.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $20,201.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,104.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.17. The transfer capital threshold is the transfer adjustment factor * $1,473.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16830.62","16659.54","46200.78","1 through 10","16738.99","28677.65","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","77523.34","58142.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","21350.75","","Case rate ($17,080.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,484.25, add-ons for qualifying new technology services are included. If operating cost exceeds $66,128.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $15,227.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,104.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.17. The transfer capital threshold is the transfer adjustment factor * $1,473.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","86867.61","86867.61","86867.61","1 through 10","16738.99","28677.65","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","77523.34","58142.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","17080.60","","Case rate ($17,080.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,484.25, add-ons for qualifying new technology services are included. If operating cost exceeds $66,128.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $15,227.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,104.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.17. The transfer capital threshold is the transfer adjustment factor * $1,473.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16622.89","16622.89","47904.85","1 through 10","16738.99","28677.65","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","77523.34","58142.50","ELDER SERVICES [1037]","HB BWH MEDICARE","22054.55","","Case rate ($22,054.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,484.25, add-ons for qualifying new technology services are included. If operating cost exceeds $66,128.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $20,201.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,104.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.17. The transfer capital threshold is the transfer adjustment factor * $1,473.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9809.60","9809.60","9809.60","1 through 10","16738.99","28677.65","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","77523.34","58142.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","22054.55","","Case rate ($22,054.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,484.25, add-ons for qualifying new technology services are included. If operating cost exceeds $66,128.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $20,201.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,104.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.17. The transfer capital threshold is the transfer adjustment factor * $1,473.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","435012.84","435012.84","435012.84","1 through 10","16738.99","28677.65","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","77523.34","58142.50","HUMANA [1012]","HB BWH MEDICARE","22054.55","","Case rate ($22,054.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,484.25, add-ons for qualifying new technology services are included. If operating cost exceeds $66,128.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $20,201.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,104.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.17. The transfer capital threshold is the transfer adjustment factor * $1,473.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38148.63","38148.63","38148.63","1 through 10","16738.99","28677.65","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","77523.34","58142.50","MEDICARE [2001]","HB BWH MEDICARE","22054.55","","Case rate ($22,054.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,484.25, add-ons for qualifying new technology services are included. If operating cost exceeds $66,128.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $20,201.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,104.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.17. The transfer capital threshold is the transfer adjustment factor * $1,473.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21776.99","0.03","26131.71","81","16738.99","28677.65","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","77523.34","58142.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16738.99","","Case rate ($17,080.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,484.25, add-ons for qualifying new technology services are included. If operating cost exceeds $66,128.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $15,227.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,104.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.17. The transfer capital threshold is the transfer adjustment factor * $1,473.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16640.09","16577.95","39440.77","1 through 10","16738.99","28677.65","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","77523.34","58142.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","16738.99","","Case rate ($17,080.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,484.25, add-ons for qualifying new technology services are included. If operating cost exceeds $66,128.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $15,227.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,104.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.17. The transfer capital threshold is the transfer adjustment factor * $1,473.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20880.45","20880.45","54072.17","1 through 10","16738.99","28677.65","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","77523.34","58142.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16738.99","","Case rate ($17,080.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,484.25, add-ons for qualifying new technology services are included. If operating cost exceeds $66,128.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $15,227.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,104.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.17. The transfer capital threshold is the transfer adjustment factor * $1,473.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16531.96","16493.91","21282.82","1 through 10","16738.99","28677.65","other","Inpatient DRG"
"Complications Of Treatment Without Cc/McC","921","MS-DRG","","","","","","","","inpatient","","","25984.05","19488.04","MEDICARE [2001]","HB BWH MEDICARE","6659.49","","Case rate ($6,659.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,939.31, add-ons for qualifying new technology services are included. If operating cost exceeds $53,583.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,994.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,725.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,559.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.93. The transfer capital threshold is the transfer adjustment factor * $553.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8385.68","8385.68","8397.81","1 through 10","6526.3","10378.0807","other","Inpatient Replacement Plans DRG"
"Complications Of Treatment Without Cc/McC","921","MS-DRG","","","","","","","","inpatient","","","25984.05","19488.04","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6526.30","","Case rate ($6,659.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,939.31, add-ons for qualifying new technology services are included. If operating cost exceeds $53,583.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,994.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,725.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,559.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $553.93. The transfer capital threshold is the transfer adjustment factor * $553.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9129.66","9129.66","9129.66","1 through 10","6526.3","10378.0807","other","Inpatient DRG"
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","both","","","1990.00","1492.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","816.36","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","816.54","816.54","816.54","1 through 10","616.9","1582.05","other","OPPS APC"
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","both","","","1990.00","1492.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","792.58","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","779.98","779.98","779.98","1 through 10","616.9","1582.05","other","OPPS APC"
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","both","","","1990.00","1492.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1582.05","79.5","","1518.91","1518.91","1518.91","1 through 10","616.9","1582.05","percent of total billed charges",""
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","both","","","1990.00","1492.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1060.67","53.3","","1518.91","1019.04","1518.91","1 through 10","616.9","1582.05","percent of total billed charges",""
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","both","","","1990.00","1492.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1293.50","65","","1254.50","1022.90","1254.50","1 through 10","616.9","1582.05","percent of total billed charges",""
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","both","","","1990.00","1492.50","MEDICARE [2001]","HB BWH MEDICARE","792.58","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","792.66","792.66","792.66","33","616.9","1582.05","other","OPPS APC"
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","both","","","1990.00","1492.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","726.35","36.5","","719.89","611.81","719.89","1 through 10","616.9","1582.05","percent of total billed charges",""
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","both","","","1990.00","1492.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","762.17","38.3","","754.63","754.63","2263.89","1 through 10","616.9","1582.05","percent of total billed charges",""
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","both","","","1990.00","1492.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","776.73","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","777.41","777.41","777.41","1 through 10","616.9","1582.05","other","OPPS APC"
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","both","","","1990.00","1492.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","776.73","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","776.81","730.65","784.51","13","616.9","1582.05","other","OPPS APC"
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","both","","","1990.00","1492.50","WELLPOINT [1015]","HB AMC WELLPOINT","1468.22","73.78","","1436.89","1436.89","1436.89","1 through 10","616.9","1582.05","percent of total billed charges",""
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","outpatient","","","1990.00","1492.50","AETNA [1001]","HB AMC AETNA HMO","1389.02","69.8","","1351.00","1351.00","1351.00","1 through 10","562.25","1701.73","percent of total billed charges",""
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","outpatient","","","1990.00","1492.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","642.96","","Case rate ($642.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1291.71","1291.71","1315.50","1 through 10","562.25","1701.73","other","ASC"
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","outpatient","","","1990.00","1492.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","642.96","","Case rate ($642.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1490.38","1490.38","1505.17","20","562.25","1701.73","other","ASC "
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","outpatient","","","1990.00","1492.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","562.25","","Case rate ($562.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1304.42","1304.42","2385.38","1 through 10","562.25","1701.73","other","Multiple Surgery"
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","outpatient","","","1990.00","1492.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","562.25","","Case rate ($562.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1371.89","1321.29","1371.89","1 through 10","562.25","1701.73","other","Multiple Surgery"
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","outpatient","","","1990.00","1492.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","562.25","","Case rate ($562.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1630.53","1630.53","1630.53","1 through 10","562.25","1701.73","other","Multiple Surgery"
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","outpatient","","","1990.00","1492.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","562.25","","Case rate ($562.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1439.36","1439.36","1439.36","1 through 10","562.25","1701.73","other","Multiple Surgery"
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","outpatient","","","1990.00","1492.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1599.96","80.4","","1505.40","965.00","1505.40","1 through 10","562.25","1701.73","percent of total billed charges",""
"Complx Cystometro W/Void Press&Uret","PX-76001268","CDM","51729","CPT","0761","RC","","","","outpatient","","","1990.00","1492.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1626.23","81.72","","2794.85","1542.84","3045.71","1 through 10","562.25","1701.73","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5448.24","52.26","","1113.10","1113.10","1113.10","1 through 10","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8288.07","79.5","","1293.60","1148.53","1603.80","1 through 10","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3805.22","36.5","","1023.42","771.29","2068.67","33","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3992.87","38.3","","850.52","759.78","1211.25","66","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4472.43","42.9","","2548.09","2548.09","2548.09","1 through 10","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4472.43","42.9","","956.46","956.46","956.46","1 through 10","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","WELLPOINT [1015]","HB AMC WELLPOINT","7691.75","73.78","","2344.73","1619.47","2530.35","16","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10425.25","7818.94","AETNA [1001]","HB AMC AETNA HMO","7276.82","69.8","","1523.63","988.41","4330.26","39","5448.24","8519.51","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10425.25","7818.94","AETNA [1001]","HB AMC AETNA PPO","8381.90","80.4","","1670.25","1670.25","1670.25","1 through 10","5448.24","8519.51","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10425.25","7818.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5448.24","52.26","","1113.10","1113.10","1113.10","1 through 10","5448.24","8519.51","percent of total billed charges",""
"COMPONENT BEARING SIZE 1-2 TRIATHLON HINGE TIBIAL","SUP-ITM-10322172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10425.25","7818.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8519.51","81.72","","1738.90","1484.65","2716.94","38","5448.24","8519.51","percent of total billed charges",""
"COMPONENT BEARING SIZE 3-4 TRIATHLON HINGE TIBIAL","SUP-ITM-10322171","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5448.24","52.26","","1113.10","1113.10","1113.10","1 through 10","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 3-4 TRIATHLON HINGE TIBIAL","SUP-ITM-10322171","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8288.07","79.5","","1293.60","1148.53","1603.80","1 through 10","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 3-4 TRIATHLON HINGE TIBIAL","SUP-ITM-10322171","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3805.22","36.5","","1023.42","771.29","2068.67","33","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 3-4 TRIATHLON HINGE TIBIAL","SUP-ITM-10322171","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3992.87","38.3","","850.52","759.78","1211.25","66","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 3-4 TRIATHLON HINGE TIBIAL","SUP-ITM-10322171","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4472.43","42.9","","2548.09","2548.09","2548.09","1 through 10","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 3-4 TRIATHLON HINGE TIBIAL","SUP-ITM-10322171","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4472.43","42.9","","956.46","956.46","956.46","1 through 10","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 3-4 TRIATHLON HINGE TIBIAL","SUP-ITM-10322171","CDM","C1776","HCPCS","0278","RC","","","","both","","","10425.25","7818.94","WELLPOINT [1015]","HB AMC WELLPOINT","7691.75","73.78","","2344.73","1619.47","2530.35","16","3231.83","8288.07","percent of total billed charges",""
"COMPONENT BEARING SIZE 3-4 TRIATHLON HINGE TIBIAL","SUP-ITM-10322171","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10425.25","7818.94","AETNA [1001]","HB AMC AETNA HMO","7276.82","69.8","","1523.63","988.41","4330.26","39","5448.24","8519.51","percent of total billed charges",""
"COMPONENT BEARING SIZE 3-4 TRIATHLON HINGE TIBIAL","SUP-ITM-10322171","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10425.25","7818.94","AETNA [1001]","HB AMC AETNA PPO","8381.90","80.4","","1670.25","1670.25","1670.25","1 through 10","5448.24","8519.51","percent of total billed charges",""
"COMPONENT BEARING SIZE 3-4 TRIATHLON HINGE TIBIAL","SUP-ITM-10322171","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10425.25","7818.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5448.24","52.26","","1113.10","1113.10","1113.10","1 through 10","5448.24","8519.51","percent of total billed charges",""
"COMPONENT BEARING SIZE 3-4 TRIATHLON HINGE TIBIAL","SUP-ITM-10322171","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10425.25","7818.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8519.51","81.72","","1738.90","1484.65","2716.94","38","5448.24","8519.51","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 3 RIGHT TRIATHLON HINGE","SUP-ITM-10322110","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9136.68","52.26","","1113.10","1113.10","1113.10","1 through 10","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 3 RIGHT TRIATHLON HINGE","SUP-ITM-10322110","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13899.09","79.5","","1293.60","1148.53","1603.80","1 through 10","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 3 RIGHT TRIATHLON HINGE","SUP-ITM-10322110","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6381.34","36.5","","1023.42","771.29","2068.67","33","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 3 RIGHT TRIATHLON HINGE","SUP-ITM-10322110","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6696.04","38.3","","850.52","759.78","1211.25","66","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 3 RIGHT TRIATHLON HINGE","SUP-ITM-10322110","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7500.26","42.9","","2548.09","2548.09","2548.09","1 through 10","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 3 RIGHT TRIATHLON HINGE","SUP-ITM-10322110","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7500.26","42.9","","956.46","956.46","956.46","1 through 10","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 3 RIGHT TRIATHLON HINGE","SUP-ITM-10322110","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","WELLPOINT [1015]","HB AMC WELLPOINT","12899.05","73.78","","2344.73","1619.47","2530.35","16","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 3 RIGHT TRIATHLON HINGE","SUP-ITM-10322110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17483.13","13112.35","AETNA [1001]","HB AMC AETNA HMO","12203.22","69.8","","1523.63","988.41","4330.26","39","9136.68","14287.21","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 3 RIGHT TRIATHLON HINGE","SUP-ITM-10322110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17483.13","13112.35","AETNA [1001]","HB AMC AETNA PPO","14056.44","80.4","","1670.25","1670.25","1670.25","1 through 10","9136.68","14287.21","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 3 RIGHT TRIATHLON HINGE","SUP-ITM-10322110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17483.13","13112.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9136.68","52.26","","1113.10","1113.10","1113.10","1 through 10","9136.68","14287.21","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 3 RIGHT TRIATHLON HINGE","SUP-ITM-10322110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17483.13","13112.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14287.21","81.72","","1738.90","1484.65","2716.94","38","9136.68","14287.21","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9136.68","52.26","","1113.10","1113.10","1113.10","1 through 10","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13899.09","79.5","","1293.60","1148.53","1603.80","1 through 10","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6381.34","36.5","","1023.42","771.29","2068.67","33","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6696.04","38.3","","850.52","759.78","1211.25","66","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7500.26","42.9","","2548.09","2548.09","2548.09","1 through 10","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7500.26","42.9","","956.46","956.46","956.46","1 through 10","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","both","","","17483.13","13112.35","WELLPOINT [1015]","HB AMC WELLPOINT","12899.05","73.78","","2344.73","1619.47","2530.35","16","5419.77","13899.09","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17483.13","13112.35","AETNA [1001]","HB AMC AETNA HMO","12203.22","69.8","","1523.63","988.41","4330.26","39","9136.68","14287.21","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17483.13","13112.35","AETNA [1001]","HB AMC AETNA PPO","14056.44","80.4","","1670.25","1670.25","1670.25","1 through 10","9136.68","14287.21","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17483.13","13112.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9136.68","52.26","","1113.10","1113.10","1113.10","1 through 10","9136.68","14287.21","percent of total billed charges",""
"COMPONENT FEMORAL SIZE 4 RIGHT TRIATHLON HINGE","SUP-ITM-10322108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17483.13","13112.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14287.21","81.72","","1738.90","1484.65","2716.94","38","9136.68","14287.21","percent of total billed charges",""
"COMPONENT IMPLANT DELIVERY SUPERION IDS","SUP-ITM-10212658","CDM","C1821","HCPCS","0278","RC","","","","both","","","23737.50","17803.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18871.31","79.5","","9828.00","9828.00","9828.00","1 through 10","7358.63","22550.63","percent of total billed charges",""
"COMPONENT IMPLANT DELIVERY SUPERION IDS","SUP-ITM-10212658","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","23737.50","17803.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","19398.29","81.72","","1958.53","1886.75","1958.53","1 through 10","12405.22","19398.29","percent of total billed charges",""
"COMPONENT MODULAR 4MM SIZE SM ELBOW ULNAR COMPONENT SUPERIOR PEG RIGHT","SUP-ITM-10082110","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1737.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1030.75","2643.38","percent of total billed charges",""
"COMPONENT MODULAR 4MM SIZE SM ELBOW ULNAR COMPONENT SUPERIOR PEG RIGHT","SUP-ITM-10082110","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2643.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1030.75","2643.38","percent of total billed charges",""
"COMPONENT MODULAR 4MM SIZE SM ELBOW ULNAR COMPONENT SUPERIOR PEG RIGHT","SUP-ITM-10082110","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1213.63","36.5","","1023.42","771.29","2068.67","33","1030.75","2643.38","percent of total billed charges",""
"COMPONENT MODULAR 4MM SIZE SM ELBOW ULNAR COMPONENT SUPERIOR PEG RIGHT","SUP-ITM-10082110","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1273.48","38.3","","850.52","759.78","1211.25","66","1030.75","2643.38","percent of total billed charges",""
"COMPONENT MODULAR 4MM SIZE SM ELBOW ULNAR COMPONENT SUPERIOR PEG RIGHT","SUP-ITM-10082110","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","2548.09","2548.09","2548.09","1 through 10","1030.75","2643.38","percent of total billed charges",""
"COMPONENT MODULAR 4MM SIZE SM ELBOW ULNAR COMPONENT SUPERIOR PEG RIGHT","SUP-ITM-10082110","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","956.46","956.46","956.46","1 through 10","1030.75","2643.38","percent of total billed charges",""
"COMPONENT MODULAR 4MM SIZE SM ELBOW ULNAR COMPONENT SUPERIOR PEG RIGHT","SUP-ITM-10082110","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","WELLPOINT [1015]","HB AMC WELLPOINT","2453.19","73.78","","2344.73","1619.47","2530.35","16","1030.75","2643.38","percent of total billed charges",""
"COMPONENT MODULAR 4MM SIZE SM ELBOW ULNAR COMPONENT SUPERIOR PEG RIGHT","SUP-ITM-10082110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA HMO","2320.85","69.8","","1523.63","988.41","4330.26","39","1737.65","2717.19","percent of total billed charges",""
"COMPONENT MODULAR 4MM SIZE SM ELBOW ULNAR COMPONENT SUPERIOR PEG RIGHT","SUP-ITM-10082110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA PPO","2673.30","80.4","","1670.25","1670.25","1670.25","1 through 10","1737.65","2717.19","percent of total billed charges",""
"COMPONENT MODULAR 4MM SIZE SM ELBOW ULNAR COMPONENT SUPERIOR PEG RIGHT","SUP-ITM-10082110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1737.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1737.65","2717.19","percent of total billed charges",""
"COMPONENT MODULAR 4MM SIZE SM ELBOW ULNAR COMPONENT SUPERIOR PEG RIGHT","SUP-ITM-10082110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2717.19","81.72","","1738.90","1484.65","2716.94","38","1737.65","2717.19","percent of total billed charges",""
"COMPONENT TIBIA SIZE 5 16MM PS ALL POLYETHYLENE","SUP-ITM-10208705","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1152.33","52.26","","1113.10","1113.10","1113.10","1 through 10","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 5 16MM PS ALL POLYETHYLENE","SUP-ITM-10208705","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1752.98","79.5","","1293.60","1148.53","1603.80","1 through 10","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 5 16MM PS ALL POLYETHYLENE","SUP-ITM-10208705","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","804.83","36.5","","1023.42","771.29","2068.67","33","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 5 16MM PS ALL POLYETHYLENE","SUP-ITM-10208705","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","844.52","38.3","","850.52","759.78","1211.25","66","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 5 16MM PS ALL POLYETHYLENE","SUP-ITM-10208705","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","945.95","42.9","","2548.09","2548.09","2548.09","1 through 10","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 5 16MM PS ALL POLYETHYLENE","SUP-ITM-10208705","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","945.95","42.9","","956.46","956.46","956.46","1 through 10","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 5 16MM PS ALL POLYETHYLENE","SUP-ITM-10208705","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","WELLPOINT [1015]","HB AMC WELLPOINT","1626.85","73.78","","2344.73","1619.47","2530.35","16","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 5 16MM PS ALL POLYETHYLENE","SUP-ITM-10208705","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","AETNA [1001]","HB AMC AETNA HMO","1539.09","69.8","","1523.63","988.41","4330.26","39","1152.33","1801.93","percent of total billed charges",""
"COMPONENT TIBIA SIZE 5 16MM PS ALL POLYETHYLENE","SUP-ITM-10208705","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","AETNA [1001]","HB AMC AETNA PPO","1772.82","80.4","","1670.25","1670.25","1670.25","1 through 10","1152.33","1801.93","percent of total billed charges",""
"COMPONENT TIBIA SIZE 5 16MM PS ALL POLYETHYLENE","SUP-ITM-10208705","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1152.33","52.26","","1113.10","1113.10","1113.10","1 through 10","1152.33","1801.93","percent of total billed charges",""
"COMPONENT TIBIA SIZE 5 16MM PS ALL POLYETHYLENE","SUP-ITM-10208705","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1801.93","81.72","","1738.90","1484.65","2716.94","38","1152.33","1801.93","percent of total billed charges",""
"COMPONENT TIBIA SIZE 6 16MM PS ALL POLYETHYLENE","SUP-ITM-10208712","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1152.33","52.26","","1113.10","1113.10","1113.10","1 through 10","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 6 16MM PS ALL POLYETHYLENE","SUP-ITM-10208712","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1752.98","79.5","","1293.60","1148.53","1603.80","1 through 10","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 6 16MM PS ALL POLYETHYLENE","SUP-ITM-10208712","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","804.83","36.5","","1023.42","771.29","2068.67","33","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 6 16MM PS ALL POLYETHYLENE","SUP-ITM-10208712","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","844.52","38.3","","850.52","759.78","1211.25","66","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 6 16MM PS ALL POLYETHYLENE","SUP-ITM-10208712","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","945.95","42.9","","2548.09","2548.09","2548.09","1 through 10","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 6 16MM PS ALL POLYETHYLENE","SUP-ITM-10208712","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","945.95","42.9","","956.46","956.46","956.46","1 through 10","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 6 16MM PS ALL POLYETHYLENE","SUP-ITM-10208712","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","WELLPOINT [1015]","HB AMC WELLPOINT","1626.85","73.78","","2344.73","1619.47","2530.35","16","683.55","1752.98","percent of total billed charges",""
"COMPONENT TIBIA SIZE 6 16MM PS ALL POLYETHYLENE","SUP-ITM-10208712","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","AETNA [1001]","HB AMC AETNA HMO","1539.09","69.8","","1523.63","988.41","4330.26","39","1152.33","1801.93","percent of total billed charges",""
"COMPONENT TIBIA SIZE 6 16MM PS ALL POLYETHYLENE","SUP-ITM-10208712","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","AETNA [1001]","HB AMC AETNA PPO","1772.82","80.4","","1670.25","1670.25","1670.25","1 through 10","1152.33","1801.93","percent of total billed charges",""
"COMPONENT TIBIA SIZE 6 16MM PS ALL POLYETHYLENE","SUP-ITM-10208712","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1152.33","52.26","","1113.10","1113.10","1113.10","1 through 10","1152.33","1801.93","percent of total billed charges",""
"COMPONENT TIBIA SIZE 6 16MM PS ALL POLYETHYLENE","SUP-ITM-10208712","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1801.93","81.72","","1738.90","1484.65","2716.94","38","1152.33","1801.93","percent of total billed charges",""
"Comprehensive Dystonia Nextgen Dna Screening Panel (90 Genes)","PX-31000768","CDM","81479","CPT","0310","RC","","","","both","","","3319.00","2489.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2638.61","79.5","","0.65","0.65","0.65","1 through 10","1028.89","3153.05","percent of total billed charges",""
"Comprehensive Dystonia Nextgen Dna Screening Panel (90 Genes)","PX-31000768","CDM","81479","CPT","0310","RC","","","","both","","","3319.00","2489.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1769.03","53.3","","0.79","0.79","0.79","1 through 10","1028.89","3153.05","percent of total billed charges",""
"Comprehensive Dystonia Nextgen Dna Screening Panel (90 Genes)","PX-31000768","CDM","81479","CPT","0310","RC","","","","outpatient","","","3319.00","2489.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1659.50","50","","1.00","1.00","1.00","1 through 10","156.55","2738.18","percent of total billed charges",""
"Comprehensive Dystonia Nextgen Dna Screening Panel (90 Genes)","PX-31000768","CDM","81479","CPT","0310","RC","","","","outpatient","","","3319.00","2489.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1742.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","2738.18","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0300","RC","","","","inpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","139.93","78.61","","138.30","138.30","138.30","1 through 10","98.43","141.51","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","127.80","71.8","","124.21","11.34","259.84","99","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","116.77","65.6","","117.12","117.12","117.12","1 through 10","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","115.70","65","","112.45","91.34","406.71","120","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","124.60","70","","173.00","74.39","223.17","78","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","CHAMPVA [160001]","HB BWH TRICARE","169.10","95","","12.72","12.72","12.72","1 through 10","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","141.51","79.5","","136.15","91.34","136.15","1348","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","94.87","53.3","","91.34","91.34","173.00","734","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","137.06","77","","133.21","133.21","399.63","26","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","115.70","65","","108.55","108.55","112.45","1 through 10","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","141.51","79.5","","136.15","9.54","136.15","1 through 10","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","55.18","31","","53.46","53.46","160.38","44","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.97","36.5","","64.53","54.84","164.52","1126","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.17","38.3","","67.64","65.74","197.22","3599","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","MOLINA [1014]","HB BWH MOLINA","62.30","35","","20.95","20.95","42.07","33","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","137.06","77","","134.94","134.94","173.00","14","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","TRICARE [160005]","HB BWH TRICARE","169.10","95","","12.08","12.08","12.72","72","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","169.10","95","","10.56","10.56","10.56","1 through 10","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.36","42.9","","138.30","76.07","138.30","91","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","178.00","133.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.36","42.9","","76.07","76.07","138.30","16","10.35","169.1","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","178.00","133.50","AETNA [1001]","HB AMC AETNA HMO","124.24","69.8","","117.12","82.69","134.94","1801","10.89","145.46","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","178.00","133.50","AETNA [1001]","HB AMC AETNA PPO","143.11","80.4","","134.94","82.69","134.94","170","10.89","145.46","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","178.00","133.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","99.50","55.9","","181.30","90.65","181.30","1 through 10","10.89","145.46","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","178.00","133.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","93.02","52.26","","26.08","11.54","107.06","21","10.89","145.46","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","178.00","133.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","143.11","80.4","","134.94","86.50","134.94","1 through 10","10.89","145.46","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","178.00","133.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","145.46","81.72","","138.30","128.60","138.30","1 through 10","10.89","145.46","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","145.46","81.72","","138.30","76.07","138.30","68","10.89","145.46","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","145.46","81.72","","138.30","76.07","138.30","1288","10.89","145.46","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","both","","","98.00","73.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","63.70","65","","185.25","185.25","185.25","1 through 10","6.55","93.1","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","both","","","98.00","73.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","68.60","70","","95.00","95.00","95.00","1 through 10","6.55","93.1","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","both","","","98.00","73.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","77.91","79.5","","193.23","74.77","224.31","26","6.55","93.1","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","both","","","98.00","73.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","52.23","53.3","","74.77","50.16","74.77","1 through 10","6.55","93.1","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","both","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","63.70","65","","123.50","123.50","123.50","1 through 10","6.55","93.1","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","both","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","77.91","79.5","","74.77","74.77","74.77","1 through 10","6.55","93.1","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","both","","","98.00","73.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","35.77","36.5","","35.44","30.12","70.88","20","6.55","93.1","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","both","","","98.00","73.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37.53","38.3","","37.15","36.10","111.45","25","6.55","93.1","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","both","","","98.00","73.50","MOLINA [1014]","HB BWH MOLINA","34.30","35","","13.25","13.25","13.25","1 through 10","6.55","93.1","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","both","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.04","42.9","","75.94","41.77","75.94","1 through 10","6.55","93.1","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","outpatient","","","98.00","73.50","AETNA [1001]","HB AMC AETNA HMO","68.40","69.8","","128.64","64.32","259.51","17","6.88","80.09","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","80.09","81.72","","75.94","41.77","75.94","22","6.88","80.09","percent of total billed charges",""
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","","","","inpatient","","","520769.55","390577.16","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","99574.52","","Case rate ($99,574.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $119,790.68, add-ons for qualifying new technology services are included. If operating cost exceeds $165,435.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $11,190.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $90,444.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $119,410.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $8,749.94. The transfer capital threshold is the transfer adjustment factor * $8,749.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","99510.31","99510.31","222518.11","1 through 10","97583.03","164399.8449","other","Inpatient Replacement Plans DRG"
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","","","","inpatient","","","520769.55","390577.16","MEDICARE [2001]","HB BWH MEDICARE","99574.52","","Case rate ($99,574.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $119,790.68, add-ons for qualifying new technology services are included. If operating cost exceeds $165,435.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $11,190.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $90,444.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $119,410.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $8,749.94. The transfer capital threshold is the transfer adjustment factor * $8,749.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","128708.15","128708.15","293520.41","1 through 10","97583.03","164399.8449","other","Inpatient Replacement Plans DRG"
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","","","","inpatient","","","520769.55","390577.16","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","97583.03","","Case rate ($99,574.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $119,790.68, add-ons for qualifying new technology services are included. If operating cost exceeds $165,435.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $11,190.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $90,444.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $119,410.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $8,749.94. The transfer capital threshold is the transfer adjustment factor * $8,749.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","137241.67","137241.67","137241.67","1 through 10","97583.03","164399.8449","other","Inpatient DRG"
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","","","","inpatient","","","190230.24","142672.68","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","63216.05","","Case rate ($61,374.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $73,805.74, add-ons for qualifying new technology services are included. If operating cost exceeds $119,450.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,820.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $55,614.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $73,425.90 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,380.35. The transfer capital threshold is the transfer adjustment factor * $5,380.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","58170.40","58170.40","58170.40","1 through 10","60147.31","93358.9624","other","Inpatient DRG"
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","","","","inpatient","","","190230.24","142672.68","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","61374.81","","Case rate ($61,374.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $73,805.74, add-ons for qualifying new technology services are included. If operating cost exceeds $119,450.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,820.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $55,614.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $73,425.90 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,380.35. The transfer capital threshold is the transfer adjustment factor * $5,380.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","56430.42","55823.66","72047.71","1 through 10","60147.31","93358.9624","other","Inpatient Replacement Plans DRG"
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","","","","inpatient","","","190230.24","142672.68","MEDICARE [2001]","HB BWH MEDICARE","61374.81","","Case rate ($61,374.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $73,805.74, add-ons for qualifying new technology services are included. If operating cost exceeds $119,450.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,820.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $55,614.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $73,425.90 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,380.35. The transfer capital threshold is the transfer adjustment factor * $5,380.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","73210.70","37072.24","73319.78","34","60147.31","93358.9624","other","Inpatient Replacement Plans DRG"
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","","","","inpatient","","","190230.24","142672.68","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","61374.81","","Case rate ($61,374.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $73,805.74, add-ons for qualifying new technology services are included. If operating cost exceeds $119,450.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,820.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $55,614.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $73,425.90 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,380.35. The transfer capital threshold is the transfer adjustment factor * $5,380.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","55310.61","55310.61","55310.61","1 through 10","60147.31","93358.9624","other","Inpatient Replacement Plans DRG"
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","","","","inpatient","","","190230.24","142672.68","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","60147.31","","Case rate ($61,374.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $73,805.74, add-ons for qualifying new technology services are included. If operating cost exceeds $119,450.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,820.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $55,614.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $73,425.90 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,380.35. The transfer capital threshold is the transfer adjustment factor * $5,380.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","55385.62","55385.62","55385.62","1 through 10","60147.31","93358.9624","other","Inpatient DRG"
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.07","978.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1036.74","79.5","","800.18","480.96","1887.97","195","404.26","1036.74","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.07","978.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","695.07","53.3","","813.12","216.42","1444.50","81","404.26","1036.74","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.07","978.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","404.26","31","","432.60","432.60","432.60","1 through 10","404.26","1036.74","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.07","978.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","475.99","36.5","","148.37","54.89","631.39","94","404.26","1036.74","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.07","978.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","499.46","38.3","","279.30","91.72","1116.77","266","404.26","1036.74","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.07","978.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","559.45","42.9","","731.00","63.70","731.00","1 through 10","404.26","1036.74","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.07","978.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","559.45","42.9","","384.74","384.74","384.74","1 through 10","404.26","1036.74","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.07","978.05","WELLPOINT [1015]","HB AMC WELLPOINT","962.14","73.78","","286.63","119.22","1107.45","105","404.26","1036.74","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1304.07","978.05","AETNA [1001]","HB AMC AETNA HMO","910.24","69.8","","675.31","184.75","1721.50","286","681.51","1065.69","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1304.07","978.05","AETNA [1001]","HB AMC AETNA PPO","1048.47","80.4","","1261.44","103.12","1514.10","21","681.51","1065.69","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1304.07","978.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1048.47","80.4","","1365.00","1365.00","1365.00","1 through 10","681.51","1065.69","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1304.07","978.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1065.69","81.72","","5157.68","5157.68","5157.68","1 through 10","681.51","1065.69","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1304.07","978.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1065.69","81.72","","431.26","71.26","1459.57","88","681.51","1065.69","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1438.75","1079.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1143.81","79.5","","800.18","480.96","1887.97","195","446.01","1143.81","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1438.75","1079.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","766.85","53.3","","813.12","216.42","1444.50","81","446.01","1143.81","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1438.75","1079.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","446.01","31","","432.60","432.60","432.60","1 through 10","446.01","1143.81","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1438.75","1079.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","525.14","36.5","","148.37","54.89","631.39","94","446.01","1143.81","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1438.75","1079.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","551.04","38.3","","279.30","91.72","1116.77","266","446.01","1143.81","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1438.75","1079.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","617.22","42.9","","731.00","63.70","731.00","1 through 10","446.01","1143.81","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1438.75","1079.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","617.22","42.9","","384.74","384.74","384.74","1 through 10","446.01","1143.81","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1438.75","1079.06","WELLPOINT [1015]","HB AMC WELLPOINT","1061.51","73.78","","286.63","119.22","1107.45","105","446.01","1143.81","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1438.75","1079.06","AETNA [1001]","HB AMC AETNA HMO","1004.25","69.8","","675.31","184.75","1721.50","286","751.89","1175.75","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1438.75","1079.06","AETNA [1001]","HB AMC AETNA PPO","1156.76","80.4","","1261.44","103.12","1514.10","21","751.89","1175.75","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1438.75","1079.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1156.76","80.4","","1365.00","1365.00","1365.00","1 through 10","751.89","1175.75","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1438.75","1079.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1175.75","81.72","","5157.68","5157.68","5157.68","1 through 10","751.89","1175.75","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1438.75","1079.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1175.75","81.72","","431.26","71.26","1459.57","88","751.89","1175.75","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1796.17","1347.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1427.96","79.5","","800.18","480.96","1887.97","195","556.81","1427.96","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1796.17","1347.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","957.36","53.3","","813.12","216.42","1444.50","81","556.81","1427.96","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1796.17","1347.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","556.81","31","","432.60","432.60","432.60","1 through 10","556.81","1427.96","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1796.17","1347.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","655.60","36.5","","148.37","54.89","631.39","94","556.81","1427.96","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1796.17","1347.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","687.93","38.3","","279.30","91.72","1116.77","266","556.81","1427.96","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1796.17","1347.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","770.56","42.9","","731.00","63.70","731.00","1 through 10","556.81","1427.96","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1796.17","1347.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","770.56","42.9","","384.74","384.74","384.74","1 through 10","556.81","1427.96","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1796.17","1347.13","WELLPOINT [1015]","HB AMC WELLPOINT","1325.21","73.78","","286.63","119.22","1107.45","105","556.81","1427.96","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1796.17","1347.13","AETNA [1001]","HB AMC AETNA HMO","1253.73","69.8","","675.31","184.75","1721.50","286","938.68","1467.83","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1796.17","1347.13","AETNA [1001]","HB AMC AETNA PPO","1444.12","80.4","","1261.44","103.12","1514.10","21","938.68","1467.83","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1796.17","1347.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1444.12","80.4","","1365.00","1365.00","1365.00","1 through 10","938.68","1467.83","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1796.17","1347.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1467.83","81.72","","5157.68","5157.68","5157.68","1 through 10","938.68","1467.83","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1796.17","1347.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1467.83","81.72","","431.26","71.26","1459.57","88","938.68","1467.83","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2351.72","1763.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1869.62","79.5","","800.18","480.96","1887.97","195","729.03","1869.62","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2351.72","1763.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1253.47","53.3","","813.12","216.42","1444.50","81","729.03","1869.62","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2351.72","1763.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","729.03","31","","432.60","432.60","432.60","1 through 10","729.03","1869.62","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2351.72","1763.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","858.38","36.5","","148.37","54.89","631.39","94","729.03","1869.62","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2351.72","1763.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","900.71","38.3","","279.30","91.72","1116.77","266","729.03","1869.62","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2351.72","1763.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1008.89","42.9","","731.00","63.70","731.00","1 through 10","729.03","1869.62","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2351.72","1763.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1008.89","42.9","","384.74","384.74","384.74","1 through 10","729.03","1869.62","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2351.72","1763.79","WELLPOINT [1015]","HB AMC WELLPOINT","1735.10","73.78","","286.63","119.22","1107.45","105","729.03","1869.62","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2351.72","1763.79","AETNA [1001]","HB AMC AETNA HMO","1641.50","69.8","","675.31","184.75","1721.50","286","1229.01","1921.83","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2351.72","1763.79","AETNA [1001]","HB AMC AETNA PPO","1890.78","80.4","","1261.44","103.12","1514.10","21","1229.01","1921.83","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2351.72","1763.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1890.78","80.4","","1365.00","1365.00","1365.00","1 through 10","1229.01","1921.83","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2351.72","1763.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1921.83","81.72","","5157.68","5157.68","5157.68","1 through 10","1229.01","1921.83","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2351.72","1763.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1921.83","81.72","","431.26","71.26","1459.57","88","1229.01","1921.83","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.48","3710.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3933.25","79.5","","800.18","480.96","1887.97","195","1533.72","3933.25","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.48","3710.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2637.01","53.3","","813.12","216.42","1444.50","81","1533.72","3933.25","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.48","3710.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1533.72","31","","432.60","432.60","432.60","1 through 10","1533.72","3933.25","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.48","3710.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1805.83","36.5","","148.37","54.89","631.39","94","1533.72","3933.25","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.48","3710.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1894.88","38.3","","279.30","91.72","1116.77","266","1533.72","3933.25","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.48","3710.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2122.47","42.9","","731.00","63.70","731.00","1 through 10","1533.72","3933.25","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.48","3710.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2122.47","42.9","","384.74","384.74","384.74","1 through 10","1533.72","3933.25","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.48","3710.61","WELLPOINT [1015]","HB AMC WELLPOINT","3650.25","73.78","","286.63","119.22","1107.45","105","1533.72","3933.25","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.48","3710.61","AETNA [1001]","HB AMC AETNA HMO","3453.34","69.8","","675.31","184.75","1721.50","286","2585.55","4043.08","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.48","3710.61","AETNA [1001]","HB AMC AETNA PPO","3977.77","80.4","","1261.44","103.12","1514.10","21","2585.55","4043.08","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.48","3710.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3977.77","80.4","","1365.00","1365.00","1365.00","1 through 10","2585.55","4043.08","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.48","3710.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4043.08","81.72","","5157.68","5157.68","5157.68","1 through 10","2585.55","4043.08","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.48","3710.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4043.08","81.72","","431.26","71.26","1459.57","88","2585.55","4043.08","percent of total billed charges",""
"CONDYLAR PLATE 4.5X242MM 10 HOLE LCP SS CURVED LEFT","SUP-ITM-10018446","CDM","C1713","HCPCS","0278","RC","","","","both","","","4404.30","3303.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3501.42","79.5","","800.18","480.96","1887.97","195","1365.33","3501.42","percent of total billed charges",""
"CONDYLAR PLATE 4.5X242MM 10 HOLE LCP SS CURVED LEFT","SUP-ITM-10018446","CDM","C1713","HCPCS","0278","RC","","","","both","","","4404.30","3303.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2347.49","53.3","","813.12","216.42","1444.50","81","1365.33","3501.42","percent of total billed charges",""
"CONDYLAR PLATE 4.5X242MM 10 HOLE LCP SS CURVED LEFT","SUP-ITM-10018446","CDM","C1713","HCPCS","0278","RC","","","","both","","","4404.30","3303.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1365.33","31","","432.60","432.60","432.60","1 through 10","1365.33","3501.42","percent of total billed charges",""
"CONDYLAR PLATE 4.5X242MM 10 HOLE LCP SS CURVED LEFT","SUP-ITM-10018446","CDM","C1713","HCPCS","0278","RC","","","","both","","","4404.30","3303.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1607.57","36.5","","148.37","54.89","631.39","94","1365.33","3501.42","percent of total billed charges",""
"CONDYLAR PLATE 4.5X242MM 10 HOLE LCP SS CURVED LEFT","SUP-ITM-10018446","CDM","C1713","HCPCS","0278","RC","","","","both","","","4404.30","3303.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1686.85","38.3","","279.30","91.72","1116.77","266","1365.33","3501.42","percent of total billed charges",""
"CONDYLAR PLATE 4.5X242MM 10 HOLE LCP SS CURVED LEFT","SUP-ITM-10018446","CDM","C1713","HCPCS","0278","RC","","","","both","","","4404.30","3303.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1889.44","42.9","","731.00","63.70","731.00","1 through 10","1365.33","3501.42","percent of total billed charges",""
"CONDYLAR PLATE 4.5X242MM 10 HOLE LCP SS CURVED LEFT","SUP-ITM-10018446","CDM","C1713","HCPCS","0278","RC","","","","both","","","4404.30","3303.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1889.44","42.9","","384.74","384.74","384.74","1 through 10","1365.33","3501.42","percent of total billed charges",""
"CONDYLAR PLATE 4.5X242MM 10 HOLE LCP SS CURVED LEFT","SUP-ITM-10018446","CDM","C1713","HCPCS","0278","RC","","","","both","","","4404.30","3303.22","WELLPOINT [1015]","HB AMC WELLPOINT","3249.49","73.78","","286.63","119.22","1107.45","105","1365.33","3501.42","percent of total billed charges",""
"CONDYLAR PLATE 4.5X242MM 10 HOLE LCP SS CURVED LEFT","SUP-ITM-10018446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4404.30","3303.22","AETNA [1001]","HB AMC AETNA HMO","3074.20","69.8","","675.31","184.75","1721.50","286","2301.69","3599.19","percent of total billed charges",""
"CONDYLAR PLATE 4.5X242MM 10 HOLE LCP SS CURVED LEFT","SUP-ITM-10018446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4404.30","3303.22","AETNA [1001]","HB AMC AETNA PPO","3541.06","80.4","","1261.44","103.12","1514.10","21","2301.69","3599.19","percent of total billed charges",""
"CONDYLAR PLATE 4.5X242MM 10 HOLE LCP SS CURVED LEFT","SUP-ITM-10018446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4404.30","3303.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3541.06","80.4","","1365.00","1365.00","1365.00","1 through 10","2301.69","3599.19","percent of total billed charges",""
"CONDYLAR PLATE 4.5X242MM 10 HOLE LCP SS CURVED LEFT","SUP-ITM-10018446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4404.30","3303.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3599.19","81.72","","5157.68","5157.68","5157.68","1 through 10","2301.69","3599.19","percent of total billed charges",""
"CONDYLAR PLATE 4.5X242MM 10 HOLE LCP SS CURVED LEFT","SUP-ITM-10018446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4404.30","3303.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3599.19","81.72","","431.26","71.26","1459.57","88","2301.69","3599.19","percent of total billed charges",""
"CONDYLAR PLATE 4.5X278MM 12 HOLE LCP SS CURVED LEFT","SUP-ITM-10018447","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.83","3374.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3576.57","79.5","","800.18","480.96","1887.97","195","1394.64","3576.57","percent of total billed charges",""
"CONDYLAR PLATE 4.5X278MM 12 HOLE LCP SS CURVED LEFT","SUP-ITM-10018447","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.83","3374.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2397.88","53.3","","813.12","216.42","1444.50","81","1394.64","3576.57","percent of total billed charges",""
"CONDYLAR PLATE 4.5X278MM 12 HOLE LCP SS CURVED LEFT","SUP-ITM-10018447","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.83","3374.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1394.64","31","","432.60","432.60","432.60","1 through 10","1394.64","3576.57","percent of total billed charges",""
"CONDYLAR PLATE 4.5X278MM 12 HOLE LCP SS CURVED LEFT","SUP-ITM-10018447","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.83","3374.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.07","36.5","","148.37","54.89","631.39","94","1394.64","3576.57","percent of total billed charges",""
"CONDYLAR PLATE 4.5X278MM 12 HOLE LCP SS CURVED LEFT","SUP-ITM-10018447","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.83","3374.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.05","38.3","","279.30","91.72","1116.77","266","1394.64","3576.57","percent of total billed charges",""
"CONDYLAR PLATE 4.5X278MM 12 HOLE LCP SS CURVED LEFT","SUP-ITM-10018447","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.83","3374.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.00","42.9","","731.00","63.70","731.00","1 through 10","1394.64","3576.57","percent of total billed charges",""
"CONDYLAR PLATE 4.5X278MM 12 HOLE LCP SS CURVED LEFT","SUP-ITM-10018447","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.83","3374.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.00","42.9","","384.74","384.74","384.74","1 through 10","1394.64","3576.57","percent of total billed charges",""
"CONDYLAR PLATE 4.5X278MM 12 HOLE LCP SS CURVED LEFT","SUP-ITM-10018447","CDM","C1713","HCPCS","0278","RC","","","","both","","","4498.83","3374.12","WELLPOINT [1015]","HB AMC WELLPOINT","3319.24","73.78","","286.63","119.22","1107.45","105","1394.64","3576.57","percent of total billed charges",""
"CONDYLAR PLATE 4.5X278MM 12 HOLE LCP SS CURVED LEFT","SUP-ITM-10018447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4498.83","3374.12","AETNA [1001]","HB AMC AETNA HMO","3140.18","69.8","","675.31","184.75","1721.50","286","2351.09","3676.44","percent of total billed charges",""
"CONDYLAR PLATE 4.5X278MM 12 HOLE LCP SS CURVED LEFT","SUP-ITM-10018447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4498.83","3374.12","AETNA [1001]","HB AMC AETNA PPO","3617.06","80.4","","1261.44","103.12","1514.10","21","2351.09","3676.44","percent of total billed charges",""
"CONDYLAR PLATE 4.5X278MM 12 HOLE LCP SS CURVED LEFT","SUP-ITM-10018447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4498.83","3374.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3617.06","80.4","","1365.00","1365.00","1365.00","1 through 10","2351.09","3676.44","percent of total billed charges",""
"CONDYLAR PLATE 4.5X278MM 12 HOLE LCP SS CURVED LEFT","SUP-ITM-10018447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4498.83","3374.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3676.44","81.72","","5157.68","5157.68","5157.68","1 through 10","2351.09","3676.44","percent of total billed charges",""
"CONDYLAR PLATE 4.5X278MM 12 HOLE LCP SS CURVED LEFT","SUP-ITM-10018447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4498.83","3374.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3676.44","81.72","","431.26","71.26","1459.57","88","2351.09","3676.44","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.95","2951.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3128.29","79.5","","800.18","480.96","1887.97","195","1219.83","3128.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.95","2951.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2097.33","53.3","","813.12","216.42","1444.50","81","1219.83","3128.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.95","2951.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1219.83","31","","432.60","432.60","432.60","1 through 10","1219.83","3128.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.95","2951.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1436.26","36.5","","148.37","54.89","631.39","94","1219.83","3128.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.95","2951.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1507.09","38.3","","279.30","91.72","1116.77","266","1219.83","3128.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.95","2951.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1688.09","42.9","","731.00","63.70","731.00","1 through 10","1219.83","3128.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.95","2951.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1688.09","42.9","","384.74","384.74","384.74","1 through 10","1219.83","3128.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.95","2951.21","WELLPOINT [1015]","HB AMC WELLPOINT","2903.21","73.78","","286.63","119.22","1107.45","105","1219.83","3128.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3934.95","2951.21","AETNA [1001]","HB AMC AETNA HMO","2746.60","69.8","","675.31","184.75","1721.50","286","2056.4","3215.64","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3934.95","2951.21","AETNA [1001]","HB AMC AETNA PPO","3163.70","80.4","","1261.44","103.12","1514.10","21","2056.4","3215.64","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3934.95","2951.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3163.70","80.4","","1365.00","1365.00","1365.00","1 through 10","2056.4","3215.64","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3934.95","2951.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3215.64","81.72","","5157.68","5157.68","5157.68","1 through 10","2056.4","3215.64","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED LEFT","SUP-ITM-10018448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3934.95","2951.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3215.64","81.72","","431.26","71.26","1459.57","88","2056.4","3215.64","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED LEFT","SUP-ITM-10018449","CDM","C1713","HCPCS","0278","RC","","","","both","","","4010.43","3007.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3188.29","79.5","","800.18","480.96","1887.97","195","1243.23","3188.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED LEFT","SUP-ITM-10018449","CDM","C1713","HCPCS","0278","RC","","","","both","","","4010.43","3007.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2137.56","53.3","","813.12","216.42","1444.50","81","1243.23","3188.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED LEFT","SUP-ITM-10018449","CDM","C1713","HCPCS","0278","RC","","","","both","","","4010.43","3007.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1243.23","31","","432.60","432.60","432.60","1 through 10","1243.23","3188.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED LEFT","SUP-ITM-10018449","CDM","C1713","HCPCS","0278","RC","","","","both","","","4010.43","3007.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1463.81","36.5","","148.37","54.89","631.39","94","1243.23","3188.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED LEFT","SUP-ITM-10018449","CDM","C1713","HCPCS","0278","RC","","","","both","","","4010.43","3007.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1535.99","38.3","","279.30","91.72","1116.77","266","1243.23","3188.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED LEFT","SUP-ITM-10018449","CDM","C1713","HCPCS","0278","RC","","","","both","","","4010.43","3007.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1720.47","42.9","","731.00","63.70","731.00","1 through 10","1243.23","3188.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED LEFT","SUP-ITM-10018449","CDM","C1713","HCPCS","0278","RC","","","","both","","","4010.43","3007.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1720.47","42.9","","384.74","384.74","384.74","1 through 10","1243.23","3188.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED LEFT","SUP-ITM-10018449","CDM","C1713","HCPCS","0278","RC","","","","both","","","4010.43","3007.82","WELLPOINT [1015]","HB AMC WELLPOINT","2958.90","73.78","","286.63","119.22","1107.45","105","1243.23","3188.29","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED LEFT","SUP-ITM-10018449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4010.43","3007.82","AETNA [1001]","HB AMC AETNA HMO","2799.28","69.8","","675.31","184.75","1721.50","286","2095.85","3277.32","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED LEFT","SUP-ITM-10018449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4010.43","3007.82","AETNA [1001]","HB AMC AETNA PPO","3224.39","80.4","","1261.44","103.12","1514.10","21","2095.85","3277.32","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED LEFT","SUP-ITM-10018449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4010.43","3007.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3224.39","80.4","","1365.00","1365.00","1365.00","1 through 10","2095.85","3277.32","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED LEFT","SUP-ITM-10018449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4010.43","3007.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3277.32","81.72","","5157.68","5157.68","5157.68","1 through 10","2095.85","3277.32","percent of total billed charges",""
"CONDYLAR PLATE 4.5X350MM 16 HOLE LCP SS CURVED LEFT","SUP-ITM-10018449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4010.43","3007.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3277.32","81.72","","431.26","71.26","1459.57","88","2095.85","3277.32","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED LEFT","SUP-ITM-10018450","CDM","C1713","HCPCS","0278","RC","","","","both","","","4234.65","3175.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3366.55","79.5","","800.18","480.96","1887.97","195","1312.74","3366.55","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED LEFT","SUP-ITM-10018450","CDM","C1713","HCPCS","0278","RC","","","","both","","","4234.65","3175.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2257.07","53.3","","813.12","216.42","1444.50","81","1312.74","3366.55","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED LEFT","SUP-ITM-10018450","CDM","C1713","HCPCS","0278","RC","","","","both","","","4234.65","3175.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1312.74","31","","432.60","432.60","432.60","1 through 10","1312.74","3366.55","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED LEFT","SUP-ITM-10018450","CDM","C1713","HCPCS","0278","RC","","","","both","","","4234.65","3175.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1545.65","36.5","","148.37","54.89","631.39","94","1312.74","3366.55","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED LEFT","SUP-ITM-10018450","CDM","C1713","HCPCS","0278","RC","","","","both","","","4234.65","3175.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1621.87","38.3","","279.30","91.72","1116.77","266","1312.74","3366.55","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED LEFT","SUP-ITM-10018450","CDM","C1713","HCPCS","0278","RC","","","","both","","","4234.65","3175.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1816.66","42.9","","731.00","63.70","731.00","1 through 10","1312.74","3366.55","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED LEFT","SUP-ITM-10018450","CDM","C1713","HCPCS","0278","RC","","","","both","","","4234.65","3175.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1816.66","42.9","","384.74","384.74","384.74","1 through 10","1312.74","3366.55","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED LEFT","SUP-ITM-10018450","CDM","C1713","HCPCS","0278","RC","","","","both","","","4234.65","3175.99","WELLPOINT [1015]","HB AMC WELLPOINT","3124.32","73.78","","286.63","119.22","1107.45","105","1312.74","3366.55","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED LEFT","SUP-ITM-10018450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4234.65","3175.99","AETNA [1001]","HB AMC AETNA HMO","2955.79","69.8","","675.31","184.75","1721.50","286","2213.03","3460.56","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED LEFT","SUP-ITM-10018450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4234.65","3175.99","AETNA [1001]","HB AMC AETNA PPO","3404.66","80.4","","1261.44","103.12","1514.10","21","2213.03","3460.56","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED LEFT","SUP-ITM-10018450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4234.65","3175.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3404.66","80.4","","1365.00","1365.00","1365.00","1 through 10","2213.03","3460.56","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED LEFT","SUP-ITM-10018450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4234.65","3175.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3460.56","81.72","","5157.68","5157.68","5157.68","1 through 10","2213.03","3460.56","percent of total billed charges",""
"CONDYLAR PLATE 4.5X386MM 18 HOLE LCP SS CURVED LEFT","SUP-ITM-10018450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4234.65","3175.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3460.56","81.72","","431.26","71.26","1459.57","88","2213.03","3460.56","percent of total billed charges",""
"CONDYLAR PLATE 4.5X422MM 20 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036514","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.92","3306.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3505.09","79.5","","800.18","480.96","1887.97","195","1366.77","3505.09","percent of total billed charges",""
"CONDYLAR PLATE 4.5X422MM 20 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036514","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.92","3306.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2349.95","53.3","","813.12","216.42","1444.50","81","1366.77","3505.09","percent of total billed charges",""
"CONDYLAR PLATE 4.5X422MM 20 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036514","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.92","3306.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1366.77","31","","432.60","432.60","432.60","1 through 10","1366.77","3505.09","percent of total billed charges",""
"CONDYLAR PLATE 4.5X422MM 20 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036514","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.92","3306.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1609.26","36.5","","148.37","54.89","631.39","94","1366.77","3505.09","percent of total billed charges",""
"CONDYLAR PLATE 4.5X422MM 20 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036514","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.92","3306.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1688.62","38.3","","279.30","91.72","1116.77","266","1366.77","3505.09","percent of total billed charges",""
"CONDYLAR PLATE 4.5X422MM 20 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036514","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.92","3306.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.43","42.9","","731.00","63.70","731.00","1 through 10","1366.77","3505.09","percent of total billed charges",""
"CONDYLAR PLATE 4.5X422MM 20 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036514","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.92","3306.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.43","42.9","","384.74","384.74","384.74","1 through 10","1366.77","3505.09","percent of total billed charges",""
"CONDYLAR PLATE 4.5X422MM 20 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036514","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.92","3306.69","WELLPOINT [1015]","HB AMC WELLPOINT","3252.90","73.78","","286.63","119.22","1107.45","105","1366.77","3505.09","percent of total billed charges",""
"CONDYLAR PLATE 4.5X422MM 20 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4408.92","3306.69","AETNA [1001]","HB AMC AETNA HMO","3077.43","69.8","","675.31","184.75","1721.50","286","2304.1","3602.97","percent of total billed charges",""
"CONDYLAR PLATE 4.5X422MM 20 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4408.92","3306.69","AETNA [1001]","HB AMC AETNA PPO","3544.77","80.4","","1261.44","103.12","1514.10","21","2304.1","3602.97","percent of total billed charges",""
"CONDYLAR PLATE 4.5X422MM 20 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4408.92","3306.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3544.77","80.4","","1365.00","1365.00","1365.00","1 through 10","2304.1","3602.97","percent of total billed charges",""
"CONDYLAR PLATE 4.5X422MM 20 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4408.92","3306.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3602.97","81.72","","5157.68","5157.68","5157.68","1 through 10","2304.1","3602.97","percent of total billed charges",""
"CONDYLAR PLATE 4.5X422MM 20 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4408.92","3306.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3602.97","81.72","","431.26","71.26","1459.57","88","2304.1","3602.97","percent of total billed charges",""
"CONDYLAR PLATE 4.5X458MM 22 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036515","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.85","3359.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3560.69","79.5","","800.18","480.96","1887.97","195","1388.44","3560.69","percent of total billed charges",""
"CONDYLAR PLATE 4.5X458MM 22 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036515","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.85","3359.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2387.23","53.3","","813.12","216.42","1444.50","81","1388.44","3560.69","percent of total billed charges",""
"CONDYLAR PLATE 4.5X458MM 22 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036515","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.85","3359.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1388.44","31","","432.60","432.60","432.60","1 through 10","1388.44","3560.69","percent of total billed charges",""
"CONDYLAR PLATE 4.5X458MM 22 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036515","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.85","3359.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1634.78","36.5","","148.37","54.89","631.39","94","1388.44","3560.69","percent of total billed charges",""
"CONDYLAR PLATE 4.5X458MM 22 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036515","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.85","3359.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1715.40","38.3","","279.30","91.72","1116.77","266","1388.44","3560.69","percent of total billed charges",""
"CONDYLAR PLATE 4.5X458MM 22 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036515","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.85","3359.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1921.43","42.9","","731.00","63.70","731.00","1 through 10","1388.44","3560.69","percent of total billed charges",""
"CONDYLAR PLATE 4.5X458MM 22 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036515","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.85","3359.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1921.43","42.9","","384.74","384.74","384.74","1 through 10","1388.44","3560.69","percent of total billed charges",""
"CONDYLAR PLATE 4.5X458MM 22 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036515","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.85","3359.14","WELLPOINT [1015]","HB AMC WELLPOINT","3304.50","73.78","","286.63","119.22","1107.45","105","1388.44","3560.69","percent of total billed charges",""
"CONDYLAR PLATE 4.5X458MM 22 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036515","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4478.85","3359.14","AETNA [1001]","HB AMC AETNA HMO","3126.24","69.8","","675.31","184.75","1721.50","286","2340.65","3660.12","percent of total billed charges",""
"CONDYLAR PLATE 4.5X458MM 22 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036515","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4478.85","3359.14","AETNA [1001]","HB AMC AETNA PPO","3601.00","80.4","","1261.44","103.12","1514.10","21","2340.65","3660.12","percent of total billed charges",""
"CONDYLAR PLATE 4.5X458MM 22 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036515","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4478.85","3359.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3601.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2340.65","3660.12","percent of total billed charges",""
"CONDYLAR PLATE 4.5X458MM 22 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036515","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4478.85","3359.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3660.12","81.72","","5157.68","5157.68","5157.68","1 through 10","2340.65","3660.12","percent of total billed charges",""
"CONDYLAR PLATE 4.5X458MM 22 HOLE LCP STAINLESS CURVED STEEL LEFT","SUP-ITM-10036515","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4478.85","3359.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3660.12","81.72","","431.26","71.26","1459.57","88","2340.65","3660.12","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X124MM 7 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002135","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.03","1793.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1900.87","79.5","","800.18","480.96","1887.97","195","741.22","1900.87","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X124MM 7 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002135","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.03","1793.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1274.42","53.3","","813.12","216.42","1444.50","81","741.22","1900.87","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X124MM 7 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002135","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.03","1793.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","741.22","31","","432.60","432.60","432.60","1 through 10","741.22","1900.87","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X124MM 7 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002135","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.03","1793.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","872.73","36.5","","148.37","54.89","631.39","94","741.22","1900.87","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X124MM 7 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002135","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.03","1793.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","915.76","38.3","","279.30","91.72","1116.77","266","741.22","1900.87","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X124MM 7 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002135","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.03","1793.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1025.75","42.9","","731.00","63.70","731.00","1 through 10","741.22","1900.87","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X124MM 7 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002135","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.03","1793.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1025.75","42.9","","384.74","384.74","384.74","1 through 10","741.22","1900.87","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X124MM 7 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002135","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.03","1793.27","WELLPOINT [1015]","HB AMC WELLPOINT","1764.10","73.78","","286.63","119.22","1107.45","105","741.22","1900.87","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X124MM 7 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2391.03","1793.27","AETNA [1001]","HB AMC AETNA HMO","1668.94","69.8","","675.31","184.75","1721.50","286","1249.55","1953.95","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X124MM 7 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2391.03","1793.27","AETNA [1001]","HB AMC AETNA PPO","1922.39","80.4","","1261.44","103.12","1514.10","21","1249.55","1953.95","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X124MM 7 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2391.03","1793.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1922.39","80.4","","1365.00","1365.00","1365.00","1 through 10","1249.55","1953.95","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X124MM 7 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2391.03","1793.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1953.95","81.72","","5157.68","5157.68","5157.68","1 through 10","1249.55","1953.95","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X124MM 7 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2391.03","1793.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1953.95","81.72","","431.26","71.26","1459.57","88","1249.55","1953.95","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X156MM 9 HOLE 95DEG LCP SS ANGLED BLADE","SUP-ITM-10001871","CDM","C1713","HCPCS","0278","RC","","","","both","","","2506.14","1879.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1992.38","79.5","","800.18","480.96","1887.97","195","776.9","1992.38","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X156MM 9 HOLE 95DEG LCP SS ANGLED BLADE","SUP-ITM-10001871","CDM","C1713","HCPCS","0278","RC","","","","both","","","2506.14","1879.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1335.77","53.3","","813.12","216.42","1444.50","81","776.9","1992.38","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X156MM 9 HOLE 95DEG LCP SS ANGLED BLADE","SUP-ITM-10001871","CDM","C1713","HCPCS","0278","RC","","","","both","","","2506.14","1879.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","776.90","31","","432.60","432.60","432.60","1 through 10","776.9","1992.38","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X156MM 9 HOLE 95DEG LCP SS ANGLED BLADE","SUP-ITM-10001871","CDM","C1713","HCPCS","0278","RC","","","","both","","","2506.14","1879.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","914.74","36.5","","148.37","54.89","631.39","94","776.9","1992.38","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X156MM 9 HOLE 95DEG LCP SS ANGLED BLADE","SUP-ITM-10001871","CDM","C1713","HCPCS","0278","RC","","","","both","","","2506.14","1879.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","959.85","38.3","","279.30","91.72","1116.77","266","776.9","1992.38","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X156MM 9 HOLE 95DEG LCP SS ANGLED BLADE","SUP-ITM-10001871","CDM","C1713","HCPCS","0278","RC","","","","both","","","2506.14","1879.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1075.13","42.9","","731.00","63.70","731.00","1 through 10","776.9","1992.38","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X156MM 9 HOLE 95DEG LCP SS ANGLED BLADE","SUP-ITM-10001871","CDM","C1713","HCPCS","0278","RC","","","","both","","","2506.14","1879.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1075.13","42.9","","384.74","384.74","384.74","1 through 10","776.9","1992.38","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X156MM 9 HOLE 95DEG LCP SS ANGLED BLADE","SUP-ITM-10001871","CDM","C1713","HCPCS","0278","RC","","","","both","","","2506.14","1879.60","WELLPOINT [1015]","HB AMC WELLPOINT","1849.03","73.78","","286.63","119.22","1107.45","105","776.9","1992.38","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X156MM 9 HOLE 95DEG LCP SS ANGLED BLADE","SUP-ITM-10001871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2506.14","1879.60","AETNA [1001]","HB AMC AETNA HMO","1749.29","69.8","","675.31","184.75","1721.50","286","1309.71","2048.02","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X156MM 9 HOLE 95DEG LCP SS ANGLED BLADE","SUP-ITM-10001871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2506.14","1879.60","AETNA [1001]","HB AMC AETNA PPO","2014.94","80.4","","1261.44","103.12","1514.10","21","1309.71","2048.02","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X156MM 9 HOLE 95DEG LCP SS ANGLED BLADE","SUP-ITM-10001871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2506.14","1879.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2014.94","80.4","","1365.00","1365.00","1365.00","1 through 10","1309.71","2048.02","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X156MM 9 HOLE 95DEG LCP SS ANGLED BLADE","SUP-ITM-10001871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2506.14","1879.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2048.02","81.72","","5157.68","5157.68","5157.68","1 through 10","1309.71","2048.02","percent of total billed charges",""
"CONDYLAR PLATE 4.5X80X156MM 9 HOLE 95DEG LCP SS ANGLED BLADE","SUP-ITM-10001871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2506.14","1879.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2048.02","81.72","","431.26","71.26","1459.57","88","1309.71","2048.02","percent of total billed charges",""
"CONDYLAR PLATE 60X299MM 18 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4098.87","3074.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3258.60","79.5","","800.18","480.96","1887.97","195","1270.65","3258.6","percent of total billed charges",""
"CONDYLAR PLATE 60X299MM 18 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4098.87","3074.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2184.70","53.3","","813.12","216.42","1444.50","81","1270.65","3258.6","percent of total billed charges",""
"CONDYLAR PLATE 60X299MM 18 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4098.87","3074.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1270.65","31","","432.60","432.60","432.60","1 through 10","1270.65","3258.6","percent of total billed charges",""
"CONDYLAR PLATE 60X299MM 18 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4098.87","3074.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1496.09","36.5","","148.37","54.89","631.39","94","1270.65","3258.6","percent of total billed charges",""
"CONDYLAR PLATE 60X299MM 18 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4098.87","3074.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1569.87","38.3","","279.30","91.72","1116.77","266","1270.65","3258.6","percent of total billed charges",""
"CONDYLAR PLATE 60X299MM 18 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4098.87","3074.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1758.42","42.9","","731.00","63.70","731.00","1 through 10","1270.65","3258.6","percent of total billed charges",""
"CONDYLAR PLATE 60X299MM 18 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4098.87","3074.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1758.42","42.9","","384.74","384.74","384.74","1 through 10","1270.65","3258.6","percent of total billed charges",""
"CONDYLAR PLATE 60X299MM 18 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002173","CDM","C1713","HCPCS","0278","RC","","","","both","","","4098.87","3074.15","WELLPOINT [1015]","HB AMC WELLPOINT","3024.15","73.78","","286.63","119.22","1107.45","105","1270.65","3258.6","percent of total billed charges",""
"CONDYLAR PLATE 60X299MM 18 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4098.87","3074.15","AETNA [1001]","HB AMC AETNA HMO","2861.01","69.8","","675.31","184.75","1721.50","286","2142.07","3349.6","percent of total billed charges",""
"CONDYLAR PLATE 60X299MM 18 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4098.87","3074.15","AETNA [1001]","HB AMC AETNA PPO","3295.49","80.4","","1261.44","103.12","1514.10","21","2142.07","3349.6","percent of total billed charges",""
"CONDYLAR PLATE 60X299MM 18 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4098.87","3074.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3295.49","80.4","","1365.00","1365.00","1365.00","1 through 10","2142.07","3349.6","percent of total billed charges",""
"CONDYLAR PLATE 60X299MM 18 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4098.87","3074.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3349.60","81.72","","5157.68","5157.68","5157.68","1 through 10","2142.07","3349.6","percent of total billed charges",""
"CONDYLAR PLATE 60X299MM 18 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4098.87","3074.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3349.60","81.72","","431.26","71.26","1459.57","88","2142.07","3349.6","percent of total billed charges",""
"CONDYLAR PLATE 60X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE STERILE","SUP-ITM-10001982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.86","1700.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1802.95","79.5","","800.18","480.96","1887.97","195","703.04","1802.95","percent of total billed charges",""
"CONDYLAR PLATE 60X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE STERILE","SUP-ITM-10001982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.86","1700.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1208.77","53.3","","813.12","216.42","1444.50","81","703.04","1802.95","percent of total billed charges",""
"CONDYLAR PLATE 60X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE STERILE","SUP-ITM-10001982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.86","1700.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","703.04","31","","432.60","432.60","432.60","1 through 10","703.04","1802.95","percent of total billed charges",""
"CONDYLAR PLATE 60X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE STERILE","SUP-ITM-10001982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.86","1700.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","827.77","36.5","","148.37","54.89","631.39","94","703.04","1802.95","percent of total billed charges",""
"CONDYLAR PLATE 60X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE STERILE","SUP-ITM-10001982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.86","1700.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","868.59","38.3","","279.30","91.72","1116.77","266","703.04","1802.95","percent of total billed charges",""
"CONDYLAR PLATE 60X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE STERILE","SUP-ITM-10001982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.86","1700.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","972.91","42.9","","731.00","63.70","731.00","1 through 10","703.04","1802.95","percent of total billed charges",""
"CONDYLAR PLATE 60X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE STERILE","SUP-ITM-10001982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.86","1700.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","972.91","42.9","","384.74","384.74","384.74","1 through 10","703.04","1802.95","percent of total billed charges",""
"CONDYLAR PLATE 60X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE STERILE","SUP-ITM-10001982","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.86","1700.89","WELLPOINT [1015]","HB AMC WELLPOINT","1673.23","73.78","","286.63","119.22","1107.45","105","703.04","1802.95","percent of total billed charges",""
"CONDYLAR PLATE 60X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE STERILE","SUP-ITM-10001982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2267.86","1700.89","AETNA [1001]","HB AMC AETNA HMO","1582.97","69.8","","675.31","184.75","1721.50","286","1185.18","1853.3","percent of total billed charges",""
"CONDYLAR PLATE 60X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE STERILE","SUP-ITM-10001982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2267.86","1700.89","AETNA [1001]","HB AMC AETNA PPO","1823.36","80.4","","1261.44","103.12","1514.10","21","1185.18","1853.3","percent of total billed charges",""
"CONDYLAR PLATE 60X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE STERILE","SUP-ITM-10001982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2267.86","1700.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1823.36","80.4","","1365.00","1365.00","1365.00","1 through 10","1185.18","1853.3","percent of total billed charges",""
"CONDYLAR PLATE 60X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE STERILE","SUP-ITM-10001982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2267.86","1700.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1853.30","81.72","","5157.68","5157.68","5157.68","1 through 10","1185.18","1853.3","percent of total billed charges",""
"CONDYLAR PLATE 60X92MM 5 HOLE 95DEG DCP SS ANGLED BLADE STERILE","SUP-ITM-10001982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2267.86","1700.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1853.30","81.72","","431.26","71.26","1459.57","88","1185.18","1853.3","percent of total billed charges",""
"CONDYLAR PLATE 70X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10001758","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3248.27","79.5","","800.18","480.96","1887.97","195","1266.62","3248.27","percent of total billed charges",""
"CONDYLAR PLATE 70X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10001758","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2177.77","53.3","","813.12","216.42","1444.50","81","1266.62","3248.27","percent of total billed charges",""
"CONDYLAR PLATE 70X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10001758","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1266.62","31","","432.60","432.60","432.60","1 through 10","1266.62","3248.27","percent of total billed charges",""
"CONDYLAR PLATE 70X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10001758","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1491.34","36.5","","148.37","54.89","631.39","94","1266.62","3248.27","percent of total billed charges",""
"CONDYLAR PLATE 70X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10001758","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1564.89","38.3","","279.30","91.72","1116.77","266","1266.62","3248.27","percent of total billed charges",""
"CONDYLAR PLATE 70X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10001758","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1752.84","42.9","","731.00","63.70","731.00","1 through 10","1266.62","3248.27","percent of total billed charges",""
"CONDYLAR PLATE 70X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10001758","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1752.84","42.9","","384.74","384.74","384.74","1 through 10","1266.62","3248.27","percent of total billed charges",""
"CONDYLAR PLATE 70X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10001758","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.87","3064.40","WELLPOINT [1015]","HB AMC WELLPOINT","3014.55","73.78","","286.63","119.22","1107.45","105","1266.62","3248.27","percent of total billed charges",""
"CONDYLAR PLATE 70X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10001758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.87","3064.40","AETNA [1001]","HB AMC AETNA HMO","2851.94","69.8","","675.31","184.75","1721.50","286","2135.28","3338.97","percent of total billed charges",""
"CONDYLAR PLATE 70X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10001758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.87","3064.40","AETNA [1001]","HB AMC AETNA PPO","3285.04","80.4","","1261.44","103.12","1514.10","21","2135.28","3338.97","percent of total billed charges",""
"CONDYLAR PLATE 70X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10001758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.87","3064.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3285.04","80.4","","1365.00","1365.00","1365.00","1 through 10","2135.28","3338.97","percent of total billed charges",""
"CONDYLAR PLATE 70X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10001758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.87","3064.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3338.97","81.72","","5157.68","5157.68","5157.68","1 through 10","2135.28","3338.97","percent of total billed charges",""
"CONDYLAR PLATE 70X235MM 14 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10001758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.87","3064.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3338.97","81.72","","431.26","71.26","1459.57","88","2135.28","3338.97","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2728.39","2046.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2169.07","79.5","","800.18","480.96","1887.97","195","845.8","2169.07","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2728.39","2046.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1454.23","53.3","","813.12","216.42","1444.50","81","845.8","2169.07","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2728.39","2046.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","845.80","31","","432.60","432.60","432.60","1 through 10","845.8","2169.07","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2728.39","2046.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","995.86","36.5","","148.37","54.89","631.39","94","845.8","2169.07","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2728.39","2046.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1044.97","38.3","","279.30","91.72","1116.77","266","845.8","2169.07","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2728.39","2046.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1170.48","42.9","","731.00","63.70","731.00","1 through 10","845.8","2169.07","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2728.39","2046.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1170.48","42.9","","384.74","384.74","384.74","1 through 10","845.8","2169.07","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2728.39","2046.29","WELLPOINT [1015]","HB AMC WELLPOINT","2013.01","73.78","","286.63","119.22","1107.45","105","845.8","2169.07","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2728.39","2046.29","AETNA [1001]","HB AMC AETNA HMO","1904.42","69.8","","675.31","184.75","1721.50","286","1425.86","2229.64","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2728.39","2046.29","AETNA [1001]","HB AMC AETNA PPO","2193.63","80.4","","1261.44","103.12","1514.10","21","1425.86","2229.64","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2728.39","2046.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2193.63","80.4","","1365.00","1365.00","1365.00","1 through 10","1425.86","2229.64","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2728.39","2046.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2229.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1425.86","2229.64","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2728.39","2046.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2229.64","81.72","","431.26","71.26","1459.57","88","1425.86","2229.64","percent of total billed charges",""
"CONDYLAR PLATE 80X267MM 16 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10030095","CDM","C1713","HCPCS","0278","RC","","","","both","","","4321.49","3241.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3435.58","79.5","","800.18","480.96","1887.97","195","1339.66","3435.58","percent of total billed charges",""
"CONDYLAR PLATE 80X267MM 16 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10030095","CDM","C1713","HCPCS","0278","RC","","","","both","","","4321.49","3241.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2303.35","53.3","","813.12","216.42","1444.50","81","1339.66","3435.58","percent of total billed charges",""
"CONDYLAR PLATE 80X267MM 16 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10030095","CDM","C1713","HCPCS","0278","RC","","","","both","","","4321.49","3241.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1339.66","31","","432.60","432.60","432.60","1 through 10","1339.66","3435.58","percent of total billed charges",""
"CONDYLAR PLATE 80X267MM 16 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10030095","CDM","C1713","HCPCS","0278","RC","","","","both","","","4321.49","3241.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1577.34","36.5","","148.37","54.89","631.39","94","1339.66","3435.58","percent of total billed charges",""
"CONDYLAR PLATE 80X267MM 16 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10030095","CDM","C1713","HCPCS","0278","RC","","","","both","","","4321.49","3241.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1655.13","38.3","","279.30","91.72","1116.77","266","1339.66","3435.58","percent of total billed charges",""
"CONDYLAR PLATE 80X267MM 16 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10030095","CDM","C1713","HCPCS","0278","RC","","","","both","","","4321.49","3241.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1853.92","42.9","","731.00","63.70","731.00","1 through 10","1339.66","3435.58","percent of total billed charges",""
"CONDYLAR PLATE 80X267MM 16 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10030095","CDM","C1713","HCPCS","0278","RC","","","","both","","","4321.49","3241.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1853.92","42.9","","384.74","384.74","384.74","1 through 10","1339.66","3435.58","percent of total billed charges",""
"CONDYLAR PLATE 80X267MM 16 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10030095","CDM","C1713","HCPCS","0278","RC","","","","both","","","4321.49","3241.12","WELLPOINT [1015]","HB AMC WELLPOINT","3188.40","73.78","","286.63","119.22","1107.45","105","1339.66","3435.58","percent of total billed charges",""
"CONDYLAR PLATE 80X267MM 16 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10030095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4321.49","3241.12","AETNA [1001]","HB AMC AETNA HMO","3016.40","69.8","","675.31","184.75","1721.50","286","2258.41","3531.52","percent of total billed charges",""
"CONDYLAR PLATE 80X267MM 16 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10030095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4321.49","3241.12","AETNA [1001]","HB AMC AETNA PPO","3474.48","80.4","","1261.44","103.12","1514.10","21","2258.41","3531.52","percent of total billed charges",""
"CONDYLAR PLATE 80X267MM 16 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10030095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4321.49","3241.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3474.48","80.4","","1365.00","1365.00","1365.00","1 through 10","2258.41","3531.52","percent of total billed charges",""
"CONDYLAR PLATE 80X267MM 16 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10030095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4321.49","3241.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3531.52","81.72","","5157.68","5157.68","5157.68","1 through 10","2258.41","3531.52","percent of total billed charges",""
"CONDYLAR PLATE 80X267MM 16 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10030095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4321.49","3241.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3531.52","81.72","","431.26","71.26","1459.57","88","2258.41","3531.52","percent of total billed charges",""
"CONE ARCOS 80MM SZ E HIP MODULAR FEMORAL REVISON SYSTEM BODY HO 03","SUP-ITM-10101095","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2632.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE ARCOS 80MM SZ E HIP MODULAR FEMORAL REVISON SYSTEM BODY HO 03","SUP-ITM-10101095","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4004.72","79.5","","1293.60","1148.53","1603.80","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE ARCOS 80MM SZ E HIP MODULAR FEMORAL REVISON SYSTEM BODY HO 03","SUP-ITM-10101095","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1838.64","36.5","","1023.42","771.29","2068.67","33","1561.59","4004.72","percent of total billed charges",""
"CONE ARCOS 80MM SZ E HIP MODULAR FEMORAL REVISON SYSTEM BODY HO 03","SUP-ITM-10101095","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1929.32","38.3","","850.52","759.78","1211.25","66","1561.59","4004.72","percent of total billed charges",""
"CONE ARCOS 80MM SZ E HIP MODULAR FEMORAL REVISON SYSTEM BODY HO 03","SUP-ITM-10101095","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2161.04","42.9","","2548.09","2548.09","2548.09","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE ARCOS 80MM SZ E HIP MODULAR FEMORAL REVISON SYSTEM BODY HO 03","SUP-ITM-10101095","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2161.04","42.9","","956.46","956.46","956.46","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE ARCOS 80MM SZ E HIP MODULAR FEMORAL REVISON SYSTEM BODY HO 03","SUP-ITM-10101095","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","WELLPOINT [1015]","HB AMC WELLPOINT","3716.58","73.78","","2344.73","1619.47","2530.35","16","1561.59","4004.72","percent of total billed charges",""
"CONE ARCOS 80MM SZ E HIP MODULAR FEMORAL REVISON SYSTEM BODY HO 03","SUP-ITM-10101095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","AETNA [1001]","HB AMC AETNA HMO","3516.09","69.8","","1523.63","988.41","4330.26","39","2632.53","4116.55","percent of total billed charges",""
"CONE ARCOS 80MM SZ E HIP MODULAR FEMORAL REVISON SYSTEM BODY HO 03","SUP-ITM-10101095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","AETNA [1001]","HB AMC AETNA PPO","4050.05","80.4","","1670.25","1670.25","1670.25","1 through 10","2632.53","4116.55","percent of total billed charges",""
"CONE ARCOS 80MM SZ E HIP MODULAR FEMORAL REVISON SYSTEM BODY HO 03","SUP-ITM-10101095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2632.53","52.26","","1113.10","1113.10","1113.10","1 through 10","2632.53","4116.55","percent of total billed charges",""
"CONE ARCOS 80MM SZ E HIP MODULAR FEMORAL REVISON SYSTEM BODY HO 03","SUP-ITM-10101095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4116.55","81.72","","1738.90","1484.65","2716.94","38","2632.53","4116.55","percent of total billed charges",""
"CONE FEMORAL 31MMX25 MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10116067","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2500.84","52.26","","1113.10","1113.10","1113.10","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 31MMX25 MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10116067","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3804.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 31MMX25 MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10116067","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1746.66","36.5","","1023.42","771.29","2068.67","33","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 31MMX25 MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10116067","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1832.80","38.3","","850.52","759.78","1211.25","66","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 31MMX25 MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10116067","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2052.93","42.9","","2548.09","2548.09","2548.09","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 31MMX25 MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10116067","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2052.93","42.9","","956.46","956.46","956.46","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 31MMX25 MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10116067","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","WELLPOINT [1015]","HB AMC WELLPOINT","3530.65","73.78","","2344.73","1619.47","2530.35","16","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 31MMX25 MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10116067","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","AETNA [1001]","HB AMC AETNA HMO","3340.20","69.8","","1523.63","988.41","4330.26","39","2500.84","3910.61","percent of total billed charges",""
"CONE FEMORAL 31MMX25 MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10116067","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","AETNA [1001]","HB AMC AETNA PPO","3847.45","80.4","","1670.25","1670.25","1670.25","1 through 10","2500.84","3910.61","percent of total billed charges",""
"CONE FEMORAL 31MMX25 MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10116067","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2500.84","52.26","","1113.10","1113.10","1113.10","1 through 10","2500.84","3910.61","percent of total billed charges",""
"CONE FEMORAL 31MMX25 MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10116067","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3910.61","81.72","","1738.90","1484.65","2716.94","38","2500.84","3910.61","percent of total billed charges",""
"CONE FEMORAL 50MM LG KNEE AUGMENT TRABECULAR METAL LEFT","SUP-ITM-10021562","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2381.75","52.26","","1113.10","1113.10","1113.10","1 through 10","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM LG KNEE AUGMENT TRABECULAR METAL LEFT","SUP-ITM-10021562","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3623.21","79.5","","1293.60","1148.53","1603.80","1 through 10","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM LG KNEE AUGMENT TRABECULAR METAL LEFT","SUP-ITM-10021562","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1663.49","36.5","","1023.42","771.29","2068.67","33","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM LG KNEE AUGMENT TRABECULAR METAL LEFT","SUP-ITM-10021562","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1745.52","38.3","","850.52","759.78","1211.25","66","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM LG KNEE AUGMENT TRABECULAR METAL LEFT","SUP-ITM-10021562","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.17","42.9","","2548.09","2548.09","2548.09","1 through 10","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM LG KNEE AUGMENT TRABECULAR METAL LEFT","SUP-ITM-10021562","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.17","42.9","","956.46","956.46","956.46","1 through 10","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM LG KNEE AUGMENT TRABECULAR METAL LEFT","SUP-ITM-10021562","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","WELLPOINT [1015]","HB AMC WELLPOINT","3362.52","73.78","","2344.73","1619.47","2530.35","16","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM LG KNEE AUGMENT TRABECULAR METAL LEFT","SUP-ITM-10021562","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","AETNA [1001]","HB AMC AETNA HMO","3181.14","69.8","","1523.63","988.41","4330.26","39","2381.75","3724.39","percent of total billed charges",""
"CONE FEMORAL 50MM LG KNEE AUGMENT TRABECULAR METAL LEFT","SUP-ITM-10021562","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","AETNA [1001]","HB AMC AETNA PPO","3664.23","80.4","","1670.25","1670.25","1670.25","1 through 10","2381.75","3724.39","percent of total billed charges",""
"CONE FEMORAL 50MM LG KNEE AUGMENT TRABECULAR METAL LEFT","SUP-ITM-10021562","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2381.75","52.26","","1113.10","1113.10","1113.10","1 through 10","2381.75","3724.39","percent of total billed charges",""
"CONE FEMORAL 50MM LG KNEE AUGMENT TRABECULAR METAL LEFT","SUP-ITM-10021562","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3724.39","81.72","","1738.90","1484.65","2716.94","38","2381.75","3724.39","percent of total billed charges",""
"CONE FEMORAL 50MM MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10049167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3623.21","79.5","","800.18","480.96","1887.97","195","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10049167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2429.15","53.3","","813.12","216.42","1444.50","81","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10049167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1412.83","31","","432.60","432.60","432.60","1 through 10","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10049167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1663.49","36.5","","148.37","54.89","631.39","94","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10049167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1745.52","38.3","","279.30","91.72","1116.77","266","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10049167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.17","42.9","","731.00","63.70","731.00","1 through 10","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10049167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.17","42.9","","384.74","384.74","384.74","1 through 10","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10049167","CDM","C1713","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","WELLPOINT [1015]","HB AMC WELLPOINT","3362.52","73.78","","286.63","119.22","1107.45","105","1412.83","3623.21","percent of total billed charges",""
"CONE FEMORAL 50MM MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10049167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","AETNA [1001]","HB AMC AETNA HMO","3181.14","69.8","","675.31","184.75","1721.50","286","2381.75","3724.39","percent of total billed charges",""
"CONE FEMORAL 50MM MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10049167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","AETNA [1001]","HB AMC AETNA PPO","3664.23","80.4","","1261.44","103.12","1514.10","21","2381.75","3724.39","percent of total billed charges",""
"CONE FEMORAL 50MM MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10049167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3664.23","80.4","","1365.00","1365.00","1365.00","1 through 10","2381.75","3724.39","percent of total billed charges",""
"CONE FEMORAL 50MM MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10049167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3724.39","81.72","","5157.68","5157.68","5157.68","1 through 10","2381.75","3724.39","percent of total billed charges",""
"CONE FEMORAL 50MM MED KNEE TRABECULAR METAL AUGMENT RT IMPLANT 19 NC","SUP-ITM-10049167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3724.39","81.72","","431.26","71.26","1459.57","88","2381.75","3724.39","percent of total billed charges",""
"CONE FEMORAL 51MMX34 25 KNEE TRABECULAR METAL AUGMENT RT LRG 19 NC","SUP-ITM-10132458","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2500.84","52.26","","1113.10","1113.10","1113.10","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 51MMX34 25 KNEE TRABECULAR METAL AUGMENT RT LRG 19 NC","SUP-ITM-10132458","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3804.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 51MMX34 25 KNEE TRABECULAR METAL AUGMENT RT LRG 19 NC","SUP-ITM-10132458","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1746.66","36.5","","1023.42","771.29","2068.67","33","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 51MMX34 25 KNEE TRABECULAR METAL AUGMENT RT LRG 19 NC","SUP-ITM-10132458","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1832.80","38.3","","850.52","759.78","1211.25","66","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 51MMX34 25 KNEE TRABECULAR METAL AUGMENT RT LRG 19 NC","SUP-ITM-10132458","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2052.93","42.9","","2548.09","2548.09","2548.09","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 51MMX34 25 KNEE TRABECULAR METAL AUGMENT RT LRG 19 NC","SUP-ITM-10132458","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2052.93","42.9","","956.46","956.46","956.46","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 51MMX34 25 KNEE TRABECULAR METAL AUGMENT RT LRG 19 NC","SUP-ITM-10132458","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","WELLPOINT [1015]","HB AMC WELLPOINT","3530.65","73.78","","2344.73","1619.47","2530.35","16","1483.47","3804.38","percent of total billed charges",""
"CONE FEMORAL 51MMX34 25 KNEE TRABECULAR METAL AUGMENT RT LRG 19 NC","SUP-ITM-10132458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","AETNA [1001]","HB AMC AETNA HMO","3340.20","69.8","","1523.63","988.41","4330.26","39","2500.84","3910.61","percent of total billed charges",""
"CONE FEMORAL 51MMX34 25 KNEE TRABECULAR METAL AUGMENT RT LRG 19 NC","SUP-ITM-10132458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","AETNA [1001]","HB AMC AETNA PPO","3847.45","80.4","","1670.25","1670.25","1670.25","1 through 10","2500.84","3910.61","percent of total billed charges",""
"CONE FEMORAL 51MMX34 25 KNEE TRABECULAR METAL AUGMENT RT LRG 19 NC","SUP-ITM-10132458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2500.84","52.26","","1113.10","1113.10","1113.10","1 through 10","2500.84","3910.61","percent of total billed charges",""
"CONE FEMORAL 51MMX34 25 KNEE TRABECULAR METAL AUGMENT RT LRG 19 NC","SUP-ITM-10132458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3910.61","81.72","","1738.90","1484.65","2716.94","38","2500.84","3910.61","percent of total billed charges",""
"CONE FEMORAL 60MM SIZE A HIP ACROS TITANIUM REVISION PROXIMALIMAL BROACHED ARCOS HIGH OFFSET","SUP-ITM-10101027","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2632.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE FEMORAL 60MM SIZE A HIP ACROS TITANIUM REVISION PROXIMALIMAL BROACHED ARCOS HIGH OFFSET","SUP-ITM-10101027","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4004.72","79.5","","1293.60","1148.53","1603.80","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE FEMORAL 60MM SIZE A HIP ACROS TITANIUM REVISION PROXIMALIMAL BROACHED ARCOS HIGH OFFSET","SUP-ITM-10101027","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1838.64","36.5","","1023.42","771.29","2068.67","33","1561.59","4004.72","percent of total billed charges",""
"CONE FEMORAL 60MM SIZE A HIP ACROS TITANIUM REVISION PROXIMALIMAL BROACHED ARCOS HIGH OFFSET","SUP-ITM-10101027","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1929.32","38.3","","850.52","759.78","1211.25","66","1561.59","4004.72","percent of total billed charges",""
"CONE FEMORAL 60MM SIZE A HIP ACROS TITANIUM REVISION PROXIMALIMAL BROACHED ARCOS HIGH OFFSET","SUP-ITM-10101027","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2161.04","42.9","","2548.09","2548.09","2548.09","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE FEMORAL 60MM SIZE A HIP ACROS TITANIUM REVISION PROXIMALIMAL BROACHED ARCOS HIGH OFFSET","SUP-ITM-10101027","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2161.04","42.9","","956.46","956.46","956.46","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE FEMORAL 60MM SIZE A HIP ACROS TITANIUM REVISION PROXIMALIMAL BROACHED ARCOS HIGH OFFSET","SUP-ITM-10101027","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","WELLPOINT [1015]","HB AMC WELLPOINT","3716.58","73.78","","2344.73","1619.47","2530.35","16","1561.59","4004.72","percent of total billed charges",""
"CONE FEMORAL 60MM SIZE A HIP ACROS TITANIUM REVISION PROXIMALIMAL BROACHED ARCOS HIGH OFFSET","SUP-ITM-10101027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","AETNA [1001]","HB AMC AETNA HMO","3516.09","69.8","","1523.63","988.41","4330.26","39","2632.53","4116.55","percent of total billed charges",""
"CONE FEMORAL 60MM SIZE A HIP ACROS TITANIUM REVISION PROXIMALIMAL BROACHED ARCOS HIGH OFFSET","SUP-ITM-10101027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","AETNA [1001]","HB AMC AETNA PPO","4050.05","80.4","","1670.25","1670.25","1670.25","1 through 10","2632.53","4116.55","percent of total billed charges",""
"CONE FEMORAL 60MM SIZE A HIP ACROS TITANIUM REVISION PROXIMALIMAL BROACHED ARCOS HIGH OFFSET","SUP-ITM-10101027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2632.53","52.26","","1113.10","1113.10","1113.10","1 through 10","2632.53","4116.55","percent of total billed charges",""
"CONE FEMORAL 60MM SIZE A HIP ACROS TITANIUM REVISION PROXIMALIMAL BROACHED ARCOS HIGH OFFSET","SUP-ITM-10101027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4116.55","81.72","","1738.90","1484.65","2716.94","38","2632.53","4116.55","percent of total billed charges",""
"CONE HIP 60MM ACROS TITANIUM REVISION PROXIMALIMAL ARCOS HIGH OFFSET","SUP-ITM-10201931","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2632.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE HIP 60MM ACROS TITANIUM REVISION PROXIMALIMAL ARCOS HIGH OFFSET","SUP-ITM-10201931","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4004.72","79.5","","1293.60","1148.53","1603.80","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE HIP 60MM ACROS TITANIUM REVISION PROXIMALIMAL ARCOS HIGH OFFSET","SUP-ITM-10201931","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1838.64","36.5","","1023.42","771.29","2068.67","33","1561.59","4004.72","percent of total billed charges",""
"CONE HIP 60MM ACROS TITANIUM REVISION PROXIMALIMAL ARCOS HIGH OFFSET","SUP-ITM-10201931","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1929.32","38.3","","850.52","759.78","1211.25","66","1561.59","4004.72","percent of total billed charges",""
"CONE HIP 60MM ACROS TITANIUM REVISION PROXIMALIMAL ARCOS HIGH OFFSET","SUP-ITM-10201931","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2161.04","42.9","","2548.09","2548.09","2548.09","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE HIP 60MM ACROS TITANIUM REVISION PROXIMALIMAL ARCOS HIGH OFFSET","SUP-ITM-10201931","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2161.04","42.9","","956.46","956.46","956.46","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE HIP 60MM ACROS TITANIUM REVISION PROXIMALIMAL ARCOS HIGH OFFSET","SUP-ITM-10201931","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","WELLPOINT [1015]","HB AMC WELLPOINT","3716.58","73.78","","2344.73","1619.47","2530.35","16","1561.59","4004.72","percent of total billed charges",""
"CONE HIP 60MM ACROS TITANIUM REVISION PROXIMALIMAL ARCOS HIGH OFFSET","SUP-ITM-10201931","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","AETNA [1001]","HB AMC AETNA HMO","3516.09","69.8","","1523.63","988.41","4330.26","39","2632.53","4116.55","percent of total billed charges",""
"CONE HIP 60MM ACROS TITANIUM REVISION PROXIMALIMAL ARCOS HIGH OFFSET","SUP-ITM-10201931","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","AETNA [1001]","HB AMC AETNA PPO","4050.05","80.4","","1670.25","1670.25","1670.25","1 through 10","2632.53","4116.55","percent of total billed charges",""
"CONE HIP 60MM ACROS TITANIUM REVISION PROXIMALIMAL ARCOS HIGH OFFSET","SUP-ITM-10201931","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2632.53","52.26","","1113.10","1113.10","1113.10","1 through 10","2632.53","4116.55","percent of total billed charges",""
"CONE HIP 60MM ACROS TITANIUM REVISION PROXIMALIMAL ARCOS HIGH OFFSET","SUP-ITM-10201931","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4116.55","81.72","","1738.90","1484.65","2716.94","38","2632.53","4116.55","percent of total billed charges",""
"CONE KNEE 15X30MM SIZE 59 TIBIAL NEXGEN TRABECULAR METAL RT 19 NC","SUP-ITM-10049175","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2500.84","52.26","","1113.10","1113.10","1113.10","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 15X30MM SIZE 59 TIBIAL NEXGEN TRABECULAR METAL RT 19 NC","SUP-ITM-10049175","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3804.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 15X30MM SIZE 59 TIBIAL NEXGEN TRABECULAR METAL RT 19 NC","SUP-ITM-10049175","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1746.66","36.5","","1023.42","771.29","2068.67","33","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 15X30MM SIZE 59 TIBIAL NEXGEN TRABECULAR METAL RT 19 NC","SUP-ITM-10049175","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1832.80","38.3","","850.52","759.78","1211.25","66","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 15X30MM SIZE 59 TIBIAL NEXGEN TRABECULAR METAL RT 19 NC","SUP-ITM-10049175","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2052.93","42.9","","2548.09","2548.09","2548.09","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 15X30MM SIZE 59 TIBIAL NEXGEN TRABECULAR METAL RT 19 NC","SUP-ITM-10049175","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2052.93","42.9","","956.46","956.46","956.46","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 15X30MM SIZE 59 TIBIAL NEXGEN TRABECULAR METAL RT 19 NC","SUP-ITM-10049175","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","WELLPOINT [1015]","HB AMC WELLPOINT","3530.65","73.78","","2344.73","1619.47","2530.35","16","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 15X30MM SIZE 59 TIBIAL NEXGEN TRABECULAR METAL RT 19 NC","SUP-ITM-10049175","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","AETNA [1001]","HB AMC AETNA HMO","3340.20","69.8","","1523.63","988.41","4330.26","39","2500.84","3910.61","percent of total billed charges",""
"CONE KNEE 15X30MM SIZE 59 TIBIAL NEXGEN TRABECULAR METAL RT 19 NC","SUP-ITM-10049175","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","AETNA [1001]","HB AMC AETNA PPO","3847.45","80.4","","1670.25","1670.25","1670.25","1 through 10","2500.84","3910.61","percent of total billed charges",""
"CONE KNEE 15X30MM SIZE 59 TIBIAL NEXGEN TRABECULAR METAL RT 19 NC","SUP-ITM-10049175","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2500.84","52.26","","1113.10","1113.10","1113.10","1 through 10","2500.84","3910.61","percent of total billed charges",""
"CONE KNEE 15X30MM SIZE 59 TIBIAL NEXGEN TRABECULAR METAL RT 19 NC","SUP-ITM-10049175","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3910.61","81.72","","1738.90","1484.65","2716.94","38","2500.84","3910.61","percent of total billed charges",""
"CONE KNEE 35MM SMALL TRABECULAR METAL FEMORAL METAPHYSEAL SZ RT 20","SUP-ITM-10192383","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2500.84","52.26","","1113.10","1113.10","1113.10","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 35MM SMALL TRABECULAR METAL FEMORAL METAPHYSEAL SZ RT 20","SUP-ITM-10192383","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3804.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 35MM SMALL TRABECULAR METAL FEMORAL METAPHYSEAL SZ RT 20","SUP-ITM-10192383","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1746.66","36.5","","1023.42","771.29","2068.67","33","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 35MM SMALL TRABECULAR METAL FEMORAL METAPHYSEAL SZ RT 20","SUP-ITM-10192383","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1832.80","38.3","","850.52","759.78","1211.25","66","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 35MM SMALL TRABECULAR METAL FEMORAL METAPHYSEAL SZ RT 20","SUP-ITM-10192383","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2052.93","42.9","","2548.09","2548.09","2548.09","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 35MM SMALL TRABECULAR METAL FEMORAL METAPHYSEAL SZ RT 20","SUP-ITM-10192383","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2052.93","42.9","","956.46","956.46","956.46","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 35MM SMALL TRABECULAR METAL FEMORAL METAPHYSEAL SZ RT 20","SUP-ITM-10192383","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","WELLPOINT [1015]","HB AMC WELLPOINT","3530.65","73.78","","2344.73","1619.47","2530.35","16","1483.47","3804.38","percent of total billed charges",""
"CONE KNEE 35MM SMALL TRABECULAR METAL FEMORAL METAPHYSEAL SZ RT 20","SUP-ITM-10192383","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","AETNA [1001]","HB AMC AETNA HMO","3340.20","69.8","","1523.63","988.41","4330.26","39","2500.84","3910.61","percent of total billed charges",""
"CONE KNEE 35MM SMALL TRABECULAR METAL FEMORAL METAPHYSEAL SZ RT 20","SUP-ITM-10192383","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","AETNA [1001]","HB AMC AETNA PPO","3847.45","80.4","","1670.25","1670.25","1670.25","1 through 10","2500.84","3910.61","percent of total billed charges",""
"CONE KNEE 35MM SMALL TRABECULAR METAL FEMORAL METAPHYSEAL SZ RT 20","SUP-ITM-10192383","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2500.84","52.26","","1113.10","1113.10","1113.10","1 through 10","2500.84","3910.61","percent of total billed charges",""
"CONE KNEE 35MM SMALL TRABECULAR METAL FEMORAL METAPHYSEAL SZ RT 20","SUP-ITM-10192383","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3910.61","81.72","","1738.90","1484.65","2716.94","38","2500.84","3910.61","percent of total billed charges",""
"CONE TIBIAL 15MM XS SIZE 48 KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10030248","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2500.84","52.26","","1113.10","1113.10","1113.10","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE TIBIAL 15MM XS SIZE 48 KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10030248","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3804.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE TIBIAL 15MM XS SIZE 48 KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10030248","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1746.66","36.5","","1023.42","771.29","2068.67","33","1483.47","3804.38","percent of total billed charges",""
"CONE TIBIAL 15MM XS SIZE 48 KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10030248","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1832.80","38.3","","850.52","759.78","1211.25","66","1483.47","3804.38","percent of total billed charges",""
"CONE TIBIAL 15MM XS SIZE 48 KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10030248","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2052.93","42.9","","2548.09","2548.09","2548.09","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE TIBIAL 15MM XS SIZE 48 KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10030248","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2052.93","42.9","","956.46","956.46","956.46","1 through 10","1483.47","3804.38","percent of total billed charges",""
"CONE TIBIAL 15MM XS SIZE 48 KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10030248","CDM","C1776","HCPCS","0278","RC","","","","both","","","4785.38","3589.03","WELLPOINT [1015]","HB AMC WELLPOINT","3530.65","73.78","","2344.73","1619.47","2530.35","16","1483.47","3804.38","percent of total billed charges",""
"CONE TIBIAL 15MM XS SIZE 48 KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10030248","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","AETNA [1001]","HB AMC AETNA HMO","3340.20","69.8","","1523.63","988.41","4330.26","39","2500.84","3910.61","percent of total billed charges",""
"CONE TIBIAL 15MM XS SIZE 48 KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10030248","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","AETNA [1001]","HB AMC AETNA PPO","3847.45","80.4","","1670.25","1670.25","1670.25","1 through 10","2500.84","3910.61","percent of total billed charges",""
"CONE TIBIAL 15MM XS SIZE 48 KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10030248","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2500.84","52.26","","1113.10","1113.10","1113.10","1 through 10","2500.84","3910.61","percent of total billed charges",""
"CONE TIBIAL 15MM XS SIZE 48 KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10030248","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4785.38","3589.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3910.61","81.72","","1738.90","1484.65","2716.94","38","2500.84","3910.61","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2632.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4004.72","79.5","","1293.60","1148.53","1603.80","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1838.64","36.5","","1023.42","771.29","2068.67","33","1561.59","4004.72","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1929.32","38.3","","850.52","759.78","1211.25","66","1561.59","4004.72","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2161.04","42.9","","2548.09","2548.09","2548.09","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2161.04","42.9","","956.46","956.46","956.46","1 through 10","1561.59","4004.72","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5037.38","3778.03","WELLPOINT [1015]","HB AMC WELLPOINT","3716.58","73.78","","2344.73","1619.47","2530.35","16","1561.59","4004.72","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","AETNA [1001]","HB AMC AETNA HMO","3516.09","69.8","","1523.63","988.41","4330.26","39","2632.53","4116.55","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","AETNA [1001]","HB AMC AETNA PPO","4050.05","80.4","","1670.25","1670.25","1670.25","1 through 10","2632.53","4116.55","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2632.53","52.26","","1113.10","1113.10","1113.10","1 through 10","2632.53","4116.55","percent of total billed charges",""
"CONE TITANIUM 70MM SIZE C COMPONENT FEMORAL HIP ACROS REVISION PROXIMALIMAL BODY STANDARD OFFSET","SUP-ITM-10101078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5037.38","3778.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4116.55","81.72","","1738.90","1484.65","2716.94","38","2632.53","4116.55","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4133.31","52.26","","1113.10","1113.10","1113.10","1 through 10","2451.83","6287.76","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6287.76","79.5","","1293.60","1148.53","1603.80","1 through 10","2451.83","6287.76","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2886.83","36.5","","1023.42","771.29","2068.67","33","2451.83","6287.76","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3029.20","38.3","","850.52","759.78","1211.25","66","2451.83","6287.76","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3393.02","42.9","","2548.09","2548.09","2548.09","1 through 10","2451.83","6287.76","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3393.02","42.9","","956.46","956.46","956.46","1 through 10","2451.83","6287.76","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","WELLPOINT [1015]","HB AMC WELLPOINT","5835.36","73.78","","2344.73","1619.47","2530.35","16","2451.83","6287.76","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7909.13","5931.85","AETNA [1001]","HB AMC AETNA HMO","5520.57","69.8","","1523.63","988.41","4330.26","39","4133.31","6463.34","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7909.13","5931.85","AETNA [1001]","HB AMC AETNA PPO","6358.94","80.4","","1670.25","1670.25","1670.25","1 through 10","4133.31","6463.34","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7909.13","5931.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4133.31","52.26","","1113.10","1113.10","1113.10","1 through 10","4133.31","6463.34","percent of total billed charges",""
"CONE WAGNER 38.3MM 22X127.2 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10114750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7909.13","5931.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6463.34","81.72","","1738.90","1484.65","2716.94","38","4133.31","6463.34","percent of total billed charges",""
"Congenital Contractures Sequencing Panel","PX-31000934","CDM","81479","CPT","0310","RC","","","","both","","","6070.00","4552.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4825.65","79.5","","0.65","0.65","0.65","1 through 10","1881.7","5766.5","percent of total billed charges",""
"Congenital Contractures Sequencing Panel","PX-31000934","CDM","81479","CPT","0310","RC","","","","both","","","6070.00","4552.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3235.31","53.3","","0.79","0.79","0.79","1 through 10","1881.7","5766.5","percent of total billed charges",""
"Congenital Contractures Sequencing Panel","PX-31000934","CDM","81479","CPT","0310","RC","","","","outpatient","","","6070.00","4552.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3035.00","50","","1.00","1.00","1.00","1 through 10","156.55","5007.75","percent of total billed charges",""
"Congenital Contractures Sequencing Panel","PX-31000934","CDM","81479","CPT","0310","RC","","","","outpatient","","","6070.00","4552.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3186.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","5007.75","percent of total billed charges",""
"Congenital Myasthenia Syndromes Panel","PX-31000816","CDM","81479","CPT","0310","RC","","","","both","","","517.00","387.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","411.02","79.5","","0.65","0.65","0.65","1 through 10","160.27","491.15","percent of total billed charges",""
"Congenital Myasthenia Syndromes Panel","PX-31000816","CDM","81479","CPT","0310","RC","","","","both","","","517.00","387.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","275.56","53.3","","0.79","0.79","0.79","1 through 10","160.27","491.15","percent of total billed charges",""
"Congenital Myasthenia Syndromes Panel","PX-31000816","CDM","81479","CPT","0310","RC","","","","outpatient","","","517.00","387.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","258.50","50","","1.00","1.00","1.00","1 through 10","156.55","426.53","percent of total billed charges",""
"Congenital Myasthenia Syndromes Panel","PX-31000816","CDM","81479","CPT","0310","RC","","","","outpatient","","","517.00","387.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","271.43","52.5","","1.00","0.53","1.00","1 through 10","156.55","426.53","percent of total billed charges",""
"Congenital Myasthenic Syndromes 13 Genes","PX-30003382","CDM","81479","CPT","0310","RC","","","","both","","","2987.00","2240.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2374.67","79.5","","0.65","0.65","0.65","1 through 10","925.97","2837.65","percent of total billed charges",""
"Congenital Myasthenic Syndromes 13 Genes","PX-30003382","CDM","81479","CPT","0310","RC","","","","both","","","2987.00","2240.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1592.07","53.3","","0.79","0.79","0.79","1 through 10","925.97","2837.65","percent of total billed charges",""
"Congenital Myasthenic Syndromes 13 Genes","PX-30003382","CDM","81479","CPT","0310","RC","","","","outpatient","","","2987.00","2240.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1493.50","50","","1.00","1.00","1.00","1 through 10","156.55","2464.28","percent of total billed charges",""
"Congenital Myasthenic Syndromes 13 Genes","PX-30003382","CDM","81479","CPT","0310","RC","","","","outpatient","","","2987.00","2240.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1568.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","2464.28","percent of total billed charges",""
"Congenital Myasthenic Syndromes and Lethal Multiple Pterygium Syndrome via the Chrna1 Gene","PX-31000804","CDM","81479","CPT","0310","RC","","","","both","","","1132.00","849.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","899.94","79.5","","0.65","0.65","0.65","1 through 10","350.92","1075.4","percent of total billed charges",""
"Congenital Myasthenic Syndromes and Lethal Multiple Pterygium Syndrome via the Chrna1 Gene","PX-31000804","CDM","81479","CPT","0310","RC","","","","both","","","1132.00","849.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","603.36","53.3","","0.79","0.79","0.79","1 through 10","350.92","1075.4","percent of total billed charges",""
"Congenital Myasthenic Syndromes and Lethal Multiple Pterygium Syndrome via the Chrna1 Gene","PX-31000804","CDM","81479","CPT","0310","RC","","","","outpatient","","","1132.00","849.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","566.00","50","","1.00","1.00","1.00","1 through 10","156.55","933.9","percent of total billed charges",""
"Congenital Myasthenic Syndromes and Lethal Multiple Pterygium Syndrome via the Chrna1 Gene","PX-31000804","CDM","81479","CPT","0310","RC","","","","outpatient","","","1132.00","849.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","594.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","933.9","percent of total billed charges",""
"Conization Cervix Cold Knife/Laser","PX-76001373","CDM","57520","CPT","0761","RC","","","","both","","","8785.00","6588.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4682.41","53.3","","14865.84","14865.84","14865.84","1 through 10","2723.35","6984.08","percent of total billed charges",""
"Conization Cervix Cold Knife/Laser","PX-76001373","CDM","57520","CPT","0761","RC","","","","outpatient","","","8785.00","6588.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5319.32","60.55","","5524.71","5424.80","5524.71","1 through 10","3514","7179.1","percent of total billed charges",""
"Conization Cervix Cold Knife/Laser","PX-76001373","CDM","57520","CPT","0761","RC","","","","outpatient","","","8785.00","6588.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4587.53","52.22","","6321.29","6259.18","6321.29","1 through 10","3514","7179.1","percent of total billed charges",""
"Conization Cervix Cold Knife/Laser","PX-76001373","CDM","57520","CPT","0761","RC","","","","outpatient","","","8785.00","6588.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7179.10","81.72","","4334.35","4334.35","4334.35","1 through 10","3514","7179.1","percent of total billed charges",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4886.00","3664.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3884.37","79.5","","3728.81","3728.81","3728.81","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4886.00","3664.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2604.24","53.3","","3728.81","3728.81","3728.81","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4886.00","3664.50","MEDICARE [2001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3412.18","3775.88","1 through 10","1514.66","4719.38","other","OPPS APC"
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4886.00","3664.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1871.34","38.3","","6360.01","1852.56","14025.42","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4886.00","3664.50","WELLPOINT [1015]","HB AMC WELLPOINT","3604.89","73.78","","8265.44","8265.44","8265.44","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","AETNA [1001]","HB AMC AETNA HMO","3410.43","69.8","","3695.64","2264.76","5880.83","1 through 10","2125.14","3992.84","percent of total billed charges",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","AETNA [1001]","HB AMC AETNA PPO","3928.34","80.4","","3695.64","3695.64","6505.20","1 through 10","2125.14","3992.84","percent of total billed charges",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5524.71","2762.36","5524.71","1 through 10","2125.14","3992.84","other","ASC"
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6259.18","6259.18","6321.29","15","2125.14","3992.84","other","ASC "
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","14790.96","4930.32","14790.96","1 through 10","2125.14","3992.84","other","Multiple Surgery"
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4994.08","4994.08","4994.08","1 through 10","2125.14","3992.84","other","Multiple Surgery"
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","6153.00","5227.84","6153.00","1 through 10","2125.14","3992.84","other","Multiple Surgery"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","","","","inpatient","","","66600.09","49950.07","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","11228.32","","Case rate ($10,901.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,045.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,690.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,368.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,593.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,665.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.09. The transfer capital threshold is the transfer adjustment factor * $928.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11153.70","11153.70","11153.70","1 through 10","10683.25","17470.8507","other","Inpatient DRG"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","","","","inpatient","","","66600.09","49950.07","MEDICARE [2001]","HB BWH MEDICARE","10901.28","","Case rate ($10,901.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,045.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,690.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,368.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,593.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,665.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.09. The transfer capital threshold is the transfer adjustment factor * $928.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13926.59","12321.55","13947.00","18","10683.25","17470.8507","other","Inpatient Replacement Plans DRG"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","","","","inpatient","","","66600.09","49950.07","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","10901.28","","Case rate ($10,901.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,045.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,690.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,368.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,593.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,665.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.09. The transfer capital threshold is the transfer adjustment factor * $928.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","100.23","100.23","100.23","1 through 10","10683.25","17470.8507","other","Inpatient Replacement Plans DRG"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","","","","inpatient","","","66600.09","49950.07","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","10683.25","","Case rate ($10,901.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,045.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,690.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,368.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,593.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,665.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.09. The transfer capital threshold is the transfer adjustment factor * $928.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10647.22","10647.22","10647.22","1 through 10","10683.25","17470.8507","other","Inpatient DRG"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","","","","inpatient","","","66600.09","49950.07","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10683.25","","Case rate ($10,901.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,045.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,690.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,368.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,593.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,665.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.09. The transfer capital threshold is the transfer adjustment factor * $928.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16158.53","16158.53","16158.53","1 through 10","10683.25","17470.8507","other","Inpatient DRG"
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","99189.28","74391.96","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","23708.73","","Case rate ($23,018.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,631.93, add-ons for qualifying new technology services are included. If operating cost exceeds $73,276.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,437.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,641.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,252.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,996.92. The transfer capital threshold is the transfer adjustment factor * $1,996.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","23945.04","23945.04","23945.04","1 through 10","22557.82","37451.3347","other","Inpatient DRG"
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","99189.28","74391.96","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","23018.18","","Case rate ($23,018.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,631.93, add-ons for qualifying new technology services are included. If operating cost exceeds $73,276.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,437.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,641.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,252.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,996.92. The transfer capital threshold is the transfer adjustment factor * $1,996.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22963.75","22963.75","22963.75","1 through 10","22557.82","37451.3347","other","Inpatient Replacement Plans DRG"
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","99189.28","74391.96","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","23018.18","","Case rate ($23,018.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,631.93, add-ons for qualifying new technology services are included. If operating cost exceeds $73,276.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,437.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,641.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,252.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,996.92. The transfer capital threshold is the transfer adjustment factor * $1,996.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22780.98","22780.98","22851.10","1 through 10","22557.82","37451.3347","other","Inpatient DRG"
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","99189.28","74391.96","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","45539.17","45539.17","45539.17","1 through 10","22557.82","37451.3347","case rate",""
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","99189.28","74391.96","HUMANA [1012]","HB BWH MEDICARE","23018.18","","Case rate ($23,018.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,631.93, add-ons for qualifying new technology services are included. If operating cost exceeds $73,276.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,437.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,641.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,252.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,996.92. The transfer capital threshold is the transfer adjustment factor * $1,996.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22780.98","22780.98","22780.98","1 through 10","22557.82","37451.3347","other","Inpatient Replacement Plans DRG"
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","99189.28","74391.96","MEDICARE [2001]","HB BWH MEDICARE","23018.18","","Case rate ($23,018.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,631.93, add-ons for qualifying new technology services are included. If operating cost exceeds $73,276.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,437.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,641.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,252.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,996.92. The transfer capital threshold is the transfer adjustment factor * $1,996.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30068.30","0.03","43060.06","30","22557.82","37451.3347","other","Inpatient Replacement Plans DRG"
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","99189.28","74391.96","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","22557.82","","Case rate ($23,018.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,631.93, add-ons for qualifying new technology services are included. If operating cost exceeds $73,276.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,437.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,641.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,252.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,996.92. The transfer capital threshold is the transfer adjustment factor * $1,996.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","34555.35","34555.35","34555.35","1 through 10","22557.82","37451.3347","other","Inpatient DRG"
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","99189.28","74391.96","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","22557.82","","Case rate ($23,018.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,631.93, add-ons for qualifying new technology services are included. If operating cost exceeds $73,276.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,437.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,641.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,252.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,996.92. The transfer capital threshold is the transfer adjustment factor * $1,996.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22860.23","22749.86","23160.89","1 through 10","22557.82","37451.3347","other","Inpatient DRG"
"Connective Tissue Disorders Without Cc/McC","547","MS-DRG","","","","","","","","inpatient","","","47722.04","35791.53","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8007.75","","Case rate ($8,007.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,562.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,206.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,113.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,955.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,182.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.86. The transfer capital threshold is the transfer adjustment factor * $672.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8963.69","8963.69","8963.69","1 through 10","7847.6","11260.9042","other","Inpatient Replacement Plans DRG"
"Connective Tissue Disorders Without Cc/McC","547","MS-DRG","","","","","","","","inpatient","","","47722.04","35791.53","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8007.75","","Case rate ($8,007.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,562.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,206.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,113.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,955.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,182.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.86. The transfer capital threshold is the transfer adjustment factor * $672.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6965.85","6965.85","6965.85","1 through 10","7847.6","11260.9042","other","Inpatient DRG"
"Connective Tissue Disorders Without Cc/McC","547","MS-DRG","","","","","","","","inpatient","","","47722.04","35791.53","HUMANA [1012]","HB BWH MEDICARE","8007.75","","Case rate ($8,007.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,562.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,206.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,113.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,955.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,182.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.86. The transfer capital threshold is the transfer adjustment factor * $672.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13871.72","13871.72","13871.72","1 through 10","7847.6","11260.9042","other","Inpatient Replacement Plans DRG"
"Connective Tissue Disorders Without Cc/McC","547","MS-DRG","","","","","","","","inpatient","","","47722.04","35791.53","MEDICARE [2001]","HB BWH MEDICARE","8007.75","","Case rate ($8,007.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,562.33, add-ons for qualifying new technology services are included. If operating cost exceeds $55,206.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,113.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,955.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,182.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.86. The transfer capital threshold is the transfer adjustment factor * $672.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","7847.6","11260.9042","other","Inpatient Replacement Plans DRG"
"Connective Tissue Disorders,EXTREME","346","DRG","","","","","","","","inpatient","","","127905.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","80558.20","","Standard inlier is a Case rate ($80,558.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $74,292, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,435.72) for the length of stay and the standard reimbursement.","80558.19","80558.19","80558.19","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,EXTREME","346","DRG","","","","","","","","inpatient","","","127905.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","90569.12","","Standard inlier is a Case rate ($90,569.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $74,292, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,855.53) for the length of stay and the standard reimbursement.","82742.71","82742.71","82742.71","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,EXTREME","346","DRG","","","","","","","","inpatient","","","127905.25","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","104445.20","104445.20","104445.20","1 through 10","7112.37","161168.5","percent of total billed charges",""
"Connective Tissue Disorders,EXTREME","346","DRG","","","","","","","","inpatient","","","127905.25","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","15216.5794","","Fee schedule rate ($102,563.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15216.5794","98606.88","98606.88","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,EXTREME","346","DRG","","","","","","","","inpatient","","","127905.25","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97003.99","","Fee schedule rate ($97,003.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","94177.57","94177.57","94177.57","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,EXTREME","346","DRG","","","","","","","","inpatient","","","127905.25","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","101855.78","","Fee schedule rate ($101,855.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","101855.78","101855.78","263727.40","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,EXTREME","346","DRG","","","","","","","","inpatient","","","127905.25","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","28661.96","","Case rate ($31,690.73). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $74,120.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","71527.15","71527.15","71527.15","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","90850.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","38805.97","","Standard inlier is a Case rate ($38,805.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,824, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,508.74) for the length of stay and the standard reimbursement.","38725.14","38725.14","38805.96","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","90850.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","43628.36","","Standard inlier is a Case rate ($43,628.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,824, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,192.68) for the length of stay and the standard reimbursement.","46895.56","46895.56","46895.56","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","90850.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","43628.36","","Standard inlier is a Case rate ($43,628.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,824, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,192.68) for the length of stay and the standard reimbursement.","43628.36","39862.92","59621.87","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","90850.84","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14491.5793","","Fee schedule rate ($35,787.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14491.5793","36275.00","36275.00","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","90850.84","","MASSHEALTH [3001]","HB BWH MEDICAID","14825.63","","Case rate ($16,392.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,822.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16388.26","1568.27","24491.87","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","90850.84","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","35159.53","","Fee schedule rate ($35,159.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34135.18","34135.18","34135.18","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","90850.84","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43433.16","","Fee schedule rate ($43,433.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40939.24","40939.24","40939.24","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","90850.84","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14825.63","","Case rate ($16,392.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,822.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16388.26","16388.26","35654.14","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,MINOR","346","DRG","","","","","","","","inpatient","","","40385.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21466.94","","Standard inlier is a Case rate ($21,466.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,495, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,047.05) for the length of stay and the standard reimbursement.","21466.94","21466.94","21466.94","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,MODERATE","346","DRG","","","","","","","","inpatient","","","58908.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","25426.49","","Standard inlier is a Case rate ($25,426.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,419, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,609.44) for the length of stay and the standard reimbursement.","23177.17","23177.17","23177.17","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,MODERATE","346","DRG","","","","","","","","inpatient","","","58908.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","28586.23","","Standard inlier is a Case rate ($28,586.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,419, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,057.58) for the length of stay and the standard reimbursement.","28586.23","28586.23","28586.23","1 through 10","7112.37","161168.5","case rate",""
"Connective Tissue Disorders,MODERATE","346","DRG","","","","","","","","inpatient","","","58908.46","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","15216.5794","","Fee schedule rate ($21,294.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15216.5794","21294.76","21294.76","1 through 10","7112.37","161168.5","case rate",""
"CONNECTOR 54X10MM NEUROSTIMULATOR MRI RESTOREULTRA SURESCAN SAFE RECHARGEABLE","SUP-ITM-10125957","CDM","C1767","HCPCS","0278","RC","","","","both","","","39427.50","29570.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14391.04","36.5","","18081.90","16994.81","18081.90","1 through 10","12222.53","31344.86","percent of total billed charges",""
"CONNECTOR 54X10MM NEUROSTIMULATOR MRI RESTOREULTRA SURESCAN SAFE RECHARGEABLE","SUP-ITM-10125957","CDM","C1767","HCPCS","0278","RC","","","","both","","","39427.50","29570.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15100.73","38.3","","17814.94","17448.38","17814.94","1 through 10","12222.53","31344.86","percent of total billed charges",""
"CONNECTOR 54X10MM NEUROSTIMULATOR MRI RESTOREULTRA SURESCAN SAFE RECHARGEABLE","SUP-ITM-10125957","CDM","C1767","HCPCS","0278","RC","","","","both","","","39427.50","29570.62","WELLPOINT [1015]","HB AMC WELLPOINT","29089.61","73.78","","33921.28","33921.28","33921.28","1 through 10","12222.53","31344.86","percent of total billed charges",""
"CONNECTOR 65X49MM NEUROSTIMULATOR RESTOREADVANCED SURESCAN MRI SAFE RECHARGEABLE OCTAPOLAR","SUP-ITM-10124800","CDM","C1767","HCPCS","0278","RC","","","","both","","","36990.00","27742.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13501.35","36.5","","18081.90","16994.81","18081.90","1 through 10","11466.9","29407.05","percent of total billed charges",""
"CONNECTOR 65X49MM NEUROSTIMULATOR RESTOREADVANCED SURESCAN MRI SAFE RECHARGEABLE OCTAPOLAR","SUP-ITM-10124800","CDM","C1767","HCPCS","0278","RC","","","","both","","","36990.00","27742.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14167.17","38.3","","17814.94","17448.38","17814.94","1 through 10","11466.9","29407.05","percent of total billed charges",""
"CONNECTOR 65X49MM NEUROSTIMULATOR RESTOREADVANCED SURESCAN MRI SAFE RECHARGEABLE OCTAPOLAR","SUP-ITM-10124800","CDM","C1767","HCPCS","0278","RC","","","","both","","","36990.00","27742.50","WELLPOINT [1015]","HB AMC WELLPOINT","27291.22","73.78","","33921.28","33921.28","33921.28","1 through 10","11466.9","29407.05","percent of total billed charges",""
"CONNECTOR ANGLED 3.5MM LATERAL OFFSET SYMPHONY","SUP-ITM-10243746","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1321.69","79.5","","800.18","480.96","1887.97","195","515.38","1321.69","percent of total billed charges",""
"CONNECTOR ANGLED 3.5MM LATERAL OFFSET SYMPHONY","SUP-ITM-10243746","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","886.11","53.3","","813.12","216.42","1444.50","81","515.38","1321.69","percent of total billed charges",""
"CONNECTOR ANGLED 3.5MM LATERAL OFFSET SYMPHONY","SUP-ITM-10243746","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","515.38","31","","432.60","432.60","432.60","1 through 10","515.38","1321.69","percent of total billed charges",""
"CONNECTOR ANGLED 3.5MM LATERAL OFFSET SYMPHONY","SUP-ITM-10243746","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","606.81","36.5","","148.37","54.89","631.39","94","515.38","1321.69","percent of total billed charges",""
"CONNECTOR ANGLED 3.5MM LATERAL OFFSET SYMPHONY","SUP-ITM-10243746","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","636.74","38.3","","279.30","91.72","1116.77","266","515.38","1321.69","percent of total billed charges",""
"CONNECTOR ANGLED 3.5MM LATERAL OFFSET SYMPHONY","SUP-ITM-10243746","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.21","42.9","","731.00","63.70","731.00","1 through 10","515.38","1321.69","percent of total billed charges",""
"CONNECTOR ANGLED 3.5MM LATERAL OFFSET SYMPHONY","SUP-ITM-10243746","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.21","42.9","","384.74","384.74","384.74","1 through 10","515.38","1321.69","percent of total billed charges",""
"CONNECTOR ANGLED 3.5MM LATERAL OFFSET SYMPHONY","SUP-ITM-10243746","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","WELLPOINT [1015]","HB AMC WELLPOINT","1226.59","73.78","","286.63","119.22","1107.45","105","515.38","1321.69","percent of total billed charges",""
"CONNECTOR ANGLED 3.5MM LATERAL OFFSET SYMPHONY","SUP-ITM-10243746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","AETNA [1001]","HB AMC AETNA HMO","1160.43","69.8","","675.31","184.75","1721.50","286","868.82","1358.6","percent of total billed charges",""
"CONNECTOR ANGLED 3.5MM LATERAL OFFSET SYMPHONY","SUP-ITM-10243746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","AETNA [1001]","HB AMC AETNA PPO","1336.65","80.4","","1261.44","103.12","1514.10","21","868.82","1358.6","percent of total billed charges",""
"CONNECTOR ANGLED 3.5MM LATERAL OFFSET SYMPHONY","SUP-ITM-10243746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1336.65","80.4","","1365.00","1365.00","1365.00","1 through 10","868.82","1358.6","percent of total billed charges",""
"CONNECTOR ANGLED 3.5MM LATERAL OFFSET SYMPHONY","SUP-ITM-10243746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1358.60","81.72","","5157.68","5157.68","5157.68","1 through 10","868.82","1358.6","percent of total billed charges",""
"CONNECTOR ANGLED 3.5MM LATERAL OFFSET SYMPHONY","SUP-ITM-10243746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1358.60","81.72","","431.26","71.26","1459.57","88","868.82","1358.6","percent of total billed charges",""
"CONNECTOR CSF 1.2-2.5MMX45CM DRAINAGE TYPE-A CATHETER BARIUM S/S","SUP-ITM-10018908","CDM","C1729","HCPCS","0272","RC","","","","both","","","329.74","247.30","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","236.75","71.8","","162.24","51.52","162.24","1 through 10","102.22","262.14","percent of total billed charges",""
"CONNECTOR CSF 1.2-2.5MMX45CM DRAINAGE TYPE-A CATHETER BARIUM S/S","SUP-ITM-10018908","CDM","C1729","HCPCS","0272","RC","","","","both","","","329.74","247.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","120.36","36.5","","94.34","22.19","146.22","26","102.22","262.14","percent of total billed charges",""
"CONNECTOR CSF 1.2-2.5MMX45CM DRAINAGE TYPE-A CATHETER BARIUM S/S","SUP-ITM-10018908","CDM","C1729","HCPCS","0272","RC","","","","both","","","329.74","247.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","126.29","38.3","","51.52","27.37","51.52","26","102.22","262.14","percent of total billed charges",""
"CONNECTOR CSF 1.2-2.5MMX45CM DRAINAGE TYPE-A CATHETER BARIUM S/S","SUP-ITM-10018908","CDM","C1729","HCPCS","0272","RC","","","","both","","","329.74","247.30","WELLPOINT [1015]","HB AMC WELLPOINT","243.28","73.78","","207.21","122.12","216.28","14","102.22","262.14","percent of total billed charges",""
"CONNECTOR CSF 1.2-2.5MMX45CM DRAINAGE TYPE-A CATHETER BARIUM S/S","SUP-ITM-10018908","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","329.74","247.30","AETNA [1001]","HB AMC AETNA HMO","230.16","69.8","","155.96","47.39","155.96","1 through 10","172.32","269.46","percent of total billed charges",""
"CONNECTOR CSF 1.2-2.5MMX45CM DRAINAGE TYPE-A CATHETER BARIUM S/S","SUP-ITM-10018908","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","329.74","247.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","269.46","81.72","","57.36","51.76","232.23","35","172.32","269.46","percent of total billed charges",""
"CONNECTOR DIA 1.5MM LENGTH 10 PROTCTR GRFT NERV AXOGUARD PORCN 3D EXTRACELLULAR MATRX FLEX WRP TRNSLUCNT PERIPH","SUP-ITM-10124171","CDM","C1763","HCPCS","0278","RC","","","","both","","","4098.50","3073.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2664.03","65","","2028.23","1653.70","2028.23","1 through 10","1270.54","3258.31","percent of total billed charges",""
"CONNECTOR DIA 1.5MM LENGTH 10 PROTCTR GRFT NERV AXOGUARD PORCN 3D EXTRACELLULAR MATRX FLEX WRP TRNSLUCNT PERIPH","SUP-ITM-10124171","CDM","C1763","HCPCS","0278","RC","","","","both","","","4098.50","3073.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1495.95","36.5","","1163.89","1163.89","1163.89","1 through 10","1270.54","3258.31","percent of total billed charges",""
"CONNECTOR DIA 1.5MM LENGTH 10 PROTCTR GRFT NERV AXOGUARD PORCN 3D EXTRACELLULAR MATRX FLEX WRP TRNSLUCNT PERIPH","SUP-ITM-10124171","CDM","C1763","HCPCS","0278","RC","","","","both","","","4098.50","3073.87","WELLPOINT [1015]","HB AMC WELLPOINT","3023.87","73.78","","4280.87","4280.87","4280.87","1 through 10","1270.54","3258.31","percent of total billed charges",""
"CONNECTOR EAR .5MM OMEGA OSSICULAR PROSTHESIS","SUP-ITM-10281728","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","757.05","567.79","AETNA [1001]","HB AMC AETNA HMO","528.42","69.8","","1013.24","1013.24","1013.24","1 through 10","378.53","624.57","percent of total billed charges",""
"CONNECTOR ROD 3.5X5.5MM MOUNTAINEER TITANIUM WEDDING BAND ADJUSTABLE","SUP-ITM-10046415","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1349.51","79.5","","1309.77","674.56","6049.93","26","526.23","1349.51","percent of total billed charges",""
"CONNECTOR ROD 3.5X5.5MM MOUNTAINEER TITANIUM WEDDING BAND ADJUSTABLE","SUP-ITM-10046415","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","904.77","53.3","","1901.83","1901.83","2962.25","1 through 10","526.23","1349.51","percent of total billed charges",""
"CONNECTOR ROD 3.5X5.5MM MOUNTAINEER TITANIUM WEDDING BAND ADJUSTABLE","SUP-ITM-10046415","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","619.59","36.5","","1620.31","1620.31","19908.88","1 through 10","526.23","1349.51","percent of total billed charges",""
"CONNECTOR ROD 3.5X5.5MM MOUNTAINEER TITANIUM WEDDING BAND ADJUSTABLE","SUP-ITM-10046415","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","650.14","38.3","","352.91","352.91","2046.30","1 through 10","526.23","1349.51","percent of total billed charges",""
"CONNECTOR ROD 3.5X5.5MM MOUNTAINEER TITANIUM WEDDING BAND ADJUSTABLE","SUP-ITM-10046415","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.23","42.9","","9668.75","9668.75","9668.75","1 through 10","526.23","1349.51","percent of total billed charges",""
"CONNECTOR ROD 3.5X5.5MM MOUNTAINEER TITANIUM WEDDING BAND ADJUSTABLE","SUP-ITM-10046415","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","WELLPOINT [1015]","HB AMC WELLPOINT","1252.42","73.78","","699.88","384.10","3443.31","33","526.23","1349.51","percent of total billed charges",""
"CONNECTOR ROD 3.5X5.5MM MOUNTAINEER TITANIUM WEDDING BAND ADJUSTABLE","SUP-ITM-10046415","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","AETNA [1001]","HB AMC AETNA HMO","1184.86","69.8","","1421.24","264.50","4933.46","29","887.11","1387.2","percent of total billed charges",""
"CONNECTOR ROD 3.5X5.5MM MOUNTAINEER TITANIUM WEDDING BAND ADJUSTABLE","SUP-ITM-10046415","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1364.79","80.4","","1022.97","1022.97","3607.50","1 through 10","887.11","1387.2","percent of total billed charges",""
"CONNECTOR ROD 3.5X5.5MM MOUNTAINEER TITANIUM WEDDING BAND ADJUSTABLE","SUP-ITM-10046415","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1387.20","81.72","","3010.54","693.88","5019.88","35","887.11","1387.2","percent of total billed charges",""
"CONNECTOR SHUNT .8X1.5-1.8MM STRAIGHT STEPDOWN PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091846","CDM","C1889","HCPCS","0278","RC","","","","both","","","639.11","479.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","508.09","79.5","","1309.77","674.56","6049.93","26","198.12","508.09","percent of total billed charges",""
"CONNECTOR SHUNT .8X1.5-1.8MM STRAIGHT STEPDOWN PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091846","CDM","C1889","HCPCS","0278","RC","","","","both","","","639.11","479.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","340.65","53.3","","1901.83","1901.83","2962.25","1 through 10","198.12","508.09","percent of total billed charges",""
"CONNECTOR SHUNT .8X1.5-1.8MM STRAIGHT STEPDOWN PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091846","CDM","C1889","HCPCS","0278","RC","","","","both","","","639.11","479.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.28","36.5","","1620.31","1620.31","19908.88","1 through 10","198.12","508.09","percent of total billed charges",""
"CONNECTOR SHUNT .8X1.5-1.8MM STRAIGHT STEPDOWN PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091846","CDM","C1889","HCPCS","0278","RC","","","","both","","","639.11","479.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","244.78","38.3","","352.91","352.91","2046.30","1 through 10","198.12","508.09","percent of total billed charges",""
"CONNECTOR SHUNT .8X1.5-1.8MM STRAIGHT STEPDOWN PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091846","CDM","C1889","HCPCS","0278","RC","","","","both","","","639.11","479.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.18","42.9","","9668.75","9668.75","9668.75","1 through 10","198.12","508.09","percent of total billed charges",""
"CONNECTOR SHUNT .8X1.5-1.8MM STRAIGHT STEPDOWN PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091846","CDM","C1889","HCPCS","0278","RC","","","","both","","","639.11","479.33","WELLPOINT [1015]","HB AMC WELLPOINT","471.54","73.78","","699.88","384.10","3443.31","33","198.12","508.09","percent of total billed charges",""
"CONNECTOR SHUNT .8X1.5-1.8MM STRAIGHT STEPDOWN PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091846","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","639.11","479.33","AETNA [1001]","HB AMC AETNA HMO","446.10","69.8","","1421.24","264.50","4933.46","29","334","522.28","percent of total billed charges",""
"CONNECTOR SHUNT .8X1.5-1.8MM STRAIGHT STEPDOWN PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091846","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","639.11","479.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","513.84","80.4","","1022.97","1022.97","3607.50","1 through 10","334","522.28","percent of total billed charges",""
"CONNECTOR SHUNT .8X1.5-1.8MM STRAIGHT STEPDOWN PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091846","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","639.11","479.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","522.28","81.72","","3010.54","693.88","5019.88","35","334","522.28","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM RT ANGLE PLASTIC X-RAY DETECTABLE BX/5EA","SUP-ITM-10091843","CDM","C1889","HCPCS","0278","RC","","","","both","","","369.46","277.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","293.72","79.5","","1309.77","674.56","6049.93","26","114.53","293.72","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM RT ANGLE PLASTIC X-RAY DETECTABLE BX/5EA","SUP-ITM-10091843","CDM","C1889","HCPCS","0278","RC","","","","both","","","369.46","277.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","196.92","53.3","","1901.83","1901.83","2962.25","1 through 10","114.53","293.72","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM RT ANGLE PLASTIC X-RAY DETECTABLE BX/5EA","SUP-ITM-10091843","CDM","C1889","HCPCS","0278","RC","","","","both","","","369.46","277.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","134.85","36.5","","1620.31","1620.31","19908.88","1 through 10","114.53","293.72","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM RT ANGLE PLASTIC X-RAY DETECTABLE BX/5EA","SUP-ITM-10091843","CDM","C1889","HCPCS","0278","RC","","","","both","","","369.46","277.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","141.50","38.3","","352.91","352.91","2046.30","1 through 10","114.53","293.72","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM RT ANGLE PLASTIC X-RAY DETECTABLE BX/5EA","SUP-ITM-10091843","CDM","C1889","HCPCS","0278","RC","","","","both","","","369.46","277.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","158.50","42.9","","9668.75","9668.75","9668.75","1 through 10","114.53","293.72","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM RT ANGLE PLASTIC X-RAY DETECTABLE BX/5EA","SUP-ITM-10091843","CDM","C1889","HCPCS","0278","RC","","","","both","","","369.46","277.09","WELLPOINT [1015]","HB AMC WELLPOINT","272.59","73.78","","699.88","384.10","3443.31","33","114.53","293.72","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM RT ANGLE PLASTIC X-RAY DETECTABLE BX/5EA","SUP-ITM-10091843","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","369.46","277.09","AETNA [1001]","HB AMC AETNA HMO","257.88","69.8","","1421.24","264.50","4933.46","29","193.08","301.92","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM RT ANGLE PLASTIC X-RAY DETECTABLE BX/5EA","SUP-ITM-10091843","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","369.46","277.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","297.05","80.4","","1022.97","1022.97","3607.50","1 through 10","193.08","301.92","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM RT ANGLE PLASTIC X-RAY DETECTABLE BX/5EA","SUP-ITM-10091843","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","369.46","277.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","301.92","81.72","","3010.54","693.88","5019.88","35","193.08","301.92","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM STRAIGHT PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091842","CDM","C1889","HCPCS","0278","RC","","","","both","","","328.79","246.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","261.39","79.5","","1309.77","674.56","6049.93","26","101.92","261.39","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM STRAIGHT PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091842","CDM","C1889","HCPCS","0278","RC","","","","both","","","328.79","246.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","175.25","53.3","","1901.83","1901.83","2962.25","1 through 10","101.92","261.39","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM STRAIGHT PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091842","CDM","C1889","HCPCS","0278","RC","","","","both","","","328.79","246.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","120.01","36.5","","1620.31","1620.31","19908.88","1 through 10","101.92","261.39","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM STRAIGHT PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091842","CDM","C1889","HCPCS","0278","RC","","","","both","","","328.79","246.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","125.93","38.3","","352.91","352.91","2046.30","1 through 10","101.92","261.39","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM STRAIGHT PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091842","CDM","C1889","HCPCS","0278","RC","","","","both","","","328.79","246.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.05","42.9","","9668.75","9668.75","9668.75","1 through 10","101.92","261.39","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM STRAIGHT PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091842","CDM","C1889","HCPCS","0278","RC","","","","both","","","328.79","246.59","WELLPOINT [1015]","HB AMC WELLPOINT","242.58","73.78","","699.88","384.10","3443.31","33","101.92","261.39","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM STRAIGHT PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091842","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","328.79","246.59","AETNA [1001]","HB AMC AETNA HMO","229.50","69.8","","1421.24","264.50","4933.46","29","171.83","268.69","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM STRAIGHT PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091842","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","328.79","246.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","264.35","80.4","","1022.97","1022.97","3607.50","1 through 10","171.83","268.69","percent of total billed charges",""
"CONNECTOR SHUNT 1X2MM STRAIGHT PLASTIC XRAY DETECTABLE BX/5EA","SUP-ITM-10091842","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","328.79","246.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","268.69","81.72","","3010.54","693.88","5019.88","35","171.83","268.69","percent of total billed charges",""
"Consult Path Surgery Ea Add","PX-31000035","CDM","88332","CPT","0312","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","154.00","70","","213.00","213.00","213.00","1 through 10","68.2","174.9","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","both","","","473.00","354.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","57.43","57.43","57.43","1 through 10","146.63","376.04","other","OPPS APC"
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","both","","","473.00","354.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","307.45","65","","484.70","484.70","484.70","1 through 10","146.63","376.04","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","both","","","473.00","354.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","331.10","70","","459.00","459.00","459.00","1 through 10","146.63","376.04","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","both","","","473.00","354.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","376.04","79.5","","362.48","242.35","1453.58","18","146.63","376.04","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","both","","","473.00","354.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","252.11","53.3","","242.35","242.35","242.35","1 through 10","146.63","376.04","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","both","","","473.00","354.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","364.21","77","","353.43","353.43","353.43","1 through 10","146.63","376.04","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","both","","","473.00","354.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","146.63","31","","141.83","141.83","141.83","1 through 10","146.63","376.04","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","both","","","473.00","354.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","172.65","36.5","","171.21","166.16","513.63","13","146.63","376.04","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","both","","","473.00","354.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","181.16","38.3","","179.47","174.42","348.84","19","146.63","376.04","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","both","","","473.00","354.75","WELLPOINT [1015]","HB AMC WELLPOINT","348.98","73.78","","341.73","341.72","800.73","1 through 10","146.63","376.04","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","outpatient","","","473.00","354.75","AETNA [1001]","HB AMC AETNA HMO","330.15","69.8","","310.74","223.73","310.74","1 through 10","163.21","887.19","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","outpatient","","","473.00","354.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","386.54","81.72","","366.92","366.92","975.58","13","163.21","887.19","percent of total billed charges",""
"Cont Gluc Mntr Physician/Qhp Provided Equiptment","PX-51000578","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.59","150.59","150.59","1 through 10","145.39","863.17","other","OPPS APC"
"Cont Gluc Mntr Physician/Qhp Provided Equiptment","PX-51000578","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","141.97","128.87","141.97","1 through 10","145.39","863.17","other","OPPS APC"
"Cont Gluc Mntr Physician/Qhp Provided Equiptment","PX-51000578","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","FALLON HEALTH [1008]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.04","153.04","153.04","1 through 10","145.39","863.17","other","OPPS APC"
"Cont Gluc Mntr Physician/Qhp Provided Equiptment","PX-51000578","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","MEDICARE [2001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.04","153.04","153.04","19","145.39","863.17","other","OPPS APC"
"Cont Gluc Mntr Physician/Qhp Provided Equiptment","PX-51000578","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","409.17","36.5","","405.45","393.49","663.40","1 through 10","145.39","863.17","percent of total billed charges",""
"Cont Gluc Mntr Physician/Qhp Provided Equiptment","PX-51000578","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","429.34","38.3","","425.02","425.02","425.02","1 through 10","145.39","863.17","percent of total billed charges",""
"Cont Gluc Mntr Physician/Qhp Provided Equiptment","PX-51000578","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","149.98","149.98","149.98","1 through 10","145.39","863.17","other","OPPS APC"
"Cont Gluc Mntr Physician/Qhp Provided Equiptment","PX-51000578","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.38","150.38","150.38","1 through 10","145.39","863.17","other","OPPS APC"
"Cont Gluc Mntr Physician/Qhp Provided Equiptment","PX-51000578","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","149.98","149.98","150.98","1 through 10","145.39","863.17","other","OPPS APC"
"Cont Gluc Mntr Physician/Qhp Provided Equiptment","PX-51000578","CDM","95250","CPT","0510","RC","","","","outpatient","","","1121.00","840.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","382.26","34.1","","855.46","855.46","855.46","1 through 10","40.19","916.08","percent of total billed charges",""
"Cont Gluc Mntr Physician/Qhp Provided Equiptment","PX-51000578","CDM","95250","CPT","0510","RC","","","","outpatient","","","1121.00","840.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","916.08","81.72","","868.95","868.95","868.95","1 through 10","40.19","916.08","percent of total billed charges",""
"Cont Gluc Monitoring Patient Provided Equiptment","PX-51000577","CDM","95249","CPT","0510","RC","","","","both","","","448.00","336.00","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","66.76","70.54","1 through 10","67.01","344.96","other","OPPS APC"
"Cont Gluc Monitoring Patient Provided Equiptment","PX-51000577","CDM","95249","CPT","0510","RC","","","","both","","","448.00","336.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","171.58","38.3","","169.69","164.92","169.69","1 through 10","67.01","344.96","percent of total billed charges",""
"Cont Gluc Monitoring Patient Provided Equiptment","PX-51000577","CDM","95249","CPT","0510","RC","","","","both","","","448.00","336.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.13","69.13","70.13","1 through 10","67.01","344.96","other","OPPS APC"
"Cont Gluc Monitoring Patient Provided Equiptment","PX-51000577","CDM","95249","CPT","0510","RC","","","","outpatient","","","448.00","336.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","366.11","81.72","","169.69","169.69","169.69","1 through 10","40.19","366.11","percent of total billed charges",""
"Contraceptive Paragard Intrauterine Copper","PX-27000253","CDM","J7300","HCPCS","0278","RC","","","","both","","","3346.00","2509.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1281.52","38.3","","3504.56","1892.73","5678.19","16","1037.26","2576.42","percent of total billed charges",""
"Contraceptive Paragard Intrauterine Copper","PX-27000253","CDM","J7300","HCPCS","0278","RC","","","","outpatient","","","3346.00","2509.50","AETNA [1001]","HB AMC AETNA HMO","2335.51","69.8","","3121.82","2313.88","3277.19","1 through 10","1317.2","2936.9","percent of total billed charges",""
"Contraceptive Paragard Intrauterine Copper","PX-27000253","CDM","J7300","HCPCS","0278","RC","","","","outpatient","","","3346.00","2509.50","AETNA [1001]","HB AMC AETNA PPO","2690.18","80.4","","3596.78","3596.78","3596.78","1 through 10","1317.2","2936.9","percent of total billed charges",""
"Contraceptive Paragard Intrauterine Copper","PX-27000253","CDM","J7300","HCPCS","0278","RC","","","","outpatient","","","3346.00","2509.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2338.85","69.9","","2246.11","2246.11","2246.11","1 through 10","1317.2","2936.9","percent of total billed charges",""
"Contraceptive Paragard Intrauterine Copper","PX-27000253","CDM","J7300","HCPCS","0278","RC","","","","outpatient","","","3346.00","2509.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1569.27","46.9","","10063.92","2328.68","10063.92","1 through 10","1317.2","2936.9","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.25","1.69","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1.62","71.8","","2.83","2.83","2.83","50","0.32","1.73","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.25","1.69","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1.48","65.6","","2.45","1.73","3.07","426","0.32","1.73","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.25","1.69","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1.58","70","","2.87","1.69","7.83","859","0.32","1.73","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.25","1.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1.46","65","","256.09","192.07","1790.10","1 through 10","0.32","1.73","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.25","1.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.70","31","","1.12","0.11","3.36","780","0.32","1.73","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.25","1.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.82","36.5","","1.35","1.15","2.60","22835","0.32","1.73","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.25","1.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.86","38.3","","1.42","1.38","1.54","53934","0.32","1.73","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.25","1.69","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1.73","77","","2.83","2.83","2.83","83","0.32","1.73","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","2.25","1.69","AETNA [1001]","HB AMC AETNA HMO","1.57","69.8","","1.88","0.17","2.83","37600","0.32","1.81","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","2.25","1.69","AETNA [1001]","HB AMC AETNA PPO","1.81","80.4","","2.83","0.28","3.80","3073","0.32","1.81","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","2.25","1.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1.18","52.26","","2.24","2.24","2.24","305","0.32","1.81","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","2.25","1.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1.81","80.4","","2.83","2.83","2.83","269","0.32","1.81","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","2.25","1.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.57","69.9","","2.51","1.94","2.78","794","1.06","1.57","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500039","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","2.25","1.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1.06","46.9","","1.68","0.01","1.68","269","1.06","1.57","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.81","0.61","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.58","71.8","","2.83","2.83","2.83","50","0.25","0.62","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.81","0.61","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.53","65.6","","2.45","1.73","3.07","426","0.25","0.62","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.81","0.61","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.57","70","","2.87","1.69","7.83","859","0.25","0.62","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.81","0.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.53","65","","256.09","192.07","1790.10","1 through 10","0.25","0.62","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.81","0.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.25","31","","1.12","0.11","3.36","780","0.25","0.62","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.81","0.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.30","36.5","","1.35","1.15","2.60","22835","0.25","0.62","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.81","0.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.31","38.3","","1.42","1.38","1.54","53934","0.25","0.62","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.81","0.61","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.62","77","","2.83","2.83","2.83","83","0.25","0.62","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","0.81","0.61","AETNA [1001]","HB AMC AETNA HMO","0.57","69.8","","1.88","0.17","2.83","37600","0.32","0.65","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","0.81","0.61","AETNA [1001]","HB AMC AETNA PPO","0.65","80.4","","2.83","0.28","3.80","3073","0.32","0.65","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","0.81","0.61","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","0.42","52.26","","2.24","2.24","2.24","305","0.32","0.65","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","0.81","0.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.65","80.4","","2.83","2.83","2.83","269","0.32","0.65","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.81","0.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.57","69.9","","2.51","1.94","2.78","794","0.38","0.57","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 1ml","PX-25500042","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.81","0.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.38","46.9","","1.68","0.01","1.68","269","0.38","0.57","percent of total billed charges",""
"Control Hemorr Oropharyngeal Smp","PX-75000069","CDM","42960","CPT","0761","RC","","","","outpatient","","","1158.00","868.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","604.71","52.22","","1304.08","1304.08","1304.08","1 through 10","463.2","946.32","percent of total billed charges",""
"CONTROL URINARY PROSTHESIS PENILE AMS 800 PUMP","SUP-ITM-10004824","CDM","C1815","HCPCS","0278","RC","","","","both","","","12675.00","9506.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10076.63","79.5","","18938.70","18113.72","18938.70","1 through 10","3929.25","10076.63","percent of total billed charges",""
"CONTROL URINARY PROSTHESIS PENILE AMS 800 PUMP","SUP-ITM-10004824","CDM","C1815","HCPCS","0278","RC","","","","both","","","12675.00","9506.25","WELLPOINT [1015]","HB AMC WELLPOINT","9351.62","73.78","","27772.46","27772.46","27772.46","1 through 10","3929.25","10076.63","percent of total billed charges",""
"CONTROLLER PATIENT APPLE IPOD TOUCH MOBILE DEVICE PROCLAIM ELITE SYSTEM - DISCONTINUED PER SUPPLIER","SUP-ITM-10209190","CDM","C1787","HCPCS","0270","RC","","","","both","","","3500.00","2625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1865.50","53.3","","3163.82","3163.82","3163.82","1 through 10","1085","2782.5","percent of total billed charges",""
"CONTROLLER PATIENT APPLE IPOD TOUCH MOBILE DEVICE PROCLAIM ELITE SYSTEM - DISCONTINUED PER SUPPLIER","SUP-ITM-10209190","CDM","C1787","HCPCS","0270","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1639.86","1566.60","1745.64","1 through 10","1085","2782.5","percent of total billed charges",""
"CONTROLLER PATIENT APPLE IPOD TOUCH MOBILE DEVICE PROCLAIM ELITE SYSTEM - DISCONTINUED PER SUPPLIER","SUP-ITM-10209190","CDM","C1787","HCPCS","0270","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","1642.20","1642.20","1642.20","1 through 10","1085","2782.5","percent of total billed charges",""
"CONTROLLER PATIENT APPLE IPOD TOUCH MOBILE DEVICE PROCLAIM ELITE SYSTEM - DISCONTINUED PER SUPPLIER","SUP-ITM-10209190","CDM","C1787","HCPCS","0270","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2332.15","846.87","3126.90","1 through 10","1085","2782.5","percent of total billed charges",""
"CONTROLLER POCKET HEARTMATE II LVAS","SUP-ITM-10117594","CDM","Q0481","HCPCS","0274","RC","","","","both","","","13750.00","10312.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8937.50","65","","21937.50","21937.50","21937.50","1 through 10","4262.5","35551.59","percent of total billed charges",""
"Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue,MAJOR","384","DRG","","","","","","","","inpatient","","","47372.62","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31820.31","","Standard inlier is a Case rate ($31,820.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,391, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,517.08) for the length of stay and the standard reimbursement.","31820.30","31820.30","31820.30","1 through 10","5477.64","254946.65","case rate",""
"Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue,MAJOR","384","DRG","","","","","","","","inpatient","","","47372.62","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9052.11","","Case rate ($10,008.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,438.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10606.58","10606.58","10606.58","1 through 10","5477.64","254946.65","case rate",""
"Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue,MODERATE","384","DRG","","","","","","","","inpatient","","","29792.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21839.88","","Standard inlier is a Case rate ($21,839.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,631, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,100.30) for the length of stay and the standard reimbursement.","19907.84","19907.84","19907.84","1 through 10","5477.64","254946.65","case rate",""
"Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue,MODERATE","384","DRG","","","","","","","","inpatient","","","29792.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24553.91","","Standard inlier is a Case rate ($24,553.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,631, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,485.22) for the length of stay and the standard reimbursement.","24553.90","24553.90","24553.90","1 through 10","5477.64","254946.65","case rate",""
"Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue,MODERATE","384","DRG","","","","","","","","inpatient","","","29792.49","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5477.64","","Case rate ($6,056.48). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,486.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6054.99","6054.99","6054.99","1 through 10","5477.64","254946.65","case rate",""
"Conv Ext Bil Drg Cath to Int-Ext Bil Drg Cath","PX-36000378","CDM","47535","CPT","0361","RC","","","","both","","","2042.00","1531.50","MEDICARE [2001]","HB BWH MEDICARE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","4190.97","4190.97","1 through 10","633.02","5238.18","other","OPPS APC"
"Conv Ext Bil Drg Cath to Int-Ext Bil Drg Cath","PX-36000378","CDM","47535","CPT","0361","RC","","","","both","","","2042.00","1531.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4106.74","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4114.55","4114.55","4114.55","1 through 10","633.02","5238.18","other","OPPS APC"
"Conv Ext Bil Drg Cath to Int-Ext Bil Drg Cath","PX-36000378","CDM","47535","CPT","0361","RC","","","","both","","","2042.00","1531.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4106.74","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4107.15","4107.15","4107.15","1 through 10","633.02","5238.18","other","OPPS APC"
"Convert Nephrostomy Cath to Nephrourtrl Cath Prq","PX-76002186","CDM","50434","CPT","0761","RC","","","","both","","","1555.00","1166.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2391.58","2384.08","4021.85","1 through 10","482.05","3040.6","other","OPPS APC"
"CONVERTER ENDOVASCULAR 18FRX80MM GRAFT COMPONENT ZENITH FLEX AAA","SUP-ITM-10011589","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4636.94","65","","6652.80","6652.80","6652.80","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ENDOVASCULAR 18FRX80MM GRAFT COMPONENT ZENITH FLEX AAA","SUP-ITM-10011589","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5671.33","79.5","","2612.61","795.38","2612.61","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ENDOVASCULAR 18FRX80MM GRAFT COMPONENT ZENITH FLEX AAA","SUP-ITM-10011589","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3802.29","53.3","","1101.80","1101.80","1101.80","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ENDOVASCULAR 18FRX80MM GRAFT COMPONENT ZENITH FLEX AAA","SUP-ITM-10011589","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4636.94","65","","1820.00","910.00","1820.00","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ENDOVASCULAR 18FRX80MM GRAFT COMPONENT ZENITH FLEX AAA","SUP-ITM-10011589","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2603.82","36.5","","1257.80","693.44","2424.50","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ENDOVASCULAR 18FRX80MM GRAFT COMPONENT ZENITH FLEX AAA","SUP-ITM-10011589","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2732.23","38.3","","1950.11","547.40","2346.00","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ENDOVASCULAR 18FRX80MM GRAFT COMPONENT ZENITH FLEX AAA","SUP-ITM-10011589","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3060.38","42.9","","5096.18","5096.18","5096.18","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ENDOVASCULAR 18FRX80MM GRAFT COMPONENT ZENITH FLEX AAA","SUP-ITM-10011589","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","WELLPOINT [1015]","HB AMC WELLPOINT","5263.28","73.78","","1172.59","1172.59","4829.94","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ENDOVASCULAR 18FRX80MM GRAFT COMPONENT ZENITH FLEX AAA","SUP-ITM-10011589","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7133.75","5350.31","AETNA [1001]","HB AMC AETNA HMO","4979.36","69.8","","1806.84","947.80","5091.72","1 through 10","3728.1","5829.7","percent of total billed charges",""
"CONVERTER ENDOVASCULAR 18FRX80MM GRAFT COMPONENT ZENITH FLEX AAA","SUP-ITM-10011589","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7133.75","5350.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5829.70","81.72","","1259.05","615.58","4586.56","1 through 10","3728.1","5829.7","percent of total billed charges",""
"CONVERTER ZENITH FLEX 36MM 12MM 82MM 12FR/7.7MM GRAFT AAA ENDOVASCULAR Z TRAK INTRODUCTION SYSTEM","SUP-ITM-10020920","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4636.94","65","","6652.80","6652.80","6652.80","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ZENITH FLEX 36MM 12MM 82MM 12FR/7.7MM GRAFT AAA ENDOVASCULAR Z TRAK INTRODUCTION SYSTEM","SUP-ITM-10020920","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5671.33","79.5","","2612.61","795.38","2612.61","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ZENITH FLEX 36MM 12MM 82MM 12FR/7.7MM GRAFT AAA ENDOVASCULAR Z TRAK INTRODUCTION SYSTEM","SUP-ITM-10020920","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3802.29","53.3","","1101.80","1101.80","1101.80","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ZENITH FLEX 36MM 12MM 82MM 12FR/7.7MM GRAFT AAA ENDOVASCULAR Z TRAK INTRODUCTION SYSTEM","SUP-ITM-10020920","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4636.94","65","","1820.00","910.00","1820.00","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ZENITH FLEX 36MM 12MM 82MM 12FR/7.7MM GRAFT AAA ENDOVASCULAR Z TRAK INTRODUCTION SYSTEM","SUP-ITM-10020920","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2603.82","36.5","","1257.80","693.44","2424.50","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ZENITH FLEX 36MM 12MM 82MM 12FR/7.7MM GRAFT AAA ENDOVASCULAR Z TRAK INTRODUCTION SYSTEM","SUP-ITM-10020920","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2732.23","38.3","","1950.11","547.40","2346.00","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ZENITH FLEX 36MM 12MM 82MM 12FR/7.7MM GRAFT AAA ENDOVASCULAR Z TRAK INTRODUCTION SYSTEM","SUP-ITM-10020920","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3060.38","42.9","","5096.18","5096.18","5096.18","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ZENITH FLEX 36MM 12MM 82MM 12FR/7.7MM GRAFT AAA ENDOVASCULAR Z TRAK INTRODUCTION SYSTEM","SUP-ITM-10020920","CDM","C1874","HCPCS","0278","RC","","","","both","","","7133.75","5350.31","WELLPOINT [1015]","HB AMC WELLPOINT","5263.28","73.78","","1172.59","1172.59","4829.94","1 through 10","2211.46","5671.33","percent of total billed charges",""
"CONVERTER ZENITH FLEX 36MM 12MM 82MM 12FR/7.7MM GRAFT AAA ENDOVASCULAR Z TRAK INTRODUCTION SYSTEM","SUP-ITM-10020920","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7133.75","5350.31","AETNA [1001]","HB AMC AETNA HMO","4979.36","69.8","","1806.84","947.80","5091.72","1 through 10","3728.1","5829.7","percent of total billed charges",""
"CONVERTER ZENITH FLEX 36MM 12MM 82MM 12FR/7.7MM GRAFT AAA ENDOVASCULAR Z TRAK INTRODUCTION SYSTEM","SUP-ITM-10020920","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7133.75","5350.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5829.70","81.72","","1259.05","615.58","4586.56","1 through 10","3728.1","5829.7","percent of total billed charges",""
"Cooled Rf Ablation Pelvis/Hip Joint","PX-76010300","CDM","27299","CPT","0761","RC","","","","both","","","1276.00","957.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","1014.42","other","OPPS APC"
"Cooled Rf Ablation Pelvis/Hip Joint","PX-98301934","CDM","27299","CPT","0983","RC","","","","both","","","762.00","571.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","236.22","605.79","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","145.00","108.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.41","69.41","69.41","1 through 10","5.55","115.28","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","145.00","108.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","115.28","79.5","","110.97","110.97","110.97","1 through 10","5.55","115.28","percent of total billed charges",""
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","145.00","108.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.29","53.3","","372.23","110.97","372.23","18","5.55","115.28","percent of total billed charges",""
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","145.00","108.75","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","66.76","70.54","1 through 10","5.55","115.28","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","145.00","108.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","52.93","36.5","","157.78","157.78","157.78","1 through 10","5.55","115.28","percent of total billed charges",""
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","145.00","108.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.54","38.3","","55.13","55.13","55.13","1 through 10","5.55","115.28","percent of total billed charges",""
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","145.00","108.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.13","69.13","69.13","1 through 10","5.55","115.28","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","145.00","108.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.13","69.13","70.54","1 through 10","5.55","115.28","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","outpatient","","","145.00","108.75","AETNA [1001]","HB AMC AETNA HMO","101.21","69.8","","91.05","67.40","95.46","1 through 10","5.55","196.9","percent of total billed charges",""
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","outpatient","","","145.00","108.75","AETNA [1001]","HB AMC AETNA PPO","116.58","80.4","","109.98","109.98","109.98","1 through 10","5.55","196.9","percent of total billed charges",""
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","outpatient","","","145.00","108.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","118.49","81.72","","225.44","62.00","225.44","1 through 10","5.55","196.9","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","both","","","118.00","88.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.86","30.86","30.86","1 through 10","5.9","254.35","other","OPPS APC"
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","both","","","118.00","88.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","84.72","71.8","","81.85","81.85","81.85","1 through 10","5.9","254.35","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","both","","","118.00","88.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","93.81","79.5","","60.19","60.19","89.72","12","5.9","254.35","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","both","","","118.00","88.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","62.89","53.3","","89.72","60.19","89.72","1 through 10","5.9","254.35","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","both","","","118.00","88.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","66.88","66.88","66.88","1 through 10","5.9","254.35","other","OPPS APC"
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","both","","","118.00","88.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","76.70","65","","370.50","222.30","370.50","1 through 10","5.9","254.35","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","both","","","118.00","88.50","MEDICARE [2001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","67.83","67.83","67.83","1 through 10","5.9","254.35","other","OPPS APC"
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","both","","","118.00","88.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","43.07","36.5","","42.52","35.80","42.52","1 through 10","5.9","254.35","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","both","","","118.00","88.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","45.19","38.3","","44.57","43.32","129.96","48","5.9","254.35","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","both","","","118.00","88.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","60.90","60.90","60.90","1 through 10","5.9","254.35","other","OPPS APC"
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","outpatient","","","118.00","88.50","AETNA [1001]","HB AMC AETNA HMO","82.36","69.8","","54.49","54.49","54.49","11","5.9","887.19","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","outpatient","","","118.00","88.50","AETNA [1001]","HB AMC AETNA PPO","94.87","80.4","","59.74","59.74","59.74","1 through 10","5.9","887.19","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","outpatient","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","96.43","81.72","","91.14","50.13","273.39","1 through 10","5.9","887.19","percent of total billed charges",""
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","both","","","185.00","138.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","121.36","65.6","","139.62","139.62","139.62","1 through 10","5.34","254.35","percent of total billed charges",""
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","both","","","185.00","138.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","129.50","70","","208.80","179.00","208.80","1 through 10","5.34","254.35","percent of total billed charges",""
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","both","","","185.00","138.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","254.35","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","24.43","24.43","24.43","1 through 10","5.34","254.35","other","OPPS APC"
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","both","","","185.00","138.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","147.08","79.5","","1155.05","116.35","1155.05","1 through 10","5.34","254.35","percent of total billed charges",""
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","both","","","185.00","138.75","MEDICARE [2001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","203.50","203.50","1 through 10","5.34","254.35","other","OPPS APC"
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","both","","","185.00","138.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.53","36.5","","66.77","66.77","66.77","1 through 10","5.34","254.35","percent of total billed charges",""
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","both","","","185.00","138.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.86","38.3","","69.99","69.99","69.99","1 through 10","5.34","254.35","percent of total billed charges",""
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","outpatient","","","185.00","138.75","AETNA [1001]","HB AMC AETNA HMO","129.13","69.8","","121.18","121.18","121.18","1 through 10","5.34","887.19","percent of total billed charges",""
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","outpatient","","","185.00","138.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","151.18","81.72","","78.71","78.71","78.71","1 through 10","5.34","887.19","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","both","","","164.00","123.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","130.38","79.5","","125.13","125.13","375.39","14","12.16","155.8","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","both","","","164.00","123.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","87.41","53.3","","83.95","83.95","125.13","1 through 10","12.16","155.8","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","both","","","164.00","123.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","126.28","77","","367.29","367.29","367.29","1 through 10","12.16","155.8","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","both","","","164.00","123.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","59.86","36.5","","59.31","50.40","177.93","16","12.16","155.8","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","both","","","164.00","123.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.81","38.3","","62.17","60.42","181.26","74","12.16","155.8","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","both","","","164.00","123.00","TRICARE [160005]","HB BWH TRICARE","155.80","95","","14.20","14.20","14.20","1 through 10","12.16","155.8","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","both","","","164.00","123.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.36","42.9","","127.10","127.10","127.10","1 through 10","12.16","155.8","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","164.00","123.00","AETNA [1001]","HB AMC AETNA HMO","114.47","69.8","","107.64","76.00","107.64","29","12.8","134.02","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","164.00","123.00","AETNA [1001]","HB AMC AETNA PPO","131.86","80.4","","249.96","124.02","249.96","1 through 10","12.8","134.02","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","164.00","123.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","91.68","55.9","","83.32","83.32","83.32","1 through 10","12.8","134.02","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","164.00","123.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","131.86","80.4","","79.50","79.50","79.50","1 through 10","12.8","134.02","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","164.00","123.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","134.02","81.72","","69.91","69.91","69.91","1 through 10","12.8","134.02","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","164.00","123.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","134.02","81.72","","127.10","69.91","127.11","22","12.8","134.02","percent of total billed charges",""
"CORD VOCAL SIZE 11 SYSTEM SURGICAL THYROPLASTY MONTGOMERY SILICONE MALE","SUP-ITM-10005073","CDM","C1878","HCPCS","0278","RC","","","","both","","","1312.50","984.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.44","79.5","","1991.51","1991.51","1991.51","1 through 10","406.88","1043.44","percent of total billed charges",""
"CORD VOCAL SIZE 11 SYSTEM SURGICAL THYROPLASTY MONTGOMERY SILICONE MALE","SUP-ITM-10005073","CDM","C1878","HCPCS","0278","RC","","","","both","","","1312.50","984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","479.06","36.5","","650.52","650.52","650.52","1 through 10","406.88","1043.44","percent of total billed charges",""
"CORD VOCAL SIZE 6 SYSTEM SURGICAL THYROPLASTY MONTGOMERY SILICONE FEMALE","SUP-ITM-10005074","CDM","C1878","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","1991.51","1991.51","1991.51","1 through 10","434","1113","percent of total billed charges",""
"CORD VOCAL SIZE 6 SYSTEM SURGICAL THYROPLASTY MONTGOMERY SILICONE FEMALE","SUP-ITM-10005074","CDM","C1878","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","650.52","650.52","650.52","1 through 10","434","1113","percent of total billed charges",""
"CORD VOCAL SIZE 7 SYSTEM SURGICAL THYROPLASTY MONTGOMERY SILICONE FEMALE","SUP-ITM-10005082","CDM","C1878","HCPCS","0278","RC","","","","both","","","1561.00","1170.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1241.00","79.5","","1991.51","1991.51","1991.51","1 through 10","483.91","1241","percent of total billed charges",""
"CORD VOCAL SIZE 7 SYSTEM SURGICAL THYROPLASTY MONTGOMERY SILICONE FEMALE","SUP-ITM-10005082","CDM","C1878","HCPCS","0278","RC","","","","both","","","1561.00","1170.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","569.77","36.5","","650.52","650.52","650.52","1 through 10","483.91","1241","percent of total billed charges",""
"CORD VOCAL SIZE 8 SYSTEM SURGICAL THYROPLASTY MONTGOMERY SILICONE MALE","SUP-ITM-10005072","CDM","C1878","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1182.56","79.5","","1991.51","1991.51","1991.51","1 through 10","461.13","1182.56","percent of total billed charges",""
"CORD VOCAL SIZE 8 SYSTEM SURGICAL THYROPLASTY MONTGOMERY SILICONE MALE","SUP-ITM-10005072","CDM","C1878","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","542.94","36.5","","650.52","650.52","650.52","1 through 10","461.13","1182.56","percent of total billed charges",""
"Cordocentesis Intrauterine","PX-72000004","CDM","59012","CPT","0761","RC","","","","outpatient","","","3326.00","2494.50","AETNA [1001]","HB AMC AETNA HMO","2321.55","69.8","","1541.55","1541.55","1541.55","1 through 10","273","2718.01","percent of total billed charges",""
"Cordocentesis Intrauterine","PX-72000004","CDM","59012","CPT","0761","RC","","","","outpatient","","","3326.00","2494.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","633.36","633.36","633.36","1 through 10","273","2718.01","other","Multiple Surgery"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1980.73","1820.83","1980.83","1 through 10","1162.19","2980.46","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1924.13","1 through 10","1162.19","2980.46","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2980.46","79.5","","2861.53","2861.53","2861.53","1 through 10","1162.19","2980.46","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1595.64","1893.34","1 through 10","1162.19","2980.46","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","FALLON HEALTH [1008]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5772.39","1924.13","5772.39","1 through 10","1162.19","2980.46","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","2886.73","77","","8399.16","8399.16","8399.16","1 through 10","1162.19","2980.46","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","HUMANA [1012]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1897.19","1897.19","1897.19","1 through 10","1162.19","2980.46","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1885.65","1885.65","1885.65","1 through 10","1162.19","2980.46","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1769.51","1924.13","96","1162.19","2980.46","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1368.39","36.5","","4068.69","4068.69","4068.69","1 through 10","1162.19","2980.46","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1435.87","38.3","","1421.68","1421.68","1421.68","1 through 10","1162.19","2980.46","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1885.65","1885.65","1885.65","1 through 10","1162.19","2980.46","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","MOLINA [1014]","HB BWH MOLINA","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3510.71","3510.71","3510.71","1 through 10","1162.19","2980.46","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","1827.93","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1769.51","1769.51","1769.51","1 through 10","1162.19","2980.46","other","Tricare OPPS"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5679.15","1891.05","5680.02","16","1162.19","2980.46","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.15","1885.65","1924.13","16","1162.19","2980.46","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","3749.00","2811.75","WELLPOINT [1015]","HB AMC WELLPOINT","2766.01","73.78","","2707.00","2707.00","2707.00","1 through 10","1162.19","2980.46","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","3749.00","2811.75","AETNA [1001]","HB AMC AETNA HMO","2616.80","69.8","","2461.57","1738.01","4923.14","1 through 10","1237.95","3063.68","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","3749.00","2811.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1599.32","","Case rate ($1,599.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3272.21","3213.03","3272.21","15","1237.95","3063.68","other","ASC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","3749.00","2811.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1599.32","","Case rate ($1,599.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3744.01","3707.22","3744.01","24","1237.95","3063.68","other","ASC "
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","3749.00","2811.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","2872.04","8616.12","1 through 10","1237.95","3063.68","other","Multiple Surgery"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","3749.00","2811.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9061.80","3020.60","9061.80","1 through 10","1237.95","3063.68","other","Multiple Surgery"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","3749.00","2811.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3169.15","3169.15","3169.15","1 through 10","1237.95","3063.68","other","Multiple Surgery"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","3749.00","2811.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3063.68","81.72","","2906.62","1598.75","2906.62","1 through 10","1237.95","3063.68","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","26042.00","19531.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3758.57","3499.57","3758.57","12","3628.7","20703.39","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","26042.00","19531.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20703.39","79.5","","13334.11","7995.00","19874.90","1 through 10","3628.7","20703.39","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","26042.00","19531.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13880.39","53.3","","13334.11","13334.11","19874.90","1 through 10","3628.7","20703.39","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","26042.00","19531.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3758.57","3758.57","3819.68","1 through 10","3628.7","20703.39","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","26042.00","19531.50","FALLON HEALTH [1008]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3743.29","3743.29","3743.29","1 through 10","3628.7","20703.39","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","26042.00","19531.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1965.57","1965.57","1965.57","1 through 10","3628.7","20703.39","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","26042.00","19531.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","16927.30","65","","16415.10","16415.10","16415.10","1 through 10","3628.7","20703.39","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","26042.00","19531.50","MEDICARE [2001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3819.68","3556.47","10669.41","112","3628.7","20703.39","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","26042.00","19531.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9505.33","36.5","","9419.74","8005.52","9419.74","1 through 10","3628.7","20703.39","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","26042.00","19531.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9974.09","38.3","","9874.31","9874.31","29622.93","1 through 10","3628.7","20703.39","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","26042.00","19531.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3743.29","3485.74","3743.69","1 through 10","3628.7","20703.39","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","26042.00","19531.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","11231.07","3743.69","22074.69","30","3628.7","20703.39","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","26042.00","19531.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3750.79","3488.19","3819.68","19","3628.7","20703.39","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","outpatient","","","26042.00","19531.50","AETNA [1001]","HB AMC AETNA HMO","18177.32","69.8","","20432.50","20432.50","20432.50","1 through 10","2529.37","21281.52","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","outpatient","","","26042.00","19531.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","11281.00","5868.14","17604.42","13","2529.37","21281.52","other","Multiple Surgery"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","outpatient","","","26042.00","19531.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","17832.06","5944.02","17832.06","1 through 10","2529.37","21281.52","other","Multiple Surgery"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","outpatient","","","26042.00","19531.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","9419.36","6475.19","9419.36","1 through 10","2529.37","21281.52","other","Multiple Surgery"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","outpatient","","","26042.00","19531.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","20937.77","80.4","","12627.00","12627.00","12627.00","1 through 10","2529.37","21281.52","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","outpatient","","","26042.00","19531.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21281.52","81.72","","20188.05","6475.19","20188.05","1 through 10","2529.37","21281.52","percent of total billed charges",""
"Coronary Artery/Graft Angio S&I","PX-48000120","CDM","93455","CPT","0481","RC","","","","both","","","30351.00","22763.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3758.57","3537.23","3758.57","1 through 10","3628.7","24129.05","other","OPPS APC"
"Coronary Artery/Graft Angio S&I","PX-48000120","CDM","93455","CPT","0481","RC","","","","both","","","30351.00","22763.25","FALLON HEALTH [1008]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3819.68","3819.68","3819.68","1 through 10","3628.7","24129.05","other","OPPS APC"
"Coronary Artery/Graft Angio S&I","PX-48000120","CDM","93455","CPT","0481","RC","","","","both","","","30351.00","22763.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3766.20","3766.20","3766.20","1 through 10","3628.7","24129.05","other","OPPS APC"
"Coronary Artery/Graft Angio S&I","PX-48000120","CDM","93455","CPT","0481","RC","","","","both","","","30351.00","22763.25","MEDICARE [2001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3819.68","3556.47","6770.90","16","3628.7","24129.05","other","OPPS APC"
"Coronary Artery/Graft Angio S&I","PX-48000120","CDM","93455","CPT","0481","RC","","","","both","","","30351.00","22763.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6635.88","6635.88","6635.88","1 through 10","3628.7","24129.05","other","OPPS APC"
"Coronary Artery/Graft Angio S&I","PX-48000120","CDM","93455","CPT","0481","RC","","","","outpatient","","","30351.00","22763.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","5868.14","5868.14","5868.14","1 through 10","2529.37","24802.84","other","Multiple Surgery"
"Coronary Bypass With Ami Or Complex Principal Diagnosis,EXTREME","165","DRG","","","","","","","","inpatient","","","346289.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","193911.52","","Standard inlier is a Case rate ($193,911.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $145,773, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($27,524.13) for the length of stay and the standard reimbursement.","262551.92","262551.92","262551.92","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,EXTREME","165","DRG","","","","","","","","inpatient","","","346289.60","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","64112.0828","","Fee schedule rate ($199,551.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","64112.0828","209050.35","209050.35","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,EXTREME","165","DRG","","","","","","","","inpatient","","","346289.60","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","82964.295","","Fee schedule rate ($199,551.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","82964.295","209050.35","209050.35","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,EXTREME","165","DRG","","","","","","","","inpatient","","","346289.60","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","61057.4366","","Fee schedule rate ($190,043.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61057.4366","190043.44","190043.44","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,EXTREME","165","DRG","","","","","","","","inpatient","","","346289.60","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","79011.4275","","Fee schedule rate ($190,043.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","79011.4275","190043.44","190043.44","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,EXTREME","165","DRG","","","","","","","","inpatient","","","346289.60","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","240095.21","","Fee schedule rate ($240,095.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","204080.93","204080.93","204080.93","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,EXTREME","165","DRG","","","","","","","","inpatient","","","346289.60","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","252103.91","","Fee schedule rate ($252,103.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","274563.41","274563.41","274563.41","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,MAJOR","165","DRG","","","","","","","","inpatient","","","342555.41","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","172477.79","","Standard inlier is a Case rate ($172,477.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $145,773, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($24,484.26) for the length of stay and the standard reimbursement.","157219.78","157219.78","172477.78","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,MAJOR","165","DRG","","","","","","","","inpatient","","","342555.41","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","193911.52","","Standard inlier is a Case rate ($193,911.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $145,773, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($27,524.13) for the length of stay and the standard reimbursement.","193911.51","177154.91","211295.78","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,MAJOR","165","DRG","","","","","","","","inpatient","","","342555.41","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","61057.4366","","Fee schedule rate ($204,382.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61057.4366","108900.44","108900.44","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,MAJOR","165","DRG","","","","","","","","inpatient","","","342555.41","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","79011.4275","","Fee schedule rate ($204,382.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","79011.4275","108900.44","108900.44","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,MAJOR","165","DRG","","","","","","","","inpatient","","","342555.41","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","224823.97","","Fee schedule rate ($224,823.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","130878.21","130878.21","130878.21","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,MAJOR","165","DRG","","","","","","","","inpatient","","","342555.41","","MASSHEALTH [3001]","HB BWH MEDICAID","42453.75","","Case rate ($46,939.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $89,369.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","60167.31","60167.31","81551.16","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,MAJOR","165","DRG","","","","","","","","inpatient","","","342555.41","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","252103.91","","Fee schedule rate ($252,103.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","167623.19","167623.19","167623.19","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,MAJOR","165","DRG","","","","","","","","inpatient","","","342555.41","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","42453.75","","Case rate ($46,939.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $89,369.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8447.04","8447.04","8447.04","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Ami Or Complex Principal Diagnosis,MODERATE","165","DRG","","","","","","","","inpatient","","","275923.92","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","143451.74","","Standard inlier is a Case rate ($143,451.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $123,202, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,363.84) for the length of stay and the standard reimbursement.","157219.78","157219.78","157219.78","1 through 10","41705.5","337235.96","case rate",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC","233","MS-DRG","","","","","","","","inpatient","","","361663.70","271247.77","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","72223.76","","Case rate ($70,120.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,333.44, add-ons for qualifying new technology services are included. If operating cost exceeds $129,977.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,591.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $63,588.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $83,953.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,151.78. The transfer capital threshold is the transfer adjustment factor * $6,151.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","73452.07","73391.85","171819.55","1 through 10","68717.76","119754.41","other","Inpatient DRG"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC","233","MS-DRG","","","","","","","","inpatient","","","361663.70","271247.77","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","90890.79","","Case rate ($90,890.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,333.44, add-ons for qualifying new technology services are included. If operating cost exceeds $129,977.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,591.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $84,359.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $83,953.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,151.78. The transfer capital threshold is the transfer adjustment factor * $6,151.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","70463.89","70460.05","91166.17","1 through 10","68717.76","119754.41","other","Inpatient DRG"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC","233","MS-DRG","","","","","","","","inpatient","","","361663.70","271247.77","MEDICARE [2001]","HB BWH MEDICARE","90890.79","","Case rate ($90,890.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,333.44, add-ons for qualifying new technology services are included. If operating cost exceeds $129,977.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,591.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $84,359.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $83,953.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,151.78. The transfer capital threshold is the transfer adjustment factor * $6,151.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","92427.03","0.03","92564.87","21","68717.76","119754.41","other","Inpatient DRG"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC","233","MS-DRG","","","","","","","","inpatient","","","361663.70","271247.77","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","90890.79","","Case rate ($90,890.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,333.44, add-ons for qualifying new technology services are included. If operating cost exceeds $129,977.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,591.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $84,359.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $83,953.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,151.78. The transfer capital threshold is the transfer adjustment factor * $6,151.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","69906.00","69906.00","69906.00","1 through 10","68717.76","119754.41","other","Inpatient DRG"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC","233","MS-DRG","","","","","","","","inpatient","","","361663.70","271247.77","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","68717.76","","Case rate ($70,120.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,333.44, add-ons for qualifying new technology services are included. If operating cost exceeds $129,977.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,591.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $63,588.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $83,953.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,151.78. The transfer capital threshold is the transfer adjustment factor * $6,151.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","69838.80","69838.80","70008.77","1 through 10","68717.76","119754.41","other","Inpatient DRG"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC","233","MS-DRG","","","","","","","","inpatient","","","361663.70","271247.77","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","68717.76","","Case rate ($70,120.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,333.44, add-ons for qualifying new technology services are included. If operating cost exceeds $129,977.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,591.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11. The base transfer operating payment is the transfer adjustment factor * $63,588.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $83,953.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,151.78. The transfer capital threshold is the transfer adjustment factor * $6,151.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","70035.81","70035.81","70035.81","1 through 10","68717.76","119754.41","other","Inpatient DRG"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC","233","MS-DRG","","","","","","","","inpatient","","","361663.70","271247.77","WELLPOINT [1015]","HB AMC WELLPOINT","119754.41","","Fee schedule rate ($119,754.41).","171309.60","171309.60","171309.60","1 through 10","68717.76","119754.41","case rate",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC","234","MS-DRG","","","","","","","","inpatient","","","296949.60","222712.20","MEDICARE [2001]","HB BWH MEDICARE","65052.34","","Case rate ($65,052.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,366.93, add-ons for qualifying new technology services are included. If operating cost exceeds $106,011.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,835.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.2. The base transfer operating payment is the transfer adjustment factor * $60,276.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $59,987.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,395.61. The transfer capital threshold is the transfer adjustment factor * $4,395.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","63092.76","63092.76","63092.76","1 through 10","49206.95","80287.1382","other","Inpatient DRG"
"Coronary Bypass With Ptca With McC","231","MS-DRG","","","","","","","","inpatient","","","511071.24","383303.43","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","75732.69","","Case rate ($77,278.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $92,950.40, add-ons for qualifying new technology services are included. If operating cost exceeds $138,594.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $9,223.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.4. The base transfer operating payment is the transfer adjustment factor * $70,115.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $92,570.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,783.19. The transfer capital threshold is the transfer adjustment factor * $6,783.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","98811.55","98811.55","98811.55","1 through 10","75732.69","127879.6249","other","Inpatient DRG"
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,EXTREME","166","DRG","","","","","","","","inpatient","","","324958.48","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","172477.79","","Standard inlier is a Case rate ($172,477.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $145,773, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($24,484.26) for the length of stay and the standard reimbursement.","210507.56","210507.56","210507.56","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,EXTREME","166","DRG","","","","","","","","inpatient","","","324958.48","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","193911.52","","Standard inlier is a Case rate ($193,911.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $145,773, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($27,524.13) for the length of stay and the standard reimbursement.","216215.96","216215.96","216215.96","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,EXTREME","166","DRG","","","","","","","","inpatient","","","324958.48","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","64112.0828","","Fee schedule rate ($214,608.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","64112.0828","255480.95","255480.95","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,EXTREME","166","DRG","","","","","","","","inpatient","","","324958.48","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","61057.4366","","Fee schedule rate ($204,382.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61057.4366","204382.92","204382.92","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,EXTREME","166","DRG","","","","","","","","inpatient","","","324958.48","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","64112.0828","","Fee schedule rate ($214,608.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","64112.0828","352658.56","352658.56","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,EXTREME","166","DRG","","","","","","","","inpatient","","","324958.48","","MASSHEALTH [3001]","HB BWH MEDICAID","42453.75","","Case rate ($46,939.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $89,369.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","95859.88","95859.88","95859.88","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,EXTREME","166","DRG","","","","","","","","inpatient","","","324958.48","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","167623.19","","Fee schedule rate ($167,623.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","225754.88","225754.88","225754.88","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,MAJOR","166","DRG","","","","","","","","inpatient","","","269253.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","143396.76","","Standard inlier is a Case rate ($143,396.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $123,160, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,356.03) for the length of stay and the standard reimbursement.","143396.75","143396.75","161216.60","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,MAJOR","166","DRG","","","","","","","","inpatient","","","269253.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","161216.60","","Standard inlier is a Case rate ($161,216.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $123,160, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($22,883.36) for the length of stay and the standard reimbursement.","161216.60","147285.29","161216.60","27","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,MAJOR","166","DRG","","","","","","","","inpatient","","","269253.28","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","61057.4366","","Fee schedule rate ($95,576.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61057.4366","95576.44","95576.44","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,MAJOR","166","DRG","","","","","","","","inpatient","","","269253.28","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","64112.0828","","Fee schedule rate ($100,358.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","64112.0828","100358.04","100358.04","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,MAJOR","166","DRG","","","","","","","","inpatient","","","269253.28","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","105135.35","","Fee schedule rate ($105,135.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","105135.36","105135.36","105135.36","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,MAJOR","166","DRG","","","","","","","","inpatient","","","269253.28","","MASSHEALTH [3001]","HB BWH MEDICAID","34785.04","","Case rate ($38,460.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,890.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","51034.48","51034.48","52369.23","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,MAJOR","166","DRG","","","","","","","","inpatient","","","269253.28","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","133116.74","","Fee schedule rate ($133,116.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","133116.74","133116.74","133116.74","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,MAJOR","166","DRG","","","","","","","","inpatient","","","269253.28","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","139774.76","","Fee schedule rate ($139,774.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","139774.76","139774.76","139774.76","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,MAJOR","166","DRG","","","","","","","","inpatient","","","269253.28","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","34785.04","","Case rate ($38,460.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,890.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","44260.30","44260.30","44260.30","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,MODERATE","166","DRG","","","","","","","","inpatient","","","234069.90","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","120751.59","","Standard inlier is a Case rate ($120,751.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $105,550, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,141.42) for the length of stay and the standard reimbursement.","130711.37","130711.37","130711.37","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,MODERATE","166","DRG","","","","","","","","inpatient","","","234069.90","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","135757.33","","Standard inlier is a Case rate ($135,757.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $105,550, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($19,269.63) for the length of stay and the standard reimbursement.","135757.33","124026.04","147285.29","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,MODERATE","166","DRG","","","","","","","","inpatient","","","234069.90","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","61057.4366","","Fee schedule rate ($95,576.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61057.4366","95576.44","95576.44","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Ami Or Complex Principal Diagnosis,MODERATE","166","DRG","","","","","","","","inpatient","","","234069.90","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","139774.76","","Fee schedule rate ($139,774.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","115717.33","115717.33","115717.33","1 through 10","27630.41","337235.96","case rate",""
"Coronary Bypass Without Cardiac Catheterization With McC","235","MS-DRG","","","","","","","","inpatient","","","282767.95","212075.96","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","55531.23","","Case rate ($53,913.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $64,824.20, add-ons for qualifying new technology services are included. If operating cost exceeds $110,468.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,162.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8. The base transfer operating payment is the transfer adjustment factor * $48,811.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $64,444.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,722.22. The transfer capital threshold is the transfer adjustment factor * $4,722.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","47830.45","38876.21","55351.93","1 through 10","52835.54","91925.75","other","Inpatient DRG"
"Coronary Bypass Without Cardiac Catheterization With McC","235","MS-DRG","","","","","","","","inpatient","","","282767.95","212075.96","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","53913.82","","Case rate ($53,913.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $64,824.20, add-ons for qualifying new technology services are included. If operating cost exceeds $110,468.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,162.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8. The base transfer operating payment is the transfer adjustment factor * $48,811.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $64,444.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,722.22. The transfer capital threshold is the transfer adjustment factor * $4,722.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","52460.26","39409.66","61880.98","22","52835.54","91925.75","other","Inpatient Replacement Plans DRG"
"Coronary Bypass Without Cardiac Catheterization With McC","235","MS-DRG","","","","","","","","inpatient","","","282767.95","212075.96","MEDICARE [2001]","HB BWH MEDICARE","53913.82","","Case rate ($53,913.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $64,824.20, add-ons for qualifying new technology services are included. If operating cost exceeds $110,468.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,162.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8. The base transfer operating payment is the transfer adjustment factor * $48,811.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $64,444.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,722.22. The transfer capital threshold is the transfer adjustment factor * $4,722.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","68897.27","0.03","69751.80","94","52835.54","91925.75","other","Inpatient Replacement Plans DRG"
"Coronary Bypass Without Cardiac Catheterization With McC","235","MS-DRG","","","","","","","","inpatient","","","282767.95","212075.96","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","53913.82","","Case rate ($53,913.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $64,824.20, add-ons for qualifying new technology services are included. If operating cost exceeds $110,468.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,162.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8. The base transfer operating payment is the transfer adjustment factor * $48,811.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $64,444.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,722.22. The transfer capital threshold is the transfer adjustment factor * $4,722.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","52648.58","39120.23","52711.01","1 through 10","52835.54","91925.75","other","Inpatient Replacement Plans DRG"
"Coronary Bypass Without Cardiac Catheterization With McC","235","MS-DRG","","","","","","","","inpatient","","","282767.95","212075.96","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","52835.54","","Case rate ($53,913.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $64,824.20, add-ons for qualifying new technology services are included. If operating cost exceeds $110,468.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,162.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8. The base transfer operating payment is the transfer adjustment factor * $48,811.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $64,444.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,722.22. The transfer capital threshold is the transfer adjustment factor * $4,722.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","39172.20","32614.70","98395.03","1 through 10","52835.54","91925.75","other","Inpatient DRG"
"Coronary Bypass Without Cardiac Catheterization With McC","235","MS-DRG","","","","","","","","inpatient","","","282767.95","212075.96","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","52835.54","","Case rate ($53,913.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $64,824.20, add-ons for qualifying new technology services are included. If operating cost exceeds $110,468.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,162.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8. The base transfer operating payment is the transfer adjustment factor * $48,811.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $64,444.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,722.22. The transfer capital threshold is the transfer adjustment factor * $4,722.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","52756.14","45615.05","75103.06","21","52835.54","91925.75","other","Inpatient DRG"
"Coronary Bypass Without Cardiac Catheterization With McC","235","MS-DRG","","","","","","","","inpatient","","","282767.95","212075.96","WELLSENSE NH [1050]","HB BWH MEDICARE","53913.82","","Case rate ($53,913.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $64,824.20, add-ons for qualifying new technology services are included. If operating cost exceeds $110,468.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,162.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8. The base transfer operating payment is the transfer adjustment factor * $48,811.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $64,444.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,722.22. The transfer capital threshold is the transfer adjustment factor * $4,722.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","52761.65","52761.65","52761.65","1 through 10","52835.54","91925.75","other","Inpatient Replacement Plans DRG"
"Coronary Bypass Without Cardiac Catheterization Without McC","236","MS-DRG","","","","","","","","inpatient","","","290410.48","217807.86","MEDICARE [2001]","HB BWH MEDICARE","38590.52","","Case rate ($38,590.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,377.95, add-ons for qualifying new technology services are included. If operating cost exceeds $92,022.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,810.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $34,840.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,998.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,370.55. The transfer capital threshold is the transfer adjustment factor * $3,370.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","48756.46","48756.46","48828.98","1 through 10","37818.71","62055.7011","other","Inpatient Replacement Plans DRG"
"Coronary Bypass Without Cardiac Catheterization Without McC","236","MS-DRG","","","","","","","","inpatient","","","290410.48","217807.86","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","37818.71","","Case rate ($38,590.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,377.95, add-ons for qualifying new technology services are included. If operating cost exceeds $92,022.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,810.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $34,840.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,998.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,370.55. The transfer capital threshold is the transfer adjustment factor * $3,370.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","52099.88","52099.88","52099.88","1 through 10","37818.71","62055.7011","other","Inpatient DRG"
"Coronary Bypass Without Cardiac Catheterization Without McC","236","MS-DRG","","","","","","","","inpatient","","","290410.48","217807.86","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","37818.71","","Case rate ($38,590.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,377.95, add-ons for qualifying new technology services are included. If operating cost exceeds $92,022.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,810.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $34,840.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,998.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,370.55. The transfer capital threshold is the transfer adjustment factor * $3,370.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","52806.23","52806.23","52806.23","1 through 10","37818.71","62055.7011","other","Inpatient DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device With McC","323","MS-DRG","","","","","","","","inpatient","","","210687.84","158015.88","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","39854.84","","Case rate ($39,854.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $47,899.96, add-ons for qualifying new technology services are included. If operating cost exceeds $93,544.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,922.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $35,992.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $47,520.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,482.08. The transfer capital threshold is the transfer adjustment factor * $3,482.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","49794.12","49794.12","49794.12","1 through 10","39057.74","67784.39","other","Inpatient Replacement Plans DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device With McC","323","MS-DRG","","","","","","","","inpatient","","","210687.84","158015.88","MEDICARE [2001]","HB BWH MEDICARE","39854.84","","Case rate ($39,854.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $47,899.96, add-ons for qualifying new technology services are included. If operating cost exceeds $93,544.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,922.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $35,992.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $47,520.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,482.08. The transfer capital threshold is the transfer adjustment factor * $3,482.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","50552.29","24672.35","50568.14","18","39057.74","67784.39","other","Inpatient Replacement Plans DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device With McC","323","MS-DRG","","","","","","","","inpatient","","","210687.84","158015.88","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","39854.84","","Case rate ($39,854.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $47,899.96, add-ons for qualifying new technology services are included. If operating cost exceeds $93,544.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,922.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $35,992.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $47,520.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,482.08. The transfer capital threshold is the transfer adjustment factor * $3,482.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38213.16","38213.16","38213.16","1 through 10","39057.74","67784.39","other","Inpatient Replacement Plans DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device With McC","323","MS-DRG","","","","","","","","inpatient","","","210687.84","158015.88","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","39057.74","","Case rate ($39,854.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $47,899.96, add-ons for qualifying new technology services are included. If operating cost exceeds $93,544.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,922.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $35,992.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $47,520.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,482.08. The transfer capital threshold is the transfer adjustment factor * $3,482.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","38256.14","38256.14","38274.75","1 through 10","39057.74","67784.39","other","Inpatient DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device With McC","323","MS-DRG","","","","","","","","inpatient","","","210687.84","158015.88","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","39057.74","","Case rate ($39,854.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $47,899.96, add-ons for qualifying new technology services are included. If operating cost exceeds $93,544.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,922.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $35,992.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $47,520.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,482.08. The transfer capital threshold is the transfer adjustment factor * $3,482.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","38385.43","38385.43","38385.43","1 through 10","39057.74","67784.39","other","Inpatient DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device Without McC","324","MS-DRG","","","","","","","","inpatient","","","144971.33","108728.50","HUMANA [1012]","HB BWH MEDICARE","29123.59","","Case rate ($29,123.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,981.65, add-ons for qualifying new technology services are included. If operating cost exceeds $80,626.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,975.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $26,208.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,601.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,535.48. The transfer capital threshold is the transfer adjustment factor * $2,535.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","241052.56","241052.56","241052.56","1 through 10","28541.12","49357.26","other","Inpatient Replacement Plans DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device Without McC","324","MS-DRG","","","","","","","","inpatient","","","144971.33","108728.50","MEDICARE [2001]","HB BWH MEDICARE","29123.59","","Case rate ($29,123.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,981.65, add-ons for qualifying new technology services are included. If operating cost exceeds $80,626.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,975.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $26,208.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,601.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,535.48. The transfer capital threshold is the transfer adjustment factor * $2,535.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","37945.80","13481.00","38002.15","22","28541.12","49357.26","other","Inpatient Replacement Plans DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device Without McC","324","MS-DRG","","","","","","","","inpatient","","","144971.33","108728.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","29123.59","","Case rate ($29,123.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,981.65, add-ons for qualifying new technology services are included. If operating cost exceeds $80,626.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,975.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $26,208.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,601.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,535.48. The transfer capital threshold is the transfer adjustment factor * $2,535.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28746.92","28746.92","28767.92","1 through 10","28541.12","49357.26","other","Inpatient Replacement Plans DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device Without McC","324","MS-DRG","","","","","","","","inpatient","","","144971.33","108728.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28541.12","","Case rate ($29,123.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,981.65, add-ons for qualifying new technology services are included. If operating cost exceeds $80,626.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,975.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $26,208.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,601.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,535.48. The transfer capital threshold is the transfer adjustment factor * $2,535.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","28704.58","28704.58","28704.58","1 through 10","28541.12","49357.26","other","Inpatient DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device Without McC","324","MS-DRG","","","","","","","","inpatient","","","144971.33","108728.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28541.12","","Case rate ($29,123.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,981.65, add-ons for qualifying new technology services are included. If operating cost exceeds $80,626.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,975.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $26,208.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,601.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,535.48. The transfer capital threshold is the transfer adjustment factor * $2,535.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","28716.09","28716.09","28733.21","1 through 10","28541.12","49357.26","other","Inpatient DRG"
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","","","","inpatient","","","167896.97","125922.73","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29665.45","","Case rate ($29,665.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,633.93, add-ons for qualifying new technology services are included. If operating cost exceeds $81,278.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,023.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $26,702.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,254.10 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,583.28. The transfer capital threshold is the transfer adjustment factor * $2,583.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30000.47","30000.47","30000.47","1 through 10","29072.14","43191.9511","other","Inpatient Replacement Plans DRG"
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","","","","inpatient","","","167896.97","125922.73","MEDICARE [2001]","HB BWH MEDICARE","29665.45","","Case rate ($29,665.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,633.93, add-ons for qualifying new technology services are included. If operating cost exceeds $81,278.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,023.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $26,702.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,254.10 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,583.28. The transfer capital threshold is the transfer adjustment factor * $2,583.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34070.49","34070.49","34070.49","1 through 10","29072.14","43191.9511","other","Inpatient Replacement Plans DRG"
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","","","","inpatient","","","167896.97","125922.73","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","29072.14","","Case rate ($29,665.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,633.93, add-ons for qualifying new technology services are included. If operating cost exceeds $81,278.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,023.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $26,702.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,254.10 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,583.28. The transfer capital threshold is the transfer adjustment factor * $2,583.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26308.52","26308.52","26308.52","1 through 10","29072.14","43191.9511","other","Inpatient DRG"
"Coronary Sinus Synching WO Implant","PX-48000541","CDM","93799","CPT","0481","RC","","","","both","","","35384.00","26538.00","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","28130.28","other","OPPS APC"
"Coronary Sinus Synching WO Implant","PX-48000541","CDM","93799","CPT","0481","RC","","","","outpatient","","","35384.00","26538.00","AETNA [1001]","HB AMC AETNA HMO","24698.03","69.8","","2022.70","2022.70","2022.70","1 through 10","454","29191.8","percent of total billed charges",""
"Coronary Sinus Synching WO Implant","PX-48000541","CDM","93799","CPT","0481","RC","","","","outpatient","","","35384.00","26538.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21425.01","60.55","","318.03","318.03","2439.77","1 through 10","454","29191.8","percent of total billed charges",""
"Coronary Sinus Synching WO Implant","PX-48000541","CDM","93799","CPT","0481","RC","","","","outpatient","","","35384.00","26538.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18477.52","52.22","","360.38","360.38","4023.00","1 through 10","454","29191.8","percent of total billed charges",""
"Coronary Sinus Synching WO Implant","PX-48000541","CDM","93799","CPT","0481","RC","","","","outpatient","","","35384.00","26538.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","19461.20","55","","13080.03","13080.03","13080.03","1 through 10","454","29191.8","percent of total billed charges",""
"CORONOID PLATE LG BUTTRESS EVOLVE TRIAD","SUP-ITM-10116808","CDM","C1713","HCPCS","0278","RC","","","","both","","","1739.50","1304.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1382.90","79.5","","800.18","480.96","1887.97","195","539.25","1382.9","percent of total billed charges",""
"CORONOID PLATE LG BUTTRESS EVOLVE TRIAD","SUP-ITM-10116808","CDM","C1713","HCPCS","0278","RC","","","","both","","","1739.50","1304.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","927.15","53.3","","813.12","216.42","1444.50","81","539.25","1382.9","percent of total billed charges",""
"CORONOID PLATE LG BUTTRESS EVOLVE TRIAD","SUP-ITM-10116808","CDM","C1713","HCPCS","0278","RC","","","","both","","","1739.50","1304.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","539.25","31","","432.60","432.60","432.60","1 through 10","539.25","1382.9","percent of total billed charges",""
"CORONOID PLATE LG BUTTRESS EVOLVE TRIAD","SUP-ITM-10116808","CDM","C1713","HCPCS","0278","RC","","","","both","","","1739.50","1304.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","634.92","36.5","","148.37","54.89","631.39","94","539.25","1382.9","percent of total billed charges",""
"CORONOID PLATE LG BUTTRESS EVOLVE TRIAD","SUP-ITM-10116808","CDM","C1713","HCPCS","0278","RC","","","","both","","","1739.50","1304.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","666.23","38.3","","279.30","91.72","1116.77","266","539.25","1382.9","percent of total billed charges",""
"CORONOID PLATE LG BUTTRESS EVOLVE TRIAD","SUP-ITM-10116808","CDM","C1713","HCPCS","0278","RC","","","","both","","","1739.50","1304.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","746.25","42.9","","731.00","63.70","731.00","1 through 10","539.25","1382.9","percent of total billed charges",""
"CORONOID PLATE LG BUTTRESS EVOLVE TRIAD","SUP-ITM-10116808","CDM","C1713","HCPCS","0278","RC","","","","both","","","1739.50","1304.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","746.25","42.9","","384.74","384.74","384.74","1 through 10","539.25","1382.9","percent of total billed charges",""
"CORONOID PLATE LG BUTTRESS EVOLVE TRIAD","SUP-ITM-10116808","CDM","C1713","HCPCS","0278","RC","","","","both","","","1739.50","1304.62","WELLPOINT [1015]","HB AMC WELLPOINT","1283.40","73.78","","286.63","119.22","1107.45","105","539.25","1382.9","percent of total billed charges",""
"CORONOID PLATE LG BUTTRESS EVOLVE TRIAD","SUP-ITM-10116808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1739.50","1304.62","AETNA [1001]","HB AMC AETNA HMO","1214.17","69.8","","675.31","184.75","1721.50","286","909.06","1421.52","percent of total billed charges",""
"CORONOID PLATE LG BUTTRESS EVOLVE TRIAD","SUP-ITM-10116808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1739.50","1304.62","AETNA [1001]","HB AMC AETNA PPO","1398.56","80.4","","1261.44","103.12","1514.10","21","909.06","1421.52","percent of total billed charges",""
"CORONOID PLATE LG BUTTRESS EVOLVE TRIAD","SUP-ITM-10116808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1739.50","1304.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1398.56","80.4","","1365.00","1365.00","1365.00","1 through 10","909.06","1421.52","percent of total billed charges",""
"CORONOID PLATE LG BUTTRESS EVOLVE TRIAD","SUP-ITM-10116808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1739.50","1304.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1421.52","81.72","","5157.68","5157.68","5157.68","1 through 10","909.06","1421.52","percent of total billed charges",""
"CORONOID PLATE LG BUTTRESS EVOLVE TRIAD","SUP-ITM-10116808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1739.50","1304.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1421.52","81.72","","431.26","71.26","1459.57","88","909.06","1421.52","percent of total billed charges",""
"CORONOID PLATE MED BUTTRESS EVOLVE TRIAD","SUP-ITM-10116807","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.00","1191.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1263.26","79.5","","800.18","480.96","1887.97","195","492.59","1263.26","percent of total billed charges",""
"CORONOID PLATE MED BUTTRESS EVOLVE TRIAD","SUP-ITM-10116807","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.00","1191.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","846.94","53.3","","813.12","216.42","1444.50","81","492.59","1263.26","percent of total billed charges",""
"CORONOID PLATE MED BUTTRESS EVOLVE TRIAD","SUP-ITM-10116807","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.00","1191.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","492.59","31","","432.60","432.60","432.60","1 through 10","492.59","1263.26","percent of total billed charges",""
"CORONOID PLATE MED BUTTRESS EVOLVE TRIAD","SUP-ITM-10116807","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.00","1191.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","579.99","36.5","","148.37","54.89","631.39","94","492.59","1263.26","percent of total billed charges",""
"CORONOID PLATE MED BUTTRESS EVOLVE TRIAD","SUP-ITM-10116807","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.00","1191.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","608.59","38.3","","279.30","91.72","1116.77","266","492.59","1263.26","percent of total billed charges",""
"CORONOID PLATE MED BUTTRESS EVOLVE TRIAD","SUP-ITM-10116807","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.00","1191.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","681.68","42.9","","731.00","63.70","731.00","1 through 10","492.59","1263.26","percent of total billed charges",""
"CORONOID PLATE MED BUTTRESS EVOLVE TRIAD","SUP-ITM-10116807","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.00","1191.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","681.68","42.9","","384.74","384.74","384.74","1 through 10","492.59","1263.26","percent of total billed charges",""
"CORONOID PLATE MED BUTTRESS EVOLVE TRIAD","SUP-ITM-10116807","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.00","1191.75","WELLPOINT [1015]","HB AMC WELLPOINT","1172.36","73.78","","286.63","119.22","1107.45","105","492.59","1263.26","percent of total billed charges",""
"CORONOID PLATE MED BUTTRESS EVOLVE TRIAD","SUP-ITM-10116807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.00","1191.75","AETNA [1001]","HB AMC AETNA HMO","1109.12","69.8","","675.31","184.75","1721.50","286","830.41","1298.53","percent of total billed charges",""
"CORONOID PLATE MED BUTTRESS EVOLVE TRIAD","SUP-ITM-10116807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.00","1191.75","AETNA [1001]","HB AMC AETNA PPO","1277.56","80.4","","1261.44","103.12","1514.10","21","830.41","1298.53","percent of total billed charges",""
"CORONOID PLATE MED BUTTRESS EVOLVE TRIAD","SUP-ITM-10116807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.00","1191.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1277.56","80.4","","1365.00","1365.00","1365.00","1 through 10","830.41","1298.53","percent of total billed charges",""
"CORONOID PLATE MED BUTTRESS EVOLVE TRIAD","SUP-ITM-10116807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.00","1191.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1298.53","81.72","","5157.68","5157.68","5157.68","1 through 10","830.41","1298.53","percent of total billed charges",""
"CORONOID PLATE MED BUTTRESS EVOLVE TRIAD","SUP-ITM-10116807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.00","1191.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1298.53","81.72","","431.26","71.26","1459.57","88","830.41","1298.53","percent of total billed charges",""
"CORONOID PLATE SM BUTTRESS EVOLVE TRIAD","SUP-ITM-10116806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.50","1089.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1154.74","79.5","","800.18","480.96","1887.97","195","450.28","1154.74","percent of total billed charges",""
"CORONOID PLATE SM BUTTRESS EVOLVE TRIAD","SUP-ITM-10116806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.50","1089.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","774.18","53.3","","813.12","216.42","1444.50","81","450.28","1154.74","percent of total billed charges",""
"CORONOID PLATE SM BUTTRESS EVOLVE TRIAD","SUP-ITM-10116806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.50","1089.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","450.28","31","","432.60","432.60","432.60","1 through 10","450.28","1154.74","percent of total billed charges",""
"CORONOID PLATE SM BUTTRESS EVOLVE TRIAD","SUP-ITM-10116806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.50","1089.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","530.16","36.5","","148.37","54.89","631.39","94","450.28","1154.74","percent of total billed charges",""
"CORONOID PLATE SM BUTTRESS EVOLVE TRIAD","SUP-ITM-10116806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.50","1089.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","556.31","38.3","","279.30","91.72","1116.77","266","450.28","1154.74","percent of total billed charges",""
"CORONOID PLATE SM BUTTRESS EVOLVE TRIAD","SUP-ITM-10116806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.50","1089.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","623.12","42.9","","731.00","63.70","731.00","1 through 10","450.28","1154.74","percent of total billed charges",""
"CORONOID PLATE SM BUTTRESS EVOLVE TRIAD","SUP-ITM-10116806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.50","1089.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","623.12","42.9","","384.74","384.74","384.74","1 through 10","450.28","1154.74","percent of total billed charges",""
"CORONOID PLATE SM BUTTRESS EVOLVE TRIAD","SUP-ITM-10116806","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.50","1089.37","WELLPOINT [1015]","HB AMC WELLPOINT","1071.65","73.78","","286.63","119.22","1107.45","105","450.28","1154.74","percent of total billed charges",""
"CORONOID PLATE SM BUTTRESS EVOLVE TRIAD","SUP-ITM-10116806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.50","1089.37","AETNA [1001]","HB AMC AETNA HMO","1013.85","69.8","","675.31","184.75","1721.50","286","759.08","1186.98","percent of total billed charges",""
"CORONOID PLATE SM BUTTRESS EVOLVE TRIAD","SUP-ITM-10116806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.50","1089.37","AETNA [1001]","HB AMC AETNA PPO","1167.81","80.4","","1261.44","103.12","1514.10","21","759.08","1186.98","percent of total billed charges",""
"CORONOID PLATE SM BUTTRESS EVOLVE TRIAD","SUP-ITM-10116806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.50","1089.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1167.81","80.4","","1365.00","1365.00","1365.00","1 through 10","759.08","1186.98","percent of total billed charges",""
"CORONOID PLATE SM BUTTRESS EVOLVE TRIAD","SUP-ITM-10116806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.50","1089.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1186.98","81.72","","5157.68","5157.68","5157.68","1 through 10","759.08","1186.98","percent of total billed charges",""
"CORONOID PLATE SM BUTTRESS EVOLVE TRIAD","SUP-ITM-10116806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.50","1089.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1186.98","81.72","","431.26","71.26","1459.57","88","759.08","1186.98","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","both","","","201.00","150.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.80","79.5","","153.47","153.47","153.47","1 through 10","16.38","190.95","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","both","","","201.00","150.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","107.13","53.3","","102.96","102.96","102.96","1 through 10","16.38","190.95","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","both","","","201.00","150.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.37","36.5","","72.74","61.23","72.74","1 through 10","16.38","190.95","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","both","","","201.00","150.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.98","38.3","","76.25","74.10","228.75","1 through 10","16.38","190.95","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","both","","","201.00","150.75","TRICARE [160005]","HB BWH TRICARE","190.95","95","","20.14","20.14","20.14","1 through 10","16.38","190.95","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","both","","","201.00","150.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.23","42.9","","85.74","85.74","85.74","1 through 10","16.38","190.95","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","outpatient","","","201.00","150.75","AETNA [1001]","HB AMC AETNA HMO","140.30","69.8","","132.02","93.21","152.10","13","17.23","164.26","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","outpatient","","","201.00","150.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","164.26","81.72","","155.88","85.74","155.88","13","17.23","164.26","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","221.00","165.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","154.70","70","","214.00","214.00","214.00","1 through 10","15.97","209.95","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","221.00","165.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","175.70","79.5","","168.42","112.99","168.42","77","15.97","209.95","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","221.00","165.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.79","53.3","","112.99","112.99","168.42","33","15.97","209.95","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","221.00","165.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.51","31","","66.13","66.13","66.13","1 through 10","15.97","209.95","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","221.00","165.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.67","36.5","","79.82","67.84","203.52","50","15.97","209.95","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","221.00","165.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.64","38.3","","83.67","70.62","239.46","152","15.97","209.95","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","221.00","165.75","MOLINA [1014]","HB BWH MOLINA","77.35","35","","32.34","32.34","32.34","1 through 10","15.97","209.95","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","221.00","165.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","170.17","77","","168.42","166.92","168.42","1 through 10","15.97","209.95","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","221.00","165.75","TRICARE [160005]","HB BWH TRICARE","209.95","95","","19.64","18.66","19.64","1 through 10","15.97","209.95","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.81","42.9","","94.10","94.10","171.07","1 through 10","15.97","209.95","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","221.00","165.75","AETNA [1001]","HB AMC AETNA HMO","154.26","69.8","","144.88","102.29","166.92","126","16.81","180.6","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","221.00","165.75","AETNA [1001]","HB AMC AETNA PPO","177.68","80.4","","166.92","112.14","333.84","1 through 10","16.81","180.6","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","221.00","165.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","123.54","55.9","","112.14","112.14","112.14","1 through 10","16.81","180.6","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","221.00","165.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","115.49","52.26","","57.74","57.74","57.74","1 through 10","16.81","180.6","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","221.00","165.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","177.68","80.4","","166.92","107.00","166.92","1 through 10","16.81","180.6","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","180.60","81.72","","171.07","94.10","214.00","1 through 10","16.81","180.6","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","180.60","81.72","","171.07","94.10","171.07","90","16.81","180.6","percent of total billed charges",""
"Cosyntropin Vl 0.25mg","PX-63600088","CDM","J0834","HCPCS","0636","RC","","","","outpatient","","","248.44","186.33","AETNA [1001]","HB AMC AETNA HMO","173.41","69.8","","37.58","37.58","37.58","1 through 10","60.24","199.75","percent of total billed charges",""
"Counseling, Preventative Med","PX-77000017","CDM","99403","CPT","0510","RC","","","","outpatient","","","298.00","223.50","AETNA [1001]","HB AMC AETNA HMO","208.00","69.8","","256.58","256.58","295.62","11","166.58","239.59","percent of total billed charges",""
"Counseling, Preventative Med","PX-77000017","CDM","99403","CPT","0510","RC","","","","outpatient","","","298.00","223.50","AETNA [1001]","HB AMC AETNA PPO","239.59","80.4","","198.60","198.60","198.60","1 through 10","166.58","239.59","percent of total billed charges",""
"Counseling, Preventative Med","PX-77000017","CDM","99403","CPT","0770","RC","","","","both","","","298.00","223.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.91","79.5","","298.27","298.27","298.27","1 through 10","92.38","326.13","percent of total billed charges",""
"Counseling, Preventative Med","PX-77000017","CDM","99403","CPT","0770","RC","","","","both","","","298.00","223.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.83","53.3","","298.27","191.40","298.27","1 through 10","92.38","326.13","percent of total billed charges",""
"Counseling, Preventative Med","PX-77000017","CDM","99403","CPT","0770","RC","","","","both","","","298.00","223.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","114.13","38.3","","113.00","113.00","113.00","1 through 10","92.38","326.13","percent of total billed charges",""
"Counseling, Preventative Med","PX-77000017","CDM","99403","CPT","0770","RC","","","","outpatient","","","298.00","223.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","243.53","81.72","","302.97","302.97","302.97","1 through 10","106.12","243.53","percent of total billed charges",""
"Counseling, Preventative Med","PX-98300547","CDM","99403","CPT","0983","RC","","","","both","","","307.00","230.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","244.07","79.5","","298.27","298.27","298.27","1 through 10","95.17","326.13","percent of total billed charges",""
"Counseling, Preventative Med","PX-98300547","CDM","99403","CPT","0983","RC","","","","both","","","307.00","230.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","163.63","53.3","","298.27","191.40","298.27","1 through 10","95.17","326.13","percent of total billed charges",""
"Counseling, Preventative Med","PX-98300547","CDM","99403","CPT","0983","RC","","","","both","","","307.00","230.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","117.58","38.3","","113.00","113.00","113.00","1 through 10","95.17","326.13","percent of total billed charges",""
"Counseling, Preventative Med","PX-98300547","CDM","99403","CPT","0983","RC","","","","outpatient","","","307.00","230.25","AETNA [1001]","HB AMC AETNA HMO","214.29","69.8","","256.58","256.58","295.62","11","106.12","250.88","percent of total billed charges",""
"Counseling, Preventative Med","PX-98300547","CDM","99403","CPT","0983","RC","","","","outpatient","","","307.00","230.25","AETNA [1001]","HB AMC AETNA PPO","246.83","80.4","","198.60","198.60","198.60","1 through 10","106.12","250.88","percent of total billed charges",""
"Counseling, Preventative Med","PX-98300547","CDM","99403","CPT","0983","RC","","","","outpatient","","","307.00","230.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","250.88","81.72","","302.97","302.97","302.97","1 through 10","106.12","250.88","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","634.13","79.5","","800.18","480.96","1887.97","195","247.27","634.13","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","425.15","53.3","","813.12","216.42","1444.50","81","247.27","634.13","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","247.27","31","","432.60","432.60","432.60","1 through 10","247.27","634.13","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","291.14","36.5","","148.37","54.89","631.39","94","247.27","634.13","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","305.50","38.3","","279.30","91.72","1116.77","266","247.27","634.13","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.19","42.9","","731.00","63.70","731.00","1 through 10","247.27","634.13","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.19","42.9","","384.74","384.74","384.74","1 through 10","247.27","634.13","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","WELLPOINT [1015]","HB AMC WELLPOINT","588.51","73.78","","286.63","119.22","1107.45","105","247.27","634.13","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","797.65","598.24","AETNA [1001]","HB AMC AETNA HMO","556.76","69.8","","675.31","184.75","1721.50","286","416.85","651.84","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","797.65","598.24","AETNA [1001]","HB AMC AETNA PPO","641.31","80.4","","1261.44","103.12","1514.10","21","416.85","651.84","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","797.65","598.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","641.31","80.4","","1365.00","1365.00","1365.00","1 through 10","416.85","651.84","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","797.65","598.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","651.84","81.72","","5157.68","5157.68","5157.68","1 through 10","416.85","651.84","percent of total billed charges",""
"COUNTERSINK BONE 3.5 4MM 2 BIT DRILL STAINLESS CORTEX CANCELLOUS SCREW TIP","SUP-ITM-10019514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","797.65","598.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","651.84","81.72","","431.26","71.26","1459.57","88","416.85","651.84","percent of total billed charges",""
"COUNTERSINK SURGICAL 2.7MM SS CORTEX","SUP-ITM-10029062","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","634.13","79.5","","800.18","480.96","1887.97","195","247.27","634.13","percent of total billed charges",""
"COUNTERSINK SURGICAL 2.7MM SS CORTEX","SUP-ITM-10029062","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","425.15","53.3","","813.12","216.42","1444.50","81","247.27","634.13","percent of total billed charges",""
"COUNTERSINK SURGICAL 2.7MM SS CORTEX","SUP-ITM-10029062","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","247.27","31","","432.60","432.60","432.60","1 through 10","247.27","634.13","percent of total billed charges",""
"COUNTERSINK SURGICAL 2.7MM SS CORTEX","SUP-ITM-10029062","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","291.14","36.5","","148.37","54.89","631.39","94","247.27","634.13","percent of total billed charges",""
"COUNTERSINK SURGICAL 2.7MM SS CORTEX","SUP-ITM-10029062","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","305.50","38.3","","279.30","91.72","1116.77","266","247.27","634.13","percent of total billed charges",""
"COUNTERSINK SURGICAL 2.7MM SS CORTEX","SUP-ITM-10029062","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.19","42.9","","731.00","63.70","731.00","1 through 10","247.27","634.13","percent of total billed charges",""
"COUNTERSINK SURGICAL 2.7MM SS CORTEX","SUP-ITM-10029062","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.19","42.9","","384.74","384.74","384.74","1 through 10","247.27","634.13","percent of total billed charges",""
"COUNTERSINK SURGICAL 2.7MM SS CORTEX","SUP-ITM-10029062","CDM","C1713","HCPCS","0278","RC","","","","both","","","797.65","598.24","WELLPOINT [1015]","HB AMC WELLPOINT","588.51","73.78","","286.63","119.22","1107.45","105","247.27","634.13","percent of total billed charges",""
"COUNTERSINK SURGICAL 2.7MM SS CORTEX","SUP-ITM-10029062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","797.65","598.24","AETNA [1001]","HB AMC AETNA HMO","556.76","69.8","","675.31","184.75","1721.50","286","416.85","651.84","percent of total billed charges",""
"COUNTERSINK SURGICAL 2.7MM SS CORTEX","SUP-ITM-10029062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","797.65","598.24","AETNA [1001]","HB AMC AETNA PPO","641.31","80.4","","1261.44","103.12","1514.10","21","416.85","651.84","percent of total billed charges",""
"COUNTERSINK SURGICAL 2.7MM SS CORTEX","SUP-ITM-10029062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","797.65","598.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","641.31","80.4","","1365.00","1365.00","1365.00","1 through 10","416.85","651.84","percent of total billed charges",""
"COUNTERSINK SURGICAL 2.7MM SS CORTEX","SUP-ITM-10029062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","797.65","598.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","651.84","81.72","","5157.68","5157.68","5157.68","1 through 10","416.85","651.84","percent of total billed charges",""
"COUNTERSINK SURGICAL 2.7MM SS CORTEX","SUP-ITM-10029062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","797.65","598.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","651.84","81.72","","431.26","71.26","1459.57","88","416.85","651.84","percent of total billed charges",""
"COUPLER ANASTOMOSIS 2.5MM VESSELXORTHOPEDIC FAST SAFE MICROVASCULAR POLYETHYLENE S/S BX/6EA","SUP-ITM-10011292","CDM","C1889","HCPCS","0278","RC","","","","both","","","1222.08","916.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","971.55","79.5","","1309.77","674.56","6049.93","26","378.84","971.55","percent of total billed charges",""
"COUPLER ANASTOMOSIS 2.5MM VESSELXORTHOPEDIC FAST SAFE MICROVASCULAR POLYETHYLENE S/S BX/6EA","SUP-ITM-10011292","CDM","C1889","HCPCS","0278","RC","","","","both","","","1222.08","916.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","651.37","53.3","","1901.83","1901.83","2962.25","1 through 10","378.84","971.55","percent of total billed charges",""
"COUPLER ANASTOMOSIS 2.5MM VESSELXORTHOPEDIC FAST SAFE MICROVASCULAR POLYETHYLENE S/S BX/6EA","SUP-ITM-10011292","CDM","C1889","HCPCS","0278","RC","","","","both","","","1222.08","916.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","446.06","36.5","","1620.31","1620.31","19908.88","1 through 10","378.84","971.55","percent of total billed charges",""
"COUPLER ANASTOMOSIS 2.5MM VESSELXORTHOPEDIC FAST SAFE MICROVASCULAR POLYETHYLENE S/S BX/6EA","SUP-ITM-10011292","CDM","C1889","HCPCS","0278","RC","","","","both","","","1222.08","916.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","468.06","38.3","","352.91","352.91","2046.30","1 through 10","378.84","971.55","percent of total billed charges",""
"COUPLER ANASTOMOSIS 2.5MM VESSELXORTHOPEDIC FAST SAFE MICROVASCULAR POLYETHYLENE S/S BX/6EA","SUP-ITM-10011292","CDM","C1889","HCPCS","0278","RC","","","","both","","","1222.08","916.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","524.27","42.9","","9668.75","9668.75","9668.75","1 through 10","378.84","971.55","percent of total billed charges",""
"COUPLER ANASTOMOSIS 2.5MM VESSELXORTHOPEDIC FAST SAFE MICROVASCULAR POLYETHYLENE S/S BX/6EA","SUP-ITM-10011292","CDM","C1889","HCPCS","0278","RC","","","","both","","","1222.08","916.56","WELLPOINT [1015]","HB AMC WELLPOINT","901.65","73.78","","699.88","384.10","3443.31","33","378.84","971.55","percent of total billed charges",""
"COUPLER ANASTOMOSIS 2.5MM VESSELXORTHOPEDIC FAST SAFE MICROVASCULAR POLYETHYLENE S/S BX/6EA","SUP-ITM-10011292","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1222.08","916.56","AETNA [1001]","HB AMC AETNA HMO","853.01","69.8","","1421.24","264.50","4933.46","29","638.66","998.68","percent of total billed charges",""
"COUPLER ANASTOMOSIS 2.5MM VESSELXORTHOPEDIC FAST SAFE MICROVASCULAR POLYETHYLENE S/S BX/6EA","SUP-ITM-10011292","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1222.08","916.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","982.55","80.4","","1022.97","1022.97","3607.50","1 through 10","638.66","998.68","percent of total billed charges",""
"COUPLER ANASTOMOSIS 2.5MM VESSELXORTHOPEDIC FAST SAFE MICROVASCULAR POLYETHYLENE S/S BX/6EA","SUP-ITM-10011292","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1222.08","916.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","998.68","81.72","","3010.54","693.88","5019.88","35","638.66","998.68","percent of total billed charges",""
"COUPLER FLOW 4.0MM PROBE ASSEMBLY","SUP-ITM-10166529","CDM","C1760","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2006.52","52.26","","487.31","487.31","487.31","1 through 10","1190.25","3052.4","percent of total billed charges",""
"COUPLER FLOW 4.0MM PROBE ASSEMBLY","SUP-ITM-10166529","CDM","C1760","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2756.76","71.8","","612.50","612.50","612.50","1 through 10","1190.25","3052.4","percent of total billed charges",""
"COUPLER FLOW 4.0MM PROBE ASSEMBLY","SUP-ITM-10166529","CDM","C1760","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2687.65","70","","612.50","612.50","612.50","1 through 10","1190.25","3052.4","percent of total billed charges",""
"COUPLER FLOW 4.0MM PROBE ASSEMBLY","SUP-ITM-10166529","CDM","C1760","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3052.40","79.5","","742.96","323.40","1446.12","32","1190.25","3052.4","percent of total billed charges",""
"COUPLER FLOW 4.0MM PROBE ASSEMBLY","SUP-ITM-10166529","CDM","C1760","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2046.45","53.3","","323.40","323.40","550.90","13","1190.25","3052.4","percent of total billed charges",""
"COUPLER FLOW 4.0MM PROBE ASSEMBLY","SUP-ITM-10166529","CDM","C1760","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1401.42","36.5","","285.08","194.16","582.48","27","1190.25","3052.4","percent of total billed charges",""
"COUPLER FLOW 4.0MM PROBE ASSEMBLY","SUP-ITM-10166529","CDM","C1760","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1470.53","38.3","","239.49","233.98","600.08","52","1190.25","3052.4","percent of total billed charges",""
"COUPLER FLOW 4.0MM PROBE ASSEMBLY","SUP-ITM-10166529","CDM","C1760","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1647.15","42.9","","278.69","278.69","278.69","1 through 10","1190.25","3052.4","percent of total billed charges",""
"COUPLER FLOW 4.0MM PROBE ASSEMBLY","SUP-ITM-10166529","CDM","C1760","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","WELLPOINT [1015]","HB AMC WELLPOINT","2832.78","73.78","","456.01","456.01","456.01","33","1190.25","3052.4","percent of total billed charges",""
"COUPLER FLOW 4.0MM PROBE ASSEMBLY","SUP-ITM-10166529","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","3839.50","2879.62","AETNA [1001]","HB AMC AETNA HMO","2679.97","69.8","","290.33","290.33","1575.00","1 through 10","2006.52","3137.64","percent of total billed charges",""
"COUPLER FLOW 4.0MM PROBE ASSEMBLY","SUP-ITM-10166529","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","3839.50","2879.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2006.52","52.26","","487.31","487.31","487.31","1 through 10","2006.52","3137.64","percent of total billed charges",""
"COUPLER FLOW 4.0MM PROBE ASSEMBLY","SUP-ITM-10166529","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","3839.50","2879.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3137.64","81.72","","489.63","489.63","489.63","1 through 10","2006.52","3137.64","percent of total billed charges",""
"COUPLER FLOW 4.0MM PROBE ASSEMBLY","SUP-ITM-10166529","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","3839.50","2879.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3137.64","81.72","","489.64","489.63","1888.58","19","2006.52","3137.64","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2730.00","2047.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1426.70","52.26","","1113.10","1113.10","1113.10","1 through 10","846.3","2170.35","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2730.00","2047.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2170.35","79.5","","1293.60","1148.53","1603.80","1 through 10","846.3","2170.35","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2730.00","2047.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","996.45","36.5","","1023.42","771.29","2068.67","33","846.3","2170.35","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2730.00","2047.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1045.59","38.3","","850.52","759.78","1211.25","66","846.3","2170.35","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2730.00","2047.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1171.17","42.9","","2548.09","2548.09","2548.09","1 through 10","846.3","2170.35","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2730.00","2047.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1171.17","42.9","","956.46","956.46","956.46","1 through 10","846.3","2170.35","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","2730.00","2047.50","WELLPOINT [1015]","HB AMC WELLPOINT","2014.19","73.78","","2344.73","1619.47","2530.35","16","846.3","2170.35","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2730.00","2047.50","AETNA [1001]","HB AMC AETNA HMO","1905.54","69.8","","1523.63","988.41","4330.26","39","1426.7","2230.96","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2730.00","2047.50","AETNA [1001]","HB AMC AETNA PPO","2194.92","80.4","","1670.25","1670.25","1670.25","1 through 10","1426.7","2230.96","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2730.00","2047.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1426.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1426.7","2230.96","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2730.00","2047.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2230.96","81.72","","1738.90","1484.65","2716.94","38","1426.7","2230.96","percent of total billed charges",""
"COVER BURR 15MM HOLE MATRIXNEURO CRANIAL TITANIUM","SUP-ITM-10076532","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","280.64","79.5","","800.18","480.96","1887.97","195","109.43","280.64","percent of total billed charges",""
"COVER BURR 15MM HOLE MATRIXNEURO CRANIAL TITANIUM","SUP-ITM-10076532","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","188.15","53.3","","813.12","216.42","1444.50","81","109.43","280.64","percent of total billed charges",""
"COVER BURR 15MM HOLE MATRIXNEURO CRANIAL TITANIUM","SUP-ITM-10076532","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","109.43","31","","432.60","432.60","432.60","1 through 10","109.43","280.64","percent of total billed charges",""
"COVER BURR 15MM HOLE MATRIXNEURO CRANIAL TITANIUM","SUP-ITM-10076532","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","128.85","36.5","","148.37","54.89","631.39","94","109.43","280.64","percent of total billed charges",""
"COVER BURR 15MM HOLE MATRIXNEURO CRANIAL TITANIUM","SUP-ITM-10076532","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","135.20","38.3","","279.30","91.72","1116.77","266","109.43","280.64","percent of total billed charges",""
"COVER BURR 15MM HOLE MATRIXNEURO CRANIAL TITANIUM","SUP-ITM-10076532","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.44","42.9","","731.00","63.70","731.00","1 through 10","109.43","280.64","percent of total billed charges",""
"COVER BURR 15MM HOLE MATRIXNEURO CRANIAL TITANIUM","SUP-ITM-10076532","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.44","42.9","","384.74","384.74","384.74","1 through 10","109.43","280.64","percent of total billed charges",""
"COVER BURR 15MM HOLE MATRIXNEURO CRANIAL TITANIUM","SUP-ITM-10076532","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","WELLPOINT [1015]","HB AMC WELLPOINT","260.45","73.78","","286.63","119.22","1107.45","105","109.43","280.64","percent of total billed charges",""
"COVER BURR 15MM HOLE MATRIXNEURO CRANIAL TITANIUM","SUP-ITM-10076532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.01","264.76","AETNA [1001]","HB AMC AETNA HMO","246.40","69.8","","675.31","184.75","1721.50","286","184.48","288.48","percent of total billed charges",""
"COVER BURR 15MM HOLE MATRIXNEURO CRANIAL TITANIUM","SUP-ITM-10076532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.01","264.76","AETNA [1001]","HB AMC AETNA PPO","283.82","80.4","","1261.44","103.12","1514.10","21","184.48","288.48","percent of total billed charges",""
"COVER BURR 15MM HOLE MATRIXNEURO CRANIAL TITANIUM","SUP-ITM-10076532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.01","264.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","283.82","80.4","","1365.00","1365.00","1365.00","1 through 10","184.48","288.48","percent of total billed charges",""
"COVER BURR 15MM HOLE MATRIXNEURO CRANIAL TITANIUM","SUP-ITM-10076532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.01","264.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","288.48","81.72","","5157.68","5157.68","5157.68","1 through 10","184.48","288.48","percent of total billed charges",""
"COVER BURR 15MM HOLE MATRIXNEURO CRANIAL TITANIUM","SUP-ITM-10076532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.01","264.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","288.48","81.72","","431.26","71.26","1459.57","88","184.48","288.48","percent of total billed charges",""
"COVER BURRR 14MM HOLE GUARDIAN SYSTEM","SUP-ITM-10174945","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","800.18","480.96","1887.97","195","1193.5","3060.75","percent of total billed charges",""
"COVER BURRR 14MM HOLE GUARDIAN SYSTEM","SUP-ITM-10174945","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2052.05","53.3","","813.12","216.42","1444.50","81","1193.5","3060.75","percent of total billed charges",""
"COVER BURRR 14MM HOLE GUARDIAN SYSTEM","SUP-ITM-10174945","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1193.50","31","","432.60","432.60","432.60","1 through 10","1193.5","3060.75","percent of total billed charges",""
"COVER BURRR 14MM HOLE GUARDIAN SYSTEM","SUP-ITM-10174945","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","148.37","54.89","631.39","94","1193.5","3060.75","percent of total billed charges",""
"COVER BURRR 14MM HOLE GUARDIAN SYSTEM","SUP-ITM-10174945","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","279.30","91.72","1116.77","266","1193.5","3060.75","percent of total billed charges",""
"COVER BURRR 14MM HOLE GUARDIAN SYSTEM","SUP-ITM-10174945","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","731.00","63.70","731.00","1 through 10","1193.5","3060.75","percent of total billed charges",""
"COVER BURRR 14MM HOLE GUARDIAN SYSTEM","SUP-ITM-10174945","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","384.74","384.74","384.74","1 through 10","1193.5","3060.75","percent of total billed charges",""
"COVER BURRR 14MM HOLE GUARDIAN SYSTEM","SUP-ITM-10174945","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","286.63","119.22","1107.45","105","1193.5","3060.75","percent of total billed charges",""
"COVER BURRR 14MM HOLE GUARDIAN SYSTEM","SUP-ITM-10174945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA HMO","2687.30","69.8","","675.31","184.75","1721.50","286","2012.01","3146.22","percent of total billed charges",""
"COVER BURRR 14MM HOLE GUARDIAN SYSTEM","SUP-ITM-10174945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA PPO","3095.40","80.4","","1261.44","103.12","1514.10","21","2012.01","3146.22","percent of total billed charges",""
"COVER BURRR 14MM HOLE GUARDIAN SYSTEM","SUP-ITM-10174945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3095.40","80.4","","1365.00","1365.00","1365.00","1 through 10","2012.01","3146.22","percent of total billed charges",""
"COVER BURRR 14MM HOLE GUARDIAN SYSTEM","SUP-ITM-10174945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3146.22","81.72","","5157.68","5157.68","5157.68","1 through 10","2012.01","3146.22","percent of total billed charges",""
"COVER BURRR 14MM HOLE GUARDIAN SYSTEM","SUP-ITM-10174945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","431.26","71.26","1459.57","88","2012.01","3146.22","percent of total billed charges",""
"COVER ELBOW 20 PLUS HUMERAL ORTHO STEM DISTAL COMPONENT DISY MOSAIC RIGHT","SUP-ITM-10017957","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3344.64","52.26","","1113.10","1113.10","1113.10","1 through 10","1984","5088","percent of total billed charges",""
"COVER ELBOW 20 PLUS HUMERAL ORTHO STEM DISTAL COMPONENT DISY MOSAIC RIGHT","SUP-ITM-10017957","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5088.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1984","5088","percent of total billed charges",""
"COVER ELBOW 20 PLUS HUMERAL ORTHO STEM DISTAL COMPONENT DISY MOSAIC RIGHT","SUP-ITM-10017957","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2336.00","36.5","","1023.42","771.29","2068.67","33","1984","5088","percent of total billed charges",""
"COVER ELBOW 20 PLUS HUMERAL ORTHO STEM DISTAL COMPONENT DISY MOSAIC RIGHT","SUP-ITM-10017957","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2451.20","38.3","","850.52","759.78","1211.25","66","1984","5088","percent of total billed charges",""
"COVER ELBOW 20 PLUS HUMERAL ORTHO STEM DISTAL COMPONENT DISY MOSAIC RIGHT","SUP-ITM-10017957","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2745.60","42.9","","2548.09","2548.09","2548.09","1 through 10","1984","5088","percent of total billed charges",""
"COVER ELBOW 20 PLUS HUMERAL ORTHO STEM DISTAL COMPONENT DISY MOSAIC RIGHT","SUP-ITM-10017957","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2745.60","42.9","","956.46","956.46","956.46","1 through 10","1984","5088","percent of total billed charges",""
"COVER ELBOW 20 PLUS HUMERAL ORTHO STEM DISTAL COMPONENT DISY MOSAIC RIGHT","SUP-ITM-10017957","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","WELLPOINT [1015]","HB AMC WELLPOINT","4721.92","73.78","","2344.73","1619.47","2530.35","16","1984","5088","percent of total billed charges",""
"COVER ELBOW 20 PLUS HUMERAL ORTHO STEM DISTAL COMPONENT DISY MOSAIC RIGHT","SUP-ITM-10017957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","AETNA [1001]","HB AMC AETNA HMO","4467.20","69.8","","1523.63","988.41","4330.26","39","3344.64","5230.08","percent of total billed charges",""
"COVER ELBOW 20 PLUS HUMERAL ORTHO STEM DISTAL COMPONENT DISY MOSAIC RIGHT","SUP-ITM-10017957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","AETNA [1001]","HB AMC AETNA PPO","5145.60","80.4","","1670.25","1670.25","1670.25","1 through 10","3344.64","5230.08","percent of total billed charges",""
"COVER ELBOW 20 PLUS HUMERAL ORTHO STEM DISTAL COMPONENT DISY MOSAIC RIGHT","SUP-ITM-10017957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3344.64","52.26","","1113.10","1113.10","1113.10","1 through 10","3344.64","5230.08","percent of total billed charges",""
"COVER ELBOW 20 PLUS HUMERAL ORTHO STEM DISTAL COMPONENT DISY MOSAIC RIGHT","SUP-ITM-10017957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5230.08","81.72","","1738.90","1484.65","2716.94","38","3344.64","5230.08","percent of total billed charges",""
"COVER HOLE DIA 1.3X2.7MM BURRR","SUP-ITM-10130418","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1029.53","79.5","","1309.77","674.56","6049.93","26","401.45","1029.53","percent of total billed charges",""
"COVER HOLE DIA 1.3X2.7MM BURRR","SUP-ITM-10130418","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","690.24","53.3","","1901.83","1901.83","2962.25","1 through 10","401.45","1029.53","percent of total billed charges",""
"COVER HOLE DIA 1.3X2.7MM BURRR","SUP-ITM-10130418","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","472.68","36.5","","1620.31","1620.31","19908.88","1 through 10","401.45","1029.53","percent of total billed charges",""
"COVER HOLE DIA 1.3X2.7MM BURRR","SUP-ITM-10130418","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","495.99","38.3","","352.91","352.91","2046.30","1 through 10","401.45","1029.53","percent of total billed charges",""
"COVER HOLE DIA 1.3X2.7MM BURRR","SUP-ITM-10130418","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","555.56","42.9","","9668.75","9668.75","9668.75","1 through 10","401.45","1029.53","percent of total billed charges",""
"COVER HOLE DIA 1.3X2.7MM BURRR","SUP-ITM-10130418","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","WELLPOINT [1015]","HB AMC WELLPOINT","955.45","73.78","","699.88","384.10","3443.31","33","401.45","1029.53","percent of total billed charges",""
"COVER HOLE DIA 1.3X2.7MM BURRR","SUP-ITM-10130418","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","AETNA [1001]","HB AMC AETNA HMO","903.91","69.8","","1421.24","264.50","4933.46","29","676.77","1058.27","percent of total billed charges",""
"COVER HOLE DIA 1.3X2.7MM BURRR","SUP-ITM-10130418","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1041.18","80.4","","1022.97","1022.97","3607.50","1 through 10","676.77","1058.27","percent of total billed charges",""
"COVER HOLE DIA 1.3X2.7MM BURRR","SUP-ITM-10130418","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1058.27","81.72","","3010.54","693.88","5019.88","35","676.77","1058.27","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","800.18","480.96","1887.97","195","54.25","139.13","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.28","53.3","","813.12","216.42","1444.50","81","54.25","139.13","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.25","31","","432.60","432.60","432.60","1 through 10","54.25","139.13","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","148.37","54.89","631.39","94","54.25","139.13","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","279.30","91.72","1116.77","266","54.25","139.13","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","731.00","63.70","731.00","1 through 10","54.25","139.13","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","384.74","384.74","384.74","1 through 10","54.25","139.13","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","286.63","119.22","1107.45","105","54.25","139.13","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","675.31","184.75","1721.50","286","91.46","143.01","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA PPO","140.70","80.4","","1261.44","103.12","1514.10","21","91.46","143.01","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","140.70","80.4","","1365.00","1365.00","1365.00","1 through 10","91.46","143.01","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.01","81.72","","5157.68","5157.68","5157.68","1 through 10","91.46","143.01","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","431.26","71.26","1459.57","88","91.46","143.01","percent of total billed charges",""
"COVER SCREW 4X5.5MM COCHLEAR BAHA TITANIUM CONICAL HEXAGON B1300","SUP-ITM-10086351","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.26","468.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","496.29","79.5","","800.18","480.96","1887.97","195","193.52","496.29","percent of total billed charges",""
"COVER SCREW 4X5.5MM COCHLEAR BAHA TITANIUM CONICAL HEXAGON B1300","SUP-ITM-10086351","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.26","468.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","332.73","53.3","","813.12","216.42","1444.50","81","193.52","496.29","percent of total billed charges",""
"COVER SCREW 4X5.5MM COCHLEAR BAHA TITANIUM CONICAL HEXAGON B1300","SUP-ITM-10086351","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.26","468.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","193.52","31","","432.60","432.60","432.60","1 through 10","193.52","496.29","percent of total billed charges",""
"COVER SCREW 4X5.5MM COCHLEAR BAHA TITANIUM CONICAL HEXAGON B1300","SUP-ITM-10086351","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.26","468.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","227.85","36.5","","148.37","54.89","631.39","94","193.52","496.29","percent of total billed charges",""
"COVER SCREW 4X5.5MM COCHLEAR BAHA TITANIUM CONICAL HEXAGON B1300","SUP-ITM-10086351","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.26","468.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.09","38.3","","279.30","91.72","1116.77","266","193.52","496.29","percent of total billed charges",""
"COVER SCREW 4X5.5MM COCHLEAR BAHA TITANIUM CONICAL HEXAGON B1300","SUP-ITM-10086351","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.26","468.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","267.81","42.9","","731.00","63.70","731.00","1 through 10","193.52","496.29","percent of total billed charges",""
"COVER SCREW 4X5.5MM COCHLEAR BAHA TITANIUM CONICAL HEXAGON B1300","SUP-ITM-10086351","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.26","468.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","267.81","42.9","","384.74","384.74","384.74","1 through 10","193.52","496.29","percent of total billed charges",""
"COVER SCREW 4X5.5MM COCHLEAR BAHA TITANIUM CONICAL HEXAGON B1300","SUP-ITM-10086351","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.26","468.19","WELLPOINT [1015]","HB AMC WELLPOINT","460.58","73.78","","286.63","119.22","1107.45","105","193.52","496.29","percent of total billed charges",""
"COVER SCREW 4X5.5MM COCHLEAR BAHA TITANIUM CONICAL HEXAGON B1300","SUP-ITM-10086351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.26","468.19","AETNA [1001]","HB AMC AETNA HMO","435.73","69.8","","675.31","184.75","1721.50","286","326.24","510.15","percent of total billed charges",""
"COVER SCREW 4X5.5MM COCHLEAR BAHA TITANIUM CONICAL HEXAGON B1300","SUP-ITM-10086351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.26","468.19","AETNA [1001]","HB AMC AETNA PPO","501.91","80.4","","1261.44","103.12","1514.10","21","326.24","510.15","percent of total billed charges",""
"COVER SCREW 4X5.5MM COCHLEAR BAHA TITANIUM CONICAL HEXAGON B1300","SUP-ITM-10086351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.26","468.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","501.91","80.4","","1365.00","1365.00","1365.00","1 through 10","326.24","510.15","percent of total billed charges",""
"COVER SCREW 4X5.5MM COCHLEAR BAHA TITANIUM CONICAL HEXAGON B1300","SUP-ITM-10086351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.26","468.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","510.15","81.72","","5157.68","5157.68","5157.68","1 through 10","326.24","510.15","percent of total billed charges",""
"COVER SCREW 4X5.5MM COCHLEAR BAHA TITANIUM CONICAL HEXAGON B1300","SUP-ITM-10086351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.26","468.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","510.15","81.72","","431.26","71.26","1459.57","88","326.24","510.15","percent of total billed charges",""
"COVER SCREW IMPLANT BAHA TITANIUM HEAD INTERNAL HEXAGON LOW - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10086347","CDM","C1713","HCPCS","0278","RC","","","","both","","","635.57","476.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","505.28","79.5","","800.18","480.96","1887.97","195","197.03","505.28","percent of total billed charges",""
"COVER SCREW IMPLANT BAHA TITANIUM HEAD INTERNAL HEXAGON LOW - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10086347","CDM","C1713","HCPCS","0278","RC","","","","both","","","635.57","476.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","338.76","53.3","","813.12","216.42","1444.50","81","197.03","505.28","percent of total billed charges",""
"COVER SCREW IMPLANT BAHA TITANIUM HEAD INTERNAL HEXAGON LOW - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10086347","CDM","C1713","HCPCS","0278","RC","","","","both","","","635.57","476.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","197.03","31","","432.60","432.60","432.60","1 through 10","197.03","505.28","percent of total billed charges",""
"COVER SCREW IMPLANT BAHA TITANIUM HEAD INTERNAL HEXAGON LOW - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10086347","CDM","C1713","HCPCS","0278","RC","","","","both","","","635.57","476.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","231.98","36.5","","148.37","54.89","631.39","94","197.03","505.28","percent of total billed charges",""
"COVER SCREW IMPLANT BAHA TITANIUM HEAD INTERNAL HEXAGON LOW - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10086347","CDM","C1713","HCPCS","0278","RC","","","","both","","","635.57","476.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","243.42","38.3","","279.30","91.72","1116.77","266","197.03","505.28","percent of total billed charges",""
"COVER SCREW IMPLANT BAHA TITANIUM HEAD INTERNAL HEXAGON LOW - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10086347","CDM","C1713","HCPCS","0278","RC","","","","both","","","635.57","476.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","272.66","42.9","","731.00","63.70","731.00","1 through 10","197.03","505.28","percent of total billed charges",""
"COVER SCREW IMPLANT BAHA TITANIUM HEAD INTERNAL HEXAGON LOW - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10086347","CDM","C1713","HCPCS","0278","RC","","","","both","","","635.57","476.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","272.66","42.9","","384.74","384.74","384.74","1 through 10","197.03","505.28","percent of total billed charges",""
"COVER SCREW IMPLANT BAHA TITANIUM HEAD INTERNAL HEXAGON LOW - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10086347","CDM","C1713","HCPCS","0278","RC","","","","both","","","635.57","476.68","WELLPOINT [1015]","HB AMC WELLPOINT","468.92","73.78","","286.63","119.22","1107.45","105","197.03","505.28","percent of total billed charges",""
"COVER SCREW IMPLANT BAHA TITANIUM HEAD INTERNAL HEXAGON LOW - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10086347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","635.57","476.68","AETNA [1001]","HB AMC AETNA HMO","443.63","69.8","","675.31","184.75","1721.50","286","332.15","519.39","percent of total billed charges",""
"COVER SCREW IMPLANT BAHA TITANIUM HEAD INTERNAL HEXAGON LOW - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10086347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","635.57","476.68","AETNA [1001]","HB AMC AETNA PPO","511.00","80.4","","1261.44","103.12","1514.10","21","332.15","519.39","percent of total billed charges",""
"COVER SCREW IMPLANT BAHA TITANIUM HEAD INTERNAL HEXAGON LOW - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10086347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","635.57","476.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","511.00","80.4","","1365.00","1365.00","1365.00","1 through 10","332.15","519.39","percent of total billed charges",""
"COVER SCREW IMPLANT BAHA TITANIUM HEAD INTERNAL HEXAGON LOW - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10086347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","635.57","476.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","519.39","81.72","","5157.68","5157.68","5157.68","1 through 10","332.15","519.39","percent of total billed charges",""
"COVER SCREW IMPLANT BAHA TITANIUM HEAD INTERNAL HEXAGON LOW - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10086347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","635.57","476.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","519.39","81.72","","431.26","71.26","1459.57","88","332.15","519.39","percent of total billed charges",""
"COVER SHUNT 17MM BURR HOLE CRANIAL MATRIXNEURO TI DRAINAGE","SUP-ITM-10076537","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","280.64","79.5","","800.18","480.96","1887.97","195","109.43","280.64","percent of total billed charges",""
"COVER SHUNT 17MM BURR HOLE CRANIAL MATRIXNEURO TI DRAINAGE","SUP-ITM-10076537","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","188.15","53.3","","813.12","216.42","1444.50","81","109.43","280.64","percent of total billed charges",""
"COVER SHUNT 17MM BURR HOLE CRANIAL MATRIXNEURO TI DRAINAGE","SUP-ITM-10076537","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","109.43","31","","432.60","432.60","432.60","1 through 10","109.43","280.64","percent of total billed charges",""
"COVER SHUNT 17MM BURR HOLE CRANIAL MATRIXNEURO TI DRAINAGE","SUP-ITM-10076537","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","128.85","36.5","","148.37","54.89","631.39","94","109.43","280.64","percent of total billed charges",""
"COVER SHUNT 17MM BURR HOLE CRANIAL MATRIXNEURO TI DRAINAGE","SUP-ITM-10076537","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","135.20","38.3","","279.30","91.72","1116.77","266","109.43","280.64","percent of total billed charges",""
"COVER SHUNT 17MM BURR HOLE CRANIAL MATRIXNEURO TI DRAINAGE","SUP-ITM-10076537","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.44","42.9","","731.00","63.70","731.00","1 through 10","109.43","280.64","percent of total billed charges",""
"COVER SHUNT 17MM BURR HOLE CRANIAL MATRIXNEURO TI DRAINAGE","SUP-ITM-10076537","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.44","42.9","","384.74","384.74","384.74","1 through 10","109.43","280.64","percent of total billed charges",""
"COVER SHUNT 17MM BURR HOLE CRANIAL MATRIXNEURO TI DRAINAGE","SUP-ITM-10076537","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.01","264.76","WELLPOINT [1015]","HB AMC WELLPOINT","260.45","73.78","","286.63","119.22","1107.45","105","109.43","280.64","percent of total billed charges",""
"COVER SHUNT 17MM BURR HOLE CRANIAL MATRIXNEURO TI DRAINAGE","SUP-ITM-10076537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.01","264.76","AETNA [1001]","HB AMC AETNA HMO","246.40","69.8","","675.31","184.75","1721.50","286","184.48","288.48","percent of total billed charges",""
"COVER SHUNT 17MM BURR HOLE CRANIAL MATRIXNEURO TI DRAINAGE","SUP-ITM-10076537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.01","264.76","AETNA [1001]","HB AMC AETNA PPO","283.82","80.4","","1261.44","103.12","1514.10","21","184.48","288.48","percent of total billed charges",""
"COVER SHUNT 17MM BURR HOLE CRANIAL MATRIXNEURO TI DRAINAGE","SUP-ITM-10076537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.01","264.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","283.82","80.4","","1365.00","1365.00","1365.00","1 through 10","184.48","288.48","percent of total billed charges",""
"COVER SHUNT 17MM BURR HOLE CRANIAL MATRIXNEURO TI DRAINAGE","SUP-ITM-10076537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.01","264.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","288.48","81.72","","5157.68","5157.68","5157.68","1 through 10","184.48","288.48","percent of total billed charges",""
"COVER SHUNT 17MM BURR HOLE CRANIAL MATRIXNEURO TI DRAINAGE","SUP-ITM-10076537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.01","264.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","288.48","81.72","","431.26","71.26","1459.57","88","184.48","288.48","percent of total billed charges",""
"Coxiella Brunetii (Q Fev) Antibody","PX-30000907","CDM","86638","CPT","0302","RC","","","","both","","","185.00","138.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","129.50","70","","281.32","281.32","281.32","1 through 10","11.88","175.75","percent of total billed charges",""
"Coxiella Brunetii (Q Fev) Antibody","PX-30000907","CDM","86638","CPT","0302","RC","","","","both","","","185.00","138.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.86","38.3","","69.99","69.99","69.99","1 through 10","11.88","175.75","percent of total billed charges",""
"Coxiella Brunetii (Q Fev) Antibody","PX-30000907","CDM","86638","CPT","0302","RC","","","","outpatient","","","185.00","138.75","AETNA [1001]","HB AMC AETNA PPO","148.74","80.4","","93.80","93.80","93.80","1 through 10","12.5","151.18","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","1114.00","835.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","885.63","79.5","","853.53","853.53","853.53","1 through 10","229.46","885.63","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","1114.00","835.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","593.76","53.3","","849.96","849.96","849.96","1 through 10","229.46","885.63","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","1114.00","835.50","FALLON HEALTH [1008]","HB BWH MEDICARE","241.51","","APC Price ($241.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","241.54","241.54","241.54","1 through 10","229.46","885.63","other","OPPS APC"
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","1114.00","835.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","426.66","38.3","","422.28","422.28","422.28","1 through 10","229.46","885.63","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","1114.00","835.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","236.68","","APC Price ($241.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","228.14","228.14","228.14","1 through 10","229.46","885.63","other","OPPS APC"
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","outpatient","","","1114.00","835.50","AETNA [1001]","HB AMC AETNA HMO","777.57","69.8","","687.10","687.10","687.10","1 through 10","440.19","910.36","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","outpatient","","","1114.00","835.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","910.36","81.72","","474.88","474.88","474.88","1 through 10","440.19","910.36","percent of total billed charges",""
"Cranial And Peripheral Nerve Disorders With McC","073","MS-DRG","","","","","","","","inpatient","","","61926.53","46444.90","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15014.43","","Case rate ($15,014.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,997, add-ons for qualifying new technology services are included. If operating cost exceeds $63,641.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,731.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,343.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,617.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.91. The transfer capital threshold is the transfer adjustment factor * $1,290.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","103531.00","103531.00","103531.00","1 through 10","14714.14","23324.6496","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders With McC","073","MS-DRG","","","","","","","","inpatient","","","61926.53","46444.90","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","11650.33","11650.33","11650.33","1 through 10","14714.14","23324.6496","case rate",""
"Cranial And Peripheral Nerve Disorders With McC","073","MS-DRG","","","","","","","","inpatient","","","61926.53","46444.90","FALLON HEALTH [1008]","HB BWH MEDICARE","15014.43","","Case rate ($15,014.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,997, add-ons for qualifying new technology services are included. If operating cost exceeds $63,641.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,731.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,343.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,617.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.91. The transfer capital threshold is the transfer adjustment factor * $1,290.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14060.10","14060.10","14060.10","1 through 10","14714.14","23324.6496","other","Inpatient Replacement Plans DRG"
"Cranial And Peripheral Nerve Disorders With McC","073","MS-DRG","","","","","","","","inpatient","","","61926.53","46444.90","MEDICARE [2001]","HB BWH MEDICARE","15014.43","","Case rate ($15,014.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,997, add-ons for qualifying new technology services are included. If operating cost exceeds $63,641.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,731.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,343.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,617.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.91. The transfer capital threshold is the transfer adjustment factor * $1,290.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18499.59","18499.59","18526.86","11","14714.14","23324.6496","other","Inpatient Replacement Plans DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","60320.51","45240.38","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10076.40","","Case rate ($9,782.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,699.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,343.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,269.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,573.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,319.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $829.44. The transfer capital threshold is the transfer adjustment factor * $829.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10077.05","10077.05","10077.05","1 through 10","9587.25","16146.45","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","60320.51","45240.38","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","12228.64","","Case rate ($9,782.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,699.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,343.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,269.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,573.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,319.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $829.44. The transfer capital threshold is the transfer adjustment factor * $829.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","9800.61","9800.61","9800.61","1 through 10","9587.25","16146.45","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","60320.51","45240.38","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9782.91","","Case rate ($9,782.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,699.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,343.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,269.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,573.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,319.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $829.44. The transfer capital threshold is the transfer adjustment factor * $829.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9599.16","9599.16","9622.54","1 through 10","9587.25","16146.45","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","60320.51","45240.38","HUMANA [1012]","HB BWH MEDICARE","9782.91","","Case rate ($9,782.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,699.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,343.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,269.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,573.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,319.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $829.44. The transfer capital threshold is the transfer adjustment factor * $829.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9557.85","9557.85","9557.85","1 through 10","9587.25","16146.45","other","Inpatient Replacement Plans DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","60320.51","45240.38","MEDICARE [2001]","HB BWH MEDICARE","9782.91","","Case rate ($9,782.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,699.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,343.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,269.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,573.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,319.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $829.44. The transfer capital threshold is the transfer adjustment factor * $829.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12567.30","0.03","12585.67","32","9587.25","16146.45","other","Inpatient Replacement Plans DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","60320.51","45240.38","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9587.25","","Case rate ($9,782.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,699.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,343.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,269.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,573.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,319.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $829.44. The transfer capital threshold is the transfer adjustment factor * $829.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9573.43","9573.43","9580.13","1 through 10","9587.25","16146.45","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","60320.51","45240.38","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","9587.25","","Case rate ($9,782.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,699.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,343.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,269.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,573.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,319.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $829.44. The transfer capital threshold is the transfer adjustment factor * $829.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5441.32","5441.32","5441.32","1 through 10","9587.25","16146.45","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","60320.51","45240.38","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9587.25","","Case rate ($9,782.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,699.28, add-ons for qualifying new technology services are included. If operating cost exceeds $57,343.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,269.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,573.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,319.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $829.44. The transfer capital threshold is the transfer adjustment factor * $829.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9589.02","9589.02","9589.02","1 through 10","9587.25","16146.45","other","Inpatient DRG"
"CRANIAL IMPLANT XL CUSTOM CRANIAL HYDROXYAPATITE CUSTOMIZED BONE","SUP-ITM-10297849","CDM","C1713","HCPCS","0278","RC","","","","both","","","40000.00","30000.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","31800.00","79.5","","800.18","480.96","1887.97","195","12400","31800","percent of total billed charges",""
"CRANIAL IMPLANT XL CUSTOM CRANIAL HYDROXYAPATITE CUSTOMIZED BONE","SUP-ITM-10297849","CDM","C1713","HCPCS","0278","RC","","","","both","","","40000.00","30000.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","21320.00","53.3","","813.12","216.42","1444.50","81","12400","31800","percent of total billed charges",""
"CRANIAL IMPLANT XL CUSTOM CRANIAL HYDROXYAPATITE CUSTOMIZED BONE","SUP-ITM-10297849","CDM","C1713","HCPCS","0278","RC","","","","both","","","40000.00","30000.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","12400.00","31","","432.60","432.60","432.60","1 through 10","12400","31800","percent of total billed charges",""
"CRANIAL IMPLANT XL CUSTOM CRANIAL HYDROXYAPATITE CUSTOMIZED BONE","SUP-ITM-10297849","CDM","C1713","HCPCS","0278","RC","","","","both","","","40000.00","30000.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14600.00","36.5","","148.37","54.89","631.39","94","12400","31800","percent of total billed charges",""
"CRANIAL IMPLANT XL CUSTOM CRANIAL HYDROXYAPATITE CUSTOMIZED BONE","SUP-ITM-10297849","CDM","C1713","HCPCS","0278","RC","","","","both","","","40000.00","30000.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15320.00","38.3","","279.30","91.72","1116.77","266","12400","31800","percent of total billed charges",""
"CRANIAL IMPLANT XL CUSTOM CRANIAL HYDROXYAPATITE CUSTOMIZED BONE","SUP-ITM-10297849","CDM","C1713","HCPCS","0278","RC","","","","both","","","40000.00","30000.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17160.00","42.9","","731.00","63.70","731.00","1 through 10","12400","31800","percent of total billed charges",""
"CRANIAL IMPLANT XL CUSTOM CRANIAL HYDROXYAPATITE CUSTOMIZED BONE","SUP-ITM-10297849","CDM","C1713","HCPCS","0278","RC","","","","both","","","40000.00","30000.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17160.00","42.9","","384.74","384.74","384.74","1 through 10","12400","31800","percent of total billed charges",""
"CRANIAL IMPLANT XL CUSTOM CRANIAL HYDROXYAPATITE CUSTOMIZED BONE","SUP-ITM-10297849","CDM","C1713","HCPCS","0278","RC","","","","both","","","40000.00","30000.00","WELLPOINT [1015]","HB AMC WELLPOINT","29512.00","73.78","","286.63","119.22","1107.45","105","12400","31800","percent of total billed charges",""
"CRANIAL IMPLANT XL CUSTOM CRANIAL HYDROXYAPATITE CUSTOMIZED BONE","SUP-ITM-10297849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40000.00","30000.00","AETNA [1001]","HB AMC AETNA HMO","27920.00","69.8","","675.31","184.75","1721.50","286","20904","32688","percent of total billed charges",""
"CRANIAL IMPLANT XL CUSTOM CRANIAL HYDROXYAPATITE CUSTOMIZED BONE","SUP-ITM-10297849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40000.00","30000.00","AETNA [1001]","HB AMC AETNA PPO","32160.00","80.4","","1261.44","103.12","1514.10","21","20904","32688","percent of total billed charges",""
"CRANIAL IMPLANT XL CUSTOM CRANIAL HYDROXYAPATITE CUSTOMIZED BONE","SUP-ITM-10297849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40000.00","30000.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","32160.00","80.4","","1365.00","1365.00","1365.00","1 through 10","20904","32688","percent of total billed charges",""
"CRANIAL IMPLANT XL CUSTOM CRANIAL HYDROXYAPATITE CUSTOMIZED BONE","SUP-ITM-10297849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40000.00","30000.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","32688.00","81.72","","5157.68","5157.68","5157.68","1 through 10","20904","32688","percent of total billed charges",""
"CRANIAL IMPLANT XL CUSTOM CRANIAL HYDROXYAPATITE CUSTOMIZED BONE","SUP-ITM-10297849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40000.00","30000.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","32688.00","81.72","","431.26","71.26","1459.57","88","20904","32688","percent of total billed charges",""
"CRANIAL PLATE .6X100MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014562","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.83","3090.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3276.06","79.5","","800.18","480.96","1887.97","195","1277.46","3276.06","percent of total billed charges",""
"CRANIAL PLATE .6X100MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014562","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.83","3090.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2196.40","53.3","","813.12","216.42","1444.50","81","1277.46","3276.06","percent of total billed charges",""
"CRANIAL PLATE .6X100MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014562","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.83","3090.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1277.46","31","","432.60","432.60","432.60","1 through 10","1277.46","3276.06","percent of total billed charges",""
"CRANIAL PLATE .6X100MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014562","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.83","3090.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1504.10","36.5","","148.37","54.89","631.39","94","1277.46","3276.06","percent of total billed charges",""
"CRANIAL PLATE .6X100MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014562","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.83","3090.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1578.28","38.3","","279.30","91.72","1116.77","266","1277.46","3276.06","percent of total billed charges",""
"CRANIAL PLATE .6X100MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014562","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.83","3090.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1767.84","42.9","","731.00","63.70","731.00","1 through 10","1277.46","3276.06","percent of total billed charges",""
"CRANIAL PLATE .6X100MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014562","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.83","3090.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1767.84","42.9","","384.74","384.74","384.74","1 through 10","1277.46","3276.06","percent of total billed charges",""
"CRANIAL PLATE .6X100MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014562","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.83","3090.62","WELLPOINT [1015]","HB AMC WELLPOINT","3040.35","73.78","","286.63","119.22","1107.45","105","1277.46","3276.06","percent of total billed charges",""
"CRANIAL PLATE .6X100MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4120.83","3090.62","AETNA [1001]","HB AMC AETNA HMO","2876.34","69.8","","675.31","184.75","1721.50","286","2153.55","3367.54","percent of total billed charges",""
"CRANIAL PLATE .6X100MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4120.83","3090.62","AETNA [1001]","HB AMC AETNA PPO","3313.15","80.4","","1261.44","103.12","1514.10","21","2153.55","3367.54","percent of total billed charges",""
"CRANIAL PLATE .6X100MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4120.83","3090.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3313.15","80.4","","1365.00","1365.00","1365.00","1 through 10","2153.55","3367.54","percent of total billed charges",""
"CRANIAL PLATE .6X100MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4120.83","3090.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3367.54","81.72","","5157.68","5157.68","5157.68","1 through 10","2153.55","3367.54","percent of total billed charges",""
"CRANIAL PLATE .6X100MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4120.83","3090.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3367.54","81.72","","431.26","71.26","1459.57","88","2153.55","3367.54","percent of total billed charges",""
"CRANIAL PLATE .6X70MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.89","2888.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3062.25","79.5","","800.18","480.96","1887.97","195","1194.09","3062.25","percent of total billed charges",""
"CRANIAL PLATE .6X70MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.89","2888.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2053.06","53.3","","813.12","216.42","1444.50","81","1194.09","3062.25","percent of total billed charges",""
"CRANIAL PLATE .6X70MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.89","2888.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1194.09","31","","432.60","432.60","432.60","1 through 10","1194.09","3062.25","percent of total billed charges",""
"CRANIAL PLATE .6X70MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.89","2888.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.94","36.5","","148.37","54.89","631.39","94","1194.09","3062.25","percent of total billed charges",""
"CRANIAL PLATE .6X70MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.89","2888.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1475.27","38.3","","279.30","91.72","1116.77","266","1194.09","3062.25","percent of total billed charges",""
"CRANIAL PLATE .6X70MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.89","2888.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1652.46","42.9","","731.00","63.70","731.00","1 through 10","1194.09","3062.25","percent of total billed charges",""
"CRANIAL PLATE .6X70MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.89","2888.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1652.46","42.9","","384.74","384.74","384.74","1 through 10","1194.09","3062.25","percent of total billed charges",""
"CRANIAL PLATE .6X70MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.89","2888.92","WELLPOINT [1015]","HB AMC WELLPOINT","2841.92","73.78","","286.63","119.22","1107.45","105","1194.09","3062.25","percent of total billed charges",""
"CRANIAL PLATE .6X70MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3851.89","2888.92","AETNA [1001]","HB AMC AETNA HMO","2688.62","69.8","","675.31","184.75","1721.50","286","2013","3147.76","percent of total billed charges",""
"CRANIAL PLATE .6X70MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3851.89","2888.92","AETNA [1001]","HB AMC AETNA PPO","3096.92","80.4","","1261.44","103.12","1514.10","21","2013","3147.76","percent of total billed charges",""
"CRANIAL PLATE .6X70MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3851.89","2888.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3096.92","80.4","","1365.00","1365.00","1365.00","1 through 10","2013","3147.76","percent of total billed charges",""
"CRANIAL PLATE .6X70MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3851.89","2888.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3147.76","81.72","","5157.68","5157.68","5157.68","1 through 10","2013","3147.76","percent of total billed charges",""
"CRANIAL PLATE .6X70MM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM","SUP-ITM-10014561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3851.89","2888.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3147.76","81.72","","431.26","71.26","1459.57","88","2013","3147.76","percent of total billed charges",""
"CRANIAL PLATE 1.5X25MM 4 HOLE TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10004265","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.77","74.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","78.52","79.5","","800.18","480.96","1887.97","195","30.62","78.52","percent of total billed charges",""
"CRANIAL PLATE 1.5X25MM 4 HOLE TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10004265","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.77","74.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","52.64","53.3","","813.12","216.42","1444.50","81","30.62","78.52","percent of total billed charges",""
"CRANIAL PLATE 1.5X25MM 4 HOLE TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10004265","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.77","74.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","30.62","31","","432.60","432.60","432.60","1 through 10","30.62","78.52","percent of total billed charges",""
"CRANIAL PLATE 1.5X25MM 4 HOLE TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10004265","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.77","74.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36.05","36.5","","148.37","54.89","631.39","94","30.62","78.52","percent of total billed charges",""
"CRANIAL PLATE 1.5X25MM 4 HOLE TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10004265","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.77","74.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37.83","38.3","","279.30","91.72","1116.77","266","30.62","78.52","percent of total billed charges",""
"CRANIAL PLATE 1.5X25MM 4 HOLE TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10004265","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.77","74.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.37","42.9","","731.00","63.70","731.00","1 through 10","30.62","78.52","percent of total billed charges",""
"CRANIAL PLATE 1.5X25MM 4 HOLE TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10004265","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.77","74.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.37","42.9","","384.74","384.74","384.74","1 through 10","30.62","78.52","percent of total billed charges",""
"CRANIAL PLATE 1.5X25MM 4 HOLE TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10004265","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.77","74.08","WELLPOINT [1015]","HB AMC WELLPOINT","72.87","73.78","","286.63","119.22","1107.45","105","30.62","78.52","percent of total billed charges",""
"CRANIAL PLATE 1.5X25MM 4 HOLE TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10004265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.77","74.08","AETNA [1001]","HB AMC AETNA HMO","68.94","69.8","","675.31","184.75","1721.50","286","51.62","80.71","percent of total billed charges",""
"CRANIAL PLATE 1.5X25MM 4 HOLE TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10004265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.77","74.08","AETNA [1001]","HB AMC AETNA PPO","79.41","80.4","","1261.44","103.12","1514.10","21","51.62","80.71","percent of total billed charges",""
"CRANIAL PLATE 1.5X25MM 4 HOLE TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10004265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.77","74.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","79.41","80.4","","1365.00","1365.00","1365.00","1 through 10","51.62","80.71","percent of total billed charges",""
"CRANIAL PLATE 1.5X25MM 4 HOLE TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10004265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.77","74.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","80.71","81.72","","5157.68","5157.68","5157.68","1 through 10","51.62","80.71","percent of total billed charges",""
"CRANIAL PLATE 1.5X25MM 4 HOLE TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10004265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.77","74.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","80.71","81.72","","431.26","71.26","1459.57","88","51.62","80.71","percent of total billed charges",""
"CRANIAL PLATE 2.4MM 6 HOLE TITANIUM COMPRESSION TENSION BAND STRAIGHT","SUP-ITM-10004314","CDM","C1713","HCPCS","0278","RC","","","","both","","","836.61","627.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","665.10","79.5","","800.18","480.96","1887.97","195","259.35","665.1","percent of total billed charges",""
"CRANIAL PLATE 2.4MM 6 HOLE TITANIUM COMPRESSION TENSION BAND STRAIGHT","SUP-ITM-10004314","CDM","C1713","HCPCS","0278","RC","","","","both","","","836.61","627.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","445.91","53.3","","813.12","216.42","1444.50","81","259.35","665.1","percent of total billed charges",""
"CRANIAL PLATE 2.4MM 6 HOLE TITANIUM COMPRESSION TENSION BAND STRAIGHT","SUP-ITM-10004314","CDM","C1713","HCPCS","0278","RC","","","","both","","","836.61","627.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","259.35","31","","432.60","432.60","432.60","1 through 10","259.35","665.1","percent of total billed charges",""
"CRANIAL PLATE 2.4MM 6 HOLE TITANIUM COMPRESSION TENSION BAND STRAIGHT","SUP-ITM-10004314","CDM","C1713","HCPCS","0278","RC","","","","both","","","836.61","627.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","305.36","36.5","","148.37","54.89","631.39","94","259.35","665.1","percent of total billed charges",""
"CRANIAL PLATE 2.4MM 6 HOLE TITANIUM COMPRESSION TENSION BAND STRAIGHT","SUP-ITM-10004314","CDM","C1713","HCPCS","0278","RC","","","","both","","","836.61","627.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","320.42","38.3","","279.30","91.72","1116.77","266","259.35","665.1","percent of total billed charges",""
"CRANIAL PLATE 2.4MM 6 HOLE TITANIUM COMPRESSION TENSION BAND STRAIGHT","SUP-ITM-10004314","CDM","C1713","HCPCS","0278","RC","","","","both","","","836.61","627.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","358.91","42.9","","731.00","63.70","731.00","1 through 10","259.35","665.1","percent of total billed charges",""
"CRANIAL PLATE 2.4MM 6 HOLE TITANIUM COMPRESSION TENSION BAND STRAIGHT","SUP-ITM-10004314","CDM","C1713","HCPCS","0278","RC","","","","both","","","836.61","627.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","358.91","42.9","","384.74","384.74","384.74","1 through 10","259.35","665.1","percent of total billed charges",""
"CRANIAL PLATE 2.4MM 6 HOLE TITANIUM COMPRESSION TENSION BAND STRAIGHT","SUP-ITM-10004314","CDM","C1713","HCPCS","0278","RC","","","","both","","","836.61","627.46","WELLPOINT [1015]","HB AMC WELLPOINT","617.25","73.78","","286.63","119.22","1107.45","105","259.35","665.1","percent of total billed charges",""
"CRANIAL PLATE 2.4MM 6 HOLE TITANIUM COMPRESSION TENSION BAND STRAIGHT","SUP-ITM-10004314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","836.61","627.46","AETNA [1001]","HB AMC AETNA HMO","583.95","69.8","","675.31","184.75","1721.50","286","437.21","683.68","percent of total billed charges",""
"CRANIAL PLATE 2.4MM 6 HOLE TITANIUM COMPRESSION TENSION BAND STRAIGHT","SUP-ITM-10004314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","836.61","627.46","AETNA [1001]","HB AMC AETNA PPO","672.63","80.4","","1261.44","103.12","1514.10","21","437.21","683.68","percent of total billed charges",""
"CRANIAL PLATE 2.4MM 6 HOLE TITANIUM COMPRESSION TENSION BAND STRAIGHT","SUP-ITM-10004314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","836.61","627.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","672.63","80.4","","1365.00","1365.00","1365.00","1 through 10","437.21","683.68","percent of total billed charges",""
"CRANIAL PLATE 2.4MM 6 HOLE TITANIUM COMPRESSION TENSION BAND STRAIGHT","SUP-ITM-10004314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","836.61","627.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","683.68","81.72","","5157.68","5157.68","5157.68","1 through 10","437.21","683.68","percent of total billed charges",""
"CRANIAL PLATE 2.4MM 6 HOLE TITANIUM COMPRESSION TENSION BAND STRAIGHT","SUP-ITM-10004314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","836.61","627.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","683.68","81.72","","431.26","71.26","1459.57","88","437.21","683.68","percent of total billed charges",""
"CRANIAL PLATE 2MM 4 HOLE MAXILLOFACIALXDCP TITANIUM","SUP-ITM-10003765","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.14","363.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","385.69","79.5","","800.18","480.96","1887.97","195","150.39","385.69","percent of total billed charges",""
"CRANIAL PLATE 2MM 4 HOLE MAXILLOFACIALXDCP TITANIUM","SUP-ITM-10003765","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.14","363.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","258.58","53.3","","813.12","216.42","1444.50","81","150.39","385.69","percent of total billed charges",""
"CRANIAL PLATE 2MM 4 HOLE MAXILLOFACIALXDCP TITANIUM","SUP-ITM-10003765","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.14","363.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","150.39","31","","432.60","432.60","432.60","1 through 10","150.39","385.69","percent of total billed charges",""
"CRANIAL PLATE 2MM 4 HOLE MAXILLOFACIALXDCP TITANIUM","SUP-ITM-10003765","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.14","363.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","177.08","36.5","","148.37","54.89","631.39","94","150.39","385.69","percent of total billed charges",""
"CRANIAL PLATE 2MM 4 HOLE MAXILLOFACIALXDCP TITANIUM","SUP-ITM-10003765","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.14","363.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","185.81","38.3","","279.30","91.72","1116.77","266","150.39","385.69","percent of total billed charges",""
"CRANIAL PLATE 2MM 4 HOLE MAXILLOFACIALXDCP TITANIUM","SUP-ITM-10003765","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.14","363.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","208.13","42.9","","731.00","63.70","731.00","1 through 10","150.39","385.69","percent of total billed charges",""
"CRANIAL PLATE 2MM 4 HOLE MAXILLOFACIALXDCP TITANIUM","SUP-ITM-10003765","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.14","363.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","208.13","42.9","","384.74","384.74","384.74","1 through 10","150.39","385.69","percent of total billed charges",""
"CRANIAL PLATE 2MM 4 HOLE MAXILLOFACIALXDCP TITANIUM","SUP-ITM-10003765","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.14","363.85","WELLPOINT [1015]","HB AMC WELLPOINT","357.94","73.78","","286.63","119.22","1107.45","105","150.39","385.69","percent of total billed charges",""
"CRANIAL PLATE 2MM 4 HOLE MAXILLOFACIALXDCP TITANIUM","SUP-ITM-10003765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","485.14","363.85","AETNA [1001]","HB AMC AETNA HMO","338.63","69.8","","675.31","184.75","1721.50","286","253.53","396.46","percent of total billed charges",""
"CRANIAL PLATE 2MM 4 HOLE MAXILLOFACIALXDCP TITANIUM","SUP-ITM-10003765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","485.14","363.85","AETNA [1001]","HB AMC AETNA PPO","390.05","80.4","","1261.44","103.12","1514.10","21","253.53","396.46","percent of total billed charges",""
"CRANIAL PLATE 2MM 4 HOLE MAXILLOFACIALXDCP TITANIUM","SUP-ITM-10003765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","485.14","363.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","390.05","80.4","","1365.00","1365.00","1365.00","1 through 10","253.53","396.46","percent of total billed charges",""
"CRANIAL PLATE 2MM 4 HOLE MAXILLOFACIALXDCP TITANIUM","SUP-ITM-10003765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","485.14","363.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","396.46","81.72","","5157.68","5157.68","5157.68","1 through 10","253.53","396.46","percent of total billed charges",""
"CRANIAL PLATE 2MM 4 HOLE MAXILLOFACIALXDCP TITANIUM","SUP-ITM-10003765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","485.14","363.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","396.46","81.72","","431.26","71.26","1459.57","88","253.53","396.46","percent of total billed charges",""
"CRANIAL PLATE 2MM 5 HOLE DCP Y SHAPE TITANIUM ARM X","SUP-ITM-10003762","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.00","390.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","413.40","79.5","","800.18","480.96","1887.97","195","161.2","413.4","percent of total billed charges",""
"CRANIAL PLATE 2MM 5 HOLE DCP Y SHAPE TITANIUM ARM X","SUP-ITM-10003762","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.00","390.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","277.16","53.3","","813.12","216.42","1444.50","81","161.2","413.4","percent of total billed charges",""
"CRANIAL PLATE 2MM 5 HOLE DCP Y SHAPE TITANIUM ARM X","SUP-ITM-10003762","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.00","390.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","161.20","31","","432.60","432.60","432.60","1 through 10","161.2","413.4","percent of total billed charges",""
"CRANIAL PLATE 2MM 5 HOLE DCP Y SHAPE TITANIUM ARM X","SUP-ITM-10003762","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.00","390.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","189.80","36.5","","148.37","54.89","631.39","94","161.2","413.4","percent of total billed charges",""
"CRANIAL PLATE 2MM 5 HOLE DCP Y SHAPE TITANIUM ARM X","SUP-ITM-10003762","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.00","390.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","199.16","38.3","","279.30","91.72","1116.77","266","161.2","413.4","percent of total billed charges",""
"CRANIAL PLATE 2MM 5 HOLE DCP Y SHAPE TITANIUM ARM X","SUP-ITM-10003762","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.00","390.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","223.08","42.9","","731.00","63.70","731.00","1 through 10","161.2","413.4","percent of total billed charges",""
"CRANIAL PLATE 2MM 5 HOLE DCP Y SHAPE TITANIUM ARM X","SUP-ITM-10003762","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.00","390.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","223.08","42.9","","384.74","384.74","384.74","1 through 10","161.2","413.4","percent of total billed charges",""
"CRANIAL PLATE 2MM 5 HOLE DCP Y SHAPE TITANIUM ARM X","SUP-ITM-10003762","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.00","390.00","WELLPOINT [1015]","HB AMC WELLPOINT","383.66","73.78","","286.63","119.22","1107.45","105","161.2","413.4","percent of total billed charges",""
"CRANIAL PLATE 2MM 5 HOLE DCP Y SHAPE TITANIUM ARM X","SUP-ITM-10003762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.00","390.00","AETNA [1001]","HB AMC AETNA HMO","362.96","69.8","","675.31","184.75","1721.50","286","271.75","424.94","percent of total billed charges",""
"CRANIAL PLATE 2MM 5 HOLE DCP Y SHAPE TITANIUM ARM X","SUP-ITM-10003762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.00","390.00","AETNA [1001]","HB AMC AETNA PPO","418.08","80.4","","1261.44","103.12","1514.10","21","271.75","424.94","percent of total billed charges",""
"CRANIAL PLATE 2MM 5 HOLE DCP Y SHAPE TITANIUM ARM X","SUP-ITM-10003762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.00","390.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","418.08","80.4","","1365.00","1365.00","1365.00","1 through 10","271.75","424.94","percent of total billed charges",""
"CRANIAL PLATE 2MM 5 HOLE DCP Y SHAPE TITANIUM ARM X","SUP-ITM-10003762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.00","390.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","424.94","81.72","","5157.68","5157.68","5157.68","1 through 10","271.75","424.94","percent of total billed charges",""
"CRANIAL PLATE 2MM 5 HOLE DCP Y SHAPE TITANIUM ARM X","SUP-ITM-10003762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.00","390.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","424.94","81.72","","431.26","71.26","1459.57","88","271.75","424.94","percent of total billed charges",""
"CRANIAL PLATE 2X55MM 8 HOLE BONE MANDIBULAR TRAUMA STRAIGHT BROAD TITANIUM","SUP-ITM-10004286","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.42","677.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","718.22","79.5","","800.18","480.96","1887.97","195","280.06","718.22","percent of total billed charges",""
"CRANIAL PLATE 2X55MM 8 HOLE BONE MANDIBULAR TRAUMA STRAIGHT BROAD TITANIUM","SUP-ITM-10004286","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.42","677.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","481.52","53.3","","813.12","216.42","1444.50","81","280.06","718.22","percent of total billed charges",""
"CRANIAL PLATE 2X55MM 8 HOLE BONE MANDIBULAR TRAUMA STRAIGHT BROAD TITANIUM","SUP-ITM-10004286","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.42","677.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","280.06","31","","432.60","432.60","432.60","1 through 10","280.06","718.22","percent of total billed charges",""
"CRANIAL PLATE 2X55MM 8 HOLE BONE MANDIBULAR TRAUMA STRAIGHT BROAD TITANIUM","SUP-ITM-10004286","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.42","677.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","329.75","36.5","","148.37","54.89","631.39","94","280.06","718.22","percent of total billed charges",""
"CRANIAL PLATE 2X55MM 8 HOLE BONE MANDIBULAR TRAUMA STRAIGHT BROAD TITANIUM","SUP-ITM-10004286","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.42","677.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","346.01","38.3","","279.30","91.72","1116.77","266","280.06","718.22","percent of total billed charges",""
"CRANIAL PLATE 2X55MM 8 HOLE BONE MANDIBULAR TRAUMA STRAIGHT BROAD TITANIUM","SUP-ITM-10004286","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.42","677.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","387.57","42.9","","731.00","63.70","731.00","1 through 10","280.06","718.22","percent of total billed charges",""
"CRANIAL PLATE 2X55MM 8 HOLE BONE MANDIBULAR TRAUMA STRAIGHT BROAD TITANIUM","SUP-ITM-10004286","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.42","677.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","387.57","42.9","","384.74","384.74","384.74","1 through 10","280.06","718.22","percent of total billed charges",""
"CRANIAL PLATE 2X55MM 8 HOLE BONE MANDIBULAR TRAUMA STRAIGHT BROAD TITANIUM","SUP-ITM-10004286","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.42","677.56","WELLPOINT [1015]","HB AMC WELLPOINT","666.54","73.78","","286.63","119.22","1107.45","105","280.06","718.22","percent of total billed charges",""
"CRANIAL PLATE 2X55MM 8 HOLE BONE MANDIBULAR TRAUMA STRAIGHT BROAD TITANIUM","SUP-ITM-10004286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.42","677.56","AETNA [1001]","HB AMC AETNA HMO","630.59","69.8","","675.31","184.75","1721.50","286","472.13","738.27","percent of total billed charges",""
"CRANIAL PLATE 2X55MM 8 HOLE BONE MANDIBULAR TRAUMA STRAIGHT BROAD TITANIUM","SUP-ITM-10004286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.42","677.56","AETNA [1001]","HB AMC AETNA PPO","726.35","80.4","","1261.44","103.12","1514.10","21","472.13","738.27","percent of total billed charges",""
"CRANIAL PLATE 2X55MM 8 HOLE BONE MANDIBULAR TRAUMA STRAIGHT BROAD TITANIUM","SUP-ITM-10004286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.42","677.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","726.35","80.4","","1365.00","1365.00","1365.00","1 through 10","472.13","738.27","percent of total billed charges",""
"CRANIAL PLATE 2X55MM 8 HOLE BONE MANDIBULAR TRAUMA STRAIGHT BROAD TITANIUM","SUP-ITM-10004286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.42","677.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","738.27","81.72","","5157.68","5157.68","5157.68","1 through 10","472.13","738.27","percent of total billed charges",""
"CRANIAL PLATE 2X55MM 8 HOLE BONE MANDIBULAR TRAUMA STRAIGHT BROAD TITANIUM","SUP-ITM-10004286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.42","677.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","738.27","81.72","","431.26","71.26","1459.57","88","472.13","738.27","percent of total billed charges",""
"Craniectomy W/Excision Tumor/Lesion Skull","PX-76001427","CDM","61500","CPT","0761","RC","","","","outpatient","","","8859.00","6644.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4626.17","52.22","","5244.52","5244.52","5244.52","1 through 10","3543.6","7239.57","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 20MM SPHERE ORBITAL CRANIOMAXILLOFACIAL MEDPOR POLYETHYLENE BIOCOMPATIBLE POROUS","SUP-ITM-10005242","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.21","1655.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1754.73","79.5","","800.18","480.96","1887.97","195","684.24","1754.73","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 20MM SPHERE ORBITAL CRANIOMAXILLOFACIAL MEDPOR POLYETHYLENE BIOCOMPATIBLE POROUS","SUP-ITM-10005242","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.21","1655.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1176.44","53.3","","813.12","216.42","1444.50","81","684.24","1754.73","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 20MM SPHERE ORBITAL CRANIOMAXILLOFACIAL MEDPOR POLYETHYLENE BIOCOMPATIBLE POROUS","SUP-ITM-10005242","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.21","1655.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","684.24","31","","432.60","432.60","432.60","1 through 10","684.24","1754.73","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 20MM SPHERE ORBITAL CRANIOMAXILLOFACIAL MEDPOR POLYETHYLENE BIOCOMPATIBLE POROUS","SUP-ITM-10005242","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.21","1655.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","805.63","36.5","","148.37","54.89","631.39","94","684.24","1754.73","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 20MM SPHERE ORBITAL CRANIOMAXILLOFACIAL MEDPOR POLYETHYLENE BIOCOMPATIBLE POROUS","SUP-ITM-10005242","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.21","1655.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","845.36","38.3","","279.30","91.72","1116.77","266","684.24","1754.73","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 20MM SPHERE ORBITAL CRANIOMAXILLOFACIAL MEDPOR POLYETHYLENE BIOCOMPATIBLE POROUS","SUP-ITM-10005242","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.21","1655.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","946.89","42.9","","731.00","63.70","731.00","1 through 10","684.24","1754.73","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 20MM SPHERE ORBITAL CRANIOMAXILLOFACIAL MEDPOR POLYETHYLENE BIOCOMPATIBLE POROUS","SUP-ITM-10005242","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.21","1655.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","946.89","42.9","","384.74","384.74","384.74","1 through 10","684.24","1754.73","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 20MM SPHERE ORBITAL CRANIOMAXILLOFACIAL MEDPOR POLYETHYLENE BIOCOMPATIBLE POROUS","SUP-ITM-10005242","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.21","1655.41","WELLPOINT [1015]","HB AMC WELLPOINT","1628.48","73.78","","286.63","119.22","1107.45","105","684.24","1754.73","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 20MM SPHERE ORBITAL CRANIOMAXILLOFACIAL MEDPOR POLYETHYLENE BIOCOMPATIBLE POROUS","SUP-ITM-10005242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.21","1655.41","AETNA [1001]","HB AMC AETNA HMO","1540.63","69.8","","675.31","184.75","1721.50","286","1153.49","1803.73","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 20MM SPHERE ORBITAL CRANIOMAXILLOFACIAL MEDPOR POLYETHYLENE BIOCOMPATIBLE POROUS","SUP-ITM-10005242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.21","1655.41","AETNA [1001]","HB AMC AETNA PPO","1774.60","80.4","","1261.44","103.12","1514.10","21","1153.49","1803.73","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 20MM SPHERE ORBITAL CRANIOMAXILLOFACIAL MEDPOR POLYETHYLENE BIOCOMPATIBLE POROUS","SUP-ITM-10005242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.21","1655.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1774.60","80.4","","1365.00","1365.00","1365.00","1 through 10","1153.49","1803.73","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 20MM SPHERE ORBITAL CRANIOMAXILLOFACIAL MEDPOR POLYETHYLENE BIOCOMPATIBLE POROUS","SUP-ITM-10005242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.21","1655.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1803.73","81.72","","5157.68","5157.68","5157.68","1 through 10","1153.49","1803.73","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 20MM SPHERE ORBITAL CRANIOMAXILLOFACIAL MEDPOR POLYETHYLENE BIOCOMPATIBLE POROUS","SUP-ITM-10005242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.21","1655.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1803.73","81.72","","431.26","71.26","1459.57","88","1153.49","1803.73","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 3MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE SUPER PETITE RIGHT","SUP-ITM-10020100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1544.04","1158.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1227.51","79.5","","800.18","480.96","1887.97","195","478.65","1227.51","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 3MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE SUPER PETITE RIGHT","SUP-ITM-10020100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1544.04","1158.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","822.97","53.3","","813.12","216.42","1444.50","81","478.65","1227.51","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 3MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE SUPER PETITE RIGHT","SUP-ITM-10020100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1544.04","1158.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","478.65","31","","432.60","432.60","432.60","1 through 10","478.65","1227.51","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 3MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE SUPER PETITE RIGHT","SUP-ITM-10020100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1544.04","1158.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","563.57","36.5","","148.37","54.89","631.39","94","478.65","1227.51","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 3MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE SUPER PETITE RIGHT","SUP-ITM-10020100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1544.04","1158.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","591.37","38.3","","279.30","91.72","1116.77","266","478.65","1227.51","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 3MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE SUPER PETITE RIGHT","SUP-ITM-10020100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1544.04","1158.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","662.39","42.9","","731.00","63.70","731.00","1 through 10","478.65","1227.51","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 3MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE SUPER PETITE RIGHT","SUP-ITM-10020100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1544.04","1158.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","662.39","42.9","","384.74","384.74","384.74","1 through 10","478.65","1227.51","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 3MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE SUPER PETITE RIGHT","SUP-ITM-10020100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1544.04","1158.03","WELLPOINT [1015]","HB AMC WELLPOINT","1139.19","73.78","","286.63","119.22","1107.45","105","478.65","1227.51","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 3MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE SUPER PETITE RIGHT","SUP-ITM-10020100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1544.04","1158.03","AETNA [1001]","HB AMC AETNA HMO","1077.74","69.8","","675.31","184.75","1721.50","286","806.92","1261.79","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 3MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE SUPER PETITE RIGHT","SUP-ITM-10020100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1544.04","1158.03","AETNA [1001]","HB AMC AETNA PPO","1241.41","80.4","","1261.44","103.12","1514.10","21","806.92","1261.79","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 3MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE SUPER PETITE RIGHT","SUP-ITM-10020100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1544.04","1158.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1241.41","80.4","","1365.00","1365.00","1365.00","1 through 10","806.92","1261.79","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 3MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE SUPER PETITE RIGHT","SUP-ITM-10020100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1544.04","1158.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1261.79","81.72","","5157.68","5157.68","5157.68","1 through 10","806.92","1261.79","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 3MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE SUPER PETITE RIGHT","SUP-ITM-10020100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1544.04","1158.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1261.79","81.72","","431.26","71.26","1459.57","88","806.92","1261.79","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 5.0MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE PETITE LEFT","SUP-ITM-10023126","CDM","C1713","HCPCS","0278","RC","","","","both","","","1864.09","1398.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1481.95","79.5","","800.18","480.96","1887.97","195","577.87","1481.95","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 5.0MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE PETITE LEFT","SUP-ITM-10023126","CDM","C1713","HCPCS","0278","RC","","","","both","","","1864.09","1398.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","993.56","53.3","","813.12","216.42","1444.50","81","577.87","1481.95","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 5.0MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE PETITE LEFT","SUP-ITM-10023126","CDM","C1713","HCPCS","0278","RC","","","","both","","","1864.09","1398.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","577.87","31","","432.60","432.60","432.60","1 through 10","577.87","1481.95","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 5.0MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE PETITE LEFT","SUP-ITM-10023126","CDM","C1713","HCPCS","0278","RC","","","","both","","","1864.09","1398.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","680.39","36.5","","148.37","54.89","631.39","94","577.87","1481.95","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 5.0MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE PETITE LEFT","SUP-ITM-10023126","CDM","C1713","HCPCS","0278","RC","","","","both","","","1864.09","1398.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","713.95","38.3","","279.30","91.72","1116.77","266","577.87","1481.95","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 5.0MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE PETITE LEFT","SUP-ITM-10023126","CDM","C1713","HCPCS","0278","RC","","","","both","","","1864.09","1398.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","799.69","42.9","","731.00","63.70","731.00","1 through 10","577.87","1481.95","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 5.0MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE PETITE LEFT","SUP-ITM-10023126","CDM","C1713","HCPCS","0278","RC","","","","both","","","1864.09","1398.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","799.69","42.9","","384.74","384.74","384.74","1 through 10","577.87","1481.95","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 5.0MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE PETITE LEFT","SUP-ITM-10023126","CDM","C1713","HCPCS","0278","RC","","","","both","","","1864.09","1398.07","WELLPOINT [1015]","HB AMC WELLPOINT","1375.33","73.78","","286.63","119.22","1107.45","105","577.87","1481.95","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 5.0MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE PETITE LEFT","SUP-ITM-10023126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1864.09","1398.07","AETNA [1001]","HB AMC AETNA HMO","1301.13","69.8","","675.31","184.75","1721.50","286","974.17","1523.33","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 5.0MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE PETITE LEFT","SUP-ITM-10023126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1864.09","1398.07","AETNA [1001]","HB AMC AETNA PPO","1498.73","80.4","","1261.44","103.12","1514.10","21","974.17","1523.33","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 5.0MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE PETITE LEFT","SUP-ITM-10023126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1864.09","1398.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1498.73","80.4","","1365.00","1365.00","1365.00","1 through 10","974.17","1523.33","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 5.0MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE PETITE LEFT","SUP-ITM-10023126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1864.09","1398.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1523.33","81.72","","5157.68","5157.68","5157.68","1 through 10","974.17","1523.33","percent of total billed charges",""
"CRANIOFACIAL IMPLANT 50X19 5.0MM CRANIOMAXILLOFACIAL MEDPOR RZ MALAR POROUS POLYETHYLENE PETITE LEFT","SUP-ITM-10023126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1864.09","1398.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1523.33","81.72","","431.26","71.26","1459.57","88","974.17","1523.33","percent of total billed charges",""
"CRANIOFACIAL PLATE .4MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10116755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1510.57","1132.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1200.90","79.5","","800.18","480.96","1887.97","195","468.28","1200.9","percent of total billed charges",""
"CRANIOFACIAL PLATE .4MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10116755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1510.57","1132.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","805.13","53.3","","813.12","216.42","1444.50","81","468.28","1200.9","percent of total billed charges",""
"CRANIOFACIAL PLATE .4MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10116755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1510.57","1132.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","468.28","31","","432.60","432.60","432.60","1 through 10","468.28","1200.9","percent of total billed charges",""
"CRANIOFACIAL PLATE .4MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10116755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1510.57","1132.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","551.36","36.5","","148.37","54.89","631.39","94","468.28","1200.9","percent of total billed charges",""
"CRANIOFACIAL PLATE .4MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10116755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1510.57","1132.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","578.55","38.3","","279.30","91.72","1116.77","266","468.28","1200.9","percent of total billed charges",""
"CRANIOFACIAL PLATE .4MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10116755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1510.57","1132.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","648.03","42.9","","731.00","63.70","731.00","1 through 10","468.28","1200.9","percent of total billed charges",""
"CRANIOFACIAL PLATE .4MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10116755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1510.57","1132.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","648.03","42.9","","384.74","384.74","384.74","1 through 10","468.28","1200.9","percent of total billed charges",""
"CRANIOFACIAL PLATE .4MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10116755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1510.57","1132.93","WELLPOINT [1015]","HB AMC WELLPOINT","1114.50","73.78","","286.63","119.22","1107.45","105","468.28","1200.9","percent of total billed charges",""
"CRANIOFACIAL PLATE .4MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10116755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1510.57","1132.93","AETNA [1001]","HB AMC AETNA HMO","1054.38","69.8","","675.31","184.75","1721.50","286","789.42","1234.44","percent of total billed charges",""
"CRANIOFACIAL PLATE .4MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10116755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1510.57","1132.93","AETNA [1001]","HB AMC AETNA PPO","1214.50","80.4","","1261.44","103.12","1514.10","21","789.42","1234.44","percent of total billed charges",""
"CRANIOFACIAL PLATE .4MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10116755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1510.57","1132.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1214.50","80.4","","1365.00","1365.00","1365.00","1 through 10","789.42","1234.44","percent of total billed charges",""
"CRANIOFACIAL PLATE .4MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10116755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1510.57","1132.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1234.44","81.72","","5157.68","5157.68","5157.68","1 through 10","789.42","1234.44","percent of total billed charges",""
"CRANIOFACIAL PLATE .4MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10116755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1510.57","1132.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1234.44","81.72","","431.26","71.26","1459.57","88","789.42","1234.44","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT","SUP-ITM-10077422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1069.01","801.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","849.86","79.5","","800.18","480.96","1887.97","195","331.39","849.86","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT","SUP-ITM-10077422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1069.01","801.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","569.78","53.3","","813.12","216.42","1444.50","81","331.39","849.86","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT","SUP-ITM-10077422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1069.01","801.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","331.39","31","","432.60","432.60","432.60","1 through 10","331.39","849.86","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT","SUP-ITM-10077422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1069.01","801.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","390.19","36.5","","148.37","54.89","631.39","94","331.39","849.86","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT","SUP-ITM-10077422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1069.01","801.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","409.43","38.3","","279.30","91.72","1116.77","266","331.39","849.86","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT","SUP-ITM-10077422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1069.01","801.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","458.61","42.9","","731.00","63.70","731.00","1 through 10","331.39","849.86","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT","SUP-ITM-10077422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1069.01","801.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","458.61","42.9","","384.74","384.74","384.74","1 through 10","331.39","849.86","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT","SUP-ITM-10077422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1069.01","801.76","WELLPOINT [1015]","HB AMC WELLPOINT","788.72","73.78","","286.63","119.22","1107.45","105","331.39","849.86","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT","SUP-ITM-10077422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1069.01","801.76","AETNA [1001]","HB AMC AETNA HMO","746.17","69.8","","675.31","184.75","1721.50","286","558.66","873.59","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT","SUP-ITM-10077422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1069.01","801.76","AETNA [1001]","HB AMC AETNA PPO","859.48","80.4","","1261.44","103.12","1514.10","21","558.66","873.59","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT","SUP-ITM-10077422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1069.01","801.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","859.48","80.4","","1365.00","1365.00","1365.00","1 through 10","558.66","873.59","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT","SUP-ITM-10077422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1069.01","801.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","873.59","81.72","","5157.68","5157.68","5157.68","1 through 10","558.66","873.59","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT","SUP-ITM-10077422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1069.01","801.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","873.59","81.72","","431.26","71.26","1459.57","88","558.66","873.59","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 1X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM Y SHAPE","SUP-ITM-10077417","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.67","350.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","371.80","79.5","","800.18","480.96","1887.97","195","144.98","371.8","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 1X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM Y SHAPE","SUP-ITM-10077417","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.67","350.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","249.27","53.3","","813.12","216.42","1444.50","81","144.98","371.8","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 1X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM Y SHAPE","SUP-ITM-10077417","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.67","350.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","144.98","31","","432.60","432.60","432.60","1 through 10","144.98","371.8","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 1X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM Y SHAPE","SUP-ITM-10077417","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.67","350.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","170.70","36.5","","148.37","54.89","631.39","94","144.98","371.8","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 1X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM Y SHAPE","SUP-ITM-10077417","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.67","350.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.12","38.3","","279.30","91.72","1116.77","266","144.98","371.8","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 1X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM Y SHAPE","SUP-ITM-10077417","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.67","350.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.63","42.9","","731.00","63.70","731.00","1 through 10","144.98","371.8","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 1X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM Y SHAPE","SUP-ITM-10077417","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.67","350.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.63","42.9","","384.74","384.74","384.74","1 through 10","144.98","371.8","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 1X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM Y SHAPE","SUP-ITM-10077417","CDM","C1713","HCPCS","0278","RC","","","","both","","","467.67","350.75","WELLPOINT [1015]","HB AMC WELLPOINT","345.05","73.78","","286.63","119.22","1107.45","105","144.98","371.8","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 1X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM Y SHAPE","SUP-ITM-10077417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.67","350.75","AETNA [1001]","HB AMC AETNA HMO","326.43","69.8","","675.31","184.75","1721.50","286","244.4","382.18","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 1X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM Y SHAPE","SUP-ITM-10077417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.67","350.75","AETNA [1001]","HB AMC AETNA PPO","376.01","80.4","","1261.44","103.12","1514.10","21","244.4","382.18","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 1X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM Y SHAPE","SUP-ITM-10077417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.67","350.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","376.01","80.4","","1365.00","1365.00","1365.00","1 through 10","244.4","382.18","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 1X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM Y SHAPE","SUP-ITM-10077417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.67","350.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","382.18","81.72","","5157.68","5157.68","5157.68","1 through 10","244.4","382.18","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 1X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM Y SHAPE","SUP-ITM-10077417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","467.67","350.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","382.18","81.72","","431.26","71.26","1459.57","88","244.4","382.18","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077315","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.08","523.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","554.97","79.5","","800.18","480.96","1887.97","195","216.4","554.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077315","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.08","523.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","372.08","53.3","","813.12","216.42","1444.50","81","216.4","554.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077315","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.08","523.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","216.40","31","","432.60","432.60","432.60","1 through 10","216.4","554.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077315","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.08","523.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","254.80","36.5","","148.37","54.89","631.39","94","216.4","554.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077315","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.08","523.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","267.36","38.3","","279.30","91.72","1116.77","266","216.4","554.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077315","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.08","523.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","299.48","42.9","","731.00","63.70","731.00","1 through 10","216.4","554.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077315","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.08","523.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","299.48","42.9","","384.74","384.74","384.74","1 through 10","216.4","554.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077315","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.08","523.56","WELLPOINT [1015]","HB AMC WELLPOINT","515.04","73.78","","286.63","119.22","1107.45","105","216.4","554.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","698.08","523.56","AETNA [1001]","HB AMC AETNA HMO","487.26","69.8","","675.31","184.75","1721.50","286","364.82","570.47","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","698.08","523.56","AETNA [1001]","HB AMC AETNA PPO","561.26","80.4","","1261.44","103.12","1514.10","21","364.82","570.47","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","698.08","523.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","561.26","80.4","","1365.00","1365.00","1365.00","1 through 10","364.82","570.47","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","698.08","523.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","570.47","81.72","","5157.68","5157.68","5157.68","1 through 10","364.82","570.47","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","698.08","523.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","570.47","81.72","","431.26","71.26","1459.57","88","364.82","570.47","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077424","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","397.23","79.5","","800.18","480.96","1887.97","195","154.89","397.23","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077424","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","266.32","53.3","","813.12","216.42","1444.50","81","154.89","397.23","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077424","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","154.89","31","","432.60","432.60","432.60","1 through 10","154.89","397.23","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077424","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","182.38","36.5","","148.37","54.89","631.39","94","154.89","397.23","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077424","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","191.37","38.3","","279.30","91.72","1116.77","266","154.89","397.23","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077424","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.35","42.9","","731.00","63.70","731.00","1 through 10","154.89","397.23","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077424","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.35","42.9","","384.74","384.74","384.74","1 through 10","154.89","397.23","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077424","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","WELLPOINT [1015]","HB AMC WELLPOINT","368.65","73.78","","286.63","119.22","1107.45","105","154.89","397.23","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","AETNA [1001]","HB AMC AETNA HMO","348.76","69.8","","675.31","184.75","1721.50","286","261.12","408.32","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","AETNA [1001]","HB AMC AETNA PPO","401.73","80.4","","1261.44","103.12","1514.10","21","261.12","408.32","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","401.73","80.4","","1365.00","1365.00","1365.00","1 through 10","261.12","408.32","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","408.32","81.72","","5157.68","5157.68","5157.68","1 through 10","261.12","408.32","percent of total billed charges",""
"CRANIOFACIAL PLATE .5MM 2X3 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","408.32","81.72","","431.26","71.26","1459.57","88","261.12","408.32","percent of total billed charges",""
"CRANIOFACIAL PLATE .6X70MM CRANIOMAXILLOFACIAL TITANIUM MESH RIGID ROUND CONTOURABLE","SUP-ITM-10014002","CDM","C1713","HCPCS","0278","RC","","","","both","","","3628.21","2721.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2884.43","79.5","","800.18","480.96","1887.97","195","1124.75","2884.43","percent of total billed charges",""
"CRANIOFACIAL PLATE .6X70MM CRANIOMAXILLOFACIAL TITANIUM MESH RIGID ROUND CONTOURABLE","SUP-ITM-10014002","CDM","C1713","HCPCS","0278","RC","","","","both","","","3628.21","2721.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1933.84","53.3","","813.12","216.42","1444.50","81","1124.75","2884.43","percent of total billed charges",""
"CRANIOFACIAL PLATE .6X70MM CRANIOMAXILLOFACIAL TITANIUM MESH RIGID ROUND CONTOURABLE","SUP-ITM-10014002","CDM","C1713","HCPCS","0278","RC","","","","both","","","3628.21","2721.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1124.75","31","","432.60","432.60","432.60","1 through 10","1124.75","2884.43","percent of total billed charges",""
"CRANIOFACIAL PLATE .6X70MM CRANIOMAXILLOFACIAL TITANIUM MESH RIGID ROUND CONTOURABLE","SUP-ITM-10014002","CDM","C1713","HCPCS","0278","RC","","","","both","","","3628.21","2721.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1324.30","36.5","","148.37","54.89","631.39","94","1124.75","2884.43","percent of total billed charges",""
"CRANIOFACIAL PLATE .6X70MM CRANIOMAXILLOFACIAL TITANIUM MESH RIGID ROUND CONTOURABLE","SUP-ITM-10014002","CDM","C1713","HCPCS","0278","RC","","","","both","","","3628.21","2721.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1389.60","38.3","","279.30","91.72","1116.77","266","1124.75","2884.43","percent of total billed charges",""
"CRANIOFACIAL PLATE .6X70MM CRANIOMAXILLOFACIAL TITANIUM MESH RIGID ROUND CONTOURABLE","SUP-ITM-10014002","CDM","C1713","HCPCS","0278","RC","","","","both","","","3628.21","2721.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1556.50","42.9","","731.00","63.70","731.00","1 through 10","1124.75","2884.43","percent of total billed charges",""
"CRANIOFACIAL PLATE .6X70MM CRANIOMAXILLOFACIAL TITANIUM MESH RIGID ROUND CONTOURABLE","SUP-ITM-10014002","CDM","C1713","HCPCS","0278","RC","","","","both","","","3628.21","2721.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1556.50","42.9","","384.74","384.74","384.74","1 through 10","1124.75","2884.43","percent of total billed charges",""
"CRANIOFACIAL PLATE .6X70MM CRANIOMAXILLOFACIAL TITANIUM MESH RIGID ROUND CONTOURABLE","SUP-ITM-10014002","CDM","C1713","HCPCS","0278","RC","","","","both","","","3628.21","2721.16","WELLPOINT [1015]","HB AMC WELLPOINT","2676.89","73.78","","286.63","119.22","1107.45","105","1124.75","2884.43","percent of total billed charges",""
"CRANIOFACIAL PLATE .6X70MM CRANIOMAXILLOFACIAL TITANIUM MESH RIGID ROUND CONTOURABLE","SUP-ITM-10014002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3628.21","2721.16","AETNA [1001]","HB AMC AETNA HMO","2532.49","69.8","","675.31","184.75","1721.50","286","1896.1","2964.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .6X70MM CRANIOMAXILLOFACIAL TITANIUM MESH RIGID ROUND CONTOURABLE","SUP-ITM-10014002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3628.21","2721.16","AETNA [1001]","HB AMC AETNA PPO","2917.08","80.4","","1261.44","103.12","1514.10","21","1896.1","2964.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .6X70MM CRANIOMAXILLOFACIAL TITANIUM MESH RIGID ROUND CONTOURABLE","SUP-ITM-10014002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3628.21","2721.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2917.08","80.4","","1365.00","1365.00","1365.00","1 through 10","1896.1","2964.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .6X70MM CRANIOMAXILLOFACIAL TITANIUM MESH RIGID ROUND CONTOURABLE","SUP-ITM-10014002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3628.21","2721.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2964.97","81.72","","5157.68","5157.68","5157.68","1 through 10","1896.1","2964.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .6X70MM CRANIOMAXILLOFACIAL TITANIUM MESH RIGID ROUND CONTOURABLE","SUP-ITM-10014002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3628.21","2721.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2964.97","81.72","","431.26","71.26","1459.57","88","1896.1","2964.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT FLOOR","SUP-ITM-10077434","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.84","1034.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1096.97","79.5","","800.18","480.96","1887.97","195","427.75","1096.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT FLOOR","SUP-ITM-10077434","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.84","1034.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","735.45","53.3","","813.12","216.42","1444.50","81","427.75","1096.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT FLOOR","SUP-ITM-10077434","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.84","1034.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","427.75","31","","432.60","432.60","432.60","1 through 10","427.75","1096.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT FLOOR","SUP-ITM-10077434","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.84","1034.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","503.64","36.5","","148.37","54.89","631.39","94","427.75","1096.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT FLOOR","SUP-ITM-10077434","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.84","1034.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","528.48","38.3","","279.30","91.72","1116.77","266","427.75","1096.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT FLOOR","SUP-ITM-10077434","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.84","1034.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","591.95","42.9","","731.00","63.70","731.00","1 through 10","427.75","1096.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT FLOOR","SUP-ITM-10077434","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.84","1034.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","591.95","42.9","","384.74","384.74","384.74","1 through 10","427.75","1096.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT FLOOR","SUP-ITM-10077434","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.84","1034.88","WELLPOINT [1015]","HB AMC WELLPOINT","1018.05","73.78","","286.63","119.22","1107.45","105","427.75","1096.97","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT FLOOR","SUP-ITM-10077434","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1379.84","1034.88","AETNA [1001]","HB AMC AETNA HMO","963.13","69.8","","675.31","184.75","1721.50","286","721.1","1127.61","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT FLOOR","SUP-ITM-10077434","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1379.84","1034.88","AETNA [1001]","HB AMC AETNA PPO","1109.39","80.4","","1261.44","103.12","1514.10","21","721.1","1127.61","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT FLOOR","SUP-ITM-10077434","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1379.84","1034.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1109.39","80.4","","1365.00","1365.00","1365.00","1 through 10","721.1","1127.61","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT FLOOR","SUP-ITM-10077434","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1379.84","1034.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1127.61","81.72","","5157.68","5157.68","5157.68","1 through 10","721.1","1127.61","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 18 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM STRUT FLOOR","SUP-ITM-10077434","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1379.84","1034.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1127.61","81.72","","431.26","71.26","1459.57","88","721.1","1127.61","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077316","CDM","C1713","HCPCS","0278","RC","","","","both","","","746.55","559.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","593.51","79.5","","800.18","480.96","1887.97","195","231.43","593.51","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077316","CDM","C1713","HCPCS","0278","RC","","","","both","","","746.55","559.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","397.91","53.3","","813.12","216.42","1444.50","81","231.43","593.51","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077316","CDM","C1713","HCPCS","0278","RC","","","","both","","","746.55","559.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","231.43","31","","432.60","432.60","432.60","1 through 10","231.43","593.51","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077316","CDM","C1713","HCPCS","0278","RC","","","","both","","","746.55","559.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","272.49","36.5","","148.37","54.89","631.39","94","231.43","593.51","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077316","CDM","C1713","HCPCS","0278","RC","","","","both","","","746.55","559.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","285.93","38.3","","279.30","91.72","1116.77","266","231.43","593.51","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077316","CDM","C1713","HCPCS","0278","RC","","","","both","","","746.55","559.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.27","42.9","","731.00","63.70","731.00","1 through 10","231.43","593.51","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077316","CDM","C1713","HCPCS","0278","RC","","","","both","","","746.55","559.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.27","42.9","","384.74","384.74","384.74","1 through 10","231.43","593.51","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077316","CDM","C1713","HCPCS","0278","RC","","","","both","","","746.55","559.91","WELLPOINT [1015]","HB AMC WELLPOINT","550.80","73.78","","286.63","119.22","1107.45","105","231.43","593.51","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","746.55","559.91","AETNA [1001]","HB AMC AETNA HMO","521.09","69.8","","675.31","184.75","1721.50","286","390.15","610.08","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","746.55","559.91","AETNA [1001]","HB AMC AETNA PPO","600.23","80.4","","1261.44","103.12","1514.10","21","390.15","610.08","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","746.55","559.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","600.23","80.4","","1365.00","1365.00","1365.00","1 through 10","390.15","610.08","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","746.55","559.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","610.08","81.72","","5157.68","5157.68","5157.68","1 through 10","390.15","610.08","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 20 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM ADAPTION","SUP-ITM-10077316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","746.55","559.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","610.08","81.72","","431.26","71.26","1459.57","88","390.15","610.08","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077437","CDM","C1713","HCPCS","0278","RC","","","","both","","","566.44","424.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","450.32","79.5","","800.18","480.96","1887.97","195","175.6","450.32","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077437","CDM","C1713","HCPCS","0278","RC","","","","both","","","566.44","424.83","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","301.91","53.3","","813.12","216.42","1444.50","81","175.6","450.32","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077437","CDM","C1713","HCPCS","0278","RC","","","","both","","","566.44","424.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","175.60","31","","432.60","432.60","432.60","1 through 10","175.6","450.32","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077437","CDM","C1713","HCPCS","0278","RC","","","","both","","","566.44","424.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","206.75","36.5","","148.37","54.89","631.39","94","175.6","450.32","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077437","CDM","C1713","HCPCS","0278","RC","","","","both","","","566.44","424.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","216.95","38.3","","279.30","91.72","1116.77","266","175.6","450.32","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077437","CDM","C1713","HCPCS","0278","RC","","","","both","","","566.44","424.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","243.00","42.9","","731.00","63.70","731.00","1 through 10","175.6","450.32","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077437","CDM","C1713","HCPCS","0278","RC","","","","both","","","566.44","424.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","243.00","42.9","","384.74","384.74","384.74","1 through 10","175.6","450.32","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077437","CDM","C1713","HCPCS","0278","RC","","","","both","","","566.44","424.83","WELLPOINT [1015]","HB AMC WELLPOINT","417.92","73.78","","286.63","119.22","1107.45","105","175.6","450.32","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","566.44","424.83","AETNA [1001]","HB AMC AETNA HMO","395.38","69.8","","675.31","184.75","1721.50","286","296.02","462.89","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","566.44","424.83","AETNA [1001]","HB AMC AETNA PPO","455.42","80.4","","1261.44","103.12","1514.10","21","296.02","462.89","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","566.44","424.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","455.42","80.4","","1365.00","1365.00","1365.00","1 through 10","296.02","462.89","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","566.44","424.83","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","462.89","81.72","","5157.68","5157.68","5157.68","1 through 10","296.02","462.89","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 3X4 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","566.44","424.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","462.89","81.72","","431.26","71.26","1459.57","88","296.02","462.89","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077440","CDM","C1713","HCPCS","0278","RC","","","","both","","","697.17","522.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","554.25","79.5","","800.18","480.96","1887.97","195","216.12","554.25","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077440","CDM","C1713","HCPCS","0278","RC","","","","both","","","697.17","522.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","371.59","53.3","","813.12","216.42","1444.50","81","216.12","554.25","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077440","CDM","C1713","HCPCS","0278","RC","","","","both","","","697.17","522.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","216.12","31","","432.60","432.60","432.60","1 through 10","216.12","554.25","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077440","CDM","C1713","HCPCS","0278","RC","","","","both","","","697.17","522.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","254.47","36.5","","148.37","54.89","631.39","94","216.12","554.25","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077440","CDM","C1713","HCPCS","0278","RC","","","","both","","","697.17","522.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","267.02","38.3","","279.30","91.72","1116.77","266","216.12","554.25","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077440","CDM","C1713","HCPCS","0278","RC","","","","both","","","697.17","522.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","299.09","42.9","","731.00","63.70","731.00","1 through 10","216.12","554.25","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077440","CDM","C1713","HCPCS","0278","RC","","","","both","","","697.17","522.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","299.09","42.9","","384.74","384.74","384.74","1 through 10","216.12","554.25","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077440","CDM","C1713","HCPCS","0278","RC","","","","both","","","697.17","522.88","WELLPOINT [1015]","HB AMC WELLPOINT","514.37","73.78","","286.63","119.22","1107.45","105","216.12","554.25","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","697.17","522.88","AETNA [1001]","HB AMC AETNA HMO","486.62","69.8","","675.31","184.75","1721.50","286","364.34","569.73","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","697.17","522.88","AETNA [1001]","HB AMC AETNA PPO","560.52","80.4","","1261.44","103.12","1514.10","21","364.34","569.73","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","697.17","522.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","560.52","80.4","","1365.00","1365.00","1365.00","1 through 10","364.34","569.73","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","697.17","522.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","569.73","81.72","","5157.68","5157.68","5157.68","1 through 10","364.34","569.73","percent of total billed charges",""
"CRANIOFACIAL PLATE .7MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE RIGHT","SUP-ITM-10077440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","697.17","522.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","569.73","81.72","","431.26","71.26","1459.57","88","364.34","569.73","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077446","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.53","446.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","473.45","79.5","","800.18","480.96","1887.97","195","184.61","473.45","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077446","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.53","446.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","317.42","53.3","","813.12","216.42","1444.50","81","184.61","473.45","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077446","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.53","446.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","184.61","31","","432.60","432.60","432.60","1 through 10","184.61","473.45","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077446","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.53","446.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","217.37","36.5","","148.37","54.89","631.39","94","184.61","473.45","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077446","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.53","446.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","228.09","38.3","","279.30","91.72","1116.77","266","184.61","473.45","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077446","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.53","446.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.48","42.9","","731.00","63.70","731.00","1 through 10","184.61","473.45","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077446","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.53","446.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.48","42.9","","384.74","384.74","384.74","1 through 10","184.61","473.45","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077446","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.53","446.65","WELLPOINT [1015]","HB AMC WELLPOINT","439.38","73.78","","286.63","119.22","1107.45","105","184.61","473.45","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.53","446.65","AETNA [1001]","HB AMC AETNA HMO","415.68","69.8","","675.31","184.75","1721.50","286","311.22","486.67","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.53","446.65","AETNA [1001]","HB AMC AETNA PPO","478.81","80.4","","1261.44","103.12","1514.10","21","311.22","486.67","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.53","446.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","478.81","80.4","","1365.00","1365.00","1365.00","1 through 10","311.22","486.67","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.53","446.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","486.67","81.72","","5157.68","5157.68","5157.68","1 through 10","311.22","486.67","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM 4X6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE LEFT","SUP-ITM-10077446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.53","446.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","486.67","81.72","","431.26","71.26","1459.57","88","311.22","486.67","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED FAN","SUP-ITM-10079478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1370.18","1027.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1089.29","79.5","","800.18","480.96","1887.97","195","424.76","1089.29","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED FAN","SUP-ITM-10079478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1370.18","1027.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","730.31","53.3","","813.12","216.42","1444.50","81","424.76","1089.29","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED FAN","SUP-ITM-10079478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1370.18","1027.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","424.76","31","","432.60","432.60","432.60","1 through 10","424.76","1089.29","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED FAN","SUP-ITM-10079478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1370.18","1027.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","500.12","36.5","","148.37","54.89","631.39","94","424.76","1089.29","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED FAN","SUP-ITM-10079478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1370.18","1027.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","524.78","38.3","","279.30","91.72","1116.77","266","424.76","1089.29","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED FAN","SUP-ITM-10079478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1370.18","1027.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","587.81","42.9","","731.00","63.70","731.00","1 through 10","424.76","1089.29","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED FAN","SUP-ITM-10079478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1370.18","1027.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","587.81","42.9","","384.74","384.74","384.74","1 through 10","424.76","1089.29","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED FAN","SUP-ITM-10079478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1370.18","1027.63","WELLPOINT [1015]","HB AMC WELLPOINT","1010.92","73.78","","286.63","119.22","1107.45","105","424.76","1089.29","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED FAN","SUP-ITM-10079478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1370.18","1027.63","AETNA [1001]","HB AMC AETNA HMO","956.39","69.8","","675.31","184.75","1721.50","286","716.06","1119.71","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED FAN","SUP-ITM-10079478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1370.18","1027.63","AETNA [1001]","HB AMC AETNA PPO","1101.62","80.4","","1261.44","103.12","1514.10","21","716.06","1119.71","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED FAN","SUP-ITM-10079478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1370.18","1027.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1101.62","80.4","","1365.00","1365.00","1365.00","1 through 10","716.06","1119.71","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED FAN","SUP-ITM-10079478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1370.18","1027.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1119.71","81.72","","5157.68","5157.68","5157.68","1 through 10","716.06","1119.71","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED FAN","SUP-ITM-10079478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1370.18","1027.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1119.71","81.72","","431.26","71.26","1459.57","88","716.06","1119.71","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED POROUS FAN EXPOSED","SUP-ITM-10079479","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.84","1313.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.92","79.5","","800.18","480.96","1887.97","195","542.76","1391.92","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED POROUS FAN EXPOSED","SUP-ITM-10079479","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.84","1313.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","933.20","53.3","","813.12","216.42","1444.50","81","542.76","1391.92","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED POROUS FAN EXPOSED","SUP-ITM-10079479","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.84","1313.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","542.76","31","","432.60","432.60","432.60","1 through 10","542.76","1391.92","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED POROUS FAN EXPOSED","SUP-ITM-10079479","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.84","1313.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","639.06","36.5","","148.37","54.89","631.39","94","542.76","1391.92","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED POROUS FAN EXPOSED","SUP-ITM-10079479","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.84","1313.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.57","38.3","","279.30","91.72","1116.77","266","542.76","1391.92","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED POROUS FAN EXPOSED","SUP-ITM-10079479","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.84","1313.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","751.11","42.9","","731.00","63.70","731.00","1 through 10","542.76","1391.92","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED POROUS FAN EXPOSED","SUP-ITM-10079479","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.84","1313.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","751.11","42.9","","384.74","384.74","384.74","1 through 10","542.76","1391.92","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED POROUS FAN EXPOSED","SUP-ITM-10079479","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.84","1313.13","WELLPOINT [1015]","HB AMC WELLPOINT","1291.77","73.78","","286.63","119.22","1107.45","105","542.76","1391.92","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED POROUS FAN EXPOSED","SUP-ITM-10079479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.84","1313.13","AETNA [1001]","HB AMC AETNA HMO","1222.09","69.8","","675.31","184.75","1721.50","286","914.99","1430.79","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED POROUS FAN EXPOSED","SUP-ITM-10079479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.84","1313.13","AETNA [1001]","HB AMC AETNA PPO","1407.68","80.4","","1261.44","103.12","1514.10","21","914.99","1430.79","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED POROUS FAN EXPOSED","SUP-ITM-10079479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.84","1313.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.68","80.4","","1365.00","1365.00","1365.00","1 through 10","914.99","1430.79","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED POROUS FAN EXPOSED","SUP-ITM-10079479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.84","1313.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1430.79","81.72","","5157.68","5157.68","5157.68","1 through 10","914.99","1430.79","percent of total billed charges",""
"CRANIOFACIAL PLATE .8MM CRANIOMAXILLOFACIAL SYNPOR POLYETHYLENE TITANIUM REINFORCED POROUS FAN EXPOSED","SUP-ITM-10079479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.84","1313.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.79","81.72","","431.26","71.26","1459.57","88","914.99","1430.79","percent of total billed charges",""
"CRANIOFACIAL PLATE 11X22MM 5 HOLE CRANIOMAXILLOFACIAL TITANIUM Y-SHAPE LOW PROFILE","SUP-ITM-10004127","CDM","C1713","HCPCS","0278","RC","","","","both","","","438.66","328.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","348.73","79.5","","800.18","480.96","1887.97","195","135.98","348.73","percent of total billed charges",""
"CRANIOFACIAL PLATE 11X22MM 5 HOLE CRANIOMAXILLOFACIAL TITANIUM Y-SHAPE LOW PROFILE","SUP-ITM-10004127","CDM","C1713","HCPCS","0278","RC","","","","both","","","438.66","328.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","233.81","53.3","","813.12","216.42","1444.50","81","135.98","348.73","percent of total billed charges",""
"CRANIOFACIAL PLATE 11X22MM 5 HOLE CRANIOMAXILLOFACIAL TITANIUM Y-SHAPE LOW PROFILE","SUP-ITM-10004127","CDM","C1713","HCPCS","0278","RC","","","","both","","","438.66","328.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","135.98","31","","432.60","432.60","432.60","1 through 10","135.98","348.73","percent of total billed charges",""
"CRANIOFACIAL PLATE 11X22MM 5 HOLE CRANIOMAXILLOFACIAL TITANIUM Y-SHAPE LOW PROFILE","SUP-ITM-10004127","CDM","C1713","HCPCS","0278","RC","","","","both","","","438.66","328.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","160.11","36.5","","148.37","54.89","631.39","94","135.98","348.73","percent of total billed charges",""
"CRANIOFACIAL PLATE 11X22MM 5 HOLE CRANIOMAXILLOFACIAL TITANIUM Y-SHAPE LOW PROFILE","SUP-ITM-10004127","CDM","C1713","HCPCS","0278","RC","","","","both","","","438.66","328.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","168.01","38.3","","279.30","91.72","1116.77","266","135.98","348.73","percent of total billed charges",""
"CRANIOFACIAL PLATE 11X22MM 5 HOLE CRANIOMAXILLOFACIAL TITANIUM Y-SHAPE LOW PROFILE","SUP-ITM-10004127","CDM","C1713","HCPCS","0278","RC","","","","both","","","438.66","328.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.19","42.9","","731.00","63.70","731.00","1 through 10","135.98","348.73","percent of total billed charges",""
"CRANIOFACIAL PLATE 11X22MM 5 HOLE CRANIOMAXILLOFACIAL TITANIUM Y-SHAPE LOW PROFILE","SUP-ITM-10004127","CDM","C1713","HCPCS","0278","RC","","","","both","","","438.66","328.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.19","42.9","","384.74","384.74","384.74","1 through 10","135.98","348.73","percent of total billed charges",""
"CRANIOFACIAL PLATE 11X22MM 5 HOLE CRANIOMAXILLOFACIAL TITANIUM Y-SHAPE LOW PROFILE","SUP-ITM-10004127","CDM","C1713","HCPCS","0278","RC","","","","both","","","438.66","328.99","WELLPOINT [1015]","HB AMC WELLPOINT","323.64","73.78","","286.63","119.22","1107.45","105","135.98","348.73","percent of total billed charges",""
"CRANIOFACIAL PLATE 11X22MM 5 HOLE CRANIOMAXILLOFACIAL TITANIUM Y-SHAPE LOW PROFILE","SUP-ITM-10004127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","438.66","328.99","AETNA [1001]","HB AMC AETNA HMO","306.18","69.8","","675.31","184.75","1721.50","286","229.24","358.47","percent of total billed charges",""
"CRANIOFACIAL PLATE 11X22MM 5 HOLE CRANIOMAXILLOFACIAL TITANIUM Y-SHAPE LOW PROFILE","SUP-ITM-10004127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","438.66","328.99","AETNA [1001]","HB AMC AETNA PPO","352.68","80.4","","1261.44","103.12","1514.10","21","229.24","358.47","percent of total billed charges",""
"CRANIOFACIAL PLATE 11X22MM 5 HOLE CRANIOMAXILLOFACIAL TITANIUM Y-SHAPE LOW PROFILE","SUP-ITM-10004127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","438.66","328.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","352.68","80.4","","1365.00","1365.00","1365.00","1 through 10","229.24","358.47","percent of total billed charges",""
"CRANIOFACIAL PLATE 11X22MM 5 HOLE CRANIOMAXILLOFACIAL TITANIUM Y-SHAPE LOW PROFILE","SUP-ITM-10004127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","438.66","328.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","358.47","81.72","","5157.68","5157.68","5157.68","1 through 10","229.24","358.47","percent of total billed charges",""
"CRANIOFACIAL PLATE 11X22MM 5 HOLE CRANIOMAXILLOFACIAL TITANIUM Y-SHAPE LOW PROFILE","SUP-ITM-10004127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","438.66","328.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","358.47","81.72","","431.26","71.26","1459.57","88","229.24","358.47","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 0.4MM FLOOR MATRIXMIDFACE ORBITAL TI ANATOMIC","SUP-ITM-10077408","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.18","1806.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1914.50","79.5","","800.18","480.96","1887.97","195","746.54","1914.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 0.4MM FLOOR MATRIXMIDFACE ORBITAL TI ANATOMIC","SUP-ITM-10077408","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.18","1806.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1283.56","53.3","","813.12","216.42","1444.50","81","746.54","1914.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 0.4MM FLOOR MATRIXMIDFACE ORBITAL TI ANATOMIC","SUP-ITM-10077408","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.18","1806.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","746.54","31","","432.60","432.60","432.60","1 through 10","746.54","1914.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 0.4MM FLOOR MATRIXMIDFACE ORBITAL TI ANATOMIC","SUP-ITM-10077408","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.18","1806.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","878.99","36.5","","148.37","54.89","631.39","94","746.54","1914.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 0.4MM FLOOR MATRIXMIDFACE ORBITAL TI ANATOMIC","SUP-ITM-10077408","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.18","1806.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","922.33","38.3","","279.30","91.72","1116.77","266","746.54","1914.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 0.4MM FLOOR MATRIXMIDFACE ORBITAL TI ANATOMIC","SUP-ITM-10077408","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.18","1806.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1033.11","42.9","","731.00","63.70","731.00","1 through 10","746.54","1914.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 0.4MM FLOOR MATRIXMIDFACE ORBITAL TI ANATOMIC","SUP-ITM-10077408","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.18","1806.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1033.11","42.9","","384.74","384.74","384.74","1 through 10","746.54","1914.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 0.4MM FLOOR MATRIXMIDFACE ORBITAL TI ANATOMIC","SUP-ITM-10077408","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.18","1806.13","WELLPOINT [1015]","HB AMC WELLPOINT","1776.76","73.78","","286.63","119.22","1107.45","105","746.54","1914.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 0.4MM FLOOR MATRIXMIDFACE ORBITAL TI ANATOMIC","SUP-ITM-10077408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2408.18","1806.13","AETNA [1001]","HB AMC AETNA HMO","1680.91","69.8","","675.31","184.75","1721.50","286","1258.51","1967.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 0.4MM FLOOR MATRIXMIDFACE ORBITAL TI ANATOMIC","SUP-ITM-10077408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2408.18","1806.13","AETNA [1001]","HB AMC AETNA PPO","1936.18","80.4","","1261.44","103.12","1514.10","21","1258.51","1967.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 0.4MM FLOOR MATRIXMIDFACE ORBITAL TI ANATOMIC","SUP-ITM-10077408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2408.18","1806.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1936.18","80.4","","1365.00","1365.00","1365.00","1 through 10","1258.51","1967.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 0.4MM FLOOR MATRIXMIDFACE ORBITAL TI ANATOMIC","SUP-ITM-10077408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2408.18","1806.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1967.96","81.72","","5157.68","5157.68","5157.68","1 through 10","1258.51","1967.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 0.4MM FLOOR MATRIXMIDFACE ORBITAL TI ANATOMIC","SUP-ITM-10077408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2408.18","1806.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1967.96","81.72","","431.26","71.26","1459.57","88","1258.51","1967.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.5MM 10 HOLE ORBITAL RAPIDSORB POLYMER RIM","SUP-ITM-10029157","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.30","398.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","422.38","79.5","","800.18","480.96","1887.97","195","164.7","422.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.5MM 10 HOLE ORBITAL RAPIDSORB POLYMER RIM","SUP-ITM-10029157","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.30","398.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","283.18","53.3","","813.12","216.42","1444.50","81","164.7","422.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.5MM 10 HOLE ORBITAL RAPIDSORB POLYMER RIM","SUP-ITM-10029157","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.30","398.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","164.70","31","","432.60","432.60","432.60","1 through 10","164.7","422.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.5MM 10 HOLE ORBITAL RAPIDSORB POLYMER RIM","SUP-ITM-10029157","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.30","398.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","193.92","36.5","","148.37","54.89","631.39","94","164.7","422.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.5MM 10 HOLE ORBITAL RAPIDSORB POLYMER RIM","SUP-ITM-10029157","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.30","398.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.49","38.3","","279.30","91.72","1116.77","266","164.7","422.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.5MM 10 HOLE ORBITAL RAPIDSORB POLYMER RIM","SUP-ITM-10029157","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.30","398.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","227.93","42.9","","731.00","63.70","731.00","1 through 10","164.7","422.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.5MM 10 HOLE ORBITAL RAPIDSORB POLYMER RIM","SUP-ITM-10029157","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.30","398.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","227.93","42.9","","384.74","384.74","384.74","1 through 10","164.7","422.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.5MM 10 HOLE ORBITAL RAPIDSORB POLYMER RIM","SUP-ITM-10029157","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.30","398.47","WELLPOINT [1015]","HB AMC WELLPOINT","391.99","73.78","","286.63","119.22","1107.45","105","164.7","422.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.5MM 10 HOLE ORBITAL RAPIDSORB POLYMER RIM","SUP-ITM-10029157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","531.30","398.47","AETNA [1001]","HB AMC AETNA HMO","370.85","69.8","","675.31","184.75","1721.50","286","277.66","434.18","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.5MM 10 HOLE ORBITAL RAPIDSORB POLYMER RIM","SUP-ITM-10029157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","531.30","398.47","AETNA [1001]","HB AMC AETNA PPO","427.17","80.4","","1261.44","103.12","1514.10","21","277.66","434.18","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.5MM 10 HOLE ORBITAL RAPIDSORB POLYMER RIM","SUP-ITM-10029157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","531.30","398.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","427.17","80.4","","1365.00","1365.00","1365.00","1 through 10","277.66","434.18","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.5MM 10 HOLE ORBITAL RAPIDSORB POLYMER RIM","SUP-ITM-10029157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","531.30","398.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","434.18","81.72","","5157.68","5157.68","5157.68","1 through 10","277.66","434.18","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.5MM 10 HOLE ORBITAL RAPIDSORB POLYMER RIM","SUP-ITM-10029157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","531.30","398.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","434.18","81.72","","431.26","71.26","1459.57","88","277.66","434.18","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1MM UNIVERSAL BONE ORBITAL FLOOR TI","SUP-ITM-10003789","CDM","C1713","HCPCS","0278","RC","","","","both","","","6725.00","5043.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5346.38","79.5","","800.18","480.96","1887.97","195","2084.75","5346.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1MM UNIVERSAL BONE ORBITAL FLOOR TI","SUP-ITM-10003789","CDM","C1713","HCPCS","0278","RC","","","","both","","","6725.00","5043.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3584.43","53.3","","813.12","216.42","1444.50","81","2084.75","5346.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1MM UNIVERSAL BONE ORBITAL FLOOR TI","SUP-ITM-10003789","CDM","C1713","HCPCS","0278","RC","","","","both","","","6725.00","5043.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2084.75","31","","432.60","432.60","432.60","1 through 10","2084.75","5346.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1MM UNIVERSAL BONE ORBITAL FLOOR TI","SUP-ITM-10003789","CDM","C1713","HCPCS","0278","RC","","","","both","","","6725.00","5043.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2454.63","36.5","","148.37","54.89","631.39","94","2084.75","5346.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1MM UNIVERSAL BONE ORBITAL FLOOR TI","SUP-ITM-10003789","CDM","C1713","HCPCS","0278","RC","","","","both","","","6725.00","5043.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2575.68","38.3","","279.30","91.72","1116.77","266","2084.75","5346.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1MM UNIVERSAL BONE ORBITAL FLOOR TI","SUP-ITM-10003789","CDM","C1713","HCPCS","0278","RC","","","","both","","","6725.00","5043.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2885.03","42.9","","731.00","63.70","731.00","1 through 10","2084.75","5346.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1MM UNIVERSAL BONE ORBITAL FLOOR TI","SUP-ITM-10003789","CDM","C1713","HCPCS","0278","RC","","","","both","","","6725.00","5043.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2885.03","42.9","","384.74","384.74","384.74","1 through 10","2084.75","5346.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1MM UNIVERSAL BONE ORBITAL FLOOR TI","SUP-ITM-10003789","CDM","C1713","HCPCS","0278","RC","","","","both","","","6725.00","5043.75","WELLPOINT [1015]","HB AMC WELLPOINT","4961.71","73.78","","286.63","119.22","1107.45","105","2084.75","5346.38","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1MM UNIVERSAL BONE ORBITAL FLOOR TI","SUP-ITM-10003789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6725.00","5043.75","AETNA [1001]","HB AMC AETNA HMO","4694.05","69.8","","675.31","184.75","1721.50","286","3514.49","5495.67","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1MM UNIVERSAL BONE ORBITAL FLOOR TI","SUP-ITM-10003789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6725.00","5043.75","AETNA [1001]","HB AMC AETNA PPO","5406.90","80.4","","1261.44","103.12","1514.10","21","3514.49","5495.67","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1MM UNIVERSAL BONE ORBITAL FLOOR TI","SUP-ITM-10003789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6725.00","5043.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5406.90","80.4","","1365.00","1365.00","1365.00","1 through 10","3514.49","5495.67","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1MM UNIVERSAL BONE ORBITAL FLOOR TI","SUP-ITM-10003789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6725.00","5043.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5495.67","81.72","","5157.68","5157.68","5157.68","1 through 10","3514.49","5495.67","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1MM UNIVERSAL BONE ORBITAL FLOOR TI","SUP-ITM-10003789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6725.00","5043.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5495.67","81.72","","431.26","71.26","1459.57","88","3514.49","5495.67","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.79","740.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","784.50","79.5","","800.18","480.96","1887.97","195","305.9","784.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.79","740.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","525.96","53.3","","813.12","216.42","1444.50","81","305.9","784.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.79","740.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","305.90","31","","432.60","432.60","432.60","1 through 10","305.9","784.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.79","740.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","360.18","36.5","","148.37","54.89","631.39","94","305.9","784.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.79","740.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","377.94","38.3","","279.30","91.72","1116.77","266","305.9","784.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.79","740.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","423.33","42.9","","731.00","63.70","731.00","1 through 10","305.9","784.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.79","740.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","423.33","42.9","","384.74","384.74","384.74","1 through 10","305.9","784.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.79","740.09","WELLPOINT [1015]","HB AMC WELLPOINT","728.05","73.78","","286.63","119.22","1107.45","105","305.9","784.5","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.79","740.09","AETNA [1001]","HB AMC AETNA HMO","688.78","69.8","","675.31","184.75","1721.50","286","515.7","806.4","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.79","740.09","AETNA [1001]","HB AMC AETNA PPO","793.38","80.4","","1261.44","103.12","1514.10","21","515.7","806.4","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.79","740.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","793.38","80.4","","1365.00","1365.00","1365.00","1 through 10","515.7","806.4","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.79","740.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","806.40","81.72","","5157.68","5157.68","5157.68","1 through 10","515.7","806.4","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.79","740.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","806.40","81.72","","431.26","71.26","1459.57","88","515.7","806.4","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM LONG OBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077319","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.99","401.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","426.11","79.5","","800.18","480.96","1887.97","195","166.16","426.11","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM LONG OBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077319","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.99","401.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","285.68","53.3","","813.12","216.42","1444.50","81","166.16","426.11","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM LONG OBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077319","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.99","401.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","166.16","31","","432.60","432.60","432.60","1 through 10","166.16","426.11","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM LONG OBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077319","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.99","401.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","195.64","36.5","","148.37","54.89","631.39","94","166.16","426.11","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM LONG OBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077319","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.99","401.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","205.28","38.3","","279.30","91.72","1116.77","266","166.16","426.11","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM LONG OBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077319","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.99","401.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","229.94","42.9","","731.00","63.70","731.00","1 through 10","166.16","426.11","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM LONG OBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077319","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.99","401.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","229.94","42.9","","384.74","384.74","384.74","1 through 10","166.16","426.11","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM LONG OBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077319","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.99","401.99","WELLPOINT [1015]","HB AMC WELLPOINT","395.45","73.78","","286.63","119.22","1107.45","105","166.16","426.11","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM LONG OBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.99","401.99","AETNA [1001]","HB AMC AETNA HMO","374.12","69.8","","675.31","184.75","1721.50","286","280.11","438.01","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM LONG OBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.99","401.99","AETNA [1001]","HB AMC AETNA PPO","430.94","80.4","","1261.44","103.12","1514.10","21","280.11","438.01","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM LONG OBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.99","401.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","430.94","80.4","","1365.00","1365.00","1365.00","1 through 10","280.11","438.01","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM LONG OBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.99","401.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","438.01","81.72","","5157.68","5157.68","5157.68","1 through 10","280.11","438.01","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM LONG OBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.99","401.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","438.01","81.72","","431.26","71.26","1459.57","88","280.11","438.01","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM MEDOBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077318","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.29","364.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","386.60","79.5","","800.18","480.96","1887.97","195","150.75","386.6","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM MEDOBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077318","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.29","364.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","259.19","53.3","","813.12","216.42","1444.50","81","150.75","386.6","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM MEDOBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077318","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.29","364.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","150.75","31","","432.60","432.60","432.60","1 through 10","150.75","386.6","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM MEDOBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077318","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.29","364.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","177.50","36.5","","148.37","54.89","631.39","94","150.75","386.6","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM MEDOBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077318","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.29","364.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","186.25","38.3","","279.30","91.72","1116.77","266","150.75","386.6","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM MEDOBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077318","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.29","364.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","208.62","42.9","","731.00","63.70","731.00","1 through 10","150.75","386.6","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM MEDOBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077318","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.29","364.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","208.62","42.9","","384.74","384.74","384.74","1 through 10","150.75","386.6","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM MEDOBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077318","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.29","364.72","WELLPOINT [1015]","HB AMC WELLPOINT","358.78","73.78","","286.63","119.22","1107.45","105","150.75","386.6","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM MEDOBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","486.29","364.72","AETNA [1001]","HB AMC AETNA HMO","339.43","69.8","","675.31","184.75","1721.50","286","254.14","397.4","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM MEDOBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","486.29","364.72","AETNA [1001]","HB AMC AETNA PPO","390.98","80.4","","1261.44","103.12","1514.10","21","254.14","397.4","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM MEDOBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","486.29","364.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","390.98","80.4","","1365.00","1365.00","1365.00","1 through 10","254.14","397.4","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM MEDOBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","486.29","364.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","397.40","81.72","","5157.68","5157.68","5157.68","1 through 10","254.14","397.4","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3X//0.8MM MEDOBLIQUE H CRANIAL MATRIXORTHOGNATHIC TI L REVERSIBLE","SUP-ITM-10077318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","486.29","364.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","397.40","81.72","","431.26","71.26","1459.57","88","254.14","397.4","percent of total billed charges",""
"Craniosacral Tx","PX-51000171","CDM","97799","CPT","0510","RC","","","","outpatient","","","135.00","135.00","AETNA [1001]","HB AMC AETNA HMO","94.23","69.8","","94.50","94.50","94.50","1 through 10","40.19","111.38","percent of total billed charges",""
"Craniosacral Tx","PX-51000171","CDM","97799","CPT","0510","RC","","","","outpatient","","","135.00","135.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","70.88","52.5","","135.00","135.00","135.00","1 through 10","40.19","111.38","percent of total billed charges",""
"Craniosunostosis Ngs Panel","PX-30003385","CDM","81479","CPT","0310","RC","","","","both","","","98.00","73.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","77.91","79.5","","0.65","0.65","0.65","1 through 10","30.38","93.1","percent of total billed charges",""
"Craniosunostosis Ngs Panel","PX-30003385","CDM","81479","CPT","0310","RC","","","","both","","","98.00","73.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","52.23","53.3","","0.79","0.79","0.79","1 through 10","30.38","93.1","percent of total billed charges",""
"Craniosunostosis Ngs Panel","PX-30003385","CDM","81479","CPT","0310","RC","","","","outpatient","","","98.00","73.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","49.00","50","","1.00","1.00","1.00","1 through 10","47.43","156.55","percent of total billed charges",""
"Craniosunostosis Ngs Panel","PX-30003385","CDM","81479","CPT","0310","RC","","","","outpatient","","","98.00","73.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","51.45","52.5","","1.00","0.53","1.00","1 through 10","47.43","156.55","percent of total billed charges",""
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","","","","inpatient","","","141704.05","106278.04","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","29604.57","","Case rate ($28,742.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,522.65, add-ons for qualifying new technology services are included. If operating cost exceeds $80,167.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,941.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $25,860.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,142.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,501.84. The transfer capital threshold is the transfer adjustment factor * $2,501.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","28916.61","28916.61","28916.61","1 through 10","28167.45","46157.3326","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","","","","inpatient","","","141704.05","106278.04","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","28742.30","","Case rate ($28,742.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,522.65, add-ons for qualifying new technology services are included. If operating cost exceeds $80,167.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,941.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $25,860.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,142.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,501.84. The transfer capital threshold is the transfer adjustment factor * $2,501.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","27738.07","27738.04","123442.56","1 through 10","28167.45","46157.3326","other","Inpatient Replacement Plans DRG"
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","","","","inpatient","","","141704.05","106278.04","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","28742.30","","Case rate ($28,742.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,522.65, add-ons for qualifying new technology services are included. If operating cost exceeds $80,167.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,941.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $25,860.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,142.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,501.84. The transfer capital threshold is the transfer adjustment factor * $2,501.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","27546.28","27546.28","27604.26","1 through 10","28167.45","46157.3326","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","","","","inpatient","","","141704.05","106278.04","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","26174.74","26174.74","26174.74","1 through 10","28167.45","46157.3326","case rate",""
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","","","","inpatient","","","141704.05","106278.04","MEDICARE [2001]","HB BWH MEDICARE","28742.30","","Case rate ($28,742.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,522.65, add-ons for qualifying new technology services are included. If operating cost exceeds $80,167.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,941.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $25,860.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,142.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,501.84. The transfer capital threshold is the transfer adjustment factor * $2,501.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","36336.60","0.03","36390.52","32","28167.45","46157.3326","other","Inpatient Replacement Plans DRG"
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","","","","inpatient","","","141704.05","106278.04","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28167.45","","Case rate ($28,742.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,522.65, add-ons for qualifying new technology services are included. If operating cost exceeds $80,167.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,941.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $25,860.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,142.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,501.84. The transfer capital threshold is the transfer adjustment factor * $2,501.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","27563.56","18477.85","37056.22","1 through 10","28167.45","46157.3326","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","","","","inpatient","","","141704.05","106278.04","WELLPOINT [1015]","HB AMC WELLPOINT","46157.3326","","Fee schedule rate ($48,702.51).","46157.3326","126059.23","126059.23","1 through 10","28167.45","46157.3326","case rate",""
"Craniotomy And Endovascular Intracranial Procedures With McC","025","MS-DRG","","","","","","","","inpatient","","","175440.33","131580.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","43110.97","","Case rate ($41,855.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,308.13, add-ons for qualifying new technology services are included. If operating cost exceeds $95,952.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,098.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $37,816.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,928.30 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,658.54. The transfer capital threshold is the transfer adjustment factor * $3,658.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","42088.80","19606.10","42170.30","13","41018.2","71219.51","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures With McC","025","MS-DRG","","","","","","","","inpatient","","","175440.33","131580.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54207.87","","Case rate ($54,207.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,308.13, add-ons for qualifying new technology services are included. If operating cost exceeds $95,952.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,098.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $50,169.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,928.30 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,658.54. The transfer capital threshold is the transfer adjustment factor * $3,658.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","40432.15","31502.91","52171.64","21","41018.2","71219.51","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures With McC","025","MS-DRG","","","","","","","","inpatient","","","175440.33","131580.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","41855.31","","Case rate ($41,855.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,308.13, add-ons for qualifying new technology services are included. If operating cost exceeds $95,952.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,098.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $37,816.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,928.30 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,658.54. The transfer capital threshold is the transfer adjustment factor * $3,658.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","37117.70","37117.70","37117.70","1 through 10","41018.2","71219.51","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures With McC","025","MS-DRG","","","","","","","","inpatient","","","175440.33","131580.25","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","41523.73","41523.73","41523.73","1 through 10","41018.2","71219.51","case rate",""
"Craniotomy And Endovascular Intracranial Procedures With McC","025","MS-DRG","","","","","","","","inpatient","","","175440.33","131580.25","HUMANA [1012]","HB BWH MEDICARE","54207.87","","Case rate ($54,207.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,308.13, add-ons for qualifying new technology services are included. If operating cost exceeds $95,952.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,098.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $50,169.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,928.30 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,658.54. The transfer capital threshold is the transfer adjustment factor * $3,658.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","40164.92","40164.92","40164.92","1 through 10","41018.2","71219.51","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures With McC","025","MS-DRG","","","","","","","","inpatient","","","175440.33","131580.25","MEDICARE [2001]","HB BWH MEDICARE","54207.87","","Case rate ($54,207.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,308.13, add-ons for qualifying new technology services are included. If operating cost exceeds $95,952.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,098.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $50,169.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,928.30 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,658.54. The transfer capital threshold is the transfer adjustment factor * $3,658.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","48948.38","0.03","53081.77","174","41018.2","71219.51","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures With McC","025","MS-DRG","","","","","","","","inpatient","","","175440.33","131580.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54207.87","","Case rate ($54,207.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,308.13, add-ons for qualifying new technology services are included. If operating cost exceeds $95,952.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,098.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $50,169.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,928.30 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,658.54. The transfer capital threshold is the transfer adjustment factor * $3,658.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","40144.53","40144.53","40144.53","1 through 10","41018.2","71219.51","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures With McC","025","MS-DRG","","","","","","","","inpatient","","","175440.33","131580.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","41018.20","","Case rate ($41,855.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,308.13, add-ons for qualifying new technology services are included. If operating cost exceeds $95,952.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,098.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $37,816.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,928.30 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,658.54. The transfer capital threshold is the transfer adjustment factor * $3,658.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","37085.06","18665.35","40201.27","11","41018.2","71219.51","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures With McC","025","MS-DRG","","","","","","","","inpatient","","","175440.33","131580.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","41018.20","","Case rate ($41,855.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,308.13, add-ons for qualifying new technology services are included. If operating cost exceeds $95,952.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,098.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $37,816.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,928.30 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,658.54. The transfer capital threshold is the transfer adjustment factor * $3,658.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","40156.49","18688.80","58074.52","24","41018.2","71219.51","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures With McC","025","MS-DRG","","","","","","","","inpatient","","","175440.33","131580.25","WELLPOINT [1015]","HB AMC WELLPOINT","71219.51","","Fee schedule rate ($71,219.51).","289709.47","161741.37","333484.44","1 through 10","41018.2","71219.51","case rate",""
"Craniotomy And Endovascular Intracranial Procedures Without Cc/McC","027","MS-DRG","","","","","","","","inpatient","","","121536.84","91152.63","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","24095.84","","Case rate ($23,394.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,084.35, add-ons for qualifying new technology services are included. If operating cost exceeds $73,728.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,470.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $20,984.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,704.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.07. The transfer capital threshold is the transfer adjustment factor * $2,030.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","23355.16","23355.16","23409.66","1 through 10","22926.14","37241.5698","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/McC","027","MS-DRG","","","","","","","","inpatient","","","121536.84","91152.63","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","30248.28","","Case rate ($30,248.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,084.35, add-ons for qualifying new technology services are included. If operating cost exceeds $73,728.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,470.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $27,838.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,704.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.07. The transfer capital threshold is the transfer adjustment factor * $2,030.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","28909.99","22433.07","28918.37","1 through 10","22926.14","37241.5698","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/McC","027","MS-DRG","","","","","","","","inpatient","","","121536.84","91152.63","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","23394.02","","Case rate ($23,394.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,084.35, add-ons for qualifying new technology services are included. If operating cost exceeds $73,728.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,470.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $20,984.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,704.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.07. The transfer capital threshold is the transfer adjustment factor * $2,030.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","22327.03","22327.03","22327.03","1 through 10","22926.14","37241.5698","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/McC","027","MS-DRG","","","","","","","","inpatient","","","121536.84","91152.63","ELDER SERVICES [1037]","HB BWH MEDICARE","30248.28","","Case rate ($30,248.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,084.35, add-ons for qualifying new technology services are included. If operating cost exceeds $73,728.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,470.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $27,838.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,704.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.07. The transfer capital threshold is the transfer adjustment factor * $2,030.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","9809.60","9809.60","9809.60","1 through 10","22926.14","37241.5698","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/McC","027","MS-DRG","","","","","","","","inpatient","","","121536.84","91152.63","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","26174.74","26174.74","26174.74","1 through 10","22926.14","37241.5698","case rate",""
"Craniotomy And Endovascular Intracranial Procedures Without Cc/McC","027","MS-DRG","","","","","","","","inpatient","","","121536.84","91152.63","MEDICARE [2001]","HB BWH MEDICARE","30248.28","","Case rate ($30,248.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,084.35, add-ons for qualifying new technology services are included. If operating cost exceeds $73,728.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,470.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $27,838.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,704.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.07. The transfer capital threshold is the transfer adjustment factor * $2,030.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","29371.55","0.03","29415.07","32","22926.14","37241.5698","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/McC","027","MS-DRG","","","","","","","","inpatient","","","121536.84","91152.63","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","30248.28","","Case rate ($30,248.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,084.35, add-ons for qualifying new technology services are included. If operating cost exceeds $73,728.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,470.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $27,838.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,704.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.07. The transfer capital threshold is the transfer adjustment factor * $2,030.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","22261.53","22261.53","22261.53","1 through 10","22926.14","37241.5698","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/McC","027","MS-DRG","","","","","","","","inpatient","","","121536.84","91152.63","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","22926.14","","Case rate ($23,394.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,084.35, add-ons for qualifying new technology services are included. If operating cost exceeds $73,728.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,470.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $20,984.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,704.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.07. The transfer capital threshold is the transfer adjustment factor * $2,030.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","22281.13","22281.13","22281.13","1 through 10","22926.14","37241.5698","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/McC","027","MS-DRG","","","","","","","","inpatient","","","121536.84","91152.63","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","22926.14","","Case rate ($23,394.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,084.35, add-ons for qualifying new technology services are included. If operating cost exceeds $73,728.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,470.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $20,984.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,704.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.07. The transfer capital threshold is the transfer adjustment factor * $2,030.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","22270.25","92.29","30115.53","19","22926.14","37241.5698","other","Inpatient DRG"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/McC","027","MS-DRG","","","","","","","","inpatient","","","121536.84","91152.63","WELLPOINT [1015]","HB AMC WELLPOINT","37241.5698","","Fee schedule rate ($39,518.71).","37241.5698","37241.56","347140.54","1 through 10","22926.14","37241.5698","case rate",""
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","","","","inpatient","","","661343.76","496007.82","MEDICARE [2001]","HB BWH MEDICARE","61781.65","","Case rate ($61,781.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $74,295.50, add-ons for qualifying new technology services are included. If operating cost exceeds $119,939.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,856.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $55,985.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $73,915.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,416.24. The transfer capital threshold is the transfer adjustment factor * $5,416.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","60546.02","91907.2082","other","Inpatient Replacement Plans DRG"
"Craniotomy For Multiple Significant Trauma,EXTREME","910","DRG","","","","","","","","inpatient","","","661343.76","","MASSHEALTH [3001]","HB BWH MEDICAID","83189.38","","Case rate ($91,980.16). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $134,410.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $8,701.51 and the sum of the standard inlier and any outlier amount.","145447.15","145447.15","145447.15","1 through 10","66186.8656","293218.17","case rate",""
"Craniotomy For Multiple Significant Trauma,EXTREME","910","DRG","","","","","","","","inpatient","","","661343.76","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","83189.38","","Case rate ($91,980.16). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $134,410.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $8,701.51 and the sum of the standard inlier and any outlier amount.","673149.28","673149.28","673149.28","1 through 10","66186.8656","293218.17","case rate",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Antineoplastic Implant Or Epilepsy With Neurostimulator","023","MS-DRG","","","","","","","","inpatient","","","215636.57","161727.43","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","54231.81","","Case rate ($52,652.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $63,305.50, add-ons for qualifying new technology services are included. If operating cost exceeds $108,949.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,051.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,661.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $62,925.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,610.94. The transfer capital threshold is the transfer adjustment factor * $4,610.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","53684.71","53684.71","53684.71","1 through 10","51599.2","86095.6641","other","Inpatient DRG"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Antineoplastic Implant Or Epilepsy With Neurostimulator","023","MS-DRG","","","","","","","","inpatient","","","215636.57","161727.43","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","68220.43","","Case rate ($68,220.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $63,305.50, add-ons for qualifying new technology services are included. If operating cost exceeds $108,949.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,051.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $63,229.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $62,925.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,610.94. The transfer capital threshold is the transfer adjustment factor * $4,610.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","60030.27","60030.27","478884.68","1 through 10","51599.2","86095.6641","other","Inpatient DRG"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Antineoplastic Implant Or Epilepsy With Neurostimulator","023","MS-DRG","","","","","","","","inpatient","","","215636.57","161727.43","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","52652.24","","Case rate ($52,652.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $63,305.50, add-ons for qualifying new technology services are included. If operating cost exceeds $108,949.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,051.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,661.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $62,925.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,610.94. The transfer capital threshold is the transfer adjustment factor * $4,610.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","51311.20","51311.20","51311.20","1 through 10","51599.2","86095.6641","other","Inpatient DRG"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Antineoplastic Implant Or Epilepsy With Neurostimulator","023","MS-DRG","","","","","","","","inpatient","","","215636.57","161727.43","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","53027.58","53027.58","53027.58","1 through 10","51599.2","86095.6641","case rate",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Antineoplastic Implant Or Epilepsy With Neurostimulator","023","MS-DRG","","","","","","","","inpatient","","","215636.57","161727.43","MEDICARE [2001]","HB BWH MEDICARE","68220.43","","Case rate ($68,220.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $63,305.50, add-ons for qualifying new technology services are included. If operating cost exceeds $108,949.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,051.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $63,229.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $62,925.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,610.94. The transfer capital threshold is the transfer adjustment factor * $4,610.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","66256.34","0.03","67637.20","49","51599.2","86095.6641","other","Inpatient DRG"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Antineoplastic Implant Or Epilepsy With Neurostimulator","023","MS-DRG","","","","","","","","inpatient","","","215636.57","161727.43","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","51599.20","","Case rate ($52,652.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $63,305.50, add-ons for qualifying new technology services are included. If operating cost exceeds $108,949.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,051.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,661.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $62,925.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,610.94. The transfer capital threshold is the transfer adjustment factor * $4,610.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","50133.69","43140.02","68960.32","1 through 10","51599.2","86095.6641","other","Inpatient DRG"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Antineoplastic Implant Or Epilepsy With Neurostimulator","023","MS-DRG","","","","","","","","inpatient","","","215636.57","161727.43","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","51599.20","","Case rate ($52,652.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $63,305.50, add-ons for qualifying new technology services are included. If operating cost exceeds $108,949.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,051.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $47,661.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $62,925.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,610.94. The transfer capital threshold is the transfer adjustment factor * $4,610.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","51223.14","48473.00","70800.95","14","51599.2","86095.6641","other","Inpatient DRG"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC","024","MS-DRG","","","","","","","","inpatient","","","149800.68","112350.51","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","37146.54","","Case rate ($36,064.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $43,337.26, add-ons for qualifying new technology services are included. If operating cost exceeds $88,981.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,587.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,537.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,957.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,147.74. The transfer capital threshold is the transfer adjustment factor * $3,147.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","35892.53","35892.53","35892.53","1 through 10","35343.31","57176.7808","other","Inpatient DRG"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC","024","MS-DRG","","","","","","","","inpatient","","","149800.68","112350.51","FALLON HEALTH [1008]","HB BWH MEDICARE","36064.60","","Case rate ($36,064.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $43,337.26, add-ons for qualifying new technology services are included. If operating cost exceeds $88,981.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,587.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,537.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,957.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,147.74. The transfer capital threshold is the transfer adjustment factor * $3,147.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","43966.15","43966.15","43966.15","1 through 10","35343.31","57176.7808","other","Inpatient Replacement Plans DRG"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC","024","MS-DRG","","","","","","","","inpatient","","","149800.68","112350.51","MEDICARE [2001]","HB BWH MEDICARE","36064.60","","Case rate ($36,064.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $43,337.26, add-ons for qualifying new technology services are included. If operating cost exceeds $88,981.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,587.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,537.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,957.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,147.74. The transfer capital threshold is the transfer adjustment factor * $3,147.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","45164.15","45097.10","45164.15","1 through 10","35343.31","57176.7808","other","Inpatient Replacement Plans DRG"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC","024","MS-DRG","","","","","","","","inpatient","","","149800.68","112350.51","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","35343.31","","Case rate ($36,064.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $43,337.26, add-ons for qualifying new technology services are included. If operating cost exceeds $88,981.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,587.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,537.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,957.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,147.74. The transfer capital threshold is the transfer adjustment factor * $3,147.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","34229.53","34229.53","34229.53","1 through 10","35343.31","57176.7808","other","Inpatient DRG"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC","024","MS-DRG","","","","","","","","inpatient","","","149800.68","112350.51","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","35343.31","","Case rate ($36,064.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $43,337.26, add-ons for qualifying new technology services are included. If operating cost exceeds $88,981.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,587.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,537.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,957.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,147.74. The transfer capital threshold is the transfer adjustment factor * $3,147.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","34214.68","34214.68","34214.68","1 through 10","35343.31","57176.7808","other","Inpatient DRG"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC","024","TRIS-DRG","","","","","","","","inpatient","","","134557.05","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","31365.15","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($55,094.65). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $6,260.76, and the first day is paid a rate of $40,068.84. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $12,521.51, and the first day is paid a rate of $25,043.02. The transfer payment is capped at $39,653.56. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $98,821.65 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a special pay post-acute discharge disposition, the outlier threshold is multiplied by (((LOS / 4.40000009536743) + 1) * 0.5). For stays with a transfer discharge disposition, the outlier threshold is multiplied by (LOS / 4.40000009536743). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($19,676.66), capped at $39,653.56. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $6,260.76, and the first day is paid a rate of $40,068.84. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $12,521.51, and the first day is paid a rate of $25,043.02. The transfer payment is capped at $39,653.56. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $98,821.65 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a special pay post-acute discharge disposition, the outlier threshold is multiplied by (((LOS / 4.40000009536743) + 1) * 0.5). For stays with a transfer discharge disposition, the outlier threshold is multiplied by (LOS / 4.40000009536743). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","60150.83","60150.83","60150.83","1 through 10","31365.15","31365.15","other","Inpatient DRGs"
"Creatine Kinase (Cpk) Isoenzyme","PX-30000390","CDM","82552","CPT","0301","RC","","","","both","","","224.00","168.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","81.76","36.5","","80.94","80.94","80.94","1 through 10","13.12","212.8","percent of total billed charges",""
"Creatine Kinase (Cpk) Mb Only","PX-30000391","CDM","82553","CPT","0301","RC","","","","both","","","152.00","114.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.02","53.3","","115.69","77.62","115.69","1 through 10","7.99","144.4","percent of total billed charges",""
"Creatine Kinase (Cpk) Mb Only","PX-30000391","CDM","82553","CPT","0301","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.48","36.5","","54.83","46.60","54.83","1 through 10","7.99","144.4","percent of total billed charges",""
"Creatine Kinase (Cpk) Mb Only","PX-30000391","CDM","82553","CPT","0301","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.22","38.3","","57.48","57.48","57.48","1 through 10","7.99","144.4","percent of total billed charges",""
"Creatine Kinase (Cpk) Mb Only","PX-30000391","CDM","82553","CPT","0301","RC","","","","outpatient","","","152.00","114.00","AETNA [1001]","HB AMC AETNA HMO","106.10","69.8","","99.52","70.27","99.52","1 through 10","7.99","124.21","percent of total billed charges",""
"Creatine Kinase (Cpk) Mb Only","PX-30000391","CDM","82553","CPT","0301","RC","","","","outpatient","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","124.21","81.72","","117.51","117.51","117.51","1 through 10","7.99","124.21","percent of total billed charges",""
"Creatine Kinase (Cpk) Mb Only","PX-30000391","CDM","82553","CPT","0301","RC","","","","outpatient","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","124.21","81.72","","64.64","64.64","64.64","1 through 10","7.99","124.21","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","71.80","71.8","","34.26","5.74","69.65","1 through 10","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","65.60","65.6","","65.67","65.67","65.67","1 through 10","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","65.00","65","","63.05","63.05","63.05","1 through 10","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","70.00","70","","209.52","69.84","209.52","1 through 10","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","79.50","79.5","","76.34","51.22","76.34","120","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","53.30","53.3","","76.34","51.22","153.66","38","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","77.00","77","","155.54","74.69","155.54","1 through 10","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","79.50","79.5","","76.34","76.34","76.34","1 through 10","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","31.00","31","","29.97","29.97","29.97","1 through 10","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36.50","36.5","","36.18","30.75","108.54","88","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38.30","38.3","","37.93","36.86","113.79","245","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","77.00","77","","75.66","75.66","75.66","1 through 10","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","TRICARE [160005]","HB BWH TRICARE","95.00","95","","104.45","7.45","104.45","1 through 10","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.90","42.9","","77.54","42.65","77.54","1 through 10","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","100.00","75.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.90","42.9","","42.65","42.65","42.65","1 through 10","6.38","95","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","100.00","75.00","AETNA [1001]","HB AMC AETNA HMO","69.80","69.8","","65.67","46.37","75.66","116","6.71","81.72","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","100.00","75.00","AETNA [1001]","HB AMC AETNA PPO","80.40","80.4","","75.66","50.83","101.66","13","6.71","81.72","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","100.00","75.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","52.26","52.26","","9.89","9.19","9.89","1 through 10","6.71","81.72","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","100.00","75.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","80.40","80.4","","48.50","48.50","48.50","1 through 10","6.71","81.72","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","100.00","75.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","81.72","81.72","","77.78","77.78","77.78","1 through 10","6.71","81.72","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","100.00","75.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","81.72","81.72","","77.54","42.65","77.54","1 through 10","6.71","81.72","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","100.00","75.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","81.72","81.72","","77.54","42.65","77.54","96","6.71","81.72","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","55.76","65.6","","63.96","55.51","63.96","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","59.50","70","","82.00","82.00","82.00","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","CHAMPVA [160001]","HB BWH TRICARE","80.75","95","","6.17","6.17","6.17","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","67.58","79.5","","64.53","43.30","64.53","147","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.31","53.3","","43.30","43.30","64.53","71","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","65.45","77","","61.60","61.60","61.60","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.25","65","","117.83","117.83","117.83","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.35","31","","25.34","25.34","50.68","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.03","36.5","","30.59","25.99","30.59","103","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.56","38.3","","32.06","31.16","32.06","361","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","65.45","77","","64.53","64.53","64.53","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","TRICARE [160005]","HB BWH TRICARE","80.75","95","","6.17","5.86","6.17","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.47","42.9","","65.55","36.06","65.55","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.47","42.9","","36.06","36.06","36.06","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","AETNA [1001]","HB AMC AETNA HMO","59.33","69.8","","55.51","39.20","63.96","190","5.29","69.46","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","AETNA [1001]","HB AMC AETNA PPO","68.34","80.4","","63.96","42.97","63.96","11","5.29","69.46","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.42","52.26","","50.74","50.74","50.74","1 through 10","5.29","69.46","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","68.34","80.4","","63.96","63.96","63.96","1 through 10","5.29","69.46","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","69.46","81.72","","65.55","65.55","65.55","1 through 10","5.29","69.46","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","69.46","81.72","","65.55","36.06","65.55","1 through 10","5.29","69.46","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","69.46","81.72","","65.55","36.06","65.55","133","5.29","69.46","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","55.76","65.6","","63.96","55.51","63.96","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","59.50","70","","82.00","82.00","82.00","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","CHAMPVA [160001]","HB BWH TRICARE","80.75","95","","6.17","6.17","6.17","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","67.58","79.5","","64.53","43.30","64.53","147","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.31","53.3","","43.30","43.30","64.53","71","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","65.45","77","","61.60","61.60","61.60","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.25","65","","117.83","117.83","117.83","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.35","31","","25.34","25.34","50.68","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.03","36.5","","30.59","25.99","30.59","103","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.56","38.3","","32.06","31.16","32.06","361","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","65.45","77","","64.53","64.53","64.53","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","TRICARE [160005]","HB BWH TRICARE","80.75","95","","6.17","5.86","6.17","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.47","42.9","","65.55","36.06","65.55","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","85.00","63.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.47","42.9","","36.06","36.06","36.06","1 through 10","5.02","80.75","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","AETNA [1001]","HB AMC AETNA HMO","59.33","69.8","","55.51","39.20","63.96","190","5.29","69.46","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","AETNA [1001]","HB AMC AETNA PPO","68.34","80.4","","63.96","42.97","63.96","11","5.29","69.46","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.42","52.26","","50.74","50.74","50.74","1 through 10","5.29","69.46","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","68.34","80.4","","63.96","63.96","63.96","1 through 10","5.29","69.46","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","69.46","81.72","","65.55","65.55","65.55","1 through 10","5.29","69.46","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","69.46","81.72","","65.55","36.06","65.55","1 through 10","5.29","69.46","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","85.00","63.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","69.46","81.72","","65.55","36.06","65.55","133","5.29","69.46","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","62.47","71.8","","60.31","13.71","180.93","68","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","57.07","65.6","","56.87","56.87","56.87","1 through 10","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","56.55","65","","54.60","44.35","66.11","57","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.90","70","","84.00","36.12","108.36","58","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","CHAMPVA [160001]","HB BWH TRICARE","82.65","95","","6.24","6.24","6.24","1 through 10","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.17","79.5","","66.11","44.35","66.11","364","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.37","53.3","","44.35","44.35","66.11","168","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.99","77","","194.04","64.68","194.04","1 through 10","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","56.55","65","","54.60","53.30","54.60","1 through 10","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","69.17","79.5","","66.11","25.00","66.11","1 through 10","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.97","31","","25.96","25.96","25.96","18","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.76","36.5","","31.33","26.63","79.89","444","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.32","38.3","","32.84","31.92","98.52","1324","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","MOLINA [1014]","HB BWH MOLINA","30.45","35","","10.28","10.28","10.28","12","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","66.99","77","","65.52","6.99","65.52","1 through 10","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","TRICARE [160005]","HB BWH TRICARE","82.65","95","","6.24","5.93","6.24","12","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.32","42.9","","36.93","36.93","67.15","15","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","87.00","65.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.32","42.9","","36.93","36.93","36.93","1 through 10","5.08","82.65","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","87.00","65.25","AETNA [1001]","HB AMC AETNA HMO","60.73","69.8","","56.87","40.15","65.52","584","5.34","71.1","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","87.00","65.25","AETNA [1001]","HB AMC AETNA PPO","69.95","80.4","","65.52","40.15","65.52","61","5.34","71.1","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","87.00","65.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","48.63","55.9","","44.02","44.02","44.02","1 through 10","5.34","71.1","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","87.00","65.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.47","52.26","","18.56","15.98","51.98","1 through 10","5.34","71.1","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","87.00","65.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","69.95","80.4","","65.52","42.00","65.52","14","5.34","71.1","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","87.00","65.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","71.10","81.72","","67.15","63.15","67.15","1 through 10","5.34","71.1","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","87.00","65.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","71.10","81.72","","45.62","36.93","67.15","23","5.34","71.1","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","87.00","65.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.10","81.72","","67.15","36.93","67.15","442","5.34","71.1","percent of total billed charges",""
"Crisis Intervention Mental Health Services","PX-90000170","CDM","S9485","HCPCS","0900","RC","","","","both","","","5455.00","4091.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1909.25","35","","718.37","718.37","718.37","1 through 10","1691.05","5182.25","percent of total billed charges",""
"Crisis Intervention Mental Health Services","PX-90000170","CDM","S9485","HCPCS","0900","RC","","","","both","","","5455.00","4091.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1991.08","36.5","","1016.05","1016.05","1016.05","1 through 10","1691.05","5182.25","percent of total billed charges",""
"Crisis Intervention Mental Health Services","PX-90000170","CDM","S9485","HCPCS","0900","RC","","","","inpatient","","","5455.00","4091.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4288.18","78.61","","17420.53","17239.06","17420.53","1 through 10","3016.62","4336.73","percent of total billed charges",""
"Crisis Intervention Mental Health Services","PX-90000170","CDM","S9485","HCPCS","0900","RC","","","","outpatient","","","5455.00","4091.25","AETNA [1001]","HB AMC AETNA PPO","4385.82","80.4","","2124.72","2124.72","2124.72","1 through 10","699.11","4457.83","percent of total billed charges",""
"Crisis Intervention Mental Health Services","PX-90000170","CDM","S9485","HCPCS","0900","RC","","","","outpatient","","","5455.00","4091.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3303.00","60.55","","1250.00","1250.00","1250.00","1 through 10","699.11","4457.83","percent of total billed charges",""
"Crisis Intervention Mental Health Services","PX-90000170","CDM","S9485","HCPCS","0900","RC","","","","outpatient","","","5455.00","4091.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2848.60","52.22","","1456.57","1442.26","1456.57","1 through 10","699.11","4457.83","percent of total billed charges",""
"Critical Care; Ea Add 30 Minutes","PX-45000007","CDM","99292","CPT","0450","RC","","","","both","","","2298.00","1723.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1826.91","79.5","","4712.14","4712.14","4712.14","1 through 10","712.38","1826.91","percent of total billed charges",""
"Crossmatch Antiglobulin (Ahg)","PX-30000086","CDM","86922","CPT","0302","RC","","","","both","","","323.00","242.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","254.35","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","18.64","18.64","18.64","20","100.13","256.79","other","OPPS APC"
"Crossmatch Antiglobulin (Ahg)","PX-30000086","CDM","86922","CPT","0302","RC","","","","outpatient","","","323.00","242.25","AETNA [1001]","HB AMC AETNA HMO","225.45","69.8","","149.62","149.61","211.90","1 through 10","168.8","887.19","percent of total billed charges",""
"Crossmatch Antiglobulin (Ahg)","PX-30000086","CDM","86922","CPT","0302","RC","","","","outpatient","","","323.00","242.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","263.96","81.72","","250.21","250.21","250.21","1 through 10","168.8","887.19","percent of total billed charges",""
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","outpatient","","","346.00","259.50","AETNA [1001]","HB AMC AETNA HMO","241.51","69.8","","227.47","227.47","227.47","1 through 10","125.2","887.19","percent of total billed charges",""
"CRT-D ACTICOR HF-T DX DF4 HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240782","CDM","C1882","HCPCS","0278","RC","","","","both","","","33750.00","25312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","17988.75","53.3","","25132.80","25132.80","25132.80","1 through 10","10462.5","26831.25","percent of total billed charges",""
"CRT-D ACTICOR HF-T DX DF4 HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240782","CDM","C1882","HCPCS","0278","RC","","","","both","","","33750.00","25312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12926.25","38.3","","18611.60","13196.25","18611.60","1 through 10","10462.5","26831.25","percent of total billed charges",""
"CRT-D ACTICOR HF-T DX DF4 HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240782","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","33750.00","25312.50","AETNA [1001]","HB AMC AETNA HMO","23557.50","69.8","","23525.75","23525.75","23525.75","1 through 10","17637.75","27580.5","percent of total billed charges",""
"CRT-D ACTICOR HF-T DX DF4 HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240782","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","33750.00","25312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","27580.50","81.72","","14745.34","14745.34","14745.34","1 through 10","17637.75","27580.5","percent of total billed charges",""
"CRT-D AMPLIA MRI QUAD CRTD US","SUP-ITM-10166721","CDM","C1882","HCPCS","0278","RC","","","","both","","","36921.25","27690.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19679.03","53.3","","25132.80","25132.80","25132.80","1 through 10","11445.59","29352.39","percent of total billed charges",""
"CRT-D AMPLIA MRI QUAD CRTD US","SUP-ITM-10166721","CDM","C1882","HCPCS","0278","RC","","","","both","","","36921.25","27690.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14140.84","38.3","","18611.60","13196.25","18611.60","1 through 10","11445.59","29352.39","percent of total billed charges",""
"CRT-D AMPLIA MRI QUAD CRTD US","SUP-ITM-10166721","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","36921.25","27690.94","AETNA [1001]","HB AMC AETNA HMO","25771.03","69.8","","23525.75","23525.75","23525.75","1 through 10","19295.05","30172.05","percent of total billed charges",""
"CRT-D AMPLIA MRI QUAD CRTD US","SUP-ITM-10166721","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","36921.25","27690.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","30172.05","81.72","","14745.34","14745.34","14745.34","1 through 10","19295.05","30172.05","percent of total billed charges",""
"CRT-D CLARIA MRI SURESCAN IS-1 DF-4","SUP-ITM-10173775","CDM","C1882","HCPCS","0278","RC","","","","both","","","38085.00","28563.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","20299.31","53.3","","25132.80","25132.80","25132.80","1 through 10","11806.35","30277.58","percent of total billed charges",""
"CRT-D CLARIA MRI SURESCAN IS-1 DF-4","SUP-ITM-10173775","CDM","C1882","HCPCS","0278","RC","","","","both","","","38085.00","28563.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14586.56","38.3","","18611.60","13196.25","18611.60","1 through 10","11806.35","30277.58","percent of total billed charges",""
"CRT-D CLARIA MRI SURESCAN IS-1 DF-4","SUP-ITM-10173775","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","38085.00","28563.75","AETNA [1001]","HB AMC AETNA HMO","26583.33","69.8","","23525.75","23525.75","23525.75","1 through 10","19903.22","31123.06","percent of total billed charges",""
"CRT-D CLARIA MRI SURESCAN IS-1 DF-4","SUP-ITM-10173775","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","38085.00","28563.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","31123.06","81.72","","14745.34","14745.34","14745.34","1 through 10","19903.22","31123.06","percent of total billed charges",""
"CRT-D QUADRA ASSURA 78X41 14MM DF4 IS4 IS CONNECTOR","SUP-ITM-10124447","CDM","C1882","HCPCS","0278","RC","","","","both","","","36875.00","27656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19654.38","53.3","","25132.80","25132.80","25132.80","1 through 10","11431.25","29315.63","percent of total billed charges",""
"CRT-D QUADRA ASSURA 78X41 14MM DF4 IS4 IS CONNECTOR","SUP-ITM-10124447","CDM","C1882","HCPCS","0278","RC","","","","both","","","36875.00","27656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14123.13","38.3","","18611.60","13196.25","18611.60","1 through 10","11431.25","29315.63","percent of total billed charges",""
"CRT-D QUADRA ASSURA 78X41 14MM DF4 IS4 IS CONNECTOR","SUP-ITM-10124447","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","36875.00","27656.25","AETNA [1001]","HB AMC AETNA HMO","25738.75","69.8","","23525.75","23525.75","23525.75","1 through 10","19270.88","30134.25","percent of total billed charges",""
"CRT-D QUADRA ASSURA 78X41 14MM DF4 IS4 IS CONNECTOR","SUP-ITM-10124447","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","36875.00","27656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","30134.25","81.72","","14745.34","14745.34","14745.34","1 through 10","19270.88","30134.25","percent of total billed charges",""
"CRT-PACEMAKER SERENA MRI IS4 QUAD","SUP-ITM-10191830","CDM","C2621","HCPCS","0275","RC","","","","outpatient","","","12217.50","9163.12","AETNA [1001]","HB AMC AETNA HMO","8527.82","69.8","","5258.00","5258.00","5258.00","1 through 10","6384.87","9984.14","percent of total billed charges",""
"CRT-PACEMAKER VALITUDE X4 33G 16.6CC 4.45CM 6.17CM .75CM RA/RV-IS1 LV-IS4 CONNECTOR","SUP-ITM-10140405","CDM","C2621","HCPCS","0275","RC","","","","outpatient","","","9250.00","6937.50","AETNA [1001]","HB AMC AETNA HMO","6456.50","69.8","","5258.00","5258.00","5258.00","1 through 10","4834.05","7559.1","percent of total billed charges",""
"Crtj Arven Fstl Xcp Dir Arven Anast Nonautog Grf","PX-36000164","CDM","36830","CPT","0361","RC","","","","outpatient","","","16272.00","12204.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","9852.70","60.55","","10054.64","10054.64","10054.64","1 through 10","6508.8","13082.69","percent of total billed charges",""
"CRYO AOROILIAC ARTERY FD-11MM DD-17MM AA-8CM ABD AORTA-9CM LEFT ILIAC-11CM","SUP-ITM-10328712","CDM","C1889","HCPCS","0278","RC","","","","both","","","63612.50","47709.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","50571.94","79.5","","1309.77","674.56","6049.93","26","19719.88","50571.94","percent of total billed charges",""
"CRYO AOROILIAC ARTERY FD-11MM DD-17MM AA-8CM ABD AORTA-9CM LEFT ILIAC-11CM","SUP-ITM-10328712","CDM","C1889","HCPCS","0278","RC","","","","both","","","63612.50","47709.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33905.46","53.3","","1901.83","1901.83","2962.25","1 through 10","19719.88","50571.94","percent of total billed charges",""
"CRYO AOROILIAC ARTERY FD-11MM DD-17MM AA-8CM ABD AORTA-9CM LEFT ILIAC-11CM","SUP-ITM-10328712","CDM","C1889","HCPCS","0278","RC","","","","both","","","63612.50","47709.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23218.56","36.5","","1620.31","1620.31","19908.88","1 through 10","19719.88","50571.94","percent of total billed charges",""
"CRYO AOROILIAC ARTERY FD-11MM DD-17MM AA-8CM ABD AORTA-9CM LEFT ILIAC-11CM","SUP-ITM-10328712","CDM","C1889","HCPCS","0278","RC","","","","both","","","63612.50","47709.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24363.59","38.3","","352.91","352.91","2046.30","1 through 10","19719.88","50571.94","percent of total billed charges",""
"CRYO AOROILIAC ARTERY FD-11MM DD-17MM AA-8CM ABD AORTA-9CM LEFT ILIAC-11CM","SUP-ITM-10328712","CDM","C1889","HCPCS","0278","RC","","","","both","","","63612.50","47709.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27289.76","42.9","","9668.75","9668.75","9668.75","1 through 10","19719.88","50571.94","percent of total billed charges",""
"CRYO AOROILIAC ARTERY FD-11MM DD-17MM AA-8CM ABD AORTA-9CM LEFT ILIAC-11CM","SUP-ITM-10328712","CDM","C1889","HCPCS","0278","RC","","","","both","","","63612.50","47709.37","WELLPOINT [1015]","HB AMC WELLPOINT","46933.30","73.78","","699.88","384.10","3443.31","33","19719.88","50571.94","percent of total billed charges",""
"CRYO AOROILIAC ARTERY FD-11MM DD-17MM AA-8CM ABD AORTA-9CM LEFT ILIAC-11CM","SUP-ITM-10328712","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","63612.50","47709.37","AETNA [1001]","HB AMC AETNA HMO","44401.53","69.8","","1421.24","264.50","4933.46","29","33243.89","51984.14","percent of total billed charges",""
"CRYO AOROILIAC ARTERY FD-11MM DD-17MM AA-8CM ABD AORTA-9CM LEFT ILIAC-11CM","SUP-ITM-10328712","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","63612.50","47709.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","51144.45","80.4","","1022.97","1022.97","3607.50","1 through 10","33243.89","51984.14","percent of total billed charges",""
"CRYO AOROILIAC ARTERY FD-11MM DD-17MM AA-8CM ABD AORTA-9CM LEFT ILIAC-11CM","SUP-ITM-10328712","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","63612.50","47709.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","51984.14","81.72","","3010.54","693.88","5019.88","35","33243.89","51984.14","percent of total billed charges",""
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","both","","","9104.00","6828.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","7237.68","other","OPPS APC"
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","both","","","9104.00","6828.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","7237.68","other","OPPS APC"
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","both","","","9104.00","6828.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4852.43","53.3","","477.31","477.31","477.31","1 through 10","333.03","7237.68","percent of total billed charges",""
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","both","","","9104.00","6828.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","7237.68","other","OPPS APC"
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","both","","","9104.00","6828.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","7237.68","other","OPPS APC"
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","both","","","9104.00","6828.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3322.96","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","7237.68","percent of total billed charges",""
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","both","","","9104.00","6828.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3486.83","38.3","","343.52","323.76","353.46","1 through 10","333.03","7237.68","percent of total billed charges",""
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","both","","","9104.00","6828.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","7237.68","other","Tricare OPPS"
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","both","","","9104.00","6828.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","7237.68","other","OPPS APC"
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","both","","","9104.00","6828.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","7237.68","other","OPPS APC"
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","both","","","9104.00","6828.00","WELLPOINT [1015]","HB AMC WELLPOINT","6716.93","73.78","","673.03","673.03","673.03","1 through 10","333.03","7237.68","percent of total billed charges",""
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","outpatient","","","9104.00","6828.00","AETNA [1001]","HB AMC AETNA HMO","6354.59","69.8","","612.01","612.01","1224.02","1 through 10","700.33","7510.8","percent of total billed charges",""
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","outpatient","","","9104.00","6828.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5512.47","60.55","","579.04","568.57","904.00","30","700.33","7510.8","percent of total billed charges",""
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","outpatient","","","9104.00","6828.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4754.11","52.22","","904.00","656.02","2938.00","26","700.33","7510.8","percent of total billed charges",""
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","outpatient","","","9104.00","6828.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4552.00","50","","1421.10","875.08","2368.50","15","700.33","7510.8","percent of total billed charges",""
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","outpatient","","","9104.00","6828.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4779.60","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","7510.8","percent of total billed charges",""
"Cryo/Laser Ablation Perc Skull Based Tumor","PX-36000459","CDM","64999","CPT","0361","RC","","","","outpatient","","","9104.00","6828.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7439.79","81.72","","722.66","722.66","17449.00","1 through 10","700.33","7510.8","percent of total billed charges",""
"Cryoablation Lymph System","PX-76002106","CDM","38999","CPT","0761","RC","","","","outpatient","","","3694.00","2770.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1929.01","52.22","","512.50","512.50","512.50","1 through 10","1234.13","3047.55","percent of total billed charges",""
"Cryoablation Lymph System","PX-76002106","CDM","38999","CPT","0761","RC","","","","outpatient","","","3694.00","2770.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1847.00","50","","6776.11","6776.11","6776.11","1 through 10","1234.13","3047.55","percent of total billed charges",""
"Cryoablation of Peritoneum","PX-76002268","CDM","49999","CPT","0761","RC","","","","both","","","15097.00","11322.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","12002.12","other","OPPS APC"
"Cryoablation of Peritoneum","PX-76002268","CDM","49999","CPT","0761","RC","","","","both","","","15097.00","11322.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","12002.12","other","OPPS APC"
"Cryoablation of Peritoneum","PX-76002268","CDM","49999","CPT","0761","RC","","","","both","","","15097.00","11322.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","1057.74","12002.12","other","OPPS APC"
"Cryoablation of Peritoneum","PX-76002268","CDM","49999","CPT","0761","RC","","","","outpatient","","","15097.00","11322.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","7548.50","50","","14640.00","14640.00","14640.00","1 through 10","7548.5","12455.03","percent of total billed charges",""
"Cryoblation Adrenal Gland","PX-76002098","CDM","60699","CPT","0761","RC","","","","both","","","3694.00","2770.50","MEDICARE [2001]","HB BWH MEDICARE","6927.95","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6928.65","6928.65","1 through 10","1145.14","8659.94","other","OPPS APC"
"Cryoblation Adrenal Gland","PX-76002098","CDM","60699","CPT","0761","RC","","","","both","","","3694.00","2770.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1414.80","38.3","","5123.54","4829.42","5123.54","1 through 10","1145.14","8659.94","percent of total billed charges",""
"Cryoblation Adrenal Gland","PX-76002098","CDM","60699","CPT","0761","RC","","","","outpatient","","","3694.00","2770.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2236.72","60.55","","13483.00","13483.00","13483.00","1 through 10","1847","15696.44","percent of total billed charges",""
"Cryoblation Adrenal Gland","PX-76002098","CDM","60699","CPT","0761","RC","","","","outpatient","","","3694.00","2770.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1929.01","52.22","","13483.00","12302.64","13483.00","1 through 10","1847","15696.44","percent of total billed charges",""
"Cryoblation Adrenal Gland","PX-76002098","CDM","60699","CPT","0761","RC","","","","outpatient","","","3694.00","2770.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1847.00","50","","13483.00","13483.00","13483.00","1 through 10","1847","15696.44","percent of total billed charges",""
"Cryoblation Adrenal Gland","PX-76002098","CDM","60699","CPT","0761","RC","","","","outpatient","","","3694.00","2770.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1939.35","52.5","","13483.00","3582.00","13483.00","1 through 10","1847","15696.44","percent of total billed charges",""
"Cryofibrinogen","PX-30000397","CDM","82585","CPT","0301","RC","","","","both","","","67.00","50.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25.66","38.3","","25.42","25.42","25.42","1 through 10","5.98","63.65","percent of total billed charges",""
"Cryoglobulin Ql or Sqn","PX-30000398","CDM","82595","CPT","0301","RC","","","","both","","","109.00","81.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","86.66","79.5","","83.42","83.42","83.42","1 through 10","6.34","103.55","percent of total billed charges",""
"Cryoglobulin Ql or Sqn","PX-30000398","CDM","82595","CPT","0301","RC","","","","both","","","109.00","81.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","58.10","53.3","","83.42","55.97","83.42","1 through 10","6.34","103.55","percent of total billed charges",""
"Cryoglobulin Ql or Sqn","PX-30000398","CDM","82595","CPT","0301","RC","","","","both","","","109.00","81.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","39.79","36.5","","39.54","33.60","39.54","1 through 10","6.34","103.55","percent of total billed charges",""
"Cryoglobulin Ql or Sqn","PX-30000398","CDM","82595","CPT","0301","RC","","","","both","","","109.00","81.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","41.75","38.3","","41.45","40.28","41.45","19","6.34","103.55","percent of total billed charges",""
"Cryoglobulin Ql or Sqn","PX-30000398","CDM","82595","CPT","0301","RC","","","","outpatient","","","109.00","81.75","AETNA [1001]","HB AMC AETNA HMO","76.08","69.8","","50.67","50.67","71.76","12","6.67","89.07","percent of total billed charges",""
"Cryoglobulin Ql or Sqn","PX-30000398","CDM","82595","CPT","0301","RC","","","","outpatient","","","109.00","81.75","AETNA [1001]","HB AMC AETNA PPO","87.64","80.4","","82.68","55.54","82.68","1 through 10","6.67","89.07","percent of total billed charges",""
"Cryoglobulin Ql or Sqn","PX-30000398","CDM","82595","CPT","0301","RC","","","","outpatient","","","109.00","81.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","89.07","81.72","","84.74","46.61","84.74","1 through 10","6.67","89.07","percent of total billed charges",""
"Cryopreservati Reproduct Testicular","PX-30000147","CDM","89335","CPT","0300","RC","","","","both","","","1090.00","817.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","397.85","36.5","","2180.00","2180.00","2180.00","1 through 10","62.18","1035.5","percent of total billed charges",""
"Cryopreservati Reproduct Testicular","PX-30000147","CDM","89335","CPT","0300","RC","","","","both","","","1090.00","817.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","417.47","38.3","","1090.00","1090.00","1090.00","1 through 10","62.18","1035.5","percent of total billed charges",""
"Cryopreservati Reproduct Testicular","PX-30000147","CDM","89335","CPT","0300","RC","","","","both","","","1090.00","817.50","WELLPOINT [1015]","HB AMC WELLPOINT","804.20","73.78","","811.51","811.51","811.51","1 through 10","62.18","1035.5","percent of total billed charges",""
"Cryopreservati Reproduct Testicular","PX-30000147","CDM","89335","CPT","0300","RC","","","","outpatient","","","1090.00","817.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","660.00","60.55","","732.81","680.38","732.81","1 through 10","189.14","890.75","percent of total billed charges",""
"Cryopreservati Reproduct Testicular","PX-30000147","CDM","89335","CPT","0300","RC","","","","outpatient","","","1090.00","817.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","569.20","52.22","","753.41","586.75","753.41","1 through 10","189.14","890.75","percent of total billed charges",""
"Cryopreservati Reproduct Testicular","PX-30000147","CDM","89335","CPT","0300","RC","","","","outpatient","","","1090.00","817.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","890.75","81.72","","871.35","871.35","871.35","1 through 10","189.14","890.75","percent of total billed charges",""
"Cryopreservation Embryos","PX-30000126","CDM","89258","CPT","0300","RC","","","","both","","","2002.00","1501.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1313.31","65.6","","1941.00","1941.00","1941.00","1 through 10","620.62","1901.9","percent of total billed charges",""
"Cryopreservation Embryos","PX-30000126","CDM","89258","CPT","0300","RC","","","","both","","","2002.00","1501.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1591.59","79.5","","1527.57","1024.85","1527.57","11","620.62","1901.9","percent of total billed charges",""
"Cryopreservation Embryos","PX-30000126","CDM","89258","CPT","0300","RC","","","","both","","","2002.00","1501.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1067.07","53.3","","1024.85","1024.85","1527.57","1 through 10","620.62","1901.9","percent of total billed charges",""
"Cryopreservation Embryos","PX-30000126","CDM","89258","CPT","0300","RC","","","","both","","","2002.00","1501.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","858.86","42.9","","1551.64","1551.64","1551.64","1 through 10","620.62","1901.9","percent of total billed charges",""
"Cryopreservation Embryos","PX-30000126","CDM","89258","CPT","0300","RC","","","","both","","","2002.00","1501.50","WELLPOINT [1015]","HB AMC WELLPOINT","1477.08","73.78","","3386.07","1445.07","3386.07","1 through 10","620.62","1901.9","percent of total billed charges",""
"Cryopreservation Embryos","PX-30000126","CDM","89258","CPT","0300","RC","","","","outpatient","","","2002.00","1501.50","AETNA [1001]","HB AMC AETNA HMO","1397.40","69.8","","927.80","927.80","927.80","1 through 10","420.84","3421.28","percent of total billed charges",""
"Cryopreservation Embryos","PX-30000126","CDM","89258","CPT","0300","RC","","","","outpatient","","","2002.00","1501.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1636.03","81.72","","1450.87","853.46","1551.64","11","420.84","3421.28","percent of total billed charges",""
"Cryopreservation Freeze & Stor","PX-31000116","CDM","88240","CPT","0311","RC","","","","outpatient","","","165.00","123.75","AETNA [1001]","HB AMC AETNA PPO","132.66","80.4","","124.80","124.80","124.80","1 through 10","37.12","134.84","percent of total billed charges",""
"Cryopreservation Mature Oocyte(S)","PX-31000498","CDM","89337","CPT","0310","RC","","","","both","","","2024.00","1518.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1327.74","65.6","","1328.95","1328.95","1328.95","1 through 10","199.41","1922.8","percent of total billed charges",""
"Cryopreservation Mature Oocyte(S)","PX-31000498","CDM","89337","CPT","0310","RC","","","","both","","","2024.00","1518.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1609.08","79.5","","1036.46","1036.46","1963.00","1 through 10","199.41","1922.8","percent of total billed charges",""
"Cryopreservation Mature Oocyte(S)","PX-31000498","CDM","89337","CPT","0310","RC","","","","both","","","2024.00","1518.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","738.76","36.5","","732.20","732.20","732.20","1 through 10","199.41","1922.8","percent of total billed charges",""
"Cryopreservation Mature Oocyte(S)","PX-31000498","CDM","89337","CPT","0310","RC","","","","both","","","2024.00","1518.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","775.19","38.3","","767.53","767.53","767.53","1 through 10","199.41","1922.8","percent of total billed charges",""
"Cryopreservation Mature Oocyte(S)","PX-31000498","CDM","89337","CPT","0310","RC","","","","both","","","2024.00","1518.00","WELLPOINT [1015]","HB AMC WELLPOINT","1493.31","73.78","","3424.45","1461.45","3424.45","1 through 10","199.41","1922.8","percent of total billed charges",""
"Cryopreservation Mature Oocyte(S)","PX-31000498","CDM","89337","CPT","0310","RC","","","","outpatient","","","2024.00","1518.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1654.01","81.72","","1569.22","863.13","1569.22","1 through 10","297.92","1654.01","percent of total billed charges",""
"Cryopreservation Sperm","PX-30000127","CDM","89259","CPT","0300","RC","","","","both","","","686.00","514.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","480.20","70","","193.33","193.33","193.33","1 through 10","199.41","651.7","percent of total billed charges",""
"Cryopreservation Sperm","PX-30000127","CDM","89259","CPT","0300","RC","","","","both","","","686.00","514.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","545.37","79.5","","432.25","351.12","665.00","1 through 10","199.41","651.7","percent of total billed charges",""
"Cryopreservation Sperm","PX-30000127","CDM","89259","CPT","0300","RC","","","","both","","","686.00","514.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","365.64","53.3","","351.12","231.70","351.12","1 through 10","199.41","651.7","percent of total billed charges",""
"Cryopreservation Sperm","PX-30000127","CDM","89259","CPT","0300","RC","","","","both","","","686.00","514.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","250.39","36.5","","240.73","210.81","248.05","1 through 10","199.41","651.7","percent of total billed charges",""
"Cryopreservation Sperm","PX-30000127","CDM","89259","CPT","0300","RC","","","","both","","","686.00","514.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","262.74","38.3","","260.02","260.02","260.02","1 through 10","199.41","651.7","percent of total billed charges",""
"Cryopreservation Sperm","PX-30000127","CDM","89259","CPT","0300","RC","","","","both","","","686.00","514.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","203.50","186.42","203.50","1 through 10","199.41","651.7","other","OPPS APC"
"Cryopreservation Sperm","PX-30000127","CDM","89259","CPT","0300","RC","","","","both","","","686.00","514.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","294.29","42.9","","531.60","531.60","531.60","1 through 10","199.41","651.7","percent of total billed charges",""
"Cryopreservation Sperm","PX-30000127","CDM","89259","CPT","0300","RC","","","","both","","","686.00","514.50","WELLPOINT [1015]","HB AMC WELLPOINT","506.13","73.78","","495.09","495.09","495.09","1 through 10","199.41","651.7","percent of total billed charges",""
"Cryopreservation Sperm","PX-30000127","CDM","89259","CPT","0300","RC","","","","outpatient","","","686.00","514.50","AETNA [1001]","HB AMC AETNA HMO","478.83","69.8","","450.21","450.21","450.21","1 through 10","163.21","887.19","percent of total billed charges",""
"Cryopreservation Sperm","PX-30000127","CDM","89259","CPT","0300","RC","","","","outpatient","","","686.00","514.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","560.60","81.72","","531.60","531.60","531.60","21","163.21","887.19","percent of total billed charges",""
"CRYOPROBE FLEXIBLE 1.1X1150MM BX/5EA","SUP-ITM-10285632","CDM","C2618","HCPCS","0272","RC","","","","both","","","1638.70","1229.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","627.62","38.3","","1876.80","640.73","1876.80","1 through 10","508","1302.77","percent of total billed charges",""
"CRYOPROBE FLEXIBLE 1.1X1150MM BX/5EA","SUP-ITM-10285632","CDM","C2618","HCPCS","0272","RC","","","","both","","","1638.70","1229.02","WELLPOINT [1015]","HB AMC WELLPOINT","1209.03","73.78","","2802.54","1220.01","4020.30","1 through 10","508","1302.77","percent of total billed charges",""
"CRYOPROBE FLEXIBLE 1.1X1150MM BX/5EA","SUP-ITM-10285632","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","1638.70","1229.02","AETNA [1001]","HB AMC AETNA HMO","1143.81","69.8","","2175.20","2175.20","2175.20","1 through 10","856.38","1339.15","percent of total billed charges",""
"CRYOPROBE FLEXIBLE 1.1X1150MM BX/5EA","SUP-ITM-10285632","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","1638.70","1229.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1339.15","81.72","","4750.00","720.54","7250.00","11","856.38","1339.15","percent of total billed charges",""
"Cryosurgical Ablation of the Prostate","PX-76002267","CDM","55899","CPT","0761","RC","","","","both","","","6097.00","4572.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2225.41","36.5","","16414.61","16414.61","16414.61","1 through 10","274.39","4847.12","percent of total billed charges",""
"Cryosurgical Ablation of the Prostate","PX-76002267","CDM","55899","CPT","0761","RC","","","","outpatient","","","6097.00","4572.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3691.73","60.55","","24192.00","270.73","32118.00","1 through 10","700.33","5030.03","percent of total billed charges",""
"Cryosurgical Ablation of the Prostate","PX-76002267","CDM","55899","CPT","0761","RC","","","","outpatient","","","6097.00","4572.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3183.85","52.22","","24192.00","613.44","32118.00","1 through 10","700.33","5030.03","percent of total billed charges",""
"Cryosurgical Ablation of the Prostate","PX-76002267","CDM","55899","CPT","0761","RC","","","","outpatient","","","6097.00","4572.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3048.50","50","","18860.73","18860.73","18860.73","1 through 10","700.33","5030.03","percent of total billed charges",""
"Cryosurgical Ablation of the Prostate","PX-76002267","CDM","55899","CPT","0761","RC","","","","outpatient","","","6097.00","4572.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4982.47","81.72","","28843.15","22507.11","28843.15","1 through 10","700.33","5030.03","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","both","","","115.00","86.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","91.43","79.5","","88.14","88.14","88.14","1 through 10","7.18","109.25","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","both","","","115.00","86.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","61.30","53.3","","264.42","59.14","264.42","1 through 10","7.18","109.25","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.98","36.5","","125.34","41.78","125.34","1 through 10","7.18","109.25","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44.05","38.3","","43.79","43.79","131.37","13","7.18","109.25","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","outpatient","","","115.00","86.25","AETNA [1001]","HB AMC AETNA HMO","80.27","69.8","","75.82","53.54","75.82","1 through 10","7.38","93.98","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","outpatient","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.98","81.72","","89.53","49.25","89.53","1 through 10","7.38","93.98","percent of total billed charges",""
"CSF Neurofilament Heavy Chain Phosphorylated Wu St Louis","PX-30003850","CDM","0443U","CPT","0300","RC","","","","both","","","412.00","309.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","219.60","53.3","","211.20","211.20","211.20","1 through 10","127.72","391.4","percent of total billed charges",""
"CSF Neurofilament Heavy Chain Phosphorylated Wu St Louis","PX-30003850","CDM","0443U","CPT","0300","RC","","","","outpatient","","","412.00","309.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","216.30","52.5","","220.00","220.00","220.00","1 through 10","164.8","339.9","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","358.34","417.32","64","402.91","3485.02","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2969.06","65.6","","436.41","436.41","436.41","1 through 10","402.91","3485.02","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3168.20","70","","3191.83","3160.08","3191.83","1 through 10","402.91","3485.02","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","530.09","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","564.01","564.01","564.01","1 through 10","402.91","3485.02","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","415.64","417.32","1 through 10","402.91","3485.02","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","FALLON HEALTH [1008]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1238.31","424.11","1272.33","1 through 10","402.91","3485.02","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1234.02","1234.02","1234.02","1 through 10","402.91","3485.02","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","3485.02","77","","3379.53","3379.53","3379.53","1 through 10","402.91","3485.02","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","HUMANA [1012]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","422.13","415.97","422.13","1 through 10","402.91","3485.02","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","418.17","418.17","1 through 10","402.91","3485.02","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1272.33","647","402.91","3485.02","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1651.99","36.5","","1637.10","1391.31","4911.30","14","402.91","3485.02","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1733.46","38.3","","1716.10","1667.82","1716.10","29","402.91","3485.02","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","415.63","415.63","418.83","1 through 10","402.91","3485.02","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","MOLINA [1014]","HB BWH MOLINA","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4806.32","841.43","4806.32","1 through 10","402.91","3485.02","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3485.02","77","","3309.31","3309.31","3309.31","1 through 10","402.91","3485.02","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","415.63","1249.20","55","402.91","3485.02","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1420.26","31.38","","1929.84","1929.84","1997.00","1 through 10","402.91","3485.02","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","415.63","411.74","420.63","70","402.91","3485.02","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","4526.00","3394.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1420.26","31.38","","1929.84","1929.84","1929.84","1 through 10","402.91","3485.02","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","4526.00","3394.50","AETNA [1001]","HB AMC AETNA HMO","3159.15","69.8","","2971.35","2971.35","2971.35","1 through 10","385.88","3638.9","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","4526.00","3394.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1617.73","1568.31","1617.73","46","385.88","3638.9","other","Multiple Imaging"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","4526.00","3394.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2365.29","52.26","","2715.91","2715.91","2715.91","1 through 10","385.88","3638.9","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","4526.00","3394.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1617.73","1568.31","1617.73","151","385.88","3638.9","other","Multiple Imaging"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","4526.00","3394.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1153.78","1153.78","1153.78","1 through 10","385.88","3638.9","other","Multiple Radiology"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","4526.00","3394.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1049.59","3148.77","51","385.88","3638.9","other","Multiple Radiology"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","4526.00","3394.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","3299.28","19","385.88","3638.9","other","Multiple Radiology"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","4526.00","3394.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1311.99","1311.99","1311.99","1 through 10","385.88","3638.9","other","Multiple Radiology"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","4526.00","3394.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1153.78","1153.78","1311.99","1 through 10","385.88","3638.9","other","Multiple Radiology"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","4526.00","3394.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3638.90","80.4","","2194.50","2194.50","2194.50","1 through 10","385.88","3638.9","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","4526.00","3394.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1420.26","31.38","","1347.42","1347.42","1929.84","1 through 10","385.88","3638.9","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","4526.00","3394.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1420.26","31.38","","13.64","13.64","1347.42","121","385.88","3638.9","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","31","272.7","1359.05","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1267.27","71.8","","1229.22","208.65","1229.22","1 through 10","272.7","1359.05","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1157.84","65.6","","299.18","299.18","299.18","1 through 10","272.7","1359.05","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1147.25","65","","1112.80","1112.80","1112.80","1 through 10","272.7","1359.05","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1235.50","70","","1232.64","282.47","1712.00","1 through 10","272.7","1359.05","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","358.78","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","113.36","113.36","113.36","1 through 10","272.7","1359.05","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","241.72","282.47","13","272.7","1359.05","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","ELDER SERVICES [1037]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.09","262.09","262.09","1 through 10","272.7","1359.05","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","FALLON HEALTH [1008]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","1359.05","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.04","283.04","283.04","1 through 10","272.7","1359.05","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1147.25","65","","1112.80","1112.80","1112.80","1 through 10","272.7","1359.05","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","179","272.7","1359.05","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","644.23","36.5","","638.58","542.70","638.58","17","272.7","1359.05","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","676.00","38.3","","669.39","650.56","669.39","45","272.7","1359.05","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.52","262.09","843.96","12","272.7","1359.05","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","MOLINA [1014]","HB BWH MOLINA","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","569.53","569.53","569.53","1 through 10","272.7","1359.05","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1984.71","1712.00","1984.71","1 through 10","272.7","1359.05","other","Tricare OPPS"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.12","281.32","852.36","28","272.7","1359.05","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.52","267.10","286.32","39","272.7","1359.05","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1765.00","1323.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","553.86","31.38","","752.77","752.77","752.77","1 through 10","272.7","1359.05","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1765.00","1323.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","1159.02","1159.02","1159.02","1 through 10","230.56","1257.41","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1765.00","1323.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","966.58","937.05","966.58","42","230.56","1257.41","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1765.00","1323.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","966.58","937.05","966.58","92","230.56","1257.41","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1765.00","1323.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","783.90","783.90","783.90","1 through 10","230.56","1257.41","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1765.00","1323.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","601.76","627.12","28","230.56","1257.41","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1765.00","1323.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","11","230.56","1257.41","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1765.00","1323.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","783.90","783.90","783.90","1 through 10","230.56","1257.41","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1765.00","1323.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","230.56","1257.41","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1765.00","1323.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","689.37","664.01","689.37","1 through 10","230.56","1257.41","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1765.00","1323.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","856.00","856.00","856.00","1 through 10","230.56","1257.41","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1765.00","1323.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","553.86","31.38","","752.77","752.77","752.77","1 through 10","230.56","1257.41","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1765.00","1323.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","553.86","31.38","","525.58","525.58","752.77","17","230.56","1257.41","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","508.46","54","402.91","2770.46","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","530.09","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","424.11","424.11","424.11","1 through 10","402.91","2770.46","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","402.91","2770.46","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","FALLON HEALTH [1008]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1261.89","1261.89","1261.89","1 through 10","402.91","2770.46","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","276","402.91","2770.46","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1313.27","36.5","","1301.40","1106.01","1301.40","11","402.91","2770.46","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1378.03","38.3","","1364.20","1325.82","1364.20","39","402.91","2770.46","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.63","414.34","418.83","16","402.91","2770.46","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","MOLINA [1014]","HB BWH MOLINA","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","841.43","841.43","841.43","1 through 10","402.91","2770.46","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","402.91","2770.46","other","Tricare OPPS"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","415.63","1255.29","30","402.91","2770.46","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","802.47","802.47","802.47","1 through 10","402.91","2770.46","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1129.05","31.38","","1534.11","1534.11","1534.11","1 through 10","402.91","2770.46","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3598.00","2698.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.33","415.63","420.63","69","402.91","2770.46","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3598.00","2698.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2362.05","2362.05","2362.05","1 through 10","385.88","1983.91","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3598.00","2698.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1880.31","52.26","","1617.73","1617.73","1617.73","1 through 10","385.88","1983.91","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3598.00","2698.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1311.99","1311.99","1311.99","1 through 10","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3598.00","2698.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1049.59","2099.18","32","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3598.00","2698.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","11","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3598.00","2698.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1311.99","1311.99","1311.99","1 through 10","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3598.00","2698.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1153.78","1045.18","1153.78","14","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3598.00","2698.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1129.05","31.38","","1071.12","1071.12","1107.04","14","385.88","1983.91","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3598.00","2698.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1111.33","1111.33","1111.33","1 through 10","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","481.98","413.01","508.46","211","402.91","2186.8","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1988.00","70","","2129.60","1391.02","2203.20","1 through 10","402.91","2186.8","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","530.09","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","417.93","282.16","417.93","1 through 10","402.91","2186.8","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","413.01","417.32","19","402.91","2186.8","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","FALLON HEALTH [1008]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1264.89","424.11","1272.33","1 through 10","402.91","2186.8","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","2186.80","77","","2120.58","2049.74","2120.58","1 through 10","402.91","2186.8","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","HUMANA [1012]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","415.63","423.87","1 through 10","402.91","2186.8","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1846.00","65","","1790.10","1781.00","1790.10","1 through 10","402.91","2186.8","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","418.17","418.17","1 through 10","402.91","2186.8","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","731","402.91","2186.8","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","880.40","31","","850.99","850.99","2552.97","1 through 10","402.91","2186.8","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1036.60","36.5","","1027.24","873.02","1027.24","107","402.91","2186.8","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1087.72","38.3","","1076.81","1046.52","1076.81","235","402.91","2186.8","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.83","414.34","418.83","34","402.91","2186.8","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2186.80","77","","2148.12","545.65","2148.12","1 through 10","402.91","2186.8","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","TRICARE [160005]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","402.90","402.90","2754.00","1 through 10","402.91","2186.8","other","Tricare OPPS"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","419.73","419.73","419.73","1 through 10","402.91","2186.8","other","Tricare OPPS"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","415.63","1251.96","51","402.91","2186.8","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","633.42","633.42","633.42","1 through 10","402.91","2186.8","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","891.19","31.38","","1210.93","845.48","2201.55","1 through 10","402.91","2186.8","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.34","415.63","420.63","222","402.91","2186.8","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2840.00","2130.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","891.19","31.38","","1210.93","1169.68","1210.93","1 through 10","402.91","2186.8","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","1864.46","1316.41","2258.28","25","385.88","1983.91","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","AETNA [1001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","1864.46","1057.31","2148.12","1 through 10","385.88","1983.91","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1484.18","52.26","","852.09","852.09","1617.73","1 through 10","385.88","1983.91","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1311.99","1153.78","1311.99","11","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1049.59","2099.18","252","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","3299.28","97","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1311.99","1261.83","1311.99","11","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","1 through 10","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1153.78","1009.38","1153.78","42","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","891.19","31.38","","2050.01","845.48","2201.55","1 through 10","385.88","1983.91","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1019.57","1019.57","1019.57","1 through 10","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","891.19","31.38","","1210.93","845.48","1210.93","1 through 10","385.88","1983.91","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","891.19","31.38","","845.48","845.48","1210.93","143","385.88","1983.91","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1261.83","1261.83","1261.83","1 through 10","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2840.00","2130.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1111.33","1111.33","1111.33","1 through 10","385.88","1983.91","other","Multiple Radiology"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3246.00","2434.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","197.32","208.03","1 through 10","200.84","2499.42","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3246.00","2434.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2272.20","70","","2266.56","2266.56","2266.56","1 through 10","200.84","2499.42","percent of total billed charges",""
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3246.00","2434.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","2499.42","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3246.00","2434.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.87","208.87","208.87","1 through 10","200.84","2499.42","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3246.00","2434.50","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","211.41","48","200.84","2499.42","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3246.00","2434.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1184.79","36.5","","1174.20","1139.58","1174.20","1 through 10","200.84","2499.42","percent of total billed charges",""
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3246.00","2434.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1243.22","38.3","","1230.87","1230.87","1230.87","1 through 10","200.84","2499.42","percent of total billed charges",""
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3246.00","2434.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.18","207.18","210.18","1 through 10","200.84","2499.42","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3246.00","2434.50","MOLINA [1014]","HB BWH MOLINA","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","419.44","419.44","419.44","1 through 10","200.84","2499.42","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3246.00","2434.50","TRICARE [160005]","HB BWH TRICARE","200.84","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","200.84","200.84","200.84","1 through 10","200.84","2499.42","other","Tricare OPPS"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3246.00","2434.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","211.41","200.53","629.04","1 through 10","200.84","2499.42","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3246.00","2434.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.18","196.52","211.41","1 through 10","200.84","2499.42","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3246.00","2434.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2131.20","2131.20","2131.20","1 through 10","201.74","1696.36","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3246.00","2434.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","819.91","845.75","1 through 10","201.74","1696.36","other","Multiple Imaging"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3246.00","2434.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","819.91","819.91","845.75","21","201.74","1696.36","other","Multiple Imaging"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3246.00","2434.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","548.73","548.73","1 through 10","201.74","1696.36","other","Multiple Radiology"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3246.00","2434.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","1696.36","other","Multiple Radiology"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","3013.00","2259.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","508.46","1 through 10","200.84","2320.01","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","3013.00","2259.75","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","33","200.84","2320.01","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","3013.00","2259.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1099.75","36.5","","1057.76","1057.76","1057.76","1 through 10","200.84","2320.01","percent of total billed charges",""
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","3013.00","2259.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1153.98","38.3","","1142.50","1110.36","1142.50","1 through 10","200.84","2320.01","percent of total billed charges",""
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","3013.00","2259.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.18","210.18","210.18","1 through 10","200.84","2320.01","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","3013.00","2259.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","209.98","209.98","209.98","1 through 10","200.84","2320.01","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","3013.00","2259.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","945.48","31.38","","1284.80","897.05","1284.80","1 through 10","200.84","2320.01","percent of total billed charges",""
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","3013.00","2259.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","211.41","207.18","211.41","1 through 10","200.84","2320.01","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","3013.00","2259.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","819.91","409.96","845.75","1 through 10","201.74","1574.59","other","Multiple Imaging"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","3013.00","2259.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","819.91","845.75","21","201.74","1574.59","other","Multiple Imaging"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","3013.00","2259.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","274.37","548.73","1 through 10","201.74","1574.59","other","Multiple Radiology"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","3013.00","2259.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","1574.59","other","Multiple Radiology"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","3013.00","2259.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","945.48","31.38","","897.05","897.05","1284.80","1 through 10","201.74","1574.59","percent of total billed charges",""
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","2193.00","1644.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","1688.61","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","2193.00","1644.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","378.87","24","119.97","1688.61","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","2193.00","1644.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","800.45","36.5","","674.26","674.26","674.26","1 through 10","119.97","1688.61","percent of total billed charges",""
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","2193.00","1644.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","839.92","38.3","","831.66","808.26","1527.19","1 through 10","119.97","1688.61","percent of total billed charges",""
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","2193.00","1644.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","118.07","126.29","1 through 10","119.97","1688.61","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","2193.00","1644.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.76","126.29","1 through 10","119.97","1688.61","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","2193.00","1644.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","471.67","457.26","471.67","1 through 10","112.51","1146.06","other","Multiple Imaging"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","2193.00","1644.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.26","457.26","471.67","13","112.51","1146.06","other","Multiple Imaging"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","2193.00","1644.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","153.01","306.03","1 through 10","112.51","1146.06","other","Multiple Radiology"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","2193.00","1644.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","308.28","160.32","320.65","1 through 10","112.51","1146.06","other","Multiple Radiology"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","2193.00","1644.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","688.16","31.38","","652.99","652.99","652.99","1 through 10","112.51","1146.06","percent of total billed charges",""
"CT Abdomen WO/Cont Ltd (52)","PX-35000097","CDM","74150","CPT","0350","RC","","","","both","","","2065.00","1548.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","1590.05","other","OPPS APC"
"CT Abdomen WO/Cont Ltd (52)","PX-35000097","CDM","74150","CPT","0350","RC","","","","both","","","2065.00","1548.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","378.87","24","119.97","1590.05","other","OPPS APC"
"CT Abdomen WO/Cont Ltd (52)","PX-35000097","CDM","74150","CPT","0350","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","753.73","36.5","","674.26","674.26","674.26","1 through 10","119.97","1590.05","percent of total billed charges",""
"CT Abdomen WO/Cont Ltd (52)","PX-35000097","CDM","74150","CPT","0350","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","790.90","38.3","","831.66","808.26","1527.19","1 through 10","119.97","1590.05","percent of total billed charges",""
"CT Abdomen WO/Cont Ltd (52)","PX-35000097","CDM","74150","CPT","0350","RC","","","","both","","","2065.00","1548.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","118.07","126.29","1 through 10","119.97","1590.05","other","OPPS APC"
"CT Abdomen WO/Cont Ltd (52)","PX-35000097","CDM","74150","CPT","0350","RC","","","","both","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.76","126.29","1 through 10","119.97","1590.05","other","OPPS APC"
"CT Abdomen WO/Cont Ltd (52)","PX-35000097","CDM","74150","CPT","0350","RC","","","","outpatient","","","2065.00","1548.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","471.67","457.26","471.67","1 through 10","112.51","1079.17","other","Multiple Imaging"
"CT Abdomen WO/Cont Ltd (52)","PX-35000097","CDM","74150","CPT","0350","RC","","","","outpatient","","","2065.00","1548.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.26","457.26","471.67","13","112.51","1079.17","other","Multiple Imaging"
"CT Abdomen WO/Cont Ltd (52)","PX-35000097","CDM","74150","CPT","0350","RC","","","","outpatient","","","2065.00","1548.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","153.01","306.03","1 through 10","112.51","1079.17","other","Multiple Radiology"
"CT Abdomen WO/Cont Ltd (52)","PX-35000097","CDM","74150","CPT","0350","RC","","","","outpatient","","","2065.00","1548.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","308.28","160.32","320.65","1 through 10","112.51","1079.17","other","Multiple Radiology"
"CT Abdomen WO/Cont Ltd (52)","PX-35000097","CDM","74150","CPT","0350","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","648.00","31.38","","652.99","652.99","652.99","1 through 10","112.51","1079.17","percent of total billed charges",""
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","197.32","417.32","50","402.91","2730.42","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2326.18","65.6","","415.63","415.63","415.63","1 through 10","402.91","2730.42","percent of total billed charges",""
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","CHAMPVA [160001]","HB BWH TRICARE","402.91","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","200.53","200.53","200.53","1 through 10","402.91","2730.42","other","Tricare OPPS"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","196.52","417.32","11","402.91","2730.42","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","FALLON HEALTH [1008]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1264.89","421.63","1272.33","1 through 10","402.91","2730.42","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","2730.42","77","","2648.03","2648.03","2648.03","1 through 10","402.91","2730.42","percent of total billed charges",""
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","HUMANA [1012]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.02","418.17","419.02","1 through 10","402.91","2730.42","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2304.90","65","","2235.35","2235.35","2235.35","1 through 10","402.91","2730.42","percent of total billed charges",""
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","418.17","418.17","1 through 10","402.91","2730.42","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","484","402.91","2730.42","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1294.29","36.5","","1282.75","1090.16","1282.75","36","402.91","2730.42","percent of total billed charges",""
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1358.12","38.3","","1344.65","1306.82","3920.46","99","402.91","2730.42","percent of total billed charges",""
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.83","199.72","1256.49","17","402.91","2730.42","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2730.42","77","","2682.42","2682.42","2682.42","1 through 10","402.91","2730.42","percent of total billed charges",""
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","TRICARE [160005]","HB BWH TRICARE","402.91","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","402.91","2730.42","other","Tricare OPPS"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","415.63","1255.29","35","402.91","2730.42","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1112.73","31.38","","1512.13","1055.77","1512.13","1 through 10","402.91","2730.42","percent of total billed charges",""
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","200.53","420.63","72","402.91","2730.42","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1112.73","31.38","","1512.13","1512.13","1512.13","1 through 10","402.91","2730.42","percent of total billed charges",""
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","both","","","3546.00","2659.50","WELLSENSE NH [1050]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.02","417.32","419.02","1 through 10","402.91","2730.42","other","OPPS APC"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2328.20","1643.84","2328.20","1 through 10","201.74","1853.14","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","819.91","845.75","108","201.74","1853.14","other","Multiple Imaging"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","819.91","845.75","338","201.74","1853.14","other","Multiple Imaging"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","659.69","342.96","685.92","1 through 10","201.74","1853.14","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","548.73","548.73","81","201.74","1853.14","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","552.77","2211.08","39","201.74","1853.14","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","905.81","905.81","905.81","1 through 10","201.74","1853.14","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","685.92","685.92","905.81","1 through 10","201.74","1853.14","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","1853.14","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","603.20","540.41","603.20","30","201.74","1853.14","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","2682.42","2682.42","2682.42","1 through 10","201.74","1853.14","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1112.73","31.38","","1324.00","1055.77","1324.00","1 through 10","201.74","1853.14","percent of total billed charges",""
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1055.77","1055.77","1055.77","1 through 10","201.74","1853.14","other","Multiple Radiology"
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1112.73","31.38","","548.73","548.73","548.73","1 through 10","201.74","1853.14","percent of total billed charges",""
"CT Angio Hrt W/3d Image","PX-35000082","CDM","75574","CPT","0352","RC","","","","outpatient","","","3546.00","2659.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1112.73","31.38","","1055.77","1055.77","1512.13","37","201.74","1853.14","percent of total billed charges",""
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","both","","","2789.00","2091.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","402.91","2147.53","other","OPPS APC"
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","both","","","2789.00","2091.75","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","489.82","516.73","20","402.91","2147.53","other","OPPS APC"
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","both","","","2789.00","2091.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1017.99","36.5","","2572.47","857.49","2572.47","1 through 10","402.91","2147.53","percent of total billed charges",""
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","both","","","2789.00","2091.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1068.19","38.3","","1057.66","1057.66","1057.66","1 through 10","402.91","2147.53","percent of total billed charges",""
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","both","","","2789.00","2091.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","511.40","511.40","511.40","1 through 10","402.91","2147.53","other","OPPS APC"
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","outpatient","","","2789.00","2091.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","808.87","784.16","1617.73","1 through 10","385.88","1617.73","other","Multiple Imaging"
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","outpatient","","","2789.00","2091.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","784.16","784.16","808.87","1 through 10","385.88","1617.73","other","Multiple Imaging"
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","outpatient","","","2789.00","2091.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1049.59","2014.30","1 through 10","385.88","1617.73","other","Multiple Radiology"
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","outpatient","","","2789.00","2091.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","875.19","31.38","","2162.38","2162.38","2162.38","1 through 10","385.88","1617.73","percent of total billed charges",""
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","2292.00","1719.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","124.27","262.40","14","119.97","1764.84","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","2292.00","1719.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","103.07","262.40","1 through 10","119.97","1764.84","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","2292.00","1719.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1764.84","77","","1711.71","1711.71","1711.71","1 through 10","119.97","1764.84","percent of total billed charges",""
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","2292.00","1719.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","378.87","81","119.97","1764.84","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","2292.00","1719.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","710.52","31","","686.91","686.91","686.91","1 through 10","119.97","1764.84","percent of total billed charges",""
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","2292.00","1719.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","836.58","36.5","","829.18","704.69","829.18","1 through 10","119.97","1764.84","percent of total billed charges",""
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","2292.00","1719.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","877.84","38.3","","869.19","869.19","2607.57","13","119.97","1764.84","percent of total billed charges",""
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","2292.00","1719.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","119.97","1764.84","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","2292.00","1719.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","261.34","1 through 10","119.97","1764.84","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","2292.00","1719.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","511.29","511.29","511.29","1 through 10","119.97","1764.84","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","2292.00","1719.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.17","118.08","253.73","14","119.97","1764.84","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","2292.00","1719.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.26","228.63","471.67","14","112.51","1197.8","other","Multiple Imaging"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","2292.00","1719.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.26","228.63","471.67","35","112.51","1197.8","other","Multiple Imaging"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","2292.00","1719.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","1 through 10","112.51","1197.8","other","Multiple Radiology"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","2292.00","1719.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","308.28","336.40","1 through 10","112.51","1197.8","other","Multiple Radiology"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","2292.00","1719.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","719.23","31.38","","682.46","682.46","977.45","1 through 10","112.51","1197.8","percent of total billed charges",""
"CT Cerebral Perfusion Analysis","PX-35000029","CDM","0042T","CPT","0351","RC","","","","both","","","11196.00","8397.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4086.54","36.5","","4049.66","4049.66","4049.66","1 through 10","3470.76","10636.2","percent of total billed charges",""
"CT Cerebral Perfusion Analysis","PX-35000029","CDM","0042T","CPT","0351","RC","","","","both","","","11196.00","8397.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4288.07","38.3","","4245.09","4245.09","4245.09","1 through 10","3470.76","10636.2","percent of total billed charges",""
"CT Cerebral Perfusion Analysis","PX-35000029","CDM","0042T","CPT","0351","RC","","","","both","","","11196.00","8397.00","WELLPOINT [1015]","HB AMC WELLPOINT","8260.41","73.78","","10857.00","10857.00","10857.00","1 through 10","3470.76","10636.2","percent of total billed charges",""
"CT Cerebral Perfusion Analysis","PX-35000029","CDM","0042T","CPT","0351","RC","","","","outpatient","","","11196.00","8397.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3513.30","31.38","","3333.10","3333.10","3333.10","1 through 10","3513.3","9001.58","percent of total billed charges",""
"CT Cervical Spine W&W/O Contrast","PX-35000036","CDM","72127","CPT","0352","RC","","","","both","","","3358.00","2518.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","508.46","508.46","1 through 10","200.84","2585.66","other","OPPS APC"
"CT Colonography Screen Postprocess","PX-35000003","CDM","74263","CPT","0350","RC","","","","both","","","4480.00","3360.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","3449.6","other","OPPS APC"
"CT Colonography Screen Postprocess","PX-35000003","CDM","74263","CPT","0350","RC","","","","both","","","4480.00","3360.00","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","3449.6","other","OPPS APC"
"CT Colonography Screen Postprocess","PX-35000003","CDM","74263","CPT","0350","RC","","","","both","","","4480.00","3360.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","281.32","281.32","1 through 10","272.7","3449.6","other","OPPS APC"
"CT Colonography W/ Cntrst","PX-35000002","CDM","74262","CPT","0350","RC","","","","both","","","5789.00","4341.75","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","211.41","1 through 10","200.84","4457.53","other","OPPS APC"
"CT Colonography W/ Cntrst","PX-35000002","CDM","74262","CPT","0350","RC","","","","outpatient","","","5789.00","4341.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","845.75","845.75","1 through 10","201.74","3025.33","other","Multiple Imaging"
"CT Colonography W/ Cntrst","PX-35000002","CDM","74262","CPT","0350","RC","","","","outpatient","","","5789.00","4341.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","819.91","819.91","819.91","1 through 10","201.74","3025.33","other","Multiple Imaging"
"CT Colonography W/O Cntrst","PX-35000001","CDM","74261","CPT","0350","RC","","","","both","","","5166.00","3874.50","MEDICARE [2001]","HB BWH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","108.88","3977.82","other","OPPS APC"
"CT Guidance &Monitoring Visc Tiss Ablation","PX-35000085","CDM","77013","CPT","0320","RC","","","","both","","","1268.00","951.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1008.06","79.5","","968.01","968.01","968.01","1 through 10","393.08","1008.06","percent of total billed charges",""
"CT Guidance &Monitoring Visc Tiss Ablation","PX-35000085","CDM","77013","CPT","0320","RC","","","","both","","","1268.00","951.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","675.84","53.3","","649.44","649.44","649.44","1 through 10","393.08","1008.06","percent of total billed charges",""
"CT Guidance &Monitoring Visc Tiss Ablation","PX-35000085","CDM","77013","CPT","0320","RC","","","","both","","","1268.00","951.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","462.82","36.5","","458.79","458.79","458.79","1 through 10","393.08","1008.06","percent of total billed charges",""
"CT Guidance &Monitoring Visc Tiss Ablation","PX-35000085","CDM","77013","CPT","0320","RC","","","","outpatient","","","1268.00","951.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1036.21","81.72","","983.26","983.26","983.26","1 through 10","662.66","1036.21","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","both","","","1826.00","1369.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","566.06","1451.67","other","OPPS APC"
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","both","","","1826.00","1369.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","566.06","1451.67","other","OPPS APC"
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","both","","","1826.00","1369.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1451.67","79.5","","2814.50","2346.50","2814.50","1 through 10","566.06","1451.67","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","both","","","1826.00","1369.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","566.06","1451.67","other","OPPS APC"
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","both","","","1826.00","1369.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","566.06","1451.67","other","OPPS APC"
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","both","","","1826.00","1369.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","666.49","36.5","","2677.58","1482.13","2910.89","1 through 10","566.06","1451.67","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","both","","","1826.00","1369.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","699.36","38.3","","2723.31","1555.62","2741.61","12","566.06","1451.67","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","both","","","1826.00","1369.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","566.06","1451.67","other","OPPS APC"
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","both","","","1826.00","1369.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","566.06","1451.67","other","OPPS APC"
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","both","","","1826.00","1369.50","WELLPOINT [1015]","HB AMC WELLPOINT","1347.22","73.78","","2687.65","2687.64","3224.43","1 through 10","566.06","1451.67","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","outpatient","","","1826.00","1369.50","AETNA [1001]","HB AMC AETNA PPO","1468.10","80.4","","1163.76","1163.76","1163.76","1 through 10","913","2384.07","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","outpatient","","","1826.00","1369.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1105.64","60.55","","1781.82","1492.00","4331.00","1 through 10","913","2384.07","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","outpatient","","","1826.00","1369.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","953.54","52.22","","3144.00","1492.00","3610.00","13","913","2384.07","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","outpatient","","","1826.00","1369.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","958.65","52.5","","1182.28","1182.28","1182.28","1 through 10","913","2384.07","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","outpatient","","","1826.00","1369.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","913.00","50","","3610.00","2269.44","3610.00","1 through 10","913","2384.07","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","outpatient","","","1826.00","1369.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","958.65","52.5","","3610.00","2382.05","4331.00","1 through 10","913","2384.07","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","outpatient","","","1826.00","1369.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1004.30","55","","4810.75","3363.17","4810.75","1 through 10","913","2384.07","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","outpatient","","","1826.00","1369.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1492.21","81.72","","8894.69","8894.69","8894.69","1 through 10","913","2384.07","percent of total billed charges",""
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","outpatient","","","1826.00","1369.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1492.21","81.72","","2885.83","2132.00","3462.21","1 through 10","913","2384.07","percent of total billed charges",""
"CT Guided Cecostomy Tube Exchange","PX-76003027","CDM","45399","CPT","0761","RC","","","","both","","","1775.00","1331.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","647.88","36.5","","2892.24","2892.24","2892.24","1 through 10","550.25","1411.13","percent of total billed charges",""
"CT Guided Cecostomy Tube Exchange","PX-76003027","CDM","45399","CPT","0761","RC","","","","both","","","1775.00","1331.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","679.83","38.3","","2777.42","2083.54","2946.52","1 through 10","550.25","1411.13","percent of total billed charges",""
"CT Guided Cecostomy Tube Exchange","PX-76003027","CDM","45399","CPT","0761","RC","","","","both","","","1775.00","1331.25","TRICARE [160005]","HB BWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","1028.57","1028.57","1 through 10","550.25","1411.13","other","Tricare OPPS"
"CT Guided Cecostomy Tube Exchange","PX-76003027","CDM","45399","CPT","0761","RC","","","","both","","","1775.00","1331.25","WELLPOINT [1015]","HB AMC WELLPOINT","1309.60","73.78","","5772.85","5772.85","7754.00","1 through 10","550.25","1411.13","percent of total billed charges",""
"CT Guided Cecostomy Tube Exchange","PX-76003027","CDM","45399","CPT","0761","RC","","","","outpatient","","","1775.00","1331.25","AETNA [1001]","HB AMC AETNA HMO","1238.95","69.8","","5249.46","3706.41","5249.46","1 through 10","887.5","2384.07","percent of total billed charges",""
"CT Guided Cecostomy Tube Exchange","PX-76003027","CDM","45399","CPT","0761","RC","","","","outpatient","","","1775.00","1331.25","AETNA [1001]","HB AMC AETNA PPO","1427.10","80.4","","6048.12","6048.12","6048.12","1 through 10","887.5","2384.07","percent of total billed charges",""
"CT Guided Cecostomy Tube Exchange","PX-76003027","CDM","45399","CPT","0761","RC","","","","outpatient","","","1775.00","1331.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1074.76","60.55","","1533.28","1533.28","7754.00","1 through 10","887.5","2384.07","percent of total billed charges",""
"CT Guided Cecostomy Tube Exchange","PX-76003027","CDM","45399","CPT","0761","RC","","","","outpatient","","","1775.00","1331.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","926.91","52.22","","1974.52","1533.28","7754.00","21","887.5","2384.07","percent of total billed charges",""
"CT Guided Cecostomy Tube Exchange","PX-76003027","CDM","45399","CPT","0761","RC","","","","outpatient","","","1775.00","1331.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","931.88","52.5","","4063.09","4063.09","4063.09","1 through 10","887.5","2384.07","percent of total billed charges",""
"CT Guided Cecostomy Tube Exchange","PX-76003027","CDM","45399","CPT","0761","RC","","","","outpatient","","","1775.00","1331.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1450.53","81.72","","6198.55","6198.55","7754.00","1 through 10","887.5","2384.07","percent of total billed charges",""
"CT Guided Cecostomy Tube Exchange","PX-76003027","CDM","45399","CPT","0761","RC","","","","outpatient","","","1775.00","1331.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1109.38","62.5","","4691.17","4691.17","4691.17","1 through 10","887.5","2384.07","percent of total billed charges",""
"CT Guided Cecostomy Tube Placement","PX-76003018","CDM","45399","CPT","0761","RC","","","","both","","","4945.00","3708.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1804.93","36.5","","2892.24","2892.24","2892.24","1 through 10","1028.57","3931.28","percent of total billed charges",""
"CT Guided Cecostomy Tube Placement","PX-76003018","CDM","45399","CPT","0761","RC","","","","both","","","4945.00","3708.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1893.94","38.3","","2777.42","2083.54","2946.52","1 through 10","1028.57","3931.28","percent of total billed charges",""
"CT Guided Cecostomy Tube Placement","PX-76003018","CDM","45399","CPT","0761","RC","","","","both","","","4945.00","3708.75","TRICARE [160005]","HB BWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","1028.57","1028.57","1 through 10","1028.57","3931.28","other","Tricare OPPS"
"CT Guided Cecostomy Tube Placement","PX-76003018","CDM","45399","CPT","0761","RC","","","","both","","","4945.00","3708.75","WELLPOINT [1015]","HB AMC WELLPOINT","3648.42","73.78","","5772.85","5772.85","7754.00","1 through 10","1028.57","3931.28","percent of total billed charges",""
"CT Guided Cecostomy Tube Placement","PX-76003018","CDM","45399","CPT","0761","RC","","","","outpatient","","","4945.00","3708.75","AETNA [1001]","HB AMC AETNA HMO","3451.61","69.8","","5249.46","3706.41","5249.46","1 through 10","2384.07","4079.63","percent of total billed charges",""
"CT Guided Cecostomy Tube Placement","PX-76003018","CDM","45399","CPT","0761","RC","","","","outpatient","","","4945.00","3708.75","AETNA [1001]","HB AMC AETNA PPO","3975.78","80.4","","6048.12","6048.12","6048.12","1 through 10","2384.07","4079.63","percent of total billed charges",""
"CT Guided Cecostomy Tube Placement","PX-76003018","CDM","45399","CPT","0761","RC","","","","outpatient","","","4945.00","3708.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2994.20","60.55","","1533.28","1533.28","7754.00","1 through 10","2384.07","4079.63","percent of total billed charges",""
"CT Guided Cecostomy Tube Placement","PX-76003018","CDM","45399","CPT","0761","RC","","","","outpatient","","","4945.00","3708.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2582.28","52.22","","1974.52","1533.28","7754.00","21","2384.07","4079.63","percent of total billed charges",""
"CT Guided Cecostomy Tube Placement","PX-76003018","CDM","45399","CPT","0761","RC","","","","outpatient","","","4945.00","3708.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2596.13","52.5","","4063.09","4063.09","4063.09","1 through 10","2384.07","4079.63","percent of total billed charges",""
"CT Guided Cecostomy Tube Placement","PX-76003018","CDM","45399","CPT","0761","RC","","","","outpatient","","","4945.00","3708.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4041.05","81.72","","6198.55","6198.55","7754.00","1 through 10","2384.07","4079.63","percent of total billed charges",""
"CT Guided Cecostomy Tube Placement","PX-76003018","CDM","45399","CPT","0761","RC","","","","outpatient","","","4945.00","3708.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","3090.63","62.5","","4691.17","4691.17","4691.17","1 through 10","2384.07","4079.63","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","both","","","1082.00","811.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","703.30","65","","2045.55","681.85","2045.55","1 through 10","335.42","1050.69","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","both","","","1082.00","811.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","757.40","70","","2265.84","705.47","2265.84","1 through 10","335.42","1050.69","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","both","","","1082.00","811.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","703.30","65","","681.85","661.70","681.85","1 through 10","335.42","1050.69","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","both","","","1082.00","811.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","394.93","36.5","","1173.84","997.59","1173.84","1 through 10","335.42","1050.69","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","both","","","1082.00","811.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","414.41","38.3","","410.16","398.62","1230.48","23","335.42","1050.69","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","outpatient","","","1082.00","811.50","AETNA [1001]","HB AMC AETNA HMO","755.24","69.8","","710.17","501.42","710.17","1 through 10","339.53","869.93","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","outpatient","","","1082.00","811.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","565.45","52.26","","649.13","649.13","649.13","1 through 10","339.53","869.93","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","outpatient","","","1082.00","811.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","869.93","80.4","","818.22","818.22","818.22","1 through 10","339.53","869.93","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","outpatient","","","1082.00","811.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","339.53","31.38","","461.25","461.25","461.25","1 through 10","339.53","869.93","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","outpatient","","","1082.00","811.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","339.53","31.38","","322.04","322.04","461.25","14","339.53","869.93","percent of total billed charges",""
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2822.00","2116.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","2172.94","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2822.00","2116.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","2172.94","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2822.00","2116.50","FALLON HEALTH [1008]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","486.02","486.02","486.02","1 through 10","200.84","2172.94","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2822.00","2116.50","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","17","200.84","2172.94","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2822.00","2116.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1080.83","38.3","","1070.17","1070.17","1070.17","1 through 10","200.84","2172.94","percent of total billed charges",""
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2822.00","2116.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.38","210.38","210.38","1 through 10","200.84","2172.94","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2822.00","2116.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","208.03","208.03","1 through 10","200.84","2172.94","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2822.00","2116.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.54","31.38","","840.26","840.26","840.26","1 through 10","200.84","2172.94","percent of total billed charges",""
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2822.00","2116.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","200.53","211.41","1 through 10","200.84","2172.94","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","outpatient","","","2822.00","2116.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","422.88","422.88","422.88","1 through 10","201.74","1474.78","other","Multiple Imaging"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","outpatient","","","2822.00","2116.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","422.88","409.96","845.75","1 through 10","201.74","1474.78","other","Multiple Imaging"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","outpatient","","","2822.00","2116.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","685.92","685.92","685.92","1 through 10","201.74","1474.78","other","Multiple Radiology"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","outpatient","","","2822.00","2116.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","274.37","274.37","274.37","1 through 10","201.74","1474.78","other","Multiple Radiology"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","outpatient","","","2822.00","2116.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","885.54","31.38","","1203.46","840.26","1203.46","1 through 10","201.74","1474.78","percent of total billed charges",""
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","both","","","2367.00","1775.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","201.87","201.87","201.87","1 through 10","200.84","1822.59","other","OPPS APC"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","both","","","2367.00","1775.25","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","211.41","634.23","17","200.84","1822.59","other","OPPS APC"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","both","","","2367.00","1775.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","508.46","207.18","508.46","1 through 10","200.84","1822.59","other","OPPS APC"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","both","","","2367.00","1775.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","211.29","207.18","509.40","1 through 10","200.84","1822.59","other","OPPS APC"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","outpatient","","","2367.00","1775.25","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","1097.01","1097.01","1097.01","1 through 10","201.74","1236.99","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","outpatient","","","2367.00","1775.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","422.88","422.88","845.75","1 through 10","201.74","1236.99","other","Multiple Imaging"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","outpatient","","","2367.00","1775.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1236.99","52.26","","845.75","845.75","845.75","1 through 10","201.74","1236.99","percent of total billed charges",""
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","outpatient","","","2367.00","1775.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","422.87","409.96","845.75","1 through 10","201.74","1236.99","other","Multiple Imaging"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","outpatient","","","2367.00","1775.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","301.60","301.60","301.60","1 through 10","201.74","1236.99","other","Multiple Radiology"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","outpatient","","","2367.00","1775.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","742.76","31.38","","704.57","704.57","704.57","1 through 10","201.74","1236.99","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","71","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1312.50","71.8","","1273.01","1273.01","1273.01","1 through 10","119.97","1407.56","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1279.60","70","","1418.40","1276.56","1773.00","1 through 10","119.97","1407.56","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","103.07","262.40","19","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","ELDER SERVICES [1037]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","FALLON HEALTH [1008]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","378.87","119.99","378.87","1 through 10","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.58","124.52","480.02","1 through 10","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","123.76","124.52","1 through 10","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","378.87","803","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","566.68","31","","547.86","547.86","547.86","1 through 10","119.97","1407.56","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","667.22","36.5","","562.04","562.04","1322.66","17","119.97","1407.56","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","700.12","38.3","","693.24","693.24","693.25","53","119.97","1407.56","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","378.87","15","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","MOLINA [1014]","HB BWH MOLINA","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","520.28","520.28","520.28","1 through 10","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1407.56","77","","1453.86","508.85","1453.86","1 through 10","119.97","1407.56","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","126.29","1 through 10","119.97","1407.56","other","Tricare OPPS"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","1407.56","other","Tricare OPPS"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","371.28","123.76","392.01","85","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","407.79","407.79","407.79","1 through 10","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","573.63","31.38","","779.59","779.59","779.59","1 through 10","119.97","1407.56","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","264.34","155","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","WELLSENSE [1003]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1346.70","1346.70","1346.70","1 through 10","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1828.00","1371.00","WELLSENSE NH [1050]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.77","124.77","124.77","1 through 10","119.97","1407.56","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1828.00","1371.00","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","1200.32","1200.32","1200.32","1 through 10","112.51","955.31","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1828.00","1371.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","471.67","457.26","471.67","74","112.51","955.31","other","Multiple Imaging"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1828.00","1371.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","471.67","235.84","471.67","153","112.51","955.31","other","Multiple Imaging"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1828.00","1371.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","191.27","191.27","191.27","1 through 10","112.51","955.31","other","Multiple Radiology"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1828.00","1371.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","2385.06","72","112.51","955.31","other","Multiple Radiology"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1828.00","1371.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","308.28","646.24","31","112.51","955.31","other","Multiple Radiology"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1828.00","1371.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","382.53","382.53","1 through 10","112.51","955.31","other","Multiple Radiology"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1828.00","1371.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","295.83","168.20","336.40","1 through 10","112.51","955.31","other","Multiple Radiology"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1828.00","1371.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","573.63","31.38","","544.31","544.31","544.31","1 through 10","112.51","955.31","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1828.00","1371.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","573.63","31.38","","779.59","779.59","779.59","1 through 10","112.51","955.31","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1828.00","1371.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","573.63","31.38","","544.31","544.31","779.59","34","112.51","955.31","percent of total billed charges",""
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","1084.00","813.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","1051.00","40","336.04","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","1084.00","813.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","711.10","65.6","","711.53","711.53","711.53","1 through 10","336.04","1052.31","percent of total billed charges",""
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","1084.00","813.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","336.04","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","1084.00","813.00","FALLON HEALTH [1008]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","825.17","825.17","825.17","1 through 10","336.04","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","1084.00","813.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","418.17","418.17","1 through 10","336.04","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","1084.00","813.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","834.68","77","","809.27","809.27","809.27","1 through 10","336.04","1052.31","percent of total billed charges",""
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","1084.00","813.00","HUMANA [1012]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.02","418.26","419.02","1 through 10","336.04","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","1084.00","813.00","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","468","336.04","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","1084.00","813.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","395.66","36.5","","392.02","380.46","392.02","1 through 10","336.04","1052.31","percent of total billed charges",""
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","1084.00","813.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","415.17","38.3","","410.94","410.94","410.94","12","336.04","1052.31","percent of total billed charges",""
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","1084.00","813.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.63","199.52","1255.89","16","336.04","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","1084.00","813.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","200.53","1255.29","26","336.04","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","1084.00","813.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.13","200.32","420.63","58","336.04","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","1084.00","813.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","819.91","845.75","47","201.74","1098.4","other","Multiple Imaging"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","1084.00","813.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","819.91","819.91","845.75","106","201.74","1098.4","other","Multiple Imaging"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","1084.00","813.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","603.20","603.20","603.20","1 through 10","201.74","1098.4","other","Multiple Radiology"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","1084.00","813.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","526.54","548.73","36","201.74","1098.4","other","Multiple Radiology"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","1084.00","813.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","479.22","574.96","13","201.74","1098.4","other","Multiple Radiology"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","1084.00","813.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","905.81","905.81","905.81","1 through 10","201.74","1098.4","other","Multiple Radiology"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","1084.00","813.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","685.92","685.92","685.92","1 through 10","201.74","1098.4","other","Multiple Radiology"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","1084.00","813.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","1098.4","other","Multiple Radiology"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","1084.00","813.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","479.22","453.51","603.20","1 through 10","201.74","1098.4","other","Multiple Radiology"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","1084.00","813.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","525.50","525.50","525.50","1 through 10","201.74","1098.4","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","1084.00","813.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","340.16","31.38","","462.12","462.12","462.12","1 through 10","201.74","1098.4","percent of total billed charges",""
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","1084.00","813.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","340.16","31.38","","322.66","322.66","462.12","21","201.74","1098.4","percent of total billed charges",""
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","1084.00","813.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","581.01","581.01","581.01","1 through 10","201.74","1098.4","other","Multiple Radiology"
"CT Hrt W/3d Image Congen","PX-35000081","CDM","75573","CPT","0352","RC","","","","both","","","1453.00","1089.75","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","402.91","1118.81","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","447.00","335.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","23","76.36","344.19","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","447.00","335.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","312.90","70","","346.40","346.40","346.40","1 through 10","76.36","344.19","percent of total billed charges",""
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","447.00","335.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","76.36","344.19","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","447.00","335.25","MEDICARE [2001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","99.18","99.18","99.18","1 through 10","76.36","344.19","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","447.00","335.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","138.57","31","","264.26","264.26","264.26","1 through 10","76.36","344.19","percent of total billed charges",""
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","447.00","335.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","163.16","36.5","","161.51","137.26","323.02","11","76.36","344.19","percent of total billed charges",""
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","447.00","335.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","171.20","38.3","","169.30","169.30","169.30","92","76.36","344.19","percent of total billed charges",""
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","447.00","335.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","99.18","104.56","1 through 10","76.36","344.19","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","447.00","335.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","102.47","1 through 10","76.36","344.19","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","447.00","335.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.27","31.38","","190.39","190.39","190.39","1 through 10","76.36","344.19","percent of total billed charges",""
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","447.00","335.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","104.56","102.47","104.56","26","76.36","344.19","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","447.00","335.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.27","31.38","","190.39","190.39","190.39","1 through 10","76.36","344.19","percent of total billed charges",""
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","447.00","335.25","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","293.14","293.14","293.14","1 through 10","140.27","399.4","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","447.00","335.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","261.17","","Case rate ($261.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","261.17","253.19","261.17","63","140.27","399.4","other","Multiple Imaging"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","447.00","335.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","261.17","","Case rate ($261.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","261.17","253.19","261.17","166","140.27","399.4","other","Multiple Imaging"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","447.00","335.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","281.45","281.45","281.45","1 through 10","140.27","399.4","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","447.00","335.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","140.27","31.38","","190.39","190.39","190.39","1 through 10","140.27","399.4","percent of total billed charges",""
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","447.00","335.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","140.27","31.38","","132.93","132.93","132.93","17","140.27","399.4","percent of total billed charges",""
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","both","","","2801.00","2100.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","508.46","508.46","1 through 10","402.91","2156.77","other","OPPS APC"
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","both","","","2801.00","2100.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","415.63","415.63","415.63","1 through 10","402.91","2156.77","other","OPPS APC"
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","both","","","2801.00","2100.75","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","419.73","516.73","1 through 10","402.91","2156.77","other","OPPS APC"
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","both","","","2801.00","2100.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.37","36.5","","2582.91","860.97","2582.91","1 through 10","402.91","2156.77","percent of total billed charges",""
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","both","","","2801.00","2100.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.78","38.3","","1061.96","1061.96","1061.96","1 through 10","402.91","2156.77","percent of total billed charges",""
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","both","","","2801.00","2100.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.63","418.63","420.63","1 through 10","402.91","2156.77","other","OPPS APC"
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","outpatient","","","2801.00","2100.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1568.31","1568.31","1617.73","1 through 10","385.88","1617.73","other","Multiple Imaging"
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","outpatient","","","2801.00","2100.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1568.31","1568.31","1617.73","1 through 10","385.88","1617.73","other","Multiple Imaging"
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","outpatient","","","2801.00","2100.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","524.79","524.79","524.79","1 through 10","385.88","1617.73","other","Multiple Radiology"
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","outpatient","","","2801.00","2100.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1153.78","1153.78","1153.78","1 through 10","385.88","1617.73","other","Multiple Radiology"
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","outpatient","","","2801.00","2100.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","878.95","31.38","","1194.23","1194.23","1194.23","1 through 10","385.88","1617.73","percent of total billed charges",""
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","262.40","18","119.97","1754.06","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","125.23","1 through 10","119.97","1754.06","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","FALLON HEALTH [1008]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","516.73","516.73","1 through 10","119.97","1754.06","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","508.46","508.46","1 through 10","119.97","1754.06","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1754.06","77","","1700.93","1700.93","1700.93","1 through 10","119.97","1754.06","percent of total billed charges",""
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","124.52","126.29","1 through 10","119.97","1754.06","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1480.70","65","","1435.85","1435.85","1435.85","1 through 10","119.97","1754.06","percent of total billed charges",""
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","359.97","131","119.97","1754.06","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","831.47","36.5","","823.96","700.25","823.96","1 through 10","119.97","1754.06","percent of total billed charges",""
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","872.47","38.3","","863.72","839.42","863.72","16","119.97","1754.06","percent of total billed charges",""
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","123.76","126.29","1 through 10","119.97","1754.06","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","378.87","21","119.97","1754.06","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.84","31.38","","678.16","678.16","678.16","1 through 10","119.97","1754.06","percent of total billed charges",""
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","2278.00","1708.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","126.29","25","119.97","1754.06","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","2278.00","1708.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","471.67","235.84","471.67","14","112.51","1190.48","other","Multiple Imaging"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","2278.00","1708.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.26","235.84","471.67","45","112.51","1190.48","other","Multiple Imaging"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","2278.00","1708.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","382.53","382.53","382.53","1 through 10","112.51","1190.48","other","Multiple Radiology"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","2278.00","1708.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","153.01","306.03","16","112.51","1190.48","other","Multiple Radiology"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","2278.00","1708.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","1190.48","other","Multiple Radiology"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","2278.00","1708.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","312.49","336.40","1 through 10","112.51","1190.48","other","Multiple Radiology"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","2278.00","1708.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","714.84","31.38","","678.16","678.16","1765.87","1 through 10","112.51","1190.48","percent of total billed charges",""
"CT Lwr Ext W/Contrast","PX-35000064","CDM","73701","CPT","0352","RC","","","","both","","","2730.00","2047.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.19","207.19","210.19","1 through 10","200.84","2102.1","other","OPPS APC"
"CT Lwr Ext W/Contrast Lt","PX-35000063","CDM","73701","CPT","0352","RC","","","","both","","","2592.00","1944.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.19","207.19","210.19","1 through 10","200.84","1995.84","other","OPPS APC"
"CT Lwr Ext W/Contrast Rt","PX-35000062","CDM","73701","CPT","0352","RC","","","","both","","","2592.00","1944.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.19","207.19","210.19","1 through 10","200.84","1995.84","other","OPPS APC"
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","both","","","2263.00","1697.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","432.77","432.77","432.77","1 through 10","119.97","1742.51","other","OPPS APC"
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","both","","","2263.00","1697.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","132.72","30","119.97","1742.51","other","OPPS APC"
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","outpatient","","","2263.00","1697.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","336.40","320.65","336.40","1 through 10","112.51","1182.64","other","Multiple Radiology"
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","outpatient","","","2263.00","1697.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","672.80","336.40","672.80","1 through 10","112.51","1182.64","other","Multiple Radiology"
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","outpatient","","","2263.00","1697.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","710.13","31.38","","2195.00","201.73","2195.00","1 through 10","112.51","1182.64","percent of total billed charges",""
"CT Lwr Ext W/O Contrast Lt","PX-35000060","CDM","73700","CPT","0352","RC","","","","both","","","2135.00","1601.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","432.77","432.77","432.77","1 through 10","119.97","1643.95","other","OPPS APC"
"CT Lwr Ext W/O Contrast Lt","PX-35000060","CDM","73700","CPT","0352","RC","","","","both","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","132.72","30","119.97","1643.95","other","OPPS APC"
"CT Lwr Ext W/O Contrast Lt","PX-35000060","CDM","73700","CPT","0352","RC","","","","outpatient","","","2135.00","1601.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","336.40","320.65","336.40","1 through 10","112.51","1115.75","other","Multiple Radiology"
"CT Lwr Ext W/O Contrast Lt","PX-35000060","CDM","73700","CPT","0352","RC","","","","outpatient","","","2135.00","1601.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","672.80","336.40","672.80","1 through 10","112.51","1115.75","other","Multiple Radiology"
"CT Lwr Ext W/O Contrast Lt","PX-35000060","CDM","73700","CPT","0352","RC","","","","outpatient","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","669.96","31.38","","2195.00","201.73","2195.00","1 through 10","112.51","1115.75","percent of total billed charges",""
"CT Max/Facial W&W/O Contrast","PX-35000023","CDM","70488","CPT","0351","RC","","","","both","","","3516.00","2637.00","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","516.73","516.73","1 through 10","200.84","2707.32","other","OPPS APC"
"CT Max/Facial W&W/O Contrast","PX-35000023","CDM","70488","CPT","0351","RC","","","","both","","","3516.00","2637.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1346.63","38.3","","1333.31","1333.31","1333.31","1 through 10","200.84","2707.32","percent of total billed charges",""
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2933.00","2199.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","2258.41","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2933.00","2199.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2053.10","70","","6143.04","6143.04","6143.04","1 through 10","200.84","2258.41","percent of total billed charges",""
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2933.00","2199.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","508.46","508.46","1 through 10","200.84","2258.41","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2933.00","2199.75","FALLON HEALTH [1008]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2258.41","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2933.00","2199.75","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","939.55","16","200.84","2258.41","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2933.00","2199.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1070.55","36.5","","3088.59","901.55","3088.59","1 through 10","200.84","2258.41","percent of total billed charges",""
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2933.00","2199.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1123.34","38.3","","1112.00","1080.72","1112.00","1 through 10","200.84","2258.41","percent of total billed charges",""
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2933.00","2199.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","506.40","210.18","506.40","1 through 10","200.84","2258.41","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2933.00","2199.75","MOLINA [1014]","HB BWH MOLINA","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1025.19","1025.19","1025.19","1 through 10","200.84","2258.41","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2933.00","2199.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","207.18","506.40","1 through 10","200.84","2258.41","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2933.00","2199.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","845.75","845.75","1 through 10","201.74","1532.79","other","Multiple Imaging"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2933.00","2199.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","819.91","845.75","1 through 10","201.74","1532.79","other","Multiple Imaging"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2933.00","2199.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","274.37","548.73","1 through 10","201.74","1532.79","other","Multiple Radiology"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2933.00","2199.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","1532.79","other","Multiple Radiology"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2933.00","2199.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","603.20","603.20","603.20","1 through 10","201.74","1532.79","other","Multiple Radiology"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2933.00","2199.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","920.38","31.38","","1250.51","1250.51","1250.51","1 through 10","201.74","1532.79","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","262.40","16","119.97","1843.38","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1556.10","65","","578.18","578.18","578.18","1 through 10","119.97","1843.38","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1675.80","70","","1857.60","1671.84","1857.60","1 through 10","119.97","1843.38","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","102.65","124.27","1 through 10","119.97","1843.38","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","119.97","1843.38","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1556.10","65","","1509.30","1509.30","1509.30","1 through 10","119.97","1843.38","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","378.87","123","119.97","1843.38","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","742.14","31","","717.50","717.50","717.50","1 through 10","119.97","1843.38","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","873.81","36.5","","2598.33","866.11","2598.33","1 through 10","119.97","1843.38","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","916.90","38.3","","907.90","882.36","907.90","64","119.97","1843.38","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","509.60","1 through 10","119.97","1843.38","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1843.38","77","","1904.04","1904.04","1904.04","1 through 10","119.97","1843.38","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","119.97","1843.38","other","Tricare OPPS"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","124.27","378.87","16","119.97","1843.38","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","534.06","534.06","534.06","1 through 10","119.97","1843.38","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","751.24","31.38","","1056.51","712.85","1056.51","1 through 10","119.97","1843.38","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2394.00","1795.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","119.99","126.29","37","119.97","1843.38","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2394.00","1795.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","1571.99","1571.99","1571.99","1 through 10","112.51","1251.1","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2394.00","1795.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","471.67","457.26","471.67","50","112.51","1251.1","other","Multiple Imaging"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2394.00","1795.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1251.10","52.26","","471.67","471.67","471.67","1 through 10","112.51","1251.1","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2394.00","1795.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.26","457.26","471.67","156","112.51","1251.1","other","Multiple Imaging"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2394.00","1795.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","336.40","324.03","382.53","1 through 10","112.51","1251.1","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2394.00","1795.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","35","112.51","1251.1","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2394.00","1795.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","641.30","16","112.51","1251.1","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2394.00","1795.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","382.53","382.53","1 through 10","112.51","1251.1","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2394.00","1795.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","191.27","336.40","1 through 10","112.51","1251.1","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2394.00","1795.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","751.24","31.38","","712.85","712.85","712.85","1 through 10","112.51","1251.1","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2394.00","1795.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","751.24","31.38","","712.85","712.85","712.85","1 through 10","112.51","1251.1","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2394.00","1795.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","751.24","31.38","","712.85","712.85","712.85","18","112.51","1251.1","percent of total billed charges",""
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","both","","","3497.00","2622.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","2692.69","other","OPPS APC"
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","both","","","3497.00","2622.75","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","37","200.84","2692.69","other","OPPS APC"
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","both","","","3497.00","2622.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1339.35","38.3","","1325.88","1325.88","1325.88","1 through 10","200.84","2692.69","percent of total billed charges",""
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","both","","","3497.00","2622.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1097.36","31.38","","1491.02","1491.02","1491.02","1 through 10","200.84","2692.69","percent of total billed charges",""
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","both","","","3497.00","2622.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.39","200.53","211.41","1 through 10","200.84","2692.69","other","OPPS APC"
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","outpatient","","","3497.00","2622.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","819.91","845.75","1 through 10","201.74","1827.53","other","Multiple Imaging"
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","outpatient","","","3497.00","2622.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","819.91","845.75","15","201.74","1827.53","other","Multiple Imaging"
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","outpatient","","","3497.00","2622.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","548.73","548.73","1 through 10","201.74","1827.53","other","Multiple Radiology"
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","outpatient","","","3497.00","2622.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","1827.53","other","Multiple Radiology"
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","outpatient","","","3497.00","2622.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","603.20","290.50","603.20","1 through 10","201.74","1827.53","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","197.32","508.46","38","200.84","2199.89","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1874.19","65.6","","2161.38","2161.38","2161.38","1 through 10","200.84","2199.89","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1999.90","70","","2699.12","2152.00","2771.00","1 through 10","200.84","2199.89","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","264.24","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","516.73","516.73","516.73","1 through 10","200.84","2199.89","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","208.03","508.46","1 through 10","200.84","2199.89","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","ELDER SERVICES [1037]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","480.02","480.02","480.02","1 through 10","200.84","2199.89","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","FALLON HEALTH [1008]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","486.02","211.41","486.02","1 through 10","200.84","2199.89","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","2199.89","77","","2133.67","2133.67","2133.67","1 through 10","200.84","2199.89","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","HUMANA [1012]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","101.64","506.40","1 through 10","200.84","2199.89","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","211.41","516.73","242","200.84","2199.89","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1042.81","36.5","","1033.58","878.41","3100.74","16","200.84","2199.89","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1094.23","38.3","","1083.46","1052.98","1083.46","32","200.84","2199.89","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","509.60","199.72","589.56","1 through 10","200.84","2199.89","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2199.89","77","","2161.38","2161.38","2161.38","1 through 10","200.84","2199.89","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","TRICARE [160005]","HB BWH TRICARE","200.84","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","366.73","200.84","516.73","1 through 10","200.84","2199.89","other","Tricare OPPS"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","200.84","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","211.41","200.53","511.63","1 through 10","200.84","2199.89","other","Tricare OPPS"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","511.40","208.03","929.16","27","200.84","2199.89","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","896.53","31.38","","1260.81","1218.41","1260.81","1 through 10","200.84","2199.89","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2857.00","2142.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","207.19","511.40","68","200.84","2199.89","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2857.00","2142.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","1324.54","1324.54","1875.97","1 through 10","201.74","1493.07","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2857.00","2142.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","819.91","409.96","845.75","71","201.74","1493.07","other","Multiple Imaging"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2857.00","2142.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","422.87","845.75","156","201.74","1493.07","other","Multiple Imaging"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2857.00","2142.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","685.92","342.96","685.92","1 through 10","201.74","1493.07","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2857.00","2142.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","274.37","548.73","46","201.74","1493.07","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2857.00","2142.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","287.48","574.96","11","201.74","1493.07","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2857.00","2142.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","685.92","659.69","685.92","1 through 10","201.74","1493.07","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2857.00","2142.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","603.20","301.60","603.20","1 through 10","201.74","1493.07","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2857.00","2142.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","603.20","603.20","603.20","1 through 10","201.74","1493.07","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2857.00","2142.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","896.53","31.38","","1218.41","1218.41","1218.41","1 through 10","201.74","1493.07","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2857.00","2142.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","896.53","31.38","","850.70","850.70","1218.41","24","201.74","1493.07","percent of total billed charges",""
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","2352.00","1764.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.40","124.27","2281.00","1 through 10","119.97","1811.04","other","OPPS APC"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","2352.00","1764.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.40","262.40","262.40","1 through 10","119.97","1811.04","other","OPPS APC"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","2352.00","1764.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.94","262.94","262.94","1 through 10","119.97","1811.04","other","OPPS APC"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","2352.00","1764.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","266.67","126.29","1550.19","16","119.97","1811.04","other","OPPS APC"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","2352.00","1764.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","900.82","38.3","","891.87","866.78","891.87","1 through 10","119.97","1811.04","percent of total billed charges",""
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","2352.00","1764.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","264.54","264.54","264.54","1 through 10","119.97","1811.04","other","OPPS APC"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","outpatient","","","2352.00","1764.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","471.67","471.67","471.67","1 through 10","112.51","1229.16","other","Multiple Imaging"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","outpatient","","","2352.00","1764.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","228.63","228.63","457.26","1 through 10","112.51","1229.16","other","Multiple Imaging"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","outpatient","","","2352.00","1764.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","336.40","336.40","1 through 10","112.51","1229.16","other","Multiple Radiology"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","outpatient","","","2352.00","1764.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","738.06","31.38","","1002.96","1002.96","1002.96","1 through 10","112.51","1229.16","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000015","CDM","70481","CPT","0351","RC","","","","both","","","3179.00","2384.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","2447.83","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000015","CDM","70481","CPT","0351","RC","","","","both","","","3179.00","2384.25","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2447.83","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000015","CDM","70481","CPT","0351","RC","","","","both","","","3179.00","2384.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1217.56","38.3","","1280.13","1280.13","1280.13","1 through 10","200.84","2447.83","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000015","CDM","70481","CPT","0351","RC","","","","both","","","3179.00","2384.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.38","210.38","210.38","1 through 10","200.84","2447.83","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000015","CDM","70481","CPT","0351","RC","","","","outpatient","","","3179.00","2384.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","845.75","845.75","1 through 10","201.74","1661.35","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000015","CDM","70481","CPT","0351","RC","","","","outpatient","","","3179.00","2384.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","845.75","845.75","1 through 10","201.74","1661.35","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000015","CDM","70481","CPT","0351","RC","","","","outpatient","","","3179.00","2384.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","548.73","548.73","1 through 10","201.74","1661.35","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000015","CDM","70481","CPT","0351","RC","","","","outpatient","","","3179.00","2384.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","1661.35","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000015","CDM","70481","CPT","0351","RC","","","","outpatient","","","3179.00","2384.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","997.57","31.38","","1005.12","481.09","1005.12","1 through 10","201.74","1661.35","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000016","CDM","70481","CPT","0351","RC","","","","both","","","3179.00","2384.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","2447.83","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000016","CDM","70481","CPT","0351","RC","","","","both","","","3179.00","2384.25","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2447.83","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000016","CDM","70481","CPT","0351","RC","","","","both","","","3179.00","2384.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1217.56","38.3","","1280.13","1280.13","1280.13","1 through 10","200.84","2447.83","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000016","CDM","70481","CPT","0351","RC","","","","both","","","3179.00","2384.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.38","210.38","210.38","1 through 10","200.84","2447.83","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000016","CDM","70481","CPT","0351","RC","","","","outpatient","","","3179.00","2384.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","845.75","845.75","1 through 10","201.74","1661.35","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000016","CDM","70481","CPT","0351","RC","","","","outpatient","","","3179.00","2384.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","845.75","845.75","1 through 10","201.74","1661.35","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000016","CDM","70481","CPT","0351","RC","","","","outpatient","","","3179.00","2384.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","548.73","548.73","1 through 10","201.74","1661.35","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000016","CDM","70481","CPT","0351","RC","","","","outpatient","","","3179.00","2384.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","1661.35","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000016","CDM","70481","CPT","0351","RC","","","","outpatient","","","3179.00","2384.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","997.57","31.38","","1005.12","481.09","1005.12","1 through 10","201.74","1661.35","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","both","","","3376.00","2532.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","2599.52","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","both","","","3376.00","2532.00","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2599.52","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","both","","","3376.00","2532.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1293.01","38.3","","1280.13","1280.13","1280.13","1 through 10","200.84","2599.52","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","both","","","3376.00","2532.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.38","210.38","210.38","1 through 10","200.84","2599.52","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","outpatient","","","3376.00","2532.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","845.75","845.75","1 through 10","201.74","1764.3","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","outpatient","","","3376.00","2532.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","845.75","845.75","1 through 10","201.74","1764.3","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","outpatient","","","3376.00","2532.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","548.73","548.73","1 through 10","201.74","1764.3","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","outpatient","","","3376.00","2532.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","1764.3","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","outpatient","","","3376.00","2532.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1059.39","31.38","","1005.12","481.09","1005.12","1 through 10","201.74","1764.3","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","126.29","1 through 10","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1933.40","70","","2276.00","2276.00","2276.00","1 through 10","119.97","2126.74","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","12","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1008.13","36.5","","1061.19","1061.19","1061.19","1 through 10","119.97","2126.74","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1057.85","38.3","","1112.40","1112.40","1112.40","11","119.97","2126.74","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","126.29","1 through 10","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","866.72","31.38","","1250.95","1250.95","1250.95","1 through 10","119.97","2126.74","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","949.20","949.20","949.20","1 through 10","112.51","1443.42","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.26","457.26","471.67","1 through 10","112.51","1443.42","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.26","457.26","471.67","21","112.51","1443.42","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","1 through 10","112.51","1443.42","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","160.32","160.32","160.32","1 through 10","112.51","1443.42","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","367.91","367.91","367.91","1 through 10","112.51","1443.42","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","308.28","308.28","308.28","1 through 10","112.51","1443.42","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","168.20","336.40","1 through 10","112.51","1443.42","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","866.72","31.38","","873.42","873.42","873.42","1 through 10","112.51","1443.42","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","308.28","308.28","308.28","1 through 10","112.51","1443.42","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","126.29","1 through 10","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1933.40","70","","2276.00","2276.00","2276.00","1 through 10","119.97","2126.74","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","12","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1008.13","36.5","","1061.19","1061.19","1061.19","1 through 10","119.97","2126.74","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1057.85","38.3","","1112.40","1112.40","1112.40","11","119.97","2126.74","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","126.29","1 through 10","119.97","2126.74","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","2762.00","2071.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","866.72","31.38","","1250.95","1250.95","1250.95","1 through 10","119.97","2126.74","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","949.20","949.20","949.20","1 through 10","112.51","1443.42","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.26","457.26","471.67","1 through 10","112.51","1443.42","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.26","457.26","471.67","21","112.51","1443.42","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","1 through 10","112.51","1443.42","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","160.32","160.32","160.32","1 through 10","112.51","1443.42","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","367.91","367.91","367.91","1 through 10","112.51","1443.42","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","308.28","308.28","308.28","1 through 10","112.51","1443.42","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","168.20","336.40","1 through 10","112.51","1443.42","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","866.72","31.38","","873.42","873.42","873.42","1 through 10","112.51","1443.42","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","2762.00","2071.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","308.28","308.28","308.28","1 through 10","112.51","1443.42","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","2934.00","2200.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","126.29","1 through 10","119.97","2259.18","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","2934.00","2200.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2053.80","70","","2276.00","2276.00","2276.00","1 through 10","119.97","2259.18","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","2934.00","2200.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","119.97","2259.18","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","2934.00","2200.50","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","2259.18","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","2934.00","2200.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","119.97","2259.18","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","2934.00","2200.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","12","119.97","2259.18","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","2934.00","2200.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1070.91","36.5","","1061.19","1061.19","1061.19","1 through 10","119.97","2259.18","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","2934.00","2200.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1123.72","38.3","","1112.40","1112.40","1112.40","11","119.97","2259.18","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","2934.00","2200.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","2259.18","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","2934.00","2200.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","126.29","1 through 10","119.97","2259.18","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","2934.00","2200.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","920.69","31.38","","1250.95","1250.95","1250.95","1 through 10","119.97","2259.18","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","2934.00","2200.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","949.20","949.20","949.20","1 through 10","112.51","1533.31","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","2934.00","2200.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.26","457.26","471.67","1 through 10","112.51","1533.31","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","2934.00","2200.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.26","457.26","471.67","21","112.51","1533.31","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","2934.00","2200.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","1 through 10","112.51","1533.31","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","2934.00","2200.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","160.32","160.32","160.32","1 through 10","112.51","1533.31","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","2934.00","2200.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","367.91","367.91","367.91","1 through 10","112.51","1533.31","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","2934.00","2200.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","308.28","308.28","308.28","1 through 10","112.51","1533.31","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","2934.00","2200.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","168.20","336.40","1 through 10","112.51","1533.31","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","2934.00","2200.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","920.69","31.38","","873.42","873.42","873.42","1 through 10","112.51","1533.31","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","2934.00","2200.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","308.28","308.28","308.28","1 through 10","112.51","1533.31","other","Multiple Radiology"
"CT Pelvis W&W/O Contrast","PX-35000046","CDM","72194","CPT","0352","RC","","","","both","","","3467.00","2600.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","2669.59","other","OPPS APC"
"CT Pelvis W&W/O Contrast","PX-35000046","CDM","72194","CPT","0352","RC","","","","both","","","3467.00","2600.25","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2669.59","other","OPPS APC"
"CT Pelvis W&W/O Contrast","PX-35000046","CDM","72194","CPT","0352","RC","","","","both","","","3467.00","2600.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1327.86","38.3","","1314.54","1314.54","1314.54","1 through 10","200.84","2669.59","percent of total billed charges",""
"CT Pelvis W&W/O Contrast","PX-35000046","CDM","72194","CPT","0352","RC","","","","outpatient","","","3467.00","2600.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","845.75","845.75","1 through 10","201.74","1811.85","other","Multiple Imaging"
"CT Pelvis W&W/O Contrast","PX-35000046","CDM","72194","CPT","0352","RC","","","","outpatient","","","3467.00","2600.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","409.96","845.75","1 through 10","201.74","1811.85","other","Multiple Imaging"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2645.00","1983.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","2036.65","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2645.00","1983.75","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","12","200.84","2036.65","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2645.00","1983.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","965.43","36.5","","813.11","813.11","813.11","1 through 10","200.84","2036.65","percent of total billed charges",""
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2645.00","1983.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1013.04","38.3","","1002.92","1002.92","1002.92","1 through 10","200.84","2036.65","percent of total billed charges",""
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2645.00","1983.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.18","210.18","210.18","1 through 10","200.84","2036.65","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2645.00","1983.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","207.18","210.19","1 through 10","200.84","2036.65","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","2645.00","1983.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","1736.51","1736.51","1736.51","1 through 10","201.74","1382.28","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","2645.00","1983.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","819.91","819.91","2565.00","1 through 10","201.74","1382.28","other","Multiple Imaging"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","2645.00","1983.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","819.91","845.75","12","201.74","1382.28","other","Multiple Imaging"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","2645.00","1983.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","548.73","548.73","1 through 10","201.74","1382.28","other","Multiple Radiology"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","2645.00","1983.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","1382.28","other","Multiple Radiology"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","2645.00","1983.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","830.00","31.38","","787.46","787.46","1127.83","1 through 10","201.74","1382.28","percent of total billed charges",""
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","2156.00","1617.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","1660.12","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","2156.00","1617.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","118.07","106.05","118.07","1 through 10","119.97","1660.12","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","2156.00","1617.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","125.95","378.87","48","119.97","1660.12","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","2156.00","1617.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","786.94","36.5","","779.94","662.85","779.94","1 through 10","119.97","1660.12","percent of total billed charges",""
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","2156.00","1617.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","825.75","38.3","","817.58","817.58","817.58","1 through 10","119.97","1660.12","percent of total billed charges",""
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","2156.00","1617.00","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","1660.12","other","Tricare OPPS"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","2156.00","1617.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","1660.12","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","2156.00","1617.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","264.34","1 through 10","119.97","1660.12","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","2156.00","1617.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","471.67","457.26","471.67","1 through 10","112.51","1126.73","other","Multiple Imaging"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","2156.00","1617.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.26","457.26","471.67","16","112.51","1126.73","other","Multiple Imaging"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","2156.00","1617.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","153.01","153.01","306.03","1 through 10","112.51","1126.73","other","Multiple Radiology"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","2156.00","1617.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","336.40","320.65","336.40","1 through 10","112.51","1126.73","other","Multiple Radiology"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","2156.00","1617.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","324.03","336.40","1 through 10","112.51","1126.73","other","Multiple Radiology"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","2156.00","1617.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","676.55","31.38","","641.94","641.94","919.41","1 through 10","112.51","1126.73","percent of total billed charges",""
"CT Reconstruction Aorta for Surg","PX-35000086","CDM","G0288","HCPCS","0352","RC","","","","both","","","361.00","270.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","131.77","36.5","","130.55","110.95","130.55","1 through 10","111.91","277.97","percent of total billed charges",""
"CT Reconstruction Aorta for Surg","PX-35000086","CDM","G0288","HCPCS","0352","RC","","","","both","","","361.00","270.75","WELLPOINT [1015]","HB AMC WELLPOINT","266.35","73.78","","610.58","248.63","610.58","1 through 10","111.91","277.97","percent of total billed charges",""
"CT Reconstruction Aorta for Surg","PX-35000086","CDM","G0288","HCPCS","0352","RC","","","","outpatient","","","361.00","270.75","AETNA [1001]","HB AMC AETNA HMO","251.98","69.8","","273.00","236.95","273.00","1 through 10","113.28","290.24","percent of total billed charges",""
"CT Reconstruction Aorta for Surg","PX-35000086","CDM","G0288","HCPCS","0352","RC","","","","outpatient","","","361.00","270.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.28","31.38","","107.45","107.45","107.45","1 through 10","113.28","290.24","percent of total billed charges",""
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","2259.00","1694.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","201.27","118.07","201.27","1 through 10","119.97","1739.43","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","2259.00","1694.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","266.67","126.29","519.25","43","119.97","1739.43","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","2259.00","1694.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","865.20","38.3","","856.68","832.58","856.68","1 through 10","119.97","1739.43","percent of total billed charges",""
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","2259.00","1694.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","265.34","123.76","799.02","1 through 10","119.97","1739.43","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","2259.00","1694.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","257.86","126.29","264.34","1 through 10","119.97","1739.43","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","2259.00","1694.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","471.67","235.84","471.67","1 through 10","112.51","1180.55","other","Multiple Imaging"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","2259.00","1694.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","235.84","228.63","471.67","13","112.51","1180.55","other","Multiple Imaging"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","2259.00","1694.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","153.01","306.03","1 through 10","112.51","1180.55","other","Multiple Radiology"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","2259.00","1694.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","462.42","462.42","462.42","1 through 10","112.51","1180.55","other","Multiple Radiology"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","2259.00","1694.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","324.03","324.03","324.03","1 through 10","112.51","1180.55","other","Multiple Radiology"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","2259.00","1694.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","1095.50","1095.50","1095.50","1 through 10","112.51","1180.55","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","2259.00","1694.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","708.87","31.38","","672.64","672.64","672.64","1 through 10","112.51","1180.55","percent of total billed charges",""
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","both","","","2768.00","2076.00","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","516.73","516.73","1 through 10","200.84","2131.36","other","OPPS APC"
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","both","","","2768.00","2076.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1010.32","36.5","","2552.49","850.83","2552.49","1 through 10","200.84","2131.36","percent of total billed charges",""
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","both","","","2768.00","2076.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1060.14","38.3","","1049.44","1049.44","1049.44","1 through 10","200.84","2131.36","percent of total billed charges",""
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","both","","","2768.00","2076.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","211.41","506.40","1 through 10","200.84","2131.36","other","OPPS APC"
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","outpatient","","","2768.00","2076.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","422.88","409.96","422.88","1 through 10","201.74","1446.56","other","Multiple Imaging"
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","outpatient","","","2768.00","2076.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","409.96","409.96","845.75","1 through 10","201.74","1446.56","other","Multiple Imaging"
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","outpatient","","","2768.00","2076.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","274.37","274.37","526.54","1 through 10","201.74","1446.56","other","Multiple Radiology"
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","outpatient","","","2768.00","2076.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","868.60","31.38","","1180.15","1180.15","1180.15","1 through 10","201.74","1446.56","percent of total billed charges",""
"CT Upper Extremity W Contrast Rt","PX-35000050","CDM","73201","CPT","0352","RC","","","","both","","","2541.00","1905.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","420.63","420.63","1 through 10","402.91","1956.57","other","OPPS APC"
"CT Upr Ext W Contrast","PX-35000052","CDM","73201","CPT","0352","RC","","","","both","","","2524.00","1893.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","420.63","420.63","1 through 10","402.91","1943.48","other","OPPS APC"
"CT Upr Ext W Contrast Lt","PX-35000051","CDM","73201","CPT","0352","RC","","","","both","","","2541.00","1905.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","420.63","420.63","1 through 10","402.91","1956.57","other","OPPS APC"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","both","","","2242.00","1681.50","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","1726.34","other","Tricare OPPS"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","both","","","2242.00","1681.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","126.29","14","119.97","1726.34","other","OPPS APC"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","outpatient","","","2242.00","1681.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","1471.80","1471.80","1471.80","1 through 10","112.51","1171.67","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","outpatient","","","2242.00","1681.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","1 through 10","112.51","1171.67","other","Multiple Radiology"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","outpatient","","","2242.00","1681.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","336.40","336.40","1 through 10","112.51","1171.67","other","Multiple Radiology"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","outpatient","","","2242.00","1681.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","703.54","31.38","","2790.56","320.65","2790.56","1 through 10","112.51","1171.67","percent of total billed charges",""
"CT Upr Ext W/O Contrast Lt","PX-35000048","CDM","73200","CPT","0352","RC","","","","both","","","2122.00","1591.50","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","1633.94","other","Tricare OPPS"
"CT Upr Ext W/O Contrast Lt","PX-35000048","CDM","73200","CPT","0352","RC","","","","both","","","2122.00","1591.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","126.29","14","119.97","1633.94","other","OPPS APC"
"CT Upr Ext W/O Contrast Lt","PX-35000048","CDM","73200","CPT","0352","RC","","","","outpatient","","","2122.00","1591.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","1471.80","1471.80","1471.80","1 through 10","112.51","1108.96","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Upr Ext W/O Contrast Lt","PX-35000048","CDM","73200","CPT","0352","RC","","","","outpatient","","","2122.00","1591.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","1 through 10","112.51","1108.96","other","Multiple Radiology"
"CT Upr Ext W/O Contrast Lt","PX-35000048","CDM","73200","CPT","0352","RC","","","","outpatient","","","2122.00","1591.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","336.40","336.40","1 through 10","112.51","1108.96","other","Multiple Radiology"
"CT Upr Ext W/O Contrast Lt","PX-35000048","CDM","73200","CPT","0352","RC","","","","outpatient","","","2122.00","1591.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","665.88","31.38","","2790.56","320.65","2790.56","1 through 10","112.51","1108.96","percent of total billed charges",""
"CT Upr Ext W/O Contrast Rt","PX-35000047","CDM","73200","CPT","0352","RC","","","","both","","","2122.00","1591.50","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","1633.94","other","Tricare OPPS"
"CT Upr Ext W/O Contrast Rt","PX-35000047","CDM","73200","CPT","0352","RC","","","","both","","","2122.00","1591.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","126.29","14","119.97","1633.94","other","OPPS APC"
"CT Upr Ext W/O Contrast Rt","PX-35000047","CDM","73200","CPT","0352","RC","","","","outpatient","","","2122.00","1591.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","1471.80","1471.80","1471.80","1 through 10","112.51","1108.96","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Upr Ext W/O Contrast Rt","PX-35000047","CDM","73200","CPT","0352","RC","","","","outpatient","","","2122.00","1591.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","1 through 10","112.51","1108.96","other","Multiple Radiology"
"CT Upr Ext W/O Contrast Rt","PX-35000047","CDM","73200","CPT","0352","RC","","","","outpatient","","","2122.00","1591.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","336.40","336.40","1 through 10","112.51","1108.96","other","Multiple Radiology"
"CT Upr Ext W/O Contrast Rt","PX-35000047","CDM","73200","CPT","0352","RC","","","","outpatient","","","2122.00","1591.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","665.88","31.38","","2790.56","320.65","2790.56","1 through 10","112.51","1108.96","percent of total billed charges",""
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3871.00","2903.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","197.32","211.41","1 through 10","200.84","2980.67","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3871.00","2903.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2539.38","65.6","","1794.41","1794.41","1794.41","1 through 10","200.84","2980.67","percent of total billed charges",""
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3871.00","2903.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","172.26","208.03","1 through 10","200.84","2980.67","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3871.00","2903.25","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","54","200.84","2980.67","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3871.00","2903.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1482.59","38.3","","1467.81","1467.81","1467.81","1 through 10","200.84","2980.67","percent of total billed charges",""
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3871.00","2903.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.38","210.38","210.38","1 through 10","200.84","2980.67","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3871.00","2903.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","209.98","209.98","209.98","1 through 10","200.84","2980.67","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3871.00","2903.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","200.53","211.41","18","200.84","2980.67","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","outpatient","","","3871.00","2903.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","415.26","","Case rate ($415.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","415.26","415.26","415.26","1 through 10","201.74","2022.98","other","Multiple Imaging"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","outpatient","","","3871.00","2903.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","415.26","","Case rate ($415.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","415.26","415.26","415.26","13","201.74","2022.98","other","Multiple Imaging"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","outpatient","","","3871.00","2903.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","548.73","548.73","1 through 10","201.74","2022.98","other","Multiple Radiology"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","outpatient","","","3871.00","2903.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","603.20","603.20","603.20","1 through 10","201.74","2022.98","other","Multiple Radiology"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","outpatient","","","3871.00","2903.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1214.72","31.38","","1152.48","1152.48","1152.48","1 through 10","201.74","2022.98","percent of total billed charges",""
"Cta Abd Aorta W/&W/O Runoff|REDUCED SERVICES","PX-35000083","CDM","75635","CPT","0352","RC","","","52","both","","","3871.00","2903.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","103.60","103.60","103.60","1 through 10","200.84","264.24","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3336.00","2502.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2335.20","70","","2588.00","2588.00","2588.00","1 through 10","200.84","2568.72","percent of total billed charges",""
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3336.00","2502.00","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2568.72","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1034.16","31","","999.62","999.62","999.62","1 through 10","200.84","2568.72","percent of total billed charges",""
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1217.64","36.5","","1206.66","1206.66","1206.66","1 through 10","200.84","2568.72","percent of total billed charges",""
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1277.69","38.3","","1264.89","1229.30","1264.89","1 through 10","200.84","2568.72","percent of total billed charges",""
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3336.00","2502.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.18","207.18","207.18","1 through 10","200.84","2568.72","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3336.00","2502.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","744.05","744.05","744.05","1 through 10","200.84","2568.72","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3336.00","2502.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","210.19","210.19","1 through 10","200.84","2568.72","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3336.00","2502.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","819.91","845.75","1 through 10","201.74","1743.39","other","Multiple Imaging"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3336.00","2502.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","845.75","819.91","845.75","1 through 10","201.74","1743.39","other","Multiple Imaging"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3336.00","2502.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","526.54","274.37","526.54","1 through 10","201.74","1743.39","other","Multiple Radiology"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3336.00","2502.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","3235.00","574.96","3235.00","1 through 10","201.74","1743.39","other","Multiple Radiology"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3336.00","2502.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1046.84","31.38","","1422.43","993.15","1422.43","1 through 10","201.74","1743.39","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","508.46","85","200.84","3208.59","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2916.90","70","","3232.80","3232.80","3232.80","1 through 10","200.84","3208.59","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","264.24","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","414.02","414.02","414.02","1 through 10","200.84","3208.59","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","207.18","208.03","1 through 10","200.84","3208.59","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","FALLON HEALTH [1008]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","600.22","211.41","634.23","1 through 10","200.84","3208.59","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","3208.59","77","","3111.57","3111.57","3111.57","1 through 10","200.84","3208.59","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","HUMANA [1012]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7.44","7.44","7.44","103","200.84","3208.59","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.45","208.45","208.45","1 through 10","200.84","3208.59","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","634.23","716","200.84","3208.59","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1291.77","31","","1248.67","1248.67","1248.67","1 through 10","200.84","3208.59","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1520.96","36.5","","1507.29","1281.00","4521.87","26","200.84","3208.59","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1595.96","38.3","","1580.03","1535.58","4606.74","62","200.84","3208.59","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.38","207.18","631.14","14","200.84","3208.59","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","MOLINA [1014]","HB BWH MOLINA","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4249.03","419.44","4249.03","1 through 10","200.84","3208.59","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3208.59","77","","3046.91","3046.91","3046.91","1 through 10","200.84","3208.59","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","591.96","207.18","634.23","65","200.84","3208.59","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","929.43","929.43","929.43","1 through 10","200.84","3208.59","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1307.60","31.38","","1240.59","1240.59","1776.83","1 through 10","200.84","3208.59","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","200.53","211.41","104","200.84","3208.59","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","4167.00","3125.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1307.60","31.38","","1776.83","1776.83","1776.83","1 through 10","200.84","3208.59","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","6776.76","2735.76","6776.76","1 through 10","201.74","2177.67","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","819.91","409.96","845.75","83","201.74","2177.67","other","Multiple Imaging"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2177.67","52.26","","2500.57","1250.29","2500.57","1 through 10","201.74","2177.67","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","819.91","409.96","845.75","201","201.74","2177.67","other","Multiple Imaging"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","685.92","301.60","685.92","1 through 10","201.74","2177.67","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","274.37","823.11","70","201.74","2177.67","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","287.48","1105.54","33","201.74","2177.67","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","685.92","342.96","685.92","1 through 10","201.74","2177.67","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","2177.67","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","603.20","556.07","603.20","1 through 10","201.74","2177.67","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","3151.98","2020.50","3151.98","1 through 10","201.74","2177.67","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1307.60","31.38","","3021.10","3021.10","3021.10","1 through 10","201.74","2177.67","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1307.60","31.38","","1776.83","1776.83","1776.83","1 through 10","201.74","2177.67","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","4167.00","3125.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1307.60","31.38","","1240.59","1240.59","2186.76","36","201.74","2177.67","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4934.00","3700.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","208.03","578.61","28","200.84","3799.18","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4934.00","3700.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","506.39","208.03","508.46","1 through 10","200.84","3799.18","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4934.00","3700.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","264.32","264.32","264.32","1 through 10","200.84","3799.18","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4934.00","3700.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","509.50","509.50","509.50","1 through 10","200.84","3799.18","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4934.00","3700.50","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","211.41","634.23","225","200.84","3799.18","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4934.00","3700.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1800.91","36.5","","1784.81","1516.85","5354.43","14","200.84","3799.18","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4934.00","3700.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1889.72","38.3","","1870.94","1870.94","5612.82","52","200.84","3799.18","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4934.00","3700.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","509.40","210.38","1528.80","1 through 10","200.84","3799.18","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4934.00","3700.50","MOLINA [1014]","HB BWH MOLINA","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1023.30","419.44","1023.30","1 through 10","200.84","3799.18","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4934.00","3700.50","TRICARE [160005]","HB BWH TRICARE","200.84","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","211.41","200.84","490.89","1 through 10","200.84","3799.18","other","Tricare OPPS"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4934.00","3700.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","629.94","209.98","1525.38","18","200.84","3799.18","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4934.00","3700.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1100.55","1100.55","1100.55","1 through 10","200.84","3799.18","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4934.00","3700.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","485.03","207.18","509.40","43","200.84","3799.18","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3239.45","3239.45","3239.45","1 through 10","201.74","2578.51","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","819.91","819.91","845.75","51","201.74","2578.51","other","Multiple Imaging"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","819.91","422.88","845.75","112","201.74","2578.51","other","Multiple Imaging"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","685.92","685.92","685.92","1 through 10","201.74","2578.51","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","274.37","548.73","29","201.74","2578.51","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","552.77","574.96","11","201.74","2578.51","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","685.92","685.92","685.92","1 through 10","201.74","2578.51","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","287.48","574.96","1 through 10","201.74","2578.51","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","581.18","535.74","603.20","1 through 10","201.74","2578.51","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","3732.30","3732.30","3732.30","1 through 10","201.74","2578.51","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1548.29","31.38","","4785.00","4174.71","4785.00","1 through 10","201.74","2578.51","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","659.69","659.69","659.69","1 through 10","201.74","2578.51","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1548.29","31.38","","1469.00","1469.00","1469.00","1 through 10","201.74","2578.51","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4934.00","3700.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1548.29","31.38","","1469.00","1469.00","2103.96","23","201.74","2578.51","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4738.00","3553.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","555.63","197.32","4595.00","1 through 10","200.84","3648.26","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4738.00","3553.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3108.13","65.6","","531.72","531.72","531.72","1 through 10","200.84","3648.26","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4738.00","3553.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","264.32","264.32","264.32","1 through 10","200.84","3648.26","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4738.00","3553.50","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","939.55","35","200.84","3648.26","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4738.00","3553.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1729.37","36.5","","1713.94","1456.62","1713.94","1 through 10","200.84","3648.26","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4738.00","3553.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1814.65","38.3","","1796.65","1796.65","5389.95","46","200.84","3648.26","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4738.00","3553.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","399.04","399.04","399.04","1 through 10","200.84","3648.26","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4738.00","3553.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","208.03","208.03","1 through 10","200.84","3648.26","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4738.00","3553.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1056.85","1056.85","1056.85","1 through 10","200.84","3648.26","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4738.00","3553.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","480.03","196.52","508.80","1 through 10","200.84","3648.26","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4738.00","3553.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3110.82","3110.82","3110.82","1 through 10","201.74","2476.08","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4738.00","3553.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","409.96","409.96","422.88","32","201.74","2476.08","other","Multiple Imaging"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4738.00","3553.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","422.88","409.96","845.75","73","201.74","2476.08","other","Multiple Imaging"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4738.00","3553.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","274.37","274.37","823.11","20","201.74","2476.08","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4738.00","3553.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","287.48","287.48","837.41","1 through 10","201.74","2476.08","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4738.00","3553.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","342.96","342.96","342.96","1 through 10","201.74","2476.08","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4738.00","3553.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","287.48","287.48","287.48","1 through 10","201.74","2476.08","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4738.00","3553.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","301.60","301.60","342.96","1 through 10","201.74","2476.08","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4738.00","3553.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1486.78","31.38","","4595.00","4121.58","4595.00","1 through 10","201.74","2476.08","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4738.00","3553.50","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","329.85","329.85","329.85","1 through 10","201.74","2476.08","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4738.00","3553.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1486.78","31.38","","1410.67","1410.67","2020.42","16","201.74","2476.08","percent of total billed charges",""
"Cta Pelvis W&W/O Contrast","PX-35000043","CDM","72191","CPT","0352","RC","","","","both","","","3417.00","2562.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","2631.09","other","OPPS APC"
"Cta Pelvis W&W/O Contrast","PX-35000043","CDM","72191","CPT","0352","RC","","","","both","","","3417.00","2562.75","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","14","200.84","2631.09","other","OPPS APC"
"Cta Upr Ext W&W/O Contrast","PX-35000058","CDM","73206","CPT","0352","RC","","","","both","","","3350.00","2512.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","210.19","210.19","1 through 10","200.84","2579.5","other","OPPS APC"
"Cta Upr Ext W&W/O Contrast Lt","PX-35000057","CDM","73206","CPT","0352","RC","","","","both","","","3524.00","2643.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","210.19","210.19","1 through 10","200.84","2713.48","other","OPPS APC"
"Cta Upr Ext W&W/O Contrast Rt","PX-35000056","CDM","73206","CPT","0352","RC","","","","both","","","3524.00","2643.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","210.19","210.19","1 through 10","200.84","2713.48","other","OPPS APC"
"Ctgt Chondrodysplasia Punctata and Related Disorders Ngs Panel","PX-31001069","CDM","81479","CPT","0310","RC","","","","both","","","199.00","149.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","158.21","79.5","","0.65","0.65","0.65","1 through 10","61.69","189.05","percent of total billed charges",""
"Ctgt Chondrodysplasia Punctata and Related Disorders Ngs Panel","PX-31001069","CDM","81479","CPT","0310","RC","","","","both","","","199.00","149.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.07","53.3","","0.79","0.79","0.79","1 through 10","61.69","189.05","percent of total billed charges",""
"Ctgt Chondrodysplasia Punctata and Related Disorders Ngs Panel","PX-31001069","CDM","81479","CPT","0310","RC","","","","outpatient","","","199.00","149.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","99.50","50","","1.00","1.00","1.00","1 through 10","96.32","164.18","percent of total billed charges",""
"Ctgt Chondrodysplasia Punctata and Related Disorders Ngs Panel","PX-31001069","CDM","81479","CPT","0310","RC","","","","outpatient","","","199.00","149.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","104.48","52.5","","1.00","0.53","1.00","1 through 10","96.32","164.18","percent of total billed charges",""
"Ctgt Col4a2 Gene Seq+Dldup","PX-31001169","CDM","81479","CPT","0310","RC","","","","both","","","2600.00","1950.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2067.00","79.5","","0.65","0.65","0.65","1 through 10","806","2470","percent of total billed charges",""
"Ctgt Col4a2 Gene Seq+Dldup","PX-31001169","CDM","81479","CPT","0310","RC","","","","both","","","2600.00","1950.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1385.80","53.3","","0.79","0.79","0.79","1 through 10","806","2470","percent of total billed charges",""
"Ctgt Col4a2 Gene Seq+Dldup","PX-31001169","CDM","81479","CPT","0310","RC","","","","outpatient","","","2600.00","1950.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1300.00","50","","1.00","1.00","1.00","1 through 10","156.55","2145","percent of total billed charges",""
"Ctgt Col4a2 Gene Seq+Dldup","PX-31001169","CDM","81479","CPT","0310","RC","","","","outpatient","","","2600.00","1950.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1365.00","52.5","","1.00","0.53","1.00","1 through 10","156.55","2145","percent of total billed charges",""
"Ctgt Ectodermal Dysplasia Ngs/Del Dup Comprehensive","PX-31001074","CDM","81479","CPT","0310","RC","","","","both","","","101.00","75.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","80.30","79.5","","0.65","0.65","0.65","1 through 10","31.31","95.95","percent of total billed charges",""
"Ctgt Ectodermal Dysplasia Ngs/Del Dup Comprehensive","PX-31001074","CDM","81479","CPT","0310","RC","","","","both","","","101.00","75.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","53.83","53.3","","0.79","0.79","0.79","1 through 10","31.31","95.95","percent of total billed charges",""
"Ctgt Ectodermal Dysplasia Ngs/Del Dup Comprehensive","PX-31001074","CDM","81479","CPT","0310","RC","","","","outpatient","","","101.00","75.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","50.50","50","","1.00","1.00","1.00","1 through 10","48.88","156.55","percent of total billed charges",""
"Ctgt Ectodermal Dysplasia Ngs/Del Dup Comprehensive","PX-31001074","CDM","81479","CPT","0310","RC","","","","outpatient","","","101.00","75.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","53.03","52.5","","1.00","0.53","1.00","1 through 10","48.88","156.55","percent of total billed charges",""
"Ctgt Fgfr3 Exons 7 10 15 19 Seq","PX-31001165","CDM","81479","CPT","0310","RC","","","","both","","","2543.00","1907.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2021.69","79.5","","0.65","0.65","0.65","1 through 10","788.33","2415.85","percent of total billed charges",""
"Ctgt Fgfr3 Exons 7 10 15 19 Seq","PX-31001165","CDM","81479","CPT","0310","RC","","","","both","","","2543.00","1907.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1355.42","53.3","","0.79","0.79","0.79","1 through 10","788.33","2415.85","percent of total billed charges",""
"Ctgt Fgfr3 Exons 7 10 15 19 Seq","PX-31001165","CDM","81479","CPT","0310","RC","","","","outpatient","","","2543.00","1907.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1271.50","50","","1.00","1.00","1.00","1 through 10","156.55","2097.98","percent of total billed charges",""
"Ctgt Fgfr3 Exons 7 10 15 19 Seq","PX-31001165","CDM","81479","CPT","0310","RC","","","","outpatient","","","2543.00","1907.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1335.08","52.5","","1.00","0.53","1.00","1 through 10","156.55","2097.98","percent of total billed charges",""
"Ctgt Nephrotic Syndrome and Related Disorders Ngs/Del Dup Comprehensive","PX-31001075","CDM","81479","CPT","0361","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Ctgt Nephrotic Syndrome and Related Disorders Ngs/Del Dup Comprehensive","PX-31001075","CDM","81479","CPT","0361","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Ctgt Nephrotic Syndrome and Related Disorders Ngs/Del Dup Comprehensive","PX-31001075","CDM","81479","CPT","0361","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Ctgt Nephrotic Syndrome and Related Disorders Ngs/Del Dup Comprehensive","PX-31001075","CDM","81479","CPT","0361","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"CUBE ALLOGRAFT 1.0 XCM CANCELLOUS DEMINERALIZED FREEZE DRIED READIGRAFT S","SUP-ITM-10010240","CDM","C1889","HCPCS","0278","RC","","","","both","","","1478.16","1108.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1175.14","79.5","","1309.77","674.56","6049.93","26","458.23","1175.14","percent of total billed charges",""
"CUBE ALLOGRAFT 1.0 XCM CANCELLOUS DEMINERALIZED FREEZE DRIED READIGRAFT S","SUP-ITM-10010240","CDM","C1889","HCPCS","0278","RC","","","","both","","","1478.16","1108.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","787.86","53.3","","1901.83","1901.83","2962.25","1 through 10","458.23","1175.14","percent of total billed charges",""
"CUBE ALLOGRAFT 1.0 XCM CANCELLOUS DEMINERALIZED FREEZE DRIED READIGRAFT S","SUP-ITM-10010240","CDM","C1889","HCPCS","0278","RC","","","","both","","","1478.16","1108.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","539.53","36.5","","1620.31","1620.31","19908.88","1 through 10","458.23","1175.14","percent of total billed charges",""
"CUBE ALLOGRAFT 1.0 XCM CANCELLOUS DEMINERALIZED FREEZE DRIED READIGRAFT S","SUP-ITM-10010240","CDM","C1889","HCPCS","0278","RC","","","","both","","","1478.16","1108.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","566.14","38.3","","352.91","352.91","2046.30","1 through 10","458.23","1175.14","percent of total billed charges",""
"CUBE ALLOGRAFT 1.0 XCM CANCELLOUS DEMINERALIZED FREEZE DRIED READIGRAFT S","SUP-ITM-10010240","CDM","C1889","HCPCS","0278","RC","","","","both","","","1478.16","1108.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","634.13","42.9","","9668.75","9668.75","9668.75","1 through 10","458.23","1175.14","percent of total billed charges",""
"CUBE ALLOGRAFT 1.0 XCM CANCELLOUS DEMINERALIZED FREEZE DRIED READIGRAFT S","SUP-ITM-10010240","CDM","C1889","HCPCS","0278","RC","","","","both","","","1478.16","1108.62","WELLPOINT [1015]","HB AMC WELLPOINT","1090.59","73.78","","699.88","384.10","3443.31","33","458.23","1175.14","percent of total billed charges",""
"CUBE ALLOGRAFT 1.0 XCM CANCELLOUS DEMINERALIZED FREEZE DRIED READIGRAFT S","SUP-ITM-10010240","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1478.16","1108.62","AETNA [1001]","HB AMC AETNA HMO","1031.76","69.8","","1421.24","264.50","4933.46","29","772.49","1207.95","percent of total billed charges",""
"CUBE ALLOGRAFT 1.0 XCM CANCELLOUS DEMINERALIZED FREEZE DRIED READIGRAFT S","SUP-ITM-10010240","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1478.16","1108.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1188.44","80.4","","1022.97","1022.97","3607.50","1 through 10","772.49","1207.95","percent of total billed charges",""
"CUBE ALLOGRAFT 1.0 XCM CANCELLOUS DEMINERALIZED FREEZE DRIED READIGRAFT S","SUP-ITM-10010240","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1478.16","1108.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1207.95","81.72","","3010.54","693.88","5019.88","35","772.49","1207.95","percent of total billed charges",""
"CUFF 4.5CM PROSTHESIS PENILE AMS 700 URINARY SPHINCTER OCCLUSIVE BELT","SUP-ITM-10004829","CDM","C1815","HCPCS","0278","RC","","","","both","","","18775.00","14081.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","14926.13","79.5","","18938.70","18113.72","18938.70","1 through 10","5820.25","14926.13","percent of total billed charges",""
"CUFF 4.5CM PROSTHESIS PENILE AMS 700 URINARY SPHINCTER OCCLUSIVE BELT","SUP-ITM-10004829","CDM","C1815","HCPCS","0278","RC","","","","both","","","18775.00","14081.25","WELLPOINT [1015]","HB AMC WELLPOINT","13852.20","73.78","","27772.46","27772.46","27772.46","1 through 10","5820.25","14926.13","percent of total billed charges",""
"CUFF DOUBLE 15FR 62CM ADULT CATHETER PERITONEAL DIALYSIS COILED LINEAR RADIOPAQUE STRIPE","SUP-ITM-10014186","CDM","C1729","HCPCS","0272","RC","","","","both","","","225.96","169.47","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","162.24","71.8","","162.24","51.52","162.24","1 through 10","70.05","179.64","percent of total billed charges",""
"CUFF DOUBLE 15FR 62CM ADULT CATHETER PERITONEAL DIALYSIS COILED LINEAR RADIOPAQUE STRIPE","SUP-ITM-10014186","CDM","C1729","HCPCS","0272","RC","","","","both","","","225.96","169.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","82.48","36.5","","94.34","22.19","146.22","26","70.05","179.64","percent of total billed charges",""
"CUFF DOUBLE 15FR 62CM ADULT CATHETER PERITONEAL DIALYSIS COILED LINEAR RADIOPAQUE STRIPE","SUP-ITM-10014186","CDM","C1729","HCPCS","0272","RC","","","","both","","","225.96","169.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","86.54","38.3","","51.52","27.37","51.52","26","70.05","179.64","percent of total billed charges",""
"CUFF DOUBLE 15FR 62CM ADULT CATHETER PERITONEAL DIALYSIS COILED LINEAR RADIOPAQUE STRIPE","SUP-ITM-10014186","CDM","C1729","HCPCS","0272","RC","","","","both","","","225.96","169.47","WELLPOINT [1015]","HB AMC WELLPOINT","166.71","73.78","","207.21","122.12","216.28","14","70.05","179.64","percent of total billed charges",""
"CUFF DOUBLE 15FR 62CM ADULT CATHETER PERITONEAL DIALYSIS COILED LINEAR RADIOPAQUE STRIPE","SUP-ITM-10014186","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","225.96","169.47","AETNA [1001]","HB AMC AETNA HMO","157.72","69.8","","155.96","47.39","155.96","1 through 10","118.09","184.65","percent of total billed charges",""
"CUFF DOUBLE 15FR 62CM ADULT CATHETER PERITONEAL DIALYSIS COILED LINEAR RADIOPAQUE STRIPE","SUP-ITM-10014186","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","225.96","169.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","184.65","81.72","","57.36","51.76","232.23","35","118.09","184.65","percent of total billed charges",""
"CUFF OCCLUSIVE 4CM IMPLANT URINARY AMS SPHINCTER 800 BELT","SUP-ITM-10001574","CDM","C1815","HCPCS","0278","RC","","","","both","","","12759.38","9569.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10143.71","79.5","","18938.70","18113.72","18938.70","1 through 10","3955.41","10143.71","percent of total billed charges",""
"CUFF OCCLUSIVE 4CM IMPLANT URINARY AMS SPHINCTER 800 BELT","SUP-ITM-10001574","CDM","C1815","HCPCS","0278","RC","","","","both","","","12759.38","9569.53","WELLPOINT [1015]","HB AMC WELLPOINT","9413.87","73.78","","27772.46","27772.46","27772.46","1 through 10","3955.41","10143.71","percent of total billed charges",""
"CUFF OCCLUSIVE 5CM IMPLANT URINARY AMS SPHINCTER 800 BELT","SUP-ITM-10007205","CDM","C1815","HCPCS","0278","RC","","","","both","","","12759.38","9569.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10143.71","79.5","","18938.70","18113.72","18938.70","1 through 10","3955.41","10143.71","percent of total billed charges",""
"CUFF OCCLUSIVE 5CM IMPLANT URINARY AMS SPHINCTER 800 BELT","SUP-ITM-10007205","CDM","C1815","HCPCS","0278","RC","","","","both","","","12759.38","9569.53","WELLPOINT [1015]","HB AMC WELLPOINT","9413.87","73.78","","27772.46","27772.46","27772.46","1 through 10","3955.41","10143.71","percent of total billed charges",""
"CUFF URINARY 4.0CM SPHINCTER INHIBIZONE OCCLUSIVE COATED","SUP-ITM-10027741","CDM","C1815","HCPCS","0278","RC","","","","both","","","15405.00","11553.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12246.98","79.5","","18938.70","18113.72","18938.70","1 through 10","4775.55","12246.98","percent of total billed charges",""
"CUFF URINARY 4.0CM SPHINCTER INHIBIZONE OCCLUSIVE COATED","SUP-ITM-10027741","CDM","C1815","HCPCS","0278","RC","","","","both","","","15405.00","11553.75","WELLPOINT [1015]","HB AMC WELLPOINT","11365.81","73.78","","27772.46","27772.46","27772.46","1 through 10","4775.55","12246.98","percent of total billed charges",""
"CUFF URINARY 6.0CM SPHINCTER OCCLUSIVE INHIBIZONE COATED","SUP-ITM-10027744","CDM","C1815","HCPCS","0278","RC","","","","both","","","16087.50","12065.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12789.56","79.5","","18938.70","18113.72","18938.70","1 through 10","4987.13","12789.56","percent of total billed charges",""
"CUFF URINARY 6.0CM SPHINCTER OCCLUSIVE INHIBIZONE COATED","SUP-ITM-10027744","CDM","C1815","HCPCS","0278","RC","","","","both","","","16087.50","12065.62","WELLPOINT [1015]","HB AMC WELLPOINT","11869.36","73.78","","27772.46","27772.46","27772.46","1 through 10","4987.13","12789.56","percent of total billed charges",""
"Cult Type Amp Prb Cult/Isol Ea","PX-30001172","CDM","87150","CPT","0306","RC","","","","both","","","444.00","333.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","236.65","53.3","","185.52","185.52","185.52","1 through 10","26.86","421.8","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","90.00","67.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","64.62","71.8","","62.47","7.13","132.07","1 through 10","5.4","85.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","90.00","67.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","63.00","70","","87.00","37.41","87.00","1 through 10","5.4","85.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","90.00","67.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","71.55","79.5","","68.47","45.94","68.47","162","5.4","85.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","90.00","67.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","47.97","53.3","","45.94","45.94","68.47","103","5.4","85.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","90.00","67.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.90","31","","26.88","26.88","26.88","1 through 10","5.4","85.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","90.00","67.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","32.85","36.5","","32.45","27.58","32.45","195","5.4","85.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","90.00","67.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.47","38.3","","34.02","33.06","34.02","675","5.4","85.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","90.00","67.50","MOLINA [1014]","HB BWH MOLINA","31.50","35","","16.03","16.03","23.98","14","5.4","85.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","90.00","67.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","69.30","77","","67.86","58.90","87.00","1 through 10","5.4","85.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","90.00","67.50","TRICARE [160005]","HB BWH TRICARE","85.50","95","","9.74","9.25","29.22","1 through 10","5.4","85.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","90.00","67.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","38.61","42.9","","69.55","69.55","69.55","17","5.4","85.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","90.00","67.50","AETNA [1001]","HB AMC AETNA HMO","62.82","69.8","","58.90","41.59","67.86","257","5.4","73.55","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","90.00","67.50","AETNA [1001]","HB AMC AETNA PPO","72.36","80.4","","45.59","41.59","67.86","46","5.4","73.55","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","90.00","67.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","50.31","55.9","","45.59","45.59","45.59","1 through 10","5.4","73.55","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","90.00","67.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","47.03","52.26","","28.87","28.87","28.87","1 through 10","5.4","73.55","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","90.00","67.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","72.36","80.4","","69.55","69.55","69.55","1 through 10","5.4","73.55","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","90.00","67.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","73.55","81.72","","63.92","63.92","63.92","1 through 10","5.4","73.55","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","90.00","67.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","73.55","81.72","","38.25","38.25","69.55","15","5.4","73.55","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","90.00","67.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","73.55","81.72","","69.55","38.26","69.55","236","5.4","73.55","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","both","","","177.00","132.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","115.05","65","","335.40","335.40","335.40","1 through 10","10.58","168.15","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","both","","","177.00","132.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","123.90","70","","172.00","172.00","172.00","1 through 10","10.58","168.15","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","both","","","177.00","132.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","140.72","79.5","","331.97","135.36","406.08","27","10.58","168.15","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","both","","","177.00","132.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","94.34","53.3","","135.36","90.82","135.36","1 through 10","10.58","168.15","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","both","","","177.00","132.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","115.05","65","","223.60","223.60","223.60","1 through 10","10.58","168.15","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","both","","","177.00","132.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","140.72","79.5","","135.36","135.36","135.36","1 through 10","10.58","168.15","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.61","36.5","","64.16","54.52","128.32","20","10.58","168.15","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.79","38.3","","67.25","65.36","201.75","26","10.58","168.15","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","both","","","177.00","132.75","MOLINA [1014]","HB BWH MOLINA","61.95","35","","21.43","21.43","21.43","1 through 10","10.58","168.15","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","both","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.93","42.9","","137.50","75.63","137.50","1 through 10","10.58","168.15","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","outpatient","","","177.00","132.75","AETNA [1001]","HB AMC AETNA HMO","123.55","69.8","","116.44","116.44","232.88","13","11.14","144.64","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","outpatient","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","144.64","81.72","","137.50","75.63","137.50","22","11.14","144.64","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","both","","","155.00","116.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","100.75","65","","292.50","292.50","292.50","1 through 10","9.28","147.25","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","both","","","155.00","116.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","108.50","70","","150.00","150.00","150.00","1 through 10","9.28","147.25","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","both","","","155.00","116.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","123.23","79.5","","220.16","79.20","354.15","18","9.28","147.25","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","both","","","155.00","116.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","82.62","53.3","","79.20","79.20","118.05","1 through 10","9.28","147.25","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","100.75","65","","195.00","195.00","195.00","1 through 10","9.28","147.25","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","both","","","155.00","116.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56.58","36.5","","55.95","53.00","55.95","11","9.28","147.25","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","both","","","155.00","116.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","59.37","38.3","","58.65","57.00","175.95","30","9.28","147.25","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.50","42.9","","119.91","119.91","119.91","1 through 10","9.28","147.25","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","outpatient","","","155.00","116.25","AETNA [1001]","HB AMC AETNA HMO","108.19","69.8","","101.55","71.70","117.00","21","9.76","126.67","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","126.67","81.72","","119.91","65.96","119.91","25","9.76","126.67","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","both","","","85.00","63.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","67.58","79.5","","129.07","64.53","129.07","1 through 10","5.4","80.75","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","both","","","85.00","63.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.31","53.3","","43.30","43.30","43.30","1 through 10","5.4","80.75","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","both","","","85.00","63.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.25","65","","53.30","53.30","53.30","1 through 10","5.4","80.75","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","both","","","85.00","63.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.03","36.5","","30.59","30.59","30.59","1 through 10","5.4","80.75","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","both","","","85.00","63.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.56","38.3","","32.06","31.16","32.06","1 through 10","5.4","80.75","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","both","","","85.00","63.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.47","42.9","","65.55","65.55","65.55","1 through 10","5.4","80.75","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","outpatient","","","85.00","63.75","AETNA [1001]","HB AMC AETNA HMO","59.33","69.8","","55.51","55.51","55.51","1 through 10","5.4","69.46","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","outpatient","","","85.00","63.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","69.46","81.72","","36.06","36.06","36.06","1 through 10","5.4","69.46","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","outpatient","","","85.00","63.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","69.46","81.72","","65.55","65.55","65.55","1 through 10","5.4","69.46","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","109.85","71.8","","106.26","106.26","106.26","1 through 10","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","99.45","65","","288.60","96.20","288.60","11","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","107.10","70","","148.00","148.00","148.00","1 through 10","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","78.14","349.43","102","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.55","53.3","","78.14","78.14","234.42","60","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","117.81","77","","113.96","113.96","113.96","1 through 10","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","99.45","65","","577.20","577.20","577.20","1 through 10","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","116.48","116.48","1 through 10","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","47.43","31","","137.19","45.73","137.19","1 through 10","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.85","36.5","","55.20","46.92","165.60","123","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","57.87","56.24","173.61","268","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","MOLINA [1014]","HB BWH MOLINA","53.55","35","","17.10","17.10","17.10","1 through 10","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","117.81","77","","148.00","115.44","148.00","1 through 10","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","TRICARE [160005]","HB BWH TRICARE","145.35","95","","10.39","10.39","10.39","1 through 10","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.64","42.9","","118.31","118.31","118.31","25","8.45","145.35","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","100.20","70.74","115.44","117","8.88","125.03","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA PPO","123.01","80.4","","115.44","77.55","155.10","20","8.88","125.03","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","85.53","55.9","","77.55","77.55","77.55","1 through 10","8.88","125.03","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","153.00","114.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","79.96","52.26","","30.92","30.92","91.58","1 through 10","8.88","125.03","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","125.03","81.72","","65.08","65.08","118.31","1 through 10","8.88","125.03","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","118.31","65.08","118.31","126","8.88","125.03","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0300","RC","","","","inpatient","","","184.00","138.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","144.64","78.61","","142.30","142.30","142.30","1 through 10","101.75","146.28","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","both","","","184.00","138.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","132.11","71.8","","9.10","9.10","9.10","1 through 10","10.11","174.8","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","both","","","184.00","138.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","128.80","70","","178.00","178.00","178.00","1 through 10","10.11","174.8","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","both","","","184.00","138.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","146.28","79.5","","140.09","105.18","140.09","13","10.11","174.8","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","both","","","184.00","138.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","98.07","53.3","","93.99","75.45","148.55","18","10.11","174.8","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","both","","","184.00","138.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","119.60","65","","231.40","231.40","231.40","1 through 10","10.11","174.8","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","both","","","184.00","138.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.16","36.5","","66.39","56.43","199.19","19","10.11","174.8","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","both","","","184.00","138.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.47","38.3","","69.60","67.64","69.60","37","10.11","174.8","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","184.00","138.00","AETNA [1001]","HB AMC AETNA HMO","128.43","69.8","","120.51","85.08","241.01","22","10.65","150.36","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","184.00","138.00","AETNA [1001]","HB AMC AETNA PPO","147.94","80.4","","93.27","93.27","93.27","1 through 10","10.65","150.36","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","184.00","138.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","96.16","52.26","","110.15","110.15","110.15","1 through 10","10.65","150.36","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","184.00","138.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","150.36","81.72","","142.29","78.27","340.00","18","10.65","150.36","percent of total billed charges",""
"Culture Chlamydia","PX-30001165","CDM","87110","CPT","0306","RC","","","","both","","","332.00","249.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","263.94","79.5","","253.41","253.41","253.41","1 through 10","19.21","315.4","percent of total billed charges",""
"Culture Fungus ID Mold","PX-30001161","CDM","87107","CPT","0306","RC","","","","both","","","141.00","105.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","112.10","79.5","","107.82","107.82","107.82","1 through 10","10.11","133.95","percent of total billed charges",""
"Culture Fungus ID Mold","PX-30001161","CDM","87107","CPT","0306","RC","","","","both","","","141.00","105.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.47","36.5","","43.43","43.43","43.43","1 through 10","10.11","133.95","percent of total billed charges",""
"Culture Fungus ID Mold","PX-30001161","CDM","87107","CPT","0306","RC","","","","both","","","141.00","105.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.00","38.3","","52.06","52.06","52.06","1 through 10","10.11","133.95","percent of total billed charges",""
"Culture Fungus ID Mold","PX-30001161","CDM","87107","CPT","0306","RC","","","","outpatient","","","141.00","105.75","AETNA [1001]","HB AMC AETNA HMO","98.42","69.8","","92.75","7.11","92.75","1 through 10","10.65","115.23","percent of total billed charges",""
"Culture Fungus ID Mold","PX-30001161","CDM","87107","CPT","0306","RC","","","","outpatient","","","141.00","105.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","115.23","81.72","","109.52","109.52","109.52","1 through 10","10.65","115.23","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","both","","","142.00","106.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","112.89","79.5","","108.61","72.86","325.83","1 through 10","10.11","134.9","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","both","","","142.00","106.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","75.69","53.3","","72.86","69.69","108.61","1 through 10","10.11","134.9","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","both","","","142.00","106.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.83","36.5","","51.47","43.75","154.41","1 through 10","10.11","134.9","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","both","","","142.00","106.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.39","38.3","","53.96","52.44","157.32","22","10.11","134.9","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","outpatient","","","142.00","106.50","AETNA [1001]","HB AMC AETNA HMO","99.12","69.8","","93.43","7.16","93.43","1 through 10","10.65","116.04","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","outpatient","","","142.00","106.50","AETNA [1001]","HB AMC AETNA PPO","114.17","80.4","","107.64","107.64","107.64","1 through 10","10.65","116.04","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","outpatient","","","142.00","106.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","116.04","81.72","","110.32","60.68","110.32","1 through 10","10.65","116.04","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","outpatient","","","142.00","106.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","116.04","81.72","","110.32","60.68","110.32","1 through 10","10.65","116.04","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","91.00","65","","265.20","265.20","265.20","1 through 10","8.24","133","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","98.00","70","","136.00","136.00","136.00","1 through 10","8.24","133","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","both","","","140.00","105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.30","79.5","","107.03","71.81","282.53","42","8.24","133","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","both","","","140.00","105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.62","53.3","","71.81","71.81","107.03","12","8.24","133","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","both","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","91.00","65","","176.80","176.80","176.80","1 through 10","8.24","133","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","both","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","111.30","79.5","","107.03","107.03","107.03","1 through 10","8.24","133","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.10","36.5","","50.73","43.11","152.19","42","8.24","133","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.62","38.3","","53.18","51.68","159.54","110","8.24","133","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","both","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.06","42.9","","108.72","59.80","108.72","1 through 10","8.24","133","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA HMO","97.72","69.8","","92.07","65.01","184.14","35","8.67","114.41","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA PPO","112.56","80.4","","106.08","71.26","106.08","1 through 10","8.67","114.41","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","outpatient","","","140.00","105.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","73.16","52.26","","84.16","84.16","84.16","1 through 10","8.67","114.41","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.41","81.72","","108.72","59.80","108.72","1 through 10","8.67","114.41","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.41","81.72","","108.72","59.80","108.72","41","8.67","114.41","percent of total billed charges",""
"Culture Mycoplasma","PX-30001163","CDM","87109","CPT","0306","RC","","","","both","","","253.00","189.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","92.35","36.5","","91.39","76.93","91.39","1 through 10","15.08","240.35","percent of total billed charges",""
"Culture Mycoplasma","PX-30001163","CDM","87109","CPT","0306","RC","","","","both","","","253.00","189.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.90","38.3","","95.80","95.80","95.80","1 through 10","15.08","240.35","percent of total billed charges",""
"Culture Mycoplasma","PX-30001163","CDM","87109","CPT","0306","RC","","","","outpatient","","","253.00","189.75","AETNA [1001]","HB AMC AETNA HMO","176.59","69.8","","191.10","165.87","191.10","1 through 10","15.86","206.75","percent of total billed charges",""
"Culture Oocyte/Embryos <4 Days","PX-30000120","CDM","89250","CPT","0300","RC","","","","both","","","6161.00","4620.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4041.62","65.6","","4045.08","4045.08","4045.08","1 through 10","199.41","5852.95","percent of total billed charges",""
"Culture Oocyte/Embryos <4 Days","PX-30000120","CDM","89250","CPT","0300","RC","","","","both","","","6161.00","4620.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4898.00","79.5","","3154.80","3154.80","5975.00","1 through 10","199.41","5852.95","percent of total billed charges",""
"Culture Oocyte/Embryos <4 Days","PX-30000120","CDM","89250","CPT","0300","RC","","","","both","","","6161.00","4620.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3283.81","53.3","","4702.33","4702.33","4702.33","1 through 10","199.41","5852.95","percent of total billed charges",""
"Culture Oocyte/Embryos <4 Days","PX-30000120","CDM","89250","CPT","0300","RC","","","","both","","","6161.00","4620.75","WELLPOINT [1015]","HB AMC WELLPOINT","4545.59","73.78","","10423.39","4448.39","10423.39","1 through 10","199.41","5852.95","percent of total billed charges",""
"Culture Oocyte/Embryos <4 Days","PX-30000120","CDM","89250","CPT","0300","RC","","","","outpatient","","","6161.00","4620.75","AETNA [1001]","HB AMC AETNA HMO","4300.38","69.8","","4045.08","2856.05","4660.50","1 through 10","297.92","5034.77","percent of total billed charges",""
"Culture Oocyte/Embryos <4 Days","PX-30000120","CDM","89250","CPT","0300","RC","","","","outpatient","","","6161.00","4620.75","AETNA [1001]","HB AMC AETNA PPO","4953.44","80.4","","4660.50","4660.50","4660.50","1 through 10","297.92","5034.77","percent of total billed charges",""
"Culture Oocyte/Embryos <4 Days","PX-30000120","CDM","89250","CPT","0300","RC","","","","outpatient","","","6161.00","4620.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5034.77","81.72","","4776.42","4776.42","4776.42","1 through 10","297.92","5034.77","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","115.00","86.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","80.50","70","","80.64","80.64","80.64","1 through 10","6.5","109.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","115.00","86.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","91.43","79.5","","88.14","59.14","105.77","82","6.5","109.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","115.00","86.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","61.30","53.3","","59.14","59.14","88.14","38","6.5","109.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","115.00","86.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","88.55","77","","86.24","86.24","86.24","1 through 10","6.5","109.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","35.65","31","","34.61","34.61","34.61","1 through 10","6.5","109.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.98","36.5","","41.78","35.50","106.50","82","6.5","109.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44.05","38.3","","43.79","42.56","127.68","328","6.5","109.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","115.00","86.25","MOLINA [1014]","HB BWH MOLINA","40.25","35","","13.15","13.15","13.15","1 through 10","6.5","109.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","115.00","86.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","88.55","77","","87.36","53.54","87.36","1 through 10","6.5","109.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","115.00","86.25","TRICARE [160005]","HB BWH TRICARE","109.25","95","","7.59","7.59","7.99","1 through 10","6.5","109.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.34","42.9","","49.25","49.25","89.53","1 through 10","6.5","109.25","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","115.00","86.25","AETNA [1001]","HB AMC AETNA HMO","80.27","69.8","","75.82","53.54","87.36","128","6.84","93.98","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","115.00","86.25","AETNA [1001]","HB AMC AETNA PPO","92.46","80.4","","58.69","58.69","87.36","13","6.84","93.98","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","115.00","86.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","64.29","55.9","","58.69","58.69","58.69","1 through 10","6.84","93.98","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","115.00","86.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","92.46","80.4","","87.36","87.36","87.36","1 through 10","6.84","93.98","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","93.98","81.72","","49.25","30.03","89.53","1 through 10","6.84","93.98","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.98","81.72","","89.53","49.25","89.53","84","6.84","93.98","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","both","","","123.00","92.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","97.79","79.5","","93.65","62.83","280.95","1 through 10","9.25","116.85","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","both","","","123.00","92.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.90","36.5","","44.39","44.39","44.39","1 through 10","9.25","116.85","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","both","","","123.00","92.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","47.11","38.3","","46.53","46.53","46.53","1 through 10","9.25","116.85","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","outpatient","","","123.00","92.25","AETNA [1001]","HB AMC AETNA HMO","85.85","69.8","","92.82","56.88","107.24","1 through 10","9.74","100.52","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","outpatient","","","123.00","92.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","100.52","81.72","","52.32","52.32","52.32","1 through 10","9.74","100.52","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","outpatient","","","123.00","92.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","100.52","81.72","","95.13","95.13","95.13","1 through 10","9.74","100.52","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","121.99","121.99","1 through 10","9.25","152","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","57.82","1 through 10","9.25","152","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","51.15","117.80","1 through 10","9.25","152","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","120.90","1 through 10","9.74","130.75","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","123.91","123.91","1 through 10","9.74","130.75","percent of total billed charges",""
"Culture Typing ID Bld Pthgn&Resist Typing 6+Trgt","PX-30003774","CDM","87154","CPT","0306","RC","","","","both","","","2591.00","1943.25","WELLPOINT [1015]","HB AMC WELLPOINT","1911.64","73.78","","1870.93","1870.93","1870.93","1 through 10","213.7","2461.45","percent of total billed charges",""
"Culture Typing ID Bld Pthgn&Resist Typing 6+Trgt","PX-30003774","CDM","87154","CPT","0306","RC","","","","outpatient","","","2591.00","1943.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2117.37","81.72","","2008.89","2008.89","2008.89","1 through 10","102.04","2137.58","percent of total billed charges",""
"Culture Typing if Ea Antiserum","PX-30001168","CDM","87140","CPT","0306","RC","","","","both","","","96.00","72.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","76.32","79.5","","73.19","73.19","73.19","1 through 10","5.46","91.2","percent of total billed charges",""
"Culture Typing Sequencing Meth Ea I","PX-30001174","CDM","87153","CPT","0306","RC","","","","outpatient","","","1389.00","1041.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1135.09","81.72","","1076.79","1076.79","1076.79","1 through 10","110.99","1135.09","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","100.52","71.8","","97.65","7.13","97.65","1 through 10","7.93","133","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","91.84","65.6","","8.32","8.32","8.32","1 through 10","7.93","133","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","91.00","65","","71.81","71.81","88.40","1 through 10","7.93","133","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","both","","","140.00","105.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","98.00","70","","175.44","28.05","175.44","1 through 10","7.93","133","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","both","","","140.00","105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.30","79.5","","107.03","71.81","107.03","74","7.93","133","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","both","","","140.00","105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.62","53.3","","71.81","71.81","107.03","35","7.93","133","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","43.40","31","","42.02","42.02","42.02","1 through 10","7.93","133","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.10","36.5","","50.73","43.11","50.73","74","7.93","133","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.62","38.3","","53.18","51.68","53.18","257","7.93","133","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","both","","","140.00","105.00","MOLINA [1014]","HB BWH MOLINA","49.00","35","","8.09","8.09","8.09","1 through 10","7.93","133","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","both","","","140.00","105.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","107.80","77","","106.08","106.08","106.08","1 through 10","7.93","133","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","both","","","140.00","105.00","TRICARE [160005]","HB BWH TRICARE","133.00","95","","9.26","9.26","9.75","1 through 10","7.93","133","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","both","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.06","42.9","","108.72","59.80","108.72","1 through 10","7.93","133","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA HMO","97.72","69.8","","92.07","65.01","106.08","130","8.36","114.41","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA PPO","112.56","80.4","","106.08","71.26","212.16","13","8.36","114.41","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","outpatient","","","140.00","105.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","73.16","52.26","","28.87","28.87","28.87","1 through 10","8.36","114.41","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","outpatient","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.56","80.4","","106.08","106.08","108.72","1 through 10","8.36","114.41","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.41","81.72","","59.80","56.58","108.72","1 through 10","8.36","114.41","percent of total billed charges",""
"Culture Urine ID Ea Isolate","PX-30001155","CDM","87088","CPT","0306","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.41","81.72","","108.72","59.80","108.72","103","8.36","114.41","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","74.67","71.8","","72.52","7.12","152.16","13","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","68.22","65.6","","8.30","8.30","8.30","1 through 10","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","67.60","65","","60.60","53.33","196.95","11","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","72.80","70","","130.29","28.91","130.29","12","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","82.68","79.5","","79.49","53.33","79.49","361","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","55.43","53.3","","53.33","53.33","79.49","184","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","80.08","77","","77.77","77.77","77.77","1 through 10","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","67.60","65","","65.65","65.65","65.65","1 through 10","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","82.68","79.5","","79.49","79.49","79.49","1 through 10","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","32.24","31","","31.21","31.21","62.42","18","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37.96","36.5","","37.67","32.02","37.67","372","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39.83","38.3","","39.49","38.38","39.49","1274","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","MOLINA [1014]","HB BWH MOLINA","36.40","35","","16.01","8.07","23.95","15","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","80.08","77","","77.77","68.38","78.78","1 through 10","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","TRICARE [160005]","HB BWH TRICARE","98.80","95","","9.72","9.23","9.72","27","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.62","42.9","","80.74","44.41","181.74","15","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","104.00","78.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.62","42.9","","44.41","44.41","44.41","1 through 10","7.91","98.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","104.00","78.00","AETNA [1001]","HB AMC AETNA HMO","72.59","69.8","","68.38","48.28","78.78","585","8.33","84.99","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","104.00","78.00","AETNA [1001]","HB AMC AETNA PPO","83.62","80.4","","67.60","48.28","78.78","69","8.33","84.99","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","104.00","78.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","58.14","55.9","","52.92","52.92","78.78","1 through 10","8.33","84.99","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","104.00","78.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","54.35","52.26","","28.87","28.87","28.87","12","8.33","84.99","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","104.00","78.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","83.62","80.4","","78.78","50.50","80.74","1 through 10","8.33","84.99","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","104.00","78.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","84.99","81.72","","80.74","80.74","99.35","1 through 10","8.33","84.99","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","84.99","81.72","","44.41","42.02","80.74","20","8.33","84.99","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","84.99","81.72","","80.74","44.41","80.74","461","8.33","84.99","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1737.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1030.75","2643.38","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2643.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1030.75","2643.38","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1213.63","36.5","","1023.42","771.29","2068.67","33","1030.75","2643.38","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1273.48","38.3","","850.52","759.78","1211.25","66","1030.75","2643.38","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","2548.09","2548.09","2548.09","1 through 10","1030.75","2643.38","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","956.46","956.46","956.46","1 through 10","1030.75","2643.38","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","WELLPOINT [1015]","HB AMC WELLPOINT","2453.19","73.78","","2344.73","1619.47","2530.35","16","1030.75","2643.38","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA HMO","2320.85","69.8","","1523.63","988.41","4330.26","39","1737.65","2717.19","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA PPO","2673.30","80.4","","1670.25","1670.25","1670.25","1 through 10","1737.65","2717.19","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1737.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1737.65","2717.19","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2717.19","81.72","","1738.90","1484.65","2716.94","38","1737.65","2717.19","percent of total billed charges",""
"Curettage Endocervical","PX-76001369","CDM","57505","CPT","0761","RC","","","","both","","","1312.00","984.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.04","79.5","","959.09","959.09","959.09","1 through 10","406.72","1292.44","percent of total billed charges",""
"Curettage Endocervical","PX-76001369","CDM","57505","CPT","0761","RC","","","","both","","","1312.00","984.00","MEDICARE [2001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1034.06","1034.06","1034.06","1 through 10","406.72","1292.44","other","OPPS APC"
"Curettage Endocervical","PX-76001369","CDM","57505","CPT","0761","RC","","","","both","","","1312.00","984.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.50","38.3","","497.35","497.35","497.35","1 through 10","406.72","1292.44","percent of total billed charges",""
"Curettage Endocervical","PX-76001369","CDM","57505","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","AETNA [1001]","HB AMC AETNA HMO","915.78","69.8","","1198.29","1198.29","1198.29","1 through 10","558.04","2384.07","percent of total billed charges",""
"Curettage Endocervical","PX-76001369","CDM","57505","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1305.65","1282.04","1305.65","1 through 10","558.04","2384.07","other","ASC"
"Curettage Endocervical","PX-76001369","CDM","57505","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1479.23","327.97","1493.91","1 through 10","558.04","2384.07","other","ASC "
"Curettage Endocervical","PX-76001369","CDM","57505","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1294.65","1294.65","1294.65","1 through 10","558.04","2384.07","other","Multiple Surgery"
"Curettage Endocervical","PX-76001369","CDM","57505","CPT","0761","RC","","","","outpatient","","","1312.00","984.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1072.17","81.72","","6667.00","1016.84","6667.00","1 through 10","558.04","2384.07","percent of total billed charges",""
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","both","","","4642.00","3481.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1777.89","38.3","","5280.84","1760.28","5280.84","1 through 10","1439.02","4719.38","percent of total billed charges",""
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","outpatient","","","4642.00","3481.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5424.80","5424.80","5424.80","1 through 10","2125.14","5545.35","other","ASC"
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","outpatient","","","4642.00","3481.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6259.18","6259.18","6321.29","1 through 10","2125.14","5545.35","other","ASC "
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","outpatient","","","4642.00","3481.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4739.06","4739.06","4739.06","1 through 10","2125.14","5545.35","other","Multiple Surgery"
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","outpatient","","","4642.00","3481.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","15556.02","15556.02","15556.02","1 through 10","2125.14","5545.35","other","Multiple Surgery"
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","outpatient","","","4642.00","3481.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","5371.04","5371.04","5371.04","1 through 10","2125.14","5545.35","other","Multiple Surgery"
"Custom Tracheostomy/Laryngectomy Tube, Cuffed, Pvc","PX-27001157","CDM","A7521","HCPCS","0274","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","31.33","31.33","31.33","1 through 10","64.42","834.75","percent of total billed charges",""
"Cva And Precerebral Occlusion With Infarction,EXTREME","045","DRG","","","","","","","","inpatient","","","95856.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","61279.73","","Standard inlier is a Case rate ($61,279.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,300, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,699.03) for the length of stay and the standard reimbursement.","61279.72","61279.72","61279.72","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,EXTREME","045","DRG","","","","","","","","inpatient","","","95856.10","","HEALTH NEW ENGLAND [1034]","HB BWH MEDICAID","21308.55","","Case rate ($23,560.27). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,990.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","331730.55","331730.55","331730.55","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,EXTREME","045","DRG","","","","","","","","inpatient","","","95856.10","","MASSHEALTH [3001]","HB BWH MEDICAID","21308.55","","Case rate ($23,560.27). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,990.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25898.77","25898.77","78015.45","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,EXTREME","045","DRG","","","","","","","","inpatient","","","95856.10","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","21308.55","","Case rate ($23,560.27). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,990.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5169.87","5169.87","5169.87","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52264.54","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","40762.60","","Standard inlier is a Case rate ($40,762.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,347, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,786.50) for the length of stay and the standard reimbursement.","40762.59","37159.76","56481.09","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52264.54","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","45828.14","","Standard inlier is a Case rate ($45,828.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,347, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,504.92) for the length of stay and the standard reimbursement.","41867.96","5302.50","45828.14","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52264.54","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18213.4481","","Fee schedule rate ($39,757.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18213.4481","39757.36","39757.36","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52264.54","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","19124.6498","","Fee schedule rate ($41,746.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19124.6498","40135.96","40135.96","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52264.54","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","43733.61","","Fee schedule rate ($43,733.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","43733.60","43733.60","43733.60","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52264.54","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","55599.68","55599.68","55599.68","1 through 10","5115.51","138604.17","percent of total billed charges",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52264.54","","MASSHEALTH [3001]","HB BWH MEDICAID","11375.68","","Case rate ($12,577.77). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,007.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12574.68","4172.93","12574.68","12","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52264.54","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38192.90","","Fee schedule rate ($38,192.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38192.90","38192.90","38192.90","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52264.54","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40103.17","","Fee schedule rate ($40,103.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40103.17","40103.17","40103.17","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","52264.54","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11375.68","","Case rate ($12,577.77). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,007.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12574.68","2486.27","12574.68","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MINOR","045","DRG","","","","","","","","inpatient","","","43013.67","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24617.97","","Standard inlier is a Case rate ($24,617.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,494.67) for the length of stay and the standard reimbursement.","24280.56","24280.56","24280.56","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MINOR","045","DRG","","","","","","","","inpatient","","","43013.67","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","27677.23","","Standard inlier is a Case rate ($27,677.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,928.55) for the length of stay and the standard reimbursement.","27677.23","27677.23","27677.23","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MINOR","045","DRG","","","","","","","","inpatient","","","43013.67","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","19124.6498","","Fee schedule rate ($19,124.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19124.6498","18386.88","18386.88","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","57975.69","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","30452.29","","Standard inlier is a Case rate ($30,452.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,329, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,322.89) for the length of stay and the standard reimbursement.","27758.36","27758.36","30452.28","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","57975.69","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","34236.58","","Standard inlier is a Case rate ($34,236.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,329, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,859.60) for the length of stay and the standard reimbursement.","34236.57","34236.57","34236.57","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","57975.69","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18213.4481","","Fee schedule rate ($24,523.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18213.4481","24523.16","24523.16","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","57975.69","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","30255.16","","Fee schedule rate ($30,255.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30654.25","30654.25","30654.25","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","57975.69","","MASSHEALTH [3001]","HB BWH MEDICAID","7046.11","","Case rate ($7,790.69). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,220.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7788.77","7788.77","7788.77","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","57975.69","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","7046.11","","Case rate ($7,790.69). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,220.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1020.93","1020.93","1020.93","1 through 10","5115.51","138604.17","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","57975.69","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7046.11","","Case rate ($7,790.69). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,220.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7788.78","7788.78","7788.78","1 through 10","5115.51","138604.17","case rate",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","154.00","115.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","110.57","71.8","","34.26","34.26","34.26","1 through 10","12.69","146.3","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","154.00","115.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","122.43","79.5","","117.26","78.67","351.78","59","12.69","146.3","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","154.00","115.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","82.08","53.3","","117.26","78.67","351.78","49","12.69","146.3","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","154.00","115.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","118.58","77","","344.19","114.73","344.19","1 through 10","12.69","146.3","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","154.00","115.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","100.10","65","","78.97","78.97","78.97","1 through 10","12.69","146.3","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","154.00","115.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","122.43","79.5","","117.26","117.26","117.26","1 through 10","12.69","146.3","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","154.00","115.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","47.74","31","","46.04","46.04","46.04","1 through 10","12.69","146.3","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","154.00","115.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56.21","36.5","","55.58","47.23","166.74","52","12.69","146.3","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","154.00","115.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.98","38.3","","58.26","58.26","174.78","190","12.69","146.3","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","154.00","115.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","118.58","77","","149.00","149.00","149.00","1 through 10","12.69","146.3","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","154.00","115.50","TRICARE [160005]","HB BWH TRICARE","146.30","95","","15.60","14.82","15.60","1 through 10","12.69","146.3","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","154.00","115.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.07","42.9","","119.11","65.52","119.11","1 through 10","12.69","146.3","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","154.00","115.50","AETNA [1001]","HB AMC AETNA HMO","107.49","69.8","","100.87","71.22","149.00","68","13.35","125.85","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","154.00","115.50","AETNA [1001]","HB AMC AETNA PPO","123.82","80.4","","116.22","78.08","156.16","1 through 10","13.35","125.85","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","154.00","115.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","80.48","52.26","","92.20","92.20","92.20","1 through 10","13.35","125.85","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","154.00","115.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","123.82","80.4","","74.50","74.50","74.50","1 through 10","13.35","125.85","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","154.00","115.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","125.85","81.72","","119.11","65.52","119.11","1 through 10","13.35","125.85","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","154.00","115.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.85","81.72","","119.11","65.52","119.11","59","13.35","125.85","percent of total billed charges",""
"Cyclosporine (Sandimmune)","PX-30000021","CDM","80158","CPT","0301","RC","","","","both","","","282.00","211.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","197.40","70","","273.00","196.56","273.00","15","17.69","267.9","percent of total billed charges",""
"Cyclosporine (Sandimmune)","PX-30000021","CDM","80158","CPT","0301","RC","","","","both","","","282.00","211.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","150.31","53.3","","214.85","200.02","214.85","12","17.69","267.9","percent of total billed charges",""
"Cyclosporine (Sandimmune)","PX-30000021","CDM","80158","CPT","0301","RC","","","","both","","","282.00","211.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","108.01","38.3","","90.09","90.09","320.22","1 through 10","17.69","267.9","percent of total billed charges",""
"Cyclosporine (Sandimmune)","PX-30000021","CDM","80158","CPT","0301","RC","","","","outpatient","","","282.00","211.50","AETNA [1001]","HB AMC AETNA HMO","196.84","69.8","","184.82","184.82","212.94","1 through 10","18.62","230.45","percent of total billed charges",""
"Cyclosporine Neoral Cap 100mg","PX-63600218","CDM","J7502","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.47","46.9","","4.96","4.61","5.25","1 through 10","0.47","4.45","percent of total billed charges",""
"Cyclosporine Neoral Cap 25mg","PX-63600224","CDM","J7515","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.47","46.9","","1.19","1.05","2.52","1 through 10","0.47","1.66","percent of total billed charges",""
"CYLINDER GRAFT SM SIZE 9 PLUG CP CHRONOS RESORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082906","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.53","1113.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1180.20","79.5","","800.18","480.96","1887.97","195","460.2","1180.2","percent of total billed charges",""
"CYLINDER GRAFT SM SIZE 9 PLUG CP CHRONOS RESORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082906","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.53","1113.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","791.25","53.3","","813.12","216.42","1444.50","81","460.2","1180.2","percent of total billed charges",""
"CYLINDER GRAFT SM SIZE 9 PLUG CP CHRONOS RESORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082906","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.53","1113.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","460.20","31","","432.60","432.60","432.60","1 through 10","460.2","1180.2","percent of total billed charges",""
"CYLINDER GRAFT SM SIZE 9 PLUG CP CHRONOS RESORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082906","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.53","1113.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","541.85","36.5","","148.37","54.89","631.39","94","460.2","1180.2","percent of total billed charges",""
"CYLINDER GRAFT SM SIZE 9 PLUG CP CHRONOS RESORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082906","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.53","1113.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","568.57","38.3","","279.30","91.72","1116.77","266","460.2","1180.2","percent of total billed charges",""
"CYLINDER GRAFT SM SIZE 9 PLUG CP CHRONOS RESORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082906","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.53","1113.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","636.86","42.9","","731.00","63.70","731.00","1 through 10","460.2","1180.2","percent of total billed charges",""
"CYLINDER GRAFT SM SIZE 9 PLUG CP CHRONOS RESORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082906","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.53","1113.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","636.86","42.9","","384.74","384.74","384.74","1 through 10","460.2","1180.2","percent of total billed charges",""
"CYLINDER GRAFT SM SIZE 9 PLUG CP CHRONOS RESORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082906","CDM","C1713","HCPCS","0278","RC","","","","both","","","1484.53","1113.40","WELLPOINT [1015]","HB AMC WELLPOINT","1095.29","73.78","","286.63","119.22","1107.45","105","460.2","1180.2","percent of total billed charges",""
"CYLINDER GRAFT SM SIZE 9 PLUG CP CHRONOS RESORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1484.53","1113.40","AETNA [1001]","HB AMC AETNA HMO","1036.20","69.8","","675.31","184.75","1721.50","286","775.82","1213.16","percent of total billed charges",""
"CYLINDER GRAFT SM SIZE 9 PLUG CP CHRONOS RESORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1484.53","1113.40","AETNA [1001]","HB AMC AETNA PPO","1193.56","80.4","","1261.44","103.12","1514.10","21","775.82","1213.16","percent of total billed charges",""
"CYLINDER GRAFT SM SIZE 9 PLUG CP CHRONOS RESORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1484.53","1113.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1193.56","80.4","","1365.00","1365.00","1365.00","1 through 10","775.82","1213.16","percent of total billed charges",""
"CYLINDER GRAFT SM SIZE 9 PLUG CP CHRONOS RESORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1484.53","1113.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1213.16","81.72","","5157.68","5157.68","5157.68","1 through 10","775.82","1213.16","percent of total billed charges",""
"CYLINDER GRAFT SM SIZE 9 PLUG CP CHRONOS RESORBABLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1484.53","1113.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1213.16","81.72","","431.26","71.26","1459.57","88","775.82","1213.16","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","117.75","71.8","","342.48","48.99","342.48","17","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","107.58","65.6","","107.64","107.64","107.64","1 through 10","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","106.60","65","","103.35","103.35","103.35","1 through 10","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","114.80","70","","114.48","69.91","159.00","1 through 10","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","130.38","79.5","","125.13","83.95","129.00","56","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","87.41","53.3","","89.39","83.95","178.78","34","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","126.28","77","","122.43","122.43","122.43","1 through 10","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","106.60","65","","224.25","103.35","224.25","1 through 10","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","50.84","31","","49.13","49.13","49.13","1 through 10","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","59.86","36.5","","59.31","50.40","114.16","70","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.81","38.3","","62.17","62.17","177.93","199","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","MOLINA [1014]","HB BWH MOLINA","57.40","35","","36.74","36.74","36.74","1 through 10","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","126.28","77","","124.02","124.02","124.02","1 through 10","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","TRICARE [160005]","HB BWH TRICARE","155.80","95","","21.20","21.20","21.20","1 through 10","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","164.00","123.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.36","42.9","","127.10","72.35","127.10","1 through 10","11.72","155.8","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","164.00","123.00","AETNA [1001]","HB AMC AETNA HMO","114.47","69.8","","107.64","76.00","124.02","114","11.72","134.02","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","164.00","123.00","AETNA [1001]","HB AMC AETNA PPO","131.86","80.4","","124.02","76.00","133.46","1 through 10","11.72","134.02","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","164.00","123.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","131.86","80.4","","124.02","124.02","124.02","1 through 10","11.72","134.02","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","164.00","123.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","134.02","81.72","","127.10","127.10","127.10","1 through 10","11.72","134.02","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","164.00","123.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","134.02","81.72","","127.10","69.91","159.00","1 through 10","11.72","134.02","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","164.00","123.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","134.02","81.72","","127.10","69.91","127.10","71","11.72","134.02","percent of total billed charges",""
"Cystic Fibrosis - Pulmonary Disease,EXTREME","131","DRG","","","","","","","","inpatient","","","64399.51","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","34100.7282","","Fee schedule rate ($74,063.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34100.7282","74063.84","74063.84","1 through 10","28273.56","122206.84","case rate",""
"Cystic Fibrosis - Pulmonary Disease,MAJOR","131","DRG","","","","","","","","inpatient","","","99800.62","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","70658.39","","Fee schedule rate ($70,658.39). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($8,175.46) multiplied by length of stay and the outlier percent (100%).","64552.53","24526.38","64552.53","1 through 10","28273.56","122206.84","case rate",""
"Cystic Fibrosis - Pulmonary Disease,MAJOR","131","DRG","","","","","","","","inpatient","","","99800.62","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","34100.7282","","Fee schedule rate ($44,953.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34100.7282","49677.89","49677.89","1 through 10","28273.56","122206.84","case rate",""
"Cystic Fibrosis - Pulmonary Disease,MAJOR","131","DRG","","","","","","","","inpatient","","","99800.62","","MASSHEALTH [3001]","HB BWH MEDICAID","31018.66","","Case rate ($34,296.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,726.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","34288.05","34288.05","34288.05","1 through 10","28273.56","122206.84","case rate",""
"Cystic Fibrosis - Pulmonary Disease,MODERATE","131","DRG","","","","","","","","inpatient","","","50678.92","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","53045.60","","Standard inlier is a Case rate ($53,045.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,339, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,529.38) for the length of stay and the standard reimbursement.","53045.60","53045.60","53045.60","1 through 10","28273.56","122206.84","case rate",""
"Cysto Fulg Lesion Minor <.5cm","PX-76001279","CDM","52224","CPT","0761","RC","","","","both","","","6992.00","5244.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3726.74","53.3","","7960.11","4841.23","7960.11","1 through 10","2167.52","5558.64","percent of total billed charges",""
"Cysto Fulg Lesion Minor <.5cm","PX-76001279","CDM","52224","CPT","0761","RC","","","","both","","","6992.00","5244.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2552.08","36.5","","6067.22","5888.29","6067.22","1 through 10","2167.52","5558.64","percent of total billed charges",""
"Cysto Fulg Lesion Minor <.5cm","PX-76001279","CDM","52224","CPT","0761","RC","","","","both","","","6992.00","5244.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2677.94","38.3","","6360.01","4810.47","6360.01","1 through 10","2167.52","5558.64","percent of total billed charges",""
"Cysto Fulg Lesion Minor <.5cm","PX-76001279","CDM","52224","CPT","0761","RC","","","","both","","","6992.00","5244.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","5383.84","77","","6400.67","6400.67","6400.67","1 through 10","2167.52","5558.64","percent of total billed charges",""
"Cysto Fulg Lesion Minor <.5cm","PX-76001279","CDM","52224","CPT","0761","RC","","","","outpatient","","","6992.00","5244.00","AETNA [1001]","HB AMC AETNA HMO","4880.42","69.8","","11563.78","9530.47","11563.78","1 through 10","2796.8","5713.86","percent of total billed charges",""
"Cysto Fulg Lesion Minor <.5cm","PX-76001279","CDM","52224","CPT","0761","RC","","","","outpatient","","","6992.00","5244.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4233.66","60.55","","4070.52","3996.91","4070.52","1 through 10","2796.8","5713.86","percent of total billed charges",""
"Cysto Fulg Lesion Minor <.5cm","PX-76001279","CDM","52224","CPT","0761","RC","","","","outpatient","","","6992.00","5244.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3651.22","52.22","","4657.42","4657.42","4657.42","1 through 10","2796.8","5713.86","percent of total billed charges",""
"Cysto Fulg Tumor Small 0.5-2.0cm","PX-76001280","CDM","52234","CPT","0761","RC","","","","both","","","6992.00","5244.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2677.94","38.3","","7909.54","7909.54","7909.54","1 through 10","2167.52","5558.64","percent of total billed charges",""
"Cysto Fulg Tumor Small 0.5-2.0cm","PX-76001280","CDM","52234","CPT","0761","RC","","","","both","","","6992.00","5244.00","WELLPOINT [1015]","HB AMC WELLPOINT","5158.70","73.78","","12110.04","12110.04","12110.04","1 through 10","2167.52","5558.64","percent of total billed charges",""
"Cysto Fulg Tumor Small 0.5-2.0cm","PX-76001280","CDM","52234","CPT","0761","RC","","","","outpatient","","","6992.00","5244.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3651.22","52.22","","7835.40","7758.42","7835.40","1 through 10","2796.8","5713.86","percent of total billed charges",""
"Cysto Fulg Tumor Small 0.5-2.0cm","PX-76001280","CDM","52234","CPT","0761","RC","","","","outpatient","","","6992.00","5244.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5713.86","81.72","","16171.06","16171.06","16171.06","1 through 10","2796.8","5713.86","percent of total billed charges",""
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4194.00","3145.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2505.46","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2504.60","2504.60","2504.60","1 through 10","1300.14","3334.23","other","OPPS APC"
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4194.00","3145.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2726.10","65","","5421.01","5421.00","7996.95","1 through 10","1300.14","3334.23","percent of total billed charges",""
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4194.00","3145.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2935.80","70","","5290.29","5290.29","5290.29","1 through 10","1300.14","3334.23","percent of total billed charges",""
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4194.00","3145.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","3040.60","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","1801.32","1801.32","1801.32","1 through 10","1300.14","3334.23","other","OPPS APC"
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4194.00","3145.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2384.08","2384.08","2384.08","1 through 10","1300.14","3334.23","other","OPPS APC"
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4194.00","3145.50","MEDICARE [2001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","1 through 10","1300.14","3334.23","other","OPPS APC"
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4194.00","3145.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1606.30","38.3","","6181.08","3260.94","6181.08","1 through 10","1300.14","3334.23","percent of total billed charges",""
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4194.00","3145.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2393.81","2393.81","2393.81","1 through 10","1300.14","3334.23","other","OPPS APC"
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4194.00","3145.50","WELLPOINT [1015]","HB AMC WELLPOINT","3094.33","73.78","","9159.58","9005.47","9159.58","1 through 10","1300.14","3334.23","percent of total billed charges",""
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","outpatient","","","4194.00","3145.50","AETNA [1001]","HB AMC AETNA HMO","2927.41","69.8","","8329.13","6505.20","8329.13","1 through 10","1565.78","5545.35","percent of total billed charges",""
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","outpatient","","","4194.00","3145.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3996.91","3996.91","3996.91","1 through 10","1565.78","5545.35","other","ASC"
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","outpatient","","","4194.00","3145.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4657.42","2305.83","4657.42","1 through 10","1565.78","5545.35","other","ASC "
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","outpatient","","","4194.00","3145.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3632.61","3632.61","7265.22","1 through 10","1565.78","5545.35","other","Multiple Surgery"
"Cysto W/Catheterizat Ureteral","PX-76001277","CDM","52005","CPT","0761","RC","","","","outpatient","","","6992.00","5244.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3651.22","52.22","","4611.66","4611.66","4611.66","1 through 10","2796.8","5713.86","percent of total billed charges",""
"Cysto W/Dilat Stricture Urethral","PX-76001282","CDM","52281","CPT","0761","RC","","","","outpatient","","","4194.00","3145.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2539.47","60.55","","3996.91","3996.91","3996.91","1 through 10","1677.6","3427.34","percent of total billed charges",""
"Cysto W/Dilat Stricture Urethral","PX-76001282","CDM","52281","CPT","0761","RC","","","","outpatient","","","4194.00","3145.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3427.34","81.72","","5409.63","5409.63","5409.63","1 through 10","1677.6","3427.34","percent of total billed charges",""
"Cysto/Pyeloscopy Diagnostic","PX-76001287","CDM","52351","CPT","0761","RC","","","","outpatient","","","3992.00","2994.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2084.62","52.22","","4657.42","2328.71","4657.42","1 through 10","1596.8","3262.26","percent of total billed charges",""
"Cystometrogram/Emg Smp","PX-76001264","CDM","51725","CPT","0761","RC","","","","both","","","1767.00","1325.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","676.76","38.3","","670.17","670.17","670.17","1 through 10","274.39","1404.77","percent of total billed charges",""
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1913.00","1434.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","816.36","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","822.64","822.64","822.64","1 through 10","593.03","1520.84","other","OPPS APC"
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1913.00","1434.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","792.58","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","779.98","779.98","779.98","1 through 10","593.03","1520.84","other","OPPS APC"
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1913.00","1434.75","MEDICARE [2001]","HB BWH MEDICARE","792.58","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","792.66","792.66","792.66","11","593.03","1520.84","other","OPPS APC"
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1913.00","1434.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","732.68","38.3","","725.31","725.31","725.31","1 through 10","593.03","1520.84","percent of total billed charges",""
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1913.00","1434.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","776.73","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","776.81","738.55","784.71","1 through 10","593.03","1520.84","other","OPPS APC"
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1913.00","1434.75","WELLPOINT [1015]","HB AMC WELLPOINT","1411.41","73.78","","6209.13","6209.13","6209.13","1 through 10","593.03","1520.84","percent of total billed charges",""
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","outpatient","","","1913.00","1434.75","AETNA [1001]","HB AMC AETNA HMO","1335.27","69.8","","1255.84","1255.84","1255.84","1 through 10","562.25","2384.07","percent of total billed charges",""
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","outpatient","","","1913.00","1434.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","642.96","","Case rate ($642.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1315.50","1291.71","1315.50","1 through 10","562.25","2384.07","other","ASC"
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","outpatient","","","1913.00","1434.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","642.96","","Case rate ($642.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1490.38","1490.38","1505.17","1 through 10","562.25","2384.07","other","ASC "
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","outpatient","","","1913.00","1434.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","562.25","","Case rate ($562.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1304.42","1304.42","1304.42","1 through 10","562.25","2384.07","other","Multiple Surgery"
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","outpatient","","","1913.00","1434.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","562.25","","Case rate ($562.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1630.53","1630.53","1630.53","1 through 10","562.25","2384.07","other","Multiple Surgery"
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","outpatient","","","1913.00","1434.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1563.30","81.72","","25675.13","25675.13","25675.13","1 through 10","562.25","2384.07","percent of total billed charges",""
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4194.00","3145.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2683.34","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2512.18","2508.39","2512.18","1 through 10","1300.14","3334.23","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4194.00","3145.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2605.19","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2393.81","2393.81","2393.81","1 through 10","1300.14","3334.23","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4194.00","3145.50","MEDICARE [2001]","HB BWH MEDICARE","2605.19","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","21","1300.14","3334.23","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4194.00","3145.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1606.30","38.3","","9378.14","9378.14","9378.14","1 through 10","1300.14","3334.23","percent of total billed charges",""
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4194.00","3145.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2605.19","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2386.58","2386.58","2386.58","1 through 10","1300.14","3334.23","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4194.00","3145.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2553.09","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2384.08","2185.57","2391.98","1 through 10","1300.14","3334.23","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","outpatient","","","4194.00","3145.50","AETNA [1001]","HB AMC AETNA HMO","2927.41","69.8","","5646.18","5506.04","5646.18","1 through 10","1565.78","5545.35","percent of total billed charges",""
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","outpatient","","","4194.00","3145.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1998.46","1998.46","1998.46","1 through 10","1565.78","5545.35","other","ASC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","outpatient","","","4194.00","3145.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4611.66","2328.71","4657.42","1 through 10","1565.78","5545.35","other","ASC "
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","outpatient","","","4194.00","3145.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3632.61","3632.61","3632.61","1 through 10","1565.78","5545.35","other","Multiple Surgery"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","outpatient","","","4194.00","3145.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","7359.16","7359.16","7359.16","1 through 10","1565.78","5545.35","other","Multiple Surgery"
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","both","","","450.00","337.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","292.50","65","","283.40","283.40","283.40","1 through 10","25.96","427.5","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","both","","","450.00","337.50","CHAMPVA [160001]","HB BWH TRICARE","427.50","95","","300.00","300.00","300.00","1 through 10","25.96","427.5","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","both","","","450.00","337.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","357.75","79.5","","343.13","230.21","1029.39","510","25.96","427.5","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","both","","","450.00","337.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","239.85","53.3","","343.13","230.21","1029.39","319","25.96","427.5","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","357.75","79.5","","343.13","343.13","1013.65","1 through 10","25.96","427.5","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","both","","","450.00","337.50","MOLINA [1014]","HB BWH MOLINA","157.50","35","","52.45","52.45","52.45","1 through 10","25.96","427.5","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","both","","","450.00","337.50","TRICARE [160005]","HB BWH TRICARE","427.50","95","","30.32","30.32","31.92","58","25.96","427.5","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","both","","","450.00","337.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","427.50","95","","26.49","26.49","26.49","1 through 10","25.96","427.5","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.05","42.9","","348.54","191.71","348.54","35","25.96","427.5","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.05","42.9","","191.71","191.71","348.54","1 through 10","25.96","427.5","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","outpatient","","","450.00","337.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","235.17","52.26","","93.83","93.83","269.80","1 through 10","71.83","367.74","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","367.74","81.72","","348.54","191.71","348.54","27","71.83","367.74","percent of total billed charges",""
"Cyto Pap Tlp Auto/Man/Revie","PX-92000089","CDM","G0145","HCPCS","0311","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","367.74","81.72","","348.54","191.71","348.54","678","71.83","367.74","percent of total billed charges",""
"Cytogenomic Neoplasia Mircroarray Analysis","PX-31001061","CDM","81277","CPT","0310","RC","","","","outpatient","","","13787.00","10340.25","AETNA [1001]","HB AMC AETNA HMO","9623.33","69.8","","9051.49","9051.49","9051.49","1 through 10","2088","11266.74","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Cytokine Panel 13, Serum","PX-30003689","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","187.00","140.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","134.27","71.8","","389.88","129.96","389.88","21","14.1","177.65","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","187.00","140.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","122.67","65.6","","141.18","122.54","141.18","1 through 10","14.1","177.65","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","187.00","140.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","121.55","65","","117.65","117.65","142.45","1 through 10","14.1","177.65","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","187.00","140.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","130.90","70","","181.00","79.59","181.00","11","14.1","177.65","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","187.00","140.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","148.67","79.5","","142.45","95.57","427.35","15","14.1","177.65","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","187.00","140.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","99.67","53.3","","95.57","95.57","142.45","1 through 10","14.1","177.65","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","187.00","140.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","121.55","65","","117.65","117.65","117.65","1 through 10","14.1","177.65","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","187.00","140.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.26","36.5","","67.51","48.31","129.96","1 through 10","14.1","177.65","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","187.00","140.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71.62","38.3","","70.77","68.78","212.31","92","14.1","177.65","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","187.00","140.25","TRICARE [160005]","HB BWH TRICARE","177.65","95","","17.34","17.34","17.34","1 through 10","14.1","177.65","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","outpatient","","","187.00","140.25","AETNA [1001]","HB AMC AETNA HMO","130.53","69.8","","122.54","86.52","141.18","39","14.84","152.82","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","outpatient","","","187.00","140.25","AETNA [1001]","HB AMC AETNA PPO","150.35","80.4","","141.18","86.52","141.18","1 through 10","14.84","152.82","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","outpatient","","","187.00","140.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","150.35","80.4","","90.50","90.50","90.50","1 through 10","14.84","152.82","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","outpatient","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","152.82","81.72","","144.69","79.59","144.69","26","14.84","152.82","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","both","","","181.00","135.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","129.96","71.8","","379.11","126.37","379.11","1 through 10","14.72","171.95","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","both","","","181.00","135.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","118.74","65.6","","119.15","119.15","119.15","1 through 10","14.72","171.95","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","both","","","181.00","135.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","117.65","65","","114.40","114.40","114.40","1 through 10","14.72","171.95","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","both","","","181.00","135.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","126.70","70","","159.75","126.72","225.00","1 through 10","14.72","171.95","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","both","","","181.00","135.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","143.90","79.5","","138.51","92.93","415.53","12","14.72","171.95","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","both","","","181.00","135.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","96.47","53.3","","92.93","92.93","138.51","1 through 10","14.72","171.95","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","both","","","181.00","135.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","66.07","36.5","","65.65","46.97","65.65","1 through 10","14.72","171.95","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","both","","","181.00","135.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","69.32","38.3","","68.82","66.88","171.46","75","14.72","171.95","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","outpatient","","","181.00","135.75","AETNA [1001]","HB AMC AETNA HMO","126.34","69.8","","119.15","84.13","137.28","37","14.72","147.91","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","outpatient","","","181.00","135.75","AETNA [1001]","HB AMC AETNA PPO","145.52","80.4","","137.28","84.13","137.28","1 through 10","14.72","147.91","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","outpatient","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","147.91","81.72","","140.69","77.39","140.70","26","14.72","147.91","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","511.00","35.15","511.00","1 through 10","60.28","418.97","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","368.90","70","","511.00","511.00","511.00","1 through 10","60.28","418.97","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","418.97","79.5","","402.06","269.81","402.16","13","60.28","418.97","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","280.89","53.3","","809.43","493.06","1206.48","28","60.28","418.97","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","FALLON HEALTH [1008]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.18","62.18","62.18","1 through 10","60.28","418.97","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","405.79","77","","1180.41","1180.41","1180.41","1 through 10","60.28","418.97","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","342.55","65","","332.15","323.05","332.15","1 through 10","60.28","418.97","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","MEDICARE [2001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.45","31.73","126.90","16","60.28","418.97","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","163.37","31","","473.70","473.70","473.70","1 through 10","60.28","418.97","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","192.36","36.5","","554.94","184.98","571.80","31","60.28","418.97","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.84","38.3","","599.40","199.80","599.40","69","60.28","418.97","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.36","124.36","124.36","1 through 10","60.28","418.97","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","57.96","57.96","57.96","1 through 10","60.28","418.97","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.08","42.9","","408.49","408.49","408.49","1 through 10","60.28","418.97","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.19","57.96","62.19","1 through 10","60.28","418.97","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","527.00","395.25","WELLPOINT [1015]","HB AMC WELLPOINT","388.82","73.78","","891.44","380.44","891.44","25","60.28","418.97","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","outpatient","","","527.00","395.25","AETNA [1001]","HB AMC AETNA HMO","367.85","69.8","","345.95","345.95","651.07","1 through 10","104.94","430.66","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","outpatient","","","527.00","395.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","423.71","80.4","","398.58","255.50","398.58","1 through 10","104.94","430.66","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","outpatient","","","527.00","395.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","430.66","81.72","","408.48","408.48","408.48","1 through 10","104.94","430.66","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","outpatient","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","430.66","81.72","","408.49","224.69","408.49","33","104.94","430.66","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","221.86","71.8","","313.05","313.05","313.05","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","216.30","70","","313.92","313.92","313.92","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","245.66","79.5","","236.10","158.40","708.30","52","25.96","293.55","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","164.70","53.3","","475.20","158.40","792.00","47","25.96","293.55","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","237.93","77","","693.00","335.72","1007.16","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","200.85","65","","283.40","274.95","283.40","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","95.79","31","","134.72","92.70","404.16","36","25.96","293.55","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","112.79","36.5","","162.63","136.90","487.89","668","25.96","293.55","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","118.35","38.3","","170.48","165.68","511.44","2204","25.96","293.55","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","237.93","77","","236.10","23.95","379.32","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","TRICARE [160005]","HB BWH TRICARE","293.55","95","","460.07","460.07","460.07","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.56","42.9","","239.82","131.91","239.82","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","AETNA [1001]","HB AMC AETNA HMO","215.68","69.8","","295.17","208.41","340.08","845","93.83","252.51","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","AETNA [1001]","HB AMC AETNA PPO","248.44","80.4","","340.08","228.46","340.08","96","93.83","252.51","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","172.73","55.9","","228.46","221.65","456.92","1 through 10","93.83","252.51","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","161.48","52.26","","185.64","185.64","185.64","1 through 10","93.83","252.51","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","248.44","80.4","","290.50","150.00","340.08","1 through 10","93.83","252.51","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","252.51","81.72","","131.91","60.16","131.91","1 through 10","93.83","252.51","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","252.51","81.72","","239.82","131.91","239.82","55","93.83","252.51","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","both","","","236.00","177.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","187.62","79.5","","180.22","120.91","180.22","1 through 10","19.85","224.2","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","both","","","236.00","177.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","125.79","53.3","","180.22","180.22","180.22","1 through 10","19.85","224.2","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","both","","","236.00","177.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","86.14","36.5","","85.42","61.12","85.42","35","19.85","224.2","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","both","","","236.00","177.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","90.39","38.3","","89.54","89.54","268.62","89","19.85","224.2","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","outpatient","","","236.00","177.00","AETNA [1001]","HB AMC AETNA HMO","164.73","69.8","","155.03","109.46","155.03","1 through 10","71.15","192.86","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","outpatient","","","236.00","177.00","AETNA [1001]","HB AMC AETNA PPO","189.74","80.4","","240.00","240.00","240.00","1 through 10","71.15","192.86","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","outpatient","","","236.00","177.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","192.86","81.72","","183.06","100.69","183.06","1 through 10","71.15","192.86","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","both","","","236.00","177.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","187.62","79.5","","180.22","120.91","901.10","47","19.85","224.2","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","both","","","236.00","177.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","125.79","53.3","","120.91","120.91","362.73","18","19.85","224.2","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","both","","","236.00","177.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","181.72","77","","30.13","30.13","30.13","1 through 10","19.85","224.2","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","both","","","236.00","177.00","TRICARE [160005]","HB BWH TRICARE","224.20","95","","23.19","23.19","24.41","1 through 10","19.85","224.2","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","outpatient","","","236.00","177.00","AETNA [1001]","HB AMC AETNA HMO","164.73","69.8","","155.03","109.46","207.64","40","52.22","206.19","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","outpatient","","","236.00","177.00","AETNA [1001]","HB AMC AETNA PPO","189.74","80.4","","178.62","120.00","239.02","1 through 10","52.22","206.19","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","outpatient","","","236.00","177.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","123.33","52.26","","141.71","71.15","141.71","1 through 10","52.22","206.19","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","outpatient","","","236.00","177.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","192.86","81.72","","183.06","100.69","183.06","53","52.22","206.19","percent of total billed charges",""
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.86","45.86","46.61","75","44.28","422.15","other","OPPS APC"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","371.70","70","","412.00","412.00","412.00","1 through 10","44.28","422.15","percent of total billed charges",""
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","422.15","79.5","","405.31","271.92","2350.78","25","44.28","422.15","percent of total billed charges",""
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","283.02","53.3","","271.92","271.92","405.31","17","44.28","422.15","percent of total billed charges",""
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.68","45.68","45.68","1 through 10","44.28","422.15","other","OPPS APC"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","ELDER SERVICES [1037]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.61","46.61","46.61","1 through 10","44.28","422.15","other","OPPS APC"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","FALLON HEALTH [1008]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","137.04","46.61","139.83","1 through 10","44.28","422.15","other","OPPS APC"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.05","46.05","46.05","1 through 10","44.28","422.15","other","OPPS APC"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","HUMANA [1012]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.68","45.68","45.68","1 through 10","44.28","422.15","other","OPPS APC"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.78","45.78","45.78","1 through 10","44.28","422.15","other","OPPS APC"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","MEDICARE [2001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.61","46.61","46.61","652","44.28","422.15","other","OPPS APC"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","164.61","31","","159.14","159.14","159.14","1 through 10","44.28","422.15","percent of total billed charges",""
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","193.82","36.5","","192.10","163.26","576.29","35","44.28","422.15","percent of total billed charges",""
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.37","38.3","","201.37","169.95","201.37","38","44.28","422.15","percent of total billed charges",""
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.68","45.68","91.36","20","44.28","422.15","other","OPPS APC"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","MOLINA [1014]","HB BWH MOLINA","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","184.19","46.61","184.19","1 through 10","44.28","422.15","other","OPPS APC"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","TRICARE [160005]","HB BWH TRICARE","44.28","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","46.61","44.28","46.61","1 through 10","44.28","422.15","other","Tricare OPPS"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","44.28","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","43.77","43.77","43.77","1 through 10","44.28","422.15","other","Tricare OPPS"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","45.68","45.68","137.04","49","44.28","422.15","other","OPPS APC"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","118.45","118.45","118.45","1 through 10","44.28","422.15","other","OPPS APC"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","227.80","42.9","","226.45","226.45","226.45","1 through 10","44.28","422.15","percent of total billed charges",""
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","45.68","42.90","45.88","110","44.28","422.15","other","OPPS APC"
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","both","","","531.00","398.25","WELLPOINT [1015]","HB AMC WELLPOINT","391.77","73.78","","383.42","383.42","898.42","25","44.28","422.15","percent of total billed charges",""
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","outpatient","","","531.00","398.25","AETNA [1001]","HB AMC AETNA HMO","370.64","69.8","","348.66","348.66","401.70","1 through 10","66.11","433.93","percent of total billed charges",""
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","outpatient","","","531.00","398.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","426.92","80.4","","401.70","401.70","401.70","1 through 10","66.11","433.93","percent of total billed charges",""
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","outpatient","","","531.00","398.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","433.93","81.72","","411.69","226.45","411.69","1 through 10","66.11","433.93","percent of total billed charges",""
"Cytopath Concentration","PX-31000068","CDM","88108","CPT","0311","RC","","","","outpatient","","","531.00","398.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","433.93","81.72","","411.69","411.69","515.00","37","66.11","433.93","percent of total billed charges",""
"Cytopath Fluid Smear Bronchial W/B","PX-31000065","CDM","88104","CPT","0311","RC","","","","both","","","242.00","181.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","128.99","53.3","","184.95","184.95","184.95","1 through 10","44.28","192.39","percent of total billed charges",""
"Cytopath Fluid Smear Bronchial W/B","PX-31000065","CDM","88104","CPT","0311","RC","","","","both","","","242.00","181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","92.69","38.3","","91.89","91.89","91.89","1 through 10","44.28","192.39","percent of total billed charges",""
"Cytopath Fluid Smear Bronchial W/B","PX-31000065","CDM","88104","CPT","0311","RC","","","","both","","","242.00","181.50","WELLPOINT [1015]","HB AMC WELLPOINT","178.55","73.78","","174.96","174.96","174.96","1 through 10","44.28","192.39","percent of total billed charges",""
"Cytopath Fluid Smear Bronchial W/B","PX-31000065","CDM","88104","CPT","0311","RC","","","","outpatient","","","242.00","181.50","AETNA [1001]","HB AMC AETNA HMO","168.92","69.8","","159.10","159.10","159.10","1 through 10","66.11","197.76","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","221.86","71.8","","313.05","313.05","313.05","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","216.30","70","","313.92","313.92","313.92","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","245.66","79.5","","236.10","158.40","708.30","52","25.96","293.55","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","164.70","53.3","","475.20","158.40","792.00","47","25.96","293.55","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","237.93","77","","693.00","335.72","1007.16","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","200.85","65","","283.40","274.95","283.40","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","95.79","31","","134.72","92.70","404.16","36","25.96","293.55","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","112.79","36.5","","162.63","136.90","487.89","668","25.96","293.55","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","118.35","38.3","","170.48","165.68","511.44","2204","25.96","293.55","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","237.93","77","","236.10","23.95","379.32","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","TRICARE [160005]","HB BWH TRICARE","293.55","95","","460.07","460.07","460.07","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","both","","","309.00","231.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.56","42.9","","239.82","131.91","239.82","1 through 10","25.96","293.55","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","AETNA [1001]","HB AMC AETNA HMO","215.68","69.8","","295.17","208.41","340.08","845","93.83","252.51","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","AETNA [1001]","HB AMC AETNA PPO","248.44","80.4","","340.08","228.46","340.08","96","93.83","252.51","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","172.73","55.9","","228.46","221.65","456.92","1 through 10","93.83","252.51","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","161.48","52.26","","185.64","185.64","185.64","1 through 10","93.83","252.51","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","248.44","80.4","","290.50","150.00","340.08","1 through 10","93.83","252.51","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","252.51","81.72","","131.91","60.16","131.91","1 through 10","93.83","252.51","percent of total billed charges",""
"Cytp C/V Auto Thin Lyr Prepj Scr Mnl Rescr Phys","PX-31000362","CDM","88175","CPT","0311","RC","","","","outpatient","","","309.00","231.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","252.51","81.72","","239.82","131.91","239.82","55","93.83","252.51","percent of total billed charges",""
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","both","","","377.00","282.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","299.72","79.5","","288.04","275.97","864.12","1 through 10","116.87","299.72","percent of total billed charges",""
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","both","","","377.00","282.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","290.29","77","","281.82","281.82","281.82","1 through 10","116.87","299.72","percent of total billed charges",""
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","both","","","377.00","282.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","137.61","36.5","","136.52","136.52","136.52","1 through 10","116.87","299.72","percent of total billed charges",""
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","both","","","377.00","282.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","144.39","38.3","","143.11","143.11","143.11","1 through 10","116.87","299.72","percent of total billed charges",""
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","both","","","377.00","282.75","WELLPOINT [1015]","HB AMC WELLPOINT","278.15","73.78","","638.49","272.49","638.49","1 through 10","116.87","299.72","percent of total billed charges",""
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","outpatient","","","377.00","282.75","AETNA [1001]","HB AMC AETNA HMO","263.15","69.8","","247.78","247.78","317.02","1 through 10","163.21","887.19","percent of total billed charges",""
"Cytp Fna Eval Dx 1st Each Site","PX-31000092","CDM","88172","CPT","0311","RC","","","","outpatient","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","308.08","81.72","","292.58","160.93","338.78","13","163.21","887.19","percent of total billed charges",""
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","both","","","4886.00","3664.50","MEDICARE [2001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","1 through 10","1514.66","4719.38","other","OPPS APC"
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","both","","","4886.00","3664.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.09","42.9","","1897.35","1897.35","1897.35","1 through 10","1514.66","4719.38","percent of total billed charges",""
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","both","","","4886.00","3664.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3700.37","3700.37","3700.37","1 through 10","1514.66","4719.38","other","OPPS APC"
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","both","","","4886.00","3664.50","WELLPOINT [1015]","HB AMC WELLPOINT","3604.89","73.78","","8340.00","7274.57","14906.37","1 through 10","1514.66","4719.38","percent of total billed charges",""
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","AETNA [1001]","HB AMC AETNA HMO","3410.43","69.8","","8325.49","8325.49","8325.49","1 through 10","2125.14","3992.84","percent of total billed charges",""
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2762.36","2762.36","2762.36","1 through 10","2125.14","3992.84","other","ASC"
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3129.59","3129.59","6321.29","1 through 10","2125.14","3992.84","other","ASC "
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3992.84","81.72","","12837.56","12837.56","12837.56","1 through 10","2125.14","3992.84","percent of total billed charges",""
"D&C, Aspiration Curettage Or Hysterotomy For Obstetric Diagnoses,MAJOR","544","DRG","","","","","","","","inpatient","","","32181.29","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25986.49","","Fee schedule rate ($25,986.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25986.49","25986.49","25986.49","1 through 10","10441.163","43331.33","case rate",""
"D&C, Aspiration Curettage Or Hysterotomy For Obstetric Diagnoses,MINOR","544","DRG","","","","","","","","inpatient","","","17605.94","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","11945.24","","Fee schedule rate ($11,945.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11945.24","11945.24","11945.24","1 through 10","10441.163","43331.33","case rate",""
"D&C, Aspiration Curettage Or Hysterotomy For Obstetric Diagnoses,MINOR","544","DRG","","","","","","","","inpatient","","","17605.94","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","13114.09","","Fee schedule rate ($13,114.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13114.09","13114.09","13114.09","1 through 10","10441.163","43331.33","case rate",""
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/McC","744","MS-DRG","","","","","","","","inpatient","","","124788.42","93591.31","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","19071.95","","Case rate ($19,071.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,881.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,525.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,088.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $17,043.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,501.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,648.83. The transfer capital threshold is the transfer adjustment factor * $1,648.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24322.63","24322.63","24322.63","1 through 10","18690.51","29487.814","other","Inpatient Replacement Plans DRG"
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/McC","744","MS-DRG","","","","","","","","inpatient","","","124788.42","93591.31","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","23839.94","","Case rate ($19,071.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,881.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,525.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,088.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $17,043.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,501.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,648.83. The transfer capital threshold is the transfer adjustment factor * $1,648.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","18014.16","18014.16","18014.16","1 through 10","18690.51","29487.814","other","Inpatient DRG"
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/McC","744","MS-DRG","","","","","","","","inpatient","","","124788.42","93591.31","MEDICARE [2001]","HB BWH MEDICARE","19071.95","","Case rate ($19,071.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,881.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,525.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,088.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $17,043.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,501.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,648.83. The transfer capital threshold is the transfer adjustment factor * $1,648.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23314.30","23314.30","23348.75","1 through 10","18690.51","29487.814","other","Inpatient Replacement Plans DRG"
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/McC","744","MS-DRG","","","","","","","","inpatient","","","124788.42","93591.31","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","18690.51","","Case rate ($19,071.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,881.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,525.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,088.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $17,043.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,501.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,648.83. The transfer capital threshold is the transfer adjustment factor * $1,648.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17727.59","17727.59","17727.59","1 through 10","18690.51","29487.814","other","Inpatient DRG"
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/McC","744","TRIS-DRG","","","","","","","","inpatient","","","227895.48","","CHAMPVA [160001]","HB BWH TRICARE","8883.25","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($15,603.93). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $59,330.93 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($10,402.62), capped at $11,230.70. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $59,330.93 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","25874.33","25874.33","25874.33","1 through 10","8883.25","8883.25","other","Inpatient DRGs"
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/McC","745","TRIS-DRG","","","","","","","","inpatient","","","118181.63","","TRICARE [160005]","HB BWH TRICARE","9144.32","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($16,062.51). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $59,789.51 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($14,602.28), capped at $11,560.75. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $59,789.51 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","6431.88","6431.88","6431.88","1 through 10","9144.32","9144.32","other","Inpatient DRGs"
"Darbepoetin 1mcg (Non Esrd)","PX-63600091","CDM","J0881","HCPCS","0636","RC","","","","both","","","14.64","10.98","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","3.66","","APC Price ($2.93). Final payment is multiplied by 125%.","2.92","2.87","2.99","240","2.85","11.27","other","OPPS APC"
"Darbepoetin 1mcg (Non Esrd)","PX-63600091","CDM","J0881","HCPCS","0636","RC","","","","both","","","14.64","10.98","ELDER SERVICES [1037]","HB BWH MEDICARE","2.93","","APC Price ($2.93).","3.04","3.04","3.04","120","2.85","11.27","other","OPPS APC"
"Darbepoetin 1mcg (Non Esrd)","PX-63600091","CDM","J0881","HCPCS","0636","RC","","","","both","","","14.64","10.98","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2.87","","APC Price ($2.93). Final payment is multiplied by 98%.","2.92","2.86","5.95","980","2.85","11.27","other","OPPS APC"
"Darbepoetin Alfa, Non-Esrd","PX-63601015","CDM","J0881","HCPCS","0636","RC","","","","both","","","14.24","10.68","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","3.66","","APC Price ($2.93). Final payment is multiplied by 125%.","2.92","2.87","2.99","240","2.85","10.96","other","OPPS APC"
"Darbepoetin Alfa, Non-Esrd","PX-63601015","CDM","J0881","HCPCS","0636","RC","","","","both","","","14.24","10.68","ELDER SERVICES [1037]","HB BWH MEDICARE","2.93","","APC Price ($2.93).","3.04","3.04","3.04","120","2.85","10.96","other","OPPS APC"
"Darbepoetin Alfa, Non-Esrd","PX-63601015","CDM","J0881","HCPCS","0636","RC","","","","both","","","14.24","10.68","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2.87","","APC Price ($2.93). Final payment is multiplied by 98%.","2.92","2.86","5.95","980","2.85","10.96","other","OPPS APC"
"Darunavir","PX-31000822","CDM","80299","CPT","0310","RC","","","","both","","","134.00","100.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","106.53","79.5","","106.25","71.28","106.25","1 through 10","18.27","127.3","percent of total billed charges",""
"Darunavir","PX-31000822","CDM","80299","CPT","0310","RC","","","","both","","","134.00","100.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","71.42","53.3","","106.25","71.28","106.25","1 through 10","18.27","127.3","percent of total billed charges",""
"Darunavir","PX-31000822","CDM","80299","CPT","0310","RC","","","","both","","","134.00","100.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.91","36.5","","50.36","42.80","92.50","13","18.27","127.3","percent of total billed charges",""
"Darunavir","PX-31000822","CDM","80299","CPT","0310","RC","","","","both","","","134.00","100.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","51.32","38.3","","52.79","44.55","158.37","30","18.27","127.3","percent of total billed charges",""
"Darunavir","PX-31000822","CDM","80299","CPT","0310","RC","","","","outpatient","","","134.00","100.50","AETNA [1001]","HB AMC AETNA HMO","93.53","69.8","","91.40","64.53","105.30","14","53.62","114.26","percent of total billed charges",""
"Darunavir","PX-31000822","CDM","80299","CPT","0310","RC","","","","outpatient","","","134.00","100.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","107.74","80.4","","105.30","105.30","105.30","1 through 10","53.62","114.26","percent of total billed charges",""
"Darunavir","PX-31000822","CDM","80299","CPT","0310","RC","","","","outpatient","","","134.00","100.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","109.50","81.72","","59.36","15.50","59.36","1 through 10","53.62","114.26","percent of total billed charges",""
"Debfa, Chromosome Breakage Deb Assay for Fanconi Anemia Diepoxybutane Induced Chrom Breakage","PX-31001276","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2946.27","79.5","","2828.48","1814.97","2828.48","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Debfa, Chromosome Breakage Deb Assay for Fanconi Anemia Diepoxybutane Induced Chrom Breakage","PX-31001276","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1975.30","53.3","","1814.97","1761.95","1814.97","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Debfa, Chromosome Breakage Deb Assay for Fanconi Anemia Diepoxybutane Induced Chrom Breakage","PX-31001276","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1352.69","36.5","","1340.56","1340.56","1340.56","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Debfa, Chromosome Breakage Deb Assay for Fanconi Anemia Diepoxybutane Induced Chrom Breakage","PX-31001276","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1419.40","38.3","","1405.25","1405.25","1405.25","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Debfa, Chromosome Breakage Deb Assay for Fanconi Anemia Diepoxybutane Induced Chrom Breakage","PX-31001276","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","WELLPOINT [1015]","HB AMC WELLPOINT","2734.29","73.78","","6269.73","2675.73","7188.00","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Debfa, Chromosome Breakage Deb Assay for Fanconi Anemia Diepoxybutane Induced Chrom Breakage","PX-31001276","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","AETNA [1001]","HB AMC AETNA HMO","2586.79","69.8","","2433.14","2433.14","2433.14","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Debfa, Chromosome Breakage Deb Assay for Fanconi Anemia Diepoxybutane Induced Chrom Breakage","PX-31001276","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2979.62","80.4","","2803.32","2803.32","2803.32","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Debfa, Chromosome Breakage Deb Assay for Fanconi Anemia Diepoxybutane Induced Chrom Breakage","PX-31001276","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3028.54","81.72","","2873.04","1533.07","3526.61","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Debr/Rem Tiss Addl 20 Sq Cm/Part","PX-76001693","CDM","97598","CPT","0761","RC","","","","both","","","272.00","204.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","144.98","53.3","","207.77","207.77","207.77","1 through 10","84.32","216.24","percent of total billed charges",""
"Debride Nail(S) 6 or More","PX-76000088","CDM","11721","CPT","0761","RC","","","","both","","","216.00","162.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","72.65","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","73.49","73.39","73.49","1 through 10","66.96","171.72","other","OPPS APC"
"Debride Nail(S) 6 or More","PX-76000088","CDM","11721","CPT","0761","RC","","","","both","","","216.00","162.00","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","66.76","70.54","22","66.96","171.72","other","OPPS APC"
"Debride Nail(S) 6 or More","PX-76000088","CDM","11721","CPT","0761","RC","","","","both","","","216.00","162.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","24.39","24.39","24.39","1 through 10","66.96","171.72","other","OPPS APC"
"Debride Nail(S) 6 or More","PX-76000088","CDM","11721","CPT","0761","RC","","","","both","","","216.00","162.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.13","24.39","69.13","16","66.96","171.72","other","OPPS APC"
"Debride Nail(S) Up to 5","PX-76000087","CDM","11720","CPT","0761","RC","","","","both","","","211.00","158.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.41","65.69","69.41","1 through 10","65.41","167.75","other","OPPS APC"
"Debride Nail(S) Up to 5","PX-76000087","CDM","11720","CPT","0761","RC","","","","both","","","211.00","158.25","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","70.54","70.54","1 through 10","65.41","167.75","other","OPPS APC"
"Debride Nail(S) Up to 5","PX-76000087","CDM","11720","CPT","0761","RC","","","","both","","","211.00","158.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","14.75","14.75","14.75","12","65.41","167.75","other","OPPS APC"
"Debride Nail(S) Up to 5","PX-76000087","CDM","11720","CPT","0761","RC","","","","both","","","211.00","158.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.02","36.5","","76.47","22.01","76.47","1 through 10","65.41","167.75","percent of total billed charges",""
"Debride Nail(S) Up to 5","PX-76000087","CDM","11720","CPT","0761","RC","","","","both","","","211.00","158.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","65.43","14.45","69.13","22","65.41","167.75","other","OPPS APC"
"Debride Nail(S) Up to 5","PX-76000087","CDM","11720","CPT","0761","RC","","","","outpatient","","","211.00","158.25","AETNA [1001]","HB AMC AETNA HMO","147.28","69.8","","97.99","97.99","97.99","1 through 10","55.9","350.18","percent of total billed charges",""
"Debride Nail(S) Up to 5","PX-76000087","CDM","11720","CPT","0761","RC","","","","outpatient","","","211.00","158.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","63.92","","Case rate ($63.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","169.88","169.88","169.88","1 through 10","55.9","350.18","other","ASC"
"Debride Nail(S) Up to 5","PX-76000087","CDM","11720","CPT","0761","RC","","","","outpatient","","","211.00","158.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","63.92","","Case rate ($63.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","148.17","148.17","148.17","1 through 10","55.9","350.18","other","ASC "
"Debride Nail(S) Up to 5","PX-76000087","CDM","11720","CPT","0761","RC","","","","outpatient","","","211.00","158.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","55.90","","Case rate ($55.90). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","129.69","124.66","129.69","1 through 10","55.9","350.18","other","Multiple Surgery"
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","both","","","2277.00","1707.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1741.20","1741.20","1741.20","1 through 10","705.87","2404.92","other","OPPS APC"
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","both","","","2277.00","1707.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","2404.92","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","1924.13","1924.13","1924.13","1 through 10","705.87","2404.92","other","OPPS APC"
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","both","","","2277.00","1707.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","705.87","2404.92","other","OPPS APC"
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","both","","","2277.00","1707.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","30","705.87","2404.92","other","OPPS APC"
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","both","","","2277.00","1707.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.75","233.75","239.95","1 through 10","705.87","2404.92","other","OPPS APC"
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","both","","","2277.00","1707.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","872.09","38.3","","863.33","863.33","863.33","1 through 10","705.87","2404.92","percent of total billed charges",""
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","outpatient","","","2277.00","1707.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3822.92","3822.92","3822.92","1 through 10","976.83","5545.35","other","ASC"
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","outpatient","","","2277.00","1707.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4317.13","3646.12","4317.13","1 through 10","976.83","5545.35","other","ASC "
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","outpatient","","","2277.00","1707.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2760.63","2760.63","2760.63","1 through 10","976.83","5545.35","other","Multiple Surgery"
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","outpatient","","","2277.00","1707.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3020.60","3020.60","3020.60","1 through 10","976.83","5545.35","other","Multiple Surgery"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","978.00","733.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","488.23","447.82","488.23","11","303.18","777.51","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","978.00","733.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","466.88","466.88","1 through 10","303.18","777.51","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","978.00","733.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","593.02","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","474.47","474.47","474.47","1 through 10","303.18","777.51","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","978.00","733.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","521.27","53.3","","500.54","500.54","500.54","1 through 10","303.18","777.51","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","978.00","733.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","428.24","466.88","1 through 10","303.18","777.51","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","978.00","733.50","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","435.20","474.47","141","303.18","777.51","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","356.97","36.5","","353.60","353.60","1060.80","1 through 10","303.18","777.51","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","374.57","38.3","","370.67","360.24","370.67","1 through 10","303.18","777.51","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","464.98","464.98","464.98","1 through 10","303.18","777.51","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","978.00","733.50","MOLINA [1014]","HB BWH MOLINA","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","941.35","941.35","941.35","1 through 10","303.18","777.51","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","978.00","733.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","464.98","426.50","464.98","1 through 10","303.18","777.51","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","978.00","733.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","464.98","426.50","472.89","31","303.18","777.51","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","978.00","733.50","WELLPOINT [1015]","HB AMC WELLPOINT","721.57","73.78","","705.79","705.79","1653.79","1 through 10","303.18","777.51","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","outpatient","","","978.00","733.50","AETNA [1001]","HB AMC AETNA HMO","682.64","69.8","","641.80","641.80","641.80","1 through 10","314.08","799.22","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","outpatient","","","978.00","733.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","721.57","721.57","734.86","20","314.08","799.22","other","ASC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","outpatient","","","978.00","733.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","840.82","832.56","840.82","51","314.08","799.22","other","ASC "
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","outpatient","","","978.00","733.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","728.67","700.40","728.67","1 through 10","314.08","799.22","other","Multiple Surgery"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","outpatient","","","978.00","733.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","766.36","738.09","766.36","1 through 10","314.08","799.22","other","Multiple Surgery"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","outpatient","","","978.00","733.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1608.08","1608.08","1608.08","1 through 10","314.08","799.22","other","Multiple Surgery"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","outpatient","","","978.00","733.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","799.22","81.72","","757.83","757.83","757.83","1 through 10","314.08","799.22","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000025","CDM","11045","CPT","0761","RC","","","","both","","","137.00","102.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","73.02","53.3","","70.22","70.22","70.22","1 through 10","42.47","108.92","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000025","CDM","11045","CPT","0761","RC","","","","both","","","137.00","102.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.01","36.5","","49.61","49.61","49.61","12","42.47","108.92","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000025","CDM","11045","CPT","0761","RC","","","","both","","","137.00","102.75","WELLPOINT [1015]","HB AMC WELLPOINT","101.08","73.78","","99.02","99.02","99.02","1 through 10","42.47","108.92","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000025","CDM","11045","CPT","0761","RC","","","","outpatient","","","137.00","102.75","AETNA [1001]","HB AMC AETNA HMO","95.63","69.8","","90.04","90.04","90.04","1 through 10","44.3","111.96","percent of total billed charges",""
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","both","","","1663.00","1247.25","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","685.47","3634.70","14","515.53","1322.09","other","OPPS APC"
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","both","","","1663.00","1247.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","607.00","36.5","","601.65","601.65","601.65","1 through 10","515.53","1322.09","percent of total billed charges",""
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","both","","","1663.00","1247.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","712.33","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","719.91","719.91","719.91","1 through 10","515.53","1322.09","other","OPPS APC"
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","outpatient","","","1663.00","1247.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1109.39","1109.39","1109.39","1 through 10","482.89","1359","other","ASC"
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","outpatient","","","1663.00","1247.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1292.72","1292.72","1292.72","1 through 10","482.89","1359","other","ASC "
"Debride Skin/Subq/Muscle Genitalia","PX-76000015","CDM","11004","CPT","0761","RC","","","","both","","","3659.00","2744.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1401.40","38.3","","1387.27","1387.27","1387.27","1 through 10","568.79","3476.05","percent of total billed charges",""
"Debride Skin/Subq/Muscle Genitalia","PX-76000015","CDM","11004","CPT","0761","RC","","","","outpatient","","","3659.00","2744.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1829.50","50","","1859.15","1859.15","1859.15","1 through 10","972.93","5545.35","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","889.00","666.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","242.81","242.81","242.81","1 through 10","164.98","706.76","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","889.00","666.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","164.98","706.76","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","889.00","666.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","294.93","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","50.00","50.00","50.00","1 through 10","164.98","706.76","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","889.00","666.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","706.76","79.5","","678.39","678.39","678.39","1 through 10","164.98","706.76","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","889.00","666.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","473.84","53.3","","678.39","678.39","678.39","1 through 10","164.98","706.76","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","889.00","666.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","197.57","197.57","197.57","1 through 10","164.98","706.76","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","889.00","666.75","HUMANA [1012]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.14","233.14","233.14","1 through 10","164.98","706.76","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","889.00","666.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","218.50","235.97","102","164.98","706.76","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","889.00","666.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","324.49","36.5","","321.53","312.04","643.06","1 through 10","164.98","706.76","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","889.00","666.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","340.49","38.3","","1011.12","58.26","1011.12","1 through 10","164.98","706.76","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","889.00","666.75","MOLINA [1014]","HB BWH MOLINA","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","468.16","468.16","468.16","1 through 10","164.98","706.76","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","889.00","666.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.25","231.25","231.25","1 through 10","164.98","706.76","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","889.00","666.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.25","116.24","232.19","27","164.98","706.76","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","outpatient","","","889.00","666.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","1 through 10","176.45","726.49","other","Multiple Surgery"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","outpatient","","","889.00","666.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","726.49","81.72","","689.08","689.08","689.08","1 through 10","176.45","726.49","percent of total billed charges",""
"Debride/Remove FB Skin/Muscle/Bone","PX-76000021","CDM","11012","CPT","0761","RC","","","","both","","","2957.00","2217.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1576.08","53.3","","3166.02","3166.02","3166.02","1 through 10","916.67","2350.82","percent of total billed charges",""
"Debride/Remove FB Skin/Subq Open","PX-76000019","CDM","11010","CPT","0761","RC","","","","both","","","2277.00","1707.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.75","826.75","826.75","1 through 10","705.87","1810.22","other","OPPS APC"
"Debridement Bone Muscle &/Fascia 20 Sq Cm/<","PX-98300858","CDM","11044","CPT","0983","RC","","","","both","","","1173.00","879.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1741.20","1741.20","1741.20","1 through 10","363.63","2404.92","other","OPPS APC"
"Debridement Bone Muscle &/Fascia 20 Sq Cm/<","PX-98300858","CDM","11044","CPT","0983","RC","","","","both","","","1173.00","879.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","2404.92","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","1924.13","1924.13","1924.13","1 through 10","363.63","2404.92","other","OPPS APC"
"Debridement Bone Muscle &/Fascia 20 Sq Cm/<","PX-98300858","CDM","11044","CPT","0983","RC","","","","both","","","1173.00","879.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","363.63","2404.92","other","OPPS APC"
"Debridement Bone Muscle &/Fascia 20 Sq Cm/<","PX-98300858","CDM","11044","CPT","0983","RC","","","","both","","","1173.00","879.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","30","363.63","2404.92","other","OPPS APC"
"Debridement Bone Muscle &/Fascia 20 Sq Cm/<","PX-98300858","CDM","11044","CPT","0983","RC","","","","both","","","1173.00","879.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.75","233.75","239.95","1 through 10","363.63","2404.92","other","OPPS APC"
"Debridement Bone Muscle &/Fascia 20 Sq Cm/<","PX-98300858","CDM","11044","CPT","0983","RC","","","","both","","","1173.00","879.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","449.26","38.3","","863.33","863.33","863.33","1 through 10","363.63","2404.92","percent of total billed charges",""
"Debridement Bone Muscle &/Fascia 20 Sq Cm/<","PX-98300858","CDM","11044","CPT","0983","RC","","","","outpatient","","","1173.00","879.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2760.63","2760.63","2760.63","1 through 10","503.22","5545.35","other","Multiple Surgery"
"Debridement Bone Muscle &/Fascia 20 Sq Cm/<","PX-98300858","CDM","11044","CPT","0983","RC","","","","outpatient","","","1173.00","879.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3020.60","3020.60","3020.60","1 through 10","503.22","5545.35","other","Multiple Surgery"
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-76002507","CDM","96574","CPT","0761","RC","","","","both","","","1992.00","1494.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","215.00","232.19","1 through 10","224.17","1583.64","other","OPPS APC"
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-76002507","CDM","96574","CPT","0761","RC","","","","both","","","1992.00","1494.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1294.80","65","","1255.80","1023.96","1255.80","1 through 10","224.17","1583.64","percent of total billed charges",""
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-76002507","CDM","96574","CPT","0761","RC","","","","both","","","1992.00","1494.00","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","218.50","707.91","47","224.17","1583.64","other","OPPS APC"
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-76002507","CDM","96574","CPT","0761","RC","","","","both","","","1992.00","1494.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","727.08","36.5","","720.64","612.44","720.64","1 through 10","224.17","1583.64","percent of total billed charges",""
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-76002507","CDM","96574","CPT","0761","RC","","","","both","","","1992.00","1494.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","762.94","38.3","","2266.23","755.41","2266.23","1 through 10","224.17","1583.64","percent of total billed charges",""
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-76002507","CDM","96574","CPT","0761","RC","","","","both","","","1992.00","1494.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","428.26","231.25","428.26","1 through 10","224.17","1583.64","other","OPPS APC"
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-76002507","CDM","96574","CPT","0761","RC","","","","both","","","1992.00","1494.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.25","231.25","231.25","1 through 10","224.17","1583.64","other","OPPS APC"
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-76002507","CDM","96574","CPT","0761","RC","","","","both","","","1992.00","1494.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","235.97","231.73","235.97","1 through 10","224.17","1583.64","other","OPPS APC"
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-76002507","CDM","96574","CPT","0761","RC","","","","both","","","1992.00","1494.00","WELLPOINT [1015]","HB AMC WELLPOINT","1469.70","73.78","","1438.37","1438.37","1438.37","1 through 10","224.17","1583.64","percent of total billed charges",""
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-76002507","CDM","96574","CPT","0761","RC","","","","outpatient","","","1992.00","1494.00","AETNA [1001]","HB AMC AETNA HMO","1390.42","69.8","","923.50","923.50","923.50","1 through 10","201.78","1627.86","percent of total billed charges",""
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-76002507","CDM","96574","CPT","0761","RC","","","","outpatient","","","1992.00","1494.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","412.84","405.38","412.84","1 through 10","201.78","1627.86","other","ASC"
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-76002507","CDM","96574","CPT","0761","RC","","","","outpatient","","","1992.00","1494.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","472.37","27","201.78","1627.86","other","ASC "
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-76002507","CDM","96574","CPT","0761","RC","","","","outpatient","","","1992.00","1494.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1627.86","81.72","","849.50","849.50","849.50","1 through 10","201.78","1627.86","percent of total billed charges",""
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-98301684","CDM","96574","CPT","0983","RC","","","","both","","","1285.00","963.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","215.00","232.19","1 through 10","224.17","1021.58","other","OPPS APC"
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-98301684","CDM","96574","CPT","0983","RC","","","","both","","","1285.00","963.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","835.25","65","","1255.80","1023.96","1255.80","1 through 10","224.17","1021.58","percent of total billed charges",""
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-98301684","CDM","96574","CPT","0983","RC","","","","both","","","1285.00","963.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","218.50","707.91","47","224.17","1021.58","other","OPPS APC"
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-98301684","CDM","96574","CPT","0983","RC","","","","both","","","1285.00","963.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","469.03","36.5","","720.64","612.44","720.64","1 through 10","224.17","1021.58","percent of total billed charges",""
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-98301684","CDM","96574","CPT","0983","RC","","","","both","","","1285.00","963.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","492.16","38.3","","2266.23","755.41","2266.23","1 through 10","224.17","1021.58","percent of total billed charges",""
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-98301684","CDM","96574","CPT","0983","RC","","","","both","","","1285.00","963.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","428.26","231.25","428.26","1 through 10","224.17","1021.58","other","OPPS APC"
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-98301684","CDM","96574","CPT","0983","RC","","","","both","","","1285.00","963.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.25","231.25","231.25","1 through 10","224.17","1021.58","other","OPPS APC"
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-98301684","CDM","96574","CPT","0983","RC","","","","both","","","1285.00","963.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","235.97","231.73","235.97","1 through 10","224.17","1021.58","other","OPPS APC"
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-98301684","CDM","96574","CPT","0983","RC","","","","both","","","1285.00","963.75","WELLPOINT [1015]","HB AMC WELLPOINT","948.07","73.78","","1438.37","1438.37","1438.37","1 through 10","224.17","1021.58","percent of total billed charges",""
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-98301684","CDM","96574","CPT","0983","RC","","","","outpatient","","","1285.00","963.75","AETNA [1001]","HB AMC AETNA HMO","896.93","69.8","","923.50","923.50","923.50","1 through 10","201.78","1050.1","percent of total billed charges",""
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-98301684","CDM","96574","CPT","0983","RC","","","","outpatient","","","1285.00","963.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","412.84","405.38","412.84","1 through 10","201.78","1050.1","other","ASC"
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-98301684","CDM","96574","CPT","0983","RC","","","","outpatient","","","1285.00","963.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","472.37","27","201.78","1050.1","other","ASC "
"Debridement Prmlg Hyperkeratotic Les W/Pdt","PX-98301684","CDM","96574","CPT","0983","RC","","","","outpatient","","","1285.00","963.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1050.10","81.72","","849.50","849.50","849.50","1 through 10","201.78","1050.1","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","209.00","156.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","135.85","65","","107.18","107.18","107.18","1 through 10","64.79","166.16","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","209.00","156.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","146.30","70","","162.72","146.16","162.72","1 through 10","64.79","166.16","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","209.00","156.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.16","79.5","","1050.64","107.18","1050.64","1 through 10","64.79","166.16","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","209.00","156.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","135.85","65","","131.95","131.95","131.95","1 through 10","64.79","166.16","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","209.00","156.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.29","36.5","","75.72","75.72","75.72","1 through 10","64.79","166.16","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","209.00","156.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.05","38.3","","79.37","77.14","79.38","1 through 10","64.79","166.16","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","209.00","156.75","WELLPOINT [1015]","HB AMC WELLPOINT","154.20","73.78","","166.25","151.13","452.00","1 through 10","64.79","166.16","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","outpatient","","","209.00","156.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","170.79","81.72","","162.28","162.28","162.28","1 through 10","109.22","170.79","percent of total billed charges",""
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","674.00","505.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","393.86","","APC Price ($393.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","387.60","387.60","387.60","1 through 10","208.94","535.83","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","674.00","505.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","438.10","65","","425.10","425.10","425.10","1 through 10","208.94","535.83","percent of total billed charges",""
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","674.00","505.50","FALLON HEALTH [1008]","HB BWH MEDICARE","393.86","","APC Price ($393.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1969.50","1969.50","1969.50","1 through 10","208.94","535.83","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","674.00","505.50","MEDICARE [2001]","HB BWH MEDICARE","393.86","","APC Price ($393.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","393.90","277.22","1181.70","19","208.94","535.83","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","outpatient","","","674.00","505.50","AETNA [1001]","HB AMC AETNA HMO","470.45","69.8","","442.76","442.76","442.76","1 through 10","288.38","1278.91","percent of total billed charges",""
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","outpatient","","","674.00","505.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","329.78","","Case rate ($329.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","674.73","662.53","674.73","1 through 10","288.38","1278.91","other","ASC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","outpatient","","","674.00","505.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","329.78","","Case rate ($329.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","772.01","764.43","772.01","1 through 10","288.38","1278.91","other","ASC "
"DEFIBRILLATOR CARDIAC COBALT HF QUAD CRT-D MRI SURESCAN MR CONDITIONAL SAFE QUADPOLE DF-4 DTPB2QQ","SUP-ITM-10273495","CDM","C1721","HCPCS","0278","RC","","","","both","","","38085.00","28563.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14586.56","38.3","","12426.00","12426.00","12426.00","1 through 10","11806.35","30277.58","percent of total billed charges",""
"DEFIBRILLATOR CARDIAC COBALT HF QUAD CRT-D MRI SURESCAN MR CONDITIONAL SAFE QUADPOLE DF-4 DTPB2QQ","SUP-ITM-10273495","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","38085.00","28563.75","AETNA [1001]","HB AMC AETNA HMO","26583.33","69.8","","16823.45","16823.45","16823.45","1 through 10","19903.22","31123.06","percent of total billed charges",""
"DEFIBRILLATOR CARDIAC COBALT HF QUAD CRT-D MRI SURESCAN MR CONDITIONAL SAFE QUADPOLE DF-4 DTPB2QQ","SUP-ITM-10273495","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","38085.00","28563.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","31123.06","81.72","","19865.09","19865.09","19865.09","1 through 10","19903.22","31123.06","percent of total billed charges",""
"DEFIBRILLATOR CARDIOVERTER IS1 DF1 68X51X13MM COBALT XT DR MRI SURESCAN LATEX FREE TITANIUM POLYURETHANE","SUP-ITM-10298265","CDM","C1721","HCPCS","0278","RC","","","","both","","","32700.00","24525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12524.10","38.3","","12426.00","12426.00","12426.00","1 through 10","10137","25996.5","percent of total billed charges",""
"DEFIBRILLATOR CARDIOVERTER IS1 DF1 68X51X13MM COBALT XT DR MRI SURESCAN LATEX FREE TITANIUM POLYURETHANE","SUP-ITM-10298265","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","32700.00","24525.00","AETNA [1001]","HB AMC AETNA HMO","22824.60","69.8","","16823.45","16823.45","16823.45","1 through 10","17089.02","26722.44","percent of total billed charges",""
"DEFIBRILLATOR CARDIOVERTER IS1 DF1 68X51X13MM COBALT XT DR MRI SURESCAN LATEX FREE TITANIUM POLYURETHANE","SUP-ITM-10298265","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","32700.00","24525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","26722.44","81.72","","19865.09","19865.09","19865.09","1 through 10","17089.02","26722.44","percent of total billed charges",""
"DEFIBRILLATOR CARDIOVERTER ISI DF1 71X51X13MM COBALT XT HF CRT-D MRI SURESCAN TITANIUM POLYURETHANE","SUP-ITM-10298269","CDM","C1882","HCPCS","0278","RC","","","","both","","","47600.00","35700.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","25370.80","53.3","","25132.80","25132.80","25132.80","1 through 10","14756","37842","percent of total billed charges",""
"DEFIBRILLATOR CARDIOVERTER ISI DF1 71X51X13MM COBALT XT HF CRT-D MRI SURESCAN TITANIUM POLYURETHANE","SUP-ITM-10298269","CDM","C1882","HCPCS","0278","RC","","","","both","","","47600.00","35700.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18230.80","38.3","","18611.60","13196.25","18611.60","1 through 10","14756","37842","percent of total billed charges",""
"DEFIBRILLATOR CARDIOVERTER ISI DF1 71X51X13MM COBALT XT HF CRT-D MRI SURESCAN TITANIUM POLYURETHANE","SUP-ITM-10298269","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","47600.00","35700.00","AETNA [1001]","HB AMC AETNA HMO","33224.80","69.8","","23525.75","23525.75","23525.75","1 through 10","24875.76","38898.72","percent of total billed charges",""
"DEFIBRILLATOR CARDIOVERTER ISI DF1 71X51X13MM COBALT XT HF CRT-D MRI SURESCAN TITANIUM POLYURETHANE","SUP-ITM-10298269","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","47600.00","35700.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","38898.72","81.72","","14745.34","14745.34","14745.34","1 through 10","24875.76","38898.72","percent of total billed charges",""
"DEFIBRILLATOR DF4 64X51X13MM ICD COBALT XT VR MRI SURESCAN TITANIUM POLYURETHANE","SUP-ITM-10298278","CDM","C1722","HCPCS","0278","RC","","","","both","","","30830.00","23122.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24509.85","79.5","","31564.33","31564.33","31564.33","1 through 10","9557.3","24509.85","percent of total billed charges",""
"DEFIBRILLATOR DF4 64X51X13MM ICD COBALT XT VR MRI SURESCAN TITANIUM POLYURETHANE","SUP-ITM-10298278","CDM","C1722","HCPCS","0278","RC","","","","both","","","30830.00","23122.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","20039.50","65","","27210.63","27210.63","27210.63","1 through 10","9557.3","24509.85","percent of total billed charges",""
"DEFIBRILLATOR DF4 64X51X13MM ICD COBALT XT VR MRI SURESCAN TITANIUM POLYURETHANE","SUP-ITM-10298278","CDM","C1722","HCPCS","0278","RC","","","","both","","","30830.00","23122.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11252.95","36.5","","46844.13","8621.25","46844.13","1 through 10","9557.3","24509.85","percent of total billed charges",""
"DEFIBRILLATOR DF4 64X51X13MM ICD COBALT XT VR MRI SURESCAN TITANIUM POLYURETHANE","SUP-ITM-10298278","CDM","C1722","HCPCS","0278","RC","","","","both","","","30830.00","23122.50","WELLPOINT [1015]","HB AMC WELLPOINT","22746.37","73.78","","16551.00","16551.00","16551.00","1 through 10","9557.3","24509.85","percent of total billed charges",""
"DEFIBRILLATOR DF4 64X51X13MM ICD COBALT XT VR MRI SURESCAN TITANIUM POLYURETHANE","SUP-ITM-10298278","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","30830.00","23122.50","AETNA [1001]","HB AMC AETNA HMO","21519.34","69.8","","74515.25","24796.25","74515.25","1 through 10","16111.76","25194.28","percent of total billed charges",""
"DEFIBRILLATOR DF4 64X51X13MM ICD COBALT XT VR MRI SURESCAN TITANIUM POLYURETHANE","SUP-ITM-10298278","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","30830.00","23122.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","25194.28","81.72","","10077.92","10077.92","10077.92","1 through 10","16111.76","25194.28","percent of total billed charges",""
"DEFIBRILLATOR DF4 64X51X13MM ICD COBALT XT VR MRI SURESCAN TITANIUM POLYURETHANE","SUP-ITM-10298278","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","30830.00","23122.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","25194.28","81.72","","41468.88","41468.88","41468.88","1 through 10","16111.76","25194.28","percent of total billed charges",""
"DEFIBRILLATOR EMBLEM 83.1MM 69.1MM 12.7MM MRI S-ICD PULSE GENERATOR","SUP-ITM-10170137","CDM","C1722","HCPCS","0278","RC","","","","both","","","41862.50","31396.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33280.69","79.5","","31564.33","31564.33","31564.33","1 through 10","12977.38","33280.69","percent of total billed charges",""
"DEFIBRILLATOR EMBLEM 83.1MM 69.1MM 12.7MM MRI S-ICD PULSE GENERATOR","SUP-ITM-10170137","CDM","C1722","HCPCS","0278","RC","","","","both","","","41862.50","31396.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","27210.63","65","","27210.63","27210.63","27210.63","1 through 10","12977.38","33280.69","percent of total billed charges",""
"DEFIBRILLATOR EMBLEM 83.1MM 69.1MM 12.7MM MRI S-ICD PULSE GENERATOR","SUP-ITM-10170137","CDM","C1722","HCPCS","0278","RC","","","","both","","","41862.50","31396.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15279.81","36.5","","46844.13","8621.25","46844.13","1 through 10","12977.38","33280.69","percent of total billed charges",""
"DEFIBRILLATOR EMBLEM 83.1MM 69.1MM 12.7MM MRI S-ICD PULSE GENERATOR","SUP-ITM-10170137","CDM","C1722","HCPCS","0278","RC","","","","both","","","41862.50","31396.87","WELLPOINT [1015]","HB AMC WELLPOINT","30886.15","73.78","","16551.00","16551.00","16551.00","1 through 10","12977.38","33280.69","percent of total billed charges",""
"DEFIBRILLATOR EMBLEM 83.1MM 69.1MM 12.7MM MRI S-ICD PULSE GENERATOR","SUP-ITM-10170137","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","41862.50","31396.87","AETNA [1001]","HB AMC AETNA HMO","29220.03","69.8","","74515.25","24796.25","74515.25","1 through 10","21877.34","34210.04","percent of total billed charges",""
"DEFIBRILLATOR EMBLEM 83.1MM 69.1MM 12.7MM MRI S-ICD PULSE GENERATOR","SUP-ITM-10170137","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","41862.50","31396.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","34210.04","81.72","","10077.92","10077.92","10077.92","1 through 10","21877.34","34210.04","percent of total billed charges",""
"DEFIBRILLATOR EMBLEM 83.1MM 69.1MM 12.7MM MRI S-ICD PULSE GENERATOR","SUP-ITM-10170137","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","41862.50","31396.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34210.04","81.72","","41468.88","41468.88","41468.88","1 through 10","21877.34","34210.04","percent of total billed charges",""
"DEFIBRILLATOR FORTIFY ASSURA CARDIOVERTER VR SINGLE CHAMBER DF 4 CONNECTOR SYSTEM","SUP-ITM-10124443","CDM","C1722","HCPCS","0278","RC","","","","both","","","27000.00","20250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21465.00","79.5","","31564.33","31564.33","31564.33","1 through 10","8370","21465","percent of total billed charges",""
"DEFIBRILLATOR FORTIFY ASSURA CARDIOVERTER VR SINGLE CHAMBER DF 4 CONNECTOR SYSTEM","SUP-ITM-10124443","CDM","C1722","HCPCS","0278","RC","","","","both","","","27000.00","20250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","17550.00","65","","27210.63","27210.63","27210.63","1 through 10","8370","21465","percent of total billed charges",""
"DEFIBRILLATOR FORTIFY ASSURA CARDIOVERTER VR SINGLE CHAMBER DF 4 CONNECTOR SYSTEM","SUP-ITM-10124443","CDM","C1722","HCPCS","0278","RC","","","","both","","","27000.00","20250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9855.00","36.5","","46844.13","8621.25","46844.13","1 through 10","8370","21465","percent of total billed charges",""
"DEFIBRILLATOR FORTIFY ASSURA CARDIOVERTER VR SINGLE CHAMBER DF 4 CONNECTOR SYSTEM","SUP-ITM-10124443","CDM","C1722","HCPCS","0278","RC","","","","both","","","27000.00","20250.00","WELLPOINT [1015]","HB AMC WELLPOINT","19920.60","73.78","","16551.00","16551.00","16551.00","1 through 10","8370","21465","percent of total billed charges",""
"DEFIBRILLATOR FORTIFY ASSURA CARDIOVERTER VR SINGLE CHAMBER DF 4 CONNECTOR SYSTEM","SUP-ITM-10124443","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","27000.00","20250.00","AETNA [1001]","HB AMC AETNA HMO","18846.00","69.8","","74515.25","24796.25","74515.25","1 through 10","14110.2","22064.4","percent of total billed charges",""
"DEFIBRILLATOR FORTIFY ASSURA CARDIOVERTER VR SINGLE CHAMBER DF 4 CONNECTOR SYSTEM","SUP-ITM-10124443","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","27000.00","20250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","22064.40","81.72","","10077.92","10077.92","10077.92","1 through 10","14110.2","22064.4","percent of total billed charges",""
"DEFIBRILLATOR FORTIFY ASSURA CARDIOVERTER VR SINGLE CHAMBER DF 4 CONNECTOR SYSTEM","SUP-ITM-10124443","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","27000.00","20250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22064.40","81.72","","41468.88","41468.88","41468.88","1 through 10","14110.2","22064.4","percent of total billed charges",""
"Defibrillator Implants,EXTREME","179","DRG","","","","","","","","inpatient","","","336478.27","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","232351.31","","Standard inlier is a Case rate ($232,351.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $172,361, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($32,980.34) for the length of stay and the standard reimbursement.","232351.30","212272.98","232351.30","1 through 10","37566.71","232351.31","case rate",""
"Defibrillator Implants,EXTREME","179","DRG","","","","","","","","inpatient","","","336478.27","","MASSHEALTH [3001]","HB BWH MEDICAID","80573.36","","Case rate ($89,087.70). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $131,517.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $10,505.63 and the sum of the standard inlier and any outlier amount.","89065.83","89065.83","89065.83","1 through 10","37566.71","232351.31","case rate",""
"Defibrillator Implants,MAJOR","179","DRG","","","","","","","","inpatient","","","262692.99","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","150692.89","","Standard inlier is a Case rate ($150,692.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $128,832, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($21,391.76) for the length of stay and the standard reimbursement.","150692.88","150692.88","150692.88","1 through 10","37566.71","232351.31","case rate",""
"Defibrillator Implants,MAJOR","179","DRG","","","","","","","","inpatient","","","262692.99","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","169419.42","","Standard inlier is a Case rate ($169,419.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $128,832, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($24,047.68) for the length of stay and the standard reimbursement.","154779.27","154779.27","169419.42","1 through 10","37566.71","232351.31","case rate",""
"Defibrillator Implants,MINOR","179","DRG","","","","","","","","inpatient","","","114479.11","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","121806.00","","Standard inlier is a Case rate ($121,806). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $95,898, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,289.35) for the length of stay and the standard reimbursement.","121806.00","121806.00","121806.00","1 through 10","37566.71","232351.31","case rate",""
"Defibrillator Implants,MODERATE","179","DRG","","","","","","","","inpatient","","","145785.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","138037.10","","Standard inlier is a Case rate ($138,037.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $107,127, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($19,593.22) for the length of stay and the standard reimbursement.","138037.10","138037.10","138037.10","1 through 10","37566.71","232351.31","case rate",""
"Defibrillator Implants,MODERATE","179","DRG","","","","","","","","inpatient","","","145785.09","","MASSHEALTH [3001]","HB BWH MEDICAID","42376.07","","Case rate ($46,854.03). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $89,284.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","46842.53","46842.53","46842.53","1 through 10","37566.71","232351.31","case rate",""
"DEFIBRILLATOR MOMENTUM X4 IS4 DF1 HEARTLOGIC","SUP-ITM-10235942","CDM","C1882","HCPCS","0278","RC","","","","both","","","33535.00","25151.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","17874.16","53.3","","25132.80","25132.80","25132.80","1 through 10","10395.85","26660.33","percent of total billed charges",""
"DEFIBRILLATOR MOMENTUM X4 IS4 DF1 HEARTLOGIC","SUP-ITM-10235942","CDM","C1882","HCPCS","0278","RC","","","","both","","","33535.00","25151.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12843.91","38.3","","18611.60","13196.25","18611.60","1 through 10","10395.85","26660.33","percent of total billed charges",""
"DEFIBRILLATOR MOMENTUM X4 IS4 DF1 HEARTLOGIC","SUP-ITM-10235942","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","33535.00","25151.25","AETNA [1001]","HB AMC AETNA HMO","23407.43","69.8","","23525.75","23525.75","23525.75","1 through 10","17525.39","27404.8","percent of total billed charges",""
"DEFIBRILLATOR MOMENTUM X4 IS4 DF1 HEARTLOGIC","SUP-ITM-10235942","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","33535.00","25151.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","27404.80","81.72","","14745.34","14745.34","14745.34","1 through 10","17525.39","27404.8","percent of total billed charges",""
"DEFIBRILLATOR UNIFY ASSURA CARDIOVERTER RF DUAL CHAMBER CRT D DF 1 CONNECTOR BIPOLAR 40J","SUP-ITM-10124448","CDM","C1882","HCPCS","0278","RC","","","","both","","","44250.00","33187.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23585.25","53.3","","25132.80","25132.80","25132.80","1 through 10","13717.5","35178.75","percent of total billed charges",""
"DEFIBRILLATOR UNIFY ASSURA CARDIOVERTER RF DUAL CHAMBER CRT D DF 1 CONNECTOR BIPOLAR 40J","SUP-ITM-10124448","CDM","C1882","HCPCS","0278","RC","","","","both","","","44250.00","33187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16947.75","38.3","","18611.60","13196.25","18611.60","1 through 10","13717.5","35178.75","percent of total billed charges",""
"DEFIBRILLATOR UNIFY ASSURA CARDIOVERTER RF DUAL CHAMBER CRT D DF 1 CONNECTOR BIPOLAR 40J","SUP-ITM-10124448","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","44250.00","33187.50","AETNA [1001]","HB AMC AETNA HMO","30886.50","69.8","","23525.75","23525.75","23525.75","1 through 10","23125.05","36161.1","percent of total billed charges",""
"DEFIBRILLATOR UNIFY ASSURA CARDIOVERTER RF DUAL CHAMBER CRT D DF 1 CONNECTOR BIPOLAR 40J","SUP-ITM-10124448","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","44250.00","33187.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","36161.10","81.72","","14745.34","14745.34","14745.34","1 through 10","23125.05","36161.1","percent of total billed charges",""
"DEFIBRILLATOR VIGILANT EL DR DF4 HEARTLOGIC","SUP-ITM-10235933","CDM","C1721","HCPCS","0278","RC","","","","both","","","24850.00","18637.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9517.55","38.3","","12426.00","12426.00","12426.00","1 through 10","7703.5","19755.75","percent of total billed charges",""
"DEFIBRILLATOR VIGILANT EL DR DF4 HEARTLOGIC","SUP-ITM-10235933","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","24850.00","18637.50","AETNA [1001]","HB AMC AETNA HMO","17345.30","69.8","","16823.45","16823.45","16823.45","1 through 10","12986.61","20307.42","percent of total billed charges",""
"DEFIBRILLATOR VIGILANT EL DR DF4 HEARTLOGIC","SUP-ITM-10235933","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","24850.00","18637.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","20307.42","81.72","","19865.09","19865.09","19865.09","1 through 10","12986.61","20307.42","percent of total billed charges",""
"DEFIBRILLATOR VIGILANT EL VR DF4 HEARTLOGIC","SUP-ITM-10235937","CDM","C1722","HCPCS","0278","RC","","","","both","","","22920.00","17190.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18221.40","79.5","","31564.33","31564.33","31564.33","1 through 10","7105.2","18221.4","percent of total billed charges",""
"DEFIBRILLATOR VIGILANT EL VR DF4 HEARTLOGIC","SUP-ITM-10235937","CDM","C1722","HCPCS","0278","RC","","","","both","","","22920.00","17190.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","14898.00","65","","27210.63","27210.63","27210.63","1 through 10","7105.2","18221.4","percent of total billed charges",""
"DEFIBRILLATOR VIGILANT EL VR DF4 HEARTLOGIC","SUP-ITM-10235937","CDM","C1722","HCPCS","0278","RC","","","","both","","","22920.00","17190.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8365.80","36.5","","46844.13","8621.25","46844.13","1 through 10","7105.2","18221.4","percent of total billed charges",""
"DEFIBRILLATOR VIGILANT EL VR DF4 HEARTLOGIC","SUP-ITM-10235937","CDM","C1722","HCPCS","0278","RC","","","","both","","","22920.00","17190.00","WELLPOINT [1015]","HB AMC WELLPOINT","16910.38","73.78","","16551.00","16551.00","16551.00","1 through 10","7105.2","18221.4","percent of total billed charges",""
"DEFIBRILLATOR VIGILANT EL VR DF4 HEARTLOGIC","SUP-ITM-10235937","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","22920.00","17190.00","AETNA [1001]","HB AMC AETNA HMO","15998.16","69.8","","74515.25","24796.25","74515.25","1 through 10","11977.99","18730.22","percent of total billed charges",""
"DEFIBRILLATOR VIGILANT EL VR DF4 HEARTLOGIC","SUP-ITM-10235937","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","22920.00","17190.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","18730.22","81.72","","10077.92","10077.92","10077.92","1 through 10","11977.99","18730.22","percent of total billed charges",""
"DEFIBRILLATOR VIGILANT EL VR DF4 HEARTLOGIC","SUP-ITM-10235937","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","22920.00","17190.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18730.22","81.72","","41468.88","41468.88","41468.88","1 through 10","11977.99","18730.22","percent of total billed charges",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,EXTREME","042","DRG","","","","","","","","inpatient","","","116500.76","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","63223.42","","Standard inlier is a Case rate ($63,223.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $60,813, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,974.95) for the length of stay and the standard reimbursement.","64937.86","64937.86","64937.86","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,EXTREME","042","DRG","","","","","","","","inpatient","","","116500.76","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13429.1468","","Fee schedule rate ($44,344.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13429.1468","44344.80","44344.80","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,EXTREME","042","DRG","","","","","","","","inpatient","","","116500.76","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($44,344.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","44344.80","44344.80","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MAJOR","042","DRG","","","","","","","","inpatient","","","71506.15","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","35507.18","","Standard inlier is a Case rate ($35,507.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,259, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,040.46) for the length of stay and the standard reimbursement.","32366.09","32366.09","32366.09","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MAJOR","042","DRG","","","","","","","","inpatient","","","71506.15","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","39919.64","","Standard inlier is a Case rate ($39,919.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,259, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,666.26) for the length of stay and the standard reimbursement.","36470.04","36470.04","36470.04","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MAJOR","042","DRG","","","","","","","","inpatient","","","71506.15","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","14100.9944","","Fee schedule rate ($23,680.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14100.9944","39684.28","39684.28","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MAJOR","042","DRG","","","","","","","","inpatient","","","71506.15","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22781.42","","Fee schedule rate ($23,680.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22781.42","39684.28","39684.28","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MAJOR","042","DRG","","","","","","","","inpatient","","","71506.15","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","29355.17","","Fee schedule rate ($29,355.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28499.92","28499.92","28499.92","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MAJOR","042","DRG","","","","","","","","inpatient","","","71506.15","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","20246.15","","Case rate ($22,385.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,815.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,399.10 and the sum of the standard inlier and any outlier amount.","22380.11","22380.11","22380.11","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MINOR","042","DRG","","","","","","","","inpatient","","","10139.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20792.03","","Standard inlier is a Case rate ($20,792.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,817, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,951.55) for the length of stay and the standard reimbursement.","20792.02","20792.02","20792.02","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MINOR","042","DRG","","","","","","","","inpatient","","","10139.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","23375.84","","Standard inlier is a Case rate ($23,375.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,817, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,318.01) for the length of stay and the standard reimbursement.","23375.84","23375.84","23580.39","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MODERATE","042","DRG","","","","","","","","inpatient","","","40942.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","26390.26","","Standard inlier is a Case rate ($26,390.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,169, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,746.26) for the length of stay and the standard reimbursement.","26897.37","26897.37","26897.37","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MODERATE","042","DRG","","","","","","","","inpatient","","","40942.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","29669.76","","Standard inlier is a Case rate ($29,669.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,169, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,211.38) for the length of stay and the standard reimbursement.","29669.76","29669.76","29669.76","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MODERATE","042","DRG","","","","","","","","inpatient","","","40942.88","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13429.1468","","Fee schedule rate ($19,105.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13429.1468","19105.88","19105.88","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MODERATE","042","DRG","","","","","","","","inpatient","","","40942.88","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($19,105.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","19105.88","19105.88","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MODERATE","042","DRG","","","","","","","","inpatient","","","40942.88","","MASSHEALTH [3001]","HB BWH MEDICAID","16077.66","","Case rate ($17,776.62). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,206.62, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17772.25","17772.25","17772.25","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MODERATE","042","DRG","","","","","","","","inpatient","","","40942.88","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","16077.66","","Case rate ($17,776.62). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,206.62, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","2221.53","1 through 10","12117.08","84525.48","case rate",""
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","82156.52","61617.39","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","27882.84","","Case rate ($27,882.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,890.30, add-ons for qualifying new technology services are included. If operating cost exceeds $71,534.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,309.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $25,633.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,510.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,869.30. The transfer capital threshold is the transfer adjustment factor * $1,869.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","45172.61","22760.67","87597.51","1 through 10","21139.97","36389.04","other","Inpatient DRG"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","82156.52","61617.39","MEDICARE [2001]","HB BWH MEDICARE","27882.84","","Case rate ($27,882.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,890.30, add-ons for qualifying new technology services are included. If operating cost exceeds $71,534.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,309.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $25,633.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,510.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,869.30. The transfer capital threshold is the transfer adjustment factor * $1,869.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29799.50","0.03","29843.66","32","21139.97","36389.04","other","Inpatient DRG"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","82156.52","61617.39","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","27882.84","","Case rate ($27,882.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,890.30, add-ons for qualifying new technology services are included. If operating cost exceeds $71,534.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,309.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $25,633.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,510.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,869.30. The transfer capital threshold is the transfer adjustment factor * $1,869.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22585.37","22585.37","22585.37","1 through 10","21139.97","36389.04","other","Inpatient DRG"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","82156.52","61617.39","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","21139.97","","Case rate ($21,571.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,890.30, add-ons for qualifying new technology services are included. If operating cost exceeds $71,534.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,309.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $19,322.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,510.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,869.30. The transfer capital threshold is the transfer adjustment factor * $1,869.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22663.60","22626.99","596808.00","1 through 10","21139.97","36389.04","other","Inpatient DRG"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","82156.52","61617.39","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","21139.97","","Case rate ($21,571.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,890.30, add-ons for qualifying new technology services are included. If operating cost exceeds $71,534.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,309.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $19,322.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,510.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,869.30. The transfer capital threshold is the transfer adjustment factor * $1,869.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22616.85","22580.60","22670.06","1 through 10","21139.97","36389.04","other","Inpatient DRG"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","47366.10","35524.57","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","12564.39","","Case rate ($12,198.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,607.10, add-ons for qualifying new technology services are included. If operating cost exceeds $60,251.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,482.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,776.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,227.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,042.52. The transfer capital threshold is the transfer adjustment factor * $1,042.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12797.09","12797.09","12797.09","1 through 10","11954.47","20294.28","other","Inpatient DRG"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","47366.10","35524.57","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12198.44","","Case rate ($12,198.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,607.10, add-ons for qualifying new technology services are included. If operating cost exceeds $60,251.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,482.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,776.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,227.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,042.52. The transfer capital threshold is the transfer adjustment factor * $1,042.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12272.89","12272.89","12272.89","1 through 10","11954.47","20294.28","other","Inpatient Replacement Plans DRG"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","47366.10","35524.57","FALLON HEALTH [1008]","HB BWH MEDICARE","12198.44","","Case rate ($12,198.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,607.10, add-ons for qualifying new technology services are included. If operating cost exceeds $60,251.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,482.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,776.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,227.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,042.52. The transfer capital threshold is the transfer adjustment factor * $1,042.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6659.00","6659.00","6659.00","1 through 10","11954.47","20294.28","other","Inpatient Replacement Plans DRG"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","47366.10","35524.57","HUMANA [1012]","HB BWH MEDICARE","12198.44","","Case rate ($12,198.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,607.10, add-ons for qualifying new technology services are included. If operating cost exceeds $60,251.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,482.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,776.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,227.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,042.52. The transfer capital threshold is the transfer adjustment factor * $1,042.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22577.90","22577.90","22577.90","1 through 10","11954.47","20294.28","other","Inpatient Replacement Plans DRG"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","47366.10","35524.57","MEDICARE [2001]","HB BWH MEDICARE","12198.44","","Case rate ($12,198.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,607.10, add-ons for qualifying new technology services are included. If operating cost exceeds $60,251.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,482.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,776.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,227.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,042.52. The transfer capital threshold is the transfer adjustment factor * $1,042.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16009.73","0.03","16033.27","66","11954.47","20294.28","other","Inpatient Replacement Plans DRG"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","47366.10","35524.57","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","12198.44","","Case rate ($12,198.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,607.10, add-ons for qualifying new technology services are included. If operating cost exceeds $60,251.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,482.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,776.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,227.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,042.52. The transfer capital threshold is the transfer adjustment factor * $1,042.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12178.81","12178.81","12178.81","1 through 10","11954.47","20294.28","other","Inpatient Replacement Plans DRG"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","47366.10","35524.57","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","11954.47","","Case rate ($12,198.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,607.10, add-ons for qualifying new technology services are included. If operating cost exceeds $60,251.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,482.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,776.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,227.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,042.52. The transfer capital threshold is the transfer adjustment factor * $1,042.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12190.00","12190.00","18077.99","1 through 10","11954.47","20294.28","other","Inpatient DRG"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","47366.10","35524.57","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11954.47","","Case rate ($12,198.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,607.10, add-ons for qualifying new technology services are included. If operating cost exceeds $60,251.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,482.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,776.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,227.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,042.52. The transfer capital threshold is the transfer adjustment factor * $1,042.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12234.92","12197.80","53579.71","1 through 10","11954.47","20294.28","other","Inpatient DRG"
"Del Vaginal Only","PX-72000016","CDM","59409","CPT","0720","RC","","","","outpatient","","","12491.00","9368.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","25926.70","25926.70","25926.70","1 through 10","2125.14","10792.81","other","Multiple Surgery"
"Deletions/Duplications via Acgh","PX-31000835","CDM","81479","CPT","0310","RC","","","","both","","","567.00","425.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","450.77","79.5","","0.65","0.65","0.65","1 through 10","175.77","538.65","percent of total billed charges",""
"Deletions/Duplications via Acgh","PX-31000835","CDM","81479","CPT","0310","RC","","","","both","","","567.00","425.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","302.21","53.3","","0.79","0.79","0.79","1 through 10","175.77","538.65","percent of total billed charges",""
"Deletions/Duplications via Acgh","PX-31000835","CDM","81479","CPT","0310","RC","","","","outpatient","","","567.00","425.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","283.50","50","","1.00","1.00","1.00","1 through 10","156.55","467.78","percent of total billed charges",""
"Deletions/Duplications via Acgh","PX-31000835","CDM","81479","CPT","0310","RC","","","","outpatient","","","567.00","425.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","297.68","52.5","","1.00","0.53","1.00","1 through 10","156.55","467.78","percent of total billed charges",""
"Delve Bio-Broad, CSF Pathogen Detection Diagnosis of Meningitis/Encephal","PX-30003845","CDM","81479","CPT","0300","RC","","","","both","","","5800.00","4350.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4611.00","79.5","","0.65","0.65","0.65","1 through 10","1798","5510","percent of total billed charges",""
"Delve Bio-Broad, CSF Pathogen Detection Diagnosis of Meningitis/Encephal","PX-30003845","CDM","81479","CPT","0300","RC","","","","both","","","5800.00","4350.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3091.40","53.3","","0.79","0.79","0.79","1 through 10","1798","5510","percent of total billed charges",""
"Delve Bio-Broad, CSF Pathogen Detection Diagnosis of Meningitis/Encephal","PX-30003845","CDM","81479","CPT","0300","RC","","","","outpatient","","","5800.00","4350.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2900.00","50","","1.00","1.00","1.00","1 through 10","156.55","4785","percent of total billed charges",""
"Delve Bio-Broad, CSF Pathogen Detection Diagnosis of Meningitis/Encephal","PX-30003845","CDM","81479","CPT","0300","RC","","","","outpatient","","","5800.00","4350.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3045.00","52.5","","1.00","0.53","1.00","1 through 10","156.55","4785","percent of total billed charges",""
"Denosumab Sq 1mg","PX-63600096","CDM","J0897","HCPCS","0636","RC","","","","both","","","56.31","42.23","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28.79","","APC Price ($29.38). Final payment is multiplied by 98%.","27.26","27.11","28.66","1260","17.46","59.4","other","OPPS APC"
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","","","","inpatient","","","40412.00","30309.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","8939.50","","Case rate ($8,679.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,370.55, add-ons for qualifying new technology services are included. If operating cost exceeds $56,014.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,172.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,567.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,990.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $732.08. The transfer capital threshold is the transfer adjustment factor * $732.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9107.34","9107.34","9107.34","1 through 10","8505.55","14251.11","other","Inpatient DRG"
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","","","","inpatient","","","40412.00","30309.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","11150.89","","Case rate ($11,150.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,370.55, add-ons for qualifying new technology services are included. If operating cost exceeds $56,014.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,172.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,038.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,990.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $732.08. The transfer capital threshold is the transfer adjustment factor * $732.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8835.59","8835.59","8835.59","1 through 10","8505.55","14251.11","other","Inpatient DRG"
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","","","","inpatient","","","40412.00","30309.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8679.13","","Case rate ($8,679.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,370.55, add-ons for qualifying new technology services are included. If operating cost exceeds $56,014.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,172.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,567.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,990.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $732.08. The transfer capital threshold is the transfer adjustment factor * $732.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8639.50","8639.50","8639.50","1 through 10","8505.55","14251.11","other","Inpatient DRG"
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","","","","inpatient","","","40412.00","30309.00","MEDICARE [2001]","HB BWH MEDICARE","11150.89","","Case rate ($11,150.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,370.55, add-ons for qualifying new technology services are included. If operating cost exceeds $56,014.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,172.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,038.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,990.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $732.08. The transfer capital threshold is the transfer adjustment factor * $732.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11383.76","11367.16","11383.76","1 through 10","8505.55","14251.11","other","Inpatient DRG"
"Dental And Oral Diseases With McC","157","MS-DRG","","","","","","","","inpatient","","","70444.27","52833.20","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","20704.89","","Case rate ($20,704.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,232.39, add-ons for qualifying new technology services are included. If operating cost exceeds $64,876.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,821.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $18,943.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,852.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,381.44. The transfer capital threshold is the transfer adjustment factor * $1,381.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19311.61","19311.61","19311.61","1 through 10","15719.84","24711.5125","other","Inpatient DRG"
"Dental And Oral Diseases With McC","157","MS-DRG","","","","","","","","inpatient","","","70444.27","52833.20","MEDICARE [2001]","HB BWH MEDICARE","20704.89","","Case rate ($20,704.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,232.39, add-ons for qualifying new technology services are included. If operating cost exceeds $64,876.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,821.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $18,943.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,852.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,381.44. The transfer capital threshold is the transfer adjustment factor * $1,381.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19583.02","19583.02","19611.90","1 through 10","15719.84","24711.5125","other","Inpatient DRG"
"Dental And Oral Diseases With McC","157","MS-DRG","","","","","","","","inpatient","","","70444.27","52833.20","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","15719.84","","Case rate ($16,040.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,232.39, add-ons for qualifying new technology services are included. If operating cost exceeds $64,876.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,821.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $14,279.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,852.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,381.44. The transfer capital threshold is the transfer adjustment factor * $1,381.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15001.58","15001.58","15001.58","1 through 10","15719.84","24711.5125","other","Inpatient DRG"
"Dental And Oral Diseases With McC","157","MS-DRG","","","","","","","","inpatient","","","70444.27","52833.20","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15719.84","","Case rate ($16,040.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,232.39, add-ons for qualifying new technology services are included. If operating cost exceeds $64,876.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,821.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $14,279.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,852.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,381.44. The transfer capital threshold is the transfer adjustment factor * $1,381.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14889.85","14889.85","14905.43","1 through 10","15719.84","24711.5125","other","Inpatient DRG"
"Dental Diseases And Disorders,EXTREME","114","DRG","","","","","","","","inpatient","","","104640.58","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","25899.99","25899.99","25899.99","1 through 10","4433.52","123993.09","percent of total billed charges",""
"Dental Diseases And Disorders,MAJOR","114","DRG","","","","","","","","inpatient","","","48978.27","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11369.5726","","Fee schedule rate ($28,791.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11369.5726","27680.84","27680.84","1 through 10","4433.52","123993.09","case rate",""
"Dentoalveolar Unlstd Proc","PX-75000334","CDM","41899","CPT","0761","RC","","","","outpatient","","","2928.00","2196.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1772.90","60.55","","481.00","481.00","481.00","1 through 10","700.33","2415.6","percent of total billed charges",""
"Deoxycortisol","PX-30000407","CDM","82634","CPT","0301","RC","","","","both","","","356.00","267.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","136.35","38.3","","134.90","134.90","134.90","1 through 10","28.69","338.2","percent of total billed charges",""
"Deoxyribonuclease (Dna) Antibody","PX-30000805","CDM","86215","CPT","0302","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","59.13","36.5","","49.30","49.30","49.30","1 through 10","12.99","153.9","percent of total billed charges",""
"Deoxyribonuclease (Dna) Antibody","PX-30000805","CDM","86215","CPT","0302","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.05","38.3","","61.39","61.39","61.39","1 through 10","12.99","153.9","percent of total billed charges",""
"Deoxyribonuclease (Dna) Antibody","PX-30000805","CDM","86215","CPT","0302","RC","","","","outpatient","","","162.00","121.50","AETNA [1001]","HB AMC AETNA HMO","113.08","69.8","","75.05","75.05","106.29","1 through 10","13.66","132.39","percent of total billed charges",""
"Deoxyribonuclease (Dna) Antibody","PX-30000805","CDM","86215","CPT","0302","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","132.39","81.72","","69.03","69.03","125.51","1 through 10","13.66","132.39","percent of total billed charges",""
"Depressive Disorders,MODERATE","751","DRG","","","","","","","","inpatient","","","95493.29","","MASSHEALTH [3001]","HB BWH MEDICAID","11608.72","","Case rate ($12,835.44). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,265.44, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,165.80 and the sum of the standard inlier and any outlier amount.","6993.08","6993.08","6993.08","1 through 10","954.59","27649.98","case rate",""
"Depressive Neuroses","881","MS-DRG","","","","","","","","inpatient","","","38064.47","28548.35","MEDICARE [2001]","HB BWH MEDICARE","11519.10","","Case rate ($11,519.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,712.07, add-ons for qualifying new technology services are included. If operating cost exceeds $56,356.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,197.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,382.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,332.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.10. The transfer capital threshold is the transfer adjustment factor * $757.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11054.76","11054.76","11070.87","1 through 10","8783.58","13794.6831","other","Inpatient DRG"
"Dermal Filler Injections","PX-76002454","CDM","G0429","HCPCS","0761","RC","","","","both","","","541.00","405.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.60","516.60","516.60","1 through 10","167.71","2715.13","other","OPPS APC"
"Dermal Filler Injections","PX-76002454","CDM","G0429","HCPCS","0761","RC","","","","both","","","541.00","405.75","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6516.96","2172.32","6516.96","21","167.71","2715.13","other","OPPS APC"
"Dermal Filler Injections","PX-76002454","CDM","G0429","HCPCS","0761","RC","","","","both","","","541.00","405.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6386.61","2128.87","6386.61","1 through 10","167.71","2715.13","other","OPPS APC"
"Dermal Filler Injections","PX-76002454","CDM","G0429","HCPCS","0761","RC","","","","both","","","541.00","405.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2136.58","2129.28","2136.58","1 through 10","167.71","2715.13","other","OPPS APC"
"Dermal Filler Injections","PX-76002454","CDM","G0429","HCPCS","0761","RC","","","","outpatient","","","541.00","405.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","327.58","60.55","","352.96","327.71","352.96","1 through 10","282.51","3166.28","percent of total billed charges",""
"Dermal Filler Injections","PX-76002454","CDM","G0429","HCPCS","0761","RC","","","","outpatient","","","541.00","405.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","282.51","52.22","","282.61","282.61","282.61","1 through 10","282.51","3166.28","percent of total billed charges",""
"Dermal Filler Injections","PX-98301638","CDM","G0429","HCPCS","0983","RC","","","","both","","","299.00","224.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.60","516.60","516.60","1 through 10","92.69","2715.13","other","OPPS APC"
"Dermal Filler Injections","PX-98301638","CDM","G0429","HCPCS","0983","RC","","","","both","","","299.00","224.25","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6516.96","2172.32","6516.96","21","92.69","2715.13","other","OPPS APC"
"Dermal Filler Injections","PX-98301638","CDM","G0429","HCPCS","0983","RC","","","","both","","","299.00","224.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6386.61","2128.87","6386.61","1 through 10","92.69","2715.13","other","OPPS APC"
"Dermal Filler Injections","PX-98301638","CDM","G0429","HCPCS","0983","RC","","","","both","","","299.00","224.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2136.58","2129.28","2136.58","1 through 10","92.69","2715.13","other","OPPS APC"
"Desensitization Rapid Ea Hr","PX-92000115","CDM","95180","CPT","0940","RC","","","","both","","","724.00","543.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","575.58","79.5","","370.66","370.66","370.66","1 through 10","224.44","592.3","percent of total billed charges",""
"Desensitization Rapid Ea Hr","PX-92000115","CDM","95180","CPT","0940","RC","","","","both","","","724.00","543.00","MEDICARE [2001]","HB BWH MEDICARE","473.84","","APC Price ($473.84). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","118.47","118.47","118.47","1 through 10","224.44","592.3","other","OPPS APC"
"Desensitization Rapid Ea Hr","PX-92000115","CDM","95180","CPT","0940","RC","","","","both","","","724.00","543.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","277.29","38.3","","274.48","274.48","274.48","1 through 10","224.44","592.3","percent of total billed charges",""
"Desensitization Rapid Ea Hr","PX-92000115","CDM","95180","CPT","0940","RC","","","","both","","","724.00","543.00","WELLPOINT [1015]","HB AMC WELLPOINT","534.17","73.78","","522.64","522.64","522.64","1 through 10","224.44","592.3","percent of total billed charges",""
"Desensitization Rapid Ea Hr","PX-92000115","CDM","95180","CPT","0940","RC","","","","outpatient","","","724.00","543.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","591.65","81.72","","561.18","561.18","561.18","1 through 10","404.72","849.51","percent of total billed charges",""
"Desmopress Inj 1mcg","PX-63600165","CDM","J2597","HCPCS","0636","RC","","","","both","","","4.09","3.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2.66","65","","1678.95","1678.95","1678.95","1 through 10","1.27","15.07","percent of total billed charges",""
"Desmopress Inj 1mcg","PX-63600165","CDM","J2597","HCPCS","0636","RC","","","","both","","","4.09","3.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1.49","36.5","","24.78","24.78","24.78","75","1.27","15.07","percent of total billed charges",""
"Desmopress Inj 1mcg","PX-63600165","CDM","J2597","HCPCS","0636","RC","","","","outpatient","","","4.09","3.07","AETNA [1001]","HB AMC AETNA HMO","2.85","69.8","","15.12","15.12","15.12","1 through 10","1.92","26.38","percent of total billed charges",""
"Dest Lesion Anus Any Method","PX-75000236","CDM","46924","CPT","0750","RC","","","","both","","","5263.00","3947.25","MEDICARE [2001]","HB BWH MEDICARE","3256.42","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3256.75","3256.75","3256.75","1 through 10","1631.53","4184.09","other","OPPS APC"
"Dest Lesion Anus Any Method","PX-75000236","CDM","46924","CPT","0750","RC","","","","outpatient","","","5263.00","3947.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5462.27","5462.27","5462.27","1 through 10","2101.12","4300.92","other","ASC"
"Dest Lesion Anus Any Method","PX-75000236","CDM","46924","CPT","0750","RC","","","","outpatient","","","5263.00","3947.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4300.92","81.72","","8085.53","8085.53","8085.53","1 through 10","2101.12","4300.92","percent of total billed charges",""
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","both","","","5263.00","3947.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2865.14","","APC Price ($2,865.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3204.64","3204.64","3204.64","1 through 10","1631.53","4184.09","other","OPPS APC"
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","both","","","5263.00","3947.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2865.14","","APC Price ($2,865.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2632.44","2632.44","2632.44","1 through 10","1631.53","4184.09","other","OPPS APC"
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","both","","","5263.00","3947.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2015.73","38.3","","8230.55","8230.55","8230.55","1 through 10","1631.53","4184.09","percent of total billed charges",""
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","outpatient","","","5263.00","3947.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5462.27","5462.27","5462.27","1 through 10","2101.12","4300.92","other","ASC"
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","outpatient","","","5263.00","3947.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2101.12","","Case rate ($2,101.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","9749.20","9749.20","9749.20","1 through 10","2101.12","4300.92","other","Multiple Surgery"
"Dest Lesion Mouth Vestib Phys Meth","PX-75000014","CDM","40820","CPT","0761","RC","","","","outpatient","","","4327.00","3245.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2620.00","60.55","","5220.53","5220.53","5220.53","1 through 10","1730.8","3536.02","percent of total billed charges",""
"Dest Lesion Mouth Vestib Phys Meth","PX-75000014","CDM","40820","CPT","0761","RC","","","","outpatient","","","4327.00","3245.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2259.56","52.22","","5973.25","5973.25","5973.25","1 through 10","1730.8","3536.02","percent of total billed charges",""
"Dest Lesion Penis Extensive","PX-76001304","CDM","54065","CPT","0761","RC","","","","both","","","5263.00","3947.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2015.73","38.3","","1995.66","1995.66","1995.66","1 through 10","1631.53","4184.09","percent of total billed charges",""
"Dest Lesion Penis Extensive","PX-76001304","CDM","54065","CPT","0761","RC","","","","outpatient","","","5263.00","3947.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4146.66","4146.66","4146.66","1 through 10","1548.96","5545.35","other","ASC "
"Dest Lesion Penis Extensive","PX-76001304","CDM","54065","CPT","0761","RC","","","","outpatient","","","5263.00","3947.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3593.59","3454.18","3593.59","1 through 10","1548.96","5545.35","other","Multiple Surgery"
"Dest Lesion Penis Smp Chemical","PX-76001300","CDM","54050","CPT","0761","RC","","","","outpatient","","","766.00","574.50","AETNA [1001]","HB AMC AETNA HMO","534.67","69.8","","9669.46","9669.46","9669.46","1 through 10","314.08","700.33","percent of total billed charges",""
"Dest Lesion Penis Smp Cryosurgery","PX-76001302","CDM","54056","CPT","0761","RC","","","","both","","","573.00","429.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","455.54","79.5","","293.57","293.57","293.57","1 through 10","177.63","468.26","percent of total billed charges",""
"Dest Lesion Penis Smp Cryosurgery","PX-76001302","CDM","54056","CPT","0761","RC","","","","both","","","573.00","429.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","305.41","53.3","","293.57","293.57","293.57","1 through 10","177.63","468.26","percent of total billed charges",""
"Dest Lesion Penis Smp Cryosurgery","PX-76001302","CDM","54056","CPT","0761","RC","","","","both","","","573.00","429.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","219.46","38.3","","217.40","217.40","217.40","1 through 10","177.63","468.26","percent of total billed charges",""
"Dest Lesion Penis Smp Cryosurgery","PX-76001302","CDM","54056","CPT","0761","RC","","","","both","","","573.00","429.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","468.26","81.72","","444.47","444.47","444.47","1 through 10","177.63","468.26","percent of total billed charges",""
"Dest Lesion Penis Smp Cryosurgery","PX-76001302","CDM","54056","CPT","0761","RC","","","","both","","","573.00","429.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","218.50","218.50","218.50","1 through 10","177.63","468.26","other","OPPS APC"
"Dest Lesion Penis Smp Cryosurgery","PX-76001302","CDM","54056","CPT","0761","RC","","","","outpatient","","","573.00","429.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","405.38","405.38","1 through 10","176.45","460.69","other","ASC"
"Dest Lesion Penis Smp Cryosurgery","PX-76001302","CDM","54056","CPT","0761","RC","","","","outpatient","","","573.00","429.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","472.37","467.73","472.37","1 through 10","176.45","460.69","other","ASC "
"Dest Lesion Penis Smp Cryosurgery","PX-76001302","CDM","54056","CPT","0761","RC","","","","outpatient","","","573.00","429.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","393.48","204.68","409.36","1 through 10","176.45","460.69","other","Multiple Surgery"
"Dest Lesion Penis Smp Cryosurgery","PX-76001302","CDM","54056","CPT","0761","RC","","","","outpatient","","","573.00","429.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","176.45","460.69","other","Multiple Surgery"
"Dest Lesion Vagina Extensive","PX-76001345","CDM","57065","CPT","0761","RC","","","","both","","","8785.00","6588.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3364.66","38.3","","19080.03","19080.03","19080.03","1 through 10","2723.35","6984.08","percent of total billed charges",""
"Dest Lesion Vagina Extensive","PX-76001345","CDM","57065","CPT","0761","RC","","","","outpatient","","","8785.00","6588.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4587.53","52.22","","6321.29","6321.29","6321.29","1 through 10","3514","7179.1","percent of total billed charges",""
"Dest Lesion Vagina Smp","PX-76001344","CDM","57061","CPT","0761","RC","","","","both","","","4886.00","3664.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3888.77","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3886.28","3886.28","3886.28","1 through 10","1514.66","4719.38","other","OPPS APC"
"Dest Lesion Vagina Smp","PX-76001344","CDM","57061","CPT","0761","RC","","","","both","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3715.47","3357.59","3715.47","1 through 10","1514.66","4719.38","other","OPPS APC"
"Dest Lesion Vagina Smp","PX-76001344","CDM","57061","CPT","0761","RC","","","","both","","","4886.00","3664.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3884.37","79.5","","14373.37","14373.37","14373.37","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Dest Lesion Vagina Smp","PX-76001344","CDM","57061","CPT","0761","RC","","","","both","","","4886.00","3664.50","MEDICARE [2001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3412.18","3775.88","12","1514.66","4719.38","other","OPPS APC"
"Dest Lesion Vagina Smp","PX-76001344","CDM","57061","CPT","0761","RC","","","","both","","","4886.00","3664.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1871.34","38.3","","7687.02","1852.56","7687.02","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Dest Lesion Vagina Smp","PX-76001344","CDM","57061","CPT","0761","RC","","","","both","","","4886.00","3664.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","11123.28","3700.36","11123.28","1 through 10","1514.66","4719.38","other","OPPS APC"
"Dest Lesion Vagina Smp","PX-76001344","CDM","57061","CPT","0761","RC","","","","both","","","4886.00","3664.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3700.36","3700.36","3700.36","1 through 10","1514.66","4719.38","other","OPPS APC"
"Dest Lesion Vagina Smp","PX-76001344","CDM","57061","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5424.80","5424.80","5424.80","1 through 10","2125.14","3992.84","other","ASC"
"Dest Lesion Vagina Smp","PX-76001344","CDM","57061","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6321.29","6259.18","6321.29","1 through 10","2125.14","3992.84","other","ASC "
"Dest Lesion Vagina Smp","PX-76001344","CDM","57061","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4930.32","4930.32","4930.32","1 through 10","2125.14","3992.84","other","Multiple Surgery"
"Dest Lesion Vulva Smp","PX-76001333","CDM","56501","CPT","0761","RC","","","","both","","","5263.00","3947.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4184.09","79.5","","14373.37","14373.37","14373.37","1 through 10","1631.53","4184.09","percent of total billed charges",""
"Dest Lesion Vulva Smp","PX-76001333","CDM","56501","CPT","0761","RC","","","","both","","","5263.00","3947.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2015.73","38.3","","1995.66","235.77","1995.66","1 through 10","1631.53","4184.09","percent of total billed charges",""
"Dest Lesion Vulva Smp","PX-76001333","CDM","56501","CPT","0761","RC","","","","outpatient","","","5263.00","3947.25","AETNA [1001]","HB AMC AETNA HMO","3673.57","69.8","","3455.41","3455.41","3455.41","1 through 10","1548.96","4300.92","percent of total billed charges",""
"Dest Lesion Vulva Smp","PX-76001333","CDM","56501","CPT","0761","RC","","","","outpatient","","","5263.00","3947.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3624.12","3624.12","3624.12","1 through 10","1548.96","4300.92","other","ASC"
"Dest Lesion Vulva Smp","PX-76001333","CDM","56501","CPT","0761","RC","","","","outpatient","","","5263.00","3947.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4146.66","4105.92","4146.66","1 through 10","1548.96","4300.92","other","ASC "
"Dest Lesion Vulva Smp","PX-76001333","CDM","56501","CPT","0761","RC","","","","outpatient","","","5263.00","3947.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3593.59","3593.59","3593.59","1 through 10","1548.96","4300.92","other","Multiple Surgery"
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","both","","","79.00","59.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","55.30","70","","216.20","77.00","216.20","1 through 10","24.49","62.81","percent of total billed charges",""
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","both","","","79.00","59.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","62.81","79.5","","60.60","40.66","116.12","68","24.49","62.81","percent of total billed charges",""
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","both","","","79.00","59.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","42.11","53.3","","60.60","40.66","325.25","41","24.49","62.81","percent of total billed charges",""
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","both","","","79.00","59.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","51.35","65","","500.50","500.50","500.50","1 through 10","24.49","62.81","percent of total billed charges",""
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","both","","","79.00","59.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28.84","36.5","","28.72","24.41","86.17","94","24.49","62.81","percent of total billed charges",""
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","both","","","79.00","59.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30.26","38.3","","30.11","30.11","90.32","355","24.49","62.81","percent of total billed charges",""
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","both","","","79.00","59.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.89","42.9","","33.86","33.86","33.86","1 through 10","24.49","62.81","percent of total billed charges",""
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","both","","","79.00","59.25","WELLPOINT [1015]","HB AMC WELLPOINT","58.29","73.78","","57.33","57.33","827.33","96","24.49","62.81","percent of total billed charges",""
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","outpatient","","","79.00","59.25","AETNA [1001]","HB AMC AETNA HMO","55.14","69.8","","52.13","36.81","60.06","124","4.11","64.56","percent of total billed charges",""
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","outpatient","","","79.00","59.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4.11","","Case rate ($4.11). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","77.00","77.00","77.00","1 through 10","4.11","64.56","other","ASC"
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","outpatient","","","79.00","59.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","41.29","52.26","","9.53","9.53","9.53","1 through 10","4.11","64.56","percent of total billed charges",""
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","outpatient","","","79.00","59.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4.11","","Case rate ($4.11). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","77.00","77.00","77.00","14","4.11","64.56","other","ASC "
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","outpatient","","","79.00","59.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","64.56","81.72","","61.56","61.56","61.56","1 through 10","4.11","64.56","percent of total billed charges",""
"Dest Lesn Bgn/Premalig 2-14","PX-76000211","CDM","17003","CPT","0761","RC","","","","outpatient","","","79.00","59.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","64.56","81.72","","61.55","33.86","61.56","85","4.11","64.56","percent of total billed charges",""
"Dest Lesn Mal Face/Ear/Lip <0.5cm","PX-76000230","CDM","17280","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","405.38","405.38","1 through 10","176.45","1170.23","other","ASC"
"Dest Lesn Mal Face/Ear/Lip <0.5cm","PX-76000230","CDM","17280","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","467.73","1 through 10","176.45","1170.23","other","ASC "
"Dest Lesn Mal Face/Ear/Lip 0.6-1.0","PX-76000231","CDM","17281","CPT","0761","RC","","","","both","","","1431.00","1073.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","231.25","231.25","1 through 10","224.17","1137.65","other","OPPS APC"
"Dest Lesn Mal Face/Ear/Lip 0.6-1.0","PX-76000231","CDM","17281","CPT","0761","RC","","","","both","","","1431.00","1073.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","224.17","1137.65","other","OPPS APC"
"Dest Lesn Mal Face/Ear/Lip 0.6-1.0","PX-76000231","CDM","17281","CPT","0761","RC","","","","both","","","1431.00","1073.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","433.50","433.50","433.50","1 through 10","224.17","1137.65","other","OPPS APC"
"Dest Lesn Mal Face/Ear/Lip 1.1-2.0","PX-76000232","CDM","17282","CPT","0761","RC","","","","both","","","1431.00","1073.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.98","117.98","235.97","1 through 10","224.17","1137.65","other","OPPS APC"
"Dest Lesn Mal Sclp/Hnd/Gen <0.5cm","PX-76000225","CDM","17270","CPT","0761","RC","","","","both","","","702.00","526.50","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","117.98","648.92","13","217.62","558.09","other","OPPS APC"
"Dest Lesn Mal Sclp/Hnd/Gen <0.5cm","PX-76000225","CDM","17270","CPT","0761","RC","","","","both","","","702.00","526.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.87","38.3","","266.27","266.27","266.27","1 through 10","217.62","558.09","percent of total billed charges",""
"Dest Lesn Mal Sclp/Hnd/Gen <0.5cm","PX-76000225","CDM","17270","CPT","0761","RC","","","","outpatient","","","702.00","526.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","225.86","225.86","225.86","1 through 10","176.45","700.33","other","Multiple Surgery"
"Dest Lesn Mal Sclp/Hnd/Gen 0.6-1.0","PX-76000226","CDM","17271","CPT","0761","RC","","","","both","","","781.00","585.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.98","117.98","235.97","1 through 10","224.17","620.9","other","OPPS APC"
"Dest Lesn Mal Sclp/Hnd/Gen 0.6-1.0","PX-76000226","CDM","17271","CPT","0761","RC","","","","both","","","781.00","585.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","299.12","38.3","","887.97","591.98","887.97","1 through 10","224.17","620.9","percent of total billed charges",""
"Dest Lesn Mal Sclp/Hnd/Gen 0.6-1.0","PX-76000226","CDM","17271","CPT","0761","RC","","","","outpatient","","","781.00","585.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","412.84","412.84","412.84","1 through 10","176.45","700.33","other","ASC"
"Dest Lesn Mal Sclp/Hnd/Gen 0.6-1.0","PX-76000226","CDM","17271","CPT","0761","RC","","","","outpatient","","","781.00","585.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","818.72","818.72","818.72","1 through 10","176.45","700.33","other","Multiple Surgery"
"Dest Lesn Mal Sclp/Hnd/Gen 1.1-2.0","PX-76000227","CDM","17272","CPT","0761","RC","","","","outpatient","","","800.00","600.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","233.87","233.87","233.87","1 through 10","176.45","700.33","other","ASC "
"Dest Lesn Mal Sclp/Hnd/Gen 2.1-3.0","PX-76000228","CDM","17273","CPT","0761","RC","","","","both","","","1404.00","1053.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","435.24","1116.18","other","OPPS APC"
"Dest Lesn Mal Sclp/Hnd/Gen 2.1-3.0","PX-76000228","CDM","17273","CPT","0761","RC","","","","both","","","1404.00","1053.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","537.73","38.3","","517.56","517.56","517.56","1 through 10","435.24","1116.18","percent of total billed charges",""
"Dest Lesn Mal Sclp/Hnd/Gen 2.1-3.0","PX-76000228","CDM","17273","CPT","0761","RC","","","","both","","","1404.00","1053.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","235.66","235.66","235.66","1 through 10","435.24","1116.18","other","OPPS APC"
"Dest Lesn Mal Sclp/Hnd/Gen 2.1-3.0","PX-76000228","CDM","17273","CPT","0761","RC","","","","outpatient","","","1404.00","1053.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","734.86","734.86","734.86","1 through 10","314.08","1147.35","other","ASC"
"Dest Lesn Mal Trunk/Arm/Leg <0.5cm","PX-76000219","CDM","17260","CPT","0761","RC","","","","both","","","524.00","393.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","243.51","243.51","243.51","1 through 10","162.44","416.58","other","OPPS APC"
"Dest Lesn Mal Trunk/Arm/Leg <0.5cm","PX-76000219","CDM","17260","CPT","0761","RC","","","","both","","","524.00","393.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","416.58","79.5","","399.80","399.80","399.80","1 through 10","162.44","416.58","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg <0.5cm","PX-76000219","CDM","17260","CPT","0761","RC","","","","both","","","524.00","393.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.29","53.3","","330.20","330.20","330.20","1 through 10","162.44","416.58","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg <0.5cm","PX-76000219","CDM","17260","CPT","0761","RC","","","","both","","","524.00","393.00","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","162.44","416.58","other","OPPS APC"
"Dest Lesn Mal Trunk/Arm/Leg <0.5cm","PX-76000219","CDM","17260","CPT","0761","RC","","","","both","","","524.00","393.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","200.69","38.3","","198.63","198.63","198.63","1 through 10","162.44","416.58","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg <0.5cm","PX-76000219","CDM","17260","CPT","0761","RC","","","","outpatient","","","524.00","393.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","57.91","57.91","405.38","1 through 10","176.45","700.33","other","ASC"
"Dest Lesn Mal Trunk/Arm/Leg <0.5cm","PX-76000219","CDM","17260","CPT","0761","RC","","","","outpatient","","","524.00","393.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","236.19","472.37","1 through 10","176.45","700.33","other","ASC "
"Dest Lesn Mal Trunk/Arm/Leg <0.5cm","PX-76000219","CDM","17260","CPT","0761","RC","","","","outpatient","","","524.00","393.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","176.45","700.33","other","Multiple Surgery"
"Dest Lesn Mal Trunk/Arm/Leg <0.5cm","PX-76000219","CDM","17260","CPT","0761","RC","","","","outpatient","","","524.00","393.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","338.95","225.86","338.95","1 through 10","176.45","700.33","other","Multiple Surgery"
"Dest Lesn Mal Trunk/Arm/Leg 0.6-1.0","PX-76000220","CDM","17261","CPT","0761","RC","","","","both","","","450.00","337.50","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","139.5","357.75","other","OPPS APC"
"Dest Lesn Mal Trunk/Arm/Leg 0.6-1.0","PX-76000220","CDM","17261","CPT","0761","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","164.25","36.5","","162.63","157.83","162.63","1 through 10","139.5","357.75","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 0.6-1.0","PX-76000220","CDM","17261","CPT","0761","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","172.35","38.3","","170.48","170.48","170.48","1 through 10","139.5","357.75","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 0.6-1.0","PX-76000220","CDM","17261","CPT","0761","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","346.50","77","","388.04","388.04","388.04","1 through 10","139.5","357.75","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 0.6-1.0","PX-76000220","CDM","17261","CPT","0761","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB AMC WELLPOINT","332.01","73.78","","324.60","324.60","324.60","1 through 10","139.5","357.75","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 0.6-1.0","PX-76000220","CDM","17261","CPT","0761","RC","","","","outpatient","","","450.00","337.50","AETNA [1001]","HB AMC AETNA HMO","314.10","69.8","","295.17","295.17","295.17","1 through 10","176.45","700.33","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 0.6-1.0","PX-76000220","CDM","17261","CPT","0761","RC","","","","outpatient","","","450.00","337.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","202.69","202.69","405.38","1 through 10","176.45","700.33","other","ASC"
"Dest Lesn Mal Trunk/Arm/Leg 0.6-1.0","PX-76000220","CDM","17261","CPT","0761","RC","","","","outpatient","","","450.00","337.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","236.19","236.18","472.37","11","176.45","700.33","other","ASC "
"Dest Lesn Mal Trunk/Arm/Leg 0.6-1.0","PX-76000220","CDM","17261","CPT","0761","RC","","","","outpatient","","","450.00","337.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","1228.08","1 through 10","176.45","700.33","other","Multiple Surgery"
"Dest Lesn Mal Trunk/Arm/Leg 0.6-1.0","PX-76000220","CDM","17261","CPT","0761","RC","","","","outpatient","","","450.00","337.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","645.81","215.27","645.81","1 through 10","176.45","700.33","other","Multiple Surgery"
"Dest Lesn Mal Trunk/Arm/Leg 0.6-1.0","PX-76000220","CDM","17261","CPT","0761","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","367.74","81.72","","348.54","348.54","348.54","1 through 10","176.45","700.33","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","both","","","575.00","431.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","243.61","243.61","243.61","1 through 10","178.25","457.13","other","OPPS APC"
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","both","","","575.00","431.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","178.25","457.13","other","OPPS APC"
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","both","","","575.00","431.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","457.13","79.5","","439.15","294.62","439.15","1 through 10","178.25","457.13","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","both","","","575.00","431.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","306.48","53.3","","883.86","883.86","883.86","1 through 10","178.25","457.13","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","both","","","575.00","431.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","15","178.25","457.13","other","OPPS APC"
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","both","","","575.00","431.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","209.88","36.5","","208.13","208.13","208.13","1 through 10","178.25","457.13","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","both","","","575.00","431.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","220.23","38.3","","218.18","212.04","218.18","1 through 10","178.25","457.13","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","both","","","575.00","431.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","233.37","233.37","233.37","1 through 10","178.25","457.13","other","OPPS APC"
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","both","","","575.00","431.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","246.68","42.9","","446.07","446.07","446.07","1 through 10","178.25","457.13","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","both","","","575.00","431.25","WELLPOINT [1015]","HB AMC WELLPOINT","424.24","73.78","","415.43","415.43","415.43","1 through 10","178.25","457.13","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","outpatient","","","575.00","431.25","AETNA [1001]","HB AMC AETNA HMO","401.35","69.8","","377.77","377.77","377.77","1 through 10","176.45","700.33","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","outpatient","","","575.00","431.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","202.69","412.84","1 through 10","176.45","700.33","other","ASC"
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","outpatient","","","575.00","431.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","233.87","472.37","18","176.45","700.33","other","ASC "
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","outpatient","","","575.00","431.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","818.72","1 through 10","176.45","700.33","other","Multiple Surgery"
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","outpatient","","","575.00","431.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","215.27","215.27","215.27","1 through 10","176.45","700.33","other","Multiple Surgery"
"Dest Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000221","CDM","17262","CPT","0761","RC","","","","outpatient","","","575.00","431.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","469.89","81.72","","446.07","446.07","446.07","1 through 10","176.45","700.33","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000222","CDM","17263","CPT","0761","RC","","","","both","","","906.00","679.50","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","224.17","720.27","other","OPPS APC"
"Dest Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000222","CDM","17263","CPT","0761","RC","","","","outpatient","","","906.00","679.50","AETNA [1001]","HB AMC AETNA HMO","632.39","69.8","","595.08","595.08","595.08","1 through 10","176.45","740.38","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000222","CDM","17263","CPT","0761","RC","","","","outpatient","","","906.00","679.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","405.38","405.38","1 through 10","176.45","740.38","other","ASC"
"Dest Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000222","CDM","17263","CPT","0761","RC","","","","outpatient","","","906.00","679.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","472.37","472.37","472.37","1 through 10","176.45","740.38","other","ASC "
"Dest Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000222","CDM","17263","CPT","0761","RC","","","","outpatient","","","906.00","679.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","1 through 10","176.45","740.38","other","Multiple Surgery"
"Dest Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000222","CDM","17263","CPT","0761","RC","","","","outpatient","","","906.00","679.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","451.71","451.71","451.71","1 through 10","176.45","740.38","other","Multiple Surgery"
"Dest Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000223","CDM","17264","CPT","0761","RC","","","","both","","","952.00","714.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","507.42","53.3","","487.34","487.34","487.34","1 through 10","295.12","756.84","percent of total billed charges",""
"Dest Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000223","CDM","17264","CPT","0761","RC","","","","both","","","952.00","714.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","435.20","435.20","435.20","1 through 10","295.12","756.84","other","OPPS APC"
"Dest Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000223","CDM","17264","CPT","0761","RC","","","","both","","","952.00","714.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","433.50","426.50","433.50","1 through 10","295.12","756.84","other","OPPS APC"
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","both","","","1176.00","882.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","488.23","488.23","488.23","1 through 10","364.56","934.92","other","OPPS APC"
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","both","","","1176.00","882.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","466.88","466.88","1 through 10","364.56","934.92","other","OPPS APC"
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","both","","","1176.00","882.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","934.92","79.5","","601.92","601.92","601.92","1 through 10","364.56","934.92","percent of total billed charges",""
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","both","","","1176.00","882.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","626.81","53.3","","601.92","601.92","601.92","1 through 10","364.56","934.92","percent of total billed charges",""
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","both","","","1176.00","882.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","191","364.56","934.92","other","OPPS APC"
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","both","","","1176.00","882.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","429.24","36.5","","425.22","425.22","425.22","1 through 10","364.56","934.92","percent of total billed charges",""
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","both","","","1176.00","882.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","450.41","38.3","","1337.22","433.20","1337.22","1 through 10","364.56","934.92","percent of total billed charges",""
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","both","","","1176.00","882.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","464.98","426.50","464.98","1 through 10","364.56","934.92","other","OPPS APC"
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","both","","","1176.00","882.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","464.98","464.98","1394.94","1 through 10","364.56","934.92","other","OPPS APC"
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","both","","","1176.00","882.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","470.13","434.40","472.89","1 through 10","364.56","934.92","other","OPPS APC"
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","both","","","1176.00","882.00","WELLPOINT [1015]","HB AMC WELLPOINT","867.65","73.78","","848.73","848.73","848.73","1 through 10","364.56","934.92","percent of total billed charges",""
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","AETNA [1001]","HB AMC AETNA HMO","820.85","69.8","","889.20","889.20","889.20","1 through 10","314.08","961.03","percent of total billed charges",""
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","721.57","721.57","734.86","11","314.08","961.03","other","ASC"
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","832.56","832.56","840.82","17","314.08","961.03","other","ASC "
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","910.83","910.83","910.83","1 through 10","314.08","961.03","other","Multiple Surgery"
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2186.01","728.67","2186.01","24","314.08","961.03","other","Multiple Surgery"
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","910.83","910.83","910.83","1 through 10","314.08","961.03","other","Multiple Surgery"
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","804.04","804.04","804.04","1 through 10","314.08","961.03","other","Multiple Surgery"
"Dest Lesn Premalignant 15+ Lesions","PX-76000212","CDM","17004","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","961.03","81.72","","911.32","501.26","911.32","1 through 10","314.08","961.03","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","244.81","243.71","246.51","1 through 10","123.07","315.62","other","OPPS APC"
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","53.91","385.00","1 through 10","123.07","315.62","other","OPPS APC"
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","258.05","65","","203.28","203.28","203.28","1 through 10","123.07","315.62","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","315.62","79.5","","303.00","203.28","580.58","46","123.07","315.62","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","211.60","53.3","","203.28","203.28","1229.31","27","123.07","315.62","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","305.69","77","","296.45","296.45","296.45","1 through 10","123.07","315.62","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","258.05","65","","250.25","250.25","250.25","1 through 10","123.07","315.62","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","42","123.07","315.62","other","OPPS APC"
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","144.91","36.5","","143.61","122.05","143.61","37","123.07","315.62","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","152.05","38.3","","150.54","150.54","150.54","180","123.07","315.62","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","231.25","231.25","1 through 10","123.07","315.62","other","OPPS APC"
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.31","42.9","","169.28","169.28","169.28","1 through 10","123.07","315.62","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.73","231.26","231.73","1 through 10","123.07","315.62","other","OPPS APC"
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","both","","","397.00","297.75","WELLPOINT [1015]","HB AMC WELLPOINT","292.91","73.78","","286.63","286.63","671.63","46","123.07","315.62","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","AETNA [1001]","HB AMC AETNA HMO","277.11","69.8","","260.65","184.03","300.30","68","176.45","350.18","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","405.38","412.84","197","176.45","350.18","other","ASC"
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","207.47","52.26","","467.73","467.73","467.73","1 through 10","176.45","350.18","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","472.37","424","176.45","350.18","other","ASC "
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","451.71","451.71","511.71","1 through 10","176.45","350.18","other","Multiple Surgery"
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","1228.08","162","176.45","350.18","other","Multiple Surgery"
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","1291.62","67","176.45","350.18","other","Multiple Surgery"
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","511.71","462.00","511.71","1 through 10","176.45","350.18","other","Multiple Surgery"
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","176.45","350.18","other","Multiple Surgery"
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","313.91","124.13","451.71","38","176.45","350.18","other","Multiple Surgery"
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","319.19","80.4","","192.50","192.50","192.50","1 through 10","176.45","350.18","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","324.43","81.72","","307.77","307.77","307.77","1 through 10","176.45","350.18","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","324.43","81.72","","307.77","169.28","307.77","48","176.45","350.18","percent of total billed charges",""
"Dest Lesn Premalignant 1st Lesion","PX-76000210","CDM","17000","CPT","0761","RC","","","","outpatient","","","397.00","297.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","434.07","434.07","434.07","1 through 10","176.45","350.18","other","Multiple Surgery"
"Dest Lesn Vascular <10 Sq Cm","PX-76000213","CDM","17106","CPT","0761","RC","","","","both","","","2290.00","1717.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1603.00","70","","1776.80","1294.03","1776.80","1 through 10","450.74","1820.55","percent of total billed charges",""
"Dest Lesn Vascular <10 Sq Cm","PX-76000213","CDM","17106","CPT","0761","RC","","","","outpatient","","","2290.00","1717.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","721.57","721.57","734.86","1 through 10","314.08","1871.39","other","ASC"
"Dest Lesn Vascular <10 Sq Cm","PX-76000213","CDM","17106","CPT","0761","RC","","","","outpatient","","","2290.00","1717.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","832.56","832.56","832.56","1 through 10","314.08","1871.39","other","ASC "
"Dest Lesn Vascular >50 Sq Cm","PX-76000215","CDM","17108","CPT","0761","RC","","","","both","","","4027.00","3020.25","WELLPOINT [1015]","HB AMC WELLPOINT","2971.12","73.78","","2907.27","2907.27","2907.27","1 through 10","1248.37","3201.47","percent of total billed charges",""
"Dest Lesn Vascular >50 Sq Cm","PX-76000215","CDM","17108","CPT","0761","RC","","","","outpatient","","","4027.00","3020.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4146.66","4105.92","4146.66","1 through 10","700.33","3290.86","other","ASC "
"Dest Nerve Lumbar/Sacral Sgl","PX-76001587","CDM","64635","CPT","0761","RC","","","","both","","","5489.00","4116.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2388.36","","APC Price ($2,318.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2387.18","2387.18","2387.18","1 through 10","1701.59","4363.76","other","OPPS APC"
"Dest Nerve Lumbar/Sacral Sgl","PX-76001587","CDM","64635","CPT","0761","RC","","","","both","","","5489.00","4116.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2318.80","","APC Price ($2,318.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2281.93","2281.93","2281.93","1 through 10","1701.59","4363.76","other","OPPS APC"
"Dest Nerve Lumbar/Sacral Sgl","PX-76001587","CDM","64635","CPT","0761","RC","","","","both","","","5489.00","4116.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2272.42","","APC Price ($2,318.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2280.15","2073.06","2280.55","14","1701.59","4363.76","other","OPPS APC"
"Dest Nerve Lumbar/Sacral Sgl|BILATERAL PROCEDURE","PX-76001587","CDM","64635","CPT","0761","RC","","","50","outpatient","","","5489.00","4116.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2798.54","","Case rate ($2,798.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6487.02","6487.02","6487.02","1 through 10","2798.54","8435.56","other","ASC"
"Dest Nerve Lumbar/Sacral Sgl|BILATERAL PROCEDURE","PX-76001587","CDM","64635","CPT","0761","RC","","","50","outpatient","","","5489.00","4116.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2798.54","","Case rate ($2,798.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6487.02","6487.02","6487.02","1 through 10","2798.54","8435.56","other","ASC "
"Dest Nerve Neurolytic Celiac Plexus","PX-76001592","CDM","64680","CPT","0761","RC","","","","both","","","4416.00","3312.00","WELLPOINT [1015]","HB AMC WELLPOINT","3258.12","73.78","","12110.04","12110.04","12110.04","1 through 10","1004.41","3510.72","percent of total billed charges",""
"Dest Nerve Neurolytic Celiac Plexus","PX-76001592","CDM","64680","CPT","0761","RC","","","","outpatient","","","4416.00","3312.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","874.64","","Case rate ($874.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1789.51","1789.51","1789.51","1 through 10","764.84","5545.35","other","ASC"
"Dest Nerve Neurolytic Celiac Plexus","PX-76001592","CDM","64680","CPT","0761","RC","","","","outpatient","","","4416.00","3312.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1774.43","1774.43","1774.43","1 through 10","764.84","5545.35","other","Multiple Surgery"
"Destr Malignant Lesion S/N/H/F/G 3.1-4.0cm","PX-76003012","CDM","17274","CPT","0761","RC","","","","both","","","1147.00","860.25","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","355.57","911.87","other","OPPS APC"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","AETNA [1001]","HB AMC AETNA HMO","323.17","69.8","","303.97","214.62","593.58","76","143.53","372.25","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","AETNA [1001]","HB AMC AETNA PPO","372.25","80.4","","350.22","235.28","350.22","1 through 10","143.53","372.25","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","243.31","242.81","243.31","1 through 10","143.53","372.25","other","OPPS APC"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","143.53","372.25","other","OPPS APC"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","324.10","70","","449.00","449.00","449.00","1 through 10","143.53","372.25","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","368.09","79.5","","353.36","237.07","353.36","46","143.53","372.25","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","246.78","53.3","","353.36","237.07","1516.54","22","143.53","372.25","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","372.25","80.4","","224.50","224.50","224.50","1 through 10","143.53","372.25","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","218.50","235.97","47","143.53","372.25","other","OPPS APC"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","78.16","78.16","78.16","1 through 10","143.53","372.25","other","OPPS APC"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","143.53","31","","138.74","138.74","138.74","1 through 10","143.53","372.25","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","169.00","36.5","","167.48","142.33","167.48","47","143.53","372.25","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","177.33","38.3","","175.56","170.62","175.56","258","143.53","372.25","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.63","42.9","","358.93","197.43","358.93","1 through 10","143.53","372.25","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.26","75.29","235.97","16","143.53","372.25","other","OPPS APC"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","both","","","463.00","347.25","WELLPOINT [1015]","HB AMC WELLPOINT","341.60","73.78","","334.28","334.28","783.28","42","143.53","372.25","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","405.38","412.84","209","176.45","378.36","other","ASC"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","241.96","52.26","","467.73","138.92","467.73","1 through 10","176.45","378.36","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","472.37","488","176.45","378.36","other","ASC "
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","511.71","226.86","511.71","1 through 10","176.45","378.36","other","Multiple Surgery"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","158","176.45","378.36","other","Multiple Surgery"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","414.66","430.54","78","176.45","378.36","other","Multiple Surgery"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","511.71","402.31","511.71","1 through 10","176.45","378.36","other","Multiple Surgery"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","338.78","338.78","338.78","1 through 10","176.45","378.36","other","Multiple Surgery"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","434.07","187.79","451.71","39","176.45","378.36","other","Multiple Surgery"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","434.07","434.07","434.07","1 through 10","176.45","378.36","other","Multiple Surgery"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","378.36","81.72","","197.43","197.43","358.93","1 through 10","176.45","378.36","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","378.36","81.72","","358.93","197.43","358.93","57","176.45","378.36","percent of total billed charges",""
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","492.30","492.30","492.30","1 through 10","176.45","378.36","other","Multiple Surgery"
"Destruct Benign Lesion Up to 14 Les","PX-76000216","CDM","17110","CPT","0761","RC","","","","outpatient","","","463.00","347.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","434.07","434.07","434.07","1 through 10","176.45","378.36","other","Multiple Surgery"
"Destruct Benign Lesions > 15","PX-76000217","CDM","17111","CPT","0761","RC","","","","both","","","480.00","360.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","381.60","79.5","","245.52","245.52","245.52","1 through 10","148.8","381.6","percent of total billed charges",""
"Destruct Benign Lesions > 15","PX-76000217","CDM","17111","CPT","0761","RC","","","","both","","","480.00","360.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","175.20","36.5","","168.33","168.33","168.33","1 through 10","148.8","381.6","percent of total billed charges",""
"Destruct Benign Lesions > 15","PX-76000217","CDM","17111","CPT","0761","RC","","","","outpatient","","","480.00","360.00","AETNA [1001]","HB AMC AETNA HMO","335.04","69.8","","314.81","222.27","314.81","1 through 10","176.45","700.33","percent of total billed charges",""
"Destruct Benign Lesions > 15","PX-76000217","CDM","17111","CPT","0761","RC","","","","outpatient","","","480.00","360.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","202.69","412.84","1 through 10","176.45","700.33","other","ASC"
"Destruct Benign Lesions > 15","PX-76000217","CDM","17111","CPT","0761","RC","","","","outpatient","","","480.00","360.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","472.37","233.87","727.39","1 through 10","176.45","700.33","other","ASC "
"Destruct Benign Lesions > 15","PX-76000217","CDM","17111","CPT","0761","RC","","","","outpatient","","","480.00","360.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","818.72","1 through 10","176.45","700.33","other","Multiple Surgery"
"Destruct Benign Lesions > 15","PX-76000217","CDM","17111","CPT","0761","RC","","","","outpatient","","","480.00","360.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","176.45","700.33","other","Multiple Surgery"
"Destruct Benign Lesions > 15","PX-76000217","CDM","17111","CPT","0761","RC","","","","outpatient","","","480.00","360.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","511.71","492.30","511.71","1 through 10","176.45","700.33","other","Multiple Surgery"
"Destruction Neurolytic Agt Genicular Nerve W/Img","PX-76002665","CDM","64624","CPT","0761","RC","","","","both","","","2481.00","1860.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2272.42","","APC Price ($2,318.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2282.84","2280.55","2282.84","1 through 10","769.11","2898.5","other","OPPS APC"
"Destruction Neurolytic Agt Genicular Nerve W/Img","PX-98301901","CDM","64624","CPT","0983","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2272.42","","APC Price ($2,318.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2282.84","2280.55","2282.84","1 through 10","237.15","2898.5","other","OPPS APC"
"Developmental Screen W/Scoring & Doc Std Instrm","PX-90000037","CDM","96110","CPT","0918","RC","","","","both","","","455.00","341.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.52","53.3","","45.06","45.06","45.06","1 through 10","141.05","361.73","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm","PX-90000037","CDM","96110","CPT","0918","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","361.73","79.5","","45.06","45.06","45.06","1 through 10","141.05","361.73","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm","PX-90000037","CDM","96110","CPT","0918","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.27","38.3","","21.51","21.51","21.51","1 through 10","141.05","361.73","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm","PX-90000037","CDM","96110","CPT","0918","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","74.47","37.24","74.47","1 through 10","35.98","643.13","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm","PX-90000037","CDM","96110","CPT","0918","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","227.50","50","","28.82","27.67","28.82","1 through 10","35.98","643.13","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm","PX-90000037","CDM","96110","CPT","0918","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","238.88","52.5","","30.25","24.53","60.50","19","35.98","643.13","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm","PX-90000037","CDM","96110","CPT","0918","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","250.25","55","","31.68","30.47","31.68","1 through 10","35.98","643.13","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm","PX-98300505","CDM","96110","CPT","0983","RC","","","","both","","","56.00","42.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","29.85","53.3","","45.06","45.06","45.06","1 through 10","17.36","351.32","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm","PX-98300505","CDM","96110","CPT","0983","RC","","","","both","","","56.00","42.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","44.52","79.5","","45.06","45.06","45.06","1 through 10","17.36","351.32","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm","PX-98300505","CDM","96110","CPT","0983","RC","","","","both","","","56.00","42.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21.45","38.3","","21.51","21.51","21.51","1 through 10","17.36","351.32","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm","PX-98300505","CDM","96110","CPT","0983","RC","","","","outpatient","","","56.00","42.00","AETNA [1001]","HB AMC AETNA HMO","39.09","69.8","","74.47","37.24","74.47","1 through 10","28","643.13","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm","PX-98300505","CDM","96110","CPT","0983","RC","","","","outpatient","","","56.00","42.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28.00","50","","28.82","27.67","28.82","1 through 10","28","643.13","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm","PX-98300505","CDM","96110","CPT","0983","RC","","","","outpatient","","","56.00","42.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","29.40","52.5","","30.25","24.53","60.50","19","28","643.13","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm","PX-98300505","CDM","96110","CPT","0983","RC","","","","outpatient","","","56.00","42.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","30.80","55","","31.68","30.47","31.68","1 through 10","28","643.13","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm (Ot)","PX-43000118","CDM","96110","CPT","0431","RC","","","","both","","","455.00","341.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.52","53.3","","45.06","45.06","45.06","1 through 10","141.05","361.73","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm (Ot)","PX-43000118","CDM","96110","CPT","0431","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","361.73","79.5","","45.06","45.06","45.06","1 through 10","141.05","361.73","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm (Ot)","PX-43000118","CDM","96110","CPT","0431","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.27","38.3","","21.51","21.51","21.51","1 through 10","141.05","361.73","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm (Ot)","PX-43000118","CDM","96110","CPT","0431","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","74.47","37.24","74.47","1 through 10","228","643.13","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm (Pt)","PX-42000111","CDM","96110","CPT","0421","RC","","","","both","","","455.00","341.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.52","53.3","","45.06","45.06","45.06","1 through 10","141.05","361.73","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm (Pt)","PX-42000111","CDM","96110","CPT","0421","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","361.73","79.5","","45.06","45.06","45.06","1 through 10","141.05","361.73","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm (Pt)","PX-42000111","CDM","96110","CPT","0421","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.27","38.3","","21.51","21.51","21.51","1 through 10","141.05","361.73","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm (Pt)","PX-42000111","CDM","96110","CPT","0421","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","74.47","37.24","74.47","1 through 10","228","643.13","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm (St)","PX-44000092","CDM","96110","CPT","0441","RC","","","","both","","","455.00","341.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.52","53.3","","45.06","45.06","45.06","1 through 10","141.05","361.73","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm (St)","PX-44000092","CDM","96110","CPT","0441","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","361.73","79.5","","45.06","45.06","45.06","1 through 10","141.05","361.73","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm (St)","PX-44000092","CDM","96110","CPT","0441","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.27","38.3","","21.51","21.51","21.51","1 through 10","141.05","361.73","percent of total billed charges",""
"Developmental Screen W/Scoring & Doc Std Instrm (St)","PX-44000092","CDM","96110","CPT","0441","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","74.47","37.24","74.47","1 through 10","35.98","643.13","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-90000132","CDM","96112","CPT","0918","RC","","","","both","","","965.00","723.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","514.35","53.3","","736.63","494.21","736.63","1 through 10","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-90000132","CDM","96112","CPT","0918","RC","","","","both","","","965.00","723.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","352.23","36.5","","296.71","296.71","296.71","1 through 10","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-90000132","CDM","96112","CPT","0918","RC","","","","both","","","965.00","723.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","369.60","38.3","","365.98","365.98","1097.94","15","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-90000132","CDM","96112","CPT","0918","RC","","","","both","","","965.00","723.75","WELLPOINT [1015]","HB AMC WELLPOINT","711.98","73.78","","696.85","696.85","936.00","1 through 10","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-90000132","CDM","96112","CPT","0918","RC","","","","outpatient","","","965.00","723.75","AETNA [1001]","HB AMC AETNA HMO","673.57","69.8","","633.67","447.41","633.67","1 through 10","312.34","788.6","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-96000027","CDM","96112","CPT","0961","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","736.63","494.21","736.63","1 through 10","162.75","417.38","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-96000027","CDM","96112","CPT","0961","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","296.71","296.71","296.71","1 through 10","162.75","417.38","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-96000027","CDM","96112","CPT","0961","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","365.98","365.98","1097.94","15","162.75","417.38","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-96000027","CDM","96112","CPT","0961","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","696.85","696.85","936.00","1 through 10","162.75","417.38","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-96000027","CDM","96112","CPT","0961","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","633.67","447.41","633.67","1 through 10","293.48","575.66","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-98301831","CDM","96112","CPT","0983","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","736.63","494.21","736.63","1 through 10","162.75","417.38","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-98301831","CDM","96112","CPT","0983","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","296.71","296.71","296.71","1 through 10","162.75","417.38","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-98301831","CDM","96112","CPT","0983","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","365.98","365.98","1097.94","15","162.75","417.38","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-98301831","CDM","96112","CPT","0983","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","696.85","696.85","936.00","1 through 10","162.75","417.38","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour","PX-98301831","CDM","96112","CPT","0983","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","633.67","447.41","633.67","1 through 10","293.48","575.66","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (Ot)","PX-43000120","CDM","96112","CPT","0431","RC","","","","both","","","965.00","723.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","514.35","53.3","","736.63","494.21","736.63","1 through 10","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (Ot)","PX-43000120","CDM","96112","CPT","0431","RC","","","","both","","","965.00","723.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","352.23","36.5","","296.71","296.71","296.71","1 through 10","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (Ot)","PX-43000120","CDM","96112","CPT","0431","RC","","","","both","","","965.00","723.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","369.60","38.3","","365.98","365.98","1097.94","15","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (Ot)","PX-43000120","CDM","96112","CPT","0431","RC","","","","both","","","965.00","723.75","WELLPOINT [1015]","HB AMC WELLPOINT","711.98","73.78","","696.85","696.85","936.00","1 through 10","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (Ot)","PX-43000120","CDM","96112","CPT","0431","RC","","","","outpatient","","","965.00","723.75","AETNA [1001]","HB AMC AETNA HMO","673.57","69.8","","633.67","447.41","633.67","1 through 10","309.97","788.6","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (Pt)","PX-42000114","CDM","96112","CPT","0421","RC","","","","both","","","965.00","723.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","514.35","53.3","","736.63","494.21","736.63","1 through 10","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (Pt)","PX-42000114","CDM","96112","CPT","0421","RC","","","","both","","","965.00","723.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","352.23","36.5","","296.71","296.71","296.71","1 through 10","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (Pt)","PX-42000114","CDM","96112","CPT","0421","RC","","","","both","","","965.00","723.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","369.60","38.3","","365.98","365.98","1097.94","15","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (Pt)","PX-42000114","CDM","96112","CPT","0421","RC","","","","both","","","965.00","723.75","WELLPOINT [1015]","HB AMC WELLPOINT","711.98","73.78","","696.85","696.85","936.00","1 through 10","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (Pt)","PX-42000114","CDM","96112","CPT","0421","RC","","","","outpatient","","","965.00","723.75","AETNA [1001]","HB AMC AETNA HMO","673.57","69.8","","633.67","447.41","633.67","1 through 10","243.78","788.6","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (St)","PX-44000094","CDM","96112","CPT","0441","RC","","","","both","","","965.00","723.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","514.35","53.3","","736.63","494.21","736.63","1 through 10","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (St)","PX-44000094","CDM","96112","CPT","0441","RC","","","","both","","","965.00","723.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","352.23","36.5","","296.71","296.71","296.71","1 through 10","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (St)","PX-44000094","CDM","96112","CPT","0441","RC","","","","both","","","965.00","723.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","369.60","38.3","","365.98","365.98","1097.94","15","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (St)","PX-44000094","CDM","96112","CPT","0441","RC","","","","both","","","965.00","723.75","WELLPOINT [1015]","HB AMC WELLPOINT","711.98","73.78","","696.85","696.85","936.00","1 through 10","176.52","767.18","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp 1st Hour (St)","PX-44000094","CDM","96112","CPT","0441","RC","","","","outpatient","","","965.00","723.75","AETNA [1001]","HB AMC AETNA HMO","673.57","69.8","","633.67","447.41","633.67","1 through 10","312.34","788.6","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-90000133","CDM","96113","CPT","0918","RC","","","","both","","","457.00","342.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","243.58","53.3","","233.90","233.90","348.64","1 through 10","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-90000133","CDM","96113","CPT","0918","RC","","","","both","","","457.00","342.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.81","36.5","","140.43","140.43","140.43","1 through 10","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-90000133","CDM","96113","CPT","0918","RC","","","","both","","","457.00","342.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","175.03","38.3","","173.21","173.21","519.64","46","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-90000133","CDM","96113","CPT","0918","RC","","","","both","","","457.00","342.75","WELLPOINT [1015]","HB AMC WELLPOINT","337.17","73.78","","329.81","329.81","443.00","19","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-90000133","CDM","96113","CPT","0918","RC","","","","outpatient","","","457.00","342.75","AETNA [1001]","HB AMC AETNA HMO","318.99","69.8","","211.76","211.76","1199.64","1 through 10","238.83","373.46","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-96000028","CDM","96113","CPT","0961","RC","","","","both","","","215.00","161.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","114.60","53.3","","233.90","233.90","348.64","1 through 10","66.65","170.93","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-96000028","CDM","96113","CPT","0961","RC","","","","both","","","215.00","161.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.48","36.5","","140.43","140.43","140.43","1 through 10","66.65","170.93","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-96000028","CDM","96113","CPT","0961","RC","","","","both","","","215.00","161.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82.35","38.3","","173.21","173.21","519.64","46","66.65","170.93","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-96000028","CDM","96113","CPT","0961","RC","","","","both","","","215.00","161.25","WELLPOINT [1015]","HB AMC WELLPOINT","158.63","73.78","","329.81","329.81","443.00","19","66.65","170.93","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-96000028","CDM","96113","CPT","0961","RC","","","","outpatient","","","215.00","161.25","AETNA [1001]","HB AMC AETNA HMO","150.07","69.8","","211.76","211.76","1199.64","1 through 10","120.19","175.7","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-98301832","CDM","96113","CPT","0983","RC","","","","both","","","215.00","161.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","114.60","53.3","","233.90","233.90","348.64","1 through 10","66.65","170.93","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-98301832","CDM","96113","CPT","0983","RC","","","","both","","","215.00","161.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.48","36.5","","140.43","140.43","140.43","1 through 10","66.65","170.93","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-98301832","CDM","96113","CPT","0983","RC","","","","both","","","215.00","161.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82.35","38.3","","173.21","173.21","519.64","46","66.65","170.93","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-98301832","CDM","96113","CPT","0983","RC","","","","both","","","215.00","161.25","WELLPOINT [1015]","HB AMC WELLPOINT","158.63","73.78","","329.81","329.81","443.00","19","66.65","170.93","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min","PX-98301832","CDM","96113","CPT","0983","RC","","","","outpatient","","","215.00","161.25","AETNA [1001]","HB AMC AETNA HMO","150.07","69.8","","211.76","211.76","1199.64","1 through 10","120.19","175.7","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (Ot)","PX-43000121","CDM","96113","CPT","0431","RC","","","","both","","","457.00","342.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","243.58","53.3","","233.90","233.90","348.64","1 through 10","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (Ot)","PX-43000121","CDM","96113","CPT","0431","RC","","","","both","","","457.00","342.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.81","36.5","","140.43","140.43","140.43","1 through 10","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (Ot)","PX-43000121","CDM","96113","CPT","0431","RC","","","","both","","","457.00","342.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","175.03","38.3","","173.21","173.21","519.64","46","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (Ot)","PX-43000121","CDM","96113","CPT","0431","RC","","","","both","","","457.00","342.75","WELLPOINT [1015]","HB AMC WELLPOINT","337.17","73.78","","329.81","329.81","443.00","19","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (Ot)","PX-43000121","CDM","96113","CPT","0431","RC","","","","outpatient","","","457.00","342.75","AETNA [1001]","HB AMC AETNA HMO","318.99","69.8","","211.76","211.76","1199.64","1 through 10","238.83","373.46","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (Pt)","PX-42000115","CDM","96113","CPT","0421","RC","","","","both","","","457.00","342.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","243.58","53.3","","233.90","233.90","348.64","1 through 10","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (Pt)","PX-42000115","CDM","96113","CPT","0421","RC","","","","both","","","457.00","342.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.81","36.5","","140.43","140.43","140.43","1 through 10","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (Pt)","PX-42000115","CDM","96113","CPT","0421","RC","","","","both","","","457.00","342.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","175.03","38.3","","173.21","173.21","519.64","46","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (Pt)","PX-42000115","CDM","96113","CPT","0421","RC","","","","both","","","457.00","342.75","WELLPOINT [1015]","HB AMC WELLPOINT","337.17","73.78","","329.81","329.81","443.00","19","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (Pt)","PX-42000115","CDM","96113","CPT","0421","RC","","","","outpatient","","","457.00","342.75","AETNA [1001]","HB AMC AETNA HMO","318.99","69.8","","211.76","211.76","1199.64","1 through 10","238.83","373.46","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (St)","PX-44000095","CDM","96113","CPT","0441","RC","","","","both","","","457.00","342.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","243.58","53.3","","233.90","233.90","348.64","1 through 10","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (St)","PX-44000095","CDM","96113","CPT","0441","RC","","","","both","","","457.00","342.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.81","36.5","","140.43","140.43","140.43","1 through 10","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (St)","PX-44000095","CDM","96113","CPT","0441","RC","","","","both","","","457.00","342.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","175.03","38.3","","173.21","173.21","519.64","46","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (St)","PX-44000095","CDM","96113","CPT","0441","RC","","","","both","","","457.00","342.75","WELLPOINT [1015]","HB AMC WELLPOINT","337.17","73.78","","329.81","329.81","443.00","19","141.67","363.32","percent of total billed charges",""
"Developmental Tst Admin Phys/Qhp Ea Addl 30 Min (St)","PX-44000095","CDM","96113","CPT","0441","RC","","","","outpatient","","","457.00","342.75","AETNA [1001]","HB AMC AETNA HMO","318.99","69.8","","211.76","211.76","1199.64","1 through 10","238.83","373.46","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.58","351.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","372.52","79.5","","800.18","480.96","1887.97","195","145.26","372.52","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.58","351.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","249.75","53.3","","813.12","216.42","1444.50","81","145.26","372.52","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.58","351.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","145.26","31","","432.60","432.60","432.60","1 through 10","145.26","372.52","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.58","351.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","171.03","36.5","","148.37","54.89","631.39","94","145.26","372.52","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.58","351.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.47","38.3","","279.30","91.72","1116.77","266","145.26","372.52","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.58","351.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.02","42.9","","731.00","63.70","731.00","1 through 10","145.26","372.52","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.58","351.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.02","42.9","","384.74","384.74","384.74","1 through 10","145.26","372.52","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.58","351.43","WELLPOINT [1015]","HB AMC WELLPOINT","345.72","73.78","","286.63","119.22","1107.45","105","145.26","372.52","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.58","351.43","AETNA [1001]","HB AMC AETNA HMO","327.07","69.8","","675.31","184.75","1721.50","286","244.88","382.92","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.58","351.43","AETNA [1001]","HB AMC AETNA PPO","376.74","80.4","","1261.44","103.12","1514.10","21","244.88","382.92","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.58","351.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","376.74","80.4","","1365.00","1365.00","1365.00","1 through 10","244.88","382.92","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.58","351.43","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","382.92","81.72","","5157.68","5157.68","5157.68","1 through 10","244.88","382.92","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.58","351.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","382.92","81.72","","431.26","71.26","1459.57","88","244.88","382.92","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","both","","","1056.10","792.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","839.60","79.5","","800.18","480.96","1887.97","195","327.39","839.6","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","both","","","1056.10","792.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","562.90","53.3","","813.12","216.42","1444.50","81","327.39","839.6","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","both","","","1056.10","792.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","327.39","31","","432.60","432.60","432.60","1 through 10","327.39","839.6","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","both","","","1056.10","792.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","385.48","36.5","","148.37","54.89","631.39","94","327.39","839.6","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","both","","","1056.10","792.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","404.49","38.3","","279.30","91.72","1116.77","266","327.39","839.6","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","both","","","1056.10","792.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.07","42.9","","731.00","63.70","731.00","1 through 10","327.39","839.6","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","both","","","1056.10","792.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.07","42.9","","384.74","384.74","384.74","1 through 10","327.39","839.6","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","both","","","1056.10","792.07","WELLPOINT [1015]","HB AMC WELLPOINT","779.19","73.78","","286.63","119.22","1107.45","105","327.39","839.6","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1056.10","792.07","AETNA [1001]","HB AMC AETNA HMO","737.16","69.8","","675.31","184.75","1721.50","286","551.92","863.04","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1056.10","792.07","AETNA [1001]","HB AMC AETNA PPO","849.10","80.4","","1261.44","103.12","1514.10","21","551.92","863.04","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1056.10","792.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","849.10","80.4","","1365.00","1365.00","1365.00","1 through 10","551.92","863.04","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1056.10","792.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","863.04","81.72","","5157.68","5157.68","5157.68","1 through 10","551.92","863.04","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1056.10","792.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","863.04","81.72","","431.26","71.26","1459.57","88","551.92","863.04","percent of total billed charges",""
"DEVICE CAPTURING 32CM SUTURE CAPIO BX/4EA","SUP-ITM-10011016","CDM","C2631","HCPCS","0278","RC","","","","both","","","2067.19","1550.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1643.42","79.5","","1091.48","1091.48","1091.48","1 through 10","640.83","1643.42","percent of total billed charges",""
"DEVICE CAPTURING 32CM SUTURE CAPIO BX/4EA","SUP-ITM-10011016","CDM","C2631","HCPCS","0278","RC","","","","both","","","2067.19","1550.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","791.73","38.3","","808.27","808.27","2356.62","11","640.83","1643.42","percent of total billed charges",""
"DEVICE CAPTURING 32CM SUTURE CAPIO BX/4EA","SUP-ITM-10011016","CDM","C2631","HCPCS","0278","RC","","","","outpatient","","","2067.19","1550.39","AETNA [1001]","HB AMC AETNA HMO","1442.90","69.8","","1399.49","979.86","3055.34","1 through 10","1080.31","1689.31","percent of total billed charges",""
"DEVICE CAPTURING 32CM SUTURE CAPIO BX/4EA","SUP-ITM-10011016","CDM","C2631","HCPCS","0278","RC","","","","outpatient","","","2067.19","1550.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1662.02","80.4","","1612.41","1033.59","1612.42","1 through 10","1080.31","1689.31","percent of total billed charges",""
"DEVICE CAPTURING 32CM SUTURE CAPIO BX/4EA","SUP-ITM-10011016","CDM","C2631","HCPCS","0278","RC","","","","outpatient","","","2067.19","1550.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1689.31","81.72","","908.94","908.94","908.94","1 through 10","1080.31","1689.31","percent of total billed charges",""
"DEVICE CAPTURING 32CM SUTURE CAPIO BX/4EA","SUP-ITM-10011016","CDM","C2631","HCPCS","0278","RC","","","","outpatient","","","2067.19","1550.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1689.31","81.72","","1652.51","1652.51","1652.51","1 through 10","1080.31","1689.31","percent of total billed charges",""
"DEVICE CLIP 35MMATRICLIP FLEX V LAA MALLEABLE SHAFT STERILE","SUP-ITM-10295227","CDM","C1889","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4293.00","79.5","","1309.77","674.56","6049.93","26","1674","4293","percent of total billed charges",""
"DEVICE CLIP 35MMATRICLIP FLEX V LAA MALLEABLE SHAFT STERILE","SUP-ITM-10295227","CDM","C1889","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2878.20","53.3","","1901.83","1901.83","2962.25","1 through 10","1674","4293","percent of total billed charges",""
"DEVICE CLIP 35MMATRICLIP FLEX V LAA MALLEABLE SHAFT STERILE","SUP-ITM-10295227","CDM","C1889","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1971.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1674","4293","percent of total billed charges",""
"DEVICE CLIP 35MMATRICLIP FLEX V LAA MALLEABLE SHAFT STERILE","SUP-ITM-10295227","CDM","C1889","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2068.20","38.3","","352.91","352.91","2046.30","1 through 10","1674","4293","percent of total billed charges",""
"DEVICE CLIP 35MMATRICLIP FLEX V LAA MALLEABLE SHAFT STERILE","SUP-ITM-10295227","CDM","C1889","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","9668.75","9668.75","9668.75","1 through 10","1674","4293","percent of total billed charges",""
"DEVICE CLIP 35MMATRICLIP FLEX V LAA MALLEABLE SHAFT STERILE","SUP-ITM-10295227","CDM","C1889","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB AMC WELLPOINT","3984.12","73.78","","699.88","384.10","3443.31","33","1674","4293","percent of total billed charges",""
"DEVICE CLIP 35MMATRICLIP FLEX V LAA MALLEABLE SHAFT STERILE","SUP-ITM-10295227","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA HMO","3769.20","69.8","","1421.24","264.50","4933.46","29","2822.04","4412.88","percent of total billed charges",""
"DEVICE CLIP 35MMATRICLIP FLEX V LAA MALLEABLE SHAFT STERILE","SUP-ITM-10295227","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4341.60","80.4","","1022.97","1022.97","3607.50","1 through 10","2822.04","4412.88","percent of total billed charges",""
"DEVICE CLIP 35MMATRICLIP FLEX V LAA MALLEABLE SHAFT STERILE","SUP-ITM-10295227","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4412.88","81.72","","3010.54","693.88","5019.88","35","2822.04","4412.88","percent of total billed charges",""
"DEVICE CLIP CLOSURE 50X55.0X8.8MM PENDITURE SYSTEM LEFT ATRIL APPENDAGE DISPOSABLE","SUP-ITM-10321316","CDM","C1889","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4968.75","79.5","","1309.77","674.56","6049.93","26","1937.5","4968.75","percent of total billed charges",""
"DEVICE CLIP CLOSURE 50X55.0X8.8MM PENDITURE SYSTEM LEFT ATRIL APPENDAGE DISPOSABLE","SUP-ITM-10321316","CDM","C1889","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3331.25","53.3","","1901.83","1901.83","2962.25","1 through 10","1937.5","4968.75","percent of total billed charges",""
"DEVICE CLIP CLOSURE 50X55.0X8.8MM PENDITURE SYSTEM LEFT ATRIL APPENDAGE DISPOSABLE","SUP-ITM-10321316","CDM","C1889","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.25","36.5","","1620.31","1620.31","19908.88","1 through 10","1937.5","4968.75","percent of total billed charges",""
"DEVICE CLIP CLOSURE 50X55.0X8.8MM PENDITURE SYSTEM LEFT ATRIL APPENDAGE DISPOSABLE","SUP-ITM-10321316","CDM","C1889","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2393.75","38.3","","352.91","352.91","2046.30","1 through 10","1937.5","4968.75","percent of total billed charges",""
"DEVICE CLIP CLOSURE 50X55.0X8.8MM PENDITURE SYSTEM LEFT ATRIL APPENDAGE DISPOSABLE","SUP-ITM-10321316","CDM","C1889","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.25","42.9","","9668.75","9668.75","9668.75","1 through 10","1937.5","4968.75","percent of total billed charges",""
"DEVICE CLIP CLOSURE 50X55.0X8.8MM PENDITURE SYSTEM LEFT ATRIL APPENDAGE DISPOSABLE","SUP-ITM-10321316","CDM","C1889","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","WELLPOINT [1015]","HB AMC WELLPOINT","4611.25","73.78","","699.88","384.10","3443.31","33","1937.5","4968.75","percent of total billed charges",""
"DEVICE CLIP CLOSURE 50X55.0X8.8MM PENDITURE SYSTEM LEFT ATRIL APPENDAGE DISPOSABLE","SUP-ITM-10321316","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","AETNA [1001]","HB AMC AETNA HMO","4362.50","69.8","","1421.24","264.50","4933.46","29","3266.25","5107.5","percent of total billed charges",""
"DEVICE CLIP CLOSURE 50X55.0X8.8MM PENDITURE SYSTEM LEFT ATRIL APPENDAGE DISPOSABLE","SUP-ITM-10321316","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5025.00","80.4","","1022.97","1022.97","3607.50","1 through 10","3266.25","5107.5","percent of total billed charges",""
"DEVICE CLIP CLOSURE 50X55.0X8.8MM PENDITURE SYSTEM LEFT ATRIL APPENDAGE DISPOSABLE","SUP-ITM-10321316","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5107.50","81.72","","3010.54","693.88","5019.88","35","3266.25","5107.5","percent of total billed charges",""
"DEVICE CLOSURE 5FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090946","CDM","C1760","HCPCS","0278","RC","","","","both","","","624.75","468.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","326.49","52.26","","487.31","487.31","487.31","1 through 10","193.67","496.68","percent of total billed charges",""
"DEVICE CLOSURE 5FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090946","CDM","C1760","HCPCS","0278","RC","","","","both","","","624.75","468.56","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","448.57","71.8","","612.50","612.50","612.50","1 through 10","193.67","496.68","percent of total billed charges",""
"DEVICE CLOSURE 5FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090946","CDM","C1760","HCPCS","0278","RC","","","","both","","","624.75","468.56","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","437.33","70","","612.50","612.50","612.50","1 through 10","193.67","496.68","percent of total billed charges",""
"DEVICE CLOSURE 5FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090946","CDM","C1760","HCPCS","0278","RC","","","","both","","","624.75","468.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","496.68","79.5","","742.96","323.40","1446.12","32","193.67","496.68","percent of total billed charges",""
"DEVICE CLOSURE 5FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090946","CDM","C1760","HCPCS","0278","RC","","","","both","","","624.75","468.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","332.99","53.3","","323.40","323.40","550.90","13","193.67","496.68","percent of total billed charges",""
"DEVICE CLOSURE 5FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090946","CDM","C1760","HCPCS","0278","RC","","","","both","","","624.75","468.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.03","36.5","","285.08","194.16","582.48","27","193.67","496.68","percent of total billed charges",""
"DEVICE CLOSURE 5FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090946","CDM","C1760","HCPCS","0278","RC","","","","both","","","624.75","468.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.28","38.3","","239.49","233.98","600.08","52","193.67","496.68","percent of total billed charges",""
"DEVICE CLOSURE 5FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090946","CDM","C1760","HCPCS","0278","RC","","","","both","","","624.75","468.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.02","42.9","","278.69","278.69","278.69","1 through 10","193.67","496.68","percent of total billed charges",""
"DEVICE CLOSURE 5FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090946","CDM","C1760","HCPCS","0278","RC","","","","both","","","624.75","468.56","WELLPOINT [1015]","HB AMC WELLPOINT","460.94","73.78","","456.01","456.01","456.01","33","193.67","496.68","percent of total billed charges",""
"DEVICE CLOSURE 5FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090946","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","624.75","468.56","AETNA [1001]","HB AMC AETNA HMO","436.08","69.8","","290.33","290.33","1575.00","1 through 10","326.49","510.55","percent of total billed charges",""
"DEVICE CLOSURE 5FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090946","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","624.75","468.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","326.49","52.26","","487.31","487.31","487.31","1 through 10","326.49","510.55","percent of total billed charges",""
"DEVICE CLOSURE 5FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090946","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","624.75","468.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","510.55","81.72","","489.63","489.63","489.63","1 through 10","326.49","510.55","percent of total billed charges",""
"DEVICE CLOSURE 5FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090946","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","624.75","468.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","510.55","81.72","","489.64","489.63","1888.58","19","326.49","510.55","percent of total billed charges",""
"DEVICE CLOSURE 6-7FR MYNXGRIP VASCULAR FEMORAL ARTERY ATRAUMATIC TIP BX/10EA","SUP-ITM-10113994","CDM","C1760","HCPCS","0278","RC","","","","both","","","679.88","509.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","355.31","52.26","","487.31","487.31","487.31","1 through 10","210.76","540.5","percent of total billed charges",""
"DEVICE CLOSURE 6-7FR MYNXGRIP VASCULAR FEMORAL ARTERY ATRAUMATIC TIP BX/10EA","SUP-ITM-10113994","CDM","C1760","HCPCS","0278","RC","","","","both","","","679.88","509.91","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","488.15","71.8","","612.50","612.50","612.50","1 through 10","210.76","540.5","percent of total billed charges",""
"DEVICE CLOSURE 6-7FR MYNXGRIP VASCULAR FEMORAL ARTERY ATRAUMATIC TIP BX/10EA","SUP-ITM-10113994","CDM","C1760","HCPCS","0278","RC","","","","both","","","679.88","509.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","475.92","70","","612.50","612.50","612.50","1 through 10","210.76","540.5","percent of total billed charges",""
"DEVICE CLOSURE 6-7FR MYNXGRIP VASCULAR FEMORAL ARTERY ATRAUMATIC TIP BX/10EA","SUP-ITM-10113994","CDM","C1760","HCPCS","0278","RC","","","","both","","","679.88","509.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","540.50","79.5","","742.96","323.40","1446.12","32","210.76","540.5","percent of total billed charges",""
"DEVICE CLOSURE 6-7FR MYNXGRIP VASCULAR FEMORAL ARTERY ATRAUMATIC TIP BX/10EA","SUP-ITM-10113994","CDM","C1760","HCPCS","0278","RC","","","","both","","","679.88","509.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","362.38","53.3","","323.40","323.40","550.90","13","210.76","540.5","percent of total billed charges",""
"DEVICE CLOSURE 6-7FR MYNXGRIP VASCULAR FEMORAL ARTERY ATRAUMATIC TIP BX/10EA","SUP-ITM-10113994","CDM","C1760","HCPCS","0278","RC","","","","both","","","679.88","509.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","248.16","36.5","","285.08","194.16","582.48","27","210.76","540.5","percent of total billed charges",""
"DEVICE CLOSURE 6-7FR MYNXGRIP VASCULAR FEMORAL ARTERY ATRAUMATIC TIP BX/10EA","SUP-ITM-10113994","CDM","C1760","HCPCS","0278","RC","","","","both","","","679.88","509.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","260.39","38.3","","239.49","233.98","600.08","52","210.76","540.5","percent of total billed charges",""
"DEVICE CLOSURE 6-7FR MYNXGRIP VASCULAR FEMORAL ARTERY ATRAUMATIC TIP BX/10EA","SUP-ITM-10113994","CDM","C1760","HCPCS","0278","RC","","","","both","","","679.88","509.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","291.67","42.9","","278.69","278.69","278.69","1 through 10","210.76","540.5","percent of total billed charges",""
"DEVICE CLOSURE 6-7FR MYNXGRIP VASCULAR FEMORAL ARTERY ATRAUMATIC TIP BX/10EA","SUP-ITM-10113994","CDM","C1760","HCPCS","0278","RC","","","","both","","","679.88","509.91","WELLPOINT [1015]","HB AMC WELLPOINT","501.62","73.78","","456.01","456.01","456.01","33","210.76","540.5","percent of total billed charges",""
"DEVICE CLOSURE 6-7FR MYNXGRIP VASCULAR FEMORAL ARTERY ATRAUMATIC TIP BX/10EA","SUP-ITM-10113994","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","679.88","509.91","AETNA [1001]","HB AMC AETNA HMO","474.56","69.8","","290.33","290.33","1575.00","1 through 10","355.31","555.6","percent of total billed charges",""
"DEVICE CLOSURE 6-7FR MYNXGRIP VASCULAR FEMORAL ARTERY ATRAUMATIC TIP BX/10EA","SUP-ITM-10113994","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","679.88","509.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","355.31","52.26","","487.31","487.31","487.31","1 through 10","355.31","555.6","percent of total billed charges",""
"DEVICE CLOSURE 6-7FR MYNXGRIP VASCULAR FEMORAL ARTERY ATRAUMATIC TIP BX/10EA","SUP-ITM-10113994","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","679.88","509.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","555.60","81.72","","489.63","489.63","489.63","1 through 10","355.31","555.6","percent of total billed charges",""
"DEVICE CLOSURE 6-7FR MYNXGRIP VASCULAR FEMORAL ARTERY ATRAUMATIC TIP BX/10EA","SUP-ITM-10113994","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","679.88","509.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","555.60","81.72","","489.64","489.63","1888.58","19","355.31","555.6","percent of total billed charges",""
"DEVICE CLOSURE 6FR .035IN VASCULAR ANGIO-SEAL VIP COLLAGEN BIOABSORBABLE INTRAARTERIAL SUTURE TETHER BX/10EA","SUP-ITM-10274451","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","411.55","52.26","","487.31","487.31","487.31","1 through 10","244.13","626.06","percent of total billed charges",""
"DEVICE CLOSURE 6FR .035IN VASCULAR ANGIO-SEAL VIP COLLAGEN BIOABSORBABLE INTRAARTERIAL SUTURE TETHER BX/10EA","SUP-ITM-10274451","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","565.43","71.8","","612.50","612.50","612.50","1 through 10","244.13","626.06","percent of total billed charges",""
"DEVICE CLOSURE 6FR .035IN VASCULAR ANGIO-SEAL VIP COLLAGEN BIOABSORBABLE INTRAARTERIAL SUTURE TETHER BX/10EA","SUP-ITM-10274451","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","551.25","70","","612.50","612.50","612.50","1 through 10","244.13","626.06","percent of total billed charges",""
"DEVICE CLOSURE 6FR .035IN VASCULAR ANGIO-SEAL VIP COLLAGEN BIOABSORBABLE INTRAARTERIAL SUTURE TETHER BX/10EA","SUP-ITM-10274451","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","626.06","79.5","","742.96","323.40","1446.12","32","244.13","626.06","percent of total billed charges",""
"DEVICE CLOSURE 6FR .035IN VASCULAR ANGIO-SEAL VIP COLLAGEN BIOABSORBABLE INTRAARTERIAL SUTURE TETHER BX/10EA","SUP-ITM-10274451","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","419.74","53.3","","323.40","323.40","550.90","13","244.13","626.06","percent of total billed charges",""
"DEVICE CLOSURE 6FR .035IN VASCULAR ANGIO-SEAL VIP COLLAGEN BIOABSORBABLE INTRAARTERIAL SUTURE TETHER BX/10EA","SUP-ITM-10274451","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","287.44","36.5","","285.08","194.16","582.48","27","244.13","626.06","percent of total billed charges",""
"DEVICE CLOSURE 6FR .035IN VASCULAR ANGIO-SEAL VIP COLLAGEN BIOABSORBABLE INTRAARTERIAL SUTURE TETHER BX/10EA","SUP-ITM-10274451","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","301.61","38.3","","239.49","233.98","600.08","52","244.13","626.06","percent of total billed charges",""
"DEVICE CLOSURE 6FR .035IN VASCULAR ANGIO-SEAL VIP COLLAGEN BIOABSORBABLE INTRAARTERIAL SUTURE TETHER BX/10EA","SUP-ITM-10274451","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.84","42.9","","278.69","278.69","278.69","1 through 10","244.13","626.06","percent of total billed charges",""
"DEVICE CLOSURE 6FR .035IN VASCULAR ANGIO-SEAL VIP COLLAGEN BIOABSORBABLE INTRAARTERIAL SUTURE TETHER BX/10EA","SUP-ITM-10274451","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","WELLPOINT [1015]","HB AMC WELLPOINT","581.02","73.78","","456.01","456.01","456.01","33","244.13","626.06","percent of total billed charges",""
"DEVICE CLOSURE 6FR .035IN VASCULAR ANGIO-SEAL VIP COLLAGEN BIOABSORBABLE INTRAARTERIAL SUTURE TETHER BX/10EA","SUP-ITM-10274451","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","AETNA [1001]","HB AMC AETNA HMO","549.68","69.8","","290.33","290.33","1575.00","1 through 10","411.55","643.55","percent of total billed charges",""
"DEVICE CLOSURE 6FR .035IN VASCULAR ANGIO-SEAL VIP COLLAGEN BIOABSORBABLE INTRAARTERIAL SUTURE TETHER BX/10EA","SUP-ITM-10274451","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","411.55","52.26","","487.31","487.31","487.31","1 through 10","411.55","643.55","percent of total billed charges",""
"DEVICE CLOSURE 6FR .035IN VASCULAR ANGIO-SEAL VIP COLLAGEN BIOABSORBABLE INTRAARTERIAL SUTURE TETHER BX/10EA","SUP-ITM-10274451","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","643.55","81.72","","489.63","489.63","489.63","1 through 10","411.55","643.55","percent of total billed charges",""
"DEVICE CLOSURE 6FR .035IN VASCULAR ANGIO-SEAL VIP COLLAGEN BIOABSORBABLE INTRAARTERIAL SUTURE TETHER BX/10EA","SUP-ITM-10274451","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","643.55","81.72","","489.64","489.63","1888.58","19","411.55","643.55","percent of total billed charges",""
"DEVICE CLOSURE 6FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090947","CDM","C1762","HCPCS","0278","RC","","","","both","","","624.75","468.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","332.99","53.3","","1112.50","1112.50","1112.50","1 through 10","193.67","496.68","percent of total billed charges",""
"DEVICE CLOSURE 6FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090947","CDM","C1762","HCPCS","0278","RC","","","","both","","","624.75","468.56","WELLPOINT [1015]","HB AMC WELLPOINT","460.94","73.78","","1568.66","1568.66","1568.66","1 through 10","193.67","496.68","percent of total billed charges",""
"DEVICE CLOSURE 6FR EXOSEAL VASCULAR FEMORAL ARTERY BX/10EA","SUP-ITM-10090947","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","624.75","468.56","AETNA [1001]","HB AMC AETNA HMO","436.08","69.8","","1281.90","1281.90","1281.90","1 through 10","326.49","510.55","percent of total billed charges",""
"DEVICE CLOSURE STARCLOSE 5-6FR VASCULAR J TIP SE APPLIER EXCHANGE SHEATH DILATOR NITINOL CLIP FEMORAL ARTERY","SUP-ITM-10029138","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","320.09","52.26","","487.31","487.31","487.31","1 through 10","189.88","486.94","percent of total billed charges",""
"DEVICE CLOSURE STARCLOSE 5-6FR VASCULAR J TIP SE APPLIER EXCHANGE SHEATH DILATOR NITINOL CLIP FEMORAL ARTERY","SUP-ITM-10029138","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","439.78","71.8","","612.50","612.50","612.50","1 through 10","189.88","486.94","percent of total billed charges",""
"DEVICE CLOSURE STARCLOSE 5-6FR VASCULAR J TIP SE APPLIER EXCHANGE SHEATH DILATOR NITINOL CLIP FEMORAL ARTERY","SUP-ITM-10029138","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","428.75","70","","612.50","612.50","612.50","1 through 10","189.88","486.94","percent of total billed charges",""
"DEVICE CLOSURE STARCLOSE 5-6FR VASCULAR J TIP SE APPLIER EXCHANGE SHEATH DILATOR NITINOL CLIP FEMORAL ARTERY","SUP-ITM-10029138","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","486.94","79.5","","742.96","323.40","1446.12","32","189.88","486.94","percent of total billed charges",""
"DEVICE CLOSURE STARCLOSE 5-6FR VASCULAR J TIP SE APPLIER EXCHANGE SHEATH DILATOR NITINOL CLIP FEMORAL ARTERY","SUP-ITM-10029138","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","326.46","53.3","","323.40","323.40","550.90","13","189.88","486.94","percent of total billed charges",""
"DEVICE CLOSURE STARCLOSE 5-6FR VASCULAR J TIP SE APPLIER EXCHANGE SHEATH DILATOR NITINOL CLIP FEMORAL ARTERY","SUP-ITM-10029138","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.56","36.5","","285.08","194.16","582.48","27","189.88","486.94","percent of total billed charges",""
"DEVICE CLOSURE STARCLOSE 5-6FR VASCULAR J TIP SE APPLIER EXCHANGE SHEATH DILATOR NITINOL CLIP FEMORAL ARTERY","SUP-ITM-10029138","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.59","38.3","","239.49","233.98","600.08","52","189.88","486.94","percent of total billed charges",""
"DEVICE CLOSURE STARCLOSE 5-6FR VASCULAR J TIP SE APPLIER EXCHANGE SHEATH DILATOR NITINOL CLIP FEMORAL ARTERY","SUP-ITM-10029138","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","262.76","42.9","","278.69","278.69","278.69","1 through 10","189.88","486.94","percent of total billed charges",""
"DEVICE CLOSURE STARCLOSE 5-6FR VASCULAR J TIP SE APPLIER EXCHANGE SHEATH DILATOR NITINOL CLIP FEMORAL ARTERY","SUP-ITM-10029138","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","WELLPOINT [1015]","HB AMC WELLPOINT","451.90","73.78","","456.01","456.01","456.01","33","189.88","486.94","percent of total billed charges",""
"DEVICE CLOSURE STARCLOSE 5-6FR VASCULAR J TIP SE APPLIER EXCHANGE SHEATH DILATOR NITINOL CLIP FEMORAL ARTERY","SUP-ITM-10029138","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","AETNA [1001]","HB AMC AETNA HMO","427.53","69.8","","290.33","290.33","1575.00","1 through 10","320.09","500.54","percent of total billed charges",""
"DEVICE CLOSURE STARCLOSE 5-6FR VASCULAR J TIP SE APPLIER EXCHANGE SHEATH DILATOR NITINOL CLIP FEMORAL ARTERY","SUP-ITM-10029138","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","320.09","52.26","","487.31","487.31","487.31","1 through 10","320.09","500.54","percent of total billed charges",""
"DEVICE CLOSURE STARCLOSE 5-6FR VASCULAR J TIP SE APPLIER EXCHANGE SHEATH DILATOR NITINOL CLIP FEMORAL ARTERY","SUP-ITM-10029138","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","500.54","81.72","","489.63","489.63","489.63","1 through 10","320.09","500.54","percent of total billed charges",""
"DEVICE CLOSURE STARCLOSE 5-6FR VASCULAR J TIP SE APPLIER EXCHANGE SHEATH DILATOR NITINOL CLIP FEMORAL ARTERY","SUP-ITM-10029138","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","500.54","81.72","","489.64","489.63","1888.58","19","320.09","500.54","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","both","","","3400.95","2550.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1054.29","31","","3038.32","3038.32","3038.32","1 through 10","1054.29","3230.9","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","both","","","3400.95","2550.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1241.35","36.5","","3559.44","1833.80","5776.47","31","1054.29","3230.9","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","both","","","3400.95","2550.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1302.56","38.3","","5604.66","2018.41","6055.23","133","1054.29","3230.9","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","both","","","3400.95","2550.71","TRICARE [160005]","HB BWH TRICARE","3230.90","95","","4916.36","4916.36","4916.36","1 through 10","1054.29","3230.9","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","both","","","3400.95","2550.71","WELLPOINT [1015]","HB AMC WELLPOINT","2509.22","73.78","","8576.59","3843.24","9005.42","1 through 10","1054.29","3230.9","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","outpatient","","","3400.95","2550.71","AETNA [1001]","HB AMC AETNA HMO","2373.86","69.8","","3494.80","2350.02","5162.18","22","1351.89","3133.75","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","outpatient","","","3400.95","2550.71","AETNA [1001]","HB AMC AETNA PPO","2734.36","80.4","","4026.50","2576.17","4026.50","1 through 10","1351.89","3133.75","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","outpatient","","","3400.95","2550.71","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","1901.13","55.9","","5409.96","5409.96","5409.96","1 through 10","1351.89","3133.75","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","outpatient","","","3400.95","2550.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2377.26","69.9","","3577.39","2281.19","10732.17","14","1351.89","3133.75","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","outpatient","","","3400.95","2550.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1595.05","46.9","","3577.39","3407.04","3577.39","1 through 10","1351.89","3133.75","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","outpatient","","","3400.95","2550.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2734.36","80.4","","3834.76","3834.76","3834.76","1 through 10","1351.89","3133.75","percent of total billed charges",""
"DEVICE CRT-P SOLARA MRI QUAD","SUP-ITM-10191553","CDM","C2621","HCPCS","0275","RC","","","","outpatient","","","11237.50","8428.12","AETNA [1001]","HB AMC AETNA HMO","7843.78","69.8","","5258.00","5258.00","5258.00","1 through 10","5872.72","9183.29","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 106CM .035IN 6CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 4","SUP-ITM-10041847","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","6632.53","71.8","","28.28","27.13","28.28","1 through 10","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 106CM .035IN 6CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 4","SUP-ITM-10041847","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","6466.25","70","","44.63","35.78","44.63","1 through 10","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 106CM .035IN 6CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 4","SUP-ITM-10041847","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7343.81","79.5","","1342.89","271.64","6954.67","1 through 10","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 106CM .035IN 6CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 4","SUP-ITM-10041847","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4923.59","53.3","","4550.00","30.49","4550.00","1 through 10","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 106CM .035IN 6CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 4","SUP-ITM-10041847","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6004.38","65","","42.09","0.04","5453.50","1 through 10","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 106CM .035IN 6CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 4","SUP-ITM-10041847","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3371.69","36.5","","310.94","18.54","1259.30","62","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 106CM .035IN 6CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 4","SUP-ITM-10041847","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3537.96","38.3","","146.86","22.58","1753.45","65","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 106CM .035IN 6CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 4","SUP-ITM-10041847","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","WELLPOINT [1015]","HB AMC WELLPOINT","6815.43","73.78","","247.29","33.09","909.09","53","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 106CM .035IN 6CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 4","SUP-ITM-10041847","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","9237.50","6928.12","AETNA [1001]","HB AMC AETNA HMO","6447.78","69.8","","30.69","30.21","30.69","1 through 10","4827.52","7548.89","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 106CM .035IN 6CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 4","SUP-ITM-10041847","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","9237.50","6928.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7426.95","80.4","","82.69","82.69","82.69","1 through 10","4827.52","7548.89","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 106CM .035IN 6CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 4","SUP-ITM-10041847","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","9237.50","6928.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7548.89","81.72","","751.01","74.72","751.01","1 through 10","4827.52","7548.89","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 106CM .035IN 6CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 4","SUP-ITM-10041847","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","9237.50","6928.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7548.89","81.72","","328.92","46.17","2701.97","59","4827.52","7548.89","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 135CM .035IN 12CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 11","SUP-ITM-10041853","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","6632.53","71.8","","28.28","27.13","28.28","1 through 10","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 135CM .035IN 12CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 11","SUP-ITM-10041853","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","6466.25","70","","44.63","35.78","44.63","1 through 10","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 135CM .035IN 12CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 11","SUP-ITM-10041853","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7343.81","79.5","","1342.89","271.64","6954.67","1 through 10","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 135CM .035IN 12CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 11","SUP-ITM-10041853","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4923.59","53.3","","4550.00","30.49","4550.00","1 through 10","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 135CM .035IN 12CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 11","SUP-ITM-10041853","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6004.38","65","","42.09","0.04","5453.50","1 through 10","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 135CM .035IN 12CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 11","SUP-ITM-10041853","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3371.69","36.5","","310.94","18.54","1259.30","62","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 135CM .035IN 12CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 11","SUP-ITM-10041853","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3537.96","38.3","","146.86","22.58","1753.45","65","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 135CM .035IN 12CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 11","SUP-ITM-10041853","CDM","C1887","HCPCS","0272","RC","","","","both","","","9237.50","6928.12","WELLPOINT [1015]","HB AMC WELLPOINT","6815.43","73.78","","247.29","33.09","909.09","53","2863.63","7343.81","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 135CM .035IN 12CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 11","SUP-ITM-10041853","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","9237.50","6928.12","AETNA [1001]","HB AMC AETNA HMO","6447.78","69.8","","30.69","30.21","30.69","1 through 10","4827.52","7548.89","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 135CM .035IN 12CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 11","SUP-ITM-10041853","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","9237.50","6928.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7426.95","80.4","","82.69","82.69","82.69","1 through 10","4827.52","7548.89","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 135CM .035IN 12CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 11","SUP-ITM-10041853","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","9237.50","6928.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7548.89","81.72","","751.01","74.72","751.01","1 through 10","4827.52","7548.89","percent of total billed charges",""
"DEVICE ENDOVASCULAR EKOSONIC 5.4FR 135CM .035IN 12CM TREATMENT ZONE MICROSONIC INTELLIGENT DRUG DELIVERY CATHETER MACH 11","SUP-ITM-10041853","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","9237.50","6928.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7548.89","81.72","","328.92","46.17","2701.97","59","4827.52","7548.89","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","626.06","79.5","","800.18","480.96","1887.97","195","244.13","626.06","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","419.74","53.3","","813.12","216.42","1444.50","81","244.13","626.06","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","244.13","31","","432.60","432.60","432.60","1 through 10","244.13","626.06","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","287.44","36.5","","148.37","54.89","631.39","94","244.13","626.06","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","301.61","38.3","","279.30","91.72","1116.77","266","244.13","626.06","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.84","42.9","","731.00","63.70","731.00","1 through 10","244.13","626.06","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.84","42.9","","384.74","384.74","384.74","1 through 10","244.13","626.06","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","WELLPOINT [1015]","HB AMC WELLPOINT","581.02","73.78","","286.63","119.22","1107.45","105","244.13","626.06","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","AETNA [1001]","HB AMC AETNA HMO","549.68","69.8","","675.31","184.75","1721.50","286","411.55","643.55","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","AETNA [1001]","HB AMC AETNA PPO","633.15","80.4","","1261.44","103.12","1514.10","21","411.55","643.55","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","633.15","80.4","","1365.00","1365.00","1365.00","1 through 10","411.55","643.55","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","643.55","81.72","","5157.68","5157.68","5157.68","1 through 10","411.55","643.55","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","643.55","81.72","","431.26","71.26","1459.57","88","411.55","643.55","percent of total billed charges",""
"DEVICE FIXATION 45MM FEMORAL ENDOBUTTON CL LF ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP STERILE","SUP-ITM-10026705","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1087.96","79.5","","800.18","480.96","1887.97","195","424.24","1087.96","percent of total billed charges",""
"DEVICE FIXATION 45MM FEMORAL ENDOBUTTON CL LF ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP STERILE","SUP-ITM-10026705","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","729.41","53.3","","813.12","216.42","1444.50","81","424.24","1087.96","percent of total billed charges",""
"DEVICE FIXATION 45MM FEMORAL ENDOBUTTON CL LF ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP STERILE","SUP-ITM-10026705","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","424.24","31","","432.60","432.60","432.60","1 through 10","424.24","1087.96","percent of total billed charges",""
"DEVICE FIXATION 45MM FEMORAL ENDOBUTTON CL LF ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP STERILE","SUP-ITM-10026705","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","499.50","36.5","","148.37","54.89","631.39","94","424.24","1087.96","percent of total billed charges",""
"DEVICE FIXATION 45MM FEMORAL ENDOBUTTON CL LF ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP STERILE","SUP-ITM-10026705","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","524.14","38.3","","279.30","91.72","1116.77","266","424.24","1087.96","percent of total billed charges",""
"DEVICE FIXATION 45MM FEMORAL ENDOBUTTON CL LF ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP STERILE","SUP-ITM-10026705","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","587.09","42.9","","731.00","63.70","731.00","1 through 10","424.24","1087.96","percent of total billed charges",""
"DEVICE FIXATION 45MM FEMORAL ENDOBUTTON CL LF ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP STERILE","SUP-ITM-10026705","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","587.09","42.9","","384.74","384.74","384.74","1 through 10","424.24","1087.96","percent of total billed charges",""
"DEVICE FIXATION 45MM FEMORAL ENDOBUTTON CL LF ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP STERILE","SUP-ITM-10026705","CDM","C1713","HCPCS","0278","RC","","","","both","","","1368.50","1026.37","WELLPOINT [1015]","HB AMC WELLPOINT","1009.68","73.78","","286.63","119.22","1107.45","105","424.24","1087.96","percent of total billed charges",""
"DEVICE FIXATION 45MM FEMORAL ENDOBUTTON CL LF ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP STERILE","SUP-ITM-10026705","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.50","1026.37","AETNA [1001]","HB AMC AETNA HMO","955.21","69.8","","675.31","184.75","1721.50","286","715.18","1118.34","percent of total billed charges",""
"DEVICE FIXATION 45MM FEMORAL ENDOBUTTON CL LF ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP STERILE","SUP-ITM-10026705","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.50","1026.37","AETNA [1001]","HB AMC AETNA PPO","1100.27","80.4","","1261.44","103.12","1514.10","21","715.18","1118.34","percent of total billed charges",""
"DEVICE FIXATION 45MM FEMORAL ENDOBUTTON CL LF ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP STERILE","SUP-ITM-10026705","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.50","1026.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1100.27","80.4","","1365.00","1365.00","1365.00","1 through 10","715.18","1118.34","percent of total billed charges",""
"DEVICE FIXATION 45MM FEMORAL ENDOBUTTON CL LF ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP STERILE","SUP-ITM-10026705","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.50","1026.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1118.34","81.72","","5157.68","5157.68","5157.68","1 through 10","715.18","1118.34","percent of total billed charges",""
"DEVICE FIXATION 45MM FEMORAL ENDOBUTTON CL LF ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP STERILE","SUP-ITM-10026705","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1368.50","1026.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1118.34","81.72","","431.26","71.26","1459.57","88","715.18","1118.34","percent of total billed charges",""
"DEVICE FLEX-V 35MM CARDIOVASCULAR - DISCONTINUED PER SUPPLIER/CONTRACTS ATRICLIP","SUP-ITM-10286897","CDM","C1889","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4293.00","79.5","","1309.77","674.56","6049.93","26","1674","4293","percent of total billed charges",""
"DEVICE FLEX-V 35MM CARDIOVASCULAR - DISCONTINUED PER SUPPLIER/CONTRACTS ATRICLIP","SUP-ITM-10286897","CDM","C1889","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2878.20","53.3","","1901.83","1901.83","2962.25","1 through 10","1674","4293","percent of total billed charges",""
"DEVICE FLEX-V 35MM CARDIOVASCULAR - DISCONTINUED PER SUPPLIER/CONTRACTS ATRICLIP","SUP-ITM-10286897","CDM","C1889","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1971.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1674","4293","percent of total billed charges",""
"DEVICE FLEX-V 35MM CARDIOVASCULAR - DISCONTINUED PER SUPPLIER/CONTRACTS ATRICLIP","SUP-ITM-10286897","CDM","C1889","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2068.20","38.3","","352.91","352.91","2046.30","1 through 10","1674","4293","percent of total billed charges",""
"DEVICE FLEX-V 35MM CARDIOVASCULAR - DISCONTINUED PER SUPPLIER/CONTRACTS ATRICLIP","SUP-ITM-10286897","CDM","C1889","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","9668.75","9668.75","9668.75","1 through 10","1674","4293","percent of total billed charges",""
"DEVICE FLEX-V 35MM CARDIOVASCULAR - DISCONTINUED PER SUPPLIER/CONTRACTS ATRICLIP","SUP-ITM-10286897","CDM","C1889","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB AMC WELLPOINT","3984.12","73.78","","699.88","384.10","3443.31","33","1674","4293","percent of total billed charges",""
"DEVICE FLEX-V 35MM CARDIOVASCULAR - DISCONTINUED PER SUPPLIER/CONTRACTS ATRICLIP","SUP-ITM-10286897","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA HMO","3769.20","69.8","","1421.24","264.50","4933.46","29","2822.04","4412.88","percent of total billed charges",""
"DEVICE FLEX-V 35MM CARDIOVASCULAR - DISCONTINUED PER SUPPLIER/CONTRACTS ATRICLIP","SUP-ITM-10286897","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4341.60","80.4","","1022.97","1022.97","3607.50","1 through 10","2822.04","4412.88","percent of total billed charges",""
"DEVICE FLEX-V 35MM CARDIOVASCULAR - DISCONTINUED PER SUPPLIER/CONTRACTS ATRICLIP","SUP-ITM-10286897","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4412.88","81.72","","3010.54","693.88","5019.88","35","2822.04","4412.88","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","both","","","1560.79","1170.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1240.83","79.5","","1309.77","674.56","6049.93","26","483.84","1240.83","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","both","","","1560.79","1170.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","831.90","53.3","","1901.83","1901.83","2962.25","1 through 10","483.84","1240.83","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","both","","","1560.79","1170.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","569.69","36.5","","1620.31","1620.31","19908.88","1 through 10","483.84","1240.83","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","both","","","1560.79","1170.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","597.78","38.3","","352.91","352.91","2046.30","1 through 10","483.84","1240.83","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","both","","","1560.79","1170.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","669.58","42.9","","9668.75","9668.75","9668.75","1 through 10","483.84","1240.83","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","both","","","1560.79","1170.59","WELLPOINT [1015]","HB AMC WELLPOINT","1151.55","73.78","","699.88","384.10","3443.31","33","483.84","1240.83","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1560.79","1170.59","AETNA [1001]","HB AMC AETNA HMO","1089.43","69.8","","1421.24","264.50","4933.46","29","815.67","1275.48","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1560.79","1170.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1254.88","80.4","","1022.97","1022.97","3607.50","1 through 10","815.67","1275.48","percent of total billed charges",""
"DEVICE FLOW CONTROL SIPHONGUARD CSF","SUP-ITM-10007145","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1560.79","1170.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1275.48","81.72","","3010.54","693.88","5019.88","35","815.67","1275.48","percent of total billed charges",""
"DEVICE HERNIA 5MM FIXATION SECURESTRAP ABSORBABLE STRAP BX/1EA","SUP-ITM-10107444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1869.88","1402.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1486.55","79.5","","800.18","480.96","1887.97","195","579.66","1486.55","percent of total billed charges",""
"DEVICE HERNIA 5MM FIXATION SECURESTRAP ABSORBABLE STRAP BX/1EA","SUP-ITM-10107444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1869.88","1402.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","996.65","53.3","","813.12","216.42","1444.50","81","579.66","1486.55","percent of total billed charges",""
"DEVICE HERNIA 5MM FIXATION SECURESTRAP ABSORBABLE STRAP BX/1EA","SUP-ITM-10107444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1869.88","1402.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","579.66","31","","432.60","432.60","432.60","1 through 10","579.66","1486.55","percent of total billed charges",""
"DEVICE HERNIA 5MM FIXATION SECURESTRAP ABSORBABLE STRAP BX/1EA","SUP-ITM-10107444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1869.88","1402.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","682.51","36.5","","148.37","54.89","631.39","94","579.66","1486.55","percent of total billed charges",""
"DEVICE HERNIA 5MM FIXATION SECURESTRAP ABSORBABLE STRAP BX/1EA","SUP-ITM-10107444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1869.88","1402.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","716.16","38.3","","279.30","91.72","1116.77","266","579.66","1486.55","percent of total billed charges",""
"DEVICE HERNIA 5MM FIXATION SECURESTRAP ABSORBABLE STRAP BX/1EA","SUP-ITM-10107444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1869.88","1402.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","802.18","42.9","","731.00","63.70","731.00","1 through 10","579.66","1486.55","percent of total billed charges",""
"DEVICE HERNIA 5MM FIXATION SECURESTRAP ABSORBABLE STRAP BX/1EA","SUP-ITM-10107444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1869.88","1402.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","802.18","42.9","","384.74","384.74","384.74","1 through 10","579.66","1486.55","percent of total billed charges",""
"DEVICE HERNIA 5MM FIXATION SECURESTRAP ABSORBABLE STRAP BX/1EA","SUP-ITM-10107444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1869.88","1402.41","WELLPOINT [1015]","HB AMC WELLPOINT","1379.60","73.78","","286.63","119.22","1107.45","105","579.66","1486.55","percent of total billed charges",""
"DEVICE HERNIA 5MM FIXATION SECURESTRAP ABSORBABLE STRAP BX/1EA","SUP-ITM-10107444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1869.88","1402.41","AETNA [1001]","HB AMC AETNA HMO","1305.18","69.8","","675.31","184.75","1721.50","286","977.2","1528.07","percent of total billed charges",""
"DEVICE HERNIA 5MM FIXATION SECURESTRAP ABSORBABLE STRAP BX/1EA","SUP-ITM-10107444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1869.88","1402.41","AETNA [1001]","HB AMC AETNA PPO","1503.38","80.4","","1261.44","103.12","1514.10","21","977.2","1528.07","percent of total billed charges",""
"DEVICE HERNIA 5MM FIXATION SECURESTRAP ABSORBABLE STRAP BX/1EA","SUP-ITM-10107444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1869.88","1402.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1503.38","80.4","","1365.00","1365.00","1365.00","1 through 10","977.2","1528.07","percent of total billed charges",""
"DEVICE HERNIA 5MM FIXATION SECURESTRAP ABSORBABLE STRAP BX/1EA","SUP-ITM-10107444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1869.88","1402.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1528.07","81.72","","5157.68","5157.68","5157.68","1 through 10","977.2","1528.07","percent of total billed charges",""
"DEVICE HERNIA 5MM FIXATION SECURESTRAP ABSORBABLE STRAP BX/1EA","SUP-ITM-10107444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1869.88","1402.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1528.07","81.72","","431.26","71.26","1459.57","88","977.2","1528.07","percent of total billed charges",""
"DEVICE INTERBODY 23 TO 31MM LG 0DEG SPINE FUSION LUMBAR ANTERIOR TI SYNEX","SUP-ITM-10030869","CDM","C1889","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7850.63","79.5","","1309.77","674.56","6049.93","26","3061.25","7850.63","percent of total billed charges",""
"DEVICE INTERBODY 23 TO 31MM LG 0DEG SPINE FUSION LUMBAR ANTERIOR TI SYNEX","SUP-ITM-10030869","CDM","C1889","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5263.38","53.3","","1901.83","1901.83","2962.25","1 through 10","3061.25","7850.63","percent of total billed charges",""
"DEVICE INTERBODY 23 TO 31MM LG 0DEG SPINE FUSION LUMBAR ANTERIOR TI SYNEX","SUP-ITM-10030869","CDM","C1889","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3604.38","36.5","","1620.31","1620.31","19908.88","1 through 10","3061.25","7850.63","percent of total billed charges",""
"DEVICE INTERBODY 23 TO 31MM LG 0DEG SPINE FUSION LUMBAR ANTERIOR TI SYNEX","SUP-ITM-10030869","CDM","C1889","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3782.13","38.3","","352.91","352.91","2046.30","1 through 10","3061.25","7850.63","percent of total billed charges",""
"DEVICE INTERBODY 23 TO 31MM LG 0DEG SPINE FUSION LUMBAR ANTERIOR TI SYNEX","SUP-ITM-10030869","CDM","C1889","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4236.38","42.9","","9668.75","9668.75","9668.75","1 through 10","3061.25","7850.63","percent of total billed charges",""
"DEVICE INTERBODY 23 TO 31MM LG 0DEG SPINE FUSION LUMBAR ANTERIOR TI SYNEX","SUP-ITM-10030869","CDM","C1889","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","WELLPOINT [1015]","HB AMC WELLPOINT","7285.78","73.78","","699.88","384.10","3443.31","33","3061.25","7850.63","percent of total billed charges",""
"DEVICE INTERBODY 23 TO 31MM LG 0DEG SPINE FUSION LUMBAR ANTERIOR TI SYNEX","SUP-ITM-10030869","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9875.00","7406.25","AETNA [1001]","HB AMC AETNA HMO","6892.75","69.8","","1421.24","264.50","4933.46","29","5160.68","8069.85","percent of total billed charges",""
"DEVICE INTERBODY 23 TO 31MM LG 0DEG SPINE FUSION LUMBAR ANTERIOR TI SYNEX","SUP-ITM-10030869","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9875.00","7406.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7939.50","80.4","","1022.97","1022.97","3607.50","1 through 10","5160.68","8069.85","percent of total billed charges",""
"DEVICE INTERBODY 23 TO 31MM LG 0DEG SPINE FUSION LUMBAR ANTERIOR TI SYNEX","SUP-ITM-10030869","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9875.00","7406.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8069.85","81.72","","3010.54","693.88","5019.88","35","5160.68","8069.85","percent of total billed charges",""
"DEVICE LOCKING .015 TO .023IN RANGE 85CM SZ E 19LB TENSILE STRENGTH LEAD LLD BX/3EA","SUP-ITM-10281205","CDM","C1773","HCPCS","0272","RC","","","","both","","","2111.67","1583.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","770.76","36.5","","114.30","97.14","114.30","1 through 10","654.62","1678.78","percent of total billed charges",""
"DEVICE LOCKING .015 TO .023IN RANGE 85CM SZ E 19LB TENSILE STRENGTH LEAD LLD BX/3EA","SUP-ITM-10281205","CDM","C1773","HCPCS","0272","RC","","","","both","","","2111.67","1583.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","808.77","38.3","","119.81","116.44","359.43","20","654.62","1678.78","percent of total billed charges",""
"DEVICE LOCKING .015 TO .023IN RANGE 85CM SZ E 19LB TENSILE STRENGTH LEAD LLD BX/3EA","SUP-ITM-10281205","CDM","C1773","HCPCS","0272","RC","","","","both","","","2111.67","1583.75","WELLPOINT [1015]","HB AMC WELLPOINT","1557.99","73.78","","875.53","228.13","875.53","1 through 10","654.62","1678.78","percent of total billed charges",""
"DEVICE LOCKING .015 TO .023IN RANGE 85CM SZ E 19LB TENSILE STRENGTH LEAD LLD BX/3EA","SUP-ITM-10281205","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","2111.67","1583.75","AETNA [1001]","HB AMC AETNA HMO","1473.95","69.8","","207.45","207.45","207.45","1 through 10","1103.56","1725.66","percent of total billed charges",""
"DEVICE LOCKING .015 TO .023IN RANGE 85CM SZ E 19LB TENSILE STRENGTH LEAD LLD BX/3EA","SUP-ITM-10281205","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","2111.67","1583.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1725.66","81.72","","244.96","134.74","244.96","1 through 10","1103.56","1725.66","percent of total billed charges",""
"DEVICE MANTA 18F CLOSURE VASCULAR BX/5EA","SUP-ITM-10238425","CDM","C1760","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1554.74","52.26","","487.31","487.31","487.31","1 through 10","922.25","2365.13","percent of total billed charges",""
"DEVICE MANTA 18F CLOSURE VASCULAR BX/5EA","SUP-ITM-10238425","CDM","C1760","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2136.05","71.8","","612.50","612.50","612.50","1 through 10","922.25","2365.13","percent of total billed charges",""
"DEVICE MANTA 18F CLOSURE VASCULAR BX/5EA","SUP-ITM-10238425","CDM","C1760","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2082.50","70","","612.50","612.50","612.50","1 through 10","922.25","2365.13","percent of total billed charges",""
"DEVICE MANTA 18F CLOSURE VASCULAR BX/5EA","SUP-ITM-10238425","CDM","C1760","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","742.96","323.40","1446.12","32","922.25","2365.13","percent of total billed charges",""
"DEVICE MANTA 18F CLOSURE VASCULAR BX/5EA","SUP-ITM-10238425","CDM","C1760","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1585.68","53.3","","323.40","323.40","550.90","13","922.25","2365.13","percent of total billed charges",""
"DEVICE MANTA 18F CLOSURE VASCULAR BX/5EA","SUP-ITM-10238425","CDM","C1760","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","285.08","194.16","582.48","27","922.25","2365.13","percent of total billed charges",""
"DEVICE MANTA 18F CLOSURE VASCULAR BX/5EA","SUP-ITM-10238425","CDM","C1760","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","239.49","233.98","600.08","52","922.25","2365.13","percent of total billed charges",""
"DEVICE MANTA 18F CLOSURE VASCULAR BX/5EA","SUP-ITM-10238425","CDM","C1760","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","278.69","278.69","278.69","1 through 10","922.25","2365.13","percent of total billed charges",""
"DEVICE MANTA 18F CLOSURE VASCULAR BX/5EA","SUP-ITM-10238425","CDM","C1760","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","WELLPOINT [1015]","HB AMC WELLPOINT","2194.96","73.78","","456.01","456.01","456.01","33","922.25","2365.13","percent of total billed charges",""
"DEVICE MANTA 18F CLOSURE VASCULAR BX/5EA","SUP-ITM-10238425","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","290.33","290.33","1575.00","1 through 10","1554.74","2431.17","percent of total billed charges",""
"DEVICE MANTA 18F CLOSURE VASCULAR BX/5EA","SUP-ITM-10238425","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1554.74","52.26","","487.31","487.31","487.31","1 through 10","1554.74","2431.17","percent of total billed charges",""
"DEVICE MANTA 18F CLOSURE VASCULAR BX/5EA","SUP-ITM-10238425","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2431.17","81.72","","489.63","489.63","489.63","1 through 10","1554.74","2431.17","percent of total billed charges",""
"DEVICE MANTA 18F CLOSURE VASCULAR BX/5EA","SUP-ITM-10238425","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","489.64","489.63","1888.58","19","1554.74","2431.17","percent of total billed charges",""
"DEVICE PACEMAKER AZURE S DR MRI","SUP-ITM-10204006","CDM","C1785","HCPCS","0275","RC","","","","both","","","9400.00","7050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3431.00","36.5","","3506.20","3100.26","3506.20","1 through 10","2914","7473","percent of total billed charges",""
"DEVICE PACEMAKER AZURE S DR MRI","SUP-ITM-10204006","CDM","C1785","HCPCS","0275","RC","","","","both","","","9400.00","7050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3600.20","38.3","","3675.40","3675.40","3675.40","1 through 10","2914","7473","percent of total billed charges",""
"DEVICE PACEMAKER AZURE S DR MRI","SUP-ITM-10204006","CDM","C1785","HCPCS","0275","RC","","","","both","","","9400.00","7050.00","WELLPOINT [1015]","HB AMC WELLPOINT","6935.32","73.78","","6998.30","6998.30","6998.30","1 through 10","2914","7473","percent of total billed charges",""
"DEVICE PACEMAKER AZURE S DR MRI","SUP-ITM-10204006","CDM","C1785","HCPCS","0275","RC","","","","outpatient","","","9400.00","7050.00","AETNA [1001]","HB AMC AETNA HMO","6561.20","69.8","","4493.20","4493.20","4493.20","1 through 10","4912.44","7681.68","percent of total billed charges",""
"DEVICE PACEMAKER AZURE XT SR MRI","SUP-ITM-10208445","CDM","C1786","HCPCS","0275","RC","","","","both","","","7125.00","5343.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2728.88","38.3","","330.52","330.52","330.52","1 through 10","2208.75","5664.38","percent of total billed charges",""
"DEVICE PACEMAKER AZURE XT SR MRI","SUP-ITM-10208445","CDM","C1786","HCPCS","0275","RC","","","","both","","","7125.00","5343.75","WELLPOINT [1015]","HB AMC WELLPOINT","5256.83","73.78","","22527.75","22527.75","22527.75","1 through 10","2208.75","5664.38","percent of total billed charges",""
"DEVICE PIPELINE 4MM 20MM FLEX EMBOLIZATION","SUP-ITM-10146448","CDM","C1889","HCPCS","0278","RC","","","","both","","","31250.00","23437.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24843.75","79.5","","1309.77","674.56","6049.93","26","9687.5","24843.75","percent of total billed charges",""
"DEVICE PIPELINE 4MM 20MM FLEX EMBOLIZATION","SUP-ITM-10146448","CDM","C1889","HCPCS","0278","RC","","","","both","","","31250.00","23437.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16656.25","53.3","","1901.83","1901.83","2962.25","1 through 10","9687.5","24843.75","percent of total billed charges",""
"DEVICE PIPELINE 4MM 20MM FLEX EMBOLIZATION","SUP-ITM-10146448","CDM","C1889","HCPCS","0278","RC","","","","both","","","31250.00","23437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11406.25","36.5","","1620.31","1620.31","19908.88","1 through 10","9687.5","24843.75","percent of total billed charges",""
"DEVICE PIPELINE 4MM 20MM FLEX EMBOLIZATION","SUP-ITM-10146448","CDM","C1889","HCPCS","0278","RC","","","","both","","","31250.00","23437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11968.75","38.3","","352.91","352.91","2046.30","1 through 10","9687.5","24843.75","percent of total billed charges",""
"DEVICE PIPELINE 4MM 20MM FLEX EMBOLIZATION","SUP-ITM-10146448","CDM","C1889","HCPCS","0278","RC","","","","both","","","31250.00","23437.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13406.25","42.9","","9668.75","9668.75","9668.75","1 through 10","9687.5","24843.75","percent of total billed charges",""
"DEVICE PIPELINE 4MM 20MM FLEX EMBOLIZATION","SUP-ITM-10146448","CDM","C1889","HCPCS","0278","RC","","","","both","","","31250.00","23437.50","WELLPOINT [1015]","HB AMC WELLPOINT","23056.25","73.78","","699.88","384.10","3443.31","33","9687.5","24843.75","percent of total billed charges",""
"DEVICE PIPELINE 4MM 20MM FLEX EMBOLIZATION","SUP-ITM-10146448","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","31250.00","23437.50","AETNA [1001]","HB AMC AETNA HMO","21812.50","69.8","","1421.24","264.50","4933.46","29","16331.25","25537.5","percent of total billed charges",""
"DEVICE PIPELINE 4MM 20MM FLEX EMBOLIZATION","SUP-ITM-10146448","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","31250.00","23437.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","25125.00","80.4","","1022.97","1022.97","3607.50","1 through 10","16331.25","25537.5","percent of total billed charges",""
"DEVICE PIPELINE 4MM 20MM FLEX EMBOLIZATION","SUP-ITM-10146448","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","31250.00","23437.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","25537.50","81.72","","3010.54","693.88","5019.88","35","16331.25","25537.5","percent of total billed charges",""
"DEVICE PIPELINE 4MM 25MM FLEX EMBOLIZATION","SUP-ITM-10146449","CDM","C1889","HCPCS","0278","RC","","","","both","","","33500.00","25125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","26632.50","79.5","","1309.77","674.56","6049.93","26","10385","26632.5","percent of total billed charges",""
"DEVICE PIPELINE 4MM 25MM FLEX EMBOLIZATION","SUP-ITM-10146449","CDM","C1889","HCPCS","0278","RC","","","","both","","","33500.00","25125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","17855.50","53.3","","1901.83","1901.83","2962.25","1 through 10","10385","26632.5","percent of total billed charges",""
"DEVICE PIPELINE 4MM 25MM FLEX EMBOLIZATION","SUP-ITM-10146449","CDM","C1889","HCPCS","0278","RC","","","","both","","","33500.00","25125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12227.50","36.5","","1620.31","1620.31","19908.88","1 through 10","10385","26632.5","percent of total billed charges",""
"DEVICE PIPELINE 4MM 25MM FLEX EMBOLIZATION","SUP-ITM-10146449","CDM","C1889","HCPCS","0278","RC","","","","both","","","33500.00","25125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12830.50","38.3","","352.91","352.91","2046.30","1 through 10","10385","26632.5","percent of total billed charges",""
"DEVICE PIPELINE 4MM 25MM FLEX EMBOLIZATION","SUP-ITM-10146449","CDM","C1889","HCPCS","0278","RC","","","","both","","","33500.00","25125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14371.50","42.9","","9668.75","9668.75","9668.75","1 through 10","10385","26632.5","percent of total billed charges",""
"DEVICE PIPELINE 4MM 25MM FLEX EMBOLIZATION","SUP-ITM-10146449","CDM","C1889","HCPCS","0278","RC","","","","both","","","33500.00","25125.00","WELLPOINT [1015]","HB AMC WELLPOINT","24716.30","73.78","","699.88","384.10","3443.31","33","10385","26632.5","percent of total billed charges",""
"DEVICE PIPELINE 4MM 25MM FLEX EMBOLIZATION","SUP-ITM-10146449","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","33500.00","25125.00","AETNA [1001]","HB AMC AETNA HMO","23383.00","69.8","","1421.24","264.50","4933.46","29","17507.1","27376.2","percent of total billed charges",""
"DEVICE PIPELINE 4MM 25MM FLEX EMBOLIZATION","SUP-ITM-10146449","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","33500.00","25125.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","26934.00","80.4","","1022.97","1022.97","3607.50","1 through 10","17507.1","27376.2","percent of total billed charges",""
"DEVICE PIPELINE 4MM 25MM FLEX EMBOLIZATION","SUP-ITM-10146449","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","33500.00","25125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","27376.20","81.72","","3010.54","693.88","5019.88","35","17507.1","27376.2","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","1309.77","674.56","6049.93","26","1550","3975","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2665.00","53.3","","1901.83","1901.83","2962.25","1 through 10","1550","3975","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1550","3975","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","352.91","352.91","2046.30","1 through 10","1550","3975","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","9668.75","9668.75","9668.75","1 through 10","1550","3975","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","699.88","384.10","3443.31","33","1550","3975","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","1421.24","264.50","4933.46","29","2613","4086","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4020.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2613","4086","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","3010.54","693.88","5019.88","35","2613","4086","percent of total billed charges",""
"DEVICE STERNAL FIXATION ZIPFIX PEEK NEEDLE","SUP-ITM-10100891","CDM","C1889","HCPCS","0278","RC","","","","both","","","238.28","178.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","189.43","79.5","","1309.77","674.56","6049.93","26","73.87","189.43","percent of total billed charges",""
"DEVICE STERNAL FIXATION ZIPFIX PEEK NEEDLE","SUP-ITM-10100891","CDM","C1889","HCPCS","0278","RC","","","","both","","","238.28","178.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","127.00","53.3","","1901.83","1901.83","2962.25","1 through 10","73.87","189.43","percent of total billed charges",""
"DEVICE STERNAL FIXATION ZIPFIX PEEK NEEDLE","SUP-ITM-10100891","CDM","C1889","HCPCS","0278","RC","","","","both","","","238.28","178.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","86.97","36.5","","1620.31","1620.31","19908.88","1 through 10","73.87","189.43","percent of total billed charges",""
"DEVICE STERNAL FIXATION ZIPFIX PEEK NEEDLE","SUP-ITM-10100891","CDM","C1889","HCPCS","0278","RC","","","","both","","","238.28","178.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.26","38.3","","352.91","352.91","2046.30","1 through 10","73.87","189.43","percent of total billed charges",""
"DEVICE STERNAL FIXATION ZIPFIX PEEK NEEDLE","SUP-ITM-10100891","CDM","C1889","HCPCS","0278","RC","","","","both","","","238.28","178.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.22","42.9","","9668.75","9668.75","9668.75","1 through 10","73.87","189.43","percent of total billed charges",""
"DEVICE STERNAL FIXATION ZIPFIX PEEK NEEDLE","SUP-ITM-10100891","CDM","C1889","HCPCS","0278","RC","","","","both","","","238.28","178.71","WELLPOINT [1015]","HB AMC WELLPOINT","175.80","73.78","","699.88","384.10","3443.31","33","73.87","189.43","percent of total billed charges",""
"DEVICE STERNAL FIXATION ZIPFIX PEEK NEEDLE","SUP-ITM-10100891","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","238.28","178.71","AETNA [1001]","HB AMC AETNA HMO","166.32","69.8","","1421.24","264.50","4933.46","29","124.53","194.72","percent of total billed charges",""
"DEVICE STERNAL FIXATION ZIPFIX PEEK NEEDLE","SUP-ITM-10100891","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","238.28","178.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","191.58","80.4","","1022.97","1022.97","3607.50","1 through 10","124.53","194.72","percent of total billed charges",""
"DEVICE STERNAL FIXATION ZIPFIX PEEK NEEDLE","SUP-ITM-10100891","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","238.28","178.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","194.72","81.72","","3010.54","693.88","5019.88","35","124.53","194.72","percent of total billed charges",""
"DEVICE SYNDESMOSIS FIXATION GRAVITY SYNCHFIX 5 TI","SUP-ITM-10239274","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.50","2669.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2829.80","79.5","","800.18","480.96","1887.97","195","1103.45","2829.8","percent of total billed charges",""
"DEVICE SYNDESMOSIS FIXATION GRAVITY SYNCHFIX 5 TI","SUP-ITM-10239274","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.50","2669.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1897.21","53.3","","813.12","216.42","1444.50","81","1103.45","2829.8","percent of total billed charges",""
"DEVICE SYNDESMOSIS FIXATION GRAVITY SYNCHFIX 5 TI","SUP-ITM-10239274","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.50","2669.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1103.45","31","","432.60","432.60","432.60","1 through 10","1103.45","2829.8","percent of total billed charges",""
"DEVICE SYNDESMOSIS FIXATION GRAVITY SYNCHFIX 5 TI","SUP-ITM-10239274","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.50","2669.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1299.22","36.5","","148.37","54.89","631.39","94","1103.45","2829.8","percent of total billed charges",""
"DEVICE SYNDESMOSIS FIXATION GRAVITY SYNCHFIX 5 TI","SUP-ITM-10239274","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.50","2669.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1363.29","38.3","","279.30","91.72","1116.77","266","1103.45","2829.8","percent of total billed charges",""
"DEVICE SYNDESMOSIS FIXATION GRAVITY SYNCHFIX 5 TI","SUP-ITM-10239274","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.50","2669.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1527.03","42.9","","731.00","63.70","731.00","1 through 10","1103.45","2829.8","percent of total billed charges",""
"DEVICE SYNDESMOSIS FIXATION GRAVITY SYNCHFIX 5 TI","SUP-ITM-10239274","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.50","2669.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1527.03","42.9","","384.74","384.74","384.74","1 through 10","1103.45","2829.8","percent of total billed charges",""
"DEVICE SYNDESMOSIS FIXATION GRAVITY SYNCHFIX 5 TI","SUP-ITM-10239274","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.50","2669.62","WELLPOINT [1015]","HB AMC WELLPOINT","2626.20","73.78","","286.63","119.22","1107.45","105","1103.45","2829.8","percent of total billed charges",""
"DEVICE SYNDESMOSIS FIXATION GRAVITY SYNCHFIX 5 TI","SUP-ITM-10239274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3559.50","2669.62","AETNA [1001]","HB AMC AETNA HMO","2484.53","69.8","","675.31","184.75","1721.50","286","1860.19","2908.82","percent of total billed charges",""
"DEVICE SYNDESMOSIS FIXATION GRAVITY SYNCHFIX 5 TI","SUP-ITM-10239274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3559.50","2669.62","AETNA [1001]","HB AMC AETNA PPO","2861.84","80.4","","1261.44","103.12","1514.10","21","1860.19","2908.82","percent of total billed charges",""
"DEVICE SYNDESMOSIS FIXATION GRAVITY SYNCHFIX 5 TI","SUP-ITM-10239274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3559.50","2669.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2861.84","80.4","","1365.00","1365.00","1365.00","1 through 10","1860.19","2908.82","percent of total billed charges",""
"DEVICE SYNDESMOSIS FIXATION GRAVITY SYNCHFIX 5 TI","SUP-ITM-10239274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3559.50","2669.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2908.82","81.72","","5157.68","5157.68","5157.68","1 through 10","1860.19","2908.82","percent of total billed charges",""
"DEVICE SYNDESMOSIS FIXATION GRAVITY SYNCHFIX 5 TI","SUP-ITM-10239274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3559.50","2669.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2908.82","81.72","","431.26","71.26","1459.57","88","1860.19","2908.82","percent of total billed charges",""
"Device Urinary Repair W/O Sling Graft T1","PX-27000216","CDM","C2631","HCPCS","0278","RC","","","","both","","","983.71","737.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","782.05","79.5","","1091.48","1091.48","1091.48","1 through 10","304.95","782.05","percent of total billed charges",""
"Device Urinary Repair W/O Sling Graft T1","PX-27000216","CDM","C2631","HCPCS","0278","RC","","","","both","","","983.71","737.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","376.76","38.3","","808.27","808.27","2356.62","11","304.95","782.05","percent of total billed charges",""
"Device Urinary Repair W/O Sling Graft T1","PX-27000216","CDM","C2631","HCPCS","0278","RC","","","","outpatient","","","983.71","737.78","AETNA [1001]","HB AMC AETNA HMO","686.63","69.8","","1399.49","979.86","3055.34","1 through 10","514.09","803.89","percent of total billed charges",""
"Device Urinary Repair W/O Sling Graft T1","PX-27000216","CDM","C2631","HCPCS","0278","RC","","","","outpatient","","","983.71","737.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","790.90","80.4","","1612.41","1033.59","1612.42","1 through 10","514.09","803.89","percent of total billed charges",""
"Device Urinary Repair W/O Sling Graft T1","PX-27000216","CDM","C2631","HCPCS","0278","RC","","","","outpatient","","","983.71","737.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","803.89","81.72","","908.94","908.94","908.94","1 through 10","514.09","803.89","percent of total billed charges",""
"Device Urinary Repair W/O Sling Graft T1","PX-27000216","CDM","C2631","HCPCS","0278","RC","","","","outpatient","","","983.71","737.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","803.89","81.72","","1652.51","1652.51","1652.51","1 through 10","514.09","803.89","percent of total billed charges",""
"Device Urinary Repair W/O Sling Graft T2","PX-27000217","CDM","C2631","HCPCS","0278","RC","","","","both","","","4090.50","3067.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3251.95","79.5","","1091.48","1091.48","1091.48","1 through 10","1268.06","3251.95","percent of total billed charges",""
"Device Urinary Repair W/O Sling Graft T2","PX-27000217","CDM","C2631","HCPCS","0278","RC","","","","both","","","4090.50","3067.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1566.66","38.3","","808.27","808.27","2356.62","11","1268.06","3251.95","percent of total billed charges",""
"Device Urinary Repair W/O Sling Graft T2","PX-27000217","CDM","C2631","HCPCS","0278","RC","","","","outpatient","","","4090.50","3067.87","AETNA [1001]","HB AMC AETNA HMO","2855.17","69.8","","1399.49","979.86","3055.34","1 through 10","2137.7","3342.76","percent of total billed charges",""
"Device Urinary Repair W/O Sling Graft T2","PX-27000217","CDM","C2631","HCPCS","0278","RC","","","","outpatient","","","4090.50","3067.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3288.76","80.4","","1612.41","1033.59","1612.42","1 through 10","2137.7","3342.76","percent of total billed charges",""
"Device Urinary Repair W/O Sling Graft T2","PX-27000217","CDM","C2631","HCPCS","0278","RC","","","","outpatient","","","4090.50","3067.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3342.76","81.72","","908.94","908.94","908.94","1 through 10","2137.7","3342.76","percent of total billed charges",""
"Device Urinary Repair W/O Sling Graft T2","PX-27000217","CDM","C2631","HCPCS","0278","RC","","","","outpatient","","","4090.50","3067.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3342.76","81.72","","1652.51","1652.51","1652.51","1 through 10","2137.7","3342.76","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","both","","","3304.25","2478.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2626.88","79.5","","1632.15","1632.15","1632.15","1 through 10","1024.32","2626.88","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","both","","","3304.25","2478.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1761.17","53.3","","9709.13","9709.13","9709.13","1 through 10","1024.32","2626.88","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","both","","","3304.25","2478.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2147.76","65","","2685.95","2190.09","2685.96","1 through 10","1024.32","2626.88","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","both","","","3304.25","2478.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1206.05","36.5","","1495.87","1455.73","1541.33","1 through 10","1024.32","2626.88","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","both","","","3304.25","2478.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1265.53","38.3","","1615.71","1615.71","1615.71","1 through 10","1024.32","2626.88","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","both","","","3304.25","2478.19","WELLPOINT [1015]","HB AMC WELLPOINT","2437.88","73.78","","3076.44","3076.44","3076.44","1 through 10","1024.32","2626.88","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3304.25","2478.19","AETNA [1001]","HB AMC AETNA HMO","2306.37","69.8","","4568.79","2411.14","4568.79","1 through 10","1726.8","2700.23","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3304.25","2478.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2656.62","80.4","","2411.14","1545.60","3223.14","1 through 10","1726.8","2700.23","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3304.25","2478.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2700.23","81.72","","1816.95","1816.95","1816.95","1 through 10","1726.8","2700.23","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3304.25","2478.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2700.23","81.72","","3303.30","3303.30","3303.30","1 through 10","1726.8","2700.23","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","both","","","4734.42","3550.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3763.86","79.5","","1632.15","1632.15","1632.15","1 through 10","1467.67","3763.86","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","both","","","4734.42","3550.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2523.45","53.3","","9709.13","9709.13","9709.13","1 through 10","1467.67","3763.86","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","both","","","4734.42","3550.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3077.37","65","","2685.95","2190.09","2685.96","1 through 10","1467.67","3763.86","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","both","","","4734.42","3550.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1728.06","36.5","","1495.87","1455.73","1541.33","1 through 10","1467.67","3763.86","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","both","","","4734.42","3550.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1813.28","38.3","","1615.71","1615.71","1615.71","1 through 10","1467.67","3763.86","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","both","","","4734.42","3550.81","WELLPOINT [1015]","HB AMC WELLPOINT","3493.06","73.78","","3076.44","3076.44","3076.44","1 through 10","1467.67","3763.86","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4734.42","3550.81","AETNA [1001]","HB AMC AETNA HMO","3304.63","69.8","","4568.79","2411.14","4568.79","1 through 10","2474.21","3868.97","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4734.42","3550.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3806.47","80.4","","2411.14","1545.60","3223.14","1 through 10","2474.21","3868.97","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4734.42","3550.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3868.97","81.72","","1816.95","1816.95","1816.95","1 through 10","2474.21","3868.97","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4734.42","3550.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3868.97","81.72","","3303.30","3303.30","3303.30","1 through 10","2474.21","3868.97","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","both","","","7065.88","5299.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5617.37","79.5","","1632.15","1632.15","1632.15","1 through 10","2190.42","5617.37","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","both","","","7065.88","5299.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3766.11","53.3","","9709.13","9709.13","9709.13","1 through 10","2190.42","5617.37","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","both","","","7065.88","5299.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4592.82","65","","2685.95","2190.09","2685.96","1 through 10","2190.42","5617.37","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","both","","","7065.88","5299.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2579.05","36.5","","1495.87","1455.73","1541.33","1 through 10","2190.42","5617.37","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","both","","","7065.88","5299.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2706.23","38.3","","1615.71","1615.71","1615.71","1 through 10","2190.42","5617.37","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","both","","","7065.88","5299.41","WELLPOINT [1015]","HB AMC WELLPOINT","5213.21","73.78","","3076.44","3076.44","3076.44","1 through 10","2190.42","5617.37","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","7065.88","5299.41","AETNA [1001]","HB AMC AETNA HMO","4931.98","69.8","","4568.79","2411.14","4568.79","1 through 10","3692.63","5774.24","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","7065.88","5299.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5680.97","80.4","","2411.14","1545.60","3223.14","1 through 10","3692.63","5774.24","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","7065.88","5299.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5774.24","81.72","","1816.95","1816.95","1816.95","1 through 10","3692.63","5774.24","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","7065.88","5299.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5774.24","81.72","","3303.30","3303.30","3303.30","1 through 10","3692.63","5774.24","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.66","65.6","","0.33","0.33","0.33","1 through 10","0.31","0.77","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.65","65","","0.63","0.63","0.63","12","0.31","0.77","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.70","70","","0.48","0.48","0.48","1 through 10","0.31","0.77","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","0.31","0.10","2.02","29","0.31","0.77","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","0.18","0.18","1.28","323","0.31","0.77","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","0.19","0.18","0.57","456","0.31","0.77","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","1.00","0.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.77","77","","0.37","0.33","0.37","17","0.31","0.77","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","0.32","0.06","0.92","309","0.26","0.8","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA PPO","0.80","80.4","","0.38","0.25","1.05","45","0.26","0.8","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.70","69.9","","0.33","0.22","1.05","295","0.26","0.8","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.47","46.9","","0.23","0.05","0.57","99","0.26","0.8","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","0.38","0.36","0.38","44","0.26","0.8","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","0.70","69.9","","0.04","0.04","3.03","1 through 10","0.26","0.8","percent of total billed charges",""
"Dfci Tele 2","PX-51000595","CDM","99442","CPT","0510","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","47.12","31","","86.52","86.52","86.52","1 through 10","47.12","144.4","percent of total billed charges",""
"Dfci Tele 2","PX-51000595","CDM","99442","CPT","0510","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.48","36.5","","200.38","170.56","200.38","1 through 10","47.12","144.4","percent of total billed charges",""
"Dfci Tele 2","PX-51000595","CDM","99442","CPT","0510","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.22","38.3","","210.32","210.32","210.32","1 through 10","47.12","144.4","percent of total billed charges",""
"Dfci Tele 2","PX-51000595","CDM","99442","CPT","0510","RC","","","","outpatient","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","124.21","81.72","","276.00","276.00","276.00","1 through 10","45","124.21","percent of total billed charges",""
"Dfci Tele 3","PX-51000596","CDM","99443","CPT","0510","RC","","","","both","","","232.00","174.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","81.20","35","","120.78","120.78","120.78","1 through 10","71.92","220.4","percent of total billed charges",""
"Dfci Tele 3","PX-51000596","CDM","99443","CPT","0510","RC","","","","both","","","232.00","174.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","71.92","31","","128.24","128.24","128.24","1 through 10","71.92","220.4","percent of total billed charges",""
"Dfci Tele 3","PX-51000596","CDM","99443","CPT","0510","RC","","","","both","","","232.00","174.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","84.68","36.5","","250.30","150.23","294.04","54","71.92","220.4","percent of total billed charges",""
"Dfci Tele 3","PX-51000596","CDM","99443","CPT","0510","RC","","","","both","","","232.00","174.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","88.86","38.3","","308.62","157.70","308.62","71","71.92","220.4","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","both","","","474.00","355.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","173.01","36.5","","171.58","145.82","514.74","138","146.94","450.3","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","both","","","474.00","355.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","181.54","38.3","","179.86","179.86","539.58","344","146.94","450.3","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","AETNA [1001]","HB AMC AETNA HMO","330.85","69.8","","311.42","219.88","622.84","37","40.19","391.05","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","161.63","34.1","","362.02","242.88","1261.56","36","40.19","391.05","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","248.85","52.5","","301.30","301.30","301.30","1 through 10","40.19","391.05","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","237.00","50","","723.12","241.04","723.12","24","40.19","391.05","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","248.85","52.5","","482.08","202.40","759.00","22","40.19","391.05","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","260.70","55","","423.94","211.97","635.90","24","40.19","391.05","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","381.10","80.4","","358.80","358.80","358.80","1 through 10","40.19","391.05","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","248.85","52.5","","496.83","496.83","496.83","1 through 10","40.19","391.05","percent of total billed charges",""
"Dfci Telegenetics","PX-51000650","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","387.35","81.72","","367.72","317.95","397.44","25","40.19","391.05","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","both","","","294.00","220.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","233.73","79.5","","224.30","150.48","224.30","1 through 10","24.76","279.3","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","both","","","294.00","220.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","156.70","53.3","","287.86","150.48","287.86","1 through 10","24.76","279.3","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","107.31","36.5","","318.93","90.35","318.93","1 through 10","24.76","279.3","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","112.60","38.3","","111.44","111.44","111.44","1 through 10","24.76","279.3","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","outpatient","","","294.00","220.50","AETNA [1001]","HB AMC AETNA HMO","205.21","69.8","","192.95","136.23","257.42","1 through 10","26.07","240.26","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","outpatient","","","294.00","220.50","AETNA [1001]","HB AMC AETNA PPO","236.38","80.4","","222.30","222.30","222.30","1 through 10","26.07","240.26","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","outpatient","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","240.26","81.72","","125.31","125.31","125.31","1 through 10","26.07","240.26","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","outpatient","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","240.26","81.72","","227.83","227.83","227.83","1 through 10","26.07","240.26","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","260.00","195.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","206.70","79.5","","198.32","133.06","198.32","37","21.79","247","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","260.00","195.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","138.58","53.3","","133.06","133.06","254.52","19","21.79","247","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","260.00","195.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","94.90","36.5","","94.00","79.88","94.00","32","21.79","247","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","260.00","195.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","99.58","38.3","","98.53","95.76","295.59","103","21.79","247","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","260.00","195.00","MOLINA [1014]","HB BWH MOLINA","91.00","35","","44.10","44.10","44.10","1 through 10","21.79","247","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","260.00","195.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","200.20","77","","198.32","198.32","198.32","1 through 10","21.79","247","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","260.00","195.00","TRICARE [160005]","HB BWH TRICARE","247.00","95","","26.79","25.45","26.79","1 through 10","21.79","247","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","260.00","195.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","111.54","42.9","","201.45","110.80","201.45","1 through 10","21.79","247","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","260.00","195.00","AETNA [1001]","HB AMC AETNA HMO","181.48","69.8","","170.60","120.46","196.56","59","22.93","212.47","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","260.00","195.00","AETNA [1001]","HB AMC AETNA PPO","209.04","80.4","","196.56","196.56","196.56","1 through 10","22.93","212.47","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","260.00","195.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","145.34","55.9","","132.05","132.05","132.05","1 through 10","22.93","212.47","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","260.00","195.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","209.04","80.4","","196.56","196.56","196.56","1 through 10","22.93","212.47","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","260.00","195.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","212.47","81.72","","201.45","110.80","201.45","51","22.93","212.47","percent of total billed charges",""
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","46316.64","34737.48","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","8811.72","","Case rate ($8,555.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,221.20, add-ons for qualifying new technology services are included. If operating cost exceeds $55,865.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,161.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,454.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,841.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.14. The transfer capital threshold is the transfer adjustment factor * $721.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8914.28","8914.28","8914.28","1 through 10","8383.97","14038.08","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","46316.64","34737.48","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","10693.84","","Case rate ($8,555.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,221.20, add-ons for qualifying new technology services are included. If operating cost exceeds $55,865.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,161.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,454.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,841.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.14. The transfer capital threshold is the transfer adjustment factor * $721.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","8450.43","8450.43","8450.43","1 through 10","8383.97","14038.08","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","46316.64","34737.48","HUMANA [1012]","HB BWH MEDICARE","10989.88","","Case rate ($10,989.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,221.20, add-ons for qualifying new technology services are included. If operating cost exceeds $55,865.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,161.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,888.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,841.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.14. The transfer capital threshold is the transfer adjustment factor * $721.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8469.34","8469.34","8469.34","1 through 10","8383.97","14038.08","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","46316.64","34737.48","MEDICARE [2001]","HB BWH MEDICARE","10989.88","","Case rate ($10,989.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,221.20, add-ons for qualifying new technology services are included. If operating cost exceeds $55,865.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,161.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,888.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,841.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.14. The transfer capital threshold is the transfer adjustment factor * $721.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11091.29","343.98","11107.47","43","8383.97","14038.08","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","46316.64","34737.48","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8383.97","","Case rate ($8,555.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,221.20, add-ons for qualifying new technology services are included. If operating cost exceeds $55,865.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,161.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,454.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,841.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.14. The transfer capital threshold is the transfer adjustment factor * $721.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8471.41","8471.41","8471.41","1 through 10","8383.97","14038.08","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","46316.64","34737.48","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8383.97","","Case rate ($8,555.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,221.20, add-ons for qualifying new technology services are included. If operating cost exceeds $55,865.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,161.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,454.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,841.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.14. The transfer capital threshold is the transfer adjustment factor * $721.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8464.89","5733.89","8538.49","1 through 10","8383.97","14038.08","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","84020.84","63015.63","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","13890.13","","Case rate ($13,485.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,156.55, add-ons for qualifying new technology services are included. If operating cost exceeds $61,800.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,596.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,949.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,776.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,156.05. The transfer capital threshold is the transfer adjustment factor * $1,156.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","13954.29","13954.29","13954.29","1 through 10","13215.85","22504.47","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","84020.84","63015.63","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","13485.56","","Case rate ($13,485.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,156.55, add-ons for qualifying new technology services are included. If operating cost exceeds $61,800.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,596.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,949.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,776.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,156.05. The transfer capital threshold is the transfer adjustment factor * $1,156.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","76602.54","76602.54","76602.54","1 through 10","13215.85","22504.47","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","84020.84","63015.63","HUMANA [1012]","HB BWH MEDICARE","13485.56","","Case rate ($13,485.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,156.55, add-ons for qualifying new technology services are included. If operating cost exceeds $61,800.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,596.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,949.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,776.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,156.05. The transfer capital threshold is the transfer adjustment factor * $1,156.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","87324.72","87324.72","87324.72","1 through 10","13215.85","22504.47","other","Inpatient Replacement Plans DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","84020.84","63015.63","MEDICARE [2001]","HB BWH MEDICARE","13485.56","","Case rate ($13,485.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,156.55, add-ons for qualifying new technology services are included. If operating cost exceeds $61,800.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,596.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,949.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,776.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,156.05. The transfer capital threshold is the transfer adjustment factor * $1,156.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17467.08","17446.81","17472.50","19","13215.85","22504.47","other","Inpatient Replacement Plans DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","84020.84","63015.63","MOLINA [1014]","HB BWH MOLINA","13215.85","","Case rate ($13,485.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,156.55, add-ons for qualifying new technology services are included. If operating cost exceeds $61,800.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,596.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,949.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,776.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,156.05. The transfer capital threshold is the transfer adjustment factor * $1,156.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26723.41","26723.41","26723.41","1 through 10","13215.85","22504.47","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","84020.84","63015.63","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","13215.85","","Case rate ($13,485.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,156.55, add-ons for qualifying new technology services are included. If operating cost exceeds $61,800.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,596.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,949.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,776.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,156.05. The transfer capital threshold is the transfer adjustment factor * $1,156.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13291.40","13291.40","13562.09","1 through 10","13215.85","22504.47","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","84020.84","63015.63","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13215.85","","Case rate ($13,485.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,156.55, add-ons for qualifying new technology services are included. If operating cost exceeds $61,800.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,596.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,949.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,776.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,156.05. The transfer capital threshold is the transfer adjustment factor * $1,156.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13226.74","13226.74","13226.74","1 through 10","13215.85","22504.47","other","Inpatient DRG"
"Diabetes,EXTREME","420","DRG","","","","","","","","inpatient","","","121638.62","","MASSHEALTH [3001]","HB BWH MEDICAID","17988.84","","Case rate ($19,889.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,319.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19884.88","19884.88","19884.88","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","60485.11","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","29255.26","","Standard inlier is a Case rate ($29,255.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,883, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,152.54) for the length of stay and the standard reimbursement.","29255.25","26727.20","35735.30","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","60485.11","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","26493.96","","Fee schedule rate ($26,493.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26843.44","26843.44","26843.44","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","60485.11","","MASSHEALTH [3001]","HB BWH MEDICAID","8539.19","","Case rate ($9,441.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,871.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9439.22","2591.41","10005.57","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","60485.11","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","8539.19","","Case rate ($9,441.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,871.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","60485.11","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24237.14","","Fee schedule rate ($24,237.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24237.14","24237.14","24237.14","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","60485.11","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25449.40","","Fee schedule rate ($25,449.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25449.40","25449.40","25449.40","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","60485.11","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8539.19","","Case rate ($9,441.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,871.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9439.22","9439.22","82485.02","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MINOR","420","DRG","","","","","","","","inpatient","","","31532.81","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12326.13","","Fee schedule rate ($12,326.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2396), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14501.37","14501.37","14501.37","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MINOR","420","DRG","","","","","","","","inpatient","","","31532.81","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5033.26","","Case rate ($5,565.14). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,995.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5563.77","5563.77","5732.76","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","49546.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","19787.11","","Standard inlier is a Case rate ($19,787.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,334, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,808.62) for the length of stay and the standard reimbursement.","18077.23","18077.23","18077.23","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","49546.05","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9875.0305","","Fee schedule rate ($16,292.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9875.0305","13905.56","13905.56","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","49546.05","","MASSHEALTH [3001]","HB BWH MEDICAID","5662.71","","Case rate ($6,261.10). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,691.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6259.56","1224.62","9439.22","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","49546.05","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","5662.71","","Case rate ($6,261.10). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,691.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","5033.26","90294.22","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","49546.05","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5662.71","","Case rate ($6,261.10). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,691.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6259.56","1205.16","17968.65","11","5033.26","90294.22","case rate",""
"Diag Aspiration, Peritonsillar","PX-76002786","CDM","42999","CPT","0761","RC","","","","both","","","981.00","735.75","AETNA [1001]","HB AMC AETNA HMO","684.74","69.8","","659.40","659.40","659.40","1 through 10","261.99","788.72","percent of total billed charges",""
"Diag Aspiration, Peritonsillar","PX-76002786","CDM","42999","CPT","0761","RC","","","","outpatient","","","981.00","735.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","512.28","52.22","","275.91","275.91","275.91","1 through 10","420.85","809.33","percent of total billed charges",""
"Diag Aspiration, Peritonsillar","PX-76002786","CDM","42999","CPT","0761","RC","","","","outpatient","","","981.00","735.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","801.67","81.72","","19339.08","19339.08","19339.08","1 through 10","420.85","809.33","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax C-/C+","PX-35000032","CDM","71270","CPT","0352","RC","","","","both","","","3623.00","2717.25","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","939.55","1 through 10","200.84","2789.71","other","OPPS APC"
"Diagnostic Computed Tomography Thorax C-/C+","PX-35000032","CDM","71270","CPT","0352","RC","","","","both","","","3623.00","2717.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","509.20","208.03","509.20","1 through 10","200.84","2789.71","other","OPPS APC"
"Diagnostic Computed Tomography Thorax C-/C+","PX-35000032","CDM","71270","CPT","0352","RC","","","","both","","","3623.00","2717.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.18","207.18","207.18","1 through 10","200.84","2789.71","other","OPPS APC"
"Diagnostic Computed Tomography Thorax C-/C+","PX-35000032","CDM","71270","CPT","0352","RC","","","","outpatient","","","3623.00","2717.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","819.91","819.91","819.91","1 through 10","201.74","1893.38","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","2740.00","117","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1977.50","70","","2192.00","187.41","2740.00","1 through 10","200.84","2175.25","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","264.24","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","635.52","208.74","635.52","1 through 10","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","506.40","208.03","508.46","23","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","ELDER SERVICES [1037]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","489.82","200.53","489.82","1 through 10","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","FALLON HEALTH [1008]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","512.40","211.41","1519.20","22","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","924.52","208.87","1519.20","12","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","2175.25","77","","2109.80","2048.20","2109.80","1 through 10","200.84","2175.25","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","512.40","1 through 10","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","HUMANA [1012]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","509.50","208.45","515.17","17","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1836.25","65","","192.07","53.30","1781.00","1 through 10","200.84","2175.25","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","509.50","509.50","509.50","1 through 10","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","211.41","516.73","1163","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","875.75","31","","2539.98","2539.98","2539.98","1 through 10","200.84","2175.25","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1031.13","36.5","","1022.02","868.58","1022.02","57","200.84","2175.25","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1081.98","38.3","","1071.34","1041.20","3123.60","106","200.84","2175.25","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.38","207.18","509.60","35","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","MOLINA [1014]","HB BWH MOLINA","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1025.19","418.59","1541.92","44","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2175.25","77","","2137.20","786.38","2137.20","1 through 10","200.84","2175.25","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","TRICARE [160005]","HB BWH TRICARE","200.84","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","490.89","200.84","516.73","1 through 10","200.84","2175.25","other","Tricare OPPS"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","200.84","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","516.73","200.53","516.73","1 through 10","200.84","2175.25","other","Tricare OPPS"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","509.20","209.98","1531.30","170","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","630.20","630.20","630.20","1 through 10","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","886.49","31.38","","1204.78","841.18","1246.70","1 through 10","200.84","2175.25","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","207.19","511.40","383","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","886.49","31.38","","1204.78","1168.80","1204.78","1 through 10","200.84","2175.25","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2825.00","2118.75","WELLSENSE [1003]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","494.72","494.72","494.72","1 through 10","200.84","2175.25","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","1309.72","1309.72","1854.98","11","201.74","1476.35","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","AETNA [1001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","1854.98","1854.98","1854.98","1 through 10","201.74","1476.35","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","422.88","409.96","845.75","276","201.74","1476.35","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1476.35","52.26","","847.76","422.88","847.76","1 through 10","201.74","1476.35","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","845.75","","Case rate ($845.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","422.88","409.96","845.75","620","201.74","1476.35","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","CIGNA ALTERNATE [1018]","HB AMC TUFTS CIGNA CARELINK HYBRID","1220.40","","Case rate ($1,220.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1179.13","1179.13","1179.13","1 through 10","201.74","1476.35","other","Multiple Imaging CT / CTA"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","342.96","342.96","685.92","1 through 10","201.74","1476.35","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","274.37","274.37","548.73","188","201.74","1476.35","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","287.48","287.48","603.20","62","201.74","1476.35","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","659.69","342.96","685.92","1 through 10","201.74","1476.35","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","287.48","287.48","287.48","1 through 10","201.74","1476.35","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","301.60","301.60","603.20","34","201.74","1476.35","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","886.49","31.38","","1204.78","841.18","1204.78","1 through 10","201.74","1476.35","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","886.49","31.38","","841.18","841.18","1204.78","120","201.74","1476.35","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2825.00","2118.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","659.69","659.69","659.69","1 through 10","201.74","1476.35","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","126.29","345","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1666.48","71.8","","98.06","98.06","98.06","1 through 10","119.97","1787.17","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1522.58","65.6","","131.35","129.95","1755.78","1 through 10","119.97","1787.17","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1508.65","65","","1681.50","1463.15","1681.50","1 through 10","119.97","1787.17","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1624.70","70","","1620.72","194.40","1800.80","1 through 10","119.97","1787.17","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","264.25","91.14","471.10","1 through 10","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","CHAMPVA [160001]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","1787.17","other","Tricare OPPS"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","CIGNA [1006]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","119.99","123.76","1 through 10","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","106.34","124.27","53","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","ELDER SERVICES [1037]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","FALLON HEALTH [1008]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","378.87","126.29","378.87","36","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","452.43","123.76","4096.82","13","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1787.17","77","","1733.27","1682.45","1733.27","1 through 10","119.97","1787.17","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.77","123.76","126.29","18","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1508.65","65","","1193.03","1193.03","1193.03","1 through 10","119.97","1787.17","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","117.59","124.52","1 through 10","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","378.87","2899","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","719.51","31","","695.56","695.56","695.56","1 through 10","119.97","1787.17","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","847.17","36.5","","839.62","713.57","839.62","53","119.97","1787.17","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","888.94","38.3","","880.14","855.38","880.14","154","119.97","1787.17","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","264.54","70","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","MOLINA [1014]","HB BWH MOLINA","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","250.56","239.98","478.04","41","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1787.17","77","","646.04","165.06","1845.82","1 through 10","119.97","1787.17","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","126.29","14","119.97","1787.17","other","Tricare OPPS"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","1787.17","other","Tricare OPPS"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","124.27","378.87","208","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","517.73","517.73","517.73","1 through 10","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.33","31.38","","691.06","691.06","989.76","1 through 10","119.97","1787.17","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","119.99","126.29","577","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.33","31.38","","691.06","691.06","691.06","1 through 10","119.97","1787.17","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","WELLSENSE [1003]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","127.55","127.55","127.55","1 through 10","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","2321.00","1740.75","WELLSENSE NH [1050]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.77","124.77","124.77","1 through 10","119.97","1787.17","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","1523.93","1523.93","3047.86","12","112.51","1212.95","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","471.67","457.26","471.67","352","112.51","1212.95","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1212.95","52.26","","1392.92","1392.92","1392.92","1 through 10","112.51","1212.95","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","471.67","","Case rate ($471.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","471.67","457.26","471.67","789","112.51","1212.95","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","367.91","336.40","382.53","11","112.51","1212.95","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","210","112.51","1212.95","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","382.53","110","112.51","1212.95","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","382.53","382.53","1 through 10","112.51","1212.95","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","1212.95","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","324.03","367.91","41","112.51","1212.95","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","1755.78","1125.50","1755.78","1 through 10","112.51","1212.95","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","324.03","324.03","324.03","1 through 10","112.51","1212.95","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","728.33","31.38","","691.06","691.06","989.76","1 through 10","112.51","1212.95","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","728.33","31.38","","691.06","691.06","989.76","117","112.51","1212.95","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","2321.00","1740.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","2251.00","2251.00","2251.00","1 through 10","112.51","1212.95","other","Multiple Radiology"
"Diagnostic Digital Breast Tomosynthesis, Unilateral or Bilateral","PX-40000129","CDM","G0279","HCPCS","0401","RC","","","","both","","","309.00","231.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","161.48","52.26","","89.42","40.45","89.42","1 through 10","17.84","293.55","percent of total billed charges",""
"Diagnostic Digital Breast Tomosynthesis, Unilateral or Bilateral","PX-40000129","CDM","G0279","HCPCS","0401","RC","","","","both","","","309.00","231.75","CHAMPVA [160001]","HB BWH TRICARE","293.55","95","","23.11","23.11","23.11","1 through 10","17.84","293.55","percent of total billed charges",""
"Diagnostic Digital Breast Tomosynthesis, Unilateral or Bilateral","PX-40000129","CDM","G0279","HCPCS","0401","RC","","","","both","","","309.00","231.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","245.66","79.5","","40.45","40.45","40.45","1 through 10","17.84","293.55","percent of total billed charges",""
"Diagnostic Digital Breast Tomosynthesis, Unilateral or Bilateral","PX-40000129","CDM","G0279","HCPCS","0401","RC","","","","both","","","309.00","231.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","293.55","95","","18.20","18.20","18.20","1 through 10","17.84","293.55","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","1524.00","1143.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","847.16","846.26","847.16","1 through 10","472.44","1211.58","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","1524.00","1143.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1211.58","79.5","","780.38","780.38","780.38","1 through 10","472.44","1211.58","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","1524.00","1143.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","812.29","53.3","","780.38","780.38","780.38","1 through 10","472.44","1211.58","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","1524.00","1143.00","ELDER SERVICES [1037]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","805.96","805.96","805.96","1 through 10","472.44","1211.58","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","1524.00","1143.00","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","2467.23","34","472.44","1211.58","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","1524.00","1143.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","556.26","36.5","","535.04","535.04","535.04","1 through 10","472.44","1211.58","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","1524.00","1143.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","583.69","38.3","","577.90","577.90","577.90","1 through 10","472.44","1211.58","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","1524.00","1143.00","TRICARE [160005]","HB BWH TRICARE","781.29","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","822.41","822.41","822.41","1 through 10","472.44","1211.58","other","Tricare OPPS"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","1524.00","1143.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","806.96","806.96","807.96","1 through 10","472.44","1211.58","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","1524.00","1143.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","747.58","739.68","822.41","1 through 10","472.44","1211.58","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","1524.00","1143.00","AETNA [1001]","HB AMC AETNA HMO","1063.75","69.8","","1152.84","706.48","1152.84","1 through 10","598.81","2384.07","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","1524.00","1143.00","AETNA [1001]","HB AMC AETNA PPO","1225.30","80.4","","774.47","774.47","774.47","1 through 10","598.81","2384.07","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","1524.00","1143.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","685.02","","Case rate ($685.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1401.55","1376.21","1401.55","1 through 10","598.81","2384.07","other","ASC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","1524.00","1143.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","685.02","","Case rate ($685.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1587.88","1587.88","1603.63","1 through 10","598.81","2384.07","other","ASC "
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","1524.00","1143.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1407.20","1407.20","1407.20","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","1524.00","1143.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1736.55","1736.55","1736.55","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","1524.00","1143.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1245.41","81.72","","1181.51","1181.51","1181.51","1 through 10","598.81","2384.07","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","both","","","467.00","350.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","847.16","846.26","847.16","1 through 10","144.77","1027.91","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","both","","","467.00","350.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","371.27","79.5","","780.38","780.38","780.38","1 through 10","144.77","1027.91","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","both","","","467.00","350.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","248.91","53.3","","780.38","780.38","780.38","1 through 10","144.77","1027.91","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","both","","","467.00","350.25","ELDER SERVICES [1037]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","805.96","805.96","805.96","1 through 10","144.77","1027.91","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","both","","","467.00","350.25","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","2467.23","34","144.77","1027.91","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","both","","","467.00","350.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","170.46","36.5","","535.04","535.04","535.04","1 through 10","144.77","1027.91","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","both","","","467.00","350.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","178.86","38.3","","577.90","577.90","577.90","1 through 10","144.77","1027.91","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","both","","","467.00","350.25","TRICARE [160005]","HB BWH TRICARE","781.29","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","822.41","822.41","822.41","1 through 10","144.77","1027.91","other","Tricare OPPS"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","both","","","467.00","350.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","806.96","806.96","807.96","1 through 10","144.77","1027.91","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","both","","","467.00","350.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","747.58","739.68","822.41","1 through 10","144.77","1027.91","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","outpatient","","","467.00","350.25","AETNA [1001]","HB AMC AETNA HMO","325.97","69.8","","1152.84","706.48","1152.84","1 through 10","261.05","2384.07","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","outpatient","","","467.00","350.25","AETNA [1001]","HB AMC AETNA PPO","375.47","80.4","","774.47","774.47","774.47","1 through 10","261.05","2384.07","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","outpatient","","","467.00","350.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1407.20","1407.20","1407.20","1 through 10","261.05","2384.07","other","Multiple Surgery"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","outpatient","","","467.00","350.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1736.55","1736.55","1736.55","1 through 10","261.05","2384.07","other","Multiple Surgery"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","outpatient","","","467.00","350.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","381.63","81.72","","1181.51","1181.51","1181.51","1 through 10","261.05","2384.07","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","570.81","71.8","","553.58","553.58","553.58","1 through 10","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","521.52","65.6","","133.27","133.27","133.27","1 through 10","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","516.75","65","","501.15","501.15","501.15","1 through 10","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","556.50","70","","771.00","771.00","771.00","1 through 10","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","CHAMPVA [160001]","HB BWH TRICARE","755.25","95","","133.68","133.68","133.68","1 through 10","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","632.03","79.5","","606.78","407.09","792.96","103","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","423.74","53.3","","407.09","407.09","1221.27","85","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","516.75","65","","501.15","501.15","501.15","1 through 10","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","632.03","79.5","","173.94","173.94","173.94","1 through 10","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","572.40","72","","555.12","555.12","555.12","1 through 10","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","246.45","31","","238.24","238.24","238.24","1 through 10","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","290.18","36.5","","287.58","244.41","733.23","66","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","304.49","38.3","","301.46","292.98","878.94","263","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","TRICARE [160005]","HB BWH TRICARE","755.25","95","","123.03","123.03","133.68","1 through 10","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","755.25","95","","129.51","129.51","129.51","1 through 10","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","341.06","42.9","","616.34","229.87","616.34","1 through 10","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","341.06","42.9","","339.01","339.01","339.01","1 through 10","126.92","755.25","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","795.00","596.25","AETNA [1001]","HB AMC AETNA HMO","554.91","69.8","","521.97","521.97","632.22","1 through 10","327.41","921.39","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","795.00","596.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","415.47","52.26","","385.87","385.87","385.87","1 through 10","327.41","921.39","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","639.18","80.4","","601.38","601.38","601.38","1 through 10","327.41","921.39","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","649.67","81.72","","339.01","339.01","339.01","1 through 10","327.41","921.39","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","649.67","81.72","","616.34","339.01","616.34","63","327.41","921.39","percent of total billed charges",""
"Diagnostic Mammography 2d Digital (Incl. Cad)","PX-40000013","CDM","77065","HCPCS","0401","RC","","","","both","","","647.00","485.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","514.37","79.5","","493.45","493.45","493.45","1 through 10","99.6","614.65","percent of total billed charges",""
"Diagnostic Mammography 2d Digital (Incl. Cad)","PX-40000013","CDM","77065","HCPCS","0401","RC","","","","both","","","647.00","485.25","TRICARE [160005]","HB BWH TRICARE","614.65","95","","101.63","101.63","101.63","1 through 10","99.6","614.65","percent of total billed charges",""
"Diagnostic Mammography 2d Digital (Incl. Cad)","PX-40000013","CDM","77065","HCPCS","0401","RC","","","","outpatient","","","647.00","485.25","AETNA [1001]","HB AMC AETNA HMO","451.61","69.8","","599.42","299.71","848.96","12","255.84","735.39","percent of total billed charges",""
"Diagnostic Mammography 2d Digital (Incl. Cad)","PX-40000013","CDM","77065","HCPCS","0401","RC","","","","outpatient","","","647.00","485.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","528.73","81.72","","468.93","352.63","468.93","1 through 10","255.84","735.39","percent of total billed charges",""
"Dialysis Other/Than Hemodialysis 1 Phys/Qhp Eval","PX-84000001","CDM","90945","CPT","0845","RC","","","","both","","","4460.00","3345.00","MEDICARE [2001]","HB BWH MEDICARE","505.64","","APC Price ($505.64). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","483.40","483.40","483.40","1 through 10","480.4","3545.7","other","OPPS APC"
"Diazepam Vl 5mg/Ml 1ml","PX-63600190","CDM","J3360","HCPCS","0636","RC","","","","both","","","4.97","3.73","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","3.83","77","","21.81","21.81","21.81","1 through 10","1.54","18.34","percent of total billed charges",""
"Diazepam Vl 5mg/Ml 1ml","PX-63600190","CDM","J3360","HCPCS","0636","RC","","","","both","","","4.97","3.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1.81","36.5","","26.73","5.70","26.73","1 through 10","1.54","18.34","percent of total billed charges",""
"Diazepam Vl 5mg/Ml 1ml","PX-63600190","CDM","J3360","HCPCS","0636","RC","","","","both","","","4.97","3.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1.90","38.3","","18.05","5.50","21.23","1 through 10","1.54","18.34","percent of total billed charges",""
"Diazepam Vl 5mg/Ml 1ml","PX-63600190","CDM","J3360","HCPCS","0636","RC","","","","outpatient","","","4.97","3.73","AETNA [1001]","HB AMC AETNA HMO","3.47","69.8","","11.04","11.04","11.04","1 through 10","2.33","13.27","percent of total billed charges",""
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","46243.73","34682.80","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","11756.37","","Case rate ($11,413.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,662.73, add-ons for qualifying new technology services are included. If operating cost exceeds $59,307.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,060.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,282.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $973.32. The transfer capital threshold is the transfer adjustment factor * $973.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11779.79","11762.28","11801.86","1 through 10","11185.67","18542.3117","other","Inpatient DRG"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","46243.73","34682.80","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","11413.95","","Case rate ($11,413.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,662.73, add-ons for qualifying new technology services are included. If operating cost exceeds $59,307.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,060.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,282.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $973.32. The transfer capital threshold is the transfer adjustment factor * $973.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11306.71","11306.71","11306.71","1 through 10","11185.67","18542.3117","other","Inpatient Replacement Plans DRG"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","46243.73","34682.80","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","11413.95","","Case rate ($11,413.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,662.73, add-ons for qualifying new technology services are included. If operating cost exceeds $59,307.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,060.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,282.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $973.32. The transfer capital threshold is the transfer adjustment factor * $973.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7223.21","7223.21","7223.21","1 through 10","11185.67","18542.3117","other","Inpatient DRG"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","46243.73","34682.80","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","11413.95","","Case rate ($11,413.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,662.73, add-ons for qualifying new technology services are included. If operating cost exceeds $59,307.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,060.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,282.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $973.32. The transfer capital threshold is the transfer adjustment factor * $973.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11240.67","11240.67","11240.67","1 through 10","11185.67","18542.3117","other","Inpatient Replacement Plans DRG"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","46243.73","34682.80","MEDICARE [2001]","HB BWH MEDICARE","11413.95","","Case rate ($11,413.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,662.73, add-ons for qualifying new technology services are included. If operating cost exceeds $59,307.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,060.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,282.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $973.32. The transfer capital threshold is the transfer adjustment factor * $973.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14763.59","0.03","14785.26","36","11185.67","18542.3117","other","Inpatient Replacement Plans DRG"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","46243.73","34682.80","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","11185.67","","Case rate ($11,413.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,662.73, add-ons for qualifying new technology services are included. If operating cost exceeds $59,307.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,413.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,060.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,282.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $973.32. The transfer capital threshold is the transfer adjustment factor * $973.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11242.22","11242.22","11263.47","1 through 10","11185.67","18542.3117","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","88855.49","66641.62","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","20485.98","","Case rate ($19,889.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,865.37, add-ons for qualifying new technology services are included. If operating cost exceeds $69,509.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,161.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $17,788.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,485.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,720.92. The transfer capital threshold is the transfer adjustment factor * $1,720.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","20081.31","20081.31","20081.31","1 through 10","19491.51","33500.6","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","88855.49","66641.62","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","25699.76","","Case rate ($25,699.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,865.37, add-ons for qualifying new technology services are included. If operating cost exceeds $69,509.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,161.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $23,598.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,485.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,720.92. The transfer capital threshold is the transfer adjustment factor * $1,720.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19232.84","19232.84","19232.84","1 through 10","19491.51","33500.6","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","88855.49","66641.62","FALLON HEALTH [1008]","HB BWH MEDICARE","25699.76","","Case rate ($25,699.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,865.37, add-ons for qualifying new technology services are included. If operating cost exceeds $69,509.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,161.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $23,598.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,485.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,720.92. The transfer capital threshold is the transfer adjustment factor * $1,720.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19076.25","19076.25","19076.25","1 through 10","19491.51","33500.6","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","88855.49","66641.62","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","25699.76","","Case rate ($25,699.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,865.37, add-ons for qualifying new technology services are included. If operating cost exceeds $69,509.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,161.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $23,598.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,485.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,720.92. The transfer capital threshold is the transfer adjustment factor * $1,720.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","96966.03","96966.03","96966.03","1 through 10","19491.51","33500.6","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","88855.49","66641.62","MEDICARE [2001]","HB BWH MEDICARE","25699.76","","Case rate ($25,699.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,865.37, add-ons for qualifying new technology services are included. If operating cost exceeds $69,509.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,161.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $23,598.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,485.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,720.92. The transfer capital threshold is the transfer adjustment factor * $1,720.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25169.92","0.03","25207.14","65","19491.51","33500.6","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","88855.49","66641.62","MOLINA [1014]","HB BWH MOLINA","19491.51","","Case rate ($19,889.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,865.37, add-ons for qualifying new technology services are included. If operating cost exceeds $69,509.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,161.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $17,788.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,485.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,720.92. The transfer capital threshold is the transfer adjustment factor * $1,720.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19630.10","19630.10","19630.10","1 through 10","19491.51","33500.6","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","88855.49","66641.62","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19491.51","","Case rate ($19,889.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,865.37, add-ons for qualifying new technology services are included. If operating cost exceeds $69,509.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,161.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $17,788.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,485.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,720.92. The transfer capital threshold is the transfer adjustment factor * $1,720.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19093.99","17042.48","19172.48","1 through 10","19491.51","33500.6","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","88855.49","66641.62","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19491.51","","Case rate ($19,889.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,865.37, add-ons for qualifying new technology services are included. If operating cost exceeds $69,509.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,161.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $17,788.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,485.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,720.92. The transfer capital threshold is the transfer adjustment factor * $1,720.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19093.48","19053.97","19142.28","1 through 10","19491.51","33500.6","other","Inpatient DRG"
"Digestive Malignancy Without Cc/McC","376","MS-DRG","","","","","","","","inpatient","","","65405.42","49054.06","MEDICARE [2001]","HB BWH MEDICARE","8811.41","","Case rate ($8,811.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,529.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,174.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,183.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,687.82 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,149.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $743.75. The transfer capital threshold is the transfer adjustment factor * $743.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10688.10","10688.10","10688.10","1 through 10","8635.18","13325.353","other","Inpatient Replacement Plans DRG"
"Digestive Malignancy,EXTREME","240","DRG","","","","","","","","inpatient","","","147517.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","58504.87","","Standard inlier is a Case rate ($58,504.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,144, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,305.12) for the length of stay and the standard reimbursement.","65775.24","65775.24","65775.24","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,EXTREME","240","DRG","","","","","","","","inpatient","","","147517.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","65775.24","","Standard inlier is a Case rate ($65,775.24). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,144, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,336.25) for the length of stay and the standard reimbursement.","61048.29","60091.36","77669.27","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,EXTREME","240","DRG","","","","","","","","inpatient","","","147517.66","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17786.2384","","Fee schedule rate ($74,652.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17786.2384","74652.08","74652.08","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,EXTREME","240","DRG","","","","","","","","inpatient","","","147517.66","","MASSHEALTH [3001]","HB BWH MEDICAID","25471.33","","Case rate ($28,162.94). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,592.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","28156.03","28156.03","28156.03","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,EXTREME","240","DRG","","","","","","","","inpatient","","","147517.66","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70623.65","","Fee schedule rate ($70,623.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","70623.65","70623.65","70623.65","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,EXTREME","240","DRG","","","","","","","","inpatient","","","147517.66","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","25471.33","","Case rate ($28,162.94). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,592.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","28156.03","28156.03","28156.03","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,MAJOR","240","DRG","","","","","","","","inpatient","","","62765.75","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","35591.27","","Standard inlier is a Case rate ($35,591.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,325, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,052.40) for the length of stay and the standard reimbursement.","32442.74","27288.58","35591.27","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,MAJOR","240","DRG","","","","","","","","inpatient","","","62765.75","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","40014.18","","Standard inlier is a Case rate ($40,014.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,325, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,679.68) for the length of stay and the standard reimbursement.","40014.18","36556.40","40014.18","12","7396.82","123177.47","case rate",""
"Digestive Malignancy,MAJOR","240","DRG","","","","","","","","inpatient","","","62765.75","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","18676.0672","","Fee schedule rate ($39,193.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18676.0672","39193.44","39193.44","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,MAJOR","240","DRG","","","","","","","","inpatient","","","62765.75","","MASSHEALTH [3001]","HB BWH MEDICAID","12873.32","","Case rate ($14,233.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,663.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14230.18","8650.56","50357.16","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,MAJOR","240","DRG","","","","","","","","inpatient","","","62765.75","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","12873.32","","Case rate ($14,233.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,663.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2781.16","2781.16","2781.16","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,MAJOR","240","DRG","","","","","","","","inpatient","","","62765.75","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38124.69","","Fee schedule rate ($38,124.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38124.69","38124.69","38124.69","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,MAJOR","240","DRG","","","","","","","","inpatient","","","62765.75","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12873.32","","Case rate ($14,233.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,663.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14230.18","14230.18","94586.15","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,MINOR","240","DRG","","","","","","","","inpatient","","","65405.42","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22580.49","","Standard inlier is a Case rate ($22,580.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,208, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,205.44) for the length of stay and the standard reimbursement.","22580.48","22580.48","22580.48","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,MODERATE","240","DRG","","","","","","","","inpatient","","","43006.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","26099.19","","Standard inlier is a Case rate ($26,099.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,943, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,704.94) for the length of stay and the standard reimbursement.","26099.18","26099.18","26099.18","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,MODERATE","240","DRG","","","","","","","","inpatient","","","43006.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","29342.52","","Standard inlier is a Case rate ($29,342.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,943, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,164.93) for the length of stay and the standard reimbursement.","29342.52","29342.52","29342.52","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,MODERATE","240","DRG","","","","","","","","inpatient","","","43006.06","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17786.2384","","Fee schedule rate ($37,326.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17786.2384","21640.08","21640.08","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,MODERATE","240","DRG","","","","","","","","inpatient","","","43006.06","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","18676.0672","","Fee schedule rate ($39,193.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18676.0672","21846.16","21846.16","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,MODERATE","240","DRG","","","","","","","","inpatient","","","43006.06","","MASSHEALTH [3001]","HB BWH MEDICAID","8327.85","","Case rate ($9,207.87). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,637.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9205.61","9205.61","9205.61","1 through 10","7396.82","123177.47","case rate",""
"Digestive Malignancy,MODERATE","240","DRG","","","","","","","","inpatient","","","43006.06","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8327.85","","Case rate ($9,207.87). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,637.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9205.61","9205.61","9205.61","1 through 10","7396.82","123177.47","case rate",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","298.69","71.8","","289.35","289.35","289.35","1 through 10","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","272.90","65.6","","403.00","403.00","403.00","1 through 10","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","270.40","65","","261.95","261.95","261.95","1 through 10","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","291.20","70","","403.00","129.51","403.00","1 through 10","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","330.72","79.5","","317.16","212.78","317.16","94","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","221.73","53.3","","212.78","212.78","638.34","84","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","270.40","65","","261.95","261.95","261.95","1 through 10","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","299.52","72","","290.16","290.16","290.16","1 through 10","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","128.96","31","","124.53","124.53","124.53","1 through 10","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","151.84","36.5","","150.32","127.75","291.78","62","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","159.33","38.3","","157.57","153.14","306.28","250","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","TRICARE [160005]","HB BWH TRICARE","395.20","95","","140.32","140.32","156.79","1 through 10","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.46","42.9","","322.16","120.16","359.91","1 through 10","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.46","42.9","","177.20","177.20","177.20","1 through 10","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","416.00","312.00","WELLPOINT [1015]","HB AMC WELLPOINT","306.92","73.78","","300.03","300.03","485.21","66","17.84","395.2","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","416.00","312.00","AETNA [1001]","HB AMC AETNA HMO","290.37","69.8","","272.83","272.83","330.46","1 through 10","80.89","343.05","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","416.00","312.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","334.46","80.4","","314.34","314.34","314.34","1 through 10","80.89","343.05","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","416.00","312.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","339.96","81.72","","177.20","177.20","177.20","1 through 10","80.89","343.05","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","416.00","312.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","339.96","81.72","","322.16","177.20","322.16","62","80.89","343.05","percent of total billed charges",""
"Digital Breast Tomosynthesis Unilateral","PX-32000399","CDM","77061","CPT","0401","RC","","","","both","","","298.00","223.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.91","79.5","","227.44","227.44","227.44","1 through 10","17.84","283.1","percent of total billed charges",""
"Digital Breast Tomosynthesis Unilateral","PX-32000399","CDM","77061","CPT","0401","RC","","","","both","","","298.00","223.50","TRICARE [160005]","HB BWH TRICARE","283.10","95","","119.83","119.83","119.83","1 through 10","17.84","283.1","percent of total billed charges",""
"Digital Breast Tomosynthesis Unilateral","PX-32000399","CDM","77061","CPT","0401","RC","","","","outpatient","","","298.00","223.50","AETNA [1001]","HB AMC AETNA HMO","208.00","69.8","","195.65","138.14","195.65","1 through 10","80.89","268.07","percent of total billed charges",""
"Digital Breast Tomosynthesis Unilateral","PX-32000399","CDM","77061","CPT","0401","RC","","","","outpatient","","","298.00","223.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","243.53","81.72","","162.54","162.54","162.54","1 through 10","80.89","268.07","percent of total billed charges",""
"Digoxin (Lanoxin)","PX-30000181","CDM","80162","CPT","0301","RC","","","","both","","","203.00","152.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","142.10","70","","197.00","197.00","197.00","1 through 10","13.01","192.85","percent of total billed charges",""
"Digoxin (Lanoxin)","PX-30000181","CDM","80162","CPT","0301","RC","","","","both","","","203.00","152.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.10","36.5","","73.48","73.48","73.48","1 through 10","13.01","192.85","percent of total billed charges",""
"Digoxin (Lanoxin)","PX-30000181","CDM","80162","CPT","0301","RC","","","","both","","","203.00","152.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.75","38.3","","141.45","141.45","141.45","1 through 10","13.01","192.85","percent of total billed charges",""
"Digoxin (Lanoxin)","PX-30000181","CDM","80162","CPT","0301","RC","","","","outpatient","","","203.00","152.25","AETNA [1001]","HB AMC AETNA HMO","141.69","69.8","","94.17","94.17","94.17","1 through 10","13.69","165.89","percent of total billed charges",""
"Digoxin (Lanoxin)","PX-30000181","CDM","80162","CPT","0301","RC","","","","outpatient","","","203.00","152.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.89","81.72","","160.18","160.18","160.18","1 through 10","13.69","165.89","percent of total billed charges",""
"Dihydrotestosterone (Dht)","PX-30003537","CDM","82642","CPT","0301","RC","","","","both","","","414.00","310.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","329.13","79.5","","315.59","315.59","315.59","1 through 10","28.69","393.3","percent of total billed charges",""
"Dihydrotestosterone (Dht)","PX-30003537","CDM","82642","CPT","0301","RC","","","","both","","","414.00","310.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","151.11","36.5","","149.57","149.57","149.57","1 through 10","28.69","393.3","percent of total billed charges",""
"Dihydrotestosterone (Dht)","PX-30003537","CDM","82642","CPT","0301","RC","","","","both","","","414.00","310.50","WELLPOINT [1015]","HB AMC WELLPOINT","305.45","73.78","","298.54","298.54","298.54","1 through 10","28.69","393.3","percent of total billed charges",""
"Dihydrotestosterone (Dht)","PX-30003537","CDM","82642","CPT","0301","RC","","","","outpatient","","","414.00","310.50","AETNA [1001]","HB AMC AETNA HMO","288.97","69.8","","271.48","271.48","271.48","1 through 10","58.55","338.32","percent of total billed charges",""
"Dilate Canal Cervical Instrumental","PX-76001376","CDM","57800","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5424.80","5424.80","5424.80","1 through 10","2125.14","3992.84","other","ASC"
"Dilate Esophagus Over Guidewire","PX-75000122","CDM","43453","CPT","0750","RC","","","","both","","","3715.00","2786.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2320.12","2320.12","2320.12","1 through 10","1151.65","2953.43","other","OPPS APC"
"Dilate Esophagus Over Guidewire","PX-75000122","CDM","43453","CPT","0750","RC","","","","both","","","3715.00","2786.25","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1151.65","2953.43","other","OPPS APC"
"Dilate Esophagus Over Guidewire","PX-75000122","CDM","43453","CPT","0750","RC","","","","both","","","3715.00","2786.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3741.18","3741.18","3741.18","1 through 10","1151.65","2953.43","other","OPPS APC"
"Dilate Esophagus Sound or Bougie","PX-75000121","CDM","43450","CPT","0750","RC","","","","both","","","2379.00","1784.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","509.02","509.02","509.02","1 through 10","737.49","1891.31","other","OPPS APC"
"Dilate Esophagus Sound or Bougie","PX-75000121","CDM","43450","CPT","0750","RC","","","","both","","","2379.00","1784.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","989.36","556.70","1113.41","1 through 10","737.49","1891.31","other","OPPS APC"
"Dilate Esophagus Sound or Bougie","PX-75000121","CDM","43450","CPT","0750","RC","","","","both","","","2379.00","1784.25","WELLPOINT [1015]","HB AMC WELLPOINT","1755.23","73.78","","1717.56","1717.56","1717.56","1 through 10","737.49","1891.31","percent of total billed charges",""
"Dilate Esophagus Sound or Bougie","PX-75000121","CDM","43450","CPT","0750","RC","","","","outpatient","","","2379.00","1784.25","AETNA [1001]","HB AMC AETNA HMO","1660.54","69.8","","1561.84","1561.84","1561.84","1 through 10","761.55","2384.07","percent of total billed charges",""
"Dilate Sphincter Anal W/Anes","PX-75000206","CDM","45905","CPT","0750","RC","","","","outpatient","","","4945.00","3708.75","AETNA [1001]","HB AMC AETNA HMO","3451.61","69.8","","2591.72","2591.72","2591.72","1 through 10","1978","4041.05","percent of total billed charges",""
"Dilate Sphincter Anal W/Anes","PX-75000206","CDM","45905","CPT","0750","RC","","","","outpatient","","","4945.00","3708.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2582.28","52.22","","2622.97","2622.97","2622.97","1 through 10","1978","4041.05","percent of total billed charges",""
"Dilate Stricture Rectal S/Anes","PX-75000207","CDM","45910","CPT","0750","RC","","","","outpatient","","","4945.00","3708.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2582.28","52.22","","2597.20","2597.20","2597.20","1 through 10","1978","4041.05","percent of total billed charges",""
"Dilation And Curettage For Non-Obstetric Diagnoses,MINOR","517","DRG","","","","","","","","inpatient","","","29544.45","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","14030.5364","","Fee schedule rate ($14,030.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14030.5364","14030.52","14030.52","1 through 10","7810.36","63899.05","case rate",""
"Dilation And Curettage For Non-Obstetric Diagnoses,MODERATE","517","DRG","","","","","","","","inpatient","","","52477.78","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","30240.61","","Standard inlier is a Case rate ($30,240.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,564, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,292.40) for the length of stay and the standard reimbursement.","30240.61","30240.61","30240.61","1 through 10","7810.36","63899.05","case rate",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","599.03","449.27","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","419.32","70","","863.10","863.10","863.10","1 through 10","185.7","476.23","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","599.03","449.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","476.23","79.5","","447.66","447.66","447.66","1 through 10","185.7","476.23","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","599.03","449.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","389.37","65","","1020.11","1020.11","1020.11","1 through 10","185.7","476.23","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","599.03","449.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","185.70","31","","208.83","208.83","208.83","1 through 10","185.7","476.23","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","599.03","449.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","218.65","36.5","","312.44","214.23","1086.03","20","185.7","476.23","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","599.03","449.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","229.43","38.3","","264.25","227.63","567.11","31","185.7","476.23","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","599.03","449.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","256.98","42.9","","79.94","79.94","79.94","1 through 10","185.7","476.23","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","599.03","449.27","WELLPOINT [1015]","HB AMC WELLPOINT","441.96","73.78","","174.45","74.45","1168.42","1 through 10","185.7","476.23","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","599.03","449.27","AETNA [1001]","HB AMC AETNA HMO","418.12","69.8","","655.01","135.40","784.73","1 through 10","313.05","489.53","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","599.03","449.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","489.53","81.72","","540.25","46.28","897.42","36","313.05","489.53","percent of total billed charges",""
"DILATOR CRE 7.5FR 6-8MM 5.5CM 240CM .035IN BALLOON ENDOSCOPIC OBLONG FILL SALINE WIREGUIDED STERILE LF DISP","SUP-ITM-10012985","CDM","C1726","HCPCS","0272","RC","","","","both","","","675.82","506.86","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","473.07","70","","863.10","863.10","863.10","1 through 10","209.5","537.28","percent of total billed charges",""
"DILATOR CRE 7.5FR 6-8MM 5.5CM 240CM .035IN BALLOON ENDOSCOPIC OBLONG FILL SALINE WIREGUIDED STERILE LF DISP","SUP-ITM-10012985","CDM","C1726","HCPCS","0272","RC","","","","both","","","675.82","506.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","537.28","79.5","","447.66","447.66","447.66","1 through 10","209.5","537.28","percent of total billed charges",""
"DILATOR CRE 7.5FR 6-8MM 5.5CM 240CM .035IN BALLOON ENDOSCOPIC OBLONG FILL SALINE WIREGUIDED STERILE LF DISP","SUP-ITM-10012985","CDM","C1726","HCPCS","0272","RC","","","","both","","","675.82","506.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","439.28","65","","1020.11","1020.11","1020.11","1 through 10","209.5","537.28","percent of total billed charges",""
"DILATOR CRE 7.5FR 6-8MM 5.5CM 240CM .035IN BALLOON ENDOSCOPIC OBLONG FILL SALINE WIREGUIDED STERILE LF DISP","SUP-ITM-10012985","CDM","C1726","HCPCS","0272","RC","","","","both","","","675.82","506.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","209.50","31","","208.83","208.83","208.83","1 through 10","209.5","537.28","percent of total billed charges",""
"DILATOR CRE 7.5FR 6-8MM 5.5CM 240CM .035IN BALLOON ENDOSCOPIC OBLONG FILL SALINE WIREGUIDED STERILE LF DISP","SUP-ITM-10012985","CDM","C1726","HCPCS","0272","RC","","","","both","","","675.82","506.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","246.67","36.5","","312.44","214.23","1086.03","20","209.5","537.28","percent of total billed charges",""
"DILATOR CRE 7.5FR 6-8MM 5.5CM 240CM .035IN BALLOON ENDOSCOPIC OBLONG FILL SALINE WIREGUIDED STERILE LF DISP","SUP-ITM-10012985","CDM","C1726","HCPCS","0272","RC","","","","both","","","675.82","506.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","258.84","38.3","","264.25","227.63","567.11","31","209.5","537.28","percent of total billed charges",""
"DILATOR CRE 7.5FR 6-8MM 5.5CM 240CM .035IN BALLOON ENDOSCOPIC OBLONG FILL SALINE WIREGUIDED STERILE LF DISP","SUP-ITM-10012985","CDM","C1726","HCPCS","0272","RC","","","","both","","","675.82","506.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.93","42.9","","79.94","79.94","79.94","1 through 10","209.5","537.28","percent of total billed charges",""
"DILATOR CRE 7.5FR 6-8MM 5.5CM 240CM .035IN BALLOON ENDOSCOPIC OBLONG FILL SALINE WIREGUIDED STERILE LF DISP","SUP-ITM-10012985","CDM","C1726","HCPCS","0272","RC","","","","both","","","675.82","506.86","WELLPOINT [1015]","HB AMC WELLPOINT","498.62","73.78","","174.45","74.45","1168.42","1 through 10","209.5","537.28","percent of total billed charges",""
"DILATOR CRE 7.5FR 6-8MM 5.5CM 240CM .035IN BALLOON ENDOSCOPIC OBLONG FILL SALINE WIREGUIDED STERILE LF DISP","SUP-ITM-10012985","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","675.82","506.86","AETNA [1001]","HB AMC AETNA HMO","471.72","69.8","","655.01","135.40","784.73","1 through 10","353.18","552.28","percent of total billed charges",""
"DILATOR CRE 7.5FR 6-8MM 5.5CM 240CM .035IN BALLOON ENDOSCOPIC OBLONG FILL SALINE WIREGUIDED STERILE LF DISP","SUP-ITM-10012985","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","675.82","506.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","552.28","81.72","","540.25","46.28","897.42","36","353.18","552.28","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","both","","","1460.03","1095.02","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1022.02","70","","863.10","863.10","863.10","1 through 10","452.61","1160.72","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","both","","","1460.03","1095.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1160.72","79.5","","447.66","447.66","447.66","1 through 10","452.61","1160.72","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","both","","","1460.03","1095.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","949.02","65","","1020.11","1020.11","1020.11","1 through 10","452.61","1160.72","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","both","","","1460.03","1095.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","452.61","31","","208.83","208.83","208.83","1 through 10","452.61","1160.72","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","both","","","1460.03","1095.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","532.91","36.5","","312.44","214.23","1086.03","20","452.61","1160.72","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","both","","","1460.03","1095.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","559.19","38.3","","264.25","227.63","567.11","31","452.61","1160.72","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","both","","","1460.03","1095.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","626.35","42.9","","79.94","79.94","79.94","1 through 10","452.61","1160.72","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","both","","","1460.03","1095.02","WELLPOINT [1015]","HB AMC WELLPOINT","1077.21","73.78","","174.45","74.45","1168.42","1 through 10","452.61","1160.72","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1460.03","1095.02","AETNA [1001]","HB AMC AETNA HMO","1019.10","69.8","","655.01","135.40","784.73","1 through 10","763.01","1193.14","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1460.03","1095.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1193.14","81.72","","540.25","46.28","897.42","36","763.01","1193.14","percent of total billed charges",""
"DILATOR SET 10 12MM 8CM 75 20 30 6ATM .035IN BALLOON ENDOSCOPIC PULMONARY DIA OBLONG FILL SALINE GUID","SUP-ITM-10025496","CDM","C1726","HCPCS","0272","RC","","","","both","","","940.91","705.68","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","658.64","70","","863.10","863.10","863.10","1 through 10","291.68","748.02","percent of total billed charges",""
"DILATOR SET 10 12MM 8CM 75 20 30 6ATM .035IN BALLOON ENDOSCOPIC PULMONARY DIA OBLONG FILL SALINE GUID","SUP-ITM-10025496","CDM","C1726","HCPCS","0272","RC","","","","both","","","940.91","705.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","748.02","79.5","","447.66","447.66","447.66","1 through 10","291.68","748.02","percent of total billed charges",""
"DILATOR SET 10 12MM 8CM 75 20 30 6ATM .035IN BALLOON ENDOSCOPIC PULMONARY DIA OBLONG FILL SALINE GUID","SUP-ITM-10025496","CDM","C1726","HCPCS","0272","RC","","","","both","","","940.91","705.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","611.59","65","","1020.11","1020.11","1020.11","1 through 10","291.68","748.02","percent of total billed charges",""
"DILATOR SET 10 12MM 8CM 75 20 30 6ATM .035IN BALLOON ENDOSCOPIC PULMONARY DIA OBLONG FILL SALINE GUID","SUP-ITM-10025496","CDM","C1726","HCPCS","0272","RC","","","","both","","","940.91","705.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","291.68","31","","208.83","208.83","208.83","1 through 10","291.68","748.02","percent of total billed charges",""
"DILATOR SET 10 12MM 8CM 75 20 30 6ATM .035IN BALLOON ENDOSCOPIC PULMONARY DIA OBLONG FILL SALINE GUID","SUP-ITM-10025496","CDM","C1726","HCPCS","0272","RC","","","","both","","","940.91","705.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","343.43","36.5","","312.44","214.23","1086.03","20","291.68","748.02","percent of total billed charges",""
"DILATOR SET 10 12MM 8CM 75 20 30 6ATM .035IN BALLOON ENDOSCOPIC PULMONARY DIA OBLONG FILL SALINE GUID","SUP-ITM-10025496","CDM","C1726","HCPCS","0272","RC","","","","both","","","940.91","705.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","360.37","38.3","","264.25","227.63","567.11","31","291.68","748.02","percent of total billed charges",""
"DILATOR SET 10 12MM 8CM 75 20 30 6ATM .035IN BALLOON ENDOSCOPIC PULMONARY DIA OBLONG FILL SALINE GUID","SUP-ITM-10025496","CDM","C1726","HCPCS","0272","RC","","","","both","","","940.91","705.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.65","42.9","","79.94","79.94","79.94","1 through 10","291.68","748.02","percent of total billed charges",""
"DILATOR SET 10 12MM 8CM 75 20 30 6ATM .035IN BALLOON ENDOSCOPIC PULMONARY DIA OBLONG FILL SALINE GUID","SUP-ITM-10025496","CDM","C1726","HCPCS","0272","RC","","","","both","","","940.91","705.68","WELLPOINT [1015]","HB AMC WELLPOINT","694.20","73.78","","174.45","74.45","1168.42","1 through 10","291.68","748.02","percent of total billed charges",""
"DILATOR SET 10 12MM 8CM 75 20 30 6ATM .035IN BALLOON ENDOSCOPIC PULMONARY DIA OBLONG FILL SALINE GUID","SUP-ITM-10025496","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","940.91","705.68","AETNA [1001]","HB AMC AETNA HMO","656.76","69.8","","655.01","135.40","784.73","1 through 10","491.72","768.91","percent of total billed charges",""
"DILATOR SET 10 12MM 8CM 75 20 30 6ATM .035IN BALLOON ENDOSCOPIC PULMONARY DIA OBLONG FILL SALINE GUID","SUP-ITM-10025496","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","940.91","705.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","768.91","81.72","","540.25","46.28","897.42","36","491.72","768.91","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.61","196.96","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","137.24","52.26","","16.24","16.24","54.15","1 through 10","81.41","208.77","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.61","196.96","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","188.55","71.8","","86.33","32.67","86.33","1 through 10","81.41","208.77","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.61","196.96","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","183.83","70","","113.68","63.00","177.34","40","81.41","208.77","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.61","196.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","208.77","79.5","","50.70","21.76","168.00","12","81.41","208.77","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.61","196.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.97","53.3","","89.31","89.31","99.75","1 through 10","81.41","208.77","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.61","196.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","170.70","65","","94.41","17.06","2275.00","1 through 10","81.41","208.77","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.61","196.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","81.41","31","","35.13","35.13","35.13","1 through 10","81.41","208.77","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.61","196.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.85","36.5","","40.08","12.40","86.17","108","81.41","208.77","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.61","196.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.58","38.3","","33.25","10.27","68.43","169","81.41","208.77","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.61","196.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.66","42.9","","25.48","14.86","90.88","1 through 10","81.41","208.77","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.61","196.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.66","42.9","","90.88","90.88","90.88","1 through 10","81.41","208.77","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.61","196.96","WELLPOINT [1015]","HB AMC WELLPOINT","193.75","73.78","","84.63","19.55","140.02","123","81.41","208.77","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.61","196.96","AETNA [1001]","HB AMC AETNA HMO","183.30","69.8","","76.96","17.77","113.68","14","137.24","214.6","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.61","196.96","AETNA [1001]","HB AMC AETNA PPO","211.14","80.4","","57.31","57.31","57.31","1 through 10","137.24","214.6","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.61","196.96","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","137.24","52.26","","16.24","16.24","54.15","1 through 10","137.24","214.6","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.61","196.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","211.14","80.4","","68.25","68.25","87.50","1 through 10","137.24","214.6","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.61","196.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","214.60","81.72","","156.19","156.19","156.19","1 through 10","137.24","214.6","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.61","196.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","214.60","81.72","","82.70","12.06","98.97","13","137.24","214.6","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.61","196.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.60","81.72","","50.47","25.30","134.30","140","137.24","214.6","percent of total billed charges",""
"DILATOR URETERAL 7F 6MMX4CM 65CM BALLOON","SUP-ITM-10001339","CDM","C1758","HCPCS","0272","RC","","","","both","","","632.45","474.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","502.80","79.5","","19.51","1.19","19.51","1 through 10","196.06","502.8","percent of total billed charges",""
"DILATOR URETERAL 7F 6MMX4CM 65CM BALLOON","SUP-ITM-10001339","CDM","C1758","HCPCS","0272","RC","","","","both","","","632.45","474.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","411.09","65","","0.94","0.94","0.94","1 through 10","196.06","502.8","percent of total billed charges",""
"DILATOR URETERAL 7F 6MMX4CM 65CM BALLOON","SUP-ITM-10001339","CDM","C1758","HCPCS","0272","RC","","","","both","","","632.45","474.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","230.84","36.5","","12.11","1.56","53.50","35","196.06","502.8","percent of total billed charges",""
"DILATOR URETERAL 7F 6MMX4CM 65CM BALLOON","SUP-ITM-10001339","CDM","C1758","HCPCS","0272","RC","","","","both","","","632.45","474.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","242.23","38.3","","1.65","0.56","14.07","55","196.06","502.8","percent of total billed charges",""
"DILATOR URETERAL 7F 6MMX4CM 65CM BALLOON","SUP-ITM-10001339","CDM","C1758","HCPCS","0272","RC","","","","both","","","632.45","474.34","WELLPOINT [1015]","HB AMC WELLPOINT","466.62","73.78","","24.17","1.07","130.81","14","196.06","502.8","percent of total billed charges",""
"DILATOR URETERAL 7F 6MMX4CM 65CM BALLOON","SUP-ITM-10001339","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","632.45","474.34","AETNA [1001]","HB AMC AETNA HMO","441.45","69.8","","1.83","0.82","15.71","1 through 10","330.52","516.84","percent of total billed charges",""
"DILATOR URETERAL 7F 6MMX4CM 65CM BALLOON","SUP-ITM-10001339","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","632.45","474.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","508.49","80.4","","0.72","0.72","0.72","1 through 10","330.52","516.84","percent of total billed charges",""
"DILATOR URETERAL 7F 6MMX4CM 65CM BALLOON","SUP-ITM-10001339","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","632.45","474.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","516.84","81.72","","10.92","1.37","10.92","1 through 10","330.52","516.84","percent of total billed charges",""
"DILATOR URETERAL 7F 6MMX4CM 65CM BALLOON","SUP-ITM-10001339","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","632.45","474.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","516.84","81.72","","19.84","1.15","26.27","14","330.52","516.84","percent of total billed charges",""
"DILATOR VASCULAR 8FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001327","CDM","C1758","HCPCS","0272","RC","","","","both","","","24.82","18.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","19.73","79.5","","19.51","1.19","19.51","1 through 10","7.69","19.73","percent of total billed charges",""
"DILATOR VASCULAR 8FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001327","CDM","C1758","HCPCS","0272","RC","","","","both","","","24.82","18.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","16.13","65","","0.94","0.94","0.94","1 through 10","7.69","19.73","percent of total billed charges",""
"DILATOR VASCULAR 8FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001327","CDM","C1758","HCPCS","0272","RC","","","","both","","","24.82","18.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9.06","36.5","","12.11","1.56","53.50","35","7.69","19.73","percent of total billed charges",""
"DILATOR VASCULAR 8FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001327","CDM","C1758","HCPCS","0272","RC","","","","both","","","24.82","18.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9.51","38.3","","1.65","0.56","14.07","55","7.69","19.73","percent of total billed charges",""
"DILATOR VASCULAR 8FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001327","CDM","C1758","HCPCS","0272","RC","","","","both","","","24.82","18.61","WELLPOINT [1015]","HB AMC WELLPOINT","18.31","73.78","","24.17","1.07","130.81","14","7.69","19.73","percent of total billed charges",""
"DILATOR VASCULAR 8FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001327","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","24.82","18.61","AETNA [1001]","HB AMC AETNA HMO","17.32","69.8","","1.83","0.82","15.71","1 through 10","12.97","20.28","percent of total billed charges",""
"DILATOR VASCULAR 8FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001327","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","24.82","18.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","19.96","80.4","","0.72","0.72","0.72","1 through 10","12.97","20.28","percent of total billed charges",""
"DILATOR VASCULAR 8FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001327","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","24.82","18.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","20.28","81.72","","10.92","1.37","10.92","1 through 10","12.97","20.28","percent of total billed charges",""
"DILATOR VASCULAR 8FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001327","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","24.82","18.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","20.28","81.72","","19.84","1.15","26.27","14","12.97","20.28","percent of total billed charges",""
"Diphenhyd Cap 50mg","PX-63600249","CDM","Q0163","HCPCS","0636","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.70","70","","0.92","0.92","0.92","1 through 10","0.31","0.77","percent of total billed charges",""
"Diphenhyd Cap 50mg","PX-63600249","CDM","Q0163","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.70","69.9","","0.57","0.57","0.57","1 through 10","0.47","2.84","percent of total billed charges",""
"Diphenhyd Vl 50mg/Ml 1ml","PX-63600105","CDM","J1200","HCPCS","0636","RC","","","","both","","","2.55","1.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1.67","65.6","","1.41","1.41","1.41","1 through 10","0.79","2.08","percent of total billed charges",""
"Diphenhyd Vl 50mg/Ml 1ml","PX-63600105","CDM","J1200","HCPCS","0636","RC","","","","both","","","2.55","1.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1.79","70","","4.78","1.49","4.78","1 through 10","0.79","2.08","percent of total billed charges",""
"Diphenhyd Vl 50mg/Ml 1ml","PX-63600105","CDM","J1200","HCPCS","0636","RC","","","","both","","","2.55","1.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1.66","65","","1.35","1.35","1.35","1 through 10","0.79","2.08","percent of total billed charges",""
"Diphenhyd Vl 50mg/Ml 1ml","PX-63600105","CDM","J1200","HCPCS","0636","RC","","","","both","","","2.55","1.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.93","36.5","","0.78","0.66","1.56","23","0.79","2.08","percent of total billed charges",""
"Diphenhyd Vl 50mg/Ml 1ml","PX-63600105","CDM","J1200","HCPCS","0636","RC","","","","both","","","2.55","1.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.98","38.3","","0.81","0.81","2.40","148","0.79","2.08","percent of total billed charges",""
"Diphenhyd Vl 50mg/Ml 1ml","PX-63600105","CDM","J1200","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","AETNA [1001]","HB AMC AETNA HMO","1.78","69.8","","1.40","0.99","1.64","41","1.2","2.05","percent of total billed charges",""
"Diphenhyd Vl 50mg/Ml 1ml","PX-63600105","CDM","J1200","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","AETNA [1001]","HB AMC AETNA PPO","2.05","80.4","","1.64","1.61","3.24","1 through 10","1.2","2.05","percent of total billed charges",""
"Diphenhyd Vl 50mg/Ml 1ml","PX-63600105","CDM","J1200","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","1.43","55.9","","1.10","1.10","1.10","1 through 10","1.2","2.05","percent of total billed charges",""
"Diphenhyd Vl 50mg/Ml 1ml","PX-63600105","CDM","J1200","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.78","69.9","","1.43","0.96","2.10","27","1.2","2.05","percent of total billed charges",""
"Diphenhyd Vl 50mg/Ml 1ml","PX-63600105","CDM","J1200","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1.20","46.9","","0.97","0.96","0.97","11","1.2","2.05","percent of total billed charges",""
"Diphenhyd Vl 50mg/Ml 1ml","PX-63600105","CDM","J1200","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1.78","69.9","","1.64","1.64","1.64","1 through 10","1.2","2.05","percent of total billed charges",""
"Diphtheria Antibody","PX-30000913","CDM","86648","CPT","0302","RC","","","","both","","","167.00","125.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.96","38.3","","61.56","61.56","61.56","1 through 10","10.07","158.65","percent of total billed charges",""
"Diphtheria Antibody","PX-30000913","CDM","86648","CPT","0302","RC","","","","outpatient","","","167.00","125.25","AETNA [1001]","HB AMC AETNA HMO","116.57","69.8","","109.67","109.67","109.67","1 through 10","10.07","136.47","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","both","","","163.00","122.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","105.95","65","","83.43","83.42","83.43","1 through 10","13.27","154.85","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","both","","","163.00","122.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","129.59","79.5","","124.35","83.42","124.35","15","13.27","154.85","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","both","","","163.00","122.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","86.88","53.3","","124.35","83.42","124.35","1 through 10","13.27","154.85","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","both","","","163.00","122.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","59.50","36.5","","58.93","49.61","58.93","1 through 10","13.27","154.85","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","both","","","163.00","122.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.43","38.3","","61.78","60.04","61.78","1 through 10","13.27","154.85","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","both","","","163.00","122.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.93","42.9","","126.30","126.30","126.30","1 through 10","13.27","154.85","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","outpatient","","","163.00","122.25","AETNA [1001]","HB AMC AETNA HMO","113.77","69.8","","106.97","75.52","106.97","1 through 10","13.98","133.2","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","outpatient","","","163.00","122.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","133.20","81.72","","126.31","69.47","126.31","1 through 10","13.98","133.2","percent of total billed charges",""
"Direct Admission of Patient for Hospital Observation Care","PX-76200007","CDM","G0379","HCPCS","0762","RC","","","","both","","","134.00","100.50","MEDICARE [2001]","HB BWH MEDICARE","728.02","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","2987.45","9433.02","12","41.54","1892","other","OPPS APC"
"Direct Admission of Patient for Hospital Observation Care","PX-76200007","CDM","G0379","HCPCS","0762","RC","","","","inpatient","","","134.00","100.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","105.34","78.61","","227.00","227.00","227.00","28","57.49","105.34","percent of total billed charges",""
"Direct Admission of Patient for Hospital Observation Care","PX-76200007","CDM","G0379","HCPCS","0762","RC","","","","outpatient","","","134.00","100.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","109.50","81.72","","227.00","227.00","227.00","137","59.56","9518","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","12250.00","9187.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9738.75","79.5","","1309.77","674.56","6049.93","26","3797.5","9738.75","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","12250.00","9187.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6529.25","53.3","","1901.83","1901.83","2962.25","1 through 10","3797.5","9738.75","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","12250.00","9187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4471.25","36.5","","1620.31","1620.31","19908.88","1 through 10","3797.5","9738.75","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","12250.00","9187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4691.75","38.3","","352.91","352.91","2046.30","1 through 10","3797.5","9738.75","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","12250.00","9187.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5255.25","42.9","","9668.75","9668.75","9668.75","1 through 10","3797.5","9738.75","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","12250.00","9187.50","WELLPOINT [1015]","HB AMC WELLPOINT","9038.05","73.78","","699.88","384.10","3443.31","33","3797.5","9738.75","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12250.00","9187.50","AETNA [1001]","HB AMC AETNA HMO","8550.50","69.8","","1421.24","264.50","4933.46","29","6401.85","10010.7","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12250.00","9187.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9849.00","80.4","","1022.97","1022.97","3607.50","1 through 10","6401.85","10010.7","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12250.00","9187.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10010.70","81.72","","3010.54","693.88","5019.88","35","6401.85","10010.7","percent of total billed charges",""
"Disopyramide","PX-31000673","CDM","80299","CPT","0310","RC","","","","both","","","122.00","91.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","96.99","79.5","","106.25","71.28","106.25","1 through 10","18.27","115.9","percent of total billed charges",""
"Disopyramide","PX-31000673","CDM","80299","CPT","0310","RC","","","","both","","","122.00","91.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","65.03","53.3","","106.25","71.28","106.25","1 through 10","18.27","115.9","percent of total billed charges",""
"Disopyramide","PX-31000673","CDM","80299","CPT","0310","RC","","","","both","","","122.00","91.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.53","36.5","","50.36","42.80","92.50","13","18.27","115.9","percent of total billed charges",""
"Disopyramide","PX-31000673","CDM","80299","CPT","0310","RC","","","","both","","","122.00","91.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.73","38.3","","52.79","44.55","158.37","30","18.27","115.9","percent of total billed charges",""
"Disopyramide","PX-31000673","CDM","80299","CPT","0310","RC","","","","outpatient","","","122.00","91.50","AETNA [1001]","HB AMC AETNA HMO","85.16","69.8","","91.40","64.53","105.30","14","53.62","114.26","percent of total billed charges",""
"Disopyramide","PX-31000673","CDM","80299","CPT","0310","RC","","","","outpatient","","","122.00","91.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","98.09","80.4","","105.30","105.30","105.30","1 through 10","53.62","114.26","percent of total billed charges",""
"Disopyramide","PX-31000673","CDM","80299","CPT","0310","RC","","","","outpatient","","","122.00","91.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","99.70","81.72","","59.36","15.50","59.36","1 through 10","53.62","114.26","percent of total billed charges",""
"Disorders Of Gallbladder And Biliary Tract,EXTREME","284","DRG","","","","","","","","inpatient","","","110069.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","63886.41","","Standard inlier is a Case rate ($63,886.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $61,328, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,069.06) for the length of stay and the standard reimbursement.","58234.79","58234.79","58234.79","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,EXTREME","284","DRG","","","","","","","","inpatient","","","110069.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","71825.54","","Standard inlier is a Case rate ($71,825.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $61,328, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,195.04) for the length of stay and the standard reimbursement.","65628.75","65618.83","71825.54","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,EXTREME","284","DRG","","","","","","","","inpatient","","","110069.05","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12961.9234","","Fee schedule rate ($72,339.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12961.9234","72339.24","72339.24","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,EXTREME","284","DRG","","","","","","","","inpatient","","","110069.05","","MASSHEALTH [3001]","HB BWH MEDICAID","23081.51","","Case rate ($25,520.57). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $67,950.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13756.64","13756.64","25514.30","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,EXTREME","284","DRG","","","","","","","","inpatient","","","110069.05","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","23081.51","","Case rate ($25,520.57). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $67,950.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25514.31","29320.87","29320.87","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","65040.39","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","36810.53","","Standard inlier is a Case rate ($36,810.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,274, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,225.48) for the length of stay and the standard reimbursement.","35941.63","33554.13","36810.52","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","65040.39","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","41384.95","","Standard inlier is a Case rate ($41,384.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,274, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,874.25) for the length of stay and the standard reimbursement.","41384.95","37808.72","41384.95","17","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","65040.39","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12344.3473","","Fee schedule rate ($29,960.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12344.3473","29960.60","29960.60","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","65040.39","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12961.9234","","Fee schedule rate ($31,459.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12961.9234","31459.48","31459.48","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","65040.39","","MASSHEALTH [3001]","HB BWH MEDICAID","12444.94","","Case rate ($13,760.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,190.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13756.64","13756.64","13756.64","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","65040.39","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37413.21","","Fee schedule rate ($37,413.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37413.21","37413.21","37413.21","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","65040.39","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12444.94","","Case rate ($13,760.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,190.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13756.64","13756.64","13756.64","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MINOR","284","DRG","","","","","","","","inpatient","","","27602.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20122.57","","Standard inlier is a Case rate ($20,122.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,295, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,856.52) for the length of stay and the standard reimbursement.","18342.45","18342.45","18342.45","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MINOR","284","DRG","","","","","","","","inpatient","","","27602.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22623.19","","Standard inlier is a Case rate ($22,623.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,295, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,211.17) for the length of stay and the standard reimbursement.","22623.19","22623.19","22623.19","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","45535.59","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","26577.83","","Standard inlier is a Case rate ($26,577.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,315, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,772.88) for the length of stay and the standard reimbursement.","26577.83","24227.91","26577.83","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","45535.59","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","29880.65","","Standard inlier is a Case rate ($29,880.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,315, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,241.31) for the length of stay and the standard reimbursement.","27298.55","27298.55","29880.65","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","45535.59","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12344.3473","","Fee schedule rate ($29,960.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12344.3473","18367.80","20696.20","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","45535.59","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12961.9234","","Fee schedule rate ($31,459.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12961.9234","31459.48","31459.48","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","45535.59","","MASSHEALTH [3001]","HB BWH MEDICAID","8456.94","","Case rate ($9,350.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,780.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9348.30","9348.30","9348.30","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","45535.59","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26615.67","","Fee schedule rate ($26,615.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26615.67","26615.67","26615.67","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","45535.59","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27946.90","","Fee schedule rate ($27,946.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27946.90","27946.90","27946.90","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","45535.59","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8456.94","","Case rate ($9,350.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,780.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9348.30","9348.30","9348.30","1 through 10","6229.32","113674.17","case rate",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","47369.76","35527.32","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","9460.96","","Case rate ($9,185.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,980.01, add-ons for qualifying new technology services are included. If operating cost exceeds $56,624.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,216.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,028.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,600.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.74. The transfer capital threshold is the transfer adjustment factor * $776.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9362.65","9362.65","9362.65","1 through 10","9001.69","14580.9242","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","47369.76","35527.32","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9185.40","","Case rate ($9,185.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,980.01, add-ons for qualifying new technology services are included. If operating cost exceeds $56,624.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,216.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,028.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,600.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.74. The transfer capital threshold is the transfer adjustment factor * $776.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8949.67","8949.67","8949.67","1 through 10","9001.69","14580.9242","other","Inpatient Replacement Plans DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","47369.76","35527.32","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","7725.64","7725.64","7725.64","1 through 10","9001.69","14580.9242","case rate",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","47369.76","35527.32","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","9185.40","","Case rate ($9,185.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,980.01, add-ons for qualifying new technology services are included. If operating cost exceeds $56,624.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,216.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,028.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,600.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.74. The transfer capital threshold is the transfer adjustment factor * $776.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8939.42","8939.42","8939.42","1 through 10","9001.69","14580.9242","other","Inpatient Replacement Plans DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","47369.76","35527.32","MEDICARE [2001]","HB BWH MEDICARE","9185.40","","Case rate ($9,185.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,980.01, add-ons for qualifying new technology services are included. If operating cost exceeds $56,624.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,216.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,028.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,600.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.74. The transfer capital threshold is the transfer adjustment factor * $776.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11668.96","0.03","11685.99","22","9001.69","14580.9242","other","Inpatient Replacement Plans DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","47369.76","35527.32","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","9185.40","","Case rate ($9,185.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,980.01, add-ons for qualifying new technology services are included. If operating cost exceeds $56,624.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,216.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,028.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,600.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.74. The transfer capital threshold is the transfer adjustment factor * $776.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8914.06","8914.06","8914.06","1 through 10","9001.69","14580.9242","other","Inpatient Replacement Plans DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","78480.51","58860.38","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","17253.80","","Case rate ($16,751.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,087.83, add-ons for qualifying new technology services are included. If operating cost exceeds $65,732.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,884.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,927.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,707.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,444.12. The transfer capital threshold is the transfer adjustment factor * $1,444.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17966.97","17966.97","36873.53","1 through 10","16416.23","28112.18","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","78480.51","58860.38","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","16751.26","","Case rate ($16,751.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,087.83, add-ons for qualifying new technology services are included. If operating cost exceeds $65,732.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,884.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,927.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,707.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,444.12. The transfer capital threshold is the transfer adjustment factor * $1,444.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22237.00","22237.00","22237.00","1 through 10","16416.23","28112.18","other","Inpatient Replacement Plans DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","78480.51","58860.38","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","16751.26","","Case rate ($16,751.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,087.83, add-ons for qualifying new technology services are included. If operating cost exceeds $65,732.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,884.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,927.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,707.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,444.12. The transfer capital threshold is the transfer adjustment factor * $1,444.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18864.82","18864.82","18864.82","1 through 10","16416.23","28112.18","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","78480.51","58860.38","FALLON HEALTH [1008]","HB BWH MEDICARE","16751.26","","Case rate ($16,751.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,087.83, add-ons for qualifying new technology services are included. If operating cost exceeds $65,732.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,884.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,927.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,707.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,444.12. The transfer capital threshold is the transfer adjustment factor * $1,444.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7435.22","7435.22","7435.22","1 through 10","16416.23","28112.18","other","Inpatient Replacement Plans DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","78480.51","58860.38","MEDICARE [2001]","HB BWH MEDICARE","16751.26","","Case rate ($16,751.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,087.83, add-ons for qualifying new technology services are included. If operating cost exceeds $65,732.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,884.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,927.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,707.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,444.12. The transfer capital threshold is the transfer adjustment factor * $1,444.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14207.16","0.03","22590.81","16","16416.23","28112.18","other","Inpatient Replacement Plans DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","78480.51","58860.38","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","16751.26","","Case rate ($16,751.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,087.83, add-ons for qualifying new technology services are included. If operating cost exceeds $65,732.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,884.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,927.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,707.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,444.12. The transfer capital threshold is the transfer adjustment factor * $1,444.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17146.37","17146.37","17146.37","1 through 10","16416.23","28112.18","other","Inpatient Replacement Plans DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","78480.51","58860.38","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16416.23","","Case rate ($16,751.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,087.83, add-ons for qualifying new technology services are included. If operating cost exceeds $65,732.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,884.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,927.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,707.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,444.12. The transfer capital threshold is the transfer adjustment factor * $1,444.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17216.81","17216.81","17216.81","1 through 10","16416.23","28112.18","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","78480.51","58860.38","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16416.23","","Case rate ($16,751.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,087.83, add-ons for qualifying new technology services are included. If operating cost exceeds $65,732.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,884.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $14,927.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,707.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,444.12. The transfer capital threshold is the transfer adjustment factor * $1,444.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17125.79","17125.79","17185.96","1 through 10","16416.23","28112.18","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/McC","443","MS-DRG","","","","","","","","inpatient","","","35326.90","26495.17","MEDICARE [2001]","HB BWH MEDICARE","6762.59","","Case rate ($6,762.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,063.40, add-ons for qualifying new technology services are included. If operating cost exceeds $53,707.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,003.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,819.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,683.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.02. The transfer capital threshold is the transfer adjustment factor * $563.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8562.52","728.09","8574.91","1 through 10","6627.34","10604.4457","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","41361.33","31021.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8053.36","","Case rate ($8,053.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,617.25, add-ons for qualifying new technology services are included. If operating cost exceeds $55,261.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,117.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,996.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,237.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.88. The transfer capital threshold is the transfer adjustment factor * $676.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7997.86","7997.86","7997.86","1 through 10","7892.29","12981.2782","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","41361.33","31021.00","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","7172.54","7172.54","7172.54","1 through 10","7892.29","12981.2782","case rate",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","41361.33","31021.00","MEDICARE [2001]","HB BWH MEDICARE","8053.36","","Case rate ($8,053.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,617.25, add-ons for qualifying new technology services are included. If operating cost exceeds $55,261.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,117.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,996.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,237.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.88. The transfer capital threshold is the transfer adjustment factor * $676.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10419.31","440.50","10434.48","12","7892.29","12981.2782","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","41361.33","31021.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7892.29","","Case rate ($8,053.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,617.25, add-ons for qualifying new technology services are included. If operating cost exceeds $55,261.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,117.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,996.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,237.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.88. The transfer capital threshold is the transfer adjustment factor * $676.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7957.69","7957.69","7957.69","1 through 10","7892.29","12981.2782","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","41361.33","31021.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7892.29","","Case rate ($8,053.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,617.25, add-ons for qualifying new technology services are included. If operating cost exceeds $55,261.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,117.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,996.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,237.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $676.88. The transfer capital threshold is the transfer adjustment factor * $676.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11163.29","11163.29","11163.29","1 through 10","7892.29","12981.2782","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","75832.54","56874.40","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15708.21","","Case rate ($15,250.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,281.42, add-ons for qualifying new technology services are included. If operating cost exceeds $63,925.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,751.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,559.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,901.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,311.75. The transfer capital threshold is the transfer adjustment factor * $1,311.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15886.14","15886.14","15886.14","1 through 10","14945.68","25535.45","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","75832.54","56874.40","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","15250.69","","Case rate ($15,250.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,281.42, add-ons for qualifying new technology services are included. If operating cost exceeds $63,925.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,751.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,559.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,901.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,311.75. The transfer capital threshold is the transfer adjustment factor * $1,311.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15200.58","15200.58","15200.58","1 through 10","14945.68","25535.45","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","75832.54","56874.40","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15250.69","","Case rate ($15,250.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,281.42, add-ons for qualifying new technology services are included. If operating cost exceeds $63,925.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,751.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,559.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,901.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,311.75. The transfer capital threshold is the transfer adjustment factor * $1,311.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15964.66","15964.66","15964.66","1 through 10","14945.68","25535.45","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","75832.54","56874.40","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","15250.69","","Case rate ($15,250.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,281.42, add-ons for qualifying new technology services are included. If operating cost exceeds $63,925.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,751.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,559.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,901.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,311.75. The transfer capital threshold is the transfer adjustment factor * $1,311.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15379.17","15379.17","15379.17","1 through 10","14945.68","25535.45","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","75832.54","56874.40","MEDICARE [2001]","HB BWH MEDICARE","15250.69","","Case rate ($15,250.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,281.42, add-ons for qualifying new technology services are included. If operating cost exceeds $63,925.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,751.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,559.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,901.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,311.75. The transfer capital threshold is the transfer adjustment factor * $1,311.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19891.91","0.03","19921.24","15","14945.68","25535.45","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","75832.54","56874.40","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14945.68","","Case rate ($15,250.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,281.42, add-ons for qualifying new technology services are included. If operating cost exceeds $63,925.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,751.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,559.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,901.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,311.75. The transfer capital threshold is the transfer adjustment factor * $1,311.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21585.49","21585.49","54446.80","1 through 10","14945.68","25535.45","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","75832.54","56874.40","WELLSENSE [1003]","HB BWH MEDICARE","15250.69","","Case rate ($15,250.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,281.42, add-ons for qualifying new technology services are included. If operating cost exceeds $63,925.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,751.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,559.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,901.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,311.75. The transfer capital threshold is the transfer adjustment factor * $1,311.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15634.37","15634.37","15634.37","1 through 10","14945.68","25535.45","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy Without Cc/McC","440","MS-DRG","","","","","","","","inpatient","","","33067.20","24800.40","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","6048.32","","Case rate ($6,048.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,203.57, add-ons for qualifying new technology services are included. If operating cost exceeds $52,848.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,940.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,168.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,823.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.01. The transfer capital threshold is the transfer adjustment factor * $500.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5777.66","5777.66","5777.66","1 through 10","5927.35","90718","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy Without Cc/McC","440","MS-DRG","","","","","","","","inpatient","","","33067.20","24800.40","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","7172.54","7172.54","7172.54","1 through 10","5927.35","90718","case rate",""
"Disorders Of Pancreas Except Malignancy Without Cc/McC","440","MS-DRG","","","","","","","","inpatient","","","33067.20","24800.40","MEDICARE [2001]","HB BWH MEDICARE","7736.55","","Case rate ($7,736.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,203.57, add-ons for qualifying new technology services are included. If operating cost exceeds $52,848.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,940.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,856.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,823.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $500.01. The transfer capital threshold is the transfer adjustment factor * $500.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7529.80","7529.80","7529.80","1 through 10","5927.35","90718","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy,EXTREME","282","DRG","","","","","","","","inpatient","","","118414.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","72977.47","","Standard inlier is a Case rate ($72,977.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $68,397, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,359.59) for the length of stay and the standard reimbursement.","72977.46","72977.46","72977.46","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,EXTREME","282","DRG","","","","","","","","inpatient","","","118414.21","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","60364.62","60364.62","60364.62","1 through 10","4591.17","139563.73","percent of total billed charges",""
"Disorders Of Pancreas Except Malignancy,EXTREME","282","DRG","","","","","","","","inpatient","","","118414.21","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","27588.14","","Case rate ($30,503.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $72,933.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $7,044.67 and the sum of the standard inlier and any outlier amount.","123789.20","123789.20","123789.20","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","70757.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","32955.48","","Standard inlier is a Case rate ($32,955.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,276, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,678.23) for the length of stay and the standard reimbursement.","32955.47","32955.47","32955.47","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","70757.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","37050.84","","Standard inlier is a Case rate ($37,050.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,276, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,259.06) for the length of stay and the standard reimbursement.","37050.84","37050.84","68991.12","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","70757.71","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13348.6256","","Fee schedule rate ($32,349.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13348.6256","31102.68","31102.68","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","70757.71","","MASSHEALTH [3001]","HB BWH MEDICAID","10645.71","","Case rate ($11,770.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,200.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11767.77","11767.77","11767.77","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","70757.71","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","10645.71","","Case rate ($11,770.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,200.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3974.15","3974.15","3974.15","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","70757.71","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10645.71","","Case rate ($11,770.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,200.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11767.77","6638.93","11767.77","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MINOR","282","DRG","","","","","","","","inpatient","","","27900.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","16626.51","","Standard inlier is a Case rate ($16,626.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,577, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,360.23) for the length of stay and the standard reimbursement.","16626.50","16626.50","16626.50","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MINOR","282","DRG","","","","","","","","inpatient","","","27900.44","","MASSHEALTH [3001]","HB BWH MEDICAID","4591.17","","Case rate ($5,076.33). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,506.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5075.08","5075.08","5075.08","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MINOR","282","DRG","","","","","","","","inpatient","","","27900.44","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16591.79","","Fee schedule rate ($16,591.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16591.79","16591.79","16591.79","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","36526.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","16626.51","","Standard inlier is a Case rate ($16,626.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,577, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,360.23) for the length of stay and the standard reimbursement.","21649.06","21649.06","21649.06","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","36526.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18692.68","","Standard inlier is a Case rate ($18,692.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,577, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,653.27) for the length of stay and the standard reimbursement.","24339.38","24339.38","24339.38","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","36526.60","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","14016.4448","","Fee schedule rate ($18,382.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14016.4448","18515.55","18515.55","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","36526.60","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13348.6256","","Fee schedule rate ($17,506.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13348.6256","17506.64","28842.24","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","36526.60","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","14016.4448","","Fee schedule rate ($18,382.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14016.4448","18382.48","18382.48","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","36526.60","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4591.17","","Case rate ($5,076.33). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,506.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7172.54","7172.54","7172.54","1 through 10","4591.17","139563.73","case rate",""
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","","","","inpatient","","","55422.16","41566.62","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","18316.65","","Case rate ($18,316.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,972.21, add-ons for qualifying new technology services are included. If operating cost exceeds $67,616.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,022.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $16,354.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,592.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,582.20. The transfer capital threshold is the transfer adjustment factor * $1,582.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16763.50","16763.50","16763.50","1 through 10","17950.32","29673.4333","other","Inpatient Replacement Plans DRG"
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","","","","inpatient","","","55422.16","41566.62","MEDICARE [2001]","HB BWH MEDICARE","18316.65","","Case rate ($18,316.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,972.21, add-ons for qualifying new technology services are included. If operating cost exceeds $67,616.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,022.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.8. The base transfer operating payment is the transfer adjustment factor * $16,354.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,592.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,582.20. The transfer capital threshold is the transfer adjustment factor * $1,582.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22159.99","22159.99","22159.99","1 through 10","17950.32","29673.4333","other","Inpatient Replacement Plans DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","53062.41","39796.81","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10673.96","","Case rate ($10,363.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,397.69, add-ons for qualifying new technology services are included. If operating cost exceeds $58,042.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,320.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,102.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,017.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.62. The transfer capital threshold is the transfer adjustment factor * $880.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10449.31","10449.31","10449.31","1 through 10","10155.81","16366.1895","other","Inpatient DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","53062.41","39796.81","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","10363.07","","Case rate ($10,363.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,397.69, add-ons for qualifying new technology services are included. If operating cost exceeds $58,042.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,320.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,102.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,017.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.62. The transfer capital threshold is the transfer adjustment factor * $880.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10011.94","10011.94","10011.94","1 through 10","10155.81","16366.1895","other","Inpatient Replacement Plans DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","53062.41","39796.81","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","10363.07","","Case rate ($10,363.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,397.69, add-ons for qualifying new technology services are included. If operating cost exceeds $58,042.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,320.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,102.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,017.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.62. The transfer capital threshold is the transfer adjustment factor * $880.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9969.70","9969.70","9969.70","1 through 10","10155.81","16366.1895","other","Inpatient DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","53062.41","39796.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","","65","","43956.23","15425.24","56342.68","1 through 10","10155.81","16366.1895","percent of total billed charges",""
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","53062.41","39796.81","MEDICARE [2001]","HB BWH MEDICARE","10363.07","","Case rate ($10,363.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,397.69, add-ons for qualifying new technology services are included. If operating cost exceeds $58,042.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,320.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,102.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,017.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.62. The transfer capital threshold is the transfer adjustment factor * $880.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13063.62","0.03","13082.75","36","10155.81","16366.1895","other","Inpatient Replacement Plans DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","53062.41","39796.81","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","10155.81","","Case rate ($10,363.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,397.69, add-ons for qualifying new technology services are included. If operating cost exceeds $58,042.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,320.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,102.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,017.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.62. The transfer capital threshold is the transfer adjustment factor * $880.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9991.81","9991.81","9991.81","1 through 10","10155.81","16366.1895","other","Inpatient DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","53062.41","39796.81","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10155.81","","Case rate ($10,363.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,397.69, add-ons for qualifying new technology services are included. If operating cost exceeds $58,042.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,320.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,102.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,017.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $880.62. The transfer capital threshold is the transfer adjustment factor * $880.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9967.15","9956.23","10001.59","1 through 10","10155.81","16366.1895","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","76083.62","57062.71","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","16090.63","","Case rate ($15,621.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,728.35, add-ons for qualifying new technology services are included. If operating cost exceeds $64,372.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,784.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,897.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,348.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,344.50. The transfer capital threshold is the transfer adjustment factor * $1,344.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","16079.88","16050.11","73898.51","1 through 10","15309.53","25419.2804","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","76083.62","57062.71","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","15621.97","","Case rate ($15,621.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,728.35, add-ons for qualifying new technology services are included. If operating cost exceeds $64,372.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,784.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,897.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,348.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,344.50. The transfer capital threshold is the transfer adjustment factor * $1,344.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15686.24","15654.14","20106.56","1 through 10","15309.53","25419.2804","other","Inpatient Replacement Plans DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","76083.62","57062.71","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15621.97","","Case rate ($15,621.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,728.35, add-ons for qualifying new technology services are included. If operating cost exceeds $64,372.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,784.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,897.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,348.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,344.50. The transfer capital threshold is the transfer adjustment factor * $1,344.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15309.27","15309.27","15333.34","1 through 10","15309.53","25419.2804","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","76083.62","57062.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","","65","","41117.82","41117.82","41117.82","1 through 10","15309.53","25419.2804","percent of total billed charges",""
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","76083.62","57062.71","MEDICARE [2001]","HB BWH MEDICARE","15621.97","","Case rate ($15,621.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,728.35, add-ons for qualifying new technology services are included. If operating cost exceeds $64,372.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,784.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,897.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,348.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,344.50. The transfer capital threshold is the transfer adjustment factor * $1,344.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20135.94","0.03","20165.64","34","15309.53","25419.2804","other","Inpatient Replacement Plans DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","76083.62","57062.71","MOLINA [1014]","HB BWH MOLINA","15309.53","","Case rate ($15,621.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,728.35, add-ons for qualifying new technology services are included. If operating cost exceeds $64,372.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,784.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,897.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,348.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,344.50. The transfer capital threshold is the transfer adjustment factor * $1,344.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","32442.23","32442.23","32442.23","1 through 10","15309.53","25419.2804","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","76083.62","57062.71","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","15309.53","","Case rate ($15,621.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,728.35, add-ons for qualifying new technology services are included. If operating cost exceeds $64,372.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,784.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,897.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,348.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,344.50. The transfer capital threshold is the transfer adjustment factor * $1,344.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15330.98","15330.98","15330.98","1 through 10","15309.53","25419.2804","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","76083.62","57062.71","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15309.53","","Case rate ($15,621.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,728.35, add-ons for qualifying new technology services are included. If operating cost exceeds $64,372.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,784.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,897.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,348.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,344.50. The transfer capital threshold is the transfer adjustment factor * $1,344.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17799.62","15311.61","78748.39","1 through 10","15309.53","25419.2804","other","Inpatient DRG"
"Disorders Of The Biliary Tract Without Cc/McC","446","MS-DRG","","","","","","","","inpatient","","","33882.40","25411.80","MEDICARE [2001]","HB BWH MEDICARE","10174.18","","Case rate ($10,174.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,464.60, add-ons for qualifying new technology services are included. If operating cost exceeds $55,109.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,105.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,128.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,084.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $665.69. The transfer capital threshold is the transfer adjustment factor * $665.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9677.79","0.03","9691.83","1 through 10","7768.03","12032.0543","other","Inpatient DRG"
"Disorders Of The Biliary Tract Without Cc/McC","446","MS-DRG","","","","","","","","inpatient","","","33882.40","25411.80","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7768.03","","Case rate ($7,926.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,464.60, add-ons for qualifying new technology services are included. If operating cost exceeds $55,109.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,105.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,881.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,084.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $665.69. The transfer capital threshold is the transfer adjustment factor * $665.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7364.88","7364.88","7364.88","1 through 10","7768.03","12032.0543","other","Inpatient DRG"
"Distal Arthrogryposis Sequencing Panel","PX-31000797","CDM","81479","CPT","0310","RC","","","","both","","","406.00","304.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","322.77","79.5","","0.65","0.65","0.65","1 through 10","125.86","385.7","percent of total billed charges",""
"Distal Arthrogryposis Sequencing Panel","PX-31000797","CDM","81479","CPT","0310","RC","","","","both","","","406.00","304.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","216.40","53.3","","0.79","0.79","0.79","1 through 10","125.86","385.7","percent of total billed charges",""
"Distal Arthrogryposis Sequencing Panel","PX-31000797","CDM","81479","CPT","0310","RC","","","","outpatient","","","406.00","304.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","203.00","50","","1.00","1.00","1.00","1 through 10","156.55","334.95","percent of total billed charges",""
"Distal Arthrogryposis Sequencing Panel","PX-31000797","CDM","81479","CPT","0310","RC","","","","outpatient","","","406.00","304.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","213.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","334.95","percent of total billed charges",""
"Distal Hereditary Motor Neuropathy Nextgen Sequencing (Ngs) Panel","PX-31000742","CDM","81479","CPT","0310","RC","","","","both","","","166.00","124.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","131.97","79.5","","0.65","0.65","0.65","1 through 10","51.46","157.7","percent of total billed charges",""
"Distal Hereditary Motor Neuropathy Nextgen Sequencing (Ngs) Panel","PX-31000742","CDM","81479","CPT","0310","RC","","","","both","","","166.00","124.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","88.48","53.3","","0.79","0.79","0.79","1 through 10","51.46","157.7","percent of total billed charges",""
"Distal Hereditary Motor Neuropathy Nextgen Sequencing (Ngs) Panel","PX-31000742","CDM","81479","CPT","0310","RC","","","","outpatient","","","166.00","124.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","83.00","50","","1.00","1.00","1.00","1 through 10","80.34","156.55","percent of total billed charges",""
"Distal Hereditary Motor Neuropathy Nextgen Sequencing (Ngs) Panel","PX-31000742","CDM","81479","CPT","0310","RC","","","","outpatient","","","166.00","124.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","87.15","52.5","","1.00","0.53","1.00","1 through 10","80.34","156.55","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2309.98","79.5","","800.18","480.96","1887.97","195","900.75","2309.98","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1548.70","53.3","","813.12","216.42","1444.50","81","900.75","2309.98","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","900.75","31","","432.60","432.60","432.60","1 through 10","900.75","2309.98","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1060.55","36.5","","148.37","54.89","631.39","94","900.75","2309.98","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1112.86","38.3","","279.30","91.72","1116.77","266","900.75","2309.98","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1246.52","42.9","","731.00","63.70","731.00","1 through 10","900.75","2309.98","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1246.52","42.9","","384.74","384.74","384.74","1 through 10","900.75","2309.98","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2905.63","2179.22","WELLPOINT [1015]","HB AMC WELLPOINT","2143.77","73.78","","286.63","119.22","1107.45","105","900.75","2309.98","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2905.63","2179.22","AETNA [1001]","HB AMC AETNA HMO","2028.13","69.8","","675.31","184.75","1721.50","286","1518.48","2374.48","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2905.63","2179.22","AETNA [1001]","HB AMC AETNA PPO","2336.13","80.4","","1261.44","103.12","1514.10","21","1518.48","2374.48","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2905.63","2179.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2336.13","80.4","","1365.00","1365.00","1365.00","1 through 10","1518.48","2374.48","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2905.63","2179.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2374.48","81.72","","5157.68","5157.68","5157.68","1 through 10","1518.48","2374.48","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2905.63","2179.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2374.48","81.72","","431.26","71.26","1459.57","88","1518.48","2374.48","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.34","2455.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2602.31","79.5","","800.18","480.96","1887.97","195","1014.74","2602.31","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.34","2455.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1744.69","53.3","","813.12","216.42","1444.50","81","1014.74","2602.31","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.34","2455.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1014.74","31","","432.60","432.60","432.60","1 through 10","1014.74","2602.31","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.34","2455.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1194.77","36.5","","148.37","54.89","631.39","94","1014.74","2602.31","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.34","2455.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1253.69","38.3","","279.30","91.72","1116.77","266","1014.74","2602.31","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.34","2455.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1404.26","42.9","","731.00","63.70","731.00","1 through 10","1014.74","2602.31","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.34","2455.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1404.26","42.9","","384.74","384.74","384.74","1 through 10","1014.74","2602.31","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.34","2455.00","WELLPOINT [1015]","HB AMC WELLPOINT","2415.07","73.78","","286.63","119.22","1107.45","105","1014.74","2602.31","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3273.34","2455.00","AETNA [1001]","HB AMC AETNA HMO","2284.79","69.8","","675.31","184.75","1721.50","286","1710.65","2674.97","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3273.34","2455.00","AETNA [1001]","HB AMC AETNA PPO","2631.77","80.4","","1261.44","103.12","1514.10","21","1710.65","2674.97","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3273.34","2455.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2631.77","80.4","","1365.00","1365.00","1365.00","1 through 10","1710.65","2674.97","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3273.34","2455.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2674.97","81.72","","5157.68","5157.68","5157.68","1 through 10","1710.65","2674.97","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3273.34","2455.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2674.97","81.72","","431.26","71.26","1459.57","88","1710.65","2674.97","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2701.81","79.5","","800.18","480.96","1887.97","195","1053.54","2701.81","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1811.40","53.3","","813.12","216.42","1444.50","81","1053.54","2701.81","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1053.54","31","","432.60","432.60","432.60","1 through 10","1053.54","2701.81","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1240.45","36.5","","148.37","54.89","631.39","94","1053.54","2701.81","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1301.63","38.3","","279.30","91.72","1116.77","266","1053.54","2701.81","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1457.96","42.9","","731.00","63.70","731.00","1 through 10","1053.54","2701.81","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1457.96","42.9","","384.74","384.74","384.74","1 through 10","1053.54","2701.81","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","WELLPOINT [1015]","HB AMC WELLPOINT","2507.41","73.78","","286.63","119.22","1107.45","105","1053.54","2701.81","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3398.50","2548.87","AETNA [1001]","HB AMC AETNA HMO","2372.15","69.8","","675.31","184.75","1721.50","286","1776.06","2777.25","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3398.50","2548.87","AETNA [1001]","HB AMC AETNA PPO","2732.39","80.4","","1261.44","103.12","1514.10","21","1776.06","2777.25","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3398.50","2548.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2732.39","80.4","","1365.00","1365.00","1365.00","1 through 10","1776.06","2777.25","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3398.50","2548.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2777.25","81.72","","5157.68","5157.68","5157.68","1 through 10","1776.06","2777.25","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3398.50","2548.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2777.25","81.72","","431.26","71.26","1459.57","88","1776.06","2777.25","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VARIAX TITANIUM LOCKING POSTERIOR MEDIAL LEFT","SUP-ITM-10100497","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2618.45","52.26","","1113.10","1113.10","1113.10","1 through 10","1553.23","3983.28","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VARIAX TITANIUM LOCKING POSTERIOR MEDIAL LEFT","SUP-ITM-10100497","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3983.28","79.5","","1293.60","1148.53","1603.80","1 through 10","1553.23","3983.28","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VARIAX TITANIUM LOCKING POSTERIOR MEDIAL LEFT","SUP-ITM-10100497","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1828.80","36.5","","1023.42","771.29","2068.67","33","1553.23","3983.28","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VARIAX TITANIUM LOCKING POSTERIOR MEDIAL LEFT","SUP-ITM-10100497","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1918.99","38.3","","850.52","759.78","1211.25","66","1553.23","3983.28","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VARIAX TITANIUM LOCKING POSTERIOR MEDIAL LEFT","SUP-ITM-10100497","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2149.47","42.9","","2548.09","2548.09","2548.09","1 through 10","1553.23","3983.28","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VARIAX TITANIUM LOCKING POSTERIOR MEDIAL LEFT","SUP-ITM-10100497","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2149.47","42.9","","956.46","956.46","956.46","1 through 10","1553.23","3983.28","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VARIAX TITANIUM LOCKING POSTERIOR MEDIAL LEFT","SUP-ITM-10100497","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","WELLPOINT [1015]","HB AMC WELLPOINT","3696.69","73.78","","2344.73","1619.47","2530.35","16","1553.23","3983.28","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VARIAX TITANIUM LOCKING POSTERIOR MEDIAL LEFT","SUP-ITM-10100497","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5010.42","3757.81","AETNA [1001]","HB AMC AETNA HMO","3497.27","69.8","","1523.63","988.41","4330.26","39","2618.45","4094.52","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VARIAX TITANIUM LOCKING POSTERIOR MEDIAL LEFT","SUP-ITM-10100497","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5010.42","3757.81","AETNA [1001]","HB AMC AETNA PPO","4028.38","80.4","","1670.25","1670.25","1670.25","1 through 10","2618.45","4094.52","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VARIAX TITANIUM LOCKING POSTERIOR MEDIAL LEFT","SUP-ITM-10100497","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5010.42","3757.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2618.45","52.26","","1113.10","1113.10","1113.10","1 through 10","2618.45","4094.52","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VARIAX TITANIUM LOCKING POSTERIOR MEDIAL LEFT","SUP-ITM-10100497","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5010.42","3757.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4094.52","81.72","","1738.90","1484.65","2716.94","38","2618.45","4094.52","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM RT WIDE","SUP-ITM-10130530","CDM","C1776","HCPCS","0278","RC","","","","both","","","3531.50","2648.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1845.56","52.26","","1113.10","1113.10","1113.10","1 through 10","1094.77","2807.54","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM RT WIDE","SUP-ITM-10130530","CDM","C1776","HCPCS","0278","RC","","","","both","","","3531.50","2648.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2807.54","79.5","","1293.60","1148.53","1603.80","1 through 10","1094.77","2807.54","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM RT WIDE","SUP-ITM-10130530","CDM","C1776","HCPCS","0278","RC","","","","both","","","3531.50","2648.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1289.00","36.5","","1023.42","771.29","2068.67","33","1094.77","2807.54","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM RT WIDE","SUP-ITM-10130530","CDM","C1776","HCPCS","0278","RC","","","","both","","","3531.50","2648.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1352.56","38.3","","850.52","759.78","1211.25","66","1094.77","2807.54","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM RT WIDE","SUP-ITM-10130530","CDM","C1776","HCPCS","0278","RC","","","","both","","","3531.50","2648.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1515.01","42.9","","2548.09","2548.09","2548.09","1 through 10","1094.77","2807.54","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM RT WIDE","SUP-ITM-10130530","CDM","C1776","HCPCS","0278","RC","","","","both","","","3531.50","2648.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1515.01","42.9","","956.46","956.46","956.46","1 through 10","1094.77","2807.54","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM RT WIDE","SUP-ITM-10130530","CDM","C1776","HCPCS","0278","RC","","","","both","","","3531.50","2648.62","WELLPOINT [1015]","HB AMC WELLPOINT","2605.54","73.78","","2344.73","1619.47","2530.35","16","1094.77","2807.54","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM RT WIDE","SUP-ITM-10130530","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3531.50","2648.62","AETNA [1001]","HB AMC AETNA HMO","2464.99","69.8","","1523.63","988.41","4330.26","39","1845.56","2885.94","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM RT WIDE","SUP-ITM-10130530","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3531.50","2648.62","AETNA [1001]","HB AMC AETNA PPO","2839.33","80.4","","1670.25","1670.25","1670.25","1 through 10","1845.56","2885.94","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM RT WIDE","SUP-ITM-10130530","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3531.50","2648.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1845.56","52.26","","1113.10","1113.10","1113.10","1 through 10","1845.56","2885.94","percent of total billed charges",""
"DISTAL PLATE 4 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM RT WIDE","SUP-ITM-10130530","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3531.50","2648.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2885.94","81.72","","1738.90","1484.65","2716.94","38","1845.56","2885.94","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1808.63","79.5","","800.18","480.96","1887.97","195","705.25","1808.63","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1212.58","53.3","","813.12","216.42","1444.50","81","705.25","1808.63","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","705.25","31","","432.60","432.60","432.60","1 through 10","705.25","1808.63","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","830.38","36.5","","148.37","54.89","631.39","94","705.25","1808.63","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","871.33","38.3","","279.30","91.72","1116.77","266","705.25","1808.63","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","975.98","42.9","","731.00","63.70","731.00","1 through 10","705.25","1808.63","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","975.98","42.9","","384.74","384.74","384.74","1 through 10","705.25","1808.63","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","WELLPOINT [1015]","HB AMC WELLPOINT","1678.50","73.78","","286.63","119.22","1107.45","105","705.25","1808.63","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","AETNA [1001]","HB AMC AETNA HMO","1587.95","69.8","","675.31","184.75","1721.50","286","1188.92","1859.13","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","AETNA [1001]","HB AMC AETNA PPO","1829.10","80.4","","1261.44","103.12","1514.10","21","1188.92","1859.13","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1829.10","80.4","","1365.00","1365.00","1365.00","1 through 10","1188.92","1859.13","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1859.13","81.72","","5157.68","5157.68","5157.68","1 through 10","1188.92","1859.13","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1859.13","81.72","","431.26","71.26","1459.57","88","1188.92","1859.13","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","208.69","79.5","","800.18","480.96","1887.97","195","81.38","208.69","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.91","53.3","","813.12","216.42","1444.50","81","81.38","208.69","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","81.38","31","","432.60","432.60","432.60","1 through 10","81.38","208.69","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.81","36.5","","148.37","54.89","631.39","94","81.38","208.69","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.54","38.3","","279.30","91.72","1116.77","266","81.38","208.69","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.61","42.9","","731.00","63.70","731.00","1 through 10","81.38","208.69","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.61","42.9","","384.74","384.74","384.74","1 through 10","81.38","208.69","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","WELLPOINT [1015]","HB AMC WELLPOINT","193.67","73.78","","286.63","119.22","1107.45","105","81.38","208.69","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","AETNA [1001]","HB AMC AETNA HMO","183.23","69.8","","675.31","184.75","1721.50","286","137.18","214.52","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","AETNA [1001]","HB AMC AETNA PPO","211.05","80.4","","1261.44","103.12","1514.10","21","137.18","214.52","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","211.05","80.4","","1365.00","1365.00","1365.00","1 through 10","137.18","214.52","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","214.52","81.72","","5157.68","5157.68","5157.68","1 through 10","137.18","214.52","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.52","81.72","","431.26","71.26","1459.57","88","137.18","214.52","percent of total billed charges",""
"Diuretic Screen, Urine","PX-30003357","CDM","80377","CPT","0301","RC","","","","both","","","386.00","289.50","WELLPOINT [1015]","HB AMC WELLPOINT","284.79","73.78","","748.00","278.44","748.00","1 through 10","119.66","366.7","percent of total billed charges",""
"Diverticulitis And Diverticulosis,EXTREME","244","DRG","","","","","","","","inpatient","","","43381.96","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","62695.55","","Standard inlier is a Case rate ($62,695.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $55,012, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,899.11) for the length of stay and the standard reimbursement.","62695.55","62695.55","62695.55","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","39951.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21545.57","","Standard inlier is a Case rate ($21,545.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,402, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,058.52) for the length of stay and the standard reimbursement.","32577.08","32577.08","32577.08","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","39951.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24223.03","","Standard inlier is a Case rate ($24,223.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,402, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,438.26) for the length of stay and the standard reimbursement.","36625.42","36625.42","36625.42","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","39951.03","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11966.345","","Fee schedule rate ($26,880.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11966.345","26880.68","26880.68","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","39951.03","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12565.01","","Fee schedule rate ($28,225.47). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12565.01","27136.64","27136.64","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","39951.03","","MASSHEALTH [3001]","HB BWH MEDICAID","6039.69","","Case rate ($6,677.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,107.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","42136.13","42136.13","42136.13","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","39951.03","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22025.41","","Fee schedule rate ($22,025.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31473.83","31473.83","31473.83","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","39951.03","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6039.69","","Case rate ($6,677.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,107.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11070.72","11070.72","11070.72","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","24638.69","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","16490.68","","Standard inlier is a Case rate ($16,490.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,340.95) for the length of stay and the standard reimbursement.","16490.67","15032.72","20102.06","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","24638.69","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18539.96","","Standard inlier is a Case rate ($18,539.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,631.59) for the length of stay and the standard reimbursement.","16937.85","16937.85","18539.96","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","24638.69","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16308.71","","Fee schedule rate ($16,308.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4904.58","4904.58","4904.58","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","24638.69","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17124.41","","Fee schedule rate ($17,124.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17124.41","17124.41","17124.41","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","24638.69","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4320.43","","Case rate ($4,776.98). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,206.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4775.80","4775.80","4775.80","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","23299.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21545.57","","Standard inlier is a Case rate ($21,545.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,402, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,058.52) for the length of stay and the standard reimbursement.","21545.57","21545.57","21545.57","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","23299.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24223.03","","Standard inlier is a Case rate ($24,223.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,402, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,438.26) for the length of stay and the standard reimbursement.","24223.03","24223.03","24223.03","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","23299.21","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12565.01","","Fee schedule rate ($16,815.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12565.01","16815.96","16815.96","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","23299.21","","MASSHEALTH [3001]","HB BWH MEDICAID","6039.69","","Case rate ($6,677.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,107.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6676.28","902.95","6676.28","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","23299.21","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20976.25","","Fee schedule rate ($20,976.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20976.25","20976.25","20976.25","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","23299.21","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22025.41","","Fee schedule rate ($22,025.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22025.41","22025.41","22025.41","1 through 10","4320.43","98343.42","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","23299.21","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6039.69","","Case rate ($6,677.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,107.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6676.28","6676.28","6676.28","1 through 10","4320.43","98343.42","case rate",""
"Dmpk Gene Analysis Eval Detect Abnormal Alleles","PX-31000973","CDM","81234","CPT","0310","RC","","","","outpatient","","","1628.00","1221.00","AETNA [1001]","HB AMC AETNA PPO","1308.91","80.4","","827.40","827.40","827.40","1 through 10","246.6","1330.4","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","229.00","171.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","164.42","71.8","","159.40","159.40","159.40","1 through 10","13.47","217.55","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","229.00","171.75","CHAMPVA [160001]","HB BWH TRICARE","217.55","95","","16.56","16.56","16.56","1 through 10","13.47","217.55","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","229.00","171.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","182.06","79.5","","174.71","117.22","174.71","82","13.47","217.55","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","229.00","171.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","122.06","53.3","","117.22","117.22","351.66","56","13.47","217.55","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","229.00","171.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","176.33","77","","512.82","170.94","512.82","1 through 10","13.47","217.55","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","229.00","171.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.59","36.5","","82.81","70.37","82.81","91","13.47","217.55","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","229.00","171.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.71","38.3","","86.80","84.36","253.08","243","13.47","217.55","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","229.00","171.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","176.33","77","","174.71","13.47","346.32","1 through 10","13.47","217.55","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","229.00","171.75","TRICARE [160005]","HB BWH TRICARE","217.55","95","","15.73","15.73","16.56","1 through 10","13.47","217.55","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","229.00","171.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.24","42.9","","177.47","177.47","177.47","1 through 10","13.47","217.55","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","229.00","171.75","AETNA [1001]","HB AMC AETNA HMO","159.84","69.8","","150.29","106.12","173.16","117","14.16","187.14","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","229.00","171.75","AETNA [1001]","HB AMC AETNA PPO","184.12","80.4","","173.16","116.33","173.16","16","14.16","187.14","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","229.00","171.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","128.01","55.9","","116.33","116.33","116.33","1 through 10","14.16","187.14","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","229.00","171.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","184.12","80.4","","173.16","111.00","173.16","1 through 10","14.16","187.14","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","229.00","171.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","187.14","81.72","","97.61","97.61","97.61","1 through 10","14.16","187.14","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","229.00","171.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","187.14","81.72","","177.47","97.61","177.47","114","14.16","187.14","percent of total billed charges",""
"Donor Apheresis C19 Clin Trial","PX-76002753","CDM","38999","CPT","0761","RC","","","","outpatient","","","2553.00","1914.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1333.18","52.22","","512.50","512.50","512.50","1 through 10","1234.13","2106.23","percent of total billed charges",""
"Donor Apheresis C19 Clin Trial","PX-76002753","CDM","38999","CPT","0761","RC","","","","outpatient","","","2553.00","1914.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1276.50","50","","6776.11","6776.11","6776.11","1 through 10","1234.13","2106.23","percent of total billed charges",""
"Dopamine Metabolism Deficiency","PX-31000935","CDM","81479","CPT","0310","RC","","","","both","","","2913.00","2184.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2315.84","79.5","","0.65","0.65","0.65","1 through 10","903.03","2767.35","percent of total billed charges",""
"Dopamine Metabolism Deficiency","PX-31000935","CDM","81479","CPT","0310","RC","","","","both","","","2913.00","2184.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1552.63","53.3","","0.79","0.79","0.79","1 through 10","903.03","2767.35","percent of total billed charges",""
"Dopamine Metabolism Deficiency","PX-31000935","CDM","81479","CPT","0310","RC","","","","outpatient","","","2913.00","2184.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1456.50","50","","1.00","1.00","1.00","1 through 10","156.55","2403.23","percent of total billed charges",""
"Dopamine Metabolism Deficiency","PX-31000935","CDM","81479","CPT","0310","RC","","","","outpatient","","","2913.00","2184.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1529.33","52.5","","1.00","0.53","1.00","1 through 10","156.55","2403.23","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","182.84","182.84","21","176.52","1538.33","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1269.36","65.6","","896.73","896.73","896.73","1 through 10","176.52","1538.33","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1538.33","79.5","","1476.41","990.53","1476.41","1 through 10","176.52","1538.33","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1031.36","53.3","","990.53","990.53","990.53","1 through 10","176.52","1538.33","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","182.84","182.84","1 through 10","176.52","1538.33","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","ELDER SERVICES [1037]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","167.07","167.07","167.07","1 through 10","176.52","1538.33","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","HUMANA [1012]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.21","182.24","185.81","1 through 10","176.52","1538.33","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1257.75","65","","1219.40","1219.40","1219.40","1 through 10","176.52","1538.33","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","176","176.52","1538.33","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","706.28","36.5","","699.75","594.69","699.75","1 through 10","176.52","1538.33","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","741.11","38.3","","733.52","733.52","733.52","1 through 10","176.52","1538.33","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.49","182.09","182.49","1 through 10","176.52","1538.33","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","TRICARE [160005]","HB BWH TRICARE","176.52","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","185.81","185.81","185.81","1 through 10","176.52","1538.33","other","Tricare OPPS"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.84","167.07","548.52","15","176.52","1538.33","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1935.00","1451.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.84","170.48","185.81","60","176.52","1538.33","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","outpatient","","","1935.00","1451.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1581.28","81.72","","1499.67","824.88","1499.67","1 through 10","312.34","1581.28","percent of total billed charges",""
"Doppler Arterial Extrem Ltd Bilat","PX-92000030","CDM","93922","CPT","0921","RC","","","","both","","","1617.00","1212.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1060.75","65.6","","749.50","749.50","749.50","1 through 10","145.42","1285.52","percent of total billed charges",""
"Doppler Arterial Extrem Ltd Bilat","PX-92000030","CDM","93922","CPT","0921","RC","","","","both","","","1617.00","1212.75","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","145.42","1285.52","other","OPPS APC"
"Doppler Arterial Extrem Ltd Bilat","PX-92000030","CDM","93922","CPT","0921","RC","","","","both","","","1617.00","1212.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","153.08","153.08","153.08","1 through 10","145.42","1285.52","other","OPPS APC"
"Doppler Arterial Extrem Ltd Bilat|REDUCED SERVICES","PX-92000030","CDM","93922","CPT","0921","RC","","","52","both","","","1617.00","1212.75","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","145.42","718.76","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","2405.00","1803.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1281.87","53.3","","1231.30","1231.30","1231.30","1 through 10","176.52","1911.98","percent of total billed charges",""
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","2405.00","1803.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","170.48","185.81","17","176.52","1911.98","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","2405.00","1803.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","921.12","38.3","","911.81","911.81","911.81","1 through 10","176.52","1911.98","percent of total billed charges",""
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","2405.00","1803.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.49","182.49","182.49","1 through 10","176.52","1911.98","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","2405.00","1803.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.09","170.48","185.81","1 through 10","176.52","1911.98","other","OPPS APC"
"DOPPLER FLOWCOUPLER 2.5MM DEVICE CLOSURE VASCULAR COUPLER ANASTAMOSIS","SUP-ITM-10094037","CDM","C1889","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3052.40","79.5","","1309.77","674.56","6049.93","26","1190.25","3052.4","percent of total billed charges",""
"DOPPLER FLOWCOUPLER 2.5MM DEVICE CLOSURE VASCULAR COUPLER ANASTAMOSIS","SUP-ITM-10094037","CDM","C1889","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2046.45","53.3","","1901.83","1901.83","2962.25","1 through 10","1190.25","3052.4","percent of total billed charges",""
"DOPPLER FLOWCOUPLER 2.5MM DEVICE CLOSURE VASCULAR COUPLER ANASTAMOSIS","SUP-ITM-10094037","CDM","C1889","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1401.42","36.5","","1620.31","1620.31","19908.88","1 through 10","1190.25","3052.4","percent of total billed charges",""
"DOPPLER FLOWCOUPLER 2.5MM DEVICE CLOSURE VASCULAR COUPLER ANASTAMOSIS","SUP-ITM-10094037","CDM","C1889","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1470.53","38.3","","352.91","352.91","2046.30","1 through 10","1190.25","3052.4","percent of total billed charges",""
"DOPPLER FLOWCOUPLER 2.5MM DEVICE CLOSURE VASCULAR COUPLER ANASTAMOSIS","SUP-ITM-10094037","CDM","C1889","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1647.15","42.9","","9668.75","9668.75","9668.75","1 through 10","1190.25","3052.4","percent of total billed charges",""
"DOPPLER FLOWCOUPLER 2.5MM DEVICE CLOSURE VASCULAR COUPLER ANASTAMOSIS","SUP-ITM-10094037","CDM","C1889","HCPCS","0278","RC","","","","both","","","3839.50","2879.62","WELLPOINT [1015]","HB AMC WELLPOINT","2832.78","73.78","","699.88","384.10","3443.31","33","1190.25","3052.4","percent of total billed charges",""
"DOPPLER FLOWCOUPLER 2.5MM DEVICE CLOSURE VASCULAR COUPLER ANASTAMOSIS","SUP-ITM-10094037","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3839.50","2879.62","AETNA [1001]","HB AMC AETNA HMO","2679.97","69.8","","1421.24","264.50","4933.46","29","2006.52","3137.64","percent of total billed charges",""
"DOPPLER FLOWCOUPLER 2.5MM DEVICE CLOSURE VASCULAR COUPLER ANASTAMOSIS","SUP-ITM-10094037","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3839.50","2879.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3086.96","80.4","","1022.97","1022.97","3607.50","1 through 10","2006.52","3137.64","percent of total billed charges",""
"DOPPLER FLOWCOUPLER 2.5MM DEVICE CLOSURE VASCULAR COUPLER ANASTAMOSIS","SUP-ITM-10094037","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3839.50","2879.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3137.64","81.72","","3010.54","693.88","5019.88","35","2006.52","3137.64","percent of total billed charges",""
"Doppler Intracranial Emboli W/O","PX-92000028","CDM","93892","CPT","0921","RC","","","","both","","","2756.00","2067.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","2191.02","other","OPPS APC"
"Doppler Intracranial Emboli W/O","PX-92000028","CDM","93892","CPT","0921","RC","","","","both","","","2756.00","2067.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2191.02","79.5","","2103.65","2103.65","2103.65","1 through 10","119.97","2191.02","percent of total billed charges",""
"Doppler Intracranial Emboli W/O","PX-92000028","CDM","93892","CPT","0921","RC","","","","both","","","2756.00","2067.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","2122.12","77","","2058.21","2058.21","2058.21","1 through 10","119.97","2191.02","percent of total billed charges",""
"Doppler Intracranial Emboli W/O","PX-92000028","CDM","93892","CPT","0921","RC","","","","both","","","2756.00","2067.00","MEDICARE [2001]","HB BWH MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","2191.02","other","OPPS APC"
"Doppler Intracranial Emboli W/O","PX-92000028","CDM","93892","CPT","0921","RC","","","","both","","","2756.00","2067.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","2191.02","other","OPPS APC"
"Doppler Intracranial Vasoreactivity","PX-92000027","CDM","93888","CPT","0921","RC","","","","both","","","2531.00","1898.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","2012.15","other","OPPS APC"
"Doppler Intracranial Vasoreactivity","PX-92000027","CDM","93888","CPT","0921","RC","","","","both","","","2531.00","1898.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","923.82","36.5","","728.84","728.84","728.84","1 through 10","119.97","2012.15","percent of total billed charges",""
"Doppler Intracranial Vasoreactivity","PX-92000027","CDM","93888","CPT","0921","RC","","","","both","","","2531.00","1898.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.37","38.3","","764.01","764.01","764.01","1 through 10","119.97","2012.15","percent of total billed charges",""
"Doppler Intracranial Vasoreactivity","PX-92000027","CDM","93888","CPT","0921","RC","","","","both","","","2531.00","1898.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","2012.15","other","OPPS APC"
"Doppler Probe US Rectum","PX-75000447","CDM","45999","CPT","0750","RC","","","","outpatient","","","603.00","452.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","314.89","52.22","","1324.00","1324.00","1324.00","1 through 10","301.5","1234.13","percent of total billed charges",""
"Doppler Probe US Rectum","PX-75000447","CDM","45999","CPT","0750","RC","","","","outpatient","","","603.00","452.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","301.50","50","","1324.00","1324.00","1324.00","1 through 10","301.5","1234.13","percent of total billed charges",""
"Doppler Probe US Rectum","PX-75000447","CDM","45999","CPT","0750","RC","","","","outpatient","","","603.00","452.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","316.58","52.5","","728.20","728.20","728.20","1 through 10","301.5","1234.13","percent of total billed charges",""
"Doppler Transcranial Cmpl","PX-92000025","CDM","93886","CPT","0921","RC","","","","both","","","2887.00","2165.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","2295.17","other","OPPS APC"
"Doppler Transcranial Cmpl","PX-92000025","CDM","93886","CPT","0921","RC","","","","both","","","2887.00","2165.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2295.17","79.5","","2397.46","2203.60","2397.46","1 through 10","272.7","2295.17","percent of total billed charges",""
"Doppler Transcranial Cmpl","PX-92000025","CDM","93886","CPT","0921","RC","","","","both","","","2887.00","2165.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1538.77","53.3","","1478.40","1478.40","1478.40","1 through 10","272.7","2295.17","percent of total billed charges",""
"Doppler Transcranial Cmpl","PX-92000025","CDM","93886","CPT","0921","RC","","","","both","","","2887.00","2165.25","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","2295.17","other","OPPS APC"
"Doppler Transcranial Cmpl","PX-92000025","CDM","93886","CPT","0921","RC","","","","both","","","2887.00","2165.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","286.32","286.32","287.06","1 through 10","272.7","2295.17","other","OPPS APC"
"Doppler Transcranial Ltd","PX-92000026","CDM","93888","CPT","0921","RC","","","","both","","","2015.00","1511.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","1601.93","other","OPPS APC"
"Doppler Transcranial Ltd","PX-92000026","CDM","93888","CPT","0921","RC","","","","both","","","2015.00","1511.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","735.48","36.5","","728.84","728.84","728.84","1 through 10","119.97","1601.93","percent of total billed charges",""
"Doppler Transcranial Ltd","PX-92000026","CDM","93888","CPT","0921","RC","","","","both","","","2015.00","1511.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","771.75","38.3","","764.01","764.01","764.01","1 through 10","119.97","1601.93","percent of total billed charges",""
"Doppler Transcranial Ltd","PX-92000026","CDM","93888","CPT","0921","RC","","","","both","","","2015.00","1511.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","1601.93","other","OPPS APC"
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,EXTREME","304","DRG","","","","","","","","inpatient","","","372273.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","220216.34","","Standard inlier is a Case rate ($220,216.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $182,896, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($31,261.04) for the length of stay and the standard reimbursement.","200735.21","200735.21","200735.21","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,EXTREME","304","DRG","","","","","","","","inpatient","","","372273.32","","MASSHEALTH [3001]","HB BWH MEDICAID","68262.08","","Case rate ($75,475.46). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $117,905.46, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","75456.94","75456.94","75456.94","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,EXTREME","304","DRG","","","","","","","","inpatient","","","372273.32","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","68262.08","","Case rate ($75,475.46). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $117,905.46, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","32671.80","32671.80","32671.80","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,EXTREME","304","DRG","","","","","","","","inpatient","","","372273.32","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","68262.08","","Case rate ($75,475.46). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $117,905.46, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","75456.94","75456.94","75456.94","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","196435.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","105509.28","","Standard inlier is a Case rate ($105,509.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $93,696, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,977.68) for the length of stay and the standard reimbursement.","148823.57","135658.11","148823.57","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","196435.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","118620.86","","Standard inlier is a Case rate ($118,620.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $93,696, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,837.25) for the length of stay and the standard reimbursement.","167317.81","152859.27","167321.47","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","196435.19","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","75361.8768","","Fee schedule rate ($128,992.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","75361.8768","135132.55","135132.55","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","196435.19","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","71771.2296","","Fee schedule rate ($122,846.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","71771.2296","122846.28","122846.28","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","196435.19","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","75361.8768","","Fee schedule rate ($128,992.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","75361.8768","128992.16","128992.16","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","196435.19","","MASSHEALTH [3001]","HB BWH MEDICAID","34775.91","","Case rate ($38,450.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,880.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","50634.64","50634.64","50634.64","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","196435.19","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","34775.91","","Case rate ($38,450.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,880.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29404.62","29404.62","29404.62","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","196435.19","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","109387.22","","Fee schedule rate ($109,387.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","109387.22","109387.22","112967.74","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","196435.19","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","114856.94","","Fee schedule rate ($114,856.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","114856.94","114856.94","114856.94","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MAJOR","304","DRG","","","","","","","","inpatient","","","196435.19","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","34775.91","","Case rate ($38,450.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,880.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","50634.63","50634.63","75705.91","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","116120.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","88814.85","","Standard inlier is a Case rate ($88,814.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $80,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,607.80) for the length of stay and the standard reimbursement.","88814.85","80957.97","88814.85","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","116120.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","99851.83","","Standard inlier is a Case rate ($99,851.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $80,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,173.14) for the length of stay and the standard reimbursement.","91228.08","91223.27","99851.83","15","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","116120.55","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","71771.2296","","Fee schedule rate ($71,771.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","71771.2296","71771.24","82159.84","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","116120.55","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","75361.8768","","Fee schedule rate ($75,361.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","75361.8768","75361.88","75361.88","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","116120.55","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","78949.32","","Fee schedule rate ($78,949.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","75907.37","75907.37","75907.37","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","116120.55","","MASSHEALTH [3001]","HB BWH MEDICAID","28137.62","","Case rate ($31,110.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $73,540.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31103.34","31103.34","38441.30","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","116120.55","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63842.06","","Fee schedule rate ($63,842.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","63842.06","63842.06","63842.06","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","116120.55","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67034.37","","Fee schedule rate ($67,034.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","67034.37","67034.37","67034.37","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","116120.55","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","28137.62","","Case rate ($31,110.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $73,540.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31103.34","31103.34","31103.34","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","142102.83","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","105509.28","","Standard inlier is a Case rate ($105,509.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $93,696, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,977.68) for the length of stay and the standard reimbursement.","96175.55","96175.55","105509.27","12","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","142102.83","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","118620.86","","Standard inlier is a Case rate ($118,620.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $93,696, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,837.25) for the length of stay and the standard reimbursement.","108385.09","108385.09","108385.09","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","142102.83","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","118620.86","","Standard inlier is a Case rate ($118,620.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $93,696, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,837.25) for the length of stay and the standard reimbursement.","108370.40","108370.40","118620.86","30","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","142102.83","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","71771.2296","","Fee schedule rate ($85,453.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","71771.2296","85453.12","85453.12","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","142102.83","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","75361.8768","","Fee schedule rate ($89,728.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","75361.8768","89728.28","89728.28","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","142102.83","","MASSHEALTH [3001]","HB BWH MEDICAID","34775.91","","Case rate ($38,450.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,880.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","38441.30","38441.30","38441.30","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","142102.83","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76384.44","","Fee schedule rate ($76,384.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","76384.44","76384.44","76384.44","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","142102.83","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","34775.91","","Case rate ($38,450.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,880.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","38441.31","38441.31","38441.31","1 through 10","28137.62","382777.96","case rate",""
"Dorsal And Lumbar Fusion Procedure For Curvature Of Back,MAJOR","303","DRG","","","","","","","","inpatient","","","452597.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","244233.76","","Standard inlier is a Case rate ($244,233.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $180,580, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($34,666.95) for the length of stay and the standard reimbursement.","244233.75","244233.75","244233.75","1 through 10","42673.08","255300.95","case rate",""
"Dorsal And Lumbar Fusion Procedure For Curvature Of Back,MODERATE","303","DRG","","","","","","","","inpatient","","","306130.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","177447.71","","Standard inlier is a Case rate ($177,447.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $134,385, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($25,187.23) for the length of stay and the standard reimbursement.","177447.70","177447.70","177447.70","1 through 10","42673.08","255300.95","case rate",""
"Dorsal And Lumbar Fusion Procedure For Curvature Of Back,MODERATE","303","DRG","","","","","","","","inpatient","","","306130.09","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","101128.3674","","Fee schedule rate ($116,786.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","101128.3674","116786.48","116786.48","1 through 10","42673.08","255300.95","case rate",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.15","155.15","157.67","493","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","862.64","65.6","","863.18","609.45","863.18","1 through 10","149.79","1045.43","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","854.75","65","","1003.43","1003.43","1003.43","13","149.79","1045.43","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","920.50","70","","1020.00","548.25","1275.00","52","149.79","1045.43","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICAID REPLACEMENT","197.07","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","149.79","149.79","149.79","1 through 10","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1045.43","79.5","","1003.43","673.20","1003.43","170","149.79","1045.43","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","700.90","53.3","","673.20","673.20","1003.43","119","149.79","1045.43","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.15","145.72","155.15","84","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","ELDER SERVICES [1037]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1480.90","1480.90","1480.90","1 through 10","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","FALLON HEALTH [1008]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","473.02","154.52","473.02","41","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","371.47","155.46","371.47","29","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1012.55","77","","953.26","953.26","981.75","13","149.79","1045.43","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","154.52","154.52","155.15","19","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","HUMANA [1012]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.15","145.72","156.09","42","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1045.43","79.5","","1738.15","1738.15","1738.15","1 through 10","149.79","1045.43","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","946.80","72","","3672.00","3672.00","3672.00","1 through 10","149.79","1045.43","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.46","154.52","155.46","30","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","MEDICARE [2001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","157.67","148.09","157.67","5223","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","407.65","31","","393.98","393.98","393.98","1 through 10","149.79","1045.43","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","479.98","36.5","","475.58","461.55","475.58","100","149.79","1045.43","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","503.65","38.3","","498.53","484.50","498.53","196","149.79","1045.43","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","154.64","145.53","154.92","34","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","MOLINA [1014]","HB BWH MOLINA","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","312.82","293.81","312.82","52","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1012.55","77","","1003.43","140.25","1003.43","1 through 10","149.79","1045.43","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","TRICARE [160005]","HB BWH TRICARE","149.79","","APC Price ($157.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","149.79","149.79","157.67","17","149.79","1045.43","other","Tricare OPPS"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","149.79","","APC Price ($157.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","157.67","157.67","157.67","1 through 10","149.79","1045.43","other","Tricare OPPS"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","154.52","154.52","463.55","430","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","293.25","293.25","293.25","1 through 10","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","564.14","42.9","","560.62","560.62","560.62","1 through 10","149.79","1045.43","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","154.52","145.15","155.15","824","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","1315.00","986.25","WELLSENSE [1003]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.74","159.25","477.74","1 through 10","149.79","1045.43","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","outpatient","","","1315.00","986.25","AETNA [1001]","HB AMC AETNA HMO","917.87","69.8","","5179.05","1218.90","8631.75","11","336.65","1074.62","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","outpatient","","","1315.00","986.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","687.22","52.26","","788.97","610.75","788.97","1 through 10","336.65","1074.62","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","outpatient","","","1315.00","986.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1057.26","80.4","","994.50","994.50","994.50","1 through 10","336.65","1074.62","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","outpatient","","","1315.00","986.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1074.62","81.72","","2564.38","2564.38","2564.38","1 through 10","336.65","1074.62","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","outpatient","","","1315.00","986.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1074.62","81.72","","1019.24","560.62","4158.73","159","336.65","1074.62","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","both","","","1939.21","1454.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1541.67","79.5","","1309.77","674.56","6049.93","26","601.16","1541.67","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","both","","","1939.21","1454.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1033.60","53.3","","1901.83","1901.83","2962.25","1 through 10","601.16","1541.67","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","both","","","1939.21","1454.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","707.81","36.5","","1620.31","1620.31","19908.88","1 through 10","601.16","1541.67","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","both","","","1939.21","1454.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","742.72","38.3","","352.91","352.91","2046.30","1 through 10","601.16","1541.67","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","both","","","1939.21","1454.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","831.92","42.9","","9668.75","9668.75","9668.75","1 through 10","601.16","1541.67","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","both","","","1939.21","1454.41","WELLPOINT [1015]","HB AMC WELLPOINT","1430.75","73.78","","699.88","384.10","3443.31","33","601.16","1541.67","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1939.21","1454.41","AETNA [1001]","HB AMC AETNA HMO","1353.57","69.8","","1421.24","264.50","4933.46","29","1013.43","1584.72","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1939.21","1454.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1559.12","80.4","","1022.97","1022.97","3607.50","1 through 10","1013.43","1584.72","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1939.21","1454.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1584.72","81.72","","3010.54","693.88","5019.88","35","1013.43","1584.72","percent of total billed charges",""
"Doxorubicin (Lyoph) IV","PX-25500040","CDM","J9000","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","6.07","6.07","6.07","1 through 10","0.31","6.58","percent of total billed charges",""
"Dpyd Gene Analysis Common Variants","PX-31000896","CDM","81232","CPT","0310","RC","","","","both","","","2078.00","1558.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1652.01","79.5","","1063.92","1063.92","1063.92","1 through 10","171.31","1974.1","percent of total billed charges",""
"Drain Abscess Finger Simple","PX-76000477","CDM","26010","CPT","0761","RC","","","","outpatient","","","899.00","674.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","472.37","472.37","472.37","1 through 10","176.45","734.66","other","ASC "
"Drain Abscess Scrotal Wall","PX-76001319","CDM","55100","CPT","0761","RC","","","","both","","","2943.00","2207.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1074.20","36.5","","904.72","904.72","904.72","1 through 10","912.33","2339.69","percent of total billed charges",""
"Drain Abscess/Cyst Dentoalveolar","PX-75000039","CDM","41800","CPT","0761","RC","","","","both","","","704.00","528.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","256.96","36.5","","741.75","741.75","741.75","1 through 10","218.24","559.68","percent of total billed charges",""
"Drain Abscess/Cyst Dentoalveolar","PX-75000039","CDM","41800","CPT","0761","RC","","","","outpatient","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","575.31","81.72","","300.32","300.32","300.32","1 through 10","281.6","575.31","percent of total billed charges",""
"Drain Abscess/Hematoma Ear Ext Smp","PX-76001660","CDM","69000","CPT","0761","RC","","","","both","","","826.00","619.50","MEDICARE [2001]","HB BWH MEDICARE","735.08","","APC Price ($735.08). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","256.06","918.85","other","OPPS APC"
"Drain Cyst Ovarian Vag Appr","PX-76001402","CDM","58800","CPT","0761","RC","","","","both","","","4886.00","3664.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1871.34","38.3","","5301.81","1852.56","5301.81","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Drain Cyst Ovarian Vag Appr","PX-76001402","CDM","58800","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5524.71","5524.71","5524.71","1 through 10","2125.14","8899.59","other","ASC"
"Drain Cyst Ovarian Vag Appr","PX-76001402","CDM","58800","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6321.29","6321.29","6321.29","1 through 10","2125.14","8899.59","other","ASC "
"Drainage Catheter Manipulation","PX-76002763","CDM","49999","CPT","0761","RC","","","","both","","","932.00","699.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","288.92","1391.62","other","OPPS APC"
"Drainage Catheter Manipulation","PX-76002763","CDM","49999","CPT","0761","RC","","","","both","","","932.00","699.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","288.92","1391.62","other","OPPS APC"
"Drainage Catheter Manipulation","PX-76002763","CDM","49999","CPT","0761","RC","","","","both","","","932.00","699.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","288.92","1391.62","other","OPPS APC"
"Drainage Catheter Manipulation","PX-76002763","CDM","49999","CPT","0761","RC","","","","outpatient","","","932.00","699.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","466.00","50","","14640.00","14640.00","14640.00","1 through 10","466","8899.59","percent of total billed charges",""
"Drainage External Ear Abscess/Hematoma Simple","PX-98301178","CDM","69000","CPT","0983","RC","","","","both","","","574.00","430.50","MEDICARE [2001]","HB BWH MEDICARE","735.08","","APC Price ($735.08). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","177.94","918.85","other","OPPS APC"
"Dress/Debride Burn <5% Total Sm","PX-76000205","CDM","16020","CPT","0761","RC","","","","both","","","524.00","393.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","60.60","60.60","60.60","1 through 10","162.44","416.58","other","OPPS APC"
"Dress/Debride Burn <5% Total Sm","PX-76000205","CDM","16020","CPT","0761","RC","","","","both","","","524.00","393.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","203.44","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","59.39","59.39","59.39","1 through 10","162.44","416.58","other","OPPS APC"
"Dressing Change W/Anes","PX-76000203","CDM","15852","CPT","0761","RC","","","","both","","","350.00","262.50","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","726.94","726.94","1 through 10","108.5","908.58","other","OPPS APC"
"Dressing Change W/Anes","PX-76000203","CDM","15852","CPT","0761","RC","","","","outpatient","","","350.00","262.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1292.72","646.36","1292.72","1 through 10","182.91","1849.47","other","ASC "
"Dressing Kit Daily Driveline","PX-27001961","CDM","Q0508","HCPCS","0272","RC","","","","both","","","63.00","47.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","40.95","65","","1092.00","1092.00","1092.00","1 through 10","19.53","59.85","percent of total billed charges",""
"Dressing Kit Daily Driveline","PX-27001961","CDM","Q0508","HCPCS","0272","RC","","","","both","","","63.00","47.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","44.10","70","","51.84","51.84","51.84","21","19.53","59.85","percent of total billed charges",""
"Dressing Kit Daily Driveline","PX-27001961","CDM","Q0508","HCPCS","0272","RC","","","","outpatient","","","63.00","47.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","38.15","60.55","","48.41","48.41","48.41","1 through 10","25.2","51.48","percent of total billed charges",""
"Dressing Kit Daily Driveline","PX-27001961","CDM","Q0508","HCPCS","0272","RC","","","","outpatient","","","63.00","47.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32.90","52.22","","43.55","43.55","43.55","24","25.2","51.48","percent of total billed charges",""
"Dressing Kit Weekly Driveline","PX-27001221","CDM","Q0508","HCPCS","0274","RC","","","","both","","","72.00","54.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","46.80","65","","1092.00","1092.00","1092.00","1 through 10","22.32","68.4","percent of total billed charges",""
"Dressing Kit Weekly Driveline","PX-27001221","CDM","Q0508","HCPCS","0274","RC","","","","both","","","72.00","54.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","50.40","70","","51.84","51.84","51.84","21","22.32","68.4","percent of total billed charges",""
"Dressing Kit Weekly Driveline","PX-27001221","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","72.00","54.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","43.60","60.55","","48.41","48.41","48.41","1 through 10","28.8","59.4","percent of total billed charges",""
"Dressing Kit Weekly Driveline","PX-27001221","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","72.00","54.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","37.60","52.22","","43.55","43.55","43.55","24","28.8","59.4","percent of total billed charges",""
"Dressing Kit Weekly Driveline","PX-27001221","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","72.00","54.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","36.00","50","","37.73","37.73","188.64","1 through 10","28.8","59.4","percent of total billed charges",""
"DRESSING WET 2.0 XIN L2 XW BOVINE COLLAGEN GLYCOSAMINOGLYCAN MESHED 2 LAYER MATRIX SYNTHETIC","SUP-ITM-10087757","CDM","Q4104","HCPCS","0636","RC","","","","outpatient","","","6457.25","4842.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4513.62","69.9","","137.95","137.95","137.95","26","115.58","5191.63","percent of total billed charges",""
"DRESSING WOUND 2.0 XIN SKIN REPLACEMENT BILAYER MATRIX","SUP-ITM-10033430","CDM","Q4104","HCPCS","0636","RC","","","","outpatient","","","5279.05","3959.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3690.06","69.9","","137.95","137.95","137.95","26","115.58","4244.36","percent of total billed charges",""
"DRESSING WOUND 4.0X10IN BILAYER MATRIX CROSS LINKED BOVINE TENDON COLLAGEN SILICONE","SUP-ITM-10033432","CDM","Q4104","HCPCS","0636","RC","","","","outpatient","","","14971.60","11228.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10465.15","69.9","","137.95","137.95","137.95","26","115.58","12037.17","percent of total billed charges",""
"DRESSING WOUND 4.0X5.0IN BILAYER MATRIX CROSS LINKED BOVINE TENDON COLLAGEN SILICONE","SUP-ITM-10033431","CDM","Q4104","HCPCS","0636","RC","","","","outpatient","","","9206.73","6905.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6435.50","69.9","","137.95","137.95","137.95","26","115.58","7402.21","percent of total billed charges",""
"DRESSING WOUND 8X10IN COLLAGEN GAG BILAYER MATRIX SHEET","SUP-ITM-10087755","CDM","Q4104","HCPCS","0636","RC","","","","outpatient","","","23480.90","17610.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","16413.15","69.9","","137.95","137.95","137.95","26","115.58","18878.64","percent of total billed charges",""
"DRIVER SHAFT 3MM SCREW SS THREADED WASHER CANNULATED","SUP-ITM-10022920","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.44","556.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","589.44","79.5","","800.18","480.96","1887.97","195","229.85","589.44","percent of total billed charges",""
"DRIVER SHAFT 3MM SCREW SS THREADED WASHER CANNULATED","SUP-ITM-10022920","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.44","556.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","395.19","53.3","","813.12","216.42","1444.50","81","229.85","589.44","percent of total billed charges",""
"DRIVER SHAFT 3MM SCREW SS THREADED WASHER CANNULATED","SUP-ITM-10022920","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.44","556.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","229.85","31","","432.60","432.60","432.60","1 through 10","229.85","589.44","percent of total billed charges",""
"DRIVER SHAFT 3MM SCREW SS THREADED WASHER CANNULATED","SUP-ITM-10022920","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.44","556.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","270.63","36.5","","148.37","54.89","631.39","94","229.85","589.44","percent of total billed charges",""
"DRIVER SHAFT 3MM SCREW SS THREADED WASHER CANNULATED","SUP-ITM-10022920","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.44","556.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","283.97","38.3","","279.30","91.72","1116.77","266","229.85","589.44","percent of total billed charges",""
"DRIVER SHAFT 3MM SCREW SS THREADED WASHER CANNULATED","SUP-ITM-10022920","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.44","556.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","318.08","42.9","","731.00","63.70","731.00","1 through 10","229.85","589.44","percent of total billed charges",""
"DRIVER SHAFT 3MM SCREW SS THREADED WASHER CANNULATED","SUP-ITM-10022920","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.44","556.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","318.08","42.9","","384.74","384.74","384.74","1 through 10","229.85","589.44","percent of total billed charges",""
"DRIVER SHAFT 3MM SCREW SS THREADED WASHER CANNULATED","SUP-ITM-10022920","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.44","556.08","WELLPOINT [1015]","HB AMC WELLPOINT","547.03","73.78","","286.63","119.22","1107.45","105","229.85","589.44","percent of total billed charges",""
"DRIVER SHAFT 3MM SCREW SS THREADED WASHER CANNULATED","SUP-ITM-10022920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.44","556.08","AETNA [1001]","HB AMC AETNA HMO","517.53","69.8","","675.31","184.75","1721.50","286","387.48","605.9","percent of total billed charges",""
"DRIVER SHAFT 3MM SCREW SS THREADED WASHER CANNULATED","SUP-ITM-10022920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.44","556.08","AETNA [1001]","HB AMC AETNA PPO","596.12","80.4","","1261.44","103.12","1514.10","21","387.48","605.9","percent of total billed charges",""
"DRIVER SHAFT 3MM SCREW SS THREADED WASHER CANNULATED","SUP-ITM-10022920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.44","556.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","596.12","80.4","","1365.00","1365.00","1365.00","1 through 10","387.48","605.9","percent of total billed charges",""
"DRIVER SHAFT 3MM SCREW SS THREADED WASHER CANNULATED","SUP-ITM-10022920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.44","556.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","605.90","81.72","","5157.68","5157.68","5157.68","1 through 10","387.48","605.9","percent of total billed charges",""
"DRIVER SHAFT 3MM SCREW SS THREADED WASHER CANNULATED","SUP-ITM-10022920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.44","556.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","605.90","81.72","","431.26","71.26","1459.57","88","387.48","605.9","percent of total billed charges",""
"Drug Admin & Hemodynamic Measure","PX-48000128","CDM","93463","CPT","0481","RC","","","","both","","","3301.00","2475.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1759.43","53.3","","2519.19","2519.19","2519.19","1 through 10","1023.31","2624.3","percent of total billed charges",""
"Drug Admin & Hemodynamic Measure","PX-48000128","CDM","93463","CPT","0481","RC","","","","both","","","3301.00","2475.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1264.28","38.3","","1251.59","1251.59","1251.59","1 through 10","1023.31","2624.3","percent of total billed charges",""
"Drug Admin & Hemodynamic Measure","PX-48000128","CDM","93463","CPT","0481","RC","","","","both","","","3301.00","2475.75","WELLPOINT [1015]","HB AMC WELLPOINT","2435.48","73.78","","2383.14","2383.14","2383.14","1 through 10","1023.31","2624.3","percent of total billed charges",""
"Drug Admin & Hemodynamic Measure","PX-48000128","CDM","93463","CPT","0481","RC","","","","outpatient","","","3301.00","2475.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2697.58","81.72","","2558.88","418.11","2558.88","1 through 10","1725.1","2697.58","percent of total billed charges",""
"Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice,EXTREME","770","DRG","","","","","","","","inpatient","","","56581.09","","MASSHEALTH [3001]","HB BWH MEDICAID","14021.40","","Case rate ($15,503.07). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,933.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16127.26","16127.26","16127.26","1 through 10","954.59","41463.81","case rate",""
"Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice,MODERATE","770","DRG","","","","","","","","inpatient","","","26654.36","","MASSHEALTH [3001]","HB BWH MEDICAID","3641.86","","Case rate ($4,026.71). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,456.71, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4025.72","4025.72","4025.72","1 through 10","954.59","41463.81","case rate",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","both","","","212.00","159.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","168.54","79.5","","162.12","162.12","162.12","1 through 10","18.27","201.4","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","both","","","212.00","159.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","113.00","53.3","","486.36","108.77","486.36","1 through 10","18.27","201.4","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.38","36.5","","76.84","76.84","76.84","1 through 10","18.27","201.4","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.20","38.3","","234.84","80.55","241.65","1 through 10","18.27","201.4","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","both","","","212.00","159.00","WELLPOINT [1015]","HB AMC WELLPOINT","156.41","73.78","","153.37","153.37","153.37","1 through 10","18.27","201.4","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA HMO","147.98","69.8","","139.46","98.47","325.46","1 through 10","33.55","174.9","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA PPO","170.45","80.4","","107.95","107.94","107.95","1 through 10","33.55","174.9","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","212.00","159.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","106.00","50","","107.94","107.94","107.94","1 through 10","33.55","174.9","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","212.00","159.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","111.30","52.5","","113.30","113.30","113.30","1 through 10","33.55","174.9","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","173.25","81.72","","90.58","90.58","90.58","1 through 10","33.55","174.9","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","173.25","81.72","","90.58","90.58","164.68","1 through 10","33.55","174.9","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","both","","","459.00","344.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","364.91","79.5","","350.22","234.96","1050.66","13","37.8","436.05","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","both","","","459.00","344.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","244.65","53.3","","436.32","234.96","1174.80","11","37.8","436.05","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","both","","","459.00","344.25","TRICARE [160005]","HB BWH TRICARE","436.05","95","","46.48","46.48","46.48","1 through 10","37.8","436.05","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","both","","","459.00","344.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","196.91","42.9","","195.67","195.67","195.67","1 through 10","37.8","436.05","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","both","","","459.00","344.25","WELLPOINT [1015]","HB AMC WELLPOINT","338.65","73.78","","331.30","331.30","776.30","11","37.8","436.05","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","outpatient","","","459.00","344.25","AETNA [1001]","HB AMC AETNA HMO","320.38","69.8","","301.27","301.27","301.27","1 through 10","143.09","375.09","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","outpatient","","","459.00","344.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","277.92","60.55","","307.93","299.18","307.93","1 through 10","143.09","375.09","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","outpatient","","","459.00","344.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","239.69","52.22","","239.55","239.54","307.59","32","143.09","375.09","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","outpatient","","","459.00","344.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","375.09","81.72","","195.67","195.67","195.67","1 through 10","143.09","375.09","percent of total billed charges",""
"Drug Assay Felbamate","PX-30003722","CDM","80167","CPT","0301","RC","","","","outpatient","","","221.00","165.75","AETNA [1001]","HB AMC AETNA HMO","154.26","69.8","","144.88","144.88","144.88","1 through 10","33.55","182.33","percent of total billed charges",""
"Drug Assay Felbamate","PX-30003722","CDM","80167","CPT","0301","RC","","","","outpatient","","","221.00","165.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","116.03","52.5","","95.44","95.44","95.44","1 through 10","33.55","182.33","percent of total billed charges",""
"Drug Assay Hydroxychloroquine","PX-30003758","CDM","80220","CPT","0301","RC","","","","both","","","221.00","165.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","175.70","79.5","","168.42","168.42","168.42","1 through 10","18.27","209.95","percent of total billed charges",""
"Drug Assay Hydroxychloroquine","PX-30003758","CDM","80220","CPT","0301","RC","","","","both","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.81","42.9","","171.07","171.07","171.07","1 through 10","18.27","209.95","percent of total billed charges",""
"Drug Assay Hydroxychloroquine","PX-30003758","CDM","80220","CPT","0301","RC","","","","outpatient","","","221.00","165.75","AETNA [1001]","HB AMC AETNA HMO","154.26","69.8","","144.88","102.29","144.88","1 through 10","40.41","182.33","percent of total billed charges",""
"Drug Assay Hydroxychloroquine","PX-30003758","CDM","80220","CPT","0301","RC","","","","outpatient","","","221.00","165.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","110.50","50","","336.42","112.14","336.42","1 through 10","40.41","182.33","percent of total billed charges",""
"Drug Assay Hydroxychloroquine","PX-30003758","CDM","80220","CPT","0301","RC","","","","outpatient","","","221.00","165.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","116.03","52.5","","117.70","113.21","117.70","1 through 10","40.41","182.33","percent of total billed charges",""
"Drug Assay Hydroxychloroquine","PX-30003758","CDM","80220","CPT","0301","RC","","","","outpatient","","","221.00","165.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","121.55","55","","123.26","123.26","123.26","1 through 10","40.41","182.33","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","both","","","323.00","242.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","256.79","79.5","","246.33","246.33","246.33","14","37.8","306.85","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","both","","","323.00","242.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","172.16","53.3","","165.26","165.26","576.85","14","37.8","306.85","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","both","","","323.00","242.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","248.71","77","","244.14","244.13","244.14","1 through 10","37.8","306.85","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","both","","","323.00","242.25","WELLPOINT [1015]","HB AMC WELLPOINT","238.31","73.78","","233.03","233.03","233.03","18","37.8","306.85","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","outpatient","","","323.00","242.25","AETNA [1001]","HB AMC AETNA HMO","225.45","69.8","","149.61","149.61","211.90","1 through 10","117.25","263.96","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","outpatient","","","323.00","242.25","AETNA [1001]","HB AMC AETNA PPO","259.69","80.4","","164.01","164.01","164.01","1 through 10","117.25","263.96","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","outpatient","","","323.00","242.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","195.58","60.55","","210.43","195.38","313.00","1 through 10","117.25","263.96","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","outpatient","","","323.00","242.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","168.67","52.22","","168.49","168.49","216.35","56","117.25","263.96","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","outpatient","","","323.00","242.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","263.96","81.72","","137.63","119.54","138.14","1 through 10","117.25","263.96","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","both","","","257.00","192.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","204.32","79.5","","195.96","147.13","195.96","1 through 10","26.57","244.15","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","both","","","257.00","192.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","136.98","53.3","","131.47","131.47","251.50","1 through 10","26.57","244.15","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","both","","","257.00","192.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.25","42.9","","199.05","199.05","199.05","1 through 10","26.57","244.15","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","both","","","257.00","192.75","WELLPOINT [1015]","HB AMC WELLPOINT","189.61","73.78","","185.38","185.38","185.38","1 through 10","26.57","244.15","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","outpatient","","","257.00","192.75","AETNA [1001]","HB AMC AETNA HMO","179.39","69.8","","168.57","168.57","194.22","1 through 10","93.29","210.02","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","outpatient","","","257.00","192.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","155.61","60.55","","167.41","134.04","167.41","1 through 10","93.29","210.02","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","outpatient","","","257.00","192.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","134.21","52.22","","134.04","134.04","172.11","1 through 10","93.29","210.02","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","outpatient","","","257.00","192.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","210.02","81.72","","109.49","109.49","109.49","1 through 10","93.29","210.02","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","outpatient","","","257.00","192.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","210.02","81.72","","199.05","109.49","199.05","1 through 10","93.29","210.02","percent of total billed charges",""
"Drug Assay Leflunomide","PX-30003726","CDM","80193","CPT","0301","RC","","","","outpatient","","","459.00","344.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","229.50","50","","233.18","233.18","233.18","1 through 10","112.14","378.68","percent of total billed charges",""
"Drug Assay Posaconazole","PX-30003608","CDM","80187","CPT","0300","RC","","","","outpatient","","","296.00","222.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","241.89","81.72","","287.00","229.43","287.00","1 through 10","100.58","241.89","percent of total billed charges",""
"Drug Assay Rufinamide","PX-30003728","CDM","80210","CPT","0301","RC","","","","outpatient","","","340.00","255.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","187.00","55","","162.08","162.08","162.08","1 through 10","48.8","280.5","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","both","","","192.00","144.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","152.64","79.5","","146.38","146.38","146.38","1 through 10","18.27","182.4","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","both","","","192.00","144.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","102.34","53.3","","439.14","98.21","439.14","1 through 10","18.27","182.4","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","both","","","192.00","144.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70.08","36.5","","69.38","69.38","69.38","1 through 10","18.27","182.4","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","both","","","192.00","144.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.54","38.3","","212.04","72.73","218.19","1 through 10","18.27","182.4","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","both","","","192.00","144.00","WELLPOINT [1015]","HB AMC WELLPOINT","141.66","73.78","","138.48","138.48","138.48","1 through 10","18.27","182.4","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","outpatient","","","192.00","144.00","AETNA [1001]","HB AMC AETNA HMO","134.02","69.8","","125.92","88.91","145.08","1 through 10","33.55","158.4","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","outpatient","","","192.00","144.00","AETNA [1001]","HB AMC AETNA PPO","154.37","80.4","","97.46","97.46","97.46","1 through 10","33.55","158.4","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","outpatient","","","192.00","144.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","96.00","50","","97.46","97.46","97.46","1 through 10","33.55","158.4","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","outpatient","","","192.00","144.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","100.80","52.5","","102.30","102.30","102.30","1 through 10","33.55","158.4","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","outpatient","","","192.00","144.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","156.90","81.72","","81.78","81.78","81.78","1 through 10","33.55","158.4","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","outpatient","","","192.00","144.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","156.90","81.72","","81.78","81.78","148.69","1 through 10","33.55","158.4","percent of total billed charges",""
"Drug Assay Vedolizumab","PX-30003611","CDM","80280","CPT","0300","RC","","","","both","","","459.00","344.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","244.65","53.3","","234.96","234.96","234.96","1 through 10","37.8","436.05","percent of total billed charges",""
"Drug Assay Vedolizumab","PX-30003611","CDM","80280","CPT","0300","RC","","","","outpatient","","","459.00","344.25","AETNA [1001]","HB AMC AETNA HMO","320.38","69.8","","301.27","301.27","301.27","1 through 10","143.09","375.09","percent of total billed charges",""
"Drug Assay Vedolizumab","PX-30003611","CDM","80280","CPT","0300","RC","","","","outpatient","","","459.00","344.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","239.69","52.22","","239.55","239.54","307.58","1 through 10","143.09","375.09","percent of total billed charges",""
"Drug Assay Vedolizumab","PX-30003611","CDM","80280","CPT","0300","RC","","","","outpatient","","","459.00","344.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","375.09","81.72","","332.68","332.68","332.68","1 through 10","143.09","375.09","percent of total billed charges",""
"Drug Assay Voriconazole","PX-30003612","CDM","80285","CPT","0300","RC","","","","outpatient","","","302.00","226.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","157.70","52.22","","157.73","157.73","157.73","1 through 10","100.58","246.79","percent of total billed charges",""
"Drug Assay Voriconazole","PX-30003612","CDM","80285","CPT","0300","RC","","","","outpatient","","","302.00","226.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","246.79","81.72","","110.61","110.61","110.61","1 through 10","100.58","246.79","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","both","","","214.00","160.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","170.13","79.5","","163.70","109.82","163.70","1 through 10","12.99","203.3","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","both","","","214.00","160.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","114.06","53.3","","109.82","109.82","163.70","1 through 10","12.99","203.3","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","both","","","214.00","160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","66.34","31","","64.27","64.27","64.27","1 through 10","12.99","203.3","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","both","","","214.00","160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.11","36.5","","75.30","65.94","77.58","15","12.99","203.3","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","both","","","214.00","160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.96","38.3","","81.33","79.04","81.33","37","12.99","203.3","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","both","","","214.00","160.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","164.78","77","","172.48","8.39","172.48","1 through 10","12.99","203.3","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","both","","","214.00","160.50","TRICARE [160005]","HB BWH TRICARE","203.30","95","","15.17","15.17","15.17","1 through 10","12.99","203.3","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","both","","","214.00","160.50","WELLPOINT [1015]","HB AMC WELLPOINT","157.89","73.78","","154.86","154.86","362.86","12","12.99","203.3","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","outpatient","","","214.00","160.50","AETNA [1001]","HB AMC AETNA HMO","149.37","69.8","","140.82","99.42","140.82","26","13.67","174.88","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","outpatient","","","214.00","160.50","AETNA [1001]","HB AMC AETNA PPO","172.06","80.4","","108.99","108.99","108.99","1 through 10","13.67","174.88","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","outpatient","","","214.00","160.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","172.06","80.4","","162.24","162.24","162.24","1 through 10","13.67","174.88","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","outpatient","","","214.00","160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.88","81.72","","166.28","53.35","166.28","29","13.67","174.88","percent of total billed charges",""
"Drug Screen Quant Clozapine","PX-30001674","CDM","80159","CPT","0301","RC","","","","both","","","213.00","159.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","169.34","79.5","","162.91","162.91","162.91","1 through 10","19.07","202.35","percent of total billed charges",""
"Drug Screen Quant Clozapine","PX-30001674","CDM","80159","CPT","0301","RC","","","","both","","","213.00","159.75","WELLPOINT [1015]","HB AMC WELLPOINT","157.15","73.78","","154.11","154.11","154.11","1 through 10","19.07","202.35","percent of total billed charges",""
"Drug Screen Quant Clozapine","PX-30001674","CDM","80159","CPT","0301","RC","","","","outpatient","","","213.00","159.75","AETNA [1001]","HB AMC AETNA HMO","148.67","69.8","","98.95","98.95","140.14","12","19.07","174.06","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Free","PX-30002831","CDM","80165","CPT","0301","RC","","","","both","","","213.00","159.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","138.45","65","","109.30","109.30","109.30","1 through 10","13.27","202.35","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","both","","","163.00","122.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","105.95","65","","83.43","83.42","83.43","1 through 10","13.27","154.85","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","both","","","163.00","122.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","129.59","79.5","","124.35","83.42","124.35","15","13.27","154.85","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","both","","","163.00","122.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","86.88","53.3","","124.35","83.42","124.35","1 through 10","13.27","154.85","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","both","","","163.00","122.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","59.50","36.5","","58.93","49.61","58.93","1 through 10","13.27","154.85","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","both","","","163.00","122.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.43","38.3","","61.78","60.04","61.78","1 through 10","13.27","154.85","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","both","","","163.00","122.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.93","42.9","","126.30","126.30","126.30","1 through 10","13.27","154.85","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","outpatient","","","163.00","122.25","AETNA [1001]","HB AMC AETNA HMO","113.77","69.8","","106.97","75.52","106.97","1 through 10","13.98","133.2","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","outpatient","","","163.00","122.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","133.20","81.72","","126.31","69.47","126.31","1 through 10","13.98","133.2","percent of total billed charges",""
"Drug Screen Quant Zonisamide","PX-30001681","CDM","80203","CPT","0301","RC","","","","both","","","231.00","173.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","123.12","53.3","","118.27","118.27","118.27","1 through 10","12.99","219.45","percent of total billed charges",""
"Drug Screen Quant Zonisamide","PX-30001681","CDM","80203","CPT","0301","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","84.32","36.5","","71.01","71.01","71.01","1 through 10","12.99","219.45","percent of total billed charges",""
"Drug Screen Quant Zonisamide","PX-30001681","CDM","80203","CPT","0301","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","88.47","38.3","","87.58","87.58","87.58","1 through 10","12.99","219.45","percent of total billed charges",""
"Drug Screen Quant Zonisamide","PX-30001681","CDM","80203","CPT","0301","RC","","","","both","","","231.00","173.25","WELLPOINT [1015]","HB AMC WELLPOINT","170.43","73.78","","166.77","166.77","166.77","1 through 10","12.99","219.45","percent of total billed charges",""
"Drug Screen Quant Zonisamide","PX-30001681","CDM","80203","CPT","0301","RC","","","","outpatient","","","231.00","173.25","AETNA [1001]","HB AMC AETNA HMO","161.24","69.8","","151.65","151.65","151.65","1 through 10","13.67","188.77","percent of total billed charges",""
"Drug Screen Quant Zonisamide","PX-30001681","CDM","80203","CPT","0301","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","188.77","81.72","","179.07","19.21","179.07","1 through 10","13.67","188.77","percent of total billed charges",""
"Drug Screen Quantitative Digoxin Total","PX-30002829","CDM","80162","CPT","0301","RC","","","","both","","","203.00","152.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","142.10","70","","197.00","197.00","197.00","1 through 10","13.01","192.85","percent of total billed charges",""
"Drug Screen Quantitative Digoxin Total","PX-30002829","CDM","80162","CPT","0301","RC","","","","both","","","203.00","152.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.10","36.5","","73.48","73.48","73.48","1 through 10","13.01","192.85","percent of total billed charges",""
"Drug Screen Quantitative Digoxin Total","PX-30002829","CDM","80162","CPT","0301","RC","","","","both","","","203.00","152.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.75","38.3","","141.45","141.45","141.45","1 through 10","13.01","192.85","percent of total billed charges",""
"Drug Screen Quantitative Digoxin Total","PX-30002829","CDM","80162","CPT","0301","RC","","","","outpatient","","","203.00","152.25","AETNA [1001]","HB AMC AETNA HMO","141.69","69.8","","94.17","94.17","94.17","1 through 10","13.69","165.89","percent of total billed charges",""
"Drug Screen Quantitative Digoxin Total","PX-30002829","CDM","80162","CPT","0301","RC","","","","outpatient","","","203.00","152.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.89","81.72","","160.18","160.18","160.18","1 through 10","13.69","165.89","percent of total billed charges",""
"Drug Screen Quantitative Oxcarbazepine","PX-30003736","CDM","80183","CPT","0301","RC","","","","both","","","174.00","130.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","138.33","79.5","","89.23","89.23","89.23","1 through 10","12.99","165.3","percent of total billed charges",""
"Drug Screen Quantitative Oxcarbazepine","PX-30003736","CDM","80183","CPT","0301","RC","","","","both","","","174.00","130.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","92.74","53.3","","89.23","89.23","89.23","1 through 10","12.99","165.3","percent of total billed charges",""
"Drug Screen Quantitative Oxcarbazepine","PX-30003736","CDM","80183","CPT","0301","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.51","36.5","","63.04","63.04","63.04","1 through 10","12.99","165.3","percent of total billed charges",""
"Drug Screen Quantitative Oxcarbazepine","PX-30003736","CDM","80183","CPT","0301","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.64","38.3","","66.08","64.22","198.24","1 through 10","12.99","165.3","percent of total billed charges",""
"Drug Screen Quantitative Oxcarbazepine","PX-30003736","CDM","80183","CPT","0301","RC","","","","both","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.65","42.9","","135.10","135.10","135.10","1 through 10","12.99","165.3","percent of total billed charges",""
"Drug Screen Quantitative Oxcarbazepine","PX-30003736","CDM","80183","CPT","0301","RC","","","","outpatient","","","174.00","130.50","AETNA [1001]","HB AMC AETNA HMO","121.45","69.8","","114.41","80.78","131.82","1 through 10","13.67","142.19","percent of total billed charges",""
"Drug Screen Quantitative Oxcarbazepine","PX-30003736","CDM","80183","CPT","0301","RC","","","","outpatient","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","142.19","81.72","","135.10","74.31","135.10","1 through 10","13.67","142.19","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","both","","","224.00","168.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","178.08","79.5","","170.78","114.58","170.78","13","12.99","212.8","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","both","","","224.00","168.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","119.39","53.3","","170.78","114.58","170.78","1 through 10","12.99","212.8","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","both","","","224.00","168.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","81.76","36.5","","80.94","68.79","161.88","15","12.99","212.8","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","both","","","224.00","168.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","85.79","38.3","","84.85","82.46","84.85","25","12.99","212.8","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","both","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.10","42.9","","95.41","95.41","95.41","1 through 10","12.99","212.8","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","both","","","224.00","168.00","WELLPOINT [1015]","HB AMC WELLPOINT","165.27","73.78","","161.56","161.56","161.56","1 through 10","12.99","212.8","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","outpatient","","","224.00","168.00","AETNA [1001]","HB AMC AETNA HMO","156.35","69.8","","146.91","103.73","169.26","1 through 10","13.67","183.05","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","outpatient","","","224.00","168.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","180.10","80.4","","169.26","169.26","169.26","1 through 10","13.67","183.05","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","outpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","183.05","81.72","","11.68","11.68","11.68","1 through 10","13.67","183.05","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","outpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.05","81.72","","173.47","18.61","173.47","13","13.67","183.05","percent of total billed charges",""
"Drug Scrn Quan Mycophenolate","PX-30001678","CDM","80180","CPT","0301","RC","","","","both","","","253.00","189.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.90","38.3","","287.40","95.80","287.40","1 through 10","17.69","240.35","percent of total billed charges",""
"Drug Scrn Quan Mycophenolate","PX-30001678","CDM","80180","CPT","0301","RC","","","","outpatient","","","253.00","189.75","AETNA [1001]","HB AMC AETNA PPO","203.41","80.4","","191.10","191.10","191.10","1 through 10","18.62","206.75","percent of total billed charges",""
"Drug Scrn Quant Oxcarbazepin","PX-30001679","CDM","80183","CPT","0301","RC","","","","both","","","174.00","130.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","138.33","79.5","","89.23","89.23","89.23","1 through 10","12.99","165.3","percent of total billed charges",""
"Drug Scrn Quant Oxcarbazepin","PX-30001679","CDM","80183","CPT","0301","RC","","","","both","","","174.00","130.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","92.74","53.3","","89.23","89.23","89.23","1 through 10","12.99","165.3","percent of total billed charges",""
"Drug Scrn Quant Oxcarbazepin","PX-30001679","CDM","80183","CPT","0301","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.51","36.5","","63.04","63.04","63.04","1 through 10","12.99","165.3","percent of total billed charges",""
"Drug Scrn Quant Oxcarbazepin","PX-30001679","CDM","80183","CPT","0301","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.64","38.3","","66.08","64.22","198.24","1 through 10","12.99","165.3","percent of total billed charges",""
"Drug Scrn Quant Oxcarbazepin","PX-30001679","CDM","80183","CPT","0301","RC","","","","both","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.65","42.9","","135.10","135.10","135.10","1 through 10","12.99","165.3","percent of total billed charges",""
"Drug Scrn Quant Oxcarbazepin","PX-30001679","CDM","80183","CPT","0301","RC","","","","outpatient","","","174.00","130.50","AETNA [1001]","HB AMC AETNA HMO","121.45","69.8","","114.41","80.78","131.82","1 through 10","13.67","142.19","percent of total billed charges",""
"Drug Scrn Quant Oxcarbazepin","PX-30001679","CDM","80183","CPT","0301","RC","","","","outpatient","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","142.19","81.72","","135.10","74.31","135.10","1 through 10","13.67","142.19","percent of total billed charges",""
"Drug Susceptability Genotypic/Pheno","PX-30001359","CDM","87900","CPT","0306","RC","","","","both","","","1655.00","1241.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","633.87","38.3","","627.56","627.56","627.56","1 through 10","127.74","1572.25","percent of total billed charges",""
"Drug Susceptability Genotypic/Pheno","PX-30001359","CDM","87900","CPT","0306","RC","","","","outpatient","","","1655.00","1241.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1352.47","81.72","","705.72","705.72","705.72","1 through 10","134.41","1352.47","percent of total billed charges",""
"Drug/Substance Definitive Qual/Quant Nos 7/More","PX-30002894","CDM","80377","CPT","0301","RC","","","","both","","","386.00","289.50","WELLPOINT [1015]","HB AMC WELLPOINT","284.79","73.78","","748.00","278.44","748.00","1 through 10","112.14","366.7","percent of total billed charges",""
"Dstrj Lesion Anus Extensive","PX-98300658","CDM","46924","CPT","0983","RC","","","","both","","","1288.00","966.00","MEDICARE [2001]","HB BWH MEDICARE","3256.42","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3256.75","3256.75","3256.75","1 through 10","399.28","4070.53","other","OPPS APC"
"Dstrj Lesion Anus Extensive","PX-98300658","CDM","46924","CPT","0983","RC","","","","outpatient","","","1288.00","966.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1052.55","81.72","","8085.53","8085.53","8085.53","1 through 10","666.04","2384.07","percent of total billed charges",""
"Dstrj Lesion Anus Simple Cryosurgery","PX-75000234","CDM","46916","CPT","0750","RC","","","","outpatient","","","1003.00","752.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","1 through 10","176.45","819.65","other","Multiple Surgery"
"Dstrj Lesion Anus Smpl Eltrdsiccation","PX-75000233","CDM","46910","CPT","0750","RC","","","","both","","","5263.00","3947.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1921.00","36.5","","2643.78","2643.78","2643.78","1 through 10","1631.53","4184.09","percent of total billed charges",""
"Dstrj Lesion Anus Smpl Eltrdsiccation","PX-75000233","CDM","46910","CPT","0750","RC","","","","outpatient","","","5263.00","3947.25","AETNA [1001]","HB AMC AETNA HMO","3673.57","69.8","","8329.13","8329.13","8329.13","1 through 10","2105.2","4300.92","percent of total billed charges",""
"Dstrj Lesion Anus Smpl Eltrdsiccation","PX-75000233","CDM","46910","CPT","0750","RC","","","","outpatient","","","5263.00","3947.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2748.34","52.22","","4146.66","4146.66","4146.66","1 through 10","2105.2","4300.92","percent of total billed charges",""
"Dtap-Ipv-Hib-Hepb Vaccine Intramuscular","PX-63601173","CDM","90697","CPT","0636","RC","","","","outpatient","","","263.40","197.55","AETNA [1001]","HB AMC AETNA HMO","183.85","69.8","","0.01","0.01","0.01","1 through 10","0.01","217.31","percent of total billed charges",""
"DUAL INFINITY 5 IPG FOR BILATERAL IMPLANT","SUP-ITM-10174935","CDM","C1767","HCPCS","0278","RC","","","","both","","","28750.00","21562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10493.75","36.5","","18081.90","16994.81","18081.90","1 through 10","8912.5","22856.25","percent of total billed charges",""
"DUAL INFINITY 5 IPG FOR BILATERAL IMPLANT","SUP-ITM-10174935","CDM","C1767","HCPCS","0278","RC","","","","both","","","28750.00","21562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11011.25","38.3","","17814.94","17448.38","17814.94","1 through 10","8912.5","22856.25","percent of total billed charges",""
"DUAL INFINITY 5 IPG FOR BILATERAL IMPLANT","SUP-ITM-10174935","CDM","C1767","HCPCS","0278","RC","","","","both","","","28750.00","21562.50","WELLPOINT [1015]","HB AMC WELLPOINT","21211.75","73.78","","33921.28","33921.28","33921.28","1 through 10","8912.5","22856.25","percent of total billed charges",""
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","both","","","526.00","394.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","287.06","1 through 10","163.06","505.13","other","OPPS APC"
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","both","","","526.00","394.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","341.90","65","","8674.32","8674.32","8674.32","1 through 10","163.06","505.13","percent of total billed charges",""
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","both","","","526.00","394.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","418.17","79.5","","2891.44","1939.87","2891.44","1 through 10","163.06","505.13","percent of total billed charges",""
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","both","","","526.00","394.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","280.36","53.3","","2891.44","1939.87","3710.73","1 through 10","163.06","505.13","percent of total billed charges",""
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","both","","","526.00","394.50","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","861.18","107","163.06","505.13","other","OPPS APC"
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","both","","","526.00","394.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.99","36.5","","1370.40","1329.99","1370.40","1 through 10","163.06","505.13","percent of total billed charges",""
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","both","","","526.00","394.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.46","38.3","","1436.53","1436.53","4309.59","32","163.06","505.13","percent of total billed charges",""
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","both","","","526.00","394.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","262.09","281.72","1 through 10","163.06","505.13","other","OPPS APC"
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","both","","","526.00","394.50","MOLINA [1014]","HB BWH MOLINA","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","569.53","568.38","569.53","1 through 10","163.06","505.13","other","OPPS APC"
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","both","","","526.00","394.50","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","272.71","272.71","272.71","1 through 10","163.06","505.13","other","Tricare OPPS"
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","both","","","526.00","394.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","283.90","281.32","849.72","1 through 10","163.06","505.13","other","OPPS APC"
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","both","","","526.00","394.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","265.10","286.32","22","163.06","505.13","other","OPPS APC"
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","outpatient","","","526.00","394.50","AETNA [1001]","HB AMC AETNA HMO","367.15","69.8","","1756.17","1756.17","1756.17","1 through 10","294.03","1051.35","percent of total billed charges",""
"Dup-Scan Artl Flo Abd/Pel/Scrot&Rpr Orgn Complete","PX-98302452","CDM","93975","CPT","0983","RC","","","","outpatient","","","526.00","394.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.85","81.72","","1615.46","1615.46","1615.46","1 through 10","294.03","1051.35","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3789.00","2841.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","287.06","1 through 10","272.7","3012.26","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3789.00","2841.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2462.85","65","","8674.32","8674.32","8674.32","1 through 10","272.7","3012.26","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3789.00","2841.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3012.26","79.5","","2891.44","1939.87","2891.44","1 through 10","272.7","3012.26","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3789.00","2841.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2019.54","53.3","","2891.44","1939.87","3710.73","1 through 10","272.7","3012.26","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3789.00","2841.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","861.18","107","272.7","3012.26","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3789.00","2841.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1382.99","36.5","","1370.40","1329.99","1370.40","1 through 10","272.7","3012.26","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3789.00","2841.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1451.19","38.3","","1436.53","1436.53","4309.59","32","272.7","3012.26","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3789.00","2841.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","262.09","281.72","1 through 10","272.7","3012.26","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3789.00","2841.75","MOLINA [1014]","HB BWH MOLINA","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","569.53","568.38","569.53","1 through 10","272.7","3012.26","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3789.00","2841.75","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","272.71","272.71","272.71","1 through 10","272.7","3012.26","other","Tricare OPPS"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3789.00","2841.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","283.90","281.32","849.72","1 through 10","272.7","3012.26","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3789.00","2841.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","265.10","286.32","22","272.7","3012.26","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","3789.00","2841.75","AETNA [1001]","HB AMC AETNA HMO","2644.72","69.8","","1756.17","1756.17","1756.17","1 through 10","529.69","3096.37","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","3789.00","2841.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1980.13","52.26","","611.16","611.16","611.16","1 through 10","529.69","3096.37","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","3789.00","2841.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3096.37","81.72","","1615.46","1615.46","1615.46","1 through 10","529.69","3096.37","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","2097.00","1572.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","88.58","126.29","1 through 10","119.97","1667.12","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","2097.00","1572.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1667.12","79.5","","1600.76","1073.95","1600.76","13","119.97","1667.12","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","2097.00","1572.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1117.70","53.3","","1600.76","1073.95","1600.76","1 through 10","119.97","1667.12","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","2097.00","1572.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","1667.12","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","2097.00","1572.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","15","119.97","1667.12","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","2097.00","1572.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","650.07","31","","628.51","628.51","628.51","1 through 10","119.97","1667.12","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","2097.00","1572.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","765.41","36.5","","736.31","644.78","758.68","1 through 10","119.97","1667.12","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","2097.00","1572.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","803.15","38.3","","795.29","772.92","795.29","14","119.97","1667.12","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","2097.00","1572.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","119.97","1667.12","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","2097.00","1572.75","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","1667.12","other","Tricare OPPS"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","2097.00","1572.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","899.61","42.9","","894.35","894.35","894.35","1 through 10","119.97","1667.12","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","2097.00","1572.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","126.29","1 through 10","119.97","1667.12","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","outpatient","","","2097.00","1572.75","AETNA [1001]","HB AMC AETNA HMO","1463.71","69.8","","1377.02","1377.02","1377.02","1 through 10","258.48","1713.67","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","outpatient","","","2097.00","1572.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1713.67","81.72","","1625.98","288.03","1625.98","11","258.48","1713.67","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2488.00","1866.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","287.06","12","272.7","1977.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2488.00","1866.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","358.78","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","267.44","267.44","267.44","1 through 10","272.7","1977.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2488.00","1866.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1977.96","79.5","","1899.03","1899.03","1899.03","1 through 10","272.7","1977.96","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2488.00","1866.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1326.10","53.3","","1274.06","1274.06","1274.06","1 through 10","272.7","1977.96","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2488.00","1866.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","1977.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2488.00","1866.00","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.04","283.04","283.04","1 through 10","272.7","1977.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2488.00","1866.00","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","93","272.7","1977.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2488.00","1866.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","908.12","36.5","","764.92","764.92","764.92","1 through 10","272.7","1977.96","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2488.00","1866.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","952.90","38.3","","943.48","943.48","943.48","1 through 10","272.7","1977.96","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2488.00","1866.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.72","281.32","281.72","1 through 10","272.7","1977.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2488.00","1866.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","281.32","281.72","1 through 10","272.7","1977.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2488.00","1866.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","265.90","286.32","29","272.7","1977.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","outpatient","","","2488.00","1866.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2000.35","80.4","","1206.50","1206.50","1206.50","1 through 10","529.69","2033.19","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","outpatient","","","2488.00","1866.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2033.19","81.72","","1928.95","1928.95","1928.95","1 through 10","529.69","2033.19","percent of total billed charges",""
"Duplex Art Upper Ext Unilat/Lmtd","PX-92000037","CDM","93931","CPT","0921","RC","","","","both","","","1430.00","1072.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","1136.85","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","3203.00","2402.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","287.06","12","272.7","2546.39","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","3203.00","2402.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2546.39","79.5","","2444.42","2274.06","2444.42","1 through 10","272.7","2546.39","percent of total billed charges",""
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","3203.00","2402.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1707.20","53.3","","2444.42","1639.97","2444.42","1 through 10","272.7","2546.39","percent of total billed charges",""
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","3203.00","2402.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","263.16","284.17","1 through 10","272.7","2546.39","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","3203.00","2402.25","ELDER SERVICES [1037]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","267.44","267.44","267.44","1 through 10","272.7","2546.39","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","3203.00","2402.25","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.62","283.62","283.62","1 through 10","272.7","2546.39","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","3203.00","2402.25","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","861.18","152","272.7","2546.39","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","3203.00","2402.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1169.10","36.5","","1158.54","1158.54","1158.54","1 through 10","272.7","2546.39","percent of total billed charges",""
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","3203.00","2402.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1226.75","38.3","","1214.45","1214.45","1214.45","1 through 10","272.7","2546.39","percent of total billed charges",""
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","3203.00","2402.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","281.32","845.16","1 through 10","272.7","2546.39","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","3203.00","2402.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2466.31","77","","2422.68","2422.68","2422.68","1 through 10","272.7","2546.39","percent of total billed charges",""
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","3203.00","2402.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","562.64","281.32","843.96","1 through 10","272.7","2546.39","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","3203.00","2402.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","262.10","287.06","29","272.7","2546.39","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","outpatient","","","3203.00","2402.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2617.49","81.72","","2482.94","1365.71","2482.94","1 through 10","529.69","2617.49","percent of total billed charges",""
"Duplex Arterial Lower Ext Unilt/Lmt","PX-92000035","CDM","93926","CPT","0921","RC","","","","both","","","2117.00","1587.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1481.90","70","","1478.16","1478.16","1478.16","1 through 10","119.97","1683.02","percent of total billed charges",""
"Duplex Arterial Lower Ext Unilt/Lmt","PX-92000035","CDM","93926","CPT","0921","RC","","","","both","","","2117.00","1587.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","1683.02","other","OPPS APC"
"Duplex Arterial Lower Ext Unilt/Lmt","PX-92000035","CDM","93926","CPT","0921","RC","","","","both","","","2117.00","1587.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","126.29","11","119.97","1683.02","other","OPPS APC"
"Duplex Arterial Lower Ext Unilt/Lmt","PX-92000035","CDM","93926","CPT","0921","RC","","","","outpatient","","","2117.00","1587.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1730.01","81.72","","1641.17","1641.17","1641.17","1 through 10","258.48","1730.01","percent of total billed charges",""
"Duplex Arterial Upper Ext Bilat","PX-92000036","CDM","93930","CPT","0921","RC","","","","both","","","2536.00","1902.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","282.47","287.06","1 through 10","272.7","2016.12","other","OPPS APC"
"Duplex Arterial Upper Ext Bilat","PX-92000036","CDM","93930","CPT","0921","RC","","","","both","","","2536.00","1902.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2016.12","79.5","","1935.23","1298.35","1935.23","1 through 10","272.7","2016.12","percent of total billed charges",""
"Duplex Arterial Upper Ext Bilat","PX-92000036","CDM","93930","CPT","0921","RC","","","","both","","","2536.00","1902.00","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","2016.12","other","OPPS APC"
"Duplex Arterial Upper Ext Bilat","PX-92000036","CDM","93930","CPT","0921","RC","","","","both","","","2536.00","1902.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","971.29","38.3","","961.47","961.47","961.47","1 through 10","272.7","2016.12","percent of total billed charges",""
"Duplex Arterial Upper Ext Bilat","PX-92000036","CDM","93930","CPT","0921","RC","","","","both","","","2536.00","1902.00","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","272.71","272.71","272.71","1 through 10","272.7","2016.12","other","Tricare OPPS"
"Duplex Arterial Upper Ext Bilat","PX-92000036","CDM","93930","CPT","0921","RC","","","","both","","","2536.00","1902.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","284.32","284.32","1 through 10","272.7","2016.12","other","OPPS APC"
"Duplex Arterial Upper Ext Bilat","PX-92000036","CDM","93930","CPT","0921","RC","","","","outpatient","","","2536.00","1902.00","AETNA [1001]","HB AMC AETNA HMO","1770.13","69.8","","1664.74","1664.74","1664.74","1 through 10","529.69","2072.42","percent of total billed charges",""
"Duplex Arterial Upper Ext Bilat","PX-92000036","CDM","93930","CPT","0921","RC","","","","outpatient","","","2536.00","1902.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2072.42","81.72","","1965.72","1965.72","1965.72","1 through 10","529.69","2072.42","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","263.16","282.47","55","272.7","2023.28","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","358.78","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","287.06","287.06","287.06","1 through 10","272.7","2023.28","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2023.28","79.5","","1942.32","1860.87","6081.95","21","272.7","2023.28","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1356.49","53.3","","1942.32","1303.10","1942.32","12","272.7","2023.28","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","237.85","282.47","1 through 10","272.7","2023.28","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","ELDER SERVICES [1037]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","267.44","262.09","267.44","1 through 10","272.7","2023.28","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.04","283.04","283.04","1 through 10","272.7","2023.28","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","861.18","394","272.7","2023.28","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","928.93","36.5","","920.56","782.36","1786.84","16","272.7","2023.28","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","974.74","38.3","","964.99","964.99","2894.97","33","272.7","2023.28","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.72","281.32","524.98","20","272.7","2023.28","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","MOLINA [1014]","HB BWH MOLINA","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","569.53","569.53","569.53","1 through 10","272.7","2023.28","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","272.71","272.71","272.71","1 through 10","272.7","2023.28","other","Tricare OPPS"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.92","263.16","844.76","37","272.7","2023.28","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1091.81","42.9","","1085.18","1085.18","1972.92","1 through 10","272.7","2023.28","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.90","265.40","286.47","86","272.7","2023.28","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2545.00","1908.75","WELLSENSE NH [1050]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","283.62","287.06","1 through 10","272.7","2023.28","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","2545.00","1908.75","AETNA [1001]","HB AMC AETNA HMO","1776.41","69.8","","1670.84","1670.84","1670.84","1 through 10","529.69","2079.77","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","2545.00","1908.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2079.77","81.72","","1085.18","1085.18","1085.18","1 through 10","529.69","2079.77","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","2545.00","1908.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2079.77","81.72","","1972.92","1085.18","1972.92","19","529.69","2079.77","percent of total billed charges",""
"Duplex Extracranial/Carotid Unilat","PX-92000024","CDM","93882","CPT","0921","RC","","","","both","","","1517.00","1137.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","1206.02","other","OPPS APC"
"Duplex Extracranial/Carotid Unilat","PX-92000024","CDM","93882","CPT","0921","RC","","","","both","","","1517.00","1137.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","1206.02","other","OPPS APC"
"Duplex Extracranial/Carotid Unilat","PX-92000024","CDM","93882","CPT","0921","RC","","","","both","","","1517.00","1137.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.16","124.16","124.16","1 through 10","119.97","1206.02","other","OPPS APC"
"Duplex Extracranial/Carotid Unilat","PX-92000024","CDM","93882","CPT","0921","RC","","","","both","","","1517.00","1137.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","124.16","124.16","1 through 10","119.97","1206.02","other","OPPS APC"
"Duplex Extrem Venous,Uni or Ltd","PX-98302512","CDM","93971","CPT","0983","RC","","","","both","","","134.00","100.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","126.29","123.77","126.29","1 through 10","41.54","505.13","other","OPPS APC"
"Duplex Extrem Venous,Uni or Ltd","PX-98302512","CDM","93971","CPT","0983","RC","","","","both","","","134.00","100.50","ELDER SERVICES [1037]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","119.99","119.99","119.99","1 through 10","41.54","505.13","other","OPPS APC"
"Duplex Extrem Venous,Uni or Ltd","PX-98302512","CDM","93971","CPT","0983","RC","","","","both","","","134.00","100.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","41.54","505.13","other","OPPS APC"
"Duplex Extrem Venous,Uni or Ltd","PX-98302512","CDM","93971","CPT","0983","RC","","","","both","","","134.00","100.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","126.29","64","41.54","505.13","other","OPPS APC"
"Duplex Extrem Venous,Uni or Ltd","PX-98302512","CDM","93971","CPT","0983","RC","","","","outpatient","","","134.00","100.50","AETNA [1001]","HB AMC AETNA HMO","93.53","69.8","","1099.45","1099.45","1099.45","1 through 10","74.91","673.26","percent of total billed charges",""
"Duplex Extrem Venous,Uni or Ltd","PX-98302512","CDM","93971","CPT","0983","RC","","","","outpatient","","","134.00","100.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","109.50","81.72","","1298.22","1298.22","1298.22","1 through 10","74.91","673.26","percent of total billed charges",""
"Duplex Extrem Venous,Uni or Ltd|REDUCED SERVICES","PX-98302512","CDM","93971","CPT","0983","RC","","","52","both","","","134.00","100.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.13","62.13","62.13","1 through 10","119.97","157.84","other","OPPS APC"
"Duplex Extrem Venous,Uni or Ltd|REDUCED SERVICES","PX-98302512","CDM","93971","CPT","0983","RC","","","52","both","","","134.00","100.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","120.00","120.00","120.00","1 through 10","119.97","157.84","other","OPPS APC"
"Duplex Extrem Venous,Uni or Ltd|REDUCED SERVICES","PX-98302512","CDM","93971","CPT","0983","RC","","","52","both","","","134.00","100.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","58.80","58.80","58.80","1 through 10","119.97","157.84","other","OPPS APC"
"Duplex Extrem Venous,Uni or Ltd|REDUCED SERVICES","PX-98302512","CDM","93971","CPT","0983","RC","","","52","both","","","134.00","100.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.14","62.14","62.14","1 through 10","119.97","157.84","other","OPPS APC"
"Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std","PX-92000177","CDM","93985","CPT","0921","RC","","","","both","","","1577.00","1182.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","295.64","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","275.19","275.19","275.19","1 through 10","272.7","1253.72","other","OPPS APC"
"Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std","PX-92000177","CDM","93985","CPT","0921","RC","","","","both","","","1577.00","1182.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","1253.72","other","OPPS APC"
"Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std","PX-92000177","CDM","93985","CPT","0921","RC","","","","both","","","1577.00","1182.75","WELLPOINT [1015]","HB AMC WELLPOINT","1163.51","73.78","","1138.34","1138.34","1138.34","1 through 10","272.7","1253.72","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","34","272.7","2052.69","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1678.30","65","","4882.80","4882.80","4882.80","1 through 10","272.7","2052.69","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2052.69","79.5","","1970.65","1322.11","1970.65","20","272.7","2052.69","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1376.21","53.3","","1322.11","1322.11","1970.65","1 through 10","272.7","2052.69","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","240.82","282.47","1 through 10","272.7","2052.69","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","ELDER SERVICES [1037]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","2052.69","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","267.39","267.39","267.39","1 through 10","272.7","2052.69","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.04","281.32","2504.00","1 through 10","272.7","2052.69","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","802.32","267","272.7","2052.69","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","942.43","36.5","","933.99","793.77","2801.97","23","272.7","2052.69","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","988.91","38.3","","979.06","979.06","979.06","59","272.7","2052.69","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","262.49","524.98","13","272.7","2052.69","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","MOLINA [1014]","HB BWH MOLINA","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","573.64","569.53","573.64","1 through 10","272.7","2052.69","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1988.14","77","","1953.12","1953.12","1953.12","1 through 10","272.7","2052.69","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","272.71","272.71","287.06","1 through 10","272.7","2052.69","other","Tricare OPPS"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","287.06","287.06","287.06","1 through 10","272.7","2052.69","other","Tricare OPPS"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","281.32","843.96","25","272.7","2052.69","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1107.68","42.9","","1101.01","1101.01","1101.01","1 through 10","272.7","2052.69","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2582.00","1936.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","281.32","286.32","69","272.7","2052.69","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","outpatient","","","2582.00","1936.50","AETNA [1001]","HB AMC AETNA HMO","1802.24","69.8","","1695.21","361.04","1695.21","1 through 10","529.69","2110.01","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","outpatient","","","2582.00","1936.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2075.93","80.4","","1252.00","1252.00","1252.00","1 through 10","529.69","2110.01","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","outpatient","","","2582.00","1936.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2110.01","81.72","","1101.01","1101.01","1101.01","1 through 10","529.69","2110.01","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","outpatient","","","2582.00","1936.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2110.01","81.72","","2001.70","1101.01","2001.70","16","529.69","2110.01","percent of total billed charges",""
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","both","","","1675.00","1256.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","126.29","123.77","126.29","1 through 10","119.97","1331.63","other","OPPS APC"
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","both","","","1675.00","1256.25","ELDER SERVICES [1037]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","119.99","119.99","119.99","1 through 10","119.97","1331.63","other","OPPS APC"
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","both","","","1675.00","1256.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","1331.63","other","OPPS APC"
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","both","","","1675.00","1256.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","119.99","126.29","64","119.97","1331.63","other","OPPS APC"
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","outpatient","","","1675.00","1256.25","AETNA [1001]","HB AMC AETNA HMO","1169.15","69.8","","1099.45","1099.45","1099.45","1 through 10","258.48","1368.81","percent of total billed charges",""
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","outpatient","","","1675.00","1256.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1368.81","81.72","","1298.22","1298.22","1298.22","1 through 10","258.48","1368.81","percent of total billed charges",""
"Duplex Venous Extremity Unilat/Lmtd|REDUCED SERVICES","PX-92000040","CDM","93971","CPT","0921","RC","","","52","both","","","1675.00","1256.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.13","62.13","62.13","1 through 10","119.97","157.84","other","OPPS APC"
"Duplex Venous Extremity Unilat/Lmtd|REDUCED SERVICES","PX-92000040","CDM","93971","CPT","0921","RC","","","52","both","","","1675.00","1256.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","120.00","120.00","120.00","1 through 10","119.97","157.84","other","OPPS APC"
"Duplex Venous Extremity Unilat/Lmtd|REDUCED SERVICES","PX-92000040","CDM","93971","CPT","0921","RC","","","52","both","","","1675.00","1256.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","58.80","58.80","58.80","1 through 10","119.97","157.84","other","OPPS APC"
"Duplex Venous Extremity Unilat/Lmtd|REDUCED SERVICES","PX-92000040","CDM","93971","CPT","0921","RC","","","52","both","","","1675.00","1256.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.14","62.14","62.14","1 through 10","119.97","157.84","other","OPPS APC"
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","2959.79","other","OPPS APC"
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","2959.79","other","OPPS APC"
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2959.79","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","2959.79","percent of total billed charges",""
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","2959.79","other","OPPS APC"
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","2959.79","other","OPPS APC"
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1358.90","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","2959.79","percent of total billed charges",""
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1425.91","38.3","","2723.31","1555.62","2741.61","12","1057.74","2959.79","percent of total billed charges",""
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","2959.79","other","OPPS APC"
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","2959.79","other","OPPS APC"
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","WELLPOINT [1015]","HB AMC WELLPOINT","2746.83","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","2959.79","percent of total billed charges",""
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","AETNA [1001]","HB AMC AETNA PPO","2993.29","80.4","","1163.76","1163.76","1163.76","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2254.28","60.55","","1781.82","1492.00","4331.00","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1944.15","52.22","","3144.00","1492.00","3610.00","13","1861.5","3071.48","percent of total billed charges",""
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1954.58","52.5","","1182.28","1182.28","1182.28","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1861.50","50","","3610.00","2269.44","3610.00","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1954.58","52.5","","3610.00","2382.05","4331.00","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2047.65","55","","4810.75","3363.17","4810.75","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3042.44","81.72","","8894.69","8894.69","8894.69","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3042.44","81.72","","2885.83","2132.00","3462.21","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Dysequilibrium","149","MS-DRG","","","","","","","","inpatient","","","38352.45","28764.34","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","7236.00","","Case rate ($7,236). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,633.32, add-ons for qualifying new technology services are included. If operating cost exceeds $54,277.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,044.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,251.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,253.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $604.78. The transfer capital threshold is the transfer adjustment factor * $604.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8961.99","8961.99","8961.99","1 through 10","7091.28","11280.5225","other","Inpatient Replacement Plans DRG"
"Dysequilibrium","149","MS-DRG","","","","","","","","inpatient","","","38352.45","28764.34","MEDICARE [2001]","HB BWH MEDICARE","7236.00","","Case rate ($7,236). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,633.32, add-ons for qualifying new technology services are included. If operating cost exceeds $54,277.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,044.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,251.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,253.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $604.78. The transfer capital threshold is the transfer adjustment factor * $604.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9090.67","803.79","43935.25","1 through 10","7091.28","11280.5225","other","Inpatient Replacement Plans DRG"
"Dysequilibrium","149","MS-DRG","","","","","","","","inpatient","","","38352.45","28764.34","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7091.28","","Case rate ($7,236). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,633.32, add-ons for qualifying new technology services are included. If operating cost exceeds $54,277.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,044.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,251.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,253.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $604.78. The transfer capital threshold is the transfer adjustment factor * $604.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6946.42","6946.42","6978.12","1 through 10","7091.28","11280.5225","other","Inpatient DRG"
"E&C Hydatidform Mole (Eap 59870)","PX-72000037","CDM","59870","CPT","0361","RC","","","","outpatient","","","8785.00","6588.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6321.29","6321.29","6321.29","1 through 10","2125.14","9843.6","other","ASC "
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","","","","inpatient","","","63745.34","47809.00","ELDER SERVICES [1037]","HB BWH MEDICARE","11978.60","","Case rate ($11,978.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,342.46, add-ons for qualifying new technology services are included. If operating cost exceeds $59,986.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,463.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,575.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,962.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.12. The transfer capital threshold is the transfer adjustment factor * $1,023.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11653.48","11653.48","11653.48","1 through 10","11739.03","18785.2768","other","Inpatient Replacement Plans DRG"
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","","","","inpatient","","","63745.34","47809.00","MEDICARE [2001]","HB BWH MEDICARE","11978.60","","Case rate ($11,978.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,342.46, add-ons for qualifying new technology services are included. If operating cost exceeds $59,986.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,463.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,575.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,962.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.12. The transfer capital threshold is the transfer adjustment factor * $1,023.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14953.43","14953.43","14953.43","1 through 10","11739.03","18785.2768","other","Inpatient Replacement Plans DRG"
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","","","","inpatient","","","63745.34","47809.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11739.03","","Case rate ($11,978.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,342.46, add-ons for qualifying new technology services are included. If operating cost exceeds $59,986.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,463.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,575.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,962.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.12. The transfer capital threshold is the transfer adjustment factor * $1,023.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11468.34","11468.34","11468.34","1 through 10","11739.03","18785.2768","other","Inpatient DRG"
"Ear, Nose, Mouth And Throat Malignancy With McC","146","MS-DRG","","","","","","","","inpatient","","","89098.36","66823.77","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","19694.99","","Case rate ($19,694.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,631.46, add-ons for qualifying new technology services are included. If operating cost exceeds $69,275.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,143.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $17,611.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,251.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,703.78. The transfer capital threshold is the transfer adjustment factor * $1,703.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20937.18","20937.18","20937.18","1 through 10","19301.09","33166.95","other","Inpatient Replacement Plans DRG"
"Ear, Nose, Mouth And Throat Malignancy With McC","146","MS-DRG","","","","","","","","inpatient","","","89098.36","66823.77","MEDICARE [2001]","HB BWH MEDICARE","19694.99","","Case rate ($19,694.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,631.46, add-ons for qualifying new technology services are included. If operating cost exceeds $69,275.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,143.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $17,611.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,251.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,703.78. The transfer capital threshold is the transfer adjustment factor * $1,703.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27364.24","27323.77","27364.24","1 through 10","19301.09","33166.95","other","Inpatient Replacement Plans DRG"
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,EXTREME","110","DRG","","","","","","","","inpatient","","","134711.08","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","59956.98","","Standard inlier is a Case rate ($59,956.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $58,273, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,511.25) for the length of stay and the standard reimbursement.","66653.36","66653.36","66653.36","1 through 10","7207.19","215641.76","case rate",""
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,EXTREME","110","DRG","","","","","","","","inpatient","","","134711.08","","MASSHEALTH [3001]","HB BWH MEDICAID","27373.37","","Case rate ($30,265.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $72,695.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","30258.55","30258.55","30258.55","1 through 10","7207.19","215641.76","case rate",""
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,EXTREME","110","DRG","","","","","","","","inpatient","","","134711.08","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70001.51","","Fee schedule rate ($70,001.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","70001.51","70001.51","70001.51","1 through 10","7207.19","215641.76","case rate",""
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,EXTREME","110","DRG","","","","","","","","inpatient","","","134711.08","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","27373.37","","Case rate ($30,265.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $72,695.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","30258.54","30258.54","30258.54","1 through 10","7207.19","215641.76","case rate",""
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,MAJOR","110","DRG","","","","","","","","inpatient","","","108910.13","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","36820.23","","Standard inlier is a Case rate ($36,820.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,280, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,226.85) for the length of stay and the standard reimbursement.","36820.22","36820.22","36820.22","1 through 10","7207.19","215641.76","case rate",""
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,MAJOR","110","DRG","","","","","","","","inpatient","","","108910.13","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","41395.86","","Standard inlier is a Case rate ($41,395.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,280, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,875.80) for the length of stay and the standard reimbursement.","45517.85","45517.85","45517.85","1 through 10","7207.19","215641.76","case rate",""
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,MAJOR","110","DRG","","","","","","","","inpatient","","","108910.13","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15786.6286","","Fee schedule rate ($86,428.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15786.6286","37236.60","37236.60","1 through 10","7207.19","215641.76","case rate",""
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,MAJOR","110","DRG","","","","","","","","inpatient","","","108910.13","","MASSHEALTH [3001]","HB BWH MEDICAID","16958.42","","Case rate ($18,750.45). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,180.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19713.80","19713.80","19713.80","1 through 10","7207.19","215641.76","case rate",""
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,MAJOR","110","DRG","","","","","","","","inpatient","","","108910.13","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","16958.42","","Case rate ($18,750.45). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,180.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18745.85","18745.85","18745.85","1 through 10","7207.19","215641.76","case rate",""
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,MINOR","110","DRG","","","","","","","","inpatient","","","16963.74","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15786.6286","","Fee schedule rate ($22,405.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15786.6286","15786.64","15786.64","1 through 10","7207.19","215641.76","case rate",""
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,MINOR","110","DRG","","","","","","","","inpatient","","","16963.74","","MASSHEALTH [3001]","HB BWH MEDICAID","7207.19","","Case rate ($7,968.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,398.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7966.83","7966.83","7966.83","1 through 10","7207.19","215641.76","case rate",""
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,MODERATE","110","DRG","","","","","","","","inpatient","","","35025.94","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","28575.32","","Standard inlier is a Case rate ($28,575.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,414, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,056.03) for the length of stay and the standard reimbursement.","28575.32","28575.32","28575.32","1 through 10","7207.19","215641.76","case rate",""
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,MODERATE","110","DRG","","","","","","","","inpatient","","","35025.94","","MASSHEALTH [3001]","HB BWH MEDICAID","9285.15","","Case rate ($10,266.33). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,696.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10263.81","10263.81","10263.81","1 through 10","7207.19","215641.76","case rate",""
"Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies,MODERATE","110","DRG","","","","","","","","inpatient","","","35025.94","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9285.15","","Case rate ($10,266.33). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,696.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10263.81","10263.81","10263.81","1 through 10","7207.19","215641.76","case rate",""
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","both","","","533.00","399.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","346.45","65","","336.05","336.05","336.05","1 through 10","42.07","423.74","percent of total billed charges",""
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","both","","","533.00","399.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","423.74","79.5","","406.88","406.88","406.88","1 through 10","42.07","423.74","percent of total billed charges",""
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","both","","","533.00","399.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","35.21","35.21","35.21","1 through 10","42.07","423.74","other","OPPS APC"
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","both","","","533.00","399.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","204.14","38.3","","202.15","202.15","202.15","1 through 10","42.07","423.74","percent of total billed charges",""
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","both","","","533.00","399.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.39","43.39","43.39","1 through 10","42.07","423.74","other","OPPS APC"
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","outpatient","","","533.00","399.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","278.55","52.26","","98.49","98.49","98.49","1 through 10","85.36","582.77","percent of total billed charges",""
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","outpatient","","","533.00","399.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","435.57","81.72","","227.32","227.32","227.32","1 through 10","85.36","582.77","percent of total billed charges",""
"Ecg Monitor/Report Up to 48 Hrs Rec","PX-73000007","CDM","93225","CPT","0731","RC","","","","both","","","1154.00","865.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.22","137.44","150.52","1 through 10","145.42","917.43","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","3210.00","2407.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","966.29","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","965.55","965.45","966.35","23","678.06","2551.95","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","3210.00","2407.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","923.23","787.33","923.23","29","678.06","2551.95","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","3210.00","2407.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","1172.69","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","25.00","25.00","25.00","1 through 10","678.06","2551.95","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","3210.00","2407.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","923.23","750.67","923.23","1 through 10","678.06","2551.95","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","3210.00","2407.50","ELDER SERVICES [1037]","HB BWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","873.88","873.88","873.88","1 through 10","678.06","2551.95","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","3210.00","2407.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","926.98","926.98","926.98","1 through 10","678.06","2551.95","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","3210.00","2407.50","HUMANA [1012]","HB BWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","925.10","919.48","927.58","1 through 10","678.06","2551.95","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","3210.00","2407.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","926.98","926.98","926.98","1 through 10","678.06","2551.95","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","3210.00","2407.50","MEDICARE [2001]","HB BWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","938.24","938.24","2814.72","486","678.06","2551.95","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","3210.00","2407.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","919.48","919.48","2758.44","1 through 10","678.06","2551.95","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","3210.00","2407.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","919.39","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2758.44","919.48","2759.64","35","678.06","2551.95","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","3210.00","2407.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","919.39","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","919.98","873.88","923.23","76","678.06","2551.95","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","3210.00","2407.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1377.09","42.9","","1368.79","1368.79","1368.79","1 through 10","678.06","2551.95","percent of total billed charges",""
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","outpatient","","","3210.00","2407.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2623.21","81.72","","2488.53","1368.79","2488.53","27","1142.94","3187.36","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","795.00","596.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","556.50","70","","555.12","555.12","555.12","1 through 10","246.45","632.03","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","795.00","596.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","632.03","79.5","","606.78","407.09","1820.34","23","246.45","632.03","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","795.00","596.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","423.74","53.3","","996.14","407.09","1820.34","21","246.45","632.03","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","246.45","31","","238.24","238.24","238.24","1 through 10","246.45","632.03","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","290.18","36.5","","287.58","244.41","862.74","37","246.45","632.03","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","304.49","38.3","","301.46","292.98","904.38","59","246.45","632.03","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","341.06","42.9","","339.01","339.01","616.34","1 through 10","246.45","632.03","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","795.00","596.25","AETNA [1001]","HB AMC AETNA HMO","554.91","69.8","","521.97","521.97","521.97","1 through 10","415.47","649.67","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","795.00","596.25","AETNA [1001]","HB AMC AETNA PPO","639.18","80.4","","601.38","601.38","601.38","1 through 10","415.47","649.67","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","649.67","81.72","","616.34","616.34","616.34","1 through 10","415.47","649.67","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","649.67","81.72","","616.34","339.01","616.34","12","415.47","649.67","percent of total billed charges",""
"Echo Congenital Anomaly Cmpl W/Cont or W/O Fol W/Cont","PX-48000180","CDM","C8921","HCPCS","0483","RC","","","","both","","","2608.00","1956.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1390.06","53.3","","5970.96","3267.47","5970.96","1 through 10","678.06","2073.36","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","1110.00","832.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","777.00","70","","774.72","774.72","774.72","1 through 10","344.1","882.45","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","1110.00","832.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","882.45","79.5","","568.13","568.13","2540.43","11","344.1","882.45","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","1110.00","832.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","591.63","53.3","","1704.39","568.13","2540.43","17","344.1","882.45","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","1110.00","832.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","405.15","36.5","","1204.05","401.35","1204.05","13","344.1","882.45","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","1110.00","832.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","425.13","38.3","","420.72","420.72","1262.16","23","344.1","882.45","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","1110.00","832.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","476.19","42.9","","473.12","473.12","473.12","1 through 10","344.1","882.45","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","1110.00","832.50","AETNA [1001]","HB AMC AETNA HMO","774.78","69.8","","728.45","728.45","728.45","1 through 10","580.09","907.09","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","1110.00","832.50","AETNA [1001]","HB AMC AETNA PPO","892.44","80.4","","839.28","839.28","839.28","1 through 10","580.09","907.09","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","1110.00","832.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","907.09","81.72","","860.15","803.21","860.16","1 through 10","580.09","907.09","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","581.00","435.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","406.70","70","","405.36","405.36","405.36","1 through 10","180.11","461.9","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","581.00","435.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","461.90","79.5","","443.08","443.08","443.08","13","180.11","461.9","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","581.00","435.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","309.67","53.3","","508.02","297.26","998.90","1 through 10","180.11","461.9","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","581.00","435.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","180.11","31","","173.97","173.97","173.97","1 through 10","180.11","461.9","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","581.00","435.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","212.07","36.5","","210.00","178.47","630.00","23","180.11","461.9","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","581.00","435.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","222.52","38.3","","220.13","213.94","427.88","39","180.11","461.9","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","581.00","435.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.25","42.9","","450.06","450.06","450.06","1 through 10","180.11","461.9","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","581.00","435.75","AETNA [1001]","HB AMC AETNA HMO","405.54","69.8","","381.15","381.15","381.15","1 through 10","303.63","474.79","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","474.79","81.72","","450.06","450.06","450.06","1 through 10","303.63","474.79","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","474.79","81.72","","450.06","247.55","450.06","1 through 10","303.63","474.79","percent of total billed charges",""
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","2928.00","2196.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","966.29","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","965.45","965.45","965.45","1 through 10","678.06","2327.76","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","2928.00","2196.00","MEDICARE [2001]","HB BWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","938.24","938.24","938.24","1 through 10","678.06","2327.76","other","OPPS APC"
"Echo Tee Cmpl W/Pf W/Cont or W/O Fol W/Cont","PX-48000190","CDM","C8925","HCPCS","0483","RC","","","","both","","","4294.00","3220.50","MEDICARE [2001]","HB BWH MEDICARE","938.15","","APC Price ($938.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","938.24","938.24","938.24","1 through 10","891.33","3413.73","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3641.00","2730.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.72","365.77","640.72","13","618.58","2894.6","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3641.00","2730.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2548.70","70","","2542.32","2542.32","2542.32","1 through 10","618.58","2894.6","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3641.00","2730.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2894.60","79.5","","2778.90","2778.90","2778.90","1 through 10","618.58","2894.6","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3641.00","2730.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1940.65","53.3","","6426.82","6426.82","6426.82","1 through 10","618.58","2894.6","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3641.00","2730.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.72","640.72","640.72","1 through 10","618.58","2894.6","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3641.00","2730.75","FALLON HEALTH [1008]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1855.36","1180.14","1855.36","1 through 10","618.58","2894.6","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3641.00","2730.75","MEDICARE [2001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","602.11","1953.42","178","618.58","2894.6","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3641.00","2730.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1328.97","36.5","","3951.18","1317.06","3951.18","1 through 10","618.58","2894.6","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3641.00","2730.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1394.50","38.3","","1380.62","1380.62","1380.62","1 through 10","618.58","2894.6","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3641.00","2730.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","638.12","638.12","638.52","1 through 10","618.58","2894.6","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3641.00","2730.75","TRICARE [160005]","HB BWH TRICARE","618.58","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","618.58","618.58","618.58","1 through 10","618.58","2894.6","other","Tricare OPPS"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3641.00","2730.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","638.52","638.12","1914.36","1 through 10","618.58","2894.6","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3641.00","2730.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","638.32","592.97","643.12","15","618.58","2894.6","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","outpatient","","","3641.00","2730.75","AETNA [1001]","HB AMC AETNA HMO","2541.42","69.8","","2390.49","2390.49","2390.49","1 through 10","1142.94","4543.76","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","outpatient","","","3641.00","2730.75","AETNA [1001]","HB AMC AETNA PPO","2927.36","80.4","","2754.18","2754.18","2754.18","1 through 10","1142.94","4543.76","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","outpatient","","","3641.00","2730.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2975.43","81.72","","2822.68","2822.68","2822.68","1 through 10","1142.94","4543.76","percent of total billed charges",""
"Echo Transthorac R-T 2d W/WO M-Mode Rec Comp","PX-48000415","CDM","93307","CPT","0483","RC","","","","both","","","2302.00","1726.50","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","267.44","267.44","267.44","1 through 10","272.7","1830.09","other","OPPS APC"
"Echo Transthorac R-T 2d W/WO M-Mode Rec Comp","PX-48000415","CDM","93307","CPT","0483","RC","","","","outpatient","","","2302.00","1726.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1881.19","81.72","","1784.26","1784.26","1784.26","1 through 10","529.69","3187.36","percent of total billed charges",""
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","1483.00","1112.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","316.25","1178.99","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","1483.00","1112.25","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1272.33","30","316.25","1178.99","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","1483.00","1112.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.63","415.63","418.25","1 through 10","316.25","1178.99","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","outpatient","","","1483.00","1112.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1211.91","81.72","","1149.54","1149.54","1149.54","1 through 10","529.69","1723.57","percent of total billed charges",""
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","outpatient","","","1483.00","1112.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1211.91","81.72","","1149.54","1149.54","1149.54","1 through 10","529.69","1723.57","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","17","272.7","1159.91","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1021.30","70","","1018.80","1018.80","1018.80","1 through 10","272.7","1159.91","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","358.78","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","144.97","144.97","144.97","1 through 10","272.7","1159.91","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1159.91","79.5","","1113.61","1113.61","1113.61","13","272.7","1159.91","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","777.65","53.3","","1307.20","747.12","2654.77","13","272.7","1159.91","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","281.32","281.32","1 through 10","272.7","1159.91","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1123.43","77","","1089.55","287.06","1089.55","1 through 10","272.7","1159.91","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.19","283.04","284.19","1 through 10","272.7","1159.91","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","861.18","234","272.7","1159.91","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","452.29","31","","437.24","437.24","437.24","1 through 10","272.7","1159.91","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","532.54","36.5","","527.80","512.23","730.56","11","272.7","1159.91","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","558.80","38.3","","553.27","546.44","1613.10","41","272.7","1159.91","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.72","262.09","845.16","1 through 10","272.7","1159.91","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1123.43","77","","1066.91","1066.91","1066.91","1 through 10","272.7","1159.91","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","287.06","272.71","287.06","1 through 10","272.7","1159.91","other","Tricare OPPS"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.92","281.32","845.16","14","272.7","1159.91","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.72","263.12","286.32","31","272.7","1159.91","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","625.91","42.9","","1131.15","1131.15","1131.15","1 through 10","272.7","1159.91","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","outpatient","","","1459.00","1094.25","AETNA [1001]","HB AMC AETNA HMO","1018.38","69.8","","1915.92","957.96","1915.92","1 through 10","529.69","1723.57","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","outpatient","","","1459.00","1094.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1192.29","81.72","","1131.15","1131.15","1131.15","1 through 10","529.69","1723.57","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","outpatient","","","1459.00","1094.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1192.29","81.72","","1131.15","622.18","1131.15","1 through 10","529.69","1723.57","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","17","272.7","1159.91","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1021.30","70","","1018.80","1018.80","1018.80","1 through 10","272.7","1159.91","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","358.78","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","144.97","144.97","144.97","1 through 10","272.7","1159.91","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1159.91","79.5","","1113.61","1113.61","1113.61","13","272.7","1159.91","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","777.65","53.3","","1307.20","747.12","2654.77","13","272.7","1159.91","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","281.32","281.32","1 through 10","272.7","1159.91","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1123.43","77","","1089.55","287.06","1089.55","1 through 10","272.7","1159.91","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.19","283.04","284.19","1 through 10","272.7","1159.91","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","861.18","234","272.7","1159.91","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","452.29","31","","437.24","437.24","437.24","1 through 10","272.7","1159.91","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","532.54","36.5","","527.80","512.23","730.56","11","272.7","1159.91","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","558.80","38.3","","553.27","546.44","1613.10","41","272.7","1159.91","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.72","262.09","845.16","1 through 10","272.7","1159.91","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1123.43","77","","1066.91","1066.91","1066.91","1 through 10","272.7","1159.91","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","287.06","272.71","287.06","1 through 10","272.7","1159.91","other","Tricare OPPS"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.92","281.32","845.16","14","272.7","1159.91","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.72","263.12","286.32","31","272.7","1159.91","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1459.00","1094.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","625.91","42.9","","1131.15","1131.15","1131.15","1 through 10","272.7","1159.91","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","outpatient","","","1459.00","1094.25","AETNA [1001]","HB AMC AETNA HMO","1018.38","69.8","","1915.92","957.96","1915.92","1 through 10","529.69","1723.57","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","outpatient","","","1459.00","1094.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1192.29","81.72","","1131.15","1131.15","1131.15","1 through 10","529.69","1723.57","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","outpatient","","","1459.00","1094.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1192.29","81.72","","1131.15","622.18","1131.15","1 through 10","529.69","1723.57","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2961.00","2220.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.72","640.72","2788.00","16","618.58","2354","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2961.00","2220.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2354.00","79.5","","1515.89","1515.89","1515.89","1 through 10","618.58","2354","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2961.00","2220.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1578.21","53.3","","5386.46","1515.89","5386.46","1 through 10","618.58","2354","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2961.00","2220.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","592.48","517.22","640.72","1 through 10","618.58","2354","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2961.00","2220.75","HUMANA [1012]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.32","640.32","640.32","1 through 10","618.58","2354","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2961.00","2220.75","MEDICARE [2001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","602.11","651.14","79","618.58","2354","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2961.00","2220.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1080.77","36.5","","1070.88","1039.30","1070.88","1 through 10","618.58","2354","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2961.00","2220.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1134.06","38.3","","1122.56","1110.05","2181.96","16","618.58","2354","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2961.00","2220.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","638.52","638.12","638.52","1 through 10","618.58","2354","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2961.00","2220.75","TRICARE [160005]","HB BWH TRICARE","618.58","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","618.58","618.58","618.58","1 through 10","618.58","2354","other","Tricare OPPS"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2961.00","2220.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","638.12","590.47","638.52","1 through 10","618.58","2354","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2961.00","2220.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","639.12","590.47","643.12","16","618.58","2354","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","2961.00","2220.75","AETNA [1001]","HB AMC AETNA HMO","2066.78","69.8","","1943.67","1943.67","1943.67","1 through 10","1142.94","3187.36","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St|REDUCED SERVICES","PX-48000418","CDM","93350","CPT","0483","RC","","","52","both","","","2961.00","2220.75","MEDICARE [2001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.57","325.57","325.57","1 through 10","618.58","813.84","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0480","RC","","","","inpatient","","","3193.00","2394.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2510.02","78.61","","2474.94","2474.94","2474.94","1 through 10","1765.73","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.72","592.48","640.72","412","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2292.57","71.8","","2222.93","686.94","6668.79","1 through 10","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2094.61","65.6","","2095.99","671.93","2414.88","13","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2075.45","65","","2012.40","2012.40","2436.55","17","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2235.10","70","","2229.12","651.14","2905.20","76","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICAID REPLACEMENT","813.84","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","651.14","651.14","651.14","1 through 10","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","813.84","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","651.14","250.00","1302.28","17","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","CHAMPVA [160001]","HB BWH TRICARE","618.58","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","602.11","602.11","602.11","1 through 10","618.58","2538.44","other","Tricare OPPS"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2538.44","79.5","","2436.55","1634.69","7309.65","312","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","CIGNA [1006]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","638.12","638.12","638.12","1 through 10","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1701.87","53.3","","2436.55","1634.69","7309.65","147","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.72","542.51","640.72","52","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","ELDER SERVICES [1037]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","602.11","651.14","1 through 10","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","FALLON HEALTH [1008]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","925.16","638.12","1953.42","19","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1917.06","602.11","1917.06","1 through 10","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","2458.61","77","","2383.92","2383.92","2383.92","1 through 10","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","638.12","638.12","1914.36","1 through 10","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","HUMANA [1012]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","642.02","638.12","644.63","25","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2075.45","65","","2012.40","2012.40","2012.40","1 through 10","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2538.44","79.5","","2436.55","2436.55","2436.55","1 through 10","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","2075.45","65","","2622.75","2622.75","2622.75","1 through 10","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.07","638.12","640.07","15","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","MEDICARE [2001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","651.14","1953.42","4281","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","989.83","31","","956.66","956.66","981.43","1 through 10","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1165.45","36.5","","1154.81","981.43","2174.38","189","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1222.92","38.3","","1210.54","1210.54","3631.62","558","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","638.52","590.47","1819.46","123","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","MOLINA [1014]","HB BWH MOLINA","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1291.86","1204.22","3875.58","39","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2458.61","77","","2414.88","1956.15","2665.55","1 through 10","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","TRICARE [160005]","HB BWH TRICARE","618.58","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","651.14","618.58","651.14","20","618.58","2538.44","other","Tricare OPPS"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","618.58","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","602.11","602.11","602.11","1 through 10","618.58","2538.44","other","Tricare OPPS"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","638.72","638.12","1922.16","337","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","712.08","712.08","712.08","1 through 10","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1369.80","42.9","","1408.68","1361.31","2474.94","1 through 10","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","638.05","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","638.72","595.07","643.12","653","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1369.80","42.9","","1361.31","1361.31","2474.94","1 through 10","618.58","2538.44","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","WELLSENSE [1003]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","657.65","657.65","657.65","1 through 10","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3193.00","2394.75","WELLSENSE NH [1050]","HB BWH MEDICARE","651.07","","APC Price ($651.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","643.33","643.33","643.33","1 through 10","618.58","2538.44","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3193.00","2394.75","AETNA [1001]","HB AMC AETNA HMO","2228.71","69.8","","2095.99","2095.99","6287.97","23","1142.94","3187.36","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3193.00","2394.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1668.66","52.26","","1915.80","1318.73","1915.81","1 through 10","1142.94","3187.36","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3193.00","2394.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2567.17","80.4","","2414.88","1548.00","2414.88","12","1142.94","3187.36","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3193.00","2394.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","2609.32","81.72","","2474.94","2306.45","3096.00","1 through 10","1142.94","3187.36","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3193.00","2394.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2609.32","81.72","","1361.31","1361.31","2474.94","1 through 10","1142.94","3187.36","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3193.00","2394.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2609.32","81.72","","2474.94","1361.31","2474.94","265","1142.94","3187.36","percent of total billed charges",""
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures","003","MS-DRG","","","","","","","","inpatient","","","1099428.59","824571.44","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","199818.30","","Case rate ($193,998.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $233,458.35, add-ons for qualifying new technology services are included. If operating cost exceeds $279,102.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $19,519.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.9. The base transfer operating payment is the transfer adjustment factor * $176,539.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $233,078.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $17,079.04. The transfer capital threshold is the transfer adjustment factor * $17,079.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","200972.47","200575.42","358698.82","1 through 10","190118.38","332471.53","other","Inpatient DRG"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures","003","MS-DRG","","","","","","","","inpatient","","","1099428.59","824571.44","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","251663.39","","Case rate ($251,663.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $233,458.35, add-ons for qualifying new technology services are included. If operating cost exceeds $279,102.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $19,519.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.9. The base transfer operating payment is the transfer adjustment factor * $234,204.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $233,078.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $17,079.04. The transfer capital threshold is the transfer adjustment factor * $17,079.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","420895.39","195115.17","1721907.18","1 through 10","190118.38","332471.53","other","Inpatient DRG"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures","003","MS-DRG","","","","","","","","inpatient","","","1099428.59","824571.44","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","242497.94","","Case rate ($193,998.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $233,458.35, add-ons for qualifying new technology services are included. If operating cost exceeds $279,102.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $19,519.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.9. The base transfer operating payment is the transfer adjustment factor * $176,539.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $233,078.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $17,079.04. The transfer capital threshold is the transfer adjustment factor * $17,079.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","788042.53","788042.53","900537.13","1 through 10","190118.38","332471.53","other","Inpatient DRG"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures","003","MS-DRG","","","","","","","","inpatient","","","1099428.59","824571.44","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","193998.35","","Case rate ($193,998.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $233,458.35, add-ons for qualifying new technology services are included. If operating cost exceeds $279,102.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $19,519.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.9. The base transfer operating payment is the transfer adjustment factor * $176,539.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $233,078.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $17,079.04. The transfer capital threshold is the transfer adjustment factor * $17,079.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","187693.92","187693.92","650558.11","1 through 10","190118.38","332471.53","other","Inpatient DRG"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures","003","MS-DRG","","","","","","","","inpatient","","","1099428.59","824571.44","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","220078.10","164950.76","259890.42","1 through 10","190118.38","332471.53","case rate",""
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures","003","MS-DRG","","","","","","","","inpatient","","","1099428.59","824571.44","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","251663.39","","Case rate ($251,663.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $233,458.35, add-ons for qualifying new technology services are included. If operating cost exceeds $279,102.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $19,519.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.9. The base transfer operating payment is the transfer adjustment factor * $234,204.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $233,078.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $17,079.04. The transfer capital threshold is the transfer adjustment factor * $17,079.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","191631.83","191631.83","191631.83","1 through 10","190118.38","332471.53","other","Inpatient DRG"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures","003","MS-DRG","","","","","","","","inpatient","","","1099428.59","824571.44","MEDICARE [2001]","HB BWH MEDICARE","251663.39","","Case rate ($251,663.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $233,458.35, add-ons for qualifying new technology services are included. If operating cost exceeds $279,102.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $19,519.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.9. The base transfer operating payment is the transfer adjustment factor * $234,204.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $233,078.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $17,079.04. The transfer capital threshold is the transfer adjustment factor * $17,079.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","252938.74","0.03","488622.72","49","190118.38","332471.53","other","Inpatient DRG"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures","003","MS-DRG","","","","","","","","inpatient","","","1099428.59","824571.44","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","251663.39","","Case rate ($251,663.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $233,458.35, add-ons for qualifying new technology services are included. If operating cost exceeds $279,102.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $19,519.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.9. The base transfer operating payment is the transfer adjustment factor * $234,204.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $233,078.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $17,079.04. The transfer capital threshold is the transfer adjustment factor * $17,079.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","260120.85","260120.85","260120.85","1 through 10","190118.38","332471.53","other","Inpatient DRG"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures","003","MS-DRG","","","","","","","","inpatient","","","1099428.59","824571.44","MOLINA [1014]","HB BWH MOLINA","190118.38","","Case rate ($193,998.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $233,458.35, add-ons for qualifying new technology services are included. If operating cost exceeds $279,102.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $19,519.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.9. The base transfer operating payment is the transfer adjustment factor * $176,539.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $233,078.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $17,079.04. The transfer capital threshold is the transfer adjustment factor * $17,079.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","353018.21","353018.21","353018.21","1 through 10","190118.38","332471.53","other","Inpatient DRG"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures","003","MS-DRG","","","","","","","","inpatient","","","1099428.59","824571.44","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","190118.38","","Case rate ($193,998.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $233,458.35, add-ons for qualifying new technology services are included. If operating cost exceeds $279,102.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $19,519.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.9. The base transfer operating payment is the transfer adjustment factor * $176,539.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $233,078.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $17,079.04. The transfer capital threshold is the transfer adjustment factor * $17,079.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","190948.04","166428.98","1958033.21","1 through 10","190118.38","332471.53","other","Inpatient DRG"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major O.R. Procedures","003","MS-DRG","","","","","","","","inpatient","","","1099428.59","824571.44","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","190118.38","","Case rate ($193,998.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $233,458.35, add-ons for qualifying new technology services are included. If operating cost exceeds $279,102.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $19,519.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.9. The base transfer operating payment is the transfer adjustment factor * $176,539.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $233,078.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $17,079.04. The transfer capital threshold is the transfer adjustment factor * $17,079.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","191587.49","191210.50","357154.82","11","190118.38","332471.53","other","Inpatient DRG"
"Ectopic Pregnancy Procedure,MODERATE","545","DRG","","","","","","","","inpatient","","","42017.45","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16518.0295","","Fee schedule rate ($19,707.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16518.0295","19707.56","19707.56","1 through 10","15192.08","32517.88","case rate",""
"Edg US Guided Transmural Injxn/Fiducial Marker","PX-75000391","CDM","43253","CPT","0750","RC","","","","both","","","3757.00","2817.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2043.55","2043.55","2043.55","1 through 10","1164.67","2986.82","other","OPPS APC"
"Edg US Guided Transmural Injxn/Fiducial Marker","PX-75000391","CDM","43253","CPT","0750","RC","","","","both","","","3757.00","2817.75","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1164.67","2986.82","other","OPPS APC"
"Edg US Guided Transmural Injxn/Fiducial Marker","PX-75000391","CDM","43253","CPT","0750","RC","","","","outpatient","","","3757.00","2817.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3871.56","3871.56","3871.56","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2328.00","1746.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","337.09","363.89","1 through 10","351.32","1850.76","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2328.00","1746.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1850.76","79.5","","1777.05","1192.22","1777.05","1 through 10","351.32","1850.76","percent of total billed charges",""
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2328.00","1746.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1240.82","53.3","","1192.22","1192.22","1777.05","1 through 10","351.32","1850.76","percent of total billed charges",""
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2328.00","1746.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","1 through 10","351.32","1850.76","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2328.00","1746.00","HUMANA [1012]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","368.42","368.42","368.42","1 through 10","351.32","1850.76","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2328.00","1746.00","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","73","351.32","1850.76","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2328.00","1746.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","849.72","36.5","","842.23","817.40","842.23","1 through 10","351.32","1850.76","percent of total billed charges",""
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2328.00","1746.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","891.62","38.3","","882.88","882.88","882.88","1 through 10","351.32","1850.76","percent of total billed charges",""
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2328.00","1746.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","362.41","362.41","1 through 10","351.32","1850.76","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2328.00","1746.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1792.56","77","","1777.05","395.34","1777.05","1 through 10","351.32","1850.76","percent of total billed charges",""
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2328.00","1746.00","TRICARE [160005]","HB BWH TRICARE","351.32","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","369.81","369.81","369.81","1 through 10","351.32","1850.76","other","Tricare OPPS"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2328.00","1746.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.81","362.41","362.81","1 through 10","351.32","1850.76","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2328.00","1746.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","363.42","362.92","363.90","12","351.32","1850.76","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","outpatient","","","2328.00","1746.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1902.44","81.72","","1805.04","615.64","1805.05","1 through 10","579.66","1902.44","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","1 through 10","351.32","1614.65","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1332.34","65.6","","941.66","941.66","941.66","1 through 10","351.32","1614.65","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1614.65","79.5","","1550.39","1040.16","1550.39","11","351.32","1614.65","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1082.52","53.3","","1550.39","1550.39","1550.39","1 through 10","351.32","1614.65","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","362.41","363.89","1 through 10","351.32","1614.65","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","1109.43","88","351.32","1614.65","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","741.32","36.5","","734.81","624.49","734.81","1 through 10","351.32","1614.65","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","777.87","38.3","","770.27","770.27","2310.81","16","351.32","1614.65","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.81","362.81","362.81","1 through 10","351.32","1614.65","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","TRICARE [160005]","HB BWH TRICARE","351.32","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","369.81","369.81","369.81","1 through 10","351.32","1614.65","other","Tricare OPPS"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.81","362.41","363.89","1 through 10","351.32","1614.65","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","871.30","42.9","","1574.82","1574.82","1574.82","1 through 10","351.32","1614.65","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","363.42","335.72","363.89","12","351.32","1614.65","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","2031.00","1523.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","871.30","42.9","","1574.82","1574.82","1574.82","1 through 10","351.32","1614.65","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","outpatient","","","2031.00","1523.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1061.40","52.26","","668.81","668.81","668.81","1 through 10","579.66","1659.73","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","outpatient","","","2031.00","1523.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1659.73","81.72","","1574.82","645.91","1574.82","1 through 10","579.66","1659.73","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","2474.00","1855.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","903.01","36.5","","760.48","760.48","760.48","1 through 10","176.52","1966.83","percent of total billed charges",""
"Eeg Intraop per Hr","PX-74000037","CDM","95955","CPT","0740","RC","","","","both","","","1182.00","886.50","WELLPOINT [1015]","HB AMC WELLPOINT","872.08","73.78","","1999.20","853.20","1999.20","1 through 10","366.42","939.69","percent of total billed charges",""
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","2232.00","1674.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","363.42","363.42","363.42","1 through 10","351.32","1774.44","other","OPPS APC"
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","both","","","3660.00","2745.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","2909.7","other","OPPS APC"
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","both","","","3660.00","2745.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","2909.7","other","OPPS APC"
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","both","","","3660.00","2745.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2909.70","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","2909.7","percent of total billed charges",""
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","both","","","3660.00","2745.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","2909.7","other","OPPS APC"
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","both","","","3660.00","2745.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","2909.7","other","OPPS APC"
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","both","","","3660.00","2745.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1335.90","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","2909.7","percent of total billed charges",""
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","both","","","3660.00","2745.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1401.78","38.3","","2723.31","1555.62","2741.61","12","1057.74","2909.7","percent of total billed charges",""
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","both","","","3660.00","2745.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","2909.7","other","OPPS APC"
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","both","","","3660.00","2745.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","2909.7","other","OPPS APC"
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","both","","","3660.00","2745.00","WELLPOINT [1015]","HB AMC WELLPOINT","2700.35","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","2909.7","percent of total billed charges",""
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","outpatient","","","3660.00","2745.00","AETNA [1001]","HB AMC AETNA PPO","2942.64","80.4","","1163.76","1163.76","1163.76","1 through 10","1830","3019.5","percent of total billed charges",""
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","outpatient","","","3660.00","2745.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2216.13","60.55","","1781.82","1492.00","4331.00","1 through 10","1830","3019.5","percent of total billed charges",""
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","outpatient","","","3660.00","2745.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1911.25","52.22","","3144.00","1492.00","3610.00","13","1830","3019.5","percent of total billed charges",""
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","outpatient","","","3660.00","2745.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1921.50","52.5","","1182.28","1182.28","1182.28","1 through 10","1830","3019.5","percent of total billed charges",""
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","outpatient","","","3660.00","2745.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1830.00","50","","3610.00","2269.44","3610.00","1 through 10","1830","3019.5","percent of total billed charges",""
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","outpatient","","","3660.00","2745.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1921.50","52.5","","3610.00","2382.05","4331.00","1 through 10","1830","3019.5","percent of total billed charges",""
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","outpatient","","","3660.00","2745.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2013.00","55","","4810.75","3363.17","4810.75","1 through 10","1830","3019.5","percent of total billed charges",""
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","outpatient","","","3660.00","2745.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2990.95","81.72","","8894.69","8894.69","8894.69","1 through 10","1830","3019.5","percent of total billed charges",""
"Egd Alone Myotomy Pop","PX-75000498","CDM","43999","CPT","0750","RC","","","","outpatient","","","3660.00","2745.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2990.95","81.72","","2885.83","2132.00","3462.21","1 through 10","1830","3019.5","percent of total billed charges",""
"Egd Duodenum With Endoscopic Submucosal Dissection (Esd)","PX-75000486","CDM","44799","CPT","0750","RC","","","","both","","","3242.00","2431.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4653.18","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1005.02","5647.06","other","OPPS APC"
"Egd Duodenum With Endoscopic Submucosal Dissection (Esd)","PX-75000486","CDM","44799","CPT","0750","RC","","","","both","","","3242.00","2431.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1005.02","5647.06","other","OPPS APC"
"Egd Duodenum With Endoscopic Submucosal Dissection (Esd)","PX-75000486","CDM","44799","CPT","0750","RC","","","","both","","","3242.00","2431.50","MEDICARE [2001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1005.02","5647.06","other","OPPS APC"
"Egd Duodenum With Endoscopic Submucosal Dissection (Esd)","PX-75000486","CDM","44799","CPT","0750","RC","","","","both","","","3242.00","2431.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4427.30","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1005.02","5647.06","other","OPPS APC"
"Egd Duodenum With Endoscopic Submucosal Dissection (Esd)","PX-75000486","CDM","44799","CPT","0750","RC","","","","both","","","3242.00","2431.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1390.82","42.9","","1932.92","1932.92","1932.92","1 through 10","1005.02","5647.06","percent of total billed charges",""
"Egd Duodenum With Endoscopic Submucosal Dissection (Esd)","PX-75000486","CDM","44799","CPT","0750","RC","","","","both","","","3242.00","2431.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4427.30","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1005.02","5647.06","other","OPPS APC"
"Egd Duodenum With Endoscopic Submucosal Dissection (Esd)","PX-75000486","CDM","44799","CPT","0750","RC","","","","both","","","3242.00","2431.50","WELLPOINT [1015]","HB AMC WELLPOINT","2391.95","73.78","","2222.33","2222.33","2222.33","1 through 10","1005.02","5647.06","percent of total billed charges",""
"Egd Duodenum With Endoscopic Submucosal Dissection (Esd)","PX-75000486","CDM","44799","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","AETNA [1001]","HB AMC AETNA HMO","2262.92","69.8","","2238.60","2238.60","2238.60","1 through 10","1621","8899.59","percent of total billed charges",""
"Egd Duodenum With Endoscopic Submucosal Dissection (Esd)","PX-75000486","CDM","44799","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1963.03","60.55","","3144.00","2870.00","3286.00","1 through 10","1621","8899.59","percent of total billed charges",""
"Egd Duodenum With Endoscopic Submucosal Dissection (Esd)","PX-75000486","CDM","44799","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1694.27","52.26","","1775.96","1775.96","1775.96","1 through 10","1621","8899.59","percent of total billed charges",""
"Egd Duodenum With Endoscopic Submucosal Dissection (Esd)","PX-75000486","CDM","44799","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1692.97","52.22","","3286.00","2018.70","5898.00","1 through 10","1621","8899.59","percent of total billed charges",""
"Egd Duodenum With Endoscopic Submucosal Dissection (Esd)","PX-75000486","CDM","44799","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1702.05","52.5","","8340.00","8340.00","8340.00","1 through 10","1621","8899.59","percent of total billed charges",""
"Egd Duodenum With Endoscopic Submucosal Dissection (Esd)","PX-75000486","CDM","44799","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2649.36","81.72","","2294.28","682.69","2294.28","1 through 10","1621","8899.59","percent of total billed charges",""
"Egd Electrohydraulic Lithotripsy(Ehl) Lg Calculi Sm Bowel","PX-75000509","CDM","44799","CPT","0750","RC","","","","both","","","7447.00","5585.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1057.74","5920.37","other","OPPS APC"
"Egd Electrohydraulic Lithotripsy(Ehl) Lg Calculi Sm Bowel","PX-75000509","CDM","44799","CPT","0750","RC","","","","both","","","7447.00","5585.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","5920.37","other","OPPS APC"
"Egd Electrohydraulic Lithotripsy(Ehl) Lg Calculi Sm Bowel","PX-75000509","CDM","44799","CPT","0750","RC","","","","both","","","7447.00","5585.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","5920.37","other","OPPS APC"
"Egd Electrohydraulic Lithotripsy(Ehl) Lg Calculi Sm Bowel","PX-75000509","CDM","44799","CPT","0750","RC","","","","both","","","7447.00","5585.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1057.74","5920.37","other","OPPS APC"
"Egd Electrohydraulic Lithotripsy(Ehl) Lg Calculi Sm Bowel","PX-75000509","CDM","44799","CPT","0750","RC","","","","both","","","7447.00","5585.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3194.76","42.9","","1932.92","1932.92","1932.92","1 through 10","1057.74","5920.37","percent of total billed charges",""
"Egd Electrohydraulic Lithotripsy(Ehl) Lg Calculi Sm Bowel","PX-75000509","CDM","44799","CPT","0750","RC","","","","both","","","7447.00","5585.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1057.74","5920.37","other","OPPS APC"
"Egd Electrohydraulic Lithotripsy(Ehl) Lg Calculi Sm Bowel","PX-75000509","CDM","44799","CPT","0750","RC","","","","both","","","7447.00","5585.25","WELLPOINT [1015]","HB AMC WELLPOINT","5494.40","73.78","","2222.33","2222.33","2222.33","1 through 10","1057.74","5920.37","percent of total billed charges",""
"Egd Electrohydraulic Lithotripsy(Ehl) Lg Calculi Sm Bowel","PX-75000509","CDM","44799","CPT","0750","RC","","","","outpatient","","","7447.00","5585.25","AETNA [1001]","HB AMC AETNA HMO","5198.01","69.8","","2238.60","2238.60","2238.60","1 through 10","3723.5","8899.59","percent of total billed charges",""
"Egd Electrohydraulic Lithotripsy(Ehl) Lg Calculi Sm Bowel","PX-75000509","CDM","44799","CPT","0750","RC","","","","outpatient","","","7447.00","5585.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4509.16","60.55","","3144.00","2870.00","3286.00","1 through 10","3723.5","8899.59","percent of total billed charges",""
"Egd Electrohydraulic Lithotripsy(Ehl) Lg Calculi Sm Bowel","PX-75000509","CDM","44799","CPT","0750","RC","","","","outpatient","","","7447.00","5585.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3891.80","52.26","","1775.96","1775.96","1775.96","1 through 10","3723.5","8899.59","percent of total billed charges",""
"Egd Electrohydraulic Lithotripsy(Ehl) Lg Calculi Sm Bowel","PX-75000509","CDM","44799","CPT","0750","RC","","","","outpatient","","","7447.00","5585.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3888.82","52.22","","3286.00","2018.70","5898.00","1 through 10","3723.5","8899.59","percent of total billed charges",""
"Egd Electrohydraulic Lithotripsy(Ehl) Lg Calculi Sm Bowel","PX-75000509","CDM","44799","CPT","0750","RC","","","","outpatient","","","7447.00","5585.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3909.68","52.5","","8340.00","8340.00","8340.00","1 through 10","3723.5","8899.59","percent of total billed charges",""
"Egd Electrohydraulic Lithotripsy(Ehl) Lg Calculi Sm Bowel","PX-75000509","CDM","44799","CPT","0750","RC","","","","outpatient","","","7447.00","5585.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6085.69","81.72","","2294.28","682.69","2294.28","1 through 10","3723.5","8899.59","percent of total billed charges",""
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","both","","","2379.00","1784.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","780.69","2216.75","1 through 10","737.49","2815.7","other","OPPS APC"
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","both","","","2379.00","1784.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1891.31","79.5","","1815.61","1815.61","1815.61","1 through 10","737.49","2815.7","percent of total billed charges",""
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","both","","","2379.00","1784.25","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","28","737.49","2815.7","other","OPPS APC"
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","both","","","2379.00","1784.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","868.34","36.5","","731.32","731.32","731.32","1 through 10","737.49","2815.7","percent of total billed charges",""
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","both","","","2379.00","1784.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","911.16","38.3","","902.04","902.04","902.04","1 through 10","737.49","2815.7","percent of total billed charges",""
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","both","","","2379.00","1784.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","2140.15","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2252.79","2252.79","2252.79","1 through 10","737.49","2815.7","other","Tricare OPPS"
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","both","","","2379.00","1784.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.24","2207.73","2215.24","1 through 10","737.49","2815.7","other","OPPS APC"
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","outpatient","","","2379.00","1784.25","AETNA [1001]","HB AMC AETNA HMO","1660.54","69.8","","1561.84","1561.84","1561.84","1 through 10","1243.27","2384.07","percent of total billed charges",""
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","outpatient","","","2379.00","1784.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3407.87","1735.32","3470.63","1 through 10","1243.27","2384.07","other","ASC"
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","outpatient","","","2379.00","1784.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1985.52","1966.01","3971.04","1 through 10","1243.27","2384.07","other","ASC "
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","outpatient","","","2379.00","1784.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3097.25","1548.63","3097.25","1 through 10","1243.27","2384.07","other","Multiple Surgery"
"Egd Endo Mucosal Resection|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA","PX-75000357","CDM","43254","CPT","0750","RC","","","74","both","","","2379.00","1784.25","MEDICARE [2001]","HB BWH MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","2207.73","2815.99","other","OPPS APC"
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","both","","","8885.00","6663.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6956.21","6956.21","6956.21","1 through 10","2754.35","8835.76","other","OPPS APC"
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","both","","","8885.00","6663.75","CIGNA [1006]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6933.59","6933.59","6933.59","1 through 10","2754.35","8835.76","other","OPPS APC"
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","both","","","8885.00","6663.75","MEDICARE [2001]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7069.32","6220.28","7069.32","14","2754.35","8835.76","other","OPPS APC"
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","both","","","8885.00","6663.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3243.03","36.5","","3213.77","3213.77","3213.77","1 through 10","2754.35","8835.76","percent of total billed charges",""
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","both","","","8885.00","6663.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","6841.45","77","","8639.74","8639.74","8639.74","1 through 10","2754.35","8835.76","percent of total billed charges",""
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","both","","","8885.00","6663.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6927.23","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6935.44","6927.93","6935.84","1 through 10","2754.35","8835.76","other","OPPS APC"
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","both","","","8885.00","6663.75","WELLPOINT [1015]","HB AMC WELLPOINT","6555.35","73.78","","6414.61","6414.61","6414.61","1 through 10","2754.35","8835.76","percent of total billed charges",""
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","outpatient","","","8885.00","6663.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5141.51","","Case rate ($5,141.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","12036.27","11918.02","12036.27","1 through 10","4046.46","7260.82","other","ASC "
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","outpatient","","","8885.00","6663.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4046.46","","Case rate ($4,046.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","28163.37","9387.79","28163.37","1 through 10","4046.46","7260.82","other","Multiple Surgery"
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","outpatient","","","8885.00","6663.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4046.46","","Case rate ($4,046.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9873.36","9873.36","9873.36","1 through 10","4046.46","7260.82","other","Multiple Surgery"
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","outpatient","","","8885.00","6663.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","4046.46","","Case rate ($4,046.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","11734.73","11734.73","11734.73","1 through 10","4046.46","7260.82","other","Multiple Surgery"
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","outpatient","","","8885.00","6663.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7260.82","81.72","","6887.63","6887.63","6887.63","1 through 10","4046.46","7260.82","percent of total billed charges",""
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","both","","","1769.00","1326.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2137.01","2137.01","2137.01","1 through 10","548.39","2815.7","other","OPPS APC"
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","both","","","1769.00","1326.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","548.39","2815.7","other","OPPS APC"
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","both","","","1769.00","1326.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1406.36","79.5","","4815.60","4815.60","4815.60","1 through 10","548.39","2815.7","percent of total billed charges",""
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","both","","","1769.00","1326.75","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","548.39","2815.7","other","OPPS APC"
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","both","","","1769.00","1326.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","645.69","36.5","","639.70","639.70","639.70","1 through 10","548.39","2815.7","percent of total billed charges",""
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","both","","","1769.00","1326.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","677.53","38.3","","670.57","670.57","670.57","1 through 10","548.39","2815.7","percent of total billed charges",""
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","both","","","1769.00","1326.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2207.73","2207.73","2207.73","1 through 10","548.39","2815.7","other","OPPS APC"
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","outpatient","","","1769.00","1326.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3407.87","3407.87","3407.87","1 through 10","924.48","2384.07","other","ASC"
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","outpatient","","","1769.00","1326.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3971.04","3932.02","3971.04","1 through 10","924.48","2384.07","other","ASC "
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","outpatient","","","1769.00","1326.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2977.09","2977.09","2977.09","1 through 10","924.48","2384.07","other","Multiple Surgery"
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","outpatient","","","1769.00","1326.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3257.45","3137.30","3257.45","1 through 10","924.48","2384.07","other","Multiple Surgery"
"Egd Esophagus With Endoscopic Submucosal Dissection (Esd)","PX-75000484","CDM","43499","CPT","0750","RC","","","","both","","","3242.00","2431.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1727.99","53.3","","0.07","0.07","0.07","30","1005.02","5647.06","percent of total billed charges",""
"Egd Esophagus With Endoscopic Submucosal Dissection (Esd)","PX-75000484","CDM","43499","CPT","0750","RC","","","","both","","","3242.00","2431.50","MEDICARE [2001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1005.02","5647.06","other","OPPS APC"
"Egd Esophagus With Endoscopic Submucosal Dissection (Esd)","PX-75000484","CDM","43499","CPT","0750","RC","","","","both","","","3242.00","2431.50","WELLPOINT [1015]","HB AMC WELLPOINT","2391.95","73.78","","2340.71","2340.71","2340.71","1 through 10","1005.02","5647.06","percent of total billed charges",""
"Egd Esophagus With Endoscopic Submucosal Dissection (Esd)","PX-75000484","CDM","43499","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1692.97","52.22","","6151.50","2038.73","10659.00","1 through 10","1621","2674.65","percent of total billed charges",""
"Egd Esophagus With Endoscopic Submucosal Dissection (Esd)","PX-75000484","CDM","43499","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1621.00","50","","3144.00","3144.00","3144.00","1 through 10","1621","2674.65","percent of total billed charges",""
"Egd Esophagus With Endoscopic Submucosal Dissection (Esd)","PX-75000484","CDM","43499","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2649.36","81.72","","1810.95","1810.95","1810.95","1 through 10","1621","2674.65","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1151.60","1018.05","1152.70","12","750.51","1924.7","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","973.53","1095.60","13","750.51","1924.7","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1694.70","70","","136.00","136.00","136.00","1 through 10","750.51","1924.7","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1924.70","79.5","","1847.88","1239.74","4294.22","11","750.51","1924.7","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1290.39","53.3","","1239.74","1185.74","1847.88","1 through 10","750.51","1924.7","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","846.42","1095.60","1 through 10","750.51","1924.7","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","FALLON HEALTH [1008]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3340.23","1113.41","3340.23","1 through 10","750.51","1924.7","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1864.17","77","","1807.96","1807.96","1807.96","1 through 10","750.51","1924.7","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","HUMANA [1012]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","969.57","969.57","969.57","1 through 10","750.51","1924.7","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1573.65","65","","1526.20","1526.20","1526.20","1 through 10","750.51","1924.7","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","169","750.51","1924.7","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","750.51","31","","725.53","725.53","725.53","1 through 10","750.51","1924.7","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","883.67","36.5","","875.80","744.32","875.80","1 through 10","750.51","1924.7","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","927.24","38.3","","918.07","892.24","918.07","20","750.51","1924.7","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1093.64","549.57","1097.14","1 through 10","750.51","1924.7","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1864.17","77","","1372.27","1372.27","1372.27","1 through 10","750.51","1924.7","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","TRICARE [160005]","HB BWH TRICARE","1057.74","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1057.74","469.94","1057.74","1 through 10","750.51","1924.7","other","Tricare OPPS"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","1091.14","1098.94","1 through 10","750.51","1924.7","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","540.04","540.04","540.04","1 through 10","750.51","1924.7","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2421.00","1815.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1095.60","969.57","1113.41","37","750.51","1924.7","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2421.00","1815.75","AETNA [1001]","HB AMC AETNA HMO","1689.86","69.8","","1589.60","1077.40","1589.60","1 through 10","761.55","2384.07","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2421.00","1815.75","AETNA [1001]","HB AMC AETNA PPO","1946.48","80.4","","1831.44","1831.44","1831.44","1 through 10","761.55","2384.07","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2421.00","1815.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1749.60","874.80","1781.82","37","761.55","2384.07","other","ASC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2421.00","1815.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2018.70","1009.35","2038.73","83","761.55","2384.07","other","ASC "
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2421.00","1815.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2208.50","2208.50","2208.50","1 through 10","761.55","2384.07","other","Multiple Surgery"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2421.00","1815.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1766.80","1698.26","3396.52","14","761.55","2384.07","other","Multiple Surgery"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2421.00","1815.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1858.18","34.89","1858.18","1 through 10","761.55","2384.07","other","Multiple Surgery"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2421.00","1815.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","2208.50","2208.50","2208.50","1 through 10","761.55","2384.07","other","Multiple Surgery"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2421.00","1815.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1858.18","1858.18","1858.18","1 through 10","761.55","2384.07","other","Multiple Surgery"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2421.00","1815.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1949.57","1949.57","1949.57","1 through 10","761.55","2384.07","other","Multiple Surgery"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2421.00","1815.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1978.44","81.72","","1876.99","1032.42","1876.99","1 through 10","761.55","2384.07","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2421.00","1815.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1789.64","1789.64","1789.64","1 through 10","761.55","2384.07","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1145.70","572.85","1154.60","44","1057.74","2935.14","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","547.79","1095.60","62","1057.74","2935.14","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2584.40","70","","2864.00","2577.60","3580.00","1 through 10","1057.74","2935.14","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","1391.62","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","375.00","375.00","375.00","1 through 10","1057.74","2935.14","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2935.14","79.5","","2817.46","1890.24","8455.71","68","1057.74","2935.14","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1967.84","53.3","","1890.24","1890.24","5670.72","43","1057.74","2935.14","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","547.80","547.80","1095.60","18","1057.74","2935.14","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","FALLON HEALTH [1008]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3273.42","1113.41","3340.23","11","1057.74","2935.14","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","2842.84","77","","2756.60","2756.60","2756.60","1 through 10","1057.74","2935.14","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","HUMANA [1012]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1093.64","545.58","1100.05","1 through 10","1057.74","2935.14","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2399.80","65","","720.80","720.80","720.80","1 through 10","1057.74","2935.14","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2935.14","79.5","","2816.47","2816.47","2816.47","1 through 10","1057.74","2935.14","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","837","1057.74","2935.14","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1144.52","31","","3318.66","1106.22","3318.66","1 through 10","1057.74","2935.14","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1347.58","36.5","","1335.34","1134.86","2570.44","66","1057.74","2935.14","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1414.04","38.3","","1399.78","1399.78","4199.34","191","1057.74","2935.14","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1091.14","488.79","3280.92","25","1057.74","2935.14","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","MOLINA [1014]","HB BWH MOLINA","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2209.01","2209.01","2209.01","1 through 10","1057.74","2935.14","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","TRICARE [160005]","HB BWH TRICARE","1057.74","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","556.70","406.70","1057.74","1 through 10","1057.74","2935.14","other","Tricare OPPS"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","973.53","3299.04","56","1057.74","2935.14","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1583.87","42.9","","2861.84","1574.13","2861.85","1 through 10","1057.74","2935.14","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","545.58","1099.05","175","1057.74","2935.14","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","3692.00","2769.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1583.87","42.9","","2861.85","2861.85","2861.85","1 through 10","1057.74","2935.14","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","AETNA [1001]","HB AMC AETNA HMO","2577.02","69.8","","2423.66","1711.24","2792.40","99","761.55","3017.1","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","AETNA [1001]","HB AMC AETNA PPO","2968.37","80.4","","2792.40","1875.92","3751.84","15","761.55","3017.1","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1749.60","874.80","1781.82","258","761.55","3017.1","other","ASC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1929.44","52.26","","1009.35","1009.35","1009.35","1 through 10","761.55","3017.1","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2018.70","1009.35","2038.73","636","761.55","3017.1","other","ASC "
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1949.57","1104.25","2208.50","20","761.55","3017.1","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1766.80","883.40","5300.40","210","761.55","3017.1","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1858.18","929.09","5574.54","109","761.55","3017.1","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 383%, 191.5 procedures at 0%.","2916.74","2916.74","2916.74","1 through 10","761.55","3017.1","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","2208.50","1104.25","2208.50","1 through 10","761.55","3017.1","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1462.18","1462.18","1462.18","1 through 10","761.55","3017.1","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1873.41","974.79","1949.57","53","761.55","3017.1","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2968.37","80.4","","2792.40","1790.00","2792.40","1 through 10","761.55","3017.1","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1873.41","1062.36","1873.41","1 through 10","761.55","3017.1","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3017.10","81.72","","1574.13","1574.13","1574.13","1 through 10","761.55","3017.1","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3017.10","81.72","","2861.85","1574.13","2861.85","73","761.55","3017.1","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1667.79","1667.79","1667.79","1 through 10","761.55","3017.1","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1873.41","1873.41","1873.41","1 through 10","761.55","3017.1","other","Multiple Surgery"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3614.00","2710.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2318.12","2318.12","2318.12","1 through 10","1120.34","2906.42","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3614.00","2710.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","1867.13","3505.00","1 through 10","1120.34","2906.42","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3614.00","2710.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2873.13","79.5","","2758.44","2758.44","2758.44","1 through 10","1120.34","2906.42","percent of total billed charges",""
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3614.00","2710.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1926.26","53.3","","1850.64","1850.64","1850.64","1 through 10","1120.34","2906.42","percent of total billed charges",""
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3614.00","2710.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1120.34","2906.42","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3614.00","2710.50","HUMANA [1012]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2219.33","2219.33","2219.33","1 through 10","1120.34","2906.42","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3614.00","2710.50","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","19","1120.34","2906.42","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3614.00","2710.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1319.11","36.5","","1307.37","1307.37","1307.37","1 through 10","1120.34","2906.42","percent of total billed charges",""
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3614.00","2710.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1384.16","38.3","","1370.46","1370.46","1370.46","1 through 10","1120.34","2906.42","percent of total billed charges",""
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3614.00","2710.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.24","2207.74","2252.79","1 through 10","1120.34","2906.42","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","outpatient","","","3614.00","2710.50","AETNA [1001]","HB AMC AETNA HMO","2522.57","69.8","","2372.89","2372.89","2372.89","1 through 10","1335.02","2953.36","percent of total billed charges",""
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","outpatient","","","3614.00","2710.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3407.87","3407.87","3470.63","1 through 10","1335.02","2953.36","other","ASC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","outpatient","","","3614.00","2710.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3932.02","3932.02","3971.04","1 through 10","1335.02","2953.36","other","ASC "
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","outpatient","","","3614.00","2710.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3097.25","3097.25","3097.25","1 through 10","1335.02","2953.36","other","Multiple Surgery"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","outpatient","","","3614.00","2710.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3417.65","3417.65","3417.65","1 through 10","1335.02","2953.36","other","Multiple Surgery"
"Egd Flex Transoral W/Ins Tube/Cath","PX-75000093","CDM","43241","CPT","0750","RC","","","","both","","","2393.00","1794.75","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","741.83","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","both","","","3730.00","2797.50","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","4518.11","1 through 10","1156.3","2965.35","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","outpatient","","","3730.00","2797.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3407.87","3407.87","3407.87","1 through 10","1335.02","3048.16","other","ASC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","outpatient","","","3730.00","2797.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3932.02","3932.02","3932.02","1 through 10","1335.02","3048.16","other","ASC "
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","outpatient","","","3730.00","2797.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3048.16","81.72","","2891.43","2891.43","2891.43","1 through 10","1335.02","3048.16","percent of total billed charges",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2325.12","2318.12","2325.12","1 through 10","1394.38","3575.91","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1394.38","3575.91","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3148.60","70","","1875.66","1875.66","1875.66","1 through 10","1394.38","3575.91","percent of total billed charges",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2397.43","53.3","","10298.67","2303.14","10298.67","1 through 10","1394.38","3575.91","percent of total billed charges",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1394.38","3575.91","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","FALLON HEALTH [1008]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6639.69","6639.69","6639.69","1 through 10","1394.38","3575.91","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4427.75","4427.75","4427.75","1 through 10","1394.38","3575.91","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","46","1394.38","3575.91","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1641.77","36.5","","1627.03","1627.03","1627.03","1 through 10","1394.38","3575.91","percent of total billed charges",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1722.73","38.3","","1705.54","1705.54","5116.62","14","1394.38","3575.91","percent of total billed charges",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2210.23","2035.24","2211.73","1 through 10","1394.38","3575.91","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","TRICARE [160005]","HB BWH TRICARE","2140.15","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2140.15","2140.15","2140.15","1 through 10","1394.38","3575.91","other","Tricare OPPS"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2209.73","2035.24","2215.53","1 through 10","1394.38","3575.91","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","4498.00","3373.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2214.64","2043.15","2223.46","14","1394.38","3575.91","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","4498.00","3373.50","AETNA [1001]","HB AMC AETNA HMO","3139.60","69.8","","2953.07","2220.45","2953.07","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","4498.00","3373.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3470.63","3407.87","3470.63","1 through 10","1335.02","5545.35","other","ASC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","4498.00","3373.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3932.02","3932.02","3971.04","11","1335.02","5545.35","other","ASC "
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","4498.00","3373.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3871.56","3871.56","3871.56","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","4498.00","3373.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3097.25","2977.09","3097.25","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","4498.00","3373.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3257.45","1628.73","3257.45","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","4498.00","3373.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","3871.56","3871.56","3871.56","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","4498.00","3373.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3616.39","80.4","","3402.36","3402.36","3402.36","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","4498.00","3373.50","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3284.15","3284.15","3284.15","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","4498.00","3373.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3675.77","81.72","","3486.98","3486.98","3486.98","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","3643.00","2732.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2324.62","2318.12","2325.12","1 through 10","1129.33","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","3643.00","2732.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1129.33","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","3643.00","2732.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2896.19","79.5","","6346.37","2780.47","6346.37","1 through 10","1129.33","2906.42","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","3643.00","2732.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1941.72","53.3","","6563.58","6563.58","6563.58","1 through 10","1129.33","2906.42","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","3643.00","2732.25","HUMANA [1012]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2207.73","2047.70","2207.73","1 through 10","1129.33","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","3643.00","2732.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2035.24","2035.24","2035.24","1 through 10","1129.33","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","3643.00","2732.25","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","77","1129.33","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","3643.00","2732.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1329.70","36.5","","6067.22","6067.22","6067.22","1 through 10","1129.33","2906.42","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","3643.00","2732.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1395.27","38.3","","1381.40","1342.54","1381.40","1 through 10","1129.33","2906.42","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","3643.00","2732.25","MOLINA [1014]","HB BWH MOLINA","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4153.56","4153.56","4153.56","1 through 10","1129.33","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","3643.00","2732.25","TRICARE [160005]","HB BWH TRICARE","2140.15","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2252.79","2252.79","2252.79","1 through 10","1129.33","2906.42","other","Tricare OPPS"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","3643.00","2732.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.53","2043.55","2216.75","1 through 10","1129.33","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","3643.00","2732.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.24","2207.74","2216.75","11","1129.33","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","3643.00","2732.25","AETNA [1001]","HB AMC AETNA HMO","2542.81","69.8","","2391.84","1688.77","3798.02","1 through 10","1335.02","2977.06","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","3643.00","2732.25","AETNA [1001]","HB AMC AETNA PPO","2928.97","80.4","","2755.74","2755.74","2755.74","1 through 10","1335.02","2977.06","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","3643.00","2732.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3407.87","3407.87","3470.63","1 through 10","1335.02","2977.06","other","ASC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","3643.00","2732.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3932.02","3932.02","3971.04","29","1335.02","2977.06","other","ASC "
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","3643.00","2732.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3871.56","3871.56","3871.56","1 through 10","1335.02","2977.06","other","Multiple Surgery"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","3643.00","2732.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3097.25","1548.63","3097.25","1 through 10","1335.02","2977.06","other","Multiple Surgery"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","3643.00","2732.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6274.60","3257.45","6274.60","1 through 10","1335.02","2977.06","other","Multiple Surgery"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","3643.00","2732.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2977.06","81.72","","7152.16","7152.16","7152.16","1 through 10","1335.02","2977.06","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","3643.00","2732.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2977.06","81.72","","2824.28","2824.28","5409.63","1 through 10","1335.02","2977.06","percent of total billed charges",""
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","both","","","3856.00","2892.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2137.01","2137.01","2137.01","1 through 10","1195.36","3065.52","other","OPPS APC"
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","both","","","3856.00","2892.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1195.36","3065.52","other","OPPS APC"
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","both","","","3856.00","2892.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3065.52","79.5","","11819.55","11819.55","11819.55","1 through 10","1195.36","3065.52","percent of total billed charges",""
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","both","","","3856.00","2892.00","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","21","1195.36","3065.52","other","OPPS APC"
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","both","","","3856.00","2892.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1407.44","36.5","","7545.42","7545.42","7545.42","1 through 10","1195.36","3065.52","percent of total billed charges",""
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","both","","","3856.00","2892.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2207.74","2207.74","2207.74","1 through 10","1195.36","3065.52","other","OPPS APC"
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","outpatient","","","3856.00","2892.00","AETNA [1001]","HB AMC AETNA PPO","3100.22","80.4","","5646.18","5646.18","5646.18","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","outpatient","","","3856.00","2892.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3470.63","3407.87","3470.63","1 through 10","1335.02","5545.35","other","ASC"
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","outpatient","","","3856.00","2892.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3932.02","3932.02","3971.04","1 through 10","1335.02","5545.35","other","ASC "
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","outpatient","","","3856.00","2892.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3417.65","3417.65","3417.65","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","outpatient","","","3856.00","2892.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3097.25","3097.25","3097.25","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","outpatient","","","3856.00","2892.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3151.12","81.72","","3667.10","2988.96","9835.02","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","both","","","2379.00","1784.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1145.70","1018.05","1145.70","1 through 10","737.49","1891.31","other","OPPS APC"
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","both","","","2379.00","1784.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1091.14","1091.14","1091.14","1 through 10","737.49","1891.31","other","OPPS APC"
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","both","","","2379.00","1784.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","989.36","1113.41","1 through 10","737.49","1891.31","other","OPPS APC"
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","both","","","2379.00","1784.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","911.16","38.3","","902.04","902.04","902.04","1 through 10","737.49","1891.31","percent of total billed charges",""
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","both","","","2379.00","1784.25","MOLINA [1014]","HB BWH MOLINA","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2209.01","2209.01","2209.01","1 through 10","737.49","1891.31","other","OPPS APC"
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","both","","","2379.00","1784.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","969.57","969.57","969.57","1 through 10","737.49","1891.31","other","OPPS APC"
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","outpatient","","","2379.00","1784.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2038.73","2038.73","2038.73","1 through 10","761.55","2384.07","other","ASC "
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","outpatient","","","2379.00","1784.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1944.12","81.72","","3333.50","3333.50","3333.50","1 through 10","761.55","2384.07","percent of total billed charges",""
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","2432.00","1824.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1145.70","1018.05","1145.70","1 through 10","753.92","1933.44","other","OPPS APC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","2432.00","1824.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","753.92","1933.44","other","OPPS APC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","2432.00","1824.00","CIGNA [1006]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1092.03","1092.03","1092.03","1 through 10","753.92","1933.44","other","OPPS APC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","2432.00","1824.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","753.92","1933.44","other","OPPS APC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","2432.00","1824.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1091.14","1091.14","1091.14","1 through 10","753.92","1933.44","other","OPPS APC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","2432.00","1824.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","17","753.92","1933.44","other","OPPS APC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","2432.00","1824.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","887.68","36.5","","9023.62","879.53","9023.62","1 through 10","753.92","1933.44","percent of total billed charges",""
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","2432.00","1824.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1095.60","545.58","1099.05","1 through 10","753.92","1933.44","other","OPPS APC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","outpatient","","","2432.00","1824.00","AETNA [1001]","HB AMC AETNA HMO","1697.54","69.8","","1839.24","1839.24","1839.24","1 through 10","761.55","5545.35","percent of total billed charges",""
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","outpatient","","","2432.00","1824.00","AETNA [1001]","HB AMC AETNA PPO","1955.33","80.4","","1839.24","1839.24","1839.24","1 through 10","761.55","5545.35","percent of total billed charges",""
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","outpatient","","","2432.00","1824.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","8823.60","1749.60","8823.60","1 through 10","761.55","5545.35","other","ASC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","outpatient","","","2432.00","1824.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2018.70","1009.35","2038.73","13","761.55","5545.35","other","ASC "
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","outpatient","","","2432.00","1824.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2124.72","2124.72","2124.72","1 through 10","761.55","5545.35","other","Multiple Surgery"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","outpatient","","","2432.00","1824.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1766.80","883.40","1766.80","1 through 10","761.55","5545.35","other","Multiple Surgery"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","outpatient","","","2432.00","1824.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1858.18","1789.64","1858.18","1 through 10","761.55","5545.35","other","Multiple Surgery"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","outpatient","","","2432.00","1824.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1987.43","81.72","","1884.98","1884.98","1884.98","1 through 10","761.55","5545.35","percent of total billed charges",""
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3607.00","2705.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2325.12","2324.62","2325.12","1 through 10","1118.17","2867.57","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3607.00","2705.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","4445.82","1 through 10","1118.17","2867.57","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3607.00","2705.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2589.83","71.8","","2511.56","2511.56","2511.56","1 through 10","1118.17","2867.57","percent of total billed charges",""
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3607.00","2705.25","FALLON HEALTH [1008]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1118.17","2867.57","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3607.00","2705.25","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","6758.37","66","1118.17","2867.57","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3607.00","2705.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1316.56","36.5","","1108.87","1108.87","1108.87","1 through 10","1118.17","2867.57","percent of total billed charges",""
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3607.00","2705.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2211.73","2211.73","2211.73","1 through 10","1118.17","2867.57","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3607.00","2705.25","TRICARE [160005]","HB BWH TRICARE","2140.15","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2252.79","2252.79","2252.79","1 through 10","1118.17","2867.57","other","Tricare OPPS"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3607.00","2705.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2036.24","2036.24","2036.24","1 through 10","1118.17","2867.57","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3607.00","2705.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.24","2038.37","2252.79","19","1118.17","2867.57","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","3607.00","2705.25","WELLPOINT [1015]","HB AMC WELLPOINT","2661.24","73.78","","2604.26","2604.26","2604.26","1 through 10","1118.17","2867.57","percent of total billed charges",""
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","outpatient","","","3607.00","2705.25","AETNA [1001]","HB AMC AETNA HMO","2517.69","69.8","","2368.15","2368.15","2368.15","1 through 10","1335.02","8899.59","percent of total billed charges",""
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","outpatient","","","3607.00","2705.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3407.87","1735.32","3470.63","1 through 10","1335.02","8899.59","other","ASC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","outpatient","","","3607.00","2705.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3932.02","3932.02","3971.04","19","1335.02","8899.59","other","ASC "
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","outpatient","","","3607.00","2705.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","9291.75","9291.75","9291.75","1 through 10","1335.02","8899.59","other","Multiple Surgery"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","outpatient","","","3607.00","2705.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2947.64","81.72","","2796.30","2796.30","2796.30","1 through 10","1335.02","8899.59","percent of total billed charges",""
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","outpatient","","","3607.00","2705.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","3871.56","3871.56","3871.56","1 through 10","1335.02","8899.59","other","Multiple Surgery"
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","both","","","2750.00","2062.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","852.5","2186.25","other","OPPS APC"
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","both","","","2750.00","2062.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","852.5","2186.25","other","OPPS APC"
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","both","","","2750.00","2062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2186.25","79.5","","2814.50","2346.50","2814.50","1 through 10","852.5","2186.25","percent of total billed charges",""
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","both","","","2750.00","2062.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","852.5","2186.25","other","OPPS APC"
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","both","","","2750.00","2062.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","852.5","2186.25","other","OPPS APC"
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","both","","","2750.00","2062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1003.75","36.5","","2677.58","1482.13","2910.89","1 through 10","852.5","2186.25","percent of total billed charges",""
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","both","","","2750.00","2062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1053.25","38.3","","2723.31","1555.62","2741.61","12","852.5","2186.25","percent of total billed charges",""
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","both","","","2750.00","2062.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","852.5","2186.25","other","OPPS APC"
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","both","","","2750.00","2062.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","852.5","2186.25","other","OPPS APC"
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","both","","","2750.00","2062.50","WELLPOINT [1015]","HB AMC WELLPOINT","2028.95","73.78","","2687.65","2687.64","3224.43","1 through 10","852.5","2186.25","percent of total billed charges",""
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","AETNA [1001]","HB AMC AETNA PPO","2211.00","80.4","","1163.76","1163.76","1163.76","1 through 10","1375","2384.07","percent of total billed charges",""
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1665.13","60.55","","1781.82","1492.00","4331.00","1 through 10","1375","2384.07","percent of total billed charges",""
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1436.05","52.22","","3144.00","1492.00","3610.00","13","1375","2384.07","percent of total billed charges",""
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1443.75","52.5","","1182.28","1182.28","1182.28","1 through 10","1375","2384.07","percent of total billed charges",""
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1375.00","50","","3610.00","2269.44","3610.00","1 through 10","1375","2384.07","percent of total billed charges",""
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1443.75","52.5","","3610.00","2382.05","4331.00","1 through 10","1375","2384.07","percent of total billed charges",""
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1512.50","55","","4810.75","3363.17","4810.75","1 through 10","1375","2384.07","percent of total billed charges",""
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2247.30","81.72","","8894.69","8894.69","8894.69","1 through 10","1375","2384.07","percent of total billed charges",""
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2247.30","81.72","","2885.83","2132.00","3462.21","1 through 10","1375","2384.07","percent of total billed charges",""
"Egd Sm Bowel Fistula Closure Transoral and Transcutaneous","PX-75000471","CDM","44799","CPT","0750","RC","","","","both","","","3403.00","2552.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1054.93","2705.39","other","OPPS APC"
"Egd Sm Bowel Fistula Closure Transoral and Transcutaneous","PX-75000471","CDM","44799","CPT","0750","RC","","","","both","","","3403.00","2552.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1054.93","2705.39","other","OPPS APC"
"Egd Sm Bowel Fistula Closure Transoral and Transcutaneous","PX-75000471","CDM","44799","CPT","0750","RC","","","","both","","","3403.00","2552.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1054.93","2705.39","other","OPPS APC"
"Egd Sm Bowel Fistula Closure Transoral and Transcutaneous","PX-75000471","CDM","44799","CPT","0750","RC","","","","both","","","3403.00","2552.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1054.93","2705.39","other","OPPS APC"
"Egd Sm Bowel Fistula Closure Transoral and Transcutaneous","PX-75000471","CDM","44799","CPT","0750","RC","","","","both","","","3403.00","2552.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1459.89","42.9","","1932.92","1932.92","1932.92","1 through 10","1054.93","2705.39","percent of total billed charges",""
"Egd Sm Bowel Fistula Closure Transoral and Transcutaneous","PX-75000471","CDM","44799","CPT","0750","RC","","","","both","","","3403.00","2552.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1054.93","2705.39","other","OPPS APC"
"Egd Sm Bowel Fistula Closure Transoral and Transcutaneous","PX-75000471","CDM","44799","CPT","0750","RC","","","","both","","","3403.00","2552.25","WELLPOINT [1015]","HB AMC WELLPOINT","2510.73","73.78","","2222.33","2222.33","2222.33","1 through 10","1054.93","2705.39","percent of total billed charges",""
"Egd Sm Bowel Fistula Closure Transoral and Transcutaneous","PX-75000471","CDM","44799","CPT","0750","RC","","","","outpatient","","","3403.00","2552.25","AETNA [1001]","HB AMC AETNA HMO","2375.29","69.8","","2238.60","2238.60","2238.60","1 through 10","1701.5","8899.59","percent of total billed charges",""
"Egd Sm Bowel Fistula Closure Transoral and Transcutaneous","PX-75000471","CDM","44799","CPT","0750","RC","","","","outpatient","","","3403.00","2552.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2060.52","60.55","","3144.00","2870.00","3286.00","1 through 10","1701.5","8899.59","percent of total billed charges",""
"Egd Sm Bowel Fistula Closure Transoral and Transcutaneous","PX-75000471","CDM","44799","CPT","0750","RC","","","","outpatient","","","3403.00","2552.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1778.41","52.26","","1775.96","1775.96","1775.96","1 through 10","1701.5","8899.59","percent of total billed charges",""
"Egd Sm Bowel Fistula Closure Transoral and Transcutaneous","PX-75000471","CDM","44799","CPT","0750","RC","","","","outpatient","","","3403.00","2552.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1777.05","52.22","","3286.00","2018.70","5898.00","1 through 10","1701.5","8899.59","percent of total billed charges",""
"Egd Sm Bowel Fistula Closure Transoral and Transcutaneous","PX-75000471","CDM","44799","CPT","0750","RC","","","","outpatient","","","3403.00","2552.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1786.58","52.5","","8340.00","8340.00","8340.00","1 through 10","1701.5","8899.59","percent of total billed charges",""
"Egd Sm Bowel Fistula Closure Transoral and Transcutaneous","PX-75000471","CDM","44799","CPT","0750","RC","","","","outpatient","","","3403.00","2552.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2780.93","81.72","","2294.28","682.69","2294.28","1 through 10","1701.5","8899.59","percent of total billed charges",""
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","both","","","3242.00","2431.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4653.18","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1005.02","5647.06","other","OPPS APC"
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","both","","","3242.00","2431.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1005.02","5647.06","other","OPPS APC"
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","both","","","3242.00","2431.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2577.39","79.5","","2814.50","2346.50","2814.50","1 through 10","1005.02","5647.06","percent of total billed charges",""
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","both","","","3242.00","2431.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1005.02","5647.06","other","OPPS APC"
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","both","","","3242.00","2431.50","MEDICARE [2001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1005.02","5647.06","other","OPPS APC"
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","both","","","3242.00","2431.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1183.33","36.5","","2677.58","1482.13","2910.89","1 through 10","1005.02","5647.06","percent of total billed charges",""
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","both","","","3242.00","2431.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1241.69","38.3","","2723.31","1555.62","2741.61","12","1005.02","5647.06","percent of total billed charges",""
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","both","","","3242.00","2431.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1005.02","5647.06","other","OPPS APC"
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","both","","","3242.00","2431.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4427.30","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1005.02","5647.06","other","OPPS APC"
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","both","","","3242.00","2431.50","WELLPOINT [1015]","HB AMC WELLPOINT","2391.95","73.78","","2687.65","2687.64","3224.43","1 through 10","1005.02","5647.06","percent of total billed charges",""
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","AETNA [1001]","HB AMC AETNA PPO","2606.57","80.4","","1163.76","1163.76","1163.76","1 through 10","1621","2674.65","percent of total billed charges",""
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1963.03","60.55","","1781.82","1492.00","4331.00","1 through 10","1621","2674.65","percent of total billed charges",""
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1692.97","52.22","","3144.00","1492.00","3610.00","13","1621","2674.65","percent of total billed charges",""
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1702.05","52.5","","1182.28","1182.28","1182.28","1 through 10","1621","2674.65","percent of total billed charges",""
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1621.00","50","","3610.00","2269.44","3610.00","1 through 10","1621","2674.65","percent of total billed charges",""
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1702.05","52.5","","3610.00","2382.05","4331.00","1 through 10","1621","2674.65","percent of total billed charges",""
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1783.10","55","","4810.75","3363.17","4810.75","1 through 10","1621","2674.65","percent of total billed charges",""
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2649.36","81.72","","8894.69","8894.69","8894.69","1 through 10","1621","2674.65","percent of total billed charges",""
"Egd Stomach With Endoscopic Submucosal Dissection (Esd)","PX-75000485","CDM","43999","CPT","0750","RC","","","","outpatient","","","3242.00","2431.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2649.36","81.72","","2885.83","2132.00","3462.21","1 through 10","1621","2674.65","percent of total billed charges",""
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","both","","","5563.00","4172.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","4422.59","other","OPPS APC"
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","both","","","5563.00","4172.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","4422.59","other","OPPS APC"
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","both","","","5563.00","4172.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4422.59","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","4422.59","percent of total billed charges",""
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","both","","","5563.00","4172.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","4422.59","other","OPPS APC"
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","both","","","5563.00","4172.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","4422.59","other","OPPS APC"
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","both","","","5563.00","4172.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2030.50","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","4422.59","percent of total billed charges",""
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","both","","","5563.00","4172.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2130.63","38.3","","2723.31","1555.62","2741.61","12","1057.74","4422.59","percent of total billed charges",""
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","both","","","5563.00","4172.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","4422.59","other","OPPS APC"
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","both","","","5563.00","4172.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","4422.59","other","OPPS APC"
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","both","","","5563.00","4172.25","WELLPOINT [1015]","HB AMC WELLPOINT","4104.38","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","4422.59","percent of total billed charges",""
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","outpatient","","","5563.00","4172.25","AETNA [1001]","HB AMC AETNA PPO","4472.65","80.4","","1163.76","1163.76","1163.76","1 through 10","2384.07","4589.48","percent of total billed charges",""
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","outpatient","","","5563.00","4172.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3368.40","60.55","","1781.82","1492.00","4331.00","1 through 10","2384.07","4589.48","percent of total billed charges",""
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","outpatient","","","5563.00","4172.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2905.00","52.22","","3144.00","1492.00","3610.00","13","2384.07","4589.48","percent of total billed charges",""
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","outpatient","","","5563.00","4172.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2920.58","52.5","","1182.28","1182.28","1182.28","1 through 10","2384.07","4589.48","percent of total billed charges",""
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","outpatient","","","5563.00","4172.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2781.50","50","","3610.00","2269.44","3610.00","1 through 10","2384.07","4589.48","percent of total billed charges",""
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","outpatient","","","5563.00","4172.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2920.58","52.5","","3610.00","2382.05","4331.00","1 through 10","2384.07","4589.48","percent of total billed charges",""
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","outpatient","","","5563.00","4172.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","3059.65","55","","4810.75","3363.17","4810.75","1 through 10","2384.07","4589.48","percent of total billed charges",""
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","outpatient","","","5563.00","4172.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4546.08","81.72","","8894.69","8894.69","8894.69","1 through 10","2384.07","4589.48","percent of total billed charges",""
"Egd Strictuloplasty Stomach","PX-75000531","CDM","43999","CPT","0750","RC","","","","outpatient","","","5563.00","4172.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4546.08","81.72","","2885.83","2132.00","3462.21","1 through 10","2384.07","4589.48","percent of total billed charges",""
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","both","","","5113.00","3834.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1057.74","4064.84","other","OPPS APC"
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","both","","","5113.00","3834.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","4064.84","other","OPPS APC"
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","both","","","5113.00","3834.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","4064.84","other","OPPS APC"
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","both","","","5113.00","3834.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1057.74","4064.84","other","OPPS APC"
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","both","","","5113.00","3834.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2193.48","42.9","","1932.92","1932.92","1932.92","1 through 10","1057.74","4064.84","percent of total billed charges",""
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","both","","","5113.00","3834.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1057.74","4064.84","other","OPPS APC"
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","both","","","5113.00","3834.75","WELLPOINT [1015]","HB AMC WELLPOINT","3772.37","73.78","","2222.33","2222.33","2222.33","1 through 10","1057.74","4064.84","percent of total billed charges",""
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","outpatient","","","5113.00","3834.75","AETNA [1001]","HB AMC AETNA HMO","3568.87","69.8","","2238.60","2238.60","2238.60","1 through 10","2556.5","8899.59","percent of total billed charges",""
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","outpatient","","","5113.00","3834.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3095.92","60.55","","3144.00","2870.00","3286.00","1 through 10","2556.5","8899.59","percent of total billed charges",""
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","outpatient","","","5113.00","3834.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2672.05","52.26","","1775.96","1775.96","1775.96","1 through 10","2556.5","8899.59","percent of total billed charges",""
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","outpatient","","","5113.00","3834.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2670.01","52.22","","3286.00","2018.70","5898.00","1 through 10","2556.5","8899.59","percent of total billed charges",""
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","outpatient","","","5113.00","3834.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2684.33","52.5","","8340.00","8340.00","8340.00","1 through 10","2556.5","8899.59","percent of total billed charges",""
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","outpatient","","","5113.00","3834.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4178.34","81.72","","2294.28","682.69","2294.28","1 through 10","2556.5","8899.59","percent of total billed charges",""
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3611.00","2708.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1119.41","2906.42","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3611.00","2708.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2347.15","65","","2276.30","2276.30","2276.30","1 through 10","1119.41","2906.42","percent of total billed charges",""
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3611.00","2708.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2870.75","79.5","","2276.30","2188.17","2276.30","1 through 10","1119.41","2906.42","percent of total billed charges",""
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3611.00","2708.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1119.41","2906.42","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3611.00","2708.25","FALLON HEALTH [1008]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1119.41","2906.42","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3611.00","2708.25","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1119.41","2906.42","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3611.00","2708.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1318.02","36.5","","1267.72","1267.72","1267.72","1 through 10","1119.41","2906.42","percent of total billed charges",""
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3611.00","2708.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2213.73","2213.73","2213.73","1 through 10","1119.41","2906.42","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3611.00","2708.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2207.74","2035.24","2252.79","1 through 10","1119.41","2906.42","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","outpatient","","","3611.00","2708.25","AETNA [1001]","HB AMC AETNA HMO","2520.48","69.8","","2370.85","2370.85","2370.85","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","outpatient","","","3611.00","2708.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3407.87","3407.87","3470.63","1 through 10","1335.02","5545.35","other","ASC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","outpatient","","","3611.00","2708.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3971.04","3932.02","3971.04","1 through 10","1335.02","5545.35","other","ASC "
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","outpatient","","","3611.00","2708.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6599.25","3097.25","6599.25","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","3692.00","2769.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2935.14","79.5","","2817.46","2817.46","2817.46","1 through 10","1144.52","2935.14","percent of total billed charges",""
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","3692.00","2769.00","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","1 through 10","1144.52","2935.14","other","OPPS APC"
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","3692.00","2769.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4419.46","4419.46","4419.46","1 through 10","1144.52","2935.14","other","OPPS APC"
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","3692.00","2769.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5163.73","5163.73","5163.73","1 through 10","1144.52","2935.14","other","OPPS APC"
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","outpatient","","","3692.00","2769.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3097.25","3097.25","3097.25","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2382.00","1786.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1150.50","1150.50","1150.50","1 through 10","738.42","1893.69","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2382.00","1786.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","547.79","1095.60","1 through 10","738.42","1893.69","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2382.00","1786.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1893.69","79.5","","20577.42","1817.97","20577.42","1 through 10","738.42","1893.69","percent of total billed charges",""
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2382.00","1786.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","989.36","1113.41","69","738.42","1893.69","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2382.00","1786.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","869.43","36.5","","5156.32","836.22","5888.29","1 through 10","738.42","1893.69","percent of total billed charges",""
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2382.00","1786.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","912.31","38.3","","903.21","877.80","4810.47","1 through 10","738.42","1893.69","percent of total billed charges",""
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2382.00","1786.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1096.54","1093.14","1098.54","1 through 10","738.42","1893.69","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2382.00","1786.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.35","494.68","1113.41","1 through 10","738.42","1893.69","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2382.00","1786.50","AETNA [1001]","HB AMC AETNA HMO","1662.64","69.8","","1801.80","1801.80","1801.80","1 through 10","761.55","5545.35","percent of total billed charges",""
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2382.00","1786.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1749.60","874.80","1781.82","1 through 10","761.55","5545.35","other","ASC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2382.00","1786.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2018.70","1019.36","2038.73","15","761.55","5545.35","other","ASC "
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2382.00","1786.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1766.80","1698.26","3396.52","1 through 10","761.55","5545.35","other","Multiple Surgery"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2382.00","1786.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1858.18","929.09","3579.28","1 through 10","761.55","5545.35","other","Multiple Surgery"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2382.00","1786.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1858.18","1858.18","1858.18","1 through 10","761.55","5545.35","other","Multiple Surgery"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2382.00","1786.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1949.57","1949.57","1949.57","1 through 10","761.55","5545.35","other","Multiple Surgery"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2382.00","1786.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1946.57","81.72","","12837.56","12837.56","12837.56","1 through 10","761.55","5545.35","percent of total billed charges",""
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","both","","","3676.00","2757.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2922.42","79.5","","8597.49","8597.49","8597.49","1 through 10","1139.56","2922.42","percent of total billed charges",""
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","both","","","3676.00","2757.00","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","18","1139.56","2922.42","other","OPPS APC"
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","both","","","3676.00","2757.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1407.91","38.3","","1393.92","1393.92","1393.92","1 through 10","1139.56","2922.42","percent of total billed charges",""
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","both","","","3676.00","2757.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2213.73","2213.73","2213.73","1 through 10","1139.56","2922.42","other","OPPS APC"
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","both","","","3676.00","2757.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2225.76","2215.24","2225.76","1 through 10","1139.56","2922.42","other","OPPS APC"
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","outpatient","","","3676.00","2757.00","AETNA [1001]","HB AMC AETNA HMO","2565.85","69.8","","3798.02","2780.70","3798.02","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","outpatient","","","3676.00","2757.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3407.87","3407.87","3407.87","1 through 10","1335.02","5545.35","other","ASC"
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","outpatient","","","3676.00","2757.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3932.02","1966.01","3971.04","1 through 10","1335.02","5545.35","other","ASC "
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","outpatient","","","3676.00","2757.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3097.25","3097.25","3097.25","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","outpatient","","","3676.00","2757.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3004.03","81.72","","1567.53","1567.53","1567.53","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","outpatient","","","3676.00","2757.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3004.03","81.72","","3417.65","3417.65","3417.65","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2318.12","2318.12","2327.02","1 through 10","1108.56","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2043.55","2216.75","1 through 10","1108.56","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2842.92","79.5","","2729.32","2614.87","2729.32","1 through 10","1108.56","2906.42","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1906.01","53.3","","1831.10","1831.10","2729.32","1 through 10","1108.56","2906.42","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","FALLON HEALTH [1008]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6758.37","6758.37","6758.37","1 through 10","1108.56","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","2753.52","77","","2670.36","2670.36","2670.36","1 through 10","1108.56","2906.42","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2842.92","79.5","","2728.21","2728.21","2728.21","1 through 10","1108.56","2906.42","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","68","1108.56","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1108.56","31","","1071.61","1071.61","1071.61","1 through 10","1108.56","2906.42","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1305.24","36.5","","1099.36","1099.36","1255.42","1 through 10","1108.56","2906.42","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1369.61","38.3","","1355.99","1355.99","1355.99","1 through 10","1108.56","2906.42","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2041.24","2041.24","2041.24","1 through 10","1108.56","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","797.64","797.64","797.64","1 through 10","1108.56","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3576.00","2682.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.24","2207.73","2252.79","16","1108.56","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3576.00","2682.00","AETNA [1001]","HB AMC AETNA HMO","2496.05","69.8","","2705.04","2347.84","2705.04","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3576.00","2682.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3407.87","3407.87","3932.02","17","1335.02","5545.35","other","ASC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3576.00","2682.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3932.02","1966.01","3971.04","46","1335.02","5545.35","other","ASC "
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3576.00","2682.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3871.56","3871.56","3871.56","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3576.00","2682.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3097.25","1548.63","3097.25","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3576.00","2682.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3257.45","1628.73","3257.45","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3576.00","2682.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3417.65","3417.65","3417.65","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3576.00","2682.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2922.31","81.72","","2772.32","1524.88","2772.32","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","both","","","4465.00","3348.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","3549.68","other","OPPS APC"
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","both","","","4465.00","3348.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","3549.68","other","OPPS APC"
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","both","","","4465.00","3348.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3549.68","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","3549.68","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","both","","","4465.00","3348.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","3549.68","other","OPPS APC"
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","both","","","4465.00","3348.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","3549.68","other","OPPS APC"
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","both","","","4465.00","3348.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1629.73","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","3549.68","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","both","","","4465.00","3348.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1710.10","38.3","","2723.31","1555.62","2741.61","12","1057.74","3549.68","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","both","","","4465.00","3348.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","3549.68","other","OPPS APC"
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","both","","","4465.00","3348.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","3549.68","other","OPPS APC"
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","both","","","4465.00","3348.75","WELLPOINT [1015]","HB AMC WELLPOINT","3294.28","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","3549.68","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","outpatient","","","4465.00","3348.75","AETNA [1001]","HB AMC AETNA PPO","3589.86","80.4","","1163.76","1163.76","1163.76","1 through 10","2232.5","3683.63","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","outpatient","","","4465.00","3348.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2703.56","60.55","","1781.82","1492.00","4331.00","1 through 10","2232.5","3683.63","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","outpatient","","","4465.00","3348.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2331.62","52.22","","3144.00","1492.00","3610.00","13","2232.5","3683.63","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","outpatient","","","4465.00","3348.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2344.13","52.5","","1182.28","1182.28","1182.28","1 through 10","2232.5","3683.63","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","outpatient","","","4465.00","3348.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2232.50","50","","3610.00","2269.44","3610.00","1 through 10","2232.5","3683.63","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","outpatient","","","4465.00","3348.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2344.13","52.5","","3610.00","2382.05","4331.00","1 through 10","2232.5","3683.63","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","outpatient","","","4465.00","3348.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2455.75","55","","4810.75","3363.17","4810.75","1 through 10","2232.5","3683.63","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","outpatient","","","4465.00","3348.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3648.80","81.72","","8894.69","8894.69","8894.69","1 through 10","2232.5","3683.63","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","outpatient","","","4465.00","3348.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3648.80","81.72","","2885.83","2132.00","3462.21","1 through 10","2232.5","3683.63","percent of total billed charges",""
"Egd W/Gallbladder Debridement via Gastric Stent","PX-75000512","CDM","47999","CPT","0750","RC","","","","both","","","3078.00","2308.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","954.18","2447.01","other","OPPS APC"
"Egd W/Gallbladder Debridement via Gastric Stent","PX-75000512","CDM","47999","CPT","0750","RC","","","","both","","","3078.00","2308.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","954.18","2447.01","other","OPPS APC"
"Egd W/Gallbladder Debridement via Gastric Stent","PX-75000512","CDM","47999","CPT","0750","RC","","","","outpatient","","","3078.00","2308.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1607.33","52.22","","3734.00","1019.30","3734.00","1 through 10","1539","9843.6","percent of total billed charges",""
"Egd W/Gallbladder Debridement via Gastric Stent With Replacement Stent","PX-75000511","CDM","47999","CPT","0750","RC","","","","both","","","4310.00","3232.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3426.45","other","OPPS APC"
"Egd W/Gallbladder Debridement via Gastric Stent With Replacement Stent","PX-75000511","CDM","47999","CPT","0750","RC","","","","both","","","4310.00","3232.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","1057.74","3426.45","other","OPPS APC"
"Egd W/Gallbladder Debridement via Gastric Stent With Replacement Stent","PX-75000511","CDM","47999","CPT","0750","RC","","","","outpatient","","","4310.00","3232.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2250.68","52.22","","3734.00","1019.30","3734.00","1 through 10","2155","9843.6","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3612.00","2709.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2318.12","2318.12","2318.12","1 through 10","1119.72","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3612.00","2709.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","602.35","2216.75","1 through 10","1119.72","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3612.00","2709.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2871.54","79.5","","2756.86","1849.58","8270.58","11","1119.72","2906.42","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3612.00","2709.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1925.20","53.3","","2756.86","1751.50","2967.98","1 through 10","1119.72","2906.42","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3612.00","2709.00","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","90","1119.72","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3612.00","2709.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1318.38","36.5","","1306.62","1306.62","1306.62","1 through 10","1119.72","2906.42","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3612.00","2709.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1383.40","38.3","","1369.67","1331.14","1369.67","1 through 10","1119.72","2906.42","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3612.00","2709.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4075.48","2207.73","4075.48","1 through 10","1119.72","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3612.00","2709.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.53","2215.13","2215.53","1 through 10","1119.72","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3612.00","2709.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2209.74","2042.25","2252.79","1 through 10","1119.72","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3612.00","2709.00","AETNA [1001]","HB AMC AETNA HMO","2521.18","69.8","","2371.53","1674.43","2371.53","16","1335.02","5545.35","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3612.00","2709.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3407.87","3407.87","3470.63","37","1335.02","5545.35","other","ASC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3612.00","2709.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3932.02","3932.02","3971.04","70","1335.02","5545.35","other","ASC "
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3612.00","2709.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3871.56","3724.71","3871.56","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3612.00","2709.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3097.25","3097.25","9291.75","23","1335.02","5545.35","other","Multiple Surgery"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3612.00","2709.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5908.90","3257.45","9772.35","28","1335.02","5545.35","other","Multiple Surgery"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3612.00","2709.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","6568.30","3284.15","6568.30","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3612.00","2709.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2951.73","81.72","","2800.30","1540.27","5600.60","16","1335.02","5545.35","percent of total billed charges",""
"Egd With Closure of Tracheoesophageal Fistula","PX-75000487","CDM","43499","CPT","0750","RC","","","","both","","","2750.00","2062.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1465.75","53.3","","0.07","0.07","0.07","30","852.5","2186.25","percent of total billed charges",""
"Egd With Closure of Tracheoesophageal Fistula","PX-75000487","CDM","43499","CPT","0750","RC","","","","both","","","2750.00","2062.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","852.5","2186.25","other","OPPS APC"
"Egd With Closure of Tracheoesophageal Fistula","PX-75000487","CDM","43499","CPT","0750","RC","","","","both","","","2750.00","2062.50","WELLPOINT [1015]","HB AMC WELLPOINT","2028.95","73.78","","2340.71","2340.71","2340.71","1 through 10","852.5","2186.25","percent of total billed charges",""
"Egd With Closure of Tracheoesophageal Fistula","PX-75000487","CDM","43499","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1436.05","52.22","","6151.50","2038.73","10659.00","1 through 10","1375","2384.07","percent of total billed charges",""
"Egd With Closure of Tracheoesophageal Fistula","PX-75000487","CDM","43499","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1375.00","50","","3144.00","3144.00","3144.00","1 through 10","1375","2384.07","percent of total billed charges",""
"Egd With Closure of Tracheoesophageal Fistula","PX-75000487","CDM","43499","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2247.30","81.72","","1810.95","1810.95","1810.95","1 through 10","1375","2384.07","percent of total billed charges",""
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","2959.79","other","OPPS APC"
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","2959.79","other","OPPS APC"
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2959.79","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","2959.79","percent of total billed charges",""
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","2959.79","other","OPPS APC"
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","2959.79","other","OPPS APC"
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1358.90","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","2959.79","percent of total billed charges",""
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1425.91","38.3","","2723.31","1555.62","2741.61","12","1057.74","2959.79","percent of total billed charges",""
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","2959.79","other","OPPS APC"
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","2959.79","other","OPPS APC"
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","both","","","3723.00","2792.25","WELLPOINT [1015]","HB AMC WELLPOINT","2746.83","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","2959.79","percent of total billed charges",""
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","AETNA [1001]","HB AMC AETNA PPO","2993.29","80.4","","1163.76","1163.76","1163.76","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2254.28","60.55","","1781.82","1492.00","4331.00","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1944.15","52.22","","3144.00","1492.00","3610.00","13","1861.5","3071.48","percent of total billed charges",""
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1954.58","52.5","","1182.28","1182.28","1182.28","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1861.50","50","","3610.00","2269.44","3610.00","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1954.58","52.5","","3610.00","2382.05","4331.00","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2047.65","55","","4810.75","3363.17","4810.75","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3042.44","81.72","","8894.69","8894.69","8894.69","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Egd With Internal G-Tube Track Closure","PX-75000501","CDM","43999","CPT","0750","RC","","","","outpatient","","","3723.00","2792.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3042.44","81.72","","2885.83","2132.00","3462.21","1 through 10","1861.5","3071.48","percent of total billed charges",""
"Egd With Zenkers Diverticulotomy","PX-75000497","CDM","43499","CPT","0750","RC","","","","both","","","5477.00","4107.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2919.24","53.3","","0.07","0.07","0.07","30","1057.74","4354.22","percent of total billed charges",""
"Egd With Zenkers Diverticulotomy","PX-75000497","CDM","43499","CPT","0750","RC","","","","both","","","5477.00","4107.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","4354.22","other","OPPS APC"
"Egd With Zenkers Diverticulotomy","PX-75000497","CDM","43499","CPT","0750","RC","","","","both","","","5477.00","4107.75","WELLPOINT [1015]","HB AMC WELLPOINT","4040.93","73.78","","2340.71","2340.71","2340.71","1 through 10","1057.74","4354.22","percent of total billed charges",""
"Egd With Zenkers Diverticulotomy","PX-75000497","CDM","43499","CPT","0750","RC","","","","outpatient","","","5477.00","4107.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2860.09","52.22","","6151.50","2038.73","10659.00","1 through 10","2384.07","4518.53","percent of total billed charges",""
"Egd With Zenkers Diverticulotomy","PX-75000497","CDM","43499","CPT","0750","RC","","","","outpatient","","","5477.00","4107.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2738.50","50","","3144.00","3144.00","3144.00","1 through 10","2384.07","4518.53","percent of total billed charges",""
"Egd With Zenkers Diverticulotomy","PX-75000497","CDM","43499","CPT","0750","RC","","","","outpatient","","","5477.00","4107.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4475.80","81.72","","1810.95","1810.95","1810.95","1 through 10","2384.07","4518.53","percent of total billed charges",""
"Egfr Gene Analysis Common Variants","PX-31000166","CDM","81235","CPT","0310","RC","","","","outpatient","","","1588.00","1191.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1297.71","81.72","","1231.08","1231.08","1231.08","1 through 10","687.23","1989.68","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","both","","","121.00","90.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.17","36.5","","130.92","130.92","130.92","1 through 10","9.98","114.95","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","both","","","121.00","90.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.34","38.3","","45.75","45.75","45.75","1 through 10","9.98","114.95","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","outpatient","","","121.00","90.75","AETNA [1001]","HB AMC AETNA HMO","84.46","69.8","","55.93","55.93","79.21","11","10.07","98.88","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","98.88","81.72","","93.53","93.53","93.53","1 through 10","10.07","98.88","percent of total billed charges",""
"Eia Ql C Difficile Toxin(S) Antigen","PX-30001233","CDM","87324","CPT","0306","RC","","","","both","","","177.00","132.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","94.34","53.3","","90.82","90.82","90.82","1 through 10","11.74","168.15","percent of total billed charges",""
"Eia Ql C Difficile Toxin(S) Antigen","PX-30001233","CDM","87324","CPT","0306","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.87","31","","53.15","53.15","53.15","1 through 10","11.74","168.15","percent of total billed charges",""
"Eia Ql C Difficile Toxin(S) Antigen","PX-30001233","CDM","87324","CPT","0306","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.61","36.5","","131.39","54.01","131.39","1 through 10","11.74","168.15","percent of total billed charges",""
"Eia Ql C Difficile Toxin(S) Antigen","PX-30001233","CDM","87324","CPT","0306","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.79","38.3","","65.36","65.36","65.36","1 through 10","11.74","168.15","percent of total billed charges",""
"Eia Ql C Difficile Toxin(S) Antigen","PX-30001233","CDM","87324","CPT","0306","RC","","","","both","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.93","42.9","","75.63","75.63","75.63","1 through 10","11.74","168.15","percent of total billed charges",""
"Eia Ql C Difficile Toxin(S) Antigen","PX-30001233","CDM","87324","CPT","0306","RC","","","","outpatient","","","177.00","132.75","AETNA [1001]","HB AMC AETNA HMO","123.55","69.8","","116.44","82.22","134.16","1 through 10","11.81","144.64","percent of total billed charges",""
"Eia Ql C Difficile Toxin(S) Antigen","PX-30001233","CDM","87324","CPT","0306","RC","","","","outpatient","","","177.00","132.75","AETNA [1001]","HB AMC AETNA PPO","142.31","80.4","","90.13","90.13","90.13","1 through 10","11.81","144.64","percent of total billed charges",""
"Eia Ql C Difficile Toxin(S) Antigen","PX-30001233","CDM","87324","CPT","0306","RC","","","","outpatient","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","144.64","81.72","","137.50","75.63","137.50","1 through 10","11.81","144.64","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","both","","","164.00","123.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","130.38","79.5","","125.13","83.95","137.98","1 through 10","11.81","155.8","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","both","","","164.00","123.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","87.41","53.3","","83.95","83.95","83.95","1 through 10","11.81","155.8","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","both","","","164.00","123.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","59.86","36.5","","59.31","59.31","59.31","1 through 10","11.81","155.8","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","both","","","164.00","123.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.81","38.3","","62.17","62.17","120.84","1 through 10","11.81","155.8","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","both","","","164.00","123.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.36","42.9","","56.39","56.39","56.39","1 through 10","11.81","155.8","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","outpatient","","","164.00","123.00","AETNA [1001]","HB AMC AETNA HMO","114.47","69.8","","107.64","76.00","107.64","1 through 10","11.81","134.02","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","outpatient","","","164.00","123.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","134.02","81.72","","127.10","69.91","127.10","1 through 10","11.81","134.02","percent of total billed charges",""
"Eia Ql E Hystolytica Group Antigen","PX-30001240","CDM","87337","CPT","0306","RC","","","","both","","","192.00","144.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","102.34","53.3","","146.38","146.38","146.38","1 through 10","11.74","182.4","percent of total billed charges",""
"Eia Ql E Hystolytica Group Antigen","PX-30001240","CDM","87337","CPT","0306","RC","","","","both","","","192.00","144.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.54","38.3","","72.73","70.68","72.73","1 through 10","11.74","182.4","percent of total billed charges",""
"Eia Ql E Hystolytica Group Antigen","PX-30001240","CDM","87337","CPT","0306","RC","","","","outpatient","","","192.00","144.00","AETNA [1001]","HB AMC AETNA HMO","134.02","69.8","","125.92","125.92","125.92","1 through 10","11.81","156.9","percent of total billed charges",""
"Eia Ql E Hystolytica Group Antigen","PX-30001240","CDM","87337","CPT","0306","RC","","","","outpatient","","","192.00","144.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","156.90","81.72","","148.69","148.69","148.69","1 through 10","11.81","156.9","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","both","","","146.00","109.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.07","79.5","","111.75","111.75","134.97","1 through 10","11.74","138.7","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","both","","","146.00","109.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.82","53.3","","74.98","74.98","74.98","1 through 10","11.74","138.7","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.29","36.5","","52.97","45.01","135.03","1 through 10","11.74","138.7","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.92","38.3","","55.52","55.52","55.52","16","11.74","138.7","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","both","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.63","42.9","","54.35","54.35","54.35","1 through 10","11.74","138.7","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA HMO","101.91","69.8","","96.13","67.88","110.76","1 through 10","11.81","119.31","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA PPO","117.38","80.4","","110.76","110.76","110.76","1 through 10","11.81","119.31","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","119.31","81.72","","62.44","62.44","62.44","1 through 10","11.81","119.31","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","119.31","81.72","","113.51","49.88","113.51","1 through 10","11.81","119.31","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","152.68","102.43","152.68","39","11.84","190","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","200.00","150.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.60","53.3","","102.43","102.43","307.29","27","11.84","190","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","62.00","31","","59.95","59.95","59.95","1 through 10","11.84","190","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","72.36","61.50","72.36","49","11.84","190","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","73.72","75.85","161","11.84","190","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","200.00","150.00","MOLINA [1014]","HB BWH MOLINA","70.00","35","","28.53","28.53","28.53","1 through 10","11.84","190","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","200.00","150.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","154.00","77","","20.13","20.13","20.13","1 through 10","11.84","190","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","200.00","150.00","TRICARE [160005]","HB BWH TRICARE","190.00","95","","17.33","16.46","17.33","1 through 10","11.84","190","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","72.46","155.08","1 through 10","11.84","190","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","131.34","92.73","151.32","48","11.84","163.44","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA PPO","160.80","80.4","","151.32","101.66","151.32","1 through 10","11.84","163.44","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","200.00","150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","104.52","52.26","","120.05","120.05","120.05","1 through 10","11.84","163.44","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","200.00","150.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","160.80","80.4","","345.32","345.32","345.32","1 through 10","11.84","163.44","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","200.00","150.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","163.44","81.72","","144.78","144.78","155.08","1 through 10","11.84","163.44","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","163.44","81.72","","155.08","48.16","155.08","1 through 10","11.84","163.44","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","85.30","155.08","40","11.84","163.44","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","96.21","71.8","","280.02","93.34","280.02","19","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","87.90","65.6","","88.01","88.01","101.40","1 through 10","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","87.10","65","","84.50","68.64","84.50","1 through 10","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","93.80","70","","128.62","55.90","130.00","11","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","CHAMPVA [160001]","HB BWH TRICARE","127.30","95","","12.45","12.45","12.45","1 through 10","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","106.53","79.5","","102.31","68.64","102.31","421","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","71.42","53.3","","68.64","68.64","205.92","223","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","103.18","77","","100.10","100.10","100.10","1 through 10","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","87.10","65","","84.50","84.50","105.30","1 through 10","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","106.53","79.5","","102.31","102.31","102.31","1 through 10","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","41.54","31","","40.17","40.17","80.34","1 through 10","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.91","36.5","","48.49","41.21","145.47","485","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","51.32","38.3","","50.83","49.40","152.49","1623","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","103.18","77","","130.00","130.00","130.00","1 through 10","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","TRICARE [160005]","HB BWH TRICARE","127.30","95","","12.45","11.83","12.45","21","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.49","42.9","","103.92","57.16","103.92","20","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","134.00","100.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.49","42.9","","57.16","57.16","103.92","1 through 10","10.12","127.3","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","134.00","100.50","AETNA [1001]","HB AMC AETNA HMO","93.53","69.8","","88.01","62.14","101.40","687","10.66","109.5","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","134.00","100.50","AETNA [1001]","HB AMC AETNA PPO","107.74","80.4","","101.40","68.12","136.24","76","10.66","109.5","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","134.00","100.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","74.91","55.9","","68.12","68.12","68.12","1 through 10","10.66","109.5","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","134.00","100.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","70.03","52.26","","36.09","36.09","80.45","1 through 10","10.66","109.5","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","134.00","100.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","107.74","80.4","","65.00","65.00","65.00","1 through 10","10.66","109.5","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","134.00","100.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","109.50","81.72","","103.92","57.16","103.92","22","10.66","109.5","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","134.00","100.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","109.50","81.72","","103.92","57.16","103.92","505","10.66","109.5","percent of total billed charges",""
"Eia Ql Hepatitis B Surf Ag","PX-30001244","CDM","87341","CPT","0306","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","133.79","89.76","133.79","11","10.12","166.25","percent of total billed charges",""
"Eia Ql Hepatitis B Surf Ag","PX-30001244","CDM","87341","CPT","0306","RC","","","","both","","","175.00","131.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.28","53.3","","89.76","89.76","133.79","1 through 10","10.12","166.25","percent of total billed charges",""
"Eia Ql Hepatitis B Surf Ag","PX-30001244","CDM","87341","CPT","0306","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","63.41","53.89","69.01","11","10.12","166.25","percent of total billed charges",""
"Eia Ql Hepatitis B Surf Ag","PX-30001244","CDM","87341","CPT","0306","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","66.47","66.47","66.47","25","10.12","166.25","percent of total billed charges",""
"Eia Ql Hepatitis B Surf Ag","PX-30001244","CDM","87341","CPT","0306","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","115.09","81.26","115.09","11","10.66","143.01","percent of total billed charges",""
"Eia Ql Hepatitis B Surf Ag","PX-30001244","CDM","87341","CPT","0306","RC","","","","outpatient","","","175.00","131.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","91.46","52.26","","36.09","36.09","36.09","1 through 10","10.66","143.01","percent of total billed charges",""
"Eia Ql Hepatitis B Surf Ag","PX-30001244","CDM","87341","CPT","0306","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.01","81.72","","74.75","74.75","74.75","1 through 10","10.66","143.01","percent of total billed charges",""
"Eia Ql Hepatitis B Surf Ag","PX-30001244","CDM","87341","CPT","0306","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","135.90","74.75","135.90","1 through 10","10.66","143.01","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","both","","","140.00","105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.30","79.5","","107.03","71.81","107.03","1 through 10","11.3","133","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","both","","","140.00","105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.62","53.3","","107.03","71.81","107.03","1 through 10","11.3","133","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.10","36.5","","50.73","42.70","76.60","1 through 10","11.3","133","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.62","38.3","","53.18","53.18","53.18","12","11.3","133","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA HMO","97.72","69.8","","92.07","65.01","106.08","1 through 10","11.9","114.41","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","outpatient","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.56","80.4","","68.00","68.00","68.00","1 through 10","11.9","114.41","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.41","81.72","","108.72","108.72","108.72","1 through 10","11.9","114.41","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","195.30","71.8","","568.65","189.55","568.65","15","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","178.43","65.6","","205.92","178.73","205.92","1 through 10","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","190.40","70","","264.00","92.76","570.24","12","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","CHAMPVA [160001]","HB BWH TRICARE","258.40","95","","29.02","29.02","29.02","1 through 10","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","216.24","79.5","","207.77","139.39","623.31","443","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","144.98","53.3","","139.39","139.39","418.17","198","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","209.44","77","","609.84","203.28","609.84","1 through 10","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","176.80","65","","171.60","139.92","232.70","1 through 10","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","216.24","79.5","","207.77","207.77","264.00","1 through 10","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","84.32","31","","81.58","81.58","244.74","20","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","99.28","36.5","","98.47","83.69","295.41","549","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","104.18","38.3","","103.22","100.32","309.66","2004","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","MOLINA [1014]","HB BWH MOLINA","95.20","35","","47.77","47.77","47.77","1 through 10","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","209.44","77","","216.00","205.92","216.00","1 through 10","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","TRICARE [160005]","HB BWH TRICARE","258.40","95","","29.02","27.57","29.02","24","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","116.69","42.9","","211.04","116.08","211.06","24","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","116.69","42.9","","116.08","116.08","116.08","1 through 10","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","272.00","204.00","WELLPOINT [1015]","HB AMC WELLPOINT","200.68","73.78","","196.55","196.55","460.55","218","23.19","258.4","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","272.00","204.00","AETNA [1001]","HB AMC AETNA HMO","189.86","69.8","","178.73","126.19","205.92","696","23.19","222.28","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","272.00","204.00","AETNA [1001]","HB AMC AETNA PPO","218.69","80.4","","205.92","138.34","276.68","84","23.19","222.28","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","272.00","204.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","152.05","55.9","","138.34","138.34","276.68","1 through 10","23.19","222.28","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","272.00","204.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","142.15","52.26","","84.55","84.55","163.37","1 through 10","23.19","222.28","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","272.00","204.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","218.69","80.4","","132.00","132.00","132.00","1 through 10","23.19","222.28","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","272.00","204.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","222.28","81.72","","211.04","211.04","211.04","1 through 10","23.19","222.28","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","272.00","204.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","222.28","81.72","","116.08","116.08","211.04","22","23.19","222.28","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","272.00","204.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","222.28","81.72","","211.04","116.08","211.04","524","23.19","222.28","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","102.43","102.43","102.43","1 through 10","11.74","190","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","61.50","61.50","61.50","1 through 10","11.74","190","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","75.85","75.86","1 through 10","11.74","190","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","155.08","155.08","1 through 10","11.74","190","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","131.34","92.73","185.46","17","11.81","163.44","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","60.38","194.00","1 through 10","11.81","163.44","percent of total billed charges",""
"Eif2ak4-Associated Disorders (Eif2ak4) Sequencing","PX-31000788","CDM","81479","CPT","0310","RC","","","","both","","","1979.00","1484.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1573.31","79.5","","0.65","0.65","0.65","1 through 10","613.49","1880.05","percent of total billed charges",""
"Eif2ak4-Associated Disorders (Eif2ak4) Sequencing","PX-31000788","CDM","81479","CPT","0310","RC","","","","both","","","1979.00","1484.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1054.81","53.3","","0.79","0.79","0.79","1 through 10","613.49","1880.05","percent of total billed charges",""
"Eif2ak4-Associated Disorders (Eif2ak4) Sequencing","PX-31000788","CDM","81479","CPT","0310","RC","","","","outpatient","","","1979.00","1484.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","989.50","50","","1.00","1.00","1.00","1 through 10","156.55","1632.68","percent of total billed charges",""
"Eif2ak4-Associated Disorders (Eif2ak4) Sequencing","PX-31000788","CDM","81479","CPT","0310","RC","","","","outpatient","","","1979.00","1484.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1038.98","52.5","","1.00","0.53","1.00","1 through 10","156.55","1632.68","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.41","43.32","141.22","211","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","239.81","71.8","","232.63","126.68","697.89","15","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","219.10","65.6","","219.35","73.49","252.72","1 through 10","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","217.10","65","","210.60","210.60","342.14","13","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","233.80","70","","233.28","223.65","259.20","29","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","88.17","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","40.73","10.00","70.54","28","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","265.53","79.5","","254.99","171.07","509.99","746","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","178.02","53.3","","171.07","171.07","513.21","298","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.41","57.35","69.41","31","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","ELDER SERVICES [1037]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","70.54","70.54","1 through 10","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","FALLON HEALTH [1008]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","14.52","14.52","69.13","1 through 10","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.13","41.00","70.13","1 through 10","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11.00","7.26","69.13","1 through 10","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","257.18","77","","249.48","249.48","748.44","32","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","HUMANA [1012]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","69.55","410.44","21","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","217.10","65","","210.60","204.75","210.60","22","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","265.53","79.5","","254.99","254.99","254.99","1 through 10","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","217.10","65","","210.60","210.60","324.00","1 through 10","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.34","69.34","69.34","1 through 10","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","70.54","70.54","1267","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","103.54","31","","100.12","100.12","200.24","19","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.91","36.5","","120.85","102.71","241.70","525","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.92","38.3","","126.68","123.12","253.36","1374","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.53","65.82","104.30","33","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","MOLINA [1014]","HB BWH MOLINA","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","139.95","133.52","139.95","12","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","257.18","77","","252.72","197.50","254.99","11","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","TRICARE [160005]","HB BWH TRICARE","67.01","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","67.01","67.01","67.01","1 through 10","67.01","265.53","other","Tricare OPPS"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.73","69.13","208.59","67","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","74.52","74.52","74.52","24","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","143.29","42.9","","147.42","142.46","259.01","27","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.33","66.23","70.13","246","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","143.29","42.9","","142.46","142.46","142.46","1 through 10","67.01","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","334.00","250.50","WELLSENSE NH [1050]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","70.54","70.54","1 through 10","67.01","265.53","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","inpatient","","","334.00","250.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","262.56","78.61","","518.02","138.41","518.02","1 through 10","184.7","265.53","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","334.00","250.50","AETNA [1001]","HB AMC AETNA HMO","233.13","69.8","","219.35","154.87","252.72","45","128.42","272.94","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","334.00","250.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","174.55","52.26","","200.49","148.17","200.49","19","128.42","272.94","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","334.00","250.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","268.54","80.4","","252.72","162.00","576.72","19","128.42","272.94","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","334.00","250.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","272.94","81.72","","259.00","242.57","259.01","1 through 10","128.42","272.94","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","334.00","250.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","272.94","81.72","","142.46","142.46","259.01","27","128.42","272.94","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","334.00","250.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","272.94","81.72","","259.01","142.46","259.01","536","128.42","272.94","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","both","","","273.00","204.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","217.04","79.5","","208.56","139.92","208.56","1 through 10","22.51","259.35","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","both","","","273.00","204.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","145.51","53.3","","401.49","208.56","401.49","1 through 10","22.51","259.35","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","both","","","273.00","204.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","99.65","36.5","","98.85","84.01","252.03","11","22.51","259.35","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","both","","","273.00","204.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","104.56","38.3","","103.62","103.62","310.86","21","22.51","259.35","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","both","","","273.00","204.75","WELLPOINT [1015]","HB AMC WELLPOINT","201.42","73.78","","197.29","197.29","462.29","1 through 10","22.51","259.35","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","273.00","204.75","AETNA [1001]","HB AMC AETNA HMO","190.55","69.8","","179.41","179.41","179.41","1 through 10","99.1","225.23","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","273.00","204.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","142.67","52.26","","163.99","163.99","163.99","1 through 10","99.1","225.23","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","273.00","204.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","142.56","52.22","","142.65","142.65","183.17","35","99.1","225.23","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","273.00","204.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","143.33","52.5","","118.19","118.19","173.58","1 through 10","99.1","225.23","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","273.00","204.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","136.50","50","","138.86","112.63","219.48","18","99.1","225.23","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","273.00","204.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","143.33","52.5","","145.75","145.75","437.25","16","99.1","225.23","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","273.00","204.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","150.15","55","","152.64","146.81","152.64","1 through 10","99.1","225.23","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","273.00","204.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","219.49","80.4","","206.70","206.70","206.70","1 through 10","99.1","225.23","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","273.00","204.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","223.10","81.72","","211.84","93.08","211.84","1 through 10","99.1","225.23","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3491.25","2618.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1824.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1082.29","2775.54","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3491.25","2618.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2775.54","79.5","","1293.60","1148.53","1603.80","1 through 10","1082.29","2775.54","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3491.25","2618.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1274.31","36.5","","1023.42","771.29","2068.67","33","1082.29","2775.54","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3491.25","2618.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1337.15","38.3","","850.52","759.78","1211.25","66","1082.29","2775.54","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3491.25","2618.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1497.75","42.9","","2548.09","2548.09","2548.09","1 through 10","1082.29","2775.54","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3491.25","2618.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1497.75","42.9","","956.46","956.46","956.46","1 through 10","1082.29","2775.54","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3491.25","2618.44","WELLPOINT [1015]","HB AMC WELLPOINT","2575.84","73.78","","2344.73","1619.47","2530.35","16","1082.29","2775.54","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3491.25","2618.44","AETNA [1001]","HB AMC AETNA HMO","2436.89","69.8","","1523.63","988.41","4330.26","39","1824.53","2853.05","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3491.25","2618.44","AETNA [1001]","HB AMC AETNA PPO","2806.97","80.4","","1670.25","1670.25","1670.25","1 through 10","1824.53","2853.05","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3491.25","2618.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1824.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1824.53","2853.05","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3491.25","2618.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2853.05","81.72","","1738.90","1484.65","2716.94","38","1824.53","2853.05","percent of total billed charges",""
"ELBOW 114819 ULNA RIGHT 3X155MM W/BEARING","SUP-ITM-10030072","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3686.94","52.26","","1113.10","1113.10","1113.10","1 through 10","2187.05","5608.73","percent of total billed charges",""
"ELBOW 114819 ULNA RIGHT 3X155MM W/BEARING","SUP-ITM-10030072","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5608.73","79.5","","1293.60","1148.53","1603.80","1 through 10","2187.05","5608.73","percent of total billed charges",""
"ELBOW 114819 ULNA RIGHT 3X155MM W/BEARING","SUP-ITM-10030072","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2575.08","36.5","","1023.42","771.29","2068.67","33","2187.05","5608.73","percent of total billed charges",""
"ELBOW 114819 ULNA RIGHT 3X155MM W/BEARING","SUP-ITM-10030072","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2702.07","38.3","","850.52","759.78","1211.25","66","2187.05","5608.73","percent of total billed charges",""
"ELBOW 114819 ULNA RIGHT 3X155MM W/BEARING","SUP-ITM-10030072","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3026.60","42.9","","2548.09","2548.09","2548.09","1 through 10","2187.05","5608.73","percent of total billed charges",""
"ELBOW 114819 ULNA RIGHT 3X155MM W/BEARING","SUP-ITM-10030072","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3026.60","42.9","","956.46","956.46","956.46","1 through 10","2187.05","5608.73","percent of total billed charges",""
"ELBOW 114819 ULNA RIGHT 3X155MM W/BEARING","SUP-ITM-10030072","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","WELLPOINT [1015]","HB AMC WELLPOINT","5205.18","73.78","","2344.73","1619.47","2530.35","16","2187.05","5608.73","percent of total billed charges",""
"ELBOW 114819 ULNA RIGHT 3X155MM W/BEARING","SUP-ITM-10030072","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7055.00","5291.25","AETNA [1001]","HB AMC AETNA HMO","4924.39","69.8","","1523.63","988.41","4330.26","39","3686.94","5765.35","percent of total billed charges",""
"ELBOW 114819 ULNA RIGHT 3X155MM W/BEARING","SUP-ITM-10030072","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7055.00","5291.25","AETNA [1001]","HB AMC AETNA PPO","5672.22","80.4","","1670.25","1670.25","1670.25","1 through 10","3686.94","5765.35","percent of total billed charges",""
"ELBOW 114819 ULNA RIGHT 3X155MM W/BEARING","SUP-ITM-10030072","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7055.00","5291.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3686.94","52.26","","1113.10","1113.10","1113.10","1 through 10","3686.94","5765.35","percent of total billed charges",""
"ELBOW 114819 ULNA RIGHT 3X155MM W/BEARING","SUP-ITM-10030072","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7055.00","5291.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5765.35","81.72","","1738.90","1484.65","2716.94","38","3686.94","5765.35","percent of total billed charges",""
"ELBOW 114929HUMEROUS RIGHT CUSTOM DISCOVERY","SUP-ITM-10033442","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3344.64","52.26","","1113.10","1113.10","1113.10","1 through 10","1984","5088","percent of total billed charges",""
"ELBOW 114929HUMEROUS RIGHT CUSTOM DISCOVERY","SUP-ITM-10033442","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5088.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1984","5088","percent of total billed charges",""
"ELBOW 114929HUMEROUS RIGHT CUSTOM DISCOVERY","SUP-ITM-10033442","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2336.00","36.5","","1023.42","771.29","2068.67","33","1984","5088","percent of total billed charges",""
"ELBOW 114929HUMEROUS RIGHT CUSTOM DISCOVERY","SUP-ITM-10033442","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2451.20","38.3","","850.52","759.78","1211.25","66","1984","5088","percent of total billed charges",""
"ELBOW 114929HUMEROUS RIGHT CUSTOM DISCOVERY","SUP-ITM-10033442","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2745.60","42.9","","2548.09","2548.09","2548.09","1 through 10","1984","5088","percent of total billed charges",""
"ELBOW 114929HUMEROUS RIGHT CUSTOM DISCOVERY","SUP-ITM-10033442","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2745.60","42.9","","956.46","956.46","956.46","1 through 10","1984","5088","percent of total billed charges",""
"ELBOW 114929HUMEROUS RIGHT CUSTOM DISCOVERY","SUP-ITM-10033442","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","WELLPOINT [1015]","HB AMC WELLPOINT","4721.92","73.78","","2344.73","1619.47","2530.35","16","1984","5088","percent of total billed charges",""
"ELBOW 114929HUMEROUS RIGHT CUSTOM DISCOVERY","SUP-ITM-10033442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","AETNA [1001]","HB AMC AETNA HMO","4467.20","69.8","","1523.63","988.41","4330.26","39","3344.64","5230.08","percent of total billed charges",""
"ELBOW 114929HUMEROUS RIGHT CUSTOM DISCOVERY","SUP-ITM-10033442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","AETNA [1001]","HB AMC AETNA PPO","5145.60","80.4","","1670.25","1670.25","1670.25","1 through 10","3344.64","5230.08","percent of total billed charges",""
"ELBOW 114929HUMEROUS RIGHT CUSTOM DISCOVERY","SUP-ITM-10033442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3344.64","52.26","","1113.10","1113.10","1113.10","1 through 10","3344.64","5230.08","percent of total billed charges",""
"ELBOW 114929HUMEROUS RIGHT CUSTOM DISCOVERY","SUP-ITM-10033442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5230.08","81.72","","1738.90","1484.65","2716.94","38","3344.64","5230.08","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2243.52","52.26","","1113.10","1113.10","1113.10","1 through 10","1330.83","3412.94","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3412.94","79.5","","1293.60","1148.53","1603.80","1 through 10","1330.83","3412.94","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1566.95","36.5","","1023.42","771.29","2068.67","33","1330.83","3412.94","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1644.22","38.3","","850.52","759.78","1211.25","66","1330.83","3412.94","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1841.70","42.9","","2548.09","2548.09","2548.09","1 through 10","1330.83","3412.94","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1841.70","42.9","","956.46","956.46","956.46","1 through 10","1330.83","3412.94","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","WELLPOINT [1015]","HB AMC WELLPOINT","3167.38","73.78","","2344.73","1619.47","2530.35","16","1330.83","3412.94","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4293.00","3219.75","AETNA [1001]","HB AMC AETNA HMO","2996.51","69.8","","1523.63","988.41","4330.26","39","2243.52","3508.24","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4293.00","3219.75","AETNA [1001]","HB AMC AETNA PPO","3451.57","80.4","","1670.25","1670.25","1670.25","1 through 10","2243.52","3508.24","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4293.00","3219.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2243.52","52.26","","1113.10","1113.10","1113.10","1 through 10","2243.52","3508.24","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4293.00","3219.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3508.24","81.72","","1738.90","1484.65","2716.94","38","2243.52","3508.24","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","15160.00","11370.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","7922.62","52.26","","1113.10","1113.10","1113.10","1 through 10","4699.6","12052.2","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","15160.00","11370.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12052.20","79.5","","1293.60","1148.53","1603.80","1 through 10","4699.6","12052.2","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","15160.00","11370.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5533.40","36.5","","1023.42","771.29","2068.67","33","4699.6","12052.2","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","15160.00","11370.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5806.28","38.3","","850.52","759.78","1211.25","66","4699.6","12052.2","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","15160.00","11370.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6503.64","42.9","","2548.09","2548.09","2548.09","1 through 10","4699.6","12052.2","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","15160.00","11370.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6503.64","42.9","","956.46","956.46","956.46","1 through 10","4699.6","12052.2","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","15160.00","11370.00","WELLPOINT [1015]","HB AMC WELLPOINT","11185.05","73.78","","2344.73","1619.47","2530.35","16","4699.6","12052.2","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15160.00","11370.00","AETNA [1001]","HB AMC AETNA HMO","10581.68","69.8","","1523.63","988.41","4330.26","39","7922.62","12388.75","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15160.00","11370.00","AETNA [1001]","HB AMC AETNA PPO","12188.64","80.4","","1670.25","1670.25","1670.25","1 through 10","7922.62","12388.75","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15160.00","11370.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","7922.62","52.26","","1113.10","1113.10","1113.10","1 through 10","7922.62","12388.75","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15160.00","11370.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12388.75","81.72","","1738.90","1484.65","2716.94","38","7922.62","12388.75","percent of total billed charges",""
"ELBOW BEARING 5X75MM ORTHO DISY COMPONENT LEFT","SUP-ITM-10021474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3686.94","52.26","","1113.10","1113.10","1113.10","1 through 10","2187.05","5608.73","percent of total billed charges",""
"ELBOW BEARING 5X75MM ORTHO DISY COMPONENT LEFT","SUP-ITM-10021474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5608.73","79.5","","1293.60","1148.53","1603.80","1 through 10","2187.05","5608.73","percent of total billed charges",""
"ELBOW BEARING 5X75MM ORTHO DISY COMPONENT LEFT","SUP-ITM-10021474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2575.08","36.5","","1023.42","771.29","2068.67","33","2187.05","5608.73","percent of total billed charges",""
"ELBOW BEARING 5X75MM ORTHO DISY COMPONENT LEFT","SUP-ITM-10021474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2702.07","38.3","","850.52","759.78","1211.25","66","2187.05","5608.73","percent of total billed charges",""
"ELBOW BEARING 5X75MM ORTHO DISY COMPONENT LEFT","SUP-ITM-10021474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3026.60","42.9","","2548.09","2548.09","2548.09","1 through 10","2187.05","5608.73","percent of total billed charges",""
"ELBOW BEARING 5X75MM ORTHO DISY COMPONENT LEFT","SUP-ITM-10021474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3026.60","42.9","","956.46","956.46","956.46","1 through 10","2187.05","5608.73","percent of total billed charges",""
"ELBOW BEARING 5X75MM ORTHO DISY COMPONENT LEFT","SUP-ITM-10021474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7055.00","5291.25","WELLPOINT [1015]","HB AMC WELLPOINT","5205.18","73.78","","2344.73","1619.47","2530.35","16","2187.05","5608.73","percent of total billed charges",""
"ELBOW BEARING 5X75MM ORTHO DISY COMPONENT LEFT","SUP-ITM-10021474","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7055.00","5291.25","AETNA [1001]","HB AMC AETNA HMO","4924.39","69.8","","1523.63","988.41","4330.26","39","3686.94","5765.35","percent of total billed charges",""
"ELBOW BEARING 5X75MM ORTHO DISY COMPONENT LEFT","SUP-ITM-10021474","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7055.00","5291.25","AETNA [1001]","HB AMC AETNA PPO","5672.22","80.4","","1670.25","1670.25","1670.25","1 through 10","3686.94","5765.35","percent of total billed charges",""
"ELBOW BEARING 5X75MM ORTHO DISY COMPONENT LEFT","SUP-ITM-10021474","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7055.00","5291.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3686.94","52.26","","1113.10","1113.10","1113.10","1 through 10","3686.94","5765.35","percent of total billed charges",""
"ELBOW BEARING 5X75MM ORTHO DISY COMPONENT LEFT","SUP-ITM-10021474","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7055.00","5291.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5765.35","81.72","","1738.90","1484.65","2716.94","38","3686.94","5765.35","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2763.25","52.26","","1113.10","1113.10","1113.10","1 through 10","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4203.56","79.5","","1293.60","1148.53","1603.80","1 through 10","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1929.94","36.5","","1023.42","771.29","2068.67","33","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2025.11","38.3","","850.52","759.78","1211.25","66","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2268.34","42.9","","2548.09","2548.09","2548.09","1 through 10","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2268.34","42.9","","956.46","956.46","956.46","1 through 10","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","WELLPOINT [1015]","HB AMC WELLPOINT","3901.12","73.78","","2344.73","1619.47","2530.35","16","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5287.50","3965.62","AETNA [1001]","HB AMC AETNA HMO","3690.68","69.8","","1523.63","988.41","4330.26","39","2763.25","4320.95","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5287.50","3965.62","AETNA [1001]","HB AMC AETNA PPO","4251.15","80.4","","1670.25","1670.25","1670.25","1 through 10","2763.25","4320.95","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5287.50","3965.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2763.25","52.26","","1113.10","1113.10","1113.10","1 through 10","2763.25","4320.95","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5287.50","3965.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4320.95","81.72","","1738.90","1484.65","2716.94","38","2763.25","4320.95","percent of total billed charges",""
"ELBOW HEAD 26MM PLUS 4MM RADIAL EVOLVE PROLINE","SUP-ITM-10012522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2229.67","52.26","","1113.10","1113.10","1113.10","1 through 10","1322.62","3391.87","percent of total billed charges",""
"ELBOW HEAD 26MM PLUS 4MM RADIAL EVOLVE PROLINE","SUP-ITM-10012522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3391.87","79.5","","1293.60","1148.53","1603.80","1 through 10","1322.62","3391.87","percent of total billed charges",""
"ELBOW HEAD 26MM PLUS 4MM RADIAL EVOLVE PROLINE","SUP-ITM-10012522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1557.27","36.5","","1023.42","771.29","2068.67","33","1322.62","3391.87","percent of total billed charges",""
"ELBOW HEAD 26MM PLUS 4MM RADIAL EVOLVE PROLINE","SUP-ITM-10012522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1634.07","38.3","","850.52","759.78","1211.25","66","1322.62","3391.87","percent of total billed charges",""
"ELBOW HEAD 26MM PLUS 4MM RADIAL EVOLVE PROLINE","SUP-ITM-10012522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1830.33","42.9","","2548.09","2548.09","2548.09","1 through 10","1322.62","3391.87","percent of total billed charges",""
"ELBOW HEAD 26MM PLUS 4MM RADIAL EVOLVE PROLINE","SUP-ITM-10012522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1830.33","42.9","","956.46","956.46","956.46","1 through 10","1322.62","3391.87","percent of total billed charges",""
"ELBOW HEAD 26MM PLUS 4MM RADIAL EVOLVE PROLINE","SUP-ITM-10012522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","WELLPOINT [1015]","HB AMC WELLPOINT","3147.82","73.78","","2344.73","1619.47","2530.35","16","1322.62","3391.87","percent of total billed charges",""
"ELBOW HEAD 26MM PLUS 4MM RADIAL EVOLVE PROLINE","SUP-ITM-10012522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4266.50","3199.87","AETNA [1001]","HB AMC AETNA HMO","2978.02","69.8","","1523.63","988.41","4330.26","39","2229.67","3486.58","percent of total billed charges",""
"ELBOW HEAD 26MM PLUS 4MM RADIAL EVOLVE PROLINE","SUP-ITM-10012522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4266.50","3199.87","AETNA [1001]","HB AMC AETNA PPO","3430.27","80.4","","1670.25","1670.25","1670.25","1 through 10","2229.67","3486.58","percent of total billed charges",""
"ELBOW HEAD 26MM PLUS 4MM RADIAL EVOLVE PROLINE","SUP-ITM-10012522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4266.50","3199.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2229.67","52.26","","1113.10","1113.10","1113.10","1 through 10","2229.67","3486.58","percent of total billed charges",""
"ELBOW HEAD 26MM PLUS 4MM RADIAL EVOLVE PROLINE","SUP-ITM-10012522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4266.50","3199.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3486.58","81.72","","1738.90","1484.65","2716.94","38","2229.67","3486.58","percent of total billed charges",""
"ELBOW HEAD 26MM RADIAL HEMI POLYMER","SUP-ITM-10266620","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2763.25","52.26","","1113.10","1113.10","1113.10","1 through 10","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 26MM RADIAL HEMI POLYMER","SUP-ITM-10266620","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4203.56","79.5","","1293.60","1148.53","1603.80","1 through 10","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 26MM RADIAL HEMI POLYMER","SUP-ITM-10266620","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1929.94","36.5","","1023.42","771.29","2068.67","33","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 26MM RADIAL HEMI POLYMER","SUP-ITM-10266620","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2025.11","38.3","","850.52","759.78","1211.25","66","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 26MM RADIAL HEMI POLYMER","SUP-ITM-10266620","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2268.34","42.9","","2548.09","2548.09","2548.09","1 through 10","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 26MM RADIAL HEMI POLYMER","SUP-ITM-10266620","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2268.34","42.9","","956.46","956.46","956.46","1 through 10","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 26MM RADIAL HEMI POLYMER","SUP-ITM-10266620","CDM","C1776","HCPCS","0278","RC","","","","both","","","5287.50","3965.62","WELLPOINT [1015]","HB AMC WELLPOINT","3901.12","73.78","","2344.73","1619.47","2530.35","16","1639.13","4203.56","percent of total billed charges",""
"ELBOW HEAD 26MM RADIAL HEMI POLYMER","SUP-ITM-10266620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5287.50","3965.62","AETNA [1001]","HB AMC AETNA HMO","3690.68","69.8","","1523.63","988.41","4330.26","39","2763.25","4320.95","percent of total billed charges",""
"ELBOW HEAD 26MM RADIAL HEMI POLYMER","SUP-ITM-10266620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5287.50","3965.62","AETNA [1001]","HB AMC AETNA PPO","4251.15","80.4","","1670.25","1670.25","1670.25","1 through 10","2763.25","4320.95","percent of total billed charges",""
"ELBOW HEAD 26MM RADIAL HEMI POLYMER","SUP-ITM-10266620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5287.50","3965.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2763.25","52.26","","1113.10","1113.10","1113.10","1 through 10","2763.25","4320.95","percent of total billed charges",""
"ELBOW HEAD 26MM RADIAL HEMI POLYMER","SUP-ITM-10266620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5287.50","3965.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4320.95","81.72","","1738.90","1484.65","2716.94","38","2763.25","4320.95","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2378.20","79.5","","800.18","480.96","1887.97","195","927.35","2378.2","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1594.44","53.3","","813.12","216.42","1444.50","81","927.35","2378.2","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","927.35","31","","432.60","432.60","432.60","1 through 10","927.35","2378.2","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1091.88","36.5","","148.37","54.89","631.39","94","927.35","2378.2","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1145.73","38.3","","279.30","91.72","1116.77","266","927.35","2378.2","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1283.33","42.9","","731.00","63.70","731.00","1 through 10","927.35","2378.2","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1283.33","42.9","","384.74","384.74","384.74","1 through 10","927.35","2378.2","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2991.45","2243.59","WELLPOINT [1015]","HB AMC WELLPOINT","2207.09","73.78","","286.63","119.22","1107.45","105","927.35","2378.2","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2991.45","2243.59","AETNA [1001]","HB AMC AETNA HMO","2088.03","69.8","","675.31","184.75","1721.50","286","1563.33","2444.61","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2991.45","2243.59","AETNA [1001]","HB AMC AETNA PPO","2405.13","80.4","","1261.44","103.12","1514.10","21","1563.33","2444.61","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2991.45","2243.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2405.13","80.4","","1365.00","1365.00","1365.00","1 through 10","1563.33","2444.61","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2991.45","2243.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2444.61","81.72","","5157.68","5157.68","5157.68","1 through 10","1563.33","2444.61","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP OLECRANON PL 90 LEFT","SUP-ITM-10125484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2991.45","2243.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2444.61","81.72","","431.26","71.26","1459.57","88","1563.33","2444.61","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP PROXIMALIMAL OLECRANON PL 73 RIGHT","SUP-ITM-10125492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2125.97","79.5","","800.18","480.96","1887.97","195","829","2125.97","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP PROXIMALIMAL OLECRANON PL 73 RIGHT","SUP-ITM-10125492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1425.34","53.3","","813.12","216.42","1444.50","81","829","2125.97","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP PROXIMALIMAL OLECRANON PL 73 RIGHT","SUP-ITM-10125492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","829.00","31","","432.60","432.60","432.60","1 through 10","829","2125.97","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP PROXIMALIMAL OLECRANON PL 73 RIGHT","SUP-ITM-10125492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","976.08","36.5","","148.37","54.89","631.39","94","829","2125.97","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP PROXIMALIMAL OLECRANON PL 73 RIGHT","SUP-ITM-10125492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1024.21","38.3","","279.30","91.72","1116.77","266","829","2125.97","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP PROXIMALIMAL OLECRANON PL 73 RIGHT","SUP-ITM-10125492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1147.22","42.9","","731.00","63.70","731.00","1 through 10","829","2125.97","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP PROXIMALIMAL OLECRANON PL 73 RIGHT","SUP-ITM-10125492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1147.22","42.9","","384.74","384.74","384.74","1 through 10","829","2125.97","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP PROXIMALIMAL OLECRANON PL 73 RIGHT","SUP-ITM-10125492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","WELLPOINT [1015]","HB AMC WELLPOINT","1973.01","73.78","","286.63","119.22","1107.45","105","829","2125.97","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP PROXIMALIMAL OLECRANON PL 73 RIGHT","SUP-ITM-10125492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2674.18","2005.63","AETNA [1001]","HB AMC AETNA HMO","1866.58","69.8","","675.31","184.75","1721.50","286","1397.53","2185.34","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP PROXIMALIMAL OLECRANON PL 73 RIGHT","SUP-ITM-10125492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2674.18","2005.63","AETNA [1001]","HB AMC AETNA PPO","2150.04","80.4","","1261.44","103.12","1514.10","21","1397.53","2185.34","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP PROXIMALIMAL OLECRANON PL 73 RIGHT","SUP-ITM-10125492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2674.18","2005.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2150.04","80.4","","1365.00","1365.00","1365.00","1 through 10","1397.53","2185.34","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP PROXIMALIMAL OLECRANON PL 73 RIGHT","SUP-ITM-10125492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2674.18","2005.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2185.34","81.72","","5157.68","5157.68","5157.68","1 through 10","1397.53","2185.34","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 2 H 2H TI VA LCP PROXIMALIMAL OLECRANON PL 73 RIGHT","SUP-ITM-10125492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2674.18","2005.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2185.34","81.72","","431.26","71.26","1459.57","88","1397.53","2185.34","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 4 H 4H TI VA LCP OLECRANON PL 116 LEFT","SUP-ITM-10125485","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2441.01","79.5","","800.18","480.96","1887.97","195","951.84","2441.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 4 H 4H TI VA LCP OLECRANON PL 116 LEFT","SUP-ITM-10125485","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1636.55","53.3","","813.12","216.42","1444.50","81","951.84","2441.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 4 H 4H TI VA LCP OLECRANON PL 116 LEFT","SUP-ITM-10125485","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","951.84","31","","432.60","432.60","432.60","1 through 10","951.84","2441.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 4 H 4H TI VA LCP OLECRANON PL 116 LEFT","SUP-ITM-10125485","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1120.71","36.5","","148.37","54.89","631.39","94","951.84","2441.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 4 H 4H TI VA LCP OLECRANON PL 116 LEFT","SUP-ITM-10125485","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1175.98","38.3","","279.30","91.72","1116.77","266","951.84","2441.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 4 H 4H TI VA LCP OLECRANON PL 116 LEFT","SUP-ITM-10125485","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1317.22","42.9","","731.00","63.70","731.00","1 through 10","951.84","2441.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 4 H 4H TI VA LCP OLECRANON PL 116 LEFT","SUP-ITM-10125485","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1317.22","42.9","","384.74","384.74","384.74","1 through 10","951.84","2441.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 4 H 4H TI VA LCP OLECRANON PL 116 LEFT","SUP-ITM-10125485","CDM","C1713","HCPCS","0278","RC","","","","both","","","3070.45","2302.84","WELLPOINT [1015]","HB AMC WELLPOINT","2265.38","73.78","","286.63","119.22","1107.45","105","951.84","2441.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 4 H 4H TI VA LCP OLECRANON PL 116 LEFT","SUP-ITM-10125485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3070.45","2302.84","AETNA [1001]","HB AMC AETNA HMO","2143.17","69.8","","675.31","184.75","1721.50","286","1604.62","2509.17","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 4 H 4H TI VA LCP OLECRANON PL 116 LEFT","SUP-ITM-10125485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3070.45","2302.84","AETNA [1001]","HB AMC AETNA PPO","2468.64","80.4","","1261.44","103.12","1514.10","21","1604.62","2509.17","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 4 H 4H TI VA LCP OLECRANON PL 116 LEFT","SUP-ITM-10125485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3070.45","2302.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2468.64","80.4","","1365.00","1365.00","1365.00","1 through 10","1604.62","2509.17","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 4 H 4H TI VA LCP OLECRANON PL 116 LEFT","SUP-ITM-10125485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3070.45","2302.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2509.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1604.62","2509.17","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 4 H 4H TI VA LCP OLECRANON PL 116 LEFT","SUP-ITM-10125485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3070.45","2302.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2509.17","81.72","","431.26","71.26","1459.57","88","1604.62","2509.17","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 6 H 6H TI VA LCP OLECRANON PL 142 LEFT","SUP-ITM-10125486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3114.48","2335.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2476.01","79.5","","800.18","480.96","1887.97","195","965.49","2476.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 6 H 6H TI VA LCP OLECRANON PL 142 LEFT","SUP-ITM-10125486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3114.48","2335.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1660.02","53.3","","813.12","216.42","1444.50","81","965.49","2476.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 6 H 6H TI VA LCP OLECRANON PL 142 LEFT","SUP-ITM-10125486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3114.48","2335.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","965.49","31","","432.60","432.60","432.60","1 through 10","965.49","2476.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 6 H 6H TI VA LCP OLECRANON PL 142 LEFT","SUP-ITM-10125486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3114.48","2335.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1136.79","36.5","","148.37","54.89","631.39","94","965.49","2476.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 6 H 6H TI VA LCP OLECRANON PL 142 LEFT","SUP-ITM-10125486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3114.48","2335.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1192.85","38.3","","279.30","91.72","1116.77","266","965.49","2476.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 6 H 6H TI VA LCP OLECRANON PL 142 LEFT","SUP-ITM-10125486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3114.48","2335.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1336.11","42.9","","731.00","63.70","731.00","1 through 10","965.49","2476.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 6 H 6H TI VA LCP OLECRANON PL 142 LEFT","SUP-ITM-10125486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3114.48","2335.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1336.11","42.9","","384.74","384.74","384.74","1 through 10","965.49","2476.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 6 H 6H TI VA LCP OLECRANON PL 142 LEFT","SUP-ITM-10125486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3114.48","2335.86","WELLPOINT [1015]","HB AMC WELLPOINT","2297.86","73.78","","286.63","119.22","1107.45","105","965.49","2476.01","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 6 H 6H TI VA LCP OLECRANON PL 142 LEFT","SUP-ITM-10125486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3114.48","2335.86","AETNA [1001]","HB AMC AETNA HMO","2173.91","69.8","","675.31","184.75","1721.50","286","1627.63","2545.15","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 6 H 6H TI VA LCP OLECRANON PL 142 LEFT","SUP-ITM-10125486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3114.48","2335.86","AETNA [1001]","HB AMC AETNA PPO","2504.04","80.4","","1261.44","103.12","1514.10","21","1627.63","2545.15","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 6 H 6H TI VA LCP OLECRANON PL 142 LEFT","SUP-ITM-10125486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3114.48","2335.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2504.04","80.4","","1365.00","1365.00","1365.00","1 through 10","1627.63","2545.15","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 6 H 6H TI VA LCP OLECRANON PL 142 LEFT","SUP-ITM-10125486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3114.48","2335.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2545.15","81.72","","5157.68","5157.68","5157.68","1 through 10","1627.63","2545.15","percent of total billed charges",""
"ELBOW IMPLANT 2.7MM 3.5 6 H 6H TI VA LCP OLECRANON PL 142 LEFT","SUP-ITM-10125486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3114.48","2335.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2545.15","81.72","","431.26","71.26","1459.57","88","1627.63","2545.15","percent of total billed charges",""
"ELBOW IMPLANT 4.0IN SM COMPONENT HUMERAL COONRAD/MORREY TITANIUM ALLOY","SUP-ITM-10006958","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3990.64","52.26","","1113.10","1113.10","1113.10","1 through 10","2367.2","6070.72","percent of total billed charges",""
"ELBOW IMPLANT 4.0IN SM COMPONENT HUMERAL COONRAD/MORREY TITANIUM ALLOY","SUP-ITM-10006958","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6070.72","79.5","","1293.60","1148.53","1603.80","1 through 10","2367.2","6070.72","percent of total billed charges",""
"ELBOW IMPLANT 4.0IN SM COMPONENT HUMERAL COONRAD/MORREY TITANIUM ALLOY","SUP-ITM-10006958","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2787.19","36.5","","1023.42","771.29","2068.67","33","2367.2","6070.72","percent of total billed charges",""
"ELBOW IMPLANT 4.0IN SM COMPONENT HUMERAL COONRAD/MORREY TITANIUM ALLOY","SUP-ITM-10006958","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2924.64","38.3","","850.52","759.78","1211.25","66","2367.2","6070.72","percent of total billed charges",""
"ELBOW IMPLANT 4.0IN SM COMPONENT HUMERAL COONRAD/MORREY TITANIUM ALLOY","SUP-ITM-10006958","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3275.90","42.9","","2548.09","2548.09","2548.09","1 through 10","2367.2","6070.72","percent of total billed charges",""
"ELBOW IMPLANT 4.0IN SM COMPONENT HUMERAL COONRAD/MORREY TITANIUM ALLOY","SUP-ITM-10006958","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3275.90","42.9","","956.46","956.46","956.46","1 through 10","2367.2","6070.72","percent of total billed charges",""
"ELBOW IMPLANT 4.0IN SM COMPONENT HUMERAL COONRAD/MORREY TITANIUM ALLOY","SUP-ITM-10006958","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","WELLPOINT [1015]","HB AMC WELLPOINT","5633.94","73.78","","2344.73","1619.47","2530.35","16","2367.2","6070.72","percent of total billed charges",""
"ELBOW IMPLANT 4.0IN SM COMPONENT HUMERAL COONRAD/MORREY TITANIUM ALLOY","SUP-ITM-10006958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7636.13","5727.10","AETNA [1001]","HB AMC AETNA HMO","5330.02","69.8","","1523.63","988.41","4330.26","39","3990.64","6240.25","percent of total billed charges",""
"ELBOW IMPLANT 4.0IN SM COMPONENT HUMERAL COONRAD/MORREY TITANIUM ALLOY","SUP-ITM-10006958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7636.13","5727.10","AETNA [1001]","HB AMC AETNA PPO","6139.45","80.4","","1670.25","1670.25","1670.25","1 through 10","3990.64","6240.25","percent of total billed charges",""
"ELBOW IMPLANT 4.0IN SM COMPONENT HUMERAL COONRAD/MORREY TITANIUM ALLOY","SUP-ITM-10006958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7636.13","5727.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3990.64","52.26","","1113.10","1113.10","1113.10","1 through 10","3990.64","6240.25","percent of total billed charges",""
"ELBOW IMPLANT 4.0IN SM COMPONENT HUMERAL COONRAD/MORREY TITANIUM ALLOY","SUP-ITM-10006958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7636.13","5727.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6240.25","81.72","","1738.90","1484.65","2716.94","38","3990.64","6240.25","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2229.67","52.26","","1113.10","1113.10","1113.10","1 through 10","1322.62","3391.87","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3391.87","79.5","","1293.60","1148.53","1603.80","1 through 10","1322.62","3391.87","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1557.27","36.5","","1023.42","771.29","2068.67","33","1322.62","3391.87","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1634.07","38.3","","850.52","759.78","1211.25","66","1322.62","3391.87","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1830.33","42.9","","2548.09","2548.09","2548.09","1 through 10","1322.62","3391.87","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1830.33","42.9","","956.46","956.46","956.46","1 through 10","1322.62","3391.87","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4266.50","3199.87","WELLPOINT [1015]","HB AMC WELLPOINT","3147.82","73.78","","2344.73","1619.47","2530.35","16","1322.62","3391.87","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4266.50","3199.87","AETNA [1001]","HB AMC AETNA HMO","2978.02","69.8","","1523.63","988.41","4330.26","39","2229.67","3486.58","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4266.50","3199.87","AETNA [1001]","HB AMC AETNA PPO","3430.27","80.4","","1670.25","1670.25","1670.25","1 through 10","2229.67","3486.58","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4266.50","3199.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2229.67","52.26","","1113.10","1113.10","1113.10","1 through 10","2229.67","3486.58","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4266.50","3199.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3486.58","81.72","","1738.90","1484.65","2716.94","38","2229.67","3486.58","percent of total billed charges",""
"ELBOW IMPLANT SM SPOOL HUMERAL LATITUDE EV TOTAL CENTER OFFSET RIGHT","SUP-ITM-10046603","CDM","C1776","HCPCS","0278","RC","","","","both","","","4527.50","3395.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2366.07","52.26","","1113.10","1113.10","1113.10","1 through 10","1403.53","3599.36","percent of total billed charges",""
"ELBOW IMPLANT SM SPOOL HUMERAL LATITUDE EV TOTAL CENTER OFFSET RIGHT","SUP-ITM-10046603","CDM","C1776","HCPCS","0278","RC","","","","both","","","4527.50","3395.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3599.36","79.5","","1293.60","1148.53","1603.80","1 through 10","1403.53","3599.36","percent of total billed charges",""
"ELBOW IMPLANT SM SPOOL HUMERAL LATITUDE EV TOTAL CENTER OFFSET RIGHT","SUP-ITM-10046603","CDM","C1776","HCPCS","0278","RC","","","","both","","","4527.50","3395.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1652.54","36.5","","1023.42","771.29","2068.67","33","1403.53","3599.36","percent of total billed charges",""
"ELBOW IMPLANT SM SPOOL HUMERAL LATITUDE EV TOTAL CENTER OFFSET RIGHT","SUP-ITM-10046603","CDM","C1776","HCPCS","0278","RC","","","","both","","","4527.50","3395.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1734.03","38.3","","850.52","759.78","1211.25","66","1403.53","3599.36","percent of total billed charges",""
"ELBOW IMPLANT SM SPOOL HUMERAL LATITUDE EV TOTAL CENTER OFFSET RIGHT","SUP-ITM-10046603","CDM","C1776","HCPCS","0278","RC","","","","both","","","4527.50","3395.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1942.30","42.9","","2548.09","2548.09","2548.09","1 through 10","1403.53","3599.36","percent of total billed charges",""
"ELBOW IMPLANT SM SPOOL HUMERAL LATITUDE EV TOTAL CENTER OFFSET RIGHT","SUP-ITM-10046603","CDM","C1776","HCPCS","0278","RC","","","","both","","","4527.50","3395.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1942.30","42.9","","956.46","956.46","956.46","1 through 10","1403.53","3599.36","percent of total billed charges",""
"ELBOW IMPLANT SM SPOOL HUMERAL LATITUDE EV TOTAL CENTER OFFSET RIGHT","SUP-ITM-10046603","CDM","C1776","HCPCS","0278","RC","","","","both","","","4527.50","3395.62","WELLPOINT [1015]","HB AMC WELLPOINT","3340.39","73.78","","2344.73","1619.47","2530.35","16","1403.53","3599.36","percent of total billed charges",""
"ELBOW IMPLANT SM SPOOL HUMERAL LATITUDE EV TOTAL CENTER OFFSET RIGHT","SUP-ITM-10046603","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4527.50","3395.62","AETNA [1001]","HB AMC AETNA HMO","3160.20","69.8","","1523.63","988.41","4330.26","39","2366.07","3699.87","percent of total billed charges",""
"ELBOW IMPLANT SM SPOOL HUMERAL LATITUDE EV TOTAL CENTER OFFSET RIGHT","SUP-ITM-10046603","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4527.50","3395.62","AETNA [1001]","HB AMC AETNA PPO","3640.11","80.4","","1670.25","1670.25","1670.25","1 through 10","2366.07","3699.87","percent of total billed charges",""
"ELBOW IMPLANT SM SPOOL HUMERAL LATITUDE EV TOTAL CENTER OFFSET RIGHT","SUP-ITM-10046603","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4527.50","3395.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2366.07","52.26","","1113.10","1113.10","1113.10","1 through 10","2366.07","3699.87","percent of total billed charges",""
"ELBOW IMPLANT SM SPOOL HUMERAL LATITUDE EV TOTAL CENTER OFFSET RIGHT","SUP-ITM-10046603","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4527.50","3395.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3699.87","81.72","","1738.90","1484.65","2716.94","38","2366.07","3699.87","percent of total billed charges",""
"ELBOW IMPLANT SZ 50 HUMERAL ASSEMBLY MODULAR","SUP-ITM-10082113","CDM","C1776","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3788.85","52.26","","1113.10","1113.10","1113.10","1 through 10","2247.5","5763.75","percent of total billed charges",""
"ELBOW IMPLANT SZ 50 HUMERAL ASSEMBLY MODULAR","SUP-ITM-10082113","CDM","C1776","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5763.75","79.5","","1293.60","1148.53","1603.80","1 through 10","2247.5","5763.75","percent of total billed charges",""
"ELBOW IMPLANT SZ 50 HUMERAL ASSEMBLY MODULAR","SUP-ITM-10082113","CDM","C1776","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2646.25","36.5","","1023.42","771.29","2068.67","33","2247.5","5763.75","percent of total billed charges",""
"ELBOW IMPLANT SZ 50 HUMERAL ASSEMBLY MODULAR","SUP-ITM-10082113","CDM","C1776","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2776.75","38.3","","850.52","759.78","1211.25","66","2247.5","5763.75","percent of total billed charges",""
"ELBOW IMPLANT SZ 50 HUMERAL ASSEMBLY MODULAR","SUP-ITM-10082113","CDM","C1776","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3110.25","42.9","","2548.09","2548.09","2548.09","1 through 10","2247.5","5763.75","percent of total billed charges",""
"ELBOW IMPLANT SZ 50 HUMERAL ASSEMBLY MODULAR","SUP-ITM-10082113","CDM","C1776","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3110.25","42.9","","956.46","956.46","956.46","1 through 10","2247.5","5763.75","percent of total billed charges",""
"ELBOW IMPLANT SZ 50 HUMERAL ASSEMBLY MODULAR","SUP-ITM-10082113","CDM","C1776","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","WELLPOINT [1015]","HB AMC WELLPOINT","5349.05","73.78","","2344.73","1619.47","2530.35","16","2247.5","5763.75","percent of total billed charges",""
"ELBOW IMPLANT SZ 50 HUMERAL ASSEMBLY MODULAR","SUP-ITM-10082113","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","AETNA [1001]","HB AMC AETNA HMO","5060.50","69.8","","1523.63","988.41","4330.26","39","3788.85","5924.7","percent of total billed charges",""
"ELBOW IMPLANT SZ 50 HUMERAL ASSEMBLY MODULAR","SUP-ITM-10082113","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","AETNA [1001]","HB AMC AETNA PPO","5829.00","80.4","","1670.25","1670.25","1670.25","1 through 10","3788.85","5924.7","percent of total billed charges",""
"ELBOW IMPLANT SZ 50 HUMERAL ASSEMBLY MODULAR","SUP-ITM-10082113","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3788.85","52.26","","1113.10","1113.10","1113.10","1 through 10","3788.85","5924.7","percent of total billed charges",""
"ELBOW IMPLANT SZ 50 HUMERAL ASSEMBLY MODULAR","SUP-ITM-10082113","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5924.70","81.72","","1738.90","1484.65","2716.94","38","3788.85","5924.7","percent of total billed charges",""
"ELBOW INSERT SYSTEM VARIAX FOR PLATES","SUP-ITM-10145660","CDM","C1776","HCPCS","0278","RC","","","","both","","","4856.25","3642.19","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2537.88","52.26","","1113.10","1113.10","1113.10","1 through 10","1505.44","3860.72","percent of total billed charges",""
"ELBOW INSERT SYSTEM VARIAX FOR PLATES","SUP-ITM-10145660","CDM","C1776","HCPCS","0278","RC","","","","both","","","4856.25","3642.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3860.72","79.5","","1293.60","1148.53","1603.80","1 through 10","1505.44","3860.72","percent of total billed charges",""
"ELBOW INSERT SYSTEM VARIAX FOR PLATES","SUP-ITM-10145660","CDM","C1776","HCPCS","0278","RC","","","","both","","","4856.25","3642.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1772.53","36.5","","1023.42","771.29","2068.67","33","1505.44","3860.72","percent of total billed charges",""
"ELBOW INSERT SYSTEM VARIAX FOR PLATES","SUP-ITM-10145660","CDM","C1776","HCPCS","0278","RC","","","","both","","","4856.25","3642.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1859.94","38.3","","850.52","759.78","1211.25","66","1505.44","3860.72","percent of total billed charges",""
"ELBOW INSERT SYSTEM VARIAX FOR PLATES","SUP-ITM-10145660","CDM","C1776","HCPCS","0278","RC","","","","both","","","4856.25","3642.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2083.33","42.9","","2548.09","2548.09","2548.09","1 through 10","1505.44","3860.72","percent of total billed charges",""
"ELBOW INSERT SYSTEM VARIAX FOR PLATES","SUP-ITM-10145660","CDM","C1776","HCPCS","0278","RC","","","","both","","","4856.25","3642.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2083.33","42.9","","956.46","956.46","956.46","1 through 10","1505.44","3860.72","percent of total billed charges",""
"ELBOW INSERT SYSTEM VARIAX FOR PLATES","SUP-ITM-10145660","CDM","C1776","HCPCS","0278","RC","","","","both","","","4856.25","3642.19","WELLPOINT [1015]","HB AMC WELLPOINT","3582.94","73.78","","2344.73","1619.47","2530.35","16","1505.44","3860.72","percent of total billed charges",""
"ELBOW INSERT SYSTEM VARIAX FOR PLATES","SUP-ITM-10145660","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4856.25","3642.19","AETNA [1001]","HB AMC AETNA HMO","3389.66","69.8","","1523.63","988.41","4330.26","39","2537.88","3968.53","percent of total billed charges",""
"ELBOW INSERT SYSTEM VARIAX FOR PLATES","SUP-ITM-10145660","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4856.25","3642.19","AETNA [1001]","HB AMC AETNA PPO","3904.43","80.4","","1670.25","1670.25","1670.25","1 through 10","2537.88","3968.53","percent of total billed charges",""
"ELBOW INSERT SYSTEM VARIAX FOR PLATES","SUP-ITM-10145660","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4856.25","3642.19","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2537.88","52.26","","1113.10","1113.10","1113.10","1 through 10","2537.88","3968.53","percent of total billed charges",""
"ELBOW INSERT SYSTEM VARIAX FOR PLATES","SUP-ITM-10145660","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4856.25","3642.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3968.53","81.72","","1738.90","1484.65","2716.94","38","2537.88","3968.53","percent of total billed charges",""
"ELBOW KIT IMPLANT ULNA BRING REVISION DISCOVERY 05","SUP-ITM-10013138","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.00","1690.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1177.94","52.26","","1113.10","1113.10","1113.10","1 through 10","698.74","1791.93","percent of total billed charges",""
"ELBOW KIT IMPLANT ULNA BRING REVISION DISCOVERY 05","SUP-ITM-10013138","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.00","1690.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1791.93","79.5","","1293.60","1148.53","1603.80","1 through 10","698.74","1791.93","percent of total billed charges",""
"ELBOW KIT IMPLANT ULNA BRING REVISION DISCOVERY 05","SUP-ITM-10013138","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.00","1690.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","822.71","36.5","","1023.42","771.29","2068.67","33","698.74","1791.93","percent of total billed charges",""
"ELBOW KIT IMPLANT ULNA BRING REVISION DISCOVERY 05","SUP-ITM-10013138","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.00","1690.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","863.28","38.3","","850.52","759.78","1211.25","66","698.74","1791.93","percent of total billed charges",""
"ELBOW KIT IMPLANT ULNA BRING REVISION DISCOVERY 05","SUP-ITM-10013138","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.00","1690.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","966.97","42.9","","2548.09","2548.09","2548.09","1 through 10","698.74","1791.93","percent of total billed charges",""
"ELBOW KIT IMPLANT ULNA BRING REVISION DISCOVERY 05","SUP-ITM-10013138","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.00","1690.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","966.97","42.9","","956.46","956.46","956.46","1 through 10","698.74","1791.93","percent of total billed charges",""
"ELBOW KIT IMPLANT ULNA BRING REVISION DISCOVERY 05","SUP-ITM-10013138","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.00","1690.50","WELLPOINT [1015]","HB AMC WELLPOINT","1663.00","73.78","","2344.73","1619.47","2530.35","16","698.74","1791.93","percent of total billed charges",""
"ELBOW KIT IMPLANT ULNA BRING REVISION DISCOVERY 05","SUP-ITM-10013138","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2254.00","1690.50","AETNA [1001]","HB AMC AETNA HMO","1573.29","69.8","","1523.63","988.41","4330.26","39","1177.94","1841.97","percent of total billed charges",""
"ELBOW KIT IMPLANT ULNA BRING REVISION DISCOVERY 05","SUP-ITM-10013138","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2254.00","1690.50","AETNA [1001]","HB AMC AETNA PPO","1812.22","80.4","","1670.25","1670.25","1670.25","1 through 10","1177.94","1841.97","percent of total billed charges",""
"ELBOW KIT IMPLANT ULNA BRING REVISION DISCOVERY 05","SUP-ITM-10013138","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2254.00","1690.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1177.94","52.26","","1113.10","1113.10","1113.10","1 through 10","1177.94","1841.97","percent of total billed charges",""
"ELBOW KIT IMPLANT ULNA BRING REVISION DISCOVERY 05","SUP-ITM-10013138","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2254.00","1690.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1841.97","81.72","","1738.90","1484.65","2716.94","38","1177.94","1841.97","percent of total billed charges",""
"ELBOW PLATE 33MM SURGICAL MAYO CLINIC CONGRUENT LOCKING TITANIUM LEFT","SUP-ITM-10030621","CDM","C1713","HCPCS","0278","RC","","","","both","","","4049.50","3037.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3219.35","79.5","","800.18","480.96","1887.97","195","1255.35","3219.35","percent of total billed charges",""
"ELBOW PLATE 33MM SURGICAL MAYO CLINIC CONGRUENT LOCKING TITANIUM LEFT","SUP-ITM-10030621","CDM","C1713","HCPCS","0278","RC","","","","both","","","4049.50","3037.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2158.38","53.3","","813.12","216.42","1444.50","81","1255.35","3219.35","percent of total billed charges",""
"ELBOW PLATE 33MM SURGICAL MAYO CLINIC CONGRUENT LOCKING TITANIUM LEFT","SUP-ITM-10030621","CDM","C1713","HCPCS","0278","RC","","","","both","","","4049.50","3037.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1255.35","31","","432.60","432.60","432.60","1 through 10","1255.35","3219.35","percent of total billed charges",""
"ELBOW PLATE 33MM SURGICAL MAYO CLINIC CONGRUENT LOCKING TITANIUM LEFT","SUP-ITM-10030621","CDM","C1713","HCPCS","0278","RC","","","","both","","","4049.50","3037.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1478.07","36.5","","148.37","54.89","631.39","94","1255.35","3219.35","percent of total billed charges",""
"ELBOW PLATE 33MM SURGICAL MAYO CLINIC CONGRUENT LOCKING TITANIUM LEFT","SUP-ITM-10030621","CDM","C1713","HCPCS","0278","RC","","","","both","","","4049.50","3037.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1550.96","38.3","","279.30","91.72","1116.77","266","1255.35","3219.35","percent of total billed charges",""
"ELBOW PLATE 33MM SURGICAL MAYO CLINIC CONGRUENT LOCKING TITANIUM LEFT","SUP-ITM-10030621","CDM","C1713","HCPCS","0278","RC","","","","both","","","4049.50","3037.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1737.24","42.9","","731.00","63.70","731.00","1 through 10","1255.35","3219.35","percent of total billed charges",""
"ELBOW PLATE 33MM SURGICAL MAYO CLINIC CONGRUENT LOCKING TITANIUM LEFT","SUP-ITM-10030621","CDM","C1713","HCPCS","0278","RC","","","","both","","","4049.50","3037.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1737.24","42.9","","384.74","384.74","384.74","1 through 10","1255.35","3219.35","percent of total billed charges",""
"ELBOW PLATE 33MM SURGICAL MAYO CLINIC CONGRUENT LOCKING TITANIUM LEFT","SUP-ITM-10030621","CDM","C1713","HCPCS","0278","RC","","","","both","","","4049.50","3037.12","WELLPOINT [1015]","HB AMC WELLPOINT","2987.72","73.78","","286.63","119.22","1107.45","105","1255.35","3219.35","percent of total billed charges",""
"ELBOW PLATE 33MM SURGICAL MAYO CLINIC CONGRUENT LOCKING TITANIUM LEFT","SUP-ITM-10030621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4049.50","3037.12","AETNA [1001]","HB AMC AETNA HMO","2826.55","69.8","","675.31","184.75","1721.50","286","2116.27","3309.25","percent of total billed charges",""
"ELBOW PLATE 33MM SURGICAL MAYO CLINIC CONGRUENT LOCKING TITANIUM LEFT","SUP-ITM-10030621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4049.50","3037.12","AETNA [1001]","HB AMC AETNA PPO","3255.80","80.4","","1261.44","103.12","1514.10","21","2116.27","3309.25","percent of total billed charges",""
"ELBOW PLATE 33MM SURGICAL MAYO CLINIC CONGRUENT LOCKING TITANIUM LEFT","SUP-ITM-10030621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4049.50","3037.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3255.80","80.4","","1365.00","1365.00","1365.00","1 through 10","2116.27","3309.25","percent of total billed charges",""
"ELBOW PLATE 33MM SURGICAL MAYO CLINIC CONGRUENT LOCKING TITANIUM LEFT","SUP-ITM-10030621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4049.50","3037.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3309.25","81.72","","5157.68","5157.68","5157.68","1 through 10","2116.27","3309.25","percent of total billed charges",""
"ELBOW PLATE 33MM SURGICAL MAYO CLINIC CONGRUENT LOCKING TITANIUM LEFT","SUP-ITM-10030621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4049.50","3037.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3309.25","81.72","","431.26","71.26","1459.57","88","2116.27","3309.25","percent of total billed charges",""
"ELBOW PLATE 4IN TITANIUM MAYO CLINIC CONGRUENT","SUP-ITM-10018578","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.50","3058.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3241.61","79.5","","800.18","480.96","1887.97","195","1264.03","3241.61","percent of total billed charges",""
"ELBOW PLATE 4IN TITANIUM MAYO CLINIC CONGRUENT","SUP-ITM-10018578","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.50","3058.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2173.31","53.3","","813.12","216.42","1444.50","81","1264.03","3241.61","percent of total billed charges",""
"ELBOW PLATE 4IN TITANIUM MAYO CLINIC CONGRUENT","SUP-ITM-10018578","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.50","3058.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1264.03","31","","432.60","432.60","432.60","1 through 10","1264.03","3241.61","percent of total billed charges",""
"ELBOW PLATE 4IN TITANIUM MAYO CLINIC CONGRUENT","SUP-ITM-10018578","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.50","3058.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1488.29","36.5","","148.37","54.89","631.39","94","1264.03","3241.61","percent of total billed charges",""
"ELBOW PLATE 4IN TITANIUM MAYO CLINIC CONGRUENT","SUP-ITM-10018578","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.50","3058.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1561.68","38.3","","279.30","91.72","1116.77","266","1264.03","3241.61","percent of total billed charges",""
"ELBOW PLATE 4IN TITANIUM MAYO CLINIC CONGRUENT","SUP-ITM-10018578","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.50","3058.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1749.25","42.9","","731.00","63.70","731.00","1 through 10","1264.03","3241.61","percent of total billed charges",""
"ELBOW PLATE 4IN TITANIUM MAYO CLINIC CONGRUENT","SUP-ITM-10018578","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.50","3058.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1749.25","42.9","","384.74","384.74","384.74","1 through 10","1264.03","3241.61","percent of total billed charges",""
"ELBOW PLATE 4IN TITANIUM MAYO CLINIC CONGRUENT","SUP-ITM-10018578","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.50","3058.12","WELLPOINT [1015]","HB AMC WELLPOINT","3008.38","73.78","","286.63","119.22","1107.45","105","1264.03","3241.61","percent of total billed charges",""
"ELBOW PLATE 4IN TITANIUM MAYO CLINIC CONGRUENT","SUP-ITM-10018578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.50","3058.12","AETNA [1001]","HB AMC AETNA HMO","2846.10","69.8","","675.31","184.75","1721.50","286","2130.9","3332.13","percent of total billed charges",""
"ELBOW PLATE 4IN TITANIUM MAYO CLINIC CONGRUENT","SUP-ITM-10018578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.50","3058.12","AETNA [1001]","HB AMC AETNA PPO","3278.31","80.4","","1261.44","103.12","1514.10","21","2130.9","3332.13","percent of total billed charges",""
"ELBOW PLATE 4IN TITANIUM MAYO CLINIC CONGRUENT","SUP-ITM-10018578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.50","3058.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3278.31","80.4","","1365.00","1365.00","1365.00","1 through 10","2130.9","3332.13","percent of total billed charges",""
"ELBOW PLATE 4IN TITANIUM MAYO CLINIC CONGRUENT","SUP-ITM-10018578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.50","3058.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3332.13","81.72","","5157.68","5157.68","5157.68","1 through 10","2130.9","3332.13","percent of total billed charges",""
"ELBOW PLATE 4IN TITANIUM MAYO CLINIC CONGRUENT","SUP-ITM-10018578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.50","3058.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3332.13","81.72","","431.26","71.26","1459.57","88","2130.9","3332.13","percent of total billed charges",""
"ELBOW PLATE 68MM CORONOID EXTENDED LEFT","SUP-ITM-10045024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.00","2949.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3126.74","79.5","","800.18","480.96","1887.97","195","1219.23","3126.74","percent of total billed charges",""
"ELBOW PLATE 68MM CORONOID EXTENDED LEFT","SUP-ITM-10045024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.00","2949.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2096.29","53.3","","813.12","216.42","1444.50","81","1219.23","3126.74","percent of total billed charges",""
"ELBOW PLATE 68MM CORONOID EXTENDED LEFT","SUP-ITM-10045024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.00","2949.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1219.23","31","","432.60","432.60","432.60","1 through 10","1219.23","3126.74","percent of total billed charges",""
"ELBOW PLATE 68MM CORONOID EXTENDED LEFT","SUP-ITM-10045024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.00","2949.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1435.55","36.5","","148.37","54.89","631.39","94","1219.23","3126.74","percent of total billed charges",""
"ELBOW PLATE 68MM CORONOID EXTENDED LEFT","SUP-ITM-10045024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.00","2949.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1506.34","38.3","","279.30","91.72","1116.77","266","1219.23","3126.74","percent of total billed charges",""
"ELBOW PLATE 68MM CORONOID EXTENDED LEFT","SUP-ITM-10045024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.00","2949.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.26","42.9","","731.00","63.70","731.00","1 through 10","1219.23","3126.74","percent of total billed charges",""
"ELBOW PLATE 68MM CORONOID EXTENDED LEFT","SUP-ITM-10045024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.00","2949.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.26","42.9","","384.74","384.74","384.74","1 through 10","1219.23","3126.74","percent of total billed charges",""
"ELBOW PLATE 68MM CORONOID EXTENDED LEFT","SUP-ITM-10045024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.00","2949.75","WELLPOINT [1015]","HB AMC WELLPOINT","2901.77","73.78","","286.63","119.22","1107.45","105","1219.23","3126.74","percent of total billed charges",""
"ELBOW PLATE 68MM CORONOID EXTENDED LEFT","SUP-ITM-10045024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3933.00","2949.75","AETNA [1001]","HB AMC AETNA HMO","2745.23","69.8","","675.31","184.75","1721.50","286","2055.39","3214.05","percent of total billed charges",""
"ELBOW PLATE 68MM CORONOID EXTENDED LEFT","SUP-ITM-10045024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3933.00","2949.75","AETNA [1001]","HB AMC AETNA PPO","3162.13","80.4","","1261.44","103.12","1514.10","21","2055.39","3214.05","percent of total billed charges",""
"ELBOW PLATE 68MM CORONOID EXTENDED LEFT","SUP-ITM-10045024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3933.00","2949.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3162.13","80.4","","1365.00","1365.00","1365.00","1 through 10","2055.39","3214.05","percent of total billed charges",""
"ELBOW PLATE 68MM CORONOID EXTENDED LEFT","SUP-ITM-10045024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3933.00","2949.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3214.05","81.72","","5157.68","5157.68","5157.68","1 through 10","2055.39","3214.05","percent of total billed charges",""
"ELBOW PLATE 68MM CORONOID EXTENDED LEFT","SUP-ITM-10045024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3933.00","2949.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3214.05","81.72","","431.26","71.26","1459.57","88","2055.39","3214.05","percent of total billed charges",""
"ELBOW PLATE 88MM 8 HOLE MEDIAL TITANIUM LOCKING DISTAL HUMERUS","SUP-ITM-10026587","CDM","C1713","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3266.66","79.5","","800.18","480.96","1887.97","195","1273.79","3266.66","percent of total billed charges",""
"ELBOW PLATE 88MM 8 HOLE MEDIAL TITANIUM LOCKING DISTAL HUMERUS","SUP-ITM-10026587","CDM","C1713","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2190.10","53.3","","813.12","216.42","1444.50","81","1273.79","3266.66","percent of total billed charges",""
"ELBOW PLATE 88MM 8 HOLE MEDIAL TITANIUM LOCKING DISTAL HUMERUS","SUP-ITM-10026587","CDM","C1713","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1273.79","31","","432.60","432.60","432.60","1 through 10","1273.79","3266.66","percent of total billed charges",""
"ELBOW PLATE 88MM 8 HOLE MEDIAL TITANIUM LOCKING DISTAL HUMERUS","SUP-ITM-10026587","CDM","C1713","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1499.79","36.5","","148.37","54.89","631.39","94","1273.79","3266.66","percent of total billed charges",""
"ELBOW PLATE 88MM 8 HOLE MEDIAL TITANIUM LOCKING DISTAL HUMERUS","SUP-ITM-10026587","CDM","C1713","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1573.75","38.3","","279.30","91.72","1116.77","266","1273.79","3266.66","percent of total billed charges",""
"ELBOW PLATE 88MM 8 HOLE MEDIAL TITANIUM LOCKING DISTAL HUMERUS","SUP-ITM-10026587","CDM","C1713","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1762.76","42.9","","731.00","63.70","731.00","1 through 10","1273.79","3266.66","percent of total billed charges",""
"ELBOW PLATE 88MM 8 HOLE MEDIAL TITANIUM LOCKING DISTAL HUMERUS","SUP-ITM-10026587","CDM","C1713","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1762.76","42.9","","384.74","384.74","384.74","1 through 10","1273.79","3266.66","percent of total billed charges",""
"ELBOW PLATE 88MM 8 HOLE MEDIAL TITANIUM LOCKING DISTAL HUMERUS","SUP-ITM-10026587","CDM","C1713","HCPCS","0278","RC","","","","both","","","4109.00","3081.75","WELLPOINT [1015]","HB AMC WELLPOINT","3031.62","73.78","","286.63","119.22","1107.45","105","1273.79","3266.66","percent of total billed charges",""
"ELBOW PLATE 88MM 8 HOLE MEDIAL TITANIUM LOCKING DISTAL HUMERUS","SUP-ITM-10026587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4109.00","3081.75","AETNA [1001]","HB AMC AETNA HMO","2868.08","69.8","","675.31","184.75","1721.50","286","2147.36","3357.87","percent of total billed charges",""
"ELBOW PLATE 88MM 8 HOLE MEDIAL TITANIUM LOCKING DISTAL HUMERUS","SUP-ITM-10026587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4109.00","3081.75","AETNA [1001]","HB AMC AETNA PPO","3303.64","80.4","","1261.44","103.12","1514.10","21","2147.36","3357.87","percent of total billed charges",""
"ELBOW PLATE 88MM 8 HOLE MEDIAL TITANIUM LOCKING DISTAL HUMERUS","SUP-ITM-10026587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4109.00","3081.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3303.64","80.4","","1365.00","1365.00","1365.00","1 through 10","2147.36","3357.87","percent of total billed charges",""
"ELBOW PLATE 88MM 8 HOLE MEDIAL TITANIUM LOCKING DISTAL HUMERUS","SUP-ITM-10026587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4109.00","3081.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3357.87","81.72","","5157.68","5157.68","5157.68","1 through 10","2147.36","3357.87","percent of total billed charges",""
"ELBOW PLATE 88MM 8 HOLE MEDIAL TITANIUM LOCKING DISTAL HUMERUS","SUP-ITM-10026587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4109.00","3081.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3357.87","81.72","","431.26","71.26","1459.57","88","2147.36","3357.87","percent of total billed charges",""
"ELBOW PLATE BONE RADIAL HEAD BOTTOM COMP","SUP-ITM-10045031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4504.50","3378.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3581.08","79.5","","800.18","480.96","1887.97","195","1396.4","3581.08","percent of total billed charges",""
"ELBOW PLATE BONE RADIAL HEAD BOTTOM COMP","SUP-ITM-10045031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4504.50","3378.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2400.90","53.3","","813.12","216.42","1444.50","81","1396.4","3581.08","percent of total billed charges",""
"ELBOW PLATE BONE RADIAL HEAD BOTTOM COMP","SUP-ITM-10045031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4504.50","3378.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1396.40","31","","432.60","432.60","432.60","1 through 10","1396.4","3581.08","percent of total billed charges",""
"ELBOW PLATE BONE RADIAL HEAD BOTTOM COMP","SUP-ITM-10045031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4504.50","3378.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1644.14","36.5","","148.37","54.89","631.39","94","1396.4","3581.08","percent of total billed charges",""
"ELBOW PLATE BONE RADIAL HEAD BOTTOM COMP","SUP-ITM-10045031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4504.50","3378.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1725.22","38.3","","279.30","91.72","1116.77","266","1396.4","3581.08","percent of total billed charges",""
"ELBOW PLATE BONE RADIAL HEAD BOTTOM COMP","SUP-ITM-10045031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4504.50","3378.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1932.43","42.9","","731.00","63.70","731.00","1 through 10","1396.4","3581.08","percent of total billed charges",""
"ELBOW PLATE BONE RADIAL HEAD BOTTOM COMP","SUP-ITM-10045031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4504.50","3378.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1932.43","42.9","","384.74","384.74","384.74","1 through 10","1396.4","3581.08","percent of total billed charges",""
"ELBOW PLATE BONE RADIAL HEAD BOTTOM COMP","SUP-ITM-10045031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4504.50","3378.37","WELLPOINT [1015]","HB AMC WELLPOINT","3323.42","73.78","","286.63","119.22","1107.45","105","1396.4","3581.08","percent of total billed charges",""
"ELBOW PLATE BONE RADIAL HEAD BOTTOM COMP","SUP-ITM-10045031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4504.50","3378.37","AETNA [1001]","HB AMC AETNA HMO","3144.14","69.8","","675.31","184.75","1721.50","286","2354.05","3681.08","percent of total billed charges",""
"ELBOW PLATE BONE RADIAL HEAD BOTTOM COMP","SUP-ITM-10045031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4504.50","3378.37","AETNA [1001]","HB AMC AETNA PPO","3621.62","80.4","","1261.44","103.12","1514.10","21","2354.05","3681.08","percent of total billed charges",""
"ELBOW PLATE BONE RADIAL HEAD BOTTOM COMP","SUP-ITM-10045031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4504.50","3378.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3621.62","80.4","","1365.00","1365.00","1365.00","1 through 10","2354.05","3681.08","percent of total billed charges",""
"ELBOW PLATE BONE RADIAL HEAD BOTTOM COMP","SUP-ITM-10045031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4504.50","3378.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3681.08","81.72","","5157.68","5157.68","5157.68","1 through 10","2354.05","3681.08","percent of total billed charges",""
"ELBOW PLATE BONE RADIAL HEAD BOTTOM COMP","SUP-ITM-10045031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4504.50","3378.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3681.08","81.72","","431.26","71.26","1459.57","88","2354.05","3681.08","percent of total billed charges",""
"ELBOW PLATE LONG SIZE 4 BONE EVOLVE HEAD PROXIMALIMAL RADIAL","SUP-ITM-10028347","CDM","C1713","HCPCS","0278","RC","","","","both","","","3419.50","2564.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2718.50","79.5","","800.18","480.96","1887.97","195","1060.05","2718.5","percent of total billed charges",""
"ELBOW PLATE LONG SIZE 4 BONE EVOLVE HEAD PROXIMALIMAL RADIAL","SUP-ITM-10028347","CDM","C1713","HCPCS","0278","RC","","","","both","","","3419.50","2564.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1822.59","53.3","","813.12","216.42","1444.50","81","1060.05","2718.5","percent of total billed charges",""
"ELBOW PLATE LONG SIZE 4 BONE EVOLVE HEAD PROXIMALIMAL RADIAL","SUP-ITM-10028347","CDM","C1713","HCPCS","0278","RC","","","","both","","","3419.50","2564.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1060.05","31","","432.60","432.60","432.60","1 through 10","1060.05","2718.5","percent of total billed charges",""
"ELBOW PLATE LONG SIZE 4 BONE EVOLVE HEAD PROXIMALIMAL RADIAL","SUP-ITM-10028347","CDM","C1713","HCPCS","0278","RC","","","","both","","","3419.50","2564.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1248.12","36.5","","148.37","54.89","631.39","94","1060.05","2718.5","percent of total billed charges",""
"ELBOW PLATE LONG SIZE 4 BONE EVOLVE HEAD PROXIMALIMAL RADIAL","SUP-ITM-10028347","CDM","C1713","HCPCS","0278","RC","","","","both","","","3419.50","2564.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1309.67","38.3","","279.30","91.72","1116.77","266","1060.05","2718.5","percent of total billed charges",""
"ELBOW PLATE LONG SIZE 4 BONE EVOLVE HEAD PROXIMALIMAL RADIAL","SUP-ITM-10028347","CDM","C1713","HCPCS","0278","RC","","","","both","","","3419.50","2564.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1466.97","42.9","","731.00","63.70","731.00","1 through 10","1060.05","2718.5","percent of total billed charges",""
"ELBOW PLATE LONG SIZE 4 BONE EVOLVE HEAD PROXIMALIMAL RADIAL","SUP-ITM-10028347","CDM","C1713","HCPCS","0278","RC","","","","both","","","3419.50","2564.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1466.97","42.9","","384.74","384.74","384.74","1 through 10","1060.05","2718.5","percent of total billed charges",""
"ELBOW PLATE LONG SIZE 4 BONE EVOLVE HEAD PROXIMALIMAL RADIAL","SUP-ITM-10028347","CDM","C1713","HCPCS","0278","RC","","","","both","","","3419.50","2564.62","WELLPOINT [1015]","HB AMC WELLPOINT","2522.91","73.78","","286.63","119.22","1107.45","105","1060.05","2718.5","percent of total billed charges",""
"ELBOW PLATE LONG SIZE 4 BONE EVOLVE HEAD PROXIMALIMAL RADIAL","SUP-ITM-10028347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3419.50","2564.62","AETNA [1001]","HB AMC AETNA HMO","2386.81","69.8","","675.31","184.75","1721.50","286","1787.03","2794.42","percent of total billed charges",""
"ELBOW PLATE LONG SIZE 4 BONE EVOLVE HEAD PROXIMALIMAL RADIAL","SUP-ITM-10028347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3419.50","2564.62","AETNA [1001]","HB AMC AETNA PPO","2749.28","80.4","","1261.44","103.12","1514.10","21","1787.03","2794.42","percent of total billed charges",""
"ELBOW PLATE LONG SIZE 4 BONE EVOLVE HEAD PROXIMALIMAL RADIAL","SUP-ITM-10028347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3419.50","2564.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2749.28","80.4","","1365.00","1365.00","1365.00","1 through 10","1787.03","2794.42","percent of total billed charges",""
"ELBOW PLATE LONG SIZE 4 BONE EVOLVE HEAD PROXIMALIMAL RADIAL","SUP-ITM-10028347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3419.50","2564.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2794.42","81.72","","5157.68","5157.68","5157.68","1 through 10","1787.03","2794.42","percent of total billed charges",""
"ELBOW PLATE LONG SIZE 4 BONE EVOLVE HEAD PROXIMALIMAL RADIAL","SUP-ITM-10028347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3419.50","2564.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2794.42","81.72","","431.26","71.26","1459.57","88","1787.03","2794.42","percent of total billed charges",""
"ELBOW PLATE MEDIAL EPICONDYLE 12 HOLE XLONG","SUP-ITM-10025635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.00","2994.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3174.44","79.5","","800.18","480.96","1887.97","195","1237.83","3174.44","percent of total billed charges",""
"ELBOW PLATE MEDIAL EPICONDYLE 12 HOLE XLONG","SUP-ITM-10025635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.00","2994.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2128.27","53.3","","813.12","216.42","1444.50","81","1237.83","3174.44","percent of total billed charges",""
"ELBOW PLATE MEDIAL EPICONDYLE 12 HOLE XLONG","SUP-ITM-10025635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.00","2994.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1237.83","31","","432.60","432.60","432.60","1 through 10","1237.83","3174.44","percent of total billed charges",""
"ELBOW PLATE MEDIAL EPICONDYLE 12 HOLE XLONG","SUP-ITM-10025635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.00","2994.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1457.45","36.5","","148.37","54.89","631.39","94","1237.83","3174.44","percent of total billed charges",""
"ELBOW PLATE MEDIAL EPICONDYLE 12 HOLE XLONG","SUP-ITM-10025635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.00","2994.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1529.32","38.3","","279.30","91.72","1116.77","266","1237.83","3174.44","percent of total billed charges",""
"ELBOW PLATE MEDIAL EPICONDYLE 12 HOLE XLONG","SUP-ITM-10025635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.00","2994.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1713.00","42.9","","731.00","63.70","731.00","1 through 10","1237.83","3174.44","percent of total billed charges",""
"ELBOW PLATE MEDIAL EPICONDYLE 12 HOLE XLONG","SUP-ITM-10025635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.00","2994.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1713.00","42.9","","384.74","384.74","384.74","1 through 10","1237.83","3174.44","percent of total billed charges",""
"ELBOW PLATE MEDIAL EPICONDYLE 12 HOLE XLONG","SUP-ITM-10025635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.00","2994.75","WELLPOINT [1015]","HB AMC WELLPOINT","2946.04","73.78","","286.63","119.22","1107.45","105","1237.83","3174.44","percent of total billed charges",""
"ELBOW PLATE MEDIAL EPICONDYLE 12 HOLE XLONG","SUP-ITM-10025635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3993.00","2994.75","AETNA [1001]","HB AMC AETNA HMO","2787.11","69.8","","675.31","184.75","1721.50","286","2086.74","3263.08","percent of total billed charges",""
"ELBOW PLATE MEDIAL EPICONDYLE 12 HOLE XLONG","SUP-ITM-10025635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3993.00","2994.75","AETNA [1001]","HB AMC AETNA PPO","3210.37","80.4","","1261.44","103.12","1514.10","21","2086.74","3263.08","percent of total billed charges",""
"ELBOW PLATE MEDIAL EPICONDYLE 12 HOLE XLONG","SUP-ITM-10025635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3993.00","2994.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3210.37","80.4","","1365.00","1365.00","1365.00","1 through 10","2086.74","3263.08","percent of total billed charges",""
"ELBOW PLATE MEDIAL EPICONDYLE 12 HOLE XLONG","SUP-ITM-10025635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3993.00","2994.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3263.08","81.72","","5157.68","5157.68","5157.68","1 through 10","2086.74","3263.08","percent of total billed charges",""
"ELBOW PLATE MEDIAL EPICONDYLE 12 HOLE XLONG","SUP-ITM-10025635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3993.00","2994.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3263.08","81.72","","431.26","71.26","1459.57","88","2086.74","3263.08","percent of total billed charges",""
"ELBOW STEM 47MM ULNAR LT LATITUDE EV","SUP-ITM-10123518","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4687.72","52.26","","1113.10","1113.10","1113.10","1 through 10","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 47MM ULNAR LT LATITUDE EV","SUP-ITM-10123518","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7131.15","79.5","","1293.60","1148.53","1603.80","1 through 10","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 47MM ULNAR LT LATITUDE EV","SUP-ITM-10123518","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3274.05","36.5","","1023.42","771.29","2068.67","33","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 47MM ULNAR LT LATITUDE EV","SUP-ITM-10123518","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3435.51","38.3","","850.52","759.78","1211.25","66","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 47MM ULNAR LT LATITUDE EV","SUP-ITM-10123518","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3848.13","42.9","","2548.09","2548.09","2548.09","1 through 10","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 47MM ULNAR LT LATITUDE EV","SUP-ITM-10123518","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3848.13","42.9","","956.46","956.46","956.46","1 through 10","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 47MM ULNAR LT LATITUDE EV","SUP-ITM-10123518","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","WELLPOINT [1015]","HB AMC WELLPOINT","6618.07","73.78","","2344.73","1619.47","2530.35","16","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 47MM ULNAR LT LATITUDE EV","SUP-ITM-10123518","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8970.00","6727.50","AETNA [1001]","HB AMC AETNA HMO","6261.06","69.8","","1523.63","988.41","4330.26","39","4687.72","7330.28","percent of total billed charges",""
"ELBOW STEM 47MM ULNAR LT LATITUDE EV","SUP-ITM-10123518","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8970.00","6727.50","AETNA [1001]","HB AMC AETNA PPO","7211.88","80.4","","1670.25","1670.25","1670.25","1 through 10","4687.72","7330.28","percent of total billed charges",""
"ELBOW STEM 47MM ULNAR LT LATITUDE EV","SUP-ITM-10123518","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8970.00","6727.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4687.72","52.26","","1113.10","1113.10","1113.10","1 through 10","4687.72","7330.28","percent of total billed charges",""
"ELBOW STEM 47MM ULNAR LT LATITUDE EV","SUP-ITM-10123518","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8970.00","6727.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7330.28","81.72","","1738.90","1484.65","2716.94","38","4687.72","7330.28","percent of total billed charges",""
"ELBOW STEM 6.5MM RADIAL EVOLVE PROLINE PLUS COBALT","SUP-ITM-10015043","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2243.52","52.26","","1113.10","1113.10","1113.10","1 through 10","1330.83","3412.94","percent of total billed charges",""
"ELBOW STEM 6.5MM RADIAL EVOLVE PROLINE PLUS COBALT","SUP-ITM-10015043","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3412.94","79.5","","1293.60","1148.53","1603.80","1 through 10","1330.83","3412.94","percent of total billed charges",""
"ELBOW STEM 6.5MM RADIAL EVOLVE PROLINE PLUS COBALT","SUP-ITM-10015043","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1566.95","36.5","","1023.42","771.29","2068.67","33","1330.83","3412.94","percent of total billed charges",""
"ELBOW STEM 6.5MM RADIAL EVOLVE PROLINE PLUS COBALT","SUP-ITM-10015043","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1644.22","38.3","","850.52","759.78","1211.25","66","1330.83","3412.94","percent of total billed charges",""
"ELBOW STEM 6.5MM RADIAL EVOLVE PROLINE PLUS COBALT","SUP-ITM-10015043","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1841.70","42.9","","2548.09","2548.09","2548.09","1 through 10","1330.83","3412.94","percent of total billed charges",""
"ELBOW STEM 6.5MM RADIAL EVOLVE PROLINE PLUS COBALT","SUP-ITM-10015043","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1841.70","42.9","","956.46","956.46","956.46","1 through 10","1330.83","3412.94","percent of total billed charges",""
"ELBOW STEM 6.5MM RADIAL EVOLVE PROLINE PLUS COBALT","SUP-ITM-10015043","CDM","C1776","HCPCS","0278","RC","","","","both","","","4293.00","3219.75","WELLPOINT [1015]","HB AMC WELLPOINT","3167.38","73.78","","2344.73","1619.47","2530.35","16","1330.83","3412.94","percent of total billed charges",""
"ELBOW STEM 6.5MM RADIAL EVOLVE PROLINE PLUS COBALT","SUP-ITM-10015043","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4293.00","3219.75","AETNA [1001]","HB AMC AETNA HMO","2996.51","69.8","","1523.63","988.41","4330.26","39","2243.52","3508.24","percent of total billed charges",""
"ELBOW STEM 6.5MM RADIAL EVOLVE PROLINE PLUS COBALT","SUP-ITM-10015043","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4293.00","3219.75","AETNA [1001]","HB AMC AETNA PPO","3451.57","80.4","","1670.25","1670.25","1670.25","1 through 10","2243.52","3508.24","percent of total billed charges",""
"ELBOW STEM 6.5MM RADIAL EVOLVE PROLINE PLUS COBALT","SUP-ITM-10015043","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4293.00","3219.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2243.52","52.26","","1113.10","1113.10","1113.10","1 through 10","2243.52","3508.24","percent of total billed charges",""
"ELBOW STEM 6.5MM RADIAL EVOLVE PROLINE PLUS COBALT","SUP-ITM-10015043","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4293.00","3219.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3508.24","81.72","","1738.90","1484.65","2716.94","38","2243.52","3508.24","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3213.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.51","36.5","","1023.42","771.29","2068.67","33","1253.18","3213.79","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.28","38.3","","850.52","759.78","1211.25","66","1253.18","3213.79","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","956.46","956.46","956.46","1 through 10","1253.18","3213.79","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","WELLPOINT [1015]","HB AMC WELLPOINT","2982.56","73.78","","2344.73","1619.47","2530.35","16","1253.18","3213.79","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA HMO","2821.67","69.8","","1523.63","988.41","4330.26","39","2112.61","3303.53","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA PPO","3250.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2112.61","3303.53","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","2112.61","3303.53","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.53","81.72","","1738.90","1484.65","2716.94","38","2112.61","3303.53","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR RT LATITUDE EV","SUP-ITM-10123450","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4687.72","52.26","","1113.10","1113.10","1113.10","1 through 10","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR RT LATITUDE EV","SUP-ITM-10123450","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7131.15","79.5","","1293.60","1148.53","1603.80","1 through 10","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR RT LATITUDE EV","SUP-ITM-10123450","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3274.05","36.5","","1023.42","771.29","2068.67","33","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR RT LATITUDE EV","SUP-ITM-10123450","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3435.51","38.3","","850.52","759.78","1211.25","66","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR RT LATITUDE EV","SUP-ITM-10123450","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3848.13","42.9","","2548.09","2548.09","2548.09","1 through 10","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR RT LATITUDE EV","SUP-ITM-10123450","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3848.13","42.9","","956.46","956.46","956.46","1 through 10","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR RT LATITUDE EV","SUP-ITM-10123450","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","WELLPOINT [1015]","HB AMC WELLPOINT","6618.07","73.78","","2344.73","1619.47","2530.35","16","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR RT LATITUDE EV","SUP-ITM-10123450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8970.00","6727.50","AETNA [1001]","HB AMC AETNA HMO","6261.06","69.8","","1523.63","988.41","4330.26","39","4687.72","7330.28","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR RT LATITUDE EV","SUP-ITM-10123450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8970.00","6727.50","AETNA [1001]","HB AMC AETNA PPO","7211.88","80.4","","1670.25","1670.25","1670.25","1 through 10","4687.72","7330.28","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR RT LATITUDE EV","SUP-ITM-10123450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8970.00","6727.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4687.72","52.26","","1113.10","1113.10","1113.10","1 through 10","4687.72","7330.28","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR RT LATITUDE EV","SUP-ITM-10123450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8970.00","6727.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7330.28","81.72","","1738.90","1484.65","2716.94","38","4687.72","7330.28","percent of total billed charges",""
"ELBOW STEM 75MM ULNAR LT LATITUDE EV","SUP-ITM-10123451","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4687.72","52.26","","1113.10","1113.10","1113.10","1 through 10","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 75MM ULNAR LT LATITUDE EV","SUP-ITM-10123451","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7131.15","79.5","","1293.60","1148.53","1603.80","1 through 10","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 75MM ULNAR LT LATITUDE EV","SUP-ITM-10123451","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3274.05","36.5","","1023.42","771.29","2068.67","33","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 75MM ULNAR LT LATITUDE EV","SUP-ITM-10123451","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3435.51","38.3","","850.52","759.78","1211.25","66","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 75MM ULNAR LT LATITUDE EV","SUP-ITM-10123451","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3848.13","42.9","","2548.09","2548.09","2548.09","1 through 10","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 75MM ULNAR LT LATITUDE EV","SUP-ITM-10123451","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3848.13","42.9","","956.46","956.46","956.46","1 through 10","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 75MM ULNAR LT LATITUDE EV","SUP-ITM-10123451","CDM","C1776","HCPCS","0278","RC","","","","both","","","8970.00","6727.50","WELLPOINT [1015]","HB AMC WELLPOINT","6618.07","73.78","","2344.73","1619.47","2530.35","16","2780.7","7131.15","percent of total billed charges",""
"ELBOW STEM 75MM ULNAR LT LATITUDE EV","SUP-ITM-10123451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8970.00","6727.50","AETNA [1001]","HB AMC AETNA HMO","6261.06","69.8","","1523.63","988.41","4330.26","39","4687.72","7330.28","percent of total billed charges",""
"ELBOW STEM 75MM ULNAR LT LATITUDE EV","SUP-ITM-10123451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8970.00","6727.50","AETNA [1001]","HB AMC AETNA PPO","7211.88","80.4","","1670.25","1670.25","1670.25","1 through 10","4687.72","7330.28","percent of total billed charges",""
"ELBOW STEM 75MM ULNAR LT LATITUDE EV","SUP-ITM-10123451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8970.00","6727.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4687.72","52.26","","1113.10","1113.10","1113.10","1 through 10","4687.72","7330.28","percent of total billed charges",""
"ELBOW STEM 75MM ULNAR LT LATITUDE EV","SUP-ITM-10123451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8970.00","6727.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7330.28","81.72","","1738.90","1484.65","2716.94","38","4687.72","7330.28","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2704.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4114.13","79.5","","1293.60","1148.53","1603.80","1 through 10","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1888.88","36.5","","1023.42","771.29","2068.67","33","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1982.03","38.3","","850.52","759.78","1211.25","66","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2220.08","42.9","","2548.09","2548.09","2548.09","1 through 10","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2220.08","42.9","","956.46","956.46","956.46","1 through 10","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","WELLPOINT [1015]","HB AMC WELLPOINT","3818.12","73.78","","2344.73","1619.47","2530.35","16","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5175.00","3881.25","AETNA [1001]","HB AMC AETNA HMO","3612.15","69.8","","1523.63","988.41","4330.26","39","2704.46","4229.01","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5175.00","3881.25","AETNA [1001]","HB AMC AETNA PPO","4160.70","80.4","","1670.25","1670.25","1670.25","1 through 10","2704.46","4229.01","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5175.00","3881.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2704.46","52.26","","1113.10","1113.10","1113.10","1 through 10","2704.46","4229.01","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5175.00","3881.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4229.01","81.72","","1738.90","1484.65","2716.94","38","2704.46","4229.01","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2704.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4114.13","79.5","","1293.60","1148.53","1603.80","1 through 10","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1888.88","36.5","","1023.42","771.29","2068.67","33","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1982.03","38.3","","850.52","759.78","1211.25","66","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2220.08","42.9","","2548.09","2548.09","2548.09","1 through 10","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2220.08","42.9","","956.46","956.46","956.46","1 through 10","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","WELLPOINT [1015]","HB AMC WELLPOINT","3818.12","73.78","","2344.73","1619.47","2530.35","16","1604.25","4114.13","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5175.00","3881.25","AETNA [1001]","HB AMC AETNA HMO","3612.15","69.8","","1523.63","988.41","4330.26","39","2704.46","4229.01","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5175.00","3881.25","AETNA [1001]","HB AMC AETNA PPO","4160.70","80.4","","1670.25","1670.25","1670.25","1 through 10","2704.46","4229.01","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5175.00","3881.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2704.46","52.26","","1113.10","1113.10","1113.10","1 through 10","2704.46","4229.01","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5175.00","3881.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4229.01","81.72","","1738.90","1484.65","2716.94","38","2704.46","4229.01","percent of total billed charges",""
"ELBOW STEM IMPLANT HUMERAL DISTAL COMPONENT DISCOVERY MOSAIC STANDARD RT 02","SUP-ITM-10018040","CDM","C1889","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5088.00","79.5","","1309.77","674.56","6049.93","26","1984","5088","percent of total billed charges",""
"ELBOW STEM IMPLANT HUMERAL DISTAL COMPONENT DISCOVERY MOSAIC STANDARD RT 02","SUP-ITM-10018040","CDM","C1889","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3411.20","53.3","","1901.83","1901.83","2962.25","1 through 10","1984","5088","percent of total billed charges",""
"ELBOW STEM IMPLANT HUMERAL DISTAL COMPONENT DISCOVERY MOSAIC STANDARD RT 02","SUP-ITM-10018040","CDM","C1889","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2336.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1984","5088","percent of total billed charges",""
"ELBOW STEM IMPLANT HUMERAL DISTAL COMPONENT DISCOVERY MOSAIC STANDARD RT 02","SUP-ITM-10018040","CDM","C1889","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2451.20","38.3","","352.91","352.91","2046.30","1 through 10","1984","5088","percent of total billed charges",""
"ELBOW STEM IMPLANT HUMERAL DISTAL COMPONENT DISCOVERY MOSAIC STANDARD RT 02","SUP-ITM-10018040","CDM","C1889","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2745.60","42.9","","9668.75","9668.75","9668.75","1 through 10","1984","5088","percent of total billed charges",""
"ELBOW STEM IMPLANT HUMERAL DISTAL COMPONENT DISCOVERY MOSAIC STANDARD RT 02","SUP-ITM-10018040","CDM","C1889","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","WELLPOINT [1015]","HB AMC WELLPOINT","4721.92","73.78","","699.88","384.10","3443.31","33","1984","5088","percent of total billed charges",""
"ELBOW STEM IMPLANT HUMERAL DISTAL COMPONENT DISCOVERY MOSAIC STANDARD RT 02","SUP-ITM-10018040","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","AETNA [1001]","HB AMC AETNA HMO","4467.20","69.8","","1421.24","264.50","4933.46","29","3344.64","5230.08","percent of total billed charges",""
"ELBOW STEM IMPLANT HUMERAL DISTAL COMPONENT DISCOVERY MOSAIC STANDARD RT 02","SUP-ITM-10018040","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5145.60","80.4","","1022.97","1022.97","3607.50","1 through 10","3344.64","5230.08","percent of total billed charges",""
"ELBOW STEM IMPLANT HUMERAL DISTAL COMPONENT DISCOVERY MOSAIC STANDARD RT 02","SUP-ITM-10018040","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5230.08","81.72","","3010.54","693.88","5019.88","35","3344.64","5230.08","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","112.26","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","112.17","108.71","113.07","14","103.56","307.67","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.27","107.27","107.27","17","103.56","307.67","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","307.67","79.5","","295.13","282.75","295.13","1 through 10","103.56","307.67","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","206.27","53.3","","198.00","198.00","295.13","11","103.56","307.67","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.75","90.75","90.75","1 through 10","103.56","307.67","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","ELDER SERVICES [1037]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.01","109.01","109.01","1 through 10","103.56","307.67","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","HUMANA [1012]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","106.83","106.83","106.83","1 through 10","103.56","307.67","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.16","107.16","107.16","1 through 10","103.56","307.67","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","MEDICARE [2001]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.01","105.65","109.01","166","103.56","307.67","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","119.97","31","","115.88","115.88","115.88","1 through 10","103.56","307.67","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","141.26","36.5","","135.75","118.88","135.75","1 through 10","103.56","307.67","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","148.22","38.3","","146.63","142.50","146.63","15","103.56","307.67","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","106.83","106.83","107.23","1 through 10","103.56","307.67","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","106.82","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.27","106.83","107.43","1 through 10","103.56","307.67","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","both","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","106.82","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.33","104.04","109.01","32","103.56","307.67","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","outpatient","","","387.00","290.25","AETNA [1001]","HB AMC AETNA HMO","270.13","69.8","","179.25","179.25","292.50","1 through 10","85.36","762.52","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-92000171","CDM","95983","CPT","0920","RC","","","","outpatient","","","387.00","290.25","AETNA [1001]","HB AMC AETNA PPO","311.15","80.4","","196.50","196.50","196.50","1 through 10","85.36","762.52","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","112.26","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","112.17","108.71","113.07","14","71.61","183.65","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.27","107.27","107.27","17","71.61","183.65","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","183.65","79.5","","295.13","282.75","295.13","1 through 10","71.61","183.65","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","123.12","53.3","","198.00","198.00","295.13","11","71.61","183.65","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.75","90.75","90.75","1 through 10","71.61","183.65","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","ELDER SERVICES [1037]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.01","109.01","109.01","1 through 10","71.61","183.65","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","HUMANA [1012]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","106.83","106.83","106.83","1 through 10","71.61","183.65","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.16","107.16","107.16","1 through 10","71.61","183.65","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","MEDICARE [2001]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.01","105.65","109.01","166","71.61","183.65","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","71.61","31","","115.88","115.88","115.88","1 through 10","71.61","183.65","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","84.32","36.5","","135.75","118.88","135.75","1 through 10","71.61","183.65","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","88.47","38.3","","146.63","142.50","146.63","15","71.61","183.65","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","106.83","106.83","107.23","1 through 10","71.61","183.65","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","106.82","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.27","106.83","107.43","1 through 10","71.61","183.65","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","both","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","106.82","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.33","104.04","109.01","32","71.61","183.65","other","OPPS APC"
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","outpatient","","","231.00","173.25","AETNA [1001]","HB AMC AETNA HMO","161.24","69.8","","179.25","179.25","292.50","1 through 10","86.21","762.52","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg 1st 15 Min","PX-98301829","CDM","95983","CPT","0983","RC","","","","outpatient","","","231.00","173.25","AETNA [1001]","HB AMC AETNA PPO","185.72","80.4","","196.50","196.50","196.50","1 through 10","86.21","762.52","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-92000172","CDM","95984","CPT","0920","RC","","","","both","","","339.00","254.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","269.51","79.5","","258.93","248.07","258.93","1 through 10","105.09","269.51","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-92000172","CDM","95984","CPT","0920","RC","","","","both","","","339.00","254.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","180.69","53.3","","173.71","173.71","258.92","15","105.09","269.51","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-92000172","CDM","95984","CPT","0920","RC","","","","both","","","339.00","254.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","105.09","31","","101.66","101.66","101.66","1 through 10","105.09","269.51","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-92000172","CDM","95984","CPT","0920","RC","","","","both","","","339.00","254.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.74","36.5","","104.30","104.30","119.10","1 through 10","105.09","269.51","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-92000172","CDM","95984","CPT","0920","RC","","","","both","","","339.00","254.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","129.84","38.3","","128.64","125.02","128.64","11","105.09","269.51","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-92000172","CDM","95984","CPT","0920","RC","","","","outpatient","","","339.00","254.25","AETNA [1001]","HB AMC AETNA HMO","236.62","69.8","","157.26","157.26","256.62","1 through 10","177.16","277.03","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-92000172","CDM","95984","CPT","0920","RC","","","","outpatient","","","339.00","254.25","AETNA [1001]","HB AMC AETNA PPO","272.56","80.4","","172.40","172.40","172.40","1 through 10","177.16","277.03","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-98301830","CDM","95984","CPT","0983","RC","","","","both","","","204.00","153.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","162.18","79.5","","258.93","248.07","258.93","1 through 10","63.24","162.18","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-98301830","CDM","95984","CPT","0983","RC","","","","both","","","204.00","153.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","108.73","53.3","","173.71","173.71","258.92","15","63.24","162.18","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-98301830","CDM","95984","CPT","0983","RC","","","","both","","","204.00","153.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","63.24","31","","101.66","101.66","101.66","1 through 10","63.24","162.18","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-98301830","CDM","95984","CPT","0983","RC","","","","both","","","204.00","153.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.46","36.5","","104.30","104.30","119.10","1 through 10","63.24","162.18","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-98301830","CDM","95984","CPT","0983","RC","","","","both","","","204.00","153.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.13","38.3","","128.64","125.02","128.64","11","63.24","162.18","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-98301830","CDM","95984","CPT","0983","RC","","","","outpatient","","","204.00","153.00","AETNA [1001]","HB AMC AETNA HMO","142.39","69.8","","157.26","157.26","256.62","1 through 10","114.04","166.71","percent of total billed charges",""
"Elec Alys Implt Brn Npgt Prgrmg Ea Addl 15 Min","PX-98301830","CDM","95984","CPT","0983","RC","","","","outpatient","","","204.00","153.00","AETNA [1001]","HB AMC AETNA PPO","164.02","80.4","","172.40","172.40","172.40","1 through 10","114.04","166.71","percent of total billed charges",""
"Elec Alys Implt Smpl Cn Npgt Prgrmg","PX-92000169","CDM","95976","CPT","0920","RC","","","","both","","","312.00","234.00","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1 through 10","42.07","248.04","other","OPPS APC"
"Elec Alys Implt Smpl Cn Npgt Prgrmg","PX-98301827","CDM","95976","CPT","0983","RC","","","","both","","","179.00","134.25","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1 through 10","42.07","142.31","other","OPPS APC"
"Elective External Defibrillator Cardioversion","PX-48000462","CDM","93799","CPT","0480","RC","","","","both","","","3257.00","2442.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","2589.32","other","OPPS APC"
"Elective External Defibrillator Cardioversion","PX-48000462","CDM","93799","CPT","0480","RC","","","","outpatient","","","3257.00","2442.75","AETNA [1001]","HB AMC AETNA HMO","2273.39","69.8","","2022.70","2022.70","2022.70","1 through 10","454","2687.03","percent of total billed charges",""
"Elective External Defibrillator Cardioversion","PX-48000462","CDM","93799","CPT","0480","RC","","","","outpatient","","","3257.00","2442.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1972.11","60.55","","318.03","318.03","2439.77","1 through 10","454","2687.03","percent of total billed charges",""
"Elective External Defibrillator Cardioversion","PX-48000462","CDM","93799","CPT","0480","RC","","","","outpatient","","","3257.00","2442.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1700.81","52.22","","360.38","360.38","4023.00","1 through 10","454","2687.03","percent of total billed charges",""
"Elective External Defibrillator Cardioversion","PX-48000462","CDM","93799","CPT","0480","RC","","","","outpatient","","","3257.00","2442.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1791.35","55","","13080.03","13080.03","13080.03","1 through 10","454","2687.03","percent of total billed charges",""
"Elective Hip Joint Replacement,MAJOR","324","DRG","","","","","","","","inpatient","","","72374.98","","MASSHEALTH [3001]","HB BWH MEDICAID","23531.60","","Case rate ($26,018.23). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $68,448.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8.85","8.85","8.85","1 through 10","17146.91","78301.26","case rate",""
"Elective Hip Joint Replacement,MAJOR","324","DRG","","","","","","","","inpatient","","","72374.98","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","23531.60","","Case rate ($26,018.23). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $68,448.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","50687.14","50687.14","50687.14","1 through 10","17146.91","78301.26","case rate",""
"Elective Hip Joint Replacement,MINOR","324","DRG","","","","","","","","inpatient","","","92756.81","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","53252.86","","Standard inlier is a Case rate ($53,252.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,482, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,558.80) for the length of stay and the standard reimbursement.","53252.85","53252.85","53252.85","1 through 10","17146.91","78301.26","case rate",""
"Elective Hip Joint Replacement,MINOR","324","DRG","","","","","","","","inpatient","","","92756.81","","MASSHEALTH [3001]","HB BWH MEDICAID","17146.91","","Case rate ($18,958.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,388.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11636.68","5183.68","72947.77","1 through 10","17146.91","78301.26","case rate",""
"Elective Hip Joint Replacement,MINOR","324","DRG","","","","","","","","inpatient","","","92756.81","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","17146.91","","Case rate ($18,958.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,388.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18954.21","18954.21","18954.21","1 through 10","17146.91","78301.26","case rate",""
"Elective Hip Joint Replacement,MODERATE","324","DRG","","","","","","","","inpatient","","","107853.23","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","51603.30","","Standard inlier is a Case rate ($51,603.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $51,777, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,325.40) for the length of stay and the standard reimbursement.","51603.29","51603.29","51603.29","1 through 10","17146.91","78301.26","case rate",""
"Elective Hip Joint Replacement,MODERATE","324","DRG","","","","","","","","inpatient","","","107853.23","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","58016.02","","Standard inlier is a Case rate ($58,016.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $51,777, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,234.89) for the length of stay and the standard reimbursement.","58016.01","58016.01","58016.01","1 through 10","17146.91","78301.26","case rate",""
"Elective Hip Joint Replacement,MODERATE","324","DRG","","","","","","","","inpatient","","","107853.23","","MASSHEALTH [3001]","HB BWH MEDICAID","17464.49","","Case rate ($19,310). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,740, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $10,109.95 and the sum of the standard inlier and any outlier amount.","19305.26","19305.26","19305.26","1 through 10","17146.91","78301.26","case rate",""
"Elective Hip Joint Replacement,MODERATE","324","DRG","","","","","","","","inpatient","","","107853.23","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","17464.49","","Case rate ($19,310). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,740, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $10,109.95 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","17146.91","78301.26","case rate",""
"Elective Hip Joint Replacement,MODERATE","324","DRG","","","","","","","","inpatient","","","107853.23","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","17464.49","","Case rate ($19,310). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,740, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $10,109.95 and the sum of the standard inlier and any outlier amount.","19305.26","19305.26","19305.26","1 through 10","17146.91","78301.26","case rate",""
"Elective Knee Joint Replacement,MINOR","326","DRG","","","","","","","","inpatient","","","82763.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","47091.73","","Standard inlier is a Case rate ($47,091.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,268, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,684.96) for the length of stay and the standard reimbursement.","42925.82","42925.82","42925.82","1 through 10","15175.19","79930.19","case rate",""
"Elective Knee Joint Replacement,MINOR","326","DRG","","","","","","","","inpatient","","","82763.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","52943.80","","Standard inlier is a Case rate ($52,943.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,268, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,514.93) for the length of stay and the standard reimbursement.","52943.79","48368.72","52943.79","1 through 10","15175.19","79930.19","case rate",""
"Elective Knee Joint Replacement,MINOR","326","DRG","","","","","","","","inpatient","","","82763.32","","MASSHEALTH [3001]","HB BWH MEDICAID","15175.19","","Case rate ($16,778.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,208.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $8,474.13 and the sum of the standard inlier and any outlier amount.","6224.99","5183.68","10329.16","1 through 10","15175.19","79930.19","case rate",""
"Elective Knee Joint Replacement,MINOR","326","DRG","","","","","","","","inpatient","","","82763.32","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15175.19","","Case rate ($16,778.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,208.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $8,474.13 and the sum of the standard inlier and any outlier amount.","5183.68","5183.68","5183.68","1 through 10","15175.19","79930.19","case rate",""
"Elective Knee Joint Replacement,MODERATE","326","DRG","","","","","","","","inpatient","","","96369.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","49992.72","","Standard inlier is a Case rate ($49,992.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,524, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,096.77) for the length of stay and the standard reimbursement.","49992.71","49992.71","49992.71","1 through 10","15175.19","79930.19","case rate",""
"Elective Knee Joint Replacement,MODERATE","326","DRG","","","","","","","","inpatient","","","96369.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","56205.29","","Standard inlier is a Case rate ($56,205.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,524, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,977.87) for the length of stay and the standard reimbursement.","56205.28","56205.28","56205.28","1 through 10","15175.19","79930.19","case rate",""
"Elective Knee Joint Replacement,MODERATE","326","DRG","","","","","","","","inpatient","","","96369.74","","MASSHEALTH [3001]","HB BWH MEDICAID","16213.60","","Case rate ($17,926.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,356.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17922.52","17922.52","17922.52","1 through 10","15175.19","79930.19","case rate",""
"Elective Knee Joint Replacement,MODERATE","326","DRG","","","","","","","","inpatient","","","96369.74","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","16213.60","","Case rate ($17,926.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,356.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17922.52","17922.52","17922.52","1 through 10","15175.19","79930.19","case rate",""
"ELECTRODE DEFIBRILLATOR EMBLEM S-ICD SUBCUTANEOUS","SUP-ITM-10209422","CDM","C1896","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7950.00","79.5","","7540.00","7540.00","7540.00","1 through 10","3100","7950","percent of total billed charges",""
"ELECTRODE DEFIBRILLATOR EMBLEM S-ICD SUBCUTANEOUS","SUP-ITM-10209422","CDM","C1896","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6500.00","65","","6500.00","6500.00","6500.00","1 through 10","3100","7950","percent of total billed charges",""
"ELECTRODE DEFIBRILLATOR EMBLEM S-ICD SUBCUTANEOUS","SUP-ITM-10209422","CDM","C1896","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3650.00","36.5","","11190.00","11190.00","11190.00","1 through 10","3100","7950","percent of total billed charges",""
"ELECTRODE DEFIBRILLATOR EMBLEM S-ICD SUBCUTANEOUS","SUP-ITM-10209422","CDM","C1896","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA HMO","6980.00","69.8","","17800.00","17800.00","17800.00","1 through 10","5226","8172","percent of total billed charges",""
"ELECTRODE DEPTH 5MM 1.12X2.41 370 PROBE SPENCER 6 CONTACTS SPACING","SUP-ITM-10143552","CDM","C1889","HCPCS","0278","RC","","","","both","","","1942.50","1456.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1544.29","79.5","","1309.77","674.56","6049.93","26","602.18","1544.29","percent of total billed charges",""
"ELECTRODE DEPTH 5MM 1.12X2.41 370 PROBE SPENCER 6 CONTACTS SPACING","SUP-ITM-10143552","CDM","C1889","HCPCS","0278","RC","","","","both","","","1942.50","1456.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1035.35","53.3","","1901.83","1901.83","2962.25","1 through 10","602.18","1544.29","percent of total billed charges",""
"ELECTRODE DEPTH 5MM 1.12X2.41 370 PROBE SPENCER 6 CONTACTS SPACING","SUP-ITM-10143552","CDM","C1889","HCPCS","0278","RC","","","","both","","","1942.50","1456.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","709.01","36.5","","1620.31","1620.31","19908.88","1 through 10","602.18","1544.29","percent of total billed charges",""
"ELECTRODE DEPTH 5MM 1.12X2.41 370 PROBE SPENCER 6 CONTACTS SPACING","SUP-ITM-10143552","CDM","C1889","HCPCS","0278","RC","","","","both","","","1942.50","1456.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","743.98","38.3","","352.91","352.91","2046.30","1 through 10","602.18","1544.29","percent of total billed charges",""
"ELECTRODE DEPTH 5MM 1.12X2.41 370 PROBE SPENCER 6 CONTACTS SPACING","SUP-ITM-10143552","CDM","C1889","HCPCS","0278","RC","","","","both","","","1942.50","1456.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","833.33","42.9","","9668.75","9668.75","9668.75","1 through 10","602.18","1544.29","percent of total billed charges",""
"ELECTRODE DEPTH 5MM 1.12X2.41 370 PROBE SPENCER 6 CONTACTS SPACING","SUP-ITM-10143552","CDM","C1889","HCPCS","0278","RC","","","","both","","","1942.50","1456.87","WELLPOINT [1015]","HB AMC WELLPOINT","1433.18","73.78","","699.88","384.10","3443.31","33","602.18","1544.29","percent of total billed charges",""
"ELECTRODE DEPTH 5MM 1.12X2.41 370 PROBE SPENCER 6 CONTACTS SPACING","SUP-ITM-10143552","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1942.50","1456.87","AETNA [1001]","HB AMC AETNA HMO","1355.87","69.8","","1421.24","264.50","4933.46","29","1015.15","1587.41","percent of total billed charges",""
"ELECTRODE DEPTH 5MM 1.12X2.41 370 PROBE SPENCER 6 CONTACTS SPACING","SUP-ITM-10143552","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1942.50","1456.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1561.77","80.4","","1022.97","1022.97","3607.50","1 through 10","1015.15","1587.41","percent of total billed charges",""
"ELECTRODE DEPTH 5MM 1.12X2.41 370 PROBE SPENCER 6 CONTACTS SPACING","SUP-ITM-10143552","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1942.50","1456.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1587.41","81.72","","3010.54","693.88","5019.88","35","1015.15","1587.41","percent of total billed charges",""
"ELECTRODE ELECTROSURGICAL 14GA 6.4FR 15CM STARBURST XL RADIO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10129699","CDM","C1886","HCPCS","0272","RC","","","","both","","","11250.00","8437.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","8077.50","71.8","","4399.55","4399.55","4399.55","1 through 10","3487.5","8943.75","percent of total billed charges",""
"ELECTRODE ELECTROSURGICAL 14GA 6.4FR 15CM STARBURST XL RADIO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10129699","CDM","C1886","HCPCS","0272","RC","","","","both","","","11250.00","8437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4106.25","36.5","","1413.19","621.27","1413.19","1 through 10","3487.5","8943.75","percent of total billed charges",""
"ELECTRODE ELECTROSURGICAL 14GA 6.4FR 15CM STARBURST XL RADIO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10129699","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","11250.00","8437.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9193.50","81.72","","8168.27","2209.17","8168.27","1 through 10","5879.25","9193.5","percent of total billed charges",""
"Electrolyte Panel","PX-30000008","CDM","80051","CPT","0301","RC","","","","both","","","131.00","98.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","104.15","79.5","","99.95","99.95","99.95","1 through 10","6.87","124.45","percent of total billed charges",""
"Electrolyte Panel","PX-30000008","CDM","80051","CPT","0301","RC","","","","both","","","131.00","98.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","69.82","53.3","","67.06","67.06","99.95","1 through 10","6.87","124.45","percent of total billed charges",""
"Electrolyte Panel","PX-30000008","CDM","80051","CPT","0301","RC","","","","both","","","131.00","98.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","50.17","38.3","","123.56","48.26","148.98","1 through 10","6.87","124.45","percent of total billed charges",""
"Electrolyte Panel","PX-30000008","CDM","80051","CPT","0301","RC","","","","both","","","131.00","98.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.20","42.9","","252.61","252.61","252.61","1 through 10","6.87","124.45","percent of total billed charges",""
"Electrolyte Panel","PX-30000008","CDM","80051","CPT","0301","RC","","","","outpatient","","","131.00","98.25","AETNA [1001]","HB AMC AETNA HMO","91.44","69.8","","213.93","85.98","213.93","1 through 10","7.24","107.05","percent of total billed charges",""
"Electrolyte Panel","PX-30000008","CDM","80051","CPT","0301","RC","","","","outpatient","","","131.00","98.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","68.46","52.26","","17.32","17.32","17.32","1 through 10","7.24","107.05","percent of total billed charges",""
"Electrolyte Panel","PX-30000008","CDM","80051","CPT","0301","RC","","","","outpatient","","","131.00","98.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","107.05","81.72","","55.84","55.84","55.84","1 through 10","7.24","107.05","percent of total billed charges",""
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","970.02","","APC Price ($970.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","954.60","954.60","2635.00","1 through 10","842.27","2160.02","other","OPPS APC"
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1766.05","65","","1712.75","1712.75","1712.75","1 through 10","842.27","2160.02","percent of total billed charges",""
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1901.90","70","","970.12","970.12","970.12","1 through 10","842.27","2160.02","percent of total billed charges",""
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2160.02","79.5","","2073.75","1676.37","7005.09","1 through 10","842.27","2160.02","percent of total billed charges",""
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1448.16","53.3","","2073.75","1330.68","2073.75","1 through 10","842.27","2160.02","percent of total billed charges",""
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","970.02","","APC Price ($970.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","950.72","800.56","950.72","1 through 10","842.27","2160.02","other","OPPS APC"
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","FALLON HEALTH [1008]","HB BWH MEDICARE","970.02","","APC Price ($970.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","919.73","919.73","919.73","1 through 10","842.27","2160.02","other","OPPS APC"
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","2092.09","77","","4924.92","4924.92","4924.92","1 through 10","842.27","2160.02","percent of total billed charges",""
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","HUMANA [1012]","HB BWH MEDICARE","970.02","","APC Price ($970.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","950.72","950.72","950.72","1 through 10","842.27","2160.02","other","OPPS APC"
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1766.05","65","","1712.75","1712.75","1712.75","1 through 10","842.27","2160.02","percent of total billed charges",""
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","MEDICARE [2001]","HB BWH MEDICARE","970.02","","APC Price ($970.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","970.12","938.50","970.12","46","842.27","2160.02","other","OPPS APC"
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","991.71","36.5","","982.86","835.30","982.86","1 through 10","842.27","2160.02","percent of total billed charges",""
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1040.61","38.3","","1030.29","1001.30","1030.29","1 through 10","842.27","2160.02","percent of total billed charges",""
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","970.02","","APC Price ($970.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","950.72","950.72","950.72","1 through 10","842.27","2160.02","other","OPPS APC"
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","TRICARE [160005]","HB BWH TRICARE","921.61","","APC Price ($970.12). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","970.12","921.61","970.12","1 through 10","842.27","2160.02","other","Tricare OPPS"
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","950.62","","APC Price ($970.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","950.72","950.72","950.72","1 through 10","842.27","2160.02","other","OPPS APC"
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1165.59","42.9","","2106.42","2106.42","2106.42","1 through 10","842.27","2160.02","percent of total billed charges",""
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","both","","","2717.00","2037.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","950.62","","APC Price ($970.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","950.72","919.73","950.72","1 through 10","842.27","2160.02","other","OPPS APC"
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","outpatient","","","2717.00","2037.75","AETNA [1001]","HB AMC AETNA HMO","1896.47","69.8","","1783.90","1783.90","1783.90","1 through 10","1086.46","3421.28","percent of total billed charges",""
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","outpatient","","","2717.00","2037.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2184.47","80.4","","2055.30","2055.30","2055.30","1 through 10","1086.46","3421.28","percent of total billed charges",""
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","outpatient","","","2717.00","2037.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2220.33","81.72","","1158.61","1158.61","1158.61","1 through 10","1086.46","3421.28","percent of total billed charges",""
"Electron Microscopy Diagnostic","PX-31000042","CDM","88348","CPT","0312","RC","","","","outpatient","","","2717.00","2037.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2220.33","81.72","","2106.42","2106.42","2106.42","1 through 10","1086.46","3421.28","percent of total billed charges",""
"ELEVATOR ENDPLATE 10MM BAYONET","SUP-ITM-10104854","CDM","C1889","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1271.60","79.5","","1309.77","674.56","6049.93","26","495.85","1271.6","percent of total billed charges",""
"ELEVATOR ENDPLATE 10MM BAYONET","SUP-ITM-10104854","CDM","C1889","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","852.53","53.3","","1901.83","1901.83","2962.25","1 through 10","495.85","1271.6","percent of total billed charges",""
"ELEVATOR ENDPLATE 10MM BAYONET","SUP-ITM-10104854","CDM","C1889","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","583.82","36.5","","1620.31","1620.31","19908.88","1 through 10","495.85","1271.6","percent of total billed charges",""
"ELEVATOR ENDPLATE 10MM BAYONET","SUP-ITM-10104854","CDM","C1889","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","612.61","38.3","","352.91","352.91","2046.30","1 through 10","495.85","1271.6","percent of total billed charges",""
"ELEVATOR ENDPLATE 10MM BAYONET","SUP-ITM-10104854","CDM","C1889","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","686.19","42.9","","9668.75","9668.75","9668.75","1 through 10","495.85","1271.6","percent of total billed charges",""
"ELEVATOR ENDPLATE 10MM BAYONET","SUP-ITM-10104854","CDM","C1889","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","WELLPOINT [1015]","HB AMC WELLPOINT","1180.11","73.78","","699.88","384.10","3443.31","33","495.85","1271.6","percent of total billed charges",""
"ELEVATOR ENDPLATE 10MM BAYONET","SUP-ITM-10104854","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1599.50","1199.62","AETNA [1001]","HB AMC AETNA HMO","1116.45","69.8","","1421.24","264.50","4933.46","29","835.9","1307.11","percent of total billed charges",""
"ELEVATOR ENDPLATE 10MM BAYONET","SUP-ITM-10104854","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1599.50","1199.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1286.00","80.4","","1022.97","1022.97","3607.50","1 through 10","835.9","1307.11","percent of total billed charges",""
"ELEVATOR ENDPLATE 10MM BAYONET","SUP-ITM-10104854","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1599.50","1199.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1307.11","81.72","","3010.54","693.88","5019.88","35","835.9","1307.11","percent of total billed charges",""
"Eln-Related Disorders: Eln Gene Sequencing","PX-31000808","CDM","81479","CPT","0310","RC","","","","both","","","3662.00","2746.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2911.29","79.5","","0.65","0.65","0.65","1 through 10","1135.22","3478.9","percent of total billed charges",""
"Eln-Related Disorders: Eln Gene Sequencing","PX-31000808","CDM","81479","CPT","0310","RC","","","","both","","","3662.00","2746.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1951.85","53.3","","0.79","0.79","0.79","1 through 10","1135.22","3478.9","percent of total billed charges",""
"Eln-Related Disorders: Eln Gene Sequencing","PX-31000808","CDM","81479","CPT","0310","RC","","","","outpatient","","","3662.00","2746.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1831.00","50","","1.00","1.00","1.00","1 through 10","156.55","3021.15","percent of total billed charges",""
"Eln-Related Disorders: Eln Gene Sequencing","PX-31000808","CDM","81479","CPT","0310","RC","","","","outpatient","","","3662.00","2746.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1922.55","52.5","","1.00","0.53","1.00","1 through 10","156.55","3021.15","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","3152.00","2364.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2505.84","79.5","","1309.77","674.56","6049.93","26","977.12","2505.84","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","3152.00","2364.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1680.02","53.3","","1901.83","1901.83","2962.25","1 through 10","977.12","2505.84","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","3152.00","2364.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1150.48","36.5","","1620.31","1620.31","19908.88","1 through 10","977.12","2505.84","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","3152.00","2364.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1207.22","38.3","","352.91","352.91","2046.30","1 through 10","977.12","2505.84","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","3152.00","2364.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1352.21","42.9","","9668.75","9668.75","9668.75","1 through 10","977.12","2505.84","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","3152.00","2364.00","WELLPOINT [1015]","HB AMC WELLPOINT","2325.55","73.78","","699.88","384.10","3443.31","33","977.12","2505.84","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3152.00","2364.00","AETNA [1001]","HB AMC AETNA HMO","2200.10","69.8","","1421.24","264.50","4933.46","29","1647.24","2575.81","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3152.00","2364.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2534.21","80.4","","1022.97","1022.97","3607.50","1 through 10","1647.24","2575.81","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3152.00","2364.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2575.81","81.72","","3010.54","693.88","5019.88","35","1647.24","2575.81","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3948.00","2961.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3138.66","79.5","","1309.77","674.56","6049.93","26","1223.88","3138.66","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3948.00","2961.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2104.28","53.3","","1901.83","1901.83","2962.25","1 through 10","1223.88","3138.66","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3948.00","2961.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1441.02","36.5","","1620.31","1620.31","19908.88","1 through 10","1223.88","3138.66","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3948.00","2961.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1512.08","38.3","","352.91","352.91","2046.30","1 through 10","1223.88","3138.66","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3948.00","2961.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1693.69","42.9","","9668.75","9668.75","9668.75","1 through 10","1223.88","3138.66","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3948.00","2961.00","WELLPOINT [1015]","HB AMC WELLPOINT","2912.83","73.78","","699.88","384.10","3443.31","33","1223.88","3138.66","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3948.00","2961.00","AETNA [1001]","HB AMC AETNA HMO","2755.70","69.8","","1421.24","264.50","4933.46","29","2063.22","3226.31","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3948.00","2961.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3174.19","80.4","","1022.97","1022.97","3607.50","1 through 10","2063.22","3226.31","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3948.00","2961.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3226.31","81.72","","3010.54","693.88","5019.88","35","2063.22","3226.31","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","5037.48","3778.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4004.80","79.5","","1309.77","674.56","6049.93","26","1561.62","4004.8","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","5037.48","3778.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2684.98","53.3","","1901.83","1901.83","2962.25","1 through 10","1561.62","4004.8","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","5037.48","3778.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1838.68","36.5","","1620.31","1620.31","19908.88","1 through 10","1561.62","4004.8","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","5037.48","3778.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1929.35","38.3","","352.91","352.91","2046.30","1 through 10","1561.62","4004.8","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","5037.48","3778.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2161.08","42.9","","9668.75","9668.75","9668.75","1 through 10","1561.62","4004.8","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","5037.48","3778.11","WELLPOINT [1015]","HB AMC WELLPOINT","3716.65","73.78","","699.88","384.10","3443.31","33","1561.62","4004.8","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5037.48","3778.11","AETNA [1001]","HB AMC AETNA HMO","3516.16","69.8","","1421.24","264.50","4933.46","29","2632.59","4116.63","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5037.48","3778.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4050.13","80.4","","1022.97","1022.97","3607.50","1 through 10","2632.59","4116.63","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5037.48","3778.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4116.63","81.72","","3010.54","693.88","5019.88","35","2632.59","4116.63","percent of total billed charges",""
"Embolization of Biliary Tract","PX-76002339","CDM","47999","CPT","0761","RC","","","","both","","","27631.00","20723.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","21966.65","other","OPPS APC"
"Embolization of Biliary Tract","PX-76002339","CDM","47999","CPT","0761","RC","","","","both","","","27631.00","20723.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","1057.74","21966.65","other","OPPS APC"
"Embolization of Biliary Tract","PX-76002339","CDM","47999","CPT","0761","RC","","","","outpatient","","","27631.00","20723.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","14428.91","52.22","","3734.00","1019.30","3734.00","1 through 10","9843.6","22795.58","percent of total billed charges",""
"Embryo Hatching Microtechnique","PX-30000122","CDM","89253","CPT","0300","RC","","","","both","","","1353.00","1014.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1075.64","79.5","","1032.54","692.74","1032.54","1 through 10","199.41","1285.35","percent of total billed charges",""
"Embryo Hatching Microtechnique","PX-30000122","CDM","89253","CPT","0300","RC","","","","both","","","1353.00","1014.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","721.15","53.3","","1032.54","1032.54","1032.54","1 through 10","199.41","1285.35","percent of total billed charges",""
"Embryo Hatching Microtechnique","PX-30000122","CDM","89253","CPT","0300","RC","","","","both","","","1353.00","1014.75","WELLPOINT [1015]","HB AMC WELLPOINT","998.24","73.78","","2288.78","976.78","2288.78","1 through 10","199.41","1285.35","percent of total billed charges",""
"Embryo Hatching Microtechnique","PX-30000122","CDM","89253","CPT","0300","RC","","","","outpatient","","","1353.00","1014.75","AETNA [1001]","HB AMC AETNA HMO","944.39","69.8","","627.14","627.14","627.14","1 through 10","420.84","1105.67","percent of total billed charges",""
"Embryo Hatching Microtechnique","PX-30000122","CDM","89253","CPT","0300","RC","","","","outpatient","","","1353.00","1014.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1105.67","81.72","","1048.81","576.89","1048.81","1 through 10","420.84","1105.67","percent of total billed charges",""
"Embryo Prep","PX-30000124","CDM","89255","CPT","0300","RC","","","","both","","","631.00","473.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","501.65","79.5","","481.64","323.14","481.64","11","62.18","599.45","percent of total billed charges",""
"Embryo Prep","PX-30000124","CDM","89255","CPT","0300","RC","","","","both","","","631.00","473.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","336.32","53.3","","323.14","323.14","323.14","1 through 10","62.18","599.45","percent of total billed charges",""
"Embryo Prep","PX-30000124","CDM","89255","CPT","0300","RC","","","","both","","","631.00","473.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","270.70","42.9","","489.23","489.23","489.23","1 through 10","62.18","599.45","percent of total billed charges",""
"Embryo Prep","PX-30000124","CDM","89255","CPT","0300","RC","","","","both","","","631.00","473.25","WELLPOINT [1015]","HB AMC WELLPOINT","465.55","73.78","","1067.63","455.63","1067.63","11","62.18","599.45","percent of total billed charges",""
"Embryo Prep","PX-30000124","CDM","89255","CPT","0300","RC","","","","outpatient","","","631.00","473.25","AETNA [1001]","HB AMC AETNA HMO","440.44","69.8","","292.54","292.54","292.54","1 through 10","189.14","515.65","percent of total billed charges",""
"Embryo Prep","PX-30000124","CDM","89255","CPT","0300","RC","","","","outpatient","","","631.00","473.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","329.51","52.22","","612.00","612.00","612.00","1 through 10","189.14","515.65","percent of total billed charges",""
"Embryo Prep","PX-30000124","CDM","89255","CPT","0300","RC","","","","outpatient","","","631.00","473.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","515.65","81.72","","269.10","269.10","269.10","1 through 10","189.14","515.65","percent of total billed charges",""
"Embryo Prep","PX-30000124","CDM","89255","CPT","0300","RC","","","","outpatient","","","631.00","473.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","515.65","81.72","","489.23","269.10","489.23","18","189.14","515.65","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","803.10","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3243.43","3235.53","3245.43","21","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3094.03","3094.03","3144.34","1 through 10","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","974.64","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","45.00","45.00","45.00","1 through 10","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2934.35","79.5","","2816.67","2623.32","29416.71","1 through 10","592.29","2934.35","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1967.30","53.3","","8450.01","1889.71","8450.01","1 through 10","592.29","2934.35","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3094.03","716.44","3094.03","63","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","ELDER SERVICES [1037]","HB BWH MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2987.45","2987.45","2987.45","1 through 10","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3083.95","715.53","3083.95","1 through 10","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","HUMANA [1012]","HB BWH MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3086.95","95.00","3090.35","1 through 10","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","MEDICARE [2001]","HB BWH MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","728.09","3144.34","185","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1144.21","31","","1105.91","1105.91","1105.91","1 through 10","592.29","2934.35","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1347.22","36.5","","1334.97","1295.60","3403.62","11","592.29","2934.35","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1413.65","38.3","","1399.39","1360.02","4198.17","26","592.29","2934.35","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3083.25","3083.25","3083.25","1 through 10","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","MOLINA [1014]","HB BWH MOLINA","764.11","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6225.79","1443.07","6227.99","1 through 10","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","TRICARE [160005]","HB BWH TRICARE","691.69","","APC Price ($728.09). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3144.34","2838.07","3144.34","1 through 10","592.29","2934.35","other","Tricare OPPS"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","764.11","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3094.03","3081.45","9255.15","14","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","764.11","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","823.17","823.17","2469.51","21","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1583.44","42.9","","6550.66","6550.66","6550.66","1 through 10","592.29","2934.35","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","764.11","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3081.46","713.53","3083.96","199","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3691.00","2768.25","WELLSENSE [1003]","HB BWH MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3175.78","735.37","3175.78","1 through 10","592.29","2934.35","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","inpatient","","","3691.00","2768.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2901.50","78.61","","4438.27","4438.27","4438.27","1 through 10","2041.12","2934.35","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3691.00","2768.25","AETNA [1001]","HB AMC AETNA HMO","2576.32","69.8","","4845.96","2422.98","4845.96","1 through 10","380.6","3016.29","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3691.00","2768.25","AETNA [1001]","HB AMC AETNA PPO","2967.56","80.4","","2791.62","1875.40","3750.80","1 through 10","380.6","3016.29","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3691.00","2768.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($864).","3579.00","3579.00","3579.00","1 through 10","380.6","3016.29","other","Emergency Room"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3691.00","2768.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($907).","4535.00","652.25","4535.00","1 through 10","380.6","3016.29","other","Emergency Room"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3691.00","2768.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($1,080).","6389.00","6389.00","6389.00","1 through 10","380.6","3016.29","other","Emergency Room"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3691.00","2768.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($950).","1211.10","950.00","1211.10","1 through 10","380.6","3016.29","other","Emergency Room"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3691.00","2768.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3016.29","81.72","","1573.69","560.15","1573.69","1 through 10","380.6","3016.29","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3691.00","2768.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3016.29","81.72","","2861.05","1573.69","6665.78","15","380.6","3016.29","percent of total billed charges",""
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","749.86","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3236.83","749.20","3245.43","131","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","728.02","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3094.03","716.44","3094.03","55","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2583.70","70","","1824.60","1824.60","1824.60","1 through 10","713.46","2583.7","percent of total billed charges",""
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","910.02","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","652.47","366.69","3144.34","1 through 10","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","CIGNA [1006]","HB BWH MEDICARE","728.02","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6176.48","6176.48","6176.48","1 through 10","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","728.02","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3094.03","716.44","3094.03","79","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","ELDER SERVICES [1037]","HB BWH MEDICARE","728.02","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3081.45","3081.45","3081.45","1 through 10","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","FALLON HEALTH [1008]","HB BWH MEDICARE","728.02","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8936.85","2987.45","9433.02","14","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","728.02","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2929.70","156.94","3083.85","1 through 10","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","HUMANA [1012]","HB BWH MEDICARE","728.02","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3083.95","713.53","3086.95","1 through 10","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","MEDICARE [2001]","HB BWH MEDICARE","728.02","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","728.09","8962.35","824","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","728.02","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3081.45","713.53","5855.40","14","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","MOLINA [1014]","HB BWH MOLINA","713.46","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5974.90","1441.62","6227.99","24","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","713.46","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9244.35","2156.79","9288.25","100","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","713.46","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","823.17","823.17","823.17","1 through 10","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","713.46","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3081.45","715.73","3083.25","183","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3691.00","2768.25","WELLSENSE [1003]","HB BWH MEDICARE","728.02","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3175.78","3175.78","3175.78","1 through 10","713.46","2583.7","other","OPPS APC"
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1879.00","1409.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","410.99","","APC Price ($328.79). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","125.00","110.00","125.00","1 through 10","312.38","1493.81","other","OPPS APC"
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1879.00","1409.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","328.79","","APC Price ($328.79). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3088.74","3088.74","3088.74","1 through 10","312.38","1493.81","other","OPPS APC"
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1879.00","1409.25","MEDICARE [2001]","HB BWH MEDICARE","328.79","","APC Price ($328.79). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","328.82","9433.02","29","312.38","1493.81","other","OPPS APC"
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1879.00","1409.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","685.84","36.5","","577.57","577.57","577.57","1 through 10","312.38","1493.81","percent of total billed charges",""
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1879.00","1409.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","719.66","38.3","","712.40","712.40","712.40","1 through 10","312.38","1493.81","percent of total billed charges",""
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1879.00","1409.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","322.21","","APC Price ($328.79). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3094.03","3094.03","3094.03","1 through 10","312.38","1493.81","other","OPPS APC"
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1879.00","1409.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","322.21","","APC Price ($328.79). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","419.06","419.06","419.06","1 through 10","312.38","1493.81","other","OPPS APC"
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1879.00","1409.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","322.21","","APC Price ($328.79). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2930.11","322.25","3083.96","1 through 10","312.38","1493.81","other","OPPS APC"
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","outpatient","","","1879.00","1409.25","AETNA [1001]","HB AMC AETNA HMO","1311.54","69.8","","2466.99","1421.16","2466.99","1 through 10","380.6","1535.52","percent of total billed charges",""
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1879.00","1409.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","338.69","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3079.98","338.35","3243.14","1 through 10","322.25","1315.3","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1879.00","1409.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","328.82","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2939.65","323.56","2939.65","1 through 10","322.25","1315.3","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1879.00","1409.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","328.82","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3088.74","2555.83","3092.25","1 through 10","322.25","1315.3","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1879.00","1409.25","FALLON HEALTH [1008]","HB BWH MEDICARE","328.82","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6986.64","6986.64","6986.64","1 through 10","322.25","1315.3","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1879.00","1409.25","HUMANA [1012]","HB BWH MEDICARE","328.82","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2933.20","2933.20","2933.20","1 through 10","322.25","1315.3","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1879.00","1409.25","MEDICARE [2001]","HB BWH MEDICARE","328.82","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","622.80","8962.35","59","322.25","1315.3","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1879.00","1409.25","MOLINA [1014]","HB BWH MOLINA","322.25","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1394.79","1394.79","5915.15","1 through 10","322.25","1315.3","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1879.00","1409.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","322.25","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2929.90","2929.90","3094.03","1 through 10","322.25","1315.3","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1879.00","1409.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","322.25","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2927.70","322.24","3081.45","13","322.25","1315.3","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1879.00","1409.25","WELLSENSE [1003]","HB BWH MEDICARE","328.82","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","15878.90","15878.90","15878.90","1 through 10","322.25","1315.3","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","outpatient","","","1879.00","1409.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","835.22","44.45","","1456.51","1456.51","1456.51","1 through 10","835.22","835.22","percent of total billed charges",""
"Emergency Department Visit May Not Req Phys/Qhp","PX-45000001","CDM","99281","CPT","0450","RC","","","","inpatient","","","781.00","585.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","613.94","78.61","","2623.57","2623.57","2623.57","1 through 10","431.89","620.9","percent of total billed charges",""
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2497.00","1872.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","520.86","","APC Price ($505.69). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3243.43","3241.14","3243.43","1 through 10","480.4","1985.12","other","OPPS APC"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2497.00","1872.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1985.12","79.5","","1905.33","1905.33","1905.33","1 through 10","480.4","1985.12","percent of total billed charges",""
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2497.00","1872.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","505.69","","APC Price ($505.69). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3091.14","2927.70","3091.14","1 through 10","480.4","1985.12","other","OPPS APC"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2497.00","1872.75","HUMANA [1012]","HB BWH MEDICARE","505.69","","APC Price ($505.69). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3088.45","3088.45","3088.45","1 through 10","480.4","1985.12","other","OPPS APC"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2497.00","1872.75","MEDICARE [2001]","HB BWH MEDICARE","505.69","","APC Price ($505.69). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","505.69","9433.02","29","480.4","1985.12","other","OPPS APC"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2497.00","1872.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","774.07","31","","748.09","748.09","748.09","1 through 10","480.4","1985.12","percent of total billed charges",""
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2497.00","1872.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","911.41","36.5","","876.40","876.40","876.40","1 through 10","480.4","1985.12","percent of total billed charges",""
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2497.00","1872.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","956.35","38.3","","2759.94","946.61","2759.94","1 through 10","480.4","1985.12","percent of total billed charges",""
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2497.00","1872.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","495.57","","APC Price ($505.69). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","556.83","556.83","556.83","1 through 10","480.4","1985.12","other","OPPS APC"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2497.00","1872.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","495.57","","APC Price ($505.69). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3081.45","475.74","3083.96","20","480.4","1985.12","other","OPPS APC"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","outpatient","","","2497.00","1872.75","AETNA [1001]","HB AMC AETNA HMO","1742.91","69.8","","1157.24","1157.24","1157.24","1 through 10","380.6","2040.55","percent of total billed charges",""
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","outpatient","","","2497.00","1872.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2040.55","81.72","","8181.28","5586.13","8181.28","1 through 10","380.6","2040.55","percent of total billed charges",""
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2497.00","1872.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","520.80","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3235.53","497.42","6396.50","1 through 10","495.52","1071.21","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2497.00","1872.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3094.03","2939.65","3094.03","1 through 10","495.52","1071.21","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2497.00","1872.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2937.38","497.60","3091.14","18","495.52","1071.21","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2497.00","1872.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2929.70","2927.70","2929.70","1 through 10","495.52","1071.21","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2497.00","1872.75","HUMANA [1012]","HB BWH MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2927.70","479.23","3083.95","1 through 10","495.52","1071.21","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2497.00","1872.75","MEDICARE [2001]","HB BWH MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","505.69","9433.02","203","495.52","1071.21","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2497.00","1872.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2929.50","2927.70","5746.26","1 through 10","495.52","1071.21","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2497.00","1872.75","MOLINA [1014]","HB BWH MOLINA","495.52","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6227.99","5974.90","6227.99","1 through 10","495.52","1071.21","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2497.00","1872.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","495.52","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2929.90","1491.29","9288.25","13","495.52","1071.21","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2497.00","1872.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","495.52","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","556.83","556.83","556.83","1 through 10","495.52","1071.21","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2497.00","1872.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","495.52","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2929.84","2927.70","3081.45","21","495.52","1071.21","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2497.00","1872.75","WELLSENSE [1003]","HB BWH MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2553.75","2553.75","3017.32","1 through 10","495.52","1071.21","other","OPPS APC"
"Emg Anal/Urethral Sphincter","PX-76001271","CDM","51784","CPT","0761","RC","","","","both","","","1222.00","916.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","971.49","79.5","","932.60","932.60","932.60","1 through 10","176.52","971.49","percent of total billed charges",""
"Emg Anal/Urethral Sphincter","PX-76001271","CDM","51784","CPT","0761","RC","","","","both","","","1222.00","916.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","651.33","53.3","","625.68","625.68","625.68","1 through 10","176.52","971.49","percent of total billed charges",""
"Emg Anal/Urethral Sphincter","PX-76001271","CDM","51784","CPT","0761","RC","","","","both","","","1222.00","916.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","794.30","65","","770.25","628.05","770.25","1 through 10","176.52","971.49","percent of total billed charges",""
"Emg Anal/Urethral Sphincter","PX-76001271","CDM","51784","CPT","0761","RC","","","","both","","","1222.00","916.50","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","971.49","other","OPPS APC"
"Emg Anal/Urethral Sphincter","PX-76001271","CDM","51784","CPT","0761","RC","","","","both","","","1222.00","916.50","WELLPOINT [1015]","HB AMC WELLPOINT","901.59","73.78","","882.23","882.23","882.23","1 through 10","176.52","971.49","percent of total billed charges",""
"Emg Anal/Urethral Sphincter","PX-76001271","CDM","51784","CPT","0761","RC","","","","outpatient","","","1222.00","916.50","AETNA [1001]","HB AMC AETNA HMO","852.96","69.8","","484.97","484.97","484.97","1 through 10","155.47","998.62","percent of total billed charges",""
"Emg Anal/Urethral Sphincter","PX-76001271","CDM","51784","CPT","0761","RC","","","","outpatient","","","1222.00","916.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","155.47","","Case rate ($155.47). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","156.17","156.17","159.05","11","155.47","998.62","other","ASC"
"Emg Anal/Urethral Sphincter","PX-76001271","CDM","51784","CPT","0761","RC","","","","outpatient","","","1222.00","916.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","155.47","","Case rate ($155.47). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","180.19","180.19","181.98","20","155.47","998.62","other","ASC "
"Emg Anal/Urethral Sphincter","PX-76001271","CDM","51784","CPT","0761","RC","","","","outpatient","","","1222.00","916.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","982.49","80.4","","924.30","592.50","924.30","1 through 10","155.47","998.62","percent of total billed charges",""
"Emg Anal/Urethral Sphincter","PX-76001271","CDM","51784","CPT","0761","RC","","","","outpatient","","","1222.00","916.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","998.62","81.72","","947.29","947.29","947.29","1 through 10","155.47","998.62","percent of total billed charges",""
"Emg Cranial Nerve Bilat","PX-92000058","CDM","95868","CPT","0922","RC","","","","both","","","798.00","598.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","634.41","79.5","","583.60","583.60","583.60","1 through 10","247.38","634.41","percent of total billed charges",""
"Emg Cranial Nerve Bilat","PX-92000058","CDM","95868","CPT","0922","RC","","","","both","","","798.00","598.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","425.33","53.3","","566.25","408.67","566.25","1 through 10","247.38","634.41","percent of total billed charges",""
"Emg Cranial Nerve Bilat","PX-92000058","CDM","95868","CPT","0922","RC","","","","both","","","798.00","598.50","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","330.03","330.03","330.03","1 through 10","247.38","634.41","other","OPPS APC"
"Emg Cranial Nerve Bilat","PX-92000058","CDM","95868","CPT","0922","RC","","","","both","","","798.00","598.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","291.27","36.5","","280.19","280.19","280.19","1 through 10","247.38","634.41","percent of total billed charges",""
"Emg Cranial Nerve Bilat","PX-92000058","CDM","95868","CPT","0922","RC","","","","both","","","798.00","598.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","305.63","38.3","","302.63","294.12","302.63","1 through 10","247.38","634.41","percent of total billed charges",""
"Emg Cranial Nerve Bilat","PX-92000058","CDM","95868","CPT","0922","RC","","","","outpatient","","","798.00","598.50","AETNA [1001]","HB AMC AETNA HMO","557.00","69.8","","524.00","524.00","524.00","1 through 10","312.34","652.13","percent of total billed charges",""
"Emg Cranial Nerve Bilat","PX-92000058","CDM","95868","CPT","0922","RC","","","","outpatient","","","798.00","598.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","652.13","81.72","","618.74","340.33","618.74","1 through 10","312.34","652.13","percent of total billed charges",""
"Emg Cranial Nerve Unilat","PX-92000057","CDM","95867","CPT","0922","RC","","","","both","","","608.00","456.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","483.36","79.5","","464.33","311.52","464.33","1 through 10","188.48","519.72","percent of total billed charges",""
"Emg Cranial Nerve Unilat","PX-92000057","CDM","95867","CPT","0922","RC","","","","both","","","608.00","456.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","324.06","53.3","","464.33","464.33","464.33","1 through 10","188.48","519.72","percent of total billed charges",""
"Emg Cranial Nerve Unilat","PX-92000057","CDM","95867","CPT","0922","RC","","","","both","","","608.00","456.00","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","188.48","519.72","other","OPPS APC"
"Emg Cranial Nerve Unilat","PX-92000057","CDM","95867","CPT","0922","RC","","","","both","","","608.00","456.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","221.92","36.5","","220.07","187.03","220.07","1 through 10","188.48","519.72","percent of total billed charges",""
"Emg Cranial Nerve Unilat","PX-92000057","CDM","95867","CPT","0922","RC","","","","both","","","608.00","456.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","232.86","38.3","","230.69","224.20","230.69","1 through 10","188.48","519.72","percent of total billed charges",""
"Emg Cranial Nerve Unilat","PX-92000057","CDM","95867","CPT","0922","RC","","","","outpatient","","","608.00","456.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","496.86","81.72","","471.65","471.65","471.65","1 through 10","312.34","545.56","percent of total billed charges",""
"Emg Dynamic Surface 1-12 Muscles","PX-92000082","CDM","96002","CPT","0922","RC","","","","both","","","184.00","138.00","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","57.04","462.21","other","OPPS APC"
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","both","","","688.00","516.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","546.96","79.5","","524.93","352.18","524.93","19","213.28","546.96","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","both","","","688.00","516.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","366.70","53.3","","352.18","352.18","524.93","1 through 10","213.28","546.96","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","both","","","688.00","516.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","251.12","36.5","","248.79","241.45","248.79","25","213.28","546.96","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","both","","","688.00","516.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","263.50","38.3","","260.80","260.80","260.80","51","213.28","546.96","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","both","","","688.00","516.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","295.15","42.9","","293.28","293.28","293.28","1 through 10","213.28","546.96","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","both","","","688.00","516.00","WELLPOINT [1015]","HB AMC WELLPOINT","507.61","73.78","","496.58","496.58","1163.58","16","213.28","546.96","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","outpatient","","","688.00","516.00","AETNA [1001]","HB AMC AETNA HMO","480.22","69.8","","903.12","451.56","903.12","1 through 10","359.55","562.23","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Compl","PX-92000066","CDM","95886","CPT","0922","RC","","","","outpatient","","","688.00","516.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","562.23","81.72","","533.20","264.07","533.20","14","359.55","562.23","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","both","","","456.00","342.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","362.52","79.5","","347.85","233.38","347.86","22","141.36","362.52","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","both","","","456.00","342.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","243.05","53.3","","233.38","233.38","347.85","1 through 10","141.36","362.52","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","both","","","456.00","342.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.44","36.5","","164.87","140.11","164.87","1 through 10","141.36","362.52","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","both","","","456.00","342.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.65","38.3","","172.82","167.96","172.82","38","141.36","362.52","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","both","","","456.00","342.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","351.12","77","","442.00","442.00","442.00","1 through 10","141.36","362.52","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","both","","","456.00","342.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.62","42.9","","353.34","353.33","353.34","1 through 10","141.36","362.52","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","both","","","456.00","342.00","WELLPOINT [1015]","HB AMC WELLPOINT","336.44","73.78","","329.07","329.07","329.07","14","141.36","362.52","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","outpatient","","","456.00","342.00","AETNA [1001]","HB AMC AETNA HMO","318.29","69.8","","598.47","299.23","598.47","1 through 10","238.31","372.64","percent of total billed charges",""
"Emg Ea Extremity W/Nerve Cond Ltd","PX-92000065","CDM","95885","CPT","0922","RC","","","","outpatient","","","456.00","342.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","372.64","81.72","","353.33","194.35","353.34","13","238.31","372.64","percent of total billed charges",""
"Emg Needle W/Chemodenervation","PX-92000063","CDM","95874","CPT","0922","RC","","","","both","","","418.00","313.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","332.31","79.5","","318.74","318.74","318.74","1 through 10","129.58","332.31","percent of total billed charges",""
"Emg Needle W/Chemodenervation","PX-92000063","CDM","95874","CPT","0922","RC","","","","both","","","418.00","313.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","222.79","53.3","","318.74","318.74","318.74","1 through 10","129.58","332.31","percent of total billed charges",""
"Emg Needle W/Chemodenervation","PX-92000063","CDM","95874","CPT","0922","RC","","","","both","","","418.00","313.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","152.57","36.5","","151.07","128.39","151.07","1 through 10","129.58","332.31","percent of total billed charges",""
"Emg Needle W/Chemodenervation","PX-92000063","CDM","95874","CPT","0922","RC","","","","both","","","418.00","313.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","160.09","38.3","","158.36","153.90","158.36","1 through 10","129.58","332.31","percent of total billed charges",""
"Emg Needle W/Chemodenervation","PX-92000063","CDM","95874","CPT","0922","RC","","","","both","","","418.00","313.50","WELLPOINT [1015]","HB AMC WELLPOINT","308.40","73.78","","301.52","301.52","301.52","16","129.58","332.31","percent of total billed charges",""
"Emg Needle W/Chemodenervation","PX-92000063","CDM","95874","CPT","0922","RC","","","","outpatient","","","418.00","313.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","336.07","80.4","","315.90","315.90","315.90","1 through 10","218.45","341.59","percent of total billed charges",""
"Emg Needle W/Chemodenervation","PX-92000063","CDM","95874","CPT","0922","RC","","","","outpatient","","","418.00","313.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","341.59","81.72","","323.76","178.08","323.76","1 through 10","218.45","341.59","percent of total billed charges",""
"Emg Non-Extremity W/Nerve Conduct","PX-92000067","CDM","95887","CPT","0922","RC","","","","both","","","631.00","473.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","501.65","79.5","","481.64","323.14","481.64","1 through 10","195.61","501.65","percent of total billed charges",""
"Emg Non-Extremity W/Nerve Conduct","PX-92000067","CDM","95887","CPT","0922","RC","","","","both","","","631.00","473.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","241.67","38.3","","239.29","239.29","239.29","1 through 10","195.61","501.65","percent of total billed charges",""
"Emg Non-Extremity W/Nerve Conduct","PX-92000067","CDM","95887","CPT","0922","RC","","","","both","","","631.00","473.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","270.70","42.9","","489.23","489.23","489.23","1 through 10","195.61","501.65","percent of total billed charges",""
"Emg Thoracic Paraspinal","PX-92000059","CDM","95869","CPT","0922","RC","","","","both","","","430.00","322.50","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","342.57","342.57","369.81","1 through 10","133.3","462.21","other","OPPS APC"
"Emg Thoracic Paraspinal","PX-92000059","CDM","95869","CPT","0922","RC","","","","both","","","430.00","322.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.62","362.62","362.62","1 through 10","133.3","462.21","other","OPPS APC"
"Emg Thoracic Paraspinal","PX-92000059","CDM","95869","CPT","0922","RC","","","","outpatient","","","430.00","322.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","351.40","81.72","","333.35","333.35","333.35","1 through 10","224.72","520.69","percent of total billed charges",""
"ENDCAP 20MM 8 DEG","SUP-ITM-10260024","CDM","C1889","HCPCS","0278","RC","","","","both","","","2047.50","1535.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1627.76","79.5","","1309.77","674.56","6049.93","26","634.73","1627.76","percent of total billed charges",""
"ENDCAP 20MM 8 DEG","SUP-ITM-10260024","CDM","C1889","HCPCS","0278","RC","","","","both","","","2047.50","1535.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1091.32","53.3","","1901.83","1901.83","2962.25","1 through 10","634.73","1627.76","percent of total billed charges",""
"ENDCAP 20MM 8 DEG","SUP-ITM-10260024","CDM","C1889","HCPCS","0278","RC","","","","both","","","2047.50","1535.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","747.34","36.5","","1620.31","1620.31","19908.88","1 through 10","634.73","1627.76","percent of total billed charges",""
"ENDCAP 20MM 8 DEG","SUP-ITM-10260024","CDM","C1889","HCPCS","0278","RC","","","","both","","","2047.50","1535.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","784.19","38.3","","352.91","352.91","2046.30","1 through 10","634.73","1627.76","percent of total billed charges",""
"ENDCAP 20MM 8 DEG","SUP-ITM-10260024","CDM","C1889","HCPCS","0278","RC","","","","both","","","2047.50","1535.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","878.38","42.9","","9668.75","9668.75","9668.75","1 through 10","634.73","1627.76","percent of total billed charges",""
"ENDCAP 20MM 8 DEG","SUP-ITM-10260024","CDM","C1889","HCPCS","0278","RC","","","","both","","","2047.50","1535.62","WELLPOINT [1015]","HB AMC WELLPOINT","1510.65","73.78","","699.88","384.10","3443.31","33","634.73","1627.76","percent of total billed charges",""
"ENDCAP 20MM 8 DEG","SUP-ITM-10260024","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2047.50","1535.62","AETNA [1001]","HB AMC AETNA HMO","1429.16","69.8","","1421.24","264.50","4933.46","29","1070.02","1673.22","percent of total billed charges",""
"ENDCAP 20MM 8 DEG","SUP-ITM-10260024","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2047.50","1535.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1646.19","80.4","","1022.97","1022.97","3607.50","1 through 10","1070.02","1673.22","percent of total billed charges",""
"ENDCAP 20MM 8 DEG","SUP-ITM-10260024","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2047.50","1535.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1673.22","81.72","","3010.54","693.88","5019.88","35","1070.02","1673.22","percent of total billed charges",""
"ENDCAP BONE 15MM NAIL","SUP-ITM-10017848","CDM","C1889","HCPCS","0278","RC","","","","both","","","584.01","438.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","464.29","79.5","","1309.77","674.56","6049.93","26","181.04","464.29","percent of total billed charges",""
"ENDCAP BONE 15MM NAIL","SUP-ITM-10017848","CDM","C1889","HCPCS","0278","RC","","","","both","","","584.01","438.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","311.28","53.3","","1901.83","1901.83","2962.25","1 through 10","181.04","464.29","percent of total billed charges",""
"ENDCAP BONE 15MM NAIL","SUP-ITM-10017848","CDM","C1889","HCPCS","0278","RC","","","","both","","","584.01","438.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","213.16","36.5","","1620.31","1620.31","19908.88","1 through 10","181.04","464.29","percent of total billed charges",""
"ENDCAP BONE 15MM NAIL","SUP-ITM-10017848","CDM","C1889","HCPCS","0278","RC","","","","both","","","584.01","438.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","223.68","38.3","","352.91","352.91","2046.30","1 through 10","181.04","464.29","percent of total billed charges",""
"ENDCAP BONE 15MM NAIL","SUP-ITM-10017848","CDM","C1889","HCPCS","0278","RC","","","","both","","","584.01","438.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.54","42.9","","9668.75","9668.75","9668.75","1 through 10","181.04","464.29","percent of total billed charges",""
"ENDCAP BONE 15MM NAIL","SUP-ITM-10017848","CDM","C1889","HCPCS","0278","RC","","","","both","","","584.01","438.01","WELLPOINT [1015]","HB AMC WELLPOINT","430.88","73.78","","699.88","384.10","3443.31","33","181.04","464.29","percent of total billed charges",""
"ENDCAP BONE 15MM NAIL","SUP-ITM-10017848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","584.01","438.01","AETNA [1001]","HB AMC AETNA HMO","407.64","69.8","","1421.24","264.50","4933.46","29","305.2","477.25","percent of total billed charges",""
"ENDCAP BONE 15MM NAIL","SUP-ITM-10017848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","584.01","438.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","469.54","80.4","","1022.97","1022.97","3607.50","1 through 10","305.2","477.25","percent of total billed charges",""
"ENDCAP BONE 15MM NAIL","SUP-ITM-10017848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","584.01","438.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","477.25","81.72","","3010.54","693.88","5019.88","35","305.2","477.25","percent of total billed charges",""
"ENDCAP CAP 0.0MM END BONE NAIL FEMORAL T40 STARDRIVE TI EXT","SUP-ITM-10020725","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","446.81","79.5","","800.18","480.96","1887.97","195","174.23","446.81","percent of total billed charges",""
"ENDCAP CAP 0.0MM END BONE NAIL FEMORAL T40 STARDRIVE TI EXT","SUP-ITM-10020725","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","299.56","53.3","","813.12","216.42","1444.50","81","174.23","446.81","percent of total billed charges",""
"ENDCAP CAP 0.0MM END BONE NAIL FEMORAL T40 STARDRIVE TI EXT","SUP-ITM-10020725","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","174.23","31","","432.60","432.60","432.60","1 through 10","174.23","446.81","percent of total billed charges",""
"ENDCAP CAP 0.0MM END BONE NAIL FEMORAL T40 STARDRIVE TI EXT","SUP-ITM-10020725","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","205.14","36.5","","148.37","54.89","631.39","94","174.23","446.81","percent of total billed charges",""
"ENDCAP CAP 0.0MM END BONE NAIL FEMORAL T40 STARDRIVE TI EXT","SUP-ITM-10020725","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","215.26","38.3","","279.30","91.72","1116.77","266","174.23","446.81","percent of total billed charges",""
"ENDCAP CAP 0.0MM END BONE NAIL FEMORAL T40 STARDRIVE TI EXT","SUP-ITM-10020725","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","241.11","42.9","","731.00","63.70","731.00","1 through 10","174.23","446.81","percent of total billed charges",""
"ENDCAP CAP 0.0MM END BONE NAIL FEMORAL T40 STARDRIVE TI EXT","SUP-ITM-10020725","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","241.11","42.9","","384.74","384.74","384.74","1 through 10","174.23","446.81","percent of total billed charges",""
"ENDCAP CAP 0.0MM END BONE NAIL FEMORAL T40 STARDRIVE TI EXT","SUP-ITM-10020725","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","WELLPOINT [1015]","HB AMC WELLPOINT","414.67","73.78","","286.63","119.22","1107.45","105","174.23","446.81","percent of total billed charges",""
"ENDCAP CAP 0.0MM END BONE NAIL FEMORAL T40 STARDRIVE TI EXT","SUP-ITM-10020725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","AETNA [1001]","HB AMC AETNA HMO","392.30","69.8","","675.31","184.75","1721.50","286","293.72","459.29","percent of total billed charges",""
"ENDCAP CAP 0.0MM END BONE NAIL FEMORAL T40 STARDRIVE TI EXT","SUP-ITM-10020725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","AETNA [1001]","HB AMC AETNA PPO","451.87","80.4","","1261.44","103.12","1514.10","21","293.72","459.29","percent of total billed charges",""
"ENDCAP CAP 0.0MM END BONE NAIL FEMORAL T40 STARDRIVE TI EXT","SUP-ITM-10020725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","451.87","80.4","","1365.00","1365.00","1365.00","1 through 10","293.72","459.29","percent of total billed charges",""
"ENDCAP CAP 0.0MM END BONE NAIL FEMORAL T40 STARDRIVE TI EXT","SUP-ITM-10020725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","459.29","81.72","","5157.68","5157.68","5157.68","1 through 10","293.72","459.29","percent of total billed charges",""
"ENDCAP CAP 0.0MM END BONE NAIL FEMORAL T40 STARDRIVE TI EXT","SUP-ITM-10020725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","459.29","81.72","","431.26","71.26","1459.57","88","293.72","459.29","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","451.97","79.5","","800.18","480.96","1887.97","195","176.24","451.97","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","303.02","53.3","","813.12","216.42","1444.50","81","176.24","451.97","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","176.24","31","","432.60","432.60","432.60","1 through 10","176.24","451.97","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","207.51","36.5","","148.37","54.89","631.39","94","176.24","451.97","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","217.74","38.3","","279.30","91.72","1116.77","266","176.24","451.97","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","243.89","42.9","","731.00","63.70","731.00","1 through 10","176.24","451.97","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","243.89","42.9","","384.74","384.74","384.74","1 through 10","176.24","451.97","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.51","426.38","WELLPOINT [1015]","HB AMC WELLPOINT","419.45","73.78","","286.63","119.22","1107.45","105","176.24","451.97","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.51","426.38","AETNA [1001]","HB AMC AETNA HMO","396.82","69.8","","675.31","184.75","1721.50","286","297.1","464.59","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.51","426.38","AETNA [1001]","HB AMC AETNA PPO","457.08","80.4","","1261.44","103.12","1514.10","21","297.1","464.59","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.51","426.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","457.08","80.4","","1365.00","1365.00","1365.00","1 through 10","297.1","464.59","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.51","426.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","464.59","81.72","","5157.68","5157.68","5157.68","1 through 10","297.1","464.59","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.51","426.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","464.59","81.72","","431.26","71.26","1459.57","88","297.1","464.59","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 0DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10020893","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2114.70","79.5","","1309.77","674.56","6049.93","26","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 0DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10020893","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1417.78","53.3","","1901.83","1901.83","2962.25","1 through 10","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 0DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10020893","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","970.90","36.5","","1620.31","1620.31","19908.88","1 through 10","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 0DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10020893","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1018.78","38.3","","352.91","352.91","2046.30","1 through 10","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 0DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10020893","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1141.14","42.9","","9668.75","9668.75","9668.75","1 through 10","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 0DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10020893","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","WELLPOINT [1015]","HB AMC WELLPOINT","1962.55","73.78","","699.88","384.10","3443.31","33","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 0DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10020893","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2660.00","1995.00","AETNA [1001]","HB AMC AETNA HMO","1856.68","69.8","","1421.24","264.50","4933.46","29","1390.12","2173.75","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 0DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10020893","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2660.00","1995.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2138.64","80.4","","1022.97","1022.97","3607.50","1 through 10","1390.12","2173.75","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 0DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10020893","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2660.00","1995.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2173.75","81.72","","3010.54","693.88","5019.88","35","1390.12","2173.75","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 8DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10021351","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2114.70","79.5","","1309.77","674.56","6049.93","26","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 8DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10021351","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1417.78","53.3","","1901.83","1901.83","2962.25","1 through 10","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 8DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10021351","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","970.90","36.5","","1620.31","1620.31","19908.88","1 through 10","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 8DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10021351","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1018.78","38.3","","352.91","352.91","2046.30","1 through 10","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 8DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10021351","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1141.14","42.9","","9668.75","9668.75","9668.75","1 through 10","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 8DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10021351","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","WELLPOINT [1015]","HB AMC WELLPOINT","1962.55","73.78","","699.88","384.10","3443.31","33","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 8DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10021351","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2660.00","1995.00","AETNA [1001]","HB AMC AETNA HMO","1856.68","69.8","","1421.24","264.50","4933.46","29","1390.12","2173.75","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 8DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10021351","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2660.00","1995.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2138.64","80.4","","1022.97","1022.97","3607.50","1 through 10","1390.12","2173.75","percent of total billed charges",""
"ENDCAP CAP 18MM DIA 8DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10021351","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2660.00","1995.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2173.75","81.72","","3010.54","693.88","5019.88","35","1390.12","2173.75","percent of total billed charges",""
"ENDCAP CAP 22MM DIA 3DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10022272","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2114.70","79.5","","1309.77","674.56","6049.93","26","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 22MM DIA 3DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10022272","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1417.78","53.3","","1901.83","1901.83","2962.25","1 through 10","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 22MM DIA 3DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10022272","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","970.90","36.5","","1620.31","1620.31","19908.88","1 through 10","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 22MM DIA 3DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10022272","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1018.78","38.3","","352.91","352.91","2046.30","1 through 10","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 22MM DIA 3DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10022272","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1141.14","42.9","","9668.75","9668.75","9668.75","1 through 10","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 22MM DIA 3DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10022272","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","WELLPOINT [1015]","HB AMC WELLPOINT","1962.55","73.78","","699.88","384.10","3443.31","33","824.6","2114.7","percent of total billed charges",""
"ENDCAP CAP 22MM DIA 3DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10022272","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2660.00","1995.00","AETNA [1001]","HB AMC AETNA HMO","1856.68","69.8","","1421.24","264.50","4933.46","29","1390.12","2173.75","percent of total billed charges",""
"ENDCAP CAP 22MM DIA 3DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10022272","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2660.00","1995.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2138.64","80.4","","1022.97","1022.97","3607.50","1 through 10","1390.12","2173.75","percent of total billed charges",""
"ENDCAP CAP 22MM DIA 3DEG END SPINAL FUSION INTERBODY STANDARD TITANIUM VLIFT","SUP-ITM-10022272","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2660.00","1995.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2173.75","81.72","","3010.54","693.88","5019.88","35","1390.12","2173.75","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM RETROGRADE T40 STARDRIVE RECESS SPIRAL BLADE","SUP-ITM-10020761","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.99","371.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","394.31","79.5","","800.18","480.96","1887.97","195","153.76","394.31","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM RETROGRADE T40 STARDRIVE RECESS SPIRAL BLADE","SUP-ITM-10020761","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.99","371.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","264.36","53.3","","813.12","216.42","1444.50","81","153.76","394.31","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM RETROGRADE T40 STARDRIVE RECESS SPIRAL BLADE","SUP-ITM-10020761","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.99","371.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","153.76","31","","432.60","432.60","432.60","1 through 10","153.76","394.31","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM RETROGRADE T40 STARDRIVE RECESS SPIRAL BLADE","SUP-ITM-10020761","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.99","371.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","181.04","36.5","","148.37","54.89","631.39","94","153.76","394.31","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM RETROGRADE T40 STARDRIVE RECESS SPIRAL BLADE","SUP-ITM-10020761","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.99","371.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","189.96","38.3","","279.30","91.72","1116.77","266","153.76","394.31","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM RETROGRADE T40 STARDRIVE RECESS SPIRAL BLADE","SUP-ITM-10020761","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.99","371.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.78","42.9","","731.00","63.70","731.00","1 through 10","153.76","394.31","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM RETROGRADE T40 STARDRIVE RECESS SPIRAL BLADE","SUP-ITM-10020761","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.99","371.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.78","42.9","","384.74","384.74","384.74","1 through 10","153.76","394.31","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM RETROGRADE T40 STARDRIVE RECESS SPIRAL BLADE","SUP-ITM-10020761","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.99","371.99","WELLPOINT [1015]","HB AMC WELLPOINT","365.94","73.78","","286.63","119.22","1107.45","105","153.76","394.31","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM RETROGRADE T40 STARDRIVE RECESS SPIRAL BLADE","SUP-ITM-10020761","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.99","371.99","AETNA [1001]","HB AMC AETNA HMO","346.20","69.8","","675.31","184.75","1721.50","286","259.2","405.32","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM RETROGRADE T40 STARDRIVE RECESS SPIRAL BLADE","SUP-ITM-10020761","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.99","371.99","AETNA [1001]","HB AMC AETNA PPO","398.78","80.4","","1261.44","103.12","1514.10","21","259.2","405.32","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM RETROGRADE T40 STARDRIVE RECESS SPIRAL BLADE","SUP-ITM-10020761","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.99","371.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","398.78","80.4","","1365.00","1365.00","1365.00","1 through 10","259.2","405.32","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM RETROGRADE T40 STARDRIVE RECESS SPIRAL BLADE","SUP-ITM-10020761","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.99","371.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","405.32","81.72","","5157.68","5157.68","5157.68","1 through 10","259.2","405.32","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM RETROGRADE T40 STARDRIVE RECESS SPIRAL BLADE","SUP-ITM-10020761","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.99","371.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","405.32","81.72","","431.26","71.26","1459.57","88","259.2","405.32","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 5MMEXTENSION T40 STARDRIVE HEAD","SUP-ITM-10020726","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","446.81","79.5","","800.18","480.96","1887.97","195","174.23","446.81","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 5MMEXTENSION T40 STARDRIVE HEAD","SUP-ITM-10020726","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","299.56","53.3","","813.12","216.42","1444.50","81","174.23","446.81","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 5MMEXTENSION T40 STARDRIVE HEAD","SUP-ITM-10020726","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","174.23","31","","432.60","432.60","432.60","1 through 10","174.23","446.81","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 5MMEXTENSION T40 STARDRIVE HEAD","SUP-ITM-10020726","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","205.14","36.5","","148.37","54.89","631.39","94","174.23","446.81","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 5MMEXTENSION T40 STARDRIVE HEAD","SUP-ITM-10020726","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","215.26","38.3","","279.30","91.72","1116.77","266","174.23","446.81","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 5MMEXTENSION T40 STARDRIVE HEAD","SUP-ITM-10020726","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","241.11","42.9","","731.00","63.70","731.00","1 through 10","174.23","446.81","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 5MMEXTENSION T40 STARDRIVE HEAD","SUP-ITM-10020726","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","241.11","42.9","","384.74","384.74","384.74","1 through 10","174.23","446.81","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 5MMEXTENSION T40 STARDRIVE HEAD","SUP-ITM-10020726","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","WELLPOINT [1015]","HB AMC WELLPOINT","414.67","73.78","","286.63","119.22","1107.45","105","174.23","446.81","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 5MMEXTENSION T40 STARDRIVE HEAD","SUP-ITM-10020726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","AETNA [1001]","HB AMC AETNA HMO","392.30","69.8","","675.31","184.75","1721.50","286","293.72","459.29","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 5MMEXTENSION T40 STARDRIVE HEAD","SUP-ITM-10020726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","AETNA [1001]","HB AMC AETNA PPO","451.87","80.4","","1261.44","103.12","1514.10","21","293.72","459.29","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 5MMEXTENSION T40 STARDRIVE HEAD","SUP-ITM-10020726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","451.87","80.4","","1365.00","1365.00","1365.00","1 through 10","293.72","459.29","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 5MMEXTENSION T40 STARDRIVE HEAD","SUP-ITM-10020726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","459.29","81.72","","5157.68","5157.68","5157.68","1 through 10","293.72","459.29","percent of total billed charges",""
"ENDCAP FEMORAL 9-12MM NAIL EX TITANIUM CANNULATED 5MMEXTENSION T40 STARDRIVE HEAD","SUP-ITM-10020726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","459.29","81.72","","431.26","71.26","1459.57","88","293.72","459.29","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","541.53","79.5","","800.18","480.96","1887.97","195","211.16","541.53","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","363.06","53.3","","813.12","216.42","1444.50","81","211.16","541.53","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","211.16","31","","432.60","432.60","432.60","1 through 10","211.16","541.53","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","248.63","36.5","","148.37","54.89","631.39","94","211.16","541.53","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","260.89","38.3","","279.30","91.72","1116.77","266","211.16","541.53","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.22","42.9","","731.00","63.70","731.00","1 through 10","211.16","541.53","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.22","42.9","","384.74","384.74","384.74","1 through 10","211.16","541.53","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.17","510.88","WELLPOINT [1015]","HB AMC WELLPOINT","502.57","73.78","","286.63","119.22","1107.45","105","211.16","541.53","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.17","510.88","AETNA [1001]","HB AMC AETNA HMO","475.46","69.8","","675.31","184.75","1721.50","286","355.98","556.65","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.17","510.88","AETNA [1001]","HB AMC AETNA PPO","547.66","80.4","","1261.44","103.12","1514.10","21","355.98","556.65","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.17","510.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","547.66","80.4","","1365.00","1365.00","1365.00","1 through 10","355.98","556.65","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.17","510.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","556.65","81.72","","5157.68","5157.68","5157.68","1 through 10","355.98","556.65","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.17","510.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","556.65","81.72","","431.26","71.26","1459.57","88","355.98","556.65","percent of total billed charges",""
"ENDCAP NAIL 0MM BONE TI CANNULATED TROCHANTERIC FIXATION NO EXTENSION","SUP-ITM-10009644","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","376.81","79.5","","800.18","480.96","1887.97","195","146.93","376.81","percent of total billed charges",""
"ENDCAP NAIL 0MM BONE TI CANNULATED TROCHANTERIC FIXATION NO EXTENSION","SUP-ITM-10009644","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","252.63","53.3","","813.12","216.42","1444.50","81","146.93","376.81","percent of total billed charges",""
"ENDCAP NAIL 0MM BONE TI CANNULATED TROCHANTERIC FIXATION NO EXTENSION","SUP-ITM-10009644","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","146.93","31","","432.60","432.60","432.60","1 through 10","146.93","376.81","percent of total billed charges",""
"ENDCAP NAIL 0MM BONE TI CANNULATED TROCHANTERIC FIXATION NO EXTENSION","SUP-ITM-10009644","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","173.00","36.5","","148.37","54.89","631.39","94","146.93","376.81","percent of total billed charges",""
"ENDCAP NAIL 0MM BONE TI CANNULATED TROCHANTERIC FIXATION NO EXTENSION","SUP-ITM-10009644","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","181.53","38.3","","279.30","91.72","1116.77","266","146.93","376.81","percent of total billed charges",""
"ENDCAP NAIL 0MM BONE TI CANNULATED TROCHANTERIC FIXATION NO EXTENSION","SUP-ITM-10009644","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","203.33","42.9","","731.00","63.70","731.00","1 through 10","146.93","376.81","percent of total billed charges",""
"ENDCAP NAIL 0MM BONE TI CANNULATED TROCHANTERIC FIXATION NO EXTENSION","SUP-ITM-10009644","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","203.33","42.9","","384.74","384.74","384.74","1 through 10","146.93","376.81","percent of total billed charges",""
"ENDCAP NAIL 0MM BONE TI CANNULATED TROCHANTERIC FIXATION NO EXTENSION","SUP-ITM-10009644","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","WELLPOINT [1015]","HB AMC WELLPOINT","349.70","73.78","","286.63","119.22","1107.45","105","146.93","376.81","percent of total billed charges",""
"ENDCAP NAIL 0MM BONE TI CANNULATED TROCHANTERIC FIXATION NO EXTENSION","SUP-ITM-10009644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.97","355.48","AETNA [1001]","HB AMC AETNA HMO","330.83","69.8","","675.31","184.75","1721.50","286","247.7","387.33","percent of total billed charges",""
"ENDCAP NAIL 0MM BONE TI CANNULATED TROCHANTERIC FIXATION NO EXTENSION","SUP-ITM-10009644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.97","355.48","AETNA [1001]","HB AMC AETNA PPO","381.07","80.4","","1261.44","103.12","1514.10","21","247.7","387.33","percent of total billed charges",""
"ENDCAP NAIL 0MM BONE TI CANNULATED TROCHANTERIC FIXATION NO EXTENSION","SUP-ITM-10009644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.97","355.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","381.07","80.4","","1365.00","1365.00","1365.00","1 through 10","247.7","387.33","percent of total billed charges",""
"ENDCAP NAIL 0MM BONE TI CANNULATED TROCHANTERIC FIXATION NO EXTENSION","SUP-ITM-10009644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.97","355.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","387.33","81.72","","5157.68","5157.68","5157.68","1 through 10","247.7","387.33","percent of total billed charges",""
"ENDCAP NAIL 0MM BONE TI CANNULATED TROCHANTERIC FIXATION NO EXTENSION","SUP-ITM-10009644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.97","355.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","387.33","81.72","","431.26","71.26","1459.57","88","247.7","387.33","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","798.35","79.5","","800.18","480.96","1887.97","195","311.31","798.35","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","535.25","53.3","","813.12","216.42","1444.50","81","311.31","798.35","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","311.31","31","","432.60","432.60","432.60","1 through 10","311.31","798.35","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","366.54","36.5","","148.37","54.89","631.39","94","311.31","798.35","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","384.62","38.3","","279.30","91.72","1116.77","266","311.31","798.35","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","430.81","42.9","","731.00","63.70","731.00","1 through 10","311.31","798.35","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","430.81","42.9","","384.74","384.74","384.74","1 through 10","311.31","798.35","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.22","753.16","WELLPOINT [1015]","HB AMC WELLPOINT","740.91","73.78","","286.63","119.22","1107.45","105","311.31","798.35","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.22","753.16","AETNA [1001]","HB AMC AETNA HMO","700.95","69.8","","675.31","184.75","1721.50","286","524.81","820.65","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.22","753.16","AETNA [1001]","HB AMC AETNA PPO","807.39","80.4","","1261.44","103.12","1514.10","21","524.81","820.65","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.22","753.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","807.39","80.4","","1365.00","1365.00","1365.00","1 through 10","524.81","820.65","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.22","753.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","820.65","81.72","","5157.68","5157.68","5157.68","1 through 10","524.81","820.65","percent of total billed charges",""
"ENDCAP NAIL 15MM T2 TITANIUM TIBIAL STANDARD","SUP-ITM-10028290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.22","753.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","820.65","81.72","","431.26","71.26","1459.57","88","524.81","820.65","percent of total billed charges",""
"Endo Biliary Rem Calculus/Calculi","PX-75000254","CDM","47554","CPT","0750","RC","","","","both","","","6229.00","4671.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","12362.70","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12140.83","12140.83","12140.83","1 through 10","1930.99","15453.37","other","OPPS APC"
"Endo Biliary Rem Calculus/Calculi","PX-75000254","CDM","47554","CPT","0750","RC","","","","both","","","6229.00","4671.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2273.59","36.5","","2253.29","2253.29","2253.29","1 through 10","1930.99","15453.37","percent of total billed charges",""
"Endo Biliary Rem Calculus/Calculi","PX-75000254","CDM","47554","CPT","0750","RC","","","","both","","","6229.00","4671.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12115.45","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","12116.68","12116.68","12124.58","1 through 10","1930.99","15453.37","other","OPPS APC"
"Endo Biliary Rem Calculus/Calculi","PX-75000254","CDM","47554","CPT","0750","RC","","","","outpatient","","","6229.00","4671.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5255.62","","Case rate ($5,255.62). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","12303.41","6151.71","12303.41","1 through 10","3255.28","8899.59","other","ASC "
"Endo Eval Small Intest Pouch","PX-75000155","CDM","44385","CPT","0750","RC","","","","both","","","2618.00","1963.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","1065.39","1065.39","1 through 10","811.58","2081.31","other","OPPS APC"
"Endo Eval Small Intest Pouch","PX-75000155","CDM","44385","CPT","0750","RC","","","","both","","","2618.00","1963.50","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","1 through 10","811.58","2081.31","other","OPPS APC"
"Endo Eval Small Intest Pouch","PX-75000155","CDM","44385","CPT","0750","RC","","","","both","","","2618.00","1963.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1002.69","38.3","","992.75","992.75","992.75","1 through 10","811.58","2081.31","percent of total billed charges",""
"Endo Eval Small Intest Pouch","PX-75000155","CDM","44385","CPT","0750","RC","","","","both","","","2618.00","1963.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","1061.06","1061.06","1 through 10","811.58","2081.31","other","OPPS APC"
"Endo Eval Small Intest Pouch","PX-75000155","CDM","44385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1994.11","997.06","1994.11","1 through 10","744.89","2384.07","other","ASC "
"Endo Eval Small Intest Pouch","PX-75000155","CDM","44385","CPT","0750","RC","","","","outpatient","","","2618.00","1963.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1817.53","1817.53","1817.53","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","both","","","2642.00","1981.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","532.70","1065.39","1 through 10","819.02","2100.39","other","OPPS APC"
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","both","","","2642.00","1981.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2100.39","79.5","","2016.29","2016.29","2016.29","1 through 10","819.02","2100.39","percent of total billed charges",""
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","both","","","2642.00","1981.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1408.19","53.3","","1352.74","1352.74","1352.74","1 through 10","819.02","2100.39","percent of total billed charges",""
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","both","","","2642.00","1981.50","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","13","819.02","2100.39","other","OPPS APC"
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","both","","","2642.00","1981.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","964.33","36.5","","2649.22","955.63","2649.22","1 through 10","819.02","2100.39","percent of total billed charges",""
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","both","","","2642.00","1981.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1011.89","38.3","","1001.74","1001.74","1001.74","1 through 10","819.02","2100.39","percent of total billed charges",""
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","both","","","2642.00","1981.50","TRICARE [160005]","HB BWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","947.63","947.63","947.63","1 through 10","819.02","2100.39","other","Tricare OPPS"
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","both","","","2642.00","1981.50","WELLSENSE NH [1050]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1069.72","1069.72","1069.72","1 through 10","819.02","2100.39","other","OPPS APC"
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","outpatient","","","2642.00","1981.50","AETNA [1001]","HB AMC AETNA HMO","1844.12","69.8","","1224.64","1224.64","1224.64","1 through 10","744.89","2384.07","percent of total billed charges",""
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","outpatient","","","2642.00","1981.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1711.31","855.66","1742.82","14","744.89","2384.07","other","ASC"
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","outpatient","","","2642.00","1981.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1974.52","1974.52","1994.11","23","744.89","2384.07","other","ASC "
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","outpatient","","","2642.00","1981.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2160.18","1039.12","2160.18","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","outpatient","","","2642.00","1981.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1728.14","1728.14","1728.14","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","outpatient","","","2642.00","1981.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1817.53","1817.53","1817.53","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","outpatient","","","2642.00","1981.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2159.04","81.72","","2048.06","1126.51","2048.06","1 through 10","744.89","2384.07","percent of total billed charges",""
"Endo Impl Material Urethr/Bldr Neck","PX-76001262","CDM","51715","CPT","0761","RC","","","","both","","","8829.00","6621.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3381.51","38.3","","4810.47","4810.47","4810.47","1 through 10","2736.99","7019.06","percent of total billed charges",""
"Endo Nasal/Sinus W/Bx/Polyp/Debr","PX-76000759","CDM","31237","CPT","0761","RC","","","","outpatient","","","4235.00","3176.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1572.91","1572.91","1572.91","1 through 10","1232.36","5545.35","other","ASC"
"Endo Nasal/Sinus W/Bx/Polyp/Debr|BILATERAL PROCEDURE","PX-76000759","CDM","31237","CPT","0761","RC","","","50","outpatient","","","4235.00","3176.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2348.79","","Case rate ($2,348.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","5444.50","5444.50","5444.50","1 through 10","2348.79","10314.36","other","ASC "
"Endo Nasal/Sinus W/Control Bleeding","PX-76000760","CDM","31238","CPT","0761","RC","","","","outpatient","","","4235.00","3176.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1577.42","1577.42","1577.42","1 through 10","1232.36","3460.84","other","Multiple Surgery"
"Endo Pancreatoscopy Dir Vis Panc","PX-75000120","CDM","43273","CPT","0750","RC","","","","both","","","981.00","735.75","WELLPOINT [1015]","HB AMC WELLPOINT","723.78","73.78","","708.01","708.01","708.01","1 through 10","304.11","779.9","percent of total billed charges",""
"Endo Pancreatoscopy Dir Vis Panc","PX-75000120","CDM","43273","CPT","0750","RC","","","","outpatient","","","981.00","735.75","AETNA [1001]","HB AMC AETNA HMO","684.74","69.8","","643.83","643.83","643.83","1 through 10","204.45","801.67","percent of total billed charges",""
"Endo Pancreatoscopy Dir Vis Panc","PX-75000120","CDM","43273","CPT","0750","RC","","","","outpatient","","","981.00","735.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","788.72","80.4","","741.78","741.78","741.78","1 through 10","204.45","801.67","percent of total billed charges",""
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","both","","","881.00","660.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","273.11","1391.62","other","OPPS APC"
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","both","","","881.00","660.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","273.11","1391.62","other","OPPS APC"
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","both","","","881.00","660.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","273.11","1391.62","other","OPPS APC"
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","both","","","881.00","660.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","273.11","1391.62","other","OPPS APC"
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","both","","","881.00","660.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","377.95","42.9","","1932.92","1932.92","1932.92","1 through 10","273.11","1391.62","percent of total billed charges",""
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","both","","","881.00","660.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","273.11","1391.62","other","OPPS APC"
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","both","","","881.00","660.75","WELLPOINT [1015]","HB AMC WELLPOINT","650.00","73.78","","2222.33","2222.33","2222.33","1 through 10","273.11","1391.62","percent of total billed charges",""
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","outpatient","","","881.00","660.75","AETNA [1001]","HB AMC AETNA HMO","614.94","69.8","","2238.60","2238.60","2238.60","1 through 10","440.5","8899.59","percent of total billed charges",""
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","outpatient","","","881.00","660.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","533.45","60.55","","3144.00","2870.00","3286.00","1 through 10","440.5","8899.59","percent of total billed charges",""
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","outpatient","","","881.00","660.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","460.41","52.26","","1775.96","1775.96","1775.96","1 through 10","440.5","8899.59","percent of total billed charges",""
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","outpatient","","","881.00","660.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","460.06","52.22","","3286.00","2018.70","5898.00","1 through 10","440.5","8899.59","percent of total billed charges",""
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","outpatient","","","881.00","660.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","462.53","52.5","","8340.00","8340.00","8340.00","1 through 10","440.5","8899.59","percent of total billed charges",""
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","outpatient","","","881.00","660.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","719.95","81.72","","2294.28","682.69","2294.28","1 through 10","440.5","8899.59","percent of total billed charges",""
"Endo Small Intest Ablation Tumor","PX-75000144","CDM","44369","CPT","0750","RC","","","","both","","","4294.00","3220.50","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2076.78","2076.78","2076.78","1 through 10","1331.14","3413.73","other","OPPS APC"
"Endo Small Intest Ablation Tumor","PX-75000144","CDM","44369","CPT","0750","RC","","","","both","","","4294.00","3220.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","957.72","957.72","957.72","1 through 10","1331.14","3413.73","other","OPPS APC"
"Endo Small Intest Ablation Tumor","PX-75000144","CDM","44369","CPT","0750","RC","","","","outpatient","","","4294.00","3220.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3470.63","3470.63","3470.63","1 through 10","1335.02","5545.35","other","ASC"
"Endo Small Intest Control Bleed","PX-75000143","CDM","44366","CPT","0750","RC","","","","both","","","4634.00","3475.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.24","2207.74","2215.64","1 through 10","1436.54","3684.03","other","OPPS APC"
"Endo Small Intest G-Tube to J-Tube","PX-75000147","CDM","44373","CPT","0750","RC","","","","both","","","4983.00","3737.25","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","1 through 10","1544.73","3961.49","other","OPPS APC"
"Endo Small Intest Rem Tumor Snare","PX-75000141","CDM","44364","CPT","0750","RC","","","","both","","","4381.00","3285.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2318.12","2318.12","2318.12","1 through 10","1358.11","3482.9","other","OPPS APC"
"Endo Small Intest Rem Tumor Snare","PX-75000141","CDM","44364","CPT","0750","RC","","","","both","","","4381.00","3285.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1599.07","36.5","","1346.62","1346.62","1346.62","1 through 10","1358.11","3482.9","percent of total billed charges",""
"Endo Small Intest Rem Tumor Snare","PX-75000141","CDM","44364","CPT","0750","RC","","","","both","","","4381.00","3285.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2207.74","2207.74","2207.74","1 through 10","1358.11","3482.9","other","OPPS APC"
"Endo Small Intest Rem Tumor Snare","PX-75000141","CDM","44364","CPT","0750","RC","","","","outpatient","","","4381.00","3285.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3470.63","3470.63","3470.63","1 through 10","1335.02","5545.35","other","ASC"
"Endo Small Intest Rem Tumor Snare","PX-75000141","CDM","44364","CPT","0750","RC","","","","outpatient","","","4381.00","3285.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7505.45","3971.04","7505.45","1 through 10","1335.02","5545.35","other","ASC "
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","both","","","3121.00","2340.75","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","967.51","2906.42","other","OPPS APC"
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","both","","","3121.00","2340.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1338.91","42.9","","2419.77","2419.77","2419.77","1 through 10","967.51","2906.42","percent of total billed charges",""
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","both","","","3121.00","2340.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1338.91","42.9","","2419.78","2419.78","2419.78","1 through 10","967.51","2906.42","percent of total billed charges",""
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","outpatient","","","3121.00","2340.75","AETNA [1001]","HB AMC AETNA HMO","2178.46","69.8","","1446.91","1446.91","2049.28","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","outpatient","","","3121.00","2340.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3470.63","3407.87","3470.63","1 through 10","1335.02","5545.35","other","ASC"
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","outpatient","","","3121.00","2340.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3971.04","3932.02","3971.04","1 through 10","1335.02","5545.35","other","ASC "
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","outpatient","","","3121.00","2340.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3097.25","3097.25","3097.25","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","outpatient","","","3121.00","2340.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3520.55","3520.55","3520.55","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","outpatient","","","3121.00","2340.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2550.48","81.72","","2419.78","2419.78","2419.78","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Endo Small Intest/Ilium Cntrl Bleed","PX-75000150","CDM","44378","CPT","0750","RC","","","","both","","","4381.00","3285.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1358.11","3482.9","other","OPPS APC"
"Endo Small Intest/Ilium Cntrl Bleed","PX-75000150","CDM","44378","CPT","0750","RC","","","","both","","","4381.00","3285.75","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1358.11","3482.9","other","OPPS APC"
"Endo Small Intest/Ilium Cntrl Bleed","PX-75000150","CDM","44378","CPT","0750","RC","","","","outpatient","","","4381.00","3285.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3470.63","3470.63","3470.63","1 through 10","1335.02","5545.35","other","ASC"
"Endo Small Intest/Ilium W/Biopsy","PX-75000149","CDM","44377","CPT","0750","RC","","","","both","","","4381.00","3285.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2327.58","2327.58","2327.58","1 through 10","1358.11","3482.9","other","OPPS APC"
"Endo Small Intest/Ilium W/Biopsy","PX-75000149","CDM","44377","CPT","0750","RC","","","","outpatient","","","4381.00","3285.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3470.63","3470.63","3470.63","1 through 10","1335.02","5545.35","other","ASC"
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","both","","","3050.00","2287.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2318.12","2318.12","2318.12","1 through 10","945.5","2906.42","other","OPPS APC"
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","both","","","3050.00","2287.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","945.5","2906.42","other","OPPS APC"
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","both","","","3050.00","2287.50","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","945.5","2906.42","other","OPPS APC"
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","outpatient","","","3050.00","2287.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3097.25","3097.25","3097.25","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","outpatient","","","3050.00","2287.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3257.45","3257.45","3257.45","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Endo Small Intestine W/Ilium","PX-75000148","CDM","44376","CPT","0750","RC","","","","both","","","2973.00","2229.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2324.02","2324.02","2324.02","1 through 10","921.63","2906.42","other","OPPS APC"
"Endo Small Intestine W/Ilium","PX-75000148","CDM","44376","CPT","0750","RC","","","","both","","","2973.00","2229.75","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","921.63","2906.42","other","OPPS APC"
"Endo Small Intestine W/Ilium","PX-75000148","CDM","44376","CPT","0750","RC","","","","outpatient","","","2973.00","2229.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3971.04","3971.04","3971.04","1 through 10","1335.02","2429.54","other","ASC "
"Endo Small Intestine W/Ilium","PX-75000148","CDM","44376","CPT","0750","RC","","","","outpatient","","","2973.00","2229.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2977.09","2977.09","2977.09","1 through 10","1335.02","2429.54","other","Multiple Surgery"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","43071.76","32303.82","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14792.55","","Case rate ($14,792.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,748.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,392.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,419.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,433.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,368.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.59. The transfer capital threshold is the transfer adjustment factor * $979.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9553.10","9553.07","9565.45","1 through 10","11255.39","15595.0394","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","43071.76","32303.82","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","11485.09","","Case rate ($11,485.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,748.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,392.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,419.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $10,125.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,368.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.59. The transfer capital threshold is the transfer adjustment factor * $979.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","99946.00","99946.00","99946.00","1 through 10","11255.39","15595.0394","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","43071.76","32303.82","ELDER SERVICES [1037]","HB BWH MEDICARE","14792.55","","Case rate ($14,792.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,748.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,392.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,419.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,433.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,368.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.59. The transfer capital threshold is the transfer adjustment factor * $979.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9760.24","9760.24","9760.24","1 through 10","11255.39","15595.0394","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","43071.76","32303.82","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","14792.55","","Case rate ($14,792.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,748.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,392.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,419.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,433.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,368.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.59. The transfer capital threshold is the transfer adjustment factor * $979.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9560.03","9560.03","9560.03","1 through 10","11255.39","15595.0394","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","43071.76","32303.82","MEDICARE [2001]","HB BWH MEDICARE","14792.55","","Case rate ($14,792.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,748.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,392.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,419.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,433.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,368.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.59. The transfer capital threshold is the transfer adjustment factor * $979.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12461.19","0.03","12461.19","30","11255.39","15595.0394","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","43071.76","32303.82","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11255.39","","Case rate ($11,485.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,748.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,392.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,419.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $10,125.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,368.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.59. The transfer capital threshold is the transfer adjustment factor * $979.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9560.73","9465.03","15135.57","1 through 10","11255.39","15595.0394","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","67537.56","50653.17","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15857.60","","Case rate ($15,395.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,456.02, add-ons for qualifying new technology services are included. If operating cost exceeds $64,100.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,764.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,691.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,076.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,324.55. The transfer capital threshold is the transfer adjustment factor * $1,324.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15876.23","15876.23","15876.23","1 through 10","15087.82","25784.51","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","67537.56","50653.17","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","19867.89","","Case rate ($19,867.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,456.02, add-ons for qualifying new technology services are included. If operating cost exceeds $64,100.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,764.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $18,163.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,076.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,324.55. The transfer capital threshold is the transfer adjustment factor * $1,324.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15155.31","15155.31","19549.69","1 through 10","15087.82","25784.51","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","67537.56","50653.17","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15395.73","","Case rate ($15,395.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,456.02, add-ons for qualifying new technology services are included. If operating cost exceeds $64,100.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,764.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,691.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,076.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,324.55. The transfer capital threshold is the transfer adjustment factor * $1,324.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15035.06","15035.06","15035.06","1 through 10","15087.82","25784.51","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","67537.56","50653.17","HUMANA [1012]","HB BWH MEDICARE","19867.89","","Case rate ($19,867.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,456.02, add-ons for qualifying new technology services are included. If operating cost exceeds $64,100.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,764.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $18,163.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,076.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,324.55. The transfer capital threshold is the transfer adjustment factor * $1,324.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15114.42","15114.42","15114.42","1 through 10","15087.82","25784.51","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","67537.56","50653.17","MEDICARE [2001]","HB BWH MEDICARE","19867.89","","Case rate ($19,867.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,456.02, add-ons for qualifying new technology services are included. If operating cost exceeds $64,100.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,764.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $18,163.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,076.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,324.55. The transfer capital threshold is the transfer adjustment factor * $1,324.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19816.45","19816.45","19845.68","37","15087.82","25784.51","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","67537.56","50653.17","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","15087.82","","Case rate ($15,395.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,456.02, add-ons for qualifying new technology services are included. If operating cost exceeds $64,100.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,764.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,691.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,076.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,324.55. The transfer capital threshold is the transfer adjustment factor * $1,324.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15124.60","15124.60","47711.96","1 through 10","15087.82","25784.51","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","67537.56","50653.17","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15087.82","","Case rate ($15,395.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,456.02, add-ons for qualifying new technology services are included. If operating cost exceeds $64,100.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,764.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,691.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,076.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,324.55. The transfer capital threshold is the transfer adjustment factor * $1,324.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15112.97","12105.96","122597.55","1 through 10","15087.82","25784.51","other","Inpatient DRG"
"Endocrine Disorders With McC","643","TRIS-DRG","","","","","","","","inpatient","","","100558.35","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","13939.04","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($24,484.71). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $4,996.88, and the first day is paid a rate of $9,993.76. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $4,996.88, and the first day is paid a rate of $9,993.76. The transfer payment is capped at $17,622.50. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $68,211.71 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 4.90000009536743). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: , capped at $17,622.50. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $4,996.88, and the first day is paid a rate of $9,993.76. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $4,996.88, and the first day is paid a rate of $9,993.76. The transfer payment is capped at $17,622.50. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $68,211.71 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 4.90000009536743). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","16553.99","16553.99","16553.99","1 through 10","13939.04","13939.04","other","Inpatient DRGs"
"Endocrine Disorders Without Cc/McC","645","MS-DRG","","","","","","","","inpatient","","","24175.98","18131.98","MEDICARE [2001]","HB BWH MEDICARE","7388.36","","Case rate ($7,388.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,816.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,461.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,058.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,390.29 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,436.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $618.22. The transfer capital threshold is the transfer adjustment factor * $618.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9458.50","9458.50","9458.50","1 through 10","7240.59","12034.65","other","Inpatient Replacement Plans DRG"
"Endometrial Biopsy W/Colposcopy","PX-76001378","CDM","58110","CPT","0761","RC","","","","both","","","273.00","204.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","217.04","79.5","","208.56","208.56","208.56","1 through 10","84.63","217.04","percent of total billed charges",""
"Endometrial Biopsy W/Colposcopy","PX-76001378","CDM","58110","CPT","0761","RC","","","","both","","","273.00","204.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","99.65","36.5","","84.01","84.01","84.01","1 through 10","84.63","217.04","percent of total billed charges",""
"Endometrial Biopsy W/Colposcopy","PX-76001378","CDM","58110","CPT","0761","RC","","","","both","","","273.00","204.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","104.56","38.3","","103.62","103.62","103.62","1 through 10","84.63","217.04","percent of total billed charges",""
"Endometrial Bx Conjunct W/Colposcopy","PX-98301135","CDM","58110","CPT","0983","RC","","","","both","","","174.00","130.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","138.33","79.5","","208.56","208.56","208.56","1 through 10","53.94","138.33","percent of total billed charges",""
"Endometrial Bx Conjunct W/Colposcopy","PX-98301135","CDM","58110","CPT","0983","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.51","36.5","","84.01","84.01","84.01","1 through 10","53.94","138.33","percent of total billed charges",""
"Endometrial Bx Conjunct W/Colposcopy","PX-98301135","CDM","58110","CPT","0983","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.64","38.3","","103.62","103.62","103.62","1 through 10","53.94","138.33","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","both","","","143.00","107.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","113.69","79.5","","328.17","139.00","328.17","1 through 10","11.85","135.85","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","both","","","143.00","107.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","76.22","53.3","","220.17","220.17","220.17","1 through 10","11.85","135.85","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","both","","","143.00","107.25","TRICARE [160005]","HB BWH TRICARE","135.85","95","","13.84","13.84","13.84","1 through 10","11.85","135.85","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","both","","","143.00","107.25","WELLPOINT [1015]","HB AMC WELLPOINT","105.51","73.78","","242.49","103.49","242.49","1 through 10","11.85","135.85","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","143.00","107.25","AETNA [1001]","HB AMC AETNA HMO","99.81","69.8","","94.10","88.43","94.10","1 through 10","35.62","117.98","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","71.50","50","","218.52","218.52","218.52","1 through 10","35.62","117.98","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","75.08","52.5","","229.35","76.45","229.35","1 through 10","35.62","117.98","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","75.08","52.5","","76.45","76.45","76.45","1 through 10","35.62","117.98","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","78.65","55","","80.06","64.91","80.06","1 through 10","35.62","117.98","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","116.86","81.72","","61.12","61.12","61.12","1 through 10","35.62","117.98","percent of total billed charges",""
"ENDOPROSTHESIS BRANCH 45MMX15CMX8MM THORACIC AORTIC GORE TAG","SUP-ITM-10317846","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","52000.00","65","","6652.80","6652.80","6652.80","1 through 10","24800","63600","percent of total billed charges",""
"ENDOPROSTHESIS BRANCH 45MMX15CMX8MM THORACIC AORTIC GORE TAG","SUP-ITM-10317846","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","63600.00","79.5","","2612.61","795.38","2612.61","1 through 10","24800","63600","percent of total billed charges",""
"ENDOPROSTHESIS BRANCH 45MMX15CMX8MM THORACIC AORTIC GORE TAG","SUP-ITM-10317846","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","42640.00","53.3","","1101.80","1101.80","1101.80","1 through 10","24800","63600","percent of total billed charges",""
"ENDOPROSTHESIS BRANCH 45MMX15CMX8MM THORACIC AORTIC GORE TAG","SUP-ITM-10317846","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","52000.00","65","","1820.00","910.00","1820.00","1 through 10","24800","63600","percent of total billed charges",""
"ENDOPROSTHESIS BRANCH 45MMX15CMX8MM THORACIC AORTIC GORE TAG","SUP-ITM-10317846","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29200.00","36.5","","1257.80","693.44","2424.50","1 through 10","24800","63600","percent of total billed charges",""
"ENDOPROSTHESIS BRANCH 45MMX15CMX8MM THORACIC AORTIC GORE TAG","SUP-ITM-10317846","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30640.00","38.3","","1950.11","547.40","2346.00","1 through 10","24800","63600","percent of total billed charges",""
"ENDOPROSTHESIS BRANCH 45MMX15CMX8MM THORACIC AORTIC GORE TAG","SUP-ITM-10317846","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34320.00","42.9","","5096.18","5096.18","5096.18","1 through 10","24800","63600","percent of total billed charges",""
"ENDOPROSTHESIS BRANCH 45MMX15CMX8MM THORACIC AORTIC GORE TAG","SUP-ITM-10317846","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","WELLPOINT [1015]","HB AMC WELLPOINT","59024.00","73.78","","1172.59","1172.59","4829.94","1 through 10","24800","63600","percent of total billed charges",""
"ENDOPROSTHESIS BRANCH 45MMX15CMX8MM THORACIC AORTIC GORE TAG","SUP-ITM-10317846","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","80000.00","60000.00","AETNA [1001]","HB AMC AETNA HMO","55840.00","69.8","","1806.84","947.80","5091.72","1 through 10","41808","65376","percent of total billed charges",""
"ENDOPROSTHESIS BRANCH 45MMX15CMX8MM THORACIC AORTIC GORE TAG","SUP-ITM-10317846","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","80000.00","60000.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","65376.00","81.72","","1259.05","615.58","4586.56","1 through 10","41808","65376","percent of total billed charges",""
"Endoscopic Cholecystoduodenostomy Stent Change With Stone Destruction","PX-75000507","CDM","47999","CPT","0750","RC","","","","both","","","8335.00","6251.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","6626.33","other","OPPS APC"
"Endoscopic Cholecystoduodenostomy Stent Change With Stone Destruction","PX-75000507","CDM","47999","CPT","0750","RC","","","","both","","","8335.00","6251.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","1057.74","6626.33","other","OPPS APC"
"Endoscopic Cholecystoduodenostomy Stent Change With Stone Destruction","PX-75000507","CDM","47999","CPT","0750","RC","","","","outpatient","","","8335.00","6251.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4352.54","52.22","","3734.00","1019.30","3734.00","1 through 10","4167.5","9843.6","percent of total billed charges",""
"Endoscopic Debridement of Necrotic Tissue of Pancreas","PX-75000404","CDM","48999","CPT","0750","RC","","","","outpatient","","","3801.00","2850.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1984.88","52.22","","1550.84","1550.84","1550.84","1 through 10","1234.13","3135.83","percent of total billed charges",""
"Endoscopic Esophageal Stricturoplasty","PX-75000510","CDM","43499","CPT","0750","RC","","","","both","","","3715.00","2786.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1980.10","53.3","","0.07","0.07","0.07","30","1057.74","2953.43","percent of total billed charges",""
"Endoscopic Esophageal Stricturoplasty","PX-75000510","CDM","43499","CPT","0750","RC","","","","both","","","3715.00","2786.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","2953.43","other","OPPS APC"
"Endoscopic Esophageal Stricturoplasty","PX-75000510","CDM","43499","CPT","0750","RC","","","","both","","","3715.00","2786.25","WELLPOINT [1015]","HB AMC WELLPOINT","2740.93","73.78","","2340.71","2340.71","2340.71","1 through 10","1057.74","2953.43","percent of total billed charges",""
"Endoscopic Esophageal Stricturoplasty","PX-75000510","CDM","43499","CPT","0750","RC","","","","outpatient","","","3715.00","2786.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1939.97","52.22","","6151.50","2038.73","10659.00","1 through 10","1857.5","3064.88","percent of total billed charges",""
"Endoscopic Esophageal Stricturoplasty","PX-75000510","CDM","43499","CPT","0750","RC","","","","outpatient","","","3715.00","2786.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1857.50","50","","3144.00","3144.00","3144.00","1 through 10","1857.5","3064.88","percent of total billed charges",""
"Endoscopic Esophageal Stricturoplasty","PX-75000510","CDM","43499","CPT","0750","RC","","","","outpatient","","","3715.00","2786.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3035.90","81.72","","1810.95","1810.95","1810.95","1 through 10","1857.5","3064.88","percent of total billed charges",""
"Endoscopic Gastric Bypass Repair","PX-75000398","CDM","C9785","CPT","0750","RC","","","","both","","","4466.00","3349.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","12362.70","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5665.10","5665.10","5665.10","1 through 10","1384.46","15453.37","other","OPPS APC"
"Endoscopic Gastric Bypass Repair","PX-75000398","CDM","C9785","CPT","0750","RC","","","","both","","","4466.00","3349.50","MEDICARE [2001]","HB BWH MEDICARE","12362.70","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12363.95","12363.95","33704.37","19","1384.46","15453.37","other","OPPS APC"
"Endoscopic Gastric Bypass Repair","PX-75000398","CDM","C9785","CPT","0750","RC","","","","both","","","4466.00","3349.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12115.45","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","11017.10","11017.10","11017.10","1 through 10","1384.46","15453.37","other","OPPS APC"
"Endoscopic Gastric Bypass Repair","PX-75000398","CDM","C9785","CPT","0750","RC","","","","both","","","4466.00","3349.50","WELLPOINT [1015]","HB AMC WELLPOINT","3295.01","73.78","","3224.43","3224.43","3224.43","1 through 10","1384.46","15453.37","percent of total billed charges",""
"Endoscopic Gastric Bypass Repair","PX-75000398","CDM","C9785","CPT","0750","RC","","","","outpatient","","","4466.00","3349.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2332.15","52.22","","4331.00","4331.00","4331.00","1 through 10","2233","11688.78","percent of total billed charges",""
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","both","","","4786.00","3589.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","3804.87","other","OPPS APC"
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","both","","","4786.00","3589.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","3804.87","other","OPPS APC"
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","both","","","4786.00","3589.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3804.87","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","3804.87","percent of total billed charges",""
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","both","","","4786.00","3589.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","3804.87","other","OPPS APC"
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","both","","","4786.00","3589.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","3804.87","other","OPPS APC"
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","both","","","4786.00","3589.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1746.89","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","3804.87","percent of total billed charges",""
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","both","","","4786.00","3589.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1833.04","38.3","","2723.31","1555.62","2741.61","12","1057.74","3804.87","percent of total billed charges",""
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","both","","","4786.00","3589.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","3804.87","other","OPPS APC"
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","both","","","4786.00","3589.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","3804.87","other","OPPS APC"
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","both","","","4786.00","3589.50","WELLPOINT [1015]","HB AMC WELLPOINT","3531.11","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","3804.87","percent of total billed charges",""
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","outpatient","","","4786.00","3589.50","AETNA [1001]","HB AMC AETNA PPO","3847.94","80.4","","1163.76","1163.76","1163.76","1 through 10","2384.07","3948.45","percent of total billed charges",""
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","outpatient","","","4786.00","3589.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2897.92","60.55","","1781.82","1492.00","4331.00","1 through 10","2384.07","3948.45","percent of total billed charges",""
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","outpatient","","","4786.00","3589.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2499.25","52.22","","3144.00","1492.00","3610.00","13","2384.07","3948.45","percent of total billed charges",""
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","outpatient","","","4786.00","3589.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2512.65","52.5","","1182.28","1182.28","1182.28","1 through 10","2384.07","3948.45","percent of total billed charges",""
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","outpatient","","","4786.00","3589.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2393.00","50","","3610.00","2269.44","3610.00","1 through 10","2384.07","3948.45","percent of total billed charges",""
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","outpatient","","","4786.00","3589.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2512.65","52.5","","3610.00","2382.05","4331.00","1 through 10","2384.07","3948.45","percent of total billed charges",""
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","outpatient","","","4786.00","3589.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2632.30","55","","4810.75","3363.17","4810.75","1 through 10","2384.07","3948.45","percent of total billed charges",""
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","outpatient","","","4786.00","3589.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3911.12","81.72","","8894.69","8894.69","8894.69","1 through 10","2384.07","3948.45","percent of total billed charges",""
"Endoscopic Hernia Tacking","PX-75000530","CDM","43999","CPT","0750","RC","","","","outpatient","","","4786.00","3589.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3911.12","81.72","","2885.83","2132.00","3462.21","1 through 10","2384.07","3948.45","percent of total billed charges",""
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","both","","","2464.00","1848.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","763.84","1958.88","other","OPPS APC"
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","both","","","2464.00","1848.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","763.84","1958.88","other","OPPS APC"
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","both","","","2464.00","1848.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1958.88","79.5","","2814.50","2346.50","2814.50","1 through 10","763.84","1958.88","percent of total billed charges",""
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","both","","","2464.00","1848.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","763.84","1958.88","other","OPPS APC"
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","both","","","2464.00","1848.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","763.84","1958.88","other","OPPS APC"
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","both","","","2464.00","1848.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","899.36","36.5","","2677.58","1482.13","2910.89","1 through 10","763.84","1958.88","percent of total billed charges",""
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","both","","","2464.00","1848.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","943.71","38.3","","2723.31","1555.62","2741.61","12","763.84","1958.88","percent of total billed charges",""
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","both","","","2464.00","1848.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","763.84","1958.88","other","OPPS APC"
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","both","","","2464.00","1848.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","763.84","1958.88","other","OPPS APC"
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","both","","","2464.00","1848.00","WELLPOINT [1015]","HB AMC WELLPOINT","1817.94","73.78","","2687.65","2687.64","3224.43","1 through 10","763.84","1958.88","percent of total billed charges",""
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","outpatient","","","2464.00","1848.00","AETNA [1001]","HB AMC AETNA PPO","1981.06","80.4","","1163.76","1163.76","1163.76","1 through 10","1232","2384.07","percent of total billed charges",""
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","outpatient","","","2464.00","1848.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1491.95","60.55","","1781.82","1492.00","4331.00","1 through 10","1232","2384.07","percent of total billed charges",""
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","outpatient","","","2464.00","1848.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1286.70","52.22","","3144.00","1492.00","3610.00","13","1232","2384.07","percent of total billed charges",""
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","outpatient","","","2464.00","1848.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1293.60","52.5","","1182.28","1182.28","1182.28","1 through 10","1232","2384.07","percent of total billed charges",""
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","outpatient","","","2464.00","1848.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1232.00","50","","3610.00","2269.44","3610.00","1 through 10","1232","2384.07","percent of total billed charges",""
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","outpatient","","","2464.00","1848.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1293.60","52.5","","3610.00","2382.05","4331.00","1 through 10","1232","2384.07","percent of total billed charges",""
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","outpatient","","","2464.00","1848.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1355.20","55","","4810.75","3363.17","4810.75","1 through 10","1232","2384.07","percent of total billed charges",""
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","outpatient","","","2464.00","1848.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2013.58","81.72","","8894.69","8894.69","8894.69","1 through 10","1232","2384.07","percent of total billed charges",""
"Endoscopic Removal Peg Tube","PX-75000521","CDM","43999","CPT","0750","RC","","","","outpatient","","","2464.00","1848.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2013.58","81.72","","2885.83","2132.00","3462.21","1 through 10","1232","2384.07","percent of total billed charges",""
"Endoscopic Sleeve Gastroplasty","PX-75000462","CDM","C9784","CPT","0750","RC","","","","both","","","8047.00","6035.25","MEDICARE [2001]","HB BWH MEDICARE","12362.70","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12363.95","12363.95","12363.95","1 through 10","2494.57","15453.37","other","OPPS APC"
"Endoscopic Sleeve Gastroplasty","PX-75000462","CDM","C9784","CPT","0750","RC","","","","both","","","8047.00","6035.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12115.45","","APC Price ($12,362.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","12116.67","12116.67","12116.67","1 through 10","2494.57","15453.37","other","OPPS APC"
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","both","","","6060.00","4545.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","4817.7","other","OPPS APC"
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","both","","","6060.00","4545.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","4817.7","other","OPPS APC"
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","both","","","6060.00","4545.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4817.70","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","4817.7","percent of total billed charges",""
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","both","","","6060.00","4545.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","4817.7","other","OPPS APC"
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","both","","","6060.00","4545.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","4817.7","other","OPPS APC"
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","both","","","6060.00","4545.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2211.90","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","4817.7","percent of total billed charges",""
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","both","","","6060.00","4545.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2320.98","38.3","","2723.31","1555.62","2741.61","12","1057.74","4817.7","percent of total billed charges",""
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","both","","","6060.00","4545.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","4817.7","other","OPPS APC"
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","both","","","6060.00","4545.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","4817.7","other","OPPS APC"
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","both","","","6060.00","4545.00","WELLPOINT [1015]","HB AMC WELLPOINT","4471.07","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","4817.7","percent of total billed charges",""
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","outpatient","","","6060.00","4545.00","AETNA [1001]","HB AMC AETNA PPO","4872.24","80.4","","1163.76","1163.76","1163.76","1 through 10","2384.07","4999.5","percent of total billed charges",""
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","outpatient","","","6060.00","4545.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3669.33","60.55","","1781.82","1492.00","4331.00","1 through 10","2384.07","4999.5","percent of total billed charges",""
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","outpatient","","","6060.00","4545.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3164.53","52.22","","3144.00","1492.00","3610.00","13","2384.07","4999.5","percent of total billed charges",""
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","outpatient","","","6060.00","4545.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","3181.50","52.5","","1182.28","1182.28","1182.28","1 through 10","2384.07","4999.5","percent of total billed charges",""
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","outpatient","","","6060.00","4545.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3030.00","50","","3610.00","2269.44","3610.00","1 through 10","2384.07","4999.5","percent of total billed charges",""
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","outpatient","","","6060.00","4545.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3181.50","52.5","","3610.00","2382.05","4331.00","1 through 10","2384.07","4999.5","percent of total billed charges",""
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","outpatient","","","6060.00","4545.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","3333.00","55","","4810.75","3363.17","4810.75","1 through 10","2384.07","4999.5","percent of total billed charges",""
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","outpatient","","","6060.00","4545.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4952.23","81.72","","8894.69","8894.69","8894.69","1 through 10","2384.07","4999.5","percent of total billed charges",""
"Endoscopic Sleeve Gastroplasty","PX-98301658","CDM","43999","CPT","0983","RC","","","","outpatient","","","6060.00","4545.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4952.23","81.72","","2885.83","2132.00","3462.21","1 through 10","2384.07","4999.5","percent of total billed charges",""
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","both","","","3801.00","2850.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","3021.8","other","OPPS APC"
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","both","","","3801.00","2850.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","3021.8","other","OPPS APC"
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","both","","","3801.00","2850.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3021.80","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","3021.8","percent of total billed charges",""
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","both","","","3801.00","2850.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","3021.8","other","OPPS APC"
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","both","","","3801.00","2850.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","3021.8","other","OPPS APC"
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","both","","","3801.00","2850.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1387.37","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","3021.8","percent of total billed charges",""
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","both","","","3801.00","2850.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1455.78","38.3","","2723.31","1555.62","2741.61","12","1057.74","3021.8","percent of total billed charges",""
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","both","","","3801.00","2850.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","3021.8","other","OPPS APC"
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","both","","","3801.00","2850.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","3021.8","other","OPPS APC"
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","both","","","3801.00","2850.75","WELLPOINT [1015]","HB AMC WELLPOINT","2804.38","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","3021.8","percent of total billed charges",""
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","outpatient","","","3801.00","2850.75","AETNA [1001]","HB AMC AETNA PPO","3056.00","80.4","","1163.76","1163.76","1163.76","1 through 10","1900.5","3135.83","percent of total billed charges",""
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","outpatient","","","3801.00","2850.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2301.51","60.55","","1781.82","1492.00","4331.00","1 through 10","1900.5","3135.83","percent of total billed charges",""
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","outpatient","","","3801.00","2850.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1984.88","52.22","","3144.00","1492.00","3610.00","13","1900.5","3135.83","percent of total billed charges",""
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","outpatient","","","3801.00","2850.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1995.53","52.5","","1182.28","1182.28","1182.28","1 through 10","1900.5","3135.83","percent of total billed charges",""
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","outpatient","","","3801.00","2850.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1900.50","50","","3610.00","2269.44","3610.00","1 through 10","1900.5","3135.83","percent of total billed charges",""
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","outpatient","","","3801.00","2850.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1995.53","52.5","","3610.00","2382.05","4331.00","1 through 10","1900.5","3135.83","percent of total billed charges",""
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","outpatient","","","3801.00","2850.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2090.55","55","","4810.75","3363.17","4810.75","1 through 10","1900.5","3135.83","percent of total billed charges",""
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","outpatient","","","3801.00","2850.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3106.18","81.72","","8894.69","8894.69","8894.69","1 through 10","1900.5","3135.83","percent of total billed charges",""
"Endoscopic Vacuum Therapy (Evt)","PX-75000517","CDM","43999","CPT","0750","RC","","","","outpatient","","","3801.00","2850.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3106.18","81.72","","2885.83","2132.00","3462.21","1 through 10","1900.5","3135.83","percent of total billed charges",""
"Endovac for Lower GI","PX-75000528","CDM","45399","CPT","0750","RC","","","","both","","","1418.00","1063.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","517.57","36.5","","2892.24","2892.24","2892.24","1 through 10","439.58","1353.25","percent of total billed charges",""
"Endovac for Lower GI","PX-75000528","CDM","45399","CPT","0750","RC","","","","both","","","1418.00","1063.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","543.09","38.3","","2777.42","2083.54","2946.52","1 through 10","439.58","1353.25","percent of total billed charges",""
"Endovac for Lower GI","PX-75000528","CDM","45399","CPT","0750","RC","","","","both","","","1418.00","1063.50","TRICARE [160005]","HB BWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","1028.57","1028.57","1 through 10","439.58","1353.25","other","Tricare OPPS"
"Endovac for Lower GI","PX-75000528","CDM","45399","CPT","0750","RC","","","","both","","","1418.00","1063.50","WELLPOINT [1015]","HB AMC WELLPOINT","1046.20","73.78","","5772.85","5772.85","7754.00","1 through 10","439.58","1353.25","percent of total billed charges",""
"Endovac for Lower GI","PX-75000528","CDM","45399","CPT","0750","RC","","","","outpatient","","","1418.00","1063.50","AETNA [1001]","HB AMC AETNA HMO","989.76","69.8","","5249.46","3706.41","5249.46","1 through 10","709","2384.07","percent of total billed charges",""
"Endovac for Lower GI","PX-75000528","CDM","45399","CPT","0750","RC","","","","outpatient","","","1418.00","1063.50","AETNA [1001]","HB AMC AETNA PPO","1140.07","80.4","","6048.12","6048.12","6048.12","1 through 10","709","2384.07","percent of total billed charges",""
"Endovac for Lower GI","PX-75000528","CDM","45399","CPT","0750","RC","","","","outpatient","","","1418.00","1063.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","858.60","60.55","","1533.28","1533.28","7754.00","1 through 10","709","2384.07","percent of total billed charges",""
"Endovac for Lower GI","PX-75000528","CDM","45399","CPT","0750","RC","","","","outpatient","","","1418.00","1063.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","740.48","52.22","","1974.52","1533.28","7754.00","21","709","2384.07","percent of total billed charges",""
"Endovac for Lower GI","PX-75000528","CDM","45399","CPT","0750","RC","","","","outpatient","","","1418.00","1063.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","744.45","52.5","","4063.09","4063.09","4063.09","1 through 10","709","2384.07","percent of total billed charges",""
"Endovac for Lower GI","PX-75000528","CDM","45399","CPT","0750","RC","","","","outpatient","","","1418.00","1063.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1158.79","81.72","","6198.55","6198.55","7754.00","1 through 10","709","2384.07","percent of total billed charges",""
"Endovac for Lower GI","PX-75000528","CDM","45399","CPT","0750","RC","","","","outpatient","","","1418.00","1063.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","886.25","62.5","","4691.17","4691.17","4691.17","1 through 10","709","2384.07","percent of total billed charges",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures With McC","266","MS-DRG","","","","","","","","inpatient","","","235779.46","176834.59","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","57972.25","","Case rate ($56,283.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $67,677.13, add-ons for qualifying new technology services are included. If operating cost exceeds $113,321.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,371.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $50,972.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $67,297.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,931.27. The transfer capital threshold is the transfer adjustment factor * $4,931.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","56357.32","56266.08","93419.83","1 through 10","55158.07","95995.26","other","Inpatient DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures With McC","266","MS-DRG","","","","","","","","inpatient","","","235779.46","176834.59","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","72933.50","","Case rate ($72,933.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $67,677.13, add-ons for qualifying new technology services are included. If operating cost exceeds $113,321.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,371.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $67,622.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $67,297.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,931.27. The transfer capital threshold is the transfer adjustment factor * $4,931.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","54654.88","54067.30","68427.90","1 through 10","55158.07","95995.26","other","Inpatient DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures With McC","266","MS-DRG","","","","","","","","inpatient","","","235779.46","176834.59","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","56283.74","","Case rate ($56,283.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $67,677.13, add-ons for qualifying new technology services are included. If operating cost exceeds $113,321.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,371.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $50,972.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $67,297.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,931.27. The transfer capital threshold is the transfer adjustment factor * $4,931.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","53561.71","53561.71","53561.71","1 through 10","55158.07","95995.26","other","Inpatient DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures With McC","266","MS-DRG","","","","","","","","inpatient","","","235779.46","176834.59","MEDICARE [2001]","HB BWH MEDICARE","72933.50","","Case rate ($72,933.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $67,677.13, add-ons for qualifying new technology services are included. If operating cost exceeds $113,321.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,371.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $67,622.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $67,297.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,931.27. The transfer capital threshold is the transfer adjustment factor * $4,931.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","70904.75","0.03","71010.38","96","55158.07","95995.26","other","Inpatient DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures With McC","266","MS-DRG","","","","","","","","inpatient","","","235779.46","176834.59","MOLINA [1014]","HB BWH MOLINA","55158.07","","Case rate ($56,283.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $67,677.13, add-ons for qualifying new technology services are included. If operating cost exceeds $113,321.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,371.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $50,972.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $67,297.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,931.27. The transfer capital threshold is the transfer adjustment factor * $4,931.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","108493.66","108493.66","108493.66","1 through 10","55158.07","95995.26","other","Inpatient DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures With McC","266","MS-DRG","","","","","","","","inpatient","","","235779.46","176834.59","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","55158.07","","Case rate ($56,283.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $67,677.13, add-ons for qualifying new technology services are included. If operating cost exceeds $113,321.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,371.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $50,972.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $67,297.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,931.27. The transfer capital threshold is the transfer adjustment factor * $4,931.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","68743.72","53567.73","76937.82","1 through 10","55158.07","95995.26","other","Inpatient DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures With McC","266","MS-DRG","","","","","","","","inpatient","","","235779.46","176834.59","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","55158.07","","Case rate ($56,283.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $67,677.13, add-ons for qualifying new technology services are included. If operating cost exceeds $113,321.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,371.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $50,972.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $67,297.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,931.27. The transfer capital threshold is the transfer adjustment factor * $4,931.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","53705.67","53561.74","58868.76","11","55158.07","95995.26","other","Inpatient DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures With McC","266","MS-DRG","","","","","","","","inpatient","","","235779.46","176834.59","WELLPOINT [1015]","HB AMC WELLPOINT","95995.26","","Fee schedule rate ($95,995.26).","136952.83","136952.83","136952.83","1 through 10","55158.07","95995.26","case rate",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC","267","MS-DRG","","","","","","","","inpatient","","","142116.12","106587.09","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","45122.61","","Case rate ($43,808.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $52,659.22, add-ons for qualifying new technology services are included. If operating cost exceeds $98,303.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,270.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $39,597.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,279.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,830.82. The transfer capital threshold is the transfer adjustment factor * $3,830.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","44288.63","44233.67","44328.67","12","42932.19","70998.6277","other","Inpatient DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC","267","MS-DRG","","","","","","","","inpatient","","","142116.12","106587.09","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","43808.36","","Case rate ($43,808.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $52,659.22, add-ons for qualifying new technology services are included. If operating cost exceeds $98,303.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,270.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $39,597.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,279.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,830.82. The transfer capital threshold is the transfer adjustment factor * $3,830.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","43040.48","42519.00","43056.38","12","42932.19","70998.6277","other","Inpatient Replacement Plans DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC","267","MS-DRG","","","","","","","","inpatient","","","142116.12","106587.09","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","43808.36","","Case rate ($43,808.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $52,659.22, add-ons for qualifying new technology services are included. If operating cost exceeds $98,303.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,270.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $39,597.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,279.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,830.82. The transfer capital threshold is the transfer adjustment factor * $3,830.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","42389.93","42389.93","42389.93","1 through 10","42932.19","70998.6277","other","Inpatient DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC","267","MS-DRG","","","","","","","","inpatient","","","142116.12","106587.09","FALLON HEALTH [1008]","HB BWH MEDICARE","43808.36","","Case rate ($43,808.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $52,659.22, add-ons for qualifying new technology services are included. If operating cost exceeds $98,303.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,270.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $39,597.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,279.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,830.82. The transfer capital threshold is the transfer adjustment factor * $3,830.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","43040.46","43040.46","43040.46","1 through 10","42932.19","70998.6277","other","Inpatient Replacement Plans DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC","267","MS-DRG","","","","","","","","inpatient","","","142116.12","106587.09","HUMANA [1012]","HB BWH MEDICARE","43808.36","","Case rate ($43,808.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $52,659.22, add-ons for qualifying new technology services are included. If operating cost exceeds $98,303.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,270.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $39,597.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,279.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,830.82. The transfer capital threshold is the transfer adjustment factor * $3,830.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","4589.17","4589.17","4589.17","1 through 10","42932.19","70998.6277","other","Inpatient Replacement Plans DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC","267","MS-DRG","","","","","","","","inpatient","","","142116.12","106587.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","","65","","135672.16","135672.16","135672.16","1 through 10","42932.19","70998.6277","percent of total billed charges",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC","267","MS-DRG","","","","","","","","inpatient","","","142116.12","106587.09","MEDICARE [2001]","HB BWH MEDICARE","43808.36","","Case rate ($43,808.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $52,659.22, add-ons for qualifying new technology services are included. If operating cost exceeds $98,303.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,270.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $39,597.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,279.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,830.82. The transfer capital threshold is the transfer adjustment factor * $3,830.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","55742.73","0.03","55825.70","212","42932.19","70998.6277","other","Inpatient Replacement Plans DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC","267","MS-DRG","","","","","","","","inpatient","","","142116.12","106587.09","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","43808.36","","Case rate ($43,808.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $52,659.22, add-ons for qualifying new technology services are included. If operating cost exceeds $98,303.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,270.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $39,597.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,279.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,830.82. The transfer capital threshold is the transfer adjustment factor * $3,830.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","42169.54","42169.54","42169.54","1 through 10","42932.19","70998.6277","other","Inpatient Replacement Plans DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC","267","MS-DRG","","","","","","","","inpatient","","","142116.12","106587.09","MOLINA [1014]","HB BWH MOLINA","42932.19","","Case rate ($43,808.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $52,659.22, add-ons for qualifying new technology services are included. If operating cost exceeds $98,303.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,270.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $39,597.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,279.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,830.82. The transfer capital threshold is the transfer adjustment factor * $3,830.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","85269.41","85269.41","85269.41","1 through 10","42932.19","70998.6277","other","Inpatient DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC","267","MS-DRG","","","","","","","","inpatient","","","142116.12","106587.09","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","42932.19","","Case rate ($43,808.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $52,659.22, add-ons for qualifying new technology services are included. If operating cost exceeds $98,303.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,270.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $39,597.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,279.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,830.82. The transfer capital threshold is the transfer adjustment factor * $3,830.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","42187.46","42145.95","42203.25","1 through 10","42932.19","70998.6277","other","Inpatient DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC","267","MS-DRG","","","","","","","","inpatient","","","142116.12","106587.09","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","42932.19","","Case rate ($43,808.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $52,659.22, add-ons for qualifying new technology services are included. If operating cost exceeds $98,303.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,270.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $39,597.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $52,279.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,830.82. The transfer capital threshold is the transfer adjustment factor * $3,830.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","42194.37","42142.36","42273.71","16","42932.19","70998.6277","other","Inpatient DRG"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without McC","267","MS-DRG","","","","","","","","inpatient","","","142116.12","106587.09","WELLPOINT [1015]","HB AMC WELLPOINT","70998.6277","","Fee schedule rate ($74,573.17).","70998.6277","91025.84","91025.84","1 through 10","42932.19","70998.6277","case rate",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","2302.65","1726.99","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1203.36","52.26","","1113.10","1113.10","1113.10","1 through 10","713.82","1830.61","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","2302.65","1726.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1830.61","79.5","","1293.60","1148.53","1603.80","1 through 10","713.82","1830.61","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","2302.65","1726.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","840.47","36.5","","1023.42","771.29","2068.67","33","713.82","1830.61","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","2302.65","1726.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","881.91","38.3","","850.52","759.78","1211.25","66","713.82","1830.61","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","2302.65","1726.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","987.84","42.9","","2548.09","2548.09","2548.09","1 through 10","713.82","1830.61","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","2302.65","1726.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","987.84","42.9","","956.46","956.46","956.46","1 through 10","713.82","1830.61","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","2302.65","1726.99","WELLPOINT [1015]","HB AMC WELLPOINT","1698.90","73.78","","2344.73","1619.47","2530.35","16","713.82","1830.61","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2302.65","1726.99","AETNA [1001]","HB AMC AETNA HMO","1607.25","69.8","","1523.63","988.41","4330.26","39","1203.36","1881.73","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2302.65","1726.99","AETNA [1001]","HB AMC AETNA PPO","1851.33","80.4","","1670.25","1670.25","1670.25","1 through 10","1203.36","1881.73","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2302.65","1726.99","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1203.36","52.26","","1113.10","1113.10","1113.10","1 through 10","1203.36","1881.73","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2302.65","1726.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1881.73","81.72","","1738.90","1484.65","2716.94","38","1203.36","1881.73","percent of total billed charges",""
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","2408.85","other","OPPS APC"
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","2408.85","other","OPPS APC"
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1614.99","53.3","","477.31","477.31","477.31","1 through 10","333.03","2408.85","percent of total billed charges",""
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","2408.85","other","OPPS APC"
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","2408.85","other","OPPS APC"
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1105.95","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","2408.85","percent of total billed charges",""
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1160.49","38.3","","343.52","323.76","353.46","1 through 10","333.03","2408.85","percent of total billed charges",""
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","2408.85","other","Tricare OPPS"
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","2408.85","other","OPPS APC"
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","2408.85","other","OPPS APC"
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","WELLPOINT [1015]","HB AMC WELLPOINT","2235.53","73.78","","673.03","673.03","673.03","1 through 10","333.03","2408.85","percent of total billed charges",""
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","outpatient","","","3030.00","2272.50","AETNA [1001]","HB AMC AETNA HMO","2114.94","69.8","","612.01","612.01","1224.02","1 through 10","700.33","2499.75","percent of total billed charges",""
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","outpatient","","","3030.00","2272.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1834.67","60.55","","579.04","568.57","904.00","30","700.33","2499.75","percent of total billed charges",""
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","outpatient","","","3030.00","2272.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1582.27","52.22","","904.00","656.02","2938.00","26","700.33","2499.75","percent of total billed charges",""
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","outpatient","","","3030.00","2272.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1515.00","50","","1421.10","875.08","2368.50","15","700.33","2499.75","percent of total billed charges",""
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","outpatient","","","3030.00","2272.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1590.75","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","2499.75","percent of total billed charges",""
"Endplate/Disc Biopsy","PX-76002118","CDM","64999","CPT","0761","RC","","","","outpatient","","","3030.00","2272.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2476.12","81.72","","722.66","722.66","17449.00","1 through 10","700.33","2499.75","percent of total billed charges",""
"Enterocutans Fistula Plg Plcm-Colon","PX-36000206","CDM","45399","CPT","0361","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","980.03","36.5","","2892.24","2892.24","2892.24","1 through 10","832.35","2134.58","percent of total billed charges",""
"Enterocutans Fistula Plg Plcm-Colon","PX-36000206","CDM","45399","CPT","0361","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1028.36","38.3","","2777.42","2083.54","2946.52","1 through 10","832.35","2134.58","percent of total billed charges",""
"Enterocutans Fistula Plg Plcm-Colon","PX-36000206","CDM","45399","CPT","0361","RC","","","","both","","","2685.00","2013.75","TRICARE [160005]","HB BWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","1028.57","1028.57","1 through 10","832.35","2134.58","other","Tricare OPPS"
"Enterocutans Fistula Plg Plcm-Colon","PX-36000206","CDM","45399","CPT","0361","RC","","","","both","","","2685.00","2013.75","WELLPOINT [1015]","HB AMC WELLPOINT","1980.99","73.78","","5772.85","5772.85","7754.00","1 through 10","832.35","2134.58","percent of total billed charges",""
"Enterocutans Fistula Plg Plcm-Colon","PX-36000206","CDM","45399","CPT","0361","RC","","","","outpatient","","","2685.00","2013.75","AETNA [1001]","HB AMC AETNA HMO","1874.13","69.8","","5249.46","3706.41","5249.46","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Enterocutans Fistula Plg Plcm-Colon","PX-36000206","CDM","45399","CPT","0361","RC","","","","outpatient","","","2685.00","2013.75","AETNA [1001]","HB AMC AETNA PPO","2158.74","80.4","","6048.12","6048.12","6048.12","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Enterocutans Fistula Plg Plcm-Colon","PX-36000206","CDM","45399","CPT","0361","RC","","","","outpatient","","","2685.00","2013.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1625.77","60.55","","1533.28","1533.28","7754.00","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Enterocutans Fistula Plg Plcm-Colon","PX-36000206","CDM","45399","CPT","0361","RC","","","","outpatient","","","2685.00","2013.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1402.11","52.22","","1974.52","1533.28","7754.00","21","1342.5","2384.07","percent of total billed charges",""
"Enterocutans Fistula Plg Plcm-Colon","PX-36000206","CDM","45399","CPT","0361","RC","","","","outpatient","","","2685.00","2013.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1409.63","52.5","","4063.09","4063.09","4063.09","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Enterocutans Fistula Plg Plcm-Colon","PX-36000206","CDM","45399","CPT","0361","RC","","","","outpatient","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2194.18","81.72","","6198.55","6198.55","7754.00","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Enterocutans Fistula Plg Plcm-Colon","PX-36000206","CDM","45399","CPT","0361","RC","","","","outpatient","","","2685.00","2013.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1678.13","62.5","","4691.17","4691.17","4691.17","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Enteroscopy Lower Double-Balloon With Emr(Retrograde)","PX-75000539","CDM","44799","CPT","0750","RC","","","","both","","","7726.00","5794.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1057.74","6142.17","other","OPPS APC"
"Enteroscopy Lower Double-Balloon With Emr(Retrograde)","PX-75000539","CDM","44799","CPT","0750","RC","","","","both","","","7726.00","5794.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","6142.17","other","OPPS APC"
"Enteroscopy Lower Double-Balloon With Emr(Retrograde)","PX-75000539","CDM","44799","CPT","0750","RC","","","","both","","","7726.00","5794.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","6142.17","other","OPPS APC"
"Enteroscopy Lower Double-Balloon With Emr(Retrograde)","PX-75000539","CDM","44799","CPT","0750","RC","","","","both","","","7726.00","5794.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1057.74","6142.17","other","OPPS APC"
"Enteroscopy Lower Double-Balloon With Emr(Retrograde)","PX-75000539","CDM","44799","CPT","0750","RC","","","","both","","","7726.00","5794.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3314.45","42.9","","1932.92","1932.92","1932.92","1 through 10","1057.74","6142.17","percent of total billed charges",""
"Enteroscopy Lower Double-Balloon With Emr(Retrograde)","PX-75000539","CDM","44799","CPT","0750","RC","","","","both","","","7726.00","5794.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1057.74","6142.17","other","OPPS APC"
"Enteroscopy Lower Double-Balloon With Emr(Retrograde)","PX-75000539","CDM","44799","CPT","0750","RC","","","","both","","","7726.00","5794.50","WELLPOINT [1015]","HB AMC WELLPOINT","5700.24","73.78","","2222.33","2222.33","2222.33","1 through 10","1057.74","6142.17","percent of total billed charges",""
"Enteroscopy Lower Double-Balloon With Emr(Retrograde)","PX-75000539","CDM","44799","CPT","0750","RC","","","","outpatient","","","7726.00","5794.50","AETNA [1001]","HB AMC AETNA HMO","5392.75","69.8","","2238.60","2238.60","2238.60","1 through 10","3863","8899.59","percent of total billed charges",""
"Enteroscopy Lower Double-Balloon With Emr(Retrograde)","PX-75000539","CDM","44799","CPT","0750","RC","","","","outpatient","","","7726.00","5794.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4678.09","60.55","","3144.00","2870.00","3286.00","1 through 10","3863","8899.59","percent of total billed charges",""
"Enteroscopy Lower Double-Balloon With Emr(Retrograde)","PX-75000539","CDM","44799","CPT","0750","RC","","","","outpatient","","","7726.00","5794.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4037.61","52.26","","1775.96","1775.96","1775.96","1 through 10","3863","8899.59","percent of total billed charges",""
"Enteroscopy Lower Double-Balloon With Emr(Retrograde)","PX-75000539","CDM","44799","CPT","0750","RC","","","","outpatient","","","7726.00","5794.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4034.52","52.22","","3286.00","2018.70","5898.00","1 through 10","3863","8899.59","percent of total billed charges",""
"Enteroscopy Lower Double-Balloon With Emr(Retrograde)","PX-75000539","CDM","44799","CPT","0750","RC","","","","outpatient","","","7726.00","5794.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4056.15","52.5","","8340.00","8340.00","8340.00","1 through 10","3863","8899.59","percent of total billed charges",""
"Enteroscopy Lower Double-Balloon With Emr(Retrograde)","PX-75000539","CDM","44799","CPT","0750","RC","","","","outpatient","","","7726.00","5794.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6313.69","81.72","","2294.28","682.69","2294.28","1 through 10","3863","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde Diagnostic","PX-75000499","CDM","44799","CPT","0750","RC","","","","both","","","1542.00","1156.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","478.02","1391.62","other","OPPS APC"
"Enteroscopy Retrograde Diagnostic","PX-75000499","CDM","44799","CPT","0750","RC","","","","both","","","1542.00","1156.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","478.02","1391.62","other","OPPS APC"
"Enteroscopy Retrograde Diagnostic","PX-75000499","CDM","44799","CPT","0750","RC","","","","both","","","1542.00","1156.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","478.02","1391.62","other","OPPS APC"
"Enteroscopy Retrograde Diagnostic","PX-75000499","CDM","44799","CPT","0750","RC","","","","both","","","1542.00","1156.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","478.02","1391.62","other","OPPS APC"
"Enteroscopy Retrograde Diagnostic","PX-75000499","CDM","44799","CPT","0750","RC","","","","both","","","1542.00","1156.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","661.52","42.9","","1932.92","1932.92","1932.92","1 through 10","478.02","1391.62","percent of total billed charges",""
"Enteroscopy Retrograde Diagnostic","PX-75000499","CDM","44799","CPT","0750","RC","","","","both","","","1542.00","1156.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","478.02","1391.62","other","OPPS APC"
"Enteroscopy Retrograde Diagnostic","PX-75000499","CDM","44799","CPT","0750","RC","","","","both","","","1542.00","1156.50","WELLPOINT [1015]","HB AMC WELLPOINT","1137.69","73.78","","2222.33","2222.33","2222.33","1 through 10","478.02","1391.62","percent of total billed charges",""
"Enteroscopy Retrograde Diagnostic","PX-75000499","CDM","44799","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","AETNA [1001]","HB AMC AETNA HMO","1076.32","69.8","","2238.60","2238.60","2238.60","1 through 10","771","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde Diagnostic","PX-75000499","CDM","44799","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","933.68","60.55","","3144.00","2870.00","3286.00","1 through 10","771","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde Diagnostic","PX-75000499","CDM","44799","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","805.85","52.26","","1775.96","1775.96","1775.96","1 through 10","771","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde Diagnostic","PX-75000499","CDM","44799","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","805.23","52.22","","3286.00","2018.70","5898.00","1 through 10","771","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde Diagnostic","PX-75000499","CDM","44799","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","809.55","52.5","","8340.00","8340.00","8340.00","1 through 10","771","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde Diagnostic","PX-75000499","CDM","44799","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1260.12","81.72","","2294.28","682.69","2294.28","1 through 10","771","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde Lesion Ablation","PX-75000505","CDM","44799","CPT","0750","RC","","","","both","","","3787.00","2840.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1057.74","3010.67","other","OPPS APC"
"Enteroscopy Retrograde Lesion Ablation","PX-75000505","CDM","44799","CPT","0750","RC","","","","both","","","3787.00","2840.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","3010.67","other","OPPS APC"
"Enteroscopy Retrograde Lesion Ablation","PX-75000505","CDM","44799","CPT","0750","RC","","","","both","","","3787.00","2840.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3010.67","other","OPPS APC"
"Enteroscopy Retrograde Lesion Ablation","PX-75000505","CDM","44799","CPT","0750","RC","","","","both","","","3787.00","2840.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1057.74","3010.67","other","OPPS APC"
"Enteroscopy Retrograde Lesion Ablation","PX-75000505","CDM","44799","CPT","0750","RC","","","","both","","","3787.00","2840.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1624.62","42.9","","1932.92","1932.92","1932.92","1 through 10","1057.74","3010.67","percent of total billed charges",""
"Enteroscopy Retrograde Lesion Ablation","PX-75000505","CDM","44799","CPT","0750","RC","","","","both","","","3787.00","2840.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1057.74","3010.67","other","OPPS APC"
"Enteroscopy Retrograde Lesion Ablation","PX-75000505","CDM","44799","CPT","0750","RC","","","","both","","","3787.00","2840.25","WELLPOINT [1015]","HB AMC WELLPOINT","2794.05","73.78","","2222.33","2222.33","2222.33","1 through 10","1057.74","3010.67","percent of total billed charges",""
"Enteroscopy Retrograde Lesion Ablation","PX-75000505","CDM","44799","CPT","0750","RC","","","","outpatient","","","3787.00","2840.25","AETNA [1001]","HB AMC AETNA HMO","2643.33","69.8","","2238.60","2238.60","2238.60","1 through 10","1893.5","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde Lesion Ablation","PX-75000505","CDM","44799","CPT","0750","RC","","","","outpatient","","","3787.00","2840.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2293.03","60.55","","3144.00","2870.00","3286.00","1 through 10","1893.5","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde Lesion Ablation","PX-75000505","CDM","44799","CPT","0750","RC","","","","outpatient","","","3787.00","2840.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1979.09","52.26","","1775.96","1775.96","1775.96","1 through 10","1893.5","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde Lesion Ablation","PX-75000505","CDM","44799","CPT","0750","RC","","","","outpatient","","","3787.00","2840.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1977.57","52.22","","3286.00","2018.70","5898.00","1 through 10","1893.5","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde Lesion Ablation","PX-75000505","CDM","44799","CPT","0750","RC","","","","outpatient","","","3787.00","2840.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1988.18","52.5","","8340.00","8340.00","8340.00","1 through 10","1893.5","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde Lesion Ablation","PX-75000505","CDM","44799","CPT","0750","RC","","","","outpatient","","","3787.00","2840.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3094.74","81.72","","2294.28","682.69","2294.28","1 through 10","1893.5","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde W Snare Polypectomy","PX-75000483","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","917.6","2353.2","other","OPPS APC"
"Enteroscopy Retrograde W Snare Polypectomy","PX-75000483","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","917.6","2353.2","other","OPPS APC"
"Enteroscopy Retrograde W Snare Polypectomy","PX-75000483","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","917.6","2353.2","other","OPPS APC"
"Enteroscopy Retrograde W Snare Polypectomy","PX-75000483","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","917.6","2353.2","other","OPPS APC"
"Enteroscopy Retrograde W Snare Polypectomy","PX-75000483","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1269.84","42.9","","1932.92","1932.92","1932.92","1 through 10","917.6","2353.2","percent of total billed charges",""
"Enteroscopy Retrograde W Snare Polypectomy","PX-75000483","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","917.6","2353.2","other","OPPS APC"
"Enteroscopy Retrograde W Snare Polypectomy","PX-75000483","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","WELLPOINT [1015]","HB AMC WELLPOINT","2183.89","73.78","","2222.33","2222.33","2222.33","1 through 10","917.6","2353.2","percent of total billed charges",""
"Enteroscopy Retrograde W Snare Polypectomy","PX-75000483","CDM","44799","CPT","0750","RC","","","","outpatient","","","2960.00","2220.00","AETNA [1001]","HB AMC AETNA HMO","2066.08","69.8","","2238.60","2238.60","2238.60","1 through 10","1480","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde W Snare Polypectomy","PX-75000483","CDM","44799","CPT","0750","RC","","","","outpatient","","","2960.00","2220.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1792.28","60.55","","3144.00","2870.00","3286.00","1 through 10","1480","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde W Snare Polypectomy","PX-75000483","CDM","44799","CPT","0750","RC","","","","outpatient","","","2960.00","2220.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1546.90","52.26","","1775.96","1775.96","1775.96","1 through 10","1480","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde W Snare Polypectomy","PX-75000483","CDM","44799","CPT","0750","RC","","","","outpatient","","","2960.00","2220.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1545.71","52.22","","3286.00","2018.70","5898.00","1 through 10","1480","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde W Snare Polypectomy","PX-75000483","CDM","44799","CPT","0750","RC","","","","outpatient","","","2960.00","2220.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1554.00","52.5","","8340.00","8340.00","8340.00","1 through 10","1480","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde W Snare Polypectomy","PX-75000483","CDM","44799","CPT","0750","RC","","","","outpatient","","","2960.00","2220.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2418.91","81.72","","2294.28","682.69","2294.28","1 through 10","1480","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","917.6","2353.2","other","OPPS APC"
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","917.6","2353.2","other","OPPS APC"
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","917.6","2353.2","other","OPPS APC"
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","917.6","2353.2","other","OPPS APC"
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1269.84","42.9","","1932.92","1932.92","1932.92","1 through 10","917.6","2353.2","percent of total billed charges",""
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","917.6","2353.2","other","OPPS APC"
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","both","","","2960.00","2220.00","WELLPOINT [1015]","HB AMC WELLPOINT","2183.89","73.78","","2222.33","2222.33","2222.33","1 through 10","917.6","2353.2","percent of total billed charges",""
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","outpatient","","","2960.00","2220.00","AETNA [1001]","HB AMC AETNA HMO","2066.08","69.8","","2238.60","2238.60","2238.60","1 through 10","1480","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","outpatient","","","2960.00","2220.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1792.28","60.55","","3144.00","2870.00","3286.00","1 through 10","1480","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","outpatient","","","2960.00","2220.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1546.90","52.26","","1775.96","1775.96","1775.96","1 through 10","1480","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","outpatient","","","2960.00","2220.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1545.71","52.22","","3286.00","2018.70","5898.00","1 through 10","1480","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","outpatient","","","2960.00","2220.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1554.00","52.5","","8340.00","8340.00","8340.00","1 through 10","1480","8899.59","percent of total billed charges",""
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","outpatient","","","2960.00","2220.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2418.91","81.72","","2294.28","682.69","2294.28","1 through 10","1480","8899.59","percent of total billed charges",""
"Enteroscopy Upper Ballon With Snare","PX-75000525","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1057.74","3603.74","other","OPPS APC"
"Enteroscopy Upper Ballon With Snare","PX-75000525","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","3603.74","other","OPPS APC"
"Enteroscopy Upper Ballon With Snare","PX-75000525","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3603.74","other","OPPS APC"
"Enteroscopy Upper Ballon With Snare","PX-75000525","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1057.74","3603.74","other","OPPS APC"
"Enteroscopy Upper Ballon With Snare","PX-75000525","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.66","42.9","","1932.92","1932.92","1932.92","1 through 10","1057.74","3603.74","percent of total billed charges",""
"Enteroscopy Upper Ballon With Snare","PX-75000525","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1057.74","3603.74","other","OPPS APC"
"Enteroscopy Upper Ballon With Snare","PX-75000525","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","WELLPOINT [1015]","HB AMC WELLPOINT","3344.45","73.78","","2222.33","2222.33","2222.33","1 through 10","1057.74","3603.74","percent of total billed charges",""
"Enteroscopy Upper Ballon With Snare","PX-75000525","CDM","44799","CPT","0750","RC","","","","outpatient","","","4533.00","3399.75","AETNA [1001]","HB AMC AETNA HMO","3164.03","69.8","","2238.60","2238.60","2238.60","1 through 10","2266.5","8899.59","percent of total billed charges",""
"Enteroscopy Upper Ballon With Snare","PX-75000525","CDM","44799","CPT","0750","RC","","","","outpatient","","","4533.00","3399.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2744.73","60.55","","3144.00","2870.00","3286.00","1 through 10","2266.5","8899.59","percent of total billed charges",""
"Enteroscopy Upper Ballon With Snare","PX-75000525","CDM","44799","CPT","0750","RC","","","","outpatient","","","4533.00","3399.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2368.95","52.26","","1775.96","1775.96","1775.96","1 through 10","2266.5","8899.59","percent of total billed charges",""
"Enteroscopy Upper Ballon With Snare","PX-75000525","CDM","44799","CPT","0750","RC","","","","outpatient","","","4533.00","3399.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2367.13","52.22","","3286.00","2018.70","5898.00","1 through 10","2266.5","8899.59","percent of total billed charges",""
"Enteroscopy Upper Ballon With Snare","PX-75000525","CDM","44799","CPT","0750","RC","","","","outpatient","","","4533.00","3399.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2379.83","52.5","","8340.00","8340.00","8340.00","1 through 10","2266.5","8899.59","percent of total billed charges",""
"Enteroscopy Upper Ballon With Snare","PX-75000525","CDM","44799","CPT","0750","RC","","","","outpatient","","","4533.00","3399.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3704.37","81.72","","2294.28","682.69","2294.28","1 through 10","2266.5","8899.59","percent of total billed charges",""
"Enteroscopy via Laparotomy","PX-75000461","CDM","45399","CPT","0750","RC","","","","both","","","2313.00","1734.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","844.25","36.5","","2892.24","2892.24","2892.24","1 through 10","717.03","1838.84","percent of total billed charges",""
"Enteroscopy via Laparotomy","PX-75000461","CDM","45399","CPT","0750","RC","","","","both","","","2313.00","1734.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","885.88","38.3","","2777.42","2083.54","2946.52","1 through 10","717.03","1838.84","percent of total billed charges",""
"Enteroscopy via Laparotomy","PX-75000461","CDM","45399","CPT","0750","RC","","","","both","","","2313.00","1734.75","TRICARE [160005]","HB BWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","1028.57","1028.57","1 through 10","717.03","1838.84","other","Tricare OPPS"
"Enteroscopy via Laparotomy","PX-75000461","CDM","45399","CPT","0750","RC","","","","both","","","2313.00","1734.75","WELLPOINT [1015]","HB AMC WELLPOINT","1706.53","73.78","","5772.85","5772.85","7754.00","1 through 10","717.03","1838.84","percent of total billed charges",""
"Enteroscopy via Laparotomy","PX-75000461","CDM","45399","CPT","0750","RC","","","","outpatient","","","2313.00","1734.75","AETNA [1001]","HB AMC AETNA HMO","1614.47","69.8","","5249.46","3706.41","5249.46","1 through 10","1156.5","2384.07","percent of total billed charges",""
"Enteroscopy via Laparotomy","PX-75000461","CDM","45399","CPT","0750","RC","","","","outpatient","","","2313.00","1734.75","AETNA [1001]","HB AMC AETNA PPO","1859.65","80.4","","6048.12","6048.12","6048.12","1 through 10","1156.5","2384.07","percent of total billed charges",""
"Enteroscopy via Laparotomy","PX-75000461","CDM","45399","CPT","0750","RC","","","","outpatient","","","2313.00","1734.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1400.52","60.55","","1533.28","1533.28","7754.00","1 through 10","1156.5","2384.07","percent of total billed charges",""
"Enteroscopy via Laparotomy","PX-75000461","CDM","45399","CPT","0750","RC","","","","outpatient","","","2313.00","1734.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1207.85","52.22","","1974.52","1533.28","7754.00","21","1156.5","2384.07","percent of total billed charges",""
"Enteroscopy via Laparotomy","PX-75000461","CDM","45399","CPT","0750","RC","","","","outpatient","","","2313.00","1734.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1214.33","52.5","","4063.09","4063.09","4063.09","1 through 10","1156.5","2384.07","percent of total billed charges",""
"Enteroscopy via Laparotomy","PX-75000461","CDM","45399","CPT","0750","RC","","","","outpatient","","","2313.00","1734.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1890.18","81.72","","6198.55","6198.55","7754.00","1 through 10","1156.5","2384.07","percent of total billed charges",""
"Enteroscopy via Laparotomy","PX-75000461","CDM","45399","CPT","0750","RC","","","","outpatient","","","2313.00","1734.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1445.63","62.5","","4691.17","4691.17","4691.17","1 through 10","1156.5","2384.07","percent of total billed charges",""
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","both","","","3389.00","2541.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1050.59","2694.26","other","OPPS APC"
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","both","","","3389.00","2541.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1050.59","2694.26","other","OPPS APC"
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","both","","","3389.00","2541.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1050.59","2694.26","other","OPPS APC"
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","both","","","3389.00","2541.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1050.59","2694.26","other","OPPS APC"
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","both","","","3389.00","2541.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1453.88","42.9","","1932.92","1932.92","1932.92","1 through 10","1050.59","2694.26","percent of total billed charges",""
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","both","","","3389.00","2541.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1050.59","2694.26","other","OPPS APC"
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","both","","","3389.00","2541.75","WELLPOINT [1015]","HB AMC WELLPOINT","2500.40","73.78","","2222.33","2222.33","2222.33","1 through 10","1050.59","2694.26","percent of total billed charges",""
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","outpatient","","","3389.00","2541.75","AETNA [1001]","HB AMC AETNA HMO","2365.52","69.8","","2238.60","2238.60","2238.60","1 through 10","1694.5","8899.59","percent of total billed charges",""
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","outpatient","","","3389.00","2541.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2052.04","60.55","","3144.00","2870.00","3286.00","1 through 10","1694.5","8899.59","percent of total billed charges",""
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","outpatient","","","3389.00","2541.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1771.09","52.26","","1775.96","1775.96","1775.96","1 through 10","1694.5","8899.59","percent of total billed charges",""
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","outpatient","","","3389.00","2541.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1769.74","52.22","","3286.00","2018.70","5898.00","1 through 10","1694.5","8899.59","percent of total billed charges",""
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","outpatient","","","3389.00","2541.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1779.23","52.5","","8340.00","8340.00","8340.00","1 through 10","1694.5","8899.59","percent of total billed charges",""
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","outpatient","","","3389.00","2541.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2769.49","81.72","","2294.28","682.69","2294.28","1 through 10","1694.5","8899.59","percent of total billed charges",""
"Enteroscopy With Emr","PX-75000504","CDM","44799","CPT","0750","RC","","","","both","","","3078.00","2308.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","954.18","2447.01","other","OPPS APC"
"Enteroscopy With Emr","PX-75000504","CDM","44799","CPT","0750","RC","","","","both","","","3078.00","2308.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","954.18","2447.01","other","OPPS APC"
"Enteroscopy With Emr","PX-75000504","CDM","44799","CPT","0750","RC","","","","both","","","3078.00","2308.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","954.18","2447.01","other","OPPS APC"
"Enteroscopy With Emr","PX-75000504","CDM","44799","CPT","0750","RC","","","","both","","","3078.00","2308.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","954.18","2447.01","other","OPPS APC"
"Enteroscopy With Emr","PX-75000504","CDM","44799","CPT","0750","RC","","","","both","","","3078.00","2308.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1320.46","42.9","","1932.92","1932.92","1932.92","1 through 10","954.18","2447.01","percent of total billed charges",""
"Enteroscopy With Emr","PX-75000504","CDM","44799","CPT","0750","RC","","","","both","","","3078.00","2308.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","954.18","2447.01","other","OPPS APC"
"Enteroscopy With Emr","PX-75000504","CDM","44799","CPT","0750","RC","","","","both","","","3078.00","2308.50","WELLPOINT [1015]","HB AMC WELLPOINT","2270.95","73.78","","2222.33","2222.33","2222.33","1 through 10","954.18","2447.01","percent of total billed charges",""
"Enteroscopy With Emr","PX-75000504","CDM","44799","CPT","0750","RC","","","","outpatient","","","3078.00","2308.50","AETNA [1001]","HB AMC AETNA HMO","2148.44","69.8","","2238.60","2238.60","2238.60","1 through 10","1539","8899.59","percent of total billed charges",""
"Enteroscopy With Emr","PX-75000504","CDM","44799","CPT","0750","RC","","","","outpatient","","","3078.00","2308.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1863.73","60.55","","3144.00","2870.00","3286.00","1 through 10","1539","8899.59","percent of total billed charges",""
"Enteroscopy With Emr","PX-75000504","CDM","44799","CPT","0750","RC","","","","outpatient","","","3078.00","2308.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1608.56","52.26","","1775.96","1775.96","1775.96","1 through 10","1539","8899.59","percent of total billed charges",""
"Enteroscopy With Emr","PX-75000504","CDM","44799","CPT","0750","RC","","","","outpatient","","","3078.00","2308.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1607.33","52.22","","3286.00","2018.70","5898.00","1 through 10","1539","8899.59","percent of total billed charges",""
"Enteroscopy With Emr","PX-75000504","CDM","44799","CPT","0750","RC","","","","outpatient","","","3078.00","2308.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1615.95","52.5","","8340.00","8340.00","8340.00","1 through 10","1539","8899.59","percent of total billed charges",""
"Enteroscopy With Emr","PX-75000504","CDM","44799","CPT","0750","RC","","","","outpatient","","","3078.00","2308.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2515.34","81.72","","2294.28","682.69","2294.28","1 through 10","1539","8899.59","percent of total billed charges",""
"ENVELOPE ECM MED CORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268991","CDM","C1889","HCPCS","0278","RC","","","","both","","","3447.50","2585.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2740.76","79.5","","1309.77","674.56","6049.93","26","1068.73","2740.76","percent of total billed charges",""
"ENVELOPE ECM MED CORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268991","CDM","C1889","HCPCS","0278","RC","","","","both","","","3447.50","2585.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1837.52","53.3","","1901.83","1901.83","2962.25","1 through 10","1068.73","2740.76","percent of total billed charges",""
"ENVELOPE ECM MED CORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268991","CDM","C1889","HCPCS","0278","RC","","","","both","","","3447.50","2585.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1258.34","36.5","","1620.31","1620.31","19908.88","1 through 10","1068.73","2740.76","percent of total billed charges",""
"ENVELOPE ECM MED CORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268991","CDM","C1889","HCPCS","0278","RC","","","","both","","","3447.50","2585.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1320.39","38.3","","352.91","352.91","2046.30","1 through 10","1068.73","2740.76","percent of total billed charges",""
"ENVELOPE ECM MED CORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268991","CDM","C1889","HCPCS","0278","RC","","","","both","","","3447.50","2585.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1478.98","42.9","","9668.75","9668.75","9668.75","1 through 10","1068.73","2740.76","percent of total billed charges",""
"ENVELOPE ECM MED CORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268991","CDM","C1889","HCPCS","0278","RC","","","","both","","","3447.50","2585.62","WELLPOINT [1015]","HB AMC WELLPOINT","2543.57","73.78","","699.88","384.10","3443.31","33","1068.73","2740.76","percent of total billed charges",""
"ENVELOPE ECM MED CORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268991","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3447.50","2585.62","AETNA [1001]","HB AMC AETNA HMO","2406.36","69.8","","1421.24","264.50","4933.46","29","1801.66","2817.3","percent of total billed charges",""
"ENVELOPE ECM MED CORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268991","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3447.50","2585.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2771.79","80.4","","1022.97","1022.97","3607.50","1 through 10","1801.66","2817.3","percent of total billed charges",""
"ENVELOPE ECM MED CORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268991","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3447.50","2585.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2817.30","81.72","","3010.54","693.88","5019.88","35","1801.66","2817.3","percent of total billed charges",""
"ENVELOPE ECM XXLCORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268988","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3478.13","79.5","","1309.77","674.56","6049.93","26","1356.25","3478.13","percent of total billed charges",""
"ENVELOPE ECM XXLCORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268988","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2331.88","53.3","","1901.83","1901.83","2962.25","1 through 10","1356.25","3478.13","percent of total billed charges",""
"ENVELOPE ECM XXLCORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268988","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1596.88","36.5","","1620.31","1620.31","19908.88","1 through 10","1356.25","3478.13","percent of total billed charges",""
"ENVELOPE ECM XXLCORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268988","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1675.63","38.3","","352.91","352.91","2046.30","1 through 10","1356.25","3478.13","percent of total billed charges",""
"ENVELOPE ECM XXLCORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268988","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1876.88","42.9","","9668.75","9668.75","9668.75","1 through 10","1356.25","3478.13","percent of total billed charges",""
"ENVELOPE ECM XXLCORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268988","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB AMC WELLPOINT","3227.88","73.78","","699.88","384.10","3443.31","33","1356.25","3478.13","percent of total billed charges",""
"ENVELOPE ECM XXLCORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268988","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","AETNA [1001]","HB AMC AETNA HMO","3053.75","69.8","","1421.24","264.50","4933.46","29","2286.38","3575.25","percent of total billed charges",""
"ENVELOPE ECM XXLCORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268988","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3517.50","80.4","","1022.97","1022.97","3607.50","1 through 10","2286.38","3575.25","percent of total billed charges",""
"ENVELOPE ECM XXLCORMATRIX CANGAROO SINGLE PACK","SUP-ITM-10268988","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3575.25","81.72","","3010.54","693.88","5019.88","35","2286.38","3575.25","percent of total billed charges",""
"ENVELOPE TYRX CARDIAC LG ABSORBABLE ANTIBACTERIAL STERILE","SUP-ITM-10133307","CDM","C1889","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2490.34","79.5","","1309.77","674.56","6049.93","26","971.08","2490.34","percent of total billed charges",""
"ENVELOPE TYRX CARDIAC LG ABSORBABLE ANTIBACTERIAL STERILE","SUP-ITM-10133307","CDM","C1889","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1669.62","53.3","","1901.83","1901.83","2962.25","1 through 10","971.08","2490.34","percent of total billed charges",""
"ENVELOPE TYRX CARDIAC LG ABSORBABLE ANTIBACTERIAL STERILE","SUP-ITM-10133307","CDM","C1889","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1143.36","36.5","","1620.31","1620.31","19908.88","1 through 10","971.08","2490.34","percent of total billed charges",""
"ENVELOPE TYRX CARDIAC LG ABSORBABLE ANTIBACTERIAL STERILE","SUP-ITM-10133307","CDM","C1889","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1199.75","38.3","","352.91","352.91","2046.30","1 through 10","971.08","2490.34","percent of total billed charges",""
"ENVELOPE TYRX CARDIAC LG ABSORBABLE ANTIBACTERIAL STERILE","SUP-ITM-10133307","CDM","C1889","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1343.84","42.9","","9668.75","9668.75","9668.75","1 through 10","971.08","2490.34","percent of total billed charges",""
"ENVELOPE TYRX CARDIAC LG ABSORBABLE ANTIBACTERIAL STERILE","SUP-ITM-10133307","CDM","C1889","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","WELLPOINT [1015]","HB AMC WELLPOINT","2311.16","73.78","","699.88","384.10","3443.31","33","971.08","2490.34","percent of total billed charges",""
"ENVELOPE TYRX CARDIAC LG ABSORBABLE ANTIBACTERIAL STERILE","SUP-ITM-10133307","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","AETNA [1001]","HB AMC AETNA HMO","2186.49","69.8","","1421.24","264.50","4933.46","29","1637.04","2559.88","percent of total billed charges",""
"ENVELOPE TYRX CARDIAC LG ABSORBABLE ANTIBACTERIAL STERILE","SUP-ITM-10133307","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2518.53","80.4","","1022.97","1022.97","3607.50","1 through 10","1637.04","2559.88","percent of total billed charges",""
"ENVELOPE TYRX CARDIAC LG ABSORBABLE ANTIBACTERIAL STERILE","SUP-ITM-10133307","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2559.88","81.72","","3010.54","693.88","5019.88","35","1637.04","2559.88","percent of total billed charges",""
"Enzymatic Activity Other Than Virus","PX-30001365","CDM","87905","CPT","0306","RC","","","","both","","","205.00","153.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","162.98","79.5","","105.07","105.07","105.07","1 through 10","11.98","194.75","percent of total billed charges",""
"Enzymatic Activity Other Than Virus","PX-30001365","CDM","87905","CPT","0306","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.83","36.5","","74.23","74.23","74.23","1 through 10","11.98","194.75","percent of total billed charges",""
"Enzymatic Activity Other Than Virus","PX-30001365","CDM","87905","CPT","0306","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.52","38.3","","77.81","77.81","77.81","1 through 10","11.98","194.75","percent of total billed charges",""
"Enzyme Activity Nonradioact Substr","PX-30000415","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Enzyme Activity Nonradioact Substr","PX-30000415","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Eo W/O Joints Custom T1","PX-27000478","CDM","L3702","HCPCS","0274","RC","","","","both","","","39.00","29.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.94","38.3","","15.25","15.25","15.25","1 through 10","12.09","386.29","percent of total billed charges",""
"Eo W/O Joints Custom T1","PX-27000478","CDM","L3702","HCPCS","0274","RC","","","","outpatient","","","39.00","29.25","AETNA [1001]","HB AMC AETNA PPO","31.36","80.4","","20.44","20.44","20.44","1 through 10","19.5","641.72","percent of total billed charges",""
"Eo W/O Joints Custom T1","PX-27000478","CDM","L3702","HCPCS","0274","RC","","","","outpatient","","","39.00","29.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","19.50","50","","20.44","20.44","20.44","1 through 10","19.5","641.72","percent of total billed charges",""
"Ep Comprehensive W/Arrhythmia","PX-48000159","CDM","93620","CPT","0480","RC","","","","both","","","18786.00","14089.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9010.41","","APC Price ($9,010.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2647.87","2647.87","2647.87","1 through 10","5823.66","14934.87","other","OPPS APC"
"Ep Comprehensive W/Arrhythmia","PX-48000159","CDM","93620","CPT","0480","RC","","","","both","","","18786.00","14089.50","HUMANA [1012]","HB BWH MEDICARE","9010.41","","APC Price ($9,010.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8903.18","8903.18","8903.18","1 through 10","5823.66","14934.87","other","OPPS APC"
"Ep Comprehensive W/Arrhythmia","PX-48000159","CDM","93620","CPT","0480","RC","","","","both","","","18786.00","14089.50","MEDICARE [2001]","HB BWH MEDICARE","9010.41","","APC Price ($9,010.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","27033.96","9011.32","27033.96","1 through 10","5823.66","14934.87","other","OPPS APC"
"Ep Comprehensive W/Arrhythmia","PX-48000159","CDM","93620","CPT","0480","RC","","","","both","","","18786.00","14089.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6856.89","36.5","","6795.31","6795.31","6795.31","1 through 10","5823.66","14934.87","percent of total billed charges",""
"Ep Comprehensive W/Arrhythmia","PX-48000159","CDM","93620","CPT","0480","RC","","","","both","","","18786.00","14089.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7195.04","38.3","","13477.50","6922.84","13477.50","1 through 10","5823.66","14934.87","percent of total billed charges",""
"Ep Comprehensive W/Arrhythmia","PX-48000159","CDM","93620","CPT","0480","RC","","","","both","","","18786.00","14089.50","TRICARE [160005]","HB BWH TRICARE","8560.76","","APC Price ($9,011.32). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","8560.75","8560.75","8560.75","1 through 10","5823.66","14934.87","other","Tricare OPPS"
"Ep Comprehensive W/Arrhythmia","PX-48000159","CDM","93620","CPT","0480","RC","","","","outpatient","","","18786.00","14089.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4587.65","","Case rate ($4,587.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","10643.35","10643.35","10643.35","1 through 10","4587.65","15351.92","other","Multiple Surgery"
"Ep Comprehensive W/Arrhythmia","PX-48000159","CDM","93620","CPT","0480","RC","","","","outpatient","","","18786.00","14089.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","15351.92","81.72","","14563.47","14563.47","14563.47","1 through 10","4587.65","15351.92","percent of total billed charges",""
"Ep Intracardiac Echo Intervent","PX-48000170","CDM","93662","CPT","0481","RC","","","","both","","","2448.00","1836.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1946.16","79.5","","1868.34","1399.90","1868.34","1 through 10","758.88","6327.88","percent of total billed charges",""
"Ep Intracardiac Echo Intervent","PX-48000170","CDM","93662","CPT","0481","RC","","","","both","","","2448.00","1836.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1304.78","53.3","","1868.34","1253.47","1868.34","1 through 10","758.88","6327.88","percent of total billed charges",""
"Ep Intracardiac Echo Intervent","PX-48000170","CDM","93662","CPT","0481","RC","","","","both","","","2448.00","1836.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1591.20","65","","1543.10","1543.10","1543.10","1 through 10","758.88","6327.88","percent of total billed charges",""
"Ep Intracardiac Echo Intervent","PX-48000170","CDM","93662","CPT","0481","RC","","","","both","","","2448.00","1836.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","893.52","36.5","","1718.78","859.39","2656.50","1 through 10","758.88","6327.88","percent of total billed charges",""
"Ep Intracardiac Echo Intervent","PX-48000170","CDM","93662","CPT","0481","RC","","","","both","","","2448.00","1836.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","937.58","38.3","","928.23","902.12","928.23","1 through 10","758.88","6327.88","percent of total billed charges",""
"Ep Intracardiac Echo Intervent","PX-48000170","CDM","93662","CPT","0481","RC","","","","outpatient","","","2448.00","1836.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2000.51","81.72","","1897.78","1043.85","3795.56","1 through 10","1279.32","2000.51","percent of total billed charges",""
"Ep IV Drug Infusion Pacing","PX-48000162","CDM","93623","CPT","0481","RC","","","","both","","","4751.00","3563.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3777.05","79.5","","3625.71","3582.19","3625.71","1 through 10","1472.81","7754.56","percent of total billed charges",""
"Ep IV Drug Infusion Pacing","PX-48000162","CDM","93623","CPT","0481","RC","","","","both","","","4751.00","3563.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2532.28","53.3","","3625.71","3625.71","3625.71","1 through 10","1472.81","7754.56","percent of total billed charges",""
"Ep IV Drug Infusion Pacing","PX-48000162","CDM","93623","CPT","0481","RC","","","","both","","","4751.00","3563.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1734.12","36.5","","5155.23","1718.41","5155.23","1 through 10","1472.81","7754.56","percent of total billed charges",""
"Ep IV Drug Infusion Pacing","PX-48000162","CDM","93623","CPT","0481","RC","","","","both","","","4751.00","3563.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1819.63","38.3","","1801.34","1638.02","3374.14","1 through 10","1472.81","7754.56","percent of total billed charges",""
"Ep IV Drug Infusion Pacing","PX-48000162","CDM","93623","CPT","0481","RC","","","","outpatient","","","4751.00","3563.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3882.52","81.72","","3682.84","2025.70","6629.11","1 through 10","2482.87","3882.52","percent of total billed charges",""
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","50125.00","37593.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","30004.55","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","29978.45","26680.47","29978.45","1 through 10","15538.75","39849.38","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","50125.00","37593.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29130.63","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28667.44","13571.41","29133.58","1 through 10","15538.75","39849.38","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","50125.00","37593.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","39849.38","79.5","","114763.50","38254.50","114763.50","1 through 10","15538.75","39849.38","percent of total billed charges",""
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","50125.00","37593.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","26716.63","53.3","","38254.50","38254.50","38254.50","1 through 10","15538.75","39849.38","percent of total billed charges",""
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","50125.00","37593.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","29130.63","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28658.11","28618.65","28658.11","1 through 10","15538.75","39849.38","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","50125.00","37593.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","32581.25","65","","31595.20","31595.20","31595.20","1 through 10","15538.75","39849.38","percent of total billed charges",""
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","50125.00","37593.75","MEDICARE [2001]","HB BWH MEDICARE","29130.63","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29133.58","29133.58","87400.74","109","15538.75","39849.38","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","50125.00","37593.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","18295.63","36.5","","54392.34","54392.34","54392.34","1 through 10","15538.75","39849.38","percent of total billed charges",""
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","50125.00","37593.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","19197.88","38.3","","19005.73","17502.86","19005.73","1 through 10","15538.75","39849.38","percent of total billed charges",""
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","50125.00","37593.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","29130.63","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28551.31","28550.91","28551.31","1 through 10","15538.75","39849.38","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","50125.00","37593.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28548.02","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","85652.73","25404.31","85674.93","1 through 10","15538.75","39849.38","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","50125.00","37593.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21503.63","42.9","","22116.64","22116.64","22116.64","1 through 10","15538.75","39849.38","percent of total billed charges",""
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","50125.00","37593.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28548.02","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28558.81","25409.51","29133.58","1 through 10","15538.75","39849.38","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","outpatient","","","50125.00","37593.75","AETNA [1001]","HB AMC AETNA HMO","34987.25","69.8","","32907.62","23234.62","37914.24","1 through 10","17292.37","50931.12","percent of total billed charges",""
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","outpatient","","","50125.00","37593.75","AETNA [1001]","HB AMC AETNA PPO","40300.50","80.4","","35582.77","35582.77","35582.77","1 through 10","17292.37","50931.12","percent of total billed charges",""
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","outpatient","","","50125.00","37593.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","40118.30","38561.99","77123.98","1 through 10","17292.37","50931.12","other","Multiple Surgery"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","outpatient","","","50125.00","37593.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","42193.38","42193.38","126580.14","1 through 10","17292.37","50931.12","other","Multiple Surgery"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","outpatient","","","50125.00","37593.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","50147.87","50147.87","50147.87","1 through 10","17292.37","50931.12","other","Multiple Surgery"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","outpatient","","","50125.00","37593.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","44268.47","44268.47","44268.47","1 through 10","17292.37","50931.12","other","Multiple Surgery"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","outpatient","","","50125.00","37593.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","40962.15","81.72","","38857.24","21372.94","44268.47","1 through 10","17292.37","50931.12","percent of total billed charges",""
"Ephys Eval W/ Ablation Ventricular","PX-48000248","CDM","93654","CPT","0481","RC","","","","both","","","51530.00","38647.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","30004.55","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","29985.45","29978.45","29987.35","1 through 10","15974.3","40966.35","other","OPPS APC"
"Ephys Eval W/ Ablation Ventricular","PX-48000248","CDM","93654","CPT","0481","RC","","","","both","","","51530.00","38647.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29130.63","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28667.44","28667.44","49971.00","1 through 10","15974.3","40966.35","other","OPPS APC"
"Ephys Eval W/ Ablation Ventricular","PX-48000248","CDM","93654","CPT","0481","RC","","","","both","","","51530.00","38647.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","40966.35","79.5","","39327.18","38855.13","39327.18","1 through 10","15974.3","40966.35","percent of total billed charges",""
"Ephys Eval W/ Ablation Ventricular","PX-48000248","CDM","93654","CPT","0481","RC","","","","both","","","51530.00","38647.50","MEDICARE [2001]","HB BWH MEDICARE","29130.63","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29133.58","29133.58","51843.48","51","15974.3","40966.35","other","OPPS APC"
"Ephys Eval W/ Ablation Ventricular","PX-48000248","CDM","93654","CPT","0481","RC","","","","both","","","51530.00","38647.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","18808.45","36.5","","36179.00","18089.50","36179.00","1 through 10","15974.3","40966.35","percent of total billed charges",""
"Ephys Eval W/ Ablation Ventricular","PX-48000248","CDM","93654","CPT","0481","RC","","","","both","","","51530.00","38647.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28548.02","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","85668.93","85668.93","85668.93","1 through 10","15974.3","40966.35","other","OPPS APC"
"Ephys Eval W/ Ablation Ventricular","PX-48000248","CDM","93654","CPT","0481","RC","","","","both","","","51530.00","38647.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28548.02","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28550.91","25408.81","28667.44","1 through 10","15974.3","40966.35","other","OPPS APC"
"Ephys Eval W/ Ablation Ventricular","PX-48000248","CDM","93654","CPT","0481","RC","","","","outpatient","","","51530.00","38647.50","AETNA [1001]","HB AMC AETNA HMO","35967.94","69.8","","33830.37","33830.37","33830.37","1 through 10","17292.37","50931.12","percent of total billed charges",""
"Ephys Eval W/ Ablation Ventricular","PX-48000248","CDM","93654","CPT","0481","RC","","","","outpatient","","","51530.00","38647.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","120354.90","40118.30","120354.90","1 through 10","17292.37","50931.12","other","Multiple Surgery"
"Ephys Eval W/ Ablation Ventricular","PX-48000248","CDM","93654","CPT","0481","RC","","","","outpatient","","","51530.00","38647.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","81274.14","42193.38","81274.14","1 through 10","17292.37","50931.12","other","Multiple Surgery"
"Ephys Eval W/ Ablation Ventricular","PX-48000248","CDM","93654","CPT","0481","RC","","","","outpatient","","","51530.00","38647.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","66229.78","66229.78","66229.78","1 through 10","17292.37","50931.12","other","Multiple Surgery"
"Ephys Eval W/ Ablation Ventricular","PX-48000248","CDM","93654","CPT","0481","RC","","","","outpatient","","","51530.00","38647.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","42110.32","81.72","","68386.39","39946.82","79419.24","1 through 10","17292.37","50931.12","percent of total billed charges",""
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","30004.55","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","29985.45","26673.47","29987.35","15","15508.37","39771.47","other","OPPS APC"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29130.63","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28667.44","13273.59","28667.44","37","15508.37","39771.47","other","OPPS APC"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","39771.47","79.5","","114539.19","25614.86","115582.63","11","15508.37","39771.47","percent of total billed charges",""
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","26664.39","53.3","","27912.63","25614.86","47396.28","1 through 10","15508.37","39771.47","percent of total billed charges",""
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","29130.63","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28550.91","25403.31","28550.91","1 through 10","15508.37","39771.47","other","OPPS APC"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","38520.79","77","","37355.01","37355.01","37355.01","1 through 10","15508.37","39771.47","percent of total billed charges",""
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","HUMANA [1012]","HB BWH MEDICARE","29130.63","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28657.94","28638.64","28665.35","1 through 10","15508.37","39771.47","other","OPPS APC"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","29130.63","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25406.31","25406.31","25406.31","1 through 10","15508.37","39771.47","other","OPPS APC"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","MEDICARE [2001]","HB BWH MEDICARE","29130.63","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29133.58","29133.58","51843.48","523","15508.37","39771.47","other","OPPS APC"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","18259.86","36.5","","18095.35","17561.71","18095.35","1 through 10","15508.37","39771.47","percent of total billed charges",""
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","19160.34","38.3","","18968.58","18968.58","36869.88","1 through 10","15508.37","39771.47","percent of total billed charges",""
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","29130.63","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28550.91","25403.31","28550.91","1 through 10","15508.37","39771.47","other","OPPS APC"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","TRICARE [160005]","HB BWH TRICARE","27676.90","","APC Price ($29,133.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","24625.65","24625.65","24625.65","1 through 10","15508.37","39771.47","other","Tricare OPPS"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28548.02","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","85668.93","28558.31","85845.40","30","15508.37","39771.47","other","OPPS APC"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","both","","","50027.00","37520.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28548.02","","APC Price ($29,130.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28557.81","25412.31","28573.14","42","15508.37","39771.47","other","OPPS APC"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","outpatient","","","50027.00","37520.25","AETNA [1001]","HB AMC AETNA HMO","34918.85","69.8","","32843.30","23189.21","44486.80","25","17292.37","50931.12","percent of total billed charges",""
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","outpatient","","","50027.00","37520.25","AETNA [1001]","HB AMC AETNA PPO","40221.71","80.4","","37972.74","37972.74","37972.74","14","17292.37","50931.12","percent of total billed charges",""
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","outpatient","","","50027.00","37520.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","26144.11","52.26","","30019.84","30019.84","30019.84","1 through 10","17292.37","50931.12","percent of total billed charges",""
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","outpatient","","","50027.00","37520.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","44268.47","44268.47","44268.47","1 through 10","17292.37","50931.12","other","Multiple Surgery"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","outpatient","","","50027.00","37520.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","40118.30","40118.30","115685.97","46","17292.37","50931.12","other","Multiple Surgery"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","outpatient","","","50027.00","37520.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","42193.38","42193.38","81274.14","12","17292.37","50931.12","other","Multiple Surgery"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","outpatient","","","50027.00","37520.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","50147.87","8186.65","50147.87","1 through 10","17292.37","50931.12","other","Multiple Surgery"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","outpatient","","","50027.00","37520.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","42193.38","42193.38","42193.38","1 through 10","17292.37","50931.12","other","Multiple Surgery"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","outpatient","","","50027.00","37520.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","44268.47","593.30","44268.47","1 through 10","17292.37","50931.12","other","Multiple Surgery"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","outpatient","","","50027.00","37520.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","38781.29","38781.29","38781.29","1 through 10","17292.37","50931.12","other","Multiple Surgery"
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","outpatient","","","50027.00","37520.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","40882.06","81.72","","38781.29","21331.17","38781.29","1 through 10","17292.37","50931.12","percent of total billed charges",""
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","outpatient","","","50027.00","37520.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","40882.06","81.72","","38781.29","38781.29","38781.29","14","17292.37","50931.12","percent of total billed charges",""
"Ephys Evl Trnsptl Tx Atrial Fib Iso","PX-48000250","CDM","93656","CPT","0481","RC","","","","outpatient","","","50027.00","37520.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","17292.37","","Case rate ($17,292.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","48750.56","48750.56","48750.56","1 through 10","17292.37","50931.12","other","Multiple Surgery"
"Epidermolysis Bullosa With Pyloric Atresia via the Itga6 Gene","PX-31000827","CDM","81479","CPT","0310","RC","","","","both","","","2081.00","1560.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1654.40","79.5","","0.65","0.65","0.65","1 through 10","645.11","1976.95","percent of total billed charges",""
"Epidermolysis Bullosa With Pyloric Atresia via the Itga6 Gene","PX-31000827","CDM","81479","CPT","0310","RC","","","","both","","","2081.00","1560.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1109.17","53.3","","0.79","0.79","0.79","1 through 10","645.11","1976.95","percent of total billed charges",""
"Epidermolysis Bullosa With Pyloric Atresia via the Itga6 Gene","PX-31000827","CDM","81479","CPT","0310","RC","","","","outpatient","","","2081.00","1560.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1040.50","50","","1.00","1.00","1.00","1 through 10","156.55","1716.83","percent of total billed charges",""
"Epidermolysis Bullosa With Pyloric Atresia via the Itga6 Gene","PX-31000827","CDM","81479","CPT","0310","RC","","","","outpatient","","","2081.00","1560.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1092.53","52.5","","1.00","0.53","1.00","1 through 10","156.55","1716.83","percent of total billed charges",""
"Epidermolysis Bullosa With Pyloric Atresia via the Itgb4 Gene","PX-31000824","CDM","81479","CPT","0310","RC","","","","both","","","2811.00","2108.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2234.75","79.5","","0.65","0.65","0.65","1 through 10","871.41","2670.45","percent of total billed charges",""
"Epidermolysis Bullosa With Pyloric Atresia via the Itgb4 Gene","PX-31000824","CDM","81479","CPT","0310","RC","","","","both","","","2811.00","2108.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1498.26","53.3","","0.79","0.79","0.79","1 through 10","871.41","2670.45","percent of total billed charges",""
"Epidermolysis Bullosa With Pyloric Atresia via the Itgb4 Gene","PX-31000824","CDM","81479","CPT","0310","RC","","","","outpatient","","","2811.00","2108.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1405.50","50","","1.00","1.00","1.00","1 through 10","156.55","2319.08","percent of total billed charges",""
"Epidermolysis Bullosa With Pyloric Atresia via the Itgb4 Gene","PX-31000824","CDM","81479","CPT","0310","RC","","","","outpatient","","","2811.00","2108.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1475.78","52.5","","1.00","0.53","1.00","1 through 10","156.55","2319.08","percent of total billed charges",""
"Epidermolysis Bullosa With Pyloric Atresia via the Plec Gene","PX-31000828","CDM","81479","CPT","0310","RC","","","","both","","","4027.00","3020.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3201.47","79.5","","0.65","0.65","0.65","1 through 10","1248.37","3825.65","percent of total billed charges",""
"Epidermolysis Bullosa With Pyloric Atresia via the Plec Gene","PX-31000828","CDM","81479","CPT","0310","RC","","","","both","","","4027.00","3020.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2146.39","53.3","","0.79","0.79","0.79","1 through 10","1248.37","3825.65","percent of total billed charges",""
"Epidermolysis Bullosa With Pyloric Atresia via the Plec Gene","PX-31000828","CDM","81479","CPT","0310","RC","","","","outpatient","","","4027.00","3020.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2013.50","50","","1.00","1.00","1.00","1 through 10","156.55","3322.28","percent of total billed charges",""
"Epidermolysis Bullosa With Pyloric Atresia via the Plec Gene","PX-31000828","CDM","81479","CPT","0310","RC","","","","outpatient","","","4027.00","3020.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2114.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","3322.28","percent of total billed charges",""
"Epinephrine Inj 0.1mg","PX-63600059","CDM","J0171","HCPCS","0636","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","19.17","19.17","19.17","1 through 10","0.31","1.91","percent of total billed charges",""
"Epinephrine Inj 0.1mg","PX-63600059","CDM","J0171","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","2.03","0.16","2.03","1 through 10","0.31","1.91","percent of total billed charges",""
"Epinephrine Inj 0.1mg","PX-63600059","CDM","J0171","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","6.27","1.15","72.53","30","0.31","1.91","percent of total billed charges",""
"Epinephrine Inj 0.1mg","PX-63600059","CDM","J0171","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","3.74","1.39","88.07","29","0.47","0.82","percent of total billed charges",""
"Epinephrine Inj 0.1mg","PX-63600059","CDM","J0171","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.70","69.9","","127.68","1.20","192.84","1 through 10","0.47","0.82","percent of total billed charges",""
"Epinephrine Inj 0.1mg","PX-63600059","CDM","J0171","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","0.70","69.9","","43.00","43.00","43.00","1 through 10","0.47","0.82","percent of total billed charges",""
"Epinephrine Inj 0.1mg","PX-63600059","CDM","J0171","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","1.63","1.63","1.63","26","0.47","0.82","percent of total billed charges",""
"Episign Variant Genetics Panel Ggc","PX-31001160","CDM","81479","CPT","0310","RC","","","","both","","","2773.00","2079.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2204.54","79.5","","0.65","0.65","0.65","1 through 10","859.63","2634.35","percent of total billed charges",""
"Episign Variant Genetics Panel Ggc","PX-31001160","CDM","81479","CPT","0310","RC","","","","both","","","2773.00","2079.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1478.01","53.3","","0.79","0.79","0.79","1 through 10","859.63","2634.35","percent of total billed charges",""
"Episign Variant Genetics Panel Ggc","PX-31001160","CDM","81479","CPT","0310","RC","","","","outpatient","","","2773.00","2079.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1386.50","50","","1.00","1.00","1.00","1 through 10","156.55","2287.73","percent of total billed charges",""
"Episign Variant Genetics Panel Ggc","PX-31001160","CDM","81479","CPT","0310","RC","","","","outpatient","","","2773.00","2079.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1455.83","52.5","","1.00","0.53","1.00","1 through 10","156.55","2287.73","percent of total billed charges",""
"Episiotomy/Vag Rpr Oth/Thn Attending - 59300","PX-72000013","CDM","59300","CPT","0761","RC","","","","outpatient","","","4622.00","3466.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6259.18","6259.18","6259.18","1 through 10","2125.14","3777.1","other","ASC "
"Epistaxis With McC","150","MS-DRG","","","","","","","","inpatient","","","85554.21","64165.66","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12275.41","","Case rate ($12,525.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,001.33, add-ons for qualifying new technology services are included. If operating cost exceeds $60,645.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,511.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,074.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,621.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,071.40. The transfer capital threshold is the transfer adjustment factor * $1,071.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12567.60","12567.60","12567.60","1 through 10","12275.41","19837.1195","other","Inpatient DRG"
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","both","","","162.00","121.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","116.32","71.8","","338.19","112.73","338.19","18","12.86","153.9","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","both","","","162.00","121.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","106.27","65.6","","106.29","106.29","106.29","1 through 10","12.86","153.9","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","both","","","162.00","121.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","105.30","65","","102.05","102.05","102.05","1 through 10","12.86","153.9","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","both","","","162.00","121.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","113.40","70","","157.00","113.04","203.00","1 through 10","12.86","153.9","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","both","","","162.00","121.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","128.79","79.5","","102.05","102.05","131.95","1 through 10","12.86","153.9","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","both","","","162.00","121.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","86.35","53.3","","82.90","82.90","82.90","1 through 10","12.86","153.9","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","105.30","65","","102.05","102.05","102.05","1 through 10","12.86","153.9","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","59.13","36.5","","112.73","112.73","112.73","1 through 10","12.86","153.9","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.05","38.3","","338.19","61.39","338.19","1 through 10","12.86","153.9","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","outpatient","","","162.00","121.50","AETNA [1001]","HB AMC AETNA HMO","113.08","69.8","","106.29","106.29","122.46","1 through 10","13.53","132.39","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","outpatient","","","162.00","121.50","AETNA [1001]","HB AMC AETNA PPO","130.25","80.4","","122.46","122.46","122.46","1 through 10","13.53","132.39","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","outpatient","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","130.25","80.4","","78.50","78.50","78.50","1 through 10","13.53","132.39","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","132.39","81.72","","125.51","125.51","125.51","1 through 10","13.53","132.39","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","179.00","134.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","128.52","71.8","","374.79","124.93","374.79","18","14.72","170.05","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","179.00","134.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","117.42","65.6","","117.80","117.80","117.80","1 through 10","14.72","170.05","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","179.00","134.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","116.35","65","","113.10","113.10","113.10","1 through 10","14.72","170.05","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","179.00","134.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","125.30","70","","174.00","125.28","225.00","1 through 10","14.72","170.05","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","179.00","134.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","142.31","79.5","","136.94","91.87","136.94","15","14.72","170.05","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","179.00","134.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.41","53.3","","91.87","91.87","136.94","1 through 10","14.72","170.05","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","179.00","134.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","116.35","65","","113.10","113.10","113.10","1 through 10","14.72","170.05","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.34","36.5","","64.90","55.16","165.48","16","14.72","170.05","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.56","38.3","","68.03","57.42","374.79","37","14.72","170.05","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","179.00","134.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","137.83","77","","17.27","17.27","17.27","1 through 10","14.72","170.05","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","179.00","134.25","TRICARE [160005]","HB BWH TRICARE","170.05","95","","18.42","17.50","18.42","1 through 10","14.72","170.05","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","179.00","134.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.79","42.9","","139.10","76.51","139.10","1 through 10","14.72","170.05","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","outpatient","","","179.00","134.25","AETNA [1001]","HB AMC AETNA HMO","124.94","69.8","","117.80","83.17","135.72","28","14.72","146.28","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","outpatient","","","179.00","134.25","AETNA [1001]","HB AMC AETNA PPO","143.92","80.4","","135.72","91.18","271.44","1 through 10","14.72","146.28","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","outpatient","","","179.00","134.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","93.55","52.26","","107.67","107.67","107.67","1 through 10","14.72","146.28","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","outpatient","","","179.00","134.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","143.92","80.4","","87.00","87.00","87.00","1 through 10","14.72","146.28","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","outpatient","","","179.00","134.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","146.28","81.72","","139.10","139.10","139.10","1 through 10","14.72","146.28","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","outpatient","","","179.00","134.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","146.28","81.72","","139.10","76.51","139.10","15","14.72","146.28","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","186.00","139.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","133.55","71.8","","387.72","129.24","387.72","38","14.72","176.7","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","186.00","139.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","122.02","65.6","","121.86","121.86","140.40","1 through 10","14.72","176.7","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","186.00","139.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","120.90","65","","117.00","117.00","141.66","1 through 10","14.72","176.7","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","186.00","139.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","130.20","70","","180.00","129.60","388.80","23","14.72","176.7","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","186.00","139.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","147.87","79.5","","141.66","95.04","283.32","38","14.72","176.7","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","186.00","139.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","99.14","53.3","","141.66","95.04","190.08","21","14.72","176.7","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","186.00","139.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","120.90","65","","117.00","117.00","234.00","1 through 10","14.72","176.7","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","186.00","139.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.89","36.5","","67.14","57.06","171.18","33","14.72","176.7","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","186.00","139.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71.24","38.3","","70.38","68.40","387.72","81","14.72","176.7","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","186.00","139.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","143.22","77","","35.72","35.72","35.72","1 through 10","14.72","176.7","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","186.00","139.50","TRICARE [160005]","HB BWH TRICARE","176.70","95","","20.77","20.77","43.72","1 through 10","14.72","176.7","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.79","42.9","","143.89","79.15","143.89","1 through 10","14.72","176.7","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","186.00","139.50","AETNA [1001]","HB AMC AETNA HMO","129.83","69.8","","121.86","86.04","140.40","59","14.72","152","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","186.00","139.50","AETNA [1001]","HB AMC AETNA PPO","149.54","80.4","","140.40","94.32","280.80","13","14.72","152","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","186.00","139.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","97.20","52.26","","111.39","111.39","111.39","1 through 10","14.72","152","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","186.00","139.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","149.54","80.4","","180.00","180.00","180.00","1 through 10","14.72","152","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","152.00","81.72","","143.89","143.89","143.89","1 through 10","14.72","152","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","152.00","81.72","","143.89","79.15","287.78","31","14.72","152","percent of total billed charges",""
"Ercp Destruct Calculi Any Method","PX-75000114","CDM","43265","CPT","0750","RC","","","","both","","","6870.00","5152.50","MEDICARE [2001]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7069.32","7069.32","7069.32","1 through 10","2129.7","8835.76","other","OPPS APC"
"Ercp Diagnostic","PX-75000109","CDM","43260","CPT","0750","RC","","","","both","","","7067.00","5300.25","MEDICARE [2001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4179.88","4179.88","4179.88","1 through 10","2190.77","5647.06","other","OPPS APC"
"Ercp Diagnostic","PX-75000109","CDM","43260","CPT","0750","RC","","","","both","","","7067.00","5300.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4427.30","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4518.11","4427.75","4518.11","1 through 10","2190.77","5647.06","other","OPPS APC"
"Ercp Diagnostic","PX-75000109","CDM","43260","CPT","0750","RC","","","","both","","","7067.00","5300.25","WELLPOINT [1015]","HB AMC WELLPOINT","5214.03","73.78","","5102.06","5102.06","5102.06","1 through 10","2190.77","5647.06","percent of total billed charges",""
"Ercp Diagnostic","PX-75000109","CDM","43260","CPT","0750","RC","","","","outpatient","","","7067.00","5300.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7487.58","7487.58","7487.58","1 through 10","2542.22","5775.15","other","ASC "
"Ercp Diagnostic","PX-75000109","CDM","43260","CPT","0750","RC","","","","outpatient","","","7067.00","5300.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5775.15","81.72","","5478.29","5478.29","5478.29","1 through 10","2542.22","5775.15","percent of total billed charges",""
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","7027.00","5270.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7280.66","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","7283.23","6407.36","7283.23","1 through 10","2178.37","8835.76","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","7027.00","5270.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6956.21","2182.85","6956.21","1 through 10","2178.37","8835.76","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","7027.00","5270.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6955.19","6955.19","6955.19","1 through 10","2178.37","8835.76","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","7027.00","5270.25","MEDICARE [2001]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7069.32","3534.66","7069.32","15","2178.37","8835.76","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","7027.00","5270.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2691.34","38.3","","2664.27","2589.32","2664.27","1 through 10","2178.37","8835.76","percent of total billed charges",""
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","7027.00","5270.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6927.23","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6935.44","6927.93","7069.32","1 through 10","2178.37","8835.76","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","outpatient","","","7027.00","5270.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5141.51","","Case rate ($5,141.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","10329.29","10329.29","10329.29","1 through 10","3672.31","5742.46","other","ASC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","outpatient","","","7027.00","5270.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5141.51","","Case rate ($5,141.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","11918.02","11918.02","12036.27","1 through 10","3672.31","5742.46","other","ASC "
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","outpatient","","","7027.00","5270.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","4046.46","","Case rate ($4,046.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","10358.94","10358.94","10358.94","1 through 10","3672.31","5742.46","other","Multiple Surgery"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","outpatient","","","7027.00","5270.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4046.46","","Case rate ($4,046.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","9387.79","9387.79","9387.79","1 through 10","3672.31","5742.46","other","Multiple Surgery"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","outpatient","","","7027.00","5270.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","4046.46","","Case rate ($4,046.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","11289.62","11289.62","11289.62","1 through 10","3672.31","5742.46","other","Multiple Surgery"
"Ercp Ea Duct/Ampulla Dilate","PX-75000363","CDM","43277","CPT","0750","RC","","","","both","","","6870.00","5152.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1421.54","1421.54","1421.54","1 through 10","2129.7","5647.06","other","OPPS APC"
"Ercp Ea Duct/Ampulla Dilate","PX-75000363","CDM","43277","CPT","0750","RC","","","","both","","","6870.00","5152.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2507.55","36.5","","2411.64","2411.64","2411.64","1 through 10","2129.7","5647.06","percent of total billed charges",""
"Ercp Ea Duct/Ampulla Dilate","PX-75000363","CDM","43277","CPT","0750","RC","","","","outpatient","","","6870.00","5152.50","AETNA [1001]","HB AMC AETNA HMO","4795.26","69.8","","4510.17","4510.17","4510.17","1 through 10","2542.22","5614.16","percent of total billed charges",""
"Ercp Ea Duct/Ampulla Dilate","PX-75000363","CDM","43277","CPT","0750","RC","","","","outpatient","","","6870.00","5152.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7561.87","3743.79","7561.87","1 through 10","2542.22","5614.16","other","ASC "
"Ercp Ea Duct/Ampulla Dilate","PX-75000363","CDM","43277","CPT","0750","RC","","","","outpatient","","","6870.00","5152.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2542.22","","Case rate ($2,542.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2948.98","2948.98","2948.98","1 through 10","2542.22","5614.16","other","Multiple Surgery"
"Ercp Removal Calculi/Debris via G-Tube","PX-75000490","CDM","47999","CPT","0750","RC","","","","both","","","4992.00","3744.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3968.64","other","OPPS APC"
"Ercp Removal Calculi/Debris via G-Tube","PX-75000490","CDM","47999","CPT","0750","RC","","","","both","","","4992.00","3744.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","1057.74","3968.64","other","OPPS APC"
"Ercp Removal Calculi/Debris via G-Tube","PX-75000490","CDM","47999","CPT","0750","RC","","","","outpatient","","","4992.00","3744.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2606.82","52.22","","3734.00","1019.30","3734.00","1 through 10","2496","9843.6","percent of total billed charges",""
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","7159.00","5369.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2324.82","2324.82","2324.82","1 through 10","2140.15","5691.41","other","OPPS APC"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","7159.00","5369.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5691.41","79.5","","5463.35","5463.35","5463.35","1 through 10","2140.15","5691.41","percent of total billed charges",""
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","7159.00","5369.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3815.75","53.3","","3665.38","3665.38","3665.38","1 through 10","2140.15","5691.41","percent of total billed charges",""
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","7159.00","5369.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2207.73","2207.73","2207.73","1 through 10","2140.15","5691.41","other","OPPS APC"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","7159.00","5369.25","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","1 through 10","2140.15","5691.41","other","OPPS APC"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","7159.00","5369.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2741.90","38.3","","2714.32","2714.32","2714.32","1 through 10","2140.15","5691.41","percent of total billed charges",""
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","7159.00","5369.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2041.24","2041.24","2041.24","1 through 10","2140.15","5691.41","other","OPPS APC"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","7159.00","5369.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2076.78","2076.78","2076.78","1 through 10","2140.15","5691.41","other","OPPS APC"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","outpatient","","","7159.00","5369.25","AETNA [1001]","HB AMC AETNA HMO","4996.98","69.8","","4699.73","4699.73","4699.73","1 through 10","2542.22","5850.33","percent of total billed charges",""
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","outpatient","","","7159.00","5369.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6489.45","6489.45","6489.45","1 through 10","2542.22","5850.33","other","ASC"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","outpatient","","","7159.00","5369.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7561.87","7487.58","7561.87","1 through 10","2542.22","5850.33","other","ASC "
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","outpatient","","","7159.00","5369.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2542.22","","Case rate ($2,542.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3254.04","3254.04","3254.04","1 through 10","2542.22","5850.33","other","Multiple Surgery"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","outpatient","","","7159.00","5369.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2542.22","","Case rate ($2,542.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","5897.95","5897.95","5897.95","1 through 10","2542.22","5850.33","other","Multiple Surgery"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","outpatient","","","7159.00","5369.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2542.22","","Case rate ($2,542.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9016.69","9016.69","9016.69","1 through 10","2542.22","5850.33","other","Multiple Surgery"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","outpatient","","","7159.00","5369.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5755.84","80.4","","5414.76","5414.76","5414.76","1 through 10","2542.22","5850.33","percent of total billed charges",""
"Ercp Sphincteroplasty via Dilated G-Tube Tract","PX-75000489","CDM","47999","CPT","0750","RC","","","","both","","","1474.00","1105.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","456.94","1391.62","other","OPPS APC"
"Ercp Sphincteroplasty via Dilated G-Tube Tract","PX-75000489","CDM","47999","CPT","0750","RC","","","","both","","","1474.00","1105.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","456.94","1391.62","other","OPPS APC"
"Ercp Sphincteroplasty via Dilated G-Tube Tract","PX-75000489","CDM","47999","CPT","0750","RC","","","","outpatient","","","1474.00","1105.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","769.72","52.22","","3734.00","1019.30","3734.00","1 through 10","737","9843.6","percent of total billed charges",""
"Ercp Sphincterotomy W Removal Debris via Gastrotomy/Port","PX-75000502","CDM","47999","CPT","0750","RC","","","","both","","","10667.00","8000.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","8480.27","other","OPPS APC"
"Ercp Sphincterotomy W Removal Debris via Gastrotomy/Port","PX-75000502","CDM","47999","CPT","0750","RC","","","","both","","","10667.00","8000.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","1057.74","8480.27","other","OPPS APC"
"Ercp Sphincterotomy W Removal Debris via Gastrotomy/Port","PX-75000502","CDM","47999","CPT","0750","RC","","","","outpatient","","","10667.00","8000.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5570.31","52.22","","3734.00","1019.30","3734.00","1 through 10","5333.5","9843.6","percent of total billed charges",""
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","7163.00","5372.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7280.66","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","7281.03","7274.33","7281.03","1 through 10","2220.53","8835.76","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","7163.00","5372.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6956.21","6946.00","6956.21","1 through 10","2220.53","8835.76","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","7163.00","5372.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","5014.10","70","","6946.00","5001.12","6946.00","1 through 10","2220.53","8835.76","percent of total billed charges",""
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","7163.00","5372.25","CIGNA [1006]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6933.59","6933.59","6933.59","1 through 10","2220.53","8835.76","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","7163.00","5372.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6955.72","6955.72","6955.72","1 through 10","2220.53","8835.76","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","7163.00","5372.25","HUMANA [1012]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6848.76","6848.76","6848.76","1 through 10","2220.53","8835.76","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","7163.00","5372.25","MEDICARE [2001]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7069.32","6220.28","7069.32","32","2220.53","8835.76","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","7163.00","5372.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2743.43","38.3","","2715.89","2715.89","2715.89","1 through 10","2220.53","8835.76","percent of total billed charges",""
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","7163.00","5372.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6927.23","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6095.87","3463.97","6935.33","1 through 10","2220.53","8835.76","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","7163.00","5372.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6927.23","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6927.94","6927.93","6927.94","1 through 10","2220.53","8835.76","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","outpatient","","","7163.00","5372.25","AETNA [1001]","HB AMC AETNA HMO","4999.77","69.8","","4702.44","4702.44","5417.88","1 through 10","3743.38","5853.6","percent of total billed charges",""
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","outpatient","","","7163.00","5372.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5141.51","","Case rate ($5,141.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","10329.29","10329.29","10329.29","1 through 10","3743.38","5853.6","other","ASC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","outpatient","","","7163.00","5372.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5141.51","","Case rate ($5,141.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","11918.02","11918.02","12036.27","24","3743.38","5853.6","other","ASC "
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","outpatient","","","7163.00","5372.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4046.46","","Case rate ($4,046.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","9387.79","9387.79","9387.79","1 through 10","3743.38","5853.6","other","Multiple Surgery"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","outpatient","","","7163.00","5372.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4046.46","","Case rate ($4,046.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9873.36","9873.36","9873.36","1 through 10","3743.38","5853.6","other","Multiple Surgery"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","outpatient","","","7163.00","5372.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5853.60","81.72","","5552.63","3054.16","6500.00","1 through 10","3743.38","5853.6","percent of total billed charges",""
"Ercp Stent Insert via Roux-en-Y Excluded Stomach Duodenum Tract","PX-75000492","CDM","47999","CPT","0750","RC","","","","both","","","7401.00","5550.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","5883.8","other","OPPS APC"
"Ercp Stent Insert via Roux-en-Y Excluded Stomach Duodenum Tract","PX-75000492","CDM","47999","CPT","0750","RC","","","","both","","","7401.00","5550.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","1057.74","5883.8","other","OPPS APC"
"Ercp Stent Insert via Roux-en-Y Excluded Stomach Duodenum Tract","PX-75000492","CDM","47999","CPT","0750","RC","","","","outpatient","","","7401.00","5550.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3864.80","52.22","","3734.00","1019.30","3734.00","1 through 10","3700.5","9843.6","percent of total billed charges",""
"Ercp Stent Removal via G-Tube","PX-75000482","CDM","47999","CPT","0750","RC","","","","both","","","3052.00","2289.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","946.12","2426.34","other","OPPS APC"
"Ercp Stent Removal via G-Tube","PX-75000482","CDM","47999","CPT","0750","RC","","","","both","","","3052.00","2289.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","946.12","2426.34","other","OPPS APC"
"Ercp Stent Removal via G-Tube","PX-75000482","CDM","47999","CPT","0750","RC","","","","outpatient","","","3052.00","2289.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1593.75","52.22","","3734.00","1019.30","3734.00","1 through 10","1526","9843.6","percent of total billed charges",""
"Ercp via Gastrostomy or Roux-en-Y Anatomy","PX-75000451","CDM","48999","CPT","0750","RC","","","","outpatient","","","3377.00","2532.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1763.47","52.22","","1550.84","1550.84","1550.84","1 through 10","1234.13","2786.03","percent of total billed charges",""
"Ercp W/Biopsy","PX-75000110","CDM","43261","CPT","0750","RC","","","","both","","","6870.00","5152.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4445.82","4445.82","4445.82","1 through 10","2129.7","5647.06","other","OPPS APC"
"Ercp W/Biopsy","PX-75000110","CDM","43261","CPT","0750","RC","","","","both","","","6870.00","5152.50","MEDICARE [2001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4518.11","4518.11","4518.11","1 through 10","2129.7","5647.06","other","OPPS APC"
"Ercp W/Biopsy","PX-75000110","CDM","43261","CPT","0750","RC","","","","both","","","6870.00","5152.50","WELLPOINT [1015]","HB AMC WELLPOINT","5068.69","73.78","","4959.85","4959.85","4959.85","1 through 10","2129.7","5647.06","percent of total billed charges",""
"Ercp W/Biopsy","PX-75000110","CDM","43261","CPT","0750","RC","","","","outpatient","","","6870.00","5152.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3743.79","3743.79","3743.79","1 through 10","2542.22","5614.16","other","ASC "
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","7032.00","5274.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4653.18","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4656.13","4655.46","4656.13","1 through 10","2179.92","5647.06","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","7032.00","5274.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6819.00","6819.00","6819.00","1 through 10","2179.92","5647.06","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","7032.00","5274.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4922.40","70","","6819.00","4909.68","6819.00","1 through 10","2179.92","5647.06","percent of total billed charges",""
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","7032.00","5274.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5590.44","79.5","","5366.55","5366.55","5366.55","1 through 10","2179.92","5647.06","percent of total billed charges",""
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","7032.00","5274.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3748.06","53.3","","3600.43","3600.43","3600.43","1 through 10","2179.92","5647.06","percent of total billed charges",""
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","7032.00","5274.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4096.28","4096.28","4096.28","1 through 10","2179.92","5647.06","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","7032.00","5274.00","HUMANA [1012]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","121.59","121.59","121.59","1 through 10","2179.92","5647.06","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","7032.00","5274.00","MEDICARE [2001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4518.11","4179.88","4518.11","19","2179.92","5647.06","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","7032.00","5274.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2693.26","38.3","","2666.23","2666.23","2666.23","1 through 10","2179.92","5647.06","percent of total billed charges",""
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","7032.00","5274.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4098.78","4098.78","4098.78","1 through 10","2179.92","5647.06","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","7032.00","5274.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4427.30","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4437.08","4435.25","4437.08","1 through 10","2179.92","5647.06","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","7032.00","5274.00","WELLPOINT [1015]","HB AMC WELLPOINT","5188.21","73.78","","5076.74","5076.74","5076.74","1 through 10","2179.92","5647.06","percent of total billed charges",""
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","7032.00","5274.00","AETNA [1001]","HB AMC AETNA HMO","4908.34","69.8","","4616.46","4616.46","4616.46","1 through 10","2542.22","5746.55","percent of total billed charges",""
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","7032.00","5274.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3244.73","3244.73","6608.97","1 through 10","2542.22","5746.55","other","ASC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","7032.00","5274.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3780.94","3743.79","7561.87","29","2542.22","5746.55","other","ASC "
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","7032.00","5274.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2542.22","","Case rate ($2,542.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6508.08","3254.04","6508.08","1 through 10","2542.22","5746.55","other","Multiple Surgery"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","7032.00","5274.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2542.22","","Case rate ($2,542.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2948.98","2948.98","2948.98","1 through 10","2542.22","5746.55","other","Multiple Surgery"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","7032.00","5274.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2542.22","","Case rate ($2,542.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3101.51","3101.51","3101.51","1 through 10","2542.22","5746.55","other","Multiple Surgery"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","7032.00","5274.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5653.73","80.4","","5318.82","5318.82","5318.82","1 through 10","2542.22","5746.55","percent of total billed charges",""
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","7032.00","5274.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2542.22","","Case rate ($2,542.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3546.40","3546.40","3546.40","1 through 10","2542.22","5746.55","other","Multiple Surgery"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","7032.00","5274.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5746.55","81.72","","5451.11","2998.31","6500.00","1 through 10","2542.22","5746.55","percent of total billed charges",""
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","6524.00","4893.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4653.18","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4658.04","4658.04","4658.04","1 through 10","2022.44","5647.06","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","6524.00","4893.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4445.82","4445.82","4445.82","1 through 10","2022.44","5647.06","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","6524.00","4893.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5186.58","79.5","","4979.35","4979.35","4979.35","1 through 10","2022.44","5647.06","percent of total billed charges",""
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","6524.00","4893.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4445.82","4445.82","4445.82","1 through 10","2022.44","5647.06","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","6524.00","4893.00","MEDICARE [2001]","HB BWH MEDICARE","4517.65","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4518.11","4518.11","4518.11","1 through 10","2022.44","5647.06","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","6524.00","4893.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2498.69","38.3","","2359.97","2359.97","2359.97","1 through 10","2022.44","5647.06","percent of total billed charges",""
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","6524.00","4893.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4427.30","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4429.75","4429.75","4429.75","1 through 10","2022.44","5647.06","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","6524.00","4893.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4427.30","","APC Price ($4,517.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4103.69","4103.69","4103.69","1 through 10","2022.44","5647.06","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","6524.00","4893.00","WELLPOINT [1015]","HB AMC WELLPOINT","4813.41","73.78","","4710.45","4710.45","4710.45","1 through 10","2022.44","5647.06","percent of total billed charges",""
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","outpatient","","","6524.00","4893.00","AETNA [1001]","HB AMC AETNA HMO","4553.75","69.8","","4283.38","4283.38","4283.38","1 through 10","2542.22","5545.35","percent of total billed charges",""
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","outpatient","","","6524.00","4893.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3304.49","3304.49","3304.49","1 through 10","2542.22","5545.35","other","ASC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","outpatient","","","6524.00","4893.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3780.94","3743.79","7487.58","1 through 10","2542.22","5545.35","other","ASC "
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","outpatient","","","6524.00","4893.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2542.22","","Case rate ($2,542.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","5897.95","5897.95","5897.95","1 through 10","2542.22","5545.35","other","Multiple Surgery"
"Ercp With Coil Embolization","PX-75000523","CDM","47999","CPT","0750","RC","","","","both","","","7111.00","5333.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","5653.25","other","OPPS APC"
"Ercp With Coil Embolization","PX-75000523","CDM","47999","CPT","0750","RC","","","","both","","","7111.00","5333.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","1057.74","5653.25","other","OPPS APC"
"Ercp With Coil Embolization","PX-75000523","CDM","47999","CPT","0750","RC","","","","outpatient","","","7111.00","5333.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3713.36","52.22","","3734.00","1019.30","3734.00","1 through 10","3555.5","9843.6","percent of total billed charges",""
"Ercp With Control of Bleeding","PX-75000458","CDM","47999","CPT","0750","RC","","","","both","","","2701.00","2025.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","837.31","2147.3","other","OPPS APC"
"Ercp With Control of Bleeding","PX-75000458","CDM","47999","CPT","0750","RC","","","","both","","","2701.00","2025.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","837.31","2147.3","other","OPPS APC"
"Ercp With Control of Bleeding","PX-75000458","CDM","47999","CPT","0750","RC","","","","outpatient","","","2701.00","2025.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1410.46","52.22","","3734.00","1019.30","3734.00","1 through 10","1350.5","9843.6","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","both","","","243.00","182.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","193.19","79.5","","124.61","124.61","185.73","1 through 10","18.41","230.85","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","both","","","243.00","182.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","129.52","53.3","","124.61","124.61","185.73","1 through 10","18.41","230.85","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","both","","","243.00","182.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","88.70","36.5","","264.09","74.10","264.09","1 through 10","18.41","230.85","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","both","","","243.00","182.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.07","38.3","","92.28","92.28","264.09","21","18.41","230.85","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","both","","","243.00","182.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","230.85","95","","18.79","18.79","18.79","1 through 10","18.41","230.85","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","outpatient","","","243.00","182.25","AETNA [1001]","HB AMC AETNA HMO","169.61","69.8","","159.77","159.77","184.08","1 through 10","19.39","198.58","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","outpatient","","","243.00","182.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","198.58","81.72","","188.66","188.66","226.41","1 through 10","19.39","198.58","percent of total billed charges",""
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","3294.00","2470.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","620.04","620.04","1 through 10","598.61","2618.73","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","3294.00","2470.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2618.73","79.5","","2513.68","2513.68","2513.68","1 through 10","598.61","2618.73","percent of total billed charges",""
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","3294.00","2470.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1755.70","53.3","","1686.43","1686.43","1686.43","1 through 10","598.61","2618.73","percent of total billed charges",""
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","3294.00","2470.50","FALLON HEALTH [1008]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1852.56","1852.56","1852.56","1 through 10","598.61","2618.73","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","3294.00","2470.50","MEDICARE [2001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","630.12","27","598.61","2618.73","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","3294.00","2470.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1202.31","36.5","","1012.50","1012.50","1012.50","1 through 10","598.61","2618.73","percent of total billed charges",""
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","3294.00","2470.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1261.60","38.3","","1248.85","1248.85","1248.85","1 through 10","598.61","2618.73","percent of total billed charges",""
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","3294.00","2470.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","617.52","617.52","617.52","1 through 10","598.61","2618.73","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","3294.00","2470.50","TRICARE [160005]","HB BWH TRICARE","598.61","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","598.61","598.61","598.61","1 through 10","598.61","2618.73","other","Tricare OPPS"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","3294.00","2470.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.52","617.52","617.92","1 through 10","598.61","2618.73","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","3294.00","2470.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.52","574.09","630.12","1 through 10","598.61","2618.73","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","3294.00","2470.50","WELLPOINT [1015]","HB AMC WELLPOINT","2430.31","73.78","","714.65","714.65","714.65","1 through 10","598.61","2618.73","percent of total billed charges",""
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","outpatient","","","3294.00","2470.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2691.86","81.72","","2553.28","1404.40","2553.28","1 through 10","922.47","2691.86","percent of total billed charges",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","58186.72","43640.04","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","12307.89","","Case rate ($11,949.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,307.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,951.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,460.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,549.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,927.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.55. The transfer capital threshold is the transfer adjustment factor * $1,020.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12347.48","12300.05","12349.58","1 through 10","11710.42","19866.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","58186.72","43640.04","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","15395.15","","Case rate ($15,395.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,307.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,951.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,460.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $13,994.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,927.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.55. The transfer capital threshold is the transfer adjustment factor * $1,020.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11985.23","11842.21","34921.16","1 through 10","11710.42","19866.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","58186.72","43640.04","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","14936.76","","Case rate ($11,949.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,307.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,951.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,460.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,549.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,927.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.55. The transfer capital threshold is the transfer adjustment factor * $1,020.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","11753.32","11753.32","11753.32","1 through 10","11710.42","19866.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","58186.72","43640.04","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","11949.41","","Case rate ($11,949.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,307.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,951.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,460.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,549.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,927.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.55. The transfer capital threshold is the transfer adjustment factor * $1,020.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11743.57","11718.56","11893.55","1 through 10","11710.42","19866.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","58186.72","43640.04","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","27211.47","27211.47","27211.47","1 through 10","11710.42","19866.65","case rate",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","58186.72","43640.04","MEDICARE [2001]","HB BWH MEDICARE","15395.15","","Case rate ($15,395.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,307.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,951.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,460.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $13,994.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,927.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.55. The transfer capital threshold is the transfer adjustment factor * $1,020.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15421.46","0.03","15444.11","111","11710.42","19866.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","58186.72","43640.04","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","11710.42","","Case rate ($11,949.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,307.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,951.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,460.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,549.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,927.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.55. The transfer capital threshold is the transfer adjustment factor * $1,020.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11732.05","11725.25","11798.80","1 through 10","11710.42","19866.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","58186.72","43640.04","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11710.42","","Case rate ($11,949.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,307.31, add-ons for qualifying new technology services are included. If operating cost exceeds $59,951.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,460.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,549.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,927.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.55. The transfer capital threshold is the transfer adjustment factor * $1,020.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11800.07","11740.84","16105.03","1 through 10","11710.42","19866.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","38232.63","28674.47","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7716.17","","Case rate ($7,491.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,940.79, add-ons for qualifying new technology services are included. If operating cost exceeds $54,585.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,067.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,484.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,560.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.31. The transfer capital threshold is the transfer adjustment factor * $627.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7622.51","7598.17","7630.28","1 through 10","7341.6","12211.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","38232.63","28674.47","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9609.46","","Case rate ($9,609.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,940.79, add-ons for qualifying new technology services are included. If operating cost exceeds $54,585.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,067.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,602.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,560.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.31. The transfer capital threshold is the transfer adjustment factor * $627.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9342.49","9342.49","9350.87","1 through 10","7341.6","12211.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","38232.63","28674.47","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","9364.29","","Case rate ($7,491.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,940.79, add-ons for qualifying new technology services are included. If operating cost exceeds $54,585.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,067.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,484.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,560.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.31. The transfer capital threshold is the transfer adjustment factor * $627.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","7378.57","7378.57","7378.57","1 through 10","7341.6","12211.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","38232.63","28674.47","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7491.43","","Case rate ($7,491.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,940.79, add-ons for qualifying new technology services are included. If operating cost exceeds $54,585.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,067.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,484.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,560.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.31. The transfer capital threshold is the transfer adjustment factor * $627.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7280.49","7280.49","7280.49","1 through 10","7341.6","12211.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","38232.63","28674.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","","65","","27331.00","27331.00","27331.00","1 through 10","7341.6","12211.65","percent of total billed charges",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","38232.63","28674.47","MARTIN'S POINT [160007]","HB BWH MEDICARE","9609.46","","Case rate ($9,609.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,940.79, add-ons for qualifying new technology services are included. If operating cost exceeds $54,585.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,067.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,602.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,560.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.31. The transfer capital threshold is the transfer adjustment factor * $627.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7228.16","7228.16","7228.16","1 through 10","7341.6","12211.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","38232.63","28674.47","MEDICARE [2001]","HB BWH MEDICARE","9609.46","","Case rate ($9,609.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,940.79, add-ons for qualifying new technology services are included. If operating cost exceeds $54,585.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,067.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,602.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,560.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.31. The transfer capital threshold is the transfer adjustment factor * $627.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9477.36","0.03","9491.12","114","7341.6","12211.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","38232.63","28674.47","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","9609.46","","Case rate ($9,609.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,940.79, add-ons for qualifying new technology services are included. If operating cost exceeds $54,585.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,067.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $8,602.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,560.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.31. The transfer capital threshold is the transfer adjustment factor * $627.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7241.37","7241.37","7241.37","1 through 10","7341.6","12211.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","38232.63","28674.47","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7341.60","","Case rate ($7,491.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,940.79, add-ons for qualifying new technology services are included. If operating cost exceeds $54,585.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,067.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,484.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,560.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.31. The transfer capital threshold is the transfer adjustment factor * $627.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7236.43","7225.63","7280.49","1 through 10","7341.6","12211.65","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","38232.63","28674.47","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7341.60","","Case rate ($7,491.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,940.79, add-ons for qualifying new technology services are included. If operating cost exceeds $54,585.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,067.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,484.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,560.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.31. The transfer capital threshold is the transfer adjustment factor * $627.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7272.09","7228.16","11488.22","16","7341.6","12211.65","other","Inpatient DRG"
"Esophagoscop Stent Placement","PX-75000354","CDM","43212","CPT","0750","RC","","","","both","","","1396.00","1047.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7280.66","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2713.01","2713.01","2713.01","1 through 10","432.76","8835.76","other","OPPS APC"
"Esophagoscop Stent Placement","PX-75000354","CDM","43212","CPT","0750","RC","","","","both","","","1396.00","1047.00","MEDICARE [2001]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7069.32","6220.28","7069.32","1 through 10","432.76","8835.76","other","OPPS APC"
"Esophagoscop Stent Placement","PX-75000354","CDM","43212","CPT","0750","RC","","","","both","","","1396.00","1047.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6927.23","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6956.21","6956.21","6956.21","1 through 10","432.76","8835.76","other","OPPS APC"
"Esophagoscopy Flex Transoral Dx","PX-75000072","CDM","43200","CPT","0750","RC","","","","both","","","2376.00","1782.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","736.56","1888.92","other","OPPS APC"
"Esophagoscopy Rig Transoral Guide Wire Dilation","PX-75000396","CDM","43196","CPT","0750","RC","","","","outpatient","","","6343.00","4757.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5183.50","81.72","","6667.00","6667.00","6667.00","1 through 10","2537.2","5183.5","percent of total billed charges",""
"Esophagoscopy Rigid Transoral Diagnostic Brush","PX-75000385","CDM","43191","CPT","0750","RC","","","","both","","","2333.00","1749.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2647.96","2647.96","2647.96","1 through 10","723.23","2815.7","other","OPPS APC"
"Esophagoscopy Rigid Transoral Inj Submucosal","PX-75000393","CDM","43192","CPT","0750","RC","","","","both","","","3527.00","2645.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2803.97","79.5","","1403.77","1403.77","1403.77","1 through 10","1093.37","2815.7","percent of total billed charges",""
"Esophagoscopy Rigid Transoral Inj Submucosal","PX-75000393","CDM","43192","CPT","0750","RC","","","","both","","","3527.00","2645.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1350.84","38.3","","1337.22","1337.22","1337.22","1 through 10","1093.37","2815.7","percent of total billed charges",""
"Esophagoscopy Rigid Transoral Inj Submucosal","PX-75000393","CDM","43192","CPT","0750","RC","","","","outpatient","","","3527.00","2645.25","AETNA [1001]","HB AMC AETNA PPO","2835.71","80.4","","4370.16","4370.16","4370.16","1 through 10","1335.02","5545.35","percent of total billed charges",""
"Esophagoscopy Rigid Transoral Inj Submucosal","PX-75000393","CDM","43192","CPT","0750","RC","","","","outpatient","","","3527.00","2645.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3407.87","3407.87","3407.87","1 through 10","1335.02","5545.35","other","ASC"
"Esophagoscopy Rigid Transoral Inj Submucosal","PX-75000393","CDM","43192","CPT","0750","RC","","","","outpatient","","","3527.00","2645.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3971.04","3932.02","3971.04","12","1335.02","5545.35","other","ASC "
"Esophagoscopy Rigid Transoral Inj Submucosal","PX-75000393","CDM","43192","CPT","0750","RC","","","","outpatient","","","3527.00","2645.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3417.65","3417.65","3417.65","1 through 10","1335.02","5545.35","other","Multiple Surgery"
"Esophagoscopy W/ Insertion of Wire W/Dilation of Esophageal Stoma","PX-75000532","CDM","43499","CPT","0750","RC","","","","both","","","3697.00","2772.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1970.50","53.3","","0.07","0.07","0.07","30","1057.74","2939.12","percent of total billed charges",""
"Esophagoscopy W/ Insertion of Wire W/Dilation of Esophageal Stoma","PX-75000532","CDM","43499","CPT","0750","RC","","","","both","","","3697.00","2772.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","2939.12","other","OPPS APC"
"Esophagoscopy W/ Insertion of Wire W/Dilation of Esophageal Stoma","PX-75000532","CDM","43499","CPT","0750","RC","","","","both","","","3697.00","2772.75","WELLPOINT [1015]","HB AMC WELLPOINT","2727.65","73.78","","2340.71","2340.71","2340.71","1 through 10","1057.74","2939.12","percent of total billed charges",""
"Esophagoscopy W/ Insertion of Wire W/Dilation of Esophageal Stoma","PX-75000532","CDM","43499","CPT","0750","RC","","","","outpatient","","","3697.00","2772.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1930.57","52.22","","6151.50","2038.73","10659.00","1 through 10","1848.5","3050.03","percent of total billed charges",""
"Esophagoscopy W/ Insertion of Wire W/Dilation of Esophageal Stoma","PX-75000532","CDM","43499","CPT","0750","RC","","","","outpatient","","","3697.00","2772.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1848.50","50","","3144.00","3144.00","3144.00","1 through 10","1848.5","3050.03","percent of total billed charges",""
"Esophagoscopy W/ Insertion of Wire W/Dilation of Esophageal Stoma","PX-75000532","CDM","43499","CPT","0750","RC","","","","outpatient","","","3697.00","2772.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3021.19","81.72","","1810.95","1810.95","1810.95","1 through 10","1848.5","3050.03","percent of total billed charges",""
"Esophagoscopy W/Dilate Balloon","PX-75000081","CDM","43220","CPT","0750","RC","","","","both","","","3597.00","2697.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2320.14","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2324.74","2318.12","2324.74","1 through 10","1115.07","2906.42","other","OPPS APC"
"Esophagoscopy W/Dilate Balloon","PX-75000081","CDM","43220","CPT","0750","RC","","","","both","","","3597.00","2697.75","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1115.07","2906.42","other","OPPS APC"
"Esophagoscopy W/Dilate Balloon","PX-75000081","CDM","43220","CPT","0750","RC","","","","outpatient","","","3597.00","2697.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3097.25","3097.25","3097.25","1 through 10","1335.02","2939.47","other","Multiple Surgery"
"Esophagoscopy W/Dilate Guide Wire","PX-75000082","CDM","43226","CPT","0750","RC","","","","both","","","3597.00","2697.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2859.62","79.5","","2629.95","2629.95","2629.95","1 through 10","1115.07","2906.42","percent of total billed charges",""
"Esophagoscopy W/Dilate Guide Wire","PX-75000082","CDM","43226","CPT","0750","RC","","","","both","","","3597.00","2697.75","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1115.07","2906.42","other","OPPS APC"
"Esophagoscopy W/Dilate Guide Wire","PX-75000082","CDM","43226","CPT","0750","RC","","","","both","","","3597.00","2697.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1312.91","36.5","","1301.02","1301.02","1301.02","1 through 10","1115.07","2906.42","percent of total billed charges",""
"Esophagoscopy W/Dilate Guide Wire","PX-75000082","CDM","43226","CPT","0750","RC","","","","outpatient","","","3597.00","2697.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3097.25","3097.25","3097.25","1 through 10","1335.02","2939.47","other","Multiple Surgery"
"Esophagoscopy W/Dilate Guide Wire","PX-75000082","CDM","43226","CPT","0750","RC","","","","outpatient","","","3597.00","2697.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2939.47","81.72","","13003.04","13003.04","13003.04","1 through 10","1335.02","2939.47","percent of total billed charges",""
"Esophagoscopy W/Dir Submucosal Inj","PX-75000073","CDM","43201","CPT","0750","RC","","","","outpatient","","","3597.00","2697.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1878.35","52.22","","3971.04","3971.04","3971.04","1 through 10","1438.8","2939.47","percent of total billed charges",""
"Esophagoscp Rig Transoral Hypopharynx Crv Esoph","PX-36000344","CDM","43180","CPT","0361","RC","","","","outpatient","","","4150.00","3112.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2167.13","52.22","","11727.60","11727.60","11727.60","1 through 10","1660","3391.38","percent of total billed charges",""
"Esr1 Gene Analysis","PX-31000777","CDM","81479","CPT","0310","RC","","","","both","","","10924.00","8193.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8684.58","79.5","","0.65","0.65","0.65","1 through 10","3386.44","10377.8","percent of total billed charges",""
"Esr1 Gene Analysis","PX-31000777","CDM","81479","CPT","0310","RC","","","","both","","","10924.00","8193.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5822.49","53.3","","0.79","0.79","0.79","1 through 10","3386.44","10377.8","percent of total billed charges",""
"Esr1 Gene Analysis","PX-31000777","CDM","81479","CPT","0310","RC","","","","outpatient","","","10924.00","8193.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5462.00","50","","1.00","1.00","1.00","1 through 10","156.55","9012.3","percent of total billed charges",""
"Esr1 Gene Analysis","PX-31000777","CDM","81479","CPT","0310","RC","","","","outpatient","","","10924.00","8193.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","5735.10","52.5","","1.00","0.53","1.00","1 through 10","156.55","9012.3","percent of total billed charges",""
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","5132.00","3849.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","855.80","","APC Price ($830.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","855.06","855.06","855.06","1 through 10","789.41","4079.94","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","5132.00","3849.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","830.88","","APC Price ($830.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","817.66","817.66","817.66","1 through 10","789.41","4079.94","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","5132.00","3849.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","1038.59","","APC Price ($830.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","638.33","509.93","638.33","1 through 10","789.41","4079.94","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","5132.00","3849.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","830.88","","APC Price ($830.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","817.66","750.49","817.66","1 through 10","789.41","4079.94","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","5132.00","3849.00","HUMANA [1012]","HB BWH MEDICARE","830.88","","APC Price ($830.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","817.66","817.66","817.66","1 through 10","789.41","4079.94","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","5132.00","3849.00","MEDICARE [2001]","HB BWH MEDICARE","830.88","","APC Price ($830.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","830.96","762.69","830.96","15","789.41","4079.94","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","5132.00","3849.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","814.26","","APC Price ($830.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1144.71","1144.71","1144.71","1 through 10","789.41","4079.94","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","5132.00","3849.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","814.26","","APC Price ($830.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","814.35","814.35","830.96","1 through 10","789.41","4079.94","other","OPPS APC"
"Estriol","PX-30000425","CDM","82677","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","161.04","161.04","161.04","1 through 10","19.13","299.25","percent of total billed charges",""
"Estriol","PX-30000425","CDM","82677","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","113.77","113.77","113.77","1 through 10","19.13","299.25","percent of total billed charges",""
"Estriol","PX-30000425","CDM","82677","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","119.26","119.26","119.26","1 through 10","19.13","299.25","percent of total billed charges",""
"Estrogen Fractionated","PX-30000423","CDM","82671","CPT","0301","RC","","","","both","","","533.00","399.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","423.74","79.5","","406.88","406.88","406.88","1 through 10","31.65","506.35","percent of total billed charges",""
"Estrogen Fractionated","PX-30000423","CDM","82671","CPT","0301","RC","","","","both","","","533.00","399.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","204.14","38.3","","202.15","202.15","202.15","1 through 10","31.65","506.35","percent of total billed charges",""
"Estrone","PX-30000426","CDM","82679","CPT","0301","RC","","","","both","","","294.00","220.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","156.70","53.3","","150.48","150.48","150.48","1 through 10","24.45","279.3","percent of total billed charges",""
"Estrone","PX-30000426","CDM","82679","CPT","0301","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","107.31","36.5","","106.31","103.17","106.31","1 through 10","24.45","279.3","percent of total billed charges",""
"Estrone","PX-30000426","CDM","82679","CPT","0301","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","112.60","38.3","","111.44","111.44","111.44","1 through 10","24.45","279.3","percent of total billed charges",""
"Estrone","PX-30000426","CDM","82679","CPT","0301","RC","","","","outpatient","","","294.00","220.50","AETNA [1001]","HB AMC AETNA HMO","205.21","69.8","","136.23","136.23","136.23","1 through 10","25.74","240.26","percent of total billed charges",""
"Estrone","PX-30000426","CDM","82679","CPT","0301","RC","","","","outpatient","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.13","42.9","","125.31","125.31","125.31","1 through 10","25.74","240.26","percent of total billed charges",""
"Ethosuximide","PX-30000024","CDM","80168","CPT","0301","RC","","","","both","","","196.00","147.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","155.82","79.5","","149.53","149.53","149.53","1 through 10","16.01","186.2","percent of total billed charges",""
"Ethosuximide","PX-30000024","CDM","80168","CPT","0301","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.54","36.5","","70.87","70.87","70.87","1 through 10","16.01","186.2","percent of total billed charges",""
"Etoh Ablation of Peritoneal Nodule/Tumor","PX-76002953","CDM","49999","CPT","0761","RC","","","","both","","","943.00","707.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","292.33","1391.62","other","OPPS APC"
"Etoh Ablation of Peritoneal Nodule/Tumor","PX-76002953","CDM","49999","CPT","0761","RC","","","","both","","","943.00","707.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","292.33","1391.62","other","OPPS APC"
"Etoh Ablation of Peritoneal Nodule/Tumor","PX-76002953","CDM","49999","CPT","0761","RC","","","","both","","","943.00","707.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","292.33","1391.62","other","OPPS APC"
"Etoh Ablation of Peritoneal Nodule/Tumor","PX-76002953","CDM","49999","CPT","0761","RC","","","","outpatient","","","943.00","707.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","471.50","50","","14640.00","14640.00","14640.00","1 through 10","471.5","8899.59","percent of total billed charges",""
"Etoh Ablation of Soft Tissue (Nodule/Mass/Metastasis)","PX-76002101","CDM","20999","CPT","0761","RC","","","","outpatient","","","9587.00","7190.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5006.33","52.22","","596.65","596.65","596.65","1 through 10","4793.5","8899.59","percent of total billed charges",""
"Etoh Ablation of Soft Tissue (Nodule/Mass/Metastasis)","PX-76002101","CDM","20999","CPT","0761","RC","","","","outpatient","","","9587.00","7190.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","5033.18","52.5","","1695.17","1695.17","1695.17","1 through 10","4793.5","8899.59","percent of total billed charges",""
"Etonogestrel Implant","PX-63600214","CDM","J7307","HCPCS","0278","RC","","","","both","","","4172.00","3129.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","3212.44","77","","3372.77","3372.77","3372.77","1 through 10","1293.32","3212.44","percent of total billed charges",""
"Etonogestrel Implant","PX-63600214","CDM","J7307","HCPCS","0278","RC","","","","both","","","4172.00","3129.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1522.78","36.5","","2777.06","1585.64","2777.06","1 through 10","1293.32","3212.44","percent of total billed charges",""
"Etonogestrel Implant","PX-63600214","CDM","J7307","HCPCS","0278","RC","","","","both","","","4172.00","3129.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1597.88","38.3","","3328.96","1712.67","5138.01","13","1293.32","3212.44","percent of total billed charges",""
"Etonogestrel Implant","PX-63600214","CDM","J7307","HCPCS","0278","RC","","","","both","","","4172.00","3129.00","WELLPOINT [1015]","HB AMC WELLPOINT","3078.10","73.78","","3261.07","3261.07","3261.07","1 through 10","1293.32","3212.44","percent of total billed charges",""
"Etonogestrel Implant","PX-63600214","CDM","J7307","HCPCS","0278","RC","","","","outpatient","","","4172.00","3129.00","AETNA [1001]","HB AMC AETNA HMO","2912.06","69.8","","2093.75","2093.75","2093.75","1 through 10","1392.12","3354.29","percent of total billed charges",""
"Etonogestrel Implant","PX-63600214","CDM","J7307","HCPCS","0278","RC","","","","outpatient","","","4172.00","3129.00","AETNA [1001]","HB AMC AETNA PPO","3354.29","80.4","","3416.57","3416.57","3416.57","1 through 10","1392.12","3354.29","percent of total billed charges",""
"Etonogestrel Implant","PX-63600214","CDM","J7307","HCPCS","0278","RC","","","","outpatient","","","4172.00","3129.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2916.23","69.9","","3035.49","2032.42","6605.38","1 through 10","1392.12","3354.29","percent of total billed charges",""
"Etonogestrel Implant","PX-63600214","CDM","J7307","HCPCS","0278","RC","","","","outpatient","","","4172.00","3129.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1956.67","46.9","","3035.49","3035.49","3035.49","1 through 10","1392.12","3354.29","percent of total billed charges",""
"Eua Pelvic Exam","PX-76001359","CDM","57410","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2712.40","2712.40","2712.40","1 through 10","2125.14","5545.35","other","ASC"
"Eua Pelvic Exam","PX-76001359","CDM","57410","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","14790.96","14790.96","14790.96","1 through 10","2125.14","5545.35","other","Multiple Surgery"
"Euglobulin Lysis","PX-30001083","CDM","85360","CPT","0305","RC","","","","both","","","113.00","84.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","89.84","79.5","","110.00","110.00","110.00","1 through 10","8.24","107.35","percent of total billed charges",""
"Euglobulin Lysis","PX-30001083","CDM","85360","CPT","0305","RC","","","","both","","","113.00","84.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.28","38.3","","43.01","43.01","43.01","1 through 10","8.24","107.35","percent of total billed charges",""
"Eus Antegrade Gastro-Pancreatic-Jejunal Duct Access","PX-75000495","CDM","48999","CPT","0750","RC","","","","outpatient","","","3802.00","2851.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1985.40","52.22","","1550.84","1550.84","1550.84","1 through 10","1234.13","3136.65","percent of total billed charges",""
"Eus Coil Embolization Rectal Varices","PX-75000515","CDM","45999","CPT","0750","RC","","","","outpatient","","","4427.00","3320.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2311.78","52.22","","1324.00","1324.00","1324.00","1 through 10","1234.13","3652.28","percent of total billed charges",""
"Eus Coil Embolization Rectal Varices","PX-75000515","CDM","45999","CPT","0750","RC","","","","outpatient","","","4427.00","3320.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2213.50","50","","1324.00","1324.00","1324.00","1 through 10","1234.13","3652.28","percent of total billed charges",""
"Eus Coil Embolization Rectal Varices","PX-75000515","CDM","45999","CPT","0750","RC","","","","outpatient","","","4427.00","3320.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2324.18","52.5","","728.20","728.20","728.20","1 through 10","1234.13","3652.28","percent of total billed charges",""
"Eus Enteroenterostomy(Antegrade)","PX-75000544","CDM","44799","CPT","0750","RC","","","","both","","","8895.00","6671.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1057.74","7071.53","other","OPPS APC"
"Eus Enteroenterostomy(Antegrade)","PX-75000544","CDM","44799","CPT","0750","RC","","","","both","","","8895.00","6671.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","7071.53","other","OPPS APC"
"Eus Enteroenterostomy(Antegrade)","PX-75000544","CDM","44799","CPT","0750","RC","","","","both","","","8895.00","6671.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","7071.53","other","OPPS APC"
"Eus Enteroenterostomy(Antegrade)","PX-75000544","CDM","44799","CPT","0750","RC","","","","both","","","8895.00","6671.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1057.74","7071.53","other","OPPS APC"
"Eus Enteroenterostomy(Antegrade)","PX-75000544","CDM","44799","CPT","0750","RC","","","","both","","","8895.00","6671.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3815.96","42.9","","1932.92","1932.92","1932.92","1 through 10","1057.74","7071.53","percent of total billed charges",""
"Eus Enteroenterostomy(Antegrade)","PX-75000544","CDM","44799","CPT","0750","RC","","","","both","","","8895.00","6671.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1057.74","7071.53","other","OPPS APC"
"Eus Enteroenterostomy(Antegrade)","PX-75000544","CDM","44799","CPT","0750","RC","","","","both","","","8895.00","6671.25","WELLPOINT [1015]","HB AMC WELLPOINT","6562.73","73.78","","2222.33","2222.33","2222.33","1 through 10","1057.74","7071.53","percent of total billed charges",""
"Eus Enteroenterostomy(Antegrade)","PX-75000544","CDM","44799","CPT","0750","RC","","","","outpatient","","","8895.00","6671.25","AETNA [1001]","HB AMC AETNA HMO","6208.71","69.8","","2238.60","2238.60","2238.60","1 through 10","4447.5","8899.59","percent of total billed charges",""
"Eus Enteroenterostomy(Antegrade)","PX-75000544","CDM","44799","CPT","0750","RC","","","","outpatient","","","8895.00","6671.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5385.92","60.55","","3144.00","2870.00","3286.00","1 through 10","4447.5","8899.59","percent of total billed charges",""
"Eus Enteroenterostomy(Antegrade)","PX-75000544","CDM","44799","CPT","0750","RC","","","","outpatient","","","8895.00","6671.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4648.53","52.26","","1775.96","1775.96","1775.96","1 through 10","4447.5","8899.59","percent of total billed charges",""
"Eus Enteroenterostomy(Antegrade)","PX-75000544","CDM","44799","CPT","0750","RC","","","","outpatient","","","8895.00","6671.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4644.97","52.22","","3286.00","2018.70","5898.00","1 through 10","4447.5","8899.59","percent of total billed charges",""
"Eus Enteroenterostomy(Antegrade)","PX-75000544","CDM","44799","CPT","0750","RC","","","","outpatient","","","8895.00","6671.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4669.88","52.5","","8340.00","8340.00","8340.00","1 through 10","4447.5","8899.59","percent of total billed charges",""
"Eus Enteroenterostomy(Antegrade)","PX-75000544","CDM","44799","CPT","0750","RC","","","","outpatient","","","8895.00","6671.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7268.99","81.72","","2294.28","682.69","2294.28","1 through 10","4447.5","8899.59","percent of total billed charges",""
"Eus Gastrobiliary Anastamosis Stent Insert","PX-75000468","CDM","47999","CPT","0750","RC","","","","both","","","3041.00","2280.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","942.71","2417.6","other","OPPS APC"
"Eus Gastrobiliary Anastamosis Stent Insert","PX-75000468","CDM","47999","CPT","0750","RC","","","","both","","","3041.00","2280.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","942.71","2417.6","other","OPPS APC"
"Eus Gastrobiliary Anastamosis Stent Insert","PX-75000468","CDM","47999","CPT","0750","RC","","","","outpatient","","","3041.00","2280.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1588.01","52.22","","3734.00","1019.30","3734.00","1 through 10","1520.5","9843.6","percent of total billed charges",""
"Eus Gastrobiliary Antegrade Ercp Stent Insert","PX-75000467","CDM","47999","CPT","0750","RC","","","","both","","","3851.00","2888.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3061.55","other","OPPS APC"
"Eus Gastrobiliary Antegrade Ercp Stent Insert","PX-75000467","CDM","47999","CPT","0750","RC","","","","both","","","3851.00","2888.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","1057.74","3061.55","other","OPPS APC"
"Eus Gastrobiliary Antegrade Ercp Stent Insert","PX-75000467","CDM","47999","CPT","0750","RC","","","","outpatient","","","3851.00","2888.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2010.99","52.22","","3734.00","1019.30","3734.00","1 through 10","1925.5","9843.6","percent of total billed charges",""
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","both","","","8613.00","6459.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","6847.34","other","OPPS APC"
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","both","","","8613.00","6459.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","6847.34","other","OPPS APC"
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","both","","","8613.00","6459.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6847.34","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","6847.34","percent of total billed charges",""
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","both","","","8613.00","6459.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","6847.34","other","OPPS APC"
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","both","","","8613.00","6459.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","6847.34","other","OPPS APC"
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","both","","","8613.00","6459.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3143.75","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","6847.34","percent of total billed charges",""
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","both","","","8613.00","6459.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3298.78","38.3","","2723.31","1555.62","2741.61","12","1057.74","6847.34","percent of total billed charges",""
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","both","","","8613.00","6459.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","6847.34","other","OPPS APC"
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","both","","","8613.00","6459.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","6847.34","other","OPPS APC"
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","both","","","8613.00","6459.75","WELLPOINT [1015]","HB AMC WELLPOINT","6354.67","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","6847.34","percent of total billed charges",""
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","outpatient","","","8613.00","6459.75","AETNA [1001]","HB AMC AETNA PPO","6924.85","80.4","","1163.76","1163.76","1163.76","1 through 10","2384.07","7105.73","percent of total billed charges",""
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","outpatient","","","8613.00","6459.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5215.17","60.55","","1781.82","1492.00","4331.00","1 through 10","2384.07","7105.73","percent of total billed charges",""
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","outpatient","","","8613.00","6459.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4497.71","52.22","","3144.00","1492.00","3610.00","13","2384.07","7105.73","percent of total billed charges",""
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","outpatient","","","8613.00","6459.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","4521.83","52.5","","1182.28","1182.28","1182.28","1 through 10","2384.07","7105.73","percent of total billed charges",""
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","outpatient","","","8613.00","6459.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4306.50","50","","3610.00","2269.44","3610.00","1 through 10","2384.07","7105.73","percent of total billed charges",""
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","outpatient","","","8613.00","6459.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4521.83","52.5","","3610.00","2382.05","4331.00","1 through 10","2384.07","7105.73","percent of total billed charges",""
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","outpatient","","","8613.00","6459.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","4737.15","55","","4810.75","3363.17","4810.75","1 through 10","2384.07","7105.73","percent of total billed charges",""
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","outpatient","","","8613.00","6459.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7038.54","81.72","","8894.69","8894.69","8894.69","1 through 10","2384.07","7105.73","percent of total billed charges",""
"Eus Gastroenterostomy(Antegrade)","PX-75000543","CDM","43999","CPT","0750","RC","","","","outpatient","","","8613.00","6459.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7038.54","81.72","","2885.83","2132.00","3462.21","1 through 10","2384.07","7105.73","percent of total billed charges",""
"Eus Gb Drainage","PX-75000470","CDM","47999","CPT","0750","RC","","","","both","","","3041.00","2280.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","942.71","2417.6","other","OPPS APC"
"Eus Gb Drainage","PX-75000470","CDM","47999","CPT","0750","RC","","","","both","","","3041.00","2280.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","942.71","2417.6","other","OPPS APC"
"Eus Gb Drainage","PX-75000470","CDM","47999","CPT","0750","RC","","","","outpatient","","","3041.00","2280.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1588.01","52.22","","3734.00","1019.30","3734.00","1 through 10","1520.5","9843.6","percent of total billed charges",""
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","both","","","3802.00","2851.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","3022.59","other","OPPS APC"
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","both","","","3802.00","2851.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","3022.59","other","OPPS APC"
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","both","","","3802.00","2851.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3022.59","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","3022.59","percent of total billed charges",""
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","both","","","3802.00","2851.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","3022.59","other","OPPS APC"
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","both","","","3802.00","2851.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","3022.59","other","OPPS APC"
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","both","","","3802.00","2851.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1387.73","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","3022.59","percent of total billed charges",""
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","both","","","3802.00","2851.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1456.17","38.3","","2723.31","1555.62","2741.61","12","1057.74","3022.59","percent of total billed charges",""
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","both","","","3802.00","2851.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","3022.59","other","OPPS APC"
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","both","","","3802.00","2851.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","3022.59","other","OPPS APC"
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","both","","","3802.00","2851.50","WELLPOINT [1015]","HB AMC WELLPOINT","2805.12","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","3022.59","percent of total billed charges",""
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","outpatient","","","3802.00","2851.50","AETNA [1001]","HB AMC AETNA PPO","3056.81","80.4","","1163.76","1163.76","1163.76","1 through 10","1901","3136.65","percent of total billed charges",""
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","outpatient","","","3802.00","2851.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2302.11","60.55","","1781.82","1492.00","4331.00","1 through 10","1901","3136.65","percent of total billed charges",""
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","outpatient","","","3802.00","2851.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1985.40","52.22","","3144.00","1492.00","3610.00","13","1901","3136.65","percent of total billed charges",""
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","outpatient","","","3802.00","2851.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1996.05","52.5","","1182.28","1182.28","1182.28","1 through 10","1901","3136.65","percent of total billed charges",""
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","outpatient","","","3802.00","2851.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1901.00","50","","3610.00","2269.44","3610.00","1 through 10","1901","3136.65","percent of total billed charges",""
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","outpatient","","","3802.00","2851.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1996.05","52.5","","3610.00","2382.05","4331.00","1 through 10","1901","3136.65","percent of total billed charges",""
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","outpatient","","","3802.00","2851.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2091.10","55","","4810.75","3363.17","4810.75","1 through 10","1901","3136.65","percent of total billed charges",""
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","outpatient","","","3802.00","2851.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3106.99","81.72","","8894.69","8894.69","8894.69","1 through 10","1901","3136.65","percent of total billed charges",""
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","outpatient","","","3802.00","2851.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3106.99","81.72","","2885.83","2132.00","3462.21","1 through 10","1901","3136.65","percent of total billed charges",""
"Eus Trans-Rectal Stent Placement Abscess","PX-75000508","CDM","45999","CPT","0750","RC","","","","outpatient","","","4194.00","3145.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2190.11","52.22","","1324.00","1324.00","1324.00","1 through 10","1234.13","3460.05","percent of total billed charges",""
"Eus Trans-Rectal Stent Placement Abscess","PX-75000508","CDM","45999","CPT","0750","RC","","","","outpatient","","","4194.00","3145.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2097.00","50","","1324.00","1324.00","1324.00","1 through 10","1234.13","3460.05","percent of total billed charges",""
"Eus Trans-Rectal Stent Placement Abscess","PX-75000508","CDM","45999","CPT","0750","RC","","","","outpatient","","","4194.00","3145.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2201.85","52.5","","728.20","728.20","728.20","1 through 10","1234.13","3460.05","percent of total billed charges",""
"Evaluate Leads Dft at Implant","PX-48000384","CDM","93799","CPT","0480","RC","","","","outpatient","","","14425.00","10818.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","7933.75","55","","13080.03","13080.03","13080.03","1 through 10","7212.5","11900.63","percent of total billed charges",""
"Evaluate Leads Dft at Implant","PX-48000384","CDM","93799","CPT","0481","RC","","","","both","","","14425.00","10818.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","11467.88","other","OPPS APC"
"Evaluate Leads Dft at Implant","PX-48000384","CDM","93799","CPT","0481","RC","","","","outpatient","","","14425.00","10818.75","AETNA [1001]","HB AMC AETNA HMO","10068.65","69.8","","2022.70","2022.70","2022.70","1 through 10","454","11788.11","percent of total billed charges",""
"Evaluate Leads Dft at Implant","PX-48000384","CDM","93799","CPT","0481","RC","","","","outpatient","","","14425.00","10818.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","8734.34","60.55","","318.03","318.03","2439.77","1 through 10","454","11788.11","percent of total billed charges",""
"Evaluate Leads Dft at Implant","PX-48000384","CDM","93799","CPT","0481","RC","","","","outpatient","","","14425.00","10818.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","7532.74","52.22","","360.38","360.38","4023.00","1 through 10","454","11788.11","percent of total billed charges",""
"Everolimus","PX-30001866","CDM","80169","CPT","0301","RC","","","","both","","","120.00","90.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","86.16","71.8","","83.29","12.11","83.29","36","7.52","114","percent of total billed charges",""
"Everolimus","PX-30001866","CDM","80169","CPT","0301","RC","","","","both","","","120.00","90.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","78.00","65","","75.40","75.40","75.40","1 through 10","7.52","114","percent of total billed charges",""
"Everolimus","PX-30001866","CDM","80169","CPT","0301","RC","","","","both","","","120.00","90.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","95.40","79.5","","91.29","91.29","91.29","1 through 10","7.52","114","percent of total billed charges",""
"Everolimus","PX-30001866","CDM","80169","CPT","0301","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","43.80","36.5","","36.77","36.77","43.27","1 through 10","7.52","114","percent of total billed charges",""
"Everolimus","PX-30001866","CDM","80169","CPT","0301","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","45.96","38.3","","45.36","43.27","45.36","11","7.52","114","percent of total billed charges",""
"Everolimus","PX-30001866","CDM","80169","CPT","0301","RC","","","","outpatient","","","120.00","90.00","AETNA [1001]","HB AMC AETNA HMO","83.76","69.8","","55.45","55.45","157.06","16","7.52","98.06","percent of total billed charges",""
"Everolimus","PX-30001866","CDM","80169","CPT","0301","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","98.06","81.72","","92.73","92.73","92.73","1 through 10","7.52","98.06","percent of total billed charges",""
"Ex Tumor Soft Tissue Abdominal Wall Subq <3cm","PX-76002470","CDM","22902","CPT","0761","RC","","","","both","","","2645.00","1983.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1013.04","38.3","","561.09","561.09","561.09","1 through 10","819.95","2575.67","percent of total billed charges",""
"Ex Tumor Soft Tissue Abdominal Wall Subq <3cm","PX-76002470","CDM","22902","CPT","0761","RC","","","","outpatient","","","2645.00","1983.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8340.00","8340.00","8340.00","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Ex Tumor Soft Tissue Abdominal Wall Subq <3cm","PX-76002470","CDM","22902","CPT","0761","RC","","","","outpatient","","","2645.00","1983.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","3874.00","3874.00","3874.00","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Exam Neurobehavrl by Psych per Hr","PX-90000039","CDM","96116","CPT","0510","RC","","","","outpatient","","","759.00","569.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","396.65","52.26","","455.44","455.44","455.44","1 through 10","40.19","396.65","percent of total billed charges",""
"Exam Neurobehavrl by Psych per Hr","PX-90000039","CDM","96116","CPT","0918","RC","","","","both","","","759.00","569.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","86.53","63.48","86.53","1 through 10","235.29","721.05","other","OPPS APC"
"Exam Neurobehavrl by Psych per Hr","PX-90000039","CDM","96116","CPT","0918","RC","","","","both","","","759.00","569.25","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","369.81","485.18","1 through 10","235.29","721.05","other","OPPS APC"
"Exc Cyst Pilonidal Smp","PX-76000098","CDM","11770","CPT","0761","RC","","","","both","","","6049.00","4536.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2207.89","36.5","","3206.30","3206.30","3206.30","1 through 10","1875.19","4808.96","percent of total billed charges",""
"Exc Cyst Pilonidal Smp","PX-76000098","CDM","11770","CPT","0761","RC","","","","both","","","6049.00","4536.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2316.77","38.3","","11008.61","11008.61","11008.61","1 through 10","1875.19","4808.96","percent of total billed charges",""
"Exc Cyst Pilonidal Smp","PX-76000098","CDM","11770","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6304.29","6304.29","6304.29","1 through 10","2140.46","8899.59","other","ASC "
"Exc Cyst Pilonidal Smp","PX-76000098","CDM","11770","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4943.24","81.72","","7152.16","7152.16","7152.16","1 through 10","2140.46","8899.59","percent of total billed charges",""
"Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion","PX-98300881","CDM","19120","CPT","0983","RC","","","","both","","","2202.00","1651.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","843.37","38.3","","5168.00","5168.00","5168.00","1 through 10","682.62","6087.35","percent of total billed charges",""
"Exc Cyst/Aberrant Breast Tissue Open 1/> Lesion","PX-98300881","CDM","19120","CPT","0983","RC","","","","outpatient","","","2202.00","1651.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2534.41","","Case rate ($2,534.41). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5956.16","5956.16","5956.16","1 through 10","1230.92","8899.59","other","Multiple Surgery"
"Exc Cyst/Lesn Breast","PX-76000252","CDM","19120","CPT","0761","RC","","","","both","","","7012.00","5259.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2685.60","38.3","","5168.00","5168.00","5168.00","1 through 10","2173.72","6087.35","percent of total billed charges",""
"Exc Cyst/Lesn Breast","PX-76000252","CDM","19120","CPT","0761","RC","","","","outpatient","","","7012.00","5259.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2534.41","","Case rate ($2,534.41). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5956.16","5956.16","5956.16","1 through 10","2534.41","8899.59","other","Multiple Surgery"
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","both","","","4886.00","3664.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3884.37","79.5","","15920.22","15920.22","15920.22","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","both","","","4886.00","3664.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1871.34","38.3","","1852.56","1852.56","1852.56","1 through 10","1514.66","4719.38","percent of total billed charges",""
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6321.29","3129.59","6321.29","1 through 10","2125.14","5545.35","other","ASC "
"Exc Hidradenitis Axillary Smp","PX-76000065","CDM","11450","CPT","0761","RC","","","","both","","","6200.00","4650.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3304.60","53.3","","14576.80","14576.80","14576.80","1 through 10","1922","4929","percent of total billed charges",""
"Exc Hidradenitis Axillary Smp","PX-76000065","CDM","11450","CPT","0761","RC","","","","both","","","6200.00","4650.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2374.60","38.3","","2350.69","2350.69","2350.69","1 through 10","1922","4929","percent of total billed charges",""
"Exc Hidradenitis Axillary Smp","PX-76000065","CDM","11450","CPT","0761","RC","","","","both","","","6200.00","4650.00","WELLPOINT [1015]","HB AMC WELLPOINT","4574.36","73.78","","4475.93","4475.93","4475.93","1 through 10","1922","4929","percent of total billed charges",""
"Exc Hidradenitis Axillary Smp","PX-76000065","CDM","11450","CPT","0761","RC","","","","outpatient","","","6200.00","4650.00","AETNA [1001]","HB AMC AETNA HMO","4327.60","69.8","","4689.36","2873.74","4689.36","1 through 10","2140.46","5545.35","percent of total billed charges",""
"Exc Hidradenitis Axillary Smp","PX-76000065","CDM","11450","CPT","0761","RC","","","","outpatient","","","6200.00","4650.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5066.64","81.72","","2643.48","2643.48","2643.48","1 through 10","2140.46","5545.35","percent of total billed charges",""
"Exc Hidradenitis Axillary Smp|BILATERAL PROCEDURE","PX-76000065","CDM","11450","CPT","0761","RC","","","50","outpatient","","","6200.00","4650.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4079.57","","Case rate ($4,079.57). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","9550.27","9550.27","9550.27","1 through 10","4079.57","12296.94","other","ASC "
"Exc Hidradenitis Ingunial Smp","PX-76000067","CDM","11462","CPT","0761","RC","","","","both","","","6200.00","4650.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2374.60","38.3","","7052.07","7052.07","7052.07","1 through 10","1922","4929","percent of total billed charges",""
"Exc Hidradenitis Ingunial Smp","PX-76000067","CDM","11462","CPT","0761","RC","","","","both","","","6200.00","4650.00","WELLPOINT [1015]","HB AMC WELLPOINT","4574.36","73.78","","10487.93","10487.93","10487.93","1 through 10","1922","4929","percent of total billed charges",""
"Exc Hidradenitis Ingunial Smp","PX-76000067","CDM","11462","CPT","0761","RC","","","","outpatient","","","6200.00","4650.00","AETNA [1001]","HB AMC AETNA HMO","4327.60","69.8","","4689.36","4689.36","4689.36","1 through 10","2140.46","5545.35","percent of total billed charges",""
"Exc Hidradenitis Ingunial Smp","PX-76000067","CDM","11462","CPT","0761","RC","","","","outpatient","","","6200.00","4650.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","7159.85","7159.85","7159.85","1 through 10","2140.46","5545.35","other","Multiple Surgery"
"Exc Hidradenitis Ingunial Smp","PX-76000067","CDM","11462","CPT","0761","RC","","","","outpatient","","","6200.00","4650.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5066.64","81.72","","2643.48","2643.48","2643.48","1 through 10","2140.46","5545.35","percent of total billed charges",""
"Exc Les Mucosa & Sbmc Vestibule Mouth W/O Rpr","PX-98300836","CDM","40810","CPT","0983","RC","","","","both","","","565.00","423.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3966.48","","APC Price ($3,850.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3963.03","3963.03","3963.03","1 through 10","175.15","4813.69","other","OPPS APC"
"Exc Les Mucosa & Sbmc Vestibule Mouth W/O Rpr","PX-98300836","CDM","40810","CPT","0983","RC","","","","both","","","565.00","423.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3850.95","","APC Price ($3,850.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3789.72","133.10","3789.72","1 through 10","175.15","4813.69","other","OPPS APC"
"Exc Les Mucosa & Sbmc Vestibule Mouth W/O Rpr","PX-98300836","CDM","40810","CPT","0983","RC","","","","both","","","565.00","423.75","MEDICARE [2001]","HB BWH MEDICARE","3850.95","","APC Price ($3,850.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11554.02","1925.67","11554.02","1 through 10","175.15","4813.69","other","OPPS APC"
"Exc Les Mucosa & Sbmc Vestibule Mouth W/O Rpr","PX-98300836","CDM","40810","CPT","0983","RC","","","","both","","","565.00","423.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","3850.95","","APC Price ($3,850.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","135.26","135.26","135.26","1 through 10","175.15","4813.69","other","OPPS APC"
"Exc Les Mucosa & Sbmc Vestibule Mouth W/O Rpr","PX-98300836","CDM","40810","CPT","0983","RC","","","","both","","","565.00","423.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","216.40","38.3","","1640.64","1640.64","1640.64","1 through 10","175.15","4813.69","percent of total billed charges",""
"Exc Les Mucosa & Sbmc Vestibule Mouth W/O Rpr","PX-98300836","CDM","40810","CPT","0983","RC","","","","both","","","565.00","423.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3773.93","","APC Price ($3,850.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3782.22","132.56","3782.22","1 through 10","175.15","4813.69","other","OPPS APC"
"Exc Les Mucosa & Sbmc Vestibule Mouth W/O Rpr","PX-98300836","CDM","40810","CPT","0983","RC","","","","outpatient","","","565.00","423.75","AETNA [1001]","HB AMC AETNA HMO","394.37","69.8","","10871.94","10871.94","10871.94","1 through 10","315.84","2384.07","percent of total billed charges",""
"Exc Les Mucosa & Sbmc Vestibule Mouth W/O Rpr","PX-98300836","CDM","40810","CPT","0983","RC","","","","outpatient","","","565.00","423.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2008.14","","Case rate ($2,008.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","574.50","574.50","4719.13","1 through 10","315.84","2384.07","other","Multiple Surgery"
"Exc Les Mucosa & Sbmc Vestibule Mouth W/O Rpr","PX-98300836","CDM","40810","CPT","0983","RC","","","","outpatient","","","565.00","423.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2008.14","","Case rate ($2,008.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","4940.02","4940.02","4940.02","1 through 10","315.84","2384.07","other","Multiple Surgery"
"Exc Lesion Dentoalveolar W/Rpr Smp","PX-75000042","CDM","41826","CPT","0761","RC","","","","both","","","6473.00","4854.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5146.04","79.5","","17336.82","17336.82","17336.82","1 through 10","2006.63","5146.04","percent of total billed charges",""
"Exc Lesion Intranasal Internal Appr","PX-76000745","CDM","30117","CPT","0761","RC","","","","outpatient","","","4470.00","3352.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2551.58","","Case rate ($2,551.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5220.53","5220.53","5220.53","1 through 10","2008.14","8899.59","other","ASC"
"Exc Lesion Palate Uvula","PX-75000048","CDM","42104","CPT","0761","RC","","","","outpatient","","","4242.00","3181.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2551.58","","Case rate ($2,551.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5126.12","5126.12","5126.12","1 through 10","2008.14","5545.35","other","ASC"
"Exc Lesion Palate Uvula","PX-75000048","CDM","42104","CPT","0761","RC","","","","outpatient","","","4242.00","3181.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2551.58","","Case rate ($2,551.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","5973.25","5973.25","5973.25","1 through 10","2008.14","5545.35","other","ASC "
"Exc Lesion Tongue W/O Clsr","PX-75000030","CDM","41110","CPT","0761","RC","","","","outpatient","","","4242.00","3181.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2551.58","","Case rate ($2,551.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","5973.25","5973.25","5973.25","1 through 10","2008.14","3466.56","other","ASC "
"Exc Lesion Tongue W/O Clsr","PX-75000030","CDM","41110","CPT","0761","RC","","","","outpatient","","","4242.00","3181.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2008.14","","Case rate ($2,008.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4899.86","4899.86","4899.86","1 through 10","2008.14","3466.56","other","Multiple Surgery"
"Exc Lesion Vestib Mouth W/O Rpr","PX-75000011","CDM","40810","CPT","0761","RC","","","","both","","","4327.00","3245.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3966.48","","APC Price ($3,850.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3963.03","3963.03","3963.03","1 through 10","1341.37","4813.69","other","OPPS APC"
"Exc Lesion Vestib Mouth W/O Rpr","PX-75000011","CDM","40810","CPT","0761","RC","","","","both","","","4327.00","3245.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3850.95","","APC Price ($3,850.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3789.72","133.10","3789.72","1 through 10","1341.37","4813.69","other","OPPS APC"
"Exc Lesion Vestib Mouth W/O Rpr","PX-75000011","CDM","40810","CPT","0761","RC","","","","both","","","4327.00","3245.25","MEDICARE [2001]","HB BWH MEDICARE","3850.95","","APC Price ($3,850.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11554.02","1925.67","11554.02","1 through 10","1341.37","4813.69","other","OPPS APC"
"Exc Lesion Vestib Mouth W/O Rpr","PX-75000011","CDM","40810","CPT","0761","RC","","","","both","","","4327.00","3245.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","3850.95","","APC Price ($3,850.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","135.26","135.26","135.26","1 through 10","1341.37","4813.69","other","OPPS APC"
"Exc Lesion Vestib Mouth W/O Rpr","PX-75000011","CDM","40810","CPT","0761","RC","","","","both","","","4327.00","3245.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1657.24","38.3","","1640.64","1640.64","1640.64","1 through 10","1341.37","4813.69","percent of total billed charges",""
"Exc Lesion Vestib Mouth W/O Rpr","PX-75000011","CDM","40810","CPT","0761","RC","","","","both","","","4327.00","3245.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3773.93","","APC Price ($3,850.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3782.22","132.56","3782.22","1 through 10","1341.37","4813.69","other","OPPS APC"
"Exc Lesion Vestib Mouth W/O Rpr","PX-75000011","CDM","40810","CPT","0761","RC","","","","outpatient","","","4327.00","3245.25","AETNA [1001]","HB AMC AETNA HMO","3020.25","69.8","","10871.94","10871.94","10871.94","1 through 10","2008.14","3536.02","percent of total billed charges",""
"Exc Lesion Vestib Mouth W/O Rpr","PX-75000011","CDM","40810","CPT","0761","RC","","","","outpatient","","","4327.00","3245.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2551.58","","Case rate ($2,551.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6340.20","6297.71","6340.20","1 through 10","2008.14","3536.02","other","ASC "
"Exc Lesion Vestib Mouth W/O Rpr","PX-75000011","CDM","40810","CPT","0761","RC","","","","outpatient","","","4327.00","3245.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2008.14","","Case rate ($2,008.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","574.50","574.50","4719.13","1 through 10","2008.14","3536.02","other","Multiple Surgery"
"Exc Lesion Vestib Mouth W/O Rpr","PX-75000011","CDM","40810","CPT","0761","RC","","","","outpatient","","","4327.00","3245.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2008.14","","Case rate ($2,008.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","4940.02","4940.02","4940.02","1 through 10","2008.14","3536.02","other","Multiple Surgery"
"Exc Lesion Vestib Mouth W/Rpr Smp","PX-75000012","CDM","40812","CPT","0761","RC","","","","outpatient","","","4327.00","3245.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2551.58","","Case rate ($2,551.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5220.53","5220.53","5220.53","1 through 10","2008.14","2551.58","other","ASC"
"Exc Lesn Bgn Face/Ear/Lip <0.5cm","PX-76000059","CDM","11440","CPT","0761","RC","","","","both","","","1133.00","849.75","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","1880.00","16","351.23","1044.34","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip <0.5cm","PX-76000059","CDM","11440","CPT","0761","RC","","","","both","","","1133.00","849.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","433.94","38.3","","1683.27","429.71","1683.27","1 through 10","351.23","1044.34","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip <0.5cm","PX-76000059","CDM","11440","CPT","0761","RC","","","","both","","","1133.00","849.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","755.61","826.75","1 through 10","351.23","1044.34","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip <0.5cm","PX-76000059","CDM","11440","CPT","0761","RC","","","","both","","","1133.00","849.75","WELLPOINT [1015]","HB AMC WELLPOINT","835.93","73.78","","1068.36","1068.36","1068.36","1 through 10","351.23","1044.34","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip <0.5cm","PX-76000059","CDM","11440","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","AETNA [1001]","HB AMC AETNA HMO","790.83","69.8","","971.50","525.32","971.50","1 through 10","579.34","1234.13","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip <0.5cm","PX-76000059","CDM","11440","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","665.49","665.49","1330.98","1 through 10","579.34","1234.13","other","ASC"
"Exc Lesn Bgn Face/Ear/Lip <0.5cm","PX-76000059","CDM","11440","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","767.85","383.93","1535.70","1 through 10","579.34","1234.13","other","ASC "
"Exc Lesn Bgn Face/Ear/Lip <0.5cm","PX-76000059","CDM","11440","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1344.07","1344.07","1344.07","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Face/Ear/Lip <0.5cm","PX-76000059","CDM","11440","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1263.27","631.64","1263.27","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Face/Ear/Lip <0.5cm","PX-76000059","CDM","11440","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","925.89","81.72","","4917.51","4917.51","4917.51","1 through 10","579.34","1234.13","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip >4.0cm","PX-76000064","CDM","11446","CPT","0761","RC","","","","both","","","6049.00","4536.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3224.12","53.3","","19039.11","19039.11","19039.11","1 through 10","335.95","4808.96","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip >4.0cm","PX-76000064","CDM","11446","CPT","0761","RC","","","","both","","","6049.00","4536.75","WELLPOINT [1015]","HB AMC WELLPOINT","4462.95","73.78","","6055.02","5020.16","6055.02","1 through 10","335.95","4808.96","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip >4.0cm","PX-76000064","CDM","11446","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","AETNA [1001]","HB AMC AETNA HMO","4222.20","69.8","","559.65","559.65","559.65","1 through 10","2140.46","5545.35","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip >4.0cm","PX-76000064","CDM","11446","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","12096.00","12096.00","12096.00","1 through 10","2140.46","5545.35","other","ASC"
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","both","","","1432.00","1074.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","859.79","859.79","866.79","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","both","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","both","","","1432.00","1074.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1138.44","79.5","","757.68","378.84","757.68","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","both","","","1432.00","1074.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","763.26","53.3","","1731.84","1731.84","1731.84","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","both","","","1432.00","1074.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","2506.68","22","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.68","36.5","","802.89","440.31","1320.93","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.46","38.3","","841.62","841.62","1683.27","22","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","both","","","1432.00","1074.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","818.85","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","both","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","614.14","614.14","822.19","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","both","","","1432.00","1074.00","WELLPOINT [1015]","HB AMC WELLPOINT","1056.53","73.78","","2423.11","1251.68","2423.11","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","AETNA [1001]","HB AMC AETNA HMO","999.54","69.8","","559.65","485.75","559.65","1 through 10","579.34","1234.13","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1330.98","665.49","1355.50","1 through 10","579.34","1234.13","other","ASC"
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.70","767.85","5654.36","24","579.34","1234.13","other","ASC "
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","1344.07","4032.21","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Face/Ear/Lip 0.6-1.0cm","PX-76000060","CDM","11441","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1170.23","81.72","","1110.37","1110.37","1110.37","1 through 10","579.34","1234.13","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","both","","","2541.00","1905.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","860.59","860.59","860.59","1 through 10","787.71","2020.1","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","both","","","2541.00","1905.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","1 through 10","787.71","2020.1","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","both","","","2541.00","1905.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2020.10","79.5","","1129.35","1129.35","1129.35","1 through 10","787.71","2020.1","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","both","","","2541.00","1905.75","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","417.78","835.56","1 through 10","787.71","2020.1","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","both","","","2541.00","1905.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","927.47","36.5","","2343.27","2343.27","2343.27","1 through 10","787.71","2020.1","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","both","","","2541.00","1905.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","973.20","38.3","","2808.96","272.65","3180.00","1 through 10","787.71","2020.1","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","both","","","2541.00","1905.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","824.85","824.85","824.85","1 through 10","787.71","2020.1","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","both","","","2541.00","1905.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","409.43","818.85","1 through 10","787.71","2020.1","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","both","","","2541.00","1905.75","WELLPOINT [1015]","HB AMC WELLPOINT","1874.75","73.78","","1251.68","1251.68","1251.68","1 through 10","787.71","2020.1","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","outpatient","","","2541.00","1905.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1330.98","665.49","1355.50","1 through 10","579.34","2384.07","other","ASC"
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","outpatient","","","2541.00","1905.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.70","1435.00","1550.94","1 through 10","579.34","2384.07","other","ASC "
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","outpatient","","","2541.00","1905.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3875.79","2016.12","4032.21","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Face/Ear/Lip 1.1-2.0cm","PX-76000061","CDM","11442","CPT","0761","RC","","","","outpatient","","","2541.00","1905.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2076.51","81.72","","1147.14","1147.14","1147.14","1 through 10","579.34","2384.07","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 2.1-3.0cm","PX-76000062","CDM","11443","CPT","0761","RC","","","","both","","","2541.00","1905.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2020.10","79.5","","1129.35","1129.35","1129.35","1 through 10","787.71","2404.92","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 2.1-3.0cm","PX-76000062","CDM","11443","CPT","0761","RC","","","","both","","","2541.00","1905.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1354.35","53.3","","1511.82","1511.82","1511.82","1 through 10","787.71","2404.92","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 2.1-3.0cm","PX-76000062","CDM","11443","CPT","0761","RC","","","","both","","","2541.00","1905.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","787.71","2404.92","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip 2.1-3.0cm","PX-76000062","CDM","11443","CPT","0761","RC","","","","both","","","2541.00","1905.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","973.20","38.3","","936.32","936.32","936.32","1 through 10","787.71","2404.92","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 2.1-3.0cm","PX-76000062","CDM","11443","CPT","0761","RC","","","","both","","","2541.00","1905.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","787.71","2404.92","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip 2.1-3.0cm","PX-76000062","CDM","11443","CPT","0761","RC","","","","both","","","2541.00","1905.75","WELLPOINT [1015]","HB AMC WELLPOINT","1874.75","73.78","","5020.16","5020.16","5020.16","1 through 10","787.71","2404.92","percent of total billed charges",""
"Exc Lesn Bgn Face/Ear/Lip 2.1-3.0cm","PX-76000062","CDM","11443","CPT","0761","RC","","","","outpatient","","","2541.00","1905.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","3646.12","3646.12","1 through 10","1237.95","2384.07","other","ASC "
"Exc Lesn Bgn Face/Ear/Lip 3.1-4.0cm","PX-76000063","CDM","11444","CPT","0761","RC","","","","both","","","2277.00","1707.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","705.87","2404.92","other","OPPS APC"
"Exc Lesn Bgn Face/Ear/Lip 3.1-4.0cm","PX-76000063","CDM","11444","CPT","0761","RC","","","","outpatient","","","2277.00","1707.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","1841.15","3646.12","1 through 10","1189.96","2384.07","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","both","","","2277.00","1707.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1810.22","79.5","","1167.04","1167.04","1167.04","1 through 10","705.87","2404.92","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","both","","","2277.00","1707.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","962.07","1924.13","1 through 10","705.87","2404.92","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","both","","","2277.00","1707.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","831.11","36.5","","2729.37","2470.74","2729.37","1 through 10","705.87","2404.92","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","both","","","2277.00","1707.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","872.09","38.3","","863.33","863.33","2589.99","11","705.87","2404.92","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","both","","","2277.00","1707.75","TRICARE [160005]","HB BWH TRICARE","1827.93","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1924.13","1924.13","1924.13","1 through 10","705.87","2404.92","other","Tricare OPPS"
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","both","","","2277.00","1707.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1741.20","1741.20","1741.20","1 through 10","705.87","2404.92","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","both","","","2277.00","1707.75","WELLPOINT [1015]","HB AMC WELLPOINT","1679.97","73.78","","1251.68","1251.68","1251.68","1 through 10","705.87","2404.92","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","outpatient","","","2277.00","1707.75","AETNA [1001]","HB AMC AETNA HMO","1589.35","69.8","","1016.26","971.50","1494.82","1 through 10","1189.96","2384.07","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","outpatient","","","2277.00","1707.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3160.08","2208.00","8133.00","1 through 10","1189.96","2384.07","other","ASC"
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","outpatient","","","2277.00","1707.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3682.30","1550.94","3682.30","1 through 10","1189.96","2384.07","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","outpatient","","","2277.00","1707.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2872.04","2760.63","2872.04","1 through 10","1189.96","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","outpatient","","","2277.00","1707.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9061.80","9061.80","9061.80","1 through 10","1189.96","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","outpatient","","","2277.00","1707.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1731.82","1731.82","1731.82","1 through 10","1189.96","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","outpatient","","","2277.00","1707.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1860.76","81.72","","1765.08","1584.58","1765.08","1 through 10","1189.96","2384.07","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen >4.0cm","PX-76000058","CDM","11426","CPT","0761","RC","","","","outpatient","","","6170.00","4627.50","AETNA [1001]","HB AMC AETNA HMO","4306.66","69.8","","1942.99","1942.99","1942.99","1 through 10","2140.46","5545.35","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen >4.0cm","PX-76000058","CDM","11426","CPT","0761","RC","","","","outpatient","","","6170.00","4627.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5564.53","5564.53","5564.53","1 through 10","2140.46","5545.35","other","ASC"
"Exc Lesn Bgn Sclp/Hnd/Gen >4.0cm","PX-76000058","CDM","11426","CPT","0761","RC","","","","outpatient","","","6170.00","4627.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6304.29","6304.29","6366.84","1 through 10","2140.46","5545.35","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen >4.0cm","PX-76000058","CDM","11426","CPT","0761","RC","","","","outpatient","","","6170.00","4627.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4965.87","4965.87","4965.87","1 through 10","2140.46","5545.35","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen >4.0cm","PX-76000058","CDM","11426","CPT","0761","RC","","","","outpatient","","","6170.00","4627.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4773.23","4773.23","4773.23","1 through 10","2140.46","5545.35","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","both","","","1432.00","1074.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1138.44","79.5","","564.67","564.67","564.67","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","both","","","1432.00","1074.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","763.26","53.3","","1093.15","733.39","1093.15","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","both","","","1432.00","1074.00","HUMANA [1012]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","823.86","823.86","823.86","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","both","","","1432.00","1074.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","1671.12","16","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.68","36.5","","1320.93","1320.93","1320.93","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.46","38.3","","543.10","527.82","1090.60","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","both","","","1432.00","1074.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","818.85","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","both","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","824.95","818.85","824.95","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","both","","","1432.00","1074.00","WELLPOINT [1015]","HB AMC WELLPOINT","1056.53","73.78","","2870.00","2870.00","2870.00","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","AETNA [1001]","HB AMC AETNA HMO","999.54","69.8","","940.35","940.35","1083.42","1 through 10","579.34","2384.07","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1435.00","1330.98","1435.00","1 through 10","579.34","2384.07","other","ASC"
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.70","767.85","1550.94","11","579.34","2384.07","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","1344.07","6720.35","11","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2120.40","680.73","2120.40","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1483.11","1322.23","2178.89","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1170.23","81.72","","1110.37","573.57","1147.14","1 through 10","579.34","2384.07","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","both","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","443.92","2404.92","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","both","","","1432.00","1074.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1138.44","79.5","","1093.14","1093.14","1093.14","1 through 10","443.92","2404.92","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","both","","","1432.00","1074.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","946.67","946.67","946.67","1 through 10","443.92","2404.92","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","both","","","1432.00","1074.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1102.64","77","","1069.53","1069.53","1069.53","1 through 10","443.92","2404.92","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","both","","","1432.00","1074.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","962.07","1924.13","12","443.92","2404.92","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.68","36.5","","1320.93","1070.52","1605.78","1 through 10","443.92","2404.92","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.46","38.3","","1629.30","1086.20","5049.78","23","443.92","2404.92","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","both","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1742.02","942.83","1886.65","1 through 10","443.92","2404.92","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","both","","","1432.00","1074.00","WELLPOINT [1015]","HB AMC WELLPOINT","1056.53","73.78","","2423.11","2423.11","2423.11","1 through 10","443.92","2404.92","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","AETNA [1001]","HB AMC AETNA HMO","999.54","69.8","","940.35","663.94","971.50","1 through 10","748.36","2384.07","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1580.04","1435.00","8133.00","1 through 10","748.36","2384.07","other","ASC"
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","920.58","3682.30","16","748.36","2384.07","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","8616.12","8616.12","13","748.36","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4530.90","4530.90","9061.80","13","748.36","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3005.00","3005.00","3005.00","1 through 10","748.36","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1170.23","81.72","","1110.37","1110.37","1110.37","1 through 10","748.36","2384.07","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","both","","","4072.00","3054.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1415.20","1415.20","1415.20","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","both","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","both","","","4072.00","3054.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","both","","","4072.00","3054.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1486.28","36.5","","1472.98","1472.98","1472.98","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","both","","","4072.00","3054.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1559.58","38.3","","4632.18","561.09","4632.18","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","both","","","4072.00","3054.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","both","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.34","1885.65","1893.34","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","AETNA [1001]","HB AMC AETNA HMO","2842.26","69.8","","2673.47","2673.47","2673.47","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3160.08","1609.14","8133.00","1 through 10","1237.95","5545.35","other","ASC"
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","717.50","3682.30","1 through 10","1237.95","5545.35","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8281.89","4308.06","8616.12","12","1237.95","5545.35","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3169.15","3169.15","3169.15","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3327.64","81.72","","1147.14","1147.14","1147.14","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 3.1-4.0cm","PX-76000057","CDM","11424","CPT","0761","RC","","","","both","","","4072.00","3054.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1986.93","1986.93","1986.93","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 3.1-4.0cm","PX-76000057","CDM","11424","CPT","0761","RC","","","","both","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 3.1-4.0cm","PX-76000057","CDM","11424","CPT","0761","RC","","","","both","","","4072.00","3054.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 3.1-4.0cm","PX-76000057","CDM","11424","CPT","0761","RC","","","","both","","","4072.00","3054.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1559.58","38.3","","1544.06","1544.06","1544.06","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 3.1-4.0cm","PX-76000057","CDM","11424","CPT","0761","RC","","","","both","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.15","1893.15","1893.15","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 3.1-4.0cm","PX-76000057","CDM","11424","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1841.15","1841.15","1841.15","1 through 10","1237.95","5545.35","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen 3.1-4.0cm","PX-76000057","CDM","11424","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","8616.12","8616.12","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen 3.1-4.0cm","PX-76000057","CDM","11424","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9061.80","9061.80","9061.80","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen 3.1-4.0cm","PX-76000057","CDM","11424","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3327.64","81.72","","1147.14","1147.14","1147.14","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","both","","","1432.00","1074.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","244.11","244.11","244.11","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","both","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","466.88","466.88","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","both","","","1432.00","1074.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","763.26","53.3","","1093.14","733.39","1093.14","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","both","","","1432.00","1074.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","237.23","1423.41","20","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.68","36.5","","880.62","227.45","1508.46","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.46","38.3","","1629.30","543.10","1629.30","47","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","both","","","1432.00","1074.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1102.64","77","","1236.21","1236.21","1236.21","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","both","","","1432.00","1074.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.50","232.50","232.50","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","both","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","614.33","42.9","","573.57","573.57","573.57","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","both","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.89","466.88","472.89","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","both","","","1432.00","1074.00","WELLPOINT [1015]","HB AMC WELLPOINT","1056.53","73.78","","1034.11","1034.11","1034.11","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","AETNA [1001]","HB AMC AETNA HMO","999.54","69.8","","940.35","342.97","940.35","1 through 10","314.08","1234.13","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","721.57","367.43","734.86","1 through 10","314.08","1234.13","other","ASC"
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","832.56","416.28","840.82","21","314.08","1234.13","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1821.70","1457.34","1821.70","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2299.08","2299.08","2299.08","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","772.64","716.82","772.64","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1170.23","81.72","","1110.37","1110.37","1110.37","1 through 10","314.08","1234.13","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","both","","","1133.00","849.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","859.79","859.79","859.79","1 through 10","351.23","1044.34","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","both","","","1133.00","849.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","900.74","79.5","","1772.56","1772.56","1772.56","1 through 10","351.23","1044.34","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","both","","","1133.00","849.75","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","557.04","1671.12","1 through 10","351.23","1044.34","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","both","","","1133.00","849.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","433.94","38.3","","1289.13","417.62","1683.27","14","351.23","1044.34","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","both","","","1133.00","849.75","WELLPOINT [1015]","HB AMC WELLPOINT","835.93","73.78","","2503.36","1917.21","2503.36","1 through 10","351.23","1044.34","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","18632.00","18632.00","18632.00","1 through 10","579.34","1234.13","other","ASC"
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.70","1535.70","10898.25","13","579.34","1234.13","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","645.97","4032.21","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1291.93","1291.93","1291.93","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1483.11","741.56","1483.11","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1344.07","1344.07","1344.07","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","925.89","81.72","","5335.20","5335.20","5335.20","1 through 10","579.34","1234.13","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1133.00","849.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","712.59","712.59","712.59","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","4072.00","3054.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1980.83","1980.83","1980.83","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","4072.00","3054.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2850.40","70","","5029.39","5029.39","5029.39","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","4072.00","3054.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3237.24","79.5","","4065.65","378.84","7878.66","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","4072.00","3054.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2170.38","53.3","","1515.36","1515.36","1515.36","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","4072.00","3054.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","4072.00","3054.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1559.58","38.3","","3119.30","2511.63","4729.54","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","4072.00","3054.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1886.65","1886.65","1886.65","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1746.89","42.9","","9586.80","1147.14","9586.80","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.34","1887.39","1893.34","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","4072.00","3054.00","WELLPOINT [1015]","HB AMC WELLPOINT","3004.32","73.78","","1424.47","1424.47","1424.47","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","AETNA [1001]","HB AMC AETNA HMO","2842.26","69.8","","5781.89","3423.76","7031.73","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","AETNA [1001]","HB AMC AETNA PPO","3273.89","80.4","","5419.21","5419.21","5419.21","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6743.00","1580.04","9316.00","1 through 10","1237.95","5545.35","other","ASC"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2128.03","52.26","","3646.12","3646.12","3646.12","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","1823.06","6048.00","18","1237.95","5545.35","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2872.04","1436.02","4308.06","12","1237.95","5545.35","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1510.30","1510.30","1510.30","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3327.64","81.72","","5335.20","5335.20","5335.20","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3327.64","81.72","","9835.02","8002.79","9835.02","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1522.68","1522.68","1522.68","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1432.00","1074.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1138.44","79.5","","733.39","733.39","733.39","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1432.00","1074.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","763.26","53.3","","2568.76","1093.14","2581.35","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1432.00","1074.00","HUMANA [1012]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","823.86","823.86","823.86","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1432.00","1074.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","767.90","835.56","34","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","443.92","31","","1287.60","1287.60","1287.60","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.68","36.5","","1320.93","502.82","1508.46","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.46","38.3","","1629.30","543.10","1683.27","47","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","818.85","818.85","818.85","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1432.00","1074.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","818.85","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","614.33","42.9","","1483.11","1483.11","1483.11","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","752.55","826.75","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1432.00","1074.00","WELLPOINT [1015]","HB AMC WELLPOINT","1056.53","73.78","","2423.11","1034.11","3765.12","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","AETNA [1001]","HB AMC AETNA HMO","999.54","69.8","","940.35","663.94","1083.42","1 through 10","579.34","1234.13","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1330.98","1330.98","1355.50","15","579.34","1234.13","other","ASC"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.70","767.85","1550.94","44","579.34","1234.13","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1483.11","1483.11","1483.11","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","2583.86","4032.21","45","579.34","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4084.35","1413.59","4240.77","19","579.34","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1483.11","1252.77","1786.96","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1170.23","81.72","","610.75","573.57","1110.37","1 through 10","579.34","1234.13","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","both","","","1432.00","1074.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","860.69","859.79","860.69","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","both","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","755.61","822.19","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","both","","","1432.00","1074.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1138.44","79.5","","2568.76","2568.76","5055.37","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","both","","","1432.00","1074.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","575.93","1671.12","19","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.68","36.5","","1554.30","1554.30","1554.30","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.46","38.3","","1629.30","543.10","1629.30","19","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","both","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.35","759.55","826.75","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","both","","","1432.00","1074.00","WELLPOINT [1015]","HB AMC WELLPOINT","1056.53","73.78","","2423.11","2423.11","3765.12","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","AETNA [1001]","HB AMC AETNA HMO","999.54","69.8","","959.14","663.94","959.14","1 through 10","579.34","2384.07","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1355.50","665.49","1355.50","1 through 10","579.34","2384.07","other","ASC"
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.70","767.85","1550.94","16","579.34","2384.07","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2016.12","1344.08","4032.21","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1361.45","1361.45","1361.45","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1413.59","1413.59","1413.59","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1483.11","957.03","1483.11","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1170.23","81.72","","1110.37","1110.37","1110.37","1 through 10","579.34","2384.07","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","both","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1273.40","1273.40","1273.40","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","both","","","4072.00","3054.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3539.02","1924.13","3539.02","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","both","","","4072.00","3054.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1486.28","36.5","","4418.94","1865.92","4418.94","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","both","","","4072.00","3054.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1559.58","38.3","","4632.18","1544.06","4632.18","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","both","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.15","1889.50","1893.15","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","both","","","4072.00","3054.00","WELLPOINT [1015]","HB AMC WELLPOINT","3004.32","73.78","","1424.48","1424.48","1424.48","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","AETNA [1001]","HB AMC AETNA HMO","2842.26","69.8","","4639.41","2673.47","4639.41","1 through 10","1237.95","3327.64","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1609.14","1435.00","1609.14","1 through 10","1237.95","3327.64","other","ASC"
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3682.30","1841.15","6423.60","1 through 10","1237.95","3327.64","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2872.04","1436.02","2872.04","1 through 10","1237.95","3327.64","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3327.64","81.72","","13003.04","630.97","13003.04","1 through 10","1237.95","3327.64","percent of total billed charges",""
"Exc Lesn Floor Mouth","PX-75000034","CDM","41116","CPT","0761","RC","","","","both","","","6473.00","4854.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5146.04","79.5","","7960.11","7960.11","7960.11","1 through 10","2776.92","5146.04","percent of total billed charges",""
"Exc Lesn Mal Face/Ear/Lip <0.5cm","PX-76000080","CDM","11640","CPT","0761","RC","","","","both","","","1309.00","981.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1040.66","79.5","","998.70","998.70","998.70","1 through 10","405.79","1044.34","percent of total billed charges",""
"Exc Lesn Mal Face/Ear/Lip <0.5cm","PX-76000080","CDM","11640","CPT","0761","RC","","","","both","","","1309.00","981.75","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","767.90","767.90","767.90","1 through 10","405.79","1044.34","other","OPPS APC"
"Exc Lesn Mal Face/Ear/Lip <0.5cm","PX-76000080","CDM","11640","CPT","0761","RC","","","","outpatient","","","1309.00","981.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1330.98","1330.98","1330.98","1 through 10","579.34","1234.13","other","ASC"
"Exc Lesn Mal Face/Ear/Lip >4.0cm","PX-76000085","CDM","11646","CPT","0761","RC","","","","both","","","2490.00","1867.50","MEDICARE [2001]","HB BWH MEDICARE","3398.51","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3101.27","3398.86","1 through 10","771.9","4248.14","other","OPPS APC"
"Exc Lesn Mal Face/Ear/Lip >4.0cm","PX-76000085","CDM","11646","CPT","0761","RC","","","","outpatient","","","2490.00","1867.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6304.29","6304.29","6304.29","1 through 10","1301.27","5545.35","other","ASC "
"Exc Lesn Mal Face/Ear/Lip 0.6-1.0cm","PX-76000081","CDM","11641","CPT","0761","RC","","","","both","","","941.00","705.75","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","291.71","1044.34","other","OPPS APC"
"Exc Lesn Mal Face/Ear/Lip 1.1-2.0cm","PX-76000082","CDM","11642","CPT","0761","RC","","","","both","","","1432.00","1074.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","763.26","53.3","","256.61","256.61","256.61","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Mal Face/Ear/Lip 1.1-2.0cm","PX-76000082","CDM","11642","CPT","0761","RC","","","","both","","","1432.00","1074.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","417.78","835.56","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Face/Ear/Lip 1.1-2.0cm","PX-76000082","CDM","11642","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1330.98","1330.98","1330.98","1 through 10","579.34","1234.13","other","ASC"
"Exc Lesn Mal Face/Ear/Lip 1.1-2.0cm","PX-76000082","CDM","11642","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.70","1535.70","1535.70","1 through 10","579.34","1234.13","other","ASC "
"Exc Lesn Mal Face/Ear/Lip 2.1-3.0cm","PX-76000083","CDM","11643","CPT","0761","RC","","","","outpatient","","","2490.00","1867.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1436.02","1436.02","1436.02","1 through 10","1237.95","2384.07","other","Multiple Surgery"
"Exc Lesn Mal Face/Ear/Lip 3.1-4.0cm","PX-76000084","CDM","11644","CPT","0761","RC","","","","outpatient","","","2490.00","1867.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2034.83","81.72","","10670.39","10670.39","10670.39","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Lesn Mal Face/Ear/Lip 3.1-4.0cm","PX-76000084","CDM","11644","CPT","0761","RC","","","","outpatient","","","2490.00","1867.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1522.68","1522.68","1522.68","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Exc Lesn Mal Sclp/Hnd/Gen <0.5cm","PX-76000074","CDM","11620","CPT","0761","RC","","","","both","","","2233.00","1674.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","692.23","2404.92","other","OPPS APC"
"Exc Lesn Mal Sclp/Hnd/Gen <0.5cm","PX-76000074","CDM","11620","CPT","0761","RC","","","","both","","","2233.00","1674.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","815.05","36.5","","6067.22","6067.22","6067.22","1 through 10","692.23","2404.92","percent of total billed charges",""
"Exc Lesn Mal Sclp/Hnd/Gen <0.5cm","PX-76000074","CDM","11620","CPT","0761","RC","","","","both","","","2233.00","1674.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","855.24","38.3","","374.06","374.06","374.06","1 through 10","692.23","2404.92","percent of total billed charges",""
"Exc Lesn Mal Sclp/Hnd/Gen <0.5cm","PX-76000074","CDM","11620","CPT","0761","RC","","","","outpatient","","","2233.00","1674.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1436.02","1436.02","1436.02","1 through 10","1166.97","2384.07","other","Multiple Surgery"
"Exc Lesn Mal Sclp/Hnd/Gen >4.0cm","PX-76000079","CDM","11626","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4943.24","81.72","","1529.52","1529.52","1529.52","1 through 10","2140.46","5545.35","percent of total billed charges",""
"Exc Lesn Mal Sclp/Hnd/Gen 0.6-1.0cm","PX-76000075","CDM","11621","CPT","0761","RC","","","","both","","","1432.00","1074.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Sclp/Hnd/Gen 0.6-1.0cm","PX-76000075","CDM","11621","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.68","36.5","","1036.20","1036.20","1036.20","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Mal Sclp/Hnd/Gen 0.6-1.0cm","PX-76000075","CDM","11621","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","2688.14","4032.21","1 through 10","579.34","1234.13","other","Multiple Surgery"
"Exc Lesn Mal Sclp/Hnd/Gen 1.1-2.0cm","PX-76000076","CDM","11622","CPT","0761","RC","","","","both","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Sclp/Hnd/Gen 1.1-2.0cm","PX-76000076","CDM","11622","CPT","0761","RC","","","","both","","","1432.00","1074.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Sclp/Hnd/Gen 1.1-2.0cm","PX-76000076","CDM","11622","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.68","36.5","","1320.93","518.10","1320.93","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Mal Sclp/Hnd/Gen 1.1-2.0cm","PX-76000076","CDM","11622","CPT","0761","RC","","","","both","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2257.19","2257.19","2257.19","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Sclp/Hnd/Gen 1.1-2.0cm","PX-76000076","CDM","11622","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2688.14","2688.14","2688.14","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Mal Sclp/Hnd/Gen 2.1-3.0cm","PX-76000077","CDM","11623","CPT","0761","RC","","","","both","","","2277.00","1707.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","705.87","2404.92","other","OPPS APC"
"Exc Lesn Mal Sclp/Hnd/Gen 2.1-3.0cm","PX-76000077","CDM","11623","CPT","0761","RC","","","","both","","","2277.00","1707.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","872.09","38.3","","839.04","839.04","839.04","1 through 10","705.87","2404.92","percent of total billed charges",""
"Exc Lesn Mal Sclp/Hnd/Gen 2.1-3.0cm","PX-76000077","CDM","11623","CPT","0761","RC","","","","both","","","2277.00","1707.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","705.87","2404.92","other","OPPS APC"
"Exc Lesn Mal Sclp/Hnd/Gen 2.1-3.0cm","PX-76000077","CDM","11623","CPT","0761","RC","","","","both","","","2277.00","1707.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","705.87","2404.92","other","OPPS APC"
"Exc Lesn Mal Sclp/Hnd/Gen 2.1-3.0cm","PX-76000077","CDM","11623","CPT","0761","RC","","","","outpatient","","","2277.00","1707.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3160.08","3160.08","3160.08","1 through 10","1189.96","2384.07","other","ASC"
"Exc Lesn Mal Sclp/Hnd/Gen 3.1-4.0cm","PX-76000078","CDM","11624","CPT","0761","RC","","","","both","","","4072.00","3054.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2646.80","65","","5286.45","5286.45","5286.45","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Mal Sclp/Hnd/Gen 3.1-4.0cm","PX-76000078","CDM","11624","CPT","0761","RC","","","","both","","","4072.00","3054.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5772.39","5772.39","5772.39","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Mal Sclp/Hnd/Gen 3.1-4.0cm","PX-76000078","CDM","11624","CPT","0761","RC","","","","both","","","4072.00","3054.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1887.15","1887.15","1887.15","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg .6-1.0cm","PX-76000069","CDM","11601","CPT","0761","RC","","","","both","","","1432.00","1074.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","626.67","835.56","14","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg .6-1.0cm","PX-76000069","CDM","11601","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.46","38.3","","280.54","280.54","280.54","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg .6-1.0cm","PX-76000069","CDM","11601","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","AETNA [1001]","HB AMC AETNA HMO","999.54","69.8","","940.35","940.35","940.35","1 through 10","579.34","1234.13","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg .6-1.0cm","PX-76000069","CDM","11601","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.70","1535.70","1535.70","1 through 10","579.34","1234.13","other","ASC "
"Exc Lesn Mal Trunk/Arm/Leg <0.5cm","PX-76000068","CDM","11600","CPT","0761","RC","","","","both","","","2368.00","1776.00","MEDICARE [2001]","HB BWH MEDICARE","894.79","","APC Price ($894.79). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","734.08","1882.56","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg <0.5cm","PX-76000068","CDM","11600","CPT","0761","RC","","","","outpatient","","","2368.00","1776.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1935.13","81.72","","14338.84","14338.84","14338.84","1 through 10","579.34","2384.07","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","both","","","4072.00","3054.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1979.93","1979.93","1979.93","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","both","","","4072.00","3054.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3237.24","79.5","","32008.08","32008.08","32008.08","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","both","","","4072.00","3054.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2170.38","53.3","","2529.65","2529.65","2529.65","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","both","","","4072.00","3054.00","ELDER SERVICES [1037]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1885.65","1885.65","1885.65","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","both","","","4072.00","3054.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","17","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","both","","","4072.00","3054.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1559.58","38.3","","19461.96","19461.96","19461.96","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","both","","","4072.00","3054.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5673.15","5673.15","5673.15","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","both","","","4072.00","3054.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1889.48","1889.48","1889.48","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","AETNA [1001]","HB AMC AETNA HMO","2842.26","69.8","","5258.84","5258.84","5258.84","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3160.08","3160.08","3160.08","1 through 10","1237.95","5545.35","other","ASC"
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","1823.06","3682.30","15","1237.95","5545.35","other","ASC "
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1436.02","1436.02","1436.02","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3273.89","80.4","","1678.95","1678.95","1678.95","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","both","","","1432.00","1074.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","489.22","489.03","495.23","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","both","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","428.24","1389.00","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","both","","","1432.00","1074.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1138.44","79.5","","55.92","55.92","55.92","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","both","","","1432.00","1074.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","355.85","948.93","80","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.68","36.5","","1554.30","1554.30","1554.30","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.46","38.3","","1629.30","1055.64","1635.90","42","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1394.94","426.50","1394.94","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","both","","","1432.00","1074.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","464.98","464.98","464.98","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","both","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","614.33","42.9","","610.74","610.74","610.74","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","both","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.49","232.50","472.89","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","AETNA [1001]","HB AMC AETNA HMO","999.54","69.8","","971.50","883.60","1880.71","1 through 10","314.08","1234.13","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","721.57","360.79","734.86","1 through 10","314.08","1234.13","other","ASC"
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","832.56","420.41","840.82","15","314.08","1234.13","other","ASC "
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1093.02","728.67","1400.80","13","314.08","1234.13","other","Multiple Surgery"
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2299.08","2214.27","2299.08","12","314.08","1234.13","other","Multiple Surgery"
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","766.36","766.36","766.36","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1608.08","772.64","1608.08","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1151.33","80.4","","694.50","694.50","694.50","1 through 10","314.08","1234.13","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1170.23","81.72","","1110.37","610.74","1110.37","1 through 10","314.08","1234.13","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","both","","","1432.00","1074.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","866.50","866.50","866.50","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","both","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","755.61","822.19","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","both","","","1432.00","1074.00","ELDER SERVICES [1037]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","752.54","752.54","752.54","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","both","","","1432.00","1074.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","626.67","835.56","54","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.46","38.3","","1629.30","543.10","1629.30","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","752.54","409.42","752.54","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","both","","","1432.00","1074.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1505.08","818.85","1505.08","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","both","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.35","818.85","827.75","1 through 10","443.92","1138.44","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","both","","","1432.00","1074.00","WELLPOINT [1015]","HB AMC WELLPOINT","1056.53","73.78","","2423.11","2423.11","2423.11","1 through 10","443.92","1138.44","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","AETNA [1001]","HB AMC AETNA HMO","999.54","69.8","","1457.24","940.35","1457.24","1 through 10","579.34","2384.07","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1355.50","677.75","1355.50","1 through 10","579.34","2384.07","other","ASC"
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1550.94","1535.70","1550.94","11","579.34","2384.07","other","ASC "
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","2688.14","4032.21","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4240.77","4240.77","4240.77","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","867.37","867.37","867.37","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1170.23","81.72","","1110.37","610.74","1110.37","1 through 10","579.34","2384.07","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1616.36","1616.36","1616.36","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Mal Trunk/Arm/Leg 2.1-3.0","PX-76000071","CDM","11603","CPT","0761","RC","","","","outpatient","","","1432.00","1074.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1425.18","1425.18","1425.18","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Exc Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000072","CDM","11604","CPT","0761","RC","","","","both","","","3125.00","2343.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","1 through 10","793.78","2484.38","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000072","CDM","11604","CPT","0761","RC","","","","both","","","3125.00","2343.75","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","767.90","835.56","1 through 10","793.78","2484.38","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000072","CDM","11604","CPT","0761","RC","","","","both","","","3125.00","2343.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.75","826.75","826.75","1 through 10","793.78","2484.38","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000072","CDM","11604","CPT","0761","RC","","","","outpatient","","","3125.00","2343.75","AETNA [1001]","HB AMC AETNA HMO","2181.25","69.8","","1927.01","1927.01","1927.01","1 through 10","579.34","5545.35","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000072","CDM","11604","CPT","0761","RC","","","","outpatient","","","3125.00","2343.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1330.98","1330.98","1330.98","1 through 10","579.34","5545.35","other","ASC"
"Exc Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000072","CDM","11604","CPT","0761","RC","","","","outpatient","","","3125.00","2343.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1550.94","1535.70","1550.94","1 through 10","579.34","5545.35","other","ASC "
"Exc Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000072","CDM","11604","CPT","0761","RC","","","","outpatient","","","3125.00","2343.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","672.04","4032.21","1 through 10","579.34","5545.35","other","Multiple Surgery"
"Exc Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000072","CDM","11604","CPT","0761","RC","","","","outpatient","","","3125.00","2343.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","741.56","741.56","741.56","1 through 10","579.34","5545.35","other","Multiple Surgery"
"Exc Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000072","CDM","11604","CPT","0761","RC","","","","outpatient","","","3125.00","2343.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2553.75","81.72","","2422.18","1720.71","2422.18","1 through 10","579.34","5545.35","percent of total billed charges",""
"Exc Nail & Matrix","PX-76000092","CDM","11750","CPT","0761","RC","","","","both","","","1252.00","939.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","329.73","329.73","474.47","1 through 10","388.12","995.34","other","OPPS APC"
"Exc of Skin and Sq Tissue for Hidradenitis, Neck; W/ Simple or Intr Repa","PX-76002940","CDM","17999","CPT","0761","RC","","","","both","","","6385.00","4788.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4490.63","3878.56","4490.63","1 through 10","224.17","5076.08","other","OPPS APC"
"Exc of Skin and Sq Tissue for Hidradenitis, Neck; W/ Simple or Intr Repa","PX-76002940","CDM","17999","CPT","0761","RC","","","","outpatient","","","6385.00","4788.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3334.25","52.22","","467.73","465.00","467.73","1 through 10","700.33","5267.63","percent of total billed charges",""
"Exc Sweat Gland Lesn Inguin,Simpl","PX-98301451","CDM","11462","CPT","0983","RC","","","","both","","","1153.00","864.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","441.60","38.3","","7052.07","7052.07","7052.07","1 through 10","357.43","4248.14","percent of total billed charges",""
"Exc Sweat Gland Lesn Inguin,Simpl","PX-98301451","CDM","11462","CPT","0983","RC","","","","both","","","1153.00","864.75","WELLPOINT [1015]","HB AMC WELLPOINT","850.68","73.78","","10487.93","10487.93","10487.93","1 through 10","357.43","4248.14","percent of total billed charges",""
"Exc Sweat Gland Lesn Inguin,Simpl","PX-98301451","CDM","11462","CPT","0983","RC","","","","outpatient","","","1153.00","864.75","AETNA [1001]","HB AMC AETNA HMO","804.79","69.8","","4689.36","4689.36","4689.36","1 through 10","644.53","5545.35","percent of total billed charges",""
"Exc Sweat Gland Lesn Inguin,Simpl","PX-98301451","CDM","11462","CPT","0983","RC","","","","outpatient","","","1153.00","864.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","7159.85","7159.85","7159.85","1 through 10","644.53","5545.35","other","Multiple Surgery"
"Exc Sweat Gland Lesn Inguin,Simpl","PX-98301451","CDM","11462","CPT","0983","RC","","","","outpatient","","","1153.00","864.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","942.23","81.72","","2643.48","2643.48","2643.48","1 through 10","644.53","5545.35","percent of total billed charges",""
"Exc Sweat Gland Lesn Perineal,Complx","PX-76002838","CDM","11471","CPT","0761","RC","","","","both","","","6465.00","4848.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2476.10","38.3","","4764.44","4764.44","4764.44","1 through 10","2004.15","5139.68","percent of total billed charges",""
"Exc Sweat Gland Lesn Perineal,Complx","PX-76002838","CDM","11471","CPT","0761","RC","","","","both","","","6465.00","4848.75","WELLPOINT [1015]","HB AMC WELLPOINT","4769.88","73.78","","10936.27","10936.27","10936.27","1 through 10","2004.15","5139.68","percent of total billed charges",""
"Exc Sweat Gland Lesn Perineal,Complx","PX-76002838","CDM","11471","CPT","0761","RC","","","","outpatient","","","6465.00","4848.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5463.90","5463.90","5463.90","1 through 10","2140.46","5545.35","other","ASC"
"Exc Sweat Gland Lesn Perineal,Complx","PX-76002838","CDM","11471","CPT","0761","RC","","","","outpatient","","","6465.00","4848.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3152.15","3152.15","3152.15","1 through 10","2140.46","5545.35","other","ASC "
"Exc Sweat Gland Lesn Perineal,Complx","PX-76002838","CDM","11471","CPT","0761","RC","","","","outpatient","","","6465.00","4848.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","7448.82","7448.82","7448.82","1 through 10","2140.46","5545.35","other","Multiple Surgery"
"Exc Sweat Gland Lesn Perineal,Complx","PX-76002838","CDM","11471","CPT","0761","RC","","","","outpatient","","","6465.00","4848.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5283.20","81.72","","5011.44","5011.44","5011.44","1 through 10","2140.46","5545.35","percent of total billed charges",""
"Exc Sweat Gland Lesn Perineal,Complx","PX-98302430","CDM","11471","CPT","0983","RC","","","","both","","","1587.00","1190.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","607.82","38.3","","4764.44","4764.44","4764.44","1 through 10","491.97","4248.14","percent of total billed charges",""
"Exc Sweat Gland Lesn Perineal,Complx","PX-98302430","CDM","11471","CPT","0983","RC","","","","both","","","1587.00","1190.25","WELLPOINT [1015]","HB AMC WELLPOINT","1170.89","73.78","","10936.27","10936.27","10936.27","1 through 10","491.97","4248.14","percent of total billed charges",""
"Exc Sweat Gland Lesn Perineal,Complx","PX-98302430","CDM","11471","CPT","0983","RC","","","","outpatient","","","1587.00","1190.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","7448.82","7448.82","7448.82","1 through 10","887.13","5545.35","other","Multiple Surgery"
"Exc Sweat Gland Lesn Perineal,Complx","PX-98302430","CDM","11471","CPT","0983","RC","","","","outpatient","","","1587.00","1190.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1296.90","81.72","","5011.44","5011.44","5011.44","1 through 10","887.13","5545.35","percent of total billed charges",""
"Exc Sweat Gland Lesn Perineal,Simpl","PX-76002802","CDM","11470","CPT","0761","RC","","","","both","","","2927.00","2195.25","MEDICARE [2001]","HB BWH MEDICARE","3398.51","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","3398.86","1 through 10","907.37","4248.14","other","OPPS APC"
"Exc Sweat Gland Lesn Perineal,Simpl","PX-76002802","CDM","11470","CPT","0761","RC","","","","both","","","2927.00","2195.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1068.36","36.5","","3175.71","3175.71","3175.71","1 through 10","907.37","4248.14","percent of total billed charges",""
"Exc Sweat Gland Lesn Perineal,Simpl","PX-76002802","CDM","11470","CPT","0761","RC","","","","outpatient","","","2927.00","2195.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2386.62","2386.62","2386.62","1 through 10","1529.65","5545.35","other","Multiple Surgery"
"Exc Tmr Nck/Chst Deep <5cm","PX-76000344","CDM","21556","CPT","0761","RC","","","","both","","","6373.00","4779.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2440.86","38.3","","9459.07","9459.07","9459.07","1 through 10","1975.63","5066.54","percent of total billed charges",""
"Exc Tmr Nck/Chst Deep <5cm","PX-76000344","CDM","21556","CPT","0761","RC","","","","outpatient","","","6373.00","4779.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3858.85","60.55","","5463.90","5463.90","5463.90","1 through 10","2549.2","5208.02","percent of total billed charges",""
"Exc Tmr Nck/Chst Deep <5cm","PX-76000344","CDM","21556","CPT","0761","RC","","","","outpatient","","","6373.00","4779.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3327.98","52.22","","6304.29","6304.29","6304.29","1 through 10","2549.2","5208.02","percent of total billed charges",""
"Exc Tum Face/Scalp Subfasc 2 +","PX-76000313","CDM","21014","CPT","0761","RC","","","","both","","","3866.00","2899.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1480.68","38.3","","3366.51","3366.51","3366.51","1 through 10","555.03","3228.91","percent of total billed charges",""
"Exc Tum Soft Tiss Face/Scalp Subfas","PX-76000312","CDM","21013","CPT","0761","RC","","","","both","","","2907.00","2180.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1549.43","53.3","","7171.14","7171.14","7171.14","1 through 10","428.31","2311.07","percent of total billed charges",""
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","both","","","6049.00","4536.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3749.00","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3504.42","2821.50","3504.42","1 through 10","1875.19","4808.96","other","OPPS APC"
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","both","","","6049.00","4536.75","MEDICARE [2001]","HB BWH MEDICARE","3639.81","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","10196.58","1 through 10","1875.19","4808.96","other","OPPS APC"
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","both","","","6049.00","4536.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2207.89","36.5","","909.79","909.79","909.79","1 through 10","1875.19","4808.96","percent of total billed charges",""
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","both","","","6049.00","4536.75","WELLPOINT [1015]","HB AMC WELLPOINT","4462.95","73.78","","2136.72","2136.72","2136.72","1 through 10","1875.19","4808.96","percent of total billed charges",""
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6304.29","3183.42","6366.84","1 through 10","2140.46","9843.6","other","ASC "
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4943.24","81.72","","5204.30","5204.30","5204.30","1 through 10","2140.46","9843.6","percent of total billed charges",""
"Exc Tum Tiss Neck/Ant Thx Subq 5+","PX-76000342","CDM","21554","CPT","0761","RC","","","","both","","","6373.00","4779.75","MEDICARE [2001]","HB BWH MEDICARE","3639.81","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","3398.86","1 through 10","1975.63","5066.54","other","OPPS APC"
"Exc Tum Tiss Neck/Ant Thx Subq 5+","PX-76000342","CDM","21554","CPT","0761","RC","","","","outpatient","","","6373.00","4779.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6304.29","6304.29","6366.84","1 through 10","2140.46","9843.6","other","ASC "
"Exc Tum Tiss Neck/Ant Thx Subq 5+","PX-76000342","CDM","21554","CPT","0761","RC","","","","outpatient","","","6373.00","4779.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","5479.58","5479.58","5479.58","1 through 10","2140.46","9843.6","other","Multiple Surgery"
"Exc Tumor Back/Flank <3cm","PX-76000352","CDM","21930","CPT","0761","RC","","","","both","","","4072.00","3054.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1412.04","1412.04","1412.04","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Tumor Back/Flank <3cm","PX-76000352","CDM","21930","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","AETNA [1001]","HB AMC AETNA HMO","2842.26","69.8","","3986.52","3986.52","3986.52","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Tumor Back/Flank <3cm","PX-76000352","CDM","21930","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3682.30","3682.30","3682.30","1 through 10","1237.95","5545.35","other","ASC "
"Exc Tumor Back/Flank <3cm","PX-76000352","CDM","21930","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","8616.12","8616.12","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Exc Tumor Back/Flank <3cm","PX-76000352","CDM","21930","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3020.60","3020.60","3020.60","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","both","","","6049.00","4536.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2060.54","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","1827.93","4808.96","other","OPPS APC"
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","both","","","6049.00","4536.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4808.96","79.5","","1515.36","1515.36","1515.36","1 through 10","1827.93","4808.96","percent of total billed charges",""
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","both","","","6049.00","4536.75","MEDICARE [2001]","HB BWH MEDICARE","2060.54","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5772.39","1924.13","5772.39","1 through 10","1827.93","4808.96","other","OPPS APC"
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","both","","","6049.00","4536.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2316.77","38.3","","18640.14","561.09","18640.14","1 through 10","1827.93","4808.96","percent of total billed charges",""
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3682.30","3682.30","3682.30","1 through 10","1237.95","9843.6","other","ASC "
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2762.51","2762.51","2762.51","1 through 10","1237.95","9843.6","other","Multiple Surgery"
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4943.24","81.72","","1147.14","1147.14","1147.14","1 through 10","1237.95","9843.6","percent of total billed charges",""
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","both","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","both","","","4072.00","3054.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3237.24","79.5","","25870.26","25870.26","25870.26","1 through 10","1262.32","3237.24","percent of total billed charges",""
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","both","","","4072.00","3054.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1262.32","3237.24","other","OPPS APC"
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","AETNA [1001]","HB AMC AETNA HMO","2842.26","69.8","","7775.15","7775.15","7775.15","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","AETNA [1001]","HB AMC AETNA PPO","3273.89","80.4","","7595.90","7595.90","7595.90","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1823.06","1823.06","1823.06","1 through 10","1237.95","5545.35","other","ASC "
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","outpatient","","","4072.00","3054.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2872.04","2872.04","2872.04","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Exc Tumor Pelvis/Hip Subq 3+","PX-76000522","CDM","27043","CPT","0761","RC","","","","both","","","6049.00","4536.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4808.96","79.5","","22150.98","22150.98","22150.98","1 through 10","1875.19","4808.96","percent of total billed charges",""
"Exc Tumor Pelvis/Hip Subq 3+","PX-76000522","CDM","27043","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","AETNA [1001]","HB AMC AETNA HMO","4222.20","69.8","","7011.78","7011.78","7011.78","1 through 10","2140.46","9843.6","percent of total billed charges",""
"Exc Tumor Shoulder Subq 3cm Grter","PX-76000379","CDM","23071","CPT","0761","RC","","","","both","","","6170.00","4627.50","WELLPOINT [1015]","HB AMC WELLPOINT","4552.23","73.78","","17644.75","17644.75","17644.75","1 through 10","1827.93","4905.15","percent of total billed charges",""
"Exc Tumor Soft Tissue Abdominal Wall Subq <3cm","PX-98300903","CDM","22902","CPT","0983","RC","","","","both","","","1520.00","1140.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","582.16","38.3","","561.09","561.09","561.09","1 through 10","471.2","2575.67","percent of total billed charges",""
"Exc Tumor Soft Tissue Abdominal Wall Subq <3cm","PX-98300903","CDM","22902","CPT","0983","RC","","","","outpatient","","","1520.00","1140.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8340.00","8340.00","8340.00","1 through 10","849.68","5545.35","other","Multiple Surgery"
"Exc Tumor Soft Tissue Abdominal Wall Subq <3cm","PX-98300903","CDM","22902","CPT","0983","RC","","","","outpatient","","","1520.00","1140.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","3874.00","3874.00","3874.00","1 through 10","849.68","5545.35","other","Multiple Surgery"
"Exc Tumor Soft Tissue Neck/Ant Thorax Subfascial <5cm","PX-98302027","CDM","21556","CPT","0983","RC","","","","both","","","2386.00","1789.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","913.84","38.3","","9459.07","9459.07","9459.07","1 through 10","739.66","1896.87","percent of total billed charges",""
"Exc Tumor Soft Tissue Neck/Ant Thorax Subfascial <5cm","PX-98302027","CDM","21556","CPT","0983","RC","","","","outpatient","","","2386.00","1789.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1444.72","60.55","","5463.90","5463.90","5463.90","1 through 10","954.4","1949.84","percent of total billed charges",""
"Exc Tumor Soft Tissue Neck/Ant Thorax Subfascial <5cm","PX-98302027","CDM","21556","CPT","0983","RC","","","","outpatient","","","2386.00","1789.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1245.97","52.22","","6304.29","6304.29","6304.29","1 through 10","954.4","1949.84","percent of total billed charges",""
"Exc Tumor Tiss Face/Scalp Subq< 2cm","PX-76000310","CDM","21011","CPT","0761","RC","","","","both","","","2233.00","1674.75","MEDICARE [2001]","HB BWH MEDICARE","2060.54","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","692.23","2575.67","other","OPPS APC"
"Exc Tumor Tiss Face/Scalp Subq< 2cm","PX-76000310","CDM","21011","CPT","0761","RC","","","","both","","","2233.00","1674.75","WELLPOINT [1015]","HB AMC WELLPOINT","1647.51","73.78","","1668.89","1668.89","1668.89","1 through 10","692.23","2575.67","percent of total billed charges",""
"Exc Tumor Tiss Face/Scalp Subq< 2cm","PX-76000310","CDM","21011","CPT","0761","RC","","","","outpatient","","","2233.00","1674.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3218.28","3218.28","3218.28","1 through 10","1166.97","2384.07","other","ASC"
"Exc Tumor Tiss Face/Scalp Subq< 2cm","PX-76000310","CDM","21011","CPT","0761","RC","","","","outpatient","","","2233.00","1674.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","3646.12","3646.12","1 through 10","1166.97","2384.07","other","ASC "
"Exc Tumr Face/Scalp Subq 2+Cm","PX-76000311","CDM","21012","CPT","0761","RC","","","","both","","","2524.00","1893.00","MEDICARE [2001]","HB BWH MEDICARE","2060.54","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","782.44","2575.67","other","OPPS APC"
"Exc Tumr Face/Scalp Subq 2+Cm","PX-76000311","CDM","21012","CPT","0761","RC","","","","outpatient","","","2524.00","1893.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3160.08","3160.08","3160.08","1 through 10","1237.95","2384.07","other","ASC"
"Exc Tumr Face/Scalp Subq 2+Cm","PX-76000311","CDM","21012","CPT","0761","RC","","","","outpatient","","","2524.00","1893.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","3646.12","3682.30","1 through 10","1237.95","2384.07","other","ASC "
"Exc Tumr Face/Scalp Subq 2+Cm","PX-76000311","CDM","21012","CPT","0761","RC","","","","outpatient","","","2524.00","1893.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2872.04","2872.04","2872.04","1 through 10","1237.95","2384.07","other","Multiple Surgery"
"Exc Tumr Face/Scalp Subq 2+Cm","PX-76000311","CDM","21012","CPT","0761","RC","","","","outpatient","","","2524.00","1893.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9061.80","9061.80","9061.80","1 through 10","1237.95","2384.07","other","Multiple Surgery"
"Exc Vaginal Lesion","PX-76002807","CDM","57130","CPT","0761","RC","","","","outpatient","","","5298.00","3973.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2766.62","52.22","","6321.29","3129.59","6321.29","1 through 10","2119.2","4329.53","percent of total billed charges",""
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4316.26","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1951.06","1949.20","4312.51","1 through 10","372","5238.18","other","OPPS APC"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","1200.00","900.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1164.00","1164.00","4123.91","1 through 10","372","5238.18","other","OPPS APC"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","1200.00","900.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2351.30","1145.38","4111.81","1 through 10","372","5238.18","other","OPPS APC"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","1200.00","900.00","MEDICARE [2001]","HB BWH MEDICARE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","2095.49","4190.97","68","372","5238.18","other","OPPS APC"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","438.00","36.5","","434.17","434.17","434.17","1 through 10","372","5238.18","percent of total billed charges",""
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4113.15","4113.15","4113.15","1 through 10","372","5238.18","other","OPPS APC"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","1200.00","900.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4106.74","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4112.55","3700.44","4112.55","1 through 10","372","5238.18","other","OPPS APC"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","1200.00","900.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","4106.74","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","267.72","267.72","267.72","1 through 10","372","5238.18","other","OPPS APC"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4106.74","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4107.16","3707.85","4115.06","18","372","5238.18","other","OPPS APC"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","outpatient","","","1200.00","900.00","AETNA [1001]","HB AMC AETNA HMO","837.60","69.8","","907.92","788.03","907.92","1 through 10","627.12","3370.43","percent of total billed charges",""
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","outpatient","","","1200.00","900.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3370.43","","Case rate ($3,370.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6771.19","6771.19","6895.90","1 through 10","627.12","3370.43","other","ASC"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","outpatient","","","1200.00","900.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3370.43","","Case rate ($3,370.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7812.66","1972.55","7890.18","12","627.12","3370.43","other","ASC "
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","outpatient","","","1200.00","900.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2652.59","","Case rate ($2,652.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6154.01","5915.28","6154.01","1 through 10","627.12","3370.43","other","Multiple Surgery"
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","outpatient","","","1200.00","900.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2652.59","","Case rate ($2,652.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6472.32","6472.32","6472.32","1 through 10","627.12","3370.43","other","Multiple Surgery"
"Exchange Nephrostomy Catheter Prq W/Img Gid Rs&I","PX-76002187","CDM","50435","CPT","0761","RC","","","","both","","","753.00","564.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","598.64","79.5","","1149.02","574.51","1149.02","1 through 10","233.43","3040.6","percent of total billed charges",""
"Exchange Nephrostomy Catheter Prq W/Img Gid Rs&I","PX-76002187","CDM","50435","CPT","0761","RC","","","","both","","","753.00","564.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2384.48","2178.57","2393.08","1 through 10","233.43","3040.6","other","OPPS APC"
"Exchange Nephrostomy Catheter Prq W/Img Gid Rs&I","PX-76002187","CDM","50435","CPT","0761","RC","","","","outpatient","","","753.00","564.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2908.21","1391.17","3052.52","1 through 10","393.52","2384.07","other","Multiple Surgery"
"Exchange Nephrostomy Catheter Prq W/Img Gid Rs&I|BILATERAL PROCEDURE","PX-76002187","CDM","50435","CPT","0761","RC","","","50","outpatient","","","753.00","564.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2984.25","","Case rate ($2,984.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6105.78","5995.36","6105.78","1 through 10","2984.25","8995.41","other","ASC"
"Exchange Nephrostomy Catheter Prq W/Img Gid Rs&I|BILATERAL PROCEDURE","PX-76002187","CDM","50435","CPT","0761","RC","","","50","outpatient","","","753.00","564.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2984.25","","Case rate ($2,984.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6917.49","6917.49","6986.13","1 through 10","2984.25","8995.41","other","ASC "
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","both","","","4774.00","3580.50","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","6230.34","1 through 10","1479.94","3795.33","other","OPPS APC"
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","both","","","4774.00","3580.50","WELLPOINT [1015]","HB AMC WELLPOINT","3522.26","73.78","","3447.04","3447.04","3447.04","1 through 10","1479.94","3795.33","percent of total billed charges",""
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","outpatient","","","4774.00","3580.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3407.87","3407.87","3407.87","1 through 10","1335.02","3901.31","other","ASC"
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","outpatient","","","4774.00","3580.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3932.02","3932.02","3932.02","1 through 10","1335.02","3901.31","other","ASC "
"Excimer Laser Skin Disease Other Than Psoriasis","PX-94000041","CDM","96999","CPT","0940","RC","","","","both","","","1962.00","1471.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1045.75","53.3","","1497.66","1497.66","1497.66","11","224.17","1559.79","percent of total billed charges",""
"Excimer Laser Skin Disease Other Than Psoriasis","PX-94000041","CDM","96999","CPT","0940","RC","","","","both","","","1962.00","1471.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","14","224.17","1559.79","other","OPPS APC"
"Excimer Laser Skin Disease Other Than Psoriasis","PX-94000041","CDM","96999","CPT","0940","RC","","","","both","","","1962.00","1471.50","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","25","224.17","1559.79","other","OPPS APC"
"Excimer Laser Skin Disease Other Than Psoriasis","PX-94000041","CDM","96999","CPT","0940","RC","","","","outpatient","","","1962.00","1471.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1187.99","60.55","","1903.00","405.38","1903.00","12","192.8","1618.65","percent of total billed charges",""
"Excimer Laser Skin Disease Other Than Psoriasis","PX-94000041","CDM","96999","CPT","0940","RC","","","","outpatient","","","1962.00","1471.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1024.56","52.22","","1903.00","467.73","1903.00","125","192.8","1618.65","percent of total billed charges",""
"Excimer Laser Skin Disease Other Than Psoriasis","PX-94000041","CDM","96999","CPT","0940","RC","","","","outpatient","","","1962.00","1471.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","981.00","50","","1903.00","860.15","1903.00","107","192.8","1618.65","percent of total billed charges",""
"Excise Excess Skin Tissue,Other","PX-36000462","CDM","15839","CPT","0361","RC","","","","both","","","4820.00","3615.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3374.00","70","","5029.37","5029.37","5029.37","1 through 10","781.54","3831.9","percent of total billed charges",""
"Excise Excess Skin Tissue,Other","PX-36000462","CDM","15839","CPT","0361","RC","","","","both","","","4820.00","3615.00","WELLPOINT [1015]","HB AMC WELLPOINT","3556.20","73.78","","5372.46","5372.46","5372.46","1 through 10","781.54","3831.9","percent of total billed charges",""
"Excise Excess Skin Tissue,Other","PX-36000462","CDM","15839","CPT","0361","RC","","","","outpatient","","","4820.00","3615.00","AETNA [1001]","HB AMC AETNA PPO","3875.28","80.4","","10706.00","10706.00","10706.00","1 through 10","2140.46","3938.9","percent of total billed charges",""
"Excise Excess Skin Tissue,Other","PX-36000462","CDM","15839","CPT","0361","RC","","","","outpatient","","","4820.00","3615.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2782.27","2731.95","9316.00","1 through 10","2140.46","3938.9","other","ASC"
"Excise Excess Skin Tissue,Other","PX-36000462","CDM","15839","CPT","0361","RC","","","","outpatient","","","4820.00","3615.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6366.84","3152.15","6366.84","1 through 10","2140.46","3938.9","other","ASC "
"Excision Hidradenitis Axillary Smpl/Intrm Rpr","PX-98302497","CDM","11450","CPT","0983","RC","","","","both","","","1199.00","899.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","639.07","53.3","","14576.80","14576.80","14576.80","1 through 10","371.69","4248.14","percent of total billed charges",""
"Excision Hidradenitis Axillary Smpl/Intrm Rpr","PX-98302497","CDM","11450","CPT","0983","RC","","","","both","","","1199.00","899.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","459.22","38.3","","2350.69","2350.69","2350.69","1 through 10","371.69","4248.14","percent of total billed charges",""
"Excision Hidradenitis Axillary Smpl/Intrm Rpr","PX-98302497","CDM","11450","CPT","0983","RC","","","","both","","","1199.00","899.25","WELLPOINT [1015]","HB AMC WELLPOINT","884.62","73.78","","4475.93","4475.93","4475.93","1 through 10","371.69","4248.14","percent of total billed charges",""
"Excision Hidradenitis Axillary Smpl/Intrm Rpr","PX-98302497","CDM","11450","CPT","0983","RC","","","","outpatient","","","1199.00","899.25","AETNA [1001]","HB AMC AETNA HMO","836.90","69.8","","4689.36","2873.74","4689.36","1 through 10","670.24","5545.35","percent of total billed charges",""
"Excision Hidradenitis Axillary Smpl/Intrm Rpr","PX-98302497","CDM","11450","CPT","0983","RC","","","","outpatient","","","1199.00","899.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","979.82","81.72","","2643.48","2643.48","2643.48","1 through 10","670.24","5545.35","percent of total billed charges",""
"Excision Hidradenitis Inguinal Complex","PX-76002967","CDM","11463","CPT","0761","RC","","","","both","","","3968.00","2976.00","MEDICARE [2001]","HB BWH MEDICARE","3398.51","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","3398.86","1 through 10","1230.08","4248.14","other","OPPS APC"
"Excision Hidradenitis Inguinal Complex","PX-76002967","CDM","11463","CPT","0761","RC","","","","both","","","3968.00","2976.00","WELLPOINT [1015]","HB AMC WELLPOINT","2927.59","73.78","","6712.84","6712.84","6712.84","1 through 10","1230.08","4248.14","percent of total billed charges",""
"Excision Hidradenitis Inguinal Complex","PX-76002967","CDM","11463","CPT","0761","RC","","","","outpatient","","","3968.00","2976.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6304.29","6304.29","6304.29","1 through 10","2073.68","5545.35","other","ASC "
"Excision Hidradenitis Inguinal Complex","PX-98302517","CDM","11463","CPT","0983","RC","","","","both","","","1500.00","1125.00","MEDICARE [2001]","HB BWH MEDICARE","3398.51","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","3398.86","1 through 10","465","4248.14","other","OPPS APC"
"Excision Hidradenitis Inguinal Complex","PX-98302517","CDM","11463","CPT","0983","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB AMC WELLPOINT","1106.70","73.78","","6712.84","6712.84","6712.84","1 through 10","465","4248.14","percent of total billed charges",""
"Excision of Bone Lower Jaw","PX-76002328","CDM","21025","CPT","0761","RC","","","","both","","","8255.00","6191.25","MEDICARE [2001]","HB BWH MEDICARE","7024.49","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7025.20","6391.56","7025.20","1 through 10","2559.05","8780.61","other","OPPS APC"
"Excision of Bone Lower Jaw","PX-76002328","CDM","21025","CPT","0761","RC","","","","both","","","8255.00","6191.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","7024.49","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","724.44","724.44","724.44","1 through 10","2559.05","8780.61","other","OPPS APC"
"Excision of Bone Lower Jaw","PX-76002328","CDM","21025","CPT","0761","RC","","","","both","","","8255.00","6191.25","MOLINA [1014]","HB BWH MOLINA","6884.00","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4303.17","4303.17","13909.90","1 through 10","2559.05","8780.61","other","OPPS APC"
"Excision of Bone Lower Jaw","PX-76002328","CDM","21025","CPT","0761","RC","","","","both","","","8255.00","6191.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6884.00","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20676.30","20676.30","20676.30","1 through 10","2559.05","8780.61","other","OPPS APC"
"Excision of Bone Lower Jaw","PX-76002328","CDM","21025","CPT","0761","RC","","","","outpatient","","","8255.00","6191.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5059.36","","Case rate ($5,059.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","12282.18","12282.18","12282.18","1 through 10","3981.81","6745.99","other","ASC"
"Excision of Bone Lower Jaw","PX-76002328","CDM","21025","CPT","0761","RC","","","","outpatient","","","8255.00","6191.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5059.36","","Case rate ($5,059.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","11727.60","11727.60","11727.60","1 through 10","3981.81","6745.99","other","ASC "
"Excision of Bone Lower Jaw","PX-76002328","CDM","21025","CPT","0761","RC","","","","outpatient","","","8255.00","6191.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","3981.81","","Case rate ($3,981.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","10193.43","10193.43","10193.43","1 through 10","3981.81","6745.99","other","Multiple Surgery"
"Excision of Bone Lower Jaw","PX-98301242","CDM","21025","CPT","0983","RC","","","","both","","","3024.00","2268.00","MEDICARE [2001]","HB BWH MEDICARE","7024.49","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7025.20","6391.56","7025.20","1 through 10","937.44","8780.61","other","OPPS APC"
"Excision of Bone Lower Jaw","PX-98301242","CDM","21025","CPT","0983","RC","","","","both","","","3024.00","2268.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","7024.49","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","724.44","724.44","724.44","1 through 10","937.44","8780.61","other","OPPS APC"
"Excision of Bone Lower Jaw","PX-98301242","CDM","21025","CPT","0983","RC","","","","both","","","3024.00","2268.00","MOLINA [1014]","HB BWH MOLINA","6884.00","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4303.17","4303.17","13909.90","1 through 10","937.44","8780.61","other","OPPS APC"
"Excision of Bone Lower Jaw","PX-98301242","CDM","21025","CPT","0983","RC","","","","both","","","3024.00","2268.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6884.00","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20676.30","20676.30","20676.30","1 through 10","937.44","8780.61","other","OPPS APC"
"Excision of Bone Lower Jaw","PX-98301242","CDM","21025","CPT","0983","RC","","","","outpatient","","","3024.00","2268.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","3981.81","","Case rate ($3,981.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","10193.43","10193.43","10193.43","1 through 10","1690.42","5545.35","other","Multiple Surgery"
"Excision of Ext Anus Papillae/Tags","PX-75000216","CDM","46230","CPT","0750","RC","","","","both","","","4945.00","3708.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3417.88","","APC Price ($3,487.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3012.21","3012.21","3012.21","1 through 10","1532.95","4359.54","other","OPPS APC"
"Excision of Ext Anus Papillae/Tags","PX-75000216","CDM","46230","CPT","0750","RC","","","","both","","","4945.00","3708.75","WELLPOINT [1015]","HB AMC WELLPOINT","3648.42","73.78","","6055.02","6055.02","6055.02","1 through 10","1532.95","4359.54","percent of total billed charges",""
"Excision of Ext Anus Papillae/Tags","PX-75000216","CDM","46230","CPT","0750","RC","","","","outpatient","","","4945.00","3708.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2101.12","","Case rate ($2,101.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4874.60","4874.60","4874.60","1 through 10","2101.12","4041.05","other","Multiple Surgery"
"Excision of Facial Bone(S)","PX-76002333","CDM","21026","CPT","0761","RC","","","","both","","","10319.00","7739.25","MEDICARE [2001]","HB BWH MEDICARE","7024.49","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7025.20","7025.20","7025.20","1 through 10","3198.89","8780.61","other","OPPS APC"
"Excision of Facial Bone(S)","PX-76002333","CDM","21026","CPT","0761","RC","","","","both","","","10319.00","7739.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","7024.49","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","480.79","480.79","480.79","1 through 10","3198.89","8780.61","other","OPPS APC"
"Excision of Facial Bone(S)","PX-76002333","CDM","21026","CPT","0761","RC","","","","both","","","10319.00","7739.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6884.00","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6263.73","6263.73","6263.73","1 through 10","3198.89","8780.61","other","OPPS APC"
"Excision of Facial Bone(S)","PX-98301244","CDM","21026","CPT","0983","RC","","","","both","","","2007.00","1505.25","MEDICARE [2001]","HB BWH MEDICARE","7024.49","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7025.20","7025.20","7025.20","1 through 10","622.17","8780.61","other","OPPS APC"
"Excision of Facial Bone(S)","PX-98301244","CDM","21026","CPT","0983","RC","","","","both","","","2007.00","1505.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","7024.49","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","480.79","480.79","480.79","1 through 10","622.17","8780.61","other","OPPS APC"
"Excision of Facial Bone(S)","PX-98301244","CDM","21026","CPT","0983","RC","","","","both","","","2007.00","1505.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6884.00","","APC Price ($7,024.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6263.73","6263.73","6263.73","1 through 10","622.17","8780.61","other","OPPS APC"
"Excision or Surgical Planning of Skin of Nose for Rhinophyma","PX-76002386","CDM","30120","CPT","0761","RC","","","","outpatient","","","3378.00","2533.50","AETNA [1001]","HB AMC AETNA HMO","2357.84","69.8","","12526.02","12526.02","12526.02","1 through 10","1765.34","2760.5","percent of total billed charges",""
"Excision Tumor S.T. Foot/Toe Subq <1.5cm","PX-36000464","CDM","28043","CPT","0361","RC","","","","both","","","5168.00","3876.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2019.33","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.55","1893.55","1893.55","1 through 10","1602.08","4108.56","other","OPPS APC"
"Excision Tumor Soft Tissue Thigh/Knee Subq <3cm","PX-36000082","CDM","27327","CPT","0361","RC","","","","both","","","6049.00","4536.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2019.33","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.55","1893.55","1893.55","1 through 10","1827.93","4808.96","other","OPPS APC"
"Excision Tumor Soft Tissue Thigh/Knee Subq <3cm","PX-98300826","CDM","27327","CPT","0983","RC","","","","both","","","1445.00","1083.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2019.33","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.55","1893.55","1893.55","1 through 10","447.95","2575.67","other","OPPS APC"
"Excision Tumor Soft Tissue Thigh/Knee Subq <3cm|BILATERAL PROCEDURE","PX-36000082","CDM","27327","CPT","0361","RC","","","50","outpatient","","","6049.00","4536.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2359.44","","Case rate ($2,359.44). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","4827.41","4827.41","4827.41","1 through 10","2359.44","10314.36","other","ASC"
"EXCLUDER ENDOPROSTHEIS 14.5MM 10CM ILIAC BRANCH COMPONENT VESSEL","SUP-ITM-10166020","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","17667.00","65","","6652.80","6652.80","6652.80","1 through 10","8425.8","21608.1","percent of total billed charges",""
"EXCLUDER ENDOPROSTHEIS 14.5MM 10CM ILIAC BRANCH COMPONENT VESSEL","SUP-ITM-10166020","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21608.10","79.5","","2612.61","795.38","2612.61","1 through 10","8425.8","21608.1","percent of total billed charges",""
"EXCLUDER ENDOPROSTHEIS 14.5MM 10CM ILIAC BRANCH COMPONENT VESSEL","SUP-ITM-10166020","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14486.94","53.3","","1101.80","1101.80","1101.80","1 through 10","8425.8","21608.1","percent of total billed charges",""
"EXCLUDER ENDOPROSTHEIS 14.5MM 10CM ILIAC BRANCH COMPONENT VESSEL","SUP-ITM-10166020","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","17667.00","65","","1820.00","910.00","1820.00","1 through 10","8425.8","21608.1","percent of total billed charges",""
"EXCLUDER ENDOPROSTHEIS 14.5MM 10CM ILIAC BRANCH COMPONENT VESSEL","SUP-ITM-10166020","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9920.70","36.5","","1257.80","693.44","2424.50","1 through 10","8425.8","21608.1","percent of total billed charges",""
"EXCLUDER ENDOPROSTHEIS 14.5MM 10CM ILIAC BRANCH COMPONENT VESSEL","SUP-ITM-10166020","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10409.94","38.3","","1950.11","547.40","2346.00","1 through 10","8425.8","21608.1","percent of total billed charges",""
"EXCLUDER ENDOPROSTHEIS 14.5MM 10CM ILIAC BRANCH COMPONENT VESSEL","SUP-ITM-10166020","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11660.22","42.9","","5096.18","5096.18","5096.18","1 through 10","8425.8","21608.1","percent of total billed charges",""
"EXCLUDER ENDOPROSTHEIS 14.5MM 10CM ILIAC BRANCH COMPONENT VESSEL","SUP-ITM-10166020","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","WELLPOINT [1015]","HB AMC WELLPOINT","20053.40","73.78","","1172.59","1172.59","4829.94","1 through 10","8425.8","21608.1","percent of total billed charges",""
"EXCLUDER ENDOPROSTHEIS 14.5MM 10CM ILIAC BRANCH COMPONENT VESSEL","SUP-ITM-10166020","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","27180.00","20385.00","AETNA [1001]","HB AMC AETNA HMO","18971.64","69.8","","1806.84","947.80","5091.72","1 through 10","14204.27","22211.5","percent of total billed charges",""
"EXCLUDER ENDOPROSTHEIS 14.5MM 10CM ILIAC BRANCH COMPONENT VESSEL","SUP-ITM-10166020","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","27180.00","20385.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22211.50","81.72","","1259.05","615.58","4586.56","1 through 10","14204.27","22211.5","percent of total billed charges",""
"Exonic Deletion/Duplication Analysis by Array-Cgh (Two+ Genes)","PX-31000769","CDM","81479","CPT","0310","RC","","","","both","","","2572.00","1929.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2044.74","79.5","","0.65","0.65","0.65","1 through 10","797.32","2443.4","percent of total billed charges",""
"Exonic Deletion/Duplication Analysis by Array-Cgh (Two+ Genes)","PX-31000769","CDM","81479","CPT","0310","RC","","","","both","","","2572.00","1929.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1370.88","53.3","","0.79","0.79","0.79","1 through 10","797.32","2443.4","percent of total billed charges",""
"Exonic Deletion/Duplication Analysis by Array-Cgh (Two+ Genes)","PX-31000769","CDM","81479","CPT","0310","RC","","","","outpatient","","","2572.00","1929.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1286.00","50","","1.00","1.00","1.00","1 through 10","156.55","2121.9","percent of total billed charges",""
"Exonic Deletion/Duplication Analysis by Array-Cgh (Two+ Genes)","PX-31000769","CDM","81479","CPT","0310","RC","","","","outpatient","","","2572.00","1929.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1350.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","2121.9","percent of total billed charges",""
"EXPANDER TISSUE 100CC 5X7CM RECTANGLE LF","SUP-ITM-10233828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3057.97","79.5","","1309.77","674.56","6049.93","26","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 100CC 5X7CM RECTANGLE LF","SUP-ITM-10233828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2050.18","53.3","","1901.83","1901.83","2962.25","1 through 10","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 100CC 5X7CM RECTANGLE LF","SUP-ITM-10233828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1403.97","36.5","","1620.31","1620.31","19908.88","1 through 10","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 100CC 5X7CM RECTANGLE LF","SUP-ITM-10233828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1473.21","38.3","","352.91","352.91","2046.30","1 through 10","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 100CC 5X7CM RECTANGLE LF","SUP-ITM-10233828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1650.15","42.9","","9668.75","9668.75","9668.75","1 through 10","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 100CC 5X7CM RECTANGLE LF","SUP-ITM-10233828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","WELLPOINT [1015]","HB AMC WELLPOINT","2837.95","73.78","","699.88","384.10","3443.31","33","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 100CC 5X7CM RECTANGLE LF","SUP-ITM-10233828","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","AETNA [1001]","HB AMC AETNA HMO","2684.86","69.8","","1421.24","264.50","4933.46","29","2010.18","3143.36","percent of total billed charges",""
"EXPANDER TISSUE 100CC 5X7CM RECTANGLE LF","SUP-ITM-10233828","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3092.59","80.4","","1022.97","1022.97","3607.50","1 through 10","2010.18","3143.36","percent of total billed charges",""
"EXPANDER TISSUE 100CC 5X7CM RECTANGLE LF","SUP-ITM-10233828","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3143.36","81.72","","3010.54","693.88","5019.88","35","2010.18","3143.36","percent of total billed charges",""
"EXPANDER TISSUE 250CC 5X13CM CRESCENT INTEGRA","SUP-ITM-10298285","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3057.97","79.5","","1309.77","674.56","6049.93","26","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 250CC 5X13CM CRESCENT INTEGRA","SUP-ITM-10298285","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2050.18","53.3","","1901.83","1901.83","2962.25","1 through 10","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 250CC 5X13CM CRESCENT INTEGRA","SUP-ITM-10298285","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1403.97","36.5","","1620.31","1620.31","19908.88","1 through 10","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 250CC 5X13CM CRESCENT INTEGRA","SUP-ITM-10298285","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1473.21","38.3","","352.91","352.91","2046.30","1 through 10","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 250CC 5X13CM CRESCENT INTEGRA","SUP-ITM-10298285","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1650.15","42.9","","9668.75","9668.75","9668.75","1 through 10","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 250CC 5X13CM CRESCENT INTEGRA","SUP-ITM-10298285","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","WELLPOINT [1015]","HB AMC WELLPOINT","2837.95","73.78","","699.88","384.10","3443.31","33","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 250CC 5X13CM CRESCENT INTEGRA","SUP-ITM-10298285","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","AETNA [1001]","HB AMC AETNA HMO","2684.86","69.8","","1421.24","264.50","4933.46","29","2010.18","3143.36","percent of total billed charges",""
"EXPANDER TISSUE 250CC 5X13CM CRESCENT INTEGRA","SUP-ITM-10298285","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3092.59","80.4","","1022.97","1022.97","3607.50","1 through 10","2010.18","3143.36","percent of total billed charges",""
"EXPANDER TISSUE 250CC 5X13CM CRESCENT INTEGRA","SUP-ITM-10298285","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3143.36","81.72","","3010.54","693.88","5019.88","35","2010.18","3143.36","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2993.97","79.5","","1309.77","674.56","6049.93","26","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2007.28","53.3","","1901.83","1901.83","2962.25","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1374.59","36.5","","1620.31","1620.31","19908.88","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1442.38","38.3","","352.91","352.91","2046.30","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1615.61","42.9","","9668.75","9668.75","9668.75","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","WELLPOINT [1015]","HB AMC WELLPOINT","2778.55","73.78","","699.88","384.10","3443.31","33","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","AETNA [1001]","HB AMC AETNA HMO","2628.67","69.8","","1421.24","264.50","4933.46","29","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3027.86","80.4","","1022.97","1022.97","3607.50","1 through 10","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3077.58","81.72","","3010.54","693.88","5019.88","35","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2993.97","79.5","","1309.77","674.56","6049.93","26","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2007.28","53.3","","1901.83","1901.83","2962.25","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1374.59","36.5","","1620.31","1620.31","19908.88","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1442.38","38.3","","352.91","352.91","2046.30","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1615.61","42.9","","9668.75","9668.75","9668.75","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","WELLPOINT [1015]","HB AMC WELLPOINT","2778.55","73.78","","699.88","384.10","3443.31","33","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","AETNA [1001]","HB AMC AETNA HMO","2628.67","69.8","","1421.24","264.50","4933.46","29","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3027.86","80.4","","1022.97","1022.97","3607.50","1 through 10","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3077.58","81.72","","3010.54","693.88","5019.88","35","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 36CC 3X5CM INTEGRA GENERAL RECTANGLE INTERNAL PORT","SUP-ITM-10159450","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3057.97","79.5","","1309.77","674.56","6049.93","26","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 36CC 3X5CM INTEGRA GENERAL RECTANGLE INTERNAL PORT","SUP-ITM-10159450","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2050.18","53.3","","1901.83","1901.83","2962.25","1 through 10","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 36CC 3X5CM INTEGRA GENERAL RECTANGLE INTERNAL PORT","SUP-ITM-10159450","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1403.97","36.5","","1620.31","1620.31","19908.88","1 through 10","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 36CC 3X5CM INTEGRA GENERAL RECTANGLE INTERNAL PORT","SUP-ITM-10159450","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1473.21","38.3","","352.91","352.91","2046.30","1 through 10","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 36CC 3X5CM INTEGRA GENERAL RECTANGLE INTERNAL PORT","SUP-ITM-10159450","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1650.15","42.9","","9668.75","9668.75","9668.75","1 through 10","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 36CC 3X5CM INTEGRA GENERAL RECTANGLE INTERNAL PORT","SUP-ITM-10159450","CDM","C1889","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","WELLPOINT [1015]","HB AMC WELLPOINT","2837.95","73.78","","699.88","384.10","3443.31","33","1192.42","3057.97","percent of total billed charges",""
"EXPANDER TISSUE 36CC 3X5CM INTEGRA GENERAL RECTANGLE INTERNAL PORT","SUP-ITM-10159450","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","AETNA [1001]","HB AMC AETNA HMO","2684.86","69.8","","1421.24","264.50","4933.46","29","2010.18","3143.36","percent of total billed charges",""
"EXPANDER TISSUE 36CC 3X5CM INTEGRA GENERAL RECTANGLE INTERNAL PORT","SUP-ITM-10159450","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3092.59","80.4","","1022.97","1022.97","3607.50","1 through 10","2010.18","3143.36","percent of total billed charges",""
"EXPANDER TISSUE 36CC 3X5CM INTEGRA GENERAL RECTANGLE INTERNAL PORT","SUP-ITM-10159450","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3143.36","81.72","","3010.54","693.88","5019.88","35","2010.18","3143.36","percent of total billed charges",""
"EXPANDER TISSUE 4X11CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237457","CDM","C1889","HCPCS","0278","RC","","","","both","","","3972.50","2979.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3158.14","79.5","","1309.77","674.56","6049.93","26","1231.48","3158.14","percent of total billed charges",""
"EXPANDER TISSUE 4X11CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237457","CDM","C1889","HCPCS","0278","RC","","","","both","","","3972.50","2979.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2117.34","53.3","","1901.83","1901.83","2962.25","1 through 10","1231.48","3158.14","percent of total billed charges",""
"EXPANDER TISSUE 4X11CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237457","CDM","C1889","HCPCS","0278","RC","","","","both","","","3972.50","2979.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1449.96","36.5","","1620.31","1620.31","19908.88","1 through 10","1231.48","3158.14","percent of total billed charges",""
"EXPANDER TISSUE 4X11CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237457","CDM","C1889","HCPCS","0278","RC","","","","both","","","3972.50","2979.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1521.47","38.3","","352.91","352.91","2046.30","1 through 10","1231.48","3158.14","percent of total billed charges",""
"EXPANDER TISSUE 4X11CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237457","CDM","C1889","HCPCS","0278","RC","","","","both","","","3972.50","2979.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1704.20","42.9","","9668.75","9668.75","9668.75","1 through 10","1231.48","3158.14","percent of total billed charges",""
"EXPANDER TISSUE 4X11CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237457","CDM","C1889","HCPCS","0278","RC","","","","both","","","3972.50","2979.37","WELLPOINT [1015]","HB AMC WELLPOINT","2930.91","73.78","","699.88","384.10","3443.31","33","1231.48","3158.14","percent of total billed charges",""
"EXPANDER TISSUE 4X11CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237457","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3972.50","2979.37","AETNA [1001]","HB AMC AETNA HMO","2772.81","69.8","","1421.24","264.50","4933.46","29","2076.03","3246.33","percent of total billed charges",""
"EXPANDER TISSUE 4X11CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237457","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3972.50","2979.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3193.89","80.4","","1022.97","1022.97","3607.50","1 through 10","2076.03","3246.33","percent of total billed charges",""
"EXPANDER TISSUE 4X11CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237457","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3972.50","2979.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3246.33","81.72","","3010.54","693.88","5019.88","35","2076.03","3246.33","percent of total billed charges",""
"EXPANDER TISSUE 4X16CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237455","CDM","C1889","HCPCS","0278","RC","","","","both","","","3972.50","2979.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3158.14","79.5","","1309.77","674.56","6049.93","26","1231.48","3158.14","percent of total billed charges",""
"EXPANDER TISSUE 4X16CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237455","CDM","C1889","HCPCS","0278","RC","","","","both","","","3972.50","2979.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2117.34","53.3","","1901.83","1901.83","2962.25","1 through 10","1231.48","3158.14","percent of total billed charges",""
"EXPANDER TISSUE 4X16CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237455","CDM","C1889","HCPCS","0278","RC","","","","both","","","3972.50","2979.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1449.96","36.5","","1620.31","1620.31","19908.88","1 through 10","1231.48","3158.14","percent of total billed charges",""
"EXPANDER TISSUE 4X16CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237455","CDM","C1889","HCPCS","0278","RC","","","","both","","","3972.50","2979.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1521.47","38.3","","352.91","352.91","2046.30","1 through 10","1231.48","3158.14","percent of total billed charges",""
"EXPANDER TISSUE 4X16CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237455","CDM","C1889","HCPCS","0278","RC","","","","both","","","3972.50","2979.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1704.20","42.9","","9668.75","9668.75","9668.75","1 through 10","1231.48","3158.14","percent of total billed charges",""
"EXPANDER TISSUE 4X16CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237455","CDM","C1889","HCPCS","0278","RC","","","","both","","","3972.50","2979.37","WELLPOINT [1015]","HB AMC WELLPOINT","2930.91","73.78","","699.88","384.10","3443.31","33","1231.48","3158.14","percent of total billed charges",""
"EXPANDER TISSUE 4X16CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237455","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3972.50","2979.37","AETNA [1001]","HB AMC AETNA HMO","2772.81","69.8","","1421.24","264.50","4933.46","29","2076.03","3246.33","percent of total billed charges",""
"EXPANDER TISSUE 4X16CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237455","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3972.50","2979.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3193.89","80.4","","1022.97","1022.97","3607.50","1 through 10","2076.03","3246.33","percent of total billed charges",""
"EXPANDER TISSUE 4X16CM ENHANCED SURFACE W/INTEGRATED PORT","SUP-ITM-10237455","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3972.50","2979.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3246.33","81.72","","3010.54","693.88","5019.88","35","2076.03","3246.33","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2993.97","79.5","","1309.77","674.56","6049.93","26","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2007.28","53.3","","1901.83","1901.83","2962.25","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1374.59","36.5","","1620.31","1620.31","19908.88","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1442.38","38.3","","352.91","352.91","2046.30","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1615.61","42.9","","9668.75","9668.75","9668.75","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","WELLPOINT [1015]","HB AMC WELLPOINT","2778.55","73.78","","699.88","384.10","3443.31","33","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","AETNA [1001]","HB AMC AETNA HMO","2628.67","69.8","","1421.24","264.50","4933.46","29","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3027.86","80.4","","1022.97","1022.97","3607.50","1 through 10","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3077.58","81.72","","3010.54","693.88","5019.88","35","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2993.97","79.5","","1309.77","674.56","6049.93","26","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2007.28","53.3","","1901.83","1901.83","2962.25","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1374.59","36.5","","1620.31","1620.31","19908.88","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1442.38","38.3","","352.91","352.91","2046.30","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1615.61","42.9","","9668.75","9668.75","9668.75","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","WELLPOINT [1015]","HB AMC WELLPOINT","2778.55","73.78","","699.88","384.10","3443.31","33","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","AETNA [1001]","HB AMC AETNA HMO","2628.67","69.8","","1421.24","264.50","4933.46","29","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3027.86","80.4","","1022.97","1022.97","3607.50","1 through 10","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3077.58","81.72","","3010.54","693.88","5019.88","35","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 600CC 6.2X15.5CM CURVE","SUP-ITM-10235074","CDM","C1889","HCPCS","0278","RC","","","","both","","","4212.00","3159.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3348.54","79.5","","1309.77","674.56","6049.93","26","1305.72","3348.54","percent of total billed charges",""
"EXPANDER TISSUE 600CC 6.2X15.5CM CURVE","SUP-ITM-10235074","CDM","C1889","HCPCS","0278","RC","","","","both","","","4212.00","3159.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2245.00","53.3","","1901.83","1901.83","2962.25","1 through 10","1305.72","3348.54","percent of total billed charges",""
"EXPANDER TISSUE 600CC 6.2X15.5CM CURVE","SUP-ITM-10235074","CDM","C1889","HCPCS","0278","RC","","","","both","","","4212.00","3159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1537.38","36.5","","1620.31","1620.31","19908.88","1 through 10","1305.72","3348.54","percent of total billed charges",""
"EXPANDER TISSUE 600CC 6.2X15.5CM CURVE","SUP-ITM-10235074","CDM","C1889","HCPCS","0278","RC","","","","both","","","4212.00","3159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1613.20","38.3","","352.91","352.91","2046.30","1 through 10","1305.72","3348.54","percent of total billed charges",""
"EXPANDER TISSUE 600CC 6.2X15.5CM CURVE","SUP-ITM-10235074","CDM","C1889","HCPCS","0278","RC","","","","both","","","4212.00","3159.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1806.95","42.9","","9668.75","9668.75","9668.75","1 through 10","1305.72","3348.54","percent of total billed charges",""
"EXPANDER TISSUE 600CC 6.2X15.5CM CURVE","SUP-ITM-10235074","CDM","C1889","HCPCS","0278","RC","","","","both","","","4212.00","3159.00","WELLPOINT [1015]","HB AMC WELLPOINT","3107.61","73.78","","699.88","384.10","3443.31","33","1305.72","3348.54","percent of total billed charges",""
"EXPANDER TISSUE 600CC 6.2X15.5CM CURVE","SUP-ITM-10235074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4212.00","3159.00","AETNA [1001]","HB AMC AETNA HMO","2939.98","69.8","","1421.24","264.50","4933.46","29","2201.19","3442.05","percent of total billed charges",""
"EXPANDER TISSUE 600CC 6.2X15.5CM CURVE","SUP-ITM-10235074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4212.00","3159.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3386.45","80.4","","1022.97","1022.97","3607.50","1 through 10","2201.19","3442.05","percent of total billed charges",""
"EXPANDER TISSUE 600CC 6.2X15.5CM CURVE","SUP-ITM-10235074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4212.00","3159.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3442.05","81.72","","3010.54","693.88","5019.88","35","2201.19","3442.05","percent of total billed charges",""
"EXPANDER TISSUE 950CC W15.5CM H16CM P8.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241085","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2993.97","79.5","","1309.77","674.56","6049.93","26","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 950CC W15.5CM H16CM P8.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241085","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2007.28","53.3","","1901.83","1901.83","2962.25","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 950CC W15.5CM H16CM P8.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241085","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1374.59","36.5","","1620.31","1620.31","19908.88","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 950CC W15.5CM H16CM P8.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241085","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1442.38","38.3","","352.91","352.91","2046.30","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 950CC W15.5CM H16CM P8.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241085","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1615.61","42.9","","9668.75","9668.75","9668.75","1 through 10","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 950CC W15.5CM H16CM P8.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241085","CDM","C1889","HCPCS","0278","RC","","","","both","","","3766.00","2824.50","WELLPOINT [1015]","HB AMC WELLPOINT","2778.55","73.78","","699.88","384.10","3443.31","33","1167.46","2993.97","percent of total billed charges",""
"EXPANDER TISSUE 950CC W15.5CM H16CM P8.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","AETNA [1001]","HB AMC AETNA HMO","2628.67","69.8","","1421.24","264.50","4933.46","29","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 950CC W15.5CM H16CM P8.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3027.86","80.4","","1022.97","1022.97","3607.50","1 through 10","1968.11","3077.58","percent of total billed charges",""
"EXPANDER TISSUE 950CC W15.5CM H16CM P8.1CM STYLE 133S SMOOTH NATRELLE FOURTE FULL EXTRA","SUP-ITM-10241085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3766.00","2824.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3077.58","81.72","","3010.54","693.88","5019.88","35","1968.11","3077.58","percent of total billed charges",""
"Ext Culture Oocytes 4-7days","PX-30000132","CDM","89272","CPT","0300","RC","","","","both","","","634.00","475.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","504.03","79.5","","484.01","324.72","484.01","1 through 10","196.54","1212.52","percent of total billed charges",""
"Ext Culture Oocytes 4-7days","PX-30000132","CDM","89272","CPT","0300","RC","","","","both","","","634.00","475.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","337.92","53.3","","324.72","324.72","484.01","1 through 10","196.54","1212.52","percent of total billed charges",""
"Ext Culture Oocytes 4-7days","PX-30000132","CDM","89272","CPT","0300","RC","","","","both","","","634.00","475.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","271.99","42.9","","491.63","491.63","491.63","1 through 10","196.54","1212.52","percent of total billed charges",""
"Ext Culture Oocytes 4-7days","PX-30000132","CDM","89272","CPT","0300","RC","","","","both","","","634.00","475.50","WELLPOINT [1015]","HB AMC WELLPOINT","467.77","73.78","","1072.87","457.87","1072.87","1 through 10","196.54","1212.52","percent of total billed charges",""
"Ext Culture Oocytes 4-7days","PX-30000132","CDM","89272","CPT","0300","RC","","","","outpatient","","","634.00","475.50","AETNA [1001]","HB AMC AETNA HMO","442.53","69.8","","293.97","293.97","293.97","1 through 10","331.33","3421.28","percent of total billed charges",""
"Ext Culture Oocytes 4-7days","PX-30000132","CDM","89272","CPT","0300","RC","","","","outpatient","","","634.00","475.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","518.10","81.72","","270.42","270.42","491.63","1 through 10","331.33","3421.28","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","626.06","79.5","","800.18","480.96","1887.97","195","244.13","626.06","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","419.74","53.3","","813.12","216.42","1444.50","81","244.13","626.06","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","244.13","31","","432.60","432.60","432.60","1 through 10","244.13","626.06","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","287.44","36.5","","148.37","54.89","631.39","94","244.13","626.06","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","301.61","38.3","","279.30","91.72","1116.77","266","244.13","626.06","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.84","42.9","","731.00","63.70","731.00","1 through 10","244.13","626.06","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.84","42.9","","384.74","384.74","384.74","1 through 10","244.13","626.06","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","WELLPOINT [1015]","HB AMC WELLPOINT","581.02","73.78","","286.63","119.22","1107.45","105","244.13","626.06","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","AETNA [1001]","HB AMC AETNA HMO","549.68","69.8","","675.31","184.75","1721.50","286","411.55","643.55","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","AETNA [1001]","HB AMC AETNA PPO","633.15","80.4","","1261.44","103.12","1514.10","21","411.55","643.55","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","633.15","80.4","","1365.00","1365.00","1365.00","1 through 10","411.55","643.55","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","643.55","81.72","","5157.68","5157.68","5157.68","1 through 10","411.55","643.55","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","643.55","81.72","","431.26","71.26","1459.57","88","411.55","643.55","percent of total billed charges",""
"EXTENDER CATHETER ADULT DIALYSIS PERITONEAL QUINTON TI","SUP-ITM-10237175","CDM","C1752","HCPCS","0278","RC","","","","both","","","382.83","287.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","248.84","65","","131.71","131.71","131.71","1 through 10","118.68","304.35","percent of total billed charges",""
"EXTENDER CATHETER ADULT DIALYSIS PERITONEAL QUINTON TI","SUP-ITM-10237175","CDM","C1752","HCPCS","0278","RC","","","","both","","","382.83","287.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","267.98","70","","249.44","163.91","249.45","1 through 10","118.68","304.35","percent of total billed charges",""
"EXTENDER CATHETER ADULT DIALYSIS PERITONEAL QUINTON TI","SUP-ITM-10237175","CDM","C1752","HCPCS","0278","RC","","","","both","","","382.83","287.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","304.35","79.5","","162.14","162.14","162.14","1 through 10","118.68","304.35","percent of total billed charges",""
"EXTENDER CATHETER ADULT DIALYSIS PERITONEAL QUINTON TI","SUP-ITM-10237175","CDM","C1752","HCPCS","0278","RC","","","","both","","","382.83","287.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","248.84","65","","193.56","193.56","193.56","1 through 10","118.68","304.35","percent of total billed charges",""
"EXTENDER CATHETER ADULT DIALYSIS PERITONEAL QUINTON TI","SUP-ITM-10237175","CDM","C1752","HCPCS","0278","RC","","","","both","","","382.83","287.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","118.68","31","","77.08","77.08","77.08","1 through 10","118.68","304.35","percent of total billed charges",""
"EXTENDER CATHETER ADULT DIALYSIS PERITONEAL QUINTON TI","SUP-ITM-10237175","CDM","C1752","HCPCS","0278","RC","","","","both","","","382.83","287.12","WELLPOINT [1015]","HB AMC WELLPOINT","282.45","73.78","","185.72","185.72","185.72","1 through 10","118.68","304.35","percent of total billed charges",""
"EXTENDER CATHETER ADULT DIALYSIS PERITONEAL QUINTON TI","SUP-ITM-10237175","CDM","C1752","HCPCS","0278","RC","","","","outpatient","","","382.83","287.12","AETNA [1001]","HB AMC AETNA HMO","267.22","69.8","","185.24","185.24","185.24","1 through 10","200.07","312.85","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2429.18","1821.88","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1269.49","52.26","","1113.10","1113.10","1113.10","1 through 10","753.05","1931.2","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2429.18","1821.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1931.20","79.5","","1293.60","1148.53","1603.80","1 through 10","753.05","1931.2","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2429.18","1821.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","886.65","36.5","","1023.42","771.29","2068.67","33","753.05","1931.2","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2429.18","1821.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","930.38","38.3","","850.52","759.78","1211.25","66","753.05","1931.2","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2429.18","1821.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1042.12","42.9","","2548.09","2548.09","2548.09","1 through 10","753.05","1931.2","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2429.18","1821.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1042.12","42.9","","956.46","956.46","956.46","1 through 10","753.05","1931.2","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2429.18","1821.88","WELLPOINT [1015]","HB AMC WELLPOINT","1792.25","73.78","","2344.73","1619.47","2530.35","16","753.05","1931.2","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2429.18","1821.88","AETNA [1001]","HB AMC AETNA HMO","1695.57","69.8","","1523.63","988.41","4330.26","39","1269.49","1985.13","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2429.18","1821.88","AETNA [1001]","HB AMC AETNA PPO","1953.06","80.4","","1670.25","1670.25","1670.25","1 through 10","1269.49","1985.13","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2429.18","1821.88","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1269.49","52.26","","1113.10","1113.10","1113.10","1 through 10","1269.49","1985.13","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2429.18","1821.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1985.13","81.72","","1738.90","1484.65","2716.94","38","1269.49","1985.13","percent of total billed charges",""
"EXTENDER LEAD 17CM OSCOR","SUP-ITM-10217378","CDM","C1883","HCPCS","0278","RC","","","","both","","","1358.00","1018.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","495.67","36.5","","1073.15","1073.15","1073.15","1 through 10","420.98","1079.61","percent of total billed charges",""
"EXTENDER LEAD 17CM OSCOR","SUP-ITM-10217378","CDM","C1883","HCPCS","0278","RC","","","","both","","","1358.00","1018.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","520.11","38.3","","1808.38","1642.20","1808.38","1 through 10","420.98","1079.61","percent of total billed charges",""
"EXTENDER LEAD 17CM OSCOR","SUP-ITM-10217378","CDM","C1883","HCPCS","0278","RC","","","","both","","","1358.00","1018.50","WELLPOINT [1015]","HB AMC WELLPOINT","1001.93","73.78","","625.38","625.38","625.38","1 through 10","420.98","1079.61","percent of total billed charges",""
"EXTENDER LEAD BULLDOG 79CM EXTRACTION CARDIAC CABLE CONDUCTOR WIRE","SUP-ITM-10036207","CDM","C1773","HCPCS","0272","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","447.13","36.5","","114.30","97.14","114.30","1 through 10","379.75","973.88","percent of total billed charges",""
"EXTENDER LEAD BULLDOG 79CM EXTRACTION CARDIAC CABLE CONDUCTOR WIRE","SUP-ITM-10036207","CDM","C1773","HCPCS","0272","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","469.18","38.3","","119.81","116.44","359.43","20","379.75","973.88","percent of total billed charges",""
"EXTENDER LEAD BULLDOG 79CM EXTRACTION CARDIAC CABLE CONDUCTOR WIRE","SUP-ITM-10036207","CDM","C1773","HCPCS","0272","RC","","","","both","","","1225.00","918.75","WELLPOINT [1015]","HB AMC WELLPOINT","903.81","73.78","","875.53","228.13","875.53","1 through 10","379.75","973.88","percent of total billed charges",""
"EXTENDER LEAD BULLDOG 79CM EXTRACTION CARDIAC CABLE CONDUCTOR WIRE","SUP-ITM-10036207","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1225.00","918.75","AETNA [1001]","HB AMC AETNA HMO","855.05","69.8","","207.45","207.45","207.45","1 through 10","640.19","1001.07","percent of total billed charges",""
"EXTENDER LEAD BULLDOG 79CM EXTRACTION CARDIAC CABLE CONDUCTOR WIRE","SUP-ITM-10036207","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1001.07","81.72","","244.96","134.74","244.96","1 through 10","640.19","1001.07","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1733.99","52.26","","1113.10","1113.10","1113.10","1 through 10","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2637.81","79.5","","1293.60","1148.53","1603.80","1 through 10","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1211.07","36.5","","1023.42","771.29","2068.67","33","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1270.79","38.3","","850.52","759.78","1211.25","66","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1423.42","42.9","","2548.09","2548.09","2548.09","1 through 10","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1423.42","42.9","","956.46","956.46","956.46","1 through 10","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","WELLPOINT [1015]","HB AMC WELLPOINT","2448.02","73.78","","2344.73","1619.47","2530.35","16","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3318.00","2488.50","AETNA [1001]","HB AMC AETNA HMO","2315.96","69.8","","1523.63","988.41","4330.26","39","1733.99","2711.47","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3318.00","2488.50","AETNA [1001]","HB AMC AETNA PPO","2667.67","80.4","","1670.25","1670.25","1670.25","1 through 10","1733.99","2711.47","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3318.00","2488.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1733.99","52.26","","1113.10","1113.10","1113.10","1 through 10","1733.99","2711.47","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3318.00","2488.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2711.47","81.72","","1738.90","1484.65","2716.94","38","1733.99","2711.47","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1733.99","52.26","","1113.10","1113.10","1113.10","1 through 10","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2637.81","79.5","","1293.60","1148.53","1603.80","1 through 10","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1211.07","36.5","","1023.42","771.29","2068.67","33","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1270.79","38.3","","850.52","759.78","1211.25","66","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1423.42","42.9","","2548.09","2548.09","2548.09","1 through 10","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1423.42","42.9","","956.46","956.46","956.46","1 through 10","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","WELLPOINT [1015]","HB AMC WELLPOINT","2448.02","73.78","","2344.73","1619.47","2530.35","16","1028.58","2637.81","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3318.00","2488.50","AETNA [1001]","HB AMC AETNA HMO","2315.96","69.8","","1523.63","988.41","4330.26","39","1733.99","2711.47","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3318.00","2488.50","AETNA [1001]","HB AMC AETNA PPO","2667.67","80.4","","1670.25","1670.25","1670.25","1 through 10","1733.99","2711.47","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3318.00","2488.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1733.99","52.26","","1113.10","1113.10","1113.10","1 through 10","1733.99","2711.47","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3318.00","2488.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2711.47","81.72","","1738.90","1484.65","2716.94","38","1733.99","2711.47","percent of total billed charges",""
"EXTENSION DBS 60CM SENSIGHT","SUP-ITM-10285800","CDM","C1883","HCPCS","0278","RC","","","","both","","","2950.50","2212.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1076.93","36.5","","1073.15","1073.15","1073.15","1 through 10","914.66","2345.65","percent of total billed charges",""
"EXTENSION DBS 60CM SENSIGHT","SUP-ITM-10285800","CDM","C1883","HCPCS","0278","RC","","","","both","","","2950.50","2212.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1130.04","38.3","","1808.38","1642.20","1808.38","1 through 10","914.66","2345.65","percent of total billed charges",""
"EXTENSION DBS 60CM SENSIGHT","SUP-ITM-10285800","CDM","C1883","HCPCS","0278","RC","","","","both","","","2950.50","2212.87","WELLPOINT [1015]","HB AMC WELLPOINT","2176.88","73.78","","625.38","625.38","625.38","1 through 10","914.66","2345.65","percent of total billed charges",""
"EXTENSION DBS 60CM SENSIGHT MARKER","SUP-ITM-10285799","CDM","C1883","HCPCS","0278","RC","","","","both","","","2978.50","2233.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1087.15","36.5","","1073.15","1073.15","1073.15","1 through 10","923.34","2367.91","percent of total billed charges",""
"EXTENSION DBS 60CM SENSIGHT MARKER","SUP-ITM-10285799","CDM","C1883","HCPCS","0278","RC","","","","both","","","2978.50","2233.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1140.77","38.3","","1808.38","1642.20","1808.38","1 through 10","923.34","2367.91","percent of total billed charges",""
"EXTENSION DBS 60CM SENSIGHT MARKER","SUP-ITM-10285799","CDM","C1883","HCPCS","0278","RC","","","","both","","","2978.50","2233.87","WELLPOINT [1015]","HB AMC WELLPOINT","2197.54","73.78","","625.38","625.38","625.38","1 through 10","923.34","2367.91","percent of total billed charges",""
"Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,EXTREME","911","DRG","","","","","","","","inpatient","","","358576.66","","MASSHEALTH [3001]","HB BWH MEDICAID","62000.77","","Case rate ($68,552.51). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $110,982.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","68535.69","68535.69","68535.69","1 through 10","28383.23","264922.34","case rate",""
"Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,EXTREME","911","DRG","","","","","","","","inpatient","","","358576.66","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","62000.77","","Case rate ($68,552.51). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $110,982.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","78676.74","78676.74","78890.33","1 through 10","28383.23","264922.34","case rate",""
"Extensive Abdominal Or Thoracic Procedures For Multiple Significant Trauma,MODERATE","911","DRG","","","","","","","","inpatient","","","106812.41","","MASSHEALTH [3001]","HB BWH MEDICAID","28383.23","","Case rate ($31,382.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $73,812.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31374.83","31374.83","31374.83","1 through 10","28383.23","264922.34","case rate",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","","","","inpatient","","","590522.55","442891.91","MEDICARE [2001]","HB BWH MEDICARE","195141.35","","Case rate ($195,141.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $234,834.30, add-ons for qualifying new technology services are included. If operating cost exceeds $280,478.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $19,620.01, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 24. The base transfer operating payment is the transfer adjustment factor * $177,581.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $234,454.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $17,179.87. The transfer capital threshold is the transfer adjustment factor * $17,179.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount.","279950.06","279950.06","279950.06","1 through 10","191238.52","322200.3955","other","Inpatient Replacement Plans DRG"
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","","","","inpatient","","","590522.55","442891.91","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","191238.52","","Case rate ($195,141.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $234,834.30, add-ons for qualifying new technology services are included. If operating cost exceeds $280,478.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $19,620.01, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 24. The base transfer operating payment is the transfer adjustment factor * $177,581.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $234,454.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $17,179.87. The transfer capital threshold is the transfer adjustment factor * $17,179.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount. Final payment is multiplied by 98%.","92571.67","92571.67","92571.67","1 through 10","191238.52","322200.3955","other","Inpatient DRG"
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","950","DRG","","","","","","","","inpatient","","","338382.01","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","171274.70","","Standard inlier is a Case rate ($171,274.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $144,837, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($24,313.48) for the length of stay and the standard reimbursement.","171274.70","171274.70","171274.70","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","950","DRG","","","","","","","","inpatient","","","338382.01","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","192558.92","","Standard inlier is a Case rate ($192,558.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $144,837, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($27,332.14) for the length of stay and the standard reimbursement.","192558.92","189577.37","192558.92","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","950","DRG","","","","","","","","inpatient","","","338382.01","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28683.4408","","Fee schedule rate ($205,941.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28683.4408","205941.92","205941.92","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","950","DRG","","","","","","","","inpatient","","","338382.01","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","30118.4464","","Fee schedule rate ($216,245.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30118.4464","207903.08","207903.08","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","950","DRG","","","","","","","","inpatient","","","338382.01","","MASSHEALTH [3001]","HB BWH MEDICAID","66084.73","","Case rate ($73,068.03). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $115,498.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18915.06","18915.06","18915.06","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","950","DRG","","","","","","","","inpatient","","","338382.01","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","66084.73","","Case rate ($73,068.03). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $115,498.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","192264.29","192264.29","192264.29","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","950","DRG","","","","","","","","inpatient","","","156903.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","93876.22","","Standard inlier is a Case rate ($93,876.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $84,649, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,326.30) for the length of stay and the standard reimbursement.","85571.59","85571.59","93876.22","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","950","DRG","","","","","","","","inpatient","","","156903.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","105542.17","","Standard inlier is a Case rate ($105,542.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $84,649, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,980.83) for the length of stay and the standard reimbursement.","105542.17","105542.17","105542.17","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","950","DRG","","","","","","","","inpatient","","","156903.53","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","25290.08","25290.08","25290.08","1 through 10","13468.5","339808.3","percent of total billed charges",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","950","DRG","","","","","","","","inpatient","","","156903.53","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28683.4408","","Fee schedule rate ($205,941.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28683.4408","88364.05","88364.05","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","950","DRG","","","","","","","","inpatient","","","156903.53","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","30118.4464","","Fee schedule rate ($216,245.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30118.4464","56638.84","56638.84","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","950","DRG","","","","","","","","inpatient","","","156903.53","","MASSHEALTH [3001]","HB BWH MEDICAID","30626.83","","Case rate ($33,863.23). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,293.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","73050.10","73050.10","73050.10","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MINOR","950","DRG","","","","","","","","inpatient","","","85080.80","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","51282.14","","Standard inlier is a Case rate ($51,282.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,119, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,279.07) for the length of stay and the standard reimbursement.","46850.66","46850.66","46850.66","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MINOR","950","DRG","","","","","","","","inpatient","","","85080.80","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","46624.32","","Fee schedule rate ($46,624.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","46624.32","46624.32","46624.32","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MINOR","950","DRG","","","","","","","","inpatient","","","85080.80","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48956.30","","Fee schedule rate ($48,956.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","48956.30","48956.30","48956.30","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","950","DRG","","","","","","","","inpatient","","","105374.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","64028.71","","Standard inlier is a Case rate ($64,028.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $61,439, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,089.26) for the length of stay and the standard reimbursement.","62000.93","56516.10","111138.99","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","950","DRG","","","","","","","","inpatient","","","105374.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","71985.53","","Standard inlier is a Case rate ($71,985.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $61,439, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,217.75) for the length of stay and the standard reimbursement.","63682.23","7367.41","69705.75","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","950","DRG","","","","","","","","inpatient","","","105374.33","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28683.4408","","Fee schedule rate ($53,940.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28683.4408","53940.24","53940.24","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","950","DRG","","","","","","","","inpatient","","","105374.33","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","30118.4464","","Fee schedule rate ($56,638.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30118.4464","56638.84","56638.84","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","950","DRG","","","","","","","","inpatient","","","105374.33","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","66548.10","","Fee schedule rate ($66,548.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","67425.92","67425.92","67425.92","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","950","DRG","","","","","","","","inpatient","","","105374.33","","MASSHEALTH [3001]","HB BWH MEDICAID","18998.69","","Case rate ($21,006.32). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,436.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21265.08","21265.08","21265.08","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","950","DRG","","","","","","","","inpatient","","","105374.33","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63408.66","","Fee schedule rate ($63,408.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","63408.66","63408.66","63408.66","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","950","DRG","","","","","","","","inpatient","","","105374.33","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","18998.69","","Case rate ($21,006.32). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,436.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21281.08","21281.08","21281.08","1 through 10","13468.5","339808.3","case rate",""
"Extensive O.R. Procedures For Other Complications Of Treatment,EXTREME","792","DRG","","","","","","","","inpatient","","","364557.13","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","31018.66","","Case rate ($34,296.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,726.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","37314.68","37314.68","37314.68","1 through 10","13916.3","185915.78","case rate",""
"Extensive O.R. Procedures For Other Complications Of Treatment,EXTREME","792","DRG","","","","","","","","inpatient","","","364557.13","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","31018.66","","Case rate ($34,296.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,726.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","13916.3","185915.78","case rate",""
"Extensive O.R. Procedures For Other Complications Of Treatment,EXTREME","792","DRG","","","","","","","","inpatient","","","364633.63","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","81606.05","","Standard inlier is a Case rate ($81,606.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $75,108, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,584.47) for the length of stay and the standard reimbursement.","35449.46","35449.46","35449.46","1 through 10","13916.3","185915.78","case rate",""
"Extensive O.R. Procedures For Other Complications Of Treatment,MAJOR","792","DRG","","","","","","","","inpatient","","","126310.76","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","81606.05","","Standard inlier is a Case rate ($81,606.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $75,108, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,584.47) for the length of stay and the standard reimbursement.","83818.97","83818.97","83818.97","1 through 10","13916.3","185915.78","case rate",""
"Extensive O.R. Procedures For Other Complications Of Treatment,MAJOR","792","DRG","","","","","","","","inpatient","","","126310.76","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","91747.19","","Standard inlier is a Case rate ($91,747.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $75,108, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,022.75) for the length of stay and the standard reimbursement.","127317.62","127317.62","127317.62","1 through 10","13916.3","185915.78","case rate",""
"Extensive O.R. Procedures For Other Complications Of Treatment,MAJOR","792","DRG","","","","","","","","inpatient","","","126310.76","","MASSHEALTH [3001]","HB BWH MEDICAID","31018.66","","Case rate ($34,296.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,726.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","34288.05","34288.05","34288.05","1 through 10","13916.3","185915.78","case rate",""
"Extensive O.R. Procedures For Other Complications Of Treatment,MAJOR","792","DRG","","","","","","","","inpatient","","","126310.76","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83457.45","","Fee schedule rate ($83,457.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","68871.09","68871.09","68871.09","1 through 10","13916.3","185915.78","case rate",""
"Extensive O.R. Procedures For Other Complications Of Treatment,MINOR","792","DRG","","","","","","","","inpatient","","","106100.23","","MASSHEALTH [3001]","HB BWH MEDICAID","13916.30","","Case rate ($15,386.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,816.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15383.09","15383.09","15383.09","1 through 10","13916.3","185915.78","case rate",""
"Extensive O.R. Procedures For Other Complications Of Treatment,MODERATE","792","DRG","","","","","","","","inpatient","","","104610.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","54772.72","","Standard inlier is a Case rate ($54,772.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,240, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,775.32) for the length of stay and the standard reimbursement.","56258.00","56258.00","56258.00","1 through 10","13916.3","185915.78","case rate",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","","","","inpatient","","","106492.16","79869.12","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","23490.73","","Case rate ($22,806.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $73,021.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,418.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $20,448.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,997.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,978.25. The transfer capital threshold is the transfer adjustment factor * $1,978.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","46863.19","46863.19","46863.19","1 through 10","22350.4","38509.94","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","","","","inpatient","","","106492.16","79869.12","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","22806.53","","Case rate ($22,806.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $73,021.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,418.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $20,448.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,997.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,978.25. The transfer capital threshold is the transfer adjustment factor * $1,978.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22236.05","22236.05","22257.95","1 through 10","22350.4","38509.94","other","Inpatient Replacement Plans DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","","","","inpatient","","","106492.16","79869.12","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","28508.16","","Case rate ($22,806.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $73,021.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,418.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $20,448.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,997.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,978.25. The transfer capital threshold is the transfer adjustment factor * $1,978.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","22500.88","22500.88","22500.88","1 through 10","22350.4","38509.94","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","","","","inpatient","","","106492.16","79869.12","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","33854.92","33854.92","33854.92","1 through 10","22350.4","38509.94","case rate",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","","","","inpatient","","","106492.16","79869.12","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","22806.53","","Case rate ($22,806.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $73,021.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,418.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $20,448.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,997.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,978.25. The transfer capital threshold is the transfer adjustment factor * $1,978.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22127.38","22127.38","22127.38","1 through 10","22350.4","38509.94","other","Inpatient Replacement Plans DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","","","","inpatient","","","106492.16","79869.12","HUMANA [1012]","HB BWH MEDICARE","22806.53","","Case rate ($22,806.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $73,021.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,418.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $20,448.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,997.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,978.25. The transfer capital threshold is the transfer adjustment factor * $1,978.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22086.35","22086.35","22086.35","1 through 10","22350.4","38509.94","other","Inpatient Replacement Plans DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","","","","inpatient","","","106492.16","79869.12","MEDICARE [2001]","HB BWH MEDICARE","22806.53","","Case rate ($22,806.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $73,021.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,418.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $20,448.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,997.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,978.25. The transfer capital threshold is the transfer adjustment factor * $1,978.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29141.66","0.03","29184.84","19","22350.4","38509.94","other","Inpatient Replacement Plans DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","","","","inpatient","","","106492.16","79869.12","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","22350.40","","Case rate ($22,806.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,377.16, add-ons for qualifying new technology services are included. If operating cost exceeds $73,021.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,418.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $20,448.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,997.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,978.25. The transfer capital threshold is the transfer adjustment factor * $1,978.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22137.74","22050.75","30516.24","1 through 10","22350.4","38509.94","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","TRIS-DRG","","","","","","","","inpatient","","","50270.14","","TRICARE [160005]","HB BWH TRICARE","19918.96","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($34,988.78). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $9,719.11, and the first day is paid a rate of $19,438.21. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $9,719.11, and the first day is paid a rate of $19,438.21. The transfer payment is capped at $25,182.66. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $78,715.78 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 3.59999990463257). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($14,281.14), capped at $25,182.66. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $9,719.11, and the first day is paid a rate of $19,438.21. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $9,719.11, and the first day is paid a rate of $19,438.21. The transfer payment is capped at $25,182.66. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $78,715.78 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 3.59999990463257). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","36678.08","36678.08","36678.08","1 through 10","19918.96","19918.96","other","Inpatient DRGs"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","981","MS-DRG","","","","","","","","inpatient","","","227620.12","170715.09","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","44474.31","","Case rate ($43,178.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,901.51, add-ons for qualifying new technology services are included. If operating cost exceeds $97,545.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,215.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $39,023.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,521.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,775.30. The transfer capital threshold is the transfer adjustment factor * $3,775.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","133907.33","133907.33","133907.33","1 through 10","42315.36","73492.36","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","981","MS-DRG","","","","","","","","inpatient","","","227620.12","170715.09","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","43178.94","","Case rate ($43,178.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,901.51, add-ons for qualifying new technology services are included. If operating cost exceeds $97,545.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,215.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $39,023.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,521.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,775.30. The transfer capital threshold is the transfer adjustment factor * $3,775.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","42960.75","42960.75","42960.75","1 through 10","42315.36","73492.36","other","Inpatient Replacement Plans DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","981","MS-DRG","","","","","","","","inpatient","","","227620.12","170715.09","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","53973.68","","Case rate ($43,178.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,901.51, add-ons for qualifying new technology services are included. If operating cost exceeds $97,545.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,215.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $39,023.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,521.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,775.30. The transfer capital threshold is the transfer adjustment factor * $3,775.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","43690.17","43690.17","43690.17","1 through 10","42315.36","73492.36","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","981","MS-DRG","","","","","","","","inpatient","","","227620.12","170715.09","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","43178.94","","Case rate ($43,178.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,901.51, add-ons for qualifying new technology services are included. If operating cost exceeds $97,545.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,215.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $39,023.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,521.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,775.30. The transfer capital threshold is the transfer adjustment factor * $3,775.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","89626.00","89626.00","89626.00","1 through 10","42315.36","73492.36","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","981","MS-DRG","","","","","","","","inpatient","","","227620.12","170715.09","HUMANA [1012]","HB BWH MEDICARE","43178.94","","Case rate ($43,178.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,901.51, add-ons for qualifying new technology services are included. If operating cost exceeds $97,545.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,215.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $39,023.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,521.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,775.30. The transfer capital threshold is the transfer adjustment factor * $3,775.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","42668.34","42668.34","42668.34","1 through 10","42315.36","73492.36","other","Inpatient Replacement Plans DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","981","MS-DRG","","","","","","","","inpatient","","","227620.12","170715.09","MEDICARE [2001]","HB BWH MEDICARE","43178.94","","Case rate ($43,178.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,901.51, add-ons for qualifying new technology services are included. If operating cost exceeds $97,545.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,215.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $39,023.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,521.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,775.30. The transfer capital threshold is the transfer adjustment factor * $3,775.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","56322.74","0.03","101666.98","34","42315.36","73492.36","other","Inpatient Replacement Plans DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","981","MS-DRG","","","","","","","","inpatient","","","227620.12","170715.09","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","42315.36","","Case rate ($43,178.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,901.51, add-ons for qualifying new technology services are included. If operating cost exceeds $97,545.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,215.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $39,023.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,521.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,775.30. The transfer capital threshold is the transfer adjustment factor * $3,775.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","42809.32","42809.32","42809.32","1 through 10","42315.36","73492.36","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","981","MS-DRG","","","","","","","","inpatient","","","227620.12","170715.09","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","42315.36","","Case rate ($43,178.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,901.51, add-ons for qualifying new technology services are included. If operating cost exceeds $97,545.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,215.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $39,023.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,521.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,775.30. The transfer capital threshold is the transfer adjustment factor * $3,775.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","42664.66","42559.33","139016.45","1 through 10","42315.36","73492.36","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC","983","MS-DRG","","","","","","","","inpatient","","","80907.32","60680.49","MEDICARE [2001]","HB BWH MEDICARE","20671.76","","Case rate ($20,671.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,201.65, add-ons for qualifying new technology services are included. If operating cost exceeds $64,846.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,819.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $18,912.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,821.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,379.18. The transfer capital threshold is the transfer adjustment factor * $1,379.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19974.36","19974.36","19974.36","1 through 10","15694.83","26848.1","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC","983","MS-DRG","","","","","","","","inpatient","","","80907.32","60680.49","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15694.83","","Case rate ($16,015.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,201.65, add-ons for qualifying new technology services are included. If operating cost exceeds $64,846.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,819.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $14,256.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,821.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,379.18. The transfer capital threshold is the transfer adjustment factor * $1,379.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22073.20","22073.20","22073.20","1 through 10","15694.83","26848.1","other","Inpatient DRG"
"Extensive Third Degree Burns With Skin Graft,EXTREME","841","DRG","","","","","","","","inpatient","","","675853.64","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","596620.33","","Standard inlier is a Case rate ($596,620.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $424,320, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($84,685.30) for the length of stay and the standard reimbursement.","545064.19","545064.19","545064.19","1 through 10","163963.8946","827842.18","case rate",""
"Extensive Third Degree Burns With Skin Graft,EXTREME","841","DRG","","","","","","","","inpatient","","","675853.64","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","170528.2447","","Fee schedule rate ($501,716.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","170528.2447","986477.12","986477.12","1 through 10","163963.8946","827842.18","case rate",""
"Extensive Third Degree Burns Without Skin Graft,EXTREME","843","DRG","","","","","","","","inpatient","","","116780.52","","MASSHEALTH [3001]","HB BWH MEDICAID","25329.68","","Case rate ($28,006.32). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,436.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","41521.50","41521.50","41521.50","1 through 10","6634.86","129265.58","case rate",""
"Extensive Third Degree Burns Without Skin Graft,MAJOR","843","DRG","","","","","","","","inpatient","","","53542.11","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","10209.32","","Case rate ($11,288.16). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,718.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12050.45","12050.45","12050.45","1 through 10","6634.86","129265.58","case rate",""
"Extensive Third Degree Burns Without Skin Graft,MAJOR","843","DRG","","","","","","","","inpatient","","","53542.11","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10209.32","","Case rate ($11,288.16). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,718.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11285.39","11285.39","11285.39","1 through 10","6634.86","129265.58","case rate",""
"Extensive Third Degree Burns Without Skin Graft,MAJOR","843","DRG","","","","","","","","inpatient","","","53542.11","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","10209.32","","Case rate ($11,288.16). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,718.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15024.03","15024.03","15024.03","1 through 10","6634.86","129265.58","case rate",""
"Extensive Third Degree Burns Without Skin Graft,MODERATE","843","DRG","","","","","","","","inpatient","","","17888.40","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22344.40","","Standard inlier is a Case rate ($22,344.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,024, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,171.92) for the length of stay and the standard reimbursement.","86957.56","86957.56","86957.56","1 through 10","6634.86","129265.58","case rate",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","48.01","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","47.96","47.96","47.96","1 through 10","44.28","714.71","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.86","45.86","872.00","1 through 10","44.28","714.71","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","584.35","65","","460.42","460.42","460.42","1 through 10","44.28","714.71","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","629.30","70","","627.84","627.84","627.84","1 through 10","44.28","714.71","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","714.71","79.5","","686.26","460.42","686.26","1 through 10","44.28","714.71","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","479.17","53.3","","460.42","460.42","460.42","1 through 10","44.28","714.71","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.68","45.68","45.68","1 through 10","44.28","714.71","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","692.23","77","","671.44","671.44","671.44","1 through 10","44.28","714.71","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","MEDICARE [2001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.61","46.61","46.61","26","44.28","714.71","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","328.14","36.5","","276.42","276.42","325.26","1 through 10","44.28","714.71","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","344.32","38.3","","340.95","340.95","340.95","22","44.28","714.71","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","46.08","46.08","46.08","1 through 10","44.28","714.71","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","45.68","45.68","46.18","1 through 10","44.28","714.71","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.67","42.9","","697.08","383.42","697.08","1 through 10","44.28","714.71","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","899.00","674.25","WELLPOINT [1015]","HB AMC WELLPOINT","663.28","73.78","","1521.20","1521.20","1521.20","1 through 10","44.28","714.71","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","899.00","674.25","AETNA [1001]","HB AMC AETNA HMO","627.50","69.8","","416.82","416.82","680.16","1 through 10","77.27","1332.31","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","899.00","674.25","AETNA [1001]","HB AMC AETNA PPO","722.80","80.4","","456.93","456.93","456.93","1 through 10","77.27","1332.31","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","899.00","674.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","734.66","81.72","","697.08","697.08","697.08","1 through 10","77.27","1332.31","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","48.01","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","48.56","47.96","48.86","1 through 10","44.28","960.36","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.86","45.86","45.86","1 through 10","44.28","960.36","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","845.60","70","","936.80","46.61","936.80","1 through 10","44.28","960.36","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","960.36","79.5","","921.58","591.36","1765.86","1 through 10","44.28","960.36","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","643.86","53.3","","921.58","591.36","921.58","1 through 10","44.28","960.36","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","960.36","79.5","","921.58","921.58","921.58","1 through 10","44.28","960.36","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","MEDICARE [2001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.61","46.61","46.61","76","44.28","960.36","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","440.92","36.5","","436.78","371.21","436.78","1 through 10","44.28","960.36","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","462.66","38.3","","457.86","444.98","457.86","51","44.28","960.36","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.68","45.68","46.08","1 through 10","44.28","960.36","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","MOLINA [1014]","HB BWH MOLINA","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","87.54","87.54","87.54","1 through 10","44.28","960.36","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","930.16","77","","65.66","65.66","65.66","1 through 10","44.28","960.36","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","46.28","46.28","46.28","1 through 10","44.28","960.36","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","45.68","43.30","46.18","1 through 10","44.28","960.36","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1208.00","906.00","WELLPOINT [1015]","HB AMC WELLPOINT","891.26","73.78","","2042.81","2042.81","2042.81","17","44.28","960.36","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","1208.00","906.00","AETNA [1001]","HB AMC AETNA HMO","843.18","69.8","","792.77","559.74","913.38","17","127.11","987.18","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","1208.00","906.00","AETNA [1001]","HB AMC AETNA PPO","971.23","80.4","","613.60","613.60","613.60","1 through 10","127.11","987.18","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","1208.00","906.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","631.30","52.26","","146.66","146.66","146.66","1 through 10","127.11","987.18","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","1208.00","906.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","971.23","80.4","","913.38","913.38","913.38","1 through 10","127.11","987.18","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","1208.00","906.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","987.18","81.72","","936.09","514.89","936.10","11","127.11","987.18","percent of total billed charges",""
"External Heart Assist Devices,EXTREME","178","DRG","","","","","","","","inpatient","","","563664.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","285189.66","","Standard inlier is a Case rate ($285,189.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $208,910, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($40,480.30) for the length of stay and the standard reimbursement.","285189.66","285189.66","285189.66","1 through 10","71483.55","285189.66","case rate",""
"External Heart Assist Devices,EXTREME","178","DRG","","","","","","","","inpatient","","","563664.33","","MASSHEALTH [3001]","HB BWH MEDICAID","96625.89","","Case rate ($106,836.53). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $149,266.53, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","130884.19","130884.19","130884.19","1 through 10","71483.55","285189.66","case rate",""
"Extracorporeal Membrane Oxygenation (Ecmo),EXTREME","009","DRG","","","","","","","","inpatient","","","1102517.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","461671.01","","Standard inlier is a Case rate ($461,671.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $370,662, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($65,536.98) for the length of stay and the standard reimbursement.","420829.94","420829.94","1143617.09","1 through 10","50996.54","519042.64","case rate",""
"Extracorporeal Membrane Oxygenation (Ecmo),EXTREME","009","DRG","","","","","","","","inpatient","","","1102517.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","519042.64","","Standard inlier is a Case rate ($519,042.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $370,662, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($73,673.79) for the length of stay and the standard reimbursement.","474190.27","120110.69","1070905.21","1 through 10","50996.54","519042.64","case rate",""
"Extracorporeal Membrane Oxygenation (Ecmo),EXTREME","009","DRG","","","","","","","","inpatient","","","1102517.33","","MASSHEALTH [3001]","HB BWH MEDICAID","195386.85","","Case rate ($216,033.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $258,463.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22421.78","9721.52","407138.54","1 through 10","50996.54","519042.64","case rate",""
"Extracorporeal Membrane Oxygenation (Ecmo),EXTREME","009","DRG","","","","","","","","inpatient","","","1102517.33","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","195386.85","","Case rate ($216,033.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $258,463.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","185812.39","185812.39","185812.39","1 through 10","50996.54","519042.64","case rate",""
"Extracorporeal Membrane Oxygenation (Ecmo),EXTREME","009","DRG","","","","","","","","inpatient","","","1102517.33","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","195386.85","","Case rate ($216,033.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $258,463.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2981.85","695.29","426425.11","11","50996.54","519042.64","case rate",""
"Extracorporeal Membrane Oxygenation (Ecmo),MAJOR","009","DRG","","","","","","","","inpatient","","","169181.12","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","93193.08","","Case rate ($103,040.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $145,470.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1348.93","1348.93","1348.93","1 through 10","50996.54","519042.64","case rate",""
"Extracranial Procedures With Cc","038","MS-DRG","","","","","","","","inpatient","","","134635.40","100976.55","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15636.81","","Case rate ($15,181.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,197.96, add-ons for qualifying new technology services are included. If operating cost exceeds $63,842.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,745.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $13,495.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,818.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.64. The transfer capital threshold is the transfer adjustment factor * $1,305.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15369.06","15369.06","15369.06","1 through 10","14877.74","24316.1283","other","Inpatient DRG"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","","","","inpatient","","","134635.40","100976.55","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","19589.68","","Case rate ($19,589.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,197.96, add-ons for qualifying new technology services are included. If operating cost exceeds $63,842.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,745.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $17,904.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,818.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.64. The transfer capital threshold is the transfer adjustment factor * $1,305.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14742.26","14742.26","14742.26","1 through 10","14877.74","24316.1283","other","Inpatient DRG"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","","","","inpatient","","","134635.40","100976.55","MEDICARE [2001]","HB BWH MEDICARE","19589.68","","Case rate ($19,589.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,197.96, add-ons for qualifying new technology services are included. If operating cost exceeds $63,842.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,745.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $17,904.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,818.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.64. The transfer capital threshold is the transfer adjustment factor * $1,305.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19296.56","19274.15","19302.56","15","14877.74","24316.1283","other","Inpatient DRG"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","","","","inpatient","","","134635.40","100976.55","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14877.74","","Case rate ($15,181.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,197.96, add-ons for qualifying new technology services are included. If operating cost exceeds $63,842.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,745.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $13,495.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,818.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.64. The transfer capital threshold is the transfer adjustment factor * $1,305.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14656.09","14656.09","14656.09","1 through 10","14877.74","24316.1283","other","Inpatient DRG"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","","","","inpatient","","","134635.40","100976.55","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14877.74","","Case rate ($15,181.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,197.96, add-ons for qualifying new technology services are included. If operating cost exceeds $63,842.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,745.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $13,495.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,818.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,305.64. The transfer capital threshold is the transfer adjustment factor * $1,305.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14658.90","14656.70","14672.39","1 through 10","14877.74","24316.1283","other","Inpatient DRG"
"Extracranial Procedures With McC","037","MS-DRG","","","","","","","","inpatient","","","175375.56","131531.67","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","31323.04","","Case rate ($30,410.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,531.10, add-ons for qualifying new technology services are included. If operating cost exceeds $82,175.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,089.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $27,381.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,151.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,649.02. The transfer capital threshold is the transfer adjustment factor * $2,649.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","31375.86","31375.86","31375.86","1 through 10","29802.51","51567.45","other","Inpatient DRG"
"Extracranial Procedures With McC","037","MS-DRG","","","","","","","","inpatient","","","175375.56","131531.67","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","30410.72","","Case rate ($30,410.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,531.10, add-ons for qualifying new technology services are included. If operating cost exceeds $82,175.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,089.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $27,381.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,151.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,649.02. The transfer capital threshold is the transfer adjustment factor * $2,649.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38856.71","38856.71","38856.71","1 through 10","29802.51","51567.45","other","Inpatient Replacement Plans DRG"
"Extracranial Procedures With McC","037","MS-DRG","","","","","","","","inpatient","","","175375.56","131531.67","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","30410.72","","Case rate ($30,410.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,531.10, add-ons for qualifying new technology services are included. If operating cost exceeds $82,175.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,089.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $27,381.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,151.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,649.02. The transfer capital threshold is the transfer adjustment factor * $2,649.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29853.51","29853.51","29853.51","1 through 10","29802.51","51567.45","other","Inpatient DRG"
"Extracranial Procedures With McC","037","MS-DRG","","","","","","","","inpatient","","","175375.56","131531.67","MEDICARE [2001]","HB BWH MEDICARE","30410.72","","Case rate ($30,410.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,531.10, add-ons for qualifying new technology services are included. If operating cost exceeds $82,175.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,089.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $27,381.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,151.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,649.02. The transfer capital threshold is the transfer adjustment factor * $2,649.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","39475.09","39428.89","40099.59","14","29802.51","51567.45","other","Inpatient Replacement Plans DRG"
"Extracranial Procedures With McC","037","MS-DRG","","","","","","","","inpatient","","","175375.56","131531.67","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","30410.72","","Case rate ($30,410.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,531.10, add-ons for qualifying new technology services are included. If operating cost exceeds $82,175.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,089.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $27,381.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,151.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,649.02. The transfer capital threshold is the transfer adjustment factor * $2,649.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29855.41","29855.41","29855.41","1 through 10","29802.51","51567.45","other","Inpatient Replacement Plans DRG"
"Extracranial Procedures With McC","037","MS-DRG","","","","","","","","inpatient","","","175375.56","131531.67","MOLINA [1014]","HB BWH MOLINA","29802.51","","Case rate ($30,410.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,531.10, add-ons for qualifying new technology services are included. If operating cost exceeds $82,175.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,089.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $27,381.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,151.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,649.02. The transfer capital threshold is the transfer adjustment factor * $2,649.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","60396.15","60396.15","60396.15","1 through 10","29802.51","51567.45","other","Inpatient DRG"
"Extracranial Procedures Without Cc/McC","039","MS-DRG","","","","","","","","inpatient","","","99760.09","74820.07","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","11435.96","","Case rate ($11,102.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,288.25, add-ons for qualifying new technology services are included. If operating cost exceeds $58,932.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,386.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,777.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,908.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $945.88. The transfer capital threshold is the transfer adjustment factor * $945.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10931.71","10931.71","10931.71","1 through 10","10880.81","17176.5762","other","Inpatient DRG"
"Extracranial Procedures Without Cc/McC","039","MS-DRG","","","","","","","","inpatient","","","99760.09","74820.07","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14296.49","","Case rate ($14,296.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,288.25, add-ons for qualifying new technology services are included. If operating cost exceeds $58,932.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,386.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $12,970.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,908.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $945.88. The transfer capital threshold is the transfer adjustment factor * $945.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10494.12","10494.12","10494.12","1 through 10","10880.81","17176.5762","other","Inpatient DRG"
"Extracranial Procedures Without Cc/McC","039","MS-DRG","","","","","","","","inpatient","","","99760.09","74820.07","MEDICARE [2001]","HB BWH MEDICARE","14296.49","","Case rate ($14,296.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,288.25, add-ons for qualifying new technology services are included. If operating cost exceeds $58,932.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,386.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $12,970.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,908.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $945.88. The transfer capital threshold is the transfer adjustment factor * $945.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13696.70","0.03","13716.76","1 through 10","10880.81","17176.5762","other","Inpatient DRG"
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","268.00","201.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","213.06","79.5","","204.62","137.28","613.86","349","17.57","254.6","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","268.00","201.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","142.84","53.3","","204.62","137.28","613.86","202","17.57","254.6","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","268.00","201.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","206.36","77","","600.60","200.20","600.60","45","17.57","254.6","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","268.00","201.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","83.08","31","","80.34","80.34","80.34","1 through 10","17.57","254.6","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","268.00","201.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.82","36.5","","96.98","82.42","117.09","246","17.57","254.6","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","268.00","201.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","102.64","38.3","","101.66","98.80","304.98","854","17.57","254.6","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","268.00","201.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","206.36","77","","1300.00","87.86","1300.00","1 through 10","17.57","254.6","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","268.00","201.00","TRICARE [160005]","HB BWH TRICARE","254.60","95","","21.61","20.53","260.00","16","17.57","254.6","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","268.00","201.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.97","42.9","","207.84","114.32","207.85","23","17.57","254.6","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","268.00","201.00","AETNA [1001]","HB AMC AETNA HMO","187.06","69.8","","176.02","124.28","202.80","322","18.49","219.01","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","268.00","201.00","AETNA [1001]","HB AMC AETNA PPO","215.47","80.4","","176.02","18.45","202.80","68","18.49","219.01","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","268.00","201.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","149.81","55.9","","136.24","136.24","136.24","1 through 10","18.49","219.01","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","268.00","201.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","215.47","80.4","","650.00","390.00","780.00","1 through 10","18.49","219.01","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","268.00","201.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","219.01","81.72","","780.00","780.00","780.00","1 through 10","18.49","219.01","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","268.00","201.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","219.01","81.72","","114.32","114.32","114.32","1 through 10","18.49","219.01","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","268.00","201.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","219.01","81.72","","207.84","114.32","337.73","299","18.49","219.01","percent of total billed charges",""
"Extraction","PX-76000003","CDM","10040","CPT","0761","RC","","","","both","","","612.00","459.00","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","189.72","486.54","other","OPPS APC"
"Extraction","PX-76000003","CDM","10040","CPT","0761","RC","","","","both","","","612.00","459.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.40","38.3","","593.00","593.00","593.00","1 through 10","189.72","486.54","percent of total billed charges",""
"Extraction","PX-76000003","CDM","10040","CPT","0761","RC","","","","outpatient","","","612.00","459.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","405.38","405.38","1 through 10","176.45","500.13","other","ASC"
"Extraction","PX-76000003","CDM","10040","CPT","0761","RC","","","","outpatient","","","612.00","459.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","472.37","472.37","472.37","1 through 10","176.45","500.13","other","ASC "
"Extraction","PX-76000003","CDM","10040","CPT","0761","RC","","","","outpatient","","","612.00","459.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","511.71","511.71","511.71","1 through 10","176.45","500.13","other","Multiple Surgery"
"Extraction","PX-98300003","CDM","10040","CPT","0983","RC","","","","both","","","360.00","270.00","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","111.6","294.93","other","OPPS APC"
"Extraction","PX-98300003","CDM","10040","CPT","0983","RC","","","","both","","","360.00","270.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","137.88","38.3","","593.00","593.00","593.00","1 through 10","111.6","294.93","percent of total billed charges",""
"Extraction","PX-98300003","CDM","10040","CPT","0983","RC","","","","outpatient","","","360.00","270.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","511.71","511.71","511.71","1 through 10","150.43","350.18","other","Multiple Surgery"
"Extraction Socket Debride (Incl Suture/Hemostasis)","PX-76002964","CDM","41899","CPT","0761","RC","","","","outpatient","","","1004.00","753.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","607.92","60.55","","481.00","481.00","481.00","1 through 10","502","828.3","percent of total billed charges",""
"EXTRACTOR SCREW BONE TI","SUP-ITM-10039408","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.12","704.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","746.60","79.5","","800.18","480.96","1887.97","195","291.13","746.6","percent of total billed charges",""
"EXTRACTOR SCREW BONE TI","SUP-ITM-10039408","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.12","704.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","500.55","53.3","","813.12","216.42","1444.50","81","291.13","746.6","percent of total billed charges",""
"EXTRACTOR SCREW BONE TI","SUP-ITM-10039408","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.12","704.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","291.13","31","","432.60","432.60","432.60","1 through 10","291.13","746.6","percent of total billed charges",""
"EXTRACTOR SCREW BONE TI","SUP-ITM-10039408","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.12","704.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","342.78","36.5","","148.37","54.89","631.39","94","291.13","746.6","percent of total billed charges",""
"EXTRACTOR SCREW BONE TI","SUP-ITM-10039408","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.12","704.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","359.68","38.3","","279.30","91.72","1116.77","266","291.13","746.6","percent of total billed charges",""
"EXTRACTOR SCREW BONE TI","SUP-ITM-10039408","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.12","704.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","402.88","42.9","","731.00","63.70","731.00","1 through 10","291.13","746.6","percent of total billed charges",""
"EXTRACTOR SCREW BONE TI","SUP-ITM-10039408","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.12","704.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","402.88","42.9","","384.74","384.74","384.74","1 through 10","291.13","746.6","percent of total billed charges",""
"EXTRACTOR SCREW BONE TI","SUP-ITM-10039408","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.12","704.34","WELLPOINT [1015]","HB AMC WELLPOINT","692.88","73.78","","286.63","119.22","1107.45","105","291.13","746.6","percent of total billed charges",""
"EXTRACTOR SCREW BONE TI","SUP-ITM-10039408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","939.12","704.34","AETNA [1001]","HB AMC AETNA HMO","655.51","69.8","","675.31","184.75","1721.50","286","490.78","767.45","percent of total billed charges",""
"EXTRACTOR SCREW BONE TI","SUP-ITM-10039408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","939.12","704.34","AETNA [1001]","HB AMC AETNA PPO","755.05","80.4","","1261.44","103.12","1514.10","21","490.78","767.45","percent of total billed charges",""
"EXTRACTOR SCREW BONE TI","SUP-ITM-10039408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","939.12","704.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","755.05","80.4","","1365.00","1365.00","1365.00","1 through 10","490.78","767.45","percent of total billed charges",""
"EXTRACTOR SCREW BONE TI","SUP-ITM-10039408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","939.12","704.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","767.45","81.72","","5157.68","5157.68","5157.68","1 through 10","490.78","767.45","percent of total billed charges",""
"EXTRACTOR SCREW BONE TI","SUP-ITM-10039408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","939.12","704.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","767.45","81.72","","431.26","71.26","1459.57","88","490.78","767.45","percent of total billed charges",""
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","","","","inpatient","","","71634.97","53726.23","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14093.74","","Case rate ($14,381.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,234.92, add-ons for qualifying new technology services are included. If operating cost exceeds $62,879.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,675.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $12,766.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,855.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,235.07. The transfer capital threshold is the transfer adjustment factor * $1,235.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13941.20","13941.20","13941.20","1 through 10","14093.74","23608.3604","other","Inpatient DRG"
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","","","","inpatient","","","337524.55","253143.41","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","38805.87","38805.87","38805.87","1 through 10","53505.14","89712.9768","case rate",""
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","","","","inpatient","","","337524.55","253143.41","WELLPOINT [1015]","HB AMC WELLPOINT","89712.9768","","Fee schedule rate ($93,098.98).","89712.9768","296214.79","296214.79","1 through 10","53505.14","89712.9768","case rate",""
"Extremity Vein Aspirate Thrombectomy Primary","PX-36000471","CDM","37799","CPT","0361","RC","","","","outpatient","","","9021.00","6765.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4710.77","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","7442.33","percent of total billed charges",""
"Extremity Vein Aspirate Thrombectomy Primary","PX-36000471","CDM","37799","CPT","0361","RC","","","","outpatient","","","9021.00","6765.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4736.03","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","7442.33","percent of total billed charges",""
"Eye Exam W/Fundus Photos","PX-51000033","CDM","92250","CPT","0510","RC","","","","both","","","524.00","393.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","200.69","38.3","","198.63","198.63","198.63","1 through 10","115.44","403.48","percent of total billed charges",""
"Eye Exam W/Fundus Photos","PX-51000033","CDM","92250","CPT","0510","RC","","","","outpatient","","","524.00","393.00","AETNA [1001]","HB AMC AETNA HMO","365.75","69.8","","687.83","687.83","687.83","1 through 10","40.19","428.21","percent of total billed charges",""
"Eye Exam W/Fundus Photos","PX-51000033","CDM","92250","CPT","0510","RC","","","","outpatient","","","524.00","393.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","178.68","34.1","","399.80","399.80","399.80","1 through 10","40.19","428.21","percent of total billed charges",""
"Eye Exam W/Fundus Photos","PX-51000033","CDM","92250","CPT","0510","RC","","","","outpatient","","","524.00","393.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","428.21","81.72","","406.10","223.37","406.10","1 through 10","40.19","428.21","percent of total billed charges",""
"Eye Infections And Other Eye Disorders,EXTREME","082","DRG","","","","","","","","inpatient","","","338131.74","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10937.463","","Fee schedule rate ($25,238.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10937.463","29633.88","29633.88","1 through 10","5565.61","87783.87","case rate",""
"Eye Infections And Other Eye Disorders,MAJOR","082","DRG","","","","","","","","inpatient","","","32120.78","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30865.49","","Fee schedule rate ($30,865.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26235.66","26235.66","26235.66","1 through 10","5565.61","87783.87","case rate",""
"Eye Infections And Other Eye Disorders,MINOR","082","DRG","","","","","","","","inpatient","","","30050.82","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","19176.26","","Standard inlier is a Case rate ($19,176.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,912, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,721.91) for the length of stay and the standard reimbursement.","19176.26","19176.26","19176.26","1 through 10","5565.61","87783.87","case rate",""
"Eye Infections And Other Eye Disorders,MINOR","082","DRG","","","","","","","","inpatient","","","30050.82","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10937.463","","Fee schedule rate ($10,937.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10937.463","10937.48","10937.48","1 through 10","5565.61","87783.87","case rate",""
"Eye Infections And Other Eye Disorders,MINOR","082","DRG","","","","","","","","inpatient","","","30050.82","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5565.61","","Case rate ($6,153.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,583.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6152.23","6152.23","6152.23","1 through 10","5565.61","87783.87","case rate",""
"Eye Infections And Other Eye Disorders,MODERATE","082","DRG","","","","","","","","inpatient","","","34354.76","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20960.20","","Standard inlier is a Case rate ($20,960.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,947, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,975.43) for the length of stay and the standard reimbursement.","20960.20","20960.20","20960.20","1 through 10","5565.61","87783.87","case rate",""
"Eye Infections And Other Eye Disorders,MODERATE","082","DRG","","","","","","","","inpatient","","","34354.76","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21888.45","","Fee schedule rate ($21,888.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21888.45","21888.45","21888.45","1 through 10","5565.61","87783.87","case rate",""
"F2 Isoprostanes, Urine","PX-30003491","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"F2 Isoprostanes, Urine","PX-30003491","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"F2 Isoprostanes, Urine","PX-30003491","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"F2 Isoprostanes, Urine","PX-30003491","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"F2 Isoprostanes, Urine","PX-30003491","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"F2 Isoprostanes, Urine","PX-30003491","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"F2 Isoprostanes, Urine","PX-30003491","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"F2 Isoprostanes, Urine","PX-30003491","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"F2 Isoprostanes, Urine","PX-30003491","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Fabry Disease Known Mutation","PX-31001355","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Fabry Disease Known Mutation","PX-31001355","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Face-to-Face Behavioral Cnsl Obe","PX-51000133","CDM","G0447","HCPCS","0510","RC","","","","both","","","173.00","129.75","MEDICARE [2001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","1 through 10","53.63","137.3","other","OPPS APC"
"Face-to-Face Behavioral Cnsl Obe","PX-51000133","CDM","G0447","HCPCS","0510","RC","","","","both","","","173.00","129.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.65","95.34","107.65","1 through 10","53.63","137.3","other","OPPS APC"
"Face-to-Face Behavioral Cnsl Obe","PX-51000133","CDM","G0447","HCPCS","0510","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.65","30.82","107.65","1 through 10","53.63","137.3","other","OPPS APC"
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","both","","","2379.00","1784.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1891.31","other","OPPS APC"
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","both","","","2379.00","1784.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1891.31","other","OPPS APC"
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","both","","","2379.00","1784.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1268.01","53.3","","477.31","477.31","477.31","1 through 10","333.03","1891.31","percent of total billed charges",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","both","","","2379.00","1784.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1891.31","other","OPPS APC"
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","both","","","2379.00","1784.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1891.31","other","OPPS APC"
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","both","","","2379.00","1784.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","868.34","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1891.31","percent of total billed charges",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","both","","","2379.00","1784.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","911.16","38.3","","343.52","323.76","353.46","1 through 10","333.03","1891.31","percent of total billed charges",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","both","","","2379.00","1784.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1891.31","other","Tricare OPPS"
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","both","","","2379.00","1784.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1891.31","other","OPPS APC"
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","both","","","2379.00","1784.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1891.31","other","OPPS APC"
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","both","","","2379.00","1784.25","WELLPOINT [1015]","HB AMC WELLPOINT","1755.23","73.78","","673.03","673.03","673.03","1 through 10","333.03","1891.31","percent of total billed charges",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","outpatient","","","2379.00","1784.25","AETNA [1001]","HB AMC AETNA HMO","1660.54","69.8","","612.01","612.01","1224.02","1 through 10","700.33","1962.68","percent of total billed charges",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","outpatient","","","2379.00","1784.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1440.48","60.55","","579.04","568.57","904.00","30","700.33","1962.68","percent of total billed charges",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","outpatient","","","2379.00","1784.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1242.31","52.22","","904.00","656.02","2938.00","26","700.33","1962.68","percent of total billed charges",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","outpatient","","","2379.00","1784.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1189.50","50","","1421.10","875.08","2368.50","15","700.33","1962.68","percent of total billed charges",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","outpatient","","","2379.00","1784.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1248.98","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","1962.68","percent of total billed charges",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","outpatient","","","2379.00","1784.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1944.12","81.72","","722.66","722.66","17449.00","1 through 10","700.33","1962.68","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","both","","","291.00","218.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","90.21","438.15","other","OPPS APC"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","both","","","291.00","218.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","90.21","438.15","other","OPPS APC"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","both","","","291.00","218.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","155.10","53.3","","477.31","477.31","477.31","1 through 10","90.21","438.15","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","both","","","291.00","218.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","90.21","438.15","other","OPPS APC"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","both","","","291.00","218.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","90.21","438.15","other","OPPS APC"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","106.22","36.5","","1095.87","337.19","1095.87","1 through 10","90.21","438.15","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","111.45","38.3","","343.52","323.76","353.46","1 through 10","90.21","438.15","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","both","","","291.00","218.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","90.21","438.15","other","Tricare OPPS"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","both","","","291.00","218.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","90.21","438.15","other","OPPS APC"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","both","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","90.21","438.15","other","OPPS APC"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","both","","","291.00","218.25","WELLPOINT [1015]","HB AMC WELLPOINT","214.70","73.78","","673.03","673.03","673.03","1 through 10","90.21","438.15","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","outpatient","","","291.00","218.25","AETNA [1001]","HB AMC AETNA HMO","203.12","69.8","","612.01","612.01","1224.02","1 through 10","145.5","700.33","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","outpatient","","","291.00","218.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","176.20","60.55","","579.04","568.57","904.00","30","145.5","700.33","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","outpatient","","","291.00","218.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","151.96","52.22","","904.00","656.02","2938.00","26","145.5","700.33","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","outpatient","","","291.00","218.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","145.50","50","","1421.10","875.08","2368.50","15","145.5","700.33","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","outpatient","","","291.00","218.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","152.78","52.5","","2985.00","904.00","2985.00","1 through 10","145.5","700.33","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Each Add'l","PX-98301787","CDM","64999","CPT","0983","RC","","","","outpatient","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","237.81","81.72","","722.66","722.66","17449.00","1 through 10","145.5","700.33","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","both","","","964.00","723.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","298.84","766.38","other","OPPS APC"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","both","","","964.00","723.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","298.84","766.38","other","OPPS APC"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","both","","","964.00","723.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","513.81","53.3","","477.31","477.31","477.31","1 through 10","298.84","766.38","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","both","","","964.00","723.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","298.84","766.38","other","OPPS APC"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","both","","","964.00","723.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","298.84","766.38","other","OPPS APC"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","both","","","964.00","723.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","351.86","36.5","","1095.87","337.19","1095.87","1 through 10","298.84","766.38","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","both","","","964.00","723.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","369.21","38.3","","343.52","323.76","353.46","1 through 10","298.84","766.38","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","both","","","964.00","723.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","298.84","766.38","other","Tricare OPPS"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","both","","","964.00","723.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","298.84","766.38","other","OPPS APC"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","both","","","964.00","723.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","298.84","766.38","other","OPPS APC"
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","both","","","964.00","723.00","WELLPOINT [1015]","HB AMC WELLPOINT","711.24","73.78","","673.03","673.03","673.03","1 through 10","298.84","766.38","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","outpatient","","","964.00","723.00","AETNA [1001]","HB AMC AETNA HMO","672.87","69.8","","612.01","612.01","1224.02","1 through 10","482","795.3","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","outpatient","","","964.00","723.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","583.70","60.55","","579.04","568.57","904.00","30","482","795.3","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","outpatient","","","964.00","723.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","503.40","52.22","","904.00","656.02","2938.00","26","482","795.3","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","outpatient","","","964.00","723.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","482.00","50","","1421.10","875.08","2368.50","15","482","795.3","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","outpatient","","","964.00","723.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","506.10","52.5","","2985.00","904.00","2985.00","1 through 10","482","795.3","percent of total billed charges",""
"Facet Denervation <80 Celcius: Cervical or Thoracic; Single","PX-98301786","CDM","64999","CPT","0983","RC","","","","outpatient","","","964.00","723.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","787.78","81.72","","722.66","722.66","17449.00","1 through 10","482","795.3","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","both","","","364.00","273.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","112.84","438.15","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","both","","","364.00","273.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","112.84","438.15","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","both","","","364.00","273.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","194.01","53.3","","477.31","477.31","477.31","1 through 10","112.84","438.15","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","both","","","364.00","273.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","112.84","438.15","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","both","","","364.00","273.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","112.84","438.15","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","both","","","364.00","273.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","132.86","36.5","","1095.87","337.19","1095.87","1 through 10","112.84","438.15","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","both","","","364.00","273.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","139.41","38.3","","343.52","323.76","353.46","1 through 10","112.84","438.15","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","both","","","364.00","273.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","112.84","438.15","other","Tricare OPPS"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","both","","","364.00","273.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","112.84","438.15","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","both","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","112.84","438.15","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","both","","","364.00","273.00","WELLPOINT [1015]","HB AMC WELLPOINT","268.56","73.78","","673.03","673.03","673.03","1 through 10","112.84","438.15","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","outpatient","","","364.00","273.00","AETNA [1001]","HB AMC AETNA HMO","254.07","69.8","","612.01","612.01","1224.02","1 through 10","182","700.33","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","outpatient","","","364.00","273.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","220.40","60.55","","579.04","568.57","904.00","30","182","700.33","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","outpatient","","","364.00","273.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","190.08","52.22","","904.00","656.02","2938.00","26","182","700.33","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","outpatient","","","364.00","273.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","182.00","50","","1421.10","875.08","2368.50","15","182","700.33","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","outpatient","","","364.00","273.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","191.10","52.5","","2985.00","904.00","2985.00","1 through 10","182","700.33","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","outpatient","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","297.46","81.72","","722.66","722.66","17449.00","1 through 10","182","700.33","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","both","","","418.00","313.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","129.58","438.15","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","both","","","418.00","313.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","129.58","438.15","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","both","","","418.00","313.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","222.79","53.3","","477.31","477.31","477.31","1 through 10","129.58","438.15","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","both","","","418.00","313.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","129.58","438.15","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","both","","","418.00","313.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","129.58","438.15","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","both","","","418.00","313.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","152.57","36.5","","1095.87","337.19","1095.87","1 through 10","129.58","438.15","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","both","","","418.00","313.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","160.09","38.3","","343.52","323.76","353.46","1 through 10","129.58","438.15","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","both","","","418.00","313.50","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","129.58","438.15","other","Tricare OPPS"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","both","","","418.00","313.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","129.58","438.15","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","both","","","418.00","313.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","129.58","438.15","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","both","","","418.00","313.50","WELLPOINT [1015]","HB AMC WELLPOINT","308.40","73.78","","673.03","673.03","673.03","1 through 10","129.58","438.15","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","outpatient","","","418.00","313.50","AETNA [1001]","HB AMC AETNA HMO","291.76","69.8","","612.01","612.01","1224.02","1 through 10","209","700.33","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","outpatient","","","418.00","313.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","253.10","60.55","","579.04","568.57","904.00","30","209","700.33","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","outpatient","","","418.00","313.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","218.28","52.22","","904.00","656.02","2938.00","26","209","700.33","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","outpatient","","","418.00","313.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","209.00","50","","1421.10","875.08","2368.50","15","209","700.33","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","outpatient","","","418.00","313.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","219.45","52.5","","2985.00","904.00","2985.00","1 through 10","209","700.33","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","outpatient","","","418.00","313.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","341.59","81.72","","722.66","722.66","17449.00","1 through 10","209","700.33","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","both","","","1416.00","1062.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1125.72","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","both","","","1416.00","1062.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1125.72","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","both","","","1416.00","1062.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","754.73","53.3","","477.31","477.31","477.31","1 through 10","333.03","1125.72","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","both","","","1416.00","1062.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1125.72","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","both","","","1416.00","1062.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1125.72","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","both","","","1416.00","1062.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","516.84","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1125.72","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","both","","","1416.00","1062.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","542.33","38.3","","343.52","323.76","353.46","1 through 10","333.03","1125.72","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","both","","","1416.00","1062.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1125.72","other","Tricare OPPS"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","both","","","1416.00","1062.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1125.72","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","both","","","1416.00","1062.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1125.72","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","both","","","1416.00","1062.00","WELLPOINT [1015]","HB AMC WELLPOINT","1044.72","73.78","","673.03","673.03","673.03","1 through 10","333.03","1125.72","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","outpatient","","","1416.00","1062.00","AETNA [1001]","HB AMC AETNA HMO","988.37","69.8","","612.01","612.01","1224.02","1 through 10","700.33","1168.2","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","outpatient","","","1416.00","1062.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","857.39","60.55","","579.04","568.57","904.00","30","700.33","1168.2","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","outpatient","","","1416.00","1062.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","739.44","52.22","","904.00","656.02","2938.00","26","700.33","1168.2","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","outpatient","","","1416.00","1062.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","708.00","50","","1421.10","875.08","2368.50","15","700.33","1168.2","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","outpatient","","","1416.00","1062.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","743.40","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","1168.2","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","outpatient","","","1416.00","1062.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1157.16","81.72","","722.66","722.66","17449.00","1 through 10","700.33","1168.2","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","both","","","1387.00","1040.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1102.67","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","both","","","1387.00","1040.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1102.67","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","both","","","1387.00","1040.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","739.27","53.3","","477.31","477.31","477.31","1 through 10","333.03","1102.67","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","both","","","1387.00","1040.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1102.67","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","both","","","1387.00","1040.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1102.67","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","both","","","1387.00","1040.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","506.26","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1102.67","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","both","","","1387.00","1040.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","531.22","38.3","","343.52","323.76","353.46","1 through 10","333.03","1102.67","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","both","","","1387.00","1040.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1102.67","other","Tricare OPPS"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","both","","","1387.00","1040.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1102.67","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","both","","","1387.00","1040.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1102.67","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","both","","","1387.00","1040.25","WELLPOINT [1015]","HB AMC WELLPOINT","1023.33","73.78","","673.03","673.03","673.03","1 through 10","333.03","1102.67","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","outpatient","","","1387.00","1040.25","AETNA [1001]","HB AMC AETNA HMO","968.13","69.8","","612.01","612.01","1224.02","1 through 10","693.5","1144.28","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","outpatient","","","1387.00","1040.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","839.83","60.55","","579.04","568.57","904.00","30","693.5","1144.28","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","outpatient","","","1387.00","1040.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","724.29","52.22","","904.00","656.02","2938.00","26","693.5","1144.28","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","outpatient","","","1387.00","1040.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","693.50","50","","1421.10","875.08","2368.50","15","693.5","1144.28","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","outpatient","","","1387.00","1040.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","728.18","52.5","","2985.00","904.00","2985.00","1 through 10","693.5","1144.28","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","outpatient","","","1387.00","1040.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1133.46","81.72","","722.66","722.66","17449.00","1 through 10","693.5","1144.28","percent of total billed charges",""
"Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,MAJOR","092","DRG","","","","","","","","inpatient","","","76881.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","89983.73","","Standard inlier is a Case rate ($89,983.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $73,889, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,772.44) for the length of stay and the standard reimbursement.","93225.06","93225.06","93225.06","1 through 10","14955.86","89983.73","case rate",""
"Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,MINOR","092","DRG","","","","","","","","inpatient","","","54186.25","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38755.56","","Fee schedule rate ($38,755.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38755.56","38755.56","38755.56","1 through 10","14955.86","89983.73","case rate",""
"Facial Bone Procedures Except Major Cranial Or Facial Bone Procedures,MINOR","092","DRG","","","","","","","","inpatient","","","54186.25","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14955.86","","Case rate ($16,536.27). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,966.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16532.21","16532.21","16532.21","1 through 10","14955.86","89983.73","case rate",""
"Factor II","PX-30001052","CDM","85210","CPT","0305","RC","","","","outpatient","","","231.00","173.25","AETNA [1001]","HB AMC AETNA HMO","161.24","69.8","","151.65","151.65","151.65","1 through 10","13.39","188.77","percent of total billed charges",""
"Factor II","PX-30001052","CDM","85210","CPT","0305","RC","","","","outpatient","","","231.00","173.25","AETNA [1001]","HB AMC AETNA PPO","185.72","80.4","","174.72","174.72","174.72","1 through 10","13.39","188.77","percent of total billed charges",""
"Factor IX (Christmas/Ptc)","PX-30001063","CDM","85250","CPT","0305","RC","","","","both","","","330.00","247.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","175.89","53.3","","251.84","168.96","251.84","11","18.66","313.5","percent of total billed charges",""
"Factor IX (Christmas/Ptc)","PX-30001063","CDM","85250","CPT","0305","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","120.45","36.5","","119.36","115.84","119.36","1 through 10","18.66","313.5","percent of total billed charges",""
"Factor IX (Christmas/Ptc)","PX-30001063","CDM","85250","CPT","0305","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","126.39","38.3","","121.60","121.60","121.60","1 through 10","18.66","313.5","percent of total billed charges",""
"Factor IX (Christmas/Ptc)","PX-30001063","CDM","85250","CPT","0305","RC","","","","outpatient","","","330.00","247.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","184.47","55.9","","167.68","167.68","167.68","1 through 10","19.63","269.68","percent of total billed charges",""
"Factor IX (Christmas/Ptc)","PX-30001063","CDM","85250","CPT","0305","RC","","","","outpatient","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","269.68","81.72","","255.81","255.81","255.81","1 through 10","19.63","269.68","percent of total billed charges",""
"Factor V (Proaccelerin) Labile","PX-30001053","CDM","85220","CPT","0305","RC","","","","both","","","296.00","222.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","235.32","79.5","","225.87","225.87","225.87","1 through 10","17.3","281.2","percent of total billed charges",""
"Factor V (Proaccelerin) Labile","PX-30001053","CDM","85220","CPT","0305","RC","","","","both","","","296.00","222.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.37","38.3","","112.22","112.22","112.22","1 through 10","17.3","281.2","percent of total billed charges",""
"Factor V (Proaccelerin) Labile","PX-30001053","CDM","85220","CPT","0305","RC","","","","outpatient","","","296.00","222.00","AETNA [1001]","HB AMC AETNA HMO","206.61","69.8","","194.30","194.30","194.30","1 through 10","18.2","241.89","percent of total billed charges",""
"Factor V (Proaccelerin) Labile","PX-30001053","CDM","85220","CPT","0305","RC","","","","outpatient","","","296.00","222.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","241.89","81.72","","229.43","229.43","229.43","1 through 10","18.2","241.89","percent of total billed charges",""
"Factor VII (Proconvertin) Stable","PX-30001054","CDM","85230","CPT","0305","RC","","","","both","","","307.00","230.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","117.58","38.3","","116.52","113.24","116.52","1 through 10","17.54","291.65","percent of total billed charges",""
"Factor VII (Proconvertin) Stable","PX-30001054","CDM","85230","CPT","0305","RC","","","","outpatient","","","307.00","230.25","AETNA [1001]","HB AMC AETNA HMO","214.29","69.8","","201.75","201.75","201.75","1 through 10","18.47","250.88","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","both","","","309.00","231.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","216.30","70","","300.00","300.00","300.00","1 through 10","17.54","293.55","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","both","","","309.00","231.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","245.66","79.5","","452.40","452.40","452.40","1 through 10","17.54","293.55","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","both","","","309.00","231.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","164.70","53.3","","236.10","236.10","236.10","1 through 10","17.54","293.55","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","both","","","309.00","231.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","200.85","65","","195.00","189.15","195.00","1 through 10","17.54","293.55","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","both","","","309.00","231.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","112.79","36.5","","111.90","111.90","111.90","1 through 10","17.54","293.55","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","both","","","309.00","231.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","118.35","38.3","","117.30","114.00","117.30","1 through 10","17.54","293.55","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","outpatient","","","309.00","231.75","AETNA [1001]","HB AMC AETNA HMO","215.68","69.8","","203.10","203.10","203.10","1 through 10","18.47","252.51","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","outpatient","","","309.00","231.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","252.51","81.72","","239.82","131.91","239.82","1 through 10","18.47","252.51","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","291.00","218.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","231.35","79.5","","221.93","148.90","282.00","1 through 10","22.48","276.45","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","291.00","218.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","155.10","53.3","","148.90","148.90","148.90","1 through 10","22.48","276.45","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","291.00","218.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","189.15","65","","183.30","183.30","183.30","1 through 10","22.48","276.45","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","291.00","218.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","231.35","79.5","","221.93","221.93","221.93","1 through 10","22.48","276.45","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","106.22","36.5","","89.39","89.39","105.19","1 through 10","22.48","276.45","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","111.45","38.3","","110.26","110.26","330.78","23","22.48","276.45","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","291.00","218.25","TRICARE [160005]","HB BWH TRICARE","276.45","95","","26.26","26.26","26.26","1 through 10","22.48","276.45","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.84","42.9","","225.43","225.43","225.43","1 through 10","22.48","276.45","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","outpatient","","","291.00","218.25","AETNA [1001]","HB AMC AETNA HMO","203.12","69.8","","190.91","134.80","219.96","12","23.65","237.81","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","outpatient","","","291.00","218.25","AETNA [1001]","HB AMC AETNA PPO","233.96","80.4","","147.77","147.77","147.77","1 through 10","23.65","237.81","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","outpatient","","","291.00","218.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","233.96","80.4","","219.96","219.96","219.96","1 through 10","23.65","237.81","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","outpatient","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","237.81","81.72","","225.43","124.00","225.43","1 through 10","23.65","237.81","percent of total billed charges",""
"Factor VIII Vw Multimetric","PX-30001061","CDM","85247","CPT","0305","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","114.90","38.3","","113.78","110.58","113.78","1 through 10","22.48","285","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","383.00","287.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","304.49","79.5","","291.98","195.89","371.00","1 through 10","22.48","363.85","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","383.00","287.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","204.14","53.3","","195.89","195.89","195.89","1 through 10","22.48","363.85","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","383.00","287.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","248.95","65","","241.15","241.15","241.15","1 through 10","22.48","363.85","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","383.00","287.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","304.49","79.5","","291.98","291.98","291.98","1 through 10","22.48","363.85","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","383.00","287.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","139.80","36.5","","117.61","117.61","138.38","1 through 10","22.48","363.85","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","383.00","287.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","146.69","38.3","","145.06","145.06","435.18","23","22.48","363.85","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","383.00","287.25","TRICARE [160005]","HB BWH TRICARE","363.85","95","","26.26","26.26","26.26","1 through 10","22.48","363.85","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","383.00","287.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","164.31","42.9","","296.58","296.58","296.58","1 through 10","22.48","363.85","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","outpatient","","","383.00","287.25","AETNA [1001]","HB AMC AETNA HMO","267.33","69.8","","251.17","177.34","289.38","12","23.65","312.99","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","outpatient","","","383.00","287.25","AETNA [1001]","HB AMC AETNA PPO","307.93","80.4","","194.40","194.40","194.40","1 through 10","23.65","312.99","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","outpatient","","","383.00","287.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","307.93","80.4","","289.38","289.38","289.38","1 through 10","23.65","312.99","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","outpatient","","","383.00","287.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","312.99","81.72","","296.58","163.13","296.58","1 through 10","23.65","312.99","percent of total billed charges",""
"Factor X (Stuart-Prower)","PX-30001064","CDM","85260","CPT","0305","RC","","","","outpatient","","","327.00","245.25","AETNA [1001]","HB AMC AETNA HMO","228.25","69.8","","214.61","214.61","214.61","1 through 10","18.47","267.22","percent of total billed charges",""
"Factor XI (Pta)","PX-30001065","CDM","85270","CPT","0305","RC","","","","both","","","311.00","233.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","113.52","36.5","","112.65","112.65","112.65","1 through 10","17.54","295.45","percent of total billed charges",""
"Factor XI (Pta)","PX-30001065","CDM","85270","CPT","0305","RC","","","","both","","","311.00","233.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.11","38.3","","118.08","114.76","118.08","1 through 10","17.54","295.45","percent of total billed charges",""
"Factor XI (Pta)","PX-30001065","CDM","85270","CPT","0305","RC","","","","outpatient","","","311.00","233.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","250.04","80.4","","235.56","235.56","235.56","1 through 10","18.47","254.15","percent of total billed charges",""
"Factor XI (Pta)","PX-30001065","CDM","85270","CPT","0305","RC","","","","outpatient","","","311.00","233.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","254.15","81.72","","241.42","241.42","241.42","1 through 10","18.47","254.15","percent of total billed charges",""
"Factor XII (Hageman)","PX-30001066","CDM","85280","CPT","0305","RC","","","","both","","","332.00","249.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","263.94","79.5","","253.41","253.41","253.41","1 through 10","18.96","315.4","percent of total billed charges",""
"Factor XII (Hageman)","PX-30001066","CDM","85280","CPT","0305","RC","","","","both","","","332.00","249.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.16","38.3","","122.36","122.36","122.36","1 through 10","18.96","315.4","percent of total billed charges",""
"Factor XII (Hageman)","PX-30001066","CDM","85280","CPT","0305","RC","","","","outpatient","","","332.00","249.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","266.93","80.4","","251.16","251.16","251.16","1 through 10","19.95","271.31","percent of total billed charges",""
"Factor XII Snp Analysis Factor 12 Snp Gene Sequencing Fxiis Njc Fxiisa","PX-31001310","CDM","81403","CPT","0310","RC","","","","outpatient","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","864.60","81.72","","820.18","820.18","820.18","1 through 10","512.07","1135.28","percent of total billed charges",""
"Factor XIII (Fibrin Stablizing)","PX-30001067","CDM","85290","CPT","0305","RC","","","","both","","","280.00","210.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","196.00","70","","272.00","272.00","272.00","1 through 10","16.01","266","percent of total billed charges",""
"Factor XIII (Fibrin Stablizing)","PX-30001067","CDM","85290","CPT","0305","RC","","","","both","","","280.00","210.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","222.60","79.5","","214.06","143.62","642.18","1 through 10","16.01","266","percent of total billed charges",""
"Factor XIII (Fibrin Stablizing)","PX-30001067","CDM","85290","CPT","0305","RC","","","","both","","","280.00","210.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","149.24","53.3","","214.06","143.62","430.86","1 through 10","16.01","266","percent of total billed charges",""
"Factor XIII (Fibrin Stablizing)","PX-30001067","CDM","85290","CPT","0305","RC","","","","both","","","280.00","210.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","182.00","65","","176.80","169.00","176.80","1 through 10","16.01","266","percent of total billed charges",""
"Factor XIII (Fibrin Stablizing)","PX-30001067","CDM","85290","CPT","0305","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","102.20","36.5","","304.38","86.22","710.22","18","16.01","266","percent of total billed charges",""
"Factor XIII (Fibrin Stablizing)","PX-30001067","CDM","85290","CPT","0305","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","107.24","38.3","","106.35","103.36","319.05","25","16.01","266","percent of total billed charges",""
"Factor XIII (Fibrin Stablizing)","PX-30001067","CDM","85290","CPT","0305","RC","","","","outpatient","","","280.00","210.00","AETNA [1001]","HB AMC AETNA HMO","195.44","69.8","","184.14","130.02","212.16","11","16.85","228.82","percent of total billed charges",""
"Factor XIII (Fibrin Stablizing)","PX-30001067","CDM","85290","CPT","0305","RC","","","","outpatient","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","228.82","81.72","","217.44","119.60","217.44","1 through 10","16.85","228.82","percent of total billed charges",""
"Factor XIII Solubility Screen","PX-30001068","CDM","85291","CPT","0305","RC","","","","both","","","152.00","114.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.02","53.3","","77.62","77.62","77.62","1 through 10","8.93","144.4","percent of total billed charges",""
"Factor XIII Solubility Screen","PX-30001068","CDM","85291","CPT","0305","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.48","36.5","","46.60","46.60","46.60","1 through 10","8.93","144.4","percent of total billed charges",""
"Factor XIII Solubility Screen","PX-30001068","CDM","85291","CPT","0305","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.22","38.3","","57.48","57.48","57.48","1 through 10","8.93","144.4","percent of total billed charges",""
"Familial Mediterranean Fever Sequencing Analysis Fmseq Fmf Sequencing Analysis","PX-31001335","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"FASTENER SCREW 2.7MM 75MM SELF-TAPPING","SUP-ITM-10320322","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.50","238.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","253.21","79.5","","800.18","480.96","1887.97","195","98.74","253.21","percent of total billed charges",""
"FASTENER SCREW 2.7MM 75MM SELF-TAPPING","SUP-ITM-10320322","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.50","238.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","169.76","53.3","","813.12","216.42","1444.50","81","98.74","253.21","percent of total billed charges",""
"FASTENER SCREW 2.7MM 75MM SELF-TAPPING","SUP-ITM-10320322","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.50","238.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","98.74","31","","432.60","432.60","432.60","1 through 10","98.74","253.21","percent of total billed charges",""
"FASTENER SCREW 2.7MM 75MM SELF-TAPPING","SUP-ITM-10320322","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.50","238.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","116.25","36.5","","148.37","54.89","631.39","94","98.74","253.21","percent of total billed charges",""
"FASTENER SCREW 2.7MM 75MM SELF-TAPPING","SUP-ITM-10320322","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.50","238.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.99","38.3","","279.30","91.72","1116.77","266","98.74","253.21","percent of total billed charges",""
"FASTENER SCREW 2.7MM 75MM SELF-TAPPING","SUP-ITM-10320322","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.50","238.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","136.64","42.9","","731.00","63.70","731.00","1 through 10","98.74","253.21","percent of total billed charges",""
"FASTENER SCREW 2.7MM 75MM SELF-TAPPING","SUP-ITM-10320322","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.50","238.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","136.64","42.9","","384.74","384.74","384.74","1 through 10","98.74","253.21","percent of total billed charges",""
"FASTENER SCREW 2.7MM 75MM SELF-TAPPING","SUP-ITM-10320322","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.50","238.87","WELLPOINT [1015]","HB AMC WELLPOINT","234.99","73.78","","286.63","119.22","1107.45","105","98.74","253.21","percent of total billed charges",""
"FASTENER SCREW 2.7MM 75MM SELF-TAPPING","SUP-ITM-10320322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.50","238.87","AETNA [1001]","HB AMC AETNA HMO","222.31","69.8","","675.31","184.75","1721.50","286","166.45","260.28","percent of total billed charges",""
"FASTENER SCREW 2.7MM 75MM SELF-TAPPING","SUP-ITM-10320322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.50","238.87","AETNA [1001]","HB AMC AETNA PPO","256.07","80.4","","1261.44","103.12","1514.10","21","166.45","260.28","percent of total billed charges",""
"FASTENER SCREW 2.7MM 75MM SELF-TAPPING","SUP-ITM-10320322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.50","238.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","256.07","80.4","","1365.00","1365.00","1365.00","1 through 10","166.45","260.28","percent of total billed charges",""
"FASTENER SCREW 2.7MM 75MM SELF-TAPPING","SUP-ITM-10320322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.50","238.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","260.28","81.72","","5157.68","5157.68","5157.68","1 through 10","166.45","260.28","percent of total billed charges",""
"FASTENER SCREW 2.7MM 75MM SELF-TAPPING","SUP-ITM-10320322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.50","238.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","260.28","81.72","","431.26","71.26","1459.57","88","166.45","260.28","percent of total billed charges",""
"FASTENER SCREW 8X145MM FULL THREAD CANNULATED","SUP-ITM-10319790","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","612.15","79.5","","800.18","480.96","1887.97","195","238.7","612.15","percent of total billed charges",""
"FASTENER SCREW 8X145MM FULL THREAD CANNULATED","SUP-ITM-10319790","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","410.41","53.3","","813.12","216.42","1444.50","81","238.7","612.15","percent of total billed charges",""
"FASTENER SCREW 8X145MM FULL THREAD CANNULATED","SUP-ITM-10319790","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","238.70","31","","432.60","432.60","432.60","1 through 10","238.7","612.15","percent of total billed charges",""
"FASTENER SCREW 8X145MM FULL THREAD CANNULATED","SUP-ITM-10319790","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","281.05","36.5","","148.37","54.89","631.39","94","238.7","612.15","percent of total billed charges",""
"FASTENER SCREW 8X145MM FULL THREAD CANNULATED","SUP-ITM-10319790","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","294.91","38.3","","279.30","91.72","1116.77","266","238.7","612.15","percent of total billed charges",""
"FASTENER SCREW 8X145MM FULL THREAD CANNULATED","SUP-ITM-10319790","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","330.33","42.9","","731.00","63.70","731.00","1 through 10","238.7","612.15","percent of total billed charges",""
"FASTENER SCREW 8X145MM FULL THREAD CANNULATED","SUP-ITM-10319790","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","330.33","42.9","","384.74","384.74","384.74","1 through 10","238.7","612.15","percent of total billed charges",""
"FASTENER SCREW 8X145MM FULL THREAD CANNULATED","SUP-ITM-10319790","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","WELLPOINT [1015]","HB AMC WELLPOINT","568.11","73.78","","286.63","119.22","1107.45","105","238.7","612.15","percent of total billed charges",""
"FASTENER SCREW 8X145MM FULL THREAD CANNULATED","SUP-ITM-10319790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","AETNA [1001]","HB AMC AETNA HMO","537.46","69.8","","675.31","184.75","1721.50","286","402.4","629.24","percent of total billed charges",""
"FASTENER SCREW 8X145MM FULL THREAD CANNULATED","SUP-ITM-10319790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","AETNA [1001]","HB AMC AETNA PPO","619.08","80.4","","1261.44","103.12","1514.10","21","402.4","629.24","percent of total billed charges",""
"FASTENER SCREW 8X145MM FULL THREAD CANNULATED","SUP-ITM-10319790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","619.08","80.4","","1365.00","1365.00","1365.00","1 through 10","402.4","629.24","percent of total billed charges",""
"FASTENER SCREW 8X145MM FULL THREAD CANNULATED","SUP-ITM-10319790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","629.24","81.72","","5157.68","5157.68","5157.68","1 through 10","402.4","629.24","percent of total billed charges",""
"FASTENER SCREW 8X145MM FULL THREAD CANNULATED","SUP-ITM-10319790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","629.24","81.72","","431.26","71.26","1459.57","88","402.4","629.24","percent of total billed charges",""
"Fat/Lipids Feces Ql","PX-30000430","CDM","82705","CPT","0301","RC","","","","both","","","82.00","61.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","65.19","79.5","","62.96","42.24","62.96","1 through 10","5","77.9","percent of total billed charges",""
"Fat/Lipids Feces Ql","PX-30000430","CDM","82705","CPT","0301","RC","","","","both","","","82.00","61.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","43.71","53.3","","42.24","42.24","42.24","1 through 10","5","77.9","percent of total billed charges",""
"Fat/Lipids Feces Ql","PX-30000430","CDM","82705","CPT","0301","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29.93","36.5","","29.84","25.12","29.84","1 through 10","5","77.9","percent of total billed charges",""
"Fat/Lipids Feces Ql","PX-30000430","CDM","82705","CPT","0301","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31.41","38.3","","31.28","30.40","31.28","1 through 10","5","77.9","percent of total billed charges",""
"Fat/Lipids Feces Ql","PX-30000430","CDM","82705","CPT","0301","RC","","","","outpatient","","","82.00","61.50","AETNA [1001]","HB AMC AETNA HMO","57.24","69.8","","54.16","38.24","54.16","1 through 10","5.25","67.01","percent of total billed charges",""
"Fat/Lipids Feces Ql","PX-30000430","CDM","82705","CPT","0301","RC","","","","outpatient","","","82.00","61.50","AETNA [1001]","HB AMC AETNA PPO","65.93","80.4","","62.40","62.40","62.40","1 through 10","5.25","67.01","percent of total billed charges",""
"Fat/Lipids Feces Ql","PX-30000430","CDM","82705","CPT","0301","RC","","","","outpatient","","","82.00","61.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","65.93","80.4","","62.40","62.40","62.40","1 through 10","5.25","67.01","percent of total billed charges",""
"Fat/Lipids Feces Ql","PX-30000430","CDM","82705","CPT","0301","RC","","","","outpatient","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","67.01","81.72","","63.95","28.10","63.95","1 through 10","5.25","67.01","percent of total billed charges",""
"Fatty Acid Oxidation Deficiency Panel by Massively Parallel Sequencing (Bcm-Mitomengssm)","PX-31000790","CDM","81479","CPT","0310","RC","","","","both","","","318.00","238.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","252.81","79.5","","0.65","0.65","0.65","1 through 10","98.58","302.1","percent of total billed charges",""
"Fatty Acid Oxidation Deficiency Panel by Massively Parallel Sequencing (Bcm-Mitomengssm)","PX-31000790","CDM","81479","CPT","0310","RC","","","","both","","","318.00","238.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","169.49","53.3","","0.79","0.79","0.79","1 through 10","98.58","302.1","percent of total billed charges",""
"Fatty Acid Oxidation Deficiency Panel by Massively Parallel Sequencing (Bcm-Mitomengssm)","PX-31000790","CDM","81479","CPT","0310","RC","","","","outpatient","","","318.00","238.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","159.00","50","","1.00","1.00","1.00","1 through 10","153.91","262.35","percent of total billed charges",""
"Fatty Acid Oxidation Deficiency Panel by Massively Parallel Sequencing (Bcm-Mitomengssm)","PX-31000790","CDM","81479","CPT","0310","RC","","","","outpatient","","","318.00","238.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","166.95","52.5","","1.00","0.53","1.00","1 through 10","153.91","262.35","percent of total billed charges",""
"Fatty Acids Nonesterified","PX-30000433","CDM","82725","CPT","0301","RC","","","","both","","","237.00","177.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","126.32","53.3","","121.44","121.44","121.44","1 through 10","13.72","225.15","percent of total billed charges",""
"Fatty Acids Nonesterified","PX-30000433","CDM","82725","CPT","0301","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","86.51","36.5","","72.91","72.91","72.91","1 through 10","13.72","225.15","percent of total billed charges",""
"Fatty Acids Nonesterified","PX-30000433","CDM","82725","CPT","0301","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","90.77","38.3","","238.38","87.40","238.38","1 through 10","13.72","225.15","percent of total billed charges",""
"Fatty Acids Nonesterified","PX-30000433","CDM","82725","CPT","0301","RC","","","","outpatient","","","237.00","177.75","AETNA [1001]","HB AMC AETNA HMO","165.43","69.8","","109.94","109.94","109.94","1 through 10","13.72","193.68","percent of total billed charges",""
"Fatty Acids Nonesterified","PX-30000433","CDM","82725","CPT","0301","RC","","","","outpatient","","","237.00","177.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","193.68","81.72","","183.86","183.86","183.86","1 through 10","13.72","193.68","percent of total billed charges",""
"Fecal Microbiota Prep Instil","PX-75000397","CDM","G0455","HCPCS","0750","RC","","","","both","","","555.00","416.25","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","1 through 10","172.05","1353.25","other","OPPS APC"
"Felbamate, Serum","PX-30003359","CDM","80299","CPT","0310","RC","","","","both","","","102.00","76.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","81.09","79.5","","106.25","71.28","106.25","1 through 10","18.27","96.9","percent of total billed charges",""
"Felbamate, Serum","PX-30003359","CDM","80299","CPT","0310","RC","","","","both","","","102.00","76.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","54.37","53.3","","106.25","71.28","106.25","1 through 10","18.27","96.9","percent of total billed charges",""
"Felbamate, Serum","PX-30003359","CDM","80299","CPT","0310","RC","","","","both","","","102.00","76.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37.23","36.5","","50.36","42.80","92.50","13","18.27","96.9","percent of total billed charges",""
"Felbamate, Serum","PX-30003359","CDM","80299","CPT","0310","RC","","","","both","","","102.00","76.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39.07","38.3","","52.79","44.55","158.37","30","18.27","96.9","percent of total billed charges",""
"Felbamate, Serum","PX-30003359","CDM","80299","CPT","0310","RC","","","","outpatient","","","102.00","76.50","AETNA [1001]","HB AMC AETNA HMO","71.20","69.8","","91.40","64.53","105.30","14","53.31","114.26","percent of total billed charges",""
"Felbamate, Serum","PX-30003359","CDM","80299","CPT","0310","RC","","","","outpatient","","","102.00","76.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","82.01","80.4","","105.30","105.30","105.30","1 through 10","53.31","114.26","percent of total billed charges",""
"Felbamate, Serum","PX-30003359","CDM","80299","CPT","0310","RC","","","","outpatient","","","102.00","76.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","83.35","81.72","","59.36","15.50","59.36","1 through 10","53.31","114.26","percent of total billed charges",""
"Female Reproductive System Infections,MAJOR","531","DRG","","","","","","","","inpatient","","","45242.30","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","34931.05","","Standard inlier is a Case rate ($34,931.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,810, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,958.17) for the length of stay and the standard reimbursement.","34931.05","34931.05","34931.05","1 through 10","4430.1","41677.95","case rate",""
"Female Reproductive System Infections,MAJOR","531","DRG","","","","","","","","inpatient","","","45242.30","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30345.92","","Fee schedule rate ($30,345.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30345.92","30345.92","30345.92","1 through 10","4430.1","41677.95","case rate",""
"Female Reproductive System Infections,MINOR","531","DRG","","","","","","","","inpatient","","","33335.27","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","17329.18","","Standard inlier is a Case rate ($17,329.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,634, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,459.73) for the length of stay and the standard reimbursement.","17329.17","17329.17","17329.17","1 through 10","4430.1","41677.95","case rate",""
"Female Reproductive System Infections,MODERATE","531","DRG","","","","","","","","inpatient","","","43190.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","17329.18","","Standard inlier is a Case rate ($17,329.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,634, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,459.73) for the length of stay and the standard reimbursement.","22623.19","22623.19","22623.19","1 through 10","4430.1","41677.95","case rate",""
"Female Reproductive System Infections,MODERATE","531","DRG","","","","","","","","inpatient","","","43190.09","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11592.8161","","Fee schedule rate ($15,381.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11592.8161","15381.80","15381.80","1 through 10","4430.1","41677.95","case rate",""
"Female Reproductive System Infections,MODERATE","531","DRG","","","","","","","","inpatient","","","43190.09","","MASSHEALTH [3001]","HB BWH MEDICAID","4430.10","","Case rate ($4,898.23). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,328.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6777.29","6777.29","6777.29","1 through 10","4430.1","41677.95","case rate",""
"Female Reproductive System Malignancy,EXTREME","530","DRG","","","","","","","","inpatient","","","165683.80","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14855.33","","Case rate ($16,425.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,855.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16421.09","16421.09","16421.09","1 through 10","6148.21","89777.54","case rate",""
"Female Reproductive System Malignancy,MAJOR","530","DRG","","","","","","","","inpatient","","","109753.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","33023.40","","Fee schedule rate ($33,023.40). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($3,820.96) multiplied by length of stay and the outlier percent (100%).","33023.39","33023.39","33023.39","1 through 10","6148.21","89777.54","case rate",""
"Female Reproductive System Malignancy,MAJOR","530","DRG","","","","","","","","inpatient","","","109753.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","37127.20","","Fee schedule rate ($37,127.20). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($4,295.77) multiplied by length of stay and the outlier percent (100%).","37127.19","37127.19","37127.19","1 through 10","6148.21","89777.54","case rate",""
"Female Reproductive System Malignancy,MAJOR","530","DRG","","","","","","","","inpatient","","","109753.05","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13851.8831","","Fee schedule rate ($33,801.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13851.8831","33801.00","33801.00","1 through 10","6148.21","89777.54","case rate",""
"Female Reproductive System Malignancy,MAJOR","530","DRG","","","","","","","","inpatient","","","109753.05","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15889.5168","","Fee schedule rate ($33,801.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15889.5168","33801.00","33801.00","1 through 10","6148.21","89777.54","case rate",""
"Female Reproductive System Malignancy,MAJOR","530","DRG","","","","","","","","inpatient","","","109753.05","","MASSHEALTH [3001]","HB BWH MEDICAID","11358.55","","Case rate ($12,558.82). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,988.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11104.75","11104.75","11104.75","1 through 10","6148.21","89777.54","case rate",""
"Female Reproductive System Malignancy,MAJOR","530","DRG","","","","","","","","inpatient","","","109753.05","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11358.55","","Case rate ($12,558.82). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,988.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12555.74","12555.74","12555.74","1 through 10","6148.21","89777.54","case rate",""
"Female Reproductive System Malignancy,MODERATE","530","DRG","","","","","","","","inpatient","","","122599.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25535.63","","Standard inlier is a Case rate ($25,535.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,310, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,624.57) for the length of stay and the standard reimbursement.","28968.49","26175.54","30445.70","1 through 10","6148.21","89777.54","case rate",""
"Female Reproductive System Malignancy,MODERATE","530","DRG","","","","","","","","inpatient","","","122599.71","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8523.19","","Case rate ($9,423.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,853.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9421.54","9421.54","9421.54","1 through 10","6148.21","89777.54","case rate",""
"FEMORAL COMPONENT 12MM 3-11 TIB EF ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE-E CRUCIATE RETAINING FIXED LT","SUP-ITM-10114298","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1471.15","52.26","","1113.10","1113.10","1113.10","1 through 10","872.67","2237.96","percent of total billed charges",""
"FEMORAL COMPONENT 12MM 3-11 TIB EF ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE-E CRUCIATE RETAINING FIXED LT","SUP-ITM-10114298","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2237.96","79.5","","1293.60","1148.53","1603.80","1 through 10","872.67","2237.96","percent of total billed charges",""
"FEMORAL COMPONENT 12MM 3-11 TIB EF ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE-E CRUCIATE RETAINING FIXED LT","SUP-ITM-10114298","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1027.49","36.5","","1023.42","771.29","2068.67","33","872.67","2237.96","percent of total billed charges",""
"FEMORAL COMPONENT 12MM 3-11 TIB EF ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE-E CRUCIATE RETAINING FIXED LT","SUP-ITM-10114298","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1078.16","38.3","","850.52","759.78","1211.25","66","872.67","2237.96","percent of total billed charges",""
"FEMORAL COMPONENT 12MM 3-11 TIB EF ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE-E CRUCIATE RETAINING FIXED LT","SUP-ITM-10114298","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1207.66","42.9","","2548.09","2548.09","2548.09","1 through 10","872.67","2237.96","percent of total billed charges",""
"FEMORAL COMPONENT 12MM 3-11 TIB EF ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE-E CRUCIATE RETAINING FIXED LT","SUP-ITM-10114298","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1207.66","42.9","","956.46","956.46","956.46","1 through 10","872.67","2237.96","percent of total billed charges",""
"FEMORAL COMPONENT 12MM 3-11 TIB EF ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE-E CRUCIATE RETAINING FIXED LT","SUP-ITM-10114298","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","WELLPOINT [1015]","HB AMC WELLPOINT","2076.94","73.78","","2344.73","1619.47","2530.35","16","872.67","2237.96","percent of total billed charges",""
"FEMORAL COMPONENT 12MM 3-11 TIB EF ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE-E CRUCIATE RETAINING FIXED LT","SUP-ITM-10114298","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2815.05","2111.29","AETNA [1001]","HB AMC AETNA HMO","1964.90","69.8","","1523.63","988.41","4330.26","39","1471.15","2300.46","percent of total billed charges",""
"FEMORAL COMPONENT 12MM 3-11 TIB EF ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE-E CRUCIATE RETAINING FIXED LT","SUP-ITM-10114298","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2815.05","2111.29","AETNA [1001]","HB AMC AETNA PPO","2263.30","80.4","","1670.25","1670.25","1670.25","1 through 10","1471.15","2300.46","percent of total billed charges",""
"FEMORAL COMPONENT 12MM 3-11 TIB EF ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE-E CRUCIATE RETAINING FIXED LT","SUP-ITM-10114298","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2815.05","2111.29","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1471.15","52.26","","1113.10","1113.10","1113.10","1 through 10","1471.15","2300.46","percent of total billed charges",""
"FEMORAL COMPONENT 12MM 3-11 TIB EF ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE-E CRUCIATE RETAINING FIXED LT","SUP-ITM-10114298","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2815.05","2111.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2300.46","81.72","","1738.90","1484.65","2716.94","38","1471.15","2300.46","percent of total billed charges",""
"FEMORAL COMPONENT 6X3X1MM KNEE ARTICULAR OFFSET","SUP-ITM-10072459","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5226.00","52.26","","1113.10","1113.10","1113.10","1 through 10","3100","7950","percent of total billed charges",""
"FEMORAL COMPONENT 6X3X1MM KNEE ARTICULAR OFFSET","SUP-ITM-10072459","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7950.00","79.5","","1293.60","1148.53","1603.80","1 through 10","3100","7950","percent of total billed charges",""
"FEMORAL COMPONENT 6X3X1MM KNEE ARTICULAR OFFSET","SUP-ITM-10072459","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3650.00","36.5","","1023.42","771.29","2068.67","33","3100","7950","percent of total billed charges",""
"FEMORAL COMPONENT 6X3X1MM KNEE ARTICULAR OFFSET","SUP-ITM-10072459","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3830.00","38.3","","850.52","759.78","1211.25","66","3100","7950","percent of total billed charges",""
"FEMORAL COMPONENT 6X3X1MM KNEE ARTICULAR OFFSET","SUP-ITM-10072459","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4290.00","42.9","","2548.09","2548.09","2548.09","1 through 10","3100","7950","percent of total billed charges",""
"FEMORAL COMPONENT 6X3X1MM KNEE ARTICULAR OFFSET","SUP-ITM-10072459","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4290.00","42.9","","956.46","956.46","956.46","1 through 10","3100","7950","percent of total billed charges",""
"FEMORAL COMPONENT 6X3X1MM KNEE ARTICULAR OFFSET","SUP-ITM-10072459","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB AMC WELLPOINT","7378.00","73.78","","2344.73","1619.47","2530.35","16","3100","7950","percent of total billed charges",""
"FEMORAL COMPONENT 6X3X1MM KNEE ARTICULAR OFFSET","SUP-ITM-10072459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA HMO","6980.00","69.8","","1523.63","988.41","4330.26","39","5226","8172","percent of total billed charges",""
"FEMORAL COMPONENT 6X3X1MM KNEE ARTICULAR OFFSET","SUP-ITM-10072459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA PPO","8040.00","80.4","","1670.25","1670.25","1670.25","1 through 10","5226","8172","percent of total billed charges",""
"FEMORAL COMPONENT 6X3X1MM KNEE ARTICULAR OFFSET","SUP-ITM-10072459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5226.00","52.26","","1113.10","1113.10","1113.10","1 through 10","5226","8172","percent of total billed charges",""
"FEMORAL COMPONENT 6X3X1MM KNEE ARTICULAR OFFSET","SUP-ITM-10072459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8172.00","81.72","","1738.90","1484.65","2716.94","38","5226","8172","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2952.69","52.26","","1113.10","1113.10","1113.10","1 through 10","1751.5","4491.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4491.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1751.5","4491.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2062.25","36.5","","1023.42","771.29","2068.67","33","1751.5","4491.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2163.95","38.3","","850.52","759.78","1211.25","66","1751.5","4491.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2423.85","42.9","","2548.09","2548.09","2548.09","1 through 10","1751.5","4491.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2423.85","42.9","","956.46","956.46","956.46","1 through 10","1751.5","4491.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","WELLPOINT [1015]","HB AMC WELLPOINT","4168.57","73.78","","2344.73","1619.47","2530.35","16","1751.5","4491.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","AETNA [1001]","HB AMC AETNA HMO","3943.70","69.8","","1523.63","988.41","4330.26","39","2952.69","4617.18","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","AETNA [1001]","HB AMC AETNA PPO","4542.60","80.4","","1670.25","1670.25","1670.25","1 through 10","2952.69","4617.18","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2952.69","52.26","","1113.10","1113.10","1113.10","1 through 10","2952.69","4617.18","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4617.18","81.72","","1738.90","1484.65","2716.94","38","2952.69","4617.18","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1023.42","771.29","2068.67","33","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","850.52","759.78","1211.25","66","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","2548.09","2548.09","2548.09","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","956.46","956.46","956.46","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","2344.73","1619.47","2530.35","16","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1523.63","988.41","4330.26","39","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA PPO","4221.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","1738.90","1484.65","2716.94","38","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1193.5","3060.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1193.5","3060.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","1023.42","771.29","2068.67","33","1193.5","3060.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","850.52","759.78","1211.25","66","1193.5","3060.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","2548.09","2548.09","2548.09","1 through 10","1193.5","3060.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","956.46","956.46","956.46","1 through 10","1193.5","3060.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","2344.73","1619.47","2530.35","16","1193.5","3060.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA HMO","2687.30","69.8","","1523.63","988.41","4330.26","39","2012.01","3146.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA PPO","3095.40","80.4","","1670.25","1670.25","1670.25","1 through 10","2012.01","3146.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","2012.01","3146.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","1738.90","1484.65","2716.94","38","2012.01","3146.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1023.42","771.29","2068.67","33","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","850.52","759.78","1211.25","66","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","2548.09","2548.09","2548.09","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","956.46","956.46","956.46","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","2344.73","1619.47","2530.35","16","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1523.63","988.41","4330.26","39","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA PPO","4221.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","1738.90","1484.65","2716.94","38","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1023.42","771.29","2068.67","33","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","850.52","759.78","1211.25","66","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","2548.09","2548.09","2548.09","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","956.46","956.46","956.46","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","2344.73","1619.47","2530.35","16","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1523.63","988.41","4330.26","39","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA PPO","4221.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","1738.90","1484.65","2716.94","38","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307928","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3244.37","52.26","","1113.10","1113.10","1113.10","1 through 10","1924.52","4935.46","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307928","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4935.46","79.5","","1293.60","1148.53","1603.80","1 through 10","1924.52","4935.46","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307928","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2265.97","36.5","","1023.42","771.29","2068.67","33","1924.52","4935.46","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307928","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2377.71","38.3","","850.52","759.78","1211.25","66","1924.52","4935.46","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307928","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2663.29","42.9","","2548.09","2548.09","2548.09","1 through 10","1924.52","4935.46","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307928","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2663.29","42.9","","956.46","956.46","956.46","1 through 10","1924.52","4935.46","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307928","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","WELLPOINT [1015]","HB AMC WELLPOINT","4580.36","73.78","","2344.73","1619.47","2530.35","16","1924.52","4935.46","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307928","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6208.13","4656.10","AETNA [1001]","HB AMC AETNA HMO","4333.27","69.8","","1523.63","988.41","4330.26","39","3244.37","5073.28","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307928","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6208.13","4656.10","AETNA [1001]","HB AMC AETNA PPO","4991.34","80.4","","1670.25","1670.25","1670.25","1 through 10","3244.37","5073.28","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307928","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6208.13","4656.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3244.37","52.26","","1113.10","1113.10","1113.10","1 through 10","3244.37","5073.28","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307928","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6208.13","4656.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5073.28","81.72","","1738.90","1484.65","2716.94","38","3244.37","5073.28","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1023.42","771.29","2068.67","33","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","850.52","759.78","1211.25","66","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","2548.09","2548.09","2548.09","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","956.46","956.46","956.46","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","2344.73","1619.47","2530.35","16","1627.5","4173.75","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1523.63","988.41","4330.26","39","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA PPO","4221.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","1738.90","1484.65","2716.94","38","2743.65","4290.3","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2304.67","52.26","","1113.10","1113.10","1113.10","1 through 10","1367.1","3505.95","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3505.95","79.5","","1293.60","1148.53","1603.80","1 through 10","1367.1","3505.95","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1609.65","36.5","","1023.42","771.29","2068.67","33","1367.1","3505.95","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1689.03","38.3","","850.52","759.78","1211.25","66","1367.1","3505.95","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.89","42.9","","2548.09","2548.09","2548.09","1 through 10","1367.1","3505.95","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.89","42.9","","956.46","956.46","956.46","1 through 10","1367.1","3505.95","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","WELLPOINT [1015]","HB AMC WELLPOINT","3253.70","73.78","","2344.73","1619.47","2530.35","16","1367.1","3505.95","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","AETNA [1001]","HB AMC AETNA HMO","3078.18","69.8","","1523.63","988.41","4330.26","39","2304.67","3603.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","AETNA [1001]","HB AMC AETNA PPO","3545.64","80.4","","1670.25","1670.25","1670.25","1 through 10","2304.67","3603.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2304.67","52.26","","1113.10","1113.10","1113.10","1 through 10","2304.67","3603.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3603.85","81.72","","1738.90","1484.65","2716.94","38","2304.67","3603.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ B LEFT XT DISTAL SEGMENT","SUP-ITM-10041416","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8587.62","52.26","","1113.10","1113.10","1113.10","1 through 10","5094.08","13063.84","percent of total billed charges",""
"FEMORAL COMPONENT SZ B LEFT XT DISTAL SEGMENT","SUP-ITM-10041416","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13063.84","79.5","","1293.60","1148.53","1603.80","1 through 10","5094.08","13063.84","percent of total billed charges",""
"FEMORAL COMPONENT SZ B LEFT XT DISTAL SEGMENT","SUP-ITM-10041416","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5997.86","36.5","","1023.42","771.29","2068.67","33","5094.08","13063.84","percent of total billed charges",""
"FEMORAL COMPONENT SZ B LEFT XT DISTAL SEGMENT","SUP-ITM-10041416","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6293.65","38.3","","850.52","759.78","1211.25","66","5094.08","13063.84","percent of total billed charges",""
"FEMORAL COMPONENT SZ B LEFT XT DISTAL SEGMENT","SUP-ITM-10041416","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7049.54","42.9","","2548.09","2548.09","2548.09","1 through 10","5094.08","13063.84","percent of total billed charges",""
"FEMORAL COMPONENT SZ B LEFT XT DISTAL SEGMENT","SUP-ITM-10041416","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7049.54","42.9","","956.46","956.46","956.46","1 through 10","5094.08","13063.84","percent of total billed charges",""
"FEMORAL COMPONENT SZ B LEFT XT DISTAL SEGMENT","SUP-ITM-10041416","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","WELLPOINT [1015]","HB AMC WELLPOINT","12123.90","73.78","","2344.73","1619.47","2530.35","16","5094.08","13063.84","percent of total billed charges",""
"FEMORAL COMPONENT SZ B LEFT XT DISTAL SEGMENT","SUP-ITM-10041416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","AETNA [1001]","HB AMC AETNA HMO","11469.89","69.8","","1523.63","988.41","4330.26","39","8587.62","13428.64","percent of total billed charges",""
"FEMORAL COMPONENT SZ B LEFT XT DISTAL SEGMENT","SUP-ITM-10041416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","AETNA [1001]","HB AMC AETNA PPO","13211.73","80.4","","1670.25","1670.25","1670.25","1 through 10","8587.62","13428.64","percent of total billed charges",""
"FEMORAL COMPONENT SZ B LEFT XT DISTAL SEGMENT","SUP-ITM-10041416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8587.62","52.26","","1113.10","1113.10","1113.10","1 through 10","8587.62","13428.64","percent of total billed charges",""
"FEMORAL COMPONENT SZ B LEFT XT DISTAL SEGMENT","SUP-ITM-10041416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13428.64","81.72","","1738.90","1484.65","2716.94","38","8587.62","13428.64","percent of total billed charges",""
"FEMORAL COMPONENT SZ Z8 CRS LT REVISION","SUP-ITM-10268444","CDM","C1776","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3658.20","52.26","","1113.10","1113.10","1113.10","1 through 10","2170","5565","percent of total billed charges",""
"FEMORAL COMPONENT SZ Z8 CRS LT REVISION","SUP-ITM-10268444","CDM","C1776","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5565.00","79.5","","1293.60","1148.53","1603.80","1 through 10","2170","5565","percent of total billed charges",""
"FEMORAL COMPONENT SZ Z8 CRS LT REVISION","SUP-ITM-10268444","CDM","C1776","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2555.00","36.5","","1023.42","771.29","2068.67","33","2170","5565","percent of total billed charges",""
"FEMORAL COMPONENT SZ Z8 CRS LT REVISION","SUP-ITM-10268444","CDM","C1776","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2681.00","38.3","","850.52","759.78","1211.25","66","2170","5565","percent of total billed charges",""
"FEMORAL COMPONENT SZ Z8 CRS LT REVISION","SUP-ITM-10268444","CDM","C1776","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3003.00","42.9","","2548.09","2548.09","2548.09","1 through 10","2170","5565","percent of total billed charges",""
"FEMORAL COMPONENT SZ Z8 CRS LT REVISION","SUP-ITM-10268444","CDM","C1776","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3003.00","42.9","","956.46","956.46","956.46","1 through 10","2170","5565","percent of total billed charges",""
"FEMORAL COMPONENT SZ Z8 CRS LT REVISION","SUP-ITM-10268444","CDM","C1776","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","WELLPOINT [1015]","HB AMC WELLPOINT","5164.60","73.78","","2344.73","1619.47","2530.35","16","2170","5565","percent of total billed charges",""
"FEMORAL COMPONENT SZ Z8 CRS LT REVISION","SUP-ITM-10268444","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","AETNA [1001]","HB AMC AETNA HMO","4886.00","69.8","","1523.63","988.41","4330.26","39","3658.2","5720.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ Z8 CRS LT REVISION","SUP-ITM-10268444","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","AETNA [1001]","HB AMC AETNA PPO","5628.00","80.4","","1670.25","1670.25","1670.25","1 through 10","3658.2","5720.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ Z8 CRS LT REVISION","SUP-ITM-10268444","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3658.20","52.26","","1113.10","1113.10","1113.10","1 through 10","3658.2","5720.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ Z8 CRS LT REVISION","SUP-ITM-10268444","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5720.40","81.72","","1738.90","1484.65","2716.94","38","3658.2","5720.4","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 LEFT EMPOWR 3D PRESSFIT","SUP-ITM-10311873","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2665.26","52.26","","1113.10","1113.10","1113.10","1 through 10","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 LEFT EMPOWR 3D PRESSFIT","SUP-ITM-10311873","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4054.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 LEFT EMPOWR 3D PRESSFIT","SUP-ITM-10311873","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1861.50","36.5","","1023.42","771.29","2068.67","33","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 LEFT EMPOWR 3D PRESSFIT","SUP-ITM-10311873","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1953.30","38.3","","850.52","759.78","1211.25","66","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 LEFT EMPOWR 3D PRESSFIT","SUP-ITM-10311873","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2187.90","42.9","","2548.09","2548.09","2548.09","1 through 10","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 LEFT EMPOWR 3D PRESSFIT","SUP-ITM-10311873","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2187.90","42.9","","956.46","956.46","956.46","1 through 10","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 LEFT EMPOWR 3D PRESSFIT","SUP-ITM-10311873","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","WELLPOINT [1015]","HB AMC WELLPOINT","3762.78","73.78","","2344.73","1619.47","2530.35","16","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 LEFT EMPOWR 3D PRESSFIT","SUP-ITM-10311873","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","AETNA [1001]","HB AMC AETNA HMO","3559.80","69.8","","1523.63","988.41","4330.26","39","2665.26","4167.72","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 LEFT EMPOWR 3D PRESSFIT","SUP-ITM-10311873","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","AETNA [1001]","HB AMC AETNA PPO","4100.40","80.4","","1670.25","1670.25","1670.25","1 through 10","2665.26","4167.72","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 LEFT EMPOWR 3D PRESSFIT","SUP-ITM-10311873","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2665.26","52.26","","1113.10","1113.10","1113.10","1 through 10","2665.26","4167.72","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 LEFT EMPOWR 3D PRESSFIT","SUP-ITM-10311873","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4167.72","81.72","","1738.90","1484.65","2716.94","38","2665.26","4167.72","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 RIGHT EMPOWR 3D PRESS FIT","SUP-ITM-10321330","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2665.26","52.26","","1113.10","1113.10","1113.10","1 through 10","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 RIGHT EMPOWR 3D PRESS FIT","SUP-ITM-10321330","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4054.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 RIGHT EMPOWR 3D PRESS FIT","SUP-ITM-10321330","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1861.50","36.5","","1023.42","771.29","2068.67","33","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 RIGHT EMPOWR 3D PRESS FIT","SUP-ITM-10321330","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1953.30","38.3","","850.52","759.78","1211.25","66","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 RIGHT EMPOWR 3D PRESS FIT","SUP-ITM-10321330","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2187.90","42.9","","2548.09","2548.09","2548.09","1 through 10","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 RIGHT EMPOWR 3D PRESS FIT","SUP-ITM-10321330","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2187.90","42.9","","956.46","956.46","956.46","1 through 10","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 RIGHT EMPOWR 3D PRESS FIT","SUP-ITM-10321330","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","WELLPOINT [1015]","HB AMC WELLPOINT","3762.78","73.78","","2344.73","1619.47","2530.35","16","1581","4054.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 RIGHT EMPOWR 3D PRESS FIT","SUP-ITM-10321330","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","AETNA [1001]","HB AMC AETNA HMO","3559.80","69.8","","1523.63","988.41","4330.26","39","2665.26","4167.72","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 RIGHT EMPOWR 3D PRESS FIT","SUP-ITM-10321330","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","AETNA [1001]","HB AMC AETNA PPO","4100.40","80.4","","1670.25","1670.25","1670.25","1 through 10","2665.26","4167.72","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 RIGHT EMPOWR 3D PRESS FIT","SUP-ITM-10321330","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2665.26","52.26","","1113.10","1113.10","1113.10","1 through 10","2665.26","4167.72","percent of total billed charges",""
"FEMORAL COMPONENT SZ6 RIGHT EMPOWR 3D PRESS FIT","SUP-ITM-10321330","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4167.72","81.72","","1738.90","1484.65","2716.94","38","2665.26","4167.72","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","768.22","52.26","","1113.10","1113.10","1113.10","1 through 10","455.7","1168.65","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1168.65","79.5","","1293.60","1148.53","1603.80","1 through 10","455.7","1168.65","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","536.55","36.5","","1023.42","771.29","2068.67","33","455.7","1168.65","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","563.01","38.3","","850.52","759.78","1211.25","66","455.7","1168.65","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","2548.09","2548.09","2548.09","1 through 10","455.7","1168.65","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","956.46","956.46","956.46","1 through 10","455.7","1168.65","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB AMC WELLPOINT","1084.57","73.78","","2344.73","1619.47","2530.35","16","455.7","1168.65","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA HMO","1026.06","69.8","","1523.63","988.41","4330.26","39","768.22","1201.28","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA PPO","1181.88","80.4","","1670.25","1670.25","1670.25","1 through 10","768.22","1201.28","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","768.22","52.26","","1113.10","1113.10","1113.10","1 through 10","768.22","1201.28","percent of total billed charges",""
"FEMORAL HEAD 28MM PLUS 3.5MM 12/14 TAPER HIP VERSYS COBALT","SUP-ITM-10275350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1201.28","81.72","","1738.90","1484.65","2716.94","38","768.22","1201.28","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4902.99","3677.24","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2562.30","52.26","","1113.10","1113.10","1113.10","1 through 10","1519.93","3897.88","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4902.99","3677.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3897.88","79.5","","1293.60","1148.53","1603.80","1 through 10","1519.93","3897.88","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4902.99","3677.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1789.59","36.5","","1023.42","771.29","2068.67","33","1519.93","3897.88","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4902.99","3677.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1877.85","38.3","","850.52","759.78","1211.25","66","1519.93","3897.88","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4902.99","3677.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2103.38","42.9","","2548.09","2548.09","2548.09","1 through 10","1519.93","3897.88","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4902.99","3677.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2103.38","42.9","","956.46","956.46","956.46","1 through 10","1519.93","3897.88","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4902.99","3677.24","WELLPOINT [1015]","HB AMC WELLPOINT","3617.43","73.78","","2344.73","1619.47","2530.35","16","1519.93","3897.88","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4902.99","3677.24","AETNA [1001]","HB AMC AETNA HMO","3422.29","69.8","","1523.63","988.41","4330.26","39","2562.3","4006.72","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4902.99","3677.24","AETNA [1001]","HB AMC AETNA PPO","3942.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2562.3","4006.72","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4902.99","3677.24","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2562.30","52.26","","1113.10","1113.10","1113.10","1 through 10","2562.3","4006.72","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4902.99","3677.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4006.72","81.72","","1738.90","1484.65","2716.94","38","2562.3","4006.72","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","993.20","52.26","","1113.10","1113.10","1113.10","1 through 10","589.16","1510.9","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1510.90","79.5","","1293.60","1148.53","1603.80","1 through 10","589.16","1510.9","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","693.68","36.5","","1023.42","771.29","2068.67","33","589.16","1510.9","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","727.89","38.3","","850.52","759.78","1211.25","66","589.16","1510.9","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","815.31","42.9","","2548.09","2548.09","2548.09","1 through 10","589.16","1510.9","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","815.31","42.9","","956.46","956.46","956.46","1 through 10","589.16","1510.9","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","WELLPOINT [1015]","HB AMC WELLPOINT","1402.19","73.78","","2344.73","1619.47","2530.35","16","589.16","1510.9","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1900.50","1425.37","AETNA [1001]","HB AMC AETNA HMO","1326.55","69.8","","1523.63","988.41","4330.26","39","993.2","1553.09","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1900.50","1425.37","AETNA [1001]","HB AMC AETNA PPO","1528.00","80.4","","1670.25","1670.25","1670.25","1 through 10","993.2","1553.09","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1900.50","1425.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","993.20","52.26","","1113.10","1113.10","1113.10","1 through 10","993.2","1553.09","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1900.50","1425.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1553.09","81.72","","1738.90","1484.65","2716.94","38","993.2","1553.09","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1862.02","52.26","","1113.10","1113.10","1113.10","1 through 10","1104.53","2832.59","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2832.59","79.5","","1293.60","1148.53","1603.80","1 through 10","1104.53","2832.59","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1300.50","36.5","","1023.42","771.29","2068.67","33","1104.53","2832.59","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1364.63","38.3","","850.52","759.78","1211.25","66","1104.53","2832.59","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1528.53","42.9","","2548.09","2548.09","2548.09","1 through 10","1104.53","2832.59","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1528.53","42.9","","956.46","956.46","956.46","1 through 10","1104.53","2832.59","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","WELLPOINT [1015]","HB AMC WELLPOINT","2628.78","73.78","","2344.73","1619.47","2530.35","16","1104.53","2832.59","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3563.00","2672.25","AETNA [1001]","HB AMC AETNA HMO","2486.97","69.8","","1523.63","988.41","4330.26","39","1862.02","2911.68","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3563.00","2672.25","AETNA [1001]","HB AMC AETNA PPO","2864.65","80.4","","1670.25","1670.25","1670.25","1 through 10","1862.02","2911.68","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3563.00","2672.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1862.02","52.26","","1113.10","1113.10","1113.10","1 through 10","1862.02","2911.68","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3563.00","2672.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2911.68","81.72","","1738.90","1484.65","2716.94","38","1862.02","2911.68","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 6MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275361","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2643.78","52.26","","1113.10","1113.10","1113.10","1 through 10","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 6MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275361","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4021.83","79.5","","1293.60","1148.53","1603.80","1 through 10","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 6MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275361","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1846.50","36.5","","1023.42","771.29","2068.67","33","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 6MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275361","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1937.56","38.3","","850.52","759.78","1211.25","66","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 6MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275361","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2170.27","42.9","","2548.09","2548.09","2548.09","1 through 10","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 6MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275361","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2170.27","42.9","","956.46","956.46","956.46","1 through 10","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 6MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275361","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","WELLPOINT [1015]","HB AMC WELLPOINT","3732.46","73.78","","2344.73","1619.47","2530.35","16","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 6MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5058.90","3794.17","AETNA [1001]","HB AMC AETNA HMO","3531.11","69.8","","1523.63","988.41","4330.26","39","2643.78","4134.13","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 6MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5058.90","3794.17","AETNA [1001]","HB AMC AETNA PPO","4067.36","80.4","","1670.25","1670.25","1670.25","1 through 10","2643.78","4134.13","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 6MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5058.90","3794.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2643.78","52.26","","1113.10","1113.10","1113.10","1 through 10","2643.78","4134.13","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 6MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5058.90","3794.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4134.13","81.72","","1738.90","1484.65","2716.94","38","2643.78","4134.13","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 9MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275360","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2643.78","52.26","","1113.10","1113.10","1113.10","1 through 10","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 9MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275360","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4021.83","79.5","","1293.60","1148.53","1603.80","1 through 10","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 9MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275360","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1846.50","36.5","","1023.42","771.29","2068.67","33","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 9MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275360","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1937.56","38.3","","850.52","759.78","1211.25","66","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 9MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275360","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2170.27","42.9","","2548.09","2548.09","2548.09","1 through 10","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 9MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275360","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2170.27","42.9","","956.46","956.46","956.46","1 through 10","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 9MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275360","CDM","C1776","HCPCS","0278","RC","","","","both","","","5058.90","3794.17","WELLPOINT [1015]","HB AMC WELLPOINT","3732.46","73.78","","2344.73","1619.47","2530.35","16","1568.26","4021.83","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 9MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275360","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5058.90","3794.17","AETNA [1001]","HB AMC AETNA HMO","3531.11","69.8","","1523.63","988.41","4330.26","39","2643.78","4134.13","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 9MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275360","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5058.90","3794.17","AETNA [1001]","HB AMC AETNA PPO","4067.36","80.4","","1670.25","1670.25","1670.25","1 through 10","2643.78","4134.13","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 9MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275360","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5058.90","3794.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2643.78","52.26","","1113.10","1113.10","1113.10","1 through 10","2643.78","4134.13","percent of total billed charges",""
"FEMORAL HEAD 36MM PLUS 9MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275360","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5058.90","3794.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4134.13","81.72","","1738.90","1484.65","2716.94","38","2643.78","4134.13","percent of total billed charges",""
"FEMORAL HEAD 41MM SHELL ENDO II TITANIUM ALLOY UNIPOLAR","SUP-ITM-10041995","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","503.00","52.26","","1113.10","1113.10","1113.10","1 through 10","298.38","765.19","percent of total billed charges",""
"FEMORAL HEAD 41MM SHELL ENDO II TITANIUM ALLOY UNIPOLAR","SUP-ITM-10041995","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","765.19","79.5","","1293.60","1148.53","1603.80","1 through 10","298.38","765.19","percent of total billed charges",""
"FEMORAL HEAD 41MM SHELL ENDO II TITANIUM ALLOY UNIPOLAR","SUP-ITM-10041995","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","351.31","36.5","","1023.42","771.29","2068.67","33","298.38","765.19","percent of total billed charges",""
"FEMORAL HEAD 41MM SHELL ENDO II TITANIUM ALLOY UNIPOLAR","SUP-ITM-10041995","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","368.64","38.3","","850.52","759.78","1211.25","66","298.38","765.19","percent of total billed charges",""
"FEMORAL HEAD 41MM SHELL ENDO II TITANIUM ALLOY UNIPOLAR","SUP-ITM-10041995","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","2548.09","2548.09","2548.09","1 through 10","298.38","765.19","percent of total billed charges",""
"FEMORAL HEAD 41MM SHELL ENDO II TITANIUM ALLOY UNIPOLAR","SUP-ITM-10041995","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","956.46","956.46","956.46","1 through 10","298.38","765.19","percent of total billed charges",""
"FEMORAL HEAD 41MM SHELL ENDO II TITANIUM ALLOY UNIPOLAR","SUP-ITM-10041995","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","WELLPOINT [1015]","HB AMC WELLPOINT","710.13","73.78","","2344.73","1619.47","2530.35","16","298.38","765.19","percent of total billed charges",""
"FEMORAL HEAD 41MM SHELL ENDO II TITANIUM ALLOY UNIPOLAR","SUP-ITM-10041995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA HMO","671.83","69.8","","1523.63","988.41","4330.26","39","503","786.56","percent of total billed charges",""
"FEMORAL HEAD 41MM SHELL ENDO II TITANIUM ALLOY UNIPOLAR","SUP-ITM-10041995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA PPO","773.85","80.4","","1670.25","1670.25","1670.25","1 through 10","503","786.56","percent of total billed charges",""
"FEMORAL HEAD 41MM SHELL ENDO II TITANIUM ALLOY UNIPOLAR","SUP-ITM-10041995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","503.00","52.26","","1113.10","1113.10","1113.10","1 through 10","503","786.56","percent of total billed charges",""
"FEMORAL HEAD 41MM SHELL ENDO II TITANIUM ALLOY UNIPOLAR","SUP-ITM-10041995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","786.56","81.72","","1738.90","1484.65","2716.94","38","503","786.56","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4648.76","79.5","","1293.60","1148.53","1603.80","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2134.34","36.5","","1023.42","771.29","2068.67","33","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2239.59","38.3","","850.52","759.78","1211.25","66","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","2548.09","2548.09","2548.09","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","956.46","956.46","956.46","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","WELLPOINT [1015]","HB AMC WELLPOINT","4314.29","73.78","","2344.73","1619.47","2530.35","16","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA HMO","4081.56","69.8","","1523.63","988.41","4330.26","39","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA PPO","4701.39","80.4","","1670.25","1670.25","1670.25","1 through 10","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4778.58","81.72","","1738.90","1484.65","2716.94","38","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4648.76","79.5","","1293.60","1148.53","1603.80","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2134.34","36.5","","1023.42","771.29","2068.67","33","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2239.59","38.3","","850.52","759.78","1211.25","66","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","2548.09","2548.09","2548.09","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","956.46","956.46","956.46","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","WELLPOINT [1015]","HB AMC WELLPOINT","4314.29","73.78","","2344.73","1619.47","2530.35","16","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA HMO","4081.56","69.8","","1523.63","988.41","4330.26","39","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA PPO","4701.39","80.4","","1670.25","1670.25","1670.25","1 through 10","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4778.58","81.72","","1738.90","1484.65","2716.94","38","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4648.76","79.5","","1293.60","1148.53","1603.80","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2134.34","36.5","","1023.42","771.29","2068.67","33","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2239.59","38.3","","850.52","759.78","1211.25","66","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","2548.09","2548.09","2548.09","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","956.46","956.46","956.46","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","WELLPOINT [1015]","HB AMC WELLPOINT","4314.29","73.78","","2344.73","1619.47","2530.35","16","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA HMO","4081.56","69.8","","1523.63","988.41","4330.26","39","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA PPO","4701.39","80.4","","1670.25","1670.25","1670.25","1 through 10","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4778.58","81.72","","1738.90","1484.65","2716.94","38","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4648.76","79.5","","1293.60","1148.53","1603.80","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2134.34","36.5","","1023.42","771.29","2068.67","33","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2239.59","38.3","","850.52","759.78","1211.25","66","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","2548.09","2548.09","2548.09","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","956.46","956.46","956.46","1 through 10","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","WELLPOINT [1015]","HB AMC WELLPOINT","4314.29","73.78","","2344.73","1619.47","2530.35","16","1812.73","4648.76","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA HMO","4081.56","69.8","","1523.63","988.41","4330.26","39","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA PPO","4701.39","80.4","","1670.25","1670.25","1670.25","1 through 10","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4778.58","81.72","","1738.90","1484.65","2716.94","38","3055.9","4778.58","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.00","3064.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.34","52.26","","1113.10","1113.10","1113.10","1 through 10","1266.66","3248.37","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.00","3064.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3248.37","79.5","","1293.60","1148.53","1603.80","1 through 10","1266.66","3248.37","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.00","3064.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1491.39","36.5","","1023.42","771.29","2068.67","33","1266.66","3248.37","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.00","3064.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1564.94","38.3","","850.52","759.78","1211.25","66","1266.66","3248.37","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.00","3064.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1752.89","42.9","","2548.09","2548.09","2548.09","1 through 10","1266.66","3248.37","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.00","3064.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1752.89","42.9","","956.46","956.46","956.46","1 through 10","1266.66","3248.37","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.00","3064.50","WELLPOINT [1015]","HB AMC WELLPOINT","3014.65","73.78","","2344.73","1619.47","2530.35","16","1266.66","3248.37","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.00","3064.50","AETNA [1001]","HB AMC AETNA HMO","2852.03","69.8","","1523.63","988.41","4330.26","39","2135.34","3339.08","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.00","3064.50","AETNA [1001]","HB AMC AETNA PPO","3285.14","80.4","","1670.25","1670.25","1670.25","1 through 10","2135.34","3339.08","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.00","3064.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.34","52.26","","1113.10","1113.10","1113.10","1 through 10","2135.34","3339.08","percent of total billed charges",""
"FEMORAL IMPLANT ITOTAL IDENTITY CR","SUP-ITM-10283844","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.00","3064.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3339.08","81.72","","1738.90","1484.65","2716.94","38","2135.34","3339.08","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1023.42","771.29","2068.67","33","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","850.52","759.78","1211.25","66","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","2548.09","2548.09","2548.09","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","956.46","956.46","956.46","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","2344.73","1619.47","2530.35","16","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1523.63","988.41","4330.26","39","2743.65","4290.3","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA PPO","4221.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2743.65","4290.3","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","2743.65","4290.3","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","1738.90","1484.65","2716.94","38","2743.65","4290.3","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1023.42","771.29","2068.67","33","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","850.52","759.78","1211.25","66","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","2548.09","2548.09","2548.09","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","956.46","956.46","956.46","1 through 10","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","2344.73","1619.47","2530.35","16","1627.5","4173.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1523.63","988.41","4330.26","39","2743.65","4290.3","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA PPO","4221.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2743.65","4290.3","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","2743.65","4290.3","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","1738.90","1484.65","2716.94","38","2743.65","4290.3","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2298.39","52.26","","1113.10","1113.10","1113.10","1 through 10","1363.38","3496.41","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3496.41","79.5","","1293.60","1148.53","1603.80","1 through 10","1363.38","3496.41","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1605.27","36.5","","1023.42","771.29","2068.67","33","1363.38","3496.41","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1684.43","38.3","","850.52","759.78","1211.25","66","1363.38","3496.41","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1886.74","42.9","","2548.09","2548.09","2548.09","1 through 10","1363.38","3496.41","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1886.74","42.9","","956.46","956.46","956.46","1 through 10","1363.38","3496.41","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","WELLPOINT [1015]","HB AMC WELLPOINT","3244.84","73.78","","2344.73","1619.47","2530.35","16","1363.38","3496.41","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4398.00","3298.50","AETNA [1001]","HB AMC AETNA HMO","3069.80","69.8","","1523.63","988.41","4330.26","39","2298.39","3594.05","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4398.00","3298.50","AETNA [1001]","HB AMC AETNA PPO","3535.99","80.4","","1670.25","1670.25","1670.25","1 through 10","2298.39","3594.05","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4398.00","3298.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2298.39","52.26","","1113.10","1113.10","1113.10","1 through 10","2298.39","3594.05","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4398.00","3298.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3594.05","81.72","","1738.90","1484.65","2716.94","38","2298.39","3594.05","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2304.67","52.26","","1113.10","1113.10","1113.10","1 through 10","1367.1","3505.95","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3505.95","79.5","","1293.60","1148.53","1603.80","1 through 10","1367.1","3505.95","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1609.65","36.5","","1023.42","771.29","2068.67","33","1367.1","3505.95","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1689.03","38.3","","850.52","759.78","1211.25","66","1367.1","3505.95","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.89","42.9","","2548.09","2548.09","2548.09","1 through 10","1367.1","3505.95","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.89","42.9","","956.46","956.46","956.46","1 through 10","1367.1","3505.95","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","WELLPOINT [1015]","HB AMC WELLPOINT","3253.70","73.78","","2344.73","1619.47","2530.35","16","1367.1","3505.95","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","AETNA [1001]","HB AMC AETNA HMO","3078.18","69.8","","1523.63","988.41","4330.26","39","2304.67","3603.85","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","AETNA [1001]","HB AMC AETNA PPO","3545.64","80.4","","1670.25","1670.25","1670.25","1 through 10","2304.67","3603.85","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2304.67","52.26","","1113.10","1113.10","1113.10","1 through 10","2304.67","3603.85","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3603.85","81.72","","1738.90","1484.65","2716.94","38","2304.67","3603.85","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8178.69","52.26","","1113.10","1113.10","1113.10","1 through 10","4851.5","12441.75","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12441.75","79.5","","1293.60","1148.53","1603.80","1 through 10","4851.5","12441.75","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5712.25","36.5","","1023.42","771.29","2068.67","33","4851.5","12441.75","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5993.95","38.3","","850.52","759.78","1211.25","66","4851.5","12441.75","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6713.85","42.9","","2548.09","2548.09","2548.09","1 through 10","4851.5","12441.75","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6713.85","42.9","","956.46","956.46","956.46","1 through 10","4851.5","12441.75","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","WELLPOINT [1015]","HB AMC WELLPOINT","11546.57","73.78","","2344.73","1619.47","2530.35","16","4851.5","12441.75","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","AETNA [1001]","HB AMC AETNA HMO","10923.70","69.8","","1523.63","988.41","4330.26","39","8178.69","12789.18","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","AETNA [1001]","HB AMC AETNA PPO","12582.60","80.4","","1670.25","1670.25","1670.25","1 through 10","8178.69","12789.18","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8178.69","52.26","","1113.10","1113.10","1113.10","1 through 10","8178.69","12789.18","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12789.18","81.72","","1738.90","1484.65","2716.94","38","8178.69","12789.18","percent of total billed charges",""
"FEMORAL NAIL 13X360MM RETROGRADE","SUP-ITM-10306510","CDM","C1713","HCPCS","0278","RC","","","","both","","","9059.95","6794.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7202.66","79.5","","800.18","480.96","1887.97","195","2808.58","7202.66","percent of total billed charges",""
"FEMORAL NAIL 13X360MM RETROGRADE","SUP-ITM-10306510","CDM","C1713","HCPCS","0278","RC","","","","both","","","9059.95","6794.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4828.95","53.3","","813.12","216.42","1444.50","81","2808.58","7202.66","percent of total billed charges",""
"FEMORAL NAIL 13X360MM RETROGRADE","SUP-ITM-10306510","CDM","C1713","HCPCS","0278","RC","","","","both","","","9059.95","6794.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2808.58","31","","432.60","432.60","432.60","1 through 10","2808.58","7202.66","percent of total billed charges",""
"FEMORAL NAIL 13X360MM RETROGRADE","SUP-ITM-10306510","CDM","C1713","HCPCS","0278","RC","","","","both","","","9059.95","6794.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3306.88","36.5","","148.37","54.89","631.39","94","2808.58","7202.66","percent of total billed charges",""
"FEMORAL NAIL 13X360MM RETROGRADE","SUP-ITM-10306510","CDM","C1713","HCPCS","0278","RC","","","","both","","","9059.95","6794.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3469.96","38.3","","279.30","91.72","1116.77","266","2808.58","7202.66","percent of total billed charges",""
"FEMORAL NAIL 13X360MM RETROGRADE","SUP-ITM-10306510","CDM","C1713","HCPCS","0278","RC","","","","both","","","9059.95","6794.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3886.72","42.9","","731.00","63.70","731.00","1 through 10","2808.58","7202.66","percent of total billed charges",""
"FEMORAL NAIL 13X360MM RETROGRADE","SUP-ITM-10306510","CDM","C1713","HCPCS","0278","RC","","","","both","","","9059.95","6794.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3886.72","42.9","","384.74","384.74","384.74","1 through 10","2808.58","7202.66","percent of total billed charges",""
"FEMORAL NAIL 13X360MM RETROGRADE","SUP-ITM-10306510","CDM","C1713","HCPCS","0278","RC","","","","both","","","9059.95","6794.96","WELLPOINT [1015]","HB AMC WELLPOINT","6684.43","73.78","","286.63","119.22","1107.45","105","2808.58","7202.66","percent of total billed charges",""
"FEMORAL NAIL 13X360MM RETROGRADE","SUP-ITM-10306510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9059.95","6794.96","AETNA [1001]","HB AMC AETNA HMO","6323.85","69.8","","675.31","184.75","1721.50","286","4734.73","7403.79","percent of total billed charges",""
"FEMORAL NAIL 13X360MM RETROGRADE","SUP-ITM-10306510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9059.95","6794.96","AETNA [1001]","HB AMC AETNA PPO","7284.20","80.4","","1261.44","103.12","1514.10","21","4734.73","7403.79","percent of total billed charges",""
"FEMORAL NAIL 13X360MM RETROGRADE","SUP-ITM-10306510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9059.95","6794.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7284.20","80.4","","1365.00","1365.00","1365.00","1 through 10","4734.73","7403.79","percent of total billed charges",""
"FEMORAL NAIL 13X360MM RETROGRADE","SUP-ITM-10306510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9059.95","6794.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7403.79","81.72","","5157.68","5157.68","5157.68","1 through 10","4734.73","7403.79","percent of total billed charges",""
"FEMORAL NAIL 13X360MM RETROGRADE","SUP-ITM-10306510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9059.95","6794.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7403.79","81.72","","431.26","71.26","1459.57","88","4734.73","7403.79","percent of total billed charges",""
"FEMORAL NAIL TI DUMMY FOR MISS A","SUP-ITM-10039449","CDM","C1889","HCPCS","0278","RC","","","","both","","","1586.27","1189.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1261.08","79.5","","1309.77","674.56","6049.93","26","491.74","1261.08","percent of total billed charges",""
"FEMORAL NAIL TI DUMMY FOR MISS A","SUP-ITM-10039449","CDM","C1889","HCPCS","0278","RC","","","","both","","","1586.27","1189.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","845.48","53.3","","1901.83","1901.83","2962.25","1 through 10","491.74","1261.08","percent of total billed charges",""
"FEMORAL NAIL TI DUMMY FOR MISS A","SUP-ITM-10039449","CDM","C1889","HCPCS","0278","RC","","","","both","","","1586.27","1189.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","578.99","36.5","","1620.31","1620.31","19908.88","1 through 10","491.74","1261.08","percent of total billed charges",""
"FEMORAL NAIL TI DUMMY FOR MISS A","SUP-ITM-10039449","CDM","C1889","HCPCS","0278","RC","","","","both","","","1586.27","1189.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","607.54","38.3","","352.91","352.91","2046.30","1 through 10","491.74","1261.08","percent of total billed charges",""
"FEMORAL NAIL TI DUMMY FOR MISS A","SUP-ITM-10039449","CDM","C1889","HCPCS","0278","RC","","","","both","","","1586.27","1189.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","680.51","42.9","","9668.75","9668.75","9668.75","1 through 10","491.74","1261.08","percent of total billed charges",""
"FEMORAL NAIL TI DUMMY FOR MISS A","SUP-ITM-10039449","CDM","C1889","HCPCS","0278","RC","","","","both","","","1586.27","1189.70","WELLPOINT [1015]","HB AMC WELLPOINT","1170.35","73.78","","699.88","384.10","3443.31","33","491.74","1261.08","percent of total billed charges",""
"FEMORAL NAIL TI DUMMY FOR MISS A","SUP-ITM-10039449","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1586.27","1189.70","AETNA [1001]","HB AMC AETNA HMO","1107.22","69.8","","1421.24","264.50","4933.46","29","828.98","1296.3","percent of total billed charges",""
"FEMORAL NAIL TI DUMMY FOR MISS A","SUP-ITM-10039449","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1586.27","1189.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1275.36","80.4","","1022.97","1022.97","3607.50","1 through 10","828.98","1296.3","percent of total billed charges",""
"FEMORAL NAIL TI DUMMY FOR MISS A","SUP-ITM-10039449","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1586.27","1189.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1296.30","81.72","","3010.54","693.88","5019.88","35","828.98","1296.3","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 5 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236310","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 5 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236310","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 5 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236310","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 5 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236310","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 5 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236310","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 5 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236310","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 5 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236310","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 5 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236310","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 5 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236310","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 5 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236310","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 5 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236310","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"FEMORAL ROD 20CM ARCOS OSS IM","SUP-ITM-10202228","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5448.83","79.5","","800.18","480.96","1887.97","195","2124.7","5448.83","percent of total billed charges",""
"FEMORAL ROD 20CM ARCOS OSS IM","SUP-ITM-10202228","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3653.12","53.3","","813.12","216.42","1444.50","81","2124.7","5448.83","percent of total billed charges",""
"FEMORAL ROD 20CM ARCOS OSS IM","SUP-ITM-10202228","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2124.70","31","","432.60","432.60","432.60","1 through 10","2124.7","5448.83","percent of total billed charges",""
"FEMORAL ROD 20CM ARCOS OSS IM","SUP-ITM-10202228","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2501.67","36.5","","148.37","54.89","631.39","94","2124.7","5448.83","percent of total billed charges",""
"FEMORAL ROD 20CM ARCOS OSS IM","SUP-ITM-10202228","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2625.04","38.3","","279.30","91.72","1116.77","266","2124.7","5448.83","percent of total billed charges",""
"FEMORAL ROD 20CM ARCOS OSS IM","SUP-ITM-10202228","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2940.31","42.9","","731.00","63.70","731.00","1 through 10","2124.7","5448.83","percent of total billed charges",""
"FEMORAL ROD 20CM ARCOS OSS IM","SUP-ITM-10202228","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2940.31","42.9","","384.74","384.74","384.74","1 through 10","2124.7","5448.83","percent of total billed charges",""
"FEMORAL ROD 20CM ARCOS OSS IM","SUP-ITM-10202228","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","WELLPOINT [1015]","HB AMC WELLPOINT","5056.79","73.78","","286.63","119.22","1107.45","105","2124.7","5448.83","percent of total billed charges",""
"FEMORAL ROD 20CM ARCOS OSS IM","SUP-ITM-10202228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","AETNA [1001]","HB AMC AETNA HMO","4784.01","69.8","","675.31","184.75","1721.50","286","3581.84","5600.99","percent of total billed charges",""
"FEMORAL ROD 20CM ARCOS OSS IM","SUP-ITM-10202228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","AETNA [1001]","HB AMC AETNA PPO","5510.52","80.4","","1261.44","103.12","1514.10","21","3581.84","5600.99","percent of total billed charges",""
"FEMORAL ROD 20CM ARCOS OSS IM","SUP-ITM-10202228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5510.52","80.4","","1365.00","1365.00","1365.00","1 through 10","3581.84","5600.99","percent of total billed charges",""
"FEMORAL ROD 20CM ARCOS OSS IM","SUP-ITM-10202228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5600.99","81.72","","5157.68","5157.68","5157.68","1 through 10","3581.84","5600.99","percent of total billed charges",""
"FEMORAL ROD 20CM ARCOS OSS IM","SUP-ITM-10202228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5600.99","81.72","","431.26","71.26","1459.57","88","3581.84","5600.99","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2939.63","52.26","","1113.10","1113.10","1113.10","1 through 10","1743.75","4471.88","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4471.88","79.5","","1293.60","1148.53","1603.80","1 through 10","1743.75","4471.88","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2053.13","36.5","","1023.42","771.29","2068.67","33","1743.75","4471.88","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2154.38","38.3","","850.52","759.78","1211.25","66","1743.75","4471.88","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2413.13","42.9","","2548.09","2548.09","2548.09","1 through 10","1743.75","4471.88","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2413.13","42.9","","956.46","956.46","956.46","1 through 10","1743.75","4471.88","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","WELLPOINT [1015]","HB AMC WELLPOINT","4150.13","73.78","","2344.73","1619.47","2530.35","16","1743.75","4471.88","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","AETNA [1001]","HB AMC AETNA HMO","3926.25","69.8","","1523.63","988.41","4330.26","39","2939.63","4596.75","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","AETNA [1001]","HB AMC AETNA PPO","4522.50","80.4","","1670.25","1670.25","1670.25","1 through 10","2939.63","4596.75","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2939.63","52.26","","1113.10","1113.10","1113.10","1 through 10","2939.63","4596.75","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4596.75","81.72","","1738.90","1484.65","2716.94","38","2939.63","4596.75","percent of total billed charges",""
"FEMORAL STEM L 130MM OD 16 EXTENDER RT SEGMENTAL VARIABLE STIFFNESS PRECOAT STRT IMPL NEXGEN","SUP-ITM-10077261","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5597.05","52.26","","1113.10","1113.10","1113.10","1 through 10","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 130MM OD 16 EXTENDER RT SEGMENTAL VARIABLE STIFFNESS PRECOAT STRT IMPL NEXGEN","SUP-ITM-10077261","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8514.45","79.5","","1293.60","1148.53","1603.80","1 through 10","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 130MM OD 16 EXTENDER RT SEGMENTAL VARIABLE STIFFNESS PRECOAT STRT IMPL NEXGEN","SUP-ITM-10077261","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3909.15","36.5","","1023.42","771.29","2068.67","33","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 130MM OD 16 EXTENDER RT SEGMENTAL VARIABLE STIFFNESS PRECOAT STRT IMPL NEXGEN","SUP-ITM-10077261","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4101.93","38.3","","850.52","759.78","1211.25","66","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 130MM OD 16 EXTENDER RT SEGMENTAL VARIABLE STIFFNESS PRECOAT STRT IMPL NEXGEN","SUP-ITM-10077261","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","2548.09","2548.09","2548.09","1 through 10","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 130MM OD 16 EXTENDER RT SEGMENTAL VARIABLE STIFFNESS PRECOAT STRT IMPL NEXGEN","SUP-ITM-10077261","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","956.46","956.46","956.46","1 through 10","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 130MM OD 16 EXTENDER RT SEGMENTAL VARIABLE STIFFNESS PRECOAT STRT IMPL NEXGEN","SUP-ITM-10077261","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","WELLPOINT [1015]","HB AMC WELLPOINT","7901.84","73.78","","2344.73","1619.47","2530.35","16","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 130MM OD 16 EXTENDER RT SEGMENTAL VARIABLE STIFFNESS PRECOAT STRT IMPL NEXGEN","SUP-ITM-10077261","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA HMO","7475.58","69.8","","1523.63","988.41","4330.26","39","5597.05","8752.21","percent of total billed charges",""
"FEMORAL STEM L 130MM OD 16 EXTENDER RT SEGMENTAL VARIABLE STIFFNESS PRECOAT STRT IMPL NEXGEN","SUP-ITM-10077261","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA PPO","8610.84","80.4","","1670.25","1670.25","1670.25","1 through 10","5597.05","8752.21","percent of total billed charges",""
"FEMORAL STEM L 130MM OD 16 EXTENDER RT SEGMENTAL VARIABLE STIFFNESS PRECOAT STRT IMPL NEXGEN","SUP-ITM-10077261","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5597.05","52.26","","1113.10","1113.10","1113.10","1 through 10","5597.05","8752.21","percent of total billed charges",""
"FEMORAL STEM L 130MM OD 16 EXTENDER RT SEGMENTAL VARIABLE STIFFNESS PRECOAT STRT IMPL NEXGEN","SUP-ITM-10077261","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8752.21","81.72","","1738.90","1484.65","2716.94","38","5597.05","8752.21","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 14 EXTENDER SEGMENTAL FLUTED CEMENTED PRECOAT STRT IMPL NEXGEN","SUP-ITM-10025553","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5597.05","52.26","","1113.10","1113.10","1113.10","1 through 10","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 14 EXTENDER SEGMENTAL FLUTED CEMENTED PRECOAT STRT IMPL NEXGEN","SUP-ITM-10025553","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8514.45","79.5","","1293.60","1148.53","1603.80","1 through 10","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 14 EXTENDER SEGMENTAL FLUTED CEMENTED PRECOAT STRT IMPL NEXGEN","SUP-ITM-10025553","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3909.15","36.5","","1023.42","771.29","2068.67","33","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 14 EXTENDER SEGMENTAL FLUTED CEMENTED PRECOAT STRT IMPL NEXGEN","SUP-ITM-10025553","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4101.93","38.3","","850.52","759.78","1211.25","66","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 14 EXTENDER SEGMENTAL FLUTED CEMENTED PRECOAT STRT IMPL NEXGEN","SUP-ITM-10025553","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","2548.09","2548.09","2548.09","1 through 10","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 14 EXTENDER SEGMENTAL FLUTED CEMENTED PRECOAT STRT IMPL NEXGEN","SUP-ITM-10025553","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","956.46","956.46","956.46","1 through 10","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 14 EXTENDER SEGMENTAL FLUTED CEMENTED PRECOAT STRT IMPL NEXGEN","SUP-ITM-10025553","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","WELLPOINT [1015]","HB AMC WELLPOINT","7901.84","73.78","","2344.73","1619.47","2530.35","16","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 14 EXTENDER SEGMENTAL FLUTED CEMENTED PRECOAT STRT IMPL NEXGEN","SUP-ITM-10025553","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA HMO","7475.58","69.8","","1523.63","988.41","4330.26","39","5597.05","8752.21","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 14 EXTENDER SEGMENTAL FLUTED CEMENTED PRECOAT STRT IMPL NEXGEN","SUP-ITM-10025553","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA PPO","8610.84","80.4","","1670.25","1670.25","1670.25","1 through 10","5597.05","8752.21","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 14 EXTENDER SEGMENTAL FLUTED CEMENTED PRECOAT STRT IMPL NEXGEN","SUP-ITM-10025553","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5597.05","52.26","","1113.10","1113.10","1113.10","1 through 10","5597.05","8752.21","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 14 EXTENDER SEGMENTAL FLUTED CEMENTED PRECOAT STRT IMPL NEXGEN","SUP-ITM-10025553","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8752.21","81.72","","1738.90","1484.65","2716.94","38","5597.05","8752.21","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 19 EXTENDER SEGMENTAL VARIABLE STIFFNESS PRECOAT BOWED IMPL NEXGEN","SUP-ITM-10082672","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5597.05","52.26","","1113.10","1113.10","1113.10","1 through 10","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 19 EXTENDER SEGMENTAL VARIABLE STIFFNESS PRECOAT BOWED IMPL NEXGEN","SUP-ITM-10082672","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8514.45","79.5","","1293.60","1148.53","1603.80","1 through 10","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 19 EXTENDER SEGMENTAL VARIABLE STIFFNESS PRECOAT BOWED IMPL NEXGEN","SUP-ITM-10082672","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3909.15","36.5","","1023.42","771.29","2068.67","33","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 19 EXTENDER SEGMENTAL VARIABLE STIFFNESS PRECOAT BOWED IMPL NEXGEN","SUP-ITM-10082672","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4101.93","38.3","","850.52","759.78","1211.25","66","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 19 EXTENDER SEGMENTAL VARIABLE STIFFNESS PRECOAT BOWED IMPL NEXGEN","SUP-ITM-10082672","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","2548.09","2548.09","2548.09","1 through 10","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 19 EXTENDER SEGMENTAL VARIABLE STIFFNESS PRECOAT BOWED IMPL NEXGEN","SUP-ITM-10082672","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","956.46","956.46","956.46","1 through 10","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 19 EXTENDER SEGMENTAL VARIABLE STIFFNESS PRECOAT BOWED IMPL NEXGEN","SUP-ITM-10082672","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","WELLPOINT [1015]","HB AMC WELLPOINT","7901.84","73.78","","2344.73","1619.47","2530.35","16","3320.1","8514.45","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 19 EXTENDER SEGMENTAL VARIABLE STIFFNESS PRECOAT BOWED IMPL NEXGEN","SUP-ITM-10082672","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA HMO","7475.58","69.8","","1523.63","988.41","4330.26","39","5597.05","8752.21","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 19 EXTENDER SEGMENTAL VARIABLE STIFFNESS PRECOAT BOWED IMPL NEXGEN","SUP-ITM-10082672","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA PPO","8610.84","80.4","","1670.25","1670.25","1670.25","1 through 10","5597.05","8752.21","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 19 EXTENDER SEGMENTAL VARIABLE STIFFNESS PRECOAT BOWED IMPL NEXGEN","SUP-ITM-10082672","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5597.05","52.26","","1113.10","1113.10","1113.10","1 through 10","5597.05","8752.21","percent of total billed charges",""
"FEMORAL STEM L 190MM OD 19 EXTENDER SEGMENTAL VARIABLE STIFFNESS PRECOAT BOWED IMPL NEXGEN","SUP-ITM-10082672","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8752.21","81.72","","1738.90","1484.65","2716.94","38","5597.05","8752.21","percent of total billed charges",""
"FEMORAL STEM ROTATING HINGE PROX MOST BASIC LT","SUP-ITM-10042948","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8178.69","52.26","","1113.10","1113.10","1113.10","1 through 10","4851.5","12441.75","percent of total billed charges",""
"FEMORAL STEM ROTATING HINGE PROX MOST BASIC LT","SUP-ITM-10042948","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12441.75","79.5","","1293.60","1148.53","1603.80","1 through 10","4851.5","12441.75","percent of total billed charges",""
"FEMORAL STEM ROTATING HINGE PROX MOST BASIC LT","SUP-ITM-10042948","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5712.25","36.5","","1023.42","771.29","2068.67","33","4851.5","12441.75","percent of total billed charges",""
"FEMORAL STEM ROTATING HINGE PROX MOST BASIC LT","SUP-ITM-10042948","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5993.95","38.3","","850.52","759.78","1211.25","66","4851.5","12441.75","percent of total billed charges",""
"FEMORAL STEM ROTATING HINGE PROX MOST BASIC LT","SUP-ITM-10042948","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6713.85","42.9","","2548.09","2548.09","2548.09","1 through 10","4851.5","12441.75","percent of total billed charges",""
"FEMORAL STEM ROTATING HINGE PROX MOST BASIC LT","SUP-ITM-10042948","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6713.85","42.9","","956.46","956.46","956.46","1 through 10","4851.5","12441.75","percent of total billed charges",""
"FEMORAL STEM ROTATING HINGE PROX MOST BASIC LT","SUP-ITM-10042948","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","WELLPOINT [1015]","HB AMC WELLPOINT","11546.57","73.78","","2344.73","1619.47","2530.35","16","4851.5","12441.75","percent of total billed charges",""
"FEMORAL STEM ROTATING HINGE PROX MOST BASIC LT","SUP-ITM-10042948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","AETNA [1001]","HB AMC AETNA HMO","10923.70","69.8","","1523.63","988.41","4330.26","39","8178.69","12789.18","percent of total billed charges",""
"FEMORAL STEM ROTATING HINGE PROX MOST BASIC LT","SUP-ITM-10042948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","AETNA [1001]","HB AMC AETNA PPO","12582.60","80.4","","1670.25","1670.25","1670.25","1 through 10","8178.69","12789.18","percent of total billed charges",""
"FEMORAL STEM ROTATING HINGE PROX MOST BASIC LT","SUP-ITM-10042948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8178.69","52.26","","1113.10","1113.10","1113.10","1 through 10","8178.69","12789.18","percent of total billed charges",""
"FEMORAL STEM ROTATING HINGE PROX MOST BASIC LT","SUP-ITM-10042948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12789.18","81.72","","1738.90","1484.65","2716.94","38","8178.69","12789.18","percent of total billed charges",""
"FEMORAL STEM SZ 10 135DEG HIP RESTORIS METAFIX CEMENTLESS STANDARD","SUP-ITM-10079871","CDM","C1776","HCPCS","0278","RC","","","","both","","","4797.50","3598.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2507.17","52.26","","1113.10","1113.10","1113.10","1 through 10","1487.23","3814.01","percent of total billed charges",""
"FEMORAL STEM SZ 10 135DEG HIP RESTORIS METAFIX CEMENTLESS STANDARD","SUP-ITM-10079871","CDM","C1776","HCPCS","0278","RC","","","","both","","","4797.50","3598.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3814.01","79.5","","1293.60","1148.53","1603.80","1 through 10","1487.23","3814.01","percent of total billed charges",""
"FEMORAL STEM SZ 10 135DEG HIP RESTORIS METAFIX CEMENTLESS STANDARD","SUP-ITM-10079871","CDM","C1776","HCPCS","0278","RC","","","","both","","","4797.50","3598.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1751.09","36.5","","1023.42","771.29","2068.67","33","1487.23","3814.01","percent of total billed charges",""
"FEMORAL STEM SZ 10 135DEG HIP RESTORIS METAFIX CEMENTLESS STANDARD","SUP-ITM-10079871","CDM","C1776","HCPCS","0278","RC","","","","both","","","4797.50","3598.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1837.44","38.3","","850.52","759.78","1211.25","66","1487.23","3814.01","percent of total billed charges",""
"FEMORAL STEM SZ 10 135DEG HIP RESTORIS METAFIX CEMENTLESS STANDARD","SUP-ITM-10079871","CDM","C1776","HCPCS","0278","RC","","","","both","","","4797.50","3598.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2058.13","42.9","","2548.09","2548.09","2548.09","1 through 10","1487.23","3814.01","percent of total billed charges",""
"FEMORAL STEM SZ 10 135DEG HIP RESTORIS METAFIX CEMENTLESS STANDARD","SUP-ITM-10079871","CDM","C1776","HCPCS","0278","RC","","","","both","","","4797.50","3598.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2058.13","42.9","","956.46","956.46","956.46","1 through 10","1487.23","3814.01","percent of total billed charges",""
"FEMORAL STEM SZ 10 135DEG HIP RESTORIS METAFIX CEMENTLESS STANDARD","SUP-ITM-10079871","CDM","C1776","HCPCS","0278","RC","","","","both","","","4797.50","3598.12","WELLPOINT [1015]","HB AMC WELLPOINT","3539.60","73.78","","2344.73","1619.47","2530.35","16","1487.23","3814.01","percent of total billed charges",""
"FEMORAL STEM SZ 10 135DEG HIP RESTORIS METAFIX CEMENTLESS STANDARD","SUP-ITM-10079871","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4797.50","3598.12","AETNA [1001]","HB AMC AETNA HMO","3348.66","69.8","","1523.63","988.41","4330.26","39","2507.17","3920.52","percent of total billed charges",""
"FEMORAL STEM SZ 10 135DEG HIP RESTORIS METAFIX CEMENTLESS STANDARD","SUP-ITM-10079871","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4797.50","3598.12","AETNA [1001]","HB AMC AETNA PPO","3857.19","80.4","","1670.25","1670.25","1670.25","1 through 10","2507.17","3920.52","percent of total billed charges",""
"FEMORAL STEM SZ 10 135DEG HIP RESTORIS METAFIX CEMENTLESS STANDARD","SUP-ITM-10079871","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4797.50","3598.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2507.17","52.26","","1113.10","1113.10","1113.10","1 through 10","2507.17","3920.52","percent of total billed charges",""
"FEMORAL STEM SZ 10 135DEG HIP RESTORIS METAFIX CEMENTLESS STANDARD","SUP-ITM-10079871","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4797.50","3598.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3920.52","81.72","","1738.90","1484.65","2716.94","38","2507.17","3920.52","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 10.7MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329989","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46038.45","79.5","","800.18","480.96","1887.97","195","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 10.7MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329989","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","30866.03","53.3","","813.12","216.42","1444.50","81","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 10.7MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329989","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","17952.10","31","","432.60","432.60","432.60","1 through 10","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 10.7MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329989","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21137.15","36.5","","148.37","54.89","631.39","94","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 10.7MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329989","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22179.53","38.3","","279.30","91.72","1116.77","266","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 10.7MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329989","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24843.39","42.9","","731.00","63.70","731.00","1 through 10","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 10.7MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329989","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24843.39","42.9","","384.74","384.74","384.74","1 through 10","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 10.7MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329989","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","WELLPOINT [1015]","HB AMC WELLPOINT","42726.00","73.78","","286.63","119.22","1107.45","105","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 10.7MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57910.00","43432.50","AETNA [1001]","HB AMC AETNA HMO","40421.18","69.8","","675.31","184.75","1721.50","286","30263.77","47324.05","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 10.7MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57910.00","43432.50","AETNA [1001]","HB AMC AETNA PPO","46559.64","80.4","","1261.44","103.12","1514.10","21","30263.77","47324.05","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 10.7MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57910.00","43432.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","46559.64","80.4","","1365.00","1365.00","1365.00","1 through 10","30263.77","47324.05","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 10.7MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57910.00","43432.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","47324.05","81.72","","5157.68","5157.68","5157.68","1 through 10","30263.77","47324.05","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 10.7MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57910.00","43432.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","47324.05","81.72","","431.26","71.26","1459.57","88","30263.77","47324.05","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 12.5MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329996","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46038.45","79.5","","800.18","480.96","1887.97","195","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 12.5MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329996","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","30866.03","53.3","","813.12","216.42","1444.50","81","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 12.5MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329996","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","17952.10","31","","432.60","432.60","432.60","1 through 10","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 12.5MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329996","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21137.15","36.5","","148.37","54.89","631.39","94","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 12.5MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329996","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22179.53","38.3","","279.30","91.72","1116.77","266","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 12.5MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329996","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24843.39","42.9","","731.00","63.70","731.00","1 through 10","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 12.5MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329996","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24843.39","42.9","","384.74","384.74","384.74","1 through 10","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 12.5MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329996","CDM","C1713","HCPCS","0278","RC","","","","both","","","57910.00","43432.50","WELLPOINT [1015]","HB AMC WELLPOINT","42726.00","73.78","","286.63","119.22","1107.45","105","17952.1","46038.45","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 12.5MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57910.00","43432.50","AETNA [1001]","HB AMC AETNA HMO","40421.18","69.8","","675.31","184.75","1721.50","286","30263.77","47324.05","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 12.5MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57910.00","43432.50","AETNA [1001]","HB AMC AETNA PPO","46559.64","80.4","","1261.44","103.12","1514.10","21","30263.77","47324.05","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 12.5MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57910.00","43432.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","46559.64","80.4","","1365.00","1365.00","1365.00","1 through 10","30263.77","47324.05","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 12.5MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57910.00","43432.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","47324.05","81.72","","5157.68","5157.68","5157.68","1 through 10","30263.77","47324.05","percent of total billed charges",""
"FEMUR ANTEGRADE TROCH 12.5MM DIAMETER 50MM DIST 215MM EA","SUP-ITM-10329996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57910.00","43432.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","47324.05","81.72","","431.26","71.26","1459.57","88","30263.77","47324.05","percent of total billed charges",""
"FEMUR HEAD 236MM DELTA OPTION CERAMIC","SUP-ITM-10206951","CDM","C1776","HCPCS","0278","RC","","","","both","","","5111.25","3833.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2671.14","52.26","","1113.10","1113.10","1113.10","1 through 10","1584.49","4063.44","percent of total billed charges",""
"FEMUR HEAD 236MM DELTA OPTION CERAMIC","SUP-ITM-10206951","CDM","C1776","HCPCS","0278","RC","","","","both","","","5111.25","3833.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4063.44","79.5","","1293.60","1148.53","1603.80","1 through 10","1584.49","4063.44","percent of total billed charges",""
"FEMUR HEAD 236MM DELTA OPTION CERAMIC","SUP-ITM-10206951","CDM","C1776","HCPCS","0278","RC","","","","both","","","5111.25","3833.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1865.61","36.5","","1023.42","771.29","2068.67","33","1584.49","4063.44","percent of total billed charges",""
"FEMUR HEAD 236MM DELTA OPTION CERAMIC","SUP-ITM-10206951","CDM","C1776","HCPCS","0278","RC","","","","both","","","5111.25","3833.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1957.61","38.3","","850.52","759.78","1211.25","66","1584.49","4063.44","percent of total billed charges",""
"FEMUR HEAD 236MM DELTA OPTION CERAMIC","SUP-ITM-10206951","CDM","C1776","HCPCS","0278","RC","","","","both","","","5111.25","3833.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2192.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1584.49","4063.44","percent of total billed charges",""
"FEMUR HEAD 236MM DELTA OPTION CERAMIC","SUP-ITM-10206951","CDM","C1776","HCPCS","0278","RC","","","","both","","","5111.25","3833.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2192.73","42.9","","956.46","956.46","956.46","1 through 10","1584.49","4063.44","percent of total billed charges",""
"FEMUR HEAD 236MM DELTA OPTION CERAMIC","SUP-ITM-10206951","CDM","C1776","HCPCS","0278","RC","","","","both","","","5111.25","3833.44","WELLPOINT [1015]","HB AMC WELLPOINT","3771.08","73.78","","2344.73","1619.47","2530.35","16","1584.49","4063.44","percent of total billed charges",""
"FEMUR HEAD 236MM DELTA OPTION CERAMIC","SUP-ITM-10206951","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5111.25","3833.44","AETNA [1001]","HB AMC AETNA HMO","3567.65","69.8","","1523.63","988.41","4330.26","39","2671.14","4176.91","percent of total billed charges",""
"FEMUR HEAD 236MM DELTA OPTION CERAMIC","SUP-ITM-10206951","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5111.25","3833.44","AETNA [1001]","HB AMC AETNA PPO","4109.45","80.4","","1670.25","1670.25","1670.25","1 through 10","2671.14","4176.91","percent of total billed charges",""
"FEMUR HEAD 236MM DELTA OPTION CERAMIC","SUP-ITM-10206951","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5111.25","3833.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2671.14","52.26","","1113.10","1113.10","1113.10","1 through 10","2671.14","4176.91","percent of total billed charges",""
"FEMUR HEAD 236MM DELTA OPTION CERAMIC","SUP-ITM-10206951","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5111.25","3833.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4176.91","81.72","","1738.90","1484.65","2716.94","38","2671.14","4176.91","percent of total billed charges",""
"FEMUR HEAD GRAFT BONE ALLOGRAFT PROXIMALIMAL FEMORAL FROZEN SIZE VARIES","SUP-ITM-10010300","CDM","C1889","HCPCS","0278","RC","","","","both","","","10851.03","8138.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8626.57","79.5","","1309.77","674.56","6049.93","26","3363.82","8626.57","percent of total billed charges",""
"FEMUR HEAD GRAFT BONE ALLOGRAFT PROXIMALIMAL FEMORAL FROZEN SIZE VARIES","SUP-ITM-10010300","CDM","C1889","HCPCS","0278","RC","","","","both","","","10851.03","8138.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5783.60","53.3","","1901.83","1901.83","2962.25","1 through 10","3363.82","8626.57","percent of total billed charges",""
"FEMUR HEAD GRAFT BONE ALLOGRAFT PROXIMALIMAL FEMORAL FROZEN SIZE VARIES","SUP-ITM-10010300","CDM","C1889","HCPCS","0278","RC","","","","both","","","10851.03","8138.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3960.63","36.5","","1620.31","1620.31","19908.88","1 through 10","3363.82","8626.57","percent of total billed charges",""
"FEMUR HEAD GRAFT BONE ALLOGRAFT PROXIMALIMAL FEMORAL FROZEN SIZE VARIES","SUP-ITM-10010300","CDM","C1889","HCPCS","0278","RC","","","","both","","","10851.03","8138.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4155.94","38.3","","352.91","352.91","2046.30","1 through 10","3363.82","8626.57","percent of total billed charges",""
"FEMUR HEAD GRAFT BONE ALLOGRAFT PROXIMALIMAL FEMORAL FROZEN SIZE VARIES","SUP-ITM-10010300","CDM","C1889","HCPCS","0278","RC","","","","both","","","10851.03","8138.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4655.09","42.9","","9668.75","9668.75","9668.75","1 through 10","3363.82","8626.57","percent of total billed charges",""
"FEMUR HEAD GRAFT BONE ALLOGRAFT PROXIMALIMAL FEMORAL FROZEN SIZE VARIES","SUP-ITM-10010300","CDM","C1889","HCPCS","0278","RC","","","","both","","","10851.03","8138.27","WELLPOINT [1015]","HB AMC WELLPOINT","8005.89","73.78","","699.88","384.10","3443.31","33","3363.82","8626.57","percent of total billed charges",""
"FEMUR HEAD GRAFT BONE ALLOGRAFT PROXIMALIMAL FEMORAL FROZEN SIZE VARIES","SUP-ITM-10010300","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10851.03","8138.27","AETNA [1001]","HB AMC AETNA HMO","7574.02","69.8","","1421.24","264.50","4933.46","29","5670.75","8867.46","percent of total billed charges",""
"FEMUR HEAD GRAFT BONE ALLOGRAFT PROXIMALIMAL FEMORAL FROZEN SIZE VARIES","SUP-ITM-10010300","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10851.03","8138.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8724.23","80.4","","1022.97","1022.97","3607.50","1 through 10","5670.75","8867.46","percent of total billed charges",""
"FEMUR HEAD GRAFT BONE ALLOGRAFT PROXIMALIMAL FEMORAL FROZEN SIZE VARIES","SUP-ITM-10010300","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10851.03","8138.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8867.46","81.72","","3010.54","693.88","5019.88","35","5670.75","8867.46","percent of total billed charges",""
"FEMUR PLATE 156MM 5 HOLE BONE LOCKING COMPRESSION DISTAL RT TITANIUM","SUP-ITM-10040376","CDM","C1713","HCPCS","0278","RC","","","","both","","","4383.96","3287.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3485.25","79.5","","800.18","480.96","1887.97","195","1359.03","3485.25","percent of total billed charges",""
"FEMUR PLATE 156MM 5 HOLE BONE LOCKING COMPRESSION DISTAL RT TITANIUM","SUP-ITM-10040376","CDM","C1713","HCPCS","0278","RC","","","","both","","","4383.96","3287.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2336.65","53.3","","813.12","216.42","1444.50","81","1359.03","3485.25","percent of total billed charges",""
"FEMUR PLATE 156MM 5 HOLE BONE LOCKING COMPRESSION DISTAL RT TITANIUM","SUP-ITM-10040376","CDM","C1713","HCPCS","0278","RC","","","","both","","","4383.96","3287.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1359.03","31","","432.60","432.60","432.60","1 through 10","1359.03","3485.25","percent of total billed charges",""
"FEMUR PLATE 156MM 5 HOLE BONE LOCKING COMPRESSION DISTAL RT TITANIUM","SUP-ITM-10040376","CDM","C1713","HCPCS","0278","RC","","","","both","","","4383.96","3287.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1600.15","36.5","","148.37","54.89","631.39","94","1359.03","3485.25","percent of total billed charges",""
"FEMUR PLATE 156MM 5 HOLE BONE LOCKING COMPRESSION DISTAL RT TITANIUM","SUP-ITM-10040376","CDM","C1713","HCPCS","0278","RC","","","","both","","","4383.96","3287.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1679.06","38.3","","279.30","91.72","1116.77","266","1359.03","3485.25","percent of total billed charges",""
"FEMUR PLATE 156MM 5 HOLE BONE LOCKING COMPRESSION DISTAL RT TITANIUM","SUP-ITM-10040376","CDM","C1713","HCPCS","0278","RC","","","","both","","","4383.96","3287.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1880.72","42.9","","731.00","63.70","731.00","1 through 10","1359.03","3485.25","percent of total billed charges",""
"FEMUR PLATE 156MM 5 HOLE BONE LOCKING COMPRESSION DISTAL RT TITANIUM","SUP-ITM-10040376","CDM","C1713","HCPCS","0278","RC","","","","both","","","4383.96","3287.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1880.72","42.9","","384.74","384.74","384.74","1 through 10","1359.03","3485.25","percent of total billed charges",""
"FEMUR PLATE 156MM 5 HOLE BONE LOCKING COMPRESSION DISTAL RT TITANIUM","SUP-ITM-10040376","CDM","C1713","HCPCS","0278","RC","","","","both","","","4383.96","3287.97","WELLPOINT [1015]","HB AMC WELLPOINT","3234.49","73.78","","286.63","119.22","1107.45","105","1359.03","3485.25","percent of total billed charges",""
"FEMUR PLATE 156MM 5 HOLE BONE LOCKING COMPRESSION DISTAL RT TITANIUM","SUP-ITM-10040376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4383.96","3287.97","AETNA [1001]","HB AMC AETNA HMO","3060.00","69.8","","675.31","184.75","1721.50","286","2291.06","3582.57","percent of total billed charges",""
"FEMUR PLATE 156MM 5 HOLE BONE LOCKING COMPRESSION DISTAL RT TITANIUM","SUP-ITM-10040376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4383.96","3287.97","AETNA [1001]","HB AMC AETNA PPO","3524.70","80.4","","1261.44","103.12","1514.10","21","2291.06","3582.57","percent of total billed charges",""
"FEMUR PLATE 156MM 5 HOLE BONE LOCKING COMPRESSION DISTAL RT TITANIUM","SUP-ITM-10040376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4383.96","3287.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3524.70","80.4","","1365.00","1365.00","1365.00","1 through 10","2291.06","3582.57","percent of total billed charges",""
"FEMUR PLATE 156MM 5 HOLE BONE LOCKING COMPRESSION DISTAL RT TITANIUM","SUP-ITM-10040376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4383.96","3287.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3582.57","81.72","","5157.68","5157.68","5157.68","1 through 10","2291.06","3582.57","percent of total billed charges",""
"FEMUR PLATE 156MM 5 HOLE BONE LOCKING COMPRESSION DISTAL RT TITANIUM","SUP-ITM-10040376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4383.96","3287.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3582.57","81.72","","431.26","71.26","1459.57","88","2291.06","3582.57","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE FEMORAL DISTAL LCP RIGHT TITANIUM","SUP-ITM-10040380","CDM","C1713","HCPCS","0278","RC","","","","both","","","4471.43","3353.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3554.79","79.5","","800.18","480.96","1887.97","195","1386.14","3554.79","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE FEMORAL DISTAL LCP RIGHT TITANIUM","SUP-ITM-10040380","CDM","C1713","HCPCS","0278","RC","","","","both","","","4471.43","3353.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2383.27","53.3","","813.12","216.42","1444.50","81","1386.14","3554.79","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE FEMORAL DISTAL LCP RIGHT TITANIUM","SUP-ITM-10040380","CDM","C1713","HCPCS","0278","RC","","","","both","","","4471.43","3353.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1386.14","31","","432.60","432.60","432.60","1 through 10","1386.14","3554.79","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE FEMORAL DISTAL LCP RIGHT TITANIUM","SUP-ITM-10040380","CDM","C1713","HCPCS","0278","RC","","","","both","","","4471.43","3353.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1632.07","36.5","","148.37","54.89","631.39","94","1386.14","3554.79","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE FEMORAL DISTAL LCP RIGHT TITANIUM","SUP-ITM-10040380","CDM","C1713","HCPCS","0278","RC","","","","both","","","4471.43","3353.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1712.56","38.3","","279.30","91.72","1116.77","266","1386.14","3554.79","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE FEMORAL DISTAL LCP RIGHT TITANIUM","SUP-ITM-10040380","CDM","C1713","HCPCS","0278","RC","","","","both","","","4471.43","3353.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1918.24","42.9","","731.00","63.70","731.00","1 through 10","1386.14","3554.79","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE FEMORAL DISTAL LCP RIGHT TITANIUM","SUP-ITM-10040380","CDM","C1713","HCPCS","0278","RC","","","","both","","","4471.43","3353.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1918.24","42.9","","384.74","384.74","384.74","1 through 10","1386.14","3554.79","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE FEMORAL DISTAL LCP RIGHT TITANIUM","SUP-ITM-10040380","CDM","C1713","HCPCS","0278","RC","","","","both","","","4471.43","3353.57","WELLPOINT [1015]","HB AMC WELLPOINT","3299.02","73.78","","286.63","119.22","1107.45","105","1386.14","3554.79","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE FEMORAL DISTAL LCP RIGHT TITANIUM","SUP-ITM-10040380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4471.43","3353.57","AETNA [1001]","HB AMC AETNA HMO","3121.06","69.8","","675.31","184.75","1721.50","286","2336.77","3654.05","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE FEMORAL DISTAL LCP RIGHT TITANIUM","SUP-ITM-10040380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4471.43","3353.57","AETNA [1001]","HB AMC AETNA PPO","3595.03","80.4","","1261.44","103.12","1514.10","21","2336.77","3654.05","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE FEMORAL DISTAL LCP RIGHT TITANIUM","SUP-ITM-10040380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4471.43","3353.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3595.03","80.4","","1365.00","1365.00","1365.00","1 through 10","2336.77","3654.05","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE FEMORAL DISTAL LCP RIGHT TITANIUM","SUP-ITM-10040380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4471.43","3353.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3654.05","81.72","","5157.68","5157.68","5157.68","1 through 10","2336.77","3654.05","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE FEMORAL DISTAL LCP RIGHT TITANIUM","SUP-ITM-10040380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4471.43","3353.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3654.05","81.72","","431.26","71.26","1459.57","88","2336.77","3654.05","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3915.27","2936.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3112.64","79.5","","800.18","480.96","1887.97","195","1213.73","3112.64","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3915.27","2936.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2086.84","53.3","","813.12","216.42","1444.50","81","1213.73","3112.64","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3915.27","2936.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1213.73","31","","432.60","432.60","432.60","1 through 10","1213.73","3112.64","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3915.27","2936.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1429.07","36.5","","148.37","54.89","631.39","94","1213.73","3112.64","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3915.27","2936.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1499.55","38.3","","279.30","91.72","1116.77","266","1213.73","3112.64","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3915.27","2936.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1679.65","42.9","","731.00","63.70","731.00","1 through 10","1213.73","3112.64","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3915.27","2936.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1679.65","42.9","","384.74","384.74","384.74","1 through 10","1213.73","3112.64","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","both","","","3915.27","2936.45","WELLPOINT [1015]","HB AMC WELLPOINT","2888.69","73.78","","286.63","119.22","1107.45","105","1213.73","3112.64","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3915.27","2936.45","AETNA [1001]","HB AMC AETNA HMO","2732.86","69.8","","675.31","184.75","1721.50","286","2046.12","3199.56","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3915.27","2936.45","AETNA [1001]","HB AMC AETNA PPO","3147.88","80.4","","1261.44","103.12","1514.10","21","2046.12","3199.56","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3915.27","2936.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3147.88","80.4","","1365.00","1365.00","1365.00","1 through 10","2046.12","3199.56","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3915.27","2936.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3199.56","81.72","","5157.68","5157.68","5157.68","1 through 10","2046.12","3199.56","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM","SUP-ITM-10040384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3915.27","2936.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3199.56","81.72","","431.26","71.26","1459.57","88","2046.12","3199.56","percent of total billed charges",""
"FEMUR PLATE 246MM 9 HOLE SHAFT BONE NCB TITANIUM DISTAL LEFT","SUP-ITM-10030468","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.48","3195.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3387.08","79.5","","800.18","480.96","1887.97","195","1320.75","3387.08","percent of total billed charges",""
"FEMUR PLATE 246MM 9 HOLE SHAFT BONE NCB TITANIUM DISTAL LEFT","SUP-ITM-10030468","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.48","3195.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2270.84","53.3","","813.12","216.42","1444.50","81","1320.75","3387.08","percent of total billed charges",""
"FEMUR PLATE 246MM 9 HOLE SHAFT BONE NCB TITANIUM DISTAL LEFT","SUP-ITM-10030468","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.48","3195.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1320.75","31","","432.60","432.60","432.60","1 through 10","1320.75","3387.08","percent of total billed charges",""
"FEMUR PLATE 246MM 9 HOLE SHAFT BONE NCB TITANIUM DISTAL LEFT","SUP-ITM-10030468","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.48","3195.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1555.08","36.5","","148.37","54.89","631.39","94","1320.75","3387.08","percent of total billed charges",""
"FEMUR PLATE 246MM 9 HOLE SHAFT BONE NCB TITANIUM DISTAL LEFT","SUP-ITM-10030468","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.48","3195.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1631.76","38.3","","279.30","91.72","1116.77","266","1320.75","3387.08","percent of total billed charges",""
"FEMUR PLATE 246MM 9 HOLE SHAFT BONE NCB TITANIUM DISTAL LEFT","SUP-ITM-10030468","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.48","3195.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1827.75","42.9","","731.00","63.70","731.00","1 through 10","1320.75","3387.08","percent of total billed charges",""
"FEMUR PLATE 246MM 9 HOLE SHAFT BONE NCB TITANIUM DISTAL LEFT","SUP-ITM-10030468","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.48","3195.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1827.75","42.9","","384.74","384.74","384.74","1 through 10","1320.75","3387.08","percent of total billed charges",""
"FEMUR PLATE 246MM 9 HOLE SHAFT BONE NCB TITANIUM DISTAL LEFT","SUP-ITM-10030468","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.48","3195.36","WELLPOINT [1015]","HB AMC WELLPOINT","3143.38","73.78","","286.63","119.22","1107.45","105","1320.75","3387.08","percent of total billed charges",""
"FEMUR PLATE 246MM 9 HOLE SHAFT BONE NCB TITANIUM DISTAL LEFT","SUP-ITM-10030468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.48","3195.36","AETNA [1001]","HB AMC AETNA HMO","2973.82","69.8","","675.31","184.75","1721.50","286","2226.53","3481.66","percent of total billed charges",""
"FEMUR PLATE 246MM 9 HOLE SHAFT BONE NCB TITANIUM DISTAL LEFT","SUP-ITM-10030468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.48","3195.36","AETNA [1001]","HB AMC AETNA PPO","3425.43","80.4","","1261.44","103.12","1514.10","21","2226.53","3481.66","percent of total billed charges",""
"FEMUR PLATE 246MM 9 HOLE SHAFT BONE NCB TITANIUM DISTAL LEFT","SUP-ITM-10030468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.48","3195.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3425.43","80.4","","1365.00","1365.00","1365.00","1 through 10","2226.53","3481.66","percent of total billed charges",""
"FEMUR PLATE 246MM 9 HOLE SHAFT BONE NCB TITANIUM DISTAL LEFT","SUP-ITM-10030468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.48","3195.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3481.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2226.53","3481.66","percent of total billed charges",""
"FEMUR PLATE 246MM 9 HOLE SHAFT BONE NCB TITANIUM DISTAL LEFT","SUP-ITM-10030468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.48","3195.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3481.66","81.72","","431.26","71.26","1459.57","88","2226.53","3481.66","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL LEFT","SUP-ITM-10040390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.10","3255.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3450.38","79.5","","800.18","480.96","1887.97","195","1345.43","3450.38","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL LEFT","SUP-ITM-10040390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.10","3255.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2313.27","53.3","","813.12","216.42","1444.50","81","1345.43","3450.38","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL LEFT","SUP-ITM-10040390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.10","3255.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1345.43","31","","432.60","432.60","432.60","1 through 10","1345.43","3450.38","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL LEFT","SUP-ITM-10040390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.10","3255.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1584.14","36.5","","148.37","54.89","631.39","94","1345.43","3450.38","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL LEFT","SUP-ITM-10040390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.10","3255.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1662.26","38.3","","279.30","91.72","1116.77","266","1345.43","3450.38","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL LEFT","SUP-ITM-10040390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.10","3255.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1861.90","42.9","","731.00","63.70","731.00","1 through 10","1345.43","3450.38","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL LEFT","SUP-ITM-10040390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.10","3255.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1861.90","42.9","","384.74","384.74","384.74","1 through 10","1345.43","3450.38","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL LEFT","SUP-ITM-10040390","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.10","3255.07","WELLPOINT [1015]","HB AMC WELLPOINT","3202.13","73.78","","286.63","119.22","1107.45","105","1345.43","3450.38","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL LEFT","SUP-ITM-10040390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4340.10","3255.07","AETNA [1001]","HB AMC AETNA HMO","3029.39","69.8","","675.31","184.75","1721.50","286","2268.14","3546.73","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL LEFT","SUP-ITM-10040390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4340.10","3255.07","AETNA [1001]","HB AMC AETNA PPO","3489.44","80.4","","1261.44","103.12","1514.10","21","2268.14","3546.73","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL LEFT","SUP-ITM-10040390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4340.10","3255.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3489.44","80.4","","1365.00","1365.00","1365.00","1 through 10","2268.14","3546.73","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL LEFT","SUP-ITM-10040390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4340.10","3255.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3546.73","81.72","","5157.68","5157.68","5157.68","1 through 10","2268.14","3546.73","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL LEFT","SUP-ITM-10040390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4340.10","3255.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3546.73","81.72","","431.26","71.26","1459.57","88","2268.14","3546.73","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL RIGHT","SUP-ITM-10040388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.24","2992.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3172.24","79.5","","800.18","480.96","1887.97","195","1236.97","3172.24","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL RIGHT","SUP-ITM-10040388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.24","2992.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2126.80","53.3","","813.12","216.42","1444.50","81","1236.97","3172.24","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL RIGHT","SUP-ITM-10040388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.24","2992.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1236.97","31","","432.60","432.60","432.60","1 through 10","1236.97","3172.24","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL RIGHT","SUP-ITM-10040388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.24","2992.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1456.44","36.5","","148.37","54.89","631.39","94","1236.97","3172.24","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL RIGHT","SUP-ITM-10040388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.24","2992.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1528.26","38.3","","279.30","91.72","1116.77","266","1236.97","3172.24","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL RIGHT","SUP-ITM-10040388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.24","2992.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1711.81","42.9","","731.00","63.70","731.00","1 through 10","1236.97","3172.24","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL RIGHT","SUP-ITM-10040388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.24","2992.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1711.81","42.9","","384.74","384.74","384.74","1 through 10","1236.97","3172.24","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL RIGHT","SUP-ITM-10040388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.24","2992.68","WELLPOINT [1015]","HB AMC WELLPOINT","2944.00","73.78","","286.63","119.22","1107.45","105","1236.97","3172.24","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL RIGHT","SUP-ITM-10040388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.24","2992.68","AETNA [1001]","HB AMC AETNA HMO","2785.19","69.8","","675.31","184.75","1721.50","286","2085.3","3260.82","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL RIGHT","SUP-ITM-10040388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.24","2992.68","AETNA [1001]","HB AMC AETNA PPO","3208.15","80.4","","1261.44","103.12","1514.10","21","2085.3","3260.82","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL RIGHT","SUP-ITM-10040388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.24","2992.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3208.15","80.4","","1365.00","1365.00","1365.00","1 through 10","2085.3","3260.82","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL RIGHT","SUP-ITM-10040388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.24","2992.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3260.82","81.72","","5157.68","5157.68","5157.68","1 through 10","2085.3","3260.82","percent of total billed charges",""
"FEMUR PLATE 276MM 11 HOLE BONE TITANIUM LOCKING COMPRESSION DISTAL FEMORAL RIGHT","SUP-ITM-10040388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.24","2992.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3260.82","81.72","","431.26","71.26","1459.57","88","2085.3","3260.82","percent of total billed charges",""
"FEMUR PLATE 4.5MM 8 HOLE LOCKING LEG CONTOUR COMPRESSION RIGHT","SUP-ITM-10130414","CDM","C1713","HCPCS","0278","RC","","","","both","","","9462.50","7096.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7522.69","79.5","","800.18","480.96","1887.97","195","2933.38","7522.69","percent of total billed charges",""
"FEMUR PLATE 4.5MM 8 HOLE LOCKING LEG CONTOUR COMPRESSION RIGHT","SUP-ITM-10130414","CDM","C1713","HCPCS","0278","RC","","","","both","","","9462.50","7096.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5043.51","53.3","","813.12","216.42","1444.50","81","2933.38","7522.69","percent of total billed charges",""
"FEMUR PLATE 4.5MM 8 HOLE LOCKING LEG CONTOUR COMPRESSION RIGHT","SUP-ITM-10130414","CDM","C1713","HCPCS","0278","RC","","","","both","","","9462.50","7096.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2933.38","31","","432.60","432.60","432.60","1 through 10","2933.38","7522.69","percent of total billed charges",""
"FEMUR PLATE 4.5MM 8 HOLE LOCKING LEG CONTOUR COMPRESSION RIGHT","SUP-ITM-10130414","CDM","C1713","HCPCS","0278","RC","","","","both","","","9462.50","7096.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3453.81","36.5","","148.37","54.89","631.39","94","2933.38","7522.69","percent of total billed charges",""
"FEMUR PLATE 4.5MM 8 HOLE LOCKING LEG CONTOUR COMPRESSION RIGHT","SUP-ITM-10130414","CDM","C1713","HCPCS","0278","RC","","","","both","","","9462.50","7096.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3624.14","38.3","","279.30","91.72","1116.77","266","2933.38","7522.69","percent of total billed charges",""
"FEMUR PLATE 4.5MM 8 HOLE LOCKING LEG CONTOUR COMPRESSION RIGHT","SUP-ITM-10130414","CDM","C1713","HCPCS","0278","RC","","","","both","","","9462.50","7096.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4059.41","42.9","","731.00","63.70","731.00","1 through 10","2933.38","7522.69","percent of total billed charges",""
"FEMUR PLATE 4.5MM 8 HOLE LOCKING LEG CONTOUR COMPRESSION RIGHT","SUP-ITM-10130414","CDM","C1713","HCPCS","0278","RC","","","","both","","","9462.50","7096.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4059.41","42.9","","384.74","384.74","384.74","1 through 10","2933.38","7522.69","percent of total billed charges",""
"FEMUR PLATE 4.5MM 8 HOLE LOCKING LEG CONTOUR COMPRESSION RIGHT","SUP-ITM-10130414","CDM","C1713","HCPCS","0278","RC","","","","both","","","9462.50","7096.87","WELLPOINT [1015]","HB AMC WELLPOINT","6981.43","73.78","","286.63","119.22","1107.45","105","2933.38","7522.69","percent of total billed charges",""
"FEMUR PLATE 4.5MM 8 HOLE LOCKING LEG CONTOUR COMPRESSION RIGHT","SUP-ITM-10130414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9462.50","7096.87","AETNA [1001]","HB AMC AETNA HMO","6604.83","69.8","","675.31","184.75","1721.50","286","4945.1","7732.76","percent of total billed charges",""
"FEMUR PLATE 4.5MM 8 HOLE LOCKING LEG CONTOUR COMPRESSION RIGHT","SUP-ITM-10130414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9462.50","7096.87","AETNA [1001]","HB AMC AETNA PPO","7607.85","80.4","","1261.44","103.12","1514.10","21","4945.1","7732.76","percent of total billed charges",""
"FEMUR PLATE 4.5MM 8 HOLE LOCKING LEG CONTOUR COMPRESSION RIGHT","SUP-ITM-10130414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9462.50","7096.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7607.85","80.4","","1365.00","1365.00","1365.00","1 through 10","4945.1","7732.76","percent of total billed charges",""
"FEMUR PLATE 4.5MM 8 HOLE LOCKING LEG CONTOUR COMPRESSION RIGHT","SUP-ITM-10130414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9462.50","7096.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7732.76","81.72","","5157.68","5157.68","5157.68","1 through 10","4945.1","7732.76","percent of total billed charges",""
"FEMUR PLATE 4.5MM 8 HOLE LOCKING LEG CONTOUR COMPRESSION RIGHT","SUP-ITM-10130414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9462.50","7096.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7732.76","81.72","","431.26","71.26","1459.57","88","4945.1","7732.76","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2031.23","79.5","","800.18","480.96","1887.97","195","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1361.82","53.3","","813.12","216.42","1444.50","81","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","792.05","31","","432.60","432.60","432.60","1 through 10","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","932.58","36.5","","148.37","54.89","631.39","94","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","978.57","38.3","","279.30","91.72","1116.77","266","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1096.10","42.9","","731.00","63.70","731.00","1 through 10","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1096.10","42.9","","384.74","384.74","384.74","1 through 10","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","WELLPOINT [1015]","HB AMC WELLPOINT","1885.08","73.78","","286.63","119.22","1107.45","105","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","AETNA [1001]","HB AMC AETNA HMO","1783.39","69.8","","675.31","184.75","1721.50","286","1335.24","2087.95","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","AETNA [1001]","HB AMC AETNA PPO","2054.22","80.4","","1261.44","103.12","1514.10","21","1335.24","2087.95","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2054.22","80.4","","1365.00","1365.00","1365.00","1 through 10","1335.24","2087.95","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2087.95","81.72","","5157.68","5157.68","5157.68","1 through 10","1335.24","2087.95","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2087.95","81.72","","431.26","71.26","1459.57","88","1335.24","2087.95","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2031.23","79.5","","800.18","480.96","1887.97","195","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1361.82","53.3","","813.12","216.42","1444.50","81","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","792.05","31","","432.60","432.60","432.60","1 through 10","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","932.58","36.5","","148.37","54.89","631.39","94","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","978.57","38.3","","279.30","91.72","1116.77","266","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1096.10","42.9","","731.00","63.70","731.00","1 through 10","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1096.10","42.9","","384.74","384.74","384.74","1 through 10","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","WELLPOINT [1015]","HB AMC WELLPOINT","1885.08","73.78","","286.63","119.22","1107.45","105","792.05","2031.23","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","AETNA [1001]","HB AMC AETNA HMO","1783.39","69.8","","675.31","184.75","1721.50","286","1335.24","2087.95","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","AETNA [1001]","HB AMC AETNA PPO","2054.22","80.4","","1261.44","103.12","1514.10","21","1335.24","2087.95","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2054.22","80.4","","1365.00","1365.00","1365.00","1 through 10","1335.24","2087.95","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2087.95","81.72","","5157.68","5157.68","5157.68","1 through 10","1335.24","2087.95","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2087.95","81.72","","431.26","71.26","1459.57","88","1335.24","2087.95","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5112.33","52.26","","1113.10","1113.10","1113.10","1 through 10","3032.58","7777.09","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7777.09","79.5","","1293.60","1148.53","1603.80","1 through 10","3032.58","7777.09","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3570.61","36.5","","1023.42","771.29","2068.67","33","3032.58","7777.09","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3746.70","38.3","","850.52","759.78","1211.25","66","3032.58","7777.09","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4196.69","42.9","","2548.09","2548.09","2548.09","1 through 10","3032.58","7777.09","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4196.69","42.9","","956.46","956.46","956.46","1 through 10","3032.58","7777.09","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","WELLPOINT [1015]","HB AMC WELLPOINT","7217.53","73.78","","2344.73","1619.47","2530.35","16","3032.58","7777.09","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9782.50","7336.87","AETNA [1001]","HB AMC AETNA HMO","6828.19","69.8","","1523.63","988.41","4330.26","39","5112.33","7994.26","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9782.50","7336.87","AETNA [1001]","HB AMC AETNA PPO","7865.13","80.4","","1670.25","1670.25","1670.25","1 through 10","5112.33","7994.26","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9782.50","7336.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5112.33","52.26","","1113.10","1113.10","1113.10","1 through 10","5112.33","7994.26","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9782.50","7336.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7994.26","81.72","","1738.90","1484.65","2716.94","38","5112.33","7994.26","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","5.37","71.8","","7.81","5.39","7.81","1 through 10","2.08","5.76","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4.91","65.6","","5.81","5.04","14.74","16","2.08","5.76","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4.86","65","","4.95","3.46","9.45","16","2.08","5.76","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","5.24","70","","7.45","3.35","13.94","87","2.08","5.76","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","5.76","77","","5.39","3.71","8.35","1 through 10","2.08","5.76","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4.86","65","","5.73","1.53","14.42","24","2.08","5.76","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2.32","31","","2.58","0.72","5.61","26","2.08","5.76","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2.73","36.5","","2.80","1.54","8.34","584","2.08","5.76","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2.86","38.3","","2.94","1.88","8.74","1524","2.08","5.76","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","5.76","77","","13.60","3.36","13.60","1 through 10","2.08","5.76","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","outpatient","","","7.48","5.61","AETNA [1001]","HB AMC AETNA HMO","5.22","69.8","","5.04","2.30","8.20","934","2.06","6.01","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","outpatient","","","7.48","5.61","AETNA [1001]","HB AMC AETNA PPO","6.01","80.4","","5.81","3.74","10.09","82","2.06","6.01","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","outpatient","","","7.48","5.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5.23","69.9","","10.03","0.06","392.51","2174","2.06","6.01","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","outpatient","","","7.48","5.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3.51","46.9","","8.70","2.54","15.05","700","2.06","6.01","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","outpatient","","","7.48","5.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6.01","80.4","","5.85","2.37","10.31","31","2.06","6.01","percent of total billed charges",""
"Fentanyl Amp 50mcg/Ml 2ml (0.1mg)","PX-63600181","CDM","J3010","HCPCS","0636","RC","","","","outpatient","","","7.48","5.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","5.23","69.9","","5.86","1.09","16.19","1 through 10","2.06","6.01","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","5.37","71.8","","7.81","5.39","7.81","1 through 10","2.08","5.76","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4.91","65.6","","5.81","5.04","14.74","16","2.08","5.76","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4.86","65","","4.95","3.46","9.45","16","2.08","5.76","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","5.24","70","","7.45","3.35","13.94","87","2.08","5.76","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","5.76","77","","5.39","3.71","8.35","1 through 10","2.08","5.76","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4.86","65","","5.73","1.53","14.42","24","2.08","5.76","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2.32","31","","2.58","0.72","5.61","26","2.08","5.76","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2.73","36.5","","2.80","1.54","8.34","584","2.08","5.76","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2.86","38.3","","2.94","1.88","8.74","1524","2.08","5.76","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","both","","","7.48","5.61","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","5.76","77","","13.60","3.36","13.60","1 through 10","2.08","5.76","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","outpatient","","","7.48","5.61","AETNA [1001]","HB AMC AETNA HMO","5.22","69.8","","5.04","2.30","8.20","934","2.06","6.01","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","outpatient","","","7.48","5.61","AETNA [1001]","HB AMC AETNA PPO","6.01","80.4","","5.81","3.74","10.09","82","2.06","6.01","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","outpatient","","","7.48","5.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5.23","69.9","","10.03","0.06","392.51","2174","2.06","6.01","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","outpatient","","","7.48","5.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3.51","46.9","","8.70","2.54","15.05","700","2.06","6.01","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","outpatient","","","7.48","5.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6.01","80.4","","5.85","2.37","10.31","31","2.06","6.01","percent of total billed charges",""
"Fentanyl Citrate Injeciton","PX-63601081","CDM","J3010","HCPCS","0636","RC","","","","outpatient","","","7.48","5.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","5.23","69.9","","5.86","1.09","16.19","1 through 10","2.06","6.01","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","127.09","71.8","","123.50","67.25","370.50","21","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","115.05","65","","111.80","90.82","111.80","1 through 10","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","123.90","70","","123.84","73.96","516.00","24","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","140.72","79.5","","135.36","90.82","135.36","805","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","94.34","53.3","","90.82","90.82","216.14","394","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","136.29","77","","397.32","132.44","397.32","1 through 10","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","115.05","65","","111.80","52.00","125.45","1 through 10","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","140.72","79.5","","135.36","135.36","135.36","1 through 10","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.87","31","","53.15","53.15","159.45","23","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.61","36.5","","64.16","54.52","163.56","762","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.79","38.3","","67.25","65.36","196.08","2684","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","MOLINA [1014]","HB BWH MOLINA","61.95","35","","27.04","26.72","27.04","1 through 10","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","136.29","77","","134.15","134.15","134.15","1 through 10","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","TRICARE [160005]","HB BWH TRICARE","168.15","95","","15.60","15.60","16.42","39","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.93","42.9","","137.50","75.63","309.50","37","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","177.00","132.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.93","42.9","","75.63","75.63","137.50","1 through 10","13.36","168.15","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","177.00","132.75","AETNA [1001]","HB AMC AETNA HMO","123.55","69.8","","116.44","82.22","134.16","1182","14.05","144.64","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","177.00","132.75","AETNA [1001]","HB AMC AETNA PPO","142.31","80.4","","134.16","90.13","134.16","112","14.05","144.64","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","177.00","132.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","98.94","55.9","","90.13","90.13","90.13","1 through 10","14.05","144.64","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","177.00","132.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","92.50","52.26","","48.46","48.46","172.00","19","14.05","144.64","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","177.00","132.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","142.31","80.4","","86.00","86.00","134.16","1 through 10","14.05","144.64","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","177.00","132.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","144.64","81.72","","137.50","137.50","137.50","1 through 10","14.05","144.64","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","144.64","81.72","","137.50","75.63","137.50","25","14.05","144.64","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","144.64","81.72","","137.50","75.63","137.50","786","14.05","144.64","percent of total billed charges",""
"Ferumoxytol Inj 1mg for Esrd","PX-63600247","CDM","Q0139","HCPCS","0636","RC","","","","both","","","3.15","2.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1.15","36.5","","10.69","10.69","10.69","1114","0.29","2.43","percent of total billed charges",""
"Ferumoxytol Inj 1mg for Esrd","PX-63600247","CDM","Q0139","HCPCS","0636","RC","","","","outpatient","","","3.15","2.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2.53","80.4","","0.89","0.87","0.89","2040","0.6","2.53","percent of total billed charges",""
"Ferumoxytol Inj 1mg Non Esrd","PX-63600246","CDM","Q0138","HCPCS","0636","RC","","","","both","","","3.15","2.36","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","0.41","","APC Price ($0.32). Final payment is multiplied by 125%.","0.32","0.32","0.32","1020","0.29","2.43","other","OPPS APC"
"Ferumoxytol Inj 1mg Non Esrd","PX-63600246","CDM","Q0138","HCPCS","0636","RC","","","","both","","","3.15","2.36","ELDER SERVICES [1037]","HB BWH MEDICARE","0.32","","APC Price ($0.32).","0.34","0.34","0.34","1020","0.29","2.43","other","OPPS APC"
"Ferumoxytol Inj 1mg Non Esrd","PX-63600246","CDM","Q0138","HCPCS","0636","RC","","","","both","","","3.15","2.36","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","0.32","","APC Price ($0.32). Final payment is multiplied by 98%.","0.33","0.30","0.37","7650","0.29","2.43","other","OPPS APC"
"Ferumoxytol Inj 1mg Non Esrd","PX-63600246","CDM","Q0138","HCPCS","0636","RC","","","","outpatient","","","3.15","2.36","AETNA [1001]","HB AMC AETNA HMO","2.20","69.8","","391.75","391.75","391.75","1 through 10","0.6","2.53","percent of total billed charges",""
"Fetal Fibronectin","PX-30000437","CDM","82731","CPT","0301","RC","","","","both","","","782.00","586.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","416.81","53.3","","596.55","400.22","596.55","1 through 10","63.12","742.9","percent of total billed charges",""
"Fetal Fibronectin","PX-30000437","CDM","82731","CPT","0301","RC","","","","both","","","782.00","586.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","285.43","36.5","","282.73","240.29","282.73","1 through 10","63.12","742.9","percent of total billed charges",""
"Fetal Fibronectin","PX-30000437","CDM","82731","CPT","0301","RC","","","","both","","","782.00","586.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","299.51","38.3","","296.38","288.04","296.38","12","63.12","742.9","percent of total billed charges",""
"Fetal Fibronectin","PX-30000437","CDM","82731","CPT","0301","RC","","","","outpatient","","","782.00","586.50","AETNA [1001]","HB AMC AETNA HMO","545.84","69.8","","513.17","362.32","591.24","1 through 10","66.42","639.05","percent of total billed charges",""
"Fetal Fibronectin","PX-30000437","CDM","82731","CPT","0301","RC","","","","outpatient","","","782.00","586.50","AETNA [1001]","HB AMC AETNA PPO","628.73","80.4","","591.24","591.24","591.24","1 through 10","66.42","639.05","percent of total billed charges",""
"Fetal Fibronectin","PX-30000437","CDM","82731","CPT","0301","RC","","","","outpatient","","","782.00","586.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","639.05","81.72","","605.95","605.95","605.95","1 through 10","66.42","639.05","percent of total billed charges",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","","","","inpatient","","","34506.88","25880.16","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8477.53","","Case rate ($8,477.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,127.87, add-ons for qualifying new technology services are included. If operating cost exceeds $55,772.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,154.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,383.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,748.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.30. The transfer capital threshold is the transfer adjustment factor * $714.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10699.48","10699.48","10699.48","1 through 10","8307.98","13904.93","other","Inpatient Replacement Plans DRG"
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","","","","inpatient","","","34506.88","25880.16","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","9047.76","9047.76","9047.76","1 through 10","8307.98","13904.93","case rate",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","","","","inpatient","","","34506.88","25880.16","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","8477.53","","Case rate ($8,477.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,127.87, add-ons for qualifying new technology services are included. If operating cost exceeds $55,772.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,154.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,383.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,748.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.30. The transfer capital threshold is the transfer adjustment factor * $714.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8271.61","8271.61","8271.61","1 through 10","8307.98","13904.93","other","Inpatient Replacement Plans DRG"
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","","","","inpatient","","","34506.88","25880.16","MEDICARE [2001]","HB BWH MEDICARE","8477.53","","Case rate ($8,477.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,127.87, add-ons for qualifying new technology services are included. If operating cost exceeds $55,772.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,154.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,383.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,748.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.30. The transfer capital threshold is the transfer adjustment factor * $714.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10864.94","0.03","10880.77","16","8307.98","13904.93","other","Inpatient Replacement Plans DRG"
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","","","","inpatient","","","34506.88","25880.16","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8307.98","","Case rate ($8,477.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,127.87, add-ons for qualifying new technology services are included. If operating cost exceeds $55,772.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,154.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,383.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,748.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.30. The transfer capital threshold is the transfer adjustment factor * $714.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8350.57","8350.57","8350.57","1 through 10","8307.98","13904.93","other","Inpatient DRG"
"Fever And Inflammatory Conditions,EXTREME","722","DRG","","","","","","","","inpatient","","","91866.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","39832.38","","Standard inlier is a Case rate ($39,832.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,199, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,653.88) for the length of stay and the standard reimbursement.","39832.38","39832.38","39832.38","1 through 10","4015.42","68405.27","case rate",""
"Fever And Inflammatory Conditions,MAJOR","722","DRG","","","","","","","","inpatient","","","38721.63","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24410.99","","Standard inlier is a Case rate ($24,410.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,630, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,465.29) for the length of stay and the standard reimbursement.","24410.98","24410.98","25072.94","1 through 10","4015.42","68405.27","case rate",""
"Fever And Inflammatory Conditions,MAJOR","722","DRG","","","","","","","","inpatient","","","38721.63","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","27444.53","","Standard inlier is a Case rate ($27,444.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,630, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,895.52) for the length of stay and the standard reimbursement.","27444.52","25072.94","37654.08","1 through 10","4015.42","68405.27","case rate",""
"Fever And Inflammatory Conditions,MINOR","722","DRG","","","","","","","","inpatient","","","19984.40","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","13420.48","","Standard inlier is a Case rate ($13,420.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $20,930, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,904.93) for the length of stay and the standard reimbursement.","13420.47","13420.47","13420.47","1 through 10","4015.42","68405.27","case rate",""
"Fever And Inflammatory Conditions,MODERATE","722","DRG","","","","","","","","inpatient","","","36924.13","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","20136.17","","Standard inlier is a Case rate ($20,136.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,576, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,858.16) for the length of stay and the standard reimbursement.","20136.16","20136.16","132573.03","1 through 10","4015.42","68405.27","case rate",""
"Fever And Inflammatory Conditions,MODERATE","722","DRG","","","","","","","","inpatient","","","36924.13","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","30092.44","30092.44","30092.44","1 through 10","4015.42","68405.27","percent of total billed charges",""
"Fever And Inflammatory Conditions,MODERATE","722","DRG","","","","","","","","inpatient","","","36924.13","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10818.9179","","Fee schedule rate ($13,599.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10818.9179","20696.20","20696.20","1 through 10","4015.42","68405.27","case rate",""
"Fgfr2","PX-31001152","CDM","81479","CPT","0310","RC","","","","both","","","5665.00","4248.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4503.68","79.5","","0.65","0.65","0.65","1 through 10","1756.15","5381.75","percent of total billed charges",""
"Fgfr2","PX-31001152","CDM","81479","CPT","0310","RC","","","","both","","","5665.00","4248.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3019.45","53.3","","0.79","0.79","0.79","1 through 10","1756.15","5381.75","percent of total billed charges",""
"Fgfr2","PX-31001152","CDM","81479","CPT","0310","RC","","","","outpatient","","","5665.00","4248.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3430.16","60.55","","1.00","1.00","1.00","1 through 10","2741.86","4673.63","percent of total billed charges",""
"Fgfr2","PX-31001152","CDM","81479","CPT","0310","RC","","","","outpatient","","","5665.00","4248.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2958.26","52.22","","1.00","1.00","1.00","1 through 10","2741.86","4673.63","percent of total billed charges",""
"Fgfr2","PX-31001152","CDM","81479","CPT","0310","RC","","","","outpatient","","","5665.00","4248.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2832.50","50","","1.00","1.00","1.00","1 through 10","2741.86","4673.63","percent of total billed charges",""
"Fgfr2","PX-31001152","CDM","81479","CPT","0310","RC","","","","outpatient","","","5665.00","4248.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2974.13","52.5","","1.00","0.53","1.00","1 through 10","2741.86","4673.63","percent of total billed charges",""
"FIBER CORTICAL 1ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10114013","CDM","C1889","HCPCS","0278","RC","","","","both","","","488.78","366.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","388.58","79.5","","1309.77","674.56","6049.93","26","151.52","388.58","percent of total billed charges",""
"FIBER CORTICAL 1ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10114013","CDM","C1889","HCPCS","0278","RC","","","","both","","","488.78","366.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","260.52","53.3","","1901.83","1901.83","2962.25","1 through 10","151.52","388.58","percent of total billed charges",""
"FIBER CORTICAL 1ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10114013","CDM","C1889","HCPCS","0278","RC","","","","both","","","488.78","366.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","178.40","36.5","","1620.31","1620.31","19908.88","1 through 10","151.52","388.58","percent of total billed charges",""
"FIBER CORTICAL 1ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10114013","CDM","C1889","HCPCS","0278","RC","","","","both","","","488.78","366.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.20","38.3","","352.91","352.91","2046.30","1 through 10","151.52","388.58","percent of total billed charges",""
"FIBER CORTICAL 1ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10114013","CDM","C1889","HCPCS","0278","RC","","","","both","","","488.78","366.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","209.69","42.9","","9668.75","9668.75","9668.75","1 through 10","151.52","388.58","percent of total billed charges",""
"FIBER CORTICAL 1ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10114013","CDM","C1889","HCPCS","0278","RC","","","","both","","","488.78","366.58","WELLPOINT [1015]","HB AMC WELLPOINT","360.62","73.78","","699.88","384.10","3443.31","33","151.52","388.58","percent of total billed charges",""
"FIBER CORTICAL 1ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10114013","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","488.78","366.58","AETNA [1001]","HB AMC AETNA HMO","341.17","69.8","","1421.24","264.50","4933.46","29","255.44","399.43","percent of total billed charges",""
"FIBER CORTICAL 1ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10114013","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","488.78","366.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","392.98","80.4","","1022.97","1022.97","3607.50","1 through 10","255.44","399.43","percent of total billed charges",""
"FIBER CORTICAL 1ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10114013","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","488.78","366.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","399.43","81.72","","3010.54","693.88","5019.88","35","255.44","399.43","percent of total billed charges",""
"FIBER CORTICAL 5ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10101177","CDM","C1889","HCPCS","0278","RC","","","","both","","","1800.75","1350.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1431.60","79.5","","1309.77","674.56","6049.93","26","558.23","1431.6","percent of total billed charges",""
"FIBER CORTICAL 5ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10101177","CDM","C1889","HCPCS","0278","RC","","","","both","","","1800.75","1350.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","959.80","53.3","","1901.83","1901.83","2962.25","1 through 10","558.23","1431.6","percent of total billed charges",""
"FIBER CORTICAL 5ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10101177","CDM","C1889","HCPCS","0278","RC","","","","both","","","1800.75","1350.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","657.27","36.5","","1620.31","1620.31","19908.88","1 through 10","558.23","1431.6","percent of total billed charges",""
"FIBER CORTICAL 5ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10101177","CDM","C1889","HCPCS","0278","RC","","","","both","","","1800.75","1350.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","689.69","38.3","","352.91","352.91","2046.30","1 through 10","558.23","1431.6","percent of total billed charges",""
"FIBER CORTICAL 5ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10101177","CDM","C1889","HCPCS","0278","RC","","","","both","","","1800.75","1350.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","772.52","42.9","","9668.75","9668.75","9668.75","1 through 10","558.23","1431.6","percent of total billed charges",""
"FIBER CORTICAL 5ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10101177","CDM","C1889","HCPCS","0278","RC","","","","both","","","1800.75","1350.56","WELLPOINT [1015]","HB AMC WELLPOINT","1328.59","73.78","","699.88","384.10","3443.31","33","558.23","1431.6","percent of total billed charges",""
"FIBER CORTICAL 5ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10101177","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1800.75","1350.56","AETNA [1001]","HB AMC AETNA HMO","1256.92","69.8","","1421.24","264.50","4933.46","29","941.07","1471.57","percent of total billed charges",""
"FIBER CORTICAL 5ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10101177","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1800.75","1350.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1447.80","80.4","","1022.97","1022.97","3607.50","1 through 10","941.07","1471.57","percent of total billed charges",""
"FIBER CORTICAL 5ML GRAFT BONE FREEZE DRIED DEMINERALIZED FLEXIGRAFT IMPLANTABLE","SUP-ITM-10101177","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1800.75","1350.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1471.57","81.72","","3010.54","693.88","5019.88","35","941.07","1471.57","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","179.00","134.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","125.30","70","","174.00","174.00","174.00","1 through 10","9.98","170.05","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","179.00","134.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","142.31","79.5","","136.94","91.87","524.80","46","9.98","170.05","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","179.00","134.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.41","53.3","","136.94","91.87","326.45","16","9.98","170.05","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","179.00","134.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","137.83","77","","401.94","133.98","401.94","1 through 10","9.98","170.05","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","179.00","134.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","116.35","65","","109.85","109.85","109.85","1 through 10","9.98","170.05","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","55.49","31","","161.31","53.77","161.31","1 through 10","9.98","170.05","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.34","36.5","","64.90","62.99","194.70","33","9.98","170.05","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.56","38.3","","68.03","68.03","204.09","114","9.98","170.05","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","179.00","134.25","TRICARE [160005]","HB BWH TRICARE","170.05","95","","11.66","11.66","11.66","1 through 10","9.98","170.05","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","outpatient","","","179.00","134.25","AETNA [1001]","HB AMC AETNA HMO","124.94","69.8","","117.80","83.17","166.34","52","10.5","146.28","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","outpatient","","","179.00","134.25","AETNA [1001]","HB AMC AETNA PPO","143.92","80.4","","91.18","91.18","91.18","1 through 10","10.5","146.28","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","outpatient","","","179.00","134.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","146.28","81.72","","130.15","130.15","139.10","1 through 10","10.5","146.28","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","outpatient","","","179.00","134.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","146.28","81.72","","139.10","76.51","139.10","27","10.5","146.28","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","146.00","109.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","104.83","71.8","","101.96","101.96","101.96","1 through 10","8.76","138.7","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","146.00","109.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","102.20","70","","284.00","102.24","284.00","1 through 10","8.76","138.7","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","146.00","109.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.07","79.5","","111.75","111.75","335.25","29","8.76","138.7","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","146.00","109.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.82","53.3","","111.75","74.98","224.94","14","8.76","138.7","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","146.00","109.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","112.42","77","","328.02","328.02","328.02","1 through 10","8.76","138.7","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","146.00","109.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","94.90","65","","89.70","89.70","89.70","1 through 10","8.76","138.7","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.29","36.5","","52.97","45.01","158.91","18","8.76","138.7","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.92","38.3","","55.52","53.96","166.56","76","8.76","138.7","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","146.00","109.50","TRICARE [160005]","HB BWH TRICARE","138.70","95","","11.12","11.12","11.12","1 through 10","8.76","138.7","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.63","42.9","","113.51","113.51","113.51","1 through 10","8.76","138.7","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA HMO","101.91","69.8","","96.13","67.88","164.01","29","8.76","119.31","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA PPO","117.38","80.4","","110.76","74.41","221.52","1 through 10","8.76","119.31","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","outpatient","","","146.00","109.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","117.38","80.4","","110.76","110.76","110.76","1 through 10","8.76","119.31","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","119.31","81.72","","113.51","62.44","113.51","30","8.76","119.31","percent of total billed charges",""
"Fibrinogen Antigen","PX-30001091","CDM","85385","CPT","0305","RC","","","","both","","","143.00","107.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.77","38.3","","105.64","54.35","105.64","1 through 10","8.76","135.85","percent of total billed charges",""
"Fibrinogen Antigen","PX-30001091","CDM","85385","CPT","0305","RC","","","","outpatient","","","143.00","107.25","AETNA [1001]","HB AMC AETNA HMO","99.81","69.8","","94.10","94.10","94.10","1 through 10","8.76","116.86","percent of total billed charges",""
"Fibrinolytic Alpha-2 Antiplasmin","PX-30001096","CDM","85410","CPT","0305","RC","","","","outpatient","","","138.00","103.50","AETNA [1001]","HB AMC AETNA PPO","110.95","80.4","","104.52","104.52","104.52","1 through 10","7.95","112.77","percent of total billed charges",""
"Fibrinolytic Plasminogen Activator","PX-30001097","CDM","85415","CPT","0305","RC","","","","both","","","286.00","214.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","227.37","79.5","","654.00","218.00","654.00","1 through 10","16.85","271.7","percent of total billed charges",""
"Fibrinolytic Plasminogen Activator","PX-30001097","CDM","85415","CPT","0305","RC","","","","both","","","286.00","214.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","152.44","53.3","","438.78","146.26","438.78","1 through 10","16.85","271.7","percent of total billed charges",""
"Fibrinolytic Plasminogen Activator","PX-30001097","CDM","85415","CPT","0305","RC","","","","both","","","286.00","214.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","104.39","36.5","","309.96","263.43","723.24","17","16.85","271.7","percent of total billed charges",""
"Fibrinolytic Plasminogen Activator","PX-30001097","CDM","85415","CPT","0305","RC","","","","both","","","286.00","214.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","109.54","38.3","","324.93","108.31","526.30","13","16.85","271.7","percent of total billed charges",""
"Fibrinolytic Plasminogen Activator","PX-30001097","CDM","85415","CPT","0305","RC","","","","outpatient","","","286.00","214.50","AETNA [1001]","HB AMC AETNA HMO","199.63","69.8","","176.20","176.20","176.20","1 through 10","17.73","233.72","percent of total billed charges",""
"Fibrinolytic Plasminogen Activator","PX-30001097","CDM","85415","CPT","0305","RC","","","","outpatient","","","286.00","214.50","AETNA [1001]","HB AMC AETNA PPO","229.94","80.4","","216.06","216.06","216.06","1 through 10","17.73","233.72","percent of total billed charges",""
"Fibrinolytic Plasminogen Activator","PX-30001097","CDM","85415","CPT","0305","RC","","","","outpatient","","","286.00","214.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","233.72","81.72","","121.80","121.80","121.80","1 through 10","17.73","233.72","percent of total billed charges",""
"Fibrnoltc Disordr Pnl, Versiti","PX-31001179","CDM","81479","CPT","0310","RC","","","","both","","","4518.00","3388.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3591.81","79.5","","0.65","0.65","0.65","1 through 10","1400.58","4292.1","percent of total billed charges",""
"Fibrnoltc Disordr Pnl, Versiti","PX-31001179","CDM","81479","CPT","0310","RC","","","","both","","","4518.00","3388.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2408.09","53.3","","0.79","0.79","0.79","1 through 10","1400.58","4292.1","percent of total billed charges",""
"Fibrnoltc Disordr Pnl, Versiti","PX-31001179","CDM","81479","CPT","0310","RC","","","","outpatient","","","4518.00","3388.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2259.00","50","","1.00","1.00","1.00","1 through 10","156.55","3727.35","percent of total billed charges",""
"Fibrnoltc Disordr Pnl, Versiti","PX-31001179","CDM","81479","CPT","0310","RC","","","","outpatient","","","4518.00","3388.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2371.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","3727.35","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1868.15","52.26","","1113.10","1113.10","1113.10","1 through 10","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2841.91","79.5","","1293.60","1148.53","1603.80","1 through 10","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1304.78","36.5","","1023.42","771.29","2068.67","33","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1369.12","38.3","","850.52","759.78","1211.25","66","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1533.56","42.9","","2548.09","2548.09","2548.09","1 through 10","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1533.56","42.9","","956.46","956.46","956.46","1 through 10","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","WELLPOINT [1015]","HB AMC WELLPOINT","2637.44","73.78","","2344.73","1619.47","2530.35","16","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3574.73","2681.05","AETNA [1001]","HB AMC AETNA HMO","2495.16","69.8","","1523.63","988.41","4330.26","39","1868.15","2921.27","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3574.73","2681.05","AETNA [1001]","HB AMC AETNA PPO","2874.08","80.4","","1670.25","1670.25","1670.25","1 through 10","1868.15","2921.27","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3574.73","2681.05","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1868.15","52.26","","1113.10","1113.10","1113.10","1 through 10","1868.15","2921.27","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3574.73","2681.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2921.27","81.72","","1738.90","1484.65","2716.94","38","1868.15","2921.27","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2017.31","79.5","","800.18","480.96","1887.97","195","786.63","2017.31","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1352.49","53.3","","813.12","216.42","1444.50","81","786.63","2017.31","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","786.63","31","","432.60","432.60","432.60","1 through 10","786.63","2017.31","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","926.19","36.5","","148.37","54.89","631.39","94","786.63","2017.31","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","971.86","38.3","","279.30","91.72","1116.77","266","786.63","2017.31","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1088.59","42.9","","731.00","63.70","731.00","1 through 10","786.63","2017.31","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1088.59","42.9","","384.74","384.74","384.74","1 through 10","786.63","2017.31","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","WELLPOINT [1015]","HB AMC WELLPOINT","1872.17","73.78","","286.63","119.22","1107.45","105","786.63","2017.31","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2537.50","1903.12","AETNA [1001]","HB AMC AETNA HMO","1771.18","69.8","","675.31","184.75","1721.50","286","1326.1","2073.65","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2537.50","1903.12","AETNA [1001]","HB AMC AETNA PPO","2040.15","80.4","","1261.44","103.12","1514.10","21","1326.1","2073.65","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2537.50","1903.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2040.15","80.4","","1365.00","1365.00","1365.00","1 through 10","1326.1","2073.65","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2537.50","1903.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2073.65","81.72","","5157.68","5157.68","5157.68","1 through 10","1326.1","2073.65","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2537.50","1903.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2073.65","81.72","","431.26","71.26","1459.57","88","1326.1","2073.65","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2212.09","79.5","","800.18","480.96","1887.97","195","862.58","2212.09","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1483.07","53.3","","813.12","216.42","1444.50","81","862.58","2212.09","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","862.58","31","","432.60","432.60","432.60","1 through 10","862.58","2212.09","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1015.61","36.5","","148.37","54.89","631.39","94","862.58","2212.09","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1065.70","38.3","","279.30","91.72","1116.77","266","862.58","2212.09","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.69","42.9","","731.00","63.70","731.00","1 through 10","862.58","2212.09","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.69","42.9","","384.74","384.74","384.74","1 through 10","862.58","2212.09","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","WELLPOINT [1015]","HB AMC WELLPOINT","2052.93","73.78","","286.63","119.22","1107.45","105","862.58","2212.09","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","AETNA [1001]","HB AMC AETNA HMO","1942.19","69.8","","675.31","184.75","1721.50","286","1454.13","2273.86","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","AETNA [1001]","HB AMC AETNA PPO","2237.13","80.4","","1261.44","103.12","1514.10","21","1454.13","2273.86","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2237.13","80.4","","1365.00","1365.00","1365.00","1 through 10","1454.13","2273.86","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2273.86","81.72","","5157.68","5157.68","5157.68","1 through 10","1454.13","2273.86","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2273.86","81.72","","431.26","71.26","1459.57","88","1454.13","2273.86","percent of total billed charges",""
"FIBULA PLATE 131MM 7 HOLE LEFT POSTEROLATERAL DISTAL ANTHEM SS","SUP-ITM-10277990","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.00","2499.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2648.94","79.5","","800.18","480.96","1887.97","195","1032.92","2648.94","percent of total billed charges",""
"FIBULA PLATE 131MM 7 HOLE LEFT POSTEROLATERAL DISTAL ANTHEM SS","SUP-ITM-10277990","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.00","2499.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1775.96","53.3","","813.12","216.42","1444.50","81","1032.92","2648.94","percent of total billed charges",""
"FIBULA PLATE 131MM 7 HOLE LEFT POSTEROLATERAL DISTAL ANTHEM SS","SUP-ITM-10277990","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.00","2499.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1032.92","31","","432.60","432.60","432.60","1 through 10","1032.92","2648.94","percent of total billed charges",""
"FIBULA PLATE 131MM 7 HOLE LEFT POSTEROLATERAL DISTAL ANTHEM SS","SUP-ITM-10277990","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.00","2499.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1216.18","36.5","","148.37","54.89","631.39","94","1032.92","2648.94","percent of total billed charges",""
"FIBULA PLATE 131MM 7 HOLE LEFT POSTEROLATERAL DISTAL ANTHEM SS","SUP-ITM-10277990","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.00","2499.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1276.16","38.3","","279.30","91.72","1116.77","266","1032.92","2648.94","percent of total billed charges",""
"FIBULA PLATE 131MM 7 HOLE LEFT POSTEROLATERAL DISTAL ANTHEM SS","SUP-ITM-10277990","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.00","2499.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1429.43","42.9","","731.00","63.70","731.00","1 through 10","1032.92","2648.94","percent of total billed charges",""
"FIBULA PLATE 131MM 7 HOLE LEFT POSTEROLATERAL DISTAL ANTHEM SS","SUP-ITM-10277990","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.00","2499.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1429.43","42.9","","384.74","384.74","384.74","1 through 10","1032.92","2648.94","percent of total billed charges",""
"FIBULA PLATE 131MM 7 HOLE LEFT POSTEROLATERAL DISTAL ANTHEM SS","SUP-ITM-10277990","CDM","C1713","HCPCS","0278","RC","","","","both","","","3332.00","2499.00","WELLPOINT [1015]","HB AMC WELLPOINT","2458.35","73.78","","286.63","119.22","1107.45","105","1032.92","2648.94","percent of total billed charges",""
"FIBULA PLATE 131MM 7 HOLE LEFT POSTEROLATERAL DISTAL ANTHEM SS","SUP-ITM-10277990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3332.00","2499.00","AETNA [1001]","HB AMC AETNA HMO","2325.74","69.8","","675.31","184.75","1721.50","286","1741.3","2722.91","percent of total billed charges",""
"FIBULA PLATE 131MM 7 HOLE LEFT POSTEROLATERAL DISTAL ANTHEM SS","SUP-ITM-10277990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3332.00","2499.00","AETNA [1001]","HB AMC AETNA PPO","2678.93","80.4","","1261.44","103.12","1514.10","21","1741.3","2722.91","percent of total billed charges",""
"FIBULA PLATE 131MM 7 HOLE LEFT POSTEROLATERAL DISTAL ANTHEM SS","SUP-ITM-10277990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3332.00","2499.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2678.93","80.4","","1365.00","1365.00","1365.00","1 through 10","1741.3","2722.91","percent of total billed charges",""
"FIBULA PLATE 131MM 7 HOLE LEFT POSTEROLATERAL DISTAL ANTHEM SS","SUP-ITM-10277990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3332.00","2499.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2722.91","81.72","","5157.68","5157.68","5157.68","1 through 10","1741.3","2722.91","percent of total billed charges",""
"FIBULA PLATE 131MM 7 HOLE LEFT POSTEROLATERAL DISTAL ANTHEM SS","SUP-ITM-10277990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3332.00","2499.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2722.91","81.72","","431.26","71.26","1459.57","88","1741.3","2722.91","percent of total billed charges",""
"FIBULA PLATE 149X3.5MM 9 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4028.15","3021.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3202.38","79.5","","800.18","480.96","1887.97","195","1248.73","3202.38","percent of total billed charges",""
"FIBULA PLATE 149X3.5MM 9 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4028.15","3021.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2147.00","53.3","","813.12","216.42","1444.50","81","1248.73","3202.38","percent of total billed charges",""
"FIBULA PLATE 149X3.5MM 9 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4028.15","3021.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1248.73","31","","432.60","432.60","432.60","1 through 10","1248.73","3202.38","percent of total billed charges",""
"FIBULA PLATE 149X3.5MM 9 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4028.15","3021.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1470.27","36.5","","148.37","54.89","631.39","94","1248.73","3202.38","percent of total billed charges",""
"FIBULA PLATE 149X3.5MM 9 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4028.15","3021.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1542.78","38.3","","279.30","91.72","1116.77","266","1248.73","3202.38","percent of total billed charges",""
"FIBULA PLATE 149X3.5MM 9 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4028.15","3021.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1728.08","42.9","","731.00","63.70","731.00","1 through 10","1248.73","3202.38","percent of total billed charges",""
"FIBULA PLATE 149X3.5MM 9 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4028.15","3021.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1728.08","42.9","","384.74","384.74","384.74","1 through 10","1248.73","3202.38","percent of total billed charges",""
"FIBULA PLATE 149X3.5MM 9 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4028.15","3021.11","WELLPOINT [1015]","HB AMC WELLPOINT","2971.97","73.78","","286.63","119.22","1107.45","105","1248.73","3202.38","percent of total billed charges",""
"FIBULA PLATE 149X3.5MM 9 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4028.15","3021.11","AETNA [1001]","HB AMC AETNA HMO","2811.65","69.8","","675.31","184.75","1721.50","286","2105.11","3291.8","percent of total billed charges",""
"FIBULA PLATE 149X3.5MM 9 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4028.15","3021.11","AETNA [1001]","HB AMC AETNA PPO","3238.63","80.4","","1261.44","103.12","1514.10","21","2105.11","3291.8","percent of total billed charges",""
"FIBULA PLATE 149X3.5MM 9 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4028.15","3021.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3238.63","80.4","","1365.00","1365.00","1365.00","1 through 10","2105.11","3291.8","percent of total billed charges",""
"FIBULA PLATE 149X3.5MM 9 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4028.15","3021.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3291.80","81.72","","5157.68","5157.68","5157.68","1 through 10","2105.11","3291.8","percent of total billed charges",""
"FIBULA PLATE 149X3.5MM 9 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4028.15","3021.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3291.80","81.72","","431.26","71.26","1459.57","88","2105.11","3291.8","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X103MM 5 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095093","CDM","C1713","HCPCS","0278","RC","","","","both","","","1356.32","1017.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1078.27","79.5","","800.18","480.96","1887.97","195","420.46","1078.27","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X103MM 5 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095093","CDM","C1713","HCPCS","0278","RC","","","","both","","","1356.32","1017.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","722.92","53.3","","813.12","216.42","1444.50","81","420.46","1078.27","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X103MM 5 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095093","CDM","C1713","HCPCS","0278","RC","","","","both","","","1356.32","1017.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","420.46","31","","432.60","432.60","432.60","1 through 10","420.46","1078.27","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X103MM 5 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095093","CDM","C1713","HCPCS","0278","RC","","","","both","","","1356.32","1017.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","495.06","36.5","","148.37","54.89","631.39","94","420.46","1078.27","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X103MM 5 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095093","CDM","C1713","HCPCS","0278","RC","","","","both","","","1356.32","1017.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","519.47","38.3","","279.30","91.72","1116.77","266","420.46","1078.27","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X103MM 5 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095093","CDM","C1713","HCPCS","0278","RC","","","","both","","","1356.32","1017.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","581.86","42.9","","731.00","63.70","731.00","1 through 10","420.46","1078.27","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X103MM 5 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095093","CDM","C1713","HCPCS","0278","RC","","","","both","","","1356.32","1017.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","581.86","42.9","","384.74","384.74","384.74","1 through 10","420.46","1078.27","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X103MM 5 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095093","CDM","C1713","HCPCS","0278","RC","","","","both","","","1356.32","1017.24","WELLPOINT [1015]","HB AMC WELLPOINT","1000.69","73.78","","286.63","119.22","1107.45","105","420.46","1078.27","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X103MM 5 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1356.32","1017.24","AETNA [1001]","HB AMC AETNA HMO","946.71","69.8","","675.31","184.75","1721.50","286","708.81","1108.38","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X103MM 5 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1356.32","1017.24","AETNA [1001]","HB AMC AETNA PPO","1090.48","80.4","","1261.44","103.12","1514.10","21","708.81","1108.38","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X103MM 5 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1356.32","1017.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1090.48","80.4","","1365.00","1365.00","1365.00","1 through 10","708.81","1108.38","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X103MM 5 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1356.32","1017.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1108.38","81.72","","5157.68","5157.68","5157.68","1 through 10","708.81","1108.38","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X103MM 5 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1356.32","1017.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1108.38","81.72","","431.26","71.26","1459.57","88","708.81","1108.38","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X116MM 6 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095095","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.48","1032.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1094.30","79.5","","800.18","480.96","1887.97","195","426.71","1094.3","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X116MM 6 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095095","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.48","1032.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","733.66","53.3","","813.12","216.42","1444.50","81","426.71","1094.3","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X116MM 6 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095095","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.48","1032.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","426.71","31","","432.60","432.60","432.60","1 through 10","426.71","1094.3","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X116MM 6 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095095","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.48","1032.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","502.42","36.5","","148.37","54.89","631.39","94","426.71","1094.3","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X116MM 6 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095095","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.48","1032.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","527.19","38.3","","279.30","91.72","1116.77","266","426.71","1094.3","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X116MM 6 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095095","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.48","1032.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","590.51","42.9","","731.00","63.70","731.00","1 through 10","426.71","1094.3","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X116MM 6 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095095","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.48","1032.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","590.51","42.9","","384.74","384.74","384.74","1 through 10","426.71","1094.3","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X116MM 6 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095095","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.48","1032.36","WELLPOINT [1015]","HB AMC WELLPOINT","1015.57","73.78","","286.63","119.22","1107.45","105","426.71","1094.3","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X116MM 6 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1376.48","1032.36","AETNA [1001]","HB AMC AETNA HMO","960.78","69.8","","675.31","184.75","1721.50","286","719.35","1124.86","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X116MM 6 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1376.48","1032.36","AETNA [1001]","HB AMC AETNA PPO","1106.69","80.4","","1261.44","103.12","1514.10","21","719.35","1124.86","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X116MM 6 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1376.48","1032.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1106.69","80.4","","1365.00","1365.00","1365.00","1 through 10","719.35","1124.86","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X116MM 6 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1376.48","1032.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1124.86","81.72","","5157.68","5157.68","5157.68","1 through 10","719.35","1124.86","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X116MM 6 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1376.48","1032.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1124.86","81.72","","431.26","71.26","1459.57","88","719.35","1124.86","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.52","1046.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1109.44","79.5","","800.18","480.96","1887.97","195","432.61","1109.44","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.52","1046.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","743.81","53.3","","813.12","216.42","1444.50","81","432.61","1109.44","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.52","1046.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","432.61","31","","432.60","432.60","432.60","1 through 10","432.61","1109.44","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.52","1046.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","509.36","36.5","","148.37","54.89","631.39","94","432.61","1109.44","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.52","1046.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","534.48","38.3","","279.30","91.72","1116.77","266","432.61","1109.44","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.52","1046.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","598.68","42.9","","731.00","63.70","731.00","1 through 10","432.61","1109.44","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.52","1046.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","598.68","42.9","","384.74","384.74","384.74","1 through 10","432.61","1109.44","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095097","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.52","1046.64","WELLPOINT [1015]","HB AMC WELLPOINT","1029.61","73.78","","286.63","119.22","1107.45","105","432.61","1109.44","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.52","1046.64","AETNA [1001]","HB AMC AETNA HMO","974.07","69.8","","675.31","184.75","1721.50","286","729.3","1140.42","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.52","1046.64","AETNA [1001]","HB AMC AETNA PPO","1122.00","80.4","","1261.44","103.12","1514.10","21","729.3","1140.42","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.52","1046.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1122.00","80.4","","1365.00","1365.00","1365.00","1 through 10","729.3","1140.42","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.52","1046.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1140.42","81.72","","5157.68","5157.68","5157.68","1 through 10","729.3","1140.42","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X129MM 7 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.52","1046.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1140.42","81.72","","431.26","71.26","1459.57","88","729.3","1140.42","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X151MM 9 HOLE LCP SS RIGHT","SUP-ITM-10091764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.84","1076.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1141.49","79.5","","800.18","480.96","1887.97","195","445.11","1141.49","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X151MM 9 HOLE LCP SS RIGHT","SUP-ITM-10091764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.84","1076.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","765.30","53.3","","813.12","216.42","1444.50","81","445.11","1141.49","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X151MM 9 HOLE LCP SS RIGHT","SUP-ITM-10091764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.84","1076.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","445.11","31","","432.60","432.60","432.60","1 through 10","445.11","1141.49","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X151MM 9 HOLE LCP SS RIGHT","SUP-ITM-10091764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.84","1076.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","524.08","36.5","","148.37","54.89","631.39","94","445.11","1141.49","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X151MM 9 HOLE LCP SS RIGHT","SUP-ITM-10091764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.84","1076.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","549.93","38.3","","279.30","91.72","1116.77","266","445.11","1141.49","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X151MM 9 HOLE LCP SS RIGHT","SUP-ITM-10091764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.84","1076.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","615.98","42.9","","731.00","63.70","731.00","1 through 10","445.11","1141.49","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X151MM 9 HOLE LCP SS RIGHT","SUP-ITM-10091764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.84","1076.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","615.98","42.9","","384.74","384.74","384.74","1 through 10","445.11","1141.49","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X151MM 9 HOLE LCP SS RIGHT","SUP-ITM-10091764","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.84","1076.88","WELLPOINT [1015]","HB AMC WELLPOINT","1059.36","73.78","","286.63","119.22","1107.45","105","445.11","1141.49","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X151MM 9 HOLE LCP SS RIGHT","SUP-ITM-10091764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1435.84","1076.88","AETNA [1001]","HB AMC AETNA HMO","1002.22","69.8","","675.31","184.75","1721.50","286","750.37","1173.37","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X151MM 9 HOLE LCP SS RIGHT","SUP-ITM-10091764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1435.84","1076.88","AETNA [1001]","HB AMC AETNA PPO","1154.42","80.4","","1261.44","103.12","1514.10","21","750.37","1173.37","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X151MM 9 HOLE LCP SS RIGHT","SUP-ITM-10091764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1435.84","1076.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1154.42","80.4","","1365.00","1365.00","1365.00","1 through 10","750.37","1173.37","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X151MM 9 HOLE LCP SS RIGHT","SUP-ITM-10091764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1435.84","1076.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1173.37","81.72","","5157.68","5157.68","5157.68","1 through 10","750.37","1173.37","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X151MM 9 HOLE LCP SS RIGHT","SUP-ITM-10091764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1435.84","1076.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1173.37","81.72","","431.26","71.26","1459.57","88","750.37","1173.37","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X155MM 9 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095099","CDM","C1713","HCPCS","0278","RC","","","","both","","","1415.68","1061.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1125.47","79.5","","800.18","480.96","1887.97","195","438.86","1125.47","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X155MM 9 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095099","CDM","C1713","HCPCS","0278","RC","","","","both","","","1415.68","1061.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","754.56","53.3","","813.12","216.42","1444.50","81","438.86","1125.47","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X155MM 9 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095099","CDM","C1713","HCPCS","0278","RC","","","","both","","","1415.68","1061.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","438.86","31","","432.60","432.60","432.60","1 through 10","438.86","1125.47","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X155MM 9 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095099","CDM","C1713","HCPCS","0278","RC","","","","both","","","1415.68","1061.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","516.72","36.5","","148.37","54.89","631.39","94","438.86","1125.47","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X155MM 9 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095099","CDM","C1713","HCPCS","0278","RC","","","","both","","","1415.68","1061.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","542.21","38.3","","279.30","91.72","1116.77","266","438.86","1125.47","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X155MM 9 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095099","CDM","C1713","HCPCS","0278","RC","","","","both","","","1415.68","1061.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","607.33","42.9","","731.00","63.70","731.00","1 through 10","438.86","1125.47","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X155MM 9 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095099","CDM","C1713","HCPCS","0278","RC","","","","both","","","1415.68","1061.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","607.33","42.9","","384.74","384.74","384.74","1 through 10","438.86","1125.47","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X155MM 9 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095099","CDM","C1713","HCPCS","0278","RC","","","","both","","","1415.68","1061.76","WELLPOINT [1015]","HB AMC WELLPOINT","1044.49","73.78","","286.63","119.22","1107.45","105","438.86","1125.47","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X155MM 9 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1415.68","1061.76","AETNA [1001]","HB AMC AETNA HMO","988.14","69.8","","675.31","184.75","1721.50","286","739.83","1156.89","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X155MM 9 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1415.68","1061.76","AETNA [1001]","HB AMC AETNA PPO","1138.21","80.4","","1261.44","103.12","1514.10","21","739.83","1156.89","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X155MM 9 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1415.68","1061.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1138.21","80.4","","1365.00","1365.00","1365.00","1 through 10","739.83","1156.89","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X155MM 9 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1415.68","1061.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1156.89","81.72","","5157.68","5157.68","5157.68","1 through 10","739.83","1156.89","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X155MM 9 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1415.68","1061.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1156.89","81.72","","431.26","71.26","1459.57","88","739.83","1156.89","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X181MM 11 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095101","CDM","C1713","HCPCS","0278","RC","","","","both","","","1436.96","1077.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1142.38","79.5","","800.18","480.96","1887.97","195","445.46","1142.38","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X181MM 11 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095101","CDM","C1713","HCPCS","0278","RC","","","","both","","","1436.96","1077.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","765.90","53.3","","813.12","216.42","1444.50","81","445.46","1142.38","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X181MM 11 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095101","CDM","C1713","HCPCS","0278","RC","","","","both","","","1436.96","1077.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","445.46","31","","432.60","432.60","432.60","1 through 10","445.46","1142.38","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X181MM 11 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095101","CDM","C1713","HCPCS","0278","RC","","","","both","","","1436.96","1077.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","524.49","36.5","","148.37","54.89","631.39","94","445.46","1142.38","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X181MM 11 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095101","CDM","C1713","HCPCS","0278","RC","","","","both","","","1436.96","1077.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","550.36","38.3","","279.30","91.72","1116.77","266","445.46","1142.38","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X181MM 11 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095101","CDM","C1713","HCPCS","0278","RC","","","","both","","","1436.96","1077.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","616.46","42.9","","731.00","63.70","731.00","1 through 10","445.46","1142.38","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X181MM 11 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095101","CDM","C1713","HCPCS","0278","RC","","","","both","","","1436.96","1077.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","616.46","42.9","","384.74","384.74","384.74","1 through 10","445.46","1142.38","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X181MM 11 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095101","CDM","C1713","HCPCS","0278","RC","","","","both","","","1436.96","1077.72","WELLPOINT [1015]","HB AMC WELLPOINT","1060.19","73.78","","286.63","119.22","1107.45","105","445.46","1142.38","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X181MM 11 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1436.96","1077.72","AETNA [1001]","HB AMC AETNA HMO","1003.00","69.8","","675.31","184.75","1721.50","286","750.96","1174.28","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X181MM 11 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1436.96","1077.72","AETNA [1001]","HB AMC AETNA PPO","1155.32","80.4","","1261.44","103.12","1514.10","21","750.96","1174.28","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X181MM 11 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1436.96","1077.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1155.32","80.4","","1365.00","1365.00","1365.00","1 through 10","750.96","1174.28","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X181MM 11 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1436.96","1077.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1174.28","81.72","","5157.68","5157.68","5157.68","1 through 10","750.96","1174.28","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X181MM 11 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1436.96","1077.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1174.28","81.72","","431.26","71.26","1459.57","88","750.96","1174.28","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X77MM 3 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1316.00","987.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1046.22","79.5","","800.18","480.96","1887.97","195","407.96","1046.22","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X77MM 3 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1316.00","987.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","701.43","53.3","","813.12","216.42","1444.50","81","407.96","1046.22","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X77MM 3 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1316.00","987.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","407.96","31","","432.60","432.60","432.60","1 through 10","407.96","1046.22","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X77MM 3 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1316.00","987.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","480.34","36.5","","148.37","54.89","631.39","94","407.96","1046.22","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X77MM 3 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1316.00","987.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","504.03","38.3","","279.30","91.72","1116.77","266","407.96","1046.22","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X77MM 3 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1316.00","987.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","564.56","42.9","","731.00","63.70","731.00","1 through 10","407.96","1046.22","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X77MM 3 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1316.00","987.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","564.56","42.9","","384.74","384.74","384.74","1 through 10","407.96","1046.22","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X77MM 3 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095089","CDM","C1713","HCPCS","0278","RC","","","","both","","","1316.00","987.00","WELLPOINT [1015]","HB AMC WELLPOINT","970.94","73.78","","286.63","119.22","1107.45","105","407.96","1046.22","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X77MM 3 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1316.00","987.00","AETNA [1001]","HB AMC AETNA HMO","918.57","69.8","","675.31","184.75","1721.50","286","687.74","1075.44","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X77MM 3 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1316.00","987.00","AETNA [1001]","HB AMC AETNA PPO","1058.06","80.4","","1261.44","103.12","1514.10","21","687.74","1075.44","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X77MM 3 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1316.00","987.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1058.06","80.4","","1365.00","1365.00","1365.00","1 through 10","687.74","1075.44","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X77MM 3 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1316.00","987.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1075.44","81.72","","5157.68","5157.68","5157.68","1 through 10","687.74","1075.44","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X77MM 3 HOLE LCP SS POSTEROLATERAL RT DISTAL","SUP-ITM-10095089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1316.00","987.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1075.44","81.72","","431.26","71.26","1459.57","88","687.74","1075.44","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X90MM 4 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1336.16","1002.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1062.25","79.5","","800.18","480.96","1887.97","195","414.21","1062.25","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X90MM 4 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1336.16","1002.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","712.17","53.3","","813.12","216.42","1444.50","81","414.21","1062.25","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X90MM 4 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1336.16","1002.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","414.21","31","","432.60","432.60","432.60","1 through 10","414.21","1062.25","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X90MM 4 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1336.16","1002.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","487.70","36.5","","148.37","54.89","631.39","94","414.21","1062.25","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X90MM 4 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1336.16","1002.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","511.75","38.3","","279.30","91.72","1116.77","266","414.21","1062.25","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X90MM 4 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1336.16","1002.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","573.21","42.9","","731.00","63.70","731.00","1 through 10","414.21","1062.25","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X90MM 4 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1336.16","1002.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","573.21","42.9","","384.74","384.74","384.74","1 through 10","414.21","1062.25","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X90MM 4 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095091","CDM","C1713","HCPCS","0278","RC","","","","both","","","1336.16","1002.12","WELLPOINT [1015]","HB AMC WELLPOINT","985.82","73.78","","286.63","119.22","1107.45","105","414.21","1062.25","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X90MM 4 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1336.16","1002.12","AETNA [1001]","HB AMC AETNA HMO","932.64","69.8","","675.31","184.75","1721.50","286","698.28","1091.91","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X90MM 4 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1336.16","1002.12","AETNA [1001]","HB AMC AETNA PPO","1074.27","80.4","","1261.44","103.12","1514.10","21","698.28","1091.91","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X90MM 4 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1336.16","1002.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1074.27","80.4","","1365.00","1365.00","1365.00","1 through 10","698.28","1091.91","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X90MM 4 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1336.16","1002.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1091.91","81.72","","5157.68","5157.68","5157.68","1 through 10","698.28","1091.91","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X90MM 4 HOLE LCP SS POSTEROLATERAL RIGHT DISTAL","SUP-ITM-10095091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1336.16","1002.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1091.91","81.72","","431.26","71.26","1459.57","88","698.28","1091.91","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.64","984.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.55","79.5","","800.18","480.96","1887.97","195","406.92","1043.55","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.64","984.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","699.64","53.3","","813.12","216.42","1444.50","81","406.92","1043.55","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.64","984.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","406.92","31","","432.60","432.60","432.60","1 through 10","406.92","1043.55","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.64","984.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","479.11","36.5","","148.37","54.89","631.39","94","406.92","1043.55","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.64","984.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.74","38.3","","279.30","91.72","1116.77","266","406.92","1043.55","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.64","984.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.12","42.9","","731.00","63.70","731.00","1 through 10","406.92","1043.55","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.64","984.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.12","42.9","","384.74","384.74","384.74","1 through 10","406.92","1043.55","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.64","984.48","WELLPOINT [1015]","HB AMC WELLPOINT","968.47","73.78","","286.63","119.22","1107.45","105","406.92","1043.55","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.64","984.48","AETNA [1001]","HB AMC AETNA HMO","916.22","69.8","","675.31","184.75","1721.50","286","685.99","1072.69","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.64","984.48","AETNA [1001]","HB AMC AETNA PPO","1055.36","80.4","","1261.44","103.12","1514.10","21","685.99","1072.69","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.64","984.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1055.36","80.4","","1365.00","1365.00","1365.00","1 through 10","685.99","1072.69","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.64","984.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1072.69","81.72","","5157.68","5157.68","5157.68","1 through 10","685.99","1072.69","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.64","984.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1072.69","81.72","","431.26","71.26","1459.57","88","685.99","1072.69","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2043.51","1532.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1624.59","79.5","","800.18","480.96","1887.97","195","633.49","1624.59","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2043.51","1532.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1089.19","53.3","","813.12","216.42","1444.50","81","633.49","1624.59","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2043.51","1532.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","633.49","31","","432.60","432.60","432.60","1 through 10","633.49","1624.59","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2043.51","1532.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","745.88","36.5","","148.37","54.89","631.39","94","633.49","1624.59","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2043.51","1532.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","782.66","38.3","","279.30","91.72","1116.77","266","633.49","1624.59","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2043.51","1532.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","876.67","42.9","","731.00","63.70","731.00","1 through 10","633.49","1624.59","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2043.51","1532.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","876.67","42.9","","384.74","384.74","384.74","1 through 10","633.49","1624.59","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2043.51","1532.63","WELLPOINT [1015]","HB AMC WELLPOINT","1507.70","73.78","","286.63","119.22","1107.45","105","633.49","1624.59","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2043.51","1532.63","AETNA [1001]","HB AMC AETNA HMO","1426.37","69.8","","675.31","184.75","1721.50","286","1067.94","1669.96","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2043.51","1532.63","AETNA [1001]","HB AMC AETNA PPO","1642.98","80.4","","1261.44","103.12","1514.10","21","1067.94","1669.96","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2043.51","1532.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1642.98","80.4","","1365.00","1365.00","1365.00","1 through 10","1067.94","1669.96","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2043.51","1532.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1669.96","81.72","","5157.68","5157.68","5157.68","1 through 10","1067.94","1669.96","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2043.51","1532.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1669.96","81.72","","431.26","71.26","1459.57","88","1067.94","1669.96","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2249.42","1687.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1788.29","79.5","","800.18","480.96","1887.97","195","697.32","1788.29","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2249.42","1687.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1198.94","53.3","","813.12","216.42","1444.50","81","697.32","1788.29","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2249.42","1687.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","697.32","31","","432.60","432.60","432.60","1 through 10","697.32","1788.29","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2249.42","1687.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","821.04","36.5","","148.37","54.89","631.39","94","697.32","1788.29","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2249.42","1687.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","861.53","38.3","","279.30","91.72","1116.77","266","697.32","1788.29","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2249.42","1687.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","965.00","42.9","","731.00","63.70","731.00","1 through 10","697.32","1788.29","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2249.42","1687.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","965.00","42.9","","384.74","384.74","384.74","1 through 10","697.32","1788.29","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2249.42","1687.06","WELLPOINT [1015]","HB AMC WELLPOINT","1659.62","73.78","","286.63","119.22","1107.45","105","697.32","1788.29","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2249.42","1687.06","AETNA [1001]","HB AMC AETNA HMO","1570.10","69.8","","675.31","184.75","1721.50","286","1175.55","1838.23","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2249.42","1687.06","AETNA [1001]","HB AMC AETNA PPO","1808.53","80.4","","1261.44","103.12","1514.10","21","1175.55","1838.23","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2249.42","1687.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1808.53","80.4","","1365.00","1365.00","1365.00","1 through 10","1175.55","1838.23","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2249.42","1687.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1838.23","81.72","","5157.68","5157.68","5157.68","1 through 10","1175.55","1838.23","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2249.42","1687.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1838.23","81.72","","431.26","71.26","1459.57","88","1175.55","1838.23","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","both","","","2360.79","1770.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1876.83","79.5","","800.18","480.96","1887.97","195","731.84","1876.83","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","both","","","2360.79","1770.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1258.30","53.3","","813.12","216.42","1444.50","81","731.84","1876.83","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","both","","","2360.79","1770.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","731.84","31","","432.60","432.60","432.60","1 through 10","731.84","1876.83","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","both","","","2360.79","1770.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","861.69","36.5","","148.37","54.89","631.39","94","731.84","1876.83","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","both","","","2360.79","1770.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","904.18","38.3","","279.30","91.72","1116.77","266","731.84","1876.83","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","both","","","2360.79","1770.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1012.78","42.9","","731.00","63.70","731.00","1 through 10","731.84","1876.83","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","both","","","2360.79","1770.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1012.78","42.9","","384.74","384.74","384.74","1 through 10","731.84","1876.83","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","both","","","2360.79","1770.59","WELLPOINT [1015]","HB AMC WELLPOINT","1741.79","73.78","","286.63","119.22","1107.45","105","731.84","1876.83","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2360.79","1770.59","AETNA [1001]","HB AMC AETNA HMO","1647.83","69.8","","675.31","184.75","1721.50","286","1233.75","1929.24","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2360.79","1770.59","AETNA [1001]","HB AMC AETNA PPO","1898.08","80.4","","1261.44","103.12","1514.10","21","1233.75","1929.24","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2360.79","1770.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1898.08","80.4","","1365.00","1365.00","1365.00","1 through 10","1233.75","1929.24","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2360.79","1770.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1929.24","81.72","","5157.68","5157.68","5157.68","1 through 10","1233.75","1929.24","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2360.79","1770.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1929.24","81.72","","431.26","71.26","1459.57","88","1233.75","1929.24","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1835.02","1376.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1458.84","79.5","","800.18","480.96","1887.97","195","568.86","1458.84","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1835.02","1376.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","978.07","53.3","","813.12","216.42","1444.50","81","568.86","1458.84","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1835.02","1376.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","568.86","31","","432.60","432.60","432.60","1 through 10","568.86","1458.84","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1835.02","1376.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","669.78","36.5","","148.37","54.89","631.39","94","568.86","1458.84","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1835.02","1376.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","702.81","38.3","","279.30","91.72","1116.77","266","568.86","1458.84","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1835.02","1376.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","787.22","42.9","","731.00","63.70","731.00","1 through 10","568.86","1458.84","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1835.02","1376.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","787.22","42.9","","384.74","384.74","384.74","1 through 10","568.86","1458.84","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","1835.02","1376.26","WELLPOINT [1015]","HB AMC WELLPOINT","1353.88","73.78","","286.63","119.22","1107.45","105","568.86","1458.84","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1835.02","1376.26","AETNA [1001]","HB AMC AETNA HMO","1280.84","69.8","","675.31","184.75","1721.50","286","958.98","1499.58","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1835.02","1376.26","AETNA [1001]","HB AMC AETNA PPO","1475.36","80.4","","1261.44","103.12","1514.10","21","958.98","1499.58","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1835.02","1376.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1475.36","80.4","","1365.00","1365.00","1365.00","1 through 10","958.98","1499.58","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1835.02","1376.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1499.58","81.72","","5157.68","5157.68","5157.68","1 through 10","958.98","1499.58","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1835.02","1376.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1499.58","81.72","","431.26","71.26","1459.57","88","958.98","1499.58","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.36","2785.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2952.12","79.5","","800.18","480.96","1887.97","195","1151.14","2952.12","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.36","2785.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1979.22","53.3","","813.12","216.42","1444.50","81","1151.14","2952.12","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.36","2785.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1151.14","31","","432.60","432.60","432.60","1 through 10","1151.14","2952.12","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.36","2785.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1355.38","36.5","","148.37","54.89","631.39","94","1151.14","2952.12","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.36","2785.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1422.22","38.3","","279.30","91.72","1116.77","266","1151.14","2952.12","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.36","2785.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1593.03","42.9","","731.00","63.70","731.00","1 through 10","1151.14","2952.12","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.36","2785.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1593.03","42.9","","384.74","384.74","384.74","1 through 10","1151.14","2952.12","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.36","2785.02","WELLPOINT [1015]","HB AMC WELLPOINT","2739.72","73.78","","286.63","119.22","1107.45","105","1151.14","2952.12","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3713.36","2785.02","AETNA [1001]","HB AMC AETNA HMO","2591.93","69.8","","675.31","184.75","1721.50","286","1940.6","3034.56","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3713.36","2785.02","AETNA [1001]","HB AMC AETNA PPO","2985.54","80.4","","1261.44","103.12","1514.10","21","1940.6","3034.56","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3713.36","2785.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2985.54","80.4","","1365.00","1365.00","1365.00","1 through 10","1940.6","3034.56","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3713.36","2785.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3034.56","81.72","","5157.68","5157.68","5157.68","1 through 10","1940.6","3034.56","percent of total billed charges",""
"FIBULA PLATE 3.5MM 113 6 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3713.36","2785.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3034.56","81.72","","431.26","71.26","1459.57","88","1940.6","3034.56","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.38","2490.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2639.70","79.5","","800.18","480.96","1887.97","195","1029.32","2639.7","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.38","2490.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1769.76","53.3","","813.12","216.42","1444.50","81","1029.32","2639.7","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.38","2490.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1029.32","31","","432.60","432.60","432.60","1 through 10","1029.32","2639.7","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.38","2490.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1211.94","36.5","","148.37","54.89","631.39","94","1029.32","2639.7","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.38","2490.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1271.71","38.3","","279.30","91.72","1116.77","266","1029.32","2639.7","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.38","2490.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1424.44","42.9","","731.00","63.70","731.00","1 through 10","1029.32","2639.7","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.38","2490.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1424.44","42.9","","384.74","384.74","384.74","1 through 10","1029.32","2639.7","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.38","2490.28","WELLPOINT [1015]","HB AMC WELLPOINT","2449.78","73.78","","286.63","119.22","1107.45","105","1029.32","2639.7","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3320.38","2490.28","AETNA [1001]","HB AMC AETNA HMO","2317.63","69.8","","675.31","184.75","1721.50","286","1735.23","2713.41","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3320.38","2490.28","AETNA [1001]","HB AMC AETNA PPO","2669.59","80.4","","1261.44","103.12","1514.10","21","1735.23","2713.41","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3320.38","2490.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2669.59","80.4","","1365.00","1365.00","1365.00","1 through 10","1735.23","2713.41","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3320.38","2490.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2713.41","81.72","","5157.68","5157.68","5157.68","1 through 10","1735.23","2713.41","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3320.38","2490.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2713.41","81.72","","431.26","71.26","1459.57","88","1735.23","2713.41","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","2014.08","1510.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1601.19","79.5","","800.18","480.96","1887.97","195","624.36","1601.19","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","2014.08","1510.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1073.50","53.3","","813.12","216.42","1444.50","81","624.36","1601.19","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","2014.08","1510.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","624.36","31","","432.60","432.60","432.60","1 through 10","624.36","1601.19","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","2014.08","1510.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","735.14","36.5","","148.37","54.89","631.39","94","624.36","1601.19","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","2014.08","1510.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","771.39","38.3","","279.30","91.72","1116.77","266","624.36","1601.19","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","2014.08","1510.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","864.04","42.9","","731.00","63.70","731.00","1 through 10","624.36","1601.19","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","2014.08","1510.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","864.04","42.9","","384.74","384.74","384.74","1 through 10","624.36","1601.19","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","both","","","2014.08","1510.56","WELLPOINT [1015]","HB AMC WELLPOINT","1485.99","73.78","","286.63","119.22","1107.45","105","624.36","1601.19","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2014.08","1510.56","AETNA [1001]","HB AMC AETNA HMO","1405.83","69.8","","675.31","184.75","1721.50","286","1052.56","1645.91","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2014.08","1510.56","AETNA [1001]","HB AMC AETNA PPO","1619.32","80.4","","1261.44","103.12","1514.10","21","1052.56","1645.91","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2014.08","1510.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1619.32","80.4","","1365.00","1365.00","1365.00","1 through 10","1052.56","1645.91","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2014.08","1510.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1645.91","81.72","","5157.68","5157.68","5157.68","1 through 10","1052.56","1645.91","percent of total billed charges",""
"FIBULA PLATE 3.5X137MM 8 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10142430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2014.08","1510.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1645.91","81.72","","431.26","71.26","1459.57","88","1052.56","1645.91","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.38","1340.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1420.97","79.5","","800.18","480.96","1887.97","195","554.09","1420.97","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.38","1340.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","952.67","53.3","","813.12","216.42","1444.50","81","554.09","1420.97","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.38","1340.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","554.09","31","","432.60","432.60","432.60","1 through 10","554.09","1420.97","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.38","1340.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","652.39","36.5","","148.37","54.89","631.39","94","554.09","1420.97","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.38","1340.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","684.57","38.3","","279.30","91.72","1116.77","266","554.09","1420.97","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.38","1340.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","766.79","42.9","","731.00","63.70","731.00","1 through 10","554.09","1420.97","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.38","1340.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","766.79","42.9","","384.74","384.74","384.74","1 through 10","554.09","1420.97","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.38","1340.53","WELLPOINT [1015]","HB AMC WELLPOINT","1318.73","73.78","","286.63","119.22","1107.45","105","554.09","1420.97","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.38","1340.53","AETNA [1001]","HB AMC AETNA HMO","1247.59","69.8","","675.31","184.75","1721.50","286","934.08","1460.65","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.38","1340.53","AETNA [1001]","HB AMC AETNA PPO","1437.05","80.4","","1261.44","103.12","1514.10","21","934.08","1460.65","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.38","1340.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1437.05","80.4","","1365.00","1365.00","1365.00","1 through 10","934.08","1460.65","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.38","1340.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1460.65","81.72","","5157.68","5157.68","5157.68","1 through 10","934.08","1460.65","percent of total billed charges",""
"FIBULA PLATE 77X3.5MM 3 HOLE VARIAX TITANIUM LOCKING LOW PROFILE","SUP-ITM-10090983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.38","1340.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1460.65","81.72","","431.26","71.26","1459.57","88","934.08","1460.65","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2841.91","79.5","","800.18","480.96","1887.97","195","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1905.33","53.3","","813.12","216.42","1444.50","81","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1108.17","31","","432.60","432.60","432.60","1 through 10","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1304.78","36.5","","148.37","54.89","631.39","94","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1369.12","38.3","","279.30","91.72","1116.77","266","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1533.56","42.9","","731.00","63.70","731.00","1 through 10","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1533.56","42.9","","384.74","384.74","384.74","1 through 10","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.73","2681.05","WELLPOINT [1015]","HB AMC WELLPOINT","2637.44","73.78","","286.63","119.22","1107.45","105","1108.17","2841.91","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3574.73","2681.05","AETNA [1001]","HB AMC AETNA HMO","2495.16","69.8","","675.31","184.75","1721.50","286","1868.15","2921.27","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3574.73","2681.05","AETNA [1001]","HB AMC AETNA PPO","2874.08","80.4","","1261.44","103.12","1514.10","21","1868.15","2921.27","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3574.73","2681.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2874.08","80.4","","1365.00","1365.00","1365.00","1 through 10","1868.15","2921.27","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3574.73","2681.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2921.27","81.72","","5157.68","5157.68","5157.68","1 through 10","1868.15","2921.27","percent of total billed charges",""
"FIBULA PLATE 89X3.5MM 4 HOLE VARIAX TITANIUM LOCKING","SUP-ITM-10092104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3574.73","2681.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2921.27","81.72","","431.26","71.26","1459.57","88","1868.15","2921.27","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1808.63","79.5","","800.18","480.96","1887.97","195","705.25","1808.63","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1212.58","53.3","","813.12","216.42","1444.50","81","705.25","1808.63","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","705.25","31","","432.60","432.60","432.60","1 through 10","705.25","1808.63","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","830.38","36.5","","148.37","54.89","631.39","94","705.25","1808.63","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","871.33","38.3","","279.30","91.72","1116.77","266","705.25","1808.63","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","975.98","42.9","","731.00","63.70","731.00","1 through 10","705.25","1808.63","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","975.98","42.9","","384.74","384.74","384.74","1 through 10","705.25","1808.63","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","WELLPOINT [1015]","HB AMC WELLPOINT","1678.50","73.78","","286.63","119.22","1107.45","105","705.25","1808.63","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","AETNA [1001]","HB AMC AETNA HMO","1587.95","69.8","","675.31","184.75","1721.50","286","1188.92","1859.13","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","AETNA [1001]","HB AMC AETNA PPO","1829.10","80.4","","1261.44","103.12","1514.10","21","1188.92","1859.13","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1829.10","80.4","","1365.00","1365.00","1365.00","1 through 10","1188.92","1859.13","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1859.13","81.72","","5157.68","5157.68","5157.68","1 through 10","1188.92","1859.13","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1859.13","81.72","","431.26","71.26","1459.57","88","1188.92","1859.13","percent of total billed charges",""
"FIBULA PLATE 96MM 7 HOLE BONE VARIAX SS STRAIGHT","SUP-ITM-10142417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.36","1829.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1939.29","79.5","","800.18","480.96","1887.97","195","756.2","1939.29","percent of total billed charges",""
"FIBULA PLATE 96MM 7 HOLE BONE VARIAX SS STRAIGHT","SUP-ITM-10142417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.36","1829.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1300.18","53.3","","813.12","216.42","1444.50","81","756.2","1939.29","percent of total billed charges",""
"FIBULA PLATE 96MM 7 HOLE BONE VARIAX SS STRAIGHT","SUP-ITM-10142417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.36","1829.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","756.20","31","","432.60","432.60","432.60","1 through 10","756.2","1939.29","percent of total billed charges",""
"FIBULA PLATE 96MM 7 HOLE BONE VARIAX SS STRAIGHT","SUP-ITM-10142417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.36","1829.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","890.37","36.5","","148.37","54.89","631.39","94","756.2","1939.29","percent of total billed charges",""
"FIBULA PLATE 96MM 7 HOLE BONE VARIAX SS STRAIGHT","SUP-ITM-10142417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.36","1829.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","934.27","38.3","","279.30","91.72","1116.77","266","756.2","1939.29","percent of total billed charges",""
"FIBULA PLATE 96MM 7 HOLE BONE VARIAX SS STRAIGHT","SUP-ITM-10142417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.36","1829.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1046.49","42.9","","731.00","63.70","731.00","1 through 10","756.2","1939.29","percent of total billed charges",""
"FIBULA PLATE 96MM 7 HOLE BONE VARIAX SS STRAIGHT","SUP-ITM-10142417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.36","1829.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1046.49","42.9","","384.74","384.74","384.74","1 through 10","756.2","1939.29","percent of total billed charges",""
"FIBULA PLATE 96MM 7 HOLE BONE VARIAX SS STRAIGHT","SUP-ITM-10142417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.36","1829.52","WELLPOINT [1015]","HB AMC WELLPOINT","1799.76","73.78","","286.63","119.22","1107.45","105","756.2","1939.29","percent of total billed charges",""
"FIBULA PLATE 96MM 7 HOLE BONE VARIAX SS STRAIGHT","SUP-ITM-10142417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.36","1829.52","AETNA [1001]","HB AMC AETNA HMO","1702.67","69.8","","675.31","184.75","1721.50","286","1274.81","1993.44","percent of total billed charges",""
"FIBULA PLATE 96MM 7 HOLE BONE VARIAX SS STRAIGHT","SUP-ITM-10142417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.36","1829.52","AETNA [1001]","HB AMC AETNA PPO","1961.25","80.4","","1261.44","103.12","1514.10","21","1274.81","1993.44","percent of total billed charges",""
"FIBULA PLATE 96MM 7 HOLE BONE VARIAX SS STRAIGHT","SUP-ITM-10142417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.36","1829.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1961.25","80.4","","1365.00","1365.00","1365.00","1 through 10","1274.81","1993.44","percent of total billed charges",""
"FIBULA PLATE 96MM 7 HOLE BONE VARIAX SS STRAIGHT","SUP-ITM-10142417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.36","1829.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1993.44","81.72","","5157.68","5157.68","5157.68","1 through 10","1274.81","1993.44","percent of total billed charges",""
"FIBULA PLATE 96MM 7 HOLE BONE VARIAX SS STRAIGHT","SUP-ITM-10142417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.36","1829.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1993.44","81.72","","431.26","71.26","1459.57","88","1274.81","1993.44","percent of total billed charges",""
"FIBULA PLATE DISTAL MAXLOCK EXTREME DFX LT LONG","SUP-ITM-10082155","CDM","C1713","HCPCS","0278","RC","","","","both","","","3957.00","2967.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3145.82","79.5","","800.18","480.96","1887.97","195","1226.67","3145.82","percent of total billed charges",""
"FIBULA PLATE DISTAL MAXLOCK EXTREME DFX LT LONG","SUP-ITM-10082155","CDM","C1713","HCPCS","0278","RC","","","","both","","","3957.00","2967.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2109.08","53.3","","813.12","216.42","1444.50","81","1226.67","3145.82","percent of total billed charges",""
"FIBULA PLATE DISTAL MAXLOCK EXTREME DFX LT LONG","SUP-ITM-10082155","CDM","C1713","HCPCS","0278","RC","","","","both","","","3957.00","2967.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1226.67","31","","432.60","432.60","432.60","1 through 10","1226.67","3145.82","percent of total billed charges",""
"FIBULA PLATE DISTAL MAXLOCK EXTREME DFX LT LONG","SUP-ITM-10082155","CDM","C1713","HCPCS","0278","RC","","","","both","","","3957.00","2967.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1444.31","36.5","","148.37","54.89","631.39","94","1226.67","3145.82","percent of total billed charges",""
"FIBULA PLATE DISTAL MAXLOCK EXTREME DFX LT LONG","SUP-ITM-10082155","CDM","C1713","HCPCS","0278","RC","","","","both","","","3957.00","2967.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1515.53","38.3","","279.30","91.72","1116.77","266","1226.67","3145.82","percent of total billed charges",""
"FIBULA PLATE DISTAL MAXLOCK EXTREME DFX LT LONG","SUP-ITM-10082155","CDM","C1713","HCPCS","0278","RC","","","","both","","","3957.00","2967.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1697.55","42.9","","731.00","63.70","731.00","1 through 10","1226.67","3145.82","percent of total billed charges",""
"FIBULA PLATE DISTAL MAXLOCK EXTREME DFX LT LONG","SUP-ITM-10082155","CDM","C1713","HCPCS","0278","RC","","","","both","","","3957.00","2967.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1697.55","42.9","","384.74","384.74","384.74","1 through 10","1226.67","3145.82","percent of total billed charges",""
"FIBULA PLATE DISTAL MAXLOCK EXTREME DFX LT LONG","SUP-ITM-10082155","CDM","C1713","HCPCS","0278","RC","","","","both","","","3957.00","2967.75","WELLPOINT [1015]","HB AMC WELLPOINT","2919.47","73.78","","286.63","119.22","1107.45","105","1226.67","3145.82","percent of total billed charges",""
"FIBULA PLATE DISTAL MAXLOCK EXTREME DFX LT LONG","SUP-ITM-10082155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3957.00","2967.75","AETNA [1001]","HB AMC AETNA HMO","2761.99","69.8","","675.31","184.75","1721.50","286","2067.93","3233.66","percent of total billed charges",""
"FIBULA PLATE DISTAL MAXLOCK EXTREME DFX LT LONG","SUP-ITM-10082155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3957.00","2967.75","AETNA [1001]","HB AMC AETNA PPO","3181.43","80.4","","1261.44","103.12","1514.10","21","2067.93","3233.66","percent of total billed charges",""
"FIBULA PLATE DISTAL MAXLOCK EXTREME DFX LT LONG","SUP-ITM-10082155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3957.00","2967.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3181.43","80.4","","1365.00","1365.00","1365.00","1 through 10","2067.93","3233.66","percent of total billed charges",""
"FIBULA PLATE DISTAL MAXLOCK EXTREME DFX LT LONG","SUP-ITM-10082155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3957.00","2967.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3233.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2067.93","3233.66","percent of total billed charges",""
"FIBULA PLATE DISTAL MAXLOCK EXTREME DFX LT LONG","SUP-ITM-10082155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3957.00","2967.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3233.66","81.72","","431.26","71.26","1459.57","88","2067.93","3233.66","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.63","1003.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1063.42","79.5","","800.18","480.96","1887.97","195","414.67","1063.42","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.63","1003.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","712.96","53.3","","813.12","216.42","1444.50","81","414.67","1063.42","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.63","1003.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","414.67","31","","432.60","432.60","432.60","1 through 10","414.67","1063.42","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.63","1003.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","488.23","36.5","","148.37","54.89","631.39","94","414.67","1063.42","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.63","1003.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","512.31","38.3","","279.30","91.72","1116.77","266","414.67","1063.42","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.63","1003.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","573.84","42.9","","731.00","63.70","731.00","1 through 10","414.67","1063.42","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.63","1003.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","573.84","42.9","","384.74","384.74","384.74","1 through 10","414.67","1063.42","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.63","1003.22","WELLPOINT [1015]","HB AMC WELLPOINT","986.90","73.78","","286.63","119.22","1107.45","105","414.67","1063.42","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1337.63","1003.22","AETNA [1001]","HB AMC AETNA HMO","933.67","69.8","","675.31","184.75","1721.50","286","699.05","1093.11","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1337.63","1003.22","AETNA [1001]","HB AMC AETNA PPO","1075.45","80.4","","1261.44","103.12","1514.10","21","699.05","1093.11","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1337.63","1003.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1075.45","80.4","","1365.00","1365.00","1365.00","1 through 10","699.05","1093.11","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1337.63","1003.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1093.11","81.72","","5157.68","5157.68","5157.68","1 through 10","699.05","1093.11","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1337.63","1003.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1093.11","81.72","","431.26","71.26","1459.57","88","699.05","1093.11","percent of total billed charges",""
"FILLER COSMETIC 1ML JUVEDERM XC ULTRA LIDOCAINE PRESERV","SUP-ITM-10215486","CDM","C1878","HCPCS","0278","RC","","","","both","","","2198.70","1649.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1747.97","79.5","","1991.51","1991.51","1991.51","1 through 10","681.6","1747.97","percent of total billed charges",""
"FILLER COSMETIC 1ML JUVEDERM XC ULTRA LIDOCAINE PRESERV","SUP-ITM-10215486","CDM","C1878","HCPCS","0278","RC","","","","both","","","2198.70","1649.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","802.53","36.5","","650.52","650.52","650.52","1 through 10","681.6","1747.97","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.00","2947.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3124.35","79.5","","800.18","480.96","1887.97","195","1218.3","3124.35","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.00","2947.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2094.69","53.3","","813.12","216.42","1444.50","81","1218.3","3124.35","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.00","2947.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1218.30","31","","432.60","432.60","432.60","1 through 10","1218.3","3124.35","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.00","2947.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1434.45","36.5","","148.37","54.89","631.39","94","1218.3","3124.35","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.00","2947.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1505.19","38.3","","279.30","91.72","1116.77","266","1218.3","3124.35","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.00","2947.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1685.97","42.9","","731.00","63.70","731.00","1 through 10","1218.3","3124.35","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.00","2947.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1685.97","42.9","","384.74","384.74","384.74","1 through 10","1218.3","3124.35","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.00","2947.50","WELLPOINT [1015]","HB AMC WELLPOINT","2899.55","73.78","","286.63","119.22","1107.45","105","1218.3","3124.35","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3930.00","2947.50","AETNA [1001]","HB AMC AETNA HMO","2743.14","69.8","","675.31","184.75","1721.50","286","2053.82","3211.6","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3930.00","2947.50","AETNA [1001]","HB AMC AETNA PPO","3159.72","80.4","","1261.44","103.12","1514.10","21","2053.82","3211.6","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3930.00","2947.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3159.72","80.4","","1365.00","1365.00","1365.00","1 through 10","2053.82","3211.6","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3930.00","2947.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3211.60","81.72","","5157.68","5157.68","5157.68","1 through 10","2053.82","3211.6","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3930.00","2947.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3211.60","81.72","","431.26","71.26","1459.57","88","2053.82","3211.6","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2490.34","79.5","","800.18","480.96","1887.97","195","971.08","2490.34","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1669.62","53.3","","813.12","216.42","1444.50","81","971.08","2490.34","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","971.08","31","","432.60","432.60","432.60","1 through 10","971.08","2490.34","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1143.36","36.5","","148.37","54.89","631.39","94","971.08","2490.34","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1199.75","38.3","","279.30","91.72","1116.77","266","971.08","2490.34","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1343.84","42.9","","731.00","63.70","731.00","1 through 10","971.08","2490.34","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1343.84","42.9","","384.74","384.74","384.74","1 through 10","971.08","2490.34","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","WELLPOINT [1015]","HB AMC WELLPOINT","2311.16","73.78","","286.63","119.22","1107.45","105","971.08","2490.34","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","AETNA [1001]","HB AMC AETNA HMO","2186.49","69.8","","675.31","184.75","1721.50","286","1637.04","2559.88","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","AETNA [1001]","HB AMC AETNA PPO","2518.53","80.4","","1261.44","103.12","1514.10","21","1637.04","2559.88","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2518.53","80.4","","1365.00","1365.00","1365.00","1 through 10","1637.04","2559.88","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2559.88","81.72","","5157.68","5157.68","5157.68","1 through 10","1637.04","2559.88","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2559.88","81.72","","431.26","71.26","1459.57","88","1637.04","2559.88","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.10","3643.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3862.19","79.5","","800.18","480.96","1887.97","195","1506.01","3862.19","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.10","3643.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2589.37","53.3","","813.12","216.42","1444.50","81","1506.01","3862.19","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.10","3643.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1506.01","31","","432.60","432.60","432.60","1 through 10","1506.01","3862.19","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.10","3643.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1773.21","36.5","","148.37","54.89","631.39","94","1506.01","3862.19","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.10","3643.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1860.65","38.3","","279.30","91.72","1116.77","266","1506.01","3862.19","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.10","3643.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2084.12","42.9","","731.00","63.70","731.00","1 through 10","1506.01","3862.19","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.10","3643.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2084.12","42.9","","384.74","384.74","384.74","1 through 10","1506.01","3862.19","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.10","3643.57","WELLPOINT [1015]","HB AMC WELLPOINT","3584.31","73.78","","286.63","119.22","1107.45","105","1506.01","3862.19","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4858.10","3643.57","AETNA [1001]","HB AMC AETNA HMO","3390.95","69.8","","675.31","184.75","1721.50","286","2538.84","3970.04","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4858.10","3643.57","AETNA [1001]","HB AMC AETNA PPO","3905.91","80.4","","1261.44","103.12","1514.10","21","2538.84","3970.04","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4858.10","3643.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3905.91","80.4","","1365.00","1365.00","1365.00","1 through 10","2538.84","3970.04","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4858.10","3643.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3970.04","81.72","","5157.68","5157.68","5157.68","1 through 10","2538.84","3970.04","percent of total billed charges",""
"FILLER VOID 10ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE IMPL NORIAN SRS","SUP-ITM-10118187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4858.10","3643.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3970.04","81.72","","431.26","71.26","1459.57","88","2538.84","3970.04","percent of total billed charges",""
"FILLER VOID 10ML BONE DRILLABLE CALCIUM","SUP-ITM-10321556","CDM","C1713","HCPCS","0278","RC","","","","both","","","7437.30","5577.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5912.65","79.5","","800.18","480.96","1887.97","195","2305.56","5912.65","percent of total billed charges",""
"FILLER VOID 10ML BONE DRILLABLE CALCIUM","SUP-ITM-10321556","CDM","C1713","HCPCS","0278","RC","","","","both","","","7437.30","5577.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3964.08","53.3","","813.12","216.42","1444.50","81","2305.56","5912.65","percent of total billed charges",""
"FILLER VOID 10ML BONE DRILLABLE CALCIUM","SUP-ITM-10321556","CDM","C1713","HCPCS","0278","RC","","","","both","","","7437.30","5577.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2305.56","31","","432.60","432.60","432.60","1 through 10","2305.56","5912.65","percent of total billed charges",""
"FILLER VOID 10ML BONE DRILLABLE CALCIUM","SUP-ITM-10321556","CDM","C1713","HCPCS","0278","RC","","","","both","","","7437.30","5577.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2714.61","36.5","","148.37","54.89","631.39","94","2305.56","5912.65","percent of total billed charges",""
"FILLER VOID 10ML BONE DRILLABLE CALCIUM","SUP-ITM-10321556","CDM","C1713","HCPCS","0278","RC","","","","both","","","7437.30","5577.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2848.49","38.3","","279.30","91.72","1116.77","266","2305.56","5912.65","percent of total billed charges",""
"FILLER VOID 10ML BONE DRILLABLE CALCIUM","SUP-ITM-10321556","CDM","C1713","HCPCS","0278","RC","","","","both","","","7437.30","5577.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3190.60","42.9","","731.00","63.70","731.00","1 through 10","2305.56","5912.65","percent of total billed charges",""
"FILLER VOID 10ML BONE DRILLABLE CALCIUM","SUP-ITM-10321556","CDM","C1713","HCPCS","0278","RC","","","","both","","","7437.30","5577.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3190.60","42.9","","384.74","384.74","384.74","1 through 10","2305.56","5912.65","percent of total billed charges",""
"FILLER VOID 10ML BONE DRILLABLE CALCIUM","SUP-ITM-10321556","CDM","C1713","HCPCS","0278","RC","","","","both","","","7437.30","5577.97","WELLPOINT [1015]","HB AMC WELLPOINT","5487.24","73.78","","286.63","119.22","1107.45","105","2305.56","5912.65","percent of total billed charges",""
"FILLER VOID 10ML BONE DRILLABLE CALCIUM","SUP-ITM-10321556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7437.30","5577.97","AETNA [1001]","HB AMC AETNA HMO","5191.24","69.8","","675.31","184.75","1721.50","286","3886.73","6077.76","percent of total billed charges",""
"FILLER VOID 10ML BONE DRILLABLE CALCIUM","SUP-ITM-10321556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7437.30","5577.97","AETNA [1001]","HB AMC AETNA PPO","5979.59","80.4","","1261.44","103.12","1514.10","21","3886.73","6077.76","percent of total billed charges",""
"FILLER VOID 10ML BONE DRILLABLE CALCIUM","SUP-ITM-10321556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7437.30","5577.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5979.59","80.4","","1365.00","1365.00","1365.00","1 through 10","3886.73","6077.76","percent of total billed charges",""
"FILLER VOID 10ML BONE DRILLABLE CALCIUM","SUP-ITM-10321556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7437.30","5577.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6077.76","81.72","","5157.68","5157.68","5157.68","1 through 10","3886.73","6077.76","percent of total billed charges",""
"FILLER VOID 10ML BONE DRILLABLE CALCIUM","SUP-ITM-10321556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7437.30","5577.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6077.76","81.72","","431.26","71.26","1459.57","88","3886.73","6077.76","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3460.24","2595.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2750.89","79.5","","800.18","480.96","1887.97","195","1072.67","2750.89","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3460.24","2595.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1844.31","53.3","","813.12","216.42","1444.50","81","1072.67","2750.89","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3460.24","2595.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1072.67","31","","432.60","432.60","432.60","1 through 10","1072.67","2750.89","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3460.24","2595.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1262.99","36.5","","148.37","54.89","631.39","94","1072.67","2750.89","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3460.24","2595.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1325.27","38.3","","279.30","91.72","1116.77","266","1072.67","2750.89","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3460.24","2595.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1484.44","42.9","","731.00","63.70","731.00","1 through 10","1072.67","2750.89","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3460.24","2595.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1484.44","42.9","","384.74","384.74","384.74","1 through 10","1072.67","2750.89","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3460.24","2595.18","WELLPOINT [1015]","HB AMC WELLPOINT","2552.97","73.78","","286.63","119.22","1107.45","105","1072.67","2750.89","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3460.24","2595.18","AETNA [1001]","HB AMC AETNA HMO","2415.25","69.8","","675.31","184.75","1721.50","286","1808.32","2827.71","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3460.24","2595.18","AETNA [1001]","HB AMC AETNA PPO","2782.03","80.4","","1261.44","103.12","1514.10","21","1808.32","2827.71","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3460.24","2595.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2782.03","80.4","","1365.00","1365.00","1365.00","1 through 10","1808.32","2827.71","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3460.24","2595.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2827.71","81.72","","5157.68","5157.68","5157.68","1 through 10","1808.32","2827.71","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3460.24","2595.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2827.71","81.72","","431.26","71.26","1459.57","88","1808.32","2827.71","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","both","","","4971.20","3728.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3952.10","79.5","","800.18","480.96","1887.97","195","1541.07","3952.1","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","both","","","4971.20","3728.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2649.65","53.3","","813.12","216.42","1444.50","81","1541.07","3952.1","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","both","","","4971.20","3728.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1541.07","31","","432.60","432.60","432.60","1 through 10","1541.07","3952.1","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","both","","","4971.20","3728.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1814.49","36.5","","148.37","54.89","631.39","94","1541.07","3952.1","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","both","","","4971.20","3728.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1903.97","38.3","","279.30","91.72","1116.77","266","1541.07","3952.1","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","both","","","4971.20","3728.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2132.64","42.9","","731.00","63.70","731.00","1 through 10","1541.07","3952.1","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","both","","","4971.20","3728.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2132.64","42.9","","384.74","384.74","384.74","1 through 10","1541.07","3952.1","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","both","","","4971.20","3728.40","WELLPOINT [1015]","HB AMC WELLPOINT","3667.75","73.78","","286.63","119.22","1107.45","105","1541.07","3952.1","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4971.20","3728.40","AETNA [1001]","HB AMC AETNA HMO","3469.90","69.8","","675.31","184.75","1721.50","286","2597.95","4062.46","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4971.20","3728.40","AETNA [1001]","HB AMC AETNA PPO","3996.84","80.4","","1261.44","103.12","1514.10","21","2597.95","4062.46","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4971.20","3728.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3996.84","80.4","","1365.00","1365.00","1365.00","1 through 10","2597.95","4062.46","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4971.20","3728.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4062.46","81.72","","5157.68","5157.68","5157.68","1 through 10","2597.95","4062.46","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4971.20","3728.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4062.46","81.72","","431.26","71.26","1459.57","88","2597.95","4062.46","percent of total billed charges",""
"FILTER BIRDS NEST 11FR 40MM 40CM VENA CAVA VASCULAR FEMORAL BX/1EA","SUP-ITM-10024720","CDM","C1880","HCPCS","0278","RC","","","","both","","","4398.75","3299.06","WELLPOINT [1015]","HB AMC WELLPOINT","3245.40","73.78","","2616.17","2616.17","2616.17","1 through 10","1363.61","3497.01","percent of total billed charges",""
"FILTER CELECT 7FR 30MM 49MM 65CM 79CM PLATINUM VENA CAVA VASCULAR FEMORAL NAVALIGN DELIVERY BX/1EA","SUP-ITM-10131862","CDM","C1880","HCPCS","0278","RC","","","","both","","","3514.00","2635.50","WELLPOINT [1015]","HB AMC WELLPOINT","2592.63","73.78","","2616.17","2616.17","2616.17","1 through 10","1089.34","2793.63","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2173.50","1630.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1727.93","79.5","","800.18","480.96","1887.97","195","673.79","1727.93","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2173.50","1630.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1158.48","53.3","","813.12","216.42","1444.50","81","673.79","1727.93","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2173.50","1630.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","673.79","31","","432.60","432.60","432.60","1 through 10","673.79","1727.93","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2173.50","1630.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","793.33","36.5","","148.37","54.89","631.39","94","673.79","1727.93","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2173.50","1630.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","832.45","38.3","","279.30","91.72","1116.77","266","673.79","1727.93","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2173.50","1630.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","932.43","42.9","","731.00","63.70","731.00","1 through 10","673.79","1727.93","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2173.50","1630.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","932.43","42.9","","384.74","384.74","384.74","1 through 10","673.79","1727.93","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2173.50","1630.12","WELLPOINT [1015]","HB AMC WELLPOINT","1603.61","73.78","","286.63","119.22","1107.45","105","673.79","1727.93","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2173.50","1630.12","AETNA [1001]","HB AMC AETNA HMO","1517.10","69.8","","675.31","184.75","1721.50","286","1135.87","1776.18","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2173.50","1630.12","AETNA [1001]","HB AMC AETNA PPO","1747.49","80.4","","1261.44","103.12","1514.10","21","1135.87","1776.18","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2173.50","1630.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1747.49","80.4","","1365.00","1365.00","1365.00","1 through 10","1135.87","1776.18","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2173.50","1630.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1776.18","81.72","","5157.68","5157.68","5157.68","1 through 10","1135.87","1776.18","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2173.50","1630.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1776.18","81.72","","431.26","71.26","1459.57","88","1135.87","1776.18","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3860.36","2895.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3068.99","79.5","","1309.77","674.56","6049.93","26","1196.71","3068.99","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3860.36","2895.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2057.57","53.3","","1901.83","1901.83","2962.25","1 through 10","1196.71","3068.99","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3860.36","2895.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1409.03","36.5","","1620.31","1620.31","19908.88","1 through 10","1196.71","3068.99","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3860.36","2895.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1478.52","38.3","","352.91","352.91","2046.30","1 through 10","1196.71","3068.99","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3860.36","2895.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1656.09","42.9","","9668.75","9668.75","9668.75","1 through 10","1196.71","3068.99","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3860.36","2895.27","WELLPOINT [1015]","HB AMC WELLPOINT","2848.17","73.78","","699.88","384.10","3443.31","33","1196.71","3068.99","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3860.36","2895.27","AETNA [1001]","HB AMC AETNA HMO","2694.53","69.8","","1421.24","264.50","4933.46","29","2017.42","3154.69","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3860.36","2895.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3103.73","80.4","","1022.97","1022.97","3607.50","1 through 10","2017.42","3154.69","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3860.36","2895.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3154.69","81.72","","3010.54","693.88","5019.88","35","2017.42","3154.69","percent of total billed charges",""
"FILTER GUNTHER TULIP 7FR 30MM 50MM 65CM VENA CAVA VASCULAR JUGULAR NAVALIGN DELIVERY BX/1EA","SUP-ITM-10077614","CDM","C1880","HCPCS","0278","RC","","","","both","","","3077.83","2308.37","WELLPOINT [1015]","HB AMC WELLPOINT","2270.82","73.78","","2616.17","2616.17","2616.17","1 through 10","954.13","2446.87","percent of total billed charges",""
"FILTER VASCULAR VENA CAVA REMOVAL SYSTEM RECOVERY CONE","SUP-ITM-10011793","CDM","C1773","HCPCS","0272","RC","","","","both","","","2082.50","1561.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","760.11","36.5","","114.30","97.14","114.30","1 through 10","645.58","1655.59","percent of total billed charges",""
"FILTER VASCULAR VENA CAVA REMOVAL SYSTEM RECOVERY CONE","SUP-ITM-10011793","CDM","C1773","HCPCS","0272","RC","","","","both","","","2082.50","1561.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","797.60","38.3","","119.81","116.44","359.43","20","645.58","1655.59","percent of total billed charges",""
"FILTER VASCULAR VENA CAVA REMOVAL SYSTEM RECOVERY CONE","SUP-ITM-10011793","CDM","C1773","HCPCS","0272","RC","","","","both","","","2082.50","1561.87","WELLPOINT [1015]","HB AMC WELLPOINT","1536.47","73.78","","875.53","228.13","875.53","1 through 10","645.58","1655.59","percent of total billed charges",""
"FILTER VASCULAR VENA CAVA REMOVAL SYSTEM RECOVERY CONE","SUP-ITM-10011793","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","2082.50","1561.87","AETNA [1001]","HB AMC AETNA HMO","1453.59","69.8","","207.45","207.45","207.45","1 through 10","1088.31","1701.82","percent of total billed charges",""
"FILTER VASCULAR VENA CAVA REMOVAL SYSTEM RECOVERY CONE","SUP-ITM-10011793","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","2082.50","1561.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1701.82","81.72","","244.96","134.74","244.96","1 through 10","1088.31","1701.82","percent of total billed charges",""
"Filter Vena Cava T1","PX-27000163","CDM","C1880","HCPCS","0278","RC","","","","both","","","3674.65","2755.99","WELLPOINT [1015]","HB AMC WELLPOINT","2711.16","73.78","","2616.17","2616.17","2616.17","1 through 10","1139.14","2921.35","percent of total billed charges",""
"Fine Needle Aspiration Bx W/CT Gdn 1st Lesion","PX-76002560","CDM","10009","CPT","0761","RC","","","","both","","","1963.00","1472.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1560.59","79.5","","7819.23","7819.23","7819.23","1 through 10","608.53","1560.59","percent of total billed charges",""
"Fine Needle Aspiration Bx W/CT Gdn 1st Lesion","PX-76002560","CDM","10009","CPT","0761","RC","","","","both","","","1963.00","1472.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","819.05","819.05","819.05","1 through 10","608.53","1560.59","other","OPPS APC"
"Fine Needle Aspiration Bx W/CT Gdn 1st Lesion","PX-76002560","CDM","10009","CPT","0761","RC","","","","outpatient","","","1963.00","1472.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.70","1535.70","1535.70","1 through 10","579.34","1604.16","other","ASC "
"Fine Needle Aspiration Bx W/CT Gdn 1st Lesion","PX-76002560","CDM","10009","CPT","0761","RC","","","","outpatient","","","1963.00","1472.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1604.16","81.72","","1522.06","1522.06","1522.06","1 through 10","579.34","1604.16","percent of total billed charges",""
"Fine Needle Aspiration Bx W/CT Gdn 1st Lesion","PX-98301812","CDM","10009","CPT","0983","RC","","","","both","","","462.00","346.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","367.29","79.5","","7819.23","7819.23","7819.23","1 through 10","143.22","1044.34","percent of total billed charges",""
"Fine Needle Aspiration Bx W/CT Gdn 1st Lesion","PX-98301812","CDM","10009","CPT","0983","RC","","","","both","","","462.00","346.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","819.05","819.05","819.05","1 through 10","143.22","1044.34","other","OPPS APC"
"Fine Needle Aspiration Bx W/CT Gdn 1st Lesion","PX-98301812","CDM","10009","CPT","0983","RC","","","","outpatient","","","462.00","346.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","377.55","81.72","","1522.06","1522.06","1522.06","1 through 10","198.2","1234.13","percent of total billed charges",""
"Fine Needle Aspiration Bx W/O Img Gdn 1st Lesion","PX-98301816","CDM","10021","CPT","0983","RC","","","","both","","","277.00","207.75","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","85.87","593.02","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","859.79","859.79","860.69","12","610.08","1564.56","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","15","610.08","1564.56","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1564.56","79.5","","4504.80","1501.60","4887.28","42","610.08","1564.56","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1048.94","53.3","","3022.26","1007.42","3278.87","27","610.08","1564.56","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","692.33","822.19","1 through 10","610.08","1564.56","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","HUMANA [1012]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","824.75","823.86","827.19","1 through 10","610.08","1564.56","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","818.85","818.85","818.85","1 through 10","610.08","1564.56","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","215","610.08","1564.56","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","610.08","31","","589.57","589.57","589.57","1 through 10","610.08","1564.56","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","718.32","36.5","","2072.10","690.70","2135.04","44","610.08","1564.56","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","753.74","38.3","","2238.09","746.03","2238.09","103","610.08","1564.56","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","818.85","752.54","818.85","1 through 10","610.08","1564.56","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","MOLINA [1014]","HB BWH MOLINA","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1657.75","1657.75","1657.75","1 through 10","610.08","1564.56","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1515.36","77","","1488.25","1488.24","1488.25","1 through 10","610.08","1564.56","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","TRICARE [160005]","HB BWH TRICARE","793.78","","APC Price ($835.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","793.78","793.78","793.78","1 through 10","610.08","1564.56","other","Tricare OPPS"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","2456.55","19","610.08","1564.56","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","820.52","818.85","826.35","36","610.08","1564.56","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1968.00","1476.00","WELLPOINT [1015]","HB AMC WELLPOINT","1451.99","73.78","","3328.51","1420.51","3328.51","41","610.08","1564.56","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","AETNA [1001]","HB AMC AETNA HMO","1373.66","69.8","","1291.72","912.02","1488.24","26","579.34","1608.25","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1330.98","1330.98","1355.50","77","579.34","1608.25","other","ASC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1028.48","52.26","","1180.67","1180.67","1180.67","1 through 10","579.34","1608.25","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.70","1535.70","1550.94","189","579.34","1608.25","other","ASC "
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1483.11","1320.90","1680.09","1 through 10","579.34","1608.25","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","1344.07","4032.21","101","579.34","1608.25","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4240.77","1413.59","4240.77","57","579.34","1608.25","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1680.09","1616.36","1680.09","1 through 10","579.34","1608.25","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1413.59","1413.59","1413.59","1 through 10","579.34","1608.25","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1483.11","1483.11","2966.22","12","579.34","1608.25","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1582.27","80.4","","1488.24","1488.24","1488.24","1 through 10","579.34","1608.25","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1525.25","1276.08","1525.25","1 through 10","579.34","1608.25","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1608.25","81.72","","1525.26","1525.26","1525.26","1 through 10","579.34","1608.25","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1968.00","1476.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1608.25","81.72","","1525.26","838.95","1525.26","32","579.34","1608.25","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","859.79","859.79","860.69","12","117.8","1044.34","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","15","117.8","1044.34","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","302.10","79.5","","4504.80","1501.60","4887.28","42","117.8","1044.34","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","202.54","53.3","","3022.26","1007.42","3278.87","27","117.8","1044.34","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","692.33","822.19","1 through 10","117.8","1044.34","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","HUMANA [1012]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","824.75","823.86","827.19","1 through 10","117.8","1044.34","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","818.85","818.85","818.85","1 through 10","117.8","1044.34","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","215","117.8","1044.34","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","117.80","31","","589.57","589.57","589.57","1 through 10","117.8","1044.34","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","138.70","36.5","","2072.10","690.70","2135.04","44","117.8","1044.34","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","145.54","38.3","","2238.09","746.03","2238.09","103","117.8","1044.34","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","818.85","752.54","818.85","1 through 10","117.8","1044.34","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","MOLINA [1014]","HB BWH MOLINA","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1657.75","1657.75","1657.75","1 through 10","117.8","1044.34","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","292.60","77","","1488.25","1488.24","1488.25","1 through 10","117.8","1044.34","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","TRICARE [160005]","HB BWH TRICARE","793.78","","APC Price ($835.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","793.78","793.78","793.78","1 through 10","117.8","1044.34","other","Tricare OPPS"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","2456.55","19","117.8","1044.34","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","820.52","818.85","826.35","36","117.8","1044.34","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","WELLPOINT [1015]","HB AMC WELLPOINT","280.36","73.78","","3328.51","1420.51","3328.51","41","117.8","1044.34","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","AETNA [1001]","HB AMC AETNA HMO","265.24","69.8","","1291.72","912.02","1488.24","26","206.4","1234.13","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1483.11","1320.90","1680.09","1 through 10","206.4","1234.13","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","1344.07","4032.21","101","206.4","1234.13","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4240.77","1413.59","4240.77","57","206.4","1234.13","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1680.09","1616.36","1680.09","1 through 10","206.4","1234.13","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1413.59","1413.59","1413.59","1 through 10","206.4","1234.13","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1483.11","1483.11","2966.22","12","206.4","1234.13","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","305.52","80.4","","1488.24","1488.24","1488.24","1 through 10","206.4","1234.13","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1525.25","1276.08","1525.25","1 through 10","206.4","1234.13","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","310.54","81.72","","1525.26","1525.26","1525.26","1 through 10","206.4","1234.13","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","310.54","81.72","","1525.26","838.95","1525.26","32","206.4","1234.13","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-76002557","CDM","10006","CPT","0761","RC","","","","both","","","1430.00","1072.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","762.19","53.3","","4776.31","4776.31","4776.31","1 through 10","443.3","1136.85","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-76002557","CDM","10006","CPT","0761","RC","","","","both","","","1430.00","1072.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","547.69","38.3","","1626.96","542.32","1626.96","1 through 10","443.3","1136.85","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-76002557","CDM","10006","CPT","0761","RC","","","","both","","","1430.00","1072.50","WELLPOINT [1015]","HB AMC WELLPOINT","1055.05","73.78","","2419.62","1032.62","2419.62","1 through 10","443.3","1136.85","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-76002557","CDM","10006","CPT","0761","RC","","","","outpatient","","","1430.00","1072.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1168.60","81.72","","1108.77","1108.77","1108.77","1 through 10","83.21","1168.6","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-98301809","CDM","10006","CPT","0983","RC","","","","both","","","258.00","193.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","137.51","53.3","","4776.31","4776.31","4776.31","1 through 10","79.98","205.11","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-98301809","CDM","10006","CPT","0983","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","98.81","38.3","","1626.96","542.32","1626.96","1 through 10","79.98","205.11","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-98301809","CDM","10006","CPT","0983","RC","","","","both","","","258.00","193.50","WELLPOINT [1015]","HB AMC WELLPOINT","190.35","73.78","","2419.62","1032.62","2419.62","1 through 10","79.98","205.11","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-98301809","CDM","10006","CPT","0983","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","210.84","81.72","","1108.77","1108.77","1108.77","1 through 10","141.7","210.84","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.43","31.22","241.26","1 through 10","60.28","412.61","other","OPPS APC"
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","363.30","70","","362.16","362.16","362.16","1 through 10","60.28","412.61","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","412.61","79.5","","395.86","379.26","1187.58","33","60.28","412.61","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","276.63","53.3","","1187.58","265.58","1187.58","1 through 10","60.28","412.61","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","399.63","77","","387.31","387.31","387.31","1 through 10","60.28","412.61","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","MEDICARE [2001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.45","59.14","63.45","17","60.28","412.61","other","OPPS APC"
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","160.89","31","","155.43","155.43","155.43","1 through 10","60.28","412.61","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","189.44","36.5","","187.62","159.45","546.26","38","60.28","412.61","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","198.78","38.3","","196.67","191.14","573.42","65","60.28","412.61","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.18","62.18","62.18","1 through 10","60.28","412.61","other","OPPS APC"
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","399.63","77","","392.34","392.34","392.34","1 through 10","60.28","412.61","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","31.09","31.09","31.09","1 through 10","60.28","412.61","other","OPPS APC"
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.65","42.9","","1206.29","1206.29","1206.29","1 through 10","60.28","412.61","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.18","31.10","62.39","1 through 10","60.28","412.61","other","OPPS APC"
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","519.00","389.25","WELLPOINT [1015]","HB AMC WELLPOINT","382.92","73.78","","877.48","374.48","2386.48","62","60.28","412.61","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","outpatient","","","519.00","389.25","AETNA [1001]","HB AMC AETNA HMO","362.26","69.8","","639.28","340.53","2383.71","1 through 10","104.94","424.13","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","outpatient","","","519.00","389.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","271.23","52.26","","311.26","311.26","311.26","1 through 10","104.94","424.13","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","outpatient","","","519.00","389.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","417.28","80.4","","326.95","251.50","392.34","1 through 10","104.94","424.13","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","outpatient","","","519.00","389.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","424.13","81.72","","402.10","402.10","402.10","1 through 10","104.94","424.13","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","outpatient","","","519.00","389.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","424.13","81.72","","402.10","221.17","402.10","68","104.94","424.13","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2597.32","52.26","","3643.50","3643.50","3643.50","1 through 10","1540.7","3951.15","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3951.15","79.5","","2867.44","1923.77","8602.29","1 through 10","1540.7","3951.15","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2649.01","53.3","","5771.31","1397.09","6509.05","16","1540.7","3951.15","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3951.15","79.5","","5730.95","5730.95","5730.95","1 through 10","1540.7","3951.15","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1814.05","36.5","","1154.99","1154.99","1318.95","1 through 10","1540.7","3951.15","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1903.51","38.3","","1424.61","1034.59","4273.83","20","1540.7","3951.15","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2132.13","42.9","","2912.61","2912.61","2912.61","1 through 10","1540.7","3951.15","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","WELLPOINT [1015]","HB AMC WELLPOINT","3666.87","73.78","","2712.59","1969.95","2712.59","1 through 10","1540.7","3951.15","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","4970.00","3727.50","AETNA [1001]","HB AMC AETNA HMO","3469.06","69.8","","4933.30","1741.59","4933.30","1 through 10","2597.32","4061.48","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","4970.00","3727.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2597.32","52.26","","3643.50","3643.50","3643.50","1 through 10","2597.32","4061.48","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","4970.00","3727.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4061.48","81.72","","2115.21","1602.05","5825.23","1 through 10","2597.32","4061.48","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3350.13","79.5","","800.18","480.96","1887.97","195","1306.34","3350.13","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2246.06","53.3","","813.12","216.42","1444.50","81","1306.34","3350.13","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1306.34","31","","432.60","432.60","432.60","1 through 10","1306.34","3350.13","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1538.11","36.5","","148.37","54.89","631.39","94","1306.34","3350.13","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1613.96","38.3","","279.30","91.72","1116.77","266","1306.34","3350.13","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1807.81","42.9","","731.00","63.70","731.00","1 through 10","1306.34","3350.13","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1807.81","42.9","","384.74","384.74","384.74","1 through 10","1306.34","3350.13","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","WELLPOINT [1015]","HB AMC WELLPOINT","3109.09","73.78","","286.63","119.22","1107.45","105","1306.34","3350.13","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","AETNA [1001]","HB AMC AETNA HMO","2941.37","69.8","","675.31","184.75","1721.50","286","2202.24","3443.68","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","AETNA [1001]","HB AMC AETNA PPO","3388.06","80.4","","1261.44","103.12","1514.10","21","2202.24","3443.68","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3388.06","80.4","","1365.00","1365.00","1365.00","1 through 10","2202.24","3443.68","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3443.68","81.72","","5157.68","5157.68","5157.68","1 through 10","2202.24","3443.68","percent of total billed charges",""
"FINGER SPACER 5MMX24CM SWANSON SILICONE TENDON ROD","SUP-ITM-10003645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3443.68","81.72","","431.26","71.26","1459.57","88","2202.24","3443.68","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","5970.00","4477.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3119.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1850.7","4746.15","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","5970.00","4477.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4746.15","79.5","","1293.60","1148.53","1603.80","1 through 10","1850.7","4746.15","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","5970.00","4477.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2179.05","36.5","","1023.42","771.29","2068.67","33","1850.7","4746.15","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","5970.00","4477.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2286.51","38.3","","850.52","759.78","1211.25","66","1850.7","4746.15","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","5970.00","4477.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2561.13","42.9","","2548.09","2548.09","2548.09","1 through 10","1850.7","4746.15","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","5970.00","4477.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2561.13","42.9","","956.46","956.46","956.46","1 through 10","1850.7","4746.15","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","5970.00","4477.50","WELLPOINT [1015]","HB AMC WELLPOINT","4404.67","73.78","","2344.73","1619.47","2530.35","16","1850.7","4746.15","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5970.00","4477.50","AETNA [1001]","HB AMC AETNA HMO","4167.06","69.8","","1523.63","988.41","4330.26","39","3119.92","4878.68","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5970.00","4477.50","AETNA [1001]","HB AMC AETNA PPO","4799.88","80.4","","1670.25","1670.25","1670.25","1 through 10","3119.92","4878.68","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5970.00","4477.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3119.92","52.26","","1113.10","1113.10","1113.10","1 through 10","3119.92","4878.68","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5970.00","4477.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4878.68","81.72","","1738.90","1484.65","2716.94","38","3119.92","4878.68","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","7770.00","5827.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4060.60","52.26","","1113.10","1113.10","1113.10","1 through 10","2408.7","6177.15","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","7770.00","5827.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6177.15","79.5","","1293.60","1148.53","1603.80","1 through 10","2408.7","6177.15","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","7770.00","5827.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2836.05","36.5","","1023.42","771.29","2068.67","33","2408.7","6177.15","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","7770.00","5827.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2975.91","38.3","","850.52","759.78","1211.25","66","2408.7","6177.15","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","7770.00","5827.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3333.33","42.9","","2548.09","2548.09","2548.09","1 through 10","2408.7","6177.15","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","7770.00","5827.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3333.33","42.9","","956.46","956.46","956.46","1 through 10","2408.7","6177.15","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","7770.00","5827.50","WELLPOINT [1015]","HB AMC WELLPOINT","5732.71","73.78","","2344.73","1619.47","2530.35","16","2408.7","6177.15","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7770.00","5827.50","AETNA [1001]","HB AMC AETNA HMO","5423.46","69.8","","1523.63","988.41","4330.26","39","4060.6","6349.64","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7770.00","5827.50","AETNA [1001]","HB AMC AETNA PPO","6247.08","80.4","","1670.25","1670.25","1670.25","1 through 10","4060.6","6349.64","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7770.00","5827.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4060.60","52.26","","1113.10","1113.10","1113.10","1 through 10","4060.6","6349.64","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7770.00","5827.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6349.64","81.72","","1738.90","1484.65","2716.94","38","4060.6","6349.64","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.62","52.26","","1113.10","1113.10","1113.10","1 through 10","1266.82","3248.79","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3248.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1266.82","3248.79","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1491.58","36.5","","1023.42","771.29","2068.67","33","1266.82","3248.79","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1565.14","38.3","","850.52","759.78","1211.25","66","1266.82","3248.79","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.12","42.9","","2548.09","2548.09","2548.09","1 through 10","1266.82","3248.79","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.12","42.9","","956.46","956.46","956.46","1 through 10","1266.82","3248.79","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","WELLPOINT [1015]","HB AMC WELLPOINT","3015.04","73.78","","2344.73","1619.47","2530.35","16","1266.82","3248.79","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.53","3064.90","AETNA [1001]","HB AMC AETNA HMO","2852.40","69.8","","1523.63","988.41","4330.26","39","2135.62","3339.51","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.53","3064.90","AETNA [1001]","HB AMC AETNA PPO","3285.57","80.4","","1670.25","1670.25","1670.25","1 through 10","2135.62","3339.51","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.53","3064.90","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.62","52.26","","1113.10","1113.10","1113.10","1 through 10","2135.62","3339.51","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.53","3064.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3339.51","81.72","","1738.90","1484.65","2716.94","38","2135.62","3339.51","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2597.32","52.26","","1113.10","1113.10","1113.10","1 through 10","1540.7","3951.15","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3951.15","79.5","","1293.60","1148.53","1603.80","1 through 10","1540.7","3951.15","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1814.05","36.5","","1023.42","771.29","2068.67","33","1540.7","3951.15","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1903.51","38.3","","850.52","759.78","1211.25","66","1540.7","3951.15","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2132.13","42.9","","2548.09","2548.09","2548.09","1 through 10","1540.7","3951.15","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2132.13","42.9","","956.46","956.46","956.46","1 through 10","1540.7","3951.15","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","WELLPOINT [1015]","HB AMC WELLPOINT","3666.87","73.78","","2344.73","1619.47","2530.35","16","1540.7","3951.15","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4970.00","3727.50","AETNA [1001]","HB AMC AETNA HMO","3469.06","69.8","","1523.63","988.41","4330.26","39","2597.32","4061.48","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4970.00","3727.50","AETNA [1001]","HB AMC AETNA PPO","3995.88","80.4","","1670.25","1670.25","1670.25","1 through 10","2597.32","4061.48","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4970.00","3727.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2597.32","52.26","","1113.10","1113.10","1113.10","1 through 10","2597.32","4061.48","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4970.00","3727.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4061.48","81.72","","1738.90","1484.65","2716.94","38","2597.32","4061.48","percent of total billed charges",""
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","both","","","440.00","330.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","246.04","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","245.83","223.78","246.63","1 through 10","136.4","349.8","other","OPPS APC"
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","both","","","440.00","330.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.08","214.00","235.08","1 through 10","136.4","349.8","other","OPPS APC"
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","both","","","440.00","330.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.08","235.08","235.08","1 through 10","136.4","349.8","other","OPPS APC"
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","both","","","440.00","330.00","MEDICARE [2001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","238.90","238.90","238.90","39","136.4","349.8","other","OPPS APC"
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","both","","","440.00","330.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","47.50","47.50","47.50","1 through 10","136.4","349.8","other","OPPS APC"
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","160.60","36.5","","159.27","159.27","159.27","1 through 10","136.4","349.8","percent of total billed charges",""
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","168.52","38.3","","166.96","166.96","166.96","1 through 10","136.4","349.8","percent of total billed charges",""
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","both","","","440.00","330.00","MOLINA [1014]","HB BWH MOLINA","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","475.47","473.98","475.47","1 through 10","136.4","349.8","other","OPPS APC"
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","both","","","440.00","330.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","706.66","213.13","706.66","1 through 10","136.4","349.8","other","OPPS APC"
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","both","","","440.00","330.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","234.12","234.12","238.90","16","136.4","349.8","other","OPPS APC"
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","both","","","440.00","330.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.76","42.9","","187.75","187.75","187.75","1 through 10","136.4","349.8","percent of total billed charges",""
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","both","","","440.00","330.00","WELLPOINT [1015]","HB AMC WELLPOINT","324.63","73.78","","317.90","317.90","317.90","1 through 10","136.4","349.8","percent of total billed charges",""
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","outpatient","","","440.00","330.00","AETNA [1001]","HB AMC AETNA HMO","307.12","69.8","","289.08","289.08","289.08","1 through 10","165.93","700.33","percent of total billed charges",""
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","outpatient","","","440.00","330.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","388.23","388.23","388.23","1 through 10","165.93","700.33","other","ASC"
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","outpatient","","","440.00","330.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","439.84","439.84","444.20","11","165.93","700.33","other","ASC "
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","outpatient","","","440.00","330.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1924.80","384.96","1924.80","1 through 10","165.93","700.33","other","Multiple Surgery"
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","outpatient","","","440.00","330.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","404.87","404.87","1 through 10","165.93","700.33","other","Multiple Surgery"
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","outpatient","","","440.00","330.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","212.39","212.39","212.39","1 through 10","165.93","700.33","other","Multiple Surgery"
"Fitting/Insertion Pessary","PX-76001352","CDM","57160","CPT","0761","RC","","","","outpatient","","","440.00","330.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","359.57","81.72","","341.34","341.34","341.34","1 through 10","165.93","700.33","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","333.90","79.5","","800.18","480.96","1887.97","195","130.2","333.9","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","223.86","53.3","","813.12","216.42","1444.50","81","130.2","333.9","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","130.20","31","","432.60","432.60","432.60","1 through 10","130.2","333.9","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","153.30","36.5","","148.37","54.89","631.39","94","130.2","333.9","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","160.86","38.3","","279.30","91.72","1116.77","266","130.2","333.9","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.18","42.9","","731.00","63.70","731.00","1 through 10","130.2","333.9","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.18","42.9","","384.74","384.74","384.74","1 through 10","130.2","333.9","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","WELLPOINT [1015]","HB AMC WELLPOINT","309.88","73.78","","286.63","119.22","1107.45","105","130.2","333.9","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","AETNA [1001]","HB AMC AETNA HMO","293.16","69.8","","675.31","184.75","1721.50","286","219.49","343.22","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","AETNA [1001]","HB AMC AETNA PPO","337.68","80.4","","1261.44","103.12","1514.10","21","219.49","343.22","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","337.68","80.4","","1365.00","1365.00","1365.00","1 through 10","219.49","343.22","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","343.22","81.72","","5157.68","5157.68","5157.68","1 through 10","219.49","343.22","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","343.22","81.72","","431.26","71.26","1459.57","88","219.49","343.22","percent of total billed charges",""
"FIXATOR WRIST 220MM LOW PROFILE SELF DRILLING ROD MR CONDITIONAL","SUP-ITM-10036580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.24","2654.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2813.70","79.5","","800.18","480.96","1887.97","195","1097.16","2813.7","percent of total billed charges",""
"FIXATOR WRIST 220MM LOW PROFILE SELF DRILLING ROD MR CONDITIONAL","SUP-ITM-10036580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.24","2654.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1886.41","53.3","","813.12","216.42","1444.50","81","1097.16","2813.7","percent of total billed charges",""
"FIXATOR WRIST 220MM LOW PROFILE SELF DRILLING ROD MR CONDITIONAL","SUP-ITM-10036580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.24","2654.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1097.16","31","","432.60","432.60","432.60","1 through 10","1097.16","2813.7","percent of total billed charges",""
"FIXATOR WRIST 220MM LOW PROFILE SELF DRILLING ROD MR CONDITIONAL","SUP-ITM-10036580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.24","2654.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1291.82","36.5","","148.37","54.89","631.39","94","1097.16","2813.7","percent of total billed charges",""
"FIXATOR WRIST 220MM LOW PROFILE SELF DRILLING ROD MR CONDITIONAL","SUP-ITM-10036580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.24","2654.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1355.53","38.3","","279.30","91.72","1116.77","266","1097.16","2813.7","percent of total billed charges",""
"FIXATOR WRIST 220MM LOW PROFILE SELF DRILLING ROD MR CONDITIONAL","SUP-ITM-10036580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.24","2654.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1518.33","42.9","","731.00","63.70","731.00","1 through 10","1097.16","2813.7","percent of total billed charges",""
"FIXATOR WRIST 220MM LOW PROFILE SELF DRILLING ROD MR CONDITIONAL","SUP-ITM-10036580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.24","2654.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1518.33","42.9","","384.74","384.74","384.74","1 through 10","1097.16","2813.7","percent of total billed charges",""
"FIXATOR WRIST 220MM LOW PROFILE SELF DRILLING ROD MR CONDITIONAL","SUP-ITM-10036580","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.24","2654.43","WELLPOINT [1015]","HB AMC WELLPOINT","2611.25","73.78","","286.63","119.22","1107.45","105","1097.16","2813.7","percent of total billed charges",""
"FIXATOR WRIST 220MM LOW PROFILE SELF DRILLING ROD MR CONDITIONAL","SUP-ITM-10036580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3539.24","2654.43","AETNA [1001]","HB AMC AETNA HMO","2470.39","69.8","","675.31","184.75","1721.50","286","1849.61","2892.27","percent of total billed charges",""
"FIXATOR WRIST 220MM LOW PROFILE SELF DRILLING ROD MR CONDITIONAL","SUP-ITM-10036580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3539.24","2654.43","AETNA [1001]","HB AMC AETNA PPO","2845.55","80.4","","1261.44","103.12","1514.10","21","1849.61","2892.27","percent of total billed charges",""
"FIXATOR WRIST 220MM LOW PROFILE SELF DRILLING ROD MR CONDITIONAL","SUP-ITM-10036580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3539.24","2654.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2845.55","80.4","","1365.00","1365.00","1365.00","1 through 10","1849.61","2892.27","percent of total billed charges",""
"FIXATOR WRIST 220MM LOW PROFILE SELF DRILLING ROD MR CONDITIONAL","SUP-ITM-10036580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3539.24","2654.43","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2892.27","81.72","","5157.68","5157.68","5157.68","1 through 10","1849.61","2892.27","percent of total billed charges",""
"FIXATOR WRIST 220MM LOW PROFILE SELF DRILLING ROD MR CONDITIONAL","SUP-ITM-10036580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3539.24","2654.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2892.27","81.72","","431.26","71.26","1459.57","88","1849.61","2892.27","percent of total billed charges",""
"FLANGE ACETABULAR 62X64 54MM SHORT CAGE HIP TRABECULAR METAL REVISION SHELL LINER RIGHT 00712306658","SUP-ITM-10200848","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2057.74","52.26","","1113.10","1113.10","1113.10","1 through 10","1220.63","3130.31","percent of total billed charges",""
"FLANGE ACETABULAR 62X64 54MM SHORT CAGE HIP TRABECULAR METAL REVISION SHELL LINER RIGHT 00712306658","SUP-ITM-10200848","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3130.31","79.5","","1293.60","1148.53","1603.80","1 through 10","1220.63","3130.31","percent of total billed charges",""
"FLANGE ACETABULAR 62X64 54MM SHORT CAGE HIP TRABECULAR METAL REVISION SHELL LINER RIGHT 00712306658","SUP-ITM-10200848","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1437.19","36.5","","1023.42","771.29","2068.67","33","1220.63","3130.31","percent of total billed charges",""
"FLANGE ACETABULAR 62X64 54MM SHORT CAGE HIP TRABECULAR METAL REVISION SHELL LINER RIGHT 00712306658","SUP-ITM-10200848","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1508.06","38.3","","850.52","759.78","1211.25","66","1220.63","3130.31","percent of total billed charges",""
"FLANGE ACETABULAR 62X64 54MM SHORT CAGE HIP TRABECULAR METAL REVISION SHELL LINER RIGHT 00712306658","SUP-ITM-10200848","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1689.19","42.9","","2548.09","2548.09","2548.09","1 through 10","1220.63","3130.31","percent of total billed charges",""
"FLANGE ACETABULAR 62X64 54MM SHORT CAGE HIP TRABECULAR METAL REVISION SHELL LINER RIGHT 00712306658","SUP-ITM-10200848","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1689.19","42.9","","956.46","956.46","956.46","1 through 10","1220.63","3130.31","percent of total billed charges",""
"FLANGE ACETABULAR 62X64 54MM SHORT CAGE HIP TRABECULAR METAL REVISION SHELL LINER RIGHT 00712306658","SUP-ITM-10200848","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","WELLPOINT [1015]","HB AMC WELLPOINT","2905.09","73.78","","2344.73","1619.47","2530.35","16","1220.63","3130.31","percent of total billed charges",""
"FLANGE ACETABULAR 62X64 54MM SHORT CAGE HIP TRABECULAR METAL REVISION SHELL LINER RIGHT 00712306658","SUP-ITM-10200848","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","AETNA [1001]","HB AMC AETNA HMO","2748.38","69.8","","1523.63","988.41","4330.26","39","2057.74","3217.73","percent of total billed charges",""
"FLANGE ACETABULAR 62X64 54MM SHORT CAGE HIP TRABECULAR METAL REVISION SHELL LINER RIGHT 00712306658","SUP-ITM-10200848","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","AETNA [1001]","HB AMC AETNA PPO","3165.75","80.4","","1670.25","1670.25","1670.25","1 through 10","2057.74","3217.73","percent of total billed charges",""
"FLANGE ACETABULAR 62X64 54MM SHORT CAGE HIP TRABECULAR METAL REVISION SHELL LINER RIGHT 00712306658","SUP-ITM-10200848","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2057.74","52.26","","1113.10","1113.10","1113.10","1 through 10","2057.74","3217.73","percent of total billed charges",""
"FLANGE ACETABULAR 62X64 54MM SHORT CAGE HIP TRABECULAR METAL REVISION SHELL LINER RIGHT 00712306658","SUP-ITM-10200848","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3217.73","81.72","","1738.90","1484.65","2716.94","38","2057.74","3217.73","percent of total billed charges",""
"FLANGE ALLOY 6.0IN LONG COMPONENT HUMERAL ELBOW COONRAD/MORREY TITANIUM REGULAR","SUP-ITM-10073155","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3990.64","52.26","","1113.10","1113.10","1113.10","1 through 10","2367.2","6070.72","percent of total billed charges",""
"FLANGE ALLOY 6.0IN LONG COMPONENT HUMERAL ELBOW COONRAD/MORREY TITANIUM REGULAR","SUP-ITM-10073155","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6070.72","79.5","","1293.60","1148.53","1603.80","1 through 10","2367.2","6070.72","percent of total billed charges",""
"FLANGE ALLOY 6.0IN LONG COMPONENT HUMERAL ELBOW COONRAD/MORREY TITANIUM REGULAR","SUP-ITM-10073155","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2787.19","36.5","","1023.42","771.29","2068.67","33","2367.2","6070.72","percent of total billed charges",""
"FLANGE ALLOY 6.0IN LONG COMPONENT HUMERAL ELBOW COONRAD/MORREY TITANIUM REGULAR","SUP-ITM-10073155","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2924.64","38.3","","850.52","759.78","1211.25","66","2367.2","6070.72","percent of total billed charges",""
"FLANGE ALLOY 6.0IN LONG COMPONENT HUMERAL ELBOW COONRAD/MORREY TITANIUM REGULAR","SUP-ITM-10073155","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3275.90","42.9","","2548.09","2548.09","2548.09","1 through 10","2367.2","6070.72","percent of total billed charges",""
"FLANGE ALLOY 6.0IN LONG COMPONENT HUMERAL ELBOW COONRAD/MORREY TITANIUM REGULAR","SUP-ITM-10073155","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3275.90","42.9","","956.46","956.46","956.46","1 through 10","2367.2","6070.72","percent of total billed charges",""
"FLANGE ALLOY 6.0IN LONG COMPONENT HUMERAL ELBOW COONRAD/MORREY TITANIUM REGULAR","SUP-ITM-10073155","CDM","C1776","HCPCS","0278","RC","","","","both","","","7636.13","5727.10","WELLPOINT [1015]","HB AMC WELLPOINT","5633.94","73.78","","2344.73","1619.47","2530.35","16","2367.2","6070.72","percent of total billed charges",""
"FLANGE ALLOY 6.0IN LONG COMPONENT HUMERAL ELBOW COONRAD/MORREY TITANIUM REGULAR","SUP-ITM-10073155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7636.13","5727.10","AETNA [1001]","HB AMC AETNA HMO","5330.02","69.8","","1523.63","988.41","4330.26","39","3990.64","6240.25","percent of total billed charges",""
"FLANGE ALLOY 6.0IN LONG COMPONENT HUMERAL ELBOW COONRAD/MORREY TITANIUM REGULAR","SUP-ITM-10073155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7636.13","5727.10","AETNA [1001]","HB AMC AETNA PPO","6139.45","80.4","","1670.25","1670.25","1670.25","1 through 10","3990.64","6240.25","percent of total billed charges",""
"FLANGE ALLOY 6.0IN LONG COMPONENT HUMERAL ELBOW COONRAD/MORREY TITANIUM REGULAR","SUP-ITM-10073155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7636.13","5727.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3990.64","52.26","","1113.10","1113.10","1113.10","1 through 10","3990.64","6240.25","percent of total billed charges",""
"FLANGE ALLOY 6.0IN LONG COMPONENT HUMERAL ELBOW COONRAD/MORREY TITANIUM REGULAR","SUP-ITM-10073155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7636.13","5727.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6240.25","81.72","","1738.90","1484.65","2716.94","38","3990.64","6240.25","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10011023","CDM","C1889","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5088.00","79.5","","1309.77","674.56","6049.93","26","1984","5088","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10011023","CDM","C1889","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3411.20","53.3","","1901.83","1901.83","2962.25","1 through 10","1984","5088","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10011023","CDM","C1889","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2336.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1984","5088","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10011023","CDM","C1889","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2451.20","38.3","","352.91","352.91","2046.30","1 through 10","1984","5088","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10011023","CDM","C1889","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2745.60","42.9","","9668.75","9668.75","9668.75","1 through 10","1984","5088","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10011023","CDM","C1889","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","WELLPOINT [1015]","HB AMC WELLPOINT","4721.92","73.78","","699.88","384.10","3443.31","33","1984","5088","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10011023","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","AETNA [1001]","HB AMC AETNA HMO","4467.20","69.8","","1421.24","264.50","4933.46","29","3344.64","5230.08","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10011023","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5145.60","80.4","","1022.97","1022.97","3607.50","1 through 10","3344.64","5230.08","percent of total billed charges",""
"FLANGE IMPLANT 100MM 5 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10011023","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5230.08","81.72","","3010.54","693.88","5019.88","35","3344.64","5230.08","percent of total billed charges",""
"FLANGE INI 3.5MM PLATE SPINE PLUG HELICAL ALTIUS","SUP-ITM-10018009","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","1309.77","674.56","6049.93","26","48.83","125.21","percent of total billed charges",""
"FLANGE INI 3.5MM PLATE SPINE PLUG HELICAL ALTIUS","SUP-ITM-10018009","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","1901.83","1901.83","2962.25","1 through 10","48.83","125.21","percent of total billed charges",""
"FLANGE INI 3.5MM PLATE SPINE PLUG HELICAL ALTIUS","SUP-ITM-10018009","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","1620.31","1620.31","19908.88","1 through 10","48.83","125.21","percent of total billed charges",""
"FLANGE INI 3.5MM PLATE SPINE PLUG HELICAL ALTIUS","SUP-ITM-10018009","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","352.91","352.91","2046.30","1 through 10","48.83","125.21","percent of total billed charges",""
"FLANGE INI 3.5MM PLATE SPINE PLUG HELICAL ALTIUS","SUP-ITM-10018009","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","9668.75","9668.75","9668.75","1 through 10","48.83","125.21","percent of total billed charges",""
"FLANGE INI 3.5MM PLATE SPINE PLUG HELICAL ALTIUS","SUP-ITM-10018009","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","699.88","384.10","3443.31","33","48.83","125.21","percent of total billed charges",""
"FLANGE INI 3.5MM PLATE SPINE PLUG HELICAL ALTIUS","SUP-ITM-10018009","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","1421.24","264.50","4933.46","29","82.31","128.71","percent of total billed charges",""
"FLANGE INI 3.5MM PLATE SPINE PLUG HELICAL ALTIUS","SUP-ITM-10018009","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","1022.97","1022.97","3607.50","1 through 10","82.31","128.71","percent of total billed charges",""
"FLANGE INI 3.5MM PLATE SPINE PLUG HELICAL ALTIUS","SUP-ITM-10018009","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","3010.54","693.88","5019.88","35","82.31","128.71","percent of total billed charges",""
"Flap Delay/Section Eye/Nose/Ear","PX-76000195","CDM","15630","CPT","0761","RC","","","","both","","","4870.00","3652.50","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","1 through 10","1509.7","3871.65","other","OPPS APC"
"Flap Delay/Section Eye/Nose/Ear","PX-76000195","CDM","15630","CPT","0761","RC","","","","both","","","4870.00","3652.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2135.85","2135.85","2135.85","1 through 10","1509.7","3871.65","other","OPPS APC"
"Flap Delay/Section Eye/Nose/Ear","PX-76000195","CDM","15630","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2052.96","2052.96","2052.96","1 through 10","1548.96","8899.59","other","ASC "
"Flap Delay/Section Eye/Nose/Ear","PX-76000195","CDM","15630","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3593.59","3593.59","3593.59","1 through 10","1548.96","8899.59","other","Multiple Surgery"
"Flap Delay/Section Forehd/Hnd/Ft","PX-76000194","CDM","15620","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2543.11","52.22","","4146.66","4146.66","4146.66","1 through 10","1948","3979.76","percent of total billed charges",""
"Flap Pedicle Eye/Nose/Ear/Lip","PX-76000191","CDM","15576","CPT","0761","RC","","","","both","","","4774.00","3580.50","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","1 through 10","1479.94","3795.33","other","OPPS APC"
"Flap Pedicle Head/Hand/Foot","PX-76000190","CDM","15574","CPT","0761","RC","","","","both","","","5148.00","3861.00","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3980.68","2172.32","3980.68","1 through 10","1595.88","4092.66","other","OPPS APC"
"Florbetaben F18, Diagnostic, per Study Dose, Up to 8.1 Millicuries","PX-34300153","CDM","Q9983","HCPCS","0343","RC","","","","both","","","11900.00","8925.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1311.97","","APC Price ($1,273.76). Final payment is multiplied by 103%.","12728.75","1311.60","12728.75","1 through 10","1248.28","11305","other","OPPS APC"
"Florbetaben F18, Diagnostic, per Study Dose, Up to 8.1 Millicuries","PX-34300153","CDM","Q9983","HCPCS","0343","RC","","","","both","","","11900.00","8925.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1273.76","","APC Price ($1,273.76).","1253.38","1253.38","1253.38","1 through 10","1248.28","11305","other","OPPS APC"
"Florbetaben F18, Diagnostic, per Study Dose, Up to 8.1 Millicuries","PX-34300153","CDM","Q9983","HCPCS","0343","RC","","","","both","","","11900.00","8925.00","ELDER SERVICES [1037]","HB BWH MEDICARE","1273.76","","APC Price ($1,273.76).","1248.28","1248.28","1248.28","1 through 10","1248.28","11305","other","OPPS APC"
"Florbetaben F18, Diagnostic, per Study Dose, Up to 8.1 Millicuries","PX-34300153","CDM","Q9983","HCPCS","0343","RC","","","","both","","","11900.00","8925.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1248.28","","APC Price ($1,273.76). Final payment is multiplied by 98%.","1248.28","144.23","1248.28","1 through 10","1248.28","11305","other","OPPS APC"
"Florbetapir F18, Diagnostic, per Study Dose, Up to 10 Millicuries","PX-34300156","CDM","A9586","HCPCS","0343","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","4660.12","4660.12","4660.12","1 through 10","0.31","2743.28","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","439.96","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","439.58","403.69","439.58","21","79.05","533.93","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","420.35","34.44","420.35","23","79.05","533.93","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","167.28","65.6","","167.22","167.22","167.22","1 through 10","79.05","533.93","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","165.75","65","","640.25","481.65","640.25","11","79.05","533.93","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","178.50","70","","247.00","247.00","533.52","1 through 10","79.05","533.93","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","533.93","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","21.13","21.13","21.13","1 through 10","79.05","533.93","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","CHAMPVA [160001]","HB BWH TRICARE","405.83","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","247.00","247.00","247.00","1 through 10","79.05","533.93","other","Tricare OPPS"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","202.73","79.5","","583.17","194.39","775.20","51","79.05","533.93","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","135.92","53.3","","249.48","130.42","916.86","16","79.05","533.93","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","352.53","418.65","11","79.05","533.93","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.68","362.68","362.68","1 through 10","79.05","533.93","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","196.35","77","","570.57","190.19","570.57","1 through 10","79.05","533.93","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","HUMANA [1012]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","423.59","423.59","423.59","1 through 10","79.05","533.93","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","165.75","65","","160.55","160.55","160.55","1 through 10","79.05","533.93","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","202.73","79.5","","194.39","194.39","194.39","1 through 10","79.05","533.93","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","MEDICARE [2001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.19","392.31","1281.57","357","79.05","533.93","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","93.08","36.5","","92.13","78.30","276.39","65","79.05","533.93","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","97.67","38.3","","96.58","93.86","289.74","130","79.05","533.93","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","384.46","1255.95","1 through 10","79.05","533.93","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","196.35","77","","192.66","24.51","192.66","1 through 10","79.05","533.93","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","TRICARE [160005]","HB BWH TRICARE","405.83","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","427.19","427.19","427.19","1 through 10","79.05","533.93","other","Tricare OPPS"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1255.95","418.65","2093.25","16","79.05","533.93","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","109.40","42.9","","197.45","197.45","197.45","1 through 10","79.05","533.93","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","418.65","427.19","42","79.05","533.93","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","255.00","191.25","WELLPOINT [1015]","HB AMC WELLPOINT","188.14","73.78","","183.89","183.89","430.89","48","79.05","533.93","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","255.00","191.25","AETNA [1001]","HB AMC AETNA HMO","177.99","69.8","","167.22","118.07","192.66","104","133.26","1680.97","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","255.00","191.25","AETNA [1001]","HB AMC AETNA PPO","205.02","80.4","","258.86","192.66","258.86","1 through 10","133.26","1680.97","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","255.00","191.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","133.26","52.26","","152.84","152.84","152.84","1 through 10","133.26","1680.97","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","205.02","80.4","","192.66","192.66","192.66","1 through 10","133.26","1680.97","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","208.39","81.72","","197.45","197.45","197.45","1 through 10","133.26","1680.97","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","208.39","81.72","","197.45","108.61","197.45","1 through 10","133.26","1680.97","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","208.39","81.72","","197.45","108.61","197.45","67","133.26","1680.97","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","243.00","182.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","159.41","65.6","","159.77","159.77","159.77","23","75.33","193.19","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","243.00","182.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","157.95","65","","460.20","460.20","742.95","91","75.33","193.19","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","243.00","182.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","170.10","70","","236.00","93.20","509.76","120","75.33","193.19","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","243.00","182.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","193.19","79.5","","557.20","185.73","899.54","629","75.33","193.19","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","243.00","182.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","129.52","53.3","","238.36","124.61","899.54","219","75.33","193.19","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","243.00","182.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","187.11","77","","545.16","181.72","545.16","111","75.33","193.19","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","243.00","182.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","157.95","65","","2761.20","2761.20","2761.20","1 through 10","75.33","193.19","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","243.00","182.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","193.19","79.5","","185.73","185.73","185.73","17","75.33","193.19","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","243.00","182.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","88.70","36.5","","224.44","88.03","264.08","781","75.33","193.19","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","243.00","182.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.07","38.3","","269.04","92.28","276.83","1587","75.33","193.19","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","243.00","182.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","187.11","77","","184.08","184.08","398.11","1 through 10","75.33","193.19","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","243.00","182.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.25","42.9","","1509.27","1509.27","1509.27","1 through 10","75.33","193.19","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","243.00","182.25","WELLPOINT [1015]","HB AMC WELLPOINT","179.29","73.78","","175.70","175.70","4895.70","377","75.33","193.19","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","243.00","182.25","AETNA [1001]","HB AMC AETNA HMO","169.61","69.8","","159.77","112.81","319.54","892","126.99","198.58","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","243.00","182.25","AETNA [1001]","HB AMC AETNA PPO","195.37","80.4","","184.08","184.08","247.33","39","126.99","198.58","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","243.00","182.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","126.99","52.26","","146.04","146.04","146.04","18","126.99","198.58","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","243.00","182.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","195.37","80.4","","184.08","184.08","184.08","27","126.99","198.58","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","243.00","182.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","198.58","81.72","","4150.48","4150.48","4150.48","1 through 10","126.99","198.58","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","243.00","182.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","198.58","81.72","","103.77","103.77","188.66","60","126.99","198.58","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","243.00","182.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","198.58","81.72","","188.66","103.77","188.66","558","126.99","198.58","percent of total billed charges",""
"Fluconazole Level Serum","PX-31000770","CDM","80299","CPT","0310","RC","","","","both","","","241.00","180.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","191.60","79.5","","106.25","71.28","106.25","1 through 10","18.27","228.95","percent of total billed charges",""
"Fluconazole Level Serum","PX-31000770","CDM","80299","CPT","0310","RC","","","","both","","","241.00","180.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","128.45","53.3","","106.25","71.28","106.25","1 through 10","18.27","228.95","percent of total billed charges",""
"Fluconazole Level Serum","PX-31000770","CDM","80299","CPT","0310","RC","","","","both","","","241.00","180.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.97","36.5","","50.36","42.80","92.50","13","18.27","228.95","percent of total billed charges",""
"Fluconazole Level Serum","PX-31000770","CDM","80299","CPT","0310","RC","","","","both","","","241.00","180.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","92.30","38.3","","52.79","44.55","158.37","30","18.27","228.95","percent of total billed charges",""
"Fluconazole Level Serum","PX-31000770","CDM","80299","CPT","0310","RC","","","","outpatient","","","241.00","180.75","AETNA [1001]","HB AMC AETNA HMO","168.22","69.8","","91.40","64.53","105.30","14","53.62","196.95","percent of total billed charges",""
"Fluconazole Level Serum","PX-31000770","CDM","80299","CPT","0310","RC","","","","outpatient","","","241.00","180.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","193.76","80.4","","105.30","105.30","105.30","1 through 10","53.62","196.95","percent of total billed charges",""
"Fluconazole Level Serum","PX-31000770","CDM","80299","CPT","0310","RC","","","","outpatient","","","241.00","180.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","196.95","81.72","","59.36","15.50","59.36","1 through 10","53.62","196.95","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","146.00","109.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.07","79.5","","111.75","111.75","335.26","36","8.98","138.7","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","146.00","109.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.82","53.3","","111.76","111.76","111.76","1 through 10","8.98","138.7","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","146.00","109.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","112.42","77","","109.34","109.34","109.34","23","8.98","138.7","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.29","36.5","","45.01","45.01","158.91","27","8.98","138.7","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.92","38.3","","55.52","53.96","104.40","28","8.98","138.7","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","146.00","109.50","TRICARE [160005]","HB BWH TRICARE","138.70","95","","13.79","13.79","13.79","1 through 10","8.98","138.7","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.63","42.9","","113.51","113.51","113.51","1 through 10","8.98","138.7","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA HMO","101.91","69.8","","110.76","96.13","1561.15","17","8.98","119.31","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA PPO","117.38","80.4","","110.76","110.76","110.76","1 through 10","8.98","119.31","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","outpatient","","","146.00","109.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","76.30","52.26","","47.09","47.09","47.09","1 through 10","8.98","119.31","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","119.31","81.72","","62.44","62.44","62.44","1 through 10","8.98","119.31","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","119.31","81.72","","113.51","113.51","113.51","22","8.98","119.31","percent of total billed charges",""
"Fluoride","PX-30000438","CDM","82735","CPT","0301","RC","","","","outpatient","","","307.00","230.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","250.88","81.72","","84.05","84.05","84.05","1 through 10","19.11","250.88","percent of total billed charges",""
"Fluoro Guidance No Charge Under 1 Hr","PX-32000433","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","287.06","1 through 10","272.7","1374.56","other","OPPS APC"
"Fluoro Guidance No Charge Under 1 Hr","PX-32000433","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1374.56","79.5","","1319.80","1319.80","1319.80","1 through 10","272.7","1374.56","percent of total billed charges",""
"Fluoro Guidance No Charge Under 1 Hr","PX-32000433","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","921.56","53.3","","885.46","885.46","885.46","1 through 10","272.7","1374.56","percent of total billed charges",""
"Fluoro Guidance No Charge Under 1 Hr","PX-32000433","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","1374.56","other","OPPS APC"
"Fluoro Guidance No Charge Under 1 Hr","PX-32000433","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.04","283.04","283.04","1 through 10","272.7","1374.56","other","OPPS APC"
"Fluoro Guidance No Charge Under 1 Hr","PX-32000433","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","16","272.7","1374.56","other","OPPS APC"
"Fluoro Guidance No Charge Under 1 Hr","PX-32000433","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","631.09","36.5","","625.52","625.52","625.52","1 through 10","272.7","1374.56","percent of total billed charges",""
"Fluoro Guidance No Charge Under 1 Hr","PX-32000433","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","662.21","38.3","","1967.13","1967.13","1967.13","1 through 10","272.7","1374.56","percent of total billed charges",""
"Fluoro Guidance No Charge Under 1 Hr","PX-32000433","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","281.32","281.32","1 through 10","272.7","1374.56","other","OPPS APC"
"Fluoro Guidance No Charge Under 1 Hr","PX-32000433","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.82","281.62","281.82","1 through 10","272.7","1374.56","other","OPPS APC"
"Fluoro Guidance No Charge Under 1 Hr","PX-32000433","CDM","76000","CPT","0320","RC","","","","outpatient","","","1729.00","1296.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1412.94","81.72","","1340.59","1253.72","1340.59","1 through 10","474.59","1412.94","percent of total billed charges",""
"Flurazepam (Benzodiazepines 1-12)","PX-30002978","CDM","80346","CPT","0301","RC","","","","both","","","110.00","82.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","78.98","71.8","","139.00","139.00","139.00","1 through 10","34.1","143.04","percent of total billed charges",""
"Flurazepam (Benzodiazepines 1-12)","PX-30002978","CDM","80346","CPT","0301","RC","","","","both","","","110.00","82.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","77.00","70","","61.12","61.12","61.12","1 through 10","34.1","143.04","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","both","","","66.00","49.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","52.47","79.5","","51.94","51.94","51.94","1 through 10","20.46","285.4","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","both","","","66.00","49.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","35.18","53.3","","51.94","34.85","51.94","1 through 10","20.46","285.4","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","both","","","66.00","49.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24.09","36.5","","20.72","20.72","20.72","1 through 10","20.46","285.4","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","both","","","66.00","49.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25.28","38.3","","25.81","25.81","25.81","1 through 10","20.46","285.4","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","both","","","66.00","49.50","WELLPOINT [1015]","HB AMC WELLPOINT","48.69","73.78","","49.14","49.14","49.14","1 through 10","20.46","285.4","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","outpatient","","","66.00","49.50","AETNA [1001]","HB AMC AETNA HMO","46.07","69.8","","44.68","44.68","44.68","1 through 10","33","474.13","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","outpatient","","","66.00","49.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","36.30","55","","38.02","38.02","38.02","1 through 10","33","474.13","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","outpatient","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","53.94","81.72","","29.02","29.02","29.02","1 through 10","33","474.13","percent of total billed charges",""
"FOIL SURGICAL 40 XMM .3 SMOOTH NYLON SUPRA BX/6EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10018389","CDM","C1781","HCPCS","0278","RC","","","","both","","","24.30","18.22","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","17.01","70","","134.04","134.04","134.04","1 through 10","7.53","19.32","percent of total billed charges",""
"FOIL SURGICAL 40 XMM .3 SMOOTH NYLON SUPRA BX/6EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10018389","CDM","C1781","HCPCS","0278","RC","","","","both","","","24.30","18.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","19.32","79.5","","948.87","198.19","1805.30","1 through 10","7.53","19.32","percent of total billed charges",""
"FOIL SURGICAL 40 XMM .3 SMOOTH NYLON SUPRA BX/6EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10018389","CDM","C1781","HCPCS","0278","RC","","","","both","","","24.30","18.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12.95","53.3","","462.00","170.45","3253.37","1 through 10","7.53","19.32","percent of total billed charges",""
"FOIL SURGICAL 40 XMM .3 SMOOTH NYLON SUPRA BX/6EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10018389","CDM","C1781","HCPCS","0278","RC","","","","both","","","24.30","18.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.87","36.5","","245.50","107.19","1371.45","1 through 10","7.53","19.32","percent of total billed charges",""
"FOIL SURGICAL 40 XMM .3 SMOOTH NYLON SUPRA BX/6EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10018389","CDM","C1781","HCPCS","0278","RC","","","","both","","","24.30","18.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9.31","38.3","","200.79","72.79","355.81","22","7.53","19.32","percent of total billed charges",""
"FOIL SURGICAL 40 XMM .3 SMOOTH NYLON SUPRA BX/6EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10018389","CDM","C1781","HCPCS","0278","RC","","","","both","","","24.30","18.22","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","18.71","77","","477.18","477.18","477.18","1 through 10","7.53","19.32","percent of total billed charges",""
"FOIL SURGICAL 40 XMM .3 SMOOTH NYLON SUPRA BX/6EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10018389","CDM","C1781","HCPCS","0278","RC","","","","both","","","24.30","18.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.42","42.9","","1045.91","1045.91","1045.91","1 through 10","7.53","19.32","percent of total billed charges",""
"FOIL SURGICAL 40 XMM .3 SMOOTH NYLON SUPRA BX/6EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10018389","CDM","C1781","HCPCS","0278","RC","","","","both","","","24.30","18.22","WELLPOINT [1015]","HB AMC WELLPOINT","17.93","73.78","","1726.50","1726.50","1726.50","1 through 10","7.53","19.32","percent of total billed charges",""
"FOIL SURGICAL 40 XMM .3 SMOOTH NYLON SUPRA BX/6EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10018389","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","24.30","18.22","AETNA [1001]","HB AMC AETNA HMO","16.96","69.8","","915.80","263.76","2881.00","1 through 10","12.7","19.86","percent of total billed charges",""
"FOIL SURGICAL 40 XMM .3 SMOOTH NYLON SUPRA BX/6EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10018389","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","24.30","18.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","19.86","81.72","","1531.57","410.52","8841.36","1 through 10","12.7","19.86","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","186.00","139.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","133.55","71.8","","129.24","12.96","129.24","1 through 10","14.41","176.7","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","186.00","139.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","130.20","70","","77.40","14.41","129.60","1 through 10","14.41","176.7","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","186.00","139.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","147.87","79.5","","141.66","95.04","174.17","43","14.41","176.7","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","186.00","139.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","99.14","53.3","","95.04","95.04","285.12","25","14.41","176.7","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","186.00","139.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","143.22","77","","415.80","138.60","415.80","1 through 10","14.41","176.7","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","186.00","139.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","120.90","65","","65.33","65.33","65.33","1 through 10","14.41","176.7","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","186.00","139.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","57.66","31","","55.62","55.62","55.62","1 through 10","14.41","176.7","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","186.00","139.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.89","36.5","","67.14","57.06","201.42","193","14.41","176.7","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","186.00","139.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71.24","38.3","","70.38","70.38","205.20","499","14.41","176.7","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","186.00","139.50","MOLINA [1014]","HB BWH MOLINA","65.10","35","","28.82","28.82","28.82","1 through 10","14.41","176.7","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","186.00","139.50","TRICARE [160005]","HB BWH TRICARE","176.70","95","","16.82","16.82","17.71","1 through 10","14.41","176.7","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.79","42.9","","143.89","79.15","143.89","1 through 10","14.41","176.7","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","186.00","139.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.79","42.9","","143.89","79.15","143.89","1 through 10","14.41","176.7","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","186.00","139.50","AETNA [1001]","HB AMC AETNA HMO","129.83","69.8","","121.86","86.04","140.40","186","15.17","152","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","186.00","139.50","AETNA [1001]","HB AMC AETNA PPO","149.54","80.4","","140.40","140.40","282.96","18","15.17","152","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","186.00","139.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","97.20","52.26","","111.38","51.55","111.39","1 through 10","15.17","152","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","186.00","139.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","149.54","80.4","","140.40","90.00","140.40","1 through 10","15.17","152","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","152.00","81.72","","143.89","79.15","143.89","1 through 10","15.17","152","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","152.00","81.72","","143.89","79.15","143.89","154","15.17","152","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","217.00","162.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","151.90","70","","210.00","210.00","210.00","1 through 10","18.21","206.15","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","217.00","162.75","CHAMPVA [160001]","HB BWH TRICARE","206.15","95","","22.39","22.39","22.39","1 through 10","18.21","206.15","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","217.00","162.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","172.52","79.5","","165.27","110.88","165.27","216","18.21","206.15","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","217.00","162.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","115.66","53.3","","110.88","110.88","165.27","103","18.21","206.15","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","217.00","162.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","172.52","79.5","","165.27","165.27","165.27","1 through 10","18.21","206.15","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","217.00","162.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","67.27","31","","64.89","64.89","129.78","1 through 10","18.21","206.15","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","217.00","162.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","79.21","36.5","","78.33","65.94","199.71","190","18.21","206.15","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","217.00","162.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","83.11","38.3","","82.11","79.80","239.40","509","18.21","206.15","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","217.00","162.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","167.09","77","","165.27","165.27","165.27","1 through 10","18.21","206.15","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","217.00","162.75","TRICARE [160005]","HB BWH TRICARE","206.15","95","","21.27","21.27","22.39","15","18.21","206.15","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","217.00","162.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.09","42.9","","167.87","92.34","167.87","11","18.21","206.15","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","217.00","162.75","AETNA [1001]","HB AMC AETNA HMO","151.47","69.8","","142.17","100.38","163.80","268","19.16","177.33","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","217.00","162.75","AETNA [1001]","HB AMC AETNA PPO","174.47","80.4","","163.80","100.38","163.80","29","19.16","177.33","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","217.00","162.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","121.30","55.9","","110.04","110.04","110.04","1 through 10","19.16","177.33","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","217.00","162.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","113.40","52.26","","65.99","65.99","65.99","1 through 10","19.16","177.33","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","217.00","162.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","174.47","80.4","","163.80","163.80","163.80","1 through 10","19.16","177.33","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","217.00","162.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","177.33","81.72","","167.87","92.34","167.87","1 through 10","19.16","177.33","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","217.00","162.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","177.33","81.72","","167.87","92.34","167.87","196","19.16","177.33","percent of total billed charges",""
"Foot And Toe Procedures,MAJOR","314","DRG","","","","","","","","inpatient","","","141451.75","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","55692.61","","Standard inlier is a Case rate ($55,692.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,169, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,905.10) for the length of stay and the standard reimbursement.","55692.61","55692.61","55692.61","1 through 10","11012.41","76506.14","case rate",""
"Foot And Toe Procedures,MAJOR","314","DRG","","","","","","","","inpatient","","","141451.75","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","22964.1989","","Fee schedule rate ($46,366.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22964.1989","44579.87","44579.87","1 through 10","11012.41","76506.14","case rate",""
"Foot And Toe Procedures,MAJOR","314","DRG","","","","","","","","inpatient","","","141451.75","","MASSHEALTH [3001]","HB BWH MEDICAID","14926.15","","Case rate ($16,503.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,933.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16499.38","16499.38","16499.38","1 through 10","11012.41","76506.14","case rate",""
"Foot And Toe Procedures,MAJOR","314","DRG","","","","","","","","inpatient","","","141451.75","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","14926.15","","Case rate ($16,503.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,933.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7648.19","7648.19","7648.19","1 through 10","11012.41","76506.14","case rate",""
"Foot And Toe Procedures,MAJOR","314","DRG","","","","","","","","inpatient","","","141451.75","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14926.15","","Case rate ($16,503.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,933.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16499.38","16499.38","16499.38","1 through 10","11012.41","76506.14","case rate",""
"Foot And Toe Procedures,MINOR","314","DRG","","","","","","","","inpatient","","","49949.87","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","39443.33","","Standard inlier is a Case rate ($39,443.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,930, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,598.65) for the length of stay and the standard reimbursement.","39443.32","39443.32","39443.32","1 through 10","11012.41","76506.14","case rate",""
"Foot And Toe Procedures,MODERATE","314","DRG","","","","","","","","inpatient","","","143626.11","","MASSHEALTH [3001]","HB BWH MEDICAID","11264.87","","Case rate ($12,455.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,885.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11.04","11.04","11.04","1 through 10","11012.41","76506.14","case rate",""
"Foot And Toe Procedures,MODERATE","314","DRG","","","","","","","","inpatient","","","143626.11","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11264.87","","Case rate ($12,455.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,885.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12452.19","12452.19","12452.19","1 through 10","11012.41","76506.14","case rate",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI TITANIUM BOW WEDGE OPENING","SUP-ITM-10117956","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.00","2814.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2982.84","79.5","","800.18","480.96","1887.97","195","1163.12","2982.84","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI TITANIUM BOW WEDGE OPENING","SUP-ITM-10117956","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.00","2814.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1999.82","53.3","","813.12","216.42","1444.50","81","1163.12","2982.84","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI TITANIUM BOW WEDGE OPENING","SUP-ITM-10117956","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.00","2814.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1163.12","31","","432.60","432.60","432.60","1 through 10","1163.12","2982.84","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI TITANIUM BOW WEDGE OPENING","SUP-ITM-10117956","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.00","2814.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1369.48","36.5","","148.37","54.89","631.39","94","1163.12","2982.84","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI TITANIUM BOW WEDGE OPENING","SUP-ITM-10117956","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.00","2814.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1437.02","38.3","","279.30","91.72","1116.77","266","1163.12","2982.84","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI TITANIUM BOW WEDGE OPENING","SUP-ITM-10117956","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.00","2814.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1609.61","42.9","","731.00","63.70","731.00","1 through 10","1163.12","2982.84","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI TITANIUM BOW WEDGE OPENING","SUP-ITM-10117956","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.00","2814.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1609.61","42.9","","384.74","384.74","384.74","1 through 10","1163.12","2982.84","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI TITANIUM BOW WEDGE OPENING","SUP-ITM-10117956","CDM","C1713","HCPCS","0278","RC","","","","both","","","3752.00","2814.00","WELLPOINT [1015]","HB AMC WELLPOINT","2768.23","73.78","","286.63","119.22","1107.45","105","1163.12","2982.84","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI TITANIUM BOW WEDGE OPENING","SUP-ITM-10117956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3752.00","2814.00","AETNA [1001]","HB AMC AETNA HMO","2618.90","69.8","","675.31","184.75","1721.50","286","1960.8","3066.13","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI TITANIUM BOW WEDGE OPENING","SUP-ITM-10117956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3752.00","2814.00","AETNA [1001]","HB AMC AETNA PPO","3016.61","80.4","","1261.44","103.12","1514.10","21","1960.8","3066.13","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI TITANIUM BOW WEDGE OPENING","SUP-ITM-10117956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3752.00","2814.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3016.61","80.4","","1365.00","1365.00","1365.00","1 through 10","1960.8","3066.13","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI TITANIUM BOW WEDGE OPENING","SUP-ITM-10117956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3752.00","2814.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3066.13","81.72","","5157.68","5157.68","5157.68","1 through 10","1960.8","3066.13","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI TITANIUM BOW WEDGE OPENING","SUP-ITM-10117956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3752.00","2814.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3066.13","81.72","","431.26","71.26","1459.57","88","1960.8","3066.13","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI WEDGE EVANS RECONSTRUCTION OPENING","SUP-ITM-10132287","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.50","3000.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3180.40","79.5","","800.18","480.96","1887.97","195","1240.16","3180.4","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI WEDGE EVANS RECONSTRUCTION OPENING","SUP-ITM-10132287","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.50","3000.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2132.27","53.3","","813.12","216.42","1444.50","81","1240.16","3180.4","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI WEDGE EVANS RECONSTRUCTION OPENING","SUP-ITM-10132287","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.50","3000.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1240.16","31","","432.60","432.60","432.60","1 through 10","1240.16","3180.4","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI WEDGE EVANS RECONSTRUCTION OPENING","SUP-ITM-10132287","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.50","3000.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1460.18","36.5","","148.37","54.89","631.39","94","1240.16","3180.4","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI WEDGE EVANS RECONSTRUCTION OPENING","SUP-ITM-10132287","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.50","3000.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1532.19","38.3","","279.30","91.72","1116.77","266","1240.16","3180.4","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI WEDGE EVANS RECONSTRUCTION OPENING","SUP-ITM-10132287","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.50","3000.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1716.21","42.9","","731.00","63.70","731.00","1 through 10","1240.16","3180.4","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI WEDGE EVANS RECONSTRUCTION OPENING","SUP-ITM-10132287","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.50","3000.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1716.21","42.9","","384.74","384.74","384.74","1 through 10","1240.16","3180.4","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI WEDGE EVANS RECONSTRUCTION OPENING","SUP-ITM-10132287","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.50","3000.37","WELLPOINT [1015]","HB AMC WELLPOINT","2951.57","73.78","","286.63","119.22","1107.45","105","1240.16","3180.4","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI WEDGE EVANS RECONSTRUCTION OPENING","SUP-ITM-10132287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4000.50","3000.37","AETNA [1001]","HB AMC AETNA HMO","2792.35","69.8","","675.31","184.75","1721.50","286","2090.66","3269.21","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI WEDGE EVANS RECONSTRUCTION OPENING","SUP-ITM-10132287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4000.50","3000.37","AETNA [1001]","HB AMC AETNA PPO","3216.40","80.4","","1261.44","103.12","1514.10","21","2090.66","3269.21","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI WEDGE EVANS RECONSTRUCTION OPENING","SUP-ITM-10132287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4000.50","3000.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3216.40","80.4","","1365.00","1365.00","1365.00","1 through 10","2090.66","3269.21","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI WEDGE EVANS RECONSTRUCTION OPENING","SUP-ITM-10132287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4000.50","3000.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3269.21","81.72","","5157.68","5157.68","5157.68","1 through 10","2090.66","3269.21","percent of total billed charges",""
"FOOT PLATE 0.0MM ORTHOLOC 3DI WEDGE EVANS RECONSTRUCTION OPENING","SUP-ITM-10132287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4000.50","3000.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3269.21","81.72","","431.26","71.26","1459.57","88","2090.66","3269.21","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2153.59","1615.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1712.10","79.5","","800.18","480.96","1887.97","195","667.61","1712.1","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2153.59","1615.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1147.86","53.3","","813.12","216.42","1444.50","81","667.61","1712.1","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2153.59","1615.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","667.61","31","","432.60","432.60","432.60","1 through 10","667.61","1712.1","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2153.59","1615.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","786.06","36.5","","148.37","54.89","631.39","94","667.61","1712.1","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2153.59","1615.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","824.82","38.3","","279.30","91.72","1116.77","266","667.61","1712.1","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2153.59","1615.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","923.89","42.9","","731.00","63.70","731.00","1 through 10","667.61","1712.1","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2153.59","1615.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","923.89","42.9","","384.74","384.74","384.74","1 through 10","667.61","1712.1","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","both","","","2153.59","1615.19","WELLPOINT [1015]","HB AMC WELLPOINT","1588.92","73.78","","286.63","119.22","1107.45","105","667.61","1712.1","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2153.59","1615.19","AETNA [1001]","HB AMC AETNA HMO","1503.21","69.8","","675.31","184.75","1721.50","286","1125.47","1759.91","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2153.59","1615.19","AETNA [1001]","HB AMC AETNA PPO","1731.49","80.4","","1261.44","103.12","1514.10","21","1125.47","1759.91","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2153.59","1615.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1731.49","80.4","","1365.00","1365.00","1365.00","1 through 10","1125.47","1759.91","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2153.59","1615.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1759.91","81.72","","5157.68","5157.68","5157.68","1 through 10","1125.47","1759.91","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2153.59","1615.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1759.91","81.72","","431.26","71.26","1459.57","88","1125.47","1759.91","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2529.14","1896.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2010.67","79.5","","800.18","480.96","1887.97","195","784.03","2010.67","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2529.14","1896.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1348.03","53.3","","813.12","216.42","1444.50","81","784.03","2010.67","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2529.14","1896.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","784.03","31","","432.60","432.60","432.60","1 through 10","784.03","2010.67","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2529.14","1896.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","923.14","36.5","","148.37","54.89","631.39","94","784.03","2010.67","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2529.14","1896.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","968.66","38.3","","279.30","91.72","1116.77","266","784.03","2010.67","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2529.14","1896.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1085.00","42.9","","731.00","63.70","731.00","1 through 10","784.03","2010.67","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2529.14","1896.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1085.00","42.9","","384.74","384.74","384.74","1 through 10","784.03","2010.67","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2529.14","1896.85","WELLPOINT [1015]","HB AMC WELLPOINT","1866.00","73.78","","286.63","119.22","1107.45","105","784.03","2010.67","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2529.14","1896.85","AETNA [1001]","HB AMC AETNA HMO","1765.34","69.8","","675.31","184.75","1721.50","286","1321.73","2066.81","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2529.14","1896.85","AETNA [1001]","HB AMC AETNA PPO","2033.43","80.4","","1261.44","103.12","1514.10","21","1321.73","2066.81","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2529.14","1896.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2033.43","80.4","","1365.00","1365.00","1365.00","1 through 10","1321.73","2066.81","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2529.14","1896.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2066.81","81.72","","5157.68","5157.68","5157.68","1 through 10","1321.73","2066.81","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2529.14","1896.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2066.81","81.72","","431.26","71.26","1459.57","88","1321.73","2066.81","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2538.20","1903.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2017.87","79.5","","800.18","480.96","1887.97","195","786.84","2017.87","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2538.20","1903.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1352.86","53.3","","813.12","216.42","1444.50","81","786.84","2017.87","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2538.20","1903.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","786.84","31","","432.60","432.60","432.60","1 through 10","786.84","2017.87","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2538.20","1903.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","926.44","36.5","","148.37","54.89","631.39","94","786.84","2017.87","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2538.20","1903.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","972.13","38.3","","279.30","91.72","1116.77","266","786.84","2017.87","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2538.20","1903.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1088.89","42.9","","731.00","63.70","731.00","1 through 10","786.84","2017.87","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2538.20","1903.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1088.89","42.9","","384.74","384.74","384.74","1 through 10","786.84","2017.87","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","2538.20","1903.65","WELLPOINT [1015]","HB AMC WELLPOINT","1872.68","73.78","","286.63","119.22","1107.45","105","786.84","2017.87","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2538.20","1903.65","AETNA [1001]","HB AMC AETNA HMO","1771.66","69.8","","675.31","184.75","1721.50","286","1326.46","2074.22","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2538.20","1903.65","AETNA [1001]","HB AMC AETNA PPO","2040.71","80.4","","1261.44","103.12","1514.10","21","1326.46","2074.22","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2538.20","1903.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2040.71","80.4","","1365.00","1365.00","1365.00","1 through 10","1326.46","2074.22","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2538.20","1903.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2074.22","81.72","","5157.68","5157.68","5157.68","1 through 10","1326.46","2074.22","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2538.20","1903.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2074.22","81.72","","431.26","71.26","1459.57","88","1326.46","2074.22","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","both","","","3166.28","2374.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2517.19","79.5","","800.18","480.96","1887.97","195","981.55","2517.19","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","both","","","3166.28","2374.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1687.63","53.3","","813.12","216.42","1444.50","81","981.55","2517.19","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","both","","","3166.28","2374.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","981.55","31","","432.60","432.60","432.60","1 through 10","981.55","2517.19","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","both","","","3166.28","2374.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1155.69","36.5","","148.37","54.89","631.39","94","981.55","2517.19","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","both","","","3166.28","2374.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1212.69","38.3","","279.30","91.72","1116.77","266","981.55","2517.19","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","both","","","3166.28","2374.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1358.33","42.9","","731.00","63.70","731.00","1 through 10","981.55","2517.19","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","both","","","3166.28","2374.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1358.33","42.9","","384.74","384.74","384.74","1 through 10","981.55","2517.19","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","both","","","3166.28","2374.71","WELLPOINT [1015]","HB AMC WELLPOINT","2336.08","73.78","","286.63","119.22","1107.45","105","981.55","2517.19","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3166.28","2374.71","AETNA [1001]","HB AMC AETNA HMO","2210.06","69.8","","675.31","184.75","1721.50","286","1654.7","2587.48","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3166.28","2374.71","AETNA [1001]","HB AMC AETNA PPO","2545.69","80.4","","1261.44","103.12","1514.10","21","1654.7","2587.48","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3166.28","2374.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2545.69","80.4","","1365.00","1365.00","1365.00","1 through 10","1654.7","2587.48","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3166.28","2374.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2587.48","81.72","","5157.68","5157.68","5157.68","1 through 10","1654.7","2587.48","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3166.28","2374.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2587.48","81.72","","431.26","71.26","1459.57","88","1654.7","2587.48","percent of total billed charges",""
"FOOT PLATE 2.4/2.7MM SM 0DEG LCP TI VARIABLE ANGLE FIRST MTP FUSION RIGHT","SUP-ITM-10096272","CDM","C1713","HCPCS","0278","RC","","","","both","","","3062.68","2297.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2434.83","79.5","","800.18","480.96","1887.97","195","949.43","2434.83","percent of total billed charges",""
"FOOT PLATE 2.4/2.7MM SM 0DEG LCP TI VARIABLE ANGLE FIRST MTP FUSION RIGHT","SUP-ITM-10096272","CDM","C1713","HCPCS","0278","RC","","","","both","","","3062.68","2297.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1632.41","53.3","","813.12","216.42","1444.50","81","949.43","2434.83","percent of total billed charges",""
"FOOT PLATE 2.4/2.7MM SM 0DEG LCP TI VARIABLE ANGLE FIRST MTP FUSION RIGHT","SUP-ITM-10096272","CDM","C1713","HCPCS","0278","RC","","","","both","","","3062.68","2297.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","949.43","31","","432.60","432.60","432.60","1 through 10","949.43","2434.83","percent of total billed charges",""
"FOOT PLATE 2.4/2.7MM SM 0DEG LCP TI VARIABLE ANGLE FIRST MTP FUSION RIGHT","SUP-ITM-10096272","CDM","C1713","HCPCS","0278","RC","","","","both","","","3062.68","2297.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1117.88","36.5","","148.37","54.89","631.39","94","949.43","2434.83","percent of total billed charges",""
"FOOT PLATE 2.4/2.7MM SM 0DEG LCP TI VARIABLE ANGLE FIRST MTP FUSION RIGHT","SUP-ITM-10096272","CDM","C1713","HCPCS","0278","RC","","","","both","","","3062.68","2297.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1173.01","38.3","","279.30","91.72","1116.77","266","949.43","2434.83","percent of total billed charges",""
"FOOT PLATE 2.4/2.7MM SM 0DEG LCP TI VARIABLE ANGLE FIRST MTP FUSION RIGHT","SUP-ITM-10096272","CDM","C1713","HCPCS","0278","RC","","","","both","","","3062.68","2297.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1313.89","42.9","","731.00","63.70","731.00","1 through 10","949.43","2434.83","percent of total billed charges",""
"FOOT PLATE 2.4/2.7MM SM 0DEG LCP TI VARIABLE ANGLE FIRST MTP FUSION RIGHT","SUP-ITM-10096272","CDM","C1713","HCPCS","0278","RC","","","","both","","","3062.68","2297.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1313.89","42.9","","384.74","384.74","384.74","1 through 10","949.43","2434.83","percent of total billed charges",""
"FOOT PLATE 2.4/2.7MM SM 0DEG LCP TI VARIABLE ANGLE FIRST MTP FUSION RIGHT","SUP-ITM-10096272","CDM","C1713","HCPCS","0278","RC","","","","both","","","3062.68","2297.01","WELLPOINT [1015]","HB AMC WELLPOINT","2259.65","73.78","","286.63","119.22","1107.45","105","949.43","2434.83","percent of total billed charges",""
"FOOT PLATE 2.4/2.7MM SM 0DEG LCP TI VARIABLE ANGLE FIRST MTP FUSION RIGHT","SUP-ITM-10096272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3062.68","2297.01","AETNA [1001]","HB AMC AETNA HMO","2137.75","69.8","","675.31","184.75","1721.50","286","1600.56","2502.82","percent of total billed charges",""
"FOOT PLATE 2.4/2.7MM SM 0DEG LCP TI VARIABLE ANGLE FIRST MTP FUSION RIGHT","SUP-ITM-10096272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3062.68","2297.01","AETNA [1001]","HB AMC AETNA PPO","2462.39","80.4","","1261.44","103.12","1514.10","21","1600.56","2502.82","percent of total billed charges",""
"FOOT PLATE 2.4/2.7MM SM 0DEG LCP TI VARIABLE ANGLE FIRST MTP FUSION RIGHT","SUP-ITM-10096272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3062.68","2297.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2462.39","80.4","","1365.00","1365.00","1365.00","1 through 10","1600.56","2502.82","percent of total billed charges",""
"FOOT PLATE 2.4/2.7MM SM 0DEG LCP TI VARIABLE ANGLE FIRST MTP FUSION RIGHT","SUP-ITM-10096272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3062.68","2297.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2502.82","81.72","","5157.68","5157.68","5157.68","1 through 10","1600.56","2502.82","percent of total billed charges",""
"FOOT PLATE 2.4/2.7MM SM 0DEG LCP TI VARIABLE ANGLE FIRST MTP FUSION RIGHT","SUP-ITM-10096272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3062.68","2297.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2502.82","81.72","","431.26","71.26","1459.57","88","1600.56","2502.82","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2470.86","1853.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1964.33","79.5","","800.18","480.96","1887.97","195","765.97","1964.33","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2470.86","1853.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1316.97","53.3","","813.12","216.42","1444.50","81","765.97","1964.33","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2470.86","1853.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","765.97","31","","432.60","432.60","432.60","1 through 10","765.97","1964.33","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2470.86","1853.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","901.86","36.5","","148.37","54.89","631.39","94","765.97","1964.33","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2470.86","1853.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","946.34","38.3","","279.30","91.72","1116.77","266","765.97","1964.33","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2470.86","1853.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1060.00","42.9","","731.00","63.70","731.00","1 through 10","765.97","1964.33","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2470.86","1853.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1060.00","42.9","","384.74","384.74","384.74","1 through 10","765.97","1964.33","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2470.86","1853.14","WELLPOINT [1015]","HB AMC WELLPOINT","1823.00","73.78","","286.63","119.22","1107.45","105","765.97","1964.33","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2470.86","1853.14","AETNA [1001]","HB AMC AETNA HMO","1724.66","69.8","","675.31","184.75","1721.50","286","1291.27","2019.19","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2470.86","1853.14","AETNA [1001]","HB AMC AETNA PPO","1986.57","80.4","","1261.44","103.12","1514.10","21","1291.27","2019.19","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2470.86","1853.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1986.57","80.4","","1365.00","1365.00","1365.00","1 through 10","1291.27","2019.19","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2470.86","1853.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2019.19","81.72","","5157.68","5157.68","5157.68","1 through 10","1291.27","2019.19","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2470.86","1853.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2019.19","81.72","","431.26","71.26","1459.57","88","1291.27","2019.19","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM SS LOCKING TALUS TARSAL","SUP-ITM-10037375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1802.70","79.5","","800.18","480.96","1887.97","195","702.94","1802.7","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM SS LOCKING TALUS TARSAL","SUP-ITM-10037375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1208.60","53.3","","813.12","216.42","1444.50","81","702.94","1802.7","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM SS LOCKING TALUS TARSAL","SUP-ITM-10037375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","702.94","31","","432.60","432.60","432.60","1 through 10","702.94","1802.7","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM SS LOCKING TALUS TARSAL","SUP-ITM-10037375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","827.66","36.5","","148.37","54.89","631.39","94","702.94","1802.7","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM SS LOCKING TALUS TARSAL","SUP-ITM-10037375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","868.47","38.3","","279.30","91.72","1116.77","266","702.94","1802.7","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM SS LOCKING TALUS TARSAL","SUP-ITM-10037375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","972.78","42.9","","731.00","63.70","731.00","1 through 10","702.94","1802.7","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM SS LOCKING TALUS TARSAL","SUP-ITM-10037375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","972.78","42.9","","384.74","384.74","384.74","1 through 10","702.94","1802.7","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM SS LOCKING TALUS TARSAL","SUP-ITM-10037375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","WELLPOINT [1015]","HB AMC WELLPOINT","1673.00","73.78","","286.63","119.22","1107.45","105","702.94","1802.7","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM SS LOCKING TALUS TARSAL","SUP-ITM-10037375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2267.55","1700.66","AETNA [1001]","HB AMC AETNA HMO","1582.75","69.8","","675.31","184.75","1721.50","286","1185.02","1853.04","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM SS LOCKING TALUS TARSAL","SUP-ITM-10037375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2267.55","1700.66","AETNA [1001]","HB AMC AETNA PPO","1823.11","80.4","","1261.44","103.12","1514.10","21","1185.02","1853.04","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM SS LOCKING TALUS TARSAL","SUP-ITM-10037375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2267.55","1700.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1823.11","80.4","","1365.00","1365.00","1365.00","1 through 10","1185.02","1853.04","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM SS LOCKING TALUS TARSAL","SUP-ITM-10037375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2267.55","1700.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1853.04","81.72","","5157.68","5157.68","5157.68","1 through 10","1185.02","1853.04","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM SS LOCKING TALUS TARSAL","SUP-ITM-10037375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2267.55","1700.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1853.04","81.72","","431.26","71.26","1459.57","88","1185.02","1853.04","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM STAINLESS LOCKING CUBOID TARSAL LEFT","SUP-ITM-10037373","CDM","C1713","HCPCS","0278","RC","","","","both","","","2294.74","1721.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1824.32","79.5","","800.18","480.96","1887.97","195","711.37","1824.32","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM STAINLESS LOCKING CUBOID TARSAL LEFT","SUP-ITM-10037373","CDM","C1713","HCPCS","0278","RC","","","","both","","","2294.74","1721.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1223.10","53.3","","813.12","216.42","1444.50","81","711.37","1824.32","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM STAINLESS LOCKING CUBOID TARSAL LEFT","SUP-ITM-10037373","CDM","C1713","HCPCS","0278","RC","","","","both","","","2294.74","1721.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","711.37","31","","432.60","432.60","432.60","1 through 10","711.37","1824.32","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM STAINLESS LOCKING CUBOID TARSAL LEFT","SUP-ITM-10037373","CDM","C1713","HCPCS","0278","RC","","","","both","","","2294.74","1721.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","837.58","36.5","","148.37","54.89","631.39","94","711.37","1824.32","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM STAINLESS LOCKING CUBOID TARSAL LEFT","SUP-ITM-10037373","CDM","C1713","HCPCS","0278","RC","","","","both","","","2294.74","1721.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","878.89","38.3","","279.30","91.72","1116.77","266","711.37","1824.32","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM STAINLESS LOCKING CUBOID TARSAL LEFT","SUP-ITM-10037373","CDM","C1713","HCPCS","0278","RC","","","","both","","","2294.74","1721.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","984.44","42.9","","731.00","63.70","731.00","1 through 10","711.37","1824.32","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM STAINLESS LOCKING CUBOID TARSAL LEFT","SUP-ITM-10037373","CDM","C1713","HCPCS","0278","RC","","","","both","","","2294.74","1721.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","984.44","42.9","","384.74","384.74","384.74","1 through 10","711.37","1824.32","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM STAINLESS LOCKING CUBOID TARSAL LEFT","SUP-ITM-10037373","CDM","C1713","HCPCS","0278","RC","","","","both","","","2294.74","1721.05","WELLPOINT [1015]","HB AMC WELLPOINT","1693.06","73.78","","286.63","119.22","1107.45","105","711.37","1824.32","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM STAINLESS LOCKING CUBOID TARSAL LEFT","SUP-ITM-10037373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2294.74","1721.05","AETNA [1001]","HB AMC AETNA HMO","1601.73","69.8","","675.31","184.75","1721.50","286","1199.23","1875.26","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM STAINLESS LOCKING CUBOID TARSAL LEFT","SUP-ITM-10037373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2294.74","1721.05","AETNA [1001]","HB AMC AETNA PPO","1844.97","80.4","","1261.44","103.12","1514.10","21","1199.23","1875.26","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM STAINLESS LOCKING CUBOID TARSAL LEFT","SUP-ITM-10037373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2294.74","1721.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1844.97","80.4","","1365.00","1365.00","1365.00","1 through 10","1199.23","1875.26","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM STAINLESS LOCKING CUBOID TARSAL LEFT","SUP-ITM-10037373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2294.74","1721.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1875.26","81.72","","5157.68","5157.68","5157.68","1 through 10","1199.23","1875.26","percent of total billed charges",""
"FOOT PLATE 2.4X2.7MM STAINLESS LOCKING CUBOID TARSAL LEFT","SUP-ITM-10037373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2294.74","1721.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1875.26","81.72","","431.26","71.26","1459.57","88","1199.23","1875.26","percent of total billed charges",""
"FOOT PLATE 2.7X18MM UNIVERSAL DARCO","SUP-ITM-10057307","CDM","C1713","HCPCS","0278","RC","","","","both","","","2971.50","2228.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2362.34","79.5","","800.18","480.96","1887.97","195","921.17","2362.34","percent of total billed charges",""
"FOOT PLATE 2.7X18MM UNIVERSAL DARCO","SUP-ITM-10057307","CDM","C1713","HCPCS","0278","RC","","","","both","","","2971.50","2228.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1583.81","53.3","","813.12","216.42","1444.50","81","921.17","2362.34","percent of total billed charges",""
"FOOT PLATE 2.7X18MM UNIVERSAL DARCO","SUP-ITM-10057307","CDM","C1713","HCPCS","0278","RC","","","","both","","","2971.50","2228.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","921.17","31","","432.60","432.60","432.60","1 through 10","921.17","2362.34","percent of total billed charges",""
"FOOT PLATE 2.7X18MM UNIVERSAL DARCO","SUP-ITM-10057307","CDM","C1713","HCPCS","0278","RC","","","","both","","","2971.50","2228.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1084.60","36.5","","148.37","54.89","631.39","94","921.17","2362.34","percent of total billed charges",""
"FOOT PLATE 2.7X18MM UNIVERSAL DARCO","SUP-ITM-10057307","CDM","C1713","HCPCS","0278","RC","","","","both","","","2971.50","2228.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1138.08","38.3","","279.30","91.72","1116.77","266","921.17","2362.34","percent of total billed charges",""
"FOOT PLATE 2.7X18MM UNIVERSAL DARCO","SUP-ITM-10057307","CDM","C1713","HCPCS","0278","RC","","","","both","","","2971.50","2228.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1274.77","42.9","","731.00","63.70","731.00","1 through 10","921.17","2362.34","percent of total billed charges",""
"FOOT PLATE 2.7X18MM UNIVERSAL DARCO","SUP-ITM-10057307","CDM","C1713","HCPCS","0278","RC","","","","both","","","2971.50","2228.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1274.77","42.9","","384.74","384.74","384.74","1 through 10","921.17","2362.34","percent of total billed charges",""
"FOOT PLATE 2.7X18MM UNIVERSAL DARCO","SUP-ITM-10057307","CDM","C1713","HCPCS","0278","RC","","","","both","","","2971.50","2228.62","WELLPOINT [1015]","HB AMC WELLPOINT","2192.37","73.78","","286.63","119.22","1107.45","105","921.17","2362.34","percent of total billed charges",""
"FOOT PLATE 2.7X18MM UNIVERSAL DARCO","SUP-ITM-10057307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2971.50","2228.62","AETNA [1001]","HB AMC AETNA HMO","2074.11","69.8","","675.31","184.75","1721.50","286","1552.91","2428.31","percent of total billed charges",""
"FOOT PLATE 2.7X18MM UNIVERSAL DARCO","SUP-ITM-10057307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2971.50","2228.62","AETNA [1001]","HB AMC AETNA PPO","2389.09","80.4","","1261.44","103.12","1514.10","21","1552.91","2428.31","percent of total billed charges",""
"FOOT PLATE 2.7X18MM UNIVERSAL DARCO","SUP-ITM-10057307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2971.50","2228.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2389.09","80.4","","1365.00","1365.00","1365.00","1 through 10","1552.91","2428.31","percent of total billed charges",""
"FOOT PLATE 2.7X18MM UNIVERSAL DARCO","SUP-ITM-10057307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2971.50","2228.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2428.31","81.72","","5157.68","5157.68","5157.68","1 through 10","1552.91","2428.31","percent of total billed charges",""
"FOOT PLATE 2.7X18MM UNIVERSAL DARCO","SUP-ITM-10057307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2971.50","2228.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2428.31","81.72","","431.26","71.26","1459.57","88","1552.91","2428.31","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2863.19","79.5","","800.18","480.96","1887.97","195","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1919.60","53.3","","813.12","216.42","1444.50","81","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1116.47","31","","432.60","432.60","432.60","1 through 10","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1314.55","36.5","","148.37","54.89","631.39","94","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1379.37","38.3","","279.30","91.72","1116.77","266","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1545.04","42.9","","731.00","63.70","731.00","1 through 10","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1545.04","42.9","","384.74","384.74","384.74","1 through 10","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","WELLPOINT [1015]","HB AMC WELLPOINT","2657.19","73.78","","286.63","119.22","1107.45","105","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3601.50","2701.12","AETNA [1001]","HB AMC AETNA HMO","2513.85","69.8","","675.31","184.75","1721.50","286","1882.14","2943.15","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3601.50","2701.12","AETNA [1001]","HB AMC AETNA PPO","2895.61","80.4","","1261.44","103.12","1514.10","21","1882.14","2943.15","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3601.50","2701.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2895.61","80.4","","1365.00","1365.00","1365.00","1 through 10","1882.14","2943.15","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3601.50","2701.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2943.15","81.72","","5157.68","5157.68","5157.68","1 through 10","1882.14","2943.15","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3601.50","2701.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2943.15","81.72","","431.26","71.26","1459.57","88","1882.14","2943.15","percent of total billed charges",""
"FOOT PLATE 2.7X25MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10020111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2863.19","79.5","","800.18","480.96","1887.97","195","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X25MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10020111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1919.60","53.3","","813.12","216.42","1444.50","81","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X25MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10020111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1116.47","31","","432.60","432.60","432.60","1 through 10","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X25MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10020111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1314.55","36.5","","148.37","54.89","631.39","94","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X25MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10020111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1379.37","38.3","","279.30","91.72","1116.77","266","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X25MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10020111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1545.04","42.9","","731.00","63.70","731.00","1 through 10","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X25MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10020111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1545.04","42.9","","384.74","384.74","384.74","1 through 10","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X25MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10020111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3601.50","2701.12","WELLPOINT [1015]","HB AMC WELLPOINT","2657.19","73.78","","286.63","119.22","1107.45","105","1116.47","2863.19","percent of total billed charges",""
"FOOT PLATE 2.7X25MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10020111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3601.50","2701.12","AETNA [1001]","HB AMC AETNA HMO","2513.85","69.8","","675.31","184.75","1721.50","286","1882.14","2943.15","percent of total billed charges",""
"FOOT PLATE 2.7X25MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10020111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3601.50","2701.12","AETNA [1001]","HB AMC AETNA PPO","2895.61","80.4","","1261.44","103.12","1514.10","21","1882.14","2943.15","percent of total billed charges",""
"FOOT PLATE 2.7X25MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10020111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3601.50","2701.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2895.61","80.4","","1365.00","1365.00","1365.00","1 through 10","1882.14","2943.15","percent of total billed charges",""
"FOOT PLATE 2.7X25MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10020111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3601.50","2701.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2943.15","81.72","","5157.68","5157.68","5157.68","1 through 10","1882.14","2943.15","percent of total billed charges",""
"FOOT PLATE 2.7X25MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10020111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3601.50","2701.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2943.15","81.72","","431.26","71.26","1459.57","88","1882.14","2943.15","percent of total billed charges",""
"FOOT PLATE LG 3.5MM FUSION A.L.P.S. CLOSED","SUP-ITM-10117150","CDM","C1874","HCPCS","0278","RC","","","","both","","","2483.85","1862.89","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1614.50","65","","6652.80","6652.80","6652.80","1 through 10","769.99","1974.66","percent of total billed charges",""
"FOOT PLATE LG 3.5MM FUSION A.L.P.S. CLOSED","SUP-ITM-10117150","CDM","C1874","HCPCS","0278","RC","","","","both","","","2483.85","1862.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1974.66","79.5","","2612.61","795.38","2612.61","1 through 10","769.99","1974.66","percent of total billed charges",""
"FOOT PLATE LG 3.5MM FUSION A.L.P.S. CLOSED","SUP-ITM-10117150","CDM","C1874","HCPCS","0278","RC","","","","both","","","2483.85","1862.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1323.89","53.3","","1101.80","1101.80","1101.80","1 through 10","769.99","1974.66","percent of total billed charges",""
"FOOT PLATE LG 3.5MM FUSION A.L.P.S. CLOSED","SUP-ITM-10117150","CDM","C1874","HCPCS","0278","RC","","","","both","","","2483.85","1862.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1614.50","65","","1820.00","910.00","1820.00","1 through 10","769.99","1974.66","percent of total billed charges",""
"FOOT PLATE LG 3.5MM FUSION A.L.P.S. CLOSED","SUP-ITM-10117150","CDM","C1874","HCPCS","0278","RC","","","","both","","","2483.85","1862.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","906.61","36.5","","1257.80","693.44","2424.50","1 through 10","769.99","1974.66","percent of total billed charges",""
"FOOT PLATE LG 3.5MM FUSION A.L.P.S. CLOSED","SUP-ITM-10117150","CDM","C1874","HCPCS","0278","RC","","","","both","","","2483.85","1862.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","951.31","38.3","","1950.11","547.40","2346.00","1 through 10","769.99","1974.66","percent of total billed charges",""
"FOOT PLATE LG 3.5MM FUSION A.L.P.S. CLOSED","SUP-ITM-10117150","CDM","C1874","HCPCS","0278","RC","","","","both","","","2483.85","1862.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1065.57","42.9","","5096.18","5096.18","5096.18","1 through 10","769.99","1974.66","percent of total billed charges",""
"FOOT PLATE LG 3.5MM FUSION A.L.P.S. CLOSED","SUP-ITM-10117150","CDM","C1874","HCPCS","0278","RC","","","","both","","","2483.85","1862.89","WELLPOINT [1015]","HB AMC WELLPOINT","1832.58","73.78","","1172.59","1172.59","4829.94","1 through 10","769.99","1974.66","percent of total billed charges",""
"FOOT PLATE LG 3.5MM FUSION A.L.P.S. CLOSED","SUP-ITM-10117150","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2483.85","1862.89","AETNA [1001]","HB AMC AETNA HMO","1733.73","69.8","","1806.84","947.80","5091.72","1 through 10","1298.06","2029.8","percent of total billed charges",""
"FOOT PLATE LG 3.5MM FUSION A.L.P.S. CLOSED","SUP-ITM-10117150","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2483.85","1862.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2029.80","81.72","","1259.05","615.58","4586.56","1 through 10","1298.06","2029.8","percent of total billed charges",""
"FOOT PLATE XL Y SHAPE MAXLOCK EXTREME","SUP-ITM-10082127","CDM","C1713","HCPCS","0278","RC","","","","both","","","4399.50","3299.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3497.60","79.5","","800.18","480.96","1887.97","195","1363.85","3497.6","percent of total billed charges",""
"FOOT PLATE XL Y SHAPE MAXLOCK EXTREME","SUP-ITM-10082127","CDM","C1713","HCPCS","0278","RC","","","","both","","","4399.50","3299.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2344.93","53.3","","813.12","216.42","1444.50","81","1363.85","3497.6","percent of total billed charges",""
"FOOT PLATE XL Y SHAPE MAXLOCK EXTREME","SUP-ITM-10082127","CDM","C1713","HCPCS","0278","RC","","","","both","","","4399.50","3299.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1363.85","31","","432.60","432.60","432.60","1 through 10","1363.85","3497.6","percent of total billed charges",""
"FOOT PLATE XL Y SHAPE MAXLOCK EXTREME","SUP-ITM-10082127","CDM","C1713","HCPCS","0278","RC","","","","both","","","4399.50","3299.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1605.82","36.5","","148.37","54.89","631.39","94","1363.85","3497.6","percent of total billed charges",""
"FOOT PLATE XL Y SHAPE MAXLOCK EXTREME","SUP-ITM-10082127","CDM","C1713","HCPCS","0278","RC","","","","both","","","4399.50","3299.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1685.01","38.3","","279.30","91.72","1116.77","266","1363.85","3497.6","percent of total billed charges",""
"FOOT PLATE XL Y SHAPE MAXLOCK EXTREME","SUP-ITM-10082127","CDM","C1713","HCPCS","0278","RC","","","","both","","","4399.50","3299.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1887.39","42.9","","731.00","63.70","731.00","1 through 10","1363.85","3497.6","percent of total billed charges",""
"FOOT PLATE XL Y SHAPE MAXLOCK EXTREME","SUP-ITM-10082127","CDM","C1713","HCPCS","0278","RC","","","","both","","","4399.50","3299.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1887.39","42.9","","384.74","384.74","384.74","1 through 10","1363.85","3497.6","percent of total billed charges",""
"FOOT PLATE XL Y SHAPE MAXLOCK EXTREME","SUP-ITM-10082127","CDM","C1713","HCPCS","0278","RC","","","","both","","","4399.50","3299.62","WELLPOINT [1015]","HB AMC WELLPOINT","3245.95","73.78","","286.63","119.22","1107.45","105","1363.85","3497.6","percent of total billed charges",""
"FOOT PLATE XL Y SHAPE MAXLOCK EXTREME","SUP-ITM-10082127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4399.50","3299.62","AETNA [1001]","HB AMC AETNA HMO","3070.85","69.8","","675.31","184.75","1721.50","286","2299.18","3595.27","percent of total billed charges",""
"FOOT PLATE XL Y SHAPE MAXLOCK EXTREME","SUP-ITM-10082127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4399.50","3299.62","AETNA [1001]","HB AMC AETNA PPO","3537.20","80.4","","1261.44","103.12","1514.10","21","2299.18","3595.27","percent of total billed charges",""
"FOOT PLATE XL Y SHAPE MAXLOCK EXTREME","SUP-ITM-10082127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4399.50","3299.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3537.20","80.4","","1365.00","1365.00","1365.00","1 through 10","2299.18","3595.27","percent of total billed charges",""
"FOOT PLATE XL Y SHAPE MAXLOCK EXTREME","SUP-ITM-10082127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4399.50","3299.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3595.27","81.72","","5157.68","5157.68","5157.68","1 through 10","2299.18","3595.27","percent of total billed charges",""
"FOOT PLATE XL Y SHAPE MAXLOCK EXTREME","SUP-ITM-10082127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4399.50","3299.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3595.27","81.72","","431.26","71.26","1459.57","88","2299.18","3595.27","percent of total billed charges",""
"FOOT PLATE XS 2.7MM LOCKING TI","SUP-ITM-10096258","CDM","C1713","HCPCS","0278","RC","","","","both","","","2924.11","2193.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2324.67","79.5","","800.18","480.96","1887.97","195","906.47","2324.67","percent of total billed charges",""
"FOOT PLATE XS 2.7MM LOCKING TI","SUP-ITM-10096258","CDM","C1713","HCPCS","0278","RC","","","","both","","","2924.11","2193.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1558.55","53.3","","813.12","216.42","1444.50","81","906.47","2324.67","percent of total billed charges",""
"FOOT PLATE XS 2.7MM LOCKING TI","SUP-ITM-10096258","CDM","C1713","HCPCS","0278","RC","","","","both","","","2924.11","2193.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","906.47","31","","432.60","432.60","432.60","1 through 10","906.47","2324.67","percent of total billed charges",""
"FOOT PLATE XS 2.7MM LOCKING TI","SUP-ITM-10096258","CDM","C1713","HCPCS","0278","RC","","","","both","","","2924.11","2193.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1067.30","36.5","","148.37","54.89","631.39","94","906.47","2324.67","percent of total billed charges",""
"FOOT PLATE XS 2.7MM LOCKING TI","SUP-ITM-10096258","CDM","C1713","HCPCS","0278","RC","","","","both","","","2924.11","2193.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1119.93","38.3","","279.30","91.72","1116.77","266","906.47","2324.67","percent of total billed charges",""
"FOOT PLATE XS 2.7MM LOCKING TI","SUP-ITM-10096258","CDM","C1713","HCPCS","0278","RC","","","","both","","","2924.11","2193.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1254.44","42.9","","731.00","63.70","731.00","1 through 10","906.47","2324.67","percent of total billed charges",""
"FOOT PLATE XS 2.7MM LOCKING TI","SUP-ITM-10096258","CDM","C1713","HCPCS","0278","RC","","","","both","","","2924.11","2193.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1254.44","42.9","","384.74","384.74","384.74","1 through 10","906.47","2324.67","percent of total billed charges",""
"FOOT PLATE XS 2.7MM LOCKING TI","SUP-ITM-10096258","CDM","C1713","HCPCS","0278","RC","","","","both","","","2924.11","2193.08","WELLPOINT [1015]","HB AMC WELLPOINT","2157.41","73.78","","286.63","119.22","1107.45","105","906.47","2324.67","percent of total billed charges",""
"FOOT PLATE XS 2.7MM LOCKING TI","SUP-ITM-10096258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2924.11","2193.08","AETNA [1001]","HB AMC AETNA HMO","2041.03","69.8","","675.31","184.75","1721.50","286","1528.14","2389.58","percent of total billed charges",""
"FOOT PLATE XS 2.7MM LOCKING TI","SUP-ITM-10096258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2924.11","2193.08","AETNA [1001]","HB AMC AETNA PPO","2350.98","80.4","","1261.44","103.12","1514.10","21","1528.14","2389.58","percent of total billed charges",""
"FOOT PLATE XS 2.7MM LOCKING TI","SUP-ITM-10096258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2924.11","2193.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2350.98","80.4","","1365.00","1365.00","1365.00","1 through 10","1528.14","2389.58","percent of total billed charges",""
"FOOT PLATE XS 2.7MM LOCKING TI","SUP-ITM-10096258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2924.11","2193.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2389.58","81.72","","5157.68","5157.68","5157.68","1 through 10","1528.14","2389.58","percent of total billed charges",""
"FOOT PLATE XS 2.7MM LOCKING TI","SUP-ITM-10096258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2924.11","2193.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2389.58","81.72","","431.26","71.26","1459.57","88","1528.14","2389.58","percent of total billed charges",""
"Foot Procedures With Cc","504","MS-DRG","","","","","","","","inpatient","","","115276.86","86457.64","MEDICARE [2001]","HB BWH MEDICARE","22509.17","","Case rate ($22,509.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,905.94, add-ons for qualifying new technology services are included. If operating cost exceeds $66,550.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,944.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $20,625.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,526.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,504.07. The transfer capital threshold is the transfer adjustment factor * $1,504.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20999.19","20999.19","20999.19","1 through 10","17082.27","26484.705","other","Inpatient DRG"
"Foot Procedures With McC","503","MS-DRG","","","","","","","","inpatient","","","194376.32","145782.24","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","25840.54","","Case rate ($25,840.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,029.52, add-ons for qualifying new technology services are included. If operating cost exceeds $76,673.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,686.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $23,214.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,649.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,245.88. The transfer capital threshold is the transfer adjustment factor * $2,245.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24034.20","24034.20","24034.20","1 through 10","25323.73","39939.8406","other","Inpatient DRG"
"Foot Procedures With McC","503","MS-DRG","","","","","","","","inpatient","","","194376.32","145782.24","MEDICARE [2001]","HB BWH MEDICARE","25840.54","","Case rate ($25,840.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,029.52, add-ons for qualifying new technology services are included. If operating cost exceeds $76,673.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,686.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $23,214.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,649.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,245.88. The transfer capital threshold is the transfer adjustment factor * $2,245.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","31526.13","31526.13","31526.13","1 through 10","25323.73","39939.8406","other","Inpatient Replacement Plans DRG"
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","1829.73","1372.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1454.64","79.5","","1309.77","674.56","6049.93","26","567.22","1454.64","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","1829.73","1372.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","975.25","53.3","","1901.83","1901.83","2962.25","1 through 10","567.22","1454.64","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","1829.73","1372.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","667.85","36.5","","1620.31","1620.31","19908.88","1 through 10","567.22","1454.64","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","1829.73","1372.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","700.79","38.3","","352.91","352.91","2046.30","1 through 10","567.22","1454.64","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","1829.73","1372.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","784.95","42.9","","9668.75","9668.75","9668.75","1 through 10","567.22","1454.64","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","1829.73","1372.30","WELLPOINT [1015]","HB AMC WELLPOINT","1349.97","73.78","","699.88","384.10","3443.31","33","567.22","1454.64","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1829.73","1372.30","AETNA [1001]","HB AMC AETNA HMO","1277.15","69.8","","1421.24","264.50","4933.46","29","956.22","1495.26","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1829.73","1372.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1471.10","80.4","","1022.97","1022.97","3607.50","1 through 10","956.22","1495.26","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1829.73","1372.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1495.26","81.72","","3010.54","693.88","5019.88","35","956.22","1495.26","percent of total billed charges",""
"FORCEPS SCREW HOLDING","SUP-ITM-10176393","CDM","C1713","HCPCS","0278","RC","","","","both","","","322.00","241.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","255.99","79.5","","800.18","480.96","1887.97","195","99.82","255.99","percent of total billed charges",""
"FORCEPS SCREW HOLDING","SUP-ITM-10176393","CDM","C1713","HCPCS","0278","RC","","","","both","","","322.00","241.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","171.63","53.3","","813.12","216.42","1444.50","81","99.82","255.99","percent of total billed charges",""
"FORCEPS SCREW HOLDING","SUP-ITM-10176393","CDM","C1713","HCPCS","0278","RC","","","","both","","","322.00","241.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","99.82","31","","432.60","432.60","432.60","1 through 10","99.82","255.99","percent of total billed charges",""
"FORCEPS SCREW HOLDING","SUP-ITM-10176393","CDM","C1713","HCPCS","0278","RC","","","","both","","","322.00","241.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","117.53","36.5","","148.37","54.89","631.39","94","99.82","255.99","percent of total billed charges",""
"FORCEPS SCREW HOLDING","SUP-ITM-10176393","CDM","C1713","HCPCS","0278","RC","","","","both","","","322.00","241.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","123.33","38.3","","279.30","91.72","1116.77","266","99.82","255.99","percent of total billed charges",""
"FORCEPS SCREW HOLDING","SUP-ITM-10176393","CDM","C1713","HCPCS","0278","RC","","","","both","","","322.00","241.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.14","42.9","","731.00","63.70","731.00","1 through 10","99.82","255.99","percent of total billed charges",""
"FORCEPS SCREW HOLDING","SUP-ITM-10176393","CDM","C1713","HCPCS","0278","RC","","","","both","","","322.00","241.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.14","42.9","","384.74","384.74","384.74","1 through 10","99.82","255.99","percent of total billed charges",""
"FORCEPS SCREW HOLDING","SUP-ITM-10176393","CDM","C1713","HCPCS","0278","RC","","","","both","","","322.00","241.50","WELLPOINT [1015]","HB AMC WELLPOINT","237.57","73.78","","286.63","119.22","1107.45","105","99.82","255.99","percent of total billed charges",""
"FORCEPS SCREW HOLDING","SUP-ITM-10176393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","322.00","241.50","AETNA [1001]","HB AMC AETNA HMO","224.76","69.8","","675.31","184.75","1721.50","286","168.28","263.14","percent of total billed charges",""
"FORCEPS SCREW HOLDING","SUP-ITM-10176393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","322.00","241.50","AETNA [1001]","HB AMC AETNA PPO","258.89","80.4","","1261.44","103.12","1514.10","21","168.28","263.14","percent of total billed charges",""
"FORCEPS SCREW HOLDING","SUP-ITM-10176393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","322.00","241.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","258.89","80.4","","1365.00","1365.00","1365.00","1 through 10","168.28","263.14","percent of total billed charges",""
"FORCEPS SCREW HOLDING","SUP-ITM-10176393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","322.00","241.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","263.14","81.72","","5157.68","5157.68","5157.68","1 through 10","168.28","263.14","percent of total billed charges",""
"FORCEPS SCREW HOLDING","SUP-ITM-10176393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","322.00","241.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","263.14","81.72","","431.26","71.26","1459.57","88","168.28","263.14","percent of total billed charges",""
"Forehead Flap W/Vasc Pedicle","PX-76002670","CDM","15731","CPT","0761","RC","","","","both","","","7151.00","5363.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4260.24","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4262.17","4262.17","4262.17","1 through 10","2216.81","5685.05","other","OPPS APC"
"Forehead Flap W/Vasc Pedicle","PX-76002670","CDM","15731","CPT","0761","RC","","","","outpatient","","","7151.00","5363.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6417.42","6417.42","6417.42","1 through 10","2766.13","5843.8","other","Multiple Surgery"
"Fracture Of Pelvis Or Dislocation Of Hip,MODERATE","341","DRG","","","","","","","","inpatient","","","12196.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21874.18","","Standard inlier is a Case rate ($21,874.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,778, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,104.86) for the length of stay and the standard reimbursement.","21874.17","21874.17","21874.17","1 through 10","5298.29","46280.12","case rate",""
"Fracture Of Pelvis Or Dislocation Of Hip,MODERATE","341","DRG","","","","","","","","inpatient","","","12196.86","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","19935.21","","Fee schedule rate ($19,935.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19935.21","19935.21","19935.21","1 through 10","5298.29","46280.12","case rate",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With McC","562","MS-DRG","","","","","","","","inpatient","","","85379.55","64034.66","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","13778.32","","Case rate ($13,377.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,025.87, add-ons for qualifying new technology services are included. If operating cost exceeds $61,670.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,586.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $11,850.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,646.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.48. The transfer capital threshold is the transfer adjustment factor * $1,146.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","13962.86","13962.86","13962.86","1 through 10","13109.47","22085.6785","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With McC","562","MS-DRG","","","","","","","","inpatient","","","85379.55","64034.66","MEDICARE [2001]","HB BWH MEDICARE","17247.93","","Case rate ($17,247.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,025.87, add-ons for qualifying new technology services are included. If operating cost exceeds $61,670.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,586.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $15,721.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,646.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.48. The transfer capital threshold is the transfer adjustment factor * $1,146.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17531.71","12917.51","17557.51","13","13109.47","22085.6785","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With McC","562","MS-DRG","","","","","","","","inpatient","","","85379.55","64034.66","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13109.47","","Case rate ($13,377.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,025.87, add-ons for qualifying new technology services are included. If operating cost exceeds $61,670.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,586.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $11,850.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,646.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,146.48. The transfer capital threshold is the transfer adjustment factor * $1,146.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","24599.52","24599.52","24599.52","1 through 10","13109.47","22085.6785","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC","563","MS-DRG","","","","","","","","inpatient","","","54917.01","41187.76","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","8805.14","","Case rate ($8,548.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,213.51, add-ons for qualifying new technology services are included. If operating cost exceeds $55,857.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,160.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,448.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,833.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.57. The transfer capital threshold is the transfer adjustment factor * $720.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8683.92","8683.92","8683.92","1 through 10","8377.71","14027.11","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC","563","MS-DRG","","","","","","","","inpatient","","","54917.01","41187.76","MEDICARE [2001]","HB BWH MEDICARE","8548.68","","Case rate ($8,548.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,213.51, add-ons for qualifying new technology services are included. If operating cost exceeds $55,857.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,160.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,448.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,833.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.57. The transfer capital threshold is the transfer adjustment factor * $720.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10831.21","0.03","10831.21","12","8377.71","14027.11","other","Inpatient Replacement Plans DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC","563","MS-DRG","","","","","","","","inpatient","","","54917.01","41187.76","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8377.71","","Case rate ($8,548.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,213.51, add-ons for qualifying new technology services are included. If operating cost exceeds $55,857.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,160.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,448.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,833.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.57. The transfer capital threshold is the transfer adjustment factor * $720.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8223.23","8223.23","8265.60","1 through 10","8377.71","14027.11","other","Inpatient DRG"
"Fractures And Dislocations Except Femur, Pelvis And Back,MAJOR","342","DRG","","","","","","","","inpatient","","","77428.05","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27186.86","","Fee schedule rate ($27,186.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26394.72","26394.72","26394.72","1 through 10","4473.51","125465.64","case rate",""
"Fractures And Dislocations Except Femur, Pelvis And Back,MINOR","342","DRG","","","","","","","","inpatient","","","26395.72","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10176.985","","Fee schedule rate ($10,176.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10176.985","10177.00","10177.00","1 through 10","4473.51","125465.64","case rate",""
"Fractures And Dislocations Except Femur, Pelvis And Back,MODERATE","342","DRG","","","","","","","","inpatient","","","38610.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21429.15","","Standard inlier is a Case rate ($21,429.15). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,312, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,042.00) for the length of stay and the standard reimbursement.","19535.01","19535.01","19535.01","1 through 10","4473.51","125465.64","case rate",""
"Fractures And Dislocations Except Femur, Pelvis And Back,MODERATE","342","DRG","","","","","","","","inpatient","","","38610.86","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10686.13","","Fee schedule rate ($16,447.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10686.13","15812.76","15812.76","1 through 10","4473.51","125465.64","case rate",""
"Fractures And Dislocations Except Femur, Pelvis And Back,MODERATE","342","DRG","","","","","","","","inpatient","","","38610.86","","MASSHEALTH [3001]","HB BWH MEDICAID","5417.10","","Case rate ($5,989.53). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,419.53, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12136.98","12136.98","12136.98","1 through 10","4473.51","125465.64","case rate",""
"Fractures Of Femur With McC","533","MS-DRG","","","","","","","","inpatient","","","51991.05","38993.29","MEDICARE [2001]","HB BWH MEDICARE","14680.55","","Case rate ($14,680.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,595.09, add-ons for qualifying new technology services are included. If operating cost exceeds $63,239.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,701.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,039.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,215.25 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,261.46. The transfer capital threshold is the transfer adjustment factor * $1,261.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18255.56","18255.56","18255.56","1 through 10","14386.94","23012.2659","other","Inpatient Replacement Plans DRG"
"Fractures Of Hip And Pelvis With McC","535","MS-DRG","","","","","","","","inpatient","","","46714.61","35035.96","MEDICARE [2001]","HB BWH MEDICARE","15557.33","","Case rate ($15,557.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,457.75, add-ons for qualifying new technology services are included. If operating cost exceeds $60,102.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,471.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $14,145.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,077.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,031.57. The transfer capital threshold is the transfer adjustment factor * $1,031.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15975.20","15956.67","15980.14","1 through 10","11832.88","20081.25","other","Inpatient DRG"
"Fractures Of Hip And Pelvis Without McC","536","MS-DRG","","","","","","","","inpatient","","","68839.69","51629.77","HUMANA [1012]","HB BWH MEDICARE","7746.86","","Case rate ($7,746.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,248.27, add-ons for qualifying new technology services are included. If operating cost exceeds $54,892.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,090.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,717.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,868.43 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.84. The transfer capital threshold is the transfer adjustment factor * $649.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7594.58","7594.58","7594.58","1 through 10","7591.92","12237.2919","other","Inpatient Replacement Plans DRG"
"Fractures Of Hip And Pelvis Without McC","536","MS-DRG","","","","","","","","inpatient","","","68839.69","51629.77","MEDICARE [2001]","HB BWH MEDICARE","7746.86","","Case rate ($7,746.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,248.27, add-ons for qualifying new technology services are included. If operating cost exceeds $54,892.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,090.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,717.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,868.43 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.84. The transfer capital threshold is the transfer adjustment factor * $649.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9852.41","9852.41","9852.41","1 through 10","7591.92","12237.2919","other","Inpatient Replacement Plans DRG"
"Fractures Of Hip And Pelvis Without McC","536","MS-DRG","","","","","","","","inpatient","","","68839.69","51629.77","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7591.92","","Case rate ($7,746.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,248.27, add-ons for qualifying new technology services are included. If operating cost exceeds $54,892.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,090.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,717.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,868.43 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.84. The transfer capital threshold is the transfer adjustment factor * $649.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17232.32","17232.32","17232.32","1 through 10","7591.92","12237.2919","other","Inpatient DRG"
"Francisella Tularensis Antibody","PX-30000931","CDM","86668","CPT","0302","RC","","","","both","","","144.00","108.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","52.56","36.5","","52.22","52.22","52.22","1 through 10","8.97","136.8","percent of total billed charges",""
"Francisella Tularensis Antibody","PX-30000931","CDM","86668","CPT","0302","RC","","","","outpatient","","","144.00","108.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","117.68","81.72","","111.92","111.92","223.83","1 through 10","8.97","117.68","percent of total billed charges",""
"Fresh Frozen Plasma Ea","PX-39000005","CDM","P9017","HCPCS","0390","RC","","","","both","","","671.00","503.25","MEDICARE [2001]","HB BWH MEDICARE","84.29","","APC Price ($84.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.29","84.29","84.29","1 through 10","80.08","533.45","other","OPPS APC"
"Fresh Frozen Plasma Ea","PX-39000005","CDM","P9017","HCPCS","0390","RC","","","","outpatient","","","671.00","503.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","335.50","50","","71.53","71.53","71.53","1 through 10","142.42","553.58","percent of total billed charges",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","","","","inpatient","","","16321.01","12240.76","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","41450.58","41450.58","41450.58","1 through 10","37647.06","65312.61","case rate",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/McC","928","MS-DRG","","","","","","","","inpatient","","","299567.19","224675.39","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","65809.97","","Case rate ($65,809.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $79,144.81, add-ons for qualifying new technology services are included. If operating cost exceeds $124,789.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,211.72, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.4. The base transfer operating payment is the transfer adjustment factor * $59,658.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $78,764.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,771.58. The transfer capital threshold is the transfer adjustment factor * $5,771.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount.","60272.33","60272.33","60272.33","1 through 10","64493.77","100791.2799","other","Inpatient Replacement Plans DRG"
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/McC","928","MS-DRG","","","","","","","","inpatient","","","299567.19","224675.39","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","65809.97","","Case rate ($65,809.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $79,144.81, add-ons for qualifying new technology services are included. If operating cost exceeds $124,789.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,211.72, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.4. The base transfer operating payment is the transfer adjustment factor * $59,658.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $78,764.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,771.58. The transfer capital threshold is the transfer adjustment factor * $5,771.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount.","59866.05","59841.71","61761.84","1 through 10","64493.77","100791.2799","other","Inpatient DRG"
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/McC","928","MS-DRG","","","","","","","","inpatient","","","299567.19","224675.39","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","125802.40","125802.40","125802.40","1 through 10","64493.77","100791.2799","case rate",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/McC","928","MS-DRG","","","","","","","","inpatient","","","299567.19","224675.39","MEDICARE [2001]","HB BWH MEDICARE","65809.97","","Case rate ($65,809.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $79,144.81, add-ons for qualifying new technology services are included. If operating cost exceeds $124,789.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,211.72, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.4. The base transfer operating payment is the transfer adjustment factor * $59,658.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $78,764.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,771.58. The transfer capital threshold is the transfer adjustment factor * $5,771.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount.","79134.64","79016.86","95453.12","1 through 10","64493.77","100791.2799","other","Inpatient Replacement Plans DRG"
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/McC","928","MS-DRG","","","","","","","","inpatient","","","299567.19","224675.39","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","64493.77","","Case rate ($65,809.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $79,144.81, add-ons for qualifying new technology services are included. If operating cost exceeds $124,789.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,211.72, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.4. The base transfer operating payment is the transfer adjustment factor * $59,658.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $78,764.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,771.58. The transfer capital threshold is the transfer adjustment factor * $5,771.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount. Final payment is multiplied by 98%.","63445.79","63445.79","63445.79","1 through 10","64493.77","100791.2799","other","Inpatient DRG"
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","","","","inpatient","","","33509.75","25132.31","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","21161.51","","Case rate ($20,545.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,654.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,299.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,218.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $18,386.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,275.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,778.78. The transfer capital threshold is the transfer adjustment factor * $1,778.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","20385.38","20385.38","20385.38","1 through 10","20134.26","32382.2678","other","Inpatient DRG"
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","","","","inpatient","","","33509.75","25132.31","MEDICARE [2001]","HB BWH MEDICARE","20545.16","","Case rate ($20,545.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,654.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,299.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,218.93, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $18,386.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,275.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,778.78. The transfer capital threshold is the transfer adjustment factor * $1,778.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount.","25575.46","728.09","25613.30","1 through 10","20134.26","32382.2678","other","Inpatient Replacement Plans DRG"
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","","","","inpatient","","","33509.75","25132.31","MOLINA [1014]","HB BWH MOLINA","20134.26","","Case rate ($20,545.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,654.91, add-ons for qualifying new technology services are included. If operating cost exceeds $70,299.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,218.93, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $18,386.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,275.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,778.78. The transfer capital threshold is the transfer adjustment factor * $1,778.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount. Final payment is multiplied by 98%.","39263.96","39263.96","39263.96","1 through 10","20134.26","32382.2678","other","Inpatient DRG"
"Fungus Antibody Not Specified","PX-30000932","CDM","86671","CPT","0302","RC","","","","both","","","168.00","126.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","133.56","79.5","","128.28","128.28","128.28","1 through 10","10.07","159.6","percent of total billed charges",""
"FUSE THUMB LG 6.4X9MMX15 DEG","SUP-ITM-10051902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3301.53","79.5","","800.18","480.96","1887.97","195","1287.39","3301.53","percent of total billed charges",""
"FUSE THUMB LG 6.4X9MMX15 DEG","SUP-ITM-10051902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2213.48","53.3","","813.12","216.42","1444.50","81","1287.39","3301.53","percent of total billed charges",""
"FUSE THUMB LG 6.4X9MMX15 DEG","SUP-ITM-10051902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1287.39","31","","432.60","432.60","432.60","1 through 10","1287.39","3301.53","percent of total billed charges",""
"FUSE THUMB LG 6.4X9MMX15 DEG","SUP-ITM-10051902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1515.80","36.5","","148.37","54.89","631.39","94","1287.39","3301.53","percent of total billed charges",""
"FUSE THUMB LG 6.4X9MMX15 DEG","SUP-ITM-10051902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1590.55","38.3","","279.30","91.72","1116.77","266","1287.39","3301.53","percent of total billed charges",""
"FUSE THUMB LG 6.4X9MMX15 DEG","SUP-ITM-10051902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1781.58","42.9","","731.00","63.70","731.00","1 through 10","1287.39","3301.53","percent of total billed charges",""
"FUSE THUMB LG 6.4X9MMX15 DEG","SUP-ITM-10051902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1781.58","42.9","","384.74","384.74","384.74","1 through 10","1287.39","3301.53","percent of total billed charges",""
"FUSE THUMB LG 6.4X9MMX15 DEG","SUP-ITM-10051902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","WELLPOINT [1015]","HB AMC WELLPOINT","3063.99","73.78","","286.63","119.22","1107.45","105","1287.39","3301.53","percent of total billed charges",""
"FUSE THUMB LG 6.4X9MMX15 DEG","SUP-ITM-10051902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4152.87","3114.65","AETNA [1001]","HB AMC AETNA HMO","2898.70","69.8","","675.31","184.75","1721.50","286","2170.29","3393.73","percent of total billed charges",""
"FUSE THUMB LG 6.4X9MMX15 DEG","SUP-ITM-10051902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4152.87","3114.65","AETNA [1001]","HB AMC AETNA PPO","3338.91","80.4","","1261.44","103.12","1514.10","21","2170.29","3393.73","percent of total billed charges",""
"FUSE THUMB LG 6.4X9MMX15 DEG","SUP-ITM-10051902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4152.87","3114.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3338.91","80.4","","1365.00","1365.00","1365.00","1 through 10","2170.29","3393.73","percent of total billed charges",""
"FUSE THUMB LG 6.4X9MMX15 DEG","SUP-ITM-10051902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4152.87","3114.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3393.73","81.72","","5157.68","5157.68","5157.68","1 through 10","2170.29","3393.73","percent of total billed charges",""
"FUSE THUMB LG 6.4X9MMX15 DEG","SUP-ITM-10051902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4152.87","3114.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3393.73","81.72","","431.26","71.26","1459.57","88","2170.29","3393.73","percent of total billed charges",""
"FUSEX9MM L 6.4 25DEG COMPONENT THUMB INTRAMEDULLARY","SUP-ITM-10051903","CDM","C1889","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3301.53","79.5","","1309.77","674.56","6049.93","26","1287.39","3301.53","percent of total billed charges",""
"FUSEX9MM L 6.4 25DEG COMPONENT THUMB INTRAMEDULLARY","SUP-ITM-10051903","CDM","C1889","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2213.48","53.3","","1901.83","1901.83","2962.25","1 through 10","1287.39","3301.53","percent of total billed charges",""
"FUSEX9MM L 6.4 25DEG COMPONENT THUMB INTRAMEDULLARY","SUP-ITM-10051903","CDM","C1889","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1515.80","36.5","","1620.31","1620.31","19908.88","1 through 10","1287.39","3301.53","percent of total billed charges",""
"FUSEX9MM L 6.4 25DEG COMPONENT THUMB INTRAMEDULLARY","SUP-ITM-10051903","CDM","C1889","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1590.55","38.3","","352.91","352.91","2046.30","1 through 10","1287.39","3301.53","percent of total billed charges",""
"FUSEX9MM L 6.4 25DEG COMPONENT THUMB INTRAMEDULLARY","SUP-ITM-10051903","CDM","C1889","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1781.58","42.9","","9668.75","9668.75","9668.75","1 through 10","1287.39","3301.53","percent of total billed charges",""
"FUSEX9MM L 6.4 25DEG COMPONENT THUMB INTRAMEDULLARY","SUP-ITM-10051903","CDM","C1889","HCPCS","0278","RC","","","","both","","","4152.87","3114.65","WELLPOINT [1015]","HB AMC WELLPOINT","3063.99","73.78","","699.88","384.10","3443.31","33","1287.39","3301.53","percent of total billed charges",""
"FUSEX9MM L 6.4 25DEG COMPONENT THUMB INTRAMEDULLARY","SUP-ITM-10051903","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4152.87","3114.65","AETNA [1001]","HB AMC AETNA HMO","2898.70","69.8","","1421.24","264.50","4933.46","29","2170.29","3393.73","percent of total billed charges",""
"FUSEX9MM L 6.4 25DEG COMPONENT THUMB INTRAMEDULLARY","SUP-ITM-10051903","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4152.87","3114.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3338.91","80.4","","1022.97","1022.97","3607.50","1 through 10","2170.29","3393.73","percent of total billed charges",""
"FUSEX9MM L 6.4 25DEG COMPONENT THUMB INTRAMEDULLARY","SUP-ITM-10051903","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4152.87","3114.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3393.73","81.72","","3010.54","693.88","5019.88","35","2170.29","3393.73","percent of total billed charges",""
"FUSION ANTEGRADE 13MMX65CM NAIL BONE FEMORAL TRIGEN SS RIGHT","SUP-ITM-10139161","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9027.92","52.26","","1113.10","1113.10","1113.10","1 through 10","5355.25","13733.63","percent of total billed charges",""
"FUSION ANTEGRADE 13MMX65CM NAIL BONE FEMORAL TRIGEN SS RIGHT","SUP-ITM-10139161","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13733.63","79.5","","1293.60","1148.53","1603.80","1 through 10","5355.25","13733.63","percent of total billed charges",""
"FUSION ANTEGRADE 13MMX65CM NAIL BONE FEMORAL TRIGEN SS RIGHT","SUP-ITM-10139161","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6305.38","36.5","","1023.42","771.29","2068.67","33","5355.25","13733.63","percent of total billed charges",""
"FUSION ANTEGRADE 13MMX65CM NAIL BONE FEMORAL TRIGEN SS RIGHT","SUP-ITM-10139161","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6616.33","38.3","","850.52","759.78","1211.25","66","5355.25","13733.63","percent of total billed charges",""
"FUSION ANTEGRADE 13MMX65CM NAIL BONE FEMORAL TRIGEN SS RIGHT","SUP-ITM-10139161","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7410.98","42.9","","2548.09","2548.09","2548.09","1 through 10","5355.25","13733.63","percent of total billed charges",""
"FUSION ANTEGRADE 13MMX65CM NAIL BONE FEMORAL TRIGEN SS RIGHT","SUP-ITM-10139161","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7410.98","42.9","","956.46","956.46","956.46","1 through 10","5355.25","13733.63","percent of total billed charges",""
"FUSION ANTEGRADE 13MMX65CM NAIL BONE FEMORAL TRIGEN SS RIGHT","SUP-ITM-10139161","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","WELLPOINT [1015]","HB AMC WELLPOINT","12745.50","73.78","","2344.73","1619.47","2530.35","16","5355.25","13733.63","percent of total billed charges",""
"FUSION ANTEGRADE 13MMX65CM NAIL BONE FEMORAL TRIGEN SS RIGHT","SUP-ITM-10139161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","AETNA [1001]","HB AMC AETNA HMO","12057.95","69.8","","1523.63","988.41","4330.26","39","9027.92","14117.13","percent of total billed charges",""
"FUSION ANTEGRADE 13MMX65CM NAIL BONE FEMORAL TRIGEN SS RIGHT","SUP-ITM-10139161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","AETNA [1001]","HB AMC AETNA PPO","13889.10","80.4","","1670.25","1670.25","1670.25","1 through 10","9027.92","14117.13","percent of total billed charges",""
"FUSION ANTEGRADE 13MMX65CM NAIL BONE FEMORAL TRIGEN SS RIGHT","SUP-ITM-10139161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9027.92","52.26","","1113.10","1113.10","1113.10","1 through 10","9027.92","14117.13","percent of total billed charges",""
"FUSION ANTEGRADE 13MMX65CM NAIL BONE FEMORAL TRIGEN SS RIGHT","SUP-ITM-10139161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14117.13","81.72","","1738.90","1484.65","2716.94","38","9027.92","14117.13","percent of total billed charges",""
"FUSION FEMORAL L 13MMX75CM NAIL TRIGEN FAN TITANIUM ALLOY LT ANTEGRADE","SUP-ITM-10139157","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9027.92","52.26","","1113.10","1113.10","1113.10","1 through 10","5355.25","13733.63","percent of total billed charges",""
"FUSION FEMORAL L 13MMX75CM NAIL TRIGEN FAN TITANIUM ALLOY LT ANTEGRADE","SUP-ITM-10139157","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13733.63","79.5","","1293.60","1148.53","1603.80","1 through 10","5355.25","13733.63","percent of total billed charges",""
"FUSION FEMORAL L 13MMX75CM NAIL TRIGEN FAN TITANIUM ALLOY LT ANTEGRADE","SUP-ITM-10139157","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6305.38","36.5","","1023.42","771.29","2068.67","33","5355.25","13733.63","percent of total billed charges",""
"FUSION FEMORAL L 13MMX75CM NAIL TRIGEN FAN TITANIUM ALLOY LT ANTEGRADE","SUP-ITM-10139157","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6616.33","38.3","","850.52","759.78","1211.25","66","5355.25","13733.63","percent of total billed charges",""
"FUSION FEMORAL L 13MMX75CM NAIL TRIGEN FAN TITANIUM ALLOY LT ANTEGRADE","SUP-ITM-10139157","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7410.98","42.9","","2548.09","2548.09","2548.09","1 through 10","5355.25","13733.63","percent of total billed charges",""
"FUSION FEMORAL L 13MMX75CM NAIL TRIGEN FAN TITANIUM ALLOY LT ANTEGRADE","SUP-ITM-10139157","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7410.98","42.9","","956.46","956.46","956.46","1 through 10","5355.25","13733.63","percent of total billed charges",""
"FUSION FEMORAL L 13MMX75CM NAIL TRIGEN FAN TITANIUM ALLOY LT ANTEGRADE","SUP-ITM-10139157","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","WELLPOINT [1015]","HB AMC WELLPOINT","12745.50","73.78","","2344.73","1619.47","2530.35","16","5355.25","13733.63","percent of total billed charges",""
"FUSION FEMORAL L 13MMX75CM NAIL TRIGEN FAN TITANIUM ALLOY LT ANTEGRADE","SUP-ITM-10139157","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","AETNA [1001]","HB AMC AETNA HMO","12057.95","69.8","","1523.63","988.41","4330.26","39","9027.92","14117.13","percent of total billed charges",""
"FUSION FEMORAL L 13MMX75CM NAIL TRIGEN FAN TITANIUM ALLOY LT ANTEGRADE","SUP-ITM-10139157","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","AETNA [1001]","HB AMC AETNA PPO","13889.10","80.4","","1670.25","1670.25","1670.25","1 through 10","9027.92","14117.13","percent of total billed charges",""
"FUSION FEMORAL L 13MMX75CM NAIL TRIGEN FAN TITANIUM ALLOY LT ANTEGRADE","SUP-ITM-10139157","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9027.92","52.26","","1113.10","1113.10","1113.10","1 through 10","9027.92","14117.13","percent of total billed charges",""
"FUSION FEMORAL L 13MMX75CM NAIL TRIGEN FAN TITANIUM ALLOY LT ANTEGRADE","SUP-ITM-10139157","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14117.13","81.72","","1738.90","1484.65","2716.94","38","9027.92","14117.13","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","4546.50","3409.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3614.47","79.5","","800.18","480.96","1887.97","195","1409.42","3614.47","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","4546.50","3409.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2423.28","53.3","","813.12","216.42","1444.50","81","1409.42","3614.47","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","4546.50","3409.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1409.42","31","","432.60","432.60","432.60","1 through 10","1409.42","3614.47","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","4546.50","3409.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1659.47","36.5","","148.37","54.89","631.39","94","1409.42","3614.47","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","4546.50","3409.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1741.31","38.3","","279.30","91.72","1116.77","266","1409.42","3614.47","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","4546.50","3409.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1950.45","42.9","","731.00","63.70","731.00","1 through 10","1409.42","3614.47","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","4546.50","3409.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1950.45","42.9","","384.74","384.74","384.74","1 through 10","1409.42","3614.47","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","both","","","4546.50","3409.87","WELLPOINT [1015]","HB AMC WELLPOINT","3354.41","73.78","","286.63","119.22","1107.45","105","1409.42","3614.47","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4546.50","3409.87","AETNA [1001]","HB AMC AETNA HMO","3173.46","69.8","","675.31","184.75","1721.50","286","2376","3715.4","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4546.50","3409.87","AETNA [1001]","HB AMC AETNA PPO","3655.39","80.4","","1261.44","103.12","1514.10","21","2376","3715.4","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4546.50","3409.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3655.39","80.4","","1365.00","1365.00","1365.00","1 through 10","2376","3715.4","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4546.50","3409.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3715.40","81.72","","5157.68","5157.68","5157.68","1 through 10","2376","3715.4","percent of total billed charges",""
"FUSION MTP PLATE BONE ORTHOLOC 3DI REVISION FIRST METARARSAL TITANIUM NITRIDE FIXATION POLYAXIAL LOCKING LEFT","SUP-ITM-10132142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4546.50","3409.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3715.40","81.72","","431.26","71.26","1459.57","88","2376","3715.4","percent of total billed charges",""
"FUSION SPINAL 16MM DIA 0DEG CAP END INTERBODY ROUND TITANIUM DOME L VBOSS","SUP-ITM-10046952","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","361.73","79.5","","1309.77","674.56","6049.93","26","141.05","361.73","percent of total billed charges",""
"FUSION SPINAL 16MM DIA 0DEG CAP END INTERBODY ROUND TITANIUM DOME L VBOSS","SUP-ITM-10046952","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.52","53.3","","1901.83","1901.83","2962.25","1 through 10","141.05","361.73","percent of total billed charges",""
"FUSION SPINAL 16MM DIA 0DEG CAP END INTERBODY ROUND TITANIUM DOME L VBOSS","SUP-ITM-10046952","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.08","36.5","","1620.31","1620.31","19908.88","1 through 10","141.05","361.73","percent of total billed charges",""
"FUSION SPINAL 16MM DIA 0DEG CAP END INTERBODY ROUND TITANIUM DOME L VBOSS","SUP-ITM-10046952","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.27","38.3","","352.91","352.91","2046.30","1 through 10","141.05","361.73","percent of total billed charges",""
"FUSION SPINAL 16MM DIA 0DEG CAP END INTERBODY ROUND TITANIUM DOME L VBOSS","SUP-ITM-10046952","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.20","42.9","","9668.75","9668.75","9668.75","1 through 10","141.05","361.73","percent of total billed charges",""
"FUSION SPINAL 16MM DIA 0DEG CAP END INTERBODY ROUND TITANIUM DOME L VBOSS","SUP-ITM-10046952","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","WELLPOINT [1015]","HB AMC WELLPOINT","335.70","73.78","","699.88","384.10","3443.31","33","141.05","361.73","percent of total billed charges",""
"FUSION SPINAL 16MM DIA 0DEG CAP END INTERBODY ROUND TITANIUM DOME L VBOSS","SUP-ITM-10046952","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","1421.24","264.50","4933.46","29","237.78","371.83","percent of total billed charges",""
"FUSION SPINAL 16MM DIA 0DEG CAP END INTERBODY ROUND TITANIUM DOME L VBOSS","SUP-ITM-10046952","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","365.82","80.4","","1022.97","1022.97","3607.50","1 through 10","237.78","371.83","percent of total billed charges",""
"FUSION SPINAL 16MM DIA 0DEG CAP END INTERBODY ROUND TITANIUM DOME L VBOSS","SUP-ITM-10046952","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.83","81.72","","3010.54","693.88","5019.88","35","237.78","371.83","percent of total billed charges",""
"FUSION SPINAL 16MM DIA SM 0DEG CAP END INTERBODY ROUND TITANIUM DOME VBOSS","SUP-ITM-10046953","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","361.73","79.5","","1309.77","674.56","6049.93","26","141.05","361.73","percent of total billed charges",""
"FUSION SPINAL 16MM DIA SM 0DEG CAP END INTERBODY ROUND TITANIUM DOME VBOSS","SUP-ITM-10046953","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.52","53.3","","1901.83","1901.83","2962.25","1 through 10","141.05","361.73","percent of total billed charges",""
"FUSION SPINAL 16MM DIA SM 0DEG CAP END INTERBODY ROUND TITANIUM DOME VBOSS","SUP-ITM-10046953","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.08","36.5","","1620.31","1620.31","19908.88","1 through 10","141.05","361.73","percent of total billed charges",""
"FUSION SPINAL 16MM DIA SM 0DEG CAP END INTERBODY ROUND TITANIUM DOME VBOSS","SUP-ITM-10046953","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.27","38.3","","352.91","352.91","2046.30","1 through 10","141.05","361.73","percent of total billed charges",""
"FUSION SPINAL 16MM DIA SM 0DEG CAP END INTERBODY ROUND TITANIUM DOME VBOSS","SUP-ITM-10046953","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.20","42.9","","9668.75","9668.75","9668.75","1 through 10","141.05","361.73","percent of total billed charges",""
"FUSION SPINAL 16MM DIA SM 0DEG CAP END INTERBODY ROUND TITANIUM DOME VBOSS","SUP-ITM-10046953","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","WELLPOINT [1015]","HB AMC WELLPOINT","335.70","73.78","","699.88","384.10","3443.31","33","141.05","361.73","percent of total billed charges",""
"FUSION SPINAL 16MM DIA SM 0DEG CAP END INTERBODY ROUND TITANIUM DOME VBOSS","SUP-ITM-10046953","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","1421.24","264.50","4933.46","29","237.78","371.83","percent of total billed charges",""
"FUSION SPINAL 16MM DIA SM 0DEG CAP END INTERBODY ROUND TITANIUM DOME VBOSS","SUP-ITM-10046953","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","365.82","80.4","","1022.97","1022.97","3607.50","1 through 10","237.78","371.83","percent of total billed charges",""
"FUSION SPINAL 16MM DIA SM 0DEG CAP END INTERBODY ROUND TITANIUM DOME VBOSS","SUP-ITM-10046953","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.83","81.72","","3010.54","693.88","5019.88","35","237.78","371.83","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4124.06","79.5","","800.18","480.96","1887.97","195","1608.13","4124.06","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2764.94","53.3","","813.12","216.42","1444.50","81","1608.13","4124.06","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1608.13","31","","432.60","432.60","432.60","1 through 10","1608.13","4124.06","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1893.44","36.5","","148.37","54.89","631.39","94","1608.13","4124.06","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1986.81","38.3","","279.30","91.72","1116.77","266","1608.13","4124.06","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2225.44","42.9","","731.00","63.70","731.00","1 through 10","1608.13","4124.06","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2225.44","42.9","","384.74","384.74","384.74","1 through 10","1608.13","4124.06","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","5187.50","3890.62","WELLPOINT [1015]","HB AMC WELLPOINT","3827.34","73.78","","286.63","119.22","1107.45","105","1608.13","4124.06","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5187.50","3890.62","AETNA [1001]","HB AMC AETNA HMO","3620.88","69.8","","675.31","184.75","1721.50","286","2710.99","4239.23","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5187.50","3890.62","AETNA [1001]","HB AMC AETNA PPO","4170.75","80.4","","1261.44","103.12","1514.10","21","2710.99","4239.23","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5187.50","3890.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4170.75","80.4","","1365.00","1365.00","1365.00","1 through 10","2710.99","4239.23","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5187.50","3890.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4239.23","81.72","","5157.68","5157.68","5157.68","1 through 10","2710.99","4239.23","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5187.50","3890.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4239.23","81.72","","431.26","71.26","1459.57","88","2710.99","4239.23","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","420.35","386.03","427.19","28","405.83","1462.01","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1462.01","79.5","","1403.22","1344.38","5648.54","17","405.83","1462.01","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","980.19","53.3","","5647.31","1403.22","5647.31","1 through 10","405.83","1462.01","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","418.65","418.65","1 through 10","405.83","1462.01","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","FALLON HEALTH [1008]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","418.65","418.65","1 through 10","405.83","1462.01","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1416.03","77","","8237.46","1372.91","8237.46","1 through 10","405.83","1462.01","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","HUMANA [1012]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","418.65","418.65","1 through 10","405.83","1462.01","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.75","418.75","418.75","1 through 10","405.83","1462.01","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","MEDICARE [2001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.19","392.31","427.19","175","405.83","1462.01","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","570.09","31","","3305.68","3305.68","3305.68","1 through 10","405.83","1462.01","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","671.24","36.5","","665.06","565.21","3990.35","1 through 10","405.83","1462.01","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","704.34","38.3","","697.15","677.54","4182.92","13","405.83","1462.01","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","418.65","418.65","1 through 10","405.83","1462.01","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","TRICARE [160005]","HB BWH TRICARE","405.83","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","427.19","427.19","427.19","1 through 10","405.83","1462.01","other","Tricare OPPS"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","384.46","1263.63","14","405.83","1462.01","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","410.09","410.09","410.09","1 through 10","405.83","1462.01","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","418.65","419.51","30","405.83","1462.01","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1839.00","1379.25","WELLPOINT [1015]","HB AMC WELLPOINT","1356.81","73.78","","1327.44","1327.44","1327.44","19","405.83","1462.01","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","outpatient","","","1839.00","1379.25","AETNA [1001]","HB AMC AETNA HMO","1283.62","69.8","","16163.03","1207.09","16163.03","1 through 10","564.46","1502.83","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","outpatient","","","1839.00","1379.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","961.06","52.26","","1103.33","564.46","1103.33","1 through 10","564.46","1502.83","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","outpatient","","","1839.00","1379.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1478.56","80.4","","5349.00","5349.00","5349.00","1 through 10","564.46","1502.83","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","outpatient","","","1839.00","1379.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1502.83","81.72","","783.99","783.99","783.99","1 through 10","564.46","1502.83","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","outpatient","","","1839.00","1379.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1502.83","81.72","","1425.33","783.99","8551.98","21","564.46","1502.83","percent of total billed charges",""
"G070123 Zenith Endovasc Bm Stent","PX-62400022","CDM","C1876","HCPCS","0624","RC","","","","both","","","4800.00","3600.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3148.80","65.6","","751.18","751.18","751.18","1 through 10","1488","3816","percent of total billed charges",""
"G070123 Zenith Endovasc Bm Stent","PX-62400022","CDM","C1876","HCPCS","0624","RC","","","","both","","","4800.00","3600.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3816.00","79.5","","4820.38","3211.27","4820.38","1 through 10","1488","3816","percent of total billed charges",""
"G070123 Zenith Endovasc Bm Stent","PX-62400022","CDM","C1876","HCPCS","0624","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1752.00","36.5","","641.00","641.00","641.00","1 through 10","1488","3816","percent of total billed charges",""
"G070123 Zenith Endovasc Bm Stent","PX-62400022","CDM","C1876","HCPCS","0624","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1838.40","38.3","","1098.43","1098.43","1098.43","1 through 10","1488","3816","percent of total billed charges",""
"G070123 Zenith Endovasc Bm Stent","PX-62400022","CDM","C1876","HCPCS","0624","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","4896.33","4896.33","4896.33","1 through 10","1488","3816","percent of total billed charges",""
"G070123 Zenith Endovasc Bm Stent","PX-62400022","CDM","C1876","HCPCS","0624","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA HMO","3350.40","69.8","","175.60","163.11","1063.91","1 through 10","2508.48","3922.56","percent of total billed charges",""
"G070123 Zenith Endovasc Bm Stent","PX-62400022","CDM","C1876","HCPCS","0624","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3922.56","81.72","","105.94","85.10","105.94","1 through 10","2508.48","3922.56","percent of total billed charges",""
"G070123 Zenith Endovasc Stent Graft","PX-62400021","CDM","C1874","HCPCS","0624","RC","","","","both","","","7500.00","5625.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4875.00","65","","6652.80","6652.80","6652.80","1 through 10","2325","5962.5","percent of total billed charges",""
"G070123 Zenith Endovasc Stent Graft","PX-62400021","CDM","C1874","HCPCS","0624","RC","","","","both","","","7500.00","5625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5962.50","79.5","","2612.61","795.38","2612.61","1 through 10","2325","5962.5","percent of total billed charges",""
"G070123 Zenith Endovasc Stent Graft","PX-62400021","CDM","C1874","HCPCS","0624","RC","","","","both","","","7500.00","5625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3997.50","53.3","","1101.80","1101.80","1101.80","1 through 10","2325","5962.5","percent of total billed charges",""
"G070123 Zenith Endovasc Stent Graft","PX-62400021","CDM","C1874","HCPCS","0624","RC","","","","both","","","7500.00","5625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4875.00","65","","1820.00","910.00","1820.00","1 through 10","2325","5962.5","percent of total billed charges",""
"G070123 Zenith Endovasc Stent Graft","PX-62400021","CDM","C1874","HCPCS","0624","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2737.50","36.5","","1257.80","693.44","2424.50","1 through 10","2325","5962.5","percent of total billed charges",""
"G070123 Zenith Endovasc Stent Graft","PX-62400021","CDM","C1874","HCPCS","0624","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2872.50","38.3","","1950.11","547.40","2346.00","1 through 10","2325","5962.5","percent of total billed charges",""
"G070123 Zenith Endovasc Stent Graft","PX-62400021","CDM","C1874","HCPCS","0624","RC","","","","both","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3217.50","42.9","","5096.18","5096.18","5096.18","1 through 10","2325","5962.5","percent of total billed charges",""
"G070123 Zenith Endovasc Stent Graft","PX-62400021","CDM","C1874","HCPCS","0624","RC","","","","both","","","7500.00","5625.00","WELLPOINT [1015]","HB AMC WELLPOINT","5533.50","73.78","","1172.59","1172.59","4829.94","1 through 10","2325","5962.5","percent of total billed charges",""
"G070123 Zenith Endovasc Stent Graft","PX-62400021","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","7500.00","5625.00","AETNA [1001]","HB AMC AETNA HMO","5235.00","69.8","","1806.84","947.80","5091.72","1 through 10","3919.5","6129","percent of total billed charges",""
"G070123 Zenith Endovasc Stent Graft","PX-62400021","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6129.00","81.72","","1259.05","615.58","4586.56","1 through 10","3919.5","6129","percent of total billed charges",""
"G090205 Kinespring Knee Implant","PX-62400135","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","800.18","480.96","1887.97","195","0.31","0.8","percent of total billed charges",""
"G090205 Kinespring Knee Implant","PX-62400135","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","813.12","216.42","1444.50","81","0.31","0.8","percent of total billed charges",""
"G090205 Kinespring Knee Implant","PX-62400135","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.31","31","","432.60","432.60","432.60","1 through 10","0.31","0.8","percent of total billed charges",""
"G090205 Kinespring Knee Implant","PX-62400135","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","148.37","54.89","631.39","94","0.31","0.8","percent of total billed charges",""
"G090205 Kinespring Knee Implant","PX-62400135","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","279.30","91.72","1116.77","266","0.31","0.8","percent of total billed charges",""
"G090205 Kinespring Knee Implant","PX-62400135","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","731.00","63.70","731.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G090205 Kinespring Knee Implant","PX-62400135","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","384.74","384.74","384.74","1 through 10","0.31","0.8","percent of total billed charges",""
"G090205 Kinespring Knee Implant","PX-62400135","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","286.63","119.22","1107.45","105","0.31","0.8","percent of total billed charges",""
"G090205 Kinespring Knee Implant","PX-62400135","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","675.31","184.75","1721.50","286","0.52","0.82","percent of total billed charges",""
"G090205 Kinespring Knee Implant","PX-62400135","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA PPO","0.80","80.4","","1261.44","103.12","1514.10","21","0.52","0.82","percent of total billed charges",""
"G090205 Kinespring Knee Implant","PX-62400135","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1365.00","1365.00","1365.00","1 through 10","0.52","0.82","percent of total billed charges",""
"G090205 Kinespring Knee Implant","PX-62400135","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","0.82","81.72","","5157.68","5157.68","5157.68","1 through 10","0.52","0.82","percent of total billed charges",""
"G090205 Kinespring Knee Implant","PX-62400135","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","431.26","71.26","1459.57","88","0.52","0.82","percent of total billed charges",""
"G110022 Airxpander Tiss Sys","PX-62400026","CDM","C1789","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","2867.44","1923.77","8602.29","1 through 10","0.31","0.8","percent of total billed charges",""
"G110022 Airxpander Tiss Sys","PX-62400026","CDM","C1789","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","5771.31","1397.09","6509.05","16","0.31","0.8","percent of total billed charges",""
"G110022 Airxpander Tiss Sys","PX-62400026","CDM","C1789","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","0.80","79.5","","5730.95","5730.95","5730.95","1 through 10","0.31","0.8","percent of total billed charges",""
"G110022 Airxpander Tiss Sys","PX-62400026","CDM","C1789","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1154.99","1154.99","1318.95","1 through 10","0.31","0.8","percent of total billed charges",""
"G110022 Airxpander Tiss Sys","PX-62400026","CDM","C1789","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1424.61","1034.59","4273.83","20","0.31","0.8","percent of total billed charges",""
"G110022 Airxpander Tiss Sys","PX-62400026","CDM","C1789","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","2912.61","2912.61","2912.61","1 through 10","0.31","0.8","percent of total billed charges",""
"G110022 Airxpander Tiss Sys","PX-62400026","CDM","C1789","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","2712.59","1969.95","2712.59","1 through 10","0.31","0.8","percent of total billed charges",""
"G110022 Airxpander Tiss Sys","PX-62400026","CDM","C1789","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","4933.30","1741.59","4933.30","1 through 10","0.52","0.82","percent of total billed charges",""
"G110022 Airxpander Tiss Sys","PX-62400026","CDM","C1789","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","0.52","52.26","","3643.50","3643.50","3643.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G110022 Airxpander Tiss Sys","PX-62400026","CDM","C1789","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","2115.21","1602.05","5825.23","1 through 10","0.52","0.82","percent of total billed charges",""
"G120020 Intramural Needle Ablation Catheter","PX-62400087","CDM","C1733","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","17511.01","17511.01","17511.01","1 through 10","0.31","0.8","percent of total billed charges",""
"G120020 Intramural Needle Ablation Catheter","PX-62400087","CDM","C1733","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","21125.00","21125.00","21125.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G120020 Intramural Needle Ablation Catheter","PX-62400087","CDM","C1733","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","7879.63","7879.63","7879.63","1 through 10","0.31","0.8","percent of total billed charges",""
"G120020 Intramural Needle Ablation Catheter","PX-62400087","CDM","C1733","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","8259.88","8259.88","16055.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G120020 Intramural Needle Ablation Catheter","PX-62400087","CDM","C1733","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","15727.56","15727.56","20473.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G120020 Intramural Needle Ablation Catheter","PX-62400087","CDM","C1733","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","0.82","81.72","","16887.32","9288.66","16887.32","1 through 10","0.52","0.82","percent of total billed charges",""
"G120020 Intramural Needle Ablation Catheter","PX-62400087","CDM","C1733","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","16887.33","11641.27","21983.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G130005 Endologix Branch Aaa Chevas Trial","PX-62400216","CDM","C1874","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","40625.00","65","","6652.80","6652.80","6652.80","1 through 10","19375","49687.5","percent of total billed charges",""
"G130005 Endologix Branch Aaa Chevas Trial","PX-62400216","CDM","C1874","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","49687.50","79.5","","2612.61","795.38","2612.61","1 through 10","19375","49687.5","percent of total billed charges",""
"G130005 Endologix Branch Aaa Chevas Trial","PX-62400216","CDM","C1874","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33312.50","53.3","","1101.80","1101.80","1101.80","1 through 10","19375","49687.5","percent of total billed charges",""
"G130005 Endologix Branch Aaa Chevas Trial","PX-62400216","CDM","C1874","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","40625.00","65","","1820.00","910.00","1820.00","1 through 10","19375","49687.5","percent of total billed charges",""
"G130005 Endologix Branch Aaa Chevas Trial","PX-62400216","CDM","C1874","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22812.50","36.5","","1257.80","693.44","2424.50","1 through 10","19375","49687.5","percent of total billed charges",""
"G130005 Endologix Branch Aaa Chevas Trial","PX-62400216","CDM","C1874","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23937.50","38.3","","1950.11","547.40","2346.00","1 through 10","19375","49687.5","percent of total billed charges",""
"G130005 Endologix Branch Aaa Chevas Trial","PX-62400216","CDM","C1874","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26812.50","42.9","","5096.18","5096.18","5096.18","1 through 10","19375","49687.5","percent of total billed charges",""
"G130005 Endologix Branch Aaa Chevas Trial","PX-62400216","CDM","C1874","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","WELLPOINT [1015]","HB AMC WELLPOINT","46112.50","73.78","","1172.59","1172.59","4829.94","1 through 10","19375","49687.5","percent of total billed charges",""
"G130005 Endologix Branch Aaa Chevas Trial","PX-62400216","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","62500.00","46875.00","AETNA [1001]","HB AMC AETNA HMO","43625.00","69.8","","1806.84","947.80","5091.72","1 through 10","32662.5","51075","percent of total billed charges",""
"G130005 Endologix Branch Aaa Chevas Trial","PX-62400216","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","62500.00","46875.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","51075.00","81.72","","1259.05","615.58","4586.56","1 through 10","32662.5","51075","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Compnt","PX-62400136","CDM","C1874","HCPCS","0624","RC","","","","both","","","27500.00","20625.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","17875.00","65","","6652.80","6652.80","6652.80","1 through 10","8525","21862.5","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Compnt","PX-62400136","CDM","C1874","HCPCS","0624","RC","","","","both","","","27500.00","20625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21862.50","79.5","","2612.61","795.38","2612.61","1 through 10","8525","21862.5","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Compnt","PX-62400136","CDM","C1874","HCPCS","0624","RC","","","","both","","","27500.00","20625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14657.50","53.3","","1101.80","1101.80","1101.80","1 through 10","8525","21862.5","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Compnt","PX-62400136","CDM","C1874","HCPCS","0624","RC","","","","both","","","27500.00","20625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","17875.00","65","","1820.00","910.00","1820.00","1 through 10","8525","21862.5","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Compnt","PX-62400136","CDM","C1874","HCPCS","0624","RC","","","","both","","","27500.00","20625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10037.50","36.5","","1257.80","693.44","2424.50","1 through 10","8525","21862.5","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Compnt","PX-62400136","CDM","C1874","HCPCS","0624","RC","","","","both","","","27500.00","20625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10532.50","38.3","","1950.11","547.40","2346.00","1 through 10","8525","21862.5","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Compnt","PX-62400136","CDM","C1874","HCPCS","0624","RC","","","","both","","","27500.00","20625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11797.50","42.9","","5096.18","5096.18","5096.18","1 through 10","8525","21862.5","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Compnt","PX-62400136","CDM","C1874","HCPCS","0624","RC","","","","both","","","27500.00","20625.00","WELLPOINT [1015]","HB AMC WELLPOINT","20289.50","73.78","","1172.59","1172.59","4829.94","1 through 10","8525","21862.5","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Compnt","PX-62400136","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","27500.00","20625.00","AETNA [1001]","HB AMC AETNA HMO","19195.00","69.8","","1806.84","947.80","5091.72","1 through 10","14371.5","22473","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Compnt","PX-62400136","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","27500.00","20625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22473.00","81.72","","1259.05","615.58","4586.56","1 through 10","14371.5","22473","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Extndr","PX-62400137","CDM","C1874","HCPCS","0624","RC","","","","both","","","11000.00","8250.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7150.00","65","","6652.80","6652.80","6652.80","1 through 10","3410","8745","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Extndr","PX-62400137","CDM","C1874","HCPCS","0624","RC","","","","both","","","11000.00","8250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8745.00","79.5","","2612.61","795.38","2612.61","1 through 10","3410","8745","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Extndr","PX-62400137","CDM","C1874","HCPCS","0624","RC","","","","both","","","11000.00","8250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5863.00","53.3","","1101.80","1101.80","1101.80","1 through 10","3410","8745","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Extndr","PX-62400137","CDM","C1874","HCPCS","0624","RC","","","","both","","","11000.00","8250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7150.00","65","","1820.00","910.00","1820.00","1 through 10","3410","8745","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Extndr","PX-62400137","CDM","C1874","HCPCS","0624","RC","","","","both","","","11000.00","8250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4015.00","36.5","","1257.80","693.44","2424.50","1 through 10","3410","8745","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Extndr","PX-62400137","CDM","C1874","HCPCS","0624","RC","","","","both","","","11000.00","8250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4213.00","38.3","","1950.11","547.40","2346.00","1 through 10","3410","8745","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Extndr","PX-62400137","CDM","C1874","HCPCS","0624","RC","","","","both","","","11000.00","8250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4719.00","42.9","","5096.18","5096.18","5096.18","1 through 10","3410","8745","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Extndr","PX-62400137","CDM","C1874","HCPCS","0624","RC","","","","both","","","11000.00","8250.00","WELLPOINT [1015]","HB AMC WELLPOINT","8115.80","73.78","","1172.59","1172.59","4829.94","1 through 10","3410","8745","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Extndr","PX-62400137","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","11000.00","8250.00","AETNA [1001]","HB AMC AETNA HMO","7678.00","69.8","","1806.84","947.80","5091.72","1 through 10","5748.6","8989.2","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Aortic Extndr","PX-62400137","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","11000.00","8250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8989.20","81.72","","1259.05","615.58","4586.56","1 through 10","5748.6","8989.2","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Introducer Sheath","PX-62400139","CDM","C1874","HCPCS","0624","RC","","","","both","","","1095.00","821.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","711.75","65","","6652.80","6652.80","6652.80","1 through 10","339.45","870.53","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Introducer Sheath","PX-62400139","CDM","C1874","HCPCS","0624","RC","","","","both","","","1095.00","821.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","870.53","79.5","","2612.61","795.38","2612.61","1 through 10","339.45","870.53","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Introducer Sheath","PX-62400139","CDM","C1874","HCPCS","0624","RC","","","","both","","","1095.00","821.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","583.64","53.3","","1101.80","1101.80","1101.80","1 through 10","339.45","870.53","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Introducer Sheath","PX-62400139","CDM","C1874","HCPCS","0624","RC","","","","both","","","1095.00","821.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","711.75","65","","1820.00","910.00","1820.00","1 through 10","339.45","870.53","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Introducer Sheath","PX-62400139","CDM","C1874","HCPCS","0624","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","399.68","36.5","","1257.80","693.44","2424.50","1 through 10","339.45","870.53","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Introducer Sheath","PX-62400139","CDM","C1874","HCPCS","0624","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","419.39","38.3","","1950.11","547.40","2346.00","1 through 10","339.45","870.53","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Introducer Sheath","PX-62400139","CDM","C1874","HCPCS","0624","RC","","","","both","","","1095.00","821.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","469.76","42.9","","5096.18","5096.18","5096.18","1 through 10","339.45","870.53","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Introducer Sheath","PX-62400139","CDM","C1874","HCPCS","0624","RC","","","","both","","","1095.00","821.25","WELLPOINT [1015]","HB AMC WELLPOINT","807.89","73.78","","1172.59","1172.59","4829.94","1 through 10","339.45","870.53","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Introducer Sheath","PX-62400139","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1095.00","821.25","AETNA [1001]","HB AMC AETNA HMO","764.31","69.8","","1806.84","947.80","5091.72","1 through 10","572.25","894.83","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Introducer Sheath","PX-62400139","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1095.00","821.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","894.83","81.72","","1259.05","615.58","4586.56","1 through 10","572.25","894.83","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Tri-Lobe Balloon Cath","PX-62400140","CDM","C1874","HCPCS","0624","RC","","","","both","","","600.00","450.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","390.00","65","","6652.80","6652.80","6652.80","1 through 10","186","477","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Tri-Lobe Balloon Cath","PX-62400140","CDM","C1874","HCPCS","0624","RC","","","","both","","","600.00","450.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","477.00","79.5","","2612.61","795.38","2612.61","1 through 10","186","477","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Tri-Lobe Balloon Cath","PX-62400140","CDM","C1874","HCPCS","0624","RC","","","","both","","","600.00","450.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","319.80","53.3","","1101.80","1101.80","1101.80","1 through 10","186","477","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Tri-Lobe Balloon Cath","PX-62400140","CDM","C1874","HCPCS","0624","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","390.00","65","","1820.00","910.00","1820.00","1 through 10","186","477","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Tri-Lobe Balloon Cath","PX-62400140","CDM","C1874","HCPCS","0624","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","219.00","36.5","","1257.80","693.44","2424.50","1 through 10","186","477","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Tri-Lobe Balloon Cath","PX-62400140","CDM","C1874","HCPCS","0624","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","229.80","38.3","","1950.11","547.40","2346.00","1 through 10","186","477","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Tri-Lobe Balloon Cath","PX-62400140","CDM","C1874","HCPCS","0624","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","257.40","42.9","","5096.18","5096.18","5096.18","1 through 10","186","477","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Tri-Lobe Balloon Cath","PX-62400140","CDM","C1874","HCPCS","0624","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB AMC WELLPOINT","442.68","73.78","","1172.59","1172.59","4829.94","1 through 10","186","477","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Tri-Lobe Balloon Cath","PX-62400140","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","600.00","450.00","AETNA [1001]","HB AMC AETNA HMO","418.80","69.8","","1806.84","947.80","5091.72","1 through 10","313.56","490.32","percent of total billed charges",""
"G130120 Gore Tag Tbe Device Tri-Lobe Balloon Cath","PX-62400140","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","490.32","81.72","","1259.05","615.58","4586.56","1 through 10","313.56","490.32","percent of total billed charges",""
"G130138 Nanostim/Aveir Vr Leadless Pacemaker System","PX-62400078","CDM","C2621","HCPCS","0624","RC","","","","outpatient","","","23750.00","17812.50","AETNA [1001]","HB AMC AETNA HMO","16577.50","69.8","","5258.00","5258.00","5258.00","1 through 10","12411.75","19408.5","percent of total billed charges",""
"G140102 Thermocool Smarttouch Sf","PX-62400142","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","2222.68","2222.68","2222.68","1 through 10","0.31","0.8","percent of total billed charges",""
"G140102 Thermocool Smarttouch Sf","PX-62400142","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","4681.38","1275.47","8371.80","20","0.31","0.8","percent of total billed charges",""
"G140102 Thermocool Smarttouch Sf","PX-62400142","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1663.12","1287.53","2528.21","1 through 10","0.31","0.8","percent of total billed charges",""
"G140102 Thermocool Smarttouch Sf","PX-62400142","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","1935.35","1935.35","1935.35","1 through 10","0.31","0.8","percent of total billed charges",""
"G140102 Thermocool Smarttouch Sf","PX-62400142","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","4813.94","2545.82","7082.06","1 through 10","0.31","0.8","percent of total billed charges",""
"G140102 Thermocool Smarttouch Sf","PX-62400142","CDM","C1732","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","2733.55","2433.63","5168.92","14","0.52","0.82","percent of total billed charges",""
"G140140 Sifs Spineology Interbody Fusion System","PX-62400107","CDM","C1781","HCPCS","0624","RC","","","","both","","","0.01","0.01","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.01","70","","134.04","134.04","134.04","1 through 10","0.01","0.01","percent of total billed charges",""
"G140140 Sifs Spineology Interbody Fusion System","PX-62400107","CDM","C1781","HCPCS","0624","RC","","","","both","","","0.01","0.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.01","79.5","","948.87","198.19","1805.30","1 through 10","0.01","0.01","percent of total billed charges",""
"G140140 Sifs Spineology Interbody Fusion System","PX-62400107","CDM","C1781","HCPCS","0624","RC","","","","both","","","0.01","0.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.01","53.3","","462.00","170.45","3253.37","1 through 10","0.01","0.01","percent of total billed charges",""
"G140140 Sifs Spineology Interbody Fusion System","PX-62400107","CDM","C1781","HCPCS","0624","RC","","","","both","","","0.01","0.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","","36.5","","245.50","107.19","1371.45","1 through 10","0.01","0.01","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"G140140 Sifs Spineology Interbody Fusion System","PX-62400107","CDM","C1781","HCPCS","0624","RC","","","","both","","","0.01","0.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","","38.3","","200.79","72.79","355.81","22","0.01","0.01","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"G140140 Sifs Spineology Interbody Fusion System","PX-62400107","CDM","C1781","HCPCS","0624","RC","","","","both","","","0.01","0.01","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.01","77","","477.18","477.18","477.18","1 through 10","0.01","0.01","percent of total billed charges",""
"G140140 Sifs Spineology Interbody Fusion System","PX-62400107","CDM","C1781","HCPCS","0624","RC","","","","both","","","0.01","0.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","","42.9","","1045.91","1045.91","1045.91","1 through 10","0.01","0.01","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"G140140 Sifs Spineology Interbody Fusion System","PX-62400107","CDM","C1781","HCPCS","0624","RC","","","","both","","","0.01","0.01","WELLPOINT [1015]","HB AMC WELLPOINT","0.01","73.78","","1726.50","1726.50","1726.50","1 through 10","0.01","0.01","percent of total billed charges",""
"G140140 Sifs Spineology Interbody Fusion System","PX-62400107","CDM","C1781","HCPCS","0624","RC","","","","outpatient","","","0.01","0.01","AETNA [1001]","HB AMC AETNA HMO","0.01","69.8","","915.80","263.76","2881.00","1 through 10","0.01","0.01","percent of total billed charges",""
"G140140 Sifs Spineology Interbody Fusion System","PX-62400107","CDM","C1781","HCPCS","0624","RC","","","","outpatient","","","0.01","0.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.01","81.72","","1531.57","410.52","8841.36","1 through 10","0.01","0.01","percent of total billed charges",""
"G150071 Taa Branch Gore Trial","PX-62400205","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.65","65","","6652.80","6652.80","6652.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G150071 Taa Branch Gore Trial","PX-62400205","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","2612.61","795.38","2612.61","1 through 10","0.31","0.8","percent of total billed charges",""
"G150071 Taa Branch Gore Trial","PX-62400205","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1101.80","1101.80","1101.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G150071 Taa Branch Gore Trial","PX-62400205","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1820.00","910.00","1820.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G150071 Taa Branch Gore Trial","PX-62400205","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1257.80","693.44","2424.50","1 through 10","0.31","0.8","percent of total billed charges",""
"G150071 Taa Branch Gore Trial","PX-62400205","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1950.11","547.40","2346.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G150071 Taa Branch Gore Trial","PX-62400205","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","5096.18","5096.18","5096.18","1 through 10","0.31","0.8","percent of total billed charges",""
"G150071 Taa Branch Gore Trial","PX-62400205","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","1172.59","1172.59","4829.94","1 through 10","0.31","0.8","percent of total billed charges",""
"G150071 Taa Branch Gore Trial","PX-62400205","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1806.84","947.80","5091.72","1 through 10","0.52","0.82","percent of total billed charges",""
"G150071 Taa Branch Gore Trial","PX-62400205","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","1259.05","615.58","4586.56","1 through 10","0.52","0.82","percent of total billed charges",""
"G150220 Sapien 3 Thv 2024p001817","PX-62400302","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G150220 Sapien 3 Thv 2024p001817","PX-62400302","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G150220 Sapien 3 Thv 2024p001817","PX-62400302","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G150220 Sapien 3 Thv 2024p001817","PX-62400302","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G150220 Sapien 3 Thv 2024p001817","PX-62400302","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G150220 Sapien 3 Thv 2024p001817","PX-62400302","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G150220 Sapien 3 Thv 2024p001817","PX-62400302","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G150220 Sapien 3 Thv 2024p001817","PX-62400302","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G150220 Sapien 3 Thv 2024p001817","PX-62400302","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G150220 Sapien 3 Ultra Resilia Thv 2024p001817","PX-62400301","CDM","C1889","HCPCS","0624","RC","","","","both","","","75000.00","56250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59625.00","79.5","","1309.77","674.56","6049.93","26","23250","59625","percent of total billed charges",""
"G150220 Sapien 3 Ultra Resilia Thv 2024p001817","PX-62400301","CDM","C1889","HCPCS","0624","RC","","","","both","","","75000.00","56250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39975.00","53.3","","1901.83","1901.83","2962.25","1 through 10","23250","59625","percent of total billed charges",""
"G150220 Sapien 3 Ultra Resilia Thv 2024p001817","PX-62400301","CDM","C1889","HCPCS","0624","RC","","","","both","","","75000.00","56250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27375.00","36.5","","1620.31","1620.31","19908.88","1 through 10","23250","59625","percent of total billed charges",""
"G150220 Sapien 3 Ultra Resilia Thv 2024p001817","PX-62400301","CDM","C1889","HCPCS","0624","RC","","","","both","","","75000.00","56250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28725.00","38.3","","352.91","352.91","2046.30","1 through 10","23250","59625","percent of total billed charges",""
"G150220 Sapien 3 Ultra Resilia Thv 2024p001817","PX-62400301","CDM","C1889","HCPCS","0624","RC","","","","both","","","75000.00","56250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32175.00","42.9","","9668.75","9668.75","9668.75","1 through 10","23250","59625","percent of total billed charges",""
"G150220 Sapien 3 Ultra Resilia Thv 2024p001817","PX-62400301","CDM","C1889","HCPCS","0624","RC","","","","both","","","75000.00","56250.00","WELLPOINT [1015]","HB AMC WELLPOINT","55335.00","73.78","","699.88","384.10","3443.31","33","23250","59625","percent of total billed charges",""
"G150220 Sapien 3 Ultra Resilia Thv 2024p001817","PX-62400301","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","75000.00","56250.00","AETNA [1001]","HB AMC AETNA HMO","52350.00","69.8","","1421.24","264.50","4933.46","29","39195","61290","percent of total billed charges",""
"G150220 Sapien 3 Ultra Resilia Thv 2024p001817","PX-62400301","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","75000.00","56250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","60300.00","80.4","","1022.97","1022.97","3607.50","1 through 10","39195","61290","percent of total billed charges",""
"G150220 Sapien 3 Ultra Resilia Thv 2024p001817","PX-62400301","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","75000.00","56250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","61290.00","81.72","","3010.54","693.88","5019.88","35","39195","61290","percent of total billed charges",""
"G150249 Accucinch Ventricular Systm - Hfref","PX-62400237","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G150249 Accucinch Ventricular Systm - Hfref","PX-62400237","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G150249 Accucinch Ventricular Systm - Hfref","PX-62400237","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G150249 Accucinch Ventricular Systm - Hfref","PX-62400237","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G150249 Accucinch Ventricular Systm - Hfref","PX-62400237","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G150249 Accucinch Ventricular Systm - Hfref","PX-62400237","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G150249 Accucinch Ventricular Systm - Hfref","PX-62400237","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G150249 Accucinch Ventricular Systm - Hfref","PX-62400237","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G150249 Accucinch Ventricular Systm - Hfref","PX-62400237","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G160173 Orthofix M6-C Cervical Disc Trial 2022p000722","PX-62400254","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G160173 Orthofix M6-C Cervical Disc Trial 2022p000722","PX-62400254","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G160173 Orthofix M6-C Cervical Disc Trial 2022p000722","PX-62400254","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G160173 Orthofix M6-C Cervical Disc Trial 2022p000722","PX-62400254","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G160173 Orthofix M6-C Cervical Disc Trial 2022p000722","PX-62400254","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G160173 Orthofix M6-C Cervical Disc Trial 2022p000722","PX-62400254","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G160173 Orthofix M6-C Cervical Disc Trial 2022p000722","PX-62400254","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G160173 Orthofix M6-C Cervical Disc Trial 2022p000722","PX-62400254","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G160173 Orthofix M6-C Cervical Disc Trial 2022p000722","PX-62400254","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G160177 Arctic Front Cryoablation Catheter","PX-62400146","CDM","C1733","HCPCS","0624","RC","","","","both","","","11250.00","8437.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8943.75","79.5","","17511.01","17511.01","17511.01","1 through 10","3487.5","8943.75","percent of total billed charges",""
"G160177 Arctic Front Cryoablation Catheter","PX-62400146","CDM","C1733","HCPCS","0624","RC","","","","both","","","11250.00","8437.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5996.25","53.3","","21125.00","21125.00","21125.00","1 through 10","3487.5","8943.75","percent of total billed charges",""
"G160177 Arctic Front Cryoablation Catheter","PX-62400146","CDM","C1733","HCPCS","0624","RC","","","","both","","","11250.00","8437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4106.25","36.5","","7879.63","7879.63","7879.63","1 through 10","3487.5","8943.75","percent of total billed charges",""
"G160177 Arctic Front Cryoablation Catheter","PX-62400146","CDM","C1733","HCPCS","0624","RC","","","","both","","","11250.00","8437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4308.75","38.3","","8259.88","8259.88","16055.00","1 through 10","3487.5","8943.75","percent of total billed charges",""
"G160177 Arctic Front Cryoablation Catheter","PX-62400146","CDM","C1733","HCPCS","0624","RC","","","","both","","","11250.00","8437.50","WELLPOINT [1015]","HB AMC WELLPOINT","8300.25","73.78","","15727.56","15727.56","20473.75","1 through 10","3487.5","8943.75","percent of total billed charges",""
"G160177 Arctic Front Cryoablation Catheter","PX-62400146","CDM","C1733","HCPCS","0624","RC","","","","outpatient","","","11250.00","8437.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","9193.50","81.72","","16887.32","9288.66","16887.32","1 through 10","5879.25","9193.5","percent of total billed charges",""
"G160177 Arctic Front Cryoablation Catheter","PX-62400146","CDM","C1733","HCPCS","0624","RC","","","","outpatient","","","11250.00","8437.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9193.50","81.72","","16887.33","11641.27","21983.50","1 through 10","5879.25","9193.5","percent of total billed charges",""
"G160177 Freezor Max Cryoablation Catheter","PX-62400145","CDM","C1733","HCPCS","0624","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","17511.01","17511.01","17511.01","1 through 10","1550","3975","percent of total billed charges",""
"G160177 Freezor Max Cryoablation Catheter","PX-62400145","CDM","C1733","HCPCS","0624","RC","","","","both","","","5000.00","3750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2665.00","53.3","","21125.00","21125.00","21125.00","1 through 10","1550","3975","percent of total billed charges",""
"G160177 Freezor Max Cryoablation Catheter","PX-62400145","CDM","C1733","HCPCS","0624","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","7879.63","7879.63","7879.63","1 through 10","1550","3975","percent of total billed charges",""
"G160177 Freezor Max Cryoablation Catheter","PX-62400145","CDM","C1733","HCPCS","0624","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","8259.88","8259.88","16055.00","1 through 10","1550","3975","percent of total billed charges",""
"G160177 Freezor Max Cryoablation Catheter","PX-62400145","CDM","C1733","HCPCS","0624","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","15727.56","15727.56","20473.75","1 through 10","1550","3975","percent of total billed charges",""
"G160177 Freezor Max Cryoablation Catheter","PX-62400145","CDM","C1733","HCPCS","0624","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4086.00","81.72","","16887.32","9288.66","16887.32","1 through 10","2613","4086","percent of total billed charges",""
"G160177 Freezor Max Cryoablation Catheter","PX-62400145","CDM","C1733","HCPCS","0624","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","16887.33","11641.27","21983.50","1 through 10","2613","4086","percent of total billed charges",""
"G160218 Gore Cardioform Asd Occluder","PX-62400144","CDM","C1817","CPT","0624","RC","","","","both","","","17250.00","12937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13713.75","79.5","","17412.37","11682.00","17412.38","1 through 10","5347.5","13713.75","percent of total billed charges",""
"G160218 Gore Cardioform Asd Occluder","PX-62400144","CDM","C1817","CPT","0624","RC","","","","both","","","17250.00","12937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9194.25","53.3","","11682.00","11682.00","11682.00","1 through 10","5347.5","13713.75","percent of total billed charges",""
"G160218 Gore Cardioform Asd Occluder","PX-62400144","CDM","C1817","CPT","0624","RC","","","","both","","","17250.00","12937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6606.75","38.3","","8650.88","8650.88","9853.20","1 through 10","5347.5","13713.75","percent of total billed charges",""
"G160218 Gore Cardioform Asd Occluder","PX-62400144","CDM","C1817","CPT","0624","RC","","","","both","","","17250.00","12937.50","WELLPOINT [1015]","HB AMC WELLPOINT","12727.05","73.78","","16472.06","16472.06","16472.06","1 through 10","5347.5","13713.75","percent of total billed charges",""
"G160218 Gore Cardioform Asd Occluder","PX-62400144","CDM","C1817","CPT","0624","RC","","","","outpatient","","","17250.00","12937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14096.70","81.72","","17686.73","17686.73","17686.73","1 through 10","9014.85","14096.7","percent of total billed charges",""
"G160226 Ovation Alto Stent Graft","PX-62400147","CDM","C1874","HCPCS","0624","RC","","","","both","","","38813.00","29109.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","25228.45","65","","6652.80","6652.80","6652.80","1 through 10","12032.03","30856.34","percent of total billed charges",""
"G160226 Ovation Alto Stent Graft","PX-62400147","CDM","C1874","HCPCS","0624","RC","","","","both","","","38813.00","29109.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","30856.34","79.5","","2612.61","795.38","2612.61","1 through 10","12032.03","30856.34","percent of total billed charges",""
"G160226 Ovation Alto Stent Graft","PX-62400147","CDM","C1874","HCPCS","0624","RC","","","","both","","","38813.00","29109.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","20687.33","53.3","","1101.80","1101.80","1101.80","1 through 10","12032.03","30856.34","percent of total billed charges",""
"G160226 Ovation Alto Stent Graft","PX-62400147","CDM","C1874","HCPCS","0624","RC","","","","both","","","38813.00","29109.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","25228.45","65","","1820.00","910.00","1820.00","1 through 10","12032.03","30856.34","percent of total billed charges",""
"G160226 Ovation Alto Stent Graft","PX-62400147","CDM","C1874","HCPCS","0624","RC","","","","both","","","38813.00","29109.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14166.75","36.5","","1257.80","693.44","2424.50","1 through 10","12032.03","30856.34","percent of total billed charges",""
"G160226 Ovation Alto Stent Graft","PX-62400147","CDM","C1874","HCPCS","0624","RC","","","","both","","","38813.00","29109.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14865.38","38.3","","1950.11","547.40","2346.00","1 through 10","12032.03","30856.34","percent of total billed charges",""
"G160226 Ovation Alto Stent Graft","PX-62400147","CDM","C1874","HCPCS","0624","RC","","","","both","","","38813.00","29109.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16650.78","42.9","","5096.18","5096.18","5096.18","1 through 10","12032.03","30856.34","percent of total billed charges",""
"G160226 Ovation Alto Stent Graft","PX-62400147","CDM","C1874","HCPCS","0624","RC","","","","both","","","38813.00","29109.75","WELLPOINT [1015]","HB AMC WELLPOINT","28636.23","73.78","","1172.59","1172.59","4829.94","1 through 10","12032.03","30856.34","percent of total billed charges",""
"G160226 Ovation Alto Stent Graft","PX-62400147","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","38813.00","29109.75","AETNA [1001]","HB AMC AETNA HMO","27091.47","69.8","","1806.84","947.80","5091.72","1 through 10","20283.67","31717.98","percent of total billed charges",""
"G160226 Ovation Alto Stent Graft","PX-62400147","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","38813.00","29109.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","31717.98","81.72","","1259.05","615.58","4586.56","1 through 10","20283.67","31717.98","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.65","65","","6652.80","6652.80","6652.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","2612.61","795.38","2612.61","1 through 10","0.31","0.8","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1101.80","1101.80","1101.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1820.00","910.00","1820.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1257.80","693.44","2424.50","1 through 10","0.31","0.8","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1950.11","547.40","2346.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","5096.18","5096.18","5096.18","1 through 10","0.31","0.8","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","1172.59","1172.59","4829.94","1 through 10","0.31","0.8","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1806.84","947.80","5091.72","1 through 10","0.4","0.83","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","0.61","60.55","","1023.34","1023.34","1023.34","1 through 10","0.4","0.83","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC TUFTS CIGNA CARELINK HYBRID","0.40","40","","1575.00","1575.00","1575.00","1 through 10","0.4","0.83","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","0.55","55","","522.18","522.18","522.18","1 through 10","0.4","0.83","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","0.53","52.5","","2238.32","2238.32","2238.32","1 through 10","0.4","0.83","percent of total billed charges",""
"G160227 Svelte Sirolimus-Eluting Coronary Stent Integ Deliv Sys","PX-62400166","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","1259.05","615.58","4586.56","1 through 10","0.4","0.83","percent of total billed charges",""
"G170070 Fire Hawk De Stent Target Trial","PX-62400231","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.65","65","","6652.80","6652.80","6652.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G170070 Fire Hawk De Stent Target Trial","PX-62400231","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","2612.61","795.38","2612.61","1 through 10","0.31","0.8","percent of total billed charges",""
"G170070 Fire Hawk De Stent Target Trial","PX-62400231","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1101.80","1101.80","1101.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G170070 Fire Hawk De Stent Target Trial","PX-62400231","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1820.00","910.00","1820.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G170070 Fire Hawk De Stent Target Trial","PX-62400231","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1257.80","693.44","2424.50","1 through 10","0.31","0.8","percent of total billed charges",""
"G170070 Fire Hawk De Stent Target Trial","PX-62400231","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1950.11","547.40","2346.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G170070 Fire Hawk De Stent Target Trial","PX-62400231","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","5096.18","5096.18","5096.18","1 through 10","0.31","0.8","percent of total billed charges",""
"G170070 Fire Hawk De Stent Target Trial","PX-62400231","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","1172.59","1172.59","4829.94","1 through 10","0.31","0.8","percent of total billed charges",""
"G170070 Fire Hawk De Stent Target Trial","PX-62400231","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1806.84","947.80","5091.72","1 through 10","0.52","0.82","percent of total billed charges",""
"G170070 Fire Hawk De Stent Target Trial","PX-62400231","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","1259.05","615.58","4586.56","1 through 10","0.52","0.82","percent of total billed charges",""
"G170081 Xience Coronary Stent","PX-62400161","CDM","C1874","HCPCS","0624","RC","","","","both","","","3784.00","2838.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2459.60","65","","6652.80","6652.80","6652.80","1 through 10","1173.04","3008.28","percent of total billed charges",""
"G170081 Xience Coronary Stent","PX-62400161","CDM","C1874","HCPCS","0624","RC","","","","both","","","3784.00","2838.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3008.28","79.5","","2612.61","795.38","2612.61","1 through 10","1173.04","3008.28","percent of total billed charges",""
"G170081 Xience Coronary Stent","PX-62400161","CDM","C1874","HCPCS","0624","RC","","","","both","","","3784.00","2838.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2016.87","53.3","","1101.80","1101.80","1101.80","1 through 10","1173.04","3008.28","percent of total billed charges",""
"G170081 Xience Coronary Stent","PX-62400161","CDM","C1874","HCPCS","0624","RC","","","","both","","","3784.00","2838.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2459.60","65","","1820.00","910.00","1820.00","1 through 10","1173.04","3008.28","percent of total billed charges",""
"G170081 Xience Coronary Stent","PX-62400161","CDM","C1874","HCPCS","0624","RC","","","","both","","","3784.00","2838.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1381.16","36.5","","1257.80","693.44","2424.50","1 through 10","1173.04","3008.28","percent of total billed charges",""
"G170081 Xience Coronary Stent","PX-62400161","CDM","C1874","HCPCS","0624","RC","","","","both","","","3784.00","2838.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1449.27","38.3","","1950.11","547.40","2346.00","1 through 10","1173.04","3008.28","percent of total billed charges",""
"G170081 Xience Coronary Stent","PX-62400161","CDM","C1874","HCPCS","0624","RC","","","","both","","","3784.00","2838.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1623.34","42.9","","5096.18","5096.18","5096.18","1 through 10","1173.04","3008.28","percent of total billed charges",""
"G170081 Xience Coronary Stent","PX-62400161","CDM","C1874","HCPCS","0624","RC","","","","both","","","3784.00","2838.00","WELLPOINT [1015]","HB AMC WELLPOINT","2791.84","73.78","","1172.59","1172.59","4829.94","1 through 10","1173.04","3008.28","percent of total billed charges",""
"G170081 Xience Coronary Stent","PX-62400161","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","3784.00","2838.00","AETNA [1001]","HB AMC AETNA HMO","2641.23","69.8","","1806.84","947.80","5091.72","1 through 10","1977.52","3092.28","percent of total billed charges",""
"G170081 Xience Coronary Stent","PX-62400161","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","3784.00","2838.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3092.28","81.72","","1259.05","615.58","4586.56","1 through 10","1977.52","3092.28","percent of total billed charges",""
"G170083 Pq Bypass System for Femoropop Detour Study","PX-62400176","CDM","C1874","CPT","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.65","65","","6652.80","6652.80","6652.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G170083 Pq Bypass System for Femoropop Detour Study","PX-62400176","CDM","C1874","CPT","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","2612.61","795.38","2612.61","1 through 10","0.31","0.8","percent of total billed charges",""
"G170083 Pq Bypass System for Femoropop Detour Study","PX-62400176","CDM","C1874","CPT","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1101.80","1101.80","1101.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G170083 Pq Bypass System for Femoropop Detour Study","PX-62400176","CDM","C1874","CPT","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1820.00","910.00","1820.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G170083 Pq Bypass System for Femoropop Detour Study","PX-62400176","CDM","C1874","CPT","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1257.80","693.44","2424.50","1 through 10","0.31","0.8","percent of total billed charges",""
"G170083 Pq Bypass System for Femoropop Detour Study","PX-62400176","CDM","C1874","CPT","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1950.11","547.40","2346.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G170083 Pq Bypass System for Femoropop Detour Study","PX-62400176","CDM","C1874","CPT","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","5096.18","5096.18","5096.18","1 through 10","0.31","0.8","percent of total billed charges",""
"G170083 Pq Bypass System for Femoropop Detour Study","PX-62400176","CDM","C1874","CPT","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","1172.59","1172.59","4829.94","1 through 10","0.31","0.8","percent of total billed charges",""
"G170083 Pq Bypass System for Femoropop Detour Study","PX-62400176","CDM","C1874","CPT","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1806.84","947.80","5091.72","1 through 10","0.52","0.82","percent of total billed charges",""
"G170083 Pq Bypass System for Femoropop Detour Study","PX-62400176","CDM","C1874","CPT","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","1259.05","615.58","4586.56","1 through 10","0.52","0.82","percent of total billed charges",""
"G170166 Pascal Trial Mitral Valve Repair","PX-62400198","CDM","C1889","CPT","0624","RC","","","","both","","","75000.00","56250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59625.00","79.5","","1309.77","674.56","6049.93","26","23250","59625","percent of total billed charges",""
"G170166 Pascal Trial Mitral Valve Repair","PX-62400198","CDM","C1889","CPT","0624","RC","","","","both","","","75000.00","56250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39975.00","53.3","","1901.83","1901.83","2962.25","1 through 10","23250","59625","percent of total billed charges",""
"G170166 Pascal Trial Mitral Valve Repair","PX-62400198","CDM","C1889","CPT","0624","RC","","","","both","","","75000.00","56250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27375.00","36.5","","1620.31","1620.31","19908.88","1 through 10","23250","59625","percent of total billed charges",""
"G170166 Pascal Trial Mitral Valve Repair","PX-62400198","CDM","C1889","CPT","0624","RC","","","","both","","","75000.00","56250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28725.00","38.3","","352.91","352.91","2046.30","1 through 10","23250","59625","percent of total billed charges",""
"G170166 Pascal Trial Mitral Valve Repair","PX-62400198","CDM","C1889","CPT","0624","RC","","","","both","","","75000.00","56250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32175.00","42.9","","9668.75","9668.75","9668.75","1 through 10","23250","59625","percent of total billed charges",""
"G170166 Pascal Trial Mitral Valve Repair","PX-62400198","CDM","C1889","CPT","0624","RC","","","","both","","","75000.00","56250.00","WELLPOINT [1015]","HB AMC WELLPOINT","55335.00","73.78","","699.88","384.10","3443.31","33","23250","59625","percent of total billed charges",""
"G170166 Pascal Trial Mitral Valve Repair","PX-62400198","CDM","C1889","CPT","0624","RC","","","","outpatient","","","75000.00","56250.00","AETNA [1001]","HB AMC AETNA HMO","52350.00","69.8","","1421.24","264.50","4933.46","29","39195","61290","percent of total billed charges",""
"G170166 Pascal Trial Mitral Valve Repair","PX-62400198","CDM","C1889","CPT","0624","RC","","","","outpatient","","","75000.00","56250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","60300.00","80.4","","1022.97","1022.97","3607.50","1 through 10","39195","61290","percent of total billed charges",""
"G170166 Pascal Trial Mitral Valve Repair","PX-62400198","CDM","C1889","CPT","0624","RC","","","","outpatient","","","75000.00","56250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","61290.00","81.72","","3010.54","693.88","5019.88","35","39195","61290","percent of total billed charges",""
"G180139 Rf Balloon Catheter Biosense Webster","PX-62400185","CDM","C1733","LOCAL","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","17511.01","17511.01","17511.01","1 through 10","0.31","0.8","percent of total billed charges",""
"G180139 Rf Balloon Catheter Biosense Webster","PX-62400185","CDM","C1733","LOCAL","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","21125.00","21125.00","21125.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G180139 Rf Balloon Catheter Biosense Webster","PX-62400185","CDM","C1733","LOCAL","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","7879.63","7879.63","7879.63","1 through 10","0.31","0.8","percent of total billed charges",""
"G180139 Rf Balloon Catheter Biosense Webster","PX-62400185","CDM","C1733","LOCAL","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","8259.88","8259.88","16055.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G180139 Rf Balloon Catheter Biosense Webster","PX-62400185","CDM","C1733","LOCAL","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","15727.56","15727.56","20473.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G180139 Rf Balloon Catheter Biosense Webster","PX-62400185","CDM","C1733","LOCAL","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","0.82","81.72","","16887.32","9288.66","16887.32","1 through 10","0.52","0.82","percent of total billed charges",""
"G180139 Rf Balloon Catheter Biosense Webster","PX-62400185","CDM","C1733","LOCAL","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","16887.33","11641.27","21983.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G180146 Shockwave Coronary IV Lithotripsy Pta System","PX-62400191","CDM","C1725","CPT","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.72","71.8","","175.91","175.91","175.91","1 through 10","0.31","0.8","percent of total billed charges",""
"G180146 Shockwave Coronary IV Lithotripsy Pta System","PX-62400191","CDM","C1725","CPT","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","147.88","147.88","1296.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G180146 Shockwave Coronary IV Lithotripsy Pta System","PX-62400191","CDM","C1725","CPT","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","181.40","177.87","181.40","21","0.31","0.8","percent of total billed charges",""
"G180146 Shockwave Coronary IV Lithotripsy Pta System","PX-62400191","CDM","C1725","CPT","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","170.15","88.95","424.24","16","0.31","0.8","percent of total billed charges",""
"G180146 Shockwave Coronary IV Lithotripsy Pta System","PX-62400191","CDM","C1725","CPT","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","699.48","699.48","699.48","12","0.31","0.8","percent of total billed charges",""
"G180146 Shockwave Coronary IV Lithotripsy Pta System","PX-62400191","CDM","C1725","CPT","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","576.52","182.40","651.44","14","0.31","0.8","percent of total billed charges",""
"G180146 Shockwave Coronary IV Lithotripsy Pta System","PX-62400191","CDM","C1725","CPT","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","181.86","100.03","402.41","21","0.52","0.82","percent of total billed charges",""
"G180149 Tacticath Se Ablation Catheter","PX-62400181","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","2222.68","2222.68","2222.68","1 through 10","0.31","0.8","percent of total billed charges",""
"G180149 Tacticath Se Ablation Catheter","PX-62400181","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","4681.38","1275.47","8371.80","20","0.31","0.8","percent of total billed charges",""
"G180149 Tacticath Se Ablation Catheter","PX-62400181","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1663.12","1287.53","2528.21","1 through 10","0.31","0.8","percent of total billed charges",""
"G180149 Tacticath Se Ablation Catheter","PX-62400181","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","1935.35","1935.35","1935.35","1 through 10","0.31","0.8","percent of total billed charges",""
"G180149 Tacticath Se Ablation Catheter","PX-62400181","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","4813.94","2545.82","7082.06","1 through 10","0.31","0.8","percent of total billed charges",""
"G180149 Tacticath Se Ablation Catheter","PX-62400181","CDM","C1732","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","2733.55","2433.63","5168.92","14","0.52","0.82","percent of total billed charges",""
"G180176 Qdot Micro Rf Ablation Catheter","PX-62400189","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","2222.68","2222.68","2222.68","1 through 10","0.31","0.8","percent of total billed charges",""
"G180176 Qdot Micro Rf Ablation Catheter","PX-62400189","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","4681.38","1275.47","8371.80","20","0.31","0.8","percent of total billed charges",""
"G180176 Qdot Micro Rf Ablation Catheter","PX-62400189","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1663.12","1287.53","2528.21","1 through 10","0.31","0.8","percent of total billed charges",""
"G180176 Qdot Micro Rf Ablation Catheter","PX-62400189","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","1935.35","1935.35","1935.35","1 through 10","0.31","0.8","percent of total billed charges",""
"G180176 Qdot Micro Rf Ablation Catheter","PX-62400189","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","4813.94","2545.82","7082.06","1 through 10","0.31","0.8","percent of total billed charges",""
"G180176 Qdot Micro Rf Ablation Catheter","PX-62400189","CDM","C1732","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","2733.55","2433.63","5168.92","14","0.52","0.82","percent of total billed charges",""
"G180263 Adagio a-Fib Albation Iclas Trial","PX-62400201","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","2222.68","2222.68","2222.68","1 through 10","0.31","0.8","percent of total billed charges",""
"G180263 Adagio a-Fib Albation Iclas Trial","PX-62400201","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","4681.38","1275.47","8371.80","20","0.31","0.8","percent of total billed charges",""
"G180263 Adagio a-Fib Albation Iclas Trial","PX-62400201","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1663.12","1287.53","2528.21","1 through 10","0.31","0.8","percent of total billed charges",""
"G180263 Adagio a-Fib Albation Iclas Trial","PX-62400201","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","1935.35","1935.35","1935.35","1 through 10","0.31","0.8","percent of total billed charges",""
"G180263 Adagio a-Fib Albation Iclas Trial","PX-62400201","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","4813.94","2545.82","7082.06","1 through 10","0.31","0.8","percent of total billed charges",""
"G180263 Adagio a-Fib Albation Iclas Trial","PX-62400201","CDM","C1732","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","2733.55","2433.63","5168.92","14","0.52","0.82","percent of total billed charges",""
"G190117 J-Valve Transfemoral (Tf) System 2025p000541, 2025p000792","PX-62400323","CDM","C1889","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69562.50","79.5","","1309.77","674.56","6049.93","26","27125","69562.5","percent of total billed charges",""
"G190117 J-Valve Transfemoral (Tf) System 2025p000541, 2025p000792","PX-62400323","CDM","C1889","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46637.50","53.3","","1901.83","1901.83","2962.25","1 through 10","27125","69562.5","percent of total billed charges",""
"G190117 J-Valve Transfemoral (Tf) System 2025p000541, 2025p000792","PX-62400323","CDM","C1889","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31937.50","36.5","","1620.31","1620.31","19908.88","1 through 10","27125","69562.5","percent of total billed charges",""
"G190117 J-Valve Transfemoral (Tf) System 2025p000541, 2025p000792","PX-62400323","CDM","C1889","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33512.50","38.3","","352.91","352.91","2046.30","1 through 10","27125","69562.5","percent of total billed charges",""
"G190117 J-Valve Transfemoral (Tf) System 2025p000541, 2025p000792","PX-62400323","CDM","C1889","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37537.50","42.9","","9668.75","9668.75","9668.75","1 through 10","27125","69562.5","percent of total billed charges",""
"G190117 J-Valve Transfemoral (Tf) System 2025p000541, 2025p000792","PX-62400323","CDM","C1889","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","WELLPOINT [1015]","HB AMC WELLPOINT","64557.50","73.78","","699.88","384.10","3443.31","33","27125","69562.5","percent of total billed charges",""
"G190117 J-Valve Transfemoral (Tf) System 2025p000541, 2025p000792","PX-62400323","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","87500.00","65625.00","AETNA [1001]","HB AMC AETNA HMO","61075.00","69.8","","1421.24","264.50","4933.46","29","45727.5","71505","percent of total billed charges",""
"G190117 J-Valve Transfemoral (Tf) System 2025p000541, 2025p000792","PX-62400323","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","87500.00","65625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","70350.00","80.4","","1022.97","1022.97","3607.50","1 through 10","45727.5","71505","percent of total billed charges",""
"G190117 J-Valve Transfemoral (Tf) System 2025p000541, 2025p000792","PX-62400323","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","87500.00","65625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71505.00","81.72","","3010.54","693.88","5019.88","35","45727.5","71505","percent of total billed charges",""
"G190212 Mitraclip Repair Surgical Candidate","PX-62400222","CDM","C1889","HCPCS","0624","RC","","","","both","","","75000.00","56250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59625.00","79.5","","1309.77","674.56","6049.93","26","23250","59625","percent of total billed charges",""
"G190212 Mitraclip Repair Surgical Candidate","PX-62400222","CDM","C1889","HCPCS","0624","RC","","","","both","","","75000.00","56250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39975.00","53.3","","1901.83","1901.83","2962.25","1 through 10","23250","59625","percent of total billed charges",""
"G190212 Mitraclip Repair Surgical Candidate","PX-62400222","CDM","C1889","HCPCS","0624","RC","","","","both","","","75000.00","56250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27375.00","36.5","","1620.31","1620.31","19908.88","1 through 10","23250","59625","percent of total billed charges",""
"G190212 Mitraclip Repair Surgical Candidate","PX-62400222","CDM","C1889","HCPCS","0624","RC","","","","both","","","75000.00","56250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28725.00","38.3","","352.91","352.91","2046.30","1 through 10","23250","59625","percent of total billed charges",""
"G190212 Mitraclip Repair Surgical Candidate","PX-62400222","CDM","C1889","HCPCS","0624","RC","","","","both","","","75000.00","56250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32175.00","42.9","","9668.75","9668.75","9668.75","1 through 10","23250","59625","percent of total billed charges",""
"G190212 Mitraclip Repair Surgical Candidate","PX-62400222","CDM","C1889","HCPCS","0624","RC","","","","both","","","75000.00","56250.00","WELLPOINT [1015]","HB AMC WELLPOINT","55335.00","73.78","","699.88","384.10","3443.31","33","23250","59625","percent of total billed charges",""
"G190212 Mitraclip Repair Surgical Candidate","PX-62400222","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","75000.00","56250.00","AETNA [1001]","HB AMC AETNA HMO","52350.00","69.8","","1421.24","264.50","4933.46","29","39195","61290","percent of total billed charges",""
"G190212 Mitraclip Repair Surgical Candidate","PX-62400222","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","75000.00","56250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","60300.00","80.4","","1022.97","1022.97","3607.50","1 through 10","39195","61290","percent of total billed charges",""
"G190212 Mitraclip Repair Surgical Candidate","PX-62400222","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","75000.00","56250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","61290.00","81.72","","3010.54","693.88","5019.88","35","39195","61290","percent of total billed charges",""
"G190226 Pq Bypass Torus Stent Graft Syst","PX-62400209","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.65","65","","6652.80","6652.80","6652.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G190226 Pq Bypass Torus Stent Graft Syst","PX-62400209","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","2612.61","795.38","2612.61","1 through 10","0.31","0.8","percent of total billed charges",""
"G190226 Pq Bypass Torus Stent Graft Syst","PX-62400209","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1101.80","1101.80","1101.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G190226 Pq Bypass Torus Stent Graft Syst","PX-62400209","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1820.00","910.00","1820.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G190226 Pq Bypass Torus Stent Graft Syst","PX-62400209","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1257.80","693.44","2424.50","1 through 10","0.31","0.8","percent of total billed charges",""
"G190226 Pq Bypass Torus Stent Graft Syst","PX-62400209","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1950.11","547.40","2346.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G190226 Pq Bypass Torus Stent Graft Syst","PX-62400209","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","5096.18","5096.18","5096.18","1 through 10","0.31","0.8","percent of total billed charges",""
"G190226 Pq Bypass Torus Stent Graft Syst","PX-62400209","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","1172.59","1172.59","4829.94","1 through 10","0.31","0.8","percent of total billed charges",""
"G190226 Pq Bypass Torus Stent Graft Syst","PX-62400209","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1806.84","947.80","5091.72","1 through 10","0.52","0.82","percent of total billed charges",""
"G190226 Pq Bypass Torus Stent Graft Syst","PX-62400209","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","1259.05","615.58","4586.56","1 through 10","0.52","0.82","percent of total billed charges",""
"G190289 Evoque Tricuspid Triscend II Valve Trial","PX-62400227","CDM","C1889","HCPCS","0624","RC","","","","both","","","95000.00","71250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","75525.00","79.5","","1309.77","674.56","6049.93","26","29450","75525","percent of total billed charges",""
"G190289 Evoque Tricuspid Triscend II Valve Trial","PX-62400227","CDM","C1889","HCPCS","0624","RC","","","","both","","","95000.00","71250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","50635.00","53.3","","1901.83","1901.83","2962.25","1 through 10","29450","75525","percent of total billed charges",""
"G190289 Evoque Tricuspid Triscend II Valve Trial","PX-62400227","CDM","C1889","HCPCS","0624","RC","","","","both","","","95000.00","71250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34675.00","36.5","","1620.31","1620.31","19908.88","1 through 10","29450","75525","percent of total billed charges",""
"G190289 Evoque Tricuspid Triscend II Valve Trial","PX-62400227","CDM","C1889","HCPCS","0624","RC","","","","both","","","95000.00","71250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","36385.00","38.3","","352.91","352.91","2046.30","1 through 10","29450","75525","percent of total billed charges",""
"G190289 Evoque Tricuspid Triscend II Valve Trial","PX-62400227","CDM","C1889","HCPCS","0624","RC","","","","both","","","95000.00","71250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40755.00","42.9","","9668.75","9668.75","9668.75","1 through 10","29450","75525","percent of total billed charges",""
"G190289 Evoque Tricuspid Triscend II Valve Trial","PX-62400227","CDM","C1889","HCPCS","0624","RC","","","","both","","","95000.00","71250.00","WELLPOINT [1015]","HB AMC WELLPOINT","70091.00","73.78","","699.88","384.10","3443.31","33","29450","75525","percent of total billed charges",""
"G190289 Evoque Tricuspid Triscend II Valve Trial","PX-62400227","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","95000.00","71250.00","AETNA [1001]","HB AMC AETNA HMO","66310.00","69.8","","1421.24","264.50","4933.46","29","49647","77634","percent of total billed charges",""
"G190289 Evoque Tricuspid Triscend II Valve Trial","PX-62400227","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","95000.00","71250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","76380.00","80.4","","1022.97","1022.97","3607.50","1 through 10","49647","77634","percent of total billed charges",""
"G190289 Evoque Tricuspid Triscend II Valve Trial","PX-62400227","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","95000.00","71250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","77634.00","81.72","","3010.54","693.88","5019.88","35","49647","77634","percent of total billed charges",""
"G190289 Mgh Efs Tricuspid Valve Trial","PX-62400210","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G190289 Mgh Efs Tricuspid Valve Trial","PX-62400210","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G190289 Mgh Efs Tricuspid Valve Trial","PX-62400210","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G190289 Mgh Efs Tricuspid Valve Trial","PX-62400210","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G190289 Mgh Efs Tricuspid Valve Trial","PX-62400210","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G190289 Mgh Efs Tricuspid Valve Trial","PX-62400210","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G190289 Mgh Efs Tricuspid Valve Trial","PX-62400210","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G190289 Mgh Efs Tricuspid Valve Trial","PX-62400210","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G190289 Mgh Efs Tricuspid Valve Trial","PX-62400210","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G200002 Everolimus De Stent Cad Trial","PX-62400214","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.65","65","","6652.80","6652.80","6652.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G200002 Everolimus De Stent Cad Trial","PX-62400214","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","2612.61","795.38","2612.61","1 through 10","0.31","0.8","percent of total billed charges",""
"G200002 Everolimus De Stent Cad Trial","PX-62400214","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1101.80","1101.80","1101.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G200002 Everolimus De Stent Cad Trial","PX-62400214","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1820.00","910.00","1820.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G200002 Everolimus De Stent Cad Trial","PX-62400214","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1257.80","693.44","2424.50","1 through 10","0.31","0.8","percent of total billed charges",""
"G200002 Everolimus De Stent Cad Trial","PX-62400214","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1950.11","547.40","2346.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G200002 Everolimus De Stent Cad Trial","PX-62400214","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","5096.18","5096.18","5096.18","1 through 10","0.31","0.8","percent of total billed charges",""
"G200002 Everolimus De Stent Cad Trial","PX-62400214","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","1172.59","1172.59","4829.94","1 through 10","0.31","0.8","percent of total billed charges",""
"G200002 Everolimus De Stent Cad Trial","PX-62400214","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1806.84","947.80","5091.72","1 through 10","0.52","0.82","percent of total billed charges",""
"G200002 Everolimus De Stent Cad Trial","PX-62400214","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","1259.05","615.58","4586.56","1 through 10","0.52","0.82","percent of total billed charges",""
"G200067 Harpoon Mitral Valve System","PX-62400221","CDM","C1889","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","49687.50","79.5","","1309.77","674.56","6049.93","26","19375","49687.5","percent of total billed charges",""
"G200067 Harpoon Mitral Valve System","PX-62400221","CDM","C1889","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33312.50","53.3","","1901.83","1901.83","2962.25","1 through 10","19375","49687.5","percent of total billed charges",""
"G200067 Harpoon Mitral Valve System","PX-62400221","CDM","C1889","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22812.50","36.5","","1620.31","1620.31","19908.88","1 through 10","19375","49687.5","percent of total billed charges",""
"G200067 Harpoon Mitral Valve System","PX-62400221","CDM","C1889","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23937.50","38.3","","352.91","352.91","2046.30","1 through 10","19375","49687.5","percent of total billed charges",""
"G200067 Harpoon Mitral Valve System","PX-62400221","CDM","C1889","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26812.50","42.9","","9668.75","9668.75","9668.75","1 through 10","19375","49687.5","percent of total billed charges",""
"G200067 Harpoon Mitral Valve System","PX-62400221","CDM","C1889","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","WELLPOINT [1015]","HB AMC WELLPOINT","46112.50","73.78","","699.88","384.10","3443.31","33","19375","49687.5","percent of total billed charges",""
"G200067 Harpoon Mitral Valve System","PX-62400221","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","62500.00","46875.00","AETNA [1001]","HB AMC AETNA HMO","43625.00","69.8","","1421.24","264.50","4933.46","29","32662.5","51075","percent of total billed charges",""
"G200067 Harpoon Mitral Valve System","PX-62400221","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","62500.00","46875.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","50250.00","80.4","","1022.97","1022.97","3607.50","1 through 10","32662.5","51075","percent of total billed charges",""
"G200067 Harpoon Mitral Valve System","PX-62400221","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","62500.00","46875.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","51075.00","81.72","","3010.54","693.88","5019.88","35","32662.5","51075","percent of total billed charges",""
"G200100 Paclitaxel Pta Balloon Instant Restenosis Trial","PX-62400230","CDM","C2623","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","3445.53","3445.53","3445.53","1 through 10","0.31","0.8","percent of total billed charges",""
"G200100 Paclitaxel Pta Balloon Instant Restenosis Trial","PX-62400230","CDM","C2623","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","5522.88","5522.88","5522.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G200100 Paclitaxel Pta Balloon Instant Restenosis Trial","PX-62400230","CDM","C2623","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","3244.16","3126.90","3244.16","1 through 10","0.31","0.8","percent of total billed charges",""
"G200100 Paclitaxel Pta Balloon Instant Restenosis Trial","PX-62400230","CDM","C2623","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","11291.52","11291.52","11291.52","1 through 10","0.52","0.82","percent of total billed charges",""
"G200106 Watchman Flx for Champion - Af Trial","PX-62400225","CDM","C1889","HCPCS","0624","RC","","","","both","","","42500.00","31875.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33787.50","79.5","","1309.77","674.56","6049.93","26","13175","33787.5","percent of total billed charges",""
"G200106 Watchman Flx for Champion - Af Trial","PX-62400225","CDM","C1889","HCPCS","0624","RC","","","","both","","","42500.00","31875.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22652.50","53.3","","1901.83","1901.83","2962.25","1 through 10","13175","33787.5","percent of total billed charges",""
"G200106 Watchman Flx for Champion - Af Trial","PX-62400225","CDM","C1889","HCPCS","0624","RC","","","","both","","","42500.00","31875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15512.50","36.5","","1620.31","1620.31","19908.88","1 through 10","13175","33787.5","percent of total billed charges",""
"G200106 Watchman Flx for Champion - Af Trial","PX-62400225","CDM","C1889","HCPCS","0624","RC","","","","both","","","42500.00","31875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16277.50","38.3","","352.91","352.91","2046.30","1 through 10","13175","33787.5","percent of total billed charges",""
"G200106 Watchman Flx for Champion - Af Trial","PX-62400225","CDM","C1889","HCPCS","0624","RC","","","","both","","","42500.00","31875.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18232.50","42.9","","9668.75","9668.75","9668.75","1 through 10","13175","33787.5","percent of total billed charges",""
"G200106 Watchman Flx for Champion - Af Trial","PX-62400225","CDM","C1889","HCPCS","0624","RC","","","","both","","","42500.00","31875.00","WELLPOINT [1015]","HB AMC WELLPOINT","31356.50","73.78","","699.88","384.10","3443.31","33","13175","33787.5","percent of total billed charges",""
"G200106 Watchman Flx for Champion - Af Trial","PX-62400225","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","42500.00","31875.00","AETNA [1001]","HB AMC AETNA HMO","29665.00","69.8","","1421.24","264.50","4933.46","29","22210.5","34731","percent of total billed charges",""
"G200106 Watchman Flx for Champion - Af Trial","PX-62400225","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","42500.00","31875.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","34170.00","80.4","","1022.97","1022.97","3607.50","1 through 10","22210.5","34731","percent of total billed charges",""
"G200106 Watchman Flx for Champion - Af Trial","PX-62400225","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","42500.00","31875.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34731.00","81.72","","3010.54","693.88","5019.88","35","22210.5","34731","percent of total billed charges",""
"G200150 Stent for Dialysis Stenosis Wave Study 2021p002354","PX-62400243","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.65","65","","6652.80","6652.80","6652.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G200150 Stent for Dialysis Stenosis Wave Study 2021p002354","PX-62400243","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","2612.61","795.38","2612.61","1 through 10","0.31","0.8","percent of total billed charges",""
"G200150 Stent for Dialysis Stenosis Wave Study 2021p002354","PX-62400243","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1101.80","1101.80","1101.80","1 through 10","0.31","0.8","percent of total billed charges",""
"G200150 Stent for Dialysis Stenosis Wave Study 2021p002354","PX-62400243","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1820.00","910.00","1820.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G200150 Stent for Dialysis Stenosis Wave Study 2021p002354","PX-62400243","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1257.80","693.44","2424.50","1 through 10","0.31","0.8","percent of total billed charges",""
"G200150 Stent for Dialysis Stenosis Wave Study 2021p002354","PX-62400243","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1950.11","547.40","2346.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G200150 Stent for Dialysis Stenosis Wave Study 2021p002354","PX-62400243","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","5096.18","5096.18","5096.18","1 through 10","0.31","0.8","percent of total billed charges",""
"G200150 Stent for Dialysis Stenosis Wave Study 2021p002354","PX-62400243","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","1172.59","1172.59","4829.94","1 through 10","0.31","0.8","percent of total billed charges",""
"G200150 Stent for Dialysis Stenosis Wave Study 2021p002354","PX-62400243","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1806.84","947.80","5091.72","1 through 10","0.52","0.82","percent of total billed charges",""
"G200150 Stent for Dialysis Stenosis Wave Study 2021p002354","PX-62400243","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","1259.05","615.58","4586.56","1 through 10","0.52","0.82","percent of total billed charges",""
"G200179 Dbs Medtronic Adapt - Pd Trial","PX-62400217","CDM","C1767","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","18081.90","16994.81","18081.90","1 through 10","0.31","0.8","percent of total billed charges",""
"G200179 Dbs Medtronic Adapt - Pd Trial","PX-62400217","CDM","C1767","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","17814.94","17448.38","17814.94","1 through 10","0.31","0.8","percent of total billed charges",""
"G200179 Dbs Medtronic Adapt - Pd Trial","PX-62400217","CDM","C1767","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","33921.28","33921.28","33921.28","1 through 10","0.31","0.8","percent of total billed charges",""
"G200185 Half Moon Transcatheter Mitral Valve Repair (Tmvr) System 2024p0","PX-62400300","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G200185 Half Moon Transcatheter Mitral Valve Repair (Tmvr) System 2024p0","PX-62400300","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G200185 Half Moon Transcatheter Mitral Valve Repair (Tmvr) System 2024p0","PX-62400300","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G200185 Half Moon Transcatheter Mitral Valve Repair (Tmvr) System 2024p0","PX-62400300","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G200185 Half Moon Transcatheter Mitral Valve Repair (Tmvr) System 2024p0","PX-62400300","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G200185 Half Moon Transcatheter Mitral Valve Repair (Tmvr) System 2024p0","PX-62400300","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G200185 Half Moon Transcatheter Mitral Valve Repair (Tmvr) System 2024p0","PX-62400300","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G200185 Half Moon Transcatheter Mitral Valve Repair (Tmvr) System 2024p0","PX-62400300","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G200185 Half Moon Transcatheter Mitral Valve Repair (Tmvr) System 2024p0","PX-62400300","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G200231 Ringer Perf Balloon Cath 2022p000837","PX-62400253","CDM","C2628","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","518.94","518.94","518.94","1 through 10","0.31","0.8","percent of total billed charges",""
"G200231 Ringer Perf Balloon Cath 2022p000837","PX-62400253","CDM","C2628","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","429.02","429.02","429.02","1 through 10","0.31","0.8","percent of total billed charges",""
"G200231 Ringer Perf Balloon Cath 2022p000837","PX-62400253","CDM","C2628","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","4636.13","4636.13","4636.13","1 through 10","0.31","0.8","percent of total billed charges",""
"G200231 Ringer Perf Balloon Cath 2022p000837","PX-62400253","CDM","C2628","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","491.39","491.39","491.39","1 through 10","0.31","0.8","percent of total billed charges",""
"G200231 Ringer Perf Balloon Cath 2022p000837","PX-62400253","CDM","C2628","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","0.82","81.72","","290.22","290.22","290.22","1 through 10","0.52","0.82","percent of total billed charges",""
"G210031 Middle Meningeal Artery Embolization (Mmae) 2024p001474,2024p003223","PX-62400316","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G210031 Middle Meningeal Artery Embolization (Mmae) 2024p001474,2024p003223","PX-62400316","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G210031 Middle Meningeal Artery Embolization (Mmae) 2024p001474,2024p003223","PX-62400316","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G210031 Middle Meningeal Artery Embolization (Mmae) 2024p001474,2024p003223","PX-62400316","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G210031 Middle Meningeal Artery Embolization (Mmae) 2024p001474,2024p003223","PX-62400316","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G210031 Middle Meningeal Artery Embolization (Mmae) 2024p001474,2024p003223","PX-62400316","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G210031 Middle Meningeal Artery Embolization (Mmae) 2024p001474,2024p003223","PX-62400316","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G210031 Middle Meningeal Artery Embolization (Mmae) 2024p001474,2024p003223","PX-62400316","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G210031 Middle Meningeal Artery Embolization (Mmae) 2024p001474,2024p003223","PX-62400316","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G210167 HC Occlutech Flex II Pfo Occluder 2022p000934","PX-62400250","CDM","C1817","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","17412.37","11682.00","17412.38","1 through 10","0.31","0.8","percent of total billed charges",""
"G210167 HC Occlutech Flex II Pfo Occluder 2022p000934","PX-62400250","CDM","C1817","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","11682.00","11682.00","11682.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G210167 HC Occlutech Flex II Pfo Occluder 2022p000934","PX-62400250","CDM","C1817","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","8650.88","8650.88","9853.20","1 through 10","0.31","0.8","percent of total billed charges",""
"G210167 HC Occlutech Flex II Pfo Occluder 2022p000934","PX-62400250","CDM","C1817","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","16472.06","16472.06","16472.06","1 through 10","0.31","0.8","percent of total billed charges",""
"G210167 HC Occlutech Flex II Pfo Occluder 2022p000934","PX-62400250","CDM","C1817","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","17686.73","17686.73","17686.73","1 through 10","0.52","0.82","percent of total billed charges",""
"G210170 Sphere-Per AF Affera Trial 2021P003115","PX-62400245","CDM","C1732","CPT","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","2222.68","2222.68","2222.68","1 through 10","0.31","0.8","percent of total billed charges",""
"G210170 Sphere-Per AF Affera Trial 2021P003115","PX-62400245","CDM","C1732","CPT","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","4681.38","1275.47","8371.80","20","0.31","0.8","percent of total billed charges",""
"G210170 Sphere-Per AF Affera Trial 2021P003115","PX-62400245","CDM","C1732","CPT","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1663.12","1287.53","2528.21","1 through 10","0.31","0.8","percent of total billed charges",""
"G210170 Sphere-Per AF Affera Trial 2021P003115","PX-62400245","CDM","C1732","CPT","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","1935.35","1935.35","1935.35","1 through 10","0.31","0.8","percent of total billed charges",""
"G210170 Sphere-Per AF Affera Trial 2021P003115","PX-62400245","CDM","C1732","CPT","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","4813.94","2545.82","7082.06","1 through 10","0.31","0.8","percent of total billed charges",""
"G210170 Sphere-Per AF Affera Trial 2021P003115","PX-62400245","CDM","C1732","CPT","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","2733.55","2433.63","5168.92","14","0.52","0.82","percent of total billed charges",""
"G210240 Optimizer Integra D Study","PX-62400277","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G210240 Optimizer Integra D Study","PX-62400277","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G210240 Optimizer Integra D Study","PX-62400277","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G210240 Optimizer Integra D Study","PX-62400277","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G210240 Optimizer Integra D Study","PX-62400277","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G210240 Optimizer Integra D Study","PX-62400277","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G210240 Optimizer Integra D Study","PX-62400277","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G210240 Optimizer Integra D Study","PX-62400277","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G210240 Optimizer Integra D Study","PX-62400277","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G22002 Cerevasc Eshunt System 2024p003522, 2024p002712","PX-62400313","CDM","C1889","CPT","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G22002 Cerevasc Eshunt System 2024p003522, 2024p002712","PX-62400313","CDM","C1889","CPT","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G22002 Cerevasc Eshunt System 2024p003522, 2024p002712","PX-62400313","CDM","C1889","CPT","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G22002 Cerevasc Eshunt System 2024p003522, 2024p002712","PX-62400313","CDM","C1889","CPT","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G22002 Cerevasc Eshunt System 2024p003522, 2024p002712","PX-62400313","CDM","C1889","CPT","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G22002 Cerevasc Eshunt System 2024p003522, 2024p002712","PX-62400313","CDM","C1889","CPT","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G22002 Cerevasc Eshunt System 2024p003522, 2024p002712","PX-62400313","CDM","C1889","CPT","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G22002 Cerevasc Eshunt System 2024p003522, 2024p002712","PX-62400313","CDM","C1889","CPT","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G22002 Cerevasc Eshunt System 2024p003522, 2024p002712","PX-62400313","CDM","C1889","CPT","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G220046 Emblok Epstm Embolic Protection System 2024p002579","PX-62400306","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G220046 Emblok Epstm Embolic Protection System 2024p002579","PX-62400306","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G220046 Emblok Epstm Embolic Protection System 2024p002579","PX-62400306","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G220046 Emblok Epstm Embolic Protection System 2024p002579","PX-62400306","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G220046 Emblok Epstm Embolic Protection System 2024p002579","PX-62400306","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G220046 Emblok Epstm Embolic Protection System 2024p002579","PX-62400306","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G220046 Emblok Epstm Embolic Protection System 2024p002579","PX-62400306","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G220046 Emblok Epstm Embolic Protection System 2024p002579","PX-62400306","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G220046 Emblok Epstm Embolic Protection System 2024p002579","PX-62400306","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G220141 Laminar Left Atrial Appendage Closure System (Laax) 2024p001292","PX-62400297","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G220141 Laminar Left Atrial Appendage Closure System (Laax) 2024p001292","PX-62400297","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G220141 Laminar Left Atrial Appendage Closure System (Laax) 2024p001292","PX-62400297","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G220141 Laminar Left Atrial Appendage Closure System (Laax) 2024p001292","PX-62400297","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G220141 Laminar Left Atrial Appendage Closure System (Laax) 2024p001292","PX-62400297","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G220141 Laminar Left Atrial Appendage Closure System (Laax) 2024p001292","PX-62400297","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G220141 Laminar Left Atrial Appendage Closure System (Laax) 2024p001292","PX-62400297","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G220141 Laminar Left Atrial Appendage Closure System (Laax) 2024p001292","PX-62400297","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G220141 Laminar Left Atrial Appendage Closure System (Laax) 2024p001292","PX-62400297","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G220163 Gie Medical Protractx3 Tts Dcb 2024p002658","PX-62400309","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.70","70","","863.10","863.10","863.10","1 through 10","0.31","0.8","percent of total billed charges",""
"G220163 Gie Medical Protractx3 Tts Dcb 2024p002658","PX-62400309","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","447.66","447.66","447.66","1 through 10","0.31","0.8","percent of total billed charges",""
"G220163 Gie Medical Protractx3 Tts Dcb 2024p002658","PX-62400309","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1020.11","1020.11","1020.11","1 through 10","0.31","0.8","percent of total billed charges",""
"G220163 Gie Medical Protractx3 Tts Dcb 2024p002658","PX-62400309","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.31","31","","208.83","208.83","208.83","1 through 10","0.31","0.8","percent of total billed charges",""
"G220163 Gie Medical Protractx3 Tts Dcb 2024p002658","PX-62400309","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","312.44","214.23","1086.03","20","0.31","0.8","percent of total billed charges",""
"G220163 Gie Medical Protractx3 Tts Dcb 2024p002658","PX-62400309","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","264.25","227.63","567.11","31","0.31","0.8","percent of total billed charges",""
"G220163 Gie Medical Protractx3 Tts Dcb 2024p002658","PX-62400309","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","79.94","79.94","79.94","1 through 10","0.31","0.8","percent of total billed charges",""
"G220163 Gie Medical Protractx3 Tts Dcb 2024p002658","PX-62400309","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","174.45","74.45","1168.42","1 through 10","0.31","0.8","percent of total billed charges",""
"G220163 Gie Medical Protractx3 Tts Dcb 2024p002658","PX-62400309","CDM","C1726","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","655.01","135.40","784.73","1 through 10","0.52","0.82","percent of total billed charges",""
"G220163 Gie Medical Protractx3 Tts Dcb 2024p002658","PX-62400309","CDM","C1726","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","540.25","46.28","897.42","36","0.52","0.82","percent of total billed charges",""
"G220168 Protractx3 Drug-Coated Balloon 2024p000797","PX-62400298","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.70","70","","863.10","863.10","863.10","1 through 10","0.31","0.8","percent of total billed charges",""
"G220168 Protractx3 Drug-Coated Balloon 2024p000797","PX-62400298","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","447.66","447.66","447.66","1 through 10","0.31","0.8","percent of total billed charges",""
"G220168 Protractx3 Drug-Coated Balloon 2024p000797","PX-62400298","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1020.11","1020.11","1020.11","1 through 10","0.31","0.8","percent of total billed charges",""
"G220168 Protractx3 Drug-Coated Balloon 2024p000797","PX-62400298","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.31","31","","208.83","208.83","208.83","1 through 10","0.31","0.8","percent of total billed charges",""
"G220168 Protractx3 Drug-Coated Balloon 2024p000797","PX-62400298","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","312.44","214.23","1086.03","20","0.31","0.8","percent of total billed charges",""
"G220168 Protractx3 Drug-Coated Balloon 2024p000797","PX-62400298","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","264.25","227.63","567.11","31","0.31","0.8","percent of total billed charges",""
"G220168 Protractx3 Drug-Coated Balloon 2024p000797","PX-62400298","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","79.94","79.94","79.94","1 through 10","0.31","0.8","percent of total billed charges",""
"G220168 Protractx3 Drug-Coated Balloon 2024p000797","PX-62400298","CDM","C1726","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","174.45","74.45","1168.42","1 through 10","0.31","0.8","percent of total billed charges",""
"G220168 Protractx3 Drug-Coated Balloon 2024p000797","PX-62400298","CDM","C1726","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","655.01","135.40","784.73","1 through 10","0.52","0.82","percent of total billed charges",""
"G220168 Protractx3 Drug-Coated Balloon 2024p000797","PX-62400298","CDM","C1726","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","540.25","46.28","897.42","36","0.52","0.82","percent of total billed charges",""
"G220229 Vclastm Vt Cryoabtaion Catheter","PX-62400305","CDM","C2618","HCPCS","0624","RC","","","","both","","","25000.00","18750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9575.00","38.3","","1876.80","640.73","1876.80","1 through 10","7750","19875","percent of total billed charges",""
"G220229 Vclastm Vt Cryoabtaion Catheter","PX-62400305","CDM","C2618","HCPCS","0624","RC","","","","both","","","25000.00","18750.00","WELLPOINT [1015]","HB AMC WELLPOINT","18445.00","73.78","","2802.54","1220.01","4020.30","1 through 10","7750","19875","percent of total billed charges",""
"G220229 Vclastm Vt Cryoabtaion Catheter","PX-62400305","CDM","C2618","HCPCS","0624","RC","","","","outpatient","","","25000.00","18750.00","AETNA [1001]","HB AMC AETNA HMO","17450.00","69.8","","2175.20","2175.20","2175.20","1 through 10","13065","20430","percent of total billed charges",""
"G220229 Vclastm Vt Cryoabtaion Catheter","PX-62400305","CDM","C2618","HCPCS","0624","RC","","","","outpatient","","","25000.00","18750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","20430.00","81.72","","4750.00","720.54","7250.00","11","13065","20430","percent of total billed charges",""
"G220310 Cranial Flap Fixation With a Bioresorbable Bone Adhesive 2024p00","PX-62400314","CDM","C1713","HCPCS","0624","RC","","","","both","","","7320.00","5490.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5819.40","79.5","","800.18","480.96","1887.97","195","2269.2","5819.4","percent of total billed charges",""
"G220310 Cranial Flap Fixation With a Bioresorbable Bone Adhesive 2024p00","PX-62400314","CDM","C1713","HCPCS","0624","RC","","","","both","","","7320.00","5490.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3901.56","53.3","","813.12","216.42","1444.50","81","2269.2","5819.4","percent of total billed charges",""
"G220310 Cranial Flap Fixation With a Bioresorbable Bone Adhesive 2024p00","PX-62400314","CDM","C1713","HCPCS","0624","RC","","","","both","","","7320.00","5490.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2269.20","31","","432.60","432.60","432.60","1 through 10","2269.2","5819.4","percent of total billed charges",""
"G220310 Cranial Flap Fixation With a Bioresorbable Bone Adhesive 2024p00","PX-62400314","CDM","C1713","HCPCS","0624","RC","","","","both","","","7320.00","5490.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2671.80","36.5","","148.37","54.89","631.39","94","2269.2","5819.4","percent of total billed charges",""
"G220310 Cranial Flap Fixation With a Bioresorbable Bone Adhesive 2024p00","PX-62400314","CDM","C1713","HCPCS","0624","RC","","","","both","","","7320.00","5490.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2803.56","38.3","","279.30","91.72","1116.77","266","2269.2","5819.4","percent of total billed charges",""
"G220310 Cranial Flap Fixation With a Bioresorbable Bone Adhesive 2024p00","PX-62400314","CDM","C1713","HCPCS","0624","RC","","","","both","","","7320.00","5490.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3140.28","42.9","","731.00","63.70","731.00","1 through 10","2269.2","5819.4","percent of total billed charges",""
"G220310 Cranial Flap Fixation With a Bioresorbable Bone Adhesive 2024p00","PX-62400314","CDM","C1713","HCPCS","0624","RC","","","","both","","","7320.00","5490.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3140.28","42.9","","384.74","384.74","384.74","1 through 10","2269.2","5819.4","percent of total billed charges",""
"G220310 Cranial Flap Fixation With a Bioresorbable Bone Adhesive 2024p00","PX-62400314","CDM","C1713","HCPCS","0624","RC","","","","both","","","7320.00","5490.00","WELLPOINT [1015]","HB AMC WELLPOINT","5400.70","73.78","","286.63","119.22","1107.45","105","2269.2","5819.4","percent of total billed charges",""
"G220310 Cranial Flap Fixation With a Bioresorbable Bone Adhesive 2024p00","PX-62400314","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","7320.00","5490.00","AETNA [1001]","HB AMC AETNA HMO","5109.36","69.8","","675.31","184.75","1721.50","286","3825.43","5981.9","percent of total billed charges",""
"G220310 Cranial Flap Fixation With a Bioresorbable Bone Adhesive 2024p00","PX-62400314","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","7320.00","5490.00","AETNA [1001]","HB AMC AETNA PPO","5885.28","80.4","","1261.44","103.12","1514.10","21","3825.43","5981.9","percent of total billed charges",""
"G220310 Cranial Flap Fixation With a Bioresorbable Bone Adhesive 2024p00","PX-62400314","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","7320.00","5490.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5885.28","80.4","","1365.00","1365.00","1365.00","1 through 10","3825.43","5981.9","percent of total billed charges",""
"G220310 Cranial Flap Fixation With a Bioresorbable Bone Adhesive 2024p00","PX-62400314","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","7320.00","5490.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5981.90","81.72","","5157.68","5157.68","5157.68","1 through 10","3825.43","5981.9","percent of total billed charges",""
"G220310 Cranial Flap Fixation With a Bioresorbable Bone Adhesive 2024p00","PX-62400314","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","7320.00","5490.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5981.90","81.72","","431.26","71.26","1459.57","88","3825.43","5981.9","percent of total billed charges",""
"G220310 Tetranite for Cranial Flap Fixation (Tn-Cff) 2023p001681","PX-62400293","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","800.18","480.96","1887.97","195","0.31","0.8","percent of total billed charges",""
"G220310 Tetranite for Cranial Flap Fixation (Tn-Cff) 2023p001681","PX-62400293","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","813.12","216.42","1444.50","81","0.31","0.8","percent of total billed charges",""
"G220310 Tetranite for Cranial Flap Fixation (Tn-Cff) 2023p001681","PX-62400293","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.31","31","","432.60","432.60","432.60","1 through 10","0.31","0.8","percent of total billed charges",""
"G220310 Tetranite for Cranial Flap Fixation (Tn-Cff) 2023p001681","PX-62400293","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","148.37","54.89","631.39","94","0.31","0.8","percent of total billed charges",""
"G220310 Tetranite for Cranial Flap Fixation (Tn-Cff) 2023p001681","PX-62400293","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","279.30","91.72","1116.77","266","0.31","0.8","percent of total billed charges",""
"G220310 Tetranite for Cranial Flap Fixation (Tn-Cff) 2023p001681","PX-62400293","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","731.00","63.70","731.00","1 through 10","0.31","0.8","percent of total billed charges",""
"G220310 Tetranite for Cranial Flap Fixation (Tn-Cff) 2023p001681","PX-62400293","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","384.74","384.74","384.74","1 through 10","0.31","0.8","percent of total billed charges",""
"G220310 Tetranite for Cranial Flap Fixation (Tn-Cff) 2023p001681","PX-62400293","CDM","C1713","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","286.63","119.22","1107.45","105","0.31","0.8","percent of total billed charges",""
"G220310 Tetranite for Cranial Flap Fixation (Tn-Cff) 2023p001681","PX-62400293","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","675.31","184.75","1721.50","286","0.52","0.82","percent of total billed charges",""
"G220310 Tetranite for Cranial Flap Fixation (Tn-Cff) 2023p001681","PX-62400293","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA PPO","0.80","80.4","","1261.44","103.12","1514.10","21","0.52","0.82","percent of total billed charges",""
"G220310 Tetranite for Cranial Flap Fixation (Tn-Cff) 2023p001681","PX-62400293","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1365.00","1365.00","1365.00","1 through 10","0.52","0.82","percent of total billed charges",""
"G220310 Tetranite for Cranial Flap Fixation (Tn-Cff) 2023p001681","PX-62400293","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","0.82","81.72","","5157.68","5157.68","5157.68","1 through 10","0.52","0.82","percent of total billed charges",""
"G220310 Tetranite for Cranial Flap Fixation (Tn-Cff) 2023p001681","PX-62400293","CDM","C1713","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","431.26","71.26","1459.57","88","0.52","0.82","percent of total billed charges",""
"G220318 Gae Embosphere Microspheres 2024p001460","PX-62400308","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G220318 Gae Embosphere Microspheres 2024p001460","PX-62400308","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G220318 Gae Embosphere Microspheres 2024p001460","PX-62400308","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G220318 Gae Embosphere Microspheres 2024p001460","PX-62400308","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G220318 Gae Embosphere Microspheres 2024p001460","PX-62400308","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G220318 Gae Embosphere Microspheres 2024p001460","PX-62400308","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G220318 Gae Embosphere Microspheres 2024p001460","PX-62400308","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G220318 Gae Embosphere Microspheres 2024p001460","PX-62400308","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G220318 Gae Embosphere Microspheres 2024p001460","PX-62400308","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G220321 Selution Slr Ptca Drug Eluting Balloon 2024p001471, 2024p001243","PX-62400294","CDM","C2623","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","3445.53","3445.53","3445.53","1 through 10","0.31","0.8","percent of total billed charges",""
"G220321 Selution Slr Ptca Drug Eluting Balloon 2024p001471, 2024p001243","PX-62400294","CDM","C2623","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","5522.88","5522.88","5522.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G220321 Selution Slr Ptca Drug Eluting Balloon 2024p001471, 2024p001243","PX-62400294","CDM","C2623","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","3244.16","3126.90","3244.16","1 through 10","0.31","0.8","percent of total billed charges",""
"G220321 Selution Slr Ptca Drug Eluting Balloon 2024p001471, 2024p001243","PX-62400294","CDM","C2623","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","11291.52","11291.52","11291.52","1 through 10","0.52","0.82","percent of total billed charges",""
"G230099 Saccular Endovascular Aneurysm Lattice System (Seal) 2024p002113","PX-62400317","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G230099 Saccular Endovascular Aneurysm Lattice System (Seal) 2024p002113","PX-62400317","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G230099 Saccular Endovascular Aneurysm Lattice System (Seal) 2024p002113","PX-62400317","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G230099 Saccular Endovascular Aneurysm Lattice System (Seal) 2024p002113","PX-62400317","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G230099 Saccular Endovascular Aneurysm Lattice System (Seal) 2024p002113","PX-62400317","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G230099 Saccular Endovascular Aneurysm Lattice System (Seal) 2024p002113","PX-62400317","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G230099 Saccular Endovascular Aneurysm Lattice System (Seal) 2024p002113","PX-62400317","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G230099 Saccular Endovascular Aneurysm Lattice System (Seal) 2024p002113","PX-62400317","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G230099 Saccular Endovascular Aneurysm Lattice System (Seal) 2024p002113","PX-62400317","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G230140 Barrigel Pprt Dfci 24-610","PX-62400312","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G230140 Barrigel Pprt Dfci 24-610","PX-62400312","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G230140 Barrigel Pprt Dfci 24-610","PX-62400312","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G230140 Barrigel Pprt Dfci 24-610","PX-62400312","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G230140 Barrigel Pprt Dfci 24-610","PX-62400312","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G230140 Barrigel Pprt Dfci 24-610","PX-62400312","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G230140 Barrigel Pprt Dfci 24-610","PX-62400312","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G230140 Barrigel Pprt Dfci 24-610","PX-62400312","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G230140 Barrigel Pprt Dfci 24-610","PX-62400312","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G230170 Thermocool Smarttouch Sf (Paf) 2023p001733","PX-62400289","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","2222.68","2222.68","2222.68","1 through 10","0.31","0.8","percent of total billed charges",""
"G230170 Thermocool Smarttouch Sf (Paf) 2023p001733","PX-62400289","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","4681.38","1275.47","8371.80","20","0.31","0.8","percent of total billed charges",""
"G230170 Thermocool Smarttouch Sf (Paf) 2023p001733","PX-62400289","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1663.12","1287.53","2528.21","1 through 10","0.31","0.8","percent of total billed charges",""
"G230170 Thermocool Smarttouch Sf (Paf) 2023p001733","PX-62400289","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","1935.35","1935.35","1935.35","1 through 10","0.31","0.8","percent of total billed charges",""
"G230170 Thermocool Smarttouch Sf (Paf) 2023p001733","PX-62400289","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","4813.94","2545.82","7082.06","1 through 10","0.31","0.8","percent of total billed charges",""
"G230170 Thermocool Smarttouch Sf (Paf) 2023p001733","PX-62400289","CDM","C1732","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","2733.55","2433.63","5168.92","14","0.52","0.82","percent of total billed charges",""
"G230212 Impede-Fx Rapidfill Implant for Aaa 2024p002426, 2024p002012","PX-62400296","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G230212 Impede-Fx Rapidfill Implant for Aaa 2024p002426, 2024p002012","PX-62400296","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G230212 Impede-Fx Rapidfill Implant for Aaa 2024p002426, 2024p002012","PX-62400296","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G230212 Impede-Fx Rapidfill Implant for Aaa 2024p002426, 2024p002012","PX-62400296","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G230212 Impede-Fx Rapidfill Implant for Aaa 2024p002426, 2024p002012","PX-62400296","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G230212 Impede-Fx Rapidfill Implant for Aaa 2024p002426, 2024p002012","PX-62400296","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G230212 Impede-Fx Rapidfill Implant for Aaa 2024p002426, 2024p002012","PX-62400296","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G230212 Impede-Fx Rapidfill Implant for Aaa 2024p002426, 2024p002012","PX-62400296","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G230212 Impede-Fx Rapidfill Implant for Aaa 2024p002426, 2024p002012","PX-62400296","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G230249 Farastar Sheath 2024p000249/2024p001859","PX-62400288","CDM","C1766","HCPCS","0624","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","3771.60","3771.60","3771.60","1 through 10","1085","2782.5","percent of total billed charges",""
"G230249 Farastar Sheath 2024p000249/2024p001859","PX-62400288","CDM","C1766","HCPCS","0624","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2275.00","65","","2161.25","2161.25","2161.25","1 through 10","1085","2782.5","percent of total billed charges",""
"G230249 Farastar Sheath 2024p000249/2024p001859","PX-62400288","CDM","C1766","HCPCS","0624","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1697.15","370.76","3720.69","1 through 10","1085","2782.5","percent of total billed charges",""
"G230249 Farastar Sheath 2024p000249/2024p001859","PX-62400288","CDM","C1766","HCPCS","0624","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","1779.05","1263.50","3458.00","16","1085","2782.5","percent of total billed charges",""
"G230249 Farastar Sheath 2024p000249/2024p001859","PX-62400288","CDM","C1766","HCPCS","0624","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","1512.88","1512.88","1512.88","1 through 10","1085","2782.5","percent of total billed charges",""
"G230249 Farastar Sheath 2024p000249/2024p001859","PX-62400288","CDM","C1766","HCPCS","0624","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","3387.48","2475.46","3387.48","1 through 10","1085","2782.5","percent of total billed charges",""
"G230249 Farastar Sheath 2024p000249/2024p001859","PX-62400288","CDM","C1766","HCPCS","0624","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","2815.54","2815.54","2815.54","1 through 10","1829.1","2860.2","percent of total billed charges",""
"G230249 Farastar Sheath 2024p000249/2024p001859","PX-62400288","CDM","C1766","HCPCS","0624","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2860.20","81.72","","3637.27","2000.64","3637.27","1 through 10","1829.1","2860.2","percent of total billed charges",""
"G230249 Farastar Sheath 2024p000249/2024p001859","PX-62400288","CDM","C1766","HCPCS","0624","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","2658.01","2000.64","3637.27","17","1829.1","2860.2","percent of total billed charges",""
"G230258 Varipulse Ablation Cath 2023p002605","PX-62400286","CDM","C1732","HCPCS","0624","RC","","","","both","","","13737.50","10303.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8929.38","65","","2222.68","2222.68","2222.68","1 through 10","4258.63","10921.31","percent of total billed charges",""
"G230258 Varipulse Ablation Cath 2023p002605","PX-62400286","CDM","C1732","HCPCS","0624","RC","","","","both","","","13737.50","10303.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5014.19","36.5","","4681.38","1275.47","8371.80","20","4258.63","10921.31","percent of total billed charges",""
"G230258 Varipulse Ablation Cath 2023p002605","PX-62400286","CDM","C1732","HCPCS","0624","RC","","","","both","","","13737.50","10303.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5261.46","38.3","","1663.12","1287.53","2528.21","1 through 10","4258.63","10921.31","percent of total billed charges",""
"G230258 Varipulse Ablation Cath 2023p002605","PX-62400286","CDM","C1732","HCPCS","0624","RC","","","","both","","","13737.50","10303.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5893.39","42.9","","1935.35","1935.35","1935.35","1 through 10","4258.63","10921.31","percent of total billed charges",""
"G230258 Varipulse Ablation Cath 2023p002605","PX-62400286","CDM","C1732","HCPCS","0624","RC","","","","both","","","13737.50","10303.12","WELLPOINT [1015]","HB AMC WELLPOINT","10135.53","73.78","","4813.94","2545.82","7082.06","1 through 10","4258.63","10921.31","percent of total billed charges",""
"G230258 Varipulse Ablation Cath 2023p002605","PX-62400286","CDM","C1732","HCPCS","0624","RC","","","","outpatient","","","13737.50","10303.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11226.29","81.72","","2733.55","2433.63","5168.92","14","7179.22","11226.29","percent of total billed charges",""
"G230284 Kardion Cory P4 Device Kit 2024p001694","PX-62400307","CDM","C1889","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","49687.50","79.5","","1309.77","674.56","6049.93","26","19375","49687.5","percent of total billed charges",""
"G230284 Kardion Cory P4 Device Kit 2024p001694","PX-62400307","CDM","C1889","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33312.50","53.3","","1901.83","1901.83","2962.25","1 through 10","19375","49687.5","percent of total billed charges",""
"G230284 Kardion Cory P4 Device Kit 2024p001694","PX-62400307","CDM","C1889","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22812.50","36.5","","1620.31","1620.31","19908.88","1 through 10","19375","49687.5","percent of total billed charges",""
"G230284 Kardion Cory P4 Device Kit 2024p001694","PX-62400307","CDM","C1889","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23937.50","38.3","","352.91","352.91","2046.30","1 through 10","19375","49687.5","percent of total billed charges",""
"G230284 Kardion Cory P4 Device Kit 2024p001694","PX-62400307","CDM","C1889","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26812.50","42.9","","9668.75","9668.75","9668.75","1 through 10","19375","49687.5","percent of total billed charges",""
"G230284 Kardion Cory P4 Device Kit 2024p001694","PX-62400307","CDM","C1889","HCPCS","0624","RC","","","","both","","","62500.00","46875.00","WELLPOINT [1015]","HB AMC WELLPOINT","46112.50","73.78","","699.88","384.10","3443.31","33","19375","49687.5","percent of total billed charges",""
"G230284 Kardion Cory P4 Device Kit 2024p001694","PX-62400307","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","62500.00","46875.00","AETNA [1001]","HB AMC AETNA HMO","43625.00","69.8","","1421.24","264.50","4933.46","29","32662.5","51075","percent of total billed charges",""
"G230284 Kardion Cory P4 Device Kit 2024p001694","PX-62400307","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","62500.00","46875.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","50250.00","80.4","","1022.97","1022.97","3607.50","1 through 10","32662.5","51075","percent of total billed charges",""
"G230284 Kardion Cory P4 Device Kit 2024p001694","PX-62400307","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","62500.00","46875.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","51075.00","81.72","","3010.54","693.88","5019.88","35","32662.5","51075","percent of total billed charges",""
"G230288 Vitalyst Temp Ventricular Support 2025p003004","PX-62400290","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G230288 Vitalyst Temp Ventricular Support 2025p003004","PX-62400290","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G230288 Vitalyst Temp Ventricular Support 2025p003004","PX-62400290","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G230288 Vitalyst Temp Ventricular Support 2025p003004","PX-62400290","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G230288 Vitalyst Temp Ventricular Support 2025p003004","PX-62400290","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G230288 Vitalyst Temp Ventricular Support 2025p003004","PX-62400290","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G230288 Vitalyst Temp Ventricular Support 2025p003004","PX-62400290","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G230288 Vitalyst Temp Ventricular Support 2025p003004","PX-62400290","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G230288 Vitalyst Temp Ventricular Support 2025p003004","PX-62400290","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G230321 Aeriseal System 2024p000988","PX-62400310","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G230321 Aeriseal System 2024p000988","PX-62400310","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G230321 Aeriseal System 2024p000988","PX-62400310","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G230321 Aeriseal System 2024p000988","PX-62400310","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G230321 Aeriseal System 2024p000988","PX-62400310","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G230321 Aeriseal System 2024p000988","PX-62400310","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G230321 Aeriseal System 2024p000988","PX-62400310","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G230321 Aeriseal System 2024p000988","PX-62400310","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G230321 Aeriseal System 2024p000988","PX-62400310","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G230353 Pulsed Field Ablation Volt-Af Ide Study 2024p001675","PX-62400299","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","2222.68","2222.68","2222.68","1 through 10","0.31","0.8","percent of total billed charges",""
"G230353 Pulsed Field Ablation Volt-Af Ide Study 2024p001675","PX-62400299","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","4681.38","1275.47","8371.80","20","0.31","0.8","percent of total billed charges",""
"G230353 Pulsed Field Ablation Volt-Af Ide Study 2024p001675","PX-62400299","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1663.12","1287.53","2528.21","1 through 10","0.31","0.8","percent of total billed charges",""
"G230353 Pulsed Field Ablation Volt-Af Ide Study 2024p001675","PX-62400299","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","1935.35","1935.35","1935.35","1 through 10","0.31","0.8","percent of total billed charges",""
"G230353 Pulsed Field Ablation Volt-Af Ide Study 2024p001675","PX-62400299","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","4813.94","2545.82","7082.06","1 through 10","0.31","0.8","percent of total billed charges",""
"G230353 Pulsed Field Ablation Volt-Af Ide Study 2024p001675","PX-62400299","CDM","C1732","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","2733.55","2433.63","5168.92","14","0.52","0.82","percent of total billed charges",""
"G240005 Boomerang Cath for Pq Deep Vein Arterialization (Pdva) 2025p0024","PX-62400332","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G240005 Boomerang Cath for Pq Deep Vein Arterialization (Pdva) 2025p0024","PX-62400332","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G240005 Boomerang Cath for Pq Deep Vein Arterialization (Pdva) 2025p0024","PX-62400332","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G240005 Boomerang Cath for Pq Deep Vein Arterialization (Pdva) 2025p0024","PX-62400332","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G240005 Boomerang Cath for Pq Deep Vein Arterialization (Pdva) 2025p0024","PX-62400332","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G240005 Boomerang Cath for Pq Deep Vein Arterialization (Pdva) 2025p0024","PX-62400332","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G240005 Boomerang Cath for Pq Deep Vein Arterialization (Pdva) 2025p0024","PX-62400332","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G240005 Boomerang Cath for Pq Deep Vein Arterialization (Pdva) 2025p0024","PX-62400332","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G240005 Boomerang Cath for Pq Deep Vein Arterialization (Pdva) 2025p0024","PX-62400332","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G240020 Briovad System 2025p001467","PX-62400325","CDM","C1889","HCPCS","0624","RC","","","","both","","","321255.00","240941.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","255397.73","79.5","","1309.77","674.56","6049.93","26","99589.05","255397.73","percent of total billed charges",""
"G240020 Briovad System 2025p001467","PX-62400325","CDM","C1889","HCPCS","0624","RC","","","","both","","","321255.00","240941.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","171228.92","53.3","","1901.83","1901.83","2962.25","1 through 10","99589.05","255397.73","percent of total billed charges",""
"G240020 Briovad System 2025p001467","PX-62400325","CDM","C1889","HCPCS","0624","RC","","","","both","","","321255.00","240941.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","117258.08","36.5","","1620.31","1620.31","19908.88","1 through 10","99589.05","255397.73","percent of total billed charges",""
"G240020 Briovad System 2025p001467","PX-62400325","CDM","C1889","HCPCS","0624","RC","","","","both","","","321255.00","240941.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","123040.67","38.3","","352.91","352.91","2046.30","1 through 10","99589.05","255397.73","percent of total billed charges",""
"G240020 Briovad System 2025p001467","PX-62400325","CDM","C1889","HCPCS","0624","RC","","","","both","","","321255.00","240941.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","137818.40","42.9","","9668.75","9668.75","9668.75","1 through 10","99589.05","255397.73","percent of total billed charges",""
"G240020 Briovad System 2025p001467","PX-62400325","CDM","C1889","HCPCS","0624","RC","","","","both","","","321255.00","240941.25","WELLPOINT [1015]","HB AMC WELLPOINT","237021.94","73.78","","699.88","384.10","3443.31","33","99589.05","255397.73","percent of total billed charges",""
"G240020 Briovad System 2025p001467","PX-62400325","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","321255.00","240941.25","AETNA [1001]","HB AMC AETNA HMO","224235.99","69.8","","1421.24","264.50","4933.46","29","167887.86","262529.59","percent of total billed charges",""
"G240020 Briovad System 2025p001467","PX-62400325","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","321255.00","240941.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","258289.02","80.4","","1022.97","1022.97","3607.50","1 through 10","167887.86","262529.59","percent of total billed charges",""
"G240020 Briovad System 2025p001467","PX-62400325","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","321255.00","240941.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","262529.59","81.72","","3010.54","693.88","5019.88","35","167887.86","262529.59","percent of total billed charges",""
"G240065 Transcatheter Bicaval Valve System 2025p000330","PX-62400321","CDM","C1889","HCPCS","0624","RC","","","","both","","","60625.00","45468.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","48196.88","79.5","","1309.77","674.56","6049.93","26","18793.75","48196.88","percent of total billed charges",""
"G240065 Transcatheter Bicaval Valve System 2025p000330","PX-62400321","CDM","C1889","HCPCS","0624","RC","","","","both","","","60625.00","45468.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","32313.13","53.3","","1901.83","1901.83","2962.25","1 through 10","18793.75","48196.88","percent of total billed charges",""
"G240065 Transcatheter Bicaval Valve System 2025p000330","PX-62400321","CDM","C1889","HCPCS","0624","RC","","","","both","","","60625.00","45468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22128.13","36.5","","1620.31","1620.31","19908.88","1 through 10","18793.75","48196.88","percent of total billed charges",""
"G240065 Transcatheter Bicaval Valve System 2025p000330","PX-62400321","CDM","C1889","HCPCS","0624","RC","","","","both","","","60625.00","45468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23219.38","38.3","","352.91","352.91","2046.30","1 through 10","18793.75","48196.88","percent of total billed charges",""
"G240065 Transcatheter Bicaval Valve System 2025p000330","PX-62400321","CDM","C1889","HCPCS","0624","RC","","","","both","","","60625.00","45468.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26008.13","42.9","","9668.75","9668.75","9668.75","1 through 10","18793.75","48196.88","percent of total billed charges",""
"G240065 Transcatheter Bicaval Valve System 2025p000330","PX-62400321","CDM","C1889","HCPCS","0624","RC","","","","both","","","60625.00","45468.75","WELLPOINT [1015]","HB AMC WELLPOINT","44729.13","73.78","","699.88","384.10","3443.31","33","18793.75","48196.88","percent of total billed charges",""
"G240065 Transcatheter Bicaval Valve System 2025p000330","PX-62400321","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","60625.00","45468.75","AETNA [1001]","HB AMC AETNA HMO","42316.25","69.8","","1421.24","264.50","4933.46","29","31682.63","49542.75","percent of total billed charges",""
"G240065 Transcatheter Bicaval Valve System 2025p000330","PX-62400321","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","60625.00","45468.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","48742.50","80.4","","1022.97","1022.97","3607.50","1 through 10","31682.63","49542.75","percent of total billed charges",""
"G240065 Transcatheter Bicaval Valve System 2025p000330","PX-62400321","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","60625.00","45468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","49542.75","81.72","","3010.54","693.88","5019.88","35","31682.63","49542.75","percent of total billed charges",""
"G240174 Ark Vascular Access Device Ark Cannulation Trial II 2024p003018","PX-62400311","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G240174 Ark Vascular Access Device Ark Cannulation Trial II 2024p003018","PX-62400311","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G240174 Ark Vascular Access Device Ark Cannulation Trial II 2024p003018","PX-62400311","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G240174 Ark Vascular Access Device Ark Cannulation Trial II 2024p003018","PX-62400311","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G240174 Ark Vascular Access Device Ark Cannulation Trial II 2024p003018","PX-62400311","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G240174 Ark Vascular Access Device Ark Cannulation Trial II 2024p003018","PX-62400311","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G240174 Ark Vascular Access Device Ark Cannulation Trial II 2024p003018","PX-62400311","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G240174 Ark Vascular Access Device Ark Cannulation Trial II 2024p003018","PX-62400311","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G240174 Ark Vascular Access Device Ark Cannulation Trial II 2024p003018","PX-62400311","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G240193 Intravascular Lithotripsy for Cad (Fracture Trial) 2024p002916,","PX-62400319","CDM","C1725","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.72","71.8","","175.91","175.91","175.91","1 through 10","0.31","0.8","percent of total billed charges",""
"G240193 Intravascular Lithotripsy for Cad (Fracture Trial) 2024p002916,","PX-62400319","CDM","C1725","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","147.88","147.88","1296.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G240193 Intravascular Lithotripsy for Cad (Fracture Trial) 2024p002916,","PX-62400319","CDM","C1725","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","181.40","177.87","181.40","21","0.31","0.8","percent of total billed charges",""
"G240193 Intravascular Lithotripsy for Cad (Fracture Trial) 2024p002916,","PX-62400319","CDM","C1725","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","170.15","88.95","424.24","16","0.31","0.8","percent of total billed charges",""
"G240193 Intravascular Lithotripsy for Cad (Fracture Trial) 2024p002916,","PX-62400319","CDM","C1725","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","699.48","699.48","699.48","12","0.31","0.8","percent of total billed charges",""
"G240193 Intravascular Lithotripsy for Cad (Fracture Trial) 2024p002916,","PX-62400319","CDM","C1725","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","576.52","182.40","651.44","14","0.31","0.8","percent of total billed charges",""
"G240193 Intravascular Lithotripsy for Cad (Fracture Trial) 2024p002916,","PX-62400319","CDM","C1725","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","181.86","100.03","402.41","21","0.52","0.82","percent of total billed charges",""
"G240222 Elevate III Perq Vad System for Pci Nct07001332 2025p001772","PX-62400328","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","47700.00","79.5","","1309.77","674.56","6049.93","26","18600","47700","percent of total billed charges",""
"G240222 Elevate III Perq Vad System for Pci Nct07001332 2025p001772","PX-62400328","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","31980.00","53.3","","1901.83","1901.83","2962.25","1 through 10","18600","47700","percent of total billed charges",""
"G240222 Elevate III Perq Vad System for Pci Nct07001332 2025p001772","PX-62400328","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21900.00","36.5","","1620.31","1620.31","19908.88","1 through 10","18600","47700","percent of total billed charges",""
"G240222 Elevate III Perq Vad System for Pci Nct07001332 2025p001772","PX-62400328","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22980.00","38.3","","352.91","352.91","2046.30","1 through 10","18600","47700","percent of total billed charges",""
"G240222 Elevate III Perq Vad System for Pci Nct07001332 2025p001772","PX-62400328","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25740.00","42.9","","9668.75","9668.75","9668.75","1 through 10","18600","47700","percent of total billed charges",""
"G240222 Elevate III Perq Vad System for Pci Nct07001332 2025p001772","PX-62400328","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","WELLPOINT [1015]","HB AMC WELLPOINT","44268.00","73.78","","699.88","384.10","3443.31","33","18600","47700","percent of total billed charges",""
"G240222 Elevate III Perq Vad System for Pci Nct07001332 2025p001772","PX-62400328","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","60000.00","45000.00","AETNA [1001]","HB AMC AETNA HMO","41880.00","69.8","","1421.24","264.50","4933.46","29","31356","49032","percent of total billed charges",""
"G240222 Elevate III Perq Vad System for Pci Nct07001332 2025p001772","PX-62400328","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","60000.00","45000.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","48240.00","80.4","","1022.97","1022.97","3607.50","1 through 10","31356","49032","percent of total billed charges",""
"G240222 Elevate III Perq Vad System for Pci Nct07001332 2025p001772","PX-62400328","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","60000.00","45000.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","49032.00","81.72","","3010.54","693.88","5019.88","35","31356","49032","percent of total billed charges",""
"G240222 Shockwave Javelin Coronary Ivl Catheter 2025p000120, 2025p000622","PX-62400315","CDM","C1761","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","8747.88","8747.88","8747.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G240222 Shockwave Javelin Coronary Ivl Catheter 2025p000120, 2025p000622","PX-62400315","CDM","C1761","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","0.53","52.5","","7637.50","7637.50","7637.50","1 through 10","0.4","0.83","percent of total billed charges",""
"G240222 Shockwave Javelin Coronary Ivl Catheter 2025p000120, 2025p000622","PX-62400315","CDM","C1761","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","18471.00","17836.50","30785.00","15","0.4","0.83","percent of total billed charges",""
"G240222 Shockwave Javelin Coronary Ivl Catheter 2025p000120, 2025p000622","PX-62400315","CDM","C1761","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","9392.95","9392.95","9392.95","1 through 10","0.4","0.83","percent of total billed charges",""
"G240247 Fenestrated Treo Stent Graft System 2025p001644","PX-62400329","CDM","C1874","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","56875.00","65","","6652.80","6652.80","6652.80","1 through 10","27125","69562.5","percent of total billed charges",""
"G240247 Fenestrated Treo Stent Graft System 2025p001644","PX-62400329","CDM","C1874","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69562.50","79.5","","2612.61","795.38","2612.61","1 through 10","27125","69562.5","percent of total billed charges",""
"G240247 Fenestrated Treo Stent Graft System 2025p001644","PX-62400329","CDM","C1874","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46637.50","53.3","","1101.80","1101.80","1101.80","1 through 10","27125","69562.5","percent of total billed charges",""
"G240247 Fenestrated Treo Stent Graft System 2025p001644","PX-62400329","CDM","C1874","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","56875.00","65","","1820.00","910.00","1820.00","1 through 10","27125","69562.5","percent of total billed charges",""
"G240247 Fenestrated Treo Stent Graft System 2025p001644","PX-62400329","CDM","C1874","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31937.50","36.5","","1257.80","693.44","2424.50","1 through 10","27125","69562.5","percent of total billed charges",""
"G240247 Fenestrated Treo Stent Graft System 2025p001644","PX-62400329","CDM","C1874","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33512.50","38.3","","1950.11","547.40","2346.00","1 through 10","27125","69562.5","percent of total billed charges",""
"G240247 Fenestrated Treo Stent Graft System 2025p001644","PX-62400329","CDM","C1874","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37537.50","42.9","","5096.18","5096.18","5096.18","1 through 10","27125","69562.5","percent of total billed charges",""
"G240247 Fenestrated Treo Stent Graft System 2025p001644","PX-62400329","CDM","C1874","HCPCS","0624","RC","","","","both","","","87500.00","65625.00","WELLPOINT [1015]","HB AMC WELLPOINT","64557.50","73.78","","1172.59","1172.59","4829.94","1 through 10","27125","69562.5","percent of total billed charges",""
"G240247 Fenestrated Treo Stent Graft System 2025p001644","PX-62400329","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","87500.00","65625.00","AETNA [1001]","HB AMC AETNA HMO","61075.00","69.8","","1806.84","947.80","5091.72","1 through 10","45727.5","71505","percent of total billed charges",""
"G240247 Fenestrated Treo Stent Graft System 2025p001644","PX-62400329","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","87500.00","65625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71505.00","81.72","","1259.05","615.58","4586.56","1 through 10","45727.5","71505","percent of total billed charges",""
"G240276 Onyx Liquid Embolic System (Les) 2025p000629","PX-62400318","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","1309.77","674.56","6049.93","26","0.31","0.8","percent of total billed charges",""
"G240276 Onyx Liquid Embolic System (Les) 2025p000629","PX-62400318","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1901.83","1901.83","2962.25","1 through 10","0.31","0.8","percent of total billed charges",""
"G240276 Onyx Liquid Embolic System (Les) 2025p000629","PX-62400318","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1620.31","1620.31","19908.88","1 through 10","0.31","0.8","percent of total billed charges",""
"G240276 Onyx Liquid Embolic System (Les) 2025p000629","PX-62400318","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","352.91","352.91","2046.30","1 through 10","0.31","0.8","percent of total billed charges",""
"G240276 Onyx Liquid Embolic System (Les) 2025p000629","PX-62400318","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","9668.75","9668.75","9668.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G240276 Onyx Liquid Embolic System (Les) 2025p000629","PX-62400318","CDM","C1889","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","699.88","384.10","3443.31","33","0.31","0.8","percent of total billed charges",""
"G240276 Onyx Liquid Embolic System (Les) 2025p000629","PX-62400318","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1421.24","264.50","4933.46","29","0.52","0.82","percent of total billed charges",""
"G240276 Onyx Liquid Embolic System (Les) 2025p000629","PX-62400318","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","1022.97","1022.97","3607.50","1 through 10","0.52","0.82","percent of total billed charges",""
"G240276 Onyx Liquid Embolic System (Les) 2025p000629","PX-62400318","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","3010.54","693.88","5019.88","35","0.52","0.82","percent of total billed charges",""
"G240300 Farapulse Pulsed Field Ablation System 2025p001184","PX-62400327","CDM","C1732","HCPCS","0624","RC","","","","both","","","2475.00","1856.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1608.75","65","","2222.68","2222.68","2222.68","1 through 10","767.25","1967.63","percent of total billed charges",""
"G240300 Farapulse Pulsed Field Ablation System 2025p001184","PX-62400327","CDM","C1732","HCPCS","0624","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","903.38","36.5","","4681.38","1275.47","8371.80","20","767.25","1967.63","percent of total billed charges",""
"G240300 Farapulse Pulsed Field Ablation System 2025p001184","PX-62400327","CDM","C1732","HCPCS","0624","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","947.93","38.3","","1663.12","1287.53","2528.21","1 through 10","767.25","1967.63","percent of total billed charges",""
"G240300 Farapulse Pulsed Field Ablation System 2025p001184","PX-62400327","CDM","C1732","HCPCS","0624","RC","","","","both","","","2475.00","1856.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1061.78","42.9","","1935.35","1935.35","1935.35","1 through 10","767.25","1967.63","percent of total billed charges",""
"G240300 Farapulse Pulsed Field Ablation System 2025p001184","PX-62400327","CDM","C1732","HCPCS","0624","RC","","","","both","","","2475.00","1856.25","WELLPOINT [1015]","HB AMC WELLPOINT","1826.06","73.78","","4813.94","2545.82","7082.06","1 through 10","767.25","1967.63","percent of total billed charges",""
"G240300 Farapulse Pulsed Field Ablation System 2025p001184","PX-62400327","CDM","C1732","HCPCS","0624","RC","","","","outpatient","","","2475.00","1856.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2022.57","81.72","","2733.55","2433.63","5168.92","14","1293.44","2022.57","percent of total billed charges",""
"G250039 Abbott Coronary Ivl Cath 2025p001140","PX-62400320","CDM","C1725","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.72","71.8","","175.91","175.91","175.91","1 through 10","0.31","0.8","percent of total billed charges",""
"G250039 Abbott Coronary Ivl Cath 2025p001140","PX-62400320","CDM","C1725","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","147.88","147.88","1296.75","1 through 10","0.31","0.8","percent of total billed charges",""
"G250039 Abbott Coronary Ivl Cath 2025p001140","PX-62400320","CDM","C1725","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","181.40","177.87","181.40","21","0.31","0.8","percent of total billed charges",""
"G250039 Abbott Coronary Ivl Cath 2025p001140","PX-62400320","CDM","C1725","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","170.15","88.95","424.24","16","0.31","0.8","percent of total billed charges",""
"G250039 Abbott Coronary Ivl Cath 2025p001140","PX-62400320","CDM","C1725","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","699.48","699.48","699.48","12","0.31","0.8","percent of total billed charges",""
"G250039 Abbott Coronary Ivl Cath 2025p001140","PX-62400320","CDM","C1725","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","576.52","182.40","651.44","14","0.31","0.8","percent of total billed charges",""
"G250039 Abbott Coronary Ivl Cath 2025p001140","PX-62400320","CDM","C1725","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","181.86","100.03","402.41","21","0.52","0.82","percent of total billed charges",""
"G250078 Agent Drug-Coated Balloon for Stent for De Novo Cad 2025p001880, 2025p002231","PX-62400330","CDM","C9610","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","11291.53","11291.53","11291.53","1 through 10","0.4","0.83","percent of total billed charges",""
"G250174 Ocs Heart Sys (Enhance) Trial 2025p002732, 2025p003173","PX-62400334","CDM","C1889","HCPCS","0624","RC","","","","both","","","196250.00","147187.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","156018.75","79.5","","1309.77","674.56","6049.93","26","60837.5","156018.75","percent of total billed charges",""
"G250174 Ocs Heart Sys (Enhance) Trial 2025p002732, 2025p003173","PX-62400334","CDM","C1889","HCPCS","0624","RC","","","","both","","","196250.00","147187.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","104601.25","53.3","","1901.83","1901.83","2962.25","1 through 10","60837.5","156018.75","percent of total billed charges",""
"G250174 Ocs Heart Sys (Enhance) Trial 2025p002732, 2025p003173","PX-62400334","CDM","C1889","HCPCS","0624","RC","","","","both","","","196250.00","147187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71631.25","36.5","","1620.31","1620.31","19908.88","1 through 10","60837.5","156018.75","percent of total billed charges",""
"G250174 Ocs Heart Sys (Enhance) Trial 2025p002732, 2025p003173","PX-62400334","CDM","C1889","HCPCS","0624","RC","","","","both","","","196250.00","147187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75163.75","38.3","","352.91","352.91","2046.30","1 through 10","60837.5","156018.75","percent of total billed charges",""
"G250174 Ocs Heart Sys (Enhance) Trial 2025p002732, 2025p003173","PX-62400334","CDM","C1889","HCPCS","0624","RC","","","","both","","","196250.00","147187.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84191.25","42.9","","9668.75","9668.75","9668.75","1 through 10","60837.5","156018.75","percent of total billed charges",""
"G250174 Ocs Heart Sys (Enhance) Trial 2025p002732, 2025p003173","PX-62400334","CDM","C1889","HCPCS","0624","RC","","","","both","","","196250.00","147187.50","WELLPOINT [1015]","HB AMC WELLPOINT","144793.25","73.78","","699.88","384.10","3443.31","33","60837.5","156018.75","percent of total billed charges",""
"G250174 Ocs Heart Sys (Enhance) Trial 2025p002732, 2025p003173","PX-62400334","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","196250.00","147187.50","AETNA [1001]","HB AMC AETNA HMO","136982.50","69.8","","1421.24","264.50","4933.46","29","102560.25","160375.5","percent of total billed charges",""
"G250174 Ocs Heart Sys (Enhance) Trial 2025p002732, 2025p003173","PX-62400334","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","196250.00","147187.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","157785.00","80.4","","1022.97","1022.97","3607.50","1 through 10","102560.25","160375.5","percent of total billed charges",""
"G250174 Ocs Heart Sys (Enhance) Trial 2025p002732, 2025p003173","PX-62400334","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","196250.00","147187.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","160375.50","81.72","","3010.54","693.88","5019.88","35","102560.25","160375.5","percent of total billed charges",""
"G6pd Enzyme Screen","PX-30000471","CDM","82960","CPT","0301","RC","","","","both","","","113.00","84.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","60.23","53.3","","58.08","58.08","58.08","1 through 10","5.93","107.35","percent of total billed charges",""
"G6pd Enzyme Screen","PX-30000471","CDM","82960","CPT","0301","RC","","","","both","","","113.00","84.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.25","36.5","","34.87","34.87","41.03","1 through 10","5.93","107.35","percent of total billed charges",""
"G6pd Enzyme Screen","PX-30000471","CDM","82960","CPT","0301","RC","","","","both","","","113.00","84.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.28","38.3","","125.40","43.01","129.03","11","5.93","107.35","percent of total billed charges",""
"G6pd Enzyme Screen","PX-30000471","CDM","82960","CPT","0301","RC","","","","outpatient","","","113.00","84.75","AETNA [1001]","HB AMC AETNA HMO","78.87","69.8","","66.81","52.58","74.47","1 through 10","5.98","92.34","percent of total billed charges",""
"G6pd Enzyme Screen","PX-30000471","CDM","82960","CPT","0301","RC","","","","outpatient","","","113.00","84.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","92.34","81.72","","87.93","87.93","87.93","1 through 10","5.98","92.34","percent of total billed charges",""
"Galc Gene Sequencing & Del/Dup","PX-31000767","CDM","81479","CPT","0310","RC","","","","both","","","1829.00","1371.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1454.06","79.5","","0.65","0.65","0.65","1 through 10","566.99","1737.55","percent of total billed charges",""
"Galc Gene Sequencing & Del/Dup","PX-31000767","CDM","81479","CPT","0310","RC","","","","both","","","1829.00","1371.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","974.86","53.3","","0.79","0.79","0.79","1 through 10","566.99","1737.55","percent of total billed charges",""
"Galc Gene Sequencing & Del/Dup","PX-31000767","CDM","81479","CPT","0310","RC","","","","outpatient","","","1829.00","1371.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","914.50","50","","1.00","1.00","1.00","1 through 10","156.55","1508.93","percent of total billed charges",""
"Galc Gene Sequencing & Del/Dup","PX-31000767","CDM","81479","CPT","0310","RC","","","","outpatient","","","1829.00","1371.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","960.23","52.5","","1.00","0.53","1.00","1 through 10","156.55","1508.93","percent of total billed charges",""
"Gamma Globin Full Gene Sequencing","PX-31000920","CDM","81479","CPT","0310","RC","","","","both","","","569.00","426.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","452.36","79.5","","0.65","0.65","0.65","1 through 10","176.39","540.55","percent of total billed charges",""
"Gamma Globin Full Gene Sequencing","PX-31000920","CDM","81479","CPT","0310","RC","","","","both","","","569.00","426.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","303.28","53.3","","0.79","0.79","0.79","1 through 10","176.39","540.55","percent of total billed charges",""
"Gamma Globin Full Gene Sequencing","PX-31000920","CDM","81479","CPT","0310","RC","","","","outpatient","","","569.00","426.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","284.50","50","","1.00","1.00","1.00","1 through 10","156.55","469.43","percent of total billed charges",""
"Gamma Globin Full Gene Sequencing","PX-31000920","CDM","81479","CPT","0310","RC","","","","outpatient","","","569.00","426.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","298.73","52.5","","1.00","0.53","1.00","1 through 10","156.55","469.43","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","194.00","145.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","135.80","70","","198.69","198.69","198.69","1 through 10","16.13","184.3","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","194.00","145.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","154.23","79.5","","147.96","99.26","147.96","55","16.13","184.3","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","194.00","145.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","103.40","53.3","","147.96","99.26","295.92","16","16.13","184.3","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","194.00","145.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","149.38","77","","144.76","144.76","144.76","1 through 10","16.13","184.3","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","194.00","145.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","126.10","65","","122.20","99.64","122.20","1 through 10","16.13","184.3","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","194.00","145.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","154.23","79.5","","147.96","147.96","147.96","1 through 10","16.13","184.3","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","194.00","145.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","60.14","31","","58.09","58.09","58.09","1 through 10","16.13","184.3","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","194.00","145.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70.81","36.5","","70.12","59.60","210.36","56","16.13","184.3","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","194.00","145.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","74.30","38.3","","73.51","71.44","220.53","167","16.13","184.3","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","194.00","145.50","MOLINA [1014]","HB BWH MOLINA","67.90","35","","32.66","32.66","32.66","1 through 10","16.13","184.3","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","194.00","145.50","TRICARE [160005]","HB BWH TRICARE","184.30","95","","19.83","19.83","19.83","1 through 10","16.13","184.3","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","194.00","145.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.23","42.9","","150.29","82.66","220.53","1 through 10","16.13","184.3","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","194.00","145.50","AETNA [1001]","HB AMC AETNA HMO","135.41","69.8","","127.28","89.86","146.64","72","16.98","158.54","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","194.00","145.50","AETNA [1001]","HB AMC AETNA PPO","155.98","80.4","","146.64","98.51","258.00","1 through 10","16.98","158.54","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","194.00","145.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","108.45","55.9","","98.51","98.51","98.51","1 through 10","16.98","158.54","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","194.00","145.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","101.38","52.26","","57.74","57.74","57.74","1 through 10","16.98","158.54","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","194.00","145.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","158.54","81.72","","150.29","82.66","150.29","1 through 10","16.98","158.54","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","194.00","145.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","158.54","81.72","","150.29","82.66","150.29","68","16.98","158.54","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","94.06","71.8","","24.60","8.20","273.56","79","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","85.94","65.6","","85.98","9.57","85.98","1 through 10","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","85.15","65","","82.55","82.55","82.55","1 through 10","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","91.70","70","","127.00","55.84","127.00","31","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","CHAMPVA [160001]","HB BWH TRICARE","124.45","95","","11.21","11.21","11.21","1 through 10","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","104.15","79.5","","99.95","67.06","299.85","569","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","69.82","53.3","","99.95","67.06","299.85","297","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","100.87","77","","293.37","97.79","293.37","16","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","85.15","65","","82.55","82.55","247.65","11","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","104.15","79.5","","99.95","99.95","99.95","1 through 10","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","40.61","31","","39.24","39.24","39.24","1 through 10","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","47.82","36.5","","47.37","40.26","52.49","477","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","50.17","38.3","","49.66","48.26","148.97","1375","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","MOLINA [1014]","HB BWH MOLINA","45.85","35","","18.45","18.45","18.45","1 through 10","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","100.87","77","","99.06","91.99","110.49","1 through 10","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","TRICARE [160005]","HB BWH TRICARE","124.45","95","","10.65","10.65","127.00","26","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","124.45","95","","9.30","9.30","9.30","1 through 10","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.20","42.9","","55.84","55.84","101.53","29","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","131.00","98.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.20","42.9","","55.84","55.84","55.84","1 through 10","7.66","124.45","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","131.00","98.25","AETNA [1001]","HB AMC AETNA HMO","91.44","69.8","","85.98","60.71","99.06","723","7.66","107.05","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","131.00","98.25","AETNA [1001]","HB AMC AETNA PPO","105.32","80.4","","99.06","63.93","199.64","99","7.66","107.05","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","131.00","98.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","73.23","55.9","","66.55","66.55","66.55","1 through 10","7.66","107.05","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","131.00","98.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","68.46","52.26","","78.59","33.00","78.59","1 through 10","7.66","107.05","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","131.00","98.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","105.32","80.4","","99.06","99.06","190.50","14","7.66","107.05","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","131.00","98.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","107.05","81.72","","304.58","304.58","304.58","1 through 10","7.66","107.05","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","131.00","98.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","107.05","81.72","","101.52","55.84","101.53","28","7.66","107.05","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","131.00","98.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","107.05","81.72","","101.52","55.84","101.53","559","7.66","107.05","percent of total billed charges",""
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","both","","","556.00","417.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","172.36","442.02","other","OPPS APC"
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","both","","","556.00","417.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","172.36","442.02","other","OPPS APC"
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","both","","","556.00","417.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","296.35","53.3","","477.31","477.31","477.31","1 through 10","172.36","442.02","percent of total billed charges",""
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","both","","","556.00","417.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","172.36","442.02","other","OPPS APC"
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","both","","","556.00","417.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","172.36","442.02","other","OPPS APC"
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","both","","","556.00","417.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","202.94","36.5","","1095.87","337.19","1095.87","1 through 10","172.36","442.02","percent of total billed charges",""
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","both","","","556.00","417.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","212.95","38.3","","343.52","323.76","353.46","1 through 10","172.36","442.02","percent of total billed charges",""
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","both","","","556.00","417.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","172.36","442.02","other","Tricare OPPS"
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","both","","","556.00","417.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","172.36","442.02","other","OPPS APC"
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","both","","","556.00","417.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","172.36","442.02","other","OPPS APC"
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","both","","","556.00","417.00","WELLPOINT [1015]","HB AMC WELLPOINT","410.22","73.78","","673.03","673.03","673.03","1 through 10","172.36","442.02","percent of total billed charges",""
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","outpatient","","","556.00","417.00","AETNA [1001]","HB AMC AETNA HMO","388.09","69.8","","612.01","612.01","1224.02","1 through 10","278","700.33","percent of total billed charges",""
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","outpatient","","","556.00","417.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","336.66","60.55","","579.04","568.57","904.00","30","278","700.33","percent of total billed charges",""
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","outpatient","","","556.00","417.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","290.34","52.22","","904.00","656.02","2938.00","26","278","700.33","percent of total billed charges",""
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","outpatient","","","556.00","417.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","278.00","50","","1421.10","875.08","2368.50","15","278","700.33","percent of total billed charges",""
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","outpatient","","","556.00","417.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","291.90","52.5","","2985.00","904.00","2985.00","1 through 10","278","700.33","percent of total billed charges",""
"Ganglion Impar Block","PX-98301790","CDM","64999","CPT","0983","RC","","","","outpatient","","","556.00","417.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","454.36","81.72","","722.66","722.66","17449.00","1 through 10","278","700.33","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","2408.85","other","OPPS APC"
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","2408.85","other","OPPS APC"
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1614.99","53.3","","477.31","477.31","477.31","1 through 10","333.03","2408.85","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","2408.85","other","OPPS APC"
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","2408.85","other","OPPS APC"
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1105.95","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","2408.85","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1160.49","38.3","","343.52","323.76","353.46","1 through 10","333.03","2408.85","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","2408.85","other","Tricare OPPS"
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","2408.85","other","OPPS APC"
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","2408.85","other","OPPS APC"
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","3030.00","2272.50","WELLPOINT [1015]","HB AMC WELLPOINT","2235.53","73.78","","673.03","673.03","673.03","1 through 10","333.03","2408.85","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","outpatient","","","3030.00","2272.50","AETNA [1001]","HB AMC AETNA HMO","2114.94","69.8","","612.01","612.01","1224.02","1 through 10","700.33","2499.75","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","outpatient","","","3030.00","2272.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1834.67","60.55","","579.04","568.57","904.00","30","700.33","2499.75","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","outpatient","","","3030.00","2272.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1582.27","52.22","","904.00","656.02","2938.00","26","700.33","2499.75","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","outpatient","","","3030.00","2272.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1515.00","50","","1421.10","875.08","2368.50","15","700.33","2499.75","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","outpatient","","","3030.00","2272.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1590.75","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","2499.75","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","outpatient","","","3030.00","2272.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2476.12","81.72","","722.66","722.66","17449.00","1 through 10","700.33","2499.75","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","139.29","71.8","","10.17","10.17","134.98","13","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","135.80","70","","82.67","82.67","82.67","1 through 10","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","154.23","79.5","","147.96","99.26","188.00","239","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","103.40","53.3","","99.27","99.26","147.96","109","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","149.38","77","","434.28","434.28","434.28","60","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","126.10","65","","122.20","44.20","244.40","1 through 10","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","154.23","79.5","","147.96","147.96","147.96","1 through 10","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","60.14","31","","68.26","58.09","68.26","1 through 10","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70.81","36.5","","70.12","59.60","210.36","196","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","74.30","38.3","","73.51","71.44","220.53","563","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","149.38","77","","163.56","137.98","163.56","1 through 10","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","TRICARE [160005]","HB BWH TRICARE","184.30","95","","13.20","13.20","13.89","23","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","184.30","95","","11.53","11.53","11.53","1 through 10","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.23","42.9","","150.29","82.66","150.29","15","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.23","42.9","","82.66","82.66","82.66","1 through 10","11.3","184.3","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","AETNA [1001]","HB AMC AETNA HMO","135.41","69.8","","127.28","89.86","254.56","324","11.81","158.54","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","AETNA [1001]","HB AMC AETNA PPO","155.98","80.4","","146.64","98.51","146.64","43","11.81","158.54","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","101.38","52.26","","41.24","41.24","116.34","1 through 10","11.81","158.54","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","155.98","80.4","","146.64","146.64","282.00","1 through 10","11.81","158.54","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","158.54","81.72","","150.29","150.29","376.00","1 through 10","11.81","158.54","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","158.54","81.72","","82.67","82.66","300.57","1 through 10","11.81","158.54","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","158.54","81.72","","150.29","82.66","150.29","198","11.81","158.54","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","both","","","888.00","666.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","63.71","182.84","19","176.52","705.96","other","OPPS APC"
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","both","","","888.00","666.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","232.23","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","50.00","50.00","50.00","1 through 10","176.52","705.96","other","OPPS APC"
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","both","","","888.00","666.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","705.96","79.5","","454.61","434.81","677.61","1 through 10","176.52","705.96","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","both","","","888.00","666.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","473.30","53.3","","454.61","454.61","677.61","1 through 10","176.52","705.96","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","both","","","888.00","666.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","683.76","77","","662.97","662.97","662.97","1 through 10","176.52","705.96","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","both","","","888.00","666.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","324.12","36.5","","503.49","272.94","503.49","1 through 10","176.52","705.96","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","both","","","888.00","666.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","340.10","38.3","","336.65","327.18","336.65","13","176.52","705.96","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","outpatient","","","888.00","666.00","AETNA [1001]","HB AMC AETNA HMO","619.82","69.8","","582.90","469.89","582.90","1 through 10","304.03","725.67","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","outpatient","","","888.00","666.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","725.67","81.72","","688.28","688.28","688.28","1 through 10","304.03","725.67","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","442.95","469.56","1 through 10","453.34","1737.87","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1569.55","71.8","","1522.16","1522.16","1522.16","1 through 10","453.34","1737.87","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","596.44","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","225.00","225.00","225.00","1 through 10","453.34","1737.87","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1737.87","79.5","","1668.44","1668.44","1668.44","1 through 10","453.34","1737.87","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1165.14","53.3","","1119.36","1119.36","1119.36","1 through 10","453.34","1737.87","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","469.56","469.56","1 through 10","453.34","1737.87","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","HUMANA [1012]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","471.47","471.47","471.47","1 through 10","453.34","1737.87","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","450.15","477.20","27","453.34","1737.87","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","837.24","38.3","","828.92","805.60","828.92","12","453.34","1737.87","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","467.66","444.15","467.66","1 through 10","453.34","1737.87","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.66","469.56","472.66","1 through 10","453.34","1737.87","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","937.79","42.9","","1694.73","1694.73","1694.73","1 through 10","453.34","1737.87","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.66","467.66","472.66","14","453.34","1737.87","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","2186.00","1639.50","AETNA [1001]","HB AMC AETNA HMO","1525.83","69.8","","1435.24","1435.24","1435.24","1 through 10","727.63","1786.4","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","2186.00","1639.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1142.40","52.26","","727.63","727.63","727.63","1 through 10","727.63","1786.4","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","2186.00","1639.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1786.40","81.72","","2120.00","1056.94","2120.00","1 through 10","727.63","1786.4","percent of total billed charges",""
"Gastric Emptyng Imag Std W/Sm Bwl Transit","PX-34000182","CDM","78265","CPT","0341","RC","","","","both","","","2542.00","1906.50","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","450.15","477.20","1 through 10","453.34","2020.89","other","OPPS APC"
"Gastric Fundoplication,MINOR","232","DRG","","","","","","","","inpatient","","","67333.12","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","36189.58","","Standard inlier is a Case rate ($36,189.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,790, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,137.33) for the length of stay and the standard reimbursement.","36189.57","36189.57","36189.57","1 through 10","9905.46","65695.25","case rate",""
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","both","","","1957.00","1467.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","606.67","1555.82","other","OPPS APC"
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","both","","","1957.00","1467.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","606.67","1555.82","other","OPPS APC"
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","both","","","1957.00","1467.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1555.82","79.5","","2814.50","2346.50","2814.50","1 through 10","606.67","1555.82","percent of total billed charges",""
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","both","","","1957.00","1467.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","606.67","1555.82","other","OPPS APC"
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","both","","","1957.00","1467.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","606.67","1555.82","other","OPPS APC"
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","both","","","1957.00","1467.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","714.31","36.5","","2677.58","1482.13","2910.89","1 through 10","606.67","1555.82","percent of total billed charges",""
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","both","","","1957.00","1467.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","749.53","38.3","","2723.31","1555.62","2741.61","12","606.67","1555.82","percent of total billed charges",""
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","both","","","1957.00","1467.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","606.67","1555.82","other","OPPS APC"
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","both","","","1957.00","1467.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","606.67","1555.82","other","OPPS APC"
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","both","","","1957.00","1467.75","WELLPOINT [1015]","HB AMC WELLPOINT","1443.87","73.78","","2687.65","2687.64","3224.43","1 through 10","606.67","1555.82","percent of total billed charges",""
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","outpatient","","","1957.00","1467.75","AETNA [1001]","HB AMC AETNA PPO","1573.43","80.4","","1163.76","1163.76","1163.76","1 through 10","978.5","2384.07","percent of total billed charges",""
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","outpatient","","","1957.00","1467.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1184.96","60.55","","1781.82","1492.00","4331.00","1 through 10","978.5","2384.07","percent of total billed charges",""
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","outpatient","","","1957.00","1467.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1021.95","52.22","","3144.00","1492.00","3610.00","13","978.5","2384.07","percent of total billed charges",""
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","outpatient","","","1957.00","1467.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1027.43","52.5","","1182.28","1182.28","1182.28","1 through 10","978.5","2384.07","percent of total billed charges",""
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","outpatient","","","1957.00","1467.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","978.50","50","","3610.00","2269.44","3610.00","1 through 10","978.5","2384.07","percent of total billed charges",""
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","outpatient","","","1957.00","1467.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1027.43","52.5","","3610.00","2382.05","4331.00","1 through 10","978.5","2384.07","percent of total billed charges",""
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","outpatient","","","1957.00","1467.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1076.35","55","","4810.75","3363.17","4810.75","1 through 10","978.5","2384.07","percent of total billed charges",""
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","outpatient","","","1957.00","1467.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1599.26","81.72","","8894.69","8894.69","8894.69","1 through 10","978.5","2384.07","percent of total billed charges",""
"Gastric Lap Band Contrast Injection","PX-76002738","CDM","43999","CPT","0761","RC","","","","outpatient","","","1957.00","1467.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1599.26","81.72","","2885.83","2132.00","3462.21","1 through 10","978.5","2384.07","percent of total billed charges",""
"Gastrin","PX-30000459","CDM","82941","CPT","0301","RC","","","","both","","","217.00","162.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","79.21","36.5","","76.02","76.02","76.02","1 through 10","17.28","206.15","percent of total billed charges",""
"Gastrin","PX-30000459","CDM","82941","CPT","0301","RC","","","","both","","","217.00","162.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","83.11","38.3","","82.11","79.80","82.11","1 through 10","17.28","206.15","percent of total billed charges",""
"Gastrin","PX-30000459","CDM","82941","CPT","0301","RC","","","","outpatient","","","217.00","162.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","177.33","81.72","","167.87","167.87","167.87","1 through 10","18.2","177.33","percent of total billed charges",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","46380.65","34785.49","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","9605.68","","Case rate ($9,325.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,149.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,793.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,229.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,156.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,769.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.13. The transfer capital threshold is the transfer adjustment factor * $789.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9542.03","9512.27","17268.20","1 through 10","9139.38","15361.68","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","46380.65","34785.49","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","11990.29","","Case rate ($11,990.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,149.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,793.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,229.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,821.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,769.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.13. The transfer capital threshold is the transfer adjustment factor * $789.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11744.32","11744.32","11744.32","1 through 10","9139.38","15361.68","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","46380.65","34785.49","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9325.90","","Case rate ($9,325.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,149.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,793.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,229.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,156.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,769.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.13. The transfer capital threshold is the transfer adjustment factor * $789.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9075.99","9075.99","9075.99","1 through 10","9139.38","15361.68","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","46380.65","34785.49","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","11930.67","11930.67","13019.18","1 through 10","9139.38","15361.68","case rate",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","46380.65","34785.49","MEDICARE [2001]","HB BWH MEDICARE","11990.29","","Case rate ($11,990.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,149.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,793.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,229.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,821.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,769.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.13. The transfer capital threshold is the transfer adjustment factor * $789.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11901.20","0.03","11901.20","69","9139.38","15361.68","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","46380.65","34785.49","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","11990.29","","Case rate ($11,990.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,149.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,793.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,229.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,821.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,769.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.13. The transfer capital threshold is the transfer adjustment factor * $789.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9089.54","9089.54","9089.54","1 through 10","9139.38","15361.68","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","46380.65","34785.49","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9139.38","","Case rate ($9,325.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,149.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,793.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,229.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,156.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,769.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.13. The transfer capital threshold is the transfer adjustment factor * $789.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9121.31","9121.31","46152.86","1 through 10","9139.38","15361.68","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","46380.65","34785.49","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9139.38","","Case rate ($9,325.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,149.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,793.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,229.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,156.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,769.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.13. The transfer capital threshold is the transfer adjustment factor * $789.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9093.53","9085.74","9148.61","1 through 10","9139.38","15361.68","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","83329.70","62497.27","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","17566.69","","Case rate ($17,055.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,453.50, add-ons for qualifying new technology services are included. If operating cost exceeds $66,097.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,911.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $15,204.29 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,073.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,470.92. The transfer capital threshold is the transfer adjustment factor * $1,470.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17291.68","17268.21","17334.81","1 through 10","16713.94","27438.4562","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","83329.70","62497.27","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","22021.39","","Case rate ($22,021.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,453.50, add-ons for qualifying new technology services are included. If operating cost exceeds $66,097.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,911.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $20,170.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,073.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,470.92. The transfer capital threshold is the transfer adjustment factor * $1,470.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16644.65","16644.65","16781.63","1 through 10","16713.94","27438.4562","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","83329.70","62497.27","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","17055.04","","Case rate ($17,055.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,453.50, add-ons for qualifying new technology services are included. If operating cost exceeds $66,097.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,911.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $15,204.29 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,073.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,470.92. The transfer capital threshold is the transfer adjustment factor * $1,470.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16571.90","16532.07","16712.01","1 through 10","16713.94","27438.4562","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","83329.70","62497.27","ELDER SERVICES [1037]","HB BWH MEDICARE","22021.39","","Case rate ($22,021.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,453.50, add-ons for qualifying new technology services are included. If operating cost exceeds $66,097.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,911.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $20,170.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,073.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,470.92. The transfer capital threshold is the transfer adjustment factor * $1,470.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16797.66","16797.66","16797.66","1 through 10","16713.94","27438.4562","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","83329.70","62497.27","MEDICARE [2001]","HB BWH MEDICARE","22021.39","","Case rate ($22,021.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,453.50, add-ons for qualifying new technology services are included. If operating cost exceeds $66,097.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,911.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $20,170.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,073.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,470.92. The transfer capital threshold is the transfer adjustment factor * $1,470.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21713.32","0.03","21745.38","79","16713.94","27438.4562","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","83329.70","62497.27","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","22021.39","","Case rate ($22,021.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,453.50, add-ons for qualifying new technology services are included. If operating cost exceeds $66,097.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,911.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $20,170.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,073.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,470.92. The transfer capital threshold is the transfer adjustment factor * $1,470.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","115.71","115.71","115.71","1 through 10","16713.94","27438.4562","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","83329.70","62497.27","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16713.94","","Case rate ($17,055.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,453.50, add-ons for qualifying new technology services are included. If operating cost exceeds $66,097.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,911.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $15,204.29 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,073.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,470.92. The transfer capital threshold is the transfer adjustment factor * $1,470.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16585.89","16483.85","16649.43","1 through 10","16713.94","27438.4562","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","83329.70","62497.27","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16713.94","","Case rate ($17,055.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,453.50, add-ons for qualifying new technology services are included. If operating cost exceeds $66,097.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,911.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $15,204.29 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,073.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,470.92. The transfer capital threshold is the transfer adjustment factor * $1,470.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16546.18","16445.91","70393.64","1 through 10","16713.94","27438.4562","other","Inpatient DRG"
"Gastrointestinal Hemorrhage Without Cc/McC","379","MS-DRG","","","","","","","","inpatient","","","31746.06","23809.54","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","6130.41","","Case rate ($6,130.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,302.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,946.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,947.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,243.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,922.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.26. The transfer capital threshold is the transfer adjustment factor * $507.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5985.39","5985.39","5985.39","1 through 10","6007.8","9608.4397","other","Inpatient DRG"
"Gastrointestinal Hemorrhage Without Cc/McC","379","MS-DRG","","","","","","","","inpatient","","","31746.06","23809.54","MEDICARE [2001]","HB BWH MEDICARE","6130.41","","Case rate ($6,130.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,302.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,946.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,947.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,243.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,922.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.26. The transfer capital threshold is the transfer adjustment factor * $507.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7795.66","7795.66","7795.66","1 through 10","6007.8","9608.4397","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","36859.46","27644.59","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7812.01","","Case rate ($7,584.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,052.80, add-ons for qualifying new technology services are included. If operating cost exceeds $54,697.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,075.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,569.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,672.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.52. The transfer capital threshold is the transfer adjustment factor * $635.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","5421.46","5421.46","5421.46","1 through 10","7432.79","12371.43","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","36859.46","27644.59","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","9480.60","","Case rate ($7,584.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,052.80, add-ons for qualifying new technology services are included. If operating cost exceeds $54,697.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,075.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,569.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,672.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.52. The transfer capital threshold is the transfer adjustment factor * $635.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","7554.18","7554.18","7554.18","1 through 10","7432.79","12371.43","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","36859.46","27644.59","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7584.48","","Case rate ($7,584.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,052.80, add-ons for qualifying new technology services are included. If operating cost exceeds $54,697.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,075.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,569.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,672.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.52. The transfer capital threshold is the transfer adjustment factor * $635.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7403.08","7403.08","7403.08","1 through 10","7432.79","12371.43","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","36859.46","27644.59","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","6126.97","6126.97","6126.97","1 through 10","7432.79","12371.43","case rate",""
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","36859.46","27644.59","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","7584.48","","Case rate ($7,584.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,052.80, add-ons for qualifying new technology services are included. If operating cost exceeds $54,697.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,075.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,569.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,672.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.52. The transfer capital threshold is the transfer adjustment factor * $635.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6897.00","6897.00","6897.00","1 through 10","7432.79","12371.43","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","36859.46","27644.59","HUMANA [1012]","HB BWH MEDICARE","7584.48","","Case rate ($7,584.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,052.80, add-ons for qualifying new technology services are included. If operating cost exceeds $54,697.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,075.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,569.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,672.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.52. The transfer capital threshold is the transfer adjustment factor * $635.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7472.30","7472.30","7472.30","1 through 10","7432.79","12371.43","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","36859.46","27644.59","MEDICARE [2001]","HB BWH MEDICARE","7584.48","","Case rate ($7,584.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,052.80, add-ons for qualifying new technology services are included. If operating cost exceeds $54,697.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,075.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,569.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,672.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.52. The transfer capital threshold is the transfer adjustment factor * $635.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9728.46","0.03","9742.59","67","7432.79","12371.43","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","36859.46","27644.59","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","7584.48","","Case rate ($7,584.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,052.80, add-ons for qualifying new technology services are included. If operating cost exceeds $54,697.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,075.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,569.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,672.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.52. The transfer capital threshold is the transfer adjustment factor * $635.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7421.90","7421.90","7421.90","1 through 10","7432.79","12371.43","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","36859.46","27644.59","MOLINA [1014]","HB BWH MOLINA","7432.79","","Case rate ($7,584.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,052.80, add-ons for qualifying new technology services are included. If operating cost exceeds $54,697.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,075.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,569.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,672.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.52. The transfer capital threshold is the transfer adjustment factor * $635.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15040.10","15040.10","15040.10","1 through 10","7432.79","12371.43","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","36859.46","27644.59","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7432.79","","Case rate ($7,584.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,052.80, add-ons for qualifying new technology services are included. If operating cost exceeds $54,697.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,075.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,569.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,672.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.52. The transfer capital threshold is the transfer adjustment factor * $635.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7436.30","7428.51","7459.67","1 through 10","7432.79","12371.43","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","36859.46","27644.59","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7432.79","","Case rate ($7,584.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,052.80, add-ons for qualifying new technology services are included. If operating cost exceeds $54,697.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,075.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,569.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,672.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.52. The transfer capital threshold is the transfer adjustment factor * $635.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7483.98","7403.09","14192.34","1 through 10","7432.79","12371.43","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","79280.58","59460.43","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","14266.90","","Case rate ($13,851.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,596.90, add-ons for qualifying new technology services are included. If operating cost exceeds $62,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,628.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,283.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,217.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,188.32. The transfer capital threshold is the transfer adjustment factor * $1,188.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14034.05","14015.12","14117.15","1 through 10","13574.33","22182.2609","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","79280.58","59460.43","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","17863.56","","Case rate ($17,863.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,596.90, add-ons for qualifying new technology services are included. If operating cost exceeds $62,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,628.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $16,295.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,217.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,188.32. The transfer capital threshold is the transfer adjustment factor * $1,188.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13554.98","13554.98","13554.98","1 through 10","13574.33","22182.2609","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","79280.58","59460.43","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","13851.36","","Case rate ($13,851.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,596.90, add-ons for qualifying new technology services are included. If operating cost exceeds $62,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,628.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,283.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,217.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,188.32. The transfer capital threshold is the transfer adjustment factor * $1,188.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13347.88","13347.88","13347.88","1 through 10","13574.33","22182.2609","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","79280.58","59460.43","ELDER SERVICES [1037]","HB BWH MEDICARE","17863.56","","Case rate ($17,863.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,596.90, add-ons for qualifying new technology services are included. If operating cost exceeds $62,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,628.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $16,295.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,217.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,188.32. The transfer capital threshold is the transfer adjustment factor * $1,188.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13654.02","13654.02","13654.02","1 through 10","13574.33","22182.2609","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","79280.58","59460.43","MEDICARE [2001]","HB BWH MEDICARE","17863.56","","Case rate ($17,863.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,596.90, add-ons for qualifying new technology services are included. If operating cost exceeds $62,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,628.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $16,295.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,217.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,188.32. The transfer capital threshold is the transfer adjustment factor * $1,188.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17607.15","0.03","17633.07","38","13574.33","22182.2609","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","79280.58","59460.43","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","13574.33","","Case rate ($13,851.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,596.90, add-ons for qualifying new technology services are included. If operating cost exceeds $62,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,628.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,283.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,217.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,188.32. The transfer capital threshold is the transfer adjustment factor * $1,188.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13439.75","13439.75","13439.75","1 through 10","13574.33","22182.2609","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","79280.58","59460.43","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13574.33","","Case rate ($13,851.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,596.90, add-ons for qualifying new technology services are included. If operating cost exceeds $62,241.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,628.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,283.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,217.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,188.32. The transfer capital threshold is the transfer adjustment factor * $1,188.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13414.43","13396.95","20295.87","1 through 10","13574.33","22182.2609","other","Inpatient DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","23543.39","17657.54","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","6820.22","","Case rate ($6,820.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,353.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,998.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,877.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,002.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $5,973.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.73. The transfer capital threshold is the transfer adjustment factor * $437.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5187.33","5187.33","5187.33","1 through 10","5235.42","8521.22","other","Inpatient DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","23543.39","17657.54","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","5342.27","","Case rate ($5,342.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,353.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,998.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,877.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,524.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $5,973.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.73. The transfer capital threshold is the transfer adjustment factor * $437.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19935.78","19935.78","19935.78","1 through 10","5235.42","8521.22","other","Inpatient DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","23543.39","17657.54","MEDICARE [2001]","HB BWH MEDICARE","6820.22","","Case rate ($6,820.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,353.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,998.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,877.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,002.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $5,973.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.73. The transfer capital threshold is the transfer adjustment factor * $437.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6729.30","6729.30","6738.96","18","5235.42","8521.22","other","Inpatient DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","23543.39","17657.54","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","5235.42","","Case rate ($5,342.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,353.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,998.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,877.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,524.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $5,973.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.73. The transfer capital threshold is the transfer adjustment factor * $437.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5174.26","5174.26","5174.26","1 through 10","5235.42","8521.22","other","Inpatient DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","23543.39","17657.54","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","5235.42","","Case rate ($5,342.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,353.62, add-ons for qualifying new technology services are included. If operating cost exceeds $51,998.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,877.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,524.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $5,973.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $437.73. The transfer capital threshold is the transfer adjustment factor * $437.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5162.46","5162.46","5211.57","1 through 10","5235.42","8521.22","other","Inpatient DRG"
"Gastrointestinal Vascular Insufficiency,EXTREME","246","DRG","","","","","","","","inpatient","","","63750.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","48372.43","","Standard inlier is a Case rate ($48,372.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,264, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,866.76) for the length of stay and the standard reimbursement.","33463.23","33463.23","33463.23","1 through 10","4505.49","103628.36","case rate",""
"Gastrointestinal Vascular Insufficiency,MAJOR","246","DRG","","","","","","","","inpatient","","","34330.26","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","32523.64","","Fee schedule rate ($32,523.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32523.64","32523.64","32523.64","1 through 10","4505.49","103628.36","case rate",""
"Gastrointestinal Vascular Insufficiency,MAJOR","246","DRG","","","","","","","","inpatient","","","34330.26","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8823.63","","Case rate ($9,756.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,186.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9753.65","9753.65","9753.65","1 through 10","4505.49","103628.36","case rate",""
"Gastrointestinal Vascular Insufficiency,MINOR","246","DRG","","","","","","","","inpatient","","","30494.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21030.62","","Standard inlier is a Case rate ($21,030.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,193, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,985.12) for the length of stay and the standard reimbursement.","21030.62","21030.62","21030.62","1 through 10","4505.49","103628.36","case rate",""
"Gastrointestinal Vascular Insufficiency,MODERATE","246","DRG","","","","","","","","inpatient","","","14529.16","","MASSHEALTH [3001]","HB BWH MEDICAID","5888.90","","Case rate ($6,511.19). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,941.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6509.59","6509.59","6509.59","1 through 10","4505.49","103628.36","case rate",""
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","both","","","6550.00","4912.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","5207.25","other","OPPS APC"
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","both","","","6550.00","4912.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","5207.25","other","OPPS APC"
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","both","","","6550.00","4912.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5207.25","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","5207.25","percent of total billed charges",""
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","both","","","6550.00","4912.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","5207.25","other","OPPS APC"
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","both","","","6550.00","4912.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","5207.25","other","OPPS APC"
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","both","","","6550.00","4912.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2390.75","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","5207.25","percent of total billed charges",""
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","both","","","6550.00","4912.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2508.65","38.3","","2723.31","1555.62","2741.61","12","1057.74","5207.25","percent of total billed charges",""
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","both","","","6550.00","4912.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","5207.25","other","OPPS APC"
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","both","","","6550.00","4912.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","5207.25","other","OPPS APC"
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","both","","","6550.00","4912.50","WELLPOINT [1015]","HB AMC WELLPOINT","4832.59","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","5207.25","percent of total billed charges",""
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","outpatient","","","6550.00","4912.50","AETNA [1001]","HB AMC AETNA PPO","5266.20","80.4","","1163.76","1163.76","1163.76","1 through 10","2384.07","5403.75","percent of total billed charges",""
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","outpatient","","","6550.00","4912.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3966.03","60.55","","1781.82","1492.00","4331.00","1 through 10","2384.07","5403.75","percent of total billed charges",""
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","outpatient","","","6550.00","4912.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3420.41","52.22","","3144.00","1492.00","3610.00","13","2384.07","5403.75","percent of total billed charges",""
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","outpatient","","","6550.00","4912.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","3438.75","52.5","","1182.28","1182.28","1182.28","1 through 10","2384.07","5403.75","percent of total billed charges",""
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","outpatient","","","6550.00","4912.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3275.00","50","","3610.00","2269.44","3610.00","1 through 10","2384.07","5403.75","percent of total billed charges",""
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","outpatient","","","6550.00","4912.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3438.75","52.5","","3610.00","2382.05","4331.00","1 through 10","2384.07","5403.75","percent of total billed charges",""
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","outpatient","","","6550.00","4912.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","3602.50","55","","4810.75","3363.17","4810.75","1 through 10","2384.07","5403.75","percent of total billed charges",""
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","outpatient","","","6550.00","4912.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5352.66","81.72","","8894.69","8894.69","8894.69","1 through 10","2384.07","5403.75","percent of total billed charges",""
"Gastroplasty With Endoscopic Myotomy (Gem)","PX-75000527","CDM","43999","CPT","0750","RC","","","","outpatient","","","6550.00","4912.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5352.66","81.72","","2885.83","2132.00","3462.21","1 through 10","2384.07","5403.75","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.88","461.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","488.83","79.5","","800.18","480.96","1887.97","195","190.61","488.83","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.88","461.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","327.73","53.3","","813.12","216.42","1444.50","81","190.61","488.83","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.88","461.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","190.61","31","","432.60","432.60","432.60","1 through 10","190.61","488.83","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.88","461.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","224.43","36.5","","148.37","54.89","631.39","94","190.61","488.83","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.88","461.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","235.50","38.3","","279.30","91.72","1116.77","266","190.61","488.83","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.88","461.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","263.78","42.9","","731.00","63.70","731.00","1 through 10","190.61","488.83","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.88","461.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","263.78","42.9","","384.74","384.74","384.74","1 through 10","190.61","488.83","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.88","461.16","WELLPOINT [1015]","HB AMC WELLPOINT","453.66","73.78","","286.63","119.22","1107.45","105","190.61","488.83","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.88","461.16","AETNA [1001]","HB AMC AETNA HMO","429.19","69.8","","675.31","184.75","1721.50","286","321.34","502.48","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.88","461.16","AETNA [1001]","HB AMC AETNA PPO","494.36","80.4","","1261.44","103.12","1514.10","21","321.34","502.48","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.88","461.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","494.36","80.4","","1365.00","1365.00","1365.00","1 through 10","321.34","502.48","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.88","461.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","502.48","81.72","","5157.68","5157.68","5157.68","1 through 10","321.34","502.48","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.88","461.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","502.48","81.72","","431.26","71.26","1459.57","88","321.34","502.48","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","both","","","514.08","385.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","408.69","79.5","","1309.77","674.56","6049.93","26","159.36","408.69","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","both","","","514.08","385.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","274.00","53.3","","1901.83","1901.83","2962.25","1 through 10","159.36","408.69","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","both","","","514.08","385.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","187.64","36.5","","1620.31","1620.31","19908.88","1 through 10","159.36","408.69","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","both","","","514.08","385.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","196.89","38.3","","352.91","352.91","2046.30","1 through 10","159.36","408.69","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","both","","","514.08","385.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.54","42.9","","9668.75","9668.75","9668.75","1 through 10","159.36","408.69","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","both","","","514.08","385.56","WELLPOINT [1015]","HB AMC WELLPOINT","379.29","73.78","","699.88","384.10","3443.31","33","159.36","408.69","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","514.08","385.56","AETNA [1001]","HB AMC AETNA HMO","358.83","69.8","","1421.24","264.50","4933.46","29","268.66","420.11","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","514.08","385.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","413.32","80.4","","1022.97","1022.97","3607.50","1 through 10","268.66","420.11","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","514.08","385.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","420.11","81.72","","3010.54","693.88","5019.88","35","268.66","420.11","percent of total billed charges",""
"Gelsolin (Gsn) Gene, Full Gene Analysis","PX-31000675","CDM","81479","CPT","0310","RC","","","","both","","","2411.00","1808.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1916.75","79.5","","0.65","0.65","0.65","1 through 10","747.41","2290.45","percent of total billed charges",""
"Gelsolin (Gsn) Gene, Full Gene Analysis","PX-31000675","CDM","81479","CPT","0310","RC","","","","both","","","2411.00","1808.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1285.06","53.3","","0.79","0.79","0.79","1 through 10","747.41","2290.45","percent of total billed charges",""
"Gelsolin (Gsn) Gene, Full Gene Analysis","PX-31000675","CDM","81479","CPT","0310","RC","","","","outpatient","","","2411.00","1808.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1205.50","50","","1.00","1.00","1.00","1 through 10","156.55","1989.08","percent of total billed charges",""
"Gelsolin (Gsn) Gene, Full Gene Analysis","PX-31000675","CDM","81479","CPT","0310","RC","","","","outpatient","","","2411.00","1808.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1265.78","52.5","","1.00","0.53","1.00","1 through 10","156.55","1989.08","percent of total billed charges",""
"Genedx Ikbkg (Nemo) Comm Del","PX-31001167","CDM","81479","CPT","0310","RC","","","","both","","","1157.00","867.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","919.82","79.5","","0.65","0.65","0.65","1 through 10","358.67","1099.15","percent of total billed charges",""
"Genedx Ikbkg (Nemo) Comm Del","PX-31001167","CDM","81479","CPT","0310","RC","","","","both","","","1157.00","867.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","616.68","53.3","","0.79","0.79","0.79","1 through 10","358.67","1099.15","percent of total billed charges",""
"Genedx Ikbkg (Nemo) Comm Del","PX-31001167","CDM","81479","CPT","0310","RC","","","","outpatient","","","1157.00","867.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","578.50","50","","1.00","1.00","1.00","1 through 10","156.55","954.53","percent of total billed charges",""
"Genedx Ikbkg (Nemo) Comm Del","PX-31001167","CDM","81479","CPT","0310","RC","","","","outpatient","","","1157.00","867.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","607.43","52.5","","1.00","0.53","1.00","1 through 10","156.55","954.53","percent of total billed charges",""
"Genedx, 410 Prenatal Targeted Chromosomal Microarray Gx410","PX-31001339","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Genedx, Gx460 Prenatal Whole Genome Chromosomal Microarray","PX-31001358","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Genedx, Gx460 Prenatal Whole Genome Chromosomal Microarray","PX-31001358","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","185.96","71.8","","1115.76","371.92","1115.76","1 through 10","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","168.35","65","","317.20","317.20","336.70","1 through 10","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","181.30","70","","351.36","214.57","397.60","1 through 10","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","205.91","79.5","","384.06","257.66","384.06","266","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","138.05","53.3","","257.66","257.66","772.98","145","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","199.43","77","","375.76","375.76","375.76","1 through 10","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","168.35","65","","317.20","104.65","317.20","11","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","205.91","79.5","","244.00","244.00","244.00","1 through 10","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","80.29","31","","150.79","150.79","150.79","1 through 10","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","94.54","36.5","","182.02","154.70","220.46","167","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","99.20","38.3","","190.81","185.44","381.62","582","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","199.43","77","","384.06","330.38","424.56","1 through 10","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","TRICARE [160005]","HB BWH TRICARE","246.05","95","","72.94","72.94","76.78","25","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","111.11","42.9","","390.11","214.57","390.11","11","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","111.11","42.9","","214.57","214.57","214.57","1 through 10","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","259.00","194.25","WELLPOINT [1015]","HB AMC WELLPOINT","191.09","73.78","","363.32","363.32","851.32","178","16.94","246.05","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","259.00","194.25","AETNA [1001]","HB AMC AETNA HMO","180.78","69.8","","330.38","233.26","380.64","359","16.94","319.59","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","259.00","194.25","AETNA [1001]","HB AMC AETNA PPO","208.24","80.4","","380.64","255.71","380.64","21","16.94","319.59","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","259.00","194.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","144.78","55.9","","255.71","255.71","255.71","1 through 10","16.94","319.59","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","259.00","194.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","135.35","52.26","","135.07","135.07","301.97","1 through 10","16.94","319.59","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","259.00","194.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","208.24","80.4","","380.64","244.00","380.64","11","16.94","319.59","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","259.00","194.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","211.65","81.72","","390.12","390.11","431.26","1 through 10","16.94","319.59","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","259.00","194.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","211.65","81.72","","390.11","390.11","390.11","11","16.94","319.59","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","259.00","194.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","211.65","81.72","","390.11","214.57","390.11","277","16.94","319.59","percent of total billed charges",""
"GENERATOR LABORATORY INFINITY","SUP-ITM-10174937","CDM","C1767","HCPCS","0278","RC","","","","both","","","55000.00","41250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20075.00","36.5","","18081.90","16994.81","18081.90","1 through 10","17050","43725","percent of total billed charges",""
"GENERATOR LABORATORY INFINITY","SUP-ITM-10174937","CDM","C1767","HCPCS","0278","RC","","","","both","","","55000.00","41250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21065.00","38.3","","17814.94","17448.38","17814.94","1 through 10","17050","43725","percent of total billed charges",""
"GENERATOR LABORATORY INFINITY","SUP-ITM-10174937","CDM","C1767","HCPCS","0278","RC","","","","both","","","55000.00","41250.00","WELLPOINT [1015]","HB AMC WELLPOINT","40579.00","73.78","","33921.28","33921.28","33921.28","1 through 10","17050","43725","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR 1000W SENTIVA VNS THERAPY PORT","SUP-ITM-10274239","CDM","C1767","HCPCS","0278","RC","","","","both","","","95292.13","71469.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34781.63","36.5","","18081.90","16994.81","18081.90","1 through 10","29540.56","75757.24","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR 1000W SENTIVA VNS THERAPY PORT","SUP-ITM-10274239","CDM","C1767","HCPCS","0278","RC","","","","both","","","95292.13","71469.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","36496.89","38.3","","17814.94","17448.38","17814.94","1 through 10","29540.56","75757.24","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR 1000W SENTIVA VNS THERAPY PORT","SUP-ITM-10274239","CDM","C1767","HCPCS","0278","RC","","","","both","","","95292.13","71469.10","WELLPOINT [1015]","HB AMC WELLPOINT","70306.53","73.78","","33921.28","33921.28","33921.28","1 through 10","29540.56","75757.24","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR INTELLIS BATTERY - DISCONTINUED PER SUPPLIER","SUP-ITM-10194186","CDM","C1820","HCPCS","0278","RC","","","","both","","","40500.00","30375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","21586.50","53.3","","54287.50","54287.50","54287.50","1 through 10","12555","32197.5","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR INTELLIS BATTERY - DISCONTINUED PER SUPPLIER","SUP-ITM-10194186","CDM","C1820","HCPCS","0278","RC","","","","both","","","40500.00","30375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14782.50","36.5","","10467.31","10467.31","10467.31","1 through 10","12555","32197.5","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR INTELLIS BATTERY - DISCONTINUED PER SUPPLIER","SUP-ITM-10194186","CDM","C1820","HCPCS","0278","RC","","","","both","","","40500.00","30375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15511.50","38.3","","21505.00","21505.00","21505.00","1 through 10","12555","32197.5","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR INTELLIS BATTERY - DISCONTINUED PER SUPPLIER","SUP-ITM-10194186","CDM","C1820","HCPCS","0278","RC","","","","both","","","40500.00","30375.00","WELLPOINT [1015]","HB AMC WELLPOINT","29880.90","73.78","","40016.88","40016.88","40016.88","1 through 10","12555","32197.5","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR PRODIGY MRI IPG WITH BURRSTDR STIMULATION - DISCONTINUED PER SUPPLIER","SUP-ITM-10174963","CDM","C1767","HCPCS","0278","RC","","","","both","","","39875.00","29906.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14554.38","36.5","","18081.90","16994.81","18081.90","1 through 10","12361.25","31700.63","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR PRODIGY MRI IPG WITH BURRSTDR STIMULATION - DISCONTINUED PER SUPPLIER","SUP-ITM-10174963","CDM","C1767","HCPCS","0278","RC","","","","both","","","39875.00","29906.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15272.13","38.3","","17814.94","17448.38","17814.94","1 through 10","12361.25","31700.63","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR PRODIGY MRI IPG WITH BURRSTDR STIMULATION - DISCONTINUED PER SUPPLIER","SUP-ITM-10174963","CDM","C1767","HCPCS","0278","RC","","","","both","","","39875.00","29906.25","WELLPOINT [1015]","HB AMC WELLPOINT","29419.78","73.78","","33921.28","33921.28","33921.28","1 through 10","12361.25","31700.63","percent of total billed charges",""
"GENERATOR PULSE 25GMX7MMX14CC THERAPY VNS ASPIRESR POLYURETHANE PROGRAMMABLE SINGLE PIN LEAD 25GMX7MMX14CC","SUP-ITM-10158803","CDM","C1767","HCPCS","0278","RC","","","","both","","","84699.63","63524.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30915.36","36.5","","18081.90","16994.81","18081.90","1 through 10","26256.89","67336.21","percent of total billed charges",""
"GENERATOR PULSE 25GMX7MMX14CC THERAPY VNS ASPIRESR POLYURETHANE PROGRAMMABLE SINGLE PIN LEAD 25GMX7MMX14CC","SUP-ITM-10158803","CDM","C1767","HCPCS","0278","RC","","","","both","","","84699.63","63524.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32439.96","38.3","","17814.94","17448.38","17814.94","1 through 10","26256.89","67336.21","percent of total billed charges",""
"GENERATOR PULSE 25GMX7MMX14CC THERAPY VNS ASPIRESR POLYURETHANE PROGRAMMABLE SINGLE PIN LEAD 25GMX7MMX14CC","SUP-ITM-10158803","CDM","C1767","HCPCS","0278","RC","","","","both","","","84699.63","63524.72","WELLPOINT [1015]","HB AMC WELLPOINT","62491.39","73.78","","33921.28","33921.28","33921.28","1 through 10","26256.89","67336.21","percent of total billed charges",""
"GENERATOR PULSE IMPLANTABLE INSPIRE VAGUS NERVE STIMULATION","SUP-ITM-10209082","CDM","C1767","HCPCS","0278","RC","","","","both","","","45562.50","34171.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16630.31","36.5","","18081.90","16994.81","18081.90","1 through 10","14124.38","36222.19","percent of total billed charges",""
"GENERATOR PULSE IMPLANTABLE INSPIRE VAGUS NERVE STIMULATION","SUP-ITM-10209082","CDM","C1767","HCPCS","0278","RC","","","","both","","","45562.50","34171.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17450.44","38.3","","17814.94","17448.38","17814.94","1 through 10","14124.38","36222.19","percent of total billed charges",""
"GENERATOR PULSE IMPLANTABLE INSPIRE VAGUS NERVE STIMULATION","SUP-ITM-10209082","CDM","C1767","HCPCS","0278","RC","","","","both","","","45562.50","34171.87","WELLPOINT [1015]","HB AMC WELLPOINT","33616.01","73.78","","33921.28","33921.28","33921.28","1 through 10","14124.38","36222.19","percent of total billed charges",""
"GENERATOR PULSE IMPLANTABLE REACTIV8","SUP-ITM-10283223","CDM","C1767","HCPCS","0278","RC","","","","both","","","59064.88","44298.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21558.68","36.5","","18081.90","16994.81","18081.90","1 through 10","18310.11","46956.58","percent of total billed charges",""
"GENERATOR PULSE IMPLANTABLE REACTIV8","SUP-ITM-10283223","CDM","C1767","HCPCS","0278","RC","","","","both","","","59064.88","44298.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22621.85","38.3","","17814.94","17448.38","17814.94","1 through 10","18310.11","46956.58","percent of total billed charges",""
"GENERATOR PULSE IMPLANTABLE REACTIV8","SUP-ITM-10283223","CDM","C1767","HCPCS","0278","RC","","","","both","","","59064.88","44298.66","WELLPOINT [1015]","HB AMC WELLPOINT","43578.07","73.78","","33921.28","33921.28","33921.28","1 through 10","18310.11","46956.58","percent of total billed charges",""
"GENERATOR PULSE PRECISION SPECTRA NEUROSTIMULATOR SPINE IMPLANTABLE","SUP-ITM-10126476","CDM","C1820","HCPCS","0278","RC","","","","both","","","40750.00","30562.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","21719.75","53.3","","54287.50","54287.50","54287.50","1 through 10","12632.5","32396.25","percent of total billed charges",""
"GENERATOR PULSE PRECISION SPECTRA NEUROSTIMULATOR SPINE IMPLANTABLE","SUP-ITM-10126476","CDM","C1820","HCPCS","0278","RC","","","","both","","","40750.00","30562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14873.75","36.5","","10467.31","10467.31","10467.31","1 through 10","12632.5","32396.25","percent of total billed charges",""
"GENERATOR PULSE PRECISION SPECTRA NEUROSTIMULATOR SPINE IMPLANTABLE","SUP-ITM-10126476","CDM","C1820","HCPCS","0278","RC","","","","both","","","40750.00","30562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15607.25","38.3","","21505.00","21505.00","21505.00","1 through 10","12632.5","32396.25","percent of total billed charges",""
"GENERATOR PULSE PRECISION SPECTRA NEUROSTIMULATOR SPINE IMPLANTABLE","SUP-ITM-10126476","CDM","C1820","HCPCS","0278","RC","","","","both","","","40750.00","30562.50","WELLPOINT [1015]","HB AMC WELLPOINT","30065.35","73.78","","40016.88","40016.88","40016.88","1 through 10","12632.5","32396.25","percent of total billed charges",""
"GENERATOR SPECTRA WAVEWRITER SPINAL CORD","SUP-ITM-10232345","CDM","C1820","HCPCS","0278","RC","","","","both","","","42500.00","31875.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22652.50","53.3","","54287.50","54287.50","54287.50","1 through 10","13175","33787.5","percent of total billed charges",""
"GENERATOR SPECTRA WAVEWRITER SPINAL CORD","SUP-ITM-10232345","CDM","C1820","HCPCS","0278","RC","","","","both","","","42500.00","31875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15512.50","36.5","","10467.31","10467.31","10467.31","1 through 10","13175","33787.5","percent of total billed charges",""
"GENERATOR SPECTRA WAVEWRITER SPINAL CORD","SUP-ITM-10232345","CDM","C1820","HCPCS","0278","RC","","","","both","","","42500.00","31875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16277.50","38.3","","21505.00","21505.00","21505.00","1 through 10","13175","33787.5","percent of total billed charges",""
"GENERATOR SPECTRA WAVEWRITER SPINAL CORD","SUP-ITM-10232345","CDM","C1820","HCPCS","0278","RC","","","","both","","","42500.00","31875.00","WELLPOINT [1015]","HB AMC WELLPOINT","31356.50","73.78","","40016.88","40016.88","40016.88","1 through 10","13175","33787.5","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","2924.72","2924.72","2924.72","1 through 10","97.65","299.25","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","2334.12","2334.12","2334.12","1 through 10","97.65","299.25","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","114.03","114.03","114.03","1 through 10","97.65","299.25","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","119.70","119.70","359.10","34","97.65","299.25","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","138.51","138.51","138.51","1 through 10","97.65","299.25","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","301.14","150.57","426.51","1 through 10","40.19","259.88","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","outpatient","","","315.00","236.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","157.50","50","","104.48","104.48","104.48","1 through 10","40.19","259.88","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","outpatient","","","315.00","236.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","165.38","52.5","","176.16","176.16","176.16","1 through 10","40.19","259.88","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","outpatient","","","315.00","236.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","173.25","55","","184.40","184.40","184.40","1 through 10","40.19","259.88","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","245.70","245.70","245.70","1 through 10","40.19","259.88","percent of total billed charges",""
"Genetic Counseling 30 Min","PX-51000065","CDM","96040","CPT","0510","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","251.81","251.81","251.81","1 through 10","40.19","259.88","percent of total billed charges",""
"Genetic Diagnostics Lab, Somatic Overgrowth Ngs Panel","PX-31001217","CDM","81479","CPT","0310","RC","","","","both","","","6564.00","4923.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5218.38","79.5","","0.65","0.65","0.65","1 through 10","2034.84","6235.8","percent of total billed charges",""
"Genetic Diagnostics Lab, Somatic Overgrowth Ngs Panel","PX-31001217","CDM","81479","CPT","0310","RC","","","","both","","","6564.00","4923.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3498.61","53.3","","0.79","0.79","0.79","1 through 10","2034.84","6235.8","percent of total billed charges",""
"Genetic Diagnostics Lab, Somatic Overgrowth Ngs Panel","PX-31001217","CDM","81479","CPT","0310","RC","","","","outpatient","","","6564.00","4923.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3282.00","50","","1.00","1.00","1.00","1 through 10","156.55","5415.3","percent of total billed charges",""
"Genetic Diagnostics Lab, Somatic Overgrowth Ngs Panel","PX-31001217","CDM","81479","CPT","0310","RC","","","","outpatient","","","6564.00","4923.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3446.10","52.5","","1.00","0.53","1.00","1 through 10","156.55","5415.3","percent of total billed charges",""
"Genomic Seq Analys Dna&Rna Analys 5-50 Gene","PX-30002913","CDM","81450","CPT","0301","RC","","","","both","","","5577.00","4182.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3658.51","65.6","","781.56","781.56","781.56","1 through 10","744.34","5298.15","percent of total billed charges",""
"Genomic Seq Analys Dna&Rna Analys 5-50 Gene","PX-30002913","CDM","81450","CPT","0301","RC","","","","both","","","5577.00","4182.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3903.90","70","","3893.76","721.55","3893.76","1 through 10","744.34","5298.15","percent of total billed charges",""
"Genomic Seq Analys Dna&Rna Analys 5-50 Gene","PX-30002913","CDM","81450","CPT","0301","RC","","","","both","","","5577.00","4182.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4433.72","79.5","","4256.10","4256.10","4256.10","1 through 10","744.34","5298.15","percent of total billed charges",""
"Genomic Seq Analys Dna&Rna Analys 5-50 Gene","PX-30002913","CDM","81450","CPT","0301","RC","","","","both","","","5577.00","4182.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2972.54","53.3","","2855.42","2855.42","2855.42","1 through 10","744.34","5298.15","percent of total billed charges",""
"Genomic Seq Analys Dna&Rna Analys 5-50 Gene","PX-30002913","CDM","81450","CPT","0301","RC","","","","outpatient","","","5577.00","4182.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4557.52","81.72","","4323.16","4323.15","4603.66","1 through 10","1966","4655.92","percent of total billed charges",""
"Genotype Hiv 1 Oth Region","PX-30001366","CDM","87906","CPT","0306","RC","","","","both","","","772.00","579.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","295.68","38.3","","292.86","292.86","292.86","1 through 10","42.43","733.4","percent of total billed charges",""
"Genotype Hiv 1 Oth Region","PX-30001366","CDM","87906","CPT","0306","RC","","","","outpatient","","","772.00","579.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","630.88","81.72","","329.34","329.34","329.34","1 through 10","42.43","876.77","percent of total billed charges",""
"Gentamicin Vl 40mg/Ml 2ml","PX-63600119","CDM","J1580","HCPCS","0636","RC","","","","both","","","3.33","2.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1.22","36.5","","9.55","2.13","9.55","16","1.03","7.17","percent of total billed charges",""
"Gentamicin Vl 40mg/Ml 2ml","PX-63600119","CDM","J1580","HCPCS","0636","RC","","","","both","","","3.33","2.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1.28","38.3","","3.68","2.59","23.01","53","1.03","7.17","percent of total billed charges",""
"Gentamicin Vl 40mg/Ml 2ml","PX-63600119","CDM","J1580","HCPCS","0636","RC","","","","outpatient","","","3.33","2.50","AETNA [1001]","HB AMC AETNA HMO","2.32","69.8","","10.50","3.19","16.27","35","1.56","5.63","percent of total billed charges",""
"Gentamicin Vl 40mg/Ml 2ml","PX-63600119","CDM","J1580","HCPCS","0636","RC","","","","outpatient","","","3.33","2.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2.33","69.9","","6.71","3.07","10.05","17","1.56","5.63","percent of total billed charges",""
"Gentamicin Vl 40mg/Ml 2ml","PX-63600119","CDM","J1580","HCPCS","0636","RC","","","","outpatient","","","3.33","2.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1.56","46.9","","14.58","3.06","14.58","12","1.56","5.63","percent of total billed charges",""
"Gentamicin Vl 40mg/Ml 2ml","PX-63600119","CDM","J1580","HCPCS","0636","RC","","","","outpatient","","","3.33","2.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2.33","69.9","","10.48","10.48","10.48","1 through 10","1.56","5.63","percent of total billed charges",""
"Gft Skin Sub F/S </=100cm Ea Addl","PX-76000181","CDM","15276","CPT","0761","RC","","","","outpatient","","","184.00","138.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","150.36","81.72","","7000.00","7000.00","7000.00","1 through 10","150.36","150.36","percent of total billed charges",""
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","both","","","4774.00","3580.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3795.33","79.5","","7878.66","7878.66","7878.66","1 through 10","1479.94","3795.33","percent of total billed charges",""
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","both","","","4774.00","3580.50","HUMANA [1012]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2141.91","2141.91","2141.91","1 through 10","1479.94","3795.33","other","OPPS APC"
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","both","","","4774.00","3580.50","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","1086.16","2172.32","1 through 10","1479.94","3795.33","other","OPPS APC"
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","both","","","4774.00","3580.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1828.44","38.3","","5504.30","1810.33","5504.30","1 through 10","1479.94","3795.33","percent of total billed charges",""
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","both","","","4774.00","3580.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2128.87","2128.87","2128.87","1 through 10","1479.94","3795.33","other","OPPS APC"
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","AETNA [1001]","HB AMC AETNA HMO","3332.25","69.8","","12526.02","12526.02","12526.02","1 through 10","1548.96","3901.31","percent of total billed charges",""
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3558.58","1779.29","3624.12","1 through 10","1548.96","3901.31","other","ASC"
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","4321.60","4321.60","4321.60","1 through 10","1548.96","3901.31","other","Multiple Surgery"
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3901.31","81.72","","7000.00","1577.42","7000.00","1 through 10","1548.96","3901.31","percent of total billed charges",""
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","both","","","4774.00","3580.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2237.26","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2235.32","2048.06","2235.62","1 through 10","1479.94","3795.33","other","OPPS APC"
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","both","","","4774.00","3580.50","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","1990.34","2172.32","21","1479.94","3795.33","other","OPPS APC"
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","both","","","4774.00","3580.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2136.38","2136.38","2136.38","1 through 10","1479.94","3795.33","other","OPPS APC"
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","AETNA [1001]","HB AMC AETNA HMO","3332.25","69.8","","11001.75","11001.75","11001.75","1 through 10","1548.96","3901.31","percent of total billed charges",""
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3558.58","3558.58","3558.58","1 through 10","1548.96","3901.31","other","ASC"
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3593.59","1796.80","3593.59","1 through 10","1548.96","3901.31","other","Multiple Surgery"
"Gft Skin Sub T/a/L >/=100cm","PX-76000178","CDM","15273","CPT","0761","RC","","","","both","","","7871.00","5903.25","MEDICARE [2001]","HB BWH MEDICARE","4347.18","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4347.62","3915.62","4347.62","1 through 10","2440.01","6257.45","other","OPPS APC"
"Gft Skin Sub T/a/L >/=100cm","PX-76000178","CDM","15273","CPT","0761","RC","","","","both","","","7871.00","5903.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4260.24","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4268.17","4268.17","4268.17","1 through 10","2440.01","6257.45","other","OPPS APC"
"Ggc Gene Deletion Duplication by Custom Array Gdggc","PX-31001278","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2946.27","79.5","","2828.48","1814.97","2828.48","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Ggc Gene Deletion Duplication by Custom Array Gdggc","PX-31001278","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1975.30","53.3","","1814.97","1761.95","1814.97","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Ggc Gene Deletion Duplication by Custom Array Gdggc","PX-31001278","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1352.69","36.5","","1340.56","1340.56","1340.56","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Ggc Gene Deletion Duplication by Custom Array Gdggc","PX-31001278","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1419.40","38.3","","1405.25","1405.25","1405.25","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Ggc Gene Deletion Duplication by Custom Array Gdggc","PX-31001278","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","WELLPOINT [1015]","HB AMC WELLPOINT","2734.29","73.78","","6269.73","2675.73","7188.00","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Ggc Gene Deletion Duplication by Custom Array Gdggc","PX-31001278","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","AETNA [1001]","HB AMC AETNA HMO","2586.79","69.8","","2433.14","2433.14","2433.14","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Ggc Gene Deletion Duplication by Custom Array Gdggc","PX-31001278","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2979.62","80.4","","2803.32","2803.32","2803.32","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Ggc Gene Deletion Duplication by Custom Array Gdggc","PX-31001278","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3028.54","81.72","","2873.04","1533.07","3526.61","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","91.00","68.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","63.70","70","","38.69","38.69","38.69","1 through 10","7.06","86.45","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","91.00","68.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","72.35","79.5","","69.26","46.46","69.26","31","7.06","86.45","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","91.00","68.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.50","53.3","","69.26","46.46","139.38","17","7.06","86.45","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","28.21","31","","27.19","27.19","27.19","1 through 10","7.06","86.45","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.22","36.5","","27.90","27.63","98.46","26","7.06","86.45","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.85","38.3","","34.41","33.44","103.23","69","7.06","86.45","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","91.00","68.25","TRICARE [160005]","HB BWH TRICARE","86.45","95","","96.25","8.68","96.25","1 through 10","7.06","86.45","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.04","42.9","","70.35","70.35","70.35","1 through 10","7.06","86.45","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA HMO","63.52","69.8","","59.58","42.06","68.64","35","7.42","74.37","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA PPO","73.16","80.4","","68.64","68.64","68.64","1 through 10","7.42","74.37","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","outpatient","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","74.37","81.72","","70.35","38.69","70.35","26","7.42","74.37","percent of total billed charges",""
"Glanzmann Thrombasthenia Panel Versiti 4870","PX-31001267","CDM","81479","CPT","0310","RC","","","","both","","","2623.00","1967.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2085.29","79.5","","0.65","0.65","0.65","1 through 10","813.13","2491.85","percent of total billed charges",""
"Glanzmann Thrombasthenia Panel Versiti 4870","PX-31001267","CDM","81479","CPT","0310","RC","","","","both","","","2623.00","1967.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1398.06","53.3","","0.79","0.79","0.79","1 through 10","813.13","2491.85","percent of total billed charges",""
"Glanzmann Thrombasthenia Panel Versiti 4870","PX-31001267","CDM","81479","CPT","0310","RC","","","","outpatient","","","2623.00","1967.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1311.50","50","","1.00","1.00","1.00","1 through 10","156.55","2163.98","percent of total billed charges",""
"Glanzmann Thrombasthenia Panel Versiti 4870","PX-31001267","CDM","81479","CPT","0310","RC","","","","outpatient","","","2623.00","1967.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1377.08","52.5","","1.00","0.53","1.00","1 through 10","156.55","2163.98","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2157.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1280.02","3282.64","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3282.64","79.5","","1293.60","1148.53","1603.80","1 through 10","1280.02","3282.64","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1507.13","36.5","","1023.42","771.29","2068.67","33","1280.02","3282.64","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1581.45","38.3","","850.52","759.78","1211.25","66","1280.02","3282.64","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1771.39","42.9","","2548.09","2548.09","2548.09","1 through 10","1280.02","3282.64","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1771.39","42.9","","956.46","956.46","956.46","1 through 10","1280.02","3282.64","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","WELLPOINT [1015]","HB AMC WELLPOINT","3046.46","73.78","","2344.73","1619.47","2530.35","16","1280.02","3282.64","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4129.11","3096.83","AETNA [1001]","HB AMC AETNA HMO","2882.12","69.8","","1523.63","988.41","4330.26","39","2157.87","3374.31","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4129.11","3096.83","AETNA [1001]","HB AMC AETNA PPO","3319.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2157.87","3374.31","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4129.11","3096.83","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2157.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2157.87","3374.31","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4129.11","3096.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3374.31","81.72","","1738.90","1484.65","2716.94","38","2157.87","3374.31","percent of total billed charges",""
"GLENOID STEM MED SOCKET REGULAR CEMENTED KEELED SHOULDER 02","SUP-ITM-10012042","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9.15","52.26","","1113.10","1113.10","1113.10","1 through 10","5.43","13.91","percent of total billed charges",""
"GLENOID STEM MED SOCKET REGULAR CEMENTED KEELED SHOULDER 02","SUP-ITM-10012042","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13.91","79.5","","1293.60","1148.53","1603.80","1 through 10","5.43","13.91","percent of total billed charges",""
"GLENOID STEM MED SOCKET REGULAR CEMENTED KEELED SHOULDER 02","SUP-ITM-10012042","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6.39","36.5","","1023.42","771.29","2068.67","33","5.43","13.91","percent of total billed charges",""
"GLENOID STEM MED SOCKET REGULAR CEMENTED KEELED SHOULDER 02","SUP-ITM-10012042","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6.70","38.3","","850.52","759.78","1211.25","66","5.43","13.91","percent of total billed charges",""
"GLENOID STEM MED SOCKET REGULAR CEMENTED KEELED SHOULDER 02","SUP-ITM-10012042","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7.51","42.9","","2548.09","2548.09","2548.09","1 through 10","5.43","13.91","percent of total billed charges",""
"GLENOID STEM MED SOCKET REGULAR CEMENTED KEELED SHOULDER 02","SUP-ITM-10012042","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7.51","42.9","","956.46","956.46","956.46","1 through 10","5.43","13.91","percent of total billed charges",""
"GLENOID STEM MED SOCKET REGULAR CEMENTED KEELED SHOULDER 02","SUP-ITM-10012042","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","WELLPOINT [1015]","HB AMC WELLPOINT","12.91","73.78","","2344.73","1619.47","2530.35","16","5.43","13.91","percent of total billed charges",""
"GLENOID STEM MED SOCKET REGULAR CEMENTED KEELED SHOULDER 02","SUP-ITM-10012042","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17.50","13.12","AETNA [1001]","HB AMC AETNA HMO","12.22","69.8","","1523.63","988.41","4330.26","39","9.15","14.3","percent of total billed charges",""
"GLENOID STEM MED SOCKET REGULAR CEMENTED KEELED SHOULDER 02","SUP-ITM-10012042","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17.50","13.12","AETNA [1001]","HB AMC AETNA PPO","14.07","80.4","","1670.25","1670.25","1670.25","1 through 10","9.15","14.3","percent of total billed charges",""
"GLENOID STEM MED SOCKET REGULAR CEMENTED KEELED SHOULDER 02","SUP-ITM-10012042","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17.50","13.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9.15","52.26","","1113.10","1113.10","1113.10","1 through 10","9.15","14.3","percent of total billed charges",""
"GLENOID STEM MED SOCKET REGULAR CEMENTED KEELED SHOULDER 02","SUP-ITM-10012042","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17.50","13.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14.30","81.72","","1738.90","1484.65","2716.94","38","9.15","14.3","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2320.03","52.26","","1113.10","1113.10","1113.10","1 through 10","1376.21","3529.32","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3529.32","79.5","","1293.60","1148.53","1603.80","1 through 10","1376.21","3529.32","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1620.38","36.5","","1023.42","771.29","2068.67","33","1376.21","3529.32","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1700.29","38.3","","850.52","759.78","1211.25","66","1376.21","3529.32","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1904.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1376.21","3529.32","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1904.50","42.9","","956.46","956.46","956.46","1 through 10","1376.21","3529.32","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","WELLPOINT [1015]","HB AMC WELLPOINT","3275.39","73.78","","2344.73","1619.47","2530.35","16","1376.21","3529.32","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4439.40","3329.55","AETNA [1001]","HB AMC AETNA HMO","3098.70","69.8","","1523.63","988.41","4330.26","39","2320.03","3627.88","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4439.40","3329.55","AETNA [1001]","HB AMC AETNA PPO","3569.28","80.4","","1670.25","1670.25","1670.25","1 through 10","2320.03","3627.88","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4439.40","3329.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2320.03","52.26","","1113.10","1113.10","1113.10","1 through 10","2320.03","3627.88","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4439.40","3329.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3627.88","81.72","","1738.90","1484.65","2716.94","38","2320.03","3627.88","percent of total billed charges",""
"Gli3 Seq & Del/Dup","PX-31001176","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Gli3 Seq & Del/Dup","PX-31001176","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Gli3 Seq & Del/Dup","PX-31001176","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Gli3 Seq & Del/Dup","PX-31001176","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","both","","","137.00","102.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","108.92","79.5","","210.68","104.67","210.68","12","11.81","130.15","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","both","","","137.00","102.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","73.02","53.3","","70.23","70.23","70.23","1 through 10","11.81","130.15","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","both","","","137.00","102.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.01","36.5","","49.61","41.76","49.61","1 through 10","11.81","130.15","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","both","","","137.00","102.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.47","38.3","","52.01","50.54","52.01","35","11.81","130.15","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","both","","","137.00","102.75","WELLPOINT [1015]","HB AMC WELLPOINT","101.08","73.78","","99.02","99.02","99.02","1 through 10","11.81","130.15","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","137.00","102.75","AETNA [1001]","HB AMC AETNA HMO","95.63","69.8","","63.58","63.58","90.04","11","20.75","113.03","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","137.00","102.75","AETNA [1001]","HB AMC AETNA PPO","110.15","80.4","","103.74","69.69","103.74","1 through 10","20.75","113.03","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","137.00","102.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","71.93","52.5","","87.12","87.12","87.12","1 through 10","20.75","113.03","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","137.00","102.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","68.50","50","","131.27","69.69","131.27","18","20.75","113.03","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","137.00","102.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","71.93","52.5","","146.30","146.30","146.30","1 through 10","20.75","113.03","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","137.00","102.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","75.35","55","","76.61","76.61","76.61","1 through 10","20.75","113.03","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","137.00","102.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","111.96","81.72","","212.64","58.48","212.64","1 through 10","20.75","113.03","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","both","","","152.68","114.51","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","79.79","52.26","","25.34","25.34","25.34","1 through 10","47.33","121.38","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","both","","","152.68","114.51","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","109.62","71.8","","105.81","105.81","366.90","1 through 10","47.33","121.38","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","both","","","152.68","114.51","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","106.88","70","","512.90","74.70","612.85","1 through 10","47.33","121.38","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","both","","","152.68","114.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.38","79.5","","200.27","182.80","200.27","1 through 10","47.33","121.38","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","both","","","152.68","114.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.38","53.3","","37.73","37.73","169.33","1 through 10","47.33","121.38","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","both","","","152.68","114.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","99.24","65","","100.27","8.48","494.52","1 through 10","47.33","121.38","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","both","","","152.68","114.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","99.24","65","","160.19","160.19","160.19","1 through 10","47.33","121.38","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","both","","","152.68","114.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","47.33","31","","28.12","28.12","28.12","1 through 10","47.33","121.38","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","both","","","152.68","114.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.73","36.5","","101.66","28.85","502.70","121","47.33","121.38","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","both","","","152.68","114.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.48","38.3","","61.58","25.32","328.44","138","47.33","121.38","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","both","","","152.68","114.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.50","42.9","","71.66","71.66","71.66","1 through 10","47.33","121.38","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","both","","","152.68","114.51","WELLPOINT [1015]","HB AMC WELLPOINT","112.65","73.78","","74.75","27.97","425.28","93","47.33","121.38","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","152.68","114.51","AETNA [1001]","HB AMC AETNA HMO","106.57","69.8","","52.67","14.36","414.90","1 through 10","79.79","124.77","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","152.68","114.51","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","79.79","52.26","","25.34","25.34","25.34","1 through 10","79.79","124.77","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","152.68","114.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","122.75","80.4","","478.02","107.84","478.02","1 through 10","79.79","124.77","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","152.68","114.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","124.77","81.72","","32.74","12.33","122.05","1 through 10","79.79","124.77","percent of total billed charges",""
"GLIDEWIRE ZIPWIRE 3CM 180CM .035IN STIFF ANGLED BX/5EA","SUP-ITM-10198229","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","152.68","114.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","124.77","81.72","","144.95","32.78","676.91","104","79.79","124.77","percent of total billed charges",""
"Glucagon","PX-30000460","CDM","82943","CPT","0301","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.07","38.3","","74.29","74.29","74.29","1 through 10","14","186.2","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","70.00","52.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","45.92","65.6","","53.04","53.04","53.04","1 through 10","3.85","66.5","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","70.00","52.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","49.00","70","","68.00","4.09","68.00","1 through 10","3.85","66.5","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","70.00","52.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","55.65","79.5","","53.52","35.90","117.86","63","3.85","66.5","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","70.00","52.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37.31","53.3","","35.90","35.90","53.52","30","3.85","66.5","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","70.00","52.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","55.65","79.5","","45.58","45.58","45.58","1 through 10","3.85","66.5","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","21.70","31","","21.01","21.01","21.01","1 through 10","3.85","66.5","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25.55","36.5","","25.36","21.56","25.36","30","3.85","66.5","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26.81","38.3","","26.59","25.84","26.59","131","3.85","66.5","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","70.00","52.50","TRICARE [160005]","HB BWH TRICARE","66.50","95","","4.74","4.50","4.74","1 through 10","3.85","66.5","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.03","42.9","","54.36","29.90","122.36","1 through 10","3.85","66.5","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA HMO","48.86","69.8","","46.04","32.50","53.04","38","4.05","57.2","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA PPO","56.28","80.4","","35.63","35.63","53.04","1 through 10","4.05","57.2","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","70.00","52.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","36.58","52.26","","12.87","12.87","12.87","1 through 10","4.05","57.2","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","70.00","52.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","56.28","80.4","","53.04","53.04","53.04","1 through 10","4.05","57.2","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","70.00","52.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","57.20","81.72","","715.36","715.36","715.36","1 through 10","4.05","57.2","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","57.20","81.72","","29.90","29.90","29.90","1 through 10","4.05","57.2","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","57.20","81.72","","54.36","29.90","54.36","39","4.05","57.2","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0300","RC","","","","inpatient","","","38.00","28.50","AETNA [1001]","HB AMC AETNA HMO","26.26","69.1","","17.69","17.69","17.69","1 through 10","21.01","30.21","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","27.28","71.8","","26.57","26.57","37.00","1 through 10","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","24.93","65.6","","28.86","17.69","28.86","1 through 10","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","24.70","65","","24.05","24.05","24.05","1 through 10","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","26.60","70","","37.00","24.42","37.00","14","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","30.21","79.5","","29.12","19.54","29.12","83","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","20.25","53.3","","19.54","19.54","29.12","34","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","29.26","77","","28.49","28.49","28.49","1 through 10","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","24.70","65","","24.05","24.05","180.20","1 through 10","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","11.78","31","","11.43","11.43","11.43","1 through 10","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13.87","36.5","","13.80","11.73","26.14","96","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.55","38.3","","14.47","14.06","28.12","286","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","MOLINA [1014]","HB BWH MOLINA","13.30","35","","6.51","6.51","6.51","1 through 10","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","29.26","77","","4.43","4.43","4.43","1 through 10","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16.30","42.9","","29.58","16.27","29.58","1 through 10","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","38.00","28.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16.30","42.9","","16.27","16.27","16.27","1 through 10","2.42","36.1","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","38.00","28.50","AETNA [1001]","HB AMC AETNA HMO","26.52","69.8","","25.05","17.69","28.86","123","2.42","31.05","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","38.00","28.50","AETNA [1001]","HB AMC AETNA PPO","30.55","80.4","","28.86","17.69","28.86","1 through 10","2.42","31.05","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","38.00","28.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","19.86","52.26","","9.29","9.29","9.29","1 through 10","2.42","31.05","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","30.55","80.4","","28.86","18.50","29.60","1 through 10","2.42","31.05","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","31.05","81.72","","29.58","29.58","29.76","1 through 10","2.42","31.05","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","38.00","28.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","31.05","81.72","","29.58","16.27","59.16","1 through 10","2.42","31.05","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","38.00","28.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","31.05","81.72","","29.58","16.27","29.58","118","2.42","31.05","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","both","","","70.00","52.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","55.65","79.5","","160.56","35.90","160.56","1 through 10","3.85","66.5","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","both","","","70.00","52.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37.31","53.3","","35.90","35.90","53.52","1 through 10","3.85","66.5","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25.55","36.5","","25.36","21.56","25.36","1 through 10","3.85","66.5","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26.81","38.3","","26.59","26.59","26.59","1 through 10","3.85","66.5","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA HMO","48.86","69.8","","53.04","32.50","92.08","1 through 10","4.05","57.2","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA PPO","56.28","80.4","","35.63","35.63","35.63","1 through 10","4.05","57.2","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","57.20","81.72","","54.36","29.90","54.36","1 through 10","4.05","57.2","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","both","","","62.00","46.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","49.29","79.5","","47.22","31.68","47.22","127","4.66","58.9","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","both","","","62.00","46.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33.05","53.3","","47.22","31.68","47.22","54","4.66","58.9","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","both","","","62.00","46.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","49.29","79.5","","47.22","47.22","47.22","1 through 10","4.66","58.9","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","both","","","62.00","46.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","19.22","31","","18.54","18.54","18.54","1 through 10","4.66","58.9","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","both","","","62.00","46.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22.63","36.5","","22.38","19.02","22.38","82","4.66","58.9","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","both","","","62.00","46.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23.75","38.3","","23.46","22.80","70.38","407","4.66","58.9","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","both","","","62.00","46.50","TRICARE [160005]","HB BWH TRICARE","58.90","95","","5.43","5.43","5.72","20","4.66","58.9","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","both","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.60","42.9","","107.96","47.96","107.96","1 through 10","4.66","58.9","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","62.00","46.50","AETNA [1001]","HB AMC AETNA HMO","43.28","69.8","","40.62","28.68","46.80","234","4.89","50.67","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","62.00","46.50","AETNA [1001]","HB AMC AETNA PPO","49.85","80.4","","46.80","31.44","46.80","24","4.89","50.67","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","62.00","46.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","32.40","52.26","","16.51","16.51","37.13","1 through 10","4.89","50.67","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","50.67","81.72","","47.96","26.38","47.96","141","4.89","50.67","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","both","","","151.00","113.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","120.05","79.5","","114.90","77.09","114.90","1 through 10","12.61","143.45","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","both","","","151.00","113.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","80.48","53.3","","77.09","77.09","77.09","1 through 10","12.61","143.45","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","both","","","151.00","113.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","46.81","31","","45.11","45.11","45.11","1 through 10","12.61","143.45","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","both","","","151.00","113.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.12","36.5","","52.85","46.28","54.46","1 through 10","12.61","143.45","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","both","","","151.00","113.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.83","38.3","","57.09","55.48","57.09","1 through 10","12.61","143.45","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","both","","","151.00","113.25","TRICARE [160005]","HB BWH TRICARE","143.45","95","","15.51","15.51","15.51","1 through 10","12.61","143.45","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","outpatient","","","151.00","113.25","AETNA [1001]","HB AMC AETNA HMO","105.40","69.8","","98.84","69.79","98.84","23","13.27","123.4","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","123.40","81.72","","116.71","64.20","116.71","1 through 10","13.27","123.4","percent of total billed charges",""
"Glucuronosyl Transferase 1a1 (Ugt1a1), Full Gene Sequencing","PX-31000940","CDM","81479","CPT","0310","RC","","","","both","","","1579.00","1184.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1255.31","79.5","","0.65","0.65","0.65","1 through 10","489.49","1500.05","percent of total billed charges",""
"Glucuronosyl Transferase 1a1 (Ugt1a1), Full Gene Sequencing","PX-31000940","CDM","81479","CPT","0310","RC","","","","both","","","1579.00","1184.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","841.61","53.3","","0.79","0.79","0.79","1 through 10","489.49","1500.05","percent of total billed charges",""
"Glucuronosyl Transferase 1a1 (Ugt1a1), Full Gene Sequencing","PX-31000940","CDM","81479","CPT","0310","RC","","","","outpatient","","","1579.00","1184.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","789.50","50","","1.00","1.00","1.00","1 through 10","156.55","1302.68","percent of total billed charges",""
"Glucuronosyl Transferase 1a1 (Ugt1a1), Full Gene Sequencing","PX-31000940","CDM","81479","CPT","0310","RC","","","","outpatient","","","1579.00","1184.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","828.98","52.5","","1.00","0.53","1.00","1 through 10","156.55","1302.68","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","both","","","176.00","132.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.92","79.5","","134.58","90.29","134.58","1 through 10","15.54","167.2","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","both","","","176.00","132.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.81","53.3","","134.58","86.36","134.58","1 through 10","15.54","167.2","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","both","","","176.00","132.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.56","31","","52.84","52.84","52.84","1 through 10","15.54","167.2","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","both","","","176.00","132.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.24","36.5","","63.78","63.78","63.78","1 through 10","15.54","167.2","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","both","","","176.00","132.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.41","38.3","","66.86","64.98","66.86","24","15.54","167.2","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","outpatient","","","176.00","132.00","AETNA [1001]","HB AMC AETNA HMO","122.85","69.8","","115.77","81.74","133.38","1 through 10","15.54","143.83","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","outpatient","","","176.00","132.00","AETNA [1001]","HB AMC AETNA PPO","141.50","80.4","","133.38","133.38","133.38","1 through 10","15.54","143.83","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","outpatient","","","176.00","132.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.83","81.72","","136.70","75.19","136.70","1 through 10","15.54","143.83","percent of total billed charges",""
"Glycogen Storage Disease Nextgen Sequencing (Ngs) Panel","PX-31000740","CDM","81479","CPT","0310","RC","","","","both","","","194.00","145.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","154.23","79.5","","0.65","0.65","0.65","1 through 10","60.14","184.3","percent of total billed charges",""
"Glycogen Storage Disease Nextgen Sequencing (Ngs) Panel","PX-31000740","CDM","81479","CPT","0310","RC","","","","both","","","194.00","145.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","103.40","53.3","","0.79","0.79","0.79","1 through 10","60.14","184.3","percent of total billed charges",""
"Glycogen Storage Disease Nextgen Sequencing (Ngs) Panel","PX-31000740","CDM","81479","CPT","0310","RC","","","","outpatient","","","194.00","145.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","97.00","50","","1.00","1.00","1.00","1 through 10","93.9","160.05","percent of total billed charges",""
"Glycogen Storage Disease Nextgen Sequencing (Ngs) Panel","PX-31000740","CDM","81479","CPT","0310","RC","","","","outpatient","","","194.00","145.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","101.85","52.5","","1.00","0.53","1.00","1 through 10","93.9","160.05","percent of total billed charges",""
"Golimumab Drug Level","PX-30003526","CDM","80299","CPT","0301","RC","","","","both","","","316.00","237.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","251.22","79.5","","106.25","71.28","106.25","1 through 10","14.12","300.2","percent of total billed charges",""
"Golimumab Drug Level","PX-30003526","CDM","80299","CPT","0301","RC","","","","both","","","316.00","237.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","168.43","53.3","","106.25","71.28","106.25","1 through 10","14.12","300.2","percent of total billed charges",""
"Golimumab Drug Level","PX-30003526","CDM","80299","CPT","0301","RC","","","","both","","","316.00","237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","115.34","36.5","","50.36","42.80","92.50","13","14.12","300.2","percent of total billed charges",""
"Golimumab Drug Level","PX-30003526","CDM","80299","CPT","0301","RC","","","","both","","","316.00","237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.03","38.3","","52.79","44.55","158.37","30","14.12","300.2","percent of total billed charges",""
"Golimumab Drug Level","PX-30003526","CDM","80299","CPT","0301","RC","","","","outpatient","","","316.00","237.00","AETNA [1001]","HB AMC AETNA HMO","220.57","69.8","","91.40","64.53","105.30","14","14.12","258.24","percent of total billed charges",""
"Golimumab Drug Level","PX-30003526","CDM","80299","CPT","0301","RC","","","","outpatient","","","316.00","237.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","254.06","80.4","","105.30","105.30","105.30","1 through 10","14.12","258.24","percent of total billed charges",""
"Golimumab Drug Level","PX-30003526","CDM","80299","CPT","0301","RC","","","","outpatient","","","316.00","237.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","258.24","81.72","","59.36","15.50","59.36","1 through 10","14.12","258.24","percent of total billed charges",""
"GRAFT ALLO 1 TO 1.5 MESHING 500CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166548","CDM","C1889","HCPCS","0278","RC","","","","both","","","3571.54","2678.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2839.37","79.5","","1309.77","674.56","6049.93","26","1107.18","2839.37","percent of total billed charges",""
"GRAFT ALLO 1 TO 1.5 MESHING 500CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166548","CDM","C1889","HCPCS","0278","RC","","","","both","","","3571.54","2678.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1903.63","53.3","","1901.83","1901.83","2962.25","1 through 10","1107.18","2839.37","percent of total billed charges",""
"GRAFT ALLO 1 TO 1.5 MESHING 500CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166548","CDM","C1889","HCPCS","0278","RC","","","","both","","","3571.54","2678.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1303.61","36.5","","1620.31","1620.31","19908.88","1 through 10","1107.18","2839.37","percent of total billed charges",""
"GRAFT ALLO 1 TO 1.5 MESHING 500CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166548","CDM","C1889","HCPCS","0278","RC","","","","both","","","3571.54","2678.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1367.90","38.3","","352.91","352.91","2046.30","1 through 10","1107.18","2839.37","percent of total billed charges",""
"GRAFT ALLO 1 TO 1.5 MESHING 500CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166548","CDM","C1889","HCPCS","0278","RC","","","","both","","","3571.54","2678.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1532.19","42.9","","9668.75","9668.75","9668.75","1 through 10","1107.18","2839.37","percent of total billed charges",""
"GRAFT ALLO 1 TO 1.5 MESHING 500CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166548","CDM","C1889","HCPCS","0278","RC","","","","both","","","3571.54","2678.65","WELLPOINT [1015]","HB AMC WELLPOINT","2635.08","73.78","","699.88","384.10","3443.31","33","1107.18","2839.37","percent of total billed charges",""
"GRAFT ALLO 1 TO 1.5 MESHING 500CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166548","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3571.54","2678.65","AETNA [1001]","HB AMC AETNA HMO","2492.93","69.8","","1421.24","264.50","4933.46","29","1866.49","2918.66","percent of total billed charges",""
"GRAFT ALLO 1 TO 1.5 MESHING 500CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166548","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3571.54","2678.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2871.52","80.4","","1022.97","1022.97","3607.50","1 through 10","1866.49","2918.66","percent of total billed charges",""
"GRAFT ALLO 1 TO 1.5 MESHING 500CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166548","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3571.54","2678.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2918.66","81.72","","3010.54","693.88","5019.88","35","1866.49","2918.66","percent of total billed charges",""
"GRAFT ALLO 2 TO 1 MESHING 232CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166547","CDM","C1889","HCPCS","0278","RC","","","","both","","","1418.20","1063.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1127.47","79.5","","1309.77","674.56","6049.93","26","439.64","1127.47","percent of total billed charges",""
"GRAFT ALLO 2 TO 1 MESHING 232CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166547","CDM","C1889","HCPCS","0278","RC","","","","both","","","1418.20","1063.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","755.90","53.3","","1901.83","1901.83","2962.25","1 through 10","439.64","1127.47","percent of total billed charges",""
"GRAFT ALLO 2 TO 1 MESHING 232CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166547","CDM","C1889","HCPCS","0278","RC","","","","both","","","1418.20","1063.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","517.64","36.5","","1620.31","1620.31","19908.88","1 through 10","439.64","1127.47","percent of total billed charges",""
"GRAFT ALLO 2 TO 1 MESHING 232CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166547","CDM","C1889","HCPCS","0278","RC","","","","both","","","1418.20","1063.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","543.17","38.3","","352.91","352.91","2046.30","1 through 10","439.64","1127.47","percent of total billed charges",""
"GRAFT ALLO 2 TO 1 MESHING 232CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166547","CDM","C1889","HCPCS","0278","RC","","","","both","","","1418.20","1063.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","608.41","42.9","","9668.75","9668.75","9668.75","1 through 10","439.64","1127.47","percent of total billed charges",""
"GRAFT ALLO 2 TO 1 MESHING 232CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166547","CDM","C1889","HCPCS","0278","RC","","","","both","","","1418.20","1063.65","WELLPOINT [1015]","HB AMC WELLPOINT","1046.35","73.78","","699.88","384.10","3443.31","33","439.64","1127.47","percent of total billed charges",""
"GRAFT ALLO 2 TO 1 MESHING 232CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166547","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1418.20","1063.65","AETNA [1001]","HB AMC AETNA HMO","989.90","69.8","","1421.24","264.50","4933.46","29","741.15","1158.95","percent of total billed charges",""
"GRAFT ALLO 2 TO 1 MESHING 232CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166547","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1418.20","1063.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1140.23","80.4","","1022.97","1022.97","3607.50","1 through 10","741.15","1158.95","percent of total billed charges",""
"GRAFT ALLO 2 TO 1 MESHING 232CM HUMAN TISSUE SOFT MESH CRYOPRESERVEDRESSING BURRN REPAIR FROZEN","SUP-ITM-10166547","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1418.20","1063.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1158.95","81.72","","3010.54","693.88","5019.88","35","741.15","1158.95","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","both","","","5379.40","4034.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4276.62","79.5","","1309.77","674.56","6049.93","26","1667.61","4276.62","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","both","","","5379.40","4034.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2867.22","53.3","","1901.83","1901.83","2962.25","1 through 10","1667.61","4276.62","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","both","","","5379.40","4034.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1963.48","36.5","","1620.31","1620.31","19908.88","1 through 10","1667.61","4276.62","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","both","","","5379.40","4034.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2060.31","38.3","","352.91","352.91","2046.30","1 through 10","1667.61","4276.62","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","both","","","5379.40","4034.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2307.76","42.9","","9668.75","9668.75","9668.75","1 through 10","1667.61","4276.62","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","both","","","5379.40","4034.55","WELLPOINT [1015]","HB AMC WELLPOINT","3968.92","73.78","","699.88","384.10","3443.31","33","1667.61","4276.62","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5379.40","4034.55","AETNA [1001]","HB AMC AETNA HMO","3754.82","69.8","","1421.24","264.50","4933.46","29","2811.27","4396.05","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5379.40","4034.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4325.04","80.4","","1022.97","1022.97","3607.50","1 through 10","2811.27","4396.05","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5379.40","4034.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4396.05","81.72","","3010.54","693.88","5019.88","35","2811.27","4396.05","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","9043.43","6782.57","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","6330.40","70","","134.04","134.04","134.04","1 through 10","2803.46","7189.53","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","9043.43","6782.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7189.53","79.5","","948.87","198.19","1805.30","1 through 10","2803.46","7189.53","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","9043.43","6782.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4820.15","53.3","","462.00","170.45","3253.37","1 through 10","2803.46","7189.53","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","9043.43","6782.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3300.85","36.5","","245.50","107.19","1371.45","1 through 10","2803.46","7189.53","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","9043.43","6782.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3463.63","38.3","","200.79","72.79","355.81","22","2803.46","7189.53","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","9043.43","6782.57","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","6963.44","77","","477.18","477.18","477.18","1 through 10","2803.46","7189.53","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","9043.43","6782.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3879.63","42.9","","1045.91","1045.91","1045.91","1 through 10","2803.46","7189.53","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","9043.43","6782.57","WELLPOINT [1015]","HB AMC WELLPOINT","6672.24","73.78","","1726.50","1726.50","1726.50","1 through 10","2803.46","7189.53","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9043.43","6782.57","AETNA [1001]","HB AMC AETNA HMO","6312.31","69.8","","915.80","263.76","2881.00","1 through 10","4726.1","7390.29","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9043.43","6782.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7390.29","81.72","","1531.57","410.52","8841.36","1 through 10","4726.1","7390.29","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","5300.00","3975.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4213.50","79.5","","1309.77","674.56","6049.93","26","1643","4213.5","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","5300.00","3975.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2824.90","53.3","","1901.83","1901.83","2962.25","1 through 10","1643","4213.5","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","5300.00","3975.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1934.50","36.5","","1620.31","1620.31","19908.88","1 through 10","1643","4213.5","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","5300.00","3975.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2029.90","38.3","","352.91","352.91","2046.30","1 through 10","1643","4213.5","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","5300.00","3975.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2273.70","42.9","","9668.75","9668.75","9668.75","1 through 10","1643","4213.5","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","5300.00","3975.00","WELLPOINT [1015]","HB AMC WELLPOINT","3910.34","73.78","","699.88","384.10","3443.31","33","1643","4213.5","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5300.00","3975.00","AETNA [1001]","HB AMC AETNA HMO","3699.40","69.8","","1421.24","264.50","4933.46","29","2769.78","4331.16","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5300.00","3975.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4261.20","80.4","","1022.97","1022.97","3607.50","1 through 10","2769.78","4331.16","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5300.00","3975.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4331.16","81.72","","3010.54","693.88","5019.88","35","2769.78","4331.16","percent of total billed charges",""
"GRAFT ALLO AVANCE 50X3.0 4.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100510","CDM","C1889","HCPCS","0278","RC","","","","both","","","14447.50","10835.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11485.76","79.5","","1309.77","674.56","6049.93","26","4478.73","11485.76","percent of total billed charges",""
"GRAFT ALLO AVANCE 50X3.0 4.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100510","CDM","C1889","HCPCS","0278","RC","","","","both","","","14447.50","10835.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7700.52","53.3","","1901.83","1901.83","2962.25","1 through 10","4478.73","11485.76","percent of total billed charges",""
"GRAFT ALLO AVANCE 50X3.0 4.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100510","CDM","C1889","HCPCS","0278","RC","","","","both","","","14447.50","10835.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5273.34","36.5","","1620.31","1620.31","19908.88","1 through 10","4478.73","11485.76","percent of total billed charges",""
"GRAFT ALLO AVANCE 50X3.0 4.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100510","CDM","C1889","HCPCS","0278","RC","","","","both","","","14447.50","10835.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5533.39","38.3","","352.91","352.91","2046.30","1 through 10","4478.73","11485.76","percent of total billed charges",""
"GRAFT ALLO AVANCE 50X3.0 4.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100510","CDM","C1889","HCPCS","0278","RC","","","","both","","","14447.50","10835.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6197.98","42.9","","9668.75","9668.75","9668.75","1 through 10","4478.73","11485.76","percent of total billed charges",""
"GRAFT ALLO AVANCE 50X3.0 4.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100510","CDM","C1889","HCPCS","0278","RC","","","","both","","","14447.50","10835.62","WELLPOINT [1015]","HB AMC WELLPOINT","10659.37","73.78","","699.88","384.10","3443.31","33","4478.73","11485.76","percent of total billed charges",""
"GRAFT ALLO AVANCE 50X3.0 4.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100510","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14447.50","10835.62","AETNA [1001]","HB AMC AETNA HMO","10084.36","69.8","","1421.24","264.50","4933.46","29","7550.26","11806.5","percent of total billed charges",""
"GRAFT ALLO AVANCE 50X3.0 4.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100510","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14447.50","10835.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11615.79","80.4","","1022.97","1022.97","3607.50","1 through 10","7550.26","11806.5","percent of total billed charges",""
"GRAFT ALLO AVANCE 50X3.0 4.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100510","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14447.50","10835.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11806.50","81.72","","3010.54","693.88","5019.88","35","7550.26","11806.5","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","both","","","12500.00","9375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9937.50","79.5","","1309.77","674.56","6049.93","26","3875","9937.5","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","both","","","12500.00","9375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6662.50","53.3","","1901.83","1901.83","2962.25","1 through 10","3875","9937.5","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","both","","","12500.00","9375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4562.50","36.5","","1620.31","1620.31","19908.88","1 through 10","3875","9937.5","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","both","","","12500.00","9375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4787.50","38.3","","352.91","352.91","2046.30","1 through 10","3875","9937.5","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","both","","","12500.00","9375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5362.50","42.9","","9668.75","9668.75","9668.75","1 through 10","3875","9937.5","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","both","","","12500.00","9375.00","WELLPOINT [1015]","HB AMC WELLPOINT","9222.50","73.78","","699.88","384.10","3443.31","33","3875","9937.5","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12500.00","9375.00","AETNA [1001]","HB AMC AETNA HMO","8725.00","69.8","","1421.24","264.50","4933.46","29","6532.5","10215","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12500.00","9375.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10050.00","80.4","","1022.97","1022.97","3607.50","1 through 10","6532.5","10215","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12500.00","9375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10215.00","81.72","","3010.54","693.88","5019.88","35","6532.5","10215","percent of total billed charges",""
"GRAFT ALLO ELBOW OSTEOARTICULAR FROZEN RIGHT","SUP-ITM-10079402","CDM","C1889","HCPCS","0278","RC","","","","both","","","26934.88","20201.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21413.23","79.5","","1309.77","674.56","6049.93","26","8349.81","21413.23","percent of total billed charges",""
"GRAFT ALLO ELBOW OSTEOARTICULAR FROZEN RIGHT","SUP-ITM-10079402","CDM","C1889","HCPCS","0278","RC","","","","both","","","26934.88","20201.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14356.29","53.3","","1901.83","1901.83","2962.25","1 through 10","8349.81","21413.23","percent of total billed charges",""
"GRAFT ALLO ELBOW OSTEOARTICULAR FROZEN RIGHT","SUP-ITM-10079402","CDM","C1889","HCPCS","0278","RC","","","","both","","","26934.88","20201.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9831.23","36.5","","1620.31","1620.31","19908.88","1 through 10","8349.81","21413.23","percent of total billed charges",""
"GRAFT ALLO ELBOW OSTEOARTICULAR FROZEN RIGHT","SUP-ITM-10079402","CDM","C1889","HCPCS","0278","RC","","","","both","","","26934.88","20201.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10316.06","38.3","","352.91","352.91","2046.30","1 through 10","8349.81","21413.23","percent of total billed charges",""
"GRAFT ALLO ELBOW OSTEOARTICULAR FROZEN RIGHT","SUP-ITM-10079402","CDM","C1889","HCPCS","0278","RC","","","","both","","","26934.88","20201.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11555.06","42.9","","9668.75","9668.75","9668.75","1 through 10","8349.81","21413.23","percent of total billed charges",""
"GRAFT ALLO ELBOW OSTEOARTICULAR FROZEN RIGHT","SUP-ITM-10079402","CDM","C1889","HCPCS","0278","RC","","","","both","","","26934.88","20201.16","WELLPOINT [1015]","HB AMC WELLPOINT","19872.55","73.78","","699.88","384.10","3443.31","33","8349.81","21413.23","percent of total billed charges",""
"GRAFT ALLO ELBOW OSTEOARTICULAR FROZEN RIGHT","SUP-ITM-10079402","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","26934.88","20201.16","AETNA [1001]","HB AMC AETNA HMO","18800.55","69.8","","1421.24","264.50","4933.46","29","14076.17","22011.18","percent of total billed charges",""
"GRAFT ALLO ELBOW OSTEOARTICULAR FROZEN RIGHT","SUP-ITM-10079402","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","26934.88","20201.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","21655.64","80.4","","1022.97","1022.97","3607.50","1 through 10","14076.17","22011.18","percent of total billed charges",""
"GRAFT ALLO ELBOW OSTEOARTICULAR FROZEN RIGHT","SUP-ITM-10079402","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","26934.88","20201.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22011.18","81.72","","3010.54","693.88","5019.88","35","14076.17","22011.18","percent of total billed charges",""
"GRAFT ALLO FEMUR DISTAL RT FROZEN","SUP-ITM-10010781","CDM","C1889","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","14865.67","79.5","","1309.77","674.56","6049.93","26","5796.67","14865.67","percent of total billed charges",""
"GRAFT ALLO FEMUR DISTAL RT FROZEN","SUP-ITM-10010781","CDM","C1889","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9966.54","53.3","","1901.83","1901.83","2962.25","1 through 10","5796.67","14865.67","percent of total billed charges",""
"GRAFT ALLO FEMUR DISTAL RT FROZEN","SUP-ITM-10010781","CDM","C1889","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6825.12","36.5","","1620.31","1620.31","19908.88","1 through 10","5796.67","14865.67","percent of total billed charges",""
"GRAFT ALLO FEMUR DISTAL RT FROZEN","SUP-ITM-10010781","CDM","C1889","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7161.70","38.3","","352.91","352.91","2046.30","1 through 10","5796.67","14865.67","percent of total billed charges",""
"GRAFT ALLO FEMUR DISTAL RT FROZEN","SUP-ITM-10010781","CDM","C1889","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8021.85","42.9","","9668.75","9668.75","9668.75","1 through 10","5796.67","14865.67","percent of total billed charges",""
"GRAFT ALLO FEMUR DISTAL RT FROZEN","SUP-ITM-10010781","CDM","C1889","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","WELLPOINT [1015]","HB AMC WELLPOINT","13796.09","73.78","","699.88","384.10","3443.31","33","5796.67","14865.67","percent of total billed charges",""
"GRAFT ALLO FEMUR DISTAL RT FROZEN","SUP-ITM-10010781","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18698.95","14024.21","AETNA [1001]","HB AMC AETNA HMO","13051.87","69.8","","1421.24","264.50","4933.46","29","9772.07","15280.78","percent of total billed charges",""
"GRAFT ALLO FEMUR DISTAL RT FROZEN","SUP-ITM-10010781","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18698.95","14024.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","15033.96","80.4","","1022.97","1022.97","3607.50","1 through 10","9772.07","15280.78","percent of total billed charges",""
"GRAFT ALLO FEMUR DISTAL RT FROZEN","SUP-ITM-10010781","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18698.95","14024.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15280.78","81.72","","3010.54","693.88","5019.88","35","9772.07","15280.78","percent of total billed charges",""
"GRAFT ALLO PROSTHESIS COMPOSITE TISSUE HUMERUS PROXIMALIMAL LT CUFF SOFT","SUP-ITM-10079408","CDM","C1889","HCPCS","0278","RC","","","","both","","","20068.75","15051.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15954.66","79.5","","1309.77","674.56","6049.93","26","6221.31","15954.66","percent of total billed charges",""
"GRAFT ALLO PROSTHESIS COMPOSITE TISSUE HUMERUS PROXIMALIMAL LT CUFF SOFT","SUP-ITM-10079408","CDM","C1889","HCPCS","0278","RC","","","","both","","","20068.75","15051.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10696.64","53.3","","1901.83","1901.83","2962.25","1 through 10","6221.31","15954.66","percent of total billed charges",""
"GRAFT ALLO PROSTHESIS COMPOSITE TISSUE HUMERUS PROXIMALIMAL LT CUFF SOFT","SUP-ITM-10079408","CDM","C1889","HCPCS","0278","RC","","","","both","","","20068.75","15051.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7325.09","36.5","","1620.31","1620.31","19908.88","1 through 10","6221.31","15954.66","percent of total billed charges",""
"GRAFT ALLO PROSTHESIS COMPOSITE TISSUE HUMERUS PROXIMALIMAL LT CUFF SOFT","SUP-ITM-10079408","CDM","C1889","HCPCS","0278","RC","","","","both","","","20068.75","15051.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7686.33","38.3","","352.91","352.91","2046.30","1 through 10","6221.31","15954.66","percent of total billed charges",""
"GRAFT ALLO PROSTHESIS COMPOSITE TISSUE HUMERUS PROXIMALIMAL LT CUFF SOFT","SUP-ITM-10079408","CDM","C1889","HCPCS","0278","RC","","","","both","","","20068.75","15051.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8609.49","42.9","","9668.75","9668.75","9668.75","1 through 10","6221.31","15954.66","percent of total billed charges",""
"GRAFT ALLO PROSTHESIS COMPOSITE TISSUE HUMERUS PROXIMALIMAL LT CUFF SOFT","SUP-ITM-10079408","CDM","C1889","HCPCS","0278","RC","","","","both","","","20068.75","15051.56","WELLPOINT [1015]","HB AMC WELLPOINT","14806.72","73.78","","699.88","384.10","3443.31","33","6221.31","15954.66","percent of total billed charges",""
"GRAFT ALLO PROSTHESIS COMPOSITE TISSUE HUMERUS PROXIMALIMAL LT CUFF SOFT","SUP-ITM-10079408","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20068.75","15051.56","AETNA [1001]","HB AMC AETNA HMO","14007.99","69.8","","1421.24","264.50","4933.46","29","10487.93","16400.18","percent of total billed charges",""
"GRAFT ALLO PROSTHESIS COMPOSITE TISSUE HUMERUS PROXIMALIMAL LT CUFF SOFT","SUP-ITM-10079408","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20068.75","15051.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","16135.28","80.4","","1022.97","1022.97","3607.50","1 through 10","10487.93","16400.18","percent of total billed charges",""
"GRAFT ALLO PROSTHESIS COMPOSITE TISSUE HUMERUS PROXIMALIMAL LT CUFF SOFT","SUP-ITM-10079408","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20068.75","15051.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16400.18","81.72","","3010.54","693.88","5019.88","35","10487.93","16400.18","percent of total billed charges",""
"GRAFT ALLO TISSUE 60MMX10CM MEDIUM FASCIA LATA FREEZE DRIED","SUP-ITM-10010709","CDM","C1762","HCPCS","0278","RC","","","","both","","","2461.38","1846.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1311.92","53.3","","1112.50","1112.50","1112.50","1 through 10","763.03","1956.8","percent of total billed charges",""
"GRAFT ALLO TISSUE 60MMX10CM MEDIUM FASCIA LATA FREEZE DRIED","SUP-ITM-10010709","CDM","C1762","HCPCS","0278","RC","","","","both","","","2461.38","1846.03","WELLPOINT [1015]","HB AMC WELLPOINT","1816.01","73.78","","1568.66","1568.66","1568.66","1 through 10","763.03","1956.8","percent of total billed charges",""
"GRAFT ALLO TISSUE 60MMX10CM MEDIUM FASCIA LATA FREEZE DRIED","SUP-ITM-10010709","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","2461.38","1846.03","AETNA [1001]","HB AMC AETNA HMO","1718.04","69.8","","1281.90","1281.90","1281.90","1 through 10","1286.32","2011.44","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","23850.00","79.5","","1309.77","674.56","6049.93","26","9300","23850","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","15990.00","53.3","","1901.83","1901.83","2962.25","1 through 10","9300","23850","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10950.00","36.5","","1620.31","1620.31","19908.88","1 through 10","9300","23850","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11490.00","38.3","","352.91","352.91","2046.30","1 through 10","9300","23850","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12870.00","42.9","","9668.75","9668.75","9668.75","1 through 10","9300","23850","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","WELLPOINT [1015]","HB AMC WELLPOINT","22134.00","73.78","","699.88","384.10","3443.31","33","9300","23850","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","30000.00","22500.00","AETNA [1001]","HB AMC AETNA HMO","20940.00","69.8","","1421.24","264.50","4933.46","29","15678","24516","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","30000.00","22500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","24120.00","80.4","","1022.97","1022.97","3607.50","1 through 10","15678","24516","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","30000.00","22500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24516.00","81.72","","3010.54","693.88","5019.88","35","15678","24516","percent of total billed charges",""
"GRAFT ASEP BONE PELVIC HEMI PELVIS RT FROZEN","SUP-ITM-10010798","CDM","C1889","HCPCS","0278","RC","","","","both","","","29081.25","21810.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","23119.59","79.5","","1309.77","674.56","6049.93","26","9015.19","23119.59","percent of total billed charges",""
"GRAFT ASEP BONE PELVIC HEMI PELVIS RT FROZEN","SUP-ITM-10010798","CDM","C1889","HCPCS","0278","RC","","","","both","","","29081.25","21810.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","15500.31","53.3","","1901.83","1901.83","2962.25","1 through 10","9015.19","23119.59","percent of total billed charges",""
"GRAFT ASEP BONE PELVIC HEMI PELVIS RT FROZEN","SUP-ITM-10010798","CDM","C1889","HCPCS","0278","RC","","","","both","","","29081.25","21810.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10614.66","36.5","","1620.31","1620.31","19908.88","1 through 10","9015.19","23119.59","percent of total billed charges",""
"GRAFT ASEP BONE PELVIC HEMI PELVIS RT FROZEN","SUP-ITM-10010798","CDM","C1889","HCPCS","0278","RC","","","","both","","","29081.25","21810.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11138.12","38.3","","352.91","352.91","2046.30","1 through 10","9015.19","23119.59","percent of total billed charges",""
"GRAFT ASEP BONE PELVIC HEMI PELVIS RT FROZEN","SUP-ITM-10010798","CDM","C1889","HCPCS","0278","RC","","","","both","","","29081.25","21810.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12475.86","42.9","","9668.75","9668.75","9668.75","1 through 10","9015.19","23119.59","percent of total billed charges",""
"GRAFT ASEP BONE PELVIC HEMI PELVIS RT FROZEN","SUP-ITM-10010798","CDM","C1889","HCPCS","0278","RC","","","","both","","","29081.25","21810.94","WELLPOINT [1015]","HB AMC WELLPOINT","21456.15","73.78","","699.88","384.10","3443.31","33","9015.19","23119.59","percent of total billed charges",""
"GRAFT ASEP BONE PELVIC HEMI PELVIS RT FROZEN","SUP-ITM-10010798","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","29081.25","21810.94","AETNA [1001]","HB AMC AETNA HMO","20298.71","69.8","","1421.24","264.50","4933.46","29","15197.86","23765.2","percent of total billed charges",""
"GRAFT ASEP BONE PELVIC HEMI PELVIS RT FROZEN","SUP-ITM-10010798","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","29081.25","21810.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","23381.33","80.4","","1022.97","1022.97","3607.50","1 through 10","15197.86","23765.2","percent of total billed charges",""
"GRAFT ASEP BONE PELVIC HEMI PELVIS RT FROZEN","SUP-ITM-10010798","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","29081.25","21810.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","23765.20","81.72","","3010.54","693.88","5019.88","35","15197.86","23765.2","percent of total billed charges",""
"GRAFT BIOLOGICAL 41CM D8-5MM ARTERY FEMORAL ANGIOGRAFT CRYO","SUP-ITM-10320151","CDM","C1889","HCPCS","0278","RC","","","","both","","","17215.00","12911.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13685.93","79.5","","1309.77","674.56","6049.93","26","5336.65","13685.93","percent of total billed charges",""
"GRAFT BIOLOGICAL 41CM D8-5MM ARTERY FEMORAL ANGIOGRAFT CRYO","SUP-ITM-10320151","CDM","C1889","HCPCS","0278","RC","","","","both","","","17215.00","12911.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9175.60","53.3","","1901.83","1901.83","2962.25","1 through 10","5336.65","13685.93","percent of total billed charges",""
"GRAFT BIOLOGICAL 41CM D8-5MM ARTERY FEMORAL ANGIOGRAFT CRYO","SUP-ITM-10320151","CDM","C1889","HCPCS","0278","RC","","","","both","","","17215.00","12911.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6283.48","36.5","","1620.31","1620.31","19908.88","1 through 10","5336.65","13685.93","percent of total billed charges",""
"GRAFT BIOLOGICAL 41CM D8-5MM ARTERY FEMORAL ANGIOGRAFT CRYO","SUP-ITM-10320151","CDM","C1889","HCPCS","0278","RC","","","","both","","","17215.00","12911.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6593.35","38.3","","352.91","352.91","2046.30","1 through 10","5336.65","13685.93","percent of total billed charges",""
"GRAFT BIOLOGICAL 41CM D8-5MM ARTERY FEMORAL ANGIOGRAFT CRYO","SUP-ITM-10320151","CDM","C1889","HCPCS","0278","RC","","","","both","","","17215.00","12911.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7385.24","42.9","","9668.75","9668.75","9668.75","1 through 10","5336.65","13685.93","percent of total billed charges",""
"GRAFT BIOLOGICAL 41CM D8-5MM ARTERY FEMORAL ANGIOGRAFT CRYO","SUP-ITM-10320151","CDM","C1889","HCPCS","0278","RC","","","","both","","","17215.00","12911.25","WELLPOINT [1015]","HB AMC WELLPOINT","12701.23","73.78","","699.88","384.10","3443.31","33","5336.65","13685.93","percent of total billed charges",""
"GRAFT BIOLOGICAL 41CM D8-5MM ARTERY FEMORAL ANGIOGRAFT CRYO","SUP-ITM-10320151","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17215.00","12911.25","AETNA [1001]","HB AMC AETNA HMO","12016.07","69.8","","1421.24","264.50","4933.46","29","8996.56","14068.1","percent of total billed charges",""
"GRAFT BIOLOGICAL 41CM D8-5MM ARTERY FEMORAL ANGIOGRAFT CRYO","SUP-ITM-10320151","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17215.00","12911.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","13840.86","80.4","","1022.97","1022.97","3607.50","1 through 10","8996.56","14068.1","percent of total billed charges",""
"GRAFT BIOLOGICAL 41CM D8-5MM ARTERY FEMORAL ANGIOGRAFT CRYO","SUP-ITM-10320151","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17215.00","12911.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14068.10","81.72","","3010.54","693.88","5019.88","35","8996.56","14068.1","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","both","","","3123.05","2342.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2482.82","79.5","","1309.77","674.56","6049.93","26","968.15","2482.82","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","both","","","3123.05","2342.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1664.59","53.3","","1901.83","1901.83","2962.25","1 through 10","968.15","2482.82","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","both","","","3123.05","2342.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1139.91","36.5","","1620.31","1620.31","19908.88","1 through 10","968.15","2482.82","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","both","","","3123.05","2342.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1196.13","38.3","","352.91","352.91","2046.30","1 through 10","968.15","2482.82","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","both","","","3123.05","2342.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1339.79","42.9","","9668.75","9668.75","9668.75","1 through 10","968.15","2482.82","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","both","","","3123.05","2342.29","WELLPOINT [1015]","HB AMC WELLPOINT","2304.19","73.78","","699.88","384.10","3443.31","33","968.15","2482.82","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3123.05","2342.29","AETNA [1001]","HB AMC AETNA HMO","2179.89","69.8","","1421.24","264.50","4933.46","29","1632.11","2552.16","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3123.05","2342.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2510.93","80.4","","1022.97","1022.97","3607.50","1 through 10","1632.11","2552.16","percent of total billed charges",""
"GRAFT BONE 1 8 TOMM 90 READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3123.05","2342.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2552.16","81.72","","3010.54","693.88","5019.88","35","1632.11","2552.16","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","563.08","422.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","447.65","79.5","","1309.77","674.56","6049.93","26","174.55","447.65","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","563.08","422.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","300.12","53.3","","1901.83","1901.83","2962.25","1 through 10","174.55","447.65","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","563.08","422.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","205.52","36.5","","1620.31","1620.31","19908.88","1 through 10","174.55","447.65","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","563.08","422.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","215.66","38.3","","352.91","352.91","2046.30","1 through 10","174.55","447.65","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","563.08","422.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","241.56","42.9","","9668.75","9668.75","9668.75","1 through 10","174.55","447.65","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","563.08","422.31","WELLPOINT [1015]","HB AMC WELLPOINT","415.44","73.78","","699.88","384.10","3443.31","33","174.55","447.65","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","563.08","422.31","AETNA [1001]","HB AMC AETNA HMO","393.03","69.8","","1421.24","264.50","4933.46","29","294.27","460.15","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","563.08","422.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","452.72","80.4","","1022.97","1022.97","3607.50","1 through 10","294.27","460.15","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","563.08","422.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","460.15","81.72","","3010.54","693.88","5019.88","35","294.27","460.15","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","421.61","316.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","335.18","79.5","","1309.77","674.56","6049.93","26","130.7","335.18","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","421.61","316.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","224.72","53.3","","1901.83","1901.83","2962.25","1 through 10","130.7","335.18","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","421.61","316.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","153.89","36.5","","1620.31","1620.31","19908.88","1 through 10","130.7","335.18","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","421.61","316.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","161.48","38.3","","352.91","352.91","2046.30","1 through 10","130.7","335.18","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","421.61","316.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.87","42.9","","9668.75","9668.75","9668.75","1 through 10","130.7","335.18","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","421.61","316.21","WELLPOINT [1015]","HB AMC WELLPOINT","311.06","73.78","","699.88","384.10","3443.31","33","130.7","335.18","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","421.61","316.21","AETNA [1001]","HB AMC AETNA HMO","294.28","69.8","","1421.24","264.50","4933.46","29","220.33","344.54","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","421.61","316.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","338.97","80.4","","1022.97","1022.97","3607.50","1 through 10","220.33","344.54","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","421.61","316.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","344.54","81.72","","3010.54","693.88","5019.88","35","220.33","344.54","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","1142.40","856.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","908.21","79.5","","1309.77","674.56","6049.93","26","354.14","908.21","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","1142.40","856.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","608.90","53.3","","1901.83","1901.83","2962.25","1 through 10","354.14","908.21","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","1142.40","856.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","416.98","36.5","","1620.31","1620.31","19908.88","1 through 10","354.14","908.21","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","1142.40","856.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","437.54","38.3","","352.91","352.91","2046.30","1 through 10","354.14","908.21","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","1142.40","856.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","490.09","42.9","","9668.75","9668.75","9668.75","1 through 10","354.14","908.21","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","1142.40","856.80","WELLPOINT [1015]","HB AMC WELLPOINT","842.86","73.78","","699.88","384.10","3443.31","33","354.14","908.21","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1142.40","856.80","AETNA [1001]","HB AMC AETNA HMO","797.40","69.8","","1421.24","264.50","4933.46","29","597.02","933.57","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1142.40","856.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","918.49","80.4","","1022.97","1022.97","3607.50","1 through 10","597.02","933.57","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1142.40","856.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","933.57","81.72","","3010.54","693.88","5019.88","35","597.02","933.57","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 15 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091322","CDM","C1889","HCPCS","0278","RC","","","","both","","","553.35","415.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","439.91","79.5","","1309.77","674.56","6049.93","26","171.54","439.91","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 15 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091322","CDM","C1889","HCPCS","0278","RC","","","","both","","","553.35","415.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","294.94","53.3","","1901.83","1901.83","2962.25","1 through 10","171.54","439.91","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 15 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091322","CDM","C1889","HCPCS","0278","RC","","","","both","","","553.35","415.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","201.97","36.5","","1620.31","1620.31","19908.88","1 through 10","171.54","439.91","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 15 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091322","CDM","C1889","HCPCS","0278","RC","","","","both","","","553.35","415.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","211.93","38.3","","352.91","352.91","2046.30","1 through 10","171.54","439.91","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 15 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091322","CDM","C1889","HCPCS","0278","RC","","","","both","","","553.35","415.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","237.39","42.9","","9668.75","9668.75","9668.75","1 through 10","171.54","439.91","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 15 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091322","CDM","C1889","HCPCS","0278","RC","","","","both","","","553.35","415.01","WELLPOINT [1015]","HB AMC WELLPOINT","408.26","73.78","","699.88","384.10","3443.31","33","171.54","439.91","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 15 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091322","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","553.35","415.01","AETNA [1001]","HB AMC AETNA HMO","386.24","69.8","","1421.24","264.50","4933.46","29","289.18","452.2","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 15 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091322","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","553.35","415.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","444.89","80.4","","1022.97","1022.97","3607.50","1 through 10","289.18","452.2","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 15 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091322","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","553.35","415.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","452.20","81.72","","3010.54","693.88","5019.88","35","289.18","452.2","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 30 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091324","CDM","C1889","HCPCS","0278","RC","","","","both","","","1053.15","789.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","837.25","79.5","","1309.77","674.56","6049.93","26","326.48","837.25","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 30 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091324","CDM","C1889","HCPCS","0278","RC","","","","both","","","1053.15","789.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","561.33","53.3","","1901.83","1901.83","2962.25","1 through 10","326.48","837.25","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 30 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091324","CDM","C1889","HCPCS","0278","RC","","","","both","","","1053.15","789.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","384.40","36.5","","1620.31","1620.31","19908.88","1 through 10","326.48","837.25","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 30 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091324","CDM","C1889","HCPCS","0278","RC","","","","both","","","1053.15","789.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","403.36","38.3","","352.91","352.91","2046.30","1 through 10","326.48","837.25","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 30 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091324","CDM","C1889","HCPCS","0278","RC","","","","both","","","1053.15","789.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","451.80","42.9","","9668.75","9668.75","9668.75","1 through 10","326.48","837.25","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 30 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091324","CDM","C1889","HCPCS","0278","RC","","","","both","","","1053.15","789.86","WELLPOINT [1015]","HB AMC WELLPOINT","777.01","73.78","","699.88","384.10","3443.31","33","326.48","837.25","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 30 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091324","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1053.15","789.86","AETNA [1001]","HB AMC AETNA HMO","735.10","69.8","","1421.24","264.50","4933.46","29","550.38","860.63","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 30 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091324","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1053.15","789.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","846.73","80.4","","1022.97","1022.97","3607.50","1 through 10","550.38","860.63","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 30 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091324","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1053.15","789.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","860.63","81.72","","3010.54","693.88","5019.88","35","550.38","860.63","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 60 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091326","CDM","C1889","HCPCS","0278","RC","","","","both","","","1927.80","1445.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1532.60","79.5","","1309.77","674.56","6049.93","26","597.62","1532.6","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 60 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091326","CDM","C1889","HCPCS","0278","RC","","","","both","","","1927.80","1445.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1027.52","53.3","","1901.83","1901.83","2962.25","1 through 10","597.62","1532.6","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 60 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091326","CDM","C1889","HCPCS","0278","RC","","","","both","","","1927.80","1445.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","703.65","36.5","","1620.31","1620.31","19908.88","1 through 10","597.62","1532.6","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 60 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091326","CDM","C1889","HCPCS","0278","RC","","","","both","","","1927.80","1445.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","738.35","38.3","","352.91","352.91","2046.30","1 through 10","597.62","1532.6","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 60 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091326","CDM","C1889","HCPCS","0278","RC","","","","both","","","1927.80","1445.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","827.03","42.9","","9668.75","9668.75","9668.75","1 through 10","597.62","1532.6","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 60 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091326","CDM","C1889","HCPCS","0278","RC","","","","both","","","1927.80","1445.85","WELLPOINT [1015]","HB AMC WELLPOINT","1422.33","73.78","","699.88","384.10","3443.31","33","597.62","1532.6","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 60 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091326","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1927.80","1445.85","AETNA [1001]","HB AMC AETNA HMO","1345.60","69.8","","1421.24","264.50","4933.46","29","1007.47","1575.4","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 60 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091326","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1927.80","1445.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1549.95","80.4","","1022.97","1022.97","3607.50","1 through 10","1007.47","1575.4","percent of total billed charges",""
"GRAFT BONE 1 TO 8MM 60 READI ALLO CHIP CANCELLOUS CRUSHED VOID FILLER PRESERVON","SUP-ITM-10091326","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1927.80","1445.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1575.40","81.72","","3010.54","693.88","5019.88","35","1007.47","1575.4","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1741.78","1306.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1384.72","79.5","","800.18","480.96","1887.97","195","539.95","1384.72","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1741.78","1306.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","928.37","53.3","","813.12","216.42","1444.50","81","539.95","1384.72","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1741.78","1306.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","539.95","31","","432.60","432.60","432.60","1 through 10","539.95","1384.72","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1741.78","1306.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","635.75","36.5","","148.37","54.89","631.39","94","539.95","1384.72","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1741.78","1306.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","667.10","38.3","","279.30","91.72","1116.77","266","539.95","1384.72","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1741.78","1306.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","747.22","42.9","","731.00","63.70","731.00","1 through 10","539.95","1384.72","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1741.78","1306.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","747.22","42.9","","384.74","384.74","384.74","1 through 10","539.95","1384.72","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1741.78","1306.33","WELLPOINT [1015]","HB AMC WELLPOINT","1285.09","73.78","","286.63","119.22","1107.45","105","539.95","1384.72","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1741.78","1306.33","AETNA [1001]","HB AMC AETNA HMO","1215.76","69.8","","675.31","184.75","1721.50","286","910.25","1423.38","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1741.78","1306.33","AETNA [1001]","HB AMC AETNA PPO","1400.39","80.4","","1261.44","103.12","1514.10","21","910.25","1423.38","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1741.78","1306.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1400.39","80.4","","1365.00","1365.00","1365.00","1 through 10","910.25","1423.38","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1741.78","1306.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1423.38","81.72","","5157.68","5157.68","5157.68","1 through 10","910.25","1423.38","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1741.78","1306.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1423.38","81.72","","431.26","71.26","1459.57","88","910.25","1423.38","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 5 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041309","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.91","677.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","718.61","79.5","","800.18","480.96","1887.97","195","280.21","718.61","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 5 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041309","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.91","677.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","481.78","53.3","","813.12","216.42","1444.50","81","280.21","718.61","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 5 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041309","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.91","677.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","280.21","31","","432.60","432.60","432.60","1 through 10","280.21","718.61","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 5 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041309","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.91","677.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","329.93","36.5","","148.37","54.89","631.39","94","280.21","718.61","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 5 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041309","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.91","677.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","346.20","38.3","","279.30","91.72","1116.77","266","280.21","718.61","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 5 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041309","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.91","677.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","387.78","42.9","","731.00","63.70","731.00","1 through 10","280.21","718.61","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 5 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041309","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.91","677.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","387.78","42.9","","384.74","384.74","384.74","1 through 10","280.21","718.61","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 5 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041309","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.91","677.93","WELLPOINT [1015]","HB AMC WELLPOINT","666.90","73.78","","286.63","119.22","1107.45","105","280.21","718.61","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 5 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.91","677.93","AETNA [1001]","HB AMC AETNA HMO","630.93","69.8","","675.31","184.75","1721.50","286","472.38","738.68","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 5 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.91","677.93","AETNA [1001]","HB AMC AETNA PPO","726.74","80.4","","1261.44","103.12","1514.10","21","472.38","738.68","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 5 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.91","677.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","726.74","80.4","","1365.00","1365.00","1365.00","1 through 10","472.38","738.68","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 5 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.91","677.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","738.68","81.72","","5157.68","5157.68","5157.68","1 through 10","472.38","738.68","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 5 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.91","677.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","738.68","81.72","","431.26","71.26","1459.57","88","472.38","738.68","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","both","","","2653.95","1990.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2109.89","79.5","","1309.77","674.56","6049.93","26","822.72","2109.89","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","both","","","2653.95","1990.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1414.56","53.3","","1901.83","1901.83","2962.25","1 through 10","822.72","2109.89","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","both","","","2653.95","1990.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","968.69","36.5","","1620.31","1620.31","19908.88","1 through 10","822.72","2109.89","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","both","","","2653.95","1990.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1016.46","38.3","","352.91","352.91","2046.30","1 through 10","822.72","2109.89","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","both","","","2653.95","1990.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1138.54","42.9","","9668.75","9668.75","9668.75","1 through 10","822.72","2109.89","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","both","","","2653.95","1990.46","WELLPOINT [1015]","HB AMC WELLPOINT","1958.08","73.78","","699.88","384.10","3443.31","33","822.72","2109.89","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2653.95","1990.46","AETNA [1001]","HB AMC AETNA HMO","1852.46","69.8","","1421.24","264.50","4933.46","29","1386.95","2168.81","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2653.95","1990.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2133.78","80.4","","1022.97","1022.97","3607.50","1 through 10","1386.95","2168.81","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2653.95","1990.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2168.81","81.72","","3010.54","693.88","5019.88","35","1386.95","2168.81","percent of total billed charges",""
"GRAFT BONE 100X25 6MM CHRONOS BETA TRICALCIUM PHOSPHATE STRI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036469","CDM","C1713","HCPCS","0278","RC","","","","both","","","5053.75","3790.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4017.73","79.5","","800.18","480.96","1887.97","195","1566.66","4017.73","percent of total billed charges",""
"GRAFT BONE 100X25 6MM CHRONOS BETA TRICALCIUM PHOSPHATE STRI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036469","CDM","C1713","HCPCS","0278","RC","","","","both","","","5053.75","3790.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2693.65","53.3","","813.12","216.42","1444.50","81","1566.66","4017.73","percent of total billed charges",""
"GRAFT BONE 100X25 6MM CHRONOS BETA TRICALCIUM PHOSPHATE STRI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036469","CDM","C1713","HCPCS","0278","RC","","","","both","","","5053.75","3790.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1566.66","31","","432.60","432.60","432.60","1 through 10","1566.66","4017.73","percent of total billed charges",""
"GRAFT BONE 100X25 6MM CHRONOS BETA TRICALCIUM PHOSPHATE STRI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036469","CDM","C1713","HCPCS","0278","RC","","","","both","","","5053.75","3790.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1844.62","36.5","","148.37","54.89","631.39","94","1566.66","4017.73","percent of total billed charges",""
"GRAFT BONE 100X25 6MM CHRONOS BETA TRICALCIUM PHOSPHATE STRI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036469","CDM","C1713","HCPCS","0278","RC","","","","both","","","5053.75","3790.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1935.59","38.3","","279.30","91.72","1116.77","266","1566.66","4017.73","percent of total billed charges",""
"GRAFT BONE 100X25 6MM CHRONOS BETA TRICALCIUM PHOSPHATE STRI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036469","CDM","C1713","HCPCS","0278","RC","","","","both","","","5053.75","3790.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2168.06","42.9","","731.00","63.70","731.00","1 through 10","1566.66","4017.73","percent of total billed charges",""
"GRAFT BONE 100X25 6MM CHRONOS BETA TRICALCIUM PHOSPHATE STRI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036469","CDM","C1713","HCPCS","0278","RC","","","","both","","","5053.75","3790.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2168.06","42.9","","384.74","384.74","384.74","1 through 10","1566.66","4017.73","percent of total billed charges",""
"GRAFT BONE 100X25 6MM CHRONOS BETA TRICALCIUM PHOSPHATE STRI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036469","CDM","C1713","HCPCS","0278","RC","","","","both","","","5053.75","3790.31","WELLPOINT [1015]","HB AMC WELLPOINT","3728.66","73.78","","286.63","119.22","1107.45","105","1566.66","4017.73","percent of total billed charges",""
"GRAFT BONE 100X25 6MM CHRONOS BETA TRICALCIUM PHOSPHATE STRI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5053.75","3790.31","AETNA [1001]","HB AMC AETNA HMO","3527.52","69.8","","675.31","184.75","1721.50","286","2641.09","4129.92","percent of total billed charges",""
"GRAFT BONE 100X25 6MM CHRONOS BETA TRICALCIUM PHOSPHATE STRI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5053.75","3790.31","AETNA [1001]","HB AMC AETNA PPO","4063.22","80.4","","1261.44","103.12","1514.10","21","2641.09","4129.92","percent of total billed charges",""
"GRAFT BONE 100X25 6MM CHRONOS BETA TRICALCIUM PHOSPHATE STRI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5053.75","3790.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4063.22","80.4","","1365.00","1365.00","1365.00","1 through 10","2641.09","4129.92","percent of total billed charges",""
"GRAFT BONE 100X25 6MM CHRONOS BETA TRICALCIUM PHOSPHATE STRI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5053.75","3790.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4129.92","81.72","","5157.68","5157.68","5157.68","1 through 10","2641.09","4129.92","percent of total billed charges",""
"GRAFT BONE 100X25 6MM CHRONOS BETA TRICALCIUM PHOSPHATE STRI - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5053.75","3790.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4129.92","81.72","","431.26","71.26","1459.57","88","2641.09","4129.92","percent of total billed charges",""
"GRAFT BONE 100X8 TO 15MM FROZEN MATRI FIBULA SHAFT IMPLANTABLE","SUP-ITM-10010275","CDM","C1889","HCPCS","0278","RC","","","","both","","","2304.09","1728.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1831.75","79.5","","1309.77","674.56","6049.93","26","714.27","1831.75","percent of total billed charges",""
"GRAFT BONE 100X8 TO 15MM FROZEN MATRI FIBULA SHAFT IMPLANTABLE","SUP-ITM-10010275","CDM","C1889","HCPCS","0278","RC","","","","both","","","2304.09","1728.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1228.08","53.3","","1901.83","1901.83","2962.25","1 through 10","714.27","1831.75","percent of total billed charges",""
"GRAFT BONE 100X8 TO 15MM FROZEN MATRI FIBULA SHAFT IMPLANTABLE","SUP-ITM-10010275","CDM","C1889","HCPCS","0278","RC","","","","both","","","2304.09","1728.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","840.99","36.5","","1620.31","1620.31","19908.88","1 through 10","714.27","1831.75","percent of total billed charges",""
"GRAFT BONE 100X8 TO 15MM FROZEN MATRI FIBULA SHAFT IMPLANTABLE","SUP-ITM-10010275","CDM","C1889","HCPCS","0278","RC","","","","both","","","2304.09","1728.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","882.47","38.3","","352.91","352.91","2046.30","1 through 10","714.27","1831.75","percent of total billed charges",""
"GRAFT BONE 100X8 TO 15MM FROZEN MATRI FIBULA SHAFT IMPLANTABLE","SUP-ITM-10010275","CDM","C1889","HCPCS","0278","RC","","","","both","","","2304.09","1728.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","988.45","42.9","","9668.75","9668.75","9668.75","1 through 10","714.27","1831.75","percent of total billed charges",""
"GRAFT BONE 100X8 TO 15MM FROZEN MATRI FIBULA SHAFT IMPLANTABLE","SUP-ITM-10010275","CDM","C1889","HCPCS","0278","RC","","","","both","","","2304.09","1728.07","WELLPOINT [1015]","HB AMC WELLPOINT","1699.96","73.78","","699.88","384.10","3443.31","33","714.27","1831.75","percent of total billed charges",""
"GRAFT BONE 100X8 TO 15MM FROZEN MATRI FIBULA SHAFT IMPLANTABLE","SUP-ITM-10010275","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2304.09","1728.07","AETNA [1001]","HB AMC AETNA HMO","1608.25","69.8","","1421.24","264.50","4933.46","29","1204.12","1882.9","percent of total billed charges",""
"GRAFT BONE 100X8 TO 15MM FROZEN MATRI FIBULA SHAFT IMPLANTABLE","SUP-ITM-10010275","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2304.09","1728.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1852.49","80.4","","1022.97","1022.97","3607.50","1 through 10","1204.12","1882.9","percent of total billed charges",""
"GRAFT BONE 100X8 TO 15MM FROZEN MATRI FIBULA SHAFT IMPLANTABLE","SUP-ITM-10010275","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2304.09","1728.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1882.90","81.72","","3010.54","693.88","5019.88","35","1204.12","1882.9","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","both","","","5685.88","4264.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4520.27","79.5","","1309.77","674.56","6049.93","26","1762.62","4520.27","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","both","","","5685.88","4264.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3030.57","53.3","","1901.83","1901.83","2962.25","1 through 10","1762.62","4520.27","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","both","","","5685.88","4264.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2075.35","36.5","","1620.31","1620.31","19908.88","1 through 10","1762.62","4520.27","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","both","","","5685.88","4264.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2177.69","38.3","","352.91","352.91","2046.30","1 through 10","1762.62","4520.27","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","both","","","5685.88","4264.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2439.24","42.9","","9668.75","9668.75","9668.75","1 through 10","1762.62","4520.27","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","both","","","5685.88","4264.41","WELLPOINT [1015]","HB AMC WELLPOINT","4195.04","73.78","","699.88","384.10","3443.31","33","1762.62","4520.27","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5685.88","4264.41","AETNA [1001]","HB AMC AETNA HMO","3968.74","69.8","","1421.24","264.50","4933.46","29","2971.44","4646.5","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5685.88","4264.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4571.45","80.4","","1022.97","1022.97","3607.50","1 through 10","2971.44","4646.5","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MAGNETOS","SUP-ITM-10282974","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5685.88","4264.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4646.50","81.72","","3010.54","693.88","5019.88","35","2971.44","4646.5","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6910.24","79.5","","1309.77","674.56","6049.93","26","2694.56","6910.24","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4632.91","53.3","","1901.83","1901.83","2962.25","1 through 10","2694.56","6910.24","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3172.63","36.5","","1620.31","1620.31","19908.88","1 through 10","2694.56","6910.24","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3329.09","38.3","","352.91","352.91","2046.30","1 through 10","2694.56","6910.24","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3728.92","42.9","","9668.75","9668.75","9668.75","1 through 10","2694.56","6910.24","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","WELLPOINT [1015]","HB AMC WELLPOINT","6413.05","73.78","","699.88","384.10","3443.31","33","2694.56","6910.24","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8692.13","6519.10","AETNA [1001]","HB AMC AETNA HMO","6067.11","69.8","","1421.24","264.50","4933.46","29","4542.51","7103.21","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8692.13","6519.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6988.47","80.4","","1022.97","1022.97","3607.50","1 through 10","4542.51","7103.21","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8692.13","6519.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7103.21","81.72","","3010.54","693.88","5019.88","35","4542.51","7103.21","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","both","","","3099.46","2324.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2464.07","79.5","","1309.77","674.56","6049.93","26","960.83","2464.07","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","both","","","3099.46","2324.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1652.01","53.3","","1901.83","1901.83","2962.25","1 through 10","960.83","2464.07","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","both","","","3099.46","2324.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1131.30","36.5","","1620.31","1620.31","19908.88","1 through 10","960.83","2464.07","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","both","","","3099.46","2324.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1187.09","38.3","","352.91","352.91","2046.30","1 through 10","960.83","2464.07","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","both","","","3099.46","2324.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1329.67","42.9","","9668.75","9668.75","9668.75","1 through 10","960.83","2464.07","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","both","","","3099.46","2324.59","WELLPOINT [1015]","HB AMC WELLPOINT","2286.78","73.78","","699.88","384.10","3443.31","33","960.83","2464.07","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3099.46","2324.59","AETNA [1001]","HB AMC AETNA HMO","2163.42","69.8","","1421.24","264.50","4933.46","29","1619.78","2532.88","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3099.46","2324.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2491.97","80.4","","1022.97","1022.97","3607.50","1 through 10","1619.78","2532.88","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3099.46","2324.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2532.88","81.72","","3010.54","693.88","5019.88","35","1619.78","2532.88","percent of total billed charges",""
"GRAFT BONE 10CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287266","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","1309.77","674.56","6049.93","26","922.25","2365.13","percent of total billed charges",""
"GRAFT BONE 10CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287266","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1585.68","53.3","","1901.83","1901.83","2962.25","1 through 10","922.25","2365.13","percent of total billed charges",""
"GRAFT BONE 10CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287266","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","1620.31","1620.31","19908.88","1 through 10","922.25","2365.13","percent of total billed charges",""
"GRAFT BONE 10CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287266","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","352.91","352.91","2046.30","1 through 10","922.25","2365.13","percent of total billed charges",""
"GRAFT BONE 10CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287266","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","9668.75","9668.75","9668.75","1 through 10","922.25","2365.13","percent of total billed charges",""
"GRAFT BONE 10CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287266","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","WELLPOINT [1015]","HB AMC WELLPOINT","2194.96","73.78","","699.88","384.10","3443.31","33","922.25","2365.13","percent of total billed charges",""
"GRAFT BONE 10CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","1421.24","264.50","4933.46","29","1554.74","2431.17","percent of total billed charges",""
"GRAFT BONE 10CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2391.90","80.4","","1022.97","1022.97","3607.50","1 through 10","1554.74","2431.17","percent of total billed charges",""
"GRAFT BONE 10CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","3010.54","693.88","5019.88","35","1554.74","2431.17","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL PLUS ALLOGRAFT DEMINERALIZED MATRIX CELLULAR","SUP-ITM-10188185","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6161.25","79.5","","1309.77","674.56","6049.93","26","2402.5","6161.25","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL PLUS ALLOGRAFT DEMINERALIZED MATRIX CELLULAR","SUP-ITM-10188185","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4130.75","53.3","","1901.83","1901.83","2962.25","1 through 10","2402.5","6161.25","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL PLUS ALLOGRAFT DEMINERALIZED MATRIX CELLULAR","SUP-ITM-10188185","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2828.75","36.5","","1620.31","1620.31","19908.88","1 through 10","2402.5","6161.25","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL PLUS ALLOGRAFT DEMINERALIZED MATRIX CELLULAR","SUP-ITM-10188185","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2968.25","38.3","","352.91","352.91","2046.30","1 through 10","2402.5","6161.25","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL PLUS ALLOGRAFT DEMINERALIZED MATRIX CELLULAR","SUP-ITM-10188185","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3324.75","42.9","","9668.75","9668.75","9668.75","1 through 10","2402.5","6161.25","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL PLUS ALLOGRAFT DEMINERALIZED MATRIX CELLULAR","SUP-ITM-10188185","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","WELLPOINT [1015]","HB AMC WELLPOINT","5717.95","73.78","","699.88","384.10","3443.31","33","2402.5","6161.25","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL PLUS ALLOGRAFT DEMINERALIZED MATRIX CELLULAR","SUP-ITM-10188185","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","AETNA [1001]","HB AMC AETNA HMO","5409.50","69.8","","1421.24","264.50","4933.46","29","4050.15","6333.3","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL PLUS ALLOGRAFT DEMINERALIZED MATRIX CELLULAR","SUP-ITM-10188185","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6231.00","80.4","","1022.97","1022.97","3607.50","1 through 10","4050.15","6333.3","percent of total billed charges",""
"GRAFT BONE 10ML OSTEOCEL PLUS ALLOGRAFT DEMINERALIZED MATRIX CELLULAR","SUP-ITM-10188185","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6333.30","81.72","","3010.54","693.88","5019.88","35","4050.15","6333.3","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","3304.49","2478.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2627.07","79.5","","1309.77","674.56","6049.93","26","1024.39","2627.07","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","3304.49","2478.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1761.29","53.3","","1901.83","1901.83","2962.25","1 through 10","1024.39","2627.07","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","3304.49","2478.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1206.14","36.5","","1620.31","1620.31","19908.88","1 through 10","1024.39","2627.07","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","3304.49","2478.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1265.62","38.3","","352.91","352.91","2046.30","1 through 10","1024.39","2627.07","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","3304.49","2478.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1417.63","42.9","","9668.75","9668.75","9668.75","1 through 10","1024.39","2627.07","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","3304.49","2478.37","WELLPOINT [1015]","HB AMC WELLPOINT","2438.05","73.78","","699.88","384.10","3443.31","33","1024.39","2627.07","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3304.49","2478.37","AETNA [1001]","HB AMC AETNA HMO","2306.53","69.8","","1421.24","264.50","4933.46","29","1726.93","2700.43","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3304.49","2478.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2656.81","80.4","","1022.97","1022.97","3607.50","1 through 10","1726.93","2700.43","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3304.49","2478.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2700.43","81.72","","3010.54","693.88","5019.88","35","1726.93","2700.43","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","both","","","3304.49","2478.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2627.07","79.5","","1309.77","674.56","6049.93","26","1024.39","2627.07","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","both","","","3304.49","2478.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1761.29","53.3","","1901.83","1901.83","2962.25","1 through 10","1024.39","2627.07","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","both","","","3304.49","2478.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1206.14","36.5","","1620.31","1620.31","19908.88","1 through 10","1024.39","2627.07","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","both","","","3304.49","2478.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1265.62","38.3","","352.91","352.91","2046.30","1 through 10","1024.39","2627.07","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","both","","","3304.49","2478.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1417.63","42.9","","9668.75","9668.75","9668.75","1 through 10","1024.39","2627.07","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","both","","","3304.49","2478.37","WELLPOINT [1015]","HB AMC WELLPOINT","2438.05","73.78","","699.88","384.10","3443.31","33","1024.39","2627.07","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3304.49","2478.37","AETNA [1001]","HB AMC AETNA HMO","2306.53","69.8","","1421.24","264.50","4933.46","29","1726.93","2700.43","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3304.49","2478.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2656.81","80.4","","1022.97","1022.97","3607.50","1 through 10","1726.93","2700.43","percent of total billed charges",""
"GRAFT BONE 12X14.5 8.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124325","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3304.49","2478.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2700.43","81.72","","3010.54","693.88","5019.88","35","1726.93","2700.43","percent of total billed charges",""
"GRAFT BONE 15 TO 17X20MM AUGMENTATION FREEZE DRIED VERTEFILL IMPLANTABLE 012017","SUP-ITM-10048790","CDM","C1889","HCPCS","0278","RC","","","","both","","","4951.20","3713.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3936.20","79.5","","1309.77","674.56","6049.93","26","1534.87","3936.2","percent of total billed charges",""
"GRAFT BONE 15 TO 17X20MM AUGMENTATION FREEZE DRIED VERTEFILL IMPLANTABLE 012017","SUP-ITM-10048790","CDM","C1889","HCPCS","0278","RC","","","","both","","","4951.20","3713.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2638.99","53.3","","1901.83","1901.83","2962.25","1 through 10","1534.87","3936.2","percent of total billed charges",""
"GRAFT BONE 15 TO 17X20MM AUGMENTATION FREEZE DRIED VERTEFILL IMPLANTABLE 012017","SUP-ITM-10048790","CDM","C1889","HCPCS","0278","RC","","","","both","","","4951.20","3713.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1807.19","36.5","","1620.31","1620.31","19908.88","1 through 10","1534.87","3936.2","percent of total billed charges",""
"GRAFT BONE 15 TO 17X20MM AUGMENTATION FREEZE DRIED VERTEFILL IMPLANTABLE 012017","SUP-ITM-10048790","CDM","C1889","HCPCS","0278","RC","","","","both","","","4951.20","3713.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1896.31","38.3","","352.91","352.91","2046.30","1 through 10","1534.87","3936.2","percent of total billed charges",""
"GRAFT BONE 15 TO 17X20MM AUGMENTATION FREEZE DRIED VERTEFILL IMPLANTABLE 012017","SUP-ITM-10048790","CDM","C1889","HCPCS","0278","RC","","","","both","","","4951.20","3713.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2124.06","42.9","","9668.75","9668.75","9668.75","1 through 10","1534.87","3936.2","percent of total billed charges",""
"GRAFT BONE 15 TO 17X20MM AUGMENTATION FREEZE DRIED VERTEFILL IMPLANTABLE 012017","SUP-ITM-10048790","CDM","C1889","HCPCS","0278","RC","","","","both","","","4951.20","3713.40","WELLPOINT [1015]","HB AMC WELLPOINT","3653.00","73.78","","699.88","384.10","3443.31","33","1534.87","3936.2","percent of total billed charges",""
"GRAFT BONE 15 TO 17X20MM AUGMENTATION FREEZE DRIED VERTEFILL IMPLANTABLE 012017","SUP-ITM-10048790","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4951.20","3713.40","AETNA [1001]","HB AMC AETNA HMO","3455.94","69.8","","1421.24","264.50","4933.46","29","2587.5","4046.12","percent of total billed charges",""
"GRAFT BONE 15 TO 17X20MM AUGMENTATION FREEZE DRIED VERTEFILL IMPLANTABLE 012017","SUP-ITM-10048790","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4951.20","3713.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3980.76","80.4","","1022.97","1022.97","3607.50","1 through 10","2587.5","4046.12","percent of total billed charges",""
"GRAFT BONE 15 TO 17X20MM AUGMENTATION FREEZE DRIED VERTEFILL IMPLANTABLE 012017","SUP-ITM-10048790","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4951.20","3713.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4046.12","81.72","","3010.54","693.88","5019.88","35","2587.5","4046.12","percent of total billed charges",""
"GRAFT BONE 15CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287270","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3199.88","79.5","","1309.77","674.56","6049.93","26","1247.75","3199.88","percent of total billed charges",""
"GRAFT BONE 15CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287270","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2145.33","53.3","","1901.83","1901.83","2962.25","1 through 10","1247.75","3199.88","percent of total billed charges",""
"GRAFT BONE 15CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287270","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1469.13","36.5","","1620.31","1620.31","19908.88","1 through 10","1247.75","3199.88","percent of total billed charges",""
"GRAFT BONE 15CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287270","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1541.58","38.3","","352.91","352.91","2046.30","1 through 10","1247.75","3199.88","percent of total billed charges",""
"GRAFT BONE 15CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287270","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.73","42.9","","9668.75","9668.75","9668.75","1 through 10","1247.75","3199.88","percent of total billed charges",""
"GRAFT BONE 15CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287270","CDM","C1889","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","WELLPOINT [1015]","HB AMC WELLPOINT","2969.65","73.78","","699.88","384.10","3443.31","33","1247.75","3199.88","percent of total billed charges",""
"GRAFT BONE 15CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287270","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","AETNA [1001]","HB AMC AETNA HMO","2809.45","69.8","","1421.24","264.50","4933.46","29","2103.47","3289.23","percent of total billed charges",""
"GRAFT BONE 15CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287270","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3236.10","80.4","","1022.97","1022.97","3607.50","1 through 10","2103.47","3289.23","percent of total billed charges",""
"GRAFT BONE 15CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287270","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3289.23","81.72","","3010.54","693.88","5019.88","35","2103.47","3289.23","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","both","","","1977.05","1482.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1571.75","79.5","","1309.77","674.56","6049.93","26","612.89","1571.75","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","both","","","1977.05","1482.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1053.77","53.3","","1901.83","1901.83","2962.25","1 through 10","612.89","1571.75","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","both","","","1977.05","1482.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","721.62","36.5","","1620.31","1620.31","19908.88","1 through 10","612.89","1571.75","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","both","","","1977.05","1482.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","757.21","38.3","","352.91","352.91","2046.30","1 through 10","612.89","1571.75","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","both","","","1977.05","1482.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","848.15","42.9","","9668.75","9668.75","9668.75","1 through 10","612.89","1571.75","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","both","","","1977.05","1482.79","WELLPOINT [1015]","HB AMC WELLPOINT","1458.67","73.78","","699.88","384.10","3443.31","33","612.89","1571.75","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1977.05","1482.79","AETNA [1001]","HB AMC AETNA HMO","1379.98","69.8","","1421.24","264.50","4933.46","29","1033.21","1615.65","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1977.05","1482.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1589.55","80.4","","1022.97","1022.97","3607.50","1 through 10","1033.21","1615.65","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1977.05","1482.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1615.65","81.72","","3010.54","693.88","5019.88","35","1033.21","1615.65","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","962.75","79.5","","800.18","480.96","1887.97","195","375.41","962.75","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","645.46","53.3","","813.12","216.42","1444.50","81","375.41","962.75","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","375.41","31","","432.60","432.60","432.60","1 through 10","375.41","962.75","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","442.02","36.5","","148.37","54.89","631.39","94","375.41","962.75","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","463.81","38.3","","279.30","91.72","1116.77","266","375.41","962.75","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","519.52","42.9","","731.00","63.70","731.00","1 through 10","375.41","962.75","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","519.52","42.9","","384.74","384.74","384.74","1 through 10","375.41","962.75","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","WELLPOINT [1015]","HB AMC WELLPOINT","893.48","73.78","","286.63","119.22","1107.45","105","375.41","962.75","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.00","908.25","AETNA [1001]","HB AMC AETNA HMO","845.28","69.8","","675.31","184.75","1721.50","286","632.87","989.63","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.00","908.25","AETNA [1001]","HB AMC AETNA PPO","973.64","80.4","","1261.44","103.12","1514.10","21","632.87","989.63","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.00","908.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","973.64","80.4","","1365.00","1365.00","1365.00","1 through 10","632.87","989.63","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.00","908.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","989.63","81.72","","5157.68","5157.68","5157.68","1 through 10","632.87","989.63","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.00","908.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","989.63","81.72","","431.26","71.26","1459.57","88","632.87","989.63","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","504.14","378.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","400.79","79.5","","1309.77","674.56","6049.93","26","156.28","400.79","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","504.14","378.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","268.71","53.3","","1901.83","1901.83","2962.25","1 through 10","156.28","400.79","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","504.14","378.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","184.01","36.5","","1620.31","1620.31","19908.88","1 through 10","156.28","400.79","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","504.14","378.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","193.09","38.3","","352.91","352.91","2046.30","1 through 10","156.28","400.79","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","504.14","378.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.28","42.9","","9668.75","9668.75","9668.75","1 through 10","156.28","400.79","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","504.14","378.10","WELLPOINT [1015]","HB AMC WELLPOINT","371.95","73.78","","699.88","384.10","3443.31","33","156.28","400.79","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","504.14","378.10","AETNA [1001]","HB AMC AETNA HMO","351.89","69.8","","1421.24","264.50","4933.46","29","263.46","411.98","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","504.14","378.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","405.33","80.4","","1022.97","1022.97","3607.50","1 through 10","263.46","411.98","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","504.14","378.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","411.98","81.72","","3010.54","693.88","5019.88","35","263.46","411.98","percent of total billed charges",""
"GRAFT BONE 1CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287269","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","1309.77","674.56","6049.93","26","162.75","417.38","percent of total billed charges",""
"GRAFT BONE 1CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287269","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","1901.83","1901.83","2962.25","1 through 10","162.75","417.38","percent of total billed charges",""
"GRAFT BONE 1CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287269","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","1620.31","1620.31","19908.88","1 through 10","162.75","417.38","percent of total billed charges",""
"GRAFT BONE 1CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287269","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","352.91","352.91","2046.30","1 through 10","162.75","417.38","percent of total billed charges",""
"GRAFT BONE 1CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287269","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","9668.75","9668.75","9668.75","1 through 10","162.75","417.38","percent of total billed charges",""
"GRAFT BONE 1CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287269","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","699.88","384.10","3443.31","33","162.75","417.38","percent of total billed charges",""
"GRAFT BONE 1CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287269","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","1421.24","264.50","4933.46","29","274.37","429.03","percent of total billed charges",""
"GRAFT BONE 1CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287269","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1022.97","1022.97","3607.50","1 through 10","274.37","429.03","percent of total billed charges",""
"GRAFT BONE 1CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287269","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","3010.54","693.88","5019.88","35","274.37","429.03","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","both","","","1207.50","905.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","959.96","79.5","","1309.77","674.56","6049.93","26","374.33","959.96","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","both","","","1207.50","905.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","643.60","53.3","","1901.83","1901.83","2962.25","1 through 10","374.33","959.96","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","both","","","1207.50","905.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","440.74","36.5","","1620.31","1620.31","19908.88","1 through 10","374.33","959.96","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","both","","","1207.50","905.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","462.47","38.3","","352.91","352.91","2046.30","1 through 10","374.33","959.96","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","both","","","1207.50","905.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","518.02","42.9","","9668.75","9668.75","9668.75","1 through 10","374.33","959.96","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","both","","","1207.50","905.62","WELLPOINT [1015]","HB AMC WELLPOINT","890.89","73.78","","699.88","384.10","3443.31","33","374.33","959.96","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1207.50","905.62","AETNA [1001]","HB AMC AETNA HMO","842.84","69.8","","1421.24","264.50","4933.46","29","631.04","986.77","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1207.50","905.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","970.83","80.4","","1022.97","1022.97","3607.50","1 through 10","631.04","986.77","percent of total billed charges",""
"GRAFT BONE 1ML OSTEOCEL MATRIX CELLULAR SM","SUP-ITM-10188187","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1207.50","905.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","986.77","81.72","","3010.54","693.88","5019.88","35","631.04","986.77","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.00","1480.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1569.33","79.5","","800.18","480.96","1887.97","195","611.94","1569.33","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.00","1480.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1052.14","53.3","","813.12","216.42","1444.50","81","611.94","1569.33","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.00","1480.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","611.94","31","","432.60","432.60","432.60","1 through 10","611.94","1569.33","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.00","1480.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","720.51","36.5","","148.37","54.89","631.39","94","611.94","1569.33","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.00","1480.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","756.04","38.3","","279.30","91.72","1116.77","266","611.94","1569.33","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.00","1480.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.85","42.9","","731.00","63.70","731.00","1 through 10","611.94","1569.33","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.00","1480.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.85","42.9","","384.74","384.74","384.74","1 through 10","611.94","1569.33","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.00","1480.50","WELLPOINT [1015]","HB AMC WELLPOINT","1456.42","73.78","","286.63","119.22","1107.45","105","611.94","1569.33","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1974.00","1480.50","AETNA [1001]","HB AMC AETNA HMO","1377.85","69.8","","675.31","184.75","1721.50","286","1031.61","1613.15","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1974.00","1480.50","AETNA [1001]","HB AMC AETNA PPO","1587.10","80.4","","1261.44","103.12","1514.10","21","1031.61","1613.15","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1974.00","1480.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1587.10","80.4","","1365.00","1365.00","1365.00","1 through 10","1031.61","1613.15","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1974.00","1480.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1613.15","81.72","","5157.68","5157.68","5157.68","1 through 10","1031.61","1613.15","percent of total billed charges",""
"GRAFT BONE 2.5 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1974.00","1480.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1613.15","81.72","","431.26","71.26","1459.57","88","1031.61","1613.15","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.58","844.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","895.63","79.5","","800.18","480.96","1887.97","195","349.24","895.63","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.58","844.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","600.47","53.3","","813.12","216.42","1444.50","81","349.24","895.63","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.58","844.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","349.24","31","","432.60","432.60","432.60","1 through 10","349.24","895.63","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.58","844.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","411.20","36.5","","148.37","54.89","631.39","94","349.24","895.63","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.58","844.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","431.48","38.3","","279.30","91.72","1116.77","266","349.24","895.63","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.58","844.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","483.30","42.9","","731.00","63.70","731.00","1 through 10","349.24","895.63","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.58","844.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","483.30","42.9","","384.74","384.74","384.74","1 through 10","349.24","895.63","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.58","844.93","WELLPOINT [1015]","HB AMC WELLPOINT","831.19","73.78","","286.63","119.22","1107.45","105","349.24","895.63","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.58","844.93","AETNA [1001]","HB AMC AETNA HMO","786.35","69.8","","675.31","184.75","1721.50","286","588.75","920.64","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.58","844.93","AETNA [1001]","HB AMC AETNA PPO","905.77","80.4","","1261.44","103.12","1514.10","21","588.75","920.64","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.58","844.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","905.77","80.4","","1365.00","1365.00","1365.00","1 through 10","588.75","920.64","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.58","844.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","920.64","81.72","","5157.68","5157.68","5157.68","1 through 10","588.75","920.64","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.58","844.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","920.64","81.72","","431.26","71.26","1459.57","88","588.75","920.64","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION","SUP-ITM-10168341","CDM","C1889","HCPCS","0278","RC","","","","both","","","5176.50","3882.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4115.32","79.5","","1309.77","674.56","6049.93","26","1604.72","4115.32","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION","SUP-ITM-10168341","CDM","C1889","HCPCS","0278","RC","","","","both","","","5176.50","3882.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2759.07","53.3","","1901.83","1901.83","2962.25","1 through 10","1604.72","4115.32","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION","SUP-ITM-10168341","CDM","C1889","HCPCS","0278","RC","","","","both","","","5176.50","3882.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1889.42","36.5","","1620.31","1620.31","19908.88","1 through 10","1604.72","4115.32","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION","SUP-ITM-10168341","CDM","C1889","HCPCS","0278","RC","","","","both","","","5176.50","3882.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1982.60","38.3","","352.91","352.91","2046.30","1 through 10","1604.72","4115.32","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION","SUP-ITM-10168341","CDM","C1889","HCPCS","0278","RC","","","","both","","","5176.50","3882.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2220.72","42.9","","9668.75","9668.75","9668.75","1 through 10","1604.72","4115.32","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION","SUP-ITM-10168341","CDM","C1889","HCPCS","0278","RC","","","","both","","","5176.50","3882.37","WELLPOINT [1015]","HB AMC WELLPOINT","3819.22","73.78","","699.88","384.10","3443.31","33","1604.72","4115.32","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION","SUP-ITM-10168341","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5176.50","3882.37","AETNA [1001]","HB AMC AETNA HMO","3613.20","69.8","","1421.24","264.50","4933.46","29","2705.24","4230.24","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION","SUP-ITM-10168341","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5176.50","3882.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4161.91","80.4","","1022.97","1022.97","3607.50","1 through 10","2705.24","4230.24","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION","SUP-ITM-10168341","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5176.50","3882.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4230.24","81.72","","3010.54","693.88","5019.88","35","2705.24","4230.24","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX FLEX","SUP-ITM-10168343","CDM","C1889","HCPCS","0278","RC","","","","both","","","3693.76","2770.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2936.54","79.5","","1309.77","674.56","6049.93","26","1145.07","2936.54","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX FLEX","SUP-ITM-10168343","CDM","C1889","HCPCS","0278","RC","","","","both","","","3693.76","2770.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1968.77","53.3","","1901.83","1901.83","2962.25","1 through 10","1145.07","2936.54","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX FLEX","SUP-ITM-10168343","CDM","C1889","HCPCS","0278","RC","","","","both","","","3693.76","2770.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1348.22","36.5","","1620.31","1620.31","19908.88","1 through 10","1145.07","2936.54","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX FLEX","SUP-ITM-10168343","CDM","C1889","HCPCS","0278","RC","","","","both","","","3693.76","2770.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1414.71","38.3","","352.91","352.91","2046.30","1 through 10","1145.07","2936.54","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX FLEX","SUP-ITM-10168343","CDM","C1889","HCPCS","0278","RC","","","","both","","","3693.76","2770.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1584.62","42.9","","9668.75","9668.75","9668.75","1 through 10","1145.07","2936.54","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX FLEX","SUP-ITM-10168343","CDM","C1889","HCPCS","0278","RC","","","","both","","","3693.76","2770.32","WELLPOINT [1015]","HB AMC WELLPOINT","2725.26","73.78","","699.88","384.10","3443.31","33","1145.07","2936.54","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX FLEX","SUP-ITM-10168343","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3693.76","2770.32","AETNA [1001]","HB AMC AETNA HMO","2578.24","69.8","","1421.24","264.50","4933.46","29","1930.36","3018.54","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX FLEX","SUP-ITM-10168343","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3693.76","2770.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2969.78","80.4","","1022.97","1022.97","3607.50","1 through 10","1930.36","3018.54","percent of total billed charges",""
"GRAFT BONE 2.5X10CM ON DEMINERALIZED MATRIX FLEX","SUP-ITM-10168343","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3693.76","2770.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3018.54","81.72","","3010.54","693.88","5019.88","35","1930.36","3018.54","percent of total billed charges",""
"GRAFT BONE 2.5X5CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION T42210","SUP-ITM-10168340","CDM","C1889","HCPCS","0278","RC","","","","both","","","4493.44","3370.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3572.28","79.5","","1309.77","674.56","6049.93","26","1392.97","3572.28","percent of total billed charges",""
"GRAFT BONE 2.5X5CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION T42210","SUP-ITM-10168340","CDM","C1889","HCPCS","0278","RC","","","","both","","","4493.44","3370.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2395.00","53.3","","1901.83","1901.83","2962.25","1 through 10","1392.97","3572.28","percent of total billed charges",""
"GRAFT BONE 2.5X5CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION T42210","SUP-ITM-10168340","CDM","C1889","HCPCS","0278","RC","","","","both","","","4493.44","3370.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1640.11","36.5","","1620.31","1620.31","19908.88","1 through 10","1392.97","3572.28","percent of total billed charges",""
"GRAFT BONE 2.5X5CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION T42210","SUP-ITM-10168340","CDM","C1889","HCPCS","0278","RC","","","","both","","","4493.44","3370.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1720.99","38.3","","352.91","352.91","2046.30","1 through 10","1392.97","3572.28","percent of total billed charges",""
"GRAFT BONE 2.5X5CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION T42210","SUP-ITM-10168340","CDM","C1889","HCPCS","0278","RC","","","","both","","","4493.44","3370.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1927.69","42.9","","9668.75","9668.75","9668.75","1 through 10","1392.97","3572.28","percent of total billed charges",""
"GRAFT BONE 2.5X5CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION T42210","SUP-ITM-10168340","CDM","C1889","HCPCS","0278","RC","","","","both","","","4493.44","3370.08","WELLPOINT [1015]","HB AMC WELLPOINT","3315.26","73.78","","699.88","384.10","3443.31","33","1392.97","3572.28","percent of total billed charges",""
"GRAFT BONE 2.5X5CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION T42210","SUP-ITM-10168340","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4493.44","3370.08","AETNA [1001]","HB AMC AETNA HMO","3136.42","69.8","","1421.24","264.50","4933.46","29","2348.27","3672.04","percent of total billed charges",""
"GRAFT BONE 2.5X5CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION T42210","SUP-ITM-10168340","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4493.44","3370.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3612.73","80.4","","1022.97","1022.97","3607.50","1 through 10","2348.27","3672.04","percent of total billed charges",""
"GRAFT BONE 2.5X5CM ON DEMINERALIZED MATRIX BOAT POSTERIOR LATERAL FUSION T42210","SUP-ITM-10168340","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4493.44","3370.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3672.04","81.72","","3010.54","693.88","5019.88","35","2348.27","3672.04","percent of total billed charges",""
"GRAFT BONE 200MM MATRI ALLO TIBIAL SHAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010305","CDM","C1889","HCPCS","0278","RC","","","","both","","","4073.37","3055.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3238.33","79.5","","1309.77","674.56","6049.93","26","1262.74","3238.33","percent of total billed charges",""
"GRAFT BONE 200MM MATRI ALLO TIBIAL SHAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010305","CDM","C1889","HCPCS","0278","RC","","","","both","","","4073.37","3055.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2171.11","53.3","","1901.83","1901.83","2962.25","1 through 10","1262.74","3238.33","percent of total billed charges",""
"GRAFT BONE 200MM MATRI ALLO TIBIAL SHAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010305","CDM","C1889","HCPCS","0278","RC","","","","both","","","4073.37","3055.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1486.78","36.5","","1620.31","1620.31","19908.88","1 through 10","1262.74","3238.33","percent of total billed charges",""
"GRAFT BONE 200MM MATRI ALLO TIBIAL SHAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010305","CDM","C1889","HCPCS","0278","RC","","","","both","","","4073.37","3055.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1560.10","38.3","","352.91","352.91","2046.30","1 through 10","1262.74","3238.33","percent of total billed charges",""
"GRAFT BONE 200MM MATRI ALLO TIBIAL SHAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010305","CDM","C1889","HCPCS","0278","RC","","","","both","","","4073.37","3055.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1747.48","42.9","","9668.75","9668.75","9668.75","1 through 10","1262.74","3238.33","percent of total billed charges",""
"GRAFT BONE 200MM MATRI ALLO TIBIAL SHAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010305","CDM","C1889","HCPCS","0278","RC","","","","both","","","4073.37","3055.03","WELLPOINT [1015]","HB AMC WELLPOINT","3005.33","73.78","","699.88","384.10","3443.31","33","1262.74","3238.33","percent of total billed charges",""
"GRAFT BONE 200MM MATRI ALLO TIBIAL SHAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010305","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4073.37","3055.03","AETNA [1001]","HB AMC AETNA HMO","2843.21","69.8","","1421.24","264.50","4933.46","29","2128.74","3328.76","percent of total billed charges",""
"GRAFT BONE 200MM MATRI ALLO TIBIAL SHAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010305","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4073.37","3055.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3274.99","80.4","","1022.97","1022.97","3607.50","1 through 10","2128.74","3328.76","percent of total billed charges",""
"GRAFT BONE 200MM MATRI ALLO TIBIAL SHAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010305","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4073.37","3055.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3328.76","81.72","","3010.54","693.88","5019.88","35","2128.74","3328.76","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2971.22","2228.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2362.12","79.5","","1309.77","674.56","6049.93","26","921.08","2362.12","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2971.22","2228.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1583.66","53.3","","1901.83","1901.83","2962.25","1 through 10","921.08","2362.12","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2971.22","2228.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1084.50","36.5","","1620.31","1620.31","19908.88","1 through 10","921.08","2362.12","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2971.22","2228.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1137.98","38.3","","352.91","352.91","2046.30","1 through 10","921.08","2362.12","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2971.22","2228.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1274.65","42.9","","9668.75","9668.75","9668.75","1 through 10","921.08","2362.12","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2971.22","2228.41","WELLPOINT [1015]","HB AMC WELLPOINT","2192.17","73.78","","699.88","384.10","3443.31","33","921.08","2362.12","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2971.22","2228.41","AETNA [1001]","HB AMC AETNA HMO","2073.91","69.8","","1421.24","264.50","4933.46","29","1552.76","2428.08","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2971.22","2228.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2388.86","80.4","","1022.97","1022.97","3607.50","1 through 10","1552.76","2428.08","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2971.22","2228.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2428.08","81.72","","3010.54","693.88","5019.88","35","1552.76","2428.08","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1418.41","1063.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1127.64","79.5","","1309.77","674.56","6049.93","26","439.71","1127.64","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1418.41","1063.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","756.01","53.3","","1901.83","1901.83","2962.25","1 through 10","439.71","1127.64","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1418.41","1063.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","517.72","36.5","","1620.31","1620.31","19908.88","1 through 10","439.71","1127.64","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1418.41","1063.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","543.25","38.3","","352.91","352.91","2046.30","1 through 10","439.71","1127.64","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1418.41","1063.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","608.50","42.9","","9668.75","9668.75","9668.75","1 through 10","439.71","1127.64","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1418.41","1063.81","WELLPOINT [1015]","HB AMC WELLPOINT","1046.50","73.78","","699.88","384.10","3443.31","33","439.71","1127.64","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1418.41","1063.81","AETNA [1001]","HB AMC AETNA HMO","990.05","69.8","","1421.24","264.50","4933.46","29","741.26","1159.12","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1418.41","1063.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1140.40","80.4","","1022.97","1022.97","3607.50","1 through 10","741.26","1159.12","percent of total billed charges",""
"GRAFT BONE 20X200MM MATRI ALLO FEMORAL STRUT CORTICAL FROZEN","SUP-ITM-10010267","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1418.41","1063.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1159.12","81.72","","3010.54","693.88","5019.88","35","741.26","1159.12","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","both","","","1636.85","1227.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1301.30","79.5","","1309.77","674.56","6049.93","26","507.42","1301.3","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","both","","","1636.85","1227.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","872.44","53.3","","1901.83","1901.83","2962.25","1 through 10","507.42","1301.3","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","both","","","1636.85","1227.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","597.45","36.5","","1620.31","1620.31","19908.88","1 through 10","507.42","1301.3","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","both","","","1636.85","1227.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","626.91","38.3","","352.91","352.91","2046.30","1 through 10","507.42","1301.3","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","both","","","1636.85","1227.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","702.21","42.9","","9668.75","9668.75","9668.75","1 through 10","507.42","1301.3","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","both","","","1636.85","1227.64","WELLPOINT [1015]","HB AMC WELLPOINT","1207.67","73.78","","699.88","384.10","3443.31","33","507.42","1301.3","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1636.85","1227.64","AETNA [1001]","HB AMC AETNA HMO","1142.52","69.8","","1421.24","264.50","4933.46","29","855.42","1337.63","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1636.85","1227.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1316.03","80.4","","1022.97","1022.97","3607.50","1 through 10","855.42","1337.63","percent of total billed charges",""
"GRAFT BONE 20X8 TO 15MM FREEZE DRIED MATRI FIBULA SEGMENT IMPLANTABLE","SUP-ITM-10010284","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1636.85","1227.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1337.63","81.72","","3010.54","693.88","5019.88","35","855.42","1337.63","percent of total billed charges",""
"GRAFT BONE 25.0X100.0 4.0MM SUBSTITUTE VITOSS BIOACTIVE FOAM STRIP","SUP-ITM-10029649","CDM","C1763","HCPCS","0278","RC","","","","both","","","5048.01","3786.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3281.21","65","","2028.23","1653.70","2028.23","1 through 10","1564.88","4013.17","percent of total billed charges",""
"GRAFT BONE 25.0X100.0 4.0MM SUBSTITUTE VITOSS BIOACTIVE FOAM STRIP","SUP-ITM-10029649","CDM","C1763","HCPCS","0278","RC","","","","both","","","5048.01","3786.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1842.52","36.5","","1163.89","1163.89","1163.89","1 through 10","1564.88","4013.17","percent of total billed charges",""
"GRAFT BONE 25.0X100.0 4.0MM SUBSTITUTE VITOSS BIOACTIVE FOAM STRIP","SUP-ITM-10029649","CDM","C1763","HCPCS","0278","RC","","","","both","","","5048.01","3786.01","WELLPOINT [1015]","HB AMC WELLPOINT","3724.42","73.78","","4280.87","4280.87","4280.87","1 through 10","1564.88","4013.17","percent of total billed charges",""
"GRAFT BONE 2CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287272","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","1309.77","674.56","6049.93","26","260.4","667.8","percent of total billed charges",""
"GRAFT BONE 2CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287272","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","1901.83","1901.83","2962.25","1 through 10","260.4","667.8","percent of total billed charges",""
"GRAFT BONE 2CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287272","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","1620.31","1620.31","19908.88","1 through 10","260.4","667.8","percent of total billed charges",""
"GRAFT BONE 2CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287272","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","352.91","352.91","2046.30","1 through 10","260.4","667.8","percent of total billed charges",""
"GRAFT BONE 2CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287272","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","9668.75","9668.75","9668.75","1 through 10","260.4","667.8","percent of total billed charges",""
"GRAFT BONE 2CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287272","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","699.88","384.10","3443.31","33","260.4","667.8","percent of total billed charges",""
"GRAFT BONE 2CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287272","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","1421.24","264.50","4933.46","29","438.98","686.45","percent of total billed charges",""
"GRAFT BONE 2CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287272","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1022.97","1022.97","3607.50","1 through 10","438.98","686.45","percent of total billed charges",""
"GRAFT BONE 2CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287272","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","3010.54","693.88","5019.88","35","438.98","686.45","percent of total billed charges",""
"GRAFT BONE 30 75MM 13X8.0 14CM ALLO PATELLA TENDON HEMI QUADRICEP FROZEN SPACE","SUP-ITM-10010681","CDM","C1889","HCPCS","0278","RC","","","","both","","","6608.13","4956.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5253.46","79.5","","1309.77","674.56","6049.93","26","2048.52","5253.46","percent of total billed charges",""
"GRAFT BONE 30 75MM 13X8.0 14CM ALLO PATELLA TENDON HEMI QUADRICEP FROZEN SPACE","SUP-ITM-10010681","CDM","C1889","HCPCS","0278","RC","","","","both","","","6608.13","4956.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3522.13","53.3","","1901.83","1901.83","2962.25","1 through 10","2048.52","5253.46","percent of total billed charges",""
"GRAFT BONE 30 75MM 13X8.0 14CM ALLO PATELLA TENDON HEMI QUADRICEP FROZEN SPACE","SUP-ITM-10010681","CDM","C1889","HCPCS","0278","RC","","","","both","","","6608.13","4956.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2411.97","36.5","","1620.31","1620.31","19908.88","1 through 10","2048.52","5253.46","percent of total billed charges",""
"GRAFT BONE 30 75MM 13X8.0 14CM ALLO PATELLA TENDON HEMI QUADRICEP FROZEN SPACE","SUP-ITM-10010681","CDM","C1889","HCPCS","0278","RC","","","","both","","","6608.13","4956.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2530.91","38.3","","352.91","352.91","2046.30","1 through 10","2048.52","5253.46","percent of total billed charges",""
"GRAFT BONE 30 75MM 13X8.0 14CM ALLO PATELLA TENDON HEMI QUADRICEP FROZEN SPACE","SUP-ITM-10010681","CDM","C1889","HCPCS","0278","RC","","","","both","","","6608.13","4956.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2834.89","42.9","","9668.75","9668.75","9668.75","1 through 10","2048.52","5253.46","percent of total billed charges",""
"GRAFT BONE 30 75MM 13X8.0 14CM ALLO PATELLA TENDON HEMI QUADRICEP FROZEN SPACE","SUP-ITM-10010681","CDM","C1889","HCPCS","0278","RC","","","","both","","","6608.13","4956.10","WELLPOINT [1015]","HB AMC WELLPOINT","4875.48","73.78","","699.88","384.10","3443.31","33","2048.52","5253.46","percent of total billed charges",""
"GRAFT BONE 30 75MM 13X8.0 14CM ALLO PATELLA TENDON HEMI QUADRICEP FROZEN SPACE","SUP-ITM-10010681","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6608.13","4956.10","AETNA [1001]","HB AMC AETNA HMO","4612.47","69.8","","1421.24","264.50","4933.46","29","3453.41","5400.16","percent of total billed charges",""
"GRAFT BONE 30 75MM 13X8.0 14CM ALLO PATELLA TENDON HEMI QUADRICEP FROZEN SPACE","SUP-ITM-10010681","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6608.13","4956.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5312.94","80.4","","1022.97","1022.97","3607.50","1 through 10","3453.41","5400.16","percent of total billed charges",""
"GRAFT BONE 30 75MM 13X8.0 14CM ALLO PATELLA TENDON HEMI QUADRICEP FROZEN SPACE","SUP-ITM-10010681","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6608.13","4956.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5400.16","81.72","","3010.54","693.88","5019.88","35","3453.41","5400.16","percent of total billed charges",""
"GRAFT BONE 30-59MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289157","CDM","C1889","HCPCS","0278","RC","","","","both","","","1783.22","1337.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1417.66","79.5","","1309.77","674.56","6049.93","26","552.8","1417.66","percent of total billed charges",""
"GRAFT BONE 30-59MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289157","CDM","C1889","HCPCS","0278","RC","","","","both","","","1783.22","1337.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","950.46","53.3","","1901.83","1901.83","2962.25","1 through 10","552.8","1417.66","percent of total billed charges",""
"GRAFT BONE 30-59MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289157","CDM","C1889","HCPCS","0278","RC","","","","both","","","1783.22","1337.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","650.88","36.5","","1620.31","1620.31","19908.88","1 through 10","552.8","1417.66","percent of total billed charges",""
"GRAFT BONE 30-59MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289157","CDM","C1889","HCPCS","0278","RC","","","","both","","","1783.22","1337.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","682.97","38.3","","352.91","352.91","2046.30","1 through 10","552.8","1417.66","percent of total billed charges",""
"GRAFT BONE 30-59MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289157","CDM","C1889","HCPCS","0278","RC","","","","both","","","1783.22","1337.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","765.00","42.9","","9668.75","9668.75","9668.75","1 through 10","552.8","1417.66","percent of total billed charges",""
"GRAFT BONE 30-59MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289157","CDM","C1889","HCPCS","0278","RC","","","","both","","","1783.22","1337.41","WELLPOINT [1015]","HB AMC WELLPOINT","1315.66","73.78","","699.88","384.10","3443.31","33","552.8","1417.66","percent of total billed charges",""
"GRAFT BONE 30-59MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289157","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1783.22","1337.41","AETNA [1001]","HB AMC AETNA HMO","1244.69","69.8","","1421.24","264.50","4933.46","29","931.91","1457.25","percent of total billed charges",""
"GRAFT BONE 30-59MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289157","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1783.22","1337.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1433.71","80.4","","1022.97","1022.97","3607.50","1 through 10","931.91","1457.25","percent of total billed charges",""
"GRAFT BONE 30-59MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289157","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1783.22","1337.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1457.25","81.72","","3010.54","693.88","5019.88","35","931.91","1457.25","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","both","","","3344.46","2508.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2658.85","79.5","","1309.77","674.56","6049.93","26","1036.78","2658.85","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","both","","","3344.46","2508.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1782.60","53.3","","1901.83","1901.83","2962.25","1 through 10","1036.78","2658.85","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","both","","","3344.46","2508.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1220.73","36.5","","1620.31","1620.31","19908.88","1 through 10","1036.78","2658.85","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","both","","","3344.46","2508.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1280.93","38.3","","352.91","352.91","2046.30","1 through 10","1036.78","2658.85","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","both","","","3344.46","2508.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1434.77","42.9","","9668.75","9668.75","9668.75","1 through 10","1036.78","2658.85","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","both","","","3344.46","2508.34","WELLPOINT [1015]","HB AMC WELLPOINT","2467.54","73.78","","699.88","384.10","3443.31","33","1036.78","2658.85","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3344.46","2508.34","AETNA [1001]","HB AMC AETNA HMO","2334.43","69.8","","1421.24","264.50","4933.46","29","1747.81","2733.09","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3344.46","2508.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2688.95","80.4","","1022.97","1022.97","3607.50","1 through 10","1747.81","2733.09","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3344.46","2508.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2733.09","81.72","","3010.54","693.88","5019.88","35","1747.81","2733.09","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2696.24","79.5","","1309.77","674.56","6049.93","26","1051.37","2696.24","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1807.67","53.3","","1901.83","1901.83","2962.25","1 through 10","1051.37","2696.24","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1237.90","36.5","","1620.31","1620.31","19908.88","1 through 10","1051.37","2696.24","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1298.94","38.3","","352.91","352.91","2046.30","1 through 10","1051.37","2696.24","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1454.95","42.9","","9668.75","9668.75","9668.75","1 through 10","1051.37","2696.24","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","3391.50","2543.62","WELLPOINT [1015]","HB AMC WELLPOINT","2502.25","73.78","","699.88","384.10","3443.31","33","1051.37","2696.24","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3391.50","2543.62","AETNA [1001]","HB AMC AETNA HMO","2367.27","69.8","","1421.24","264.50","4933.46","29","1772.4","2771.53","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3391.50","2543.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2726.77","80.4","","1022.97","1022.97","3607.50","1 through 10","1772.4","2771.53","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3391.50","2543.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2771.53","81.72","","3010.54","693.88","5019.88","35","1772.4","2771.53","percent of total billed charges",""
"GRAFT BONE 4ML REGENERATION INJECTABLE PRODENSE","SUP-ITM-10057121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.00","3195.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3386.70","79.5","","800.18","480.96","1887.97","195","1320.6","3386.7","percent of total billed charges",""
"GRAFT BONE 4ML REGENERATION INJECTABLE PRODENSE","SUP-ITM-10057121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.00","3195.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2270.58","53.3","","813.12","216.42","1444.50","81","1320.6","3386.7","percent of total billed charges",""
"GRAFT BONE 4ML REGENERATION INJECTABLE PRODENSE","SUP-ITM-10057121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.00","3195.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1320.60","31","","432.60","432.60","432.60","1 through 10","1320.6","3386.7","percent of total billed charges",""
"GRAFT BONE 4ML REGENERATION INJECTABLE PRODENSE","SUP-ITM-10057121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.00","3195.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1554.90","36.5","","148.37","54.89","631.39","94","1320.6","3386.7","percent of total billed charges",""
"GRAFT BONE 4ML REGENERATION INJECTABLE PRODENSE","SUP-ITM-10057121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.00","3195.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1631.58","38.3","","279.30","91.72","1116.77","266","1320.6","3386.7","percent of total billed charges",""
"GRAFT BONE 4ML REGENERATION INJECTABLE PRODENSE","SUP-ITM-10057121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.00","3195.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1827.54","42.9","","731.00","63.70","731.00","1 through 10","1320.6","3386.7","percent of total billed charges",""
"GRAFT BONE 4ML REGENERATION INJECTABLE PRODENSE","SUP-ITM-10057121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.00","3195.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1827.54","42.9","","384.74","384.74","384.74","1 through 10","1320.6","3386.7","percent of total billed charges",""
"GRAFT BONE 4ML REGENERATION INJECTABLE PRODENSE","SUP-ITM-10057121","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.00","3195.00","WELLPOINT [1015]","HB AMC WELLPOINT","3143.03","73.78","","286.63","119.22","1107.45","105","1320.6","3386.7","percent of total billed charges",""
"GRAFT BONE 4ML REGENERATION INJECTABLE PRODENSE","SUP-ITM-10057121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.00","3195.00","AETNA [1001]","HB AMC AETNA HMO","2973.48","69.8","","675.31","184.75","1721.50","286","2226.28","3481.27","percent of total billed charges",""
"GRAFT BONE 4ML REGENERATION INJECTABLE PRODENSE","SUP-ITM-10057121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.00","3195.00","AETNA [1001]","HB AMC AETNA PPO","3425.04","80.4","","1261.44","103.12","1514.10","21","2226.28","3481.27","percent of total billed charges",""
"GRAFT BONE 4ML REGENERATION INJECTABLE PRODENSE","SUP-ITM-10057121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.00","3195.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3425.04","80.4","","1365.00","1365.00","1365.00","1 through 10","2226.28","3481.27","percent of total billed charges",""
"GRAFT BONE 4ML REGENERATION INJECTABLE PRODENSE","SUP-ITM-10057121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.00","3195.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3481.27","81.72","","5157.68","5157.68","5157.68","1 through 10","2226.28","3481.27","percent of total billed charges",""
"GRAFT BONE 4ML REGENERATION INJECTABLE PRODENSE","SUP-ITM-10057121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.00","3195.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3481.27","81.72","","431.26","71.26","1459.57","88","2226.28","3481.27","percent of total billed charges",""
"GRAFT BONE 50 70MM ALLO FEMORAL HEMI CONDYLE BISECTED DISTAL FROZEN","SUP-ITM-10010280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4793.79","3595.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3811.06","79.5","","1309.77","674.56","6049.93","26","1486.07","3811.06","percent of total billed charges",""
"GRAFT BONE 50 70MM ALLO FEMORAL HEMI CONDYLE BISECTED DISTAL FROZEN","SUP-ITM-10010280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4793.79","3595.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2555.09","53.3","","1901.83","1901.83","2962.25","1 through 10","1486.07","3811.06","percent of total billed charges",""
"GRAFT BONE 50 70MM ALLO FEMORAL HEMI CONDYLE BISECTED DISTAL FROZEN","SUP-ITM-10010280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4793.79","3595.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1749.73","36.5","","1620.31","1620.31","19908.88","1 through 10","1486.07","3811.06","percent of total billed charges",""
"GRAFT BONE 50 70MM ALLO FEMORAL HEMI CONDYLE BISECTED DISTAL FROZEN","SUP-ITM-10010280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4793.79","3595.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1836.02","38.3","","352.91","352.91","2046.30","1 through 10","1486.07","3811.06","percent of total billed charges",""
"GRAFT BONE 50 70MM ALLO FEMORAL HEMI CONDYLE BISECTED DISTAL FROZEN","SUP-ITM-10010280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4793.79","3595.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2056.54","42.9","","9668.75","9668.75","9668.75","1 through 10","1486.07","3811.06","percent of total billed charges",""
"GRAFT BONE 50 70MM ALLO FEMORAL HEMI CONDYLE BISECTED DISTAL FROZEN","SUP-ITM-10010280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4793.79","3595.34","WELLPOINT [1015]","HB AMC WELLPOINT","3536.86","73.78","","699.88","384.10","3443.31","33","1486.07","3811.06","percent of total billed charges",""
"GRAFT BONE 50 70MM ALLO FEMORAL HEMI CONDYLE BISECTED DISTAL FROZEN","SUP-ITM-10010280","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4793.79","3595.34","AETNA [1001]","HB AMC AETNA HMO","3346.07","69.8","","1421.24","264.50","4933.46","29","2505.23","3917.49","percent of total billed charges",""
"GRAFT BONE 50 70MM ALLO FEMORAL HEMI CONDYLE BISECTED DISTAL FROZEN","SUP-ITM-10010280","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4793.79","3595.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3854.21","80.4","","1022.97","1022.97","3607.50","1 through 10","2505.23","3917.49","percent of total billed charges",""
"GRAFT BONE 50 70MM ALLO FEMORAL HEMI CONDYLE BISECTED DISTAL FROZEN","SUP-ITM-10010280","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4793.79","3595.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3917.49","81.72","","3010.54","693.88","5019.88","35","2505.23","3917.49","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3680.56","79.5","","1309.77","674.56","6049.93","26","1435.19","3680.56","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2467.59","53.3","","1901.83","1901.83","2962.25","1 through 10","1435.19","3680.56","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1689.81","36.5","","1620.31","1620.31","19908.88","1 through 10","1435.19","3680.56","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1773.15","38.3","","352.91","352.91","2046.30","1 through 10","1435.19","3680.56","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.11","42.9","","9668.75","9668.75","9668.75","1 through 10","1435.19","3680.56","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","WELLPOINT [1015]","HB AMC WELLPOINT","3415.74","73.78","","699.88","384.10","3443.31","33","1435.19","3680.56","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4629.63","3472.22","AETNA [1001]","HB AMC AETNA HMO","3231.48","69.8","","1421.24","264.50","4933.46","29","2419.44","3783.33","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4629.63","3472.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3722.22","80.4","","1022.97","1022.97","3607.50","1 through 10","2419.44","3783.33","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4629.63","3472.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3783.33","81.72","","3010.54","693.88","5019.88","35","2419.44","3783.33","percent of total billed charges",""
"GRAFT BONE 5CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1767.50","1325.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1405.16","79.5","","1309.77","674.56","6049.93","26","547.93","1405.16","percent of total billed charges",""
"GRAFT BONE 5CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1767.50","1325.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","942.08","53.3","","1901.83","1901.83","2962.25","1 through 10","547.93","1405.16","percent of total billed charges",""
"GRAFT BONE 5CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1767.50","1325.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","645.14","36.5","","1620.31","1620.31","19908.88","1 through 10","547.93","1405.16","percent of total billed charges",""
"GRAFT BONE 5CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1767.50","1325.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","676.95","38.3","","352.91","352.91","2046.30","1 through 10","547.93","1405.16","percent of total billed charges",""
"GRAFT BONE 5CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1767.50","1325.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","758.26","42.9","","9668.75","9668.75","9668.75","1 through 10","547.93","1405.16","percent of total billed charges",""
"GRAFT BONE 5CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287267","CDM","C1889","HCPCS","0278","RC","","","","both","","","1767.50","1325.62","WELLPOINT [1015]","HB AMC WELLPOINT","1304.06","73.78","","699.88","384.10","3443.31","33","547.93","1405.16","percent of total billed charges",""
"GRAFT BONE 5CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287267","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1767.50","1325.62","AETNA [1001]","HB AMC AETNA HMO","1233.72","69.8","","1421.24","264.50","4933.46","29","923.7","1444.4","percent of total billed charges",""
"GRAFT BONE 5CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287267","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1767.50","1325.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1421.07","80.4","","1022.97","1022.97","3607.50","1 through 10","923.7","1444.4","percent of total billed charges",""
"GRAFT BONE 5CC PUTTY VESUVIUS DBM 100","SUP-ITM-10287267","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1767.50","1325.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1444.40","81.72","","3010.54","693.88","5019.88","35","923.7","1444.4","percent of total billed charges",""
"GRAFT BONE 5CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287271","CDM","C1889","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1182.56","79.5","","1309.77","674.56","6049.93","26","461.13","1182.56","percent of total billed charges",""
"GRAFT BONE 5CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287271","CDM","C1889","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","792.84","53.3","","1901.83","1901.83","2962.25","1 through 10","461.13","1182.56","percent of total billed charges",""
"GRAFT BONE 5CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287271","CDM","C1889","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","542.94","36.5","","1620.31","1620.31","19908.88","1 through 10","461.13","1182.56","percent of total billed charges",""
"GRAFT BONE 5CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287271","CDM","C1889","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","569.71","38.3","","352.91","352.91","2046.30","1 through 10","461.13","1182.56","percent of total billed charges",""
"GRAFT BONE 5CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287271","CDM","C1889","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","638.14","42.9","","9668.75","9668.75","9668.75","1 through 10","461.13","1182.56","percent of total billed charges",""
"GRAFT BONE 5CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287271","CDM","C1889","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","WELLPOINT [1015]","HB AMC WELLPOINT","1097.48","73.78","","699.88","384.10","3443.31","33","461.13","1182.56","percent of total billed charges",""
"GRAFT BONE 5CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287271","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","AETNA [1001]","HB AMC AETNA HMO","1038.28","69.8","","1421.24","264.50","4933.46","29","777.37","1215.59","percent of total billed charges",""
"GRAFT BONE 5CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287271","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1195.95","80.4","","1022.97","1022.97","3607.50","1 through 10","777.37","1215.59","percent of total billed charges",""
"GRAFT BONE 5CC VESUVIUS DEMINERALIZED CORTICAL FIBER CANCELLOUS CHIP OSTEOCONDUCTIVE OSTEOGENIC","SUP-ITM-10287271","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1215.59","81.72","","3010.54","693.88","5019.88","35","777.37","1215.59","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","2076.62","1557.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1650.91","79.5","","1309.77","674.56","6049.93","26","643.75","1650.91","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","2076.62","1557.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1106.84","53.3","","1901.83","1901.83","2962.25","1 through 10","643.75","1650.91","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","2076.62","1557.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","757.97","36.5","","1620.31","1620.31","19908.88","1 through 10","643.75","1650.91","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","2076.62","1557.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","795.35","38.3","","352.91","352.91","2046.30","1 through 10","643.75","1650.91","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","2076.62","1557.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","890.87","42.9","","9668.75","9668.75","9668.75","1 through 10","643.75","1650.91","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","2076.62","1557.46","WELLPOINT [1015]","HB AMC WELLPOINT","1532.13","73.78","","699.88","384.10","3443.31","33","643.75","1650.91","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2076.62","1557.46","AETNA [1001]","HB AMC AETNA HMO","1449.48","69.8","","1421.24","264.50","4933.46","29","1085.24","1697.01","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2076.62","1557.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1669.60","80.4","","1022.97","1022.97","3607.50","1 through 10","1085.24","1697.01","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2076.62","1557.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1697.01","81.72","","3010.54","693.88","5019.88","35","1085.24","1697.01","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4233.38","79.5","","1309.77","674.56","6049.93","26","1650.75","4233.38","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2838.23","53.3","","1901.83","1901.83","2962.25","1 through 10","1650.75","4233.38","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1943.63","36.5","","1620.31","1620.31","19908.88","1 through 10","1650.75","4233.38","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2039.48","38.3","","352.91","352.91","2046.30","1 through 10","1650.75","4233.38","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2284.43","42.9","","9668.75","9668.75","9668.75","1 through 10","1650.75","4233.38","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","WELLPOINT [1015]","HB AMC WELLPOINT","3928.79","73.78","","699.88","384.10","3443.31","33","1650.75","4233.38","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5325.00","3993.75","AETNA [1001]","HB AMC AETNA HMO","3716.85","69.8","","1421.24","264.50","4933.46","29","2782.85","4351.59","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5325.00","3993.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4281.30","80.4","","1022.97","1022.97","3607.50","1 through 10","2782.85","4351.59","percent of total billed charges",""
"GRAFT BONE 5ML OSTEOCEL MATRIX CELLULAR MED","SUP-ITM-10188188","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5325.00","3993.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4351.59","81.72","","3010.54","693.88","5019.88","35","2782.85","4351.59","percent of total billed charges",""
"GRAFT BONE 5ML SUBST RESORBABLE MINI BEAD OSTEOSET FAST CURE","SUP-ITM-10018457","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1744.63","79.5","","800.18","480.96","1887.97","195","680.3","1744.63","percent of total billed charges",""
"GRAFT BONE 5ML SUBST RESORBABLE MINI BEAD OSTEOSET FAST CURE","SUP-ITM-10018457","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1169.67","53.3","","813.12","216.42","1444.50","81","680.3","1744.63","percent of total billed charges",""
"GRAFT BONE 5ML SUBST RESORBABLE MINI BEAD OSTEOSET FAST CURE","SUP-ITM-10018457","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","680.30","31","","432.60","432.60","432.60","1 through 10","680.3","1744.63","percent of total billed charges",""
"GRAFT BONE 5ML SUBST RESORBABLE MINI BEAD OSTEOSET FAST CURE","SUP-ITM-10018457","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","800.99","36.5","","148.37","54.89","631.39","94","680.3","1744.63","percent of total billed charges",""
"GRAFT BONE 5ML SUBST RESORBABLE MINI BEAD OSTEOSET FAST CURE","SUP-ITM-10018457","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","840.49","38.3","","279.30","91.72","1116.77","266","680.3","1744.63","percent of total billed charges",""
"GRAFT BONE 5ML SUBST RESORBABLE MINI BEAD OSTEOSET FAST CURE","SUP-ITM-10018457","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","941.44","42.9","","731.00","63.70","731.00","1 through 10","680.3","1744.63","percent of total billed charges",""
"GRAFT BONE 5ML SUBST RESORBABLE MINI BEAD OSTEOSET FAST CURE","SUP-ITM-10018457","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","941.44","42.9","","384.74","384.74","384.74","1 through 10","680.3","1744.63","percent of total billed charges",""
"GRAFT BONE 5ML SUBST RESORBABLE MINI BEAD OSTEOSET FAST CURE","SUP-ITM-10018457","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","WELLPOINT [1015]","HB AMC WELLPOINT","1619.10","73.78","","286.63","119.22","1107.45","105","680.3","1744.63","percent of total billed charges",""
"GRAFT BONE 5ML SUBST RESORBABLE MINI BEAD OSTEOSET FAST CURE","SUP-ITM-10018457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2194.50","1645.87","AETNA [1001]","HB AMC AETNA HMO","1531.76","69.8","","675.31","184.75","1721.50","286","1146.85","1793.35","percent of total billed charges",""
"GRAFT BONE 5ML SUBST RESORBABLE MINI BEAD OSTEOSET FAST CURE","SUP-ITM-10018457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2194.50","1645.87","AETNA [1001]","HB AMC AETNA PPO","1764.38","80.4","","1261.44","103.12","1514.10","21","1146.85","1793.35","percent of total billed charges",""
"GRAFT BONE 5ML SUBST RESORBABLE MINI BEAD OSTEOSET FAST CURE","SUP-ITM-10018457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2194.50","1645.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1764.38","80.4","","1365.00","1365.00","1365.00","1 through 10","1146.85","1793.35","percent of total billed charges",""
"GRAFT BONE 5ML SUBST RESORBABLE MINI BEAD OSTEOSET FAST CURE","SUP-ITM-10018457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2194.50","1645.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1793.35","81.72","","5157.68","5157.68","5157.68","1 through 10","1146.85","1793.35","percent of total billed charges",""
"GRAFT BONE 5ML SUBST RESORBABLE MINI BEAD OSTEOSET FAST CURE","SUP-ITM-10018457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2194.50","1645.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1793.35","81.72","","431.26","71.26","1459.57","88","1146.85","1793.35","percent of total billed charges",""
"GRAFT BONE 6.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199699","CDM","C1889","HCPCS","0278","RC","","","","both","","","3424.65","2568.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2722.60","79.5","","1309.77","674.56","6049.93","26","1061.64","2722.6","percent of total billed charges",""
"GRAFT BONE 6.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199699","CDM","C1889","HCPCS","0278","RC","","","","both","","","3424.65","2568.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1825.34","53.3","","1901.83","1901.83","2962.25","1 through 10","1061.64","2722.6","percent of total billed charges",""
"GRAFT BONE 6.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199699","CDM","C1889","HCPCS","0278","RC","","","","both","","","3424.65","2568.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1250.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1061.64","2722.6","percent of total billed charges",""
"GRAFT BONE 6.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199699","CDM","C1889","HCPCS","0278","RC","","","","both","","","3424.65","2568.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1311.64","38.3","","352.91","352.91","2046.30","1 through 10","1061.64","2722.6","percent of total billed charges",""
"GRAFT BONE 6.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199699","CDM","C1889","HCPCS","0278","RC","","","","both","","","3424.65","2568.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1469.17","42.9","","9668.75","9668.75","9668.75","1 through 10","1061.64","2722.6","percent of total billed charges",""
"GRAFT BONE 6.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199699","CDM","C1889","HCPCS","0278","RC","","","","both","","","3424.65","2568.49","WELLPOINT [1015]","HB AMC WELLPOINT","2526.71","73.78","","699.88","384.10","3443.31","33","1061.64","2722.6","percent of total billed charges",""
"GRAFT BONE 6.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199699","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3424.65","2568.49","AETNA [1001]","HB AMC AETNA HMO","2390.41","69.8","","1421.24","264.50","4933.46","29","1789.72","2798.62","percent of total billed charges",""
"GRAFT BONE 6.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199699","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3424.65","2568.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2753.42","80.4","","1022.97","1022.97","3607.50","1 through 10","1789.72","2798.62","percent of total billed charges",""
"GRAFT BONE 6.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199699","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3424.65","2568.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2798.62","81.72","","3010.54","693.88","5019.88","35","1789.72","2798.62","percent of total billed charges",""
"GRAFT BONE 60-90MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289158","CDM","C1889","HCPCS","0278","RC","","","","both","","","2136.65","1602.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1698.64","79.5","","1309.77","674.56","6049.93","26","662.36","1698.64","percent of total billed charges",""
"GRAFT BONE 60-90MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289158","CDM","C1889","HCPCS","0278","RC","","","","both","","","2136.65","1602.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1138.83","53.3","","1901.83","1901.83","2962.25","1 through 10","662.36","1698.64","percent of total billed charges",""
"GRAFT BONE 60-90MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289158","CDM","C1889","HCPCS","0278","RC","","","","both","","","2136.65","1602.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","779.88","36.5","","1620.31","1620.31","19908.88","1 through 10","662.36","1698.64","percent of total billed charges",""
"GRAFT BONE 60-90MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289158","CDM","C1889","HCPCS","0278","RC","","","","both","","","2136.65","1602.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","818.34","38.3","","352.91","352.91","2046.30","1 through 10","662.36","1698.64","percent of total billed charges",""
"GRAFT BONE 60-90MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289158","CDM","C1889","HCPCS","0278","RC","","","","both","","","2136.65","1602.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","916.62","42.9","","9668.75","9668.75","9668.75","1 through 10","662.36","1698.64","percent of total billed charges",""
"GRAFT BONE 60-90MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289158","CDM","C1889","HCPCS","0278","RC","","","","both","","","2136.65","1602.49","WELLPOINT [1015]","HB AMC WELLPOINT","1576.42","73.78","","699.88","384.10","3443.31","33","662.36","1698.64","percent of total billed charges",""
"GRAFT BONE 60-90MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289158","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2136.65","1602.49","AETNA [1001]","HB AMC AETNA HMO","1491.38","69.8","","1421.24","264.50","4933.46","29","1116.61","1746.07","percent of total billed charges",""
"GRAFT BONE 60-90MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289158","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2136.65","1602.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1717.87","80.4","","1022.97","1022.97","3607.50","1 through 10","1116.61","1746.07","percent of total billed charges",""
"GRAFT BONE 60-90MM CARTILAGE COSTAL FROZEN ALLOGRAFT","SUP-ITM-10289158","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2136.65","1602.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1746.07","81.72","","3010.54","693.88","5019.88","35","1116.61","1746.07","percent of total billed charges",""
"GRAFT BONE 7.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199700","CDM","C1889","HCPCS","0278","RC","","","","both","","","3424.65","2568.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2722.60","79.5","","1309.77","674.56","6049.93","26","1061.64","2722.6","percent of total billed charges",""
"GRAFT BONE 7.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199700","CDM","C1889","HCPCS","0278","RC","","","","both","","","3424.65","2568.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1825.34","53.3","","1901.83","1901.83","2962.25","1 through 10","1061.64","2722.6","percent of total billed charges",""
"GRAFT BONE 7.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199700","CDM","C1889","HCPCS","0278","RC","","","","both","","","3424.65","2568.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1250.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1061.64","2722.6","percent of total billed charges",""
"GRAFT BONE 7.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199700","CDM","C1889","HCPCS","0278","RC","","","","both","","","3424.65","2568.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1311.64","38.3","","352.91","352.91","2046.30","1 through 10","1061.64","2722.6","percent of total billed charges",""
"GRAFT BONE 7.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199700","CDM","C1889","HCPCS","0278","RC","","","","both","","","3424.65","2568.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1469.17","42.9","","9668.75","9668.75","9668.75","1 through 10","1061.64","2722.6","percent of total billed charges",""
"GRAFT BONE 7.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199700","CDM","C1889","HCPCS","0278","RC","","","","both","","","3424.65","2568.49","WELLPOINT [1015]","HB AMC WELLPOINT","2526.71","73.78","","699.88","384.10","3443.31","33","1061.64","2722.6","percent of total billed charges",""
"GRAFT BONE 7.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199700","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3424.65","2568.49","AETNA [1001]","HB AMC AETNA HMO","2390.41","69.8","","1421.24","264.50","4933.46","29","1789.72","2798.62","percent of total billed charges",""
"GRAFT BONE 7.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199700","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3424.65","2568.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2753.42","80.4","","1022.97","1022.97","3607.50","1 through 10","1789.72","2798.62","percent of total billed charges",""
"GRAFT BONE 7.0MM 7DEG VERTI VG2 CERVICAL LORDOSIS","SUP-ITM-10199700","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3424.65","2568.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2798.62","81.72","","3010.54","693.88","5019.88","35","1789.72","2798.62","percent of total billed charges",""
"GRAFT BONE ALLO FIBULA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10079397","CDM","C1889","HCPCS","0278","RC","","","","both","","","5818.60","4363.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4625.79","79.5","","1309.77","674.56","6049.93","26","1803.77","4625.79","percent of total billed charges",""
"GRAFT BONE ALLO FIBULA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10079397","CDM","C1889","HCPCS","0278","RC","","","","both","","","5818.60","4363.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3101.31","53.3","","1901.83","1901.83","2962.25","1 through 10","1803.77","4625.79","percent of total billed charges",""
"GRAFT BONE ALLO FIBULA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10079397","CDM","C1889","HCPCS","0278","RC","","","","both","","","5818.60","4363.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2123.79","36.5","","1620.31","1620.31","19908.88","1 through 10","1803.77","4625.79","percent of total billed charges",""
"GRAFT BONE ALLO FIBULA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10079397","CDM","C1889","HCPCS","0278","RC","","","","both","","","5818.60","4363.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2228.52","38.3","","352.91","352.91","2046.30","1 through 10","1803.77","4625.79","percent of total billed charges",""
"GRAFT BONE ALLO FIBULA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10079397","CDM","C1889","HCPCS","0278","RC","","","","both","","","5818.60","4363.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2496.18","42.9","","9668.75","9668.75","9668.75","1 through 10","1803.77","4625.79","percent of total billed charges",""
"GRAFT BONE ALLO FIBULA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10079397","CDM","C1889","HCPCS","0278","RC","","","","both","","","5818.60","4363.95","WELLPOINT [1015]","HB AMC WELLPOINT","4292.96","73.78","","699.88","384.10","3443.31","33","1803.77","4625.79","percent of total billed charges",""
"GRAFT BONE ALLO FIBULA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10079397","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5818.60","4363.95","AETNA [1001]","HB AMC AETNA HMO","4061.38","69.8","","1421.24","264.50","4933.46","29","3040.8","4754.96","percent of total billed charges",""
"GRAFT BONE ALLO FIBULA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10079397","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5818.60","4363.95","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4678.15","80.4","","1022.97","1022.97","3607.50","1 through 10","3040.8","4754.96","percent of total billed charges",""
"GRAFT BONE ALLO FIBULA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10079397","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5818.60","4363.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4754.96","81.72","","3010.54","693.88","5019.88","35","3040.8","4754.96","percent of total billed charges",""
"GRAFT BONE ALLO HUMERUS CUFF FROZEN WHOLE LEFT","SUP-ITM-10010805","CDM","C1889","HCPCS","0278","RC","","","","both","","","18513.30","13884.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","14718.07","79.5","","1309.77","674.56","6049.93","26","5739.12","14718.07","percent of total billed charges",""
"GRAFT BONE ALLO HUMERUS CUFF FROZEN WHOLE LEFT","SUP-ITM-10010805","CDM","C1889","HCPCS","0278","RC","","","","both","","","18513.30","13884.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9867.59","53.3","","1901.83","1901.83","2962.25","1 through 10","5739.12","14718.07","percent of total billed charges",""
"GRAFT BONE ALLO HUMERUS CUFF FROZEN WHOLE LEFT","SUP-ITM-10010805","CDM","C1889","HCPCS","0278","RC","","","","both","","","18513.30","13884.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6757.35","36.5","","1620.31","1620.31","19908.88","1 through 10","5739.12","14718.07","percent of total billed charges",""
"GRAFT BONE ALLO HUMERUS CUFF FROZEN WHOLE LEFT","SUP-ITM-10010805","CDM","C1889","HCPCS","0278","RC","","","","both","","","18513.30","13884.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7090.59","38.3","","352.91","352.91","2046.30","1 through 10","5739.12","14718.07","percent of total billed charges",""
"GRAFT BONE ALLO HUMERUS CUFF FROZEN WHOLE LEFT","SUP-ITM-10010805","CDM","C1889","HCPCS","0278","RC","","","","both","","","18513.30","13884.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7942.21","42.9","","9668.75","9668.75","9668.75","1 through 10","5739.12","14718.07","percent of total billed charges",""
"GRAFT BONE ALLO HUMERUS CUFF FROZEN WHOLE LEFT","SUP-ITM-10010805","CDM","C1889","HCPCS","0278","RC","","","","both","","","18513.30","13884.97","WELLPOINT [1015]","HB AMC WELLPOINT","13659.11","73.78","","699.88","384.10","3443.31","33","5739.12","14718.07","percent of total billed charges",""
"GRAFT BONE ALLO HUMERUS CUFF FROZEN WHOLE LEFT","SUP-ITM-10010805","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18513.30","13884.97","AETNA [1001]","HB AMC AETNA HMO","12922.28","69.8","","1421.24","264.50","4933.46","29","9675.05","15129.07","percent of total billed charges",""
"GRAFT BONE ALLO HUMERUS CUFF FROZEN WHOLE LEFT","SUP-ITM-10010805","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18513.30","13884.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","14884.69","80.4","","1022.97","1022.97","3607.50","1 through 10","9675.05","15129.07","percent of total billed charges",""
"GRAFT BONE ALLO HUMERUS CUFF FROZEN WHOLE LEFT","SUP-ITM-10010805","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18513.30","13884.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15129.07","81.72","","3010.54","693.88","5019.88","35","9675.05","15129.07","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN MEDIAL RIGHT","SUP-ITM-10079412","CDM","C1889","HCPCS","0278","RC","","","","both","","","14416.25","10812.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11460.92","79.5","","1309.77","674.56","6049.93","26","4469.04","11460.92","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN MEDIAL RIGHT","SUP-ITM-10079412","CDM","C1889","HCPCS","0278","RC","","","","both","","","14416.25","10812.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7683.86","53.3","","1901.83","1901.83","2962.25","1 through 10","4469.04","11460.92","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN MEDIAL RIGHT","SUP-ITM-10079412","CDM","C1889","HCPCS","0278","RC","","","","both","","","14416.25","10812.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5261.93","36.5","","1620.31","1620.31","19908.88","1 through 10","4469.04","11460.92","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN MEDIAL RIGHT","SUP-ITM-10079412","CDM","C1889","HCPCS","0278","RC","","","","both","","","14416.25","10812.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5521.42","38.3","","352.91","352.91","2046.30","1 through 10","4469.04","11460.92","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN MEDIAL RIGHT","SUP-ITM-10079412","CDM","C1889","HCPCS","0278","RC","","","","both","","","14416.25","10812.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6184.57","42.9","","9668.75","9668.75","9668.75","1 through 10","4469.04","11460.92","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN MEDIAL RIGHT","SUP-ITM-10079412","CDM","C1889","HCPCS","0278","RC","","","","both","","","14416.25","10812.19","WELLPOINT [1015]","HB AMC WELLPOINT","10636.31","73.78","","699.88","384.10","3443.31","33","4469.04","11460.92","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN MEDIAL RIGHT","SUP-ITM-10079412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14416.25","10812.19","AETNA [1001]","HB AMC AETNA HMO","10062.54","69.8","","1421.24","264.50","4933.46","29","7533.93","11780.96","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN MEDIAL RIGHT","SUP-ITM-10079412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14416.25","10812.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11590.67","80.4","","1022.97","1022.97","3607.50","1 through 10","7533.93","11780.96","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN MEDIAL RIGHT","SUP-ITM-10079412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14416.25","10812.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11780.96","81.72","","3010.54","693.88","5019.88","35","7533.93","11780.96","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","both","","","12349.98","9262.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9818.23","79.5","","1309.77","674.56","6049.93","26","3828.49","9818.23","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","both","","","12349.98","9262.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6582.54","53.3","","1901.83","1901.83","2962.25","1 through 10","3828.49","9818.23","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","both","","","12349.98","9262.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4507.74","36.5","","1620.31","1620.31","19908.88","1 through 10","3828.49","9818.23","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","both","","","12349.98","9262.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4730.04","38.3","","352.91","352.91","2046.30","1 through 10","3828.49","9818.23","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","both","","","12349.98","9262.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5298.14","42.9","","9668.75","9668.75","9668.75","1 through 10","3828.49","9818.23","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","both","","","12349.98","9262.48","WELLPOINT [1015]","HB AMC WELLPOINT","9111.82","73.78","","699.88","384.10","3443.31","33","3828.49","9818.23","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12349.98","9262.48","AETNA [1001]","HB AMC AETNA HMO","8620.29","69.8","","1421.24","264.50","4933.46","29","6454.1","10092.4","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12349.98","9262.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9929.38","80.4","","1022.97","1022.97","3607.50","1 through 10","6454.1","10092.4","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12349.98","9262.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10092.40","81.72","","3010.54","693.88","5019.88","35","6454.1","10092.4","percent of total billed charges",""
"GRAFT BONE ALLO OSTEOARTICULAR HUMERUS PROXIMALIMAL CUFF LEFT","SUP-ITM-10010818","CDM","C1889","HCPCS","0278","RC","","","","both","","","20446.38","15334.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","16254.87","79.5","","1309.77","674.56","6049.93","26","6338.38","16254.87","percent of total billed charges",""
"GRAFT BONE ALLO OSTEOARTICULAR HUMERUS PROXIMALIMAL CUFF LEFT","SUP-ITM-10010818","CDM","C1889","HCPCS","0278","RC","","","","both","","","20446.38","15334.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10897.92","53.3","","1901.83","1901.83","2962.25","1 through 10","6338.38","16254.87","percent of total billed charges",""
"GRAFT BONE ALLO OSTEOARTICULAR HUMERUS PROXIMALIMAL CUFF LEFT","SUP-ITM-10010818","CDM","C1889","HCPCS","0278","RC","","","","both","","","20446.38","15334.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7462.93","36.5","","1620.31","1620.31","19908.88","1 through 10","6338.38","16254.87","percent of total billed charges",""
"GRAFT BONE ALLO OSTEOARTICULAR HUMERUS PROXIMALIMAL CUFF LEFT","SUP-ITM-10010818","CDM","C1889","HCPCS","0278","RC","","","","both","","","20446.38","15334.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7830.96","38.3","","352.91","352.91","2046.30","1 through 10","6338.38","16254.87","percent of total billed charges",""
"GRAFT BONE ALLO OSTEOARTICULAR HUMERUS PROXIMALIMAL CUFF LEFT","SUP-ITM-10010818","CDM","C1889","HCPCS","0278","RC","","","","both","","","20446.38","15334.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8771.50","42.9","","9668.75","9668.75","9668.75","1 through 10","6338.38","16254.87","percent of total billed charges",""
"GRAFT BONE ALLO OSTEOARTICULAR HUMERUS PROXIMALIMAL CUFF LEFT","SUP-ITM-10010818","CDM","C1889","HCPCS","0278","RC","","","","both","","","20446.38","15334.78","WELLPOINT [1015]","HB AMC WELLPOINT","15085.34","73.78","","699.88","384.10","3443.31","33","6338.38","16254.87","percent of total billed charges",""
"GRAFT BONE ALLO OSTEOARTICULAR HUMERUS PROXIMALIMAL CUFF LEFT","SUP-ITM-10010818","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20446.38","15334.78","AETNA [1001]","HB AMC AETNA HMO","14271.57","69.8","","1421.24","264.50","4933.46","29","10685.28","16708.78","percent of total billed charges",""
"GRAFT BONE ALLO OSTEOARTICULAR HUMERUS PROXIMALIMAL CUFF LEFT","SUP-ITM-10010818","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20446.38","15334.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","16438.89","80.4","","1022.97","1022.97","3607.50","1 through 10","10685.28","16708.78","percent of total billed charges",""
"GRAFT BONE ALLO OSTEOARTICULAR HUMERUS PROXIMALIMAL CUFF LEFT","SUP-ITM-10010818","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20446.38","15334.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16708.78","81.72","","3010.54","693.88","5019.88","35","10685.28","16708.78","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA BTB FROZEN PROXIMALIMAL RIGHT","SUP-ITM-10010786","CDM","C1889","HCPCS","0278","RC","","","","both","","","19610.75","14708.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15590.55","79.5","","1309.77","674.56","6049.93","26","6079.33","15590.55","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA BTB FROZEN PROXIMALIMAL RIGHT","SUP-ITM-10010786","CDM","C1889","HCPCS","0278","RC","","","","both","","","19610.75","14708.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10452.53","53.3","","1901.83","1901.83","2962.25","1 through 10","6079.33","15590.55","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA BTB FROZEN PROXIMALIMAL RIGHT","SUP-ITM-10010786","CDM","C1889","HCPCS","0278","RC","","","","both","","","19610.75","14708.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7157.92","36.5","","1620.31","1620.31","19908.88","1 through 10","6079.33","15590.55","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA BTB FROZEN PROXIMALIMAL RIGHT","SUP-ITM-10010786","CDM","C1889","HCPCS","0278","RC","","","","both","","","19610.75","14708.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7510.92","38.3","","352.91","352.91","2046.30","1 through 10","6079.33","15590.55","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA BTB FROZEN PROXIMALIMAL RIGHT","SUP-ITM-10010786","CDM","C1889","HCPCS","0278","RC","","","","both","","","19610.75","14708.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8413.01","42.9","","9668.75","9668.75","9668.75","1 through 10","6079.33","15590.55","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA BTB FROZEN PROXIMALIMAL RIGHT","SUP-ITM-10010786","CDM","C1889","HCPCS","0278","RC","","","","both","","","19610.75","14708.06","WELLPOINT [1015]","HB AMC WELLPOINT","14468.81","73.78","","699.88","384.10","3443.31","33","6079.33","15590.55","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA BTB FROZEN PROXIMALIMAL RIGHT","SUP-ITM-10010786","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19610.75","14708.06","AETNA [1001]","HB AMC AETNA HMO","13688.30","69.8","","1421.24","264.50","4933.46","29","10248.58","16025.9","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA BTB FROZEN PROXIMALIMAL RIGHT","SUP-ITM-10010786","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19610.75","14708.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","15767.04","80.4","","1022.97","1022.97","3607.50","1 through 10","10248.58","16025.9","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA BTB FROZEN PROXIMALIMAL RIGHT","SUP-ITM-10010786","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19610.75","14708.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16025.90","81.72","","3010.54","693.88","5019.88","35","10248.58","16025.9","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL LEFT","SUP-ITM-10010790","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.00","3877.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4110.15","79.5","","800.18","480.96","1887.97","195","1602.7","4110.15","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL LEFT","SUP-ITM-10010790","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.00","3877.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2755.61","53.3","","813.12","216.42","1444.50","81","1602.7","4110.15","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL LEFT","SUP-ITM-10010790","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.00","3877.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1602.70","31","","432.60","432.60","432.60","1 through 10","1602.7","4110.15","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL LEFT","SUP-ITM-10010790","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.00","3877.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1887.05","36.5","","148.37","54.89","631.39","94","1602.7","4110.15","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL LEFT","SUP-ITM-10010790","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.00","3877.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1980.11","38.3","","279.30","91.72","1116.77","266","1602.7","4110.15","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL LEFT","SUP-ITM-10010790","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.00","3877.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2217.93","42.9","","731.00","63.70","731.00","1 through 10","1602.7","4110.15","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL LEFT","SUP-ITM-10010790","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.00","3877.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2217.93","42.9","","384.74","384.74","384.74","1 through 10","1602.7","4110.15","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL LEFT","SUP-ITM-10010790","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.00","3877.50","WELLPOINT [1015]","HB AMC WELLPOINT","3814.43","73.78","","286.63","119.22","1107.45","105","1602.7","4110.15","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL LEFT","SUP-ITM-10010790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.00","3877.50","AETNA [1001]","HB AMC AETNA HMO","3608.66","69.8","","675.31","184.75","1721.50","286","2701.84","4224.92","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL LEFT","SUP-ITM-10010790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.00","3877.50","AETNA [1001]","HB AMC AETNA PPO","4156.68","80.4","","1261.44","103.12","1514.10","21","2701.84","4224.92","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL LEFT","SUP-ITM-10010790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.00","3877.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4156.68","80.4","","1365.00","1365.00","1365.00","1 through 10","2701.84","4224.92","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL LEFT","SUP-ITM-10010790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.00","3877.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4224.92","81.72","","5157.68","5157.68","5157.68","1 through 10","2701.84","4224.92","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL LEFT","SUP-ITM-10010790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.00","3877.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4224.92","81.72","","431.26","71.26","1459.57","88","2701.84","4224.92","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10010789","CDM","C1713","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","14865.67","79.5","","800.18","480.96","1887.97","195","5796.67","14865.67","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10010789","CDM","C1713","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9966.54","53.3","","813.12","216.42","1444.50","81","5796.67","14865.67","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10010789","CDM","C1713","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","5796.67","31","","432.60","432.60","432.60","1 through 10","5796.67","14865.67","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10010789","CDM","C1713","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6825.12","36.5","","148.37","54.89","631.39","94","5796.67","14865.67","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10010789","CDM","C1713","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7161.70","38.3","","279.30","91.72","1116.77","266","5796.67","14865.67","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10010789","CDM","C1713","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8021.85","42.9","","731.00","63.70","731.00","1 through 10","5796.67","14865.67","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10010789","CDM","C1713","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8021.85","42.9","","384.74","384.74","384.74","1 through 10","5796.67","14865.67","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10010789","CDM","C1713","HCPCS","0278","RC","","","","both","","","18698.95","14024.21","WELLPOINT [1015]","HB AMC WELLPOINT","13796.09","73.78","","286.63","119.22","1107.45","105","5796.67","14865.67","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10010789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18698.95","14024.21","AETNA [1001]","HB AMC AETNA HMO","13051.87","69.8","","675.31","184.75","1721.50","286","9772.07","15280.78","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10010789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18698.95","14024.21","AETNA [1001]","HB AMC AETNA PPO","15033.96","80.4","","1261.44","103.12","1514.10","21","9772.07","15280.78","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10010789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18698.95","14024.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","15033.96","80.4","","1365.00","1365.00","1365.00","1 through 10","9772.07","15280.78","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10010789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18698.95","14024.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","15280.78","81.72","","5157.68","5157.68","5157.68","1 through 10","9772.07","15280.78","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN PROXIMALIMAL LEFT","SUP-ITM-10010789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18698.95","14024.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15280.78","81.72","","431.26","71.26","1459.57","88","9772.07","15280.78","percent of total billed charges",""
"GRAFT BONE FREEZE DRIED MATRI PROXIMALIMAL FEMORAL W/OUT HEAD IMPLANTABLE","SUP-ITM-10010299","CDM","C1889","HCPCS","0278","RC","","","","both","","","8958.35","6718.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7121.89","79.5","","1309.77","674.56","6049.93","26","2777.09","7121.89","percent of total billed charges",""
"GRAFT BONE FREEZE DRIED MATRI PROXIMALIMAL FEMORAL W/OUT HEAD IMPLANTABLE","SUP-ITM-10010299","CDM","C1889","HCPCS","0278","RC","","","","both","","","8958.35","6718.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4774.80","53.3","","1901.83","1901.83","2962.25","1 through 10","2777.09","7121.89","percent of total billed charges",""
"GRAFT BONE FREEZE DRIED MATRI PROXIMALIMAL FEMORAL W/OUT HEAD IMPLANTABLE","SUP-ITM-10010299","CDM","C1889","HCPCS","0278","RC","","","","both","","","8958.35","6718.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3269.80","36.5","","1620.31","1620.31","19908.88","1 through 10","2777.09","7121.89","percent of total billed charges",""
"GRAFT BONE FREEZE DRIED MATRI PROXIMALIMAL FEMORAL W/OUT HEAD IMPLANTABLE","SUP-ITM-10010299","CDM","C1889","HCPCS","0278","RC","","","","both","","","8958.35","6718.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3431.05","38.3","","352.91","352.91","2046.30","1 through 10","2777.09","7121.89","percent of total billed charges",""
"GRAFT BONE FREEZE DRIED MATRI PROXIMALIMAL FEMORAL W/OUT HEAD IMPLANTABLE","SUP-ITM-10010299","CDM","C1889","HCPCS","0278","RC","","","","both","","","8958.35","6718.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3843.13","42.9","","9668.75","9668.75","9668.75","1 through 10","2777.09","7121.89","percent of total billed charges",""
"GRAFT BONE FREEZE DRIED MATRI PROXIMALIMAL FEMORAL W/OUT HEAD IMPLANTABLE","SUP-ITM-10010299","CDM","C1889","HCPCS","0278","RC","","","","both","","","8958.35","6718.76","WELLPOINT [1015]","HB AMC WELLPOINT","6609.47","73.78","","699.88","384.10","3443.31","33","2777.09","7121.89","percent of total billed charges",""
"GRAFT BONE FREEZE DRIED MATRI PROXIMALIMAL FEMORAL W/OUT HEAD IMPLANTABLE","SUP-ITM-10010299","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8958.35","6718.76","AETNA [1001]","HB AMC AETNA HMO","6252.93","69.8","","1421.24","264.50","4933.46","29","4681.63","7320.76","percent of total billed charges",""
"GRAFT BONE FREEZE DRIED MATRI PROXIMALIMAL FEMORAL W/OUT HEAD IMPLANTABLE","SUP-ITM-10010299","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8958.35","6718.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7202.51","80.4","","1022.97","1022.97","3607.50","1 through 10","4681.63","7320.76","percent of total billed charges",""
"GRAFT BONE FREEZE DRIED MATRI PROXIMALIMAL FEMORAL W/OUT HEAD IMPLANTABLE","SUP-ITM-10010299","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8958.35","6718.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7320.76","81.72","","3010.54","693.88","5019.88","35","4681.63","7320.76","percent of total billed charges",""
"GRAFT BONE L 3CM 30MMX10 ALLO CARTILAGE COSTAL FROZEN","SUP-ITM-10079530","CDM","C1889","HCPCS","0278","RC","","","","both","","","1958.43","1468.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1556.95","79.5","","1309.77","674.56","6049.93","26","607.11","1556.95","percent of total billed charges",""
"GRAFT BONE L 3CM 30MMX10 ALLO CARTILAGE COSTAL FROZEN","SUP-ITM-10079530","CDM","C1889","HCPCS","0278","RC","","","","both","","","1958.43","1468.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1043.84","53.3","","1901.83","1901.83","2962.25","1 through 10","607.11","1556.95","percent of total billed charges",""
"GRAFT BONE L 3CM 30MMX10 ALLO CARTILAGE COSTAL FROZEN","SUP-ITM-10079530","CDM","C1889","HCPCS","0278","RC","","","","both","","","1958.43","1468.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","714.83","36.5","","1620.31","1620.31","19908.88","1 through 10","607.11","1556.95","percent of total billed charges",""
"GRAFT BONE L 3CM 30MMX10 ALLO CARTILAGE COSTAL FROZEN","SUP-ITM-10079530","CDM","C1889","HCPCS","0278","RC","","","","both","","","1958.43","1468.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","750.08","38.3","","352.91","352.91","2046.30","1 through 10","607.11","1556.95","percent of total billed charges",""
"GRAFT BONE L 3CM 30MMX10 ALLO CARTILAGE COSTAL FROZEN","SUP-ITM-10079530","CDM","C1889","HCPCS","0278","RC","","","","both","","","1958.43","1468.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","840.17","42.9","","9668.75","9668.75","9668.75","1 through 10","607.11","1556.95","percent of total billed charges",""
"GRAFT BONE L 3CM 30MMX10 ALLO CARTILAGE COSTAL FROZEN","SUP-ITM-10079530","CDM","C1889","HCPCS","0278","RC","","","","both","","","1958.43","1468.82","WELLPOINT [1015]","HB AMC WELLPOINT","1444.93","73.78","","699.88","384.10","3443.31","33","607.11","1556.95","percent of total billed charges",""
"GRAFT BONE L 3CM 30MMX10 ALLO CARTILAGE COSTAL FROZEN","SUP-ITM-10079530","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1958.43","1468.82","AETNA [1001]","HB AMC AETNA HMO","1366.98","69.8","","1421.24","264.50","4933.46","29","1023.48","1600.43","percent of total billed charges",""
"GRAFT BONE L 3CM 30MMX10 ALLO CARTILAGE COSTAL FROZEN","SUP-ITM-10079530","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1958.43","1468.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1574.58","80.4","","1022.97","1022.97","3607.50","1 through 10","1023.48","1600.43","percent of total billed charges",""
"GRAFT BONE L 3CM 30MMX10 ALLO CARTILAGE COSTAL FROZEN","SUP-ITM-10079530","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1958.43","1468.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1600.43","81.72","","3010.54","693.88","5019.88","35","1023.48","1600.43","percent of total billed charges",""
"GRAFT BONE MD LG TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133233","CDM","C1889","HCPCS","0278","RC","","","","both","","","10560.00","7920.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8395.20","79.5","","1309.77","674.56","6049.93","26","3273.6","8395.2","percent of total billed charges",""
"GRAFT BONE MD LG TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133233","CDM","C1889","HCPCS","0278","RC","","","","both","","","10560.00","7920.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5628.48","53.3","","1901.83","1901.83","2962.25","1 through 10","3273.6","8395.2","percent of total billed charges",""
"GRAFT BONE MD LG TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133233","CDM","C1889","HCPCS","0278","RC","","","","both","","","10560.00","7920.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3854.40","36.5","","1620.31","1620.31","19908.88","1 through 10","3273.6","8395.2","percent of total billed charges",""
"GRAFT BONE MD LG TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133233","CDM","C1889","HCPCS","0278","RC","","","","both","","","10560.00","7920.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4044.48","38.3","","352.91","352.91","2046.30","1 through 10","3273.6","8395.2","percent of total billed charges",""
"GRAFT BONE MD LG TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133233","CDM","C1889","HCPCS","0278","RC","","","","both","","","10560.00","7920.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4530.24","42.9","","9668.75","9668.75","9668.75","1 through 10","3273.6","8395.2","percent of total billed charges",""
"GRAFT BONE MD LG TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133233","CDM","C1889","HCPCS","0278","RC","","","","both","","","10560.00","7920.00","WELLPOINT [1015]","HB AMC WELLPOINT","7791.17","73.78","","699.88","384.10","3443.31","33","3273.6","8395.2","percent of total billed charges",""
"GRAFT BONE MD LG TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133233","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10560.00","7920.00","AETNA [1001]","HB AMC AETNA HMO","7370.88","69.8","","1421.24","264.50","4933.46","29","5518.66","8629.63","percent of total billed charges",""
"GRAFT BONE MD LG TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133233","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10560.00","7920.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8490.24","80.4","","1022.97","1022.97","3607.50","1 through 10","5518.66","8629.63","percent of total billed charges",""
"GRAFT BONE MD LG TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133233","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10560.00","7920.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8629.63","81.72","","3010.54","693.88","5019.88","35","5518.66","8629.63","percent of total billed charges",""
"GRAFT BONE MED TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133234","CDM","C1889","HCPCS","0278","RC","","","","both","","","5537.50","4153.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4402.31","79.5","","1309.77","674.56","6049.93","26","1716.63","4402.31","percent of total billed charges",""
"GRAFT BONE MED TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133234","CDM","C1889","HCPCS","0278","RC","","","","both","","","5537.50","4153.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2951.49","53.3","","1901.83","1901.83","2962.25","1 through 10","1716.63","4402.31","percent of total billed charges",""
"GRAFT BONE MED TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133234","CDM","C1889","HCPCS","0278","RC","","","","both","","","5537.50","4153.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2021.19","36.5","","1620.31","1620.31","19908.88","1 through 10","1716.63","4402.31","percent of total billed charges",""
"GRAFT BONE MED TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133234","CDM","C1889","HCPCS","0278","RC","","","","both","","","5537.50","4153.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2120.86","38.3","","352.91","352.91","2046.30","1 through 10","1716.63","4402.31","percent of total billed charges",""
"GRAFT BONE MED TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133234","CDM","C1889","HCPCS","0278","RC","","","","both","","","5537.50","4153.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2375.59","42.9","","9668.75","9668.75","9668.75","1 through 10","1716.63","4402.31","percent of total billed charges",""
"GRAFT BONE MED TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133234","CDM","C1889","HCPCS","0278","RC","","","","both","","","5537.50","4153.12","WELLPOINT [1015]","HB AMC WELLPOINT","4085.57","73.78","","699.88","384.10","3443.31","33","1716.63","4402.31","percent of total billed charges",""
"GRAFT BONE MED TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5537.50","4153.12","AETNA [1001]","HB AMC AETNA HMO","3865.18","69.8","","1421.24","264.50","4933.46","29","2893.9","4525.25","percent of total billed charges",""
"GRAFT BONE MED TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5537.50","4153.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4452.15","80.4","","1022.97","1022.97","3607.50","1 through 10","2893.9","4525.25","percent of total billed charges",""
"GRAFT BONE MED TRINITY ELITE ALLO DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5537.50","4153.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4525.25","81.72","","3010.54","693.88","5019.88","35","2893.9","4525.25","percent of total billed charges",""
"GRAFT BONE OSTEOARTICULAR TIBIA PROXIMALIMAL FROZEN LEFT","SUP-ITM-10010817","CDM","C1889","HCPCS","0278","RC","","","","both","","","29480.88","22110.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","23437.30","79.5","","1309.77","674.56","6049.93","26","9139.07","23437.3","percent of total billed charges",""
"GRAFT BONE OSTEOARTICULAR TIBIA PROXIMALIMAL FROZEN LEFT","SUP-ITM-10010817","CDM","C1889","HCPCS","0278","RC","","","","both","","","29480.88","22110.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","15713.31","53.3","","1901.83","1901.83","2962.25","1 through 10","9139.07","23437.3","percent of total billed charges",""
"GRAFT BONE OSTEOARTICULAR TIBIA PROXIMALIMAL FROZEN LEFT","SUP-ITM-10010817","CDM","C1889","HCPCS","0278","RC","","","","both","","","29480.88","22110.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10760.52","36.5","","1620.31","1620.31","19908.88","1 through 10","9139.07","23437.3","percent of total billed charges",""
"GRAFT BONE OSTEOARTICULAR TIBIA PROXIMALIMAL FROZEN LEFT","SUP-ITM-10010817","CDM","C1889","HCPCS","0278","RC","","","","both","","","29480.88","22110.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11291.18","38.3","","352.91","352.91","2046.30","1 through 10","9139.07","23437.3","percent of total billed charges",""
"GRAFT BONE OSTEOARTICULAR TIBIA PROXIMALIMAL FROZEN LEFT","SUP-ITM-10010817","CDM","C1889","HCPCS","0278","RC","","","","both","","","29480.88","22110.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12647.30","42.9","","9668.75","9668.75","9668.75","1 through 10","9139.07","23437.3","percent of total billed charges",""
"GRAFT BONE OSTEOARTICULAR TIBIA PROXIMALIMAL FROZEN LEFT","SUP-ITM-10010817","CDM","C1889","HCPCS","0278","RC","","","","both","","","29480.88","22110.66","WELLPOINT [1015]","HB AMC WELLPOINT","21750.99","73.78","","699.88","384.10","3443.31","33","9139.07","23437.3","percent of total billed charges",""
"GRAFT BONE OSTEOARTICULAR TIBIA PROXIMALIMAL FROZEN LEFT","SUP-ITM-10010817","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","29480.88","22110.66","AETNA [1001]","HB AMC AETNA HMO","20577.65","69.8","","1421.24","264.50","4933.46","29","15406.71","24091.78","percent of total billed charges",""
"GRAFT BONE OSTEOARTICULAR TIBIA PROXIMALIMAL FROZEN LEFT","SUP-ITM-10010817","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","29480.88","22110.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","23702.63","80.4","","1022.97","1022.97","3607.50","1 through 10","15406.71","24091.78","percent of total billed charges",""
"GRAFT BONE OSTEOARTICULAR TIBIA PROXIMALIMAL FROZEN LEFT","SUP-ITM-10010817","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","29480.88","22110.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24091.78","81.72","","3010.54","693.88","5019.88","35","15406.71","24091.78","percent of total billed charges",""
"GRAFT BONE ROTATOR CUFF READI LT PROXIMALIMAL HUMERAL HEAD IMPLANTABLE","SUP-ITM-10130434","CDM","C1889","HCPCS","0278","RC","","","","both","","","13687.38","10265.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10881.47","79.5","","1309.77","674.56","6049.93","26","4243.09","10881.47","percent of total billed charges",""
"GRAFT BONE ROTATOR CUFF READI LT PROXIMALIMAL HUMERAL HEAD IMPLANTABLE","SUP-ITM-10130434","CDM","C1889","HCPCS","0278","RC","","","","both","","","13687.38","10265.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7295.37","53.3","","1901.83","1901.83","2962.25","1 through 10","4243.09","10881.47","percent of total billed charges",""
"GRAFT BONE ROTATOR CUFF READI LT PROXIMALIMAL HUMERAL HEAD IMPLANTABLE","SUP-ITM-10130434","CDM","C1889","HCPCS","0278","RC","","","","both","","","13687.38","10265.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4995.89","36.5","","1620.31","1620.31","19908.88","1 through 10","4243.09","10881.47","percent of total billed charges",""
"GRAFT BONE ROTATOR CUFF READI LT PROXIMALIMAL HUMERAL HEAD IMPLANTABLE","SUP-ITM-10130434","CDM","C1889","HCPCS","0278","RC","","","","both","","","13687.38","10265.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5242.27","38.3","","352.91","352.91","2046.30","1 through 10","4243.09","10881.47","percent of total billed charges",""
"GRAFT BONE ROTATOR CUFF READI LT PROXIMALIMAL HUMERAL HEAD IMPLANTABLE","SUP-ITM-10130434","CDM","C1889","HCPCS","0278","RC","","","","both","","","13687.38","10265.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5871.89","42.9","","9668.75","9668.75","9668.75","1 through 10","4243.09","10881.47","percent of total billed charges",""
"GRAFT BONE ROTATOR CUFF READI LT PROXIMALIMAL HUMERAL HEAD IMPLANTABLE","SUP-ITM-10130434","CDM","C1889","HCPCS","0278","RC","","","","both","","","13687.38","10265.53","WELLPOINT [1015]","HB AMC WELLPOINT","10098.55","73.78","","699.88","384.10","3443.31","33","4243.09","10881.47","percent of total billed charges",""
"GRAFT BONE ROTATOR CUFF READI LT PROXIMALIMAL HUMERAL HEAD IMPLANTABLE","SUP-ITM-10130434","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13687.38","10265.53","AETNA [1001]","HB AMC AETNA HMO","9553.79","69.8","","1421.24","264.50","4933.46","29","7153.02","11185.33","percent of total billed charges",""
"GRAFT BONE ROTATOR CUFF READI LT PROXIMALIMAL HUMERAL HEAD IMPLANTABLE","SUP-ITM-10130434","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13687.38","10265.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11004.65","80.4","","1022.97","1022.97","3607.50","1 through 10","7153.02","11185.33","percent of total billed charges",""
"GRAFT BONE ROTATOR CUFF READI LT PROXIMALIMAL HUMERAL HEAD IMPLANTABLE","SUP-ITM-10130434","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13687.38","10265.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11185.33","81.72","","3010.54","693.88","5019.88","35","7153.02","11185.33","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","both","","","30625.00","22968.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24346.88","79.5","","1309.77","674.56","6049.93","26","9493.75","24346.88","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","both","","","30625.00","22968.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16323.13","53.3","","1901.83","1901.83","2962.25","1 through 10","9493.75","24346.88","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","both","","","30625.00","22968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11178.13","36.5","","1620.31","1620.31","19908.88","1 through 10","9493.75","24346.88","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","both","","","30625.00","22968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11729.38","38.3","","352.91","352.91","2046.30","1 through 10","9493.75","24346.88","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","both","","","30625.00","22968.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13138.13","42.9","","9668.75","9668.75","9668.75","1 through 10","9493.75","24346.88","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","both","","","30625.00","22968.75","WELLPOINT [1015]","HB AMC WELLPOINT","22595.13","73.78","","699.88","384.10","3443.31","33","9493.75","24346.88","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","30625.00","22968.75","AETNA [1001]","HB AMC AETNA HMO","21376.25","69.8","","1421.24","264.50","4933.46","29","16004.63","25026.75","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","30625.00","22968.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","24622.50","80.4","","1022.97","1022.97","3607.50","1 through 10","16004.63","25026.75","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","30625.00","22968.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","25026.75","81.72","","3010.54","693.88","5019.88","35","16004.63","25026.75","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","both","","","2677.50","2008.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2128.61","79.5","","1309.77","674.56","6049.93","26","830.03","2128.61","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","both","","","2677.50","2008.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1427.11","53.3","","1901.83","1901.83","2962.25","1 through 10","830.03","2128.61","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","both","","","2677.50","2008.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","977.29","36.5","","1620.31","1620.31","19908.88","1 through 10","830.03","2128.61","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","both","","","2677.50","2008.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1025.48","38.3","","352.91","352.91","2046.30","1 through 10","830.03","2128.61","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","both","","","2677.50","2008.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1148.65","42.9","","9668.75","9668.75","9668.75","1 through 10","830.03","2128.61","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","both","","","2677.50","2008.12","WELLPOINT [1015]","HB AMC WELLPOINT","1975.46","73.78","","699.88","384.10","3443.31","33","830.03","2128.61","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2677.50","2008.12","AETNA [1001]","HB AMC AETNA HMO","1868.90","69.8","","1421.24","264.50","4933.46","29","1399.26","2188.05","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2677.50","2008.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2152.71","80.4","","1022.97","1022.97","3607.50","1 through 10","1399.26","2188.05","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2677.50","2008.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2188.05","81.72","","3010.54","693.88","5019.88","35","1399.26","2188.05","percent of total billed charges",""
"GRAFT BONE STRUCTURAL ALLO WHOLE FEMUR FROZEN LEFT","SUP-ITM-10010780","CDM","C1889","HCPCS","0278","RC","","","","both","","","32404.15","24303.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","25761.30","79.5","","1309.77","674.56","6049.93","26","10045.29","25761.3","percent of total billed charges",""
"GRAFT BONE STRUCTURAL ALLO WHOLE FEMUR FROZEN LEFT","SUP-ITM-10010780","CDM","C1889","HCPCS","0278","RC","","","","both","","","32404.15","24303.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","17271.41","53.3","","1901.83","1901.83","2962.25","1 through 10","10045.29","25761.3","percent of total billed charges",""
"GRAFT BONE STRUCTURAL ALLO WHOLE FEMUR FROZEN LEFT","SUP-ITM-10010780","CDM","C1889","HCPCS","0278","RC","","","","both","","","32404.15","24303.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11827.51","36.5","","1620.31","1620.31","19908.88","1 through 10","10045.29","25761.3","percent of total billed charges",""
"GRAFT BONE STRUCTURAL ALLO WHOLE FEMUR FROZEN LEFT","SUP-ITM-10010780","CDM","C1889","HCPCS","0278","RC","","","","both","","","32404.15","24303.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12410.79","38.3","","352.91","352.91","2046.30","1 through 10","10045.29","25761.3","percent of total billed charges",""
"GRAFT BONE STRUCTURAL ALLO WHOLE FEMUR FROZEN LEFT","SUP-ITM-10010780","CDM","C1889","HCPCS","0278","RC","","","","both","","","32404.15","24303.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13901.38","42.9","","9668.75","9668.75","9668.75","1 through 10","10045.29","25761.3","percent of total billed charges",""
"GRAFT BONE STRUCTURAL ALLO WHOLE FEMUR FROZEN LEFT","SUP-ITM-10010780","CDM","C1889","HCPCS","0278","RC","","","","both","","","32404.15","24303.11","WELLPOINT [1015]","HB AMC WELLPOINT","23907.78","73.78","","699.88","384.10","3443.31","33","10045.29","25761.3","percent of total billed charges",""
"GRAFT BONE STRUCTURAL ALLO WHOLE FEMUR FROZEN LEFT","SUP-ITM-10010780","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","32404.15","24303.11","AETNA [1001]","HB AMC AETNA HMO","22618.10","69.8","","1421.24","264.50","4933.46","29","16934.41","26480.67","percent of total billed charges",""
"GRAFT BONE STRUCTURAL ALLO WHOLE FEMUR FROZEN LEFT","SUP-ITM-10010780","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","32404.15","24303.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","26052.94","80.4","","1022.97","1022.97","3607.50","1 through 10","16934.41","26480.67","percent of total billed charges",""
"GRAFT BONE STRUCTURAL ALLO WHOLE FEMUR FROZEN LEFT","SUP-ITM-10010780","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","32404.15","24303.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","26480.67","81.72","","3010.54","693.88","5019.88","35","16934.41","26480.67","percent of total billed charges",""
"GRAFT BONE XLG 16CC ALLO TRINITY ELITE DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133232","CDM","C1889","HCPCS","0278","RC","","","","both","","","13200.00","9900.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10494.00","79.5","","1309.77","674.56","6049.93","26","4092","10494","percent of total billed charges",""
"GRAFT BONE XLG 16CC ALLO TRINITY ELITE DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133232","CDM","C1889","HCPCS","0278","RC","","","","both","","","13200.00","9900.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7035.60","53.3","","1901.83","1901.83","2962.25","1 through 10","4092","10494","percent of total billed charges",""
"GRAFT BONE XLG 16CC ALLO TRINITY ELITE DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133232","CDM","C1889","HCPCS","0278","RC","","","","both","","","13200.00","9900.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4818.00","36.5","","1620.31","1620.31","19908.88","1 through 10","4092","10494","percent of total billed charges",""
"GRAFT BONE XLG 16CC ALLO TRINITY ELITE DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133232","CDM","C1889","HCPCS","0278","RC","","","","both","","","13200.00","9900.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5055.60","38.3","","352.91","352.91","2046.30","1 through 10","4092","10494","percent of total billed charges",""
"GRAFT BONE XLG 16CC ALLO TRINITY ELITE DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133232","CDM","C1889","HCPCS","0278","RC","","","","both","","","13200.00","9900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5662.80","42.9","","9668.75","9668.75","9668.75","1 through 10","4092","10494","percent of total billed charges",""
"GRAFT BONE XLG 16CC ALLO TRINITY ELITE DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133232","CDM","C1889","HCPCS","0278","RC","","","","both","","","13200.00","9900.00","WELLPOINT [1015]","HB AMC WELLPOINT","9738.96","73.78","","699.88","384.10","3443.31","33","4092","10494","percent of total billed charges",""
"GRAFT BONE XLG 16CC ALLO TRINITY ELITE DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133232","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13200.00","9900.00","AETNA [1001]","HB AMC AETNA HMO","9213.60","69.8","","1421.24","264.50","4933.46","29","6898.32","10787.04","percent of total billed charges",""
"GRAFT BONE XLG 16CC ALLO TRINITY ELITE DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133232","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13200.00","9900.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10612.80","80.4","","1022.97","1022.97","3607.50","1 through 10","6898.32","10787.04","percent of total billed charges",""
"GRAFT BONE XLG 16CC ALLO TRINITY ELITE DEMINERALIZED MATRIX CANCELLOUS","SUP-ITM-10133232","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13200.00","9900.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10787.04","81.72","","3010.54","693.88","5019.88","35","6898.32","10787.04","percent of total billed charges",""
"GRAFT CARDIOVASCULAR 5X7.5CM 0.6MM PATCH EPTFE GORE TEX","SUP-ITM-10005035","CDM","C1781","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1200.50","70","","134.04","134.04","134.04","1 through 10","531.65","1363.43","percent of total billed charges",""
"GRAFT CARDIOVASCULAR 5X7.5CM 0.6MM PATCH EPTFE GORE TEX","SUP-ITM-10005035","CDM","C1781","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1363.43","79.5","","948.87","198.19","1805.30","1 through 10","531.65","1363.43","percent of total billed charges",""
"GRAFT CARDIOVASCULAR 5X7.5CM 0.6MM PATCH EPTFE GORE TEX","SUP-ITM-10005035","CDM","C1781","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","914.10","53.3","","462.00","170.45","3253.37","1 through 10","531.65","1363.43","percent of total billed charges",""
"GRAFT CARDIOVASCULAR 5X7.5CM 0.6MM PATCH EPTFE GORE TEX","SUP-ITM-10005035","CDM","C1781","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","625.98","36.5","","245.50","107.19","1371.45","1 through 10","531.65","1363.43","percent of total billed charges",""
"GRAFT CARDIOVASCULAR 5X7.5CM 0.6MM PATCH EPTFE GORE TEX","SUP-ITM-10005035","CDM","C1781","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","656.85","38.3","","200.79","72.79","355.81","22","531.65","1363.43","percent of total billed charges",""
"GRAFT CARDIOVASCULAR 5X7.5CM 0.6MM PATCH EPTFE GORE TEX","SUP-ITM-10005035","CDM","C1781","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1320.55","77","","477.18","477.18","477.18","1 through 10","531.65","1363.43","percent of total billed charges",""
"GRAFT CARDIOVASCULAR 5X7.5CM 0.6MM PATCH EPTFE GORE TEX","SUP-ITM-10005035","CDM","C1781","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.74","42.9","","1045.91","1045.91","1045.91","1 through 10","531.65","1363.43","percent of total billed charges",""
"GRAFT CARDIOVASCULAR 5X7.5CM 0.6MM PATCH EPTFE GORE TEX","SUP-ITM-10005035","CDM","C1781","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","WELLPOINT [1015]","HB AMC WELLPOINT","1265.33","73.78","","1726.50","1726.50","1726.50","1 through 10","531.65","1363.43","percent of total billed charges",""
"GRAFT CARDIOVASCULAR 5X7.5CM 0.6MM PATCH EPTFE GORE TEX","SUP-ITM-10005035","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","AETNA [1001]","HB AMC AETNA HMO","1197.07","69.8","","915.80","263.76","2881.00","1 through 10","896.26","1401.5","percent of total billed charges",""
"GRAFT CARDIOVASCULAR 5X7.5CM 0.6MM PATCH EPTFE GORE TEX","SUP-ITM-10005035","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1401.50","81.72","","1531.57","410.52","8841.36","1 through 10","896.26","1401.5","percent of total billed charges",""
"GRAFT DURA 3 XIN DUREPAIR NON SYNTHETIC COLLAGEN ACELLULAR BOVINE REGENERATION MATRIX PATCH","SUP-ITM-10014448","CDM","C1763","HCPCS","0278","RC","","","","both","","","1366.21","1024.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","888.04","65","","2028.23","1653.70","2028.23","1 through 10","423.53","1086.14","percent of total billed charges",""
"GRAFT DURA 3 XIN DUREPAIR NON SYNTHETIC COLLAGEN ACELLULAR BOVINE REGENERATION MATRIX PATCH","SUP-ITM-10014448","CDM","C1763","HCPCS","0278","RC","","","","both","","","1366.21","1024.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","498.67","36.5","","1163.89","1163.89","1163.89","1 through 10","423.53","1086.14","percent of total billed charges",""
"GRAFT DURA 3 XIN DUREPAIR NON SYNTHETIC COLLAGEN ACELLULAR BOVINE REGENERATION MATRIX PATCH","SUP-ITM-10014448","CDM","C1763","HCPCS","0278","RC","","","","both","","","1366.21","1024.66","WELLPOINT [1015]","HB AMC WELLPOINT","1007.99","73.78","","4280.87","4280.87","4280.87","1 through 10","423.53","1086.14","percent of total billed charges",""
"GRAFT DURA 4X5IN DUREPAIR NON SYNTHETIC COLLAGEN ACELLULAR BOVINE REGENERATION MATRIX PATCH","SUP-ITM-10014449","CDM","C1763","HCPCS","0278","RC","","","","both","","","2646.07","1984.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1719.95","65","","2028.23","1653.70","2028.23","1 through 10","820.28","2103.63","percent of total billed charges",""
"GRAFT DURA 4X5IN DUREPAIR NON SYNTHETIC COLLAGEN ACELLULAR BOVINE REGENERATION MATRIX PATCH","SUP-ITM-10014449","CDM","C1763","HCPCS","0278","RC","","","","both","","","2646.07","1984.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","965.82","36.5","","1163.89","1163.89","1163.89","1 through 10","820.28","2103.63","percent of total billed charges",""
"GRAFT DURA 4X5IN DUREPAIR NON SYNTHETIC COLLAGEN ACELLULAR BOVINE REGENERATION MATRIX PATCH","SUP-ITM-10014449","CDM","C1763","HCPCS","0278","RC","","","","both","","","2646.07","1984.55","WELLPOINT [1015]","HB AMC WELLPOINT","1952.27","73.78","","4280.87","4280.87","4280.87","1 through 10","820.28","2103.63","percent of total billed charges",""
"GRAFT DURAL 3 XIN DURAMATRIX SUBSTITUTE COLLAGEN MEMBRANE ROSORBABLE","SUP-ITM-10043059","CDM","C1763","HCPCS","0278","RC","","","","both","","","2869.02","2151.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1864.86","65","","2028.23","1653.70","2028.23","1 through 10","889.4","2280.87","percent of total billed charges",""
"GRAFT DURAL 3 XIN DURAMATRIX SUBSTITUTE COLLAGEN MEMBRANE ROSORBABLE","SUP-ITM-10043059","CDM","C1763","HCPCS","0278","RC","","","","both","","","2869.02","2151.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1047.19","36.5","","1163.89","1163.89","1163.89","1 through 10","889.4","2280.87","percent of total billed charges",""
"GRAFT DURAL 3 XIN DURAMATRIX SUBSTITUTE COLLAGEN MEMBRANE ROSORBABLE","SUP-ITM-10043059","CDM","C1763","HCPCS","0278","RC","","","","both","","","2869.02","2151.76","WELLPOINT [1015]","HB AMC WELLPOINT","2116.76","73.78","","4280.87","4280.87","4280.87","1 through 10","889.4","2280.87","percent of total billed charges",""
"GRAFT DURAL 4.0X5.0IN DURAMATRIX ONLAY TYPE I COLLAGEN SUBSTITUTE MEMBRANE RESORBABLE","SUP-ITM-10043055","CDM","C1763","HCPCS","0278","RC","","","","both","","","4749.95","3562.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3087.47","65","","2028.23","1653.70","2028.23","1 through 10","1472.48","3776.21","percent of total billed charges",""
"GRAFT DURAL 4.0X5.0IN DURAMATRIX ONLAY TYPE I COLLAGEN SUBSTITUTE MEMBRANE RESORBABLE","SUP-ITM-10043055","CDM","C1763","HCPCS","0278","RC","","","","both","","","4749.95","3562.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1733.73","36.5","","1163.89","1163.89","1163.89","1 through 10","1472.48","3776.21","percent of total billed charges",""
"GRAFT DURAL 4.0X5.0IN DURAMATRIX ONLAY TYPE I COLLAGEN SUBSTITUTE MEMBRANE RESORBABLE","SUP-ITM-10043055","CDM","C1763","HCPCS","0278","RC","","","","both","","","4749.95","3562.46","WELLPOINT [1015]","HB AMC WELLPOINT","3504.51","73.78","","4280.87","4280.87","4280.87","1 through 10","1472.48","3776.21","percent of total billed charges",""
"GRAFT DURAL 4X5IN DURAMATRIX SUBSTITUTE COLLAGEN MEMBRANE ROSORBABLE","SUP-ITM-10043060","CDM","C1763","HCPCS","0278","RC","","","","both","","","4208.82","3156.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2735.73","65","","2028.23","1653.70","2028.23","1 through 10","1304.73","3346.01","percent of total billed charges",""
"GRAFT DURAL 4X5IN DURAMATRIX SUBSTITUTE COLLAGEN MEMBRANE ROSORBABLE","SUP-ITM-10043060","CDM","C1763","HCPCS","0278","RC","","","","both","","","4208.82","3156.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1536.22","36.5","","1163.89","1163.89","1163.89","1 through 10","1304.73","3346.01","percent of total billed charges",""
"GRAFT DURAL 4X5IN DURAMATRIX SUBSTITUTE COLLAGEN MEMBRANE ROSORBABLE","SUP-ITM-10043060","CDM","C1763","HCPCS","0278","RC","","","","both","","","4208.82","3156.61","WELLPOINT [1015]","HB AMC WELLPOINT","3105.27","73.78","","4280.87","4280.87","4280.87","1 through 10","1304.73","3346.01","percent of total billed charges",""
"GRAFT DURAL 7.5 XCM DURAMATRIX ONLAY TYPE I COLLAGEN SUBSTITUTE MEMBRANE RESORBABLE","SUP-ITM-10043054","CDM","C1763","HCPCS","0278","RC","","","","both","","","3777.54","2833.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2455.40","65","","2028.23","1653.70","2028.23","1 through 10","1171.04","3003.14","percent of total billed charges",""
"GRAFT DURAL 7.5 XCM DURAMATRIX ONLAY TYPE I COLLAGEN SUBSTITUTE MEMBRANE RESORBABLE","SUP-ITM-10043054","CDM","C1763","HCPCS","0278","RC","","","","both","","","3777.54","2833.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1378.80","36.5","","1163.89","1163.89","1163.89","1 through 10","1171.04","3003.14","percent of total billed charges",""
"GRAFT DURAL 7.5 XCM DURAMATRIX ONLAY TYPE I COLLAGEN SUBSTITUTE MEMBRANE RESORBABLE","SUP-ITM-10043054","CDM","C1763","HCPCS","0278","RC","","","","both","","","3777.54","2833.15","WELLPOINT [1015]","HB AMC WELLPOINT","2787.07","73.78","","4280.87","4280.87","4280.87","1 through 10","1171.04","3003.14","percent of total billed charges",""
"GRAFT EACH/1 SPECIALTY MATCHED RADIUS DISTAL LT OSTEOARTICULAR FROZEN 42295502","SUP-ITM-10130455","CDM","C1889","HCPCS","0278","RC","","","","both","","","19477.38","14608.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15484.52","79.5","","1309.77","674.56","6049.93","26","6037.99","15484.52","percent of total billed charges",""
"GRAFT EACH/1 SPECIALTY MATCHED RADIUS DISTAL LT OSTEOARTICULAR FROZEN 42295502","SUP-ITM-10130455","CDM","C1889","HCPCS","0278","RC","","","","both","","","19477.38","14608.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10381.44","53.3","","1901.83","1901.83","2962.25","1 through 10","6037.99","15484.52","percent of total billed charges",""
"GRAFT EACH/1 SPECIALTY MATCHED RADIUS DISTAL LT OSTEOARTICULAR FROZEN 42295502","SUP-ITM-10130455","CDM","C1889","HCPCS","0278","RC","","","","both","","","19477.38","14608.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7109.24","36.5","","1620.31","1620.31","19908.88","1 through 10","6037.99","15484.52","percent of total billed charges",""
"GRAFT EACH/1 SPECIALTY MATCHED RADIUS DISTAL LT OSTEOARTICULAR FROZEN 42295502","SUP-ITM-10130455","CDM","C1889","HCPCS","0278","RC","","","","both","","","19477.38","14608.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7459.84","38.3","","352.91","352.91","2046.30","1 through 10","6037.99","15484.52","percent of total billed charges",""
"GRAFT EACH/1 SPECIALTY MATCHED RADIUS DISTAL LT OSTEOARTICULAR FROZEN 42295502","SUP-ITM-10130455","CDM","C1889","HCPCS","0278","RC","","","","both","","","19477.38","14608.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8355.80","42.9","","9668.75","9668.75","9668.75","1 through 10","6037.99","15484.52","percent of total billed charges",""
"GRAFT EACH/1 SPECIALTY MATCHED RADIUS DISTAL LT OSTEOARTICULAR FROZEN 42295502","SUP-ITM-10130455","CDM","C1889","HCPCS","0278","RC","","","","both","","","19477.38","14608.03","WELLPOINT [1015]","HB AMC WELLPOINT","14370.41","73.78","","699.88","384.10","3443.31","33","6037.99","15484.52","percent of total billed charges",""
"GRAFT EACH/1 SPECIALTY MATCHED RADIUS DISTAL LT OSTEOARTICULAR FROZEN 42295502","SUP-ITM-10130455","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19477.38","14608.03","AETNA [1001]","HB AMC AETNA HMO","13595.21","69.8","","1421.24","264.50","4933.46","29","10178.88","15916.91","percent of total billed charges",""
"GRAFT EACH/1 SPECIALTY MATCHED RADIUS DISTAL LT OSTEOARTICULAR FROZEN 42295502","SUP-ITM-10130455","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19477.38","14608.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","15659.81","80.4","","1022.97","1022.97","3607.50","1 through 10","10178.88","15916.91","percent of total billed charges",""
"GRAFT EACH/1 SPECIALTY MATCHED RADIUS DISTAL LT OSTEOARTICULAR FROZEN 42295502","SUP-ITM-10130455","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19477.38","14608.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15916.91","81.72","","3010.54","693.88","5019.88","35","10178.88","15916.91","percent of total billed charges",""
"Graft Ear Crtlg Autogenous Nose/Ear","PX-76000320","CDM","21235","CPT","0761","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1548.33","36.5","","10424.60","6729.11","10424.60","1 through 10","610.45","6673.94","percent of total billed charges",""
"Graft Ear Crtlg Autogenous Nose/Ear","PX-76000320","CDM","21235","CPT","0761","RC","","","","both","","","4242.00","3181.50","WELLPOINT [1015]","HB AMC WELLPOINT","3129.75","73.78","","11955.93","11955.93","11955.93","1 through 10","610.45","6673.94","percent of total billed charges",""
"Graft Ear Crtlg Autogenous Nose/Ear","PX-76000320","CDM","21235","CPT","0761","RC","","","","outpatient","","","4242.00","3181.50","AETNA [1001]","HB AMC AETNA HMO","2960.92","69.8","","10871.94","10825.23","10871.94","1 through 10","2216.87","12511.21","percent of total billed charges",""
"Graft Ear Crtlg Autogenous Nose/Ear","PX-76000320","CDM","21235","CPT","0761","RC","","","","outpatient","","","4242.00","3181.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5059.36","","Case rate ($5,059.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","10351.45","10164.25","10351.45","1 through 10","2216.87","12511.21","other","ASC"
"Graft Ear Crtlg Autogenous Nose/Ear","PX-76000320","CDM","21235","CPT","0761","RC","","","","outpatient","","","4242.00","3181.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5059.36","","Case rate ($5,059.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","11843.96","11727.60","11843.96","1 through 10","2216.87","12511.21","other","ASC "
"Graft Ear Crtlg Autogenous Nose/Ear","PX-76000320","CDM","21235","CPT","0761","RC","","","","outpatient","","","4242.00","3181.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3981.81","","Case rate ($3,981.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","27713.40","26638.32","27713.40","16","2216.87","12511.21","other","Multiple Surgery"
"Graft Ear Crtlg Autogenous Nose/Ear","PX-76000320","CDM","21235","CPT","0761","RC","","","","outpatient","","","4242.00","3181.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3981.81","","Case rate ($3,981.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9715.62","9715.62","9715.62","1 through 10","2216.87","12511.21","other","Multiple Surgery"
"Graft Ear Crtlg Autogenous Nose/Ear","PX-76000320","CDM","21235","CPT","0761","RC","","","","outpatient","","","4242.00","3181.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","3981.81","","Case rate ($3,981.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9715.62","9715.62","9715.62","1 through 10","2216.87","12511.21","other","Multiple Surgery"
"Graft Ear Crtlg Autogenous Nose/Ear","PX-76000320","CDM","21235","CPT","0761","RC","","","","outpatient","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3466.56","81.72","","11253.55","11253.55","11253.55","1 through 10","2216.87","12511.21","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 17X12MMX6CM GORE TAG THORACIC BRANCH","SUP-ITM-10318570","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","12675.00","65","","6652.80","6652.80","6652.80","1 through 10","6045","15502.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 17X12MMX6CM GORE TAG THORACIC BRANCH","SUP-ITM-10318570","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15502.50","79.5","","2612.61","795.38","2612.61","1 through 10","6045","15502.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 17X12MMX6CM GORE TAG THORACIC BRANCH","SUP-ITM-10318570","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10393.50","53.3","","1101.80","1101.80","1101.80","1 through 10","6045","15502.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 17X12MMX6CM GORE TAG THORACIC BRANCH","SUP-ITM-10318570","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","12675.00","65","","1820.00","910.00","1820.00","1 through 10","6045","15502.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 17X12MMX6CM GORE TAG THORACIC BRANCH","SUP-ITM-10318570","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7117.50","36.5","","1257.80","693.44","2424.50","1 through 10","6045","15502.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 17X12MMX6CM GORE TAG THORACIC BRANCH","SUP-ITM-10318570","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7468.50","38.3","","1950.11","547.40","2346.00","1 through 10","6045","15502.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 17X12MMX6CM GORE TAG THORACIC BRANCH","SUP-ITM-10318570","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8365.50","42.9","","5096.18","5096.18","5096.18","1 through 10","6045","15502.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 17X12MMX6CM GORE TAG THORACIC BRANCH","SUP-ITM-10318570","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","WELLPOINT [1015]","HB AMC WELLPOINT","14387.10","73.78","","1172.59","1172.59","4829.94","1 through 10","6045","15502.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 17X12MMX6CM GORE TAG THORACIC BRANCH","SUP-ITM-10318570","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19500.00","14625.00","AETNA [1001]","HB AMC AETNA HMO","13611.00","69.8","","1806.84","947.80","5091.72","1 through 10","10190.7","15935.4","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 17X12MMX6CM GORE TAG THORACIC BRANCH","SUP-ITM-10318570","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19500.00","14625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15935.40","81.72","","1259.05","615.58","4586.56","1 through 10","10190.7","15935.4","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 2 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283262","CDM","C1874","HCPCS","0278","RC","","","","both","","","41922.50","31441.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","27249.63","65","","6652.80","6652.80","6652.80","1 through 10","12995.98","33328.39","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 2 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283262","CDM","C1874","HCPCS","0278","RC","","","","both","","","41922.50","31441.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33328.39","79.5","","2612.61","795.38","2612.61","1 through 10","12995.98","33328.39","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 2 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283262","CDM","C1874","HCPCS","0278","RC","","","","both","","","41922.50","31441.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22344.69","53.3","","1101.80","1101.80","1101.80","1 through 10","12995.98","33328.39","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 2 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283262","CDM","C1874","HCPCS","0278","RC","","","","both","","","41922.50","31441.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","27249.63","65","","1820.00","910.00","1820.00","1 through 10","12995.98","33328.39","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 2 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283262","CDM","C1874","HCPCS","0278","RC","","","","both","","","41922.50","31441.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15301.71","36.5","","1257.80","693.44","2424.50","1 through 10","12995.98","33328.39","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 2 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283262","CDM","C1874","HCPCS","0278","RC","","","","both","","","41922.50","31441.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16056.32","38.3","","1950.11","547.40","2346.00","1 through 10","12995.98","33328.39","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 2 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283262","CDM","C1874","HCPCS","0278","RC","","","","both","","","41922.50","31441.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17984.75","42.9","","5096.18","5096.18","5096.18","1 through 10","12995.98","33328.39","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 2 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283262","CDM","C1874","HCPCS","0278","RC","","","","both","","","41922.50","31441.87","WELLPOINT [1015]","HB AMC WELLPOINT","30930.42","73.78","","1172.59","1172.59","4829.94","1 through 10","12995.98","33328.39","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 2 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283262","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","41922.50","31441.87","AETNA [1001]","HB AMC AETNA HMO","29261.91","69.8","","1806.84","947.80","5091.72","1 through 10","21908.7","34259.07","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 2 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283262","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","41922.50","31441.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34259.07","81.72","","1259.05","615.58","4586.56","1 through 10","21908.7","34259.07","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","20072.00","65","","6652.80","6652.80","6652.80","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24549.60","79.5","","2612.61","795.38","2612.61","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16459.04","53.3","","1101.80","1101.80","1101.80","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","20072.00","65","","1820.00","910.00","1820.00","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11271.20","36.5","","1257.80","693.44","2424.50","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11827.04","38.3","","1950.11","547.40","2346.00","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13247.52","42.9","","5096.18","5096.18","5096.18","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","WELLPOINT [1015]","HB AMC WELLPOINT","22783.26","73.78","","1172.59","1172.59","4829.94","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30880.00","23160.00","AETNA [1001]","HB AMC AETNA HMO","21554.24","69.8","","1806.84","947.80","5091.72","1 through 10","16137.89","25235.14","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30880.00","23160.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","25235.14","81.72","","1259.05","615.58","4586.56","1 through 10","16137.89","25235.14","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","20072.00","65","","6652.80","6652.80","6652.80","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24549.60","79.5","","2612.61","795.38","2612.61","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16459.04","53.3","","1101.80","1101.80","1101.80","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","20072.00","65","","1820.00","910.00","1820.00","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11271.20","36.5","","1257.80","693.44","2424.50","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11827.04","38.3","","1950.11","547.40","2346.00","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13247.52","42.9","","5096.18","5096.18","5096.18","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","WELLPOINT [1015]","HB AMC WELLPOINT","22783.26","73.78","","1172.59","1172.59","4829.94","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30880.00","23160.00","AETNA [1001]","HB AMC AETNA HMO","21554.24","69.8","","1806.84","947.80","5091.72","1 through 10","16137.89","25235.14","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30880.00","23160.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","25235.14","81.72","","1259.05","615.58","4586.56","1 through 10","16137.89","25235.14","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","20072.00","65","","6652.80","6652.80","6652.80","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24549.60","79.5","","2612.61","795.38","2612.61","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16459.04","53.3","","1101.80","1101.80","1101.80","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","20072.00","65","","1820.00","910.00","1820.00","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11271.20","36.5","","1257.80","693.44","2424.50","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11827.04","38.3","","1950.11","547.40","2346.00","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13247.52","42.9","","5096.18","5096.18","5096.18","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","both","","","30880.00","23160.00","WELLPOINT [1015]","HB AMC WELLPOINT","22783.26","73.78","","1172.59","1172.59","4829.94","1 through 10","9572.8","24549.6","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30880.00","23160.00","AETNA [1001]","HB AMC AETNA HMO","21554.24","69.8","","1806.84","947.80","5091.72","1 through 10","16137.89","25235.14","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30880.00","23160.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","25235.14","81.72","","1259.05","615.58","4586.56","1 through 10","16137.89","25235.14","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","both","","","10945.00","8208.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7114.25","65","","6652.80","6652.80","6652.80","1 through 10","3392.95","8701.28","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","both","","","10945.00","8208.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8701.28","79.5","","2612.61","795.38","2612.61","1 through 10","3392.95","8701.28","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","both","","","10945.00","8208.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5833.69","53.3","","1101.80","1101.80","1101.80","1 through 10","3392.95","8701.28","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","both","","","10945.00","8208.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7114.25","65","","1820.00","910.00","1820.00","1 through 10","3392.95","8701.28","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","both","","","10945.00","8208.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3994.93","36.5","","1257.80","693.44","2424.50","1 through 10","3392.95","8701.28","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","both","","","10945.00","8208.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4191.94","38.3","","1950.11","547.40","2346.00","1 through 10","3392.95","8701.28","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","both","","","10945.00","8208.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4695.41","42.9","","5096.18","5096.18","5096.18","1 through 10","3392.95","8701.28","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","both","","","10945.00","8208.75","WELLPOINT [1015]","HB AMC WELLPOINT","8075.22","73.78","","1172.59","1172.59","4829.94","1 through 10","3392.95","8701.28","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10945.00","8208.75","AETNA [1001]","HB AMC AETNA HMO","7639.61","69.8","","1806.84","947.80","5091.72","1 through 10","5719.86","8944.25","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10945.00","8208.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8944.25","81.72","","1259.05","615.58","4586.56","1 through 10","5719.86","8944.25","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 3 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283261","CDM","C1874","HCPCS","0278","RC","","","","both","","","48317.50","36238.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","31406.38","65","","6652.80","6652.80","6652.80","1 through 10","14978.43","38412.41","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 3 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283261","CDM","C1874","HCPCS","0278","RC","","","","both","","","48317.50","36238.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","38412.41","79.5","","2612.61","795.38","2612.61","1 through 10","14978.43","38412.41","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 3 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283261","CDM","C1874","HCPCS","0278","RC","","","","both","","","48317.50","36238.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","25753.23","53.3","","1101.80","1101.80","1101.80","1 through 10","14978.43","38412.41","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 3 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283261","CDM","C1874","HCPCS","0278","RC","","","","both","","","48317.50","36238.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","31406.38","65","","1820.00","910.00","1820.00","1 through 10","14978.43","38412.41","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 3 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283261","CDM","C1874","HCPCS","0278","RC","","","","both","","","48317.50","36238.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17635.89","36.5","","1257.80","693.44","2424.50","1 through 10","14978.43","38412.41","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 3 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283261","CDM","C1874","HCPCS","0278","RC","","","","both","","","48317.50","36238.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18505.60","38.3","","1950.11","547.40","2346.00","1 through 10","14978.43","38412.41","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 3 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283261","CDM","C1874","HCPCS","0278","RC","","","","both","","","48317.50","36238.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20728.21","42.9","","5096.18","5096.18","5096.18","1 through 10","14978.43","38412.41","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 3 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283261","CDM","C1874","HCPCS","0278","RC","","","","both","","","48317.50","36238.12","WELLPOINT [1015]","HB AMC WELLPOINT","35648.65","73.78","","1172.59","1172.59","4829.94","1 through 10","14978.43","38412.41","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 3 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283261","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","48317.50","36238.12","AETNA [1001]","HB AMC AETNA HMO","33725.62","69.8","","1806.84","947.80","5091.72","1 through 10","25250.73","39485.06","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 3 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283261","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","48317.50","36238.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","39485.06","81.72","","1259.05","615.58","4586.56","1 through 10","25250.73","39485.06","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 4 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283260","CDM","C1874","HCPCS","0278","RC","","","","both","","","54640.00","40980.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","35516.00","65","","6652.80","6652.80","6652.80","1 through 10","16938.4","43438.8","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 4 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283260","CDM","C1874","HCPCS","0278","RC","","","","both","","","54640.00","40980.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","43438.80","79.5","","2612.61","795.38","2612.61","1 through 10","16938.4","43438.8","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 4 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283260","CDM","C1874","HCPCS","0278","RC","","","","both","","","54640.00","40980.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","29123.12","53.3","","1101.80","1101.80","1101.80","1 through 10","16938.4","43438.8","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 4 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283260","CDM","C1874","HCPCS","0278","RC","","","","both","","","54640.00","40980.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","35516.00","65","","1820.00","910.00","1820.00","1 through 10","16938.4","43438.8","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 4 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283260","CDM","C1874","HCPCS","0278","RC","","","","both","","","54640.00","40980.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19943.60","36.5","","1257.80","693.44","2424.50","1 through 10","16938.4","43438.8","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 4 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283260","CDM","C1874","HCPCS","0278","RC","","","","both","","","54640.00","40980.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20927.12","38.3","","1950.11","547.40","2346.00","1 through 10","16938.4","43438.8","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 4 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283260","CDM","C1874","HCPCS","0278","RC","","","","both","","","54640.00","40980.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23440.56","42.9","","5096.18","5096.18","5096.18","1 through 10","16938.4","43438.8","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 4 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283260","CDM","C1874","HCPCS","0278","RC","","","","both","","","54640.00","40980.00","WELLPOINT [1015]","HB AMC WELLPOINT","40313.39","73.78","","1172.59","1172.59","4829.94","1 through 10","16938.4","43438.8","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 4 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283260","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","54640.00","40980.00","AETNA [1001]","HB AMC AETNA HMO","38138.72","69.8","","1806.84","947.80","5091.72","1 through 10","28554.86","44651.81","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 4 PC CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283260","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","54640.00","40980.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","44651.81","81.72","","1259.05","615.58","4586.56","1 through 10","28554.86","44651.81","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 40X4.3MMX6CM 26FR GORE TAG THORACIC BRANCH","SUP-ITM-10318578","CDM","C1874","HCPCS","0278","RC","","","","both","","","27500.00","20625.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","17875.00","65","","6652.80","6652.80","6652.80","1 through 10","8525","21862.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 40X4.3MMX6CM 26FR GORE TAG THORACIC BRANCH","SUP-ITM-10318578","CDM","C1874","HCPCS","0278","RC","","","","both","","","27500.00","20625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21862.50","79.5","","2612.61","795.38","2612.61","1 through 10","8525","21862.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 40X4.3MMX6CM 26FR GORE TAG THORACIC BRANCH","SUP-ITM-10318578","CDM","C1874","HCPCS","0278","RC","","","","both","","","27500.00","20625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14657.50","53.3","","1101.80","1101.80","1101.80","1 through 10","8525","21862.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 40X4.3MMX6CM 26FR GORE TAG THORACIC BRANCH","SUP-ITM-10318578","CDM","C1874","HCPCS","0278","RC","","","","both","","","27500.00","20625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","17875.00","65","","1820.00","910.00","1820.00","1 through 10","8525","21862.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 40X4.3MMX6CM 26FR GORE TAG THORACIC BRANCH","SUP-ITM-10318578","CDM","C1874","HCPCS","0278","RC","","","","both","","","27500.00","20625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10037.50","36.5","","1257.80","693.44","2424.50","1 through 10","8525","21862.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 40X4.3MMX6CM 26FR GORE TAG THORACIC BRANCH","SUP-ITM-10318578","CDM","C1874","HCPCS","0278","RC","","","","both","","","27500.00","20625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10532.50","38.3","","1950.11","547.40","2346.00","1 through 10","8525","21862.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 40X4.3MMX6CM 26FR GORE TAG THORACIC BRANCH","SUP-ITM-10318578","CDM","C1874","HCPCS","0278","RC","","","","both","","","27500.00","20625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11797.50","42.9","","5096.18","5096.18","5096.18","1 through 10","8525","21862.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 40X4.3MMX6CM 26FR GORE TAG THORACIC BRANCH","SUP-ITM-10318578","CDM","C1874","HCPCS","0278","RC","","","","both","","","27500.00","20625.00","WELLPOINT [1015]","HB AMC WELLPOINT","20289.50","73.78","","1172.59","1172.59","4829.94","1 through 10","8525","21862.5","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 40X4.3MMX6CM 26FR GORE TAG THORACIC BRANCH","SUP-ITM-10318578","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","27500.00","20625.00","AETNA [1001]","HB AMC AETNA HMO","19195.00","69.8","","1806.84","947.80","5091.72","1 through 10","14371.5","22473","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 40X4.3MMX6CM 26FR GORE TAG THORACIC BRANCH","SUP-ITM-10318578","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","27500.00","20625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22473.00","81.72","","1259.05","615.58","4586.56","1 through 10","14371.5","22473","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X22 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024593","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","12541.75","65","","6652.80","6652.80","6652.80","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X22 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024593","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15339.53","79.5","","2612.61","795.38","2612.61","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X22 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024593","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10284.24","53.3","","1101.80","1101.80","1101.80","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X22 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024593","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","12541.75","65","","1820.00","910.00","1820.00","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X22 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024593","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7042.68","36.5","","1257.80","693.44","2424.50","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X22 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024593","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7389.99","38.3","","1950.11","547.40","2346.00","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X22 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024593","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8277.56","42.9","","5096.18","5096.18","5096.18","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X22 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024593","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","WELLPOINT [1015]","HB AMC WELLPOINT","14235.85","73.78","","1172.59","1172.59","4829.94","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X22 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024593","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19295.00","14471.25","AETNA [1001]","HB AMC AETNA HMO","13467.91","69.8","","1806.84","947.80","5091.72","1 through 10","10083.57","15767.87","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X22 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024593","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19295.00","14471.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15767.87","81.72","","1259.05","615.58","4586.56","1 through 10","10083.57","15767.87","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X24 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024594","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","12541.75","65","","6652.80","6652.80","6652.80","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X24 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024594","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15339.53","79.5","","2612.61","795.38","2612.61","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X24 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024594","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10284.24","53.3","","1101.80","1101.80","1101.80","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X24 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024594","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","12541.75","65","","1820.00","910.00","1820.00","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X24 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024594","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7042.68","36.5","","1257.80","693.44","2424.50","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X24 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024594","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7389.99","38.3","","1950.11","547.40","2346.00","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X24 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024594","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8277.56","42.9","","5096.18","5096.18","5096.18","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X24 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024594","CDM","C1874","HCPCS","0278","RC","","","","both","","","19295.00","14471.25","WELLPOINT [1015]","HB AMC WELLPOINT","14235.85","73.78","","1172.59","1172.59","4829.94","1 through 10","5981.45","15339.53","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X24 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024594","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19295.00","14471.25","AETNA [1001]","HB AMC AETNA HMO","13467.91","69.8","","1806.84","947.80","5091.72","1 through 10","10083.57","15767.87","percent of total billed charges",""
"GRAFT ENDOVASCULAR 113X24 12 XSEC 7.1MM IDSEC 18FR AAA ANCILLARY CONVERTER Z TRAK INTRODUCTION SYST ZENITH RENU IMPLANT","SUP-ITM-10024594","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19295.00","14471.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15767.87","81.72","","1259.05","615.58","4586.56","1 through 10","10083.57","15767.87","percent of total billed charges",""
"GRAFT ENDOVASCULAR 18FR 24X82MM POLYESTER BIFURCATED MAIN BODY WOVEN ZENITH FLEX ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10061747","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","15356.25","65","","6652.80","6652.80","6652.80","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ENDOVASCULAR 18FR 24X82MM POLYESTER BIFURCATED MAIN BODY WOVEN ZENITH FLEX ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10061747","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18781.88","79.5","","2612.61","795.38","2612.61","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ENDOVASCULAR 18FR 24X82MM POLYESTER BIFURCATED MAIN BODY WOVEN ZENITH FLEX ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10061747","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12592.13","53.3","","1101.80","1101.80","1101.80","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ENDOVASCULAR 18FR 24X82MM POLYESTER BIFURCATED MAIN BODY WOVEN ZENITH FLEX ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10061747","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","15356.25","65","","1820.00","910.00","1820.00","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ENDOVASCULAR 18FR 24X82MM POLYESTER BIFURCATED MAIN BODY WOVEN ZENITH FLEX ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10061747","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8623.13","36.5","","1257.80","693.44","2424.50","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ENDOVASCULAR 18FR 24X82MM POLYESTER BIFURCATED MAIN BODY WOVEN ZENITH FLEX ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10061747","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9048.38","38.3","","1950.11","547.40","2346.00","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ENDOVASCULAR 18FR 24X82MM POLYESTER BIFURCATED MAIN BODY WOVEN ZENITH FLEX ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10061747","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10135.13","42.9","","5096.18","5096.18","5096.18","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ENDOVASCULAR 18FR 24X82MM POLYESTER BIFURCATED MAIN BODY WOVEN ZENITH FLEX ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10061747","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","WELLPOINT [1015]","HB AMC WELLPOINT","17430.53","73.78","","1172.59","1172.59","4829.94","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ENDOVASCULAR 18FR 24X82MM POLYESTER BIFURCATED MAIN BODY WOVEN ZENITH FLEX ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10061747","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","23625.00","17718.75","AETNA [1001]","HB AMC AETNA HMO","16490.25","69.8","","1806.84","947.80","5091.72","1 through 10","12346.43","19306.35","percent of total billed charges",""
"GRAFT ENDOVASCULAR 18FR 24X82MM POLYESTER BIFURCATED MAIN BODY WOVEN ZENITH FLEX ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10061747","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","23625.00","17718.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","19306.35","81.72","","1259.05","615.58","4586.56","1 through 10","12346.43","19306.35","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 55MM SHORT ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10120310","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5685.88","65","","6652.80","6652.80","6652.80","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 55MM SHORT ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10120310","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6954.26","79.5","","2612.61","795.38","2612.61","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 55MM SHORT ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10120310","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4662.42","53.3","","1101.80","1101.80","1101.80","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 55MM SHORT ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10120310","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5685.88","65","","1820.00","910.00","1820.00","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 55MM SHORT ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10120310","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3192.84","36.5","","1257.80","693.44","2424.50","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 55MM SHORT ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10120310","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3350.29","38.3","","1950.11","547.40","2346.00","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 55MM SHORT ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10120310","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3752.68","42.9","","5096.18","5096.18","5096.18","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 55MM SHORT ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10120310","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","WELLPOINT [1015]","HB AMC WELLPOINT","6453.91","73.78","","1172.59","1172.59","4829.94","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 55MM SHORT ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10120310","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8747.50","6560.62","AETNA [1001]","HB AMC AETNA HMO","6105.76","69.8","","1806.84","947.80","5091.72","1 through 10","4571.44","7148.46","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 55MM SHORT ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10120310","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8747.50","6560.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7148.46","81.72","","1259.05","615.58","4586.56","1 through 10","4571.44","7148.46","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 65MM LONG ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10118193","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5685.88","65","","6652.80","6652.80","6652.80","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 65MM LONG ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10118193","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6954.26","79.5","","2612.61","795.38","2612.61","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 65MM LONG ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10118193","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4662.42","53.3","","1101.80","1101.80","1101.80","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 65MM LONG ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10118193","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5685.88","65","","1820.00","910.00","1820.00","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 65MM LONG ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10118193","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3192.84","36.5","","1257.80","693.44","2424.50","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 65MM LONG ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10118193","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3350.29","38.3","","1950.11","547.40","2346.00","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 65MM LONG ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10118193","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3752.68","42.9","","5096.18","5096.18","5096.18","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 65MM LONG ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10118193","CDM","C1874","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","WELLPOINT [1015]","HB AMC WELLPOINT","6453.91","73.78","","1172.59","1172.59","4829.94","1 through 10","2711.73","6954.26","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 65MM LONG ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10118193","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8747.50","6560.62","AETNA [1001]","HB AMC AETNA HMO","6105.76","69.8","","1806.84","947.80","5091.72","1 through 10","4571.44","7148.46","percent of total billed charges",""
"GRAFT ENDOVASCULAR 20X25 65MM LONG ILIAC LIMB EXTENSION ABDOMINAL AORTA AFX IMPLANTABLE","SUP-ITM-10118193","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8747.50","6560.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7148.46","81.72","","1259.05","615.58","4586.56","1 through 10","4571.44","7148.46","percent of total billed charges",""
"GRAFT ENDOVASCULAR 25X25X95MM VELA AFX SUPRARENAL","SUP-ITM-10213268","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8610.88","65","","6652.80","6652.80","6652.80","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 25X25X95MM VELA AFX SUPRARENAL","SUP-ITM-10213268","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10531.76","79.5","","2612.61","795.38","2612.61","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 25X25X95MM VELA AFX SUPRARENAL","SUP-ITM-10213268","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7060.92","53.3","","1101.80","1101.80","1101.80","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 25X25X95MM VELA AFX SUPRARENAL","SUP-ITM-10213268","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8610.88","65","","1820.00","910.00","1820.00","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 25X25X95MM VELA AFX SUPRARENAL","SUP-ITM-10213268","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4835.34","36.5","","1257.80","693.44","2424.50","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 25X25X95MM VELA AFX SUPRARENAL","SUP-ITM-10213268","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5073.79","38.3","","1950.11","547.40","2346.00","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 25X25X95MM VELA AFX SUPRARENAL","SUP-ITM-10213268","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5683.18","42.9","","5096.18","5096.18","5096.18","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 25X25X95MM VELA AFX SUPRARENAL","SUP-ITM-10213268","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","WELLPOINT [1015]","HB AMC WELLPOINT","9774.01","73.78","","1172.59","1172.59","4829.94","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 25X25X95MM VELA AFX SUPRARENAL","SUP-ITM-10213268","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13247.50","9935.62","AETNA [1001]","HB AMC AETNA HMO","9246.76","69.8","","1806.84","947.80","5091.72","1 through 10","6923.14","10825.86","percent of total billed charges",""
"GRAFT ENDOVASCULAR 25X25X95MM VELA AFX SUPRARENAL","SUP-ITM-10213268","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13247.50","9935.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10825.86","81.72","","1259.05","615.58","4586.56","1 through 10","6923.14","10825.86","percent of total billed charges",""
"GRAFT ENDOVASCULAR 28X75 20IN VELA AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL","SUP-ITM-10139140","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8610.88","65","","6652.80","6652.80","6652.80","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 28X75 20IN VELA AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL","SUP-ITM-10139140","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10531.76","79.5","","2612.61","795.38","2612.61","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 28X75 20IN VELA AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL","SUP-ITM-10139140","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7060.92","53.3","","1101.80","1101.80","1101.80","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 28X75 20IN VELA AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL","SUP-ITM-10139140","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8610.88","65","","1820.00","910.00","1820.00","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 28X75 20IN VELA AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL","SUP-ITM-10139140","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4835.34","36.5","","1257.80","693.44","2424.50","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 28X75 20IN VELA AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL","SUP-ITM-10139140","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5073.79","38.3","","1950.11","547.40","2346.00","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 28X75 20IN VELA AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL","SUP-ITM-10139140","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5683.18","42.9","","5096.18","5096.18","5096.18","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 28X75 20IN VELA AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL","SUP-ITM-10139140","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","WELLPOINT [1015]","HB AMC WELLPOINT","9774.01","73.78","","1172.59","1172.59","4829.94","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 28X75 20IN VELA AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL","SUP-ITM-10139140","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13247.50","9935.62","AETNA [1001]","HB AMC AETNA HMO","9246.76","69.8","","1806.84","947.80","5091.72","1 through 10","6923.14","10825.86","percent of total billed charges",""
"GRAFT ENDOVASCULAR 28X75 20IN VELA AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL","SUP-ITM-10139140","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13247.50","9935.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10825.86","81.72","","1259.05","615.58","4586.56","1 through 10","6923.14","10825.86","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X24 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101338","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","19773.81","65","","6652.80","6652.80","6652.80","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X24 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101338","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24184.89","79.5","","2612.61","795.38","2612.61","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X24 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101338","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16214.53","53.3","","1101.80","1101.80","1101.80","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X24 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101338","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","19773.81","65","","1820.00","910.00","1820.00","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X24 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101338","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11103.76","36.5","","1257.80","693.44","2424.50","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X24 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101338","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11651.34","38.3","","1950.11","547.40","2346.00","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X24 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101338","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13050.72","42.9","","5096.18","5096.18","5096.18","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X24 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101338","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","WELLPOINT [1015]","HB AMC WELLPOINT","22444.80","73.78","","1172.59","1172.59","4829.94","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X24 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101338","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30421.25","22815.94","AETNA [1001]","HB AMC AETNA HMO","21234.03","69.8","","1806.84","947.80","5091.72","1 through 10","15898.15","24860.25","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X24 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101338","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30421.25","22815.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24860.25","81.72","","1259.05","615.58","4586.56","1 through 10","15898.15","24860.25","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X26 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101341","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","19773.81","65","","6652.80","6652.80","6652.80","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X26 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101341","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24184.89","79.5","","2612.61","795.38","2612.61","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X26 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101341","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16214.53","53.3","","1101.80","1101.80","1101.80","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X26 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101341","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","19773.81","65","","1820.00","910.00","1820.00","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X26 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101341","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11103.76","36.5","","1257.80","693.44","2424.50","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X26 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101341","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11651.34","38.3","","1950.11","547.40","2346.00","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X26 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101341","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13050.72","42.9","","5096.18","5096.18","5096.18","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X26 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101341","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","WELLPOINT [1015]","HB AMC WELLPOINT","22444.80","73.78","","1172.59","1172.59","4829.94","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X26 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101341","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30421.25","22815.94","AETNA [1001]","HB AMC AETNA HMO","21234.03","69.8","","1806.84","947.80","5091.72","1 through 10","15898.15","24860.25","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X26 94MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101341","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30421.25","22815.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24860.25","81.72","","1259.05","615.58","4586.56","1 through 10","15898.15","24860.25","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X28 94MM PROXIMALIMAL BODY FENESTRATED AAA ZENITH","SUP-ITM-10101344","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","19773.81","65","","6652.80","6652.80","6652.80","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X28 94MM PROXIMALIMAL BODY FENESTRATED AAA ZENITH","SUP-ITM-10101344","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24184.89","79.5","","2612.61","795.38","2612.61","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X28 94MM PROXIMALIMAL BODY FENESTRATED AAA ZENITH","SUP-ITM-10101344","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16214.53","53.3","","1101.80","1101.80","1101.80","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X28 94MM PROXIMALIMAL BODY FENESTRATED AAA ZENITH","SUP-ITM-10101344","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","19773.81","65","","1820.00","910.00","1820.00","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X28 94MM PROXIMALIMAL BODY FENESTRATED AAA ZENITH","SUP-ITM-10101344","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11103.76","36.5","","1257.80","693.44","2424.50","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X28 94MM PROXIMALIMAL BODY FENESTRATED AAA ZENITH","SUP-ITM-10101344","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11651.34","38.3","","1950.11","547.40","2346.00","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X28 94MM PROXIMALIMAL BODY FENESTRATED AAA ZENITH","SUP-ITM-10101344","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13050.72","42.9","","5096.18","5096.18","5096.18","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X28 94MM PROXIMALIMAL BODY FENESTRATED AAA ZENITH","SUP-ITM-10101344","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","WELLPOINT [1015]","HB AMC WELLPOINT","22444.80","73.78","","1172.59","1172.59","4829.94","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X28 94MM PROXIMALIMAL BODY FENESTRATED AAA ZENITH","SUP-ITM-10101344","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30421.25","22815.94","AETNA [1001]","HB AMC AETNA HMO","21234.03","69.8","","1806.84","947.80","5091.72","1 through 10","15898.15","24860.25","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X28 94MM PROXIMALIMAL BODY FENESTRATED AAA ZENITH","SUP-ITM-10101344","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30421.25","22815.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24860.25","81.72","","1259.05","615.58","4586.56","1 through 10","15898.15","24860.25","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X36 107MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101354","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","19773.81","65","","6652.80","6652.80","6652.80","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X36 107MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101354","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24184.89","79.5","","2612.61","795.38","2612.61","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X36 107MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101354","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16214.53","53.3","","1101.80","1101.80","1101.80","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X36 107MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101354","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","19773.81","65","","1820.00","910.00","1820.00","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X36 107MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101354","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11103.76","36.5","","1257.80","693.44","2424.50","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X36 107MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101354","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11651.34","38.3","","1950.11","547.40","2346.00","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X36 107MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101354","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13050.72","42.9","","5096.18","5096.18","5096.18","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X36 107MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101354","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","WELLPOINT [1015]","HB AMC WELLPOINT","22444.80","73.78","","1172.59","1172.59","4829.94","1 through 10","9430.59","24184.89","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X36 107MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101354","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30421.25","22815.94","AETNA [1001]","HB AMC AETNA HMO","21234.03","69.8","","1806.84","947.80","5091.72","1 through 10","15898.15","24860.25","percent of total billed charges",""
"GRAFT ENDOVASCULAR 2X36 107MM INTERNAL FENESTRATED PROXIMALIMAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101354","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30421.25","22815.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24860.25","81.72","","1259.05","615.58","4586.56","1 through 10","15898.15","24860.25","percent of total billed charges",""
"GRAFT ENDOVASCULAR 37X20X160MM 22MM SHEATH EXCLUDER THORACOABDOMINAL AORTIC","SUP-ITM-10337414","CDM","C1874","HCPCS","0278","RC","","","","both","","","72500.00","54375.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","47125.00","65","","6652.80","6652.80","6652.80","1 through 10","22475","57637.5","percent of total billed charges",""
"GRAFT ENDOVASCULAR 37X20X160MM 22MM SHEATH EXCLUDER THORACOABDOMINAL AORTIC","SUP-ITM-10337414","CDM","C1874","HCPCS","0278","RC","","","","both","","","72500.00","54375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","57637.50","79.5","","2612.61","795.38","2612.61","1 through 10","22475","57637.5","percent of total billed charges",""
"GRAFT ENDOVASCULAR 37X20X160MM 22MM SHEATH EXCLUDER THORACOABDOMINAL AORTIC","SUP-ITM-10337414","CDM","C1874","HCPCS","0278","RC","","","","both","","","72500.00","54375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","38642.50","53.3","","1101.80","1101.80","1101.80","1 through 10","22475","57637.5","percent of total billed charges",""
"GRAFT ENDOVASCULAR 37X20X160MM 22MM SHEATH EXCLUDER THORACOABDOMINAL AORTIC","SUP-ITM-10337414","CDM","C1874","HCPCS","0278","RC","","","","both","","","72500.00","54375.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","47125.00","65","","1820.00","910.00","1820.00","1 through 10","22475","57637.5","percent of total billed charges",""
"GRAFT ENDOVASCULAR 37X20X160MM 22MM SHEATH EXCLUDER THORACOABDOMINAL AORTIC","SUP-ITM-10337414","CDM","C1874","HCPCS","0278","RC","","","","both","","","72500.00","54375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26462.50","36.5","","1257.80","693.44","2424.50","1 through 10","22475","57637.5","percent of total billed charges",""
"GRAFT ENDOVASCULAR 37X20X160MM 22MM SHEATH EXCLUDER THORACOABDOMINAL AORTIC","SUP-ITM-10337414","CDM","C1874","HCPCS","0278","RC","","","","both","","","72500.00","54375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27767.50","38.3","","1950.11","547.40","2346.00","1 through 10","22475","57637.5","percent of total billed charges",""
"GRAFT ENDOVASCULAR 37X20X160MM 22MM SHEATH EXCLUDER THORACOABDOMINAL AORTIC","SUP-ITM-10337414","CDM","C1874","HCPCS","0278","RC","","","","both","","","72500.00","54375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31102.50","42.9","","5096.18","5096.18","5096.18","1 through 10","22475","57637.5","percent of total billed charges",""
"GRAFT ENDOVASCULAR 37X20X160MM 22MM SHEATH EXCLUDER THORACOABDOMINAL AORTIC","SUP-ITM-10337414","CDM","C1874","HCPCS","0278","RC","","","","both","","","72500.00","54375.00","WELLPOINT [1015]","HB AMC WELLPOINT","53490.50","73.78","","1172.59","1172.59","4829.94","1 through 10","22475","57637.5","percent of total billed charges",""
"GRAFT ENDOVASCULAR 37X20X160MM 22MM SHEATH EXCLUDER THORACOABDOMINAL AORTIC","SUP-ITM-10337414","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","72500.00","54375.00","AETNA [1001]","HB AMC AETNA HMO","50605.00","69.8","","1806.84","947.80","5091.72","1 through 10","37888.5","59247","percent of total billed charges",""
"GRAFT ENDOVASCULAR 37X20X160MM 22MM SHEATH EXCLUDER THORACOABDOMINAL AORTIC","SUP-ITM-10337414","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","72500.00","54375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","59247.00","81.72","","1259.05","615.58","4586.56","1 through 10","37888.5","59247","percent of total billed charges",""
"GRAFT ENDOVASCULAR 39X28 XSEC 7.7MM IDSEC 18FR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10016545","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3722.88","65","","6652.80","6652.80","6652.80","1 through 10","1775.53","4553.36","percent of total billed charges",""
"GRAFT ENDOVASCULAR 39X28 XSEC 7.7MM IDSEC 18FR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10016545","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4553.36","79.5","","2612.61","795.38","2612.61","1 through 10","1775.53","4553.36","percent of total billed charges",""
"GRAFT ENDOVASCULAR 39X28 XSEC 7.7MM IDSEC 18FR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10016545","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3052.76","53.3","","1101.80","1101.80","1101.80","1 through 10","1775.53","4553.36","percent of total billed charges",""
"GRAFT ENDOVASCULAR 39X28 XSEC 7.7MM IDSEC 18FR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10016545","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3722.88","65","","1820.00","910.00","1820.00","1 through 10","1775.53","4553.36","percent of total billed charges",""
"GRAFT ENDOVASCULAR 39X28 XSEC 7.7MM IDSEC 18FR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10016545","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2090.54","36.5","","1257.80","693.44","2424.50","1 through 10","1775.53","4553.36","percent of total billed charges",""
"GRAFT ENDOVASCULAR 39X28 XSEC 7.7MM IDSEC 18FR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10016545","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2193.63","38.3","","1950.11","547.40","2346.00","1 through 10","1775.53","4553.36","percent of total billed charges",""
"GRAFT ENDOVASCULAR 39X28 XSEC 7.7MM IDSEC 18FR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10016545","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2457.10","42.9","","5096.18","5096.18","5096.18","1 through 10","1775.53","4553.36","percent of total billed charges",""
"GRAFT ENDOVASCULAR 39X28 XSEC 7.7MM IDSEC 18FR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10016545","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","WELLPOINT [1015]","HB AMC WELLPOINT","4225.75","73.78","","1172.59","1172.59","4829.94","1 through 10","1775.53","4553.36","percent of total billed charges",""
"GRAFT ENDOVASCULAR 39X28 XSEC 7.7MM IDSEC 18FR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10016545","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5727.50","4295.62","AETNA [1001]","HB AMC AETNA HMO","3997.80","69.8","","1806.84","947.80","5091.72","1 through 10","2993.19","4680.51","percent of total billed charges",""
"GRAFT ENDOVASCULAR 39X28 XSEC 7.7MM IDSEC 18FR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10016545","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5727.50","4295.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4680.51","81.72","","1259.05","615.58","4586.56","1 through 10","2993.19","4680.51","percent of total billed charges",""
"GRAFT ENDOVASCULAR 76X28 12MM BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR ITEM MUST","SUP-ITM-10101359","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6859.13","65","","6652.80","6652.80","6652.80","1 through 10","3271.28","8389.24","percent of total billed charges",""
"GRAFT ENDOVASCULAR 76X28 12MM BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR ITEM MUST","SUP-ITM-10101359","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8389.24","79.5","","2612.61","795.38","2612.61","1 through 10","3271.28","8389.24","percent of total billed charges",""
"GRAFT ENDOVASCULAR 76X28 12MM BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR ITEM MUST","SUP-ITM-10101359","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5624.48","53.3","","1101.80","1101.80","1101.80","1 through 10","3271.28","8389.24","percent of total billed charges",""
"GRAFT ENDOVASCULAR 76X28 12MM BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR ITEM MUST","SUP-ITM-10101359","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6859.13","65","","1820.00","910.00","1820.00","1 through 10","3271.28","8389.24","percent of total billed charges",""
"GRAFT ENDOVASCULAR 76X28 12MM BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR ITEM MUST","SUP-ITM-10101359","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3851.66","36.5","","1257.80","693.44","2424.50","1 through 10","3271.28","8389.24","percent of total billed charges",""
"GRAFT ENDOVASCULAR 76X28 12MM BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR ITEM MUST","SUP-ITM-10101359","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4041.61","38.3","","1950.11","547.40","2346.00","1 through 10","3271.28","8389.24","percent of total billed charges",""
"GRAFT ENDOVASCULAR 76X28 12MM BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR ITEM MUST","SUP-ITM-10101359","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4527.02","42.9","","5096.18","5096.18","5096.18","1 through 10","3271.28","8389.24","percent of total billed charges",""
"GRAFT ENDOVASCULAR 76X28 12MM BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR ITEM MUST","SUP-ITM-10101359","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","WELLPOINT [1015]","HB AMC WELLPOINT","7785.63","73.78","","1172.59","1172.59","4829.94","1 through 10","3271.28","8389.24","percent of total billed charges",""
"GRAFT ENDOVASCULAR 76X28 12MM BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR ITEM MUST","SUP-ITM-10101359","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10552.50","7914.37","AETNA [1001]","HB AMC AETNA HMO","7365.65","69.8","","1806.84","947.80","5091.72","1 through 10","5514.74","8623.5","percent of total billed charges",""
"GRAFT ENDOVASCULAR 76X28 12MM BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR ITEM MUST","SUP-ITM-10101359","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10552.50","7914.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8623.50","81.72","","1259.05","615.58","4586.56","1 through 10","5514.74","8623.5","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8610.88","65","","6652.80","6652.80","6652.80","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10531.76","79.5","","2612.61","795.38","2612.61","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7060.92","53.3","","1101.80","1101.80","1101.80","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8610.88","65","","1820.00","910.00","1820.00","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4835.34","36.5","","1257.80","693.44","2424.50","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5073.79","38.3","","1950.11","547.40","2346.00","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5683.18","42.9","","5096.18","5096.18","5096.18","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","both","","","13247.50","9935.62","WELLPOINT [1015]","HB AMC WELLPOINT","9774.01","73.78","","1172.59","1172.59","4829.94","1 through 10","4106.73","10531.76","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13247.50","9935.62","AETNA [1001]","HB AMC AETNA HMO","9246.76","69.8","","1806.84","947.80","5091.72","1 through 10","6923.14","10825.86","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13247.50","9935.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10825.86","81.72","","1259.05","615.58","4586.56","1 through 10","6923.14","10825.86","percent of total billed charges",""
"GRAFT ENDOVASCULAR THORACIC ZENITH ALPHA PROXIMALIMAL COMPONENT 30 155 W","SUP-ITM-10164788","CDM","C1874","HCPCS","0278","RC","","","","both","","","42400.00","31800.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","27560.00","65","","6652.80","6652.80","6652.80","1 through 10","13144","33708","percent of total billed charges",""
"GRAFT ENDOVASCULAR THORACIC ZENITH ALPHA PROXIMALIMAL COMPONENT 30 155 W","SUP-ITM-10164788","CDM","C1874","HCPCS","0278","RC","","","","both","","","42400.00","31800.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33708.00","79.5","","2612.61","795.38","2612.61","1 through 10","13144","33708","percent of total billed charges",""
"GRAFT ENDOVASCULAR THORACIC ZENITH ALPHA PROXIMALIMAL COMPONENT 30 155 W","SUP-ITM-10164788","CDM","C1874","HCPCS","0278","RC","","","","both","","","42400.00","31800.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22599.20","53.3","","1101.80","1101.80","1101.80","1 through 10","13144","33708","percent of total billed charges",""
"GRAFT ENDOVASCULAR THORACIC ZENITH ALPHA PROXIMALIMAL COMPONENT 30 155 W","SUP-ITM-10164788","CDM","C1874","HCPCS","0278","RC","","","","both","","","42400.00","31800.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","27560.00","65","","1820.00","910.00","1820.00","1 through 10","13144","33708","percent of total billed charges",""
"GRAFT ENDOVASCULAR THORACIC ZENITH ALPHA PROXIMALIMAL COMPONENT 30 155 W","SUP-ITM-10164788","CDM","C1874","HCPCS","0278","RC","","","","both","","","42400.00","31800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15476.00","36.5","","1257.80","693.44","2424.50","1 through 10","13144","33708","percent of total billed charges",""
"GRAFT ENDOVASCULAR THORACIC ZENITH ALPHA PROXIMALIMAL COMPONENT 30 155 W","SUP-ITM-10164788","CDM","C1874","HCPCS","0278","RC","","","","both","","","42400.00","31800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16239.20","38.3","","1950.11","547.40","2346.00","1 through 10","13144","33708","percent of total billed charges",""
"GRAFT ENDOVASCULAR THORACIC ZENITH ALPHA PROXIMALIMAL COMPONENT 30 155 W","SUP-ITM-10164788","CDM","C1874","HCPCS","0278","RC","","","","both","","","42400.00","31800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18189.60","42.9","","5096.18","5096.18","5096.18","1 through 10","13144","33708","percent of total billed charges",""
"GRAFT ENDOVASCULAR THORACIC ZENITH ALPHA PROXIMALIMAL COMPONENT 30 155 W","SUP-ITM-10164788","CDM","C1874","HCPCS","0278","RC","","","","both","","","42400.00","31800.00","WELLPOINT [1015]","HB AMC WELLPOINT","31282.72","73.78","","1172.59","1172.59","4829.94","1 through 10","13144","33708","percent of total billed charges",""
"GRAFT ENDOVASCULAR THORACIC ZENITH ALPHA PROXIMALIMAL COMPONENT 30 155 W","SUP-ITM-10164788","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42400.00","31800.00","AETNA [1001]","HB AMC AETNA HMO","29595.20","69.8","","1806.84","947.80","5091.72","1 through 10","22158.24","34649.28","percent of total billed charges",""
"GRAFT ENDOVASCULAR THORACIC ZENITH ALPHA PROXIMALIMAL COMPONENT 30 155 W","SUP-ITM-10164788","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42400.00","31800.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34649.28","81.72","","1259.05","615.58","4586.56","1 through 10","22158.24","34649.28","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5003.38","65","","6652.80","6652.80","6652.80","1 through 10","2386.23","6119.51","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6119.51","79.5","","2612.61","795.38","2612.61","1 through 10","2386.23","6119.51","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4102.77","53.3","","1101.80","1101.80","1101.80","1 through 10","2386.23","6119.51","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5003.38","65","","1820.00","910.00","1820.00","1 through 10","2386.23","6119.51","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2809.59","36.5","","1257.80","693.44","2424.50","1 through 10","2386.23","6119.51","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2948.14","38.3","","1950.11","547.40","2346.00","1 through 10","2386.23","6119.51","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3302.23","42.9","","5096.18","5096.18","5096.18","1 through 10","2386.23","6119.51","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","WELLPOINT [1015]","HB AMC WELLPOINT","5679.22","73.78","","1172.59","1172.59","4829.94","1 through 10","2386.23","6119.51","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7697.50","5773.12","AETNA [1001]","HB AMC AETNA HMO","5372.86","69.8","","1806.84","947.80","5091.72","1 through 10","4022.71","6290.4","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7697.50","5773.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6290.40","81.72","","1259.05","615.58","4586.56","1 through 10","4022.71","6290.4","percent of total billed charges",""
"GRAFT EXCLUDER 23X10 ILIAC BRANCH ENDOPROSTHESIS","SUP-ITM-10166189","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","17667.00","65","","6652.80","6652.80","6652.80","1 through 10","8425.8","21608.1","percent of total billed charges",""
"GRAFT EXCLUDER 23X10 ILIAC BRANCH ENDOPROSTHESIS","SUP-ITM-10166189","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21608.10","79.5","","2612.61","795.38","2612.61","1 through 10","8425.8","21608.1","percent of total billed charges",""
"GRAFT EXCLUDER 23X10 ILIAC BRANCH ENDOPROSTHESIS","SUP-ITM-10166189","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14486.94","53.3","","1101.80","1101.80","1101.80","1 through 10","8425.8","21608.1","percent of total billed charges",""
"GRAFT EXCLUDER 23X10 ILIAC BRANCH ENDOPROSTHESIS","SUP-ITM-10166189","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","17667.00","65","","1820.00","910.00","1820.00","1 through 10","8425.8","21608.1","percent of total billed charges",""
"GRAFT EXCLUDER 23X10 ILIAC BRANCH ENDOPROSTHESIS","SUP-ITM-10166189","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9920.70","36.5","","1257.80","693.44","2424.50","1 through 10","8425.8","21608.1","percent of total billed charges",""
"GRAFT EXCLUDER 23X10 ILIAC BRANCH ENDOPROSTHESIS","SUP-ITM-10166189","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10409.94","38.3","","1950.11","547.40","2346.00","1 through 10","8425.8","21608.1","percent of total billed charges",""
"GRAFT EXCLUDER 23X10 ILIAC BRANCH ENDOPROSTHESIS","SUP-ITM-10166189","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11660.22","42.9","","5096.18","5096.18","5096.18","1 through 10","8425.8","21608.1","percent of total billed charges",""
"GRAFT EXCLUDER 23X10 ILIAC BRANCH ENDOPROSTHESIS","SUP-ITM-10166189","CDM","C1874","HCPCS","0278","RC","","","","both","","","27180.00","20385.00","WELLPOINT [1015]","HB AMC WELLPOINT","20053.40","73.78","","1172.59","1172.59","4829.94","1 through 10","8425.8","21608.1","percent of total billed charges",""
"GRAFT EXCLUDER 23X10 ILIAC BRANCH ENDOPROSTHESIS","SUP-ITM-10166189","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","27180.00","20385.00","AETNA [1001]","HB AMC AETNA HMO","18971.64","69.8","","1806.84","947.80","5091.72","1 through 10","14204.27","22211.5","percent of total billed charges",""
"GRAFT EXCLUDER 23X10 ILIAC BRANCH ENDOPROSTHESIS","SUP-ITM-10166189","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","27180.00","20385.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22211.50","81.72","","1259.05","615.58","4586.56","1 through 10","14204.27","22211.5","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","both","","","30750.00","23062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24446.25","79.5","","1309.77","674.56","6049.93","26","9532.5","24446.25","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","both","","","30750.00","23062.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16389.75","53.3","","1901.83","1901.83","2962.25","1 through 10","9532.5","24446.25","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","both","","","30750.00","23062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11223.75","36.5","","1620.31","1620.31","19908.88","1 through 10","9532.5","24446.25","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","both","","","30750.00","23062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11777.25","38.3","","352.91","352.91","2046.30","1 through 10","9532.5","24446.25","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","both","","","30750.00","23062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13191.75","42.9","","9668.75","9668.75","9668.75","1 through 10","9532.5","24446.25","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","both","","","30750.00","23062.50","WELLPOINT [1015]","HB AMC WELLPOINT","22687.35","73.78","","699.88","384.10","3443.31","33","9532.5","24446.25","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","30750.00","23062.50","AETNA [1001]","HB AMC AETNA HMO","21463.50","69.8","","1421.24","264.50","4933.46","29","16069.95","25128.9","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","30750.00","23062.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","24723.00","80.4","","1022.97","1022.97","3607.50","1 through 10","16069.95","25128.9","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","30750.00","23062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","25128.90","81.72","","3010.54","693.88","5019.88","35","16069.95","25128.9","percent of total billed charges",""
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","both","","","6012.00","4509.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2237.26","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2235.32","2235.32","2235.32","1 through 10","1863.72","4779.54","other","OPPS APC"
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","both","","","6012.00","4509.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2137.56","2137.56","2137.56","1 through 10","1863.72","4779.54","other","OPPS APC"
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","both","","","6012.00","4509.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3907.80","65","","3789.50","3789.50","3789.50","1 through 10","1863.72","4779.54","percent of total billed charges",""
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","both","","","6012.00","4509.00","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","1990.34","6516.96","51","1863.72","4779.54","other","OPPS APC"
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","both","","","6012.00","4509.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2302.60","38.3","","2279.53","2279.53","2279.53","1 through 10","1863.72","4779.54","percent of total billed charges",""
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","both","","","6012.00","4509.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1064.44","1064.44","1064.44","1 through 10","1863.72","4779.54","other","OPPS APC"
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","both","","","6012.00","4509.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2132.03","1954.52","2172.32","1 through 10","1863.72","4779.54","other","OPPS APC"
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","both","","","6012.00","4509.00","WELLPOINT [1015]","HB AMC WELLPOINT","4435.65","73.78","","4340.44","4340.44","4340.44","1 through 10","1863.72","4779.54","percent of total billed charges",""
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","outpatient","","","6012.00","4509.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3624.12","1812.06","3624.12","1 through 10","1548.96","5545.35","other","ASC"
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","outpatient","","","6012.00","4509.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4105.92","2052.96","4146.66","1 through 10","1548.96","5545.35","other","ASC "
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","outpatient","","","6012.00","4509.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3454.18","3454.18","3454.18","1 through 10","1548.96","5545.35","other","Multiple Surgery"
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","outpatient","","","6012.00","4509.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3810.44","3810.44","3810.44","1 through 10","1548.96","5545.35","other","Multiple Surgery"
"Graft Full Eye/Ns/Ear/Lip <20cm","PX-76000175","CDM","15260","CPT","0761","RC","","","","outpatient","","","6012.00","4509.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4913.01","81.72","","2563.45","2563.45","2563.45","1 through 10","1548.96","5545.35","percent of total billed charges",""
"Graft Full Forehd/Chin/Mth <20cm","PX-76000173","CDM","15240","CPT","0761","RC","","","","both","","","5601.00","4200.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2137.56","2137.56","2137.56","1 through 10","1736.31","4452.8","other","OPPS APC"
"Graft Full Forehd/Chin/Mth <20cm","PX-76000173","CDM","15240","CPT","0761","RC","","","","both","","","5601.00","4200.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4452.80","79.5","","5539.50","5539.50","5539.50","1 through 10","1736.31","4452.8","percent of total billed charges",""
"Graft Full Forehd/Chin/Mth <20cm","PX-76000173","CDM","15240","CPT","0761","RC","","","","both","","","5601.00","4200.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2128.87","2128.87","2128.87","1 through 10","1736.31","4452.8","other","OPPS APC"
"Graft Full Forehd/Chin/Mth <20cm","PX-76000173","CDM","15240","CPT","0761","RC","","","","both","","","5601.00","4200.75","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","1990.34","2172.32","11","1736.31","4452.8","other","OPPS APC"
"Graft Full Forehd/Chin/Mth <20cm","PX-76000173","CDM","15240","CPT","0761","RC","","","","both","","","5601.00","4200.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2145.18","38.3","","8318.13","4702.56","8318.13","1 through 10","1736.31","4452.8","percent of total billed charges",""
"Graft Full Forehd/Chin/Mth <20cm","PX-76000173","CDM","15240","CPT","0761","RC","","","","both","","","5601.00","4200.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2133.88","1954.52","2172.32","1 through 10","1736.31","4452.8","other","OPPS APC"
"Graft Full Forehd/Chin/Mth <20cm","PX-76000173","CDM","15240","CPT","0761","RC","","","","outpatient","","","5601.00","4200.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3624.12","3624.12","3624.12","1 through 10","1548.96","8899.59","other","ASC"
"Graft Full Forehd/Chin/Mth <20cm","PX-76000173","CDM","15240","CPT","0761","RC","","","","outpatient","","","5601.00","4200.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2073.33","2073.33","2073.33","1 through 10","1548.96","8899.59","other","ASC "
"Graft Full Forehd/Chin/Mth <20cm","PX-76000173","CDM","15240","CPT","0761","RC","","","","outpatient","","","5601.00","4200.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3640.06","3640.06","3640.06","1 through 10","1548.96","8899.59","other","Multiple Surgery"
"Graft Full Forehd/Chin/Mth <20cm","PX-76000173","CDM","15240","CPT","0761","RC","","","","outpatient","","","5601.00","4200.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4577.14","81.72","","23925.64","23925.64","23925.64","1 through 10","1548.96","8899.59","percent of total billed charges",""
"Graft Full Forehd/Chin/Mth Add 20cm","PX-76000174","CDM","15241","CPT","0761","RC","","","","both","","","760.00","570.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","604.20","79.5","","5539.50","5539.50","5539.50","1 through 10","235.6","604.2","percent of total billed charges",""
"Graft Full Forehd/Chin/Mth Add 20cm","PX-76000174","CDM","15241","CPT","0761","RC","","","","both","","","760.00","570.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","291.08","38.3","","8318.13","4702.56","8318.13","1 through 10","235.6","604.2","percent of total billed charges",""
"Graft Full Scalp/Arm/Leg <20cm","PX-76000171","CDM","15220","CPT","0761","RC","","","","both","","","4774.00","3580.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3795.33","79.5","","7878.66","7878.66","7878.66","1 through 10","1479.94","3795.33","percent of total billed charges",""
"Graft Full Scalp/Arm/Leg <20cm","PX-76000171","CDM","15220","CPT","0761","RC","","","","both","","","4774.00","3580.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2544.54","53.3","","5340.46","5340.46","5340.46","1 through 10","1479.94","3795.33","percent of total billed charges",""
"Graft Full Scalp/Arm/Leg <20cm","PX-76000171","CDM","15220","CPT","0761","RC","","","","both","","","4774.00","3580.50","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","6516.96","22","1479.94","3795.33","other","OPPS APC"
"Graft Full Scalp/Arm/Leg <20cm","PX-76000171","CDM","15220","CPT","0761","RC","","","","both","","","4774.00","3580.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2128.87","975.27","2128.87","1 through 10","1479.94","3795.33","other","OPPS APC"
"Graft Full Scalp/Arm/Leg <20cm","PX-76000171","CDM","15220","CPT","0761","RC","","","","both","","","4774.00","3580.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1957.94","1957.94","1957.94","1 through 10","1479.94","3795.33","other","OPPS APC"
"Graft Full Scalp/Arm/Leg <20cm","PX-76000171","CDM","15220","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","AETNA [1001]","HB AMC AETNA HMO","3332.25","69.8","","4834.73","3134.51","4834.73","1 through 10","1548.96","5545.35","percent of total billed charges",""
"Graft Full Scalp/Arm/Leg <20cm","PX-76000171","CDM","15220","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3624.12","3624.12","4146.66","1 through 10","1548.96","5545.35","other","ASC"
"Graft Full Scalp/Arm/Leg <20cm","PX-76000171","CDM","15220","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2073.33","2073.33","2073.33","1 through 10","1548.96","5545.35","other","ASC "
"Graft Full Scalp/Arm/Leg <20cm","PX-76000171","CDM","15220","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1796.80","1796.80","1796.80","1 through 10","1548.96","5545.35","other","Multiple Surgery"
"Graft Full Scalp/Arm/Lg Add 20cm","PX-76000172","CDM","15221","CPT","0761","RC","","","","both","","","483.00","362.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","383.99","79.5","","7878.66","7878.66","7878.66","1 through 10","70.31","383.99","percent of total billed charges",""
"Graft Full Trunk <20cm","PX-76000169","CDM","15200","CPT","0761","RC","","","","outpatient","","","7871.00","5903.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3558.58","3558.58","3558.58","1 through 10","1548.96","8899.59","other","ASC"
"Graft Full Trunk <20cm","PX-76000169","CDM","15200","CPT","0761","RC","","","","outpatient","","","7871.00","5903.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2052.96","2052.96","2052.96","1 through 10","1548.96","8899.59","other","ASC "
"GRAFT HERNIA 15CMX13 BIODESIGN VASCULARIZED NONDERMIS BASED NONCROSSLINKED","SUP-ITM-10087086","CDM","C1763","HCPCS","0278","RC","","","","both","","","14347.50","10760.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","9325.88","65","","2028.23","1653.70","2028.23","1 through 10","4447.73","11406.26","percent of total billed charges",""
"GRAFT HERNIA 15CMX13 BIODESIGN VASCULARIZED NONDERMIS BASED NONCROSSLINKED","SUP-ITM-10087086","CDM","C1763","HCPCS","0278","RC","","","","both","","","14347.50","10760.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5236.84","36.5","","1163.89","1163.89","1163.89","1 through 10","4447.73","11406.26","percent of total billed charges",""
"GRAFT HERNIA 15CMX13 BIODESIGN VASCULARIZED NONDERMIS BASED NONCROSSLINKED","SUP-ITM-10087086","CDM","C1763","HCPCS","0278","RC","","","","both","","","14347.50","10760.62","WELLPOINT [1015]","HB AMC WELLPOINT","10585.59","73.78","","4280.87","4280.87","4280.87","1 through 10","4447.73","11406.26","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","both","","","2354.07","1765.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1871.49","79.5","","1309.77","674.56","6049.93","26","729.76","1871.49","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","both","","","2354.07","1765.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1254.72","53.3","","1901.83","1901.83","2962.25","1 through 10","729.76","1871.49","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","both","","","2354.07","1765.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","859.24","36.5","","1620.31","1620.31","19908.88","1 through 10","729.76","1871.49","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","both","","","2354.07","1765.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","901.61","38.3","","352.91","352.91","2046.30","1 through 10","729.76","1871.49","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","both","","","2354.07","1765.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1009.90","42.9","","9668.75","9668.75","9668.75","1 through 10","729.76","1871.49","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","both","","","2354.07","1765.55","WELLPOINT [1015]","HB AMC WELLPOINT","1736.83","73.78","","699.88","384.10","3443.31","33","729.76","1871.49","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2354.07","1765.55","AETNA [1001]","HB AMC AETNA HMO","1643.14","69.8","","1421.24","264.50","4933.46","29","1230.24","1923.75","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2354.07","1765.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1892.67","80.4","","1022.97","1022.97","3607.50","1 through 10","1230.24","1923.75","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2354.07","1765.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1923.75","81.72","","3010.54","693.88","5019.88","35","1230.24","1923.75","percent of total billed charges",""
"GRAFT IMPLANT 1OZ 21GA SYNTHETIC TISSUE INJECTABLE CALCIUM HYDROXYLAPATITE SODIUM CMC RESORBABLE COAPTITE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020071","CDM","L8606","HCPCS","0278","RC","","","","both","","","1558.19","1168.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.79","38.3","","1436.93","1436.93","1436.93","1 through 10","483.04","1238.76","percent of total billed charges",""
"GRAFT IMPLANT 5ML SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS BONE MORSEL","SUP-ITM-10026783","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1126.91","79.5","","800.18","480.96","1887.97","195","439.43","1126.91","percent of total billed charges",""
"GRAFT IMPLANT 5ML SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS BONE MORSEL","SUP-ITM-10026783","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","755.53","53.3","","813.12","216.42","1444.50","81","439.43","1126.91","percent of total billed charges",""
"GRAFT IMPLANT 5ML SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS BONE MORSEL","SUP-ITM-10026783","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","439.43","31","","432.60","432.60","432.60","1 through 10","439.43","1126.91","percent of total billed charges",""
"GRAFT IMPLANT 5ML SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS BONE MORSEL","SUP-ITM-10026783","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","517.39","36.5","","148.37","54.89","631.39","94","439.43","1126.91","percent of total billed charges",""
"GRAFT IMPLANT 5ML SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS BONE MORSEL","SUP-ITM-10026783","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","542.90","38.3","","279.30","91.72","1116.77","266","439.43","1126.91","percent of total billed charges",""
"GRAFT IMPLANT 5ML SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS BONE MORSEL","SUP-ITM-10026783","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","608.11","42.9","","731.00","63.70","731.00","1 through 10","439.43","1126.91","percent of total billed charges",""
"GRAFT IMPLANT 5ML SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS BONE MORSEL","SUP-ITM-10026783","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","608.11","42.9","","384.74","384.74","384.74","1 through 10","439.43","1126.91","percent of total billed charges",""
"GRAFT IMPLANT 5ML SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS BONE MORSEL","SUP-ITM-10026783","CDM","C1713","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","WELLPOINT [1015]","HB AMC WELLPOINT","1045.83","73.78","","286.63","119.22","1107.45","105","439.43","1126.91","percent of total billed charges",""
"GRAFT IMPLANT 5ML SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS BONE MORSEL","SUP-ITM-10026783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","AETNA [1001]","HB AMC AETNA HMO","989.42","69.8","","675.31","184.75","1721.50","286","740.79","1158.38","percent of total billed charges",""
"GRAFT IMPLANT 5ML SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS BONE MORSEL","SUP-ITM-10026783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","AETNA [1001]","HB AMC AETNA PPO","1139.67","80.4","","1261.44","103.12","1514.10","21","740.79","1158.38","percent of total billed charges",""
"GRAFT IMPLANT 5ML SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS BONE MORSEL","SUP-ITM-10026783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1139.67","80.4","","1365.00","1365.00","1365.00","1 through 10","740.79","1158.38","percent of total billed charges",""
"GRAFT IMPLANT 5ML SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS BONE MORSEL","SUP-ITM-10026783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1158.38","81.72","","5157.68","5157.68","5157.68","1 through 10","740.79","1158.38","percent of total billed charges",""
"GRAFT IMPLANT 5ML SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS BONE MORSEL","SUP-ITM-10026783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1158.38","81.72","","431.26","71.26","1459.57","88","740.79","1158.38","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","7415.63","5561.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5895.43","79.5","","800.18","480.96","1887.97","195","2298.85","5895.43","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","7415.63","5561.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3952.53","53.3","","813.12","216.42","1444.50","81","2298.85","5895.43","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","7415.63","5561.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2298.85","31","","432.60","432.60","432.60","1 through 10","2298.85","5895.43","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","7415.63","5561.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2706.70","36.5","","148.37","54.89","631.39","94","2298.85","5895.43","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","7415.63","5561.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2840.19","38.3","","279.30","91.72","1116.77","266","2298.85","5895.43","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","7415.63","5561.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3181.31","42.9","","731.00","63.70","731.00","1 through 10","2298.85","5895.43","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","7415.63","5561.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3181.31","42.9","","384.74","384.74","384.74","1 through 10","2298.85","5895.43","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","7415.63","5561.72","WELLPOINT [1015]","HB AMC WELLPOINT","5471.25","73.78","","286.63","119.22","1107.45","105","2298.85","5895.43","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7415.63","5561.72","AETNA [1001]","HB AMC AETNA HMO","5176.11","69.8","","675.31","184.75","1721.50","286","3875.41","6060.05","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7415.63","5561.72","AETNA [1001]","HB AMC AETNA PPO","5962.17","80.4","","1261.44","103.12","1514.10","21","3875.41","6060.05","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7415.63","5561.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5962.17","80.4","","1365.00","1365.00","1365.00","1 through 10","3875.41","6060.05","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7415.63","5561.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6060.05","81.72","","5157.68","5157.68","5157.68","1 through 10","3875.41","6060.05","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7415.63","5561.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6060.05","81.72","","431.26","71.26","1459.57","88","3875.41","6060.05","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","752.50","564.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","526.75","70","","134.04","134.04","134.04","1 through 10","233.28","598.24","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","752.50","564.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","598.24","79.5","","948.87","198.19","1805.30","1 through 10","233.28","598.24","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","752.50","564.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","401.08","53.3","","462.00","170.45","3253.37","1 through 10","233.28","598.24","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","752.50","564.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","274.66","36.5","","245.50","107.19","1371.45","1 through 10","233.28","598.24","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","752.50","564.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","288.21","38.3","","200.79","72.79","355.81","22","233.28","598.24","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","752.50","564.37","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","579.43","77","","477.18","477.18","477.18","1 through 10","233.28","598.24","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","752.50","564.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","322.82","42.9","","1045.91","1045.91","1045.91","1 through 10","233.28","598.24","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","752.50","564.37","WELLPOINT [1015]","HB AMC WELLPOINT","555.19","73.78","","1726.50","1726.50","1726.50","1 through 10","233.28","598.24","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","752.50","564.37","AETNA [1001]","HB AMC AETNA HMO","525.25","69.8","","915.80","263.76","2881.00","1 through 10","393.26","614.94","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","752.50","564.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","614.94","81.72","","1531.57","410.52","8841.36","1 through 10","393.26","614.94","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","910.00","682.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","637.00","70","","134.04","134.04","134.04","1 through 10","282.1","723.45","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","910.00","682.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","723.45","79.5","","948.87","198.19","1805.30","1 through 10","282.1","723.45","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","910.00","682.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","485.03","53.3","","462.00","170.45","3253.37","1 through 10","282.1","723.45","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","910.00","682.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","332.15","36.5","","245.50","107.19","1371.45","1 through 10","282.1","723.45","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","910.00","682.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","348.53","38.3","","200.79","72.79","355.81","22","282.1","723.45","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","910.00","682.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","700.70","77","","477.18","477.18","477.18","1 through 10","282.1","723.45","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","910.00","682.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","390.39","42.9","","1045.91","1045.91","1045.91","1 through 10","282.1","723.45","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","910.00","682.50","WELLPOINT [1015]","HB AMC WELLPOINT","671.40","73.78","","1726.50","1726.50","1726.50","1 through 10","282.1","723.45","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","910.00","682.50","AETNA [1001]","HB AMC AETNA HMO","635.18","69.8","","915.80","263.76","2881.00","1 through 10","475.57","743.65","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","910.00","682.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","743.65","81.72","","1531.57","410.52","8841.36","1 through 10","475.57","743.65","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","42742.50","32056.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","29919.75","70","","134.04","134.04","134.04","1 through 10","13250.18","33980.29","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","42742.50","32056.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33980.29","79.5","","948.87","198.19","1805.30","1 through 10","13250.18","33980.29","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","42742.50","32056.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22781.75","53.3","","462.00","170.45","3253.37","1 through 10","13250.18","33980.29","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","42742.50","32056.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15601.01","36.5","","245.50","107.19","1371.45","1 through 10","13250.18","33980.29","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","42742.50","32056.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16370.38","38.3","","200.79","72.79","355.81","22","13250.18","33980.29","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","42742.50","32056.87","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","32911.73","77","","477.18","477.18","477.18","1 through 10","13250.18","33980.29","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","42742.50","32056.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18336.53","42.9","","1045.91","1045.91","1045.91","1 through 10","13250.18","33980.29","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","42742.50","32056.87","WELLPOINT [1015]","HB AMC WELLPOINT","31535.42","73.78","","1726.50","1726.50","1726.50","1 through 10","13250.18","33980.29","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","42742.50","32056.87","AETNA [1001]","HB AMC AETNA HMO","29834.27","69.8","","915.80","263.76","2881.00","1 through 10","22337.23","34929.17","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","42742.50","32056.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34929.17","81.72","","1531.57","410.52","8841.36","1 through 10","22337.23","34929.17","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","11839.75","8879.81","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","8287.83","70","","134.04","134.04","134.04","1 through 10","3670.32","9412.6","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","11839.75","8879.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9412.60","79.5","","948.87","198.19","1805.30","1 through 10","3670.32","9412.6","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","11839.75","8879.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6310.59","53.3","","462.00","170.45","3253.37","1 through 10","3670.32","9412.6","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","11839.75","8879.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4321.51","36.5","","245.50","107.19","1371.45","1 through 10","3670.32","9412.6","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","11839.75","8879.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4534.62","38.3","","200.79","72.79","355.81","22","3670.32","9412.6","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","11839.75","8879.81","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","9116.61","77","","477.18","477.18","477.18","1 through 10","3670.32","9412.6","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","11839.75","8879.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5079.25","42.9","","1045.91","1045.91","1045.91","1 through 10","3670.32","9412.6","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","11839.75","8879.81","WELLPOINT [1015]","HB AMC WELLPOINT","8735.37","73.78","","1726.50","1726.50","1726.50","1 through 10","3670.32","9412.6","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","11839.75","8879.81","AETNA [1001]","HB AMC AETNA HMO","8264.15","69.8","","915.80","263.76","2881.00","1 through 10","6187.45","9675.44","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","11839.75","8879.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9675.44","81.72","","1531.57","410.52","8841.36","1 through 10","6187.45","9675.44","percent of total billed charges",""
"GRAFT MESH 12IN 18IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR","SUP-ITM-10236410","CDM","C1781","HCPCS","0278","RC","","","","both","","","78491.00","58868.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","54943.70","70","","134.04","134.04","134.04","1 through 10","24332.21","62400.35","percent of total billed charges",""
"GRAFT MESH 12IN 18IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR","SUP-ITM-10236410","CDM","C1781","HCPCS","0278","RC","","","","both","","","78491.00","58868.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","62400.35","79.5","","948.87","198.19","1805.30","1 through 10","24332.21","62400.35","percent of total billed charges",""
"GRAFT MESH 12IN 18IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR","SUP-ITM-10236410","CDM","C1781","HCPCS","0278","RC","","","","both","","","78491.00","58868.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","41835.70","53.3","","462.00","170.45","3253.37","1 through 10","24332.21","62400.35","percent of total billed charges",""
"GRAFT MESH 12IN 18IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR","SUP-ITM-10236410","CDM","C1781","HCPCS","0278","RC","","","","both","","","78491.00","58868.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28649.22","36.5","","245.50","107.19","1371.45","1 through 10","24332.21","62400.35","percent of total billed charges",""
"GRAFT MESH 12IN 18IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR","SUP-ITM-10236410","CDM","C1781","HCPCS","0278","RC","","","","both","","","78491.00","58868.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30062.05","38.3","","200.79","72.79","355.81","22","24332.21","62400.35","percent of total billed charges",""
"GRAFT MESH 12IN 18IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR","SUP-ITM-10236410","CDM","C1781","HCPCS","0278","RC","","","","both","","","78491.00","58868.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","60438.07","77","","477.18","477.18","477.18","1 through 10","24332.21","62400.35","percent of total billed charges",""
"GRAFT MESH 12IN 18IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR","SUP-ITM-10236410","CDM","C1781","HCPCS","0278","RC","","","","both","","","78491.00","58868.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33672.64","42.9","","1045.91","1045.91","1045.91","1 through 10","24332.21","62400.35","percent of total billed charges",""
"GRAFT MESH 12IN 18IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR","SUP-ITM-10236410","CDM","C1781","HCPCS","0278","RC","","","","both","","","78491.00","58868.25","WELLPOINT [1015]","HB AMC WELLPOINT","57910.66","73.78","","1726.50","1726.50","1726.50","1 through 10","24332.21","62400.35","percent of total billed charges",""
"GRAFT MESH 12IN 18IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR","SUP-ITM-10236410","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","78491.00","58868.25","AETNA [1001]","HB AMC AETNA HMO","54786.72","69.8","","915.80","263.76","2881.00","1 through 10","41019.4","64142.85","percent of total billed charges",""
"GRAFT MESH 12IN 18IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR","SUP-ITM-10236410","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","78491.00","58868.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","64142.85","81.72","","1531.57","410.52","8841.36","1 through 10","41019.4","64142.85","percent of total billed charges",""
"GRAFT MESH 12X8CM LT SIDE PARIETEX PROGRIP MACROPOROUS POLYESTER ANATOMICAL FLAP HERNIA BX/1EA","SUP-ITM-10042942","CDM","C1781","HCPCS","0278","RC","","","","both","","","745.75","559.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","522.03","70","","134.04","134.04","134.04","1 through 10","231.18","592.87","percent of total billed charges",""
"GRAFT MESH 12X8CM LT SIDE PARIETEX PROGRIP MACROPOROUS POLYESTER ANATOMICAL FLAP HERNIA BX/1EA","SUP-ITM-10042942","CDM","C1781","HCPCS","0278","RC","","","","both","","","745.75","559.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","592.87","79.5","","948.87","198.19","1805.30","1 through 10","231.18","592.87","percent of total billed charges",""
"GRAFT MESH 12X8CM LT SIDE PARIETEX PROGRIP MACROPOROUS POLYESTER ANATOMICAL FLAP HERNIA BX/1EA","SUP-ITM-10042942","CDM","C1781","HCPCS","0278","RC","","","","both","","","745.75","559.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","397.48","53.3","","462.00","170.45","3253.37","1 through 10","231.18","592.87","percent of total billed charges",""
"GRAFT MESH 12X8CM LT SIDE PARIETEX PROGRIP MACROPOROUS POLYESTER ANATOMICAL FLAP HERNIA BX/1EA","SUP-ITM-10042942","CDM","C1781","HCPCS","0278","RC","","","","both","","","745.75","559.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","272.20","36.5","","245.50","107.19","1371.45","1 through 10","231.18","592.87","percent of total billed charges",""
"GRAFT MESH 12X8CM LT SIDE PARIETEX PROGRIP MACROPOROUS POLYESTER ANATOMICAL FLAP HERNIA BX/1EA","SUP-ITM-10042942","CDM","C1781","HCPCS","0278","RC","","","","both","","","745.75","559.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","285.62","38.3","","200.79","72.79","355.81","22","231.18","592.87","percent of total billed charges",""
"GRAFT MESH 12X8CM LT SIDE PARIETEX PROGRIP MACROPOROUS POLYESTER ANATOMICAL FLAP HERNIA BX/1EA","SUP-ITM-10042942","CDM","C1781","HCPCS","0278","RC","","","","both","","","745.75","559.31","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","574.23","77","","477.18","477.18","477.18","1 through 10","231.18","592.87","percent of total billed charges",""
"GRAFT MESH 12X8CM LT SIDE PARIETEX PROGRIP MACROPOROUS POLYESTER ANATOMICAL FLAP HERNIA BX/1EA","SUP-ITM-10042942","CDM","C1781","HCPCS","0278","RC","","","","both","","","745.75","559.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","319.93","42.9","","1045.91","1045.91","1045.91","1 through 10","231.18","592.87","percent of total billed charges",""
"GRAFT MESH 12X8CM LT SIDE PARIETEX PROGRIP MACROPOROUS POLYESTER ANATOMICAL FLAP HERNIA BX/1EA","SUP-ITM-10042942","CDM","C1781","HCPCS","0278","RC","","","","both","","","745.75","559.31","WELLPOINT [1015]","HB AMC WELLPOINT","550.21","73.78","","1726.50","1726.50","1726.50","1 through 10","231.18","592.87","percent of total billed charges",""
"GRAFT MESH 12X8CM LT SIDE PARIETEX PROGRIP MACROPOROUS POLYESTER ANATOMICAL FLAP HERNIA BX/1EA","SUP-ITM-10042942","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","745.75","559.31","AETNA [1001]","HB AMC AETNA HMO","520.53","69.8","","915.80","263.76","2881.00","1 through 10","389.73","609.43","percent of total billed charges",""
"GRAFT MESH 12X8CM LT SIDE PARIETEX PROGRIP MACROPOROUS POLYESTER ANATOMICAL FLAP HERNIA BX/1EA","SUP-ITM-10042942","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","745.75","559.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","609.43","81.72","","1531.57","410.52","8841.36","1 through 10","389.73","609.43","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.84","542.88","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","506.69","70","","134.04","134.04","134.04","1 through 10","224.39","575.45","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.84","542.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","575.45","79.5","","948.87","198.19","1805.30","1 through 10","224.39","575.45","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.84","542.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","385.81","53.3","","462.00","170.45","3253.37","1 through 10","224.39","575.45","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.84","542.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","264.20","36.5","","245.50","107.19","1371.45","1 through 10","224.39","575.45","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.84","542.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","277.23","38.3","","200.79","72.79","355.81","22","224.39","575.45","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.84","542.88","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","557.36","77","","477.18","477.18","477.18","1 through 10","224.39","575.45","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.84","542.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","310.53","42.9","","1045.91","1045.91","1045.91","1 through 10","224.39","575.45","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.84","542.88","WELLPOINT [1015]","HB AMC WELLPOINT","534.05","73.78","","1726.50","1726.50","1726.50","1 through 10","224.39","575.45","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","723.84","542.88","AETNA [1001]","HB AMC AETNA HMO","505.24","69.8","","915.80","263.76","2881.00","1 through 10","378.28","591.52","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","723.84","542.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","591.52","81.72","","1531.57","410.52","8841.36","1 through 10","378.28","591.52","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1813.00","70","","134.04","134.04","134.04","1 through 10","802.9","2059.05","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2059.05","79.5","","948.87","198.19","1805.30","1 through 10","802.9","2059.05","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1380.47","53.3","","462.00","170.45","3253.37","1 through 10","802.9","2059.05","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","945.35","36.5","","245.50","107.19","1371.45","1 through 10","802.9","2059.05","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","991.97","38.3","","200.79","72.79","355.81","22","802.9","2059.05","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1994.30","77","","477.18","477.18","477.18","1 through 10","802.9","2059.05","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1111.11","42.9","","1045.91","1045.91","1045.91","1 through 10","802.9","2059.05","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2590.00","1942.50","WELLPOINT [1015]","HB AMC WELLPOINT","1910.90","73.78","","1726.50","1726.50","1726.50","1 through 10","802.9","2059.05","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","AETNA [1001]","HB AMC AETNA HMO","1807.82","69.8","","915.80","263.76","2881.00","1 through 10","1353.53","2116.55","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2590.00","1942.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2116.55","81.72","","1531.57","410.52","8841.36","1 through 10","1353.53","2116.55","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.00","551.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","514.50","70","","134.04","134.04","134.04","1 through 10","227.85","584.33","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.00","551.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","584.33","79.5","","948.87","198.19","1805.30","1 through 10","227.85","584.33","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.00","551.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","391.76","53.3","","462.00","170.45","3253.37","1 through 10","227.85","584.33","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.00","551.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","268.28","36.5","","245.50","107.19","1371.45","1 through 10","227.85","584.33","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.00","551.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","281.51","38.3","","200.79","72.79","355.81","22","227.85","584.33","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.00","551.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","565.95","77","","477.18","477.18","477.18","1 through 10","227.85","584.33","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.00","551.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.32","42.9","","1045.91","1045.91","1045.91","1 through 10","227.85","584.33","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.00","551.25","WELLPOINT [1015]","HB AMC WELLPOINT","542.28","73.78","","1726.50","1726.50","1726.50","1 through 10","227.85","584.33","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","735.00","551.25","AETNA [1001]","HB AMC AETNA HMO","513.03","69.8","","915.80","263.76","2881.00","1 through 10","384.11","600.64","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","735.00","551.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","600.64","81.72","","1531.57","410.52","8841.36","1 through 10","384.11","600.64","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","4575.00","3431.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3202.50","70","","134.04","134.04","134.04","1 through 10","1418.25","3637.13","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","4575.00","3431.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3637.13","79.5","","948.87","198.19","1805.30","1 through 10","1418.25","3637.13","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","4575.00","3431.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2438.48","53.3","","462.00","170.45","3253.37","1 through 10","1418.25","3637.13","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","4575.00","3431.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1669.88","36.5","","245.50","107.19","1371.45","1 through 10","1418.25","3637.13","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","4575.00","3431.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1752.23","38.3","","200.79","72.79","355.81","22","1418.25","3637.13","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","4575.00","3431.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3522.75","77","","477.18","477.18","477.18","1 through 10","1418.25","3637.13","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","4575.00","3431.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1962.68","42.9","","1045.91","1045.91","1045.91","1 through 10","1418.25","3637.13","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","4575.00","3431.25","WELLPOINT [1015]","HB AMC WELLPOINT","3375.44","73.78","","1726.50","1726.50","1726.50","1 through 10","1418.25","3637.13","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4575.00","3431.25","AETNA [1001]","HB AMC AETNA HMO","3193.35","69.8","","915.80","263.76","2881.00","1 through 10","2390.9","3738.69","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4575.00","3431.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3738.69","81.72","","1531.57","410.52","8841.36","1 through 10","2390.9","3738.69","percent of total billed charges",""
"GRAFT MESH 40X50MM BIOLOGICAL PORCINE COLLAGEN MATRIX EXTREMITY BIO GIDE","SUP-ITM-10011290","CDM","C1762","HCPCS","0278","RC","","","","both","","","2107.00","1580.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1123.03","53.3","","1112.50","1112.50","1112.50","1 through 10","653.17","1675.07","percent of total billed charges",""
"GRAFT MESH 40X50MM BIOLOGICAL PORCINE COLLAGEN MATRIX EXTREMITY BIO GIDE","SUP-ITM-10011290","CDM","C1762","HCPCS","0278","RC","","","","both","","","2107.00","1580.25","WELLPOINT [1015]","HB AMC WELLPOINT","1554.54","73.78","","1568.66","1568.66","1568.66","1 through 10","653.17","1675.07","percent of total billed charges",""
"GRAFT MESH 40X50MM BIOLOGICAL PORCINE COLLAGEN MATRIX EXTREMITY BIO GIDE","SUP-ITM-10011290","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","2107.00","1580.25","AETNA [1001]","HB AMC AETNA HMO","1470.69","69.8","","1281.90","1281.90","1281.90","1 through 10","1101.12","1721.84","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","both","","","8554.25","6415.69","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","5987.98","70","","134.04","134.04","134.04","1 through 10","2651.82","6800.63","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","both","","","8554.25","6415.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6800.63","79.5","","948.87","198.19","1805.30","1 through 10","2651.82","6800.63","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","both","","","8554.25","6415.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4559.42","53.3","","462.00","170.45","3253.37","1 through 10","2651.82","6800.63","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","both","","","8554.25","6415.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3122.30","36.5","","245.50","107.19","1371.45","1 through 10","2651.82","6800.63","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","both","","","8554.25","6415.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3276.28","38.3","","200.79","72.79","355.81","22","2651.82","6800.63","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","both","","","8554.25","6415.69","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","6586.77","77","","477.18","477.18","477.18","1 through 10","2651.82","6800.63","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","both","","","8554.25","6415.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3669.77","42.9","","1045.91","1045.91","1045.91","1 through 10","2651.82","6800.63","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","both","","","8554.25","6415.69","WELLPOINT [1015]","HB AMC WELLPOINT","6311.33","73.78","","1726.50","1726.50","1726.50","1 through 10","2651.82","6800.63","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8554.25","6415.69","AETNA [1001]","HB AMC AETNA HMO","5970.87","69.8","","915.80","263.76","2881.00","1 through 10","4470.45","6990.53","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8554.25","6415.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6990.53","81.72","","1531.57","410.52","8841.36","1 through 10","4470.45","6990.53","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","both","","","17023.25","12767.44","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","11916.28","70","","134.04","134.04","134.04","1 through 10","5277.21","13533.48","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","both","","","17023.25","12767.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13533.48","79.5","","948.87","198.19","1805.30","1 through 10","5277.21","13533.48","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","both","","","17023.25","12767.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9073.39","53.3","","462.00","170.45","3253.37","1 through 10","5277.21","13533.48","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","both","","","17023.25","12767.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6213.49","36.5","","245.50","107.19","1371.45","1 through 10","5277.21","13533.48","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","both","","","17023.25","12767.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6519.90","38.3","","200.79","72.79","355.81","22","5277.21","13533.48","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","both","","","17023.25","12767.44","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","13107.90","77","","477.18","477.18","477.18","1 through 10","5277.21","13533.48","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","both","","","17023.25","12767.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7302.97","42.9","","1045.91","1045.91","1045.91","1 through 10","5277.21","13533.48","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","both","","","17023.25","12767.44","WELLPOINT [1015]","HB AMC WELLPOINT","12559.75","73.78","","1726.50","1726.50","1726.50","1 through 10","5277.21","13533.48","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","17023.25","12767.44","AETNA [1001]","HB AMC AETNA HMO","11882.23","69.8","","915.80","263.76","2881.00","1 through 10","8896.35","13911.4","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","17023.25","12767.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13911.40","81.72","","1531.57","410.52","8841.36","1 through 10","8896.35","13911.4","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","840.00","630.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","588.00","70","","134.04","134.04","134.04","1 through 10","260.4","667.8","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","948.87","198.19","1805.30","1 through 10","260.4","667.8","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","462.00","170.45","3253.37","1 through 10","260.4","667.8","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","245.50","107.19","1371.45","1 through 10","260.4","667.8","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","200.79","72.79","355.81","22","260.4","667.8","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","840.00","630.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","646.80","77","","477.18","477.18","477.18","1 through 10","260.4","667.8","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","1045.91","1045.91","1045.91","1 through 10","260.4","667.8","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","1726.50","1726.50","1726.50","1 through 10","260.4","667.8","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","915.80","263.76","2881.00","1 through 10","438.98","686.45","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","1531.57","410.52","8841.36","1 through 10","438.98","686.45","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","both","","","28438.25","21328.69","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","19906.78","70","","134.04","134.04","134.04","1 through 10","8815.86","22608.41","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","both","","","28438.25","21328.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","22608.41","79.5","","948.87","198.19","1805.30","1 through 10","8815.86","22608.41","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","both","","","28438.25","21328.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","15157.59","53.3","","462.00","170.45","3253.37","1 through 10","8815.86","22608.41","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","both","","","28438.25","21328.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10379.96","36.5","","245.50","107.19","1371.45","1 through 10","8815.86","22608.41","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","both","","","28438.25","21328.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10891.85","38.3","","200.79","72.79","355.81","22","8815.86","22608.41","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","both","","","28438.25","21328.69","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","21897.45","77","","477.18","477.18","477.18","1 through 10","8815.86","22608.41","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","both","","","28438.25","21328.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12200.01","42.9","","1045.91","1045.91","1045.91","1 through 10","8815.86","22608.41","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","both","","","28438.25","21328.69","WELLPOINT [1015]","HB AMC WELLPOINT","20981.74","73.78","","1726.50","1726.50","1726.50","1 through 10","8815.86","22608.41","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","28438.25","21328.69","AETNA [1001]","HB AMC AETNA HMO","19849.90","69.8","","915.80","263.76","2881.00","1 through 10","14861.83","23239.74","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","28438.25","21328.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","23239.74","81.72","","1531.57","410.52","8841.36","1 through 10","14861.83","23239.74","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","both","","","16992.50","12744.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13509.04","79.5","","1309.77","674.56","6049.93","26","5267.68","13509.04","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","both","","","16992.50","12744.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9057.00","53.3","","1901.83","1901.83","2962.25","1 through 10","5267.68","13509.04","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","both","","","16992.50","12744.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6202.26","36.5","","1620.31","1620.31","19908.88","1 through 10","5267.68","13509.04","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","both","","","16992.50","12744.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6508.13","38.3","","352.91","352.91","2046.30","1 through 10","5267.68","13509.04","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","both","","","16992.50","12744.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7289.78","42.9","","9668.75","9668.75","9668.75","1 through 10","5267.68","13509.04","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","both","","","16992.50","12744.37","WELLPOINT [1015]","HB AMC WELLPOINT","12537.07","73.78","","699.88","384.10","3443.31","33","5267.68","13509.04","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","16992.50","12744.37","AETNA [1001]","HB AMC AETNA HMO","11860.77","69.8","","1421.24","264.50","4933.46","29","8880.28","13886.27","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","16992.50","12744.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","13661.97","80.4","","1022.97","1022.97","3607.50","1 through 10","8880.28","13886.27","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","16992.50","12744.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13886.27","81.72","","3010.54","693.88","5019.88","35","8880.28","13886.27","percent of total billed charges",""
"GRAFT NERVE 3.0 TO 4.0X70MM PERIPH ALLO AVANCE IMPLANTABLE","SUP-ITM-10101012","CDM","C1889","HCPCS","0278","RC","","","","both","","","18617.50","13963.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","14800.91","79.5","","1309.77","674.56","6049.93","26","5771.43","14800.91","percent of total billed charges",""
"GRAFT NERVE 3.0 TO 4.0X70MM PERIPH ALLO AVANCE IMPLANTABLE","SUP-ITM-10101012","CDM","C1889","HCPCS","0278","RC","","","","both","","","18617.50","13963.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9923.13","53.3","","1901.83","1901.83","2962.25","1 through 10","5771.43","14800.91","percent of total billed charges",""
"GRAFT NERVE 3.0 TO 4.0X70MM PERIPH ALLO AVANCE IMPLANTABLE","SUP-ITM-10101012","CDM","C1889","HCPCS","0278","RC","","","","both","","","18617.50","13963.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6795.39","36.5","","1620.31","1620.31","19908.88","1 through 10","5771.43","14800.91","percent of total billed charges",""
"GRAFT NERVE 3.0 TO 4.0X70MM PERIPH ALLO AVANCE IMPLANTABLE","SUP-ITM-10101012","CDM","C1889","HCPCS","0278","RC","","","","both","","","18617.50","13963.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7130.50","38.3","","352.91","352.91","2046.30","1 through 10","5771.43","14800.91","percent of total billed charges",""
"GRAFT NERVE 3.0 TO 4.0X70MM PERIPH ALLO AVANCE IMPLANTABLE","SUP-ITM-10101012","CDM","C1889","HCPCS","0278","RC","","","","both","","","18617.50","13963.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7986.91","42.9","","9668.75","9668.75","9668.75","1 through 10","5771.43","14800.91","percent of total billed charges",""
"GRAFT NERVE 3.0 TO 4.0X70MM PERIPH ALLO AVANCE IMPLANTABLE","SUP-ITM-10101012","CDM","C1889","HCPCS","0278","RC","","","","both","","","18617.50","13963.12","WELLPOINT [1015]","HB AMC WELLPOINT","13735.99","73.78","","699.88","384.10","3443.31","33","5771.43","14800.91","percent of total billed charges",""
"GRAFT NERVE 3.0 TO 4.0X70MM PERIPH ALLO AVANCE IMPLANTABLE","SUP-ITM-10101012","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18617.50","13963.12","AETNA [1001]","HB AMC AETNA HMO","12995.02","69.8","","1421.24","264.50","4933.46","29","9729.51","15214.22","percent of total billed charges",""
"GRAFT NERVE 3.0 TO 4.0X70MM PERIPH ALLO AVANCE IMPLANTABLE","SUP-ITM-10101012","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18617.50","13963.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","14968.47","80.4","","1022.97","1022.97","3607.50","1 through 10","9729.51","15214.22","percent of total billed charges",""
"GRAFT NERVE 3.0 TO 4.0X70MM PERIPH ALLO AVANCE IMPLANTABLE","SUP-ITM-10101012","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18617.50","13963.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15214.22","81.72","","3010.54","693.88","5019.88","35","9729.51","15214.22","percent of total billed charges",""
"GRAFT NERVE 30X3.0 4.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100508","CDM","C1889","HCPCS","0278","RC","","","","both","","","8622.50","6466.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6854.89","79.5","","1309.77","674.56","6049.93","26","2672.98","6854.89","percent of total billed charges",""
"GRAFT NERVE 30X3.0 4.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100508","CDM","C1889","HCPCS","0278","RC","","","","both","","","8622.50","6466.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4595.79","53.3","","1901.83","1901.83","2962.25","1 through 10","2672.98","6854.89","percent of total billed charges",""
"GRAFT NERVE 30X3.0 4.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100508","CDM","C1889","HCPCS","0278","RC","","","","both","","","8622.50","6466.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3147.21","36.5","","1620.31","1620.31","19908.88","1 through 10","2672.98","6854.89","percent of total billed charges",""
"GRAFT NERVE 30X3.0 4.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100508","CDM","C1889","HCPCS","0278","RC","","","","both","","","8622.50","6466.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3302.42","38.3","","352.91","352.91","2046.30","1 through 10","2672.98","6854.89","percent of total billed charges",""
"GRAFT NERVE 30X3.0 4.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100508","CDM","C1889","HCPCS","0278","RC","","","","both","","","8622.50","6466.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3699.05","42.9","","9668.75","9668.75","9668.75","1 through 10","2672.98","6854.89","percent of total billed charges",""
"GRAFT NERVE 30X3.0 4.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100508","CDM","C1889","HCPCS","0278","RC","","","","both","","","8622.50","6466.87","WELLPOINT [1015]","HB AMC WELLPOINT","6361.68","73.78","","699.88","384.10","3443.31","33","2672.98","6854.89","percent of total billed charges",""
"GRAFT NERVE 30X3.0 4.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100508","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8622.50","6466.87","AETNA [1001]","HB AMC AETNA HMO","6018.51","69.8","","1421.24","264.50","4933.46","29","4506.12","7046.31","percent of total billed charges",""
"GRAFT NERVE 30X3.0 4.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100508","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8622.50","6466.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6932.49","80.4","","1022.97","1022.97","3607.50","1 through 10","4506.12","7046.31","percent of total billed charges",""
"GRAFT NERVE 30X3.0 4.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100508","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8622.50","6466.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7046.31","81.72","","3010.54","693.88","5019.88","35","4506.12","7046.31","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","both","","","13375.00","10031.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10633.13","79.5","","1309.77","674.56","6049.93","26","4146.25","10633.13","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","both","","","13375.00","10031.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7128.88","53.3","","1901.83","1901.83","2962.25","1 through 10","4146.25","10633.13","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","both","","","13375.00","10031.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4881.88","36.5","","1620.31","1620.31","19908.88","1 through 10","4146.25","10633.13","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","both","","","13375.00","10031.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5122.63","38.3","","352.91","352.91","2046.30","1 through 10","4146.25","10633.13","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","both","","","13375.00","10031.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5737.88","42.9","","9668.75","9668.75","9668.75","1 through 10","4146.25","10633.13","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","both","","","13375.00","10031.25","WELLPOINT [1015]","HB AMC WELLPOINT","9868.08","73.78","","699.88","384.10","3443.31","33","4146.25","10633.13","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13375.00","10031.25","AETNA [1001]","HB AMC AETNA HMO","9335.75","69.8","","1421.24","264.50","4933.46","29","6989.78","10930.05","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13375.00","10031.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10753.50","80.4","","1022.97","1022.97","3607.50","1 through 10","6989.78","10930.05","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13375.00","10031.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10930.05","81.72","","3010.54","693.88","5019.88","35","6989.78","10930.05","percent of total billed charges",""
"GRAFT SKIN 154SQCM 1/6SQFT ALLOGRAFT CRYOPRESERVED NONMESHED","SUP-ITM-10274584","CDM","C1889","HCPCS","0278","RC","","","","both","","","1389.50","1042.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1104.65","79.5","","1309.77","674.56","6049.93","26","430.75","1104.65","percent of total billed charges",""
"GRAFT SKIN 154SQCM 1/6SQFT ALLOGRAFT CRYOPRESERVED NONMESHED","SUP-ITM-10274584","CDM","C1889","HCPCS","0278","RC","","","","both","","","1389.50","1042.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","740.60","53.3","","1901.83","1901.83","2962.25","1 through 10","430.75","1104.65","percent of total billed charges",""
"GRAFT SKIN 154SQCM 1/6SQFT ALLOGRAFT CRYOPRESERVED NONMESHED","SUP-ITM-10274584","CDM","C1889","HCPCS","0278","RC","","","","both","","","1389.50","1042.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","507.17","36.5","","1620.31","1620.31","19908.88","1 through 10","430.75","1104.65","percent of total billed charges",""
"GRAFT SKIN 154SQCM 1/6SQFT ALLOGRAFT CRYOPRESERVED NONMESHED","SUP-ITM-10274584","CDM","C1889","HCPCS","0278","RC","","","","both","","","1389.50","1042.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","532.18","38.3","","352.91","352.91","2046.30","1 through 10","430.75","1104.65","percent of total billed charges",""
"GRAFT SKIN 154SQCM 1/6SQFT ALLOGRAFT CRYOPRESERVED NONMESHED","SUP-ITM-10274584","CDM","C1889","HCPCS","0278","RC","","","","both","","","1389.50","1042.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","596.10","42.9","","9668.75","9668.75","9668.75","1 through 10","430.75","1104.65","percent of total billed charges",""
"GRAFT SKIN 154SQCM 1/6SQFT ALLOGRAFT CRYOPRESERVED NONMESHED","SUP-ITM-10274584","CDM","C1889","HCPCS","0278","RC","","","","both","","","1389.50","1042.12","WELLPOINT [1015]","HB AMC WELLPOINT","1025.17","73.78","","699.88","384.10","3443.31","33","430.75","1104.65","percent of total billed charges",""
"GRAFT SKIN 154SQCM 1/6SQFT ALLOGRAFT CRYOPRESERVED NONMESHED","SUP-ITM-10274584","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1389.50","1042.12","AETNA [1001]","HB AMC AETNA HMO","969.87","69.8","","1421.24","264.50","4933.46","29","726.15","1135.5","percent of total billed charges",""
"GRAFT SKIN 154SQCM 1/6SQFT ALLOGRAFT CRYOPRESERVED NONMESHED","SUP-ITM-10274584","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1389.50","1042.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1117.16","80.4","","1022.97","1022.97","3607.50","1 through 10","726.15","1135.5","percent of total billed charges",""
"GRAFT SKIN 154SQCM 1/6SQFT ALLOGRAFT CRYOPRESERVED NONMESHED","SUP-ITM-10274584","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1389.50","1042.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1135.50","81.72","","3010.54","693.88","5019.88","35","726.15","1135.5","percent of total billed charges",""
"GRAFT SKIN 464SQ CMX1/2SQ FT CRYOPRESERVED MESHED","SUP-ITM-10273912","CDM","C1889","HCPCS","0278","RC","","","","both","","","4182.50","3136.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3325.09","79.5","","1309.77","674.56","6049.93","26","1296.58","3325.09","percent of total billed charges",""
"GRAFT SKIN 464SQ CMX1/2SQ FT CRYOPRESERVED MESHED","SUP-ITM-10273912","CDM","C1889","HCPCS","0278","RC","","","","both","","","4182.50","3136.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2229.27","53.3","","1901.83","1901.83","2962.25","1 through 10","1296.58","3325.09","percent of total billed charges",""
"GRAFT SKIN 464SQ CMX1/2SQ FT CRYOPRESERVED MESHED","SUP-ITM-10273912","CDM","C1889","HCPCS","0278","RC","","","","both","","","4182.50","3136.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1526.61","36.5","","1620.31","1620.31","19908.88","1 through 10","1296.58","3325.09","percent of total billed charges",""
"GRAFT SKIN 464SQ CMX1/2SQ FT CRYOPRESERVED MESHED","SUP-ITM-10273912","CDM","C1889","HCPCS","0278","RC","","","","both","","","4182.50","3136.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1601.90","38.3","","352.91","352.91","2046.30","1 through 10","1296.58","3325.09","percent of total billed charges",""
"GRAFT SKIN 464SQ CMX1/2SQ FT CRYOPRESERVED MESHED","SUP-ITM-10273912","CDM","C1889","HCPCS","0278","RC","","","","both","","","4182.50","3136.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1794.29","42.9","","9668.75","9668.75","9668.75","1 through 10","1296.58","3325.09","percent of total billed charges",""
"GRAFT SKIN 464SQ CMX1/2SQ FT CRYOPRESERVED MESHED","SUP-ITM-10273912","CDM","C1889","HCPCS","0278","RC","","","","both","","","4182.50","3136.87","WELLPOINT [1015]","HB AMC WELLPOINT","3085.85","73.78","","699.88","384.10","3443.31","33","1296.58","3325.09","percent of total billed charges",""
"GRAFT SKIN 464SQ CMX1/2SQ FT CRYOPRESERVED MESHED","SUP-ITM-10273912","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4182.50","3136.87","AETNA [1001]","HB AMC AETNA HMO","2919.39","69.8","","1421.24","264.50","4933.46","29","2185.77","3417.94","percent of total billed charges",""
"GRAFT SKIN 464SQ CMX1/2SQ FT CRYOPRESERVED MESHED","SUP-ITM-10273912","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4182.50","3136.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3362.73","80.4","","1022.97","1022.97","3607.50","1 through 10","2185.77","3417.94","percent of total billed charges",""
"GRAFT SKIN 464SQ CMX1/2SQ FT CRYOPRESERVED MESHED","SUP-ITM-10273912","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4182.50","3136.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3417.94","81.72","","3010.54","693.88","5019.88","35","2185.77","3417.94","percent of total billed charges",""
"GRAFT SOFT 23CMX7.5MM TISSUE FROZEN FLEXI PERONEUS LONGUS TENDON IMPLANTABLE","SUP-ITM-10124337","CDM","C1762","HCPCS","0278","RC","","","","both","","","5179.83","3884.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2760.85","53.3","","1112.50","1112.50","1112.50","1 through 10","1605.75","4117.96","percent of total billed charges",""
"GRAFT SOFT 23CMX7.5MM TISSUE FROZEN FLEXI PERONEUS LONGUS TENDON IMPLANTABLE","SUP-ITM-10124337","CDM","C1762","HCPCS","0278","RC","","","","both","","","5179.83","3884.87","WELLPOINT [1015]","HB AMC WELLPOINT","3821.68","73.78","","1568.66","1568.66","1568.66","1 through 10","1605.75","4117.96","percent of total billed charges",""
"GRAFT SOFT 23CMX7.5MM TISSUE FROZEN FLEXI PERONEUS LONGUS TENDON IMPLANTABLE","SUP-ITM-10124337","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","5179.83","3884.87","AETNA [1001]","HB AMC AETNA HMO","3615.52","69.8","","1281.90","1281.90","1281.90","1 through 10","2706.98","4232.96","percent of total billed charges",""
"GRAFT SPACER 9.0X25.0MM SHORT POSTERIOR LUMBAR INTERBODY FUSION BIO AVS UNILIF PEEK ABLE","SUP-ITM-10100955","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5565.00","79.5","","1309.77","674.56","6049.93","26","2170","5565","percent of total billed charges",""
"GRAFT SPACER 9.0X25.0MM SHORT POSTERIOR LUMBAR INTERBODY FUSION BIO AVS UNILIF PEEK ABLE","SUP-ITM-10100955","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3731.00","53.3","","1901.83","1901.83","2962.25","1 through 10","2170","5565","percent of total billed charges",""
"GRAFT SPACER 9.0X25.0MM SHORT POSTERIOR LUMBAR INTERBODY FUSION BIO AVS UNILIF PEEK ABLE","SUP-ITM-10100955","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2555.00","36.5","","1620.31","1620.31","19908.88","1 through 10","2170","5565","percent of total billed charges",""
"GRAFT SPACER 9.0X25.0MM SHORT POSTERIOR LUMBAR INTERBODY FUSION BIO AVS UNILIF PEEK ABLE","SUP-ITM-10100955","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2681.00","38.3","","352.91","352.91","2046.30","1 through 10","2170","5565","percent of total billed charges",""
"GRAFT SPACER 9.0X25.0MM SHORT POSTERIOR LUMBAR INTERBODY FUSION BIO AVS UNILIF PEEK ABLE","SUP-ITM-10100955","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3003.00","42.9","","9668.75","9668.75","9668.75","1 through 10","2170","5565","percent of total billed charges",""
"GRAFT SPACER 9.0X25.0MM SHORT POSTERIOR LUMBAR INTERBODY FUSION BIO AVS UNILIF PEEK ABLE","SUP-ITM-10100955","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","WELLPOINT [1015]","HB AMC WELLPOINT","5164.60","73.78","","699.88","384.10","3443.31","33","2170","5565","percent of total billed charges",""
"GRAFT SPACER 9.0X25.0MM SHORT POSTERIOR LUMBAR INTERBODY FUSION BIO AVS UNILIF PEEK ABLE","SUP-ITM-10100955","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","AETNA [1001]","HB AMC AETNA HMO","4886.00","69.8","","1421.24","264.50","4933.46","29","3658.2","5720.4","percent of total billed charges",""
"GRAFT SPACER 9.0X25.0MM SHORT POSTERIOR LUMBAR INTERBODY FUSION BIO AVS UNILIF PEEK ABLE","SUP-ITM-10100955","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5628.00","80.4","","1022.97","1022.97","3607.50","1 through 10","3658.2","5720.4","percent of total billed charges",""
"GRAFT SPACER 9.0X25.0MM SHORT POSTERIOR LUMBAR INTERBODY FUSION BIO AVS UNILIF PEEK ABLE","SUP-ITM-10100955","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5720.40","81.72","","3010.54","693.88","5019.88","35","3658.2","5720.4","percent of total billed charges",""
"GRAFT SPINE 26X30MM LG 5DEG CHRONOS SYNTHETIC BETA TRICALCIU - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036468","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2811.72","79.5","","800.18","480.96","1887.97","195","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 26X30MM LG 5DEG CHRONOS SYNTHETIC BETA TRICALCIU - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036468","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1885.09","53.3","","813.12","216.42","1444.50","81","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 26X30MM LG 5DEG CHRONOS SYNTHETIC BETA TRICALCIU - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036468","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1096.39","31","","432.60","432.60","432.60","1 through 10","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 26X30MM LG 5DEG CHRONOS SYNTHETIC BETA TRICALCIU - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036468","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1290.91","36.5","","148.37","54.89","631.39","94","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 26X30MM LG 5DEG CHRONOS SYNTHETIC BETA TRICALCIU - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036468","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1354.58","38.3","","279.30","91.72","1116.77","266","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 26X30MM LG 5DEG CHRONOS SYNTHETIC BETA TRICALCIU - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036468","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1517.27","42.9","","731.00","63.70","731.00","1 through 10","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 26X30MM LG 5DEG CHRONOS SYNTHETIC BETA TRICALCIU - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036468","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1517.27","42.9","","384.74","384.74","384.74","1 through 10","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 26X30MM LG 5DEG CHRONOS SYNTHETIC BETA TRICALCIU - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036468","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","WELLPOINT [1015]","HB AMC WELLPOINT","2609.41","73.78","","286.63","119.22","1107.45","105","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 26X30MM LG 5DEG CHRONOS SYNTHETIC BETA TRICALCIU - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3536.75","2652.56","AETNA [1001]","HB AMC AETNA HMO","2468.65","69.8","","675.31","184.75","1721.50","286","1848.31","2890.23","percent of total billed charges",""
"GRAFT SPINE 26X30MM LG 5DEG CHRONOS SYNTHETIC BETA TRICALCIU - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3536.75","2652.56","AETNA [1001]","HB AMC AETNA PPO","2843.55","80.4","","1261.44","103.12","1514.10","21","1848.31","2890.23","percent of total billed charges",""
"GRAFT SPINE 26X30MM LG 5DEG CHRONOS SYNTHETIC BETA TRICALCIU - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3536.75","2652.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2843.55","80.4","","1365.00","1365.00","1365.00","1 through 10","1848.31","2890.23","percent of total billed charges",""
"GRAFT SPINE 26X30MM LG 5DEG CHRONOS SYNTHETIC BETA TRICALCIU - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3536.75","2652.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2890.23","81.72","","5157.68","5157.68","5157.68","1 through 10","1848.31","2890.23","percent of total billed charges",""
"GRAFT SPINE 26X30MM LG 5DEG CHRONOS SYNTHETIC BETA TRICALCIU - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3536.75","2652.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2890.23","81.72","","431.26","71.26","1459.57","88","1848.31","2890.23","percent of total billed charges",""
"GRAFT SPINE 50X25 3MM CHRONOS SYNTHETIC BETA TRICALCIUM PHOS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2811.72","79.5","","800.18","480.96","1887.97","195","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 50X25 3MM CHRONOS SYNTHETIC BETA TRICALCIUM PHOS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1885.09","53.3","","813.12","216.42","1444.50","81","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 50X25 3MM CHRONOS SYNTHETIC BETA TRICALCIUM PHOS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1096.39","31","","432.60","432.60","432.60","1 through 10","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 50X25 3MM CHRONOS SYNTHETIC BETA TRICALCIUM PHOS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1290.91","36.5","","148.37","54.89","631.39","94","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 50X25 3MM CHRONOS SYNTHETIC BETA TRICALCIUM PHOS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1354.58","38.3","","279.30","91.72","1116.77","266","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 50X25 3MM CHRONOS SYNTHETIC BETA TRICALCIUM PHOS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1517.27","42.9","","731.00","63.70","731.00","1 through 10","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 50X25 3MM CHRONOS SYNTHETIC BETA TRICALCIUM PHOS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1517.27","42.9","","384.74","384.74","384.74","1 through 10","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 50X25 3MM CHRONOS SYNTHETIC BETA TRICALCIUM PHOS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036466","CDM","C1713","HCPCS","0278","RC","","","","both","","","3536.75","2652.56","WELLPOINT [1015]","HB AMC WELLPOINT","2609.41","73.78","","286.63","119.22","1107.45","105","1096.39","2811.72","percent of total billed charges",""
"GRAFT SPINE 50X25 3MM CHRONOS SYNTHETIC BETA TRICALCIUM PHOS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3536.75","2652.56","AETNA [1001]","HB AMC AETNA HMO","2468.65","69.8","","675.31","184.75","1721.50","286","1848.31","2890.23","percent of total billed charges",""
"GRAFT SPINE 50X25 3MM CHRONOS SYNTHETIC BETA TRICALCIUM PHOS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3536.75","2652.56","AETNA [1001]","HB AMC AETNA PPO","2843.55","80.4","","1261.44","103.12","1514.10","21","1848.31","2890.23","percent of total billed charges",""
"GRAFT SPINE 50X25 3MM CHRONOS SYNTHETIC BETA TRICALCIUM PHOS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3536.75","2652.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2843.55","80.4","","1365.00","1365.00","1365.00","1 through 10","1848.31","2890.23","percent of total billed charges",""
"GRAFT SPINE 50X25 3MM CHRONOS SYNTHETIC BETA TRICALCIUM PHOS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3536.75","2652.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2890.23","81.72","","5157.68","5157.68","5157.68","1 through 10","1848.31","2890.23","percent of total billed charges",""
"GRAFT SPINE 50X25 3MM CHRONOS SYNTHETIC BETA TRICALCIUM PHOS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10036466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3536.75","2652.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2890.23","81.72","","431.26","71.26","1459.57","88","1848.31","2890.23","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","3063.66","2297.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2435.61","79.5","","1309.77","674.56","6049.93","26","949.73","2435.61","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","3063.66","2297.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1632.93","53.3","","1901.83","1901.83","2962.25","1 through 10","949.73","2435.61","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","3063.66","2297.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1118.24","36.5","","1620.31","1620.31","19908.88","1 through 10","949.73","2435.61","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","3063.66","2297.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1173.38","38.3","","352.91","352.91","2046.30","1 through 10","949.73","2435.61","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","3063.66","2297.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1314.31","42.9","","9668.75","9668.75","9668.75","1 through 10","949.73","2435.61","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","3063.66","2297.74","WELLPOINT [1015]","HB AMC WELLPOINT","2260.37","73.78","","699.88","384.10","3443.31","33","949.73","2435.61","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3063.66","2297.74","AETNA [1001]","HB AMC AETNA HMO","2138.43","69.8","","1421.24","264.50","4933.46","29","1601.07","2503.62","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3063.66","2297.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2463.18","80.4","","1022.97","1022.97","3607.50","1 through 10","1601.07","2503.62","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3063.66","2297.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2503.62","81.72","","3010.54","693.88","5019.88","35","1601.07","2503.62","percent of total billed charges",""
"GRAFT SPINE 8MM CERVICAL CANCELLOUS CORTICAL","SUP-ITM-10021587","CDM","C1889","HCPCS","0278","RC","","","","both","","","4116.00","3087.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3272.22","79.5","","1309.77","674.56","6049.93","26","1275.96","3272.22","percent of total billed charges",""
"GRAFT SPINE 8MM CERVICAL CANCELLOUS CORTICAL","SUP-ITM-10021587","CDM","C1889","HCPCS","0278","RC","","","","both","","","4116.00","3087.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2193.83","53.3","","1901.83","1901.83","2962.25","1 through 10","1275.96","3272.22","percent of total billed charges",""
"GRAFT SPINE 8MM CERVICAL CANCELLOUS CORTICAL","SUP-ITM-10021587","CDM","C1889","HCPCS","0278","RC","","","","both","","","4116.00","3087.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1502.34","36.5","","1620.31","1620.31","19908.88","1 through 10","1275.96","3272.22","percent of total billed charges",""
"GRAFT SPINE 8MM CERVICAL CANCELLOUS CORTICAL","SUP-ITM-10021587","CDM","C1889","HCPCS","0278","RC","","","","both","","","4116.00","3087.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1576.43","38.3","","352.91","352.91","2046.30","1 through 10","1275.96","3272.22","percent of total billed charges",""
"GRAFT SPINE 8MM CERVICAL CANCELLOUS CORTICAL","SUP-ITM-10021587","CDM","C1889","HCPCS","0278","RC","","","","both","","","4116.00","3087.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1765.76","42.9","","9668.75","9668.75","9668.75","1 through 10","1275.96","3272.22","percent of total billed charges",""
"GRAFT SPINE 8MM CERVICAL CANCELLOUS CORTICAL","SUP-ITM-10021587","CDM","C1889","HCPCS","0278","RC","","","","both","","","4116.00","3087.00","WELLPOINT [1015]","HB AMC WELLPOINT","3036.78","73.78","","699.88","384.10","3443.31","33","1275.96","3272.22","percent of total billed charges",""
"GRAFT SPINE 8MM CERVICAL CANCELLOUS CORTICAL","SUP-ITM-10021587","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4116.00","3087.00","AETNA [1001]","HB AMC AETNA HMO","2872.97","69.8","","1421.24","264.50","4933.46","29","2151.02","3363.6","percent of total billed charges",""
"GRAFT SPINE 8MM CERVICAL CANCELLOUS CORTICAL","SUP-ITM-10021587","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4116.00","3087.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3309.26","80.4","","1022.97","1022.97","3607.50","1 through 10","2151.02","3363.6","percent of total billed charges",""
"GRAFT SPINE 8MM CERVICAL CANCELLOUS CORTICAL","SUP-ITM-10021587","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4116.00","3087.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3363.60","81.72","","3010.54","693.88","5019.88","35","2151.02","3363.6","percent of total billed charges",""
"GRAFT SPINE 8X11 14MM TRIAD ALLO INTERBODY FUSION CERVICAL LORDOTIC","SUP-ITM-10187554","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","1309.77","674.56","6049.93","26","759.5","1947.75","percent of total billed charges",""
"GRAFT SPINE 8X11 14MM TRIAD ALLO INTERBODY FUSION CERVICAL LORDOTIC","SUP-ITM-10187554","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.85","53.3","","1901.83","1901.83","2962.25","1 through 10","759.5","1947.75","percent of total billed charges",""
"GRAFT SPINE 8X11 14MM TRIAD ALLO INTERBODY FUSION CERVICAL LORDOTIC","SUP-ITM-10187554","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","1620.31","1620.31","19908.88","1 through 10","759.5","1947.75","percent of total billed charges",""
"GRAFT SPINE 8X11 14MM TRIAD ALLO INTERBODY FUSION CERVICAL LORDOTIC","SUP-ITM-10187554","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","352.91","352.91","2046.30","1 through 10","759.5","1947.75","percent of total billed charges",""
"GRAFT SPINE 8X11 14MM TRIAD ALLO INTERBODY FUSION CERVICAL LORDOTIC","SUP-ITM-10187554","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","9668.75","9668.75","9668.75","1 through 10","759.5","1947.75","percent of total billed charges",""
"GRAFT SPINE 8X11 14MM TRIAD ALLO INTERBODY FUSION CERVICAL LORDOTIC","SUP-ITM-10187554","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","699.88","384.10","3443.31","33","759.5","1947.75","percent of total billed charges",""
"GRAFT SPINE 8X11 14MM TRIAD ALLO INTERBODY FUSION CERVICAL LORDOTIC","SUP-ITM-10187554","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","1421.24","264.50","4933.46","29","1280.37","2002.14","percent of total billed charges",""
"GRAFT SPINE 8X11 14MM TRIAD ALLO INTERBODY FUSION CERVICAL LORDOTIC","SUP-ITM-10187554","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.80","80.4","","1022.97","1022.97","3607.50","1 through 10","1280.37","2002.14","percent of total billed charges",""
"GRAFT SPINE 8X11 14MM TRIAD ALLO INTERBODY FUSION CERVICAL LORDOTIC","SUP-ITM-10187554","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","3010.54","693.88","5019.88","35","1280.37","2002.14","percent of total billed charges",""
"Graft Split Face 1st 100 Sq Cm Chld","PX-76000168","CDM","15120","CPT","0761","RC","","","","both","","","7871.00","5903.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4347.18","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4278.06","3852.97","4278.06","1 through 10","2440.01","6257.45","other","OPPS APC"
"Graft Split Face 1st 100 Sq Cm Chld","PX-76000168","CDM","15120","CPT","0761","RC","","","","both","","","7871.00","5903.25","MEDICARE [2001]","HB BWH MEDICARE","4347.18","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4347.62","4347.62","4347.62","1 through 10","2440.01","6257.45","other","OPPS APC"
"Graft Split Face 1st 100 Sq Cm Chld","PX-76000168","CDM","15120","CPT","0761","RC","","","","both","","","7871.00","5903.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3014.59","38.3","","8361.33","8361.33","8361.33","1 through 10","2440.01","6257.45","percent of total billed charges",""
"Graft Split Face 1st 100 Sq Cm Chld","PX-76000168","CDM","15120","CPT","0761","RC","","","","both","","","7871.00","5903.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4260.24","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3837.31","3837.31","3837.31","1 through 10","2440.01","6257.45","other","OPPS APC"
"Graft Split Face 1st 100 Sq Cm Chld","PX-76000168","CDM","15120","CPT","0761","RC","","","","outpatient","","","7871.00","5903.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3163.23","","Case rate ($3,163.23). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6354.93","3177.47","6354.93","1 through 10","2766.13","6432.18","other","ASC"
"Graft Split Face 1st 100 Sq Cm Chld","PX-76000168","CDM","15120","CPT","0761","RC","","","","outpatient","","","7871.00","5903.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","8021.78","8021.78","8021.78","1 through 10","2766.13","6432.18","other","Multiple Surgery"
"Graft Split Face 1st 100 Sq Cm Chld","PX-76000168","CDM","15120","CPT","0761","RC","","","","outpatient","","","7871.00","5903.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3208.71","3208.71","3208.71","1 through 10","2766.13","6432.18","other","Multiple Surgery"
"Graft Split Face 1st 100 Sq Cm Chld","PX-76000168","CDM","15120","CPT","0761","RC","","","","outpatient","","","7871.00","5903.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6328.28","80.4","","5953.74","5953.74","5953.74","1 through 10","2766.13","6432.18","percent of total billed charges",""
"Graft Split Face 1st 100 Sq Cm Chld","PX-76000168","CDM","15120","CPT","0761","RC","","","","outpatient","","","7871.00","5903.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6432.18","81.72","","3402.34","3402.34","3402.34","1 through 10","2766.13","6432.18","percent of total billed charges",""
"Graft Split Trunk 1st 100 Sq Cm","PX-76000167","CDM","15100","CPT","0761","RC","","","","both","","","7871.00","5903.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6257.45","79.5","","15914.14","15914.14","15914.14","1 through 10","2440.01","6257.45","percent of total billed charges",""
"Graft Split Trunk 1st 100 Sq Cm","PX-76000167","CDM","15100","CPT","0761","RC","","","","outpatient","","","7871.00","5903.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4765.89","60.55","","3624.12","3624.12","3624.12","1 through 10","3148.4","6432.18","percent of total billed charges",""
"Graft Split Trunk 1st 100 Sq Cm","PX-76000167","CDM","15100","CPT","0761","RC","","","","outpatient","","","7871.00","5903.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4110.24","52.22","","2052.96","2052.96","2052.96","1 through 10","3148.4","6432.18","percent of total billed charges",""
"Graft Split Trunk 1st 100 Sq Cm","PX-76000167","CDM","15100","CPT","0761","RC","","","","outpatient","","","7871.00","5903.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6432.18","81.72","","25675.13","25675.13","25675.13","1 through 10","3148.4","6432.18","percent of total billed charges",""
"GRAFT STENT 20FR 26X21X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269176","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","29900.00","65","","6652.80","6652.80","6652.80","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 20FR 26X21X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269176","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","36570.00","79.5","","2612.61","795.38","2612.61","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 20FR 26X21X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269176","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","24518.00","53.3","","1101.80","1101.80","1101.80","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 20FR 26X21X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269176","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","29900.00","65","","1820.00","910.00","1820.00","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 20FR 26X21X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269176","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16790.00","36.5","","1257.80","693.44","2424.50","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 20FR 26X21X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269176","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17618.00","38.3","","1950.11","547.40","2346.00","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 20FR 26X21X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269176","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19734.00","42.9","","5096.18","5096.18","5096.18","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 20FR 26X21X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269176","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","WELLPOINT [1015]","HB AMC WELLPOINT","33938.80","73.78","","1172.59","1172.59","4829.94","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 20FR 26X21X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269176","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46000.00","34500.00","AETNA [1001]","HB AMC AETNA HMO","32108.00","69.8","","1806.84","947.80","5091.72","1 through 10","24039.6","37591.2","percent of total billed charges",""
"GRAFT STENT 20FR 26X21X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269176","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46000.00","34500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","37591.20","81.72","","1259.05","615.58","4586.56","1 through 10","24039.6","37591.2","percent of total billed charges",""
"GRAFT STENT 22FR 37X37X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269162","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","29900.00","65","","6652.80","6652.80","6652.80","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 22FR 37X37X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269162","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","36570.00","79.5","","2612.61","795.38","2612.61","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 22FR 37X37X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269162","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","24518.00","53.3","","1101.80","1101.80","1101.80","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 22FR 37X37X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269162","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","29900.00","65","","1820.00","910.00","1820.00","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 22FR 37X37X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269162","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16790.00","36.5","","1257.80","693.44","2424.50","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 22FR 37X37X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269162","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17618.00","38.3","","1950.11","547.40","2346.00","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 22FR 37X37X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269162","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19734.00","42.9","","5096.18","5096.18","5096.18","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 22FR 37X37X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269162","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","WELLPOINT [1015]","HB AMC WELLPOINT","33938.80","73.78","","1172.59","1172.59","4829.94","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 22FR 37X37X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269162","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46000.00","34500.00","AETNA [1001]","HB AMC AETNA HMO","32108.00","69.8","","1806.84","947.80","5091.72","1 through 10","24039.6","37591.2","percent of total billed charges",""
"GRAFT STENT 22FR 37X37X10CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269162","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46000.00","34500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","37591.20","81.72","","1259.05","615.58","4586.56","1 through 10","24039.6","37591.2","percent of total billed charges",""
"GRAFT STENT 24FR 45X45X20CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269167","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","29900.00","65","","6652.80","6652.80","6652.80","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 24FR 45X45X20CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269167","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","36570.00","79.5","","2612.61","795.38","2612.61","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 24FR 45X45X20CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269167","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","24518.00","53.3","","1101.80","1101.80","1101.80","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 24FR 45X45X20CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269167","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","29900.00","65","","1820.00","910.00","1820.00","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 24FR 45X45X20CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269167","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16790.00","36.5","","1257.80","693.44","2424.50","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 24FR 45X45X20CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269167","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17618.00","38.3","","1950.11","547.40","2346.00","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 24FR 45X45X20CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269167","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19734.00","42.9","","5096.18","5096.18","5096.18","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 24FR 45X45X20CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269167","CDM","C1874","HCPCS","0278","RC","","","","both","","","46000.00","34500.00","WELLPOINT [1015]","HB AMC WELLPOINT","33938.80","73.78","","1172.59","1172.59","4829.94","1 through 10","14260","36570","percent of total billed charges",""
"GRAFT STENT 24FR 45X45X20CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269167","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46000.00","34500.00","AETNA [1001]","HB AMC AETNA HMO","32108.00","69.8","","1806.84","947.80","5091.72","1 through 10","24039.6","37591.2","percent of total billed charges",""
"GRAFT STENT 24FR 45X45X20CM TAG CONFORM THORACIC SG AC","SUP-ITM-10269167","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46000.00","34500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","37591.20","81.72","","1259.05","615.58","4586.56","1 through 10","24039.6","37591.2","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC RELAY PLUS","SUP-ITM-10216677","CDM","C1874","HCPCS","0278","RC","","","","both","","","26000.00","19500.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","16900.00","65","","6652.80","6652.80","6652.80","1 through 10","8060","20670","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC RELAY PLUS","SUP-ITM-10216677","CDM","C1874","HCPCS","0278","RC","","","","both","","","26000.00","19500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20670.00","79.5","","2612.61","795.38","2612.61","1 through 10","8060","20670","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC RELAY PLUS","SUP-ITM-10216677","CDM","C1874","HCPCS","0278","RC","","","","both","","","26000.00","19500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13858.00","53.3","","1101.80","1101.80","1101.80","1 through 10","8060","20670","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC RELAY PLUS","SUP-ITM-10216677","CDM","C1874","HCPCS","0278","RC","","","","both","","","26000.00","19500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","16900.00","65","","1820.00","910.00","1820.00","1 through 10","8060","20670","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC RELAY PLUS","SUP-ITM-10216677","CDM","C1874","HCPCS","0278","RC","","","","both","","","26000.00","19500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9490.00","36.5","","1257.80","693.44","2424.50","1 through 10","8060","20670","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC RELAY PLUS","SUP-ITM-10216677","CDM","C1874","HCPCS","0278","RC","","","","both","","","26000.00","19500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9958.00","38.3","","1950.11","547.40","2346.00","1 through 10","8060","20670","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC RELAY PLUS","SUP-ITM-10216677","CDM","C1874","HCPCS","0278","RC","","","","both","","","26000.00","19500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11154.00","42.9","","5096.18","5096.18","5096.18","1 through 10","8060","20670","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC RELAY PLUS","SUP-ITM-10216677","CDM","C1874","HCPCS","0278","RC","","","","both","","","26000.00","19500.00","WELLPOINT [1015]","HB AMC WELLPOINT","19182.80","73.78","","1172.59","1172.59","4829.94","1 through 10","8060","20670","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC RELAY PLUS","SUP-ITM-10216677","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","26000.00","19500.00","AETNA [1001]","HB AMC AETNA HMO","18148.00","69.8","","1806.84","947.80","5091.72","1 through 10","13587.6","21247.2","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC RELAY PLUS","SUP-ITM-10216677","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","26000.00","19500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21247.20","81.72","","1259.05","615.58","4586.56","1 through 10","13587.6","21247.2","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC STRAIGHT RELAY PRO NBS","SUP-ITM-10306397","CDM","C1874","HCPCS","0278","RC","","","","both","","","39875.00","29906.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","25918.75","65","","6652.80","6652.80","6652.80","1 through 10","12361.25","31700.63","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC STRAIGHT RELAY PRO NBS","SUP-ITM-10306397","CDM","C1874","HCPCS","0278","RC","","","","both","","","39875.00","29906.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","31700.63","79.5","","2612.61","795.38","2612.61","1 through 10","12361.25","31700.63","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC STRAIGHT RELAY PRO NBS","SUP-ITM-10306397","CDM","C1874","HCPCS","0278","RC","","","","both","","","39875.00","29906.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","21253.38","53.3","","1101.80","1101.80","1101.80","1 through 10","12361.25","31700.63","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC STRAIGHT RELAY PRO NBS","SUP-ITM-10306397","CDM","C1874","HCPCS","0278","RC","","","","both","","","39875.00","29906.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","25918.75","65","","1820.00","910.00","1820.00","1 through 10","12361.25","31700.63","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC STRAIGHT RELAY PRO NBS","SUP-ITM-10306397","CDM","C1874","HCPCS","0278","RC","","","","both","","","39875.00","29906.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14554.38","36.5","","1257.80","693.44","2424.50","1 through 10","12361.25","31700.63","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC STRAIGHT RELAY PRO NBS","SUP-ITM-10306397","CDM","C1874","HCPCS","0278","RC","","","","both","","","39875.00","29906.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15272.13","38.3","","1950.11","547.40","2346.00","1 through 10","12361.25","31700.63","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC STRAIGHT RELAY PRO NBS","SUP-ITM-10306397","CDM","C1874","HCPCS","0278","RC","","","","both","","","39875.00","29906.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17106.38","42.9","","5096.18","5096.18","5096.18","1 through 10","12361.25","31700.63","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC STRAIGHT RELAY PRO NBS","SUP-ITM-10306397","CDM","C1874","HCPCS","0278","RC","","","","both","","","39875.00","29906.25","WELLPOINT [1015]","HB AMC WELLPOINT","29419.78","73.78","","1172.59","1172.59","4829.94","1 through 10","12361.25","31700.63","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC STRAIGHT RELAY PRO NBS","SUP-ITM-10306397","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","39875.00","29906.25","AETNA [1001]","HB AMC AETNA HMO","27832.75","69.8","","1806.84","947.80","5091.72","1 through 10","20838.68","32585.85","percent of total billed charges",""
"GRAFT STENT 34X100MM THORACIC STRAIGHT RELAY PRO NBS","SUP-ITM-10306397","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","39875.00","29906.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","32585.85","81.72","","1259.05","615.58","4586.56","1 through 10","20838.68","32585.85","percent of total billed charges",""
"GRAFT STENT 46X150MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216633","CDM","C1874","HCPCS","0278","RC","","","","both","","","30450.00","22837.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","19792.50","65","","6652.80","6652.80","6652.80","1 through 10","9439.5","24207.75","percent of total billed charges",""
"GRAFT STENT 46X150MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216633","CDM","C1874","HCPCS","0278","RC","","","","both","","","30450.00","22837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24207.75","79.5","","2612.61","795.38","2612.61","1 through 10","9439.5","24207.75","percent of total billed charges",""
"GRAFT STENT 46X150MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216633","CDM","C1874","HCPCS","0278","RC","","","","both","","","30450.00","22837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16229.85","53.3","","1101.80","1101.80","1101.80","1 through 10","9439.5","24207.75","percent of total billed charges",""
"GRAFT STENT 46X150MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216633","CDM","C1874","HCPCS","0278","RC","","","","both","","","30450.00","22837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","19792.50","65","","1820.00","910.00","1820.00","1 through 10","9439.5","24207.75","percent of total billed charges",""
"GRAFT STENT 46X150MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216633","CDM","C1874","HCPCS","0278","RC","","","","both","","","30450.00","22837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11114.25","36.5","","1257.80","693.44","2424.50","1 through 10","9439.5","24207.75","percent of total billed charges",""
"GRAFT STENT 46X150MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216633","CDM","C1874","HCPCS","0278","RC","","","","both","","","30450.00","22837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11662.35","38.3","","1950.11","547.40","2346.00","1 through 10","9439.5","24207.75","percent of total billed charges",""
"GRAFT STENT 46X150MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216633","CDM","C1874","HCPCS","0278","RC","","","","both","","","30450.00","22837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13063.05","42.9","","5096.18","5096.18","5096.18","1 through 10","9439.5","24207.75","percent of total billed charges",""
"GRAFT STENT 46X150MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216633","CDM","C1874","HCPCS","0278","RC","","","","both","","","30450.00","22837.50","WELLPOINT [1015]","HB AMC WELLPOINT","22466.01","73.78","","1172.59","1172.59","4829.94","1 through 10","9439.5","24207.75","percent of total billed charges",""
"GRAFT STENT 46X150MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216633","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30450.00","22837.50","AETNA [1001]","HB AMC AETNA HMO","21254.10","69.8","","1806.84","947.80","5091.72","1 through 10","15913.17","24883.74","percent of total billed charges",""
"GRAFT STENT 46X150MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216633","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30450.00","22837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24883.74","81.72","","1259.05","615.58","4586.56","1 through 10","15913.17","24883.74","percent of total billed charges",""
"GRAFT STENT 46X200MM THORACIC RELAY PLUS","SUP-ITM-10216631","CDM","C1874","HCPCS","0278","RC","","","","both","","","34800.00","26100.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","22620.00","65","","6652.80","6652.80","6652.80","1 through 10","10788","27666","percent of total billed charges",""
"GRAFT STENT 46X200MM THORACIC RELAY PLUS","SUP-ITM-10216631","CDM","C1874","HCPCS","0278","RC","","","","both","","","34800.00","26100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","27666.00","79.5","","2612.61","795.38","2612.61","1 through 10","10788","27666","percent of total billed charges",""
"GRAFT STENT 46X200MM THORACIC RELAY PLUS","SUP-ITM-10216631","CDM","C1874","HCPCS","0278","RC","","","","both","","","34800.00","26100.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","18548.40","53.3","","1101.80","1101.80","1101.80","1 through 10","10788","27666","percent of total billed charges",""
"GRAFT STENT 46X200MM THORACIC RELAY PLUS","SUP-ITM-10216631","CDM","C1874","HCPCS","0278","RC","","","","both","","","34800.00","26100.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","22620.00","65","","1820.00","910.00","1820.00","1 through 10","10788","27666","percent of total billed charges",""
"GRAFT STENT 46X200MM THORACIC RELAY PLUS","SUP-ITM-10216631","CDM","C1874","HCPCS","0278","RC","","","","both","","","34800.00","26100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12702.00","36.5","","1257.80","693.44","2424.50","1 through 10","10788","27666","percent of total billed charges",""
"GRAFT STENT 46X200MM THORACIC RELAY PLUS","SUP-ITM-10216631","CDM","C1874","HCPCS","0278","RC","","","","both","","","34800.00","26100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","13328.40","38.3","","1950.11","547.40","2346.00","1 through 10","10788","27666","percent of total billed charges",""
"GRAFT STENT 46X200MM THORACIC RELAY PLUS","SUP-ITM-10216631","CDM","C1874","HCPCS","0278","RC","","","","both","","","34800.00","26100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14929.20","42.9","","5096.18","5096.18","5096.18","1 through 10","10788","27666","percent of total billed charges",""
"GRAFT STENT 46X200MM THORACIC RELAY PLUS","SUP-ITM-10216631","CDM","C1874","HCPCS","0278","RC","","","","both","","","34800.00","26100.00","WELLPOINT [1015]","HB AMC WELLPOINT","25675.44","73.78","","1172.59","1172.59","4829.94","1 through 10","10788","27666","percent of total billed charges",""
"GRAFT STENT 46X200MM THORACIC RELAY PLUS","SUP-ITM-10216631","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","34800.00","26100.00","AETNA [1001]","HB AMC AETNA HMO","24290.40","69.8","","1806.84","947.80","5091.72","1 through 10","18186.48","28438.56","percent of total billed charges",""
"GRAFT STENT 46X200MM THORACIC RELAY PLUS","SUP-ITM-10216631","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","34800.00","26100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","28438.56","81.72","","1259.05","615.58","4586.56","1 through 10","18186.48","28438.56","percent of total billed charges",""
"GRAFT STENT 46X250MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216629","CDM","C1874","HCPCS","0278","RC","","","","both","","","39150.00","29362.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","25447.50","65","","6652.80","6652.80","6652.80","1 through 10","12136.5","31124.25","percent of total billed charges",""
"GRAFT STENT 46X250MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216629","CDM","C1874","HCPCS","0278","RC","","","","both","","","39150.00","29362.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","31124.25","79.5","","2612.61","795.38","2612.61","1 through 10","12136.5","31124.25","percent of total billed charges",""
"GRAFT STENT 46X250MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216629","CDM","C1874","HCPCS","0278","RC","","","","both","","","39150.00","29362.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","20866.95","53.3","","1101.80","1101.80","1101.80","1 through 10","12136.5","31124.25","percent of total billed charges",""
"GRAFT STENT 46X250MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216629","CDM","C1874","HCPCS","0278","RC","","","","both","","","39150.00","29362.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","25447.50","65","","1820.00","910.00","1820.00","1 through 10","12136.5","31124.25","percent of total billed charges",""
"GRAFT STENT 46X250MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216629","CDM","C1874","HCPCS","0278","RC","","","","both","","","39150.00","29362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14289.75","36.5","","1257.80","693.44","2424.50","1 through 10","12136.5","31124.25","percent of total billed charges",""
"GRAFT STENT 46X250MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216629","CDM","C1874","HCPCS","0278","RC","","","","both","","","39150.00","29362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14994.45","38.3","","1950.11","547.40","2346.00","1 through 10","12136.5","31124.25","percent of total billed charges",""
"GRAFT STENT 46X250MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216629","CDM","C1874","HCPCS","0278","RC","","","","both","","","39150.00","29362.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16795.35","42.9","","5096.18","5096.18","5096.18","1 through 10","12136.5","31124.25","percent of total billed charges",""
"GRAFT STENT 46X250MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216629","CDM","C1874","HCPCS","0278","RC","","","","both","","","39150.00","29362.50","WELLPOINT [1015]","HB AMC WELLPOINT","28884.87","73.78","","1172.59","1172.59","4829.94","1 through 10","12136.5","31124.25","percent of total billed charges",""
"GRAFT STENT 46X250MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216629","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","39150.00","29362.50","AETNA [1001]","HB AMC AETNA HMO","27326.70","69.8","","1806.84","947.80","5091.72","1 through 10","20459.79","31993.38","percent of total billed charges",""
"GRAFT STENT 46X250MM STRAIGHT THORACIC RELAY PLUS","SUP-ITM-10216629","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","39150.00","29362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","31993.38","81.72","","1259.05","615.58","4586.56","1 through 10","20459.79","31993.38","percent of total billed charges",""
"GRAFT SURGICAL 10X16CM XENOSURE BIOLOGIC PATCH","SUP-ITM-10287445","CDM","C1781","HCPCS","0278","RC","","","","both","","","2170.00","1627.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1519.00","70","","134.04","134.04","134.04","1 through 10","672.7","1725.15","percent of total billed charges",""
"GRAFT SURGICAL 10X16CM XENOSURE BIOLOGIC PATCH","SUP-ITM-10287445","CDM","C1781","HCPCS","0278","RC","","","","both","","","2170.00","1627.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1725.15","79.5","","948.87","198.19","1805.30","1 through 10","672.7","1725.15","percent of total billed charges",""
"GRAFT SURGICAL 10X16CM XENOSURE BIOLOGIC PATCH","SUP-ITM-10287445","CDM","C1781","HCPCS","0278","RC","","","","both","","","2170.00","1627.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1156.61","53.3","","462.00","170.45","3253.37","1 through 10","672.7","1725.15","percent of total billed charges",""
"GRAFT SURGICAL 10X16CM XENOSURE BIOLOGIC PATCH","SUP-ITM-10287445","CDM","C1781","HCPCS","0278","RC","","","","both","","","2170.00","1627.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","792.05","36.5","","245.50","107.19","1371.45","1 through 10","672.7","1725.15","percent of total billed charges",""
"GRAFT SURGICAL 10X16CM XENOSURE BIOLOGIC PATCH","SUP-ITM-10287445","CDM","C1781","HCPCS","0278","RC","","","","both","","","2170.00","1627.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","831.11","38.3","","200.79","72.79","355.81","22","672.7","1725.15","percent of total billed charges",""
"GRAFT SURGICAL 10X16CM XENOSURE BIOLOGIC PATCH","SUP-ITM-10287445","CDM","C1781","HCPCS","0278","RC","","","","both","","","2170.00","1627.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1670.90","77","","477.18","477.18","477.18","1 through 10","672.7","1725.15","percent of total billed charges",""
"GRAFT SURGICAL 10X16CM XENOSURE BIOLOGIC PATCH","SUP-ITM-10287445","CDM","C1781","HCPCS","0278","RC","","","","both","","","2170.00","1627.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","930.93","42.9","","1045.91","1045.91","1045.91","1 through 10","672.7","1725.15","percent of total billed charges",""
"GRAFT SURGICAL 10X16CM XENOSURE BIOLOGIC PATCH","SUP-ITM-10287445","CDM","C1781","HCPCS","0278","RC","","","","both","","","2170.00","1627.50","WELLPOINT [1015]","HB AMC WELLPOINT","1601.03","73.78","","1726.50","1726.50","1726.50","1 through 10","672.7","1725.15","percent of total billed charges",""
"GRAFT SURGICAL 10X16CM XENOSURE BIOLOGIC PATCH","SUP-ITM-10287445","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2170.00","1627.50","AETNA [1001]","HB AMC AETNA HMO","1514.66","69.8","","915.80","263.76","2881.00","1 through 10","1134.04","1773.32","percent of total billed charges",""
"GRAFT SURGICAL 10X16CM XENOSURE BIOLOGIC PATCH","SUP-ITM-10287445","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2170.00","1627.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1773.32","81.72","","1531.57","410.52","8841.36","1 through 10","1134.04","1773.32","percent of total billed charges",""
"GRAFT SURGICAL 7X10CM MESH BIODESIGN COLLAGEN HIATAL HERNIA","SUP-ITM-10018563","CDM","C1763","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2718.30","65","","2028.23","1653.70","2028.23","1 through 10","1296.42","3324.69","percent of total billed charges",""
"GRAFT SURGICAL 7X10CM MESH BIODESIGN COLLAGEN HIATAL HERNIA","SUP-ITM-10018563","CDM","C1763","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1526.43","36.5","","1163.89","1163.89","1163.89","1 through 10","1296.42","3324.69","percent of total billed charges",""
"GRAFT SURGICAL 7X10CM MESH BIODESIGN COLLAGEN HIATAL HERNIA","SUP-ITM-10018563","CDM","C1763","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","WELLPOINT [1015]","HB AMC WELLPOINT","3085.48","73.78","","4280.87","4280.87","4280.87","1 through 10","1296.42","3324.69","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","both","","","13503.05","10127.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10734.92","79.5","","1309.77","674.56","6049.93","26","4185.95","10734.92","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","both","","","13503.05","10127.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7197.13","53.3","","1901.83","1901.83","2962.25","1 through 10","4185.95","10734.92","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","both","","","13503.05","10127.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4928.61","36.5","","1620.31","1620.31","19908.88","1 through 10","4185.95","10734.92","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","both","","","13503.05","10127.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5171.67","38.3","","352.91","352.91","2046.30","1 through 10","4185.95","10734.92","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","both","","","13503.05","10127.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5792.81","42.9","","9668.75","9668.75","9668.75","1 through 10","4185.95","10734.92","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","both","","","13503.05","10127.29","WELLPOINT [1015]","HB AMC WELLPOINT","9962.55","73.78","","699.88","384.10","3443.31","33","4185.95","10734.92","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13503.05","10127.29","AETNA [1001]","HB AMC AETNA HMO","9425.13","69.8","","1421.24","264.50","4933.46","29","7056.69","11034.69","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13503.05","10127.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10856.45","80.4","","1022.97","1022.97","3607.50","1 through 10","7056.69","11034.69","percent of total billed charges",""
"GRAFT TENDON 10MM PATELLA FROZEN WHOLE","SUP-ITM-10088731","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13503.05","10127.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11034.69","81.72","","3010.54","693.88","5019.88","35","7056.69","11034.69","percent of total billed charges",""
"GRAFT TENDON 20MM PATELLAR WHOLE QUADRICEP FROZEN MINIMUM","SUP-ITM-10010309","CDM","C1889","HCPCS","0278","RC","","","","both","","","9546.48","7159.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7589.45","79.5","","1309.77","674.56","6049.93","26","2959.41","7589.45","percent of total billed charges",""
"GRAFT TENDON 20MM PATELLAR WHOLE QUADRICEP FROZEN MINIMUM","SUP-ITM-10010309","CDM","C1889","HCPCS","0278","RC","","","","both","","","9546.48","7159.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5088.27","53.3","","1901.83","1901.83","2962.25","1 through 10","2959.41","7589.45","percent of total billed charges",""
"GRAFT TENDON 20MM PATELLAR WHOLE QUADRICEP FROZEN MINIMUM","SUP-ITM-10010309","CDM","C1889","HCPCS","0278","RC","","","","both","","","9546.48","7159.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3484.47","36.5","","1620.31","1620.31","19908.88","1 through 10","2959.41","7589.45","percent of total billed charges",""
"GRAFT TENDON 20MM PATELLAR WHOLE QUADRICEP FROZEN MINIMUM","SUP-ITM-10010309","CDM","C1889","HCPCS","0278","RC","","","","both","","","9546.48","7159.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3656.30","38.3","","352.91","352.91","2046.30","1 through 10","2959.41","7589.45","percent of total billed charges",""
"GRAFT TENDON 20MM PATELLAR WHOLE QUADRICEP FROZEN MINIMUM","SUP-ITM-10010309","CDM","C1889","HCPCS","0278","RC","","","","both","","","9546.48","7159.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4095.44","42.9","","9668.75","9668.75","9668.75","1 through 10","2959.41","7589.45","percent of total billed charges",""
"GRAFT TENDON 20MM PATELLAR WHOLE QUADRICEP FROZEN MINIMUM","SUP-ITM-10010309","CDM","C1889","HCPCS","0278","RC","","","","both","","","9546.48","7159.86","WELLPOINT [1015]","HB AMC WELLPOINT","7043.39","73.78","","699.88","384.10","3443.31","33","2959.41","7589.45","percent of total billed charges",""
"GRAFT TENDON 20MM PATELLAR WHOLE QUADRICEP FROZEN MINIMUM","SUP-ITM-10010309","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9546.48","7159.86","AETNA [1001]","HB AMC AETNA HMO","6663.44","69.8","","1421.24","264.50","4933.46","29","4988.99","7801.38","percent of total billed charges",""
"GRAFT TENDON 20MM PATELLAR WHOLE QUADRICEP FROZEN MINIMUM","SUP-ITM-10010309","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9546.48","7159.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7675.37","80.4","","1022.97","1022.97","3607.50","1 through 10","4988.99","7801.38","percent of total billed charges",""
"GRAFT TENDON 20MM PATELLAR WHOLE QUADRICEP FROZEN MINIMUM","SUP-ITM-10010309","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9546.48","7159.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7801.38","81.72","","3010.54","693.88","5019.88","35","4988.99","7801.38","percent of total billed charges",""
"GRAFT TENDON 22 38CMX6 12MM ALLO PERONEUS LONGUS FROZEN","SUP-ITM-10048911","CDM","C1889","HCPCS","0278","RC","","","","both","","","4803.75","3602.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3818.98","79.5","","1309.77","674.56","6049.93","26","1489.16","3818.98","percent of total billed charges",""
"GRAFT TENDON 22 38CMX6 12MM ALLO PERONEUS LONGUS FROZEN","SUP-ITM-10048911","CDM","C1889","HCPCS","0278","RC","","","","both","","","4803.75","3602.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2560.40","53.3","","1901.83","1901.83","2962.25","1 through 10","1489.16","3818.98","percent of total billed charges",""
"GRAFT TENDON 22 38CMX6 12MM ALLO PERONEUS LONGUS FROZEN","SUP-ITM-10048911","CDM","C1889","HCPCS","0278","RC","","","","both","","","4803.75","3602.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1753.37","36.5","","1620.31","1620.31","19908.88","1 through 10","1489.16","3818.98","percent of total billed charges",""
"GRAFT TENDON 22 38CMX6 12MM ALLO PERONEUS LONGUS FROZEN","SUP-ITM-10048911","CDM","C1889","HCPCS","0278","RC","","","","both","","","4803.75","3602.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1839.84","38.3","","352.91","352.91","2046.30","1 through 10","1489.16","3818.98","percent of total billed charges",""
"GRAFT TENDON 22 38CMX6 12MM ALLO PERONEUS LONGUS FROZEN","SUP-ITM-10048911","CDM","C1889","HCPCS","0278","RC","","","","both","","","4803.75","3602.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2060.81","42.9","","9668.75","9668.75","9668.75","1 through 10","1489.16","3818.98","percent of total billed charges",""
"GRAFT TENDON 22 38CMX6 12MM ALLO PERONEUS LONGUS FROZEN","SUP-ITM-10048911","CDM","C1889","HCPCS","0278","RC","","","","both","","","4803.75","3602.81","WELLPOINT [1015]","HB AMC WELLPOINT","3544.21","73.78","","699.88","384.10","3443.31","33","1489.16","3818.98","percent of total billed charges",""
"GRAFT TENDON 22 38CMX6 12MM ALLO PERONEUS LONGUS FROZEN","SUP-ITM-10048911","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4803.75","3602.81","AETNA [1001]","HB AMC AETNA HMO","3353.02","69.8","","1421.24","264.50","4933.46","29","2510.44","3925.62","percent of total billed charges",""
"GRAFT TENDON 22 38CMX6 12MM ALLO PERONEUS LONGUS FROZEN","SUP-ITM-10048911","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4803.75","3602.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3862.22","80.4","","1022.97","1022.97","3607.50","1 through 10","2510.44","3925.62","percent of total billed charges",""
"GRAFT TENDON 22 38CMX6 12MM ALLO PERONEUS LONGUS FROZEN","SUP-ITM-10048911","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4803.75","3602.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3925.62","81.72","","3010.54","693.88","5019.88","35","2510.44","3925.62","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3950.63","2962.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3140.75","79.5","","1309.77","674.56","6049.93","26","1224.7","3140.75","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3950.63","2962.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2105.69","53.3","","1901.83","1901.83","2962.25","1 through 10","1224.7","3140.75","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3950.63","2962.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1441.98","36.5","","1620.31","1620.31","19908.88","1 through 10","1224.7","3140.75","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3950.63","2962.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1513.09","38.3","","352.91","352.91","2046.30","1 through 10","1224.7","3140.75","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3950.63","2962.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1694.82","42.9","","9668.75","9668.75","9668.75","1 through 10","1224.7","3140.75","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3950.63","2962.97","WELLPOINT [1015]","HB AMC WELLPOINT","2914.77","73.78","","699.88","384.10","3443.31","33","1224.7","3140.75","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3950.63","2962.97","AETNA [1001]","HB AMC AETNA HMO","2757.54","69.8","","1421.24","264.50","4933.46","29","2064.6","3228.45","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3950.63","2962.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3176.31","80.4","","1022.97","1022.97","3607.50","1 through 10","2064.6","3228.45","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3950.63","2962.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3228.45","81.72","","3010.54","693.88","5019.88","35","2064.6","3228.45","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","both","","","716.70","537.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","569.78","79.5","","1309.77","674.56","6049.93","26","222.18","569.78","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","both","","","716.70","537.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","382.00","53.3","","1901.83","1901.83","2962.25","1 through 10","222.18","569.78","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","both","","","716.70","537.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","261.60","36.5","","1620.31","1620.31","19908.88","1 through 10","222.18","569.78","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","both","","","716.70","537.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.50","38.3","","352.91","352.91","2046.30","1 through 10","222.18","569.78","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","both","","","716.70","537.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.46","42.9","","9668.75","9668.75","9668.75","1 through 10","222.18","569.78","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","both","","","716.70","537.52","WELLPOINT [1015]","HB AMC WELLPOINT","528.78","73.78","","699.88","384.10","3443.31","33","222.18","569.78","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","716.70","537.52","AETNA [1001]","HB AMC AETNA HMO","500.26","69.8","","1421.24","264.50","4933.46","29","374.55","585.69","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","716.70","537.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","576.23","80.4","","1022.97","1022.97","3607.50","1 through 10","374.55","585.69","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","716.70","537.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","585.69","81.72","","3010.54","693.88","5019.88","35","374.55","585.69","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","both","","","2137.17","1602.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1699.05","79.5","","1309.77","674.56","6049.93","26","662.52","1699.05","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","both","","","2137.17","1602.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1139.11","53.3","","1901.83","1901.83","2962.25","1 through 10","662.52","1699.05","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","both","","","2137.17","1602.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","780.07","36.5","","1620.31","1620.31","19908.88","1 through 10","662.52","1699.05","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","both","","","2137.17","1602.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","818.54","38.3","","352.91","352.91","2046.30","1 through 10","662.52","1699.05","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","both","","","2137.17","1602.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","916.85","42.9","","9668.75","9668.75","9668.75","1 through 10","662.52","1699.05","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","both","","","2137.17","1602.88","WELLPOINT [1015]","HB AMC WELLPOINT","1576.80","73.78","","699.88","384.10","3443.31","33","662.52","1699.05","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2137.17","1602.88","AETNA [1001]","HB AMC AETNA HMO","1491.74","69.8","","1421.24","264.50","4933.46","29","1116.89","1746.5","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2137.17","1602.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1718.28","80.4","","1022.97","1022.97","3607.50","1 through 10","1116.89","1746.5","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2137.17","1602.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1746.50","81.72","","3010.54","693.88","5019.88","35","1116.89","1746.5","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX15 20CM GORE TEX PATCH SOFT KEYHOLE BX/1EA","SUP-ITM-10005080","CDM","C1781","HCPCS","0278","RC","","","","both","","","4529.00","3396.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3170.30","70","","134.04","134.04","134.04","1 through 10","1403.99","3600.56","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX15 20CM GORE TEX PATCH SOFT KEYHOLE BX/1EA","SUP-ITM-10005080","CDM","C1781","HCPCS","0278","RC","","","","both","","","4529.00","3396.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3600.56","79.5","","948.87","198.19","1805.30","1 through 10","1403.99","3600.56","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX15 20CM GORE TEX PATCH SOFT KEYHOLE BX/1EA","SUP-ITM-10005080","CDM","C1781","HCPCS","0278","RC","","","","both","","","4529.00","3396.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2413.96","53.3","","462.00","170.45","3253.37","1 through 10","1403.99","3600.56","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX15 20CM GORE TEX PATCH SOFT KEYHOLE BX/1EA","SUP-ITM-10005080","CDM","C1781","HCPCS","0278","RC","","","","both","","","4529.00","3396.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1653.09","36.5","","245.50","107.19","1371.45","1 through 10","1403.99","3600.56","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX15 20CM GORE TEX PATCH SOFT KEYHOLE BX/1EA","SUP-ITM-10005080","CDM","C1781","HCPCS","0278","RC","","","","both","","","4529.00","3396.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1734.61","38.3","","200.79","72.79","355.81","22","1403.99","3600.56","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX15 20CM GORE TEX PATCH SOFT KEYHOLE BX/1EA","SUP-ITM-10005080","CDM","C1781","HCPCS","0278","RC","","","","both","","","4529.00","3396.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3487.33","77","","477.18","477.18","477.18","1 through 10","1403.99","3600.56","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX15 20CM GORE TEX PATCH SOFT KEYHOLE BX/1EA","SUP-ITM-10005080","CDM","C1781","HCPCS","0278","RC","","","","both","","","4529.00","3396.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1942.94","42.9","","1045.91","1045.91","1045.91","1 through 10","1403.99","3600.56","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX15 20CM GORE TEX PATCH SOFT KEYHOLE BX/1EA","SUP-ITM-10005080","CDM","C1781","HCPCS","0278","RC","","","","both","","","4529.00","3396.75","WELLPOINT [1015]","HB AMC WELLPOINT","3341.50","73.78","","1726.50","1726.50","1726.50","1 through 10","1403.99","3600.56","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX15 20CM GORE TEX PATCH SOFT KEYHOLE BX/1EA","SUP-ITM-10005080","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4529.00","3396.75","AETNA [1001]","HB AMC AETNA HMO","3161.24","69.8","","915.80","263.76","2881.00","1 through 10","2366.86","3701.1","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX15 20CM GORE TEX PATCH SOFT KEYHOLE BX/1EA","SUP-ITM-10005080","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4529.00","3396.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3701.10","81.72","","1531.57","410.52","8841.36","1 through 10","2366.86","3701.1","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2390.50","1792.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1673.35","70","","134.04","134.04","134.04","1 through 10","741.06","1900.45","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2390.50","1792.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1900.45","79.5","","948.87","198.19","1805.30","1 through 10","741.06","1900.45","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2390.50","1792.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1274.14","53.3","","462.00","170.45","3253.37","1 through 10","741.06","1900.45","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2390.50","1792.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","872.53","36.5","","245.50","107.19","1371.45","1 through 10","741.06","1900.45","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2390.50","1792.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","915.56","38.3","","200.79","72.79","355.81","22","741.06","1900.45","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2390.50","1792.87","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1840.69","77","","477.18","477.18","477.18","1 through 10","741.06","1900.45","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2390.50","1792.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1025.52","42.9","","1045.91","1045.91","1045.91","1 through 10","741.06","1900.45","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2390.50","1792.87","WELLPOINT [1015]","HB AMC WELLPOINT","1763.71","73.78","","1726.50","1726.50","1726.50","1 through 10","741.06","1900.45","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2390.50","1792.87","AETNA [1001]","HB AMC AETNA HMO","1668.57","69.8","","915.80","263.76","2881.00","1 through 10","1249.28","1953.52","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2390.50","1792.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1953.52","81.72","","1531.57","410.52","8841.36","1 through 10","1249.28","1953.52","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOUR SM NON PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132983","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5510.00","4132.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2011.15","36.5","","23.35","23.35","23.35","264","1708.1","4242.7","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOUR SM NON PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132983","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5510.00","4132.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2110.33","38.3","","350.11","350.11","350.11","1108","1708.1","4242.7","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOUR SM NON PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132983","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5510.00","4132.50","WELLPOINT [1015]","HB AMC WELLPOINT","4065.28","73.78","","77.77","77.77","77.77","528","1708.1","4242.7","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOUR SM NON PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132983","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5510.00","4132.50","AETNA [1001]","HB AMC AETNA HMO","3845.98","69.8","","35.22","35.22","35.22","397","2584.19","4430.04","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOUR SM NON PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132983","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5510.00","4132.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3851.49","69.9","","34.18","34.18","34.18","1057","2584.19","4430.04","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOUR SM NON PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132983","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5510.00","4132.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2584.19","46.9","","34.18","34.18","34.18","528","2584.19","4430.04","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOURED SM PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132985","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5672.50","4254.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2070.46","36.5","","23.35","23.35","23.35","264","1758.48","4367.83","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOURED SM PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132985","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5672.50","4254.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2172.57","38.3","","350.11","350.11","350.11","1108","1758.48","4367.83","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOURED SM PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132985","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5672.50","4254.37","WELLPOINT [1015]","HB AMC WELLPOINT","4185.17","73.78","","77.77","77.77","77.77","528","1758.48","4367.83","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOURED SM PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132985","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5672.50","4254.37","AETNA [1001]","HB AMC AETNA HMO","3959.41","69.8","","35.22","35.22","35.22","397","2660.4","4560.69","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOURED SM PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132985","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5672.50","4254.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3965.08","69.9","","34.18","34.18","34.18","1057","2660.4","4560.69","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM HUMAN ALLODERM MED CONTOURED SM PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132985","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5672.50","4254.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2660.40","46.9","","34.18","34.18","34.18","528","2660.4","4560.69","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","both","","","12082.50","9061.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4410.11","36.5","","23.35","23.35","23.35","264","3745.58","9303.53","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","both","","","12082.50","9061.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4627.60","38.3","","350.11","350.11","350.11","1108","3745.58","9303.53","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","both","","","12082.50","9061.87","WELLPOINT [1015]","HB AMC WELLPOINT","8914.47","73.78","","77.77","77.77","77.77","528","3745.58","9303.53","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","12082.50","9061.87","AETNA [1001]","HB AMC AETNA HMO","8433.59","69.8","","35.22","35.22","35.22","397","5666.69","9714.33","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","12082.50","9061.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8445.67","69.9","","34.18","34.18","34.18","1057","5666.69","9714.33","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","12082.50","9061.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5666.69","46.9","","34.18","34.18","34.18","528","5666.69","9714.33","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MEDIUM CONTOUR NON PERFORATED RTU ALLODERM","SUP-ITM-10132704","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9442.50","7081.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3446.51","36.5","","23.35","23.35","23.35","264","2927.18","7270.73","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MEDIUM CONTOUR NON PERFORATED RTU ALLODERM","SUP-ITM-10132704","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9442.50","7081.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3616.48","38.3","","350.11","350.11","350.11","1108","2927.18","7270.73","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MEDIUM CONTOUR NON PERFORATED RTU ALLODERM","SUP-ITM-10132704","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9442.50","7081.87","WELLPOINT [1015]","HB AMC WELLPOINT","6966.68","73.78","","77.77","77.77","77.77","528","2927.18","7270.73","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MEDIUM CONTOUR NON PERFORATED RTU ALLODERM","SUP-ITM-10132704","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9442.50","7081.87","AETNA [1001]","HB AMC AETNA HMO","6590.87","69.8","","35.22","35.22","35.22","397","4428.53","7591.77","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MEDIUM CONTOUR NON PERFORATED RTU ALLODERM","SUP-ITM-10132704","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9442.50","7081.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6600.31","69.9","","34.18","34.18","34.18","1057","4428.53","7591.77","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MEDIUM CONTOUR NON PERFORATED RTU ALLODERM","SUP-ITM-10132704","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9442.50","7081.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4428.53","46.9","","34.18","34.18","34.18","528","4428.53","7591.77","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9725.00","7293.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3549.63","36.5","","23.35","23.35","23.35","264","3014.75","7488.25","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9725.00","7293.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3724.68","38.3","","350.11","350.11","350.11","1108","3014.75","7488.25","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9725.00","7293.75","WELLPOINT [1015]","HB AMC WELLPOINT","7175.11","73.78","","77.77","77.77","77.77","528","3014.75","7488.25","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9725.00","7293.75","AETNA [1001]","HB AMC AETNA HMO","6788.05","69.8","","35.22","35.22","35.22","397","4561.03","7818.9","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9725.00","7293.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6797.78","69.9","","34.18","34.18","34.18","1057","4561.03","7818.9","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9725.00","7293.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4561.03","46.9","","34.18","34.18","34.18","528","4561.03","7818.9","percent of total billed charges",""
"GRAFT TISSUE 1/4 SQ FT MATRIX MESH CRYOPRESERVE BURRN REPAIR SOFT","SUP-ITM-10010318","CDM","C1889","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1129.70","79.5","","1309.77","674.56","6049.93","26","440.51","1129.7","percent of total billed charges",""
"GRAFT TISSUE 1/4 SQ FT MATRIX MESH CRYOPRESERVE BURRN REPAIR SOFT","SUP-ITM-10010318","CDM","C1889","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","757.39","53.3","","1901.83","1901.83","2962.25","1 through 10","440.51","1129.7","percent of total billed charges",""
"GRAFT TISSUE 1/4 SQ FT MATRIX MESH CRYOPRESERVE BURRN REPAIR SOFT","SUP-ITM-10010318","CDM","C1889","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","518.67","36.5","","1620.31","1620.31","19908.88","1 through 10","440.51","1129.7","percent of total billed charges",""
"GRAFT TISSUE 1/4 SQ FT MATRIX MESH CRYOPRESERVE BURRN REPAIR SOFT","SUP-ITM-10010318","CDM","C1889","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","544.24","38.3","","352.91","352.91","2046.30","1 through 10","440.51","1129.7","percent of total billed charges",""
"GRAFT TISSUE 1/4 SQ FT MATRIX MESH CRYOPRESERVE BURRN REPAIR SOFT","SUP-ITM-10010318","CDM","C1889","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","609.61","42.9","","9668.75","9668.75","9668.75","1 through 10","440.51","1129.7","percent of total billed charges",""
"GRAFT TISSUE 1/4 SQ FT MATRIX MESH CRYOPRESERVE BURRN REPAIR SOFT","SUP-ITM-10010318","CDM","C1889","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","WELLPOINT [1015]","HB AMC WELLPOINT","1048.41","73.78","","699.88","384.10","3443.31","33","440.51","1129.7","percent of total billed charges",""
"GRAFT TISSUE 1/4 SQ FT MATRIX MESH CRYOPRESERVE BURRN REPAIR SOFT","SUP-ITM-10010318","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1421.00","1065.75","AETNA [1001]","HB AMC AETNA HMO","991.86","69.8","","1421.24","264.50","4933.46","29","742.61","1161.24","percent of total billed charges",""
"GRAFT TISSUE 1/4 SQ FT MATRIX MESH CRYOPRESERVE BURRN REPAIR SOFT","SUP-ITM-10010318","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1421.00","1065.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1142.48","80.4","","1022.97","1022.97","3607.50","1 through 10","742.61","1161.24","percent of total billed charges",""
"GRAFT TISSUE 1/4 SQ FT MATRIX MESH CRYOPRESERVE BURRN REPAIR SOFT","SUP-ITM-10010318","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1421.00","1065.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1161.24","81.72","","3010.54","693.88","5019.88","35","742.61","1161.24","percent of total billed charges",""
"GRAFT TISSUE 100MM FROZEN HUMERUS PROXIMALIMAL LT W/OUT ROTATOR CUFF","SUP-ITM-10010807","CDM","C1889","HCPCS","0278","RC","","","","both","","","10196.65","7647.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8106.34","79.5","","1309.77","674.56","6049.93","26","3160.96","8106.34","percent of total billed charges",""
"GRAFT TISSUE 100MM FROZEN HUMERUS PROXIMALIMAL LT W/OUT ROTATOR CUFF","SUP-ITM-10010807","CDM","C1889","HCPCS","0278","RC","","","","both","","","10196.65","7647.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5434.81","53.3","","1901.83","1901.83","2962.25","1 through 10","3160.96","8106.34","percent of total billed charges",""
"GRAFT TISSUE 100MM FROZEN HUMERUS PROXIMALIMAL LT W/OUT ROTATOR CUFF","SUP-ITM-10010807","CDM","C1889","HCPCS","0278","RC","","","","both","","","10196.65","7647.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3721.78","36.5","","1620.31","1620.31","19908.88","1 through 10","3160.96","8106.34","percent of total billed charges",""
"GRAFT TISSUE 100MM FROZEN HUMERUS PROXIMALIMAL LT W/OUT ROTATOR CUFF","SUP-ITM-10010807","CDM","C1889","HCPCS","0278","RC","","","","both","","","10196.65","7647.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3905.32","38.3","","352.91","352.91","2046.30","1 through 10","3160.96","8106.34","percent of total billed charges",""
"GRAFT TISSUE 100MM FROZEN HUMERUS PROXIMALIMAL LT W/OUT ROTATOR CUFF","SUP-ITM-10010807","CDM","C1889","HCPCS","0278","RC","","","","both","","","10196.65","7647.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4374.36","42.9","","9668.75","9668.75","9668.75","1 through 10","3160.96","8106.34","percent of total billed charges",""
"GRAFT TISSUE 100MM FROZEN HUMERUS PROXIMALIMAL LT W/OUT ROTATOR CUFF","SUP-ITM-10010807","CDM","C1889","HCPCS","0278","RC","","","","both","","","10196.65","7647.49","WELLPOINT [1015]","HB AMC WELLPOINT","7523.09","73.78","","699.88","384.10","3443.31","33","3160.96","8106.34","percent of total billed charges",""
"GRAFT TISSUE 100MM FROZEN HUMERUS PROXIMALIMAL LT W/OUT ROTATOR CUFF","SUP-ITM-10010807","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10196.65","7647.49","AETNA [1001]","HB AMC AETNA HMO","7117.26","69.8","","1421.24","264.50","4933.46","29","5328.77","8332.7","percent of total billed charges",""
"GRAFT TISSUE 100MM FROZEN HUMERUS PROXIMALIMAL LT W/OUT ROTATOR CUFF","SUP-ITM-10010807","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10196.65","7647.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8198.11","80.4","","1022.97","1022.97","3607.50","1 through 10","5328.77","8332.7","percent of total billed charges",""
"GRAFT TISSUE 100MM FROZEN HUMERUS PROXIMALIMAL LT W/OUT ROTATOR CUFF","SUP-ITM-10010807","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10196.65","7647.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8332.70","81.72","","3010.54","693.88","5019.88","35","5328.77","8332.7","percent of total billed charges",""
"GRAFT TISSUE 100MMX18CM LARGE ALLO FASCIA LATA FREEZE DRIED","SUP-ITM-10010703","CDM","C1762","HCPCS","0278","RC","","","","both","","","4294.68","3221.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2289.06","53.3","","1112.50","1112.50","1112.50","1 through 10","1331.35","3414.27","percent of total billed charges",""
"GRAFT TISSUE 100MMX18CM LARGE ALLO FASCIA LATA FREEZE DRIED","SUP-ITM-10010703","CDM","C1762","HCPCS","0278","RC","","","","both","","","4294.68","3221.01","WELLPOINT [1015]","HB AMC WELLPOINT","3168.61","73.78","","1568.66","1568.66","1568.66","1 through 10","1331.35","3414.27","percent of total billed charges",""
"GRAFT TISSUE 100MMX18CM LARGE ALLO FASCIA LATA FREEZE DRIED","SUP-ITM-10010703","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","4294.68","3221.01","AETNA [1001]","HB AMC AETNA HMO","2997.69","69.8","","1281.90","1281.90","1281.90","1 through 10","2244.4","3509.61","percent of total billed charges",""
"GRAFT TISSUE 10CMX15 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138492","CDM","C1781","HCPCS","0278","RC","","","","both","","","13437.50","10078.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","9406.25","70","","134.04","134.04","134.04","1 through 10","4165.63","10682.81","percent of total billed charges",""
"GRAFT TISSUE 10CMX15 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138492","CDM","C1781","HCPCS","0278","RC","","","","both","","","13437.50","10078.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10682.81","79.5","","948.87","198.19","1805.30","1 through 10","4165.63","10682.81","percent of total billed charges",""
"GRAFT TISSUE 10CMX15 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138492","CDM","C1781","HCPCS","0278","RC","","","","both","","","13437.50","10078.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7162.19","53.3","","462.00","170.45","3253.37","1 through 10","4165.63","10682.81","percent of total billed charges",""
"GRAFT TISSUE 10CMX15 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138492","CDM","C1781","HCPCS","0278","RC","","","","both","","","13437.50","10078.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4904.69","36.5","","245.50","107.19","1371.45","1 through 10","4165.63","10682.81","percent of total billed charges",""
"GRAFT TISSUE 10CMX15 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138492","CDM","C1781","HCPCS","0278","RC","","","","both","","","13437.50","10078.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5146.56","38.3","","200.79","72.79","355.81","22","4165.63","10682.81","percent of total billed charges",""
"GRAFT TISSUE 10CMX15 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138492","CDM","C1781","HCPCS","0278","RC","","","","both","","","13437.50","10078.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","10346.88","77","","477.18","477.18","477.18","1 through 10","4165.63","10682.81","percent of total billed charges",""
"GRAFT TISSUE 10CMX15 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138492","CDM","C1781","HCPCS","0278","RC","","","","both","","","13437.50","10078.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5764.69","42.9","","1045.91","1045.91","1045.91","1 through 10","4165.63","10682.81","percent of total billed charges",""
"GRAFT TISSUE 10CMX15 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138492","CDM","C1781","HCPCS","0278","RC","","","","both","","","13437.50","10078.12","WELLPOINT [1015]","HB AMC WELLPOINT","9914.19","73.78","","1726.50","1726.50","1726.50","1 through 10","4165.63","10682.81","percent of total billed charges",""
"GRAFT TISSUE 10CMX15 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138492","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","13437.50","10078.12","AETNA [1001]","HB AMC AETNA HMO","9379.38","69.8","","915.80","263.76","2881.00","1 through 10","7022.44","10981.13","percent of total billed charges",""
"GRAFT TISSUE 10CMX15 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138492","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","13437.50","10078.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10981.13","81.72","","1531.57","410.52","8841.36","1 through 10","7022.44","10981.13","percent of total billed charges",""
"GRAFT TISSUE 10X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132951","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11445.00","8583.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4177.43","36.5","","23.35","23.35","23.35","264","3547.95","8812.65","percent of total billed charges",""
"GRAFT TISSUE 10X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132951","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11445.00","8583.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4383.44","38.3","","350.11","350.11","350.11","1108","3547.95","8812.65","percent of total billed charges",""
"GRAFT TISSUE 10X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132951","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11445.00","8583.75","WELLPOINT [1015]","HB AMC WELLPOINT","8444.12","73.78","","77.77","77.77","77.77","528","3547.95","8812.65","percent of total billed charges",""
"GRAFT TISSUE 10X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132951","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11445.00","8583.75","AETNA [1001]","HB AMC AETNA HMO","7988.61","69.8","","35.22","35.22","35.22","397","5367.71","9201.78","percent of total billed charges",""
"GRAFT TISSUE 10X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132951","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11445.00","8583.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8000.06","69.9","","34.18","34.18","34.18","1057","5367.71","9201.78","percent of total billed charges",""
"GRAFT TISSUE 10X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132951","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11445.00","8583.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5367.71","46.9","","34.18","34.18","34.18","528","5367.71","9201.78","percent of total billed charges",""
"GRAFT TISSUE 10X20CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132953","CDM","Q4116","HCPCS","0636","RC","","","","both","","","14307.50","10730.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5222.24","36.5","","23.35","23.35","23.35","264","4435.33","11016.78","percent of total billed charges",""
"GRAFT TISSUE 10X20CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132953","CDM","Q4116","HCPCS","0636","RC","","","","both","","","14307.50","10730.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5479.77","38.3","","350.11","350.11","350.11","1108","4435.33","11016.78","percent of total billed charges",""
"GRAFT TISSUE 10X20CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132953","CDM","Q4116","HCPCS","0636","RC","","","","both","","","14307.50","10730.62","WELLPOINT [1015]","HB AMC WELLPOINT","10556.07","73.78","","77.77","77.77","77.77","528","4435.33","11016.78","percent of total billed charges",""
"GRAFT TISSUE 10X20CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132953","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","14307.50","10730.62","AETNA [1001]","HB AMC AETNA HMO","9986.64","69.8","","35.22","35.22","35.22","397","6710.22","11503.23","percent of total billed charges",""
"GRAFT TISSUE 10X20CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132953","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","14307.50","10730.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10000.94","69.9","","34.18","34.18","34.18","1057","6710.22","11503.23","percent of total billed charges",""
"GRAFT TISSUE 10X20CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132953","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","14307.50","10730.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6710.22","46.9","","34.18","34.18","34.18","528","6710.22","11503.23","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","941.50","706.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","659.05","70","","134.04","134.04","134.04","1 through 10","291.87","748.49","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","941.50","706.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","748.49","79.5","","948.87","198.19","1805.30","1 through 10","291.87","748.49","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","941.50","706.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","501.82","53.3","","462.00","170.45","3253.37","1 through 10","291.87","748.49","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","941.50","706.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","343.65","36.5","","245.50","107.19","1371.45","1 through 10","291.87","748.49","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","941.50","706.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","360.59","38.3","","200.79","72.79","355.81","22","291.87","748.49","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","941.50","706.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","724.96","77","","477.18","477.18","477.18","1 through 10","291.87","748.49","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","941.50","706.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.90","42.9","","1045.91","1045.91","1045.91","1 through 10","291.87","748.49","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","941.50","706.12","WELLPOINT [1015]","HB AMC WELLPOINT","694.64","73.78","","1726.50","1726.50","1726.50","1 through 10","291.87","748.49","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","941.50","706.12","AETNA [1001]","HB AMC AETNA HMO","657.17","69.8","","915.80","263.76","2881.00","1 through 10","492.03","769.39","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","941.50","706.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","769.39","81.72","","1531.57","410.52","8841.36","1 through 10","492.03","769.39","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","12475.00","9356.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9917.63","79.5","","1309.77","674.56","6049.93","26","3867.25","9917.63","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","12475.00","9356.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6649.18","53.3","","1901.83","1901.83","2962.25","1 through 10","3867.25","9917.63","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","12475.00","9356.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4553.38","36.5","","1620.31","1620.31","19908.88","1 through 10","3867.25","9917.63","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","12475.00","9356.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4777.93","38.3","","352.91","352.91","2046.30","1 through 10","3867.25","9917.63","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","12475.00","9356.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5351.78","42.9","","9668.75","9668.75","9668.75","1 through 10","3867.25","9917.63","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","12475.00","9356.25","WELLPOINT [1015]","HB AMC WELLPOINT","9204.06","73.78","","699.88","384.10","3443.31","33","3867.25","9917.63","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12475.00","9356.25","AETNA [1001]","HB AMC AETNA HMO","8707.55","69.8","","1421.24","264.50","4933.46","29","6519.44","10194.57","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12475.00","9356.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10029.90","80.4","","1022.97","1022.97","3607.50","1 through 10","6519.44","10194.57","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12475.00","9356.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10194.57","81.72","","3010.54","693.88","5019.88","35","6519.44","10194.57","percent of total billed charges",""
"GRAFT TISSUE 12X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132955","CDM","Q4116","HCPCS","0636","RC","","","","both","","","13735.00","10301.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5013.28","36.5","","23.35","23.35","23.35","264","4257.85","10575.95","percent of total billed charges",""
"GRAFT TISSUE 12X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132955","CDM","Q4116","HCPCS","0636","RC","","","","both","","","13735.00","10301.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5260.51","38.3","","350.11","350.11","350.11","1108","4257.85","10575.95","percent of total billed charges",""
"GRAFT TISSUE 12X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132955","CDM","Q4116","HCPCS","0636","RC","","","","both","","","13735.00","10301.25","WELLPOINT [1015]","HB AMC WELLPOINT","10133.68","73.78","","77.77","77.77","77.77","528","4257.85","10575.95","percent of total billed charges",""
"GRAFT TISSUE 12X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132955","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","13735.00","10301.25","AETNA [1001]","HB AMC AETNA HMO","9587.03","69.8","","35.22","35.22","35.22","397","6441.72","11042.94","percent of total billed charges",""
"GRAFT TISSUE 12X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132955","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","13735.00","10301.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9600.77","69.9","","34.18","34.18","34.18","1057","6441.72","11042.94","percent of total billed charges",""
"GRAFT TISSUE 12X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132955","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","13735.00","10301.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6441.72","46.9","","34.18","34.18","34.18","528","6441.72","11042.94","percent of total billed charges",""
"GRAFT TISSUE 12X20CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132957","CDM","Q4116","HCPCS","0636","RC","","","","both","","","17167.50","12875.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6266.14","36.5","","23.35","23.35","23.35","264","5321.93","13218.98","percent of total billed charges",""
"GRAFT TISSUE 12X20CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132957","CDM","Q4116","HCPCS","0636","RC","","","","both","","","17167.50","12875.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6575.15","38.3","","350.11","350.11","350.11","1108","5321.93","13218.98","percent of total billed charges",""
"GRAFT TISSUE 12X20CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132957","CDM","Q4116","HCPCS","0636","RC","","","","both","","","17167.50","12875.62","WELLPOINT [1015]","HB AMC WELLPOINT","12666.18","73.78","","77.77","77.77","77.77","528","5321.93","13218.98","percent of total billed charges",""
"GRAFT TISSUE 12X20CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132957","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","17167.50","12875.62","AETNA [1001]","HB AMC AETNA HMO","11982.92","69.8","","35.22","35.22","35.22","397","8051.56","13802.67","percent of total billed charges",""
"GRAFT TISSUE 12X20CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132957","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","17167.50","12875.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12000.08","69.9","","34.18","34.18","34.18","1057","8051.56","13802.67","percent of total billed charges",""
"GRAFT TISSUE 12X20CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132957","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","17167.50","12875.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8051.56","46.9","","34.18","34.18","34.18","528","8051.56","13802.67","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","21000.00","70","","134.04","134.04","134.04","1 through 10","9300","23850","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","23850.00","79.5","","948.87","198.19","1805.30","1 through 10","9300","23850","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","15990.00","53.3","","462.00","170.45","3253.37","1 through 10","9300","23850","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10950.00","36.5","","245.50","107.19","1371.45","1 through 10","9300","23850","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11490.00","38.3","","200.79","72.79","355.81","22","9300","23850","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","23100.00","77","","477.18","477.18","477.18","1 through 10","9300","23850","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12870.00","42.9","","1045.91","1045.91","1045.91","1 through 10","9300","23850","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","both","","","30000.00","22500.00","WELLPOINT [1015]","HB AMC WELLPOINT","22134.00","73.78","","1726.50","1726.50","1726.50","1 through 10","9300","23850","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","30000.00","22500.00","AETNA [1001]","HB AMC AETNA HMO","20940.00","69.8","","915.80","263.76","2881.00","1 through 10","15678","24516","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","30000.00","22500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24516.00","81.72","","1531.57","410.52","8841.36","1 through 10","15678","24516","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","both","","","57500.00","43125.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","40250.00","70","","134.04","134.04","134.04","1 through 10","17825","45712.5","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","both","","","57500.00","43125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","45712.50","79.5","","948.87","198.19","1805.30","1 through 10","17825","45712.5","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","both","","","57500.00","43125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","30647.50","53.3","","462.00","170.45","3253.37","1 through 10","17825","45712.5","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","both","","","57500.00","43125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20987.50","36.5","","245.50","107.19","1371.45","1 through 10","17825","45712.5","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","both","","","57500.00","43125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22022.50","38.3","","200.79","72.79","355.81","22","17825","45712.5","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","both","","","57500.00","43125.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","44275.00","77","","477.18","477.18","477.18","1 through 10","17825","45712.5","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","both","","","57500.00","43125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24667.50","42.9","","1045.91","1045.91","1045.91","1 through 10","17825","45712.5","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","both","","","57500.00","43125.00","WELLPOINT [1015]","HB AMC WELLPOINT","42423.50","73.78","","1726.50","1726.50","1726.50","1 through 10","17825","45712.5","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","57500.00","43125.00","AETNA [1001]","HB AMC AETNA HMO","40135.00","69.8","","915.80","263.76","2881.00","1 through 10","30049.5","46989","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","57500.00","43125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","46989.00","81.72","","1531.57","410.52","8841.36","1 through 10","30049.5","46989","percent of total billed charges",""
"GRAFT TISSUE 2.0 XIN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL CA/1EA","SUP-ITM-10021981","CDM","C1763","HCPCS","0278","RC","","","","both","","","995.40","746.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","647.01","65","","2028.23","1653.70","2028.23","1 through 10","308.57","791.34","percent of total billed charges",""
"GRAFT TISSUE 2.0 XIN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL CA/1EA","SUP-ITM-10021981","CDM","C1763","HCPCS","0278","RC","","","","both","","","995.40","746.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","363.32","36.5","","1163.89","1163.89","1163.89","1 through 10","308.57","791.34","percent of total billed charges",""
"GRAFT TISSUE 2.0 XIN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL CA/1EA","SUP-ITM-10021981","CDM","C1763","HCPCS","0278","RC","","","","both","","","995.40","746.55","WELLPOINT [1015]","HB AMC WELLPOINT","734.41","73.78","","4280.87","4280.87","4280.87","1 through 10","308.57","791.34","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","10165.00","7623.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","7115.50","70","","134.04","134.04","134.04","1 through 10","3151.15","8081.18","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","10165.00","7623.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8081.18","79.5","","948.87","198.19","1805.30","1 through 10","3151.15","8081.18","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","10165.00","7623.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5417.95","53.3","","462.00","170.45","3253.37","1 through 10","3151.15","8081.18","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","10165.00","7623.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3710.23","36.5","","245.50","107.19","1371.45","1 through 10","3151.15","8081.18","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","10165.00","7623.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3893.20","38.3","","200.79","72.79","355.81","22","3151.15","8081.18","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","10165.00","7623.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","7827.05","77","","477.18","477.18","477.18","1 through 10","3151.15","8081.18","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","10165.00","7623.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4360.79","42.9","","1045.91","1045.91","1045.91","1 through 10","3151.15","8081.18","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","10165.00","7623.75","WELLPOINT [1015]","HB AMC WELLPOINT","7499.74","73.78","","1726.50","1726.50","1726.50","1 through 10","3151.15","8081.18","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","10165.00","7623.75","AETNA [1001]","HB AMC AETNA HMO","7095.17","69.8","","915.80","263.76","2881.00","1 through 10","5312.23","8306.84","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","10165.00","7623.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8306.84","81.72","","1531.57","410.52","8841.36","1 through 10","5312.23","8306.84","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","both","","","36500.00","27375.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","25550.00","70","","134.04","134.04","134.04","1 through 10","11315","29017.5","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","both","","","36500.00","27375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","29017.50","79.5","","948.87","198.19","1805.30","1 through 10","11315","29017.5","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","both","","","36500.00","27375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19454.50","53.3","","462.00","170.45","3253.37","1 through 10","11315","29017.5","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","both","","","36500.00","27375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13322.50","36.5","","245.50","107.19","1371.45","1 through 10","11315","29017.5","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","both","","","36500.00","27375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","13979.50","38.3","","200.79","72.79","355.81","22","11315","29017.5","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","both","","","36500.00","27375.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","28105.00","77","","477.18","477.18","477.18","1 through 10","11315","29017.5","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","both","","","36500.00","27375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15658.50","42.9","","1045.91","1045.91","1045.91","1 through 10","11315","29017.5","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","both","","","36500.00","27375.00","WELLPOINT [1015]","HB AMC WELLPOINT","26929.70","73.78","","1726.50","1726.50","1726.50","1 through 10","11315","29017.5","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","36500.00","27375.00","AETNA [1001]","HB AMC AETNA HMO","25477.00","69.8","","915.80","263.76","2881.00","1 through 10","19074.9","29827.8","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","36500.00","27375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","29827.80","81.72","","1531.57","410.52","8841.36","1 through 10","19074.9","29827.8","percent of total billed charges",""
"GRAFT TISSUE 20MMX5CM SM ALLOPATCH FASCIA LATA FREEZE DRIED","SUP-ITM-10010711","CDM","C1762","HCPCS","0278","RC","","","","both","","","1273.13","954.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","678.58","53.3","","1112.50","1112.50","1112.50","1 through 10","394.67","1012.14","percent of total billed charges",""
"GRAFT TISSUE 20MMX5CM SM ALLOPATCH FASCIA LATA FREEZE DRIED","SUP-ITM-10010711","CDM","C1762","HCPCS","0278","RC","","","","both","","","1273.13","954.85","WELLPOINT [1015]","HB AMC WELLPOINT","939.32","73.78","","1568.66","1568.66","1568.66","1 through 10","394.67","1012.14","percent of total billed charges",""
"GRAFT TISSUE 20MMX5CM SM ALLOPATCH FASCIA LATA FREEZE DRIED","SUP-ITM-10010711","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","1273.13","954.85","AETNA [1001]","HB AMC AETNA HMO","888.64","69.8","","1281.90","1281.90","1281.90","1 through 10","665.34","1040.4","percent of total billed charges",""
"GRAFT TISSUE 20X16CM MED HUMAN RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132959","CDM","Q4116","HCPCS","0636","RC","","","","both","","","23580.00","17685.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8606.70","36.5","","23.35","23.35","23.35","264","7309.8","18156.6","percent of total billed charges",""
"GRAFT TISSUE 20X16CM MED HUMAN RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132959","CDM","Q4116","HCPCS","0636","RC","","","","both","","","23580.00","17685.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9031.14","38.3","","350.11","350.11","350.11","1108","7309.8","18156.6","percent of total billed charges",""
"GRAFT TISSUE 20X16CM MED HUMAN RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132959","CDM","Q4116","HCPCS","0636","RC","","","","both","","","23580.00","17685.00","WELLPOINT [1015]","HB AMC WELLPOINT","17397.32","73.78","","77.77","77.77","77.77","528","7309.8","18156.6","percent of total billed charges",""
"GRAFT TISSUE 20X16CM MED HUMAN RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132959","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","23580.00","17685.00","AETNA [1001]","HB AMC AETNA HMO","16458.84","69.8","","35.22","35.22","35.22","397","11059.02","18958.32","percent of total billed charges",""
"GRAFT TISSUE 20X16CM MED HUMAN RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132959","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","23580.00","17685.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","16482.42","69.9","","34.18","34.18","34.18","1057","11059.02","18958.32","percent of total billed charges",""
"GRAFT TISSUE 20X16CM MED HUMAN RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132959","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","23580.00","17685.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11059.02","46.9","","34.18","34.18","34.18","528","11059.02","18958.32","percent of total billed charges",""
"GRAFT TISSUE 3 XIN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL CA/1EA","SUP-ITM-10012385","CDM","C1763","HCPCS","0278","RC","","","","both","","","2045.61","1534.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1329.65","65","","2028.23","1653.70","2028.23","1 through 10","634.14","1626.26","percent of total billed charges",""
"GRAFT TISSUE 3 XIN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL CA/1EA","SUP-ITM-10012385","CDM","C1763","HCPCS","0278","RC","","","","both","","","2045.61","1534.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","746.65","36.5","","1163.89","1163.89","1163.89","1 through 10","634.14","1626.26","percent of total billed charges",""
"GRAFT TISSUE 3 XIN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL CA/1EA","SUP-ITM-10012385","CDM","C1763","HCPCS","0278","RC","","","","both","","","2045.61","1534.21","WELLPOINT [1015]","HB AMC WELLPOINT","1509.25","73.78","","4280.87","4280.87","4280.87","1 through 10","634.14","1626.26","percent of total billed charges",""
"GRAFT TISSUE 30CMX45 XENMATRIX AB SURGICAL GRAFT","SUP-ITM-10270075","CDM","C1781","HCPCS","0278","RC","","","","both","","","117500.00","88125.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","82250.00","70","","134.04","134.04","134.04","1 through 10","36425","93412.5","percent of total billed charges",""
"GRAFT TISSUE 30CMX45 XENMATRIX AB SURGICAL GRAFT","SUP-ITM-10270075","CDM","C1781","HCPCS","0278","RC","","","","both","","","117500.00","88125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","93412.50","79.5","","948.87","198.19","1805.30","1 through 10","36425","93412.5","percent of total billed charges",""
"GRAFT TISSUE 30CMX45 XENMATRIX AB SURGICAL GRAFT","SUP-ITM-10270075","CDM","C1781","HCPCS","0278","RC","","","","both","","","117500.00","88125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","62627.50","53.3","","462.00","170.45","3253.37","1 through 10","36425","93412.5","percent of total billed charges",""
"GRAFT TISSUE 30CMX45 XENMATRIX AB SURGICAL GRAFT","SUP-ITM-10270075","CDM","C1781","HCPCS","0278","RC","","","","both","","","117500.00","88125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","42887.50","36.5","","245.50","107.19","1371.45","1 through 10","36425","93412.5","percent of total billed charges",""
"GRAFT TISSUE 30CMX45 XENMATRIX AB SURGICAL GRAFT","SUP-ITM-10270075","CDM","C1781","HCPCS","0278","RC","","","","both","","","117500.00","88125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","45002.50","38.3","","200.79","72.79","355.81","22","36425","93412.5","percent of total billed charges",""
"GRAFT TISSUE 30CMX45 XENMATRIX AB SURGICAL GRAFT","SUP-ITM-10270075","CDM","C1781","HCPCS","0278","RC","","","","both","","","117500.00","88125.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","90475.00","77","","477.18","477.18","477.18","1 through 10","36425","93412.5","percent of total billed charges",""
"GRAFT TISSUE 30CMX45 XENMATRIX AB SURGICAL GRAFT","SUP-ITM-10270075","CDM","C1781","HCPCS","0278","RC","","","","both","","","117500.00","88125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50407.50","42.9","","1045.91","1045.91","1045.91","1 through 10","36425","93412.5","percent of total billed charges",""
"GRAFT TISSUE 30CMX45 XENMATRIX AB SURGICAL GRAFT","SUP-ITM-10270075","CDM","C1781","HCPCS","0278","RC","","","","both","","","117500.00","88125.00","WELLPOINT [1015]","HB AMC WELLPOINT","86691.50","73.78","","1726.50","1726.50","1726.50","1 through 10","36425","93412.5","percent of total billed charges",""
"GRAFT TISSUE 30CMX45 XENMATRIX AB SURGICAL GRAFT","SUP-ITM-10270075","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","117500.00","88125.00","AETNA [1001]","HB AMC AETNA HMO","82015.00","69.8","","915.80","263.76","2881.00","1 through 10","61405.5","96021","percent of total billed charges",""
"GRAFT TISSUE 30CMX45 XENMATRIX AB SURGICAL GRAFT","SUP-ITM-10270075","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","117500.00","88125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","96021.00","81.72","","1531.57","410.52","8841.36","1 through 10","61405.5","96021","percent of total billed charges",""
"GRAFT TISSUE 3X3IN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL PK/5EA","SUP-ITM-10215594","CDM","C1763","HCPCS","0278","RC","","","","both","","","1622.67","1217.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1054.74","65","","2028.23","1653.70","2028.23","1 through 10","503.03","1290.02","percent of total billed charges",""
"GRAFT TISSUE 3X3IN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL PK/5EA","SUP-ITM-10215594","CDM","C1763","HCPCS","0278","RC","","","","both","","","1622.67","1217.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","592.27","36.5","","1163.89","1163.89","1163.89","1 through 10","503.03","1290.02","percent of total billed charges",""
"GRAFT TISSUE 3X3IN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL PK/5EA","SUP-ITM-10215594","CDM","C1763","HCPCS","0278","RC","","","","both","","","1622.67","1217.00","WELLPOINT [1015]","HB AMC WELLPOINT","1197.21","73.78","","4280.87","4280.87","4280.87","1 through 10","503.03","1290.02","percent of total billed charges",""
"GRAFT TISSUE 4.0X5.0IN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL","SUP-ITM-10012386","CDM","C1763","HCPCS","0278","RC","","","","both","","","3035.55","2276.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1973.11","65","","2028.23","1653.70","2028.23","1 through 10","941.02","2413.26","percent of total billed charges",""
"GRAFT TISSUE 4.0X5.0IN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL","SUP-ITM-10012386","CDM","C1763","HCPCS","0278","RC","","","","both","","","3035.55","2276.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1107.98","36.5","","1163.89","1163.89","1163.89","1 through 10","941.02","2413.26","percent of total billed charges",""
"GRAFT TISSUE 4.0X5.0IN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL","SUP-ITM-10012386","CDM","C1763","HCPCS","0278","RC","","","","both","","","3035.55","2276.66","WELLPOINT [1015]","HB AMC WELLPOINT","2239.63","73.78","","4280.87","4280.87","4280.87","1 through 10","941.02","2413.26","percent of total billed charges",""
"GRAFT TISSUE 4X12CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132961","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4546.50","3409.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1659.47","36.5","","23.35","23.35","23.35","264","1409.42","3500.81","percent of total billed charges",""
"GRAFT TISSUE 4X12CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132961","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4546.50","3409.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1741.31","38.3","","350.11","350.11","350.11","1108","1409.42","3500.81","percent of total billed charges",""
"GRAFT TISSUE 4X12CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132961","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4546.50","3409.87","WELLPOINT [1015]","HB AMC WELLPOINT","3354.41","73.78","","77.77","77.77","77.77","528","1409.42","3500.81","percent of total billed charges",""
"GRAFT TISSUE 4X12CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132961","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4546.50","3409.87","AETNA [1001]","HB AMC AETNA HMO","3173.46","69.8","","35.22","35.22","35.22","397","2132.31","3655.39","percent of total billed charges",""
"GRAFT TISSUE 4X12CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132961","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4546.50","3409.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3178.00","69.9","","34.18","34.18","34.18","1057","2132.31","3655.39","percent of total billed charges",""
"GRAFT TISSUE 4X12CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132961","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4546.50","3409.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2132.31","46.9","","34.18","34.18","34.18","528","2132.31","3655.39","percent of total billed charges",""
"GRAFT TISSUE 4X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132963","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5196.00","3897.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1896.54","36.5","","23.35","23.35","23.35","264","1610.76","4000.92","percent of total billed charges",""
"GRAFT TISSUE 4X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132963","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5196.00","3897.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1990.07","38.3","","350.11","350.11","350.11","1108","1610.76","4000.92","percent of total billed charges",""
"GRAFT TISSUE 4X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132963","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5196.00","3897.00","WELLPOINT [1015]","HB AMC WELLPOINT","3833.61","73.78","","77.77","77.77","77.77","528","1610.76","4000.92","percent of total billed charges",""
"GRAFT TISSUE 4X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132963","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5196.00","3897.00","AETNA [1001]","HB AMC AETNA HMO","3626.81","69.8","","35.22","35.22","35.22","397","2436.92","4177.58","percent of total billed charges",""
"GRAFT TISSUE 4X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132963","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5196.00","3897.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3632.00","69.9","","34.18","34.18","34.18","1057","2436.92","4177.58","percent of total billed charges",""
"GRAFT TISSUE 4X16CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132963","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5196.00","3897.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2436.92","46.9","","34.18","34.18","34.18","528","2436.92","4177.58","percent of total billed charges",""
"GRAFT TISSUE 4X7CM PERICARDIUM FASCIA LATA TUTOPLAST","SUP-ITM-10239660","CDM","C1762","HCPCS","0278","RC","","","","both","","","5532.50","4149.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2948.82","53.3","","1112.50","1112.50","1112.50","1 through 10","1715.08","4398.34","percent of total billed charges",""
"GRAFT TISSUE 4X7CM PERICARDIUM FASCIA LATA TUTOPLAST","SUP-ITM-10239660","CDM","C1762","HCPCS","0278","RC","","","","both","","","5532.50","4149.37","WELLPOINT [1015]","HB AMC WELLPOINT","4081.88","73.78","","1568.66","1568.66","1568.66","1 through 10","1715.08","4398.34","percent of total billed charges",""
"GRAFT TISSUE 4X7CM PERICARDIUM FASCIA LATA TUTOPLAST","SUP-ITM-10239660","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","5532.50","4149.37","AETNA [1001]","HB AMC AETNA HMO","3861.69","69.8","","1281.90","1281.90","1281.90","1 through 10","2891.28","4521.16","percent of total billed charges",""
"GRAFT TISSUE 5IN 4 DURAGEN COLLAGEN REGENERATION SUTURABLE SINGLE UNIT MATRIX DURAL CA/1EA","SUP-ITM-10021979","CDM","C1763","HCPCS","0278","RC","","","","both","","","3910.06","2932.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2541.54","65","","2028.23","1653.70","2028.23","1 through 10","1212.12","3108.5","percent of total billed charges",""
"GRAFT TISSUE 5IN 4 DURAGEN COLLAGEN REGENERATION SUTURABLE SINGLE UNIT MATRIX DURAL CA/1EA","SUP-ITM-10021979","CDM","C1763","HCPCS","0278","RC","","","","both","","","3910.06","2932.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1427.17","36.5","","1163.89","1163.89","1163.89","1 through 10","1212.12","3108.5","percent of total billed charges",""
"GRAFT TISSUE 5IN 4 DURAGEN COLLAGEN REGENERATION SUTURABLE SINGLE UNIT MATRIX DURAL CA/1EA","SUP-ITM-10021979","CDM","C1763","HCPCS","0278","RC","","","","both","","","3910.06","2932.54","WELLPOINT [1015]","HB AMC WELLPOINT","2884.84","73.78","","4280.87","4280.87","4280.87","1 through 10","1212.12","3108.5","percent of total billed charges",""
"GRAFT TISSUE 6X12CM ALLOMAX ACELLULAR COLLAGEN DERMAL MATRIX RECTANGULAR CA/1EA","SUP-ITM-10072524","CDM","C1781","HCPCS","0278","RC","","","","both","","","5469.33","4102.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3828.53","70","","134.04","134.04","134.04","1 through 10","1695.49","4348.12","percent of total billed charges",""
"GRAFT TISSUE 6X12CM ALLOMAX ACELLULAR COLLAGEN DERMAL MATRIX RECTANGULAR CA/1EA","SUP-ITM-10072524","CDM","C1781","HCPCS","0278","RC","","","","both","","","5469.33","4102.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4348.12","79.5","","948.87","198.19","1805.30","1 through 10","1695.49","4348.12","percent of total billed charges",""
"GRAFT TISSUE 6X12CM ALLOMAX ACELLULAR COLLAGEN DERMAL MATRIX RECTANGULAR CA/1EA","SUP-ITM-10072524","CDM","C1781","HCPCS","0278","RC","","","","both","","","5469.33","4102.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2915.15","53.3","","462.00","170.45","3253.37","1 through 10","1695.49","4348.12","percent of total billed charges",""
"GRAFT TISSUE 6X12CM ALLOMAX ACELLULAR COLLAGEN DERMAL MATRIX RECTANGULAR CA/1EA","SUP-ITM-10072524","CDM","C1781","HCPCS","0278","RC","","","","both","","","5469.33","4102.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1996.31","36.5","","245.50","107.19","1371.45","1 through 10","1695.49","4348.12","percent of total billed charges",""
"GRAFT TISSUE 6X12CM ALLOMAX ACELLULAR COLLAGEN DERMAL MATRIX RECTANGULAR CA/1EA","SUP-ITM-10072524","CDM","C1781","HCPCS","0278","RC","","","","both","","","5469.33","4102.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2094.75","38.3","","200.79","72.79","355.81","22","1695.49","4348.12","percent of total billed charges",""
"GRAFT TISSUE 6X12CM ALLOMAX ACELLULAR COLLAGEN DERMAL MATRIX RECTANGULAR CA/1EA","SUP-ITM-10072524","CDM","C1781","HCPCS","0278","RC","","","","both","","","5469.33","4102.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4211.38","77","","477.18","477.18","477.18","1 through 10","1695.49","4348.12","percent of total billed charges",""
"GRAFT TISSUE 6X12CM ALLOMAX ACELLULAR COLLAGEN DERMAL MATRIX RECTANGULAR CA/1EA","SUP-ITM-10072524","CDM","C1781","HCPCS","0278","RC","","","","both","","","5469.33","4102.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2346.34","42.9","","1045.91","1045.91","1045.91","1 through 10","1695.49","4348.12","percent of total billed charges",""
"GRAFT TISSUE 6X12CM ALLOMAX ACELLULAR COLLAGEN DERMAL MATRIX RECTANGULAR CA/1EA","SUP-ITM-10072524","CDM","C1781","HCPCS","0278","RC","","","","both","","","5469.33","4102.00","WELLPOINT [1015]","HB AMC WELLPOINT","4035.27","73.78","","1726.50","1726.50","1726.50","1 through 10","1695.49","4348.12","percent of total billed charges",""
"GRAFT TISSUE 6X12CM ALLOMAX ACELLULAR COLLAGEN DERMAL MATRIX RECTANGULAR CA/1EA","SUP-ITM-10072524","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5469.33","4102.00","AETNA [1001]","HB AMC AETNA HMO","3817.59","69.8","","915.80","263.76","2881.00","1 through 10","2858.27","4469.54","percent of total billed charges",""
"GRAFT TISSUE 6X12CM ALLOMAX ACELLULAR COLLAGEN DERMAL MATRIX RECTANGULAR CA/1EA","SUP-ITM-10072524","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5469.33","4102.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4469.54","81.72","","1531.57","410.52","8841.36","1 through 10","2858.27","4469.54","percent of total billed charges",""
"GRAFT TISSUE 6X12CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132965","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4875.00","3656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1779.38","36.5","","23.35","23.35","23.35","264","1511.25","3753.75","percent of total billed charges",""
"GRAFT TISSUE 6X12CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132965","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4875.00","3656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1867.13","38.3","","350.11","350.11","350.11","1108","1511.25","3753.75","percent of total billed charges",""
"GRAFT TISSUE 6X12CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132965","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4875.00","3656.25","WELLPOINT [1015]","HB AMC WELLPOINT","3596.78","73.78","","77.77","77.77","77.77","528","1511.25","3753.75","percent of total billed charges",""
"GRAFT TISSUE 6X12CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132965","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4875.00","3656.25","AETNA [1001]","HB AMC AETNA HMO","3402.75","69.8","","35.22","35.22","35.22","397","2286.38","3919.5","percent of total billed charges",""
"GRAFT TISSUE 6X12CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132965","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4875.00","3656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3407.63","69.9","","34.18","34.18","34.18","1057","2286.38","3919.5","percent of total billed charges",""
"GRAFT TISSUE 6X12CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132965","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4875.00","3656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2286.38","46.9","","34.18","34.18","34.18","528","2286.38","3919.5","percent of total billed charges",""
"GRAFT TISSUE 6X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132967","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6867.50","5150.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2506.64","36.5","","23.35","23.35","23.35","264","2128.93","5287.98","percent of total billed charges",""
"GRAFT TISSUE 6X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132967","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6867.50","5150.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2630.25","38.3","","350.11","350.11","350.11","1108","2128.93","5287.98","percent of total billed charges",""
"GRAFT TISSUE 6X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132967","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6867.50","5150.62","WELLPOINT [1015]","HB AMC WELLPOINT","5066.84","73.78","","77.77","77.77","77.77","528","2128.93","5287.98","percent of total billed charges",""
"GRAFT TISSUE 6X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132967","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","6867.50","5150.62","AETNA [1001]","HB AMC AETNA HMO","4793.52","69.8","","35.22","35.22","35.22","397","3220.86","5521.47","percent of total billed charges",""
"GRAFT TISSUE 6X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132967","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","6867.50","5150.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4800.38","69.9","","34.18","34.18","34.18","1057","3220.86","5521.47","percent of total billed charges",""
"GRAFT TISSUE 6X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132967","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","6867.50","5150.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3220.86","46.9","","34.18","34.18","34.18","528","3220.86","5521.47","percent of total billed charges",""
"GRAFT TISSUE 6X18CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132969","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2819.63","36.5","","23.35","23.35","23.35","264","2394.75","5948.25","percent of total billed charges",""
"GRAFT TISSUE 6X18CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132969","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2958.68","38.3","","350.11","350.11","350.11","1108","2394.75","5948.25","percent of total billed charges",""
"GRAFT TISSUE 6X18CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132969","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7725.00","5793.75","WELLPOINT [1015]","HB AMC WELLPOINT","5699.51","73.78","","77.77","77.77","77.77","528","2394.75","5948.25","percent of total billed charges",""
"GRAFT TISSUE 6X18CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132969","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7725.00","5793.75","AETNA [1001]","HB AMC AETNA HMO","5392.05","69.8","","35.22","35.22","35.22","397","3623.03","6210.9","percent of total billed charges",""
"GRAFT TISSUE 6X18CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132969","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7725.00","5793.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5399.78","69.9","","34.18","34.18","34.18","1057","3623.03","6210.9","percent of total billed charges",""
"GRAFT TISSUE 6X18CM MED HUMAN ALLODERM REGENERATIVE","SUP-ITM-10132969","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7725.00","5793.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3623.03","46.9","","34.18","34.18","34.18","528","3623.03","6210.9","percent of total billed charges",""
"GRAFT TISSUE 7X5IN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL PK/1EA","SUP-ITM-10216108","CDM","C1763","HCPCS","0278","RC","","","","both","","","3455.27","2591.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2245.93","65","","2028.23","1653.70","2028.23","1 through 10","1071.13","2746.94","percent of total billed charges",""
"GRAFT TISSUE 7X5IN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL PK/1EA","SUP-ITM-10216108","CDM","C1763","HCPCS","0278","RC","","","","both","","","3455.27","2591.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1261.17","36.5","","1163.89","1163.89","1163.89","1 through 10","1071.13","2746.94","percent of total billed charges",""
"GRAFT TISSUE 7X5IN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL PK/1EA","SUP-ITM-10216108","CDM","C1763","HCPCS","0278","RC","","","","both","","","3455.27","2591.45","WELLPOINT [1015]","HB AMC WELLPOINT","2549.30","73.78","","4280.87","4280.87","4280.87","1 through 10","1071.13","2746.94","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM READY TO USE REGENERATIVE MATRIX XTHICK","SUP-ITM-10100954","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9157.50","6868.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3342.49","36.5","","23.35","23.35","23.35","264","2838.83","7051.28","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM READY TO USE REGENERATIVE MATRIX XTHICK","SUP-ITM-10100954","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9157.50","6868.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3507.32","38.3","","350.11","350.11","350.11","1108","2838.83","7051.28","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM READY TO USE REGENERATIVE MATRIX XTHICK","SUP-ITM-10100954","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9157.50","6868.12","WELLPOINT [1015]","HB AMC WELLPOINT","6756.40","73.78","","77.77","77.77","77.77","528","2838.83","7051.28","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM READY TO USE REGENERATIVE MATRIX XTHICK","SUP-ITM-10100954","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9157.50","6868.12","AETNA [1001]","HB AMC AETNA HMO","6391.94","69.8","","35.22","35.22","35.22","397","4294.87","7362.63","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM READY TO USE REGENERATIVE MATRIX XTHICK","SUP-ITM-10100954","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9157.50","6868.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6401.09","69.9","","34.18","34.18","34.18","1057","4294.87","7362.63","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM READY TO USE REGENERATIVE MATRIX XTHICK","SUP-ITM-10100954","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9157.50","6868.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4294.87","46.9","","34.18","34.18","34.18","528","4294.87","7362.63","percent of total billed charges",""
"GRAFT TISSUE FROZEN FEMORAL DISTAL VARIES MATRI IMPLANTABLE","SUP-ITM-10010270","CDM","C1889","HCPCS","0278","RC","","","","both","","","10226.28","7669.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8129.89","79.5","","1309.77","674.56","6049.93","26","3170.15","8129.89","percent of total billed charges",""
"GRAFT TISSUE FROZEN FEMORAL DISTAL VARIES MATRI IMPLANTABLE","SUP-ITM-10010270","CDM","C1889","HCPCS","0278","RC","","","","both","","","10226.28","7669.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5450.61","53.3","","1901.83","1901.83","2962.25","1 through 10","3170.15","8129.89","percent of total billed charges",""
"GRAFT TISSUE FROZEN FEMORAL DISTAL VARIES MATRI IMPLANTABLE","SUP-ITM-10010270","CDM","C1889","HCPCS","0278","RC","","","","both","","","10226.28","7669.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3732.59","36.5","","1620.31","1620.31","19908.88","1 through 10","3170.15","8129.89","percent of total billed charges",""
"GRAFT TISSUE FROZEN FEMORAL DISTAL VARIES MATRI IMPLANTABLE","SUP-ITM-10010270","CDM","C1889","HCPCS","0278","RC","","","","both","","","10226.28","7669.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3916.67","38.3","","352.91","352.91","2046.30","1 through 10","3170.15","8129.89","percent of total billed charges",""
"GRAFT TISSUE FROZEN FEMORAL DISTAL VARIES MATRI IMPLANTABLE","SUP-ITM-10010270","CDM","C1889","HCPCS","0278","RC","","","","both","","","10226.28","7669.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4387.07","42.9","","9668.75","9668.75","9668.75","1 through 10","3170.15","8129.89","percent of total billed charges",""
"GRAFT TISSUE FROZEN FEMORAL DISTAL VARIES MATRI IMPLANTABLE","SUP-ITM-10010270","CDM","C1889","HCPCS","0278","RC","","","","both","","","10226.28","7669.71","WELLPOINT [1015]","HB AMC WELLPOINT","7544.95","73.78","","699.88","384.10","3443.31","33","3170.15","8129.89","percent of total billed charges",""
"GRAFT TISSUE FROZEN FEMORAL DISTAL VARIES MATRI IMPLANTABLE","SUP-ITM-10010270","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10226.28","7669.71","AETNA [1001]","HB AMC AETNA HMO","7137.94","69.8","","1421.24","264.50","4933.46","29","5344.25","8356.92","percent of total billed charges",""
"GRAFT TISSUE FROZEN FEMORAL DISTAL VARIES MATRI IMPLANTABLE","SUP-ITM-10010270","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10226.28","7669.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8221.93","80.4","","1022.97","1022.97","3607.50","1 through 10","5344.25","8356.92","percent of total billed charges",""
"GRAFT TISSUE FROZEN FEMORAL DISTAL VARIES MATRI IMPLANTABLE","SUP-ITM-10010270","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10226.28","7669.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8356.92","81.72","","3010.54","693.88","5019.88","35","5344.25","8356.92","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL RT STRUCTURAL ALLO","SUP-ITM-10010816","CDM","C1889","HCPCS","0278","RC","","","","both","","","5954.90","4466.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4734.15","79.5","","1309.77","674.56","6049.93","26","1846.02","4734.15","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL RT STRUCTURAL ALLO","SUP-ITM-10010816","CDM","C1889","HCPCS","0278","RC","","","","both","","","5954.90","4466.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3173.96","53.3","","1901.83","1901.83","2962.25","1 through 10","1846.02","4734.15","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL RT STRUCTURAL ALLO","SUP-ITM-10010816","CDM","C1889","HCPCS","0278","RC","","","","both","","","5954.90","4466.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2173.54","36.5","","1620.31","1620.31","19908.88","1 through 10","1846.02","4734.15","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL RT STRUCTURAL ALLO","SUP-ITM-10010816","CDM","C1889","HCPCS","0278","RC","","","","both","","","5954.90","4466.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2280.73","38.3","","352.91","352.91","2046.30","1 through 10","1846.02","4734.15","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL RT STRUCTURAL ALLO","SUP-ITM-10010816","CDM","C1889","HCPCS","0278","RC","","","","both","","","5954.90","4466.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2554.65","42.9","","9668.75","9668.75","9668.75","1 through 10","1846.02","4734.15","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL RT STRUCTURAL ALLO","SUP-ITM-10010816","CDM","C1889","HCPCS","0278","RC","","","","both","","","5954.90","4466.17","WELLPOINT [1015]","HB AMC WELLPOINT","4393.53","73.78","","699.88","384.10","3443.31","33","1846.02","4734.15","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL RT STRUCTURAL ALLO","SUP-ITM-10010816","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5954.90","4466.17","AETNA [1001]","HB AMC AETNA HMO","4156.52","69.8","","1421.24","264.50","4933.46","29","3112.03","4866.34","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL RT STRUCTURAL ALLO","SUP-ITM-10010816","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5954.90","4466.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4787.74","80.4","","1022.97","1022.97","3607.50","1 through 10","3112.03","4866.34","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL RT STRUCTURAL ALLO","SUP-ITM-10010816","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5954.90","4466.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4866.34","81.72","","3010.54","693.88","5019.88","35","3112.03","4866.34","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS WHOLE RT W/OUT ROTATOR CUFF","SUP-ITM-10010814","CDM","C1889","HCPCS","0278","RC","","","","both","","","15143.40","11357.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12039.00","79.5","","1309.77","674.56","6049.93","26","4694.45","12039","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS WHOLE RT W/OUT ROTATOR CUFF","SUP-ITM-10010814","CDM","C1889","HCPCS","0278","RC","","","","both","","","15143.40","11357.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8071.43","53.3","","1901.83","1901.83","2962.25","1 through 10","4694.45","12039","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS WHOLE RT W/OUT ROTATOR CUFF","SUP-ITM-10010814","CDM","C1889","HCPCS","0278","RC","","","","both","","","15143.40","11357.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5527.34","36.5","","1620.31","1620.31","19908.88","1 through 10","4694.45","12039","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS WHOLE RT W/OUT ROTATOR CUFF","SUP-ITM-10010814","CDM","C1889","HCPCS","0278","RC","","","","both","","","15143.40","11357.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5799.92","38.3","","352.91","352.91","2046.30","1 through 10","4694.45","12039","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS WHOLE RT W/OUT ROTATOR CUFF","SUP-ITM-10010814","CDM","C1889","HCPCS","0278","RC","","","","both","","","15143.40","11357.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6496.52","42.9","","9668.75","9668.75","9668.75","1 through 10","4694.45","12039","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS WHOLE RT W/OUT ROTATOR CUFF","SUP-ITM-10010814","CDM","C1889","HCPCS","0278","RC","","","","both","","","15143.40","11357.55","WELLPOINT [1015]","HB AMC WELLPOINT","11172.80","73.78","","699.88","384.10","3443.31","33","4694.45","12039","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS WHOLE RT W/OUT ROTATOR CUFF","SUP-ITM-10010814","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","15143.40","11357.55","AETNA [1001]","HB AMC AETNA HMO","10570.09","69.8","","1421.24","264.50","4933.46","29","7913.94","12375.19","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS WHOLE RT W/OUT ROTATOR CUFF","SUP-ITM-10010814","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","15143.40","11357.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","12175.29","80.4","","1022.97","1022.97","3607.50","1 through 10","7913.94","12375.19","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS WHOLE RT W/OUT ROTATOR CUFF","SUP-ITM-10010814","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","15143.40","11357.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12375.19","81.72","","3010.54","693.88","5019.88","35","7913.94","12375.19","percent of total billed charges",""
"GRAFT TISSUE FROZEN RADIUS WHOLE RT STRUCTURAL ALLO","SUP-ITM-10010810","CDM","C1889","HCPCS","0278","RC","","","","both","","","8864.20","6648.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7047.04","79.5","","1309.77","674.56","6049.93","26","2747.9","7047.04","percent of total billed charges",""
"GRAFT TISSUE FROZEN RADIUS WHOLE RT STRUCTURAL ALLO","SUP-ITM-10010810","CDM","C1889","HCPCS","0278","RC","","","","both","","","8864.20","6648.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4724.62","53.3","","1901.83","1901.83","2962.25","1 through 10","2747.9","7047.04","percent of total billed charges",""
"GRAFT TISSUE FROZEN RADIUS WHOLE RT STRUCTURAL ALLO","SUP-ITM-10010810","CDM","C1889","HCPCS","0278","RC","","","","both","","","8864.20","6648.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3235.43","36.5","","1620.31","1620.31","19908.88","1 through 10","2747.9","7047.04","percent of total billed charges",""
"GRAFT TISSUE FROZEN RADIUS WHOLE RT STRUCTURAL ALLO","SUP-ITM-10010810","CDM","C1889","HCPCS","0278","RC","","","","both","","","8864.20","6648.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3394.99","38.3","","352.91","352.91","2046.30","1 through 10","2747.9","7047.04","percent of total billed charges",""
"GRAFT TISSUE FROZEN RADIUS WHOLE RT STRUCTURAL ALLO","SUP-ITM-10010810","CDM","C1889","HCPCS","0278","RC","","","","both","","","8864.20","6648.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3802.74","42.9","","9668.75","9668.75","9668.75","1 through 10","2747.9","7047.04","percent of total billed charges",""
"GRAFT TISSUE FROZEN RADIUS WHOLE RT STRUCTURAL ALLO","SUP-ITM-10010810","CDM","C1889","HCPCS","0278","RC","","","","both","","","8864.20","6648.15","WELLPOINT [1015]","HB AMC WELLPOINT","6540.01","73.78","","699.88","384.10","3443.31","33","2747.9","7047.04","percent of total billed charges",""
"GRAFT TISSUE FROZEN RADIUS WHOLE RT STRUCTURAL ALLO","SUP-ITM-10010810","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8864.20","6648.15","AETNA [1001]","HB AMC AETNA HMO","6187.21","69.8","","1421.24","264.50","4933.46","29","4632.43","7243.82","percent of total billed charges",""
"GRAFT TISSUE FROZEN RADIUS WHOLE RT STRUCTURAL ALLO","SUP-ITM-10010810","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8864.20","6648.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7126.82","80.4","","1022.97","1022.97","3607.50","1 through 10","4632.43","7243.82","percent of total billed charges",""
"GRAFT TISSUE FROZEN RADIUS WHOLE RT STRUCTURAL ALLO","SUP-ITM-10010810","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8864.20","6648.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7243.82","81.72","","3010.54","693.88","5019.88","35","4632.43","7243.82","percent of total billed charges",""
"GRAFT TISSUE LG HUMAN OSTEOARTICULAR SEGMENTAL RECONSTRUCTIVE STRUCTURAL LT ELBOW ALLO IMPLANTABLE","SUP-ITM-10079401","CDM","C1889","HCPCS","0278","RC","","","","both","","","26934.88","20201.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21413.23","79.5","","1309.77","674.56","6049.93","26","8349.81","21413.23","percent of total billed charges",""
"GRAFT TISSUE LG HUMAN OSTEOARTICULAR SEGMENTAL RECONSTRUCTIVE STRUCTURAL LT ELBOW ALLO IMPLANTABLE","SUP-ITM-10079401","CDM","C1889","HCPCS","0278","RC","","","","both","","","26934.88","20201.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14356.29","53.3","","1901.83","1901.83","2962.25","1 through 10","8349.81","21413.23","percent of total billed charges",""
"GRAFT TISSUE LG HUMAN OSTEOARTICULAR SEGMENTAL RECONSTRUCTIVE STRUCTURAL LT ELBOW ALLO IMPLANTABLE","SUP-ITM-10079401","CDM","C1889","HCPCS","0278","RC","","","","both","","","26934.88","20201.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9831.23","36.5","","1620.31","1620.31","19908.88","1 through 10","8349.81","21413.23","percent of total billed charges",""
"GRAFT TISSUE LG HUMAN OSTEOARTICULAR SEGMENTAL RECONSTRUCTIVE STRUCTURAL LT ELBOW ALLO IMPLANTABLE","SUP-ITM-10079401","CDM","C1889","HCPCS","0278","RC","","","","both","","","26934.88","20201.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10316.06","38.3","","352.91","352.91","2046.30","1 through 10","8349.81","21413.23","percent of total billed charges",""
"GRAFT TISSUE LG HUMAN OSTEOARTICULAR SEGMENTAL RECONSTRUCTIVE STRUCTURAL LT ELBOW ALLO IMPLANTABLE","SUP-ITM-10079401","CDM","C1889","HCPCS","0278","RC","","","","both","","","26934.88","20201.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11555.06","42.9","","9668.75","9668.75","9668.75","1 through 10","8349.81","21413.23","percent of total billed charges",""
"GRAFT TISSUE LG HUMAN OSTEOARTICULAR SEGMENTAL RECONSTRUCTIVE STRUCTURAL LT ELBOW ALLO IMPLANTABLE","SUP-ITM-10079401","CDM","C1889","HCPCS","0278","RC","","","","both","","","26934.88","20201.16","WELLPOINT [1015]","HB AMC WELLPOINT","19872.55","73.78","","699.88","384.10","3443.31","33","8349.81","21413.23","percent of total billed charges",""
"GRAFT TISSUE LG HUMAN OSTEOARTICULAR SEGMENTAL RECONSTRUCTIVE STRUCTURAL LT ELBOW ALLO IMPLANTABLE","SUP-ITM-10079401","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","26934.88","20201.16","AETNA [1001]","HB AMC AETNA HMO","18800.55","69.8","","1421.24","264.50","4933.46","29","14076.17","22011.18","percent of total billed charges",""
"GRAFT TISSUE LG HUMAN OSTEOARTICULAR SEGMENTAL RECONSTRUCTIVE STRUCTURAL LT ELBOW ALLO IMPLANTABLE","SUP-ITM-10079401","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","26934.88","20201.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","21655.64","80.4","","1022.97","1022.97","3607.50","1 through 10","14076.17","22011.18","percent of total billed charges",""
"GRAFT TISSUE LG HUMAN OSTEOARTICULAR SEGMENTAL RECONSTRUCTIVE STRUCTURAL LT ELBOW ALLO IMPLANTABLE","SUP-ITM-10079401","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","26934.88","20201.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22011.18","81.72","","3010.54","693.88","5019.88","35","14076.17","22011.18","percent of total billed charges",""
"GRAFT TISSUE LG TISSUE CONTOUR NON PERFORATED MEDIUM RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132705","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11730.00","8797.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4281.45","36.5","","23.35","23.35","23.35","264","3636.3","9032.1","percent of total billed charges",""
"GRAFT TISSUE LG TISSUE CONTOUR NON PERFORATED MEDIUM RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132705","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11730.00","8797.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4492.59","38.3","","350.11","350.11","350.11","1108","3636.3","9032.1","percent of total billed charges",""
"GRAFT TISSUE LG TISSUE CONTOUR NON PERFORATED MEDIUM RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132705","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11730.00","8797.50","WELLPOINT [1015]","HB AMC WELLPOINT","8654.39","73.78","","77.77","77.77","77.77","528","3636.3","9032.1","percent of total billed charges",""
"GRAFT TISSUE LG TISSUE CONTOUR NON PERFORATED MEDIUM RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132705","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11730.00","8797.50","AETNA [1001]","HB AMC AETNA HMO","8187.54","69.8","","35.22","35.22","35.22","397","5501.37","9430.92","percent of total billed charges",""
"GRAFT TISSUE LG TISSUE CONTOUR NON PERFORATED MEDIUM RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132705","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11730.00","8797.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8199.27","69.9","","34.18","34.18","34.18","1057","5501.37","9430.92","percent of total billed charges",""
"GRAFT TISSUE LG TISSUE CONTOUR NON PERFORATED MEDIUM RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132705","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11730.00","8797.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5501.37","46.9","","34.18","34.18","34.18","528","5501.37","9430.92","percent of total billed charges",""
"GRAFT TISSUE SM HUMAN VIABLE CELL TRINITY ELITE IMPLANTABLE","SUP-ITM-10133235","CDM","C1889","HCPCS","0278","RC","","","","both","","","1886.50","1414.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1499.77","79.5","","1309.77","674.56","6049.93","26","584.82","1499.77","percent of total billed charges",""
"GRAFT TISSUE SM HUMAN VIABLE CELL TRINITY ELITE IMPLANTABLE","SUP-ITM-10133235","CDM","C1889","HCPCS","0278","RC","","","","both","","","1886.50","1414.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1005.50","53.3","","1901.83","1901.83","2962.25","1 through 10","584.82","1499.77","percent of total billed charges",""
"GRAFT TISSUE SM HUMAN VIABLE CELL TRINITY ELITE IMPLANTABLE","SUP-ITM-10133235","CDM","C1889","HCPCS","0278","RC","","","","both","","","1886.50","1414.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","688.57","36.5","","1620.31","1620.31","19908.88","1 through 10","584.82","1499.77","percent of total billed charges",""
"GRAFT TISSUE SM HUMAN VIABLE CELL TRINITY ELITE IMPLANTABLE","SUP-ITM-10133235","CDM","C1889","HCPCS","0278","RC","","","","both","","","1886.50","1414.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","722.53","38.3","","352.91","352.91","2046.30","1 through 10","584.82","1499.77","percent of total billed charges",""
"GRAFT TISSUE SM HUMAN VIABLE CELL TRINITY ELITE IMPLANTABLE","SUP-ITM-10133235","CDM","C1889","HCPCS","0278","RC","","","","both","","","1886.50","1414.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","809.31","42.9","","9668.75","9668.75","9668.75","1 through 10","584.82","1499.77","percent of total billed charges",""
"GRAFT TISSUE SM HUMAN VIABLE CELL TRINITY ELITE IMPLANTABLE","SUP-ITM-10133235","CDM","C1889","HCPCS","0278","RC","","","","both","","","1886.50","1414.87","WELLPOINT [1015]","HB AMC WELLPOINT","1391.86","73.78","","699.88","384.10","3443.31","33","584.82","1499.77","percent of total billed charges",""
"GRAFT TISSUE SM HUMAN VIABLE CELL TRINITY ELITE IMPLANTABLE","SUP-ITM-10133235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1886.50","1414.87","AETNA [1001]","HB AMC AETNA HMO","1316.78","69.8","","1421.24","264.50","4933.46","29","985.88","1541.65","percent of total billed charges",""
"GRAFT TISSUE SM HUMAN VIABLE CELL TRINITY ELITE IMPLANTABLE","SUP-ITM-10133235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1886.50","1414.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1516.75","80.4","","1022.97","1022.97","3607.50","1 through 10","985.88","1541.65","percent of total billed charges",""
"GRAFT TISSUE SM HUMAN VIABLE CELL TRINITY ELITE IMPLANTABLE","SUP-ITM-10133235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1886.50","1414.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1541.65","81.72","","3010.54","693.88","5019.88","35","985.88","1541.65","percent of total billed charges",""
"GRAFT VASCULAR 111X22 XSEC 18FR ZENITH FLEX AAA POLYESTER FABRIC SS BIFURCATED MAIN BODY","SUP-ITM-10061744","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","15356.25","65","","6652.80","6652.80","6652.80","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT VASCULAR 111X22 XSEC 18FR ZENITH FLEX AAA POLYESTER FABRIC SS BIFURCATED MAIN BODY","SUP-ITM-10061744","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18781.88","79.5","","2612.61","795.38","2612.61","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT VASCULAR 111X22 XSEC 18FR ZENITH FLEX AAA POLYESTER FABRIC SS BIFURCATED MAIN BODY","SUP-ITM-10061744","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12592.13","53.3","","1101.80","1101.80","1101.80","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT VASCULAR 111X22 XSEC 18FR ZENITH FLEX AAA POLYESTER FABRIC SS BIFURCATED MAIN BODY","SUP-ITM-10061744","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","15356.25","65","","1820.00","910.00","1820.00","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT VASCULAR 111X22 XSEC 18FR ZENITH FLEX AAA POLYESTER FABRIC SS BIFURCATED MAIN BODY","SUP-ITM-10061744","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8623.13","36.5","","1257.80","693.44","2424.50","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT VASCULAR 111X22 XSEC 18FR ZENITH FLEX AAA POLYESTER FABRIC SS BIFURCATED MAIN BODY","SUP-ITM-10061744","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9048.38","38.3","","1950.11","547.40","2346.00","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT VASCULAR 111X22 XSEC 18FR ZENITH FLEX AAA POLYESTER FABRIC SS BIFURCATED MAIN BODY","SUP-ITM-10061744","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10135.13","42.9","","5096.18","5096.18","5096.18","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT VASCULAR 111X22 XSEC 18FR ZENITH FLEX AAA POLYESTER FABRIC SS BIFURCATED MAIN BODY","SUP-ITM-10061744","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","WELLPOINT [1015]","HB AMC WELLPOINT","17430.53","73.78","","1172.59","1172.59","4829.94","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT VASCULAR 111X22 XSEC 18FR ZENITH FLEX AAA POLYESTER FABRIC SS BIFURCATED MAIN BODY","SUP-ITM-10061744","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","23625.00","17718.75","AETNA [1001]","HB AMC AETNA HMO","16490.25","69.8","","1806.84","947.80","5091.72","1 through 10","12346.43","19306.35","percent of total billed charges",""
"GRAFT VASCULAR 111X22 XSEC 18FR ZENITH FLEX AAA POLYESTER FABRIC SS BIFURCATED MAIN BODY","SUP-ITM-10061744","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","23625.00","17718.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","19306.35","81.72","","1259.05","615.58","4586.56","1 through 10","12346.43","19306.35","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","4126.50","3094.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2888.55","70","","134.04","134.04","134.04","1 through 10","1279.22","3280.57","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","4126.50","3094.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3280.57","79.5","","948.87","198.19","1805.30","1 through 10","1279.22","3280.57","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","4126.50","3094.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2199.42","53.3","","462.00","170.45","3253.37","1 through 10","1279.22","3280.57","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","4126.50","3094.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1506.17","36.5","","245.50","107.19","1371.45","1 through 10","1279.22","3280.57","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","4126.50","3094.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1580.45","38.3","","200.79","72.79","355.81","22","1279.22","3280.57","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","4126.50","3094.87","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3177.41","77","","477.18","477.18","477.18","1 through 10","1279.22","3280.57","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","4126.50","3094.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1770.27","42.9","","1045.91","1045.91","1045.91","1 through 10","1279.22","3280.57","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","4126.50","3094.87","WELLPOINT [1015]","HB AMC WELLPOINT","3044.53","73.78","","1726.50","1726.50","1726.50","1 through 10","1279.22","3280.57","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4126.50","3094.87","AETNA [1001]","HB AMC AETNA HMO","2880.30","69.8","","915.80","263.76","2881.00","1 through 10","2156.51","3372.18","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4126.50","3094.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3372.18","81.72","","1531.57","410.52","8841.36","1 through 10","2156.51","3372.18","percent of total billed charges",""
"GRAFT VASCULAR 21MM CRYOVALVE ALLO AORTIC CONDUIT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10019578","CDM","C1889","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20868.75","79.5","","1309.77","674.56","6049.93","26","8137.5","20868.75","percent of total billed charges",""
"GRAFT VASCULAR 21MM CRYOVALVE ALLO AORTIC CONDUIT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10019578","CDM","C1889","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13991.25","53.3","","1901.83","1901.83","2962.25","1 through 10","8137.5","20868.75","percent of total billed charges",""
"GRAFT VASCULAR 21MM CRYOVALVE ALLO AORTIC CONDUIT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10019578","CDM","C1889","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9581.25","36.5","","1620.31","1620.31","19908.88","1 through 10","8137.5","20868.75","percent of total billed charges",""
"GRAFT VASCULAR 21MM CRYOVALVE ALLO AORTIC CONDUIT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10019578","CDM","C1889","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10053.75","38.3","","352.91","352.91","2046.30","1 through 10","8137.5","20868.75","percent of total billed charges",""
"GRAFT VASCULAR 21MM CRYOVALVE ALLO AORTIC CONDUIT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10019578","CDM","C1889","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11261.25","42.9","","9668.75","9668.75","9668.75","1 through 10","8137.5","20868.75","percent of total billed charges",""
"GRAFT VASCULAR 21MM CRYOVALVE ALLO AORTIC CONDUIT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10019578","CDM","C1889","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","WELLPOINT [1015]","HB AMC WELLPOINT","19367.25","73.78","","699.88","384.10","3443.31","33","8137.5","20868.75","percent of total billed charges",""
"GRAFT VASCULAR 21MM CRYOVALVE ALLO AORTIC CONDUIT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10019578","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","26250.00","19687.50","AETNA [1001]","HB AMC AETNA HMO","18322.50","69.8","","1421.24","264.50","4933.46","29","13718.25","21451.5","percent of total billed charges",""
"GRAFT VASCULAR 21MM CRYOVALVE ALLO AORTIC CONDUIT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10019578","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","26250.00","19687.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","21105.00","80.4","","1022.97","1022.97","3607.50","1 through 10","13718.25","21451.5","percent of total billed charges",""
"GRAFT VASCULAR 21MM CRYOVALVE ALLO AORTIC CONDUIT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10019578","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","26250.00","19687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21451.50","81.72","","3010.54","693.88","5019.88","35","13718.25","21451.5","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOARTERY ALLO ARTERY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10115323","CDM","C1874","HCPCS","0278","RC","","","","both","","","13050.00","9787.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8482.50","65","","6652.80","6652.80","6652.80","1 through 10","4045.5","10374.75","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOARTERY ALLO ARTERY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10115323","CDM","C1874","HCPCS","0278","RC","","","","both","","","13050.00","9787.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10374.75","79.5","","2612.61","795.38","2612.61","1 through 10","4045.5","10374.75","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOARTERY ALLO ARTERY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10115323","CDM","C1874","HCPCS","0278","RC","","","","both","","","13050.00","9787.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6955.65","53.3","","1101.80","1101.80","1101.80","1 through 10","4045.5","10374.75","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOARTERY ALLO ARTERY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10115323","CDM","C1874","HCPCS","0278","RC","","","","both","","","13050.00","9787.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8482.50","65","","1820.00","910.00","1820.00","1 through 10","4045.5","10374.75","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOARTERY ALLO ARTERY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10115323","CDM","C1874","HCPCS","0278","RC","","","","both","","","13050.00","9787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4763.25","36.5","","1257.80","693.44","2424.50","1 through 10","4045.5","10374.75","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOARTERY ALLO ARTERY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10115323","CDM","C1874","HCPCS","0278","RC","","","","both","","","13050.00","9787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4998.15","38.3","","1950.11","547.40","2346.00","1 through 10","4045.5","10374.75","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOARTERY ALLO ARTERY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10115323","CDM","C1874","HCPCS","0278","RC","","","","both","","","13050.00","9787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5598.45","42.9","","5096.18","5096.18","5096.18","1 through 10","4045.5","10374.75","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOARTERY ALLO ARTERY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10115323","CDM","C1874","HCPCS","0278","RC","","","","both","","","13050.00","9787.50","WELLPOINT [1015]","HB AMC WELLPOINT","9628.29","73.78","","1172.59","1172.59","4829.94","1 through 10","4045.5","10374.75","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOARTERY ALLO ARTERY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10115323","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13050.00","9787.50","AETNA [1001]","HB AMC AETNA HMO","9108.90","69.8","","1806.84","947.80","5091.72","1 through 10","6819.93","10664.46","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOARTERY ALLO ARTERY - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10115323","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13050.00","9787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10664.46","81.72","","1259.05","615.58","4586.56","1 through 10","6819.93","10664.46","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOVEIN ALLO FEMORAL VEIN","SUP-ITM-10086435","CDM","C1889","HCPCS","0278","RC","","","","both","","","16712.50","12534.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13286.44","79.5","","1309.77","674.56","6049.93","26","5180.88","13286.44","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOVEIN ALLO FEMORAL VEIN","SUP-ITM-10086435","CDM","C1889","HCPCS","0278","RC","","","","both","","","16712.50","12534.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8907.76","53.3","","1901.83","1901.83","2962.25","1 through 10","5180.88","13286.44","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOVEIN ALLO FEMORAL VEIN","SUP-ITM-10086435","CDM","C1889","HCPCS","0278","RC","","","","both","","","16712.50","12534.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6100.06","36.5","","1620.31","1620.31","19908.88","1 through 10","5180.88","13286.44","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOVEIN ALLO FEMORAL VEIN","SUP-ITM-10086435","CDM","C1889","HCPCS","0278","RC","","","","both","","","16712.50","12534.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6400.89","38.3","","352.91","352.91","2046.30","1 through 10","5180.88","13286.44","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOVEIN ALLO FEMORAL VEIN","SUP-ITM-10086435","CDM","C1889","HCPCS","0278","RC","","","","both","","","16712.50","12534.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7169.66","42.9","","9668.75","9668.75","9668.75","1 through 10","5180.88","13286.44","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOVEIN ALLO FEMORAL VEIN","SUP-ITM-10086435","CDM","C1889","HCPCS","0278","RC","","","","both","","","16712.50","12534.37","WELLPOINT [1015]","HB AMC WELLPOINT","12330.48","73.78","","699.88","384.10","3443.31","33","5180.88","13286.44","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOVEIN ALLO FEMORAL VEIN","SUP-ITM-10086435","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","16712.50","12534.37","AETNA [1001]","HB AMC AETNA HMO","11665.33","69.8","","1421.24","264.50","4933.46","29","8733.95","13657.46","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOVEIN ALLO FEMORAL VEIN","SUP-ITM-10086435","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","16712.50","12534.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","13436.85","80.4","","1022.97","1022.97","3607.50","1 through 10","8733.95","13657.46","percent of total billed charges",""
"GRAFT VASCULAR 30CM CRYOVEIN ALLO FEMORAL VEIN","SUP-ITM-10086435","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","16712.50","12534.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13657.46","81.72","","3010.54","693.88","5019.88","35","8733.95","13657.46","percent of total billed charges",""
"GRAFT VASCULAR 50 TO 59CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134474","CDM","C1889","HCPCS","0278","RC","","","","both","","","19962.50","14971.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15870.19","79.5","","1309.77","674.56","6049.93","26","6188.38","15870.19","percent of total billed charges",""
"GRAFT VASCULAR 50 TO 59CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134474","CDM","C1889","HCPCS","0278","RC","","","","both","","","19962.50","14971.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10640.01","53.3","","1901.83","1901.83","2962.25","1 through 10","6188.38","15870.19","percent of total billed charges",""
"GRAFT VASCULAR 50 TO 59CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134474","CDM","C1889","HCPCS","0278","RC","","","","both","","","19962.50","14971.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7286.31","36.5","","1620.31","1620.31","19908.88","1 through 10","6188.38","15870.19","percent of total billed charges",""
"GRAFT VASCULAR 50 TO 59CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134474","CDM","C1889","HCPCS","0278","RC","","","","both","","","19962.50","14971.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7645.64","38.3","","352.91","352.91","2046.30","1 through 10","6188.38","15870.19","percent of total billed charges",""
"GRAFT VASCULAR 50 TO 59CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134474","CDM","C1889","HCPCS","0278","RC","","","","both","","","19962.50","14971.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8563.91","42.9","","9668.75","9668.75","9668.75","1 through 10","6188.38","15870.19","percent of total billed charges",""
"GRAFT VASCULAR 50 TO 59CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134474","CDM","C1889","HCPCS","0278","RC","","","","both","","","19962.50","14971.87","WELLPOINT [1015]","HB AMC WELLPOINT","14728.33","73.78","","699.88","384.10","3443.31","33","6188.38","15870.19","percent of total billed charges",""
"GRAFT VASCULAR 50 TO 59CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134474","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19962.50","14971.87","AETNA [1001]","HB AMC AETNA HMO","13933.83","69.8","","1421.24","264.50","4933.46","29","10432.4","16313.36","percent of total billed charges",""
"GRAFT VASCULAR 50 TO 59CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134474","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19962.50","14971.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","16049.85","80.4","","1022.97","1022.97","3607.50","1 through 10","10432.4","16313.36","percent of total billed charges",""
"GRAFT VASCULAR 50 TO 59CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134474","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19962.50","14971.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16313.36","81.72","","3010.54","693.88","5019.88","35","10432.4","16313.36","percent of total billed charges",""
"GRAFT VASCULAR 6-15X10-30MM CRYOVEIN ALLOGRAFT FEMORAL VEIN","SUP-ITM-10026304","CDM","C1889","HCPCS","0278","RC","","","","both","","","15462.50","11596.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12292.69","79.5","","1309.77","674.56","6049.93","26","4793.38","12292.69","percent of total billed charges",""
"GRAFT VASCULAR 6-15X10-30MM CRYOVEIN ALLOGRAFT FEMORAL VEIN","SUP-ITM-10026304","CDM","C1889","HCPCS","0278","RC","","","","both","","","15462.50","11596.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8241.51","53.3","","1901.83","1901.83","2962.25","1 through 10","4793.38","12292.69","percent of total billed charges",""
"GRAFT VASCULAR 6-15X10-30MM CRYOVEIN ALLOGRAFT FEMORAL VEIN","SUP-ITM-10026304","CDM","C1889","HCPCS","0278","RC","","","","both","","","15462.50","11596.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5643.81","36.5","","1620.31","1620.31","19908.88","1 through 10","4793.38","12292.69","percent of total billed charges",""
"GRAFT VASCULAR 6-15X10-30MM CRYOVEIN ALLOGRAFT FEMORAL VEIN","SUP-ITM-10026304","CDM","C1889","HCPCS","0278","RC","","","","both","","","15462.50","11596.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5922.14","38.3","","352.91","352.91","2046.30","1 through 10","4793.38","12292.69","percent of total billed charges",""
"GRAFT VASCULAR 6-15X10-30MM CRYOVEIN ALLOGRAFT FEMORAL VEIN","SUP-ITM-10026304","CDM","C1889","HCPCS","0278","RC","","","","both","","","15462.50","11596.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6633.41","42.9","","9668.75","9668.75","9668.75","1 through 10","4793.38","12292.69","percent of total billed charges",""
"GRAFT VASCULAR 6-15X10-30MM CRYOVEIN ALLOGRAFT FEMORAL VEIN","SUP-ITM-10026304","CDM","C1889","HCPCS","0278","RC","","","","both","","","15462.50","11596.87","WELLPOINT [1015]","HB AMC WELLPOINT","11408.23","73.78","","699.88","384.10","3443.31","33","4793.38","12292.69","percent of total billed charges",""
"GRAFT VASCULAR 6-15X10-30MM CRYOVEIN ALLOGRAFT FEMORAL VEIN","SUP-ITM-10026304","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","15462.50","11596.87","AETNA [1001]","HB AMC AETNA HMO","10792.83","69.8","","1421.24","264.50","4933.46","29","8080.7","12635.96","percent of total billed charges",""
"GRAFT VASCULAR 6-15X10-30MM CRYOVEIN ALLOGRAFT FEMORAL VEIN","SUP-ITM-10026304","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","15462.50","11596.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","12431.85","80.4","","1022.97","1022.97","3607.50","1 through 10","8080.7","12635.96","percent of total billed charges",""
"GRAFT VASCULAR 6-15X10-30MM CRYOVEIN ALLOGRAFT FEMORAL VEIN","SUP-ITM-10026304","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","15462.50","11596.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12635.96","81.72","","3010.54","693.88","5019.88","35","8080.7","12635.96","percent of total billed charges",""
"GRAFT VASCULAR 6X8CM XENOSURE PATCH BIOLOGIC","SUP-ITM-10092641","CDM","C1781","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","992.25","70","","134.04","134.04","134.04","1 through 10","439.43","1126.91","percent of total billed charges",""
"GRAFT VASCULAR 6X8CM XENOSURE PATCH BIOLOGIC","SUP-ITM-10092641","CDM","C1781","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1126.91","79.5","","948.87","198.19","1805.30","1 through 10","439.43","1126.91","percent of total billed charges",""
"GRAFT VASCULAR 6X8CM XENOSURE PATCH BIOLOGIC","SUP-ITM-10092641","CDM","C1781","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","755.53","53.3","","462.00","170.45","3253.37","1 through 10","439.43","1126.91","percent of total billed charges",""
"GRAFT VASCULAR 6X8CM XENOSURE PATCH BIOLOGIC","SUP-ITM-10092641","CDM","C1781","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","517.39","36.5","","245.50","107.19","1371.45","1 through 10","439.43","1126.91","percent of total billed charges",""
"GRAFT VASCULAR 6X8CM XENOSURE PATCH BIOLOGIC","SUP-ITM-10092641","CDM","C1781","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","542.90","38.3","","200.79","72.79","355.81","22","439.43","1126.91","percent of total billed charges",""
"GRAFT VASCULAR 6X8CM XENOSURE PATCH BIOLOGIC","SUP-ITM-10092641","CDM","C1781","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1091.48","77","","477.18","477.18","477.18","1 through 10","439.43","1126.91","percent of total billed charges",""
"GRAFT VASCULAR 6X8CM XENOSURE PATCH BIOLOGIC","SUP-ITM-10092641","CDM","C1781","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","608.11","42.9","","1045.91","1045.91","1045.91","1 through 10","439.43","1126.91","percent of total billed charges",""
"GRAFT VASCULAR 6X8CM XENOSURE PATCH BIOLOGIC","SUP-ITM-10092641","CDM","C1781","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","WELLPOINT [1015]","HB AMC WELLPOINT","1045.83","73.78","","1726.50","1726.50","1726.50","1 through 10","439.43","1126.91","percent of total billed charges",""
"GRAFT VASCULAR 6X8CM XENOSURE PATCH BIOLOGIC","SUP-ITM-10092641","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","AETNA [1001]","HB AMC AETNA HMO","989.42","69.8","","915.80","263.76","2881.00","1 through 10","740.79","1158.38","percent of total billed charges",""
"GRAFT VASCULAR 6X8CM XENOSURE PATCH BIOLOGIC","SUP-ITM-10092641","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1158.38","81.72","","1531.57","410.52","8841.36","1 through 10","740.79","1158.38","percent of total billed charges",""
"GRAFT VASCULAR 7.0X15CM PATCH ECM PERICARDIAL CLOSURE 4 PLY","SUP-ITM-10049118","CDM","C1763","HCPCS","0278","RC","","","","both","","","4933.50","3700.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3206.78","65","","2028.23","1653.70","2028.23","1 through 10","1529.39","3922.13","percent of total billed charges",""
"GRAFT VASCULAR 7.0X15CM PATCH ECM PERICARDIAL CLOSURE 4 PLY","SUP-ITM-10049118","CDM","C1763","HCPCS","0278","RC","","","","both","","","4933.50","3700.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1800.73","36.5","","1163.89","1163.89","1163.89","1 through 10","1529.39","3922.13","percent of total billed charges",""
"GRAFT VASCULAR 7.0X15CM PATCH ECM PERICARDIAL CLOSURE 4 PLY","SUP-ITM-10049118","CDM","C1763","HCPCS","0278","RC","","","","both","","","4933.50","3700.12","WELLPOINT [1015]","HB AMC WELLPOINT","3639.94","73.78","","4280.87","4280.87","4280.87","1 through 10","1529.39","3922.13","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","both","","","22462.50","16846.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","17857.69","79.5","","1309.77","674.56","6049.93","26","6963.38","17857.69","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","both","","","22462.50","16846.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11972.51","53.3","","1901.83","1901.83","2962.25","1 through 10","6963.38","17857.69","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","both","","","22462.50","16846.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8198.81","36.5","","1620.31","1620.31","19908.88","1 through 10","6963.38","17857.69","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","both","","","22462.50","16846.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8603.14","38.3","","352.91","352.91","2046.30","1 through 10","6963.38","17857.69","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","both","","","22462.50","16846.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9636.41","42.9","","9668.75","9668.75","9668.75","1 through 10","6963.38","17857.69","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","both","","","22462.50","16846.87","WELLPOINT [1015]","HB AMC WELLPOINT","16572.83","73.78","","699.88","384.10","3443.31","33","6963.38","17857.69","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","22462.50","16846.87","AETNA [1001]","HB AMC AETNA HMO","15678.83","69.8","","1421.24","264.50","4933.46","29","11738.9","18356.36","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","22462.50","16846.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","18059.85","80.4","","1022.97","1022.97","3607.50","1 through 10","11738.9","18356.36","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","22462.50","16846.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18356.36","81.72","","3010.54","693.88","5019.88","35","11738.9","18356.36","percent of total billed charges",""
"GRAFT VASCULAR 8 TO 15MMX6 11CM ILIAC 4 5 CRYOARTERY ALLO ARTERY AOTOILIAC BIFURCATED AORTA","SUP-ITM-10072418","CDM","C1874","HCPCS","0278","RC","","","","both","","","56987.50","42740.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","37041.88","65","","6652.80","6652.80","6652.80","1 through 10","17666.13","45305.06","percent of total billed charges",""
"GRAFT VASCULAR 8 TO 15MMX6 11CM ILIAC 4 5 CRYOARTERY ALLO ARTERY AOTOILIAC BIFURCATED AORTA","SUP-ITM-10072418","CDM","C1874","HCPCS","0278","RC","","","","both","","","56987.50","42740.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","45305.06","79.5","","2612.61","795.38","2612.61","1 through 10","17666.13","45305.06","percent of total billed charges",""
"GRAFT VASCULAR 8 TO 15MMX6 11CM ILIAC 4 5 CRYOARTERY ALLO ARTERY AOTOILIAC BIFURCATED AORTA","SUP-ITM-10072418","CDM","C1874","HCPCS","0278","RC","","","","both","","","56987.50","42740.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","30374.34","53.3","","1101.80","1101.80","1101.80","1 through 10","17666.13","45305.06","percent of total billed charges",""
"GRAFT VASCULAR 8 TO 15MMX6 11CM ILIAC 4 5 CRYOARTERY ALLO ARTERY AOTOILIAC BIFURCATED AORTA","SUP-ITM-10072418","CDM","C1874","HCPCS","0278","RC","","","","both","","","56987.50","42740.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","37041.88","65","","1820.00","910.00","1820.00","1 through 10","17666.13","45305.06","percent of total billed charges",""
"GRAFT VASCULAR 8 TO 15MMX6 11CM ILIAC 4 5 CRYOARTERY ALLO ARTERY AOTOILIAC BIFURCATED AORTA","SUP-ITM-10072418","CDM","C1874","HCPCS","0278","RC","","","","both","","","56987.50","42740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20800.44","36.5","","1257.80","693.44","2424.50","1 through 10","17666.13","45305.06","percent of total billed charges",""
"GRAFT VASCULAR 8 TO 15MMX6 11CM ILIAC 4 5 CRYOARTERY ALLO ARTERY AOTOILIAC BIFURCATED AORTA","SUP-ITM-10072418","CDM","C1874","HCPCS","0278","RC","","","","both","","","56987.50","42740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21826.21","38.3","","1950.11","547.40","2346.00","1 through 10","17666.13","45305.06","percent of total billed charges",""
"GRAFT VASCULAR 8 TO 15MMX6 11CM ILIAC 4 5 CRYOARTERY ALLO ARTERY AOTOILIAC BIFURCATED AORTA","SUP-ITM-10072418","CDM","C1874","HCPCS","0278","RC","","","","both","","","56987.50","42740.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24447.64","42.9","","5096.18","5096.18","5096.18","1 through 10","17666.13","45305.06","percent of total billed charges",""
"GRAFT VASCULAR 8 TO 15MMX6 11CM ILIAC 4 5 CRYOARTERY ALLO ARTERY AOTOILIAC BIFURCATED AORTA","SUP-ITM-10072418","CDM","C1874","HCPCS","0278","RC","","","","both","","","56987.50","42740.62","WELLPOINT [1015]","HB AMC WELLPOINT","42045.38","73.78","","1172.59","1172.59","4829.94","1 through 10","17666.13","45305.06","percent of total billed charges",""
"GRAFT VASCULAR 8 TO 15MMX6 11CM ILIAC 4 5 CRYOARTERY ALLO ARTERY AOTOILIAC BIFURCATED AORTA","SUP-ITM-10072418","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","56987.50","42740.62","AETNA [1001]","HB AMC AETNA HMO","39777.28","69.8","","1806.84","947.80","5091.72","1 through 10","29781.67","46570.19","percent of total billed charges",""
"GRAFT VASCULAR 8 TO 15MMX6 11CM ILIAC 4 5 CRYOARTERY ALLO ARTERY AOTOILIAC BIFURCATED AORTA","SUP-ITM-10072418","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","56987.50","42740.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","46570.19","81.72","","1259.05","615.58","4586.56","1 through 10","29781.67","46570.19","percent of total billed charges",""
"GRAFT VASCULAR 80CM CRYOVEIN ALLOGRAFT SAPHENOUS VEIN","SUP-ITM-10086434","CDM","C1889","HCPCS","0278","RC","","","","both","","","24462.50","18346.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","19447.69","79.5","","1309.77","674.56","6049.93","26","7583.38","19447.69","percent of total billed charges",""
"GRAFT VASCULAR 80CM CRYOVEIN ALLOGRAFT SAPHENOUS VEIN","SUP-ITM-10086434","CDM","C1889","HCPCS","0278","RC","","","","both","","","24462.50","18346.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13038.51","53.3","","1901.83","1901.83","2962.25","1 through 10","7583.38","19447.69","percent of total billed charges",""
"GRAFT VASCULAR 80CM CRYOVEIN ALLOGRAFT SAPHENOUS VEIN","SUP-ITM-10086434","CDM","C1889","HCPCS","0278","RC","","","","both","","","24462.50","18346.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8928.81","36.5","","1620.31","1620.31","19908.88","1 through 10","7583.38","19447.69","percent of total billed charges",""
"GRAFT VASCULAR 80CM CRYOVEIN ALLOGRAFT SAPHENOUS VEIN","SUP-ITM-10086434","CDM","C1889","HCPCS","0278","RC","","","","both","","","24462.50","18346.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9369.14","38.3","","352.91","352.91","2046.30","1 through 10","7583.38","19447.69","percent of total billed charges",""
"GRAFT VASCULAR 80CM CRYOVEIN ALLOGRAFT SAPHENOUS VEIN","SUP-ITM-10086434","CDM","C1889","HCPCS","0278","RC","","","","both","","","24462.50","18346.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10494.41","42.9","","9668.75","9668.75","9668.75","1 through 10","7583.38","19447.69","percent of total billed charges",""
"GRAFT VASCULAR 80CM CRYOVEIN ALLOGRAFT SAPHENOUS VEIN","SUP-ITM-10086434","CDM","C1889","HCPCS","0278","RC","","","","both","","","24462.50","18346.87","WELLPOINT [1015]","HB AMC WELLPOINT","18048.43","73.78","","699.88","384.10","3443.31","33","7583.38","19447.69","percent of total billed charges",""
"GRAFT VASCULAR 80CM CRYOVEIN ALLOGRAFT SAPHENOUS VEIN","SUP-ITM-10086434","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","24462.50","18346.87","AETNA [1001]","HB AMC AETNA HMO","17074.83","69.8","","1421.24","264.50","4933.46","29","12784.1","19990.76","percent of total billed charges",""
"GRAFT VASCULAR 80CM CRYOVEIN ALLOGRAFT SAPHENOUS VEIN","SUP-ITM-10086434","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","24462.50","18346.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","19667.85","80.4","","1022.97","1022.97","3607.50","1 through 10","12784.1","19990.76","percent of total billed charges",""
"GRAFT VASCULAR 80CM CRYOVEIN ALLOGRAFT SAPHENOUS VEIN","SUP-ITM-10086434","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","24462.50","18346.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","19990.76","81.72","","3010.54","693.88","5019.88","35","12784.1","19990.76","percent of total billed charges",""
"GRAFT VASCULAR L 20 TO 80CM 3 6MM SAPHENOUS VEIN CRYOVEIN IMPLANTABLE BYPASS AV ACCESS","SUP-ITM-10134473","CDM","C1889","HCPCS","0278","RC","","","","both","","","18712.50","14034.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","14876.44","79.5","","1309.77","674.56","6049.93","26","5800.88","14876.44","percent of total billed charges",""
"GRAFT VASCULAR L 20 TO 80CM 3 6MM SAPHENOUS VEIN CRYOVEIN IMPLANTABLE BYPASS AV ACCESS","SUP-ITM-10134473","CDM","C1889","HCPCS","0278","RC","","","","both","","","18712.50","14034.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9973.76","53.3","","1901.83","1901.83","2962.25","1 through 10","5800.88","14876.44","percent of total billed charges",""
"GRAFT VASCULAR L 20 TO 80CM 3 6MM SAPHENOUS VEIN CRYOVEIN IMPLANTABLE BYPASS AV ACCESS","SUP-ITM-10134473","CDM","C1889","HCPCS","0278","RC","","","","both","","","18712.50","14034.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6830.06","36.5","","1620.31","1620.31","19908.88","1 through 10","5800.88","14876.44","percent of total billed charges",""
"GRAFT VASCULAR L 20 TO 80CM 3 6MM SAPHENOUS VEIN CRYOVEIN IMPLANTABLE BYPASS AV ACCESS","SUP-ITM-10134473","CDM","C1889","HCPCS","0278","RC","","","","both","","","18712.50","14034.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7166.89","38.3","","352.91","352.91","2046.30","1 through 10","5800.88","14876.44","percent of total billed charges",""
"GRAFT VASCULAR L 20 TO 80CM 3 6MM SAPHENOUS VEIN CRYOVEIN IMPLANTABLE BYPASS AV ACCESS","SUP-ITM-10134473","CDM","C1889","HCPCS","0278","RC","","","","both","","","18712.50","14034.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8027.66","42.9","","9668.75","9668.75","9668.75","1 through 10","5800.88","14876.44","percent of total billed charges",""
"GRAFT VASCULAR L 20 TO 80CM 3 6MM SAPHENOUS VEIN CRYOVEIN IMPLANTABLE BYPASS AV ACCESS","SUP-ITM-10134473","CDM","C1889","HCPCS","0278","RC","","","","both","","","18712.50","14034.37","WELLPOINT [1015]","HB AMC WELLPOINT","13806.08","73.78","","699.88","384.10","3443.31","33","5800.88","14876.44","percent of total billed charges",""
"GRAFT VASCULAR L 20 TO 80CM 3 6MM SAPHENOUS VEIN CRYOVEIN IMPLANTABLE BYPASS AV ACCESS","SUP-ITM-10134473","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18712.50","14034.37","AETNA [1001]","HB AMC AETNA HMO","13061.33","69.8","","1421.24","264.50","4933.46","29","9779.15","15291.86","percent of total billed charges",""
"GRAFT VASCULAR L 20 TO 80CM 3 6MM SAPHENOUS VEIN CRYOVEIN IMPLANTABLE BYPASS AV ACCESS","SUP-ITM-10134473","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18712.50","14034.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","15044.85","80.4","","1022.97","1022.97","3607.50","1 through 10","9779.15","15291.86","percent of total billed charges",""
"GRAFT VASCULAR L 20 TO 80CM 3 6MM SAPHENOUS VEIN CRYOVEIN IMPLANTABLE BYPASS AV ACCESS","SUP-ITM-10134473","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18712.50","14034.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15291.86","81.72","","3010.54","693.88","5019.88","35","9779.15","15291.86","percent of total billed charges",""
"GRAFT VASCULAR L 60CM 3 6MM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134475","CDM","C1889","HCPCS","0278","RC","","","","both","","","21212.50","15909.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","16863.94","79.5","","1309.77","674.56","6049.93","26","6575.88","16863.94","percent of total billed charges",""
"GRAFT VASCULAR L 60CM 3 6MM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134475","CDM","C1889","HCPCS","0278","RC","","","","both","","","21212.50","15909.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11306.26","53.3","","1901.83","1901.83","2962.25","1 through 10","6575.88","16863.94","percent of total billed charges",""
"GRAFT VASCULAR L 60CM 3 6MM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134475","CDM","C1889","HCPCS","0278","RC","","","","both","","","21212.50","15909.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7742.56","36.5","","1620.31","1620.31","19908.88","1 through 10","6575.88","16863.94","percent of total billed charges",""
"GRAFT VASCULAR L 60CM 3 6MM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134475","CDM","C1889","HCPCS","0278","RC","","","","both","","","21212.50","15909.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8124.39","38.3","","352.91","352.91","2046.30","1 through 10","6575.88","16863.94","percent of total billed charges",""
"GRAFT VASCULAR L 60CM 3 6MM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134475","CDM","C1889","HCPCS","0278","RC","","","","both","","","21212.50","15909.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9100.16","42.9","","9668.75","9668.75","9668.75","1 through 10","6575.88","16863.94","percent of total billed charges",""
"GRAFT VASCULAR L 60CM 3 6MM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134475","CDM","C1889","HCPCS","0278","RC","","","","both","","","21212.50","15909.37","WELLPOINT [1015]","HB AMC WELLPOINT","15650.58","73.78","","699.88","384.10","3443.31","33","6575.88","16863.94","percent of total billed charges",""
"GRAFT VASCULAR L 60CM 3 6MM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134475","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","21212.50","15909.37","AETNA [1001]","HB AMC AETNA HMO","14806.33","69.8","","1421.24","264.50","4933.46","29","11085.65","17334.86","percent of total billed charges",""
"GRAFT VASCULAR L 60CM 3 6MM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134475","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","21212.50","15909.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","17054.85","80.4","","1022.97","1022.97","3607.50","1 through 10","11085.65","17334.86","percent of total billed charges",""
"GRAFT VASCULAR L 60CM 3 6MM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134475","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","21212.50","15909.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","17334.86","81.72","","3010.54","693.88","5019.88","35","11085.65","17334.86","percent of total billed charges",""
"GRAFT WHOLE 2.6X2.3 6.6MM CONDYLE LT FEMORAL FRESH ALLO","SUP-ITM-10138481","CDM","C1889","HCPCS","0278","RC","","","","both","","","53375.00","40031.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","42433.13","79.5","","1309.77","674.56","6049.93","26","16546.25","42433.13","percent of total billed charges",""
"GRAFT WHOLE 2.6X2.3 6.6MM CONDYLE LT FEMORAL FRESH ALLO","SUP-ITM-10138481","CDM","C1889","HCPCS","0278","RC","","","","both","","","53375.00","40031.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","28448.88","53.3","","1901.83","1901.83","2962.25","1 through 10","16546.25","42433.13","percent of total billed charges",""
"GRAFT WHOLE 2.6X2.3 6.6MM CONDYLE LT FEMORAL FRESH ALLO","SUP-ITM-10138481","CDM","C1889","HCPCS","0278","RC","","","","both","","","53375.00","40031.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19481.88","36.5","","1620.31","1620.31","19908.88","1 through 10","16546.25","42433.13","percent of total billed charges",""
"GRAFT WHOLE 2.6X2.3 6.6MM CONDYLE LT FEMORAL FRESH ALLO","SUP-ITM-10138481","CDM","C1889","HCPCS","0278","RC","","","","both","","","53375.00","40031.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20442.63","38.3","","352.91","352.91","2046.30","1 through 10","16546.25","42433.13","percent of total billed charges",""
"GRAFT WHOLE 2.6X2.3 6.6MM CONDYLE LT FEMORAL FRESH ALLO","SUP-ITM-10138481","CDM","C1889","HCPCS","0278","RC","","","","both","","","53375.00","40031.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","22897.88","42.9","","9668.75","9668.75","9668.75","1 through 10","16546.25","42433.13","percent of total billed charges",""
"GRAFT WHOLE 2.6X2.3 6.6MM CONDYLE LT FEMORAL FRESH ALLO","SUP-ITM-10138481","CDM","C1889","HCPCS","0278","RC","","","","both","","","53375.00","40031.25","WELLPOINT [1015]","HB AMC WELLPOINT","39380.08","73.78","","699.88","384.10","3443.31","33","16546.25","42433.13","percent of total billed charges",""
"GRAFT WHOLE 2.6X2.3 6.6MM CONDYLE LT FEMORAL FRESH ALLO","SUP-ITM-10138481","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","53375.00","40031.25","AETNA [1001]","HB AMC AETNA HMO","37255.75","69.8","","1421.24","264.50","4933.46","29","27893.78","43618.05","percent of total billed charges",""
"GRAFT WHOLE 2.6X2.3 6.6MM CONDYLE LT FEMORAL FRESH ALLO","SUP-ITM-10138481","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","53375.00","40031.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","42913.50","80.4","","1022.97","1022.97","3607.50","1 through 10","27893.78","43618.05","percent of total billed charges",""
"GRAFT WHOLE 2.6X2.3 6.6MM CONDYLE LT FEMORAL FRESH ALLO","SUP-ITM-10138481","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","53375.00","40031.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","43618.05","81.72","","3010.54","693.88","5019.88","35","27893.78","43618.05","percent of total billed charges",""
"GRAFT ZENITH FLEX 26MM 82MM 18FR/7.1MM AAA BIFURCATED MAIN BODY ENDOVASCULAR","SUP-ITM-10057442","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","15356.25","65","","6652.80","6652.80","6652.80","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ZENITH FLEX 26MM 82MM 18FR/7.1MM AAA BIFURCATED MAIN BODY ENDOVASCULAR","SUP-ITM-10057442","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18781.88","79.5","","2612.61","795.38","2612.61","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ZENITH FLEX 26MM 82MM 18FR/7.1MM AAA BIFURCATED MAIN BODY ENDOVASCULAR","SUP-ITM-10057442","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12592.13","53.3","","1101.80","1101.80","1101.80","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ZENITH FLEX 26MM 82MM 18FR/7.1MM AAA BIFURCATED MAIN BODY ENDOVASCULAR","SUP-ITM-10057442","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","15356.25","65","","1820.00","910.00","1820.00","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ZENITH FLEX 26MM 82MM 18FR/7.1MM AAA BIFURCATED MAIN BODY ENDOVASCULAR","SUP-ITM-10057442","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8623.13","36.5","","1257.80","693.44","2424.50","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ZENITH FLEX 26MM 82MM 18FR/7.1MM AAA BIFURCATED MAIN BODY ENDOVASCULAR","SUP-ITM-10057442","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9048.38","38.3","","1950.11","547.40","2346.00","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ZENITH FLEX 26MM 82MM 18FR/7.1MM AAA BIFURCATED MAIN BODY ENDOVASCULAR","SUP-ITM-10057442","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10135.13","42.9","","5096.18","5096.18","5096.18","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ZENITH FLEX 26MM 82MM 18FR/7.1MM AAA BIFURCATED MAIN BODY ENDOVASCULAR","SUP-ITM-10057442","CDM","C1874","HCPCS","0278","RC","","","","both","","","23625.00","17718.75","WELLPOINT [1015]","HB AMC WELLPOINT","17430.53","73.78","","1172.59","1172.59","4829.94","1 through 10","7323.75","18781.88","percent of total billed charges",""
"GRAFT ZENITH FLEX 26MM 82MM 18FR/7.1MM AAA BIFURCATED MAIN BODY ENDOVASCULAR","SUP-ITM-10057442","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","23625.00","17718.75","AETNA [1001]","HB AMC AETNA HMO","16490.25","69.8","","1806.84","947.80","5091.72","1 through 10","12346.43","19306.35","percent of total billed charges",""
"GRAFT ZENITH FLEX 26MM 82MM 18FR/7.1MM AAA BIFURCATED MAIN BODY ENDOVASCULAR","SUP-ITM-10057442","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","23625.00","17718.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","19306.35","81.72","","1259.05","615.58","4586.56","1 through 10","12346.43","19306.35","percent of total billed charges",""
"Grhpr Gene, Full Gene Analysis","PX-31000689","CDM","81479","CPT","0310","RC","","","","both","","","865.00","648.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","687.68","79.5","","0.65","0.65","0.65","1 through 10","268.15","821.75","percent of total billed charges",""
"Grhpr Gene, Full Gene Analysis","PX-31000689","CDM","81479","CPT","0310","RC","","","","both","","","865.00","648.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","461.05","53.3","","0.79","0.79","0.79","1 through 10","268.15","821.75","percent of total billed charges",""
"Grhpr Gene, Full Gene Analysis","PX-31000689","CDM","81479","CPT","0310","RC","","","","outpatient","","","865.00","648.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","432.50","50","","1.00","1.00","1.00","1 through 10","156.55","713.63","percent of total billed charges",""
"Grhpr Gene, Full Gene Analysis","PX-31000689","CDM","81479","CPT","0310","RC","","","","outpatient","","","865.00","648.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","454.13","52.5","","1.00","0.53","1.00","1 through 10","156.55","713.63","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","800.18","480.96","1887.97","195","1302","3339","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2238.60","53.3","","813.12","216.42","1444.50","81","1302","3339","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1302.00","31","","432.60","432.60","432.60","1 through 10","1302","3339","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","148.37","54.89","631.39","94","1302","3339","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","279.30","91.72","1116.77","266","1302","3339","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","731.00","63.70","731.00","1 through 10","1302","3339","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","384.74","384.74","384.74","1 through 10","1302","3339","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","286.63","119.22","1107.45","105","1302","3339","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","675.31","184.75","1721.50","286","2194.92","3432.24","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1261.44","103.12","1514.10","21","2194.92","3432.24","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3376.80","80.4","","1365.00","1365.00","1365.00","1 through 10","2194.92","3432.24","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3432.24","81.72","","5157.68","5157.68","5157.68","1 through 10","2194.92","3432.24","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","431.26","71.26","1459.57","88","2194.92","3432.24","percent of total billed charges",""
"GRIP TROCHANTER 125MM ACCORD TI 5 CABLE STANDARD","SUP-ITM-10026381","CDM","C1713","HCPCS","0278","RC","","","","both","","","1046.50","784.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","831.97","79.5","","800.18","480.96","1887.97","195","324.42","831.97","percent of total billed charges",""
"GRIP TROCHANTER 125MM ACCORD TI 5 CABLE STANDARD","SUP-ITM-10026381","CDM","C1713","HCPCS","0278","RC","","","","both","","","1046.50","784.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","557.78","53.3","","813.12","216.42","1444.50","81","324.42","831.97","percent of total billed charges",""
"GRIP TROCHANTER 125MM ACCORD TI 5 CABLE STANDARD","SUP-ITM-10026381","CDM","C1713","HCPCS","0278","RC","","","","both","","","1046.50","784.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","324.42","31","","432.60","432.60","432.60","1 through 10","324.42","831.97","percent of total billed charges",""
"GRIP TROCHANTER 125MM ACCORD TI 5 CABLE STANDARD","SUP-ITM-10026381","CDM","C1713","HCPCS","0278","RC","","","","both","","","1046.50","784.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","381.97","36.5","","148.37","54.89","631.39","94","324.42","831.97","percent of total billed charges",""
"GRIP TROCHANTER 125MM ACCORD TI 5 CABLE STANDARD","SUP-ITM-10026381","CDM","C1713","HCPCS","0278","RC","","","","both","","","1046.50","784.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","400.81","38.3","","279.30","91.72","1116.77","266","324.42","831.97","percent of total billed charges",""
"GRIP TROCHANTER 125MM ACCORD TI 5 CABLE STANDARD","SUP-ITM-10026381","CDM","C1713","HCPCS","0278","RC","","","","both","","","1046.50","784.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","448.95","42.9","","731.00","63.70","731.00","1 through 10","324.42","831.97","percent of total billed charges",""
"GRIP TROCHANTER 125MM ACCORD TI 5 CABLE STANDARD","SUP-ITM-10026381","CDM","C1713","HCPCS","0278","RC","","","","both","","","1046.50","784.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","448.95","42.9","","384.74","384.74","384.74","1 through 10","324.42","831.97","percent of total billed charges",""
"GRIP TROCHANTER 125MM ACCORD TI 5 CABLE STANDARD","SUP-ITM-10026381","CDM","C1713","HCPCS","0278","RC","","","","both","","","1046.50","784.87","WELLPOINT [1015]","HB AMC WELLPOINT","772.11","73.78","","286.63","119.22","1107.45","105","324.42","831.97","percent of total billed charges",""
"GRIP TROCHANTER 125MM ACCORD TI 5 CABLE STANDARD","SUP-ITM-10026381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1046.50","784.87","AETNA [1001]","HB AMC AETNA HMO","730.46","69.8","","675.31","184.75","1721.50","286","546.9","855.2","percent of total billed charges",""
"GRIP TROCHANTER 125MM ACCORD TI 5 CABLE STANDARD","SUP-ITM-10026381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1046.50","784.87","AETNA [1001]","HB AMC AETNA PPO","841.39","80.4","","1261.44","103.12","1514.10","21","546.9","855.2","percent of total billed charges",""
"GRIP TROCHANTER 125MM ACCORD TI 5 CABLE STANDARD","SUP-ITM-10026381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1046.50","784.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","841.39","80.4","","1365.00","1365.00","1365.00","1 through 10","546.9","855.2","percent of total billed charges",""
"GRIP TROCHANTER 125MM ACCORD TI 5 CABLE STANDARD","SUP-ITM-10026381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1046.50","784.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","855.20","81.72","","5157.68","5157.68","5157.68","1 through 10","546.9","855.2","percent of total billed charges",""
"GRIP TROCHANTER 125MM ACCORD TI 5 CABLE STANDARD","SUP-ITM-10026381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1046.50","784.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","855.20","81.72","","431.26","71.26","1459.57","88","546.9","855.2","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","235.00","176.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","456.00","456.00","456.00","1 through 10","44.28","186.83","other","OPPS APC"
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","235.00","176.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","164.50","70","","164.16","164.16","164.16","1 through 10","44.28","186.83","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","235.00","176.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.83","79.5","","180.31","179.44","358.88","1 through 10","44.28","186.83","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","235.00","176.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","125.26","53.3","","358.88","115.14","814.64","16","44.28","186.83","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","235.00","176.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.78","36.5","","170.08","72.28","216.84","13","44.28","186.83","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","235.00","176.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","90.01","38.3","","178.30","89.15","534.90","48","44.28","186.83","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","235.00","176.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","180.95","77","","154.36","154.36","154.36","1 through 10","44.28","186.83","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","235.00","176.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.82","42.9","","182.26","182.26","182.26","1 through 10","44.28","186.83","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","235.00","176.25","WELLPOINT [1015]","HB AMC WELLPOINT","173.38","73.78","","339.50","169.75","679.00","16","44.28","186.83","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","outpatient","","","235.00","176.25","AETNA [1001]","HB AMC AETNA HMO","164.03","69.8","","308.72","217.96","308.72","1 through 10","66.11","196.9","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","outpatient","","","235.00","176.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.81","52.26","","66.11","66.11","66.11","1 through 10","66.11","196.9","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","outpatient","","","235.00","176.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","188.94","80.4","","177.84","177.84","177.84","1 through 10","66.11","196.9","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","outpatient","","","235.00","176.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","192.04","81.72","","364.52","182.26","729.04","29","66.11","196.9","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.43","62.43","161.88","1 through 10","60.28","411.81","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","362.60","70","","367.80","367.80","367.80","1 through 10","60.28","411.81","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","411.81","79.5","","395.07","265.06","1185.21","36","60.28","411.81","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","276.09","53.3","","530.12","265.06","2370.42","31","60.28","411.81","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.18","62.18","62.18","1 through 10","60.28","411.81","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","398.86","77","","386.54","386.54","386.54","1 through 10","60.28","411.81","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","MEDICARE [2001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.45","59.14","126.90","57","60.28","411.81","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","160.58","31","","155.12","155.12","155.12","1 through 10","60.28","411.81","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","189.07","36.5","","187.25","159.13","954.78","80","60.28","411.81","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","198.39","38.3","","196.28","190.76","588.84","204","60.28","411.81","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.18","57.96","115.92","1 through 10","60.28","411.81","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","398.86","77","","88.83","88.83","88.83","1 through 10","60.28","411.81","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","TRICARE [160005]","HB BWH TRICARE","60.28","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","63.45","60.28","63.45","1 through 10","60.28","411.81","other","Tricare OPPS"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.18","62.18","63.45","1 through 10","60.28","411.81","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.22","42.9","","401.30","208.00","401.30","1 through 10","60.28","411.81","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.19","57.96","62.19","22","60.28","411.81","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","518.00","388.50","WELLPOINT [1015]","HB AMC WELLPOINT","382.18","73.78","","875.74","373.74","982.00","60","60.28","411.81","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","518.00","388.50","AETNA [1001]","HB AMC AETNA HMO","361.56","69.8","","339.85","239.96","339.85","1 through 10","104.94","423.31","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","518.00","388.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","423.31","81.72","","502.00","502.00","502.00","1 through 10","104.94","423.31","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","423.31","81.72","","401.30","220.73","401.30","1 through 10","104.94","423.31","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","423.31","81.72","","401.30","220.73","802.60","66","104.94","423.31","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.43","62.43","334.28","241","60.28","398.3","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","359.72","71.8","","1046.85","190.03","1046.85","1 through 10","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","328.66","65.6","","329.02","232.31","329.02","1 through 10","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","325.65","65","","947.70","315.90","1283.05","11","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","350.70","70","","1049.76","339.84","2075.65","18","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","79.31","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","118.18","63.45","203.50","1 through 10","60.28","398.3","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","398.30","79.5","","1147.44","382.33","3442.32","1069","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","267.03","53.3","","1147.44","256.61","3442.32","614","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.18","50.60","62.18","11","60.28","398.3","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.43","62.43","62.43","1 through 10","60.28","398.3","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","385.77","77","","374.22","374.22","1122.66","28","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","HUMANA [1012]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.18","62.18","62.18","1 through 10","60.28","398.3","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","325.65","65","","315.90","306.80","1227.20","23","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","398.30","79.5","","3059.84","1028.97","3059.84","16","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","325.65","65","","315.90","315.90","315.90","1 through 10","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","MEDICARE [2001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.45","59.14","63.45","1198","60.28","398.3","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","155.31","31","","600.68","150.17","1802.04","60","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","182.87","36.5","","527.79","175.93","1395.80","1222","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","191.88","38.3","","570.09","190.03","1438.64","3766","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.18","57.96","62.18","51","60.28","398.3","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","MOLINA [1014]","HB BWH MOLINA","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","234.66","117.33","234.66","1 through 10","60.28","398.3","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","385.77","77","","382.48","374.22","748.44","1 through 10","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","TRICARE [160005]","HB BWH TRICARE","60.28","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","63.45","60.28","3402.00","23","60.28","398.3","other","Tricare OPPS"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","57.96","15.55","62.18","65","60.28","398.3","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","670.68","111.78","670.68","11","60.28","398.3","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.93","42.9","","777.02","213.69","3108.08","76","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.19","57.96","63.09","198","60.28","398.3","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.93","42.9","","388.51","213.69","777.02","1 through 10","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","501.00","375.75","WELLPOINT [1015]","HB AMC WELLPOINT","369.64","73.78","","1085.49","361.83","5934.81","817","60.28","398.3","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","501.00","375.75","AETNA [1001]","HB AMC AETNA HMO","349.70","69.8","","929.24","329.02","2632.16","249","104.94","409.42","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","501.00","375.75","AETNA [1001]","HB AMC AETNA PPO","402.80","80.4","","379.08","379.08","379.08","1 through 10","104.94","409.42","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","501.00","375.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","261.82","52.26","","601.48","104.94","2105.18","38","104.94","409.42","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","501.00","375.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","402.80","80.4","","758.16","243.00","2653.56","44","104.94","409.42","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","501.00","375.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","409.42","81.72","","2719.57","388.51","2719.57","1 through 10","104.94","409.42","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","501.00","375.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","409.42","81.72","","641.07","213.69","1068.45","49","104.94","409.42","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","501.00","375.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","409.42","81.72","","854.76","388.51","2719.57","1661","104.94","409.42","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","929.00","203.39","2787.00","11","296.98","761.61","other","OPPS APC"
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","628.45","65.6","","628.93","628.93","628.93","1 through 10","296.98","761.61","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","622.70","65","","603.85","603.85","603.85","1 through 10","296.98","761.61","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","670.60","70","","2229.60","929.00","2229.60","1 through 10","296.98","761.61","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","761.61","79.5","","1844.72","731.12","8773.44","113","296.98","761.61","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","510.61","53.3","","3753.20","490.51","5117.84","58","296.98","761.61","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","737.66","77","","805.42","715.33","805.42","1 through 10","296.98","761.61","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","622.70","65","","1207.70","603.85","1207.70","1 through 10","296.98","761.61","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","622.70","65","","603.85","603.85","603.85","1 through 10","296.98","761.61","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","MEDICARE [2001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.19","392.31","1281.57","1 through 10","296.98","761.61","other","OPPS APC"
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","296.98","31","","287.06","287.06","287.06","1 through 10","296.98","761.61","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","349.67","36.5","","1386.08","336.30","2772.16","89","296.98","761.61","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","366.91","38.3","","726.48","363.24","4236.24","163","296.98","761.61","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","TRICARE [160005]","HB BWH TRICARE","405.83","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","929.00","929.00","929.00","1 through 10","296.98","761.61","other","Tricare OPPS"
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","427.34","213.67","427.34","1 through 10","296.98","761.61","other","OPPS APC"
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","381.94","381.94","381.94","1 through 10","296.98","761.61","other","OPPS APC"
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","958.00","718.50","WELLPOINT [1015]","HB AMC WELLPOINT","706.81","73.78","","1383.28","691.64","4861.92","46","296.98","761.61","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","958.00","718.50","AETNA [1001]","HB AMC AETNA HMO","668.68","69.8","","1257.86","628.93","1370.26","17","420.84","1680.97","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","958.00","718.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","500.65","52.26","","574.87","574.87","574.87","1 through 10","420.84","1680.97","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","958.00","718.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","770.23","80.4","","1449.24","464.50","2173.86","1 through 10","420.84","1680.97","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","958.00","718.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","782.88","81.72","","408.48","408.48","408.48","1 through 10","420.84","1680.97","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","958.00","718.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","782.88","81.72","","1485.28","742.64","5198.48","144","420.84","1680.97","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1442.00","1081.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","970.02","","APC Price ($970.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1398.00","1398.00","1398.00","1 through 10","447.02","1212.52","other","OPPS APC"
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1442.00","1081.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1146.39","79.5","","1100.23","738.14","1117.43","1 through 10","447.02","1212.52","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1442.00","1081.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","768.59","53.3","","738.14","738.14","738.14","1 through 10","447.02","1212.52","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1442.00","1081.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1110.34","77","","1076.46","1076.46","1076.46","1 through 10","447.02","1212.52","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1442.00","1081.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","937.30","65","","908.70","908.70","908.70","1 through 10","447.02","1212.52","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1442.00","1081.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","526.33","36.5","","521.45","521.45","1564.35","19","447.02","1212.52","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1442.00","1081.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","552.29","38.3","","1129.28","531.24","1639.86","25","447.02","1212.52","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1442.00","1081.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1110.34","77","","1054.09","1054.09","1054.09","1 through 10","447.02","1212.52","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1442.00","1081.50","WELLPOINT [1015]","HB AMC WELLPOINT","1063.91","73.78","","1040.81","1040.81","1040.81","11","447.02","1212.52","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","outpatient","","","1442.00","1081.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1159.37","80.4","","1090.44","1090.44","1090.44","1 through 10","753.59","3421.28","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","outpatient","","","1442.00","1081.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1178.40","81.72","","1117.56","1117.56","2235.12","15","753.59","3421.28","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","183.00","137.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.56","28.64","29.56","1 through 10","27.63","145.49","other","OPPS APC"
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","183.00","137.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","145.49","79.5","","139.30","93.46","139.30","1 through 10","27.63","145.49","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","183.00","137.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","97.54","53.3","","316.21","139.30","417.82","1 through 10","27.63","145.49","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","183.00","137.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","145.49","79.5","","278.40","278.40","278.40","1 through 10","27.63","145.49","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","183.00","137.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","66.80","36.5","","66.02","56.11","112.22","1 through 10","27.63","145.49","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","183.00","137.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.09","38.3","","69.21","69.21","415.26","31","27.63","145.49","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","183.00","137.25","TRICARE [160005]","HB BWH TRICARE","27.63","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","177.00","177.00","177.00","1 through 10","27.63","145.49","other","Tricare OPPS"
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","183.00","137.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","244.26","244.26","244.26","1 through 10","27.63","145.49","other","OPPS APC"
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.51","42.9","","141.49","141.49","141.49","1 through 10","27.63","145.49","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","183.00","137.25","WELLPOINT [1015]","HB AMC WELLPOINT","135.02","73.78","","308.78","131.78","308.78","12","27.63","145.49","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","outpatient","","","183.00","137.25","AETNA [1001]","HB AMC AETNA HMO","127.73","69.8","","239.66","239.66","239.66","1 through 10","35.33","149.55","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","outpatient","","","183.00","137.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","95.64","52.26","","177.00","177.00","177.00","1 through 10","35.33","149.55","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","outpatient","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","149.55","81.72","","155.66","141.49","282.98","17","35.33","149.55","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","both","","","277.00","207.75","CHAMPVA [160001]","HB BWH TRICARE","263.15","95","","20.09","20.09","20.09","1 through 10","16.34","263.15","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","both","","","277.00","207.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","220.22","79.5","","211.70","211.70","211.70","1 through 10","16.34","263.15","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","both","","","277.00","207.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","101.11","36.5","","100.34","100.34","100.34","1 through 10","16.34","263.15","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","both","","","277.00","207.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","106.09","38.3","","105.18","88.77","105.18","1 through 10","16.34","263.15","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","both","","","277.00","207.75","TRICARE [160005]","HB BWH TRICARE","263.15","95","","20.09","20.09","20.09","1 through 10","16.34","263.15","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","outpatient","","","277.00","207.75","AETNA [1001]","HB AMC AETNA HMO","193.35","69.8","","182.11","128.58","182.11","1 through 10","17.2","226.36","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","outpatient","","","277.00","207.75","AETNA [1001]","HB AMC AETNA PPO","222.71","80.4","","209.82","209.82","209.82","1 through 10","17.2","226.36","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","outpatient","","","277.00","207.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","226.36","81.72","","215.04","215.04","215.04","1 through 10","17.2","226.36","percent of total billed charges",""
"Growth Stimulation Expressed Gene 2","PX-30002920","CDM","83006","CPT","0301","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","153.30","36.5","","294.66","294.66","294.66","1 through 10","74.09","399","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","both","","","1183.00","887.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","776.05","65.6","","1147.00","1147.00","1147.00","1 through 10","261.91","940.49","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","both","","","1183.00","887.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","828.10","70","","825.84","825.84","825.84","1 through 10","261.91","940.49","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","both","","","1183.00","887.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","940.49","79.5","","902.69","864.84","902.69","1 through 10","261.91","940.49","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","both","","","1183.00","887.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","630.54","53.3","","579.24","579.24","579.24","1 through 10","261.91","940.49","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","both","","","1183.00","887.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","431.80","36.5","","415.21","415.21","427.83","1 through 10","261.91","940.49","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","both","","","1183.00","887.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","453.09","38.3","","448.48","448.48","448.48","1 through 10","261.91","940.49","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","outpatient","","","1183.00","887.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","618.24","52.26","","709.76","709.76","709.76","1 through 10","618.24","966.75","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","outpatient","","","1183.00","887.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","966.75","81.72","","916.91","916.91","916.91","1 through 10","618.24","966.75","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 2","PX-33000110","CDM","77387","CPT","0333","RC","","","","both","","","1183.00","887.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","776.05","65.6","","1147.00","1147.00","1147.00","1 through 10","261.91","940.49","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 2","PX-33000110","CDM","77387","CPT","0333","RC","","","","both","","","1183.00","887.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","828.10","70","","825.84","825.84","825.84","1 through 10","261.91","940.49","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 2","PX-33000110","CDM","77387","CPT","0333","RC","","","","both","","","1183.00","887.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","940.49","79.5","","902.69","864.84","902.69","1 through 10","261.91","940.49","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 2","PX-33000110","CDM","77387","CPT","0333","RC","","","","both","","","1183.00","887.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","630.54","53.3","","579.24","579.24","579.24","1 through 10","261.91","940.49","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 2","PX-33000110","CDM","77387","CPT","0333","RC","","","","both","","","1183.00","887.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","431.80","36.5","","415.21","415.21","427.83","1 through 10","261.91","940.49","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 2","PX-33000110","CDM","77387","CPT","0333","RC","","","","both","","","1183.00","887.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","453.09","38.3","","448.48","448.48","448.48","1 through 10","261.91","940.49","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 2","PX-33000110","CDM","77387","CPT","0333","RC","","","","outpatient","","","1183.00","887.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","618.24","52.26","","709.76","709.76","709.76","1 through 10","618.24","966.75","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 2","PX-33000110","CDM","77387","CPT","0333","RC","","","","outpatient","","","1183.00","887.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","966.75","81.72","","916.91","916.91","916.91","1 through 10","618.24","966.75","percent of total billed charges",""
"GUIDE PIN 1.4X508MM ROUND","SUP-ITM-10152621","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","800.18","480.96","1887.97","195","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM ROUND","SUP-ITM-10152621","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","813.12","216.42","1444.50","81","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM ROUND","SUP-ITM-10152621","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","97.65","31","","432.60","432.60","432.60","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM ROUND","SUP-ITM-10152621","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","148.37","54.89","631.39","94","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM ROUND","SUP-ITM-10152621","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","279.30","91.72","1116.77","266","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM ROUND","SUP-ITM-10152621","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","731.00","63.70","731.00","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM ROUND","SUP-ITM-10152621","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","384.74","384.74","384.74","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM ROUND","SUP-ITM-10152621","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB AMC WELLPOINT","232.41","73.78","","286.63","119.22","1107.45","105","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM ROUND","SUP-ITM-10152621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","675.31","184.75","1721.50","286","164.62","257.42","percent of total billed charges",""
"GUIDE PIN 1.4X508MM ROUND","SUP-ITM-10152621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA PPO","253.26","80.4","","1261.44","103.12","1514.10","21","164.62","257.42","percent of total billed charges",""
"GUIDE PIN 1.4X508MM ROUND","SUP-ITM-10152621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","1365.00","1365.00","1365.00","1 through 10","164.62","257.42","percent of total billed charges",""
"GUIDE PIN 1.4X508MM ROUND","SUP-ITM-10152621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","257.42","81.72","","5157.68","5157.68","5157.68","1 through 10","164.62","257.42","percent of total billed charges",""
"GUIDE PIN 1.4X508MM ROUND","SUP-ITM-10152621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","431.26","71.26","1459.57","88","164.62","257.42","percent of total billed charges",""
"GUIDE PIN 1.4X508MM TROCAR ROUND","SUP-ITM-10156084","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","800.18","480.96","1887.97","195","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM TROCAR ROUND","SUP-ITM-10156084","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","813.12","216.42","1444.50","81","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM TROCAR ROUND","SUP-ITM-10156084","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","97.65","31","","432.60","432.60","432.60","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM TROCAR ROUND","SUP-ITM-10156084","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","148.37","54.89","631.39","94","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM TROCAR ROUND","SUP-ITM-10156084","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","279.30","91.72","1116.77","266","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM TROCAR ROUND","SUP-ITM-10156084","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","731.00","63.70","731.00","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM TROCAR ROUND","SUP-ITM-10156084","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","384.74","384.74","384.74","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM TROCAR ROUND","SUP-ITM-10156084","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB AMC WELLPOINT","232.41","73.78","","286.63","119.22","1107.45","105","97.65","250.43","percent of total billed charges",""
"GUIDE PIN 1.4X508MM TROCAR ROUND","SUP-ITM-10156084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","675.31","184.75","1721.50","286","164.62","257.42","percent of total billed charges",""
"GUIDE PIN 1.4X508MM TROCAR ROUND","SUP-ITM-10156084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA PPO","253.26","80.4","","1261.44","103.12","1514.10","21","164.62","257.42","percent of total billed charges",""
"GUIDE PIN 1.4X508MM TROCAR ROUND","SUP-ITM-10156084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","1365.00","1365.00","1365.00","1 through 10","164.62","257.42","percent of total billed charges",""
"GUIDE PIN 1.4X508MM TROCAR ROUND","SUP-ITM-10156084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","257.42","81.72","","5157.68","5157.68","5157.68","1 through 10","164.62","257.42","percent of total billed charges",""
"GUIDE PIN 1.4X508MM TROCAR ROUND","SUP-ITM-10156084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","431.26","71.26","1459.57","88","164.62","257.42","percent of total billed charges",""
"GUIDE SINUS WORLEY 9FR 40CM ADVANCED CORONARY PEBAX NYLON STANDARD CURVE","SUP-ITM-10130397","CDM","C1892","HCPCS","0272","RC","","","","both","","","1274.00","955.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","465.01","36.5","","66.97","66.97","66.97","1 through 10","394.94","1012.83","percent of total billed charges",""
"GUIDE SINUS WORLEY 9FR 40CM ADVANCED CORONARY PEBAX NYLON STANDARD CURVE","SUP-ITM-10130397","CDM","C1892","HCPCS","0272","RC","","","","both","","","1274.00","955.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","487.94","38.3","","70.21","44.61","70.21","1 through 10","394.94","1012.83","percent of total billed charges",""
"GUIDE SINUS WORLEY 9FR 40CM ADVANCED CORONARY PEBAX NYLON STANDARD CURVE","SUP-ITM-10130397","CDM","C1892","HCPCS","0272","RC","","","","both","","","1274.00","955.50","WELLPOINT [1015]","HB AMC WELLPOINT","939.96","73.78","","84.95","84.95","84.95","1 through 10","394.94","1012.83","percent of total billed charges",""
"GUIDE SINUS WORLEY 9FR 40CM ADVANCED CORONARY PEBAX NYLON STANDARD CURVE","SUP-ITM-10130397","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","1274.00","955.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1041.11","81.72","","91.21","50.17","91.21","1 through 10","665.79","1041.11","percent of total billed charges",""
"GUIDE SINUS WORLEY 9FR 40CM ADVANCED CORONARY PEBAX NYLON STANDARD CURVE","SUP-ITM-10130397","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","1274.00","955.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1041.11","81.72","","50.17","50.17","50.17","1 through 10","665.79","1041.11","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.63","367.97","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","352.27","71.8","","105.81","105.81","366.90","1 through 10","152.1","390.05","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.63","367.97","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","343.44","70","","512.90","74.70","612.85","1 through 10","152.1","390.05","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.63","367.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","390.05","79.5","","200.27","182.80","200.27","1 through 10","152.1","390.05","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.63","367.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","261.51","53.3","","37.73","37.73","169.33","1 through 10","152.1","390.05","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.63","367.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","318.91","65","","100.27","8.48","494.52","1 through 10","152.1","390.05","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.63","367.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","318.91","65","","160.19","160.19","160.19","1 through 10","152.1","390.05","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.63","367.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","152.10","31","","28.12","28.12","28.12","1 through 10","152.1","390.05","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.63","367.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","179.08","36.5","","101.66","28.85","502.70","121","152.1","390.05","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.63","367.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.91","38.3","","61.58","25.32","328.44","138","152.1","390.05","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.63","367.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.48","42.9","","71.66","71.66","71.66","1 through 10","152.1","390.05","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.63","367.97","WELLPOINT [1015]","HB AMC WELLPOINT","361.99","73.78","","74.75","27.97","425.28","93","152.1","390.05","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.63","367.97","AETNA [1001]","HB AMC AETNA HMO","342.46","69.8","","52.67","14.36","414.90","1 through 10","256.4","400.94","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.63","367.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","256.40","52.26","","25.34","25.34","25.34","1 through 10","256.4","400.94","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.63","367.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","394.47","80.4","","478.02","107.84","478.02","1 through 10","256.4","400.94","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.63","367.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","400.94","81.72","","32.74","12.33","122.05","1 through 10","256.4","400.94","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.63","367.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","400.94","81.72","","144.95","32.78","676.91","104","256.4","400.94","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","177.86","133.39","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","127.70","71.8","","105.81","105.81","366.90","1 through 10","55.14","141.4","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","177.86","133.39","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","124.50","70","","512.90","74.70","612.85","1 through 10","55.14","141.4","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","177.86","133.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","141.40","79.5","","200.27","182.80","200.27","1 through 10","55.14","141.4","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","177.86","133.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","94.80","53.3","","37.73","37.73","169.33","1 through 10","55.14","141.4","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","177.86","133.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","115.61","65","","100.27","8.48","494.52","1 through 10","55.14","141.4","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","177.86","133.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","115.61","65","","160.19","160.19","160.19","1 through 10","55.14","141.4","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","177.86","133.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","55.14","31","","28.12","28.12","28.12","1 through 10","55.14","141.4","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","177.86","133.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.92","36.5","","101.66","28.85","502.70","121","55.14","141.4","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","177.86","133.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.12","38.3","","61.58","25.32","328.44","138","55.14","141.4","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","177.86","133.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.30","42.9","","71.66","71.66","71.66","1 through 10","55.14","141.4","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","177.86","133.39","WELLPOINT [1015]","HB AMC WELLPOINT","131.23","73.78","","74.75","27.97","425.28","93","55.14","141.4","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","177.86","133.39","AETNA [1001]","HB AMC AETNA HMO","124.15","69.8","","52.67","14.36","414.90","1 through 10","92.95","145.35","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","177.86","133.39","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","92.95","52.26","","25.34","25.34","25.34","1 through 10","92.95","145.35","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","177.86","133.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","143.00","80.4","","478.02","107.84","478.02","1 through 10","92.95","145.35","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","177.86","133.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","145.35","81.72","","32.74","12.33","122.05","1 through 10","92.95","145.35","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","177.86","133.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","145.35","81.72","","144.95","32.78","676.91","104","92.95","145.35","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","462.00","346.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","241.44","52.26","","25.34","25.34","25.34","1 through 10","143.22","367.29","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","462.00","346.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","331.72","71.8","","105.81","105.81","366.90","1 through 10","143.22","367.29","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","462.00","346.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","323.40","70","","512.90","74.70","612.85","1 through 10","143.22","367.29","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","462.00","346.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","367.29","79.5","","200.27","182.80","200.27","1 through 10","143.22","367.29","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","462.00","346.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","246.25","53.3","","37.73","37.73","169.33","1 through 10","143.22","367.29","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","462.00","346.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","300.30","65","","100.27","8.48","494.52","1 through 10","143.22","367.29","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","462.00","346.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","300.30","65","","160.19","160.19","160.19","1 through 10","143.22","367.29","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","462.00","346.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","143.22","31","","28.12","28.12","28.12","1 through 10","143.22","367.29","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","462.00","346.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","168.63","36.5","","101.66","28.85","502.70","121","143.22","367.29","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","462.00","346.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","176.95","38.3","","61.58","25.32","328.44","138","143.22","367.29","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","462.00","346.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.20","42.9","","71.66","71.66","71.66","1 through 10","143.22","367.29","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","462.00","346.50","WELLPOINT [1015]","HB AMC WELLPOINT","340.86","73.78","","74.75","27.97","425.28","93","143.22","367.29","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","462.00","346.50","AETNA [1001]","HB AMC AETNA HMO","322.48","69.8","","52.67","14.36","414.90","1 through 10","241.44","377.55","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","462.00","346.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","241.44","52.26","","25.34","25.34","25.34","1 through 10","241.44","377.55","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","462.00","346.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","371.45","80.4","","478.02","107.84","478.02","1 through 10","241.44","377.55","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","462.00","346.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","377.55","81.72","","32.74","12.33","122.05","1 through 10","241.44","377.55","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","462.00","346.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","377.55","81.72","","144.95","32.78","676.91","104","241.44","377.55","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","both","","","1452.50","1089.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","759.08","52.26","","25.34","25.34","25.34","1 through 10","450.28","1154.74","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","both","","","1452.50","1089.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1042.90","71.8","","105.81","105.81","366.90","1 through 10","450.28","1154.74","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","both","","","1452.50","1089.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1016.75","70","","512.90","74.70","612.85","1 through 10","450.28","1154.74","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","both","","","1452.50","1089.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1154.74","79.5","","200.27","182.80","200.27","1 through 10","450.28","1154.74","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","both","","","1452.50","1089.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","774.18","53.3","","37.73","37.73","169.33","1 through 10","450.28","1154.74","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","both","","","1452.50","1089.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","944.13","65","","100.27","8.48","494.52","1 through 10","450.28","1154.74","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","both","","","1452.50","1089.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","944.13","65","","160.19","160.19","160.19","1 through 10","450.28","1154.74","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","both","","","1452.50","1089.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","450.28","31","","28.12","28.12","28.12","1 through 10","450.28","1154.74","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","both","","","1452.50","1089.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","530.16","36.5","","101.66","28.85","502.70","121","450.28","1154.74","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","both","","","1452.50","1089.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","556.31","38.3","","61.58","25.32","328.44","138","450.28","1154.74","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","both","","","1452.50","1089.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","623.12","42.9","","71.66","71.66","71.66","1 through 10","450.28","1154.74","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","both","","","1452.50","1089.37","WELLPOINT [1015]","HB AMC WELLPOINT","1071.65","73.78","","74.75","27.97","425.28","93","450.28","1154.74","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1452.50","1089.37","AETNA [1001]","HB AMC AETNA HMO","1013.85","69.8","","52.67","14.36","414.90","1 through 10","759.08","1186.98","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1452.50","1089.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","759.08","52.26","","25.34","25.34","25.34","1 through 10","759.08","1186.98","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1452.50","1089.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1167.81","80.4","","478.02","107.84","478.02","1 through 10","759.08","1186.98","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1452.50","1089.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1186.98","81.72","","32.74","12.33","122.05","1 through 10","759.08","1186.98","percent of total billed charges",""
"GUIDEWIRE 3X900MM BALL NOSE STERILE","SUP-ITM-10330271","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1452.50","1089.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1186.98","81.72","","144.95","32.78","676.91","104","759.08","1186.98","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","both","","","245.00","183.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","128.04","52.26","","25.34","25.34","25.34","1 through 10","75.95","194.78","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","both","","","245.00","183.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","175.91","71.8","","105.81","105.81","366.90","1 through 10","75.95","194.78","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","both","","","245.00","183.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","171.50","70","","512.90","74.70","612.85","1 through 10","75.95","194.78","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","both","","","245.00","183.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","194.78","79.5","","200.27","182.80","200.27","1 through 10","75.95","194.78","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","both","","","245.00","183.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.59","53.3","","37.73","37.73","169.33","1 through 10","75.95","194.78","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","both","","","245.00","183.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","159.25","65","","100.27","8.48","494.52","1 through 10","75.95","194.78","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","both","","","245.00","183.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","159.25","65","","160.19","160.19","160.19","1 through 10","75.95","194.78","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","75.95","31","","28.12","28.12","28.12","1 through 10","75.95","194.78","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.43","36.5","","101.66","28.85","502.70","121","75.95","194.78","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.84","38.3","","61.58","25.32","328.44","138","75.95","194.78","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.11","42.9","","71.66","71.66","71.66","1 through 10","75.95","194.78","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","both","","","245.00","183.75","WELLPOINT [1015]","HB AMC WELLPOINT","180.76","73.78","","74.75","27.97","425.28","93","75.95","194.78","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA HMO","171.01","69.8","","52.67","14.36","414.90","1 through 10","128.04","200.21","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","245.00","183.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","128.04","52.26","","25.34","25.34","25.34","1 through 10","128.04","200.21","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","245.00","183.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","196.98","80.4","","478.02","107.84","478.02","1 through 10","128.04","200.21","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","200.21","81.72","","32.74","12.33","122.05","1 through 10","128.04","200.21","percent of total billed charges",""
"GUIDEWIRE ACUITY 190CM .014IN VASCULAR STRAIGHT TIP SS HYDROPHILIC COATED EXTRA SUPPORT WHISPER VIEW BX/5EA","SUP-ITM-10126013","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","200.21","81.72","","144.95","32.78","676.91","104","128.04","200.21","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","63.69","52.26","","25.34","25.34","25.34","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","87.50","71.8","","105.81","105.81","366.90","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","85.31","70","","512.90","74.70","612.85","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","96.89","79.5","","200.27","182.80","200.27","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","64.96","53.3","","37.73","37.73","169.33","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","79.22","65","","100.27","8.48","494.52","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","79.22","65","","160.19","160.19","160.19","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","37.78","31","","28.12","28.12","28.12","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.48","36.5","","101.66","28.85","502.70","121","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.68","38.3","","61.58","25.32","328.44","138","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.28","42.9","","71.66","71.66","71.66","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","WELLPOINT [1015]","HB AMC WELLPOINT","89.92","73.78","","74.75","27.97","425.28","93","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","121.87","91.40","AETNA [1001]","HB AMC AETNA HMO","85.07","69.8","","52.67","14.36","414.90","1 through 10","63.69","99.59","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","121.87","91.40","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","63.69","52.26","","25.34","25.34","25.34","1 through 10","63.69","99.59","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","121.87","91.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","97.98","80.4","","478.02","107.84","478.02","1 through 10","63.69","99.59","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","121.87","91.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","99.59","81.72","","32.74","12.33","122.05","1 through 10","63.69","99.59","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","121.87","91.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","99.59","81.72","","144.95","32.78","676.91","104","63.69","99.59","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.22","114.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","80.07","52.26","","25.34","25.34","25.34","1 through 10","47.5","121.81","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.22","114.91","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","110.01","71.8","","105.81","105.81","366.90","1 through 10","47.5","121.81","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.22","114.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","107.25","70","","512.90","74.70","612.85","1 through 10","47.5","121.81","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.22","114.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.81","79.5","","200.27","182.80","200.27","1 through 10","47.5","121.81","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.22","114.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.67","53.3","","37.73","37.73","169.33","1 through 10","47.5","121.81","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.22","114.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","99.59","65","","100.27","8.48","494.52","1 through 10","47.5","121.81","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.22","114.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","99.59","65","","160.19","160.19","160.19","1 through 10","47.5","121.81","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.22","114.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","47.50","31","","28.12","28.12","28.12","1 through 10","47.5","121.81","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.22","114.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.93","36.5","","101.66","28.85","502.70","121","47.5","121.81","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.22","114.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.68","38.3","","61.58","25.32","328.44","138","47.5","121.81","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.22","114.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.73","42.9","","71.66","71.66","71.66","1 through 10","47.5","121.81","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.22","114.91","WELLPOINT [1015]","HB AMC WELLPOINT","113.05","73.78","","74.75","27.97","425.28","93","47.5","121.81","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","153.22","114.91","AETNA [1001]","HB AMC AETNA HMO","106.95","69.8","","52.67","14.36","414.90","1 through 10","80.07","125.21","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","153.22","114.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","80.07","52.26","","25.34","25.34","25.34","1 through 10","80.07","125.21","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","153.22","114.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","123.19","80.4","","478.02","107.84","478.02","1 through 10","80.07","125.21","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","153.22","114.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","125.21","81.72","","32.74","12.33","122.05","1 through 10","80.07","125.21","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 1CM 260CM .035IN STRAIGHT TIP SHORT TAPER PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000406","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","153.22","114.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.21","81.72","","144.95","32.78","676.91","104","80.07","125.21","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.00","63.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","43.90","52.26","","25.34","25.34","25.34","1 through 10","26.04","66.78","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.00","63.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","60.31","71.8","","105.81","105.81","366.90","1 through 10","26.04","66.78","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.00","63.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","58.80","70","","512.90","74.70","612.85","1 through 10","26.04","66.78","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.00","63.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","66.78","79.5","","200.27","182.80","200.27","1 through 10","26.04","66.78","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.00","63.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","44.77","53.3","","37.73","37.73","169.33","1 through 10","26.04","66.78","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","54.60","65","","100.27","8.48","494.52","1 through 10","26.04","66.78","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","54.60","65","","160.19","160.19","160.19","1 through 10","26.04","66.78","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.04","31","","28.12","28.12","28.12","1 through 10","26.04","66.78","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30.66","36.5","","101.66","28.85","502.70","121","26.04","66.78","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.17","38.3","","61.58","25.32","328.44","138","26.04","66.78","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.04","42.9","","71.66","71.66","71.66","1 through 10","26.04","66.78","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.00","63.00","WELLPOINT [1015]","HB AMC WELLPOINT","61.98","73.78","","74.75","27.97","425.28","93","26.04","66.78","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","AETNA [1001]","HB AMC AETNA HMO","58.63","69.8","","52.67","14.36","414.90","1 through 10","43.9","68.64","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","43.90","52.26","","25.34","25.34","25.34","1 through 10","43.9","68.64","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","67.54","80.4","","478.02","107.84","478.02","1 through 10","43.9","68.64","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","68.64","81.72","","32.74","12.33","122.05","1 through 10","43.9","68.64","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 145CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009676","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","68.64","81.72","","144.95","32.78","676.91","104","43.9","68.64","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","both","","","140.42","105.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","73.38","52.26","","25.34","25.34","25.34","1 through 10","43.53","111.63","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","both","","","140.42","105.31","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","100.82","71.8","","105.81","105.81","366.90","1 through 10","43.53","111.63","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","both","","","140.42","105.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","98.29","70","","512.90","74.70","612.85","1 through 10","43.53","111.63","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","both","","","140.42","105.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.63","79.5","","200.27","182.80","200.27","1 through 10","43.53","111.63","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","both","","","140.42","105.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.84","53.3","","37.73","37.73","169.33","1 through 10","43.53","111.63","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","both","","","140.42","105.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","91.27","65","","100.27","8.48","494.52","1 through 10","43.53","111.63","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","both","","","140.42","105.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","91.27","65","","160.19","160.19","160.19","1 through 10","43.53","111.63","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","both","","","140.42","105.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","43.53","31","","28.12","28.12","28.12","1 through 10","43.53","111.63","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","both","","","140.42","105.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.25","36.5","","101.66","28.85","502.70","121","43.53","111.63","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","both","","","140.42","105.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.78","38.3","","61.58","25.32","328.44","138","43.53","111.63","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","both","","","140.42","105.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.24","42.9","","71.66","71.66","71.66","1 through 10","43.53","111.63","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","both","","","140.42","105.31","WELLPOINT [1015]","HB AMC WELLPOINT","103.60","73.78","","74.75","27.97","425.28","93","43.53","111.63","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","140.42","105.31","AETNA [1001]","HB AMC AETNA HMO","98.01","69.8","","52.67","14.36","414.90","1 through 10","73.38","114.75","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","140.42","105.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","73.38","52.26","","25.34","25.34","25.34","1 through 10","73.38","114.75","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","140.42","105.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.90","80.4","","478.02","107.84","478.02","1 through 10","73.38","114.75","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","140.42","105.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.75","81.72","","32.74","12.33","122.05","1 through 10","73.38","114.75","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 180CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000305","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","140.42","105.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.75","81.72","","144.95","32.78","676.91","104","73.38","114.75","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","25.34","25.34","25.34","1 through 10","27.13","69.56","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","87.50","65.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","62.83","71.8","","105.81","105.81","366.90","1 through 10","27.13","69.56","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","87.50","65.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","61.25","70","","512.90","74.70","612.85","1 through 10","27.13","69.56","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","200.27","182.80","200.27","1 through 10","27.13","69.56","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","87.50","65.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.64","53.3","","37.73","37.73","169.33","1 through 10","27.13","69.56","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","56.88","65","","100.27","8.48","494.52","1 through 10","27.13","69.56","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","56.88","65","","160.19","160.19","160.19","1 through 10","27.13","69.56","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.13","31","","28.12","28.12","28.12","1 through 10","27.13","69.56","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","101.66","28.85","502.70","121","27.13","69.56","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","61.58","25.32","328.44","138","27.13","69.56","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","71.66","71.66","71.66","1 through 10","27.13","69.56","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","74.75","27.97","425.28","93","27.13","69.56","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","52.67","14.36","414.90","1 through 10","45.73","71.51","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","25.34","25.34","25.34","1 through 10","45.73","71.51","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","70.35","80.4","","478.02","107.84","478.02","1 through 10","45.73","71.51","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","71.51","81.72","","32.74","12.33","122.05","1 through 10","45.73","71.51","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","144.95","32.78","676.91","104","45.73","71.51","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.00","68.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","47.56","52.26","","25.34","25.34","25.34","1 through 10","28.21","72.35","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.00","68.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","65.34","71.8","","105.81","105.81","366.90","1 through 10","28.21","72.35","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.00","68.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","63.70","70","","512.90","74.70","612.85","1 through 10","28.21","72.35","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.00","68.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","72.35","79.5","","200.27","182.80","200.27","1 through 10","28.21","72.35","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.00","68.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.50","53.3","","37.73","37.73","169.33","1 through 10","28.21","72.35","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.00","68.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","59.15","65","","100.27","8.48","494.52","1 through 10","28.21","72.35","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.00","68.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","59.15","65","","160.19","160.19","160.19","1 through 10","28.21","72.35","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","28.21","31","","28.12","28.12","28.12","1 through 10","28.21","72.35","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.22","36.5","","101.66","28.85","502.70","121","28.21","72.35","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.85","38.3","","61.58","25.32","328.44","138","28.21","72.35","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.04","42.9","","71.66","71.66","71.66","1 through 10","28.21","72.35","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.00","68.25","WELLPOINT [1015]","HB AMC WELLPOINT","67.14","73.78","","74.75","27.97","425.28","93","28.21","72.35","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA HMO","63.52","69.8","","52.67","14.36","414.90","1 through 10","47.56","74.37","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","91.00","68.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","47.56","52.26","","25.34","25.34","25.34","1 through 10","47.56","74.37","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","91.00","68.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","73.16","80.4","","478.02","107.84","478.02","1 through 10","47.56","74.37","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","74.37","81.72","","32.74","12.33","122.05","1 through 10","47.56","74.37","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 75CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009673","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","74.37","81.72","","144.95","32.78","676.91","104","47.56","74.37","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","292.66","52.26","","25.34","25.34","25.34","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","402.08","71.8","","105.81","105.81","366.90","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","392.00","70","","512.90","74.70","612.85","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","445.20","79.5","","200.27","182.80","200.27","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","298.48","53.3","","37.73","37.73","169.33","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","364.00","65","","100.27","8.48","494.52","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","364.00","65","","160.19","160.19","160.19","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","173.60","31","","28.12","28.12","28.12","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","204.40","36.5","","101.66","28.85","502.70","121","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","214.48","38.3","","61.58","25.32","328.44","138","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","240.24","42.9","","71.66","71.66","71.66","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","WELLPOINT [1015]","HB AMC WELLPOINT","413.17","73.78","","74.75","27.97","425.28","93","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","AETNA [1001]","HB AMC AETNA HMO","390.88","69.8","","52.67","14.36","414.90","1 through 10","292.66","457.63","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","292.66","52.26","","25.34","25.34","25.34","1 through 10","292.66","457.63","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","450.24","80.4","","478.02","107.84","478.02","1 through 10","292.66","457.63","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","457.63","81.72","","32.74","12.33","122.05","1 through 10","292.66","457.63","percent of total billed charges",""
"GUIDEWIRE ATTAIN 88CM HYBRID FOR 4196 LEAD","SUP-ITM-10051555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","457.63","81.72","","144.95","32.78","676.91","104","292.66","457.63","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","511.00","383.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","267.05","52.26","","25.34","25.34","25.34","1 through 10","158.41","406.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","511.00","383.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","366.90","71.8","","105.81","105.81","366.90","1 through 10","158.41","406.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","511.00","383.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","357.70","70","","512.90","74.70","612.85","1 through 10","158.41","406.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","511.00","383.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","406.25","79.5","","200.27","182.80","200.27","1 through 10","158.41","406.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","511.00","383.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","272.36","53.3","","37.73","37.73","169.33","1 through 10","158.41","406.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","511.00","383.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","332.15","65","","100.27","8.48","494.52","1 through 10","158.41","406.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","511.00","383.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","332.15","65","","160.19","160.19","160.19","1 through 10","158.41","406.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","511.00","383.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","158.41","31","","28.12","28.12","28.12","1 through 10","158.41","406.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","511.00","383.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","186.52","36.5","","101.66","28.85","502.70","121","158.41","406.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","511.00","383.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","195.71","38.3","","61.58","25.32","328.44","138","158.41","406.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","511.00","383.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","219.22","42.9","","71.66","71.66","71.66","1 through 10","158.41","406.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","511.00","383.25","WELLPOINT [1015]","HB AMC WELLPOINT","377.02","73.78","","74.75","27.97","425.28","93","158.41","406.25","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","511.00","383.25","AETNA [1001]","HB AMC AETNA HMO","356.68","69.8","","52.67","14.36","414.90","1 through 10","267.05","417.59","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","511.00","383.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","267.05","52.26","","25.34","25.34","25.34","1 through 10","267.05","417.59","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","511.00","383.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","410.84","80.4","","478.02","107.84","478.02","1 through 10","267.05","417.59","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","511.00","383.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","417.59","81.72","","32.74","12.33","122.05","1 through 10","267.05","417.59","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","511.00","383.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","417.59","81.72","","144.95","32.78","676.91","104","267.05","417.59","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","364.00","273.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","190.23","52.26","","25.34","25.34","25.34","1 through 10","112.84","289.38","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","364.00","273.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","261.35","71.8","","105.81","105.81","366.90","1 through 10","112.84","289.38","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","364.00","273.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","254.80","70","","512.90","74.70","612.85","1 through 10","112.84","289.38","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","364.00","273.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","289.38","79.5","","200.27","182.80","200.27","1 through 10","112.84","289.38","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","364.00","273.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","194.01","53.3","","37.73","37.73","169.33","1 through 10","112.84","289.38","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","364.00","273.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","236.60","65","","100.27","8.48","494.52","1 through 10","112.84","289.38","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","364.00","273.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","236.60","65","","160.19","160.19","160.19","1 through 10","112.84","289.38","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","364.00","273.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","112.84","31","","28.12","28.12","28.12","1 through 10","112.84","289.38","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","364.00","273.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","132.86","36.5","","101.66","28.85","502.70","121","112.84","289.38","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","364.00","273.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","139.41","38.3","","61.58","25.32","328.44","138","112.84","289.38","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.16","42.9","","71.66","71.66","71.66","1 through 10","112.84","289.38","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","364.00","273.00","WELLPOINT [1015]","HB AMC WELLPOINT","268.56","73.78","","74.75","27.97","425.28","93","112.84","289.38","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","364.00","273.00","AETNA [1001]","HB AMC AETNA HMO","254.07","69.8","","52.67","14.36","414.90","1 through 10","190.23","297.46","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","364.00","273.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","190.23","52.26","","25.34","25.34","25.34","1 through 10","190.23","297.46","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","364.00","273.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","292.66","80.4","","478.02","107.84","478.02","1 through 10","190.23","297.46","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","297.46","81.72","","32.74","12.33","122.05","1 through 10","190.23","297.46","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","297.46","81.72","","144.95","32.78","676.91","104","190.23","297.46","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","450.63","337.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","235.50","52.26","","25.34","25.34","25.34","1 through 10","139.7","358.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","450.63","337.97","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","323.55","71.8","","105.81","105.81","366.90","1 through 10","139.7","358.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","450.63","337.97","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","315.44","70","","512.90","74.70","612.85","1 through 10","139.7","358.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","450.63","337.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","358.25","79.5","","200.27","182.80","200.27","1 through 10","139.7","358.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","450.63","337.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","240.19","53.3","","37.73","37.73","169.33","1 through 10","139.7","358.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","450.63","337.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","292.91","65","","100.27","8.48","494.52","1 through 10","139.7","358.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","450.63","337.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","292.91","65","","160.19","160.19","160.19","1 through 10","139.7","358.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","450.63","337.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","139.70","31","","28.12","28.12","28.12","1 through 10","139.7","358.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","450.63","337.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","164.48","36.5","","101.66","28.85","502.70","121","139.7","358.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","450.63","337.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","172.59","38.3","","61.58","25.32","328.44","138","139.7","358.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","450.63","337.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.32","42.9","","71.66","71.66","71.66","1 through 10","139.7","358.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","450.63","337.97","WELLPOINT [1015]","HB AMC WELLPOINT","332.47","73.78","","74.75","27.97","425.28","93","139.7","358.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","450.63","337.97","AETNA [1001]","HB AMC AETNA HMO","314.54","69.8","","52.67","14.36","414.90","1 through 10","235.5","368.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","450.63","337.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","235.50","52.26","","25.34","25.34","25.34","1 through 10","235.5","368.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","450.63","337.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","362.31","80.4","","478.02","107.84","478.02","1 through 10","235.5","368.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","450.63","337.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","368.25","81.72","","32.74","12.33","122.05","1 through 10","235.5","368.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","450.63","337.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","368.25","81.72","","144.95","32.78","676.91","104","235.5","368.25","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.00","52.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","36.58","52.26","","25.34","25.34","25.34","1 through 10","21.7","55.65","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.00","52.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","50.26","71.8","","105.81","105.81","366.90","1 through 10","21.7","55.65","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.00","52.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","49.00","70","","512.90","74.70","612.85","1 through 10","21.7","55.65","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.00","52.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","55.65","79.5","","200.27","182.80","200.27","1 through 10","21.7","55.65","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.00","52.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37.31","53.3","","37.73","37.73","169.33","1 through 10","21.7","55.65","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.00","52.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","45.50","65","","100.27","8.48","494.52","1 through 10","21.7","55.65","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.00","52.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","45.50","65","","160.19","160.19","160.19","1 through 10","21.7","55.65","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","21.70","31","","28.12","28.12","28.12","1 through 10","21.7","55.65","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25.55","36.5","","101.66","28.85","502.70","121","21.7","55.65","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26.81","38.3","","61.58","25.32","328.44","138","21.7","55.65","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.03","42.9","","71.66","71.66","71.66","1 through 10","21.7","55.65","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.00","52.50","WELLPOINT [1015]","HB AMC WELLPOINT","51.65","73.78","","74.75","27.97","425.28","93","21.7","55.65","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA HMO","48.86","69.8","","52.67","14.36","414.90","1 through 10","36.58","57.2","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.00","52.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","36.58","52.26","","25.34","25.34","25.34","1 through 10","36.58","57.2","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.00","52.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","56.28","80.4","","478.02","107.84","478.02","1 through 10","36.58","57.2","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","57.20","81.72","","32.74","12.33","122.05","1 through 10","36.58","57.2","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","57.20","81.72","","144.95","32.78","676.91","104","36.58","57.2","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","231.07","52.26","","25.34","25.34","25.34","1 through 10","137.07","351.52","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","317.47","71.8","","105.81","105.81","366.90","1 through 10","137.07","351.52","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","309.51","70","","512.90","74.70","612.85","1 through 10","137.07","351.52","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","351.52","79.5","","200.27","182.80","200.27","1 through 10","137.07","351.52","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","235.67","53.3","","37.73","37.73","169.33","1 through 10","137.07","351.52","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","287.40","65","","100.27","8.48","494.52","1 through 10","137.07","351.52","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","287.40","65","","160.19","160.19","160.19","1 through 10","137.07","351.52","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","137.07","31","","28.12","28.12","28.12","1 through 10","137.07","351.52","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","161.39","36.5","","101.66","28.85","502.70","121","137.07","351.52","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","169.35","38.3","","61.58","25.32","328.44","138","137.07","351.52","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.69","42.9","","71.66","71.66","71.66","1 through 10","137.07","351.52","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","WELLPOINT [1015]","HB AMC WELLPOINT","326.23","73.78","","74.75","27.97","425.28","93","137.07","351.52","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","442.16","331.62","AETNA [1001]","HB AMC AETNA HMO","308.63","69.8","","52.67","14.36","414.90","1 through 10","231.07","361.33","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","442.16","331.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","231.07","52.26","","25.34","25.34","25.34","1 through 10","231.07","361.33","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","442.16","331.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","355.50","80.4","","478.02","107.84","478.02","1 through 10","231.07","361.33","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","442.16","331.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","361.33","81.72","","32.74","12.33","122.05","1 through 10","231.07","361.33","percent of total billed charges",""
"GUIDEWIRE BONE 2.0X150MM ORTHOPEDIC ASNIS III SS THREADLESS","SUP-ITM-10145109","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","442.16","331.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","361.33","81.72","","144.95","32.78","676.91","104","231.07","361.33","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","351.86","263.89","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","183.88","52.26","","25.34","25.34","25.34","1 through 10","109.08","279.73","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","351.86","263.89","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","252.64","71.8","","105.81","105.81","366.90","1 through 10","109.08","279.73","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","351.86","263.89","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","246.30","70","","512.90","74.70","612.85","1 through 10","109.08","279.73","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","351.86","263.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","279.73","79.5","","200.27","182.80","200.27","1 through 10","109.08","279.73","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","351.86","263.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","187.54","53.3","","37.73","37.73","169.33","1 through 10","109.08","279.73","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","351.86","263.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","228.71","65","","100.27","8.48","494.52","1 through 10","109.08","279.73","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","351.86","263.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","228.71","65","","160.19","160.19","160.19","1 through 10","109.08","279.73","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","351.86","263.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","109.08","31","","28.12","28.12","28.12","1 through 10","109.08","279.73","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","351.86","263.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","128.43","36.5","","101.66","28.85","502.70","121","109.08","279.73","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","351.86","263.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","134.76","38.3","","61.58","25.32","328.44","138","109.08","279.73","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","351.86","263.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.95","42.9","","71.66","71.66","71.66","1 through 10","109.08","279.73","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","351.86","263.89","WELLPOINT [1015]","HB AMC WELLPOINT","259.60","73.78","","74.75","27.97","425.28","93","109.08","279.73","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","351.86","263.89","AETNA [1001]","HB AMC AETNA HMO","245.60","69.8","","52.67","14.36","414.90","1 through 10","183.88","287.54","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","351.86","263.89","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","183.88","52.26","","25.34","25.34","25.34","1 through 10","183.88","287.54","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","351.86","263.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","282.90","80.4","","478.02","107.84","478.02","1 through 10","183.88","287.54","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","351.86","263.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","287.54","81.72","","32.74","12.33","122.05","1 through 10","183.88","287.54","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","351.86","263.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","287.54","81.72","","144.95","32.78","676.91","104","183.88","287.54","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.62","94.21","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","65.65","52.26","","25.34","25.34","25.34","1 through 10","38.94","99.87","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.62","94.21","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","90.20","71.8","","105.81","105.81","366.90","1 through 10","38.94","99.87","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.62","94.21","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","87.93","70","","512.90","74.70","612.85","1 through 10","38.94","99.87","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.62","94.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","99.87","79.5","","200.27","182.80","200.27","1 through 10","38.94","99.87","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.62","94.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","66.96","53.3","","37.73","37.73","169.33","1 through 10","38.94","99.87","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.62","94.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","81.65","65","","100.27","8.48","494.52","1 through 10","38.94","99.87","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.62","94.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","81.65","65","","160.19","160.19","160.19","1 through 10","38.94","99.87","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.62","94.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","38.94","31","","28.12","28.12","28.12","1 through 10","38.94","99.87","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.62","94.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","45.85","36.5","","101.66","28.85","502.70","121","38.94","99.87","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.62","94.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48.11","38.3","","61.58","25.32","328.44","138","38.94","99.87","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.62","94.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.89","42.9","","71.66","71.66","71.66","1 through 10","38.94","99.87","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.62","94.21","WELLPOINT [1015]","HB AMC WELLPOINT","92.68","73.78","","74.75","27.97","425.28","93","38.94","99.87","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","125.62","94.21","AETNA [1001]","HB AMC AETNA HMO","87.68","69.8","","52.67","14.36","414.90","1 through 10","65.65","102.66","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","125.62","94.21","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","65.65","52.26","","25.34","25.34","25.34","1 through 10","65.65","102.66","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","125.62","94.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","101.00","80.4","","478.02","107.84","478.02","1 through 10","65.65","102.66","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","125.62","94.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","102.66","81.72","","32.74","12.33","122.05","1 through 10","65.65","102.66","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","125.62","94.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","102.66","81.72","","144.95","32.78","676.91","104","65.65","102.66","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","both","","","735.42","551.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","384.33","52.26","","25.34","25.34","25.34","1 through 10","227.98","584.66","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","both","","","735.42","551.56","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","528.03","71.8","","105.81","105.81","366.90","1 through 10","227.98","584.66","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","both","","","735.42","551.56","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","514.79","70","","512.90","74.70","612.85","1 through 10","227.98","584.66","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","both","","","735.42","551.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","584.66","79.5","","200.27","182.80","200.27","1 through 10","227.98","584.66","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","both","","","735.42","551.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","391.98","53.3","","37.73","37.73","169.33","1 through 10","227.98","584.66","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","both","","","735.42","551.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","478.02","65","","100.27","8.48","494.52","1 through 10","227.98","584.66","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","both","","","735.42","551.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","478.02","65","","160.19","160.19","160.19","1 through 10","227.98","584.66","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","both","","","735.42","551.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","227.98","31","","28.12","28.12","28.12","1 through 10","227.98","584.66","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","both","","","735.42","551.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","268.43","36.5","","101.66","28.85","502.70","121","227.98","584.66","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","both","","","735.42","551.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","281.67","38.3","","61.58","25.32","328.44","138","227.98","584.66","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","both","","","735.42","551.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.50","42.9","","71.66","71.66","71.66","1 through 10","227.98","584.66","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","both","","","735.42","551.56","WELLPOINT [1015]","HB AMC WELLPOINT","542.59","73.78","","74.75","27.97","425.28","93","227.98","584.66","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","735.42","551.56","AETNA [1001]","HB AMC AETNA HMO","513.32","69.8","","52.67","14.36","414.90","1 through 10","384.33","600.99","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","735.42","551.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","384.33","52.26","","25.34","25.34","25.34","1 through 10","384.33","600.99","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","735.42","551.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","591.28","80.4","","478.02","107.84","478.02","1 through 10","384.33","600.99","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","735.42","551.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","600.99","81.72","","32.74","12.33","122.05","1 through 10","384.33","600.99","percent of total billed charges",""
"GUIDEWIRE BONE 2X700MM AFFIXUS SS BALL NOSE EA/1","SUP-ITM-10071915","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","735.42","551.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","600.99","81.72","","144.95","32.78","676.91","104","384.33","600.99","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","both","","","423.96","317.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","221.56","52.26","","25.34","25.34","25.34","1 through 10","131.43","337.05","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","both","","","423.96","317.97","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","304.40","71.8","","105.81","105.81","366.90","1 through 10","131.43","337.05","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","both","","","423.96","317.97","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","296.77","70","","512.90","74.70","612.85","1 through 10","131.43","337.05","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","both","","","423.96","317.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","337.05","79.5","","200.27","182.80","200.27","1 through 10","131.43","337.05","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","both","","","423.96","317.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","225.97","53.3","","37.73","37.73","169.33","1 through 10","131.43","337.05","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","both","","","423.96","317.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","275.57","65","","100.27","8.48","494.52","1 through 10","131.43","337.05","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","both","","","423.96","317.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","275.57","65","","160.19","160.19","160.19","1 through 10","131.43","337.05","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","both","","","423.96","317.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","131.43","31","","28.12","28.12","28.12","1 through 10","131.43","337.05","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","both","","","423.96","317.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","154.75","36.5","","101.66","28.85","502.70","121","131.43","337.05","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","both","","","423.96","317.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","162.38","38.3","","61.58","25.32","328.44","138","131.43","337.05","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","both","","","423.96","317.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.88","42.9","","71.66","71.66","71.66","1 through 10","131.43","337.05","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","both","","","423.96","317.97","WELLPOINT [1015]","HB AMC WELLPOINT","312.80","73.78","","74.75","27.97","425.28","93","131.43","337.05","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","423.96","317.97","AETNA [1001]","HB AMC AETNA HMO","295.92","69.8","","52.67","14.36","414.90","1 through 10","221.56","346.46","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","423.96","317.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","221.56","52.26","","25.34","25.34","25.34","1 through 10","221.56","346.46","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","423.96","317.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","340.86","80.4","","478.02","107.84","478.02","1 through 10","221.56","346.46","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","423.96","317.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","346.46","81.72","","32.74","12.33","122.05","1 through 10","221.56","346.46","percent of total billed charges",""
"GUIDEWIRE BONE 3.0MMX100CM ORTHOPEDIC MDN SS BALL TIP INTRAMEDULLARY","SUP-ITM-10018552","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","423.96","317.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","346.46","81.72","","144.95","32.78","676.91","104","221.56","346.46","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","56.00","42.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","29.27","52.26","","25.34","25.34","25.34","1 through 10","17.36","44.52","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","56.00","42.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","40.21","71.8","","105.81","105.81","366.90","1 through 10","17.36","44.52","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","56.00","42.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","39.20","70","","512.90","74.70","612.85","1 through 10","17.36","44.52","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","56.00","42.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","44.52","79.5","","200.27","182.80","200.27","1 through 10","17.36","44.52","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","56.00","42.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","29.85","53.3","","37.73","37.73","169.33","1 through 10","17.36","44.52","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","56.00","42.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","36.40","65","","100.27","8.48","494.52","1 through 10","17.36","44.52","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","56.00","42.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","36.40","65","","160.19","160.19","160.19","1 through 10","17.36","44.52","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","56.00","42.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","17.36","31","","28.12","28.12","28.12","1 through 10","17.36","44.52","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","56.00","42.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20.44","36.5","","101.66","28.85","502.70","121","17.36","44.52","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","56.00","42.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21.45","38.3","","61.58","25.32","328.44","138","17.36","44.52","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","56.00","42.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.02","42.9","","71.66","71.66","71.66","1 through 10","17.36","44.52","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","56.00","42.00","WELLPOINT [1015]","HB AMC WELLPOINT","41.32","73.78","","74.75","27.97","425.28","93","17.36","44.52","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","56.00","42.00","AETNA [1001]","HB AMC AETNA HMO","39.09","69.8","","52.67","14.36","414.90","1 through 10","29.27","45.76","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","56.00","42.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","29.27","52.26","","25.34","25.34","25.34","1 through 10","29.27","45.76","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","56.00","42.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","45.02","80.4","","478.02","107.84","478.02","1 through 10","29.27","45.76","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","56.00","42.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","45.76","81.72","","32.74","12.33","122.05","1 through 10","29.27","45.76","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","56.00","42.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","45.76","81.72","","144.95","32.78","676.91","104","29.27","45.76","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","52.50","39.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","27.44","52.26","","25.34","25.34","25.34","1 through 10","16.28","41.74","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","52.50","39.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","37.70","71.8","","105.81","105.81","366.90","1 through 10","16.28","41.74","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","52.50","39.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","36.75","70","","512.90","74.70","612.85","1 through 10","16.28","41.74","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","52.50","39.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","41.74","79.5","","200.27","182.80","200.27","1 through 10","16.28","41.74","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","52.50","39.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","27.98","53.3","","37.73","37.73","169.33","1 through 10","16.28","41.74","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","52.50","39.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","34.13","65","","100.27","8.48","494.52","1 through 10","16.28","41.74","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","52.50","39.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","34.13","65","","160.19","160.19","160.19","1 through 10","16.28","41.74","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","52.50","39.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","16.28","31","","28.12","28.12","28.12","1 through 10","16.28","41.74","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","52.50","39.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19.16","36.5","","101.66","28.85","502.70","121","16.28","41.74","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","52.50","39.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20.11","38.3","","61.58","25.32","328.44","138","16.28","41.74","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","52.50","39.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","22.52","42.9","","71.66","71.66","71.66","1 through 10","16.28","41.74","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","52.50","39.37","WELLPOINT [1015]","HB AMC WELLPOINT","38.73","73.78","","74.75","27.97","425.28","93","16.28","41.74","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","AETNA [1001]","HB AMC AETNA HMO","36.65","69.8","","52.67","14.36","414.90","1 through 10","27.44","42.9","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","27.44","52.26","","25.34","25.34","25.34","1 through 10","27.44","42.9","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","42.21","80.4","","478.02","107.84","478.02","1 through 10","27.44","42.9","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","42.90","81.72","","32.74","12.33","122.05","1 through 10","27.44","42.9","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","42.90","81.72","","144.95","32.78","676.91","104","27.44","42.9","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","25.34","25.34","25.34","1 through 10","542.5","1391.25","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1256.50","71.8","","105.81","105.81","366.90","1 through 10","542.5","1391.25","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1225.00","70","","512.90","74.70","612.85","1 through 10","542.5","1391.25","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","200.27","182.80","200.27","1 through 10","542.5","1391.25","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","37.73","37.73","169.33","1 through 10","542.5","1391.25","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1137.50","65","","100.27","8.48","494.52","1 through 10","542.5","1391.25","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","1137.50","65","","160.19","160.19","160.19","1 through 10","542.5","1391.25","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","542.50","31","","28.12","28.12","28.12","1 through 10","542.5","1391.25","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","101.66","28.85","502.70","121","542.5","1391.25","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","61.58","25.32","328.44","138","542.5","1391.25","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","71.66","71.66","71.66","1 through 10","542.5","1391.25","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","74.75","27.97","425.28","93","542.5","1391.25","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","52.67","14.36","414.90","1 through 10","914.55","1430.1","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","25.34","25.34","25.34","1 through 10","914.55","1430.1","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","478.02","107.84","478.02","1 through 10","914.55","1430.1","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1430.10","81.72","","32.74","12.33","122.05","1 through 10","914.55","1430.1","percent of total billed charges",""
"GUIDEWIRE CARDIOVASCULAR .018INX260CM 8CM STIFF STRAIGHT TIP IMPELLA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10308358","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","144.95","32.78","676.91","104","914.55","1430.1","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","148.33","111.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","77.52","52.26","","25.34","25.34","25.34","1 through 10","45.98","117.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","148.33","111.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","106.50","71.8","","105.81","105.81","366.90","1 through 10","45.98","117.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","148.33","111.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","103.83","70","","512.90","74.70","612.85","1 through 10","45.98","117.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","148.33","111.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","117.92","79.5","","200.27","182.80","200.27","1 through 10","45.98","117.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","148.33","111.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","79.06","53.3","","37.73","37.73","169.33","1 through 10","45.98","117.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","148.33","111.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","96.41","65","","100.27","8.48","494.52","1 through 10","45.98","117.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","148.33","111.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","96.41","65","","160.19","160.19","160.19","1 through 10","45.98","117.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","148.33","111.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.98","31","","28.12","28.12","28.12","1 through 10","45.98","117.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","148.33","111.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54.14","36.5","","101.66","28.85","502.70","121","45.98","117.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","148.33","111.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.81","38.3","","61.58","25.32","328.44","138","45.98","117.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","148.33","111.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.63","42.9","","71.66","71.66","71.66","1 through 10","45.98","117.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","148.33","111.25","WELLPOINT [1015]","HB AMC WELLPOINT","109.44","73.78","","74.75","27.97","425.28","93","45.98","117.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","148.33","111.25","AETNA [1001]","HB AMC AETNA HMO","103.53","69.8","","52.67","14.36","414.90","1 through 10","77.52","121.22","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","148.33","111.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","77.52","52.26","","25.34","25.34","25.34","1 through 10","77.52","121.22","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","148.33","111.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","119.26","80.4","","478.02","107.84","478.02","1 through 10","77.52","121.22","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","148.33","111.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","121.22","81.72","","32.74","12.33","122.05","1 through 10","77.52","121.22","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","148.33","111.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","121.22","81.72","","144.95","32.78","676.91","104","77.52","121.22","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.01","44.26","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","30.84","52.26","","25.34","25.34","25.34","1 through 10","18.29","46.91","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.01","44.26","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","42.37","71.8","","105.81","105.81","366.90","1 through 10","18.29","46.91","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.01","44.26","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","41.31","70","","512.90","74.70","612.85","1 through 10","18.29","46.91","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.01","44.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46.91","79.5","","200.27","182.80","200.27","1 through 10","18.29","46.91","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.01","44.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","31.45","53.3","","37.73","37.73","169.33","1 through 10","18.29","46.91","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.01","44.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","38.36","65","","100.27","8.48","494.52","1 through 10","18.29","46.91","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.01","44.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","38.36","65","","160.19","160.19","160.19","1 through 10","18.29","46.91","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.01","44.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","18.29","31","","28.12","28.12","28.12","1 through 10","18.29","46.91","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.01","44.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21.54","36.5","","101.66","28.85","502.70","121","18.29","46.91","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.01","44.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22.60","38.3","","61.58","25.32","328.44","138","18.29","46.91","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.01","44.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.32","42.9","","71.66","71.66","71.66","1 through 10","18.29","46.91","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.01","44.26","WELLPOINT [1015]","HB AMC WELLPOINT","43.54","73.78","","74.75","27.97","425.28","93","18.29","46.91","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","59.01","44.26","AETNA [1001]","HB AMC AETNA HMO","41.19","69.8","","52.67","14.36","414.90","1 through 10","30.84","48.22","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","59.01","44.26","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","30.84","52.26","","25.34","25.34","25.34","1 through 10","30.84","48.22","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","59.01","44.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","47.44","80.4","","478.02","107.84","478.02","1 through 10","30.84","48.22","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","59.01","44.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","48.22","81.72","","32.74","12.33","122.05","1 through 10","30.84","48.22","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 150CM L .038IN UROLOGY J WIRE/STIFF PTFE COATED","SUP-ITM-10155646","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","59.01","44.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","48.22","81.72","","144.95","32.78","676.91","104","30.84","48.22","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","36.84","52.26","","25.34","25.34","25.34","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","50.61","71.8","","105.81","105.81","366.90","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","49.34","70","","512.90","74.70","612.85","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","56.04","79.5","","200.27","182.80","200.27","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37.57","53.3","","37.73","37.73","169.33","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","45.82","65","","100.27","8.48","494.52","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","45.82","65","","160.19","160.19","160.19","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","21.85","31","","28.12","28.12","28.12","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25.73","36.5","","101.66","28.85","502.70","121","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27.00","38.3","","61.58","25.32","328.44","138","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.24","42.9","","71.66","71.66","71.66","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","WELLPOINT [1015]","HB AMC WELLPOINT","52.01","73.78","","74.75","27.97","425.28","93","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.49","52.87","AETNA [1001]","HB AMC AETNA HMO","49.20","69.8","","52.67","14.36","414.90","1 through 10","36.84","57.6","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.49","52.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","36.84","52.26","","25.34","25.34","25.34","1 through 10","36.84","57.6","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.49","52.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","56.67","80.4","","478.02","107.84","478.02","1 through 10","36.84","57.6","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.49","52.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","57.60","81.72","","32.74","12.33","122.05","1 through 10","36.84","57.6","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 15CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE BENTSON STRAIGHT TIP","SUP-ITM-10155650","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.49","52.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","57.60","81.72","","144.95","32.78","676.91","104","36.84","57.6","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","51.00","38.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","26.65","52.26","","25.34","25.34","25.34","1 through 10","15.81","40.55","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","51.00","38.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","36.62","71.8","","105.81","105.81","366.90","1 through 10","15.81","40.55","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","51.00","38.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","35.70","70","","512.90","74.70","612.85","1 through 10","15.81","40.55","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","51.00","38.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","40.55","79.5","","200.27","182.80","200.27","1 through 10","15.81","40.55","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","51.00","38.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","27.18","53.3","","37.73","37.73","169.33","1 through 10","15.81","40.55","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","51.00","38.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","33.15","65","","100.27","8.48","494.52","1 through 10","15.81","40.55","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","51.00","38.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","33.15","65","","160.19","160.19","160.19","1 through 10","15.81","40.55","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","51.00","38.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","15.81","31","","28.12","28.12","28.12","1 through 10","15.81","40.55","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","51.00","38.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","18.62","36.5","","101.66","28.85","502.70","121","15.81","40.55","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","51.00","38.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","19.53","38.3","","61.58","25.32","328.44","138","15.81","40.55","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","51.00","38.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21.88","42.9","","71.66","71.66","71.66","1 through 10","15.81","40.55","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","51.00","38.25","WELLPOINT [1015]","HB AMC WELLPOINT","37.63","73.78","","74.75","27.97","425.28","93","15.81","40.55","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","51.00","38.25","AETNA [1001]","HB AMC AETNA HMO","35.60","69.8","","52.67","14.36","414.90","1 through 10","26.65","41.68","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","51.00","38.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","26.65","52.26","","25.34","25.34","25.34","1 through 10","26.65","41.68","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","51.00","38.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","41.00","80.4","","478.02","107.84","478.02","1 through 10","26.65","41.68","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","51.00","38.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","41.68","81.72","","32.74","12.33","122.05","1 through 10","26.65","41.68","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","51.00","38.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","41.68","81.72","","144.95","32.78","676.91","104","26.65","41.68","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","36.84","52.26","","25.34","25.34","25.34","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","50.61","71.8","","105.81","105.81","366.90","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","49.34","70","","512.90","74.70","612.85","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","56.04","79.5","","200.27","182.80","200.27","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37.57","53.3","","37.73","37.73","169.33","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","45.82","65","","100.27","8.48","494.52","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","45.82","65","","160.19","160.19","160.19","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","21.85","31","","28.12","28.12","28.12","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25.73","36.5","","101.66","28.85","502.70","121","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27.00","38.3","","61.58","25.32","328.44","138","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.24","42.9","","71.66","71.66","71.66","1 through 10","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","both","","","70.49","52.87","WELLPOINT [1015]","HB AMC WELLPOINT","52.01","73.78","","74.75","27.97","425.28","93","21.85","56.04","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.49","52.87","AETNA [1001]","HB AMC AETNA HMO","49.20","69.8","","52.67","14.36","414.90","1 through 10","36.84","57.6","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.49","52.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","36.84","52.26","","25.34","25.34","25.34","1 through 10","36.84","57.6","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.49","52.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","56.67","80.4","","478.02","107.84","478.02","1 through 10","36.84","57.6","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.49","52.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","57.60","81.72","","32.74","12.33","122.05","1 through 10","36.84","57.6","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3X150CM .038IN ENDOSCOPY UROLOGICALSENOR DUAL STRAIGHT FLEXIBLE TIP PTFE COATED","SUP-ITM-10155769","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","70.49","52.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","57.60","81.72","","144.95","32.78","676.91","104","36.84","57.6","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.00","21.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","14.63","52.26","","25.34","25.34","25.34","1 through 10","8.68","22.26","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.00","21.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","20.10","71.8","","105.81","105.81","366.90","1 through 10","8.68","22.26","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.00","21.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","19.60","70","","512.90","74.70","612.85","1 through 10","8.68","22.26","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.00","21.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","22.26","79.5","","200.27","182.80","200.27","1 through 10","8.68","22.26","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.00","21.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14.92","53.3","","37.73","37.73","169.33","1 through 10","8.68","22.26","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.00","21.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","18.20","65","","100.27","8.48","494.52","1 through 10","8.68","22.26","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.00","21.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","18.20","65","","160.19","160.19","160.19","1 through 10","8.68","22.26","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.00","21.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","8.68","31","","28.12","28.12","28.12","1 through 10","8.68","22.26","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.00","21.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10.22","36.5","","101.66","28.85","502.70","121","8.68","22.26","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.00","21.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10.72","38.3","","61.58","25.32","328.44","138","8.68","22.26","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.00","21.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12.01","42.9","","71.66","71.66","71.66","1 through 10","8.68","22.26","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.00","21.00","WELLPOINT [1015]","HB AMC WELLPOINT","20.66","73.78","","74.75","27.97","425.28","93","8.68","22.26","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","28.00","21.00","AETNA [1001]","HB AMC AETNA HMO","19.54","69.8","","52.67","14.36","414.90","1 through 10","14.63","22.88","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","28.00","21.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","14.63","52.26","","25.34","25.34","25.34","1 through 10","14.63","22.88","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","28.00","21.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","22.51","80.4","","478.02","107.84","478.02","1 through 10","14.63","22.88","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","28.00","21.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","22.88","81.72","","32.74","12.33","122.05","1 through 10","14.63","22.88","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC .035INX175CM EMERALD FIXED-CORE PTFE COATED 3MM J-CURVE BX/5EA","SUP-ITM-10008269","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","28.00","21.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22.88","81.72","","144.95","32.78","676.91","104","14.63","22.88","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.91","21.68","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","15.11","52.26","","25.34","25.34","25.34","1 through 10","8.96","22.98","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.91","21.68","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","20.76","71.8","","105.81","105.81","366.90","1 through 10","8.96","22.98","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.91","21.68","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","20.24","70","","512.90","74.70","612.85","1 through 10","8.96","22.98","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.91","21.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","22.98","79.5","","200.27","182.80","200.27","1 through 10","8.96","22.98","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.91","21.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","15.41","53.3","","37.73","37.73","169.33","1 through 10","8.96","22.98","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.91","21.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","18.79","65","","100.27","8.48","494.52","1 through 10","8.96","22.98","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.91","21.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","18.79","65","","160.19","160.19","160.19","1 through 10","8.96","22.98","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.91","21.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","8.96","31","","28.12","28.12","28.12","1 through 10","8.96","22.98","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.91","21.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10.55","36.5","","101.66","28.85","502.70","121","8.96","22.98","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.91","21.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11.07","38.3","","61.58","25.32","328.44","138","8.96","22.98","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.91","21.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12.40","42.9","","71.66","71.66","71.66","1 through 10","8.96","22.98","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","28.91","21.68","WELLPOINT [1015]","HB AMC WELLPOINT","21.33","73.78","","74.75","27.97","425.28","93","8.96","22.98","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","28.91","21.68","AETNA [1001]","HB AMC AETNA HMO","20.18","69.8","","52.67","14.36","414.90","1 through 10","15.11","23.63","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","28.91","21.68","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","15.11","52.26","","25.34","25.34","25.34","1 through 10","15.11","23.63","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","28.91","21.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","23.24","80.4","","478.02","107.84","478.02","1 through 10","15.11","23.63","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","28.91","21.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","23.63","81.72","","32.74","12.33","122.05","1 through 10","15.11","23.63","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","28.91","21.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","23.63","81.72","","144.95","32.78","676.91","104","15.11","23.63","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","301.80","52.26","","25.34","25.34","25.34","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","414.65","71.8","","105.81","105.81","366.90","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","404.25","70","","512.90","74.70","612.85","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","459.11","79.5","","200.27","182.80","200.27","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","307.81","53.3","","37.73","37.73","169.33","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","375.38","65","","100.27","8.48","494.52","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","375.38","65","","160.19","160.19","160.19","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","179.03","31","","28.12","28.12","28.12","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","210.79","36.5","","101.66","28.85","502.70","121","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","221.18","38.3","","61.58","25.32","328.44","138","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.75","42.9","","71.66","71.66","71.66","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","WELLPOINT [1015]","HB AMC WELLPOINT","426.08","73.78","","74.75","27.97","425.28","93","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","577.50","433.12","AETNA [1001]","HB AMC AETNA HMO","403.10","69.8","","52.67","14.36","414.90","1 through 10","301.8","471.93","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","577.50","433.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","301.80","52.26","","25.34","25.34","25.34","1 through 10","301.8","471.93","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","464.31","80.4","","478.02","107.84","478.02","1 through 10","301.8","471.93","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","471.93","81.72","","32.74","12.33","122.05","1 through 10","301.8","471.93","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE .035IN 260CM BILIARY NITINOL ENDOGALIDE COATED ANGLED TIP ROUND BX/2EA","SUP-ITM-10210624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","471.93","81.72","","144.95","32.78","676.91","104","301.8","471.93","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","301.80","52.26","","25.34","25.34","25.34","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","414.65","71.8","","105.81","105.81","366.90","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","404.25","70","","512.90","74.70","612.85","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","459.11","79.5","","200.27","182.80","200.27","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","307.81","53.3","","37.73","37.73","169.33","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","375.38","65","","100.27","8.48","494.52","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","375.38","65","","160.19","160.19","160.19","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","179.03","31","","28.12","28.12","28.12","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","210.79","36.5","","101.66","28.85","502.70","121","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","221.18","38.3","","61.58","25.32","328.44","138","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.75","42.9","","71.66","71.66","71.66","1 through 10","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","577.50","433.12","WELLPOINT [1015]","HB AMC WELLPOINT","426.08","73.78","","74.75","27.97","425.28","93","179.03","459.11","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","577.50","433.12","AETNA [1001]","HB AMC AETNA HMO","403.10","69.8","","52.67","14.36","414.90","1 through 10","301.8","471.93","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","577.50","433.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","301.80","52.26","","25.34","25.34","25.34","1 through 10","301.8","471.93","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","464.31","80.4","","478.02","107.84","478.02","1 through 10","301.8","471.93","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","471.93","81.72","","32.74","12.33","122.05","1 through 10","301.8","471.93","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","471.93","81.72","","144.95","32.78","676.91","104","301.8","471.93","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","both","","","598.61","448.96","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","312.83","52.26","","25.34","25.34","25.34","1 through 10","185.57","475.89","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","both","","","598.61","448.96","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","429.80","71.8","","105.81","105.81","366.90","1 through 10","185.57","475.89","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","both","","","598.61","448.96","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","419.03","70","","512.90","74.70","612.85","1 through 10","185.57","475.89","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","both","","","598.61","448.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","475.89","79.5","","200.27","182.80","200.27","1 through 10","185.57","475.89","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","both","","","598.61","448.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","319.06","53.3","","37.73","37.73","169.33","1 through 10","185.57","475.89","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","both","","","598.61","448.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","389.10","65","","100.27","8.48","494.52","1 through 10","185.57","475.89","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","both","","","598.61","448.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","389.10","65","","160.19","160.19","160.19","1 through 10","185.57","475.89","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","both","","","598.61","448.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","185.57","31","","28.12","28.12","28.12","1 through 10","185.57","475.89","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","both","","","598.61","448.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","218.49","36.5","","101.66","28.85","502.70","121","185.57","475.89","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","both","","","598.61","448.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","229.27","38.3","","61.58","25.32","328.44","138","185.57","475.89","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","both","","","598.61","448.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","256.80","42.9","","71.66","71.66","71.66","1 through 10","185.57","475.89","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","both","","","598.61","448.96","WELLPOINT [1015]","HB AMC WELLPOINT","441.65","73.78","","74.75","27.97","425.28","93","185.57","475.89","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","598.61","448.96","AETNA [1001]","HB AMC AETNA HMO","417.83","69.8","","52.67","14.36","414.90","1 through 10","312.83","489.18","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","598.61","448.96","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","312.83","52.26","","25.34","25.34","25.34","1 through 10","312.83","489.18","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","598.61","448.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","481.28","80.4","","478.02","107.84","478.02","1 through 10","312.83","489.18","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","598.61","448.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","489.18","81.72","","32.74","12.33","122.05","1 through 10","312.83","489.18","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 450CM 0.025IN VISIGLIDE STRAIGHT TIP HYDROPHILIC COATING","SUP-ITM-10150964","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","598.61","448.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","489.18","81.72","","144.95","32.78","676.91","104","312.83","489.18","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","630.88","473.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","329.70","52.26","","25.34","25.34","25.34","1 through 10","195.57","501.55","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","630.88","473.16","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","452.97","71.8","","105.81","105.81","366.90","1 through 10","195.57","501.55","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","630.88","473.16","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","441.62","70","","512.90","74.70","612.85","1 through 10","195.57","501.55","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","630.88","473.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","501.55","79.5","","200.27","182.80","200.27","1 through 10","195.57","501.55","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","630.88","473.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","336.26","53.3","","37.73","37.73","169.33","1 through 10","195.57","501.55","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","630.88","473.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","410.07","65","","100.27","8.48","494.52","1 through 10","195.57","501.55","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","630.88","473.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","410.07","65","","160.19","160.19","160.19","1 through 10","195.57","501.55","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","630.88","473.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","195.57","31","","28.12","28.12","28.12","1 through 10","195.57","501.55","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","630.88","473.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","230.27","36.5","","101.66","28.85","502.70","121","195.57","501.55","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","630.88","473.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","241.63","38.3","","61.58","25.32","328.44","138","195.57","501.55","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","630.88","473.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","270.65","42.9","","71.66","71.66","71.66","1 through 10","195.57","501.55","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","630.88","473.16","WELLPOINT [1015]","HB AMC WELLPOINT","465.46","73.78","","74.75","27.97","425.28","93","195.57","501.55","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","630.88","473.16","AETNA [1001]","HB AMC AETNA HMO","440.35","69.8","","52.67","14.36","414.90","1 through 10","329.7","515.56","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","630.88","473.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","329.70","52.26","","25.34","25.34","25.34","1 through 10","329.7","515.56","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","630.88","473.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","507.23","80.4","","478.02","107.84","478.02","1 through 10","329.7","515.56","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","630.88","473.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","515.56","81.72","","32.74","12.33","122.05","1 through 10","329.7","515.56","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","630.88","473.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","515.56","81.72","","144.95","32.78","676.91","104","329.7","515.56","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","both","","","507.50","380.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","265.22","52.26","","25.34","25.34","25.34","1 through 10","157.33","403.46","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","both","","","507.50","380.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","364.39","71.8","","105.81","105.81","366.90","1 through 10","157.33","403.46","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","both","","","507.50","380.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","355.25","70","","512.90","74.70","612.85","1 through 10","157.33","403.46","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","both","","","507.50","380.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.46","79.5","","200.27","182.80","200.27","1 through 10","157.33","403.46","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","both","","","507.50","380.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.50","53.3","","37.73","37.73","169.33","1 through 10","157.33","403.46","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","both","","","507.50","380.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","329.88","65","","100.27","8.48","494.52","1 through 10","157.33","403.46","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","both","","","507.50","380.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","329.88","65","","160.19","160.19","160.19","1 through 10","157.33","403.46","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","157.33","31","","28.12","28.12","28.12","1 through 10","157.33","403.46","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.24","36.5","","101.66","28.85","502.70","121","157.33","403.46","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.37","38.3","","61.58","25.32","328.44","138","157.33","403.46","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","both","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.72","42.9","","71.66","71.66","71.66","1 through 10","157.33","403.46","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","both","","","507.50","380.62","WELLPOINT [1015]","HB AMC WELLPOINT","374.43","73.78","","74.75","27.97","425.28","93","157.33","403.46","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","507.50","380.62","AETNA [1001]","HB AMC AETNA HMO","354.24","69.8","","52.67","14.36","414.90","1 through 10","265.22","414.73","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","507.50","380.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","265.22","52.26","","25.34","25.34","25.34","1 through 10","265.22","414.73","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","507.50","380.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","408.03","80.4","","478.02","107.84","478.02","1 through 10","265.22","414.73","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","414.73","81.72","","32.74","12.33","122.05","1 through 10","265.22","414.73","percent of total billed charges",""
"GUIDEWIRE ENROUTE .014IN 95CM BX/5EA","SUP-ITM-10159277","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","414.73","81.72","","144.95","32.78","676.91","104","265.22","414.73","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","both","","","978.78","734.08","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","511.51","52.26","","25.34","25.34","25.34","1 through 10","303.42","778.13","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","both","","","978.78","734.08","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","702.76","71.8","","105.81","105.81","366.90","1 through 10","303.42","778.13","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","both","","","978.78","734.08","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","685.15","70","","512.90","74.70","612.85","1 through 10","303.42","778.13","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","both","","","978.78","734.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","778.13","79.5","","200.27","182.80","200.27","1 through 10","303.42","778.13","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","both","","","978.78","734.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","521.69","53.3","","37.73","37.73","169.33","1 through 10","303.42","778.13","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","both","","","978.78","734.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","636.21","65","","100.27","8.48","494.52","1 through 10","303.42","778.13","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","both","","","978.78","734.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","636.21","65","","160.19","160.19","160.19","1 through 10","303.42","778.13","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","both","","","978.78","734.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","303.42","31","","28.12","28.12","28.12","1 through 10","303.42","778.13","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","both","","","978.78","734.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","357.25","36.5","","101.66","28.85","502.70","121","303.42","778.13","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","both","","","978.78","734.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","374.87","38.3","","61.58","25.32","328.44","138","303.42","778.13","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","both","","","978.78","734.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","419.90","42.9","","71.66","71.66","71.66","1 through 10","303.42","778.13","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","both","","","978.78","734.08","WELLPOINT [1015]","HB AMC WELLPOINT","722.14","73.78","","74.75","27.97","425.28","93","303.42","778.13","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","978.78","734.08","AETNA [1001]","HB AMC AETNA HMO","683.19","69.8","","52.67","14.36","414.90","1 through 10","511.51","799.86","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","978.78","734.08","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","511.51","52.26","","25.34","25.34","25.34","1 through 10","511.51","799.86","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","978.78","734.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","786.94","80.4","","478.02","107.84","478.02","1 through 10","511.51","799.86","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","978.78","734.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","799.86","81.72","","32.74","12.33","122.05","1 through 10","511.51","799.86","percent of total billed charges",""
"GUIDEWIRE FATHOM-14 10CM 200CM .014IN EMBOLIZATION STRAIGHT TIP S/S HYDROPHILIC COATED STEERABLE PERIPHERAL","SUP-ITM-10166160","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","978.78","734.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","799.86","81.72","","144.95","32.78","676.91","104","511.51","799.86","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","both","","","954.07","715.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","498.60","52.26","","25.34","25.34","25.34","1 through 10","295.76","758.49","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","both","","","954.07","715.55","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","685.02","71.8","","105.81","105.81","366.90","1 through 10","295.76","758.49","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","both","","","954.07","715.55","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","667.85","70","","512.90","74.70","612.85","1 through 10","295.76","758.49","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","both","","","954.07","715.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","758.49","79.5","","200.27","182.80","200.27","1 through 10","295.76","758.49","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","both","","","954.07","715.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","508.52","53.3","","37.73","37.73","169.33","1 through 10","295.76","758.49","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","both","","","954.07","715.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","620.15","65","","100.27","8.48","494.52","1 through 10","295.76","758.49","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","both","","","954.07","715.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","620.15","65","","160.19","160.19","160.19","1 through 10","295.76","758.49","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","both","","","954.07","715.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","295.76","31","","28.12","28.12","28.12","1 through 10","295.76","758.49","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","both","","","954.07","715.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","348.24","36.5","","101.66","28.85","502.70","121","295.76","758.49","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","both","","","954.07","715.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","365.41","38.3","","61.58","25.32","328.44","138","295.76","758.49","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","both","","","954.07","715.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.30","42.9","","71.66","71.66","71.66","1 through 10","295.76","758.49","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","both","","","954.07","715.55","WELLPOINT [1015]","HB AMC WELLPOINT","703.91","73.78","","74.75","27.97","425.28","93","295.76","758.49","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","954.07","715.55","AETNA [1001]","HB AMC AETNA HMO","665.94","69.8","","52.67","14.36","414.90","1 through 10","498.6","779.67","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","954.07","715.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","498.60","52.26","","25.34","25.34","25.34","1 through 10","498.6","779.67","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","954.07","715.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","767.07","80.4","","478.02","107.84","478.02","1 through 10","498.6","779.67","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","954.07","715.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","779.67","81.72","","32.74","12.33","122.05","1 through 10","498.6","779.67","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 180CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10079548","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","954.07","715.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","779.67","81.72","","144.95","32.78","676.91","104","498.6","779.67","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.00","315.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","219.49","52.26","","25.34","25.34","25.34","1 through 10","130.2","333.9","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.00","315.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","301.56","71.8","","105.81","105.81","366.90","1 through 10","130.2","333.9","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.00","315.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","294.00","70","","512.90","74.70","612.85","1 through 10","130.2","333.9","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.00","315.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","333.90","79.5","","200.27","182.80","200.27","1 through 10","130.2","333.9","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.00","315.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","223.86","53.3","","37.73","37.73","169.33","1 through 10","130.2","333.9","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","273.00","65","","100.27","8.48","494.52","1 through 10","130.2","333.9","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","273.00","65","","160.19","160.19","160.19","1 through 10","130.2","333.9","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","130.20","31","","28.12","28.12","28.12","1 through 10","130.2","333.9","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","153.30","36.5","","101.66","28.85","502.70","121","130.2","333.9","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","160.86","38.3","","61.58","25.32","328.44","138","130.2","333.9","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.18","42.9","","71.66","71.66","71.66","1 through 10","130.2","333.9","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.00","315.00","WELLPOINT [1015]","HB AMC WELLPOINT","309.88","73.78","","74.75","27.97","425.28","93","130.2","333.9","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","420.00","315.00","AETNA [1001]","HB AMC AETNA HMO","293.16","69.8","","52.67","14.36","414.90","1 through 10","219.49","343.22","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","420.00","315.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","219.49","52.26","","25.34","25.34","25.34","1 through 10","219.49","343.22","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","337.68","80.4","","478.02","107.84","478.02","1 through 10","219.49","343.22","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","343.22","81.72","","32.74","12.33","122.05","1 through 10","219.49","343.22","percent of total billed charges",""
"GUIDEWIRE GLADIUS MONGO 190CM .014IN PTCA STRAIGHT US BX/5EA","SUP-ITM-10237547","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","343.22","81.72","","144.95","32.78","676.91","104","219.49","343.22","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","both","","","929.25","696.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","485.63","52.26","","25.34","25.34","25.34","1 through 10","288.07","738.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","both","","","929.25","696.94","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","667.20","71.8","","105.81","105.81","366.90","1 through 10","288.07","738.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","both","","","929.25","696.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","650.48","70","","512.90","74.70","612.85","1 through 10","288.07","738.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","both","","","929.25","696.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","738.75","79.5","","200.27","182.80","200.27","1 through 10","288.07","738.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","both","","","929.25","696.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","495.29","53.3","","37.73","37.73","169.33","1 through 10","288.07","738.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","both","","","929.25","696.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","604.01","65","","100.27","8.48","494.52","1 through 10","288.07","738.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","both","","","929.25","696.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","604.01","65","","160.19","160.19","160.19","1 through 10","288.07","738.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","both","","","929.25","696.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","288.07","31","","28.12","28.12","28.12","1 through 10","288.07","738.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","both","","","929.25","696.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","339.18","36.5","","101.66","28.85","502.70","121","288.07","738.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","both","","","929.25","696.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","355.90","38.3","","61.58","25.32","328.44","138","288.07","738.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","both","","","929.25","696.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","398.65","42.9","","71.66","71.66","71.66","1 through 10","288.07","738.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","both","","","929.25","696.94","WELLPOINT [1015]","HB AMC WELLPOINT","685.60","73.78","","74.75","27.97","425.28","93","288.07","738.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","929.25","696.94","AETNA [1001]","HB AMC AETNA HMO","648.62","69.8","","52.67","14.36","414.90","1 through 10","485.63","759.38","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","929.25","696.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","485.63","52.26","","25.34","25.34","25.34","1 through 10","485.63","759.38","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","929.25","696.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","747.12","80.4","","478.02","107.84","478.02","1 through 10","485.63","759.38","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","929.25","696.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","759.38","81.72","","32.74","12.33","122.05","1 through 10","485.63","759.38","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .014IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281349","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","929.25","696.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","759.38","81.72","","144.95","32.78","676.91","104","485.63","759.38","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","both","","","906.50","679.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","473.74","52.26","","25.34","25.34","25.34","1 through 10","281.02","720.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","both","","","906.50","679.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","650.87","71.8","","105.81","105.81","366.90","1 through 10","281.02","720.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","both","","","906.50","679.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","634.55","70","","512.90","74.70","612.85","1 through 10","281.02","720.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","both","","","906.50","679.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","720.67","79.5","","200.27","182.80","200.27","1 through 10","281.02","720.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","both","","","906.50","679.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","483.16","53.3","","37.73","37.73","169.33","1 through 10","281.02","720.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","both","","","906.50","679.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","589.23","65","","100.27","8.48","494.52","1 through 10","281.02","720.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","both","","","906.50","679.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","589.23","65","","160.19","160.19","160.19","1 through 10","281.02","720.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","both","","","906.50","679.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","281.02","31","","28.12","28.12","28.12","1 through 10","281.02","720.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","both","","","906.50","679.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","330.87","36.5","","101.66","28.85","502.70","121","281.02","720.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","both","","","906.50","679.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","347.19","38.3","","61.58","25.32","328.44","138","281.02","720.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","both","","","906.50","679.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","388.89","42.9","","71.66","71.66","71.66","1 through 10","281.02","720.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","both","","","906.50","679.87","WELLPOINT [1015]","HB AMC WELLPOINT","668.82","73.78","","74.75","27.97","425.28","93","281.02","720.67","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","906.50","679.87","AETNA [1001]","HB AMC AETNA HMO","632.74","69.8","","52.67","14.36","414.90","1 through 10","473.74","740.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","906.50","679.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","473.74","52.26","","25.34","25.34","25.34","1 through 10","473.74","740.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","906.50","679.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","728.83","80.4","","478.02","107.84","478.02","1 through 10","473.74","740.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","906.50","679.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","740.79","81.72","","32.74","12.33","122.05","1 through 10","473.74","740.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .018IN 300CM 35DEG ANGLED ADVANTAGE TRACK PERIPHERAL BX/1EA","SUP-ITM-10281347","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","906.50","679.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","740.79","81.72","","144.95","32.78","676.91","104","473.74","740.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","both","","","1330.00","997.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","695.06","52.26","","25.34","25.34","25.34","1 through 10","412.3","1057.35","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","both","","","1330.00","997.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","954.94","71.8","","105.81","105.81","366.90","1 through 10","412.3","1057.35","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","both","","","1330.00","997.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","931.00","70","","512.90","74.70","612.85","1 through 10","412.3","1057.35","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","both","","","1330.00","997.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1057.35","79.5","","200.27","182.80","200.27","1 through 10","412.3","1057.35","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","both","","","1330.00","997.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","708.89","53.3","","37.73","37.73","169.33","1 through 10","412.3","1057.35","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","both","","","1330.00","997.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","864.50","65","","100.27","8.48","494.52","1 through 10","412.3","1057.35","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","both","","","1330.00","997.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","864.50","65","","160.19","160.19","160.19","1 through 10","412.3","1057.35","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","both","","","1330.00","997.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","412.30","31","","28.12","28.12","28.12","1 through 10","412.3","1057.35","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","both","","","1330.00","997.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","485.45","36.5","","101.66","28.85","502.70","121","412.3","1057.35","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","both","","","1330.00","997.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","509.39","38.3","","61.58","25.32","328.44","138","412.3","1057.35","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","both","","","1330.00","997.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","570.57","42.9","","71.66","71.66","71.66","1 through 10","412.3","1057.35","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","both","","","1330.00","997.50","WELLPOINT [1015]","HB AMC WELLPOINT","981.27","73.78","","74.75","27.97","425.28","93","412.3","1057.35","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1330.00","997.50","AETNA [1001]","HB AMC AETNA HMO","928.34","69.8","","52.67","14.36","414.90","1 through 10","695.06","1086.88","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1330.00","997.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","695.06","52.26","","25.34","25.34","25.34","1 through 10","695.06","1086.88","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1330.00","997.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1069.32","80.4","","478.02","107.84","478.02","1 through 10","695.06","1086.88","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1330.00","997.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1086.88","81.72","","32.74","12.33","122.05","1 through 10","695.06","1086.88","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STD HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281340","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1330.00","997.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1086.88","81.72","","144.95","32.78","676.91","104","695.06","1086.88","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","both","","","1487.50","1115.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","777.37","52.26","","25.34","25.34","25.34","1 through 10","461.13","1182.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","both","","","1487.50","1115.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1068.03","71.8","","105.81","105.81","366.90","1 through 10","461.13","1182.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","both","","","1487.50","1115.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1041.25","70","","512.90","74.70","612.85","1 through 10","461.13","1182.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","both","","","1487.50","1115.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1182.56","79.5","","200.27","182.80","200.27","1 through 10","461.13","1182.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","both","","","1487.50","1115.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","792.84","53.3","","37.73","37.73","169.33","1 through 10","461.13","1182.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","both","","","1487.50","1115.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","966.88","65","","100.27","8.48","494.52","1 through 10","461.13","1182.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","both","","","1487.50","1115.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","966.88","65","","160.19","160.19","160.19","1 through 10","461.13","1182.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","461.13","31","","28.12","28.12","28.12","1 through 10","461.13","1182.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","542.94","36.5","","101.66","28.85","502.70","121","461.13","1182.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","569.71","38.3","","61.58","25.32","328.44","138","461.13","1182.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","both","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","638.14","42.9","","71.66","71.66","71.66","1 through 10","461.13","1182.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","both","","","1487.50","1115.62","WELLPOINT [1015]","HB AMC WELLPOINT","1097.48","73.78","","74.75","27.97","425.28","93","461.13","1182.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1487.50","1115.62","AETNA [1001]","HB AMC AETNA HMO","1038.28","69.8","","52.67","14.36","414.90","1 through 10","777.37","1215.59","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1487.50","1115.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","777.37","52.26","","25.34","25.34","25.34","1 through 10","777.37","1215.59","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1487.50","1115.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1195.95","80.4","","478.02","107.84","478.02","1 through 10","777.37","1215.59","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1215.59","81.72","","32.74","12.33","122.05","1 through 10","777.37","1215.59","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE .035IN 400CM 45DEG ANGLE STIFF HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10281330","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1215.59","81.72","","144.95","32.78","676.91","104","777.37","1215.59","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","both","","","199.50","149.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","104.26","52.26","","25.34","25.34","25.34","1 through 10","61.85","158.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","both","","","199.50","149.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","143.24","71.8","","105.81","105.81","366.90","1 through 10","61.85","158.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","both","","","199.50","149.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","139.65","70","","512.90","74.70","612.85","1 through 10","61.85","158.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","both","","","199.50","149.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","158.60","79.5","","200.27","182.80","200.27","1 through 10","61.85","158.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","both","","","199.50","149.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.33","53.3","","37.73","37.73","169.33","1 through 10","61.85","158.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","both","","","199.50","149.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","129.68","65","","100.27","8.48","494.52","1 through 10","61.85","158.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","both","","","199.50","149.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","129.68","65","","160.19","160.19","160.19","1 through 10","61.85","158.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","both","","","199.50","149.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","61.85","31","","28.12","28.12","28.12","1 through 10","61.85","158.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","both","","","199.50","149.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.82","36.5","","101.66","28.85","502.70","121","61.85","158.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","both","","","199.50","149.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.41","38.3","","61.58","25.32","328.44","138","61.85","158.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","both","","","199.50","149.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.59","42.9","","71.66","71.66","71.66","1 through 10","61.85","158.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","both","","","199.50","149.62","WELLPOINT [1015]","HB AMC WELLPOINT","147.19","73.78","","74.75","27.97","425.28","93","61.85","158.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","199.50","149.62","AETNA [1001]","HB AMC AETNA HMO","139.25","69.8","","52.67","14.36","414.90","1 through 10","104.26","163.03","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","199.50","149.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","104.26","52.26","","25.34","25.34","25.34","1 through 10","104.26","163.03","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","199.50","149.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","160.40","80.4","","478.02","107.84","478.02","1 through 10","104.26","163.03","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","199.50","149.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","163.03","81.72","","32.74","12.33","122.05","1 through 10","104.26","163.03","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000141","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","199.50","149.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.03","81.72","","144.95","32.78","676.91","104","104.26","163.03","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","106.75","80.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","55.79","52.26","","25.34","25.34","25.34","1 through 10","33.09","84.87","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","106.75","80.06","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","76.65","71.8","","105.81","105.81","366.90","1 through 10","33.09","84.87","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","106.75","80.06","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","74.73","70","","512.90","74.70","612.85","1 through 10","33.09","84.87","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","106.75","80.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","84.87","79.5","","200.27","182.80","200.27","1 through 10","33.09","84.87","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","106.75","80.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","56.90","53.3","","37.73","37.73","169.33","1 through 10","33.09","84.87","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","106.75","80.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","69.39","65","","100.27","8.48","494.52","1 through 10","33.09","84.87","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","106.75","80.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","69.39","65","","160.19","160.19","160.19","1 through 10","33.09","84.87","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","106.75","80.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","33.09","31","","28.12","28.12","28.12","1 through 10","33.09","84.87","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","106.75","80.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.96","36.5","","101.66","28.85","502.70","121","33.09","84.87","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","106.75","80.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.89","38.3","","61.58","25.32","328.44","138","33.09","84.87","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","106.75","80.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.80","42.9","","71.66","71.66","71.66","1 through 10","33.09","84.87","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","106.75","80.06","WELLPOINT [1015]","HB AMC WELLPOINT","78.76","73.78","","74.75","27.97","425.28","93","33.09","84.87","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","106.75","80.06","AETNA [1001]","HB AMC AETNA HMO","74.51","69.8","","52.67","14.36","414.90","1 through 10","55.79","87.24","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","106.75","80.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","55.79","52.26","","25.34","25.34","25.34","1 through 10","55.79","87.24","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","106.75","80.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","85.83","80.4","","478.02","107.84","478.02","1 through 10","55.79","87.24","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","106.75","80.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","87.24","81.72","","32.74","12.33","122.05","1 through 10","55.79","87.24","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","106.75","80.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.24","81.72","","144.95","32.78","676.91","104","55.79","87.24","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","both","","","114.45","85.84","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","59.81","52.26","","25.34","25.34","25.34","1 through 10","35.48","90.99","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","both","","","114.45","85.84","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","82.18","71.8","","105.81","105.81","366.90","1 through 10","35.48","90.99","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","both","","","114.45","85.84","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","80.12","70","","512.90","74.70","612.85","1 through 10","35.48","90.99","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","both","","","114.45","85.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","90.99","79.5","","200.27","182.80","200.27","1 through 10","35.48","90.99","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","both","","","114.45","85.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","61.00","53.3","","37.73","37.73","169.33","1 through 10","35.48","90.99","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","both","","","114.45","85.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","74.39","65","","100.27","8.48","494.52","1 through 10","35.48","90.99","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","both","","","114.45","85.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","74.39","65","","160.19","160.19","160.19","1 through 10","35.48","90.99","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","both","","","114.45","85.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","35.48","31","","28.12","28.12","28.12","1 through 10","35.48","90.99","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","both","","","114.45","85.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.77","36.5","","101.66","28.85","502.70","121","35.48","90.99","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","both","","","114.45","85.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.83","38.3","","61.58","25.32","328.44","138","35.48","90.99","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","both","","","114.45","85.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.10","42.9","","71.66","71.66","71.66","1 through 10","35.48","90.99","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","both","","","114.45","85.84","WELLPOINT [1015]","HB AMC WELLPOINT","84.44","73.78","","74.75","27.97","425.28","93","35.48","90.99","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","114.45","85.84","AETNA [1001]","HB AMC AETNA HMO","79.89","69.8","","52.67","14.36","414.90","1 through 10","59.81","93.53","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","114.45","85.84","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","59.81","52.26","","25.34","25.34","25.34","1 through 10","59.81","93.53","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","114.45","85.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","92.02","80.4","","478.02","107.84","478.02","1 through 10","59.81","93.53","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","114.45","85.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","93.53","81.72","","32.74","12.33","122.05","1 through 10","59.81","93.53","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .038IN 8CM LONG TAPER ANGLE FLEXIB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000177","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","114.45","85.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.53","81.72","","144.95","32.78","676.91","104","59.81","93.53","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","both","","","197.75","148.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","103.34","52.26","","25.34","25.34","25.34","1 through 10","61.3","157.21","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","both","","","197.75","148.31","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","141.98","71.8","","105.81","105.81","366.90","1 through 10","61.3","157.21","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","both","","","197.75","148.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","138.43","70","","512.90","74.70","612.85","1 through 10","61.3","157.21","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","both","","","197.75","148.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","157.21","79.5","","200.27","182.80","200.27","1 through 10","61.3","157.21","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","both","","","197.75","148.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","105.40","53.3","","37.73","37.73","169.33","1 through 10","61.3","157.21","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","both","","","197.75","148.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","128.54","65","","100.27","8.48","494.52","1 through 10","61.3","157.21","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","both","","","197.75","148.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","128.54","65","","160.19","160.19","160.19","1 through 10","61.3","157.21","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","both","","","197.75","148.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","61.30","31","","28.12","28.12","28.12","1 through 10","61.3","157.21","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","both","","","197.75","148.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.18","36.5","","101.66","28.85","502.70","121","61.3","157.21","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","both","","","197.75","148.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.74","38.3","","61.58","25.32","328.44","138","61.3","157.21","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","both","","","197.75","148.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.83","42.9","","71.66","71.66","71.66","1 through 10","61.3","157.21","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","both","","","197.75","148.31","WELLPOINT [1015]","HB AMC WELLPOINT","145.90","73.78","","74.75","27.97","425.28","93","61.3","157.21","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","197.75","148.31","AETNA [1001]","HB AMC AETNA HMO","138.03","69.8","","52.67","14.36","414.90","1 through 10","103.34","161.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","197.75","148.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","103.34","52.26","","25.34","25.34","25.34","1 through 10","103.34","161.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","197.75","148.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","158.99","80.4","","478.02","107.84","478.02","1 through 10","103.34","161.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","197.75","148.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","161.60","81.72","","32.74","12.33","122.05","1 through 10","103.34","161.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .025IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007479","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","197.75","148.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","161.60","81.72","","144.95","32.78","676.91","104","103.34","161.6","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.25","108.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","75.91","52.26","","25.34","25.34","25.34","1 through 10","45.03","115.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.25","108.94","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","104.29","71.8","","105.81","105.81","366.90","1 through 10","45.03","115.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.25","108.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","101.68","70","","512.90","74.70","612.85","1 through 10","45.03","115.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.25","108.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","115.47","79.5","","200.27","182.80","200.27","1 through 10","45.03","115.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.25","108.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.42","53.3","","37.73","37.73","169.33","1 through 10","45.03","115.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.25","108.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","94.41","65","","100.27","8.48","494.52","1 through 10","45.03","115.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.25","108.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","94.41","65","","160.19","160.19","160.19","1 through 10","45.03","115.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.25","108.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.03","31","","28.12","28.12","28.12","1 through 10","45.03","115.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.25","108.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.02","36.5","","101.66","28.85","502.70","121","45.03","115.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.25","108.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.63","38.3","","61.58","25.32","328.44","138","45.03","115.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.25","108.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.31","42.9","","71.66","71.66","71.66","1 through 10","45.03","115.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.25","108.94","WELLPOINT [1015]","HB AMC WELLPOINT","107.17","73.78","","74.75","27.97","425.28","93","45.03","115.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","145.25","108.94","AETNA [1001]","HB AMC AETNA HMO","101.38","69.8","","52.67","14.36","414.90","1 through 10","75.91","118.7","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","145.25","108.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","75.91","52.26","","25.34","25.34","25.34","1 through 10","75.91","118.7","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","145.25","108.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","116.78","80.4","","478.02","107.84","478.02","1 through 10","75.91","118.7","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","145.25","108.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","118.70","81.72","","32.74","12.33","122.05","1 through 10","75.91","118.7","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","145.25","108.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","118.70","81.72","","144.95","32.78","676.91","104","75.91","118.7","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.50","128.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","89.63","52.26","","25.34","25.34","25.34","1 through 10","53.17","136.34","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.50","128.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","123.14","71.8","","105.81","105.81","366.90","1 through 10","53.17","136.34","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.50","128.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","120.05","70","","512.90","74.70","612.85","1 through 10","53.17","136.34","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.50","128.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","136.34","79.5","","200.27","182.80","200.27","1 through 10","53.17","136.34","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.50","128.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","91.41","53.3","","37.73","37.73","169.33","1 through 10","53.17","136.34","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.50","128.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","111.48","65","","100.27","8.48","494.52","1 through 10","53.17","136.34","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.50","128.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","111.48","65","","160.19","160.19","160.19","1 through 10","53.17","136.34","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.50","128.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","53.17","31","","28.12","28.12","28.12","1 through 10","53.17","136.34","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.50","128.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","62.60","36.5","","101.66","28.85","502.70","121","53.17","136.34","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.50","128.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","65.68","38.3","","61.58","25.32","328.44","138","53.17","136.34","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.50","128.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","73.57","42.9","","71.66","71.66","71.66","1 through 10","53.17","136.34","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.50","128.62","WELLPOINT [1015]","HB AMC WELLPOINT","126.53","73.78","","74.75","27.97","425.28","93","53.17","136.34","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","171.50","128.62","AETNA [1001]","HB AMC AETNA HMO","119.71","69.8","","52.67","14.36","414.90","1 through 10","89.63","140.15","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","171.50","128.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","89.63","52.26","","25.34","25.34","25.34","1 through 10","89.63","140.15","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","171.50","128.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","137.89","80.4","","478.02","107.84","478.02","1 through 10","89.63","140.15","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","171.50","128.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","140.15","81.72","","32.74","12.33","122.05","1 through 10","89.63","140.15","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","171.50","128.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","140.15","81.72","","144.95","32.78","676.91","104","89.63","140.15","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","164.50","123.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","85.97","52.26","","25.34","25.34","25.34","1 through 10","51","130.78","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","164.50","123.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","118.11","71.8","","105.81","105.81","366.90","1 through 10","51","130.78","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","164.50","123.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","115.15","70","","512.90","74.70","612.85","1 through 10","51","130.78","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","164.50","123.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","130.78","79.5","","200.27","182.80","200.27","1 through 10","51","130.78","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","164.50","123.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","87.68","53.3","","37.73","37.73","169.33","1 through 10","51","130.78","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","164.50","123.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","106.93","65","","100.27","8.48","494.52","1 through 10","51","130.78","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","164.50","123.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","106.93","65","","160.19","160.19","160.19","1 through 10","51","130.78","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","164.50","123.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","51.00","31","","28.12","28.12","28.12","1 through 10","51","130.78","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","164.50","123.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.04","36.5","","101.66","28.85","502.70","121","51","130.78","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","164.50","123.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.00","38.3","","61.58","25.32","328.44","138","51","130.78","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","164.50","123.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.57","42.9","","71.66","71.66","71.66","1 through 10","51","130.78","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","164.50","123.37","WELLPOINT [1015]","HB AMC WELLPOINT","121.37","73.78","","74.75","27.97","425.28","93","51","130.78","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","164.50","123.37","AETNA [1001]","HB AMC AETNA HMO","114.82","69.8","","52.67","14.36","414.90","1 through 10","85.97","134.43","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","164.50","123.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","85.97","52.26","","25.34","25.34","25.34","1 through 10","85.97","134.43","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","164.50","123.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","132.26","80.4","","478.02","107.84","478.02","1 through 10","85.97","134.43","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","164.50","123.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","134.43","81.72","","32.74","12.33","122.05","1 through 10","85.97","134.43","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","164.50","123.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","134.43","81.72","","144.95","32.78","676.91","104","85.97","134.43","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.75","137.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","96.03","52.26","","25.34","25.34","25.34","1 through 10","56.96","146.08","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.75","137.81","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","131.93","71.8","","105.81","105.81","366.90","1 through 10","56.96","146.08","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.75","137.81","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","128.63","70","","512.90","74.70","612.85","1 through 10","56.96","146.08","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.75","137.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","146.08","79.5","","200.27","182.80","200.27","1 through 10","56.96","146.08","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.75","137.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","97.94","53.3","","37.73","37.73","169.33","1 through 10","56.96","146.08","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.75","137.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","119.44","65","","100.27","8.48","494.52","1 through 10","56.96","146.08","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.75","137.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","119.44","65","","160.19","160.19","160.19","1 through 10","56.96","146.08","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.75","137.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","56.96","31","","28.12","28.12","28.12","1 through 10","56.96","146.08","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.75","137.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.07","36.5","","101.66","28.85","502.70","121","56.96","146.08","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.75","137.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.38","38.3","","61.58","25.32","328.44","138","56.96","146.08","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.75","137.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.83","42.9","","71.66","71.66","71.66","1 through 10","56.96","146.08","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.75","137.81","WELLPOINT [1015]","HB AMC WELLPOINT","135.57","73.78","","74.75","27.97","425.28","93","56.96","146.08","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","183.75","137.81","AETNA [1001]","HB AMC AETNA HMO","128.26","69.8","","52.67","14.36","414.90","1 through 10","96.03","150.16","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","183.75","137.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","96.03","52.26","","25.34","25.34","25.34","1 through 10","96.03","150.16","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","183.75","137.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","147.74","80.4","","478.02","107.84","478.02","1 through 10","96.03","150.16","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","183.75","137.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","150.16","81.72","","32.74","12.33","122.05","1 through 10","96.03","150.16","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007539","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","183.75","137.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","150.16","81.72","","144.95","32.78","676.91","104","96.03","150.16","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","both","","","166.25","124.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","86.88","52.26","","25.34","25.34","25.34","1 through 10","51.54","132.17","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","both","","","166.25","124.69","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","119.37","71.8","","105.81","105.81","366.90","1 through 10","51.54","132.17","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","both","","","166.25","124.69","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","116.38","70","","512.90","74.70","612.85","1 through 10","51.54","132.17","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","both","","","166.25","124.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","132.17","79.5","","200.27","182.80","200.27","1 through 10","51.54","132.17","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","both","","","166.25","124.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","88.61","53.3","","37.73","37.73","169.33","1 through 10","51.54","132.17","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","both","","","166.25","124.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","108.06","65","","100.27","8.48","494.52","1 through 10","51.54","132.17","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","both","","","166.25","124.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","108.06","65","","160.19","160.19","160.19","1 through 10","51.54","132.17","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","both","","","166.25","124.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","51.54","31","","28.12","28.12","28.12","1 through 10","51.54","132.17","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","both","","","166.25","124.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.68","36.5","","101.66","28.85","502.70","121","51.54","132.17","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","both","","","166.25","124.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.67","38.3","","61.58","25.32","328.44","138","51.54","132.17","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","both","","","166.25","124.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.32","42.9","","71.66","71.66","71.66","1 through 10","51.54","132.17","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","both","","","166.25","124.69","WELLPOINT [1015]","HB AMC WELLPOINT","122.66","73.78","","74.75","27.97","425.28","93","51.54","132.17","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","166.25","124.69","AETNA [1001]","HB AMC AETNA HMO","116.04","69.8","","52.67","14.36","414.90","1 through 10","86.88","135.86","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","166.25","124.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","86.88","52.26","","25.34","25.34","25.34","1 through 10","86.88","135.86","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","166.25","124.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","133.67","80.4","","478.02","107.84","478.02","1 through 10","86.88","135.86","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","166.25","124.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","135.86","81.72","","32.74","12.33","122.05","1 through 10","86.88","135.86","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 80CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10007349","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","166.25","124.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","135.86","81.72","","144.95","32.78","676.91","104","86.88","135.86","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","581.00","435.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","303.63","52.26","","25.34","25.34","25.34","1 through 10","180.11","461.9","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","581.00","435.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","417.16","71.8","","105.81","105.81","366.90","1 through 10","180.11","461.9","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","581.00","435.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","406.70","70","","512.90","74.70","612.85","1 through 10","180.11","461.9","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","581.00","435.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","461.90","79.5","","200.27","182.80","200.27","1 through 10","180.11","461.9","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","581.00","435.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","309.67","53.3","","37.73","37.73","169.33","1 through 10","180.11","461.9","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","581.00","435.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","377.65","65","","100.27","8.48","494.52","1 through 10","180.11","461.9","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","581.00","435.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","377.65","65","","160.19","160.19","160.19","1 through 10","180.11","461.9","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","581.00","435.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","180.11","31","","28.12","28.12","28.12","1 through 10","180.11","461.9","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","581.00","435.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","212.07","36.5","","101.66","28.85","502.70","121","180.11","461.9","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","581.00","435.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","222.52","38.3","","61.58","25.32","328.44","138","180.11","461.9","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.25","42.9","","71.66","71.66","71.66","1 through 10","180.11","461.9","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","581.00","435.75","WELLPOINT [1015]","HB AMC WELLPOINT","428.66","73.78","","74.75","27.97","425.28","93","180.11","461.9","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","581.00","435.75","AETNA [1001]","HB AMC AETNA HMO","405.54","69.8","","52.67","14.36","414.90","1 through 10","303.63","474.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","581.00","435.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","303.63","52.26","","25.34","25.34","25.34","1 through 10","303.63","474.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","581.00","435.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","467.12","80.4","","478.02","107.84","478.02","1 through 10","303.63","474.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","474.79","81.72","","32.74","12.33","122.05","1 through 10","303.63","474.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","474.79","81.72","","144.95","32.78","676.91","104","303.63","474.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","652.75","489.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","341.13","52.26","","25.34","25.34","25.34","1 through 10","202.35","518.94","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","652.75","489.56","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","468.67","71.8","","105.81","105.81","366.90","1 through 10","202.35","518.94","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","652.75","489.56","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","456.93","70","","512.90","74.70","612.85","1 through 10","202.35","518.94","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","652.75","489.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","518.94","79.5","","200.27","182.80","200.27","1 through 10","202.35","518.94","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","652.75","489.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","347.92","53.3","","37.73","37.73","169.33","1 through 10","202.35","518.94","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","652.75","489.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","424.29","65","","100.27","8.48","494.52","1 through 10","202.35","518.94","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","652.75","489.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","424.29","65","","160.19","160.19","160.19","1 through 10","202.35","518.94","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","652.75","489.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","202.35","31","","28.12","28.12","28.12","1 through 10","202.35","518.94","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","652.75","489.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","238.25","36.5","","101.66","28.85","502.70","121","202.35","518.94","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","652.75","489.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","250.00","38.3","","61.58","25.32","328.44","138","202.35","518.94","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","652.75","489.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.03","42.9","","71.66","71.66","71.66","1 through 10","202.35","518.94","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","652.75","489.56","WELLPOINT [1015]","HB AMC WELLPOINT","481.60","73.78","","74.75","27.97","425.28","93","202.35","518.94","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","652.75","489.56","AETNA [1001]","HB AMC AETNA HMO","455.62","69.8","","52.67","14.36","414.90","1 through 10","341.13","533.43","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","652.75","489.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","341.13","52.26","","25.34","25.34","25.34","1 through 10","341.13","533.43","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","652.75","489.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","524.81","80.4","","478.02","107.84","478.02","1 through 10","341.13","533.43","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","652.75","489.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","533.43","81.72","","32.74","12.33","122.05","1 through 10","341.13","533.43","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","652.75","489.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","533.43","81.72","","144.95","32.78","676.91","104","341.13","533.43","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","both","","","38.50","28.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","20.12","52.26","","25.34","25.34","25.34","1 through 10","11.94","30.61","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","both","","","38.50","28.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","27.64","71.8","","105.81","105.81","366.90","1 through 10","11.94","30.61","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","both","","","38.50","28.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","26.95","70","","512.90","74.70","612.85","1 through 10","11.94","30.61","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","both","","","38.50","28.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","30.61","79.5","","200.27","182.80","200.27","1 through 10","11.94","30.61","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","both","","","38.50","28.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","20.52","53.3","","37.73","37.73","169.33","1 through 10","11.94","30.61","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","both","","","38.50","28.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","25.03","65","","100.27","8.48","494.52","1 through 10","11.94","30.61","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","both","","","38.50","28.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","25.03","65","","160.19","160.19","160.19","1 through 10","11.94","30.61","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","both","","","38.50","28.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","11.94","31","","28.12","28.12","28.12","1 through 10","11.94","30.61","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","both","","","38.50","28.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14.05","36.5","","101.66","28.85","502.70","121","11.94","30.61","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","both","","","38.50","28.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.75","38.3","","61.58","25.32","328.44","138","11.94","30.61","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","both","","","38.50","28.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16.52","42.9","","71.66","71.66","71.66","1 through 10","11.94","30.61","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","both","","","38.50","28.87","WELLPOINT [1015]","HB AMC WELLPOINT","28.41","73.78","","74.75","27.97","425.28","93","11.94","30.61","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","38.50","28.87","AETNA [1001]","HB AMC AETNA HMO","26.87","69.8","","52.67","14.36","414.90","1 through 10","20.12","31.46","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","38.50","28.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","20.12","52.26","","25.34","25.34","25.34","1 through 10","20.12","31.46","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","38.50","28.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","30.95","80.4","","478.02","107.84","478.02","1 through 10","20.12","31.46","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","38.50","28.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","31.46","81.72","","32.74","12.33","122.05","1 through 10","20.12","31.46","percent of total billed charges",""
"GUIDEWIRE GUIDERIGHT 7CM 260CM .035IN DIAGNOSTIC VASCULAR PTFE COATED EXCHANGE BX/5EA","SUP-ITM-10203931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","38.50","28.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","31.46","81.72","","144.95","32.78","676.91","104","20.12","31.46","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","both","","","262.50","196.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","137.18","52.26","","25.34","25.34","25.34","1 through 10","81.38","208.69","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","both","","","262.50","196.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","188.48","71.8","","105.81","105.81","366.90","1 through 10","81.38","208.69","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","both","","","262.50","196.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","183.75","70","","512.90","74.70","612.85","1 through 10","81.38","208.69","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","both","","","262.50","196.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","208.69","79.5","","200.27","182.80","200.27","1 through 10","81.38","208.69","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","both","","","262.50","196.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.91","53.3","","37.73","37.73","169.33","1 through 10","81.38","208.69","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","both","","","262.50","196.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","170.63","65","","100.27","8.48","494.52","1 through 10","81.38","208.69","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","both","","","262.50","196.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","170.63","65","","160.19","160.19","160.19","1 through 10","81.38","208.69","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","81.38","31","","28.12","28.12","28.12","1 through 10","81.38","208.69","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.81","36.5","","101.66","28.85","502.70","121","81.38","208.69","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.54","38.3","","61.58","25.32","328.44","138","81.38","208.69","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","both","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.61","42.9","","71.66","71.66","71.66","1 through 10","81.38","208.69","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","both","","","262.50","196.87","WELLPOINT [1015]","HB AMC WELLPOINT","193.67","73.78","","74.75","27.97","425.28","93","81.38","208.69","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","262.50","196.87","AETNA [1001]","HB AMC AETNA HMO","183.23","69.8","","52.67","14.36","414.90","1 through 10","137.18","214.52","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","262.50","196.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","137.18","52.26","","25.34","25.34","25.34","1 through 10","137.18","214.52","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","262.50","196.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","211.05","80.4","","478.02","107.84","478.02","1 through 10","137.18","214.52","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","214.52","81.72","","32.74","12.33","122.05","1 through 10","137.18","214.52","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 3CM 190CM .014IN STRAIGHT TIP VASCULAR MIDDLEWEIGHT ELASTINITE NITINOL CORONARY BALANCE","SUP-ITM-10000449","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.52","81.72","","144.95","32.78","676.91","104","137.18","214.52","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","both","","","455.00","341.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","237.78","52.26","","25.34","25.34","25.34","1 through 10","141.05","361.73","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","326.69","71.8","","105.81","105.81","366.90","1 through 10","141.05","361.73","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","318.50","70","","512.90","74.70","612.85","1 through 10","141.05","361.73","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","both","","","455.00","341.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","361.73","79.5","","200.27","182.80","200.27","1 through 10","141.05","361.73","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","both","","","455.00","341.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.52","53.3","","37.73","37.73","169.33","1 through 10","141.05","361.73","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","295.75","65","","100.27","8.48","494.52","1 through 10","141.05","361.73","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","295.75","65","","160.19","160.19","160.19","1 through 10","141.05","361.73","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","141.05","31","","28.12","28.12","28.12","1 through 10","141.05","361.73","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.08","36.5","","101.66","28.85","502.70","121","141.05","361.73","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.27","38.3","","61.58","25.32","328.44","138","141.05","361.73","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","both","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.20","42.9","","71.66","71.66","71.66","1 through 10","141.05","361.73","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","both","","","455.00","341.25","WELLPOINT [1015]","HB AMC WELLPOINT","335.70","73.78","","74.75","27.97","425.28","93","141.05","361.73","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","52.67","14.36","414.90","1 through 10","237.78","371.83","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","455.00","341.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","237.78","52.26","","25.34","25.34","25.34","1 through 10","237.78","371.83","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","365.82","80.4","","478.02","107.84","478.02","1 through 10","237.78","371.83","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","371.83","81.72","","32.74","12.33","122.05","1 through 10","237.78","371.83","percent of total billed charges",""
"GUIDEWIRE HI-TORQUE .018IN 300CM COMMAND 18ST BX/5EA","SUP-ITM-10209184","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.83","81.72","","144.95","32.78","676.91","104","237.78","371.83","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.30","32.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","22.63","52.26","","25.34","25.34","25.34","1 through 10","13.42","34.42","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.30","32.47","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","31.09","71.8","","105.81","105.81","366.90","1 through 10","13.42","34.42","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.30","32.47","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","30.31","70","","512.90","74.70","612.85","1 through 10","13.42","34.42","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.30","32.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","34.42","79.5","","200.27","182.80","200.27","1 through 10","13.42","34.42","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.30","32.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23.08","53.3","","37.73","37.73","169.33","1 through 10","13.42","34.42","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.30","32.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","28.15","65","","100.27","8.48","494.52","1 through 10","13.42","34.42","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.30","32.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","28.15","65","","160.19","160.19","160.19","1 through 10","13.42","34.42","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.30","32.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","13.42","31","","28.12","28.12","28.12","1 through 10","13.42","34.42","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.30","32.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15.80","36.5","","101.66","28.85","502.70","121","13.42","34.42","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.30","32.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.58","38.3","","61.58","25.32","328.44","138","13.42","34.42","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.30","32.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.58","42.9","","71.66","71.66","71.66","1 through 10","13.42","34.42","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.30","32.47","WELLPOINT [1015]","HB AMC WELLPOINT","31.95","73.78","","74.75","27.97","425.28","93","13.42","34.42","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","43.30","32.47","AETNA [1001]","HB AMC AETNA HMO","30.22","69.8","","52.67","14.36","414.90","1 through 10","22.63","35.38","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","43.30","32.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","22.63","52.26","","25.34","25.34","25.34","1 through 10","22.63","35.38","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","43.30","32.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","34.81","80.4","","478.02","107.84","478.02","1 through 10","22.63","35.38","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","43.30","32.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","35.38","81.72","","32.74","12.33","122.05","1 through 10","22.63","35.38","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","43.30","32.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","35.38","81.72","","144.95","32.78","676.91","104","22.63","35.38","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","320.28","52.26","","25.34","25.34","25.34","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","440.03","71.8","","105.81","105.81","366.90","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","429.00","70","","512.90","74.70","612.85","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","487.22","79.5","","200.27","182.80","200.27","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","326.65","53.3","","37.73","37.73","169.33","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","398.35","65","","100.27","8.48","494.52","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","398.35","65","","160.19","160.19","160.19","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","189.98","31","","28.12","28.12","28.12","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.69","36.5","","101.66","28.85","502.70","121","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.72","38.3","","61.58","25.32","328.44","138","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","262.91","42.9","","71.66","71.66","71.66","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","WELLPOINT [1015]","HB AMC WELLPOINT","452.16","73.78","","74.75","27.97","425.28","93","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","612.85","459.64","AETNA [1001]","HB AMC AETNA HMO","427.77","69.8","","52.67","14.36","414.90","1 through 10","320.28","500.82","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","612.85","459.64","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","320.28","52.26","","25.34","25.34","25.34","1 through 10","320.28","500.82","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","612.85","459.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","492.73","80.4","","478.02","107.84","478.02","1 through 10","320.28","500.82","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","612.85","459.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","500.82","81.72","","32.74","12.33","122.05","1 through 10","320.28","500.82","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","612.85","459.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","500.82","81.72","","144.95","32.78","676.91","104","320.28","500.82","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.72","47.04","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","32.78","52.26","","25.34","25.34","25.34","1 through 10","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.72","47.04","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","45.03","71.8","","105.81","105.81","366.90","1 through 10","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.72","47.04","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","43.90","70","","512.90","74.70","612.85","1 through 10","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.72","47.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","49.86","79.5","","200.27","182.80","200.27","1 through 10","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.72","47.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33.43","53.3","","37.73","37.73","169.33","1 through 10","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.72","47.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","40.77","65","","100.27","8.48","494.52","1 through 10","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.72","47.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","40.77","65","","160.19","160.19","160.19","1 through 10","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.72","47.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","19.44","31","","28.12","28.12","28.12","1 through 10","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.72","47.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22.89","36.5","","101.66","28.85","502.70","121","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.72","47.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.02","38.3","","61.58","25.32","328.44","138","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.72","47.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.91","42.9","","71.66","71.66","71.66","1 through 10","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","62.72","47.04","WELLPOINT [1015]","HB AMC WELLPOINT","46.27","73.78","","74.75","27.97","425.28","93","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","62.72","47.04","AETNA [1001]","HB AMC AETNA HMO","43.78","69.8","","52.67","14.36","414.90","1 through 10","32.78","51.25","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","62.72","47.04","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","32.78","52.26","","25.34","25.34","25.34","1 through 10","32.78","51.25","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","62.72","47.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","50.43","80.4","","478.02","107.84","478.02","1 through 10","32.78","51.25","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","62.72","47.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","51.25","81.72","","32.74","12.33","122.05","1 through 10","32.78","51.25","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","62.72","47.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","51.25","81.72","","144.95","32.78","676.91","104","32.78","51.25","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","256.07","52.26","","25.34","25.34","25.34","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","351.82","71.8","","105.81","105.81","366.90","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","343.00","70","","512.90","74.70","612.85","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","389.55","79.5","","200.27","182.80","200.27","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","261.17","53.3","","37.73","37.73","169.33","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","318.50","65","","100.27","8.48","494.52","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","318.50","65","","160.19","160.19","160.19","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","151.90","31","","28.12","28.12","28.12","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","178.85","36.5","","101.66","28.85","502.70","121","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.67","38.3","","61.58","25.32","328.44","138","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.21","42.9","","71.66","71.66","71.66","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","WELLPOINT [1015]","HB AMC WELLPOINT","361.52","73.78","","74.75","27.97","425.28","93","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.00","367.50","AETNA [1001]","HB AMC AETNA HMO","342.02","69.8","","52.67","14.36","414.90","1 through 10","256.07","400.43","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.00","367.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","256.07","52.26","","25.34","25.34","25.34","1 through 10","256.07","400.43","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.00","367.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","393.96","80.4","","478.02","107.84","478.02","1 through 10","256.07","400.43","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.00","367.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","400.43","81.72","","32.74","12.33","122.05","1 through 10","256.07","400.43","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSCMG-35-260-LESDC BX/5EA","SUP-ITM-10151424","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.00","367.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","400.43","81.72","","144.95","32.78","676.91","104","256.07","400.43","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","437.85","328.39","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","228.82","52.26","","25.34","25.34","25.34","1 through 10","135.73","348.09","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","437.85","328.39","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","314.38","71.8","","105.81","105.81","366.90","1 through 10","135.73","348.09","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","437.85","328.39","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","306.50","70","","512.90","74.70","612.85","1 through 10","135.73","348.09","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","437.85","328.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","348.09","79.5","","200.27","182.80","200.27","1 through 10","135.73","348.09","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","437.85","328.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","233.37","53.3","","37.73","37.73","169.33","1 through 10","135.73","348.09","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","437.85","328.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","284.60","65","","100.27","8.48","494.52","1 through 10","135.73","348.09","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","437.85","328.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","284.60","65","","160.19","160.19","160.19","1 through 10","135.73","348.09","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","437.85","328.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","135.73","31","","28.12","28.12","28.12","1 through 10","135.73","348.09","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","437.85","328.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","159.82","36.5","","101.66","28.85","502.70","121","135.73","348.09","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","437.85","328.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","167.70","38.3","","61.58","25.32","328.44","138","135.73","348.09","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","437.85","328.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.84","42.9","","71.66","71.66","71.66","1 through 10","135.73","348.09","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","437.85","328.39","WELLPOINT [1015]","HB AMC WELLPOINT","323.05","73.78","","74.75","27.97","425.28","93","135.73","348.09","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","437.85","328.39","AETNA [1001]","HB AMC AETNA HMO","305.62","69.8","","52.67","14.36","414.90","1 through 10","228.82","357.81","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","437.85","328.39","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","228.82","52.26","","25.34","25.34","25.34","1 through 10","228.82","357.81","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","437.85","328.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","352.03","80.4","","478.02","107.84","478.02","1 through 10","228.82","357.81","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","437.85","328.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","357.81","81.72","","32.74","12.33","122.05","1 through 10","228.82","357.81","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","437.85","328.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","357.81","81.72","","144.95","32.78","676.91","104","228.82","357.81","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","256.07","52.26","","25.34","25.34","25.34","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","351.82","71.8","","105.81","105.81","366.90","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","343.00","70","","512.90","74.70","612.85","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","389.55","79.5","","200.27","182.80","200.27","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","261.17","53.3","","37.73","37.73","169.33","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","318.50","65","","100.27","8.48","494.52","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","318.50","65","","160.19","160.19","160.19","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","151.90","31","","28.12","28.12","28.12","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","178.85","36.5","","101.66","28.85","502.70","121","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.67","38.3","","61.58","25.32","328.44","138","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.21","42.9","","71.66","71.66","71.66","1 through 10","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.00","367.50","WELLPOINT [1015]","HB AMC WELLPOINT","361.52","73.78","","74.75","27.97","425.28","93","151.9","389.55","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.00","367.50","AETNA [1001]","HB AMC AETNA HMO","342.02","69.8","","52.67","14.36","414.90","1 through 10","256.07","400.43","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.00","367.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","256.07","52.26","","25.34","25.34","25.34","1 through 10","256.07","400.43","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.00","367.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","393.96","80.4","","478.02","107.84","478.02","1 through 10","256.07","400.43","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.00","367.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","400.43","81.72","","32.74","12.33","122.05","1 through 10","256.07","400.43","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 300CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED BX/5EA","SUP-ITM-10158896","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.00","367.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","400.43","81.72","","144.95","32.78","676.91","104","256.07","400.43","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","both","","","510.30","382.72","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","266.68","52.26","","25.34","25.34","25.34","1 through 10","158.19","405.69","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","both","","","510.30","382.72","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","366.40","71.8","","105.81","105.81","366.90","1 through 10","158.19","405.69","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","both","","","510.30","382.72","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","357.21","70","","512.90","74.70","612.85","1 through 10","158.19","405.69","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","both","","","510.30","382.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","405.69","79.5","","200.27","182.80","200.27","1 through 10","158.19","405.69","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","both","","","510.30","382.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","271.99","53.3","","37.73","37.73","169.33","1 through 10","158.19","405.69","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","both","","","510.30","382.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","331.70","65","","100.27","8.48","494.52","1 through 10","158.19","405.69","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","both","","","510.30","382.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","331.70","65","","160.19","160.19","160.19","1 through 10","158.19","405.69","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","both","","","510.30","382.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","158.19","31","","28.12","28.12","28.12","1 through 10","158.19","405.69","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","both","","","510.30","382.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","186.26","36.5","","101.66","28.85","502.70","121","158.19","405.69","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","both","","","510.30","382.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","195.44","38.3","","61.58","25.32","328.44","138","158.19","405.69","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","both","","","510.30","382.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","218.92","42.9","","71.66","71.66","71.66","1 through 10","158.19","405.69","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","both","","","510.30","382.72","WELLPOINT [1015]","HB AMC WELLPOINT","376.50","73.78","","74.75","27.97","425.28","93","158.19","405.69","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","510.30","382.72","AETNA [1001]","HB AMC AETNA HMO","356.19","69.8","","52.67","14.36","414.90","1 through 10","266.68","417.02","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","510.30","382.72","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","266.68","52.26","","25.34","25.34","25.34","1 through 10","266.68","417.02","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","510.30","382.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","410.28","80.4","","478.02","107.84","478.02","1 through 10","266.68","417.02","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","510.30","382.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","417.02","81.72","","32.74","12.33","122.05","1 through 10","266.68","417.02","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 300X11CM .035IN SUPPORT EXTRA-STIFF DOUBLE CURVED EXCHANGE BX/5EA","SUP-ITM-10213380","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","510.30","382.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","417.02","81.72","","144.95","32.78","676.91","104","266.68","417.02","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.00","120.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","84.14","52.26","","25.34","25.34","25.34","1 through 10","49.91","128","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.00","120.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","115.60","71.8","","105.81","105.81","366.90","1 through 10","49.91","128","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.00","120.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.70","70","","512.90","74.70","612.85","1 through 10","49.91","128","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.00","120.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","128.00","79.5","","200.27","182.80","200.27","1 through 10","49.91","128","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.00","120.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.81","53.3","","37.73","37.73","169.33","1 through 10","49.91","128","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.00","120.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.65","65","","100.27","8.48","494.52","1 through 10","49.91","128","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.00","120.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","104.65","65","","160.19","160.19","160.19","1 through 10","49.91","128","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.00","120.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.91","31","","28.12","28.12","28.12","1 through 10","49.91","128","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.00","120.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.77","36.5","","101.66","28.85","502.70","121","49.91","128","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.00","120.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.66","38.3","","61.58","25.32","328.44","138","49.91","128","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.00","120.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.07","42.9","","71.66","71.66","71.66","1 through 10","49.91","128","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.00","120.75","WELLPOINT [1015]","HB AMC WELLPOINT","118.79","73.78","","74.75","27.97","425.28","93","49.91","128","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","161.00","120.75","AETNA [1001]","HB AMC AETNA HMO","112.38","69.8","","52.67","14.36","414.90","1 through 10","84.14","131.57","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","161.00","120.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","84.14","52.26","","25.34","25.34","25.34","1 through 10","84.14","131.57","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","161.00","120.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","129.44","80.4","","478.02","107.84","478.02","1 through 10","84.14","131.57","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","161.00","120.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","131.57","81.72","","32.74","12.33","122.05","1 through 10","84.14","131.57","percent of total billed charges",""
"GUIDEWIRE MEIER C TIP 10CM 260CM .035IN VASCULAR BX/5EA","SUP-ITM-10073096","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","161.00","120.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","131.57","81.72","","144.95","32.78","676.91","104","84.14","131.57","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","both","","","1519.00","1139.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","793.83","52.26","","25.34","25.34","25.34","1 through 10","470.89","1207.61","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","both","","","1519.00","1139.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1090.64","71.8","","105.81","105.81","366.90","1 through 10","470.89","1207.61","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","both","","","1519.00","1139.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1063.30","70","","512.90","74.70","612.85","1 through 10","470.89","1207.61","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","both","","","1519.00","1139.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1207.61","79.5","","200.27","182.80","200.27","1 through 10","470.89","1207.61","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","both","","","1519.00","1139.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","809.63","53.3","","37.73","37.73","169.33","1 through 10","470.89","1207.61","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","both","","","1519.00","1139.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","987.35","65","","100.27","8.48","494.52","1 through 10","470.89","1207.61","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","both","","","1519.00","1139.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","987.35","65","","160.19","160.19","160.19","1 through 10","470.89","1207.61","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","both","","","1519.00","1139.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","470.89","31","","28.12","28.12","28.12","1 through 10","470.89","1207.61","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","both","","","1519.00","1139.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","554.44","36.5","","101.66","28.85","502.70","121","470.89","1207.61","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","both","","","1519.00","1139.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","581.78","38.3","","61.58","25.32","328.44","138","470.89","1207.61","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","both","","","1519.00","1139.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","651.65","42.9","","71.66","71.66","71.66","1 through 10","470.89","1207.61","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","both","","","1519.00","1139.25","WELLPOINT [1015]","HB AMC WELLPOINT","1120.72","73.78","","74.75","27.97","425.28","93","470.89","1207.61","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1519.00","1139.25","AETNA [1001]","HB AMC AETNA HMO","1060.26","69.8","","52.67","14.36","414.90","1 through 10","793.83","1241.33","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1519.00","1139.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","793.83","52.26","","25.34","25.34","25.34","1 through 10","793.83","1241.33","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1519.00","1139.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1221.28","80.4","","478.02","107.84","478.02","1 through 10","793.83","1241.33","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1519.00","1139.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1241.33","81.72","","32.74","12.33","122.05","1 through 10","793.83","1241.33","percent of total billed charges",""
"GUIDEWIRE MIRAGE 10CM 200CM .008IN VASCULAR IMAGING XSTIFF STRAIGHT TIP S/S HYDROPHILIC ADULT","SUP-ITM-10007121","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1519.00","1139.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1241.33","81.72","","144.95","32.78","676.91","104","793.83","1241.33","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","both","","","359.78","269.83","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","188.02","52.26","","25.34","25.34","25.34","1 through 10","111.53","286.03","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","both","","","359.78","269.83","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","258.32","71.8","","105.81","105.81","366.90","1 through 10","111.53","286.03","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","both","","","359.78","269.83","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","251.85","70","","512.90","74.70","612.85","1 through 10","111.53","286.03","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","both","","","359.78","269.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","286.03","79.5","","200.27","182.80","200.27","1 through 10","111.53","286.03","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","both","","","359.78","269.83","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","191.76","53.3","","37.73","37.73","169.33","1 through 10","111.53","286.03","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","both","","","359.78","269.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","233.86","65","","100.27","8.48","494.52","1 through 10","111.53","286.03","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","both","","","359.78","269.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","233.86","65","","160.19","160.19","160.19","1 through 10","111.53","286.03","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","both","","","359.78","269.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","111.53","31","","28.12","28.12","28.12","1 through 10","111.53","286.03","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","both","","","359.78","269.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","131.32","36.5","","101.66","28.85","502.70","121","111.53","286.03","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","both","","","359.78","269.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","137.80","38.3","","61.58","25.32","328.44","138","111.53","286.03","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","both","","","359.78","269.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","154.35","42.9","","71.66","71.66","71.66","1 through 10","111.53","286.03","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","both","","","359.78","269.83","WELLPOINT [1015]","HB AMC WELLPOINT","265.45","73.78","","74.75","27.97","425.28","93","111.53","286.03","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","359.78","269.83","AETNA [1001]","HB AMC AETNA HMO","251.13","69.8","","52.67","14.36","414.90","1 through 10","188.02","294.01","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","359.78","269.83","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","188.02","52.26","","25.34","25.34","25.34","1 through 10","188.02","294.01","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","359.78","269.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","289.26","80.4","","478.02","107.84","478.02","1 through 10","188.02","294.01","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","359.78","269.83","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","294.01","81.72","","32.74","12.33","122.05","1 through 10","188.02","294.01","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .018IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134605","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","359.78","269.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","294.01","81.72","","144.95","32.78","676.91","104","188.02","294.01","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","320.28","52.26","","25.34","25.34","25.34","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","440.03","71.8","","105.81","105.81","366.90","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","429.00","70","","512.90","74.70","612.85","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","487.22","79.5","","200.27","182.80","200.27","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","326.65","53.3","","37.73","37.73","169.33","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","398.35","65","","100.27","8.48","494.52","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","398.35","65","","160.19","160.19","160.19","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","189.98","31","","28.12","28.12","28.12","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.69","36.5","","101.66","28.85","502.70","121","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.72","38.3","","61.58","25.32","328.44","138","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","262.91","42.9","","71.66","71.66","71.66","1 through 10","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","both","","","612.85","459.64","WELLPOINT [1015]","HB AMC WELLPOINT","452.16","73.78","","74.75","27.97","425.28","93","189.98","487.22","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","612.85","459.64","AETNA [1001]","HB AMC AETNA HMO","427.77","69.8","","52.67","14.36","414.90","1 through 10","320.28","500.82","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","612.85","459.64","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","320.28","52.26","","25.34","25.34","25.34","1 through 10","320.28","500.82","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","612.85","459.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","492.73","80.4","","478.02","107.84","478.02","1 through 10","320.28","500.82","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","612.85","459.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","500.82","81.72","","32.74","12.33","122.05","1 through 10","320.28","500.82","percent of total billed charges",""
"GUIDEWIRE NON-VASCULAR .025IN 260CM EXTENDABLE JAGWIRE REVOLUTION ST BX/2EA","SUP-ITM-10270034","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","612.85","459.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","500.82","81.72","","144.95","32.78","676.91","104","320.28","500.82","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","49.86","79.5","","800.18","480.96","1887.97","195","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33.43","53.3","","813.12","216.42","1444.50","81","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","19.44","31","","432.60","432.60","432.60","1 through 10","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22.89","36.5","","148.37","54.89","631.39","94","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.02","38.3","","279.30","91.72","1116.77","266","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.91","42.9","","731.00","63.70","731.00","1 through 10","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.91","42.9","","384.74","384.74","384.74","1 through 10","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","WELLPOINT [1015]","HB AMC WELLPOINT","46.27","73.78","","286.63","119.22","1107.45","105","19.44","49.86","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.72","47.04","AETNA [1001]","HB AMC AETNA HMO","43.78","69.8","","675.31","184.75","1721.50","286","32.78","51.25","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.72","47.04","AETNA [1001]","HB AMC AETNA PPO","50.43","80.4","","1261.44","103.12","1514.10","21","32.78","51.25","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.72","47.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","50.43","80.4","","1365.00","1365.00","1365.00","1 through 10","32.78","51.25","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.72","47.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","51.25","81.72","","5157.68","5157.68","5157.68","1 through 10","32.78","51.25","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.72","47.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","51.25","81.72","","431.26","71.26","1459.57","88","32.78","51.25","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","227.26","170.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","118.77","52.26","","25.34","25.34","25.34","1 through 10","70.45","180.67","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","227.26","170.44","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","163.17","71.8","","105.81","105.81","366.90","1 through 10","70.45","180.67","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","227.26","170.44","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","159.08","70","","512.90","74.70","612.85","1 through 10","70.45","180.67","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","227.26","170.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","180.67","79.5","","200.27","182.80","200.27","1 through 10","70.45","180.67","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","227.26","170.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","121.13","53.3","","37.73","37.73","169.33","1 through 10","70.45","180.67","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","227.26","170.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","147.72","65","","100.27","8.48","494.52","1 through 10","70.45","180.67","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","227.26","170.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","147.72","65","","160.19","160.19","160.19","1 through 10","70.45","180.67","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","227.26","170.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","70.45","31","","28.12","28.12","28.12","1 through 10","70.45","180.67","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","227.26","170.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","82.95","36.5","","101.66","28.85","502.70","121","70.45","180.67","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","227.26","170.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.04","38.3","","61.58","25.32","328.44","138","70.45","180.67","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","227.26","170.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.49","42.9","","71.66","71.66","71.66","1 through 10","70.45","180.67","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","227.26","170.44","WELLPOINT [1015]","HB AMC WELLPOINT","167.67","73.78","","74.75","27.97","425.28","93","70.45","180.67","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","227.26","170.44","AETNA [1001]","HB AMC AETNA HMO","158.63","69.8","","52.67","14.36","414.90","1 through 10","118.77","185.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","227.26","170.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","118.77","52.26","","25.34","25.34","25.34","1 through 10","118.77","185.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","227.26","170.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","182.72","80.4","","478.02","107.84","478.02","1 through 10","118.77","185.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","227.26","170.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","185.72","81.72","","32.74","12.33","122.05","1 through 10","118.77","185.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","227.26","170.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","185.72","81.72","","144.95","32.78","676.91","104","118.77","185.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","201.60","151.20","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","105.36","52.26","","25.34","25.34","25.34","1 through 10","62.5","160.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","201.60","151.20","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","144.75","71.8","","105.81","105.81","366.90","1 through 10","62.5","160.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","201.60","151.20","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","141.12","70","","512.90","74.70","612.85","1 through 10","62.5","160.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","201.60","151.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.27","79.5","","200.27","182.80","200.27","1 through 10","62.5","160.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","201.60","151.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","107.45","53.3","","37.73","37.73","169.33","1 through 10","62.5","160.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","201.60","151.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","131.04","65","","100.27","8.48","494.52","1 through 10","62.5","160.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","201.60","151.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","131.04","65","","160.19","160.19","160.19","1 through 10","62.5","160.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","201.60","151.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","62.50","31","","28.12","28.12","28.12","1 through 10","62.5","160.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","201.60","151.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.58","36.5","","101.66","28.85","502.70","121","62.5","160.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","201.60","151.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.21","38.3","","61.58","25.32","328.44","138","62.5","160.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","201.60","151.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.49","42.9","","71.66","71.66","71.66","1 through 10","62.5","160.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","201.60","151.20","WELLPOINT [1015]","HB AMC WELLPOINT","148.74","73.78","","74.75","27.97","425.28","93","62.5","160.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","201.60","151.20","AETNA [1001]","HB AMC AETNA HMO","140.72","69.8","","52.67","14.36","414.90","1 through 10","105.36","164.75","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","201.60","151.20","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","105.36","52.26","","25.34","25.34","25.34","1 through 10","105.36","164.75","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","201.60","151.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","162.09","80.4","","478.02","107.84","478.02","1 through 10","105.36","164.75","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","201.60","151.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","164.75","81.72","","32.74","12.33","122.05","1 through 10","105.36","164.75","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","201.60","151.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","164.75","81.72","","144.95","32.78","676.91","104","105.36","164.75","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","167.06","125.29","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","87.31","52.26","","25.34","25.34","25.34","1 through 10","51.79","132.81","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","167.06","125.29","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","119.95","71.8","","105.81","105.81","366.90","1 through 10","51.79","132.81","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","167.06","125.29","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","116.94","70","","512.90","74.70","612.85","1 through 10","51.79","132.81","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","167.06","125.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","132.81","79.5","","200.27","182.80","200.27","1 through 10","51.79","132.81","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","167.06","125.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","89.04","53.3","","37.73","37.73","169.33","1 through 10","51.79","132.81","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","167.06","125.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","108.59","65","","100.27","8.48","494.52","1 through 10","51.79","132.81","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","167.06","125.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","108.59","65","","160.19","160.19","160.19","1 through 10","51.79","132.81","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","167.06","125.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","51.79","31","","28.12","28.12","28.12","1 through 10","51.79","132.81","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","167.06","125.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.98","36.5","","101.66","28.85","502.70","121","51.79","132.81","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","167.06","125.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.98","38.3","","61.58","25.32","328.44","138","51.79","132.81","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","167.06","125.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.67","42.9","","71.66","71.66","71.66","1 through 10","51.79","132.81","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","167.06","125.29","WELLPOINT [1015]","HB AMC WELLPOINT","123.26","73.78","","74.75","27.97","425.28","93","51.79","132.81","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","167.06","125.29","AETNA [1001]","HB AMC AETNA HMO","116.61","69.8","","52.67","14.36","414.90","1 through 10","87.31","136.52","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","167.06","125.29","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","87.31","52.26","","25.34","25.34","25.34","1 through 10","87.31","136.52","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","167.06","125.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","134.32","80.4","","478.02","107.84","478.02","1 through 10","87.31","136.52","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","167.06","125.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","136.52","81.72","","32.74","12.33","122.05","1 through 10","87.31","136.52","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","167.06","125.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","136.52","81.72","","144.95","32.78","676.91","104","87.31","136.52","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","1034.22","775.66","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","540.48","52.26","","25.34","25.34","25.34","1 through 10","320.61","822.2","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","1034.22","775.66","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","742.57","71.8","","105.81","105.81","366.90","1 through 10","320.61","822.2","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","1034.22","775.66","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","723.95","70","","512.90","74.70","612.85","1 through 10","320.61","822.2","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","1034.22","775.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","822.20","79.5","","200.27","182.80","200.27","1 through 10","320.61","822.2","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","1034.22","775.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","551.24","53.3","","37.73","37.73","169.33","1 through 10","320.61","822.2","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","1034.22","775.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","672.24","65","","100.27","8.48","494.52","1 through 10","320.61","822.2","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","1034.22","775.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","672.24","65","","160.19","160.19","160.19","1 through 10","320.61","822.2","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","1034.22","775.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","320.61","31","","28.12","28.12","28.12","1 through 10","320.61","822.2","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","1034.22","775.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","377.49","36.5","","101.66","28.85","502.70","121","320.61","822.2","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","1034.22","775.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","396.11","38.3","","61.58","25.32","328.44","138","320.61","822.2","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","1034.22","775.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","443.68","42.9","","71.66","71.66","71.66","1 through 10","320.61","822.2","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","1034.22","775.66","WELLPOINT [1015]","HB AMC WELLPOINT","763.05","73.78","","74.75","27.97","425.28","93","320.61","822.2","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1034.22","775.66","AETNA [1001]","HB AMC AETNA HMO","721.89","69.8","","52.67","14.36","414.90","1 through 10","540.48","845.16","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1034.22","775.66","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","540.48","52.26","","25.34","25.34","25.34","1 through 10","540.48","845.16","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1034.22","775.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","831.51","80.4","","478.02","107.84","478.02","1 through 10","540.48","845.16","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1034.22","775.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","845.16","81.72","","32.74","12.33","122.05","1 through 10","540.48","845.16","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1034.22","775.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","845.16","81.72","","144.95","32.78","676.91","104","540.48","845.16","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.81","173.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","184.29","79.5","","800.18","480.96","1887.97","195","71.86","184.29","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.81","173.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","123.55","53.3","","813.12","216.42","1444.50","81","71.86","184.29","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.81","173.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","71.86","31","","432.60","432.60","432.60","1 through 10","71.86","184.29","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.81","173.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","84.61","36.5","","148.37","54.89","631.39","94","71.86","184.29","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.81","173.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","88.78","38.3","","279.30","91.72","1116.77","266","71.86","184.29","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.81","173.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.45","42.9","","731.00","63.70","731.00","1 through 10","71.86","184.29","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.81","173.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.45","42.9","","384.74","384.74","384.74","1 through 10","71.86","184.29","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.81","173.86","WELLPOINT [1015]","HB AMC WELLPOINT","171.03","73.78","","286.63","119.22","1107.45","105","71.86","184.29","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.81","173.86","AETNA [1001]","HB AMC AETNA HMO","161.80","69.8","","675.31","184.75","1721.50","286","121.14","189.44","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.81","173.86","AETNA [1001]","HB AMC AETNA PPO","186.38","80.4","","1261.44","103.12","1514.10","21","121.14","189.44","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.81","173.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","186.38","80.4","","1365.00","1365.00","1365.00","1 through 10","121.14","189.44","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.81","173.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","189.44","81.72","","5157.68","5157.68","5157.68","1 through 10","121.14","189.44","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.81","173.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","189.44","81.72","","431.26","71.26","1459.57","88","121.14","189.44","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","244.76","183.57","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","127.91","52.26","","25.34","25.34","25.34","1 through 10","75.88","194.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","244.76","183.57","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","175.74","71.8","","105.81","105.81","366.90","1 through 10","75.88","194.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","244.76","183.57","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","171.33","70","","512.90","74.70","612.85","1 through 10","75.88","194.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","244.76","183.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","194.58","79.5","","200.27","182.80","200.27","1 through 10","75.88","194.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","244.76","183.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.46","53.3","","37.73","37.73","169.33","1 through 10","75.88","194.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","244.76","183.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","159.09","65","","100.27","8.48","494.52","1 through 10","75.88","194.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","244.76","183.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","159.09","65","","160.19","160.19","160.19","1 through 10","75.88","194.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","244.76","183.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","75.88","31","","28.12","28.12","28.12","1 through 10","75.88","194.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","244.76","183.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.34","36.5","","101.66","28.85","502.70","121","75.88","194.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","244.76","183.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.74","38.3","","61.58","25.32","328.44","138","75.88","194.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","244.76","183.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.00","42.9","","71.66","71.66","71.66","1 through 10","75.88","194.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","244.76","183.57","WELLPOINT [1015]","HB AMC WELLPOINT","180.58","73.78","","74.75","27.97","425.28","93","75.88","194.58","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","244.76","183.57","AETNA [1001]","HB AMC AETNA HMO","170.84","69.8","","52.67","14.36","414.90","1 through 10","127.91","200.02","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","244.76","183.57","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","127.91","52.26","","25.34","25.34","25.34","1 through 10","127.91","200.02","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","244.76","183.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","196.79","80.4","","478.02","107.84","478.02","1 through 10","127.91","200.02","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","244.76","183.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","200.02","81.72","","32.74","12.33","122.05","1 through 10","127.91","200.02","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","244.76","183.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","200.02","81.72","","144.95","32.78","676.91","104","127.91","200.02","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","760.66","570.49","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","397.52","52.26","","25.34","25.34","25.34","1 through 10","235.8","604.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","760.66","570.49","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","546.15","71.8","","105.81","105.81","366.90","1 through 10","235.8","604.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","760.66","570.49","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","532.46","70","","512.90","74.70","612.85","1 through 10","235.8","604.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","760.66","570.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","604.72","79.5","","200.27","182.80","200.27","1 through 10","235.8","604.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","760.66","570.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","405.43","53.3","","37.73","37.73","169.33","1 through 10","235.8","604.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","760.66","570.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","494.43","65","","100.27","8.48","494.52","1 through 10","235.8","604.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","760.66","570.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","494.43","65","","160.19","160.19","160.19","1 through 10","235.8","604.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","760.66","570.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","235.80","31","","28.12","28.12","28.12","1 through 10","235.8","604.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","760.66","570.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","277.64","36.5","","101.66","28.85","502.70","121","235.8","604.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","760.66","570.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","291.33","38.3","","61.58","25.32","328.44","138","235.8","604.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","760.66","570.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.32","42.9","","71.66","71.66","71.66","1 through 10","235.8","604.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","760.66","570.49","WELLPOINT [1015]","HB AMC WELLPOINT","561.21","73.78","","74.75","27.97","425.28","93","235.8","604.72","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","760.66","570.49","AETNA [1001]","HB AMC AETNA HMO","530.94","69.8","","52.67","14.36","414.90","1 through 10","397.52","621.61","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","760.66","570.49","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","397.52","52.26","","25.34","25.34","25.34","1 through 10","397.52","621.61","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","760.66","570.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","611.57","80.4","","478.02","107.84","478.02","1 through 10","397.52","621.61","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","760.66","570.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","621.61","81.72","","32.74","12.33","122.05","1 through 10","397.52","621.61","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","760.66","570.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","621.61","81.72","","144.95","32.78","676.91","104","397.52","621.61","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","1112.90","834.67","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","581.60","52.26","","25.34","25.34","25.34","1 through 10","345","884.76","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","1112.90","834.67","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","799.06","71.8","","105.81","105.81","366.90","1 through 10","345","884.76","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","1112.90","834.67","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","779.03","70","","512.90","74.70","612.85","1 through 10","345","884.76","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","1112.90","834.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","884.76","79.5","","200.27","182.80","200.27","1 through 10","345","884.76","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","1112.90","834.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","593.18","53.3","","37.73","37.73","169.33","1 through 10","345","884.76","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","1112.90","834.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","723.39","65","","100.27","8.48","494.52","1 through 10","345","884.76","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","1112.90","834.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","723.39","65","","160.19","160.19","160.19","1 through 10","345","884.76","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","1112.90","834.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","345.00","31","","28.12","28.12","28.12","1 through 10","345","884.76","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","1112.90","834.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","406.21","36.5","","101.66","28.85","502.70","121","345","884.76","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","1112.90","834.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","426.24","38.3","","61.58","25.32","328.44","138","345","884.76","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","1112.90","834.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","477.43","42.9","","71.66","71.66","71.66","1 through 10","345","884.76","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","1112.90","834.67","WELLPOINT [1015]","HB AMC WELLPOINT","821.10","73.78","","74.75","27.97","425.28","93","345","884.76","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1112.90","834.67","AETNA [1001]","HB AMC AETNA HMO","776.80","69.8","","52.67","14.36","414.90","1 through 10","581.6","909.46","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1112.90","834.67","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","581.60","52.26","","25.34","25.34","25.34","1 through 10","581.6","909.46","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1112.90","834.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","894.77","80.4","","478.02","107.84","478.02","1 through 10","581.6","909.46","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1112.90","834.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","909.46","81.72","","32.74","12.33","122.05","1 through 10","581.6","909.46","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1112.90","834.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","909.46","81.72","","144.95","32.78","676.91","104","581.6","909.46","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","249.94","187.45","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","130.62","52.26","","25.34","25.34","25.34","1 through 10","77.48","198.7","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","249.94","187.45","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","179.46","71.8","","105.81","105.81","366.90","1 through 10","77.48","198.7","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","249.94","187.45","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","174.96","70","","512.90","74.70","612.85","1 through 10","77.48","198.7","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","249.94","187.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","198.70","79.5","","200.27","182.80","200.27","1 through 10","77.48","198.7","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","249.94","187.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","133.22","53.3","","37.73","37.73","169.33","1 through 10","77.48","198.7","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","249.94","187.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","162.46","65","","100.27","8.48","494.52","1 through 10","77.48","198.7","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","249.94","187.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","162.46","65","","160.19","160.19","160.19","1 through 10","77.48","198.7","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","249.94","187.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","77.48","31","","28.12","28.12","28.12","1 through 10","77.48","198.7","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","249.94","187.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91.23","36.5","","101.66","28.85","502.70","121","77.48","198.7","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","249.94","187.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","95.73","38.3","","61.58","25.32","328.44","138","77.48","198.7","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","249.94","187.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","107.22","42.9","","71.66","71.66","71.66","1 through 10","77.48","198.7","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","249.94","187.45","WELLPOINT [1015]","HB AMC WELLPOINT","184.41","73.78","","74.75","27.97","425.28","93","77.48","198.7","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","249.94","187.45","AETNA [1001]","HB AMC AETNA HMO","174.46","69.8","","52.67","14.36","414.90","1 through 10","130.62","204.25","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","249.94","187.45","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","130.62","52.26","","25.34","25.34","25.34","1 through 10","130.62","204.25","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","249.94","187.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","200.95","80.4","","478.02","107.84","478.02","1 through 10","130.62","204.25","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","249.94","187.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","204.25","81.72","","32.74","12.33","122.05","1 through 10","130.62","204.25","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","249.94","187.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","204.25","81.72","","144.95","32.78","676.91","104","130.62","204.25","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","278.25","79.5","","800.18","480.96","1887.97","195","108.5","278.25","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","186.55","53.3","","813.12","216.42","1444.50","81","108.5","278.25","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","108.50","31","","432.60","432.60","432.60","1 through 10","108.5","278.25","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.75","36.5","","148.37","54.89","631.39","94","108.5","278.25","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","134.05","38.3","","279.30","91.72","1116.77","266","108.5","278.25","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","731.00","63.70","731.00","1 through 10","108.5","278.25","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","384.74","384.74","384.74","1 through 10","108.5","278.25","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","WELLPOINT [1015]","HB AMC WELLPOINT","258.23","73.78","","286.63","119.22","1107.45","105","108.5","278.25","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA HMO","244.30","69.8","","675.31","184.75","1721.50","286","182.91","286.02","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA PPO","281.40","80.4","","1261.44","103.12","1514.10","21","182.91","286.02","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","281.40","80.4","","1365.00","1365.00","1365.00","1 through 10","182.91","286.02","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","286.02","81.72","","5157.68","5157.68","5157.68","1 through 10","182.91","286.02","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","286.02","81.72","","431.26","71.26","1459.57","88","182.91","286.02","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","both","","","272.16","204.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","142.23","52.26","","25.34","25.34","25.34","1 through 10","84.37","216.37","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","both","","","272.16","204.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","195.41","71.8","","105.81","105.81","366.90","1 through 10","84.37","216.37","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","both","","","272.16","204.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","190.51","70","","512.90","74.70","612.85","1 through 10","84.37","216.37","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","both","","","272.16","204.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","216.37","79.5","","200.27","182.80","200.27","1 through 10","84.37","216.37","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","both","","","272.16","204.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","145.06","53.3","","37.73","37.73","169.33","1 through 10","84.37","216.37","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","both","","","272.16","204.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","176.90","65","","100.27","8.48","494.52","1 through 10","84.37","216.37","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","both","","","272.16","204.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","176.90","65","","160.19","160.19","160.19","1 through 10","84.37","216.37","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","both","","","272.16","204.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","84.37","31","","28.12","28.12","28.12","1 through 10","84.37","216.37","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","both","","","272.16","204.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","99.34","36.5","","101.66","28.85","502.70","121","84.37","216.37","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","both","","","272.16","204.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","104.24","38.3","","61.58","25.32","328.44","138","84.37","216.37","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","both","","","272.16","204.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","116.76","42.9","","71.66","71.66","71.66","1 through 10","84.37","216.37","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","both","","","272.16","204.12","WELLPOINT [1015]","HB AMC WELLPOINT","200.80","73.78","","74.75","27.97","425.28","93","84.37","216.37","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","272.16","204.12","AETNA [1001]","HB AMC AETNA HMO","189.97","69.8","","52.67","14.36","414.90","1 through 10","142.23","222.41","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","272.16","204.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","142.23","52.26","","25.34","25.34","25.34","1 through 10","142.23","222.41","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","272.16","204.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","218.82","80.4","","478.02","107.84","478.02","1 through 10","142.23","222.41","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","272.16","204.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","222.41","81.72","","32.74","12.33","122.05","1 through 10","142.23","222.41","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS .018IN 180CM SPECIALTY VASCULAR SS GALIDEX COATED","SUP-ITM-10211913","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","272.16","204.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","222.41","81.72","","144.95","32.78","676.91","104","142.23","222.41","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","315.00","236.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","164.62","52.26","","25.34","25.34","25.34","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","315.00","236.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","226.17","71.8","","105.81","105.81","366.90","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","315.00","236.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","220.50","70","","512.90","74.70","612.85","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","200.27","182.80","200.27","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","37.73","37.73","169.33","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","204.75","65","","100.27","8.48","494.52","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","204.75","65","","160.19","160.19","160.19","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","97.65","31","","28.12","28.12","28.12","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","101.66","28.85","502.70","121","97.65","250.43","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","61.58","25.32","328.44","138","97.65","250.43","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","71.66","71.66","71.66","1 through 10","97.65","250.43","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB AMC WELLPOINT","232.41","73.78","","74.75","27.97","425.28","93","97.65","250.43","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","52.67","14.36","414.90","1 through 10","164.62","257.42","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","315.00","236.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","164.62","52.26","","25.34","25.34","25.34","1 through 10","164.62","257.42","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","478.02","107.84","478.02","1 through 10","164.62","257.42","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","257.42","81.72","","32.74","12.33","122.05","1 through 10","164.62","257.42","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","144.95","32.78","676.91","104","164.62","257.42","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","both","","","430.83","323.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","225.15","52.26","","25.34","25.34","25.34","1 through 10","133.56","342.51","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","both","","","430.83","323.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","309.34","71.8","","105.81","105.81","366.90","1 through 10","133.56","342.51","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","both","","","430.83","323.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","301.58","70","","512.90","74.70","612.85","1 through 10","133.56","342.51","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","both","","","430.83","323.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","342.51","79.5","","200.27","182.80","200.27","1 through 10","133.56","342.51","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","both","","","430.83","323.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","229.63","53.3","","37.73","37.73","169.33","1 through 10","133.56","342.51","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","both","","","430.83","323.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","280.04","65","","100.27","8.48","494.52","1 through 10","133.56","342.51","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","both","","","430.83","323.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","280.04","65","","160.19","160.19","160.19","1 through 10","133.56","342.51","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","both","","","430.83","323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","133.56","31","","28.12","28.12","28.12","1 through 10","133.56","342.51","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","both","","","430.83","323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","157.25","36.5","","101.66","28.85","502.70","121","133.56","342.51","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","both","","","430.83","323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","165.01","38.3","","61.58","25.32","328.44","138","133.56","342.51","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","both","","","430.83","323.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","184.83","42.9","","71.66","71.66","71.66","1 through 10","133.56","342.51","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","both","","","430.83","323.12","WELLPOINT [1015]","HB AMC WELLPOINT","317.87","73.78","","74.75","27.97","425.28","93","133.56","342.51","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","430.83","323.12","AETNA [1001]","HB AMC AETNA HMO","300.72","69.8","","52.67","14.36","414.90","1 through 10","225.15","352.07","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","430.83","323.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","225.15","52.26","","25.34","25.34","25.34","1 through 10","225.15","352.07","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","430.83","323.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","346.39","80.4","","478.02","107.84","478.02","1 through 10","225.15","352.07","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","430.83","323.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","352.07","81.72","","32.74","12.33","122.05","1 through 10","225.15","352.07","percent of total billed charges",""
"GUIDEWIRE PULMONARY 180CM .035 JAGWIRE STIFF SHAFT STRAIGHT TIP BX/2EA","SUP-ITM-10139079","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","430.83","323.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","352.07","81.72","","144.95","32.78","676.91","104","225.15","352.07","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.97","94.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","65.83","52.26","","25.34","25.34","25.34","1 through 10","39.05","100.15","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.97","94.48","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","90.45","71.8","","105.81","105.81","366.90","1 through 10","39.05","100.15","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.97","94.48","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","88.18","70","","512.90","74.70","612.85","1 through 10","39.05","100.15","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.97","94.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","100.15","79.5","","200.27","182.80","200.27","1 through 10","39.05","100.15","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.97","94.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","67.14","53.3","","37.73","37.73","169.33","1 through 10","39.05","100.15","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.97","94.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","81.88","65","","100.27","8.48","494.52","1 through 10","39.05","100.15","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.97","94.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","81.88","65","","160.19","160.19","160.19","1 through 10","39.05","100.15","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.97","94.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","39.05","31","","28.12","28.12","28.12","1 through 10","39.05","100.15","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.97","94.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","45.98","36.5","","101.66","28.85","502.70","121","39.05","100.15","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.97","94.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48.25","38.3","","61.58","25.32","328.44","138","39.05","100.15","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.97","94.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.04","42.9","","71.66","71.66","71.66","1 through 10","39.05","100.15","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","both","","","125.97","94.48","WELLPOINT [1015]","HB AMC WELLPOINT","92.94","73.78","","74.75","27.97","425.28","93","39.05","100.15","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","125.97","94.48","AETNA [1001]","HB AMC AETNA HMO","87.93","69.8","","52.67","14.36","414.90","1 through 10","65.83","102.94","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","125.97","94.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","65.83","52.26","","25.34","25.34","25.34","1 through 10","65.83","102.94","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","125.97","94.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","101.28","80.4","","478.02","107.84","478.02","1 through 10","65.83","102.94","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","125.97","94.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","102.94","81.72","","32.74","12.33","122.05","1 through 10","65.83","102.94","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 9CM 180CM .035IN ANGLED PLATINUM TIP NIMBLE FLOPPY FLEXIBLE SHAFT POLYURETHANE COATED NITINOL MANDRIL HYDROPHILIC","SUP-ITM-10087388","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","125.97","94.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","102.94","81.72","","144.95","32.78","676.91","104","65.83","102.94","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","both","","","1050.00","787.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","548.73","52.26","","25.34","25.34","25.34","1 through 10","325.5","834.75","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","both","","","1050.00","787.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","753.90","71.8","","105.81","105.81","366.90","1 through 10","325.5","834.75","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","both","","","1050.00","787.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","735.00","70","","512.90","74.70","612.85","1 through 10","325.5","834.75","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","both","","","1050.00","787.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","834.75","79.5","","200.27","182.80","200.27","1 through 10","325.5","834.75","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","both","","","1050.00","787.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","559.65","53.3","","37.73","37.73","169.33","1 through 10","325.5","834.75","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","682.50","65","","100.27","8.48","494.52","1 through 10","325.5","834.75","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","682.50","65","","160.19","160.19","160.19","1 through 10","325.5","834.75","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","325.50","31","","28.12","28.12","28.12","1 through 10","325.5","834.75","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","101.66","28.85","502.70","121","325.5","834.75","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","61.58","25.32","328.44","138","325.5","834.75","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","71.66","71.66","71.66","1 through 10","325.5","834.75","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB AMC WELLPOINT","774.69","73.78","","74.75","27.97","425.28","93","325.5","834.75","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA HMO","732.90","69.8","","52.67","14.36","414.90","1 through 10","548.73","858.06","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1050.00","787.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","548.73","52.26","","25.34","25.34","25.34","1 through 10","548.73","858.06","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","844.20","80.4","","478.02","107.84","478.02","1 through 10","548.73","858.06","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","858.06","81.72","","32.74","12.33","122.05","1 through 10","548.73","858.06","percent of total billed charges",""
"GUIDEWIRE SAFARI2 275CM .035IN XS CURVE BX/5EA","SUP-ITM-10168048","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","858.06","81.72","","144.95","32.78","676.91","104","548.73","858.06","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","both","","","89.22","66.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","46.63","52.26","","25.34","25.34","25.34","1 through 10","27.66","70.93","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","both","","","89.22","66.91","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","64.06","71.8","","105.81","105.81","366.90","1 through 10","27.66","70.93","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","both","","","89.22","66.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","62.45","70","","512.90","74.70","612.85","1 through 10","27.66","70.93","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","both","","","89.22","66.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","70.93","79.5","","200.27","182.80","200.27","1 through 10","27.66","70.93","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","both","","","89.22","66.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","47.55","53.3","","37.73","37.73","169.33","1 through 10","27.66","70.93","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","both","","","89.22","66.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","57.99","65","","100.27","8.48","494.52","1 through 10","27.66","70.93","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","both","","","89.22","66.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","57.99","65","","160.19","160.19","160.19","1 through 10","27.66","70.93","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","both","","","89.22","66.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.66","31","","28.12","28.12","28.12","1 through 10","27.66","70.93","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","both","","","89.22","66.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","32.57","36.5","","101.66","28.85","502.70","121","27.66","70.93","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","both","","","89.22","66.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.17","38.3","","61.58","25.32","328.44","138","27.66","70.93","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","both","","","89.22","66.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","38.28","42.9","","71.66","71.66","71.66","1 through 10","27.66","70.93","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","both","","","89.22","66.91","WELLPOINT [1015]","HB AMC WELLPOINT","65.83","73.78","","74.75","27.97","425.28","93","27.66","70.93","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","89.22","66.91","AETNA [1001]","HB AMC AETNA HMO","62.28","69.8","","52.67","14.36","414.90","1 through 10","46.63","72.91","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","89.22","66.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","46.63","52.26","","25.34","25.34","25.34","1 through 10","46.63","72.91","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","89.22","66.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","71.73","80.4","","478.02","107.84","478.02","1 through 10","46.63","72.91","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","89.22","66.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","72.91","81.72","","32.74","12.33","122.05","1 through 10","46.63","72.91","percent of total billed charges",""
"GUIDEWIRE SAFE-T-J 3MM 260CM .035IN PTFE COATED S/S FIXED CORE CURVED VASCULAR","SUP-ITM-10008215","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","89.22","66.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","72.91","81.72","","144.95","32.78","676.91","104","46.63","72.91","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","223.71","167.78","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","116.91","52.26","","25.34","25.34","25.34","1 through 10","69.35","177.85","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","223.71","167.78","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","160.62","71.8","","105.81","105.81","366.90","1 through 10","69.35","177.85","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","223.71","167.78","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","156.60","70","","512.90","74.70","612.85","1 through 10","69.35","177.85","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","223.71","167.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","177.85","79.5","","200.27","182.80","200.27","1 through 10","69.35","177.85","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","223.71","167.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","119.24","53.3","","37.73","37.73","169.33","1 through 10","69.35","177.85","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","223.71","167.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","145.41","65","","100.27","8.48","494.52","1 through 10","69.35","177.85","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","223.71","167.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","145.41","65","","160.19","160.19","160.19","1 through 10","69.35","177.85","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","223.71","167.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","69.35","31","","28.12","28.12","28.12","1 through 10","69.35","177.85","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","223.71","167.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","81.65","36.5","","101.66","28.85","502.70","121","69.35","177.85","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","223.71","167.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","85.68","38.3","","61.58","25.32","328.44","138","69.35","177.85","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","223.71","167.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","95.97","42.9","","71.66","71.66","71.66","1 through 10","69.35","177.85","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","223.71","167.78","WELLPOINT [1015]","HB AMC WELLPOINT","165.05","73.78","","74.75","27.97","425.28","93","69.35","177.85","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","223.71","167.78","AETNA [1001]","HB AMC AETNA HMO","156.15","69.8","","52.67","14.36","414.90","1 through 10","116.91","182.82","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","223.71","167.78","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","116.91","52.26","","25.34","25.34","25.34","1 through 10","116.91","182.82","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","223.71","167.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","179.86","80.4","","478.02","107.84","478.02","1 through 10","116.91","182.82","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","223.71","167.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","182.82","81.72","","32.74","12.33","122.05","1 through 10","116.91","182.82","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","223.71","167.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","182.82","81.72","","144.95","32.78","676.91","104","116.91","182.82","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","both","","","297.50","223.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","155.47","52.26","","25.34","25.34","25.34","1 through 10","92.23","236.51","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","both","","","297.50","223.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","213.61","71.8","","105.81","105.81","366.90","1 through 10","92.23","236.51","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","both","","","297.50","223.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","208.25","70","","512.90","74.70","612.85","1 through 10","92.23","236.51","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","both","","","297.50","223.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.51","79.5","","200.27","182.80","200.27","1 through 10","92.23","236.51","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","both","","","297.50","223.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.57","53.3","","37.73","37.73","169.33","1 through 10","92.23","236.51","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","both","","","297.50","223.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","193.38","65","","100.27","8.48","494.52","1 through 10","92.23","236.51","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","both","","","297.50","223.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","193.38","65","","160.19","160.19","160.19","1 through 10","92.23","236.51","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","92.23","31","","28.12","28.12","28.12","1 through 10","92.23","236.51","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.59","36.5","","101.66","28.85","502.70","121","92.23","236.51","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.94","38.3","","61.58","25.32","328.44","138","92.23","236.51","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","both","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.63","42.9","","71.66","71.66","71.66","1 through 10","92.23","236.51","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","both","","","297.50","223.12","WELLPOINT [1015]","HB AMC WELLPOINT","219.50","73.78","","74.75","27.97","425.28","93","92.23","236.51","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","297.50","223.12","AETNA [1001]","HB AMC AETNA HMO","207.66","69.8","","52.67","14.36","414.90","1 through 10","155.47","243.12","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","297.50","223.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","155.47","52.26","","25.34","25.34","25.34","1 through 10","155.47","243.12","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","297.50","223.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","239.19","80.4","","478.02","107.84","478.02","1 through 10","155.47","243.12","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","243.12","81.72","","32.74","12.33","122.05","1 through 10","155.47","243.12","percent of total billed charges",""
"GUIDEWIRE SION BLUE 180CM .014IN PTCA STRAIGHT TIP VASCULAR BX/5EA","SUP-ITM-10185401","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","243.12","81.72","","144.95","32.78","676.91","104","155.47","243.12","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","292.66","52.26","","25.34","25.34","25.34","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","402.08","71.8","","105.81","105.81","366.90","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","392.00","70","","512.90","74.70","612.85","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","445.20","79.5","","200.27","182.80","200.27","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","298.48","53.3","","37.73","37.73","169.33","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","364.00","65","","100.27","8.48","494.52","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","364.00","65","","160.19","160.19","160.19","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","173.60","31","","28.12","28.12","28.12","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","204.40","36.5","","101.66","28.85","502.70","121","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","214.48","38.3","","61.58","25.32","328.44","138","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","240.24","42.9","","71.66","71.66","71.66","1 through 10","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","both","","","560.00","420.00","WELLPOINT [1015]","HB AMC WELLPOINT","413.17","73.78","","74.75","27.97","425.28","93","173.6","445.2","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","AETNA [1001]","HB AMC AETNA HMO","390.88","69.8","","52.67","14.36","414.90","1 through 10","292.66","457.63","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","292.66","52.26","","25.34","25.34","25.34","1 through 10","292.66","457.63","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","450.24","80.4","","478.02","107.84","478.02","1 through 10","292.66","457.63","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","457.63","81.72","","32.74","12.33","122.05","1 through 10","292.66","457.63","percent of total billed charges",""
"GUIDEWIRE SPINE 1.37MM VIPER 2 SHARP THREADED VIPER2","SUP-ITM-10115703","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","457.63","81.72","","144.95","32.78","676.91","104","292.66","457.63","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","both","","","22.75","17.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","11.89","52.26","","25.34","25.34","25.34","1 through 10","7.05","18.09","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","both","","","22.75","17.06","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","16.33","71.8","","105.81","105.81","366.90","1 through 10","7.05","18.09","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","both","","","22.75","17.06","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","15.93","70","","512.90","74.70","612.85","1 through 10","7.05","18.09","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","both","","","22.75","17.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18.09","79.5","","200.27","182.80","200.27","1 through 10","7.05","18.09","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","both","","","22.75","17.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12.13","53.3","","37.73","37.73","169.33","1 through 10","7.05","18.09","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","both","","","22.75","17.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","14.79","65","","100.27","8.48","494.52","1 through 10","7.05","18.09","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","both","","","22.75","17.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","14.79","65","","160.19","160.19","160.19","1 through 10","7.05","18.09","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","both","","","22.75","17.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","7.05","31","","28.12","28.12","28.12","1 through 10","7.05","18.09","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","both","","","22.75","17.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.30","36.5","","101.66","28.85","502.70","121","7.05","18.09","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","both","","","22.75","17.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8.71","38.3","","61.58","25.32","328.44","138","7.05","18.09","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","both","","","22.75","17.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.76","42.9","","71.66","71.66","71.66","1 through 10","7.05","18.09","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","both","","","22.75","17.06","WELLPOINT [1015]","HB AMC WELLPOINT","16.78","73.78","","74.75","27.97","425.28","93","7.05","18.09","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","22.75","17.06","AETNA [1001]","HB AMC AETNA HMO","15.88","69.8","","52.67","14.36","414.90","1 through 10","11.89","18.59","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","22.75","17.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","11.89","52.26","","25.34","25.34","25.34","1 through 10","11.89","18.59","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","22.75","17.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","18.29","80.4","","478.02","107.84","478.02","1 through 10","11.89","18.59","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","22.75","17.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","18.59","81.72","","32.74","12.33","122.05","1 through 10","11.89","18.59","percent of total billed charges",""
"GUIDEWIRE STANDARD 180CM 0.035IN J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321260","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","22.75","17.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18.59","81.72","","144.95","32.78","676.91","104","11.89","18.59","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","both","","","40.25","30.19","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","21.03","52.26","","25.34","25.34","25.34","1 through 10","12.48","32","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","both","","","40.25","30.19","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","28.90","71.8","","105.81","105.81","366.90","1 through 10","12.48","32","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","both","","","40.25","30.19","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","28.18","70","","512.90","74.70","612.85","1 through 10","12.48","32","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","both","","","40.25","30.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","32.00","79.5","","200.27","182.80","200.27","1 through 10","12.48","32","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","both","","","40.25","30.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","21.45","53.3","","37.73","37.73","169.33","1 through 10","12.48","32","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","both","","","40.25","30.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","26.16","65","","100.27","8.48","494.52","1 through 10","12.48","32","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","both","","","40.25","30.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","26.16","65","","160.19","160.19","160.19","1 through 10","12.48","32","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","both","","","40.25","30.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","12.48","31","","28.12","28.12","28.12","1 through 10","12.48","32","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","both","","","40.25","30.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14.69","36.5","","101.66","28.85","502.70","121","12.48","32","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","both","","","40.25","30.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15.42","38.3","","61.58","25.32","328.44","138","12.48","32","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","both","","","40.25","30.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17.27","42.9","","71.66","71.66","71.66","1 through 10","12.48","32","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","both","","","40.25","30.19","WELLPOINT [1015]","HB AMC WELLPOINT","29.70","73.78","","74.75","27.97","425.28","93","12.48","32","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","40.25","30.19","AETNA [1001]","HB AMC AETNA HMO","28.09","69.8","","52.67","14.36","414.90","1 through 10","21.03","32.89","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","40.25","30.19","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","21.03","52.26","","25.34","25.34","25.34","1 through 10","21.03","32.89","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","40.25","30.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","32.36","80.4","","478.02","107.84","478.02","1 through 10","21.03","32.89","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","40.25","30.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","32.89","81.72","","32.74","12.33","122.05","1 through 10","21.03","32.89","percent of total billed charges",""
"GUIDEWIRE STANDARD 260CM 0.035IN EXCHANGE J3MM FX GUIDERIGHT BX/5EA","SUP-ITM-10321259","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","40.25","30.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","32.89","81.72","","144.95","32.78","676.91","104","21.03","32.89","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","both","","","35.00","26.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","18.29","52.26","","25.34","25.34","25.34","1 through 10","10.85","27.83","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","both","","","35.00","26.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","25.13","71.8","","105.81","105.81","366.90","1 through 10","10.85","27.83","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","both","","","35.00","26.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","24.50","70","","512.90","74.70","612.85","1 through 10","10.85","27.83","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","both","","","35.00","26.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","27.83","79.5","","200.27","182.80","200.27","1 through 10","10.85","27.83","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","both","","","35.00","26.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","18.66","53.3","","37.73","37.73","169.33","1 through 10","10.85","27.83","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","both","","","35.00","26.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","22.75","65","","100.27","8.48","494.52","1 through 10","10.85","27.83","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","both","","","35.00","26.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","22.75","65","","160.19","160.19","160.19","1 through 10","10.85","27.83","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","both","","","35.00","26.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","10.85","31","","28.12","28.12","28.12","1 through 10","10.85","27.83","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","both","","","35.00","26.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12.78","36.5","","101.66","28.85","502.70","121","10.85","27.83","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","both","","","35.00","26.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","13.41","38.3","","61.58","25.32","328.44","138","10.85","27.83","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","both","","","35.00","26.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.02","42.9","","71.66","71.66","71.66","1 through 10","10.85","27.83","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","both","","","35.00","26.25","WELLPOINT [1015]","HB AMC WELLPOINT","25.82","73.78","","74.75","27.97","425.28","93","10.85","27.83","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","35.00","26.25","AETNA [1001]","HB AMC AETNA HMO","24.43","69.8","","52.67","14.36","414.90","1 through 10","18.29","28.6","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","35.00","26.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","18.29","52.26","","25.34","25.34","25.34","1 through 10","18.29","28.6","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","35.00","26.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","28.14","80.4","","478.02","107.84","478.02","1 through 10","18.29","28.6","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","35.00","26.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","28.60","81.72","","32.74","12.33","122.05","1 through 10","18.29","28.6","percent of total billed charges",""
"GUIDEWIRE STARTER 10CM 150CM .035IN 3MM J CURVED FIXED CORE PTFE COATED BX/10EA","SUP-ITM-10008558","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","35.00","26.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","28.60","81.72","","144.95","32.78","676.91","104","18.29","28.6","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.01","35.26","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","24.57","52.26","","25.34","25.34","25.34","1 through 10","14.57","37.37","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.01","35.26","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","33.75","71.8","","105.81","105.81","366.90","1 through 10","14.57","37.37","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.01","35.26","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","32.91","70","","512.90","74.70","612.85","1 through 10","14.57","37.37","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.01","35.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","37.37","79.5","","200.27","182.80","200.27","1 through 10","14.57","37.37","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.01","35.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","25.06","53.3","","37.73","37.73","169.33","1 through 10","14.57","37.37","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.01","35.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","30.56","65","","100.27","8.48","494.52","1 through 10","14.57","37.37","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.01","35.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","30.56","65","","160.19","160.19","160.19","1 through 10","14.57","37.37","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.01","35.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","14.57","31","","28.12","28.12","28.12","1 through 10","14.57","37.37","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.01","35.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17.16","36.5","","101.66","28.85","502.70","121","14.57","37.37","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.01","35.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18.00","38.3","","61.58","25.32","328.44","138","14.57","37.37","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.01","35.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20.17","42.9","","71.66","71.66","71.66","1 through 10","14.57","37.37","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.01","35.26","WELLPOINT [1015]","HB AMC WELLPOINT","34.68","73.78","","74.75","27.97","425.28","93","14.57","37.37","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","47.01","35.26","AETNA [1001]","HB AMC AETNA HMO","32.81","69.8","","52.67","14.36","414.90","1 through 10","24.57","38.42","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","47.01","35.26","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","24.57","52.26","","25.34","25.34","25.34","1 through 10","24.57","38.42","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","47.01","35.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","37.80","80.4","","478.02","107.84","478.02","1 through 10","24.57","38.42","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","47.01","35.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","38.42","81.72","","32.74","12.33","122.05","1 through 10","24.57","38.42","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 150CM .035IN STRAIGHT NEW BENTSON PTFE COATED BX/10EA","SUP-ITM-10008802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","47.01","35.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","38.42","81.72","","144.95","32.78","676.91","104","24.57","38.42","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","50.43","37.82","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","26.35","52.26","","25.34","25.34","25.34","1 through 10","15.63","40.09","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","50.43","37.82","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","36.21","71.8","","105.81","105.81","366.90","1 through 10","15.63","40.09","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","50.43","37.82","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","35.30","70","","512.90","74.70","612.85","1 through 10","15.63","40.09","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","50.43","37.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","40.09","79.5","","200.27","182.80","200.27","1 through 10","15.63","40.09","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","50.43","37.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","26.88","53.3","","37.73","37.73","169.33","1 through 10","15.63","40.09","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","50.43","37.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","32.78","65","","100.27","8.48","494.52","1 through 10","15.63","40.09","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","50.43","37.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","32.78","65","","160.19","160.19","160.19","1 through 10","15.63","40.09","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","50.43","37.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","15.63","31","","28.12","28.12","28.12","1 through 10","15.63","40.09","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","50.43","37.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","18.41","36.5","","101.66","28.85","502.70","121","15.63","40.09","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","50.43","37.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","19.31","38.3","","61.58","25.32","328.44","138","15.63","40.09","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","50.43","37.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21.63","42.9","","71.66","71.66","71.66","1 through 10","15.63","40.09","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","50.43","37.82","WELLPOINT [1015]","HB AMC WELLPOINT","37.21","73.78","","74.75","27.97","425.28","93","15.63","40.09","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","50.43","37.82","AETNA [1001]","HB AMC AETNA HMO","35.20","69.8","","52.67","14.36","414.90","1 through 10","26.35","41.21","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","50.43","37.82","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","26.35","52.26","","25.34","25.34","25.34","1 through 10","26.35","41.21","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","50.43","37.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","40.55","80.4","","478.02","107.84","478.02","1 through 10","26.35","41.21","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","50.43","37.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","41.21","81.72","","32.74","12.33","122.05","1 through 10","26.35","41.21","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","50.43","37.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","41.21","81.72","","144.95","32.78","676.91","104","26.35","41.21","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","both","","","37.56","28.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","19.63","52.26","","25.34","25.34","25.34","1 through 10","11.64","29.86","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","both","","","37.56","28.17","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","26.97","71.8","","105.81","105.81","366.90","1 through 10","11.64","29.86","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","both","","","37.56","28.17","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","26.29","70","","512.90","74.70","612.85","1 through 10","11.64","29.86","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","both","","","37.56","28.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","29.86","79.5","","200.27","182.80","200.27","1 through 10","11.64","29.86","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","both","","","37.56","28.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","20.02","53.3","","37.73","37.73","169.33","1 through 10","11.64","29.86","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","both","","","37.56","28.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","24.41","65","","100.27","8.48","494.52","1 through 10","11.64","29.86","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","both","","","37.56","28.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","24.41","65","","160.19","160.19","160.19","1 through 10","11.64","29.86","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","both","","","37.56","28.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","11.64","31","","28.12","28.12","28.12","1 through 10","11.64","29.86","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","both","","","37.56","28.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13.71","36.5","","101.66","28.85","502.70","121","11.64","29.86","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","both","","","37.56","28.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.39","38.3","","61.58","25.32","328.44","138","11.64","29.86","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","both","","","37.56","28.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16.11","42.9","","71.66","71.66","71.66","1 through 10","11.64","29.86","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","both","","","37.56","28.17","WELLPOINT [1015]","HB AMC WELLPOINT","27.71","73.78","","74.75","27.97","425.28","93","11.64","29.86","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","37.56","28.17","AETNA [1001]","HB AMC AETNA HMO","26.22","69.8","","52.67","14.36","414.90","1 through 10","19.63","30.69","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","37.56","28.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","19.63","52.26","","25.34","25.34","25.34","1 through 10","19.63","30.69","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","37.56","28.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","30.20","80.4","","478.02","107.84","478.02","1 through 10","19.63","30.69","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","37.56","28.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","30.69","81.72","","32.74","12.33","122.05","1 through 10","19.63","30.69","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 150CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/10EA","SUP-ITM-10008235","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","37.56","28.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","30.69","81.72","","144.95","32.78","676.91","104","19.63","30.69","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.29","45.22","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","31.51","52.26","","25.34","25.34","25.34","1 through 10","18.69","47.93","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.29","45.22","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","43.29","71.8","","105.81","105.81","366.90","1 through 10","18.69","47.93","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.29","45.22","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","42.20","70","","512.90","74.70","612.85","1 through 10","18.69","47.93","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.29","45.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","47.93","79.5","","200.27","182.80","200.27","1 through 10","18.69","47.93","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.29","45.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","32.13","53.3","","37.73","37.73","169.33","1 through 10","18.69","47.93","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.29","45.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","39.19","65","","100.27","8.48","494.52","1 through 10","18.69","47.93","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.29","45.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","39.19","65","","160.19","160.19","160.19","1 through 10","18.69","47.93","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.29","45.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","18.69","31","","28.12","28.12","28.12","1 through 10","18.69","47.93","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.29","45.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22.01","36.5","","101.66","28.85","502.70","121","18.69","47.93","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.29","45.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23.09","38.3","","61.58","25.32","328.44","138","18.69","47.93","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.29","45.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.86","42.9","","71.66","71.66","71.66","1 through 10","18.69","47.93","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.29","45.22","WELLPOINT [1015]","HB AMC WELLPOINT","44.48","73.78","","74.75","27.97","425.28","93","18.69","47.93","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","60.29","45.22","AETNA [1001]","HB AMC AETNA HMO","42.08","69.8","","52.67","14.36","414.90","1 through 10","31.51","49.27","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","60.29","45.22","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","31.51","52.26","","25.34","25.34","25.34","1 through 10","31.51","49.27","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","60.29","45.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","48.47","80.4","","478.02","107.84","478.02","1 through 10","31.51","49.27","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","60.29","45.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","49.27","81.72","","32.74","12.33","122.05","1 through 10","31.51","49.27","percent of total billed charges",""
"GUIDEWIRE STARTER 4CM 260CM .035IN 1.5MM J TIP ROSEN PTFE COATED BX/5EA","SUP-ITM-10010134","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","60.29","45.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","49.27","81.72","","144.95","32.78","676.91","104","31.51","49.27","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","both","","","2537.36","1903.02","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1326.02","52.26","","25.34","25.34","25.34","1 through 10","786.58","2017.2","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","both","","","2537.36","1903.02","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1821.82","71.8","","105.81","105.81","366.90","1 through 10","786.58","2017.2","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","both","","","2537.36","1903.02","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1776.15","70","","512.90","74.70","612.85","1 through 10","786.58","2017.2","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","both","","","2537.36","1903.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2017.20","79.5","","200.27","182.80","200.27","1 through 10","786.58","2017.2","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","both","","","2537.36","1903.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1352.41","53.3","","37.73","37.73","169.33","1 through 10","786.58","2017.2","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","both","","","2537.36","1903.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1649.28","65","","100.27","8.48","494.52","1 through 10","786.58","2017.2","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","both","","","2537.36","1903.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","1649.28","65","","160.19","160.19","160.19","1 through 10","786.58","2017.2","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","both","","","2537.36","1903.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","786.58","31","","28.12","28.12","28.12","1 through 10","786.58","2017.2","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","both","","","2537.36","1903.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","926.14","36.5","","101.66","28.85","502.70","121","786.58","2017.2","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","both","","","2537.36","1903.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","971.81","38.3","","61.58","25.32","328.44","138","786.58","2017.2","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","both","","","2537.36","1903.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1088.53","42.9","","71.66","71.66","71.66","1 through 10","786.58","2017.2","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","both","","","2537.36","1903.02","WELLPOINT [1015]","HB AMC WELLPOINT","1872.06","73.78","","74.75","27.97","425.28","93","786.58","2017.2","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2537.36","1903.02","AETNA [1001]","HB AMC AETNA HMO","1771.08","69.8","","52.67","14.36","414.90","1 through 10","1326.02","2073.53","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2537.36","1903.02","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1326.02","52.26","","25.34","25.34","25.34","1 through 10","1326.02","2073.53","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2537.36","1903.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2040.04","80.4","","478.02","107.84","478.02","1 through 10","1326.02","2073.53","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2537.36","1903.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2073.53","81.72","","32.74","12.33","122.05","1 through 10","1326.02","2073.53","percent of total billed charges",""
"GUIDEWIRE SYNCHRO2 200CM .014IN STANDARD TIP ACCESS LENGTH VASCULAR IMAGING HI TORQUE VERIFLEX NITINOL HYDROPHILIC ADULT","SUP-ITM-10022839","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2537.36","1903.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2073.53","81.72","","144.95","32.78","676.91","104","1326.02","2073.53","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","both","","","595.00","446.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","310.95","52.26","","25.34","25.34","25.34","1 through 10","184.45","473.03","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","both","","","595.00","446.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","427.21","71.8","","105.81","105.81","366.90","1 through 10","184.45","473.03","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","both","","","595.00","446.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","416.50","70","","512.90","74.70","612.85","1 through 10","184.45","473.03","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","both","","","595.00","446.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","473.03","79.5","","200.27","182.80","200.27","1 through 10","184.45","473.03","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","both","","","595.00","446.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","317.14","53.3","","37.73","37.73","169.33","1 through 10","184.45","473.03","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","both","","","595.00","446.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","386.75","65","","100.27","8.48","494.52","1 through 10","184.45","473.03","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","both","","","595.00","446.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","386.75","65","","160.19","160.19","160.19","1 through 10","184.45","473.03","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","184.45","31","","28.12","28.12","28.12","1 through 10","184.45","473.03","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","217.18","36.5","","101.66","28.85","502.70","121","184.45","473.03","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","227.89","38.3","","61.58","25.32","328.44","138","184.45","473.03","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","both","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.26","42.9","","71.66","71.66","71.66","1 through 10","184.45","473.03","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","both","","","595.00","446.25","WELLPOINT [1015]","HB AMC WELLPOINT","438.99","73.78","","74.75","27.97","425.28","93","184.45","473.03","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","595.00","446.25","AETNA [1001]","HB AMC AETNA HMO","415.31","69.8","","52.67","14.36","414.90","1 through 10","310.95","486.23","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","595.00","446.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","310.95","52.26","","25.34","25.34","25.34","1 through 10","310.95","486.23","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","595.00","446.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","478.38","80.4","","478.02","107.84","478.02","1 through 10","310.95","486.23","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","486.23","81.72","","32.74","12.33","122.05","1 through 10","310.95","486.23","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 175CM S/S W/SPRING COIL","SUP-ITM-10022586","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","486.23","81.72","","144.95","32.78","676.91","104","310.95","486.23","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","both","","","682.50","511.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","356.67","52.26","","25.34","25.34","25.34","1 through 10","211.58","542.59","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","both","","","682.50","511.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","490.04","71.8","","105.81","105.81","366.90","1 through 10","211.58","542.59","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","both","","","682.50","511.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","477.75","70","","512.90","74.70","612.85","1 through 10","211.58","542.59","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","both","","","682.50","511.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","542.59","79.5","","200.27","182.80","200.27","1 through 10","211.58","542.59","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","both","","","682.50","511.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","363.77","53.3","","37.73","37.73","169.33","1 through 10","211.58","542.59","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","both","","","682.50","511.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","443.63","65","","100.27","8.48","494.52","1 through 10","211.58","542.59","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","both","","","682.50","511.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","443.63","65","","160.19","160.19","160.19","1 through 10","211.58","542.59","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","211.58","31","","28.12","28.12","28.12","1 through 10","211.58","542.59","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","249.11","36.5","","101.66","28.85","502.70","121","211.58","542.59","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.40","38.3","","61.58","25.32","328.44","138","211.58","542.59","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","both","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.79","42.9","","71.66","71.66","71.66","1 through 10","211.58","542.59","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","both","","","682.50","511.87","WELLPOINT [1015]","HB AMC WELLPOINT","503.55","73.78","","74.75","27.97","425.28","93","211.58","542.59","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","682.50","511.87","AETNA [1001]","HB AMC AETNA HMO","476.39","69.8","","52.67","14.36","414.90","1 through 10","356.67","557.74","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","682.50","511.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","356.67","52.26","","25.34","25.34","25.34","1 through 10","356.67","557.74","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","682.50","511.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","548.73","80.4","","478.02","107.84","478.02","1 through 10","356.67","557.74","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","557.74","81.72","","32.74","12.33","122.05","1 through 10","356.67","557.74","percent of total billed charges",""
"GUIDEWIRE TORAYGUIDE .025IN 230CM S/S W/SPRING COIL","SUP-ITM-10158133","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","557.74","81.72","","144.95","32.78","676.91","104","356.67","557.74","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1218.00","913.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","636.53","52.26","","25.34","25.34","25.34","1 through 10","377.58","968.31","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1218.00","913.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","874.52","71.8","","105.81","105.81","366.90","1 through 10","377.58","968.31","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1218.00","913.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","852.60","70","","512.90","74.70","612.85","1 through 10","377.58","968.31","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1218.00","913.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","968.31","79.5","","200.27","182.80","200.27","1 through 10","377.58","968.31","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1218.00","913.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","649.19","53.3","","37.73","37.73","169.33","1 through 10","377.58","968.31","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1218.00","913.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","791.70","65","","100.27","8.48","494.52","1 through 10","377.58","968.31","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1218.00","913.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","791.70","65","","160.19","160.19","160.19","1 through 10","377.58","968.31","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1218.00","913.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","377.58","31","","28.12","28.12","28.12","1 through 10","377.58","968.31","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1218.00","913.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","444.57","36.5","","101.66","28.85","502.70","121","377.58","968.31","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1218.00","913.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","466.49","38.3","","61.58","25.32","328.44","138","377.58","968.31","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1218.00","913.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","522.52","42.9","","71.66","71.66","71.66","1 through 10","377.58","968.31","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","both","","","1218.00","913.50","WELLPOINT [1015]","HB AMC WELLPOINT","898.64","73.78","","74.75","27.97","425.28","93","377.58","968.31","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1218.00","913.50","AETNA [1001]","HB AMC AETNA HMO","850.16","69.8","","52.67","14.36","414.90","1 through 10","636.53","995.35","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1218.00","913.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","636.53","52.26","","25.34","25.34","25.34","1 through 10","636.53","995.35","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1218.00","913.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","979.27","80.4","","478.02","107.84","478.02","1 through 10","636.53","995.35","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1218.00","913.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","995.35","81.72","","32.74","12.33","122.05","1 through 10","636.53","995.35","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 600CM .035IN 5CM STRAIGHT TIP DIRECT NITINOL PTFE HYDROPHILIC COATED","SUP-ITM-10086884","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1218.00","913.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","995.35","81.72","","144.95","32.78","676.91","104","636.53","995.35","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","both","","","2553.46","1915.09","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1334.44","52.26","","25.34","25.34","25.34","1 through 10","791.57","2030","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","both","","","2553.46","1915.09","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1833.38","71.8","","105.81","105.81","366.90","1 through 10","791.57","2030","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","both","","","2553.46","1915.09","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1787.42","70","","512.90","74.70","612.85","1 through 10","791.57","2030","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","both","","","2553.46","1915.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2030.00","79.5","","200.27","182.80","200.27","1 through 10","791.57","2030","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","both","","","2553.46","1915.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1360.99","53.3","","37.73","37.73","169.33","1 through 10","791.57","2030","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","both","","","2553.46","1915.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1659.75","65","","100.27","8.48","494.52","1 through 10","791.57","2030","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","both","","","2553.46","1915.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","1659.75","65","","160.19","160.19","160.19","1 through 10","791.57","2030","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","both","","","2553.46","1915.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","791.57","31","","28.12","28.12","28.12","1 through 10","791.57","2030","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","both","","","2553.46","1915.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","932.01","36.5","","101.66","28.85","502.70","121","791.57","2030","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","both","","","2553.46","1915.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","977.98","38.3","","61.58","25.32","328.44","138","791.57","2030","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","both","","","2553.46","1915.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1095.43","42.9","","71.66","71.66","71.66","1 through 10","791.57","2030","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","both","","","2553.46","1915.09","WELLPOINT [1015]","HB AMC WELLPOINT","1883.94","73.78","","74.75","27.97","425.28","93","791.57","2030","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2553.46","1915.09","AETNA [1001]","HB AMC AETNA HMO","1782.32","69.8","","52.67","14.36","414.90","1 through 10","1334.44","2086.69","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2553.46","1915.09","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1334.44","52.26","","25.34","25.34","25.34","1 through 10","1334.44","2086.69","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2553.46","1915.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2052.98","80.4","","478.02","107.84","478.02","1 through 10","1334.44","2086.69","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2553.46","1915.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2086.69","81.72","","32.74","12.33","122.05","1 through 10","1334.44","2086.69","percent of total billed charges",""
"GUIDEWIRE TRANSEND 300CM .014IN 2CM SHAPABLE TIP FLOPPY","SUP-ITM-10011178","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2553.46","1915.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2086.69","81.72","","144.95","32.78","676.91","104","1334.44","2086.69","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.60","135.45","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","94.38","52.26","","25.34","25.34","25.34","1 through 10","55.99","143.58","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.60","135.45","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","129.67","71.8","","105.81","105.81","366.90","1 through 10","55.99","143.58","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.60","135.45","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","126.42","70","","512.90","74.70","612.85","1 through 10","55.99","143.58","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.60","135.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","143.58","79.5","","200.27","182.80","200.27","1 through 10","55.99","143.58","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.60","135.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","96.26","53.3","","37.73","37.73","169.33","1 through 10","55.99","143.58","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.60","135.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","117.39","65","","100.27","8.48","494.52","1 through 10","55.99","143.58","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.60","135.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","117.39","65","","160.19","160.19","160.19","1 through 10","55.99","143.58","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.60","135.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","55.99","31","","28.12","28.12","28.12","1 through 10","55.99","143.58","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.60","135.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.92","36.5","","101.66","28.85","502.70","121","55.99","143.58","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.60","135.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","69.17","38.3","","61.58","25.32","328.44","138","55.99","143.58","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.60","135.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.48","42.9","","71.66","71.66","71.66","1 through 10","55.99","143.58","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","180.60","135.45","WELLPOINT [1015]","HB AMC WELLPOINT","133.25","73.78","","74.75","27.97","425.28","93","55.99","143.58","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","180.60","135.45","AETNA [1001]","HB AMC AETNA HMO","126.06","69.8","","52.67","14.36","414.90","1 through 10","94.38","147.59","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","180.60","135.45","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","94.38","52.26","","25.34","25.34","25.34","1 through 10","94.38","147.59","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","180.60","135.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","145.20","80.4","","478.02","107.84","478.02","1 through 10","94.38","147.59","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","180.60","135.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","147.59","81.72","","32.74","12.33","122.05","1 through 10","94.38","147.59","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","180.60","135.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","147.59","81.72","","144.95","32.78","676.91","104","94.38","147.59","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","175.18","131.38","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","91.55","52.26","","25.34","25.34","25.34","1 through 10","54.31","139.27","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","175.18","131.38","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","125.78","71.8","","105.81","105.81","366.90","1 through 10","54.31","139.27","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","175.18","131.38","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","122.63","70","","512.90","74.70","612.85","1 through 10","54.31","139.27","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","175.18","131.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.27","79.5","","200.27","182.80","200.27","1 through 10","54.31","139.27","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","175.18","131.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.37","53.3","","37.73","37.73","169.33","1 through 10","54.31","139.27","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","175.18","131.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","113.87","65","","100.27","8.48","494.52","1 through 10","54.31","139.27","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","175.18","131.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","113.87","65","","160.19","160.19","160.19","1 through 10","54.31","139.27","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","175.18","131.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.31","31","","28.12","28.12","28.12","1 through 10","54.31","139.27","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","175.18","131.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.94","36.5","","101.66","28.85","502.70","121","54.31","139.27","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","175.18","131.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.09","38.3","","61.58","25.32","328.44","138","54.31","139.27","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","175.18","131.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.15","42.9","","71.66","71.66","71.66","1 through 10","54.31","139.27","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","175.18","131.38","WELLPOINT [1015]","HB AMC WELLPOINT","129.25","73.78","","74.75","27.97","425.28","93","54.31","139.27","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","175.18","131.38","AETNA [1001]","HB AMC AETNA HMO","122.28","69.8","","52.67","14.36","414.90","1 through 10","91.55","143.16","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","175.18","131.38","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","91.55","52.26","","25.34","25.34","25.34","1 through 10","91.55","143.16","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","175.18","131.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","140.84","80.4","","478.02","107.84","478.02","1 through 10","91.55","143.16","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","175.18","131.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.16","81.72","","32.74","12.33","122.05","1 through 10","91.55","143.16","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","175.18","131.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.16","81.72","","144.95","32.78","676.91","104","91.55","143.16","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","both","","","251.37","188.53","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","131.37","52.26","","25.34","25.34","25.34","1 through 10","77.92","199.84","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","both","","","251.37","188.53","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","180.48","71.8","","105.81","105.81","366.90","1 through 10","77.92","199.84","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","both","","","251.37","188.53","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","175.96","70","","512.90","74.70","612.85","1 through 10","77.92","199.84","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","both","","","251.37","188.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","199.84","79.5","","200.27","182.80","200.27","1 through 10","77.92","199.84","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","both","","","251.37","188.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","133.98","53.3","","37.73","37.73","169.33","1 through 10","77.92","199.84","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","both","","","251.37","188.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","163.39","65","","100.27","8.48","494.52","1 through 10","77.92","199.84","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","both","","","251.37","188.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","163.39","65","","160.19","160.19","160.19","1 through 10","77.92","199.84","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","both","","","251.37","188.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","77.92","31","","28.12","28.12","28.12","1 through 10","77.92","199.84","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","both","","","251.37","188.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91.75","36.5","","101.66","28.85","502.70","121","77.92","199.84","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","both","","","251.37","188.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.27","38.3","","61.58","25.32","328.44","138","77.92","199.84","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","both","","","251.37","188.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","107.84","42.9","","71.66","71.66","71.66","1 through 10","77.92","199.84","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","both","","","251.37","188.53","WELLPOINT [1015]","HB AMC WELLPOINT","185.46","73.78","","74.75","27.97","425.28","93","77.92","199.84","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","251.37","188.53","AETNA [1001]","HB AMC AETNA HMO","175.46","69.8","","52.67","14.36","414.90","1 through 10","131.37","205.42","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","251.37","188.53","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","131.37","52.26","","25.34","25.34","25.34","1 through 10","131.37","205.42","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","251.37","188.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","202.10","80.4","","478.02","107.84","478.02","1 through 10","131.37","205.42","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","251.37","188.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","205.42","81.72","","32.74","12.33","122.05","1 through 10","131.37","205.42","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL 150CM .018IN ZIPWIRE STRAIGHT URETERAL NITINOL POLYURETHANE HYDROPHILIC RADIOPAQUE STEERABLE STANDARD SHAFT BX/5EA","SUP-ITM-10155652","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","251.37","188.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","205.42","81.72","","144.95","32.78","676.91","104","131.37","205.42","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","417.41","313.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","218.14","52.26","","25.34","25.34","25.34","1 through 10","129.4","331.84","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","417.41","313.06","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","299.70","71.8","","105.81","105.81","366.90","1 through 10","129.4","331.84","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","417.41","313.06","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","292.19","70","","512.90","74.70","612.85","1 through 10","129.4","331.84","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","417.41","313.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","331.84","79.5","","200.27","182.80","200.27","1 through 10","129.4","331.84","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","417.41","313.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","222.48","53.3","","37.73","37.73","169.33","1 through 10","129.4","331.84","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","417.41","313.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","271.32","65","","100.27","8.48","494.52","1 through 10","129.4","331.84","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","417.41","313.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","271.32","65","","160.19","160.19","160.19","1 through 10","129.4","331.84","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","417.41","313.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","129.40","31","","28.12","28.12","28.12","1 through 10","129.4","331.84","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","417.41","313.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","152.35","36.5","","101.66","28.85","502.70","121","129.4","331.84","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","417.41","313.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","159.87","38.3","","61.58","25.32","328.44","138","129.4","331.84","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","417.41","313.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","179.07","42.9","","71.66","71.66","71.66","1 through 10","129.4","331.84","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","417.41","313.06","WELLPOINT [1015]","HB AMC WELLPOINT","307.97","73.78","","74.75","27.97","425.28","93","129.4","331.84","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","417.41","313.06","AETNA [1001]","HB AMC AETNA HMO","291.35","69.8","","52.67","14.36","414.90","1 through 10","218.14","341.11","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","417.41","313.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","218.14","52.26","","25.34","25.34","25.34","1 through 10","218.14","341.11","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","417.41","313.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","335.60","80.4","","478.02","107.84","478.02","1 through 10","218.14","341.11","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","417.41","313.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","341.11","81.72","","32.74","12.33","122.05","1 through 10","218.14","341.11","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","417.41","313.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","341.11","81.72","","144.95","32.78","676.91","104","218.14","341.11","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","both","","","781.89","586.42","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","408.62","52.26","","25.34","25.34","25.34","1 through 10","242.39","621.6","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","both","","","781.89","586.42","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","561.40","71.8","","105.81","105.81","366.90","1 through 10","242.39","621.6","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","both","","","781.89","586.42","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","547.32","70","","512.90","74.70","612.85","1 through 10","242.39","621.6","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","both","","","781.89","586.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","621.60","79.5","","200.27","182.80","200.27","1 through 10","242.39","621.6","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","both","","","781.89","586.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","416.75","53.3","","37.73","37.73","169.33","1 through 10","242.39","621.6","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","both","","","781.89","586.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","508.23","65","","100.27","8.48","494.52","1 through 10","242.39","621.6","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","both","","","781.89","586.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","508.23","65","","160.19","160.19","160.19","1 through 10","242.39","621.6","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","both","","","781.89","586.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","242.39","31","","28.12","28.12","28.12","1 through 10","242.39","621.6","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","both","","","781.89","586.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","285.39","36.5","","101.66","28.85","502.70","121","242.39","621.6","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","both","","","781.89","586.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","299.46","38.3","","61.58","25.32","328.44","138","242.39","621.6","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","both","","","781.89","586.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","335.43","42.9","","71.66","71.66","71.66","1 through 10","242.39","621.6","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","both","","","781.89","586.42","WELLPOINT [1015]","HB AMC WELLPOINT","576.88","73.78","","74.75","27.97","425.28","93","242.39","621.6","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","781.89","586.42","AETNA [1001]","HB AMC AETNA HMO","545.76","69.8","","52.67","14.36","414.90","1 through 10","408.62","638.96","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","781.89","586.42","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","408.62","52.26","","25.34","25.34","25.34","1 through 10","408.62","638.96","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","781.89","586.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","628.64","80.4","","478.02","107.84","478.02","1 through 10","408.62","638.96","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","781.89","586.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","638.96","81.72","","32.74","12.33","122.05","1 through 10","408.62","638.96","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 450CM GLIDEWIRE POLYURETHANE TUNGSTEN JACKET NITINOL CORE HYDROPHILIC COATED STIFF STRAIGHT TIP EWSS4535 BX/5EA","SUP-ITM-10118215","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","781.89","586.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","638.96","81.72","","144.95","32.78","676.91","104","408.62","638.96","percent of total billed charges",""
"GUIDEWIRE UROLOGY 145CM 0.038IN AMPLATZ SUPER STIFF PTFE COATED BX/5EA","SUP-ITM-10155772","CDM","C1726","HCPCS","0272","RC","","","","both","","","121.87","91.40","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","85.31","70","","863.10","863.10","863.10","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 145CM 0.038IN AMPLATZ SUPER STIFF PTFE COATED BX/5EA","SUP-ITM-10155772","CDM","C1726","HCPCS","0272","RC","","","","both","","","121.87","91.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","96.89","79.5","","447.66","447.66","447.66","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 145CM 0.038IN AMPLATZ SUPER STIFF PTFE COATED BX/5EA","SUP-ITM-10155772","CDM","C1726","HCPCS","0272","RC","","","","both","","","121.87","91.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","79.22","65","","1020.11","1020.11","1020.11","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 145CM 0.038IN AMPLATZ SUPER STIFF PTFE COATED BX/5EA","SUP-ITM-10155772","CDM","C1726","HCPCS","0272","RC","","","","both","","","121.87","91.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","37.78","31","","208.83","208.83","208.83","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 145CM 0.038IN AMPLATZ SUPER STIFF PTFE COATED BX/5EA","SUP-ITM-10155772","CDM","C1726","HCPCS","0272","RC","","","","both","","","121.87","91.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.48","36.5","","312.44","214.23","1086.03","20","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 145CM 0.038IN AMPLATZ SUPER STIFF PTFE COATED BX/5EA","SUP-ITM-10155772","CDM","C1726","HCPCS","0272","RC","","","","both","","","121.87","91.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.68","38.3","","264.25","227.63","567.11","31","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 145CM 0.038IN AMPLATZ SUPER STIFF PTFE COATED BX/5EA","SUP-ITM-10155772","CDM","C1726","HCPCS","0272","RC","","","","both","","","121.87","91.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.28","42.9","","79.94","79.94","79.94","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 145CM 0.038IN AMPLATZ SUPER STIFF PTFE COATED BX/5EA","SUP-ITM-10155772","CDM","C1726","HCPCS","0272","RC","","","","both","","","121.87","91.40","WELLPOINT [1015]","HB AMC WELLPOINT","89.92","73.78","","174.45","74.45","1168.42","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 145CM 0.038IN AMPLATZ SUPER STIFF PTFE COATED BX/5EA","SUP-ITM-10155772","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","121.87","91.40","AETNA [1001]","HB AMC AETNA HMO","85.07","69.8","","655.01","135.40","784.73","1 through 10","63.69","99.59","percent of total billed charges",""
"GUIDEWIRE UROLOGY 145CM 0.038IN AMPLATZ SUPER STIFF PTFE COATED BX/5EA","SUP-ITM-10155772","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","121.87","91.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","99.59","81.72","","540.25","46.28","897.42","36","63.69","99.59","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","63.69","52.26","","25.34","25.34","25.34","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","87.50","71.8","","105.81","105.81","366.90","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","85.31","70","","512.90","74.70","612.85","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","96.89","79.5","","200.27","182.80","200.27","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","64.96","53.3","","37.73","37.73","169.33","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","79.22","65","","100.27","8.48","494.52","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","79.22","65","","160.19","160.19","160.19","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","37.78","31","","28.12","28.12","28.12","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.48","36.5","","101.66","28.85","502.70","121","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.68","38.3","","61.58","25.32","328.44","138","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.28","42.9","","71.66","71.66","71.66","1 through 10","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","121.87","91.40","WELLPOINT [1015]","HB AMC WELLPOINT","89.92","73.78","","74.75","27.97","425.28","93","37.78","96.89","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","121.87","91.40","AETNA [1001]","HB AMC AETNA HMO","85.07","69.8","","52.67","14.36","414.90","1 through 10","63.69","99.59","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","121.87","91.40","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","63.69","52.26","","25.34","25.34","25.34","1 through 10","63.69","99.59","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","121.87","91.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","97.98","80.4","","478.02","107.84","478.02","1 through 10","63.69","99.59","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","121.87","91.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","99.59","81.72","","32.74","12.33","122.05","1 through 10","63.69","99.59","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","121.87","91.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","99.59","81.72","","144.95","32.78","676.91","104","63.69","99.59","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","both","","","193.23","144.92","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","100.98","52.26","","25.34","25.34","25.34","1 through 10","59.9","153.62","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","both","","","193.23","144.92","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","138.74","71.8","","105.81","105.81","366.90","1 through 10","59.9","153.62","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","both","","","193.23","144.92","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","135.26","70","","512.90","74.70","612.85","1 through 10","59.9","153.62","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","both","","","193.23","144.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","153.62","79.5","","200.27","182.80","200.27","1 through 10","59.9","153.62","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","both","","","193.23","144.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","102.99","53.3","","37.73","37.73","169.33","1 through 10","59.9","153.62","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","both","","","193.23","144.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","125.60","65","","100.27","8.48","494.52","1 through 10","59.9","153.62","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","both","","","193.23","144.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","125.60","65","","160.19","160.19","160.19","1 through 10","59.9","153.62","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","both","","","193.23","144.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","59.90","31","","28.12","28.12","28.12","1 through 10","59.9","153.62","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","both","","","193.23","144.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70.53","36.5","","101.66","28.85","502.70","121","59.9","153.62","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","both","","","193.23","144.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","74.01","38.3","","61.58","25.32","328.44","138","59.9","153.62","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","both","","","193.23","144.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.90","42.9","","71.66","71.66","71.66","1 through 10","59.9","153.62","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","both","","","193.23","144.92","WELLPOINT [1015]","HB AMC WELLPOINT","142.57","73.78","","74.75","27.97","425.28","93","59.9","153.62","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","193.23","144.92","AETNA [1001]","HB AMC AETNA HMO","134.87","69.8","","52.67","14.36","414.90","1 through 10","100.98","157.91","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","193.23","144.92","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","100.98","52.26","","25.34","25.34","25.34","1 through 10","100.98","157.91","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","193.23","144.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","155.36","80.4","","478.02","107.84","478.02","1 through 10","100.98","157.91","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","193.23","144.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","157.91","81.72","","32.74","12.33","122.05","1 through 10","100.98","157.91","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.025IN GLIDEWIRE HYDROPHILIC COATED STRAIGHT TAPERED TIP REGULAR PK/5EA","SUP-ITM-10115549","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","193.23","144.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","157.91","81.72","","144.95","32.78","676.91","104","100.98","157.91","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","both","","","151.87","113.90","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","79.37","52.26","","25.34","25.34","25.34","1 through 10","47.08","120.74","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","both","","","151.87","113.90","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","109.04","71.8","","105.81","105.81","366.90","1 through 10","47.08","120.74","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","both","","","151.87","113.90","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","106.31","70","","512.90","74.70","612.85","1 through 10","47.08","120.74","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","both","","","151.87","113.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","120.74","79.5","","200.27","182.80","200.27","1 through 10","47.08","120.74","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","both","","","151.87","113.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","80.95","53.3","","37.73","37.73","169.33","1 through 10","47.08","120.74","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","both","","","151.87","113.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","98.72","65","","100.27","8.48","494.52","1 through 10","47.08","120.74","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","both","","","151.87","113.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","98.72","65","","160.19","160.19","160.19","1 through 10","47.08","120.74","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","both","","","151.87","113.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","47.08","31","","28.12","28.12","28.12","1 through 10","47.08","120.74","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","both","","","151.87","113.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.43","36.5","","101.66","28.85","502.70","121","47.08","120.74","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","both","","","151.87","113.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.17","38.3","","61.58","25.32","328.44","138","47.08","120.74","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","both","","","151.87","113.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.15","42.9","","71.66","71.66","71.66","1 through 10","47.08","120.74","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","both","","","151.87","113.90","WELLPOINT [1015]","HB AMC WELLPOINT","112.05","73.78","","74.75","27.97","425.28","93","47.08","120.74","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","151.87","113.90","AETNA [1001]","HB AMC AETNA HMO","106.01","69.8","","52.67","14.36","414.90","1 through 10","79.37","124.11","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","151.87","113.90","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","79.37","52.26","","25.34","25.34","25.34","1 through 10","79.37","124.11","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","151.87","113.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","122.10","80.4","","478.02","107.84","478.02","1 through 10","79.37","124.11","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","151.87","113.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","124.11","81.72","","32.74","12.33","122.05","1 through 10","79.37","124.11","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3CMX150 0.035IN EZ GLIDER NITINOL CORE HYDROPHILIC COAT MOVEABLE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10118045","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","151.87","113.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","124.11","81.72","","144.95","32.78","676.91","104","79.37","124.11","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","294.00","220.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","153.64","52.26","","25.34","25.34","25.34","1 through 10","91.14","233.73","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","294.00","220.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","211.09","71.8","","105.81","105.81","366.90","1 through 10","91.14","233.73","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","294.00","220.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","205.80","70","","512.90","74.70","612.85","1 through 10","91.14","233.73","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","294.00","220.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","233.73","79.5","","200.27","182.80","200.27","1 through 10","91.14","233.73","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","294.00","220.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","156.70","53.3","","37.73","37.73","169.33","1 through 10","91.14","233.73","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","191.10","65","","100.27","8.48","494.52","1 through 10","91.14","233.73","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","191.10","65","","160.19","160.19","160.19","1 through 10","91.14","233.73","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","91.14","31","","28.12","28.12","28.12","1 through 10","91.14","233.73","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","107.31","36.5","","101.66","28.85","502.70","121","91.14","233.73","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","112.60","38.3","","61.58","25.32","328.44","138","91.14","233.73","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.13","42.9","","71.66","71.66","71.66","1 through 10","91.14","233.73","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","294.00","220.50","WELLPOINT [1015]","HB AMC WELLPOINT","216.91","73.78","","74.75","27.97","425.28","93","91.14","233.73","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","294.00","220.50","AETNA [1001]","HB AMC AETNA HMO","205.21","69.8","","52.67","14.36","414.90","1 through 10","153.64","240.26","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","294.00","220.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","153.64","52.26","","25.34","25.34","25.34","1 through 10","153.64","240.26","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","236.38","80.4","","478.02","107.84","478.02","1 through 10","153.64","240.26","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","240.26","81.72","","32.74","12.33","122.05","1 through 10","153.64","240.26","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","240.26","81.72","","144.95","32.78","676.91","104","153.64","240.26","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","both","","","160.94","120.70","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","84.11","52.26","","25.34","25.34","25.34","1 through 10","49.89","127.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","both","","","160.94","120.70","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","115.55","71.8","","105.81","105.81","366.90","1 through 10","49.89","127.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","both","","","160.94","120.70","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.66","70","","512.90","74.70","612.85","1 through 10","49.89","127.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","both","","","160.94","120.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.95","79.5","","200.27","182.80","200.27","1 through 10","49.89","127.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","both","","","160.94","120.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.78","53.3","","37.73","37.73","169.33","1 through 10","49.89","127.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","both","","","160.94","120.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.61","65","","100.27","8.48","494.52","1 through 10","49.89","127.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","both","","","160.94","120.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","104.61","65","","160.19","160.19","160.19","1 through 10","49.89","127.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","both","","","160.94","120.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.89","31","","28.12","28.12","28.12","1 through 10","49.89","127.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","both","","","160.94","120.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.74","36.5","","101.66","28.85","502.70","121","49.89","127.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","both","","","160.94","120.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.64","38.3","","61.58","25.32","328.44","138","49.89","127.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","both","","","160.94","120.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.04","42.9","","71.66","71.66","71.66","1 through 10","49.89","127.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","both","","","160.94","120.70","WELLPOINT [1015]","HB AMC WELLPOINT","118.74","73.78","","74.75","27.97","425.28","93","49.89","127.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","160.94","120.70","AETNA [1001]","HB AMC AETNA HMO","112.34","69.8","","52.67","14.36","414.90","1 through 10","84.11","131.52","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","160.94","120.70","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","84.11","52.26","","25.34","25.34","25.34","1 through 10","84.11","131.52","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","160.94","120.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","129.40","80.4","","478.02","107.84","478.02","1 through 10","84.11","131.52","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","160.94","120.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","131.52","81.72","","32.74","12.33","122.05","1 through 10","84.11","131.52","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 260CM NITINOL POLYMER HYDROPHILIC PERIPHERAL TAPER STRAIGHT TIP BX/5EA","SUP-ITM-10213331","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","160.94","120.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","131.52","81.72","","144.95","32.78","676.91","104","84.11","131.52","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","both","","","146.50","109.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","76.56","52.26","","25.34","25.34","25.34","1 through 10","45.42","116.47","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","both","","","146.50","109.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","105.19","71.8","","105.81","105.81","366.90","1 through 10","45.42","116.47","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","both","","","146.50","109.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","102.55","70","","512.90","74.70","612.85","1 through 10","45.42","116.47","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","both","","","146.50","109.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.47","79.5","","200.27","182.80","200.27","1 through 10","45.42","116.47","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","both","","","146.50","109.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.08","53.3","","37.73","37.73","169.33","1 through 10","45.42","116.47","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","both","","","146.50","109.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","95.23","65","","100.27","8.48","494.52","1 through 10","45.42","116.47","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","both","","","146.50","109.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","95.23","65","","160.19","160.19","160.19","1 through 10","45.42","116.47","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","both","","","146.50","109.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.42","31","","28.12","28.12","28.12","1 through 10","45.42","116.47","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","both","","","146.50","109.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.47","36.5","","101.66","28.85","502.70","121","45.42","116.47","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","both","","","146.50","109.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.11","38.3","","61.58","25.32","328.44","138","45.42","116.47","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","both","","","146.50","109.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.85","42.9","","71.66","71.66","71.66","1 through 10","45.42","116.47","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","both","","","146.50","109.87","WELLPOINT [1015]","HB AMC WELLPOINT","108.09","73.78","","74.75","27.97","425.28","93","45.42","116.47","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","146.50","109.87","AETNA [1001]","HB AMC AETNA HMO","102.26","69.8","","52.67","14.36","414.90","1 through 10","76.56","119.72","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","146.50","109.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","76.56","52.26","","25.34","25.34","25.34","1 through 10","76.56","119.72","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","146.50","109.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","117.79","80.4","","478.02","107.84","478.02","1 through 10","76.56","119.72","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","146.50","109.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","119.72","81.72","","32.74","12.33","122.05","1 through 10","76.56","119.72","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 3X80CM ZIPWIRE HYDROPHILIC COATED STIFF ANGLED TIP BX/5EA","SUP-ITM-10198228","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","146.50","109.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","119.72","81.72","","144.95","32.78","676.91","104","76.56","119.72","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","72.80","54.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","38.05","52.26","","25.34","25.34","25.34","1 through 10","22.57","57.88","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","72.80","54.60","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","52.27","71.8","","105.81","105.81","366.90","1 through 10","22.57","57.88","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","72.80","54.60","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","50.96","70","","512.90","74.70","612.85","1 through 10","22.57","57.88","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","72.80","54.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","57.88","79.5","","200.27","182.80","200.27","1 through 10","22.57","57.88","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","72.80","54.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","38.80","53.3","","37.73","37.73","169.33","1 through 10","22.57","57.88","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","72.80","54.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","47.32","65","","100.27","8.48","494.52","1 through 10","22.57","57.88","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","72.80","54.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","47.32","65","","160.19","160.19","160.19","1 through 10","22.57","57.88","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","72.80","54.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","22.57","31","","28.12","28.12","28.12","1 through 10","22.57","57.88","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","72.80","54.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.57","36.5","","101.66","28.85","502.70","121","22.57","57.88","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","72.80","54.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27.88","38.3","","61.58","25.32","328.44","138","22.57","57.88","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","72.80","54.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.23","42.9","","71.66","71.66","71.66","1 through 10","22.57","57.88","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","both","","","72.80","54.60","WELLPOINT [1015]","HB AMC WELLPOINT","53.71","73.78","","74.75","27.97","425.28","93","22.57","57.88","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","72.80","54.60","AETNA [1001]","HB AMC AETNA HMO","50.81","69.8","","52.67","14.36","414.90","1 through 10","38.05","59.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","72.80","54.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","38.05","52.26","","25.34","25.34","25.34","1 through 10","38.05","59.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","72.80","54.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","58.53","80.4","","478.02","107.84","478.02","1 through 10","38.05","59.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","72.80","54.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","59.49","81.72","","32.74","12.33","122.05","1 through 10","38.05","59.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035INX15 145CM 6 PERIPHERAL BENTSON SS PTFE COATED FIXED CORE","SUP-ITM-10175486","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","72.80","54.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","59.49","81.72","","144.95","32.78","676.91","104","38.05","59.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","both","","","157.50","118.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","82.31","52.26","","25.34","25.34","25.34","1 through 10","48.83","125.21","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","both","","","157.50","118.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","113.09","71.8","","105.81","105.81","366.90","1 through 10","48.83","125.21","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","both","","","157.50","118.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","110.25","70","","512.90","74.70","612.85","1 through 10","48.83","125.21","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","200.27","182.80","200.27","1 through 10","48.83","125.21","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","37.73","37.73","169.33","1 through 10","48.83","125.21","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","both","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","102.38","65","","100.27","8.48","494.52","1 through 10","48.83","125.21","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","both","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","102.38","65","","160.19","160.19","160.19","1 through 10","48.83","125.21","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.83","31","","28.12","28.12","28.12","1 through 10","48.83","125.21","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","101.66","28.85","502.70","121","48.83","125.21","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","61.58","25.32","328.44","138","48.83","125.21","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","71.66","71.66","71.66","1 through 10","48.83","125.21","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","74.75","27.97","425.28","93","48.83","125.21","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","52.67","14.36","414.90","1 through 10","82.31","128.71","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","157.50","118.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","82.31","52.26","","25.34","25.34","25.34","1 through 10","82.31","128.71","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","478.02","107.84","478.02","1 through 10","82.31","128.71","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.71","81.72","","32.74","12.33","122.05","1 through 10","82.31","128.71","percent of total billed charges",""
"GUIDEWIRE VASCULAR 0.035INX150CM TIGERWIRE STAINLESS STEEL PTFE COATED STEERABLE STRAIGHT TIP STANDARD STERILE DISPOSABLE","SUP-ITM-10073206","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","144.95","32.78","676.91","104","82.31","128.71","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.88","35.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","25.02","52.26","","25.34","25.34","25.34","1 through 10","14.84","38.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.88","35.91","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","34.38","71.8","","105.81","105.81","366.90","1 through 10","14.84","38.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.88","35.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","33.52","70","","512.90","74.70","612.85","1 through 10","14.84","38.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.88","35.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","38.06","79.5","","200.27","182.80","200.27","1 through 10","14.84","38.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.88","35.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","25.52","53.3","","37.73","37.73","169.33","1 through 10","14.84","38.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.88","35.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","31.12","65","","100.27","8.48","494.52","1 through 10","14.84","38.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.88","35.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","31.12","65","","160.19","160.19","160.19","1 through 10","14.84","38.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.88","35.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","14.84","31","","28.12","28.12","28.12","1 through 10","14.84","38.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.88","35.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17.48","36.5","","101.66","28.85","502.70","121","14.84","38.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.88","35.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18.34","38.3","","61.58","25.32","328.44","138","14.84","38.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.88","35.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20.54","42.9","","71.66","71.66","71.66","1 through 10","14.84","38.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","both","","","47.88","35.91","WELLPOINT [1015]","HB AMC WELLPOINT","35.33","73.78","","74.75","27.97","425.28","93","14.84","38.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","47.88","35.91","AETNA [1001]","HB AMC AETNA HMO","33.42","69.8","","52.67","14.36","414.90","1 through 10","25.02","39.13","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","47.88","35.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","25.02","52.26","","25.34","25.34","25.34","1 through 10","25.02","39.13","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","47.88","35.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","38.50","80.4","","478.02","107.84","478.02","1 through 10","25.02","39.13","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","47.88","35.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","39.13","81.72","","32.74","12.33","122.05","1 through 10","25.02","39.13","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 80CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10011463","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","47.88","35.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","39.13","81.72","","144.95","32.78","676.91","104","25.02","39.13","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.47","107.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","74.98","52.26","","25.34","25.34","25.34","1 through 10","44.48","114.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.47","107.60","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","103.01","71.8","","105.81","105.81","366.90","1 through 10","44.48","114.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.47","107.60","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","100.43","70","","512.90","74.70","612.85","1 through 10","44.48","114.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.47","107.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","114.06","79.5","","200.27","182.80","200.27","1 through 10","44.48","114.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.47","107.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","76.47","53.3","","37.73","37.73","169.33","1 through 10","44.48","114.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.47","107.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","93.26","65","","100.27","8.48","494.52","1 through 10","44.48","114.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.47","107.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","93.26","65","","160.19","160.19","160.19","1 through 10","44.48","114.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.47","107.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","44.48","31","","28.12","28.12","28.12","1 through 10","44.48","114.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.47","107.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","52.37","36.5","","101.66","28.85","502.70","121","44.48","114.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.47","107.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.95","38.3","","61.58","25.32","328.44","138","44.48","114.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.47","107.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.55","42.9","","71.66","71.66","71.66","1 through 10","44.48","114.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.47","107.60","WELLPOINT [1015]","HB AMC WELLPOINT","105.85","73.78","","74.75","27.97","425.28","93","44.48","114.06","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","143.47","107.60","AETNA [1001]","HB AMC AETNA HMO","100.14","69.8","","52.67","14.36","414.90","1 through 10","74.98","117.24","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","143.47","107.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","74.98","52.26","","25.34","25.34","25.34","1 through 10","74.98","117.24","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","143.47","107.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","115.35","80.4","","478.02","107.84","478.02","1 through 10","74.98","117.24","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","143.47","107.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","117.24","81.72","","32.74","12.33","122.05","1 through 10","74.98","117.24","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","143.47","107.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","117.24","81.72","","144.95","32.78","676.91","104","74.98","117.24","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","both","","","14.88","11.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","7.78","52.26","","25.34","25.34","25.34","1 through 10","4.61","11.83","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","both","","","14.88","11.16","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","10.68","71.8","","105.81","105.81","366.90","1 through 10","4.61","11.83","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","both","","","14.88","11.16","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","10.42","70","","512.90","74.70","612.85","1 through 10","4.61","11.83","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","both","","","14.88","11.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11.83","79.5","","200.27","182.80","200.27","1 through 10","4.61","11.83","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","both","","","14.88","11.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7.93","53.3","","37.73","37.73","169.33","1 through 10","4.61","11.83","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","both","","","14.88","11.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","9.67","65","","100.27","8.48","494.52","1 through 10","4.61","11.83","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","both","","","14.88","11.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","9.67","65","","160.19","160.19","160.19","1 through 10","4.61","11.83","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","both","","","14.88","11.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4.61","31","","28.12","28.12","28.12","1 through 10","4.61","11.83","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","both","","","14.88","11.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5.43","36.5","","101.66","28.85","502.70","121","4.61","11.83","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","both","","","14.88","11.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5.70","38.3","","61.58","25.32","328.44","138","4.61","11.83","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","both","","","14.88","11.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.38","42.9","","71.66","71.66","71.66","1 through 10","4.61","11.83","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","both","","","14.88","11.16","WELLPOINT [1015]","HB AMC WELLPOINT","10.98","73.78","","74.75","27.97","425.28","93","4.61","11.83","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","14.88","11.16","AETNA [1001]","HB AMC AETNA HMO","10.39","69.8","","52.67","14.36","414.90","1 through 10","7.78","12.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","14.88","11.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","7.78","52.26","","25.34","25.34","25.34","1 through 10","7.78","12.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","14.88","11.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11.96","80.4","","478.02","107.84","478.02","1 through 10","7.78","12.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","14.88","11.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","12.16","81.72","","32.74","12.33","122.05","1 through 10","7.78","12.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM .035IN STRAIGHT TIP GUIDERIGHT SS PTFE COATED FIXED CORE STANDARD BX/5EA","SUP-ITM-10011483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","14.88","11.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12.16","81.72","","144.95","32.78","676.91","104","7.78","12.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","both","","","624.75","468.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","326.49","52.26","","25.34","25.34","25.34","1 through 10","193.67","496.68","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","both","","","624.75","468.56","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","448.57","71.8","","105.81","105.81","366.90","1 through 10","193.67","496.68","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","both","","","624.75","468.56","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","437.33","70","","512.90","74.70","612.85","1 through 10","193.67","496.68","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","both","","","624.75","468.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","496.68","79.5","","200.27","182.80","200.27","1 through 10","193.67","496.68","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","both","","","624.75","468.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","332.99","53.3","","37.73","37.73","169.33","1 through 10","193.67","496.68","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","both","","","624.75","468.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","406.09","65","","100.27","8.48","494.52","1 through 10","193.67","496.68","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","both","","","624.75","468.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","406.09","65","","160.19","160.19","160.19","1 through 10","193.67","496.68","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","both","","","624.75","468.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","193.67","31","","28.12","28.12","28.12","1 through 10","193.67","496.68","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","both","","","624.75","468.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.03","36.5","","101.66","28.85","502.70","121","193.67","496.68","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","both","","","624.75","468.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.28","38.3","","61.58","25.32","328.44","138","193.67","496.68","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","both","","","624.75","468.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.02","42.9","","71.66","71.66","71.66","1 through 10","193.67","496.68","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","both","","","624.75","468.56","WELLPOINT [1015]","HB AMC WELLPOINT","460.94","73.78","","74.75","27.97","425.28","93","193.67","496.68","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","624.75","468.56","AETNA [1001]","HB AMC AETNA HMO","436.08","69.8","","52.67","14.36","414.90","1 through 10","326.49","510.55","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","624.75","468.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","326.49","52.26","","25.34","25.34","25.34","1 through 10","326.49","510.55","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","624.75","468.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","502.30","80.4","","478.02","107.84","478.02","1 through 10","326.49","510.55","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","624.75","468.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","510.55","81.72","","32.74","12.33","122.05","1 through 10","326.49","510.55","percent of total billed charges",""
"GUIDEWIRE VASCULAR 180CM .018IN GOLD TIP HYDROPHILIC COATED DOUBLE ANGLE 90 TO 60 DEGREE GOLD COIL 25CM GRIND","SUP-ITM-10013759","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","624.75","468.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","510.55","81.72","","144.95","32.78","676.91","104","326.49","510.55","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.68","27.51","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","19.17","52.26","","25.34","25.34","25.34","1 through 10","11.37","29.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.68","27.51","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","26.34","71.8","","105.81","105.81","366.90","1 through 10","11.37","29.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.68","27.51","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","25.68","70","","512.90","74.70","612.85","1 through 10","11.37","29.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.68","27.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","29.16","79.5","","200.27","182.80","200.27","1 through 10","11.37","29.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.68","27.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19.55","53.3","","37.73","37.73","169.33","1 through 10","11.37","29.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.68","27.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","23.84","65","","100.27","8.48","494.52","1 through 10","11.37","29.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.68","27.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","23.84","65","","160.19","160.19","160.19","1 through 10","11.37","29.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.68","27.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","11.37","31","","28.12","28.12","28.12","1 through 10","11.37","29.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.68","27.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13.39","36.5","","101.66","28.85","502.70","121","11.37","29.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.68","27.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.05","38.3","","61.58","25.32","328.44","138","11.37","29.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.68","27.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.74","42.9","","71.66","71.66","71.66","1 through 10","11.37","29.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.68","27.51","WELLPOINT [1015]","HB AMC WELLPOINT","27.06","73.78","","74.75","27.97","425.28","93","11.37","29.16","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","36.68","27.51","AETNA [1001]","HB AMC AETNA HMO","25.60","69.8","","52.67","14.36","414.90","1 through 10","19.17","29.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","36.68","27.51","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","19.17","52.26","","25.34","25.34","25.34","1 through 10","19.17","29.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","36.68","27.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","29.49","80.4","","478.02","107.84","478.02","1 through 10","19.17","29.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","36.68","27.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","29.97","81.72","","32.74","12.33","122.05","1 through 10","19.17","29.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 23 5/8X0.032IN DUOFLEX STRAIGHT SOFT TIP J ARROW ADVANCER CS/25EA","SUP-ITM-10065802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","36.68","27.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","29.97","81.72","","144.95","32.78","676.91","104","19.17","29.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","both","","","82.22","61.66","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","42.97","52.26","","25.34","25.34","25.34","1 through 10","25.49","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","both","","","82.22","61.66","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","59.03","71.8","","105.81","105.81","366.90","1 through 10","25.49","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","both","","","82.22","61.66","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","57.55","70","","512.90","74.70","612.85","1 through 10","25.49","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","both","","","82.22","61.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","65.36","79.5","","200.27","182.80","200.27","1 through 10","25.49","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","both","","","82.22","61.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","43.82","53.3","","37.73","37.73","169.33","1 through 10","25.49","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","both","","","82.22","61.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","53.44","65","","100.27","8.48","494.52","1 through 10","25.49","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","both","","","82.22","61.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","53.44","65","","160.19","160.19","160.19","1 through 10","25.49","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","both","","","82.22","61.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","25.49","31","","28.12","28.12","28.12","1 through 10","25.49","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","both","","","82.22","61.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30.01","36.5","","101.66","28.85","502.70","121","25.49","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","both","","","82.22","61.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31.49","38.3","","61.58","25.32","328.44","138","25.49","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","both","","","82.22","61.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.27","42.9","","71.66","71.66","71.66","1 through 10","25.49","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","both","","","82.22","61.66","WELLPOINT [1015]","HB AMC WELLPOINT","60.66","73.78","","74.75","27.97","425.28","93","25.49","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","82.22","61.66","AETNA [1001]","HB AMC AETNA HMO","57.39","69.8","","52.67","14.36","414.90","1 through 10","42.97","67.19","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","82.22","61.66","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","42.97","52.26","","25.34","25.34","25.34","1 through 10","42.97","67.19","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","82.22","61.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","66.10","80.4","","478.02","107.84","478.02","1 through 10","42.97","67.19","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","82.22","61.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","67.19","81.72","","32.74","12.33","122.05","1 through 10","42.97","67.19","percent of total billed charges",""
"GUIDEWIRE VASCULAR 260CM .035IN STANDARD TIP PTFE COATED BENTSON S/S","SUP-ITM-10008220","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","82.22","61.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","67.19","81.72","","144.95","32.78","676.91","104","42.97","67.19","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.47","44.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","31.08","52.26","","25.34","25.34","25.34","1 through 10","18.44","47.28","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.47","44.60","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","42.70","71.8","","105.81","105.81","366.90","1 through 10","18.44","47.28","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.47","44.60","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","41.63","70","","512.90","74.70","612.85","1 through 10","18.44","47.28","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.47","44.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","47.28","79.5","","200.27","182.80","200.27","1 through 10","18.44","47.28","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.47","44.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","31.70","53.3","","37.73","37.73","169.33","1 through 10","18.44","47.28","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.47","44.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","38.66","65","","100.27","8.48","494.52","1 through 10","18.44","47.28","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.47","44.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","38.66","65","","160.19","160.19","160.19","1 through 10","18.44","47.28","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.47","44.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","18.44","31","","28.12","28.12","28.12","1 through 10","18.44","47.28","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.47","44.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21.71","36.5","","101.66","28.85","502.70","121","18.44","47.28","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.47","44.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22.78","38.3","","61.58","25.32","328.44","138","18.44","47.28","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.47","44.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.51","42.9","","71.66","71.66","71.66","1 through 10","18.44","47.28","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","both","","","59.47","44.60","WELLPOINT [1015]","HB AMC WELLPOINT","43.88","73.78","","74.75","27.97","425.28","93","18.44","47.28","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","59.47","44.60","AETNA [1001]","HB AMC AETNA HMO","41.51","69.8","","52.67","14.36","414.90","1 through 10","31.08","48.6","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","59.47","44.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","31.08","52.26","","25.34","25.34","25.34","1 through 10","31.08","48.6","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","59.47","44.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","47.81","80.4","","478.02","107.84","478.02","1 through 10","31.08","48.6","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","59.47","44.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","48.60","81.72","","32.74","12.33","122.05","1 through 10","31.08","48.6","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MM 145CM .025IN SAFE T J TIP PTFE COATED FIXED CORE CURVED S/S","SUP-ITM-10000287","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","59.47","44.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","48.60","81.72","","144.95","32.78","676.91","104","31.08","48.6","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","both","","","31.54","23.65","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","16.48","52.26","","25.34","25.34","25.34","1 through 10","9.78","25.07","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","both","","","31.54","23.65","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","22.65","71.8","","105.81","105.81","366.90","1 through 10","9.78","25.07","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","both","","","31.54","23.65","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","22.08","70","","512.90","74.70","612.85","1 through 10","9.78","25.07","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","both","","","31.54","23.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","25.07","79.5","","200.27","182.80","200.27","1 through 10","9.78","25.07","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","both","","","31.54","23.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16.81","53.3","","37.73","37.73","169.33","1 through 10","9.78","25.07","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","both","","","31.54","23.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","20.50","65","","100.27","8.48","494.52","1 through 10","9.78","25.07","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","both","","","31.54","23.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","20.50","65","","160.19","160.19","160.19","1 through 10","9.78","25.07","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","both","","","31.54","23.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","9.78","31","","28.12","28.12","28.12","1 through 10","9.78","25.07","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","both","","","31.54","23.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11.51","36.5","","101.66","28.85","502.70","121","9.78","25.07","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","both","","","31.54","23.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12.08","38.3","","61.58","25.32","328.44","138","9.78","25.07","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","both","","","31.54","23.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13.53","42.9","","71.66","71.66","71.66","1 through 10","9.78","25.07","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","both","","","31.54","23.65","WELLPOINT [1015]","HB AMC WELLPOINT","23.27","73.78","","74.75","27.97","425.28","93","9.78","25.07","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","31.54","23.65","AETNA [1001]","HB AMC AETNA HMO","22.01","69.8","","52.67","14.36","414.90","1 through 10","16.48","25.77","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","31.54","23.65","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","16.48","52.26","","25.34","25.34","25.34","1 through 10","16.48","25.77","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","31.54","23.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","25.36","80.4","","478.02","107.84","478.02","1 through 10","16.48","25.77","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","31.54","23.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","25.77","81.72","","32.74","12.33","122.05","1 through 10","16.48","25.77","percent of total billed charges",""
"GUIDEWIRE VASCULAR 68CM .035IN J TIP/STRAIGHT SOFT TIP ARROW ADVANCER CS/25EA","SUP-ITM-10003212","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","31.54","23.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","25.77","81.72","","144.95","32.78","676.91","104","16.48","25.77","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.22","72.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","50.28","52.26","","25.34","25.34","25.34","1 through 10","29.83","76.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.22","72.16","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","69.09","71.8","","105.81","105.81","366.90","1 through 10","29.83","76.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.22","72.16","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","67.35","70","","512.90","74.70","612.85","1 through 10","29.83","76.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.22","72.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","76.49","79.5","","200.27","182.80","200.27","1 through 10","29.83","76.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.22","72.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","51.29","53.3","","37.73","37.73","169.33","1 through 10","29.83","76.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.22","72.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","62.54","65","","100.27","8.48","494.52","1 through 10","29.83","76.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.22","72.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","62.54","65","","160.19","160.19","160.19","1 through 10","29.83","76.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.22","72.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","29.83","31","","28.12","28.12","28.12","1 through 10","29.83","76.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.22","72.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","35.12","36.5","","101.66","28.85","502.70","121","29.83","76.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.22","72.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","36.85","38.3","","61.58","25.32","328.44","138","29.83","76.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.22","72.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.28","42.9","","71.66","71.66","71.66","1 through 10","29.83","76.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.22","72.16","WELLPOINT [1015]","HB AMC WELLPOINT","70.99","73.78","","74.75","27.97","425.28","93","29.83","76.49","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.22","72.16","AETNA [1001]","HB AMC AETNA HMO","67.16","69.8","","52.67","14.36","414.90","1 through 10","50.28","78.63","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.22","72.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","50.28","52.26","","25.34","25.34","25.34","1 through 10","50.28","78.63","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.22","72.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","77.36","80.4","","478.02","107.84","478.02","1 through 10","50.28","78.63","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.22","72.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","78.63","81.72","","32.74","12.33","122.05","1 through 10","50.28","78.63","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7CM 145CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10000179","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.22","72.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","78.63","81.72","","144.95","32.78","676.91","104","50.28","78.63","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","54.86","52.26","","25.34","25.34","25.34","1 through 10","32.54","83.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","75.37","71.8","","105.81","105.81","366.90","1 through 10","32.54","83.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","73.48","70","","512.90","74.70","612.85","1 through 10","32.54","83.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","83.45","79.5","","200.27","182.80","200.27","1 through 10","32.54","83.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","55.95","53.3","","37.73","37.73","169.33","1 through 10","32.54","83.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","68.23","65","","100.27","8.48","494.52","1 through 10","32.54","83.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","68.23","65","","160.19","160.19","160.19","1 through 10","32.54","83.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","32.54","31","","28.12","28.12","28.12","1 through 10","32.54","83.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.31","36.5","","101.66","28.85","502.70","121","32.54","83.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.20","38.3","","61.58","25.32","328.44","138","32.54","83.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.03","42.9","","71.66","71.66","71.66","1 through 10","32.54","83.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.97","78.73","WELLPOINT [1015]","HB AMC WELLPOINT","77.45","73.78","","74.75","27.97","425.28","93","32.54","83.45","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","104.97","78.73","AETNA [1001]","HB AMC AETNA HMO","73.27","69.8","","52.67","14.36","414.90","1 through 10","54.86","85.78","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","104.97","78.73","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","54.86","52.26","","25.34","25.34","25.34","1 through 10","54.86","85.78","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","104.97","78.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","84.40","80.4","","478.02","107.84","478.02","1 through 10","54.86","85.78","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","104.97","78.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","85.78","81.72","","32.74","12.33","122.05","1 through 10","54.86","85.78","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 145CM .035IN 3CM FLOPPY 3MM CURVE AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10003566","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","104.97","78.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","85.78","81.72","","144.95","32.78","676.91","104","54.86","85.78","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","both","","","101.47","76.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","53.03","52.26","","25.34","25.34","25.34","1 through 10","31.46","80.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","both","","","101.47","76.10","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","72.86","71.8","","105.81","105.81","366.90","1 through 10","31.46","80.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","both","","","101.47","76.10","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","71.03","70","","512.90","74.70","612.85","1 through 10","31.46","80.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","both","","","101.47","76.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","80.67","79.5","","200.27","182.80","200.27","1 through 10","31.46","80.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","both","","","101.47","76.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","54.08","53.3","","37.73","37.73","169.33","1 through 10","31.46","80.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","both","","","101.47","76.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","65.96","65","","100.27","8.48","494.52","1 through 10","31.46","80.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","both","","","101.47","76.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","65.96","65","","160.19","160.19","160.19","1 through 10","31.46","80.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","both","","","101.47","76.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","31.46","31","","28.12","28.12","28.12","1 through 10","31.46","80.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","both","","","101.47","76.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37.04","36.5","","101.66","28.85","502.70","121","31.46","80.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","both","","","101.47","76.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38.86","38.3","","61.58","25.32","328.44","138","31.46","80.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","both","","","101.47","76.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.53","42.9","","71.66","71.66","71.66","1 through 10","31.46","80.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","both","","","101.47","76.10","WELLPOINT [1015]","HB AMC WELLPOINT","74.86","73.78","","74.75","27.97","425.28","93","31.46","80.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","101.47","76.10","AETNA [1001]","HB AMC AETNA HMO","70.83","69.8","","52.67","14.36","414.90","1 through 10","53.03","82.92","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","101.47","76.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","53.03","52.26","","25.34","25.34","25.34","1 through 10","53.03","82.92","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","101.47","76.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","81.58","80.4","","478.02","107.84","478.02","1 through 10","53.03","82.92","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","101.47","76.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","82.92","81.72","","32.74","12.33","122.05","1 through 10","53.03","82.92","percent of total billed charges",""
"GUIDEWIRE VASCULAR 7MM 80CM .035IN 3CM FLOPPY STRAIGHT AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10025210","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","101.47","76.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","82.92","81.72","","144.95","32.78","676.91","104","53.03","82.92","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","both","","","198.77","149.08","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","103.88","52.26","","25.34","25.34","25.34","1 through 10","61.62","158.02","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","both","","","198.77","149.08","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","142.72","71.8","","105.81","105.81","366.90","1 through 10","61.62","158.02","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","both","","","198.77","149.08","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","139.14","70","","512.90","74.70","612.85","1 through 10","61.62","158.02","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","both","","","198.77","149.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","158.02","79.5","","200.27","182.80","200.27","1 through 10","61.62","158.02","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","both","","","198.77","149.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","105.94","53.3","","37.73","37.73","169.33","1 through 10","61.62","158.02","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","both","","","198.77","149.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","129.20","65","","100.27","8.48","494.52","1 through 10","61.62","158.02","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","both","","","198.77","149.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","129.20","65","","160.19","160.19","160.19","1 through 10","61.62","158.02","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","both","","","198.77","149.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","61.62","31","","28.12","28.12","28.12","1 through 10","61.62","158.02","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","both","","","198.77","149.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.55","36.5","","101.66","28.85","502.70","121","61.62","158.02","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","both","","","198.77","149.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.13","38.3","","61.58","25.32","328.44","138","61.62","158.02","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","both","","","198.77","149.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.27","42.9","","71.66","71.66","71.66","1 through 10","61.62","158.02","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","both","","","198.77","149.08","WELLPOINT [1015]","HB AMC WELLPOINT","146.65","73.78","","74.75","27.97","425.28","93","61.62","158.02","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","198.77","149.08","AETNA [1001]","HB AMC AETNA HMO","138.74","69.8","","52.67","14.36","414.90","1 through 10","103.88","162.43","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","198.77","149.08","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","103.88","52.26","","25.34","25.34","25.34","1 through 10","103.88","162.43","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","198.77","149.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","159.81","80.4","","478.02","107.84","478.02","1 through 10","103.88","162.43","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","198.77","149.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","162.43","81.72","","32.74","12.33","122.05","1 through 10","103.88","162.43","percent of total billed charges",""
"GUIDEWIRE VASCULAR 80CM 15DEG 0.014IN NITREX NITINOL CORE SILICONE COATED INTERMEDIATE ANGLED TIP PK/3EA","SUP-ITM-10175848","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","198.77","149.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","162.43","81.72","","144.95","32.78","676.91","104","103.88","162.43","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.47","60.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","42.05","52.26","","25.34","25.34","25.34","1 through 10","24.95","63.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.47","60.35","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","57.78","71.8","","105.81","105.81","366.90","1 through 10","24.95","63.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.47","60.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","56.33","70","","512.90","74.70","612.85","1 through 10","24.95","63.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.47","60.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","63.97","79.5","","200.27","182.80","200.27","1 through 10","24.95","63.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.47","60.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","42.89","53.3","","37.73","37.73","169.33","1 through 10","24.95","63.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.47","60.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","52.31","65","","100.27","8.48","494.52","1 through 10","24.95","63.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.47","60.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","52.31","65","","160.19","160.19","160.19","1 through 10","24.95","63.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.47","60.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","24.95","31","","28.12","28.12","28.12","1 through 10","24.95","63.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.47","60.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29.37","36.5","","101.66","28.85","502.70","121","24.95","63.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.47","60.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30.82","38.3","","61.58","25.32","328.44","138","24.95","63.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.47","60.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.52","42.9","","71.66","71.66","71.66","1 through 10","24.95","63.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.47","60.35","WELLPOINT [1015]","HB AMC WELLPOINT","59.37","73.78","","74.75","27.97","425.28","93","24.95","63.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","80.47","60.35","AETNA [1001]","HB AMC AETNA HMO","56.17","69.8","","52.67","14.36","414.90","1 through 10","42.05","65.76","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","80.47","60.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","42.05","52.26","","25.34","25.34","25.34","1 through 10","42.05","65.76","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","80.47","60.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","64.70","80.4","","478.02","107.84","478.02","1 through 10","42.05","65.76","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","80.47","60.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","65.76","81.72","","32.74","12.33","122.05","1 through 10","42.05","65.76","percent of total billed charges",""
"GUIDEWIRE VASCULAR 8CM 180CM .032IN J TIP AMPLATZ SUPPORT PTFE COATED S/S EXTRA STIFF","SUP-ITM-10011490","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","80.47","60.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","65.76","81.72","","144.95","32.78","676.91","104","42.05","65.76","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","both","","","105.00","78.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","54.87","52.26","","25.34","25.34","25.34","1 through 10","32.55","83.48","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","75.39","71.8","","105.81","105.81","366.90","1 through 10","32.55","83.48","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","73.50","70","","512.90","74.70","612.85","1 through 10","32.55","83.48","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","both","","","105.00","78.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","83.48","79.5","","200.27","182.80","200.27","1 through 10","32.55","83.48","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","both","","","105.00","78.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","55.97","53.3","","37.73","37.73","169.33","1 through 10","32.55","83.48","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","68.25","65","","100.27","8.48","494.52","1 through 10","32.55","83.48","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","68.25","65","","160.19","160.19","160.19","1 through 10","32.55","83.48","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","32.55","31","","28.12","28.12","28.12","1 through 10","32.55","83.48","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.33","36.5","","101.66","28.85","502.70","121","32.55","83.48","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.22","38.3","","61.58","25.32","328.44","138","32.55","83.48","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.05","42.9","","71.66","71.66","71.66","1 through 10","32.55","83.48","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","both","","","105.00","78.75","WELLPOINT [1015]","HB AMC WELLPOINT","77.47","73.78","","74.75","27.97","425.28","93","32.55","83.48","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","105.00","78.75","AETNA [1001]","HB AMC AETNA HMO","73.29","69.8","","52.67","14.36","414.90","1 through 10","54.87","85.81","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","105.00","78.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","54.87","52.26","","25.34","25.34","25.34","1 through 10","54.87","85.81","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","84.42","80.4","","478.02","107.84","478.02","1 through 10","54.87","85.81","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","85.81","81.72","","32.74","12.33","122.05","1 through 10","54.87","85.81","percent of total billed charges",""
"GUIDEWIRE ZIPWIRE .038INX150CM HYDROPHILIC ANGLED TAPERED STANDARD BX/5EA VASCULAR BX/5EA","SUP-ITM-10213108","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","85.81","81.72","","144.95","32.78","676.91","104","54.87","85.81","percent of total billed charges",""
"Gx 564 Aspa Gene Sequencing & Del/Dup","PX-31001177","CDM","81479","CPT","0310","RC","","","","both","","","1863.00","1397.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1481.09","79.5","","0.65","0.65","0.65","1 through 10","577.53","1769.85","percent of total billed charges",""
"Gx 564 Aspa Gene Sequencing & Del/Dup","PX-31001177","CDM","81479","CPT","0310","RC","","","","both","","","1863.00","1397.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","992.98","53.3","","0.79","0.79","0.79","1 through 10","577.53","1769.85","percent of total billed charges",""
"Gx 564 Aspa Gene Sequencing & Del/Dup","PX-31001177","CDM","81479","CPT","0310","RC","","","","outpatient","","","1863.00","1397.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","931.50","50","","1.00","1.00","1.00","1 through 10","156.55","1536.98","percent of total billed charges",""
"Gx 564 Aspa Gene Sequencing & Del/Dup","PX-31001177","CDM","81479","CPT","0310","RC","","","","outpatient","","","1863.00","1397.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","978.08","52.5","","1.00","0.53","1.00","1 through 10","156.55","1536.98","percent of total billed charges",""
"Gynecologic Procedures For Leiomyoma,MAJOR","519","DRG","","","","","","","","inpatient","","","298512.10","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18790.5167","","Fee schedule rate ($48,048.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18790.5167","48048.80","48048.80","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","83552.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","28650.89","","Standard inlier is a Case rate ($28,650.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,928, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,067.17) for the length of stay and the standard reimbursement.","45552.21","45552.21","45552.21","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","83552.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","32211.32","","Standard inlier is a Case rate ($32,211.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,928, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,572.13) for the length of stay and the standard reimbursement.","29427.82","29427.82","29427.82","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","83552.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32211.32","","Standard inlier is a Case rate ($32,211.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,928, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,572.13) for the length of stay and the standard reimbursement.","37924.77","37924.77","37924.77","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","83552.86","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18790.5167","","Fee schedule rate ($18,790.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18790.5167","18066.36","18066.36","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","83552.86","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","19730.5886","","Fee schedule rate ($19,730.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19730.5886","19730.60","19730.60","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","83552.86","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","23182.56","","Fee schedule rate ($23,182.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23488.36","23488.36","23488.36","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","83552.86","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","49751.70","49751.70","59714.81","1 through 10","8003.42","79281.47","percent of total billed charges",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","83552.86","","MASSHEALTH [3001]","HB BWH MEDICAID","8003.42","","Case rate ($8,849.15). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,279.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8846.98","8846.98","8846.98","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","83552.86","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20281.45","","Fee schedule rate ($20,281.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19690.51","19690.51","19690.51","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","83552.86","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21295.86","","Fee schedule rate ($21,295.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21295.86","21295.86","21295.86","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","83552.86","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8003.42","","Case rate ($8,849.15). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,279.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8846.98","8846.98","8846.98","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MODERATE","519","DRG","","","","","","","","inpatient","","","108231.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","36409.50","","Standard inlier is a Case rate ($36,409.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,961, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,168.55) for the length of stay and the standard reimbursement.","33188.58","33188.58","38537.42","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MODERATE","519","DRG","","","","","","","","inpatient","","","108231.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","40934.09","","Standard inlier is a Case rate ($40,934.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,961, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,810.25) for the length of stay and the standard reimbursement.","37396.82","37396.82","37396.82","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MODERATE","519","DRG","","","","","","","","inpatient","","","108231.51","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18790.5167","","Fee schedule rate ($23,295.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18790.5167","23295.24","23295.24","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Leiomyoma,MODERATE","519","DRG","","","","","","","","inpatient","","","108231.51","","MASSHEALTH [3001]","HB BWH MEDICAID","10667.41","","Case rate ($11,794.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,224.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","104424.57","104424.57","104424.57","1 through 10","8003.42","79281.47","case rate",""
"Gynecologic Procedures For Malignancy,EXTREME","511","DRG","","","","","","","","inpatient","","","320120.64","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","158362.34","","Standard inlier is a Case rate ($158,362.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $121,186, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($22,478.22) for the length of stay and the standard reimbursement.","158362.34","158362.34","158362.34","1 through 10","12641.42","229632.82","case rate",""
"Gynecologic Procedures For Malignancy,EXTREME","511","DRG","","","","","","","","inpatient","","","320120.64","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","64869.25","","Case rate ($71,724.11). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $114,154.11, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","92603.25","92603.25","92603.25","1 through 10","12641.42","229632.82","case rate",""
"Gynecologic Procedures For Malignancy,MAJOR","511","DRG","","","","","","","","inpatient","","","206763.89","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","76480.00","","Standard inlier is a Case rate ($76,480.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,122, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,856.80) for the length of stay and the standard reimbursement.","76479.99","69714.30","82034.20","1 through 10","12641.42","229632.82","case rate",""
"Gynecologic Procedures For Malignancy,MAJOR","511","DRG","","","","","","","","inpatient","","","206763.89","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","85984.13","","Standard inlier is a Case rate ($85,984.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,122, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,204.73) for the length of stay and the standard reimbursement.","85984.12","85984.12","85984.12","1 through 10","12641.42","229632.82","case rate",""
"Gynecologic Procedures For Malignancy,MAJOR","511","DRG","","","","","","","","inpatient","","","206763.89","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","27652.3221","","Fee schedule rate ($61,227.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27652.3221","61227.44","61227.44","1 through 10","12641.42","229632.82","case rate",""
"Gynecologic Procedures For Malignancy,MAJOR","511","DRG","","","","","","","","inpatient","","","206763.89","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","29035.7418","","Fee schedule rate ($64,290.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29035.7418","61810.48","61810.48","1 through 10","12641.42","229632.82","case rate",""
"Gynecologic Procedures For Malignancy,MINOR","511","DRG","","","","","","","","inpatient","","","132572.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","48075.19","","Standard inlier is a Case rate ($48,075.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $44,900, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,823.87) for the length of stay and the standard reimbursement.","43920.83","43920.83","54373.78","1 through 10","12641.42","229632.82","case rate",""
"Gynecologic Procedures For Malignancy,MODERATE","511","DRG","","","","","","","","inpatient","","","163903.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","58383.25","","Standard inlier is a Case rate ($58,383.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,030, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,287.02) for the length of stay and the standard reimbursement.","58383.25","53338.14","79236.36","1 through 10","12641.42","229632.82","case rate",""
"Gynecologic Procedures For Malignancy,MODERATE","511","DRG","","","","","","","","inpatient","","","163903.50","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","27652.3221","","Fee schedule rate ($61,227.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27652.3221","34597.28","34597.28","1 through 10","12641.42","229632.82","case rate",""
"Gynecologic Procedures For Malignancy,MODERATE","511","DRG","","","","","","","","inpatient","","","163903.50","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","29035.7418","","Fee schedule rate ($64,290.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29035.7418","34926.76","34926.76","1 through 10","12641.42","229632.82","case rate",""
"Gynecologic Procedures For Malignancy,MODERATE","511","DRG","","","","","","","","inpatient","","","163903.50","","MASSHEALTH [3001]","HB BWH MEDICAID","15024.40","","Case rate ($16,612.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,042.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17280.90","17280.90","17280.90","1 through 10","12641.42","229632.82","case rate",""
"Gynecologic Procedures For Malignancy,MODERATE","511","DRG","","","","","","","","inpatient","","","163903.50","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68964.61","","Fee schedule rate ($68,964.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","48787.60","48787.60","48787.60","1 through 10","12641.42","229632.82","case rate",""
"Gynecologic Procedures For Malignancy,MODERATE","511","DRG","","","","","","","","inpatient","","","163903.50","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15024.40","","Case rate ($16,612.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,042.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16607.98","16607.98","16607.98","1 through 10","12641.42","229632.82","case rate",""
"Gynecologic Procedures Without Malignancy,MAJOR","513","DRG","","","","","","","","inpatient","","","79556.19","","MASSHEALTH [3001]","HB BWH MEDICAID","16115.36","","Case rate ($17,818.30). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,248.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18535.71","18535.71","18535.71","1 through 10","7963.43","68161.69","case rate",""
"Gynecologic Procedures Without Malignancy,MINOR","513","DRG","","","","","","","","inpatient","","","78982.94","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","30297.05","","Standard inlier is a Case rate ($30,297.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,207, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,300.85) for the length of stay and the standard reimbursement.","30297.04","30297.04","30297.04","1 through 10","7963.43","68161.69","case rate",""
"Gynecologic Procedures Without Malignancy,MINOR","513","DRG","","","","","","","","inpatient","","","78982.94","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","34062.05","","Standard inlier is a Case rate ($34,062.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,207, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,834.82) for the length of stay and the standard reimbursement.","34062.04","34062.04","34062.04","1 through 10","7963.43","68161.69","case rate",""
"Gynecologic Procedures Without Malignancy,MINOR","513","DRG","","","","","","","","inpatient","","","78982.94","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18638.4211","","Fee schedule rate ($18,638.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18638.4211","18638.44","18638.44","1 through 10","7963.43","68161.69","case rate",""
"Gynecologic Procedures Without Malignancy,MODERATE","513","DRG","","","","","","","","inpatient","","","95673.02","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","36470.95","","Standard inlier is a Case rate ($36,470.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,010, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,177.27) for the length of stay and the standard reimbursement.","37459.93","37459.93","37459.93","1 through 10","7963.43","68161.69","case rate",""
"Gynecologic Procedures Without Malignancy,MODERATE","513","DRG","","","","","","","","inpatient","","","95673.02","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","41003.17","","Standard inlier is a Case rate ($41,003.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,010, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,820.06) for the length of stay and the standard reimbursement.","41003.17","41003.17","41003.17","1 through 10","7963.43","68161.69","case rate",""
"Gynecologic Procedures Without Malignancy,MODERATE","513","DRG","","","","","","","","inpatient","","","95673.02","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18638.4211","","Fee schedule rate ($22,575.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18638.4211","22575.00","22575.00","1 through 10","7963.43","68161.69","case rate",""
"Gynecologic Procedures Without Malignancy,MODERATE","513","DRG","","","","","","","","inpatient","","","95673.02","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","33423.28","33423.28","33423.28","1 through 10","7963.43","68161.69","percent of total billed charges",""
"Gynecologic Procedures Without Malignancy,MODERATE","513","DRG","","","","","","","","inpatient","","","95673.02","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10377.25","","Case rate ($11,473.84). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,903.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11471.02","11471.02","11471.02","1 through 10","7963.43","68161.69","case rate",""
"Haemophilus Influenza Antibody","PX-30000938","CDM","86684","CPT","0302","RC","","","","both","","","163.00","122.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","129.59","79.5","","124.35","124.35","158.00","1 through 10","10.07","154.85","percent of total billed charges",""
"Haemophilus Influenza Antibody","PX-30000938","CDM","86684","CPT","0302","RC","","","","both","","","163.00","122.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","59.50","36.5","","50.09","49.61","58.93","1 through 10","10.07","154.85","percent of total billed charges",""
"Haemophilus Influenza Antibody","PX-30000938","CDM","86684","CPT","0302","RC","","","","both","","","163.00","122.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.43","38.3","","61.78","61.78","61.78","1 through 10","10.07","154.85","percent of total billed charges",""
"Haemophilus Influenza Antibody","PX-30000938","CDM","86684","CPT","0302","RC","","","","outpatient","","","163.00","122.25","AETNA [1001]","HB AMC AETNA HMO","113.77","69.8","","75.52","75.52","123.24","1 through 10","10.07","133.2","percent of total billed charges",""
"Haemophilus Influenza Antibody","PX-30000938","CDM","86684","CPT","0302","RC","","","","outpatient","","","163.00","122.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","133.20","81.72","","126.31","69.47","126.31","1 through 10","10.07","133.2","percent of total billed charges",""
"Hand And Wrist Procedures,MAJOR","316","DRG","","","","","","","","inpatient","","","235479.71","","MASSHEALTH [3001]","HB BWH MEDICAID","19929.72","","Case rate ($22,035.73). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,465.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22030.32","22030.32","22030.32","1 through 10","9702.11","119553.09","case rate",""
"Hand And Wrist Procedures,MINOR","316","DRG","","","","","","","","inpatient","","","78483.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","28797.12","","Standard inlier is a Case rate ($28,797.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,567, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,087.51) for the length of stay and the standard reimbursement.","28797.12","28797.12","28797.12","1 through 10","9702.11","119553.09","case rate",""
"Hand And Wrist Procedures,MODERATE","316","DRG","","","","","","","","inpatient","","","142240.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","34585.47","","Standard inlier is a Case rate ($34,585.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,542, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,909.62) for the length of stay and the standard reimbursement.","34585.46","34585.46","34585.46","1 through 10","9702.11","119553.09","case rate",""
"Hand And Wrist Procedures,MODERATE","316","DRG","","","","","","","","inpatient","","","142240.98","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16721.5692","","Fee schedule rate ($25,406.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16721.5692","25406.68","25406.68","1 through 10","9702.11","119553.09","case rate",""
"Hand And Wrist Procedures,MODERATE","316","DRG","","","","","","","","inpatient","","","142240.98","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","27947.68","","Fee schedule rate ($27,947.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26870.84","26870.84","26870.84","1 through 10","9702.11","119553.09","case rate",""
"Hand And Wrist Procedures,MODERATE","316","DRG","","","","","","","","inpatient","","","142240.98","","MASSHEALTH [3001]","HB BWH MEDICAID","12427.80","","Case rate ($13,741.07). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,171.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","99864.64","99864.64","99864.64","1 through 10","9702.11","119553.09","case rate",""
"Hand And Wrist Procedures,MODERATE","316","DRG","","","","","","","","inpatient","","","142240.98","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12427.80","","Case rate ($13,741.07). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,171.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1020.93","1020.93","13737.70","1 through 10","9702.11","119553.09","case rate",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/McC","513","MS-DRG","","","","","","","","inpatient","","","84695.98","63521.98","MEDICARE [2001]","HB BWH MEDICARE","14740.77","","Case rate ($14,740.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,667.57, add-ons for qualifying new technology services are included. If operating cost exceeds $63,312.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,706.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,094.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,287.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,266.77. The transfer capital threshold is the transfer adjustment factor * $1,266.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","14445.95","22721.0096","other","Inpatient Replacement Plans DRG"
"HAND PLATE LG COMPRESSION PROFYLE BAR 5 HOLE","SUP-ITM-10028301","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.23","1486.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1575.87","79.5","","800.18","480.96","1887.97","195","614.49","1575.87","percent of total billed charges",""
"HAND PLATE LG COMPRESSION PROFYLE BAR 5 HOLE","SUP-ITM-10028301","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.23","1486.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1056.53","53.3","","813.12","216.42","1444.50","81","614.49","1575.87","percent of total billed charges",""
"HAND PLATE LG COMPRESSION PROFYLE BAR 5 HOLE","SUP-ITM-10028301","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.23","1486.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","614.49","31","","432.60","432.60","432.60","1 through 10","614.49","1575.87","percent of total billed charges",""
"HAND PLATE LG COMPRESSION PROFYLE BAR 5 HOLE","SUP-ITM-10028301","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.23","1486.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","723.51","36.5","","148.37","54.89","631.39","94","614.49","1575.87","percent of total billed charges",""
"HAND PLATE LG COMPRESSION PROFYLE BAR 5 HOLE","SUP-ITM-10028301","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.23","1486.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","759.19","38.3","","279.30","91.72","1116.77","266","614.49","1575.87","percent of total billed charges",""
"HAND PLATE LG COMPRESSION PROFYLE BAR 5 HOLE","SUP-ITM-10028301","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.23","1486.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","850.38","42.9","","731.00","63.70","731.00","1 through 10","614.49","1575.87","percent of total billed charges",""
"HAND PLATE LG COMPRESSION PROFYLE BAR 5 HOLE","SUP-ITM-10028301","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.23","1486.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","850.38","42.9","","384.74","384.74","384.74","1 through 10","614.49","1575.87","percent of total billed charges",""
"HAND PLATE LG COMPRESSION PROFYLE BAR 5 HOLE","SUP-ITM-10028301","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.23","1486.67","WELLPOINT [1015]","HB AMC WELLPOINT","1462.49","73.78","","286.63","119.22","1107.45","105","614.49","1575.87","percent of total billed charges",""
"HAND PLATE LG COMPRESSION PROFYLE BAR 5 HOLE","SUP-ITM-10028301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1982.23","1486.67","AETNA [1001]","HB AMC AETNA HMO","1383.60","69.8","","675.31","184.75","1721.50","286","1035.91","1619.88","percent of total billed charges",""
"HAND PLATE LG COMPRESSION PROFYLE BAR 5 HOLE","SUP-ITM-10028301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1982.23","1486.67","AETNA [1001]","HB AMC AETNA PPO","1593.71","80.4","","1261.44","103.12","1514.10","21","1035.91","1619.88","percent of total billed charges",""
"HAND PLATE LG COMPRESSION PROFYLE BAR 5 HOLE","SUP-ITM-10028301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1982.23","1486.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1593.71","80.4","","1365.00","1365.00","1365.00","1 through 10","1035.91","1619.88","percent of total billed charges",""
"HAND PLATE LG COMPRESSION PROFYLE BAR 5 HOLE","SUP-ITM-10028301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1982.23","1486.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1619.88","81.72","","5157.68","5157.68","5157.68","1 through 10","1035.91","1619.88","percent of total billed charges",""
"HAND PLATE LG COMPRESSION PROFYLE BAR 5 HOLE","SUP-ITM-10028301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1982.23","1486.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1619.88","81.72","","431.26","71.26","1459.57","88","1035.91","1619.88","percent of total billed charges",""
"Hand Procedures For Injuries","906","MS-DRG","","","","","","","","inpatient","","","188081.92","141061.44","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","18847.33","","Case rate ($18,298.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,950.24, add-ons for qualifying new technology services are included. If operating cost exceeds $67,594.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,020.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $16,337.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,570.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,580.59. The transfer capital threshold is the transfer adjustment factor * $1,580.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","20754.22","20754.22","20754.22","1 through 10","17932.41","30768.8","other","Inpatient DRG"
"Hand Procedures For Injuries","906","MS-DRG","","","","","","","","inpatient","","","188081.92","141061.44","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","17932.41","","Case rate ($18,298.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,950.24, add-ons for qualifying new technology services are included. If operating cost exceeds $67,594.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,020.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $16,337.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,570.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,580.59. The transfer capital threshold is the transfer adjustment factor * $1,580.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19726.55","19726.55","19726.55","1 through 10","17932.41","30768.8","other","Inpatient DRG"
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","both","","","196.00","147.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","140.73","71.8","","136.42","136.42","136.42","1 through 10","12.33","186.2","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","both","","","196.00","147.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","137.20","70","","1.01","1.01","1.01","1 through 10","12.33","186.2","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","both","","","196.00","147.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","155.82","79.5","","149.53","100.32","448.59","26","12.33","186.2","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","both","","","196.00","147.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","104.47","53.3","","149.53","100.32","448.59","14","12.33","186.2","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","both","","","196.00","147.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","150.92","77","","438.90","438.90","438.90","1 through 10","12.33","186.2","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.54","36.5","","60.23","60.23","70.87","12","12.33","186.2","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.07","38.3","","74.29","74.29","222.87","38","12.33","186.2","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","both","","","196.00","147.00","TRICARE [160005]","HB BWH TRICARE","186.20","95","","14.40","14.40","14.40","1 through 10","12.33","186.2","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","both","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.08","42.9","","151.89","151.89","151.89","1 through 10","12.33","186.2","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","outpatient","","","196.00","147.00","AETNA [1001]","HB AMC AETNA HMO","136.81","69.8","","128.63","90.82","219.45","23","12.97","160.17","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","outpatient","","","196.00","147.00","AETNA [1001]","HB AMC AETNA PPO","157.58","80.4","","148.20","148.20","148.20","1 through 10","12.97","160.17","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","outpatient","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","160.17","81.72","","151.89","25.00","151.89","14","12.97","160.17","percent of total billed charges",""
"Harvest Bone Marrow Algnc","PX-76001198","CDM","38230","CPT","0761","RC","","","","outpatient","","","10678.00","8008.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","6465.53","60.55","","36081.00","36081.00","36081.00","1 through 10","4271.2","8726.06","percent of total billed charges",""
"Harvest Bone Marrow Algnc","PX-76001198","CDM","38230","CPT","0761","RC","","","","outpatient","","","10678.00","8008.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5576.05","52.22","","3305.51","3305.51","3338.31","1 through 10","4271.2","8726.06","percent of total billed charges",""
"Harvest Progen Cell/Collect Allogen","PX-76001185","CDM","38205","CPT","0761","RC","","","","both","","","563.00","422.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","394.10","70","","234.78","72.95","234.78","1 through 10","85.77","1429.69","percent of total billed charges",""
"Harvest Progen Cell/Collect Allogen","PX-76001185","CDM","38205","CPT","0761","RC","","","","both","","","563.00","422.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","300.08","53.3","","275.73","275.73","275.73","1 through 10","85.77","1429.69","percent of total billed charges",""
"Harvest Progen Cell/Collect Allogen","PX-76001185","CDM","38205","CPT","0761","RC","","","","both","","","563.00","422.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","365.95","65","","344.50","344.50","344.50","1 through 10","85.77","1429.69","percent of total billed charges",""
"Harvest Progen Cell/Collect Allogen","PX-76001185","CDM","38205","CPT","0761","RC","","","","outpatient","","","563.00","422.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","140.29","","Case rate ($140.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","287.03","287.03","287.03","1 through 10","140.29","4776.01","other","ASC"
"Harvest Progen Cell/Collect Allogen","PX-76001185","CDM","38205","CPT","0761","RC","","","","outpatient","","","563.00","422.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","294.22","52.26","","337.87","337.87","337.87","1 through 10","140.29","4776.01","percent of total billed charges",""
"Harvest Progen Cell/Collect Allogen","PX-76001185","CDM","38205","CPT","0761","RC","","","","outpatient","","","563.00","422.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","140.29","","Case rate ($140.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","328.42","325.19","546.00","1 through 10","140.29","4776.01","other","ASC "
"Harvest Progen Cell/Collect Allogen","PX-76001185","CDM","38205","CPT","0761","RC","","","","outpatient","","","563.00","422.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","460.08","81.72","","436.47","436.47","436.47","1 through 10","140.29","4776.01","percent of total billed charges",""
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","both","","","4943.00","3707.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1915.59","1915.59","1915.59","1 through 10","1532.33","3929.69","other","OPPS APC"
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","both","","","4943.00","3707.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3212.95","65","","3115.45","2530.70","3115.45","1 through 10","1532.33","3929.69","percent of total billed charges",""
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","both","","","4943.00","3707.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3460.10","70","","3450.96","2060.99","7572.94","31","1532.33","3929.69","percent of total billed charges",""
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","both","","","4943.00","3707.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3929.69","79.5","","3772.09","3772.09","3772.09","1 through 10","1532.33","3929.69","percent of total billed charges",""
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","both","","","4943.00","3707.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1915.59","1438.50","1915.59","1 through 10","1532.33","3929.69","other","OPPS APC"
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","both","","","4943.00","3707.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1923.38","1923.38","1923.38","1 through 10","1532.33","3929.69","other","OPPS APC"
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","both","","","4943.00","3707.25","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.80","508.80","508.80","1 through 10","1532.33","3929.69","other","OPPS APC"
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","both","","","4943.00","3707.25","MEDICARE [2001]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1946.74","1674.59","5840.22","20","1532.33","3929.69","other","OPPS APC"
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","both","","","4943.00","3707.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1907.81","1907.81","1907.81","1 through 10","1532.33","3929.69","other","OPPS APC"
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","both","","","4943.00","3707.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1907.62","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1946.74","1674.59","1946.74","1 through 10","1532.33","3929.69","other","OPPS APC"
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","both","","","4943.00","3707.25","WELLPOINT [1015]","HB AMC WELLPOINT","3646.95","73.78","","3568.39","3410.98","3568.39","1 through 10","1532.33","3929.69","percent of total billed charges",""
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","both","","","4943.00","3707.25","WELLSENSE [1003]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1966.21","1966.21","1966.21","1 through 10","1532.33","3929.69","other","OPPS APC"
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","outpatient","","","4943.00","3707.25","AETNA [1001]","HB AMC AETNA HMO","3450.21","69.8","","3244.86","3244.86","3738.54","1 through 10","1426.02","4776.01","percent of total billed charges",""
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","outpatient","","","4943.00","3707.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1426.02","","Case rate ($1,426.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2864.87","2864.87","2917.64","13","1426.02","4776.01","other","ASC"
"Harvest Progen Cell/Collect Autolog","PX-76001186","CDM","38206","CPT","0761","RC","","","","outpatient","","","4943.00","3707.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1426.02","","Case rate ($1,426.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3305.51","3305.51","3338.31","43","1426.02","4776.01","other","ASC "
"Harvest Progen Cell/Collect Autolog|REDUCED SERVICES","PX-76001186","CDM","38206","CPT","0761","RC","","","52","both","","","4943.00","3707.25","MEDICARE [2001]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.37","973.37","973.37","1 through 10","1849.41","2433.18","other","OPPS APC"
"Hba1/Hba2 Gene Analysis Dup/Del Variants","PX-31000900","CDM","81269","CPT","0310","RC","","","","both","","","1727.00","1295.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","920.49","53.3","","884.40","884.40","884.40","1 through 10","198.35","1640.65","percent of total billed charges",""
"Hba1/Hba2 Gene Analysis Dup/Del Variants","PX-31000900","CDM","81269","CPT","0310","RC","","","","both","","","1727.00","1295.25","WELLPOINT [1015]","HB AMC WELLPOINT","1274.18","73.78","","2922.04","2922.04","2922.04","1 through 10","198.35","1640.65","percent of total billed charges",""
"Hba1/Hba2 Gene Analysis Full Gene Sequence","PX-31000899","CDM","81259","CPT","0310","RC","","","","outpatient","","","7271.00","5453.25","CIGNA ALTERNATE [1018]","HB AMC TUFTS CIGNA CARELINK HYBRID","2639.37","36.3","","2503.25","2503.25","2503.25","1 through 10","1716.79","5941.86","percent of total billed charges",""
"HC Alcohol (Quant Alcohols Biomarkers 1 or 2)","PX-30002838","CDM","80321","CPT","0301","RC","","","","both","","","241.00","180.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","173.04","71.8","","234.00","234.00","234.00","14","42.77","228.95","percent of total billed charges",""
"HC Alcohol (Quant Alcohols Biomarkers 1 or 2)","PX-30002838","CDM","80321","CPT","0301","RC","","","","both","","","241.00","180.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","156.65","65","","152.10","152.10","152.10","1 through 10","42.77","228.95","percent of total billed charges",""
"HC Alcohol (Quant Alcohols Biomarkers 1 or 2)","PX-30002838","CDM","80321","CPT","0301","RC","","","","both","","","241.00","180.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","168.70","70","","168.48","102.89","168.48","1 through 10","42.77","228.95","percent of total billed charges",""
"HC Alcohol (Quant Alcohols Biomarkers 1 or 2)","PX-30002838","CDM","80321","CPT","0301","RC","","","","outpatient","","","241.00","180.75","AETNA [1001]","HB AMC AETNA HMO","168.22","69.8","","111.85","111.85","111.85","1 through 10","44.46","438.27","percent of total billed charges",""
"HC Alkaloids (Alkaloids Not Otherwise Specified)","PX-30002840","CDM","80323","CPT","0301","RC","","","","both","","","358.00","268.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","257.04","71.8","","694.00","694.00","694.00","1 through 10","110.34","340.1","percent of total billed charges",""
"HC Alkaloids (Alkaloids Not Otherwise Specified)","PX-30002840","CDM","80323","CPT","0301","RC","","","","both","","","358.00","268.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","234.85","65.6","","234.92","234.92","234.92","1 through 10","110.34","340.1","percent of total billed charges",""
"HC Alkaloids (Alkaloids Not Otherwise Specified)","PX-30002840","CDM","80323","CPT","0301","RC","","","","both","","","358.00","268.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","232.70","65","","225.55","102.70","225.55","1 through 10","110.34","340.1","percent of total billed charges",""
"HC Alkaloids (Alkaloids Not Otherwise Specified)","PX-30002840","CDM","80323","CPT","0301","RC","","","","both","","","358.00","268.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","250.60","70","","336.00","249.84","347.00","1 through 10","110.34","340.1","percent of total billed charges",""
"HC Alkaloids (Alkaloids Not Otherwise Specified)","PX-30002840","CDM","80323","CPT","0301","RC","","","","both","","","358.00","268.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","284.61","79.5","","250.89","250.89","250.89","1 through 10","110.34","340.1","percent of total billed charges",""
"HC Alkaloids (Alkaloids Not Otherwise Specified)","PX-30002840","CDM","80323","CPT","0301","RC","","","","outpatient","","","358.00","268.50","AETNA [1001]","HB AMC AETNA PPO","287.83","80.4","","270.66","270.66","270.66","1 through 10","59.12","438.27","percent of total billed charges",""
"HC Alkaloids (Alkaloids Not Otherwise Specified)","PX-30002840","CDM","80323","CPT","0301","RC","","","","outpatient","","","358.00","268.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","292.56","81.72","","258.75","258.75","258.75","1 through 10","59.12","438.27","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7790.00","5842.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2843.35","36.5","","23.35","23.35","23.35","264","2414.9","5998.3","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7790.00","5842.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2983.57","38.3","","350.11","350.11","350.11","1108","2414.9","5998.3","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7790.00","5842.50","WELLPOINT [1015]","HB AMC WELLPOINT","5747.46","73.78","","77.77","77.77","77.77","528","2414.9","5998.3","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7790.00","5842.50","AETNA [1001]","HB AMC AETNA HMO","5437.42","69.8","","35.22","35.22","35.22","397","3653.51","6263.16","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7790.00","5842.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5445.21","69.9","","34.18","34.18","34.18","1057","3653.51","6263.16","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7790.00","5842.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3653.51","46.9","","34.18","34.18","34.18","528","3653.51","6263.16","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11577.50","8683.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4225.79","36.5","","23.35","23.35","23.35","264","3589.03","8914.68","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11577.50","8683.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4434.18","38.3","","350.11","350.11","350.11","1108","3589.03","8914.68","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11577.50","8683.12","WELLPOINT [1015]","HB AMC WELLPOINT","8541.88","73.78","","77.77","77.77","77.77","528","3589.03","8914.68","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11577.50","8683.12","AETNA [1001]","HB AMC AETNA HMO","8081.10","69.8","","35.22","35.22","35.22","397","5429.85","9308.31","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11577.50","8683.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8092.67","69.9","","34.18","34.18","34.18","1057","5429.85","9308.31","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11577.50","8683.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5429.85","46.9","","34.18","34.18","34.18","528","5429.85","9308.31","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11575.00","8681.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4224.88","36.5","","23.35","23.35","23.35","264","3588.25","8912.75","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11575.00","8681.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4433.23","38.3","","350.11","350.11","350.11","1108","3588.25","8912.75","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11575.00","8681.25","WELLPOINT [1015]","HB AMC WELLPOINT","8540.04","73.78","","77.77","77.77","77.77","528","3588.25","8912.75","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11575.00","8681.25","AETNA [1001]","HB AMC AETNA HMO","8079.35","69.8","","35.22","35.22","35.22","397","5428.68","9306.3","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11575.00","8681.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8090.93","69.9","","34.18","34.18","34.18","1057","5428.68","9306.3","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11575.00","8681.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5428.68","46.9","","34.18","34.18","34.18","528","5428.68","9306.3","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","both","","","13892.50","10419.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5070.76","36.5","","23.35","23.35","23.35","264","4306.68","10697.23","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","both","","","13892.50","10419.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5320.83","38.3","","350.11","350.11","350.11","1108","4306.68","10697.23","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","both","","","13892.50","10419.37","WELLPOINT [1015]","HB AMC WELLPOINT","10249.89","73.78","","77.77","77.77","77.77","528","4306.68","10697.23","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","13892.50","10419.37","AETNA [1001]","HB AMC AETNA HMO","9696.97","69.8","","35.22","35.22","35.22","397","6515.58","11169.57","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","13892.50","10419.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9710.86","69.9","","34.18","34.18","34.18","1057","6515.58","11169.57","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","13892.50","10419.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6515.58","46.9","","34.18","34.18","34.18","528","6515.58","11169.57","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","both","","","14472.50","10854.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5282.46","36.5","","23.35","23.35","23.35","264","4486.48","11143.83","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","both","","","14472.50","10854.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5542.97","38.3","","350.11","350.11","350.11","1108","4486.48","11143.83","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","both","","","14472.50","10854.37","WELLPOINT [1015]","HB AMC WELLPOINT","10677.81","73.78","","77.77","77.77","77.77","528","4486.48","11143.83","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","14472.50","10854.37","AETNA [1001]","HB AMC AETNA HMO","10101.81","69.8","","35.22","35.22","35.22","397","6787.6","11635.89","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","14472.50","10854.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10116.28","69.9","","34.18","34.18","34.18","1057","6787.6","11635.89","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","14472.50","10854.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6787.60","46.9","","34.18","34.18","34.18","528","6787.6","11635.89","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","both","","","17367.50","13025.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6339.14","36.5","","23.35","23.35","23.35","264","5383.93","13372.98","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","both","","","17367.50","13025.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6651.75","38.3","","350.11","350.11","350.11","1108","5383.93","13372.98","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","both","","","17367.50","13025.62","WELLPOINT [1015]","HB AMC WELLPOINT","12813.74","73.78","","77.77","77.77","77.77","528","5383.93","13372.98","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","17367.50","13025.62","AETNA [1001]","HB AMC AETNA HMO","12122.52","69.8","","35.22","35.22","35.22","397","8145.36","13963.47","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","17367.50","13025.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12139.88","69.9","","34.18","34.18","34.18","1057","8145.36","13963.47","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","17367.50","13025.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8145.36","46.9","","34.18","34.18","34.18","528","8145.36","13963.47","percent of total billed charges",""
"HC Ankle Control Ortho Ankle Air Gel Prefab Tier1","PX-27000532","CDM","L4350","HCPCS","0274","RC","","","","outpatient","","","80.19","60.14","AETNA [1001]","HB AMC AETNA HMO","55.97","69.8","","54.29","54.29","54.29","1 through 10","40.1","242.91","percent of total billed charges",""
"HC Ankle-Foot Orthotic Ankle Brace Prefab Tier1","PX-27000341","CDM","L1930","HCPCS","0274","RC","","","","outpatient","","","120.82","90.61","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","63.43","52.5","","66.45","66.45","66.45","1 through 10","60.41","638.66","percent of total billed charges",""
"HC Bcw 4855 Elane Gene Seq and Del/Dup","PX-31001178","CDM","81479","CPT","0310","RC","","","","both","","","1789.00","1341.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1422.26","79.5","","0.65","0.65","0.65","1 through 10","554.59","1699.55","percent of total billed charges",""
"HC Bcw 4855 Elane Gene Seq and Del/Dup","PX-31001178","CDM","81479","CPT","0310","RC","","","","both","","","1789.00","1341.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","953.54","53.3","","0.79","0.79","0.79","1 through 10","554.59","1699.55","percent of total billed charges",""
"HC Bcw 4855 Elane Gene Seq and Del/Dup","PX-31001178","CDM","81479","CPT","0310","RC","","","","outpatient","","","1789.00","1341.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","894.50","50","","1.00","1.00","1.00","1 through 10","156.55","1475.93","percent of total billed charges",""
"HC Bcw 4855 Elane Gene Seq and Del/Dup","PX-31001178","CDM","81479","CPT","0310","RC","","","","outpatient","","","1789.00","1341.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","939.23","52.5","","1.00","0.53","1.00","1 through 10","156.55","1475.93","percent of total billed charges",""
"HC Benzodiazepines (Benzodiazepines 1-12)","PX-30002863","CDM","80346","CPT","0301","RC","","","","both","","","110.00","82.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","78.98","71.8","","139.00","139.00","139.00","1 through 10","34.1","143.04","percent of total billed charges",""
"HC Benzodiazepines (Benzodiazepines 1-12)","PX-30002863","CDM","80346","CPT","0301","RC","","","","both","","","110.00","82.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","77.00","70","","61.12","61.12","61.12","1 through 10","34.1","143.04","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0300","RC","","","","inpatient","","","103.00","77.25","AETNA [1001]","HB AMC AETNA HMO","71.17","69.1","","47.80","47.80","47.80","1 through 10","56.96","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","100.00","13.38","100.00","55","3.08","81.89","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","73.95","71.8","","215.40","71.80","215.40","21","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","67.57","65.6","","67.70","67.70","78.00","1 through 10","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","66.95","65","","65.00","52.80","65.00","1 through 10","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","72.10","70","","100.00","72.00","216.00","27","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","58.26","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","13.65","2.42","23.12","1 through 10","3.08","81.89","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","81.89","79.5","","78.70","52.80","236.10","506","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","54.90","53.3","","78.70","52.80","236.10","242","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.30","34.30","34.30","1 through 10","3.08","81.89","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","79.31","77","","231.00","77.00","231.00","17","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","66.95","65","","65.00","65.00","70.85","18","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","81.89","79.5","","78.70","75.40","78.70","1 through 10","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","MEDICARE [2001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","100.00","100.00","100.00","1 through 10","3.08","81.89","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","31.93","31","","30.90","30.90","92.70","1 through 10","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37.60","36.5","","37.30","31.70","111.90","362","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39.45","38.3","","39.10","38.00","117.30","1127","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","79.31","77","","78.00","78.00","78.00","1 through 10","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","TRICARE [160005]","HB BWH TRICARE","44.28","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","100.00","100.00","100.00","1 through 10","3.08","81.89","other","Tricare OPPS"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","23.00","23.00","23.00","1 through 10","3.08","81.89","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.19","42.9","","79.94","43.97","100.00","24","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2.93","2.93","2.93","1 through 10","3.08","81.89","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","103.00","77.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.19","42.9","","43.97","43.97","43.97","1 through 10","3.08","81.89","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","103.00","77.25","AETNA [1001]","HB AMC AETNA HMO","71.89","69.8","","67.70","47.80","78.00","635","3.08","196.9","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","103.00","77.25","AETNA [1001]","HB AMC AETNA PPO","82.81","80.4","","78.00","52.40","78.00","74","3.08","196.9","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","103.00","77.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","53.83","52.26","","66.11","61.88","66.11","1 through 10","3.08","196.9","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","103.00","77.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","82.81","80.4","","78.00","50.00","82.19","18","3.08","196.9","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","103.00","77.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","84.17","81.72","","79.94","79.94","79.94","1 through 10","3.08","196.9","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","84.17","81.72","","43.97","43.97","79.94","21","3.08","196.9","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","84.17","81.72","","79.94","43.97","79.94","547","3.08","196.9","percent of total billed charges",""
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","352.66","","APC Price ($342.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","358.04","352.32","359.51","22","103.23","427.99","other","OPPS APC"
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","342.39","","APC Price ($342.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","336.91","336.91","341.43","28","103.23","427.99","other","OPPS APC"
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","239.09","71.8","","239.09","239.09","239.09","1 through 10","103.23","427.99","percent of total billed charges",""
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","264.74","79.5","","262.07","262.07","786.21","1 through 10","103.23","427.99","percent of total billed charges",""
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","177.49","53.3","","262.07","262.07","262.07","1 through 10","103.23","427.99","percent of total billed charges",""
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","ELDER SERVICES [1037]","HB BWH MEDICARE","342.39","","APC Price ($342.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","342.39","342.39","342.39","1 through 10","103.23","427.99","other","OPPS APC"
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","MEDICARE [2001]","HB BWH MEDICARE","342.39","","APC Price ($342.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","342.39","342.39","1027.17","153","103.23","427.99","other","OPPS APC"
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.55","36.5","","124.21","124.21","124.21","1 through 10","103.23","427.99","percent of total billed charges",""
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.54","38.3","","130.20","130.20","390.60","21","103.23","427.99","percent of total billed charges",""
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","342.39","","APC Price ($342.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","341.54","341.54","341.54","1 through 10","103.23","427.99","other","OPPS APC"
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","MOLINA [1014]","HB BWH MOLINA","335.54","","APC Price ($342.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","342.39","342.39","342.39","1 through 10","103.23","427.99","other","OPPS APC"
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","335.54","","APC Price ($342.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1020.12","336.91","1020.12","11","103.23","427.99","other","OPPS APC"
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.86","42.9","","146.42","146.42","146.42","1 through 10","103.23","427.99","percent of total billed charges",""
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","335.54","","APC Price ($342.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","336.88","335.54","341.38","29","103.23","427.99","other","OPPS APC"
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.86","42.9","","146.42","146.42","146.42","1 through 10","103.23","427.99","percent of total billed charges",""
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","333.00","249.75","WELLPOINT [1015]","HB AMC WELLPOINT","245.69","73.78","","247.92","247.92","247.92","12","103.23","427.99","percent of total billed charges",""
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","outpatient","","","333.00","249.75","AETNA [1001]","HB AMC AETNA HMO","232.43","69.8","","225.44","159.17","225.44","1 through 10","174.03","1434.82","percent of total billed charges",""
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","outpatient","","","333.00","249.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","272.13","81.72","","266.20","266.20","266.20","11","174.03","1434.82","percent of total billed charges",""
"HC Buprenorphine","PX-30002865","CDM","80348","CPT","0301","RC","","","","both","","","85.00","63.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","61.03","71.8","","178.00","178.00","178.00","1 through 10","26.35","143.04","percent of total billed charges",""
"HC Buprenorphine","PX-30002865","CDM","80348","CPT","0301","RC","","","","both","","","85.00","63.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","59.50","70","","78.27","78.27","78.27","1 through 10","26.35","143.04","percent of total billed charges",""
"HC Buprenorphine","PX-30002865","CDM","80348","CPT","0301","RC","","","","both","","","85.00","63.75","WELLPOINT [1015]","HB AMC WELLPOINT","62.71","73.78","","132.52","132.52","132.52","1 through 10","26.35","143.04","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Bwh Lambda Free Light Chain","PX-30002820","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"HC Cardiac Resynch Therapy With Icd Dev Tier3","PX-27000165","CDM","C1882","HCPCS","0278","RC","","","","both","","","47941.98","35956.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","25553.08","53.3","","25132.80","25132.80","25132.80","1 through 10","14862.01","38113.87","percent of total billed charges",""
"HC Cardiac Resynch Therapy With Icd Dev Tier3","PX-27000165","CDM","C1882","HCPCS","0278","RC","","","","both","","","47941.98","35956.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18361.78","38.3","","18611.60","13196.25","18611.60","1 through 10","14862.01","38113.87","percent of total billed charges",""
"HC Cardiac Resynch Therapy With Icd Dev Tier3","PX-27000165","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","47941.98","35956.48","AETNA [1001]","HB AMC AETNA HMO","33463.50","69.8","","23525.75","23525.75","23525.75","1 through 10","25054.48","39178.19","percent of total billed charges",""
"HC Cardiac Resynch Therapy With Icd Dev Tier3","PX-27000165","CDM","C1882","HCPCS","0278","RC","","","","outpatient","","","47941.98","35956.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","39178.19","81.72","","14745.34","14745.34","14745.34","1 through 10","25054.48","39178.19","percent of total billed charges",""
"HC Catheter Ep Abl Non-3d or Vmap Cool-Tip Tier1","PX-27000214","CDM","C2630","HCPCS","0272","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","3714.50","3714.50","3714.50","1 through 10","1193.5","3060.75","percent of total billed charges",""
"HC Catheter Ep Abl Non-3d or Vmap Cool-Tip Tier2","PX-27000215","CDM","C2630","HCPCS","0272","RC","","","","both","","","4875.00","3656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1867.13","38.3","","3714.50","3714.50","3714.50","1 through 10","1511.25","3875.63","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier1","PX-27000051","CDM","C1733","HCPCS","0272","RC","","","","both","","","2511.04","1883.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1996.28","79.5","","17511.01","17511.01","17511.01","1 through 10","778.42","1996.28","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier1","PX-27000051","CDM","C1733","HCPCS","0272","RC","","","","both","","","2511.04","1883.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1338.38","53.3","","21125.00","21125.00","21125.00","1 through 10","778.42","1996.28","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier1","PX-27000051","CDM","C1733","HCPCS","0272","RC","","","","both","","","2511.04","1883.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","916.53","36.5","","7879.63","7879.63","7879.63","1 through 10","778.42","1996.28","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier1","PX-27000051","CDM","C1733","HCPCS","0272","RC","","","","both","","","2511.04","1883.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","961.73","38.3","","8259.88","8259.88","16055.00","1 through 10","778.42","1996.28","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier1","PX-27000051","CDM","C1733","HCPCS","0272","RC","","","","both","","","2511.04","1883.28","WELLPOINT [1015]","HB AMC WELLPOINT","1852.65","73.78","","15727.56","15727.56","20473.75","1 through 10","778.42","1996.28","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier1","PX-27000051","CDM","C1733","HCPCS","0272","RC","","","","outpatient","","","2511.04","1883.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2052.02","81.72","","16887.32","9288.66","16887.32","1 through 10","1312.27","2052.02","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier1","PX-27000051","CDM","C1733","HCPCS","0272","RC","","","","outpatient","","","2511.04","1883.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2052.02","81.72","","16887.33","11641.27","21983.50","1 through 10","1312.27","2052.02","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier2","PX-27000052","CDM","C1733","HCPCS","0272","RC","","","","both","","","4125.00","3093.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3279.38","79.5","","17511.01","17511.01","17511.01","1 through 10","1278.75","3279.38","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier2","PX-27000052","CDM","C1733","HCPCS","0272","RC","","","","both","","","4125.00","3093.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2198.63","53.3","","21125.00","21125.00","21125.00","1 through 10","1278.75","3279.38","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier2","PX-27000052","CDM","C1733","HCPCS","0272","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1505.63","36.5","","7879.63","7879.63","7879.63","1 through 10","1278.75","3279.38","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier2","PX-27000052","CDM","C1733","HCPCS","0272","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1579.88","38.3","","8259.88","8259.88","16055.00","1 through 10","1278.75","3279.38","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier2","PX-27000052","CDM","C1733","HCPCS","0272","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB AMC WELLPOINT","3043.43","73.78","","15727.56","15727.56","20473.75","1 through 10","1278.75","3279.38","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier2","PX-27000052","CDM","C1733","HCPCS","0272","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3370.95","81.72","","16887.32","9288.66","16887.32","1 through 10","2155.73","3370.95","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier2","PX-27000052","CDM","C1733","HCPCS","0272","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3370.95","81.72","","16887.33","11641.27","21983.50","1 through 10","2155.73","3370.95","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier3","PX-27000053","CDM","C1733","HCPCS","0272","RC","","","","both","","","10600.00","7950.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8427.00","79.5","","17511.01","17511.01","17511.01","1 through 10","3286","8427","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier3","PX-27000053","CDM","C1733","HCPCS","0272","RC","","","","both","","","10600.00","7950.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5649.80","53.3","","21125.00","21125.00","21125.00","1 through 10","3286","8427","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier3","PX-27000053","CDM","C1733","HCPCS","0272","RC","","","","both","","","10600.00","7950.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3869.00","36.5","","7879.63","7879.63","7879.63","1 through 10","3286","8427","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier3","PX-27000053","CDM","C1733","HCPCS","0272","RC","","","","both","","","10600.00","7950.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4059.80","38.3","","8259.88","8259.88","16055.00","1 through 10","3286","8427","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier3","PX-27000053","CDM","C1733","HCPCS","0272","RC","","","","both","","","10600.00","7950.00","WELLPOINT [1015]","HB AMC WELLPOINT","7820.68","73.78","","15727.56","15727.56","20473.75","1 through 10","3286","8427","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier3","PX-27000053","CDM","C1733","HCPCS","0272","RC","","","","outpatient","","","10600.00","7950.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8662.32","81.72","","16887.32","9288.66","16887.32","1 through 10","5539.56","8662.32","percent of total billed charges",""
"HC Catheter Ep Abl Othr Than 3d/Vec/Cool-Tip Tier3","PX-27000053","CDM","C1733","HCPCS","0272","RC","","","","outpatient","","","10600.00","7950.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8662.32","81.72","","16887.33","11641.27","21983.50","1 through 10","5539.56","8662.32","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier1","PX-27000048","CDM","C1732","HCPCS","0272","RC","","","","both","","","1732.50","1299.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1126.13","65","","2222.68","2222.68","2222.68","1 through 10","537.08","1377.34","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier1","PX-27000048","CDM","C1732","HCPCS","0272","RC","","","","both","","","1732.50","1299.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","632.36","36.5","","4681.38","1275.47","8371.80","20","537.08","1377.34","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier1","PX-27000048","CDM","C1732","HCPCS","0272","RC","","","","both","","","1732.50","1299.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","663.55","38.3","","1663.12","1287.53","2528.21","1 through 10","537.08","1377.34","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier1","PX-27000048","CDM","C1732","HCPCS","0272","RC","","","","both","","","1732.50","1299.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","743.24","42.9","","1935.35","1935.35","1935.35","1 through 10","537.08","1377.34","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier1","PX-27000048","CDM","C1732","HCPCS","0272","RC","","","","both","","","1732.50","1299.37","WELLPOINT [1015]","HB AMC WELLPOINT","1278.24","73.78","","4813.94","2545.82","7082.06","1 through 10","537.08","1377.34","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier1","PX-27000048","CDM","C1732","HCPCS","0272","RC","","","","outpatient","","","1732.50","1299.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1415.80","81.72","","2733.55","2433.63","5168.92","14","905.4","1415.8","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier2","PX-27000049","CDM","C1732","HCPCS","0272","RC","","","","both","","","4812.00","3609.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3127.80","65","","2222.68","2222.68","2222.68","1 through 10","1491.72","3825.54","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier2","PX-27000049","CDM","C1732","HCPCS","0272","RC","","","","both","","","4812.00","3609.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1756.38","36.5","","4681.38","1275.47","8371.80","20","1491.72","3825.54","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier2","PX-27000049","CDM","C1732","HCPCS","0272","RC","","","","both","","","4812.00","3609.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1843.00","38.3","","1663.12","1287.53","2528.21","1 through 10","1491.72","3825.54","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier2","PX-27000049","CDM","C1732","HCPCS","0272","RC","","","","both","","","4812.00","3609.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2064.35","42.9","","1935.35","1935.35","1935.35","1 through 10","1491.72","3825.54","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier2","PX-27000049","CDM","C1732","HCPCS","0272","RC","","","","both","","","4812.00","3609.00","WELLPOINT [1015]","HB AMC WELLPOINT","3550.29","73.78","","4813.94","2545.82","7082.06","1 through 10","1491.72","3825.54","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier2","PX-27000049","CDM","C1732","HCPCS","0272","RC","","","","outpatient","","","4812.00","3609.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3932.37","81.72","","2733.55","2433.63","5168.92","14","2514.75","3932.37","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier3","PX-27000050","CDM","C1732","HCPCS","0272","RC","","","","both","","","5926.73","4445.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3852.37","65","","2222.68","2222.68","2222.68","1 through 10","1837.29","4711.75","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier3","PX-27000050","CDM","C1732","HCPCS","0272","RC","","","","both","","","5926.73","4445.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2163.26","36.5","","4681.38","1275.47","8371.80","20","1837.29","4711.75","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier3","PX-27000050","CDM","C1732","HCPCS","0272","RC","","","","both","","","5926.73","4445.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2269.94","38.3","","1663.12","1287.53","2528.21","1 through 10","1837.29","4711.75","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier3","PX-27000050","CDM","C1732","HCPCS","0272","RC","","","","both","","","5926.73","4445.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2542.57","42.9","","1935.35","1935.35","1935.35","1 through 10","1837.29","4711.75","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier3","PX-27000050","CDM","C1732","HCPCS","0272","RC","","","","both","","","5926.73","4445.05","WELLPOINT [1015]","HB AMC WELLPOINT","4372.74","73.78","","4813.94","2545.82","7082.06","1 through 10","1837.29","4711.75","percent of total billed charges",""
"HC Catheter Ep Ablation 3d or Vector Mapping Tier3","PX-27000050","CDM","C1732","HCPCS","0272","RC","","","","outpatient","","","5926.73","4445.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4843.32","81.72","","2733.55","2433.63","5168.92","14","3097.31","4843.32","percent of total billed charges",""
"HC Catheter Ep Diag, 19 or < Electrodes Tier1","PX-27000045","CDM","C1730","HCPCS","0272","RC","","","","both","","","1118.99","839.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","889.60","79.5","","765.06","765.06","765.06","1 through 10","346.89","889.6","percent of total billed charges",""
"HC Catheter Ep Diag, 19 or < Electrodes Tier1","PX-27000045","CDM","C1730","HCPCS","0272","RC","","","","both","","","1118.99","839.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","596.42","53.3","","6427.95","6427.95","6427.95","1 through 10","346.89","889.6","percent of total billed charges",""
"HC Catheter Ep Diag, 19 or < Electrodes Tier1","PX-27000045","CDM","C1730","HCPCS","0272","RC","","","","both","","","1118.99","839.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","727.34","65","","1193.16","1193.16","1193.16","1 through 10","346.89","889.6","percent of total billed charges",""
"HC Catheter Ep Diag, 19 or < Electrodes Tier1","PX-27000045","CDM","C1730","HCPCS","0272","RC","","","","both","","","1118.99","839.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","408.43","36.5","","2053.37","54.83","3398.85","20","346.89","889.6","percent of total billed charges",""
"HC Catheter Ep Diag, 19 or < Electrodes Tier1","PX-27000045","CDM","C1730","HCPCS","0272","RC","","","","both","","","1118.99","839.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","428.57","38.3","","232.75","124.53","2541.50","39","346.89","889.6","percent of total billed charges",""
"HC Catheter Ep Diag, 19 or < Electrodes Tier1","PX-27000045","CDM","C1730","HCPCS","0272","RC","","","","both","","","1118.99","839.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","480.05","42.9","","66.89","66.89","66.89","1 through 10","346.89","889.6","percent of total billed charges",""
"HC Catheter Ep Diag, 19 or < Electrodes Tier1","PX-27000045","CDM","C1730","HCPCS","0272","RC","","","","both","","","1118.99","839.24","WELLPOINT [1015]","HB AMC WELLPOINT","825.59","73.78","","2392.81","1818.08","6339.98","15","346.89","889.6","percent of total billed charges",""
"HC Catheter Ep Diag, 19 or < Electrodes Tier1","PX-27000045","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","1118.99","839.24","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","584.78","52.26","","1988.81","1988.81","1988.81","1 through 10","584.78","914.44","percent of total billed charges",""
"HC Catheter Ep Diag, 19 or < Electrodes Tier1","PX-27000045","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","1118.99","839.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","914.44","81.72","","2569.25","132.34","2569.25","1 through 10","584.78","914.44","percent of total billed charges",""
"HC Catheter Ep Diag, 19 or < Electrodes Tier1","PX-27000045","CDM","C1730","HCPCS","0272","RC","","","","outpatient","","","1118.99","839.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","914.44","81.72","","727.92","102.34","6154.18","26","584.78","914.44","percent of total billed charges",""
"HC Catheter Ep Diag, 20 or > Electrodes Tier1","PX-27000046","CDM","C1731","HCPCS","0272","RC","","","","both","","","3508.61","2631.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2789.34","79.5","","4230.00","4230.00","4230.00","1 through 10","1087.67","2789.34","percent of total billed charges",""
"HC Catheter Ep Diag, 20 or > Electrodes Tier1","PX-27000046","CDM","C1731","HCPCS","0272","RC","","","","both","","","3508.61","2631.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1343.80","38.3","","1995.27","1920.70","1995.27","1 through 10","1087.67","2789.34","percent of total billed charges",""
"HC Catheter Ep Diag, 20 or > Electrodes Tier1","PX-27000046","CDM","C1731","HCPCS","0272","RC","","","","both","","","3508.61","2631.46","WELLPOINT [1015]","HB AMC WELLPOINT","2588.65","73.78","","3799.18","3799.18","3799.18","1 through 10","1087.67","2789.34","percent of total billed charges",""
"HC Catheter Ep Diag, 20 or > Electrodes Tier1","PX-27000046","CDM","C1731","HCPCS","0272","RC","","","","outpatient","","","3508.61","2631.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2867.24","81.72","","2243.79","2243.79","2243.79","1 through 10","1833.6","2867.24","percent of total billed charges",""
"HC Catheter Ep Diag, 20 or > Electrodes Tier1","PX-27000046","CDM","C1731","HCPCS","0272","RC","","","","outpatient","","","3508.61","2631.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2867.24","81.72","","4400.70","4079.34","4400.70","1 through 10","1833.6","2867.24","percent of total billed charges",""
"HC Catheter Ep Diag, 20 or > Electrodes Tier2","PX-27000047","CDM","C1731","HCPCS","0272","RC","","","","both","","","4853.82","3640.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3858.79","79.5","","4230.00","4230.00","4230.00","1 through 10","1504.68","3858.79","percent of total billed charges",""
"HC Catheter Ep Diag, 20 or > Electrodes Tier2","PX-27000047","CDM","C1731","HCPCS","0272","RC","","","","both","","","4853.82","3640.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1859.01","38.3","","1995.27","1920.70","1995.27","1 through 10","1504.68","3858.79","percent of total billed charges",""
"HC Catheter Ep Diag, 20 or > Electrodes Tier2","PX-27000047","CDM","C1731","HCPCS","0272","RC","","","","both","","","4853.82","3640.36","WELLPOINT [1015]","HB AMC WELLPOINT","3581.15","73.78","","3799.18","3799.18","3799.18","1 through 10","1504.68","3858.79","percent of total billed charges",""
"HC Catheter Ep Diag, 20 or > Electrodes Tier2","PX-27000047","CDM","C1731","HCPCS","0272","RC","","","","outpatient","","","4853.82","3640.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3966.54","81.72","","2243.79","2243.79","2243.79","1 through 10","2536.61","3966.54","percent of total billed charges",""
"HC Catheter Ep Diag, 20 or > Electrodes Tier2","PX-27000047","CDM","C1731","HCPCS","0272","RC","","","","outpatient","","","4853.82","3640.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3966.54","81.72","","4400.70","4079.34","4400.70","1 through 10","2536.61","3966.54","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier1","PX-27000174","CDM","C1886","HCPCS","0272","RC","","","","both","","","4081.00","3060.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2930.16","71.8","","4399.55","4399.55","4399.55","1 through 10","1265.11","3244.4","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier1","PX-27000174","CDM","C1886","HCPCS","0272","RC","","","","both","","","4081.00","3060.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1489.57","36.5","","1413.19","621.27","1413.19","1 through 10","1265.11","3244.4","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier1","PX-27000174","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","4081.00","3060.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3334.99","81.72","","8168.27","2209.17","8168.27","1 through 10","2132.73","3334.99","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier2","PX-27000175","CDM","C1886","HCPCS","0272","RC","","","","both","","","3955.35","2966.51","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2839.94","71.8","","4399.55","4399.55","4399.55","1 through 10","1226.16","3144.5","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier2","PX-27000175","CDM","C1886","HCPCS","0272","RC","","","","both","","","3955.35","2966.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1443.70","36.5","","1413.19","621.27","1413.19","1 through 10","1226.16","3144.5","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier2","PX-27000175","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","3955.35","2966.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3232.31","81.72","","8168.27","2209.17","8168.27","1 through 10","2067.07","3232.31","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier3","PX-27000176","CDM","C1886","HCPCS","0272","RC","","","","both","","","12641.20","9480.90","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","9076.38","71.8","","4399.55","4399.55","4399.55","1 through 10","3918.77","10049.75","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier3","PX-27000176","CDM","C1886","HCPCS","0272","RC","","","","both","","","12641.20","9480.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4614.04","36.5","","1413.19","621.27","1413.19","1 through 10","3918.77","10049.75","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier3","PX-27000176","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","12641.20","9480.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10330.39","81.72","","8168.27","2209.17","8168.27","1 through 10","6606.29","10330.39","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","both","","","608.37","456.28","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","436.81","71.8","","28.28","27.13","28.28","1 through 10","188.59","483.65","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","both","","","608.37","456.28","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","425.86","70","","44.63","35.78","44.63","1 through 10","188.59","483.65","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","both","","","608.37","456.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","483.65","79.5","","1342.89","271.64","6954.67","1 through 10","188.59","483.65","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","both","","","608.37","456.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","324.26","53.3","","4550.00","30.49","4550.00","1 through 10","188.59","483.65","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","both","","","608.37","456.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","395.44","65","","42.09","0.04","5453.50","1 through 10","188.59","483.65","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","both","","","608.37","456.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","222.06","36.5","","310.94","18.54","1259.30","62","188.59","483.65","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","both","","","608.37","456.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","233.01","38.3","","146.86","22.58","1753.45","65","188.59","483.65","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","both","","","608.37","456.28","WELLPOINT [1015]","HB AMC WELLPOINT","448.86","73.78","","247.29","33.09","909.09","53","188.59","483.65","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","608.37","456.28","AETNA [1001]","HB AMC AETNA HMO","424.64","69.8","","30.69","30.21","30.69","1 through 10","317.93","497.16","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","608.37","456.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","489.13","80.4","","82.69","82.69","82.69","1 through 10","317.93","497.16","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","608.37","456.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","497.16","81.72","","751.01","74.72","751.01","1 through 10","317.93","497.16","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","608.37","456.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","497.16","81.72","","328.92","46.17","2701.97","59","317.93","497.16","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","both","","","218.17","163.63","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","156.65","71.8","","28.28","27.13","28.28","1 through 10","67.63","173.45","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","both","","","218.17","163.63","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","152.72","70","","44.63","35.78","44.63","1 through 10","67.63","173.45","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","both","","","218.17","163.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","173.45","79.5","","1342.89","271.64","6954.67","1 through 10","67.63","173.45","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","both","","","218.17","163.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","116.28","53.3","","4550.00","30.49","4550.00","1 through 10","67.63","173.45","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","both","","","218.17","163.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","141.81","65","","42.09","0.04","5453.50","1 through 10","67.63","173.45","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","both","","","218.17","163.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","79.63","36.5","","310.94","18.54","1259.30","62","67.63","173.45","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","both","","","218.17","163.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","83.56","38.3","","146.86","22.58","1753.45","65","67.63","173.45","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","both","","","218.17","163.63","WELLPOINT [1015]","HB AMC WELLPOINT","160.97","73.78","","247.29","33.09","909.09","53","67.63","173.45","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","218.17","163.63","AETNA [1001]","HB AMC AETNA HMO","152.28","69.8","","30.69","30.21","30.69","1 through 10","114.02","178.29","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","218.17","163.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","175.41","80.4","","82.69","82.69","82.69","1 through 10","114.02","178.29","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","218.17","163.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","178.29","81.72","","751.01","74.72","751.01","1 through 10","114.02","178.29","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","218.17","163.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","178.29","81.72","","328.92","46.17","2701.97","59","114.02","178.29","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","both","","","5654.18","4240.63","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","4059.70","71.8","","28.28","27.13","28.28","1 through 10","1752.8","4495.07","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","both","","","5654.18","4240.63","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3957.93","70","","44.63","35.78","44.63","1 through 10","1752.8","4495.07","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","both","","","5654.18","4240.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4495.07","79.5","","1342.89","271.64","6954.67","1 through 10","1752.8","4495.07","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","both","","","5654.18","4240.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3013.68","53.3","","4550.00","30.49","4550.00","1 through 10","1752.8","4495.07","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","both","","","5654.18","4240.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3675.22","65","","42.09","0.04","5453.50","1 through 10","1752.8","4495.07","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","both","","","5654.18","4240.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2063.78","36.5","","310.94","18.54","1259.30","62","1752.8","4495.07","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","both","","","5654.18","4240.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2165.55","38.3","","146.86","22.58","1753.45","65","1752.8","4495.07","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","both","","","5654.18","4240.63","WELLPOINT [1015]","HB AMC WELLPOINT","4171.65","73.78","","247.29","33.09","909.09","53","1752.8","4495.07","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","5654.18","4240.63","AETNA [1001]","HB AMC AETNA HMO","3946.62","69.8","","30.69","30.21","30.69","1 through 10","2954.87","4620.6","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","5654.18","4240.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4545.96","80.4","","82.69","82.69","82.69","1 through 10","2954.87","4620.6","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","5654.18","4240.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4620.60","81.72","","751.01","74.72","751.01","1 through 10","2954.87","4620.6","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","5654.18","4240.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4620.60","81.72","","328.92","46.17","2701.97","59","2954.87","4620.6","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier1","PX-27000054","CDM","C1750","HCPCS","0278","RC","","","","both","","","1022.18","766.63","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","664.42","65","","1371.74","196.32","1371.74","1 through 10","316.88","812.63","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier1","PX-27000054","CDM","C1750","HCPCS","0278","RC","","","","both","","","1022.18","766.63","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","715.53","70","","249.45","107.26","1254.96","14","316.88","812.63","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier1","PX-27000054","CDM","C1750","HCPCS","0278","RC","","","","both","","","1022.18","766.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","812.63","79.5","","196.32","85.01","196.32","1 through 10","316.88","812.63","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier1","PX-27000054","CDM","C1750","HCPCS","0278","RC","","","","both","","","1022.18","766.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","544.82","53.3","","1132.95","1132.95","1132.95","1 through 10","316.88","812.63","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier1","PX-27000054","CDM","C1750","HCPCS","0278","RC","","","","both","","","1022.18","766.63","WELLPOINT [1015]","HB AMC WELLPOINT","754.16","73.78","","1297.66","185.72","1297.66","1 through 10","316.88","812.63","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier1","PX-27000054","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1022.18","766.63","AETNA [1001]","HB AMC AETNA HMO","713.48","69.8","","76.96","76.96","76.96","1 through 10","534.19","835.33","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier1","PX-27000054","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1022.18","766.63","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","534.19","52.26","","154.36","154.36","154.36","1 through 10","534.19","835.33","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier1","PX-27000054","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1022.18","766.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","835.33","81.72","","199.41","199.41","199.41","1 through 10","534.19","835.33","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier2","PX-27000055","CDM","C1750","HCPCS","0278","RC","","","","both","","","4387.50","3290.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2851.88","65","","1371.74","196.32","1371.74","1 through 10","1360.13","3488.06","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier2","PX-27000055","CDM","C1750","HCPCS","0278","RC","","","","both","","","4387.50","3290.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3071.25","70","","249.45","107.26","1254.96","14","1360.13","3488.06","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier2","PX-27000055","CDM","C1750","HCPCS","0278","RC","","","","both","","","4387.50","3290.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3488.06","79.5","","196.32","85.01","196.32","1 through 10","1360.13","3488.06","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier2","PX-27000055","CDM","C1750","HCPCS","0278","RC","","","","both","","","4387.50","3290.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2338.54","53.3","","1132.95","1132.95","1132.95","1 through 10","1360.13","3488.06","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier2","PX-27000055","CDM","C1750","HCPCS","0278","RC","","","","both","","","4387.50","3290.62","WELLPOINT [1015]","HB AMC WELLPOINT","3237.10","73.78","","1297.66","185.72","1297.66","1 through 10","1360.13","3488.06","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier2","PX-27000055","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","4387.50","3290.62","AETNA [1001]","HB AMC AETNA HMO","3062.48","69.8","","76.96","76.96","76.96","1 through 10","2292.91","3585.47","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier2","PX-27000055","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","4387.50","3290.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2292.91","52.26","","154.36","154.36","154.36","1 through 10","2292.91","3585.47","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier2","PX-27000055","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","4387.50","3290.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3585.47","81.72","","199.41","199.41","199.41","1 through 10","2292.91","3585.47","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier3","PX-27000056","CDM","C1750","HCPCS","0278","RC","","","","both","","","4759.50","3569.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3093.68","65","","1371.74","196.32","1371.74","1 through 10","1475.45","3783.8","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier3","PX-27000056","CDM","C1750","HCPCS","0278","RC","","","","both","","","4759.50","3569.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3331.65","70","","249.45","107.26","1254.96","14","1475.45","3783.8","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier3","PX-27000056","CDM","C1750","HCPCS","0278","RC","","","","both","","","4759.50","3569.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3783.80","79.5","","196.32","85.01","196.32","1 through 10","1475.45","3783.8","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier3","PX-27000056","CDM","C1750","HCPCS","0278","RC","","","","both","","","4759.50","3569.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2536.81","53.3","","1132.95","1132.95","1132.95","1 through 10","1475.45","3783.8","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier3","PX-27000056","CDM","C1750","HCPCS","0278","RC","","","","both","","","4759.50","3569.62","WELLPOINT [1015]","HB AMC WELLPOINT","3511.56","73.78","","1297.66","185.72","1297.66","1 through 10","1475.45","3783.8","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier3","PX-27000056","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","4759.50","3569.62","AETNA [1001]","HB AMC AETNA HMO","3322.13","69.8","","76.96","76.96","76.96","1 through 10","2487.31","3889.46","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier3","PX-27000056","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","4759.50","3569.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2487.31","52.26","","154.36","154.36","154.36","1 through 10","2487.31","3889.46","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier3","PX-27000056","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","4759.50","3569.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3889.46","81.72","","199.41","199.41","199.41","1 through 10","2487.31","3889.46","percent of total billed charges",""
"HC Catheter Hemodialysis/per Short-Term Tier1","PX-27000060","CDM","C1752","HCPCS","0278","RC","","","","both","","","887.60","665.70","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","576.94","65","","131.71","131.71","131.71","1 through 10","275.16","705.64","percent of total billed charges",""
"HC Catheter Hemodialysis/per Short-Term Tier1","PX-27000060","CDM","C1752","HCPCS","0278","RC","","","","both","","","887.60","665.70","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","621.32","70","","249.44","163.91","249.45","1 through 10","275.16","705.64","percent of total billed charges",""
"HC Catheter Hemodialysis/per Short-Term Tier1","PX-27000060","CDM","C1752","HCPCS","0278","RC","","","","both","","","887.60","665.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","705.64","79.5","","162.14","162.14","162.14","1 through 10","275.16","705.64","percent of total billed charges",""
"HC Catheter Hemodialysis/per Short-Term Tier1","PX-27000060","CDM","C1752","HCPCS","0278","RC","","","","both","","","887.60","665.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","576.94","65","","193.56","193.56","193.56","1 through 10","275.16","705.64","percent of total billed charges",""
"HC Catheter Hemodialysis/per Short-Term Tier1","PX-27000060","CDM","C1752","HCPCS","0278","RC","","","","both","","","887.60","665.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","275.16","31","","77.08","77.08","77.08","1 through 10","275.16","705.64","percent of total billed charges",""
"HC Catheter Hemodialysis/per Short-Term Tier1","PX-27000060","CDM","C1752","HCPCS","0278","RC","","","","both","","","887.60","665.70","WELLPOINT [1015]","HB AMC WELLPOINT","654.87","73.78","","185.72","185.72","185.72","1 through 10","275.16","705.64","percent of total billed charges",""
"HC Catheter Hemodialysis/per Short-Term Tier1","PX-27000060","CDM","C1752","HCPCS","0278","RC","","","","outpatient","","","887.60","665.70","AETNA [1001]","HB AMC AETNA HMO","619.54","69.8","","185.24","185.24","185.24","1 through 10","463.86","725.35","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier1","PX-27000057","CDM","C1751","HCPCS","0272","RC","","","","both","","","424.20","318.15","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","296.94","70","","1389.50","602.17","3167.85","27","131.5","337.24","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier1","PX-27000057","CDM","C1751","HCPCS","0272","RC","","","","both","","","424.20","318.15","WELLPOINT [1015]","HB AMC WELLPOINT","312.97","73.78","","1089.20","218.86","1089.20","1 through 10","131.5","337.24","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier1","PX-27000057","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","424.20","318.15","AETNA [1001]","HB AMC AETNA HMO","296.09","69.8","","1389.50","940.69","1389.50","1 through 10","221.69","346.66","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier1","PX-27000057","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","424.20","318.15","AETNA [1001]","HB AMC AETNA PPO","341.06","80.4","","190.26","190.26","190.26","1 through 10","221.69","346.66","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier1","PX-27000057","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","424.20","318.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","346.66","81.72","","1110.77","235.00","1169.52","1 through 10","221.69","346.66","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier2","PX-27000058","CDM","C1751","HCPCS","0272","RC","","","","both","","","354.29","265.72","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","248.00","70","","1389.50","602.17","3167.85","27","109.83","281.66","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier2","PX-27000058","CDM","C1751","HCPCS","0272","RC","","","","both","","","354.29","265.72","WELLPOINT [1015]","HB AMC WELLPOINT","261.40","73.78","","1089.20","218.86","1089.20","1 through 10","109.83","281.66","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier2","PX-27000058","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","354.29","265.72","AETNA [1001]","HB AMC AETNA HMO","247.29","69.8","","1389.50","940.69","1389.50","1 through 10","185.15","289.53","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier2","PX-27000058","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","354.29","265.72","AETNA [1001]","HB AMC AETNA PPO","284.85","80.4","","190.26","190.26","190.26","1 through 10","185.15","289.53","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier2","PX-27000058","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","354.29","265.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","289.53","81.72","","1110.77","235.00","1169.52","1 through 10","185.15","289.53","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier3","PX-27000059","CDM","C1751","HCPCS","0272","RC","","","","both","","","6225.00","4668.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4357.50","70","","1389.50","602.17","3167.85","27","1929.75","4948.88","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier3","PX-27000059","CDM","C1751","HCPCS","0272","RC","","","","both","","","6225.00","4668.75","WELLPOINT [1015]","HB AMC WELLPOINT","4592.81","73.78","","1089.20","218.86","1089.20","1 through 10","1929.75","4948.88","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier3","PX-27000059","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","6225.00","4668.75","AETNA [1001]","HB AMC AETNA HMO","4345.05","69.8","","1389.50","940.69","1389.50","1 through 10","3253.19","5087.07","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier3","PX-27000059","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","6225.00","4668.75","AETNA [1001]","HB AMC AETNA PPO","5004.90","80.4","","190.26","190.26","190.26","1 through 10","3253.19","5087.07","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier3","PX-27000059","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","6225.00","4668.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5087.07","81.72","","1110.77","235.00","1169.52","1 through 10","3253.19","5087.07","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","both","","","639.38","479.53","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","459.07","71.8","","175.91","175.91","175.91","1 through 10","198.21","508.31","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","both","","","639.38","479.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","415.60","65","","147.88","147.88","1296.75","1 through 10","198.21","508.31","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","both","","","639.38","479.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.37","36.5","","181.40","177.87","181.40","21","198.21","508.31","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","both","","","639.38","479.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","244.88","38.3","","170.15","88.95","424.24","16","198.21","508.31","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","both","","","639.38","479.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.29","42.9","","699.48","699.48","699.48","12","198.21","508.31","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","both","","","639.38","479.53","WELLPOINT [1015]","HB AMC WELLPOINT","471.73","73.78","","576.52","182.40","651.44","14","198.21","508.31","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","639.38","479.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","522.50","81.72","","181.86","100.03","402.41","21","334.14","522.5","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","both","","","690.35","517.76","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","495.67","71.8","","175.91","175.91","175.91","1 through 10","214.01","548.83","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","both","","","690.35","517.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","448.73","65","","147.88","147.88","1296.75","1 through 10","214.01","548.83","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","both","","","690.35","517.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","251.98","36.5","","181.40","177.87","181.40","21","214.01","548.83","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","both","","","690.35","517.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","264.40","38.3","","170.15","88.95","424.24","16","214.01","548.83","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","both","","","690.35","517.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","296.16","42.9","","699.48","699.48","699.48","12","214.01","548.83","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","both","","","690.35","517.76","WELLPOINT [1015]","HB AMC WELLPOINT","509.34","73.78","","576.52","182.40","651.44","14","214.01","548.83","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","690.35","517.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","564.15","81.72","","181.86","100.03","402.41","21","360.78","564.15","percent of total billed charges",""
"HC Collar Cer Flex N/Adj Foam Prefabricated Tier1","PX-27000256","CDM","L0120","HCPCS","0274","RC","","","","both","","","12.15","9.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4.65","38.3","","4.75","4.75","4.75","1 through 10","3.77","37.38","percent of total billed charges",""
"HC Collar Cer Flex N/Adj Foam Prefabricated Tier1","PX-27000256","CDM","L0120","HCPCS","0274","RC","","","","both","","","12.15","9.11","WELLPOINT [1015]","HB AMC WELLPOINT","8.96","73.78","","9.05","9.05","9.05","1 through 10","3.77","37.38","percent of total billed charges",""
"HC Collar Cer Flex N/Adj Foam Prefabricated Tier1","PX-27000256","CDM","L0120","HCPCS","0274","RC","","","","outpatient","","","12.15","9.11","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6.08","50","","6.37","6.11","6.37","1 through 10","6.08","62.05","percent of total billed charges",""
"HC Collar Cer Flex N/Adj Foam Prefabricated Tier1","PX-27000256","CDM","L0120","HCPCS","0274","RC","","","","outpatient","","","12.15","9.11","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6.38","52.5","","6.68","6.68","6.68","1 through 10","6.08","62.05","percent of total billed charges",""
"HC Collar Cer Flex N/Adj Foam Prefabricated Tier1","PX-27000256","CDM","L0120","HCPCS","0274","RC","","","","outpatient","","","12.15","9.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9.77","80.4","","9.48","9.48","9.48","1 through 10","6.08","62.05","percent of total billed charges",""
"HC Collar Cerv Srig Th/Plast 2 Pc Pre T1","PX-27000261","CDM","L0172","HCPCS","0274","RC","","","","both","","","139.51","104.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.43","38.3","","17.01","17.01","17.01","1 through 10","43.25","178.79","percent of total billed charges",""
"HC Collar Cerv Srig Th/Plast 2 Pc Pre T1","PX-27000261","CDM","L0172","HCPCS","0274","RC","","","","both","","","139.51","104.63","WELLPOINT [1015]","HB AMC WELLPOINT","102.93","73.78","","32.39","32.39","32.39","1 through 10","43.25","178.79","percent of total billed charges",""
"HC Collar Cerv Srig Th/Plast 2 Pc Pre T1","PX-27000261","CDM","L0172","HCPCS","0274","RC","","","","outpatient","","","139.51","104.63","AETNA [1001]","HB AMC AETNA HMO","97.38","69.8","","26.36","26.36","26.36","1 through 10","69.76","297.02","percent of total billed charges",""
"HC Collar Cerv Srig Th/Plast 2 Pc Pre T1","PX-27000261","CDM","L0172","HCPCS","0274","RC","","","","outpatient","","","139.51","104.63","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","69.76","50","","22.80","22.80","22.80","1 through 10","69.76","297.02","percent of total billed charges",""
"HC Collar Cerv Srig Th/Plast 2 Pc Thorex Pre Tier1","PX-27000262","CDM","L0174","HCPCS","0274","RC","","","","both","","","367.00","275.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","291.77","79.5","","288.83","288.83","288.83","1 through 10","113.77","515.8","percent of total billed charges",""
"HC Collar Cerv Srig Th/Plast 2 Pc Thorex Pre Tier1","PX-27000262","CDM","L0174","HCPCS","0274","RC","","","","both","","","367.00","275.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","133.96","36.5","","136.89","136.89","136.89","1 through 10","113.77","515.8","percent of total billed charges",""
"HC Collar Cerv Srig Th/Plast 2 Pc Thorex Pre Tier1","PX-27000262","CDM","L0174","HCPCS","0274","RC","","","","both","","","367.00","275.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","140.56","38.3","","143.50","143.50","143.50","1 through 10","113.77","515.8","percent of total billed charges",""
"HC Collar Cerv Srig Th/Plast 2 Pc Thorex Pre Tier1","PX-27000262","CDM","L0174","HCPCS","0274","RC","","","","both","","","367.00","275.25","WELLPOINT [1015]","HB AMC WELLPOINT","270.77","73.78","","273.23","273.23","273.23","1 through 10","113.77","515.8","percent of total billed charges",""
"HC Collar Cerv Srig Th/Plast 2 Pc Thorex Pre Tier1","PX-27000262","CDM","L0174","HCPCS","0274","RC","","","","outpatient","","","367.00","275.25","AETNA [1001]","HB AMC AETNA HMO","256.17","69.8","","248.46","240.39","248.46","1 through 10","183.5","856.81","percent of total billed charges",""
"HC Collar Cerv Srig Th/Plast 2 Pc Thorex Pre Tier1","PX-27000262","CDM","L0174","HCPCS","0274","RC","","","","outpatient","","","367.00","275.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","192.68","52.5","","209.19","209.19","209.19","1 through 10","183.5","856.81","percent of total billed charges",""
"HC Collar Cerv Srig Th/Plast 2 Pc Thorex Pre Tier1","PX-27000262","CDM","L0174","HCPCS","0274","RC","","","","outpatient","","","367.00","275.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","183.50","50","","192.31","192.31","192.31","1 through 10","183.5","856.81","percent of total billed charges",""
"HC Collect Blood From Catheter Venous","PX-76001108","CDM","36592","CPT","0761","RC","","","","both","","","290.00","217.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.02","126.84","150.63","12","89.9","230.55","other","OPPS APC"
"HC Collect Blood From Catheter Venous","PX-76001108","CDM","36592","CPT","0761","RC","","","","both","","","290.00","217.50","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","89.9","230.55","other","OPPS APC"
"HC Collect Blood From Catheter Venous","PX-76001108","CDM","36592","CPT","0761","RC","","","","outpatient","","","290.00","217.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","282.26","282.26","282.26","1 through 10","121.77","407.82","other","ASC "
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","2622.00","1966.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1442.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","720.42","720.42","720.42","1 through 10","812.82","2084.49","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","2622.00","1966.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","862.48","862.48","862.48","1 through 10","812.82","2084.49","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","2622.00","1966.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2084.49","79.5","","1342.70","1342.70","1342.70","1 through 10","812.82","2084.49","percent of total billed charges",""
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","2622.00","1966.50","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","700.11","1400.23","1 through 10","812.82","2084.49","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","2622.00","1966.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","957.03","36.5","","948.54","948.54","948.54","1 through 10","812.82","2084.49","percent of total billed charges",""
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","2622.00","1966.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1004.23","38.3","","994.31","994.31","994.31","1 through 10","812.82","2084.49","percent of total billed charges",""
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","2622.00","1966.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","686.12","1372.23","1 through 10","812.82","2084.49","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","outpatient","","","2622.00","1966.50","AETNA [1001]","HB AMC AETNA HMO","1830.16","69.8","","1721.61","1721.61","1721.61","1 through 10","979.79","2384.07","percent of total billed charges",""
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","outpatient","","","2622.00","1966.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2292.44","2292.44","2292.44","1 through 10","979.79","2384.07","other","ASC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","outpatient","","","2622.00","1966.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2597.20","2597.20","2597.20","1 through 10","979.79","2384.07","other","ASC "
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","outpatient","","","2622.00","1966.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2142.70","81.72","","2032.87","1254.13","2032.87","1 through 10","979.79","2384.07","percent of total billed charges",""
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","4645.00","3483.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1030.57","","APC Price ($1,000.55). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3235.53","3235.53","3241.49","1 through 10","950.62","3692.78","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","4645.00","3483.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1000.55","","APC Price ($1,000.55). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3094.03","3081.45","3094.03","1 through 10","950.62","3692.78","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","4645.00","3483.75","MEDICARE [2001]","HB BWH MEDICARE","1000.55","","APC Price ($1,000.55). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","3144.34","9433.02","19","950.62","3692.78","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","4645.00","3483.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1695.43","36.5","","1679.99","1679.99","1679.99","1 through 10","950.62","3692.78","percent of total billed charges",""
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","4645.00","3483.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1779.04","38.3","","5283.18","1761.06","5283.18","1 through 10","950.62","3692.78","percent of total billed charges",""
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","4645.00","3483.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","980.54","","APC Price ($1,000.55). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2941.92","2941.92","2941.92","1 through 10","950.62","3692.78","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","4645.00","3483.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","980.54","","APC Price ($1,000.55). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3083.46","3081.45","3083.96","12","950.62","3692.78","other","OPPS APC"
"HC Dihydrocodeinone","PX-30002878","CDM","80361","CPT","0301","RC","","","","both","","","24.00","18.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","17.23","71.8","","271.00","271.00","271.00","1 through 10","7.44","143.04","percent of total billed charges",""
"HC Dihydrocodeinone","PX-30002878","CDM","80361","CPT","0301","RC","","","","both","","","24.00","18.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","16.80","70","","119.16","119.16","119.16","1 through 10","7.44","143.04","percent of total billed charges",""
"HC Dihydromorphinone","PX-30002980","CDM","80361","CPT","0301","RC","","","","both","","","24.00","18.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","17.23","71.8","","271.00","271.00","271.00","1 through 10","7.44","143.04","percent of total billed charges",""
"HC Dihydromorphinone","PX-30002980","CDM","80361","CPT","0301","RC","","","","both","","","24.00","18.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","16.80","70","","119.16","119.16","119.16","1 through 10","7.44","143.04","percent of total billed charges",""
"HC Elbow Ortho With Adjustments Jnt Prefab Tier1","PX-27000483","CDM","L3760","HCPCS","0274","RC","","","","both","","","395.68","296.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","144.42","36.5","","442.77","442.77","442.77","1 through 10","122.66","669","percent of total billed charges",""
"HC Enoxaparin Sodium 10 Mg","PX-63601200","CDM","J1650","HCPCS","0636","RC","","","","both","","","5.23","3.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1.91","36.5","","1.10","1.10","1.10","1 through 10","1.61","4.03","percent of total billed charges",""
"HC Enoxaparin Sodium 10 Mg","PX-63601200","CDM","J1650","HCPCS","0636","RC","","","","both","","","5.23","3.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2.00","38.3","","1.26","1.26","1.26","70","1.61","4.03","percent of total billed charges",""
"HC Enoxaparin Sodium 10 Mg","PX-63601200","CDM","J1650","HCPCS","0636","RC","","","","outpatient","","","5.23","3.92","AETNA [1001]","HB AMC AETNA HMO","3.65","69.8","","2.24","2.24","7.53","1 through 10","0.01","4.2","percent of total billed charges",""
"HC Enoxaparin Sodium 10 Mg","PX-63601200","CDM","J1650","HCPCS","0636","RC","","","","outpatient","","","5.23","3.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3.66","69.9","","20.57","20.57","20.57","1 through 10","0.01","4.2","percent of total billed charges",""
"HC Ewo Rigit Without Joints Custom Tier1","PX-27000485","CDM","L3763","HCPCS","0274","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","459.60","38.3","","396.00","396.00","396.00","1 through 10","372","1140","percent of total billed charges",""
"HC Fing Ortho P/D Intrphl W/O Jnt/Spr Prefab Tier1","PX-27000503","CDM","L3927","HCPCS","0274","RC","","","","outpatient","","","66.00","49.50","AETNA [1001]","HB AMC AETNA HMO","46.07","69.8","","44.68","44.68","44.68","1 through 10","33","77.62","percent of total billed charges",""
"HC Fing Ortho P/D Intrphl W/O Jnt/Spr Prefab Tier1","PX-27000503","CDM","L3927","HCPCS","0274","RC","","","","outpatient","","","66.00","49.50","AETNA [1001]","HB AMC AETNA PPO","53.06","80.4","","51.48","51.48","51.48","1 through 10","33","77.62","percent of total billed charges",""
"HC Fing Ortho P/D Intrphl W/O Jnt/Spr Prefab Tier1","PX-27000503","CDM","L3927","HCPCS","0274","RC","","","","outpatient","","","66.00","49.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33.00","50","","34.58","34.58","34.58","1 through 10","33","77.62","percent of total billed charges",""
"HC Finger Ortho Finger Knckle Bender Prefab Tier1","PX-27000502","CDM","L3925","HCPCS","0274","RC","","","","both","","","67.06","50.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24.48","36.5","","25.01","25.01","25.01","1 through 10","20.79","71.91","percent of total billed charges",""
"HC Finger Ortho Finger Knckle Bender Prefab Tier1","PX-27000502","CDM","L3925","HCPCS","0274","RC","","","","both","","","67.06","50.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25.68","38.3","","26.22","25.48","26.22","1 through 10","20.79","71.91","percent of total billed charges",""
"HC Finger Ortho Finger Knckle Bender Prefab Tier1","PX-27000502","CDM","L3925","HCPCS","0274","RC","","","","outpatient","","","67.06","50.29","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33.53","50","","35.14","35.14","35.14","1 through 10","33.53","119.46","percent of total billed charges",""
"HC Finger Ortho Finger Knckle Bender Prefab Tier1","PX-27000502","CDM","L3925","HCPCS","0274","RC","","","","outpatient","","","67.06","50.29","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","36.88","55","","77.25","77.25","77.25","1 through 10","33.53","119.46","percent of total billed charges",""
"HC Florbetaben F - 18 Inj per Study Dose","PX-34300151","CDM","Q9983","HCPCS","0343","RC","","","","both","","","11900.00","8925.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1311.97","","APC Price ($1,273.76). Final payment is multiplied by 103%.","12728.75","1311.60","12728.75","1 through 10","1248.28","11305","other","OPPS APC"
"HC Florbetaben F - 18 Inj per Study Dose","PX-34300151","CDM","Q9983","HCPCS","0343","RC","","","","both","","","11900.00","8925.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1273.76","","APC Price ($1,273.76).","1253.38","1253.38","1253.38","1 through 10","1248.28","11305","other","OPPS APC"
"HC Florbetaben F - 18 Inj per Study Dose","PX-34300151","CDM","Q9983","HCPCS","0343","RC","","","","both","","","11900.00","8925.00","ELDER SERVICES [1037]","HB BWH MEDICARE","1273.76","","APC Price ($1,273.76).","1248.28","1248.28","1248.28","1 through 10","1248.28","11305","other","OPPS APC"
"HC Florbetaben F - 18 Inj per Study Dose","PX-34300151","CDM","Q9983","HCPCS","0343","RC","","","","both","","","11900.00","8925.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1248.28","","APC Price ($1,273.76). Final payment is multiplied by 98%.","1248.28","144.23","1248.28","1 through 10","1248.28","11305","other","OPPS APC"
"HC G130120 Gore Tag Tbe Device Side Brnch Compnt","PX-62400138","CDM","C1874","HCPCS","0624","RC","","","","both","","","5500.00","4125.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3575.00","65","","6652.80","6652.80","6652.80","1 through 10","1705","4372.5","percent of total billed charges",""
"HC G130120 Gore Tag Tbe Device Side Brnch Compnt","PX-62400138","CDM","C1874","HCPCS","0624","RC","","","","both","","","5500.00","4125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4372.50","79.5","","2612.61","795.38","2612.61","1 through 10","1705","4372.5","percent of total billed charges",""
"HC G130120 Gore Tag Tbe Device Side Brnch Compnt","PX-62400138","CDM","C1874","HCPCS","0624","RC","","","","both","","","5500.00","4125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2931.50","53.3","","1101.80","1101.80","1101.80","1 through 10","1705","4372.5","percent of total billed charges",""
"HC G130120 Gore Tag Tbe Device Side Brnch Compnt","PX-62400138","CDM","C1874","HCPCS","0624","RC","","","","both","","","5500.00","4125.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3575.00","65","","1820.00","910.00","1820.00","1 through 10","1705","4372.5","percent of total billed charges",""
"HC G130120 Gore Tag Tbe Device Side Brnch Compnt","PX-62400138","CDM","C1874","HCPCS","0624","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2007.50","36.5","","1257.80","693.44","2424.50","1 through 10","1705","4372.5","percent of total billed charges",""
"HC G130120 Gore Tag Tbe Device Side Brnch Compnt","PX-62400138","CDM","C1874","HCPCS","0624","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2106.50","38.3","","1950.11","547.40","2346.00","1 through 10","1705","4372.5","percent of total billed charges",""
"HC G130120 Gore Tag Tbe Device Side Brnch Compnt","PX-62400138","CDM","C1874","HCPCS","0624","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2359.50","42.9","","5096.18","5096.18","5096.18","1 through 10","1705","4372.5","percent of total billed charges",""
"HC G130120 Gore Tag Tbe Device Side Brnch Compnt","PX-62400138","CDM","C1874","HCPCS","0624","RC","","","","both","","","5500.00","4125.00","WELLPOINT [1015]","HB AMC WELLPOINT","4057.90","73.78","","1172.59","1172.59","4829.94","1 through 10","1705","4372.5","percent of total billed charges",""
"HC G130120 Gore Tag Tbe Device Side Brnch Compnt","PX-62400138","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","5500.00","4125.00","AETNA [1001]","HB AMC AETNA HMO","3839.00","69.8","","1806.84","947.80","5091.72","1 through 10","2874.3","4494.6","percent of total billed charges",""
"HC G130120 Gore Tag Tbe Device Side Brnch Compnt","PX-62400138","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4494.60","81.72","","1259.05","615.58","4586.56","1 through 10","2874.3","4494.6","percent of total billed charges",""
"HC Gen Neurostimulator Non-Rechargeable Tier3","PX-27000082","CDM","C1767","HCPCS","0278","RC","","","","both","","","29100.70","21825.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10621.76","36.5","","18081.90","16994.81","18081.90","1 through 10","9021.22","23135.06","percent of total billed charges",""
"HC Gen Neurostimulator Non-Rechargeable Tier3","PX-27000082","CDM","C1767","HCPCS","0278","RC","","","","both","","","29100.70","21825.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11145.57","38.3","","17814.94","17448.38","17814.94","1 through 10","9021.22","23135.06","percent of total billed charges",""
"HC Gen Neurostimulator Non-Rechargeable Tier3","PX-27000082","CDM","C1767","HCPCS","0278","RC","","","","both","","","29100.70","21825.52","WELLPOINT [1015]","HB AMC WELLPOINT","21470.50","73.78","","33921.28","33921.28","33921.28","1 through 10","9021.22","23135.06","percent of total billed charges",""
"HC Hfo With Nontorsion Joints Custom Tier1","PX-27000500","CDM","L3921","HCPCS","0274","RC","","","","both","","","229.00","171.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.71","38.3","","89.54","89.54","89.54","1 through 10","70.99","429.73","percent of total billed charges",""
"HC Hfo With Nontorsion Joints Custom Tier1","PX-27000500","CDM","L3921","HCPCS","0274","RC","","","","outpatient","","","229.00","171.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","120.23","52.5","","125.95","125.95","125.95","1 through 10","114.5","713.8","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","both","","","325.80","244.35","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","233.92","71.8","","701.76","233.92","701.76","1 through 10","101","309.51","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","both","","","325.80","244.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.92","36.5","","121.52","103.28","364.56","65","101","309.51","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","both","","","325.80","244.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.78","38.3","","127.39","123.80","139.38","155","101","309.51","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","both","","","325.80","244.35","TRICARE [160005]","HB BWH TRICARE","309.51","95","","199.28","199.28","398.56","1 through 10","101","309.51","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","both","","","325.80","244.35","WELLPOINT [1015]","HB AMC WELLPOINT","240.38","73.78","","242.56","242.56","568.36","24","101","309.51","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","outpatient","","","325.80","244.35","AETNA [1001]","HB AMC AETNA HMO","227.41","69.8","","220.57","155.73","220.57","31","152.8","524.72","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","outpatient","","","325.80","244.35","AETNA [1001]","HB AMC AETNA PPO","261.94","80.4","","254.12","170.72","254.12","1 through 10","152.8","524.72","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","outpatient","","","325.80","244.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","227.73","69.9","","225.78","151.17","245.65","20","152.8","524.72","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","outpatient","","","325.80","244.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","152.80","46.9","","151.17","151.17","151.17","11","152.8","524.72","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","440.00","330.00","AETNA [1001]","HB AMC AETNA HMO","307.12","69.8","","250.49","176.86","288.60","23","34.39","418","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","440.00","330.00","AETNA [1001]","HB AMC AETNA PPO","353.76","80.4","","193.88","176.86","193.88","1 through 10","34.39","418","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","440.00","330.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","349.80","79.5","","291.19","291.19","873.57","11","34.39","418","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","440.00","330.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","234.52","53.3","","195.36","195.36","195.36","1 through 10","34.39","418","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","160.60","36.5","","138.01","117.29","414.03","37","34.39","418","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","168.52","38.3","","144.67","140.60","421.80","66","34.39","418","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","440.00","330.00","TRICARE [160005]","HB BWH TRICARE","418.00","95","","42.28","40.17","42.28","1 through 10","34.39","418","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","440.00","330.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.76","42.9","","295.78","162.69","295.78","1 through 10","34.39","418","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","440.00","330.00","WELLPOINT [1015]","HB AMC WELLPOINT","324.63","73.78","","275.47","275.47","275.47","1 through 10","34.39","418","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","outpatient","","","440.00","330.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","359.57","81.72","","295.78","162.69","295.78","1 through 10","63.16","359.57","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","outpatient","","","440.00","330.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","359.57","81.72","","295.78","295.78","295.78","19","63.16","359.57","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","127.09","71.8","","370.50","123.50","370.50","14","14.69","168.15","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","115.05","65","","111.80","111.80","111.80","1 through 10","14.69","168.15","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","123.90","70","","74.26","74.26","172.00","27","14.69","168.15","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","140.72","79.5","","135.37","111.80","406.10","20","14.69","168.15","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","94.34","53.3","","135.37","90.82","406.10","15","14.69","168.15","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","115.05","65","","111.80","111.80","152.10","1 through 10","14.69","168.15","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.61","36.5","","62.26","54.01","64.16","15","14.69","168.15","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.79","38.3","","67.25","56.76","201.75","42","14.69","168.15","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","outpatient","","","177.00","132.75","AETNA [1001]","HB AMC AETNA HMO","123.55","69.8","","232.89","82.22","232.89","43","15.46","144.64","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","outpatient","","","177.00","132.75","AETNA [1001]","HB AMC AETNA PPO","142.31","80.4","","180.26","90.13","270.39","13","15.46","144.64","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","outpatient","","","177.00","132.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","142.31","80.4","","86.00","86.00","86.00","1 through 10","15.46","144.64","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","outpatient","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","144.64","81.72","","137.50","137.50","137.50","1 through 10","15.46","144.64","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","outpatient","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","144.64","81.72","","137.50","50.56","137.50","14","15.46","144.64","percent of total billed charges",""
"HC Implant Cochlear Int/Ext Components Tier2","PX-27000564","CDM","L8614","HCPCS","0278","RC","","","","both","","","4425.00","3318.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2358.53","53.3","","39045.04","39045.04","39045.04","1 through 10","1371.75","3517.88","percent of total billed charges",""
"HC Implant Cochlear Int/Ext Components Tier2","PX-27000564","CDM","L8614","HCPCS","0278","RC","","","","both","","","4425.00","3318.75","WELLPOINT [1015]","HB AMC WELLPOINT","3264.77","73.78","","36936.51","36936.51","36936.51","1 through 10","1371.75","3517.88","percent of total billed charges",""
"HC Implant Cochlear Int/Ext Components Tier3","PX-27000565","CDM","L8614","HCPCS","0278","RC","","","","both","","","7237.50","5428.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3857.59","53.3","","39045.04","39045.04","39045.04","1 through 10","2243.63","5753.81","percent of total billed charges",""
"HC Implant Cochlear Int/Ext Components Tier3","PX-27000565","CDM","L8614","HCPCS","0278","RC","","","","both","","","7237.50","5428.12","WELLPOINT [1015]","HB AMC WELLPOINT","5339.83","73.78","","36936.51","36936.51","36936.51","1 through 10","2243.63","5753.81","percent of total billed charges",""
"HC Infantile Myofibromatosis & Basal Ganglia Calc via Pdgfrb Gene","PX-31000535","CDM","81479","CPT","0310","RC","","","","both","","","2366.00","1774.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1880.97","79.5","","0.65","0.65","0.65","1 through 10","733.46","2247.7","percent of total billed charges",""
"HC Infantile Myofibromatosis & Basal Ganglia Calc via Pdgfrb Gene","PX-31000535","CDM","81479","CPT","0310","RC","","","","both","","","2366.00","1774.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1261.08","53.3","","0.79","0.79","0.79","1 through 10","733.46","2247.7","percent of total billed charges",""
"HC Infantile Myofibromatosis & Basal Ganglia Calc via Pdgfrb Gene","PX-31000535","CDM","81479","CPT","0310","RC","","","","outpatient","","","2366.00","1774.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1183.00","50","","1.00","1.00","1.00","1 through 10","156.55","1951.95","percent of total billed charges",""
"HC Infantile Myofibromatosis & Basal Ganglia Calc via Pdgfrb Gene","PX-31000535","CDM","81479","CPT","0310","RC","","","","outpatient","","","2366.00","1774.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1242.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","1951.95","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","86.97","43.67","87.33","49","75.72","218.63","other","OPPS APC"
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.59","37.83","84.52","91","75.72","218.63","other","OPPS APC"
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","197.45","71.8","","191.71","191.71","191.71","1 through 10","75.72","218.63","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","180.40","65.6","","87.33","87.33","87.33","1 through 10","75.72","218.63","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","192.50","70","","192.24","114.81","207.77","13","75.72","218.63","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","105.64","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","84.52","59.94","84.52","1 through 10","75.72","218.63","other","OPPS APC"
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","218.63","79.5","","210.13","140.98","630.39","72","75.72","218.63","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","146.58","53.3","","210.13","140.98","210.13","34","75.72","218.63","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.59","20.79","83.17","41","75.72","218.63","other","OPPS APC"
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","ELDER SERVICES [1037]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","76.89","76.89","76.89","1 through 10","75.72","218.63","other","OPPS APC"
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.70","150.70","150.70","1 through 10","75.72","218.63","other","OPPS APC"
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","HUMANA [1012]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","83.34","82.83","84.52","1 through 10","75.72","218.63","other","OPPS APC"
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","178.75","65","","0.74","0.74","0.74","1 through 10","75.72","218.63","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","38.45","84.52","1857","75.72","218.63","other","OPPS APC"
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.25","31","","82.51","82.51","82.51","1 through 10","75.72","218.63","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.38","36.5","","99.59","84.64","99.59","145","75.72","218.63","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.33","38.3","","104.40","104.40","208.79","403","75.72","218.63","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.83","75.35","248.49","30","75.72","218.63","other","OPPS APC"
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","TRICARE [160005]","HB BWH TRICARE","80.29","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","80.29","73.04","80.29","1 through 10","75.72","218.63","other","Tricare OPPS"
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","41.42","20.71","151.32","73","75.72","218.63","other","OPPS APC"
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","184.23","61.41","184.23","1 through 10","75.72","218.63","other","OPPS APC"
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.98","42.9","","117.40","117.40","213.44","19","75.72","218.63","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","both","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","41.59","84.52","301","75.72","218.63","other","OPPS APC"
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","inpatient","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","216.18","78.61","","2744.02","2744.02","2744.02","1 through 10","152.08","218.63","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","outpatient","","","275.00","206.25","AETNA [1001]","HB AMC AETNA HMO","191.95","69.8","","180.76","127.63","208.26","140","137.27","315.07","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","outpatient","","","275.00","206.25","AETNA [1001]","HB AMC AETNA PPO","221.10","80.4","","208.26","86.97","208.26","1 through 10","137.27","315.07","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","outpatient","","","275.00","206.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","143.72","52.26","","159.96","158.39","165.22","1 through 10","137.27","315.07","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","outpatient","","","275.00","206.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","221.10","80.4","","208.26","208.26","208.26","1 through 10","137.27","315.07","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","outpatient","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","224.73","81.72","","213.44","213.44","213.44","1 through 10","137.27","315.07","percent of total billed charges",""
"HC Inject Antibiotic Im","PX-76002007","CDM","96372","CPT","0761","RC","","","","outpatient","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","224.73","81.72","","213.44","117.40","267.00","74","137.27","315.07","percent of total billed charges",""
"HC Insj Eltrd Car Ven Sys Tm Insj Dfb/Pm Pls Gen","PX-48000060","CDM","33225","CPT","0361","RC","","","","both","","","13916.00","10437.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7417.23","53.3","","7125.36","7125.36","7125.36","1 through 10","4313.96","11063.22","percent of total billed charges",""
"HC Insj Eltrd Car Ven Sys Tm Insj Dfb/Pm Pls Gen","PX-48000060","CDM","33225","CPT","0361","RC","","","","both","","","13916.00","10437.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5329.83","38.3","","5276.55","5276.55","5276.55","1 through 10","4313.96","11063.22","percent of total billed charges",""
"HC Insj Eltrd Car Ven Sys Tm Insj Dfb/Pm Pls Gen","PX-48000060","CDM","33225","CPT","0361","RC","","","","outpatient","","","13916.00","10437.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11372.16","81.72","","5933.75","5933.75","5933.75","1 through 10","799.06","11372.16","percent of total billed charges",""
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","41969.00","31476.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","38071.20","","APC Price ($38,071.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","37465.85","37465.85","37465.85","1 through 10","13010.39","47589","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","41969.00","31476.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","47589.00","","APC Price ($38,071.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","350.00","350.00","350.00","1 through 10","13010.39","47589","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","41969.00","31476.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22369.48","53.3","","21489.07","21489.07","21489.07","1 through 10","13010.39","47589","percent of total billed charges",""
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","41969.00","31476.75","FALLON HEALTH [1008]","HB BWH MEDICARE","38071.20","","APC Price ($38,071.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107690.91","107690.91","107690.91","1 through 10","13010.39","47589","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","41969.00","31476.75","MEDICARE [2001]","HB BWH MEDICARE","38071.20","","APC Price ($38,071.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38075.05","38075.05","107720.46","41","13010.39","47589","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","41969.00","31476.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","37309.78","","APC Price ($38,071.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111962.85","35194.08","112140.55","1 through 10","13010.39","47589","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","41969.00","31476.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","37309.78","","APC Price ($38,071.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","35202.88","35188.68","37332.64","1 through 10","13010.39","47589","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","outpatient","","","41969.00","31476.75","AETNA [1001]","HB AMC AETNA HMO","29294.36","69.8","","27553.22","27553.22","27553.22","1 through 10","19926.65","45709.74","percent of total billed charges",""
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","outpatient","","","41969.00","31476.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","35057.32","","Case rate ($35,057.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","70430.16","70324.98","71727.28","1 through 10","19926.65","45709.74","other","ASC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","outpatient","","","41969.00","31476.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35057.32","","Case rate ($35,057.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","82069.19","81262.87","82069.19","1 through 10","19926.65","45709.74","other","ASC "
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","outpatient","","","41969.00","31476.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","19926.65","","Case rate ($19,926.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","88872.86","46229.83","88872.86","1 through 10","19926.65","45709.74","other","Multiple Surgery"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","outpatient","","","41969.00","31476.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","19926.65","","Case rate ($19,926.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","57787.29","57787.29","57787.29","1 through 10","19926.65","45709.74","other","Multiple Surgery"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","outpatient","","","41969.00","31476.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","34297.07","81.72","","32534.78","17895.35","32534.78","1 through 10","19926.65","45709.74","percent of total billed charges",""
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","outpatient","","","41969.00","31476.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34297.07","81.72","","17895.35","17895.35","17895.35","1 through 10","19926.65","45709.74","percent of total billed charges",""
"HC Intro Sheath Non-Guide Intracard Ep Laser Tier3","PX-27000213","CDM","C2629","HCPCS","0272","RC","","","","both","","","5650.00","4237.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2062.25","36.5","","8098.77","8098.77","8098.77","1 through 10","1751.5","4491.75","percent of total billed charges",""
"HC Intro/Sheath Guide Ic Ep Fc Peel-Away Tier1","PX-27000183","CDM","C1892","HCPCS","0272","RC","","","","both","","","198.21","148.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.35","36.5","","66.97","66.97","66.97","1 through 10","61.45","157.58","percent of total billed charges",""
"HC Intro/Sheath Guide Ic Ep Fc Peel-Away Tier1","PX-27000183","CDM","C1892","HCPCS","0272","RC","","","","both","","","198.21","148.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.91","38.3","","70.21","44.61","70.21","1 through 10","61.45","157.58","percent of total billed charges",""
"HC Intro/Sheath Guide Ic Ep Fc Peel-Away Tier1","PX-27000183","CDM","C1892","HCPCS","0272","RC","","","","both","","","198.21","148.66","WELLPOINT [1015]","HB AMC WELLPOINT","146.24","73.78","","84.95","84.95","84.95","1 through 10","61.45","157.58","percent of total billed charges",""
"HC Intro/Sheath Guide Ic Ep Fc Peel-Away Tier1","PX-27000183","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","198.21","148.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","161.98","81.72","","91.21","50.17","91.21","1 through 10","103.58","161.98","percent of total billed charges",""
"HC Intro/Sheath Guide Ic Ep Fc Peel-Away Tier1","PX-27000183","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","198.21","148.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","161.98","81.72","","50.17","50.17","50.17","1 through 10","103.58","161.98","percent of total billed charges",""
"HC Intro/Sheath Intrcard Ep Strble Non Peel Tier1","PX-27000081","CDM","C1766","HCPCS","0272","RC","","","","both","","","3169.57","2377.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2519.81","79.5","","3771.60","3771.60","3771.60","1 through 10","982.57","2519.81","percent of total billed charges",""
"HC Intro/Sheath Intrcard Ep Strble Non Peel Tier1","PX-27000081","CDM","C1766","HCPCS","0272","RC","","","","both","","","3169.57","2377.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2060.22","65","","2161.25","2161.25","2161.25","1 through 10","982.57","2519.81","percent of total billed charges",""
"HC Intro/Sheath Intrcard Ep Strble Non Peel Tier1","PX-27000081","CDM","C1766","HCPCS","0272","RC","","","","both","","","3169.57","2377.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1156.89","36.5","","1697.15","370.76","3720.69","1 through 10","982.57","2519.81","percent of total billed charges",""
"HC Intro/Sheath Intrcard Ep Strble Non Peel Tier1","PX-27000081","CDM","C1766","HCPCS","0272","RC","","","","both","","","3169.57","2377.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1213.95","38.3","","1779.05","1263.50","3458.00","16","982.57","2519.81","percent of total billed charges",""
"HC Intro/Sheath Intrcard Ep Strble Non Peel Tier1","PX-27000081","CDM","C1766","HCPCS","0272","RC","","","","both","","","3169.57","2377.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1359.75","42.9","","1512.88","1512.88","1512.88","1 through 10","982.57","2519.81","percent of total billed charges",""
"HC Intro/Sheath Intrcard Ep Strble Non Peel Tier1","PX-27000081","CDM","C1766","HCPCS","0272","RC","","","","both","","","3169.57","2377.18","WELLPOINT [1015]","HB AMC WELLPOINT","2338.51","73.78","","3387.48","2475.46","3387.48","1 through 10","982.57","2519.81","percent of total billed charges",""
"HC Intro/Sheath Intrcard Ep Strble Non Peel Tier1","PX-27000081","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","3169.57","2377.18","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1656.42","52.26","","2815.54","2815.54","2815.54","1 through 10","1656.42","2590.17","percent of total billed charges",""
"HC Intro/Sheath Intrcard Ep Strble Non Peel Tier1","PX-27000081","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","3169.57","2377.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2590.17","81.72","","3637.27","2000.64","3637.27","1 through 10","1656.42","2590.17","percent of total billed charges",""
"HC Intro/Sheath Intrcard Ep Strble Non Peel Tier1","PX-27000081","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","3169.57","2377.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2590.17","81.72","","2658.01","2000.64","3637.27","17","1656.42","2590.17","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","215.95","161.96","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","155.05","71.8","","86.33","32.67","86.33","1 through 10","66.94","171.68","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","215.95","161.96","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","151.17","70","","113.68","63.00","177.34","40","66.94","171.68","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","215.95","161.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","171.68","79.5","","50.70","21.76","168.00","12","66.94","171.68","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","215.95","161.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","115.10","53.3","","89.31","89.31","99.75","1 through 10","66.94","171.68","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","215.95","161.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","140.37","65","","94.41","17.06","2275.00","1 through 10","66.94","171.68","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","215.95","161.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","66.94","31","","35.13","35.13","35.13","1 through 10","66.94","171.68","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","215.95","161.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.82","36.5","","40.08","12.40","86.17","108","66.94","171.68","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","215.95","161.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82.71","38.3","","33.25","10.27","68.43","169","66.94","171.68","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","215.95","161.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.64","42.9","","25.48","14.86","90.88","1 through 10","66.94","171.68","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","215.95","161.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.64","42.9","","90.88","90.88","90.88","1 through 10","66.94","171.68","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","215.95","161.96","WELLPOINT [1015]","HB AMC WELLPOINT","159.33","73.78","","84.63","19.55","140.02","123","66.94","171.68","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","215.95","161.96","AETNA [1001]","HB AMC AETNA HMO","150.73","69.8","","76.96","17.77","113.68","14","112.86","176.47","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","215.95","161.96","AETNA [1001]","HB AMC AETNA PPO","173.62","80.4","","57.31","57.31","57.31","1 through 10","112.86","176.47","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","215.95","161.96","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","112.86","52.26","","16.24","16.24","54.15","1 through 10","112.86","176.47","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","215.95","161.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","173.62","80.4","","68.25","68.25","87.50","1 through 10","112.86","176.47","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","215.95","161.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","176.47","81.72","","156.19","156.19","156.19","1 through 10","112.86","176.47","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","215.95","161.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","176.47","81.72","","82.70","12.06","98.97","13","112.86","176.47","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","215.95","161.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","176.47","81.72","","50.47","25.30","134.30","140","112.86","176.47","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.47","228.35","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","218.61","71.8","","86.33","32.67","86.33","1 through 10","94.39","242.05","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.47","228.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","213.13","70","","113.68","63.00","177.34","40","94.39","242.05","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.47","228.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","242.05","79.5","","50.70","21.76","168.00","12","94.39","242.05","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.47","228.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","162.28","53.3","","89.31","89.31","99.75","1 through 10","94.39","242.05","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.47","228.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","197.91","65","","94.41","17.06","2275.00","1 through 10","94.39","242.05","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.47","228.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","94.39","31","","35.13","35.13","35.13","1 through 10","94.39","242.05","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.47","228.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","111.13","36.5","","40.08","12.40","86.17","108","94.39","242.05","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.47","228.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","116.61","38.3","","33.25","10.27","68.43","169","94.39","242.05","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.47","228.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.62","42.9","","25.48","14.86","90.88","1 through 10","94.39","242.05","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.47","228.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.62","42.9","","90.88","90.88","90.88","1 through 10","94.39","242.05","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.47","228.35","WELLPOINT [1015]","HB AMC WELLPOINT","224.64","73.78","","84.63","19.55","140.02","123","94.39","242.05","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.47","228.35","AETNA [1001]","HB AMC AETNA HMO","212.52","69.8","","76.96","17.77","113.68","14","159.12","248.81","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.47","228.35","AETNA [1001]","HB AMC AETNA PPO","244.79","80.4","","57.31","57.31","57.31","1 through 10","159.12","248.81","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.47","228.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","159.12","52.26","","16.24","16.24","54.15","1 through 10","159.12","248.81","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.47","228.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","244.79","80.4","","68.25","68.25","87.50","1 through 10","159.12","248.81","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.47","228.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","248.81","81.72","","156.19","156.19","156.19","1 through 10","159.12","248.81","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.47","228.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","248.81","81.72","","82.70","12.06","98.97","13","159.12","248.81","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.47","228.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","248.81","81.72","","50.47","25.30","134.30","140","159.12","248.81","percent of total billed charges",""
"HC Lead Icd Biventricular Tier1","PX-27000189","CDM","C1896","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2086.88","79.5","","7540.00","7540.00","7540.00","1 through 10","813.75","2086.88","percent of total billed charges",""
"HC Lead Icd Biventricular Tier1","PX-27000189","CDM","C1896","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1706.25","65","","6500.00","6500.00","6500.00","1 through 10","813.75","2086.88","percent of total billed charges",""
"HC Lead Icd Biventricular Tier1","PX-27000189","CDM","C1896","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","958.13","36.5","","11190.00","11190.00","11190.00","1 through 10","813.75","2086.88","percent of total billed charges",""
"HC Lead Icd Biventricular Tier1","PX-27000189","CDM","C1896","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","AETNA [1001]","HB AMC AETNA HMO","1832.25","69.8","","17800.00","17800.00","17800.00","1 through 10","1371.83","2145.15","percent of total billed charges",""
"HC Lead Icd Biventricular Tier3","PX-27000190","CDM","C1896","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4968.75","79.5","","7540.00","7540.00","7540.00","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HC Lead Icd Biventricular Tier3","PX-27000190","CDM","C1896","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4062.50","65","","6500.00","6500.00","6500.00","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HC Lead Icd Biventricular Tier3","PX-27000190","CDM","C1896","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.25","36.5","","11190.00","11190.00","11190.00","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HC Lead Icd Biventricular Tier3","PX-27000190","CDM","C1896","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","AETNA [1001]","HB AMC AETNA HMO","4362.50","69.8","","17800.00","17800.00","17800.00","1 through 10","3266.25","5107.5","percent of total billed charges",""
"HC Lead Icd Device Dual Coil Tier2","PX-27000187","CDM","C1895","HCPCS","0278","RC","","","","both","","","2021.25","1515.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1077.33","53.3","","3630.00","3630.00","3630.00","1 through 10","626.59","1606.89","percent of total billed charges",""
"HC Lead Icd Device Dual Coil Tier3","PX-27000188","CDM","C1895","HCPCS","0278","RC","","","","both","","","9070.75","6803.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4834.71","53.3","","3630.00","3630.00","3630.00","1 through 10","2811.93","7211.25","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","both","","","244.83","183.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","194.64","79.5","","192.68","192.68","192.68","1 through 10","75.9","232.59","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","both","","","244.83","183.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.49","53.3","","129.27","129.27","129.27","1 through 10","75.9","232.59","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","both","","","244.83","183.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","194.64","79.5","","192.68","192.68","192.68","1 through 10","75.9","232.59","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","both","","","244.83","183.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.36","36.5","","232.83","77.61","232.83","1 through 10","75.9","232.59","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","both","","","244.83","183.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.77","38.3","","95.73","93.04","186.08","14","75.9","232.59","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","both","","","244.83","183.62","TRICARE [160005]","HB BWH TRICARE","232.59","95","","91.65","91.65","91.65","1 through 10","75.9","232.59","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","both","","","244.83","183.62","WELLPOINT [1015]","HB AMC WELLPOINT","180.64","73.78","","182.28","182.28","182.28","1 through 10","75.9","232.59","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","outpatient","","","244.83","183.62","AETNA [1001]","HB AMC AETNA HMO","170.89","69.8","","165.75","165.75","165.75","1 through 10","122.42","201.98","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","outpatient","","","244.83","183.62","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","128.54","52.5","","154.00","141.02","154.00","1 through 10","122.42","201.98","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","outpatient","","","244.83","183.62","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","122.42","50","","128.29","123.15","128.29","1 through 10","122.42","201.98","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","outpatient","","","244.83","183.62","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","128.54","52.5","","253.89","134.66","259.04","1 through 10","122.42","201.98","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","outpatient","","","244.83","183.62","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","153.02","62.5","","160.36","160.36","160.36","1 through 10","122.42","201.98","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","outpatient","","","244.83","183.62","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","134.66","55","","141.02","141.02","141.02","1 through 10","122.42","201.98","percent of total billed charges",""
"HC Lo Sag Rigid Post Panel Prefab Cstm Fit Pt T1","PX-27000280","CDM","L0626","HCPCS","0274","RC","","","","outpatient","","","244.83","183.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","200.08","81.72","","195.72","195.72","195.72","1 through 10","122.42","201.98","percent of total billed charges",""
"HC Material Vocal Cord Medialization Syn Tier1","PX-27000161","CDM","C1878","HCPCS","0278","RC","","","","both","","","1137.50","853.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","904.31","79.5","","1991.51","1991.51","1991.51","1 through 10","352.63","904.31","percent of total billed charges",""
"HC Material Vocal Cord Medialization Syn Tier1","PX-27000161","CDM","C1878","HCPCS","0278","RC","","","","both","","","1137.50","853.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","415.19","36.5","","650.52","650.52","650.52","1 through 10","352.63","904.31","percent of total billed charges",""
"HC Mgh Drug Atenol Tenormin","PX-30001512","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Atenol Tenormin","PX-30001512","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Atenol Tenormin","PX-30001512","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Atenol Tenormin","PX-30001512","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Atenol Tenormin","PX-30001512","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Atenol Tenormin","PX-30001512","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Atenol Tenormin","PX-30001512","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Azathioprine","PX-30001501","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Azathioprine","PX-30001501","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Azathioprine","PX-30001501","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Azathioprine","PX-30001501","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Azathioprine","PX-30001501","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Azathioprine","PX-30001501","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Azathioprine","PX-30001501","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Baclofen","PX-30001511","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Baclofen","PX-30001511","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Baclofen","PX-30001511","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Baclofen","PX-30001511","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Baclofen","PX-30001511","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Baclofen","PX-30001511","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Baclofen","PX-30001511","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Buprenorphine","PX-30001499","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Buprenorphine","PX-30001499","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Buprenorphine","PX-30001499","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Buprenorphine","PX-30001499","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Buprenorphine","PX-30001499","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Buprenorphine","PX-30001499","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Buprenorphine","PX-30001499","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Buproprion Oh Bup","PX-30001502","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Buproprion Oh Bup","PX-30001502","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Buproprion Oh Bup","PX-30001502","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Buproprion Oh Bup","PX-30001502","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Buproprion Oh Bup","PX-30001502","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Buproprion Oh Bup","PX-30001502","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Buproprion Oh Bup","PX-30001502","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Diltiazem","PX-30001503","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Diltiazem","PX-30001503","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Diltiazem","PX-30001503","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Diltiazem","PX-30001503","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Diltiazem","PX-30001503","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Diltiazem","PX-30001503","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Diltiazem","PX-30001503","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Disopyramine","PX-30001518","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Disopyramine","PX-30001518","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Disopyramine","PX-30001518","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Disopyramine","PX-30001518","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Disopyramine","PX-30001518","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Disopyramine","PX-30001518","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Disopyramine","PX-30001518","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Efavirenz","PX-30001504","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Efavirenz","PX-30001504","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Efavirenz","PX-30001504","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Efavirenz","PX-30001504","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Efavirenz","PX-30001504","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Efavirenz","PX-30001504","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Efavirenz","PX-30001504","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Felbamate","PX-30001498","CDM","80299","CPT","0301","RC","","","","both","","","269.00","201.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","213.86","79.5","","106.25","71.28","106.25","1 through 10","14.12","255.55","percent of total billed charges",""
"HC Mgh Drug Felbamate","PX-30001498","CDM","80299","CPT","0301","RC","","","","both","","","269.00","201.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","143.38","53.3","","106.25","71.28","106.25","1 through 10","14.12","255.55","percent of total billed charges",""
"HC Mgh Drug Felbamate","PX-30001498","CDM","80299","CPT","0301","RC","","","","both","","","269.00","201.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","98.19","36.5","","50.36","42.80","92.50","13","14.12","255.55","percent of total billed charges",""
"HC Mgh Drug Felbamate","PX-30001498","CDM","80299","CPT","0301","RC","","","","both","","","269.00","201.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","103.03","38.3","","52.79","44.55","158.37","30","14.12","255.55","percent of total billed charges",""
"HC Mgh Drug Felbamate","PX-30001498","CDM","80299","CPT","0301","RC","","","","outpatient","","","269.00","201.75","AETNA [1001]","HB AMC AETNA HMO","187.76","69.8","","91.40","64.53","105.30","14","14.12","219.83","percent of total billed charges",""
"HC Mgh Drug Felbamate","PX-30001498","CDM","80299","CPT","0301","RC","","","","outpatient","","","269.00","201.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","216.28","80.4","","105.30","105.30","105.30","1 through 10","14.12","219.83","percent of total billed charges",""
"HC Mgh Drug Felbamate","PX-30001498","CDM","80299","CPT","0301","RC","","","","outpatient","","","269.00","201.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","219.83","81.72","","59.36","15.50","59.36","1 through 10","14.12","219.83","percent of total billed charges",""
"HC Mgh Drug Fre Sialic Acd","PX-30001515","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Fre Sialic Acd","PX-30001515","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Fre Sialic Acd","PX-30001515","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Fre Sialic Acd","PX-30001515","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Fre Sialic Acd","PX-30001515","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Fre Sialic Acd","PX-30001515","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Fre Sialic Acd","PX-30001515","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Gabapentin","PX-30001505","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Gabapentin","PX-30001505","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Gabapentin","PX-30001505","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Gabapentin","PX-30001505","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Gabapentin","PX-30001505","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Gabapentin","PX-30001505","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Gabapentin","PX-30001505","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Levetiracetam","PX-30001506","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Levetiracetam","PX-30001506","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Levetiracetam","PX-30001506","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Levetiracetam","PX-30001506","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Levetiracetam","PX-30001506","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Levetiracetam","PX-30001506","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Levetiracetam","PX-30001506","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Mertazapine Remrn","PX-30001507","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Mertazapine Remrn","PX-30001507","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Mertazapine Remrn","PX-30001507","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Mertazapine Remrn","PX-30001507","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Mertazapine Remrn","PX-30001507","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Mertazapine Remrn","PX-30001507","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Mertazapine Remrn","PX-30001507","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Mycophenolic Acid","PX-30001517","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Mycophenolic Acid","PX-30001517","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Mycophenolic Acid","PX-30001517","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Mycophenolic Acid","PX-30001517","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Mycophenolic Acid","PX-30001517","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Mycophenolic Acid","PX-30001517","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Mycophenolic Acid","PX-30001517","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Olanzapine Zyprex","PX-30001508","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Olanzapine Zyprex","PX-30001508","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Olanzapine Zyprex","PX-30001508","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Olanzapine Zyprex","PX-30001508","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Olanzapine Zyprex","PX-30001508","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Olanzapine Zyprex","PX-30001508","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Olanzapine Zyprex","PX-30001508","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Protriptyline","PX-30001509","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Protriptyline","PX-30001509","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Protriptyline","PX-30001509","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Protriptyline","PX-30001509","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Protriptyline","PX-30001509","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Protriptyline","PX-30001509","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Protriptyline","PX-30001509","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Psilocin","PX-30001500","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Psilocin","PX-30001500","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Psilocin","PX-30001500","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Psilocin","PX-30001500","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Psilocin","PX-30001500","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Psilocin","PX-30001500","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Psilocin","PX-30001500","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Risperidone","PX-30001510","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Risperidone","PX-30001510","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Risperidone","PX-30001510","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Risperidone","PX-30001510","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Risperidone","PX-30001510","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Risperidone","PX-30001510","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Risperidone","PX-30001510","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Sulfametoxazole","PX-30001516","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Sulfametoxazole","PX-30001516","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Sulfametoxazole","PX-30001516","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Sulfametoxazole","PX-30001516","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Sulfametoxazole","PX-30001516","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Sulfametoxazole","PX-30001516","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Sulfametoxazole","PX-30001516","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Tiagabine","PX-30001513","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Tiagabine","PX-30001513","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Tiagabine","PX-30001513","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Tiagabine","PX-30001513","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Tiagabine","PX-30001513","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Tiagabine","PX-30001513","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Tiagabine","PX-30001513","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Warfarin","PX-30001514","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Warfarin","PX-30001514","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Warfarin","PX-30001514","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Warfarin","PX-30001514","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Drug Warfarin","PX-30001514","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Warfarin","PX-30001514","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Drug Warfarin","PX-30001514","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Furosemide Inj Up to 1 Mg","PX-63600140","CDM","J1938","HCPCS","0636","RC","","","","both","","","0.16","0.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.13","79.5","","0.09","0.04","0.50","30","0.05","0.13","percent of total billed charges",""
"HC Mgh Furosemide Inj Up to 1 Mg","PX-63600140","CDM","J1938","HCPCS","0636","RC","","","","both","","","0.16","0.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.09","53.3","","0.06","0.06","0.06","20","0.05","0.13","percent of total billed charges",""
"HC Mgh Furosemide Inj Up to 1 Mg","PX-63600140","CDM","J1938","HCPCS","0636","RC","","","","both","","","0.16","0.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.06","38.3","","0.03","0.02","0.08","320","0.05","0.13","percent of total billed charges",""
"HC Mgh Furosemide Inj Up to 1 Mg","PX-63600140","CDM","J1938","HCPCS","0636","RC","","","","both","","","0.16","0.12","WELLPOINT [1015]","HB AMC WELLPOINT","0.12","73.78","","0.05","0.05","0.05","40","0.05","0.13","percent of total billed charges",""
"HC Mgh Furosemide Inj Up to 1 Mg","PX-63600140","CDM","J1938","HCPCS","0636","RC","","","","outpatient","","","0.16","0.12","AETNA [1001]","HB AMC AETNA HMO","0.11","69.8","","0.03","0.03","0.14","140","0.04","0.13","percent of total billed charges",""
"HC Mgh Furosemide Inj Up to 1 Mg","PX-63600140","CDM","J1938","HCPCS","0636","RC","","","","outpatient","","","0.16","0.12","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.08","50","","0.12","0.12","0.12","41","0.04","0.13","percent of total billed charges",""
"HC Mgh Furosemide Inj Up to 1 Mg","PX-63600140","CDM","J1938","HCPCS","0636","RC","","","","outpatient","","","0.16","0.12","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.08","52.5","","0.02","0.02","0.02","80","0.04","0.13","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002072","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002073","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002104","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"HC Mgh Ia Anal Quan","PX-30002105","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"HC Mgh Inj Eculizumab 2mg","PX-63601112","CDM","J1299","HCPCS","0636","RC","","","","both","","","165.33","124.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.92","","APC Price ($44.82). Final payment is multiplied by 98%.","43.88","43.88","43.96","4350","42.53","131.44","other","OPPS APC"
"HC Mgh Protozoa","PX-30001884","CDM","86753","CPT","0300","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","108.58","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"HC Mgh Protozoa","PX-30001884","CDM","86753","CPT","0300","RC","","","","both","","","153.00","114.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.55","53.3","","78.14","78.14","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"HC Mgh Protozoa","PX-30001884","CDM","86753","CPT","0300","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.85","36.5","","165.60","55.20","165.60","1 through 10","9.6","145.35","percent of total billed charges",""
"HC Mgh Protozoa","PX-30001884","CDM","86753","CPT","0300","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","57.87","57.87","57.87","14","9.6","145.35","percent of total billed charges",""
"HC Mgh Protozoa","PX-30001884","CDM","86753","CPT","0300","RC","","","","both","","","153.00","114.75","TRICARE [160005]","HB BWH TRICARE","145.35","95","","14.93","14.18","14.93","1 through 10","9.6","145.35","percent of total billed charges",""
"HC Mgh Protozoa","PX-30001884","CDM","86753","CPT","0300","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","141.48","70.74","200.40","1 through 10","9.6","125.03","percent of total billed charges",""
"HC Mgh Protozoa","PX-30001884","CDM","86753","CPT","0300","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","118.31","65.08","118.31","13","9.6","125.03","percent of total billed charges",""
"HC Mgh Quan Drug","PX-30001558","CDM","80299","CPT","0301","RC","","","","both","","","242.00","181.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","192.39","79.5","","106.25","71.28","106.25","1 through 10","14.12","229.9","percent of total billed charges",""
"HC Mgh Quan Drug","PX-30001558","CDM","80299","CPT","0301","RC","","","","both","","","242.00","181.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","128.99","53.3","","106.25","71.28","106.25","1 through 10","14.12","229.9","percent of total billed charges",""
"HC Mgh Quan Drug","PX-30001558","CDM","80299","CPT","0301","RC","","","","both","","","242.00","181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","88.33","36.5","","50.36","42.80","92.50","13","14.12","229.9","percent of total billed charges",""
"HC Mgh Quan Drug","PX-30001558","CDM","80299","CPT","0301","RC","","","","both","","","242.00","181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","92.69","38.3","","52.79","44.55","158.37","30","14.12","229.9","percent of total billed charges",""
"HC Mgh Quan Drug","PX-30001558","CDM","80299","CPT","0301","RC","","","","outpatient","","","242.00","181.50","AETNA [1001]","HB AMC AETNA HMO","168.92","69.8","","91.40","64.53","105.30","14","14.12","197.76","percent of total billed charges",""
"HC Mgh Quan Drug","PX-30001558","CDM","80299","CPT","0301","RC","","","","outpatient","","","242.00","181.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","194.57","80.4","","105.30","105.30","105.30","1 through 10","14.12","197.76","percent of total billed charges",""
"HC Mgh Quan Drug","PX-30001558","CDM","80299","CPT","0301","RC","","","","outpatient","","","242.00","181.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","197.76","81.72","","59.36","15.50","59.36","1 through 10","14.12","197.76","percent of total billed charges",""
"HC Mgh Quantitation of Drug 80299","PX-30001574","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Quantitation of Drug 80299","PX-30001574","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"HC Mgh Quantitation of Drug 80299","PX-30001574","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"HC Mgh Quantitation of Drug 80299","PX-30001574","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"HC Mgh Quantitation of Drug 80299","PX-30001574","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"HC Mgh Quantitation of Drug 80299","PX-30001574","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Quantitation of Drug 80299","PX-30001574","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"HC Mgh Xomedxslice (Phenotype-Drvn Gene Lst Using Wes Capture)","PX-31000590","CDM","81479","CPT","0310","RC","","","","both","","","5419.00","4064.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4308.11","79.5","","0.65","0.65","0.65","1 through 10","1679.89","5148.05","percent of total billed charges",""
"HC Mgh Xomedxslice (Phenotype-Drvn Gene Lst Using Wes Capture)","PX-31000590","CDM","81479","CPT","0310","RC","","","","both","","","5419.00","4064.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2888.33","53.3","","0.79","0.79","0.79","1 through 10","1679.89","5148.05","percent of total billed charges",""
"HC Mgh Xomedxslice (Phenotype-Drvn Gene Lst Using Wes Capture)","PX-31000590","CDM","81479","CPT","0310","RC","","","","outpatient","","","5419.00","4064.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2709.50","50","","1.00","1.00","1.00","1 through 10","156.55","4470.68","percent of total billed charges",""
"HC Mgh Xomedxslice (Phenotype-Drvn Gene Lst Using Wes Capture)","PX-31000590","CDM","81479","CPT","0310","RC","","","","outpatient","","","5419.00","4064.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2844.98","52.5","","1.00","0.53","1.00","1 through 10","156.55","4470.68","percent of total billed charges",""
"HC Microprocessor Used With Ventr Assist Dev Tier1","PX-27000570","CDM","Q0481","HCPCS","0274","RC","","","","both","","","11250.00","8437.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7312.50","65","","21937.50","21937.50","21937.50","1 through 10","3487.5","21401.69","percent of total billed charges",""
"HC N-Methylhistamine, 24 Hour, Urine","PX-30003652","CDM","82542","CPT","0300","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"HC N-Methylhistamine, 24 Hour, Urine","PX-30003652","CDM","82542","CPT","0300","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"HC N-Methylhistamine, 24 Hour, Urine","PX-30003652","CDM","82542","CPT","0300","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"HC N-Methylhistamine, 24 Hour, Urine","PX-30003652","CDM","82542","CPT","0300","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"HC N-Methylhistamine, 24 Hour, Urine","PX-30003652","CDM","82542","CPT","0300","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"HC N-Methylhistamine, 24 Hour, Urine","PX-30003652","CDM","82542","CPT","0300","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"HC N-Methylhistamine, 24 Hour, Urine","PX-30003652","CDM","82542","CPT","0300","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"HC N-Methylhistamine, 24 Hour, Urine","PX-30003652","CDM","82542","CPT","0300","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"HC N-Methylhistamine, 24 Hour, Urine","PX-30003652","CDM","82542","CPT","0300","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)","PX-76001531","CDM","64490","CPT","0761","RC","","","","both","","","2239.00","1679.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1780.01","79.5","","3629.64","3629.64","3629.64","1 through 10","694.09","1780.01","percent of total billed charges",""
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)","PX-76001531","CDM","64490","CPT","0761","RC","","","","both","","","2239.00","1679.25","FALLON HEALTH [1008]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1036.12","1036.12","1036.12","1 through 10","694.09","1780.01","other","OPPS APC"
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)","PX-76001531","CDM","64490","CPT","0761","RC","","","","both","","","2239.00","1679.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","857.54","38.3","","3180.00","3180.00","3180.00","1 through 10","694.09","1780.01","percent of total billed charges",""
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)","PX-76001531","CDM","64490","CPT","0761","RC","","","","both","","","2239.00","1679.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1040.35","978.90","1554.20","1 through 10","694.09","1780.01","other","OPPS APC"
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)","PX-76001531","CDM","64490","CPT","0761","RC","","","","outpatient","","","2239.00","1679.25","AETNA [1001]","HB AMC AETNA HMO","1562.82","69.8","","1102.27","1102.27","1102.27","1 through 10","764.84","4218.09","percent of total billed charges",""
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)|BILATERAL PROCEDURE","PX-76001531","CDM","64490","CPT","0761","RC","","","50","both","","","2239.00","1679.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1560.54","1560.54","1560.54","1 through 10","1004.41","1321.46","other","OPPS APC"
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)|BILATERAL PROCEDURE","PX-76001531","CDM","64490","CPT","0761","RC","","","50","both","","","2239.00","1679.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1588.37","1588.37","1588.37","1 through 10","1004.41","1321.46","other","OPPS APC"
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)|BILATERAL PROCEDURE","PX-76001531","CDM","64490","CPT","0761","RC","","","50","both","","","2239.00","1679.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1559.59","1559.59","1559.59","1 through 10","1004.41","1321.46","other","OPPS APC"
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)|BILATERAL PROCEDURE","PX-76001531","CDM","64490","CPT","0761","RC","","","50","outpatient","","","2239.00","1679.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2635.73","2635.73","2635.73","1 through 10","1311.96","6327.14","other","ASC"
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)|BILATERAL PROCEDURE","PX-76001531","CDM","64490","CPT","0761","RC","","","50","outpatient","","","2239.00","1679.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3071.30","3041.12","3071.30","1 through 10","1311.96","6327.14","other","ASC "
"HC Open/Perq Placement Intravascular Stent Initial","PX-76001940","CDM","37236","CPT","0761","RC","","","","both","","","21352.00","16014.00","MEDICARE [2001]","HB BWH MEDICARE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13467.61","13467.61","13467.61","1 through 10","6619.12","16974.84","other","OPPS APC"
"HC Open/Perq Placement Intravascular Stent Initial","PX-76001940","CDM","37236","CPT","0761","RC","","","","both","","","21352.00","16014.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7793.48","36.5","","7723.34","7723.34","7723.34","1 through 10","6619.12","16974.84","percent of total billed charges",""
"HC Open/Perq Placement Intravascular Stent Initial","PX-76001940","CDM","37236","CPT","0761","RC","","","","outpatient","","","21352.00","16014.00","AETNA [1001]","HB AMC AETNA HMO","14903.70","69.8","","14017.96","14017.96","14017.96","1 through 10","5545.35","17448.85","percent of total billed charges",""
"HC Opiate, Drug and Metab, Ea Proc (Opioids and Opiate Analogs 1, 2)","PX-30002879","CDM","80362","CPT","0301","RC","","","","both","","","20.00","15.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","14.36","71.8","","313.00","313.00","313.00","1 through 10","6.2","143.04","percent of total billed charges",""
"HC Opiate, Drug and Metab, Ea Proc (Opioids and Opiate Analogs 1, 2)","PX-30002879","CDM","80362","CPT","0301","RC","","","","both","","","20.00","15.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","14.00","70","","137.63","137.63","137.63","1 through 10","6.2","143.04","percent of total billed charges",""
"HC Opiate, Drug and Metab, Ea Proc (Opioids and Opiate Analogs 1, 2)","PX-30002879","CDM","80362","CPT","0301","RC","","","","both","","","20.00","15.00","WELLPOINT [1015]","HB AMC WELLPOINT","14.76","73.78","","233.03","233.03","233.03","1 through 10","6.2","143.04","percent of total billed charges",""
"HC Opiate, Drug and Metab, Each Procedure (Opiates 1+)","PX-30002981","CDM","80361","CPT","0301","RC","","","","both","","","24.00","18.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","17.23","71.8","","271.00","271.00","271.00","1 through 10","7.44","143.04","percent of total billed charges",""
"HC Opiate, Drug and Metab, Each Procedure (Opiates 1+)","PX-30002981","CDM","80361","CPT","0301","RC","","","","both","","","24.00","18.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","16.80","70","","119.16","119.16","119.16","1 through 10","7.44","143.04","percent of total billed charges",""
"HC Pan Cardiomyopathy Panel 51 Genes","PX-31000519","CDM","81479","CPT","0310","RC","","","","both","","","5020.00","3765.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3990.90","79.5","","0.65","0.65","0.65","1 through 10","1556.2","4769","percent of total billed charges",""
"HC Pan Cardiomyopathy Panel 51 Genes","PX-31000519","CDM","81479","CPT","0310","RC","","","","both","","","5020.00","3765.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2675.66","53.3","","0.79","0.79","0.79","1 through 10","1556.2","4769","percent of total billed charges",""
"HC Pan Cardiomyopathy Panel 51 Genes","PX-31000519","CDM","81479","CPT","0310","RC","","","","outpatient","","","5020.00","3765.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2510.00","50","","1.00","1.00","1.00","1 through 10","156.55","4141.5","percent of total billed charges",""
"HC Pan Cardiomyopathy Panel 51 Genes","PX-31000519","CDM","81479","CPT","0310","RC","","","","outpatient","","","5020.00","3765.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2635.50","52.5","","1.00","0.53","1.00","1 through 10","156.55","4141.5","percent of total billed charges",""
"HC Pg Tubular Acidosis Panel","PX-31001154","CDM","81479","CPT","0310","RC","","","","both","","","2119.00","1589.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1684.61","79.5","","0.65","0.65","0.65","1 through 10","656.89","2013.05","percent of total billed charges",""
"HC Pg Tubular Acidosis Panel","PX-31001154","CDM","81479","CPT","0310","RC","","","","both","","","2119.00","1589.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1129.43","53.3","","0.79","0.79","0.79","1 through 10","656.89","2013.05","percent of total billed charges",""
"HC Pg Tubular Acidosis Panel","PX-31001154","CDM","81479","CPT","0310","RC","","","","outpatient","","","2119.00","1589.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1059.50","50","","1.00","1.00","1.00","1 through 10","156.55","1748.18","percent of total billed charges",""
"HC Pg Tubular Acidosis Panel","PX-31001154","CDM","81479","CPT","0310","RC","","","","outpatient","","","2119.00","1589.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1112.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","1748.18","percent of total billed charges",""
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","2196.00","1647.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.50","40.50","40.50","1 through 10","42.07","1745.82","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","2196.00","1647.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","55.35","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","44.28","44.28","44.28","1 through 10","42.07","1745.82","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","2196.00","1647.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1745.82","79.5","","1384.50","513.12","1676.31","1 through 10","42.07","1745.82","percent of total billed charges",""
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","2196.00","1647.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1170.47","53.3","","5028.93","1124.64","5028.93","1 through 10","42.07","1745.82","percent of total billed charges",""
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","2196.00","1647.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1690.92","77","","1640.10","1640.10","1640.10","1 through 10","42.07","1745.82","percent of total billed charges",""
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","2196.00","1647.00","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","88.56","47","42.07","1745.82","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","2196.00","1647.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","801.54","36.5","","2025.63","675.21","2383.47","1 through 10","42.07","1745.82","percent of total billed charges",""
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","2196.00","1647.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","841.07","38.3","","2498.49","809.40","2498.49","1 through 10","42.07","1745.82","percent of total billed charges",""
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","2196.00","1647.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.79","43.79","43.79","1 through 10","42.07","1745.82","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","2196.00","1647.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.79","40.74","43.79","1 through 10","42.07","1745.82","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","2196.00","1647.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.90","41.16","43.90","1 through 10","42.07","1745.82","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","outpatient","","","2196.00","1647.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1794.57","81.72","","1702.72","1702.72","1702.72","1 through 10","85.36","1794.57","percent of total billed charges",""
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","outpatient","","","2196.00","1647.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1794.57","81.72","","1702.72","936.56","1702.72","1 through 10","85.36","1794.57","percent of total billed charges",""
"HC Probe/Needle Cryoablation Tier1","PX-27000201","CDM","C2618","HCPCS","0272","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1675.63","38.3","","1876.80","640.73","1876.80","1 through 10","1356.25","3478.13","percent of total billed charges",""
"HC Probe/Needle Cryoablation Tier1","PX-27000201","CDM","C2618","HCPCS","0272","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB AMC WELLPOINT","3227.88","73.78","","2802.54","1220.01","4020.30","1 through 10","1356.25","3478.13","percent of total billed charges",""
"HC Probe/Needle Cryoablation Tier1","PX-27000201","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","4375.00","3281.25","AETNA [1001]","HB AMC AETNA HMO","3053.75","69.8","","2175.20","2175.20","2175.20","1 through 10","2286.38","3575.25","percent of total billed charges",""
"HC Probe/Needle Cryoablation Tier1","PX-27000201","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3575.25","81.72","","4750.00","720.54","7250.00","11","2286.38","3575.25","percent of total billed charges",""
"HC Probe/Needle Cryoablation Tier3","PX-27000202","CDM","C2618","HCPCS","0272","RC","","","","both","","","2608.00","1956.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","998.86","38.3","","1876.80","640.73","1876.80","1 through 10","808.48","2073.36","percent of total billed charges",""
"HC Probe/Needle Cryoablation Tier3","PX-27000202","CDM","C2618","HCPCS","0272","RC","","","","both","","","2608.00","1956.00","WELLPOINT [1015]","HB AMC WELLPOINT","1924.18","73.78","","2802.54","1220.01","4020.30","1 through 10","808.48","2073.36","percent of total billed charges",""
"HC Probe/Needle Cryoablation Tier3","PX-27000202","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","2608.00","1956.00","AETNA [1001]","HB AMC AETNA HMO","1820.38","69.8","","2175.20","2175.20","2175.20","1 through 10","1362.94","2131.26","percent of total billed charges",""
"HC Probe/Needle Cryoablation Tier3","PX-27000202","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","2608.00","1956.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2131.26","81.72","","4750.00","720.54","7250.00","11","1362.94","2131.26","percent of total billed charges",""
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","both","","","209.00","156.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","196.34","196.34","197.14","1 through 10","64.79","198.55","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","both","","","209.00","156.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","171.23","187.76","12","64.79","198.55","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","both","","","209.00","156.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","149.48","149.48","187.76","1 through 10","64.79","198.55","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","both","","","209.00","156.75","HUMANA [1012]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","188.52","188.52","188.52","1 through 10","64.79","198.55","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","both","","","209.00","156.75","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","572.43","76","64.79","198.55","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","both","","","209.00","156.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","563.28","563.28","563.28","1 through 10","64.79","198.55","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","outpatient","","","209.00","156.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","104.50","50","","106.37","106.37","106.37","1 through 10","104.36","179.52","percent of total billed charges",""
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","outpatient","","","209.00","156.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","109.73","52.5","","111.65","90.54","111.65","12","104.36","179.52","percent of total billed charges",""
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","outpatient","","","209.00","156.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","170.79","81.72","","176.61","176.61","203.00","1 through 10","104.36","179.52","percent of total billed charges",""
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","316.00","237.00","AETNA [1001]","HB AMC AETNA HMO","220.57","69.8","","207.16","207.16","214.20","23","97.96","300.2","percent of total billed charges",""
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","316.00","237.00","AETNA [1001]","HB AMC AETNA PPO","254.06","80.4","","214.20","214.20","214.20","1 through 10","97.96","300.2","percent of total billed charges",""
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","316.00","237.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","196.34","196.34","197.14","30","97.96","300.2","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","316.00","237.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","187.76","187.76","1 through 10","97.96","300.2","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","316.00","237.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","158.10","187.76","13","97.96","300.2","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","316.00","237.00","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","190.81","246","97.96","300.2","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","316.00","237.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","81.63","81.63","81.63","1 through 10","97.96","300.2","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","316.00","237.00","MOLINA [1014]","HB BWH MOLINA","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","342.86","342.86","342.86","1 through 10","97.96","300.2","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","316.00","237.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.76","187.76","563.28","1 through 10","97.96","300.2","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","outpatient","","","316.00","237.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","158.00","50","","160.34","153.92","160.34","106","156.22","260.7","percent of total billed charges",""
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","outpatient","","","316.00","237.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","165.90","52.5","","168.30","136.48","168.30","44","156.22","260.7","percent of total billed charges",""
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","outpatient","","","316.00","237.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","197.50","62.5","","194.58","194.58","194.58","1 through 10","156.22","260.7","percent of total billed charges",""
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","outpatient","","","316.00","237.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","173.80","55","","194.58","186.20","194.58","16","156.22","260.7","percent of total billed charges",""
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","472.00","354.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","196.34","179.56","197.14","25","146.32","448.4","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","472.00","354.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","187.76","187.76","18","146.32","448.4","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","472.00","354.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","158.10","148.87","187.76","1 through 10","146.32","448.4","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","472.00","354.00","HUMANA [1012]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.99","186.99","186.99","1 through 10","146.32","448.4","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","472.00","354.00","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","190.81","340","146.32","448.4","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","472.00","354.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","120.78","120.78","120.78","1 through 10","146.32","448.4","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","outpatient","","","472.00","354.00","AETNA [1001]","HB AMC AETNA HMO","329.46","69.8","","320.60","320.60","320.60","1 through 10","156.22","389.4","percent of total billed charges",""
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","outpatient","","","472.00","354.00","AETNA [1001]","HB AMC AETNA PPO","379.49","80.4","","320.60","320.60","320.60","1 through 10","156.22","389.4","percent of total billed charges",""
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","outpatient","","","472.00","354.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","236.00","50","","239.99","239.99","239.99","26","156.22","389.4","percent of total billed charges",""
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","outpatient","","","472.00","354.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.80","52.5","","204.27","204.27","251.90","43","156.22","389.4","percent of total billed charges",""
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","outpatient","","","472.00","354.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","259.60","55","","397.73","397.73","397.73","1 through 10","156.22","389.4","percent of total billed charges",""
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","outpatient","","","472.00","354.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","385.72","81.72","","398.46","398.46","398.46","1 through 10","156.22","389.4","percent of total billed charges",""
"HC Removal Implantable Defib Pulse Generator Only","PX-48000071","CDM","33241","CPT","0361","RC","","","","outpatient","","","8651.00","6488.25","AETNA [1001]","HB AMC AETNA HMO","6038.40","69.8","","9537.53","9537.53","9537.53","1 through 10","3130.53","7069.6","percent of total billed charges",""
"HC Removal Implantable Defib Pulse Generator Only","PX-48000071","CDM","33241","CPT","0361","RC","","","","outpatient","","","8651.00","6488.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3579.94","","Case rate ($3,579.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3662.28","3596.05","7192.10","1 through 10","3130.53","7069.6","other","ASC"
"HC Removal Implantable Defib Pulse Generator Only","PX-48000071","CDM","33241","CPT","0361","RC","","","","outpatient","","","8651.00","6488.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3579.94","","Case rate ($3,579.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4190.32","3662.28","4190.32","1 through 10","3130.53","7069.6","other","ASC "
"HC Removal Implantable Defib Pulse Generator Only","PX-48000071","CDM","33241","CPT","0361","RC","","","","outpatient","","","8651.00","6488.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3130.53","","Case rate ($3,130.53). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6981.08","3631.42","6981.08","1 through 10","3130.53","7069.6","other","Multiple Surgery"
"HC Rmvl Impltbl Dfb Pls Gen W/Rplcmt Pls Gen Mlt Ld","PX-48000077","CDM","33264","CPT","0361","RC","","","","both","","","27751.00","20813.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","22062.05","79.5","","32802.17","32802.17","32802.17","1 through 10","8602.81","47589","percent of total billed charges",""
"HC Rmvl Impltbl Dfb Pls Gen W/Rplcmt Pls Gen Mlt Ld","PX-48000077","CDM","33264","CPT","0361","RC","","","","both","","","27751.00","20813.25","MEDICARE [2001]","HB BWH MEDICARE","38071.20","","APC Price ($38,071.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38075.05","38075.05","114225.15","24","8602.81","47589","other","OPPS APC"
"HC Rmvl Impltbl Dfb Pls Gen W/Rplcmt Pls Gen Mlt Ld","PX-48000077","CDM","33264","CPT","0361","RC","","","","both","","","27751.00","20813.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10628.63","38.3","","10522.20","10522.20","10522.20","1 through 10","8602.81","47589","percent of total billed charges",""
"HC Rmvl Impltbl Dfb Pls Gen W/Rplcmt Pls Gen Mlt Ld","PX-48000077","CDM","33264","CPT","0361","RC","","","","both","","","27751.00","20813.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","37309.78","","APC Price ($38,071.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","38075.05","35196.59","38075.05","1 through 10","8602.81","47589","other","OPPS APC"
"HC Rmvl Impltbl Dfb Pls Gen W/Rplcmt Pls Gen Mlt Ld","PX-48000077","CDM","33264","CPT","0361","RC","","","","outpatient","","","27751.00","20813.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","35057.32","","Case rate ($35,057.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","71727.28","70430.16","71727.28","1 through 10","14502.67","45709.74","other","ASC"
"HC Rmvl Impltbl Dfb Pls Gen W/Rplcmt Pls Gen Mlt Ld","PX-48000077","CDM","33264","CPT","0361","RC","","","","outpatient","","","27751.00","20813.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35057.32","","Case rate ($35,057.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","82069.19","81262.87","82069.19","1 through 10","14502.67","45709.74","other","ASC "
"HC Rmvl Impltbl Dfb Pls Gen W/Rplcmt Pls Gen Mlt Ld","PX-48000077","CDM","33264","CPT","0361","RC","","","","outpatient","","","27751.00","20813.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","19926.65","","Case rate ($19,926.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","48621.03","48621.03","48621.03","1 through 10","14502.67","45709.74","other","Multiple Surgery"
"HC Rmvl1/Dual Chmbr Impltbl Dfb Eltrd Transvns Xtrj","PX-48000073","CDM","33244","CPT","0361","RC","","","","both","","","21591.00","16193.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4235.02","","APC Price ($4,321.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4235.45","4235.45","4235.45","1 through 10","4105.79","17164.85","other","OPPS APC"
"HC Rmvl1/Dual Chmbr Impltbl Dfb Eltrd Transvns Xtrj","PX-48000073","CDM","33244","CPT","0361","RC","","","","outpatient","","","21591.00","16193.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3579.94","","Case rate ($3,579.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3662.28","3596.05","7192.10","1 through 10","3130.53","17644.17","other","ASC"
"HC Rmvl1/Dual Chmbr Impltbl Dfb Eltrd Transvns Xtrj","PX-48000073","CDM","33244","CPT","0361","RC","","","","outpatient","","","21591.00","16193.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3579.94","","Case rate ($3,579.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4149.15","3662.28","8380.64","1 through 10","3130.53","17644.17","other","ASC "
"HC Rmvl1/Dual Chmbr Impltbl Dfb Eltrd Transvns Xtrj","PX-48000073","CDM","33244","CPT","0361","RC","","","","outpatient","","","21591.00","16193.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3130.53","","Case rate ($3,130.53). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3631.42","3631.42","3631.42","1 through 10","3130.53","17644.17","other","Multiple Surgery"
"HC Sacroiliac Ortho Pelvic-Sacral Sup Prefab Tier1","PX-27000276","CDM","L0621","HCPCS","0274","RC","","","","both","","","160.76","120.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.57","38.3","","62.86","62.86","62.86","1 through 10","49.84","152.72","percent of total billed charges",""
"HC Sacroiliac Ortho Pelvic-Sacral Sup Prefab Tier1","PX-27000276","CDM","L0621","HCPCS","0274","RC","","","","outpatient","","","160.76","120.57","AETNA [1001]","HB AMC AETNA HMO","112.21","69.8","","76.84","76.84","76.84","1 through 10","80.38","252.72","percent of total billed charges",""
"HC Sacroiliac Ortho Pelvic-Sacral Sup Prefab Tier1","PX-27000276","CDM","L0621","HCPCS","0274","RC","","","","outpatient","","","160.76","120.57","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","80.38","50","","84.24","80.86","84.24","1 through 10","80.38","252.72","percent of total billed charges",""
"HC Sculptra per 0.5 Mg","PX-63601332","CDM","Q2028","HCPCS","0636","RC","","","","both","","","1.86","1.39","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1.00","","APC Price ($1).","1.38","1.38","1.38","735","0.58","1.77","other","OPPS APC"
"HC Sculptra per 0.5 Mg","PX-63601332","CDM","Q2028","HCPCS","0636","RC","","","","both","","","1.86","1.39","MEDICARE [2001]","HB BWH MEDICARE","1.00","","APC Price ($1).","1.40","1.40","1.40","2205","0.58","1.77","other","OPPS APC"
"HC Sculptra per 0.5 Mg","PX-63601332","CDM","Q2028","HCPCS","0636","RC","","","","both","","","1.86","1.39","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","0.98","","APC Price ($1). Final payment is multiplied by 98%.","0.98","0.98","0.98","1996","0.58","1.77","other","OPPS APC"
"HC Shoulder Ortho Shoulder Brace Prefab Tier1","PX-27000474","CDM","L3670","HCPCS","0274","RC","","","","both","","","171.99","128.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","62.78","36.5","","54.89","54.89","54.89","1 through 10","53.32","163.39","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier2","PX-27000151","CDM","C1874","HCPCS","0278","RC","","","","both","","","4718.64","3538.98","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3067.12","65","","6652.80","6652.80","6652.80","1 through 10","1462.78","3751.32","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier2","PX-27000151","CDM","C1874","HCPCS","0278","RC","","","","both","","","4718.64","3538.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3751.32","79.5","","2612.61","795.38","2612.61","1 through 10","1462.78","3751.32","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier2","PX-27000151","CDM","C1874","HCPCS","0278","RC","","","","both","","","4718.64","3538.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2515.04","53.3","","1101.80","1101.80","1101.80","1 through 10","1462.78","3751.32","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier2","PX-27000151","CDM","C1874","HCPCS","0278","RC","","","","both","","","4718.64","3538.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3067.12","65","","1820.00","910.00","1820.00","1 through 10","1462.78","3751.32","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier2","PX-27000151","CDM","C1874","HCPCS","0278","RC","","","","both","","","4718.64","3538.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1722.30","36.5","","1257.80","693.44","2424.50","1 through 10","1462.78","3751.32","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier2","PX-27000151","CDM","C1874","HCPCS","0278","RC","","","","both","","","4718.64","3538.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1807.24","38.3","","1950.11","547.40","2346.00","1 through 10","1462.78","3751.32","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier2","PX-27000151","CDM","C1874","HCPCS","0278","RC","","","","both","","","4718.64","3538.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2024.30","42.9","","5096.18","5096.18","5096.18","1 through 10","1462.78","3751.32","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier2","PX-27000151","CDM","C1874","HCPCS","0278","RC","","","","both","","","4718.64","3538.98","WELLPOINT [1015]","HB AMC WELLPOINT","3481.41","73.78","","1172.59","1172.59","4829.94","1 through 10","1462.78","3751.32","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier2","PX-27000151","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4718.64","3538.98","AETNA [1001]","HB AMC AETNA HMO","3293.61","69.8","","1806.84","947.80","5091.72","1 through 10","2465.96","3856.07","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier2","PX-27000151","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4718.64","3538.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3856.07","81.72","","1259.05","615.58","4586.56","1 through 10","2465.96","3856.07","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier3","PX-27000152","CDM","C1874","HCPCS","0278","RC","","","","both","","","7769.93","5827.45","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5050.45","65","","6652.80","6652.80","6652.80","1 through 10","2408.68","6177.09","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier3","PX-27000152","CDM","C1874","HCPCS","0278","RC","","","","both","","","7769.93","5827.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6177.09","79.5","","2612.61","795.38","2612.61","1 through 10","2408.68","6177.09","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier3","PX-27000152","CDM","C1874","HCPCS","0278","RC","","","","both","","","7769.93","5827.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4141.37","53.3","","1101.80","1101.80","1101.80","1 through 10","2408.68","6177.09","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier3","PX-27000152","CDM","C1874","HCPCS","0278","RC","","","","both","","","7769.93","5827.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5050.45","65","","1820.00","910.00","1820.00","1 through 10","2408.68","6177.09","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier3","PX-27000152","CDM","C1874","HCPCS","0278","RC","","","","both","","","7769.93","5827.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2836.02","36.5","","1257.80","693.44","2424.50","1 through 10","2408.68","6177.09","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier3","PX-27000152","CDM","C1874","HCPCS","0278","RC","","","","both","","","7769.93","5827.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2975.88","38.3","","1950.11","547.40","2346.00","1 through 10","2408.68","6177.09","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier3","PX-27000152","CDM","C1874","HCPCS","0278","RC","","","","both","","","7769.93","5827.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3333.30","42.9","","5096.18","5096.18","5096.18","1 through 10","2408.68","6177.09","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier3","PX-27000152","CDM","C1874","HCPCS","0278","RC","","","","both","","","7769.93","5827.45","WELLPOINT [1015]","HB AMC WELLPOINT","5732.65","73.78","","1172.59","1172.59","4829.94","1 through 10","2408.68","6177.09","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier3","PX-27000152","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7769.93","5827.45","AETNA [1001]","HB AMC AETNA HMO","5423.41","69.8","","1806.84","947.80","5091.72","1 through 10","4060.57","6349.59","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier3","PX-27000152","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7769.93","5827.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6349.59","81.72","","1259.05","615.58","4586.56","1 through 10","4060.57","6349.59","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","both","","","334.88","251.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","266.23","79.5","","304.65","204.39","304.65","1 through 10","103.81","266.23","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","both","","","334.88","251.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","178.49","53.3","","204.39","204.39","304.65","1 through 10","103.81","266.23","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","both","","","334.88","251.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","122.23","36.5","","144.39","122.71","144.39","1 through 10","103.81","266.23","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","both","","","334.88","251.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","128.26","38.3","","151.36","147.10","454.08","13","103.81","266.23","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","both","","","334.88","251.16","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","257.86","77","","304.65","304.65","304.65","1 through 10","103.81","266.23","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","both","","","334.88","251.16","WELLPOINT [1015]","HB AMC WELLPOINT","247.07","73.78","","675.30","288.20","675.30","1 through 10","103.81","266.23","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","334.88","251.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","273.66","81.72","","183.26","154.72","309.45","1 through 10","175.01","273.66","percent of total billed charges",""
"HC Stent Non-Coronary Temp With Delivery Tier1","PX-27000208","CDM","C2625","HCPCS","0278","RC","","","","both","","","382.27","286.70","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","267.59","70","","470.75","470.75","470.75","1 through 10","118.5","303.9","percent of total billed charges",""
"HC Stent Non-Coronary Temp With Delivery Tier1","PX-27000208","CDM","C2625","HCPCS","0278","RC","","","","both","","","382.27","286.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","146.41","38.3","","184.07","124.37","184.07","1 through 10","118.5","303.9","percent of total billed charges",""
"HC Stent Non-Coronary Temp With Delivery Tier1","PX-27000208","CDM","C2625","HCPCS","0278","RC","","","","both","","","382.27","286.70","WELLPOINT [1015]","HB AMC WELLPOINT","282.04","73.78","","243.67","243.67","243.67","1 through 10","118.5","303.9","percent of total billed charges",""
"HC Stent Non-Coronary Temp With Delivery Tier1","PX-27000208","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","382.27","286.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","312.39","81.72","","376.32","376.32","376.32","1 through 10","199.77","312.39","percent of total billed charges",""
"HC Stent Non-Coronary Temp With Delivery Tier3","PX-27000209","CDM","C2625","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4375.00","70","","470.75","470.75","470.75","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HC Stent Non-Coronary Temp With Delivery Tier3","PX-27000209","CDM","C2625","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2393.75","38.3","","184.07","124.37","184.07","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HC Stent Non-Coronary Temp With Delivery Tier3","PX-27000209","CDM","C2625","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","WELLPOINT [1015]","HB AMC WELLPOINT","4611.25","73.78","","243.67","243.67","243.67","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HC Stent Non-Coronary Temp With Delivery Tier3","PX-27000209","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5107.50","81.72","","376.32","376.32","376.32","1 through 10","3266.25","5107.5","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier1","PX-27000156","CDM","C1876","HCPCS","0278","RC","","","","both","","","2259.36","1694.52","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1482.14","65.6","","751.18","751.18","751.18","1 through 10","700.4","1796.19","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier1","PX-27000156","CDM","C1876","HCPCS","0278","RC","","","","both","","","2259.36","1694.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1796.19","79.5","","4820.38","3211.27","4820.38","1 through 10","700.4","1796.19","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier1","PX-27000156","CDM","C1876","HCPCS","0278","RC","","","","both","","","2259.36","1694.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","824.67","36.5","","641.00","641.00","641.00","1 through 10","700.4","1796.19","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier1","PX-27000156","CDM","C1876","HCPCS","0278","RC","","","","both","","","2259.36","1694.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","865.33","38.3","","1098.43","1098.43","1098.43","1 through 10","700.4","1796.19","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier1","PX-27000156","CDM","C1876","HCPCS","0278","RC","","","","both","","","2259.36","1694.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","969.27","42.9","","4896.33","4896.33","4896.33","1 through 10","700.4","1796.19","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier1","PX-27000156","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2259.36","1694.52","AETNA [1001]","HB AMC AETNA HMO","1577.03","69.8","","175.60","163.11","1063.91","1 through 10","1180.74","1846.35","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier1","PX-27000156","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2259.36","1694.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1846.35","81.72","","105.94","85.10","105.94","1 through 10","1180.74","1846.35","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier2","PX-27000157","CDM","C1876","HCPCS","0278","RC","","","","both","","","4440.63","3330.47","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2913.05","65.6","","751.18","751.18","751.18","1 through 10","1376.6","3530.3","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier2","PX-27000157","CDM","C1876","HCPCS","0278","RC","","","","both","","","4440.63","3330.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3530.30","79.5","","4820.38","3211.27","4820.38","1 through 10","1376.6","3530.3","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier2","PX-27000157","CDM","C1876","HCPCS","0278","RC","","","","both","","","4440.63","3330.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1620.83","36.5","","641.00","641.00","641.00","1 through 10","1376.6","3530.3","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier2","PX-27000157","CDM","C1876","HCPCS","0278","RC","","","","both","","","4440.63","3330.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1700.76","38.3","","1098.43","1098.43","1098.43","1 through 10","1376.6","3530.3","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier2","PX-27000157","CDM","C1876","HCPCS","0278","RC","","","","both","","","4440.63","3330.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1905.03","42.9","","4896.33","4896.33","4896.33","1 through 10","1376.6","3530.3","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier2","PX-27000157","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4440.63","3330.47","AETNA [1001]","HB AMC AETNA HMO","3099.56","69.8","","175.60","163.11","1063.91","1 through 10","2320.67","3628.88","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier2","PX-27000157","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4440.63","3330.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3628.88","81.72","","105.94","85.10","105.94","1 through 10","2320.67","3628.88","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier3","PX-27000158","CDM","C1876","HCPCS","0278","RC","","","","both","","","5170.50","3877.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3391.85","65.6","","751.18","751.18","751.18","1 through 10","1602.86","4110.55","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier3","PX-27000158","CDM","C1876","HCPCS","0278","RC","","","","both","","","5170.50","3877.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4110.55","79.5","","4820.38","3211.27","4820.38","1 through 10","1602.86","4110.55","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier3","PX-27000158","CDM","C1876","HCPCS","0278","RC","","","","both","","","5170.50","3877.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1887.23","36.5","","641.00","641.00","641.00","1 through 10","1602.86","4110.55","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier3","PX-27000158","CDM","C1876","HCPCS","0278","RC","","","","both","","","5170.50","3877.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1980.30","38.3","","1098.43","1098.43","1098.43","1 through 10","1602.86","4110.55","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier3","PX-27000158","CDM","C1876","HCPCS","0278","RC","","","","both","","","5170.50","3877.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2218.14","42.9","","4896.33","4896.33","4896.33","1 through 10","1602.86","4110.55","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier3","PX-27000158","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","5170.50","3877.87","AETNA [1001]","HB AMC AETNA HMO","3609.01","69.8","","175.60","163.11","1063.91","1 through 10","2702.1","4225.33","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier3","PX-27000158","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","5170.50","3877.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4225.33","81.72","","105.94","85.10","105.94","1 through 10","2702.1","4225.33","percent of total billed charges",""
"HC Tracheostomy Speaking Valve T1","PX-27000983","CDM","L8501","HCPCS","0274","RC","","","","outpatient","","","528.50","396.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","275.98","52.22","","387.28","365.30","387.28","1 through 10","264.25","436.01","percent of total billed charges",""
"HC Whfo With Nontorsion Joints Custome Tier1","PX-27000489","CDM","L3806","HCPCS","0274","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.45","38.3","","58.65","58.65","58.65","1 through 10","46.5","607.71","percent of total billed charges",""
"HC Who Cock-Up Control Extension Prefab Tier1","PX-27000496","CDM","L3908","HCPCS","0274","RC","","","","both","","","17.43","13.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6.68","38.3","","6.82","6.82","6.82","1 through 10","5.4","110.08","percent of total billed charges",""
"HC Who Cock-Up Control Extension Prefab Tier1","PX-27000496","CDM","L3908","HCPCS","0274","RC","","","","outpatient","","","17.43","13.07","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8.72","50","","17.21","9.13","17.21","1 through 10","8.72","182.91","percent of total billed charges",""
"HC Who Cock-Up Control Extension Prefab Tier1","PX-27000496","CDM","L3908","HCPCS","0274","RC","","","","outpatient","","","17.43","13.07","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","9.15","52.5","","9.59","9.59","9.59","1 through 10","8.72","182.91","percent of total billed charges",""
"HC Who Cock-Up Control Extension Prefab Tier1","PX-27000496","CDM","L3908","HCPCS","0274","RC","","","","outpatient","","","17.43","13.07","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","9.59","55","","10.04","10.04","10.04","1 through 10","8.72","182.91","percent of total billed charges",""
"HC Who Cock-Up Control Extension Prefab Tier1","PX-27000496","CDM","L3908","HCPCS","0274","RC","","","","outpatient","","","17.43","13.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14.24","81.72","","13.93","13.93","13.93","1 through 10","8.72","182.91","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","both","","","143.00","107.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","113.69","79.5","","112.54","112.54","112.54","1 through 10","44.33","646.45","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","both","","","143.00","107.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","76.22","53.3","","75.50","75.50","75.50","1 through 10","44.33","646.45","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","both","","","143.00","107.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","52.20","36.5","","53.34","53.34","53.34","1 through 10","44.33","646.45","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","both","","","143.00","107.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.77","38.3","","55.91","54.34","55.91","1 through 10","44.33","646.45","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","143.00","107.25","AETNA [1001]","HB AMC AETNA HMO","99.81","69.8","","111.54","96.81","111.54","1 through 10","71.5","1073.9","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","71.50","50","","74.93","74.93","74.93","1 through 10","71.5","1073.9","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","78.65","55","","82.37","82.37","82.37","1 through 10","71.5","1073.9","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","116.86","81.72","","62.88","62.88","62.88","1 through 10","71.5","1073.9","percent of total billed charges",""
"HC Who With Nontorsion Joints Custom Tier1","PX-27000494","CDM","L3905","HCPCS","0274","RC","","","","both","","","459.76","344.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","176.09","38.3","","179.77","179.77","179.77","1 through 10","142.53","1326.74","percent of total billed charges",""
"HC Who With Nontorsion Joints Custom Tier1","PX-27000494","CDM","L3905","HCPCS","0274","RC","","","","outpatient","","","459.76","344.82","AETNA [1001]","HB AMC AETNA HMO","320.91","69.8","","311.26","311.26","311.26","1 through 10","229.88","2203.9","percent of total billed charges",""
"HC Who With Nontorsion Joints Custom Tier1","PX-27000494","CDM","L3905","HCPCS","0274","RC","","","","outpatient","","","459.76","344.82","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","229.88","50","","240.91","240.91","240.91","1 through 10","229.88","2203.9","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","249.00","186.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","178.78","71.8","","173.04","173.04","173.04","1 through 10","14.75","236.55","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","249.00","186.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","174.30","70","","241.00","241.00","241.00","1 through 10","14.75","236.55","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","249.00","186.75","CHAMPVA [160001]","HB BWH TRICARE","236.55","95","","18.14","18.14","18.14","1 through 10","14.75","236.55","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","249.00","186.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","197.96","79.5","","189.67","127.25","189.67","368","14.75","236.55","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","249.00","186.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","132.72","53.3","","127.25","127.25","236.34","148","14.75","236.55","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","249.00","186.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","161.85","65","","152.10","127.73","152.10","1 through 10","14.75","236.55","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","249.00","186.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","197.96","79.5","","189.67","189.67","189.67","1 through 10","14.75","236.55","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","249.00","186.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","77.19","31","","74.47","74.47","223.41","16","14.75","236.55","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","249.00","186.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","90.89","36.5","","89.89","76.40","261.72","221","14.75","236.55","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","249.00","186.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","95.37","38.3","","94.23","91.58","282.69","912","14.75","236.55","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","249.00","186.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","191.73","77","","189.67","21.07","189.67","1 through 10","14.75","236.55","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","249.00","186.75","TRICARE [160005]","HB BWH TRICARE","236.55","95","","17.23","17.23","18.14","31","14.75","236.55","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","249.00","186.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.82","42.9","","192.66","105.97","192.66","18","14.75","236.55","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","249.00","186.75","AETNA [1001]","HB AMC AETNA HMO","173.80","69.8","","163.16","115.20","187.98","445","15.53","203.48","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","249.00","186.75","AETNA [1001]","HB AMC AETNA PPO","200.20","80.4","","187.98","115.20","252.56","58","15.53","203.48","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","249.00","186.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","200.20","80.4","","187.98","187.98","187.98","1 through 10","15.53","203.48","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","249.00","186.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","203.48","81.72","","192.66","192.66","192.66","1 through 10","15.53","203.48","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","249.00","186.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","203.48","81.72","","105.97","105.97","192.66","1 through 10","15.53","203.48","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","249.00","186.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","203.48","81.72","","192.66","105.97","192.66","332","15.53","203.48","percent of total billed charges",""
"Hcpr Intralesional Chemo Admin, 8+ Lesn","PX-98301794","CDM","96406","CPT","0983","RC","","","","both","","","195.00","146.25","MEDICARE [2001]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.21","250.21","500.42","1 through 10","60.45","312.73","other","OPPS APC"
"Hcpr Intralesional Chemo Admin, 8+ Lesn","PX-98301794","CDM","96406","CPT","0983","RC","","","","both","","","195.00","146.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","74.69","38.3","","609.18","609.18","609.18","1 through 10","60.45","312.73","percent of total billed charges",""
"Hcpr Intralesional Chemo Admin, 8+ Lesn","PX-98301794","CDM","96406","CPT","0983","RC","","","","both","","","195.00","146.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","245.21","245.21","245.21","1 through 10","60.45","312.73","other","OPPS APC"
"Hcpr Intralesional Chemo Admin, 8+ Lesn","PX-98301794","CDM","96406","CPT","0983","RC","","","","outpatient","","","195.00","146.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","159.35","81.72","","1245.46","1245.46","1245.46","1 through 10","109.01","1237.13","percent of total billed charges",""
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","13.33","438.15","other","OPPS APC"
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","both","","","43.00","32.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","13.33","438.15","other","OPPS APC"
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","both","","","43.00","32.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22.92","53.3","","477.31","477.31","477.31","1 through 10","13.33","438.15","percent of total billed charges",""
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","both","","","43.00","32.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","13.33","438.15","other","OPPS APC"
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","both","","","43.00","32.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","13.33","438.15","other","OPPS APC"
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15.70","36.5","","1095.87","337.19","1095.87","1 through 10","13.33","438.15","percent of total billed charges",""
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.47","38.3","","343.52","323.76","353.46","1 through 10","13.33","438.15","percent of total billed charges",""
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","both","","","43.00","32.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","13.33","438.15","other","Tricare OPPS"
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","13.33","438.15","other","OPPS APC"
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","both","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","13.33","438.15","other","OPPS APC"
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","both","","","43.00","32.25","WELLPOINT [1015]","HB AMC WELLPOINT","31.73","73.78","","673.03","673.03","673.03","1 through 10","13.33","438.15","percent of total billed charges",""
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","outpatient","","","43.00","32.25","AETNA [1001]","HB AMC AETNA HMO","30.01","69.8","","612.01","612.01","1224.02","1 through 10","21.5","700.33","percent of total billed charges",""
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","outpatient","","","43.00","32.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","26.04","60.55","","579.04","568.57","904.00","30","21.5","700.33","percent of total billed charges",""
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","outpatient","","","43.00","32.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22.45","52.22","","904.00","656.02","2938.00","26","21.5","700.33","percent of total billed charges",""
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","outpatient","","","43.00","32.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21.50","50","","1421.10","875.08","2368.50","15","21.5","700.33","percent of total billed charges",""
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","outpatient","","","43.00","32.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22.58","52.5","","2985.00","904.00","2985.00","1 through 10","21.5","700.33","percent of total billed charges",""
"Hcpr Mgh Application of Patch","PX-98300613","CDM","64999","CPT","0983","RC","","","","outpatient","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","35.14","81.72","","722.66","722.66","17449.00","1 through 10","21.5","700.33","percent of total billed charges",""
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","both","","","289.00","216.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","89.59","438.15","other","OPPS APC"
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","both","","","289.00","216.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","89.59","438.15","other","OPPS APC"
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","both","","","289.00","216.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","154.04","53.3","","477.31","477.31","477.31","1 through 10","89.59","438.15","percent of total billed charges",""
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","both","","","289.00","216.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","89.59","438.15","other","OPPS APC"
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","both","","","289.00","216.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","89.59","438.15","other","OPPS APC"
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","both","","","289.00","216.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.49","36.5","","1095.87","337.19","1095.87","1 through 10","89.59","438.15","percent of total billed charges",""
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","both","","","289.00","216.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","110.69","38.3","","343.52","323.76","353.46","1 through 10","89.59","438.15","percent of total billed charges",""
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","both","","","289.00","216.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","89.59","438.15","other","Tricare OPPS"
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","both","","","289.00","216.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","89.59","438.15","other","OPPS APC"
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","both","","","289.00","216.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","89.59","438.15","other","OPPS APC"
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","both","","","289.00","216.75","WELLPOINT [1015]","HB AMC WELLPOINT","213.22","73.78","","673.03","673.03","673.03","1 through 10","89.59","438.15","percent of total billed charges",""
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","outpatient","","","289.00","216.75","AETNA [1001]","HB AMC AETNA HMO","201.72","69.8","","612.01","612.01","1224.02","1 through 10","144.5","700.33","percent of total billed charges",""
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","outpatient","","","289.00","216.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","174.99","60.55","","579.04","568.57","904.00","30","144.5","700.33","percent of total billed charges",""
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","outpatient","","","289.00","216.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","150.92","52.22","","904.00","656.02","2938.00","26","144.5","700.33","percent of total billed charges",""
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","outpatient","","","289.00","216.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","144.50","50","","1421.10","875.08","2368.50","15","144.5","700.33","percent of total billed charges",""
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","outpatient","","","289.00","216.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","151.73","52.5","","2985.00","904.00","2985.00","1 through 10","144.5","700.33","percent of total billed charges",""
"Hcpr Mgh Impar Ganglion Block","PX-98300614","CDM","64999","CPT","0983","RC","","","","outpatient","","","289.00","216.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","236.17","81.72","","722.66","722.66","17449.00","1 through 10","144.5","700.33","percent of total billed charges",""
"Hcpr New Pt - Level 1 Visit","PX-98300515","CDM","99201","CPT","0983","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","88.26","81.72","","135.10","135.10","258.21","21","88.26","88.26","percent of total billed charges",""
"Hcpr Psych - New Pt - Level 1 Visit","PX-96100040","CDM","99201","CPT","0961","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","88.26","81.72","","135.10","135.10","258.21","21","88.26","120.8","percent of total billed charges",""
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","both","","","304.00","228.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","196.34","196.34","197.14","1 through 10","94.24","288.8","other","OPPS APC"
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","both","","","304.00","228.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","171.23","187.76","12","94.24","288.8","other","OPPS APC"
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","both","","","304.00","228.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","149.48","149.48","187.76","1 through 10","94.24","288.8","other","OPPS APC"
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","both","","","304.00","228.00","HUMANA [1012]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","188.52","188.52","188.52","1 through 10","94.24","288.8","other","OPPS APC"
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","both","","","304.00","228.00","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","572.43","76","94.24","288.8","other","OPPS APC"
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","both","","","304.00","228.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","563.28","563.28","563.28","1 through 10","94.24","288.8","other","OPPS APC"
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","outpatient","","","304.00","228.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","152.00","50","","106.37","106.37","106.37","1 through 10","104.36","250.8","percent of total billed charges",""
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","outpatient","","","304.00","228.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","159.60","52.5","","111.65","90.54","111.65","12","104.36","250.8","percent of total billed charges",""
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","outpatient","","","304.00","228.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","248.43","81.72","","176.61","176.61","203.00","1 through 10","104.36","250.8","percent of total billed charges",""
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","401.00","300.75","AETNA [1001]","HB AMC AETNA HMO","279.90","69.8","","207.16","207.16","214.20","23","124.31","380.95","percent of total billed charges",""
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","401.00","300.75","AETNA [1001]","HB AMC AETNA PPO","322.40","80.4","","214.20","214.20","214.20","1 through 10","124.31","380.95","percent of total billed charges",""
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","401.00","300.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","196.34","196.34","197.14","30","124.31","380.95","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","401.00","300.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","187.76","187.76","1 through 10","124.31","380.95","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","401.00","300.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","158.10","187.76","13","124.31","380.95","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","401.00","300.75","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","190.81","246","124.31","380.95","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","401.00","300.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","81.63","81.63","81.63","1 through 10","124.31","380.95","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","401.00","300.75","MOLINA [1014]","HB BWH MOLINA","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","342.86","342.86","342.86","1 through 10","124.31","380.95","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","401.00","300.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.76","187.76","563.28","1 through 10","124.31","380.95","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","outpatient","","","401.00","300.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","200.50","50","","160.34","153.92","160.34","106","156.22","330.83","percent of total billed charges",""
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","outpatient","","","401.00","300.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","210.53","52.5","","168.30","136.48","168.30","44","156.22","330.83","percent of total billed charges",""
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","outpatient","","","401.00","300.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","250.63","62.5","","194.58","194.58","194.58","1 through 10","156.22","330.83","percent of total billed charges",""
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","outpatient","","","401.00","300.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","220.55","55","","194.58","186.20","194.58","16","156.22","330.83","percent of total billed charges",""
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","593.00","444.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","196.34","179.56","197.14","25","183.83","563.35","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","593.00","444.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","187.76","187.76","18","183.83","563.35","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","593.00","444.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","158.10","148.87","187.76","1 through 10","183.83","563.35","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","593.00","444.75","HUMANA [1012]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.99","186.99","186.99","1 through 10","183.83","563.35","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","593.00","444.75","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","190.81","340","183.83","563.35","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","593.00","444.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","120.78","120.78","120.78","1 through 10","183.83","563.35","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","outpatient","","","593.00","444.75","AETNA [1001]","HB AMC AETNA HMO","413.91","69.8","","320.60","320.60","320.60","1 through 10","156.22","489.23","percent of total billed charges",""
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","outpatient","","","593.00","444.75","AETNA [1001]","HB AMC AETNA PPO","476.77","80.4","","320.60","320.60","320.60","1 through 10","156.22","489.23","percent of total billed charges",""
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","outpatient","","","593.00","444.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","296.50","50","","239.99","239.99","239.99","26","156.22","489.23","percent of total billed charges",""
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","outpatient","","","593.00","444.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","311.33","52.5","","204.27","204.27","251.90","43","156.22","489.23","percent of total billed charges",""
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","outpatient","","","593.00","444.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","326.15","55","","397.73","397.73","397.73","1 through 10","156.22","489.23","percent of total billed charges",""
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","outpatient","","","593.00","444.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","484.60","81.72","","398.46","398.46","398.46","1 through 10","156.22","489.23","percent of total billed charges",""
"Hcpr Pvb Thoracic Second & Addl Inj Site W/Img Gid","PX-98300897","CDM","21554","CPT","0983","RC","","","","both","","","3264.00","2448.00","MEDICARE [2001]","HB BWH MEDICARE","3639.81","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","3398.86","1 through 10","1011.84","4549.76","other","OPPS APC"
"Hcpr Pvb Thoracic Second & Addl Inj Site W/Img Gid","PX-98300897","CDM","21554","CPT","0983","RC","","","","outpatient","","","3264.00","2448.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6304.29","6304.29","6366.84","1 through 10","1824.58","9843.6","other","ASC "
"Hcpr Pvb Thoracic Second & Addl Inj Site W/Img Gid","PX-98300897","CDM","21554","CPT","0983","RC","","","","outpatient","","","3264.00","2448.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","5479.58","5479.58","5479.58","1 through 10","1824.58","9843.6","other","Multiple Surgery"
"Hdr Rdncl Ntrstl/Intrcav Brachytx >12 Channels","PX-33000126","CDM","77772","CPT","0333","RC","","","","both","","","5354.00","4015.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2296.87","42.9","","2282.92","2282.92","2282.92","1 through 10","782.74","4256.43","percent of total billed charges",""
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","1863.00","1397.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","823.86","","APC Price ($823.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","810.76","810.76","810.76","13","577.53","1481.09","other","OPPS APC"
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","1863.00","1397.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1337.63","71.8","","1297.43","1297.43","1297.43","1 through 10","577.53","1481.09","percent of total billed charges",""
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","1863.00","1397.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1481.09","79.5","","1422.11","1422.11","1422.11","1 through 10","577.53","1481.09","percent of total billed charges",""
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","1863.00","1397.25","ELDER SERVICES [1037]","HB BWH MEDICARE","823.86","","APC Price ($823.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","823.94","823.94","823.94","1 through 10","577.53","1481.09","other","OPPS APC"
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","1863.00","1397.25","HUMANA [1012]","HB BWH MEDICARE","823.86","","APC Price ($823.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","807.46","807.46","807.46","1 through 10","577.53","1481.09","other","OPPS APC"
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","1863.00","1397.25","MEDICARE [2001]","HB BWH MEDICARE","823.86","","APC Price ($823.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","823.94","823.94","2471.82","66","577.53","1481.09","other","OPPS APC"
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","1863.00","1397.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","680.00","36.5","","674.01","674.01","674.01","1 through 10","577.53","1481.09","percent of total billed charges",""
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","1863.00","1397.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","713.53","38.3","","706.54","706.54","2119.62","17","577.53","1481.09","percent of total billed charges",""
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","1863.00","1397.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","823.86","","APC Price ($823.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","807.46","807.46","807.46","1 through 10","577.53","1481.09","other","OPPS APC"
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","1863.00","1397.25","MOLINA [1014]","HB BWH MOLINA","807.38","","APC Price ($823.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","823.94","823.94","823.94","1 through 10","577.53","1481.09","other","OPPS APC"
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","1863.00","1397.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","807.38","","APC Price ($823.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2300.64","1533.76","2300.64","1 through 10","577.53","1481.09","other","OPPS APC"
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","1863.00","1397.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","807.38","","APC Price ($823.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","807.46","766.88","807.46","1 through 10","577.53","1481.09","other","OPPS APC"
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","1863.00","1397.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","799.23","42.9","","794.54","794.54","794.54","1 through 10","577.53","1481.09","percent of total billed charges",""
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","outpatient","","","1863.00","1397.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1522.44","81.72","","1444.52","1444.52","1444.52","12","973.6","4590.64","percent of total billed charges",""
"Hdr Rdncl Ntrstl/Intrcav Brachytx 2-12 Channel","PX-33000125","CDM","77771","CPT","0333","RC","","","","both","","","3395.00","2546.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","823.86","","APC Price ($823.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","810.76","810.76","810.76","1 through 10","782.74","2699.03","other","OPPS APC"
"Hdr Rdncl Ntrstl/Intrcav Brachytx 2-12 Channel","PX-33000125","CDM","77771","CPT","0333","RC","","","","both","","","3395.00","2546.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1300.29","38.3","","1287.17","1287.17","1287.17","1 through 10","782.74","2699.03","percent of total billed charges",""
"Hdr Rdncl Sk Srf Brchytx Les >2cm&2chan/Mlt Les","PX-33000123","CDM","77768","CPT","0333","RC","","","","both","","","2368.00","1776.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","307.30","307.30","307.30","1 through 10","296.69","1882.56","other","OPPS APC"
"Hdr Rdncl Sk Srf Brchytx Les >2cm&2chan/Mlt Les","PX-33000123","CDM","77768","CPT","0333","RC","","","","both","","","2368.00","1776.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1882.56","79.5","","8299.70","1806.95","8299.70","1 through 10","296.69","1882.56","percent of total billed charges",""
"Hdr Rdncl Sk Srf Brchytx Les >2cm&2chan/Mlt Les","PX-33000123","CDM","77768","CPT","0333","RC","","","","both","","","2368.00","1776.00","MEDICARE [2001]","HB BWH MEDICARE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","312.30","312.30","312.30","11","296.69","1882.56","other","OPPS APC"
"Hdr Rdncl Sk Srf Brchytx Les >2cm&2chan/Mlt Les","PX-33000123","CDM","77768","CPT","0333","RC","","","","both","","","2368.00","1776.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","906.94","38.3","","897.74","897.74","897.74","1 through 10","296.69","1882.56","percent of total billed charges",""
"Hdr Rdncl Sk Srf Brchytx Les >2cm&2chan/Mlt Les","PX-33000123","CDM","77768","CPT","0333","RC","","","","both","","","2368.00","1776.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","306.03","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","307.25","307.25","307.25","1 through 10","296.69","1882.56","other","OPPS APC"
"Hdr Rdncl Sk Srf Brchytx Les >2cm&2chan/Mlt Les","PX-33000123","CDM","77768","CPT","0333","RC","","","","both","","","2368.00","1776.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","306.03","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","288.63","288.05","307.31","13","296.69","1882.56","other","OPPS APC"
"HEAD BIOLOX SZ 28MM DELTA FEMORAL NECK LENGTH LONG TAPER 12/14","SUP-ITM-10318629","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","993.20","52.26","","1113.10","1113.10","1113.10","1 through 10","589.16","1510.9","percent of total billed charges",""
"HEAD BIOLOX SZ 28MM DELTA FEMORAL NECK LENGTH LONG TAPER 12/14","SUP-ITM-10318629","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1510.90","79.5","","1293.60","1148.53","1603.80","1 through 10","589.16","1510.9","percent of total billed charges",""
"HEAD BIOLOX SZ 28MM DELTA FEMORAL NECK LENGTH LONG TAPER 12/14","SUP-ITM-10318629","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","693.68","36.5","","1023.42","771.29","2068.67","33","589.16","1510.9","percent of total billed charges",""
"HEAD BIOLOX SZ 28MM DELTA FEMORAL NECK LENGTH LONG TAPER 12/14","SUP-ITM-10318629","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","727.89","38.3","","850.52","759.78","1211.25","66","589.16","1510.9","percent of total billed charges",""
"HEAD BIOLOX SZ 28MM DELTA FEMORAL NECK LENGTH LONG TAPER 12/14","SUP-ITM-10318629","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","815.31","42.9","","2548.09","2548.09","2548.09","1 through 10","589.16","1510.9","percent of total billed charges",""
"HEAD BIOLOX SZ 28MM DELTA FEMORAL NECK LENGTH LONG TAPER 12/14","SUP-ITM-10318629","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","815.31","42.9","","956.46","956.46","956.46","1 through 10","589.16","1510.9","percent of total billed charges",""
"HEAD BIOLOX SZ 28MM DELTA FEMORAL NECK LENGTH LONG TAPER 12/14","SUP-ITM-10318629","CDM","C1776","HCPCS","0278","RC","","","","both","","","1900.50","1425.37","WELLPOINT [1015]","HB AMC WELLPOINT","1402.19","73.78","","2344.73","1619.47","2530.35","16","589.16","1510.9","percent of total billed charges",""
"HEAD BIOLOX SZ 28MM DELTA FEMORAL NECK LENGTH LONG TAPER 12/14","SUP-ITM-10318629","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1900.50","1425.37","AETNA [1001]","HB AMC AETNA HMO","1326.55","69.8","","1523.63","988.41","4330.26","39","993.2","1553.09","percent of total billed charges",""
"HEAD BIOLOX SZ 28MM DELTA FEMORAL NECK LENGTH LONG TAPER 12/14","SUP-ITM-10318629","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1900.50","1425.37","AETNA [1001]","HB AMC AETNA PPO","1528.00","80.4","","1670.25","1670.25","1670.25","1 through 10","993.2","1553.09","percent of total billed charges",""
"HEAD BIOLOX SZ 28MM DELTA FEMORAL NECK LENGTH LONG TAPER 12/14","SUP-ITM-10318629","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1900.50","1425.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","993.20","52.26","","1113.10","1113.10","1113.10","1 through 10","993.2","1553.09","percent of total billed charges",""
"HEAD BIOLOX SZ 28MM DELTA FEMORAL NECK LENGTH LONG TAPER 12/14","SUP-ITM-10318629","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1900.50","1425.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1553.09","81.72","","1738.90","1484.65","2716.94","38","993.2","1553.09","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","550.56","52.26","","1113.10","1113.10","1113.10","1 through 10","326.59","837.53","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","837.53","79.5","","1293.60","1148.53","1603.80","1 through 10","326.59","837.53","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","384.53","36.5","","1023.42","771.29","2068.67","33","326.59","837.53","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","403.49","38.3","","850.52","759.78","1211.25","66","326.59","837.53","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","451.95","42.9","","2548.09","2548.09","2548.09","1 through 10","326.59","837.53","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","451.95","42.9","","956.46","956.46","956.46","1 through 10","326.59","837.53","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","WELLPOINT [1015]","HB AMC WELLPOINT","777.27","73.78","","2344.73","1619.47","2530.35","16","326.59","837.53","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1053.50","790.12","AETNA [1001]","HB AMC AETNA HMO","735.34","69.8","","1523.63","988.41","4330.26","39","550.56","860.92","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1053.50","790.12","AETNA [1001]","HB AMC AETNA PPO","847.01","80.4","","1670.25","1670.25","1670.25","1 through 10","550.56","860.92","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1053.50","790.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","550.56","52.26","","1113.10","1113.10","1113.10","1 through 10","550.56","860.92","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1053.50","790.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","860.92","81.72","","1738.90","1484.65","2716.94","38","550.56","860.92","percent of total billed charges",""
"HEAD FEMORAL 36MM +0 12/14 TAPER CERAMIC HIP","SUP-ITM-10303409","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1371.83","52.26","","1113.10","1113.10","1113.10","1 through 10","813.75","2086.88","percent of total billed charges",""
"HEAD FEMORAL 36MM +0 12/14 TAPER CERAMIC HIP","SUP-ITM-10303409","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2086.88","79.5","","1293.60","1148.53","1603.80","1 through 10","813.75","2086.88","percent of total billed charges",""
"HEAD FEMORAL 36MM +0 12/14 TAPER CERAMIC HIP","SUP-ITM-10303409","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","958.13","36.5","","1023.42","771.29","2068.67","33","813.75","2086.88","percent of total billed charges",""
"HEAD FEMORAL 36MM +0 12/14 TAPER CERAMIC HIP","SUP-ITM-10303409","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1005.38","38.3","","850.52","759.78","1211.25","66","813.75","2086.88","percent of total billed charges",""
"HEAD FEMORAL 36MM +0 12/14 TAPER CERAMIC HIP","SUP-ITM-10303409","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1126.13","42.9","","2548.09","2548.09","2548.09","1 through 10","813.75","2086.88","percent of total billed charges",""
"HEAD FEMORAL 36MM +0 12/14 TAPER CERAMIC HIP","SUP-ITM-10303409","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1126.13","42.9","","956.46","956.46","956.46","1 through 10","813.75","2086.88","percent of total billed charges",""
"HEAD FEMORAL 36MM +0 12/14 TAPER CERAMIC HIP","SUP-ITM-10303409","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","WELLPOINT [1015]","HB AMC WELLPOINT","1936.73","73.78","","2344.73","1619.47","2530.35","16","813.75","2086.88","percent of total billed charges",""
"HEAD FEMORAL 36MM +0 12/14 TAPER CERAMIC HIP","SUP-ITM-10303409","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","AETNA [1001]","HB AMC AETNA HMO","1832.25","69.8","","1523.63","988.41","4330.26","39","1371.83","2145.15","percent of total billed charges",""
"HEAD FEMORAL 36MM +0 12/14 TAPER CERAMIC HIP","SUP-ITM-10303409","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","AETNA [1001]","HB AMC AETNA PPO","2110.50","80.4","","1670.25","1670.25","1670.25","1 through 10","1371.83","2145.15","percent of total billed charges",""
"HEAD FEMORAL 36MM +0 12/14 TAPER CERAMIC HIP","SUP-ITM-10303409","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1371.83","52.26","","1113.10","1113.10","1113.10","1 through 10","1371.83","2145.15","percent of total billed charges",""
"HEAD FEMORAL 36MM +0 12/14 TAPER CERAMIC HIP","SUP-ITM-10303409","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2145.15","81.72","","1738.90","1484.65","2716.94","38","1371.83","2145.15","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","651","1669.5","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1293.60","1148.53","1603.80","1 through 10","651","1669.5","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1023.42","771.29","2068.67","33","651","1669.5","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","850.52","759.78","1211.25","66","651","1669.5","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","2548.09","2548.09","2548.09","1 through 10","651","1669.5","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","956.46","956.46","956.46","1 through 10","651","1669.5","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","2344.73","1619.47","2530.35","16","651","1669.5","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1523.63","988.41","4330.26","39","1097.46","1716.12","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1670.25","1670.25","1670.25","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1738.90","1484.65","2716.94","38","1097.46","1716.12","percent of total billed charges",""
"HEAD HUMERAL 42X16MM MODULAR OFFSET PRIMARY NECKLESS COBALT-CHROME TOTAL TURON","SUP-ITM-10081034","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","951.13","52.26","","1113.10","1113.10","1113.10","1 through 10","564.2","1446.9","percent of total billed charges",""
"HEAD HUMERAL 42X16MM MODULAR OFFSET PRIMARY NECKLESS COBALT-CHROME TOTAL TURON","SUP-ITM-10081034","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1446.90","79.5","","1293.60","1148.53","1603.80","1 through 10","564.2","1446.9","percent of total billed charges",""
"HEAD HUMERAL 42X16MM MODULAR OFFSET PRIMARY NECKLESS COBALT-CHROME TOTAL TURON","SUP-ITM-10081034","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","664.30","36.5","","1023.42","771.29","2068.67","33","564.2","1446.9","percent of total billed charges",""
"HEAD HUMERAL 42X16MM MODULAR OFFSET PRIMARY NECKLESS COBALT-CHROME TOTAL TURON","SUP-ITM-10081034","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","697.06","38.3","","850.52","759.78","1211.25","66","564.2","1446.9","percent of total billed charges",""
"HEAD HUMERAL 42X16MM MODULAR OFFSET PRIMARY NECKLESS COBALT-CHROME TOTAL TURON","SUP-ITM-10081034","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","780.78","42.9","","2548.09","2548.09","2548.09","1 through 10","564.2","1446.9","percent of total billed charges",""
"HEAD HUMERAL 42X16MM MODULAR OFFSET PRIMARY NECKLESS COBALT-CHROME TOTAL TURON","SUP-ITM-10081034","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","780.78","42.9","","956.46","956.46","956.46","1 through 10","564.2","1446.9","percent of total billed charges",""
"HEAD HUMERAL 42X16MM MODULAR OFFSET PRIMARY NECKLESS COBALT-CHROME TOTAL TURON","SUP-ITM-10081034","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","WELLPOINT [1015]","HB AMC WELLPOINT","1342.80","73.78","","2344.73","1619.47","2530.35","16","564.2","1446.9","percent of total billed charges",""
"HEAD HUMERAL 42X16MM MODULAR OFFSET PRIMARY NECKLESS COBALT-CHROME TOTAL TURON","SUP-ITM-10081034","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1820.00","1365.00","AETNA [1001]","HB AMC AETNA HMO","1270.36","69.8","","1523.63","988.41","4330.26","39","951.13","1487.3","percent of total billed charges",""
"HEAD HUMERAL 42X16MM MODULAR OFFSET PRIMARY NECKLESS COBALT-CHROME TOTAL TURON","SUP-ITM-10081034","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1820.00","1365.00","AETNA [1001]","HB AMC AETNA PPO","1463.28","80.4","","1670.25","1670.25","1670.25","1 through 10","951.13","1487.3","percent of total billed charges",""
"HEAD HUMERAL 42X16MM MODULAR OFFSET PRIMARY NECKLESS COBALT-CHROME TOTAL TURON","SUP-ITM-10081034","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1820.00","1365.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","951.13","52.26","","1113.10","1113.10","1113.10","1 through 10","951.13","1487.3","percent of total billed charges",""
"HEAD HUMERAL 42X16MM MODULAR OFFSET PRIMARY NECKLESS COBALT-CHROME TOTAL TURON","SUP-ITM-10081034","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1820.00","1365.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1487.30","81.72","","1738.90","1484.65","2716.94","38","951.13","1487.3","percent of total billed charges",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,EXTREME","055","DRG","","","","","","","","inpatient","","","138025.13","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","73627.52","","Standard inlier is a Case rate ($73,627.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $68,904, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,451.87) for the length of stay and the standard reimbursement.","73627.52","73627.52","73627.52","1 through 10","5417.1","133810.08","case rate",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,EXTREME","055","DRG","","","","","","","","inpatient","","","138025.13","","MASSHEALTH [3001]","HB BWH MEDICAID","28644.83","","Case rate ($31,671.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $74,101.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31664.01","31664.01","58974.87","1 through 10","5417.1","133810.08","case rate",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,EXTREME","055","DRG","","","","","","","","inpatient","","","138025.13","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87654.07","","Fee schedule rate ($87,654.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","87654.07","87654.07","87654.07","1 through 10","5417.1","133810.08","case rate",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,EXTREME","055","DRG","","","","","","","","inpatient","","","138025.13","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","28644.83","","Case rate ($31,671.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $74,101.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31664.01","31664.01","91773.03","1 through 10","5417.1","133810.08","case rate",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,MAJOR","055","DRG","","","","","","","","inpatient","","","42253.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","46849.86","","Standard inlier is a Case rate ($46,849.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $44,054, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,649.95) for the length of stay and the standard reimbursement.","42801.39","42801.39","46849.86","1 through 10","5417.1","133810.08","case rate",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,MAJOR","055","DRG","","","","","","","","inpatient","","","42253.10","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12746.9533","","Fee schedule rate ($40,220.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12746.9533","40220.32","40220.32","1 through 10","5417.1","133810.08","case rate",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,MAJOR","055","DRG","","","","","","","","inpatient","","","42253.10","","MASSHEALTH [3001]","HB BWH MEDICAID","13270.87","","Case rate ($14,673.22). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,103.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14669.63","14669.63","14669.63","1 through 10","5417.1","133810.08","case rate",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,MAJOR","055","DRG","","","","","","","","inpatient","","","42253.10","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","13270.87","","Case rate ($14,673.22). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,103.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","5417.1","133810.08","case rate",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,MAJOR","055","DRG","","","","","","","","inpatient","","","42253.10","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44211.95","","Fee schedule rate ($44,211.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42923.86","42923.86","42923.86","1 through 10","5417.1","133810.08","case rate",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,MINOR","055","DRG","","","","","","","","inpatient","","","24806.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22194.14","","Standard inlier is a Case rate ($22,194.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,998, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,150.27) for the length of stay and the standard reimbursement.","20276.26","20276.26","20276.26","1 through 10","5417.1","133810.08","case rate",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,MODERATE","055","DRG","","","","","","","","inpatient","","","53734.16","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22194.14","","Standard inlier is a Case rate ($22,194.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,998, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,150.27) for the length of stay and the standard reimbursement.","31262.32","31262.32","31262.32","1 through 10","5417.1","133810.08","case rate",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,MODERATE","055","DRG","","","","","","","","inpatient","","","53734.16","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12746.9533","","Fee schedule rate ($20,897.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12746.9533","20897.48","20897.48","1 through 10","5417.1","133810.08","case rate",""
"Head Trauma With Coma > 1 Hour Or Hemorrhage,MODERATE","055","DRG","","","","","","","","inpatient","","","53734.16","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5417.10","","Case rate ($5,989.53). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,419.53, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5604.93","5604.93","8777.53","1 through 10","5417.1","133810.08","case rate",""
"Headaches With McC","102","MS-DRG","","","","","","","","inpatient","","","51020.27","38265.20","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","10604.81","","Case rate ($10,604.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,688.68, add-ons for qualifying new technology services are included. If operating cost exceeds $58,333.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,342.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,323.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,308.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $901.94. The transfer capital threshold is the transfer adjustment factor * $901.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10591.66","10591.66","10591.66","1 through 10","10392.71","17557.78","other","Inpatient DRG"
"Headaches With McC","102","MS-DRG","","","","","","","","inpatient","","","51020.27","38265.20","MEDICARE [2001]","HB BWH MEDICARE","13650.09","","Case rate ($13,650.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,688.68, add-ons for qualifying new technology services are included. If operating cost exceeds $58,333.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,342.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $12,368.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,308.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $901.94. The transfer capital threshold is the transfer adjustment factor * $901.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13947.82","0.03","13968.27","1 through 10","10392.71","17557.78","other","Inpatient DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","40509.42","30382.06","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8008.66","","Case rate ($8,008.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,563.44, add-ons for qualifying new technology services are included. If operating cost exceeds $55,207.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,113.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,955.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,183.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.94. The transfer capital threshold is the transfer adjustment factor * $672.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7908.06","7908.06","7908.06","1 through 10","7848.49","12830.3682","other","Inpatient Replacement Plans DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","40509.42","30382.06","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8008.66","","Case rate ($8,008.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,563.44, add-ons for qualifying new technology services are included. If operating cost exceeds $55,207.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,113.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,955.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,183.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.94. The transfer capital threshold is the transfer adjustment factor * $672.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7894.93","7835.44","7910.51","1 through 10","7848.49","12830.3682","other","Inpatient DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","40509.42","30382.06","MEDICARE [2001]","HB BWH MEDICARE","8008.66","","Case rate ($8,008.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,563.44, add-ons for qualifying new technology services are included. If operating cost exceeds $55,207.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,113.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,955.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,183.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.94. The transfer capital threshold is the transfer adjustment factor * $672.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10301.43","0.03","10301.43","1 through 10","7848.49","12830.3682","other","Inpatient Replacement Plans DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","40509.42","30382.06","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7848.49","","Case rate ($8,008.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,563.44, add-ons for qualifying new technology services are included. If operating cost exceeds $55,207.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,113.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,955.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,183.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $672.94. The transfer capital threshold is the transfer adjustment factor * $672.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7905.00","7905.00","7905.00","1 through 10","7848.49","12830.3682","other","Inpatient DRG"
"Health Behavior Assessment/Re-Assessment","PX-90000160","CDM","96156","CPT","0916","RC","","","","both","","","469.00","351.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","1 through 10","104.36","372.86","other","OPPS APC"
"Health Behavior Assessment/Re-Assessment","PX-90000160","CDM","96156","CPT","0916","RC","","","","both","","","469.00","351.75","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","1 through 10","104.36","372.86","other","OPPS APC"
"Health Behavior Assessment/Re-Assessment","PX-96000048","CDM","96156","CPT","0961","RC","","","","both","","","382.00","286.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","1 through 10","104.36","303.69","other","OPPS APC"
"Health Behavior Assessment/Re-Assessment","PX-96000048","CDM","96156","CPT","0961","RC","","","","both","","","382.00","286.50","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","1 through 10","104.36","303.69","other","OPPS APC"
"Health Behavior Ivntj Indiv F2f 1st 30 Min","PX-90000154","CDM","96158","CPT","0914","RC","","","","both","","","325.00","243.75","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","190.81","23","100.75","258.38","other","OPPS APC"
"Health Behavior Ivntj Indiv F2f 1st 30 Min","PX-96000049","CDM","96158","CPT","0961","RC","","","","both","","","262.00","196.50","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","190.81","23","81.22","208.29","other","OPPS APC"
"Heart And/Or Lung Transplant,EXTREME","002","DRG","","","","","","","","inpatient","","","1703555.91","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","816438.35","","Standard inlier is a Case rate ($816,438.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $576,367, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($115,886.64) for the length of stay and the standard reimbursement.","816438.34","816438.34","816438.34","1 through 10","153865.28","1062276.47","case rate",""
"Heart And/Or Lung Transplant,EXTREME","002","DRG","","","","","","","","inpatient","","","1703555.91","","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","196267.00","","Case rate ($196,267). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($412,160), then multiplying the difference by the percent of outlier that is reimbursed (38.3%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","479212.28","479212.28","567497.31","1 through 10","153865.28","1062276.47","case rate",""
"Heart And/Or Lung Transplant,EXTREME","002","DRG","","","","","","","","inpatient","","","1703555.91","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","180975.00","","Case rate ($180,975). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($325,755), then multiplying the difference by the percent of outlier that is reimbursed (60%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","2238627.90","2238627.90","2238627.90","1 through 10","153865.28","1062276.47","case rate",""
"Heart And/Or Lung Transplant,EXTREME","002","DRG","","","","","","","","inpatient","","","1703555.91","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","244992.00","","Case rate ($244,992). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($495,638), then multiplying the difference by the percent of outlier that is reimbursed (43%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","360145.62","54517.37","1005120.46","1 through 10","153865.28","1062276.47","case rate",""
"Heart And/Or Lung Transplant,EXTREME","002","DRG","","","","","","","","inpatient","","","1703555.91","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","625569.00","","Case rate ($625,569). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($1,138,378), then multiplying the difference by the percent of outlier that is reimbursed (49.7%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","1085782.75","1085782.75","1085782.75","1 through 10","153865.28","1062276.47","case rate",""
"Heart And/Or Lung Transplant,EXTREME","002","DRG","","","","","","","","inpatient","","","1703555.91","","MASSHEALTH [3001]","HB BWH MEDICAID","513386.13","","Case rate ($567,636.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $610,066.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $9,051.77 and the sum of the standard inlier and any outlier amount.","567497.31","567497.31","567497.31","1 through 10","153865.28","1062276.47","case rate",""
"Heart And/Or Lung Transplant,EXTREME","002","DRG","","","","","","","","inpatient","","","1703555.91","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","513386.13","","Case rate ($567,636.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $610,066.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $9,051.77 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","153865.28","1062276.47","case rate",""
"Heart And/Or Lung Transplant,EXTREME","002","DRG","","","","","","","","inpatient","","","1703555.91","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","513386.13","","Case rate ($567,636.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $610,066.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $9,051.77 and the sum of the standard inlier and any outlier amount.","13363.22","13363.22","694639.29","1 through 10","153865.28","1062276.47","case rate",""
"Heart And/Or Lung Transplant,MAJOR","002","DRG","","","","","","","","inpatient","","","975143.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","449067.72","","Standard inlier is a Case rate ($449,067.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $360,860, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($63,747.87) for the length of stay and the standard reimbursement.","461245.21","461245.21","461245.21","1 through 10","153865.28","1062276.47","case rate",""
"Heart And/Or Lung Transplant,MAJOR","002","DRG","","","","","","","","inpatient","","","975143.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","504873.14","","Standard inlier is a Case rate ($504,873.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $360,860, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($71,662.55) for the length of stay and the standard reimbursement.","461245.21","461245.21","504873.14","1 through 10","153865.28","1062276.47","case rate",""
"Heart And/Or Lung Transplant,MAJOR","002","DRG","","","","","","","","inpatient","","","975143.60","","HEALTH NEW ENGLAND [1034]","HB BWH MEDICAID","216245.31","","Case rate ($239,096.37). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $281,526.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","239037.69","239037.69","239037.69","1 through 10","153865.28","1062276.47","case rate",""
"Heart And/Or Lung Transplant,MODERATE","002","DRG","","","","","","","","inpatient","","","802777.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","333257.83","","Standard inlier is a Case rate ($333,257.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $270,801, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($47,307.96) for the length of stay and the standard reimbursement.","333257.83","333257.83","333257.83","1 through 10","153865.28","1062276.47","case rate",""
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","","","","inpatient","","","67558.98","50669.23","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","10431.08","","Case rate ($10,431.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,702.89, add-ons for qualifying new technology services are included. If operating cost exceeds $55,347.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,123.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,368.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,323.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.16. The transfer capital threshold is the transfer adjustment factor * $683.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","39074.59","39074.59","39074.59","1 through 10","7962.01","13298.74","other","Inpatient DRG"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","","","","inpatient","","","67558.98","50669.23","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8124.50","","Case rate ($8,124.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,702.89, add-ons for qualifying new technology services are included. If operating cost exceeds $55,347.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,123.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,061.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,323.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.16. The transfer capital threshold is the transfer adjustment factor * $683.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8001.19","8001.19","8001.19","1 through 10","7962.01","13298.74","other","Inpatient DRG"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","","","","inpatient","","","67558.98","50669.23","MEDICARE [2001]","HB BWH MEDICARE","10431.08","","Case rate ($10,431.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,702.89, add-ons for qualifying new technology services are included. If operating cost exceeds $55,347.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,123.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,368.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,323.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.16. The transfer capital threshold is the transfer adjustment factor * $683.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10431.12","1167.87","10446.30","16","7962.01","13298.74","other","Inpatient DRG"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","","","","inpatient","","","67558.98","50669.23","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7962.01","","Case rate ($8,124.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,702.89, add-ons for qualifying new technology services are included. If operating cost exceeds $55,347.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,123.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,061.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,323.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.16. The transfer capital threshold is the transfer adjustment factor * $683.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8145.44","8145.44","8145.44","1 through 10","7962.01","13298.74","other","Inpatient DRG"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","","","","inpatient","","","67558.98","50669.23","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7962.01","","Case rate ($8,124.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,702.89, add-ons for qualifying new technology services are included. If operating cost exceeds $55,347.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,123.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,061.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,323.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $683.16. The transfer capital threshold is the transfer adjustment factor * $683.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8066.73","7959.41","12291.07","1 through 10","7962.01","13298.74","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","75058.52","56293.89","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","12453.51","","Case rate ($12,090.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,477.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,121.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,473.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,677.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,097.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,033.02. The transfer capital threshold is the transfer adjustment factor * $1,033.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12489.93","12473.11","12539.43","23","11848.97","19690.7368","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","75058.52","56293.89","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","15578.64","","Case rate ($15,578.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,477.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,121.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,473.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $14,165.79 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,097.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,033.02. The transfer capital threshold is the transfer adjustment factor * $1,033.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11990.09","11990.09","15460.49","1 through 10","11848.97","19690.7368","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","75058.52","56293.89","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","15113.49","","Case rate ($12,090.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,477.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,121.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,473.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,677.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,097.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,033.02. The transfer capital threshold is the transfer adjustment factor * $1,033.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","12121.64","12121.64","12121.64","1 through 10","11848.97","19690.7368","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","75058.52","56293.89","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","12090.79","","Case rate ($12,090.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,477.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,121.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,473.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,677.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,097.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,033.02. The transfer capital threshold is the transfer adjustment factor * $1,033.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11923.94","9200.35","18172.00","17","11848.97","19690.7368","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","75058.52","56293.89","ELDER SERVICES [1037]","HB BWH MEDICARE","15578.64","","Case rate ($15,578.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,477.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,121.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,473.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $14,165.79 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,097.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,033.02. The transfer capital threshold is the transfer adjustment factor * $1,033.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35693.03","35693.03","35693.03","1 through 10","11848.97","19690.7368","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","75058.52","56293.89","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10598.45","10598.45","10598.45","1 through 10","11848.97","19690.7368","case rate",""
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","75058.52","56293.89","FALLON HEALTH [1008]","HB BWH MEDICARE","15578.64","","Case rate ($15,578.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,477.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,121.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,473.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $14,165.79 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,097.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,033.02. The transfer capital threshold is the transfer adjustment factor * $1,033.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11918.14","11918.14","11918.14","1 through 10","11848.97","19690.7368","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","75058.52","56293.89","HUMANA [1012]","HB BWH MEDICARE","15578.64","","Case rate ($15,578.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,477.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,121.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,473.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $14,165.79 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,097.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,033.02. The transfer capital threshold is the transfer adjustment factor * $1,033.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12240.79","12240.79","24224.94","1 through 10","11848.97","19690.7368","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","75058.52","56293.89","MEDICARE [2001]","HB BWH MEDICARE","15578.64","","Case rate ($15,578.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,477.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,121.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,473.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $14,165.79 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,097.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,033.02. The transfer capital threshold is the transfer adjustment factor * $1,033.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15660.76","0.03","15683.78","261","11848.97","19690.7368","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","75058.52","56293.89","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","15578.64","","Case rate ($15,578.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,477.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,121.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,473.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $14,165.79 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,097.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,033.02. The transfer capital threshold is the transfer adjustment factor * $1,033.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11898.14","11879.14","11911.42","1 through 10","11848.97","19690.7368","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","75058.52","56293.89","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","11848.97","","Case rate ($12,090.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,477.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,121.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,473.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,677.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,097.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,033.02. The transfer capital threshold is the transfer adjustment factor * $1,033.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11929.15","11885.16","12012.60","12","11848.97","19690.7368","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","75058.52","56293.89","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11848.97","","Case rate ($12,090.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,477.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,121.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,473.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,677.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,097.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,033.02. The transfer capital threshold is the transfer adjustment factor * $1,033.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11937.16","11879.24","12113.87","56","11848.97","19690.7368","other","Inpatient DRG"
"Heart Failure And Shock Without Cc/McC","293","MS-DRG","","","","","","","","inpatient","","","41854.50","31390.87","ELDER SERVICES [1037]","HB BWH MEDICARE","7080.68","","Case rate ($7,080.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,595.21, add-ons for qualifying new technology services are included. If operating cost exceeds $52,239.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,895.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,245.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,215.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $455.44. The transfer capital threshold is the transfer adjustment factor * $455.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9809.60","9809.60","9809.60","1 through 10","5432.1","8280.4317","other","Inpatient DRG"
"Heart Failure,EXTREME","194","DRG","","","","","","","","inpatient","","","120624.76","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","44999.27","","Standard inlier is a Case rate ($44,999.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,642, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,387.92) for the length of stay and the standard reimbursement.","29115.04","29115.04","29115.04","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,EXTREME","194","DRG","","","","","","","","inpatient","","","120624.76","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","50591.30","","Standard inlier is a Case rate ($50,591.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,642, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,181.02) for the length of stay and the standard reimbursement.","50591.30","50591.30","50591.30","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,EXTREME","194","DRG","","","","","","","","inpatient","","","120624.76","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","13894.3176","","Fee schedule rate ($74,267.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13894.3176","16462.88","16462.88","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,EXTREME","194","DRG","","","","","","","","inpatient","","","120624.76","","MASSHEALTH [3001]","HB BWH MEDICAID","15459.64","","Case rate ($17,093.29). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,523.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17089.09","17089.09","17089.09","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,EXTREME","194","DRG","","","","","","","","inpatient","","","120624.76","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57820.45","","Fee schedule rate ($57,820.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","57820.45","57820.45","57820.45","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,EXTREME","194","DRG","","","","","","","","inpatient","","","120624.76","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15459.64","","Case rate ($17,093.29). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,523.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","32364.13","32364.13","32364.13","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","84386.20","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","29685.80","","Standard inlier is a Case rate ($29,685.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,733, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,214.08) for the length of stay and the standard reimbursement.","28059.69","27059.69","33374.84","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","84386.20","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","33374.84","","Standard inlier is a Case rate ($33,374.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,733, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,737.28) for the length of stay and the standard reimbursement.","30490.80","33374.84","33374.84","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","84386.20","","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","","38.3","","35724.29","35724.29","35724.29","1 through 10","4775.09","116704.15","percent of total billed charges",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","84386.20","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13232.3172","","Fee schedule rate ($30,803.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13232.3172","29616.68","29616.68","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","84386.20","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","13894.3176","","Fee schedule rate ($32,344.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13894.3176","32344.92","32344.92","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","84386.20","","MASSHEALTH [3001]","HB BWH MEDICAID","9587.88","","Case rate ($10,601.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,031.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10598.45","1491.33","10598.45","11","4775.09","116704.15","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","84386.20","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","9587.88","","Case rate ($10,601.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,031.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2085.87","2085.87","2085.87","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","84386.20","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34023.48","","Fee schedule rate ($34,023.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33032.32","33032.32","33032.32","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","84386.20","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35724.29","","Fee schedule rate ($35,724.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35724.29","35724.29","35724.29","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","84386.20","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9587.88","","Case rate ($10,601.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,031.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10598.45","695.29","18117.80","26","4775.09","116704.15","case rate",""
"Heart Failure,MINOR","194","DRG","","","","","","","","inpatient","","","13970.55","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","13894.3176","","Fee schedule rate ($19,056.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13894.3176","13358.32","13358.32","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","58113.14","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21461.49","","Standard inlier is a Case rate ($21,461.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,336, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,046.59) for the length of stay and the standard reimbursement.","21461.48","21461.48","22231.37","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","58113.14","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24128.50","","Standard inlier is a Case rate ($24,128.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,336, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,424.84) for the length of stay and the standard reimbursement.","22043.46","22043.46","24128.49","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","58113.14","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13232.3172","","Fee schedule rate ($30,803.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13232.3172","18148.60","18148.60","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","58113.14","","MASSHEALTH [3001]","HB BWH MEDICAID","6856.48","","Case rate ($7,581.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,011.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7579.16","7579.16","7579.16","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","58113.14","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34023.48","","Fee schedule rate ($34,023.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24417.03","24417.03","24417.03","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","58113.14","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35724.29","","Fee schedule rate ($35,724.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25637.62","25637.62","25637.62","1 through 10","4775.09","116704.15","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","58113.14","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6856.48","","Case rate ($7,581.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,011.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7579.16","222.21","9119.89","12","4775.09","116704.15","case rate",""
"Heart Transplant Or Implant Of Heart Assist System With McC","001","MS-DRG","","","","","","","","inpatient","","","1537842.40","1153381.80","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","263697.32","","Case rate ($256,016.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $308,116.34, add-ons for qualifying new technology services are included. If operating cost exceeds $353,760.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $24,989.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $233,087.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $307,736.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $22,549.67. The transfer capital threshold is the transfer adjustment factor * $22,549.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","335219.49","335219.49","335219.49","1 through 10","179000","438966.37","other","Inpatient DRG"
"Heart Transplant Or Implant Of Heart Assist System With McC","001","MS-DRG","","","","","","","","inpatient","","","1537842.40","1153381.80","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","256016.82","","Case rate ($256,016.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $308,116.34, add-ons for qualifying new technology services are included. If operating cost exceeds $353,760.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $24,989.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $233,087.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $307,736.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $22,549.67. The transfer capital threshold is the transfer adjustment factor * $22,549.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","257797.29","257797.29","338689.96","1 through 10","179000","438966.37","other","Inpatient Replacement Plans DRG"
"Heart Transplant Or Implant Of Heart Assist System With McC","001","MS-DRG","","","","","","","","inpatient","","","1537842.40","1153381.80","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","","","Payment is accumulated by days. Day 1 - 20, Case rate ($160,000). Day 21 - 9999, Per diem ($2,000).","538322.90","480895.72","861357.65","1 through 10","179000","438966.37","other","Heart Transplant"
"Heart Transplant Or Implant Of Heart Assist System With McC","001","MS-DRG","","","","","","","","inpatient","","","1537842.40","1153381.80","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","320021.03","","Case rate ($256,016.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $308,116.34, add-ons for qualifying new technology services are included. If operating cost exceeds $353,760.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $24,989.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $233,087.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $307,736.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $22,549.67. The transfer capital threshold is the transfer adjustment factor * $22,549.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 125%.","443651.10","443651.10","443651.10","1 through 10","179000","438966.37","other","Inpatient DRG"
"Heart Transplant Or Implant Of Heart Assist System With McC","001","MS-DRG","","","","","","","","inpatient","","","1537842.40","1153381.80","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","179000.00","","Case rate ($179,000). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($298,321), then multiplying the difference by the percent of outlier that is reimbursed (60%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","394664.86","394664.86","394664.86","1 through 10","179000","438966.37","case rate",""
"Heart Transplant Or Implant Of Heart Assist System With McC","001","MS-DRG","","","","","","","","inpatient","","","1537842.40","1153381.80","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","12696.00","4433.38","429326.54","1 through 10","179000","438966.37","case rate",""
"Heart Transplant Or Implant Of Heart Assist System With McC","001","MS-DRG","","","","","","","","inpatient","","","1537842.40","1153381.80","MEDICARE [2001]","HB BWH MEDICARE","256016.82","","Case rate ($256,016.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $308,116.34, add-ons for qualifying new technology services are included. If operating cost exceeds $353,760.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $24,989.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $233,087.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $307,736.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $22,549.67. The transfer capital threshold is the transfer adjustment factor * $22,549.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","332855.49","19657.94","644517.29","20","179000","438966.37","other","Inpatient Replacement Plans DRG"
"Heart Transplant Or Implant Of Heart Assist System With McC","001","MS-DRG","","","","","","","","inpatient","","","1537842.40","1153381.80","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","250896.48","","Case rate ($256,016.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $308,116.34, add-ons for qualifying new technology services are included. If operating cost exceeds $353,760.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $24,989.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 25.8. The base transfer operating payment is the transfer adjustment factor * $233,087.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $307,736.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $22,549.67. The transfer capital threshold is the transfer adjustment factor * $22,549.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","663816.57","204316.14","1443374.21","1 through 10","179000","438966.37","other","Inpatient DRG"
"Heartware Battery, Each","PX-27000764","CDM","Q0506","HCPCS","0274","RC","","","","both","","","2625.00","1968.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1706.25","65","","4265.63","4265.63","4265.63","1 through 10","813.75","2493.75","percent of total billed charges",""
"Heartware Battery, Each","PX-27000764","CDM","Q0506","HCPCS","0274","RC","","","","both","","","2625.00","1968.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1837.50","70","","1260.00","1260.00","1260.00","1 through 10","813.75","2493.75","percent of total billed charges",""
"Heartware Battery, Each","PX-27000764","CDM","Q0506","HCPCS","0274","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1005.38","38.3","","684.25","684.25","684.25","1 through 10","813.75","2493.75","percent of total billed charges",""
"Heartware Battery, Each","PX-27000764","CDM","Q0506","HCPCS","0274","RC","","","","both","","","2625.00","1968.75","WELLPOINT [1015]","HB AMC WELLPOINT","1936.73","73.78","","1628.60","1628.60","1628.60","1 through 10","813.75","2493.75","percent of total billed charges",""
"Heartware Battery, Each","PX-27000764","CDM","Q0506","HCPCS","0274","RC","","","","outpatient","","","2625.00","1968.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1312.50","50","","917.00","917.00","917.00","1 through 10","1312.5","2165.63","percent of total billed charges",""
"Heartware Battery, Each","PX-27000764","CDM","Q0506","HCPCS","0274","RC","","","","outpatient","","","2625.00","1968.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1378.13","52.5","","2887.50","2887.50","2887.50","1 through 10","1312.5","2165.63","percent of total billed charges",""
"Heartware Controller","PX-27000871","CDM","Q0481","HCPCS","0274","RC","","","","both","","","17875.00","13406.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","11618.75","65","","21937.50","21937.50","21937.50","1 through 10","5541.25","21401.69","percent of total billed charges",""
"Heartware Controller Ac Adapter","PX-27000855","CDM","Q0508","HCPCS","0274","RC","","","","both","","","3000.00","2250.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1950.00","65","","1092.00","1092.00","1092.00","1 through 10","930","2850","percent of total billed charges",""
"Heartware Controller Ac Adapter","PX-27000855","CDM","Q0508","HCPCS","0274","RC","","","","both","","","3000.00","2250.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2100.00","70","","51.84","51.84","51.84","21","930","2850","percent of total billed charges",""
"Heartware Controller Ac Adapter","PX-27000855","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","3000.00","2250.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1816.50","60.55","","48.41","48.41","48.41","1 through 10","1200","2475","percent of total billed charges",""
"Heartware Controller Ac Adapter","PX-27000855","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","3000.00","2250.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1566.60","52.22","","43.55","43.55","43.55","24","1200","2475","percent of total billed charges",""
"Heartware Controller Ac Adapter","PX-27000855","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","3000.00","2250.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1500.00","50","","37.73","37.73","188.64","1 through 10","1200","2475","percent of total billed charges",""
"Heartwr Monitor Kit","PX-27000877","CDM","Q0508","HCPCS","0274","RC","","","","both","","","24875.00","18656.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","16168.75","65","","1092.00","1092.00","1092.00","1 through 10","7711.25","23631.25","percent of total billed charges",""
"Heartwr Monitor Kit","PX-27000877","CDM","Q0508","HCPCS","0274","RC","","","","both","","","24875.00","18656.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","17412.50","70","","51.84","51.84","51.84","21","7711.25","23631.25","percent of total billed charges",""
"Heartwr Monitor Kit","PX-27000877","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","24875.00","18656.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","15061.81","60.55","","48.41","48.41","48.41","1 through 10","9950","20521.88","percent of total billed charges",""
"Heartwr Monitor Kit","PX-27000877","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","24875.00","18656.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","12989.73","52.22","","43.55","43.55","43.55","24","9950","20521.88","percent of total billed charges",""
"Heartwr Monitor Kit","PX-27000877","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","24875.00","18656.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12437.50","50","","37.73","37.73","188.64","1 through 10","9950","20521.88","percent of total billed charges",""
"Heavy Metal Qn Ea","PX-30000491","CDM","83018","CPT","0301","RC","","","","both","","","260.00","195.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","138.58","53.3","","133.06","133.06","133.06","1 through 10","21.52","247","percent of total billed charges",""
"Heavy Metal Qn Ea","PX-30000491","CDM","83018","CPT","0301","RC","","","","both","","","260.00","195.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","99.58","38.3","","98.53","95.76","98.53","1 through 10","21.52","247","percent of total billed charges",""
"Heavy Metal Qn Ea","PX-30000491","CDM","83018","CPT","0301","RC","","","","outpatient","","","260.00","195.00","AETNA [1001]","HB AMC AETNA HMO","181.48","69.8","","170.60","170.60","170.60","1 through 10","22.65","212.47","percent of total billed charges",""
"Heavy Metal Qn Ea","PX-30000491","CDM","83018","CPT","0301","RC","","","","outpatient","","","260.00","195.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","212.47","81.72","","201.45","110.80","201.45","1 through 10","22.65","212.47","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Hemalogics, Myel/Lymh Leuk, Myeloid/Lymphoid Leukemia","PX-31001231","CDM","81479","CPT","0310","RC","","","","both","","","722.00","541.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","573.99","79.5","","0.65","0.65","0.65","1 through 10","223.82","685.9","percent of total billed charges",""
"Hemalogics, Myel/Lymh Leuk, Myeloid/Lymphoid Leukemia","PX-31001231","CDM","81479","CPT","0310","RC","","","","both","","","722.00","541.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","384.83","53.3","","0.79","0.79","0.79","1 through 10","223.82","685.9","percent of total billed charges",""
"Hemalogics, Myel/Lymh Leuk, Myeloid/Lymphoid Leukemia","PX-31001231","CDM","81479","CPT","0310","RC","","","","outpatient","","","722.00","541.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","361.00","50","","1.00","1.00","1.00","1 through 10","156.55","595.65","percent of total billed charges",""
"Hemalogics, Myel/Lymh Leuk, Myeloid/Lymphoid Leukemia","PX-31001231","CDM","81479","CPT","0310","RC","","","","outpatient","","","722.00","541.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","379.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","595.65","percent of total billed charges",""
"Hematologics Inc-Myel/Lymh Leuk, Myeloid/Lymphoid Leukemia","PX-31001261","CDM","81479","CPT","0310","RC","","","","both","","","722.00","541.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","573.99","79.5","","0.65","0.65","0.65","1 through 10","223.82","685.9","percent of total billed charges",""
"Hematologics Inc-Myel/Lymh Leuk, Myeloid/Lymphoid Leukemia","PX-31001261","CDM","81479","CPT","0310","RC","","","","both","","","722.00","541.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","384.83","53.3","","0.79","0.79","0.79","1 through 10","223.82","685.9","percent of total billed charges",""
"Hematologics Inc-Myel/Lymh Leuk, Myeloid/Lymphoid Leukemia","PX-31001261","CDM","81479","CPT","0310","RC","","","","outpatient","","","722.00","541.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","361.00","50","","1.00","1.00","1.00","1 through 10","156.55","595.65","percent of total billed charges",""
"Hematologics Inc-Myel/Lymh Leuk, Myeloid/Lymphoid Leukemia","PX-31001261","CDM","81479","CPT","0310","RC","","","","outpatient","","","722.00","541.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","379.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","595.65","percent of total billed charges",""
"Hematologics, Custon/Specific Gene Minimal Residual Disease (Mrd)","PX-31001209","CDM","81479","CPT","0310","RC","","","","both","","","1798.00","1348.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1429.41","79.5","","0.65","0.65","0.65","1 through 10","557.38","1708.1","percent of total billed charges",""
"Hematologics, Custon/Specific Gene Minimal Residual Disease (Mrd)","PX-31001209","CDM","81479","CPT","0310","RC","","","","both","","","1798.00","1348.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","958.33","53.3","","0.79","0.79","0.79","1 through 10","557.38","1708.1","percent of total billed charges",""
"Hematologics, Custon/Specific Gene Minimal Residual Disease (Mrd)","PX-31001209","CDM","81479","CPT","0310","RC","","","","outpatient","","","1798.00","1348.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","899.00","50","","1.00","1.00","1.00","1 through 10","156.55","1483.35","percent of total billed charges",""
"Hematologics, Custon/Specific Gene Minimal Residual Disease (Mrd)","PX-31001209","CDM","81479","CPT","0310","RC","","","","outpatient","","","1798.00","1348.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","943.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","1483.35","percent of total billed charges",""
"Hematologics, Hmatlg Custom/Specific Gene Minimal Residual Disease","PX-31001210","CDM","81479","CPT","0310","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","0.65","0.65","0.65","1 through 10","542.5","1662.5","percent of total billed charges",""
"Hematologics, Hmatlg Custom/Specific Gene Minimal Residual Disease","PX-31001210","CDM","81479","CPT","0310","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","0.79","0.79","0.79","1 through 10","542.5","1662.5","percent of total billed charges",""
"Hematologics, Hmatlg Custom/Specific Gene Minimal Residual Disease","PX-31001210","CDM","81479","CPT","0310","RC","","","","outpatient","","","1750.00","1312.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","875.00","50","","1.00","1.00","1.00","1 through 10","156.55","1443.75","percent of total billed charges",""
"Hematologics, Hmatlg Custom/Specific Gene Minimal Residual Disease","PX-31001210","CDM","81479","CPT","0310","RC","","","","outpatient","","","1750.00","1312.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","918.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","1443.75","percent of total billed charges",""
"Hematologics, Matlg Custom Specific Gene Minimal Residual Disease","PX-31001212","CDM","81479","CPT","0310","RC","","","","both","","","766.00","574.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","608.97","79.5","","0.65","0.65","0.65","1 through 10","237.46","727.7","percent of total billed charges",""
"Hematologics, Matlg Custom Specific Gene Minimal Residual Disease","PX-31001212","CDM","81479","CPT","0310","RC","","","","both","","","766.00","574.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","408.28","53.3","","0.79","0.79","0.79","1 through 10","237.46","727.7","percent of total billed charges",""
"Hematologics, Matlg Custom Specific Gene Minimal Residual Disease","PX-31001212","CDM","81479","CPT","0310","RC","","","","outpatient","","","766.00","574.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","383.00","50","","1.00","1.00","1.00","1 through 10","156.55","631.95","percent of total billed charges",""
"Hematologics, Matlg Custom Specific Gene Minimal Residual Disease","PX-31001212","CDM","81479","CPT","0310","RC","","","","outpatient","","","766.00","574.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","402.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","631.95","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","165.00","123.75","CHAMPVA [160001]","HB BWH TRICARE","156.75","95","","15.51","15.51","15.51","1 through 10","12.61","156.75","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","165.00","123.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","131.18","79.5","","125.92","84.48","125.92","58","12.61","156.75","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","165.00","123.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","87.95","53.3","","125.92","84.48","125.92","23","12.61","156.75","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","165.00","123.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.23","36.5","","59.68","50.72","59.68","49","12.61","156.75","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","165.00","123.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.20","38.3","","62.56","62.56","187.68","174","12.61","156.75","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","165.00","123.75","TRICARE [160005]","HB BWH TRICARE","156.75","95","","14.73","14.73","14.73","1 through 10","12.61","156.75","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.79","42.9","","127.90","70.35","127.90","1 through 10","12.61","156.75","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","165.00","123.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.79","42.9","","70.35","70.35","70.35","1 through 10","12.61","156.75","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","outpatient","","","165.00","123.75","AETNA [1001]","HB AMC AETNA HMO","115.17","69.8","","108.32","76.48","124.80","87","13.27","134.84","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","outpatient","","","165.00","123.75","AETNA [1001]","HB AMC AETNA PPO","132.66","80.4","","124.80","76.48","124.80","1 through 10","13.27","134.84","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","134.84","81.72","","70.35","70.35","70.35","1 through 10","13.27","134.84","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","134.84","81.72","","127.90","70.35","127.91","71","13.27","134.84","percent of total billed charges",""
"Hemoglobin Fetal Kleihauer-Betke","PX-30001102","CDM","85460","CPT","0305","RC","","","","both","","","88.00","66.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.96","79.5","","66.90","66.90","66.90","1 through 10","5.98","83.6","percent of total billed charges",""
"Hemoglobin Fetal Kleihauer-Betke","PX-30001102","CDM","85460","CPT","0305","RC","","","","both","","","88.00","66.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.70","38.3","","33.24","33.24","33.24","1 through 10","5.98","83.6","percent of total billed charges",""
"Hemoglobin Fetal Kleihauer-Betke","PX-30001102","CDM","85460","CPT","0305","RC","","","","outpatient","","","88.00","66.00","AETNA [1001]","HB AMC AETNA HMO","61.42","69.8","","57.55","40.63","66.30","1 through 10","5.98","71.91","percent of total billed charges",""
"Hemoglobin Fetal Kleihauer-Betke","PX-30001102","CDM","85460","CPT","0305","RC","","","","outpatient","","","88.00","66.00","AETNA [1001]","HB AMC AETNA PPO","70.75","80.4","","132.60","132.60","132.60","1 through 10","5.98","71.91","percent of total billed charges",""
"Hemoglobin Fetal Kleihauer-Betke","PX-30001102","CDM","85460","CPT","0305","RC","","","","outpatient","","","88.00","66.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.91","81.72","","67.95","35.05","67.95","1 through 10","5.98","71.91","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","117.03","71.8","","235.44","25.68","340.32","32","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","106.93","65.6","","106.97","106.97","106.97","1 through 10","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","105.95","65","","271.70","83.42","308.10","12","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","114.10","70","","135.88","69.47","158.00","12","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CHAMPVA [160001]","HB BWH TRICARE","154.85","95","","11.70","11.70","11.70","1 through 10","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","129.59","79.5","","124.35","83.42","124.35","1365","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","86.88","53.3","","83.42","83.42","250.26","789","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","125.51","77","","121.66","117.81","121.66","1 through 10","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","105.95","65","","102.70","99.45","210.60","16","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","50.53","31","","48.82","48.82","146.46","72","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","59.50","36.5","","58.93","50.09","171.60","1710","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.43","38.3","","61.78","61.78","185.34","5604","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","MOLINA [1014]","HB BWH MOLINA","57.05","35","","19.26","19.04","19.26","1 through 10","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","125.51","77","","123.24","24.73","259.00","16","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","TRICARE [160005]","HB BWH TRICARE","154.85","95","","11.12","11.12","11.70","60","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.93","42.9","","126.31","69.47","126.31","71","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","163.00","122.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.93","42.9","","69.47","69.47","126.31","20","9.52","154.85","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","AETNA [1001]","HB AMC AETNA HMO","113.77","69.8","","106.97","75.52","123.24","2010","10.01","133.2","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","AETNA [1001]","HB AMC AETNA PPO","131.05","80.4","","123.24","75.52","123.24","171","10.01","133.2","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","91.12","55.9","","165.58","82.79","165.58","1 through 10","10.01","133.2","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","85.18","52.26","","34.02","34.02","97.77","29","10.01","133.2","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","131.05","80.4","","123.24","79.00","281.24","15","10.01","133.2","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","133.20","81.72","","126.30","117.83","126.31","1 through 10","10.01","133.2","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","133.20","81.72","","69.47","69.47","126.31","68","10.01","133.2","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","163.00","122.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","133.20","81.72","","126.31","69.47","126.31","1333","10.01","133.2","percent of total billed charges",""
"Hemoglobin Plasma","PX-30000501","CDM","83051","CPT","0301","RC","","","","both","","","120.00","90.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","95.40","79.5","","91.29","91.29","91.29","1 through 10","7.16","114","percent of total billed charges",""
"Hemoglobin Plasma","PX-30000501","CDM","83051","CPT","0301","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","45.96","38.3","","45.36","44.08","45.36","1 through 10","7.16","114","percent of total billed charges",""
"Hemoglobinopathy Prof","PX-31001182","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Hemoglobinopathy Prof","PX-31001182","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Hemoglobinopathy Prof","PX-31001182","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Hemoglobinopathy Prof","PX-31001182","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Hemolysins/Agglutinins Incubation","PX-30000093","CDM","86941","CPT","0300","RC","","","","both","","","202.00","151.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","145.04","71.8","","140.73","140.73","140.73","1 through 10","11.87","191.9","percent of total billed charges",""
"Hemolysins/Agglutinins Incubation","PX-30000093","CDM","86941","CPT","0300","RC","","","","both","","","202.00","151.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.59","79.5","","103.49","103.49","154.25","15","11.87","191.9","percent of total billed charges",""
"Hemolysins/Agglutinins Incubation","PX-30000093","CDM","86941","CPT","0300","RC","","","","both","","","202.00","151.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","107.67","53.3","","103.49","103.49","103.49","1 through 10","11.87","191.9","percent of total billed charges",""
"Hemolysins/Agglutinins Incubation","PX-30000093","CDM","86941","CPT","0300","RC","","","","both","","","202.00","151.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","131.30","65","","127.40","127.40","127.40","1 through 10","11.87","191.9","percent of total billed charges",""
"Hemolysins/Agglutinins Incubation","PX-30000093","CDM","86941","CPT","0300","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","62.62","31","","60.56","60.56","60.56","1 through 10","11.87","191.9","percent of total billed charges",""
"Hemolysins/Agglutinins Incubation","PX-30000093","CDM","86941","CPT","0300","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.73","36.5","","73.11","62.13","219.33","15","11.87","191.9","percent of total billed charges",""
"Hemolysins/Agglutinins Incubation","PX-30000093","CDM","86941","CPT","0300","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.37","38.3","","76.64","74.48","229.92","36","11.87","191.9","percent of total billed charges",""
"Hemolysins/Agglutinins Incubation","PX-30000093","CDM","86941","CPT","0300","RC","","","","both","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.66","42.9","","86.18","86.18","86.18","1 through 10","11.87","191.9","percent of total billed charges",""
"Hemolysins/Agglutinins Incubation","PX-30000093","CDM","86941","CPT","0300","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA HMO","141.00","69.8","","132.69","93.69","187.38","16","12.49","165.07","percent of total billed charges",""
"Hemolysins/Agglutinins Incubation","PX-30000093","CDM","86941","CPT","0300","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA PPO","162.41","80.4","","152.88","145.52","305.76","1 through 10","12.49","165.07","percent of total billed charges",""
"Hemolysins/Agglutinins Incubation","PX-30000093","CDM","86941","CPT","0300","RC","","","","outpatient","","","202.00","151.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","105.57","52.26","","42.28","42.28","42.28","1 through 10","12.49","165.07","percent of total billed charges",""
"Hemolysins/Agglutinins Incubation","PX-30000093","CDM","86941","CPT","0300","RC","","","","outpatient","","","202.00","151.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","162.41","80.4","","145.52","145.52","145.52","1 through 10","12.49","165.07","percent of total billed charges",""
"Hemolysins/Agglutinins Incubation","PX-30000093","CDM","86941","CPT","0300","RC","","","","outpatient","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.07","81.72","","156.68","86.18","313.36","15","12.49","165.07","percent of total billed charges",""
"Hemophilia C F11 Gene-Next Gen Seq","PX-31001155","CDM","81479","CPT","0310","RC","","","","both","","","3572.00","2679.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2839.74","79.5","","0.65","0.65","0.65","1 through 10","1107.32","3393.4","percent of total billed charges",""
"Hemophilia C F11 Gene-Next Gen Seq","PX-31001155","CDM","81479","CPT","0310","RC","","","","both","","","3572.00","2679.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1903.88","53.3","","0.79","0.79","0.79","1 through 10","1107.32","3393.4","percent of total billed charges",""
"Hemophilia C F11 Gene-Next Gen Seq","PX-31001155","CDM","81479","CPT","0310","RC","","","","outpatient","","","3572.00","2679.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1786.00","50","","1.00","1.00","1.00","1 through 10","156.55","2946.9","percent of total billed charges",""
"Hemophilia C F11 Gene-Next Gen Seq","PX-31001155","CDM","81479","CPT","0310","RC","","","","outpatient","","","3572.00","2679.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1875.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","2946.9","percent of total billed charges",""
"Hemorrhage Or Hematoma Due To Complication,EXTREME","810","DRG","","","","","","","","inpatient","","","73813.67","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","72534.56","","Standard inlier is a Case rate ($72,534.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $61,819, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,295.68) for the length of stay and the standard reimbursement.","66266.58","66266.58","66266.58","1 through 10","5436.52","72588.52","case rate",""
"Hemorrhage Or Hematoma Due To Complication,MAJOR","810","DRG","","","","","","","","inpatient","","","61744.02","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31354.60","","Standard inlier is a Case rate ($31,354.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,031, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,450.97) for the length of stay and the standard reimbursement.","28580.86","28580.86","28580.86","1 through 10","5436.52","72588.52","case rate",""
"Hemorrhage Or Hematoma Due To Complication,MAJOR","810","DRG","","","","","","","","inpatient","","","61744.02","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35251.02","","Standard inlier is a Case rate ($35,251.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,031, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,003.59) for the length of stay and the standard reimbursement.","35251.02","35251.02","39775.64","1 through 10","5436.52","72588.52","case rate",""
"Hemorrhage Or Hematoma Due To Complication,MINOR","810","DRG","","","","","","","","inpatient","","","30028.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","14297.96","","Standard inlier is a Case rate ($14,297.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,767, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,029.68) for the length of stay and the standard reimbursement.","14297.95","14297.95","14297.95","1 through 10","5436.52","72588.52","case rate",""
"Hemorrhage Or Hematoma Due To Complication,MODERATE","810","DRG","","","","","","","","inpatient","","","60788.67","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19951.16","","Standard inlier is a Case rate ($19,951.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,162, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,832.19) for the length of stay and the standard reimbursement.","26696.21","26696.21","26696.21","1 through 10","5436.52","72588.52","case rate",""
"Hemorrhoidectomy External 2 or More","PX-75000217","CDM","46250","CPT","0750","RC","","","","both","","","6649.00","4986.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","3487.63","","APC Price ($3,487.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3194.11","3194.11","3194.11","1 through 10","2061.19","5285.96","other","OPPS APC"
"Hemorrhoidectomy External 2 or More","PX-75000217","CDM","46250","CPT","0750","RC","","","","outpatient","","","6649.00","4986.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2731.14","2731.14","2731.14","1 through 10","2101.12","8899.59","other","ASC"
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6307.00","4730.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3354.12","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3360.10","3360.10","3360.10","1 through 10","1955.17","5014.07","other","OPPS APC"
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6307.00","4730.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3256.42","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3015.46","3015.46","3015.46","1 through 10","1955.17","5014.07","other","OPPS APC"
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6307.00","4730.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3361.63","53.3","","12773.38","12773.38","12773.38","1 through 10","1955.17","5014.07","percent of total billed charges",""
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6307.00","4730.25","MEDICARE [2001]","HB BWH MEDICARE","3256.42","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3256.75","3256.75","3256.75","1 through 10","1955.17","5014.07","other","OPPS APC"
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6307.00","4730.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2302.06","36.5","","7668.86","5156.32","9023.62","1 through 10","1955.17","5014.07","percent of total billed charges",""
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6307.00","4730.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2415.58","38.3","","7909.54","7909.54","7909.54","1 through 10","1955.17","5014.07","percent of total billed charges",""
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","outpatient","","","6307.00","4730.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5462.27","5462.27","5462.27","1 through 10","2101.12","8899.59","other","ASC"
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","outpatient","","","6307.00","4730.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2101.12","","Case rate ($2,101.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5126.73","5126.73","5126.73","1 through 10","2101.12","8899.59","other","Multiple Surgery"
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","both","","","1681.00","1260.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1027.64","1027.64","1027.64","1 through 10","521.11","1353.25","other","OPPS APC"
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","both","","","1681.00","1260.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1336.40","79.5","","1282.81","1282.81","1282.81","1 through 10","521.11","1353.25","percent of total billed charges",""
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","both","","","1681.00","1260.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","895.97","53.3","","1282.81","1282.81","1282.81","1 through 10","521.11","1353.25","percent of total billed charges",""
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","both","","","1681.00","1260.75","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","1082.71","1082.71","22","521.11","1353.25","other","OPPS APC"
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","both","","","1681.00","1260.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","613.57","36.5","","607.99","516.71","607.99","1 through 10","521.11","1353.25","percent of total billed charges",""
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","both","","","1681.00","1260.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","643.82","38.3","","637.33","637.33","637.33","14","521.11","1353.25","percent of total billed charges",""
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","both","","","1681.00","1260.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","984.56","984.56","984.56","1 through 10","521.11","1353.25","other","OPPS APC"
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","outpatient","","","1681.00","1260.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1742.82","1711.31","1994.11","1 through 10","721.15","2384.07","other","ASC"
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","outpatient","","","1681.00","1260.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1974.52","1974.52","1994.11","40","721.15","2384.07","other","ASC "
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","outpatient","","","1681.00","1260.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2160.18","2160.18","2160.18","1 through 10","721.15","2384.07","other","Multiple Surgery"
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","outpatient","","","1681.00","1260.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1728.14","1728.14","1728.14","1 through 10","721.15","2384.07","other","Multiple Surgery"
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","outpatient","","","1681.00","1260.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1817.53","1817.53","1817.53","1 through 10","721.15","2384.07","other","Multiple Surgery"
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","outpatient","","","1681.00","1260.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1906.92","1906.92","1906.92","1 through 10","721.15","2384.07","other","Multiple Surgery"
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","outpatient","","","1681.00","1260.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2078.24","2078.24","2078.24","1 through 10","721.15","2384.07","other","Multiple Surgery"
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","outpatient","","","1681.00","1260.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1373.71","81.72","","1303.02","1303.02","13003.04","1 through 10","721.15","2384.07","percent of total billed charges",""
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","outpatient","","","1681.00","1260.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1832.43","1832.43","1832.43","1 through 10","721.15","2384.07","other","Multiple Surgery"
"Hepa Vaccine Adult Dose for Intramuscular Use","PX-63600301","CDM","90632","CPT","0636","RC","","","","both","","","95.82","71.86","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","62.28","65","","164.26","164.26","164.26","1 through 10","29.7","171.89","percent of total billed charges",""
"Hepa Vaccine Adult Dose for Intramuscular Use","PX-63600301","CDM","90632","CPT","0636","RC","","","","both","","","95.82","71.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34.97","36.5","","35.74","30.37","35.74","1 through 10","29.7","171.89","percent of total billed charges",""
"Hepa Vaccine Adult Dose for Intramuscular Use","PX-63600301","CDM","90632","CPT","0636","RC","","","","both","","","95.82","71.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","36.70","38.3","","37.47","37.47","37.47","34","29.7","171.89","percent of total billed charges",""
"Hepa Vaccine Adult Dose for Intramuscular Use","PX-63600301","CDM","90632","CPT","0636","RC","","","","outpatient","","","95.82","71.86","AETNA [1001]","HB AMC AETNA HMO","66.88","69.8","","64.87","45.80","74.74","1 through 10","44.94","78.3","percent of total billed charges",""
"Hepa Vaccine Adult Dose for Intramuscular Use","PX-63600301","CDM","90632","CPT","0636","RC","","","","outpatient","","","95.82","71.86","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","53.56","55.9","","50.21","50.21","50.21","1 through 10","44.94","78.3","percent of total billed charges",""
"Hepa Vaccine Adult Dose for Intramuscular Use","PX-63600301","CDM","90632","CPT","0636","RC","","","","outpatient","","","95.82","71.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","66.98","69.9","","66.40","66.40","66.40","1 through 10","44.94","78.3","percent of total billed charges",""
"Hepa Vaccine Adult Dose for Intramuscular Use","PX-63600301","CDM","90632","CPT","0636","RC","","","","outpatient","","","95.82","71.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","44.94","46.9","","44.46","44.46","66.40","1 through 10","44.94","78.3","percent of total billed charges",""
"Hepa Vaccine Adult Dose for Intramuscular Use","PX-63600301","CDM","90632","CPT","0636","RC","","","","outpatient","","","95.82","71.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","78.30","81.72","","153.96","153.96","153.96","1 through 10","44.94","78.3","percent of total billed charges",""
"Hepa Vaccine Adult Dose for Intramuscular Use","PX-63600301","CDM","90632","CPT","0636","RC","","","","outpatient","","","95.82","71.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","78.30","81.72","","95.82","95.82","153.96","1 through 10","44.94","78.3","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","both","","","231.00","173.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","161.70","70","","224.00","224.00","224.00","1 through 10","12.83","219.45","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","both","","","231.00","173.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","183.65","79.5","","118.27","118.27","176.29","1 through 10","12.83","219.45","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","both","","","231.00","173.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","123.12","53.3","","176.29","113.12","354.81","1 through 10","12.83","219.45","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","both","","","231.00","173.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","177.87","77","","517.44","517.44","517.44","1 through 10","12.83","219.45","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","both","","","231.00","173.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","150.15","65","","145.60","136.50","291.20","1 through 10","12.83","219.45","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","84.32","36.5","","83.55","71.01","250.65","15","12.83","219.45","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","88.47","38.3","","87.58","85.12","262.74","28","12.83","219.45","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","outpatient","","","231.00","173.25","AETNA [1001]","HB AMC AETNA HMO","161.24","69.8","","151.65","107.07","214.14","16","13.5","188.77","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","outpatient","","","231.00","173.25","AETNA [1001]","HB AMC AETNA PPO","185.72","80.4","","234.76","151.65","234.76","1 through 10","13.5","188.77","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","outpatient","","","231.00","173.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","185.72","80.4","","112.00","112.00","112.00","1 through 10","13.5","188.77","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","188.77","81.72","","98.49","98.49","98.49","1 through 10","13.5","188.77","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","188.77","81.72","","179.07","98.49","179.07","20","13.5","188.77","percent of total billed charges",""
"Heparin Na Flush Pf Vl 10u/Ml 1ml","PX-63600124","CDM","J1642","HCPCS","0636","RC","","","","both","","","0.22","0.16","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.15","70","","0.38","0.38","0.38","20","0.04","0.17","percent of total billed charges",""
"Heparin Na Flush Pf Vl 10u/Ml 1ml","PX-63600124","CDM","J1642","HCPCS","0636","RC","","","","both","","","0.22","0.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.08","38.3","","0.02","0.02","0.02","1188","0.04","0.17","percent of total billed charges",""
"Heparin Na Flush Pf Vl 10u/Ml 1ml","PX-63600124","CDM","J1642","HCPCS","0636","RC","","","","outpatient","","","0.22","0.16","AETNA [1001]","HB AMC AETNA HMO","0.15","69.8","","0.11","0.11","0.35","68","0.04","0.18","percent of total billed charges",""
"Heparin Na Flush Pf Vl 10u/Ml 1ml","PX-63600124","CDM","J1642","HCPCS","0636","RC","","","","outpatient","","","0.22","0.16","AETNA [1001]","HB AMC AETNA PPO","0.18","80.4","","0.29","0.29","0.29","1 through 10","0.04","0.18","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0250","RC","","","","inpatient","","","15.00","11.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8.00","53.3","","0.01","0.01","0.01","1 through 10","6.44","11.93","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","10.77","71.8","","0.60","0.42","0.60","1 through 10","0.7","11.55","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","9.84","65.6","","0.62","0.62","0.62","20","0.7","11.55","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","9.75","65","","0.78","0.78","0.78","204","0.7","11.55","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","10.50","70","","0.57","0.57","0.57","1 through 10","0.7","11.55","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","11.55","77","","1.31","0.44","1.31","20","0.7","11.55","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","9.75","65","","0.79","0.50","6.51","23","0.7","11.55","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4.65","31","","0.40","0.18","0.40","15","0.7","11.55","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5.48","36.5","","0.56","0.21","0.80","934","0.7","11.55","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5.75","38.3","","0.30","0.22","0.95","1218","0.7","11.55","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","15.00","11.25","AETNA [1001]","HB AMC AETNA HMO","10.47","69.8","","0.51","0.31","0.74","1504","0.47","12.06","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","15.00","11.25","AETNA [1001]","HB AMC AETNA PPO","12.06","80.4","","0.60","0.43","0.60","120","0.47","12.06","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","15.00","11.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10.49","69.9","","0.82","0.39","1.61","1442","0.47","12.06","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","15.00","11.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7.04","46.9","","0.80","0.26","1.19","1053","0.47","12.06","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600125","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","12.06","80.4","","0.74","0.44","1.54","12","0.47","12.06","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0250","RC","","","","inpatient","","","0.40","0.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.21","53.3","","0.01","0.01","0.01","1 through 10","0.17","0.32","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","both","","","0.40","0.30","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.29","71.8","","0.60","0.42","0.60","1 through 10","0.12","0.7","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","both","","","0.40","0.30","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.26","65.6","","0.62","0.62","0.62","20","0.12","0.7","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","both","","","0.40","0.30","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.26","65","","0.78","0.78","0.78","204","0.12","0.7","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","both","","","0.40","0.30","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.28","70","","0.57","0.57","0.57","1 through 10","0.12","0.7","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","both","","","0.40","0.30","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","0.31","77","","1.31","0.44","1.31","20","0.12","0.7","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","both","","","0.40","0.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.26","65","","0.79","0.50","6.51","23","0.12","0.7","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","both","","","0.40","0.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.12","31","","0.40","0.18","0.40","15","0.12","0.7","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","both","","","0.40","0.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.15","36.5","","0.56","0.21","0.80","934","0.12","0.7","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","both","","","0.40","0.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.15","38.3","","0.30","0.22","0.95","1218","0.12","0.7","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","0.40","0.30","AETNA [1001]","HB AMC AETNA HMO","0.28","69.8","","0.51","0.31","0.74","1504","0.19","0.47","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","0.40","0.30","AETNA [1001]","HB AMC AETNA PPO","0.32","80.4","","0.60","0.43","0.60","120","0.19","0.47","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","0.40","0.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.28","69.9","","0.82","0.39","1.61","1442","0.19","0.47","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","0.40","0.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.19","46.9","","0.80","0.26","1.19","1053","0.19","0.47","percent of total billed charges",""
"Heparin Na Vl 1000u/Ml 1ml","PX-63600126","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","0.40","0.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.32","80.4","","0.74","0.44","1.54","12","0.19","0.47","percent of total billed charges",""
"Hepatic Coma And Other Major Acute Liver Disorders,EXTREME","279","DRG","","","","","","","","inpatient","","","100424.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","61787.48","","Standard inlier is a Case rate ($61,787.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,696, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,771.11) for the length of stay and the standard reimbursement.","63462.98","63462.98","63462.98","1 through 10","2824","142239.41","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,EXTREME","279","DRG","","","","","","","","inpatient","","","100424.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","69465.78","","Standard inlier is a Case rate ($69,465.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,696, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,860.09) for the length of stay and the standard reimbursement.","63462.98","63462.98","63462.98","1 through 10","2824","142239.41","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,EXTREME","279","DRG","","","","","","","","inpatient","","","100424.22","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12664.1954","","Fee schedule rate ($86,204.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12664.1954","86204.64","86204.64","1 through 10","2824","142239.41","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,EXTREME","279","DRG","","","","","","","","inpatient","","","100424.22","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","13297.7732","","Fee schedule rate ($90,517.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13297.7732","90517.40","90517.40","1 through 10","2824","142239.41","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,EXTREME","279","DRG","","","","","","","","inpatient","","","100424.22","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76079.65","","Fee schedule rate ($76,079.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","76079.65","76079.65","76079.65","1 through 10","2824","142239.41","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,MAJOR","279","DRG","","","","","","","","inpatient","","","52037.12","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","33273.04","","Standard inlier is a Case rate ($33,273.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,662, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,722.83) for the length of stay and the standard reimbursement.","4314.69","4314.69","4314.69","1 through 10","2824","142239.41","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,MAJOR","279","DRG","","","","","","","","inpatient","","","52037.12","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12664.1954","","Fee schedule rate ($32,599.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12664.1954","32599.92","32599.92","1 through 10","2824","142239.41","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,MAJOR","279","DRG","","","","","","","","inpatient","","","52037.12","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31702.09","","Fee schedule rate ($31,702.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31702.09","31702.09","31702.09","1 through 10","2824","142239.41","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,MODERATE","279","DRG","","","","","","","","inpatient","","","53107.10","","MASSHEALTH [3001]","HB BWH MEDICAID","6989.00","","Case rate ($7,727.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,157.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,256.51 and the sum of the standard inlier and any outlier amount.","7725.64","7725.64","7725.64","1 through 10","2824","142239.41","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,MODERATE","279","DRG","","","","","","","","inpatient","","","53107.10","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6989.00","","Case rate ($7,727.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,157.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,256.51 and the sum of the standard inlier and any outlier amount.","7725.64","7725.64","7725.64","1 through 10","2824","142239.41","case rate",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","102.67","71.8","","99.80","51.85","99.80","15","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","93.81","65.6","","108.42","8.41","108.42","1 through 10","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","92.95","65","","90.35","90.35","90.35","1 through 10","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","100.10","70","","139.00","100.08","417.00","11","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","CHAMPVA [160001]","HB BWH TRICARE","135.85","95","","9.84","9.84","9.84","1 through 10","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","113.69","79.5","","109.39","73.39","109.39","655","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","76.22","53.3","","73.39","73.39","220.17","459","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","110.11","77","","107.03","107.03","321.09","1 through 10","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","92.95","65","","90.35","66.30","1918.15","1 through 10","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","113.69","79.5","","109.39","109.39","109.39","1 through 10","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","44.33","31","","42.95","42.95","128.85","22","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","52.20","36.5","","51.85","44.06","132.18","655","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.77","38.3","","54.35","52.82","163.05","2087","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","MOLINA [1014]","HB BWH MOLINA","50.05","35","","16.21","16.21","16.21","1 through 10","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","110.11","77","","108.41","104.81","109.39","1 through 10","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","TRICARE [160005]","HB BWH TRICARE","135.85","95","","9.35","9.35","9.84","21","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.35","42.9","","111.12","61.12","250.12","28","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","143.00","107.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.35","42.9","","61.12","61.12","183.36","1 through 10","8.01","135.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","143.00","107.25","AETNA [1001]","HB AMC AETNA HMO","99.81","69.8","","94.10","66.44","108.42","878","8.43","116.86","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","143.00","107.25","AETNA [1001]","HB AMC AETNA PPO","114.97","80.4","","108.42","69.69","108.42","97","8.43","116.86","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","143.00","107.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","79.94","55.9","","72.84","72.84","72.84","1 through 10","8.43","116.86","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","143.00","107.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","74.73","52.26","","86.01","11.69","86.02","1 through 10","8.43","116.86","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","114.97","80.4","","108.42","69.50","108.42","1 through 10","8.43","116.86","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","116.86","81.72","","111.12","102.42","333.35","1 through 10","8.43","116.86","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","116.86","81.72","","61.12","61.12","111.12","34","8.43","116.86","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","116.86","81.72","","111.12","61.12","111.12","630","8.43","116.86","percent of total billed charges",""
"Hepatitis a & B Vaccine Hepa-Hepb Adult Im","PX-63601191","CDM","90636","CPT","0636","RC","","","","both","","","188.56","141.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.82","36.5","","59.77","59.77","70.33","1 through 10","58.45","179.13","percent of total billed charges",""
"Hepatitis a & B Vaccine Hepa-Hepb Adult Im","PX-63601191","CDM","90636","CPT","0636","RC","","","","both","","","188.56","141.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.22","38.3","","73.73","73.73","73.73","1 through 10","58.45","179.13","percent of total billed charges",""
"Hepatitis a & B Vaccine Hepa-Hepb Adult Im","PX-63601191","CDM","90636","CPT","0636","RC","","","","both","","","188.56","141.42","WELLPOINT [1015]","HB AMC WELLPOINT","139.12","73.78","","188.56","188.56","188.56","1 through 10","58.45","179.13","percent of total billed charges",""
"Hepatitis a & B Vaccine Hepa-Hepb Adult Im","PX-63601191","CDM","90636","CPT","0636","RC","","","","outpatient","","","188.56","141.42","AETNA [1001]","HB AMC AETNA HMO","131.61","69.8","","127.66","90.13","147.08","1 through 10","88.43","154.09","percent of total billed charges",""
"Hepatitis a & B Vaccine Hepa-Hepb Adult Im","PX-63601191","CDM","90636","CPT","0636","RC","","","","outpatient","","","188.56","141.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","131.80","69.9","","130.67","87.49","130.67","1 through 10","88.43","154.09","percent of total billed charges",""
"Hepatitis a & B Vaccine Hepa-Hepb Adult Im","PX-63601191","CDM","90636","CPT","0636","RC","","","","outpatient","","","188.56","141.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","88.43","46.9","","130.67","130.67","130.67","1 through 10","88.43","154.09","percent of total billed charges",""
"Hepatitis a & B Vaccine Hepa-Hepb Adult Im","PX-63601191","CDM","90636","CPT","0636","RC","","","","outpatient","","","188.56","141.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","154.09","81.72","","278.06","278.06","278.06","1 through 10","88.43","154.09","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","both","","","188.00","141.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","122.20","65","","143.23","143.23","143.23","1 through 10","11.03","178.6","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","both","","","188.00","141.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","149.46","79.5","","143.23","96.10","143.23","1 through 10","11.03","178.6","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","both","","","188.00","141.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.20","53.3","","183.82","96.10","183.82","1 through 10","11.03","178.6","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","both","","","188.00","141.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","144.76","77","","140.14","140.14","140.14","1 through 10","11.03","178.6","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.62","36.5","","67.89","57.69","203.67","13","11.03","178.6","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","71.16","69.16","213.48","24","11.03","178.6","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","123.21","87.00","141.96","13","11.62","153.63","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","outpatient","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","153.63","81.72","","145.49","145.49","145.49","1 through 10","11.62","153.63","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","outpatient","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","153.63","81.72","","80.03","80.03","145.49","1 through 10","11.62","153.63","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","153.00","114.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","109.85","71.8","","318.78","106.26","318.78","15","11.99","145.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","153.00","114.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","99.45","65","","116.48","96.20","116.48","1 through 10","11.99","145.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","153.00","114.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","107.10","70","","148.00","106.56","148.00","1 through 10","11.99","145.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","78.14","121.55","35","11.99","145.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.55","53.3","","116.48","78.14","349.44","23","11.99","145.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","153.00","114.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","117.81","77","","113.96","113.96","113.96","1 through 10","11.99","145.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","99.45","65","","96.20","96.20","121.55","1 through 10","11.99","145.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","116.48","116.48","1 through 10","11.99","145.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.85","36.5","","55.20","46.92","165.60","37","11.99","145.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","57.87","57.87","173.61","137","11.99","145.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","153.00","114.75","TRICARE [160005]","HB BWH TRICARE","145.35","95","","14.93","14.93","14.93","1 through 10","11.99","145.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.64","42.9","","118.31","118.31","118.31","1 through 10","11.99","145.35","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","100.20","70.74","115.44","52","11.99","125.03","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA PPO","123.01","80.4","","115.44","115.44","115.44","1 through 10","11.99","125.03","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","85.53","55.9","","77.55","77.55","77.55","1 through 10","11.99","125.03","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","123.01","80.4","","74.00","74.00","74.00","1 through 10","11.99","125.03","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","125.03","81.72","","118.31","118.31","118.31","1 through 10","11.99","125.03","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","118.31","65.08","118.31","40","11.99","125.03","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","both","","","197.00","147.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","156.62","79.5","","150.32","100.85","150.32","18","11.53","187.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","both","","","197.00","147.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","105.00","53.3","","150.32","100.85","192.92","11","11.53","187.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","both","","","197.00","147.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.91","36.5","","71.24","60.55","213.72","19","11.53","187.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","both","","","197.00","147.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.45","38.3","","74.68","74.68","137.14","48","11.53","187.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","both","","","197.00","147.75","TRICARE [160005]","HB BWH TRICARE","187.15","95","","14.18","14.18","14.18","1 through 10","11.53","187.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","outpatient","","","197.00","147.75","AETNA [1001]","HB AMC AETNA HMO","137.51","69.8","","129.31","91.30","148.98","23","12.15","160.99","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","outpatient","","","197.00","147.75","AETNA [1001]","HB AMC AETNA PPO","158.39","80.4","","148.98","148.98","148.98","1 through 10","12.15","160.99","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","outpatient","","","197.00","147.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","102.95","52.26","","118.19","118.19","118.19","1 through 10","12.15","160.99","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","outpatient","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","160.99","81.72","","152.69","83.98","152.69","19","12.15","160.99","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","112.73","71.8","","327.42","109.14","327.42","20","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","102.99","65.6","","102.90","102.90","118.56","1 through 10","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","102.05","65","","98.80","80.26","119.62","1 through 10","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","109.90","70","","152.00","65.36","152.00","16","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.82","79.5","","119.62","80.26","119.62","183","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.68","53.3","","80.26","80.26","240.78","126","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","120.89","77","","351.12","117.04","351.12","1 through 10","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","102.05","65","","98.80","98.80","123.50","1 through 10","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.67","31","","93.94","46.97","93.94","1 through 10","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.31","36.5","","56.70","48.18","170.10","257","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.13","38.3","","59.43","59.43","178.29","701","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","120.89","77","","152.00","152.00","152.00","1 through 10","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","TRICARE [160005]","HB BWH TRICARE","149.15","95","","14.52","13.79","14.52","12","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.35","42.9","","121.51","66.83","121.51","1 through 10","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","157.00","117.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.35","42.9","","66.83","66.83","66.83","1 through 10","11.81","149.15","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA HMO","109.59","69.8","","102.90","72.66","118.56","303","12.43","128.3","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA PPO","126.23","80.4","","118.56","79.65","159.30","32","12.43","128.3","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","87.76","55.9","","79.65","79.65","79.65","1 through 10","12.43","128.3","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","157.00","117.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","82.05","52.26","","94.06","42.28","94.06","1 through 10","12.43","128.3","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","157.00","117.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.23","80.4","","76.00","76.00","76.00","1 through 10","12.43","128.3","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.30","81.72","","121.51","66.83","121.51","11","12.43","128.3","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.30","81.72","","121.51","66.83","121.51","233","12.43","128.3","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","94.78","71.8","","275.70","91.90","275.70","15","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","86.59","65.6","","86.66","86.66","99.84","1 through 10","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","85.80","65","","83.20","67.58","100.74","1 through 10","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","92.40","70","","128.00","55.04","128.00","12","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","104.94","79.5","","100.74","67.58","100.74","195","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","70.36","53.3","","100.74","67.58","202.74","128","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","101.64","77","","295.68","98.56","295.68","1 through 10","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","85.80","65","","83.20","83.20","105.95","1 through 10","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","104.94","79.5","","100.74","100.74","100.74","1 through 10","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","40.92","31","","79.10","39.55","79.10","1 through 10","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.18","36.5","","47.74","40.58","143.22","274","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","50.56","38.3","","50.05","50.05","150.15","900","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","101.64","77","","128.00","128.00","128.00","1 through 10","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","TRICARE [160005]","HB BWH TRICARE","125.40","95","","12.94","12.29","12.94","15","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.63","42.9","","102.32","56.28","102.32","1 through 10","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","132.00","99.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.63","42.9","","56.28","56.28","56.28","1 through 10","10.53","125.4","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","132.00","99.00","AETNA [1001]","HB AMC AETNA HMO","92.14","69.8","","86.66","61.18","99.84","309","10.79","107.87","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","132.00","99.00","AETNA [1001]","HB AMC AETNA PPO","106.13","80.4","","99.84","67.07","134.14","41","10.79","107.87","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","132.00","99.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","73.79","55.9","","67.07","67.07","67.07","1 through 10","10.79","107.87","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","132.00","99.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","68.98","52.26","","79.21","38.14","79.21","1 through 10","10.79","107.87","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","132.00","99.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","106.13","80.4","","64.00","64.00","64.00","1 through 10","10.79","107.87","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","132.00","99.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","107.87","81.72","","102.32","102.32","102.32","1 through 10","10.79","107.87","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","132.00","99.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","107.87","81.72","","102.32","56.28","102.32","11","10.79","107.87","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","132.00","99.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","107.87","81.72","","102.32","56.28","102.32","245","10.79","107.87","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","both","","","142.00","106.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","99.40","70","","62.79","62.79","62.79","1 through 10","11.34","134.9","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","both","","","142.00","106.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","112.89","79.5","","108.61","108.61","108.61","1 through 10","11.34","134.9","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","both","","","142.00","106.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","75.69","53.3","","108.61","72.86","108.61","1 through 10","11.34","134.9","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","both","","","142.00","106.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.83","36.5","","51.47","43.33","76.99","1 through 10","11.34","134.9","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","both","","","142.00","106.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.39","38.3","","53.96","53.96","53.96","11","11.34","134.9","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","outpatient","","","142.00","106.50","AETNA [1001]","HB AMC AETNA HMO","99.12","69.8","","93.43","65.96","107.64","1 through 10","11.93","116.04","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","outpatient","","","142.00","106.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","114.17","80.4","","69.00","69.00","69.00","1 through 10","11.93","116.04","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","outpatient","","","142.00","106.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","116.04","81.72","","110.32","110.32","110.32","1 through 10","11.93","116.04","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","143.60","71.8","","417.87","139.29","417.87","23","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","131.20","65.6","","131.34","131.34","151.32","1 through 10","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","130.00","65","","126.10","102.43","126.10","1 through 10","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","140.00","70","","133.48","74.30","194.00","15","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","CHAMPVA [160001]","HB BWH TRICARE","190.00","95","","17.20","17.20","17.20","1 through 10","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","152.68","102.43","152.68","420","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.60","53.3","","102.43","102.43","307.29","208","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","154.00","77","","448.14","149.38","448.14","1 through 10","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","130.00","65","","126.10","122.20","126.10","1 through 10","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","159.00","79.5","","152.68","152.68","152.68","1 through 10","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","62.00","31","","59.95","59.95","119.90","17","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","72.36","61.50","217.08","471","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","73.72","227.55","1727","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","154.00","77","","194.00","151.32","194.00","1 through 10","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","TRICARE [160005]","HB BWH TRICARE","190.00","95","","17.20","16.34","17.20","24","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","85.30","155.09","24","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","85.30","85.30","85.30","1 through 10","11.99","190","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","131.34","92.73","151.32","652","11.99","163.44","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA PPO","160.80","80.4","","151.32","101.66","203.32","71","11.99","163.44","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","111.80","55.9","","101.66","101.66","101.66","1 through 10","11.99","163.44","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","200.00","150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","104.52","52.26","","50.53","50.53","120.05","1 through 10","11.99","163.44","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","200.00","150.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","160.80","80.4","","97.00","97.00","97.00","1 through 10","11.99","163.44","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","200.00","150.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","155.08","155.08","1 through 10","11.99","163.44","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","163.44","81.72","","85.30","85.30","155.08","15","11.99","163.44","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","85.30","155.08","505","11.99","163.44","percent of total billed charges",""
"Hepatitis Delta Agent Antibody","PX-30000943","CDM","86692","CPT","0302","RC","","","","both","","","216.00","162.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.84","36.5","","110.61","65.63","110.61","1 through 10","16.82","205.2","percent of total billed charges",""
"Hepatitis Delta Agent Antibody","PX-30000943","CDM","86692","CPT","0302","RC","","","","both","","","216.00","162.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82.73","38.3","","81.72","81.72","81.72","1 through 10","16.82","205.2","percent of total billed charges",""
"Hepatitis Delta Agent Antibody","PX-30000943","CDM","86692","CPT","0302","RC","","","","outpatient","","","216.00","162.00","AETNA [1001]","HB AMC AETNA HMO","150.77","69.8","","141.49","141.49","141.49","1 through 10","17.43","176.52","percent of total billed charges",""
"Hepatitis Delta Agent Antibody","PX-30000943","CDM","86692","CPT","0302","RC","","","","outpatient","","","216.00","162.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","176.52","81.72","","91.90","91.90","91.90","1 through 10","17.43","176.52","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Hepatitis E Virus by Quant Pcr Arup","PX-30003757","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","","","","inpatient","","","70579.15","52934.36","MEDICARE [2001]","HB BWH MEDICARE","20949.96","","Case rate ($20,949.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,459.70, add-ons for qualifying new technology services are included. If operating cost exceeds $65,104.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,838.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $19,172.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,079.86 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,398.09. The transfer capital threshold is the transfer adjustment factor * $1,398.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","15904.9","24713.0216","other","Inpatient DRG"
"Hepatobiliary Diagnostic Procedures With McC","420","MS-DRG","","","","","","","","inpatient","","","174557.26","130917.94","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","40716.24","","Case rate ($40,716.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $37,793.94, add-ons for qualifying new technology services are included. If operating cost exceeds $83,438.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,181.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $37,594.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,414.10 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,741.55. The transfer capital threshold is the transfer adjustment factor * $2,741.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","31966.47","31966.47","31966.47","1 through 10","30830.56","53368.81","other","Inpatient DRG"
"Hepatobiliary Diagnostic Procedures With McC","420","MS-DRG","","","","","","","","inpatient","","","174557.26","130917.94","MEDICARE [2001]","HB BWH MEDICARE","40716.24","","Case rate ($40,716.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $37,793.94, add-ons for qualifying new technology services are included. If operating cost exceeds $83,438.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,181.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $37,594.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,414.10 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,741.55. The transfer capital threshold is the transfer adjustment factor * $2,741.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","41888.12","41888.12","41888.12","1 through 10","30830.56","53368.81","other","Inpatient DRG"
"Hepb Vaccine Adult 2/4 Dose Schedule for Im Use","PX-63601183","CDM","90739","CPT","0636","RC","","","","both","","","232.84","174.63","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","167.18","71.8","","167.18","167.18","167.18","1 through 10","72.18","393.15","percent of total billed charges",""
"Hepb Vaccine Adult 2/4 Dose Schedule for Im Use","PX-63601183","CDM","90739","CPT","0636","RC","","","","both","","","232.84","174.63","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","151.35","65","","108.04","108.04","108.04","1 through 10","72.18","393.15","percent of total billed charges",""
"Hepb Vaccine Adult 2/4 Dose Schedule for Im Use","PX-63601183","CDM","90739","CPT","0636","RC","","","","both","","","232.84","174.63","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","81.49","35","","47.46","47.46","47.46","1 through 10","72.18","393.15","percent of total billed charges",""
"Hepb Vaccine Adult 2/4 Dose Schedule for Im Use","PX-63601183","CDM","90739","CPT","0636","RC","","","","both","","","232.84","174.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","84.99","36.5","","86.85","73.81","86.85","22","72.18","393.15","percent of total billed charges",""
"Hepb Vaccine Adult 2/4 Dose Schedule for Im Use","PX-63601183","CDM","90739","CPT","0636","RC","","","","both","","","232.84","174.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.18","38.3","","91.04","91.04","91.04","76","72.18","393.15","percent of total billed charges",""
"Hepb Vaccine Adult 2/4 Dose Schedule for Im Use","PX-63601183","CDM","90739","CPT","0636","RC","","","","outpatient","","","232.84","174.63","AETNA [1001]","HB AMC AETNA HMO","162.52","69.8","","157.63","111.30","315.26","11","109.2","360.27","percent of total billed charges",""
"Hepb Vaccine Adult 2/4 Dose Schedule for Im Use","PX-63601183","CDM","90739","CPT","0636","RC","","","","outpatient","","","232.84","174.63","AETNA [1001]","HB AMC AETNA PPO","187.20","80.4","","181.62","122.01","181.62","1 through 10","109.2","360.27","percent of total billed charges",""
"Hepb Vaccine Adult 2/4 Dose Schedule for Im Use","PX-63601183","CDM","90739","CPT","0636","RC","","","","outpatient","","","232.84","174.63","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","130.16","55.9","","122.01","122.01","122.01","1 through 10","109.2","360.27","percent of total billed charges",""
"Hepb Vaccine Adult 2/4 Dose Schedule for Im Use","PX-63601183","CDM","90739","CPT","0636","RC","","","","outpatient","","","232.84","174.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","162.76","69.9","","108.04","108.04","161.36","1 through 10","109.2","360.27","percent of total billed charges",""
"Hepb Vaccine Adult 2/4 Dose Schedule for Im Use","PX-63601183","CDM","90739","CPT","0636","RC","","","","outpatient","","","232.84","174.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.20","46.9","","108.04","108.04","161.36","12","109.2","360.27","percent of total billed charges",""
"Hepb Vaccine Adult 2/4 Dose Schedule for Im Use","PX-63601183","CDM","90739","CPT","0636","RC","","","","outpatient","","","232.84","174.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","190.28","81.72","","344.60","162.38","361.85","19","109.2","360.27","percent of total billed charges",""
"Hepb Vaccine Adult 3 Dose Schedule for Im Use","PX-63600327","CDM","90746","CPT","0636","RC","","","","both","","","93.34","70.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34.07","36.5","","34.82","34.82","34.82","1 through 10","28.94","172.62","percent of total billed charges",""
"Hepb Vaccine Adult 3 Dose Schedule for Im Use","PX-63600327","CDM","90746","CPT","0636","RC","","","","both","","","93.34","70.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35.75","38.3","","71.12","71.12","71.12","1 through 10","28.94","172.62","percent of total billed charges",""
"Hepb Vaccine Adult 3 Dose Schedule for Im Use","PX-63600327","CDM","90746","CPT","0636","RC","","","","outpatient","","","93.34","70.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","43.78","46.9","","64.68","64.68","64.68","1 through 10","43.78","153.57","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Hereditary Erythrocytosis Mutations","PX-31000758","CDM","81479","CPT","0310","RC","","","","both","","","629.00","471.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","500.06","79.5","","0.65","0.65","0.65","1 through 10","194.99","597.55","percent of total billed charges",""
"Hereditary Erythrocytosis Mutations","PX-31000758","CDM","81479","CPT","0310","RC","","","","both","","","629.00","471.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","335.26","53.3","","0.79","0.79","0.79","1 through 10","194.99","597.55","percent of total billed charges",""
"Hereditary Erythrocytosis Mutations","PX-31000758","CDM","81479","CPT","0310","RC","","","","outpatient","","","629.00","471.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.50","50","","1.00","1.00","1.00","1 through 10","156.55","518.93","percent of total billed charges",""
"Hereditary Erythrocytosis Mutations","PX-31000758","CDM","81479","CPT","0310","RC","","","","outpatient","","","629.00","471.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","330.23","52.5","","1.00","0.53","1.00","1 through 10","156.55","518.93","percent of total billed charges",""
"Hereditary Hemorrhagic Telangiectasia","PX-31001359","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Hereditary Hemorrhagic Telangiectasia","PX-31001359","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Hereditary Hemorrhagic Telangiectasia","PX-31001384","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Hereditary Hemorrhagic Telangiectasia (Hht) Testing","PX-31000792","CDM","81479","CPT","0310","RC","","","","both","","","458.00","343.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","364.11","79.5","","0.65","0.65","0.65","1 through 10","141.98","435.1","percent of total billed charges",""
"Hereditary Hemorrhagic Telangiectasia (Hht) Testing","PX-31000792","CDM","81479","CPT","0310","RC","","","","both","","","458.00","343.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","244.11","53.3","","0.79","0.79","0.79","1 through 10","141.98","435.1","percent of total billed charges",""
"Hereditary Hemorrhagic Telangiectasia (Hht) Testing","PX-31000792","CDM","81479","CPT","0310","RC","","","","outpatient","","","458.00","343.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","229.00","50","","1.00","1.00","1.00","1 through 10","156.55","377.85","percent of total billed charges",""
"Hereditary Hemorrhagic Telangiectasia (Hht) Testing","PX-31000792","CDM","81479","CPT","0310","RC","","","","outpatient","","","458.00","343.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","240.45","52.5","","1.00","0.53","1.00","1 through 10","156.55","377.85","percent of total billed charges",""
"Hereditary Renal Tubular Disorders Evaluation","PX-31000737","CDM","81479","CPT","0310","RC","","","","both","","","1886.00","1414.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1499.37","79.5","","0.65","0.65","0.65","1 through 10","584.66","1791.7","percent of total billed charges",""
"Hereditary Renal Tubular Disorders Evaluation","PX-31000737","CDM","81479","CPT","0310","RC","","","","both","","","1886.00","1414.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1005.24","53.3","","0.79","0.79","0.79","1 through 10","584.66","1791.7","percent of total billed charges",""
"Hereditary Renal Tubular Disorders Evaluation","PX-31000737","CDM","81479","CPT","0310","RC","","","","outpatient","","","1886.00","1414.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","943.00","50","","1.00","1.00","1.00","1 through 10","156.55","1555.95","percent of total billed charges",""
"Hereditary Renal Tubular Disorders Evaluation","PX-31000737","CDM","81479","CPT","0310","RC","","","","outpatient","","","1886.00","1414.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","990.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","1555.95","percent of total billed charges",""
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","","","","inpatient","","","94557.45","70918.09","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","20297.66","","Case rate ($20,297.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,854.64, add-ons for qualifying new technology services are included. If operating cost exceeds $64,499.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,793.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $18,564.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,474.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,353.76. The transfer capital threshold is the transfer adjustment factor * $1,353.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15561.09","15561.09","15561.09","1 through 10","15412.34","25671.3001","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","","","","inpatient","","","94557.45","70918.09","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15726.88","","Case rate ($15,726.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,854.64, add-ons for qualifying new technology services are included. If operating cost exceeds $64,499.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,793.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,993.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,474.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,353.76. The transfer capital threshold is the transfer adjustment factor * $1,353.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","75608.40","75608.40","75608.40","1 through 10","15412.34","25671.3001","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","","","","inpatient","","","94557.45","70918.09","MEDICARE [2001]","HB BWH MEDICARE","20297.66","","Case rate ($20,297.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,854.64, add-ons for qualifying new technology services are included. If operating cost exceeds $64,499.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,793.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $18,564.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,474.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,353.76. The transfer capital threshold is the transfer adjustment factor * $1,353.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20332.82","0.03","20362.81","15","15412.34","25671.3001","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","","","","inpatient","","","94557.45","70918.09","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","15412.34","","Case rate ($15,726.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,854.64, add-ons for qualifying new technology services are included. If operating cost exceeds $64,499.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,793.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,993.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,474.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,353.76. The transfer capital threshold is the transfer adjustment factor * $1,353.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15412.24","15412.24","15412.24","1 through 10","15412.34","25671.3001","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","","","","inpatient","","","94557.45","70918.09","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","15412.34","","Case rate ($15,726.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,854.64, add-ons for qualifying new technology services are included. If operating cost exceeds $64,499.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,793.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,993.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,474.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,353.76. The transfer capital threshold is the transfer adjustment factor * $1,353.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","24157.02","24157.02","24157.02","1 through 10","15412.34","25671.3001","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","","","","inpatient","","","94557.45","70918.09","WELLPOINT [1015]","HB AMC WELLPOINT","25671.3001","","Fee schedule rate ($26,353.11).","25671.3001","65879.08","65879.08","1 through 10","15412.34","25671.3001","case rate",""
"Hernia Procedures Except Inguinal And Femoral With McC","353","MS-DRG","","","","","","","","inpatient","","","133608.65","100206.49","MEDICARE [2001]","HB BWH MEDICARE","26852.19","","Case rate ($26,852.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,247.33, add-ons for qualifying new technology services are included. If operating cost exceeds $77,891.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,775.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $24,137.23 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,867.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,335.12. The transfer capital threshold is the transfer adjustment factor * $2,335.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34855.87","34855.87","34907.60","1 through 10","26315.15","44261.903","other","Inpatient Replacement Plans DRG"
"Hernia Procedures Except Inguinal And Femoral Without Cc/McC","355","MS-DRG","","","","","","","","inpatient","","","68233.07","51174.80","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","13028.54","","Case rate ($12,649.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,149.57, add-ons for qualifying new technology services are included. If operating cost exceeds $60,794.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,522.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,186.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,769.74 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,082.27. The transfer capital threshold is the transfer adjustment factor * $1,082.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12787.14","12787.14","12787.14","1 through 10","12396.09","20119.3212","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral Without Cc/McC","355","MS-DRG","","","","","","","","inpatient","","","68233.07","51174.80","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","16303.19","","Case rate ($16,303.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,149.57, add-ons for qualifying new technology services are included. If operating cost exceeds $60,794.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,522.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $14,841.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,769.74 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,082.27. The transfer capital threshold is the transfer adjustment factor * $1,082.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15748.03","15748.03","15748.03","1 through 10","12396.09","20119.3212","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral Without Cc/McC","355","MS-DRG","","","","","","","","inpatient","","","68233.07","51174.80","MEDICARE [2001]","HB BWH MEDICARE","16303.19","","Case rate ($16,303.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,149.57, add-ons for qualifying new technology services are included. If operating cost exceeds $60,794.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,522.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $14,841.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,769.74 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,082.27. The transfer capital threshold is the transfer adjustment factor * $1,082.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15995.58","15995.58","16019.08","1 through 10","12396.09","20119.3212","other","Inpatient DRG"
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MAJOR","227","DRG","","","","","","","","inpatient","","","146990.61","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","66066.19","","Standard inlier is a Case rate ($66,066.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,023, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,378.49) for the length of stay and the standard reimbursement.","67857.73","67857.73","67857.73","1 through 10","9795.79","165752.23","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MAJOR","227","DRG","","","","","","","","inpatient","","","146990.61","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","74276.21","","Standard inlier is a Case rate ($74,276.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,023, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,542.89) for the length of stay and the standard reimbursement.","74276.20","74276.20","74276.20","1 through 10","9795.79","165752.23","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MAJOR","227","DRG","","","","","","","","inpatient","","","146990.61","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","19678.40","","Case rate ($21,757.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,187.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","34032.45","34032.45","34032.45","1 through 10","9795.79","165752.23","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MINOR","227","DRG","","","","","","","","inpatient","","","108932.30","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","37366.79","","Standard inlier is a Case rate ($37,366.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,706, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,304.44) for the length of stay and the standard reimbursement.","34061.19","34061.19","34061.19","1 through 10","9795.79","165752.23","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MINOR","227","DRG","","","","","","","","inpatient","","","108932.30","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","42010.34","","Standard inlier is a Case rate ($42,010.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,706, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,963.02) for the length of stay and the standard reimbursement.","42010.34","42010.34","42010.34","1 through 10","9795.79","165752.23","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MINOR","227","DRG","","","","","","","","inpatient","","","108932.30","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15652.4266","","Fee schedule rate ($29,853.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15652.4266","22552.64","22552.64","1 through 10","9795.79","165752.23","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MINOR","227","DRG","","","","","","","","inpatient","","","108932.30","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","22552.6461","","Fee schedule rate ($29,853.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22552.6461","22552.64","22552.64","1 through 10","9795.79","165752.23","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MINOR","227","DRG","","","","","","","","inpatient","","","108932.30","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9795.79","","Case rate ($10,830.93). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,260.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","46165.15","46165.15","46165.15","1 through 10","9795.79","165752.23","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MODERATE","227","DRG","","","","","","","","inpatient","","","107111.47","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","46745.68","","Standard inlier is a Case rate ($46,745.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,000, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,635.83) for the length of stay and the standard reimbursement.","42610.39","42610.39","42610.39","1 through 10","9795.79","165752.23","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MODERATE","227","DRG","","","","","","","","inpatient","","","107111.47","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","52554.74","","Standard inlier is a Case rate ($52,554.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,000, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,459.71) for the length of stay and the standard reimbursement.","52554.74","52554.74","52554.74","1 through 10","9795.79","165752.23","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MODERATE","227","DRG","","","","","","","","inpatient","","","107111.47","","MASSHEALTH [3001]","HB BWH MEDICAID","12933.87","","Case rate ($14,300.61). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,730.61, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14297.10","14297.10","14297.10","1 through 10","9795.79","165752.23","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MODERATE","227","DRG","","","","","","","","inpatient","","","107111.47","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","42234.59","","Fee schedule rate ($42,234.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42234.59","42234.59","42234.59","1 through 10","9795.79","165752.23","case rate",""
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MODERATE","227","DRG","","","","","","","","inpatient","","","107111.47","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12933.87","","Case rate ($14,300.61). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,730.61, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14297.10","14297.10","14297.10","1 through 10","9795.79","165752.23","case rate",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","both","","","171.00","128.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","119.70","70","","119.52","119.52","119.52","1 through 10","14.1","162.45","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","both","","","171.00","128.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","135.95","79.5","","130.64","87.65","391.92","27","14.1","162.45","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","both","","","171.00","128.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","91.14","53.3","","87.65","87.65","261.28","1 through 10","14.1","162.45","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","both","","","171.00","128.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","62.42","36.5","","61.92","52.62","185.76","34","14.1","162.45","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","both","","","171.00","128.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","65.49","38.3","","64.91","64.91","189.24","90","14.1","162.45","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","both","","","171.00","128.25","TRICARE [160005]","HB BWH TRICARE","162.45","95","","16.48","16.48","16.48","1 through 10","14.1","162.45","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","outpatient","","","171.00","128.25","AETNA [1001]","HB AMC AETNA HMO","119.36","69.8","","112.38","79.35","129.48","35","14.84","139.74","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","outpatient","","","171.00","128.25","AETNA [1001]","HB AMC AETNA PPO","137.48","80.4","","129.48","129.48","129.48","1 through 10","14.84","139.74","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","outpatient","","","171.00","128.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","139.74","81.72","","72.99","72.99","72.99","1 through 10","14.84","139.74","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","outpatient","","","171.00","128.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","139.74","81.72","","132.70","72.99","265.40","30","14.84","139.74","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1 through 10","5.08","81.7","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","131.46","40.91","131.46","1 through 10","5.08","81.7","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.06","30.96","1 through 10","5.08","81.7","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","27.39","32.45","22","5.08","81.7","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","both","","","86.00","64.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","64.74","64.74","64.74","1 through 10","5.08","81.7","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","6.24","6.24","6.24","1 through 10","5.08","81.7","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","56.19","14","5.34","70.28","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","43.49","43.49","43.49","1 through 10","5.34","70.28","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","66.35","66.35","66.35","1 through 10","5.34","70.28","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","36.50","66.35","1 through 10","5.34","70.28","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","both","","","108.00","81.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","85.86","79.5","","85.00","85.00","85.00","1 through 10","33.48","362.33","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","both","","","108.00","81.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","39.42","36.5","","34.24","34.24","34.24","1 through 10","33.48","362.33","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","both","","","108.00","81.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","41.36","38.3","","42.23","42.23","42.23","12","33.48","362.33","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","both","","","108.00","81.00","WELLPOINT [1015]","HB AMC WELLPOINT","79.68","73.78","","80.41","80.41","80.41","1 through 10","33.48","362.33","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","108.00","81.00","AETNA [1001]","HB AMC AETNA HMO","75.38","69.8","","73.12","51.62","84.24","1 through 10","54","601.88","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","108.00","81.00","AETNA [1001]","HB AMC AETNA PPO","86.83","80.4","","84.24","84.24","84.24","1 through 10","54","601.88","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","108.00","81.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","56.70","52.5","","70.74","62.21","70.74","1 through 10","54","601.88","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","108.00","81.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","54.00","50","","56.59","56.59","56.59","1 through 10","54","601.88","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","108.00","81.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","56.70","52.5","","59.40","59.40","59.40","1 through 10","54","601.88","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","108.00","81.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","59.40","55","","108.00","108.00","108.00","1 through 10","54","601.88","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","88.26","81.72","","62.21","62.21","62.21","1 through 10","54","601.88","percent of total billed charges",""
"High Altitude Simulat Test O2","PX-46000034","CDM","94453","CPT","0460","RC","","","","both","","","2275.00","1706.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","191.33","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","25.00","25.00","25.00","1 through 10","145.42","1808.63","other","OPPS APC"
"High Altitude Simulat Test O2","PX-46000034","CDM","94453","CPT","0460","RC","","","","both","","","2275.00","1706.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1808.63","79.5","","1164.77","1164.77","1164.77","1 through 10","145.42","1808.63","percent of total billed charges",""
"High Altitude Simulat Test O2","PX-46000034","CDM","94453","CPT","0460","RC","","","","both","","","2275.00","1706.25","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","145.42","1808.63","other","OPPS APC"
"High Altitude Simulat Test O2","PX-46000034","CDM","94453","CPT","0460","RC","","","","both","","","2275.00","1706.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.42","150.42","150.42","1 through 10","145.42","1808.63","other","OPPS APC"
"High Altitude Simulat Test O2","PX-46000034","CDM","94453","CPT","0460","RC","","","","both","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.52","150.02","150.64","1 through 10","145.42","1808.63","other","OPPS APC"
"HINGE ARTICULAR 17MM IMPLANT KNEE SIZE C TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10016407","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2444.59","52.26","","1113.10","1113.10","1113.10","1 through 10","1450.1","3718.81","percent of total billed charges",""
"HINGE ARTICULAR 17MM IMPLANT KNEE SIZE C TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10016407","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3718.81","79.5","","1293.60","1148.53","1603.80","1 through 10","1450.1","3718.81","percent of total billed charges",""
"HINGE ARTICULAR 17MM IMPLANT KNEE SIZE C TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10016407","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1707.38","36.5","","1023.42","771.29","2068.67","33","1450.1","3718.81","percent of total billed charges",""
"HINGE ARTICULAR 17MM IMPLANT KNEE SIZE C TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10016407","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1791.58","38.3","","850.52","759.78","1211.25","66","1450.1","3718.81","percent of total billed charges",""
"HINGE ARTICULAR 17MM IMPLANT KNEE SIZE C TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10016407","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2006.75","42.9","","2548.09","2548.09","2548.09","1 through 10","1450.1","3718.81","percent of total billed charges",""
"HINGE ARTICULAR 17MM IMPLANT KNEE SIZE C TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10016407","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2006.75","42.9","","956.46","956.46","956.46","1 through 10","1450.1","3718.81","percent of total billed charges",""
"HINGE ARTICULAR 17MM IMPLANT KNEE SIZE C TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10016407","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","WELLPOINT [1015]","HB AMC WELLPOINT","3451.24","73.78","","2344.73","1619.47","2530.35","16","1450.1","3718.81","percent of total billed charges",""
"HINGE ARTICULAR 17MM IMPLANT KNEE SIZE C TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10016407","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4677.75","3508.31","AETNA [1001]","HB AMC AETNA HMO","3265.07","69.8","","1523.63","988.41","4330.26","39","2444.59","3822.66","percent of total billed charges",""
"HINGE ARTICULAR 17MM IMPLANT KNEE SIZE C TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10016407","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4677.75","3508.31","AETNA [1001]","HB AMC AETNA PPO","3760.91","80.4","","1670.25","1670.25","1670.25","1 through 10","2444.59","3822.66","percent of total billed charges",""
"HINGE ARTICULAR 17MM IMPLANT KNEE SIZE C TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10016407","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4677.75","3508.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2444.59","52.26","","1113.10","1113.10","1113.10","1 through 10","2444.59","3822.66","percent of total billed charges",""
"HINGE ARTICULAR 17MM IMPLANT KNEE SIZE C TIBIAL SURFACE ROTATING NEXGEN RHK 08 ONC 06 NC","SUP-ITM-10016407","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4677.75","3508.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3822.66","81.72","","1738.90","1484.65","2716.94","38","2444.59","3822.66","percent of total billed charges",""
"HINGE BUMPER +3 DEGREES TRIATHLON","SUP-ITM-10322167","CDM","C1776","HCPCS","0278","RC","","","","both","","","2791.25","2093.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1458.71","52.26","","1113.10","1113.10","1113.10","1 through 10","865.29","2219.04","percent of total billed charges",""
"HINGE BUMPER +3 DEGREES TRIATHLON","SUP-ITM-10322167","CDM","C1776","HCPCS","0278","RC","","","","both","","","2791.25","2093.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2219.04","79.5","","1293.60","1148.53","1603.80","1 through 10","865.29","2219.04","percent of total billed charges",""
"HINGE BUMPER +3 DEGREES TRIATHLON","SUP-ITM-10322167","CDM","C1776","HCPCS","0278","RC","","","","both","","","2791.25","2093.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1018.81","36.5","","1023.42","771.29","2068.67","33","865.29","2219.04","percent of total billed charges",""
"HINGE BUMPER +3 DEGREES TRIATHLON","SUP-ITM-10322167","CDM","C1776","HCPCS","0278","RC","","","","both","","","2791.25","2093.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1069.05","38.3","","850.52","759.78","1211.25","66","865.29","2219.04","percent of total billed charges",""
"HINGE BUMPER +3 DEGREES TRIATHLON","SUP-ITM-10322167","CDM","C1776","HCPCS","0278","RC","","","","both","","","2791.25","2093.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1197.45","42.9","","2548.09","2548.09","2548.09","1 through 10","865.29","2219.04","percent of total billed charges",""
"HINGE BUMPER +3 DEGREES TRIATHLON","SUP-ITM-10322167","CDM","C1776","HCPCS","0278","RC","","","","both","","","2791.25","2093.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1197.45","42.9","","956.46","956.46","956.46","1 through 10","865.29","2219.04","percent of total billed charges",""
"HINGE BUMPER +3 DEGREES TRIATHLON","SUP-ITM-10322167","CDM","C1776","HCPCS","0278","RC","","","","both","","","2791.25","2093.44","WELLPOINT [1015]","HB AMC WELLPOINT","2059.38","73.78","","2344.73","1619.47","2530.35","16","865.29","2219.04","percent of total billed charges",""
"HINGE BUMPER +3 DEGREES TRIATHLON","SUP-ITM-10322167","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2791.25","2093.44","AETNA [1001]","HB AMC AETNA HMO","1948.29","69.8","","1523.63","988.41","4330.26","39","1458.71","2281.01","percent of total billed charges",""
"HINGE BUMPER +3 DEGREES TRIATHLON","SUP-ITM-10322167","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2791.25","2093.44","AETNA [1001]","HB AMC AETNA PPO","2244.17","80.4","","1670.25","1670.25","1670.25","1 through 10","1458.71","2281.01","percent of total billed charges",""
"HINGE BUMPER +3 DEGREES TRIATHLON","SUP-ITM-10322167","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2791.25","2093.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1458.71","52.26","","1113.10","1113.10","1113.10","1 through 10","1458.71","2281.01","percent of total billed charges",""
"HINGE BUMPER +3 DEGREES TRIATHLON","SUP-ITM-10322167","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2791.25","2093.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2281.01","81.72","","1738.90","1484.65","2716.94","38","1458.71","2281.01","percent of total billed charges",""
"HINGE EXTERNAL 90DEG FIXATION DEVICE ILIZAROV SS LOW PROFILE","SUP-ITM-10062142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1363.43","79.5","","800.18","480.96","1887.97","195","531.65","1363.43","percent of total billed charges",""
"HINGE EXTERNAL 90DEG FIXATION DEVICE ILIZAROV SS LOW PROFILE","SUP-ITM-10062142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","914.10","53.3","","813.12","216.42","1444.50","81","531.65","1363.43","percent of total billed charges",""
"HINGE EXTERNAL 90DEG FIXATION DEVICE ILIZAROV SS LOW PROFILE","SUP-ITM-10062142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","531.65","31","","432.60","432.60","432.60","1 through 10","531.65","1363.43","percent of total billed charges",""
"HINGE EXTERNAL 90DEG FIXATION DEVICE ILIZAROV SS LOW PROFILE","SUP-ITM-10062142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","625.98","36.5","","148.37","54.89","631.39","94","531.65","1363.43","percent of total billed charges",""
"HINGE EXTERNAL 90DEG FIXATION DEVICE ILIZAROV SS LOW PROFILE","SUP-ITM-10062142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","656.85","38.3","","279.30","91.72","1116.77","266","531.65","1363.43","percent of total billed charges",""
"HINGE EXTERNAL 90DEG FIXATION DEVICE ILIZAROV SS LOW PROFILE","SUP-ITM-10062142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.74","42.9","","731.00","63.70","731.00","1 through 10","531.65","1363.43","percent of total billed charges",""
"HINGE EXTERNAL 90DEG FIXATION DEVICE ILIZAROV SS LOW PROFILE","SUP-ITM-10062142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.74","42.9","","384.74","384.74","384.74","1 through 10","531.65","1363.43","percent of total billed charges",""
"HINGE EXTERNAL 90DEG FIXATION DEVICE ILIZAROV SS LOW PROFILE","SUP-ITM-10062142","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","WELLPOINT [1015]","HB AMC WELLPOINT","1265.33","73.78","","286.63","119.22","1107.45","105","531.65","1363.43","percent of total billed charges",""
"HINGE EXTERNAL 90DEG FIXATION DEVICE ILIZAROV SS LOW PROFILE","SUP-ITM-10062142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","AETNA [1001]","HB AMC AETNA HMO","1197.07","69.8","","675.31","184.75","1721.50","286","896.26","1401.5","percent of total billed charges",""
"HINGE EXTERNAL 90DEG FIXATION DEVICE ILIZAROV SS LOW PROFILE","SUP-ITM-10062142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","AETNA [1001]","HB AMC AETNA PPO","1378.86","80.4","","1261.44","103.12","1514.10","21","896.26","1401.5","percent of total billed charges",""
"HINGE EXTERNAL 90DEG FIXATION DEVICE ILIZAROV SS LOW PROFILE","SUP-ITM-10062142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1378.86","80.4","","1365.00","1365.00","1365.00","1 through 10","896.26","1401.5","percent of total billed charges",""
"HINGE EXTERNAL 90DEG FIXATION DEVICE ILIZAROV SS LOW PROFILE","SUP-ITM-10062142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1401.50","81.72","","5157.68","5157.68","5157.68","1 through 10","896.26","1401.5","percent of total billed charges",""
"HINGE EXTERNAL 90DEG FIXATION DEVICE ILIZAROV SS LOW PROFILE","SUP-ITM-10062142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1401.50","81.72","","431.26","71.26","1459.57","88","896.26","1401.5","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1139.53","52.26","","1113.10","1113.10","1113.10","1 through 10","675.96","1733.5","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1733.50","79.5","","1293.60","1148.53","1603.80","1 through 10","675.96","1733.5","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","795.88","36.5","","1023.42","771.29","2068.67","33","675.96","1733.5","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","835.13","38.3","","850.52","759.78","1211.25","66","675.96","1733.5","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","935.43","42.9","","2548.09","2548.09","2548.09","1 through 10","675.96","1733.5","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","935.43","42.9","","956.46","956.46","956.46","1 through 10","675.96","1733.5","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","WELLPOINT [1015]","HB AMC WELLPOINT","1608.77","73.78","","2344.73","1619.47","2530.35","16","675.96","1733.5","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","AETNA [1001]","HB AMC AETNA HMO","1521.99","69.8","","1523.63","988.41","4330.26","39","1139.53","1781.9","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","AETNA [1001]","HB AMC AETNA PPO","1753.12","80.4","","1670.25","1670.25","1670.25","1 through 10","1139.53","1781.9","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1139.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1139.53","1781.9","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1781.90","81.72","","1738.90","1484.65","2716.94","38","1139.53","1781.9","percent of total billed charges",""
"HINGE ROTATING 12MM COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL SIZE C","SUP-ITM-10030057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2444.59","52.26","","1113.10","1113.10","1113.10","1 through 10","1450.1","3718.81","percent of total billed charges",""
"HINGE ROTATING 12MM COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL SIZE C","SUP-ITM-10030057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3718.81","79.5","","1293.60","1148.53","1603.80","1 through 10","1450.1","3718.81","percent of total billed charges",""
"HINGE ROTATING 12MM COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL SIZE C","SUP-ITM-10030057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1707.38","36.5","","1023.42","771.29","2068.67","33","1450.1","3718.81","percent of total billed charges",""
"HINGE ROTATING 12MM COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL SIZE C","SUP-ITM-10030057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1791.58","38.3","","850.52","759.78","1211.25","66","1450.1","3718.81","percent of total billed charges",""
"HINGE ROTATING 12MM COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL SIZE C","SUP-ITM-10030057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2006.75","42.9","","2548.09","2548.09","2548.09","1 through 10","1450.1","3718.81","percent of total billed charges",""
"HINGE ROTATING 12MM COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL SIZE C","SUP-ITM-10030057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2006.75","42.9","","956.46","956.46","956.46","1 through 10","1450.1","3718.81","percent of total billed charges",""
"HINGE ROTATING 12MM COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL SIZE C","SUP-ITM-10030057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","WELLPOINT [1015]","HB AMC WELLPOINT","3451.24","73.78","","2344.73","1619.47","2530.35","16","1450.1","3718.81","percent of total billed charges",""
"HINGE ROTATING 12MM COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL SIZE C","SUP-ITM-10030057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4677.75","3508.31","AETNA [1001]","HB AMC AETNA HMO","3265.07","69.8","","1523.63","988.41","4330.26","39","2444.59","3822.66","percent of total billed charges",""
"HINGE ROTATING 12MM COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL SIZE C","SUP-ITM-10030057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4677.75","3508.31","AETNA [1001]","HB AMC AETNA PPO","3760.91","80.4","","1670.25","1670.25","1670.25","1 through 10","2444.59","3822.66","percent of total billed charges",""
"HINGE ROTATING 12MM COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL SIZE C","SUP-ITM-10030057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4677.75","3508.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2444.59","52.26","","1113.10","1113.10","1113.10","1 through 10","2444.59","3822.66","percent of total billed charges",""
"HINGE ROTATING 12MM COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL SIZE C","SUP-ITM-10030057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4677.75","3508.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3822.66","81.72","","1738.90","1484.65","2716.94","38","2444.59","3822.66","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1832.76","52.26","","1113.10","1113.10","1113.10","1 through 10","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2788.07","79.5","","1293.60","1148.53","1603.80","1 through 10","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1280.06","36.5","","1023.42","771.29","2068.67","33","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1343.18","38.3","","850.52","759.78","1211.25","66","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1504.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1504.50","42.9","","956.46","956.46","956.46","1 through 10","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","WELLPOINT [1015]","HB AMC WELLPOINT","2587.46","73.78","","2344.73","1619.47","2530.35","16","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","AETNA [1001]","HB AMC AETNA HMO","2447.89","69.8","","1523.63","988.41","4330.26","39","1832.76","2865.92","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","AETNA [1001]","HB AMC AETNA PPO","2819.63","80.4","","1670.25","1670.25","1670.25","1 through 10","1832.76","2865.92","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1832.76","52.26","","1113.10","1113.10","1113.10","1 through 10","1832.76","2865.92","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2865.92","81.72","","1738.90","1484.65","2716.94","38","1832.76","2865.92","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1832.76","52.26","","1113.10","1113.10","1113.10","1 through 10","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2788.07","79.5","","1293.60","1148.53","1603.80","1 through 10","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1280.06","36.5","","1023.42","771.29","2068.67","33","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1343.18","38.3","","850.52","759.78","1211.25","66","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1504.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1504.50","42.9","","956.46","956.46","956.46","1 through 10","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","WELLPOINT [1015]","HB AMC WELLPOINT","2587.46","73.78","","2344.73","1619.47","2530.35","16","1087.17","2788.07","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","AETNA [1001]","HB AMC AETNA HMO","2447.89","69.8","","1523.63","988.41","4330.26","39","1832.76","2865.92","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","AETNA [1001]","HB AMC AETNA PPO","2819.63","80.4","","1670.25","1670.25","1670.25","1 through 10","1832.76","2865.92","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1832.76","52.26","","1113.10","1113.10","1113.10","1 through 10","1832.76","2865.92","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2865.92","81.72","","1738.90","1484.65","2716.94","38","1832.76","2865.92","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3636.71","52.26","","1113.10","1113.10","1113.10","1 through 10","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5532.31","79.5","","1293.60","1148.53","1603.80","1 through 10","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2539.99","36.5","","1023.42","771.29","2068.67","33","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2665.25","38.3","","850.52","759.78","1211.25","66","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2985.36","42.9","","2548.09","2548.09","2548.09","1 through 10","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2985.36","42.9","","956.46","956.46","956.46","1 through 10","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","WELLPOINT [1015]","HB AMC WELLPOINT","5134.26","73.78","","2344.73","1619.47","2530.35","16","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","AETNA [1001]","HB AMC AETNA HMO","4857.30","69.8","","1523.63","988.41","4330.26","39","3636.71","5686.8","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","AETNA [1001]","HB AMC AETNA PPO","5594.94","80.4","","1670.25","1670.25","1670.25","1 through 10","3636.71","5686.8","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3636.71","52.26","","1113.10","1113.10","1113.10","1 through 10","3636.71","5686.8","percent of total billed charges",""
"HINGE ROTATING 46X67MM SIZE 3 COMPONENT TIBIAL KNEE NEXGEN COMPLETE PRECOAT NONMODULAR","SUP-ITM-10126195","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5686.80","81.72","","1738.90","1484.65","2716.94","38","3636.71","5686.8","percent of total billed charges",""
"HINGE ROTATING 46X70MM SIZE 4 COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10011132","CDM","C1713","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5532.31","79.5","","800.18","480.96","1887.97","195","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X70MM SIZE 4 COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10011132","CDM","C1713","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3709.08","53.3","","813.12","216.42","1444.50","81","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X70MM SIZE 4 COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10011132","CDM","C1713","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2157.25","31","","432.60","432.60","432.60","1 through 10","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X70MM SIZE 4 COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10011132","CDM","C1713","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2539.99","36.5","","148.37","54.89","631.39","94","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X70MM SIZE 4 COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10011132","CDM","C1713","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2665.25","38.3","","279.30","91.72","1116.77","266","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X70MM SIZE 4 COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10011132","CDM","C1713","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2985.36","42.9","","731.00","63.70","731.00","1 through 10","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X70MM SIZE 4 COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10011132","CDM","C1713","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2985.36","42.9","","384.74","384.74","384.74","1 through 10","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X70MM SIZE 4 COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10011132","CDM","C1713","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","WELLPOINT [1015]","HB AMC WELLPOINT","5134.26","73.78","","286.63","119.22","1107.45","105","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 46X70MM SIZE 4 COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10011132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","AETNA [1001]","HB AMC AETNA HMO","4857.30","69.8","","675.31","184.75","1721.50","286","3636.71","5686.8","percent of total billed charges",""
"HINGE ROTATING 46X70MM SIZE 4 COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10011132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","AETNA [1001]","HB AMC AETNA PPO","5594.94","80.4","","1261.44","103.12","1514.10","21","3636.71","5686.8","percent of total billed charges",""
"HINGE ROTATING 46X70MM SIZE 4 COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10011132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5594.94","80.4","","1365.00","1365.00","1365.00","1 through 10","3636.71","5686.8","percent of total billed charges",""
"HINGE ROTATING 46X70MM SIZE 4 COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10011132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5686.80","81.72","","5157.68","5157.68","5157.68","1 through 10","3636.71","5686.8","percent of total billed charges",""
"HINGE ROTATING 46X70MM SIZE 4 COMPONENT ARTICULAR SURFACE TIBIAL KNEE NEXGEN TRABECULAR METAL","SUP-ITM-10011132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5686.80","81.72","","431.26","71.26","1459.57","88","3636.71","5686.8","percent of total billed charges",""
"HINGE ROTATING 50X74MM SIZE 5 COMPONENT KNEE NEXGEN COMPLETE PRECOAT","SUP-ITM-10030912","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3636.71","52.26","","1113.10","1113.10","1113.10","1 through 10","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 50X74MM SIZE 5 COMPONENT KNEE NEXGEN COMPLETE PRECOAT","SUP-ITM-10030912","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5532.31","79.5","","1293.60","1148.53","1603.80","1 through 10","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 50X74MM SIZE 5 COMPONENT KNEE NEXGEN COMPLETE PRECOAT","SUP-ITM-10030912","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2539.99","36.5","","1023.42","771.29","2068.67","33","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 50X74MM SIZE 5 COMPONENT KNEE NEXGEN COMPLETE PRECOAT","SUP-ITM-10030912","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2665.25","38.3","","850.52","759.78","1211.25","66","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 50X74MM SIZE 5 COMPONENT KNEE NEXGEN COMPLETE PRECOAT","SUP-ITM-10030912","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2985.36","42.9","","2548.09","2548.09","2548.09","1 through 10","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 50X74MM SIZE 5 COMPONENT KNEE NEXGEN COMPLETE PRECOAT","SUP-ITM-10030912","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2985.36","42.9","","956.46","956.46","956.46","1 through 10","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 50X74MM SIZE 5 COMPONENT KNEE NEXGEN COMPLETE PRECOAT","SUP-ITM-10030912","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","WELLPOINT [1015]","HB AMC WELLPOINT","5134.26","73.78","","2344.73","1619.47","2530.35","16","2157.25","5532.31","percent of total billed charges",""
"HINGE ROTATING 50X74MM SIZE 5 COMPONENT KNEE NEXGEN COMPLETE PRECOAT","SUP-ITM-10030912","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","AETNA [1001]","HB AMC AETNA HMO","4857.30","69.8","","1523.63","988.41","4330.26","39","3636.71","5686.8","percent of total billed charges",""
"HINGE ROTATING 50X74MM SIZE 5 COMPONENT KNEE NEXGEN COMPLETE PRECOAT","SUP-ITM-10030912","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","AETNA [1001]","HB AMC AETNA PPO","5594.94","80.4","","1670.25","1670.25","1670.25","1 through 10","3636.71","5686.8","percent of total billed charges",""
"HINGE ROTATING 50X74MM SIZE 5 COMPONENT KNEE NEXGEN COMPLETE PRECOAT","SUP-ITM-10030912","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3636.71","52.26","","1113.10","1113.10","1113.10","1 through 10","3636.71","5686.8","percent of total billed charges",""
"HINGE ROTATING 50X74MM SIZE 5 COMPONENT KNEE NEXGEN COMPLETE PRECOAT","SUP-ITM-10030912","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5686.80","81.72","","1738.90","1484.65","2716.94","38","3636.71","5686.8","percent of total billed charges",""
"HINGE ROTATING 58X68MM KNEE 5880 14 02 FEMORAL COMPONENT OPTION SZ D RT 07 ONC NC","SUP-ITM-10033410","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8759.11","52.26","","1113.10","1113.10","1113.10","1 through 10","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING 58X68MM KNEE 5880 14 02 FEMORAL COMPONENT OPTION SZ D RT 07 ONC NC","SUP-ITM-10033410","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13324.70","79.5","","1293.60","1148.53","1603.80","1 through 10","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING 58X68MM KNEE 5880 14 02 FEMORAL COMPONENT OPTION SZ D RT 07 ONC NC","SUP-ITM-10033410","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6117.63","36.5","","1023.42","771.29","2068.67","33","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING 58X68MM KNEE 5880 14 02 FEMORAL COMPONENT OPTION SZ D RT 07 ONC NC","SUP-ITM-10033410","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6419.32","38.3","","850.52","759.78","1211.25","66","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING 58X68MM KNEE 5880 14 02 FEMORAL COMPONENT OPTION SZ D RT 07 ONC NC","SUP-ITM-10033410","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7190.31","42.9","","2548.09","2548.09","2548.09","1 through 10","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING 58X68MM KNEE 5880 14 02 FEMORAL COMPONENT OPTION SZ D RT 07 ONC NC","SUP-ITM-10033410","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7190.31","42.9","","956.46","956.46","956.46","1 through 10","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING 58X68MM KNEE 5880 14 02 FEMORAL COMPONENT OPTION SZ D RT 07 ONC NC","SUP-ITM-10033410","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","WELLPOINT [1015]","HB AMC WELLPOINT","12365.99","73.78","","2344.73","1619.47","2530.35","16","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING 58X68MM KNEE 5880 14 02 FEMORAL COMPONENT OPTION SZ D RT 07 ONC NC","SUP-ITM-10033410","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16760.63","12570.47","AETNA [1001]","HB AMC AETNA HMO","11698.92","69.8","","1523.63","988.41","4330.26","39","8759.11","13696.79","percent of total billed charges",""
"HINGE ROTATING 58X68MM KNEE 5880 14 02 FEMORAL COMPONENT OPTION SZ D RT 07 ONC NC","SUP-ITM-10033410","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16760.63","12570.47","AETNA [1001]","HB AMC AETNA PPO","13475.55","80.4","","1670.25","1670.25","1670.25","1 through 10","8759.11","13696.79","percent of total billed charges",""
"HINGE ROTATING 58X68MM KNEE 5880 14 02 FEMORAL COMPONENT OPTION SZ D RT 07 ONC NC","SUP-ITM-10033410","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16760.63","12570.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8759.11","52.26","","1113.10","1113.10","1113.10","1 through 10","8759.11","13696.79","percent of total billed charges",""
"HINGE ROTATING 58X68MM KNEE 5880 14 02 FEMORAL COMPONENT OPTION SZ D RT 07 ONC NC","SUP-ITM-10033410","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16760.63","12570.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13696.79","81.72","","1738.90","1484.65","2716.94","38","8759.11","13696.79","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5585.29","52.26","","1113.10","1113.10","1113.10","1 through 10","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8496.56","79.5","","1293.60","1148.53","1603.80","1 through 10","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3900.94","36.5","","1023.42","771.29","2068.67","33","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4093.31","38.3","","850.52","759.78","1211.25","66","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4584.94","42.9","","2548.09","2548.09","2548.09","1 through 10","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4584.94","42.9","","956.46","956.46","956.46","1 through 10","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","WELLPOINT [1015]","HB AMC WELLPOINT","7885.24","73.78","","2344.73","1619.47","2530.35","16","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10687.50","8015.62","AETNA [1001]","HB AMC AETNA HMO","7459.88","69.8","","1523.63","988.41","4330.26","39","5585.29","8733.83","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10687.50","8015.62","AETNA [1001]","HB AMC AETNA PPO","8592.75","80.4","","1670.25","1670.25","1670.25","1 through 10","5585.29","8733.83","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10687.50","8015.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5585.29","52.26","","1113.10","1113.10","1113.10","1 through 10","5585.29","8733.83","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10687.50","8015.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8733.83","81.72","","1738.90","1484.65","2716.94","38","5585.29","8733.83","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5585.29","52.26","","1113.10","1113.10","1113.10","1 through 10","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8496.56","79.5","","1293.60","1148.53","1603.80","1 through 10","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3900.94","36.5","","1023.42","771.29","2068.67","33","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4093.31","38.3","","850.52","759.78","1211.25","66","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4584.94","42.9","","2548.09","2548.09","2548.09","1 through 10","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4584.94","42.9","","956.46","956.46","956.46","1 through 10","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","10687.50","8015.62","WELLPOINT [1015]","HB AMC WELLPOINT","7885.24","73.78","","2344.73","1619.47","2530.35","16","3313.13","8496.56","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10687.50","8015.62","AETNA [1001]","HB AMC AETNA HMO","7459.88","69.8","","1523.63","988.41","4330.26","39","5585.29","8733.83","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10687.50","8015.62","AETNA [1001]","HB AMC AETNA PPO","8592.75","80.4","","1670.25","1670.25","1670.25","1 through 10","5585.29","8733.83","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10687.50","8015.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5585.29","52.26","","1113.10","1113.10","1113.10","1 through 10","5585.29","8733.83","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10687.50","8015.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8733.83","81.72","","1738.90","1484.65","2716.94","38","5585.29","8733.83","percent of total billed charges",""
"HINGE ROTATING F 66X76MM COMPONENT FEMORAL KNEE NEXGEN COMPLETE OPTION RT SIZE","SUP-ITM-10130324","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8759.11","52.26","","1113.10","1113.10","1113.10","1 through 10","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING F 66X76MM COMPONENT FEMORAL KNEE NEXGEN COMPLETE OPTION RT SIZE","SUP-ITM-10130324","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13324.70","79.5","","1293.60","1148.53","1603.80","1 through 10","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING F 66X76MM COMPONENT FEMORAL KNEE NEXGEN COMPLETE OPTION RT SIZE","SUP-ITM-10130324","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6117.63","36.5","","1023.42","771.29","2068.67","33","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING F 66X76MM COMPONENT FEMORAL KNEE NEXGEN COMPLETE OPTION RT SIZE","SUP-ITM-10130324","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6419.32","38.3","","850.52","759.78","1211.25","66","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING F 66X76MM COMPONENT FEMORAL KNEE NEXGEN COMPLETE OPTION RT SIZE","SUP-ITM-10130324","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7190.31","42.9","","2548.09","2548.09","2548.09","1 through 10","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING F 66X76MM COMPONENT FEMORAL KNEE NEXGEN COMPLETE OPTION RT SIZE","SUP-ITM-10130324","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7190.31","42.9","","956.46","956.46","956.46","1 through 10","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING F 66X76MM COMPONENT FEMORAL KNEE NEXGEN COMPLETE OPTION RT SIZE","SUP-ITM-10130324","CDM","C1776","HCPCS","0278","RC","","","","both","","","16760.63","12570.47","WELLPOINT [1015]","HB AMC WELLPOINT","12365.99","73.78","","2344.73","1619.47","2530.35","16","5195.8","13324.7","percent of total billed charges",""
"HINGE ROTATING F 66X76MM COMPONENT FEMORAL KNEE NEXGEN COMPLETE OPTION RT SIZE","SUP-ITM-10130324","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16760.63","12570.47","AETNA [1001]","HB AMC AETNA HMO","11698.92","69.8","","1523.63","988.41","4330.26","39","8759.11","13696.79","percent of total billed charges",""
"HINGE ROTATING F 66X76MM COMPONENT FEMORAL KNEE NEXGEN COMPLETE OPTION RT SIZE","SUP-ITM-10130324","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16760.63","12570.47","AETNA [1001]","HB AMC AETNA PPO","13475.55","80.4","","1670.25","1670.25","1670.25","1 through 10","8759.11","13696.79","percent of total billed charges",""
"HINGE ROTATING F 66X76MM COMPONENT FEMORAL KNEE NEXGEN COMPLETE OPTION RT SIZE","SUP-ITM-10130324","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16760.63","12570.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8759.11","52.26","","1113.10","1113.10","1113.10","1 through 10","8759.11","13696.79","percent of total billed charges",""
"HINGE ROTATING F 66X76MM COMPONENT FEMORAL KNEE NEXGEN COMPLETE OPTION RT SIZE","SUP-ITM-10130324","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16760.63","12570.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13696.79","81.72","","1738.90","1484.65","2716.94","38","8759.11","13696.79","percent of total billed charges",""
"HINGE SWANSON SIZE 2 PROSTHESIS STEM TOE FLEXIBLE GROMMET","SUP-ITM-10005009","CDM","C1776","HCPCS","0278","RC","","","","both","","","3209.50","2407.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1677.28","52.26","","1113.10","1113.10","1113.10","1 through 10","994.95","2551.55","percent of total billed charges",""
"HINGE SWANSON SIZE 2 PROSTHESIS STEM TOE FLEXIBLE GROMMET","SUP-ITM-10005009","CDM","C1776","HCPCS","0278","RC","","","","both","","","3209.50","2407.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2551.55","79.5","","1293.60","1148.53","1603.80","1 through 10","994.95","2551.55","percent of total billed charges",""
"HINGE SWANSON SIZE 2 PROSTHESIS STEM TOE FLEXIBLE GROMMET","SUP-ITM-10005009","CDM","C1776","HCPCS","0278","RC","","","","both","","","3209.50","2407.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1171.47","36.5","","1023.42","771.29","2068.67","33","994.95","2551.55","percent of total billed charges",""
"HINGE SWANSON SIZE 2 PROSTHESIS STEM TOE FLEXIBLE GROMMET","SUP-ITM-10005009","CDM","C1776","HCPCS","0278","RC","","","","both","","","3209.50","2407.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1229.24","38.3","","850.52","759.78","1211.25","66","994.95","2551.55","percent of total billed charges",""
"HINGE SWANSON SIZE 2 PROSTHESIS STEM TOE FLEXIBLE GROMMET","SUP-ITM-10005009","CDM","C1776","HCPCS","0278","RC","","","","both","","","3209.50","2407.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1376.88","42.9","","2548.09","2548.09","2548.09","1 through 10","994.95","2551.55","percent of total billed charges",""
"HINGE SWANSON SIZE 2 PROSTHESIS STEM TOE FLEXIBLE GROMMET","SUP-ITM-10005009","CDM","C1776","HCPCS","0278","RC","","","","both","","","3209.50","2407.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1376.88","42.9","","956.46","956.46","956.46","1 through 10","994.95","2551.55","percent of total billed charges",""
"HINGE SWANSON SIZE 2 PROSTHESIS STEM TOE FLEXIBLE GROMMET","SUP-ITM-10005009","CDM","C1776","HCPCS","0278","RC","","","","both","","","3209.50","2407.12","WELLPOINT [1015]","HB AMC WELLPOINT","2367.97","73.78","","2344.73","1619.47","2530.35","16","994.95","2551.55","percent of total billed charges",""
"HINGE SWANSON SIZE 2 PROSTHESIS STEM TOE FLEXIBLE GROMMET","SUP-ITM-10005009","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3209.50","2407.12","AETNA [1001]","HB AMC AETNA HMO","2240.23","69.8","","1523.63","988.41","4330.26","39","1677.28","2622.8","percent of total billed charges",""
"HINGE SWANSON SIZE 2 PROSTHESIS STEM TOE FLEXIBLE GROMMET","SUP-ITM-10005009","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3209.50","2407.12","AETNA [1001]","HB AMC AETNA PPO","2580.44","80.4","","1670.25","1670.25","1670.25","1 through 10","1677.28","2622.8","percent of total billed charges",""
"HINGE SWANSON SIZE 2 PROSTHESIS STEM TOE FLEXIBLE GROMMET","SUP-ITM-10005009","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3209.50","2407.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1677.28","52.26","","1113.10","1113.10","1113.10","1 through 10","1677.28","2622.8","percent of total billed charges",""
"HINGE SWANSON SIZE 2 PROSTHESIS STEM TOE FLEXIBLE GROMMET","SUP-ITM-10005009","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3209.50","2407.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2622.80","81.72","","1738.90","1484.65","2716.94","38","1677.28","2622.8","percent of total billed charges",""
"HIP 12 TO 14X36MM CONSTRAINED FREEDOM STANDARD","SUP-ITM-10123053","CDM","C1776","HCPCS","0278","RC","","","","both","","","4088.00","3066.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2136.39","52.26","","1113.10","1113.10","1113.10","1 through 10","1267.28","3249.96","percent of total billed charges",""
"HIP 12 TO 14X36MM CONSTRAINED FREEDOM STANDARD","SUP-ITM-10123053","CDM","C1776","HCPCS","0278","RC","","","","both","","","4088.00","3066.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3249.96","79.5","","1293.60","1148.53","1603.80","1 through 10","1267.28","3249.96","percent of total billed charges",""
"HIP 12 TO 14X36MM CONSTRAINED FREEDOM STANDARD","SUP-ITM-10123053","CDM","C1776","HCPCS","0278","RC","","","","both","","","4088.00","3066.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1492.12","36.5","","1023.42","771.29","2068.67","33","1267.28","3249.96","percent of total billed charges",""
"HIP 12 TO 14X36MM CONSTRAINED FREEDOM STANDARD","SUP-ITM-10123053","CDM","C1776","HCPCS","0278","RC","","","","both","","","4088.00","3066.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1565.70","38.3","","850.52","759.78","1211.25","66","1267.28","3249.96","percent of total billed charges",""
"HIP 12 TO 14X36MM CONSTRAINED FREEDOM STANDARD","SUP-ITM-10123053","CDM","C1776","HCPCS","0278","RC","","","","both","","","4088.00","3066.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.75","42.9","","2548.09","2548.09","2548.09","1 through 10","1267.28","3249.96","percent of total billed charges",""
"HIP 12 TO 14X36MM CONSTRAINED FREEDOM STANDARD","SUP-ITM-10123053","CDM","C1776","HCPCS","0278","RC","","","","both","","","4088.00","3066.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.75","42.9","","956.46","956.46","956.46","1 through 10","1267.28","3249.96","percent of total billed charges",""
"HIP 12 TO 14X36MM CONSTRAINED FREEDOM STANDARD","SUP-ITM-10123053","CDM","C1776","HCPCS","0278","RC","","","","both","","","4088.00","3066.00","WELLPOINT [1015]","HB AMC WELLPOINT","3016.13","73.78","","2344.73","1619.47","2530.35","16","1267.28","3249.96","percent of total billed charges",""
"HIP 12 TO 14X36MM CONSTRAINED FREEDOM STANDARD","SUP-ITM-10123053","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4088.00","3066.00","AETNA [1001]","HB AMC AETNA HMO","2853.42","69.8","","1523.63","988.41","4330.26","39","2136.39","3340.71","percent of total billed charges",""
"HIP 12 TO 14X36MM CONSTRAINED FREEDOM STANDARD","SUP-ITM-10123053","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4088.00","3066.00","AETNA [1001]","HB AMC AETNA PPO","3286.75","80.4","","1670.25","1670.25","1670.25","1 through 10","2136.39","3340.71","percent of total billed charges",""
"HIP 12 TO 14X36MM CONSTRAINED FREEDOM STANDARD","SUP-ITM-10123053","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4088.00","3066.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2136.39","52.26","","1113.10","1113.10","1113.10","1 through 10","2136.39","3340.71","percent of total billed charges",""
"HIP 12 TO 14X36MM CONSTRAINED FREEDOM STANDARD","SUP-ITM-10123053","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4088.00","3066.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3340.71","81.72","","1738.90","1484.65","2716.94","38","2136.39","3340.71","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","550.56","52.26","","1113.10","1113.10","1113.10","1 through 10","326.59","837.53","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","837.53","79.5","","1293.60","1148.53","1603.80","1 through 10","326.59","837.53","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","384.53","36.5","","1023.42","771.29","2068.67","33","326.59","837.53","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","403.49","38.3","","850.52","759.78","1211.25","66","326.59","837.53","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","451.95","42.9","","2548.09","2548.09","2548.09","1 through 10","326.59","837.53","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","451.95","42.9","","956.46","956.46","956.46","1 through 10","326.59","837.53","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","1053.50","790.12","WELLPOINT [1015]","HB AMC WELLPOINT","777.27","73.78","","2344.73","1619.47","2530.35","16","326.59","837.53","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1053.50","790.12","AETNA [1001]","HB AMC AETNA HMO","735.34","69.8","","1523.63","988.41","4330.26","39","550.56","860.92","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1053.50","790.12","AETNA [1001]","HB AMC AETNA PPO","847.01","80.4","","1670.25","1670.25","1670.25","1 through 10","550.56","860.92","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1053.50","790.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","550.56","52.26","","1113.10","1113.10","1113.10","1 through 10","550.56","860.92","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1053.50","790.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","860.92","81.72","","1738.90","1484.65","2716.94","38","550.56","860.92","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","965.76","52.26","","1113.10","1113.10","1113.10","1 through 10","572.88","1469.16","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1469.16","79.5","","1293.60","1148.53","1603.80","1 through 10","572.88","1469.16","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","674.52","36.5","","1023.42","771.29","2068.67","33","572.88","1469.16","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","707.78","38.3","","850.52","759.78","1211.25","66","572.88","1469.16","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","792.79","42.9","","2548.09","2548.09","2548.09","1 through 10","572.88","1469.16","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","792.79","42.9","","956.46","956.46","956.46","1 through 10","572.88","1469.16","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","WELLPOINT [1015]","HB AMC WELLPOINT","1363.45","73.78","","2344.73","1619.47","2530.35","16","572.88","1469.16","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","AETNA [1001]","HB AMC AETNA HMO","1289.90","69.8","","1523.63","988.41","4330.26","39","965.76","1510.19","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","AETNA [1001]","HB AMC AETNA PPO","1485.79","80.4","","1670.25","1670.25","1670.25","1 through 10","965.76","1510.19","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","965.76","52.26","","1113.10","1113.10","1113.10","1 through 10","965.76","1510.19","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1510.19","81.72","","1738.90","1484.65","2716.94","38","965.76","1510.19","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","965.76","52.26","","1113.10","1113.10","1113.10","1 through 10","572.88","1469.16","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1469.16","79.5","","1293.60","1148.53","1603.80","1 through 10","572.88","1469.16","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","674.52","36.5","","1023.42","771.29","2068.67","33","572.88","1469.16","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","707.78","38.3","","850.52","759.78","1211.25","66","572.88","1469.16","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","792.79","42.9","","2548.09","2548.09","2548.09","1 through 10","572.88","1469.16","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","792.79","42.9","","956.46","956.46","956.46","1 through 10","572.88","1469.16","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1848.00","1386.00","WELLPOINT [1015]","HB AMC WELLPOINT","1363.45","73.78","","2344.73","1619.47","2530.35","16","572.88","1469.16","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","AETNA [1001]","HB AMC AETNA HMO","1289.90","69.8","","1523.63","988.41","4330.26","39","965.76","1510.19","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","AETNA [1001]","HB AMC AETNA PPO","1485.79","80.4","","1670.25","1670.25","1670.25","1 through 10","965.76","1510.19","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","965.76","52.26","","1113.10","1113.10","1113.10","1 through 10","965.76","1510.19","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1848.00","1386.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1510.19","81.72","","1738.90","1484.65","2716.94","38","965.76","1510.19","percent of total billed charges",""
"HIP 28MM DIA 6 METAL COCR MOD 05","SUP-ITM-10029454","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","768.22","52.26","","1113.10","1113.10","1113.10","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 28MM DIA 6 METAL COCR MOD 05","SUP-ITM-10029454","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1168.65","79.5","","1293.60","1148.53","1603.80","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 28MM DIA 6 METAL COCR MOD 05","SUP-ITM-10029454","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","536.55","36.5","","1023.42","771.29","2068.67","33","455.7","1168.65","percent of total billed charges",""
"HIP 28MM DIA 6 METAL COCR MOD 05","SUP-ITM-10029454","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","563.01","38.3","","850.52","759.78","1211.25","66","455.7","1168.65","percent of total billed charges",""
"HIP 28MM DIA 6 METAL COCR MOD 05","SUP-ITM-10029454","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","2548.09","2548.09","2548.09","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 28MM DIA 6 METAL COCR MOD 05","SUP-ITM-10029454","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","956.46","956.46","956.46","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 28MM DIA 6 METAL COCR MOD 05","SUP-ITM-10029454","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB AMC WELLPOINT","1084.57","73.78","","2344.73","1619.47","2530.35","16","455.7","1168.65","percent of total billed charges",""
"HIP 28MM DIA 6 METAL COCR MOD 05","SUP-ITM-10029454","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA HMO","1026.06","69.8","","1523.63","988.41","4330.26","39","768.22","1201.28","percent of total billed charges",""
"HIP 28MM DIA 6 METAL COCR MOD 05","SUP-ITM-10029454","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA PPO","1181.88","80.4","","1670.25","1670.25","1670.25","1 through 10","768.22","1201.28","percent of total billed charges",""
"HIP 28MM DIA 6 METAL COCR MOD 05","SUP-ITM-10029454","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","768.22","52.26","","1113.10","1113.10","1113.10","1 through 10","768.22","1201.28","percent of total billed charges",""
"HIP 28MM DIA 6 METAL COCR MOD 05","SUP-ITM-10029454","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1201.28","81.72","","1738.90","1484.65","2716.94","38","768.22","1201.28","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","731.64","52.26","","1113.10","1113.10","1113.10","1 through 10","434","1113","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","1293.60","1148.53","1603.80","1 through 10","434","1113","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1023.42","771.29","2068.67","33","434","1113","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","850.52","759.78","1211.25","66","434","1113","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","2548.09","2548.09","2548.09","1 through 10","434","1113","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","956.46","956.46","956.46","1 through 10","434","1113","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","2344.73","1619.47","2530.35","16","434","1113","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1523.63","988.41","4330.26","39","731.64","1144.08","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA PPO","1125.60","80.4","","1670.25","1670.25","1670.25","1 through 10","731.64","1144.08","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","731.64","52.26","","1113.10","1113.10","1113.10","1 through 10","731.64","1144.08","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","1738.90","1484.65","2716.94","38","731.64","1144.08","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","768.22","52.26","","1113.10","1113.10","1113.10","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1168.65","79.5","","1293.60","1148.53","1603.80","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","536.55","36.5","","1023.42","771.29","2068.67","33","455.7","1168.65","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","563.01","38.3","","850.52","759.78","1211.25","66","455.7","1168.65","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","2548.09","2548.09","2548.09","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","956.46","956.46","956.46","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB AMC WELLPOINT","1084.57","73.78","","2344.73","1619.47","2530.35","16","455.7","1168.65","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA HMO","1026.06","69.8","","1523.63","988.41","4330.26","39","768.22","1201.28","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA PPO","1181.88","80.4","","1670.25","1670.25","1670.25","1 through 10","768.22","1201.28","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","768.22","52.26","","1113.10","1113.10","1113.10","1 through 10","768.22","1201.28","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1201.28","81.72","","1738.90","1484.65","2716.94","38","768.22","1201.28","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","768.22","52.26","","1113.10","1113.10","1113.10","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1168.65","79.5","","1293.60","1148.53","1603.80","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","536.55","36.5","","1023.42","771.29","2068.67","33","455.7","1168.65","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","563.01","38.3","","850.52","759.78","1211.25","66","455.7","1168.65","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","2548.09","2548.09","2548.09","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","956.46","956.46","956.46","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB AMC WELLPOINT","1084.57","73.78","","2344.73","1619.47","2530.35","16","455.7","1168.65","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA HMO","1026.06","69.8","","1523.63","988.41","4330.26","39","768.22","1201.28","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA PPO","1181.88","80.4","","1670.25","1670.25","1670.25","1 through 10","768.22","1201.28","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","768.22","52.26","","1113.10","1113.10","1113.10","1 through 10","768.22","1201.28","percent of total billed charges",""
"HIP 32MM IMPLANT HD MODULAR COBALT BIOMOORE STANDARD 05","SUP-ITM-10016342","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1201.28","81.72","","1738.90","1484.65","2716.94","38","768.22","1201.28","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","548.73","52.26","","1113.10","1113.10","1113.10","1 through 10","325.5","834.75","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","834.75","79.5","","1293.60","1148.53","1603.80","1 through 10","325.5","834.75","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","1023.42","771.29","2068.67","33","325.5","834.75","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","850.52","759.78","1211.25","66","325.5","834.75","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","2548.09","2548.09","2548.09","1 through 10","325.5","834.75","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","956.46","956.46","956.46","1 through 10","325.5","834.75","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB AMC WELLPOINT","774.69","73.78","","2344.73","1619.47","2530.35","16","325.5","834.75","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA HMO","732.90","69.8","","1523.63","988.41","4330.26","39","548.73","858.06","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA PPO","844.20","80.4","","1670.25","1670.25","1670.25","1 through 10","548.73","858.06","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","548.73","52.26","","1113.10","1113.10","1113.10","1 through 10","548.73","858.06","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","858.06","81.72","","1738.90","1484.65","2716.94","38","548.73","858.06","percent of total billed charges",""
"HIP 36MM FREEDOM MODULAR STANDARD","SUP-ITM-10021780","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2243.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1330.64","3412.46","percent of total billed charges",""
"HIP 36MM FREEDOM MODULAR STANDARD","SUP-ITM-10021780","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3412.46","79.5","","1293.60","1148.53","1603.80","1 through 10","1330.64","3412.46","percent of total billed charges",""
"HIP 36MM FREEDOM MODULAR STANDARD","SUP-ITM-10021780","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1566.73","36.5","","1023.42","771.29","2068.67","33","1330.64","3412.46","percent of total billed charges",""
"HIP 36MM FREEDOM MODULAR STANDARD","SUP-ITM-10021780","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1643.99","38.3","","850.52","759.78","1211.25","66","1330.64","3412.46","percent of total billed charges",""
"HIP 36MM FREEDOM MODULAR STANDARD","SUP-ITM-10021780","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1841.44","42.9","","2548.09","2548.09","2548.09","1 through 10","1330.64","3412.46","percent of total billed charges",""
"HIP 36MM FREEDOM MODULAR STANDARD","SUP-ITM-10021780","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1841.44","42.9","","956.46","956.46","956.46","1 through 10","1330.64","3412.46","percent of total billed charges",""
"HIP 36MM FREEDOM MODULAR STANDARD","SUP-ITM-10021780","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","WELLPOINT [1015]","HB AMC WELLPOINT","3166.93","73.78","","2344.73","1619.47","2530.35","16","1330.64","3412.46","percent of total billed charges",""
"HIP 36MM FREEDOM MODULAR STANDARD","SUP-ITM-10021780","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4292.40","3219.30","AETNA [1001]","HB AMC AETNA HMO","2996.10","69.8","","1523.63","988.41","4330.26","39","2243.21","3507.75","percent of total billed charges",""
"HIP 36MM FREEDOM MODULAR STANDARD","SUP-ITM-10021780","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4292.40","3219.30","AETNA [1001]","HB AMC AETNA PPO","3451.09","80.4","","1670.25","1670.25","1670.25","1 through 10","2243.21","3507.75","percent of total billed charges",""
"HIP 36MM FREEDOM MODULAR STANDARD","SUP-ITM-10021780","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4292.40","3219.30","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2243.21","52.26","","1113.10","1113.10","1113.10","1 through 10","2243.21","3507.75","percent of total billed charges",""
"HIP 36MM FREEDOM MODULAR STANDARD","SUP-ITM-10021780","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4292.40","3219.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3507.75","81.72","","1738.90","1484.65","2716.94","38","2243.21","3507.75","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","768.22","52.26","","1113.10","1113.10","1113.10","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1168.65","79.5","","1293.60","1148.53","1603.80","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","536.55","36.5","","1023.42","771.29","2068.67","33","455.7","1168.65","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","563.01","38.3","","850.52","759.78","1211.25","66","455.7","1168.65","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","2548.09","2548.09","2548.09","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","956.46","956.46","956.46","1 through 10","455.7","1168.65","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB AMC WELLPOINT","1084.57","73.78","","2344.73","1619.47","2530.35","16","455.7","1168.65","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA HMO","1026.06","69.8","","1523.63","988.41","4330.26","39","768.22","1201.28","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA PPO","1181.88","80.4","","1670.25","1670.25","1670.25","1 through 10","768.22","1201.28","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","768.22","52.26","","1113.10","1113.10","1113.10","1 through 10","768.22","1201.28","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1201.28","81.72","","1738.90","1484.65","2716.94","38","768.22","1201.28","percent of total billed charges",""
"HIP 48MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10122594","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2449.69","52.26","","1113.10","1113.10","1113.10","1 through 10","1453.13","3726.56","percent of total billed charges",""
"HIP 48MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10122594","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3726.56","79.5","","1293.60","1148.53","1603.80","1 through 10","1453.13","3726.56","percent of total billed charges",""
"HIP 48MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10122594","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1710.94","36.5","","1023.42","771.29","2068.67","33","1453.13","3726.56","percent of total billed charges",""
"HIP 48MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10122594","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1795.31","38.3","","850.52","759.78","1211.25","66","1453.13","3726.56","percent of total billed charges",""
"HIP 48MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10122594","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2010.94","42.9","","2548.09","2548.09","2548.09","1 through 10","1453.13","3726.56","percent of total billed charges",""
"HIP 48MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10122594","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2010.94","42.9","","956.46","956.46","956.46","1 through 10","1453.13","3726.56","percent of total billed charges",""
"HIP 48MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10122594","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","WELLPOINT [1015]","HB AMC WELLPOINT","3458.44","73.78","","2344.73","1619.47","2530.35","16","1453.13","3726.56","percent of total billed charges",""
"HIP 48MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10122594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4687.50","3515.62","AETNA [1001]","HB AMC AETNA HMO","3271.88","69.8","","1523.63","988.41","4330.26","39","2449.69","3830.63","percent of total billed charges",""
"HIP 48MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10122594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4687.50","3515.62","AETNA [1001]","HB AMC AETNA PPO","3768.75","80.4","","1670.25","1670.25","1670.25","1 through 10","2449.69","3830.63","percent of total billed charges",""
"HIP 48MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10122594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4687.50","3515.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2449.69","52.26","","1113.10","1113.10","1113.10","1 through 10","2449.69","3830.63","percent of total billed charges",""
"HIP 48MM MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10122594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4687.50","3515.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3830.63","81.72","","1738.90","1484.65","2716.94","38","2449.69","3830.63","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5950.00","4462.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3109.47","52.26","","1113.10","1113.10","1113.10","1 through 10","1844.5","4730.25","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5950.00","4462.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4730.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1844.5","4730.25","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5950.00","4462.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2171.75","36.5","","1023.42","771.29","2068.67","33","1844.5","4730.25","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5950.00","4462.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2278.85","38.3","","850.52","759.78","1211.25","66","1844.5","4730.25","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5950.00","4462.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2552.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1844.5","4730.25","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5950.00","4462.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2552.55","42.9","","956.46","956.46","956.46","1 through 10","1844.5","4730.25","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5950.00","4462.50","WELLPOINT [1015]","HB AMC WELLPOINT","4389.91","73.78","","2344.73","1619.47","2530.35","16","1844.5","4730.25","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5950.00","4462.50","AETNA [1001]","HB AMC AETNA HMO","4153.10","69.8","","1523.63","988.41","4330.26","39","3109.47","4862.34","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5950.00","4462.50","AETNA [1001]","HB AMC AETNA PPO","4783.80","80.4","","1670.25","1670.25","1670.25","1 through 10","3109.47","4862.34","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5950.00","4462.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3109.47","52.26","","1113.10","1113.10","1113.10","1 through 10","3109.47","4862.34","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5950.00","4462.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4862.34","81.72","","1738.90","1484.65","2716.94","38","3109.47","4862.34","percent of total billed charges",""
"HIP 53MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10018261","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","503.00","52.26","","1113.10","1113.10","1113.10","1 through 10","298.38","765.19","percent of total billed charges",""
"HIP 53MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10018261","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","765.19","79.5","","1293.60","1148.53","1603.80","1 through 10","298.38","765.19","percent of total billed charges",""
"HIP 53MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10018261","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","351.31","36.5","","1023.42","771.29","2068.67","33","298.38","765.19","percent of total billed charges",""
"HIP 53MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10018261","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","368.64","38.3","","850.52","759.78","1211.25","66","298.38","765.19","percent of total billed charges",""
"HIP 53MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10018261","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","2548.09","2548.09","2548.09","1 through 10","298.38","765.19","percent of total billed charges",""
"HIP 53MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10018261","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","956.46","956.46","956.46","1 through 10","298.38","765.19","percent of total billed charges",""
"HIP 53MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10018261","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","WELLPOINT [1015]","HB AMC WELLPOINT","710.13","73.78","","2344.73","1619.47","2530.35","16","298.38","765.19","percent of total billed charges",""
"HIP 53MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10018261","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA HMO","671.83","69.8","","1523.63","988.41","4330.26","39","503","786.56","percent of total billed charges",""
"HIP 53MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10018261","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA PPO","773.85","80.4","","1670.25","1670.25","1670.25","1 through 10","503","786.56","percent of total billed charges",""
"HIP 53MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10018261","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","503.00","52.26","","1113.10","1113.10","1113.10","1 through 10","503","786.56","percent of total billed charges",""
"HIP 53MM VERSYS ZIMALOY COBALT ENDOPROSTHESIS 12/14 TAPER BX/1EA","SUP-ITM-10018261","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","786.56","81.72","","1738.90","1484.65","2716.94","38","503","786.56","percent of total billed charges",""
"HIP ACETABULAR 36X54MM CUP XETER X3 RIMFIT","SUP-ITM-10208959","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2665.26","52.26","","1113.10","1113.10","1113.10","1 through 10","1581","4054.5","percent of total billed charges",""
"HIP ACETABULAR 36X54MM CUP XETER X3 RIMFIT","SUP-ITM-10208959","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4054.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1581","4054.5","percent of total billed charges",""
"HIP ACETABULAR 36X54MM CUP XETER X3 RIMFIT","SUP-ITM-10208959","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1861.50","36.5","","1023.42","771.29","2068.67","33","1581","4054.5","percent of total billed charges",""
"HIP ACETABULAR 36X54MM CUP XETER X3 RIMFIT","SUP-ITM-10208959","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1953.30","38.3","","850.52","759.78","1211.25","66","1581","4054.5","percent of total billed charges",""
"HIP ACETABULAR 36X54MM CUP XETER X3 RIMFIT","SUP-ITM-10208959","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2187.90","42.9","","2548.09","2548.09","2548.09","1 through 10","1581","4054.5","percent of total billed charges",""
"HIP ACETABULAR 36X54MM CUP XETER X3 RIMFIT","SUP-ITM-10208959","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2187.90","42.9","","956.46","956.46","956.46","1 through 10","1581","4054.5","percent of total billed charges",""
"HIP ACETABULAR 36X54MM CUP XETER X3 RIMFIT","SUP-ITM-10208959","CDM","C1776","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","WELLPOINT [1015]","HB AMC WELLPOINT","3762.78","73.78","","2344.73","1619.47","2530.35","16","1581","4054.5","percent of total billed charges",""
"HIP ACETABULAR 36X54MM CUP XETER X3 RIMFIT","SUP-ITM-10208959","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","AETNA [1001]","HB AMC AETNA HMO","3559.80","69.8","","1523.63","988.41","4330.26","39","2665.26","4167.72","percent of total billed charges",""
"HIP ACETABULAR 36X54MM CUP XETER X3 RIMFIT","SUP-ITM-10208959","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","AETNA [1001]","HB AMC AETNA PPO","4100.40","80.4","","1670.25","1670.25","1670.25","1 through 10","2665.26","4167.72","percent of total billed charges",""
"HIP ACETABULAR 36X54MM CUP XETER X3 RIMFIT","SUP-ITM-10208959","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2665.26","52.26","","1113.10","1113.10","1113.10","1 through 10","2665.26","4167.72","percent of total billed charges",""
"HIP ACETABULAR 36X54MM CUP XETER X3 RIMFIT","SUP-ITM-10208959","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4167.72","81.72","","1738.90","1484.65","2716.94","38","2665.26","4167.72","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1023.42","771.29","2068.67","33","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","850.52","759.78","1211.25","66","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","956.46","956.46","956.46","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2344.73","1619.47","2530.35","16","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1523.63","988.41","4330.26","39","1829.1","2860.2","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1829.1","2860.2","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1829.1","2860.2","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","1738.90","1484.65","2716.94","38","1829.1","2860.2","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1023.42","771.29","2068.67","33","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","850.52","759.78","1211.25","66","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","956.46","956.46","956.46","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2344.73","1619.47","2530.35","16","1085","2782.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1523.63","988.41","4330.26","39","1829.1","2860.2","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1829.1","2860.2","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1829.1","2860.2","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","1738.90","1484.65","2716.94","38","1829.1","2860.2","percent of total billed charges",""
"Hip And Femur Fracture Repair,EXTREME","308","DRG","","","","","","","","inpatient","","","314443.06","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","27268.28","","Case rate ($30,149.77). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $72,579.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","35092.51","35092.51","35092.51","1 through 10","11475.07","197233.05","case rate",""
"Hip And Femur Fracture Repair,MAJOR","308","DRG","","","","","","","","inpatient","","","167426.40","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","75614.26","","Standard inlier is a Case rate ($75,614.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,950, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,732.82) for the length of stay and the standard reimbursement.","75614.25","75614.25","75614.25","1 through 10","11475.07","197233.05","case rate",""
"Hip And Femur Fracture Repair,MAJOR","308","DRG","","","","","","","","inpatient","","","167426.40","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","29761.5302","","Fee schedule rate ($76,284.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29761.5302","60493.80","60493.80","1 through 10","11475.07","197233.05","case rate",""
"Hip And Femur Fracture Repair,MAJOR","308","DRG","","","","","","","","inpatient","","","167426.40","","MASSHEALTH [3001]","HB BWH MEDICAID","17714.67","","Case rate ($19,586.61). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,016.61, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19581.81","19581.81","19581.81","1 through 10","11475.07","197233.05","case rate",""
"Hip And Femur Fracture Repair,MINOR","308","DRG","","","","","","","","inpatient","","","93923.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","49929.55","","Standard inlier is a Case rate ($49,929.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,183, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,087.09) for the length of stay and the standard reimbursement.","45614.95","45614.95","49929.55","1 through 10","11475.07","197233.05","case rate",""
"Hip And Femur Fracture Repair,MINOR","308","DRG","","","","","","","","inpatient","","","93923.74","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","29761.5302","","Fee schedule rate ($29,761.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29761.5302","29761.52","29761.52","1 through 10","11475.07","197233.05","case rate",""
"Hip And Femur Fracture Repair,MINOR","308","DRG","","","","","","","","inpatient","","","93923.74","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","31250.4716","","Fee schedule rate ($31,250.47). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31250.4716","30044.96","30044.96","1 through 10","11475.07","197233.05","case rate",""
"Hip And Femur Fracture Repair,MINOR","308","DRG","","","","","","","","inpatient","","","93923.74","","MASSHEALTH [3001]","HB BWH MEDICAID","11475.07","","Case rate ($12,687.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,117.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12684.55","12684.55","12684.55","1 through 10","11475.07","197233.05","case rate",""
"Hip And Femur Fracture Repair,MINOR","308","DRG","","","","","","","","inpatient","","","93923.74","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11475.07","","Case rate ($12,687.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,117.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12684.54","12684.54","12684.54","1 through 10","11475.07","197233.05","case rate",""
"Hip And Femur Fracture Repair,MODERATE","308","DRG","","","","","","","","inpatient","","","130041.18","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","58895.93","","Standard inlier is a Case rate ($58,895.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,384, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,359.79) for the length of stay and the standard reimbursement.","53806.51","53806.51","53806.51","1 through 10","11475.07","197233.05","case rate",""
"Hip And Femur Fracture Repair,MODERATE","308","DRG","","","","","","","","inpatient","","","130041.18","","MASSHEALTH [3001]","HB BWH MEDICAID","13950.57","","Case rate ($15,424.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,854.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,779.24 and the sum of the standard inlier and any outlier amount.","15420.97","5033.63","16346.23","1 through 10","11475.07","197233.05","case rate",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","123241.09","92430.82","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","20070.67","","Case rate ($19,486.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,380, add-ons for qualifying new technology services are included. If operating cost exceeds $69,024.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,125.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,420.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,000.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,685.36. The transfer capital threshold is the transfer adjustment factor * $1,685.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","19732.17","19732.14","19739.94","1 through 10","19096.37","32808.25","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","123241.09","92430.82","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","25176.47","","Case rate ($25,176.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,380, add-ons for qualifying new technology services are included. If operating cost exceeds $69,024.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,125.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,111.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,000.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,685.36. The transfer capital threshold is the transfer adjustment factor * $1,685.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18905.10","18905.07","24377.32","1 through 10","19096.37","32808.25","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","123241.09","92430.82","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","19486.09","","Case rate ($19,486.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,380, add-ons for qualifying new technology services are included. If operating cost exceeds $69,024.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,125.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,420.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,000.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,685.36. The transfer capital threshold is the transfer adjustment factor * $1,685.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18754.83","18754.83","18754.83","1 through 10","19096.37","32808.25","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","123241.09","92430.82","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","25176.47","","Case rate ($25,176.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,380, add-ons for qualifying new technology services are included. If operating cost exceeds $69,024.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,125.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,111.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,000.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,685.36. The transfer capital threshold is the transfer adjustment factor * $1,685.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18846.14","18846.14","18846.14","1 through 10","19096.37","32808.25","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","123241.09","92430.82","MEDICARE [2001]","HB BWH MEDICARE","25176.47","","Case rate ($25,176.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,380, add-ons for qualifying new technology services are included. If operating cost exceeds $69,024.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,125.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,111.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,000.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,685.36. The transfer capital threshold is the transfer adjustment factor * $1,685.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24739.62","0.03","24776.20","88","19096.37","32808.25","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","123241.09","92430.82","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","25176.47","","Case rate ($25,176.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,380, add-ons for qualifying new technology services are included. If operating cost exceeds $69,024.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,125.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,111.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,000.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,685.36. The transfer capital threshold is the transfer adjustment factor * $1,685.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18782.80","18782.80","18782.80","1 through 10","19096.37","32808.25","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","123241.09","92430.82","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19096.37","","Case rate ($19,486.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,380, add-ons for qualifying new technology services are included. If operating cost exceeds $69,024.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,125.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,420.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,000.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,685.36. The transfer capital threshold is the transfer adjustment factor * $1,685.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18842.88","18751.29","26530.11","1 through 10","19096.37","32808.25","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","123241.09","92430.82","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19096.37","","Case rate ($19,486.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,380, add-ons for qualifying new technology services are included. If operating cost exceeds $69,024.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,125.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,420.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,000.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,685.36. The transfer capital threshold is the transfer adjustment factor * $1,685.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18809.37","18729.29","18946.22","1 through 10","19096.37","32808.25","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","123241.09","92430.82","WELLPOINT [1015]","HB AMC WELLPOINT","32808.25","","Fee schedule rate ($32,808.25).","94480.11","94480.11","94480.11","1 through 10","19096.37","32808.25","case rate",""
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","149041.96","111781.47","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","34858.34","","Case rate ($34,858.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,360.43, add-ons for qualifying new technology services are included. If operating cost exceeds $78,004.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,783.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,135.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,980.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,343.41. The transfer capital threshold is the transfer adjustment factor * $2,343.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34458.06","34458.06","34458.06","1 through 10","26407.23","44382.631","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","149041.96","111781.47","ELDER SERVICES [1037]","HB BWH MEDICARE","34858.34","","Case rate ($34,858.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,360.43, add-ons for qualifying new technology services are included. If operating cost exceeds $78,004.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,783.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,135.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,980.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,343.41. The transfer capital threshold is the transfer adjustment factor * $2,343.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9809.60","9809.60","9809.60","1 through 10","26407.23","44382.631","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","149041.96","111781.47","MEDICARE [2001]","HB BWH MEDICARE","34858.34","","Case rate ($34,858.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,360.43, add-ons for qualifying new technology services are included. If operating cost exceeds $78,004.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,783.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,135.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,980.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,343.41. The transfer capital threshold is the transfer adjustment factor * $2,343.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34950.19","0.03","35002.05","40","26407.23","44382.631","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","149041.96","111781.47","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","26407.23","","Case rate ($26,946.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,360.43, add-ons for qualifying new technology services are included. If operating cost exceeds $78,004.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,783.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,222.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,980.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,343.41. The transfer capital threshold is the transfer adjustment factor * $2,343.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26433.50","26433.44","26674.50","1 through 10","26407.23","44382.631","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","149041.96","111781.47","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","26407.23","","Case rate ($26,946.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,360.43, add-ons for qualifying new technology services are included. If operating cost exceeds $78,004.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,783.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,222.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,980.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,343.41. The transfer capital threshold is the transfer adjustment factor * $2,343.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26433.40","25885.04","26582.06","1 through 10","26407.23","44382.631","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","149041.96","111781.47","WELLPOINT [1015]","HB AMC WELLPOINT","44382.631","","Fee schedule rate ($45,618.27).","44382.631","115166.80","115166.80","1 through 10","26407.23","44382.631","case rate",""
"Hip And Femur Procedures Except Major Joint Without Cc/McC","482","MS-DRG","","","","","","","","inpatient","","","95294.20","71470.65","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15715.74","","Case rate ($15,258). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,290.20, add-ons for qualifying new technology services are included. If operating cost exceeds $63,934.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,752.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,565.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,910.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,312.40. The transfer capital threshold is the transfer adjustment factor * $1,312.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15163.21","15163.21","15163.21","1 through 10","14952.84","25547.98","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint Without Cc/McC","482","MS-DRG","","","","","","","","inpatient","","","95294.20","71470.65","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","15258.00","","Case rate ($15,258). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,290.20, add-ons for qualifying new technology services are included. If operating cost exceeds $63,934.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,752.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,565.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,910.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,312.40. The transfer capital threshold is the transfer adjustment factor * $1,312.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18702.07","18702.07","18702.07","1 through 10","14952.84","25547.98","other","Inpatient Replacement Plans DRG"
"Hip And Femur Procedures Except Major Joint Without Cc/McC","482","MS-DRG","","","","","","","","inpatient","","","95294.20","71470.65","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","48236.49","48236.49","48236.49","1 through 10","14952.84","25547.98","case rate",""
"Hip And Femur Procedures Except Major Joint Without Cc/McC","482","MS-DRG","","","","","","","","inpatient","","","95294.20","71470.65","MEDICARE [2001]","HB BWH MEDICARE","15258.00","","Case rate ($15,258). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,290.20, add-ons for qualifying new technology services are included. If operating cost exceeds $63,934.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,752.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,565.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,910.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,312.40. The transfer capital threshold is the transfer adjustment factor * $1,312.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15662.80","0.03","19008.60","1 through 10","14952.84","25547.98","other","Inpatient Replacement Plans DRG"
"Hip And Femur Procedures Except Major Joint Without Cc/McC","482","MS-DRG","","","","","","","","inpatient","","","95294.20","71470.65","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14952.84","","Case rate ($15,258). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,290.20, add-ons for qualifying new technology services are included. If operating cost exceeds $63,934.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,752.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,565.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,910.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,312.40. The transfer capital threshold is the transfer adjustment factor * $1,312.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14504.82","14504.82","14504.82","1 through 10","14952.84","25547.98","other","Inpatient DRG"
"HIP CENTRALIZER 10MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10041988","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","265.22","52.26","","1113.10","1113.10","1113.10","1 through 10","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 10MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10041988","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.46","79.5","","1293.60","1148.53","1603.80","1 through 10","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 10MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10041988","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.24","36.5","","1023.42","771.29","2068.67","33","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 10MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10041988","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.37","38.3","","850.52","759.78","1211.25","66","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 10MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10041988","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.72","42.9","","2548.09","2548.09","2548.09","1 through 10","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 10MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10041988","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.72","42.9","","956.46","956.46","956.46","1 through 10","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 10MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10041988","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","WELLPOINT [1015]","HB AMC WELLPOINT","374.43","73.78","","2344.73","1619.47","2530.35","16","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 10MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10041988","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","AETNA [1001]","HB AMC AETNA HMO","354.24","69.8","","1523.63","988.41","4330.26","39","265.22","414.73","percent of total billed charges",""
"HIP CENTRALIZER 10MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10041988","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","AETNA [1001]","HB AMC AETNA PPO","408.03","80.4","","1670.25","1670.25","1670.25","1 through 10","265.22","414.73","percent of total billed charges",""
"HIP CENTRALIZER 10MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10041988","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","265.22","52.26","","1113.10","1113.10","1113.10","1 through 10","265.22","414.73","percent of total billed charges",""
"HIP CENTRALIZER 10MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10041988","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","414.73","81.72","","1738.90","1484.65","2716.94","38","265.22","414.73","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","91.46","52.26","","1113.10","1113.10","1113.10","1 through 10","54.25","139.13","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","1293.60","1148.53","1603.80","1 through 10","54.25","139.13","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","1023.42","771.29","2068.67","33","54.25","139.13","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","850.52","759.78","1211.25","66","54.25","139.13","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","2548.09","2548.09","2548.09","1 through 10","54.25","139.13","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","956.46","956.46","956.46","1 through 10","54.25","139.13","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","2344.73","1619.47","2530.35","16","54.25","139.13","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","1523.63","988.41","4330.26","39","91.46","143.01","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA PPO","140.70","80.4","","1670.25","1670.25","1670.25","1 through 10","91.46","143.01","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","91.46","52.26","","1113.10","1113.10","1113.10","1 through 10","91.46","143.01","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","1738.90","1484.65","2716.94","38","91.46","143.01","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","both","","","183.75","137.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","96.03","52.26","","1113.10","1113.10","1113.10","1 through 10","56.96","146.08","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","both","","","183.75","137.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","146.08","79.5","","1293.60","1148.53","1603.80","1 through 10","56.96","146.08","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","both","","","183.75","137.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.07","36.5","","1023.42","771.29","2068.67","33","56.96","146.08","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","both","","","183.75","137.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.38","38.3","","850.52","759.78","1211.25","66","56.96","146.08","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","both","","","183.75","137.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.83","42.9","","2548.09","2548.09","2548.09","1 through 10","56.96","146.08","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","both","","","183.75","137.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.83","42.9","","956.46","956.46","956.46","1 through 10","56.96","146.08","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","both","","","183.75","137.81","WELLPOINT [1015]","HB AMC WELLPOINT","135.57","73.78","","2344.73","1619.47","2530.35","16","56.96","146.08","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","183.75","137.81","AETNA [1001]","HB AMC AETNA HMO","128.26","69.8","","1523.63","988.41","4330.26","39","96.03","150.16","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","183.75","137.81","AETNA [1001]","HB AMC AETNA PPO","147.74","80.4","","1670.25","1670.25","1670.25","1 through 10","96.03","150.16","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","183.75","137.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","96.03","52.26","","1113.10","1113.10","1113.10","1 through 10","96.03","150.16","percent of total billed charges",""
"HIP CENTRALIZER 9MM IMPLANT CEMENTED VERSYS 16B BX/1EA","SUP-ITM-10013781","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","183.75","137.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","150.16","81.72","","1738.90","1484.65","2716.94","38","96.03","150.16","percent of total billed charges",""
"HIP CENTRALIZER 9MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10001497","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","265.22","52.26","","1113.10","1113.10","1113.10","1 through 10","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 9MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10001497","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.46","79.5","","1293.60","1148.53","1603.80","1 through 10","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 9MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10001497","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.24","36.5","","1023.42","771.29","2068.67","33","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 9MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10001497","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.37","38.3","","850.52","759.78","1211.25","66","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 9MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10001497","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.72","42.9","","2548.09","2548.09","2548.09","1 through 10","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 9MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10001497","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.72","42.9","","956.46","956.46","956.46","1 through 10","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 9MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10001497","CDM","C1776","HCPCS","0278","RC","","","","both","","","507.50","380.62","WELLPOINT [1015]","HB AMC WELLPOINT","374.43","73.78","","2344.73","1619.47","2530.35","16","157.33","403.46","percent of total billed charges",""
"HIP CENTRALIZER 9MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10001497","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","AETNA [1001]","HB AMC AETNA HMO","354.24","69.8","","1523.63","988.41","4330.26","39","265.22","414.73","percent of total billed charges",""
"HIP CENTRALIZER 9MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10001497","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","AETNA [1001]","HB AMC AETNA PPO","408.03","80.4","","1670.25","1670.25","1670.25","1 through 10","265.22","414.73","percent of total billed charges",""
"HIP CENTRALIZER 9MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10001497","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","265.22","52.26","","1113.10","1113.10","1113.10","1 through 10","265.22","414.73","percent of total billed charges",""
"HIP CENTRALIZER 9MM INTEGRAL PRIMARY POLYMETHYLMETHACRYLATE STEM POSITIONER","SUP-ITM-10001497","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","414.73","81.72","","1738.90","1484.65","2716.94","38","265.22","414.73","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1293.60","1148.53","1603.80","1 through 10","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1023.42","771.29","2068.67","33","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","850.52","759.78","1211.25","66","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","2548.09","2548.09","2548.09","1 through 10","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","956.46","956.46","956.46","1 through 10","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","2344.73","1619.47","2530.35","16","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1523.63","988.41","4330.26","39","1097.46","1716.12","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1670.25","1670.25","1670.25","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1738.90","1484.65","2716.94","38","1097.46","1716.12","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1293.60","1148.53","1603.80","1 through 10","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1023.42","771.29","2068.67","33","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","850.52","759.78","1211.25","66","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","2548.09","2548.09","2548.09","1 through 10","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","956.46","956.46","956.46","1 through 10","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","2344.73","1619.47","2530.35","16","651","1669.5","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1523.63","988.41","4330.26","39","1097.46","1716.12","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1670.25","1670.25","1670.25","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1738.90","1484.65","2716.94","38","1097.46","1716.12","percent of total billed charges",""
"HIP CONE 24X105MM PROSTHESIS RECLAIM CEMENTLESS PROXIMALIMAL BODY LOCKING BOLT CONICAL","SUP-ITM-10119679","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP CONE 24X105MM PROSTHESIS RECLAIM CEMENTLESS PROXIMALIMAL BODY LOCKING BOLT CONICAL","SUP-ITM-10119679","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4648.76","79.5","","1293.60","1148.53","1603.80","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP CONE 24X105MM PROSTHESIS RECLAIM CEMENTLESS PROXIMALIMAL BODY LOCKING BOLT CONICAL","SUP-ITM-10119679","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2134.34","36.5","","1023.42","771.29","2068.67","33","1812.73","4648.76","percent of total billed charges",""
"HIP CONE 24X105MM PROSTHESIS RECLAIM CEMENTLESS PROXIMALIMAL BODY LOCKING BOLT CONICAL","SUP-ITM-10119679","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2239.59","38.3","","850.52","759.78","1211.25","66","1812.73","4648.76","percent of total billed charges",""
"HIP CONE 24X105MM PROSTHESIS RECLAIM CEMENTLESS PROXIMALIMAL BODY LOCKING BOLT CONICAL","SUP-ITM-10119679","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","2548.09","2548.09","2548.09","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP CONE 24X105MM PROSTHESIS RECLAIM CEMENTLESS PROXIMALIMAL BODY LOCKING BOLT CONICAL","SUP-ITM-10119679","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","956.46","956.46","956.46","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP CONE 24X105MM PROSTHESIS RECLAIM CEMENTLESS PROXIMALIMAL BODY LOCKING BOLT CONICAL","SUP-ITM-10119679","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","WELLPOINT [1015]","HB AMC WELLPOINT","4314.29","73.78","","2344.73","1619.47","2530.35","16","1812.73","4648.76","percent of total billed charges",""
"HIP CONE 24X105MM PROSTHESIS RECLAIM CEMENTLESS PROXIMALIMAL BODY LOCKING BOLT CONICAL","SUP-ITM-10119679","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA HMO","4081.56","69.8","","1523.63","988.41","4330.26","39","3055.9","4778.58","percent of total billed charges",""
"HIP CONE 24X105MM PROSTHESIS RECLAIM CEMENTLESS PROXIMALIMAL BODY LOCKING BOLT CONICAL","SUP-ITM-10119679","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA PPO","4701.39","80.4","","1670.25","1670.25","1670.25","1 through 10","3055.9","4778.58","percent of total billed charges",""
"HIP CONE 24X105MM PROSTHESIS RECLAIM CEMENTLESS PROXIMALIMAL BODY LOCKING BOLT CONICAL","SUP-ITM-10119679","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","3055.9","4778.58","percent of total billed charges",""
"HIP CONE 24X105MM PROSTHESIS RECLAIM CEMENTLESS PROXIMALIMAL BODY LOCKING BOLT CONICAL","SUP-ITM-10119679","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4778.58","81.72","","1738.90","1484.65","2716.94","38","3055.9","4778.58","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1023.42","771.29","2068.67","33","1085","2782.5","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","850.52","759.78","1211.25","66","1085","2782.5","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","956.46","956.46","956.46","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2344.73","1619.47","2530.35","16","1085","2782.5","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1523.63","988.41","4330.26","39","1829.1","2860.2","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1829.1","2860.2","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1829.1","2860.2","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","1738.90","1484.65","2716.94","38","1829.1","2860.2","percent of total billed charges",""
"HIP CUSTOM BROWN RT TRIFLANGE SZ 23","SUP-ITM-10280234","CDM","C1776","HCPCS","0278","RC","","","","both","","","33737.50","25303.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","17631.22","52.26","","1113.10","1113.10","1113.10","1 through 10","10458.63","26821.31","percent of total billed charges",""
"HIP CUSTOM BROWN RT TRIFLANGE SZ 23","SUP-ITM-10280234","CDM","C1776","HCPCS","0278","RC","","","","both","","","33737.50","25303.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","26821.31","79.5","","1293.60","1148.53","1603.80","1 through 10","10458.63","26821.31","percent of total billed charges",""
"HIP CUSTOM BROWN RT TRIFLANGE SZ 23","SUP-ITM-10280234","CDM","C1776","HCPCS","0278","RC","","","","both","","","33737.50","25303.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12314.19","36.5","","1023.42","771.29","2068.67","33","10458.63","26821.31","percent of total billed charges",""
"HIP CUSTOM BROWN RT TRIFLANGE SZ 23","SUP-ITM-10280234","CDM","C1776","HCPCS","0278","RC","","","","both","","","33737.50","25303.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12921.46","38.3","","850.52","759.78","1211.25","66","10458.63","26821.31","percent of total billed charges",""
"HIP CUSTOM BROWN RT TRIFLANGE SZ 23","SUP-ITM-10280234","CDM","C1776","HCPCS","0278","RC","","","","both","","","33737.50","25303.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14473.39","42.9","","2548.09","2548.09","2548.09","1 through 10","10458.63","26821.31","percent of total billed charges",""
"HIP CUSTOM BROWN RT TRIFLANGE SZ 23","SUP-ITM-10280234","CDM","C1776","HCPCS","0278","RC","","","","both","","","33737.50","25303.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14473.39","42.9","","956.46","956.46","956.46","1 through 10","10458.63","26821.31","percent of total billed charges",""
"HIP CUSTOM BROWN RT TRIFLANGE SZ 23","SUP-ITM-10280234","CDM","C1776","HCPCS","0278","RC","","","","both","","","33737.50","25303.12","WELLPOINT [1015]","HB AMC WELLPOINT","24891.53","73.78","","2344.73","1619.47","2530.35","16","10458.63","26821.31","percent of total billed charges",""
"HIP CUSTOM BROWN RT TRIFLANGE SZ 23","SUP-ITM-10280234","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","33737.50","25303.12","AETNA [1001]","HB AMC AETNA HMO","23548.78","69.8","","1523.63","988.41","4330.26","39","17631.22","27570.29","percent of total billed charges",""
"HIP CUSTOM BROWN RT TRIFLANGE SZ 23","SUP-ITM-10280234","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","33737.50","25303.12","AETNA [1001]","HB AMC AETNA PPO","27124.95","80.4","","1670.25","1670.25","1670.25","1 through 10","17631.22","27570.29","percent of total billed charges",""
"HIP CUSTOM BROWN RT TRIFLANGE SZ 23","SUP-ITM-10280234","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","33737.50","25303.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","17631.22","52.26","","1113.10","1113.10","1113.10","1 through 10","17631.22","27570.29","percent of total billed charges",""
"HIP CUSTOM BROWN RT TRIFLANGE SZ 23","SUP-ITM-10280234","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","33737.50","25303.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","27570.29","81.72","","1738.90","1484.65","2716.94","38","17631.22","27570.29","percent of total billed charges",""
"HIP CUSTOM GREEN LT TRIFLANGE SZ 23","SUP-ITM-10280235","CDM","C1776","HCPCS","0278","RC","","","","both","","","32012.50","24009.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","16729.73","52.26","","1113.10","1113.10","1113.10","1 through 10","9923.88","25449.94","percent of total billed charges",""
"HIP CUSTOM GREEN LT TRIFLANGE SZ 23","SUP-ITM-10280235","CDM","C1776","HCPCS","0278","RC","","","","both","","","32012.50","24009.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","25449.94","79.5","","1293.60","1148.53","1603.80","1 through 10","9923.88","25449.94","percent of total billed charges",""
"HIP CUSTOM GREEN LT TRIFLANGE SZ 23","SUP-ITM-10280235","CDM","C1776","HCPCS","0278","RC","","","","both","","","32012.50","24009.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11684.56","36.5","","1023.42","771.29","2068.67","33","9923.88","25449.94","percent of total billed charges",""
"HIP CUSTOM GREEN LT TRIFLANGE SZ 23","SUP-ITM-10280235","CDM","C1776","HCPCS","0278","RC","","","","both","","","32012.50","24009.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12260.79","38.3","","850.52","759.78","1211.25","66","9923.88","25449.94","percent of total billed charges",""
"HIP CUSTOM GREEN LT TRIFLANGE SZ 23","SUP-ITM-10280235","CDM","C1776","HCPCS","0278","RC","","","","both","","","32012.50","24009.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13733.36","42.9","","2548.09","2548.09","2548.09","1 through 10","9923.88","25449.94","percent of total billed charges",""
"HIP CUSTOM GREEN LT TRIFLANGE SZ 23","SUP-ITM-10280235","CDM","C1776","HCPCS","0278","RC","","","","both","","","32012.50","24009.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13733.36","42.9","","956.46","956.46","956.46","1 through 10","9923.88","25449.94","percent of total billed charges",""
"HIP CUSTOM GREEN LT TRIFLANGE SZ 23","SUP-ITM-10280235","CDM","C1776","HCPCS","0278","RC","","","","both","","","32012.50","24009.37","WELLPOINT [1015]","HB AMC WELLPOINT","23618.82","73.78","","2344.73","1619.47","2530.35","16","9923.88","25449.94","percent of total billed charges",""
"HIP CUSTOM GREEN LT TRIFLANGE SZ 23","SUP-ITM-10280235","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","32012.50","24009.37","AETNA [1001]","HB AMC AETNA HMO","22344.73","69.8","","1523.63","988.41","4330.26","39","16729.73","26160.62","percent of total billed charges",""
"HIP CUSTOM GREEN LT TRIFLANGE SZ 23","SUP-ITM-10280235","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","32012.50","24009.37","AETNA [1001]","HB AMC AETNA PPO","25738.05","80.4","","1670.25","1670.25","1670.25","1 through 10","16729.73","26160.62","percent of total billed charges",""
"HIP CUSTOM GREEN LT TRIFLANGE SZ 23","SUP-ITM-10280235","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","32012.50","24009.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","16729.73","52.26","","1113.10","1113.10","1113.10","1 through 10","16729.73","26160.62","percent of total billed charges",""
"HIP CUSTOM GREEN LT TRIFLANGE SZ 23","SUP-ITM-10280235","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","32012.50","24009.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","26160.62","81.72","","1738.90","1484.65","2716.94","38","16729.73","26160.62","percent of total billed charges",""
"HIP EXTENSION 12X130MM STEM SEGMENTAL FLUTED STRAIGHT ONC 03B","SUP-ITM-10168443","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5597.05","52.26","","1113.10","1113.10","1113.10","1 through 10","3320.1","8514.45","percent of total billed charges",""
"HIP EXTENSION 12X130MM STEM SEGMENTAL FLUTED STRAIGHT ONC 03B","SUP-ITM-10168443","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8514.45","79.5","","1293.60","1148.53","1603.80","1 through 10","3320.1","8514.45","percent of total billed charges",""
"HIP EXTENSION 12X130MM STEM SEGMENTAL FLUTED STRAIGHT ONC 03B","SUP-ITM-10168443","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3909.15","36.5","","1023.42","771.29","2068.67","33","3320.1","8514.45","percent of total billed charges",""
"HIP EXTENSION 12X130MM STEM SEGMENTAL FLUTED STRAIGHT ONC 03B","SUP-ITM-10168443","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4101.93","38.3","","850.52","759.78","1211.25","66","3320.1","8514.45","percent of total billed charges",""
"HIP EXTENSION 12X130MM STEM SEGMENTAL FLUTED STRAIGHT ONC 03B","SUP-ITM-10168443","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","2548.09","2548.09","2548.09","1 through 10","3320.1","8514.45","percent of total billed charges",""
"HIP EXTENSION 12X130MM STEM SEGMENTAL FLUTED STRAIGHT ONC 03B","SUP-ITM-10168443","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","956.46","956.46","956.46","1 through 10","3320.1","8514.45","percent of total billed charges",""
"HIP EXTENSION 12X130MM STEM SEGMENTAL FLUTED STRAIGHT ONC 03B","SUP-ITM-10168443","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","WELLPOINT [1015]","HB AMC WELLPOINT","7901.84","73.78","","2344.73","1619.47","2530.35","16","3320.1","8514.45","percent of total billed charges",""
"HIP EXTENSION 12X130MM STEM SEGMENTAL FLUTED STRAIGHT ONC 03B","SUP-ITM-10168443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA HMO","7475.58","69.8","","1523.63","988.41","4330.26","39","5597.05","8752.21","percent of total billed charges",""
"HIP EXTENSION 12X130MM STEM SEGMENTAL FLUTED STRAIGHT ONC 03B","SUP-ITM-10168443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA PPO","8610.84","80.4","","1670.25","1670.25","1670.25","1 through 10","5597.05","8752.21","percent of total billed charges",""
"HIP EXTENSION 12X130MM STEM SEGMENTAL FLUTED STRAIGHT ONC 03B","SUP-ITM-10168443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5597.05","52.26","","1113.10","1113.10","1113.10","1 through 10","5597.05","8752.21","percent of total billed charges",""
"HIP EXTENSION 12X130MM STEM SEGMENTAL FLUTED STRAIGHT ONC 03B","SUP-ITM-10168443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8752.21","81.72","","1738.90","1484.65","2716.94","38","5597.05","8752.21","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","731.64","52.26","","1113.10","1113.10","1113.10","1 through 10","434","1113","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","1293.60","1148.53","1603.80","1 through 10","434","1113","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1023.42","771.29","2068.67","33","434","1113","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","850.52","759.78","1211.25","66","434","1113","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","2548.09","2548.09","2548.09","1 through 10","434","1113","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","956.46","956.46","956.46","1 through 10","434","1113","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","2344.73","1619.47","2530.35","16","434","1113","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1523.63","988.41","4330.26","39","731.64","1144.08","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA PPO","1125.60","80.4","","1670.25","1670.25","1670.25","1 through 10","731.64","1144.08","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","731.64","52.26","","1113.10","1113.10","1113.10","1 through 10","731.64","1144.08","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","1738.90","1484.65","2716.94","38","731.64","1144.08","percent of total billed charges",""
"HIP HEAD 32MM 3 MODULAR CONSTRAINED FREEDOM / NECK","SUP-ITM-10201682","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2243.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1330.64","3412.46","percent of total billed charges",""
"HIP HEAD 32MM 3 MODULAR CONSTRAINED FREEDOM / NECK","SUP-ITM-10201682","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3412.46","79.5","","1293.60","1148.53","1603.80","1 through 10","1330.64","3412.46","percent of total billed charges",""
"HIP HEAD 32MM 3 MODULAR CONSTRAINED FREEDOM / NECK","SUP-ITM-10201682","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1566.73","36.5","","1023.42","771.29","2068.67","33","1330.64","3412.46","percent of total billed charges",""
"HIP HEAD 32MM 3 MODULAR CONSTRAINED FREEDOM / NECK","SUP-ITM-10201682","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1643.99","38.3","","850.52","759.78","1211.25","66","1330.64","3412.46","percent of total billed charges",""
"HIP HEAD 32MM 3 MODULAR CONSTRAINED FREEDOM / NECK","SUP-ITM-10201682","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1841.44","42.9","","2548.09","2548.09","2548.09","1 through 10","1330.64","3412.46","percent of total billed charges",""
"HIP HEAD 32MM 3 MODULAR CONSTRAINED FREEDOM / NECK","SUP-ITM-10201682","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1841.44","42.9","","956.46","956.46","956.46","1 through 10","1330.64","3412.46","percent of total billed charges",""
"HIP HEAD 32MM 3 MODULAR CONSTRAINED FREEDOM / NECK","SUP-ITM-10201682","CDM","C1776","HCPCS","0278","RC","","","","both","","","4292.40","3219.30","WELLPOINT [1015]","HB AMC WELLPOINT","3166.93","73.78","","2344.73","1619.47","2530.35","16","1330.64","3412.46","percent of total billed charges",""
"HIP HEAD 32MM 3 MODULAR CONSTRAINED FREEDOM / NECK","SUP-ITM-10201682","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4292.40","3219.30","AETNA [1001]","HB AMC AETNA HMO","2996.10","69.8","","1523.63","988.41","4330.26","39","2243.21","3507.75","percent of total billed charges",""
"HIP HEAD 32MM 3 MODULAR CONSTRAINED FREEDOM / NECK","SUP-ITM-10201682","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4292.40","3219.30","AETNA [1001]","HB AMC AETNA PPO","3451.09","80.4","","1670.25","1670.25","1670.25","1 through 10","2243.21","3507.75","percent of total billed charges",""
"HIP HEAD 32MM 3 MODULAR CONSTRAINED FREEDOM / NECK","SUP-ITM-10201682","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4292.40","3219.30","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2243.21","52.26","","1113.10","1113.10","1113.10","1 through 10","2243.21","3507.75","percent of total billed charges",""
"HIP HEAD 32MM 3 MODULAR CONSTRAINED FREEDOM / NECK","SUP-ITM-10201682","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4292.40","3219.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3507.75","81.72","","1738.90","1484.65","2716.94","38","2243.21","3507.75","percent of total billed charges",""
"HIP HEAD 36MM FEMORAL BIOLOX DELTA","SUP-ITM-10196524","CDM","C1776","HCPCS","0278","RC","","","","both","","","2733.50","2050.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1428.53","52.26","","1113.10","1113.10","1113.10","1 through 10","847.39","2173.13","percent of total billed charges",""
"HIP HEAD 36MM FEMORAL BIOLOX DELTA","SUP-ITM-10196524","CDM","C1776","HCPCS","0278","RC","","","","both","","","2733.50","2050.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2173.13","79.5","","1293.60","1148.53","1603.80","1 through 10","847.39","2173.13","percent of total billed charges",""
"HIP HEAD 36MM FEMORAL BIOLOX DELTA","SUP-ITM-10196524","CDM","C1776","HCPCS","0278","RC","","","","both","","","2733.50","2050.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","997.73","36.5","","1023.42","771.29","2068.67","33","847.39","2173.13","percent of total billed charges",""
"HIP HEAD 36MM FEMORAL BIOLOX DELTA","SUP-ITM-10196524","CDM","C1776","HCPCS","0278","RC","","","","both","","","2733.50","2050.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1046.93","38.3","","850.52","759.78","1211.25","66","847.39","2173.13","percent of total billed charges",""
"HIP HEAD 36MM FEMORAL BIOLOX DELTA","SUP-ITM-10196524","CDM","C1776","HCPCS","0278","RC","","","","both","","","2733.50","2050.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1172.67","42.9","","2548.09","2548.09","2548.09","1 through 10","847.39","2173.13","percent of total billed charges",""
"HIP HEAD 36MM FEMORAL BIOLOX DELTA","SUP-ITM-10196524","CDM","C1776","HCPCS","0278","RC","","","","both","","","2733.50","2050.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1172.67","42.9","","956.46","956.46","956.46","1 through 10","847.39","2173.13","percent of total billed charges",""
"HIP HEAD 36MM FEMORAL BIOLOX DELTA","SUP-ITM-10196524","CDM","C1776","HCPCS","0278","RC","","","","both","","","2733.50","2050.12","WELLPOINT [1015]","HB AMC WELLPOINT","2016.78","73.78","","2344.73","1619.47","2530.35","16","847.39","2173.13","percent of total billed charges",""
"HIP HEAD 36MM FEMORAL BIOLOX DELTA","SUP-ITM-10196524","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2733.50","2050.12","AETNA [1001]","HB AMC AETNA HMO","1907.98","69.8","","1523.63","988.41","4330.26","39","1428.53","2233.82","percent of total billed charges",""
"HIP HEAD 36MM FEMORAL BIOLOX DELTA","SUP-ITM-10196524","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2733.50","2050.12","AETNA [1001]","HB AMC AETNA PPO","2197.73","80.4","","1670.25","1670.25","1670.25","1 through 10","1428.53","2233.82","percent of total billed charges",""
"HIP HEAD 36MM FEMORAL BIOLOX DELTA","SUP-ITM-10196524","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2733.50","2050.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1428.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1428.53","2233.82","percent of total billed charges",""
"HIP HEAD 36MM FEMORAL BIOLOX DELTA","SUP-ITM-10196524","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2733.50","2050.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2233.82","81.72","","1738.90","1484.65","2716.94","38","1428.53","2233.82","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1862.02","52.26","","1113.10","1113.10","1113.10","1 through 10","1104.53","2832.59","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2832.59","79.5","","1293.60","1148.53","1603.80","1 through 10","1104.53","2832.59","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1300.50","36.5","","1023.42","771.29","2068.67","33","1104.53","2832.59","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1364.63","38.3","","850.52","759.78","1211.25","66","1104.53","2832.59","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1528.53","42.9","","2548.09","2548.09","2548.09","1 through 10","1104.53","2832.59","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1528.53","42.9","","956.46","956.46","956.46","1 through 10","1104.53","2832.59","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3563.00","2672.25","WELLPOINT [1015]","HB AMC WELLPOINT","2628.78","73.78","","2344.73","1619.47","2530.35","16","1104.53","2832.59","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3563.00","2672.25","AETNA [1001]","HB AMC AETNA HMO","2486.97","69.8","","1523.63","988.41","4330.26","39","1862.02","2911.68","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3563.00","2672.25","AETNA [1001]","HB AMC AETNA PPO","2864.65","80.4","","1670.25","1670.25","1670.25","1 through 10","1862.02","2911.68","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3563.00","2672.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1862.02","52.26","","1113.10","1113.10","1113.10","1 through 10","1862.02","2911.68","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3563.00","2672.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2911.68","81.72","","1738.90","1484.65","2716.94","38","1862.02","2911.68","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4797.47","52.26","","1113.10","1113.10","1113.10","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7298.10","79.5","","1293.60","1148.53","1603.80","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3350.70","36.5","","1023.42","771.29","2068.67","33","2845.8","7298.1","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3515.94","38.3","","850.52","759.78","1211.25","66","2845.8","7298.1","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3938.22","42.9","","2548.09","2548.09","2548.09","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3938.22","42.9","","956.46","956.46","956.46","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","WELLPOINT [1015]","HB AMC WELLPOINT","6773.00","73.78","","2344.73","1619.47","2530.35","16","2845.8","7298.1","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","AETNA [1001]","HB AMC AETNA HMO","6407.64","69.8","","1523.63","988.41","4330.26","39","4797.47","7501.9","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","AETNA [1001]","HB AMC AETNA PPO","7380.72","80.4","","1670.25","1670.25","1670.25","1 through 10","4797.47","7501.9","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4797.47","52.26","","1113.10","1113.10","1113.10","1 through 10","4797.47","7501.9","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7501.90","81.72","","1738.90","1484.65","2716.94","38","4797.47","7501.9","percent of total billed charges",""
"HIP IMPLANT 40X35MM BODY CALCAR FEMORAL POROUS STANDARD OFFSET A","SUP-ITM-10016702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1288.70","52.26","","1113.10","1113.10","1113.10","1 through 10","764.44","1960.41","percent of total billed charges",""
"HIP IMPLANT 40X35MM BODY CALCAR FEMORAL POROUS STANDARD OFFSET A","SUP-ITM-10016702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1960.41","79.5","","1293.60","1148.53","1603.80","1 through 10","764.44","1960.41","percent of total billed charges",""
"HIP IMPLANT 40X35MM BODY CALCAR FEMORAL POROUS STANDARD OFFSET A","SUP-ITM-10016702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","900.06","36.5","","1023.42","771.29","2068.67","33","764.44","1960.41","percent of total billed charges",""
"HIP IMPLANT 40X35MM BODY CALCAR FEMORAL POROUS STANDARD OFFSET A","SUP-ITM-10016702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","944.45","38.3","","850.52","759.78","1211.25","66","764.44","1960.41","percent of total billed charges",""
"HIP IMPLANT 40X35MM BODY CALCAR FEMORAL POROUS STANDARD OFFSET A","SUP-ITM-10016702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1057.88","42.9","","2548.09","2548.09","2548.09","1 through 10","764.44","1960.41","percent of total billed charges",""
"HIP IMPLANT 40X35MM BODY CALCAR FEMORAL POROUS STANDARD OFFSET A","SUP-ITM-10016702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1057.88","42.9","","956.46","956.46","956.46","1 through 10","764.44","1960.41","percent of total billed charges",""
"HIP IMPLANT 40X35MM BODY CALCAR FEMORAL POROUS STANDARD OFFSET A","SUP-ITM-10016702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2465.93","1849.45","WELLPOINT [1015]","HB AMC WELLPOINT","1819.36","73.78","","2344.73","1619.47","2530.35","16","764.44","1960.41","percent of total billed charges",""
"HIP IMPLANT 40X35MM BODY CALCAR FEMORAL POROUS STANDARD OFFSET A","SUP-ITM-10016702","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","AETNA [1001]","HB AMC AETNA HMO","1721.22","69.8","","1523.63","988.41","4330.26","39","1288.7","2015.16","percent of total billed charges",""
"HIP IMPLANT 40X35MM BODY CALCAR FEMORAL POROUS STANDARD OFFSET A","SUP-ITM-10016702","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","AETNA [1001]","HB AMC AETNA PPO","1982.61","80.4","","1670.25","1670.25","1670.25","1 through 10","1288.7","2015.16","percent of total billed charges",""
"HIP IMPLANT 40X35MM BODY CALCAR FEMORAL POROUS STANDARD OFFSET A","SUP-ITM-10016702","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1288.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1288.7","2015.16","percent of total billed charges",""
"HIP IMPLANT 40X35MM BODY CALCAR FEMORAL POROUS STANDARD OFFSET A","SUP-ITM-10016702","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2465.93","1849.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2015.16","81.72","","1738.90","1484.65","2716.94","38","1288.7","2015.16","percent of total billed charges",""
"HIP IMPLANT CUSTOM 3D PERSONALIZED RT PELVIC PT L F","SUP-ITM-10297340","CDM","C1776","HCPCS","0278","RC","","","","both","","","88700.00","66525.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","46354.62","52.26","","1113.10","1113.10","1113.10","1 through 10","27497","70516.5","percent of total billed charges",""
"HIP IMPLANT CUSTOM 3D PERSONALIZED RT PELVIC PT L F","SUP-ITM-10297340","CDM","C1776","HCPCS","0278","RC","","","","both","","","88700.00","66525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","70516.50","79.5","","1293.60","1148.53","1603.80","1 through 10","27497","70516.5","percent of total billed charges",""
"HIP IMPLANT CUSTOM 3D PERSONALIZED RT PELVIC PT L F","SUP-ITM-10297340","CDM","C1776","HCPCS","0278","RC","","","","both","","","88700.00","66525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","32375.50","36.5","","1023.42","771.29","2068.67","33","27497","70516.5","percent of total billed charges",""
"HIP IMPLANT CUSTOM 3D PERSONALIZED RT PELVIC PT L F","SUP-ITM-10297340","CDM","C1776","HCPCS","0278","RC","","","","both","","","88700.00","66525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33972.10","38.3","","850.52","759.78","1211.25","66","27497","70516.5","percent of total billed charges",""
"HIP IMPLANT CUSTOM 3D PERSONALIZED RT PELVIC PT L F","SUP-ITM-10297340","CDM","C1776","HCPCS","0278","RC","","","","both","","","88700.00","66525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","38052.30","42.9","","2548.09","2548.09","2548.09","1 through 10","27497","70516.5","percent of total billed charges",""
"HIP IMPLANT CUSTOM 3D PERSONALIZED RT PELVIC PT L F","SUP-ITM-10297340","CDM","C1776","HCPCS","0278","RC","","","","both","","","88700.00","66525.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","38052.30","42.9","","956.46","956.46","956.46","1 through 10","27497","70516.5","percent of total billed charges",""
"HIP IMPLANT CUSTOM 3D PERSONALIZED RT PELVIC PT L F","SUP-ITM-10297340","CDM","C1776","HCPCS","0278","RC","","","","both","","","88700.00","66525.00","WELLPOINT [1015]","HB AMC WELLPOINT","65442.86","73.78","","2344.73","1619.47","2530.35","16","27497","70516.5","percent of total billed charges",""
"HIP IMPLANT CUSTOM 3D PERSONALIZED RT PELVIC PT L F","SUP-ITM-10297340","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","88700.00","66525.00","AETNA [1001]","HB AMC AETNA HMO","61912.60","69.8","","1523.63","988.41","4330.26","39","46354.62","72485.64","percent of total billed charges",""
"HIP IMPLANT CUSTOM 3D PERSONALIZED RT PELVIC PT L F","SUP-ITM-10297340","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","88700.00","66525.00","AETNA [1001]","HB AMC AETNA PPO","71314.80","80.4","","1670.25","1670.25","1670.25","1 through 10","46354.62","72485.64","percent of total billed charges",""
"HIP IMPLANT CUSTOM 3D PERSONALIZED RT PELVIC PT L F","SUP-ITM-10297340","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","88700.00","66525.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","46354.62","52.26","","1113.10","1113.10","1113.10","1 through 10","46354.62","72485.64","percent of total billed charges",""
"HIP IMPLANT CUSTOM 3D PERSONALIZED RT PELVIC PT L F","SUP-ITM-10297340","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","88700.00","66525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","72485.64","81.72","","1738.90","1484.65","2716.94","38","46354.62","72485.64","percent of total billed charges",""
"HIP IMPLANT CUSTOM SZ 24 PT RT TRIFLANGE C J","SUP-ITM-10286066","CDM","C1776","HCPCS","0278","RC","","","","both","","","34025.00","25518.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","17781.47","52.26","","1113.10","1113.10","1113.10","1 through 10","10547.75","27049.88","percent of total billed charges",""
"HIP IMPLANT CUSTOM SZ 24 PT RT TRIFLANGE C J","SUP-ITM-10286066","CDM","C1776","HCPCS","0278","RC","","","","both","","","34025.00","25518.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","27049.88","79.5","","1293.60","1148.53","1603.80","1 through 10","10547.75","27049.88","percent of total billed charges",""
"HIP IMPLANT CUSTOM SZ 24 PT RT TRIFLANGE C J","SUP-ITM-10286066","CDM","C1776","HCPCS","0278","RC","","","","both","","","34025.00","25518.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12419.13","36.5","","1023.42","771.29","2068.67","33","10547.75","27049.88","percent of total billed charges",""
"HIP IMPLANT CUSTOM SZ 24 PT RT TRIFLANGE C J","SUP-ITM-10286066","CDM","C1776","HCPCS","0278","RC","","","","both","","","34025.00","25518.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","13031.58","38.3","","850.52","759.78","1211.25","66","10547.75","27049.88","percent of total billed charges",""
"HIP IMPLANT CUSTOM SZ 24 PT RT TRIFLANGE C J","SUP-ITM-10286066","CDM","C1776","HCPCS","0278","RC","","","","both","","","34025.00","25518.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14596.73","42.9","","2548.09","2548.09","2548.09","1 through 10","10547.75","27049.88","percent of total billed charges",""
"HIP IMPLANT CUSTOM SZ 24 PT RT TRIFLANGE C J","SUP-ITM-10286066","CDM","C1776","HCPCS","0278","RC","","","","both","","","34025.00","25518.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14596.73","42.9","","956.46","956.46","956.46","1 through 10","10547.75","27049.88","percent of total billed charges",""
"HIP IMPLANT CUSTOM SZ 24 PT RT TRIFLANGE C J","SUP-ITM-10286066","CDM","C1776","HCPCS","0278","RC","","","","both","","","34025.00","25518.75","WELLPOINT [1015]","HB AMC WELLPOINT","25103.65","73.78","","2344.73","1619.47","2530.35","16","10547.75","27049.88","percent of total billed charges",""
"HIP IMPLANT CUSTOM SZ 24 PT RT TRIFLANGE C J","SUP-ITM-10286066","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","34025.00","25518.75","AETNA [1001]","HB AMC AETNA HMO","23749.45","69.8","","1523.63","988.41","4330.26","39","17781.47","27805.23","percent of total billed charges",""
"HIP IMPLANT CUSTOM SZ 24 PT RT TRIFLANGE C J","SUP-ITM-10286066","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","34025.00","25518.75","AETNA [1001]","HB AMC AETNA PPO","27356.10","80.4","","1670.25","1670.25","1670.25","1 through 10","17781.47","27805.23","percent of total billed charges",""
"HIP IMPLANT CUSTOM SZ 24 PT RT TRIFLANGE C J","SUP-ITM-10286066","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","34025.00","25518.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","17781.47","52.26","","1113.10","1113.10","1113.10","1 through 10","17781.47","27805.23","percent of total billed charges",""
"HIP IMPLANT CUSTOM SZ 24 PT RT TRIFLANGE C J","SUP-ITM-10286066","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","34025.00","25518.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","27805.23","81.72","","1738.90","1484.65","2716.94","38","17781.47","27805.23","percent of total billed charges",""
"HIP IMPLANT SZ 23 TRIFLANGE M C CUSTOM","SUP-ITM-10297919","CDM","C1776","HCPCS","0278","RC","","","","both","","","32875.00","24656.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","17180.48","52.26","","1113.10","1113.10","1113.10","1 through 10","10191.25","26135.63","percent of total billed charges",""
"HIP IMPLANT SZ 23 TRIFLANGE M C CUSTOM","SUP-ITM-10297919","CDM","C1776","HCPCS","0278","RC","","","","both","","","32875.00","24656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","26135.63","79.5","","1293.60","1148.53","1603.80","1 through 10","10191.25","26135.63","percent of total billed charges",""
"HIP IMPLANT SZ 23 TRIFLANGE M C CUSTOM","SUP-ITM-10297919","CDM","C1776","HCPCS","0278","RC","","","","both","","","32875.00","24656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11999.38","36.5","","1023.42","771.29","2068.67","33","10191.25","26135.63","percent of total billed charges",""
"HIP IMPLANT SZ 23 TRIFLANGE M C CUSTOM","SUP-ITM-10297919","CDM","C1776","HCPCS","0278","RC","","","","both","","","32875.00","24656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12591.13","38.3","","850.52","759.78","1211.25","66","10191.25","26135.63","percent of total billed charges",""
"HIP IMPLANT SZ 23 TRIFLANGE M C CUSTOM","SUP-ITM-10297919","CDM","C1776","HCPCS","0278","RC","","","","both","","","32875.00","24656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14103.38","42.9","","2548.09","2548.09","2548.09","1 through 10","10191.25","26135.63","percent of total billed charges",""
"HIP IMPLANT SZ 23 TRIFLANGE M C CUSTOM","SUP-ITM-10297919","CDM","C1776","HCPCS","0278","RC","","","","both","","","32875.00","24656.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14103.38","42.9","","956.46","956.46","956.46","1 through 10","10191.25","26135.63","percent of total billed charges",""
"HIP IMPLANT SZ 23 TRIFLANGE M C CUSTOM","SUP-ITM-10297919","CDM","C1776","HCPCS","0278","RC","","","","both","","","32875.00","24656.25","WELLPOINT [1015]","HB AMC WELLPOINT","24255.18","73.78","","2344.73","1619.47","2530.35","16","10191.25","26135.63","percent of total billed charges",""
"HIP IMPLANT SZ 23 TRIFLANGE M C CUSTOM","SUP-ITM-10297919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","32875.00","24656.25","AETNA [1001]","HB AMC AETNA HMO","22946.75","69.8","","1523.63","988.41","4330.26","39","17180.48","26865.45","percent of total billed charges",""
"HIP IMPLANT SZ 23 TRIFLANGE M C CUSTOM","SUP-ITM-10297919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","32875.00","24656.25","AETNA [1001]","HB AMC AETNA PPO","26431.50","80.4","","1670.25","1670.25","1670.25","1 through 10","17180.48","26865.45","percent of total billed charges",""
"HIP IMPLANT SZ 23 TRIFLANGE M C CUSTOM","SUP-ITM-10297919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","32875.00","24656.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","17180.48","52.26","","1113.10","1113.10","1113.10","1 through 10","17180.48","26865.45","percent of total billed charges",""
"HIP IMPLANT SZ 23 TRIFLANGE M C CUSTOM","SUP-ITM-10297919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","32875.00","24656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","26865.45","81.72","","1738.90","1484.65","2716.94","38","17180.48","26865.45","percent of total billed charges",""
"HIP IMPLANT TITANIUM 10MM STEM FEMORAL ECHO PF PRESS FIT","SUP-ITM-10042019","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1463.28","52.26","","1113.10","1113.10","1113.10","1 through 10","868","2226","percent of total billed charges",""
"HIP IMPLANT TITANIUM 10MM STEM FEMORAL ECHO PF PRESS FIT","SUP-ITM-10042019","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","1293.60","1148.53","1603.80","1 through 10","868","2226","percent of total billed charges",""
"HIP IMPLANT TITANIUM 10MM STEM FEMORAL ECHO PF PRESS FIT","SUP-ITM-10042019","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","1023.42","771.29","2068.67","33","868","2226","percent of total billed charges",""
"HIP IMPLANT TITANIUM 10MM STEM FEMORAL ECHO PF PRESS FIT","SUP-ITM-10042019","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","850.52","759.78","1211.25","66","868","2226","percent of total billed charges",""
"HIP IMPLANT TITANIUM 10MM STEM FEMORAL ECHO PF PRESS FIT","SUP-ITM-10042019","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","2548.09","2548.09","2548.09","1 through 10","868","2226","percent of total billed charges",""
"HIP IMPLANT TITANIUM 10MM STEM FEMORAL ECHO PF PRESS FIT","SUP-ITM-10042019","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","956.46","956.46","956.46","1 through 10","868","2226","percent of total billed charges",""
"HIP IMPLANT TITANIUM 10MM STEM FEMORAL ECHO PF PRESS FIT","SUP-ITM-10042019","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","2344.73","1619.47","2530.35","16","868","2226","percent of total billed charges",""
"HIP IMPLANT TITANIUM 10MM STEM FEMORAL ECHO PF PRESS FIT","SUP-ITM-10042019","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA HMO","1954.40","69.8","","1523.63","988.41","4330.26","39","1463.28","2288.16","percent of total billed charges",""
"HIP IMPLANT TITANIUM 10MM STEM FEMORAL ECHO PF PRESS FIT","SUP-ITM-10042019","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA PPO","2251.20","80.4","","1670.25","1670.25","1670.25","1 through 10","1463.28","2288.16","percent of total billed charges",""
"HIP IMPLANT TITANIUM 10MM STEM FEMORAL ECHO PF PRESS FIT","SUP-ITM-10042019","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1463.28","52.26","","1113.10","1113.10","1113.10","1 through 10","1463.28","2288.16","percent of total billed charges",""
"HIP IMPLANT TITANIUM 10MM STEM FEMORAL ECHO PF PRESS FIT","SUP-ITM-10042019","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","1738.90","1484.65","2716.94","38","1463.28","2288.16","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1371.83","52.26","","1113.10","1113.10","1113.10","1 through 10","813.75","2086.88","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2086.88","79.5","","1293.60","1148.53","1603.80","1 through 10","813.75","2086.88","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","958.13","36.5","","1023.42","771.29","2068.67","33","813.75","2086.88","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1005.38","38.3","","850.52","759.78","1211.25","66","813.75","2086.88","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1126.13","42.9","","2548.09","2548.09","2548.09","1 through 10","813.75","2086.88","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1126.13","42.9","","956.46","956.46","956.46","1 through 10","813.75","2086.88","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","WELLPOINT [1015]","HB AMC WELLPOINT","1936.73","73.78","","2344.73","1619.47","2530.35","16","813.75","2086.88","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","AETNA [1001]","HB AMC AETNA HMO","1832.25","69.8","","1523.63","988.41","4330.26","39","1371.83","2145.15","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","AETNA [1001]","HB AMC AETNA PPO","2110.50","80.4","","1670.25","1670.25","1670.25","1 through 10","1371.83","2145.15","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1371.83","52.26","","1113.10","1113.10","1113.10","1 through 10","1371.83","2145.15","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2145.15","81.72","","1738.90","1484.65","2716.94","38","1371.83","2145.15","percent of total billed charges",""
"HIP INSERT 28X52MM FEMORAL CONSTRAINED TRIDENT ALL POLY","SUP-ITM-10031083","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1401.09","52.26","","1113.10","1113.10","1113.10","1 through 10","831.11","2131.4","percent of total billed charges",""
"HIP INSERT 28X52MM FEMORAL CONSTRAINED TRIDENT ALL POLY","SUP-ITM-10031083","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2131.40","79.5","","1293.60","1148.53","1603.80","1 through 10","831.11","2131.4","percent of total billed charges",""
"HIP INSERT 28X52MM FEMORAL CONSTRAINED TRIDENT ALL POLY","SUP-ITM-10031083","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","978.57","36.5","","1023.42","771.29","2068.67","33","831.11","2131.4","percent of total billed charges",""
"HIP INSERT 28X52MM FEMORAL CONSTRAINED TRIDENT ALL POLY","SUP-ITM-10031083","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1026.82","38.3","","850.52","759.78","1211.25","66","831.11","2131.4","percent of total billed charges",""
"HIP INSERT 28X52MM FEMORAL CONSTRAINED TRIDENT ALL POLY","SUP-ITM-10031083","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.15","42.9","","2548.09","2548.09","2548.09","1 through 10","831.11","2131.4","percent of total billed charges",""
"HIP INSERT 28X52MM FEMORAL CONSTRAINED TRIDENT ALL POLY","SUP-ITM-10031083","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1150.15","42.9","","956.46","956.46","956.46","1 through 10","831.11","2131.4","percent of total billed charges",""
"HIP INSERT 28X52MM FEMORAL CONSTRAINED TRIDENT ALL POLY","SUP-ITM-10031083","CDM","C1776","HCPCS","0278","RC","","","","both","","","2681.00","2010.75","WELLPOINT [1015]","HB AMC WELLPOINT","1978.04","73.78","","2344.73","1619.47","2530.35","16","831.11","2131.4","percent of total billed charges",""
"HIP INSERT 28X52MM FEMORAL CONSTRAINED TRIDENT ALL POLY","SUP-ITM-10031083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2681.00","2010.75","AETNA [1001]","HB AMC AETNA HMO","1871.34","69.8","","1523.63","988.41","4330.26","39","1401.09","2190.91","percent of total billed charges",""
"HIP INSERT 28X52MM FEMORAL CONSTRAINED TRIDENT ALL POLY","SUP-ITM-10031083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2681.00","2010.75","AETNA [1001]","HB AMC AETNA PPO","2155.52","80.4","","1670.25","1670.25","1670.25","1 through 10","1401.09","2190.91","percent of total billed charges",""
"HIP INSERT 28X52MM FEMORAL CONSTRAINED TRIDENT ALL POLY","SUP-ITM-10031083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1401.09","52.26","","1113.10","1113.10","1113.10","1 through 10","1401.09","2190.91","percent of total billed charges",""
"HIP INSERT 28X52MM FEMORAL CONSTRAINED TRIDENT ALL POLY","SUP-ITM-10031083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2681.00","2010.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2190.91","81.72","","1738.90","1484.65","2716.94","38","1401.09","2190.91","percent of total billed charges",""
"HIP INSERT 6MM FEMORAL BIO MOORE II ENDO TITANIUM ALLOY TAPER MINUS","SUP-ITM-10041983","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","310.95","52.26","","1113.10","1113.10","1113.10","1 through 10","184.45","473.03","percent of total billed charges",""
"HIP INSERT 6MM FEMORAL BIO MOORE II ENDO TITANIUM ALLOY TAPER MINUS","SUP-ITM-10041983","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","473.03","79.5","","1293.60","1148.53","1603.80","1 through 10","184.45","473.03","percent of total billed charges",""
"HIP INSERT 6MM FEMORAL BIO MOORE II ENDO TITANIUM ALLOY TAPER MINUS","SUP-ITM-10041983","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","217.18","36.5","","1023.42","771.29","2068.67","33","184.45","473.03","percent of total billed charges",""
"HIP INSERT 6MM FEMORAL BIO MOORE II ENDO TITANIUM ALLOY TAPER MINUS","SUP-ITM-10041983","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","227.89","38.3","","850.52","759.78","1211.25","66","184.45","473.03","percent of total billed charges",""
"HIP INSERT 6MM FEMORAL BIO MOORE II ENDO TITANIUM ALLOY TAPER MINUS","SUP-ITM-10041983","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.26","42.9","","2548.09","2548.09","2548.09","1 through 10","184.45","473.03","percent of total billed charges",""
"HIP INSERT 6MM FEMORAL BIO MOORE II ENDO TITANIUM ALLOY TAPER MINUS","SUP-ITM-10041983","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.26","42.9","","956.46","956.46","956.46","1 through 10","184.45","473.03","percent of total billed charges",""
"HIP INSERT 6MM FEMORAL BIO MOORE II ENDO TITANIUM ALLOY TAPER MINUS","SUP-ITM-10041983","CDM","C1776","HCPCS","0278","RC","","","","both","","","595.00","446.25","WELLPOINT [1015]","HB AMC WELLPOINT","438.99","73.78","","2344.73","1619.47","2530.35","16","184.45","473.03","percent of total billed charges",""
"HIP INSERT 6MM FEMORAL BIO MOORE II ENDO TITANIUM ALLOY TAPER MINUS","SUP-ITM-10041983","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","AETNA [1001]","HB AMC AETNA HMO","415.31","69.8","","1523.63","988.41","4330.26","39","310.95","486.23","percent of total billed charges",""
"HIP INSERT 6MM FEMORAL BIO MOORE II ENDO TITANIUM ALLOY TAPER MINUS","SUP-ITM-10041983","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","AETNA [1001]","HB AMC AETNA PPO","478.38","80.4","","1670.25","1670.25","1670.25","1 through 10","310.95","486.23","percent of total billed charges",""
"HIP INSERT 6MM FEMORAL BIO MOORE II ENDO TITANIUM ALLOY TAPER MINUS","SUP-ITM-10041983","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","310.95","52.26","","1113.10","1113.10","1113.10","1 through 10","310.95","486.23","percent of total billed charges",""
"HIP INSERT 6MM FEMORAL BIO MOORE II ENDO TITANIUM ALLOY TAPER MINUS","SUP-ITM-10041983","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","486.23","81.72","","1738.90","1484.65","2716.94","38","310.95","486.23","percent of total billed charges",""
"Hip Joint Replacement,MAJOR","301","DRG","","","","","","","","inpatient","","","172560.66","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","47042.2744","","Fee schedule rate ($62,046.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","47042.2744","59654.88","59654.88","1 through 10","34980.01","206020.36","case rate",""
"Hip Joint Replacement,MAJOR","301","DRG","","","","","","","","inpatient","","","172560.66","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","49395.7552","","Fee schedule rate ($65,150.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","49395.7552","65150.16","65150.16","1 through 10","34980.01","206020.36","case rate",""
"Hip Joint Replacement,MAJOR","301","DRG","","","","","","","","inpatient","","","172560.66","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","45165.34","","Fee schedule rate ($45,165.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","58277.62","58277.62","58277.62","1 through 10","34980.01","206020.36","case rate",""
"Hip Joint Replacement,MINOR","301","DRG","","","","","","","","inpatient","","","98061.17","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","47042.2744","","Fee schedule rate ($47,042.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","47042.2744","52167.04","52167.04","1 through 10","34980.01","206020.36","case rate",""
"Hip Joint Replacement,MINOR","301","DRG","","","","","","","","inpatient","","","98061.17","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41153.57","","Fee schedule rate ($41,153.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","41153.57","41153.57","41153.57","1 through 10","34980.01","206020.36","case rate",""
"Hip Joint Replacement,MODERATE","301","DRG","","","","","","","","inpatient","","","88067.24","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","47042.2744","","Fee schedule rate ($48,999.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","47042.2744","48999.40","48999.40","1 through 10","34980.01","206020.36","case rate",""
"Hip Joint Replacement,MODERATE","301","DRG","","","","","","","","inpatient","","","88067.24","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","43014.44","","Fee schedule rate ($43,014.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","41761.07","41761.07","41761.07","1 through 10","34980.01","206020.36","case rate",""
"Hip Joint Replacement,MODERATE","301","DRG","","","","","","","","inpatient","","","88067.24","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","45165.34","","Fee schedule rate ($45,165.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","45165.34","45165.34","45165.34","1 through 10","34980.01","206020.36","case rate",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","both","","","1102.50","826.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","576.17","52.26","","1113.10","1113.10","1113.10","1 through 10","341.78","876.49","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","both","","","1102.50","826.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","876.49","79.5","","1293.60","1148.53","1603.80","1 through 10","341.78","876.49","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","both","","","1102.50","826.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","402.41","36.5","","1023.42","771.29","2068.67","33","341.78","876.49","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","both","","","1102.50","826.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","422.26","38.3","","850.52","759.78","1211.25","66","341.78","876.49","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","both","","","1102.50","826.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","472.97","42.9","","2548.09","2548.09","2548.09","1 through 10","341.78","876.49","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","both","","","1102.50","826.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","472.97","42.9","","956.46","956.46","956.46","1 through 10","341.78","876.49","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","both","","","1102.50","826.87","WELLPOINT [1015]","HB AMC WELLPOINT","813.42","73.78","","2344.73","1619.47","2530.35","16","341.78","876.49","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","AETNA [1001]","HB AMC AETNA HMO","769.55","69.8","","1523.63","988.41","4330.26","39","576.17","900.96","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","AETNA [1001]","HB AMC AETNA PPO","886.41","80.4","","1670.25","1670.25","1670.25","1 through 10","576.17","900.96","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","576.17","52.26","","1113.10","1113.10","1113.10","1 through 10","576.17","900.96","percent of total billed charges",""
"HIP LINER 28X50 52MM IMPLANT FEMORAL MULIPOLAR BIPOLAR 20A","SUP-ITM-10016135","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","900.96","81.72","","1738.90","1484.65","2716.94","38","576.17","900.96","percent of total billed charges",""
"HIP LINER 32MM 58 ACTEBAULAR CONTINUUM LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED","SUP-ITM-10132730","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1471.15","52.26","","1113.10","1113.10","1113.10","1 through 10","872.67","2237.96","percent of total billed charges",""
"HIP LINER 32MM 58 ACTEBAULAR CONTINUUM LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED","SUP-ITM-10132730","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2237.96","79.5","","1293.60","1148.53","1603.80","1 through 10","872.67","2237.96","percent of total billed charges",""
"HIP LINER 32MM 58 ACTEBAULAR CONTINUUM LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED","SUP-ITM-10132730","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1027.49","36.5","","1023.42","771.29","2068.67","33","872.67","2237.96","percent of total billed charges",""
"HIP LINER 32MM 58 ACTEBAULAR CONTINUUM LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED","SUP-ITM-10132730","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1078.16","38.3","","850.52","759.78","1211.25","66","872.67","2237.96","percent of total billed charges",""
"HIP LINER 32MM 58 ACTEBAULAR CONTINUUM LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED","SUP-ITM-10132730","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1207.66","42.9","","2548.09","2548.09","2548.09","1 through 10","872.67","2237.96","percent of total billed charges",""
"HIP LINER 32MM 58 ACTEBAULAR CONTINUUM LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED","SUP-ITM-10132730","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1207.66","42.9","","956.46","956.46","956.46","1 through 10","872.67","2237.96","percent of total billed charges",""
"HIP LINER 32MM 58 ACTEBAULAR CONTINUUM LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED","SUP-ITM-10132730","CDM","C1776","HCPCS","0278","RC","","","","both","","","2815.05","2111.29","WELLPOINT [1015]","HB AMC WELLPOINT","2076.94","73.78","","2344.73","1619.47","2530.35","16","872.67","2237.96","percent of total billed charges",""
"HIP LINER 32MM 58 ACTEBAULAR CONTINUUM LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED","SUP-ITM-10132730","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2815.05","2111.29","AETNA [1001]","HB AMC AETNA HMO","1964.90","69.8","","1523.63","988.41","4330.26","39","1471.15","2300.46","percent of total billed charges",""
"HIP LINER 32MM 58 ACTEBAULAR CONTINUUM LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED","SUP-ITM-10132730","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2815.05","2111.29","AETNA [1001]","HB AMC AETNA PPO","2263.30","80.4","","1670.25","1670.25","1670.25","1 through 10","1471.15","2300.46","percent of total billed charges",""
"HIP LINER 32MM 58 ACTEBAULAR CONTINUUM LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED","SUP-ITM-10132730","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2815.05","2111.29","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1471.15","52.26","","1113.10","1113.10","1113.10","1 through 10","1471.15","2300.46","percent of total billed charges",""
"HIP LINER 32MM 58 ACTEBAULAR CONTINUUM LONGEVITY HIGHLY CROSSLINKED POLYETHYLENE CONSTRAINED","SUP-ITM-10132730","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2815.05","2111.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2300.46","81.72","","1738.90","1484.65","2716.94","38","1471.15","2300.46","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1335.24","52.26","","1113.10","1113.10","1113.10","1 through 10","792.05","2031.23","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2031.23","79.5","","1293.60","1148.53","1603.80","1 through 10","792.05","2031.23","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","932.58","36.5","","1023.42","771.29","2068.67","33","792.05","2031.23","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","978.57","38.3","","850.52","759.78","1211.25","66","792.05","2031.23","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1096.10","42.9","","2548.09","2548.09","2548.09","1 through 10","792.05","2031.23","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1096.10","42.9","","956.46","956.46","956.46","1 through 10","792.05","2031.23","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","WELLPOINT [1015]","HB AMC WELLPOINT","1885.08","73.78","","2344.73","1619.47","2530.35","16","792.05","2031.23","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","AETNA [1001]","HB AMC AETNA HMO","1783.39","69.8","","1523.63","988.41","4330.26","39","1335.24","2087.95","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","AETNA [1001]","HB AMC AETNA PPO","2054.22","80.4","","1670.25","1670.25","1670.25","1 through 10","1335.24","2087.95","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1335.24","52.26","","1113.10","1113.10","1113.10","1 through 10","1335.24","2087.95","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2087.95","81.72","","1738.90","1484.65","2716.94","38","1335.24","2087.95","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR G7 VIT E +5MM","SUP-ITM-10268725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5240.83","3930.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2738.86","52.26","","1113.10","1113.10","1113.10","1 through 10","1624.66","4166.46","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR G7 VIT E +5MM","SUP-ITM-10268725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5240.83","3930.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4166.46","79.5","","1293.60","1148.53","1603.80","1 through 10","1624.66","4166.46","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR G7 VIT E +5MM","SUP-ITM-10268725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5240.83","3930.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1912.90","36.5","","1023.42","771.29","2068.67","33","1624.66","4166.46","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR G7 VIT E +5MM","SUP-ITM-10268725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5240.83","3930.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2007.24","38.3","","850.52","759.78","1211.25","66","1624.66","4166.46","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR G7 VIT E +5MM","SUP-ITM-10268725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5240.83","3930.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2248.32","42.9","","2548.09","2548.09","2548.09","1 through 10","1624.66","4166.46","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR G7 VIT E +5MM","SUP-ITM-10268725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5240.83","3930.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2248.32","42.9","","956.46","956.46","956.46","1 through 10","1624.66","4166.46","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR G7 VIT E +5MM","SUP-ITM-10268725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5240.83","3930.62","WELLPOINT [1015]","HB AMC WELLPOINT","3866.68","73.78","","2344.73","1619.47","2530.35","16","1624.66","4166.46","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR G7 VIT E +5MM","SUP-ITM-10268725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5240.83","3930.62","AETNA [1001]","HB AMC AETNA HMO","3658.10","69.8","","1523.63","988.41","4330.26","39","2738.86","4282.81","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR G7 VIT E +5MM","SUP-ITM-10268725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5240.83","3930.62","AETNA [1001]","HB AMC AETNA PPO","4213.63","80.4","","1670.25","1670.25","1670.25","1 through 10","2738.86","4282.81","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR G7 VIT E +5MM","SUP-ITM-10268725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5240.83","3930.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2738.86","52.26","","1113.10","1113.10","1113.10","1 through 10","2738.86","4282.81","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR G7 VIT E +5MM","SUP-ITM-10268725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5240.83","3930.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4282.81","81.72","","1738.90","1484.65","2716.94","38","2738.86","4282.81","percent of total billed charges",""
"HIP LINER 36MM IDX52MM OD ACETABULAR HIGH ARCOMXL POLYETHYLENE WALL","SUP-ITM-10123248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","779.75","52.26","","1113.10","1113.10","1113.10","1 through 10","462.54","1186.18","percent of total billed charges",""
"HIP LINER 36MM IDX52MM OD ACETABULAR HIGH ARCOMXL POLYETHYLENE WALL","SUP-ITM-10123248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1186.18","79.5","","1293.60","1148.53","1603.80","1 through 10","462.54","1186.18","percent of total billed charges",""
"HIP LINER 36MM IDX52MM OD ACETABULAR HIGH ARCOMXL POLYETHYLENE WALL","SUP-ITM-10123248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","544.60","36.5","","1023.42","771.29","2068.67","33","462.54","1186.18","percent of total billed charges",""
"HIP LINER 36MM IDX52MM OD ACETABULAR HIGH ARCOMXL POLYETHYLENE WALL","SUP-ITM-10123248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","571.46","38.3","","850.52","759.78","1211.25","66","462.54","1186.18","percent of total billed charges",""
"HIP LINER 36MM IDX52MM OD ACETABULAR HIGH ARCOMXL POLYETHYLENE WALL","SUP-ITM-10123248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","640.09","42.9","","2548.09","2548.09","2548.09","1 through 10","462.54","1186.18","percent of total billed charges",""
"HIP LINER 36MM IDX52MM OD ACETABULAR HIGH ARCOMXL POLYETHYLENE WALL","SUP-ITM-10123248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","640.09","42.9","","956.46","956.46","956.46","1 through 10","462.54","1186.18","percent of total billed charges",""
"HIP LINER 36MM IDX52MM OD ACETABULAR HIGH ARCOMXL POLYETHYLENE WALL","SUP-ITM-10123248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","WELLPOINT [1015]","HB AMC WELLPOINT","1100.83","73.78","","2344.73","1619.47","2530.35","16","462.54","1186.18","percent of total billed charges",""
"HIP LINER 36MM IDX52MM OD ACETABULAR HIGH ARCOMXL POLYETHYLENE WALL","SUP-ITM-10123248","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1492.05","1119.04","AETNA [1001]","HB AMC AETNA HMO","1041.45","69.8","","1523.63","988.41","4330.26","39","779.75","1219.3","percent of total billed charges",""
"HIP LINER 36MM IDX52MM OD ACETABULAR HIGH ARCOMXL POLYETHYLENE WALL","SUP-ITM-10123248","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1492.05","1119.04","AETNA [1001]","HB AMC AETNA PPO","1199.61","80.4","","1670.25","1670.25","1670.25","1 through 10","779.75","1219.3","percent of total billed charges",""
"HIP LINER 36MM IDX52MM OD ACETABULAR HIGH ARCOMXL POLYETHYLENE WALL","SUP-ITM-10123248","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1492.05","1119.04","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","779.75","52.26","","1113.10","1113.10","1113.10","1 through 10","779.75","1219.3","percent of total billed charges",""
"HIP LINER 36MM IDX52MM OD ACETABULAR HIGH ARCOMXL POLYETHYLENE WALL","SUP-ITM-10123248","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1492.05","1119.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1219.30","81.72","","1738.90","1484.65","2716.94","38","779.75","1219.3","percent of total billed charges",""
"HIP LINER 40MM G ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268835","CDM","C1776","HCPCS","0278","RC","","","","both","","","5180.19","3885.14","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2707.17","52.26","","1113.10","1113.10","1113.10","1 through 10","1605.86","4118.25","percent of total billed charges",""
"HIP LINER 40MM G ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268835","CDM","C1776","HCPCS","0278","RC","","","","both","","","5180.19","3885.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4118.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1605.86","4118.25","percent of total billed charges",""
"HIP LINER 40MM G ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268835","CDM","C1776","HCPCS","0278","RC","","","","both","","","5180.19","3885.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1890.77","36.5","","1023.42","771.29","2068.67","33","1605.86","4118.25","percent of total billed charges",""
"HIP LINER 40MM G ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268835","CDM","C1776","HCPCS","0278","RC","","","","both","","","5180.19","3885.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1984.01","38.3","","850.52","759.78","1211.25","66","1605.86","4118.25","percent of total billed charges",""
"HIP LINER 40MM G ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268835","CDM","C1776","HCPCS","0278","RC","","","","both","","","5180.19","3885.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2222.30","42.9","","2548.09","2548.09","2548.09","1 through 10","1605.86","4118.25","percent of total billed charges",""
"HIP LINER 40MM G ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268835","CDM","C1776","HCPCS","0278","RC","","","","both","","","5180.19","3885.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2222.30","42.9","","956.46","956.46","956.46","1 through 10","1605.86","4118.25","percent of total billed charges",""
"HIP LINER 40MM G ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268835","CDM","C1776","HCPCS","0278","RC","","","","both","","","5180.19","3885.14","WELLPOINT [1015]","HB AMC WELLPOINT","3821.94","73.78","","2344.73","1619.47","2530.35","16","1605.86","4118.25","percent of total billed charges",""
"HIP LINER 40MM G ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268835","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5180.19","3885.14","AETNA [1001]","HB AMC AETNA HMO","3615.77","69.8","","1523.63","988.41","4330.26","39","2707.17","4233.25","percent of total billed charges",""
"HIP LINER 40MM G ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268835","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5180.19","3885.14","AETNA [1001]","HB AMC AETNA PPO","4164.87","80.4","","1670.25","1670.25","1670.25","1 through 10","2707.17","4233.25","percent of total billed charges",""
"HIP LINER 40MM G ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268835","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5180.19","3885.14","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2707.17","52.26","","1113.10","1113.10","1113.10","1 through 10","2707.17","4233.25","percent of total billed charges",""
"HIP LINER 40MM G ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268835","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5180.19","3885.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4233.25","81.72","","1738.90","1484.65","2716.94","38","2707.17","4233.25","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","670.28","52.26","","1113.10","1113.10","1113.10","1 through 10","397.6","1019.65","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1019.65","79.5","","1293.60","1148.53","1603.80","1 through 10","397.6","1019.65","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","468.14","36.5","","1023.42","771.29","2068.67","33","397.6","1019.65","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","491.23","38.3","","850.52","759.78","1211.25","66","397.6","1019.65","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","550.23","42.9","","2548.09","2548.09","2548.09","1 through 10","397.6","1019.65","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","550.23","42.9","","956.46","956.46","956.46","1 through 10","397.6","1019.65","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","WELLPOINT [1015]","HB AMC WELLPOINT","946.29","73.78","","2344.73","1619.47","2530.35","16","397.6","1019.65","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1282.58","961.93","AETNA [1001]","HB AMC AETNA HMO","895.24","69.8","","1523.63","988.41","4330.26","39","670.28","1048.12","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1282.58","961.93","AETNA [1001]","HB AMC AETNA PPO","1031.19","80.4","","1670.25","1670.25","1670.25","1 through 10","670.28","1048.12","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1282.58","961.93","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","670.28","52.26","","1113.10","1113.10","1113.10","1 through 10","670.28","1048.12","percent of total billed charges",""
"HIP LINER 40X60MM FEMORAL IMPLANT CUP LONGEVITY HIGHLY CROSSLINKED STD POLYETHYLENE 10 BX/1EA","SUP-ITM-10016680","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1282.58","961.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1048.12","81.72","","1738.90","1484.65","2716.94","38","670.28","1048.12","percent of total billed charges",""
"HIP LINER 40X62 64MM 10DEG ACETABULAR SHELL LONGEVITY REVISION HIGHLY CROSSLINKED POLYETHYLENE OBLIQUE","SUP-ITM-10134625","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","779.75","52.26","","1113.10","1113.10","1113.10","1 through 10","462.54","1186.18","percent of total billed charges",""
"HIP LINER 40X62 64MM 10DEG ACETABULAR SHELL LONGEVITY REVISION HIGHLY CROSSLINKED POLYETHYLENE OBLIQUE","SUP-ITM-10134625","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1186.18","79.5","","1293.60","1148.53","1603.80","1 through 10","462.54","1186.18","percent of total billed charges",""
"HIP LINER 40X62 64MM 10DEG ACETABULAR SHELL LONGEVITY REVISION HIGHLY CROSSLINKED POLYETHYLENE OBLIQUE","SUP-ITM-10134625","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","544.60","36.5","","1023.42","771.29","2068.67","33","462.54","1186.18","percent of total billed charges",""
"HIP LINER 40X62 64MM 10DEG ACETABULAR SHELL LONGEVITY REVISION HIGHLY CROSSLINKED POLYETHYLENE OBLIQUE","SUP-ITM-10134625","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","571.46","38.3","","850.52","759.78","1211.25","66","462.54","1186.18","percent of total billed charges",""
"HIP LINER 40X62 64MM 10DEG ACETABULAR SHELL LONGEVITY REVISION HIGHLY CROSSLINKED POLYETHYLENE OBLIQUE","SUP-ITM-10134625","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","640.09","42.9","","2548.09","2548.09","2548.09","1 through 10","462.54","1186.18","percent of total billed charges",""
"HIP LINER 40X62 64MM 10DEG ACETABULAR SHELL LONGEVITY REVISION HIGHLY CROSSLINKED POLYETHYLENE OBLIQUE","SUP-ITM-10134625","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","640.09","42.9","","956.46","956.46","956.46","1 through 10","462.54","1186.18","percent of total billed charges",""
"HIP LINER 40X62 64MM 10DEG ACETABULAR SHELL LONGEVITY REVISION HIGHLY CROSSLINKED POLYETHYLENE OBLIQUE","SUP-ITM-10134625","CDM","C1776","HCPCS","0278","RC","","","","both","","","1492.05","1119.04","WELLPOINT [1015]","HB AMC WELLPOINT","1100.83","73.78","","2344.73","1619.47","2530.35","16","462.54","1186.18","percent of total billed charges",""
"HIP LINER 40X62 64MM 10DEG ACETABULAR SHELL LONGEVITY REVISION HIGHLY CROSSLINKED POLYETHYLENE OBLIQUE","SUP-ITM-10134625","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1492.05","1119.04","AETNA [1001]","HB AMC AETNA HMO","1041.45","69.8","","1523.63","988.41","4330.26","39","779.75","1219.3","percent of total billed charges",""
"HIP LINER 40X62 64MM 10DEG ACETABULAR SHELL LONGEVITY REVISION HIGHLY CROSSLINKED POLYETHYLENE OBLIQUE","SUP-ITM-10134625","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1492.05","1119.04","AETNA [1001]","HB AMC AETNA PPO","1199.61","80.4","","1670.25","1670.25","1670.25","1 through 10","779.75","1219.3","percent of total billed charges",""
"HIP LINER 40X62 64MM 10DEG ACETABULAR SHELL LONGEVITY REVISION HIGHLY CROSSLINKED POLYETHYLENE OBLIQUE","SUP-ITM-10134625","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1492.05","1119.04","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","779.75","52.26","","1113.10","1113.10","1113.10","1 through 10","779.75","1219.3","percent of total billed charges",""
"HIP LINER 40X62 64MM 10DEG ACETABULAR SHELL LONGEVITY REVISION HIGHLY CROSSLINKED POLYETHYLENE OBLIQUE","SUP-ITM-10134625","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1492.05","1119.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1219.30","81.72","","1738.90","1484.65","2716.94","38","779.75","1219.3","percent of total billed charges",""
"HIP PLATE 5 HOLE 150DEG STANDARD BARREL KEYLESS OMEGA3","SUP-ITM-10034704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3327.42","2495.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2645.30","79.5","","800.18","480.96","1887.97","195","1031.5","2645.3","percent of total billed charges",""
"HIP PLATE 5 HOLE 150DEG STANDARD BARREL KEYLESS OMEGA3","SUP-ITM-10034704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3327.42","2495.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1773.51","53.3","","813.12","216.42","1444.50","81","1031.5","2645.3","percent of total billed charges",""
"HIP PLATE 5 HOLE 150DEG STANDARD BARREL KEYLESS OMEGA3","SUP-ITM-10034704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3327.42","2495.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1031.50","31","","432.60","432.60","432.60","1 through 10","1031.5","2645.3","percent of total billed charges",""
"HIP PLATE 5 HOLE 150DEG STANDARD BARREL KEYLESS OMEGA3","SUP-ITM-10034704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3327.42","2495.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1214.51","36.5","","148.37","54.89","631.39","94","1031.5","2645.3","percent of total billed charges",""
"HIP PLATE 5 HOLE 150DEG STANDARD BARREL KEYLESS OMEGA3","SUP-ITM-10034704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3327.42","2495.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1274.40","38.3","","279.30","91.72","1116.77","266","1031.5","2645.3","percent of total billed charges",""
"HIP PLATE 5 HOLE 150DEG STANDARD BARREL KEYLESS OMEGA3","SUP-ITM-10034704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3327.42","2495.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1427.46","42.9","","731.00","63.70","731.00","1 through 10","1031.5","2645.3","percent of total billed charges",""
"HIP PLATE 5 HOLE 150DEG STANDARD BARREL KEYLESS OMEGA3","SUP-ITM-10034704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3327.42","2495.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1427.46","42.9","","384.74","384.74","384.74","1 through 10","1031.5","2645.3","percent of total billed charges",""
"HIP PLATE 5 HOLE 150DEG STANDARD BARREL KEYLESS OMEGA3","SUP-ITM-10034704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3327.42","2495.56","WELLPOINT [1015]","HB AMC WELLPOINT","2454.97","73.78","","286.63","119.22","1107.45","105","1031.5","2645.3","percent of total billed charges",""
"HIP PLATE 5 HOLE 150DEG STANDARD BARREL KEYLESS OMEGA3","SUP-ITM-10034704","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3327.42","2495.56","AETNA [1001]","HB AMC AETNA HMO","2322.54","69.8","","675.31","184.75","1721.50","286","1738.91","2719.17","percent of total billed charges",""
"HIP PLATE 5 HOLE 150DEG STANDARD BARREL KEYLESS OMEGA3","SUP-ITM-10034704","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3327.42","2495.56","AETNA [1001]","HB AMC AETNA PPO","2675.25","80.4","","1261.44","103.12","1514.10","21","1738.91","2719.17","percent of total billed charges",""
"HIP PLATE 5 HOLE 150DEG STANDARD BARREL KEYLESS OMEGA3","SUP-ITM-10034704","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3327.42","2495.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2675.25","80.4","","1365.00","1365.00","1365.00","1 through 10","1738.91","2719.17","percent of total billed charges",""
"HIP PLATE 5 HOLE 150DEG STANDARD BARREL KEYLESS OMEGA3","SUP-ITM-10034704","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3327.42","2495.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2719.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1738.91","2719.17","percent of total billed charges",""
"HIP PLATE 5 HOLE 150DEG STANDARD BARREL KEYLESS OMEGA3","SUP-ITM-10034704","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3327.42","2495.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2719.17","81.72","","431.26","71.26","1459.57","88","1738.91","2719.17","percent of total billed charges",""
"HIP PLATE 90.5MM 6 HOLE BONE MATTA SS CURVED PELVIC","SUP-ITM-10142486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3473.58","2605.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2761.50","79.5","","800.18","480.96","1887.97","195","1076.81","2761.5","percent of total billed charges",""
"HIP PLATE 90.5MM 6 HOLE BONE MATTA SS CURVED PELVIC","SUP-ITM-10142486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3473.58","2605.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1851.42","53.3","","813.12","216.42","1444.50","81","1076.81","2761.5","percent of total billed charges",""
"HIP PLATE 90.5MM 6 HOLE BONE MATTA SS CURVED PELVIC","SUP-ITM-10142486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3473.58","2605.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1076.81","31","","432.60","432.60","432.60","1 through 10","1076.81","2761.5","percent of total billed charges",""
"HIP PLATE 90.5MM 6 HOLE BONE MATTA SS CURVED PELVIC","SUP-ITM-10142486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3473.58","2605.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1267.86","36.5","","148.37","54.89","631.39","94","1076.81","2761.5","percent of total billed charges",""
"HIP PLATE 90.5MM 6 HOLE BONE MATTA SS CURVED PELVIC","SUP-ITM-10142486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3473.58","2605.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1330.38","38.3","","279.30","91.72","1116.77","266","1076.81","2761.5","percent of total billed charges",""
"HIP PLATE 90.5MM 6 HOLE BONE MATTA SS CURVED PELVIC","SUP-ITM-10142486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3473.58","2605.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1490.17","42.9","","731.00","63.70","731.00","1 through 10","1076.81","2761.5","percent of total billed charges",""
"HIP PLATE 90.5MM 6 HOLE BONE MATTA SS CURVED PELVIC","SUP-ITM-10142486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3473.58","2605.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1490.17","42.9","","384.74","384.74","384.74","1 through 10","1076.81","2761.5","percent of total billed charges",""
"HIP PLATE 90.5MM 6 HOLE BONE MATTA SS CURVED PELVIC","SUP-ITM-10142486","CDM","C1713","HCPCS","0278","RC","","","","both","","","3473.58","2605.18","WELLPOINT [1015]","HB AMC WELLPOINT","2562.81","73.78","","286.63","119.22","1107.45","105","1076.81","2761.5","percent of total billed charges",""
"HIP PLATE 90.5MM 6 HOLE BONE MATTA SS CURVED PELVIC","SUP-ITM-10142486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3473.58","2605.18","AETNA [1001]","HB AMC AETNA HMO","2424.56","69.8","","675.31","184.75","1721.50","286","1815.29","2838.61","percent of total billed charges",""
"HIP PLATE 90.5MM 6 HOLE BONE MATTA SS CURVED PELVIC","SUP-ITM-10142486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3473.58","2605.18","AETNA [1001]","HB AMC AETNA PPO","2792.76","80.4","","1261.44","103.12","1514.10","21","1815.29","2838.61","percent of total billed charges",""
"HIP PLATE 90.5MM 6 HOLE BONE MATTA SS CURVED PELVIC","SUP-ITM-10142486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3473.58","2605.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2792.76","80.4","","1365.00","1365.00","1365.00","1 through 10","1815.29","2838.61","percent of total billed charges",""
"HIP PLATE 90.5MM 6 HOLE BONE MATTA SS CURVED PELVIC","SUP-ITM-10142486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3473.58","2605.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2838.61","81.72","","5157.68","5157.68","5157.68","1 through 10","1815.29","2838.61","percent of total billed charges",""
"HIP PLATE 90.5MM 6 HOLE BONE MATTA SS CURVED PELVIC","SUP-ITM-10142486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3473.58","2605.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2838.61","81.72","","431.26","71.26","1459.57","88","1815.29","2838.61","percent of total billed charges",""
"HIP PLUG ACETABULAR APICAL G7","SUP-ITM-10165969","CDM","C1713","HCPCS","0278","RC","","","","both","","","505.33","379.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","401.74","79.5","","800.18","480.96","1887.97","195","156.65","401.74","percent of total billed charges",""
"HIP PLUG ACETABULAR APICAL G7","SUP-ITM-10165969","CDM","C1713","HCPCS","0278","RC","","","","both","","","505.33","379.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","269.34","53.3","","813.12","216.42","1444.50","81","156.65","401.74","percent of total billed charges",""
"HIP PLUG ACETABULAR APICAL G7","SUP-ITM-10165969","CDM","C1713","HCPCS","0278","RC","","","","both","","","505.33","379.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","156.65","31","","432.60","432.60","432.60","1 through 10","156.65","401.74","percent of total billed charges",""
"HIP PLUG ACETABULAR APICAL G7","SUP-ITM-10165969","CDM","C1713","HCPCS","0278","RC","","","","both","","","505.33","379.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","184.45","36.5","","148.37","54.89","631.39","94","156.65","401.74","percent of total billed charges",""
"HIP PLUG ACETABULAR APICAL G7","SUP-ITM-10165969","CDM","C1713","HCPCS","0278","RC","","","","both","","","505.33","379.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","193.54","38.3","","279.30","91.72","1116.77","266","156.65","401.74","percent of total billed charges",""
"HIP PLUG ACETABULAR APICAL G7","SUP-ITM-10165969","CDM","C1713","HCPCS","0278","RC","","","","both","","","505.33","379.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.79","42.9","","731.00","63.70","731.00","1 through 10","156.65","401.74","percent of total billed charges",""
"HIP PLUG ACETABULAR APICAL G7","SUP-ITM-10165969","CDM","C1713","HCPCS","0278","RC","","","","both","","","505.33","379.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.79","42.9","","384.74","384.74","384.74","1 through 10","156.65","401.74","percent of total billed charges",""
"HIP PLUG ACETABULAR APICAL G7","SUP-ITM-10165969","CDM","C1713","HCPCS","0278","RC","","","","both","","","505.33","379.00","WELLPOINT [1015]","HB AMC WELLPOINT","372.83","73.78","","286.63","119.22","1107.45","105","156.65","401.74","percent of total billed charges",""
"HIP PLUG ACETABULAR APICAL G7","SUP-ITM-10165969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","505.33","379.00","AETNA [1001]","HB AMC AETNA HMO","352.72","69.8","","675.31","184.75","1721.50","286","264.09","412.96","percent of total billed charges",""
"HIP PLUG ACETABULAR APICAL G7","SUP-ITM-10165969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","505.33","379.00","AETNA [1001]","HB AMC AETNA PPO","406.29","80.4","","1261.44","103.12","1514.10","21","264.09","412.96","percent of total billed charges",""
"HIP PLUG ACETABULAR APICAL G7","SUP-ITM-10165969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","505.33","379.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","406.29","80.4","","1365.00","1365.00","1365.00","1 through 10","264.09","412.96","percent of total billed charges",""
"HIP PLUG ACETABULAR APICAL G7","SUP-ITM-10165969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","505.33","379.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","412.96","81.72","","5157.68","5157.68","5157.68","1 through 10","264.09","412.96","percent of total billed charges",""
"HIP PLUG ACETABULAR APICAL G7","SUP-ITM-10165969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","505.33","379.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","412.96","81.72","","431.26","71.26","1459.57","88","264.09","412.96","percent of total billed charges",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture With McC","521","MS-DRG","","","","","","","","inpatient","","","177024.46","132768.34","MEDICARE [2001]","HB BWH MEDICARE","26562.10","","Case rate ($26,562.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,898.13, add-ons for qualifying new technology services are included. If operating cost exceeds $77,542.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,749.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,872.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,518.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,309.53. The transfer capital threshold is the transfer adjustment factor * $2,309.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","34691.54","0.03","34691.54","16","26030.86","43985.7377","other","Inpatient Replacement Plans DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture With McC","521","MS-DRG","","","","","","","","inpatient","","","177024.46","132768.34","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","26030.86","","Case rate ($26,562.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,898.13, add-ons for qualifying new technology services are included. If operating cost exceeds $77,542.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,749.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,872.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,518.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,309.53. The transfer capital threshold is the transfer adjustment factor * $2,309.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","26402.43","26402.43","33624.81","1 through 10","26030.86","43985.7377","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","124831.11","93623.33","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","20288.65","","Case rate ($19,697.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,634.76, add-ons for qualifying new technology services are included. If operating cost exceeds $69,279.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,144.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,613.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,254.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,704.03. The transfer capital threshold is the transfer adjustment factor * $1,704.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","20008.10","20008.10","20059.12","1 through 10","19303.77","31813.3371","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","124831.11","93623.33","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","19697.72","","Case rate ($19,697.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,634.76, add-ons for qualifying new technology services are included. If operating cost exceeds $69,279.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,144.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,613.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,254.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,704.03. The transfer capital threshold is the transfer adjustment factor * $1,704.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","19203.20","19203.20","19203.20","1 through 10","19303.77","31813.3371","other","Inpatient Replacement Plans DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","124831.11","93623.33","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","19697.72","","Case rate ($19,697.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,634.76, add-ons for qualifying new technology services are included. If operating cost exceeds $69,279.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,144.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,613.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,254.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,704.03. The transfer capital threshold is the transfer adjustment factor * $1,704.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","19145.51","19145.51","19145.51","1 through 10","19303.77","31813.3371","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","124831.11","93623.33","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","19697.72","","Case rate ($19,697.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,634.76, add-ons for qualifying new technology services are included. If operating cost exceeds $69,279.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,144.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,613.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,254.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,704.03. The transfer capital threshold is the transfer adjustment factor * $1,704.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","21503.94","21503.94","21503.94","1 through 10","19303.77","31813.3371","other","Inpatient Replacement Plans DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","124831.11","93623.33","MEDICARE [2001]","HB BWH MEDICARE","19697.72","","Case rate ($19,697.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,634.76, add-ons for qualifying new technology services are included. If operating cost exceeds $69,279.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,144.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,613.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,254.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,704.03. The transfer capital threshold is the transfer adjustment factor * $1,704.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","25131.00","0.03","25168.17","29","19303.77","31813.3371","other","Inpatient Replacement Plans DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","124831.11","93623.33","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","19697.72","","Case rate ($19,697.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,634.76, add-ons for qualifying new technology services are included. If operating cost exceeds $69,279.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,144.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,613.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,254.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,704.03. The transfer capital threshold is the transfer adjustment factor * $1,704.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","19077.86","19077.86","19077.86","1 through 10","19303.77","31813.3371","other","Inpatient Replacement Plans DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","124831.11","93623.33","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19303.77","","Case rate ($19,697.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,634.76, add-ons for qualifying new technology services are included. If operating cost exceeds $69,279.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,144.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,613.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,254.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,704.03. The transfer capital threshold is the transfer adjustment factor * $1,704.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","19032.41","19024.64","28039.65","1 through 10","19303.77","31813.3371","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","124831.11","93623.33","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19303.77","","Case rate ($19,697.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,634.76, add-ons for qualifying new technology services are included. If operating cost exceeds $69,279.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,144.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,613.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,254.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,704.03. The transfer capital threshold is the transfer adjustment factor * $1,704.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","19110.19","19059.60","19164.19","1 through 10","19303.77","31813.3371","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","TRIS-DRG","","","","","","","","inpatient","","","375460.62","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","17667.93","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($31,034.70). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $4,849.17, and the first day is paid a rate of $25,215.70. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $9,698.35, and the first day is paid a rate of $19,396.69. The transfer payment is capped at $22,336.77. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $74,761.71 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a special pay post-acute discharge disposition, the outlier threshold is multiplied by (((LOS / 3.20000004768372) + 1) * 0.5). For stays with a transfer discharge disposition, the outlier threshold is multiplied by (LOS / 3.20000004768372). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: , capped at $22,336.77. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $4,849.17, and the first day is paid a rate of $25,215.70. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $9,698.35, and the first day is paid a rate of $19,396.69. The transfer payment is capped at $22,336.77. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $74,761.71 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a special pay post-acute discharge disposition, the outlier threshold is multiplied by (((LOS / 3.20000004768372) + 1) * 0.5). For stays with a transfer discharge disposition, the outlier threshold is multiplied by (LOS / 3.20000004768372). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","35761.52","35761.52","35761.52","1 through 10","17667.93","17667.93","other","Inpatient DRGs"
"HIP SHELL 66MM SZ I MULTIHOLE G7","SUP-ITM-10194227","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2218.24","52.26","","1113.10","1113.10","1113.10","1 through 10","1315.84","3374.48","percent of total billed charges",""
"HIP SHELL 66MM SZ I MULTIHOLE G7","SUP-ITM-10194227","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3374.48","79.5","","1293.60","1148.53","1603.80","1 through 10","1315.84","3374.48","percent of total billed charges",""
"HIP SHELL 66MM SZ I MULTIHOLE G7","SUP-ITM-10194227","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1549.29","36.5","","1023.42","771.29","2068.67","33","1315.84","3374.48","percent of total billed charges",""
"HIP SHELL 66MM SZ I MULTIHOLE G7","SUP-ITM-10194227","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1625.69","38.3","","850.52","759.78","1211.25","66","1315.84","3374.48","percent of total billed charges",""
"HIP SHELL 66MM SZ I MULTIHOLE G7","SUP-ITM-10194227","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1820.95","42.9","","2548.09","2548.09","2548.09","1 through 10","1315.84","3374.48","percent of total billed charges",""
"HIP SHELL 66MM SZ I MULTIHOLE G7","SUP-ITM-10194227","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1820.95","42.9","","956.46","956.46","956.46","1 through 10","1315.84","3374.48","percent of total billed charges",""
"HIP SHELL 66MM SZ I MULTIHOLE G7","SUP-ITM-10194227","CDM","C1776","HCPCS","0278","RC","","","","both","","","4244.63","3183.47","WELLPOINT [1015]","HB AMC WELLPOINT","3131.69","73.78","","2344.73","1619.47","2530.35","16","1315.84","3374.48","percent of total billed charges",""
"HIP SHELL 66MM SZ I MULTIHOLE G7","SUP-ITM-10194227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4244.63","3183.47","AETNA [1001]","HB AMC AETNA HMO","2962.75","69.8","","1523.63","988.41","4330.26","39","2218.24","3468.71","percent of total billed charges",""
"HIP SHELL 66MM SZ I MULTIHOLE G7","SUP-ITM-10194227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4244.63","3183.47","AETNA [1001]","HB AMC AETNA PPO","3412.68","80.4","","1670.25","1670.25","1670.25","1 through 10","2218.24","3468.71","percent of total billed charges",""
"HIP SHELL 66MM SZ I MULTIHOLE G7","SUP-ITM-10194227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4244.63","3183.47","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2218.24","52.26","","1113.10","1113.10","1113.10","1 through 10","2218.24","3468.71","percent of total billed charges",""
"HIP SHELL 66MM SZ I MULTIHOLE G7","SUP-ITM-10194227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4244.63","3183.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3468.71","81.72","","1738.90","1484.65","2716.94","38","2218.24","3468.71","percent of total billed charges",""
"HIP SPACER 52MM STAGEONE MOLD CEMENT SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092302","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2449.69","52.26","","1113.10","1113.10","1113.10","1 through 10","1453.13","3726.56","percent of total billed charges",""
"HIP SPACER 52MM STAGEONE MOLD CEMENT SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092302","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3726.56","79.5","","1293.60","1148.53","1603.80","1 through 10","1453.13","3726.56","percent of total billed charges",""
"HIP SPACER 52MM STAGEONE MOLD CEMENT SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092302","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1710.94","36.5","","1023.42","771.29","2068.67","33","1453.13","3726.56","percent of total billed charges",""
"HIP SPACER 52MM STAGEONE MOLD CEMENT SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092302","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1795.31","38.3","","850.52","759.78","1211.25","66","1453.13","3726.56","percent of total billed charges",""
"HIP SPACER 52MM STAGEONE MOLD CEMENT SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092302","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2010.94","42.9","","2548.09","2548.09","2548.09","1 through 10","1453.13","3726.56","percent of total billed charges",""
"HIP SPACER 52MM STAGEONE MOLD CEMENT SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092302","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2010.94","42.9","","956.46","956.46","956.46","1 through 10","1453.13","3726.56","percent of total billed charges",""
"HIP SPACER 52MM STAGEONE MOLD CEMENT SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092302","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","WELLPOINT [1015]","HB AMC WELLPOINT","3458.44","73.78","","2344.73","1619.47","2530.35","16","1453.13","3726.56","percent of total billed charges",""
"HIP SPACER 52MM STAGEONE MOLD CEMENT SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4687.50","3515.62","AETNA [1001]","HB AMC AETNA HMO","3271.88","69.8","","1523.63","988.41","4330.26","39","2449.69","3830.63","percent of total billed charges",""
"HIP SPACER 52MM STAGEONE MOLD CEMENT SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4687.50","3515.62","AETNA [1001]","HB AMC AETNA PPO","3768.75","80.4","","1670.25","1670.25","1670.25","1 through 10","2449.69","3830.63","percent of total billed charges",""
"HIP SPACER 52MM STAGEONE MOLD CEMENT SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4687.50","3515.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2449.69","52.26","","1113.10","1113.10","1113.10","1 through 10","2449.69","3830.63","percent of total billed charges",""
"HIP SPACER 52MM STAGEONE MOLD CEMENT SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4687.50","3515.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3830.63","81.72","","1738.90","1484.65","2716.94","38","2449.69","3830.63","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","800.18","480.96","1887.97","195","27.13","69.56","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.64","53.3","","813.12","216.42","1444.50","81","27.13","69.56","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.13","31","","432.60","432.60","432.60","1 through 10","27.13","69.56","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","148.37","54.89","631.39","94","27.13","69.56","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","279.30","91.72","1116.77","266","27.13","69.56","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","731.00","63.70","731.00","1 through 10","27.13","69.56","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","384.74","384.74","384.74","1 through 10","27.13","69.56","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","286.63","119.22","1107.45","105","27.13","69.56","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","675.31","184.75","1721.50","286","45.73","71.51","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","1261.44","103.12","1514.10","21","45.73","71.51","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","70.35","80.4","","1365.00","1365.00","1365.00","1 through 10","45.73","71.51","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","71.51","81.72","","5157.68","5157.68","5157.68","1 through 10","45.73","71.51","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","431.26","71.26","1459.57","88","45.73","71.51","percent of total billed charges",""
"HIP STEM 10X115MM FEMORAL VERSYS HERITAGE PRIMARY ZIMALOY COBALT CHROM ALLOY CEMENTED STD","SUP-ITM-10017399","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2304.67","52.26","","1113.10","1113.10","1113.10","1 through 10","1367.1","3505.95","percent of total billed charges",""
"HIP STEM 10X115MM FEMORAL VERSYS HERITAGE PRIMARY ZIMALOY COBALT CHROM ALLOY CEMENTED STD","SUP-ITM-10017399","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3505.95","79.5","","1293.60","1148.53","1603.80","1 through 10","1367.1","3505.95","percent of total billed charges",""
"HIP STEM 10X115MM FEMORAL VERSYS HERITAGE PRIMARY ZIMALOY COBALT CHROM ALLOY CEMENTED STD","SUP-ITM-10017399","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1609.65","36.5","","1023.42","771.29","2068.67","33","1367.1","3505.95","percent of total billed charges",""
"HIP STEM 10X115MM FEMORAL VERSYS HERITAGE PRIMARY ZIMALOY COBALT CHROM ALLOY CEMENTED STD","SUP-ITM-10017399","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1689.03","38.3","","850.52","759.78","1211.25","66","1367.1","3505.95","percent of total billed charges",""
"HIP STEM 10X115MM FEMORAL VERSYS HERITAGE PRIMARY ZIMALOY COBALT CHROM ALLOY CEMENTED STD","SUP-ITM-10017399","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.89","42.9","","2548.09","2548.09","2548.09","1 through 10","1367.1","3505.95","percent of total billed charges",""
"HIP STEM 10X115MM FEMORAL VERSYS HERITAGE PRIMARY ZIMALOY COBALT CHROM ALLOY CEMENTED STD","SUP-ITM-10017399","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.89","42.9","","956.46","956.46","956.46","1 through 10","1367.1","3505.95","percent of total billed charges",""
"HIP STEM 10X115MM FEMORAL VERSYS HERITAGE PRIMARY ZIMALOY COBALT CHROM ALLOY CEMENTED STD","SUP-ITM-10017399","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","WELLPOINT [1015]","HB AMC WELLPOINT","3253.70","73.78","","2344.73","1619.47","2530.35","16","1367.1","3505.95","percent of total billed charges",""
"HIP STEM 10X115MM FEMORAL VERSYS HERITAGE PRIMARY ZIMALOY COBALT CHROM ALLOY CEMENTED STD","SUP-ITM-10017399","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","AETNA [1001]","HB AMC AETNA HMO","3078.18","69.8","","1523.63","988.41","4330.26","39","2304.67","3603.85","percent of total billed charges",""
"HIP STEM 10X115MM FEMORAL VERSYS HERITAGE PRIMARY ZIMALOY COBALT CHROM ALLOY CEMENTED STD","SUP-ITM-10017399","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","AETNA [1001]","HB AMC AETNA PPO","3545.64","80.4","","1670.25","1670.25","1670.25","1 through 10","2304.67","3603.85","percent of total billed charges",""
"HIP STEM 10X115MM FEMORAL VERSYS HERITAGE PRIMARY ZIMALOY COBALT CHROM ALLOY CEMENTED STD","SUP-ITM-10017399","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2304.67","52.26","","1113.10","1113.10","1113.10","1 through 10","2304.67","3603.85","percent of total billed charges",""
"HIP STEM 10X115MM FEMORAL VERSYS HERITAGE PRIMARY ZIMALOY COBALT CHROM ALLOY CEMENTED STD","SUP-ITM-10017399","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3603.85","81.72","","1738.90","1484.65","2716.94","38","2304.67","3603.85","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4132.01","79.5","","1293.60","1148.53","1603.80","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1897.09","36.5","","1023.42","771.29","2068.67","33","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1990.64","38.3","","850.52","759.78","1211.25","66","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","956.46","956.46","956.46","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","WELLPOINT [1015]","HB AMC WELLPOINT","3834.72","73.78","","2344.73","1619.47","2530.35","16","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA HMO","3627.86","69.8","","1523.63","988.41","4330.26","39","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA PPO","4178.79","80.4","","1670.25","1670.25","1670.25","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 10X34.3 140MM 1 SZ TAPERLOC PPS COATED COMPLETE FULL PROFILE STD OFFSET TYPE","SUP-ITM-10124547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4247.40","81.72","","1738.90","1484.65","2716.94","38","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 113MM SZ 9 FEMORAL TRI LOCK GRIPTON BPS CEMENTLESS STANDARD OFFSET","SUP-ITM-10090269","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 113MM SZ 9 FEMORAL TRI LOCK GRIPTON BPS CEMENTLESS STANDARD OFFSET","SUP-ITM-10090269","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 113MM SZ 9 FEMORAL TRI LOCK GRIPTON BPS CEMENTLESS STANDARD OFFSET","SUP-ITM-10090269","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"HIP STEM 113MM SZ 9 FEMORAL TRI LOCK GRIPTON BPS CEMENTLESS STANDARD OFFSET","SUP-ITM-10090269","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"HIP STEM 113MM SZ 9 FEMORAL TRI LOCK GRIPTON BPS CEMENTLESS STANDARD OFFSET","SUP-ITM-10090269","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 113MM SZ 9 FEMORAL TRI LOCK GRIPTON BPS CEMENTLESS STANDARD OFFSET","SUP-ITM-10090269","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 113MM SZ 9 FEMORAL TRI LOCK GRIPTON BPS CEMENTLESS STANDARD OFFSET","SUP-ITM-10090269","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"HIP STEM 113MM SZ 9 FEMORAL TRI LOCK GRIPTON BPS CEMENTLESS STANDARD OFFSET","SUP-ITM-10090269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 113MM SZ 9 FEMORAL TRI LOCK GRIPTON BPS CEMENTLESS STANDARD OFFSET","SUP-ITM-10090269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 113MM SZ 9 FEMORAL TRI LOCK GRIPTON BPS CEMENTLESS STANDARD OFFSET","SUP-ITM-10090269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 113MM SZ 9 FEMORAL TRI LOCK GRIPTON BPS CEMENTLESS STANDARD OFFSET","SUP-ITM-10090269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 11X120MM FEMORAL VERSYS LD FX ZIMALOY COBALT CEMENTED BX/1EA","SUP-ITM-10007522","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1536.44","52.26","","1113.10","1113.10","1113.10","1 through 10","911.4","2337.3","percent of total billed charges",""
"HIP STEM 11X120MM FEMORAL VERSYS LD FX ZIMALOY COBALT CEMENTED BX/1EA","SUP-ITM-10007522","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2337.30","79.5","","1293.60","1148.53","1603.80","1 through 10","911.4","2337.3","percent of total billed charges",""
"HIP STEM 11X120MM FEMORAL VERSYS LD FX ZIMALOY COBALT CEMENTED BX/1EA","SUP-ITM-10007522","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1073.10","36.5","","1023.42","771.29","2068.67","33","911.4","2337.3","percent of total billed charges",""
"HIP STEM 11X120MM FEMORAL VERSYS LD FX ZIMALOY COBALT CEMENTED BX/1EA","SUP-ITM-10007522","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1126.02","38.3","","850.52","759.78","1211.25","66","911.4","2337.3","percent of total billed charges",""
"HIP STEM 11X120MM FEMORAL VERSYS LD FX ZIMALOY COBALT CEMENTED BX/1EA","SUP-ITM-10007522","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1261.26","42.9","","2548.09","2548.09","2548.09","1 through 10","911.4","2337.3","percent of total billed charges",""
"HIP STEM 11X120MM FEMORAL VERSYS LD FX ZIMALOY COBALT CEMENTED BX/1EA","SUP-ITM-10007522","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1261.26","42.9","","956.46","956.46","956.46","1 through 10","911.4","2337.3","percent of total billed charges",""
"HIP STEM 11X120MM FEMORAL VERSYS LD FX ZIMALOY COBALT CEMENTED BX/1EA","SUP-ITM-10007522","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","WELLPOINT [1015]","HB AMC WELLPOINT","2169.13","73.78","","2344.73","1619.47","2530.35","16","911.4","2337.3","percent of total billed charges",""
"HIP STEM 11X120MM FEMORAL VERSYS LD FX ZIMALOY COBALT CEMENTED BX/1EA","SUP-ITM-10007522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2940.00","2205.00","AETNA [1001]","HB AMC AETNA HMO","2052.12","69.8","","1523.63","988.41","4330.26","39","1536.44","2402.57","percent of total billed charges",""
"HIP STEM 11X120MM FEMORAL VERSYS LD FX ZIMALOY COBALT CEMENTED BX/1EA","SUP-ITM-10007522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2940.00","2205.00","AETNA [1001]","HB AMC AETNA PPO","2363.76","80.4","","1670.25","1670.25","1670.25","1 through 10","1536.44","2402.57","percent of total billed charges",""
"HIP STEM 11X120MM FEMORAL VERSYS LD FX ZIMALOY COBALT CEMENTED BX/1EA","SUP-ITM-10007522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2940.00","2205.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1536.44","52.26","","1113.10","1113.10","1113.10","1 through 10","1536.44","2402.57","percent of total billed charges",""
"HIP STEM 11X120MM FEMORAL VERSYS LD FX ZIMALOY COBALT CEMENTED BX/1EA","SUP-ITM-10007522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2940.00","2205.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2402.57","81.72","","1738.90","1484.65","2716.94","38","1536.44","2402.57","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4132.01","79.5","","1293.60","1148.53","1603.80","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1897.09","36.5","","1023.42","771.29","2068.67","33","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1990.64","38.3","","850.52","759.78","1211.25","66","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","956.46","956.46","956.46","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","WELLPOINT [1015]","HB AMC WELLPOINT","3834.72","73.78","","2344.73","1619.47","2530.35","16","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA HMO","3627.86","69.8","","1523.63","988.41","4330.26","39","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA PPO","4178.79","80.4","","1670.25","1670.25","1670.25","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 11X135MM 135DEG BIMETRIC FULL IMAL PROFILE STANDARD ALLOY POROUS PLASMA SPRAYED TITANIUM","SUP-ITM-10057609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4247.40","81.72","","1738.90","1484.65","2716.94","38","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 12 14 16X145MM LARGE VERSYS FIBER METAL TIVANIUM TITANIUM ALLOY TAPER 786201630","SUP-ITM-10002479","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 12 14 16X145MM LARGE VERSYS FIBER METAL TIVANIUM TITANIUM ALLOY TAPER 786201630","SUP-ITM-10002479","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4132.01","79.5","","1293.60","1148.53","1603.80","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 12 14 16X145MM LARGE VERSYS FIBER METAL TIVANIUM TITANIUM ALLOY TAPER 786201630","SUP-ITM-10002479","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1897.09","36.5","","1023.42","771.29","2068.67","33","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 12 14 16X145MM LARGE VERSYS FIBER METAL TIVANIUM TITANIUM ALLOY TAPER 786201630","SUP-ITM-10002479","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1990.64","38.3","","850.52","759.78","1211.25","66","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 12 14 16X145MM LARGE VERSYS FIBER METAL TIVANIUM TITANIUM ALLOY TAPER 786201630","SUP-ITM-10002479","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 12 14 16X145MM LARGE VERSYS FIBER METAL TIVANIUM TITANIUM ALLOY TAPER 786201630","SUP-ITM-10002479","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","956.46","956.46","956.46","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 12 14 16X145MM LARGE VERSYS FIBER METAL TIVANIUM TITANIUM ALLOY TAPER 786201630","SUP-ITM-10002479","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","WELLPOINT [1015]","HB AMC WELLPOINT","3834.72","73.78","","2344.73","1619.47","2530.35","16","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 12 14 16X145MM LARGE VERSYS FIBER METAL TIVANIUM TITANIUM ALLOY TAPER 786201630","SUP-ITM-10002479","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA HMO","3627.86","69.8","","1523.63","988.41","4330.26","39","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 12 14 16X145MM LARGE VERSYS FIBER METAL TIVANIUM TITANIUM ALLOY TAPER 786201630","SUP-ITM-10002479","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA PPO","4178.79","80.4","","1670.25","1670.25","1670.25","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 12 14 16X145MM LARGE VERSYS FIBER METAL TIVANIUM TITANIUM ALLOY TAPER 786201630","SUP-ITM-10002479","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 12 14 16X145MM LARGE VERSYS FIBER METAL TIVANIUM TITANIUM ALLOY TAPER 786201630","SUP-ITM-10002479","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4247.40","81.72","","1738.90","1484.65","2716.94","38","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4648.76","79.5","","1293.60","1148.53","1603.80","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2134.34","36.5","","1023.42","771.29","2068.67","33","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2239.59","38.3","","850.52","759.78","1211.25","66","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","2548.09","2548.09","2548.09","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","956.46","956.46","956.46","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","WELLPOINT [1015]","HB AMC WELLPOINT","4314.29","73.78","","2344.73","1619.47","2530.35","16","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA HMO","4081.56","69.8","","1523.63","988.41","4330.26","39","3055.9","4778.58","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA PPO","4701.39","80.4","","1670.25","1670.25","1670.25","1 through 10","3055.9","4778.58","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","3055.9","4778.58","percent of total billed charges",""
"HIP STEM 120MM FEMORAL PROSTALAC CEMENTED ED HIGH","SUP-ITM-10022274","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4778.58","81.72","","1738.90","1484.65","2716.94","38","3055.9","4778.58","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","1113.10","1113.10","1113.10","1 through 10","27.13","69.56","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","1293.60","1148.53","1603.80","1 through 10","27.13","69.56","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","1023.42","771.29","2068.67","33","27.13","69.56","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","850.52","759.78","1211.25","66","27.13","69.56","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","2548.09","2548.09","2548.09","1 through 10","27.13","69.56","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","956.46","956.46","956.46","1 through 10","27.13","69.56","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","2344.73","1619.47","2530.35","16","27.13","69.56","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","1523.63","988.41","4330.26","39","45.73","71.51","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","1670.25","1670.25","1670.25","1 through 10","45.73","71.51","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","1113.10","1113.10","1113.10","1 through 10","45.73","71.51","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","1738.90","1484.65","2716.94","38","45.73","71.51","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4797.47","52.26","","1113.10","1113.10","1113.10","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7298.10","79.5","","1293.60","1148.53","1603.80","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3350.70","36.5","","1023.42","771.29","2068.67","33","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3515.94","38.3","","850.52","759.78","1211.25","66","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3938.22","42.9","","2548.09","2548.09","2548.09","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3938.22","42.9","","956.46","956.46","956.46","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","WELLPOINT [1015]","HB AMC WELLPOINT","6773.00","73.78","","2344.73","1619.47","2530.35","16","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","AETNA [1001]","HB AMC AETNA HMO","6407.64","69.8","","1523.63","988.41","4330.26","39","4797.47","7501.9","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","AETNA [1001]","HB AMC AETNA PPO","7380.72","80.4","","1670.25","1670.25","1670.25","1 through 10","4797.47","7501.9","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4797.47","52.26","","1113.10","1113.10","1113.10","1 through 10","4797.47","7501.9","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7501.90","81.72","","1738.90","1484.65","2716.94","38","4797.47","7501.9","percent of total billed charges",""
"HIP STEM 135MM SZ 3 FEMORAL SPECTRON EF COBALT CHROMIUM PRIMARY COLLARED STD OFFSET 12/14 TAPER","SUP-ITM-10015275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 135MM SZ 3 FEMORAL SPECTRON EF COBALT CHROMIUM PRIMARY COLLARED STD OFFSET 12/14 TAPER","SUP-ITM-10015275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 135MM SZ 3 FEMORAL SPECTRON EF COBALT CHROMIUM PRIMARY COLLARED STD OFFSET 12/14 TAPER","SUP-ITM-10015275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"HIP STEM 135MM SZ 3 FEMORAL SPECTRON EF COBALT CHROMIUM PRIMARY COLLARED STD OFFSET 12/14 TAPER","SUP-ITM-10015275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"HIP STEM 135MM SZ 3 FEMORAL SPECTRON EF COBALT CHROMIUM PRIMARY COLLARED STD OFFSET 12/14 TAPER","SUP-ITM-10015275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 135MM SZ 3 FEMORAL SPECTRON EF COBALT CHROMIUM PRIMARY COLLARED STD OFFSET 12/14 TAPER","SUP-ITM-10015275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 135MM SZ 3 FEMORAL SPECTRON EF COBALT CHROMIUM PRIMARY COLLARED STD OFFSET 12/14 TAPER","SUP-ITM-10015275","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"HIP STEM 135MM SZ 3 FEMORAL SPECTRON EF COBALT CHROMIUM PRIMARY COLLARED STD OFFSET 12/14 TAPER","SUP-ITM-10015275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 135MM SZ 3 FEMORAL SPECTRON EF COBALT CHROMIUM PRIMARY COLLARED STD OFFSET 12/14 TAPER","SUP-ITM-10015275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 135MM SZ 3 FEMORAL SPECTRON EF COBALT CHROMIUM PRIMARY COLLARED STD OFFSET 12/14 TAPER","SUP-ITM-10015275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 135MM SZ 3 FEMORAL SPECTRON EF COBALT CHROMIUM PRIMARY COLLARED STD OFFSET 12/14 TAPER","SUP-ITM-10015275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3266.25","52.26","","1113.10","1113.10","1113.10","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4968.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.25","36.5","","1023.42","771.29","2068.67","33","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2393.75","38.3","","850.52","759.78","1211.25","66","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.25","42.9","","2548.09","2548.09","2548.09","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.25","42.9","","956.46","956.46","956.46","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","WELLPOINT [1015]","HB AMC WELLPOINT","4611.25","73.78","","2344.73","1619.47","2530.35","16","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","AETNA [1001]","HB AMC AETNA HMO","4362.50","69.8","","1523.63","988.41","4330.26","39","3266.25","5107.5","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","AETNA [1001]","HB AMC AETNA PPO","5025.00","80.4","","1670.25","1670.25","1670.25","1 through 10","3266.25","5107.5","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3266.25","52.26","","1113.10","1113.10","1113.10","1 through 10","3266.25","5107.5","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5107.50","81.72","","1738.90","1484.65","2716.94","38","3266.25","5107.5","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2367.38","52.26","","1113.10","1113.10","1113.10","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3601.35","79.5","","1293.60","1148.53","1603.80","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1653.45","36.5","","1023.42","771.29","2068.67","33","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1734.99","38.3","","850.52","759.78","1211.25","66","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1943.37","42.9","","2548.09","2548.09","2548.09","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1943.37","42.9","","956.46","956.46","956.46","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","WELLPOINT [1015]","HB AMC WELLPOINT","3342.23","73.78","","2344.73","1619.47","2530.35","16","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","AETNA [1001]","HB AMC AETNA HMO","3161.94","69.8","","1523.63","988.41","4330.26","39","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","AETNA [1001]","HB AMC AETNA PPO","3642.12","80.4","","1670.25","1670.25","1670.25","1 through 10","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2367.38","52.26","","1113.10","1113.10","1113.10","1 through 10","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3701.92","81.72","","1738.90","1484.65","2716.94","38","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","6115.00","4586.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3195.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1895.65","4861.43","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","6115.00","4586.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4861.43","79.5","","1293.60","1148.53","1603.80","1 through 10","1895.65","4861.43","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","6115.00","4586.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2231.98","36.5","","1023.42","771.29","2068.67","33","1895.65","4861.43","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","6115.00","4586.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2342.05","38.3","","850.52","759.78","1211.25","66","1895.65","4861.43","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","6115.00","4586.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2623.34","42.9","","2548.09","2548.09","2548.09","1 through 10","1895.65","4861.43","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","6115.00","4586.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2623.34","42.9","","956.46","956.46","956.46","1 through 10","1895.65","4861.43","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","6115.00","4586.25","WELLPOINT [1015]","HB AMC WELLPOINT","4511.65","73.78","","2344.73","1619.47","2530.35","16","1895.65","4861.43","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6115.00","4586.25","AETNA [1001]","HB AMC AETNA HMO","4268.27","69.8","","1523.63","988.41","4330.26","39","3195.7","4997.18","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6115.00","4586.25","AETNA [1001]","HB AMC AETNA PPO","4916.46","80.4","","1670.25","1670.25","1670.25","1 through 10","3195.7","4997.18","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6115.00","4586.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3195.70","52.26","","1113.10","1113.10","1113.10","1 through 10","3195.7","4997.18","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6115.00","4586.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4997.18","81.72","","1738.90","1484.65","2716.94","38","3195.7","4997.18","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4797.47","52.26","","1113.10","1113.10","1113.10","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7298.10","79.5","","1293.60","1148.53","1603.80","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3350.70","36.5","","1023.42","771.29","2068.67","33","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3515.94","38.3","","850.52","759.78","1211.25","66","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3938.22","42.9","","2548.09","2548.09","2548.09","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3938.22","42.9","","956.46","956.46","956.46","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","WELLPOINT [1015]","HB AMC WELLPOINT","6773.00","73.78","","2344.73","1619.47","2530.35","16","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","AETNA [1001]","HB AMC AETNA HMO","6407.64","69.8","","1523.63","988.41","4330.26","39","4797.47","7501.9","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","AETNA [1001]","HB AMC AETNA PPO","7380.72","80.4","","1670.25","1670.25","1670.25","1 through 10","4797.47","7501.9","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4797.47","52.26","","1113.10","1113.10","1113.10","1 through 10","4797.47","7501.9","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7501.90","81.72","","1738.90","1484.65","2716.94","38","4797.47","7501.9","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4797.47","52.26","","1113.10","1113.10","1113.10","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7298.10","79.5","","1293.60","1148.53","1603.80","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3350.70","36.5","","1023.42","771.29","2068.67","33","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3515.94","38.3","","850.52","759.78","1211.25","66","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3938.22","42.9","","2548.09","2548.09","2548.09","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3938.22","42.9","","956.46","956.46","956.46","1 through 10","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","9180.00","6885.00","WELLPOINT [1015]","HB AMC WELLPOINT","6773.00","73.78","","2344.73","1619.47","2530.35","16","2845.8","7298.1","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","AETNA [1001]","HB AMC AETNA HMO","6407.64","69.8","","1523.63","988.41","4330.26","39","4797.47","7501.9","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","AETNA [1001]","HB AMC AETNA PPO","7380.72","80.4","","1670.25","1670.25","1670.25","1 through 10","4797.47","7501.9","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4797.47","52.26","","1113.10","1113.10","1113.10","1 through 10","4797.47","7501.9","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9180.00","6885.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7501.90","81.72","","1738.90","1484.65","2716.94","38","4797.47","7501.9","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3266.25","52.26","","1113.10","1113.10","1113.10","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4968.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.25","36.5","","1023.42","771.29","2068.67","33","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2393.75","38.3","","850.52","759.78","1211.25","66","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.25","42.9","","2548.09","2548.09","2548.09","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.25","42.9","","956.46","956.46","956.46","1 through 10","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","WELLPOINT [1015]","HB AMC WELLPOINT","4611.25","73.78","","2344.73","1619.47","2530.35","16","1937.5","4968.75","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","AETNA [1001]","HB AMC AETNA HMO","4362.50","69.8","","1523.63","988.41","4330.26","39","3266.25","5107.5","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","AETNA [1001]","HB AMC AETNA PPO","5025.00","80.4","","1670.25","1670.25","1670.25","1 through 10","3266.25","5107.5","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3266.25","52.26","","1113.10","1113.10","1113.10","1 through 10","3266.25","5107.5","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5107.50","81.72","","1738.90","1484.65","2716.94","38","3266.25","5107.5","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4132.01","79.5","","1293.60","1148.53","1603.80","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1897.09","36.5","","1023.42","771.29","2068.67","33","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1990.64","38.3","","850.52","759.78","1211.25","66","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","956.46","956.46","956.46","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","WELLPOINT [1015]","HB AMC WELLPOINT","3834.72","73.78","","2344.73","1619.47","2530.35","16","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA HMO","3627.86","69.8","","1523.63","988.41","4330.26","39","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA PPO","4178.79","80.4","","1670.25","1670.25","1670.25","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 15X39.6 150MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE HIGH OFFSET TYPE","SUP-ITM-10126260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4247.40","81.72","","1738.90","1484.65","2716.94","38","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 16.0X152MM FEMORAL TAPERLOC TITANIUM ALLOY POROUS LATERALIZED OFFSET","SUP-ITM-10122609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM 16.0X152MM FEMORAL TAPERLOC TITANIUM ALLOY POROUS LATERALIZED OFFSET","SUP-ITM-10122609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM 16.0X152MM FEMORAL TAPERLOC TITANIUM ALLOY POROUS LATERALIZED OFFSET","SUP-ITM-10122609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","1023.42","771.29","2068.67","33","1534.5","3935.25","percent of total billed charges",""
"HIP STEM 16.0X152MM FEMORAL TAPERLOC TITANIUM ALLOY POROUS LATERALIZED OFFSET","SUP-ITM-10122609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","850.52","759.78","1211.25","66","1534.5","3935.25","percent of total billed charges",""
"HIP STEM 16.0X152MM FEMORAL TAPERLOC TITANIUM ALLOY POROUS LATERALIZED OFFSET","SUP-ITM-10122609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM 16.0X152MM FEMORAL TAPERLOC TITANIUM ALLOY POROUS LATERALIZED OFFSET","SUP-ITM-10122609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","956.46","956.46","956.46","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM 16.0X152MM FEMORAL TAPERLOC TITANIUM ALLOY POROUS LATERALIZED OFFSET","SUP-ITM-10122609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","2344.73","1619.47","2530.35","16","1534.5","3935.25","percent of total billed charges",""
"HIP STEM 16.0X152MM FEMORAL TAPERLOC TITANIUM ALLOY POROUS LATERALIZED OFFSET","SUP-ITM-10122609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","1523.63","988.41","4330.26","39","2586.87","4045.14","percent of total billed charges",""
"HIP STEM 16.0X152MM FEMORAL TAPERLOC TITANIUM ALLOY POROUS LATERALIZED OFFSET","SUP-ITM-10122609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA PPO","3979.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2586.87","4045.14","percent of total billed charges",""
"HIP STEM 16.0X152MM FEMORAL TAPERLOC TITANIUM ALLOY POROUS LATERALIZED OFFSET","SUP-ITM-10122609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2586.87","4045.14","percent of total billed charges",""
"HIP STEM 16.0X152MM FEMORAL TAPERLOC TITANIUM ALLOY POROUS LATERALIZED OFFSET","SUP-ITM-10122609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","1738.90","1484.65","2716.94","38","2586.87","4045.14","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","10200.00","7650.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5330.52","52.26","","1113.10","1113.10","1113.10","1 through 10","3162","8109","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","10200.00","7650.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8109.00","79.5","","1293.60","1148.53","1603.80","1 through 10","3162","8109","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","10200.00","7650.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3723.00","36.5","","1023.42","771.29","2068.67","33","3162","8109","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","10200.00","7650.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3906.60","38.3","","850.52","759.78","1211.25","66","3162","8109","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","10200.00","7650.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4375.80","42.9","","2548.09","2548.09","2548.09","1 through 10","3162","8109","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","10200.00","7650.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4375.80","42.9","","956.46","956.46","956.46","1 through 10","3162","8109","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","10200.00","7650.00","WELLPOINT [1015]","HB AMC WELLPOINT","7525.56","73.78","","2344.73","1619.47","2530.35","16","3162","8109","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10200.00","7650.00","AETNA [1001]","HB AMC AETNA HMO","7119.60","69.8","","1523.63","988.41","4330.26","39","5330.52","8335.44","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10200.00","7650.00","AETNA [1001]","HB AMC AETNA PPO","8200.80","80.4","","1670.25","1670.25","1670.25","1 through 10","5330.52","8335.44","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10200.00","7650.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5330.52","52.26","","1113.10","1113.10","1113.10","1 through 10","5330.52","8335.44","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10200.00","7650.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8335.44","81.72","","1738.90","1484.65","2716.94","38","5330.52","8335.44","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2367.38","52.26","","1113.10","1113.10","1113.10","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3601.35","79.5","","1293.60","1148.53","1603.80","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1653.45","36.5","","1023.42","771.29","2068.67","33","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1734.99","38.3","","850.52","759.78","1211.25","66","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1943.37","42.9","","2548.09","2548.09","2548.09","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1943.37","42.9","","956.46","956.46","956.46","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","WELLPOINT [1015]","HB AMC WELLPOINT","3342.23","73.78","","2344.73","1619.47","2530.35","16","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","AETNA [1001]","HB AMC AETNA HMO","3161.94","69.8","","1523.63","988.41","4330.26","39","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","AETNA [1001]","HB AMC AETNA PPO","3642.12","80.4","","1670.25","1670.25","1670.25","1 through 10","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2367.38","52.26","","1113.10","1113.10","1113.10","1 through 10","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3701.92","81.72","","1738.90","1484.65","2716.94","38","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2367.38","52.26","","1113.10","1113.10","1113.10","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3601.35","79.5","","1293.60","1148.53","1603.80","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1653.45","36.5","","1023.42","771.29","2068.67","33","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1734.99","38.3","","850.52","759.78","1211.25","66","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1943.37","42.9","","2548.09","2548.09","2548.09","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1943.37","42.9","","956.46","956.46","956.46","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","WELLPOINT [1015]","HB AMC WELLPOINT","3342.23","73.78","","2344.73","1619.47","2530.35","16","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","AETNA [1001]","HB AMC AETNA HMO","3161.94","69.8","","1523.63","988.41","4330.26","39","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","AETNA [1001]","HB AMC AETNA PPO","3642.12","80.4","","1670.25","1670.25","1670.25","1 through 10","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2367.38","52.26","","1113.10","1113.10","1113.10","1 through 10","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3701.92","81.72","","1738.90","1484.65","2716.94","38","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2367.38","52.26","","1113.10","1113.10","1113.10","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3601.35","79.5","","1293.60","1148.53","1603.80","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1653.45","36.5","","1023.42","771.29","2068.67","33","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1734.99","38.3","","850.52","759.78","1211.25","66","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1943.37","42.9","","2548.09","2548.09","2548.09","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1943.37","42.9","","956.46","956.46","956.46","1 through 10","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","WELLPOINT [1015]","HB AMC WELLPOINT","3342.23","73.78","","2344.73","1619.47","2530.35","16","1404.3","3601.35","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","AETNA [1001]","HB AMC AETNA HMO","3161.94","69.8","","1523.63","988.41","4330.26","39","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","AETNA [1001]","HB AMC AETNA PPO","3642.12","80.4","","1670.25","1670.25","1670.25","1 through 10","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2367.38","52.26","","1113.10","1113.10","1113.10","1 through 10","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3701.92","81.72","","1738.90","1484.65","2716.94","38","2367.38","3701.92","percent of total billed charges",""
"HIP STEM 18X185MM XL IMPLANT FEMORAL POROUS ZMR TAPERED 03","SUP-ITM-10016211","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4133.31","52.26","","1113.10","1113.10","1113.10","1 through 10","2451.83","6287.76","percent of total billed charges",""
"HIP STEM 18X185MM XL IMPLANT FEMORAL POROUS ZMR TAPERED 03","SUP-ITM-10016211","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6287.76","79.5","","1293.60","1148.53","1603.80","1 through 10","2451.83","6287.76","percent of total billed charges",""
"HIP STEM 18X185MM XL IMPLANT FEMORAL POROUS ZMR TAPERED 03","SUP-ITM-10016211","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2886.83","36.5","","1023.42","771.29","2068.67","33","2451.83","6287.76","percent of total billed charges",""
"HIP STEM 18X185MM XL IMPLANT FEMORAL POROUS ZMR TAPERED 03","SUP-ITM-10016211","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3029.20","38.3","","850.52","759.78","1211.25","66","2451.83","6287.76","percent of total billed charges",""
"HIP STEM 18X185MM XL IMPLANT FEMORAL POROUS ZMR TAPERED 03","SUP-ITM-10016211","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3393.02","42.9","","2548.09","2548.09","2548.09","1 through 10","2451.83","6287.76","percent of total billed charges",""
"HIP STEM 18X185MM XL IMPLANT FEMORAL POROUS ZMR TAPERED 03","SUP-ITM-10016211","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3393.02","42.9","","956.46","956.46","956.46","1 through 10","2451.83","6287.76","percent of total billed charges",""
"HIP STEM 18X185MM XL IMPLANT FEMORAL POROUS ZMR TAPERED 03","SUP-ITM-10016211","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","WELLPOINT [1015]","HB AMC WELLPOINT","5835.36","73.78","","2344.73","1619.47","2530.35","16","2451.83","6287.76","percent of total billed charges",""
"HIP STEM 18X185MM XL IMPLANT FEMORAL POROUS ZMR TAPERED 03","SUP-ITM-10016211","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7909.13","5931.85","AETNA [1001]","HB AMC AETNA HMO","5520.57","69.8","","1523.63","988.41","4330.26","39","4133.31","6463.34","percent of total billed charges",""
"HIP STEM 18X185MM XL IMPLANT FEMORAL POROUS ZMR TAPERED 03","SUP-ITM-10016211","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7909.13","5931.85","AETNA [1001]","HB AMC AETNA PPO","6358.94","80.4","","1670.25","1670.25","1670.25","1 through 10","4133.31","6463.34","percent of total billed charges",""
"HIP STEM 18X185MM XL IMPLANT FEMORAL POROUS ZMR TAPERED 03","SUP-ITM-10016211","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7909.13","5931.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4133.31","52.26","","1113.10","1113.10","1113.10","1 through 10","4133.31","6463.34","percent of total billed charges",""
"HIP STEM 18X185MM XL IMPLANT FEMORAL POROUS ZMR TAPERED 03","SUP-ITM-10016211","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7909.13","5931.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6463.34","81.72","","1738.90","1484.65","2716.94","38","4133.31","6463.34","percent of total billed charges",""
"HIP STEM 19.5X220MM XL IMPLANT POROUS ZMR BOWED 03","SUP-ITM-10016528","CDM","C1776","HCPCS","0278","RC","","","","both","","","7532.50","5649.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3936.48","52.26","","1113.10","1113.10","1113.10","1 through 10","2335.08","5988.34","percent of total billed charges",""
"HIP STEM 19.5X220MM XL IMPLANT POROUS ZMR BOWED 03","SUP-ITM-10016528","CDM","C1776","HCPCS","0278","RC","","","","both","","","7532.50","5649.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5988.34","79.5","","1293.60","1148.53","1603.80","1 through 10","2335.08","5988.34","percent of total billed charges",""
"HIP STEM 19.5X220MM XL IMPLANT POROUS ZMR BOWED 03","SUP-ITM-10016528","CDM","C1776","HCPCS","0278","RC","","","","both","","","7532.50","5649.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2749.36","36.5","","1023.42","771.29","2068.67","33","2335.08","5988.34","percent of total billed charges",""
"HIP STEM 19.5X220MM XL IMPLANT POROUS ZMR BOWED 03","SUP-ITM-10016528","CDM","C1776","HCPCS","0278","RC","","","","both","","","7532.50","5649.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2884.95","38.3","","850.52","759.78","1211.25","66","2335.08","5988.34","percent of total billed charges",""
"HIP STEM 19.5X220MM XL IMPLANT POROUS ZMR BOWED 03","SUP-ITM-10016528","CDM","C1776","HCPCS","0278","RC","","","","both","","","7532.50","5649.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3231.44","42.9","","2548.09","2548.09","2548.09","1 through 10","2335.08","5988.34","percent of total billed charges",""
"HIP STEM 19.5X220MM XL IMPLANT POROUS ZMR BOWED 03","SUP-ITM-10016528","CDM","C1776","HCPCS","0278","RC","","","","both","","","7532.50","5649.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3231.44","42.9","","956.46","956.46","956.46","1 through 10","2335.08","5988.34","percent of total billed charges",""
"HIP STEM 19.5X220MM XL IMPLANT POROUS ZMR BOWED 03","SUP-ITM-10016528","CDM","C1776","HCPCS","0278","RC","","","","both","","","7532.50","5649.37","WELLPOINT [1015]","HB AMC WELLPOINT","5557.48","73.78","","2344.73","1619.47","2530.35","16","2335.08","5988.34","percent of total billed charges",""
"HIP STEM 19.5X220MM XL IMPLANT POROUS ZMR BOWED 03","SUP-ITM-10016528","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7532.50","5649.37","AETNA [1001]","HB AMC AETNA HMO","5257.69","69.8","","1523.63","988.41","4330.26","39","3936.48","6155.56","percent of total billed charges",""
"HIP STEM 19.5X220MM XL IMPLANT POROUS ZMR BOWED 03","SUP-ITM-10016528","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7532.50","5649.37","AETNA [1001]","HB AMC AETNA PPO","6056.13","80.4","","1670.25","1670.25","1670.25","1 through 10","3936.48","6155.56","percent of total billed charges",""
"HIP STEM 19.5X220MM XL IMPLANT POROUS ZMR BOWED 03","SUP-ITM-10016528","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7532.50","5649.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3936.48","52.26","","1113.10","1113.10","1113.10","1 through 10","3936.48","6155.56","percent of total billed charges",""
"HIP STEM 19.5X220MM XL IMPLANT POROUS ZMR BOWED 03","SUP-ITM-10016528","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7532.50","5649.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6155.56","81.72","","1738.90","1484.65","2716.94","38","3936.48","6155.56","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4648.76","79.5","","1293.60","1148.53","1603.80","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2134.34","36.5","","1023.42","771.29","2068.67","33","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2239.59","38.3","","850.52","759.78","1211.25","66","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","2548.09","2548.09","2548.09","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","956.46","956.46","956.46","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","WELLPOINT [1015]","HB AMC WELLPOINT","4314.29","73.78","","2344.73","1619.47","2530.35","16","1812.73","4648.76","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA HMO","4081.56","69.8","","1523.63","988.41","4330.26","39","3055.9","4778.58","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA PPO","4701.39","80.4","","1670.25","1670.25","1670.25","1 through 10","3055.9","4778.58","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","3055.9","4778.58","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4778.58","81.72","","1738.90","1484.65","2716.94","38","3055.9","4778.58","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2822.04","52.26","","1113.10","1113.10","1113.10","1 through 10","1674","4293","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4293.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1674","4293","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1971.00","36.5","","1023.42","771.29","2068.67","33","1674","4293","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2068.20","38.3","","850.52","759.78","1211.25","66","1674","4293","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","2548.09","2548.09","2548.09","1 through 10","1674","4293","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","956.46","956.46","956.46","1 through 10","1674","4293","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB AMC WELLPOINT","3984.12","73.78","","2344.73","1619.47","2530.35","16","1674","4293","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA HMO","3769.20","69.8","","1523.63","988.41","4330.26","39","2822.04","4412.88","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA PPO","4341.60","80.4","","1670.25","1670.25","1670.25","1 through 10","2822.04","4412.88","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2822.04","52.26","","1113.10","1113.10","1113.10","1 through 10","2822.04","4412.88","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4412.88","81.72","","1738.90","1484.65","2716.94","38","2822.04","4412.88","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1023.42","771.29","2068.67","33","1085","2782.5","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","850.52","759.78","1211.25","66","1085","2782.5","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","956.46","956.46","956.46","1 through 10","1085","2782.5","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2344.73","1619.47","2530.35","16","1085","2782.5","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1523.63","988.41","4330.26","39","1829.1","2860.2","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1829.1","2860.2","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1829.1","2860.2","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","1738.90","1484.65","2716.94","38","1829.1","2860.2","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 40X170MM SIZE 11 127DEG STR NECK ANGLE SECURFIT MAX 01","SUP-ITM-10021480","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 40X170MM SIZE 11 127DEG STR NECK ANGLE SECURFIT MAX 01","SUP-ITM-10021480","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 40X170MM SIZE 11 127DEG STR NECK ANGLE SECURFIT MAX 01","SUP-ITM-10021480","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"HIP STEM 40X170MM SIZE 11 127DEG STR NECK ANGLE SECURFIT MAX 01","SUP-ITM-10021480","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"HIP STEM 40X170MM SIZE 11 127DEG STR NECK ANGLE SECURFIT MAX 01","SUP-ITM-10021480","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 40X170MM SIZE 11 127DEG STR NECK ANGLE SECURFIT MAX 01","SUP-ITM-10021480","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM 40X170MM SIZE 11 127DEG STR NECK ANGLE SECURFIT MAX 01","SUP-ITM-10021480","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"HIP STEM 40X170MM SIZE 11 127DEG STR NECK ANGLE SECURFIT MAX 01","SUP-ITM-10021480","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 40X170MM SIZE 11 127DEG STR NECK ANGLE SECURFIT MAX 01","SUP-ITM-10021480","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 40X170MM SIZE 11 127DEG STR NECK ANGLE SECURFIT MAX 01","SUP-ITM-10021480","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 40X170MM SIZE 11 127DEG STR NECK ANGLE SECURFIT MAX 01","SUP-ITM-10021480","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4132.01","79.5","","1293.60","1148.53","1603.80","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1897.09","36.5","","1023.42","771.29","2068.67","33","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1990.64","38.3","","850.52","759.78","1211.25","66","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","956.46","956.46","956.46","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","WELLPOINT [1015]","HB AMC WELLPOINT","3834.72","73.78","","2344.73","1619.47","2530.35","16","1611.23","4132.01","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA HMO","3627.86","69.8","","1523.63","988.41","4330.26","39","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA PPO","4178.79","80.4","","1670.25","1670.25","1670.25","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 4X34.3 128MM 1 SIZE TAPERLOC PPS COATED COMPLETE FULL PROFILE STANDARD OFFSET TYPE","SUP-ITM-10132459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4247.40","81.72","","1738.90","1484.65","2716.94","38","2716.21","4247.4","percent of total billed charges",""
"HIP STEM 7.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1536.44","52.26","","1113.10","1113.10","1113.10","1 through 10","911.4","2337.3","percent of total billed charges",""
"HIP STEM 7.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2337.30","79.5","","1293.60","1148.53","1603.80","1 through 10","911.4","2337.3","percent of total billed charges",""
"HIP STEM 7.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1073.10","36.5","","1023.42","771.29","2068.67","33","911.4","2337.3","percent of total billed charges",""
"HIP STEM 7.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1126.02","38.3","","850.52","759.78","1211.25","66","911.4","2337.3","percent of total billed charges",""
"HIP STEM 7.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1261.26","42.9","","2548.09","2548.09","2548.09","1 through 10","911.4","2337.3","percent of total billed charges",""
"HIP STEM 7.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1261.26","42.9","","956.46","956.46","956.46","1 through 10","911.4","2337.3","percent of total billed charges",""
"HIP STEM 7.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","WELLPOINT [1015]","HB AMC WELLPOINT","2169.13","73.78","","2344.73","1619.47","2530.35","16","911.4","2337.3","percent of total billed charges",""
"HIP STEM 7.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2940.00","2205.00","AETNA [1001]","HB AMC AETNA HMO","2052.12","69.8","","1523.63","988.41","4330.26","39","1536.44","2402.57","percent of total billed charges",""
"HIP STEM 7.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2940.00","2205.00","AETNA [1001]","HB AMC AETNA PPO","2363.76","80.4","","1670.25","1670.25","1670.25","1 through 10","1536.44","2402.57","percent of total billed charges",""
"HIP STEM 7.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2940.00","2205.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1536.44","52.26","","1113.10","1113.10","1113.10","1 through 10","1536.44","2402.57","percent of total billed charges",""
"HIP STEM 7.0MM FEMORAL ECHO FX COBALT CHROMIUM","SUP-ITM-10042027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2940.00","2205.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2402.57","81.72","","1738.90","1484.65","2716.94","38","1536.44","2402.57","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2449.69","52.26","","1113.10","1113.10","1113.10","1 through 10","1453.13","3726.56","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3726.56","79.5","","1293.60","1148.53","1603.80","1 through 10","1453.13","3726.56","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1710.94","36.5","","1023.42","771.29","2068.67","33","1453.13","3726.56","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1795.31","38.3","","850.52","759.78","1211.25","66","1453.13","3726.56","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2010.94","42.9","","2548.09","2548.09","2548.09","1 through 10","1453.13","3726.56","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2010.94","42.9","","956.46","956.46","956.46","1 through 10","1453.13","3726.56","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","both","","","4687.50","3515.62","WELLPOINT [1015]","HB AMC WELLPOINT","3458.44","73.78","","2344.73","1619.47","2530.35","16","1453.13","3726.56","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4687.50","3515.62","AETNA [1001]","HB AMC AETNA HMO","3271.88","69.8","","1523.63","988.41","4330.26","39","2449.69","3830.63","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4687.50","3515.62","AETNA [1001]","HB AMC AETNA PPO","3768.75","80.4","","1670.25","1670.25","1670.25","1 through 10","2449.69","3830.63","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4687.50","3515.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2449.69","52.26","","1113.10","1113.10","1113.10","1 through 10","2449.69","3830.63","percent of total billed charges",""
"HIP STEM 9MMX125 MOLD CEMENT SPACER STAGEONE SILICONE SS REINFORCED TEMPORARY","SUP-ITM-10092303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4687.50","3515.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3830.63","81.72","","1738.90","1484.65","2716.94","38","2449.69","3830.63","percent of total billed charges",""
"HIP STEM FEMORAL 16X160MM VERSYS FIBER METAL MIDCOAT TITAVANIUM TITANIUM ALLOY POROUS COLLARLESS BODY","SUP-ITM-10057457","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 16X160MM VERSYS FIBER METAL MIDCOAT TITAVANIUM TITANIUM ALLOY POROUS COLLARLESS BODY","SUP-ITM-10057457","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 16X160MM VERSYS FIBER METAL MIDCOAT TITAVANIUM TITANIUM ALLOY POROUS COLLARLESS BODY","SUP-ITM-10057457","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","1023.42","771.29","2068.67","33","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 16X160MM VERSYS FIBER METAL MIDCOAT TITAVANIUM TITANIUM ALLOY POROUS COLLARLESS BODY","SUP-ITM-10057457","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","850.52","759.78","1211.25","66","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 16X160MM VERSYS FIBER METAL MIDCOAT TITAVANIUM TITANIUM ALLOY POROUS COLLARLESS BODY","SUP-ITM-10057457","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 16X160MM VERSYS FIBER METAL MIDCOAT TITAVANIUM TITANIUM ALLOY POROUS COLLARLESS BODY","SUP-ITM-10057457","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","956.46","956.46","956.46","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 16X160MM VERSYS FIBER METAL MIDCOAT TITAVANIUM TITANIUM ALLOY POROUS COLLARLESS BODY","SUP-ITM-10057457","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","2344.73","1619.47","2530.35","16","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 16X160MM VERSYS FIBER METAL MIDCOAT TITAVANIUM TITANIUM ALLOY POROUS COLLARLESS BODY","SUP-ITM-10057457","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","1523.63","988.41","4330.26","39","2586.87","4045.14","percent of total billed charges",""
"HIP STEM FEMORAL 16X160MM VERSYS FIBER METAL MIDCOAT TITAVANIUM TITANIUM ALLOY POROUS COLLARLESS BODY","SUP-ITM-10057457","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA PPO","3979.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2586.87","4045.14","percent of total billed charges",""
"HIP STEM FEMORAL 16X160MM VERSYS FIBER METAL MIDCOAT TITAVANIUM TITANIUM ALLOY POROUS COLLARLESS BODY","SUP-ITM-10057457","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2586.87","4045.14","percent of total billed charges",""
"HIP STEM FEMORAL 16X160MM VERSYS FIBER METAL MIDCOAT TITAVANIUM TITANIUM ALLOY POROUS COLLARLESS BODY","SUP-ITM-10057457","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","1738.90","1484.65","2716.94","38","2586.87","4045.14","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","1023.42","771.29","2068.67","33","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","850.52","759.78","1211.25","66","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","956.46","956.46","956.46","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","2344.73","1619.47","2530.35","16","1534.5","3935.25","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","1523.63","988.41","4330.26","39","2586.87","4045.14","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA PPO","3979.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2586.87","4045.14","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2586.87","4045.14","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","1738.90","1484.65","2716.94","38","2586.87","4045.14","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5112.33","52.26","","1113.10","1113.10","1113.10","1 through 10","3032.58","7777.09","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7777.09","79.5","","1293.60","1148.53","1603.80","1 through 10","3032.58","7777.09","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3570.61","36.5","","1023.42","771.29","2068.67","33","3032.58","7777.09","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3746.70","38.3","","850.52","759.78","1211.25","66","3032.58","7777.09","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4196.69","42.9","","2548.09","2548.09","2548.09","1 through 10","3032.58","7777.09","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4196.69","42.9","","956.46","956.46","956.46","1 through 10","3032.58","7777.09","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","WELLPOINT [1015]","HB AMC WELLPOINT","7217.53","73.78","","2344.73","1619.47","2530.35","16","3032.58","7777.09","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9782.50","7336.87","AETNA [1001]","HB AMC AETNA HMO","6828.19","69.8","","1523.63","988.41","4330.26","39","5112.33","7994.26","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9782.50","7336.87","AETNA [1001]","HB AMC AETNA PPO","7865.13","80.4","","1670.25","1670.25","1670.25","1 through 10","5112.33","7994.26","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9782.50","7336.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5112.33","52.26","","1113.10","1113.10","1113.10","1 through 10","5112.33","7994.26","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9782.50","7336.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7994.26","81.72","","1738.90","1484.65","2716.94","38","5112.33","7994.26","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3070.28","52.26","","1113.10","1113.10","1113.10","1 through 10","1821.25","4670.63","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4670.63","79.5","","1293.60","1148.53","1603.80","1 through 10","1821.25","4670.63","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2144.38","36.5","","1023.42","771.29","2068.67","33","1821.25","4670.63","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2250.13","38.3","","850.52","759.78","1211.25","66","1821.25","4670.63","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2520.38","42.9","","2548.09","2548.09","2548.09","1 through 10","1821.25","4670.63","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2520.38","42.9","","956.46","956.46","956.46","1 through 10","1821.25","4670.63","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","WELLPOINT [1015]","HB AMC WELLPOINT","4334.58","73.78","","2344.73","1619.47","2530.35","16","1821.25","4670.63","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5875.00","4406.25","AETNA [1001]","HB AMC AETNA HMO","4100.75","69.8","","1523.63","988.41","4330.26","39","3070.28","4801.05","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5875.00","4406.25","AETNA [1001]","HB AMC AETNA PPO","4723.50","80.4","","1670.25","1670.25","1670.25","1 through 10","3070.28","4801.05","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5875.00","4406.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3070.28","52.26","","1113.10","1113.10","1113.10","1 through 10","3070.28","4801.05","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5875.00","4406.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4801.05","81.72","","1738.90","1484.65","2716.94","38","3070.28","4801.05","percent of total billed charges",""
"HIP STEM SIZE 1 FEMORAL POLAR CEMENTLESS STANDARD TI 6AL4V","SUP-ITM-10198417","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 1 FEMORAL POLAR CEMENTLESS STANDARD TI 6AL4V","SUP-ITM-10198417","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 1 FEMORAL POLAR CEMENTLESS STANDARD TI 6AL4V","SUP-ITM-10198417","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","1023.42","771.29","2068.67","33","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 1 FEMORAL POLAR CEMENTLESS STANDARD TI 6AL4V","SUP-ITM-10198417","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","850.52","759.78","1211.25","66","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 1 FEMORAL POLAR CEMENTLESS STANDARD TI 6AL4V","SUP-ITM-10198417","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 1 FEMORAL POLAR CEMENTLESS STANDARD TI 6AL4V","SUP-ITM-10198417","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","956.46","956.46","956.46","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 1 FEMORAL POLAR CEMENTLESS STANDARD TI 6AL4V","SUP-ITM-10198417","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","2344.73","1619.47","2530.35","16","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 1 FEMORAL POLAR CEMENTLESS STANDARD TI 6AL4V","SUP-ITM-10198417","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","1523.63","988.41","4330.26","39","2586.87","4045.14","percent of total billed charges",""
"HIP STEM SIZE 1 FEMORAL POLAR CEMENTLESS STANDARD TI 6AL4V","SUP-ITM-10198417","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA PPO","3979.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2586.87","4045.14","percent of total billed charges",""
"HIP STEM SIZE 1 FEMORAL POLAR CEMENTLESS STANDARD TI 6AL4V","SUP-ITM-10198417","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2586.87","4045.14","percent of total billed charges",""
"HIP STEM SIZE 1 FEMORAL POLAR CEMENTLESS STANDARD TI 6AL4V","SUP-ITM-10198417","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","1738.90","1484.65","2716.94","38","2586.87","4045.14","percent of total billed charges",""
"HIP STEM SIZE 4 POLAR CEMENTLESS TI 6AL4V","SUP-ITM-10198404","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 4 POLAR CEMENTLESS TI 6AL4V","SUP-ITM-10198404","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 4 POLAR CEMENTLESS TI 6AL4V","SUP-ITM-10198404","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","1023.42","771.29","2068.67","33","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 4 POLAR CEMENTLESS TI 6AL4V","SUP-ITM-10198404","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","850.52","759.78","1211.25","66","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 4 POLAR CEMENTLESS TI 6AL4V","SUP-ITM-10198404","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 4 POLAR CEMENTLESS TI 6AL4V","SUP-ITM-10198404","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","956.46","956.46","956.46","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 4 POLAR CEMENTLESS TI 6AL4V","SUP-ITM-10198404","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","2344.73","1619.47","2530.35","16","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SIZE 4 POLAR CEMENTLESS TI 6AL4V","SUP-ITM-10198404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","1523.63","988.41","4330.26","39","2586.87","4045.14","percent of total billed charges",""
"HIP STEM SIZE 4 POLAR CEMENTLESS TI 6AL4V","SUP-ITM-10198404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA PPO","3979.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2586.87","4045.14","percent of total billed charges",""
"HIP STEM SIZE 4 POLAR CEMENTLESS TI 6AL4V","SUP-ITM-10198404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2586.87","4045.14","percent of total billed charges",""
"HIP STEM SIZE 4 POLAR CEMENTLESS TI 6AL4V","SUP-ITM-10198404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","1738.90","1484.65","2716.94","38","2586.87","4045.14","percent of total billed charges",""
"HIP STEM STANDARD SZ 2 POLARSTEM CEMENTED","SUP-ITM-10321554","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 2 POLARSTEM CEMENTED","SUP-ITM-10321554","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 2 POLARSTEM CEMENTED","SUP-ITM-10321554","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 2 POLARSTEM CEMENTED","SUP-ITM-10321554","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 2 POLARSTEM CEMENTED","SUP-ITM-10321554","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 2 POLARSTEM CEMENTED","SUP-ITM-10321554","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 2 POLARSTEM CEMENTED","SUP-ITM-10321554","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 2 POLARSTEM CEMENTED","SUP-ITM-10321554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"HIP STEM STANDARD SZ 2 POLARSTEM CEMENTED","SUP-ITM-10321554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM STANDARD SZ 2 POLARSTEM CEMENTED","SUP-ITM-10321554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM STANDARD SZ 2 POLARSTEM CEMENTED","SUP-ITM-10321554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"HIP STEM STANDARD SZ 3 POLARSTEM CEMENTED","SUP-ITM-10321740","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 3 POLARSTEM CEMENTED","SUP-ITM-10321740","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 3 POLARSTEM CEMENTED","SUP-ITM-10321740","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 3 POLARSTEM CEMENTED","SUP-ITM-10321740","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 3 POLARSTEM CEMENTED","SUP-ITM-10321740","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 3 POLARSTEM CEMENTED","SUP-ITM-10321740","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 3 POLARSTEM CEMENTED","SUP-ITM-10321740","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"HIP STEM STANDARD SZ 3 POLARSTEM CEMENTED","SUP-ITM-10321740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"HIP STEM STANDARD SZ 3 POLARSTEM CEMENTED","SUP-ITM-10321740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM STANDARD SZ 3 POLARSTEM CEMENTED","SUP-ITM-10321740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM STANDARD SZ 3 POLARSTEM CEMENTED","SUP-ITM-10321740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"HIP STEM SZ 0 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10285277","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2377.83","52.26","","1113.10","1113.10","1113.10","1 through 10","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 0 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10285277","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3617.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 0 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10285277","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1660.75","36.5","","1023.42","771.29","2068.67","33","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 0 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10285277","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1742.65","38.3","","850.52","759.78","1211.25","66","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 0 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10285277","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.95","42.9","","2548.09","2548.09","2548.09","1 through 10","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 0 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10285277","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.95","42.9","","956.46","956.46","956.46","1 through 10","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 0 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10285277","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","WELLPOINT [1015]","HB AMC WELLPOINT","3356.99","73.78","","2344.73","1619.47","2530.35","16","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 0 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10285277","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","AETNA [1001]","HB AMC AETNA HMO","3175.90","69.8","","1523.63","988.41","4330.26","39","2377.83","3718.26","percent of total billed charges",""
"HIP STEM SZ 0 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10285277","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","AETNA [1001]","HB AMC AETNA PPO","3658.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2377.83","3718.26","percent of total billed charges",""
"HIP STEM SZ 0 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10285277","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2377.83","52.26","","1113.10","1113.10","1113.10","1 through 10","2377.83","3718.26","percent of total billed charges",""
"HIP STEM SZ 0 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10285277","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3718.26","81.72","","1738.90","1484.65","2716.94","38","2377.83","3718.26","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2377.83","52.26","","1113.10","1113.10","1113.10","1 through 10","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3617.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1660.75","36.5","","1023.42","771.29","2068.67","33","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1742.65","38.3","","850.52","759.78","1211.25","66","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.95","42.9","","2548.09","2548.09","2548.09","1 through 10","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.95","42.9","","956.46","956.46","956.46","1 through 10","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","WELLPOINT [1015]","HB AMC WELLPOINT","3356.99","73.78","","2344.73","1619.47","2530.35","16","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","AETNA [1001]","HB AMC AETNA HMO","3175.90","69.8","","1523.63","988.41","4330.26","39","2377.83","3718.26","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","AETNA [1001]","HB AMC AETNA PPO","3658.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2377.83","3718.26","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2377.83","52.26","","1113.10","1113.10","1113.10","1 through 10","2377.83","3718.26","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3718.26","81.72","","1738.90","1484.65","2716.94","38","2377.83","3718.26","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"HIP STEM SZ 15 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284733","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 15 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284733","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4648.76","79.5","","1293.60","1148.53","1603.80","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 15 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284733","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2134.34","36.5","","1023.42","771.29","2068.67","33","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 15 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284733","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2239.59","38.3","","850.52","759.78","1211.25","66","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 15 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284733","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","2548.09","2548.09","2548.09","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 15 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284733","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","956.46","956.46","956.46","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 15 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284733","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","WELLPOINT [1015]","HB AMC WELLPOINT","4314.29","73.78","","2344.73","1619.47","2530.35","16","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 15 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA HMO","4081.56","69.8","","1523.63","988.41","4330.26","39","3055.9","4778.58","percent of total billed charges",""
"HIP STEM SZ 15 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA PPO","4701.39","80.4","","1670.25","1670.25","1670.25","1 through 10","3055.9","4778.58","percent of total billed charges",""
"HIP STEM SZ 15 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","3055.9","4778.58","percent of total billed charges",""
"HIP STEM SZ 15 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4778.58","81.72","","1738.90","1484.65","2716.94","38","3055.9","4778.58","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4648.76","79.5","","1293.60","1148.53","1603.80","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2134.34","36.5","","1023.42","771.29","2068.67","33","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2239.59","38.3","","850.52","759.78","1211.25","66","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","2548.09","2548.09","2548.09","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2508.58","42.9","","956.46","956.46","956.46","1 through 10","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","5847.50","4385.62","WELLPOINT [1015]","HB AMC WELLPOINT","4314.29","73.78","","2344.73","1619.47","2530.35","16","1812.73","4648.76","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA HMO","4081.56","69.8","","1523.63","988.41","4330.26","39","3055.9","4778.58","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","AETNA [1001]","HB AMC AETNA PPO","4701.39","80.4","","1670.25","1670.25","1670.25","1 through 10","3055.9","4778.58","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3055.90","52.26","","1113.10","1113.10","1113.10","1 through 10","3055.9","4778.58","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5847.50","4385.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4778.58","81.72","","1738.90","1484.65","2716.94","38","3055.9","4778.58","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3951.50","2963.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2065.05","52.26","","1113.10","1113.10","1113.10","1 through 10","1224.97","3141.44","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3951.50","2963.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3141.44","79.5","","1293.60","1148.53","1603.80","1 through 10","1224.97","3141.44","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3951.50","2963.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1442.30","36.5","","1023.42","771.29","2068.67","33","1224.97","3141.44","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3951.50","2963.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1513.42","38.3","","850.52","759.78","1211.25","66","1224.97","3141.44","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3951.50","2963.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1695.19","42.9","","2548.09","2548.09","2548.09","1 through 10","1224.97","3141.44","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3951.50","2963.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1695.19","42.9","","956.46","956.46","956.46","1 through 10","1224.97","3141.44","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3951.50","2963.62","WELLPOINT [1015]","HB AMC WELLPOINT","2915.42","73.78","","2344.73","1619.47","2530.35","16","1224.97","3141.44","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3951.50","2963.62","AETNA [1001]","HB AMC AETNA HMO","2758.15","69.8","","1523.63","988.41","4330.26","39","2065.05","3229.17","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3951.50","2963.62","AETNA [1001]","HB AMC AETNA PPO","3177.01","80.4","","1670.25","1670.25","1670.25","1 through 10","2065.05","3229.17","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3951.50","2963.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2065.05","52.26","","1113.10","1113.10","1113.10","1 through 10","2065.05","3229.17","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3951.50","2963.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3229.17","81.72","","1738.90","1484.65","2716.94","38","2065.05","3229.17","percent of total billed charges",""
"HIP STEM SZ 4 50MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197243","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SZ 4 50MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197243","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SZ 4 50MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197243","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","1023.42","771.29","2068.67","33","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SZ 4 50MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197243","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","850.52","759.78","1211.25","66","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SZ 4 50MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197243","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SZ 4 50MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197243","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","956.46","956.46","956.46","1 through 10","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SZ 4 50MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197243","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","2344.73","1619.47","2530.35","16","1534.5","3935.25","percent of total billed charges",""
"HIP STEM SZ 4 50MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197243","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","1523.63","988.41","4330.26","39","2586.87","4045.14","percent of total billed charges",""
"HIP STEM SZ 4 50MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197243","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA PPO","3979.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2586.87","4045.14","percent of total billed charges",""
"HIP STEM SZ 4 50MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197243","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2586.87","4045.14","percent of total billed charges",""
"HIP STEM SZ 4 50MM TAPERED TAPERFIT OFFSET","SUP-ITM-10197243","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","1738.90","1484.65","2716.94","38","2586.87","4045.14","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2822.04","52.26","","1113.10","1113.10","1113.10","1 through 10","1674","4293","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4293.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1674","4293","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1971.00","36.5","","1023.42","771.29","2068.67","33","1674","4293","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2068.20","38.3","","850.52","759.78","1211.25","66","1674","4293","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","2548.09","2548.09","2548.09","1 through 10","1674","4293","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","956.46","956.46","956.46","1 through 10","1674","4293","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB AMC WELLPOINT","3984.12","73.78","","2344.73","1619.47","2530.35","16","1674","4293","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA HMO","3769.20","69.8","","1523.63","988.41","4330.26","39","2822.04","4412.88","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA PPO","4341.60","80.4","","1670.25","1670.25","1670.25","1 through 10","2822.04","4412.88","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2822.04","52.26","","1113.10","1113.10","1113.10","1 through 10","2822.04","4412.88","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4412.88","81.72","","1738.90","1484.65","2716.94","38","2822.04","4412.88","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4132.01","79.5","","1293.60","1148.53","1603.80","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1897.09","36.5","","1023.42","771.29","2068.67","33","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1990.64","38.3","","850.52","759.78","1211.25","66","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","956.46","956.46","956.46","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","WELLPOINT [1015]","HB AMC WELLPOINT","3834.72","73.78","","2344.73","1619.47","2530.35","16","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA HMO","3627.86","69.8","","1523.63","988.41","4330.26","39","2716.21","4247.4","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA PPO","4178.79","80.4","","1670.25","1670.25","1670.25","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4247.40","81.72","","1738.90","1484.65","2716.94","38","2716.21","4247.4","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4132.01","79.5","","1293.60","1148.53","1603.80","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1897.09","36.5","","1023.42","771.29","2068.67","33","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1990.64","38.3","","850.52","759.78","1211.25","66","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","956.46","956.46","956.46","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","WELLPOINT [1015]","HB AMC WELLPOINT","3834.72","73.78","","2344.73","1619.47","2530.35","16","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA HMO","3627.86","69.8","","1523.63","988.41","4330.26","39","2716.21","4247.4","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA PPO","4178.79","80.4","","1670.25","1670.25","1670.25","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4247.40","81.72","","1738.90","1484.65","2716.94","38","2716.21","4247.4","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4132.01","79.5","","1293.60","1148.53","1603.80","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1897.09","36.5","","1023.42","771.29","2068.67","33","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1990.64","38.3","","850.52","759.78","1211.25","66","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2229.73","42.9","","956.46","956.46","956.46","1 through 10","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","5197.50","3898.12","WELLPOINT [1015]","HB AMC WELLPOINT","3834.72","73.78","","2344.73","1619.47","2530.35","16","1611.23","4132.01","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA HMO","3627.86","69.8","","1523.63","988.41","4330.26","39","2716.21","4247.4","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","AETNA [1001]","HB AMC AETNA PPO","4178.79","80.4","","1670.25","1670.25","1670.25","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2716.21","52.26","","1113.10","1113.10","1113.10","1 through 10","2716.21","4247.4","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5197.50","3898.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4247.40","81.72","","1738.90","1484.65","2716.94","38","2716.21","4247.4","percent of total billed charges",""
"HIP STEM SZ 8 STANDARD OFFSET INSIGNIA COLLARED","SUP-ITM-10295256","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2822.04","52.26","","1113.10","1113.10","1113.10","1 through 10","1674","4293","percent of total billed charges",""
"HIP STEM SZ 8 STANDARD OFFSET INSIGNIA COLLARED","SUP-ITM-10295256","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4293.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1674","4293","percent of total billed charges",""
"HIP STEM SZ 8 STANDARD OFFSET INSIGNIA COLLARED","SUP-ITM-10295256","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1971.00","36.5","","1023.42","771.29","2068.67","33","1674","4293","percent of total billed charges",""
"HIP STEM SZ 8 STANDARD OFFSET INSIGNIA COLLARED","SUP-ITM-10295256","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2068.20","38.3","","850.52","759.78","1211.25","66","1674","4293","percent of total billed charges",""
"HIP STEM SZ 8 STANDARD OFFSET INSIGNIA COLLARED","SUP-ITM-10295256","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","2548.09","2548.09","2548.09","1 through 10","1674","4293","percent of total billed charges",""
"HIP STEM SZ 8 STANDARD OFFSET INSIGNIA COLLARED","SUP-ITM-10295256","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","956.46","956.46","956.46","1 through 10","1674","4293","percent of total billed charges",""
"HIP STEM SZ 8 STANDARD OFFSET INSIGNIA COLLARED","SUP-ITM-10295256","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB AMC WELLPOINT","3984.12","73.78","","2344.73","1619.47","2530.35","16","1674","4293","percent of total billed charges",""
"HIP STEM SZ 8 STANDARD OFFSET INSIGNIA COLLARED","SUP-ITM-10295256","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA HMO","3769.20","69.8","","1523.63","988.41","4330.26","39","2822.04","4412.88","percent of total billed charges",""
"HIP STEM SZ 8 STANDARD OFFSET INSIGNIA COLLARED","SUP-ITM-10295256","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA PPO","4341.60","80.4","","1670.25","1670.25","1670.25","1 through 10","2822.04","4412.88","percent of total billed charges",""
"HIP STEM SZ 8 STANDARD OFFSET INSIGNIA COLLARED","SUP-ITM-10295256","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2822.04","52.26","","1113.10","1113.10","1113.10","1 through 10","2822.04","4412.88","percent of total billed charges",""
"HIP STEM SZ 8 STANDARD OFFSET INSIGNIA COLLARED","SUP-ITM-10295256","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4412.88","81.72","","1738.90","1484.65","2716.94","38","2822.04","4412.88","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2377.83","52.26","","1113.10","1113.10","1113.10","1 through 10","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3617.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1660.75","36.5","","1023.42","771.29","2068.67","33","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1742.65","38.3","","850.52","759.78","1211.25","66","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.95","42.9","","2548.09","2548.09","2548.09","1 through 10","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.95","42.9","","956.46","956.46","956.46","1 through 10","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","WELLPOINT [1015]","HB AMC WELLPOINT","3356.99","73.78","","2344.73","1619.47","2530.35","16","1410.5","3617.25","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","AETNA [1001]","HB AMC AETNA HMO","3175.90","69.8","","1523.63","988.41","4330.26","39","2377.83","3718.26","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","AETNA [1001]","HB AMC AETNA PPO","3658.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2377.83","3718.26","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2377.83","52.26","","1113.10","1113.10","1113.10","1 through 10","2377.83","3718.26","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3718.26","81.72","","1738.90","1484.65","2716.94","38","2377.83","3718.26","percent of total billed charges",""
"Histamine","PX-30000511","CDM","83088","CPT","0301","RC","","","","both","","","351.00","263.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","279.05","79.5","","267.58","267.58","267.58","1 through 10","28.94","333.45","percent of total billed charges",""
"Histamine","PX-30000511","CDM","83088","CPT","0301","RC","","","","both","","","351.00","263.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","134.43","38.3","","132.94","132.94","132.94","1 through 10","28.94","333.45","percent of total billed charges",""
"Histamine","PX-30000511","CDM","83088","CPT","0301","RC","","","","both","","","351.00","263.25","TRICARE [160005]","HB BWH TRICARE","333.45","95","","33.80","33.80","33.80","1 through 10","28.94","333.45","percent of total billed charges",""
"Histamine","PX-30000511","CDM","83088","CPT","0301","RC","","","","outpatient","","","351.00","263.25","AETNA [1001]","HB AMC AETNA HMO","245.00","69.8","","230.18","162.52","230.18","1 through 10","30.45","286.84","percent of total billed charges",""
"Histamine","PX-30000511","CDM","83088","CPT","0301","RC","","","","outpatient","","","351.00","263.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","286.84","81.72","","271.80","271.80","271.80","1 through 10","30.45","286.84","percent of total billed charges",""
"Histoplasma Antibody","PX-30000950","CDM","86698","CPT","0302","RC","","","","both","","","190.00","142.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.77","38.3","","71.95","71.94","71.95","1 through 10","12.89","180.5","percent of total billed charges",""
"Hiv With Major Hiv Related Condition,EXTREME","892","DRG","","","","","","","","inpatient","","","83052.45","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","61274.40","","Fee schedule rate ($61,274.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61274.40","61274.40","61274.40","1 through 10","8710.54","101103.99","case rate",""
"Hiv With Major Hiv Related Condition,EXTREME","892","DRG","","","","","","","","inpatient","","","83052.45","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","22821.05","","Case rate ($25,232.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $67,662.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,433.01 and the sum of the standard inlier and any outlier amount.","137467.97","137467.97","137467.97","1 through 10","8710.54","101103.99","case rate",""
"Hiv With Major Hiv Related Condition,MAJOR","892","DRG","","","","","","","","inpatient","","","58034.64","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","30338.60","","Fee schedule rate ($30,338.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7292.36","7292.36","7292.36","1 through 10","8710.54","101103.99","case rate",""
"Hiv With Major Hiv Related Condition,MAJOR","892","DRG","","","","","","","","inpatient","","","58034.64","","MASSHEALTH [3001]","HB BWH MEDICAID","11749.23","","Case rate ($12,990.80). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,420.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12987.61","12987.61","12987.61","1 through 10","8710.54","101103.99","case rate",""
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","","","","inpatient","","","49913.42","37435.06","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","12192.97","","Case rate ($12,192.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,600.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,244.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,482.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,771.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,220.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,042.03. The transfer capital threshold is the transfer adjustment factor * $1,042.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16083.05","16083.05","16083.05","1 through 10","11949.11","20284.88","other","Inpatient DRG"
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","","","","inpatient","","","49913.42","37435.06","MEDICARE [2001]","HB BWH MEDICARE","12192.97","","Case rate ($12,192.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,600.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,244.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,482.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,771.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,220.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,042.03. The transfer capital threshold is the transfer adjustment factor * $1,042.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17035.39","17035.39","17035.39","1 through 10","11949.11","20284.88","other","Inpatient Replacement Plans DRG"
"Hiv With Major Related Condition With McC","974","MS-DRG","","","","","","","","inpatient","","","277909.14","208431.85","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","26706.23","","Case rate ($26,706.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,071.63, add-ons for qualifying new technology services are included. If operating cost exceeds $77,716.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,762.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $24,004.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,691.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,322.24. The transfer capital threshold is the transfer adjustment factor * $2,322.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27023.05","27023.05","27023.05","1 through 10","26172.11","44012.9015","other","Inpatient Replacement Plans DRG"
"Hiv With Major Related Condition With McC","974","MS-DRG","","","","","","","","inpatient","","","277909.14","208431.85","MEDICARE [2001]","HB BWH MEDICARE","26706.23","","Case rate ($26,706.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,071.63, add-ons for qualifying new technology services are included. If operating cost exceeds $77,716.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,762.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $24,004.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,691.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,322.24. The transfer capital threshold is the transfer adjustment factor * $2,322.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","26172.11","44012.9015","other","Inpatient Replacement Plans DRG"
"Hiv With Major Related Condition With McC","974","MS-DRG","","","","","","","","inpatient","","","277909.14","208431.85","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","26172.11","","Case rate ($26,706.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,071.63, add-ons for qualifying new technology services are included. If operating cost exceeds $77,716.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,762.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $24,004.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,691.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,322.24. The transfer capital threshold is the transfer adjustment factor * $2,322.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","27105.92","27105.92","263393.30","1 through 10","26172.11","44012.9015","other","Inpatient DRG"
"Hiv With Multiple Major Hiv Related Conditions,EXTREME","890","DRG","","","","","","","","inpatient","","","148219.35","","MASSHEALTH [3001]","HB BWH MEDICAID","29452.48","","Case rate ($32,564.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $74,994.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","151646.96","151646.96","151646.96","1 through 10","15413.94","265933.56","case rate",""
"Hiv With Multiple Major Hiv Related Conditions,EXTREME","890","DRG","","","","","","","","inpatient","","","148219.35","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","29452.48","","Case rate ($32,564.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $74,994.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5562.32","5562.32","5562.32","1 through 10","15413.94","265933.56","case rate",""
"Hiv With Multiple Major Hiv Related Conditions,EXTREME","890","DRG","","","","","","","","inpatient","","","148219.35","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","29452.48","","Case rate ($32,564.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $74,994.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","163199.53","163199.53","163199.53","1 through 10","15413.94","265933.56","case rate",""
"Hiv With Multiple Major Hiv Related Conditions,MAJOR","890","DRG","","","","","","","","inpatient","","","60861.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","45671.80","","Standard inlier is a Case rate ($45,671.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,239, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,482.73) for the length of stay and the standard reimbursement.","45671.79","45671.79","45671.79","1 through 10","15413.94","265933.56","case rate",""
"Hiv With Multiple Major Hiv Related Conditions,MAJOR","890","DRG","","","","","","","","inpatient","","","60861.05","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15413.94","","Case rate ($17,042.77). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,472.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","15413.94","265933.56","case rate",""
"Hiv With Multiple Significant Hiv Related Conditions,MAJOR","893","DRG","","","","","","","","inpatient","","","151783.48","","MASSHEALTH [3001]","HB BWH MEDICAID","12669.98","","Case rate ($14,008.84). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,438.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14005.41","14005.41","14005.41","1 through 10","10285.86","50321.33","case rate",""
"Hiv With Multiple Significant Hiv Related Conditions,MAJOR","893","DRG","","","","","","","","inpatient","","","151783.48","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","12669.98","","Case rate ($14,008.84). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,438.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","10285.86","50321.33","case rate",""
"Hiv With One Significant Hiv Condition Or Without Significant Related Conditions,MINOR","894","DRG","","","","","","","","inpatient","","","31648.21","","MASSHEALTH [3001]","HB BWH MEDICAID","6208.76","","Case rate ($6,864.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,294.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6863.16","6863.16","6863.16","1 through 10","6208.76","40194.32","case rate",""
"Hiv With One Significant Hiv Condition Or Without Significant Related Conditions,MINOR","894","DRG","","","","","","","","inpatient","","","31648.21","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6208.76","","Case rate ($6,864.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,294.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1407.61","1407.61","6863.17","1 through 10","6208.76","40194.32","case rate",""
"Hiv With One Significant Hiv Condition Or Without Significant Related Conditions,MODERATE","894","DRG","","","","","","","","inpatient","","","59295.24","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8114.23","","Case rate ($8,971.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,401.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8969.47","8969.47","8969.47","1 through 10","6208.76","40194.32","case rate",""
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","","","","inpatient","","","64531.21","48398.41","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","12217.61","","Case rate ($12,217.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,630.17, add-ons for qualifying new technology services are included. If operating cost exceeds $60,274.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,484.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,793.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,250.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.21. The transfer capital threshold is the transfer adjustment factor * $1,044.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","33072.13","33072.13","33072.13","1 through 10","11973.26","20327.17","other","Inpatient DRG"
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","","","","inpatient","","","64531.21","48398.41","MEDICARE [2001]","HB BWH MEDICARE","15743.23","","Case rate ($15,743.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,630.17, add-ons for qualifying new technology services are included. If operating cost exceeds $60,274.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,484.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,319.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,250.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.21. The transfer capital threshold is the transfer adjustment factor * $1,044.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17277.07","17277.07","17277.07","1 through 10","11973.26","20327.17","other","Inpatient DRG"
"Hiv-1 Antibody","PX-30000952","CDM","86701","CPT","0302","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.30","38.3","","55.91","54.34","55.91","1 through 10","8.71","139.65","percent of total billed charges",""
"Hiv-2 Antibody","PX-30000953","CDM","86702","CPT","0302","RC","","","","both","","","178.00","133.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.17","38.3","","67.64","65.74","67.64","1 through 10","10.89","169.1","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","both","","","1665.00","1248.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1195.47","71.8","","856.53","684.76","3478.71","16","129.88","1581.75","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","both","","","1665.00","1248.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1092.24","65.6","","1093.36","333.14","1259.70","1 through 10","129.88","1581.75","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","both","","","1665.00","1248.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1082.25","65","","1049.75","1049.75","1271.01","14","129.88","1581.75","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","both","","","1665.00","1248.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1165.50","70","","1615.00","694.45","3488.40","18","129.88","1581.75","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","both","","","1665.00","1248.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1323.68","79.5","","1119.90","852.72","1271.01","1 through 10","129.88","1581.75","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","both","","","1665.00","1248.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","887.45","53.3","","1049.75","852.72","1271.01","1 through 10","129.88","1581.75","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","both","","","1665.00","1248.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1082.25","65","","1049.75","924.95","1268.80","1 through 10","129.88","1581.75","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","both","","","1665.00","1248.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","516.15","31","","499.04","499.04","499.04","1 through 10","129.88","1581.75","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","both","","","1665.00","1248.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","607.73","36.5","","602.40","431.04","684.76","1 through 10","129.88","1581.75","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","both","","","1665.00","1248.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","637.70","38.3","","684.76","602.40","2054.28","1 through 10","129.88","1581.75","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","both","","","1665.00","1248.75","WELLPOINT [1015]","HB AMC WELLPOINT","1228.44","73.78","","2817.37","1202.37","2817.37","25","129.88","1581.75","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","outpatient","","","1665.00","1248.75","AETNA [1001]","HB AMC AETNA HMO","1162.17","69.8","","1093.36","771.97","2519.40","14","129.88","1984.59","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","outpatient","","","1665.00","1248.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1338.66","80.4","","807.50","807.50","807.50","1 through 10","129.88","1984.59","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","outpatient","","","1665.00","1248.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1360.64","81.72","","1291.03","1291.03","1291.03","1 through 10","129.88","1984.59","percent of total billed charges",""
"Hla Class I High Defin Panel Qual","PX-30001397","CDM","86832","CPT","0302","RC","","","","outpatient","","","1665.00","1248.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1360.64","81.72","","1291.03","1291.03","1320.90","1 through 10","129.88","1984.59","percent of total billed charges",""
"Hla Class I Semi-Quantitative Panel","PX-30001399","CDM","86834","CPT","0302","RC","","","","both","","","5963.00","4472.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","4281.43","71.8","","4152.19","4152.19","4152.19","1 through 10","350.41","5664.85","percent of total billed charges",""
"Hla Class I Semi-Quantitative Panel","PX-30001399","CDM","86834","CPT","0302","RC","","","","both","","","5963.00","4472.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3875.95","65","","3758.95","3758.95","3758.95","1 through 10","350.41","5664.85","percent of total billed charges",""
"Hla Class I Semi-Quantitative Panel","PX-30001399","CDM","86834","CPT","0302","RC","","","","both","","","5963.00","4472.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3178.28","53.3","","4551.22","4551.22","4551.22","1 through 10","350.41","5664.85","percent of total billed charges",""
"Hla Class I Semi-Quantitative Panel","PX-30001399","CDM","86834","CPT","0302","RC","","","","both","","","5963.00","4472.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","4591.51","77","","8647.10","8647.10","8647.10","1 through 10","350.41","5664.85","percent of total billed charges",""
"Hla Class I Semi-Quantitative Panel","PX-30001399","CDM","86834","CPT","0302","RC","","","","both","","","5963.00","4472.25","WELLPOINT [1015]","HB AMC WELLPOINT","4399.50","73.78","","10088.44","4305.44","10088.44","1 through 10","350.41","5664.85","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","both","","","1467.00","1100.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1053.31","71.8","","861.93","603.35","3065.13","14","118.08","1393.65","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","both","","","1467.00","1100.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","962.35","65.6","","963.37","335.25","963.37","1 through 10","118.08","1393.65","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","both","","","1467.00","1100.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","953.55","65","","924.95","751.34","1119.90","14","118.08","1393.65","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","both","","","1467.00","1100.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1026.90","70","","1138.40","522.88","3073.68","18","118.08","1393.65","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","both","","","1467.00","1100.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1166.27","79.5","","1119.90","751.34","1119.90","1 through 10","118.08","1393.65","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","both","","","1467.00","1100.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","781.91","53.3","","924.95","751.34","1119.90","1 through 10","118.08","1393.65","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","both","","","1467.00","1100.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","953.55","65","","924.95","924.95","1155.05","1 through 10","118.08","1393.65","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","both","","","1467.00","1100.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","454.77","31","","439.71","439.71","439.71","1 through 10","118.08","1393.65","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","both","","","1467.00","1100.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","535.46","36.5","","512.85","379.80","603.35","1 through 10","118.08","1393.65","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","both","","","1467.00","1100.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","561.86","38.3","","603.35","556.39","1810.05","11","118.08","1393.65","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","both","","","1467.00","1100.25","WELLPOINT [1015]","HB AMC WELLPOINT","1082.35","73.78","","2482.42","1059.42","2482.42","20","118.08","1393.65","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","outpatient","","","1467.00","1100.25","AETNA [1001]","HB AMC AETNA HMO","1023.97","69.8","","963.37","680.19","2219.88","15","118.08","1997.15","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","outpatient","","","1467.00","1100.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1179.47","80.4","","711.50","711.50","711.50","1 through 10","118.08","1997.15","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","outpatient","","","1467.00","1100.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1198.83","81.72","","1137.55","1137.55","1137.55","1 through 10","118.08","1997.15","percent of total billed charges",""
"Hla Class II High Defin Panel Qual","PX-30001398","CDM","86833","CPT","0302","RC","","","","outpatient","","","1467.00","1100.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1198.83","81.72","","1329.26","1137.55","1329.26","1 through 10","118.08","1997.15","percent of total billed charges",""
"Hla Class II Semi-Quant Panel","PX-30001400","CDM","86835","CPT","0302","RC","","","","both","","","5361.00","4020.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3849.20","71.8","","3732.88","3732.88","3732.88","1 through 10","316.5","5092.95","percent of total billed charges",""
"Hla Class II Semi-Quant Panel","PX-30001400","CDM","86835","CPT","0302","RC","","","","both","","","5361.00","4020.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3484.65","65","","3379.35","3379.35","3379.35","1 through 10","316.5","5092.95","percent of total billed charges",""
"Hla Class II Semi-Quant Panel","PX-30001400","CDM","86835","CPT","0302","RC","","","","both","","","5361.00","4020.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2857.41","53.3","","4091.61","4091.61","4091.61","1 through 10","316.5","5092.95","percent of total billed charges",""
"Hla Class II Semi-Quant Panel","PX-30001400","CDM","86835","CPT","0302","RC","","","","both","","","5361.00","4020.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","4127.97","77","","7773.92","7773.92","7773.92","1 through 10","316.5","5092.95","percent of total billed charges",""
"Hla Class II Semi-Quant Panel","PX-30001400","CDM","86835","CPT","0302","RC","","","","both","","","5361.00","4020.75","WELLPOINT [1015]","HB AMC WELLPOINT","3955.35","73.78","","3870.66","3870.66","3870.66","1 through 10","316.5","5092.95","percent of total billed charges",""
"Hla Typing I & II High Res","PX-30000766","CDM","81378","CPT","0302","RC","","","","both","","","2890.00","2167.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2023.00","70","","2018.16","2018.16","2018.16","1 through 10","338.66","2745.5","percent of total billed charges",""
"Hla Typing I & II Low Res","PX-30000758","CDM","81370","CPT","0310","RC","","","","both","","","4924.00","3693.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3535.43","71.8","","6073.80","4775.00","6073.80","1 through 10","394.08","4677.8","percent of total billed charges",""
"Hla Typing I & II Low Res","PX-30000758","CDM","81370","CPT","0310","RC","","","","both","","","4924.00","3693.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3446.80","70","","1465.40","254.18","3438.00","1 through 10","394.08","4677.8","percent of total billed charges",""
"Hla Typing I & II Low Res","PX-30000758","CDM","81370","CPT","0310","RC","","","","both","","","4924.00","3693.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3914.58","79.5","","11273.79","3103.75","11273.79","1 through 10","394.08","4677.8","percent of total billed charges",""
"Hla Typing I & II Low Res","PX-30000758","CDM","81370","CPT","0310","RC","","","","both","","","4924.00","3693.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3200.60","65","","3103.75","3103.75","4022.20","1 through 10","394.08","4677.8","percent of total billed charges",""
"Hla Typing I & II Low Res","PX-30000758","CDM","81370","CPT","0310","RC","","","","both","","","4924.00","3693.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1797.26","36.5","","2024.60","1513.68","2024.60","1 through 10","394.08","4677.8","percent of total billed charges",""
"Hla Typing I & II Low Res","PX-30000758","CDM","81370","CPT","0310","RC","","","","both","","","4924.00","3693.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1885.89","38.3","","6073.80","6073.80","6073.80","1 through 10","394.08","4677.8","percent of total billed charges",""
"Hla Typing I & II Low Res","PX-30000758","CDM","81370","CPT","0310","RC","","","","outpatient","","","4924.00","3693.00","AETNA [1001]","HB AMC AETNA HMO","3436.95","69.8","","3232.68","3232.68","3232.68","1 through 10","1420.85","4023.89","percent of total billed charges",""
"Hla Typing I & II Low Res","PX-30000758","CDM","81370","CPT","0310","RC","","","","outpatient","","","4924.00","3693.00","AETNA [1001]","HB AMC AETNA PPO","3958.90","80.4","","3724.50","3724.50","3724.50","1 through 10","1420.85","4023.89","percent of total billed charges",""
"Hla Typing I & II Low Res","PX-30000758","CDM","81370","CPT","0310","RC","","","","outpatient","","","4924.00","3693.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3958.90","80.4","","2387.50","2387.50","2387.50","1 through 10","1420.85","4023.89","percent of total billed charges",""
"Hla Typing I & II Low Res","PX-30000758","CDM","81370","CPT","0310","RC","","","","outpatient","","","4924.00","3693.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4023.89","81.72","","3817.14","3813.43","3817.14","1 through 10","1420.85","4023.89","percent of total billed charges",""
"Hla Typing I High Res 1 Allele","PX-30000769","CDM","81381","CPT","0310","RC","","","","both","","","759.00","569.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","404.55","53.3","","579.23","579.23","579.23","1 through 10","166.5","721.05","percent of total billed charges",""
"Hla Typing I High Res 1 Allele","PX-30000769","CDM","81381","CPT","0310","RC","","","","both","","","759.00","569.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","290.70","38.3","","287.78","279.68","287.78","1 through 10","166.5","721.05","percent of total billed charges",""
"Hla Typing I High Res 1 Allele","PX-30000769","CDM","81381","CPT","0310","RC","","","","outpatient","","","759.00","569.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","610.24","80.4","","368.00","368.00","368.00","1 through 10","319.11","1041.49","percent of total billed charges",""
"Hla Typing I High Res 1 Locus","PX-30000768","CDM","81380","CPT","0302","RC","","","","outpatient","","","1315.00","986.25","AETNA [1001]","HB AMC AETNA HMO","917.87","69.8","","863.18","863.18","863.18","1 through 10","182.77","1207.24","percent of total billed charges",""
"Hla Typing I Low Res 1 Antigen","PX-30000762","CDM","81374","CPT","0310","RC","","","","both","","","844.00","633.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","670.98","79.5","","643.77","431.90","1931.31","13","72.84","801.8","percent of total billed charges",""
"Hla Typing I Low Res 1 Antigen","PX-30000762","CDM","81374","CPT","0310","RC","","","","both","","","844.00","633.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","449.85","53.3","","643.77","431.90","1931.31","13","72.84","801.8","percent of total billed charges",""
"Hla Typing I Low Res 1 Antigen","PX-30000762","CDM","81374","CPT","0310","RC","","","","both","","","844.00","633.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","308.06","36.5","","305.11","305.11","305.11","11","72.84","801.8","percent of total billed charges",""
"Hla Typing I Low Res 1 Antigen","PX-30000762","CDM","81374","CPT","0310","RC","","","","both","","","844.00","633.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","323.25","38.3","","319.84","310.84","959.52","41","72.84","801.8","percent of total billed charges",""
"Hla Typing I Low Res 1 Antigen","PX-30000762","CDM","81374","CPT","0310","RC","","","","outpatient","","","844.00","633.00","AETNA [1001]","HB AMC AETNA HMO","589.11","69.8","","553.79","391.00","638.04","18","256.75","689.72","percent of total billed charges",""
"Hla Typing I Low Res 1 Antigen","PX-30000762","CDM","81374","CPT","0310","RC","","","","outpatient","","","844.00","633.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","689.72","81.72","","653.91","653.91","653.91","1 through 10","256.75","689.72","percent of total billed charges",""
"Hla Typing I Low Res 1 Locus","PX-30000761","CDM","81373","CPT","0310","RC","","","","both","","","1818.00","1363.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1445.31","79.5","","1387.48","1387.48","1387.48","1 through 10","124.88","1727.1","percent of total billed charges",""
"Hla Typing II High Res 1 Locus Ea","PX-30000770","CDM","81382","CPT","0310","RC","","","","both","","","1561.00","1170.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1092.70","70","","1090.08","1090.08","1090.08","1 through 10","121.21","1482.95","percent of total billed charges",""
"Hla Typing II High Res 1 Locus Ea","PX-30000770","CDM","81382","CPT","0310","RC","","","","both","","","1561.00","1170.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","569.77","36.5","","641.94","641.94","641.94","1 through 10","121.21","1482.95","percent of total billed charges",""
"Hla Typing II High Res 1 Locus Ea","PX-30000770","CDM","81382","CPT","0310","RC","","","","both","","","1561.00","1170.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","597.86","38.3","","591.97","591.97","591.97","1 through 10","121.21","1482.95","percent of total billed charges",""
"Hla Typing II Low Res 1 Locus Ea","PX-30000764","CDM","81376","CPT","0310","RC","","","","both","","","1999.00","1499.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1589.21","79.5","","1526.00","1526.00","1526.00","1 through 10","119.78","1899.05","percent of total billed charges",""
"Hla Typing II Low Res 1 Locus Ea","PX-30000764","CDM","81376","CPT","0310","RC","","","","both","","","1999.00","1499.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1065.47","53.3","","1526.00","1023.79","1526.00","1 through 10","119.78","1899.05","percent of total billed charges",""
"Hla Typing II Low Res 1 Locus Ea","PX-30000764","CDM","81376","CPT","0310","RC","","","","both","","","1999.00","1499.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","765.62","38.3","","758.15","758.15","758.15","1 through 10","119.78","1899.05","percent of total billed charges",""
"Hla Typing II Low Res 1 Locus Ea","PX-30000764","CDM","81376","CPT","0310","RC","","","","outpatient","","","1999.00","1499.25","AETNA [1001]","HB AMC AETNA HMO","1395.30","69.8","","1312.71","926.84","1312.71","1 through 10","432.04","1633.58","percent of total billed charges",""
"Hla Typing II Low Res 1 Locus Ea","PX-30000764","CDM","81376","CPT","0310","RC","","","","outpatient","","","1999.00","1499.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1633.58","81.72","","1550.04","1550.04","3100.07","1 through 10","432.04","1633.58","percent of total billed charges",""
"Hla Xsmatch Noncytotoxic 1st Ser/Di","PX-30001026","CDM","86825","CPT","0302","RC","","","","both","","","1375.00","1031.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","987.25","71.8","","565.19","565.19","1130.38","1 through 10","34.01","1306.25","percent of total billed charges",""
"Hla Xsmatch Noncytotoxic 1st Ser/Di","PX-30001026","CDM","86825","CPT","0302","RC","","","","both","","","1375.00","1031.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","902.00","65.6","","902.44","112.66","902.44","1 through 10","34.01","1306.25","percent of total billed charges",""
"Hla Xsmatch Noncytotoxic 1st Ser/Di","PX-30001026","CDM","86825","CPT","0302","RC","","","","both","","","1375.00","1031.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","893.75","65","","866.45","673.17","1049.07","1 through 10","34.01","1306.25","percent of total billed charges",""
"Hla Xsmatch Noncytotoxic 1st Ser/Di","PX-30001026","CDM","86825","CPT","0302","RC","","","","both","","","1375.00","1031.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","962.50","70","","959.76","572.00","959.76","1 through 10","34.01","1306.25","percent of total billed charges",""
"Hla Xsmatch Noncytotoxic 1st Ser/Di","PX-30001026","CDM","86825","CPT","0302","RC","","","","both","","","1375.00","1031.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","893.75","65","","866.45","362.35","866.45","11","34.01","1306.25","percent of total billed charges",""
"Hla Xsmatch Noncytotoxic 1st Ser/Di","PX-30001026","CDM","86825","CPT","0302","RC","","","","both","","","1375.00","1031.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","501.88","36.5","","565.19","565.19","565.19","1 through 10","34.01","1306.25","percent of total billed charges",""
"Hla Xsmatch Noncytotoxic 1st Ser/Di","PX-30001026","CDM","86825","CPT","0302","RC","","","","outpatient","","","1375.00","1031.25","AETNA [1001]","HB AMC AETNA HMO","959.75","69.8","","902.44","902.44","1039.74","1 through 10","34.01","1123.65","percent of total billed charges",""
"Hla Xsmatch Noncytotoxic 1st Ser/Di","PX-30001026","CDM","86825","CPT","0302","RC","","","","outpatient","","","1375.00","1031.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1105.50","80.4","","1039.74","1039.74","1039.74","1 through 10","34.01","1123.65","percent of total billed charges",""
"Hm Battery 14v, Each","PX-27001055","CDM","Q0506","HCPCS","0274","RC","","","","both","","","2187.50","1640.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1421.88","65","","4265.63","4265.63","4265.63","1 through 10","678.13","2078.13","percent of total billed charges",""
"Hm Battery 14v, Each","PX-27001055","CDM","Q0506","HCPCS","0274","RC","","","","both","","","2187.50","1640.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1531.25","70","","1260.00","1260.00","1260.00","1 through 10","678.13","2078.13","percent of total billed charges",""
"Hm Battery 14v, Each","PX-27001055","CDM","Q0506","HCPCS","0274","RC","","","","both","","","2187.50","1640.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","837.81","38.3","","684.25","684.25","684.25","1 through 10","678.13","2078.13","percent of total billed charges",""
"Hm Battery 14v, Each","PX-27001055","CDM","Q0506","HCPCS","0274","RC","","","","both","","","2187.50","1640.62","WELLPOINT [1015]","HB AMC WELLPOINT","1613.94","73.78","","1628.60","1628.60","1628.60","1 through 10","678.13","2078.13","percent of total billed charges",""
"Hm Battery 14v, Each","PX-27001055","CDM","Q0506","HCPCS","0274","RC","","","","outpatient","","","2187.50","1640.62","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1093.75","50","","917.00","917.00","917.00","1 through 10","1093.75","1922.43","percent of total billed charges",""
"Hm Battery 14v, Each","PX-27001055","CDM","Q0506","HCPCS","0274","RC","","","","outpatient","","","2187.50","1640.62","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1148.44","52.5","","2887.50","2887.50","2887.50","1 through 10","1093.75","1922.43","percent of total billed charges",""
"Hm Battery Clip Set","PX-27000582","CDM","Q0497","HCPCS","0274","RC","","","","both","","","3850.00","2887.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2502.50","65","","7507.50","7507.50","7507.50","1 through 10","540.58","3657.5","percent of total billed charges",""
"Hm Battery Clip Set","PX-27000582","CDM","Q0497","HCPCS","0274","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","2866.33","2866.33","2866.33","1 through 10","540.58","3657.5","percent of total billed charges",""
"Hm Battery Clip Set","PX-27000582","CDM","Q0497","HCPCS","0274","RC","","","","outpatient","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2010.47","52.22","","2072.46","2072.46","2072.46","1 through 10","1145.37","3176.25","percent of total billed charges",""
"Hm Consolidated Bag","PX-27000873","CDM","Q0499","HCPCS","0274","RC","","","","outpatient","","","1138.00","853.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","594.26","52.22","","612.59","612.59","612.59","1 through 10","408.29","938.85","percent of total billed charges",""
"Hm Controller","PX-27000886","CDM","Q0481","HCPCS","0274","RC","","","","both","","","11250.00","8437.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7312.50","65","","21937.50","21937.50","21937.50","1 through 10","3487.5","21401.69","percent of total billed charges",""
"Hm Emergency Backup Battery 11v (Ebb)","PX-27001181","CDM","Q0506","HCPCS","0274","RC","","","","both","","","1750.00","1312.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1137.50","65","","4265.63","4265.63","4265.63","1 through 10","542.5","1662.5","percent of total billed charges",""
"Hm Emergency Backup Battery 11v (Ebb)","PX-27001181","CDM","Q0506","HCPCS","0274","RC","","","","both","","","1750.00","1312.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1225.00","70","","1260.00","1260.00","1260.00","1 through 10","542.5","1662.5","percent of total billed charges",""
"Hm Emergency Backup Battery 11v (Ebb)","PX-27001181","CDM","Q0506","HCPCS","0274","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","684.25","684.25","684.25","1 through 10","542.5","1662.5","percent of total billed charges",""
"Hm Emergency Backup Battery 11v (Ebb)","PX-27001181","CDM","Q0506","HCPCS","0274","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","1628.60","1628.60","1628.60","1 through 10","542.5","1662.5","percent of total billed charges",""
"Hm Emergency Backup Battery 11v (Ebb)","PX-27001181","CDM","Q0506","HCPCS","0274","RC","","","","outpatient","","","1750.00","1312.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","875.00","50","","917.00","917.00","917.00","1 through 10","875","1922.43","percent of total billed charges",""
"Hm Emergency Backup Battery 11v (Ebb)","PX-27001181","CDM","Q0506","HCPCS","0274","RC","","","","outpatient","","","1750.00","1312.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","918.75","52.5","","2887.50","2887.50","2887.50","1 through 10","875","1922.43","percent of total billed charges",""
"Hm III Patient Kit, Pocket Controller","PX-27001121","CDM","Q0481","HCPCS","0274","RC","","","","both","","","36962.50","27721.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","24025.63","65","","21937.50","21937.50","21937.50","1 through 10","11458.38","35114.38","percent of total billed charges",""
"Hm Pocket Controller With Emergency Backup Battery 11v (Ebb)","PX-27001182","CDM","Q0481","HCPCS","0274","RC","","","","both","","","13750.00","10312.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8937.50","65","","21937.50","21937.50","21937.50","1 through 10","4262.5","21401.69","percent of total billed charges",""
"Hm Power Module Cable 106525us","PX-27001180","CDM","Q0508","HCPCS","0274","RC","","","","both","","","12375.00","9281.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8043.75","65","","1092.00","1092.00","1092.00","1 through 10","3836.25","11756.25","percent of total billed charges",""
"Hm Power Module Cable 106525us","PX-27001180","CDM","Q0508","HCPCS","0274","RC","","","","both","","","12375.00","9281.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","8662.50","70","","51.84","51.84","51.84","21","3836.25","11756.25","percent of total billed charges",""
"Hm Power Module Cable 106525us","PX-27001180","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","12375.00","9281.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","7493.06","60.55","","48.41","48.41","48.41","1 through 10","4950","10209.38","percent of total billed charges",""
"Hm Power Module Cable 106525us","PX-27001180","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","12375.00","9281.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6462.23","52.22","","43.55","43.55","43.55","24","4950","10209.38","percent of total billed charges",""
"Hm Power Module Cable 106525us","PX-27001180","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","12375.00","9281.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6187.50","50","","37.73","37.73","188.64","1 through 10","4950","10209.38","percent of total billed charges",""
"Hm Stabilization Belt","PX-27000584","CDM","Q0508","HCPCS","0274","RC","","","","both","","","350.00","262.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","227.50","65","","1092.00","1092.00","1092.00","1 through 10","108.5","332.5","percent of total billed charges",""
"Hm Stabilization Belt","PX-27000584","CDM","Q0508","HCPCS","0274","RC","","","","both","","","350.00","262.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","245.00","70","","51.84","51.84","51.84","21","108.5","332.5","percent of total billed charges",""
"Hm Stabilization Belt","PX-27000584","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","350.00","262.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","211.93","60.55","","48.41","48.41","48.41","1 through 10","140","288.75","percent of total billed charges",""
"Hm Stabilization Belt","PX-27000584","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","350.00","262.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","182.77","52.22","","43.55","43.55","43.55","24","140","288.75","percent of total billed charges",""
"Hm Stabilization Belt","PX-27000584","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","350.00","262.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","175.00","50","","37.73","37.73","188.64","1 through 10","140","288.75","percent of total billed charges",""
"Hm Stabilization Belt, Each (Go-Gear)","PX-27001059","CDM","Q0499","HCPCS","0274","RC","","","","outpatient","","","1208.00","906.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","630.82","52.22","","612.59","612.59","612.59","1 through 10","408.29","996.6","percent of total billed charges",""
"Hm System Controller Battery Module","PX-27001058","CDM","Q0508","HCPCS","0274","RC","","","","both","","","928.00","696.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","603.20","65","","1092.00","1092.00","1092.00","1 through 10","287.68","881.6","percent of total billed charges",""
"Hm System Controller Battery Module","PX-27001058","CDM","Q0508","HCPCS","0274","RC","","","","both","","","928.00","696.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","649.60","70","","51.84","51.84","51.84","21","287.68","881.6","percent of total billed charges",""
"Hm System Controller Battery Module","PX-27001058","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","928.00","696.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","561.90","60.55","","48.41","48.41","48.41","1 through 10","371.2","765.6","percent of total billed charges",""
"Hm System Controller Battery Module","PX-27001058","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","928.00","696.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","484.60","52.22","","43.55","43.55","43.55","24","371.2","765.6","percent of total billed charges",""
"Hm System Controller Battery Module","PX-27001058","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","928.00","696.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","464.00","50","","37.73","37.73","188.64","1 through 10","371.2","765.6","percent of total billed charges",""
"Hm Travel Bag","PX-27000587","CDM","Q0508","HCPCS","0274","RC","","","","both","","","560.00","420.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","364.00","65","","1092.00","1092.00","1092.00","1 through 10","173.6","532","percent of total billed charges",""
"Hm Travel Bag","PX-27000587","CDM","Q0508","HCPCS","0274","RC","","","","both","","","560.00","420.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","392.00","70","","51.84","51.84","51.84","21","173.6","532","percent of total billed charges",""
"Hm Travel Bag","PX-27000587","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","560.00","420.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","339.08","60.55","","48.41","48.41","48.41","1 through 10","224","462","percent of total billed charges",""
"Hm Travel Bag","PX-27000587","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","560.00","420.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","292.43","52.22","","43.55","43.55","43.55","24","224","462","percent of total billed charges",""
"Hm Travel Bag","PX-27000587","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","560.00","420.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","280.00","50","","37.73","37.73","188.64","1 through 10","224","462","percent of total billed charges",""
"Hm Wearable Accessory Kit","PX-27001063","CDM","Q0508","HCPCS","0274","RC","","","","both","","","595.00","446.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","386.75","65","","1092.00","1092.00","1092.00","1 through 10","184.45","565.25","percent of total billed charges",""
"Hm Wearable Accessory Kit","PX-27001063","CDM","Q0508","HCPCS","0274","RC","","","","both","","","595.00","446.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","416.50","70","","51.84","51.84","51.84","21","184.45","565.25","percent of total billed charges",""
"Hm Wearable Accessory Kit","PX-27001063","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","595.00","446.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","360.27","60.55","","48.41","48.41","48.41","1 through 10","238","490.88","percent of total billed charges",""
"Hm Wearable Accessory Kit","PX-27001063","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","595.00","446.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","310.71","52.22","","43.55","43.55","43.55","24","238","490.88","percent of total billed charges",""
"Hm Wearable Accessory Kit","PX-27001063","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","595.00","446.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","297.50","50","","37.73","37.73","188.64","1 through 10","238","490.88","percent of total billed charges",""
"Hmii Patient Kit, Pocket Controller W/Equip","PX-27001122","CDM","Q0481","HCPCS","0274","RC","","","","both","","","74962.50","56221.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","48725.63","65","","21937.50","21937.50","21937.50","1 through 10","16778.92","71214.38","percent of total billed charges",""
"Ho W/O Joints Custom T1","PX-27000499","CDM","L3919","HCPCS","0274","RC","","","","both","","","21.00","15.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11.19","53.3","","11.09","11.09","11.09","1 through 10","6.51","362.33","percent of total billed charges",""
"Ho W/O Joints Custom T1","PX-27000499","CDM","L3919","HCPCS","0274","RC","","","","both","","","21.00","15.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8.04","38.3","","8.21","8.21","8.21","1 through 10","6.51","362.33","percent of total billed charges",""
"Ho W/O Joints Custom T1","PX-27000499","CDM","L3919","HCPCS","0274","RC","","","","outpatient","","","21.00","15.75","AETNA [1001]","HB AMC AETNA HMO","14.66","69.8","","14.22","14.22","14.22","1 through 10","10.5","601.88","percent of total billed charges",""
"Ho W/O Joints Custom T1","PX-27000499","CDM","L3919","HCPCS","0274","RC","","","","outpatient","","","21.00","15.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10.50","50","","11.00","10.56","11.00","1 through 10","10.5","601.88","percent of total billed charges",""
"Ho W/O Joints Custom T1","PX-27000499","CDM","L3919","HCPCS","0274","RC","","","","outpatient","","","21.00","15.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","13.13","62.5","","13.65","13.65","13.65","1 through 10","10.5","601.88","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.03","79.5","","4287.55","1443.20","20392.29","31","72.54","186.03","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.72","53.3","","359.57","119.86","535.95","913","72.54","186.03","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","180.18","77","","524.37","174.79","524.37","32","72.54","186.03","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.54","31","","14.03","7.01","56.11","170","72.54","186.03","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.41","36.5","","71.96","8.43","215.88","2486","72.54","186.03","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.62","38.3","","88.76","10.14","266.27","5389","72.54","186.03","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.39","42.9","","181.46","181.46","181.46","14","72.54","186.03","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","WELLPOINT [1015]","HB AMC WELLPOINT","172.65","73.78","","169.00","169.00","169.00","283","72.54","186.03","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.95","78.61","","181.46","181.46","181.46","64","129.4","186.03","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA HMO","163.33","69.8","","153.68","108.51","262.19","2444","122.29","8433","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA PPO","188.14","80.4","","177.06","118.95","227.00","470","122.29","8433","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,312).","531.20","252.95","1328.00","481","122.29","8433","other","Observation Flat Rate <=24 units"
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.29","52.26","","652.75","652.75","652.75","1 through 10","122.29","8433","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,222).","527.40","239.73","1492.00","2365","122.29","8433","other","Observation Flat Rate <=24 units"
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","191.22","81.72","","7264.00","7264.00","7264.00","1 through 10","122.29","8433","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.22","81.72","","99.81","49.91","227.00","153","122.29","8433","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.22","81.72","","99.81","99.81","227.00","839","122.29","8433","percent of total billed charges",""
"Home/Res Visit New Patient Mod Mdm 60 Minutes","PX-98300821","CDM","99344","CPT","0983","RC","","","","both","","","735.00","551.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","281.51","38.3","","287.39","287.39","287.39","1 through 10","144.86","698.25","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","both","","","229.00","171.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","164.42","71.8","","159.40","159.40","159.40","1 through 10","17.39","217.55","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","both","","","229.00","171.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","160.30","70","","222.00","222.00","222.00","1 through 10","17.39","217.55","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","both","","","229.00","171.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","182.06","79.5","","174.71","117.22","524.13","26","17.39","217.55","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","both","","","229.00","171.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","122.06","53.3","","174.71","117.22","351.66","18","17.39","217.55","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","both","","","229.00","171.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","176.33","77","","170.94","170.94","170.94","1 through 10","17.39","217.55","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","both","","","229.00","171.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","148.85","65","","144.30","144.30","170.95","1 through 10","17.39","217.55","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","both","","","229.00","171.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.59","36.5","","211.11","70.37","579.67","31","17.39","217.55","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","both","","","229.00","171.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.71","38.3","","86.80","86.80","260.40","56","17.39","217.55","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","both","","","229.00","171.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.24","42.9","","97.61","97.61","97.61","1 through 10","17.39","217.55","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","229.00","171.75","AETNA [1001]","HB AMC AETNA HMO","159.84","69.8","","150.29","106.12","173.16","1 through 10","17.39","187.14","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","229.00","171.75","AETNA [1001]","HB AMC AETNA PPO","184.12","80.4","","173.16","173.16","346.32","1 through 10","17.39","187.14","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","229.00","171.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","187.14","81.72","","177.47","97.61","177.47","20","17.39","187.14","percent of total billed charges",""
"HOOK BONE 34X26MM SM ONE LEVEL SPINE CLOSED THROAT TI","SUP-ITM-10006100","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","1309.77","674.56","6049.93","26","542.5","1391.25","percent of total billed charges",""
"HOOK BONE 34X26MM SM ONE LEVEL SPINE CLOSED THROAT TI","SUP-ITM-10006100","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","1901.83","1901.83","2962.25","1 through 10","542.5","1391.25","percent of total billed charges",""
"HOOK BONE 34X26MM SM ONE LEVEL SPINE CLOSED THROAT TI","SUP-ITM-10006100","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","1620.31","1620.31","19908.88","1 through 10","542.5","1391.25","percent of total billed charges",""
"HOOK BONE 34X26MM SM ONE LEVEL SPINE CLOSED THROAT TI","SUP-ITM-10006100","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","352.91","352.91","2046.30","1 through 10","542.5","1391.25","percent of total billed charges",""
"HOOK BONE 34X26MM SM ONE LEVEL SPINE CLOSED THROAT TI","SUP-ITM-10006100","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","9668.75","9668.75","9668.75","1 through 10","542.5","1391.25","percent of total billed charges",""
"HOOK BONE 34X26MM SM ONE LEVEL SPINE CLOSED THROAT TI","SUP-ITM-10006100","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","699.88","384.10","3443.31","33","542.5","1391.25","percent of total billed charges",""
"HOOK BONE 34X26MM SM ONE LEVEL SPINE CLOSED THROAT TI","SUP-ITM-10006100","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","1421.24","264.50","4933.46","29","914.55","1430.1","percent of total billed charges",""
"HOOK BONE 34X26MM SM ONE LEVEL SPINE CLOSED THROAT TI","SUP-ITM-10006100","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","1022.97","1022.97","3607.50","1 through 10","914.55","1430.1","percent of total billed charges",""
"HOOK BONE 34X26MM SM ONE LEVEL SPINE CLOSED THROAT TI","SUP-ITM-10006100","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","3010.54","693.88","5019.88","35","914.55","1430.1","percent of total billed charges",""
"HOOK BONE LG BLADE NARROW LEGACY TITANIUM","SUP-ITM-10058510","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","1309.77","674.56","6049.93","26","434","1113","percent of total billed charges",""
"HOOK BONE LG BLADE NARROW LEGACY TITANIUM","SUP-ITM-10058510","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","1901.83","1901.83","2962.25","1 through 10","434","1113","percent of total billed charges",""
"HOOK BONE LG BLADE NARROW LEGACY TITANIUM","SUP-ITM-10058510","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1620.31","1620.31","19908.88","1 through 10","434","1113","percent of total billed charges",""
"HOOK BONE LG BLADE NARROW LEGACY TITANIUM","SUP-ITM-10058510","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","352.91","352.91","2046.30","1 through 10","434","1113","percent of total billed charges",""
"HOOK BONE LG BLADE NARROW LEGACY TITANIUM","SUP-ITM-10058510","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","9668.75","9668.75","9668.75","1 through 10","434","1113","percent of total billed charges",""
"HOOK BONE LG BLADE NARROW LEGACY TITANIUM","SUP-ITM-10058510","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","699.88","384.10","3443.31","33","434","1113","percent of total billed charges",""
"HOOK BONE LG BLADE NARROW LEGACY TITANIUM","SUP-ITM-10058510","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1421.24","264.50","4933.46","29","731.64","1144.08","percent of total billed charges",""
"HOOK BONE LG BLADE NARROW LEGACY TITANIUM","SUP-ITM-10058510","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1022.97","1022.97","3607.50","1 through 10","731.64","1144.08","percent of total billed charges",""
"HOOK BONE LG BLADE NARROW LEGACY TITANIUM","SUP-ITM-10058510","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","3010.54","693.88","5019.88","35","731.64","1144.08","percent of total billed charges",""
"HOOK PLATE 16MM 7 HOLE VARIAX TITANIUM LOCKING ANTERIOR CLAVICLE RIGHT","SUP-ITM-10156061","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.73","3551.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3764.11","79.5","","800.18","480.96","1887.97","195","1467.77","3764.11","percent of total billed charges",""
"HOOK PLATE 16MM 7 HOLE VARIAX TITANIUM LOCKING ANTERIOR CLAVICLE RIGHT","SUP-ITM-10156061","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.73","3551.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2523.61","53.3","","813.12","216.42","1444.50","81","1467.77","3764.11","percent of total billed charges",""
"HOOK PLATE 16MM 7 HOLE VARIAX TITANIUM LOCKING ANTERIOR CLAVICLE RIGHT","SUP-ITM-10156061","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.73","3551.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1467.77","31","","432.60","432.60","432.60","1 through 10","1467.77","3764.11","percent of total billed charges",""
"HOOK PLATE 16MM 7 HOLE VARIAX TITANIUM LOCKING ANTERIOR CLAVICLE RIGHT","SUP-ITM-10156061","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.73","3551.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1728.18","36.5","","148.37","54.89","631.39","94","1467.77","3764.11","percent of total billed charges",""
"HOOK PLATE 16MM 7 HOLE VARIAX TITANIUM LOCKING ANTERIOR CLAVICLE RIGHT","SUP-ITM-10156061","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.73","3551.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1813.40","38.3","","279.30","91.72","1116.77","266","1467.77","3764.11","percent of total billed charges",""
"HOOK PLATE 16MM 7 HOLE VARIAX TITANIUM LOCKING ANTERIOR CLAVICLE RIGHT","SUP-ITM-10156061","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.73","3551.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2031.20","42.9","","731.00","63.70","731.00","1 through 10","1467.77","3764.11","percent of total billed charges",""
"HOOK PLATE 16MM 7 HOLE VARIAX TITANIUM LOCKING ANTERIOR CLAVICLE RIGHT","SUP-ITM-10156061","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.73","3551.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2031.20","42.9","","384.74","384.74","384.74","1 through 10","1467.77","3764.11","percent of total billed charges",""
"HOOK PLATE 16MM 7 HOLE VARIAX TITANIUM LOCKING ANTERIOR CLAVICLE RIGHT","SUP-ITM-10156061","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.73","3551.05","WELLPOINT [1015]","HB AMC WELLPOINT","3493.28","73.78","","286.63","119.22","1107.45","105","1467.77","3764.11","percent of total billed charges",""
"HOOK PLATE 16MM 7 HOLE VARIAX TITANIUM LOCKING ANTERIOR CLAVICLE RIGHT","SUP-ITM-10156061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4734.73","3551.05","AETNA [1001]","HB AMC AETNA HMO","3304.84","69.8","","675.31","184.75","1721.50","286","2474.37","3869.22","percent of total billed charges",""
"HOOK PLATE 16MM 7 HOLE VARIAX TITANIUM LOCKING ANTERIOR CLAVICLE RIGHT","SUP-ITM-10156061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4734.73","3551.05","AETNA [1001]","HB AMC AETNA PPO","3806.72","80.4","","1261.44","103.12","1514.10","21","2474.37","3869.22","percent of total billed charges",""
"HOOK PLATE 16MM 7 HOLE VARIAX TITANIUM LOCKING ANTERIOR CLAVICLE RIGHT","SUP-ITM-10156061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4734.73","3551.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3806.72","80.4","","1365.00","1365.00","1365.00","1 through 10","2474.37","3869.22","percent of total billed charges",""
"HOOK PLATE 16MM 7 HOLE VARIAX TITANIUM LOCKING ANTERIOR CLAVICLE RIGHT","SUP-ITM-10156061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4734.73","3551.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3869.22","81.72","","5157.68","5157.68","5157.68","1 through 10","2474.37","3869.22","percent of total billed charges",""
"HOOK PLATE 16MM 7 HOLE VARIAX TITANIUM LOCKING ANTERIOR CLAVICLE RIGHT","SUP-ITM-10156061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4734.73","3551.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3869.22","81.72","","431.26","71.26","1459.57","88","2474.37","3869.22","percent of total billed charges",""
"HOOK SPINE 6MM SM LAMINA TITANIUM DUAL OPENING FRONTAL ROD","SUP-ITM-10033169","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","1309.77","674.56","6049.93","26","434","1113","percent of total billed charges",""
"HOOK SPINE 6MM SM LAMINA TITANIUM DUAL OPENING FRONTAL ROD","SUP-ITM-10033169","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","1901.83","1901.83","2962.25","1 through 10","434","1113","percent of total billed charges",""
"HOOK SPINE 6MM SM LAMINA TITANIUM DUAL OPENING FRONTAL ROD","SUP-ITM-10033169","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1620.31","1620.31","19908.88","1 through 10","434","1113","percent of total billed charges",""
"HOOK SPINE 6MM SM LAMINA TITANIUM DUAL OPENING FRONTAL ROD","SUP-ITM-10033169","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","352.91","352.91","2046.30","1 through 10","434","1113","percent of total billed charges",""
"HOOK SPINE 6MM SM LAMINA TITANIUM DUAL OPENING FRONTAL ROD","SUP-ITM-10033169","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","9668.75","9668.75","9668.75","1 through 10","434","1113","percent of total billed charges",""
"HOOK SPINE 6MM SM LAMINA TITANIUM DUAL OPENING FRONTAL ROD","SUP-ITM-10033169","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","699.88","384.10","3443.31","33","434","1113","percent of total billed charges",""
"HOOK SPINE 6MM SM LAMINA TITANIUM DUAL OPENING FRONTAL ROD","SUP-ITM-10033169","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1421.24","264.50","4933.46","29","731.64","1144.08","percent of total billed charges",""
"HOOK SPINE 6MM SM LAMINA TITANIUM DUAL OPENING FRONTAL ROD","SUP-ITM-10033169","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1022.97","1022.97","3607.50","1 through 10","731.64","1144.08","percent of total billed charges",""
"HOOK SPINE 6MM SM LAMINA TITANIUM DUAL OPENING FRONTAL ROD","SUP-ITM-10033169","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","3010.54","693.88","5019.88","35","731.64","1144.08","percent of total billed charges",""
"Hpa-1 Genotyping Gene Analysis Common Variant","PX-31000886","CDM","81105","CPT","0310","RC","","","","outpatient","","","1829.00","1371.75","AETNA [1001]","HB AMC AETNA HMO","1276.64","69.8","","1201.00","1201.00","1201.00","1 through 10","432.04","1494.66","percent of total billed charges",""
"Hpa-15 Genotyping Gene Analysis Common Variant","PX-31000913","CDM","81112","CPT","0310","RC","","","","outpatient","","","1829.00","1371.75","AETNA [1001]","HB AMC AETNA HMO","1276.64","69.8","","1201.00","1201.00","1201.00","1 through 10","432.04","1494.66","percent of total billed charges",""
"Hpa-2 Genotyping Gene Analysis Common Variant","PX-31000887","CDM","81106","CPT","0310","RC","","","","outpatient","","","1829.00","1371.75","AETNA [1001]","HB AMC AETNA HMO","1276.64","69.8","","1201.00","1201.00","1201.00","1 through 10","432.04","1494.66","percent of total billed charges",""
"Hpa-3 Genotyping Gene Analysis Common Variant","PX-31000888","CDM","81107","CPT","0310","RC","","","","outpatient","","","1829.00","1371.75","AETNA [1001]","HB AMC AETNA HMO","1276.64","69.8","","1201.00","1201.00","1201.00","1 through 10","432.04","1494.66","percent of total billed charges",""
"Hpa-4 Genotyping Gene Analysis Common Variant","PX-31000889","CDM","81108","CPT","0310","RC","","","","outpatient","","","1829.00","1371.75","AETNA [1001]","HB AMC AETNA HMO","1276.64","69.8","","1201.00","1201.00","1201.00","1 through 10","432.04","1494.66","percent of total billed charges",""
"Hpa-5 Genotyping Gene Analysis Common Variant","PX-31000910","CDM","81109","CPT","0310","RC","","","","outpatient","","","1829.00","1371.75","AETNA [1001]","HB AMC AETNA HMO","1276.64","69.8","","1201.00","1201.00","1201.00","1 through 10","432.04","1494.66","percent of total billed charges",""
"Hpa-6 Genotyping Gene Analysis Common Variant","PX-31000911","CDM","81110","CPT","0310","RC","","","","outpatient","","","1829.00","1371.75","AETNA [1001]","HB AMC AETNA HMO","1276.64","69.8","","1201.00","1201.00","1201.00","1 through 10","432.04","1494.66","percent of total billed charges",""
"Hpa-9 Genotyping Gene Analysis Common Variant","PX-31000912","CDM","81111","CPT","0310","RC","","","","outpatient","","","1829.00","1371.75","AETNA [1001]","HB AMC AETNA HMO","1276.64","69.8","","1201.00","1201.00","1201.00","1 through 10","432.04","1494.66","percent of total billed charges",""
"Hppan1 for Dex Z","PX-31001341","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Human Epididymis Protein 4 (He4)","PX-30000821","CDM","86305","CPT","0302","RC","","","","both","","","286.00","214.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","104.39","36.5","","103.32","103.32","103.32","1 through 10","20.39","271.7","percent of total billed charges",""
"HUMERAL BEARING 36MM STD PROLONG COMPREHENSIVE REVERSE XLPE","SUP-ITM-10281417","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1044.78","52.26","","1113.10","1113.10","1113.10","1 through 10","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 36MM STD PROLONG COMPREHENSIVE REVERSE XLPE","SUP-ITM-10281417","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1589.36","79.5","","1293.60","1148.53","1603.80","1 through 10","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 36MM STD PROLONG COMPREHENSIVE REVERSE XLPE","SUP-ITM-10281417","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","729.71","36.5","","1023.42","771.29","2068.67","33","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 36MM STD PROLONG COMPREHENSIVE REVERSE XLPE","SUP-ITM-10281417","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","765.69","38.3","","850.52","759.78","1211.25","66","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 36MM STD PROLONG COMPREHENSIVE REVERSE XLPE","SUP-ITM-10281417","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","857.66","42.9","","2548.09","2548.09","2548.09","1 through 10","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 36MM STD PROLONG COMPREHENSIVE REVERSE XLPE","SUP-ITM-10281417","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","857.66","42.9","","956.46","956.46","956.46","1 through 10","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 36MM STD PROLONG COMPREHENSIVE REVERSE XLPE","SUP-ITM-10281417","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","WELLPOINT [1015]","HB AMC WELLPOINT","1475.01","73.78","","2344.73","1619.47","2530.35","16","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 36MM STD PROLONG COMPREHENSIVE REVERSE XLPE","SUP-ITM-10281417","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1999.20","1499.40","AETNA [1001]","HB AMC AETNA HMO","1395.44","69.8","","1523.63","988.41","4330.26","39","1044.78","1633.75","percent of total billed charges",""
"HUMERAL BEARING 36MM STD PROLONG COMPREHENSIVE REVERSE XLPE","SUP-ITM-10281417","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1999.20","1499.40","AETNA [1001]","HB AMC AETNA PPO","1607.36","80.4","","1670.25","1670.25","1670.25","1 through 10","1044.78","1633.75","percent of total billed charges",""
"HUMERAL BEARING 36MM STD PROLONG COMPREHENSIVE REVERSE XLPE","SUP-ITM-10281417","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1999.20","1499.40","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1044.78","52.26","","1113.10","1113.10","1113.10","1 through 10","1044.78","1633.75","percent of total billed charges",""
"HUMERAL BEARING 36MM STD PROLONG COMPREHENSIVE REVERSE XLPE","SUP-ITM-10281417","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1999.20","1499.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1633.75","81.72","","1738.90","1484.65","2716.94","38","1044.78","1633.75","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1044.78","52.26","","1113.10","1113.10","1113.10","1 through 10","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1589.36","79.5","","1293.60","1148.53","1603.80","1 through 10","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","729.71","36.5","","1023.42","771.29","2068.67","33","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","765.69","38.3","","850.52","759.78","1211.25","66","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","857.66","42.9","","2548.09","2548.09","2548.09","1 through 10","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","857.66","42.9","","956.46","956.46","956.46","1 through 10","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1999.20","1499.40","WELLPOINT [1015]","HB AMC WELLPOINT","1475.01","73.78","","2344.73","1619.47","2530.35","16","619.75","1589.36","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1999.20","1499.40","AETNA [1001]","HB AMC AETNA HMO","1395.44","69.8","","1523.63","988.41","4330.26","39","1044.78","1633.75","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1999.20","1499.40","AETNA [1001]","HB AMC AETNA PPO","1607.36","80.4","","1670.25","1670.25","1670.25","1 through 10","1044.78","1633.75","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1999.20","1499.40","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1044.78","52.26","","1113.10","1113.10","1113.10","1 through 10","1044.78","1633.75","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1999.20","1499.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1633.75","81.72","","1738.90","1484.65","2716.94","38","1044.78","1633.75","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3344.64","52.26","","1113.10","1113.10","1113.10","1 through 10","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5088.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2336.00","36.5","","1023.42","771.29","2068.67","33","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2451.20","38.3","","850.52","759.78","1211.25","66","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2745.60","42.9","","2548.09","2548.09","2548.09","1 through 10","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2745.60","42.9","","956.46","956.46","956.46","1 through 10","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","WELLPOINT [1015]","HB AMC WELLPOINT","4721.92","73.78","","2344.73","1619.47","2530.35","16","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","AETNA [1001]","HB AMC AETNA HMO","4467.20","69.8","","1523.63","988.41","4330.26","39","3344.64","5230.08","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","AETNA [1001]","HB AMC AETNA PPO","5145.60","80.4","","1670.25","1670.25","1670.25","1 through 10","3344.64","5230.08","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3344.64","52.26","","1113.10","1113.10","1113.10","1 through 10","3344.64","5230.08","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5230.08","81.72","","1738.90","1484.65","2716.94","38","3344.64","5230.08","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3344.64","52.26","","1113.10","1113.10","1113.10","1 through 10","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5088.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2336.00","36.5","","1023.42","771.29","2068.67","33","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2451.20","38.3","","850.52","759.78","1211.25","66","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2745.60","42.9","","2548.09","2548.09","2548.09","1 through 10","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2745.60","42.9","","956.46","956.46","956.46","1 through 10","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","WELLPOINT [1015]","HB AMC WELLPOINT","4721.92","73.78","","2344.73","1619.47","2530.35","16","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","AETNA [1001]","HB AMC AETNA HMO","4467.20","69.8","","1523.63","988.41","4330.26","39","3344.64","5230.08","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","AETNA [1001]","HB AMC AETNA PPO","5145.60","80.4","","1670.25","1670.25","1670.25","1 through 10","3344.64","5230.08","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3344.64","52.26","","1113.10","1113.10","1113.10","1 through 10","3344.64","5230.08","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5230.08","81.72","","1738.90","1484.65","2716.94","38","3344.64","5230.08","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3344.64","52.26","","1113.10","1113.10","1113.10","1 through 10","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5088.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2336.00","36.5","","1023.42","771.29","2068.67","33","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2451.20","38.3","","850.52","759.78","1211.25","66","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2745.60","42.9","","2548.09","2548.09","2548.09","1 through 10","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2745.60","42.9","","956.46","956.46","956.46","1 through 10","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","6400.00","4800.00","WELLPOINT [1015]","HB AMC WELLPOINT","4721.92","73.78","","2344.73","1619.47","2530.35","16","1984","5088","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","AETNA [1001]","HB AMC AETNA HMO","4467.20","69.8","","1523.63","988.41","4330.26","39","3344.64","5230.08","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","AETNA [1001]","HB AMC AETNA PPO","5145.60","80.4","","1670.25","1670.25","1670.25","1 through 10","3344.64","5230.08","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3344.64","52.26","","1113.10","1113.10","1113.10","1 through 10","3344.64","5230.08","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6400.00","4800.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5230.08","81.72","","1738.90","1484.65","2716.94","38","3344.64","5230.08","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2761.94","52.26","","1113.10","1113.10","1113.10","1 through 10","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4201.58","79.5","","1293.60","1148.53","1603.80","1 through 10","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1929.03","36.5","","1023.42","771.29","2068.67","33","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2024.16","38.3","","850.52","759.78","1211.25","66","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2267.27","42.9","","2548.09","2548.09","2548.09","1 through 10","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2267.27","42.9","","956.46","956.46","956.46","1 through 10","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","WELLPOINT [1015]","HB AMC WELLPOINT","3899.27","73.78","","2344.73","1619.47","2530.35","16","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5285.00","3963.75","AETNA [1001]","HB AMC AETNA HMO","3688.93","69.8","","1523.63","988.41","4330.26","39","2761.94","4318.9","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5285.00","3963.75","AETNA [1001]","HB AMC AETNA PPO","4249.14","80.4","","1670.25","1670.25","1670.25","1 through 10","2761.94","4318.9","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5285.00","3963.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2761.94","52.26","","1113.10","1113.10","1113.10","1 through 10","2761.94","4318.9","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5285.00","3963.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4318.90","81.72","","1738.90","1484.65","2716.94","38","2761.94","4318.9","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2761.94","52.26","","1113.10","1113.10","1113.10","1 through 10","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4201.58","79.5","","1293.60","1148.53","1603.80","1 through 10","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1929.03","36.5","","1023.42","771.29","2068.67","33","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2024.16","38.3","","850.52","759.78","1211.25","66","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2267.27","42.9","","2548.09","2548.09","2548.09","1 through 10","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2267.27","42.9","","956.46","956.46","956.46","1 through 10","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","WELLPOINT [1015]","HB AMC WELLPOINT","3899.27","73.78","","2344.73","1619.47","2530.35","16","1638.35","4201.58","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5285.00","3963.75","AETNA [1001]","HB AMC AETNA HMO","3688.93","69.8","","1523.63","988.41","4330.26","39","2761.94","4318.9","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5285.00","3963.75","AETNA [1001]","HB AMC AETNA PPO","4249.14","80.4","","1670.25","1670.25","1670.25","1 through 10","2761.94","4318.9","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5285.00","3963.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2761.94","52.26","","1113.10","1113.10","1113.10","1 through 10","2761.94","4318.9","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5285.00","3963.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4318.90","81.72","","1738.90","1484.65","2716.94","38","2761.94","4318.9","percent of total billed charges",""
"HUMERAL CONNECTOR 35MM ELBOW TOTAL COMPONENT ONC 19","SUP-ITM-10082111","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2613.00","52.26","","1113.10","1113.10","1113.10","1 through 10","1550","3975","percent of total billed charges",""
"HUMERAL CONNECTOR 35MM ELBOW TOTAL COMPONENT ONC 19","SUP-ITM-10082111","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1550","3975","percent of total billed charges",""
"HUMERAL CONNECTOR 35MM ELBOW TOTAL COMPONENT ONC 19","SUP-ITM-10082111","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","1023.42","771.29","2068.67","33","1550","3975","percent of total billed charges",""
"HUMERAL CONNECTOR 35MM ELBOW TOTAL COMPONENT ONC 19","SUP-ITM-10082111","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","850.52","759.78","1211.25","66","1550","3975","percent of total billed charges",""
"HUMERAL CONNECTOR 35MM ELBOW TOTAL COMPONENT ONC 19","SUP-ITM-10082111","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","2548.09","2548.09","2548.09","1 through 10","1550","3975","percent of total billed charges",""
"HUMERAL CONNECTOR 35MM ELBOW TOTAL COMPONENT ONC 19","SUP-ITM-10082111","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","956.46","956.46","956.46","1 through 10","1550","3975","percent of total billed charges",""
"HUMERAL CONNECTOR 35MM ELBOW TOTAL COMPONENT ONC 19","SUP-ITM-10082111","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","2344.73","1619.47","2530.35","16","1550","3975","percent of total billed charges",""
"HUMERAL CONNECTOR 35MM ELBOW TOTAL COMPONENT ONC 19","SUP-ITM-10082111","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","1523.63","988.41","4330.26","39","2613","4086","percent of total billed charges",""
"HUMERAL CONNECTOR 35MM ELBOW TOTAL COMPONENT ONC 19","SUP-ITM-10082111","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA PPO","4020.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2613","4086","percent of total billed charges",""
"HUMERAL CONNECTOR 35MM ELBOW TOTAL COMPONENT ONC 19","SUP-ITM-10082111","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2613.00","52.26","","1113.10","1113.10","1113.10","1 through 10","2613","4086","percent of total billed charges",""
"HUMERAL CONNECTOR 35MM ELBOW TOTAL COMPONENT ONC 19","SUP-ITM-10082111","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","1738.90","1484.65","2716.94","38","2613","4086","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1904.00","1428.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","995.03","52.26","","1113.10","1113.10","1113.10","1 through 10","590.24","1513.68","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1904.00","1428.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1513.68","79.5","","1293.60","1148.53","1603.80","1 through 10","590.24","1513.68","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1904.00","1428.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","694.96","36.5","","1023.42","771.29","2068.67","33","590.24","1513.68","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1904.00","1428.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","729.23","38.3","","850.52","759.78","1211.25","66","590.24","1513.68","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1904.00","1428.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","816.82","42.9","","2548.09","2548.09","2548.09","1 through 10","590.24","1513.68","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1904.00","1428.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","816.82","42.9","","956.46","956.46","956.46","1 through 10","590.24","1513.68","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1904.00","1428.00","WELLPOINT [1015]","HB AMC WELLPOINT","1404.77","73.78","","2344.73","1619.47","2530.35","16","590.24","1513.68","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1904.00","1428.00","AETNA [1001]","HB AMC AETNA HMO","1328.99","69.8","","1523.63","988.41","4330.26","39","995.03","1555.95","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1904.00","1428.00","AETNA [1001]","HB AMC AETNA PPO","1530.82","80.4","","1670.25","1670.25","1670.25","1 through 10","995.03","1555.95","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1904.00","1428.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","995.03","52.26","","1113.10","1113.10","1113.10","1 through 10","995.03","1555.95","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1904.00","1428.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1555.95","81.72","","1738.90","1484.65","2716.94","38","995.03","1555.95","percent of total billed charges",""
"HUMERAL CUP 6MM 9 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3961.65","2971.24","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2070.36","52.26","","1113.10","1113.10","1113.10","1 through 10","1228.11","3149.51","percent of total billed charges",""
"HUMERAL CUP 6MM 9 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3961.65","2971.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3149.51","79.5","","1293.60","1148.53","1603.80","1 through 10","1228.11","3149.51","percent of total billed charges",""
"HUMERAL CUP 6MM 9 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3961.65","2971.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1446.00","36.5","","1023.42","771.29","2068.67","33","1228.11","3149.51","percent of total billed charges",""
"HUMERAL CUP 6MM 9 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3961.65","2971.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1517.31","38.3","","850.52","759.78","1211.25","66","1228.11","3149.51","percent of total billed charges",""
"HUMERAL CUP 6MM 9 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3961.65","2971.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1699.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1228.11","3149.51","percent of total billed charges",""
"HUMERAL CUP 6MM 9 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3961.65","2971.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1699.55","42.9","","956.46","956.46","956.46","1 through 10","1228.11","3149.51","percent of total billed charges",""
"HUMERAL CUP 6MM 9 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3961.65","2971.24","WELLPOINT [1015]","HB AMC WELLPOINT","2922.91","73.78","","2344.73","1619.47","2530.35","16","1228.11","3149.51","percent of total billed charges",""
"HUMERAL CUP 6MM 9 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3961.65","2971.24","AETNA [1001]","HB AMC AETNA HMO","2765.23","69.8","","1523.63","988.41","4330.26","39","2070.36","3237.46","percent of total billed charges",""
"HUMERAL CUP 6MM 9 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3961.65","2971.24","AETNA [1001]","HB AMC AETNA PPO","3185.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2070.36","3237.46","percent of total billed charges",""
"HUMERAL CUP 6MM 9 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3961.65","2971.24","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2070.36","52.26","","1113.10","1113.10","1113.10","1 through 10","2070.36","3237.46","percent of total billed charges",""
"HUMERAL CUP 6MM 9 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3961.65","2971.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3237.46","81.72","","1738.90","1484.65","2716.94","38","2070.36","3237.46","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","273.85","79.5","","800.18","480.96","1887.97","195","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","183.60","53.3","","813.12","216.42","1444.50","81","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","106.79","31","","432.60","432.60","432.60","1 through 10","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","125.73","36.5","","148.37","54.89","631.39","94","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","131.93","38.3","","279.30","91.72","1116.77","266","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.78","42.9","","731.00","63.70","731.00","1 through 10","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.78","42.9","","384.74","384.74","384.74","1 through 10","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","WELLPOINT [1015]","HB AMC WELLPOINT","254.15","73.78","","286.63","119.22","1107.45","105","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","AETNA [1001]","HB AMC AETNA HMO","240.44","69.8","","675.31","184.75","1721.50","286","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","AETNA [1001]","HB AMC AETNA PPO","276.95","80.4","","1261.44","103.12","1514.10","21","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","276.95","80.4","","1365.00","1365.00","1365.00","1 through 10","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","281.50","81.72","","5157.68","5157.68","5157.68","1 through 10","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","281.50","81.72","","431.26","71.26","1459.57","88","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI T25 STARDRIVE","SUP-ITM-10027389","CDM","C1713","HCPCS","0278","RC","","","","both","","","466.20","349.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","370.63","79.5","","800.18","480.96","1887.97","195","144.52","370.63","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI T25 STARDRIVE","SUP-ITM-10027389","CDM","C1713","HCPCS","0278","RC","","","","both","","","466.20","349.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","248.48","53.3","","813.12","216.42","1444.50","81","144.52","370.63","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI T25 STARDRIVE","SUP-ITM-10027389","CDM","C1713","HCPCS","0278","RC","","","","both","","","466.20","349.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","144.52","31","","432.60","432.60","432.60","1 through 10","144.52","370.63","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI T25 STARDRIVE","SUP-ITM-10027389","CDM","C1713","HCPCS","0278","RC","","","","both","","","466.20","349.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","170.16","36.5","","148.37","54.89","631.39","94","144.52","370.63","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI T25 STARDRIVE","SUP-ITM-10027389","CDM","C1713","HCPCS","0278","RC","","","","both","","","466.20","349.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","178.55","38.3","","279.30","91.72","1116.77","266","144.52","370.63","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI T25 STARDRIVE","SUP-ITM-10027389","CDM","C1713","HCPCS","0278","RC","","","","both","","","466.20","349.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.00","42.9","","731.00","63.70","731.00","1 through 10","144.52","370.63","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI T25 STARDRIVE","SUP-ITM-10027389","CDM","C1713","HCPCS","0278","RC","","","","both","","","466.20","349.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.00","42.9","","384.74","384.74","384.74","1 through 10","144.52","370.63","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI T25 STARDRIVE","SUP-ITM-10027389","CDM","C1713","HCPCS","0278","RC","","","","both","","","466.20","349.65","WELLPOINT [1015]","HB AMC WELLPOINT","343.96","73.78","","286.63","119.22","1107.45","105","144.52","370.63","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI T25 STARDRIVE","SUP-ITM-10027389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","466.20","349.65","AETNA [1001]","HB AMC AETNA HMO","325.41","69.8","","675.31","184.75","1721.50","286","243.64","380.98","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI T25 STARDRIVE","SUP-ITM-10027389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","466.20","349.65","AETNA [1001]","HB AMC AETNA PPO","374.82","80.4","","1261.44","103.12","1514.10","21","243.64","380.98","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI T25 STARDRIVE","SUP-ITM-10027389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","466.20","349.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","374.82","80.4","","1365.00","1365.00","1365.00","1 through 10","243.64","380.98","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI T25 STARDRIVE","SUP-ITM-10027389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","466.20","349.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","380.98","81.72","","5157.68","5157.68","5157.68","1 through 10","243.64","380.98","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI T25 STARDRIVE","SUP-ITM-10027389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","466.20","349.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","380.98","81.72","","431.26","71.26","1459.57","88","243.64","380.98","percent of total billed charges",""
"HUMERAL ENDCAP 10MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039999","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","273.85","79.5","","800.18","480.96","1887.97","195","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 10MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039999","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","183.60","53.3","","813.12","216.42","1444.50","81","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 10MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039999","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","106.79","31","","432.60","432.60","432.60","1 through 10","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 10MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039999","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","125.73","36.5","","148.37","54.89","631.39","94","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 10MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039999","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","131.93","38.3","","279.30","91.72","1116.77","266","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 10MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039999","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.78","42.9","","731.00","63.70","731.00","1 through 10","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 10MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039999","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.78","42.9","","384.74","384.74","384.74","1 through 10","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 10MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039999","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","WELLPOINT [1015]","HB AMC WELLPOINT","254.15","73.78","","286.63","119.22","1107.45","105","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 10MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","AETNA [1001]","HB AMC AETNA HMO","240.44","69.8","","675.31","184.75","1721.50","286","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 10MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","AETNA [1001]","HB AMC AETNA PPO","276.95","80.4","","1261.44","103.12","1514.10","21","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 10MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","276.95","80.4","","1365.00","1365.00","1365.00","1 through 10","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 10MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","281.50","81.72","","5157.68","5157.68","5157.68","1 through 10","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 10MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","281.50","81.72","","431.26","71.26","1459.57","88","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 15MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10040000","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","273.85","79.5","","800.18","480.96","1887.97","195","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 15MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10040000","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","183.60","53.3","","813.12","216.42","1444.50","81","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 15MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10040000","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","106.79","31","","432.60","432.60","432.60","1 through 10","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 15MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10040000","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","125.73","36.5","","148.37","54.89","631.39","94","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 15MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10040000","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","131.93","38.3","","279.30","91.72","1116.77","266","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 15MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10040000","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.78","42.9","","731.00","63.70","731.00","1 through 10","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 15MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10040000","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.78","42.9","","384.74","384.74","384.74","1 through 10","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 15MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10040000","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.47","258.35","WELLPOINT [1015]","HB AMC WELLPOINT","254.15","73.78","","286.63","119.22","1107.45","105","106.79","273.85","percent of total billed charges",""
"HUMERAL ENDCAP 15MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10040000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","AETNA [1001]","HB AMC AETNA HMO","240.44","69.8","","675.31","184.75","1721.50","286","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 15MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10040000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","AETNA [1001]","HB AMC AETNA PPO","276.95","80.4","","1261.44","103.12","1514.10","21","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 15MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10040000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","276.95","80.4","","1365.00","1365.00","1365.00","1 through 10","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 15MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10040000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","281.50","81.72","","5157.68","5157.68","5157.68","1 through 10","180.02","281.5","percent of total billed charges",""
"HUMERAL ENDCAP 15MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10040000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.47","258.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","281.50","81.72","","431.26","71.26","1459.57","88","180.02","281.5","percent of total billed charges",""
"HUMERAL HEAD 12X130MM STEM BIGLIANI / FLATOW COBALT ALLOY MODULAR","SUP-ITM-10014224","CDM","C1776","HCPCS","0278","RC","","","","both","","","5112.45","3834.34","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2671.77","52.26","","1113.10","1113.10","1113.10","1 through 10","1584.86","4064.4","percent of total billed charges",""
"HUMERAL HEAD 12X130MM STEM BIGLIANI / FLATOW COBALT ALLOY MODULAR","SUP-ITM-10014224","CDM","C1776","HCPCS","0278","RC","","","","both","","","5112.45","3834.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4064.40","79.5","","1293.60","1148.53","1603.80","1 through 10","1584.86","4064.4","percent of total billed charges",""
"HUMERAL HEAD 12X130MM STEM BIGLIANI / FLATOW COBALT ALLOY MODULAR","SUP-ITM-10014224","CDM","C1776","HCPCS","0278","RC","","","","both","","","5112.45","3834.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1866.04","36.5","","1023.42","771.29","2068.67","33","1584.86","4064.4","percent of total billed charges",""
"HUMERAL HEAD 12X130MM STEM BIGLIANI / FLATOW COBALT ALLOY MODULAR","SUP-ITM-10014224","CDM","C1776","HCPCS","0278","RC","","","","both","","","5112.45","3834.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1958.07","38.3","","850.52","759.78","1211.25","66","1584.86","4064.4","percent of total billed charges",""
"HUMERAL HEAD 12X130MM STEM BIGLIANI / FLATOW COBALT ALLOY MODULAR","SUP-ITM-10014224","CDM","C1776","HCPCS","0278","RC","","","","both","","","5112.45","3834.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2193.24","42.9","","2548.09","2548.09","2548.09","1 through 10","1584.86","4064.4","percent of total billed charges",""
"HUMERAL HEAD 12X130MM STEM BIGLIANI / FLATOW COBALT ALLOY MODULAR","SUP-ITM-10014224","CDM","C1776","HCPCS","0278","RC","","","","both","","","5112.45","3834.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2193.24","42.9","","956.46","956.46","956.46","1 through 10","1584.86","4064.4","percent of total billed charges",""
"HUMERAL HEAD 12X130MM STEM BIGLIANI / FLATOW COBALT ALLOY MODULAR","SUP-ITM-10014224","CDM","C1776","HCPCS","0278","RC","","","","both","","","5112.45","3834.34","WELLPOINT [1015]","HB AMC WELLPOINT","3771.97","73.78","","2344.73","1619.47","2530.35","16","1584.86","4064.4","percent of total billed charges",""
"HUMERAL HEAD 12X130MM STEM BIGLIANI / FLATOW COBALT ALLOY MODULAR","SUP-ITM-10014224","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5112.45","3834.34","AETNA [1001]","HB AMC AETNA HMO","3568.49","69.8","","1523.63","988.41","4330.26","39","2671.77","4177.89","percent of total billed charges",""
"HUMERAL HEAD 12X130MM STEM BIGLIANI / FLATOW COBALT ALLOY MODULAR","SUP-ITM-10014224","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5112.45","3834.34","AETNA [1001]","HB AMC AETNA PPO","4110.41","80.4","","1670.25","1670.25","1670.25","1 through 10","2671.77","4177.89","percent of total billed charges",""
"HUMERAL HEAD 12X130MM STEM BIGLIANI / FLATOW COBALT ALLOY MODULAR","SUP-ITM-10014224","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5112.45","3834.34","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2671.77","52.26","","1113.10","1113.10","1113.10","1 through 10","2671.77","4177.89","percent of total billed charges",""
"HUMERAL HEAD 12X130MM STEM BIGLIANI / FLATOW COBALT ALLOY MODULAR","SUP-ITM-10014224","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5112.45","3834.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4177.89","81.72","","1738.90","1484.65","2716.94","38","2671.77","4177.89","percent of total billed charges",""
"HUMERAL HEAD 19X50MM DIA UNIVERSE 3D TOTAL SHOULDER","SUP-ITM-10012043","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","976.5","2504.25","percent of total billed charges",""
"HUMERAL HEAD 19X50MM DIA UNIVERSE 3D TOTAL SHOULDER","SUP-ITM-10012043","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2504.25","79.5","","1293.60","1148.53","1603.80","1 through 10","976.5","2504.25","percent of total billed charges",""
"HUMERAL HEAD 19X50MM DIA UNIVERSE 3D TOTAL SHOULDER","SUP-ITM-10012043","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1149.75","36.5","","1023.42","771.29","2068.67","33","976.5","2504.25","percent of total billed charges",""
"HUMERAL HEAD 19X50MM DIA UNIVERSE 3D TOTAL SHOULDER","SUP-ITM-10012043","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1206.45","38.3","","850.52","759.78","1211.25","66","976.5","2504.25","percent of total billed charges",""
"HUMERAL HEAD 19X50MM DIA UNIVERSE 3D TOTAL SHOULDER","SUP-ITM-10012043","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","2548.09","2548.09","2548.09","1 through 10","976.5","2504.25","percent of total billed charges",""
"HUMERAL HEAD 19X50MM DIA UNIVERSE 3D TOTAL SHOULDER","SUP-ITM-10012043","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","956.46","956.46","956.46","1 through 10","976.5","2504.25","percent of total billed charges",""
"HUMERAL HEAD 19X50MM DIA UNIVERSE 3D TOTAL SHOULDER","SUP-ITM-10012043","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","WELLPOINT [1015]","HB AMC WELLPOINT","2324.07","73.78","","2344.73","1619.47","2530.35","16","976.5","2504.25","percent of total billed charges",""
"HUMERAL HEAD 19X50MM DIA UNIVERSE 3D TOTAL SHOULDER","SUP-ITM-10012043","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA HMO","2198.70","69.8","","1523.63","988.41","4330.26","39","1646.19","2574.18","percent of total billed charges",""
"HUMERAL HEAD 19X50MM DIA UNIVERSE 3D TOTAL SHOULDER","SUP-ITM-10012043","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA PPO","2532.60","80.4","","1670.25","1670.25","1670.25","1 through 10","1646.19","2574.18","percent of total billed charges",""
"HUMERAL HEAD 19X50MM DIA UNIVERSE 3D TOTAL SHOULDER","SUP-ITM-10012043","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","1646.19","2574.18","percent of total billed charges",""
"HUMERAL HEAD 19X50MM DIA UNIVERSE 3D TOTAL SHOULDER","SUP-ITM-10012043","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2574.18","81.72","","1738.90","1484.65","2716.94","38","1646.19","2574.18","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3516.44","52.26","","1113.10","1113.10","1113.10","1 through 10","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5349.36","79.5","","1293.60","1148.53","1603.80","1 through 10","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2455.99","36.5","","1023.42","771.29","2068.67","33","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2577.11","38.3","","850.52","759.78","1211.25","66","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2886.63","42.9","","2548.09","2548.09","2548.09","1 through 10","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2886.63","42.9","","956.46","956.46","956.46","1 through 10","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","WELLPOINT [1015]","HB AMC WELLPOINT","4964.47","73.78","","2344.73","1619.47","2530.35","16","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6728.75","5046.56","AETNA [1001]","HB AMC AETNA HMO","4696.67","69.8","","1523.63","988.41","4330.26","39","3516.44","5498.73","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6728.75","5046.56","AETNA [1001]","HB AMC AETNA PPO","5409.92","80.4","","1670.25","1670.25","1670.25","1 through 10","3516.44","5498.73","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6728.75","5046.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3516.44","52.26","","1113.10","1113.10","1113.10","1 through 10","3516.44","5498.73","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6728.75","5046.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5498.73","81.72","","1738.90","1484.65","2716.94","38","3516.44","5498.73","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3361.26","79.5","","800.18","480.96","1887.97","195","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2253.52","53.3","","813.12","216.42","1444.50","81","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1310.68","31","","432.60","432.60","432.60","1 through 10","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1543.22","36.5","","148.37","54.89","631.39","94","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1619.32","38.3","","279.30","91.72","1116.77","266","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.81","42.9","","731.00","63.70","731.00","1 through 10","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.81","42.9","","384.74","384.74","384.74","1 through 10","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","WELLPOINT [1015]","HB AMC WELLPOINT","3119.42","73.78","","286.63","119.22","1107.45","105","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","AETNA [1001]","HB AMC AETNA HMO","2951.14","69.8","","675.31","184.75","1721.50","286","2209.55","3455.12","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","AETNA [1001]","HB AMC AETNA PPO","3399.31","80.4","","1261.44","103.12","1514.10","21","2209.55","3455.12","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3399.31","80.4","","1365.00","1365.00","1365.00","1 through 10","2209.55","3455.12","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3455.12","81.72","","5157.68","5157.68","5157.68","1 through 10","2209.55","3455.12","percent of total billed charges",""
"HUMERAL HEAD 36MM COBALT-CHROME RETAINING SCREW STERILE REVERSE","SUP-ITM-10082331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3455.12","81.72","","431.26","71.26","1459.57","88","2209.55","3455.12","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3521.02","52.26","","1113.10","1113.10","1113.10","1 through 10","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5356.31","79.5","","1293.60","1148.53","1603.80","1 through 10","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2459.19","36.5","","1023.42","771.29","2068.67","33","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2580.46","38.3","","850.52","759.78","1211.25","66","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2890.39","42.9","","2548.09","2548.09","2548.09","1 through 10","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2890.39","42.9","","956.46","956.46","956.46","1 through 10","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","WELLPOINT [1015]","HB AMC WELLPOINT","4970.93","73.78","","2344.73","1619.47","2530.35","16","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.50","5053.12","AETNA [1001]","HB AMC AETNA HMO","4702.78","69.8","","1523.63","988.41","4330.26","39","3521.02","5505.89","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.50","5053.12","AETNA [1001]","HB AMC AETNA PPO","5416.95","80.4","","1670.25","1670.25","1670.25","1 through 10","3521.02","5505.89","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.50","5053.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3521.02","52.26","","1113.10","1113.10","1113.10","1 through 10","3521.02","5505.89","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.50","5053.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5505.89","81.72","","1738.90","1484.65","2716.94","38","3521.02","5505.89","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2209.55","52.26","","1113.10","1113.10","1113.10","1 through 10","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3361.26","79.5","","1293.60","1148.53","1603.80","1 through 10","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1543.22","36.5","","1023.42","771.29","2068.67","33","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1619.32","38.3","","850.52","759.78","1211.25","66","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.81","42.9","","2548.09","2548.09","2548.09","1 through 10","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.81","42.9","","956.46","956.46","956.46","1 through 10","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","WELLPOINT [1015]","HB AMC WELLPOINT","3119.42","73.78","","2344.73","1619.47","2530.35","16","1310.68","3361.26","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","AETNA [1001]","HB AMC AETNA HMO","2951.14","69.8","","1523.63","988.41","4330.26","39","2209.55","3455.12","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","AETNA [1001]","HB AMC AETNA PPO","3399.31","80.4","","1670.25","1670.25","1670.25","1 through 10","2209.55","3455.12","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2209.55","52.26","","1113.10","1113.10","1113.10","1 through 10","2209.55","3455.12","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3455.12","81.72","","1738.90","1484.65","2716.94","38","2209.55","3455.12","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1085","2782.5","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1085","2782.5","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1023.42","771.29","2068.67","33","1085","2782.5","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","850.52","759.78","1211.25","66","1085","2782.5","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1085","2782.5","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","956.46","956.46","956.46","1 through 10","1085","2782.5","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2344.73","1619.47","2530.35","16","1085","2782.5","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1523.63","988.41","4330.26","39","1829.1","2860.2","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1829.1","2860.2","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1829.1","2860.2","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","1738.90","1484.65","2716.94","38","1829.1","2860.2","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","951.13","52.26","","1113.10","1113.10","1113.10","1 through 10","564.2","1446.9","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1446.90","79.5","","1293.60","1148.53","1603.80","1 through 10","564.2","1446.9","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","664.30","36.5","","1023.42","771.29","2068.67","33","564.2","1446.9","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","697.06","38.3","","850.52","759.78","1211.25","66","564.2","1446.9","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","780.78","42.9","","2548.09","2548.09","2548.09","1 through 10","564.2","1446.9","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","780.78","42.9","","956.46","956.46","956.46","1 through 10","564.2","1446.9","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","WELLPOINT [1015]","HB AMC WELLPOINT","1342.80","73.78","","2344.73","1619.47","2530.35","16","564.2","1446.9","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1820.00","1365.00","AETNA [1001]","HB AMC AETNA HMO","1270.36","69.8","","1523.63","988.41","4330.26","39","951.13","1487.3","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1820.00","1365.00","AETNA [1001]","HB AMC AETNA PPO","1463.28","80.4","","1670.25","1670.25","1670.25","1 through 10","951.13","1487.3","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1820.00","1365.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","951.13","52.26","","1113.10","1113.10","1113.10","1 through 10","951.13","1487.3","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1820.00","1365.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1487.30","81.72","","1738.90","1484.65","2716.94","38","951.13","1487.3","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3516.44","52.26","","1113.10","1113.10","1113.10","1 through 10","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5349.36","79.5","","1293.60","1148.53","1603.80","1 through 10","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2455.99","36.5","","1023.42","771.29","2068.67","33","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2577.11","38.3","","850.52","759.78","1211.25","66","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2886.63","42.9","","2548.09","2548.09","2548.09","1 through 10","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2886.63","42.9","","956.46","956.46","956.46","1 through 10","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","WELLPOINT [1015]","HB AMC WELLPOINT","4964.47","73.78","","2344.73","1619.47","2530.35","16","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6728.75","5046.56","AETNA [1001]","HB AMC AETNA HMO","4696.67","69.8","","1523.63","988.41","4330.26","39","3516.44","5498.73","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6728.75","5046.56","AETNA [1001]","HB AMC AETNA PPO","5409.92","80.4","","1670.25","1670.25","1670.25","1 through 10","3516.44","5498.73","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6728.75","5046.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3516.44","52.26","","1113.10","1113.10","1113.10","1 through 10","3516.44","5498.73","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6728.75","5046.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5498.73","81.72","","1738.90","1484.65","2716.94","38","3516.44","5498.73","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3516.44","52.26","","1113.10","1113.10","1113.10","1 through 10","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5349.36","79.5","","1293.60","1148.53","1603.80","1 through 10","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2455.99","36.5","","1023.42","771.29","2068.67","33","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2577.11","38.3","","850.52","759.78","1211.25","66","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2886.63","42.9","","2548.09","2548.09","2548.09","1 through 10","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2886.63","42.9","","956.46","956.46","956.46","1 through 10","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","6728.75","5046.56","WELLPOINT [1015]","HB AMC WELLPOINT","4964.47","73.78","","2344.73","1619.47","2530.35","16","2085.91","5349.36","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6728.75","5046.56","AETNA [1001]","HB AMC AETNA HMO","4696.67","69.8","","1523.63","988.41","4330.26","39","3516.44","5498.73","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6728.75","5046.56","AETNA [1001]","HB AMC AETNA PPO","5409.92","80.4","","1670.25","1670.25","1670.25","1 through 10","3516.44","5498.73","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6728.75","5046.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3516.44","52.26","","1113.10","1113.10","1113.10","1 through 10","3516.44","5498.73","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6728.75","5046.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5498.73","81.72","","1738.90","1484.65","2716.94","38","3516.44","5498.73","percent of total billed charges",""
"HUMERAL HEAD 52X21MM SURGICAL","SUP-ITM-10118765","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3521.02","52.26","","1113.10","1113.10","1113.10","1 through 10","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 52X21MM SURGICAL","SUP-ITM-10118765","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5356.31","79.5","","1293.60","1148.53","1603.80","1 through 10","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 52X21MM SURGICAL","SUP-ITM-10118765","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2459.19","36.5","","1023.42","771.29","2068.67","33","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 52X21MM SURGICAL","SUP-ITM-10118765","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2580.46","38.3","","850.52","759.78","1211.25","66","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 52X21MM SURGICAL","SUP-ITM-10118765","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2890.39","42.9","","2548.09","2548.09","2548.09","1 through 10","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 52X21MM SURGICAL","SUP-ITM-10118765","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2890.39","42.9","","956.46","956.46","956.46","1 through 10","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 52X21MM SURGICAL","SUP-ITM-10118765","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.50","5053.12","WELLPOINT [1015]","HB AMC WELLPOINT","4970.93","73.78","","2344.73","1619.47","2530.35","16","2088.63","5356.31","percent of total billed charges",""
"HUMERAL HEAD 52X21MM SURGICAL","SUP-ITM-10118765","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.50","5053.12","AETNA [1001]","HB AMC AETNA HMO","4702.78","69.8","","1523.63","988.41","4330.26","39","3521.02","5505.89","percent of total billed charges",""
"HUMERAL HEAD 52X21MM SURGICAL","SUP-ITM-10118765","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.50","5053.12","AETNA [1001]","HB AMC AETNA PPO","5416.95","80.4","","1670.25","1670.25","1670.25","1 through 10","3521.02","5505.89","percent of total billed charges",""
"HUMERAL HEAD 52X21MM SURGICAL","SUP-ITM-10118765","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.50","5053.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3521.02","52.26","","1113.10","1113.10","1113.10","1 through 10","3521.02","5505.89","percent of total billed charges",""
"HUMERAL HEAD 52X21MM SURGICAL","SUP-ITM-10118765","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.50","5053.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5505.89","81.72","","1738.90","1484.65","2716.94","38","3521.02","5505.89","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2761.94","52.26","","1113.10","1113.10","1113.10","1 through 10","1638.35","4201.58","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4201.58","79.5","","1293.60","1148.53","1603.80","1 through 10","1638.35","4201.58","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1929.03","36.5","","1023.42","771.29","2068.67","33","1638.35","4201.58","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2024.16","38.3","","850.52","759.78","1211.25","66","1638.35","4201.58","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2267.27","42.9","","2548.09","2548.09","2548.09","1 through 10","1638.35","4201.58","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2267.27","42.9","","956.46","956.46","956.46","1 through 10","1638.35","4201.58","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","5285.00","3963.75","WELLPOINT [1015]","HB AMC WELLPOINT","3899.27","73.78","","2344.73","1619.47","2530.35","16","1638.35","4201.58","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5285.00","3963.75","AETNA [1001]","HB AMC AETNA HMO","3688.93","69.8","","1523.63","988.41","4330.26","39","2761.94","4318.9","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5285.00","3963.75","AETNA [1001]","HB AMC AETNA PPO","4249.14","80.4","","1670.25","1670.25","1670.25","1 through 10","2761.94","4318.9","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5285.00","3963.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2761.94","52.26","","1113.10","1113.10","1113.10","1 through 10","2761.94","4318.9","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5285.00","3963.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4318.90","81.72","","1738.90","1484.65","2716.94","38","2761.94","4318.9","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1293.60","1148.53","1603.80","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1023.42","771.29","2068.67","33","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","850.52","759.78","1211.25","66","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","2548.09","2548.09","2548.09","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","956.46","956.46","956.46","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","2344.73","1619.47","2530.35","16","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1523.63","988.41","4330.26","39","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1670.25","1670.25","1670.25","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1738.90","1484.65","2716.94","38","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1293.60","1148.53","1603.80","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1023.42","771.29","2068.67","33","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","850.52","759.78","1211.25","66","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","2548.09","2548.09","2548.09","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","956.46","956.46","956.46","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","2344.73","1619.47","2530.35","16","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1523.63","988.41","4330.26","39","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1670.25","1670.25","1670.25","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1738.90","1484.65","2716.94","38","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 36 42X12MM AEQUALIS REVERSED LATERALIZED COMBINATION","SUP-ITM-10136273","CDM","C1776","HCPCS","0278","RC","","","","both","","","3867.50","2900.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2021.16","52.26","","1113.10","1113.10","1113.10","1 through 10","1198.93","3074.66","percent of total billed charges",""
"HUMERAL INSERT 36 42X12MM AEQUALIS REVERSED LATERALIZED COMBINATION","SUP-ITM-10136273","CDM","C1776","HCPCS","0278","RC","","","","both","","","3867.50","2900.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3074.66","79.5","","1293.60","1148.53","1603.80","1 through 10","1198.93","3074.66","percent of total billed charges",""
"HUMERAL INSERT 36 42X12MM AEQUALIS REVERSED LATERALIZED COMBINATION","SUP-ITM-10136273","CDM","C1776","HCPCS","0278","RC","","","","both","","","3867.50","2900.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1411.64","36.5","","1023.42","771.29","2068.67","33","1198.93","3074.66","percent of total billed charges",""
"HUMERAL INSERT 36 42X12MM AEQUALIS REVERSED LATERALIZED COMBINATION","SUP-ITM-10136273","CDM","C1776","HCPCS","0278","RC","","","","both","","","3867.50","2900.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1481.25","38.3","","850.52","759.78","1211.25","66","1198.93","3074.66","percent of total billed charges",""
"HUMERAL INSERT 36 42X12MM AEQUALIS REVERSED LATERALIZED COMBINATION","SUP-ITM-10136273","CDM","C1776","HCPCS","0278","RC","","","","both","","","3867.50","2900.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1659.16","42.9","","2548.09","2548.09","2548.09","1 through 10","1198.93","3074.66","percent of total billed charges",""
"HUMERAL INSERT 36 42X12MM AEQUALIS REVERSED LATERALIZED COMBINATION","SUP-ITM-10136273","CDM","C1776","HCPCS","0278","RC","","","","both","","","3867.50","2900.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1659.16","42.9","","956.46","956.46","956.46","1 through 10","1198.93","3074.66","percent of total billed charges",""
"HUMERAL INSERT 36 42X12MM AEQUALIS REVERSED LATERALIZED COMBINATION","SUP-ITM-10136273","CDM","C1776","HCPCS","0278","RC","","","","both","","","3867.50","2900.62","WELLPOINT [1015]","HB AMC WELLPOINT","2853.44","73.78","","2344.73","1619.47","2530.35","16","1198.93","3074.66","percent of total billed charges",""
"HUMERAL INSERT 36 42X12MM AEQUALIS REVERSED LATERALIZED COMBINATION","SUP-ITM-10136273","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3867.50","2900.62","AETNA [1001]","HB AMC AETNA HMO","2699.52","69.8","","1523.63","988.41","4330.26","39","2021.16","3160.52","percent of total billed charges",""
"HUMERAL INSERT 36 42X12MM AEQUALIS REVERSED LATERALIZED COMBINATION","SUP-ITM-10136273","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3867.50","2900.62","AETNA [1001]","HB AMC AETNA PPO","3109.47","80.4","","1670.25","1670.25","1670.25","1 through 10","2021.16","3160.52","percent of total billed charges",""
"HUMERAL INSERT 36 42X12MM AEQUALIS REVERSED LATERALIZED COMBINATION","SUP-ITM-10136273","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3867.50","2900.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2021.16","52.26","","1113.10","1113.10","1113.10","1 through 10","2021.16","3160.52","percent of total billed charges",""
"HUMERAL INSERT 36 42X12MM AEQUALIS REVERSED LATERALIZED COMBINATION","SUP-ITM-10136273","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3867.50","2900.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3160.52","81.72","","1738.90","1484.65","2716.94","38","2021.16","3160.52","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3552.50","2664.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1856.54","52.26","","1113.10","1113.10","1113.10","1 through 10","1101.28","2824.24","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3552.50","2664.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2824.24","79.5","","1293.60","1148.53","1603.80","1 through 10","1101.28","2824.24","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3552.50","2664.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1296.66","36.5","","1023.42","771.29","2068.67","33","1101.28","2824.24","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3552.50","2664.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1360.61","38.3","","850.52","759.78","1211.25","66","1101.28","2824.24","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3552.50","2664.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1524.02","42.9","","2548.09","2548.09","2548.09","1 through 10","1101.28","2824.24","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3552.50","2664.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1524.02","42.9","","956.46","956.46","956.46","1 through 10","1101.28","2824.24","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3552.50","2664.37","WELLPOINT [1015]","HB AMC WELLPOINT","2621.03","73.78","","2344.73","1619.47","2530.35","16","1101.28","2824.24","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3552.50","2664.37","AETNA [1001]","HB AMC AETNA HMO","2479.65","69.8","","1523.63","988.41","4330.26","39","1856.54","2903.1","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3552.50","2664.37","AETNA [1001]","HB AMC AETNA PPO","2856.21","80.4","","1670.25","1670.25","1670.25","1 through 10","1856.54","2903.1","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3552.50","2664.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1856.54","52.26","","1113.10","1113.10","1113.10","1 through 10","1856.54","2903.1","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3552.50","2664.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2903.10","81.72","","1738.90","1484.65","2716.94","38","1856.54","2903.1","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1216.81","52.26","","1113.10","1113.10","1113.10","1 through 10","721.8","1851.06","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1851.06","79.5","","1293.60","1148.53","1603.80","1 through 10","721.8","1851.06","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","849.86","36.5","","1023.42","771.29","2068.67","33","721.8","1851.06","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","891.77","38.3","","850.52","759.78","1211.25","66","721.8","1851.06","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","998.88","42.9","","2548.09","2548.09","2548.09","1 through 10","721.8","1851.06","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","998.88","42.9","","956.46","956.46","956.46","1 through 10","721.8","1851.06","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","WELLPOINT [1015]","HB AMC WELLPOINT","1717.88","73.78","","2344.73","1619.47","2530.35","16","721.8","1851.06","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2328.38","1746.28","AETNA [1001]","HB AMC AETNA HMO","1625.21","69.8","","1523.63","988.41","4330.26","39","1216.81","1902.75","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2328.38","1746.28","AETNA [1001]","HB AMC AETNA PPO","1872.02","80.4","","1670.25","1670.25","1670.25","1 through 10","1216.81","1902.75","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2328.38","1746.28","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1216.81","52.26","","1113.10","1113.10","1113.10","1 through 10","1216.81","1902.75","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2328.38","1746.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1902.75","81.72","","1738.90","1484.65","2716.94","38","1216.81","1902.75","percent of total billed charges",""
"HUMERAL INSERT 36MM AQUEALIS REVERSED CEMENTLESS METAPHASIS","SUP-ITM-10136186","CDM","C1776","HCPCS","0278","RC","","","","both","","","7225.00","5418.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3775.79","52.26","","1113.10","1113.10","1113.10","1 through 10","2239.75","5743.88","percent of total billed charges",""
"HUMERAL INSERT 36MM AQUEALIS REVERSED CEMENTLESS METAPHASIS","SUP-ITM-10136186","CDM","C1776","HCPCS","0278","RC","","","","both","","","7225.00","5418.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5743.88","79.5","","1293.60","1148.53","1603.80","1 through 10","2239.75","5743.88","percent of total billed charges",""
"HUMERAL INSERT 36MM AQUEALIS REVERSED CEMENTLESS METAPHASIS","SUP-ITM-10136186","CDM","C1776","HCPCS","0278","RC","","","","both","","","7225.00","5418.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2637.13","36.5","","1023.42","771.29","2068.67","33","2239.75","5743.88","percent of total billed charges",""
"HUMERAL INSERT 36MM AQUEALIS REVERSED CEMENTLESS METAPHASIS","SUP-ITM-10136186","CDM","C1776","HCPCS","0278","RC","","","","both","","","7225.00","5418.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2767.18","38.3","","850.52","759.78","1211.25","66","2239.75","5743.88","percent of total billed charges",""
"HUMERAL INSERT 36MM AQUEALIS REVERSED CEMENTLESS METAPHASIS","SUP-ITM-10136186","CDM","C1776","HCPCS","0278","RC","","","","both","","","7225.00","5418.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3099.53","42.9","","2548.09","2548.09","2548.09","1 through 10","2239.75","5743.88","percent of total billed charges",""
"HUMERAL INSERT 36MM AQUEALIS REVERSED CEMENTLESS METAPHASIS","SUP-ITM-10136186","CDM","C1776","HCPCS","0278","RC","","","","both","","","7225.00","5418.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3099.53","42.9","","956.46","956.46","956.46","1 through 10","2239.75","5743.88","percent of total billed charges",""
"HUMERAL INSERT 36MM AQUEALIS REVERSED CEMENTLESS METAPHASIS","SUP-ITM-10136186","CDM","C1776","HCPCS","0278","RC","","","","both","","","7225.00","5418.75","WELLPOINT [1015]","HB AMC WELLPOINT","5330.61","73.78","","2344.73","1619.47","2530.35","16","2239.75","5743.88","percent of total billed charges",""
"HUMERAL INSERT 36MM AQUEALIS REVERSED CEMENTLESS METAPHASIS","SUP-ITM-10136186","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7225.00","5418.75","AETNA [1001]","HB AMC AETNA HMO","5043.05","69.8","","1523.63","988.41","4330.26","39","3775.79","5904.27","percent of total billed charges",""
"HUMERAL INSERT 36MM AQUEALIS REVERSED CEMENTLESS METAPHASIS","SUP-ITM-10136186","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7225.00","5418.75","AETNA [1001]","HB AMC AETNA PPO","5808.90","80.4","","1670.25","1670.25","1670.25","1 through 10","3775.79","5904.27","percent of total billed charges",""
"HUMERAL INSERT 36MM AQUEALIS REVERSED CEMENTLESS METAPHASIS","SUP-ITM-10136186","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7225.00","5418.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3775.79","52.26","","1113.10","1113.10","1113.10","1 through 10","3775.79","5904.27","percent of total billed charges",""
"HUMERAL INSERT 36MM AQUEALIS REVERSED CEMENTLESS METAPHASIS","SUP-ITM-10136186","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7225.00","5418.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5904.27","81.72","","1738.90","1484.65","2716.94","38","3775.79","5904.27","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED LATERALIZED STANDARD","SUP-ITM-10017353","CDM","C1776","HCPCS","0278","RC","","","","both","","","2453.50","1840.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1282.20","52.26","","1113.10","1113.10","1113.10","1 through 10","760.59","1950.53","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED LATERALIZED STANDARD","SUP-ITM-10017353","CDM","C1776","HCPCS","0278","RC","","","","both","","","2453.50","1840.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1950.53","79.5","","1293.60","1148.53","1603.80","1 through 10","760.59","1950.53","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED LATERALIZED STANDARD","SUP-ITM-10017353","CDM","C1776","HCPCS","0278","RC","","","","both","","","2453.50","1840.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","895.53","36.5","","1023.42","771.29","2068.67","33","760.59","1950.53","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED LATERALIZED STANDARD","SUP-ITM-10017353","CDM","C1776","HCPCS","0278","RC","","","","both","","","2453.50","1840.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","939.69","38.3","","850.52","759.78","1211.25","66","760.59","1950.53","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED LATERALIZED STANDARD","SUP-ITM-10017353","CDM","C1776","HCPCS","0278","RC","","","","both","","","2453.50","1840.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1052.55","42.9","","2548.09","2548.09","2548.09","1 through 10","760.59","1950.53","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED LATERALIZED STANDARD","SUP-ITM-10017353","CDM","C1776","HCPCS","0278","RC","","","","both","","","2453.50","1840.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1052.55","42.9","","956.46","956.46","956.46","1 through 10","760.59","1950.53","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED LATERALIZED STANDARD","SUP-ITM-10017353","CDM","C1776","HCPCS","0278","RC","","","","both","","","2453.50","1840.12","WELLPOINT [1015]","HB AMC WELLPOINT","1810.19","73.78","","2344.73","1619.47","2530.35","16","760.59","1950.53","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED LATERALIZED STANDARD","SUP-ITM-10017353","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2453.50","1840.12","AETNA [1001]","HB AMC AETNA HMO","1712.54","69.8","","1523.63","988.41","4330.26","39","1282.2","2005","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED LATERALIZED STANDARD","SUP-ITM-10017353","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2453.50","1840.12","AETNA [1001]","HB AMC AETNA PPO","1972.61","80.4","","1670.25","1670.25","1670.25","1 through 10","1282.2","2005","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED LATERALIZED STANDARD","SUP-ITM-10017353","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2453.50","1840.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1282.20","52.26","","1113.10","1113.10","1113.10","1 through 10","1282.2","2005","percent of total billed charges",""
"HUMERAL INSERT 36MMX12 AEQUALIS REVERSED LATERALIZED STANDARD","SUP-ITM-10017353","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2453.50","1840.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2005.00","81.72","","1738.90","1484.65","2716.94","38","1282.2","2005","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2741.55","2056.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1432.73","52.26","","1113.10","1113.10","1113.10","1 through 10","849.88","2179.53","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2741.55","2056.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2179.53","79.5","","1293.60","1148.53","1603.80","1 through 10","849.88","2179.53","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2741.55","2056.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1000.67","36.5","","1023.42","771.29","2068.67","33","849.88","2179.53","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2741.55","2056.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1050.01","38.3","","850.52","759.78","1211.25","66","849.88","2179.53","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2741.55","2056.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1176.12","42.9","","2548.09","2548.09","2548.09","1 through 10","849.88","2179.53","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2741.55","2056.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1176.12","42.9","","956.46","956.46","956.46","1 through 10","849.88","2179.53","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2741.55","2056.16","WELLPOINT [1015]","HB AMC WELLPOINT","2022.72","73.78","","2344.73","1619.47","2530.35","16","849.88","2179.53","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2741.55","2056.16","AETNA [1001]","HB AMC AETNA HMO","1913.60","69.8","","1523.63","988.41","4330.26","39","1432.73","2240.39","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2741.55","2056.16","AETNA [1001]","HB AMC AETNA PPO","2204.21","80.4","","1670.25","1670.25","1670.25","1 through 10","1432.73","2240.39","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2741.55","2056.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1432.73","52.26","","1113.10","1113.10","1113.10","1 through 10","1432.73","2240.39","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2741.55","2056.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2240.39","81.72","","1738.90","1484.65","2716.94","38","1432.73","2240.39","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136040","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136040","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1293.60","1148.53","1603.80","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136040","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1023.42","771.29","2068.67","33","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136040","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","850.52","759.78","1211.25","66","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136040","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","2548.09","2548.09","2548.09","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136040","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","956.46","956.46","956.46","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136040","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","2344.73","1619.47","2530.35","16","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136040","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1523.63","988.41","4330.26","39","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136040","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1670.25","1670.25","1670.25","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136040","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 36XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136040","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1738.90","1484.65","2716.94","38","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 40MM PLUS 0MMH STD POLYETHYLENE SEMI CONSTRAINED REVERSE RSP","SUP-ITM-10021997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2611.00","1958.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1364.51","52.26","","1113.10","1113.10","1113.10","1 through 10","809.41","2075.75","percent of total billed charges",""
"HUMERAL INSERT 40MM PLUS 0MMH STD POLYETHYLENE SEMI CONSTRAINED REVERSE RSP","SUP-ITM-10021997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2611.00","1958.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2075.75","79.5","","1293.60","1148.53","1603.80","1 through 10","809.41","2075.75","percent of total billed charges",""
"HUMERAL INSERT 40MM PLUS 0MMH STD POLYETHYLENE SEMI CONSTRAINED REVERSE RSP","SUP-ITM-10021997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2611.00","1958.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","953.02","36.5","","1023.42","771.29","2068.67","33","809.41","2075.75","percent of total billed charges",""
"HUMERAL INSERT 40MM PLUS 0MMH STD POLYETHYLENE SEMI CONSTRAINED REVERSE RSP","SUP-ITM-10021997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2611.00","1958.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1000.01","38.3","","850.52","759.78","1211.25","66","809.41","2075.75","percent of total billed charges",""
"HUMERAL INSERT 40MM PLUS 0MMH STD POLYETHYLENE SEMI CONSTRAINED REVERSE RSP","SUP-ITM-10021997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2611.00","1958.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1120.12","42.9","","2548.09","2548.09","2548.09","1 through 10","809.41","2075.75","percent of total billed charges",""
"HUMERAL INSERT 40MM PLUS 0MMH STD POLYETHYLENE SEMI CONSTRAINED REVERSE RSP","SUP-ITM-10021997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2611.00","1958.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1120.12","42.9","","956.46","956.46","956.46","1 through 10","809.41","2075.75","percent of total billed charges",""
"HUMERAL INSERT 40MM PLUS 0MMH STD POLYETHYLENE SEMI CONSTRAINED REVERSE RSP","SUP-ITM-10021997","CDM","C1776","HCPCS","0278","RC","","","","both","","","2611.00","1958.25","WELLPOINT [1015]","HB AMC WELLPOINT","1926.40","73.78","","2344.73","1619.47","2530.35","16","809.41","2075.75","percent of total billed charges",""
"HUMERAL INSERT 40MM PLUS 0MMH STD POLYETHYLENE SEMI CONSTRAINED REVERSE RSP","SUP-ITM-10021997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2611.00","1958.25","AETNA [1001]","HB AMC AETNA HMO","1822.48","69.8","","1523.63","988.41","4330.26","39","1364.51","2133.71","percent of total billed charges",""
"HUMERAL INSERT 40MM PLUS 0MMH STD POLYETHYLENE SEMI CONSTRAINED REVERSE RSP","SUP-ITM-10021997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2611.00","1958.25","AETNA [1001]","HB AMC AETNA PPO","2099.24","80.4","","1670.25","1670.25","1670.25","1 through 10","1364.51","2133.71","percent of total billed charges",""
"HUMERAL INSERT 40MM PLUS 0MMH STD POLYETHYLENE SEMI CONSTRAINED REVERSE RSP","SUP-ITM-10021997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2611.00","1958.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1364.51","52.26","","1113.10","1113.10","1113.10","1 through 10","1364.51","2133.71","percent of total billed charges",""
"HUMERAL INSERT 40MM PLUS 0MMH STD POLYETHYLENE SEMI CONSTRAINED REVERSE RSP","SUP-ITM-10021997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2611.00","1958.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2133.71","81.72","","1738.90","1484.65","2716.94","38","1364.51","2133.71","percent of total billed charges",""
"HUMERAL INSERT 42XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136028","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 42XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136028","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1293.60","1148.53","1603.80","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 42XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136028","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1023.42","771.29","2068.67","33","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 42XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136028","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","850.52","759.78","1211.25","66","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 42XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136028","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","2548.09","2548.09","2548.09","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 42XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136028","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","956.46","956.46","956.46","1 through 10","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 42XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136028","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","2344.73","1619.47","2530.35","16","651","1669.5","percent of total billed charges",""
"HUMERAL INSERT 42XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136028","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1523.63","988.41","4330.26","39","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 42XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136028","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1670.25","1670.25","1670.25","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 42XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136028","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1097.46","1716.12","percent of total billed charges",""
"HUMERAL INSERT 42XPLUS 9 7.5MM AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED","SUP-ITM-10136028","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1738.90","1484.65","2716.94","38","1097.46","1716.12","percent of total billed charges",""
"HUMERAL NAIL 7MM/150 EX TI CANNULATED PROXIMAL EX/150MM","SUP-ITM-10031414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3309.93","79.5","","800.18","480.96","1887.97","195","1290.66","3309.93","percent of total billed charges",""
"HUMERAL NAIL 7MM/150 EX TI CANNULATED PROXIMAL EX/150MM","SUP-ITM-10031414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2219.11","53.3","","813.12","216.42","1444.50","81","1290.66","3309.93","percent of total billed charges",""
"HUMERAL NAIL 7MM/150 EX TI CANNULATED PROXIMAL EX/150MM","SUP-ITM-10031414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1290.66","31","","432.60","432.60","432.60","1 through 10","1290.66","3309.93","percent of total billed charges",""
"HUMERAL NAIL 7MM/150 EX TI CANNULATED PROXIMAL EX/150MM","SUP-ITM-10031414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1519.65","36.5","","148.37","54.89","631.39","94","1290.66","3309.93","percent of total billed charges",""
"HUMERAL NAIL 7MM/150 EX TI CANNULATED PROXIMAL EX/150MM","SUP-ITM-10031414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1594.59","38.3","","279.30","91.72","1116.77","266","1290.66","3309.93","percent of total billed charges",""
"HUMERAL NAIL 7MM/150 EX TI CANNULATED PROXIMAL EX/150MM","SUP-ITM-10031414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1786.11","42.9","","731.00","63.70","731.00","1 through 10","1290.66","3309.93","percent of total billed charges",""
"HUMERAL NAIL 7MM/150 EX TI CANNULATED PROXIMAL EX/150MM","SUP-ITM-10031414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1786.11","42.9","","384.74","384.74","384.74","1 through 10","1290.66","3309.93","percent of total billed charges",""
"HUMERAL NAIL 7MM/150 EX TI CANNULATED PROXIMAL EX/150MM","SUP-ITM-10031414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","WELLPOINT [1015]","HB AMC WELLPOINT","3071.78","73.78","","286.63","119.22","1107.45","105","1290.66","3309.93","percent of total billed charges",""
"HUMERAL NAIL 7MM/150 EX TI CANNULATED PROXIMAL EX/150MM","SUP-ITM-10031414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","AETNA [1001]","HB AMC AETNA HMO","2906.07","69.8","","675.31","184.75","1721.50","286","2175.81","3402.35","percent of total billed charges",""
"HUMERAL NAIL 7MM/150 EX TI CANNULATED PROXIMAL EX/150MM","SUP-ITM-10031414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","AETNA [1001]","HB AMC AETNA PPO","3347.40","80.4","","1261.44","103.12","1514.10","21","2175.81","3402.35","percent of total billed charges",""
"HUMERAL NAIL 7MM/150 EX TI CANNULATED PROXIMAL EX/150MM","SUP-ITM-10031414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3347.40","80.4","","1365.00","1365.00","1365.00","1 through 10","2175.81","3402.35","percent of total billed charges",""
"HUMERAL NAIL 7MM/150 EX TI CANNULATED PROXIMAL EX/150MM","SUP-ITM-10031414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3402.35","81.72","","5157.68","5157.68","5157.68","1 through 10","2175.81","3402.35","percent of total billed charges",""
"HUMERAL NAIL 7MM/150 EX TI CANNULATED PROXIMAL EX/150MM","SUP-ITM-10031414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3402.35","81.72","","431.26","71.26","1459.57","88","2175.81","3402.35","percent of total billed charges",""
"HUMERAL NAIL 8.5MM/240 TI CANNULATED MULTILOC LEFT","SUP-ITM-10125459","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.87","3344.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3544.80","79.5","","800.18","480.96","1887.97","195","1382.25","3544.8","percent of total billed charges",""
"HUMERAL NAIL 8.5MM/240 TI CANNULATED MULTILOC LEFT","SUP-ITM-10125459","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.87","3344.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2376.58","53.3","","813.12","216.42","1444.50","81","1382.25","3544.8","percent of total billed charges",""
"HUMERAL NAIL 8.5MM/240 TI CANNULATED MULTILOC LEFT","SUP-ITM-10125459","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.87","3344.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1382.25","31","","432.60","432.60","432.60","1 through 10","1382.25","3544.8","percent of total billed charges",""
"HUMERAL NAIL 8.5MM/240 TI CANNULATED MULTILOC LEFT","SUP-ITM-10125459","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.87","3344.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1627.49","36.5","","148.37","54.89","631.39","94","1382.25","3544.8","percent of total billed charges",""
"HUMERAL NAIL 8.5MM/240 TI CANNULATED MULTILOC LEFT","SUP-ITM-10125459","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.87","3344.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1707.75","38.3","","279.30","91.72","1116.77","266","1382.25","3544.8","percent of total billed charges",""
"HUMERAL NAIL 8.5MM/240 TI CANNULATED MULTILOC LEFT","SUP-ITM-10125459","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.87","3344.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1912.86","42.9","","731.00","63.70","731.00","1 through 10","1382.25","3544.8","percent of total billed charges",""
"HUMERAL NAIL 8.5MM/240 TI CANNULATED MULTILOC LEFT","SUP-ITM-10125459","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.87","3344.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1912.86","42.9","","384.74","384.74","384.74","1 through 10","1382.25","3544.8","percent of total billed charges",""
"HUMERAL NAIL 8.5MM/240 TI CANNULATED MULTILOC LEFT","SUP-ITM-10125459","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.87","3344.15","WELLPOINT [1015]","HB AMC WELLPOINT","3289.75","73.78","","286.63","119.22","1107.45","105","1382.25","3544.8","percent of total billed charges",""
"HUMERAL NAIL 8.5MM/240 TI CANNULATED MULTILOC LEFT","SUP-ITM-10125459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4458.87","3344.15","AETNA [1001]","HB AMC AETNA HMO","3112.29","69.8","","675.31","184.75","1721.50","286","2330.21","3643.79","percent of total billed charges",""
"HUMERAL NAIL 8.5MM/240 TI CANNULATED MULTILOC LEFT","SUP-ITM-10125459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4458.87","3344.15","AETNA [1001]","HB AMC AETNA PPO","3584.93","80.4","","1261.44","103.12","1514.10","21","2330.21","3643.79","percent of total billed charges",""
"HUMERAL NAIL 8.5MM/240 TI CANNULATED MULTILOC LEFT","SUP-ITM-10125459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4458.87","3344.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3584.93","80.4","","1365.00","1365.00","1365.00","1 through 10","2330.21","3643.79","percent of total billed charges",""
"HUMERAL NAIL 8.5MM/240 TI CANNULATED MULTILOC LEFT","SUP-ITM-10125459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4458.87","3344.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3643.79","81.72","","5157.68","5157.68","5157.68","1 through 10","2330.21","3643.79","percent of total billed charges",""
"HUMERAL NAIL 8.5MM/240 TI CANNULATED MULTILOC LEFT","SUP-ITM-10125459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4458.87","3344.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3643.79","81.72","","431.26","71.26","1459.57","88","2330.21","3643.79","percent of total billed charges",""
"HUMERAL NAIL 9.5MM/160 TI CANNULATED ROUND CROSS SECTION MULTILOC LEFT","SUP-ITM-10097305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3401.84","79.5","","800.18","480.96","1887.97","195","1326.51","3401.84","percent of total billed charges",""
"HUMERAL NAIL 9.5MM/160 TI CANNULATED ROUND CROSS SECTION MULTILOC LEFT","SUP-ITM-10097305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2280.73","53.3","","813.12","216.42","1444.50","81","1326.51","3401.84","percent of total billed charges",""
"HUMERAL NAIL 9.5MM/160 TI CANNULATED ROUND CROSS SECTION MULTILOC LEFT","SUP-ITM-10097305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1326.51","31","","432.60","432.60","432.60","1 through 10","1326.51","3401.84","percent of total billed charges",""
"HUMERAL NAIL 9.5MM/160 TI CANNULATED ROUND CROSS SECTION MULTILOC LEFT","SUP-ITM-10097305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1561.85","36.5","","148.37","54.89","631.39","94","1326.51","3401.84","percent of total billed charges",""
"HUMERAL NAIL 9.5MM/160 TI CANNULATED ROUND CROSS SECTION MULTILOC LEFT","SUP-ITM-10097305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1638.88","38.3","","279.30","91.72","1116.77","266","1326.51","3401.84","percent of total billed charges",""
"HUMERAL NAIL 9.5MM/160 TI CANNULATED ROUND CROSS SECTION MULTILOC LEFT","SUP-ITM-10097305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1835.71","42.9","","731.00","63.70","731.00","1 through 10","1326.51","3401.84","percent of total billed charges",""
"HUMERAL NAIL 9.5MM/160 TI CANNULATED ROUND CROSS SECTION MULTILOC LEFT","SUP-ITM-10097305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1835.71","42.9","","384.74","384.74","384.74","1 through 10","1326.51","3401.84","percent of total billed charges",""
"HUMERAL NAIL 9.5MM/160 TI CANNULATED ROUND CROSS SECTION MULTILOC LEFT","SUP-ITM-10097305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4279.05","3209.29","WELLPOINT [1015]","HB AMC WELLPOINT","3157.08","73.78","","286.63","119.22","1107.45","105","1326.51","3401.84","percent of total billed charges",""
"HUMERAL NAIL 9.5MM/160 TI CANNULATED ROUND CROSS SECTION MULTILOC LEFT","SUP-ITM-10097305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4279.05","3209.29","AETNA [1001]","HB AMC AETNA HMO","2986.78","69.8","","675.31","184.75","1721.50","286","2236.23","3496.84","percent of total billed charges",""
"HUMERAL NAIL 9.5MM/160 TI CANNULATED ROUND CROSS SECTION MULTILOC LEFT","SUP-ITM-10097305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4279.05","3209.29","AETNA [1001]","HB AMC AETNA PPO","3440.36","80.4","","1261.44","103.12","1514.10","21","2236.23","3496.84","percent of total billed charges",""
"HUMERAL NAIL 9.5MM/160 TI CANNULATED ROUND CROSS SECTION MULTILOC LEFT","SUP-ITM-10097305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4279.05","3209.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3440.36","80.4","","1365.00","1365.00","1365.00","1 through 10","2236.23","3496.84","percent of total billed charges",""
"HUMERAL NAIL 9.5MM/160 TI CANNULATED ROUND CROSS SECTION MULTILOC LEFT","SUP-ITM-10097305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4279.05","3209.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3496.84","81.72","","5157.68","5157.68","5157.68","1 through 10","2236.23","3496.84","percent of total billed charges",""
"HUMERAL NAIL 9.5MM/160 TI CANNULATED ROUND CROSS SECTION MULTILOC LEFT","SUP-ITM-10097305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4279.05","3209.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3496.84","81.72","","431.26","71.26","1459.57","88","2236.23","3496.84","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1085","2782.5","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1085","2782.5","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1023.42","771.29","2068.67","33","1085","2782.5","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","850.52","759.78","1211.25","66","1085","2782.5","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1085","2782.5","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","956.46","956.46","956.46","1 through 10","1085","2782.5","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2344.73","1619.47","2530.35","16","1085","2782.5","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1523.63","988.41","4330.26","39","1829.1","2860.2","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1829.1","2860.2","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1829.1","2860.2","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","1738.90","1484.65","2716.94","38","1829.1","2860.2","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2857.93","2143.45","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1493.55","52.26","","1113.10","1113.10","1113.10","1 through 10","885.96","2272.05","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2857.93","2143.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2272.05","79.5","","1293.60","1148.53","1603.80","1 through 10","885.96","2272.05","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2857.93","2143.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1043.14","36.5","","1023.42","771.29","2068.67","33","885.96","2272.05","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2857.93","2143.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1094.59","38.3","","850.52","759.78","1211.25","66","885.96","2272.05","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2857.93","2143.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1226.05","42.9","","2548.09","2548.09","2548.09","1 through 10","885.96","2272.05","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2857.93","2143.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1226.05","42.9","","956.46","956.46","956.46","1 through 10","885.96","2272.05","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2857.93","2143.45","WELLPOINT [1015]","HB AMC WELLPOINT","2108.58","73.78","","2344.73","1619.47","2530.35","16","885.96","2272.05","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2857.93","2143.45","AETNA [1001]","HB AMC AETNA HMO","1994.84","69.8","","1523.63","988.41","4330.26","39","1493.55","2335.5","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2857.93","2143.45","AETNA [1001]","HB AMC AETNA PPO","2297.78","80.4","","1670.25","1670.25","1670.25","1 through 10","1493.55","2335.5","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2857.93","2143.45","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1493.55","52.26","","1113.10","1113.10","1113.10","1 through 10","1493.55","2335.5","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2857.93","2143.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2335.50","81.72","","1738.90","1484.65","2716.94","38","1493.55","2335.5","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1671.80","52.26","","1113.10","1113.10","1113.10","1 through 10","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2543.21","79.5","","1293.60","1148.53","1603.80","1 through 10","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1167.64","36.5","","1023.42","771.29","2068.67","33","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1225.22","38.3","","850.52","759.78","1211.25","66","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1372.37","42.9","","2548.09","2548.09","2548.09","1 through 10","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1372.37","42.9","","956.46","956.46","956.46","1 through 10","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","WELLPOINT [1015]","HB AMC WELLPOINT","2360.22","73.78","","2344.73","1619.47","2530.35","16","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3199.00","2399.25","AETNA [1001]","HB AMC AETNA HMO","2232.90","69.8","","1523.63","988.41","4330.26","39","1671.8","2614.22","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3199.00","2399.25","AETNA [1001]","HB AMC AETNA PPO","2572.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1671.8","2614.22","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3199.00","2399.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1671.80","52.26","","1113.10","1113.10","1113.10","1 through 10","1671.8","2614.22","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3199.00","2399.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2614.22","81.72","","1738.90","1484.65","2716.94","38","1671.8","2614.22","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","5304.00","3978.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2771.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1644.24","4216.68","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","5304.00","3978.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4216.68","79.5","","1293.60","1148.53","1603.80","1 through 10","1644.24","4216.68","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","5304.00","3978.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1935.96","36.5","","1023.42","771.29","2068.67","33","1644.24","4216.68","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","5304.00","3978.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2031.43","38.3","","850.52","759.78","1211.25","66","1644.24","4216.68","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","5304.00","3978.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2275.42","42.9","","2548.09","2548.09","2548.09","1 through 10","1644.24","4216.68","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","5304.00","3978.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2275.42","42.9","","956.46","956.46","956.46","1 through 10","1644.24","4216.68","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","5304.00","3978.00","WELLPOINT [1015]","HB AMC WELLPOINT","3913.29","73.78","","2344.73","1619.47","2530.35","16","1644.24","4216.68","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5304.00","3978.00","AETNA [1001]","HB AMC AETNA HMO","3702.19","69.8","","1523.63","988.41","4330.26","39","2771.87","4334.43","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5304.00","3978.00","AETNA [1001]","HB AMC AETNA PPO","4264.42","80.4","","1670.25","1670.25","1670.25","1 through 10","2771.87","4334.43","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5304.00","3978.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2771.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2771.87","4334.43","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5304.00","3978.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4334.43","81.72","","1738.90","1484.65","2716.94","38","2771.87","4334.43","percent of total billed charges",""
"HUMERAL STEM 10X122MM COMPREHENSIVE STANDARD REVERSE","SUP-ITM-10091555","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3374.69","52.26","","1113.10","1113.10","1113.10","1 through 10","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 10X122MM COMPREHENSIVE STANDARD REVERSE","SUP-ITM-10091555","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5133.71","79.5","","1293.60","1148.53","1603.80","1 through 10","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 10X122MM COMPREHENSIVE STANDARD REVERSE","SUP-ITM-10091555","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2356.99","36.5","","1023.42","771.29","2068.67","33","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 10X122MM COMPREHENSIVE STANDARD REVERSE","SUP-ITM-10091555","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2473.22","38.3","","850.52","759.78","1211.25","66","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 10X122MM COMPREHENSIVE STANDARD REVERSE","SUP-ITM-10091555","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2770.27","42.9","","2548.09","2548.09","2548.09","1 through 10","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 10X122MM COMPREHENSIVE STANDARD REVERSE","SUP-ITM-10091555","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2770.27","42.9","","956.46","956.46","956.46","1 through 10","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 10X122MM COMPREHENSIVE STANDARD REVERSE","SUP-ITM-10091555","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","WELLPOINT [1015]","HB AMC WELLPOINT","4764.34","73.78","","2344.73","1619.47","2530.35","16","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 10X122MM COMPREHENSIVE STANDARD REVERSE","SUP-ITM-10091555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6457.50","4843.12","AETNA [1001]","HB AMC AETNA HMO","4507.34","69.8","","1523.63","988.41","4330.26","39","3374.69","5277.07","percent of total billed charges",""
"HUMERAL STEM 10X122MM COMPREHENSIVE STANDARD REVERSE","SUP-ITM-10091555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6457.50","4843.12","AETNA [1001]","HB AMC AETNA PPO","5191.83","80.4","","1670.25","1670.25","1670.25","1 through 10","3374.69","5277.07","percent of total billed charges",""
"HUMERAL STEM 10X122MM COMPREHENSIVE STANDARD REVERSE","SUP-ITM-10091555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6457.50","4843.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3374.69","52.26","","1113.10","1113.10","1113.10","1 through 10","3374.69","5277.07","percent of total billed charges",""
"HUMERAL STEM 10X122MM COMPREHENSIVE STANDARD REVERSE","SUP-ITM-10091555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6457.50","4843.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5277.07","81.72","","1738.90","1484.65","2716.94","38","3374.69","5277.07","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2721.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4140.36","79.5","","1293.60","1148.53","1603.80","1 through 10","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1900.92","36.5","","1023.42","771.29","2068.67","33","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1994.66","38.3","","850.52","759.78","1211.25","66","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2234.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2234.23","42.9","","956.46","956.46","956.46","1 through 10","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","WELLPOINT [1015]","HB AMC WELLPOINT","3842.46","73.78","","2344.73","1619.47","2530.35","16","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.00","3906.00","AETNA [1001]","HB AMC AETNA HMO","3635.18","69.8","","1523.63","988.41","4330.26","39","2721.7","4255.98","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.00","3906.00","AETNA [1001]","HB AMC AETNA PPO","4187.23","80.4","","1670.25","1670.25","1670.25","1 through 10","2721.7","4255.98","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.00","3906.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2721.70","52.26","","1113.10","1113.10","1113.10","1 through 10","2721.7","4255.98","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.00","3906.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4255.98","81.72","","1738.90","1484.65","2716.94","38","2721.7","4255.98","percent of total billed charges",""
"HUMERAL STEM 10X135MM SHOULDER GLOBAL ADVANTAGE TITANIUM STANDARD","SUP-ITM-10016535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2544.54","52.26","","1113.10","1113.10","1113.10","1 through 10","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 10X135MM SHOULDER GLOBAL ADVANTAGE TITANIUM STANDARD","SUP-ITM-10016535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3870.86","79.5","","1293.60","1148.53","1603.80","1 through 10","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 10X135MM SHOULDER GLOBAL ADVANTAGE TITANIUM STANDARD","SUP-ITM-10016535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1777.19","36.5","","1023.42","771.29","2068.67","33","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 10X135MM SHOULDER GLOBAL ADVANTAGE TITANIUM STANDARD","SUP-ITM-10016535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1864.83","38.3","","850.52","759.78","1211.25","66","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 10X135MM SHOULDER GLOBAL ADVANTAGE TITANIUM STANDARD","SUP-ITM-10016535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2088.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 10X135MM SHOULDER GLOBAL ADVANTAGE TITANIUM STANDARD","SUP-ITM-10016535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2088.80","42.9","","956.46","956.46","956.46","1 through 10","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 10X135MM SHOULDER GLOBAL ADVANTAGE TITANIUM STANDARD","SUP-ITM-10016535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","WELLPOINT [1015]","HB AMC WELLPOINT","3592.35","73.78","","2344.73","1619.47","2530.35","16","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 10X135MM SHOULDER GLOBAL ADVANTAGE TITANIUM STANDARD","SUP-ITM-10016535","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4869.00","3651.75","AETNA [1001]","HB AMC AETNA HMO","3398.56","69.8","","1523.63","988.41","4330.26","39","2544.54","3978.95","percent of total billed charges",""
"HUMERAL STEM 10X135MM SHOULDER GLOBAL ADVANTAGE TITANIUM STANDARD","SUP-ITM-10016535","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4869.00","3651.75","AETNA [1001]","HB AMC AETNA PPO","3914.68","80.4","","1670.25","1670.25","1670.25","1 through 10","2544.54","3978.95","percent of total billed charges",""
"HUMERAL STEM 10X135MM SHOULDER GLOBAL ADVANTAGE TITANIUM STANDARD","SUP-ITM-10016535","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4869.00","3651.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2544.54","52.26","","1113.10","1113.10","1113.10","1 through 10","2544.54","3978.95","percent of total billed charges",""
"HUMERAL STEM 10X135MM SHOULDER GLOBAL ADVANTAGE TITANIUM STANDARD","SUP-ITM-10016535","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4869.00","3651.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3978.95","81.72","","1738.90","1484.65","2716.94","38","2544.54","3978.95","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2216.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3372.39","79.5","","1293.60","1148.53","1603.80","1 through 10","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1548.33","36.5","","1023.42","771.29","2068.67","33","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1624.69","38.3","","850.52","759.78","1211.25","66","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1819.82","42.9","","2548.09","2548.09","2548.09","1 through 10","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1819.82","42.9","","956.46","956.46","956.46","1 through 10","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","WELLPOINT [1015]","HB AMC WELLPOINT","3129.75","73.78","","2344.73","1619.47","2530.35","16","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","AETNA [1001]","HB AMC AETNA HMO","2960.92","69.8","","1523.63","988.41","4330.26","39","2216.87","3466.56","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","AETNA [1001]","HB AMC AETNA PPO","3410.57","80.4","","1670.25","1670.25","1670.25","1 through 10","2216.87","3466.56","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2216.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2216.87","3466.56","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3466.56","81.72","","1738.90","1484.65","2716.94","38","2216.87","3466.56","percent of total billed charges",""
"HUMERAL STEM 11MM PRIMARY COMPR STD REVERSE 01","SUP-ITM-10113683","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3374.69","52.26","","1113.10","1113.10","1113.10","1 through 10","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 11MM PRIMARY COMPR STD REVERSE 01","SUP-ITM-10113683","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5133.71","79.5","","1293.60","1148.53","1603.80","1 through 10","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 11MM PRIMARY COMPR STD REVERSE 01","SUP-ITM-10113683","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2356.99","36.5","","1023.42","771.29","2068.67","33","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 11MM PRIMARY COMPR STD REVERSE 01","SUP-ITM-10113683","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2473.22","38.3","","850.52","759.78","1211.25","66","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 11MM PRIMARY COMPR STD REVERSE 01","SUP-ITM-10113683","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2770.27","42.9","","2548.09","2548.09","2548.09","1 through 10","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 11MM PRIMARY COMPR STD REVERSE 01","SUP-ITM-10113683","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2770.27","42.9","","956.46","956.46","956.46","1 through 10","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 11MM PRIMARY COMPR STD REVERSE 01","SUP-ITM-10113683","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","WELLPOINT [1015]","HB AMC WELLPOINT","4764.34","73.78","","2344.73","1619.47","2530.35","16","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 11MM PRIMARY COMPR STD REVERSE 01","SUP-ITM-10113683","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6457.50","4843.12","AETNA [1001]","HB AMC AETNA HMO","4507.34","69.8","","1523.63","988.41","4330.26","39","3374.69","5277.07","percent of total billed charges",""
"HUMERAL STEM 11MM PRIMARY COMPR STD REVERSE 01","SUP-ITM-10113683","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6457.50","4843.12","AETNA [1001]","HB AMC AETNA PPO","5191.83","80.4","","1670.25","1670.25","1670.25","1 through 10","3374.69","5277.07","percent of total billed charges",""
"HUMERAL STEM 11MM PRIMARY COMPR STD REVERSE 01","SUP-ITM-10113683","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6457.50","4843.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3374.69","52.26","","1113.10","1113.10","1113.10","1 through 10","3374.69","5277.07","percent of total billed charges",""
"HUMERAL STEM 11MM PRIMARY COMPR STD REVERSE 01","SUP-ITM-10113683","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6457.50","4843.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5277.07","81.72","","1738.90","1484.65","2716.94","38","3374.69","5277.07","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2748.88","52.26","","1113.10","1113.10","1113.10","1 through 10","1630.6","4181.7","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4181.70","79.5","","1293.60","1148.53","1603.80","1 through 10","1630.6","4181.7","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1919.90","36.5","","1023.42","771.29","2068.67","33","1630.6","4181.7","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2014.58","38.3","","850.52","759.78","1211.25","66","1630.6","4181.7","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2256.54","42.9","","2548.09","2548.09","2548.09","1 through 10","1630.6","4181.7","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2256.54","42.9","","956.46","956.46","956.46","1 through 10","1630.6","4181.7","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","WELLPOINT [1015]","HB AMC WELLPOINT","3880.83","73.78","","2344.73","1619.47","2530.35","16","1630.6","4181.7","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5260.00","3945.00","AETNA [1001]","HB AMC AETNA HMO","3671.48","69.8","","1523.63","988.41","4330.26","39","2748.88","4298.47","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5260.00","3945.00","AETNA [1001]","HB AMC AETNA PPO","4229.04","80.4","","1670.25","1670.25","1670.25","1 through 10","2748.88","4298.47","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5260.00","3945.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2748.88","52.26","","1113.10","1113.10","1113.10","1 through 10","2748.88","4298.47","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5260.00","3945.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4298.47","81.72","","1738.90","1484.65","2716.94","38","2748.88","4298.47","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2613.00","52.26","","1113.10","1113.10","1113.10","1 through 10","1550","3975","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1550","3975","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","1023.42","771.29","2068.67","33","1550","3975","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","850.52","759.78","1211.25","66","1550","3975","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","2548.09","2548.09","2548.09","1 through 10","1550","3975","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","956.46","956.46","956.46","1 through 10","1550","3975","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","2344.73","1619.47","2530.35","16","1550","3975","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","1523.63","988.41","4330.26","39","2613","4086","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA PPO","4020.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2613","4086","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2613.00","52.26","","1113.10","1113.10","1113.10","1 through 10","2613","4086","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","1738.90","1484.65","2716.94","38","2613","4086","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","6826.66","52.26","","1113.10","1113.10","1113.10","1 through 10","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10384.99","79.5","","1293.60","1148.53","1603.80","1 through 10","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4767.95","36.5","","1023.42","771.29","2068.67","33","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5003.08","38.3","","850.52","759.78","1211.25","66","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5603.98","42.9","","2548.09","2548.09","2548.09","1 through 10","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5603.98","42.9","","956.46","956.46","956.46","1 through 10","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","WELLPOINT [1015]","HB AMC WELLPOINT","9637.79","73.78","","2344.73","1619.47","2530.35","16","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13062.88","9797.16","AETNA [1001]","HB AMC AETNA HMO","9117.89","69.8","","1523.63","988.41","4330.26","39","6826.66","10674.99","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13062.88","9797.16","AETNA [1001]","HB AMC AETNA PPO","10502.56","80.4","","1670.25","1670.25","1670.25","1 through 10","6826.66","10674.99","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13062.88","9797.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","6826.66","52.26","","1113.10","1113.10","1113.10","1 through 10","6826.66","10674.99","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13062.88","9797.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10674.99","81.72","","1738.90","1484.65","2716.94","38","6826.66","10674.99","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2216.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3372.39","79.5","","1293.60","1148.53","1603.80","1 through 10","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1548.33","36.5","","1023.42","771.29","2068.67","33","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1624.69","38.3","","850.52","759.78","1211.25","66","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1819.82","42.9","","2548.09","2548.09","2548.09","1 through 10","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1819.82","42.9","","956.46","956.46","956.46","1 through 10","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","WELLPOINT [1015]","HB AMC WELLPOINT","3129.75","73.78","","2344.73","1619.47","2530.35","16","1315.02","3372.39","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","AETNA [1001]","HB AMC AETNA HMO","2960.92","69.8","","1523.63","988.41","4330.26","39","2216.87","3466.56","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","AETNA [1001]","HB AMC AETNA PPO","3410.57","80.4","","1670.25","1670.25","1670.25","1 through 10","2216.87","3466.56","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2216.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2216.87","3466.56","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3466.56","81.72","","1738.90","1484.65","2716.94","38","2216.87","3466.56","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1671.80","52.26","","1113.10","1113.10","1113.10","1 through 10","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2543.21","79.5","","1293.60","1148.53","1603.80","1 through 10","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1167.64","36.5","","1023.42","771.29","2068.67","33","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1225.22","38.3","","850.52","759.78","1211.25","66","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1372.37","42.9","","2548.09","2548.09","2548.09","1 through 10","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1372.37","42.9","","956.46","956.46","956.46","1 through 10","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","WELLPOINT [1015]","HB AMC WELLPOINT","2360.22","73.78","","2344.73","1619.47","2530.35","16","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3199.00","2399.25","AETNA [1001]","HB AMC AETNA HMO","2232.90","69.8","","1523.63","988.41","4330.26","39","1671.8","2614.22","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3199.00","2399.25","AETNA [1001]","HB AMC AETNA PPO","2572.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1671.8","2614.22","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3199.00","2399.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1671.80","52.26","","1113.10","1113.10","1113.10","1 through 10","1671.8","2614.22","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3199.00","2399.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2614.22","81.72","","1738.90","1484.65","2716.94","38","1671.8","2614.22","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9004.87","79.5","","800.18","480.96","1887.97","195","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6037.23","53.3","","813.12","216.42","1444.50","81","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3511.33","31","","432.60","432.60","432.60","1 through 10","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4134.31","36.5","","148.37","54.89","631.39","94","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4338.20","38.3","","279.30","91.72","1116.77","266","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4859.23","42.9","","731.00","63.70","731.00","1 through 10","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4859.23","42.9","","384.74","384.74","384.74","1 through 10","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","WELLPOINT [1015]","HB AMC WELLPOINT","8356.97","73.78","","286.63","119.22","1107.45","105","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11326.88","8495.16","AETNA [1001]","HB AMC AETNA HMO","7906.16","69.8","","675.31","184.75","1721.50","286","5919.43","9256.33","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11326.88","8495.16","AETNA [1001]","HB AMC AETNA PPO","9106.81","80.4","","1261.44","103.12","1514.10","21","5919.43","9256.33","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11326.88","8495.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9106.81","80.4","","1365.00","1365.00","1365.00","1 through 10","5919.43","9256.33","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11326.88","8495.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","9256.33","81.72","","5157.68","5157.68","5157.68","1 through 10","5919.43","9256.33","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11326.88","8495.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9256.33","81.72","","431.26","71.26","1459.57","88","5919.43","9256.33","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2445.77","52.26","","1113.10","1113.10","1113.10","1 through 10","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3720.60","79.5","","1293.60","1148.53","1603.80","1 through 10","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1708.20","36.5","","1023.42","771.29","2068.67","33","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1792.44","38.3","","850.52","759.78","1211.25","66","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2007.72","42.9","","2548.09","2548.09","2548.09","1 through 10","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2007.72","42.9","","956.46","956.46","956.46","1 through 10","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","WELLPOINT [1015]","HB AMC WELLPOINT","3452.90","73.78","","2344.73","1619.47","2530.35","16","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4680.00","3510.00","AETNA [1001]","HB AMC AETNA HMO","3266.64","69.8","","1523.63","988.41","4330.26","39","2445.77","3824.5","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4680.00","3510.00","AETNA [1001]","HB AMC AETNA PPO","3762.72","80.4","","1670.25","1670.25","1670.25","1 through 10","2445.77","3824.5","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4680.00","3510.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2445.77","52.26","","1113.10","1113.10","1113.10","1 through 10","2445.77","3824.5","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4680.00","3510.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3824.50","81.72","","1738.90","1484.65","2716.94","38","2445.77","3824.5","percent of total billed charges",""
"HUMERAL STEM 12X190MM GLOBAL UNITE REVISION POROCOAT REVERSE","SUP-ITM-10151407","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3946.74","52.26","","1113.10","1113.10","1113.10","1 through 10","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 12X190MM GLOBAL UNITE REVISION POROCOAT REVERSE","SUP-ITM-10151407","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6003.94","79.5","","1293.60","1148.53","1603.80","1 through 10","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 12X190MM GLOBAL UNITE REVISION POROCOAT REVERSE","SUP-ITM-10151407","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2756.53","36.5","","1023.42","771.29","2068.67","33","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 12X190MM GLOBAL UNITE REVISION POROCOAT REVERSE","SUP-ITM-10151407","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2892.47","38.3","","850.52","759.78","1211.25","66","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 12X190MM GLOBAL UNITE REVISION POROCOAT REVERSE","SUP-ITM-10151407","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3239.86","42.9","","2548.09","2548.09","2548.09","1 through 10","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 12X190MM GLOBAL UNITE REVISION POROCOAT REVERSE","SUP-ITM-10151407","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3239.86","42.9","","956.46","956.46","956.46","1 through 10","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 12X190MM GLOBAL UNITE REVISION POROCOAT REVERSE","SUP-ITM-10151407","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","WELLPOINT [1015]","HB AMC WELLPOINT","5571.96","73.78","","2344.73","1619.47","2530.35","16","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 12X190MM GLOBAL UNITE REVISION POROCOAT REVERSE","SUP-ITM-10151407","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7552.13","5664.10","AETNA [1001]","HB AMC AETNA HMO","5271.39","69.8","","1523.63","988.41","4330.26","39","3946.74","6171.6","percent of total billed charges",""
"HUMERAL STEM 12X190MM GLOBAL UNITE REVISION POROCOAT REVERSE","SUP-ITM-10151407","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7552.13","5664.10","AETNA [1001]","HB AMC AETNA PPO","6071.91","80.4","","1670.25","1670.25","1670.25","1 through 10","3946.74","6171.6","percent of total billed charges",""
"HUMERAL STEM 12X190MM GLOBAL UNITE REVISION POROCOAT REVERSE","SUP-ITM-10151407","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7552.13","5664.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3946.74","52.26","","1113.10","1113.10","1113.10","1 through 10","3946.74","6171.6","percent of total billed charges",""
"HUMERAL STEM 12X190MM GLOBAL UNITE REVISION POROCOAT REVERSE","SUP-ITM-10151407","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7552.13","5664.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6171.60","81.72","","1738.90","1484.65","2716.94","38","3946.74","6171.6","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2544.54","52.26","","1113.10","1113.10","1113.10","1 through 10","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3870.86","79.5","","1293.60","1148.53","1603.80","1 through 10","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1777.19","36.5","","1023.42","771.29","2068.67","33","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1864.83","38.3","","850.52","759.78","1211.25","66","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2088.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2088.80","42.9","","956.46","956.46","956.46","1 through 10","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","WELLPOINT [1015]","HB AMC WELLPOINT","3592.35","73.78","","2344.73","1619.47","2530.35","16","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4869.00","3651.75","AETNA [1001]","HB AMC AETNA HMO","3398.56","69.8","","1523.63","988.41","4330.26","39","2544.54","3978.95","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4869.00","3651.75","AETNA [1001]","HB AMC AETNA PPO","3914.68","80.4","","1670.25","1670.25","1670.25","1 through 10","2544.54","3978.95","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4869.00","3651.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2544.54","52.26","","1113.10","1113.10","1113.10","1 through 10","2544.54","3978.95","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4869.00","3651.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3978.95","81.72","","1738.90","1484.65","2716.94","38","2544.54","3978.95","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 12 GLOBAL PC AP","SUP-ITM-10147057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2544.54","52.26","","1113.10","1113.10","1113.10","1 through 10","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 12 GLOBAL PC AP","SUP-ITM-10147057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3870.86","79.5","","1293.60","1148.53","1603.80","1 through 10","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 12 GLOBAL PC AP","SUP-ITM-10147057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1777.19","36.5","","1023.42","771.29","2068.67","33","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 12 GLOBAL PC AP","SUP-ITM-10147057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1864.83","38.3","","850.52","759.78","1211.25","66","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 12 GLOBAL PC AP","SUP-ITM-10147057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2088.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 12 GLOBAL PC AP","SUP-ITM-10147057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2088.80","42.9","","956.46","956.46","956.46","1 through 10","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 12 GLOBAL PC AP","SUP-ITM-10147057","CDM","C1776","HCPCS","0278","RC","","","","both","","","4869.00","3651.75","WELLPOINT [1015]","HB AMC WELLPOINT","3592.35","73.78","","2344.73","1619.47","2530.35","16","1509.39","3870.86","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 12 GLOBAL PC AP","SUP-ITM-10147057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4869.00","3651.75","AETNA [1001]","HB AMC AETNA HMO","3398.56","69.8","","1523.63","988.41","4330.26","39","2544.54","3978.95","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 12 GLOBAL PC AP","SUP-ITM-10147057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4869.00","3651.75","AETNA [1001]","HB AMC AETNA PPO","3914.68","80.4","","1670.25","1670.25","1670.25","1 through 10","2544.54","3978.95","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 12 GLOBAL PC AP","SUP-ITM-10147057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4869.00","3651.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2544.54","52.26","","1113.10","1113.10","1113.10","1 through 10","2544.54","3978.95","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 12 GLOBAL PC AP","SUP-ITM-10147057","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4869.00","3651.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3978.95","81.72","","1738.90","1484.65","2716.94","38","2544.54","3978.95","percent of total billed charges",""
"HUMERAL STEM 14X98MM SHOULDER RENION PRESS-FIT","SUP-ITM-10289572","CDM","C1776","HCPCS","0278","RC","","","","both","","","8424.69","6318.52","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4402.74","52.26","","1113.10","1113.10","1113.10","1 through 10","2611.65","6697.63","percent of total billed charges",""
"HUMERAL STEM 14X98MM SHOULDER RENION PRESS-FIT","SUP-ITM-10289572","CDM","C1776","HCPCS","0278","RC","","","","both","","","8424.69","6318.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6697.63","79.5","","1293.60","1148.53","1603.80","1 through 10","2611.65","6697.63","percent of total billed charges",""
"HUMERAL STEM 14X98MM SHOULDER RENION PRESS-FIT","SUP-ITM-10289572","CDM","C1776","HCPCS","0278","RC","","","","both","","","8424.69","6318.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3075.01","36.5","","1023.42","771.29","2068.67","33","2611.65","6697.63","percent of total billed charges",""
"HUMERAL STEM 14X98MM SHOULDER RENION PRESS-FIT","SUP-ITM-10289572","CDM","C1776","HCPCS","0278","RC","","","","both","","","8424.69","6318.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3226.66","38.3","","850.52","759.78","1211.25","66","2611.65","6697.63","percent of total billed charges",""
"HUMERAL STEM 14X98MM SHOULDER RENION PRESS-FIT","SUP-ITM-10289572","CDM","C1776","HCPCS","0278","RC","","","","both","","","8424.69","6318.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3614.19","42.9","","2548.09","2548.09","2548.09","1 through 10","2611.65","6697.63","percent of total billed charges",""
"HUMERAL STEM 14X98MM SHOULDER RENION PRESS-FIT","SUP-ITM-10289572","CDM","C1776","HCPCS","0278","RC","","","","both","","","8424.69","6318.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3614.19","42.9","","956.46","956.46","956.46","1 through 10","2611.65","6697.63","percent of total billed charges",""
"HUMERAL STEM 14X98MM SHOULDER RENION PRESS-FIT","SUP-ITM-10289572","CDM","C1776","HCPCS","0278","RC","","","","both","","","8424.69","6318.52","WELLPOINT [1015]","HB AMC WELLPOINT","6215.74","73.78","","2344.73","1619.47","2530.35","16","2611.65","6697.63","percent of total billed charges",""
"HUMERAL STEM 14X98MM SHOULDER RENION PRESS-FIT","SUP-ITM-10289572","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8424.69","6318.52","AETNA [1001]","HB AMC AETNA HMO","5880.43","69.8","","1523.63","988.41","4330.26","39","4402.74","6884.66","percent of total billed charges",""
"HUMERAL STEM 14X98MM SHOULDER RENION PRESS-FIT","SUP-ITM-10289572","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8424.69","6318.52","AETNA [1001]","HB AMC AETNA PPO","6773.45","80.4","","1670.25","1670.25","1670.25","1 through 10","4402.74","6884.66","percent of total billed charges",""
"HUMERAL STEM 14X98MM SHOULDER RENION PRESS-FIT","SUP-ITM-10289572","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8424.69","6318.52","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4402.74","52.26","","1113.10","1113.10","1113.10","1 through 10","4402.74","6884.66","percent of total billed charges",""
"HUMERAL STEM 14X98MM SHOULDER RENION PRESS-FIT","SUP-ITM-10289572","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8424.69","6318.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6884.66","81.72","","1738.90","1484.65","2716.94","38","4402.74","6884.66","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2543.21","79.5","","800.18","480.96","1887.97","195","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1705.07","53.3","","813.12","216.42","1444.50","81","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","991.69","31","","432.60","432.60","432.60","1 through 10","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1167.64","36.5","","148.37","54.89","631.39","94","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1225.22","38.3","","279.30","91.72","1116.77","266","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1372.37","42.9","","731.00","63.70","731.00","1 through 10","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1372.37","42.9","","384.74","384.74","384.74","1 through 10","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","3199.00","2399.25","WELLPOINT [1015]","HB AMC WELLPOINT","2360.22","73.78","","286.63","119.22","1107.45","105","991.69","2543.21","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3199.00","2399.25","AETNA [1001]","HB AMC AETNA HMO","2232.90","69.8","","675.31","184.75","1721.50","286","1671.8","2614.22","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3199.00","2399.25","AETNA [1001]","HB AMC AETNA PPO","2572.00","80.4","","1261.44","103.12","1514.10","21","1671.8","2614.22","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3199.00","2399.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2572.00","80.4","","1365.00","1365.00","1365.00","1 through 10","1671.8","2614.22","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3199.00","2399.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2614.22","81.72","","5157.68","5157.68","5157.68","1 through 10","1671.8","2614.22","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3199.00","2399.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2614.22","81.72","","431.26","71.26","1459.57","88","1671.8","2614.22","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3374.69","52.26","","1113.10","1113.10","1113.10","1 through 10","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5133.71","79.5","","1293.60","1148.53","1603.80","1 through 10","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2356.99","36.5","","1023.42","771.29","2068.67","33","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2473.22","38.3","","850.52","759.78","1211.25","66","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2770.27","42.9","","2548.09","2548.09","2548.09","1 through 10","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2770.27","42.9","","956.46","956.46","956.46","1 through 10","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","both","","","6457.50","4843.12","WELLPOINT [1015]","HB AMC WELLPOINT","4764.34","73.78","","2344.73","1619.47","2530.35","16","2001.83","5133.71","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6457.50","4843.12","AETNA [1001]","HB AMC AETNA HMO","4507.34","69.8","","1523.63","988.41","4330.26","39","3374.69","5277.07","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6457.50","4843.12","AETNA [1001]","HB AMC AETNA PPO","5191.83","80.4","","1670.25","1670.25","1670.25","1 through 10","3374.69","5277.07","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6457.50","4843.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3374.69","52.26","","1113.10","1113.10","1113.10","1 through 10","3374.69","5277.07","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6457.50","4843.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5277.07","81.72","","1738.90","1484.65","2716.94","38","3374.69","5277.07","percent of total billed charges",""
"HUMERAL STEM 177MM SZ 8 GLOBAL UNITE REVISION","SUP-ITM-10170742","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3946.74","52.26","","1113.10","1113.10","1113.10","1 through 10","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 177MM SZ 8 GLOBAL UNITE REVISION","SUP-ITM-10170742","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6003.94","79.5","","1293.60","1148.53","1603.80","1 through 10","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 177MM SZ 8 GLOBAL UNITE REVISION","SUP-ITM-10170742","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2756.53","36.5","","1023.42","771.29","2068.67","33","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 177MM SZ 8 GLOBAL UNITE REVISION","SUP-ITM-10170742","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2892.47","38.3","","850.52","759.78","1211.25","66","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 177MM SZ 8 GLOBAL UNITE REVISION","SUP-ITM-10170742","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3239.86","42.9","","2548.09","2548.09","2548.09","1 through 10","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 177MM SZ 8 GLOBAL UNITE REVISION","SUP-ITM-10170742","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3239.86","42.9","","956.46","956.46","956.46","1 through 10","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 177MM SZ 8 GLOBAL UNITE REVISION","SUP-ITM-10170742","CDM","C1776","HCPCS","0278","RC","","","","both","","","7552.13","5664.10","WELLPOINT [1015]","HB AMC WELLPOINT","5571.96","73.78","","2344.73","1619.47","2530.35","16","2341.16","6003.94","percent of total billed charges",""
"HUMERAL STEM 177MM SZ 8 GLOBAL UNITE REVISION","SUP-ITM-10170742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7552.13","5664.10","AETNA [1001]","HB AMC AETNA HMO","5271.39","69.8","","1523.63","988.41","4330.26","39","3946.74","6171.6","percent of total billed charges",""
"HUMERAL STEM 177MM SZ 8 GLOBAL UNITE REVISION","SUP-ITM-10170742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7552.13","5664.10","AETNA [1001]","HB AMC AETNA PPO","6071.91","80.4","","1670.25","1670.25","1670.25","1 through 10","3946.74","6171.6","percent of total billed charges",""
"HUMERAL STEM 177MM SZ 8 GLOBAL UNITE REVISION","SUP-ITM-10170742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7552.13","5664.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3946.74","52.26","","1113.10","1113.10","1113.10","1 through 10","3946.74","6171.6","percent of total billed charges",""
"HUMERAL STEM 177MM SZ 8 GLOBAL UNITE REVISION","SUP-ITM-10170742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7552.13","5664.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6171.60","81.72","","1738.90","1484.65","2716.94","38","3946.74","6171.6","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","3297.00","2472.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1723.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1022.07","2621.12","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","3297.00","2472.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2621.12","79.5","","1293.60","1148.53","1603.80","1 through 10","1022.07","2621.12","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","3297.00","2472.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1203.41","36.5","","1023.42","771.29","2068.67","33","1022.07","2621.12","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","3297.00","2472.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1262.75","38.3","","850.52","759.78","1211.25","66","1022.07","2621.12","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","3297.00","2472.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1414.41","42.9","","2548.09","2548.09","2548.09","1 through 10","1022.07","2621.12","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","3297.00","2472.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1414.41","42.9","","956.46","956.46","956.46","1 through 10","1022.07","2621.12","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","3297.00","2472.75","WELLPOINT [1015]","HB AMC WELLPOINT","2432.53","73.78","","2344.73","1619.47","2530.35","16","1022.07","2621.12","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3297.00","2472.75","AETNA [1001]","HB AMC AETNA HMO","2301.31","69.8","","1523.63","988.41","4330.26","39","1723.01","2694.31","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3297.00","2472.75","AETNA [1001]","HB AMC AETNA PPO","2650.79","80.4","","1670.25","1670.25","1670.25","1 through 10","1723.01","2694.31","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3297.00","2472.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1723.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1723.01","2694.31","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3297.00","2472.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2694.31","81.72","","1738.90","1484.65","2716.94","38","1723.01","2694.31","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136188","CDM","C1776","HCPCS","0278","RC","","","","both","","","6865.00","5148.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3587.65","52.26","","1113.10","1113.10","1113.10","1 through 10","2128.15","5457.68","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136188","CDM","C1776","HCPCS","0278","RC","","","","both","","","6865.00","5148.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5457.68","79.5","","1293.60","1148.53","1603.80","1 through 10","2128.15","5457.68","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136188","CDM","C1776","HCPCS","0278","RC","","","","both","","","6865.00","5148.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2505.73","36.5","","1023.42","771.29","2068.67","33","2128.15","5457.68","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136188","CDM","C1776","HCPCS","0278","RC","","","","both","","","6865.00","5148.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2629.30","38.3","","850.52","759.78","1211.25","66","2128.15","5457.68","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136188","CDM","C1776","HCPCS","0278","RC","","","","both","","","6865.00","5148.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2945.09","42.9","","2548.09","2548.09","2548.09","1 through 10","2128.15","5457.68","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136188","CDM","C1776","HCPCS","0278","RC","","","","both","","","6865.00","5148.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2945.09","42.9","","956.46","956.46","956.46","1 through 10","2128.15","5457.68","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136188","CDM","C1776","HCPCS","0278","RC","","","","both","","","6865.00","5148.75","WELLPOINT [1015]","HB AMC WELLPOINT","5065.00","73.78","","2344.73","1619.47","2530.35","16","2128.15","5457.68","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6865.00","5148.75","AETNA [1001]","HB AMC AETNA HMO","4791.77","69.8","","1523.63","988.41","4330.26","39","3587.65","5610.08","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6865.00","5148.75","AETNA [1001]","HB AMC AETNA PPO","5519.46","80.4","","1670.25","1670.25","1670.25","1 through 10","3587.65","5610.08","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6865.00","5148.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3587.65","52.26","","1113.10","1113.10","1113.10","1 through 10","3587.65","5610.08","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6865.00","5148.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5610.08","81.72","","1738.90","1484.65","2716.94","38","3587.65","5610.08","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX150 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136189","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4530.94","52.26","","1113.10","1113.10","1113.10","1 through 10","2687.7","6892.65","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX150 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136189","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6892.65","79.5","","1293.60","1148.53","1603.80","1 through 10","2687.7","6892.65","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX150 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136189","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3164.55","36.5","","1023.42","771.29","2068.67","33","2687.7","6892.65","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX150 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136189","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3320.61","38.3","","850.52","759.78","1211.25","66","2687.7","6892.65","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX150 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136189","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3719.43","42.9","","2548.09","2548.09","2548.09","1 through 10","2687.7","6892.65","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX150 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136189","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3719.43","42.9","","956.46","956.46","956.46","1 through 10","2687.7","6892.65","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX150 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136189","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","WELLPOINT [1015]","HB AMC WELLPOINT","6396.73","73.78","","2344.73","1619.47","2530.35","16","2687.7","6892.65","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX150 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136189","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8670.00","6502.50","AETNA [1001]","HB AMC AETNA HMO","6051.66","69.8","","1523.63","988.41","4330.26","39","4530.94","7085.12","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX150 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136189","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8670.00","6502.50","AETNA [1001]","HB AMC AETNA PPO","6970.68","80.4","","1670.25","1670.25","1670.25","1 through 10","4530.94","7085.12","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX150 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136189","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8670.00","6502.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4530.94","52.26","","1113.10","1113.10","1113.10","1 through 10","4530.94","7085.12","percent of total billed charges",""
"HUMERAL STEM 6.5MM DIAMETERX150 AEQUALIS REVERSED LS CEMENTLESS","SUP-ITM-10136189","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8670.00","6502.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7085.12","81.72","","1738.90","1484.65","2716.94","38","4530.94","7085.12","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","6826.66","52.26","","1113.10","1113.10","1113.10","1 through 10","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10384.99","79.5","","1293.60","1148.53","1603.80","1 through 10","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4767.95","36.5","","1023.42","771.29","2068.67","33","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5003.08","38.3","","850.52","759.78","1211.25","66","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5603.98","42.9","","2548.09","2548.09","2548.09","1 through 10","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5603.98","42.9","","956.46","956.46","956.46","1 through 10","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","13062.88","9797.16","WELLPOINT [1015]","HB AMC WELLPOINT","9637.79","73.78","","2344.73","1619.47","2530.35","16","4049.49","10384.99","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13062.88","9797.16","AETNA [1001]","HB AMC AETNA HMO","9117.89","69.8","","1523.63","988.41","4330.26","39","6826.66","10674.99","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13062.88","9797.16","AETNA [1001]","HB AMC AETNA PPO","10502.56","80.4","","1670.25","1670.25","1670.25","1 through 10","6826.66","10674.99","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13062.88","9797.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","6826.66","52.26","","1113.10","1113.10","1113.10","1 through 10","6826.66","10674.99","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13062.88","9797.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10674.99","81.72","","1738.90","1484.65","2716.94","38","6826.66","10674.99","percent of total billed charges",""
"HUMERAL STEM 72MM SM LATITUDE EV STD RT","SUP-ITM-10298372","CDM","C1776","HCPCS","0278","RC","","","","both","","","11022.50","8266.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5760.36","52.26","","1113.10","1113.10","1113.10","1 through 10","3416.98","8762.89","percent of total billed charges",""
"HUMERAL STEM 72MM SM LATITUDE EV STD RT","SUP-ITM-10298372","CDM","C1776","HCPCS","0278","RC","","","","both","","","11022.50","8266.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8762.89","79.5","","1293.60","1148.53","1603.80","1 through 10","3416.98","8762.89","percent of total billed charges",""
"HUMERAL STEM 72MM SM LATITUDE EV STD RT","SUP-ITM-10298372","CDM","C1776","HCPCS","0278","RC","","","","both","","","11022.50","8266.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4023.21","36.5","","1023.42","771.29","2068.67","33","3416.98","8762.89","percent of total billed charges",""
"HUMERAL STEM 72MM SM LATITUDE EV STD RT","SUP-ITM-10298372","CDM","C1776","HCPCS","0278","RC","","","","both","","","11022.50","8266.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4221.62","38.3","","850.52","759.78","1211.25","66","3416.98","8762.89","percent of total billed charges",""
"HUMERAL STEM 72MM SM LATITUDE EV STD RT","SUP-ITM-10298372","CDM","C1776","HCPCS","0278","RC","","","","both","","","11022.50","8266.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4728.65","42.9","","2548.09","2548.09","2548.09","1 through 10","3416.98","8762.89","percent of total billed charges",""
"HUMERAL STEM 72MM SM LATITUDE EV STD RT","SUP-ITM-10298372","CDM","C1776","HCPCS","0278","RC","","","","both","","","11022.50","8266.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4728.65","42.9","","956.46","956.46","956.46","1 through 10","3416.98","8762.89","percent of total billed charges",""
"HUMERAL STEM 72MM SM LATITUDE EV STD RT","SUP-ITM-10298372","CDM","C1776","HCPCS","0278","RC","","","","both","","","11022.50","8266.87","WELLPOINT [1015]","HB AMC WELLPOINT","8132.40","73.78","","2344.73","1619.47","2530.35","16","3416.98","8762.89","percent of total billed charges",""
"HUMERAL STEM 72MM SM LATITUDE EV STD RT","SUP-ITM-10298372","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11022.50","8266.87","AETNA [1001]","HB AMC AETNA HMO","7693.71","69.8","","1523.63","988.41","4330.26","39","5760.36","9007.59","percent of total billed charges",""
"HUMERAL STEM 72MM SM LATITUDE EV STD RT","SUP-ITM-10298372","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11022.50","8266.87","AETNA [1001]","HB AMC AETNA PPO","8862.09","80.4","","1670.25","1670.25","1670.25","1 through 10","5760.36","9007.59","percent of total billed charges",""
"HUMERAL STEM 72MM SM LATITUDE EV STD RT","SUP-ITM-10298372","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11022.50","8266.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5760.36","52.26","","1113.10","1113.10","1113.10","1 through 10","5760.36","9007.59","percent of total billed charges",""
"HUMERAL STEM 72MM SM LATITUDE EV STD RT","SUP-ITM-10298372","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11022.50","8266.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9007.59","81.72","","1738.90","1484.65","2716.94","38","5760.36","9007.59","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3527.55","52.26","","1113.10","1113.10","1113.10","1 through 10","2092.5","5366.25","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5366.25","79.5","","1293.60","1148.53","1603.80","1 through 10","2092.5","5366.25","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2463.75","36.5","","1023.42","771.29","2068.67","33","2092.5","5366.25","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2585.25","38.3","","850.52","759.78","1211.25","66","2092.5","5366.25","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2895.75","42.9","","2548.09","2548.09","2548.09","1 through 10","2092.5","5366.25","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2895.75","42.9","","956.46","956.46","956.46","1 through 10","2092.5","5366.25","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","WELLPOINT [1015]","HB AMC WELLPOINT","4980.15","73.78","","2344.73","1619.47","2530.35","16","2092.5","5366.25","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","AETNA [1001]","HB AMC AETNA HMO","4711.50","69.8","","1523.63","988.41","4330.26","39","3527.55","5516.1","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","AETNA [1001]","HB AMC AETNA PPO","5427.00","80.4","","1670.25","1670.25","1670.25","1 through 10","3527.55","5516.1","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3527.55","52.26","","1113.10","1113.10","1113.10","1 through 10","3527.55","5516.1","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5516.10","81.72","","1738.90","1484.65","2716.94","38","3527.55","5516.1","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2721.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4140.36","79.5","","1293.60","1148.53","1603.80","1 through 10","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1900.92","36.5","","1023.42","771.29","2068.67","33","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1994.66","38.3","","850.52","759.78","1211.25","66","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2234.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2234.23","42.9","","956.46","956.46","956.46","1 through 10","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","WELLPOINT [1015]","HB AMC WELLPOINT","3842.46","73.78","","2344.73","1619.47","2530.35","16","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.00","3906.00","AETNA [1001]","HB AMC AETNA HMO","3635.18","69.8","","1523.63","988.41","4330.26","39","2721.7","4255.98","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.00","3906.00","AETNA [1001]","HB AMC AETNA PPO","4187.23","80.4","","1670.25","1670.25","1670.25","1 through 10","2721.7","4255.98","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.00","3906.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2721.70","52.26","","1113.10","1113.10","1113.10","1 through 10","2721.7","4255.98","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.00","3906.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4255.98","81.72","","1738.90","1484.65","2716.94","38","2721.7","4255.98","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5919.43","52.26","","1113.10","1113.10","1113.10","1 through 10","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9004.87","79.5","","1293.60","1148.53","1603.80","1 through 10","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4134.31","36.5","","1023.42","771.29","2068.67","33","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4338.20","38.3","","850.52","759.78","1211.25","66","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4859.23","42.9","","2548.09","2548.09","2548.09","1 through 10","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4859.23","42.9","","956.46","956.46","956.46","1 through 10","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","11326.88","8495.16","WELLPOINT [1015]","HB AMC WELLPOINT","8356.97","73.78","","2344.73","1619.47","2530.35","16","3511.33","9004.87","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11326.88","8495.16","AETNA [1001]","HB AMC AETNA HMO","7906.16","69.8","","1523.63","988.41","4330.26","39","5919.43","9256.33","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11326.88","8495.16","AETNA [1001]","HB AMC AETNA PPO","9106.81","80.4","","1670.25","1670.25","1670.25","1 through 10","5919.43","9256.33","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11326.88","8495.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5919.43","52.26","","1113.10","1113.10","1113.10","1 through 10","5919.43","9256.33","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11326.88","8495.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9256.33","81.72","","1738.90","1484.65","2716.94","38","5919.43","9256.33","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2721.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4140.36","79.5","","1293.60","1148.53","1603.80","1 through 10","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1900.92","36.5","","1023.42","771.29","2068.67","33","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1994.66","38.3","","850.52","759.78","1211.25","66","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2234.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2234.23","42.9","","956.46","956.46","956.46","1 through 10","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.00","3906.00","WELLPOINT [1015]","HB AMC WELLPOINT","3842.46","73.78","","2344.73","1619.47","2530.35","16","1614.48","4140.36","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.00","3906.00","AETNA [1001]","HB AMC AETNA HMO","3635.18","69.8","","1523.63","988.41","4330.26","39","2721.7","4255.98","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.00","3906.00","AETNA [1001]","HB AMC AETNA PPO","4187.23","80.4","","1670.25","1670.25","1670.25","1 through 10","2721.7","4255.98","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.00","3906.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2721.70","52.26","","1113.10","1113.10","1113.10","1 through 10","2721.7","4255.98","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.00","3906.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4255.98","81.72","","1738.90","1484.65","2716.94","38","2721.7","4255.98","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","11448.50","8586.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5982.99","52.26","","1113.10","1113.10","1113.10","1 through 10","3549.04","9101.56","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","11448.50","8586.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9101.56","79.5","","1293.60","1148.53","1603.80","1 through 10","3549.04","9101.56","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","11448.50","8586.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4178.70","36.5","","1023.42","771.29","2068.67","33","3549.04","9101.56","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","11448.50","8586.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4384.78","38.3","","850.52","759.78","1211.25","66","3549.04","9101.56","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","11448.50","8586.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4911.41","42.9","","2548.09","2548.09","2548.09","1 through 10","3549.04","9101.56","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","11448.50","8586.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4911.41","42.9","","956.46","956.46","956.46","1 through 10","3549.04","9101.56","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","11448.50","8586.37","WELLPOINT [1015]","HB AMC WELLPOINT","8446.70","73.78","","2344.73","1619.47","2530.35","16","3549.04","9101.56","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11448.50","8586.37","AETNA [1001]","HB AMC AETNA HMO","7991.05","69.8","","1523.63","988.41","4330.26","39","5982.99","9355.71","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11448.50","8586.37","AETNA [1001]","HB AMC AETNA PPO","9204.59","80.4","","1670.25","1670.25","1670.25","1 through 10","5982.99","9355.71","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11448.50","8586.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5982.99","52.26","","1113.10","1113.10","1113.10","1 through 10","5982.99","9355.71","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11448.50","8586.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9355.71","81.72","","1738.90","1484.65","2716.94","38","5982.99","9355.71","percent of total billed charges",""
"HUMERAL STEM 9MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017977","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2613.00","52.26","","1113.10","1113.10","1113.10","1 through 10","1550","3975","percent of total billed charges",""
"HUMERAL STEM 9MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017977","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1550","3975","percent of total billed charges",""
"HUMERAL STEM 9MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017977","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","1023.42","771.29","2068.67","33","1550","3975","percent of total billed charges",""
"HUMERAL STEM 9MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017977","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","850.52","759.78","1211.25","66","1550","3975","percent of total billed charges",""
"HUMERAL STEM 9MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017977","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","2548.09","2548.09","2548.09","1 through 10","1550","3975","percent of total billed charges",""
"HUMERAL STEM 9MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017977","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","956.46","956.46","956.46","1 through 10","1550","3975","percent of total billed charges",""
"HUMERAL STEM 9MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017977","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","2344.73","1619.47","2530.35","16","1550","3975","percent of total billed charges",""
"HUMERAL STEM 9MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017977","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","1523.63","988.41","4330.26","39","2613","4086","percent of total billed charges",""
"HUMERAL STEM 9MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017977","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA PPO","4020.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2613","4086","percent of total billed charges",""
"HUMERAL STEM 9MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017977","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2613.00","52.26","","1113.10","1113.10","1113.10","1 through 10","2613","4086","percent of total billed charges",""
"HUMERAL STEM 9MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017977","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","1738.90","1484.65","2716.94","38","2613","4086","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","both","","","5845.00","4383.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4646.78","79.5","","1309.77","674.56","6049.93","26","1811.95","4646.78","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","both","","","5845.00","4383.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3115.39","53.3","","1901.83","1901.83","2962.25","1 through 10","1811.95","4646.78","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","both","","","5845.00","4383.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2133.43","36.5","","1620.31","1620.31","19908.88","1 through 10","1811.95","4646.78","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","both","","","5845.00","4383.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2238.64","38.3","","352.91","352.91","2046.30","1 through 10","1811.95","4646.78","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","both","","","5845.00","4383.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2507.51","42.9","","9668.75","9668.75","9668.75","1 through 10","1811.95","4646.78","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","both","","","5845.00","4383.75","WELLPOINT [1015]","HB AMC WELLPOINT","4312.44","73.78","","699.88","384.10","3443.31","33","1811.95","4646.78","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5845.00","4383.75","AETNA [1001]","HB AMC AETNA HMO","4079.81","69.8","","1421.24","264.50","4933.46","29","3054.6","4776.53","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5845.00","4383.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4699.38","80.4","","1022.97","1022.97","3607.50","1 through 10","3054.6","4776.53","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5845.00","4383.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4776.53","81.72","","3010.54","693.88","5019.88","35","3054.6","4776.53","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2553.49","52.26","","1113.10","1113.10","1113.10","1 through 10","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3884.47","79.5","","1293.60","1148.53","1603.80","1 through 10","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1783.44","36.5","","1023.42","771.29","2068.67","33","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1871.39","38.3","","850.52","759.78","1211.25","66","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.15","42.9","","2548.09","2548.09","2548.09","1 through 10","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.15","42.9","","956.46","956.46","956.46","1 through 10","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","WELLPOINT [1015]","HB AMC WELLPOINT","3604.99","73.78","","2344.73","1619.47","2530.35","16","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4886.13","3664.60","AETNA [1001]","HB AMC AETNA HMO","3410.52","69.8","","1523.63","988.41","4330.26","39","2553.49","3992.95","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4886.13","3664.60","AETNA [1001]","HB AMC AETNA PPO","3928.45","80.4","","1670.25","1670.25","1670.25","1 through 10","2553.49","3992.95","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4886.13","3664.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2553.49","52.26","","1113.10","1113.10","1113.10","1 through 10","2553.49","3992.95","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4886.13","3664.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3992.95","81.72","","1738.90","1484.65","2716.94","38","2553.49","3992.95","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","6212.50","4659.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3246.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1925.88","4938.94","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","6212.50","4659.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4938.94","79.5","","1293.60","1148.53","1603.80","1 through 10","1925.88","4938.94","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","6212.50","4659.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2267.56","36.5","","1023.42","771.29","2068.67","33","1925.88","4938.94","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","6212.50","4659.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2379.39","38.3","","850.52","759.78","1211.25","66","1925.88","4938.94","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","6212.50","4659.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2665.16","42.9","","2548.09","2548.09","2548.09","1 through 10","1925.88","4938.94","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","6212.50","4659.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2665.16","42.9","","956.46","956.46","956.46","1 through 10","1925.88","4938.94","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","6212.50","4659.37","WELLPOINT [1015]","HB AMC WELLPOINT","4583.58","73.78","","2344.73","1619.47","2530.35","16","1925.88","4938.94","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6212.50","4659.37","AETNA [1001]","HB AMC AETNA HMO","4336.33","69.8","","1523.63","988.41","4330.26","39","3246.65","5076.86","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6212.50","4659.37","AETNA [1001]","HB AMC AETNA PPO","4994.85","80.4","","1670.25","1670.25","1670.25","1 through 10","3246.65","5076.86","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6212.50","4659.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3246.65","52.26","","1113.10","1113.10","1113.10","1 through 10","3246.65","5076.86","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6212.50","4659.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5076.86","81.72","","1738.90","1484.65","2716.94","38","3246.65","5076.86","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2553.49","52.26","","1113.10","1113.10","1113.10","1 through 10","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3884.47","79.5","","1293.60","1148.53","1603.80","1 through 10","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1783.44","36.5","","1023.42","771.29","2068.67","33","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1871.39","38.3","","850.52","759.78","1211.25","66","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.15","42.9","","2548.09","2548.09","2548.09","1 through 10","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.15","42.9","","956.46","956.46","956.46","1 through 10","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","WELLPOINT [1015]","HB AMC WELLPOINT","3604.99","73.78","","2344.73","1619.47","2530.35","16","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4886.13","3664.60","AETNA [1001]","HB AMC AETNA HMO","3410.52","69.8","","1523.63","988.41","4330.26","39","2553.49","3992.95","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4886.13","3664.60","AETNA [1001]","HB AMC AETNA PPO","3928.45","80.4","","1670.25","1670.25","1670.25","1 through 10","2553.49","3992.95","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4886.13","3664.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2553.49","52.26","","1113.10","1113.10","1113.10","1 through 10","2553.49","3992.95","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4886.13","3664.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3992.95","81.72","","1738.90","1484.65","2716.94","38","2553.49","3992.95","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2553.49","52.26","","1113.10","1113.10","1113.10","1 through 10","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3884.47","79.5","","1293.60","1148.53","1603.80","1 through 10","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1783.44","36.5","","1023.42","771.29","2068.67","33","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1871.39","38.3","","850.52","759.78","1211.25","66","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.15","42.9","","2548.09","2548.09","2548.09","1 through 10","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.15","42.9","","956.46","956.46","956.46","1 through 10","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4886.13","3664.60","WELLPOINT [1015]","HB AMC WELLPOINT","3604.99","73.78","","2344.73","1619.47","2530.35","16","1514.7","3884.47","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4886.13","3664.60","AETNA [1001]","HB AMC AETNA HMO","3410.52","69.8","","1523.63","988.41","4330.26","39","2553.49","3992.95","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4886.13","3664.60","AETNA [1001]","HB AMC AETNA PPO","3928.45","80.4","","1670.25","1670.25","1670.25","1 through 10","2553.49","3992.95","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4886.13","3664.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2553.49","52.26","","1113.10","1113.10","1113.10","1 through 10","2553.49","3992.95","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4886.13","3664.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3992.95","81.72","","1738.90","1484.65","2716.94","38","2553.49","3992.95","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2445.77","52.26","","1113.10","1113.10","1113.10","1 through 10","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3720.60","79.5","","1293.60","1148.53","1603.80","1 through 10","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1708.20","36.5","","1023.42","771.29","2068.67","33","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1792.44","38.3","","850.52","759.78","1211.25","66","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2007.72","42.9","","2548.09","2548.09","2548.09","1 through 10","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2007.72","42.9","","956.46","956.46","956.46","1 through 10","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","4680.00","3510.00","WELLPOINT [1015]","HB AMC WELLPOINT","3452.90","73.78","","2344.73","1619.47","2530.35","16","1450.8","3720.6","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4680.00","3510.00","AETNA [1001]","HB AMC AETNA HMO","3266.64","69.8","","1523.63","988.41","4330.26","39","2445.77","3824.5","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4680.00","3510.00","AETNA [1001]","HB AMC AETNA PPO","3762.72","80.4","","1670.25","1670.25","1670.25","1 through 10","2445.77","3824.5","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4680.00","3510.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2445.77","52.26","","1113.10","1113.10","1113.10","1 through 10","2445.77","3824.5","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4680.00","3510.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3824.50","81.72","","1738.90","1484.65","2716.94","38","2445.77","3824.5","percent of total billed charges",""
"HUMERAL STEM SZ 3 PERFORM SYSTEM","SUP-ITM-10281793","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4703.40","52.26","","1113.10","1113.10","1113.10","1 through 10","2790","7155","percent of total billed charges",""
"HUMERAL STEM SZ 3 PERFORM SYSTEM","SUP-ITM-10281793","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7155.00","79.5","","1293.60","1148.53","1603.80","1 through 10","2790","7155","percent of total billed charges",""
"HUMERAL STEM SZ 3 PERFORM SYSTEM","SUP-ITM-10281793","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3285.00","36.5","","1023.42","771.29","2068.67","33","2790","7155","percent of total billed charges",""
"HUMERAL STEM SZ 3 PERFORM SYSTEM","SUP-ITM-10281793","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3447.00","38.3","","850.52","759.78","1211.25","66","2790","7155","percent of total billed charges",""
"HUMERAL STEM SZ 3 PERFORM SYSTEM","SUP-ITM-10281793","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3861.00","42.9","","2548.09","2548.09","2548.09","1 through 10","2790","7155","percent of total billed charges",""
"HUMERAL STEM SZ 3 PERFORM SYSTEM","SUP-ITM-10281793","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3861.00","42.9","","956.46","956.46","956.46","1 through 10","2790","7155","percent of total billed charges",""
"HUMERAL STEM SZ 3 PERFORM SYSTEM","SUP-ITM-10281793","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","WELLPOINT [1015]","HB AMC WELLPOINT","6640.20","73.78","","2344.73","1619.47","2530.35","16","2790","7155","percent of total billed charges",""
"HUMERAL STEM SZ 3 PERFORM SYSTEM","SUP-ITM-10281793","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9000.00","6750.00","AETNA [1001]","HB AMC AETNA HMO","6282.00","69.8","","1523.63","988.41","4330.26","39","4703.4","7354.8","percent of total billed charges",""
"HUMERAL STEM SZ 3 PERFORM SYSTEM","SUP-ITM-10281793","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9000.00","6750.00","AETNA [1001]","HB AMC AETNA PPO","7236.00","80.4","","1670.25","1670.25","1670.25","1 through 10","4703.4","7354.8","percent of total billed charges",""
"HUMERAL STEM SZ 3 PERFORM SYSTEM","SUP-ITM-10281793","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9000.00","6750.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4703.40","52.26","","1113.10","1113.10","1113.10","1 through 10","4703.4","7354.8","percent of total billed charges",""
"HUMERAL STEM SZ 3 PERFORM SYSTEM","SUP-ITM-10281793","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9000.00","6750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7354.80","81.72","","1738.90","1484.65","2716.94","38","4703.4","7354.8","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1395","3577.5","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1395","3577.5","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","1023.42","771.29","2068.67","33","1395","3577.5","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","850.52","759.78","1211.25","66","1395","3577.5","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1395","3577.5","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","956.46","956.46","956.46","1 through 10","1395","3577.5","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","2344.73","1619.47","2530.35","16","1395","3577.5","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","1523.63","988.41","4330.26","39","2351.7","3677.4","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA PPO","3618.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2351.7","3677.4","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","2351.7","3677.4","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","1738.90","1484.65","2716.94","38","2351.7","3677.4","percent of total billed charges",""
"HUMERUS PLATE 140MM PROXIMALIMAL A.L.P.S. HIGH 7 HOLE RIGHT","SUP-ITM-10175168","CDM","C1713","HCPCS","0278","RC","","","","both","","","4686.50","3514.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3725.77","79.5","","800.18","480.96","1887.97","195","1452.82","3725.77","percent of total billed charges",""
"HUMERUS PLATE 140MM PROXIMALIMAL A.L.P.S. HIGH 7 HOLE RIGHT","SUP-ITM-10175168","CDM","C1713","HCPCS","0278","RC","","","","both","","","4686.50","3514.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2497.90","53.3","","813.12","216.42","1444.50","81","1452.82","3725.77","percent of total billed charges",""
"HUMERUS PLATE 140MM PROXIMALIMAL A.L.P.S. HIGH 7 HOLE RIGHT","SUP-ITM-10175168","CDM","C1713","HCPCS","0278","RC","","","","both","","","4686.50","3514.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1452.82","31","","432.60","432.60","432.60","1 through 10","1452.82","3725.77","percent of total billed charges",""
"HUMERUS PLATE 140MM PROXIMALIMAL A.L.P.S. HIGH 7 HOLE RIGHT","SUP-ITM-10175168","CDM","C1713","HCPCS","0278","RC","","","","both","","","4686.50","3514.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1710.57","36.5","","148.37","54.89","631.39","94","1452.82","3725.77","percent of total billed charges",""
"HUMERUS PLATE 140MM PROXIMALIMAL A.L.P.S. HIGH 7 HOLE RIGHT","SUP-ITM-10175168","CDM","C1713","HCPCS","0278","RC","","","","both","","","4686.50","3514.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1794.93","38.3","","279.30","91.72","1116.77","266","1452.82","3725.77","percent of total billed charges",""
"HUMERUS PLATE 140MM PROXIMALIMAL A.L.P.S. HIGH 7 HOLE RIGHT","SUP-ITM-10175168","CDM","C1713","HCPCS","0278","RC","","","","both","","","4686.50","3514.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2010.51","42.9","","731.00","63.70","731.00","1 through 10","1452.82","3725.77","percent of total billed charges",""
"HUMERUS PLATE 140MM PROXIMALIMAL A.L.P.S. HIGH 7 HOLE RIGHT","SUP-ITM-10175168","CDM","C1713","HCPCS","0278","RC","","","","both","","","4686.50","3514.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2010.51","42.9","","384.74","384.74","384.74","1 through 10","1452.82","3725.77","percent of total billed charges",""
"HUMERUS PLATE 140MM PROXIMALIMAL A.L.P.S. HIGH 7 HOLE RIGHT","SUP-ITM-10175168","CDM","C1713","HCPCS","0278","RC","","","","both","","","4686.50","3514.87","WELLPOINT [1015]","HB AMC WELLPOINT","3457.70","73.78","","286.63","119.22","1107.45","105","1452.82","3725.77","percent of total billed charges",""
"HUMERUS PLATE 140MM PROXIMALIMAL A.L.P.S. HIGH 7 HOLE RIGHT","SUP-ITM-10175168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4686.50","3514.87","AETNA [1001]","HB AMC AETNA HMO","3271.18","69.8","","675.31","184.75","1721.50","286","2449.16","3829.81","percent of total billed charges",""
"HUMERUS PLATE 140MM PROXIMALIMAL A.L.P.S. HIGH 7 HOLE RIGHT","SUP-ITM-10175168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4686.50","3514.87","AETNA [1001]","HB AMC AETNA PPO","3767.95","80.4","","1261.44","103.12","1514.10","21","2449.16","3829.81","percent of total billed charges",""
"HUMERUS PLATE 140MM PROXIMALIMAL A.L.P.S. HIGH 7 HOLE RIGHT","SUP-ITM-10175168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4686.50","3514.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3767.95","80.4","","1365.00","1365.00","1365.00","1 through 10","2449.16","3829.81","percent of total billed charges",""
"HUMERUS PLATE 140MM PROXIMALIMAL A.L.P.S. HIGH 7 HOLE RIGHT","SUP-ITM-10175168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4686.50","3514.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3829.81","81.72","","5157.68","5157.68","5157.68","1 through 10","2449.16","3829.81","percent of total billed charges",""
"HUMERUS PLATE 140MM PROXIMALIMAL A.L.P.S. HIGH 7 HOLE RIGHT","SUP-ITM-10175168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4686.50","3514.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3829.81","81.72","","431.26","71.26","1459.57","88","2449.16","3829.81","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2409.09","79.5","","800.18","480.96","1887.97","195","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1615.15","53.3","","813.12","216.42","1444.50","81","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","939.39","31","","432.60","432.60","432.60","1 through 10","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1106.06","36.5","","148.37","54.89","631.39","94","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1160.60","38.3","","279.30","91.72","1116.77","266","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1300.00","42.9","","731.00","63.70","731.00","1 through 10","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1300.00","42.9","","384.74","384.74","384.74","1 through 10","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","WELLPOINT [1015]","HB AMC WELLPOINT","2235.76","73.78","","286.63","119.22","1107.45","105","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","AETNA [1001]","HB AMC AETNA HMO","2115.15","69.8","","675.31","184.75","1721.50","286","1583.63","2476.36","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","AETNA [1001]","HB AMC AETNA PPO","2436.36","80.4","","1261.44","103.12","1514.10","21","1583.63","2476.36","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2436.36","80.4","","1365.00","1365.00","1365.00","1 through 10","1583.63","2476.36","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2476.36","81.72","","5157.68","5157.68","5157.68","1 through 10","1583.63","2476.36","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2476.36","81.72","","431.26","71.26","1459.57","88","1583.63","2476.36","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2516.16","79.5","","800.18","480.96","1887.97","195","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1686.93","53.3","","813.12","216.42","1444.50","81","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","981.14","31","","432.60","432.60","432.60","1 through 10","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1155.22","36.5","","148.37","54.89","631.39","94","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1212.19","38.3","","279.30","91.72","1116.77","266","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1357.78","42.9","","731.00","63.70","731.00","1 through 10","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1357.78","42.9","","384.74","384.74","384.74","1 through 10","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","WELLPOINT [1015]","HB AMC WELLPOINT","2335.12","73.78","","286.63","119.22","1107.45","105","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3164.98","2373.73","AETNA [1001]","HB AMC AETNA HMO","2209.16","69.8","","675.31","184.75","1721.50","286","1654.02","2586.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3164.98","2373.73","AETNA [1001]","HB AMC AETNA PPO","2544.64","80.4","","1261.44","103.12","1514.10","21","1654.02","2586.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3164.98","2373.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2544.64","80.4","","1365.00","1365.00","1365.00","1 through 10","1654.02","2586.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3164.98","2373.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2586.42","81.72","","5157.68","5157.68","5157.68","1 through 10","1654.02","2586.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE ELBOW VA LCP SS DISTAL MEDIAL LEFT","SUP-ITM-10114076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3164.98","2373.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2586.42","81.72","","431.26","71.26","1459.57","88","1654.02","2586.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.40","2447.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2594.40","79.5","","800.18","480.96","1887.97","195","1011.65","2594.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.40","2447.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1739.39","53.3","","813.12","216.42","1444.50","81","1011.65","2594.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.40","2447.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1011.65","31","","432.60","432.60","432.60","1 through 10","1011.65","2594.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.40","2447.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1191.14","36.5","","148.37","54.89","631.39","94","1011.65","2594.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.40","2447.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1249.88","38.3","","279.30","91.72","1116.77","266","1011.65","2594.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.40","2447.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1400.00","42.9","","731.00","63.70","731.00","1 through 10","1011.65","2594.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.40","2447.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1400.00","42.9","","384.74","384.74","384.74","1 through 10","1011.65","2594.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.40","2447.55","WELLPOINT [1015]","HB AMC WELLPOINT","2407.74","73.78","","286.63","119.22","1107.45","105","1011.65","2594.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3263.40","2447.55","AETNA [1001]","HB AMC AETNA HMO","2277.85","69.8","","675.31","184.75","1721.50","286","1705.45","2666.85","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3263.40","2447.55","AETNA [1001]","HB AMC AETNA PPO","2623.77","80.4","","1261.44","103.12","1514.10","21","1705.45","2666.85","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3263.40","2447.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2623.77","80.4","","1365.00","1365.00","1365.00","1 through 10","1705.45","2666.85","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3263.40","2447.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2666.85","81.72","","5157.68","5157.68","5157.68","1 through 10","1705.45","2666.85","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3263.40","2447.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2666.85","81.72","","431.26","71.26","1459.57","88","1705.45","2666.85","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2516.16","79.5","","800.18","480.96","1887.97","195","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1686.93","53.3","","813.12","216.42","1444.50","81","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","981.14","31","","432.60","432.60","432.60","1 through 10","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1155.22","36.5","","148.37","54.89","631.39","94","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1212.19","38.3","","279.30","91.72","1116.77","266","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1357.78","42.9","","731.00","63.70","731.00","1 through 10","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1357.78","42.9","","384.74","384.74","384.74","1 through 10","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","both","","","3164.98","2373.73","WELLPOINT [1015]","HB AMC WELLPOINT","2335.12","73.78","","286.63","119.22","1107.45","105","981.14","2516.16","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3164.98","2373.73","AETNA [1001]","HB AMC AETNA HMO","2209.16","69.8","","675.31","184.75","1721.50","286","1654.02","2586.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3164.98","2373.73","AETNA [1001]","HB AMC AETNA PPO","2544.64","80.4","","1261.44","103.12","1514.10","21","1654.02","2586.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3164.98","2373.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2544.64","80.4","","1365.00","1365.00","1365.00","1 through 10","1654.02","2586.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3164.98","2373.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2586.42","81.72","","5157.68","5157.68","5157.68","1 through 10","1654.02","2586.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3164.98","2373.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2586.42","81.72","","431.26","71.26","1459.57","88","1654.02","2586.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2409.09","79.5","","800.18","480.96","1887.97","195","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1615.15","53.3","","813.12","216.42","1444.50","81","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","939.39","31","","432.60","432.60","432.60","1 through 10","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1106.06","36.5","","148.37","54.89","631.39","94","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1160.60","38.3","","279.30","91.72","1116.77","266","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1300.00","42.9","","731.00","63.70","731.00","1 through 10","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1300.00","42.9","","384.74","384.74","384.74","1 through 10","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","WELLPOINT [1015]","HB AMC WELLPOINT","2235.76","73.78","","286.63","119.22","1107.45","105","939.39","2409.09","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","AETNA [1001]","HB AMC AETNA HMO","2115.15","69.8","","675.31","184.75","1721.50","286","1583.63","2476.36","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","AETNA [1001]","HB AMC AETNA PPO","2436.36","80.4","","1261.44","103.12","1514.10","21","1583.63","2476.36","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2436.36","80.4","","1365.00","1365.00","1365.00","1 through 10","1583.63","2476.36","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2476.36","81.72","","5157.68","5157.68","5157.68","1 through 10","1583.63","2476.36","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2476.36","81.72","","431.26","71.26","1459.57","88","1583.63","2476.36","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X85MM MED 2 HOLE ARM LCP TITANIUM VARIABLE ANGLE EXTENDEDMM MEDIAL DISTAL LT","SUP-ITM-10125563","CDM","C1713","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2734.42","79.5","","800.18","480.96","1887.97","195","1066.25","2734.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X85MM MED 2 HOLE ARM LCP TITANIUM VARIABLE ANGLE EXTENDEDMM MEDIAL DISTAL LT","SUP-ITM-10125563","CDM","C1713","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1833.26","53.3","","813.12","216.42","1444.50","81","1066.25","2734.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X85MM MED 2 HOLE ARM LCP TITANIUM VARIABLE ANGLE EXTENDEDMM MEDIAL DISTAL LT","SUP-ITM-10125563","CDM","C1713","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1066.25","31","","432.60","432.60","432.60","1 through 10","1066.25","2734.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X85MM MED 2 HOLE ARM LCP TITANIUM VARIABLE ANGLE EXTENDEDMM MEDIAL DISTAL LT","SUP-ITM-10125563","CDM","C1713","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1255.42","36.5","","148.37","54.89","631.39","94","1066.25","2734.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X85MM MED 2 HOLE ARM LCP TITANIUM VARIABLE ANGLE EXTENDEDMM MEDIAL DISTAL LT","SUP-ITM-10125563","CDM","C1713","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1317.34","38.3","","279.30","91.72","1116.77","266","1066.25","2734.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X85MM MED 2 HOLE ARM LCP TITANIUM VARIABLE ANGLE EXTENDEDMM MEDIAL DISTAL LT","SUP-ITM-10125563","CDM","C1713","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1475.55","42.9","","731.00","63.70","731.00","1 through 10","1066.25","2734.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X85MM MED 2 HOLE ARM LCP TITANIUM VARIABLE ANGLE EXTENDEDMM MEDIAL DISTAL LT","SUP-ITM-10125563","CDM","C1713","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1475.55","42.9","","384.74","384.74","384.74","1 through 10","1066.25","2734.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X85MM MED 2 HOLE ARM LCP TITANIUM VARIABLE ANGLE EXTENDEDMM MEDIAL DISTAL LT","SUP-ITM-10125563","CDM","C1713","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","WELLPOINT [1015]","HB AMC WELLPOINT","2537.68","73.78","","286.63","119.22","1107.45","105","1066.25","2734.42","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X85MM MED 2 HOLE ARM LCP TITANIUM VARIABLE ANGLE EXTENDEDMM MEDIAL DISTAL LT","SUP-ITM-10125563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3439.52","2579.64","AETNA [1001]","HB AMC AETNA HMO","2400.78","69.8","","675.31","184.75","1721.50","286","1797.49","2810.78","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X85MM MED 2 HOLE ARM LCP TITANIUM VARIABLE ANGLE EXTENDEDMM MEDIAL DISTAL LT","SUP-ITM-10125563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3439.52","2579.64","AETNA [1001]","HB AMC AETNA PPO","2765.37","80.4","","1261.44","103.12","1514.10","21","1797.49","2810.78","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X85MM MED 2 HOLE ARM LCP TITANIUM VARIABLE ANGLE EXTENDEDMM MEDIAL DISTAL LT","SUP-ITM-10125563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3439.52","2579.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2765.37","80.4","","1365.00","1365.00","1365.00","1 through 10","1797.49","2810.78","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X85MM MED 2 HOLE ARM LCP TITANIUM VARIABLE ANGLE EXTENDEDMM MEDIAL DISTAL LT","SUP-ITM-10125563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3439.52","2579.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2810.78","81.72","","5157.68","5157.68","5157.68","1 through 10","1797.49","2810.78","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X85MM MED 2 HOLE ARM LCP TITANIUM VARIABLE ANGLE EXTENDEDMM MEDIAL DISTAL LT","SUP-ITM-10125563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3439.52","2579.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2810.78","81.72","","431.26","71.26","1459.57","88","1797.49","2810.78","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POST LATERAL DISTAL LEFT","SUP-ITM-10129764","CDM","C1776","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2401.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POST LATERAL DISTAL LEFT","SUP-ITM-10129764","CDM","C1776","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3653.82","79.5","","1293.60","1148.53","1603.80","1 through 10","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POST LATERAL DISTAL LEFT","SUP-ITM-10129764","CDM","C1776","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1677.54","36.5","","1023.42","771.29","2068.67","33","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POST LATERAL DISTAL LEFT","SUP-ITM-10129764","CDM","C1776","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1760.27","38.3","","850.52","759.78","1211.25","66","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POST LATERAL DISTAL LEFT","SUP-ITM-10129764","CDM","C1776","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1971.68","42.9","","2548.09","2548.09","2548.09","1 through 10","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POST LATERAL DISTAL LEFT","SUP-ITM-10129764","CDM","C1776","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1971.68","42.9","","956.46","956.46","956.46","1 through 10","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POST LATERAL DISTAL LEFT","SUP-ITM-10129764","CDM","C1776","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","WELLPOINT [1015]","HB AMC WELLPOINT","3390.93","73.78","","2344.73","1619.47","2530.35","16","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POST LATERAL DISTAL LEFT","SUP-ITM-10129764","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4596.00","3447.00","AETNA [1001]","HB AMC AETNA HMO","3208.01","69.8","","1523.63","988.41","4330.26","39","2401.87","3755.85","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POST LATERAL DISTAL LEFT","SUP-ITM-10129764","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4596.00","3447.00","AETNA [1001]","HB AMC AETNA PPO","3695.18","80.4","","1670.25","1670.25","1670.25","1 through 10","2401.87","3755.85","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POST LATERAL DISTAL LEFT","SUP-ITM-10129764","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4596.00","3447.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2401.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2401.87","3755.85","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POST LATERAL DISTAL LEFT","SUP-ITM-10129764","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4596.00","3447.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3755.85","81.72","","1738.90","1484.65","2716.94","38","2401.87","3755.85","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POSTEROLATERAL DISTAL RIGHT","SUP-ITM-10129765","CDM","C1713","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3653.82","79.5","","800.18","480.96","1887.97","195","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POSTEROLATERAL DISTAL RIGHT","SUP-ITM-10129765","CDM","C1713","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2449.67","53.3","","813.12","216.42","1444.50","81","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POSTEROLATERAL DISTAL RIGHT","SUP-ITM-10129765","CDM","C1713","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1424.76","31","","432.60","432.60","432.60","1 through 10","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POSTEROLATERAL DISTAL RIGHT","SUP-ITM-10129765","CDM","C1713","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1677.54","36.5","","148.37","54.89","631.39","94","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POSTEROLATERAL DISTAL RIGHT","SUP-ITM-10129765","CDM","C1713","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1760.27","38.3","","279.30","91.72","1116.77","266","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POSTEROLATERAL DISTAL RIGHT","SUP-ITM-10129765","CDM","C1713","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1971.68","42.9","","731.00","63.70","731.00","1 through 10","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POSTEROLATERAL DISTAL RIGHT","SUP-ITM-10129765","CDM","C1713","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1971.68","42.9","","384.74","384.74","384.74","1 through 10","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POSTEROLATERAL DISTAL RIGHT","SUP-ITM-10129765","CDM","C1713","HCPCS","0278","RC","","","","both","","","4596.00","3447.00","WELLPOINT [1015]","HB AMC WELLPOINT","3390.93","73.78","","286.63","119.22","1107.45","105","1424.76","3653.82","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POSTEROLATERAL DISTAL RIGHT","SUP-ITM-10129765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4596.00","3447.00","AETNA [1001]","HB AMC AETNA HMO","3208.01","69.8","","675.31","184.75","1721.50","286","2401.87","3755.85","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POSTEROLATERAL DISTAL RIGHT","SUP-ITM-10129765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4596.00","3447.00","AETNA [1001]","HB AMC AETNA PPO","3695.18","80.4","","1261.44","103.12","1514.10","21","2401.87","3755.85","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POSTEROLATERAL DISTAL RIGHT","SUP-ITM-10129765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4596.00","3447.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3695.18","80.4","","1365.00","1365.00","1365.00","1 through 10","2401.87","3755.85","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POSTEROLATERAL DISTAL RIGHT","SUP-ITM-10129765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4596.00","3447.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3755.85","81.72","","5157.68","5157.68","5157.68","1 through 10","2401.87","3755.85","percent of total billed charges",""
"HUMERUS PLATE 203MM 15 HOLE BONE ARM POSTEROLATERAL DISTAL RIGHT","SUP-ITM-10129765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4596.00","3447.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3755.85","81.72","","431.26","71.26","1459.57","88","2401.87","3755.85","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3613.04","79.5","","800.18","480.96","1887.97","195","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2422.33","53.3","","813.12","216.42","1444.50","81","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1408.86","31","","432.60","432.60","432.60","1 through 10","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1658.82","36.5","","148.37","54.89","631.39","94","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1740.62","38.3","","279.30","91.72","1116.77","266","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1949.68","42.9","","731.00","63.70","731.00","1 through 10","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1949.68","42.9","","384.74","384.74","384.74","1 through 10","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","WELLPOINT [1015]","HB AMC WELLPOINT","3353.08","73.78","","286.63","119.22","1107.45","105","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","AETNA [1001]","HB AMC AETNA HMO","3172.20","69.8","","675.31","184.75","1721.50","286","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","AETNA [1001]","HB AMC AETNA PPO","3653.94","80.4","","1261.44","103.12","1514.10","21","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3653.94","80.4","","1365.00","1365.00","1365.00","1 through 10","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3713.93","81.72","","5157.68","5157.68","5157.68","1 through 10","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3713.93","81.72","","431.26","71.26","1459.57","88","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.95","1563.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1657.54","79.5","","800.18","480.96","1887.97","195","646.33","1657.54","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.95","1563.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1111.28","53.3","","813.12","216.42","1444.50","81","646.33","1657.54","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.95","1563.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","646.33","31","","432.60","432.60","432.60","1 through 10","646.33","1657.54","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.95","1563.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","761.01","36.5","","148.37","54.89","631.39","94","646.33","1657.54","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.95","1563.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","798.54","38.3","","279.30","91.72","1116.77","266","646.33","1657.54","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.95","1563.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","894.44","42.9","","731.00","63.70","731.00","1 through 10","646.33","1657.54","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.95","1563.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","894.44","42.9","","384.74","384.74","384.74","1 through 10","646.33","1657.54","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.95","1563.71","WELLPOINT [1015]","HB AMC WELLPOINT","1538.28","73.78","","286.63","119.22","1107.45","105","646.33","1657.54","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2084.95","1563.71","AETNA [1001]","HB AMC AETNA HMO","1455.30","69.8","","675.31","184.75","1721.50","286","1089.59","1703.82","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2084.95","1563.71","AETNA [1001]","HB AMC AETNA PPO","1676.30","80.4","","1261.44","103.12","1514.10","21","1089.59","1703.82","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2084.95","1563.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1676.30","80.4","","1365.00","1365.00","1365.00","1 through 10","1089.59","1703.82","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2084.95","1563.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1703.82","81.72","","5157.68","5157.68","5157.68","1 through 10","1089.59","1703.82","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2084.95","1563.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1703.82","81.72","","431.26","71.26","1459.57","88","1089.59","1703.82","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","2314.17","1735.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1839.77","79.5","","800.18","480.96","1887.97","195","717.39","1839.77","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","2314.17","1735.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1233.45","53.3","","813.12","216.42","1444.50","81","717.39","1839.77","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","2314.17","1735.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","717.39","31","","432.60","432.60","432.60","1 through 10","717.39","1839.77","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","2314.17","1735.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","844.67","36.5","","148.37","54.89","631.39","94","717.39","1839.77","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","2314.17","1735.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","886.33","38.3","","279.30","91.72","1116.77","266","717.39","1839.77","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","2314.17","1735.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","992.78","42.9","","731.00","63.70","731.00","1 through 10","717.39","1839.77","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","2314.17","1735.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","992.78","42.9","","384.74","384.74","384.74","1 through 10","717.39","1839.77","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","2314.17","1735.63","WELLPOINT [1015]","HB AMC WELLPOINT","1707.39","73.78","","286.63","119.22","1107.45","105","717.39","1839.77","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2314.17","1735.63","AETNA [1001]","HB AMC AETNA HMO","1615.29","69.8","","675.31","184.75","1721.50","286","1209.39","1891.14","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2314.17","1735.63","AETNA [1001]","HB AMC AETNA PPO","1860.59","80.4","","1261.44","103.12","1514.10","21","1209.39","1891.14","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2314.17","1735.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1860.59","80.4","","1365.00","1365.00","1365.00","1 through 10","1209.39","1891.14","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2314.17","1735.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1891.14","81.72","","5157.68","5157.68","5157.68","1 through 10","1209.39","1891.14","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2314.17","1735.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1891.14","81.72","","431.26","71.26","1459.57","88","1209.39","1891.14","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2544.68","1908.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2023.02","79.5","","800.18","480.96","1887.97","195","788.85","2023.02","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2544.68","1908.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1356.31","53.3","","813.12","216.42","1444.50","81","788.85","2023.02","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2544.68","1908.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","788.85","31","","432.60","432.60","432.60","1 through 10","788.85","2023.02","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2544.68","1908.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","928.81","36.5","","148.37","54.89","631.39","94","788.85","2023.02","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2544.68","1908.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","974.61","38.3","","279.30","91.72","1116.77","266","788.85","2023.02","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2544.68","1908.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1091.67","42.9","","731.00","63.70","731.00","1 through 10","788.85","2023.02","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2544.68","1908.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1091.67","42.9","","384.74","384.74","384.74","1 through 10","788.85","2023.02","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2544.68","1908.51","WELLPOINT [1015]","HB AMC WELLPOINT","1877.46","73.78","","286.63","119.22","1107.45","105","788.85","2023.02","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2544.68","1908.51","AETNA [1001]","HB AMC AETNA HMO","1776.19","69.8","","675.31","184.75","1721.50","286","1329.85","2079.51","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2544.68","1908.51","AETNA [1001]","HB AMC AETNA PPO","2045.92","80.4","","1261.44","103.12","1514.10","21","1329.85","2079.51","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2544.68","1908.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2045.92","80.4","","1365.00","1365.00","1365.00","1 through 10","1329.85","2079.51","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2544.68","1908.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2079.51","81.72","","5157.68","5157.68","5157.68","1 through 10","1329.85","2079.51","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2544.68","1908.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2079.51","81.72","","431.26","71.26","1459.57","88","1329.85","2079.51","percent of total billed charges",""
"HUMERUS PLATE 3.5X114MM 3 HOLE SHAFT LCP PROXIMAL STANDARD TITANIUM","SUP-ITM-10040760","CDM","C1713","HCPCS","0278","RC","","","","both","","","4438.89","3329.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3528.92","79.5","","800.18","480.96","1887.97","195","1376.06","3528.92","percent of total billed charges",""
"HUMERUS PLATE 3.5X114MM 3 HOLE SHAFT LCP PROXIMAL STANDARD TITANIUM","SUP-ITM-10040760","CDM","C1713","HCPCS","0278","RC","","","","both","","","4438.89","3329.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2365.93","53.3","","813.12","216.42","1444.50","81","1376.06","3528.92","percent of total billed charges",""
"HUMERUS PLATE 3.5X114MM 3 HOLE SHAFT LCP PROXIMAL STANDARD TITANIUM","SUP-ITM-10040760","CDM","C1713","HCPCS","0278","RC","","","","both","","","4438.89","3329.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1376.06","31","","432.60","432.60","432.60","1 through 10","1376.06","3528.92","percent of total billed charges",""
"HUMERUS PLATE 3.5X114MM 3 HOLE SHAFT LCP PROXIMAL STANDARD TITANIUM","SUP-ITM-10040760","CDM","C1713","HCPCS","0278","RC","","","","both","","","4438.89","3329.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1620.19","36.5","","148.37","54.89","631.39","94","1376.06","3528.92","percent of total billed charges",""
"HUMERUS PLATE 3.5X114MM 3 HOLE SHAFT LCP PROXIMAL STANDARD TITANIUM","SUP-ITM-10040760","CDM","C1713","HCPCS","0278","RC","","","","both","","","4438.89","3329.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1700.09","38.3","","279.30","91.72","1116.77","266","1376.06","3528.92","percent of total billed charges",""
"HUMERUS PLATE 3.5X114MM 3 HOLE SHAFT LCP PROXIMAL STANDARD TITANIUM","SUP-ITM-10040760","CDM","C1713","HCPCS","0278","RC","","","","both","","","4438.89","3329.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1904.28","42.9","","731.00","63.70","731.00","1 through 10","1376.06","3528.92","percent of total billed charges",""
"HUMERUS PLATE 3.5X114MM 3 HOLE SHAFT LCP PROXIMAL STANDARD TITANIUM","SUP-ITM-10040760","CDM","C1713","HCPCS","0278","RC","","","","both","","","4438.89","3329.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1904.28","42.9","","384.74","384.74","384.74","1 through 10","1376.06","3528.92","percent of total billed charges",""
"HUMERUS PLATE 3.5X114MM 3 HOLE SHAFT LCP PROXIMAL STANDARD TITANIUM","SUP-ITM-10040760","CDM","C1713","HCPCS","0278","RC","","","","both","","","4438.89","3329.17","WELLPOINT [1015]","HB AMC WELLPOINT","3275.01","73.78","","286.63","119.22","1107.45","105","1376.06","3528.92","percent of total billed charges",""
"HUMERUS PLATE 3.5X114MM 3 HOLE SHAFT LCP PROXIMAL STANDARD TITANIUM","SUP-ITM-10040760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4438.89","3329.17","AETNA [1001]","HB AMC AETNA HMO","3098.35","69.8","","675.31","184.75","1721.50","286","2319.76","3627.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X114MM 3 HOLE SHAFT LCP PROXIMAL STANDARD TITANIUM","SUP-ITM-10040760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4438.89","3329.17","AETNA [1001]","HB AMC AETNA PPO","3568.87","80.4","","1261.44","103.12","1514.10","21","2319.76","3627.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X114MM 3 HOLE SHAFT LCP PROXIMAL STANDARD TITANIUM","SUP-ITM-10040760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4438.89","3329.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3568.87","80.4","","1365.00","1365.00","1365.00","1 through 10","2319.76","3627.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X114MM 3 HOLE SHAFT LCP PROXIMAL STANDARD TITANIUM","SUP-ITM-10040760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4438.89","3329.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3627.46","81.72","","5157.68","5157.68","5157.68","1 through 10","2319.76","3627.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X114MM 3 HOLE SHAFT LCP PROXIMAL STANDARD TITANIUM","SUP-ITM-10040760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4438.89","3329.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3627.46","81.72","","431.26","71.26","1459.57","88","2319.76","3627.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.29","2660.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2820.10","79.5","","800.18","480.96","1887.97","195","1099.66","2820.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.29","2660.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1890.71","53.3","","813.12","216.42","1444.50","81","1099.66","2820.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.29","2660.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1099.66","31","","432.60","432.60","432.60","1 through 10","1099.66","2820.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.29","2660.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1294.76","36.5","","148.37","54.89","631.39","94","1099.66","2820.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.29","2660.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1358.61","38.3","","279.30","91.72","1116.77","266","1099.66","2820.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.29","2660.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1521.79","42.9","","731.00","63.70","731.00","1 through 10","1099.66","2820.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.29","2660.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1521.79","42.9","","384.74","384.74","384.74","1 through 10","1099.66","2820.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.29","2660.47","WELLPOINT [1015]","HB AMC WELLPOINT","2617.19","73.78","","286.63","119.22","1107.45","105","1099.66","2820.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3547.29","2660.47","AETNA [1001]","HB AMC AETNA HMO","2476.01","69.8","","675.31","184.75","1721.50","286","1853.81","2898.85","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3547.29","2660.47","AETNA [1001]","HB AMC AETNA PPO","2852.02","80.4","","1261.44","103.12","1514.10","21","1853.81","2898.85","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3547.29","2660.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2852.02","80.4","","1365.00","1365.00","1365.00","1 through 10","1853.81","2898.85","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3547.29","2660.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2898.85","81.72","","5157.68","5157.68","5157.68","1 through 10","1853.81","2898.85","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3547.29","2660.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2898.85","81.72","","431.26","71.26","1459.57","88","1853.81","2898.85","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.95","3306.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3505.12","79.5","","800.18","480.96","1887.97","195","1366.77","3505.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.95","3306.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2349.97","53.3","","813.12","216.42","1444.50","81","1366.77","3505.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.95","3306.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1366.77","31","","432.60","432.60","432.60","1 through 10","1366.77","3505.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.95","3306.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1609.27","36.5","","148.37","54.89","631.39","94","1366.77","3505.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.95","3306.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1688.63","38.3","","279.30","91.72","1116.77","266","1366.77","3505.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.95","3306.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.44","42.9","","731.00","63.70","731.00","1 through 10","1366.77","3505.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.95","3306.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.44","42.9","","384.74","384.74","384.74","1 through 10","1366.77","3505.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","both","","","4408.95","3306.71","WELLPOINT [1015]","HB AMC WELLPOINT","3252.92","73.78","","286.63","119.22","1107.45","105","1366.77","3505.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4408.95","3306.71","AETNA [1001]","HB AMC AETNA HMO","3077.45","69.8","","675.31","184.75","1721.50","286","2304.12","3602.99","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4408.95","3306.71","AETNA [1001]","HB AMC AETNA PPO","3544.80","80.4","","1261.44","103.12","1514.10","21","2304.12","3602.99","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4408.95","3306.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3544.80","80.4","","1365.00","1365.00","1365.00","1 through 10","2304.12","3602.99","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4408.95","3306.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3602.99","81.72","","5157.68","5157.68","5157.68","1 through 10","2304.12","3602.99","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4408.95","3306.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3602.99","81.72","","431.26","71.26","1459.57","88","2304.12","3602.99","percent of total billed charges",""
"HUMERUS PLATE 3.5X143MM 9 HOLE POSTEROLATERAL DISTAL LCP SS LEFT","SUP-ITM-10018939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2747.99","2060.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2184.65","79.5","","800.18","480.96","1887.97","195","851.88","2184.65","percent of total billed charges",""
"HUMERUS PLATE 3.5X143MM 9 HOLE POSTEROLATERAL DISTAL LCP SS LEFT","SUP-ITM-10018939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2747.99","2060.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1464.68","53.3","","813.12","216.42","1444.50","81","851.88","2184.65","percent of total billed charges",""
"HUMERUS PLATE 3.5X143MM 9 HOLE POSTEROLATERAL DISTAL LCP SS LEFT","SUP-ITM-10018939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2747.99","2060.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","851.88","31","","432.60","432.60","432.60","1 through 10","851.88","2184.65","percent of total billed charges",""
"HUMERUS PLATE 3.5X143MM 9 HOLE POSTEROLATERAL DISTAL LCP SS LEFT","SUP-ITM-10018939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2747.99","2060.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1003.02","36.5","","148.37","54.89","631.39","94","851.88","2184.65","percent of total billed charges",""
"HUMERUS PLATE 3.5X143MM 9 HOLE POSTEROLATERAL DISTAL LCP SS LEFT","SUP-ITM-10018939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2747.99","2060.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1052.48","38.3","","279.30","91.72","1116.77","266","851.88","2184.65","percent of total billed charges",""
"HUMERUS PLATE 3.5X143MM 9 HOLE POSTEROLATERAL DISTAL LCP SS LEFT","SUP-ITM-10018939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2747.99","2060.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1178.89","42.9","","731.00","63.70","731.00","1 through 10","851.88","2184.65","percent of total billed charges",""
"HUMERUS PLATE 3.5X143MM 9 HOLE POSTEROLATERAL DISTAL LCP SS LEFT","SUP-ITM-10018939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2747.99","2060.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1178.89","42.9","","384.74","384.74","384.74","1 through 10","851.88","2184.65","percent of total billed charges",""
"HUMERUS PLATE 3.5X143MM 9 HOLE POSTEROLATERAL DISTAL LCP SS LEFT","SUP-ITM-10018939","CDM","C1713","HCPCS","0278","RC","","","","both","","","2747.99","2060.99","WELLPOINT [1015]","HB AMC WELLPOINT","2027.47","73.78","","286.63","119.22","1107.45","105","851.88","2184.65","percent of total billed charges",""
"HUMERUS PLATE 3.5X143MM 9 HOLE POSTEROLATERAL DISTAL LCP SS LEFT","SUP-ITM-10018939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2747.99","2060.99","AETNA [1001]","HB AMC AETNA HMO","1918.10","69.8","","675.31","184.75","1721.50","286","1436.1","2245.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X143MM 9 HOLE POSTEROLATERAL DISTAL LCP SS LEFT","SUP-ITM-10018939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2747.99","2060.99","AETNA [1001]","HB AMC AETNA PPO","2209.38","80.4","","1261.44","103.12","1514.10","21","1436.1","2245.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X143MM 9 HOLE POSTEROLATERAL DISTAL LCP SS LEFT","SUP-ITM-10018939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2747.99","2060.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2209.38","80.4","","1365.00","1365.00","1365.00","1 through 10","1436.1","2245.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X143MM 9 HOLE POSTEROLATERAL DISTAL LCP SS LEFT","SUP-ITM-10018939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2747.99","2060.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2245.66","81.72","","5157.68","5157.68","5157.68","1 through 10","1436.1","2245.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X143MM 9 HOLE POSTEROLATERAL DISTAL LCP SS LEFT","SUP-ITM-10018939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2747.99","2060.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2245.66","81.72","","431.26","71.26","1459.57","88","1436.1","2245.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","both","","","4923.93","3692.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3914.52","79.5","","800.18","480.96","1887.97","195","1526.42","3914.52","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","both","","","4923.93","3692.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2624.45","53.3","","813.12","216.42","1444.50","81","1526.42","3914.52","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","both","","","4923.93","3692.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1526.42","31","","432.60","432.60","432.60","1 through 10","1526.42","3914.52","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","both","","","4923.93","3692.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1797.23","36.5","","148.37","54.89","631.39","94","1526.42","3914.52","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","both","","","4923.93","3692.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1885.87","38.3","","279.30","91.72","1116.77","266","1526.42","3914.52","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","both","","","4923.93","3692.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2112.37","42.9","","731.00","63.70","731.00","1 through 10","1526.42","3914.52","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","both","","","4923.93","3692.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2112.37","42.9","","384.74","384.74","384.74","1 through 10","1526.42","3914.52","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","both","","","4923.93","3692.95","WELLPOINT [1015]","HB AMC WELLPOINT","3632.88","73.78","","286.63","119.22","1107.45","105","1526.42","3914.52","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4923.93","3692.95","AETNA [1001]","HB AMC AETNA HMO","3436.90","69.8","","675.31","184.75","1721.50","286","2573.25","4023.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4923.93","3692.95","AETNA [1001]","HB AMC AETNA PPO","3958.84","80.4","","1261.44","103.12","1514.10","21","2573.25","4023.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4923.93","3692.95","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3958.84","80.4","","1365.00","1365.00","1365.00","1 through 10","2573.25","4023.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4923.93","3692.95","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4023.84","81.72","","5157.68","5157.68","5157.68","1 through 10","2573.25","4023.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4923.93","3692.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4023.84","81.72","","431.26","71.26","1459.57","88","2573.25","4023.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.48","3043.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3225.70","79.5","","800.18","480.96","1887.97","195","1257.82","3225.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.48","3043.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2162.64","53.3","","813.12","216.42","1444.50","81","1257.82","3225.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.48","3043.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1257.82","31","","432.60","432.60","432.60","1 through 10","1257.82","3225.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.48","3043.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1480.98","36.5","","148.37","54.89","631.39","94","1257.82","3225.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.48","3043.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1554.01","38.3","","279.30","91.72","1116.77","266","1257.82","3225.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.48","3043.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1740.66","42.9","","731.00","63.70","731.00","1 through 10","1257.82","3225.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.48","3043.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1740.66","42.9","","384.74","384.74","384.74","1 through 10","1257.82","3225.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.48","3043.11","WELLPOINT [1015]","HB AMC WELLPOINT","2993.61","73.78","","286.63","119.22","1107.45","105","1257.82","3225.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4057.48","3043.11","AETNA [1001]","HB AMC AETNA HMO","2832.12","69.8","","675.31","184.75","1721.50","286","2120.44","3315.77","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4057.48","3043.11","AETNA [1001]","HB AMC AETNA PPO","3262.21","80.4","","1261.44","103.12","1514.10","21","2120.44","3315.77","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4057.48","3043.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3262.21","80.4","","1365.00","1365.00","1365.00","1 through 10","2120.44","3315.77","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4057.48","3043.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3315.77","81.72","","5157.68","5157.68","5157.68","1 through 10","2120.44","3315.77","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4057.48","3043.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3315.77","81.72","","431.26","71.26","1459.57","88","2120.44","3315.77","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","5045.19","3783.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4010.93","79.5","","800.18","480.96","1887.97","195","1564.01","4010.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","5045.19","3783.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2689.09","53.3","","813.12","216.42","1444.50","81","1564.01","4010.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","5045.19","3783.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1564.01","31","","432.60","432.60","432.60","1 through 10","1564.01","4010.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","5045.19","3783.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1841.49","36.5","","148.37","54.89","631.39","94","1564.01","4010.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","5045.19","3783.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1932.31","38.3","","279.30","91.72","1116.77","266","1564.01","4010.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","5045.19","3783.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2164.39","42.9","","731.00","63.70","731.00","1 through 10","1564.01","4010.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","5045.19","3783.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2164.39","42.9","","384.74","384.74","384.74","1 through 10","1564.01","4010.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","5045.19","3783.89","WELLPOINT [1015]","HB AMC WELLPOINT","3722.34","73.78","","286.63","119.22","1107.45","105","1564.01","4010.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5045.19","3783.89","AETNA [1001]","HB AMC AETNA HMO","3521.54","69.8","","675.31","184.75","1721.50","286","2636.62","4122.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5045.19","3783.89","AETNA [1001]","HB AMC AETNA PPO","4056.33","80.4","","1261.44","103.12","1514.10","21","2636.62","4122.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5045.19","3783.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4056.33","80.4","","1365.00","1365.00","1365.00","1 through 10","2636.62","4122.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5045.19","3783.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4122.93","81.72","","5157.68","5157.68","5157.68","1 through 10","2636.62","4122.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5045.19","3783.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4122.93","81.72","","431.26","71.26","1459.57","88","2636.62","4122.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.31","3230.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3424.31","79.5","","800.18","480.96","1887.97","195","1335.27","3424.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.31","3230.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2295.80","53.3","","813.12","216.42","1444.50","81","1335.27","3424.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.31","3230.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1335.27","31","","432.60","432.60","432.60","1 through 10","1335.27","3424.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.31","3230.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1572.17","36.5","","148.37","54.89","631.39","94","1335.27","3424.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.31","3230.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1649.70","38.3","","279.30","91.72","1116.77","266","1335.27","3424.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.31","3230.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1847.84","42.9","","731.00","63.70","731.00","1 through 10","1335.27","3424.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.31","3230.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1847.84","42.9","","384.74","384.74","384.74","1 through 10","1335.27","3424.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4307.31","3230.48","WELLPOINT [1015]","HB AMC WELLPOINT","3177.93","73.78","","286.63","119.22","1107.45","105","1335.27","3424.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4307.31","3230.48","AETNA [1001]","HB AMC AETNA HMO","3006.50","69.8","","675.31","184.75","1721.50","286","2251","3519.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4307.31","3230.48","AETNA [1001]","HB AMC AETNA PPO","3463.08","80.4","","1261.44","103.12","1514.10","21","2251","3519.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4307.31","3230.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3463.08","80.4","","1365.00","1365.00","1365.00","1 through 10","2251","3519.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4307.31","3230.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3519.93","81.72","","5157.68","5157.68","5157.68","1 through 10","2251","3519.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4307.31","3230.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3519.93","81.72","","431.26","71.26","1459.57","88","2251","3519.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","4126.41","3094.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3280.50","79.5","","800.18","480.96","1887.97","195","1279.19","3280.5","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","4126.41","3094.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2199.38","53.3","","813.12","216.42","1444.50","81","1279.19","3280.5","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","4126.41","3094.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1279.19","31","","432.60","432.60","432.60","1 through 10","1279.19","3280.5","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","4126.41","3094.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1506.14","36.5","","148.37","54.89","631.39","94","1279.19","3280.5","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","4126.41","3094.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1580.42","38.3","","279.30","91.72","1116.77","266","1279.19","3280.5","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","4126.41","3094.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1770.23","42.9","","731.00","63.70","731.00","1 through 10","1279.19","3280.5","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","4126.41","3094.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1770.23","42.9","","384.74","384.74","384.74","1 through 10","1279.19","3280.5","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","4126.41","3094.81","WELLPOINT [1015]","HB AMC WELLPOINT","3044.47","73.78","","286.63","119.22","1107.45","105","1279.19","3280.5","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4126.41","3094.81","AETNA [1001]","HB AMC AETNA HMO","2880.23","69.8","","675.31","184.75","1721.50","286","2156.46","3372.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4126.41","3094.81","AETNA [1001]","HB AMC AETNA PPO","3317.63","80.4","","1261.44","103.12","1514.10","21","2156.46","3372.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4126.41","3094.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3317.63","80.4","","1365.00","1365.00","1365.00","1 through 10","2156.46","3372.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4126.41","3094.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3372.10","81.72","","5157.68","5157.68","5157.68","1 through 10","2156.46","3372.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4126.41","3094.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3372.10","81.72","","431.26","71.26","1459.57","88","2156.46","3372.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5194.83","3896.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4129.89","79.5","","800.18","480.96","1887.97","195","1610.4","4129.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5194.83","3896.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2768.84","53.3","","813.12","216.42","1444.50","81","1610.4","4129.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5194.83","3896.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1610.40","31","","432.60","432.60","432.60","1 through 10","1610.4","4129.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5194.83","3896.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1896.11","36.5","","148.37","54.89","631.39","94","1610.4","4129.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5194.83","3896.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1989.62","38.3","","279.30","91.72","1116.77","266","1610.4","4129.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5194.83","3896.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2228.58","42.9","","731.00","63.70","731.00","1 through 10","1610.4","4129.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5194.83","3896.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2228.58","42.9","","384.74","384.74","384.74","1 through 10","1610.4","4129.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5194.83","3896.12","WELLPOINT [1015]","HB AMC WELLPOINT","3832.75","73.78","","286.63","119.22","1107.45","105","1610.4","4129.89","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5194.83","3896.12","AETNA [1001]","HB AMC AETNA HMO","3625.99","69.8","","675.31","184.75","1721.50","286","2714.82","4245.22","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5194.83","3896.12","AETNA [1001]","HB AMC AETNA PPO","4176.64","80.4","","1261.44","103.12","1514.10","21","2714.82","4245.22","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5194.83","3896.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4176.64","80.4","","1365.00","1365.00","1365.00","1 through 10","2714.82","4245.22","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5194.83","3896.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4245.22","81.72","","5157.68","5157.68","5157.68","1 through 10","2714.82","4245.22","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5194.83","3896.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4245.22","81.72","","431.26","71.26","1459.57","88","2714.82","4245.22","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3907.41","2930.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3106.39","79.5","","800.18","480.96","1887.97","195","1211.3","3106.39","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3907.41","2930.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2082.65","53.3","","813.12","216.42","1444.50","81","1211.3","3106.39","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3907.41","2930.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1211.30","31","","432.60","432.60","432.60","1 through 10","1211.3","3106.39","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3907.41","2930.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1426.20","36.5","","148.37","54.89","631.39","94","1211.3","3106.39","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3907.41","2930.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1496.54","38.3","","279.30","91.72","1116.77","266","1211.3","3106.39","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3907.41","2930.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1676.28","42.9","","731.00","63.70","731.00","1 through 10","1211.3","3106.39","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3907.41","2930.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1676.28","42.9","","384.74","384.74","384.74","1 through 10","1211.3","3106.39","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3907.41","2930.56","WELLPOINT [1015]","HB AMC WELLPOINT","2882.89","73.78","","286.63","119.22","1107.45","105","1211.3","3106.39","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3907.41","2930.56","AETNA [1001]","HB AMC AETNA HMO","2727.37","69.8","","675.31","184.75","1721.50","286","2042.01","3193.14","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3907.41","2930.56","AETNA [1001]","HB AMC AETNA PPO","3141.56","80.4","","1261.44","103.12","1514.10","21","2042.01","3193.14","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3907.41","2930.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3141.56","80.4","","1365.00","1365.00","1365.00","1 through 10","2042.01","3193.14","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3907.41","2930.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3193.14","81.72","","5157.68","5157.68","5157.68","1 through 10","2042.01","3193.14","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3907.41","2930.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3193.14","81.72","","431.26","71.26","1459.57","88","2042.01","3193.14","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM","SUP-ITM-10040765","CDM","C1713","HCPCS","0278","RC","","","","both","","","5239.98","3929.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4165.78","79.5","","800.18","480.96","1887.97","195","1624.39","4165.78","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM","SUP-ITM-10040765","CDM","C1713","HCPCS","0278","RC","","","","both","","","5239.98","3929.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2792.91","53.3","","813.12","216.42","1444.50","81","1624.39","4165.78","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM","SUP-ITM-10040765","CDM","C1713","HCPCS","0278","RC","","","","both","","","5239.98","3929.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1624.39","31","","432.60","432.60","432.60","1 through 10","1624.39","4165.78","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM","SUP-ITM-10040765","CDM","C1713","HCPCS","0278","RC","","","","both","","","5239.98","3929.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1912.59","36.5","","148.37","54.89","631.39","94","1624.39","4165.78","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM","SUP-ITM-10040765","CDM","C1713","HCPCS","0278","RC","","","","both","","","5239.98","3929.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2006.91","38.3","","279.30","91.72","1116.77","266","1624.39","4165.78","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM","SUP-ITM-10040765","CDM","C1713","HCPCS","0278","RC","","","","both","","","5239.98","3929.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2247.95","42.9","","731.00","63.70","731.00","1 through 10","1624.39","4165.78","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM","SUP-ITM-10040765","CDM","C1713","HCPCS","0278","RC","","","","both","","","5239.98","3929.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2247.95","42.9","","384.74","384.74","384.74","1 through 10","1624.39","4165.78","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM","SUP-ITM-10040765","CDM","C1713","HCPCS","0278","RC","","","","both","","","5239.98","3929.98","WELLPOINT [1015]","HB AMC WELLPOINT","3866.06","73.78","","286.63","119.22","1107.45","105","1624.39","4165.78","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM","SUP-ITM-10040765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5239.98","3929.98","AETNA [1001]","HB AMC AETNA HMO","3657.51","69.8","","675.31","184.75","1721.50","286","2738.41","4282.11","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM","SUP-ITM-10040765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5239.98","3929.98","AETNA [1001]","HB AMC AETNA PPO","4212.94","80.4","","1261.44","103.12","1514.10","21","2738.41","4282.11","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM","SUP-ITM-10040765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5239.98","3929.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4212.94","80.4","","1365.00","1365.00","1365.00","1 through 10","2738.41","4282.11","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM","SUP-ITM-10040765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5239.98","3929.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4282.11","81.72","","5157.68","5157.68","5157.68","1 through 10","2738.41","4282.11","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM","SUP-ITM-10040765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5239.98","3929.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4282.11","81.72","","431.26","71.26","1459.57","88","2738.41","4282.11","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM STERILE","SUP-ITM-10040880","CDM","C1713","HCPCS","0278","RC","","","","both","","","4764.40","3573.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3787.70","79.5","","800.18","480.96","1887.97","195","1476.96","3787.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM STERILE","SUP-ITM-10040880","CDM","C1713","HCPCS","0278","RC","","","","both","","","4764.40","3573.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2539.43","53.3","","813.12","216.42","1444.50","81","1476.96","3787.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM STERILE","SUP-ITM-10040880","CDM","C1713","HCPCS","0278","RC","","","","both","","","4764.40","3573.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1476.96","31","","432.60","432.60","432.60","1 through 10","1476.96","3787.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM STERILE","SUP-ITM-10040880","CDM","C1713","HCPCS","0278","RC","","","","both","","","4764.40","3573.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1739.01","36.5","","148.37","54.89","631.39","94","1476.96","3787.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM STERILE","SUP-ITM-10040880","CDM","C1713","HCPCS","0278","RC","","","","both","","","4764.40","3573.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1824.77","38.3","","279.30","91.72","1116.77","266","1476.96","3787.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM STERILE","SUP-ITM-10040880","CDM","C1713","HCPCS","0278","RC","","","","both","","","4764.40","3573.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2043.93","42.9","","731.00","63.70","731.00","1 through 10","1476.96","3787.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM STERILE","SUP-ITM-10040880","CDM","C1713","HCPCS","0278","RC","","","","both","","","4764.40","3573.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2043.93","42.9","","384.74","384.74","384.74","1 through 10","1476.96","3787.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM STERILE","SUP-ITM-10040880","CDM","C1713","HCPCS","0278","RC","","","","both","","","4764.40","3573.30","WELLPOINT [1015]","HB AMC WELLPOINT","3515.17","73.78","","286.63","119.22","1107.45","105","1476.96","3787.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM STERILE","SUP-ITM-10040880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4764.40","3573.30","AETNA [1001]","HB AMC AETNA HMO","3325.55","69.8","","675.31","184.75","1721.50","286","2489.88","3893.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM STERILE","SUP-ITM-10040880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4764.40","3573.30","AETNA [1001]","HB AMC AETNA PPO","3830.58","80.4","","1261.44","103.12","1514.10","21","2489.88","3893.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM STERILE","SUP-ITM-10040880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4764.40","3573.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3830.58","80.4","","1365.00","1365.00","1365.00","1 through 10","2489.88","3893.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM STERILE","SUP-ITM-10040880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4764.40","3573.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3893.47","81.72","","5157.68","5157.68","5157.68","1 through 10","2489.88","3893.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X232MM LONG 10 HOLE SHAFT LCP PROXIMAL TITANIUM STERILE","SUP-ITM-10040880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4764.40","3573.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3893.47","81.72","","431.26","71.26","1459.57","88","2489.88","3893.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.13","3398.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3602.25","79.5","","800.18","480.96","1887.97","195","1404.65","3602.25","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.13","3398.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2415.09","53.3","","813.12","216.42","1444.50","81","1404.65","3602.25","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.13","3398.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1404.65","31","","432.60","432.60","432.60","1 through 10","1404.65","3602.25","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.13","3398.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1653.86","36.5","","148.37","54.89","631.39","94","1404.65","3602.25","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.13","3398.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1735.42","38.3","","279.30","91.72","1116.77","266","1404.65","3602.25","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.13","3398.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1943.85","42.9","","731.00","63.70","731.00","1 through 10","1404.65","3602.25","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.13","3398.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1943.85","42.9","","384.74","384.74","384.74","1 through 10","1404.65","3602.25","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.13","3398.35","WELLPOINT [1015]","HB AMC WELLPOINT","3343.07","73.78","","286.63","119.22","1107.45","105","1404.65","3602.25","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4531.13","3398.35","AETNA [1001]","HB AMC AETNA HMO","3162.73","69.8","","675.31","184.75","1721.50","286","2367.97","3702.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4531.13","3398.35","AETNA [1001]","HB AMC AETNA PPO","3643.03","80.4","","1261.44","103.12","1514.10","21","2367.97","3702.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4531.13","3398.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3643.03","80.4","","1365.00","1365.00","1365.00","1 through 10","2367.97","3702.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4531.13","3398.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3702.84","81.72","","5157.68","5157.68","5157.68","1 through 10","2367.97","3702.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4531.13","3398.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3702.84","81.72","","431.26","71.26","1459.57","88","2367.97","3702.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","both","","","4911.03","3683.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3904.27","79.5","","800.18","480.96","1887.97","195","1522.42","3904.27","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","both","","","4911.03","3683.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2617.58","53.3","","813.12","216.42","1444.50","81","1522.42","3904.27","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","both","","","4911.03","3683.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1522.42","31","","432.60","432.60","432.60","1 through 10","1522.42","3904.27","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","both","","","4911.03","3683.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1792.53","36.5","","148.37","54.89","631.39","94","1522.42","3904.27","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","both","","","4911.03","3683.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1880.92","38.3","","279.30","91.72","1116.77","266","1522.42","3904.27","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","both","","","4911.03","3683.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2106.83","42.9","","731.00","63.70","731.00","1 through 10","1522.42","3904.27","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","both","","","4911.03","3683.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2106.83","42.9","","384.74","384.74","384.74","1 through 10","1522.42","3904.27","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","both","","","4911.03","3683.27","WELLPOINT [1015]","HB AMC WELLPOINT","3623.36","73.78","","286.63","119.22","1107.45","105","1522.42","3904.27","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4911.03","3683.27","AETNA [1001]","HB AMC AETNA HMO","3427.90","69.8","","675.31","184.75","1721.50","286","2566.5","4013.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4911.03","3683.27","AETNA [1001]","HB AMC AETNA PPO","3948.47","80.4","","1261.44","103.12","1514.10","21","2566.5","4013.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4911.03","3683.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3948.47","80.4","","1365.00","1365.00","1365.00","1 through 10","2566.5","4013.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4911.03","3683.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4013.29","81.72","","5157.68","5157.68","5157.68","1 through 10","2566.5","4013.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4911.03","3683.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4013.29","81.72","","431.26","71.26","1459.57","88","2566.5","4013.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","4709.58","3532.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3744.12","79.5","","800.18","480.96","1887.97","195","1459.97","3744.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","4709.58","3532.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2510.21","53.3","","813.12","216.42","1444.50","81","1459.97","3744.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","4709.58","3532.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1459.97","31","","432.60","432.60","432.60","1 through 10","1459.97","3744.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","4709.58","3532.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1719.00","36.5","","148.37","54.89","631.39","94","1459.97","3744.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","4709.58","3532.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1803.77","38.3","","279.30","91.72","1116.77","266","1459.97","3744.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","4709.58","3532.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2020.41","42.9","","731.00","63.70","731.00","1 through 10","1459.97","3744.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","4709.58","3532.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2020.41","42.9","","384.74","384.74","384.74","1 through 10","1459.97","3744.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","4709.58","3532.18","WELLPOINT [1015]","HB AMC WELLPOINT","3474.73","73.78","","286.63","119.22","1107.45","105","1459.97","3744.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4709.58","3532.18","AETNA [1001]","HB AMC AETNA HMO","3287.29","69.8","","675.31","184.75","1721.50","286","2461.23","3848.67","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4709.58","3532.18","AETNA [1001]","HB AMC AETNA PPO","3786.50","80.4","","1261.44","103.12","1514.10","21","2461.23","3848.67","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4709.58","3532.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3786.50","80.4","","1365.00","1365.00","1365.00","1 through 10","2461.23","3848.67","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4709.58","3532.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3848.67","81.72","","5157.68","5157.68","5157.68","1 through 10","2461.23","3848.67","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4709.58","3532.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3848.67","81.72","","431.26","71.26","1459.57","88","2461.23","3848.67","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.87","1793.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1901.54","79.5","","800.18","480.96","1887.97","195","741.48","1901.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.87","1793.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1274.87","53.3","","813.12","216.42","1444.50","81","741.48","1901.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.87","1793.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","741.48","31","","432.60","432.60","432.60","1 through 10","741.48","1901.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.87","1793.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","873.03","36.5","","148.37","54.89","631.39","94","741.48","1901.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.87","1793.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","916.09","38.3","","279.30","91.72","1116.77","266","741.48","1901.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.87","1793.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1026.11","42.9","","731.00","63.70","731.00","1 through 10","741.48","1901.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.87","1793.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1026.11","42.9","","384.74","384.74","384.74","1 through 10","741.48","1901.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2391.87","1793.90","WELLPOINT [1015]","HB AMC WELLPOINT","1764.72","73.78","","286.63","119.22","1107.45","105","741.48","1901.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2391.87","1793.90","AETNA [1001]","HB AMC AETNA HMO","1669.53","69.8","","675.31","184.75","1721.50","286","1249.99","1954.64","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2391.87","1793.90","AETNA [1001]","HB AMC AETNA PPO","1923.06","80.4","","1261.44","103.12","1514.10","21","1249.99","1954.64","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2391.87","1793.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1923.06","80.4","","1365.00","1365.00","1365.00","1 through 10","1249.99","1954.64","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2391.87","1793.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1954.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1249.99","1954.64","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2391.87","1793.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1954.64","81.72","","431.26","71.26","1459.57","88","1249.99","1954.64","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4280.43","3210.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3402.94","79.5","","800.18","480.96","1887.97","195","1326.93","3402.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4280.43","3210.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2281.47","53.3","","813.12","216.42","1444.50","81","1326.93","3402.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4280.43","3210.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1326.93","31","","432.60","432.60","432.60","1 through 10","1326.93","3402.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4280.43","3210.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1562.36","36.5","","148.37","54.89","631.39","94","1326.93","3402.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4280.43","3210.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1639.40","38.3","","279.30","91.72","1116.77","266","1326.93","3402.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4280.43","3210.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1836.30","42.9","","731.00","63.70","731.00","1 through 10","1326.93","3402.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4280.43","3210.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1836.30","42.9","","384.74","384.74","384.74","1 through 10","1326.93","3402.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","4280.43","3210.32","WELLPOINT [1015]","HB AMC WELLPOINT","3158.10","73.78","","286.63","119.22","1107.45","105","1326.93","3402.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4280.43","3210.32","AETNA [1001]","HB AMC AETNA HMO","2987.74","69.8","","675.31","184.75","1721.50","286","2236.95","3497.97","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4280.43","3210.32","AETNA [1001]","HB AMC AETNA PPO","3441.47","80.4","","1261.44","103.12","1514.10","21","2236.95","3497.97","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4280.43","3210.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3441.47","80.4","","1365.00","1365.00","1365.00","1 through 10","2236.95","3497.97","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4280.43","3210.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3497.97","81.72","","5157.68","5157.68","5157.68","1 through 10","2236.95","3497.97","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4280.43","3210.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3497.97","81.72","","431.26","71.26","1459.57","88","2236.95","3497.97","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2608.13","1956.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2073.46","79.5","","800.18","480.96","1887.97","195","808.52","2073.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2608.13","1956.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1390.13","53.3","","813.12","216.42","1444.50","81","808.52","2073.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2608.13","1956.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","808.52","31","","432.60","432.60","432.60","1 through 10","808.52","2073.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2608.13","1956.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","951.97","36.5","","148.37","54.89","631.39","94","808.52","2073.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2608.13","1956.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","998.91","38.3","","279.30","91.72","1116.77","266","808.52","2073.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2608.13","1956.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1118.89","42.9","","731.00","63.70","731.00","1 through 10","808.52","2073.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2608.13","1956.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1118.89","42.9","","384.74","384.74","384.74","1 through 10","808.52","2073.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2608.13","1956.10","WELLPOINT [1015]","HB AMC WELLPOINT","1924.28","73.78","","286.63","119.22","1107.45","105","808.52","2073.46","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2608.13","1956.10","AETNA [1001]","HB AMC AETNA HMO","1820.47","69.8","","675.31","184.75","1721.50","286","1363.01","2131.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2608.13","1956.10","AETNA [1001]","HB AMC AETNA PPO","2096.94","80.4","","1261.44","103.12","1514.10","21","1363.01","2131.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2608.13","1956.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2096.94","80.4","","1365.00","1365.00","1365.00","1 through 10","1363.01","2131.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2608.13","1956.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2131.36","81.72","","5157.68","5157.68","5157.68","1 through 10","1363.01","2131.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2608.13","1956.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2131.36","81.72","","431.26","71.26","1459.57","88","1363.01","2131.36","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2675.10","79.5","","800.18","480.96","1887.97","195","1043.12","2675.1","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1793.49","53.3","","813.12","216.42","1444.50","81","1043.12","2675.1","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1043.12","31","","432.60","432.60","432.60","1 through 10","1043.12","2675.1","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1228.19","36.5","","148.37","54.89","631.39","94","1043.12","2675.1","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1288.76","38.3","","279.30","91.72","1116.77","266","1043.12","2675.1","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1443.54","42.9","","731.00","63.70","731.00","1 through 10","1043.12","2675.1","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1443.54","42.9","","384.74","384.74","384.74","1 through 10","1043.12","2675.1","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","WELLPOINT [1015]","HB AMC WELLPOINT","2482.62","73.78","","286.63","119.22","1107.45","105","1043.12","2675.1","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.90","2523.67","AETNA [1001]","HB AMC AETNA HMO","2348.70","69.8","","675.31","184.75","1721.50","286","1758.5","2749.8","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.90","2523.67","AETNA [1001]","HB AMC AETNA PPO","2705.38","80.4","","1261.44","103.12","1514.10","21","1758.5","2749.8","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.90","2523.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2705.38","80.4","","1365.00","1365.00","1365.00","1 through 10","1758.5","2749.8","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.90","2523.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2749.80","81.72","","5157.68","5157.68","5157.68","1 through 10","1758.5","2749.8","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.90","2523.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2749.80","81.72","","431.26","71.26","1459.57","88","1758.5","2749.8","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3613.04","79.5","","800.18","480.96","1887.97","195","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2422.33","53.3","","813.12","216.42","1444.50","81","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1408.86","31","","432.60","432.60","432.60","1 through 10","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1658.82","36.5","","148.37","54.89","631.39","94","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1740.62","38.3","","279.30","91.72","1116.77","266","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1949.68","42.9","","731.00","63.70","731.00","1 through 10","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1949.68","42.9","","384.74","384.74","384.74","1 through 10","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","WELLPOINT [1015]","HB AMC WELLPOINT","3353.08","73.78","","286.63","119.22","1107.45","105","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","AETNA [1001]","HB AMC AETNA HMO","3172.20","69.8","","675.31","184.75","1721.50","286","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","AETNA [1001]","HB AMC AETNA PPO","3653.94","80.4","","1261.44","103.12","1514.10","21","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3653.94","80.4","","1365.00","1365.00","1365.00","1 through 10","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3713.93","81.72","","5157.68","5157.68","5157.68","1 through 10","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3713.93","81.72","","431.26","71.26","1459.57","88","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE 80MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10174983","CDM","C1713","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3783.09","79.5","","800.18","480.96","1887.97","195","1475.17","3783.09","percent of total billed charges",""
"HUMERUS PLATE 80MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10174983","CDM","C1713","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2536.33","53.3","","813.12","216.42","1444.50","81","1475.17","3783.09","percent of total billed charges",""
"HUMERUS PLATE 80MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10174983","CDM","C1713","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1475.17","31","","432.60","432.60","432.60","1 through 10","1475.17","3783.09","percent of total billed charges",""
"HUMERUS PLATE 80MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10174983","CDM","C1713","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1736.89","36.5","","148.37","54.89","631.39","94","1475.17","3783.09","percent of total billed charges",""
"HUMERUS PLATE 80MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10174983","CDM","C1713","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1822.54","38.3","","279.30","91.72","1116.77","266","1475.17","3783.09","percent of total billed charges",""
"HUMERUS PLATE 80MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10174983","CDM","C1713","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2041.44","42.9","","731.00","63.70","731.00","1 through 10","1475.17","3783.09","percent of total billed charges",""
"HUMERUS PLATE 80MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10174983","CDM","C1713","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2041.44","42.9","","384.74","384.74","384.74","1 through 10","1475.17","3783.09","percent of total billed charges",""
"HUMERUS PLATE 80MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10174983","CDM","C1713","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","WELLPOINT [1015]","HB AMC WELLPOINT","3510.90","73.78","","286.63","119.22","1107.45","105","1475.17","3783.09","percent of total billed charges",""
"HUMERUS PLATE 80MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10174983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4758.60","3568.95","AETNA [1001]","HB AMC AETNA HMO","3321.50","69.8","","675.31","184.75","1721.50","286","2486.84","3888.73","percent of total billed charges",""
"HUMERUS PLATE 80MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10174983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4758.60","3568.95","AETNA [1001]","HB AMC AETNA PPO","3825.91","80.4","","1261.44","103.12","1514.10","21","2486.84","3888.73","percent of total billed charges",""
"HUMERUS PLATE 80MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10174983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4758.60","3568.95","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3825.91","80.4","","1365.00","1365.00","1365.00","1 through 10","2486.84","3888.73","percent of total billed charges",""
"HUMERUS PLATE 80MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10174983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4758.60","3568.95","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3888.73","81.72","","5157.68","5157.68","5157.68","1 through 10","2486.84","3888.73","percent of total billed charges",""
"HUMERUS PLATE 80MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10174983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4758.60","3568.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3888.73","81.72","","431.26","71.26","1459.57","88","2486.84","3888.73","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE RIGHT","SUP-ITM-10175169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4974.90","3731.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3955.05","79.5","","800.18","480.96","1887.97","195","1542.22","3955.05","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE RIGHT","SUP-ITM-10175169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4974.90","3731.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2651.62","53.3","","813.12","216.42","1444.50","81","1542.22","3955.05","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE RIGHT","SUP-ITM-10175169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4974.90","3731.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1542.22","31","","432.60","432.60","432.60","1 through 10","1542.22","3955.05","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE RIGHT","SUP-ITM-10175169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4974.90","3731.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1815.84","36.5","","148.37","54.89","631.39","94","1542.22","3955.05","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE RIGHT","SUP-ITM-10175169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4974.90","3731.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1905.39","38.3","","279.30","91.72","1116.77","266","1542.22","3955.05","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE RIGHT","SUP-ITM-10175169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4974.90","3731.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2134.23","42.9","","731.00","63.70","731.00","1 through 10","1542.22","3955.05","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE RIGHT","SUP-ITM-10175169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4974.90","3731.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2134.23","42.9","","384.74","384.74","384.74","1 through 10","1542.22","3955.05","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE RIGHT","SUP-ITM-10175169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4974.90","3731.17","WELLPOINT [1015]","HB AMC WELLPOINT","3670.48","73.78","","286.63","119.22","1107.45","105","1542.22","3955.05","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE RIGHT","SUP-ITM-10175169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4974.90","3731.17","AETNA [1001]","HB AMC AETNA HMO","3472.48","69.8","","675.31","184.75","1721.50","286","2599.88","4065.49","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE RIGHT","SUP-ITM-10175169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4974.90","3731.17","AETNA [1001]","HB AMC AETNA PPO","3999.82","80.4","","1261.44","103.12","1514.10","21","2599.88","4065.49","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE RIGHT","SUP-ITM-10175169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4974.90","3731.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3999.82","80.4","","1365.00","1365.00","1365.00","1 through 10","2599.88","4065.49","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE RIGHT","SUP-ITM-10175169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4974.90","3731.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4065.49","81.72","","5157.68","5157.68","5157.68","1 through 10","2599.88","4065.49","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE RIGHT","SUP-ITM-10175169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4974.90","3731.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4065.49","81.72","","431.26","71.26","1459.57","88","2599.88","4065.49","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3613.04","79.5","","800.18","480.96","1887.97","195","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2422.33","53.3","","813.12","216.42","1444.50","81","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1408.86","31","","432.60","432.60","432.60","1 through 10","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1658.82","36.5","","148.37","54.89","631.39","94","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1740.62","38.3","","279.30","91.72","1116.77","266","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1949.68","42.9","","731.00","63.70","731.00","1 through 10","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1949.68","42.9","","384.74","384.74","384.74","1 through 10","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","WELLPOINT [1015]","HB AMC WELLPOINT","3353.08","73.78","","286.63","119.22","1107.45","105","1408.86","3613.04","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","AETNA [1001]","HB AMC AETNA HMO","3172.20","69.8","","675.31","184.75","1721.50","286","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","AETNA [1001]","HB AMC AETNA PPO","3653.94","80.4","","1261.44","103.12","1514.10","21","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3653.94","80.4","","1365.00","1365.00","1365.00","1 through 10","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3713.93","81.72","","5157.68","5157.68","5157.68","1 through 10","2375.06","3713.93","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3713.93","81.72","","431.26","71.26","1459.57","88","2375.06","3713.93","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","both","","","5845.00","4383.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4646.78","79.5","","1309.77","674.56","6049.93","26","1811.95","4646.78","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","both","","","5845.00","4383.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3115.39","53.3","","1901.83","1901.83","2962.25","1 through 10","1811.95","4646.78","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","both","","","5845.00","4383.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2133.43","36.5","","1620.31","1620.31","19908.88","1 through 10","1811.95","4646.78","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","both","","","5845.00","4383.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2238.64","38.3","","352.91","352.91","2046.30","1 through 10","1811.95","4646.78","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","both","","","5845.00","4383.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2507.51","42.9","","9668.75","9668.75","9668.75","1 through 10","1811.95","4646.78","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","both","","","5845.00","4383.75","WELLPOINT [1015]","HB AMC WELLPOINT","4312.44","73.78","","699.88","384.10","3443.31","33","1811.95","4646.78","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5845.00","4383.75","AETNA [1001]","HB AMC AETNA HMO","4079.81","69.8","","1421.24","264.50","4933.46","29","3054.6","4776.53","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5845.00","4383.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4699.38","80.4","","1022.97","1022.97","3607.50","1 through 10","3054.6","4776.53","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5845.00","4383.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4776.53","81.72","","3010.54","693.88","5019.88","35","3054.6","4776.53","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3527.55","52.26","","1113.10","1113.10","1113.10","1 through 10","2092.5","5366.25","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5366.25","79.5","","1293.60","1148.53","1603.80","1 through 10","2092.5","5366.25","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2463.75","36.5","","1023.42","771.29","2068.67","33","2092.5","5366.25","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2585.25","38.3","","850.52","759.78","1211.25","66","2092.5","5366.25","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2895.75","42.9","","2548.09","2548.09","2548.09","1 through 10","2092.5","5366.25","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2895.75","42.9","","956.46","956.46","956.46","1 through 10","2092.5","5366.25","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","WELLPOINT [1015]","HB AMC WELLPOINT","4980.15","73.78","","2344.73","1619.47","2530.35","16","2092.5","5366.25","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","AETNA [1001]","HB AMC AETNA HMO","4711.50","69.8","","1523.63","988.41","4330.26","39","3527.55","5516.1","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","AETNA [1001]","HB AMC AETNA PPO","5427.00","80.4","","1670.25","1670.25","1670.25","1 through 10","3527.55","5516.1","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3527.55","52.26","","1113.10","1113.10","1113.10","1 through 10","3527.55","5516.1","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5516.10","81.72","","1738.90","1484.65","2716.94","38","3527.55","5516.1","percent of total billed charges",""
"HYDROCOIL AZUR 10MM 15CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024951","CDM","C1889","HCPCS","0278","RC","","","","both","","","3062.50","2296.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2434.69","79.5","","1309.77","674.56","6049.93","26","949.38","2434.69","percent of total billed charges",""
"HYDROCOIL AZUR 10MM 15CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024951","CDM","C1889","HCPCS","0278","RC","","","","both","","","3062.50","2296.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1632.31","53.3","","1901.83","1901.83","2962.25","1 through 10","949.38","2434.69","percent of total billed charges",""
"HYDROCOIL AZUR 10MM 15CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024951","CDM","C1889","HCPCS","0278","RC","","","","both","","","3062.50","2296.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1117.81","36.5","","1620.31","1620.31","19908.88","1 through 10","949.38","2434.69","percent of total billed charges",""
"HYDROCOIL AZUR 10MM 15CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024951","CDM","C1889","HCPCS","0278","RC","","","","both","","","3062.50","2296.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1172.94","38.3","","352.91","352.91","2046.30","1 through 10","949.38","2434.69","percent of total billed charges",""
"HYDROCOIL AZUR 10MM 15CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024951","CDM","C1889","HCPCS","0278","RC","","","","both","","","3062.50","2296.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1313.81","42.9","","9668.75","9668.75","9668.75","1 through 10","949.38","2434.69","percent of total billed charges",""
"HYDROCOIL AZUR 10MM 15CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024951","CDM","C1889","HCPCS","0278","RC","","","","both","","","3062.50","2296.87","WELLPOINT [1015]","HB AMC WELLPOINT","2259.51","73.78","","699.88","384.10","3443.31","33","949.38","2434.69","percent of total billed charges",""
"HYDROCOIL AZUR 10MM 15CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024951","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3062.50","2296.87","AETNA [1001]","HB AMC AETNA HMO","2137.63","69.8","","1421.24","264.50","4933.46","29","1600.46","2502.68","percent of total billed charges",""
"HYDROCOIL AZUR 10MM 15CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024951","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3062.50","2296.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2462.25","80.4","","1022.97","1022.97","3607.50","1 through 10","1600.46","2502.68","percent of total billed charges",""
"HYDROCOIL AZUR 10MM 15CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024951","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3062.50","2296.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2502.68","81.72","","3010.54","693.88","5019.88","35","1600.46","2502.68","percent of total billed charges",""
"HYDROCOIL AZUR 12MM 30CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091833","CDM","C1889","HCPCS","0278","RC","","","","both","","","4209.00","3156.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3346.16","79.5","","1309.77","674.56","6049.93","26","1304.79","3346.16","percent of total billed charges",""
"HYDROCOIL AZUR 12MM 30CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091833","CDM","C1889","HCPCS","0278","RC","","","","both","","","4209.00","3156.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2243.40","53.3","","1901.83","1901.83","2962.25","1 through 10","1304.79","3346.16","percent of total billed charges",""
"HYDROCOIL AZUR 12MM 30CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091833","CDM","C1889","HCPCS","0278","RC","","","","both","","","4209.00","3156.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1536.29","36.5","","1620.31","1620.31","19908.88","1 through 10","1304.79","3346.16","percent of total billed charges",""
"HYDROCOIL AZUR 12MM 30CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091833","CDM","C1889","HCPCS","0278","RC","","","","both","","","4209.00","3156.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1612.05","38.3","","352.91","352.91","2046.30","1 through 10","1304.79","3346.16","percent of total billed charges",""
"HYDROCOIL AZUR 12MM 30CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091833","CDM","C1889","HCPCS","0278","RC","","","","both","","","4209.00","3156.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1805.66","42.9","","9668.75","9668.75","9668.75","1 through 10","1304.79","3346.16","percent of total billed charges",""
"HYDROCOIL AZUR 12MM 30CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091833","CDM","C1889","HCPCS","0278","RC","","","","both","","","4209.00","3156.75","WELLPOINT [1015]","HB AMC WELLPOINT","3105.40","73.78","","699.88","384.10","3443.31","33","1304.79","3346.16","percent of total billed charges",""
"HYDROCOIL AZUR 12MM 30CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091833","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4209.00","3156.75","AETNA [1001]","HB AMC AETNA HMO","2937.88","69.8","","1421.24","264.50","4933.46","29","2199.62","3439.59","percent of total billed charges",""
"HYDROCOIL AZUR 12MM 30CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091833","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4209.00","3156.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3384.04","80.4","","1022.97","1022.97","3607.50","1 through 10","2199.62","3439.59","percent of total billed charges",""
"HYDROCOIL AZUR 12MM 30CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091833","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4209.00","3156.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3439.59","81.72","","3010.54","693.88","5019.88","35","2199.62","3439.59","percent of total billed charges",""
"HYDROCOIL AZUR 15MM 30CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076108","CDM","C1889","HCPCS","0278","RC","","","","both","","","3606.75","2705.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2867.37","79.5","","1309.77","674.56","6049.93","26","1118.09","2867.37","percent of total billed charges",""
"HYDROCOIL AZUR 15MM 30CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076108","CDM","C1889","HCPCS","0278","RC","","","","both","","","3606.75","2705.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1922.40","53.3","","1901.83","1901.83","2962.25","1 through 10","1118.09","2867.37","percent of total billed charges",""
"HYDROCOIL AZUR 15MM 30CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076108","CDM","C1889","HCPCS","0278","RC","","","","both","","","3606.75","2705.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1316.46","36.5","","1620.31","1620.31","19908.88","1 through 10","1118.09","2867.37","percent of total billed charges",""
"HYDROCOIL AZUR 15MM 30CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076108","CDM","C1889","HCPCS","0278","RC","","","","both","","","3606.75","2705.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1381.39","38.3","","352.91","352.91","2046.30","1 through 10","1118.09","2867.37","percent of total billed charges",""
"HYDROCOIL AZUR 15MM 30CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076108","CDM","C1889","HCPCS","0278","RC","","","","both","","","3606.75","2705.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1547.30","42.9","","9668.75","9668.75","9668.75","1 through 10","1118.09","2867.37","percent of total billed charges",""
"HYDROCOIL AZUR 15MM 30CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076108","CDM","C1889","HCPCS","0278","RC","","","","both","","","3606.75","2705.06","WELLPOINT [1015]","HB AMC WELLPOINT","2661.06","73.78","","699.88","384.10","3443.31","33","1118.09","2867.37","percent of total billed charges",""
"HYDROCOIL AZUR 15MM 30CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076108","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3606.75","2705.06","AETNA [1001]","HB AMC AETNA HMO","2517.51","69.8","","1421.24","264.50","4933.46","29","1884.89","2947.44","percent of total billed charges",""
"HYDROCOIL AZUR 15MM 30CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076108","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3606.75","2705.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2899.83","80.4","","1022.97","1022.97","3607.50","1 through 10","1884.89","2947.44","percent of total billed charges",""
"HYDROCOIL AZUR 15MM 30CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076108","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3606.75","2705.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2947.44","81.72","","3010.54","693.88","5019.88","35","1884.89","2947.44","percent of total billed charges",""
"HYDROCOIL AZUR 3MM 5CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076099","CDM","C1889","HCPCS","0278","RC","","","","both","","","2719.50","2039.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2162.00","79.5","","1309.77","674.56","6049.93","26","843.05","2162","percent of total billed charges",""
"HYDROCOIL AZUR 3MM 5CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076099","CDM","C1889","HCPCS","0278","RC","","","","both","","","2719.50","2039.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1449.49","53.3","","1901.83","1901.83","2962.25","1 through 10","843.05","2162","percent of total billed charges",""
"HYDROCOIL AZUR 3MM 5CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076099","CDM","C1889","HCPCS","0278","RC","","","","both","","","2719.50","2039.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","992.62","36.5","","1620.31","1620.31","19908.88","1 through 10","843.05","2162","percent of total billed charges",""
"HYDROCOIL AZUR 3MM 5CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076099","CDM","C1889","HCPCS","0278","RC","","","","both","","","2719.50","2039.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1041.57","38.3","","352.91","352.91","2046.30","1 through 10","843.05","2162","percent of total billed charges",""
"HYDROCOIL AZUR 3MM 5CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076099","CDM","C1889","HCPCS","0278","RC","","","","both","","","2719.50","2039.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1166.67","42.9","","9668.75","9668.75","9668.75","1 through 10","843.05","2162","percent of total billed charges",""
"HYDROCOIL AZUR 3MM 5CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076099","CDM","C1889","HCPCS","0278","RC","","","","both","","","2719.50","2039.62","WELLPOINT [1015]","HB AMC WELLPOINT","2006.45","73.78","","699.88","384.10","3443.31","33","843.05","2162","percent of total billed charges",""
"HYDROCOIL AZUR 3MM 5CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076099","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2719.50","2039.62","AETNA [1001]","HB AMC AETNA HMO","1898.21","69.8","","1421.24","264.50","4933.46","29","1421.21","2222.38","percent of total billed charges",""
"HYDROCOIL AZUR 3MM 5CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076099","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2719.50","2039.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2186.48","80.4","","1022.97","1022.97","3607.50","1 through 10","1421.21","2222.38","percent of total billed charges",""
"HYDROCOIL AZUR 3MM 5CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10076099","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2719.50","2039.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2222.38","81.72","","3010.54","693.88","5019.88","35","1421.21","2222.38","percent of total billed charges",""
"HYDROCOIL AZUR 4MM 10CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024946","CDM","C1889","HCPCS","0278","RC","","","","both","","","2880.50","2160.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2290.00","79.5","","1309.77","674.56","6049.93","26","892.96","2290","percent of total billed charges",""
"HYDROCOIL AZUR 4MM 10CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024946","CDM","C1889","HCPCS","0278","RC","","","","both","","","2880.50","2160.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1535.31","53.3","","1901.83","1901.83","2962.25","1 through 10","892.96","2290","percent of total billed charges",""
"HYDROCOIL AZUR 4MM 10CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024946","CDM","C1889","HCPCS","0278","RC","","","","both","","","2880.50","2160.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1051.38","36.5","","1620.31","1620.31","19908.88","1 through 10","892.96","2290","percent of total billed charges",""
"HYDROCOIL AZUR 4MM 10CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024946","CDM","C1889","HCPCS","0278","RC","","","","both","","","2880.50","2160.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1103.23","38.3","","352.91","352.91","2046.30","1 through 10","892.96","2290","percent of total billed charges",""
"HYDROCOIL AZUR 4MM 10CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024946","CDM","C1889","HCPCS","0278","RC","","","","both","","","2880.50","2160.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1235.73","42.9","","9668.75","9668.75","9668.75","1 through 10","892.96","2290","percent of total billed charges",""
"HYDROCOIL AZUR 4MM 10CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024946","CDM","C1889","HCPCS","0278","RC","","","","both","","","2880.50","2160.37","WELLPOINT [1015]","HB AMC WELLPOINT","2125.23","73.78","","699.88","384.10","3443.31","33","892.96","2290","percent of total billed charges",""
"HYDROCOIL AZUR 4MM 10CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024946","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2880.50","2160.37","AETNA [1001]","HB AMC AETNA HMO","2010.59","69.8","","1421.24","264.50","4933.46","29","1505.35","2353.94","percent of total billed charges",""
"HYDROCOIL AZUR 4MM 10CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024946","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2880.50","2160.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2315.92","80.4","","1022.97","1022.97","3607.50","1 through 10","1505.35","2353.94","percent of total billed charges",""
"HYDROCOIL AZUR 4MM 10CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024946","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2880.50","2160.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2353.94","81.72","","3010.54","693.88","5019.88","35","1505.35","2353.94","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 15CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091037","CDM","C1889","HCPCS","0278","RC","","","","both","","","4319.00","3239.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3433.61","79.5","","1309.77","674.56","6049.93","26","1338.89","3433.61","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 15CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091037","CDM","C1889","HCPCS","0278","RC","","","","both","","","4319.00","3239.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2302.03","53.3","","1901.83","1901.83","2962.25","1 through 10","1338.89","3433.61","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 15CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091037","CDM","C1889","HCPCS","0278","RC","","","","both","","","4319.00","3239.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1576.44","36.5","","1620.31","1620.31","19908.88","1 through 10","1338.89","3433.61","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 15CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091037","CDM","C1889","HCPCS","0278","RC","","","","both","","","4319.00","3239.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1654.18","38.3","","352.91","352.91","2046.30","1 through 10","1338.89","3433.61","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 15CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091037","CDM","C1889","HCPCS","0278","RC","","","","both","","","4319.00","3239.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1852.85","42.9","","9668.75","9668.75","9668.75","1 through 10","1338.89","3433.61","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 15CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091037","CDM","C1889","HCPCS","0278","RC","","","","both","","","4319.00","3239.25","WELLPOINT [1015]","HB AMC WELLPOINT","3186.56","73.78","","699.88","384.10","3443.31","33","1338.89","3433.61","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 15CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091037","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4319.00","3239.25","AETNA [1001]","HB AMC AETNA HMO","3014.66","69.8","","1421.24","264.50","4933.46","29","2257.11","3529.49","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 15CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091037","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4319.00","3239.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3472.48","80.4","","1022.97","1022.97","3607.50","1 through 10","2257.11","3529.49","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 15CM .035IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10091037","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4319.00","3239.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3529.49","81.72","","3010.54","693.88","5019.88","35","2257.11","3529.49","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 20CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024953","CDM","C1889","HCPCS","0278","RC","","","","both","","","3249.75","2437.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2583.55","79.5","","1309.77","674.56","6049.93","26","1007.42","2583.55","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 20CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024953","CDM","C1889","HCPCS","0278","RC","","","","both","","","3249.75","2437.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1732.12","53.3","","1901.83","1901.83","2962.25","1 through 10","1007.42","2583.55","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 20CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024953","CDM","C1889","HCPCS","0278","RC","","","","both","","","3249.75","2437.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1186.16","36.5","","1620.31","1620.31","19908.88","1 through 10","1007.42","2583.55","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 20CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024953","CDM","C1889","HCPCS","0278","RC","","","","both","","","3249.75","2437.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1244.65","38.3","","352.91","352.91","2046.30","1 through 10","1007.42","2583.55","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 20CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024953","CDM","C1889","HCPCS","0278","RC","","","","both","","","3249.75","2437.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1394.14","42.9","","9668.75","9668.75","9668.75","1 through 10","1007.42","2583.55","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 20CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024953","CDM","C1889","HCPCS","0278","RC","","","","both","","","3249.75","2437.31","WELLPOINT [1015]","HB AMC WELLPOINT","2397.67","73.78","","699.88","384.10","3443.31","33","1007.42","2583.55","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 20CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024953","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3249.75","2437.31","AETNA [1001]","HB AMC AETNA HMO","2268.33","69.8","","1421.24","264.50","4933.46","29","1698.32","2655.7","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 20CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024953","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3249.75","2437.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2612.80","80.4","","1022.97","1022.97","3607.50","1 through 10","1698.32","2655.7","percent of total billed charges",""
"HYDROCOIL AZUR 8MM 20CM .018IN DETACHABLE EMBOLIZATION HYDROGEL BX/1EA","SUP-ITM-10024953","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3249.75","2437.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2655.70","81.72","","3010.54","693.88","5019.88","35","1698.32","2655.7","percent of total billed charges",""
"HYDROCOIL AZUR CX 10MM 19CM .035IN DETACHABLE PERIPHERAL","SUP-ITM-10159171","CDM","C1889","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3094.14","79.5","","1309.77","674.56","6049.93","26","1206.52","3094.14","percent of total billed charges",""
"HYDROCOIL AZUR CX 10MM 19CM .035IN DETACHABLE PERIPHERAL","SUP-ITM-10159171","CDM","C1889","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2074.44","53.3","","1901.83","1901.83","2962.25","1 through 10","1206.52","3094.14","percent of total billed charges",""
"HYDROCOIL AZUR CX 10MM 19CM .035IN DETACHABLE PERIPHERAL","SUP-ITM-10159171","CDM","C1889","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1420.58","36.5","","1620.31","1620.31","19908.88","1 through 10","1206.52","3094.14","percent of total billed charges",""
"HYDROCOIL AZUR CX 10MM 19CM .035IN DETACHABLE PERIPHERAL","SUP-ITM-10159171","CDM","C1889","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1490.64","38.3","","352.91","352.91","2046.30","1 through 10","1206.52","3094.14","percent of total billed charges",""
"HYDROCOIL AZUR CX 10MM 19CM .035IN DETACHABLE PERIPHERAL","SUP-ITM-10159171","CDM","C1889","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.67","42.9","","9668.75","9668.75","9668.75","1 through 10","1206.52","3094.14","percent of total billed charges",""
"HYDROCOIL AZUR CX 10MM 19CM .035IN DETACHABLE PERIPHERAL","SUP-ITM-10159171","CDM","C1889","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","WELLPOINT [1015]","HB AMC WELLPOINT","2871.52","73.78","","699.88","384.10","3443.31","33","1206.52","3094.14","percent of total billed charges",""
"HYDROCOIL AZUR CX 10MM 19CM .035IN DETACHABLE PERIPHERAL","SUP-ITM-10159171","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","AETNA [1001]","HB AMC AETNA HMO","2716.62","69.8","","1421.24","264.50","4933.46","29","2033.96","3180.54","percent of total billed charges",""
"HYDROCOIL AZUR CX 10MM 19CM .035IN DETACHABLE PERIPHERAL","SUP-ITM-10159171","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3129.17","80.4","","1022.97","1022.97","3607.50","1 through 10","2033.96","3180.54","percent of total billed charges",""
"HYDROCOIL AZUR CX 10MM 19CM .035IN DETACHABLE PERIPHERAL","SUP-ITM-10159171","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3180.54","81.72","","3010.54","693.88","5019.88","35","2033.96","3180.54","percent of total billed charges",""
"Hydromorphone Inj 4mg/Ml 1ml","PX-63600104","CDM","J1170","HCPCS","0636","RC","","","","both","","","5.87","4.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2.25","38.3","","14.94","6.38","14.94","1 through 10","1.82","9.87","percent of total billed charges",""
"Hydromorphone Inj 4mg/Ml 1ml","PX-63600104","CDM","J1170","HCPCS","0636","RC","","","","outpatient","","","5.87","4.40","AETNA [1001]","HB AMC AETNA HMO","4.10","69.8","","6.61","4.83","9.67","1 through 10","2.75","4.8","percent of total billed charges",""
"Hydroxyindolacetic 5-(Hiaa)","PX-30000516","CDM","83497","CPT","0301","RC","","","","both","","","214.00","160.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","170.13","79.5","","163.70","104.00","163.70","1 through 10","12.64","203.3","percent of total billed charges",""
"Hydroxyindolacetic 5-(Hiaa)","PX-30000516","CDM","83497","CPT","0301","RC","","","","both","","","214.00","160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.11","36.5","","65.94","65.94","65.94","1 through 10","12.64","203.3","percent of total billed charges",""
"Hydroxyindolacetic 5-(Hiaa)","PX-30000516","CDM","83497","CPT","0301","RC","","","","both","","","214.00","160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.96","38.3","","81.33","81.33","81.33","1 through 10","12.64","203.3","percent of total billed charges",""
"Hydroxyindolacetic 5-(Hiaa)","PX-30000516","CDM","83497","CPT","0301","RC","","","","outpatient","","","214.00","160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.88","81.72","","166.28","91.46","166.28","1 through 10","13.29","174.88","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","both","","","317.00","237.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","252.02","79.5","","241.61","162.10","307.00","17","26.63","301.15","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","both","","","317.00","237.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","168.96","53.3","","162.10","162.10","241.61","12","26.63","301.15","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","both","","","317.00","237.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","98.27","31","","94.86","94.86","94.86","1 through 10","26.63","301.15","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","both","","","317.00","237.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","115.71","36.5","","114.51","81.94","343.53","26","26.63","301.15","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","both","","","317.00","237.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.41","38.3","","120.04","116.66","360.12","70","26.63","301.15","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","both","","","317.00","237.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","244.09","77","","241.61","241.61","241.61","1 through 10","26.63","301.15","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","both","","","317.00","237.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.99","42.9","","245.42","245.42","245.42","1 through 10","26.63","301.15","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","outpatient","","","317.00","237.75","AETNA [1001]","HB AMC AETNA HMO","221.27","69.8","","207.84","146.75","239.46","41","28.01","259.05","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","outpatient","","","317.00","237.75","AETNA [1001]","HB AMC AETNA PPO","254.87","80.4","","160.87","146.75","239.46","1 through 10","28.01","259.05","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","outpatient","","","317.00","237.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","254.87","80.4","","239.46","239.46","239.46","1 through 10","28.01","259.05","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","outpatient","","","317.00","237.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","259.05","81.72","","245.42","134.99","245.42","31","28.01","259.05","percent of total billed charges",""
"Hylan Polymers Inj 1mg","PX-63600215","CDM","J7325","HCPCS","0636","RC","","","","both","","","53.55","40.16","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7.79","","APC Price ($7.95). Final payment is multiplied by 98%.","8.91","8.91","9.07","432","7.79","41.23","other","OPPS APC"
"Hylan Polymers Inj 1mg","PX-63600216","CDM","J7325","HCPCS","0636","RC","","","","both","","","53.55","40.16","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7.79","","APC Price ($7.95). Final payment is multiplied by 98%.","8.91","8.91","9.07","432","7.79","41.23","other","OPPS APC"
"Hypertension With McC","304","MS-DRG","","","","","","","","inpatient","","","68968.03","51726.02","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","11572.20","","Case rate ($11,235.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,447.49, add-ons for qualifying new technology services are included. If operating cost exceeds $59,091.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,397.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,897.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,067.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.54. The transfer capital threshold is the transfer adjustment factor * $957.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11259.03","11259.03","11259.03","1 through 10","11010.45","17728.9068","other","Inpatient DRG"
"Hypertension With McC","304","MS-DRG","","","","","","","","inpatient","","","68968.03","51726.02","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","11235.15","","Case rate ($11,235.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,447.49, add-ons for qualifying new technology services are included. If operating cost exceeds $59,091.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,397.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,897.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,067.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.54. The transfer capital threshold is the transfer adjustment factor * $957.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10752.80","10752.80","10752.80","1 through 10","11010.45","17728.9068","other","Inpatient DRG"
"Hypertension With McC","304","MS-DRG","","","","","","","","inpatient","","","68968.03","51726.02","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10441.86","10441.86","10441.86","1 through 10","11010.45","17728.9068","case rate",""
"Hypertension With McC","304","MS-DRG","","","","","","","","inpatient","","","68968.03","51726.02","MEDICARE [2001]","HB BWH MEDICARE","14468.17","","Case rate ($14,468.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,447.49, add-ons for qualifying new technology services are included. If operating cost exceeds $59,091.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,397.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,130.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,067.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.54. The transfer capital threshold is the transfer adjustment factor * $957.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14128.19","0.03","14148.91","12","11010.45","17728.9068","other","Inpatient DRG"
"Hypertension With McC","304","MS-DRG","","","","","","","","inpatient","","","68968.03","51726.02","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","11010.45","","Case rate ($11,235.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,447.49, add-ons for qualifying new technology services are included. If operating cost exceeds $59,091.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,397.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,897.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,067.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.54. The transfer capital threshold is the transfer adjustment factor * $957.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10786.32","10786.32","10786.32","1 through 10","11010.45","17728.9068","other","Inpatient DRG"
"Hypertension With McC","304","MS-DRG","","","","","","","","inpatient","","","68968.03","51726.02","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11010.45","","Case rate ($11,235.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,447.49, add-ons for qualifying new technology services are included. If operating cost exceeds $59,091.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,397.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,897.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,067.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $957.54. The transfer capital threshold is the transfer adjustment factor * $957.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15147.46","15147.46","15147.46","1 through 10","11010.45","17728.9068","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","46704.65","35028.49","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","5793.60","5793.60","5793.60","1 through 10","7122.59","11827.89","case rate",""
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","46704.65","35028.49","MEDICARE [2001]","HB BWH MEDICARE","9319.42","","Case rate ($9,319.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,671.76, add-ons for qualifying new technology services are included. If operating cost exceeds $54,316.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,047.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,331.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,291.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.60. The transfer capital threshold is the transfer adjustment factor * $607.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9128.38","0.03","9141.63","17","7122.59","11827.89","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","46704.65","35028.49","MOLINA [1014]","HB BWH MOLINA","7122.59","","Case rate ($7,267.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,671.76, add-ons for qualifying new technology services are included. If operating cost exceeds $54,316.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,047.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,280.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,291.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.60. The transfer capital threshold is the transfer adjustment factor * $607.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14173.31","14173.31","14173.31","1 through 10","7122.59","11827.89","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","46704.65","35028.49","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7122.59","","Case rate ($7,267.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,671.76, add-ons for qualifying new technology services are included. If operating cost exceeds $54,316.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,047.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,280.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,291.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.60. The transfer capital threshold is the transfer adjustment factor * $607.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6995.75","6995.75","6995.75","1 through 10","7122.59","11827.89","other","Inpatient DRG"
"Hypertension,EXTREME","199","DRG","","","","","","","","inpatient","","","73302.13","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","43926.52","","Standard inlier is a Case rate ($43,926.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $42,030, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,235.00) for the length of stay and the standard reimbursement.","43926.51","43926.51","43926.51","1 through 10","3740.11","90312.67","case rate",""
"Hypertension,EXTREME","199","DRG","","","","","","","","inpatient","","","73302.13","","MASSHEALTH [3001]","HB BWH MEDICAID","15696.11","","Case rate ($17,354.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,784.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18053.49","17350.49","55369.97","1 through 10","3740.11","90312.67","case rate",""
"Hypertension,MAJOR","199","DRG","","","","","","","","inpatient","","","68733.56","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","30080.63","","Standard inlier is a Case rate ($30,080.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,453, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,269.70) for the length of stay and the standard reimbursement.","30080.62","30080.62","30080.62","1 through 10","3740.11","90312.67","case rate",""
"Hypertension,MAJOR","199","DRG","","","","","","","","inpatient","","","68733.56","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9577.5494","","Fee schedule rate ($20,758.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9577.5494","19958.80","19958.80","1 through 10","3740.11","90312.67","case rate",""
"Hypertension,MAJOR","199","DRG","","","","","","","","inpatient","","","68733.56","","MASSHEALTH [3001]","HB BWH MEDICAID","9446.22","","Case rate ($10,444.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,874.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10441.86","10441.86","10441.86","1 through 10","3740.11","90312.67","case rate",""
"Hypertension,MAJOR","199","DRG","","","","","","","","inpatient","","","68733.56","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","9446.22","","Case rate ($10,444.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,874.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","3740.11","90312.67","case rate",""
"Hypertension,MAJOR","199","DRG","","","","","","","","inpatient","","","68733.56","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23981.39","","Fee schedule rate ($23,981.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23981.39","23981.39","23981.39","1 through 10","3740.11","90312.67","case rate",""
"Hypertension,MAJOR","199","DRG","","","","","","","","inpatient","","","68733.56","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9446.22","","Case rate ($10,444.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,874.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","38298.92","38298.92","38298.92","1 through 10","3740.11","90312.67","case rate",""
"Hypertension,MINOR","199","DRG","","","","","","","","inpatient","","","15354.34","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","15895.60","","Standard inlier is a Case rate ($15,895.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,008, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,256.48) for the length of stay and the standard reimbursement.","14489.42","14489.42","14489.42","1 through 10","3740.11","90312.67","case rate",""
"Hypertension,MODERATE","199","DRG","","","","","","","","inpatient","","","37203.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19424.00","","Standard inlier is a Case rate ($19,424.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,752, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,757.35) for the length of stay and the standard reimbursement.","17705.68","17705.68","19424.00","1 through 10","3740.11","90312.67","case rate",""
"Hypertension,MODERATE","199","DRG","","","","","","","","inpatient","","","37203.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21837.82","","Standard inlier is a Case rate ($21,837.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,752, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,099.70) for the length of stay and the standard reimbursement.","21837.81","21837.81","21837.82","1 through 10","3740.11","90312.67","case rate",""
"Hypertension,MODERATE","199","DRG","","","","","","","","inpatient","","","37203.10","","MASSHEALTH [3001]","HB BWH MEDICAID","5241.18","","Case rate ($5,795.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,225.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","194.80","194.80","194.80","1 through 10","3740.11","90312.67","case rate",""
"Hypertension,MODERATE","199","DRG","","","","","","","","inpatient","","","37203.10","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5241.18","","Case rate ($5,795.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,225.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5793.60","5793.60","5793.60","1 through 10","3740.11","90312.67","case rate",""
"Hypo Hyper Kal Paralysis Nextgen Dna Sequence (5 Genes) (Hhkal)","PX-31000681","CDM","81479","CPT","0310","RC","","","","both","","","1811.00","1358.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1439.75","79.5","","0.65","0.65","0.65","1 through 10","561.41","1720.45","percent of total billed charges",""
"Hypo Hyper Kal Paralysis Nextgen Dna Sequence (5 Genes) (Hhkal)","PX-31000681","CDM","81479","CPT","0310","RC","","","","both","","","1811.00","1358.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","965.26","53.3","","0.79","0.79","0.79","1 through 10","561.41","1720.45","percent of total billed charges",""
"Hypo Hyper Kal Paralysis Nextgen Dna Sequence (5 Genes) (Hhkal)","PX-31000681","CDM","81479","CPT","0310","RC","","","","outpatient","","","1811.00","1358.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","905.50","50","","1.00","1.00","1.00","1 through 10","156.55","1494.08","percent of total billed charges",""
"Hypo Hyper Kal Paralysis Nextgen Dna Sequence (5 Genes) (Hhkal)","PX-31000681","CDM","81479","CPT","0310","RC","","","","outpatient","","","1811.00","1358.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","950.78","52.5","","1.00","0.53","1.00","1 through 10","156.55","1494.08","percent of total billed charges",""
"Hypovolemia And Related Electrolyte Disorders,EXTREME","422","DRG","","","","","","","","inpatient","","","90007.81","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","7926.8648","","Fee schedule rate ($57,102.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7926.8648","57102.96","57102.96","1 through 10","3790.37","94221.02","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MAJOR","422","DRG","","","","","","","","inpatient","","","46484.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","23042.96","","Standard inlier is a Case rate ($23,042.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,567, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,271.09) for the length of stay and the standard reimbursement.","21004.50","21004.50","21004.50","1 through 10","3790.37","94221.02","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MAJOR","422","DRG","","","","","","","","inpatient","","","46484.43","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","8323.4384","","Fee schedule rate ($23,272.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8323.4384","22374.52","22374.52","1 through 10","3790.37","94221.02","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MAJOR","422","DRG","","","","","","","","inpatient","","","46484.43","","MASSHEALTH [3001]","HB BWH MEDICAID","7941.73","","Case rate ($8,780.95). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,210.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9134.49","9134.49","9134.49","1 through 10","3790.37","94221.02","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MAJOR","422","DRG","","","","","","","","inpatient","","","46484.43","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7941.73","","Case rate ($8,780.95). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,210.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8778.79","8778.79","8778.79","1 through 10","3790.37","94221.02","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MODERATE","422","DRG","","","","","","","","inpatient","","","34791.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","15830.92","","Standard inlier is a Case rate ($15,830.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,959, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,247.29) for the length of stay and the standard reimbursement.","15830.91","15830.91","15830.91","1 through 10","3790.37","94221.02","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MODERATE","422","DRG","","","","","","","","inpatient","","","34791.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","17798.22","","Standard inlier is a Case rate ($17,798.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,959, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,526.31) for the length of stay and the standard reimbursement.","17798.22","17798.22","17798.22","1 through 10","3790.37","94221.02","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MODERATE","422","DRG","","","","","","","","inpatient","","","34791.55","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","7926.8648","","Fee schedule rate ($22,163.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7926.8648","11845.56","11845.56","1 through 10","3790.37","94221.02","case rate",""
"Hysteroscopy Ablat Endometrial","PX-76001397","CDM","58563","CPT","0761","RC","","","","outpatient","","","9814.00","7360.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","5522.56","5468.30","5522.56","1 through 10","3713.25","9843.6","other","ASC "
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3888.77","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3517.83","3512.03","3517.83","1 through 10","2700.1","6924.45","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","26735.22","26735.22","26735.22","1 through 10","2700.1","6924.45","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6924.45","79.5","","8446.00","4459.49","38460.68","18","2700.1","6924.45","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4642.43","53.3","","8588.45","3227.49","19747.40","17","2700.1","6924.45","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3715.47","3715.47","3715.47","1 through 10","2700.1","6924.45","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3715.47","3715.47","3715.47","1 through 10","2700.1","6924.45","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","HUMANA [1012]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3723.02","3723.02","3723.02","1 through 10","2700.1","6924.45","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","MEDICARE [2001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3412.18","3775.88","25","2700.1","6924.45","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2700.10","31","","11404.89","11404.89","11404.89","1 through 10","2700.1","6924.45","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3179.15","36.5","","7322.90","3057.45","15751.80","18","2700.1","6924.45","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3335.93","38.3","","6604.78","3302.39","19080.03","82","2700.1","6924.45","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","TRICARE [160005]","HB BWH TRICARE","3587.09","","APC Price ($3,775.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","7551.76","3587.09","7551.76","1 through 10","2700.1","6924.45","other","Tricare OPPS"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3736.59","42.9","","1865.96","1865.96","1865.96","1 through 10","2700.1","6924.45","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","8710.00","6532.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3708.67","3351.84","3775.88","1 through 10","2700.1","6924.45","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","8710.00","6532.50","AETNA [1001]","HB AMC AETNA HMO","6079.58","69.8","","6505.20","4037.19","11012.08","18","2125.14","7117.81","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","8710.00","6532.50","AETNA [1001]","HB AMC AETNA PPO","7002.84","80.4","","4798.17","4798.16","6587.88","1 through 10","2125.14","7117.81","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","8710.00","6532.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5424.80","5424.80","5524.71","59","2125.14","7117.81","other","ASC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","8710.00","6532.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6259.18","6259.18","6321.29","140","2125.14","7117.81","other","ASC "
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","8710.00","6532.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6162.91","5440.36","6162.91","1 through 10","2125.14","7117.81","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","8710.00","6532.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4930.32","4930.32","14790.96","46","2125.14","7117.81","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","8710.00","6532.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5185.34","5185.34","14982.24","32","2125.14","7117.81","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","8710.00","6532.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 383%, 191.5 procedures at 0%.","8139.29","8139.29","8139.29","1 through 10","2125.14","7117.81","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","8710.00","6532.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","6396.67","6396.67","6396.67","1 through 10","2125.14","7117.81","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","8710.00","6532.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4080.27","4080.27","4080.27","1 through 10","2125.14","7117.81","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","8710.00","6532.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","10455.68","5440.36","10880.72","1 through 10","2125.14","7117.81","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","8710.00","6532.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7117.81","81.72","","6751.73","3333.50","13003.04","15","2125.14","7117.81","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","6265.00","4698.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4980.68","79.5","","4781.03","3207.60","4781.03","1 through 10","1942.15","4980.68","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","6265.00","4698.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3339.25","53.3","","3207.60","2978.49","5956.98","1 through 10","1942.15","4980.68","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","6265.00","4698.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","4980.68","79.5","","4781.03","4781.03","4781.03","1 through 10","1942.15","4980.68","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","6265.00","4698.75","MEDICARE [2001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3412.18","3775.88","1 through 10","1942.15","4980.68","other","OPPS APC"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","6265.00","4698.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2286.73","36.5","","2265.98","1925.78","2265.98","11","1942.15","4980.68","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","6265.00","4698.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2399.50","38.3","","2375.33","2375.33","2375.33","62","1942.15","4980.68","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","6265.00","4698.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","3587.09","","APC Price ($3,775.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3775.88","3775.88","3775.88","1 through 10","1942.15","4980.68","other","Tricare OPPS"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","both","","","6265.00","4698.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3775.88","3357.59","3775.88","1 through 10","1942.15","4980.68","other","OPPS APC"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","AETNA [1001]","HB AMC AETNA HMO","4372.97","69.8","","4112.78","2903.85","4738.50","24","2125.14","5119.76","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","AETNA [1001]","HB AMC AETNA PPO","5037.06","80.4","","4738.50","2903.85","4738.50","1 through 10","2125.14","5119.76","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5424.80","5424.80","5524.71","68","2125.14","5119.76","other","ASC"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6259.18","6259.18","6321.29","122","2125.14","5119.76","other","ASC "
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6162.91","6162.91","6162.91","1 through 10","2125.14","5119.76","other","Multiple Surgery"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4930.32","4930.32","4930.32","31","2125.14","5119.76","other","Multiple Surgery"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5185.34","5185.34","15556.02","22","2125.14","5119.76","other","Multiple Surgery"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5185.34","5185.34","5185.34","1 through 10","2125.14","5119.76","other","Multiple Surgery"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","5440.36","5165.71","5440.36","1 through 10","2125.14","5119.76","other","Multiple Surgery"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5037.06","80.4","","3037.50","3037.50","3037.50","1 through 10","2125.14","5119.76","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5227.84","5227.84","5227.84","1 through 10","2125.14","5119.76","other","Multiple Surgery"
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5119.76","81.72","","4856.36","2671.18","4937.48","18","2125.14","5119.76","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","5929.14","5929.14","5929.14","1 through 10","2125.14","5119.76","other","Multiple Surgery"
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","both","","","6265.00","4698.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4980.68","79.5","","6495.98","4781.03","6495.98","1 through 10","1942.15","8083.96","percent of total billed charges",""
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","both","","","6265.00","4698.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3339.25","53.3","","4781.03","2165.33","16958.30","1 through 10","1942.15","8083.96","percent of total billed charges",""
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","both","","","6265.00","4698.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2399.50","38.3","","6360.01","2375.33","8230.55","1 through 10","1942.15","8083.96","percent of total billed charges",""
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","both","","","6265.00","4698.75","TRICARE [160005]","HB BWH TRICARE","5569.21","","APC Price ($5,862.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","5862.33","5862.33","5862.33","1 through 10","1942.15","8083.96","other","Tricare OPPS"
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","both","","","6265.00","4698.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","5744.50","","APC Price ($5,861.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5862.33","5862.33","5862.33","1 through 10","1942.15","8083.96","other","OPPS APC"
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","AETNA [1001]","HB AMC AETNA HMO","4372.97","69.8","","28501.70","2903.85","28501.70","1 through 10","3274.09","5545.35","percent of total billed charges",""
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","9478.70","9478.70","9653.27","1 through 10","3274.09","5545.35","other","ASC"
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","11045.12","10936.60","11045.12","12","3274.09","5545.35","other","ASC "
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","25844.22","8614.74","25844.22","1 through 10","3274.09","5545.35","other","Multiple Surgery"
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","27180.99","9060.33","27180.99","1 through 10","3274.09","5545.35","other","Multiple Surgery"
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","9505.92","9505.92","9505.92","1 through 10","3274.09","5545.35","other","Multiple Surgery"
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5119.76","81.72","","9835.02","4917.51","9835.02","1 through 10","3274.09","5545.35","percent of total billed charges",""
"Hysteroscopy Lysis Intrauterine Adhesions","PX-98302481","CDM","58559","CPT","0983","RC","","","","both","","","2164.00","1623.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1720.38","79.5","","6495.98","4781.03","6495.98","1 through 10","670.84","8083.96","percent of total billed charges",""
"Hysteroscopy Lysis Intrauterine Adhesions","PX-98302481","CDM","58559","CPT","0983","RC","","","","both","","","2164.00","1623.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1153.41","53.3","","4781.03","2165.33","16958.30","1 through 10","670.84","8083.96","percent of total billed charges",""
"Hysteroscopy Lysis Intrauterine Adhesions","PX-98302481","CDM","58559","CPT","0983","RC","","","","both","","","2164.00","1623.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","828.81","38.3","","6360.01","2375.33","8230.55","1 through 10","670.84","8083.96","percent of total billed charges",""
"Hysteroscopy Lysis Intrauterine Adhesions","PX-98302481","CDM","58559","CPT","0983","RC","","","","both","","","2164.00","1623.00","TRICARE [160005]","HB BWH TRICARE","5569.21","","APC Price ($5,862.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","5862.33","5862.33","5862.33","1 through 10","670.84","8083.96","other","Tricare OPPS"
"Hysteroscopy Lysis Intrauterine Adhesions","PX-98302481","CDM","58559","CPT","0983","RC","","","","both","","","2164.00","1623.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","5744.50","","APC Price ($5,861.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5862.33","5862.33","5862.33","1 through 10","670.84","8083.96","other","OPPS APC"
"Hysteroscopy Lysis Intrauterine Adhesions","PX-98302481","CDM","58559","CPT","0983","RC","","","","outpatient","","","2164.00","1623.00","AETNA [1001]","HB AMC AETNA HMO","1510.47","69.8","","28501.70","2903.85","28501.70","1 through 10","1209.68","5545.35","percent of total billed charges",""
"Hysteroscopy Lysis Intrauterine Adhesions","PX-98302481","CDM","58559","CPT","0983","RC","","","","outpatient","","","2164.00","1623.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","9478.70","9478.70","9653.27","1 through 10","1209.68","5545.35","other","ASC"
"Hysteroscopy Lysis Intrauterine Adhesions","PX-98302481","CDM","58559","CPT","0983","RC","","","","outpatient","","","2164.00","1623.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","11045.12","10936.60","11045.12","12","1209.68","5545.35","other","ASC "
"Hysteroscopy Lysis Intrauterine Adhesions","PX-98302481","CDM","58559","CPT","0983","RC","","","","outpatient","","","2164.00","1623.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","25844.22","8614.74","25844.22","1 through 10","1209.68","5545.35","other","Multiple Surgery"
"Hysteroscopy Lysis Intrauterine Adhesions","PX-98302481","CDM","58559","CPT","0983","RC","","","","outpatient","","","2164.00","1623.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","27180.99","9060.33","27180.99","1 through 10","1209.68","5545.35","other","Multiple Surgery"
"Hysteroscopy Lysis Intrauterine Adhesions","PX-98302481","CDM","58559","CPT","0983","RC","","","","outpatient","","","2164.00","1623.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","9505.92","9505.92","9505.92","1 through 10","1209.68","5545.35","other","Multiple Surgery"
"Hysteroscopy Lysis Intrauterine Adhesions","PX-98302481","CDM","58559","CPT","0983","RC","","","","outpatient","","","2164.00","1623.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1768.42","81.72","","9835.02","4917.51","9835.02","1 through 10","1209.68","5545.35","percent of total billed charges",""
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","both","","","6265.00","4698.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2286.73","36.5","","8925.14","8925.14","8925.14","1 through 10","1942.15","4980.68","percent of total billed charges",""
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","both","","","6265.00","4698.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2399.50","38.3","","4675.14","4675.14","4675.14","1 through 10","1942.15","4980.68","percent of total billed charges",""
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","AETNA [1001]","HB AMC AETNA HMO","4372.97","69.8","","11012.08","11012.08","11012.08","1 through 10","2125.14","8899.59","percent of total billed charges",""
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2762.36","2762.36","2762.36","1 through 10","2125.14","8899.59","other","ASC"
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","outpatient","","","6265.00","4698.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6321.29","6259.18","6321.29","1 through 10","2125.14","8899.59","other","ASC "
"Hysteroscopy Removal Impacted Foreign Body","PX-98300657","CDM","58562","CPT","0983","RC","","","","both","","","1106.00","829.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","403.69","36.5","","8925.14","8925.14","8925.14","1 through 10","342.86","4719.38","percent of total billed charges",""
"Hysteroscopy Removal Impacted Foreign Body","PX-98300657","CDM","58562","CPT","0983","RC","","","","both","","","1106.00","829.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","423.60","38.3","","4675.14","4675.14","4675.14","1 through 10","342.86","4719.38","percent of total billed charges",""
"Hysteroscopy Removal Impacted Foreign Body","PX-98300657","CDM","58562","CPT","0983","RC","","","","outpatient","","","1106.00","829.50","AETNA [1001]","HB AMC AETNA HMO","771.99","69.8","","11012.08","11012.08","11012.08","1 through 10","618.25","8899.59","percent of total billed charges",""
"Hysteroscopy Removal Leiomyomata","PX-98301143","CDM","58561","CPT","0983","RC","","","","both","","","2372.00","1779.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1885.74","79.5","","32806.88","25328.16","32806.88","1 through 10","735.32","8083.96","percent of total billed charges",""
"Hysteroscopy Removal Leiomyomata","PX-98301143","CDM","58561","CPT","0983","RC","","","","both","","","2372.00","1779.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1264.28","53.3","","6399.01","6399.01","6399.01","1 through 10","735.32","8083.96","percent of total billed charges",""
"Hysteroscopy Removal Leiomyomata","PX-98301143","CDM","58561","CPT","0983","RC","","","","both","","","2372.00","1779.00","MEDICARE [2001]","HB BWH MEDICARE","5861.74","","APC Price ($5,861.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5862.33","5862.33","5862.33","1 through 10","735.32","8083.96","other","OPPS APC"
"Hysteroscopy Removal Leiomyomata","PX-98301143","CDM","58561","CPT","0983","RC","","","","both","","","2372.00","1779.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","865.78","36.5","","10834.48","4589.02","10834.48","1 through 10","735.32","8083.96","percent of total billed charges",""
"Hysteroscopy Removal Leiomyomata","PX-98301143","CDM","58561","CPT","0983","RC","","","","both","","","2372.00","1779.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","908.48","38.3","","6360.01","4810.47","12558.14","1 through 10","735.32","8083.96","percent of total billed charges",""
"Hysteroscopy Removal Leiomyomata","PX-98301143","CDM","58561","CPT","0983","RC","","","","both","","","2372.00","1779.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","5744.50","","APC Price ($5,861.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5768.53","5768.53","5768.53","1 through 10","735.32","8083.96","other","OPPS APC"
"Hysteroscopy Removal Leiomyomata","PX-98301143","CDM","58561","CPT","0983","RC","","","","outpatient","","","2372.00","1779.00","AETNA [1001]","HB AMC AETNA HMO","1655.66","69.8","","11012.08","11012.08","11012.08","1 through 10","1054.35","9843.6","percent of total billed charges",""
"Hysteroscopy Removal Leiomyomata","PX-98301143","CDM","58561","CPT","0983","RC","","","","outpatient","","","2372.00","1779.00","AETNA [1001]","HB AMC AETNA PPO","1907.09","80.4","","7775.15","7775.15","7775.15","1 through 10","1054.35","9843.6","percent of total billed charges",""
"Hysteroscopy Removal Leiomyomata","PX-98301143","CDM","58561","CPT","0983","RC","","","","outpatient","","","2372.00","1779.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","9653.27","9478.70","9653.27","1 through 10","1054.35","9843.6","other","ASC"
"Hysteroscopy Removal Leiomyomata","PX-98301143","CDM","58561","CPT","0983","RC","","","","outpatient","","","2372.00","1779.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","10936.60","5522.56","11045.12","18","1054.35","9843.6","other","ASC "
"Hysteroscopy Removal Leiomyomata","PX-98301143","CDM","58561","CPT","0983","RC","","","","outpatient","","","2372.00","1779.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8614.74","8280.55","8614.74","1 through 10","1054.35","9843.6","other","Multiple Surgery"
"Hysteroscopy Removal Leiomyomata","PX-98301143","CDM","58561","CPT","0983","RC","","","","outpatient","","","2372.00","1779.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9060.33","8280.55","9060.33","1 through 10","1054.35","9843.6","other","Multiple Surgery"
"Hysteroscopy Removal Leiomyomata","PX-98301143","CDM","58561","CPT","0983","RC","","","","outpatient","","","2372.00","1779.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1938.40","81.72","","10000.00","4917.51","10000.00","1 through 10","1054.35","9843.6","percent of total billed charges",""
"I&D Abscess Cplx","PX-76000005","CDM","10061","CPT","0761","RC","","","","both","","","1141.00","855.75","FALLON HEALTH [1008]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","464.98","464.98","464.98","1 through 10","353.71","907.1","other","OPPS APC"
"I&D Abscess Cplx","PX-76000005","CDM","10061","CPT","0761","RC","","","","both","","","1141.00","855.75","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","353.71","907.1","other","OPPS APC"
"I&D Abscess Cplx","PX-76000005","CDM","10061","CPT","0761","RC","","","","both","","","1141.00","855.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","416.47","36.5","","412.54","412.54","412.54","1 through 10","353.71","907.1","percent of total billed charges",""
"I&D Abscess Cplx","PX-76000005","CDM","10061","CPT","0761","RC","","","","both","","","1141.00","855.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","437.00","38.3","","432.45","420.28","432.45","1 through 10","353.71","907.1","percent of total billed charges",""
"I&D Abscess Cplx","PX-76000005","CDM","10061","CPT","0761","RC","","","","both","","","1141.00","855.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1394.94","1394.94","1394.94","1 through 10","353.71","907.1","other","OPPS APC"
"I&D Abscess Cplx","PX-76000005","CDM","10061","CPT","0761","RC","","","","both","","","1141.00","855.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.49","433.50","472.89","1 through 10","353.71","907.1","other","OPPS APC"
"I&D Abscess Cplx","PX-76000005","CDM","10061","CPT","0761","RC","","","","outpatient","","","1141.00","855.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","734.86","734.86","734.86","1 through 10","314.08","932.43","other","ASC"
"I&D Abscess Cplx","PX-76000005","CDM","10061","CPT","0761","RC","","","","outpatient","","","1141.00","855.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","840.82","832.56","840.82","1 through 10","314.08","932.43","other","ASC "
"I&D Abscess Cplx","PX-76000005","CDM","10061","CPT","0761","RC","","","","outpatient","","","1141.00","855.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","932.43","81.72","","884.14","884.14","884.14","1 through 10","314.08","932.43","percent of total billed charges",""
"I&D Abscess Gland Bartholin's","PX-76001331","CDM","56420","CPT","0761","RC","","","","both","","","637.00","477.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","243.97","38.3","","469.68","187.72","469.68","1 through 10","197.47","506.42","percent of total billed charges",""
"I&D Abscess Gland Bartholin's","PX-76001331","CDM","56420","CPT","0761","RC","","","","outpatient","","","637.00","477.75","AETNA [1001]","HB AMC AETNA HMO","444.63","69.8","","482.04","482.04","482.04","1 through 10","165.93","2384.07","percent of total billed charges",""
"I&D Abscess Gland Bartholin's","PX-76001331","CDM","56420","CPT","0761","RC","","","","outpatient","","","637.00","477.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","388.23","388.23","388.23","1 through 10","165.93","2384.07","other","ASC"
"I&D Abscess Gland Bartholin's","PX-76001331","CDM","56420","CPT","0761","RC","","","","outpatient","","","637.00","477.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","439.84","439.84","439.84","1 through 10","165.93","2384.07","other","ASC "
"I&D Abscess Gland Bartholin's","PX-76001331","CDM","56420","CPT","0761","RC","","","","outpatient","","","637.00","477.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","384.96","384.96","384.96","1 through 10","165.93","2384.07","other","Multiple Surgery"
"I&D Abscess Gland Bartholin's","PX-76001331","CDM","56420","CPT","0761","RC","","","","outpatient","","","637.00","477.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","268.08","268.08","268.08","1 through 10","165.93","2384.07","other","Multiple Surgery"
"I&D Abscess Gland Bartholin's","PX-76001331","CDM","56420","CPT","0761","RC","","","","outpatient","","","637.00","477.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","520.56","81.72","","494.03","494.03","494.03","1 through 10","165.93","2384.07","percent of total billed charges",""
"I&D Abscess Neck/Thorax","PX-76000340","CDM","21501","CPT","0761","RC","","","","outpatient","","","5464.00","4098.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2782.27","2782.27","2782.27","1 through 10","2140.46","5545.35","other","ASC"
"I&D Abscess Neck/Thorax","PX-76000340","CDM","21501","CPT","0761","RC","","","","outpatient","","","5464.00","4098.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6304.29","6304.29","6304.29","1 through 10","2140.46","5545.35","other","ASC "
"I&D Abscess Neck/Thorax","PX-76000340","CDM","21501","CPT","0761","RC","","","","outpatient","","","5464.00","4098.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4465.18","81.72","","22507.11","22507.11","22507.11","1 through 10","2140.46","5545.35","percent of total billed charges",""
"I&D Abscess Perianal Superficial","PX-75000212","CDM","46050","CPT","0750","RC","","","","both","","","1681.00","1260.75","MEDICARE [2001]","HB BWH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","1 through 10","521.11","1336.4","other","OPPS APC"
"I&D Abscess Perianal Superficial","PX-75000212","CDM","46050","CPT","0750","RC","","","","both","","","1681.00","1260.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","613.57","36.5","","1509.54","590.06","1509.54","1 through 10","521.11","1336.4","percent of total billed charges",""
"I&D Abscess Perianal Superficial","PX-75000212","CDM","46050","CPT","0750","RC","","","","both","","","1681.00","1260.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","643.82","38.3","","637.33","637.33","637.33","1 through 10","521.11","1336.4","percent of total billed charges",""
"I&D Abscess Perianal Superficial","PX-75000212","CDM","46050","CPT","0750","RC","","","","both","","","1681.00","1260.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","933.47","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1063.56","1063.56","1063.56","1 through 10","521.11","1336.4","other","OPPS APC"
"I&D Abscess Perianal Superficial","PX-75000212","CDM","46050","CPT","0750","RC","","","","outpatient","","","1681.00","1260.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","871.41","855.66","871.41","1 through 10","744.89","1373.71","other","ASC"
"I&D Abscess Perianal Superficial","PX-75000212","CDM","46050","CPT","0750","RC","","","","outpatient","","","1681.00","1260.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1994.11","987.26","1994.11","1 through 10","744.89","1373.71","other","ASC "
"I&D Abscess Peritonsillar","PX-75000061","CDM","42700","CPT","0761","RC","","","","both","","","952.00","714.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","756.84","79.5","","726.40","726.40","726.40","1 through 10","146.67","756.84","percent of total billed charges",""
"I&D Abscess Peritonsillar","PX-75000061","CDM","42700","CPT","0761","RC","","","","both","","","952.00","714.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","347.48","36.5","","344.28","344.28","344.28","1 through 10","146.67","756.84","percent of total billed charges",""
"I&D Abscess Peritonsillar","PX-75000061","CDM","42700","CPT","0761","RC","","","","outpatient","","","952.00","714.00","AETNA [1001]","HB AMC AETNA PPO","765.41","80.4","","284.59","284.59","284.59","1 through 10","206.14","2384.07","percent of total billed charges",""
"I&D Abscess Peritonsillar","PX-75000061","CDM","42700","CPT","0761","RC","","","","outpatient","","","952.00","714.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","235.73","","Case rate ($235.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","546.42","546.42","546.42","1 through 10","206.14","2384.07","other","ASC "
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","242.81","242.81","242.81","1 through 10","207.7","532.65","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","116.09","232.19","1 through 10","207.7","532.65","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","532.65","79.5","","511.55","511.55","1300.00","1 through 10","207.7","532.65","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","357.11","53.3","","511.55","343.20","511.55","1 through 10","207.7","532.65","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","207.7","532.65","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","218.50","437.00","31","207.7","532.65","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","244.55","36.5","","242.45","206.05","242.45","1 through 10","207.7","532.65","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","256.61","38.3","","254.15","247.00","762.45","20","207.7","532.65","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","214.13","231.25","1 through 10","207.7","532.65","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","TRICARE [160005]","HB BWH TRICARE","224.17","","APC Price ($235.97). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","235.97","235.97","235.97","1 through 10","207.7","532.65","other","Tricare OPPS"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","214.13","214.13","214.13","1 through 10","207.7","532.65","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","287.43","42.9","","519.61","519.61","519.61","1 through 10","207.7","532.65","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.25","117.99","235.97","1 through 10","207.7","532.65","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","670.00","502.50","WELLPOINT [1015]","HB AMC WELLPOINT","494.33","73.78","","483.93","483.93","483.93","1 through 10","207.7","532.65","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","670.00","502.50","AETNA [1001]","HB AMC AETNA HMO","467.66","69.8","","440.05","310.70","507.00","1 through 10","176.45","700.33","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","670.00","502.50","AETNA [1001]","HB AMC AETNA PPO","538.68","80.4","","507.00","507.00","507.00","1 through 10","176.45","700.33","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","670.00","502.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","412.84","405.38","738.78","12","176.45","700.33","other","ASC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","670.00","502.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","472.37","28","176.45","700.33","other","ASC "
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","670.00","502.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","1 through 10","176.45","700.33","other","Multiple Surgery"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","670.00","502.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","176.45","700.33","other","Multiple Surgery"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","670.00","502.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","451.71","451.71","451.71","1 through 10","176.45","700.33","other","Multiple Surgery"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","670.00","502.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","547.52","81.72","","285.81","285.81","285.81","1 through 10","176.45","700.33","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","670.00","502.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","547.52","81.72","","519.61","519.61","7152.16","1 through 10","176.45","700.33","percent of total billed charges",""
"I&D Abscess Vulva/Perineal","PX-76001330","CDM","56405","CPT","0761","RC","","","","both","","","775.00","581.25","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","180.62","180.62","180.62","1 through 10","240.25","616.13","other","OPPS APC"
"I&D Abscess Vulva/Perineal","PX-76001330","CDM","56405","CPT","0761","RC","","","","both","","","775.00","581.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","296.83","38.3","","6360.01","294.03","6360.01","1 through 10","240.25","616.13","percent of total billed charges",""
"I&D Abscess Vulva/Perineal","PX-76001330","CDM","56405","CPT","0761","RC","","","","outpatient","","","775.00","581.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","633.36","633.36","633.36","1 through 10","273","2384.07","other","Multiple Surgery"
"I&D Cyst Pilonidal Smp","PX-76000006","CDM","10080","CPT","0761","RC","","","","outpatient","","","667.00","500.25","AETNA [1001]","HB AMC AETNA HMO","465.57","69.8","","438.02","438.02","438.02","1 through 10","286.14","2384.07","percent of total billed charges",""
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","both","","","3002.00","2251.50","AETNA [1001]","HB AMC AETNA HMO","2095.40","69.8","","19831.44","19831.44","19831.44","1 through 10","930.62","2413.61","percent of total billed charges",""
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","both","","","3002.00","2251.50","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","930.62","2413.61","other","OPPS APC"
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","both","","","3002.00","2251.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","930.62","2413.61","other","OPPS APC"
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","outpatient","","","3002.00","2251.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1823.06","1823.06","1823.06","1 through 10","1237.95","2453.23","other","ASC"
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","outpatient","","","3002.00","2251.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","1823.06","3682.30","1 through 10","1237.95","2453.23","other","ASC "
"I&D Perianal Abscess Superficial","PX-98301079","CDM","46050","CPT","0983","RC","","","","both","","","542.00","406.50","MEDICARE [2001]","HB BWH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","1 through 10","168.02","1190.65","other","OPPS APC"
"I&D Perianal Abscess Superficial","PX-98301079","CDM","46050","CPT","0983","RC","","","","both","","","542.00","406.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","197.83","36.5","","1509.54","590.06","1509.54","1 through 10","168.02","1190.65","percent of total billed charges",""
"I&D Perianal Abscess Superficial","PX-98301079","CDM","46050","CPT","0983","RC","","","","both","","","542.00","406.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","207.59","38.3","","637.33","637.33","637.33","1 through 10","168.02","1190.65","percent of total billed charges",""
"I&D Perianal Abscess Superficial","PX-98301079","CDM","46050","CPT","0983","RC","","","","both","","","542.00","406.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","933.47","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1063.56","1063.56","1063.56","1 through 10","168.02","1190.65","other","OPPS APC"
"I&D Wound Post OP Complex","PX-76000012","CDM","10180","CPT","0761","RC","","","","both","","","5574.00","4180.50","MEDICARE [2001]","HB BWH MEDICARE","3398.51","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","3398.86","1 through 10","1727.94","4431.33","other","OPPS APC"
"I&D Wound Post OP Complex","PX-76000012","CDM","10180","CPT","0761","RC","","","","outpatient","","","5574.00","4180.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6304.29","6304.29","6304.29","1 through 10","2140.46","5545.35","other","ASC "
"Iaadiadoo Severe Aqt Respir Synd Coronavirus","PX-30003780","CDM","87811","CPT","0302","RC","","","","both","","","150.00","112.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","119.25","79.5","","75.00","75.00","75.00","1 through 10","40.55","142.5","percent of total billed charges",""
"Iaadiadoo Severe Aqt Respir Synd Coronavirus","PX-30003780","CDM","87811","CPT","0302","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","46.50","31","","46.35","46.35","46.35","1 through 10","40.55","142.5","percent of total billed charges",""
"Iaadiadoo Severe Aqt Respir Synd Coronavirus","PX-30003780","CDM","87811","CPT","0302","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54.75","36.5","","54.30","47.55","55.95","19","40.55","142.5","percent of total billed charges",""
"Iaadiadoo Severe Aqt Respir Synd Coronavirus","PX-30003780","CDM","87811","CPT","0302","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.45","38.3","","58.65","58.65","58.65","14","40.55","142.5","percent of total billed charges",""
"Iaadiadoo Severe Aqt Respir Synd Coronavirus","PX-30003780","CDM","87811","CPT","0302","RC","","","","outpatient","","","150.00","112.50","AETNA [1001]","HB AMC AETNA HMO","104.70","69.8","","117.00","117.00","117.00","1 through 10","21.56","123.75","percent of total billed charges",""
"Iaadiadoo Severe Aqt Respir Synd Coronavirus","PX-30003780","CDM","87811","CPT","0302","RC","","","","outpatient","","","150.00","112.50","AETNA [1001]","HB AMC AETNA PPO","120.60","80.4","","117.00","117.00","117.00","1 through 10","21.56","123.75","percent of total billed charges",""
"Iaadiadoo Severe Aqt Respir Synd Coronavirus","PX-30003780","CDM","87811","CPT","0302","RC","","","","outpatient","","","150.00","112.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","75.00","50","","78.60","78.60","150.90","17","21.56","123.75","percent of total billed charges",""
"Iaadiadoo Severe Aqt Respir Synd Coronavirus","PX-30003780","CDM","87811","CPT","0302","RC","","","","outpatient","","","150.00","112.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","78.75","52.5","","82.50","79.35","82.50","1 through 10","21.56","123.75","percent of total billed charges",""
"Iaadiadoo Severe Aqt Respir Synd Coronavirus","PX-30003780","CDM","87811","CPT","0302","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","122.58","81.72","","119.91","65.96","119.91","1 through 10","21.56","123.75","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","428.00","321.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","340.26","79.5","","326.61","219.12","1394.83","33","34.39","406.6","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","428.00","321.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","228.12","53.3","","219.12","219.12","326.61","17","34.39","406.6","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","428.00","321.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","132.68","31","","830.00","830.00","830.00","1 through 10","34.39","406.6","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","428.00","321.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","156.22","36.5","","154.80","131.56","154.80","26","34.39","406.6","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","428.00","321.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","163.92","38.3","","162.27","162.27","162.27","81","34.39","406.6","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","428.00","321.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","329.56","77","","647.40","34.39","647.40","1 through 10","34.39","406.6","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","428.00","321.00","TRICARE [160005]","HB BWH TRICARE","406.60","95","","42.28","40.17","42.28","1 through 10","34.39","406.6","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","428.00","321.00","WELLPOINT [1015]","HB AMC WELLPOINT","315.78","73.78","","308.97","308.97","308.97","23","34.39","406.6","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","428.00","321.00","AETNA [1001]","HB AMC AETNA HMO","298.74","69.8","","280.96","198.37","323.70","17","102.06","353.1","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","224.70","52.5","","239.04","239.04","239.04","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","214.00","50","","217.46","217.46","415.00","78","102.06","353.1","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","224.70","52.5","","228.25","219.54","228.25","27","102.06","353.1","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","267.50","62.5","","271.83","271.83","271.83","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","235.40","55","","239.04","185.09","478.08","15","102.06","353.1","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","428.00","321.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","349.76","81.72","","415.00","415.00","415.00","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","428.00","321.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","224.70","52.5","","331.75","331.75","331.75","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","428.00","321.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","349.76","81.72","","331.75","182.48","331.75","54","102.06","353.1","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","428.00","321.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","340.26","79.5","","326.61","219.12","1394.83","28","34.39","406.6","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","428.00","321.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","228.12","53.3","","219.12","219.12","326.61","16","34.39","406.6","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","428.00","321.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","132.68","31","","830.00","830.00","830.00","1 through 10","34.39","406.6","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","428.00","321.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","156.22","36.5","","154.80","131.56","154.80","21","34.39","406.6","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","428.00","321.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","163.92","38.3","","162.27","162.27","162.27","72","34.39","406.6","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","428.00","321.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","329.56","77","","647.40","34.39","647.40","1 through 10","34.39","406.6","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","428.00","321.00","TRICARE [160005]","HB BWH TRICARE","406.60","95","","40.17","40.17","42.28","1 through 10","34.39","406.6","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","428.00","321.00","WELLPOINT [1015]","HB AMC WELLPOINT","315.78","73.78","","308.97","308.97","723.97","19","34.39","406.6","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","428.00","321.00","AETNA [1001]","HB AMC AETNA HMO","298.74","69.8","","280.96","198.37","323.70","15","102.06","353.1","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","224.70","52.5","","239.04","239.04","239.04","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","214.00","50","","217.46","208.75","415.00","75","102.06","353.1","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","224.70","52.5","","228.25","185.09","228.25","26","102.06","353.1","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","267.50","62.5","","271.83","271.83","271.83","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","235.40","55","","229.91","185.09","239.04","11","102.06","353.1","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","428.00","321.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","349.76","81.72","","415.00","415.00","415.00","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","428.00","321.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","349.76","81.72","","331.75","182.48","331.75","43","102.06","353.1","percent of total billed charges",""
"Iadna Borrelia Miyamotoi Amplified Prb Technique","PX-30003807","CDM","87478","CPT","0306","RC","","","","outpatient","","","428.00","321.00","AETNA [1001]","HB AMC AETNA HMO","298.74","69.8","","198.37","198.37","198.37","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Borrelia Miyamotoi Amplified Prb Technique","PX-30003807","CDM","87478","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","224.70","52.5","","228.25","228.25","228.25","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Borrelia Miyamotoi Amplified Prb Technique","PX-30003807","CDM","87478","CPT","0306","RC","","","","outpatient","","","428.00","321.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","349.76","81.72","","331.75","181.76","331.75","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Dna/Rna Zika Virus Amplified Probe Tq","PX-30003476","CDM","87662","CPT","0306","RC","","","","outpatient","","","749.00","561.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","612.08","81.72","","319.22","319.22","319.22","1 through 10","181.48","612.08","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","428.00","321.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","340.26","79.5","","326.61","219.12","1394.83","33","34.39","406.6","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","428.00","321.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","228.12","53.3","","219.12","219.12","326.61","17","34.39","406.6","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","428.00","321.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","132.68","31","","830.00","830.00","830.00","1 through 10","34.39","406.6","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","428.00","321.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","156.22","36.5","","154.80","131.56","154.80","26","34.39","406.6","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","428.00","321.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","163.92","38.3","","162.27","162.27","162.27","82","34.39","406.6","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","428.00","321.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","329.56","77","","647.40","34.39","647.40","1 through 10","34.39","406.6","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","428.00","321.00","TRICARE [160005]","HB BWH TRICARE","406.60","95","","42.28","40.17","42.28","1 through 10","34.39","406.6","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","428.00","321.00","WELLPOINT [1015]","HB AMC WELLPOINT","315.78","73.78","","308.97","308.97","308.97","23","34.39","406.6","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","428.00","321.00","AETNA [1001]","HB AMC AETNA HMO","298.74","69.8","","280.96","198.37","323.70","16","102.06","353.1","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","224.70","52.5","","239.04","239.04","239.04","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","214.00","50","","217.46","217.46","415.00","79","102.06","353.1","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","224.70","52.5","","228.25","219.54","271.83","28","102.06","353.1","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","267.50","62.5","","271.83","271.83","271.83","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","428.00","321.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","235.40","55","","239.04","185.09","478.08","15","102.06","353.1","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","428.00","321.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","349.76","81.72","","415.00","415.00","415.00","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","428.00","321.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","224.70","52.5","","331.75","331.75","331.75","1 through 10","102.06","353.1","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","428.00","321.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","349.76","81.72","","331.75","182.48","331.75","54","102.06","353.1","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","879.00","659.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","631.12","71.8","","611.74","611.74","611.74","1 through 10","68.8","835.05","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","879.00","659.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","615.30","70","","613.44","613.44","613.44","1 through 10","68.8","835.05","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","879.00","659.25","CHAMPVA [160001]","HB BWH TRICARE","835.05","95","","253.77","253.77","253.77","1 through 10","68.8","835.05","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","879.00","659.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","698.81","79.5","","670.52","449.86","2011.56","291","68.8","835.05","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","879.00","659.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","468.51","53.3","","852.00","449.86","2011.56","182","68.8","835.05","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","879.00","659.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","676.83","77","","1968.12","656.04","1968.12","1 through 10","68.8","835.05","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","879.00","659.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","320.84","36.5","","317.80","270.08","953.40","305","68.8","835.05","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","879.00","659.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","336.66","38.3","","333.13","333.13","999.39","987","68.8","835.05","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","879.00","659.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","676.83","77","","112.12","63.18","670.52","1 through 10","68.8","835.05","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","879.00","659.25","TRICARE [160005]","HB BWH TRICARE","835.05","95","","80.36","80.36","84.59","17","68.8","835.05","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","879.00","659.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","377.09","42.9","","681.09","374.62","681.09","12","68.8","835.05","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","879.00","659.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","377.09","42.9","","374.62","374.62","374.62","1 through 10","68.8","835.05","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","879.00","659.25","WELLPOINT [1015]","HB AMC WELLPOINT","648.53","73.78","","634.31","634.31","1486.31","178","68.8","835.05","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","AETNA [1001]","HB AMC AETNA HMO","613.54","69.8","","576.80","407.26","664.56","356","203.9","725.18","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","AETNA [1001]","HB AMC AETNA PPO","706.72","80.4","","664.56","576.80","892.90","32","203.9","725.18","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","491.36","55.9","","446.45","446.45","446.45","1 through 10","203.9","725.18","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","459.37","52.26","","203.90","203.90","203.90","1 through 10","203.9","725.18","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","461.48","52.5","","558.06","490.75","558.06","52","203.9","725.18","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","725.18","82.5","","736.13","736.13","736.13","1 through 10","203.9","725.18","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","549.38","62.5","","558.06","553.80","558.06","22","203.9","725.18","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","461.48","52.5","","468.60","379.99","468.60","1 through 10","203.9","725.18","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","483.45","55","","490.75","490.75","490.75","100","203.9","725.18","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","706.72","80.4","","426.00","426.00","426.00","1 through 10","203.9","725.18","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","461.48","52.5","","1029.63","681.09","1029.63","1 through 10","203.9","725.18","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","718.32","81.72","","374.62","374.62","681.09","1 through 10","203.9","725.18","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","718.32","81.72","","681.09","374.62","681.09","290","203.9","725.18","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","879.00","659.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","549.38","62.5","","558.06","558.06","558.06","1 through 10","203.9","725.18","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","441.00","330.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","286.65","65","","278.20","278.20","278.20","1 through 10","34.39","418.95","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","441.00","330.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","350.60","79.5","","336.84","225.98","1010.52","250","34.39","418.95","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","441.00","330.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","235.05","53.3","","428.00","225.98","1010.52","169","34.39","418.95","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","441.00","330.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","339.57","77","","988.68","988.68","988.68","1 through 10","34.39","418.95","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","441.00","330.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","286.65","65","","278.20","270.40","278.20","1 through 10","34.39","418.95","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","441.00","330.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","136.71","31","","264.50","264.50","396.75","55","34.39","418.95","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","441.00","330.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","160.97","36.5","","407.04","135.68","478.92","462","34.39","418.95","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","441.00","330.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","168.90","38.3","","464.82","167.35","502.05","1660","34.39","418.95","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","441.00","330.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","339.57","77","","313.67","42.79","313.67","1 through 10","34.39","418.95","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","441.00","330.75","TRICARE [160005]","HB BWH TRICARE","418.95","95","","42.28","40.17","42.28","23","34.39","418.95","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","441.00","330.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","418.95","95","","35.09","35.09","35.09","1 through 10","34.39","418.95","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","441.00","330.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.19","42.9","","342.14","188.19","770.14","11","34.39","418.95","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","441.00","330.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.19","42.9","","188.19","188.19","342.14","1 through 10","34.39","418.95","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","441.00","330.75","AETNA [1001]","HB AMC AETNA HMO","307.82","69.8","","289.76","204.58","333.84","376","123.73","360.39","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","441.00","330.75","AETNA [1001]","HB AMC AETNA PPO","354.56","80.4","","333.84","224.27","448.54","40","123.73","360.39","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","441.00","330.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","246.52","55.9","","224.27","217.98","224.27","1 through 10","123.73","360.39","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","441.00","330.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","230.47","52.26","","264.85","123.73","264.85","1 through 10","123.73","360.39","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","441.00","330.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","354.56","80.4","","333.84","291.20","333.84","1 through 10","123.73","360.39","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","441.00","330.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","360.39","81.72","","342.14","178.06","342.14","13","123.73","360.39","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","441.00","330.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","360.39","81.72","","342.14","188.19","342.14","294","123.73","360.39","percent of total billed charges",""
"Iadna Pneumocystis Jirovecii Amplified Probe Tq","PX-30003847","CDM","87594","CPT","0306","RC","","","","both","","","439.00","329.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","285.35","65","","830.70","830.70","830.70","1 through 10","34.39","417.05","percent of total billed charges",""
"Iadna Pneumocystis Jirovecii Amplified Probe Tq","PX-30003847","CDM","87594","CPT","0306","RC","","","","both","","","439.00","329.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","307.30","70","","426.00","340.80","426.00","1 through 10","34.39","417.05","percent of total billed charges",""
"Iadna Pneumocystis Jirovecii Amplified Probe Tq","PX-30003847","CDM","87594","CPT","0306","RC","","","","both","","","439.00","329.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","349.01","79.5","","335.26","335.26","335.26","1 through 10","34.39","417.05","percent of total billed charges",""
"Iadna Pneumocystis Jirovecii Amplified Probe Tq","PX-30003847","CDM","87594","CPT","0306","RC","","","","both","","","439.00","329.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","168.14","38.3","","166.57","166.57","166.57","1 through 10","34.39","417.05","percent of total billed charges",""
"Iadna Pneumocystis Jirovecii Amplified Probe Tq","PX-30003847","CDM","87594","CPT","0306","RC","","","","both","","","439.00","329.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.33","42.9","","340.54","340.54","340.54","1 through 10","34.39","417.05","percent of total billed charges",""
"Iadna Pneumocystis Jirovecii Amplified Probe Tq","PX-30003847","CDM","87594","CPT","0306","RC","","","","both","","","439.00","329.25","WELLPOINT [1015]","HB AMC WELLPOINT","323.89","73.78","","317.16","317.16","317.16","1 through 10","34.39","417.05","percent of total billed charges",""
"Iadna Pneumocystis Jirovecii Amplified Probe Tq","PX-30003847","CDM","87594","CPT","0306","RC","","","","outpatient","","","439.00","329.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","265.81","60.55","","286.40","286.40","286.40","1 through 10","175.6","362.18","percent of total billed charges",""
"Iadna Pneumocystis Jirovecii Amplified Probe Tq","PX-30003847","CDM","87594","CPT","0306","RC","","","","outpatient","","","439.00","329.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","229.25","52.22","","265.91","265.91","265.91","1 through 10","175.6","362.18","percent of total billed charges",""
"Iadna Pneumocystis Jirovecii Amplified Probe Tq","PX-30003847","CDM","87594","CPT","0306","RC","","","","outpatient","","","439.00","329.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","241.45","55","","242.82","242.82","242.82","1 through 10","175.6","362.18","percent of total billed charges",""
"Iadna Pneumocystis Jirovecii Amplified Probe Tq","PX-30003847","CDM","87594","CPT","0306","RC","","","","outpatient","","","439.00","329.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","358.75","81.72","","426.00","242.82","426.00","1 through 10","175.6","362.18","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","both","","","1699.00","1274.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1104.35","65","","3213.60","3213.60","3213.60","1 through 10","78.13","1614.05","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","both","","","1699.00","1274.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1189.30","70","","903.29","903.29","1272.49","1 through 10","78.13","1614.05","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","both","","","1699.00","1274.25","CHAMPVA [160001]","HB BWH TRICARE","1614.05","95","","171.87","171.87","171.87","1 through 10","78.13","1614.05","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","both","","","1699.00","1274.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1350.71","79.5","","1296.98","870.14","5011.39","18","78.13","1614.05","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","both","","","1699.00","1274.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","905.57","53.3","","876.08","832.24","3560.82","14","78.13","1614.05","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","both","","","1699.00","1274.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1308.23","77","","3806.88","3806.88","3806.88","1 through 10","78.13","1614.05","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","both","","","1699.00","1274.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1104.35","65","","4284.80","4284.80","4284.80","1 through 10","78.13","1614.05","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","both","","","1699.00","1274.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","526.69","31","","509.23","509.23","509.23","1 through 10","78.13","1614.05","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","both","","","1699.00","1274.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","620.14","36.5","","614.70","522.42","614.70","45","78.13","1614.05","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","both","","","1699.00","1274.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","650.72","38.3","","644.37","626.24","1933.11","121","78.13","1614.05","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","both","","","1699.00","1274.25","TRICARE [160005]","HB BWH TRICARE","1614.05","95","","171.87","163.28","171.87","1 through 10","78.13","1614.05","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","both","","","1699.00","1274.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.87","42.9","","1317.41","724.63","1317.41","1 through 10","78.13","1614.05","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","outpatient","","","1699.00","1274.25","AETNA [1001]","HB AMC AETNA HMO","1185.90","69.8","","1115.70","787.74","2570.88","32","78.13","1388.42","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","outpatient","","","1699.00","1274.25","AETNA [1001]","HB AMC AETNA PPO","1366.00","80.4","","1115.70","146.76","1285.44","1 through 10","78.13","1388.42","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","outpatient","","","1699.00","1274.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","887.90","52.26","","452.65","452.65","452.65","1 through 10","78.13","1388.42","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","outpatient","","","1699.00","1274.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1388.42","81.72","","1317.41","724.63","1317.41","1 through 10","78.13","1388.42","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","outpatient","","","1699.00","1274.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1388.42","81.72","","1317.41","646.19","1317.41","35","78.13","1388.42","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","112.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","107.70","71.8","","51.31","51.31","51.31","1 through 10","46.5","142.5","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","112.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","97.50","65","","292.50","292.50","292.50","1 through 10","46.5","142.5","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","112.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","105.00","70","","5094.00","150.00","5094.00","1 through 10","46.5","142.5","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","112.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","119.25","79.5","","118.05","79.20","265.82","20","46.5","142.5","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","112.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","79.95","53.3","","79.20","75.75","281.42","21","46.5","142.5","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","97.50","65","","297.70","297.70","297.70","1 through 10","46.5","142.5","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","112.50","TRICARE [160005]","HB BWH TRICARE","142.50","95","","61.83","58.74","61.83","1 through 10","46.5","142.5","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.35","42.9","","119.91","65.96","119.91","1 through 10","46.5","142.5","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","112.50","AETNA [1001]","HB AMC AETNA HMO","104.70","69.8","","71.10","51.36","102.72","33","54.45","314.59","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","112.50","AETNA [1001]","HB AMC AETNA PPO","120.60","80.4","","78.60","51.36","117.00","1 through 10","54.45","314.59","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","112.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","78.39","52.26","","92.38","92.38","92.38","1 through 10","54.45","314.59","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","112.50","CIGNA ALTERNATE [1018]","HB AMC TUFTS CIGNA CARELINK HYBRID","54.45","36.3","","54.45","54.45","54.45","1 through 10","54.45","314.59","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","122.58","81.72","","119.91","65.96","119.91","1 through 10","54.45","314.59","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","122.58","81.72","","119.91","65.96","450.00","48","54.45","314.59","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq","PX-30003716","CDM","87637","CPT","0300","RC","","","","both","","","478.00","358.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","310.70","65","","252.38","252.38","252.38","1 through 10","103.06","454.1","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq","PX-30003716","CDM","87637","CPT","0300","RC","","","","both","","","478.00","358.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","380.01","79.5","","376.19","252.38","376.19","1 through 10","103.06","454.1","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq","PX-30003716","CDM","87637","CPT","0300","RC","","","","both","","","478.00","358.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","254.77","53.3","","376.19","252.38","376.19","1 through 10","103.06","454.1","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq","PX-30003716","CDM","87637","CPT","0300","RC","","","","both","","","478.00","358.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","174.47","36.5","","178.29","151.53","178.29","1 through 10","103.06","454.1","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq","PX-30003716","CDM","87637","CPT","0300","RC","","","","both","","","478.00","358.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","183.07","38.3","","186.90","186.90","186.90","1 through 10","103.06","454.1","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq","PX-30003716","CDM","87637","CPT","0300","RC","","","","both","","","478.00","358.50","TRICARE [160005]","HB BWH TRICARE","454.10","95","","171.87","171.87","171.87","1 through 10","103.06","454.1","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq","PX-30003716","CDM","87637","CPT","0300","RC","","","","outpatient","","","478.00","358.50","AETNA [1001]","HB AMC AETNA HMO","333.64","69.8","","323.61","228.48","323.61","15","173.51","874.38","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq","PX-30003716","CDM","87637","CPT","0300","RC","","","","outpatient","","","478.00","358.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","390.62","81.72","","382.11","382.11","382.11","12","173.51","874.38","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","206.50","70","","286.00","286.00","286.00","1 through 10","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","234.53","79.5","","225.08","151.01","431.28","178","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","157.24","53.3","","151.01","151.01","453.03","78","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","227.15","77","","220.22","220.22","660.66","1 through 10","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","191.75","65","","185.90","185.90","185.90","1 through 10","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","234.53","79.5","","225.08","225.08","225.08","1 through 10","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","91.45","31","","88.37","88.37","176.74","13","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","107.68","36.5","","106.68","90.66","320.04","474","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","112.99","38.3","","111.83","111.83","335.49","1319","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","MOLINA [1014]","HB BWH MOLINA","103.25","35","","69.62","69.62","69.62","1 through 10","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","227.15","77","","43.86","31.58","223.08","1 through 10","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","TRICARE [160005]","HB BWH TRICARE","280.25","95","","42.28","40.17","42.28","16","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.56","42.9","","125.75","125.75","228.63","1 through 10","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.56","42.9","","125.75","125.75","125.75","1 through 10","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","295.00","221.25","WELLPOINT [1015]","HB AMC WELLPOINT","217.65","73.78","","212.93","212.93","498.93","144","26.86","280.25","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","295.00","221.25","AETNA [1001]","HB AMC AETNA HMO","205.91","69.8","","193.62","136.71","223.08","329","26.86","241.07","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","295.00","221.25","AETNA [1001]","HB AMC AETNA PPO","237.18","80.4","","223.08","149.86","299.72","67","26.86","241.07","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","295.00","221.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","164.91","55.9","","299.72","149.86","299.72","1 through 10","26.86","241.07","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","295.00","221.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","154.17","52.26","","176.98","123.73","176.98","1 through 10","26.86","241.07","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","295.00","221.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","237.18","80.4","","223.08","223.08","228.63","1 through 10","26.86","241.07","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","295.00","221.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","241.07","81.72","","125.75","118.98","278.38","19","26.86","241.07","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","295.00","221.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","241.07","81.72","","228.63","125.75","228.63","278","26.86","241.07","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","both","","","3482.00","2611.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2500.08","71.8","","231.92","231.92","231.92","1 through 10","257.73","3307.9","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","both","","","3482.00","2611.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2768.19","79.5","","4064.00","2145.79","8128.00","1 through 10","257.73","3307.9","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","both","","","3482.00","2611.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1855.91","53.3","","2145.79","2145.79","2145.79","1 through 10","257.73","3307.9","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","both","","","3482.00","2611.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1270.93","36.5","","1515.87","1288.29","1515.87","21","257.73","3307.9","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","both","","","3482.00","2611.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1333.61","38.3","","1589.02","1544.32","1589.02","71","257.73","3307.9","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","both","","","3482.00","2611.50","TRICARE [160005]","HB BWH TRICARE","3307.90","95","","316.90","301.06","316.90","1 through 10","257.73","3307.9","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","both","","","3482.00","2611.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1493.78","42.9","","3248.76","3248.76","3248.76","1 through 10","257.73","3307.9","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","both","","","3482.00","2611.50","WELLPOINT [1015]","HB AMC WELLPOINT","2569.02","73.78","","3025.65","3025.65","3025.65","11","257.73","3307.9","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","outpatient","","","3482.00","2611.50","AETNA [1001]","HB AMC AETNA HMO","2430.44","69.8","","2751.33","1942.59","2751.33","21","548.38","2845.49","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","outpatient","","","3482.00","2611.50","AETNA [1001]","HB AMC AETNA PPO","2799.53","80.4","","2129.54","2129.54","2129.54","1 through 10","548.38","2845.49","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","outpatient","","","3482.00","2611.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","1946.44","55.9","","2129.54","2129.54","2129.54","1 through 10","548.38","2845.49","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","outpatient","","","3482.00","2611.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1819.69","52.26","","2514.81","2514.81","2514.81","1 through 10","548.38","2845.49","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","outpatient","","","3482.00","2611.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2845.49","81.72","","3248.76","1025.66","3248.76","1 through 10","548.38","2845.49","percent of total billed charges",""
"Iadna-Dna/Rna GI Pthgn Multiplex Probe Tq 6-11","PX-30002922","CDM","87506","CPT","0306","RC","","","","outpatient","","","3482.00","2611.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2845.49","81.72","","3248.76","1786.94","3248.76","22","548.38","2845.49","percent of total billed charges",""
"Icar Catheter Ablation Arrhythmia","PX-48000249","CDM","93655","CPT","0481","RC","","","","both","","","10948.00","8211.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8703.66","79.5","","8800.68","6260.65","8800.68","1 through 10","3393.88","8703.66","percent of total billed charges",""
"Icar Catheter Ablation Arrhythmia","PX-48000249","CDM","93655","CPT","0481","RC","","","","both","","","10948.00","8211.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5835.28","53.3","","3730.66","3730.66","3730.66","1 through 10","3393.88","8703.66","percent of total billed charges",""
"Icar Catheter Ablation Arrhythmia","PX-48000249","CDM","93655","CPT","0481","RC","","","","both","","","10948.00","8211.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","8429.96","77","","8175.09","8175.09","8175.09","1 through 10","3393.88","8703.66","percent of total billed charges",""
"Icar Catheter Ablation Arrhythmia","PX-48000249","CDM","93655","CPT","0481","RC","","","","both","","","10948.00","8211.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3996.02","36.5","","3960.14","3843.35","3960.14","1 through 10","3393.88","8703.66","percent of total billed charges",""
"Icar Catheter Ablation Arrhythmia","PX-48000249","CDM","93655","CPT","0481","RC","","","","both","","","10948.00","8211.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4193.08","38.3","","4151.25","4151.25","8068.92","1 through 10","3393.88","8703.66","percent of total billed charges",""
"Icar Catheter Ablation Arrhythmia","PX-48000249","CDM","93655","CPT","0481","RC","","","","both","","","10948.00","8211.00","WELLPOINT [1015]","HB AMC WELLPOINT","8077.43","73.78","","7904.36","7904.36","7904.36","1 through 10","3393.88","8703.66","percent of total billed charges",""
"Icar Catheter Ablation Arrhythmia","PX-48000249","CDM","93655","CPT","0481","RC","","","","outpatient","","","10948.00","8211.00","AETNA [1001]","HB AMC AETNA HMO","7641.70","69.8","","5291.46","5074.93","8281.26","22","5721.42","8946.71","percent of total billed charges",""
"Icar Catheter Ablation Arrhythmia","PX-48000249","CDM","93655","CPT","0481","RC","","","","outpatient","","","10948.00","8211.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8946.71","81.72","","8487.23","3283.25","8487.23","1 through 10","5721.42","8946.71","percent of total billed charges",""
"ICD ACTICOR DX DF4 SINGLE DEVICE HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240774","CDM","C1722","HCPCS","0278","RC","","","","both","","","22000.00","16500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","17490.00","79.5","","31564.33","31564.33","31564.33","1 through 10","6820","17490","percent of total billed charges",""
"ICD ACTICOR DX DF4 SINGLE DEVICE HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240774","CDM","C1722","HCPCS","0278","RC","","","","both","","","22000.00","16500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","14300.00","65","","27210.63","27210.63","27210.63","1 through 10","6820","17490","percent of total billed charges",""
"ICD ACTICOR DX DF4 SINGLE DEVICE HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240774","CDM","C1722","HCPCS","0278","RC","","","","both","","","22000.00","16500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8030.00","36.5","","46844.13","8621.25","46844.13","1 through 10","6820","17490","percent of total billed charges",""
"ICD ACTICOR DX DF4 SINGLE DEVICE HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240774","CDM","C1722","HCPCS","0278","RC","","","","both","","","22000.00","16500.00","WELLPOINT [1015]","HB AMC WELLPOINT","16231.60","73.78","","16551.00","16551.00","16551.00","1 through 10","6820","17490","percent of total billed charges",""
"ICD ACTICOR DX DF4 SINGLE DEVICE HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240774","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","22000.00","16500.00","AETNA [1001]","HB AMC AETNA HMO","15356.00","69.8","","74515.25","24796.25","74515.25","1 through 10","11497.2","17978.4","percent of total billed charges",""
"ICD ACTICOR DX DF4 SINGLE DEVICE HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240774","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","22000.00","16500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","17978.40","81.72","","10077.92","10077.92","10077.92","1 through 10","11497.2","17978.4","percent of total billed charges",""
"ICD ACTICOR DX DF4 SINGLE DEVICE HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240774","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","22000.00","16500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","17978.40","81.72","","41468.88","41468.88","41468.88","1 through 10","11497.2","17978.4","percent of total billed charges",""
"ICD DUAL-CHAMBER FORTIFY ASSURA 71X40 14MM NON-COATED DF4 CONNECTOR","SUP-ITM-10124439","CDM","C1721","HCPCS","0278","RC","","","","both","","","32100.00","24075.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12294.30","38.3","","12426.00","12426.00","12426.00","1 through 10","9951","25519.5","percent of total billed charges",""
"ICD DUAL-CHAMBER FORTIFY ASSURA 71X40 14MM NON-COATED DF4 CONNECTOR","SUP-ITM-10124439","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","32100.00","24075.00","AETNA [1001]","HB AMC AETNA HMO","22405.80","69.8","","16823.45","16823.45","16823.45","1 through 10","16775.46","26232.12","percent of total billed charges",""
"ICD DUAL-CHAMBER FORTIFY ASSURA 71X40 14MM NON-COATED DF4 CONNECTOR","SUP-ITM-10124439","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","32100.00","24075.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","26232.12","81.72","","19865.09","19865.09","19865.09","1 through 10","16775.46","26232.12","percent of total billed charges",""
"ICD EVERA S 34CM 68MM 51MM 13MM MRI DR SURESCAN DUAL CHAMBER DF4 PFZ","SUP-ITM-10157610","CDM","C1721","HCPCS","0278","RC","","","","both","","","24115.00","18086.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9236.05","38.3","","12426.00","12426.00","12426.00","1 through 10","7475.65","19171.43","percent of total billed charges",""
"ICD EVERA S 34CM 68MM 51MM 13MM MRI DR SURESCAN DUAL CHAMBER DF4 PFZ","SUP-ITM-10157610","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","24115.00","18086.25","AETNA [1001]","HB AMC AETNA HMO","16832.27","69.8","","16823.45","16823.45","16823.45","1 through 10","12602.5","19706.78","percent of total billed charges",""
"ICD EVERA S 34CM 68MM 51MM 13MM MRI DR SURESCAN DUAL CHAMBER DF4 PFZ","SUP-ITM-10157610","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","24115.00","18086.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","19706.78","81.72","","19865.09","19865.09","19865.09","1 through 10","12602.5","19706.78","percent of total billed charges",""
"ICD EVERA XT 34CM 68MM 51MM 13MM MRI DR SURESCAN DUAL CHAMBER DF4 PFZ","SUP-ITM-10157609","CDM","C1721","HCPCS","0278","RC","","","","both","","","26687.50","20015.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10221.31","38.3","","12426.00","12426.00","12426.00","1 through 10","8273.13","21216.56","percent of total billed charges",""
"ICD EVERA XT 34CM 68MM 51MM 13MM MRI DR SURESCAN DUAL CHAMBER DF4 PFZ","SUP-ITM-10157609","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","26687.50","20015.62","AETNA [1001]","HB AMC AETNA HMO","18627.88","69.8","","16823.45","16823.45","16823.45","1 through 10","13946.89","21809.03","percent of total billed charges",""
"ICD EVERA XT 34CM 68MM 51MM 13MM MRI DR SURESCAN DUAL CHAMBER DF4 PFZ","SUP-ITM-10157609","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","26687.50","20015.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","21809.03","81.72","","19865.09","19865.09","19865.09","1 through 10","13946.89","21809.03","percent of total billed charges",""
"ICD RIVACOR DR-T DF4 DUAL DEVICE HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240775","CDM","C1721","HCPCS","0278","RC","","","","both","","","24000.00","18000.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9192.00","38.3","","12426.00","12426.00","12426.00","1 through 10","7440","19080","percent of total billed charges",""
"ICD RIVACOR DR-T DF4 DUAL DEVICE HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240775","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","24000.00","18000.00","AETNA [1001]","HB AMC AETNA HMO","16752.00","69.8","","16823.45","16823.45","16823.45","1 through 10","12542.4","19612.8","percent of total billed charges",""
"ICD RIVACOR DR-T DF4 DUAL DEVICE HIGH ENERGY WITH PROMRI TI AND CLS","SUP-ITM-10240775","CDM","C1721","HCPCS","0278","RC","","","","outpatient","","","24000.00","18000.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","19612.80","81.72","","19865.09","19865.09","19865.09","1 through 10","12542.4","19612.8","percent of total billed charges",""
"ICD VISIA AF MRI VR DF4 US SINGLE CHAMBER PACEMAKER","SUP-ITM-10169088","CDM","C1722","HCPCS","0278","RC","","","","both","","","24830.00","18622.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","19739.85","79.5","","31564.33","31564.33","31564.33","1 through 10","7697.3","19739.85","percent of total billed charges",""
"ICD VISIA AF MRI VR DF4 US SINGLE CHAMBER PACEMAKER","SUP-ITM-10169088","CDM","C1722","HCPCS","0278","RC","","","","both","","","24830.00","18622.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","16139.50","65","","27210.63","27210.63","27210.63","1 through 10","7697.3","19739.85","percent of total billed charges",""
"ICD VISIA AF MRI VR DF4 US SINGLE CHAMBER PACEMAKER","SUP-ITM-10169088","CDM","C1722","HCPCS","0278","RC","","","","both","","","24830.00","18622.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9062.95","36.5","","46844.13","8621.25","46844.13","1 through 10","7697.3","19739.85","percent of total billed charges",""
"ICD VISIA AF MRI VR DF4 US SINGLE CHAMBER PACEMAKER","SUP-ITM-10169088","CDM","C1722","HCPCS","0278","RC","","","","both","","","24830.00","18622.50","WELLPOINT [1015]","HB AMC WELLPOINT","18319.57","73.78","","16551.00","16551.00","16551.00","1 through 10","7697.3","19739.85","percent of total billed charges",""
"ICD VISIA AF MRI VR DF4 US SINGLE CHAMBER PACEMAKER","SUP-ITM-10169088","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","24830.00","18622.50","AETNA [1001]","HB AMC AETNA HMO","17331.34","69.8","","74515.25","24796.25","74515.25","1 through 10","12976.16","20291.08","percent of total billed charges",""
"ICD VISIA AF MRI VR DF4 US SINGLE CHAMBER PACEMAKER","SUP-ITM-10169088","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","24830.00","18622.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","20291.08","81.72","","10077.92","10077.92","10077.92","1 through 10","12976.16","20291.08","percent of total billed charges",""
"ICD VISIA AF MRI VR DF4 US SINGLE CHAMBER PACEMAKER","SUP-ITM-10169088","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","24830.00","18622.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","20291.08","81.72","","41468.88","41468.88","41468.88","1 through 10","12976.16","20291.08","percent of total billed charges",""
"ICD-VR EV4 AURORA EV","SUP-ITM-10330335","CDM","C1722","HCPCS","0278","RC","","","","both","","","51875.00","38906.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","41240.63","79.5","","31564.33","31564.33","31564.33","1 through 10","16081.25","41240.63","percent of total billed charges",""
"ICD-VR EV4 AURORA EV","SUP-ITM-10330335","CDM","C1722","HCPCS","0278","RC","","","","both","","","51875.00","38906.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","33718.75","65","","27210.63","27210.63","27210.63","1 through 10","16081.25","41240.63","percent of total billed charges",""
"ICD-VR EV4 AURORA EV","SUP-ITM-10330335","CDM","C1722","HCPCS","0278","RC","","","","both","","","51875.00","38906.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","18934.38","36.5","","46844.13","8621.25","46844.13","1 through 10","16081.25","41240.63","percent of total billed charges",""
"ICD-VR EV4 AURORA EV","SUP-ITM-10330335","CDM","C1722","HCPCS","0278","RC","","","","both","","","51875.00","38906.25","WELLPOINT [1015]","HB AMC WELLPOINT","38273.38","73.78","","16551.00","16551.00","16551.00","1 through 10","16081.25","41240.63","percent of total billed charges",""
"ICD-VR EV4 AURORA EV","SUP-ITM-10330335","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","51875.00","38906.25","AETNA [1001]","HB AMC AETNA HMO","36208.75","69.8","","74515.25","24796.25","74515.25","1 through 10","27109.88","42392.25","percent of total billed charges",""
"ICD-VR EV4 AURORA EV","SUP-ITM-10330335","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","51875.00","38906.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","42392.25","81.72","","10077.92","10077.92","10077.92","1 through 10","27109.88","42392.25","percent of total billed charges",""
"ICD-VR EV4 AURORA EV","SUP-ITM-10330335","CDM","C1722","HCPCS","0278","RC","","","","outpatient","","","51875.00","38906.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","42392.25","81.72","","41468.88","41468.88","41468.88","1 through 10","27109.88","42392.25","percent of total billed charges",""
"Ide G120136 Zenith P-Branch Endovascular Graft","PX-62400104","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4420.00","65","","6652.80","6652.80","6652.80","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith P-Branch Endovascular Graft","PX-62400104","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5406.00","79.5","","2612.61","795.38","2612.61","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith P-Branch Endovascular Graft","PX-62400104","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3624.40","53.3","","1101.80","1101.80","1101.80","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith P-Branch Endovascular Graft","PX-62400104","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4420.00","65","","1820.00","910.00","1820.00","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith P-Branch Endovascular Graft","PX-62400104","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2482.00","36.5","","1257.80","693.44","2424.50","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith P-Branch Endovascular Graft","PX-62400104","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2604.40","38.3","","1950.11","547.40","2346.00","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith P-Branch Endovascular Graft","PX-62400104","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2917.20","42.9","","5096.18","5096.18","5096.18","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith P-Branch Endovascular Graft","PX-62400104","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","WELLPOINT [1015]","HB AMC WELLPOINT","5017.04","73.78","","1172.59","1172.59","4829.94","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith P-Branch Endovascular Graft","PX-62400104","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","6800.00","5100.00","AETNA [1001]","HB AMC AETNA HMO","4746.40","69.8","","1806.84","947.80","5091.72","1 through 10","3553.68","5556.96","percent of total billed charges",""
"Ide G120136 Zenith P-Branch Endovascular Graft","PX-62400104","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","6800.00","5100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5556.96","81.72","","1259.05","615.58","4586.56","1 through 10","3553.68","5556.96","percent of total billed charges",""
"Ide G120136 Zenith Universal Distal Body Endovascular Graft","PX-62400105","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4420.00","65","","6652.80","6652.80","6652.80","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith Universal Distal Body Endovascular Graft","PX-62400105","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5406.00","79.5","","2612.61","795.38","2612.61","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith Universal Distal Body Endovascular Graft","PX-62400105","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3624.40","53.3","","1101.80","1101.80","1101.80","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith Universal Distal Body Endovascular Graft","PX-62400105","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4420.00","65","","1820.00","910.00","1820.00","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith Universal Distal Body Endovascular Graft","PX-62400105","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2482.00","36.5","","1257.80","693.44","2424.50","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith Universal Distal Body Endovascular Graft","PX-62400105","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2604.40","38.3","","1950.11","547.40","2346.00","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith Universal Distal Body Endovascular Graft","PX-62400105","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2917.20","42.9","","5096.18","5096.18","5096.18","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith Universal Distal Body Endovascular Graft","PX-62400105","CDM","C1874","HCPCS","0624","RC","","","","both","","","6800.00","5100.00","WELLPOINT [1015]","HB AMC WELLPOINT","5017.04","73.78","","1172.59","1172.59","4829.94","1 through 10","2108","5406","percent of total billed charges",""
"Ide G120136 Zenith Universal Distal Body Endovascular Graft","PX-62400105","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","6800.00","5100.00","AETNA [1001]","HB AMC AETNA HMO","4746.40","69.8","","1806.84","947.80","5091.72","1 through 10","3553.68","5556.96","percent of total billed charges",""
"Ide G120136 Zenith Universal Distal Body Endovascular Graft","PX-62400105","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","6800.00","5100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5556.96","81.72","","1259.05","615.58","4586.56","1 through 10","3553.68","5556.96","percent of total billed charges",""
"Ide# G150175 Lead Quartet 1457q/75/86","PX-62400120","CDM","C1900","HCPCS","0624","RC","","","","both","","","4200.00","3150.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2238.60","53.3","","2692.80","2257.20","2692.80","1 through 10","1302","3339","percent of total billed charges",""
"Ide# G150175 Lead Quartet 1457q/75/86","PX-62400120","CDM","C1900","HCPCS","0624","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","1671.53","1671.53","1671.53","1 through 10","1302","3339","percent of total billed charges",""
"Ide# G150175 Lead Quartet 1457q/75/86","PX-62400120","CDM","C1900","HCPCS","0624","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1935.90","1935.90","1935.90","1 through 10","2194.92","3432.24","percent of total billed charges",""
"Ide# G150175 Lead Quartet 1457q/75/86","PX-62400120","CDM","C1900","HCPCS","0624","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1769.79","1769.79","1769.79","1 through 10","2194.92","3432.24","percent of total billed charges",""
"IDENTITI CERVICAL POROUS TI SPACER 8 X 14 X 12 MM 7DEG","SUP-ITM-10248315","CDM","C1821","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","9828.00","9828.00","9828.00","1 through 10","759.5","2327.5","percent of total billed charges",""
"IDENTITI CERVICAL POROUS TI SPACER 8 X 14 X 12 MM 7DEG","SUP-ITM-10248315","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","1958.53","1886.75","1958.53","1 through 10","1280.37","2002.14","percent of total billed charges",""
"Ifr (During Dx/Pci Coronary Artery), Ea Addl Vessel","PX-48000492","CDM","93799","CPT","0481","RC","","","","both","","","2065.00","1548.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","1641.68","other","OPPS APC"
"Ifr (During Dx/Pci Coronary Artery), Ea Addl Vessel","PX-48000492","CDM","93799","CPT","0481","RC","","","","outpatient","","","2065.00","1548.75","AETNA [1001]","HB AMC AETNA HMO","1441.37","69.8","","2022.70","2022.70","2022.70","1 through 10","454","1703.63","percent of total billed charges",""
"Ifr (During Dx/Pci Coronary Artery), Ea Addl Vessel","PX-48000492","CDM","93799","CPT","0481","RC","","","","outpatient","","","2065.00","1548.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1250.36","60.55","","318.03","318.03","2439.77","1 through 10","454","1703.63","percent of total billed charges",""
"Ifr (During Dx/Pci Coronary Artery), Ea Addl Vessel","PX-48000492","CDM","93799","CPT","0481","RC","","","","outpatient","","","2065.00","1548.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1078.34","52.22","","360.38","360.38","4023.00","1 through 10","454","1703.63","percent of total billed charges",""
"Ifr (During Dx/Pci Coronary Artery), Ea Addl Vessel","PX-48000492","CDM","93799","CPT","0481","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1135.75","55","","13080.03","13080.03","13080.03","1 through 10","454","1703.63","percent of total billed charges",""
"Ifr (During Dx/Pci Coronary Artery), Init Vessel","PX-48000491","CDM","93799","CPT","0481","RC","","","","both","","","4149.00","3111.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","3298.46","other","OPPS APC"
"Ifr (During Dx/Pci Coronary Artery), Init Vessel","PX-48000491","CDM","93799","CPT","0481","RC","","","","outpatient","","","4149.00","3111.75","AETNA [1001]","HB AMC AETNA HMO","2896.00","69.8","","2022.70","2022.70","2022.70","1 through 10","454","3422.93","percent of total billed charges",""
"Ifr (During Dx/Pci Coronary Artery), Init Vessel","PX-48000491","CDM","93799","CPT","0481","RC","","","","outpatient","","","4149.00","3111.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2512.22","60.55","","318.03","318.03","2439.77","1 through 10","454","3422.93","percent of total billed charges",""
"Ifr (During Dx/Pci Coronary Artery), Init Vessel","PX-48000491","CDM","93799","CPT","0481","RC","","","","outpatient","","","4149.00","3111.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2166.61","52.22","","360.38","360.38","4023.00","1 through 10","454","3422.93","percent of total billed charges",""
"Ifr (During Dx/Pci Coronary Artery), Init Vessel","PX-48000491","CDM","93799","CPT","0481","RC","","","","outpatient","","","4149.00","3111.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2281.95","55","","13080.03","13080.03","13080.03","1 through 10","454","3422.93","percent of total billed charges",""
"Ifr Alone Coronary Artery","PX-48000488","CDM","93799","CPT","0481","RC","","","","both","","","3543.00","2657.25","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","2816.69","other","OPPS APC"
"Ifr Alone Coronary Artery","PX-48000488","CDM","93799","CPT","0481","RC","","","","outpatient","","","3543.00","2657.25","AETNA [1001]","HB AMC AETNA HMO","2473.01","69.8","","2022.70","2022.70","2022.70","1 through 10","454","2922.98","percent of total billed charges",""
"Ifr Alone Coronary Artery","PX-48000488","CDM","93799","CPT","0481","RC","","","","outpatient","","","3543.00","2657.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2145.29","60.55","","318.03","318.03","2439.77","1 through 10","454","2922.98","percent of total billed charges",""
"Ifr Alone Coronary Artery","PX-48000488","CDM","93799","CPT","0481","RC","","","","outpatient","","","3543.00","2657.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1850.15","52.22","","360.38","360.38","4023.00","1 through 10","454","2922.98","percent of total billed charges",""
"Ifr Alone Coronary Artery","PX-48000488","CDM","93799","CPT","0481","RC","","","","outpatient","","","3543.00","2657.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1948.65","55","","13080.03","13080.03","13080.03","1 through 10","454","2922.98","percent of total billed charges",""
"Ig Paraprotein Qual Imprcip&Ms Bld/UR W/Isotype","PX-30003738","CDM","0077U","CPT","0300","RC","","","","both","","","100.00","75.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","79.50","79.5","","373.98","373.98","373.98","1 through 10","31","95","percent of total billed charges",""
"Ig Paraprotein Qual Imprcip&Ms Bld/UR W/Isotype","PX-30003738","CDM","0077U","CPT","0300","RC","","","","both","","","100.00","75.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","53.30","53.3","","402.16","402.16","402.16","1 through 10","31","95","percent of total billed charges",""
"Ig Paraprotein Qual Imprcip&Ms Bld/UR W/Isotype","PX-30003738","CDM","0077U","CPT","0300","RC","","","","both","","","100.00","75.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38.30","38.3","","97.00","97.00","97.00","1 through 10","31","95","percent of total billed charges",""
"Ig Paraprotein Qual Imprcip&Ms Bld/UR W/Isotype","PX-30003738","CDM","0077U","CPT","0300","RC","","","","both","","","100.00","75.00","WELLPOINT [1015]","HB AMC WELLPOINT","73.78","73.78","","380.44","380.44","380.44","1 through 10","31","95","percent of total billed charges",""
"Ig Paraprotein Qual Imprcip&Ms Bld/UR W/Isotype","PX-30003738","CDM","0077U","CPT","0300","RC","","","","outpatient","","","100.00","75.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","52.22","52.22","","275.07","52.22","275.07","1 through 10","36.3","82.5","percent of total billed charges",""
"Ig Paraprotein Qual Imprcip&Ms Bld/UR W/Isotype","PX-30003738","CDM","0077U","CPT","0300","RC","","","","outpatient","","","100.00","75.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","52.50","52.5","","53.35","53.35","53.35","1 through 10","36.3","82.5","percent of total billed charges",""
"Ig Paraprotein Qual Imprcip&Ms Bld/UR W/Isotype","PX-30003738","CDM","0077U","CPT","0300","RC","","","","outpatient","","","100.00","75.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","55.00","55","","294.34","294.34","294.34","1 through 10","36.3","82.5","percent of total billed charges",""
"Ig Paraprotein Qual Imprcip&Ms Bld/UR W/Isotype","PX-30003738","CDM","0077U","CPT","0300","RC","","","","outpatient","","","100.00","75.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","81.72","81.72","","77.54","77.54","77.54","1 through 10","36.3","82.5","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Igh Somatic Hypermutation Analysis, B-Cell Chronic Lymphocytic Leukemia (B-Cll)","PX-31000807","CDM","81479","CPT","0310","RC","","","","both","","","3147.00","2360.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2501.87","79.5","","0.65","0.65","0.65","1 through 10","975.57","2989.65","percent of total billed charges",""
"Igh Somatic Hypermutation Analysis, B-Cell Chronic Lymphocytic Leukemia (B-Cll)","PX-31000807","CDM","81479","CPT","0310","RC","","","","both","","","3147.00","2360.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1677.35","53.3","","0.79","0.79","0.79","1 through 10","975.57","2989.65","percent of total billed charges",""
"Igh Somatic Hypermutation Analysis, B-Cell Chronic Lymphocytic Leukemia (B-Cll)","PX-31000807","CDM","81479","CPT","0310","RC","","","","outpatient","","","3147.00","2360.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1573.50","50","","1.00","1.00","1.00","1 through 10","156.55","2596.28","percent of total billed charges",""
"Igh Somatic Hypermutation Analysis, B-Cell Chronic Lymphocytic Leukemia (B-Cll)","PX-31000807","CDM","81479","CPT","0310","RC","","","","outpatient","","","3147.00","2360.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1652.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","2596.28","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","both","","","126.64","94.98","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","88.65","70","","54.46","54.46","54.46","1 through 10","39.26","180.05","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","both","","","126.64","94.98","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","44.32","35","","27.92","27.92","27.92","1 through 10","39.26","180.05","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","both","","","126.64","94.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","39.26","31","","39.13","39.13","39.13","1 through 10","39.26","180.05","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","both","","","126.64","94.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","46.22","36.5","","45.84","40.14","47.24","1 through 10","39.26","180.05","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","both","","","126.64","94.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48.50","38.3","","49.52","48.12","192.48","1 through 10","39.26","180.05","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","both","","","126.64","94.98","MOLINA [1014]","HB BWH MOLINA","44.32","35","","56.98","55.76","56.98","1 through 10","39.26","180.05","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","outpatient","","","126.64","94.98","AETNA [1001]","HB AMC AETNA HMO","88.39","69.8","","85.74","60.53","98.78","1 through 10","59.39","199.17","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","outpatient","","","126.64","94.98","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","66.18","52.26","","78.36","78.36","78.36","1 through 10","59.39","199.17","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","outpatient","","","126.64","94.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","88.52","69.9","","87.76","58.76","98.05","1 through 10","59.39","199.17","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","outpatient","","","126.64","94.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","59.39","46.9","","58.76","58.76","58.76","1 through 10","59.39","199.17","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","outpatient","","","126.64","94.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","103.49","81.72","","126.64","126.64","126.64","1 through 10","59.39","199.17","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","outpatient","","","126.64","94.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","103.49","81.72","","157.81","157.81","179.50","1 through 10","59.39","199.17","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","29.90","22.42","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","10.47","35","","6.60","6.40","6.60","1 through 10","9.27","28.41","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","29.90","22.42","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","23.02","77","","22.59","22.59","22.59","1 through 10","9.27","28.41","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","29.90","22.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","9.27","31","","18.48","9.24","27.72","16","9.27","28.41","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","29.90","22.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10.91","36.5","","11.15","9.48","21.64","86","9.27","28.41","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","29.90","22.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11.45","38.3","","11.69","11.36","34.08","110","9.27","28.41","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","29.90","22.42","MOLINA [1014]","HB BWH MOLINA","10.47","35","","20.06","20.06","20.06","1 through 10","9.27","28.41","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","29.90","22.42","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","23.02","77","","17.36","17.36","17.36","1 through 10","9.27","28.41","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","29.90","22.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12.83","42.9","","48.05","48.05","48.05","1 through 10","9.27","28.41","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","29.90","22.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12.83","42.9","","27.91","27.91","27.91","1 through 10","9.27","28.41","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","29.90","22.42","WELLPOINT [1015]","HB AMC WELLPOINT","22.06","73.78","","29.90","29.90","59.80","40","9.27","28.41","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","outpatient","","","29.90","22.42","AETNA [1001]","HB AMC AETNA HMO","20.87","69.8","","20.24","14.29","23.32","66","14.02","47.11","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","outpatient","","","29.90","22.42","AETNA [1001]","HB AMC AETNA PPO","24.04","80.4","","23.32","15.67","23.32","1 through 10","14.02","47.11","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","outpatient","","","29.90","22.42","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","16.71","55.9","","15.67","15.67","15.67","1 through 10","14.02","47.11","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","outpatient","","","29.90","22.42","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","15.63","52.26","","18.50","18.50","18.50","1 through 10","14.02","47.11","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","outpatient","","","29.90","22.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20.90","69.9","","20.72","13.87","22.54","57","14.02","47.11","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","outpatient","","","29.90","22.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14.02","46.9","","20.72","13.87","30.20","30","14.02","47.11","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","outpatient","","","29.90","22.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","20.90","69.9","","23.28","23.28","23.28","1 through 10","14.02","47.11","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","outpatient","","","29.90","22.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","24.43","81.72","","29.90","27.91","48.05","1 through 10","14.02","47.11","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","outpatient","","","29.90","22.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24.43","81.72","","27.91","27.91","48.05","68","14.02","47.11","percent of total billed charges",""
"Iiv4 Vacc Presrv Free 0.5 Ml Dos for Im Use","PX-63600500","CDM","90686","CPT","0636","RC","","","","both","","","33.20","24.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12.12","36.5","","9.93","9.93","9.93","1 through 10","10.29","54.82","percent of total billed charges",""
"Iiv4 Vacc Presrv Free 0.5 Ml Dos for Im Use","PX-63600500","CDM","90686","CPT","0636","RC","","","","outpatient","","","33.20","24.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","23.21","69.9","","25.03","25.03","25.03","1 through 10","15.57","47.74","percent of total billed charges",""
"Ikzf1 Gene Analysis","PX-31000786","CDM","81479","CPT","0310","RC","","","","both","","","5259.00","3944.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4180.91","79.5","","0.65","0.65","0.65","1 through 10","1630.29","4996.05","percent of total billed charges",""
"Ikzf1 Gene Analysis","PX-31000786","CDM","81479","CPT","0310","RC","","","","both","","","5259.00","3944.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2803.05","53.3","","0.79","0.79","0.79","1 through 10","1630.29","4996.05","percent of total billed charges",""
"Ikzf1 Gene Analysis","PX-31000786","CDM","81479","CPT","0310","RC","","","","outpatient","","","5259.00","3944.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3184.32","60.55","","1.00","1.00","1.00","1 through 10","2545.36","4338.68","percent of total billed charges",""
"Ikzf1 Gene Analysis","PX-31000786","CDM","81479","CPT","0310","RC","","","","outpatient","","","5259.00","3944.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2746.25","52.22","","1.00","1.00","1.00","1 through 10","2545.36","4338.68","percent of total billed charges",""
"Ikzf1 Gene Analysis","PX-31000786","CDM","81479","CPT","0310","RC","","","","outpatient","","","5259.00","3944.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2629.50","50","","1.00","1.00","1.00","1 through 10","2545.36","4338.68","percent of total billed charges",""
"Ikzf1 Gene Analysis","PX-31000786","CDM","81479","CPT","0310","RC","","","","outpatient","","","5259.00","3944.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2760.98","52.5","","1.00","0.53","1.00","1 through 10","2545.36","4338.68","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Ileoscopy Stoma W/Balloon Dilation","PX-36000345","CDM","44381","CPT","0750","RC","","","","both","","","1649.00","1236.75","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","511.19","2815.7","other","OPPS APC"
"Ileoscopy Stoma W/Balloon Dilation","PX-36000345","CDM","44381","CPT","0750","RC","","","","outpatient","","","1649.00","1236.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3932.02","3932.02","3932.02","1 through 10","861.77","11688.78","other","ASC "
"Ileoscopy Thru Stoma","PX-75000152","CDM","44380","CPT","0750","RC","","","","both","","","2994.00","2245.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","545.58","545.58","545.58","1 through 10","928.14","2380.23","other","OPPS APC"
"Ileoscopy Thru Stoma","PX-75000152","CDM","44380","CPT","0750","RC","","","","outpatient","","","2994.00","2245.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2018.70","1009.35","2018.70","1 through 10","761.55","2446.7","other","ASC "
"Ileoscopy Thru Stoma W/Biopsy","PX-75000153","CDM","44382","CPT","0750","RC","","","","both","","","3006.00","2254.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2389.77","79.5","","2294.11","2294.11","2294.11","1 through 10","931.86","2389.77","percent of total billed charges",""
"Ileoscopy Thru Stoma W/Biopsy","PX-75000153","CDM","44382","CPT","0750","RC","","","","both","","","3006.00","2254.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","494.68","1113.41","1 through 10","931.86","2389.77","other","OPPS APC"
"Ileoscopy Thru Stoma W/Biopsy","PX-75000153","CDM","44382","CPT","0750","RC","","","","both","","","3006.00","2254.50","TRICARE [160005]","HB BWH TRICARE","1057.74","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1057.74","1057.74","1057.74","1 through 10","931.86","2389.77","other","Tricare OPPS"
"Ileoscopy Thru Stoma W/Biopsy","PX-75000153","CDM","44382","CPT","0750","RC","","","","outpatient","","","3006.00","2254.50","AETNA [1001]","HB AMC AETNA HMO","2098.19","69.8","","2273.70","2273.70","2273.70","1 through 10","761.55","2456.5","percent of total billed charges",""
"Ileoscopy Thru Stoma W/Biopsy","PX-75000153","CDM","44382","CPT","0750","RC","","","","outpatient","","","3006.00","2254.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1781.82","1781.82","1781.82","1 through 10","761.55","2456.5","other","ASC"
"Ileoscopy Thru Stoma W/Biopsy","PX-75000153","CDM","44382","CPT","0750","RC","","","","outpatient","","","3006.00","2254.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2018.70","1009.35","2038.73","1 through 10","761.55","2456.5","other","ASC "
"Ileoscopy Thru Stoma W/Biopsy","PX-75000153","CDM","44382","CPT","0750","RC","","","","outpatient","","","3006.00","2254.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1766.80","1766.80","1766.80","1 through 10","761.55","2456.5","other","Multiple Surgery"
"Ileoscopy Thru Stoma W/Biopsy","PX-75000153","CDM","44382","CPT","0750","RC","","","","outpatient","","","3006.00","2254.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1858.18","929.09","1858.18","1 through 10","761.55","2456.5","other","Multiple Surgery"
"Ileoscopy Thru Stoma W/Biopsy","PX-75000153","CDM","44382","CPT","0750","RC","","","","outpatient","","","3006.00","2254.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2456.50","81.72","","2330.25","2330.25","2330.25","1 through 10","761.55","2456.5","percent of total billed charges",""
"Ileoscopy via Ilial Stoma W Cold Snare Polypectomy","PX-75000503","CDM","44799","CPT","0750","RC","","","","both","","","2034.00","1525.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","630.54","1617.03","other","OPPS APC"
"Ileoscopy via Ilial Stoma W Cold Snare Polypectomy","PX-75000503","CDM","44799","CPT","0750","RC","","","","both","","","2034.00","1525.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","630.54","1617.03","other","OPPS APC"
"Ileoscopy via Ilial Stoma W Cold Snare Polypectomy","PX-75000503","CDM","44799","CPT","0750","RC","","","","both","","","2034.00","1525.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","630.54","1617.03","other","OPPS APC"
"Ileoscopy via Ilial Stoma W Cold Snare Polypectomy","PX-75000503","CDM","44799","CPT","0750","RC","","","","both","","","2034.00","1525.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","630.54","1617.03","other","OPPS APC"
"Ileoscopy via Ilial Stoma W Cold Snare Polypectomy","PX-75000503","CDM","44799","CPT","0750","RC","","","","both","","","2034.00","1525.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","872.59","42.9","","1932.92","1932.92","1932.92","1 through 10","630.54","1617.03","percent of total billed charges",""
"Ileoscopy via Ilial Stoma W Cold Snare Polypectomy","PX-75000503","CDM","44799","CPT","0750","RC","","","","both","","","2034.00","1525.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","630.54","1617.03","other","OPPS APC"
"Ileoscopy via Ilial Stoma W Cold Snare Polypectomy","PX-75000503","CDM","44799","CPT","0750","RC","","","","both","","","2034.00","1525.50","WELLPOINT [1015]","HB AMC WELLPOINT","1500.69","73.78","","2222.33","2222.33","2222.33","1 through 10","630.54","1617.03","percent of total billed charges",""
"Ileoscopy via Ilial Stoma W Cold Snare Polypectomy","PX-75000503","CDM","44799","CPT","0750","RC","","","","outpatient","","","2034.00","1525.50","AETNA [1001]","HB AMC AETNA HMO","1419.73","69.8","","2238.60","2238.60","2238.60","1 through 10","1017","8899.59","percent of total billed charges",""
"Ileoscopy via Ilial Stoma W Cold Snare Polypectomy","PX-75000503","CDM","44799","CPT","0750","RC","","","","outpatient","","","2034.00","1525.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1231.59","60.55","","3144.00","2870.00","3286.00","1 through 10","1017","8899.59","percent of total billed charges",""
"Ileoscopy via Ilial Stoma W Cold Snare Polypectomy","PX-75000503","CDM","44799","CPT","0750","RC","","","","outpatient","","","2034.00","1525.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1062.97","52.26","","1775.96","1775.96","1775.96","1 through 10","1017","8899.59","percent of total billed charges",""
"Ileoscopy via Ilial Stoma W Cold Snare Polypectomy","PX-75000503","CDM","44799","CPT","0750","RC","","","","outpatient","","","2034.00","1525.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1062.15","52.22","","3286.00","2018.70","5898.00","1 through 10","1017","8899.59","percent of total billed charges",""
"Ileoscopy via Ilial Stoma W Cold Snare Polypectomy","PX-75000503","CDM","44799","CPT","0750","RC","","","","outpatient","","","2034.00","1525.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1067.85","52.5","","8340.00","8340.00","8340.00","1 through 10","1017","8899.59","percent of total billed charges",""
"Ileoscopy via Ilial Stoma W Cold Snare Polypectomy","PX-75000503","CDM","44799","CPT","0750","RC","","","","outpatient","","","2034.00","1525.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1662.18","81.72","","2294.28","682.69","2294.28","1 through 10","1017","8899.59","percent of total billed charges",""
"Ileoscopy W/ Catheter Decompression","PX-75000469","CDM","47999","CPT","0750","RC","","","","both","","","1366.00","1024.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","423.46","1391.62","other","OPPS APC"
"Ileoscopy W/ Catheter Decompression","PX-75000469","CDM","47999","CPT","0750","RC","","","","both","","","1366.00","1024.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","423.46","1391.62","other","OPPS APC"
"Ileoscopy W/ Catheter Decompression","PX-75000469","CDM","47999","CPT","0750","RC","","","","outpatient","","","1366.00","1024.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","713.33","52.22","","3734.00","1019.30","3734.00","1 through 10","683","9843.6","percent of total billed charges",""
"Iliac Bone Augmentation","PX-76002510","CDM","27299","CPT","0761","RC","","","","both","","","2947.00","2210.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","2342.87","other","OPPS APC"
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","both","","","2320.50","1740.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1844.80","79.5","","1309.77","674.56","6049.93","26","719.36","1844.8","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","both","","","2320.50","1740.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1236.83","53.3","","1901.83","1901.83","2962.25","1 through 10","719.36","1844.8","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","both","","","2320.50","1740.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","846.98","36.5","","1620.31","1620.31","19908.88","1 through 10","719.36","1844.8","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","both","","","2320.50","1740.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","888.75","38.3","","352.91","352.91","2046.30","1 through 10","719.36","1844.8","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","both","","","2320.50","1740.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","995.49","42.9","","9668.75","9668.75","9668.75","1 through 10","719.36","1844.8","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","both","","","2320.50","1740.37","WELLPOINT [1015]","HB AMC WELLPOINT","1712.06","73.78","","699.88","384.10","3443.31","33","719.36","1844.8","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2320.50","1740.37","AETNA [1001]","HB AMC AETNA HMO","1619.71","69.8","","1421.24","264.50","4933.46","29","1212.69","1896.31","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2320.50","1740.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1865.68","80.4","","1022.97","1022.97","3607.50","1 through 10","1212.69","1896.31","percent of total billed charges",""
"ILIAC WEDGE 8MM 18 GRAFT BONE MATRIGRAFT ALLOGRAFT CREST FREEZE DRIED","SUP-ITM-10008888","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2320.50","1740.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1896.31","81.72","","3010.54","693.88","5019.88","35","1212.69","1896.31","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","both","","","1576.58","1182.43","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","823.92","52.26","","25.34","25.34","25.34","1 through 10","488.74","1253.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","both","","","1576.58","1182.43","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1131.98","71.8","","105.81","105.81","366.90","1 through 10","488.74","1253.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","both","","","1576.58","1182.43","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1103.61","70","","512.90","74.70","612.85","1 through 10","488.74","1253.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","both","","","1576.58","1182.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1253.38","79.5","","200.27","182.80","200.27","1 through 10","488.74","1253.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","both","","","1576.58","1182.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","840.32","53.3","","37.73","37.73","169.33","1 through 10","488.74","1253.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","both","","","1576.58","1182.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1024.78","65","","100.27","8.48","494.52","1 through 10","488.74","1253.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","both","","","1576.58","1182.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","1024.78","65","","160.19","160.19","160.19","1 through 10","488.74","1253.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","both","","","1576.58","1182.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","488.74","31","","28.12","28.12","28.12","1 through 10","488.74","1253.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","both","","","1576.58","1182.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","575.45","36.5","","101.66","28.85","502.70","121","488.74","1253.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","both","","","1576.58","1182.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","603.83","38.3","","61.58","25.32","328.44","138","488.74","1253.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","both","","","1576.58","1182.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","676.35","42.9","","71.66","71.66","71.66","1 through 10","488.74","1253.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","both","","","1576.58","1182.43","WELLPOINT [1015]","HB AMC WELLPOINT","1163.20","73.78","","74.75","27.97","425.28","93","488.74","1253.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1576.58","1182.43","AETNA [1001]","HB AMC AETNA HMO","1100.45","69.8","","52.67","14.36","414.90","1 through 10","823.92","1288.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1576.58","1182.43","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","823.92","52.26","","25.34","25.34","25.34","1 through 10","823.92","1288.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1576.58","1182.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1267.57","80.4","","478.02","107.84","478.02","1 through 10","823.92","1288.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1576.58","1182.43","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1288.38","81.72","","32.74","12.33","122.05","1 through 10","823.92","1288.38","percent of total billed charges",""
"ILLUMINATOR SINUS 100CM RELIEVA LUMA SENTRY SYSTEM SINUPLASTY BX/5EA","SUP-ITM-10056497","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1576.58","1182.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1288.38","81.72","","144.95","32.78","676.91","104","823.92","1288.38","percent of total billed charges",""
"Image Cath Fluid Colxn Visc","PX-76001946","CDM","49405","CPT","0761","RC","","","","outpatient","","","4652.00","3489.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","3646.12","3646.12","1 through 10","1237.95","5545.35","other","ASC "
"Image Cath Fluid Colxn Visc","PX-76001946","CDM","49405","CPT","0761","RC","","","","outpatient","","","4652.00","3489.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3045.36","3045.36","3045.36","1 through 10","1237.95","5545.35","other","Multiple Surgery"
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","both","","","4455.00","3341.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2374.52","53.3","","3399.84","3399.84","3399.84","1 through 10","1381.05","3541.73","percent of total billed charges",""
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","both","","","4455.00","3341.25","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1699.43","1924.13","1 through 10","1381.05","3541.73","other","OPPS APC"
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","both","","","4455.00","3341.25","WELLPOINT [1015]","HB AMC WELLPOINT","3286.90","73.78","","3216.24","3216.24","3216.24","1 through 10","1381.05","3541.73","percent of total billed charges",""
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","outpatient","","","4455.00","3341.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1609.14","1580.04","3218.28","1 through 10","1237.95","5545.35","other","ASC"
"Image Cath Fluid Peri/Retro","PX-98300642","CDM","49406","CPT","0983","RC","","","","both","","","1034.00","775.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","551.12","53.3","","3399.84","3399.84","3399.84","1 through 10","320.54","2404.92","percent of total billed charges",""
"Image Cath Fluid Peri/Retro","PX-98300642","CDM","49406","CPT","0983","RC","","","","both","","","1034.00","775.50","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1699.43","1924.13","1 through 10","320.54","2404.92","other","OPPS APC"
"Image Cath Fluid Peri/Retro","PX-98300642","CDM","49406","CPT","0983","RC","","","","both","","","1034.00","775.50","WELLPOINT [1015]","HB AMC WELLPOINT","762.89","73.78","","3216.24","3216.24","3216.24","1 through 10","320.54","2404.92","percent of total billed charges",""
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","both","","","4350.00","3262.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","3458.25","other","OPPS APC"
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","both","","","4350.00","3262.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","1391.62","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","1091.65","1091.65","1091.65","1 through 10","1057.74","3458.25","other","OPPS APC"
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","both","","","4350.00","3262.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2318.55","53.3","","3319.57","3319.57","3319.57","1 through 10","1057.74","3458.25","percent of total billed charges",""
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","both","","","4350.00","3262.50","HUMANA [1012]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2212.16","2212.16","2212.16","1 through 10","1057.74","3458.25","other","OPPS APC"
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","both","","","4350.00","3262.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","36","1057.74","3458.25","other","OPPS APC"
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1587.75","36.5","","1337.11","1337.11","1573.31","1 through 10","1057.74","3458.25","percent of total billed charges",""
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1666.05","38.3","","1649.24","1649.24","3915.92","13","1057.74","3458.25","percent of total billed charges",""
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3285.82","3285.82","3285.82","1 through 10","1057.74","3458.25","other","OPPS APC"
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","both","","","4350.00","3262.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.65","975.17","1092.15","1 through 10","1057.74","3458.25","other","OPPS APC"
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","both","","","4350.00","3262.50","WELLPOINT [1015]","HB AMC WELLPOINT","3209.43","73.78","","3140.30","3140.30","3140.30","1 through 10","1057.74","3458.25","percent of total billed charges",""
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","outpatient","","","4350.00","3262.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1766.80","849.13","3396.52","1 through 10","761.55","5010.16","other","Multiple Surgery"
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","outpatient","","","4350.00","3262.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1858.18","1789.64","1858.18","1 through 10","761.55","5010.16","other","Multiple Surgery"
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","outpatient","","","4350.00","3262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3554.82","81.72","","1949.57","1854.65","3371.87","1 through 10","761.55","5010.16","percent of total billed charges",""
"Image-Guided Catheter Fluid Collection Drainage","PX-76001973","CDM","10030","CPT","0761","RC","","","","both","","","1141.00","855.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","741.65","65","","583.97","583.97","583.97","1 through 10","353.71","1044.34","percent of total billed charges",""
"Image-Guided Catheter Fluid Collection Drainage","PX-76001973","CDM","10030","CPT","0761","RC","","","","both","","","1141.00","855.75","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","626.67","835.56","1 through 10","353.71","1044.34","other","OPPS APC"
"Image-Guided Catheter Fluid Collection Drainage","PX-76001973","CDM","10030","CPT","0761","RC","","","","both","","","1141.00","855.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","437.00","38.3","","432.45","420.28","432.45","1 through 10","353.71","1044.34","percent of total billed charges",""
"Image-Guided Catheter Fluid Collection Drainage","PX-76001973","CDM","10030","CPT","0761","RC","","","","both","","","1141.00","855.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2478.75","824.25","2478.75","1 through 10","353.71","1044.34","other","OPPS APC"
"Image-Guided Catheter Fluid Collection Drainage","PX-76001973","CDM","10030","CPT","0761","RC","","","","both","","","1141.00","855.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","752.55","752.55","752.55","1 through 10","353.71","1044.34","other","OPPS APC"
"Image-Guided Catheter Fluid Collection Drainage","PX-76001973","CDM","10030","CPT","0761","RC","","","","outpatient","","","1141.00","855.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","665.49","665.49","665.49","1 through 10","579.34","932.43","other","ASC"
"Image-Guided Catheter Fluid Collection Drainage","PX-76001973","CDM","10030","CPT","0761","RC","","","","outpatient","","","1141.00","855.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1550.94","1535.70","1550.94","1 through 10","579.34","932.43","other","ASC "
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","405.00","303.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","265.68","65.6","","187.85","187.85","266.06","12","125.55","321.98","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","405.00","303.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","283.50","70","","393.00","393.00","481.00","1 through 10","125.55","321.98","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","405.00","303.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","321.98","79.5","","309.29","207.50","927.87","175","125.55","321.98","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","405.00","303.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","215.87","53.3","","291.29","207.50","622.51","71","125.55","321.98","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","405.00","303.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","311.85","77","","302.61","302.61","302.61","1 through 10","125.55","321.98","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","405.00","303.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","263.25","65","","4853.55","510.90","4853.55","1 through 10","125.55","321.98","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","405.00","303.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","321.98","79.5","","309.29","309.29","309.29","13","125.55","321.98","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","405.00","303.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","147.83","36.5","","146.59","124.58","439.77","212","125.55","321.98","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","405.00","303.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","155.12","38.3","","153.66","149.34","153.67","282","125.55","321.98","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","405.00","303.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.75","42.9","","172.80","172.80","1884.98","11","125.55","321.98","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","405.00","303.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.75","42.9","","172.80","172.80","172.80","1 through 10","125.55","321.98","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","405.00","303.75","WELLPOINT [1015]","HB AMC WELLPOINT","298.81","73.78","","1522.60","292.59","5401.59","228","125.55","321.98","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","405.00","303.75","AETNA [1001]","HB AMC AETNA HMO","282.69","69.8","","266.06","266.06","1064.24","18","211.65","330.97","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","405.00","303.75","AETNA [1001]","HB AMC AETNA PPO","325.62","80.4","","1532.70","1532.70","1532.70","1 through 10","211.65","330.97","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","405.00","303.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","211.65","52.26","","206.86","206.86","206.86","1 through 10","211.65","330.97","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","405.00","303.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","325.62","80.4","","306.54","306.54","306.54","15","211.65","330.97","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","405.00","303.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","330.97","81.72","","314.17","314.16","4712.46","1 through 10","211.65","330.97","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","405.00","303.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","330.97","81.72","","172.80","8.96","314.17","1 through 10","211.65","330.97","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","405.00","303.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","330.97","81.72","","314.16","172.80","314.17","291","211.65","330.97","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","420.35","51.32","420.35","1 through 10","238.39","611.36","other","OPPS APC"
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","611.36","79.5","","587.10","393.89","587.10","1 through 10","238.39","611.36","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","409.88","53.3","","393.89","393.89","587.10","1 through 10","238.39","611.36","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","418.65","418.65","1 through 10","238.39","611.36","other","OPPS APC"
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","FALLON HEALTH [1008]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","627.98","627.98","627.98","1 through 10","238.39","611.36","other","OPPS APC"
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","592.13","77","","574.42","574.42","574.42","1 through 10","238.39","611.36","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","499.85","65","","484.90","484.90","484.90","1 through 10","238.39","611.36","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","611.36","79.5","","562.48","562.48","562.48","1 through 10","238.39","611.36","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","MEDICARE [2001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","213.60","142.40","427.19","90","238.39","611.36","other","OPPS APC"
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","280.69","36.5","","278.26","236.48","278.26","1 through 10","238.39","611.36","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","294.53","38.3","","283.48","246.18","291.69","14","238.39","611.36","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","418.65","418.65","1 through 10","238.39","611.36","other","OPPS APC"
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","418.65","418.65","1 through 10","238.39","611.36","other","OPPS APC"
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","384.47","427.19","1 through 10","238.39","611.36","other","OPPS APC"
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","WELLPOINT [1015]","HB AMC WELLPOINT","567.37","73.78","","555.40","555.40","1301.40","1 through 10","238.39","611.36","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","769.00","576.75","WELLSENSE NH [1050]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","844.12","844.12","844.12","1 through 10","238.39","611.36","other","OPPS APC"
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","outpatient","","","769.00","576.75","AETNA [1001]","HB AMC AETNA HMO","536.76","69.8","","145.12","145.12","910.08","1 through 10","265.8","1680.97","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","outpatient","","","769.00","576.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","628.43","81.72","","596.35","596.35","596.35","1 through 10","265.8","1680.97","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","outpatient","","","769.00","576.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","628.43","81.72","","328.02","328.02","328.02","1 through 10","265.8","1680.97","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","outpatient","","","769.00","576.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","628.43","81.72","","596.35","596.35","1118.82","18","265.8","1680.97","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","200.24","91.72","407.00","69","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","275.52","65.6","","275.54","275.54","275.54","1 through 10","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","273.00","65","","264.55","264.55","264.55","1 through 10","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","294.00","70","","325.60","325.60","484.00","1 through 10","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","254.35","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","59.32","59.32","59.32","1 through 10","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","CHAMPVA [160001]","HB BWH TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","407.00","407.00","407.00","1 through 10","130.2","333.9","other","Tricare OPPS"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","333.90","79.5","","320.31","214.90","960.93","94","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","CIGNA [1006]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","199.43","199.43","1 through 10","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","223.86","53.3","","320.31","214.90","1222.12","35","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","167.93","199.43","1 through 10","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","FALLON HEALTH [1008]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","199.43","203.50","1 through 10","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.70","182.70","182.70","1 through 10","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","200.65","182.69","398.86","1 through 10","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","323.40","77","","745.36","313.39","745.36","1 through 10","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","HUMANA [1012]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","99.72","199.43","11","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","273.00","65","","264.55","23.18","264.55","1 through 10","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","333.90","79.5","","320.31","320.31","320.31","1 through 10","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.53","199.43","199.53","1 through 10","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","MEDICARE [2001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","186.42","203.50","408","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","130.20","31","","125.76","125.76","125.76","1 through 10","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","153.30","36.5","","151.81","129.02","455.43","82","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","160.86","38.3","","159.14","154.66","159.14","207","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","99.72","199.43","1 through 10","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","MOLINA [1014]","HB BWH MOLINA","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","403.74","369.86","403.74","1 through 10","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","323.40","77","","1380.88","320.31","1380.88","1 through 10","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","TRICARE [160005]","HB BWH TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","203.50","193.33","203.50","11","130.2","333.9","other","Tricare OPPS"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","203.50","186.42","203.50","1 through 10","130.2","333.9","other","Tricare OPPS"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","199.43","199.43","30","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","93.61","93.61","93.61","1 through 10","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.18","42.9","","325.36","178.96","325.36","1 through 10","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","182.70","199.63","73","130.2","333.9","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.18","42.9","","178.96","178.96","178.96","1 through 10","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","420.00","315.00","WELLPOINT [1015]","HB AMC WELLPOINT","309.88","73.78","","710.01","303.01","1117.01","121","130.2","333.9","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","420.00","315.00","AETNA [1001]","HB AMC AETNA HMO","293.16","69.8","","275.54","275.54","826.62","22","219.49","887.19","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","420.00","315.00","AETNA [1001]","HB AMC AETNA PPO","337.68","80.4","","317.46","317.46","317.46","1 through 10","219.49","887.19","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","420.00","315.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","219.49","52.26","","297.92","297.92","297.92","1 through 10","219.49","887.19","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","337.68","80.4","","317.46","317.46","407.00","1 through 10","219.49","887.19","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","343.22","81.72","","325.35","325.35","325.36","1 through 10","219.49","887.19","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","343.22","81.72","","178.96","13.44","325.36","1 through 10","219.49","887.19","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","343.22","81.72","","325.36","178.96","325.36","143","219.49","887.19","percent of total billed charges",""
"Imm Admn Sarscov2 Bvl 3 Mcg/0.2 Ml 3rd Dose 6mo-4yrs","PX-77100065","CDM","0173A","CPT","0771","RC","","","","outpatient","","","75.00","56.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37.50","50","","91.76","91.76","91.76","1 through 10","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","50.78","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","50.74","48.94","50.74","54","23.25","61.63","other","OPPS APC"
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.52","46.80","48.52","30","23.25","61.63","other","OPPS APC"
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","53.85","71.8","","53.85","53.85","53.85","1 through 10","23.25","61.63","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59.63","79.5","","59.03","39.60","177.09","35","23.25","61.63","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39.98","53.3","","59.03","37.88","96.97","20","23.25","61.63","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.32","40.69","48.32","1 through 10","23.25","61.63","other","OPPS APC"
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","FALLON HEALTH [1008]","HB BWH MEDICARE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.93","147.93","147.93","1 through 10","23.25","61.63","other","OPPS APC"
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","93.22","46.61","93.22","1 through 10","23.25","61.63","other","OPPS APC"
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","57.75","77","","115.50","57.75","115.50","1 through 10","23.25","61.63","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","HUMANA [1012]","HB BWH MEDICARE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.32","46.61","48.32","1 through 10","23.25","61.63","other","OPPS APC"
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","MEDICARE [2001]","HB BWH MEDICARE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","49.31","47.56","49.31","597","23.25","61.63","other","OPPS APC"
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","23.25","31","","23.18","23.18","69.54","1 through 10","23.25","61.63","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.38","36.5","","27.98","23.78","54.30","95","23.25","61.63","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.73","38.3","","29.33","28.50","57.00","310","23.25","61.63","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.32","46.61","93.22","36","23.25","61.63","other","OPPS APC"
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","MOLINA [1014]","HB BWH MOLINA","48.32","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","97.63","95.12","97.63","1 through 10","23.25","61.63","other","OPPS APC"
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","57.75","77","","294.29","35.85","294.29","1 through 10","23.25","61.63","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","TRICARE [160005]","HB BWH TRICARE","46.84","","APC Price ($49.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","46.84","45.18","49.31","1 through 10","23.25","61.63","other","Tricare OPPS"
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","48.32","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","93.22","48.32","144.96","14","23.25","61.63","other","OPPS APC"
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","48.32","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","17.25","17.25","17.25","1 through 10","23.25","61.63","other","OPPS APC"
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.18","42.9","","59.95","59.95","59.95","1 through 10","23.25","61.63","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","48.32","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","48.32","46.61","48.52","277","23.25","61.63","other","OPPS APC"
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.18","42.9","","32.98","32.98","32.98","1 through 10","23.25","61.63","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB AMC WELLPOINT","55.34","73.78","","55.84","55.84","130.84","37","23.25","61.63","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","AETNA [1001]","HB AMC AETNA HMO","52.35","69.8","","50.78","35.85","58.50","60","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","AETNA [1001]","HB AMC AETNA PPO","60.30","80.4","","58.50","39.30","58.50","1 through 10","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","41.93","55.9","","39.30","39.30","39.30","1 through 10","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","45.41","60.55","","45.88","45.88","45.88","267","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","39.20","52.26","","46.41","46.41","46.41","1 through 10","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","39.17","52.22","","45.88","45.88","45.88","418","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","39.38","52.5","","49.13","43.20","49.13","1 through 10","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37.50","50","","74.03","39.30","74.03","344","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","39.38","52.5","","77.78","39.68","77.78","119","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","46.88","62.5","","49.13","47.18","49.13","1 through 10","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","39.38","52.5","","41.25","39.68","75.00","1 through 10","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","41.25","55","","41.55","31.69","43.20","21","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","39.38","52.5","","47.18","47.18","47.18","1 through 10","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","61.29","81.72","","59.96","32.98","75.00","1 through 10","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","61.29","81.72","","59.96","32.98","75.00","54","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","46.88","62.5","","47.18","47.18","47.18","1 through 10","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","39.38","52.5","","41.25","41.25","41.25","1 through 10","37.5","61.88","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","41.25","55","","41.55","41.55","41.55","1 through 10","37.5","61.88","percent of total billed charges",""
"IMMOBILIZER KNEE 20IN L UNIVERSAL ONE SIZE FITS MOST FOAM CNTORD POST MEDIA LAT ALUMINIUM STAY ELAS PATELLA STRAP","SUP-ITM-10001230","CDM","L1830","HCPCS","0274","RC","","","","both","","","52.05","39.04","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","27.33","52.5","","73.75","73.75","73.75","1 through 10","16.14","204.66","percent of total billed charges",""
"IMMOBILIZER KNEE 20IN L UNIVERSAL ONE SIZE FITS MOST FOAM CNTORD POST MEDIA LAT ALUMINIUM STAY ELAS PATELLA STRAP","SUP-ITM-10001230","CDM","L1830","HCPCS","0274","RC","","","","outpatient","","","52.05","39.04","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","27.33","52.5","","73.75","73.75","73.75","1 through 10","26.03","204.66","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Immun Admin Any Route 1st Vacc/Tox","PX-77100001","CDM","90460","CPT","0771","RC","","","","both","","","43.00","32.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","34.19","79.5","","33.06","33.05","33.06","17","13.33","40.85","percent of total billed charges",""
"Immun Admin Any Route 1st Vacc/Tox","PX-77100001","CDM","90460","CPT","0771","RC","","","","both","","","43.00","32.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22.92","53.3","","22.18","21.21","33.05","1 through 10","13.33","40.85","percent of total billed charges",""
"Immun Admin Any Route 1st Vacc/Tox","PX-77100001","CDM","90460","CPT","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","13.33","31","","12.98","12.98","12.98","1 through 10","13.33","40.85","percent of total billed charges",""
"Immun Admin Any Route 1st Vacc/Tox","PX-77100001","CDM","90460","CPT","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15.70","36.5","","15.67","15.21","15.67","27","13.33","40.85","percent of total billed charges",""
"Immun Admin Any Route 1st Vacc/Tox","PX-77100001","CDM","90460","CPT","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.47","38.3","","16.42","15.96","49.27","69","13.33","40.85","percent of total billed charges",""
"Immun Admin Any Route 1st Vacc/Tox","PX-77100001","CDM","90460","CPT","0771","RC","","","","both","","","43.00","32.25","WELLPOINT [1015]","HB AMC WELLPOINT","31.73","73.78","","31.27","31.27","31.27","1 through 10","13.33","40.85","percent of total billed charges",""
"Immun Admin Any Route 1st Vacc/Tox","PX-77100001","CDM","90460","CPT","0771","RC","","","","outpatient","","","43.00","32.25","AETNA [1001]","HB AMC AETNA HMO","30.01","69.8","","28.44","20.08","28.44","1 through 10","22.47","228.84","percent of total billed charges",""
"Immun Admin Any Route 1st Vacc/Tox","PX-77100001","CDM","90460","CPT","0771","RC","","","","outpatient","","","43.00","32.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","35.14","81.72","","67.15","67.15","67.15","1 through 10","22.47","228.84","percent of total billed charges",""
"Immun Admin Any Route 1st Vacc/Tox","PX-77100001","CDM","90460","CPT","0771","RC","","","","outpatient","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","35.14","81.72","","33.57","18.47","42.00","12","22.47","228.84","percent of total billed charges",""
"Immun Admin Any Route Ea Addl Vacc/","PX-77100002","CDM","90461","CPT","0771","RC","","","","both","","","38.00","28.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","30.21","79.5","","29.12","29.12","29.12","1 through 10","8.89","36.1","percent of total billed charges",""
"Immun Admin Any Route Ea Addl Vacc/","PX-77100002","CDM","90461","CPT","0771","RC","","","","both","","","38.00","28.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","20.25","53.3","","18.69","18.69","29.12","1 through 10","8.89","36.1","percent of total billed charges",""
"Immun Admin Any Route Ea Addl Vacc/","PX-77100002","CDM","90461","CPT","0771","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","11.78","31","","11.43","11.43","11.43","1 through 10","8.89","36.1","percent of total billed charges",""
"Immun Admin Any Route Ea Addl Vacc/","PX-77100002","CDM","90461","CPT","0771","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13.87","36.5","","13.80","11.73","13.80","28","8.89","36.1","percent of total billed charges",""
"Immun Admin Any Route Ea Addl Vacc/","PX-77100002","CDM","90461","CPT","0771","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.55","38.3","","14.47","14.47","43.40","65","8.89","36.1","percent of total billed charges",""
"Immun Admin Any Route Ea Addl Vacc/","PX-77100002","CDM","90461","CPT","0771","RC","","","","both","","","38.00","28.50","WELLPOINT [1015]","HB AMC WELLPOINT","28.04","73.78","","27.55","27.55","27.55","1 through 10","8.89","36.1","percent of total billed charges",""
"Immun Admin Any Route Ea Addl Vacc/","PX-77100002","CDM","90461","CPT","0771","RC","","","","outpatient","","","38.00","28.50","AETNA [1001]","HB AMC AETNA HMO","26.52","69.8","","25.05","17.69","25.05","1 through 10","19.86","114.44","percent of total billed charges",""
"Immun Admin Any Route Ea Addl Vacc/","PX-77100002","CDM","90461","CPT","0771","RC","","","","outpatient","","","38.00","28.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","31.05","81.72","","16.27","16.27","16.27","1 through 10","19.86","114.44","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","39.00","29.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","28.00","71.8","","81.86","81.86","81.86","1 through 10","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","39.00","29.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","27.30","70","","16.34","16.34","16.34","1 through 10","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","39.00","29.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","31.01","79.5","","29.91","20.06","29.91","33","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","39.00","29.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","20.79","53.3","","20.06","20.06","29.91","41","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","39.00","29.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","31.01","79.5","","29.91","29.91","29.91","1 through 10","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","39.00","29.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","12.09","31","","35.22","11.74","35.22","1 through 10","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","39.00","29.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14.24","36.5","","14.17","12.05","14.18","142","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","39.00","29.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.94","38.3","","14.86","14.44","14.86","256","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","39.00","29.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16.73","42.9","","30.38","30.38","30.38","1 through 10","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","39.00","29.25","WELLPOINT [1015]","HB AMC WELLPOINT","28.77","73.78","","28.29","28.29","66.29","35","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","outpatient","","","39.00","29.25","AETNA [1001]","HB AMC AETNA HMO","27.22","69.8","","25.73","18.16","29.64","70","20.38","31.87","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","outpatient","","","39.00","29.25","AETNA [1001]","HB AMC AETNA PPO","31.36","80.4","","29.64","29.64","29.64","1 through 10","20.38","31.87","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","outpatient","","","39.00","29.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","21.80","55.9","","19.91","19.91","19.91","1 through 10","20.38","31.87","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","outpatient","","","39.00","29.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","31.87","81.72","","38.00","38.00","38.00","1 through 10","20.38","31.87","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","outpatient","","","39.00","29.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","31.87","81.72","","30.38","16.71","38.00","50","20.38","31.87","percent of total billed charges",""
"Immune Admin Ea Add Vacc Oral/Nasal","PX-77100006","CDM","90474","CPT","0771","RC","","","","both","","","39.00","29.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","31.01","79.5","","29.91","29.91","29.91","1 through 10","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Oral/Nasal","PX-77100006","CDM","90474","CPT","0771","RC","","","","both","","","39.00","29.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","20.79","53.3","","29.91","20.06","29.91","1 through 10","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Oral/Nasal","PX-77100006","CDM","90474","CPT","0771","RC","","","","both","","","39.00","29.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14.24","36.5","","14.17","12.05","14.17","23","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Oral/Nasal","PX-77100006","CDM","90474","CPT","0771","RC","","","","both","","","39.00","29.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.94","38.3","","14.86","14.86","14.86","27","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Oral/Nasal","PX-77100006","CDM","90474","CPT","0771","RC","","","","both","","","39.00","29.25","WELLPOINT [1015]","HB AMC WELLPOINT","28.77","73.78","","28.29","28.29","28.29","1 through 10","12.09","31.01","percent of total billed charges",""
"Immune Admin Ea Add Vacc Oral/Nasal","PX-77100006","CDM","90474","CPT","0771","RC","","","","outpatient","","","39.00","29.25","AETNA [1001]","HB AMC AETNA HMO","27.22","69.8","","25.73","18.16","25.73","11","20.38","31.87","percent of total billed charges",""
"Immune Admin Ea Add Vacc Oral/Nasal","PX-77100006","CDM","90474","CPT","0771","RC","","","","outpatient","","","39.00","29.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","31.87","81.72","","16.71","16.71","16.71","1 through 10","20.38","31.87","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","83.17","83.17","83.17","1 through 10","13.33","105.64","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","30.87","71.8","","90.48","30.16","90.48","1 through 10","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","27.95","65","","265.20","22.18","265.20","1 through 10","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","30.10","70","","18.06","18.06","18.06","1 through 10","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","105.64","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","10.29","10.29","10.29","1 through 10","13.33","105.64","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","34.19","79.5","","33.05","22.18","33.05","264","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22.92","53.3","","22.18","22.18","33.05","149","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","33.11","77","","32.34","32.34","32.34","1 through 10","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","34.19","79.5","","33.05","30.56","33.05","1 through 10","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","48","13.33","105.64","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","13.33","31","","12.98","12.98","38.94","32","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15.70","36.5","","15.67","13.31","15.67","517","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.47","38.3","","16.42","15.96","31.92","1492","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.83","75.35","82.83","1 through 10","13.33","105.64","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","33.11","77","","30.80","20.08","489.46","1 through 10","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","TRICARE [160005]","HB BWH TRICARE","80.29","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","42.00","42.00","84.52","1 through 10","13.33","105.64","other","Tricare OPPS"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","82.83","82.83","1 through 10","13.33","105.64","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9.66","9.66","9.66","1 through 10","13.33","105.64","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.45","42.9","","19.11","18.47","33.57","1 through 10","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","82.83","124.83","17","13.33","105.64","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.45","42.9","","18.47","18.47","18.47","1 through 10","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","43.00","32.25","WELLPOINT [1015]","HB AMC WELLPOINT","31.73","73.78","","31.27","31.27","73.27","241","13.33","105.64","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","43.00","32.25","AETNA [1001]","HB AMC AETNA HMO","30.01","69.8","","28.43","20.08","32.76","380","22.47","228.84","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","43.00","32.25","AETNA [1001]","HB AMC AETNA PPO","34.57","80.4","","32.76","22.01","32.76","46","22.47","228.84","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","43.00","32.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","24.04","55.9","","22.01","22.01","22.01","1 through 10","22.47","228.84","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","43.00","32.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","22.47","52.26","","25.99","25.99","168.72","1 through 10","22.47","228.84","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","43.00","32.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","35.14","81.72","","42.00","42.00","42.00","1 through 10","22.47","228.84","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","35.14","81.72","","33.57","18.47","42.00","17","22.47","228.84","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","35.14","81.72","","33.57","18.47","42.00","300","22.47","228.84","percent of total billed charges",""
"Immune Admin One Vacc Oral/Nasal","PX-77100005","CDM","90473","CPT","0771","RC","","","","both","","","43.00","32.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.47","38.3","","16.42","16.42","16.42","1 through 10","13.33","105.64","percent of total billed charges",""
"Immune Complex Assay","PX-30000836","CDM","86332","CPT","0302","RC","","","","both","","","299.00","224.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","237.71","79.5","","228.23","228.23","228.23","1 through 10","23.88","284.05","percent of total billed charges",""
"Immune Complex Assay","PX-30000836","CDM","86332","CPT","0302","RC","","","","both","","","299.00","224.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","114.52","38.3","","113.39","113.39","113.39","1 through 10","23.88","284.05","percent of total billed charges",""
"Immune Complex Assay","PX-30000836","CDM","86332","CPT","0302","RC","","","","outpatient","","","299.00","224.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","244.34","81.72","","223.30","223.30","223.30","1 through 10","25.14","244.34","percent of total billed charges",""
"Immune Globulin Gammagard IV 500mg","PX-63600115","CDM","J1569","HCPCS","0636","RC","","","","both","","","142.38","106.78","MEDICARE [2001]","HB BWH MEDICARE","45.31","","APC Price ($45.31).","45.13","45.13","47.80","60","44.14","109.63","other","OPPS APC"
"Immune Globulin Gammagard IV 500mg","PX-63600115","CDM","J1569","HCPCS","0636","RC","","","","both","","","142.38","106.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.97","36.5","","56.60","56.60","56.60","130","44.14","109.63","percent of total billed charges",""
"Immune Globulin Gammagard IV 500mg","PX-63600115","CDM","J1569","HCPCS","0636","RC","","","","both","","","142.38","106.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.53","38.3","","57.66","57.66","59.33","300","44.14","109.63","percent of total billed charges",""
"Immune Globulin Gammagard IV 500mg","PX-63600115","CDM","J1569","HCPCS","0636","RC","","","","both","","","142.38","106.78","TRICARE [160005]","HB BWH TRICARE","45.41","","APC Price ($47.80). Final payment is multiplied by 95%.","9.56","9.03","9.56","804","44.14","109.63","other","Tricare OPPS"
"Immune Globulin Gammagard IV 500mg","PX-63600115","CDM","J1569","HCPCS","0636","RC","","","","both","","","142.38","106.78","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","44.41","","APC Price ($45.31). Final payment is multiplied by 98%.","45.72","44.32","48.70","1560","44.14","109.63","other","OPPS APC"
"Immune Globulin Gamunex IV 500mg","PX-63600113","CDM","J1561","HCPCS","0636","RC","","","","both","","","149.00","111.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.07","38.3","","96.70","96.70","96.70","50","45.63","120.83","percent of total billed charges",""
"Immune Globulin Gamunex IV 500mg","PX-63600113","CDM","J1561","HCPCS","0636","RC","","","","outpatient","","","149.00","111.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","104.15","69.9","","114.75","114.75","114.75","140","56.09","119.8","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","139.29","71.8","","10.17","10.17","134.98","13","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","135.80","70","","82.67","82.67","82.67","1 through 10","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","154.23","79.5","","147.96","99.26","188.00","239","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","103.40","53.3","","99.27","99.26","147.96","109","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","149.38","77","","434.28","434.28","434.28","60","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","126.10","65","","122.20","44.20","244.40","1 through 10","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","154.23","79.5","","147.96","147.96","147.96","1 through 10","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","60.14","31","","68.26","58.09","68.26","1 through 10","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70.81","36.5","","70.12","59.60","210.36","196","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","74.30","38.3","","73.51","71.44","220.53","563","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","149.38","77","","163.56","137.98","163.56","1 through 10","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","TRICARE [160005]","HB BWH TRICARE","184.30","95","","13.20","13.20","13.89","23","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","184.30","95","","11.53","11.53","11.53","1 through 10","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.23","42.9","","150.29","82.66","150.29","15","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","194.00","145.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.23","42.9","","82.66","82.66","82.66","1 through 10","11.3","184.3","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","AETNA [1001]","HB AMC AETNA HMO","135.41","69.8","","127.28","89.86","254.56","324","11.81","158.54","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","AETNA [1001]","HB AMC AETNA PPO","155.98","80.4","","146.64","98.51","146.64","43","11.81","158.54","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","101.38","52.26","","41.24","41.24","116.34","1 through 10","11.81","158.54","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","155.98","80.4","","146.64","146.64","282.00","1 through 10","11.81","158.54","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","158.54","81.72","","150.29","150.29","376.00","1 through 10","11.81","158.54","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","158.54","81.72","","82.67","82.66","300.57","1 through 10","11.81","158.54","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","194.00","145.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","158.54","81.72","","150.29","82.66","150.29","198","11.81","158.54","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","both","","","229.00","171.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","164.42","71.8","","159.40","159.40","159.40","1 through 10","13.93","217.55","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","both","","","229.00","171.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","182.06","79.5","","524.13","174.71","524.13","1 through 10","13.93","217.55","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","both","","","229.00","171.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","122.06","53.3","","174.71","174.71","174.71","1 through 10","13.93","217.55","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","both","","","229.00","171.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.59","36.5","","80.36","70.37","80.36","1 through 10","13.93","217.55","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","both","","","229.00","171.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.71","38.3","","86.80","84.36","163.83","13","13.93","217.55","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","both","","","229.00","171.75","TRICARE [160005]","HB BWH TRICARE","217.55","95","","21.06","21.06","21.06","1 through 10","13.93","217.55","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","outpatient","","","229.00","171.75","AETNA [1001]","HB AMC AETNA HMO","159.84","69.8","","106.12","106.12","150.29","1 through 10","13.93","187.14","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","outpatient","","","229.00","171.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","187.14","81.72","","177.47","177.47","177.47","1 through 10","13.93","187.14","percent of total billed charges",""
"Immunoassay Optical Organism","PX-30001358","CDM","87899","CPT","0306","RC","","","","both","","","405.00","303.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","290.79","71.8","","14.17","14.17","14.17","1 through 10","11.81","384.75","percent of total billed charges",""
"Immunoassay Optical Organism","PX-30001358","CDM","87899","CPT","0306","RC","","","","both","","","405.00","303.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","283.50","70","","393.00","393.00","393.00","1 through 10","11.81","384.75","percent of total billed charges",""
"Immunoassay Optical Organism","PX-30001358","CDM","87899","CPT","0306","RC","","","","both","","","405.00","303.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","215.87","53.3","","166.91","166.91","166.91","1 through 10","11.81","384.75","percent of total billed charges",""
"Immunoassay Optical Organism","PX-30001358","CDM","87899","CPT","0306","RC","","","","both","","","405.00","303.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","155.12","38.3","","153.66","78.20","153.66","1 through 10","11.81","384.75","percent of total billed charges",""
"Immunoassay Optical Organism","PX-30001358","CDM","87899","CPT","0306","RC","","","","outpatient","","","405.00","303.75","AETNA [1001]","HB AMC AETNA HMO","282.69","69.8","","187.85","95.60","306.54","1 through 10","11.81","330.97","percent of total billed charges",""
"Immunoassay Optical Organism","PX-30001358","CDM","87899","CPT","0306","RC","","","","outpatient","","","405.00","303.75","AETNA [1001]","HB AMC AETNA PPO","325.62","80.4","","306.54","306.54","306.54","1 through 10","11.81","330.97","percent of total billed charges",""
"Immunoassay Optical Organism","PX-30001358","CDM","87899","CPT","0306","RC","","","","outpatient","","","405.00","303.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","330.97","81.72","","314.16","314.16","314.16","1 through 10","11.81","330.97","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","both","","","138.00","103.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","109.71","79.5","","105.46","70.75","105.46","38","11.81","131.1","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","both","","","138.00","103.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","73.55","53.3","","105.46","70.75","105.46","15","11.81","131.1","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","both","","","138.00","103.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","109.71","79.5","","83.90","83.90","83.90","1 through 10","11.81","131.1","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","42.78","31","","41.41","41.41","41.41","1 through 10","11.81","131.1","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.37","36.5","","49.98","42.48","49.98","34","11.81","131.1","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.85","38.3","","52.39","50.92","157.17","97","11.81","131.1","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","both","","","138.00","103.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","106.26","77","","104.52","104.52","104.52","1 through 10","11.81","131.1","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","both","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.20","42.9","","58.92","58.92","58.92","1 through 10","11.81","131.1","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","outpatient","","","138.00","103.50","AETNA [1001]","HB AMC AETNA HMO","96.32","69.8","","90.72","64.05","90.72","45","11.81","112.77","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","outpatient","","","138.00","103.50","AETNA [1001]","HB AMC AETNA PPO","110.95","80.4","","70.22","70.22","104.52","1 through 10","11.81","112.77","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","112.77","81.72","","67.44","67.44","67.44","1 through 10","11.81","112.77","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","112.77","81.72","","107.12","58.92","107.12","1 through 10","11.81","112.77","percent of total billed charges",""
"Immunoassay Tumor Ag Other Ag Qn","PX-30000825","CDM","86316","CPT","0302","RC","","","","both","","","260.00","195.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","138.58","53.3","","133.06","133.06","133.06","1 through 10","20.39","247","percent of total billed charges",""
"Immunoassay Tumor Ag Other Ag Qn","PX-30000825","CDM","86316","CPT","0302","RC","","","","outpatient","","","260.00","195.00","AETNA [1001]","HB AMC AETNA PPO","209.04","80.4","","170.60","170.60","170.60","1 through 10","21.45","212.47","percent of total billed charges",""
"Immunoassay Tumor Ag Other Ag Qn","PX-30000825","CDM","86316","CPT","0302","RC","","","","outpatient","","","260.00","195.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","212.47","81.72","","110.80","110.80","251.82","1 through 10","21.45","212.47","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","both","","","268.00","201.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","213.06","79.5","","204.62","137.28","204.62","1 through 10","20.39","254.6","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","both","","","268.00","201.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","142.84","53.3","","137.28","137.28","204.62","1 through 10","20.39","254.6","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","both","","","268.00","201.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.82","36.5","","96.98","94.12","247.26","1 through 10","20.39","254.6","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","both","","","268.00","201.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","102.64","38.3","","101.66","101.66","296.40","18","20.39","254.6","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","outpatient","","","268.00","201.00","AETNA [1001]","HB AMC AETNA HMO","187.06","69.8","","176.02","124.28","176.02","15","21.45","219.01","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","outpatient","","","268.00","201.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","140.06","52.26","","160.89","160.89","160.89","1 through 10","21.45","219.01","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","outpatient","","","268.00","201.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","215.47","80.4","","202.80","202.80","202.80","1 through 10","21.45","219.01","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","outpatient","","","268.00","201.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","219.01","81.72","","207.84","114.32","207.84","15","21.45","219.01","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 15-3","PX-30000818","CDM","86300","CPT","0302","RC","","","","outpatient","","","247.00","185.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","201.85","81.72","","191.86","191.86","191.86","1 through 10","21.45","201.85","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","both","","","256.00","192.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","203.52","79.5","","195.18","130.94","195.18","1 through 10","20.39","243.2","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","both","","","256.00","192.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","136.45","53.3","","195.18","195.18","195.18","1 through 10","20.39","243.2","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","93.44","36.5","","92.50","89.78","92.50","1 through 10","20.39","243.2","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","98.05","38.3","","96.97","96.97","96.97","13","20.39","243.2","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","both","","","256.00","192.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","109.82","42.9","","198.25","198.25","198.25","1 through 10","20.39","243.2","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","outpatient","","","256.00","192.00","AETNA [1001]","HB AMC AETNA HMO","178.69","69.8","","167.90","167.90","193.44","1 through 10","21.45","209.2","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","outpatient","","","256.00","192.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","205.82","80.4","","193.44","193.44","193.44","1 through 10","21.45","209.2","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","outpatient","","","256.00","192.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","209.20","81.72","","109.05","109.05","109.05","1 through 10","21.45","209.2","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","outpatient","","","256.00","192.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","209.20","81.72","","109.05","85.81","198.25","1 through 10","21.45","209.2","percent of total billed charges",""
"Immunodiffusion Gel Ea Ag Ab Ql","PX-30000834","CDM","86331","CPT","0302","RC","","","","both","","","202.00","151.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","141.40","70","","196.00","196.00","196.00","1 through 10","11.74","191.9","percent of total billed charges",""
"Immunodiffusion Gel Ea Ag Ab Ql","PX-30000834","CDM","86331","CPT","0302","RC","","","","both","","","202.00","151.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.59","79.5","","154.25","154.25","154.25","1 through 10","11.74","191.9","percent of total billed charges",""
"Immunodiffusion Gel Ea Ag Ab Ql","PX-30000834","CDM","86331","CPT","0302","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.73","36.5","","73.11","73.11","73.11","1 through 10","11.74","191.9","percent of total billed charges",""
"Immunodiffusion Gel Ea Ag Ab Ql","PX-30000834","CDM","86331","CPT","0302","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.37","38.3","","76.64","76.64","76.64","1 through 10","11.74","191.9","percent of total billed charges",""
"Immunodiffusion Gel Ea Ag Ab Ql","PX-30000834","CDM","86331","CPT","0302","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA HMO","141.00","69.8","","132.69","93.69","132.69","12","12.36","165.07","percent of total billed charges",""
"Immunofixation Electroph Other","PX-30000839","CDM","86335","CPT","0302","RC","","","","both","","","436.00","327.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","135.16","31","","130.71","130.71","130.71","1 through 10","28.76","414.2","percent of total billed charges",""
"Immunofixation Electroph Other","PX-30000839","CDM","86335","CPT","0302","RC","","","","both","","","436.00","327.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","166.99","38.3","","496.17","160.74","496.17","1 through 10","28.76","414.2","percent of total billed charges",""
"Immunofixation Electroph Other","PX-30000839","CDM","86335","CPT","0302","RC","","","","outpatient","","","436.00","327.00","AETNA [1001]","HB AMC AETNA HMO","304.33","69.8","","202.19","202.19","202.19","1 through 10","30.26","356.3","percent of total billed charges",""
"Immunofixation Electroph Other","PX-30000839","CDM","86335","CPT","0302","RC","","","","outpatient","","","436.00","327.00","AETNA [1001]","HB AMC AETNA PPO","350.54","80.4","","202.19","202.19","202.19","1 through 10","30.26","356.3","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","274.99","71.8","","266.38","19.70","799.14","26","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","251.25","65.6","","22.99","22.99","22.99","1 through 10","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","248.95","65","","241.15","241.15","241.15","1 through 10","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","268.10","70","","371.00","267.12","371.00","1 through 10","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","CHAMPVA [160001]","HB BWH TRICARE","363.85","95","","26.92","26.92","26.92","1 through 10","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","304.49","79.5","","291.98","195.89","291.98","61","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","204.14","53.3","","195.89","195.89","875.94","37","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","294.91","77","","857.01","857.01","857.01","1 through 10","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","248.95","65","","241.15","241.15","241.15","1 through 10","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","118.73","31","","114.64","114.64","114.64","1 through 10","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","139.80","36.5","","138.38","117.61","138.38","61","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","146.69","38.3","","145.06","140.98","435.18","173","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","MOLINA [1014]","HB BWH MOLINA","134.05","35","","44.32","44.32","44.32","1 through 10","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","294.91","77","","271.44","271.44","271.44","1 through 10","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","TRICARE [160005]","HB BWH TRICARE","363.85","95","","25.57","25.57","25.57","1 through 10","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","164.31","42.9","","163.13","163.13","296.58","1 through 10","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","383.00","287.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","164.31","42.9","","163.13","163.13","163.13","1 through 10","21.89","363.85","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","383.00","287.25","AETNA [1001]","HB AMC AETNA HMO","267.33","69.8","","251.17","177.34","289.38","77","23.04","312.99","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","383.00","287.25","AETNA [1001]","HB AMC AETNA PPO","307.93","80.4","","289.38","194.40","578.76","14","23.04","312.99","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","383.00","287.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","200.16","52.26","","54.68","54.68","54.68","1 through 10","23.04","312.99","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","383.00","287.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","307.93","80.4","","185.50","185.50","289.38","1 through 10","23.04","312.99","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","383.00","287.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","312.99","81.72","","296.58","163.13","296.58","1 through 10","23.04","312.99","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","383.00","287.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","312.99","81.72","","296.58","163.13","296.58","76","23.04","312.99","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","200.24","200.24","200.24","11","163.37","418.97","other","OPPS APC"
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","342.55","65","","332.15","332.15","332.15","1 through 10","163.37","418.97","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","368.90","70","","224.69","224.69","224.69","1 through 10","163.37","418.97","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","254.35","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","74.48","74.48","74.48","1 through 10","163.37","418.97","other","OPPS APC"
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","418.97","79.5","","402.16","269.81","402.16","14","163.37","418.97","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","280.89","53.3","","402.16","258.06","402.16","1 through 10","163.37","418.97","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","199.43","199.43","1 through 10","163.37","418.97","other","OPPS APC"
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","405.79","77","","763.84","763.84","763.84","1 through 10","163.37","418.97","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","342.55","65","","332.15","332.15","332.15","1 through 10","163.37","418.97","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.53","199.53","199.53","1 through 10","163.37","418.97","other","OPPS APC"
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","MEDICARE [2001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","186.42","610.50","95","163.37","418.97","other","OPPS APC"
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","192.36","36.5","","190.60","161.99","190.60","1 through 10","163.37","418.97","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.84","38.3","","199.80","199.80","199.80","12","163.37","418.97","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","199.43","199.43","1 through 10","163.37","418.97","other","OPPS APC"
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","MOLINA [1014]","HB BWH MOLINA","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1211.22","1211.22","1211.22","1 through 10","163.37","418.97","other","OPPS APC"
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","600.72","182.69","600.72","1 through 10","163.37","418.97","other","OPPS APC"
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.08","42.9","","408.49","381.97","408.49","1 through 10","163.37","418.97","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","182.70","203.50","15","163.37","418.97","other","OPPS APC"
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","WELLPOINT [1015]","HB AMC WELLPOINT","388.82","73.78","","380.44","380.44","891.44","1 through 10","163.37","418.97","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","outpatient","","","527.00","395.25","AETNA [1001]","HB AMC AETNA HMO","367.85","69.8","","691.90","345.95","691.90","1 through 10","265.8","1680.97","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","outpatient","","","527.00","395.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","423.71","80.4","","398.58","398.58","398.58","1 through 10","265.8","1680.97","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","outpatient","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","430.66","81.72","","224.69","224.69","224.69","1 through 10","265.8","1680.97","percent of total billed charges",""
"Immunofluorescence per Spec 1st Singl Antb Stain","PX-31000038","CDM","88346","CPT","0312","RC","","","","outpatient","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","430.66","81.72","","408.49","224.69","2042.47","1 through 10","265.8","1680.97","percent of total billed charges",""
"Immunofluorescence per Spec Add Singl Antb Stain","PX-31000717","CDM","88350","CPT","0310","RC","","","","both","","","515.00","386.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","334.75","65","","324.35","324.35","324.35","1 through 10","159.65","409.43","percent of total billed charges",""
"Immunofluorescence per Spec Add Singl Antb Stain","PX-31000717","CDM","88350","CPT","0310","RC","","","","both","","","515.00","386.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","409.43","79.5","","392.71","376.25","392.71","31","159.65","409.43","percent of total billed charges",""
"Immunofluorescence per Spec Add Singl Antb Stain","PX-31000717","CDM","88350","CPT","0310","RC","","","","both","","","515.00","386.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","274.50","53.3","","392.71","392.71","392.71","1 through 10","159.65","409.43","percent of total billed charges",""
"Immunofluorescence per Spec Add Singl Antb Stain","PX-31000717","CDM","88350","CPT","0310","RC","","","","both","","","515.00","386.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","396.55","77","","745.36","745.36","745.36","16","159.65","409.43","percent of total billed charges",""
"Immunofluorescence per Spec Add Singl Antb Stain","PX-31000717","CDM","88350","CPT","0310","RC","","","","both","","","515.00","386.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","334.75","65","","324.35","324.35","2919.15","1 through 10","159.65","409.43","percent of total billed charges",""
"Immunofluorescence per Spec Add Singl Antb Stain","PX-31000717","CDM","88350","CPT","0310","RC","","","","both","","","515.00","386.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","187.98","36.5","","186.13","158.18","186.13","50","159.65","409.43","percent of total billed charges",""
"Immunofluorescence per Spec Add Singl Antb Stain","PX-31000717","CDM","88350","CPT","0310","RC","","","","both","","","515.00","386.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","197.25","38.3","","195.11","189.62","195.11","77","159.65","409.43","percent of total billed charges",""
"Immunofluorescence per Spec Add Singl Antb Stain","PX-31000717","CDM","88350","CPT","0310","RC","","","","both","","","515.00","386.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.94","42.9","","398.90","398.90","1490.92","1 through 10","159.65","409.43","percent of total billed charges",""
"Immunofluorescence per Spec Add Singl Antb Stain","PX-31000717","CDM","88350","CPT","0310","RC","","","","both","","","515.00","386.25","WELLPOINT [1015]","HB AMC WELLPOINT","379.97","73.78","","371.51","371.51","2367.51","17","159.65","409.43","percent of total billed charges",""
"Immunofluorescence per Spec Add Singl Antb Stain","PX-31000717","CDM","88350","CPT","0310","RC","","","","outpatient","","","515.00","386.25","AETNA [1001]","HB AMC AETNA HMO","359.47","69.8","","2702.58","2702.58","2702.58","1 through 10","269.14","420.86","percent of total billed charges",""
"Immunofluorescence per Spec Add Singl Antb Stain","PX-31000717","CDM","88350","CPT","0310","RC","","","","outpatient","","","515.00","386.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","414.06","80.4","","389.22","389.22","389.22","1 through 10","269.14","420.86","percent of total billed charges",""
"Immunofluorescence per Spec Add Singl Antb Stain","PX-31000717","CDM","88350","CPT","0310","RC","","","","outpatient","","","515.00","386.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","420.86","81.72","","219.41","219.41","219.41","1 through 10","269.14","420.86","percent of total billed charges",""
"Immunofluorescence per Spec Add Singl Antb Stain","PX-31000717","CDM","88350","CPT","0310","RC","","","","outpatient","","","515.00","386.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","420.86","81.72","","398.90","219.41","983.58","34","269.14","420.86","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","147.91","71.8","","143.60","15.23","430.80","52","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","135.14","65.6","","156.00","17.77","156.00","1 through 10","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","133.90","65","","130.00","130.00","314.80","1 through 10","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","144.20","70","","144.00","135.26","200.00","28","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","163.77","79.5","","157.40","130.00","157.40","124","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.80","53.3","","157.40","105.60","472.20","34","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","133.90","65","","130.00","130.00","260.00","1 through 10","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","75.19","36.5","","74.60","63.40","85.65","113","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.90","38.3","","78.20","76.00","234.60","210","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","MOLINA [1014]","HB BWH MOLINA","72.10","35","","34.27","34.27","34.27","1 through 10","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","158.62","77","","156.00","156.00","156.00","1 through 10","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","TRICARE [160005]","HB BWH TRICARE","195.70","95","","19.77","19.77","19.77","1 through 10","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","195.70","95","","17.27","17.27","17.27","1 through 10","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.37","42.9","","91.00","87.94","91.00","1 through 10","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.37","42.9","","87.94","87.94","87.94","1 through 10","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","206.00","154.50","WELLPOINT [1015]","HB AMC WELLPOINT","151.99","73.78","","148.90","148.90","548.90","171","16.92","195.7","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","206.00","154.50","AETNA [1001]","HB AMC AETNA HMO","143.79","69.8","","135.40","95.60","156.00","198","31.09","169.95","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","206.00","154.50","AETNA [1001]","HB AMC AETNA PPO","165.62","80.4","","156.00","95.60","312.00","19","31.09","169.95","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","206.00","154.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","107.66","52.26","","31.09","31.09","31.09","1 through 10","31.09","169.95","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","206.00","154.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","108.15","52.5","","125.80","115.20","131.00","1 through 10","31.09","169.95","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","206.00","154.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","103.00","50","","104.80","104.80","209.60","329","31.09","169.95","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","206.00","154.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","108.15","52.5","","110.00","110.00","220.00","86","31.09","169.95","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","206.00","154.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","169.95","82.5","","172.80","172.80","172.80","1 through 10","31.09","169.95","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","206.00","154.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","128.75","62.5","","131.00","131.00","131.00","1 through 10","31.09","169.95","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","206.00","154.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","108.15","52.5","","110.00","110.00","110.00","1 through 10","31.09","169.95","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","206.00","154.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","113.30","55","","115.20","110.80","230.40","62","31.09","169.95","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","206.00","154.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","165.62","80.4","","200.00","200.00","200.00","1 through 10","31.09","169.95","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","206.00","154.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","168.34","81.72","","159.88","159.88","159.88","1 through 10","31.09","169.95","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","206.00","154.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","168.34","81.72","","159.88","87.94","319.76","81","31.09","169.95","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","both","","","62.00","46.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","44.52","71.8","","7.07","7.07","7.07","1 through 10","3.8","58.9","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","both","","","62.00","46.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","43.40","70","","44.67","44.67","44.67","1 through 10","3.8","58.9","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","both","","","62.00","46.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","49.29","79.5","","47.22","31.68","141.66","111","3.8","58.9","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","both","","","62.00","46.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33.05","53.3","","90.90","31.68","141.66","44","3.8","58.9","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","both","","","62.00","46.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22.63","36.5","","22.38","19.02","28.13","44","3.8","58.9","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","both","","","62.00","46.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23.75","38.3","","23.46","23.46","70.38","183","3.8","58.9","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","both","","","62.00","46.50","TRICARE [160005]","HB BWH TRICARE","58.90","95","","38.64","38.64","38.64","1 through 10","3.8","58.9","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","both","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.60","42.9","","26.38","26.38","26.38","1 through 10","3.8","58.9","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","outpatient","","","62.00","46.50","AETNA [1001]","HB AMC AETNA HMO","43.28","69.8","","40.62","28.68","40.62","70","3.8","54.62","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","outpatient","","","62.00","46.50","AETNA [1001]","HB AMC AETNA PPO","49.85","80.4","","93.60","31.44","94.32","41","3.8","54.62","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","outpatient","","","62.00","46.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","49.85","80.4","","46.80","46.80","46.80","1 through 10","3.8","54.62","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","outpatient","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","50.67","81.72","","26.38","26.38","26.38","1 through 10","3.8","54.62","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","outpatient","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","50.67","81.72","","47.97","26.38","47.97","69","3.8","54.62","percent of total billed charges",""
"Immunology Unlstd Proc","PX-30001401","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","298.48","65.6","","298.56","298.56","298.56","1 through 10","141.05","361.73","percent of total billed charges",""
"Immunology Unlstd Proc","PX-30001401","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","295.75","65","","286.65","286.65","347.07","11","141.05","361.73","percent of total billed charges",""
"Immunology Unlstd Proc","PX-30001401","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","318.50","70","","317.52","189.63","317.52","1 through 10","141.05","361.73","percent of total billed charges",""
"Immunology Unlstd Proc","PX-30001401","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","295.75","65","","286.65","270.40","286.65","12","141.05","361.73","percent of total billed charges",""
"Immunology Unlstd Proc","PX-30001401","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","295.75","65","","286.65","286.65","286.65","1 through 10","141.05","361.73","percent of total billed charges",""
"Immunology Unlstd Proc","PX-30001401","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","WELLPOINT [1015]","HB AMC WELLPOINT","335.70","73.78","","328.32","306.01","328.32","1 through 10","141.05","361.73","percent of total billed charges",""
"Immunology Unlstd Proc","PX-30001401","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","298.56","298.56","343.98","1 through 10","227.5","375.38","percent of total billed charges",""
"Immunology Unlstd Proc","PX-30001401","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA PPO","365.82","80.4","","343.98","343.98","343.98","1 through 10","227.5","375.38","percent of total billed charges",""
"Immunology Unlstd Proc","PX-30001401","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","227.50","50","","441.00","441.00","441.00","12","227.5","375.38","percent of total billed charges",""
"Immunology Unlstd Proc","PX-30001401","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","238.88","52.5","","441.00","441.00","441.00","1 through 10","227.5","375.38","percent of total billed charges",""
"Immunology Unlstd Proc","PX-30001401","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","250.25","55","","254.02","254.02","254.02","1 through 10","227.5","375.38","percent of total billed charges",""
"Immunology Unlstd Proc","PX-30001401","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","365.82","80.4","","343.98","343.98","343.98","1 through 10","227.5","375.38","percent of total billed charges",""
"Immunology Unlstd Proc","PX-30001401","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","284.38","62.5","","288.86","277.39","288.86","1 through 10","227.5","375.38","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","200.24","91.72","407.00","69","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","317.50","65.6","","275.54","275.54","275.54","1 through 10","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","314.60","65","","264.55","264.55","264.55","1 through 10","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","338.80","70","","325.60","325.60","484.00","1 through 10","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","254.35","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","59.32","59.32","59.32","1 through 10","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","CHAMPVA [160001]","HB BWH TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","407.00","407.00","407.00","1 through 10","150.04","384.78","other","Tricare OPPS"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","384.78","79.5","","320.31","214.90","960.93","94","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","CIGNA [1006]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","199.43","199.43","1 through 10","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","257.97","53.3","","320.31","214.90","1222.12","35","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","167.93","199.43","1 through 10","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","FALLON HEALTH [1008]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","199.43","203.50","1 through 10","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.70","182.70","182.70","1 through 10","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","200.65","182.69","398.86","1 through 10","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","372.68","77","","745.36","313.39","745.36","1 through 10","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","HUMANA [1012]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","99.72","199.43","11","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","314.60","65","","264.55","23.18","264.55","1 through 10","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","384.78","79.5","","320.31","320.31","320.31","1 through 10","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.53","199.43","199.53","1 through 10","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","MEDICARE [2001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","186.42","203.50","408","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","150.04","31","","125.76","125.76","125.76","1 through 10","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","176.66","36.5","","151.81","129.02","455.43","82","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","185.37","38.3","","159.14","154.66","159.14","207","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","99.72","199.43","1 through 10","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","MOLINA [1014]","HB BWH MOLINA","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","403.74","369.86","403.74","1 through 10","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","372.68","77","","1380.88","320.31","1380.88","1 through 10","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","TRICARE [160005]","HB BWH TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","203.50","193.33","203.50","11","150.04","384.78","other","Tricare OPPS"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","203.50","186.42","203.50","1 through 10","150.04","384.78","other","Tricare OPPS"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","199.43","199.43","30","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","93.61","93.61","93.61","1 through 10","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","207.64","42.9","","325.36","178.96","325.36","1 through 10","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","182.70","199.63","73","150.04","384.78","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","207.64","42.9","","178.96","178.96","178.96","1 through 10","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","484.00","363.00","WELLPOINT [1015]","HB AMC WELLPOINT","357.10","73.78","","710.01","303.01","1117.01","121","150.04","384.78","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","484.00","363.00","AETNA [1001]","HB AMC AETNA HMO","337.83","69.8","","275.54","275.54","826.62","22","252.94","887.19","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","484.00","363.00","AETNA [1001]","HB AMC AETNA PPO","389.14","80.4","","317.46","317.46","317.46","1 through 10","252.94","887.19","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","484.00","363.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","252.94","52.26","","297.92","297.92","297.92","1 through 10","252.94","887.19","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","484.00","363.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","389.14","80.4","","317.46","317.46","407.00","1 through 10","252.94","887.19","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","484.00","363.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","395.52","81.72","","325.35","325.35","325.36","1 through 10","252.94","887.19","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","484.00","363.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","395.52","81.72","","178.96","13.44","325.36","1 through 10","252.94","887.19","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","484.00","363.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","395.52","81.72","","325.36","178.96","325.36","143","252.94","887.19","percent of total billed charges",""
"Immunothpy Alergn 1 Inj W/O Extract","PX-92000105","CDM","95115","CPT","0940","RC","","","","both","","","76.00","57.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.61","1 through 10","23.56","68.49","other","OPPS APC"
"Immunothpy Alergn 1 Inj W/O Extract","PX-92000105","CDM","95115","CPT","0940","RC","","","","both","","","76.00","57.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","1 through 10","23.56","68.49","other","OPPS APC"
"Immunothpy Alergn 1 Inj W/O Extract","PX-92000105","CDM","95115","CPT","0940","RC","","","","both","","","76.00","57.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","60.42","79.5","","39.07","39.07","58.24","23","23.56","68.49","percent of total billed charges",""
"Immunothpy Alergn 1 Inj W/O Extract","PX-92000105","CDM","95115","CPT","0940","RC","","","","both","","","76.00","57.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","40.51","53.3","","58.24","39.07","58.24","40","23.56","68.49","percent of total billed charges",""
"Immunothpy Alergn 1 Inj W/O Extract","PX-92000105","CDM","95115","CPT","0940","RC","","","","both","","","76.00","57.00","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","54.79","54.79","54","23.56","68.49","other","OPPS APC"
"Immunothpy Alergn 1 Inj W/O Extract","PX-92000105","CDM","95115","CPT","0940","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.11","38.3","","28.93","28.12","28.93","93","23.56","68.49","percent of total billed charges",""
"Immunothpy Alergn 1 Inj W/O Extract","PX-92000105","CDM","95115","CPT","0940","RC","","","","both","","","76.00","57.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","53.69","53.69","1 through 10","23.56","68.49","other","OPPS APC"
"Immunothpy Alergn 1 Inj W/O Extract","PX-92000105","CDM","95115","CPT","0940","RC","","","","both","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.60","42.9","","32.54","32.54","59.16","1 through 10","23.56","68.49","percent of total billed charges",""
"Immunothpy Alergn 1 Inj W/O Extract","PX-92000105","CDM","95115","CPT","0940","RC","","","","both","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","50.82","53.69","1 through 10","23.56","68.49","other","OPPS APC"
"Immunothpy Alergn 1 Inj W/O Extract","PX-92000105","CDM","95115","CPT","0940","RC","","","","both","","","76.00","57.00","WELLPOINT [1015]","HB AMC WELLPOINT","56.07","73.78","","55.09","55.09","55.09","1 through 10","23.56","68.49","percent of total billed charges",""
"Immunothpy Alergn 1 Inj W/O Extract","PX-92000105","CDM","95115","CPT","0940","RC","","","","outpatient","","","76.00","57.00","AETNA [1001]","HB AMC AETNA HMO","53.05","69.8","","50.10","35.37","50.10","13","42.48","204.32","percent of total billed charges",""
"Immunothpy Alergn 1 Inj W/O Extract","PX-92000105","CDM","95115","CPT","0940","RC","","","","outpatient","","","76.00","57.00","AETNA [1001]","HB AMC AETNA PPO","61.10","80.4","","38.78","38.78","38.78","1 through 10","42.48","204.32","percent of total billed charges",""
"Immunothpy Alergn 1 Inj W/O Extract","PX-92000105","CDM","95115","CPT","0940","RC","","","","outpatient","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","62.11","81.72","","59.16","59.16","59.16","72","42.48","204.32","percent of total billed charges",""
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","AETNA [1001]","HB AMC AETNA HMO","92.14","69.8","","86.66","61.18","99.84","442","40.92","106.13","percent of total billed charges",""
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","AETNA [1001]","HB AMC AETNA PPO","106.13","80.4","","99.84","67.07","199.68","55","40.92","106.13","percent of total billed charges",""
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.61","16","40.92","106.13","other","OPPS APC"
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","39","40.92","106.13","other","OPPS APC"
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","104.94","79.5","","100.74","67.58","100.74","260","40.92","106.13","percent of total billed charges",""
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","70.36","53.3","","100.74","67.58","100.74","67","40.92","106.13","percent of total billed charges",""
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","ELDER SERVICES [1037]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.85","51.85","54.79","1 through 10","40.92","106.13","other","OPPS APC"
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","54.79","54.79","469","40.92","106.13","other","OPPS APC"
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","40.92","31","","39.55","39.55","39.55","1 through 10","40.92","106.13","percent of total billed charges",""
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.18","36.5","","47.74","40.58","47.74","169","40.92","106.13","percent of total billed charges",""
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","50.56","38.3","","50.05","50.05","50.05","1485","40.92","106.13","percent of total billed charges",""
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.81","53.69","24","40.92","106.13","other","OPPS APC"
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","101.64","77","","21.72","21.72","21.72","1 through 10","40.92","106.13","percent of total billed charges",""
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","TRICARE [160005]","HB BWH TRICARE","52.05","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","54.79","52.05","54.79","13","40.92","106.13","other","Tricare OPPS"
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","53.69","161.07","30","40.92","106.13","other","OPPS APC"
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.63","42.9","","56.28","56.28","102.32","36","40.92","106.13","percent of total billed charges",""
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","50.82","54.79","99","40.92","106.13","other","OPPS APC"
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","both","","","132.00","99.00","WELLPOINT [1015]","HB AMC WELLPOINT","97.39","73.78","","95.30","95.30","95.30","93","40.92","106.13","percent of total billed charges",""
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","outpatient","","","132.00","99.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","107.87","81.72","","56.28","56.28","56.28","14","92.43","204.32","percent of total billed charges",""
"Immunothpy Alrgn 2+ Inj W/O Extract","PX-92000106","CDM","95117","CPT","0940","RC","","","","outpatient","","","132.00","99.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","107.87","81.72","","102.32","92.43","102.32","331","92.43","204.32","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 1 Venom","PX-92000108","CDM","95145","CPT","0940","RC","","","","both","","","310.00","232.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","51.02","53.91","1 through 10","52.05","246.45","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd 1 Venom","PX-92000108","CDM","95145","CPT","0940","RC","","","","both","","","310.00","232.50","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","54.79","1 through 10","52.05","246.45","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd 1 Venom","PX-92000108","CDM","95145","CPT","0940","RC","","","","both","","","310.00","232.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","118.73","38.3","","117.69","117.69","117.69","1 through 10","52.05","246.45","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 1 Venom","PX-92000108","CDM","95145","CPT","0940","RC","","","","outpatient","","","310.00","232.50","AETNA [1001]","HB AMC AETNA PPO","249.24","80.4","","157.72","157.72","157.72","1 through 10","92.43","253.33","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 2 Venom","PX-92000109","CDM","95146","CPT","0940","RC","","","","both","","","401.00","300.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","1 through 10","52.05","318.8","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd 2 Venom","PX-92000109","CDM","95146","CPT","0940","RC","","","","both","","","401.00","300.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","318.80","79.5","","306.14","40.18","306.14","1 through 10","52.05","318.8","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 2 Venom","PX-92000109","CDM","95146","CPT","0940","RC","","","","both","","","401.00","300.75","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","54.79","54.79","11","52.05","318.8","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd 2 Venom","PX-92000109","CDM","95146","CPT","0940","RC","","","","both","","","401.00","300.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","124.31","31","","120.20","120.20","120.20","1 through 10","52.05","318.8","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 2 Venom","PX-92000109","CDM","95146","CPT","0940","RC","","","","both","","","401.00","300.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","146.37","36.5","","123.31","123.31","123.31","1 through 10","52.05","318.8","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 2 Venom","PX-92000109","CDM","95146","CPT","0940","RC","","","","both","","","401.00","300.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","153.58","38.3","","152.10","147.82","152.10","1 through 10","52.05","318.8","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 2 Venom","PX-92000109","CDM","95146","CPT","0940","RC","","","","outpatient","","","401.00","300.75","AETNA [1001]","HB AMC AETNA HMO","279.90","69.8","","185.94","185.94","185.94","1 through 10","92.43","564.7","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 3 Venom","PX-92000110","CDM","95147","CPT","0940","RC","","","","both","","","401.00","300.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","318.80","79.5","","306.14","306.14","306.14","1 through 10","80.29","318.8","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 3 Venom","PX-92000110","CDM","95147","CPT","0940","RC","","","","both","","","401.00","300.75","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","1 through 10","80.29","318.8","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd 3 Venom","PX-92000110","CDM","95147","CPT","0940","RC","","","","both","","","401.00","300.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","153.58","38.3","","152.10","147.82","152.10","1 through 10","80.29","318.8","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 3 Venom","PX-92000110","CDM","95147","CPT","0940","RC","","","","both","","","401.00","300.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","84.52","84.52","84.52","1 through 10","80.29","318.8","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd 3 Venom","PX-92000110","CDM","95147","CPT","0940","RC","","","","outpatient","","","401.00","300.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","327.70","81.72","","310.97","310.97","310.97","1 through 10","145.79","564.7","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 4 Venom","PX-92000111","CDM","95148","CPT","0940","RC","","","","both","","","310.00","232.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","87.33","87.33","87.33","1 through 10","80.29","246.45","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd 4 Venom","PX-92000111","CDM","95148","CPT","0940","RC","","","","both","","","310.00","232.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","246.45","79.5","","236.89","236.89","236.89","13","80.29","246.45","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 4 Venom","PX-92000111","CDM","95148","CPT","0940","RC","","","","both","","","310.00","232.50","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","35","80.29","246.45","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd 4 Venom","PX-92000111","CDM","95148","CPT","0940","RC","","","","both","","","310.00","232.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","118.73","38.3","","117.69","114.38","117.69","12","80.29","246.45","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 4 Venom","PX-92000111","CDM","95148","CPT","0940","RC","","","","both","","","310.00","232.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","84.52","83.17","84.52","1 through 10","80.29","246.45","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd 4 Venom","PX-92000111","CDM","95148","CPT","0940","RC","","","","outpatient","","","310.00","232.50","AETNA [1001]","HB AMC AETNA HMO","216.38","69.8","","143.88","143.88","143.88","1 through 10","145.79","294.98","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 4 Venom","PX-92000111","CDM","95148","CPT","0940","RC","","","","outpatient","","","310.00","232.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","253.33","81.72","","240.62","240.62","240.62","1 through 10","145.79","294.98","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 5 Venom","PX-92000112","CDM","95149","CPT","0940","RC","","","","both","","","167.00","125.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","87.33","86.97","87.33","1 through 10","51.77","132.77","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd 5 Venom","PX-92000112","CDM","95149","CPT","0940","RC","","","","both","","","167.00","125.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","132.77","79.5","","127.49","127.49","127.49","1 through 10","51.77","132.77","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd 5 Venom","PX-92000112","CDM","95149","CPT","0940","RC","","","","both","","","167.00","125.25","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","21","51.77","132.77","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd 5 Venom","PX-92000112","CDM","95149","CPT","0940","RC","","","","both","","","167.00","125.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","84.52","83.17","84.52","12","51.77","132.77","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd 5 Venom","PX-92000112","CDM","95149","CPT","0940","RC","","","","outpatient","","","167.00","125.25","AETNA [1001]","HB AMC AETNA HMO","116.57","69.8","","77.44","77.44","77.44","15","93.35","294.98","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","both","","","111.00","83.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","17.01","17.01","53.91","11","34.41","88.25","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","both","","","111.00","83.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","88.25","79.5","","85.00","57.02","85.00","185","34.41","88.25","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","both","","","111.00","83.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","59.16","53.3","","85.00","57.02","171.07","68","34.41","88.25","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","both","","","111.00","83.25","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1.83","1.73","3.04","108","34.41","88.25","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","34.41","31","","33.37","33.37","33.37","1 through 10","34.41","88.25","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","40.52","36.5","","40.28","34.24","40.29","484","34.41","88.25","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","42.51","38.3","","42.23","42.23","42.23","4853","34.41","88.25","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","34.41","88.25","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","both","","","111.00","83.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","85.47","77","","54.99","54.99","54.99","1 through 10","34.41","88.25","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","both","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.62","42.9","","47.49","47.49","86.34","89","34.41","88.25","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","both","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1.79","1.79","2.69","51","34.41","88.25","other","OPPS APC"
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","both","","","111.00","83.25","WELLPOINT [1015]","HB AMC WELLPOINT","81.90","73.78","","80.41","80.41","80.41","225","34.41","88.25","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","outpatient","","","111.00","83.25","AETNA [1001]","HB AMC AETNA HMO","77.48","69.8","","73.12","51.62","84.24","1011","62.05","204.32","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","outpatient","","","111.00","83.25","AETNA [1001]","HB AMC AETNA PPO","89.24","80.4","","84.24","56.59","84.24","138","62.05","204.32","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","90.71","81.72","","47.49","47.49","47.49","54","62.05","204.32","percent of total billed charges",""
"Immunothpy Alrgn Prep/Provd Doses","PX-92000113","CDM","95165","CPT","0940","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","90.71","81.72","","86.34","47.49","89.02","1002","62.05","204.32","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","both","","","1574.00","1180.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1251.33","other","OPPS APC"
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","both","","","1574.00","1180.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1251.33","other","OPPS APC"
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","both","","","1574.00","1180.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","838.94","53.3","","477.31","477.31","477.31","1 through 10","333.03","1251.33","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","both","","","1574.00","1180.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1251.33","other","OPPS APC"
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","both","","","1574.00","1180.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1251.33","other","OPPS APC"
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","both","","","1574.00","1180.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","574.51","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1251.33","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","both","","","1574.00","1180.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","602.84","38.3","","343.52","323.76","353.46","1 through 10","333.03","1251.33","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","both","","","1574.00","1180.50","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1251.33","other","Tricare OPPS"
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","both","","","1574.00","1180.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1251.33","other","OPPS APC"
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","both","","","1574.00","1180.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1251.33","other","OPPS APC"
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","both","","","1574.00","1180.50","WELLPOINT [1015]","HB AMC WELLPOINT","1161.30","73.78","","673.03","673.03","673.03","1 through 10","333.03","1251.33","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","outpatient","","","1574.00","1180.50","AETNA [1001]","HB AMC AETNA HMO","1098.65","69.8","","612.01","612.01","1224.02","1 through 10","700.33","1298.55","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","outpatient","","","1574.00","1180.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","953.06","60.55","","579.04","568.57","904.00","30","700.33","1298.55","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","outpatient","","","1574.00","1180.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","821.94","52.22","","904.00","656.02","2938.00","26","700.33","1298.55","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","outpatient","","","1574.00","1180.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","787.00","50","","1421.10","875.08","2368.50","15","700.33","1298.55","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","outpatient","","","1574.00","1180.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","826.35","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","1298.55","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","outpatient","","","1574.00","1180.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1286.27","81.72","","722.66","722.66","17449.00","1 through 10","700.33","1298.55","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","both","","","1713.00","1284.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1361.84","other","OPPS APC"
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","both","","","1713.00","1284.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1361.84","other","OPPS APC"
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","both","","","1713.00","1284.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","913.03","53.3","","477.31","477.31","477.31","1 through 10","333.03","1361.84","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","both","","","1713.00","1284.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1361.84","other","OPPS APC"
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","both","","","1713.00","1284.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1361.84","other","OPPS APC"
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","both","","","1713.00","1284.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","625.25","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1361.84","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","both","","","1713.00","1284.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","656.08","38.3","","343.52","323.76","353.46","1 through 10","333.03","1361.84","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","both","","","1713.00","1284.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1361.84","other","Tricare OPPS"
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","both","","","1713.00","1284.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1361.84","other","OPPS APC"
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","both","","","1713.00","1284.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1361.84","other","OPPS APC"
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","both","","","1713.00","1284.75","WELLPOINT [1015]","HB AMC WELLPOINT","1263.85","73.78","","673.03","673.03","673.03","1 through 10","333.03","1361.84","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","outpatient","","","1713.00","1284.75","AETNA [1001]","HB AMC AETNA HMO","1195.67","69.8","","612.01","612.01","1224.02","1 through 10","700.33","1413.23","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","outpatient","","","1713.00","1284.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1037.22","60.55","","579.04","568.57","904.00","30","700.33","1413.23","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","outpatient","","","1713.00","1284.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","894.53","52.22","","904.00","656.02","2938.00","26","700.33","1413.23","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","outpatient","","","1713.00","1284.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","856.50","50","","1421.10","875.08","2368.50","15","700.33","1413.23","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","outpatient","","","1713.00","1284.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","899.33","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","1413.23","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","outpatient","","","1713.00","1284.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1399.86","81.72","","722.66","722.66","17449.00","1 through 10","700.33","1413.23","percent of total billed charges",""
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","16113.00","12084.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","8026.84","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","10845.19","8026.86","10845.19","1 through 10","4995.03","12809.84","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","16113.00","12084.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3834.57","3834.57","3834.57","1 through 10","4995.03","12809.84","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","16113.00","12084.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8588.23","53.3","","18168.65","18168.65","18168.65","1 through 10","4995.03","12809.84","percent of total billed charges",""
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","16113.00","12084.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7669.14","7669.14","7669.14","1 through 10","4995.03","12809.84","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","16113.00","12084.75","MEDICARE [2001]","HB BWH MEDICARE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3896.92","3896.92","3896.92","16","4995.03","12809.84","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","16113.00","12084.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7637.19","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7645.76","7645.76","7645.76","1 through 10","4995.03","12809.84","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","16113.00","12084.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7637.19","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3834.57","3834.57","7645.47","1 through 10","4995.03","12809.84","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","16113.00","12084.75","WELLPOINT [1015]","HB AMC WELLPOINT","11888.17","73.78","","26862.30","19523.56","26862.30","1 through 10","4995.03","12809.84","percent of total billed charges",""
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","outpatient","","","16113.00","12084.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","6837.93","","Case rate ($6,837.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6868.70","6868.70","6995.20","1 through 10","5381.58","13167.54","other","ASC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","outpatient","","","16113.00","12084.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6837.93","","Case rate ($6,837.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7925.16","7925.16","15850.32","15","5381.58","13167.54","other","ASC "
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","outpatient","","","16113.00","12084.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5381.58","","Case rate ($5,381.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6242.64","6000.46","6242.64","1 through 10","5381.58","13167.54","other","Multiple Surgery"
"Impl Elect Neurostim Peripher Perc","PX-76001555","CDM","64555","CPT","0761","RC","","","","both","","","16113.00","12084.75","MEDICARE [2001]","HB BWH MEDICARE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7793.84","7793.84","7793.84","1 through 10","4995.03","12809.84","other","OPPS APC"
"Impl Elect Neurostim Peripher Perc","PX-76001555","CDM","64555","CPT","0761","RC","","","","both","","","16113.00","12084.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7637.19","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7639.96","7639.96","7639.96","1 through 10","4995.03","12809.84","other","OPPS APC"
"Impl Elect Neurostim Peripher Perc","PX-76001555","CDM","64555","CPT","0761","RC","","","","outpatient","","","16113.00","12084.75","AETNA [1001]","HB AMC AETNA HMO","11246.87","69.8","","10578.13","10578.13","10578.13","1 through 10","2384.07","13167.54","percent of total billed charges",""
"Impl Elect Neurostim Peripher Perc","PX-76001555","CDM","64555","CPT","0761","RC","","","","outpatient","","","16113.00","12084.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","6837.93","","Case rate ($6,837.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6995.20","6995.20","6995.20","1 through 10","2384.07","13167.54","other","ASC"
"Impl Elect Neurostim Peripher Perc","PX-76001555","CDM","64555","CPT","0761","RC","","","","outpatient","","","16113.00","12084.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6837.93","","Case rate ($6,837.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","15850.32","15850.32","16007.59","1 through 10","2384.07","13167.54","other","ASC "
"Impl Elect Neurostim Sacral Perc","PX-76001556","CDM","64561","CPT","0761","RC","","","","both","","","16113.00","12084.75","MEDICARE [2001]","HB BWH MEDICARE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7793.84","7793.84","7793.84","1 through 10","4995.03","12809.84","other","OPPS APC"
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T1","PX-27000141","CDM","C1820","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","54287.50","54287.50","54287.50","1 through 10","542.5","1391.25","percent of total billed charges",""
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T1","PX-27000141","CDM","C1820","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","10467.31","10467.31","10467.31","1 through 10","542.5","1391.25","percent of total billed charges",""
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T1","PX-27000141","CDM","C1820","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","21505.00","21505.00","21505.00","1 through 10","542.5","1391.25","percent of total billed charges",""
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T1","PX-27000141","CDM","C1820","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","40016.88","40016.88","40016.88","1 through 10","542.5","1391.25","percent of total billed charges",""
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T3","PX-27000142","CDM","C1820","HCPCS","0278","RC","","","","both","","","40812.50","30609.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","21753.06","53.3","","54287.50","54287.50","54287.50","1 through 10","12651.88","32445.94","percent of total billed charges",""
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T3","PX-27000142","CDM","C1820","HCPCS","0278","RC","","","","both","","","40812.50","30609.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14896.56","36.5","","10467.31","10467.31","10467.31","1 through 10","12651.88","32445.94","percent of total billed charges",""
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T3","PX-27000142","CDM","C1820","HCPCS","0278","RC","","","","both","","","40812.50","30609.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15631.19","38.3","","21505.00","21505.00","21505.00","1 through 10","12651.88","32445.94","percent of total billed charges",""
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T3","PX-27000142","CDM","C1820","HCPCS","0278","RC","","","","both","","","40812.50","30609.37","WELLPOINT [1015]","HB AMC WELLPOINT","30111.46","73.78","","40016.88","40016.88","40016.88","1 through 10","12651.88","32445.94","percent of total billed charges",""
"Impl/Rev Cath Epidur/Intrathecal","PX-76001477","CDM","62350","CPT","0761","RC","","","","outpatient","","","12133.00","9099.75","AETNA [1001]","HB AMC AETNA HMO","8468.83","69.8","","10517.67","10517.67","10517.67","1 through 10","4853.2","9915.09","percent of total billed charges",""
"Impl/Rev Cath Epidur/Intrathecal","PX-76001477","CDM","62350","CPT","0761","RC","","","","outpatient","","","12133.00","9099.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6335.85","52.22","","6111.83","6051.78","12103.55","1 through 10","4853.2","9915.09","percent of total billed charges",""
"Impl/Rev Cath Epidur/Intrathecal","PX-76001477","CDM","62350","CPT","0761","RC","","","","outpatient","","","12133.00","9099.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9915.09","81.72","","7131.55","7131.55","7131.55","1 through 10","4853.2","9915.09","percent of total billed charges",""
"IMPLANT 0.6X3 8MM PROSTHESIS OSSICULAR RECONSTRUCTION POLYCEL TOTAL BRACKMANN MODIFIED SS TRIMABLE MALLEABLE","SUP-ITM-10021906","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1323.11","992.33","AETNA [1001]","HB AMC AETNA HMO","923.53","69.8","","1013.24","1013.24","1013.24","1 through 10","661.56","1091.57","percent of total billed charges",""
"IMPLANT 12.5MMX18CM PENILE CYLINDER INFLATABLE AMBICOR","SUP-ITM-10005229","CDM","C1813","HCPCS","0278","RC","","","","both","","","43689.75","32767.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16733.17","38.3","","12613.42","12613.42","12613.42","1 through 10","13543.82","34733.35","percent of total billed charges",""
"IMPLANT 12.5MMX18CM PENILE CYLINDER INFLATABLE AMBICOR","SUP-ITM-10005229","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","43689.75","32767.31","AETNA [1001]","HB AMC AETNA HMO","30495.45","69.8","","34275.85","34275.85","50471.26","19","22832.26","35703.26","percent of total billed charges",""
"IMPLANT 18CMX12MM PENILE INFLATABLE MINOCYCLINE RIFAMPIN INHIBIZONE PARYLENE","SUP-ITM-10021020","CDM","C1813","HCPCS","0278","RC","","","","both","","","26120.25","19590.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10004.06","38.3","","12613.42","12613.42","12613.42","1 through 10","8097.28","20765.6","percent of total billed charges",""
"IMPLANT 18CMX12MM PENILE INFLATABLE MINOCYCLINE RIFAMPIN INHIBIZONE PARYLENE","SUP-ITM-10021020","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","26120.25","19590.19","AETNA [1001]","HB AMC AETNA HMO","18231.93","69.8","","34275.85","34275.85","50471.26","19","13650.44","21345.47","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1029.53","79.5","","1309.77","674.56","6049.93","26","401.45","1029.53","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","690.24","53.3","","1901.83","1901.83","2962.25","1 through 10","401.45","1029.53","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","472.68","36.5","","1620.31","1620.31","19908.88","1 through 10","401.45","1029.53","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","495.99","38.3","","352.91","352.91","2046.30","1 through 10","401.45","1029.53","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","555.56","42.9","","9668.75","9668.75","9668.75","1 through 10","401.45","1029.53","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1295.00","971.25","WELLPOINT [1015]","HB AMC WELLPOINT","955.45","73.78","","699.88","384.10","3443.31","33","401.45","1029.53","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","AETNA [1001]","HB AMC AETNA HMO","903.91","69.8","","1421.24","264.50","4933.46","29","676.77","1058.27","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1041.18","80.4","","1022.97","1022.97","3607.50","1 through 10","676.77","1058.27","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1058.27","81.72","","3010.54","693.88","5019.88","35","676.77","1058.27","percent of total billed charges",""
"IMPLANT 20CMXBIOSCAFFOLD REINFORCED OVITEX RESORBABLE","SUP-ITM-10203786","CDM","C1781","HCPCS","0278","RC","","","","both","","","9500.00","7125.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","6650.00","70","","134.04","134.04","134.04","1 through 10","2945","7552.5","percent of total billed charges",""
"IMPLANT 20CMXBIOSCAFFOLD REINFORCED OVITEX RESORBABLE","SUP-ITM-10203786","CDM","C1781","HCPCS","0278","RC","","","","both","","","9500.00","7125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7552.50","79.5","","948.87","198.19","1805.30","1 through 10","2945","7552.5","percent of total billed charges",""
"IMPLANT 20CMXBIOSCAFFOLD REINFORCED OVITEX RESORBABLE","SUP-ITM-10203786","CDM","C1781","HCPCS","0278","RC","","","","both","","","9500.00","7125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5063.50","53.3","","462.00","170.45","3253.37","1 through 10","2945","7552.5","percent of total billed charges",""
"IMPLANT 20CMXBIOSCAFFOLD REINFORCED OVITEX RESORBABLE","SUP-ITM-10203786","CDM","C1781","HCPCS","0278","RC","","","","both","","","9500.00","7125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3467.50","36.5","","245.50","107.19","1371.45","1 through 10","2945","7552.5","percent of total billed charges",""
"IMPLANT 20CMXBIOSCAFFOLD REINFORCED OVITEX RESORBABLE","SUP-ITM-10203786","CDM","C1781","HCPCS","0278","RC","","","","both","","","9500.00","7125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3638.50","38.3","","200.79","72.79","355.81","22","2945","7552.5","percent of total billed charges",""
"IMPLANT 20CMXBIOSCAFFOLD REINFORCED OVITEX RESORBABLE","SUP-ITM-10203786","CDM","C1781","HCPCS","0278","RC","","","","both","","","9500.00","7125.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","7315.00","77","","477.18","477.18","477.18","1 through 10","2945","7552.5","percent of total billed charges",""
"IMPLANT 20CMXBIOSCAFFOLD REINFORCED OVITEX RESORBABLE","SUP-ITM-10203786","CDM","C1781","HCPCS","0278","RC","","","","both","","","9500.00","7125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4075.50","42.9","","1045.91","1045.91","1045.91","1 through 10","2945","7552.5","percent of total billed charges",""
"IMPLANT 20CMXBIOSCAFFOLD REINFORCED OVITEX RESORBABLE","SUP-ITM-10203786","CDM","C1781","HCPCS","0278","RC","","","","both","","","9500.00","7125.00","WELLPOINT [1015]","HB AMC WELLPOINT","7009.10","73.78","","1726.50","1726.50","1726.50","1 through 10","2945","7552.5","percent of total billed charges",""
"IMPLANT 20CMXBIOSCAFFOLD REINFORCED OVITEX RESORBABLE","SUP-ITM-10203786","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9500.00","7125.00","AETNA [1001]","HB AMC AETNA HMO","6631.00","69.8","","915.80","263.76","2881.00","1 through 10","4964.7","7763.4","percent of total billed charges",""
"IMPLANT 20CMXBIOSCAFFOLD REINFORCED OVITEX RESORBABLE","SUP-ITM-10203786","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9500.00","7125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7763.40","81.72","","1531.57","410.52","8841.36","1 through 10","4964.7","7763.4","percent of total billed charges",""
"IMPLANT 32X36 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10146433","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1006.01","52.26","","1113.10","1113.10","1113.10","1 through 10","596.75","1530.38","percent of total billed charges",""
"IMPLANT 32X36 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10146433","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1530.38","79.5","","1293.60","1148.53","1603.80","1 through 10","596.75","1530.38","percent of total billed charges",""
"IMPLANT 32X36 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10146433","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","702.63","36.5","","1023.42","771.29","2068.67","33","596.75","1530.38","percent of total billed charges",""
"IMPLANT 32X36 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10146433","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","737.28","38.3","","850.52","759.78","1211.25","66","596.75","1530.38","percent of total billed charges",""
"IMPLANT 32X36 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10146433","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","2548.09","2548.09","2548.09","1 through 10","596.75","1530.38","percent of total billed charges",""
"IMPLANT 32X36 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10146433","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","956.46","956.46","956.46","1 through 10","596.75","1530.38","percent of total billed charges",""
"IMPLANT 32X36 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10146433","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","WELLPOINT [1015]","HB AMC WELLPOINT","1420.27","73.78","","2344.73","1619.47","2530.35","16","596.75","1530.38","percent of total billed charges",""
"IMPLANT 32X36 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10146433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA HMO","1343.65","69.8","","1523.63","988.41","4330.26","39","1006.01","1573.11","percent of total billed charges",""
"IMPLANT 32X36 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10146433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA PPO","1547.70","80.4","","1670.25","1670.25","1670.25","1 through 10","1006.01","1573.11","percent of total billed charges",""
"IMPLANT 32X36 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10146433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1006.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1006.01","1573.11","percent of total billed charges",""
"IMPLANT 32X36 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10146433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1573.11","81.72","","1738.90","1484.65","2716.94","38","1006.01","1573.11","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2320.03","52.26","","1113.10","1113.10","1113.10","1 through 10","1376.21","3529.32","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3529.32","79.5","","1293.60","1148.53","1603.80","1 through 10","1376.21","3529.32","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1620.38","36.5","","1023.42","771.29","2068.67","33","1376.21","3529.32","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1700.29","38.3","","850.52","759.78","1211.25","66","1376.21","3529.32","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1904.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1376.21","3529.32","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1904.50","42.9","","956.46","956.46","956.46","1 through 10","1376.21","3529.32","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","WELLPOINT [1015]","HB AMC WELLPOINT","3275.39","73.78","","2344.73","1619.47","2530.35","16","1376.21","3529.32","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4439.40","3329.55","AETNA [1001]","HB AMC AETNA HMO","3098.70","69.8","","1523.63","988.41","4330.26","39","2320.03","3627.88","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4439.40","3329.55","AETNA [1001]","HB AMC AETNA PPO","3569.28","80.4","","1670.25","1670.25","1670.25","1 through 10","2320.03","3627.88","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4439.40","3329.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2320.03","52.26","","1113.10","1113.10","1113.10","1 through 10","2320.03","3627.88","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4439.40","3329.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3627.88","81.72","","1738.90","1484.65","2716.94","38","2320.03","3627.88","percent of total billed charges",""
"IMPLANT 51MM BODY TUMOR COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122541","CDM","C1776","HCPCS","0278","RC","","","","both","","","6688.50","5016.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3495.41","52.26","","1113.10","1113.10","1113.10","1 through 10","2073.44","5317.36","percent of total billed charges",""
"IMPLANT 51MM BODY TUMOR COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122541","CDM","C1776","HCPCS","0278","RC","","","","both","","","6688.50","5016.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5317.36","79.5","","1293.60","1148.53","1603.80","1 through 10","2073.44","5317.36","percent of total billed charges",""
"IMPLANT 51MM BODY TUMOR COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122541","CDM","C1776","HCPCS","0278","RC","","","","both","","","6688.50","5016.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2441.30","36.5","","1023.42","771.29","2068.67","33","2073.44","5317.36","percent of total billed charges",""
"IMPLANT 51MM BODY TUMOR COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122541","CDM","C1776","HCPCS","0278","RC","","","","both","","","6688.50","5016.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2561.70","38.3","","850.52","759.78","1211.25","66","2073.44","5317.36","percent of total billed charges",""
"IMPLANT 51MM BODY TUMOR COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122541","CDM","C1776","HCPCS","0278","RC","","","","both","","","6688.50","5016.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2869.37","42.9","","2548.09","2548.09","2548.09","1 through 10","2073.44","5317.36","percent of total billed charges",""
"IMPLANT 51MM BODY TUMOR COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122541","CDM","C1776","HCPCS","0278","RC","","","","both","","","6688.50","5016.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2869.37","42.9","","956.46","956.46","956.46","1 through 10","2073.44","5317.36","percent of total billed charges",""
"IMPLANT 51MM BODY TUMOR COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122541","CDM","C1776","HCPCS","0278","RC","","","","both","","","6688.50","5016.37","WELLPOINT [1015]","HB AMC WELLPOINT","4934.78","73.78","","2344.73","1619.47","2530.35","16","2073.44","5317.36","percent of total billed charges",""
"IMPLANT 51MM BODY TUMOR COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122541","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6688.50","5016.37","AETNA [1001]","HB AMC AETNA HMO","4668.57","69.8","","1523.63","988.41","4330.26","39","3495.41","5465.84","percent of total billed charges",""
"IMPLANT 51MM BODY TUMOR COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122541","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6688.50","5016.37","AETNA [1001]","HB AMC AETNA PPO","5377.55","80.4","","1670.25","1670.25","1670.25","1 through 10","3495.41","5465.84","percent of total billed charges",""
"IMPLANT 51MM BODY TUMOR COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122541","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6688.50","5016.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3495.41","52.26","","1113.10","1113.10","1113.10","1 through 10","3495.41","5465.84","percent of total billed charges",""
"IMPLANT 51MM BODY TUMOR COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122541","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6688.50","5016.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5465.84","81.72","","1738.90","1484.65","2716.94","38","3495.41","5465.84","percent of total billed charges",""
"IMPLANT 8X14MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042198","CDM","C1776","HCPCS","0278","RC","","","","both","","","3832.50","2874.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2002.86","52.26","","1113.10","1113.10","1113.10","1 through 10","1188.08","3046.84","percent of total billed charges",""
"IMPLANT 8X14MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042198","CDM","C1776","HCPCS","0278","RC","","","","both","","","3832.50","2874.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3046.84","79.5","","1293.60","1148.53","1603.80","1 through 10","1188.08","3046.84","percent of total billed charges",""
"IMPLANT 8X14MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042198","CDM","C1776","HCPCS","0278","RC","","","","both","","","3832.50","2874.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1398.86","36.5","","1023.42","771.29","2068.67","33","1188.08","3046.84","percent of total billed charges",""
"IMPLANT 8X14MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042198","CDM","C1776","HCPCS","0278","RC","","","","both","","","3832.50","2874.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1467.85","38.3","","850.52","759.78","1211.25","66","1188.08","3046.84","percent of total billed charges",""
"IMPLANT 8X14MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042198","CDM","C1776","HCPCS","0278","RC","","","","both","","","3832.50","2874.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1644.14","42.9","","2548.09","2548.09","2548.09","1 through 10","1188.08","3046.84","percent of total billed charges",""
"IMPLANT 8X14MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042198","CDM","C1776","HCPCS","0278","RC","","","","both","","","3832.50","2874.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1644.14","42.9","","956.46","956.46","956.46","1 through 10","1188.08","3046.84","percent of total billed charges",""
"IMPLANT 8X14MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042198","CDM","C1776","HCPCS","0278","RC","","","","both","","","3832.50","2874.37","WELLPOINT [1015]","HB AMC WELLPOINT","2827.62","73.78","","2344.73","1619.47","2530.35","16","1188.08","3046.84","percent of total billed charges",""
"IMPLANT 8X14MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042198","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3832.50","2874.37","AETNA [1001]","HB AMC AETNA HMO","2675.09","69.8","","1523.63","988.41","4330.26","39","2002.86","3131.92","percent of total billed charges",""
"IMPLANT 8X14MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042198","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3832.50","2874.37","AETNA [1001]","HB AMC AETNA PPO","3081.33","80.4","","1670.25","1670.25","1670.25","1 through 10","2002.86","3131.92","percent of total billed charges",""
"IMPLANT 8X14MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042198","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3832.50","2874.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2002.86","52.26","","1113.10","1113.10","1113.10","1 through 10","2002.86","3131.92","percent of total billed charges",""
"IMPLANT 8X14MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042198","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3832.50","2874.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3131.92","81.72","","1738.90","1484.65","2716.94","38","2002.86","3131.92","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2013.08","79.5","","800.18","480.96","1887.97","195","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.65","53.3","","813.12","216.42","1444.50","81","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","784.97","31","","432.60","432.60","432.60","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.24","36.5","","148.37","54.89","631.39","94","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.82","38.3","","279.30","91.72","1116.77","266","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","731.00","63.70","731.00","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","384.74","384.74","384.74","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","WELLPOINT [1015]","HB AMC WELLPOINT","1868.24","73.78","","286.63","119.22","1107.45","105","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA HMO","1767.45","69.8","","675.31","184.75","1721.50","286","1323.31","2069.29","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA PPO","2035.86","80.4","","1261.44","103.12","1514.10","21","1323.31","2069.29","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2069.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2069.29","81.72","","431.26","71.26","1459.57","88","1323.31","2069.29","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2013.08","79.5","","800.18","480.96","1887.97","195","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.65","53.3","","813.12","216.42","1444.50","81","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","784.97","31","","432.60","432.60","432.60","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.24","36.5","","148.37","54.89","631.39","94","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.82","38.3","","279.30","91.72","1116.77","266","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","731.00","63.70","731.00","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","384.74","384.74","384.74","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","WELLPOINT [1015]","HB AMC WELLPOINT","1868.24","73.78","","286.63","119.22","1107.45","105","784.97","2013.08","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA HMO","1767.45","69.8","","675.31","184.75","1721.50","286","1323.31","2069.29","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA PPO","2035.86","80.4","","1261.44","103.12","1514.10","21","1323.31","2069.29","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2069.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2069.29","81.72","","431.26","71.26","1459.57","88","1323.31","2069.29","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.58","4042.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4284.72","79.5","","800.18","480.96","1887.97","195","1670.77","4284.72","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.58","4042.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2872.65","53.3","","813.12","216.42","1444.50","81","1670.77","4284.72","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.58","4042.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1670.77","31","","432.60","432.60","432.60","1 through 10","1670.77","4284.72","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.58","4042.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1967.20","36.5","","148.37","54.89","631.39","94","1670.77","4284.72","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.58","4042.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2064.21","38.3","","279.30","91.72","1116.77","266","1670.77","4284.72","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.58","4042.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2312.13","42.9","","731.00","63.70","731.00","1 through 10","1670.77","4284.72","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.58","4042.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2312.13","42.9","","384.74","384.74","384.74","1 through 10","1670.77","4284.72","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.58","4042.18","WELLPOINT [1015]","HB AMC WELLPOINT","3976.43","73.78","","286.63","119.22","1107.45","105","1670.77","4284.72","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.58","4042.18","AETNA [1001]","HB AMC AETNA HMO","3761.93","69.8","","675.31","184.75","1721.50","286","2816.59","4404.36","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.58","4042.18","AETNA [1001]","HB AMC AETNA PPO","4333.22","80.4","","1261.44","103.12","1514.10","21","2816.59","4404.36","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.58","4042.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4333.22","80.4","","1365.00","1365.00","1365.00","1 through 10","2816.59","4404.36","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.58","4042.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4404.36","81.72","","5157.68","5157.68","5157.68","1 through 10","2816.59","4404.36","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.58","4042.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4404.36","81.72","","431.26","71.26","1459.57","88","2816.59","4404.36","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1963.50","1472.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1560.98","79.5","","1293.60","1148.53","1603.80","1 through 10","608.69","1560.98","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1963.50","1472.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","716.68","36.5","","1023.42","771.29","2068.67","33","608.69","1560.98","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1963.50","1472.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","752.02","38.3","","850.52","759.78","1211.25","66","608.69","1560.98","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1963.50","1472.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","842.34","42.9","","2548.09","2548.09","2548.09","1 through 10","608.69","1560.98","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1963.50","1472.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","842.34","42.9","","956.46","956.46","956.46","1 through 10","608.69","1560.98","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1963.50","1472.62","WELLPOINT [1015]","HB AMC WELLPOINT","1448.67","73.78","","2344.73","1619.47","2530.35","16","608.69","1560.98","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1963.50","1472.62","AETNA [1001]","HB AMC AETNA HMO","1370.52","69.8","","1523.63","988.41","4330.26","39","1026.13","1604.57","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1963.50","1472.62","AETNA [1001]","HB AMC AETNA PPO","1578.65","80.4","","1670.25","1670.25","1670.25","1 through 10","1026.13","1604.57","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1963.50","1472.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1026.13","52.26","","1113.10","1113.10","1113.10","1 through 10","1026.13","1604.57","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1963.50","1472.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1604.57","81.72","","1738.90","1484.65","2716.94","38","1026.13","1604.57","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3613.04","79.5","","1293.60","1148.53","1603.80","1 through 10","1408.86","3613.04","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1658.82","36.5","","1023.42","771.29","2068.67","33","1408.86","3613.04","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1740.62","38.3","","850.52","759.78","1211.25","66","1408.86","3613.04","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1949.68","42.9","","2548.09","2548.09","2548.09","1 through 10","1408.86","3613.04","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1949.68","42.9","","956.46","956.46","956.46","1 through 10","1408.86","3613.04","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4544.70","3408.52","WELLPOINT [1015]","HB AMC WELLPOINT","3353.08","73.78","","2344.73","1619.47","2530.35","16","1408.86","3613.04","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","AETNA [1001]","HB AMC AETNA HMO","3172.20","69.8","","1523.63","988.41","4330.26","39","2375.06","3713.93","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","AETNA [1001]","HB AMC AETNA PPO","3653.94","80.4","","1670.25","1670.25","1670.25","1 through 10","2375.06","3713.93","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2375.06","52.26","","1113.10","1113.10","1113.10","1 through 10","2375.06","3713.93","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4544.70","3408.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3713.93","81.72","","1738.90","1484.65","2716.94","38","2375.06","3713.93","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","8636.60","6477.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6866.10","79.5","","1293.60","1148.53","1603.80","1 through 10","2677.35","6866.1","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","8636.60","6477.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3152.36","36.5","","1023.42","771.29","2068.67","33","2677.35","6866.1","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","8636.60","6477.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3307.82","38.3","","850.52","759.78","1211.25","66","2677.35","6866.1","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","8636.60","6477.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3705.10","42.9","","2548.09","2548.09","2548.09","1 through 10","2677.35","6866.1","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","8636.60","6477.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3705.10","42.9","","956.46","956.46","956.46","1 through 10","2677.35","6866.1","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","8636.60","6477.45","WELLPOINT [1015]","HB AMC WELLPOINT","6372.08","73.78","","2344.73","1619.47","2530.35","16","2677.35","6866.1","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8636.60","6477.45","AETNA [1001]","HB AMC AETNA HMO","6028.35","69.8","","1523.63","988.41","4330.26","39","4513.49","7057.83","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8636.60","6477.45","AETNA [1001]","HB AMC AETNA PPO","6943.83","80.4","","1670.25","1670.25","1670.25","1 through 10","4513.49","7057.83","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8636.60","6477.45","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4513.49","52.26","","1113.10","1113.10","1113.10","1 through 10","4513.49","7057.83","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8636.60","6477.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7057.83","81.72","","1738.90","1484.65","2716.94","38","4513.49","7057.83","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2013.08","79.5","","800.18","480.96","1887.97","195","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.65","53.3","","813.12","216.42","1444.50","81","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","784.97","31","","432.60","432.60","432.60","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.24","36.5","","148.37","54.89","631.39","94","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.82","38.3","","279.30","91.72","1116.77","266","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","731.00","63.70","731.00","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","384.74","384.74","384.74","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","WELLPOINT [1015]","HB AMC WELLPOINT","1868.24","73.78","","286.63","119.22","1107.45","105","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA HMO","1767.45","69.8","","675.31","184.75","1721.50","286","1323.31","2069.29","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA PPO","2035.86","80.4","","1261.44","103.12","1514.10","21","1323.31","2069.29","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2069.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2069.29","81.72","","431.26","71.26","1459.57","88","1323.31","2069.29","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2013.08","79.5","","800.18","480.96","1887.97","195","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.65","53.3","","813.12","216.42","1444.50","81","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","784.97","31","","432.60","432.60","432.60","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.24","36.5","","148.37","54.89","631.39","94","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.82","38.3","","279.30","91.72","1116.77","266","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","731.00","63.70","731.00","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","384.74","384.74","384.74","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","WELLPOINT [1015]","HB AMC WELLPOINT","1868.24","73.78","","286.63","119.22","1107.45","105","784.97","2013.08","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA HMO","1767.45","69.8","","675.31","184.75","1721.50","286","1323.31","2069.29","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA PPO","2035.86","80.4","","1261.44","103.12","1514.10","21","1323.31","2069.29","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2069.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2069.29","81.72","","431.26","71.26","1459.57","88","1323.31","2069.29","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","8403.13","6302.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6680.49","79.5","","800.18","480.96","1887.97","195","2604.97","6680.49","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","8403.13","6302.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4478.87","53.3","","813.12","216.42","1444.50","81","2604.97","6680.49","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","8403.13","6302.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2604.97","31","","432.60","432.60","432.60","1 through 10","2604.97","6680.49","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","8403.13","6302.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3067.14","36.5","","148.37","54.89","631.39","94","2604.97","6680.49","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","8403.13","6302.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3218.40","38.3","","279.30","91.72","1116.77","266","2604.97","6680.49","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","8403.13","6302.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3604.94","42.9","","731.00","63.70","731.00","1 through 10","2604.97","6680.49","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","8403.13","6302.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3604.94","42.9","","384.74","384.74","384.74","1 through 10","2604.97","6680.49","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","8403.13","6302.35","WELLPOINT [1015]","HB AMC WELLPOINT","6199.83","73.78","","286.63","119.22","1107.45","105","2604.97","6680.49","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8403.13","6302.35","AETNA [1001]","HB AMC AETNA HMO","5865.38","69.8","","675.31","184.75","1721.50","286","4391.48","6867.04","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8403.13","6302.35","AETNA [1001]","HB AMC AETNA PPO","6756.12","80.4","","1261.44","103.12","1514.10","21","4391.48","6867.04","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8403.13","6302.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6756.12","80.4","","1365.00","1365.00","1365.00","1 through 10","4391.48","6867.04","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8403.13","6302.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6867.04","81.72","","5157.68","5157.68","5157.68","1 through 10","4391.48","6867.04","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8403.13","6302.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6867.04","81.72","","431.26","71.26","1459.57","88","4391.48","6867.04","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","both","","","2415.81","1811.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1920.57","79.5","","2867.44","1923.77","8602.29","1 through 10","748.9","1920.57","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","both","","","2415.81","1811.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1287.63","53.3","","5771.31","1397.09","6509.05","16","748.9","1920.57","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","both","","","2415.81","1811.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1920.57","79.5","","5730.95","5730.95","5730.95","1 through 10","748.9","1920.57","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","both","","","2415.81","1811.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","881.77","36.5","","1154.99","1154.99","1318.95","1 through 10","748.9","1920.57","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","both","","","2415.81","1811.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","925.26","38.3","","1424.61","1034.59","4273.83","20","748.9","1920.57","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","both","","","2415.81","1811.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1036.38","42.9","","2912.61","2912.61","2912.61","1 through 10","748.9","1920.57","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","both","","","2415.81","1811.86","WELLPOINT [1015]","HB AMC WELLPOINT","1782.38","73.78","","2712.59","1969.95","2712.59","1 through 10","748.9","1920.57","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2415.81","1811.86","AETNA [1001]","HB AMC AETNA HMO","1686.24","69.8","","4933.30","1741.59","4933.30","1 through 10","1262.5","1974.2","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2415.81","1811.86","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1262.50","52.26","","3643.50","3643.50","3643.50","1 through 10","1262.5","1974.2","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2415.81","1811.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1974.20","81.72","","2115.21","1602.05","5825.23","1 through 10","1262.5","1974.2","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","both","","","6625.00","4968.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5266.88","79.5","","2867.44","1923.77","8602.29","1 through 10","2053.75","5266.88","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","both","","","6625.00","4968.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3531.13","53.3","","5771.31","1397.09","6509.05","16","2053.75","5266.88","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","both","","","6625.00","4968.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","5266.88","79.5","","5730.95","5730.95","5730.95","1 through 10","2053.75","5266.88","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","both","","","6625.00","4968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2418.13","36.5","","1154.99","1154.99","1318.95","1 through 10","2053.75","5266.88","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","both","","","6625.00","4968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2537.38","38.3","","1424.61","1034.59","4273.83","20","2053.75","5266.88","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","both","","","6625.00","4968.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2842.13","42.9","","2912.61","2912.61","2912.61","1 through 10","2053.75","5266.88","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","both","","","6625.00","4968.75","WELLPOINT [1015]","HB AMC WELLPOINT","4887.93","73.78","","2712.59","1969.95","2712.59","1 through 10","2053.75","5266.88","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","6625.00","4968.75","AETNA [1001]","HB AMC AETNA HMO","4624.25","69.8","","4933.30","1741.59","4933.30","1 through 10","3462.23","5413.95","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","6625.00","4968.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3462.23","52.26","","3643.50","3643.50","3643.50","1 through 10","3462.23","5413.95","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","6625.00","4968.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5413.95","81.72","","2115.21","1602.05","5825.23","1 through 10","3462.23","5413.95","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.21","715.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","758.60","79.5","","800.18","480.96","1887.97","195","295.81","758.6","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.21","715.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","508.59","53.3","","813.12","216.42","1444.50","81","295.81","758.6","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.21","715.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","295.81","31","","432.60","432.60","432.60","1 through 10","295.81","758.6","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.21","715.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","348.29","36.5","","148.37","54.89","631.39","94","295.81","758.6","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.21","715.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","365.46","38.3","","279.30","91.72","1116.77","266","295.81","758.6","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.21","715.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.36","42.9","","731.00","63.70","731.00","1 through 10","295.81","758.6","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.21","715.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.36","42.9","","384.74","384.74","384.74","1 through 10","295.81","758.6","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.21","715.66","WELLPOINT [1015]","HB AMC WELLPOINT","704.02","73.78","","286.63","119.22","1107.45","105","295.81","758.6","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.21","715.66","AETNA [1001]","HB AMC AETNA HMO","666.04","69.8","","675.31","184.75","1721.50","286","498.67","779.78","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.21","715.66","AETNA [1001]","HB AMC AETNA PPO","767.18","80.4","","1261.44","103.12","1514.10","21","498.67","779.78","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.21","715.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","767.18","80.4","","1365.00","1365.00","1365.00","1 through 10","498.67","779.78","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.21","715.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","779.78","81.72","","5157.68","5157.68","5157.68","1 through 10","498.67","779.78","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.21","715.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","779.78","81.72","","431.26","71.26","1459.57","88","498.67","779.78","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.48","2992.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3172.43","79.5","","800.18","480.96","1887.97","195","1237.05","3172.43","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.48","2992.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2126.93","53.3","","813.12","216.42","1444.50","81","1237.05","3172.43","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.48","2992.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1237.05","31","","432.60","432.60","432.60","1 through 10","1237.05","3172.43","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.48","2992.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1456.53","36.5","","148.37","54.89","631.39","94","1237.05","3172.43","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.48","2992.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1528.35","38.3","","279.30","91.72","1116.77","266","1237.05","3172.43","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.48","2992.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1711.92","42.9","","731.00","63.70","731.00","1 through 10","1237.05","3172.43","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.48","2992.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1711.92","42.9","","384.74","384.74","384.74","1 through 10","1237.05","3172.43","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.48","2992.86","WELLPOINT [1015]","HB AMC WELLPOINT","2944.18","73.78","","286.63","119.22","1107.45","105","1237.05","3172.43","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.48","2992.86","AETNA [1001]","HB AMC AETNA HMO","2785.36","69.8","","675.31","184.75","1721.50","286","2085.42","3261.02","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.48","2992.86","AETNA [1001]","HB AMC AETNA PPO","3208.35","80.4","","1261.44","103.12","1514.10","21","2085.42","3261.02","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.48","2992.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3208.35","80.4","","1365.00","1365.00","1365.00","1 through 10","2085.42","3261.02","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.48","2992.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3261.02","81.72","","5157.68","5157.68","5157.68","1 through 10","2085.42","3261.02","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.48","2992.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3261.02","81.72","","431.26","71.26","1459.57","88","2085.42","3261.02","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","5475.60","4106.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4353.10","79.5","","800.18","480.96","1887.97","195","1697.44","4353.1","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","5475.60","4106.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2918.49","53.3","","813.12","216.42","1444.50","81","1697.44","4353.1","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","5475.60","4106.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1697.44","31","","432.60","432.60","432.60","1 through 10","1697.44","4353.1","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","5475.60","4106.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1998.59","36.5","","148.37","54.89","631.39","94","1697.44","4353.1","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","5475.60","4106.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2097.15","38.3","","279.30","91.72","1116.77","266","1697.44","4353.1","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","5475.60","4106.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2349.03","42.9","","731.00","63.70","731.00","1 through 10","1697.44","4353.1","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","5475.60","4106.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2349.03","42.9","","384.74","384.74","384.74","1 through 10","1697.44","4353.1","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","5475.60","4106.70","WELLPOINT [1015]","HB AMC WELLPOINT","4039.90","73.78","","286.63","119.22","1107.45","105","1697.44","4353.1","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5475.60","4106.70","AETNA [1001]","HB AMC AETNA HMO","3821.97","69.8","","675.31","184.75","1721.50","286","2861.55","4474.66","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5475.60","4106.70","AETNA [1001]","HB AMC AETNA PPO","4402.38","80.4","","1261.44","103.12","1514.10","21","2861.55","4474.66","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5475.60","4106.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4402.38","80.4","","1365.00","1365.00","1365.00","1 through 10","2861.55","4474.66","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5475.60","4106.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4474.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2861.55","4474.66","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5475.60","4106.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4474.66","81.72","","431.26","71.26","1459.57","88","2861.55","4474.66","percent of total billed charges",""
"IMPLANT COCHLEAR NUCLEUS PROFILE PLUS CONTOUR ADVANCE ELECTRODE","SUP-ITM-10240874","CDM","L8614","HCPCS","0278","RC","","","","both","","","46749.85","35062.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","24917.67","53.3","","39045.04","39045.04","39045.04","1 through 10","14492.45","47716.66","percent of total billed charges",""
"IMPLANT COCHLEAR NUCLEUS PROFILE PLUS CONTOUR ADVANCE ELECTRODE","SUP-ITM-10240874","CDM","L8614","HCPCS","0278","RC","","","","both","","","46749.85","35062.39","WELLPOINT [1015]","HB AMC WELLPOINT","34492.04","73.78","","36936.51","36936.51","36936.51","1 through 10","14492.45","47716.66","percent of total billed charges",""
"IMPLANT COCHLEAR NUCLEUS PROFILE PLUS WITH SLIM MODIOLAR ELECTRODE","SUP-ITM-10240872","CDM","L8614","HCPCS","0278","RC","","","","both","","","46747.53","35060.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","24916.43","53.3","","39045.04","39045.04","39045.04","1 through 10","14491.73","47716.66","percent of total billed charges",""
"IMPLANT COCHLEAR NUCLEUS PROFILE PLUS WITH SLIM MODIOLAR ELECTRODE","SUP-ITM-10240872","CDM","L8614","HCPCS","0278","RC","","","","both","","","46747.53","35060.65","WELLPOINT [1015]","HB AMC WELLPOINT","34490.33","73.78","","36936.51","36936.51","36936.51","1 through 10","14491.73","47716.66","percent of total billed charges",""
"IMPLANT CUSTOM SKULL MEDIUM","SUP-ITM-10168031","CDM","C1713","HCPCS","0278","RC","","","","both","","","19875.00","14906.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15800.63","79.5","","800.18","480.96","1887.97","195","6161.25","15800.63","percent of total billed charges",""
"IMPLANT CUSTOM SKULL MEDIUM","SUP-ITM-10168031","CDM","C1713","HCPCS","0278","RC","","","","both","","","19875.00","14906.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10593.38","53.3","","813.12","216.42","1444.50","81","6161.25","15800.63","percent of total billed charges",""
"IMPLANT CUSTOM SKULL MEDIUM","SUP-ITM-10168031","CDM","C1713","HCPCS","0278","RC","","","","both","","","19875.00","14906.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","6161.25","31","","432.60","432.60","432.60","1 through 10","6161.25","15800.63","percent of total billed charges",""
"IMPLANT CUSTOM SKULL MEDIUM","SUP-ITM-10168031","CDM","C1713","HCPCS","0278","RC","","","","both","","","19875.00","14906.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7254.38","36.5","","148.37","54.89","631.39","94","6161.25","15800.63","percent of total billed charges",""
"IMPLANT CUSTOM SKULL MEDIUM","SUP-ITM-10168031","CDM","C1713","HCPCS","0278","RC","","","","both","","","19875.00","14906.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7612.13","38.3","","279.30","91.72","1116.77","266","6161.25","15800.63","percent of total billed charges",""
"IMPLANT CUSTOM SKULL MEDIUM","SUP-ITM-10168031","CDM","C1713","HCPCS","0278","RC","","","","both","","","19875.00","14906.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8526.38","42.9","","731.00","63.70","731.00","1 through 10","6161.25","15800.63","percent of total billed charges",""
"IMPLANT CUSTOM SKULL MEDIUM","SUP-ITM-10168031","CDM","C1713","HCPCS","0278","RC","","","","both","","","19875.00","14906.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8526.38","42.9","","384.74","384.74","384.74","1 through 10","6161.25","15800.63","percent of total billed charges",""
"IMPLANT CUSTOM SKULL MEDIUM","SUP-ITM-10168031","CDM","C1713","HCPCS","0278","RC","","","","both","","","19875.00","14906.25","WELLPOINT [1015]","HB AMC WELLPOINT","14663.78","73.78","","286.63","119.22","1107.45","105","6161.25","15800.63","percent of total billed charges",""
"IMPLANT CUSTOM SKULL MEDIUM","SUP-ITM-10168031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19875.00","14906.25","AETNA [1001]","HB AMC AETNA HMO","13872.75","69.8","","675.31","184.75","1721.50","286","10386.68","16241.85","percent of total billed charges",""
"IMPLANT CUSTOM SKULL MEDIUM","SUP-ITM-10168031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19875.00","14906.25","AETNA [1001]","HB AMC AETNA PPO","15979.50","80.4","","1261.44","103.12","1514.10","21","10386.68","16241.85","percent of total billed charges",""
"IMPLANT CUSTOM SKULL MEDIUM","SUP-ITM-10168031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19875.00","14906.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","15979.50","80.4","","1365.00","1365.00","1365.00","1 through 10","10386.68","16241.85","percent of total billed charges",""
"IMPLANT CUSTOM SKULL MEDIUM","SUP-ITM-10168031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19875.00","14906.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","16241.85","81.72","","5157.68","5157.68","5157.68","1 through 10","10386.68","16241.85","percent of total billed charges",""
"IMPLANT CUSTOM SKULL MEDIUM","SUP-ITM-10168031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19875.00","14906.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16241.85","81.72","","431.26","71.26","1459.57","88","10386.68","16241.85","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS LARGE","SUP-ITM-10273898","CDM","C1713","HCPCS","0278","RC","","","","both","","","22375.00","16781.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","17788.13","79.5","","800.18","480.96","1887.97","195","6936.25","17788.13","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS LARGE","SUP-ITM-10273898","CDM","C1713","HCPCS","0278","RC","","","","both","","","22375.00","16781.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11925.88","53.3","","813.12","216.42","1444.50","81","6936.25","17788.13","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS LARGE","SUP-ITM-10273898","CDM","C1713","HCPCS","0278","RC","","","","both","","","22375.00","16781.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","6936.25","31","","432.60","432.60","432.60","1 through 10","6936.25","17788.13","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS LARGE","SUP-ITM-10273898","CDM","C1713","HCPCS","0278","RC","","","","both","","","22375.00","16781.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8166.88","36.5","","148.37","54.89","631.39","94","6936.25","17788.13","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS LARGE","SUP-ITM-10273898","CDM","C1713","HCPCS","0278","RC","","","","both","","","22375.00","16781.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8569.63","38.3","","279.30","91.72","1116.77","266","6936.25","17788.13","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS LARGE","SUP-ITM-10273898","CDM","C1713","HCPCS","0278","RC","","","","both","","","22375.00","16781.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9598.88","42.9","","731.00","63.70","731.00","1 through 10","6936.25","17788.13","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS LARGE","SUP-ITM-10273898","CDM","C1713","HCPCS","0278","RC","","","","both","","","22375.00","16781.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9598.88","42.9","","384.74","384.74","384.74","1 through 10","6936.25","17788.13","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS LARGE","SUP-ITM-10273898","CDM","C1713","HCPCS","0278","RC","","","","both","","","22375.00","16781.25","WELLPOINT [1015]","HB AMC WELLPOINT","16508.28","73.78","","286.63","119.22","1107.45","105","6936.25","17788.13","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS LARGE","SUP-ITM-10273898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22375.00","16781.25","AETNA [1001]","HB AMC AETNA HMO","15617.75","69.8","","675.31","184.75","1721.50","286","11693.18","18284.85","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS LARGE","SUP-ITM-10273898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22375.00","16781.25","AETNA [1001]","HB AMC AETNA PPO","17989.50","80.4","","1261.44","103.12","1514.10","21","11693.18","18284.85","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS LARGE","SUP-ITM-10273898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22375.00","16781.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","17989.50","80.4","","1365.00","1365.00","1365.00","1 through 10","11693.18","18284.85","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS LARGE","SUP-ITM-10273898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22375.00","16781.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","18284.85","81.72","","5157.68","5157.68","5157.68","1 through 10","11693.18","18284.85","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS LARGE","SUP-ITM-10273898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22375.00","16781.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18284.85","81.72","","431.26","71.26","1459.57","88","11693.18","18284.85","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS MEDIUM","SUP-ITM-10273899","CDM","C1713","HCPCS","0278","RC","","","","both","","","20625.00","15468.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","16396.88","79.5","","800.18","480.96","1887.97","195","6393.75","16396.88","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS MEDIUM","SUP-ITM-10273899","CDM","C1713","HCPCS","0278","RC","","","","both","","","20625.00","15468.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10993.13","53.3","","813.12","216.42","1444.50","81","6393.75","16396.88","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS MEDIUM","SUP-ITM-10273899","CDM","C1713","HCPCS","0278","RC","","","","both","","","20625.00","15468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","6393.75","31","","432.60","432.60","432.60","1 through 10","6393.75","16396.88","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS MEDIUM","SUP-ITM-10273899","CDM","C1713","HCPCS","0278","RC","","","","both","","","20625.00","15468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7528.13","36.5","","148.37","54.89","631.39","94","6393.75","16396.88","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS MEDIUM","SUP-ITM-10273899","CDM","C1713","HCPCS","0278","RC","","","","both","","","20625.00","15468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7899.38","38.3","","279.30","91.72","1116.77","266","6393.75","16396.88","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS MEDIUM","SUP-ITM-10273899","CDM","C1713","HCPCS","0278","RC","","","","both","","","20625.00","15468.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8848.13","42.9","","731.00","63.70","731.00","1 through 10","6393.75","16396.88","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS MEDIUM","SUP-ITM-10273899","CDM","C1713","HCPCS","0278","RC","","","","both","","","20625.00","15468.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8848.13","42.9","","384.74","384.74","384.74","1 through 10","6393.75","16396.88","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS MEDIUM","SUP-ITM-10273899","CDM","C1713","HCPCS","0278","RC","","","","both","","","20625.00","15468.75","WELLPOINT [1015]","HB AMC WELLPOINT","15217.13","73.78","","286.63","119.22","1107.45","105","6393.75","16396.88","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS MEDIUM","SUP-ITM-10273899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20625.00","15468.75","AETNA [1001]","HB AMC AETNA HMO","14396.25","69.8","","675.31","184.75","1721.50","286","10778.63","16854.75","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS MEDIUM","SUP-ITM-10273899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20625.00","15468.75","AETNA [1001]","HB AMC AETNA PPO","16582.50","80.4","","1261.44","103.12","1514.10","21","10778.63","16854.75","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS MEDIUM","SUP-ITM-10273899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20625.00","15468.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","16582.50","80.4","","1365.00","1365.00","1365.00","1 through 10","10778.63","16854.75","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS MEDIUM","SUP-ITM-10273899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20625.00","15468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","16854.75","81.72","","5157.68","5157.68","5157.68","1 through 10","10778.63","16854.75","percent of total billed charges",""
"IMPLANT CUSTOM SKULL W/INTEGRATED FIXATION SYSTEM TABS MEDIUM","SUP-ITM-10273899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20625.00","15468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16854.75","81.72","","431.26","71.26","1459.57","88","10778.63","16854.75","percent of total billed charges",""
"IMPLANT EAR .8X8MM OSSICULAR TORP GOLDENBERG HYDROXYLAPATITE","SUP-ITM-10019420","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1385.37","1039.03","AETNA [1001]","HB AMC AETNA HMO","966.99","69.8","","1013.24","1013.24","1013.24","1 through 10","692.69","1142.93","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3531.89","2648.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2807.85","79.5","","1293.60","1148.53","1603.80","1 through 10","1094.89","2807.85","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3531.89","2648.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1289.14","36.5","","1023.42","771.29","2068.67","33","1094.89","2807.85","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3531.89","2648.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1352.71","38.3","","850.52","759.78","1211.25","66","1094.89","2807.85","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3531.89","2648.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1515.18","42.9","","2548.09","2548.09","2548.09","1 through 10","1094.89","2807.85","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3531.89","2648.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1515.18","42.9","","956.46","956.46","956.46","1 through 10","1094.89","2807.85","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3531.89","2648.92","WELLPOINT [1015]","HB AMC WELLPOINT","2605.83","73.78","","2344.73","1619.47","2530.35","16","1094.89","2807.85","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3531.89","2648.92","AETNA [1001]","HB AMC AETNA HMO","2465.26","69.8","","1523.63","988.41","4330.26","39","1845.77","2886.26","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3531.89","2648.92","AETNA [1001]","HB AMC AETNA PPO","2839.64","80.4","","1670.25","1670.25","1670.25","1 through 10","1845.77","2886.26","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3531.89","2648.92","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1845.77","52.26","","1113.10","1113.10","1113.10","1 through 10","1845.77","2886.26","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3531.89","2648.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2886.26","81.72","","1738.90","1484.65","2716.94","38","1845.77","2886.26","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","4533.60","3400.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3604.21","79.5","","1293.60","1148.53","1603.80","1 through 10","1405.42","3604.21","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","4533.60","3400.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1654.76","36.5","","1023.42","771.29","2068.67","33","1405.42","3604.21","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","4533.60","3400.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1736.37","38.3","","850.52","759.78","1211.25","66","1405.42","3604.21","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","4533.60","3400.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.91","42.9","","2548.09","2548.09","2548.09","1 through 10","1405.42","3604.21","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","4533.60","3400.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.91","42.9","","956.46","956.46","956.46","1 through 10","1405.42","3604.21","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","4533.60","3400.20","WELLPOINT [1015]","HB AMC WELLPOINT","3344.89","73.78","","2344.73","1619.47","2530.35","16","1405.42","3604.21","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4533.60","3400.20","AETNA [1001]","HB AMC AETNA HMO","3164.45","69.8","","1523.63","988.41","4330.26","39","2369.26","3704.86","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4533.60","3400.20","AETNA [1001]","HB AMC AETNA PPO","3645.01","80.4","","1670.25","1670.25","1670.25","1 through 10","2369.26","3704.86","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4533.60","3400.20","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2369.26","52.26","","1113.10","1113.10","1113.10","1 through 10","2369.26","3704.86","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4533.60","3400.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3704.86","81.72","","1738.90","1484.65","2716.94","38","2369.26","3704.86","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","7711.28","5783.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6130.47","79.5","","1293.60","1148.53","1603.80","1 through 10","2390.5","6130.47","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","7711.28","5783.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2814.62","36.5","","1023.42","771.29","2068.67","33","2390.5","6130.47","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","7711.28","5783.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2953.42","38.3","","850.52","759.78","1211.25","66","2390.5","6130.47","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","7711.28","5783.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3308.14","42.9","","2548.09","2548.09","2548.09","1 through 10","2390.5","6130.47","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","7711.28","5783.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3308.14","42.9","","956.46","956.46","956.46","1 through 10","2390.5","6130.47","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","7711.28","5783.46","WELLPOINT [1015]","HB AMC WELLPOINT","5689.38","73.78","","2344.73","1619.47","2530.35","16","2390.5","6130.47","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7711.28","5783.46","AETNA [1001]","HB AMC AETNA HMO","5382.47","69.8","","1523.63","988.41","4330.26","39","4029.91","6301.66","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7711.28","5783.46","AETNA [1001]","HB AMC AETNA PPO","6199.87","80.4","","1670.25","1670.25","1670.25","1 through 10","4029.91","6301.66","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7711.28","5783.46","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4029.91","52.26","","1113.10","1113.10","1113.10","1 through 10","4029.91","6301.66","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7711.28","5783.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6301.66","81.72","","1738.90","1484.65","2716.94","38","4029.91","6301.66","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2013.08","79.5","","800.18","480.96","1887.97","195","784.97","2013.08","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.65","53.3","","813.12","216.42","1444.50","81","784.97","2013.08","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","784.97","31","","432.60","432.60","432.60","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.24","36.5","","148.37","54.89","631.39","94","784.97","2013.08","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.82","38.3","","279.30","91.72","1116.77","266","784.97","2013.08","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","731.00","63.70","731.00","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","384.74","384.74","384.74","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","WELLPOINT [1015]","HB AMC WELLPOINT","1868.24","73.78","","286.63","119.22","1107.45","105","784.97","2013.08","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA HMO","1767.45","69.8","","675.31","184.75","1721.50","286","1323.31","2069.29","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA PPO","2035.86","80.4","","1261.44","103.12","1514.10","21","1323.31","2069.29","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2069.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2069.29","81.72","","431.26","71.26","1459.57","88","1323.31","2069.29","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.62","52.26","","1113.10","1113.10","1113.10","1 through 10","1266.82","3248.79","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3248.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1266.82","3248.79","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1491.58","36.5","","1023.42","771.29","2068.67","33","1266.82","3248.79","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1565.14","38.3","","850.52","759.78","1211.25","66","1266.82","3248.79","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.12","42.9","","2548.09","2548.09","2548.09","1 through 10","1266.82","3248.79","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.12","42.9","","956.46","956.46","956.46","1 through 10","1266.82","3248.79","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.53","3064.90","WELLPOINT [1015]","HB AMC WELLPOINT","3015.04","73.78","","2344.73","1619.47","2530.35","16","1266.82","3248.79","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.53","3064.90","AETNA [1001]","HB AMC AETNA HMO","2852.40","69.8","","1523.63","988.41","4330.26","39","2135.62","3339.51","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.53","3064.90","AETNA [1001]","HB AMC AETNA PPO","3285.57","80.4","","1670.25","1670.25","1670.25","1 through 10","2135.62","3339.51","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.53","3064.90","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.62","52.26","","1113.10","1113.10","1113.10","1 through 10","2135.62","3339.51","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.53","3064.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3339.51","81.72","","1738.90","1484.65","2716.94","38","2135.62","3339.51","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3911.43","2933.57","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2044.11","52.26","","1113.10","1113.10","1113.10","1 through 10","1212.54","3109.59","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3911.43","2933.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3109.59","79.5","","1293.60","1148.53","1603.80","1 through 10","1212.54","3109.59","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3911.43","2933.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1427.67","36.5","","1023.42","771.29","2068.67","33","1212.54","3109.59","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3911.43","2933.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1498.08","38.3","","850.52","759.78","1211.25","66","1212.54","3109.59","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3911.43","2933.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1678.00","42.9","","2548.09","2548.09","2548.09","1 through 10","1212.54","3109.59","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3911.43","2933.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1678.00","42.9","","956.46","956.46","956.46","1 through 10","1212.54","3109.59","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3911.43","2933.57","WELLPOINT [1015]","HB AMC WELLPOINT","2885.85","73.78","","2344.73","1619.47","2530.35","16","1212.54","3109.59","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3911.43","2933.57","AETNA [1001]","HB AMC AETNA HMO","2730.18","69.8","","1523.63","988.41","4330.26","39","2044.11","3196.42","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3911.43","2933.57","AETNA [1001]","HB AMC AETNA PPO","3144.79","80.4","","1670.25","1670.25","1670.25","1 through 10","2044.11","3196.42","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3911.43","2933.57","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2044.11","52.26","","1113.10","1113.10","1113.10","1 through 10","2044.11","3196.42","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3911.43","2933.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3196.42","81.72","","1738.90","1484.65","2716.94","38","2044.11","3196.42","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","218750.00","164062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","173906.25","79.5","","1309.77","674.56","6049.93","26","67812.5","173906.25","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","218750.00","164062.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","116593.75","53.3","","1901.83","1901.83","2962.25","1 through 10","67812.5","173906.25","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","218750.00","164062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","79843.75","36.5","","1620.31","1620.31","19908.88","1 through 10","67812.5","173906.25","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","218750.00","164062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","83781.25","38.3","","352.91","352.91","2046.30","1 through 10","67812.5","173906.25","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","218750.00","164062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93843.75","42.9","","9668.75","9668.75","9668.75","1 through 10","67812.5","173906.25","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","218750.00","164062.50","WELLPOINT [1015]","HB AMC WELLPOINT","161393.75","73.78","","699.88","384.10","3443.31","33","67812.5","173906.25","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","218750.00","164062.50","AETNA [1001]","HB AMC AETNA HMO","152687.50","69.8","","1421.24","264.50","4933.46","29","114318.75","178762.5","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","218750.00","164062.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","175875.00","80.4","","1022.97","1022.97","3607.50","1 through 10","114318.75","178762.5","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","218750.00","164062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","178762.50","81.72","","3010.54","693.88","5019.88","35","114318.75","178762.5","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1917.02","1437.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1524.03","79.5","","1293.60","1148.53","1603.80","1 through 10","594.28","1524.03","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1917.02","1437.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","699.71","36.5","","1023.42","771.29","2068.67","33","594.28","1524.03","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1917.02","1437.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","734.22","38.3","","850.52","759.78","1211.25","66","594.28","1524.03","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1917.02","1437.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","822.40","42.9","","2548.09","2548.09","2548.09","1 through 10","594.28","1524.03","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1917.02","1437.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","822.40","42.9","","956.46","956.46","956.46","1 through 10","594.28","1524.03","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1917.02","1437.76","WELLPOINT [1015]","HB AMC WELLPOINT","1414.38","73.78","","2344.73","1619.47","2530.35","16","594.28","1524.03","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1917.02","1437.76","AETNA [1001]","HB AMC AETNA HMO","1338.08","69.8","","1523.63","988.41","4330.26","39","1001.83","1566.59","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1917.02","1437.76","AETNA [1001]","HB AMC AETNA PPO","1541.28","80.4","","1670.25","1670.25","1670.25","1 through 10","1001.83","1566.59","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1917.02","1437.76","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1001.83","52.26","","1113.10","1113.10","1113.10","1 through 10","1001.83","1566.59","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1917.02","1437.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1566.59","81.72","","1738.90","1484.65","2716.94","38","1001.83","1566.59","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","4786.95","3590.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3805.63","79.5","","1293.60","1148.53","1603.80","1 through 10","1483.95","3805.63","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","4786.95","3590.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1747.24","36.5","","1023.42","771.29","2068.67","33","1483.95","3805.63","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","4786.95","3590.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1833.40","38.3","","850.52","759.78","1211.25","66","1483.95","3805.63","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","4786.95","3590.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2053.60","42.9","","2548.09","2548.09","2548.09","1 through 10","1483.95","3805.63","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","4786.95","3590.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2053.60","42.9","","956.46","956.46","956.46","1 through 10","1483.95","3805.63","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","4786.95","3590.21","WELLPOINT [1015]","HB AMC WELLPOINT","3531.81","73.78","","2344.73","1619.47","2530.35","16","1483.95","3805.63","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4786.95","3590.21","AETNA [1001]","HB AMC AETNA HMO","3341.29","69.8","","1523.63","988.41","4330.26","39","2501.66","3911.9","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4786.95","3590.21","AETNA [1001]","HB AMC AETNA PPO","3848.71","80.4","","1670.25","1670.25","1670.25","1 through 10","2501.66","3911.9","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4786.95","3590.21","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2501.66","52.26","","1113.10","1113.10","1113.10","1 through 10","2501.66","3911.9","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4786.95","3590.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3911.90","81.72","","1738.90","1484.65","2716.94","38","2501.66","3911.9","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","5456.38","4092.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4337.82","79.5","","1293.60","1148.53","1603.80","1 through 10","1691.48","4337.82","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","5456.38","4092.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1991.58","36.5","","1023.42","771.29","2068.67","33","1691.48","4337.82","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","5456.38","4092.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2089.79","38.3","","850.52","759.78","1211.25","66","1691.48","4337.82","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","5456.38","4092.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2340.79","42.9","","2548.09","2548.09","2548.09","1 through 10","1691.48","4337.82","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","5456.38","4092.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2340.79","42.9","","956.46","956.46","956.46","1 through 10","1691.48","4337.82","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","5456.38","4092.28","WELLPOINT [1015]","HB AMC WELLPOINT","4025.72","73.78","","2344.73","1619.47","2530.35","16","1691.48","4337.82","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5456.38","4092.28","AETNA [1001]","HB AMC AETNA HMO","3808.55","69.8","","1523.63","988.41","4330.26","39","2851.5","4458.95","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5456.38","4092.28","AETNA [1001]","HB AMC AETNA PPO","4386.93","80.4","","1670.25","1670.25","1670.25","1 through 10","2851.5","4458.95","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5456.38","4092.28","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2851.50","52.26","","1113.10","1113.10","1113.10","1 through 10","2851.5","4458.95","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5456.38","4092.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4458.95","81.72","","1738.90","1484.65","2716.94","38","2851.5","4458.95","percent of total billed charges",""
"IMPLANT HIRES ULTRA 3D WITH HIFOCUS SLIMJ ELECTRODE","SUP-ITM-10240069","CDM","L8614","HCPCS","0278","RC","","","","both","","","36250.00","27187.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19321.25","53.3","","39045.04","39045.04","39045.04","1 through 10","11237.5","47716.66","percent of total billed charges",""
"IMPLANT HIRES ULTRA 3D WITH HIFOCUS SLIMJ ELECTRODE","SUP-ITM-10240069","CDM","L8614","HCPCS","0278","RC","","","","both","","","36250.00","27187.50","WELLPOINT [1015]","HB AMC WELLPOINT","26745.25","73.78","","36936.51","36936.51","36936.51","1 through 10","11237.5","47716.66","percent of total billed charges",""
"IMPLANT INJECTABLE 1CC RADIESSE VOICE 30% CALCIUM HYDROXYLAPATITE PREFILLED SYRINGE BX/1EA","SUP-ITM-10016338","CDM","C1878","HCPCS","0278","RC","","","","both","","","2572.50","1929.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2045.14","79.5","","1991.51","1991.51","1991.51","1 through 10","797.48","2045.14","percent of total billed charges",""
"IMPLANT INJECTABLE 1CC RADIESSE VOICE 30% CALCIUM HYDROXYLAPATITE PREFILLED SYRINGE BX/1EA","SUP-ITM-10016338","CDM","C1878","HCPCS","0278","RC","","","","both","","","2572.50","1929.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","938.96","36.5","","650.52","650.52","650.52","1 through 10","797.48","2045.14","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","2227.09","1670.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1770.54","79.5","","1293.60","1148.53","1603.80","1 through 10","690.4","1770.54","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","2227.09","1670.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","812.89","36.5","","1023.42","771.29","2068.67","33","690.4","1770.54","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","2227.09","1670.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","852.98","38.3","","850.52","759.78","1211.25","66","690.4","1770.54","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","2227.09","1670.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","955.42","42.9","","2548.09","2548.09","2548.09","1 through 10","690.4","1770.54","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","2227.09","1670.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","955.42","42.9","","956.46","956.46","956.46","1 through 10","690.4","1770.54","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","2227.09","1670.32","WELLPOINT [1015]","HB AMC WELLPOINT","1643.15","73.78","","2344.73","1619.47","2530.35","16","690.4","1770.54","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2227.09","1670.32","AETNA [1001]","HB AMC AETNA HMO","1554.51","69.8","","1523.63","988.41","4330.26","39","1163.88","1819.98","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2227.09","1670.32","AETNA [1001]","HB AMC AETNA PPO","1790.58","80.4","","1670.25","1670.25","1670.25","1 through 10","1163.88","1819.98","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2227.09","1670.32","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1163.88","52.26","","1113.10","1113.10","1113.10","1 through 10","1163.88","1819.98","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2227.09","1670.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1819.98","81.72","","1738.90","1484.65","2716.94","38","1163.88","1819.98","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","4402.71","3302.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3500.15","79.5","","1293.60","1148.53","1603.80","1 through 10","1364.84","3500.15","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","4402.71","3302.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1606.99","36.5","","1023.42","771.29","2068.67","33","1364.84","3500.15","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","4402.71","3302.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1686.24","38.3","","850.52","759.78","1211.25","66","1364.84","3500.15","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","4402.71","3302.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1888.76","42.9","","2548.09","2548.09","2548.09","1 through 10","1364.84","3500.15","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","4402.71","3302.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1888.76","42.9","","956.46","956.46","956.46","1 through 10","1364.84","3500.15","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","4402.71","3302.03","WELLPOINT [1015]","HB AMC WELLPOINT","3248.32","73.78","","2344.73","1619.47","2530.35","16","1364.84","3500.15","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4402.71","3302.03","AETNA [1001]","HB AMC AETNA HMO","3073.09","69.8","","1523.63","988.41","4330.26","39","2300.86","3597.89","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4402.71","3302.03","AETNA [1001]","HB AMC AETNA PPO","3539.78","80.4","","1670.25","1670.25","1670.25","1 through 10","2300.86","3597.89","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4402.71","3302.03","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2300.86","52.26","","1113.10","1113.10","1113.10","1 through 10","2300.86","3597.89","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4402.71","3302.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3597.89","81.72","","1738.90","1484.65","2716.94","38","2300.86","3597.89","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","7643.28","5732.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6076.41","79.5","","1293.60","1148.53","1603.80","1 through 10","2369.42","6076.41","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","7643.28","5732.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2789.80","36.5","","1023.42","771.29","2068.67","33","2369.42","6076.41","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","7643.28","5732.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2927.38","38.3","","850.52","759.78","1211.25","66","2369.42","6076.41","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","7643.28","5732.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3278.97","42.9","","2548.09","2548.09","2548.09","1 through 10","2369.42","6076.41","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","7643.28","5732.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3278.97","42.9","","956.46","956.46","956.46","1 through 10","2369.42","6076.41","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","7643.28","5732.46","WELLPOINT [1015]","HB AMC WELLPOINT","5639.21","73.78","","2344.73","1619.47","2530.35","16","2369.42","6076.41","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7643.28","5732.46","AETNA [1001]","HB AMC AETNA HMO","5335.01","69.8","","1523.63","988.41","4330.26","39","3994.38","6246.09","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7643.28","5732.46","AETNA [1001]","HB AMC AETNA PPO","6145.20","80.4","","1670.25","1670.25","1670.25","1 through 10","3994.38","6246.09","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7643.28","5732.46","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3994.38","52.26","","1113.10","1113.10","1113.10","1 through 10","3994.38","6246.09","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7643.28","5732.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6246.09","81.72","","1738.90","1484.65","2716.94","38","3994.38","6246.09","percent of total billed charges",""
"IMPLANT MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE SD980.109","SUP-ITM-10239699","CDM","C1713","HCPCS","0278","RC","","","","both","","","22176.00","16632.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","17629.92","79.5","","800.18","480.96","1887.97","195","6874.56","17629.92","percent of total billed charges",""
"IMPLANT MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE SD980.109","SUP-ITM-10239699","CDM","C1713","HCPCS","0278","RC","","","","both","","","22176.00","16632.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11819.81","53.3","","813.12","216.42","1444.50","81","6874.56","17629.92","percent of total billed charges",""
"IMPLANT MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE SD980.109","SUP-ITM-10239699","CDM","C1713","HCPCS","0278","RC","","","","both","","","22176.00","16632.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","6874.56","31","","432.60","432.60","432.60","1 through 10","6874.56","17629.92","percent of total billed charges",""
"IMPLANT MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE SD980.109","SUP-ITM-10239699","CDM","C1713","HCPCS","0278","RC","","","","both","","","22176.00","16632.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8094.24","36.5","","148.37","54.89","631.39","94","6874.56","17629.92","percent of total billed charges",""
"IMPLANT MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE SD980.109","SUP-ITM-10239699","CDM","C1713","HCPCS","0278","RC","","","","both","","","22176.00","16632.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8493.41","38.3","","279.30","91.72","1116.77","266","6874.56","17629.92","percent of total billed charges",""
"IMPLANT MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE SD980.109","SUP-ITM-10239699","CDM","C1713","HCPCS","0278","RC","","","","both","","","22176.00","16632.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9513.50","42.9","","731.00","63.70","731.00","1 through 10","6874.56","17629.92","percent of total billed charges",""
"IMPLANT MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE SD980.109","SUP-ITM-10239699","CDM","C1713","HCPCS","0278","RC","","","","both","","","22176.00","16632.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9513.50","42.9","","384.74","384.74","384.74","1 through 10","6874.56","17629.92","percent of total billed charges",""
"IMPLANT MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE SD980.109","SUP-ITM-10239699","CDM","C1713","HCPCS","0278","RC","","","","both","","","22176.00","16632.00","WELLPOINT [1015]","HB AMC WELLPOINT","16361.45","73.78","","286.63","119.22","1107.45","105","6874.56","17629.92","percent of total billed charges",""
"IMPLANT MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE SD980.109","SUP-ITM-10239699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22176.00","16632.00","AETNA [1001]","HB AMC AETNA HMO","15478.85","69.8","","675.31","184.75","1721.50","286","11589.18","18122.23","percent of total billed charges",""
"IMPLANT MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE SD980.109","SUP-ITM-10239699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22176.00","16632.00","AETNA [1001]","HB AMC AETNA PPO","17829.50","80.4","","1261.44","103.12","1514.10","21","11589.18","18122.23","percent of total billed charges",""
"IMPLANT MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE SD980.109","SUP-ITM-10239699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22176.00","16632.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","17829.50","80.4","","1365.00","1365.00","1365.00","1 through 10","11589.18","18122.23","percent of total billed charges",""
"IMPLANT MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE SD980.109","SUP-ITM-10239699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22176.00","16632.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","18122.23","81.72","","5157.68","5157.68","5157.68","1 through 10","11589.18","18122.23","percent of total billed charges",""
"IMPLANT MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE SD980.109","SUP-ITM-10239699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22176.00","16632.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18122.23","81.72","","431.26","71.26","1459.57","88","11589.18","18122.23","percent of total billed charges",""
"IMPLANT MANDIBLE MED PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239698","CDM","C1713","HCPCS","0278","RC","","","","both","","","18018.00","13513.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","14324.31","79.5","","800.18","480.96","1887.97","195","5585.58","14324.31","percent of total billed charges",""
"IMPLANT MANDIBLE MED PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239698","CDM","C1713","HCPCS","0278","RC","","","","both","","","18018.00","13513.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9603.59","53.3","","813.12","216.42","1444.50","81","5585.58","14324.31","percent of total billed charges",""
"IMPLANT MANDIBLE MED PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239698","CDM","C1713","HCPCS","0278","RC","","","","both","","","18018.00","13513.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","5585.58","31","","432.60","432.60","432.60","1 through 10","5585.58","14324.31","percent of total billed charges",""
"IMPLANT MANDIBLE MED PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239698","CDM","C1713","HCPCS","0278","RC","","","","both","","","18018.00","13513.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6576.57","36.5","","148.37","54.89","631.39","94","5585.58","14324.31","percent of total billed charges",""
"IMPLANT MANDIBLE MED PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239698","CDM","C1713","HCPCS","0278","RC","","","","both","","","18018.00","13513.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6900.89","38.3","","279.30","91.72","1116.77","266","5585.58","14324.31","percent of total billed charges",""
"IMPLANT MANDIBLE MED PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239698","CDM","C1713","HCPCS","0278","RC","","","","both","","","18018.00","13513.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7729.72","42.9","","731.00","63.70","731.00","1 through 10","5585.58","14324.31","percent of total billed charges",""
"IMPLANT MANDIBLE MED PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239698","CDM","C1713","HCPCS","0278","RC","","","","both","","","18018.00","13513.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7729.72","42.9","","384.74","384.74","384.74","1 through 10","5585.58","14324.31","percent of total billed charges",""
"IMPLANT MANDIBLE MED PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239698","CDM","C1713","HCPCS","0278","RC","","","","both","","","18018.00","13513.50","WELLPOINT [1015]","HB AMC WELLPOINT","13293.68","73.78","","286.63","119.22","1107.45","105","5585.58","14324.31","percent of total billed charges",""
"IMPLANT MANDIBLE MED PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18018.00","13513.50","AETNA [1001]","HB AMC AETNA HMO","12576.56","69.8","","675.31","184.75","1721.50","286","9416.21","14724.31","percent of total billed charges",""
"IMPLANT MANDIBLE MED PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18018.00","13513.50","AETNA [1001]","HB AMC AETNA PPO","14486.47","80.4","","1261.44","103.12","1514.10","21","9416.21","14724.31","percent of total billed charges",""
"IMPLANT MANDIBLE MED PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18018.00","13513.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","14486.47","80.4","","1365.00","1365.00","1365.00","1 through 10","9416.21","14724.31","percent of total billed charges",""
"IMPLANT MANDIBLE MED PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18018.00","13513.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","14724.31","81.72","","5157.68","5157.68","5157.68","1 through 10","9416.21","14724.31","percent of total billed charges",""
"IMPLANT MANDIBLE MED PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18018.00","13513.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14724.31","81.72","","431.26","71.26","1459.57","88","9416.21","14724.31","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","14229.60","10672.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11312.53","79.5","","800.18","480.96","1887.97","195","4411.18","11312.53","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","14229.60","10672.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7584.38","53.3","","813.12","216.42","1444.50","81","4411.18","11312.53","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","14229.60","10672.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4411.18","31","","432.60","432.60","432.60","1 through 10","4411.18","11312.53","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","14229.60","10672.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5193.80","36.5","","148.37","54.89","631.39","94","4411.18","11312.53","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","14229.60","10672.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5449.94","38.3","","279.30","91.72","1116.77","266","4411.18","11312.53","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","14229.60","10672.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6104.50","42.9","","731.00","63.70","731.00","1 through 10","4411.18","11312.53","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","14229.60","10672.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6104.50","42.9","","384.74","384.74","384.74","1 through 10","4411.18","11312.53","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","14229.60","10672.20","WELLPOINT [1015]","HB AMC WELLPOINT","10498.60","73.78","","286.63","119.22","1107.45","105","4411.18","11312.53","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14229.60","10672.20","AETNA [1001]","HB AMC AETNA HMO","9932.26","69.8","","675.31","184.75","1721.50","286","7436.39","11628.43","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14229.60","10672.20","AETNA [1001]","HB AMC AETNA PPO","11440.60","80.4","","1261.44","103.12","1514.10","21","7436.39","11628.43","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14229.60","10672.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11440.60","80.4","","1365.00","1365.00","1365.00","1 through 10","7436.39","11628.43","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14229.60","10672.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","11628.43","81.72","","5157.68","5157.68","5157.68","1 through 10","7436.39","11628.43","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14229.60","10672.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11628.43","81.72","","431.26","71.26","1459.57","88","7436.39","11628.43","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.107","SUP-ITM-10239697","CDM","C1713","HCPCS","0278","RC","","","","both","","","13860.00","10395.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11018.70","79.5","","800.18","480.96","1887.97","195","4296.6","11018.7","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.107","SUP-ITM-10239697","CDM","C1713","HCPCS","0278","RC","","","","both","","","13860.00","10395.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7387.38","53.3","","813.12","216.42","1444.50","81","4296.6","11018.7","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.107","SUP-ITM-10239697","CDM","C1713","HCPCS","0278","RC","","","","both","","","13860.00","10395.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4296.60","31","","432.60","432.60","432.60","1 through 10","4296.6","11018.7","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.107","SUP-ITM-10239697","CDM","C1713","HCPCS","0278","RC","","","","both","","","13860.00","10395.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5058.90","36.5","","148.37","54.89","631.39","94","4296.6","11018.7","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.107","SUP-ITM-10239697","CDM","C1713","HCPCS","0278","RC","","","","both","","","13860.00","10395.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5308.38","38.3","","279.30","91.72","1116.77","266","4296.6","11018.7","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.107","SUP-ITM-10239697","CDM","C1713","HCPCS","0278","RC","","","","both","","","13860.00","10395.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5945.94","42.9","","731.00","63.70","731.00","1 through 10","4296.6","11018.7","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.107","SUP-ITM-10239697","CDM","C1713","HCPCS","0278","RC","","","","both","","","13860.00","10395.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5945.94","42.9","","384.74","384.74","384.74","1 through 10","4296.6","11018.7","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.107","SUP-ITM-10239697","CDM","C1713","HCPCS","0278","RC","","","","both","","","13860.00","10395.00","WELLPOINT [1015]","HB AMC WELLPOINT","10225.91","73.78","","286.63","119.22","1107.45","105","4296.6","11018.7","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.107","SUP-ITM-10239697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13860.00","10395.00","AETNA [1001]","HB AMC AETNA HMO","9674.28","69.8","","675.31","184.75","1721.50","286","7243.24","11326.39","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.107","SUP-ITM-10239697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13860.00","10395.00","AETNA [1001]","HB AMC AETNA PPO","11143.44","80.4","","1261.44","103.12","1514.10","21","7243.24","11326.39","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.107","SUP-ITM-10239697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13860.00","10395.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11143.44","80.4","","1365.00","1365.00","1365.00","1 through 10","7243.24","11326.39","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.107","SUP-ITM-10239697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13860.00","10395.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","11326.39","81.72","","5157.68","5157.68","5157.68","1 through 10","7243.24","11326.39","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.107","SUP-ITM-10239697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13860.00","10395.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11326.39","81.72","","431.26","71.26","1459.57","88","7243.24","11326.39","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2013.08","79.5","","800.18","480.96","1887.97","195","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.65","53.3","","813.12","216.42","1444.50","81","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","784.97","31","","432.60","432.60","432.60","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.24","36.5","","148.37","54.89","631.39","94","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.82","38.3","","279.30","91.72","1116.77","266","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","731.00","63.70","731.00","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","384.74","384.74","384.74","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","WELLPOINT [1015]","HB AMC WELLPOINT","1868.24","73.78","","286.63","119.22","1107.45","105","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA HMO","1767.45","69.8","","675.31","184.75","1721.50","286","1323.31","2069.29","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA PPO","2035.86","80.4","","1261.44","103.12","1514.10","21","1323.31","2069.29","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2069.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2069.29","81.72","","431.26","71.26","1459.57","88","1323.31","2069.29","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2013.08","79.5","","800.18","480.96","1887.97","195","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.65","53.3","","813.12","216.42","1444.50","81","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","784.97","31","","432.60","432.60","432.60","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.24","36.5","","148.37","54.89","631.39","94","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.82","38.3","","279.30","91.72","1116.77","266","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","731.00","63.70","731.00","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","384.74","384.74","384.74","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","WELLPOINT [1015]","HB AMC WELLPOINT","1868.24","73.78","","286.63","119.22","1107.45","105","784.97","2013.08","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA HMO","1767.45","69.8","","675.31","184.75","1721.50","286","1323.31","2069.29","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA PPO","2035.86","80.4","","1261.44","103.12","1514.10","21","1323.31","2069.29","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2069.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2069.29","81.72","","431.26","71.26","1459.57","88","1323.31","2069.29","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","5676.65","4257.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4512.94","79.5","","800.18","480.96","1887.97","195","1759.76","4512.94","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","5676.65","4257.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3025.65","53.3","","813.12","216.42","1444.50","81","1759.76","4512.94","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","5676.65","4257.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1759.76","31","","432.60","432.60","432.60","1 through 10","1759.76","4512.94","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","5676.65","4257.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2071.98","36.5","","148.37","54.89","631.39","94","1759.76","4512.94","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","5676.65","4257.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2174.16","38.3","","279.30","91.72","1116.77","266","1759.76","4512.94","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","5676.65","4257.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2435.28","42.9","","731.00","63.70","731.00","1 through 10","1759.76","4512.94","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","5676.65","4257.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2435.28","42.9","","384.74","384.74","384.74","1 through 10","1759.76","4512.94","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","5676.65","4257.49","WELLPOINT [1015]","HB AMC WELLPOINT","4188.23","73.78","","286.63","119.22","1107.45","105","1759.76","4512.94","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5676.65","4257.49","AETNA [1001]","HB AMC AETNA HMO","3962.30","69.8","","675.31","184.75","1721.50","286","2966.62","4638.96","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5676.65","4257.49","AETNA [1001]","HB AMC AETNA PPO","4564.03","80.4","","1261.44","103.12","1514.10","21","2966.62","4638.96","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5676.65","4257.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4564.03","80.4","","1365.00","1365.00","1365.00","1 through 10","2966.62","4638.96","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5676.65","4257.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4638.96","81.72","","5157.68","5157.68","5157.68","1 through 10","2966.62","4638.96","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5676.65","4257.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4638.96","81.72","","431.26","71.26","1459.57","88","2966.62","4638.96","percent of total billed charges",""
"Implant Neuroelectrode Additional","PX-76002017","CDM","61864","CPT","0761","RC","","","","outpatient","","","2815.00","2111.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1469.99","52.22","","1134.27","1134.27","1134.27","1 through 10","1126","2300.42","percent of total billed charges",""
"IMPLANT ORBIT PRINTED 3D TI TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239693","CDM","C1713","HCPCS","0278","RC","","","","both","","","11088.00","8316.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8814.96","79.5","","800.18","480.96","1887.97","195","3437.28","8814.96","percent of total billed charges",""
"IMPLANT ORBIT PRINTED 3D TI TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239693","CDM","C1713","HCPCS","0278","RC","","","","both","","","11088.00","8316.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5909.90","53.3","","813.12","216.42","1444.50","81","3437.28","8814.96","percent of total billed charges",""
"IMPLANT ORBIT PRINTED 3D TI TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239693","CDM","C1713","HCPCS","0278","RC","","","","both","","","11088.00","8316.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3437.28","31","","432.60","432.60","432.60","1 through 10","3437.28","8814.96","percent of total billed charges",""
"IMPLANT ORBIT PRINTED 3D TI TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239693","CDM","C1713","HCPCS","0278","RC","","","","both","","","11088.00","8316.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4047.12","36.5","","148.37","54.89","631.39","94","3437.28","8814.96","percent of total billed charges",""
"IMPLANT ORBIT PRINTED 3D TI TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239693","CDM","C1713","HCPCS","0278","RC","","","","both","","","11088.00","8316.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4246.70","38.3","","279.30","91.72","1116.77","266","3437.28","8814.96","percent of total billed charges",""
"IMPLANT ORBIT PRINTED 3D TI TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239693","CDM","C1713","HCPCS","0278","RC","","","","both","","","11088.00","8316.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4756.75","42.9","","731.00","63.70","731.00","1 through 10","3437.28","8814.96","percent of total billed charges",""
"IMPLANT ORBIT PRINTED 3D TI TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239693","CDM","C1713","HCPCS","0278","RC","","","","both","","","11088.00","8316.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4756.75","42.9","","384.74","384.74","384.74","1 through 10","3437.28","8814.96","percent of total billed charges",""
"IMPLANT ORBIT PRINTED 3D TI TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239693","CDM","C1713","HCPCS","0278","RC","","","","both","","","11088.00","8316.00","WELLPOINT [1015]","HB AMC WELLPOINT","8180.73","73.78","","286.63","119.22","1107.45","105","3437.28","8814.96","percent of total billed charges",""
"IMPLANT ORBIT PRINTED 3D TI TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11088.00","8316.00","AETNA [1001]","HB AMC AETNA HMO","7739.42","69.8","","675.31","184.75","1721.50","286","5794.59","9061.11","percent of total billed charges",""
"IMPLANT ORBIT PRINTED 3D TI TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11088.00","8316.00","AETNA [1001]","HB AMC AETNA PPO","8914.75","80.4","","1261.44","103.12","1514.10","21","5794.59","9061.11","percent of total billed charges",""
"IMPLANT ORBIT PRINTED 3D TI TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11088.00","8316.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8914.75","80.4","","1365.00","1365.00","1365.00","1 through 10","5794.59","9061.11","percent of total billed charges",""
"IMPLANT ORBIT PRINTED 3D TI TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11088.00","8316.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","9061.11","81.72","","5157.68","5157.68","5157.68","1 through 10","5794.59","9061.11","percent of total billed charges",""
"IMPLANT ORBIT PRINTED 3D TI TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11088.00","8316.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9061.11","81.72","","431.26","71.26","1459.57","88","5794.59","9061.11","percent of total billed charges",""
"IMPLANT PENILE 0.5-3CM EXTENDER SILICONE SOLID ELASTOMER REAR TIP NONSTACKING CXR","SUP-ITM-10019481","CDM","C1813","HCPCS","0278","RC","","","","both","","","0.04","0.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.02","38.3","","12613.42","12613.42","12613.42","1 through 10","0.01","0.03","percent of total billed charges",""
"IMPLANT PENILE 0.5-3CM EXTENDER SILICONE SOLID ELASTOMER REAR TIP NONSTACKING CXR","SUP-ITM-10019481","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","0.04","0.03","AETNA [1001]","HB AMC AETNA HMO","0.03","69.8","","34275.85","34275.85","50471.26","19","0.02","0.03","percent of total billed charges",""
"IMPLANT PENILE 18CM TITAN TOUCH SCROTAL ZERO ANGLE NARROW BASE CYLINDER PUMP","SUP-ITM-10239652","CDM","C1813","HCPCS","0278","RC","","","","both","","","28200.00","21150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10800.60","38.3","","12613.42","12613.42","12613.42","1 through 10","8742","22419","percent of total billed charges",""
"IMPLANT PENILE 18CM TITAN TOUCH SCROTAL ZERO ANGLE NARROW BASE CYLINDER PUMP","SUP-ITM-10239652","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","28200.00","21150.00","AETNA [1001]","HB AMC AETNA HMO","19683.60","69.8","","34275.85","34275.85","50471.26","19","14737.32","23045.04","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.95","277.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","294.11","79.5","","800.18","480.96","1887.97","195","114.68","294.11","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.95","277.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","197.18","53.3","","813.12","216.42","1444.50","81","114.68","294.11","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.95","277.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","114.68","31","","432.60","432.60","432.60","1 through 10","114.68","294.11","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.95","277.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","135.03","36.5","","148.37","54.89","631.39","94","114.68","294.11","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.95","277.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","141.69","38.3","","279.30","91.72","1116.77","266","114.68","294.11","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.95","277.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","158.71","42.9","","731.00","63.70","731.00","1 through 10","114.68","294.11","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.95","277.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","158.71","42.9","","384.74","384.74","384.74","1 through 10","114.68","294.11","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","369.95","277.46","WELLPOINT [1015]","HB AMC WELLPOINT","272.95","73.78","","286.63","119.22","1107.45","105","114.68","294.11","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","369.95","277.46","AETNA [1001]","HB AMC AETNA HMO","258.23","69.8","","675.31","184.75","1721.50","286","193.34","302.32","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","369.95","277.46","AETNA [1001]","HB AMC AETNA PPO","297.44","80.4","","1261.44","103.12","1514.10","21","193.34","302.32","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","369.95","277.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","297.44","80.4","","1365.00","1365.00","1365.00","1 through 10","193.34","302.32","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","369.95","277.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","302.32","81.72","","5157.68","5157.68","5157.68","1 through 10","193.34","302.32","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","369.95","277.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","302.32","81.72","","431.26","71.26","1459.57","88","193.34","302.32","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2013.08","79.5","","800.18","480.96","1887.97","195","784.97","2013.08","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.65","53.3","","813.12","216.42","1444.50","81","784.97","2013.08","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","784.97","31","","432.60","432.60","432.60","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.24","36.5","","148.37","54.89","631.39","94","784.97","2013.08","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.82","38.3","","279.30","91.72","1116.77","266","784.97","2013.08","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","731.00","63.70","731.00","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","384.74","384.74","384.74","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","WELLPOINT [1015]","HB AMC WELLPOINT","1868.24","73.78","","286.63","119.22","1107.45","105","784.97","2013.08","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA HMO","1767.45","69.8","","675.31","184.75","1721.50","286","1323.31","2069.29","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA PPO","2035.86","80.4","","1261.44","103.12","1514.10","21","1323.31","2069.29","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2069.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2069.29","81.72","","431.26","71.26","1459.57","88","1323.31","2069.29","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","6090.00","4567.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4841.55","79.5","","800.18","480.96","1887.97","195","1887.9","4841.55","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","6090.00","4567.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3245.97","53.3","","813.12","216.42","1444.50","81","1887.9","4841.55","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","6090.00","4567.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1887.90","31","","432.60","432.60","432.60","1 through 10","1887.9","4841.55","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","6090.00","4567.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2222.85","36.5","","148.37","54.89","631.39","94","1887.9","4841.55","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","6090.00","4567.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2332.47","38.3","","279.30","91.72","1116.77","266","1887.9","4841.55","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","6090.00","4567.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2612.61","42.9","","731.00","63.70","731.00","1 through 10","1887.9","4841.55","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","6090.00","4567.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2612.61","42.9","","384.74","384.74","384.74","1 through 10","1887.9","4841.55","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","6090.00","4567.50","WELLPOINT [1015]","HB AMC WELLPOINT","4493.20","73.78","","286.63","119.22","1107.45","105","1887.9","4841.55","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6090.00","4567.50","AETNA [1001]","HB AMC AETNA HMO","4250.82","69.8","","675.31","184.75","1721.50","286","3182.63","4976.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6090.00","4567.50","AETNA [1001]","HB AMC AETNA PPO","4896.36","80.4","","1261.44","103.12","1514.10","21","3182.63","4976.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6090.00","4567.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4896.36","80.4","","1365.00","1365.00","1365.00","1 through 10","3182.63","4976.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6090.00","4567.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4976.75","81.72","","5157.68","5157.68","5157.68","1 through 10","3182.63","4976.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6090.00","4567.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4976.75","81.72","","431.26","71.26","1459.57","88","3182.63","4976.75","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2013.08","79.5","","800.18","480.96","1887.97","195","784.97","2013.08","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.65","53.3","","813.12","216.42","1444.50","81","784.97","2013.08","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","784.97","31","","432.60","432.60","432.60","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.24","36.5","","148.37","54.89","631.39","94","784.97","2013.08","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.82","38.3","","279.30","91.72","1116.77","266","784.97","2013.08","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","731.00","63.70","731.00","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","384.74","384.74","384.74","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","WELLPOINT [1015]","HB AMC WELLPOINT","1868.24","73.78","","286.63","119.22","1107.45","105","784.97","2013.08","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA HMO","1767.45","69.8","","675.31","184.75","1721.50","286","1323.31","2069.29","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA PPO","2035.86","80.4","","1261.44","103.12","1514.10","21","1323.31","2069.29","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2069.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2069.29","81.72","","431.26","71.26","1459.57","88","1323.31","2069.29","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2013.08","79.5","","800.18","480.96","1887.97","195","784.97","2013.08","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.65","53.3","","813.12","216.42","1444.50","81","784.97","2013.08","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","784.97","31","","432.60","432.60","432.60","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.24","36.5","","148.37","54.89","631.39","94","784.97","2013.08","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.82","38.3","","279.30","91.72","1116.77","266","784.97","2013.08","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","731.00","63.70","731.00","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","384.74","384.74","384.74","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","WELLPOINT [1015]","HB AMC WELLPOINT","1868.24","73.78","","286.63","119.22","1107.45","105","784.97","2013.08","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA HMO","1767.45","69.8","","675.31","184.75","1721.50","286","1323.31","2069.29","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA PPO","2035.86","80.4","","1261.44","103.12","1514.10","21","1323.31","2069.29","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2069.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2069.29","81.72","","431.26","71.26","1459.57","88","1323.31","2069.29","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","7300.63","5475.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5804.00","79.5","","800.18","480.96","1887.97","195","2263.2","5804","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","7300.63","5475.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3891.24","53.3","","813.12","216.42","1444.50","81","2263.2","5804","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","7300.63","5475.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2263.20","31","","432.60","432.60","432.60","1 through 10","2263.2","5804","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","7300.63","5475.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2664.73","36.5","","148.37","54.89","631.39","94","2263.2","5804","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","7300.63","5475.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2796.14","38.3","","279.30","91.72","1116.77","266","2263.2","5804","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","7300.63","5475.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3131.97","42.9","","731.00","63.70","731.00","1 through 10","2263.2","5804","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","7300.63","5475.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3131.97","42.9","","384.74","384.74","384.74","1 through 10","2263.2","5804","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","7300.63","5475.47","WELLPOINT [1015]","HB AMC WELLPOINT","5386.40","73.78","","286.63","119.22","1107.45","105","2263.2","5804","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7300.63","5475.47","AETNA [1001]","HB AMC AETNA HMO","5095.84","69.8","","675.31","184.75","1721.50","286","3815.31","5966.07","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7300.63","5475.47","AETNA [1001]","HB AMC AETNA PPO","5869.71","80.4","","1261.44","103.12","1514.10","21","3815.31","5966.07","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7300.63","5475.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5869.71","80.4","","1365.00","1365.00","1365.00","1 through 10","3815.31","5966.07","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7300.63","5475.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5966.07","81.72","","5157.68","5157.68","5157.68","1 through 10","3815.31","5966.07","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7300.63","5475.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5966.07","81.72","","431.26","71.26","1459.57","88","3815.31","5966.07","percent of total billed charges",""
"Implant Pump Infus Programmable","PX-76001481","CDM","62362","CPT","0761","RC","","","","both","","","53756.00","40317.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","21616.57","","APC Price ($20,986.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","21603.66","20035.95","21603.66","1 through 10","16664.36","42736.02","other","OPPS APC"
"Implant Pump Infus Programmable","PX-76001481","CDM","62362","CPT","0761","RC","","","","both","","","53756.00","40317.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","20986.96","","APC Price ($20,986.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20653.25","19153.33","20653.25","1 through 10","16664.36","42736.02","other","OPPS APC"
"Implant Pump Infus Programmable","PX-76001481","CDM","62362","CPT","0761","RC","","","","both","","","53756.00","40317.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","42736.02","79.5","","85187.25","24686.62","85187.25","1 through 10","16664.36","42736.02","percent of total billed charges",""
"Implant Pump Infus Programmable","PX-76001481","CDM","62362","CPT","0761","RC","","","","both","","","53756.00","40317.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","28651.95","53.3","","38126.49","38126.49","38126.49","1 through 10","16664.36","42736.02","percent of total billed charges",""
"Implant Pump Infus Programmable","PX-76001481","CDM","62362","CPT","0761","RC","","","","both","","","53756.00","40317.00","MEDICARE [2001]","HB BWH MEDICARE","20986.96","","APC Price ($20,986.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20989.08","20989.08","38929.54","42","16664.36","42736.02","other","OPPS APC"
"Implant Pump Infus Programmable","PX-76001481","CDM","62362","CPT","0761","RC","","","","both","","","53756.00","40317.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20567.22","","APC Price ($20,986.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20653.26","20653.25","20653.26","1 through 10","16664.36","42736.02","other","OPPS APC"
"Implant Pump Infus Programmable","PX-76001481","CDM","62362","CPT","0761","RC","","","","outpatient","","","53756.00","40317.00","AETNA [1001]","HB AMC AETNA HMO","37521.69","69.8","","10517.67","10517.67","10517.67","1 through 10","10443.8","43929.4","percent of total billed charges",""
"Implant Pump Infus Programmable","PX-76001481","CDM","62362","CPT","0761","RC","","","","outpatient","","","53756.00","40317.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","18373.98","","Case rate ($18,373.98). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","37593.16","37593.16","37593.16","1 through 10","10443.8","43929.4","other","ASC"
"Implant Pump Infus Programmable","PX-76001481","CDM","62362","CPT","0761","RC","","","","outpatient","","","53756.00","40317.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18373.98","","Case rate ($18,373.98). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","42590.89","42590.89","43013.49","1 through 10","10443.8","43929.4","other","ASC "
"Implant Pump Infus Programmable","PX-76001481","CDM","62362","CPT","0761","RC","","","","outpatient","","","53756.00","40317.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","10443.80","","Case rate ($10,443.80). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","26736.13","26736.13","26736.13","1 through 10","10443.8","43929.4","other","Multiple Surgery"
"Implant Pump Infus Programmable","PX-76001481","CDM","62362","CPT","0761","RC","","","","outpatient","","","53756.00","40317.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","43929.40","81.72","","22507.11","22507.11","22507.11","1 through 10","10443.8","43929.4","percent of total billed charges",""
"IMPLANT SHOULDER 120MM ULNA PROXIMALIMAL SEGMENT INTERCALARY HP COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122547","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5963.33","52.26","","1113.10","1113.10","1113.10","1 through 10","3537.37","9071.65","percent of total billed charges",""
"IMPLANT SHOULDER 120MM ULNA PROXIMALIMAL SEGMENT INTERCALARY HP COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122547","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9071.65","79.5","","1293.60","1148.53","1603.80","1 through 10","3537.37","9071.65","percent of total billed charges",""
"IMPLANT SHOULDER 120MM ULNA PROXIMALIMAL SEGMENT INTERCALARY HP COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122547","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4164.97","36.5","","1023.42","771.29","2068.67","33","3537.37","9071.65","percent of total billed charges",""
"IMPLANT SHOULDER 120MM ULNA PROXIMALIMAL SEGMENT INTERCALARY HP COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122547","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4370.37","38.3","","850.52","759.78","1211.25","66","3537.37","9071.65","percent of total billed charges",""
"IMPLANT SHOULDER 120MM ULNA PROXIMALIMAL SEGMENT INTERCALARY HP COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122547","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4895.27","42.9","","2548.09","2548.09","2548.09","1 through 10","3537.37","9071.65","percent of total billed charges",""
"IMPLANT SHOULDER 120MM ULNA PROXIMALIMAL SEGMENT INTERCALARY HP COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122547","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4895.27","42.9","","956.46","956.46","956.46","1 through 10","3537.37","9071.65","percent of total billed charges",""
"IMPLANT SHOULDER 120MM ULNA PROXIMALIMAL SEGMENT INTERCALARY HP COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122547","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","WELLPOINT [1015]","HB AMC WELLPOINT","8418.95","73.78","","2344.73","1619.47","2530.35","16","3537.37","9071.65","percent of total billed charges",""
"IMPLANT SHOULDER 120MM ULNA PROXIMALIMAL SEGMENT INTERCALARY HP COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","AETNA [1001]","HB AMC AETNA HMO","7964.79","69.8","","1523.63","988.41","4330.26","39","5963.33","9324.97","percent of total billed charges",""
"IMPLANT SHOULDER 120MM ULNA PROXIMALIMAL SEGMENT INTERCALARY HP COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","AETNA [1001]","HB AMC AETNA PPO","9174.35","80.4","","1670.25","1670.25","1670.25","1 through 10","5963.33","9324.97","percent of total billed charges",""
"IMPLANT SHOULDER 120MM ULNA PROXIMALIMAL SEGMENT INTERCALARY HP COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5963.33","52.26","","1113.10","1113.10","1113.10","1 through 10","5963.33","9324.97","percent of total billed charges",""
"IMPLANT SHOULDER 120MM ULNA PROXIMALIMAL SEGMENT INTERCALARY HP COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9324.97","81.72","","1738.90","1484.65","2716.94","38","5963.33","9324.97","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2760.80","2070.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2194.84","79.5","","1293.60","1148.53","1603.80","1 through 10","855.85","2194.84","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2760.80","2070.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1007.69","36.5","","1023.42","771.29","2068.67","33","855.85","2194.84","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2760.80","2070.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1057.39","38.3","","850.52","759.78","1211.25","66","855.85","2194.84","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2760.80","2070.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1184.38","42.9","","2548.09","2548.09","2548.09","1 through 10","855.85","2194.84","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2760.80","2070.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1184.38","42.9","","956.46","956.46","956.46","1 through 10","855.85","2194.84","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2760.80","2070.60","WELLPOINT [1015]","HB AMC WELLPOINT","2036.92","73.78","","2344.73","1619.47","2530.35","16","855.85","2194.84","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2760.80","2070.60","AETNA [1001]","HB AMC AETNA HMO","1927.04","69.8","","1523.63","988.41","4330.26","39","1442.79","2256.13","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2760.80","2070.60","AETNA [1001]","HB AMC AETNA PPO","2219.68","80.4","","1670.25","1670.25","1670.25","1 through 10","1442.79","2256.13","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2760.80","2070.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1442.79","52.26","","1113.10","1113.10","1113.10","1 through 10","1442.79","2256.13","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2760.80","2070.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2256.13","81.72","","1738.90","1484.65","2716.94","38","1442.79","2256.13","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.87","3605.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3821.46","79.5","","1293.60","1148.53","1603.80","1 through 10","1490.13","3821.46","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.87","3605.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1754.51","36.5","","1023.42","771.29","2068.67","33","1490.13","3821.46","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.87","3605.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1841.03","38.3","","850.52","759.78","1211.25","66","1490.13","3821.46","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.87","3605.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2062.15","42.9","","2548.09","2548.09","2548.09","1 through 10","1490.13","3821.46","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.87","3605.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2062.15","42.9","","956.46","956.46","956.46","1 through 10","1490.13","3821.46","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4806.87","3605.15","WELLPOINT [1015]","HB AMC WELLPOINT","3546.51","73.78","","2344.73","1619.47","2530.35","16","1490.13","3821.46","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4806.87","3605.15","AETNA [1001]","HB AMC AETNA HMO","3355.20","69.8","","1523.63","988.41","4330.26","39","2512.07","3928.17","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4806.87","3605.15","AETNA [1001]","HB AMC AETNA PPO","3864.72","80.4","","1670.25","1670.25","1670.25","1 through 10","2512.07","3928.17","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4806.87","3605.15","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2512.07","52.26","","1113.10","1113.10","1113.10","1 through 10","2512.07","3928.17","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4806.87","3605.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3928.17","81.72","","1738.90","1484.65","2716.94","38","2512.07","3928.17","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","6357.53","4768.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5054.24","79.5","","1293.60","1148.53","1603.80","1 through 10","1970.83","5054.24","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","6357.53","4768.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2320.50","36.5","","1023.42","771.29","2068.67","33","1970.83","5054.24","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","6357.53","4768.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2434.93","38.3","","850.52","759.78","1211.25","66","1970.83","5054.24","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","6357.53","4768.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2727.38","42.9","","2548.09","2548.09","2548.09","1 through 10","1970.83","5054.24","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","6357.53","4768.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2727.38","42.9","","956.46","956.46","956.46","1 through 10","1970.83","5054.24","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","6357.53","4768.15","WELLPOINT [1015]","HB AMC WELLPOINT","4690.59","73.78","","2344.73","1619.47","2530.35","16","1970.83","5054.24","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6357.53","4768.15","AETNA [1001]","HB AMC AETNA HMO","4437.56","69.8","","1523.63","988.41","4330.26","39","3322.45","5195.37","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6357.53","4768.15","AETNA [1001]","HB AMC AETNA PPO","5111.45","80.4","","1670.25","1670.25","1670.25","1 through 10","3322.45","5195.37","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6357.53","4768.15","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3322.45","52.26","","1113.10","1113.10","1113.10","1 through 10","3322.45","5195.37","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6357.53","4768.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5195.37","81.72","","1738.90","1484.65","2716.94","38","3322.45","5195.37","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","1165.40","874.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","926.49","79.5","","1309.77","674.56","6049.93","26","361.27","926.49","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","1165.40","874.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","621.16","53.3","","1901.83","1901.83","2962.25","1 through 10","361.27","926.49","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","1165.40","874.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","425.37","36.5","","1620.31","1620.31","19908.88","1 through 10","361.27","926.49","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","1165.40","874.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","446.35","38.3","","352.91","352.91","2046.30","1 through 10","361.27","926.49","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","1165.40","874.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","499.96","42.9","","9668.75","9668.75","9668.75","1 through 10","361.27","926.49","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","1165.40","874.05","WELLPOINT [1015]","HB AMC WELLPOINT","859.83","73.78","","699.88","384.10","3443.31","33","361.27","926.49","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1165.40","874.05","AETNA [1001]","HB AMC AETNA HMO","813.45","69.8","","1421.24","264.50","4933.46","29","609.04","952.36","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1165.40","874.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","936.98","80.4","","1022.97","1022.97","3607.50","1 through 10","609.04","952.36","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1165.40","874.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","952.36","81.72","","3010.54","693.88","5019.88","35","609.04","952.36","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2013.08","79.5","","1309.77","674.56","6049.93","26","784.97","2013.08","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.65","53.3","","1901.83","1901.83","2962.25","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.24","36.5","","1620.31","1620.31","19908.88","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.82","38.3","","352.91","352.91","2046.30","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","9668.75","9668.75","9668.75","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","WELLPOINT [1015]","HB AMC WELLPOINT","1868.24","73.78","","699.88","384.10","3443.31","33","784.97","2013.08","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA HMO","1767.45","69.8","","1421.24","264.50","4933.46","29","1323.31","2069.29","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.86","80.4","","1022.97","1022.97","3607.50","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2069.29","81.72","","3010.54","693.88","5019.88","35","1323.31","2069.29","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","7601.25","5700.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6042.99","79.5","","1309.77","674.56","6049.93","26","2356.39","6042.99","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","7601.25","5700.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4051.47","53.3","","1901.83","1901.83","2962.25","1 through 10","2356.39","6042.99","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","7601.25","5700.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2774.46","36.5","","1620.31","1620.31","19908.88","1 through 10","2356.39","6042.99","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","7601.25","5700.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2911.28","38.3","","352.91","352.91","2046.30","1 through 10","2356.39","6042.99","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","7601.25","5700.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3260.94","42.9","","9668.75","9668.75","9668.75","1 through 10","2356.39","6042.99","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","7601.25","5700.94","WELLPOINT [1015]","HB AMC WELLPOINT","5608.20","73.78","","699.88","384.10","3443.31","33","2356.39","6042.99","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7601.25","5700.94","AETNA [1001]","HB AMC AETNA HMO","5305.67","69.8","","1421.24","264.50","4933.46","29","3972.41","6211.74","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7601.25","5700.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6111.41","80.4","","1022.97","1022.97","3607.50","1 through 10","3972.41","6211.74","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7601.25","5700.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6211.74","81.72","","3010.54","693.88","5019.88","35","3972.41","6211.74","percent of total billed charges",""
"IMPLANT SPINE 7X90MM IFUSE 3D SACRAL ILIAC","SUP-ITM-10249711","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6161.25","79.5","","1309.77","674.56","6049.93","26","2402.5","6161.25","percent of total billed charges",""
"IMPLANT SPINE 7X90MM IFUSE 3D SACRAL ILIAC","SUP-ITM-10249711","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4130.75","53.3","","1901.83","1901.83","2962.25","1 through 10","2402.5","6161.25","percent of total billed charges",""
"IMPLANT SPINE 7X90MM IFUSE 3D SACRAL ILIAC","SUP-ITM-10249711","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2828.75","36.5","","1620.31","1620.31","19908.88","1 through 10","2402.5","6161.25","percent of total billed charges",""
"IMPLANT SPINE 7X90MM IFUSE 3D SACRAL ILIAC","SUP-ITM-10249711","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2968.25","38.3","","352.91","352.91","2046.30","1 through 10","2402.5","6161.25","percent of total billed charges",""
"IMPLANT SPINE 7X90MM IFUSE 3D SACRAL ILIAC","SUP-ITM-10249711","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3324.75","42.9","","9668.75","9668.75","9668.75","1 through 10","2402.5","6161.25","percent of total billed charges",""
"IMPLANT SPINE 7X90MM IFUSE 3D SACRAL ILIAC","SUP-ITM-10249711","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","WELLPOINT [1015]","HB AMC WELLPOINT","5717.95","73.78","","699.88","384.10","3443.31","33","2402.5","6161.25","percent of total billed charges",""
"IMPLANT SPINE 7X90MM IFUSE 3D SACRAL ILIAC","SUP-ITM-10249711","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","AETNA [1001]","HB AMC AETNA HMO","5409.50","69.8","","1421.24","264.50","4933.46","29","4050.15","6333.3","percent of total billed charges",""
"IMPLANT SPINE 7X90MM IFUSE 3D SACRAL ILIAC","SUP-ITM-10249711","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6231.00","80.4","","1022.97","1022.97","3607.50","1 through 10","4050.15","6333.3","percent of total billed charges",""
"IMPLANT SPINE 7X90MM IFUSE 3D SACRAL ILIAC","SUP-ITM-10249711","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6333.30","81.72","","3010.54","693.88","5019.88","35","4050.15","6333.3","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","219.82","79.5","","800.18","480.96","1887.97","195","85.72","219.82","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.37","53.3","","813.12","216.42","1444.50","81","85.72","219.82","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.72","31","","432.60","432.60","432.60","1 through 10","85.72","219.82","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.92","36.5","","148.37","54.89","631.39","94","85.72","219.82","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.90","38.3","","279.30","91.72","1116.77","266","85.72","219.82","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.62","42.9","","731.00","63.70","731.00","1 through 10","85.72","219.82","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.62","42.9","","384.74","384.74","384.74","1 through 10","85.72","219.82","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","WELLPOINT [1015]","HB AMC WELLPOINT","204.00","73.78","","286.63","119.22","1107.45","105","85.72","219.82","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","AETNA [1001]","HB AMC AETNA HMO","193.00","69.8","","675.31","184.75","1721.50","286","144.5","225.96","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","AETNA [1001]","HB AMC AETNA PPO","222.31","80.4","","1261.44","103.12","1514.10","21","144.5","225.96","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","222.31","80.4","","1365.00","1365.00","1365.00","1 through 10","144.5","225.96","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","225.96","81.72","","5157.68","5157.68","5157.68","1 through 10","144.5","225.96","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","225.96","81.72","","431.26","71.26","1459.57","88","144.5","225.96","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.00","3710.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3932.87","79.5","","800.18","480.96","1887.97","195","1533.57","3932.87","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.00","3710.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2636.75","53.3","","813.12","216.42","1444.50","81","1533.57","3932.87","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.00","3710.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1533.57","31","","432.60","432.60","432.60","1 through 10","1533.57","3932.87","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.00","3710.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1805.66","36.5","","148.37","54.89","631.39","94","1533.57","3932.87","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.00","3710.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1894.70","38.3","","279.30","91.72","1116.77","266","1533.57","3932.87","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.00","3710.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2122.26","42.9","","731.00","63.70","731.00","1 through 10","1533.57","3932.87","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.00","3710.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2122.26","42.9","","384.74","384.74","384.74","1 through 10","1533.57","3932.87","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.00","3710.25","WELLPOINT [1015]","HB AMC WELLPOINT","3649.90","73.78","","286.63","119.22","1107.45","105","1533.57","3932.87","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.00","3710.25","AETNA [1001]","HB AMC AETNA HMO","3453.01","69.8","","675.31","184.75","1721.50","286","2585.3","4042.69","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.00","3710.25","AETNA [1001]","HB AMC AETNA PPO","3977.39","80.4","","1261.44","103.12","1514.10","21","2585.3","4042.69","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.00","3710.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3977.39","80.4","","1365.00","1365.00","1365.00","1 through 10","2585.3","4042.69","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.00","3710.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4042.69","81.72","","5157.68","5157.68","5157.68","1 through 10","2585.3","4042.69","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.00","3710.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4042.69","81.72","","431.26","71.26","1459.57","88","2585.3","4042.69","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3565.58","79.5","","800.18","480.96","1887.97","195","1390.35","3565.58","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2390.51","53.3","","813.12","216.42","1444.50","81","1390.35","3565.58","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1390.35","31","","432.60","432.60","432.60","1 through 10","1390.35","3565.58","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1637.03","36.5","","148.37","54.89","631.39","94","1390.35","3565.58","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1717.76","38.3","","279.30","91.72","1116.77","266","1390.35","3565.58","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1924.07","42.9","","731.00","63.70","731.00","1 through 10","1390.35","3565.58","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1924.07","42.9","","384.74","384.74","384.74","1 through 10","1390.35","3565.58","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","WELLPOINT [1015]","HB AMC WELLPOINT","3309.03","73.78","","286.63","119.22","1107.45","105","1390.35","3565.58","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","AETNA [1001]","HB AMC AETNA HMO","3130.53","69.8","","675.31","184.75","1721.50","286","2343.86","3665.14","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","AETNA [1001]","HB AMC AETNA PPO","3605.94","80.4","","1261.44","103.12","1514.10","21","2343.86","3665.14","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3605.94","80.4","","1365.00","1365.00","1365.00","1 through 10","2343.86","3665.14","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3665.14","81.72","","5157.68","5157.68","5157.68","1 through 10","2343.86","3665.14","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3665.14","81.72","","431.26","71.26","1459.57","88","2343.86","3665.14","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","both","","","6252.50","4689.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4970.74","79.5","","1309.77","674.56","6049.93","26","1938.28","4970.74","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","both","","","6252.50","4689.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3332.58","53.3","","1901.83","1901.83","2962.25","1 through 10","1938.28","4970.74","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","both","","","6252.50","4689.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2282.16","36.5","","1620.31","1620.31","19908.88","1 through 10","1938.28","4970.74","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","both","","","6252.50","4689.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2394.71","38.3","","352.91","352.91","2046.30","1 through 10","1938.28","4970.74","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","both","","","6252.50","4689.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2682.32","42.9","","9668.75","9668.75","9668.75","1 through 10","1938.28","4970.74","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","both","","","6252.50","4689.37","WELLPOINT [1015]","HB AMC WELLPOINT","4613.09","73.78","","699.88","384.10","3443.31","33","1938.28","4970.74","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6252.50","4689.37","AETNA [1001]","HB AMC AETNA HMO","4364.25","69.8","","1421.24","264.50","4933.46","29","3267.56","5109.54","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6252.50","4689.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5027.01","80.4","","1022.97","1022.97","3607.50","1 through 10","3267.56","5109.54","percent of total billed charges",""
"IMPLANT TESTICULAR 3.5CMX2.5CM SM SALINE FILLED PROSTHESIS","SUP-ITM-10028048","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6252.50","4689.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5109.54","81.72","","3010.54","693.88","5019.88","35","3267.56","5109.54","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1309.77","674.56","6049.93","26","1627.5","4173.75","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","1901.83","1901.83","2962.25","1 through 10","1627.5","4173.75","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1620.31","1620.31","19908.88","1 through 10","1627.5","4173.75","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","352.91","352.91","2046.30","1 through 10","1627.5","4173.75","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","9668.75","9668.75","9668.75","1 through 10","1627.5","4173.75","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","699.88","384.10","3443.31","33","1627.5","4173.75","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1421.24","264.50","4933.46","29","2743.65","4290.3","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4221.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2743.65","4290.3","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","3010.54","693.88","5019.88","35","2743.65","4290.3","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3565.03","2673.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2834.20","79.5","","1309.77","674.56","6049.93","26","1105.16","2834.2","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3565.03","2673.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1900.16","53.3","","1901.83","1901.83","2962.25","1 through 10","1105.16","2834.2","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3565.03","2673.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1301.24","36.5","","1620.31","1620.31","19908.88","1 through 10","1105.16","2834.2","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3565.03","2673.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1365.41","38.3","","352.91","352.91","2046.30","1 through 10","1105.16","2834.2","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3565.03","2673.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1529.40","42.9","","9668.75","9668.75","9668.75","1 through 10","1105.16","2834.2","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3565.03","2673.77","WELLPOINT [1015]","HB AMC WELLPOINT","2630.28","73.78","","699.88","384.10","3443.31","33","1105.16","2834.2","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3565.03","2673.77","AETNA [1001]","HB AMC AETNA HMO","2488.39","69.8","","1421.24","264.50","4933.46","29","1863.08","2913.34","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3565.03","2673.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2866.28","80.4","","1022.97","1022.97","3607.50","1 through 10","1863.08","2913.34","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3565.03","2673.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2913.34","81.72","","3010.54","693.88","5019.88","35","1863.08","2913.34","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.01","3300.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3498.01","79.5","","1309.77","674.56","6049.93","26","1364","3498.01","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.01","3300.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2345.21","53.3","","1901.83","1901.83","2962.25","1 through 10","1364","3498.01","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.01","3300.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1606.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1364","3498.01","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.01","3300.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1685.20","38.3","","352.91","352.91","2046.30","1 through 10","1364","3498.01","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.01","3300.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1887.60","42.9","","9668.75","9668.75","9668.75","1 through 10","1364","3498.01","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.01","3300.01","WELLPOINT [1015]","HB AMC WELLPOINT","3246.33","73.78","","699.88","384.10","3443.31","33","1364","3498.01","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4400.01","3300.01","AETNA [1001]","HB AMC AETNA HMO","3071.21","69.8","","1421.24","264.50","4933.46","29","2299.45","3595.69","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4400.01","3300.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3537.61","80.4","","1022.97","1022.97","3607.50","1 through 10","2299.45","3595.69","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4400.01","3300.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3595.69","81.72","","3010.54","693.88","5019.88","35","2299.45","3595.69","percent of total billed charges",""
"IMPLANT TSI BARRIER 40X40X2.5X0.73MM MEDPOR POLYETHYLENE SHEET STERILE LARGE","SUP-ITM-10026885","CDM","C1713","HCPCS","0278","RC","","","","both","","","2474.70","1856.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1967.39","79.5","","800.18","480.96","1887.97","195","767.16","1967.39","percent of total billed charges",""
"IMPLANT TSI BARRIER 40X40X2.5X0.73MM MEDPOR POLYETHYLENE SHEET STERILE LARGE","SUP-ITM-10026885","CDM","C1713","HCPCS","0278","RC","","","","both","","","2474.70","1856.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1319.02","53.3","","813.12","216.42","1444.50","81","767.16","1967.39","percent of total billed charges",""
"IMPLANT TSI BARRIER 40X40X2.5X0.73MM MEDPOR POLYETHYLENE SHEET STERILE LARGE","SUP-ITM-10026885","CDM","C1713","HCPCS","0278","RC","","","","both","","","2474.70","1856.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","767.16","31","","432.60","432.60","432.60","1 through 10","767.16","1967.39","percent of total billed charges",""
"IMPLANT TSI BARRIER 40X40X2.5X0.73MM MEDPOR POLYETHYLENE SHEET STERILE LARGE","SUP-ITM-10026885","CDM","C1713","HCPCS","0278","RC","","","","both","","","2474.70","1856.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","903.27","36.5","","148.37","54.89","631.39","94","767.16","1967.39","percent of total billed charges",""
"IMPLANT TSI BARRIER 40X40X2.5X0.73MM MEDPOR POLYETHYLENE SHEET STERILE LARGE","SUP-ITM-10026885","CDM","C1713","HCPCS","0278","RC","","","","both","","","2474.70","1856.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","947.81","38.3","","279.30","91.72","1116.77","266","767.16","1967.39","percent of total billed charges",""
"IMPLANT TSI BARRIER 40X40X2.5X0.73MM MEDPOR POLYETHYLENE SHEET STERILE LARGE","SUP-ITM-10026885","CDM","C1713","HCPCS","0278","RC","","","","both","","","2474.70","1856.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1061.65","42.9","","731.00","63.70","731.00","1 through 10","767.16","1967.39","percent of total billed charges",""
"IMPLANT TSI BARRIER 40X40X2.5X0.73MM MEDPOR POLYETHYLENE SHEET STERILE LARGE","SUP-ITM-10026885","CDM","C1713","HCPCS","0278","RC","","","","both","","","2474.70","1856.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1061.65","42.9","","384.74","384.74","384.74","1 through 10","767.16","1967.39","percent of total billed charges",""
"IMPLANT TSI BARRIER 40X40X2.5X0.73MM MEDPOR POLYETHYLENE SHEET STERILE LARGE","SUP-ITM-10026885","CDM","C1713","HCPCS","0278","RC","","","","both","","","2474.70","1856.02","WELLPOINT [1015]","HB AMC WELLPOINT","1825.83","73.78","","286.63","119.22","1107.45","105","767.16","1967.39","percent of total billed charges",""
"IMPLANT TSI BARRIER 40X40X2.5X0.73MM MEDPOR POLYETHYLENE SHEET STERILE LARGE","SUP-ITM-10026885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2474.70","1856.02","AETNA [1001]","HB AMC AETNA HMO","1727.34","69.8","","675.31","184.75","1721.50","286","1293.28","2022.32","percent of total billed charges",""
"IMPLANT TSI BARRIER 40X40X2.5X0.73MM MEDPOR POLYETHYLENE SHEET STERILE LARGE","SUP-ITM-10026885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2474.70","1856.02","AETNA [1001]","HB AMC AETNA PPO","1989.66","80.4","","1261.44","103.12","1514.10","21","1293.28","2022.32","percent of total billed charges",""
"IMPLANT TSI BARRIER 40X40X2.5X0.73MM MEDPOR POLYETHYLENE SHEET STERILE LARGE","SUP-ITM-10026885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2474.70","1856.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1989.66","80.4","","1365.00","1365.00","1365.00","1 through 10","1293.28","2022.32","percent of total billed charges",""
"IMPLANT TSI BARRIER 40X40X2.5X0.73MM MEDPOR POLYETHYLENE SHEET STERILE LARGE","SUP-ITM-10026885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2474.70","1856.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2022.32","81.72","","5157.68","5157.68","5157.68","1 through 10","1293.28","2022.32","percent of total billed charges",""
"IMPLANT TSI BARRIER 40X40X2.5X0.73MM MEDPOR POLYETHYLENE SHEET STERILE LARGE","SUP-ITM-10026885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2474.70","1856.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2022.32","81.72","","431.26","71.26","1459.57","88","1293.28","2022.32","percent of total billed charges",""
"IMPLANT VOICE 1.5CC RENU CALCIUM HYDROXYLAPATITE INJECTABLE SYRINGE FOLD - DISCONTINUED PER CONTRACTS/SUPPLIER","SUP-ITM-10237361","CDM","C1878","HCPCS","0278","RC","","","","both","","","1260.00","945.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1001.70","79.5","","1991.51","1991.51","1991.51","1 through 10","390.6","1001.7","percent of total billed charges",""
"IMPLANT VOICE 1.5CC RENU CALCIUM HYDROXYLAPATITE INJECTABLE SYRINGE FOLD - DISCONTINUED PER CONTRACTS/SUPPLIER","SUP-ITM-10237361","CDM","C1878","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","459.90","36.5","","650.52","650.52","650.52","1 through 10","390.6","1001.7","percent of total billed charges",""
"IMPLANT VOICE 1.5CC RENU HYDROGEL INJECTABLE SYRINGE FOLD - DISCONTINUED PER CONTRACTS/SUPPLIER","SUP-ITM-10237362","CDM","C1878","HCPCS","0278","RC","","","","both","","","1190.00","892.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","946.05","79.5","","1991.51","1991.51","1991.51","1 through 10","368.9","946.05","percent of total billed charges",""
"IMPLANT VOICE 1.5CC RENU HYDROGEL INJECTABLE SYRINGE FOLD - DISCONTINUED PER CONTRACTS/SUPPLIER","SUP-ITM-10237362","CDM","C1878","HCPCS","0278","RC","","","","both","","","1190.00","892.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","434.35","36.5","","650.52","650.52","650.52","1 through 10","368.9","946.05","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2013.08","79.5","","800.18","480.96","1887.97","195","784.97","2013.08","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.65","53.3","","813.12","216.42","1444.50","81","784.97","2013.08","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","784.97","31","","432.60","432.60","432.60","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.24","36.5","","148.37","54.89","631.39","94","784.97","2013.08","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.82","38.3","","279.30","91.72","1116.77","266","784.97","2013.08","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","731.00","63.70","731.00","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.30","42.9","","384.74","384.74","384.74","1 through 10","784.97","2013.08","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","2532.17","1899.13","WELLPOINT [1015]","HB AMC WELLPOINT","1868.24","73.78","","286.63","119.22","1107.45","105","784.97","2013.08","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA HMO","1767.45","69.8","","675.31","184.75","1721.50","286","1323.31","2069.29","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","AETNA [1001]","HB AMC AETNA PPO","2035.86","80.4","","1261.44","103.12","1514.10","21","1323.31","2069.29","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2069.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1323.31","2069.29","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2532.17","1899.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2069.29","81.72","","431.26","71.26","1459.57","88","1323.31","2069.29","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.48","2194.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2325.76","79.5","","1293.60","1148.53","1603.80","1 through 10","906.9","2325.76","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.48","2194.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1067.80","36.5","","1023.42","771.29","2068.67","33","906.9","2325.76","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.48","2194.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1120.46","38.3","","850.52","759.78","1211.25","66","906.9","2325.76","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.48","2194.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1255.03","42.9","","2548.09","2548.09","2548.09","1 through 10","906.9","2325.76","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.48","2194.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1255.03","42.9","","956.46","956.46","956.46","1 through 10","906.9","2325.76","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.48","2194.11","WELLPOINT [1015]","HB AMC WELLPOINT","2158.42","73.78","","2344.73","1619.47","2530.35","16","906.9","2325.76","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2925.48","2194.11","AETNA [1001]","HB AMC AETNA HMO","2041.99","69.8","","1523.63","988.41","4330.26","39","1528.86","2390.7","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2925.48","2194.11","AETNA [1001]","HB AMC AETNA PPO","2352.09","80.4","","1670.25","1670.25","1670.25","1 through 10","1528.86","2390.7","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2925.48","2194.11","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1528.86","52.26","","1113.10","1113.10","1113.10","1 through 10","1528.86","2390.7","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2925.48","2194.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2390.70","81.72","","1738.90","1484.65","2716.94","38","1528.86","2390.7","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","4428.00","3321.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3520.26","79.5","","1293.60","1148.53","1603.80","1 through 10","1372.68","3520.26","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","4428.00","3321.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1616.22","36.5","","1023.42","771.29","2068.67","33","1372.68","3520.26","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","4428.00","3321.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1695.92","38.3","","850.52","759.78","1211.25","66","1372.68","3520.26","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","4428.00","3321.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1899.61","42.9","","2548.09","2548.09","2548.09","1 through 10","1372.68","3520.26","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","4428.00","3321.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1899.61","42.9","","956.46","956.46","956.46","1 through 10","1372.68","3520.26","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","4428.00","3321.00","WELLPOINT [1015]","HB AMC WELLPOINT","3266.98","73.78","","2344.73","1619.47","2530.35","16","1372.68","3520.26","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4428.00","3321.00","AETNA [1001]","HB AMC AETNA HMO","3090.74","69.8","","1523.63","988.41","4330.26","39","2314.07","3618.56","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4428.00","3321.00","AETNA [1001]","HB AMC AETNA PPO","3560.11","80.4","","1670.25","1670.25","1670.25","1 through 10","2314.07","3618.56","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4428.00","3321.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2314.07","52.26","","1113.10","1113.10","1113.10","1 through 10","2314.07","3618.56","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4428.00","3321.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3618.56","81.72","","1738.90","1484.65","2716.94","38","2314.07","3618.56","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","6251.75","4688.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4970.14","79.5","","1293.60","1148.53","1603.80","1 through 10","1938.04","4970.14","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","6251.75","4688.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.89","36.5","","1023.42","771.29","2068.67","33","1938.04","4970.14","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","6251.75","4688.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2394.42","38.3","","850.52","759.78","1211.25","66","1938.04","4970.14","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","6251.75","4688.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2682.00","42.9","","2548.09","2548.09","2548.09","1 through 10","1938.04","4970.14","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","6251.75","4688.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2682.00","42.9","","956.46","956.46","956.46","1 through 10","1938.04","4970.14","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","6251.75","4688.81","WELLPOINT [1015]","HB AMC WELLPOINT","4612.54","73.78","","2344.73","1619.47","2530.35","16","1938.04","4970.14","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6251.75","4688.81","AETNA [1001]","HB AMC AETNA HMO","4363.72","69.8","","1523.63","988.41","4330.26","39","3267.16","5108.93","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6251.75","4688.81","AETNA [1001]","HB AMC AETNA PPO","5026.41","80.4","","1670.25","1670.25","1670.25","1 through 10","3267.16","5108.93","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6251.75","4688.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3267.16","52.26","","1113.10","1113.10","1113.10","1 through 10","3267.16","5108.93","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6251.75","4688.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5108.93","81.72","","1738.90","1484.65","2716.94","38","3267.16","5108.93","percent of total billed charges",""
"Implantable Heart Assist Systems,EXTREME","161","DRG","","","","","","","","inpatient","","","1181300.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","155945.0679","","Standard inlier is a Case rate ($752,510.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $596,829, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($106,823.39) for the length of stay and the standard reimbursement.","155945.0679","685940.64","685940.64","1 through 10","42376.07","957260.45","case rate",""
"Implantable Heart Assist Systems,EXTREME","161","DRG","","","","","","","","inpatient","","","1181300.10","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","","65","","522164.38","522164.38","522164.38","1 through 10","42376.07","957260.45","percent of total billed charges",""
"Implantable Heart Assist Systems,EXTREME","161","DRG","","","","","","","","inpatient","","","1181300.10","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","278322.06","278322.06","278322.06","1 through 10","42376.07","957260.45","percent of total billed charges",""
"Implantable Heart Assist Systems,EXTREME","161","DRG","","","","","","","","inpatient","","","1181300.10","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","105782.4898","","Fee schedule rate ($580,150.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","105782.4898","914043.42","914043.42","1 through 10","42376.07","957260.45","case rate",""
"Implantable Heart Assist Systems,EXTREME","161","DRG","","","","","","","","inpatient","","","1181300.10","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","715753.59","","Fee schedule rate ($715,753.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","725194.95","725194.95","725194.95","1 through 10","42376.07","957260.45","case rate",""
"Implantable Heart Assist Systems,EXTREME","161","DRG","","","","","","","","inpatient","","","1181300.10","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","562362.71","","Fee schedule rate ($562,362.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","545984.60","545984.60","545984.60","1 through 10","42376.07","957260.45","case rate",""
"Implantable Heart Assist Systems,EXTREME","161","DRG","","","","","","","","inpatient","","","1181300.10","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","694681.84","","Fee schedule rate ($694,681.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","694681.84","694681.84","694681.84","1 through 10","42376.07","957260.45","case rate",""
"Implantable Heart Assist Systems,MAJOR","161","DRG","","","","","","","","inpatient","","","356208.01","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","105782.4898","","Fee schedule rate ($105,782.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","105782.4898","244507.08","244507.08","1 through 10","42376.07","957260.45","case rate",""
"Implantable Heart Assist Systems,MAJOR","161","DRG","","","","","","","","inpatient","","","356208.01","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","66599.94","","Case rate ($73,637.68). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $116,067.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12830.96","12830.96","12830.96","1 through 10","42376.07","957260.45","case rate",""
"Implantable Heart Assist Systems,MINOR","161","DRG","","","","","","","","inpatient","","","160981.59","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","105782.4898","","Fee schedule rate ($105,782.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","105782.4898","105782.48","105782.48","1 through 10","42376.07","957260.45","case rate",""
"Implantable Heart Assist Systems,MINOR","161","DRG","","","","","","","","inpatient","","","160981.59","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","111074.6884","","Fee schedule rate ($111,074.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","111074.6884","111074.68","111074.68","1 through 10","42376.07","957260.45","case rate",""
"Implantable Heart Assist Systems,MODERATE","161","DRG","","","","","","","","inpatient","","","197179.29","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","105782.4898","","Fee schedule rate ($149,076.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","105782.4898","143330.84","143330.84","1 through 10","42376.07","957260.45","case rate",""
"IMPLANTABLE PULSE GENERATOR CLOSED LOOP INS NGRC-ECAPS MRI","SUP-ITM-10327771","CDM","C1820","HCPCS","0278","RC","","","","both","","","53750.00","40312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","28648.75","53.3","","54287.50","54287.50","54287.50","1 through 10","16662.5","42731.25","percent of total billed charges",""
"IMPLANTABLE PULSE GENERATOR CLOSED LOOP INS NGRC-ECAPS MRI","SUP-ITM-10327771","CDM","C1820","HCPCS","0278","RC","","","","both","","","53750.00","40312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19618.75","36.5","","10467.31","10467.31","10467.31","1 through 10","16662.5","42731.25","percent of total billed charges",""
"IMPLANTABLE PULSE GENERATOR CLOSED LOOP INS NGRC-ECAPS MRI","SUP-ITM-10327771","CDM","C1820","HCPCS","0278","RC","","","","both","","","53750.00","40312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20586.25","38.3","","21505.00","21505.00","21505.00","1 through 10","16662.5","42731.25","percent of total billed charges",""
"IMPLANTABLE PULSE GENERATOR CLOSED LOOP INS NGRC-ECAPS MRI","SUP-ITM-10327771","CDM","C1820","HCPCS","0278","RC","","","","both","","","53750.00","40312.50","WELLPOINT [1015]","HB AMC WELLPOINT","39656.75","73.78","","40016.88","40016.88","40016.88","1 through 10","16662.5","42731.25","percent of total billed charges",""
"Impltj Revj/Rpsg Ithcl/Edrl Cath Pmp W/O Lam","PX-98301695","CDM","62350","CPT","0983","RC","","","","outpatient","","","2067.00","1550.25","AETNA [1001]","HB AMC AETNA HMO","1442.77","69.8","","10517.67","10517.67","10517.67","1 through 10","826.8","1689.15","percent of total billed charges",""
"Impltj Revj/Rpsg Ithcl/Edrl Cath Pmp W/O Lam","PX-98301695","CDM","62350","CPT","0983","RC","","","","outpatient","","","2067.00","1550.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1079.39","52.22","","6111.83","6051.78","12103.55","1 through 10","826.8","1689.15","percent of total billed charges",""
"Impltj Revj/Rpsg Ithcl/Edrl Cath Pmp W/O Lam","PX-98301695","CDM","62350","CPT","0983","RC","","","","outpatient","","","2067.00","1550.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1689.15","81.72","","7131.55","7131.55","7131.55","1 through 10","826.8","1689.15","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","37.76","37.76","207.17","1 through 10","193.33","550.14","other","OPPS APC"
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","484.40","70","","671.00","671.00","671.00","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","550.14","79.5","","528.08","338.86","528.08","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","368.84","53.3","","1062.87","1062.87","1062.87","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","FALLON HEALTH [1008]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","598.29","203.50","598.29","1 through 10","193.33","550.14","other","OPPS APC"
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","449.80","65","","436.15","436.15","436.15","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","550.14","79.5","","528.08","528.08","528.08","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","MEDICARE [2001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","186.42","203.50","13","193.33","550.14","other","OPPS APC"
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","252.58","36.5","","250.28","210.69","250.28","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","265.04","38.3","","262.36","221.43","262.36","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","TRICARE [160005]","HB BWH TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","193.33","193.33","193.33","1 through 10","193.33","550.14","other","Tricare OPPS"
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","154.33","154.33","154.33","1 through 10","193.33","550.14","other","OPPS APC"
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","186.42","186.42","186.42","1 through 10","193.33","550.14","other","OPPS APC"
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","WELLPOINT [1015]","HB AMC WELLPOINT","510.56","73.78","","1170.56","499.55","1170.56","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","outpatient","","","692.00","519.00","AETNA [1001]","HB AMC AETNA HMO","483.02","69.8","","454.27","454.27","454.27","1 through 10","265.8","887.19","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","outpatient","","","692.00","519.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","361.64","52.26","","297.92","297.92","297.92","1 through 10","265.8","887.19","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","outpatient","","","692.00","519.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","556.37","80.4","","523.38","523.38","523.38","1 through 10","265.8","887.19","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","outpatient","","","692.00","519.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","565.50","81.72","","536.40","536.40","536.40","1 through 10","265.8","887.19","percent of total billed charges",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","outpatient","","","692.00","519.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","565.50","81.72","","536.40","295.04","536.40","14","265.8","887.19","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","37.76","37.76","207.17","1 through 10","193.33","550.14","other","OPPS APC"
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","484.40","70","","671.00","671.00","671.00","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","550.14","79.5","","528.08","338.86","528.08","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","368.84","53.3","","1062.87","1062.87","1062.87","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","FALLON HEALTH [1008]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","598.29","203.50","598.29","1 through 10","193.33","550.14","other","OPPS APC"
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","449.80","65","","436.15","436.15","436.15","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","550.14","79.5","","528.08","528.08","528.08","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","MEDICARE [2001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","186.42","203.50","13","193.33","550.14","other","OPPS APC"
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","252.58","36.5","","250.28","210.69","250.28","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","265.04","38.3","","262.36","221.43","262.36","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","TRICARE [160005]","HB BWH TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","193.33","193.33","193.33","1 through 10","193.33","550.14","other","Tricare OPPS"
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","154.33","154.33","154.33","1 through 10","193.33","550.14","other","OPPS APC"
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","186.42","186.42","186.42","1 through 10","193.33","550.14","other","OPPS APC"
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","both","","","692.00","519.00","WELLPOINT [1015]","HB AMC WELLPOINT","510.56","73.78","","1170.56","499.55","1170.56","1 through 10","193.33","550.14","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","outpatient","","","692.00","519.00","AETNA [1001]","HB AMC AETNA HMO","483.02","69.8","","454.27","454.27","454.27","1 through 10","265.8","887.19","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","outpatient","","","692.00","519.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","361.64","52.26","","297.92","297.92","297.92","1 through 10","265.8","887.19","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","outpatient","","","692.00","519.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","556.37","80.4","","523.38","523.38","523.38","1 through 10","265.8","887.19","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","outpatient","","","692.00","519.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","565.50","81.72","","536.40","536.40","536.40","1 through 10","265.8","887.19","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","outpatient","","","692.00","519.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","565.50","81.72","","536.40","295.04","536.40","14","265.8","887.19","percent of total billed charges",""
"In Situ Hybridization Ea Addl Probe Stain","PX-31000502","CDM","88364","CPT","0312","RC","","","","both","","","577.00","432.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","458.72","79.5","","440.72","440.72","440.72","1 through 10","178.87","458.72","percent of total billed charges",""
"In Situ Hybridization Ea Addl Probe Stain","PX-31000502","CDM","88364","CPT","0312","RC","","","","both","","","577.00","432.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","307.54","53.3","","440.72","440.72","440.72","1 through 10","178.87","458.72","percent of total billed charges",""
"In Situ Hybridization Ea Addl Probe Stain","PX-31000502","CDM","88364","CPT","0312","RC","","","","both","","","577.00","432.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","458.72","79.5","","440.72","440.72","440.72","1 through 10","178.87","458.72","percent of total billed charges",""
"In Situ Hybridization Ea Addl Probe Stain","PX-31000502","CDM","88364","CPT","0312","RC","","","","both","","","577.00","432.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","210.61","36.5","","177.52","175.84","208.88","1 through 10","178.87","458.72","percent of total billed charges",""
"In Situ Hybridization Ea Addl Probe Stain","PX-31000502","CDM","88364","CPT","0312","RC","","","","both","","","577.00","432.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","220.99","38.3","","218.96","184.80","218.96","1 through 10","178.87","458.72","percent of total billed charges",""
"In Situ Hybridization Ea Addl Probe Stain","PX-31000502","CDM","88364","CPT","0312","RC","","","","both","","","577.00","432.75","WELLPOINT [1015]","HB AMC WELLPOINT","425.71","73.78","","1536.92","416.92","1536.92","1 through 10","178.87","458.72","percent of total billed charges",""
"In Situ Hybridization Ea Addl Probe Stain","PX-31000502","CDM","88364","CPT","0312","RC","","","","outpatient","","","577.00","432.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","301.54","52.26","","315.36","315.36","315.36","1 through 10","301.54","471.52","percent of total billed charges",""
"In Situ Hybridization Ea Addl Probe Stain","PX-31000502","CDM","88364","CPT","0312","RC","","","","outpatient","","","577.00","432.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","471.52","81.72","","447.66","246.23","447.67","1 through 10","301.54","471.52","percent of total billed charges",""
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","","","","inpatient","","","47205.14","35403.85","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","13752.96","","Case rate ($13,352.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,996.23, add-ons for qualifying new technology services are included. If operating cost exceeds $61,640.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,584.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,828.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,616.39 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.31. The transfer capital threshold is the transfer adjustment factor * $1,144.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11917.87","11917.87","11917.87","1 through 10","13085.34","18729.4401","other","Inpatient DRG"
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","","","","inpatient","","","47205.14","35403.85","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","13352.39","","Case rate ($13,352.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,996.23, add-ons for qualifying new technology services are included. If operating cost exceeds $61,640.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,584.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,828.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,616.39 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.31. The transfer capital threshold is the transfer adjustment factor * $1,144.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11418.12","11418.12","11418.12","1 through 10","13085.34","18729.4401","other","Inpatient Replacement Plans DRG"
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","","","","inpatient","","","47205.14","35403.85","MEDICARE [2001]","HB BWH MEDICARE","13352.39","","Case rate ($13,352.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,996.23, add-ons for qualifying new technology services are included. If operating cost exceeds $61,640.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,584.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,828.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,616.39 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,144.31. The transfer capital threshold is the transfer adjustment factor * $1,144.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14927.09","14927.09","14927.09","1 through 10","13085.34","18729.4401","other","Inpatient Replacement Plans DRG"
"Inborn Errors Of Metabolism,EXTREME","423","DRG","","","","","","","","inpatient","","","168503.75","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9995.8123","","Fee schedule rate ($117,605.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9995.8123","117605.68","117605.68","1 through 10","9611.0314","194051.75","case rate",""
"Inc Hemorrhoid External","PX-75000214","CDM","46083","CPT","0761","RC","","","","outpatient","","","750.00","562.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","265.83","265.83","265.83","1 through 10","231.42","700.33","other","ASC"
"Incision/Remove FB Subq Complex","PX-76000009","CDM","10121","CPT","0761","RC","","","","both","","","3993.00","2994.75","MEDICARE [2001]","HB BWH MEDICARE","2060.54","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1237.83","3174.44","other","OPPS APC"
"Incision/Remove FB Subq Complex","PX-76000009","CDM","10121","CPT","0761","RC","","","","both","","","3993.00","2994.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1237.83","31","","2577.06","2577.06","2577.06","1 through 10","1237.83","3174.44","percent of total billed charges",""
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","both","","","978.00","733.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","488.23","488.23","488.23","1 through 10","303.18","786.31","other","OPPS APC"
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","both","","","978.00","733.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","393.14","466.88","1 through 10","303.18","786.31","other","OPPS APC"
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","both","","","978.00","733.50","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","303.18","786.31","other","OPPS APC"
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","374.57","38.3","","370.67","200.58","370.67","1 through 10","303.18","786.31","percent of total billed charges",""
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","470.98","470.98","470.98","1 through 10","303.18","786.31","other","OPPS APC"
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","outpatient","","","978.00","733.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","721.57","721.57","721.57","1 through 10","314.08","799.22","other","ASC"
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","outpatient","","","978.00","733.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","832.56","832.56","832.56","1 through 10","314.08","799.22","other","ASC "
"Incisional Biopsy Skin Single Lesion","PX-76002569","CDM","11106","CPT","0761","RC","","","","both","","","1043.00","782.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","748.67","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","748.02","60.82","748.02","1 through 10","323.33","908.58","other","OPPS APC"
"Incisional Biopsy Skin Single Lesion","PX-76002569","CDM","11106","CPT","0761","RC","","","","both","","","1043.00","782.25","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2180.82","726.94","2180.82","1 through 10","323.33","908.58","other","OPPS APC"
"Incisional Biopsy Skin Single Lesion","PX-76002569","CDM","11106","CPT","0761","RC","","","","both","","","1043.00","782.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","399.47","38.3","","1185.90","1185.90","1185.90","1 through 10","323.33","908.58","percent of total billed charges",""
"Incisional Biopsy Skin Single Lesion","PX-76002569","CDM","11106","CPT","0761","RC","","","","outpatient","","","1043.00","782.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","721.57","721.57","721.57","1 through 10","314.08","852.34","other","ASC"
"Incisional Biopsy Skin Single Lesion","PX-76002569","CDM","11106","CPT","0761","RC","","","","outpatient","","","1043.00","782.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","840.82","832.56","840.82","1 through 10","314.08","852.34","other","ASC "
"Incisional Biopsy Skin Single Lesion","PX-98301821","CDM","11106","CPT","0983","RC","","","","both","","","247.00","185.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","748.67","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","748.02","60.82","748.02","1 through 10","76.57","908.58","other","OPPS APC"
"Incisional Biopsy Skin Single Lesion","PX-98301821","CDM","11106","CPT","0983","RC","","","","both","","","247.00","185.25","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2180.82","726.94","2180.82","1 through 10","76.57","908.58","other","OPPS APC"
"Incisional Biopsy Skin Single Lesion","PX-98301821","CDM","11106","CPT","0983","RC","","","","both","","","247.00","185.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","94.60","38.3","","1185.90","1185.90","1185.90","1 through 10","76.57","908.58","percent of total billed charges",""
"Induced Abortion Dilation and Curettage","PX-98300788","CDM","59840","CPT","0983","RC","","","","both","","","983.00","737.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","376.49","38.3","","5557.68","1852.56","5557.68","22","304.73","4719.38","percent of total billed charges",""
"Induced Abortion Dilation and Curettage","PX-98300788","CDM","59840","CPT","0983","RC","","","","both","","","983.00","737.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3775.88","3775.88","3775.88","1 through 10","304.73","4719.38","other","OPPS APC"
"Induced Abortion Dilation and Curettage","PX-98300788","CDM","59840","CPT","0983","RC","","","","both","","","983.00","737.25","WELLPOINT [1015]","HB AMC WELLPOINT","725.26","73.78","","8265.44","3527.44","8265.44","1 through 10","304.73","4719.38","percent of total billed charges",""
"Induced Abortion Dilation and Curettage","PX-98300788","CDM","59840","CPT","0983","RC","","","","outpatient","","","983.00","737.25","AETNA [1001]","HB AMC AETNA PPO","790.33","80.4","","3695.64","3695.64","3695.64","1 through 10","549.5","9843.6","percent of total billed charges",""
"Induced Abortion Dilation and Curettage","PX-98300788","CDM","59840","CPT","0983","RC","","","","outpatient","","","983.00","737.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4738.00","4738.00","4738.00","1 through 10","549.5","9843.6","other","Multiple Surgery"
"Induced Abortion Dilation and Curettage","PX-98300788","CDM","59840","CPT","0983","RC","","","","outpatient","","","983.00","737.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","24651.60","4930.32","24651.60","1 through 10","549.5","9843.6","other","Multiple Surgery"
"Induced Abortion Dilation and Curettage","PX-98300788","CDM","59840","CPT","0983","RC","","","","outpatient","","","983.00","737.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5185.34","2507.93","15556.02","1 through 10","549.5","9843.6","other","Multiple Surgery"
"Induced Abortion Dilation and Curettage","PX-98300788","CDM","59840","CPT","0983","RC","","","","outpatient","","","983.00","737.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","10500.81","6162.91","10500.81","1 through 10","549.5","9843.6","other","Multiple Surgery"
"Induced Abortion Dilation and Curettage","PX-98300788","CDM","59840","CPT","0983","RC","","","","outpatient","","","983.00","737.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","803.31","81.72","","2083.30","2083.30","2083.30","1 through 10","549.5","9843.6","percent of total billed charges",""
"Induced Abortion Dilation and Curettage","PX-98300788","CDM","59840","CPT","0983","RC","","","","outpatient","","","983.00","737.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","803.31","81.72","","3787.56","2083.30","11350.00","1 through 10","549.5","9843.6","percent of total billed charges",""
"Induced Abortn by Dil/Evac","PX-98301585","CDM","59841","CPT","0983","RC","","","","both","","","1637.00","1227.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1301.42","79.5","","11254.00","3060.29","11254.00","1 through 10","507.47","4719.38","percent of total billed charges",""
"Induced Abortn by Dil/Evac","PX-98301585","CDM","59841","CPT","0983","RC","","","","both","","","1637.00","1227.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","872.52","53.3","","3060.29","3060.29","3060.29","1 through 10","507.47","4719.38","percent of total billed charges",""
"Induced Abortn by Dil/Evac","PX-98301585","CDM","59841","CPT","0983","RC","","","","both","","","1637.00","1227.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3715.47","3715.47","3715.47","1 through 10","507.47","4719.38","other","OPPS APC"
"Induced Abortn by Dil/Evac","PX-98301585","CDM","59841","CPT","0983","RC","","","","both","","","1637.00","1227.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","507.47","31","","3581.92","3581.92","3581.92","1 through 10","507.47","4719.38","percent of total billed charges",""
"Induced Abortn by Dil/Evac","PX-98301585","CDM","59841","CPT","0983","RC","","","","both","","","1637.00","1227.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","597.51","36.5","","6485.73","1837.33","6485.73","1 through 10","507.47","4719.38","percent of total billed charges",""
"Induced Abortn by Dil/Evac","PX-98301585","CDM","59841","CPT","0983","RC","","","","both","","","1637.00","1227.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","626.97","38.3","","2266.24","2202.48","6798.72","14","507.47","4719.38","percent of total billed charges",""
"Induced Abortn by Dil/Evac","PX-98301585","CDM","59841","CPT","0983","RC","","","","both","","","1637.00","1227.75","TRICARE [160005]","HB BWH TRICARE","3587.09","","APC Price ($3,775.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","5796.00","5796.00","5796.00","1 through 10","507.47","4719.38","other","Tricare OPPS"
"Induced Abortn by Dil/Evac","PX-98301585","CDM","59841","CPT","0983","RC","","","","both","","","1637.00","1227.75","WELLPOINT [1015]","HB AMC WELLPOINT","1207.78","73.78","","15907.12","10111.12","15907.12","1 through 10","507.47","4719.38","percent of total billed charges",""
"Induced Abortn by Dil/Evac","PX-98301585","CDM","59841","CPT","0983","RC","","","","outpatient","","","1637.00","1227.75","AETNA [1001]","HB AMC AETNA HMO","1142.63","69.8","","3923.89","2770.49","3923.89","1 through 10","915.08","9843.6","percent of total billed charges",""
"Induced Abortn by Dil/Evac","PX-98301585","CDM","59841","CPT","0983","RC","","","","outpatient","","","1637.00","1227.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","14790.96","4930.32","24651.60","12","915.08","9843.6","other","Multiple Surgery"
"Induced Abortn by Dil/Evac","PX-98301585","CDM","59841","CPT","0983","RC","","","","outpatient","","","1637.00","1227.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9988.16","5185.34","9988.16","1 through 10","915.08","9843.6","other","Multiple Surgery"
"Induced Abortn by Dil/Evac","PX-98301585","CDM","59841","CPT","0983","RC","","","","outpatient","","","1637.00","1227.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","5440.36","5227.84","5440.36","1 through 10","915.08","9843.6","other","Multiple Surgery"
"Induced Abortn by Dil/Evac","PX-98301585","CDM","59841","CPT","0983","RC","","","","outpatient","","","1637.00","1227.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1337.76","81.72","","4633.32","4633.32","5796.00","1 through 10","915.08","9843.6","percent of total billed charges",""
"Inf Agent Genotype Nuc Acid Cytomeg","PX-30001406","CDM","87910","CPT","0306","RC","","","","both","","","3434.00","2575.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2465.61","71.8","","2390.94","2390.94","2390.94","1 through 10","84.84","3262.3","percent of total billed charges",""
"Inf Agent Genotype Nuc Acid Cytomeg","PX-30001406","CDM","87910","CPT","0306","RC","","","","both","","","3434.00","2575.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2232.10","65","","2164.50","2164.50","2164.50","1 through 10","84.84","3262.3","percent of total billed charges",""
"Inf Agent Genotype Nuc Acid Cytomeg","PX-30001406","CDM","87910","CPT","0306","RC","","","","outpatient","","","3434.00","2575.50","AETNA [1001]","HB AMC AETNA HMO","2396.93","69.8","","2597.40","2597.40","2597.40","1 through 10","84.84","2806.26","percent of total billed charges",""
"Inf Agent Genotype Nuc Acid Cytomeg","PX-30001406","CDM","87910","CPT","0306","RC","","","","outpatient","","","3434.00","2575.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2806.26","81.72","","1124.18","1124.18","1124.18","1 through 10","84.84","2806.26","percent of total billed charges",""
"Inf Agent Genotype Nuc Acid Hep B","PX-30001407","CDM","87912","CPT","0306","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1611.66","38.3","","1595.67","1595.67","1595.67","1 through 10","84.84","3997.6","percent of total billed charges",""
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","both","","","4.60","3.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2.99","65","","4.97","4.97","4.97","1 through 10","1.43","6.32","percent of total billed charges",""
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","both","","","4.60","3.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1.43","31","","2.36","2.36","2.36","1 through 10","1.43","6.32","percent of total billed charges",""
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","both","","","4.60","3.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1.68","36.5","","2.85","2.85","8.55","16","1.43","6.32","percent of total billed charges",""
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","both","","","4.60","3.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1.76","38.3","","2.99","2.99","8.97","25","1.43","6.32","percent of total billed charges",""
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","both","","","4.60","3.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1.97","42.9","","5.38","5.38","5.38","1 through 10","1.43","6.32","percent of total billed charges",""
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","outpatient","","","4.60","3.45","AETNA [1001]","HB AMC AETNA HMO","3.21","69.8","","5.18","3.66","5.18","51","2.16","3.76","percent of total billed charges",""
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","outpatient","","","4.60","3.45","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","2.57","55.9","","4.01","4.01","4.01","1 through 10","2.16","3.76","percent of total billed charges",""
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","outpatient","","","4.60","3.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3.22","69.9","","5.30","3.55","5.77","1 through 10","2.16","3.76","percent of total billed charges",""
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","outpatient","","","4.60","3.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2.16","46.9","","10.65","3.86","16.62","11","2.16","3.76","percent of total billed charges",""
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","outpatient","","","4.60","3.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3.70","80.4","","5.97","5.97","5.97","1 through 10","2.16","3.76","percent of total billed charges",""
"Inf Normal Saline Sol 1,000 Cc","PX-63601267","CDM","J7030","HCPCS","0636","RC","","","","outpatient","","","4.60","3.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3.76","81.72","","5.38","5.31","5.78","1 through 10","2.16","3.76","percent of total billed charges",""
"Inf Nucleic Acid Virus 6-11 Targets","PX-30001403","CDM","87632","CPT","0306","RC","","","","both","","","3556.00","2667.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2553.21","71.8","","192.30","192.30","192.30","1 through 10","118.46","3378.2","percent of total billed charges",""
"Inf Nucleic Acid Virus 6-11 Targets","PX-30001403","CDM","87632","CPT","0306","RC","","","","both","","","3556.00","2667.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2332.74","65.6","","3448.00","3448.00","3448.00","1 through 10","118.46","3378.2","percent of total billed charges",""
"Inf Nucleic Acid Virus 6-11 Targets","PX-30001403","CDM","87632","CPT","0306","RC","","","","both","","","3556.00","2667.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1895.35","53.3","","1820.54","1820.54","1820.54","1 through 10","118.46","3378.2","percent of total billed charges",""
"Inf Nucleic Acid Virus 6-11 Targets","PX-30001403","CDM","87632","CPT","0306","RC","","","","both","","","3556.00","2667.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2311.40","65","","3235.05","3235.05","3235.05","1 through 10","118.46","3378.2","percent of total billed charges",""
"Inf Nucleic Acid Virus 6-11 Targets","PX-30001403","CDM","87632","CPT","0306","RC","","","","both","","","3556.00","2667.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1297.94","36.5","","1093.02","1093.02","1286.10","1 through 10","118.46","3378.2","percent of total billed charges",""
"Inf Nucleic Acid Virus 6-11 Targets","PX-30001403","CDM","87632","CPT","0306","RC","","","","both","","","3556.00","2667.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1361.95","38.3","","1348.17","1310.24","1348.17","14","118.46","3378.2","percent of total billed charges",""
"Inf Nucleic Acid Virus 6-11 Targets","PX-30001403","CDM","87632","CPT","0306","RC","","","","both","","","3556.00","2667.00","WELLPOINT [1015]","HB AMC WELLPOINT","2623.62","73.78","","2567.04","2567.04","2567.04","1 through 10","118.46","3378.2","percent of total billed charges",""
"Inf Nucleic Acid Virus 6-11 Targets","PX-30001403","CDM","87632","CPT","0306","RC","","","","outpatient","","","3556.00","2667.00","AETNA [1001]","HB AMC AETNA HMO","2482.09","69.8","","4668.60","4668.60","4668.60","1 through 10","118.46","2905.96","percent of total billed charges",""
"Inf Nucleic Acid Virus 6-11 Targets","PX-30001403","CDM","87632","CPT","0306","RC","","","","outpatient","","","3556.00","2667.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2905.96","81.72","","2756.33","967.53","3348.00","1 through 10","118.46","2905.96","percent of total billed charges",""
"Infections Of Upper Respiratory Tract,EXTREME","113","DRG","","","","","","","","inpatient","","","66578.56","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11874.5216","","Fee schedule rate ($46,572.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11874.5216","111225.92","111225.92","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,EXTREME","113","DRG","","","","","","","","inpatient","","","66578.56","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","8694.5172","","Fee schedule rate ($46,572.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8694.5172","111225.92","111225.92","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,EXTREME","113","DRG","","","","","","","","inpatient","","","66578.56","","MASSHEALTH [3001]","HB BWH MEDICAID","19122.06","","Case rate ($21,142.73). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,572.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21137.54","3275.98","21137.54","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,EXTREME","113","DRG","","","","","","","","inpatient","","","66578.56","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","49618.72","","Fee schedule rate ($49,618.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","49618.72","49618.72","49618.72","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","33707.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25081.13","","Standard inlier is a Case rate ($25,081.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,997, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,560.06) for the length of stay and the standard reimbursement.","22913.77","22913.77","22913.77","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","33707.33","","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","","38.3","","12456.74","12456.74","12456.74","1 through 10","3270.59","73184.6","percent of total billed charges",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","33707.33","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11308.7552","","Fee schedule rate ($17,508.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11308.7552","17508.88","17508.88","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","33707.33","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8280.2634","","Fee schedule rate ($17,508.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8280.2634","17508.88","17508.88","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","33707.33","","MASSHEALTH [3001]","HB BWH MEDICAID","8563.18","","Case rate ($9,468.06). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,898.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9465.74","9465.74","9465.74","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","33707.33","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24992.87","","Fee schedule rate ($24,992.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24992.87","24992.87","24992.87","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","33707.33","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8563.18","","Case rate ($9,468.06). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,898.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9465.74","9465.74","27471.32","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,MINOR","113","DRG","","","","","","","","inpatient","","","37894.27","","MASSHEALTH [3001]","HB BWH MEDICAID","3270.59","","Case rate ($3,616.20). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,046.20, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2728.54","2728.54","2728.54","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","24082.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","10374.99","","Standard inlier is a Case rate ($10,374.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $19,716, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,472.79) for the length of stay and the standard reimbursement.","20335.30","20335.30","20335.30","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","24082.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","11664.29","","Standard inlier is a Case rate ($11,664.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $19,716, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,655.65) for the length of stay and the standard reimbursement.","17212.82","15725.40","17212.82","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","24082.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16506.75","","Fee schedule rate ($16,506.75). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16506.75","16506.75","16506.75","1 through 10","3270.59","73184.6","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","24082.71","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","3270.59","","Case rate ($3,616.20). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,046.20, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5427.39","1415.84","5753.04","1 through 10","3270.59","73184.6","case rate",""
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","","","","inpatient","","","45242.30","33931.72","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9310.38","","Case rate ($9,310.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,130.45, add-ons for qualifying new technology services are included. If operating cost exceeds $56,774.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,227.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,142.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,750.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.76. The transfer capital threshold is the transfer adjustment factor * $787.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9373.10","9373.10","9373.10","1 through 10","9124.17","15335.06","other","Inpatient DRG"
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","","","","inpatient","","","45242.30","33931.72","MEDICARE [2001]","HB BWH MEDICARE","9310.38","","Case rate ($9,310.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,130.45, add-ons for qualifying new technology services are included. If operating cost exceeds $56,774.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,227.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,142.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,750.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.76. The transfer capital threshold is the transfer adjustment factor * $787.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12294.97","1090.50","12312.94","1 through 10","9124.17","15335.06","other","Inpatient Replacement Plans DRG"
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","","","","inpatient","","","45242.30","33931.72","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9124.17","","Case rate ($9,310.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,130.45, add-ons for qualifying new technology services are included. If operating cost exceeds $56,774.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,227.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,142.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,750.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.76. The transfer capital threshold is the transfer adjustment factor * $787.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9420.85","9420.85","9420.85","1 through 10","9124.17","15335.06","other","Inpatient DRG"
"Infections, Female Reproductive System With McC","757","MS-DRG","","","","","","","","inpatient","","","37852.94","28389.70","FALLON HEALTH [1008]","HB BWH MEDICARE","13441.80","","Case rate ($13,441.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,103.84, add-ons for qualifying new technology services are included. If operating cost exceeds $61,748.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,592.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,909.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,724.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,152.19. The transfer capital threshold is the transfer adjustment factor * $1,152.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12874.28","12874.28","12874.28","1 through 10","13172.96","21358.2923","other","Inpatient Replacement Plans DRG"
"Infections, Female Reproductive System With McC","757","MS-DRG","","","","","","","","inpatient","","","37852.94","28389.70","MEDICARE [2001]","HB BWH MEDICARE","13441.80","","Case rate ($13,441.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,103.84, add-ons for qualifying new technology services are included. If operating cost exceeds $61,748.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,592.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,909.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,724.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,152.19. The transfer capital threshold is the transfer adjustment factor * $1,152.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","48721.53","48721.53","48721.53","1 through 10","13172.96","21358.2923","other","Inpatient Replacement Plans DRG"
"Infections, Female Reproductive System Without Cc/McC","759","MS-DRG","","","","","","","","inpatient","","","33335.27","25001.45","MEDICARE [2001]","HB BWH MEDICARE","6433.27","","Case rate ($6,433.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,666.97, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,974.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,519.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,287.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.97. The transfer capital threshold is the transfer adjustment factor * $533.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7834.62","7834.62","7834.62","1 through 10","6304.6","9658.24","other","Inpatient Replacement Plans DRG"
"Infectious Agent Dna Detection for Central Nervous Syst Pathogen 12-25 Targets","PX-30003344","CDM","87483","CPT","0306","RC","","","","both","","","4159.00","3119.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2216.75","53.3","","3188.74","3173.97","3188.74","1 through 10","408.44","3951.05","percent of total billed charges",""
"Infectious Agent Dna Detection for Central Nervous Syst Pathogen 12-25 Targets","PX-30003344","CDM","87483","CPT","0306","RC","","","","both","","","4159.00","3119.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1518.04","36.5","","1459.95","1459.95","1459.95","1 through 10","408.44","3951.05","percent of total billed charges",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","284343.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","59543.02","","Standard inlier is a Case rate ($59,543.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,951, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,452.49) for the length of stay and the standard reimbursement.","141271.95","141271.95","241504.36","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","284343.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","66942.40","","Standard inlier is a Case rate ($66,942.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,951, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,501.92) for the length of stay and the standard reimbursement.","158827.75","145102.86","249724.52","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","284343.98","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","80816.45","80816.45","80816.45","1 through 10","12063.38","265933.56","percent of total billed charges",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","284343.98","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","169233.07","","Fee schedule rate ($169,233.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","170458.04","170458.04","170458.04","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","284343.98","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","161169.89","","Fee schedule rate ($161,169.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","161169.88","161169.88","161169.88","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","284343.98","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","169233.07","","Fee schedule rate ($169,233.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","169233.08","169233.08","169233.08","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","284343.98","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","198841.29","","Fee schedule rate ($198,841.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","201464.17","201464.17","201464.17","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","284343.98","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","177289.04","","Fee schedule rate ($177,289.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","212854.93","212854.93","212854.93","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","284343.98","","MASSHEALTH [3001]","HB BWH MEDICAID","20655.12","","Case rate ($22,837.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,267.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","62048.94","7864.87","125209.98","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","284343.98","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","20655.12","","Case rate ($22,837.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,267.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","1390.58","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","284343.98","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","20655.12","","Case rate ($22,837.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,267.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22832.18","2605.12","202769.78","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MAJOR","710","DRG","","","","","","","","inpatient","","","160632.38","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","76602.89","","Standard inlier is a Case rate ($76,602.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,216, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,874.24) for the length of stay and the standard reimbursement.","76602.89","76602.89","76602.89","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MAJOR","710","DRG","","","","","","","","inpatient","","","160632.38","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","86122.30","","Standard inlier is a Case rate ($86,122.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,216, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,224.34) for the length of stay and the standard reimbursement.","78680.15","78680.15","78680.15","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MAJOR","710","DRG","","","","","","","","inpatient","","","160632.38","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","78065.12","","Fee schedule rate ($78,065.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","169233.08","169233.08","169233.08","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MAJOR","710","DRG","","","","","","","","inpatient","","","160632.38","","MASSHEALTH [3001]","HB BWH MEDICAID","20367.24","","Case rate ($22,519.49). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,949.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8451.19","8451.19","20282.85","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MAJOR","710","DRG","","","","","","","","inpatient","","","160632.38","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77762.61","","Fee schedule rate ($77,762.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","77762.61","77762.61","77762.61","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MODERATE","710","DRG","","","","","","","","inpatient","","","55196.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","46755.38","","Standard inlier is a Case rate ($46,755.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,006, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,637.21) for the length of stay and the standard reimbursement.","21452.59","21452.59","21452.59","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MODERATE","710","DRG","","","","","","","","inpatient","","","55196.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","52565.65","","Standard inlier is a Case rate ($52,565.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,006, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,461.26) for the length of stay and the standard reimbursement.","48023.26","48023.26","48023.26","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MODERATE","710","DRG","","","","","","","","inpatient","","","55196.22","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","45088.42","","Fee schedule rate ($45,088.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","45088.44","45088.44","45088.44","1 through 10","12063.38","265933.56","case rate",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","105259.36","78944.52","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","19164.92","","Case rate ($18,606.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,321.41, add-ons for qualifying new technology services are included. If operating cost exceeds $67,965.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,047.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,619.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,941.57 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,607.79. The transfer capital threshold is the transfer adjustment factor * $1,607.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","25417.28","25417.28","25417.28","1 through 10","18234.59","30153.3271","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","105259.36","78944.52","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","18606.72","","Case rate ($18,606.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,321.41, add-ons for qualifying new technology services are included. If operating cost exceeds $67,965.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,047.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,619.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,941.57 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,607.79. The transfer capital threshold is the transfer adjustment factor * $1,607.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18190.20","18190.20","18190.20","1 through 10","18234.59","30153.3271","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","105259.36","78944.52","MEDICARE [2001]","HB BWH MEDICARE","18606.72","","Case rate ($18,606.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,321.41, add-ons for qualifying new technology services are included. If operating cost exceeds $67,965.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,047.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,619.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,941.57 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,607.79. The transfer capital threshold is the transfer adjustment factor * $1,607.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23834.21","23834.21","23869.44","1 through 10","18234.59","30153.3271","other","Inpatient Replacement Plans DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","105259.36","78944.52","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","18234.59","","Case rate ($18,606.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,321.41, add-ons for qualifying new technology services are included. If operating cost exceeds $67,965.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,047.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,619.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,941.57 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,607.79. The transfer capital threshold is the transfer adjustment factor * $1,607.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18073.71","18073.71","18073.71","1 through 10","18234.59","30153.3271","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","284910.59","213682.94","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","46793.19","","Case rate ($45,430.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,611.68, add-ons for qualifying new technology services are included. If operating cost exceeds $100,256.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,414.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $41,076.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,231.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,973.89. The transfer capital threshold is the transfer adjustment factor * $3,973.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","47014.63","44894.62","141137.89","1 through 10","44521.67","75474.6183","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","284910.59","213682.94","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","45430.28","","Case rate ($45,430.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,611.68, add-ons for qualifying new technology services are included. If operating cost exceeds $100,256.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,414.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $41,076.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,231.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,973.89. The transfer capital threshold is the transfer adjustment factor * $3,973.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","56958.67","45673.51","58367.01","1 through 10","44521.67","75474.6183","other","Inpatient Replacement Plans DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","284910.59","213682.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","","65.6","","406087.15","406087.15","406087.15","1 through 10","44521.67","75474.6183","percent of total billed charges",""
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","284910.59","213682.94","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","56787.85","","Case rate ($45,430.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,611.68, add-ons for qualifying new technology services are included. If operating cost exceeds $100,256.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,414.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $41,076.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,231.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,973.89. The transfer capital threshold is the transfer adjustment factor * $3,973.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","45911.24","45911.24","45911.24","1 through 10","44521.67","75474.6183","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","284910.59","213682.94","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","45430.28","","Case rate ($45,430.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,611.68, add-ons for qualifying new technology services are included. If operating cost exceeds $100,256.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,414.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $41,076.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,231.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,973.89. The transfer capital threshold is the transfer adjustment factor * $3,973.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","42839.74","42839.74","42839.74","1 through 10","44521.67","75474.6183","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","284910.59","213682.94","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10911.61","10911.61","10911.61","1 through 10","44521.67","75474.6183","case rate",""
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","284910.59","213682.94","FALLON HEALTH [1008]","HB BWH MEDICARE","45430.28","","Case rate ($45,430.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,611.68, add-ons for qualifying new technology services are included. If operating cost exceeds $100,256.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,414.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $41,076.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,231.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,973.89. The transfer capital threshold is the transfer adjustment factor * $3,973.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","44833.39","44833.39","44833.39","1 through 10","44521.67","75474.6183","other","Inpatient Replacement Plans DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","284910.59","213682.94","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","45430.28","","Case rate ($45,430.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,611.68, add-ons for qualifying new technology services are included. If operating cost exceeds $100,256.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,414.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $41,076.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,231.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,973.89. The transfer capital threshold is the transfer adjustment factor * $3,973.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","44999.35","44999.35","44999.35","1 through 10","44521.67","75474.6183","other","Inpatient Replacement Plans DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","284910.59","213682.94","MEDICARE [2001]","HB BWH MEDICARE","45430.28","","Case rate ($45,430.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,611.68, add-ons for qualifying new technology services are included. If operating cost exceeds $100,256.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,414.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $41,076.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,231.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,973.89. The transfer capital threshold is the transfer adjustment factor * $3,973.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","59239.38","0.03","91718.80","77","44521.67","75474.6183","other","Inpatient Replacement Plans DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","284910.59","213682.94","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","44521.67","","Case rate ($45,430.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,611.68, add-ons for qualifying new technology services are included. If operating cost exceeds $100,256.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,414.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $41,076.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,231.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,973.89. The transfer capital threshold is the transfer adjustment factor * $3,973.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","44793.70","44760.19","90925.06","1 through 10","44521.67","75474.6183","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","284910.59","213682.94","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","44521.67","","Case rate ($45,430.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,611.68, add-ons for qualifying new technology services are included. If operating cost exceeds $100,256.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,414.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $41,076.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,231.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,973.89. The transfer capital threshold is the transfer adjustment factor * $3,973.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","45027.52","41979.59","86104.97","16","44521.67","75474.6183","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","284910.59","213682.94","WELLPOINT [1015]","HB AMC WELLPOINT","75474.6183","","Fee schedule rate ($77,358.23).","75474.6183","212808.09","212808.09","1 through 10","44521.67","75474.6183","case rate",""
"Inflammation Of The Male Reproductive System With McC","727","MS-DRG","","","","","","","","inpatient","","","81269.96","60952.47","MEDICARE [2001]","HB BWH MEDICARE","13907.01","","Case rate ($13,907.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,663.88, add-ons for qualifying new technology services are included. If operating cost exceeds $62,308.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,633.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,333.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,284.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,193.23. The transfer capital threshold is the transfer adjustment factor * $1,193.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17601.27","17601.27","17601.27","1 through 10","13628.87","22174.7154","other","Inpatient Replacement Plans DRG"
"Inflammation Of The Male Reproductive System With McC","727","MS-DRG","","","","","","","","inpatient","","","81269.96","60952.47","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13628.87","","Case rate ($13,907.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,663.88, add-ons for qualifying new technology services are included. If operating cost exceeds $62,308.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,633.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,333.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,284.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,193.23. The transfer capital threshold is the transfer adjustment factor * $1,193.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13380.82","13380.82","13380.82","1 through 10","13628.87","22174.7154","other","Inpatient DRG"
"Inflammation Of The Male Reproductive System Without McC","728","MS-DRG","","","","","","","","inpatient","","","35668.34","26751.25","MEDICARE [2001]","HB BWH MEDICARE","9983.57","","Case rate ($9,983.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,287.80, add-ons for qualifying new technology services are included. If operating cost exceeds $54,932.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,092.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,951.00 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,907.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $652.74. The transfer capital threshold is the transfer adjustment factor * $652.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9911.21","9911.21","9925.63","1 through 10","7624.1","12330.8561","other","Inpatient DRG"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","","","","inpatient","","","54989.57","41242.18","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","9564.32","","Case rate ($9,285.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,100.80, add-ons for qualifying new technology services are included. If operating cost exceeds $56,745.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,225.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,120.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,720.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $785.59. The transfer capital threshold is the transfer adjustment factor * $785.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9635.11","9635.11","9635.11","1 through 10","9100.04","14977.8175","other","Inpatient DRG"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","","","","inpatient","","","54989.57","41242.18","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9285.75","","Case rate ($9,285.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,100.80, add-ons for qualifying new technology services are included. If operating cost exceeds $56,745.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,225.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,120.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,720.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $785.59. The transfer capital threshold is the transfer adjustment factor * $785.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11820.89","11820.89","11820.89","1 through 10","9100.04","14977.8175","other","Inpatient Replacement Plans DRG"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","","","","inpatient","","","54989.57","41242.18","MEDICARE [2001]","HB BWH MEDICARE","9285.75","","Case rate ($9,285.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,100.80, add-ons for qualifying new technology services are included. If operating cost exceeds $56,745.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,225.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,120.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,720.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $785.59. The transfer capital threshold is the transfer adjustment factor * $785.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11996.52","11979.02","11996.52","1 through 10","9100.04","14977.8175","other","Inpatient Replacement Plans DRG"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","","","","inpatient","","","54989.57","41242.18","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9100.04","","Case rate ($9,285.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,100.80, add-ons for qualifying new technology services are included. If operating cost exceeds $56,745.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,225.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,120.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,720.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $785.59. The transfer capital threshold is the transfer adjustment factor * $785.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9197.90","9197.90","9197.90","1 through 10","9100.04","14977.8175","other","Inpatient DRG"
"Inflammatory Bowel Disease With McC","385","MS-DRG","","","","","","","","inpatient","","","80655.40","60491.55","MEDICARE [2001]","HB BWH MEDICARE","19112.56","","Case rate ($19,112.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,755.41, add-ons for qualifying new technology services are included. If operating cost exceeds $63,399.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,713.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,459.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,375.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,273.21. The transfer capital threshold is the transfer adjustment factor * $1,273.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19433.31","0.03","22205.60","1 through 10","14517.47","24519.8568","other","Inpatient DRG"
"Inflammatory Bowel Disease Without Cc/McC","387","MS-DRG","","","","","","","","inpatient","","","32157.26","24117.94","MEDICARE [2001]","HB BWH MEDICARE","6594.73","","Case rate ($6,594.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,861.34, add-ons for qualifying new technology services are included. If operating cost exceeds $53,505.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,988.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $5,666.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,481.50 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.21. The transfer capital threshold is the transfer adjustment factor * $548.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8192.40","8192.40","8192.40","1 through 10","6462.84","10115.4973","other","Inpatient Replacement Plans DRG"
"Inflammatory Bowel Disease,EXTREME","245","DRG","","","","","","","","inpatient","","","64735.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","63462.74","","Standard inlier is a Case rate ($63,462.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $55,545, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,008.01) for the length of stay and the standard reimbursement.","57978.69","57978.69","57978.69","1 through 10","6022.55","91419.85","case rate",""
"Inflammatory Bowel Disease,EXTREME","245","DRG","","","","","","","","inpatient","","","64735.19","","MASSHEALTH [3001]","HB BWH MEDICAID","22745.65","","Case rate ($25,149.23). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $67,579.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25143.06","908.81","25143.06","1 through 10","6022.55","91419.85","case rate",""
"Inflammatory Bowel Disease,EXTREME","245","DRG","","","","","","","","inpatient","","","64735.19","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","22745.65","","Case rate ($25,149.23). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $67,579.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25143.05","25143.05","25143.05","1 through 10","6022.55","91419.85","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","79413.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","32305.42","","Standard inlier is a Case rate ($32,305.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,770, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,585.95) for the length of stay and the standard reimbursement.","32305.42","32305.42","32305.42","1 through 10","6022.55","91419.85","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","79413.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","36320.00","","Standard inlier is a Case rate ($36,320.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,770, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,155.32) for the length of stay and the standard reimbursement.","36320.00","33181.46","46267.90","1 through 10","6022.55","91419.85","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","79413.26","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14782.3503","","Fee schedule rate ($29,497.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14782.3503","28360.80","28360.80","1 through 10","6022.55","91419.85","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","79413.26","","MASSHEALTH [3001]","HB BWH MEDICAID","12747.66","","Case rate ($14,094.73). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,524.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2911.42","2911.42","14091.28","1 through 10","6022.55","91419.85","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","79413.26","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12747.66","","Case rate ($14,094.73). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,524.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1346.57","1346.57","14091.27","1 through 10","6022.55","91419.85","case rate",""
"Inflammatory Bowel Disease,MINOR","245","DRG","","","","","","","","inpatient","","","41364.33","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17812.20","","Fee schedule rate ($17,812.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2396), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20955.70","20955.70","20955.70","1 through 10","6022.55","91419.85","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","37676.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22519.04","","Standard inlier is a Case rate ($22,519.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,159, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,196.71) for the length of stay and the standard reimbursement.","22519.03","2605.55","22519.03","1 through 10","6022.55","91419.85","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","37676.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25317.47","","Standard inlier is a Case rate ($25,317.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,159, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,593.60) for the length of stay and the standard reimbursement.","25317.46","2929.33","33181.46","1 through 10","6022.55","91419.85","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","37676.49","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14782.3503","","Fee schedule rate ($18,217.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14782.3503","18217.92","18217.92","1 through 10","6022.55","91419.85","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","37676.49","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","15521.8974","","Fee schedule rate ($19,129.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15521.8974","19129.36","19129.36","1 through 10","6022.55","91419.85","case rate",""
"Infliximab Vl 10mg","PX-63600133","CDM","J1745","HCPCS","0636","RC","","","","both","","","269.37","202.03","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","31.09","","APC Price ($31.09).","30.04","30.03","31.58","382","29.62","207.41","other","OPPS APC"
"Infliximab Vl 10mg","PX-63600133","CDM","J1745","HCPCS","0636","RC","","","","both","","","269.37","202.03","MEDICARE [2001]","HB BWH MEDICARE","31.09","","APC Price ($31.09).","30.53","30.52","32.22","7303","29.62","207.41","other","OPPS APC"
"Infliximab Vl 10mg","PX-63600133","CDM","J1745","HCPCS","0636","RC","","","","both","","","269.37","202.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","98.32","36.5","","58.78","58.37","59.16","181","29.62","207.41","percent of total billed charges",""
"Infliximab Vl 10mg","PX-63600133","CDM","J1745","HCPCS","0636","RC","","","","both","","","269.37","202.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","103.17","38.3","","72.50","70.92","139.85","896","29.62","207.41","percent of total billed charges",""
"Infliximab Vl 10mg","PX-63600133","CDM","J1745","HCPCS","0636","RC","","","","both","","","269.37","202.03","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","30.47","","APC Price ($31.09). Final payment is multiplied by 98%.","30.04","29.91","91.67","898","29.62","207.41","other","OPPS APC"
"Infliximab Vl 10mg","PX-63600133","CDM","J1745","HCPCS","0636","RC","","","","both","","","269.37","202.03","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","30.47","","APC Price ($31.09). Final payment is multiplied by 98%.","31.58","29.92","31.58","244","29.62","207.41","other","OPPS APC"
"Infliximab Vl 10mg","PX-63600133","CDM","J1745","HCPCS","0636","RC","","","","outpatient","","","269.37","202.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","188.29","69.9","","128.49","127.26","288.76","1543","0.01","216.57","percent of total billed charges",""
"Infliximab Vl 10mg","PX-63600133","CDM","J1745","HCPCS","0636","RC","","","","outpatient","","","269.37","202.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","126.33","46.9","","128.49","85.44","284.47","955","0.01","216.57","percent of total billed charges",""
"INFRAPECTINEAL PLATE LG QUADRILATERAL SURFACE","SUP-ITM-10142554","CDM","C1713","HCPCS","0278","RC","","","","both","","","6016.78","4512.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4783.34","79.5","","800.18","480.96","1887.97","195","1865.2","4783.34","percent of total billed charges",""
"INFRAPECTINEAL PLATE LG QUADRILATERAL SURFACE","SUP-ITM-10142554","CDM","C1713","HCPCS","0278","RC","","","","both","","","6016.78","4512.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3206.94","53.3","","813.12","216.42","1444.50","81","1865.2","4783.34","percent of total billed charges",""
"INFRAPECTINEAL PLATE LG QUADRILATERAL SURFACE","SUP-ITM-10142554","CDM","C1713","HCPCS","0278","RC","","","","both","","","6016.78","4512.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1865.20","31","","432.60","432.60","432.60","1 through 10","1865.2","4783.34","percent of total billed charges",""
"INFRAPECTINEAL PLATE LG QUADRILATERAL SURFACE","SUP-ITM-10142554","CDM","C1713","HCPCS","0278","RC","","","","both","","","6016.78","4512.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2196.12","36.5","","148.37","54.89","631.39","94","1865.2","4783.34","percent of total billed charges",""
"INFRAPECTINEAL PLATE LG QUADRILATERAL SURFACE","SUP-ITM-10142554","CDM","C1713","HCPCS","0278","RC","","","","both","","","6016.78","4512.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2304.43","38.3","","279.30","91.72","1116.77","266","1865.2","4783.34","percent of total billed charges",""
"INFRAPECTINEAL PLATE LG QUADRILATERAL SURFACE","SUP-ITM-10142554","CDM","C1713","HCPCS","0278","RC","","","","both","","","6016.78","4512.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2581.20","42.9","","731.00","63.70","731.00","1 through 10","1865.2","4783.34","percent of total billed charges",""
"INFRAPECTINEAL PLATE LG QUADRILATERAL SURFACE","SUP-ITM-10142554","CDM","C1713","HCPCS","0278","RC","","","","both","","","6016.78","4512.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2581.20","42.9","","384.74","384.74","384.74","1 through 10","1865.2","4783.34","percent of total billed charges",""
"INFRAPECTINEAL PLATE LG QUADRILATERAL SURFACE","SUP-ITM-10142554","CDM","C1713","HCPCS","0278","RC","","","","both","","","6016.78","4512.58","WELLPOINT [1015]","HB AMC WELLPOINT","4439.18","73.78","","286.63","119.22","1107.45","105","1865.2","4783.34","percent of total billed charges",""
"INFRAPECTINEAL PLATE LG QUADRILATERAL SURFACE","SUP-ITM-10142554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6016.78","4512.58","AETNA [1001]","HB AMC AETNA HMO","4199.71","69.8","","675.31","184.75","1721.50","286","3144.37","4916.91","percent of total billed charges",""
"INFRAPECTINEAL PLATE LG QUADRILATERAL SURFACE","SUP-ITM-10142554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6016.78","4512.58","AETNA [1001]","HB AMC AETNA PPO","4837.49","80.4","","1261.44","103.12","1514.10","21","3144.37","4916.91","percent of total billed charges",""
"INFRAPECTINEAL PLATE LG QUADRILATERAL SURFACE","SUP-ITM-10142554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6016.78","4512.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4837.49","80.4","","1365.00","1365.00","1365.00","1 through 10","3144.37","4916.91","percent of total billed charges",""
"INFRAPECTINEAL PLATE LG QUADRILATERAL SURFACE","SUP-ITM-10142554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6016.78","4512.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4916.91","81.72","","5157.68","5157.68","5157.68","1 through 10","3144.37","4916.91","percent of total billed charges",""
"INFRAPECTINEAL PLATE LG QUADRILATERAL SURFACE","SUP-ITM-10142554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6016.78","4512.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4916.91","81.72","","431.26","71.26","1459.57","88","3144.37","4916.91","percent of total billed charges",""
"INFRAPECTINEAL PLATE SM QUADRILATERAL SURFACE LEFT 425932S","SUP-ITM-10133225","CDM","C1713","HCPCS","0278","RC","","","","both","","","5470.78","4103.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4349.27","79.5","","800.18","480.96","1887.97","195","1695.94","4349.27","percent of total billed charges",""
"INFRAPECTINEAL PLATE SM QUADRILATERAL SURFACE LEFT 425932S","SUP-ITM-10133225","CDM","C1713","HCPCS","0278","RC","","","","both","","","5470.78","4103.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2915.93","53.3","","813.12","216.42","1444.50","81","1695.94","4349.27","percent of total billed charges",""
"INFRAPECTINEAL PLATE SM QUADRILATERAL SURFACE LEFT 425932S","SUP-ITM-10133225","CDM","C1713","HCPCS","0278","RC","","","","both","","","5470.78","4103.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1695.94","31","","432.60","432.60","432.60","1 through 10","1695.94","4349.27","percent of total billed charges",""
"INFRAPECTINEAL PLATE SM QUADRILATERAL SURFACE LEFT 425932S","SUP-ITM-10133225","CDM","C1713","HCPCS","0278","RC","","","","both","","","5470.78","4103.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1996.83","36.5","","148.37","54.89","631.39","94","1695.94","4349.27","percent of total billed charges",""
"INFRAPECTINEAL PLATE SM QUADRILATERAL SURFACE LEFT 425932S","SUP-ITM-10133225","CDM","C1713","HCPCS","0278","RC","","","","both","","","5470.78","4103.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2095.31","38.3","","279.30","91.72","1116.77","266","1695.94","4349.27","percent of total billed charges",""
"INFRAPECTINEAL PLATE SM QUADRILATERAL SURFACE LEFT 425932S","SUP-ITM-10133225","CDM","C1713","HCPCS","0278","RC","","","","both","","","5470.78","4103.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2346.96","42.9","","731.00","63.70","731.00","1 through 10","1695.94","4349.27","percent of total billed charges",""
"INFRAPECTINEAL PLATE SM QUADRILATERAL SURFACE LEFT 425932S","SUP-ITM-10133225","CDM","C1713","HCPCS","0278","RC","","","","both","","","5470.78","4103.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2346.96","42.9","","384.74","384.74","384.74","1 through 10","1695.94","4349.27","percent of total billed charges",""
"INFRAPECTINEAL PLATE SM QUADRILATERAL SURFACE LEFT 425932S","SUP-ITM-10133225","CDM","C1713","HCPCS","0278","RC","","","","both","","","5470.78","4103.08","WELLPOINT [1015]","HB AMC WELLPOINT","4036.34","73.78","","286.63","119.22","1107.45","105","1695.94","4349.27","percent of total billed charges",""
"INFRAPECTINEAL PLATE SM QUADRILATERAL SURFACE LEFT 425932S","SUP-ITM-10133225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5470.78","4103.08","AETNA [1001]","HB AMC AETNA HMO","3818.60","69.8","","675.31","184.75","1721.50","286","2859.03","4470.72","percent of total billed charges",""
"INFRAPECTINEAL PLATE SM QUADRILATERAL SURFACE LEFT 425932S","SUP-ITM-10133225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5470.78","4103.08","AETNA [1001]","HB AMC AETNA PPO","4398.51","80.4","","1261.44","103.12","1514.10","21","2859.03","4470.72","percent of total billed charges",""
"INFRAPECTINEAL PLATE SM QUADRILATERAL SURFACE LEFT 425932S","SUP-ITM-10133225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5470.78","4103.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4398.51","80.4","","1365.00","1365.00","1365.00","1 through 10","2859.03","4470.72","percent of total billed charges",""
"INFRAPECTINEAL PLATE SM QUADRILATERAL SURFACE LEFT 425932S","SUP-ITM-10133225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5470.78","4103.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4470.72","81.72","","5157.68","5157.68","5157.68","1 through 10","2859.03","4470.72","percent of total billed charges",""
"INFRAPECTINEAL PLATE SM QUADRILATERAL SURFACE LEFT 425932S","SUP-ITM-10133225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5470.78","4103.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4470.72","81.72","","431.26","71.26","1459.57","88","2859.03","4470.72","percent of total billed charges",""
"Infusion Pump Programmable Implantable T1","PX-27000090","CDM","C1772","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","22036.00","22036.00","22036.00","1 through 10","434","1113","percent of total billed charges",""
"Infusion Pump Programmable Implantable T1","PX-27000090","CDM","C1772","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","14140.00","14140.00","14140.00","1 through 10","434","1113","percent of total billed charges",""
"Infusion Pump Programmable Implantable T1","PX-27000090","CDM","C1772","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","13384.00","13272.00","13384.00","1 through 10","731.64","1144.08","percent of total billed charges",""
"Infusion Pump Programmable Implantable T1","PX-27000090","CDM","C1772","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","22383.20","22383.20","22383.20","1 through 10","731.64","1144.08","percent of total billed charges",""
"Infusion Pump Programmable Implantable T3","PX-27000091","CDM","C1772","HCPCS","0278","RC","","","","both","","","25200.00","18900.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20034.00","79.5","","22036.00","22036.00","22036.00","1 through 10","7812","20034","percent of total billed charges",""
"Infusion Pump Programmable Implantable T3","PX-27000091","CDM","C1772","HCPCS","0278","RC","","","","both","","","25200.00","18900.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13431.60","53.3","","14140.00","14140.00","14140.00","1 through 10","7812","20034","percent of total billed charges",""
"Infusion Pump Programmable Implantable T3","PX-27000091","CDM","C1772","HCPCS","0278","RC","","","","outpatient","","","25200.00","18900.00","AETNA [1001]","HB AMC AETNA HMO","17589.60","69.8","","13384.00","13272.00","13384.00","1 through 10","13169.52","20593.44","percent of total billed charges",""
"Infusion Pump Programmable Implantable T3","PX-27000091","CDM","C1772","HCPCS","0278","RC","","","","outpatient","","","25200.00","18900.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","20593.44","81.72","","22383.20","22383.20","22383.20","1 through 10","13169.52","20593.44","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-92000135","CDM","95079","CPT","0924","RC","","","","both","","","412.00","309.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","327.54","79.5","","314.80","301.60","314.80","1 through 10","127.72","327.54","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-92000135","CDM","95079","CPT","0924","RC","","","","both","","","412.00","309.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","219.60","53.3","","211.20","211.20","211.20","1 through 10","127.72","327.54","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-92000135","CDM","95079","CPT","0924","RC","","","","both","","","412.00","309.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","150.38","36.5","","149.20","126.80","149.20","1 through 10","127.72","327.54","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-92000135","CDM","95079","CPT","0924","RC","","","","both","","","412.00","309.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.80","38.3","","156.40","152.00","469.20","26","127.72","327.54","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-92000135","CDM","95079","CPT","0924","RC","","","","both","","","412.00","309.00","WELLPOINT [1015]","HB AMC WELLPOINT","303.97","73.78","","297.80","297.80","297.80","1 through 10","127.72","327.54","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-92000135","CDM","95079","CPT","0924","RC","","","","outpatient","","","412.00","309.00","AETNA [1001]","HB AMC AETNA HMO","287.58","69.8","","270.80","191.20","312.00","1 through 10","215.31","336.69","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-92000135","CDM","95079","CPT","0924","RC","","","","outpatient","","","412.00","309.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","336.69","81.72","","319.76","175.88","319.76","1 through 10","215.31","336.69","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-98302593","CDM","95079","CPT","0983","RC","","","","both","","","289.00","216.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","229.76","79.5","","314.80","301.60","314.80","1 through 10","89.59","229.76","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-98302593","CDM","95079","CPT","0983","RC","","","","both","","","289.00","216.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","154.04","53.3","","211.20","211.20","211.20","1 through 10","89.59","229.76","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-98302593","CDM","95079","CPT","0983","RC","","","","both","","","289.00","216.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.49","36.5","","149.20","126.80","149.20","1 through 10","89.59","229.76","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-98302593","CDM","95079","CPT","0983","RC","","","","both","","","289.00","216.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","110.69","38.3","","156.40","152.00","469.20","26","89.59","229.76","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-98302593","CDM","95079","CPT","0983","RC","","","","both","","","289.00","216.75","WELLPOINT [1015]","HB AMC WELLPOINT","213.22","73.78","","297.80","297.80","297.80","1 through 10","89.59","229.76","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-98302593","CDM","95079","CPT","0983","RC","","","","outpatient","","","289.00","216.75","AETNA [1001]","HB AMC AETNA HMO","201.72","69.8","","270.80","191.20","312.00","1 through 10","161.55","236.17","percent of total billed charges",""
"Ingestion Challenge Test Each Addl 60 Minutes","PX-98302593","CDM","95079","CPT","0983","RC","","","","outpatient","","","289.00","216.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","236.17","81.72","","319.76","175.88","319.76","1 through 10","161.55","236.17","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","648.96","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","648.40","648.40","649.30","1 through 10","340.07","872.12","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","620.04","620.04","1 through 10","340.07","872.12","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","719.63","65.6","","720.33","720.33","829.92","1 through 10","340.07","872.12","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","872.12","79.5","","837.37","561.79","837.37","20","340.07","872.12","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","584.70","53.3","","561.79","561.79","837.37","14","340.07","872.12","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","HUMANA [1012]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","576.79","576.79","622.71","1 through 10","340.07","872.12","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","MEDICARE [2001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","630.12","111","340.07","872.12","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","400.41","36.5","","396.87","337.29","649.36","23","340.07","872.12","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","420.15","38.3","","416.02","416.02","1248.06","85","340.07","872.12","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","617.92","617.52","617.92","1 through 10","340.07","872.12","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","TRICARE [160005]","HB BWH TRICARE","598.61","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","630.12","630.12","630.12","1 through 10","340.07","872.12","other","Tricare OPPS"
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1852.56","618.12","1852.56","13","340.07","872.12","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","470.61","42.9","","850.56","850.56","850.56","1 through 10","340.07","872.12","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","618.02","574.29","620.75","1 through 10","340.07","872.12","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","both","","","1097.00","822.75","WELLPOINT [1015]","HB AMC WELLPOINT","809.37","73.78","","792.15","792.15","1856.15","16","340.07","872.12","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","outpatient","","","1097.00","822.75","AETNA [1001]","HB AMC AETNA HMO","765.71","69.8","","720.33","508.59","829.92","38","573.29","2287.66","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","outpatient","","","1097.00","822.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","573.29","52.26","","1206.82","1206.82","1206.82","1 through 10","573.29","2287.66","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-92000134","CDM","95076","CPT","0924","RC","","","","outpatient","","","1097.00","822.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","896.47","81.72","","850.56","850.56","850.56","25","573.29","2287.66","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","648.96","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","648.40","648.40","649.30","1 through 10","97.34","787.57","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","620.04","620.04","1 through 10","97.34","787.57","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","205.98","65.6","","720.33","720.33","829.92","1 through 10","97.34","787.57","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","249.63","79.5","","837.37","561.79","837.37","20","97.34","787.57","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.36","53.3","","561.79","561.79","837.37","14","97.34","787.57","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","HUMANA [1012]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","576.79","576.79","622.71","1 through 10","97.34","787.57","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","MEDICARE [2001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","630.12","111","97.34","787.57","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.61","36.5","","396.87","337.29","649.36","23","97.34","787.57","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.26","38.3","","416.02","416.02","1248.06","85","97.34","787.57","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","617.92","617.52","617.92","1 through 10","97.34","787.57","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","TRICARE [160005]","HB BWH TRICARE","598.61","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","630.12","630.12","630.12","1 through 10","97.34","787.57","other","Tricare OPPS"
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1852.56","618.12","1852.56","13","97.34","787.57","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.71","42.9","","850.56","850.56","850.56","1 through 10","97.34","787.57","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","618.02","574.29","620.75","1 through 10","97.34","787.57","other","OPPS APC"
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","both","","","314.00","235.50","WELLPOINT [1015]","HB AMC WELLPOINT","231.67","73.78","","792.15","792.15","1856.15","16","97.34","787.57","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","outpatient","","","314.00","235.50","AETNA [1001]","HB AMC AETNA HMO","219.17","69.8","","720.33","508.59","829.92","38","175.53","2287.66","percent of total billed charges",""
"Ingestion Challenge Test Initial 120 Minutes","PX-98302592","CDM","95076","CPT","0983","RC","","","","outpatient","","","314.00","235.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","256.60","81.72","","850.56","850.56","850.56","25","175.53","2287.66","percent of total billed charges",""
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","","","","inpatient","","","79966.04","59974.53","MEDICARE [2001]","HB BWH MEDICARE","18428.29","","Case rate ($18,428.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,120.70, add-ons for qualifying new technology services are included. If operating cost exceeds $62,765.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $16,821.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,740.86 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,226.70. The transfer capital threshold is the transfer adjustment factor * $1,226.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18041.59","18041.59","18041.59","1 through 10","14000.77","22704.4095","other","Inpatient DRG"
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","","","","inpatient","","","79966.04","59974.53","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14000.77","","Case rate ($14,286.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,120.70, add-ons for qualifying new technology services are included. If operating cost exceeds $62,765.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,666.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $12,679.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,740.86 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,226.70. The transfer capital threshold is the transfer adjustment factor * $1,226.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18374.44","18374.44","18374.44","1 through 10","14000.77","22704.4095","other","Inpatient DRG"
"Inguinal And Femoral Hernia Procedures With McC","350","MS-DRG","","","","","","","","inpatient","","","126296.40","94722.30","MEDICARE [2001]","HB BWH MEDICARE","23111.22","","Case rate ($23,111.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,743.93, add-ons for qualifying new technology services are included. If operating cost exceeds $73,388.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,445.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $20,726.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,364.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,005.13. The transfer capital threshold is the transfer adjustment factor * $2,005.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28792.70","28792.70","28792.70","1 through 10","22649","36500.6017","other","Inpatient Replacement Plans DRG"
"Inguinal And Femoral Hernia Procedures Without Cc/McC","352","MS-DRG","","","","","","","","inpatient","","","73981.84","55486.38","MEDICARE [2001]","HB BWH MEDICARE","14205.33","","Case rate ($14,205.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,203.70, add-ons for qualifying new technology services are included. If operating cost exceeds $58,848.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,379.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,885.82 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,823.86 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $939.68. The transfer capital threshold is the transfer adjustment factor * $939.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13277.02","13277.02","13277.02","1 through 10","10811.98","16639.3366","other","Inpatient DRG"
"Inguinal And Femoral Hernia Procedures Without Cc/McC","352","MS-DRG","","","","","","","","inpatient","","","73981.84","55486.38","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10811.98","","Case rate ($11,032.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,203.70, add-ons for qualifying new technology services are included. If operating cost exceeds $58,848.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,379.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $9,713.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,823.86 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $939.68. The transfer capital threshold is the transfer adjustment factor * $939.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10101.89","10101.89","10101.89","1 through 10","10811.98","16639.3366","other","Inpatient DRG"
"Inguinal, Femoral And Umbilical Hernia Procedures,MAJOR","228","DRG","","","","","","","","inpatient","","","87819.77","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","56048.94","","Standard inlier is a Case rate ($56,048.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,416, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,955.68) for the length of stay and the standard reimbursement.","56048.94","56048.94","56048.94","1 through 10","6697.69","91836.89","case rate",""
"Inguinal, Femoral And Umbilical Hernia Procedures,MAJOR","228","DRG","","","","","","","","inpatient","","","87819.77","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","12864.18","","Case rate ($14,223.57). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,653.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8662.18","8662.18","8662.18","1 through 10","6697.69","91836.89","case rate",""
"Inguinal, Femoral And Umbilical Hernia Procedures,MAJOR","228","DRG","","","","","","","","inpatient","","","87819.77","","MASSHEALTH [3001]","HB BWH MEDICAID","12864.18","","Case rate ($14,223.57). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,653.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","66.33","66.33","66.33","1 through 10","6697.69","91836.89","case rate",""
"Inguinal, Femoral And Umbilical Hernia Procedures,MINOR","228","DRG","","","","","","","","inpatient","","","55369.11","","MASSHEALTH [3001]","HB BWH MEDICAID","6697.69","","Case rate ($7,405.45). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,835.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7403.64","7403.64","7403.64","1 through 10","6697.69","91836.89","case rate",""
"Inguinal, Femoral And Umbilical Hernia Procedures,MINOR","228","DRG","","","","","","","","inpatient","","","55369.11","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6697.69","","Case rate ($7,405.45). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,835.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7403.63","7403.63","7403.63","1 through 10","6697.69","91836.89","case rate",""
"Inguinal, Femoral And Umbilical Hernia Procedures,MODERATE","228","DRG","","","","","","","","inpatient","","","81557.02","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","41159.52","","Standard inlier is a Case rate ($41,159.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,117, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,842.25) for the length of stay and the standard reimbursement.","37602.77","37602.77","37602.77","1 through 10","6697.69","91836.89","case rate",""
"Inguinal, Femoral And Umbilical Hernia Procedures,MODERATE","228","DRG","","","","","","","","inpatient","","","81557.02","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15652.4266","","Fee schedule rate ($21,760.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15652.4266","21760.84","21760.84","1 through 10","6697.69","91836.89","case rate",""
"Inguinal, Femoral And Umbilical Hernia Procedures,MODERATE","228","DRG","","","","","","","","inpatient","","","81557.02","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","22552.6461","","Fee schedule rate ($21,760.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22552.6461","21760.84","21760.84","1 through 10","6697.69","91836.89","case rate",""
"Inguinal, Femoral And Umbilical Hernia Procedures,MODERATE","228","DRG","","","","","","","","inpatient","","","81557.02","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37077.53","","Fee schedule rate ($37,077.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37077.53","37077.53","37077.53","1 through 10","6697.69","91836.89","case rate",""
"Inhibin A","PX-30000840","CDM","86336","CPT","0302","RC","","","","both","","","186.00","139.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","99.14","53.3","","141.66","95.04","141.66","1 through 10","15.28","176.7","percent of total billed charges",""
"Inhibin A","PX-30000840","CDM","86336","CPT","0302","RC","","","","both","","","186.00","139.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.89","36.5","","67.14","67.14","67.14","1 through 10","15.28","176.7","percent of total billed charges",""
"Inhibin A","PX-30000840","CDM","86336","CPT","0302","RC","","","","both","","","186.00","139.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71.24","38.3","","70.38","68.40","70.38","1 through 10","15.28","176.7","percent of total billed charges",""
"Inhibin A","PX-30000840","CDM","86336","CPT","0302","RC","","","","outpatient","","","186.00","139.50","AETNA [1001]","HB AMC AETNA HMO","129.83","69.8","","86.04","86.04","86.04","1 through 10","16.07","152","percent of total billed charges",""
"Inhibin A","PX-30000840","CDM","86336","CPT","0302","RC","","","","outpatient","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","152.00","81.72","","79.15","64.26","143.89","1 through 10","16.07","152","percent of total billed charges",""
"Init/Sbsq Psych Care Mgmt 1st 30 Min","PX-51000645","CDM","G2214","HCPCS","0510","RC","","","","both","","","181.00","135.75","MEDICARE [2001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","1 through 10","56.11","139.37","other","OPPS APC"
"Init/Sbsq Psych Care Mgmt 1st 30 Min","PX-51000645","CDM","G2214","HCPCS","0510","RC","","","","both","","","181.00","135.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.95","39.89","40.95","1 through 10","56.11","139.37","other","OPPS APC"
"Init/Sbsq Psych Care Mgmt 1st 30 Min","PX-51000645","CDM","G2214","HCPCS","0510","RC","","","","both","","","181.00","135.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","66.07","36.5","","55.79","55.79","55.79","1 through 10","56.11","139.37","percent of total billed charges",""
"Init/Sbsq Psych Care Mgmt 1st 30 Min","PX-51000645","CDM","G2214","HCPCS","0510","RC","","","","both","","","181.00","135.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","69.32","38.3","","68.82","64.12","68.82","1 through 10","56.11","139.37","percent of total billed charges",""
"Init/Sbsq Psych Care Mgmt 1st 30 Min","PX-51000645","CDM","G2214","HCPCS","0510","RC","","","","both","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","108.16","108.09","108.26","1 through 10","56.11","139.37","other","OPPS APC"
"Init/Sbsq Psych Care Mgmt 1st 30 Min","PX-51000645","CDM","G2214","HCPCS","0510","RC","","","","both","","","181.00","135.75","WELLPOINT [1015]","HB AMC WELLPOINT","133.54","73.78","","122.10","122.10","122.10","1 through 10","56.11","139.37","percent of total billed charges",""
"Init/Sbsq Psych Care Mgmt 1st 30 Min","PX-51000645","CDM","G2214","HCPCS","0510","RC","","","","outpatient","","","181.00","135.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","90.50","50","","92.22","85.94","92.22","1 through 10","40.19","149.33","percent of total billed charges",""
"Init/Sub Psych Care M 1st 30","PX-98302022","CDM","G2214","HCPCS","0983","RC","","","","both","","","166.00","124.50","MEDICARE [2001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","1 through 10","51.46","137.3","other","OPPS APC"
"Init/Sub Psych Care M 1st 30","PX-98302022","CDM","G2214","HCPCS","0983","RC","","","","both","","","166.00","124.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.95","39.89","40.95","1 through 10","51.46","137.3","other","OPPS APC"
"Init/Sub Psych Care M 1st 30","PX-98302022","CDM","G2214","HCPCS","0983","RC","","","","both","","","166.00","124.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.59","36.5","","55.79","55.79","55.79","1 through 10","51.46","137.3","percent of total billed charges",""
"Init/Sub Psych Care M 1st 30","PX-98302022","CDM","G2214","HCPCS","0983","RC","","","","both","","","166.00","124.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.58","38.3","","68.82","64.12","68.82","1 through 10","51.46","137.3","percent of total billed charges",""
"Init/Sub Psych Care M 1st 30","PX-98302022","CDM","G2214","HCPCS","0983","RC","","","","both","","","166.00","124.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","108.16","108.09","108.26","1 through 10","51.46","137.3","other","OPPS APC"
"Init/Sub Psych Care M 1st 30","PX-98302022","CDM","G2214","HCPCS","0983","RC","","","","both","","","166.00","124.50","WELLPOINT [1015]","HB AMC WELLPOINT","122.47","73.78","","122.10","122.10","122.10","1 through 10","51.46","137.3","percent of total billed charges",""
"Init/Sub Psych Care M 1st 30","PX-98302022","CDM","G2214","HCPCS","0983","RC","","","","outpatient","","","166.00","124.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","83.00","50","","92.22","85.94","92.22","1 through 10","83","136.95","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","3966.26","other","OPPS APC"
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","3966.26","other","OPPS APC"
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2659.14","53.3","","477.31","477.31","477.31","1 through 10","333.03","3966.26","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","3966.26","other","OPPS APC"
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","3966.26","other","OPPS APC"
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1820.99","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","3966.26","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1910.79","38.3","","343.52","323.76","353.46","1 through 10","333.03","3966.26","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","3966.26","other","Tricare OPPS"
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","3966.26","other","OPPS APC"
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","3966.26","other","OPPS APC"
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","WELLPOINT [1015]","HB AMC WELLPOINT","3680.88","73.78","","673.03","673.03","673.03","1 through 10","333.03","3966.26","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","outpatient","","","4989.00","3741.75","AETNA [1001]","HB AMC AETNA HMO","3482.32","69.8","","612.01","612.01","1224.02","1 through 10","700.33","4115.93","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","outpatient","","","4989.00","3741.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3020.84","60.55","","579.04","568.57","904.00","30","700.33","4115.93","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","outpatient","","","4989.00","3741.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2605.26","52.22","","904.00","656.02","2938.00","26","700.33","4115.93","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","outpatient","","","4989.00","3741.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2494.50","50","","1421.10","875.08","2368.50","15","700.33","4115.93","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","outpatient","","","4989.00","3741.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2619.23","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","4115.93","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Cont Inf via Cath","PX-76002910","CDM","64999","CPT","0761","RC","","","","outpatient","","","4989.00","3741.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4077.01","81.72","","722.66","722.66","17449.00","1 through 10","700.33","4115.93","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","925.38","other","OPPS APC"
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","925.38","other","OPPS APC"
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","620.41","53.3","","477.31","477.31","477.31","1 through 10","333.03","925.38","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","925.38","other","OPPS APC"
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","925.38","other","OPPS APC"
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","424.86","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","925.38","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","445.81","38.3","","343.52","323.76","353.46","1 through 10","333.03","925.38","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","925.38","other","Tricare OPPS"
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","925.38","other","OPPS APC"
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","925.38","other","OPPS APC"
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","WELLPOINT [1015]","HB AMC WELLPOINT","858.80","73.78","","673.03","673.03","673.03","1 through 10","333.03","925.38","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","outpatient","","","1164.00","873.00","AETNA [1001]","HB AMC AETNA HMO","812.47","69.8","","612.01","612.01","1224.02","1 through 10","582","960.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","outpatient","","","1164.00","873.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","704.80","60.55","","579.04","568.57","904.00","30","582","960.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","outpatient","","","1164.00","873.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","607.84","52.22","","904.00","656.02","2938.00","26","582","960.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","outpatient","","","1164.00","873.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","582.00","50","","1421.10","875.08","2368.50","15","582","960.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","outpatient","","","1164.00","873.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","611.10","52.5","","2985.00","904.00","2985.00","1 through 10","582","960.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Fascia Iliaca; Single Shot","PX-76002909","CDM","64999","CPT","0761","RC","","","","outpatient","","","1164.00","873.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","951.22","81.72","","722.66","722.66","17449.00","1 through 10","582","960.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","both","","","2161.00","1620.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1718","other","OPPS APC"
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","both","","","2161.00","1620.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1718","other","OPPS APC"
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","both","","","2161.00","1620.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1151.81","53.3","","477.31","477.31","477.31","1 through 10","333.03","1718","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","both","","","2161.00","1620.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1718","other","OPPS APC"
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","both","","","2161.00","1620.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1718","other","OPPS APC"
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","both","","","2161.00","1620.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","788.77","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1718","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","both","","","2161.00","1620.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","827.66","38.3","","343.52","323.76","353.46","1 through 10","333.03","1718","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","both","","","2161.00","1620.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1718","other","Tricare OPPS"
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","both","","","2161.00","1620.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1718","other","OPPS APC"
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","both","","","2161.00","1620.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1718","other","OPPS APC"
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","both","","","2161.00","1620.75","WELLPOINT [1015]","HB AMC WELLPOINT","1594.39","73.78","","673.03","673.03","673.03","1 through 10","333.03","1718","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","outpatient","","","2161.00","1620.75","AETNA [1001]","HB AMC AETNA HMO","1508.38","69.8","","612.01","612.01","1224.02","1 through 10","700.33","1782.83","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","outpatient","","","2161.00","1620.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1308.49","60.55","","579.04","568.57","904.00","30","700.33","1782.83","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","outpatient","","","2161.00","1620.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1128.47","52.22","","904.00","656.02","2938.00","26","700.33","1782.83","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","outpatient","","","2161.00","1620.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1080.50","50","","1421.10","875.08","2368.50","15","700.33","1782.83","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","outpatient","","","2161.00","1620.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1134.53","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","1782.83","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Cont Inf via Cath","PX-76002908","CDM","64999","CPT","0761","RC","","","","outpatient","","","2161.00","1620.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1765.97","81.72","","722.66","722.66","17449.00","1 through 10","700.33","1782.83","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","both","","","2204.00","1653.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1752.18","other","OPPS APC"
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","both","","","2204.00","1653.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1752.18","other","OPPS APC"
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","both","","","2204.00","1653.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1174.73","53.3","","477.31","477.31","477.31","1 through 10","333.03","1752.18","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","both","","","2204.00","1653.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1752.18","other","OPPS APC"
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","both","","","2204.00","1653.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1752.18","other","OPPS APC"
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","both","","","2204.00","1653.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","804.46","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1752.18","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","both","","","2204.00","1653.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","844.13","38.3","","343.52","323.76","353.46","1 through 10","333.03","1752.18","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","both","","","2204.00","1653.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1752.18","other","Tricare OPPS"
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","both","","","2204.00","1653.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1752.18","other","OPPS APC"
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","both","","","2204.00","1653.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1752.18","other","OPPS APC"
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","both","","","2204.00","1653.00","WELLPOINT [1015]","HB AMC WELLPOINT","1626.11","73.78","","673.03","673.03","673.03","1 through 10","333.03","1752.18","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","outpatient","","","2204.00","1653.00","AETNA [1001]","HB AMC AETNA HMO","1538.39","69.8","","612.01","612.01","1224.02","1 through 10","700.33","1818.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","outpatient","","","2204.00","1653.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1334.52","60.55","","579.04","568.57","904.00","30","700.33","1818.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","outpatient","","","2204.00","1653.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1150.93","52.22","","904.00","656.02","2938.00","26","700.33","1818.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","outpatient","","","2204.00","1653.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1102.00","50","","1421.10","875.08","2368.50","15","700.33","1818.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","outpatient","","","2204.00","1653.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1157.10","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","1818.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Ipack; Single Shot(S)","PX-76002907","CDM","64999","CPT","0761","RC","","","","outpatient","","","2204.00","1653.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1801.11","81.72","","722.66","722.66","17449.00","1 through 10","700.33","1818.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","627.87","53.3","","477.31","477.31","477.31","1 through 10","333.03","936.51","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","429.97","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","936.51","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","451.17","38.3","","343.52","323.76","353.46","1 through 10","333.03","936.51","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","936.51","other","Tricare OPPS"
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","WELLPOINT [1015]","HB AMC WELLPOINT","869.13","73.78","","673.03","673.03","673.03","1 through 10","333.03","936.51","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","AETNA [1001]","HB AMC AETNA HMO","822.24","69.8","","612.01","612.01","1224.02","1 through 10","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","713.28","60.55","","579.04","568.57","904.00","30","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","615.15","52.22","","904.00","656.02","2938.00","26","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","589.00","50","","1421.10","875.08","2368.50","15","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","618.45","52.5","","2985.00","904.00","2985.00","1 through 10","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","962.66","81.72","","722.66","722.66","17449.00","1 through 10","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","689.17","53.3","","477.31","477.31","477.31","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","471.95","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","495.22","38.3","","343.52","323.76","353.46","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1027.94","other","Tricare OPPS"
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","WELLPOINT [1015]","HB AMC WELLPOINT","953.98","73.78","","673.03","673.03","673.03","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","AETNA [1001]","HB AMC AETNA HMO","902.51","69.8","","612.01","612.01","1224.02","1 through 10","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","782.91","60.55","","579.04","568.57","904.00","30","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","675.20","52.22","","904.00","656.02","2938.00","26","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","646.50","50","","1421.10","875.08","2368.50","15","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","678.83","52.5","","2985.00","904.00","2985.00","1 through 10","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1056.64","81.72","","722.66","722.66","17449.00","1 through 10","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1946.96","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1946.96","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.32","53.3","","477.31","477.31","477.31","1 through 10","333.03","1946.96","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1946.96","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1946.96","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","893.89","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1946.96","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","937.97","38.3","","343.52","323.76","353.46","1 through 10","333.03","1946.96","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1946.96","other","Tricare OPPS"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1946.96","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1946.96","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","WELLPOINT [1015]","HB AMC WELLPOINT","1806.87","73.78","","673.03","673.03","673.03","1 through 10","333.03","1946.96","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","outpatient","","","2449.00","1836.75","AETNA [1001]","HB AMC AETNA HMO","1709.40","69.8","","612.01","612.01","1224.02","1 through 10","700.33","2020.43","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","outpatient","","","2449.00","1836.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1482.87","60.55","","579.04","568.57","904.00","30","700.33","2020.43","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","outpatient","","","2449.00","1836.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1278.87","52.22","","904.00","656.02","2938.00","26","700.33","2020.43","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","outpatient","","","2449.00","1836.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1224.50","50","","1421.10","875.08","2368.50","15","700.33","2020.43","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","outpatient","","","2449.00","1836.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1285.73","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","2020.43","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Addl Level","PX-76002912","CDM","64999","CPT","0761","RC","","","","outpatient","","","2449.00","1836.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2001.32","81.72","","722.66","722.66","17449.00","1 through 10","700.33","2020.43","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","627.87","53.3","","477.31","477.31","477.31","1 through 10","333.03","936.51","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","429.97","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","936.51","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","451.17","38.3","","343.52","323.76","353.46","1 through 10","333.03","936.51","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","936.51","other","Tricare OPPS"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","WELLPOINT [1015]","HB AMC WELLPOINT","869.13","73.78","","673.03","673.03","673.03","1 through 10","333.03","936.51","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","AETNA [1001]","HB AMC AETNA HMO","822.24","69.8","","612.01","612.01","1224.02","1 through 10","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","713.28","60.55","","579.04","568.57","904.00","30","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","615.15","52.22","","904.00","656.02","2938.00","26","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","589.00","50","","1421.10","875.08","2368.50","15","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","618.45","52.5","","2985.00","904.00","2985.00","1 through 10","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Cont Inf via Cath","PX-76002913","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","962.66","81.72","","722.66","722.66","17449.00","1 through 10","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","689.17","53.3","","477.31","477.31","477.31","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","471.95","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","495.22","38.3","","343.52","323.76","353.46","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1027.94","other","Tricare OPPS"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","WELLPOINT [1015]","HB AMC WELLPOINT","953.98","73.78","","673.03","673.03","673.03","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","AETNA [1001]","HB AMC AETNA HMO","902.51","69.8","","612.01","612.01","1224.02","1 through 10","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","782.91","60.55","","579.04","568.57","904.00","30","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","675.20","52.22","","904.00","656.02","2938.00","26","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","646.50","50","","1421.10","875.08","2368.50","15","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","678.83","52.5","","2985.00","904.00","2985.00","1 through 10","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecto-Intercostal Fascial Plane (Pifb); Single Level","PX-76002911","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1056.64","81.72","","722.66","722.66","17449.00","1 through 10","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","3966.26","other","OPPS APC"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","3966.26","other","OPPS APC"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2659.14","53.3","","477.31","477.31","477.31","1 through 10","333.03","3966.26","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","3966.26","other","OPPS APC"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","3966.26","other","OPPS APC"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1820.99","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","3966.26","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1910.79","38.3","","343.52","323.76","353.46","1 through 10","333.03","3966.26","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","3966.26","other","Tricare OPPS"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","3966.26","other","OPPS APC"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","3966.26","other","OPPS APC"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","both","","","4989.00","3741.75","WELLPOINT [1015]","HB AMC WELLPOINT","3680.88","73.78","","673.03","673.03","673.03","1 through 10","333.03","3966.26","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","outpatient","","","4989.00","3741.75","AETNA [1001]","HB AMC AETNA HMO","3482.32","69.8","","612.01","612.01","1224.02","1 through 10","700.33","4115.93","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","outpatient","","","4989.00","3741.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3020.84","60.55","","579.04","568.57","904.00","30","700.33","4115.93","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","outpatient","","","4989.00","3741.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2605.26","52.22","","904.00","656.02","2938.00","26","700.33","4115.93","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","outpatient","","","4989.00","3741.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2494.50","50","","1421.10","875.08","2368.50","15","700.33","4115.93","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","outpatient","","","4989.00","3741.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2619.23","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","4115.93","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Cont Inf via Cath","PX-76002906","CDM","64999","CPT","0761","RC","","","","outpatient","","","4989.00","3741.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4077.01","81.72","","722.66","722.66","17449.00","1 through 10","700.33","4115.93","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","925.38","other","OPPS APC"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","925.38","other","OPPS APC"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","620.41","53.3","","477.31","477.31","477.31","1 through 10","333.03","925.38","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","925.38","other","OPPS APC"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","925.38","other","OPPS APC"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","424.86","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","925.38","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","445.81","38.3","","343.52","323.76","353.46","1 through 10","333.03","925.38","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","925.38","other","Tricare OPPS"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","925.38","other","OPPS APC"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","925.38","other","OPPS APC"
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","both","","","1164.00","873.00","WELLPOINT [1015]","HB AMC WELLPOINT","858.80","73.78","","673.03","673.03","673.03","1 through 10","333.03","925.38","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","outpatient","","","1164.00","873.00","AETNA [1001]","HB AMC AETNA HMO","812.47","69.8","","612.01","612.01","1224.02","1 through 10","582","960.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","outpatient","","","1164.00","873.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","704.80","60.55","","579.04","568.57","904.00","30","582","960.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","outpatient","","","1164.00","873.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","607.84","52.22","","904.00","656.02","2938.00","26","582","960.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","outpatient","","","1164.00","873.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","582.00","50","","1421.10","875.08","2368.50","15","582","960.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","outpatient","","","1164.00","873.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","611.10","52.5","","2985.00","904.00","2985.00","1 through 10","582","960.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Peng(Pericapsular Nerve Group); Single Shot","PX-76002905","CDM","64999","CPT","0761","RC","","","","outpatient","","","1164.00","873.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","951.22","81.72","","722.66","722.66","17449.00","1 through 10","582","960.3","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","both","","","538.00","403.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","166.78","438.15","other","OPPS APC"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","both","","","538.00","403.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","166.78","438.15","other","OPPS APC"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","both","","","538.00","403.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","286.75","53.3","","477.31","477.31","477.31","1 through 10","166.78","438.15","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","both","","","538.00","403.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","166.78","438.15","other","OPPS APC"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","both","","","538.00","403.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","166.78","438.15","other","OPPS APC"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","both","","","538.00","403.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","196.37","36.5","","1095.87","337.19","1095.87","1 through 10","166.78","438.15","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","both","","","538.00","403.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","206.05","38.3","","343.52","323.76","353.46","1 through 10","166.78","438.15","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","both","","","538.00","403.50","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","166.78","438.15","other","Tricare OPPS"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","both","","","538.00","403.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","166.78","438.15","other","OPPS APC"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","both","","","538.00","403.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","166.78","438.15","other","OPPS APC"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","both","","","538.00","403.50","WELLPOINT [1015]","HB AMC WELLPOINT","396.94","73.78","","673.03","673.03","673.03","1 through 10","166.78","438.15","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","outpatient","","","538.00","403.50","AETNA [1001]","HB AMC AETNA HMO","375.52","69.8","","612.01","612.01","1224.02","1 through 10","269","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","outpatient","","","538.00","403.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","325.76","60.55","","579.04","568.57","904.00","30","269","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","outpatient","","","538.00","403.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","280.94","52.22","","904.00","656.02","2938.00","26","269","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","outpatient","","","538.00","403.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","269.00","50","","1421.10","875.08","2368.50","15","269","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","outpatient","","","538.00","403.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","282.45","52.5","","2985.00","904.00","2985.00","1 through 10","269","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Bilateral","PX-76002918","CDM","64999","CPT","0761","RC","","","","outpatient","","","538.00","403.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","439.65","81.72","","722.66","722.66","17449.00","1 through 10","269","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","both","","","432.00","324.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","133.92","438.15","other","OPPS APC"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","both","","","432.00","324.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","133.92","438.15","other","OPPS APC"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","both","","","432.00","324.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","230.26","53.3","","477.31","477.31","477.31","1 through 10","133.92","438.15","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","both","","","432.00","324.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","133.92","438.15","other","OPPS APC"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","both","","","432.00","324.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","133.92","438.15","other","OPPS APC"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","both","","","432.00","324.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","157.68","36.5","","1095.87","337.19","1095.87","1 through 10","133.92","438.15","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","both","","","432.00","324.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","165.46","38.3","","343.52","323.76","353.46","1 through 10","133.92","438.15","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","both","","","432.00","324.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","133.92","438.15","other","Tricare OPPS"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","both","","","432.00","324.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","133.92","438.15","other","OPPS APC"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","both","","","432.00","324.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","133.92","438.15","other","OPPS APC"
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","both","","","432.00","324.00","WELLPOINT [1015]","HB AMC WELLPOINT","318.73","73.78","","673.03","673.03","673.03","1 through 10","133.92","438.15","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","outpatient","","","432.00","324.00","AETNA [1001]","HB AMC AETNA HMO","301.54","69.8","","612.01","612.01","1224.02","1 through 10","216","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","outpatient","","","432.00","324.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","261.58","60.55","","579.04","568.57","904.00","30","216","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","outpatient","","","432.00","324.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","225.59","52.22","","904.00","656.02","2938.00","26","216","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","outpatient","","","432.00","324.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","216.00","50","","1421.10","875.08","2368.50","15","216","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","outpatient","","","432.00","324.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","226.80","52.5","","2985.00","904.00","2985.00","1 through 10","216","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Quadratus Lumborum; Single Shot, Unilateral","PX-76002917","CDM","64999","CPT","0761","RC","","","","outpatient","","","432.00","324.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","353.03","81.72","","722.66","722.66","17449.00","1 through 10","216","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","both","","","567.00","425.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","175.77","450.77","other","OPPS APC"
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","both","","","567.00","425.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","175.77","450.77","other","OPPS APC"
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","both","","","567.00","425.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","302.21","53.3","","477.31","477.31","477.31","1 through 10","175.77","450.77","percent of total billed charges",""
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","both","","","567.00","425.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","175.77","450.77","other","OPPS APC"
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","both","","","567.00","425.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","175.77","450.77","other","OPPS APC"
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","both","","","567.00","425.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","206.96","36.5","","1095.87","337.19","1095.87","1 through 10","175.77","450.77","percent of total billed charges",""
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","both","","","567.00","425.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","217.16","38.3","","343.52","323.76","353.46","1 through 10","175.77","450.77","percent of total billed charges",""
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","both","","","567.00","425.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","175.77","450.77","other","Tricare OPPS"
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","both","","","567.00","425.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","175.77","450.77","other","OPPS APC"
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","both","","","567.00","425.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","175.77","450.77","other","OPPS APC"
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","both","","","567.00","425.25","WELLPOINT [1015]","HB AMC WELLPOINT","418.33","73.78","","673.03","673.03","673.03","1 through 10","175.77","450.77","percent of total billed charges",""
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","outpatient","","","567.00","425.25","AETNA [1001]","HB AMC AETNA HMO","395.77","69.8","","612.01","612.01","1224.02","1 through 10","283.5","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","outpatient","","","567.00","425.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","343.32","60.55","","579.04","568.57","904.00","30","283.5","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","outpatient","","","567.00","425.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","296.09","52.22","","904.00","656.02","2938.00","26","283.5","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","outpatient","","","567.00","425.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","283.50","50","","1421.10","875.08","2368.50","15","283.5","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","outpatient","","","567.00","425.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","297.68","52.5","","2985.00","904.00","2985.00","1 through 10","283.5","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Retrolaminar; Cont Inf via Cath","PX-76002920","CDM","64999","CPT","0761","RC","","","","outpatient","","","567.00","425.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","463.35","81.72","","722.66","722.66","17449.00","1 through 10","283.5","700.33","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1946.96","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1946.96","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.32","53.3","","477.31","477.31","477.31","1 through 10","333.03","1946.96","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1946.96","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1946.96","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","893.89","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1946.96","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","937.97","38.3","","343.52","323.76","353.46","1 through 10","333.03","1946.96","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1946.96","other","Tricare OPPS"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1946.96","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1946.96","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","both","","","2449.00","1836.75","WELLPOINT [1015]","HB AMC WELLPOINT","1806.87","73.78","","673.03","673.03","673.03","1 through 10","333.03","1946.96","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","outpatient","","","2449.00","1836.75","AETNA [1001]","HB AMC AETNA HMO","1709.40","69.8","","612.01","612.01","1224.02","1 through 10","700.33","2020.43","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","outpatient","","","2449.00","1836.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1482.87","60.55","","579.04","568.57","904.00","30","700.33","2020.43","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","outpatient","","","2449.00","1836.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1278.87","52.22","","904.00","656.02","2938.00","26","700.33","2020.43","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","outpatient","","","2449.00","1836.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1224.50","50","","1421.10","875.08","2368.50","15","700.33","2020.43","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","outpatient","","","2449.00","1836.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1285.73","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","2020.43","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Addl Level","PX-76002915","CDM","64999","CPT","0761","RC","","","","outpatient","","","2449.00","1836.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2001.32","81.72","","722.66","722.66","17449.00","1 through 10","700.33","2020.43","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","627.87","53.3","","477.31","477.31","477.31","1 through 10","333.03","936.51","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","429.97","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","936.51","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","451.17","38.3","","343.52","323.76","353.46","1 through 10","333.03","936.51","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","936.51","other","Tricare OPPS"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","936.51","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","both","","","1178.00","883.50","WELLPOINT [1015]","HB AMC WELLPOINT","869.13","73.78","","673.03","673.03","673.03","1 through 10","333.03","936.51","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","AETNA [1001]","HB AMC AETNA HMO","822.24","69.8","","612.01","612.01","1224.02","1 through 10","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","713.28","60.55","","579.04","568.57","904.00","30","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","615.15","52.22","","904.00","656.02","2938.00","26","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","589.00","50","","1421.10","875.08","2368.50","15","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","618.45","52.5","","2985.00","904.00","2985.00","1 through 10","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Cont Inf via Cath","PX-76002916","CDM","64999","CPT","0761","RC","","","","outpatient","","","1178.00","883.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","962.66","81.72","","722.66","722.66","17449.00","1 through 10","589","971.85","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","689.17","53.3","","477.31","477.31","477.31","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","471.95","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","495.22","38.3","","343.52","323.76","353.46","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1027.94","other","Tricare OPPS"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1027.94","other","OPPS APC"
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","WELLPOINT [1015]","HB AMC WELLPOINT","953.98","73.78","","673.03","673.03","673.03","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","AETNA [1001]","HB AMC AETNA HMO","902.51","69.8","","612.01","612.01","1224.02","1 through 10","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","782.91","60.55","","579.04","568.57","904.00","30","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","675.20","52.22","","904.00","656.02","2938.00","26","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","646.50","50","","1421.10","875.08","2368.50","15","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","678.83","52.5","","2985.00","904.00","2985.00","1 through 10","646.5","1066.73","percent of total billed charges",""
"Inj Anes/Ther Agent, Serratus Fascial Plane; Single Level","PX-76002914","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1056.64","81.72","","722.66","722.66","17449.00","1 through 10","646.5","1066.73","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","both","","","122.83","92.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","80.58","65.6","","0.96","0.96","0.96","1 through 10","38.08","97.65","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","both","","","122.83","92.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","85.98","70","","4.45","1.98","14.99","1 through 10","38.08","97.65","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","both","","","122.83","92.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","97.65","79.5","","414.25","7.38","1891.33","1713","38.08","97.65","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","both","","","122.83","92.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","65.47","53.3","","6.50","1.93","26.16","91","38.08","97.65","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","both","","","122.83","92.12","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","94.58","77","","4.84","4.84","4.84","1 through 10","38.08","97.65","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","both","","","122.83","92.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","79.84","65","","11.15","6.10","14.62","1 through 10","38.08","97.65","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","both","","","122.83","92.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","97.65","79.5","","0.59","0.59","1.48","1 through 10","38.08","97.65","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","both","","","122.83","92.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","38.08","31","","0.83","0.83","0.83","1 through 10","38.08","97.65","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","both","","","122.83","92.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.83","36.5","","2.33","0.78","11.19","64","38.08","97.65","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","both","","","122.83","92.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","47.04","38.3","","3.61","0.89","16.20","213","38.08","97.65","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","both","","","122.83","92.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","94.58","77","","9.22","3.56","12.86","1 through 10","38.08","97.65","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","both","","","122.83","92.12","WELLPOINT [1015]","HB AMC WELLPOINT","90.62","73.78","","5.23","1.33","24.91","47","38.08","97.65","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","122.83","92.12","AETNA [1001]","HB AMC AETNA HMO","85.74","69.8","","6.04","1.31","22.28","143","61.42","101.33","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","122.83","92.12","AETNA [1001]","HB AMC AETNA PPO","98.76","80.4","","4.95","1.52","30.51","1 through 10","61.42","101.33","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","122.83","92.12","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","64.49","52.5","","533.60","0.69","533.60","1 through 10","61.42","101.33","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","122.83","92.12","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","61.42","50","","4.92","1.04","22.14","217","61.42","101.33","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","122.83","92.12","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","64.49","52.5","","11.25","1.46","33.02","97","61.42","101.33","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","122.83","92.12","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","76.77","62.5","","4.81","4.81","4.81","1 through 10","61.42","101.33","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","122.83","92.12","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","67.56","55","","9.85","1.05","154.76","17","61.42","101.33","percent of total billed charges",""
"Inj Arginie (R-Gene)","PX-63601110","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","122.83","92.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","98.76","80.4","","8.31","5.24","14.69","13","61.42","101.33","percent of total billed charges",""
"Inj Bleomycin Sulfate per 15 Units","PX-63601291","CDM","J9040","HCPCS","0636","RC","","","","outpatient","","","113.99","85.49","AETNA [1001]","HB AMC AETNA HMO","79.57","69.8","","22.14","22.14","22.14","1 through 10","44.94","91.65","percent of total billed charges",""
"Inj Bupivicaine Hcl per 30 Ml","PX-63601266","CDM","S0020","HCPCS","0636","RC","","","","both","","","2.74","2.05","WELLPOINT [1015]","HB AMC WELLPOINT","2.02","73.78","","7.85","7.85","7.85","1 through 10","0.85","2.18","percent of total billed charges",""
"Inj Cntr W/Fluor Evl G/D/J/G-J/C TB","PX-75000306","CDM","49465","CPT","0761","RC","","","","both","","","582.00","436.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","287.06","287.06","287.06","1 through 10","180.42","462.69","other","OPPS APC"
"Inj Cntr W/Fluor Evl G/D/J/G-J/C TB","PX-75000306","CDM","49465","CPT","0761","RC","","","","both","","","582.00","436.50","WELLPOINT [1015]","HB AMC WELLPOINT","429.40","73.78","","419.90","419.90","419.90","1 through 10","180.42","462.69","percent of total billed charges",""
"Inj Cntr W/Fluor Evl G/D/J/G-J/C TB","PX-75000306","CDM","49465","CPT","0761","RC","","","","outpatient","","","582.00","436.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","263.66","","Case rate ($263.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","617.23","611.16","617.23","1 through 10","263.66","883.04","other","ASC "
"Inj Dx/Ther Agnt Paravt Facet Jnt,Img Guide,Lumbar/Sac,1st Level","PX-98300847","CDM","64493","CPT","0983","RC","","","","both","","","453.00","339.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","241.45","53.3","","1218.10","1218.10","1218.10","1 through 10","140.43","1627.62","percent of total billed charges",""
"Inj Dx/Ther Agnt Paravt Facet Jnt,Img Guide,Lumbar/Sac,1st Level","PX-98300847","CDM","64493","CPT","0983","RC","","","","both","","","453.00","339.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1561.70","1462.38","1562.10","24","140.43","1627.62","other","OPPS APC"
"Inj Dx/Ther Agnt Paravt Facet Jnt,Img Guide,Lumbar/Sac,1st Level","PX-98300847","CDM","64493","CPT","0983","RC","","","","outpatient","","","453.00","339.75","AETNA [1001]","HB AMC AETNA HMO","316.19","69.8","","1102.75","1102.75","1102.75","1 through 10","194.34","4218.09","percent of total billed charges",""
"Inj Dx/Ther Agnt Paravt Facet Jnt,Img Guide,Lumbar/Sac,1st Level","PX-98300847","CDM","64493","CPT","0983","RC","","","","outpatient","","","453.00","339.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1866.21","1797.37","1866.21","1 through 10","194.34","4218.09","other","Multiple Surgery"
"Inj Dx/Ther Agnt Paravt Facet Jnt,Img Guide,Lumbar/Sac,1st Level","PX-98300847","CDM","64493","CPT","0983","RC","","","","outpatient","","","453.00","339.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2936.99","2936.99","2936.99","1 through 10","194.34","4218.09","other","Multiple Surgery"
"Inj Dx/Ther Agnt Paravt Facet Jnt,Img Guide,Lumbar/Sac,1st Level|BILATERAL PROCEDURE","PX-98300847","CDM","64493","CPT","0983","RC","","","50","both","","","453.00","339.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1088.88","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1632.81","1632.81","1635.24","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Dx/Ther Agnt Paravt Facet Jnt,Img Guide,Lumbar/Sac,1st Level|BILATERAL PROCEDURE","PX-98300847","CDM","64493","CPT","0983","RC","","","50","both","","","453.00","339.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4614.00","1560.54","4614.00","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Dx/Ther Agnt Paravt Facet Jnt,Img Guide,Lumbar/Sac,1st Level|BILATERAL PROCEDURE","PX-98300847","CDM","64493","CPT","0983","RC","","","50","both","","","453.00","339.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1560.54","1462.38","1560.54","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Dx/Ther Agnt Paravt Facet Jnt,Img Guide,Lumbar/Sac,1st Level|BILATERAL PROCEDURE","PX-98300847","CDM","64493","CPT","0983","RC","","","50","both","","","453.00","339.75","MEDICARE [2001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1585.91","1492.21","1585.91","13","1004.41","1321.46","other","OPPS APC"
"Inj Dx/Ther Agnt Paravt Facet Jnt,Img Guide,Lumbar/Sac,1st Level|BILATERAL PROCEDURE","PX-98300847","CDM","64493","CPT","0983","RC","","","50","both","","","453.00","339.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1554.19","1462.37","1554.19","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Dx/Ther Agnt Paravt Facet Jnt,Img Guide,Lumbar/Sac,1st Level|BILATERAL PROCEDURE","PX-98300847","CDM","64493","CPT","0983","RC","","","50","both","","","453.00","339.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1561.99","1557.19","2940.36","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Dx/Ther Agnt Paravt Facet Jnt,Img Guide,Lumbar/Sac,1st Level|BILATERAL PROCEDURE","PX-98300847","CDM","64493","CPT","0983","RC","","","50","both","","","453.00","339.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1462.38","1294.84","1585.91","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","both","","","0.09","0.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.07","79.5","","0.02","0.01","0.37","3151","0.03","0.07","percent of total billed charges",""
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","both","","","0.09","0.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.05","53.3","","0.01","0.01","0.02","960","0.03","0.07","percent of total billed charges",""
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","both","","","0.09","0.07","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","0.07","77","","0.02","0.02","0.02","80","0.03","0.07","percent of total billed charges",""
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","both","","","0.09","0.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.03","36.5","","0.01","0.01","0.01","160","0.03","0.07","percent of total billed charges",""
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","both","","","0.09","0.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.03","38.3","","0.01","0.01","0.01","960","0.03","0.07","percent of total billed charges",""
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","both","","","0.09","0.07","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.07","77","","0.03","0.03","0.03","80","0.03","0.07","percent of total billed charges",""
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","both","","","0.09","0.07","WELLPOINT [1015]","HB AMC WELLPOINT","0.07","73.78","","0.02","0.02","0.02","1600","0.03","0.07","percent of total billed charges",""
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","outpatient","","","0.09","0.07","AETNA [1001]","HB AMC AETNA HMO","0.06","69.8","","0.02","0.01","0.02","2924","0.02","0.07","percent of total billed charges",""
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","outpatient","","","0.09","0.07","AETNA [1001]","HB AMC AETNA PPO","0.07","80.4","","0.02","0.01","0.02","160","0.02","0.07","percent of total billed charges",""
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","outpatient","","","0.09","0.07","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","0.05","52.5","","0.02","0.02","0.02","80","0.02","0.07","percent of total billed charges",""
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","outpatient","","","0.09","0.07","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.05","50","","0.04","0.01","0.29","1524","0.02","0.07","percent of total billed charges",""
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","outpatient","","","0.09","0.07","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.05","52.5","","0.01","0.01","0.01","404","0.02","0.07","percent of total billed charges",""
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","outpatient","","","0.09","0.07","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","0.05","52.5","","0.01","0.01","0.01","80","0.02","0.07","percent of total billed charges",""
"Inj Famotidine 0.25 Mg","PX-63601461","CDM","J1308","HCPCS","0636","RC","","","","outpatient","","","0.09","0.07","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","0.05","55","","1.57","0.99","1.57","1 through 10","0.02","0.07","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","both","","","7.14","5.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4.68","65.6","","0.96","0.96","0.96","1 through 10","2.21","5.68","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","both","","","7.14","5.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","5.00","70","","4.45","1.98","14.99","1 through 10","2.21","5.68","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","both","","","7.14","5.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5.68","79.5","","414.25","7.38","1891.33","1713","2.21","5.68","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","both","","","7.14","5.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3.81","53.3","","6.50","1.93","26.16","91","2.21","5.68","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","both","","","7.14","5.35","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","5.50","77","","4.84","4.84","4.84","1 through 10","2.21","5.68","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","both","","","7.14","5.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4.64","65","","11.15","6.10","14.62","1 through 10","2.21","5.68","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","both","","","7.14","5.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","5.68","79.5","","0.59","0.59","1.48","1 through 10","2.21","5.68","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","both","","","7.14","5.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2.21","31","","0.83","0.83","0.83","1 through 10","2.21","5.68","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","both","","","7.14","5.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2.61","36.5","","2.33","0.78","11.19","64","2.21","5.68","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","both","","","7.14","5.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2.73","38.3","","3.61","0.89","16.20","213","2.21","5.68","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","both","","","7.14","5.35","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","5.50","77","","9.22","3.56","12.86","1 through 10","2.21","5.68","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","both","","","7.14","5.35","WELLPOINT [1015]","HB AMC WELLPOINT","5.27","73.78","","5.23","1.33","24.91","47","2.21","5.68","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","7.14","5.35","AETNA [1001]","HB AMC AETNA HMO","4.98","69.8","","6.04","1.31","22.28","143","3.57","5.89","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","7.14","5.35","AETNA [1001]","HB AMC AETNA PPO","5.74","80.4","","4.95","1.52","30.51","1 through 10","3.57","5.89","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","7.14","5.35","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","3.75","52.5","","533.60","0.69","533.60","1 through 10","3.57","5.89","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","7.14","5.35","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3.57","50","","4.92","1.04","22.14","217","3.57","5.89","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","7.14","5.35","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3.75","52.5","","11.25","1.46","33.02","97","3.57","5.89","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","7.14","5.35","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","4.46","62.5","","4.81","4.81","4.81","1 through 10","3.57","5.89","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","7.14","5.35","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","3.93","55","","9.85","1.05","154.76","17","3.57","5.89","percent of total billed charges",""
"Inj Famotidine 20 Mg","PX-63601106","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","7.14","5.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5.74","80.4","","8.31","5.24","14.69","13","3.57","5.89","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","both","","","0.89","0.67","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.64","71.8","","0.57","0.57","0.57","90","0.28","0.79","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","both","","","0.89","0.67","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.58","65.6","","0.53","0.53","0.54","166","0.28","0.79","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","both","","","0.89","0.67","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.62","70","","0.57","0.05","1.73","409","0.28","0.79","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","both","","","0.89","0.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.58","65","","38.60","26.77","47.99","11","0.28","0.79","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","both","","","0.89","0.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","0.64","72","","46.22","46.22","46.22","1 through 10","0.28","0.79","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","both","","","0.89","0.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.28","31","","0.25","0.25","0.74","1317","0.28","0.79","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","both","","","0.89","0.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.32","36.5","","0.30","0.25","0.87","33102","0.28","0.79","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","both","","","0.89","0.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.34","38.3","","0.31","0.31","0.93","79504","0.28","0.79","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","both","","","0.89","0.67","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.69","77","","0.79","0.55","0.80","328","0.28","0.79","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","both","","","0.89","0.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.38","42.9","","0.60","0.56","0.67","2278","0.28","0.79","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","both","","","0.89","0.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.38","42.9","","0.60","0.56","0.60","164","0.28","0.79","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","outpatient","","","0.89","0.67","AETNA [1001]","HB AMC AETNA HMO","0.62","69.8","","0.54","0.38","0.62","55208","0.42","0.73","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","outpatient","","","0.89","0.67","AETNA [1001]","HB AMC AETNA PPO","0.72","80.4","","0.62","0.42","0.63","3595","0.42","0.73","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","outpatient","","","0.89","0.67","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","0.50","55.9","","0.41","0.41","0.42","259","0.42","0.73","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","outpatient","","","0.89","0.67","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","0.47","52.26","","1.43","0.49","1.43","1086","0.42","0.73","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","outpatient","","","0.89","0.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.62","69.9","","0.56","0.23","508.48","1124","0.42","0.73","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","outpatient","","","0.89","0.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.42","46.9","","0.37","0.37","0.37","106","0.42","0.73","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","outpatient","","","0.89","0.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.72","80.4","","0.62","0.22","0.63","618","0.42","0.73","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","outpatient","","","0.89","0.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","0.73","81.72","","46.50","29.40","56.28","1 through 10","0.42","0.73","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","outpatient","","","0.89","0.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","0.73","81.72","","0.60","0.56","0.60","1876","0.42","0.73","percent of total billed charges",""
"Inj Gadobutrol, 0.1ml","PX-25500052","CDM","A9585","HCPCS","0255","RC","","","","outpatient","","","0.89","0.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.73","81.72","","0.60","0.56","0.67","33807","0.42","0.73","percent of total billed charges",""
"Inj Gadoterate Meglumi 0.1ml","PX-25500051","CDM","A9575","HCPCS","0255","RC","","","","both","","","0.62","0.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.23","36.5","","0.38","0.38","0.38","180","0.19","0.48","percent of total billed charges",""
"Inj Gadoterate Meglumi 0.1ml","PX-25500051","CDM","A9575","HCPCS","0255","RC","","","","both","","","0.62","0.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.24","38.3","","0.41","0.14","0.76","680","0.19","0.48","percent of total billed charges",""
"Inj Gadoterate Meglumi 0.1ml","PX-25500051","CDM","A9575","HCPCS","0255","RC","","","","outpatient","","","0.62","0.46","AETNA [1001]","HB AMC AETNA HMO","0.43","69.8","","0.96","0.71","0.96","330","0.29","0.51","percent of total billed charges",""
"Inj Gadoterate Meglumi 0.1ml","PX-25500051","CDM","A9575","HCPCS","0255","RC","","","","outpatient","","","0.62","0.46","AETNA [1001]","HB AMC AETNA PPO","0.50","80.4","","0.82","0.82","0.82","142","0.29","0.51","percent of total billed charges",""
"Inj Gadoterate Meglumi 0.1ml","PX-25500051","CDM","A9575","HCPCS","0255","RC","","","","outpatient","","","0.62","0.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.51","81.72","","0.26","0.26","0.26","190","0.29","0.51","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0250","RC","","","","inpatient","","","15.00","11.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8.00","53.3","","0.01","0.01","0.01","1 through 10","6.44","11.93","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","10.77","71.8","","0.60","0.42","0.60","1 through 10","0.7","11.55","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","9.84","65.6","","0.62","0.62","0.62","20","0.7","11.55","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","9.75","65","","0.78","0.78","0.78","204","0.7","11.55","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","10.50","70","","0.57","0.57","0.57","1 through 10","0.7","11.55","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","11.55","77","","1.31","0.44","1.31","20","0.7","11.55","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","9.75","65","","0.79","0.50","6.51","23","0.7","11.55","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4.65","31","","0.40","0.18","0.40","15","0.7","11.55","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5.48","36.5","","0.56","0.21","0.80","934","0.7","11.55","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5.75","38.3","","0.30","0.22","0.95","1218","0.7","11.55","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","15.00","11.25","AETNA [1001]","HB AMC AETNA HMO","10.47","69.8","","0.51","0.31","0.74","1504","0.47","12.06","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","15.00","11.25","AETNA [1001]","HB AMC AETNA PPO","12.06","80.4","","0.60","0.43","0.60","120","0.47","12.06","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","15.00","11.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10.49","69.9","","0.82","0.39","1.61","1442","0.47","12.06","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","15.00","11.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7.04","46.9","","0.80","0.26","1.19","1053","0.47","12.06","percent of total billed charges",""
"Inj Heparin Sodium per 1000u","PX-63601075","CDM","J1644","HCPCS","0636","RC","","","","outpatient","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","12.06","80.4","","0.74","0.44","1.54","12","0.47","12.06","percent of total billed charges",""
"Inj Lidocaine Hcl in 5% Dextrose 1 Mg","PX-63601443","CDM","J2002","HCPCS","0636","RC","","","","outpatient","","","0.05","0.04","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.03","52.5","","0.01","0.01","0.01","8000","0.01","0.04","percent of total billed charges",""
"Inj Lidocaine Hcl in 5% Dextrose 1 Mg","PX-63601443","CDM","J2002","HCPCS","0636","RC","","","","outpatient","","","0.05","0.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.04","80.4","","0.01","0.01","0.01","200","0.01","0.04","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","both","","","0.95","0.71","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.62","65","","0.07","0.07","0.07","200","0.29","0.76","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","both","","","0.95","0.71","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.67","70","","0.07","0.03","0.17","4401","0.29","0.76","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","both","","","0.95","0.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.76","79.5","","0.07","0.02","0.20","6986","0.29","0.76","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","both","","","0.95","0.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.51","53.3","","0.05","0.02","0.14","5826","0.29","0.76","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","both","","","0.95","0.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.62","65","","0.06","0.06","0.06","271","0.29","0.76","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","both","","","0.95","0.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.29","31","","0.03","0.01","0.03","800","0.29","0.76","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","both","","","0.95","0.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.35","36.5","","0.03","0.01","0.07","5312","0.29","0.76","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","both","","","0.95","0.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.36","38.3","","0.04","0.01","0.08","15079","0.29","0.76","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","both","","","0.95","0.71","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.73","77","","18.64","18.64","18.64","1 through 10","0.29","0.76","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","both","","","0.95","0.71","WELLPOINT [1015]","HB AMC WELLPOINT","0.70","73.78","","0.07","0.02","0.07","6599","0.29","0.76","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","outpatient","","","0.95","0.71","AETNA [1001]","HB AMC AETNA HMO","0.66","69.8","","0.06","0.02","0.07","1259","0.09","0.78","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","outpatient","","","0.95","0.71","AETNA [1001]","HB AMC AETNA PPO","0.76","80.4","","0.07","0.07","0.07","330","0.09","0.78","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","outpatient","","","0.95","0.71","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","0.50","52.5","","0.05","0.02","0.06","1150","0.09","0.78","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","outpatient","","","0.95","0.71","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.48","50","","0.05","0.02","0.14","31200","0.09","0.78","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","outpatient","","","0.95","0.71","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.50","52.5","","0.05","0.02","0.41","8915","0.09","0.78","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","outpatient","","","0.95","0.71","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","0.59","62.5","","0.06","0.04","0.06","1255","0.09","0.78","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","outpatient","","","0.95","0.71","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","0.50","52.5","","0.05","0.05","0.05","245","0.09","0.78","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","outpatient","","","0.95","0.71","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","0.52","55","","0.02","0.02","0.05","2819","0.09","0.78","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","outpatient","","","0.95","0.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.76","80.4","","0.07","0.07","0.07","200","0.09","0.78","percent of total billed charges",""
"Inj Lidocaine Hcl With Epinephrine 1 Mg","PX-63601444","CDM","J2004","HCPCS","0636","RC","","","","outpatient","","","0.95","0.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","0.52","55","","0.05","0.05","0.05","203","0.09","0.78","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.25","71.8","","0.21","0.01","0.21","310","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.23","65.6","","0.01","0.01","0.01","280","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.23","65","","0.17","0.01","315.93","2281","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.25","70","","0.02","0.01","0.08","5022","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.28","79.5","","0.04","0.01","493.56","45642","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.19","53.3","","0.02","0.01","331.13","26751","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","0.27","77","","0.04","0.02","0.05","980","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.23","65","","0.01","0.01","0.01","313","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","0.28","79.5","","9.79","9.79","9.79","1 through 10","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","0.25","72","","6.44","6.44","6.44","1 through 10","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.11","31","","0.07","0.01","0.17","2055","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.13","36.5","","0.03","0.01","0.20","38133","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.13","38.3","","0.02","0.01","0.21","95475","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.27","77","","0.03","0.02","0.03","417","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","both","","","0.35","0.26","WELLPOINT [1015]","HB AMC WELLPOINT","0.26","73.78","","0.03","0.01","3.67","26523","0.11","0.28","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","AETNA [1001]","HB AMC AETNA HMO","0.24","69.8","","0.01","0.01","0.03","10209","0.13","0.29","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","AETNA [1001]","HB AMC AETNA PPO","0.28","80.4","","0.02","0.01","0.07","1742","0.13","0.29","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","0.20","55.9","","0.29","0.29","0.29","200","0.13","0.29","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","0.18","52.5","","0.01","0.01","0.03","4272","0.13","0.29","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.18","50","","0.03","0.01","0.07","132704","0.13","0.29","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.18","52.5","","0.03","0.01","0.07","54037","0.13","0.29","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","0.29","82.5","","0.04","0.01","0.04","340","0.13","0.29","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","0.22","62.5","","0.01","0.01","0.03","4819","0.13","0.29","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","0.18","52.5","","0.02","0.01","0.15","1226","0.13","0.29","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","0.19","55","","0.01","0.01","0.03","10237","0.13","0.29","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.28","80.4","","0.01","0.01","0.02","1273","0.13","0.29","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","0.18","52.5","","0.01","0.01","0.01","282","0.13","0.29","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","0.18","52.5","","0.01","0.01","0.01","80","0.13","0.29","percent of total billed charges",""
"Inj Lidocaine Hydrochloride 1 Mg","PX-63601442","CDM","J2003","HCPCS","0636","RC","","","","outpatient","","","0.35","0.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","0.19","55","","0.01","0.01","0.02","820","0.13","0.29","percent of total billed charges",""
"Inj Magnesium Sulfate","PX-63601084","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1.56","70","","7.68","2.41","12.27","24","0.69","1.87","percent of total billed charges",""
"Inj Magnesium Sulfate","PX-63601084","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1.72","77","","2.62","2.62","2.62","1 through 10","0.69","1.87","percent of total billed charges",""
"Inj Magnesium Sulfate","PX-63601084","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1.45","65","","1.41","1.41","5.64","1 through 10","0.69","1.87","percent of total billed charges",""
"Inj Magnesium Sulfate","PX-63601084","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.69","31","","1.05","1.05","1.05","1 through 10","0.69","1.87","percent of total billed charges",""
"Inj Magnesium Sulfate","PX-63601084","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.81","36.5","","2.12","0.77","3.80","112","0.69","1.87","percent of total billed charges",""
"Inj Magnesium Sulfate","PX-63601084","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.85","38.3","","3.07","0.17","3.62","672","0.69","1.87","percent of total billed charges",""
"Inj Magnesium Sulfate","PX-63601084","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1.72","77","","1.64","1.64","1.64","1 through 10","0.69","1.87","percent of total billed charges",""
"Inj Magnesium Sulfate","PX-63601084","CDM","J3475","HCPCS","0636","RC","","","","outpatient","","","2.23","1.67","AETNA [1001]","HB AMC AETNA HMO","1.56","69.8","","2.30","1.63","3.20","79","1.05","1.79","percent of total billed charges",""
"Inj Magnesium Sulfate","PX-63601084","CDM","J3475","HCPCS","0636","RC","","","","outpatient","","","2.23","1.67","AETNA [1001]","HB AMC AETNA PPO","1.79","80.4","","3.25","1.62","3.25","13","1.05","1.79","percent of total billed charges",""
"Inj Magnesium Sulfate","PX-63601084","CDM","J3475","HCPCS","0636","RC","","","","outpatient","","","2.23","1.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.56","69.9","","1.63","0.29","2.56","134","1.05","1.79","percent of total billed charges",""
"Inj Magnesium Sulfate","PX-63601084","CDM","J3475","HCPCS","0636","RC","","","","outpatient","","","2.23","1.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1.05","46.9","","1.58","1.43","5.15","56","1.05","1.79","percent of total billed charges",""
"Inj Magnesium Sulfate","PX-63601084","CDM","J3475","HCPCS","0636","RC","","","","outpatient","","","2.23","1.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1.79","80.4","","1.69","1.69","4.33","11","1.05","1.79","percent of total billed charges",""
"Inj Magnesium Sulfate","PX-63601084","CDM","J3475","HCPCS","0636","RC","","","","outpatient","","","2.23","1.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1.56","69.9","","6.82","6.82","6.82","1 through 10","1.05","1.79","percent of total billed charges",""
"Inj Methotrexate Sodium 50mg","PX-63601272","CDM","J9260","HCPCS","0636","RC","","","","both","","","4.97","3.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1.81","36.5","","6.85","5.14","6.85","1 through 10","1.54","5.7","percent of total billed charges",""
"Inj Methotrexate Sodium 50mg","PX-63601272","CDM","J9260","HCPCS","0636","RC","","","","both","","","4.97","3.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1.90","38.3","","10.01","5.84","10.01","1 through 10","1.54","5.7","percent of total billed charges",""
"Inj Methotrexate Sodium 50mg","PX-63601272","CDM","J9260","HCPCS","0636","RC","","","","outpatient","","","4.97","3.73","AETNA [1001]","HB AMC AETNA HMO","3.47","69.8","","12.91","7.69","15.55","12","2.33","4.86","percent of total billed charges",""
"Inj Methotrexate Sodium 50mg","PX-63601272","CDM","J9260","HCPCS","0636","RC","","","","outpatient","","","4.97","3.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3.47","69.9","","8.17","8.17","8.17","1 through 10","2.33","4.86","percent of total billed charges",""
"Inj Methotrexate Sodium 50mg","PX-63601272","CDM","J9260","HCPCS","0636","RC","","","","outpatient","","","4.97","3.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2.33","46.9","","10.65","10.65","10.65","1 through 10","2.33","4.86","percent of total billed charges",""
"Inj of Fetus for Tx Fetal Arrhythmia, Incls Img Guidance","PX-76003010","CDM","59897","CPT","0761","RC","","","","both","","","4025.00","3018.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2145.33","53.3","","3658.50","3658.50","3658.50","1 through 10","226.96","3199.88","percent of total billed charges",""
"Inj of Fetus for Tx Fetal Arrhythmia, Incls Img Guidance","PX-76003010","CDM","59897","CPT","0761","RC","","","","outpatient","","","4025.00","3018.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3289.23","81.72","","6095.22","6095.22","6095.22","1 through 10","1234.13","3320.63","percent of total billed charges",""
"Inj Paravert F Jnt C/T 1 Lev","PX-76001532","CDM","64490","CPT","0761","RC","","","","both","","","2378.00","1783.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1890.51","79.5","","3629.64","3629.64","3629.64","1 through 10","737.18","1890.51","percent of total billed charges",""
"Inj Paravert F Jnt C/T 1 Lev","PX-76001532","CDM","64490","CPT","0761","RC","","","","both","","","2378.00","1783.50","FALLON HEALTH [1008]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1036.12","1036.12","1036.12","1 through 10","737.18","1890.51","other","OPPS APC"
"Inj Paravert F Jnt C/T 1 Lev","PX-76001532","CDM","64490","CPT","0761","RC","","","","both","","","2378.00","1783.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","910.77","38.3","","3180.00","3180.00","3180.00","1 through 10","737.18","1890.51","percent of total billed charges",""
"Inj Paravert F Jnt C/T 1 Lev","PX-76001532","CDM","64490","CPT","0761","RC","","","","both","","","2378.00","1783.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1040.35","978.90","1554.20","1 through 10","737.18","1890.51","other","OPPS APC"
"Inj Paravert F Jnt C/T 1 Lev","PX-76001532","CDM","64490","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","AETNA [1001]","HB AMC AETNA HMO","1659.84","69.8","","1102.27","1102.27","1102.27","1 through 10","764.84","4218.09","percent of total billed charges",""
"Inj Paravert F Jnt C/T 1 Lev|BILATERAL PROCEDURE","PX-76001532","CDM","64490","CPT","0761","RC","","","50","both","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1560.54","1560.54","1560.54","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Paravert F Jnt C/T 1 Lev|BILATERAL PROCEDURE","PX-76001532","CDM","64490","CPT","0761","RC","","","50","both","","","2378.00","1783.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1588.37","1588.37","1588.37","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Paravert F Jnt C/T 1 Lev|BILATERAL PROCEDURE","PX-76001532","CDM","64490","CPT","0761","RC","","","50","both","","","2378.00","1783.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1559.59","1559.59","1559.59","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Paravert F Jnt C/T 1 Lev|BILATERAL PROCEDURE","PX-76001532","CDM","64490","CPT","0761","RC","","","50","outpatient","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2635.73","2635.73","2635.73","1 through 10","1311.96","6327.14","other","ASC"
"Inj Paravert F Jnt C/T 1 Lev|BILATERAL PROCEDURE","PX-76001532","CDM","64490","CPT","0761","RC","","","50","outpatient","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3071.30","3041.12","3071.30","1 through 10","1311.96","6327.14","other","ASC "
"Inj Paravert F Jnt C/T 2 Lev","PX-76001535","CDM","64491","CPT","0761","RC","","","","both","","","463.00","347.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","368.09","79.5","","706.73","706.73","706.73","1 through 10","143.53","1627.62","percent of total billed charges",""
"Inj Paravert F Jnt C/T 2 Lev","PX-76001535","CDM","64491","CPT","0761","RC","","","","both","","","463.00","347.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","177.33","38.3","","3180.00","3180.00","3180.00","1 through 10","143.53","1627.62","percent of total billed charges",""
"Inj Paravert F Jnt C/T 2 Lev","PX-76001535","CDM","64491","CPT","0761","RC","","","","outpatient","","","463.00","347.25","AETNA [1001]","HB AMC AETNA HMO","323.17","69.8","","214.62","214.62","214.62","1 through 10","100.56","378.36","percent of total billed charges",""
"Inj Paravert F Jnt L/S 1 Lev","PX-76001541","CDM","64493","CPT","0761","RC","","","","both","","","2379.00","1784.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1268.01","53.3","","1218.10","1218.10","1218.10","1 through 10","737.49","1891.31","percent of total billed charges",""
"Inj Paravert F Jnt L/S 1 Lev","PX-76001541","CDM","64493","CPT","0761","RC","","","","both","","","2379.00","1784.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1561.70","1462.38","1562.10","24","737.49","1891.31","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev","PX-76001541","CDM","64493","CPT","0761","RC","","","","outpatient","","","2379.00","1784.25","AETNA [1001]","HB AMC AETNA HMO","1660.54","69.8","","1102.75","1102.75","1102.75","1 through 10","764.84","4218.09","percent of total billed charges",""
"Inj Paravert F Jnt L/S 1 Lev","PX-76001541","CDM","64493","CPT","0761","RC","","","","outpatient","","","2379.00","1784.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1866.21","1797.37","1866.21","1 through 10","764.84","4218.09","other","Multiple Surgery"
"Inj Paravert F Jnt L/S 1 Lev","PX-76001541","CDM","64493","CPT","0761","RC","","","","outpatient","","","2379.00","1784.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2936.99","2936.99","2936.99","1 through 10","764.84","4218.09","other","Multiple Surgery"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2379.00","1784.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1088.88","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1632.81","1632.81","1635.24","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2379.00","1784.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4614.00","1560.54","4614.00","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2379.00","1784.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1560.54","1462.38","1560.54","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2379.00","1784.25","MEDICARE [2001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1585.91","1492.21","1585.91","13","1004.41","1321.46","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2379.00","1784.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1554.19","1462.37","1554.19","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2379.00","1784.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1561.99","1557.19","2940.36","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2379.00","1784.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1462.38","1294.84","1585.91","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","outpatient","","","2379.00","1784.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2635.73","2635.73","2684.27","1 through 10","1311.96","6327.14","other","ASC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","outpatient","","","2379.00","1784.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3041.12","3041.12","3071.30","27","1311.96","6327.14","other","ASC "
"Inj Paravert F Jnt L/S 2 Lev","PX-76001544","CDM","64494","CPT","0761","RC","","","","both","","","394.00","295.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","210.00","53.3","","201.70","201.70","201.70","1 through 10","122.14","1627.62","percent of total billed charges",""
"Inj Paravert F Jnt L/S 2 Lev","PX-76001544","CDM","64494","CPT","0761","RC","","","","outpatient","","","394.00","295.50","AETNA [1001]","HB AMC AETNA HMO","275.01","69.8","","182.60","182.60","182.60","1 through 10","87.13","321.98","percent of total billed charges",""
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","496.00","372.00","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","76.89","84.52","1 through 10","80.29","394.32","other","OPPS APC"
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","496.00","372.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","83.17","83.17","83.17","1 through 10","80.29","394.32","other","OPPS APC"
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","1141.00","855.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","907.10","79.5","","583.97","583.97","583.97","1 through 10","80.29","907.1","percent of total billed charges",""
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","1141.00","855.75","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","1 through 10","80.29","907.1","other","OPPS APC"
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","1141.00","855.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","416.47","36.5","","412.54","412.54","412.54","1 through 10","80.29","907.1","percent of total billed charges",""
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","1141.00","855.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","437.00","38.3","","432.45","432.45","432.45","1 through 10","80.29","907.1","percent of total billed charges",""
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","outpatient","","","1141.00","855.75","AETNA [1001]","HB AMC AETNA HMO","796.42","69.8","","748.76","528.67","862.68","1 through 10","137.27","932.43","percent of total billed charges",""
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","outpatient","","","1141.00","855.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","932.43","81.72","","884.14","884.13","884.14","1 through 10","137.27","932.43","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","both","","","64.90","48.67","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","42.57","65.6","","0.96","0.96","0.96","1 through 10","20.12","51.6","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","both","","","64.90","48.67","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","45.43","70","","4.45","1.98","14.99","1 through 10","20.12","51.6","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","both","","","64.90","48.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","51.60","79.5","","414.25","7.38","1891.33","1713","20.12","51.6","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","both","","","64.90","48.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","34.59","53.3","","6.50","1.93","26.16","91","20.12","51.6","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","both","","","64.90","48.67","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","49.97","77","","4.84","4.84","4.84","1 through 10","20.12","51.6","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","both","","","64.90","48.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","42.19","65","","11.15","6.10","14.62","1 through 10","20.12","51.6","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","both","","","64.90","48.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","51.60","79.5","","0.59","0.59","1.48","1 through 10","20.12","51.6","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","both","","","64.90","48.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","20.12","31","","0.83","0.83","0.83","1 through 10","20.12","51.6","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","both","","","64.90","48.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.69","36.5","","2.33","0.78","11.19","64","20.12","51.6","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","both","","","64.90","48.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.86","38.3","","3.61","0.89","16.20","213","20.12","51.6","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","both","","","64.90","48.67","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","49.97","77","","9.22","3.56","12.86","1 through 10","20.12","51.6","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","both","","","64.90","48.67","WELLPOINT [1015]","HB AMC WELLPOINT","47.88","73.78","","5.23","1.33","24.91","47","20.12","51.6","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","64.90","48.67","AETNA [1001]","HB AMC AETNA HMO","45.30","69.8","","6.04","1.31","22.28","143","32.45","53.54","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","64.90","48.67","AETNA [1001]","HB AMC AETNA PPO","52.18","80.4","","4.95","1.52","30.51","1 through 10","32.45","53.54","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","64.90","48.67","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","34.07","52.5","","533.60","0.69","533.60","1 through 10","32.45","53.54","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","64.90","48.67","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","32.45","50","","4.92","1.04","22.14","217","32.45","53.54","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","64.90","48.67","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","34.07","52.5","","11.25","1.46","33.02","97","32.45","53.54","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","64.90","48.67","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","40.56","62.5","","4.81","4.81","4.81","1 through 10","32.45","53.54","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","64.90","48.67","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","35.70","55","","9.85","1.05","154.76","17","32.45","53.54","percent of total billed charges",""
"Inj Sodium Thiosulfate 25%","PX-63601109","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","64.90","48.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","52.18","80.4","","8.31","5.24","14.69","13","32.45","53.54","percent of total billed charges",""
"Inj Vedolizumab 1 Mg","PX-63601206","CDM","J3380","HCPCS","0636","RC","","","","both","","","68.27","51.20","CHAMPVA [160001]","HB BWH TRICARE","20.96","","APC Price ($22.06). Final payment is multiplied by 95%.","21.67","21.67","22.06","900","20.88","54.69","other","Tricare OPPS"
"Inj Vedolizumab 1 Mg","PX-63601206","CDM","J3380","HCPCS","0636","RC","","","","both","","","68.27","51.20","TRICARE [160005]","HB BWH TRICARE","20.96","","APC Price ($22.06). Final payment is multiplied by 95%.","21.15","21.15","21.15","302","20.88","54.69","other","Tricare OPPS"
"Inj Vedolizumab 1 Mg","PX-63601206","CDM","J3380","HCPCS","0636","RC","","","","both","","","68.27","51.20","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20.88","","APC Price ($21.31). Final payment is multiplied by 98%.","21.62","20.82","21.81","3300","20.88","54.69","other","OPPS APC"
"Inj Vedolizumab 1 Mg","PX-63601206","CDM","J3380","HCPCS","0636","RC","","","","outpatient","","","68.27","51.20","AETNA [1001]","HB AMC AETNA HMO","47.65","69.8","","80.42","80.42","80.42","303","0.01","54.89","percent of total billed charges",""
"Inj Zoledronic Acid Nos per 1 Mg","PX-63601107","CDM","J3489","HCPCS","0636","RC","","","","both","","","340.01","255.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","124.10","36.5","","1.90","1.90","1.90","1 through 10","17.01","261.81","percent of total billed charges",""
"Inj Zoledronic Acid Nos per 1 Mg","PX-63601107","CDM","J3489","HCPCS","0636","RC","","","","both","","","340.01","255.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","130.22","38.3","","1.96","1.93","1.99","18","17.01","261.81","percent of total billed charges",""
"Inj Zoledronic Acid Nos per 1 Mg","PX-63601107","CDM","J3489","HCPCS","0636","RC","","","","both","","","340.01","255.01","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","261.81","77","","20.38","20.38","20.38","1 through 10","17.01","261.81","percent of total billed charges",""
"Inj Zoledronic Acid Nos per 1 Mg","PX-63601107","CDM","J3489","HCPCS","0636","RC","","","","outpatient","","","340.01","255.01","AETNA [1001]","HB AMC AETNA HMO","237.33","69.8","","19.62","19.62","19.62","1 through 10","11.18","273.37","percent of total billed charges",""
"Inj Zoledronic Acid Nos per 1 Mg","PX-63601107","CDM","J3489","HCPCS","0636","RC","","","","outpatient","","","340.01","255.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","237.67","69.9","","112.80","112.80","112.80","1 through 10","11.18","273.37","percent of total billed charges",""
"Inject Anes Celiac Plexus","PX-76001552","CDM","64530","CPT","0761","RC","","","","both","","","2378.00","1783.50","MEDICARE [2001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1057.27","1057.27","1057.27","1 through 10","737.18","1890.51","other","OPPS APC"
"Inject Anes Celiac Plexus","PX-76001552","CDM","64530","CPT","0761","RC","","","","both","","","2378.00","1783.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","910.77","38.3","","9459.07","9459.07","9459.07","1 through 10","737.18","1890.51","percent of total billed charges",""
"Inject Anes Celiac Plexus","PX-76001552","CDM","64530","CPT","0761","RC","","","","both","","","2378.00","1783.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1044.03","1044.03","1044.03","1 through 10","737.18","1890.51","other","OPPS APC"
"Inject Anes Celiac Plexus","PX-76001552","CDM","64530","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","AETNA [1001]","HB AMC AETNA PPO","1911.91","80.4","","1798.68","1798.68","1798.68","1 through 10","764.84","2384.07","percent of total billed charges",""
"Inject Anes Celiac Plexus","PX-76001552","CDM","64530","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","874.64","","Case rate ($874.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2047.53","2027.42","2047.53","1 through 10","764.84","2384.07","other","ASC "
"Inject Anes Ganglion Stellate","PX-76001549","CDM","64510","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1866.21","1866.21","1866.21","1 through 10","764.84","2384.07","other","Multiple Surgery"
"Inject Anes Hypogastric Plexus","PX-76001550","CDM","64517","CPT","0761","RC","","","","both","","","2378.00","1783.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1088.88","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1088.83","1088.83","1088.83","1 through 10","609.18","1890.51","other","OPPS APC"
"Inject Anes Lumbar/Thoracic|BILATERAL PROCEDURE","PX-76001551","CDM","64520","CPT","0761","RC","","","50","both","","","2378.00","1783.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1462.56","1462.56","1462.56","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","507.00","380.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","157.17","438.15","other","OPPS APC"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","507.00","380.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","157.17","438.15","other","OPPS APC"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","507.00","380.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.23","53.3","","477.31","477.31","477.31","1 through 10","157.17","438.15","percent of total billed charges",""
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","507.00","380.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","157.17","438.15","other","OPPS APC"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","507.00","380.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","157.17","438.15","other","OPPS APC"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.06","36.5","","1095.87","337.19","1095.87","1 through 10","157.17","438.15","percent of total billed charges",""
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.18","38.3","","343.52","323.76","353.46","1 through 10","157.17","438.15","percent of total billed charges",""
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","507.00","380.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","157.17","438.15","other","Tricare OPPS"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","507.00","380.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","157.17","438.15","other","OPPS APC"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","507.00","380.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","157.17","438.15","other","OPPS APC"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","507.00","380.25","WELLPOINT [1015]","HB AMC WELLPOINT","374.06","73.78","","673.03","673.03","673.03","1 through 10","157.17","438.15","percent of total billed charges",""
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","outpatient","","","507.00","380.25","AETNA [1001]","HB AMC AETNA HMO","353.89","69.8","","612.01","612.01","1224.02","1 through 10","253.5","700.33","percent of total billed charges",""
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","outpatient","","","507.00","380.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","306.99","60.55","","579.04","568.57","904.00","30","253.5","700.33","percent of total billed charges",""
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","outpatient","","","507.00","380.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","264.76","52.22","","904.00","656.02","2938.00","26","253.5","700.33","percent of total billed charges",""
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","253.50","50","","1421.10","875.08","2368.50","15","253.5","700.33","percent of total billed charges",""
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","266.18","52.5","","2985.00","904.00","2985.00","1 through 10","253.5","700.33","percent of total billed charges",""
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","outpatient","","","507.00","380.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","414.32","81.72","","722.66","722.66","17449.00","1 through 10","253.5","700.33","percent of total billed charges",""
"Inject Anes Nerve Greater Occipital","PX-76001499","CDM","64405","CPT","0761","RC","","","","both","","","1255.00","941.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","878.50","70","","350.56","350.56","350.56","1 through 10","333.03","997.73","percent of total billed charges",""
"Inject Anes Nerve Greater Occipital","PX-76001499","CDM","64405","CPT","0761","RC","","","","both","","","1255.00","941.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","1 through 10","333.03","997.73","other","OPPS APC"
"Inject Anes Nerve Greater Occipital","PX-76001499","CDM","64405","CPT","0761","RC","","","","both","","","1255.00","941.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.33","171.78","515.33","1 through 10","333.03","997.73","other","OPPS APC"
"Inject Anes Nerve Greater Occipital","PX-76001499","CDM","64405","CPT","0761","RC","","","","outpatient","","","1255.00","941.25","AETNA [1001]","HB AMC AETNA PPO","1009.02","80.4","","949.26","949.26","949.26","1 through 10","247.48","1234.13","percent of total billed charges",""
"Inject Anes Nerve Greater Occipital","PX-98300435","CDM","64405","CPT","0983","RC","","","","both","","","329.00","246.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","230.30","70","","350.56","350.56","350.56","1 through 10","101.99","609.18","percent of total billed charges",""
"Inject Anes Nerve Greater Occipital","PX-98300435","CDM","64405","CPT","0983","RC","","","","both","","","329.00","246.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","1 through 10","101.99","609.18","other","OPPS APC"
"Inject Anes Nerve Greater Occipital","PX-98300435","CDM","64405","CPT","0983","RC","","","","both","","","329.00","246.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.33","171.78","515.33","1 through 10","101.99","609.18","other","OPPS APC"
"Inject Anes Nerve Greater Occipital","PX-98300435","CDM","64405","CPT","0983","RC","","","","outpatient","","","329.00","246.75","AETNA [1001]","HB AMC AETNA PPO","264.52","80.4","","949.26","949.26","949.26","1 through 10","141.14","1234.13","percent of total billed charges",""
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","both","","","1255.00","941.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","541.78","361.53","541.78","1 through 10","333.03","438.15","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","both","","","1255.00","941.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","290.47","290.47","290.47","1 through 10","333.03","438.15","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","both","","","1255.00","941.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","350.56","525.83","1 through 10","333.03","438.15","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","outpatient","","","1255.00","941.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","852.86","426.43","852.86","1 through 10","424.52","2295.49","other","ASC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","outpatient","","","1255.00","941.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","496.90","496.90","496.90","1 through 10","424.52","2295.49","other","ASC "
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-98300435","CDM","64405","CPT","0983","RC","","","50","both","","","329.00","246.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","541.78","361.53","541.78","1 through 10","333.03","438.15","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-98300435","CDM","64405","CPT","0983","RC","","","50","both","","","329.00","246.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","290.47","290.47","290.47","1 through 10","333.03","438.15","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-98300435","CDM","64405","CPT","0983","RC","","","50","both","","","329.00","246.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","350.56","525.83","1 through 10","333.03","438.15","other","OPPS APC"
"Inject Anes Nerve Intercostal Sgl","PX-76001506","CDM","64420","CPT","0761","RC","","","","both","","","1255.00","941.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","538.40","42.9","","1938.91","1938.91","1938.91","1 through 10","389.05","1027.91","percent of total billed charges",""
"Inject Anes Nerve Paracervical","PX-76001510","CDM","64435","CPT","0761","RC","","","","outpatient","","","1255.00","941.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","389.94","389.94","389.94","1 through 10","598.81","1234.13","other","Multiple Surgery"
"Inject Anes Nerve Paracervical","PX-76001510","CDM","64435","CPT","0761","RC","","","","outpatient","","","1255.00","941.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1025.59","81.72","","972.87","535.11","972.87","1 through 10","598.81","1234.13","percent of total billed charges",""
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","1255.00","941.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","878.50","70","","1209.84","1209.84","1209.84","1 through 10","389.05","1027.91","percent of total billed charges",""
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","1255.00","941.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","809.25","809.25","1 through 10","389.05","1027.91","other","OPPS APC"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","1255.00","941.25","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","754.77","822.41","1 through 10","389.05","1027.91","other","OPPS APC"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","1255.00","941.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","458.08","36.5","","453.94","153.87","453.94","1 through 10","389.05","1027.91","percent of total billed charges",""
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","1255.00","941.25","TRICARE [160005]","HB BWH TRICARE","781.29","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","822.41","822.41","822.41","1 through 10","389.05","1027.91","other","Tricare OPPS"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","1255.00","941.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.87","805.97","813.87","1 through 10","389.05","1027.91","other","OPPS APC"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","outpatient","","","1255.00","941.25","AETNA [1001]","HB AMC AETNA HMO","875.99","69.8","","949.26","823.91","949.26","1 through 10","598.81","1234.13","percent of total billed charges",""
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","outpatient","","","1255.00","941.25","AETNA [1001]","HB AMC AETNA PPO","1009.02","80.4","","949.26","949.26","949.26","1 through 10","598.81","1234.13","percent of total billed charges",""
"Inject Anes Nerve Peripheral Other|BILATERAL PROCEDURE","PX-76001516","CDM","64450","CPT","0761","RC","","","50","both","","","1255.00","941.25","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1233.61","1233.61","1233.61","1 through 10","781.29","1027.91","other","OPPS APC"
"Inject Anes Nerve Peripheral Other|BILATERAL PROCEDURE","PX-76001516","CDM","64450","CPT","0761","RC","","","50","both","","","1255.00","941.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1233.61","1233.61","1233.61","1 through 10","781.29","1027.91","other","OPPS APC"
"Inject Anes Nerve Peripheral Other|BILATERAL PROCEDURE","PX-76001516","CDM","64450","CPT","0761","RC","","","50","outpatient","","","1255.00","941.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1027.16","","Case rate ($1,027.16). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2380.96","2380.96","2404.58","1 through 10","1027.16","3440.16","other","ASC "
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1027.94","other","OPPS APC"
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1027.94","other","OPPS APC"
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","689.17","53.3","","477.31","477.31","477.31","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1027.94","other","OPPS APC"
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1027.94","other","OPPS APC"
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","471.95","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","495.22","38.3","","343.52","323.76","353.46","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1027.94","other","Tricare OPPS"
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1027.94","other","OPPS APC"
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1027.94","other","OPPS APC"
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","both","","","1293.00","969.75","WELLPOINT [1015]","HB AMC WELLPOINT","953.98","73.78","","673.03","673.03","673.03","1 through 10","333.03","1027.94","percent of total billed charges",""
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","AETNA [1001]","HB AMC AETNA HMO","902.51","69.8","","612.01","612.01","1224.02","1 through 10","646.5","1066.73","percent of total billed charges",""
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","782.91","60.55","","579.04","568.57","904.00","30","646.5","1066.73","percent of total billed charges",""
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","675.20","52.22","","904.00","656.02","2938.00","26","646.5","1066.73","percent of total billed charges",""
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","646.50","50","","1421.10","875.08","2368.50","15","646.5","1066.73","percent of total billed charges",""
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","678.83","52.5","","2985.00","904.00","2985.00","1 through 10","646.5","1066.73","percent of total billed charges",""
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","outpatient","","","1293.00","969.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1056.64","81.72","","722.66","722.66","17449.00","1 through 10","646.5","1066.73","percent of total billed charges",""
"Inject Anes Nerve Pudendal","PX-76001509","CDM","64430","CPT","0761","RC","","","","both","","","2378.00","1783.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1043.63","1043.63","1043.63","1 through 10","609.18","1890.51","other","OPPS APC"
"Inject Anes Nerve Pudendal|BILATERAL PROCEDURE","PX-76001509","CDM","64430","CPT","0761","RC","","","50","both","","","2378.00","1783.50","MEDICARE [2001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1585.91","1585.91","1585.91","1 through 10","1004.41","1321.46","other","OPPS APC"
"Inject Anes Nerve Suprascapular","PX-76001505","CDM","64418","CPT","0761","RC","","","","both","","","1255.00","941.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.87","813.87","813.87","1 through 10","389.05","1027.91","other","OPPS APC"
"Inject Anes Nerve Trigeminal","PX-76001497","CDM","64400","CPT","0761","RC","","","","both","","","718.00","538.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","262.92","350.56","1 through 10","222.58","609.18","other","OPPS APC"
"Inject Anes Nerve Trigeminal","PX-76001497","CDM","64400","CPT","0761","RC","","","","both","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.56","350.56","350.56","1 through 10","222.58","609.18","other","OPPS APC"
"Inject Anes Nerve Trigeminal","PX-98300434","CDM","64400","CPT","0983","RC","","","","both","","","364.00","273.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","262.92","350.56","1 through 10","112.84","609.18","other","OPPS APC"
"Inject Anes Nerve Trigeminal","PX-98300434","CDM","64400","CPT","0983","RC","","","","both","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.56","350.56","350.56","1 through 10","112.84","609.18","other","OPPS APC"
"Inject Anes Nerve Trigeminal|BILATERAL PROCEDURE","PX-76001497","CDM","64400","CPT","0761","RC","","","50","both","","","718.00","538.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","484.89","525.83","1 through 10","319.15","438.15","other","OPPS APC"
"Inject Anes Nerve Trigeminal|BILATERAL PROCEDURE","PX-76001497","CDM","64400","CPT","0761","RC","","","50","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","492.02","492.02","492.02","1 through 10","424.52","2295.49","other","ASC "
"Inject Anes Nerve Trigeminal|BILATERAL PROCEDURE","PX-98300434","CDM","64400","CPT","0983","RC","","","50","both","","","364.00","273.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","484.89","525.83","1 through 10","161.8","438.15","other","OPPS APC"
"Inject Arthrogram Hip W/O Anes","PX-76000527","CDM","27093","CPT","0761","RC","","","","outpatient","","","504.00","378.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","411.87","81.72","","390.91","390.91","390.91","1 through 10","117.81","411.87","percent of total billed charges",""
"Inject Arthrogram Sacroiliac Joint","PX-76001795","CDM","27096","CPT","0761","RC","","","","both","","","474.00","355.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","252.64","53.3","","362.02","362.02","362.02","1 through 10","146.94","1027.91","percent of total billed charges",""
"Inject Arthrogram Sacroiliac Joint","PX-76001795","CDM","27096","CPT","0761","RC","","","","outpatient","","","474.00","355.50","AETNA [1001]","HB AMC AETNA HMO","330.85","69.8","","219.88","219.88","219.88","1 through 10","140.26","598.81","percent of total billed charges",""
"Inject Arthrogram Sacroiliac Joint","PX-76001795","CDM","27096","CPT","0761","RC","","","","outpatient","","","474.00","355.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1407.20","1407.20","1407.20","1 through 10","140.26","598.81","other","Multiple Surgery"
"Inject Arthrogram Sacroiliac Joint|BILATERAL PROCEDURE","PX-76001795","CDM","27096","CPT","0761","RC","","","50","outpatient","","","474.00","355.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","210.39","","Case rate ($210.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","430.46","422.67","430.46","1 through 10","210.39","3440.16","other","ASC"
"Inject Arthrogram Sacroiliac Joint|BILATERAL PROCEDURE","PX-76001795","CDM","27096","CPT","0761","RC","","","50","outpatient","","","474.00","355.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","210.39","","Case rate ($210.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","487.68","487.68","492.52","1 through 10","210.39","3440.16","other","ASC "
"Inject Carpal Tunnel Therapeutic","PX-76000285","CDM","20526","CPT","0761","RC","","","","both","","","704.00","528.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","323.26","323.26","323.26","1 through 10","218.24","559.68","other","OPPS APC"
"Inject Carpal Tunnel Therapeutic","PX-76000285","CDM","20526","CPT","0761","RC","","","","both","","","704.00","528.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","269.63","38.3","","267.05","259.54","267.05","1 through 10","218.24","559.68","percent of total billed charges",""
"Inject Carpal Tunnel Therapeutic","PX-76000285","CDM","20526","CPT","0761","RC","","","","outpatient","","","704.00","528.00","AETNA [1001]","HB AMC AETNA HMO","491.39","69.8","","326.47","326.47","326.47","1 through 10","247.48","700.33","percent of total billed charges",""
"Inject Contrast Abcs/Cyst","PX-75000294","CDM","49424","CPT","0361","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","104.26","104.26","104.26","1 through 10","92.07","236.12","percent of total billed charges",""
"Inject Contrast Abcs/Cyst","PX-75000294","CDM","49424","CPT","0361","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","224.64","224.64","1 through 10","64.13","242.71","percent of total billed charges",""
"Inject Cystogram/Voiding","PX-76001254","CDM","51600","CPT","0761","RC","","","","both","","","340.00","255.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","270.30","79.5","","259.71","259.71","259.71","1 through 10","105.4","270.3","percent of total billed charges",""
"Inject Cystogram/Voiding","PX-76001254","CDM","51600","CPT","0761","RC","","","","both","","","340.00","255.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","221.00","65","","214.50","214.50","214.50","1 through 10","105.4","270.3","percent of total billed charges",""
"Inject Cystogram/Voiding","PX-76001254","CDM","51600","CPT","0761","RC","","","","both","","","340.00","255.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","124.10","36.5","","123.09","123.09","123.09","1 through 10","105.4","270.3","percent of total billed charges",""
"Inject Cystogram/Voiding","PX-76001254","CDM","51600","CPT","0761","RC","","","","both","","","340.00","255.00","WELLPOINT [1015]","HB AMC WELLPOINT","250.85","73.78","","245.69","245.69","245.69","1 through 10","105.4","270.3","percent of total billed charges",""
"Inject Cystogram/Voiding","PX-76001254","CDM","51600","CPT","0761","RC","","","","outpatient","","","340.00","255.00","AETNA [1001]","HB AMC AETNA HMO","237.32","69.8","","257.40","157.74","257.40","1 through 10","75.24","277.85","percent of total billed charges",""
"Inject Cystogram/Voiding","PX-76001254","CDM","51600","CPT","0761","RC","","","","outpatient","","","340.00","255.00","AETNA [1001]","HB AMC AETNA PPO","273.36","80.4","","257.40","257.40","257.40","1 through 10","75.24","277.85","percent of total billed charges",""
"Inject Enzyme Palmar Fascial Cord","PX-76000286","CDM","20527","CPT","0761","RC","","","","both","","","704.00","528.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","1 through 10","218.24","559.68","other","OPPS APC"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","2332.00","1749.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","606.94","606.94","606.94","1 through 10","722.92","1853.94","other","OPPS APC"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","2332.00","1749.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1242.96","53.3","","1779.41","1779.41","1779.41","1 through 10","722.92","1853.94","percent of total billed charges",""
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","2332.00","1749.00","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","616.81","566.08","822.41","13","722.92","1853.94","other","OPPS APC"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","2332.00","1749.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","893.16","38.3","","884.05","884.05","884.05","1 through 10","722.92","1853.94","percent of total billed charges",""
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","2332.00","1749.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","822.41","813.97","822.41","1 through 10","722.92","1853.94","other","OPPS APC"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","2332.00","1749.00","WELLPOINT [1015]","HB AMC WELLPOINT","1720.55","73.78","","1614.64","1614.64","1614.64","1 through 10","722.92","1853.94","percent of total billed charges",""
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","2332.00","1749.00","AETNA [1001]","HB AMC AETNA HMO","1627.74","69.8","","1530.70","1437.73","1763.58","1 through 10","598.81","2384.07","percent of total billed charges",""
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","2332.00","1749.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1401.04","1375.70","1401.04","1 through 10","598.81","2384.07","other","ASC"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","2332.00","1749.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","801.53","793.65","1603.05","20","598.81","2384.07","other","ASC "
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","2332.00","1749.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1389.24","1335.35","1389.24","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","2332.00","1749.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1461.10","1461.10","1461.10","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","2332.00","1749.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1905.71","81.72","","994.16","994.16","994.16","1 through 10","598.81","2384.07","percent of total billed charges",""
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","2332.00","1749.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1905.71","81.72","","1807.44","1807.44","1807.44","1 through 10","598.81","2384.07","percent of total billed charges",""
"Inject Ganglion Cyst","PX-76000296","CDM","20612","CPT","0761","RC","","","","both","","","718.00","538.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.81","79.5","","547.75","547.75","547.75","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Ganglion Cyst","PX-76000296","CDM","20612","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","262.07","36.5","","259.61","259.61","259.61","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Ganglion Cyst","PX-76000296","CDM","20612","CPT","0761","RC","","","","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","568.57","568.57","568.57","1 through 10","247.48","700.33","other","ASC"
"Inject Ganglion Cyst","PX-76000296","CDM","20612","CPT","0761","RC","","","","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","662.53","662.53","662.53","1 through 10","247.48","700.33","other","ASC "
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","287.00","287.00","287.00","1 through 10","91.76","294.93","other","OPPS APC"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","91.76","294.93","other","OPPS APC"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","235.32","79.5","","225.87","151.54","225.87","41","91.76","294.93","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","157.77","53.3","","151.54","151.54","225.87","16","91.76","294.93","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.48","30.48","187.70","1 through 10","91.76","294.93","other","OPPS APC"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","227.92","77","","220.99","220.99","220.99","1 through 10","91.76","294.93","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.55","30.55","30.55","1 through 10","91.76","294.93","other","OPPS APC"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","13","91.76","294.93","other","OPPS APC"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.98","30.98","32.17","17","91.76","294.93","other","OPPS APC"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","91.76","31","","197.74","88.68","197.74","1 through 10","91.76","294.93","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.04","36.5","","107.05","90.98","107.05","38","91.76","294.93","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.37","38.3","","112.22","112.22","112.22","152","91.76","294.93","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","30.36","231.25","1 through 10","91.76","294.93","other","OPPS APC"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","30.36","30.36","231.25","1 through 10","91.76","294.93","other","OPPS APC"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.26","30.37","235.97","1 through 10","91.76","294.93","other","OPPS APC"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.98","42.9","","126.19","126.19","126.19","1 through 10","91.76","294.93","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","both","","","296.00","222.00","WELLPOINT [1015]","HB AMC WELLPOINT","218.39","73.78","","213.67","213.67","500.67","50","91.76","294.93","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","AETNA [1001]","HB AMC AETNA HMO","206.61","69.8","","194.30","137.19","223.86","45","154.69","350.18","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","AETNA [1001]","HB AMC AETNA PPO","237.98","80.4","","223.86","146.20","223.86","1 through 10","154.69","350.18","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","405.38","412.84","150","154.69","350.18","other","ASC"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","154.69","52.26","","467.73","467.73","467.73","1 through 10","154.69","350.18","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","472.37","340","154.69","350.18","other","ASC "
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","451.71","288.89","456.76","1 through 10","154.69","350.18","other","Multiple Surgery"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","393.48","409.36","102","154.69","350.18","other","Multiple Surgery"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","275.73","430.54","39","154.69","350.18","other","Multiple Surgery"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","492.30","288.42","511.71","1 through 10","154.69","350.18","other","Multiple Surgery"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","317.09","44.33","430.54","1 through 10","154.69","350.18","other","Multiple Surgery"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","288.88","129.88","451.71","19","154.69","350.18","other","Multiple Surgery"
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","241.89","81.72","","230.36","229.43","321.42","1 through 10","154.69","350.18","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","241.89","81.72","","126.19","126.19","126.19","1 through 10","154.69","350.18","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","241.89","81.72","","229.43","115.59","332.55","38","154.69","350.18","percent of total billed charges",""
"Inject Intralesnal <7 Lesions","PX-76000099","CDM","11900","CPT","0761","RC","","","","outpatient","","","296.00","222.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","434.07","290.79","434.07","1 through 10","154.69","350.18","other","Multiple Surgery"
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","both","","","415.00","311.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","329.93","79.5","","212.26","212.26","316.37","1 through 10","128.65","329.93","percent of total billed charges",""
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","both","","","415.00","311.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","221.20","53.3","","212.26","212.26","316.37","1 through 10","128.65","329.93","percent of total billed charges",""
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","both","","","415.00","311.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","128.65","329.93","other","OPPS APC"
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","both","","","415.00","311.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","128.65","329.93","other","OPPS APC"
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","both","","","415.00","311.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","151.48","36.5","","149.95","145.52","412.04","26","128.65","329.93","percent of total billed charges",""
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","both","","","415.00","311.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","158.95","38.3","","157.18","157.18","157.18","46","128.65","329.93","percent of total billed charges",""
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","both","","","415.00","311.25","WELLPOINT [1015]","HB AMC WELLPOINT","306.19","73.78","","299.29","299.29","701.29","17","128.65","329.93","percent of total billed charges",""
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","outpatient","","","415.00","311.25","AETNA [1001]","HB AMC AETNA HMO","289.67","69.8","","272.15","192.16","313.56","22","176.45","350.18","percent of total billed charges",""
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","outpatient","","","415.00","311.25","AETNA [1001]","HB AMC AETNA PPO","333.66","80.4","","210.65","210.65","210.65","1 through 10","176.45","350.18","percent of total billed charges",""
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","outpatient","","","415.00","311.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","231.99","55.9","","210.65","210.65","210.65","1 through 10","176.45","350.18","percent of total billed charges",""
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","outpatient","","","415.00","311.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","405.38","412.84","37","176.45","350.18","other","ASC"
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","outpatient","","","415.00","311.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","472.37","102","176.45","350.18","other","ASC "
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","outpatient","","","415.00","311.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","451.71","402.00","451.71","1 through 10","176.45","350.18","other","Multiple Surgery"
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","outpatient","","","415.00","311.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","818.72","29","176.45","350.18","other","Multiple Surgery"
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","outpatient","","","415.00","311.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","1291.62","20","176.45","350.18","other","Multiple Surgery"
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","outpatient","","","415.00","311.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","318.02","318.02","318.02","1 through 10","176.45","350.18","other","Multiple Surgery"
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","outpatient","","","415.00","311.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","339.14","81.72","","321.36","321.36","321.36","1 through 10","176.45","350.18","percent of total billed charges",""
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","outpatient","","","415.00","311.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","339.14","81.72","","321.36","321.36","321.36","1 through 10","176.45","350.18","percent of total billed charges",""
"Inject Intralesnal >7 Lesions","PX-76000100","CDM","11901","CPT","0761","RC","","","","outpatient","","","415.00","311.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","339.14","81.72","","176.76","176.76","321.36","1 through 10","176.45","350.18","percent of total billed charges",""
"Inject Nerv Blck,Paracervical","PX-98301587","CDM","64435","CPT","0983","RC","","","","outpatient","","","191.00","143.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","389.94","389.94","389.94","1 through 10","106.77","1234.13","other","Multiple Surgery"
"Inject Nerv Blck,Paracervical","PX-98301587","CDM","64435","CPT","0983","RC","","","","outpatient","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","156.09","81.72","","972.87","535.11","972.87","1 through 10","106.77","1234.13","percent of total billed charges",""
"Inject Sentinel Node ID|BILATERAL PROCEDURE","PX-76001212","CDM","38792","CPT","0761","RC","","","50","outpatient","","","906.00","679.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","606.36","","Case rate ($606.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","702.77","702.77","702.77","1 through 10","606.36","2202.91","other","ASC "
"Inject Single Tendon Origin/Insert","PX-76000288","CDM","20551","CPT","0761","RC","","","","both","","","718.00","538.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","39.98","39.98","39.98","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Single Tendon Origin/Insert","PX-76000288","CDM","20551","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.99","38.3","","272.14","96.18","272.14","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Single Tendon Origin/Insert","PX-76000288","CDM","20551","CPT","0761","RC","","","","both","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","261.62","39.59","261.62","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Single Tendon Origin/Insert","PX-76000288","CDM","20551","CPT","0761","RC","","","","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","398.12","398.12","398.12","1 through 10","247.48","700.33","other","ASC"
"Inject Single Tendon Origin/Insert","PX-76000288","CDM","20551","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","574.15","47.10","574.15","1 through 10","247.48","700.33","other","Multiple Surgery"
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","both","","","718.00","538.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","360.73","360.73","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","both","","","718.00","538.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.81","79.5","","547.75","367.49","547.75","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","both","","","718.00","538.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","382.69","53.3","","547.75","351.48","547.75","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","both","","","718.00","538.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","32","222.58","570.81","other","OPPS APC"
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","262.07","36.5","","259.61","259.61","259.61","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.99","38.3","","272.14","264.48","272.14","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","316.79","343.55","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","both","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.95","316.79","350.56","16","222.58","570.81","other","OPPS APC"
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","both","","","718.00","538.50","WELLPOINT [1015]","HB AMC WELLPOINT","529.74","73.78","","518.17","518.17","518.17","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","outpatient","","","718.00","538.50","AETNA [1001]","HB AMC AETNA HMO","501.16","69.8","","471.19","332.69","471.19","1 through 10","247.48","700.33","percent of total billed charges",""
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","outpatient","","","718.00","538.50","AETNA [1001]","HB AMC AETNA PPO","577.27","80.4","","942.38","942.38","942.38","1 through 10","247.48","700.33","percent of total billed charges",""
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","662.53","662.53","662.53","1 through 10","247.48","700.33","other","ASC "
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","608.80","608.80","608.80","1 through 10","247.48","700.33","other","Multiple Surgery"
"Inject Single Tendon/Ligament","PX-76000287","CDM","20550","CPT","0761","RC","","","","outpatient","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","586.75","81.72","","306.03","306.03","306.03","1 through 10","247.48","700.33","percent of total billed charges",""
"Inject Single Tendon/Ligament|BILATERAL PROCEDURE","PX-76000287","CDM","20550","CPT","0761","RC","","","50","both","","","718.00","538.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","525.83","525.83","1 through 10","333.03","438.15","other","OPPS APC"
"Inject Single Tendon/Ligament|BILATERAL PROCEDURE","PX-76000287","CDM","20550","CPT","0761","RC","","","50","both","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","475.19","475.19","475.19","1 through 10","333.03","438.15","other","OPPS APC"
"Inject Single Tendon/Ligament|BILATERAL PROCEDURE","PX-76000287","CDM","20550","CPT","0761","RC","","","50","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","868.57","852.86","868.57","1 through 10","424.52","1421.77","other","ASC"
"Inject Single Tendon/Ligament|BILATERAL PROCEDURE","PX-76000287","CDM","20550","CPT","0761","RC","","","50","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","984.04","984.04","993.80","1 through 10","424.52","1421.77","other","ASC "
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","718.00","538.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","361.53","360.73","361.63","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","696.00","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","718.00","538.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.81","79.5","","547.75","547.75","8425.62","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","718.00","538.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","718.00","538.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","696.00","48","222.58","570.81","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","718.00","538.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.21","38.21","38.21","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","262.07","36.5","","259.61","259.61","259.61","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.99","38.3","","272.14","64.52","5179.97","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","343.55","343.55","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","718.00","538.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","37.45","344.95","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","348.43","343.55","350.56","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","718.00","538.50","WELLPOINT [1015]","HB AMC WELLPOINT","529.74","73.78","","518.17","518.17","518.17","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","718.00","538.50","AETNA [1001]","HB AMC AETNA HMO","501.16","69.8","","671.58","332.69","942.38","1 through 10","247.48","700.33","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","579.04","289.52","678.00","1 through 10","247.48","700.33","other","ASC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","765.45","656.02","767.34","36","247.48","700.33","other","ASC "
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","574.15","574.15","861.24","1 through 10","247.48","700.33","other","Multiple Surgery"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","603.85","90.75","603.85","1 through 10","247.48","700.33","other","Multiple Surgery"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","603.85","603.85","603.85","1 through 10","247.48","700.33","other","Multiple Surgery"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","586.75","81.72","","556.38","556.38","13838.41","1 through 10","247.48","700.33","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","361.53","333.43","361.63","21","222.58","570.81","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","21.39","344.95","37","222.58","570.81","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.81","79.5","","547.75","168.19","547.75","31","222.58","570.81","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","382.69","53.3","","367.49","168.19","547.75","47","222.58","570.81","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","42.77","344.95","14","222.58","570.81","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","HUMANA [1012]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","345.65","42.86","345.65","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","696.00","178","222.58","570.81","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.47","43.47","43.47","24","222.58","570.81","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","222.58","31","","215.06","215.06","215.06","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","262.07","36.5","","259.61","67.14","259.61","24","222.58","570.81","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.99","38.3","","272.14","70.38","272.14","101","222.58","570.81","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","316.79","343.55","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","552.86","77","","535.92","535.92","535.92","1 through 10","222.58","570.81","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","307.09","273.56","333.03","1 through 10","222.58","570.81","other","Tricare OPPS"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","343.55","343.55","1 through 10","222.58","570.81","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","323.26","350.56","60","222.58","570.81","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","718.00","538.50","WELLPOINT [1015]","HB AMC WELLPOINT","529.74","73.78","","518.17","518.17","652.18","29","222.58","570.81","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","718.00","538.50","AETNA [1001]","HB AMC AETNA HMO","501.16","69.8","","471.19","332.69","11464.83","16","247.48","700.33","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","718.00","538.50","AETNA [1001]","HB AMC AETNA PPO","577.27","80.4","","683.28","542.88","4370.16","1 through 10","247.48","700.33","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","692.95","568.57","820.38","118","247.48","700.33","other","ASC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","780.40","656.02","820.38","273","247.48","700.33","other","ASC "
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","717.69","633.55","721.93","1 through 10","247.48","700.33","other","Multiple Surgery"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","574.15","287.08","574.15","30","247.48","700.33","other","Multiple Surgery"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","603.85","180.00","1811.55","18","247.48","700.33","other","Multiple Surgery"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","581.58","581.58","581.58","1 through 10","247.48","700.33","other","Multiple Surgery"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","718.00","538.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","633.55","608.80","633.55","20","247.48","700.33","other","Multiple Surgery"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","586.75","81.72","","556.38","306.03","700.27","41","247.48","700.33","percent of total billed charges",""
"Inject Urethrocystogram Retro","PX-76001255","CDM","51610","CPT","0761","RC","","","","both","","","504.00","378.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","400.68","79.5","","384.84","258.19","384.84","1 through 10","156.24","400.68","percent of total billed charges",""
"Inject Urethrocystogram Retro","PX-76001255","CDM","51610","CPT","0761","RC","","","","both","","","504.00","378.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","268.63","53.3","","258.19","258.19","258.19","1 through 10","156.24","400.68","percent of total billed charges",""
"Inject Wrist Arthrogram","PX-76000442","CDM","25246","CPT","0761","RC","","","","outpatient","","","554.00","415.50","AETNA [1001]","HB AMC AETNA PPO","445.42","80.4","","418.86","418.86","418.86","1 through 10","126.25","452.73","percent of total billed charges",""
"Injection Aa&/Strd Genicular Nrv Branches W/Img","PX-76002664","CDM","64454","CPT","0761","RC","","","","both","","","1374.00","1030.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.47","746.68","813.87","1 through 10","425.94","1305.3","other","OPPS APC"
"Injection Aa&/Strd Genicular Nrv Branches W/Img","PX-98301900","CDM","64454","CPT","0983","RC","","","","both","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.47","746.68","813.87","1 through 10","132.06","1027.91","other","OPPS APC"
"Injection Aa&/Strd Nerves Nrvtg Si Joint W/Img","PX-76002663","CDM","64451","CPT","0761","RC","","","","both","","","1328.00","996.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1211.42","805.97","1216.85","1 through 10","411.68","1055.76","other","OPPS APC"
"Injection Aa&/Strd Nerves Nrvtg Si Joint W/Img","PX-98301899","CDM","64451","CPT","0983","RC","","","","both","","","413.00","309.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1211.42","805.97","1216.85","1 through 10","128.03","1027.91","other","OPPS APC"
"Injection Anesthetic Agent Pudendal Nerve","PX-98301703","CDM","64430","CPT","0983","RC","","","","both","","","567.00","425.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1043.63","1043.63","1043.63","1 through 10","175.77","1321.46","other","OPPS APC"
"Injection Anesthetic Agent Pudendal Nerve|BILATERAL PROCEDURE","PX-98301703","CDM","64430","CPT","0983","RC","","","50","both","","","567.00","425.25","MEDICARE [2001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1585.91","1585.91","1585.91","1 through 10","1004.41","1321.46","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","1291.00","968.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1026.35","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","1291.00","968.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1026.35","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","1291.00","968.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","688.10","53.3","","477.31","477.31","477.31","1 through 10","333.03","1026.35","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","1291.00","968.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1026.35","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","1291.00","968.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1026.35","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","1291.00","968.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","471.22","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1026.35","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","1291.00","968.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","494.45","38.3","","343.52","323.76","353.46","1 through 10","333.03","1026.35","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","1291.00","968.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1026.35","other","Tricare OPPS"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","1291.00","968.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1026.35","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","1291.00","968.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1026.35","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","1291.00","968.25","WELLPOINT [1015]","HB AMC WELLPOINT","952.50","73.78","","673.03","673.03","673.03","1 through 10","333.03","1026.35","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","outpatient","","","1291.00","968.25","AETNA [1001]","HB AMC AETNA HMO","901.12","69.8","","612.01","612.01","1224.02","1 through 10","645.5","1065.08","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","outpatient","","","1291.00","968.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","781.70","60.55","","579.04","568.57","904.00","30","645.5","1065.08","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","outpatient","","","1291.00","968.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","674.16","52.22","","904.00","656.02","2938.00","26","645.5","1065.08","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","outpatient","","","1291.00","968.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","645.50","50","","1421.10","875.08","2368.50","15","645.5","1065.08","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","outpatient","","","1291.00","968.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","677.78","52.5","","2985.00","904.00","2985.00","1 through 10","645.5","1065.08","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","outpatient","","","1291.00","968.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1055.01","81.72","","722.66","722.66","17449.00","1 through 10","645.5","1065.08","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","581.00","435.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","180.11","461.9","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","581.00","435.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","180.11","461.9","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","581.00","435.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","309.67","53.3","","477.31","477.31","477.31","1 through 10","180.11","461.9","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","581.00","435.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","180.11","461.9","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","581.00","435.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","180.11","461.9","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","581.00","435.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","212.07","36.5","","1095.87","337.19","1095.87","1 through 10","180.11","461.9","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","581.00","435.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","222.52","38.3","","343.52","323.76","353.46","1 through 10","180.11","461.9","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","581.00","435.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","180.11","461.9","other","Tricare OPPS"
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","581.00","435.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","180.11","461.9","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","180.11","461.9","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","581.00","435.75","WELLPOINT [1015]","HB AMC WELLPOINT","428.66","73.78","","673.03","673.03","673.03","1 through 10","180.11","461.9","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","outpatient","","","581.00","435.75","AETNA [1001]","HB AMC AETNA HMO","405.54","69.8","","612.01","612.01","1224.02","1 through 10","290.5","700.33","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","outpatient","","","581.00","435.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","351.80","60.55","","579.04","568.57","904.00","30","290.5","700.33","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","outpatient","","","581.00","435.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","303.40","52.22","","904.00","656.02","2938.00","26","290.5","700.33","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","outpatient","","","581.00","435.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","290.50","50","","1421.10","875.08","2368.50","15","290.5","700.33","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","outpatient","","","581.00","435.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","305.03","52.5","","2985.00","904.00","2985.00","1 through 10","290.5","700.33","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","outpatient","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","474.79","81.72","","722.66","722.66","17449.00","1 through 10","290.5","700.33","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","both","","","37.00","27.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","24.27","65.6","","0.33","0.33","0.33","1 through 10","11.47","29.42","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","both","","","37.00","27.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","24.05","65","","0.63","0.63","0.63","12","11.47","29.42","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","both","","","37.00","27.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","25.90","70","","0.48","0.48","0.48","1 through 10","11.47","29.42","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","both","","","37.00","27.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","29.42","79.5","","0.33","0.22","1.05","295","11.47","29.42","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","both","","","37.00","27.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19.72","53.3","","0.23","0.05","0.57","99","11.47","29.42","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","both","","","37.00","27.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","24.05","65","","0.31","0.10","2.02","29","11.47","29.42","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","both","","","37.00","27.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","29.42","79.5","","0.04","0.04","3.03","1 through 10","11.47","29.42","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","both","","","37.00","27.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13.51","36.5","","0.18","0.18","1.28","323","11.47","29.42","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","both","","","37.00","27.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.17","38.3","","0.19","0.18","0.57","456","11.47","29.42","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","both","","","37.00","27.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","28.49","77","","0.37","0.33","0.37","17","11.47","29.42","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","both","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.87","42.9","","0.24","0.19","0.24","30","11.47","29.42","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","both","","","37.00","27.75","WELLPOINT [1015]","HB AMC WELLPOINT","27.30","73.78","","0.27","0.10","0.31","164","11.47","29.42","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","outpatient","","","37.00","27.75","AETNA [1001]","HB AMC AETNA HMO","25.83","69.8","","0.32","0.06","0.92","309","17.91","30.24","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","outpatient","","","37.00","27.75","AETNA [1001]","HB AMC AETNA PPO","29.75","80.4","","0.38","0.25","1.05","45","17.91","30.24","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","outpatient","","","37.00","27.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","29.75","80.4","","0.38","0.36","0.38","44","17.91","30.24","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","outpatient","","","37.00","27.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","30.24","81.72","","1.91","0.96","1.91","1 through 10","17.91","30.24","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","outpatient","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","30.24","81.72","","0.24","0.19","0.24","20","17.91","30.24","percent of total billed charges",""
"Injection Dexamethasone Sod Phos 1mg (Newborn Referral)","PX-25001015","CDM","J1100","HCPCS","0250","RC","","","","outpatient","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","30.24","81.72","","0.24","0.19","0.48","245","17.91","30.24","percent of total billed charges",""
"Injection Dopamine Hcl 40 Mg (Newborn Referral)","PX-25001014","CDM","J1265","HCPCS","0250","RC","","","","both","","","99.00","74.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","78.71","79.5","","2.06","2.06","2.06","1 through 10","30.69","78.71","percent of total billed charges",""
"Injection for Bladder X-Ray","PX-98301340","CDM","51600","CPT","0983","RC","","","","both","","","832.00","624.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","661.44","79.5","","259.71","259.71","259.71","1 through 10","257.92","661.44","percent of total billed charges",""
"Injection for Bladder X-Ray","PX-98301340","CDM","51600","CPT","0983","RC","","","","both","","","832.00","624.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","540.80","65","","214.50","214.50","214.50","1 through 10","257.92","661.44","percent of total billed charges",""
"Injection for Bladder X-Ray","PX-98301340","CDM","51600","CPT","0983","RC","","","","both","","","832.00","624.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","303.68","36.5","","123.09","123.09","123.09","1 through 10","257.92","661.44","percent of total billed charges",""
"Injection for Bladder X-Ray","PX-98301340","CDM","51600","CPT","0983","RC","","","","both","","","832.00","624.00","WELLPOINT [1015]","HB AMC WELLPOINT","613.85","73.78","","245.69","245.69","245.69","1 through 10","257.92","661.44","percent of total billed charges",""
"Injection for Bladder X-Ray","PX-98301340","CDM","51600","CPT","0983","RC","","","","outpatient","","","832.00","624.00","AETNA [1001]","HB AMC AETNA HMO","580.74","69.8","","257.40","157.74","257.40","1 through 10","152.68","679.91","percent of total billed charges",""
"Injection for Bladder X-Ray","PX-98301340","CDM","51600","CPT","0983","RC","","","","outpatient","","","832.00","624.00","AETNA [1001]","HB AMC AETNA PPO","668.93","80.4","","257.40","257.40","257.40","1 through 10","152.68","679.91","percent of total billed charges",""
"Injection Procedure Myelography/CT Lumbar","PX-36000346","CDM","62284","CPT","0361","RC","","","","both","","","642.00","481.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","510.39","79.5","","328.94","328.94","328.94","1 through 10","199.02","510.39","percent of total billed charges",""
"Injection Procedure Myelography/CT Lumbar","PX-36000346","CDM","62284","CPT","0361","RC","","","","both","","","642.00","481.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","342.19","53.3","","328.94","328.94","328.94","1 through 10","199.02","510.39","percent of total billed charges",""
"Injection Procedure Myelography/CT Lumbar","PX-36000346","CDM","62284","CPT","0361","RC","","","","both","","","642.00","481.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","234.33","36.5","","592.47","197.49","592.47","1 through 10","199.02","510.39","percent of total billed charges",""
"Injection Procedure Myelography/CT Lumbar","PX-36000346","CDM","62284","CPT","0361","RC","","","","both","","","642.00","481.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.89","38.3","","243.59","243.59","243.59","1 through 10","199.02","510.39","percent of total billed charges",""
"Injection Procedure Myelography/CT Lumbar","PX-36000346","CDM","62284","CPT","0361","RC","","","","outpatient","","","642.00","481.50","AETNA [1001]","HB AMC AETNA HMO","448.12","69.8","","485.94","485.94","485.94","1 through 10","149.48","524.64","percent of total billed charges",""
"Injection Procedure Myelography/CT Lumbar","PX-98301694","CDM","62284","CPT","0983","RC","","","","both","","","834.00","625.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","663.03","79.5","","328.94","328.94","328.94","1 through 10","258.54","663.03","percent of total billed charges",""
"Injection Procedure Myelography/CT Lumbar","PX-98301694","CDM","62284","CPT","0983","RC","","","","both","","","834.00","625.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","444.52","53.3","","328.94","328.94","328.94","1 through 10","258.54","663.03","percent of total billed charges",""
"Injection Procedure Myelography/CT Lumbar","PX-98301694","CDM","62284","CPT","0983","RC","","","","both","","","834.00","625.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","304.41","36.5","","592.47","197.49","592.47","1 through 10","258.54","663.03","percent of total billed charges",""
"Injection Procedure Myelography/CT Lumbar","PX-98301694","CDM","62284","CPT","0983","RC","","","","both","","","834.00","625.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","319.42","38.3","","243.59","243.59","243.59","1 through 10","258.54","663.03","percent of total billed charges",""
"Injection Procedure Myelography/CT Lumbar","PX-98301694","CDM","62284","CPT","0983","RC","","","","outpatient","","","834.00","625.50","AETNA [1001]","HB AMC AETNA HMO","582.13","69.8","","485.94","485.94","485.94","1 through 10","363.97","681.54","percent of total billed charges",""
"Injection Remdesivir, 1 Mg","PX-63601353","CDM","J0248","HCPCS","0636","RC","","","","both","","","22.10","16.57","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","6.93","","APC Price ($6.73). Final payment is multiplied by 103%.","5.67","5.67","5.67","500","6.39","17.02","other","OPPS APC"
"Injection Remdesivir, 1 Mg","PX-63601353","CDM","J0248","HCPCS","0636","RC","","","","both","","","22.10","16.57","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6.59","","APC Price ($6.73). Final payment is multiplied by 98%.","6.22","6.22","6.22","200","6.39","17.02","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0510","RC","","","","inpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","84.90","78.61","","2744.02","2744.02","2744.02","1 through 10","59.72","85.86","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","86.97","43.67","87.33","49","33.48","105.64","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.59","37.83","84.52","91","33.48","105.64","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","77.54","71.8","","191.71","191.71","191.71","1 through 10","33.48","105.64","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","70.85","65.6","","87.33","87.33","87.33","1 through 10","33.48","105.64","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","75.60","70","","192.24","114.81","207.77","13","33.48","105.64","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","105.64","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","84.52","59.94","84.52","1 through 10","33.48","105.64","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","85.86","79.5","","210.13","140.98","630.39","72","33.48","105.64","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","57.56","53.3","","210.13","140.98","210.13","34","33.48","105.64","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.59","20.79","83.17","41","33.48","105.64","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","ELDER SERVICES [1037]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","76.89","76.89","76.89","1 through 10","33.48","105.64","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.70","150.70","150.70","1 through 10","33.48","105.64","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","HUMANA [1012]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","83.34","82.83","84.52","1 through 10","33.48","105.64","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","70.20","65","","0.74","0.74","0.74","1 through 10","33.48","105.64","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","38.45","84.52","1857","33.48","105.64","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","33.48","31","","82.51","82.51","82.51","1 through 10","33.48","105.64","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","39.42","36.5","","99.59","84.64","99.59","145","33.48","105.64","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","41.36","38.3","","104.40","104.40","208.79","403","33.48","105.64","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.83","75.35","248.49","30","33.48","105.64","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","TRICARE [160005]","HB BWH TRICARE","80.29","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","80.29","73.04","80.29","1 through 10","33.48","105.64","other","Tricare OPPS"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","41.42","20.71","151.32","73","33.48","105.64","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","184.23","61.41","184.23","1 through 10","33.48","105.64","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.33","42.9","","117.40","117.40","213.44","19","33.48","105.64","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","41.59","84.52","301","33.48","105.64","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","outpatient","","","108.00","81.00","AETNA [1001]","HB AMC AETNA HMO","75.38","69.8","","180.76","127.63","208.26","140","60.37","315.07","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","outpatient","","","108.00","81.00","AETNA [1001]","HB AMC AETNA PPO","86.83","80.4","","208.26","86.97","208.26","1 through 10","60.37","315.07","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","outpatient","","","108.00","81.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","86.83","80.4","","208.26","208.26","208.26","1 through 10","60.37","315.07","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","88.26","81.72","","213.44","213.44","213.44","1 through 10","60.37","315.07","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","88.26","81.72","","213.44","117.40","267.00","74","60.37","315.07","percent of total billed charges",""
"Injection, Adenosine, 1 Mg","PX-63601121","CDM","J0153","HCPCS","0636","RC","","","","both","","","11.83","8.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","7.76","65.6","","0.70","0.70","0.70","60","1.31","9.11","percent of total billed charges",""
"Injection, Adenosine, 1 Mg","PX-63601121","CDM","J0153","HCPCS","0636","RC","","","","both","","","11.83","8.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7.69","65","","56.21","56.21","56.21","1 through 10","1.31","9.11","percent of total billed charges",""
"Injection, Cabotegravir, 1 Mg","PX-63601401","CDM","J0739","HCPCS","0636","RC","","","","both","","","93.84","70.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34.25","36.5","","9.26","9.04","10.90","3000","6.88","89.15","percent of total billed charges",""
"Injection, Cabotegravir, 1 Mg","PX-63601401","CDM","J0739","HCPCS","0636","RC","","","","both","","","93.84","70.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35.94","38.3","","11.15","10.60","11.43","6000","6.88","89.15","percent of total billed charges",""
"Injection, Cabotegravir, 1 Mg","PX-63601401","CDM","J0739","HCPCS","0636","RC","","","","outpatient","","","93.84","70.38","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","46.92","50","","27.46","14.94","27.46","1800","9.86","77.42","percent of total billed charges",""
"Injection, Cabotegravir, 1 Mg","PX-63601401","CDM","J0739","HCPCS","0636","RC","","","","outpatient","","","93.84","70.38","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","49.27","52.5","","9408.95","8828.99","9408.95","1 through 10","9.86","77.42","percent of total billed charges",""
"Injection, Epoetin Alfa-Epbx, Biosimilar, (Retacrit) (for Esrd on Dialysis), 100 Units","PX-63500002","CDM","Q5105","HCPCS","0635","RC","","","","both","","","3.87","2.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2.52","65","","142.91","142.91","142.91","1 through 10","0.72","3.08","percent of total billed charges",""
"Injection, Epoetin Alfa-Epbx, Biosimilar, (Retacrit) (for Esrd on Dialysis), 100 Units","PX-63500002","CDM","Q5105","HCPCS","0635","RC","","","","both","","","3.87","2.90","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","0.77","","APC Price ($0.79). Final payment is multiplied by 98%.","0.69","0.69","0.69","60","0.72","3.08","other","OPPS APC"
"INJECTOR PELLET 1.25 3MM OSTEOSET BONE GRAFT RADIOPAQUE","SUP-ITM-10005463","CDM","C1713","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1129.70","79.5","","800.18","480.96","1887.97","195","440.51","1129.7","percent of total billed charges",""
"INJECTOR PELLET 1.25 3MM OSTEOSET BONE GRAFT RADIOPAQUE","SUP-ITM-10005463","CDM","C1713","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","757.39","53.3","","813.12","216.42","1444.50","81","440.51","1129.7","percent of total billed charges",""
"INJECTOR PELLET 1.25 3MM OSTEOSET BONE GRAFT RADIOPAQUE","SUP-ITM-10005463","CDM","C1713","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","440.51","31","","432.60","432.60","432.60","1 through 10","440.51","1129.7","percent of total billed charges",""
"INJECTOR PELLET 1.25 3MM OSTEOSET BONE GRAFT RADIOPAQUE","SUP-ITM-10005463","CDM","C1713","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","518.67","36.5","","148.37","54.89","631.39","94","440.51","1129.7","percent of total billed charges",""
"INJECTOR PELLET 1.25 3MM OSTEOSET BONE GRAFT RADIOPAQUE","SUP-ITM-10005463","CDM","C1713","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","544.24","38.3","","279.30","91.72","1116.77","266","440.51","1129.7","percent of total billed charges",""
"INJECTOR PELLET 1.25 3MM OSTEOSET BONE GRAFT RADIOPAQUE","SUP-ITM-10005463","CDM","C1713","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","609.61","42.9","","731.00","63.70","731.00","1 through 10","440.51","1129.7","percent of total billed charges",""
"INJECTOR PELLET 1.25 3MM OSTEOSET BONE GRAFT RADIOPAQUE","SUP-ITM-10005463","CDM","C1713","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","609.61","42.9","","384.74","384.74","384.74","1 through 10","440.51","1129.7","percent of total billed charges",""
"INJECTOR PELLET 1.25 3MM OSTEOSET BONE GRAFT RADIOPAQUE","SUP-ITM-10005463","CDM","C1713","HCPCS","0278","RC","","","","both","","","1421.00","1065.75","WELLPOINT [1015]","HB AMC WELLPOINT","1048.41","73.78","","286.63","119.22","1107.45","105","440.51","1129.7","percent of total billed charges",""
"INJECTOR PELLET 1.25 3MM OSTEOSET BONE GRAFT RADIOPAQUE","SUP-ITM-10005463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1421.00","1065.75","AETNA [1001]","HB AMC AETNA HMO","991.86","69.8","","675.31","184.75","1721.50","286","742.61","1161.24","percent of total billed charges",""
"INJECTOR PELLET 1.25 3MM OSTEOSET BONE GRAFT RADIOPAQUE","SUP-ITM-10005463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1421.00","1065.75","AETNA [1001]","HB AMC AETNA PPO","1142.48","80.4","","1261.44","103.12","1514.10","21","742.61","1161.24","percent of total billed charges",""
"INJECTOR PELLET 1.25 3MM OSTEOSET BONE GRAFT RADIOPAQUE","SUP-ITM-10005463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1421.00","1065.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1142.48","80.4","","1365.00","1365.00","1365.00","1 through 10","742.61","1161.24","percent of total billed charges",""
"INJECTOR PELLET 1.25 3MM OSTEOSET BONE GRAFT RADIOPAQUE","SUP-ITM-10005463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1421.00","1065.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1161.24","81.72","","5157.68","5157.68","5157.68","1 through 10","742.61","1161.24","percent of total billed charges",""
"INJECTOR PELLET 1.25 3MM OSTEOSET BONE GRAFT RADIOPAQUE","SUP-ITM-10005463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1421.00","1065.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1161.24","81.72","","431.26","71.26","1459.57","88","742.61","1161.24","percent of total billed charges",""
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","both","","","5261.00","3945.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3451.22","65.6","","3369.43","3369.43","3369.43","1 through 10","789.41","4182.5","percent of total billed charges",""
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","both","","","5261.00","3945.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4182.50","79.5","","1025.44","1025.44","1025.44","1 through 10","789.41","4182.5","percent of total billed charges",""
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","both","","","5261.00","3945.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3419.65","65","","3235.05","884.00","3235.05","30","789.41","4182.5","percent of total billed charges",""
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","both","","","5261.00","3945.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","3419.65","65","","4666.88","2917.65","4666.88","1 through 10","789.41","4182.5","percent of total billed charges",""
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","both","","","5261.00","3945.75","MEDICARE [2001]","HB BWH MEDICARE","830.88","","APC Price ($830.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","830.96","830.96","830.96","1 through 10","789.41","4182.5","other","OPPS APC"
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","both","","","5261.00","3945.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1920.27","36.5","","3603.34","3603.34","3603.34","1 through 10","789.41","4182.5","percent of total billed charges",""
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","outpatient","","","5261.00","3945.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2630.50","50","","2137.92","2137.92","2607.95","1 through 10","1405.4","4340.33","percent of total billed charges",""
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","outpatient","","","5261.00","3945.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4229.84","80.4","","2488.52","2488.50","2488.52","1 through 10","1405.4","4340.33","percent of total billed charges",""
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","both","","","20212.00","15159.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12426.95","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11468.03","11468.03","11468.03","1 through 10","6265.72","16068.54","other","OPPS APC"
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","both","","","20212.00","15159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7377.38","36.5","","7310.80","7310.80","7310.80","1 through 10","6265.72","16068.54","percent of total billed charges",""
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","both","","","20212.00","15159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7741.20","38.3","","7663.60","7663.60","7663.60","1 through 10","6265.72","16068.54","percent of total billed charges",""
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","both","","","20212.00","15159.00","TRICARE [160005]","HB BWH TRICARE","11806.80","","APC Price ($12,428.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","11654.50","11654.50","11654.50","1 through 10","6265.72","16068.54","other","Tricare OPPS"
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","both","","","20212.00","15159.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12178.41","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","12187.15","11421.41","12428.21","1 through 10","6265.72","16068.54","other","OPPS APC"
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","both","","","20212.00","15159.00","WELLPOINT [1015]","HB AMC WELLPOINT","14912.41","73.78","","14592.20","14592.20","14592.20","1 through 10","6265.72","16068.54","percent of total billed charges",""
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","outpatient","","","20212.00","15159.00","AETNA [1001]","HB AMC AETNA HMO","14107.98","69.8","","12694.72","9368.80","12694.72","1 through 10","6421.57","26484.33","percent of total billed charges",""
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","outpatient","","","20212.00","15159.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","11297.59","","Case rate ($11,297.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","23114.87","19600.00","23114.87","1 through 10","6421.57","26484.33","other","ASC"
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","outpatient","","","20212.00","15159.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","11297.59","","Case rate ($11,297.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","26447.66","22696.86","26447.66","1 through 10","6421.57","26484.33","other","ASC "
"Ins New/ Repl Perm Pacemaker Atrial","PX-48000043","CDM","33206","CPT","0361","RC","","","","both","","","13116.00","9837.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12178.41","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20841.28","20841.28","20841.28","1 through 10","4065.96","15533.69","other","OPPS APC"
"Ins Vena Cava Filter Endovascular","PX-76001134","CDM","37191","CPT","0361","RC","","","","both","","","10393.00","7794.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","6611.51","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","6172.69","6172.69","6172.69","1 through 10","3221.83","8262.44","other","OPPS APC"
"Ins Vena Cava Filter Endovascular","PX-76001134","CDM","37191","CPT","0361","RC","","","","both","","","10393.00","7794.75","MEDICARE [2001]","HB BWH MEDICARE","6418.94","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6419.59","6419.59","6419.59","1 through 10","3221.83","8262.44","other","OPPS APC"
"Ins Vena Cava Filter Endovascular","PX-76001134","CDM","37191","CPT","0361","RC","","","","both","","","10393.00","7794.75","WELLPOINT [1015]","HB AMC WELLPOINT","7667.96","73.78","","7503.82","7503.82","7503.82","1 through 10","3221.83","8262.44","percent of total billed charges",""
"Ins Vena Cava Filter Endovascular","PX-76001134","CDM","37191","CPT","0361","RC","","","","outpatient","","","10393.00","7794.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5004.80","","Case rate ($5,004.80). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","11601.13","11601.13","11601.13","1 through 10","3938.87","15696.44","other","ASC "
"Ins/Rplcmnt Perm Subq Impltbl Dfb W/Subq Eltrd","PX-36000309","CDM","33270","CPT","0480","RC","","","","both","","","19300.00","14475.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15343.50","79.5","","11206.70","11206.70","11206.70","1 through 10","5983","47589","percent of total billed charges",""
"Ins/Rplcmnt Perm Subq Impltbl Dfb W/Subq Eltrd","PX-36000309","CDM","33270","CPT","0480","RC","","","","both","","","19300.00","14475.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","12545.00","65","","12165.40","12165.40","12165.40","1 through 10","5983","47589","percent of total billed charges",""
"Ins/Rplcmnt Perm Subq Impltbl Dfb W/Subq Eltrd","PX-36000309","CDM","33270","CPT","0480","RC","","","","both","","","19300.00","14475.00","MEDICARE [2001]","HB BWH MEDICARE","38071.20","","APC Price ($38,071.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","71813.64","38075.05","107720.46","1 through 10","5983","47589","other","OPPS APC"
"Ins/Rplcmnt Perm Subq Impltbl Dfb W/Subq Eltrd","PX-36000309","CDM","33270","CPT","0480","RC","","","","both","","","19300.00","14475.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7044.50","36.5","","49243.83","49243.83","49243.83","1 through 10","5983","47589","percent of total billed charges",""
"Ins/Rplcmnt Perm Subq Impltbl Dfb W/Subq Eltrd","PX-36000309","CDM","33270","CPT","0480","RC","","","","both","","","19300.00","14475.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","14861.00","77","","44491.05","44491.05","44491.05","1 through 10","5983","47589","percent of total billed charges",""
"Ins/Rplcmnt Perm Subq Impltbl Dfb W/Subq Eltrd","PX-36000309","CDM","33270","CPT","0480","RC","","","","both","","","19300.00","14475.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","37309.78","","APC Price ($38,071.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","37321.05","37321.05","37321.05","1 through 10","5983","47589","other","OPPS APC"
"Ins/Rplcmnt Perm Subq Impltbl Dfb W/Subq Eltrd","PX-36000309","CDM","33270","CPT","0480","RC","","","","outpatient","","","19300.00","14475.00","AETNA [1001]","HB AMC AETNA HMO","13471.40","69.8","","33314.48","33314.48","33314.48","1 through 10","10086.18","44740.96","percent of total billed charges",""
"Ins/Rplcmnt Perm Subq Impltbl Dfb W/Subq Eltrd","PX-36000309","CDM","33270","CPT","0480","RC","","","","outpatient","","","19300.00","14475.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","35057.32","","Case rate ($35,057.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","70430.16","70430.16","82069.19","1 through 10","10086.18","44740.96","other","ASC"
"Ins/Rplcmnt Perm Subq Impltbl Dfb W/Subq Eltrd","PX-36000309","CDM","33270","CPT","0480","RC","","","","outpatient","","","19300.00","14475.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35057.32","","Case rate ($35,057.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","71727.28","71727.28","71727.28","1 through 10","10086.18","44740.96","other","ASC "
"Insemination Artificial Uterine","PX-76001385","CDM","58322","CPT","0761","RC","","","","both","","","450.00","337.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","357.75","79.5","","343.13","230.21","343.13","1 through 10","139.5","427.5","percent of total billed charges",""
"Insemination Artificial Uterine","PX-76001385","CDM","58322","CPT","0761","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","172.35","38.3","","165.68","165.68","165.68","1 through 10","139.5","427.5","percent of total billed charges",""
"Insemination Artificial Uterine","PX-76001385","CDM","58322","CPT","0761","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","238.90","217.48","238.90","1 through 10","139.5","427.5","other","OPPS APC"
"Insemination Artificial Uterine","PX-76001385","CDM","58322","CPT","0761","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB AMC WELLPOINT","332.01","73.78","","324.60","324.60","324.60","1 through 10","139.5","427.5","percent of total billed charges",""
"Insemination Artificial Uterine","PX-76001385","CDM","58322","CPT","0761","RC","","","","outpatient","","","450.00","337.50","AETNA [1001]","HB AMC AETNA HMO","314.10","69.8","","295.17","208.41","436.00","13","165.93","1234.13","percent of total billed charges",""
"Insemination Artificial Uterine","PX-76001385","CDM","58322","CPT","0761","RC","","","","outpatient","","","450.00","337.50","AETNA [1001]","HB AMC AETNA PPO","361.80","80.4","","340.08","340.08","340.08","1 through 10","165.93","1234.13","percent of total billed charges",""
"Insemination Artificial Uterine","PX-76001385","CDM","58322","CPT","0761","RC","","","","outpatient","","","450.00","337.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","388.23","381.21","388.23","1 through 10","165.93","1234.13","other","ASC"
"Insemination Artificial Uterine","PX-76001385","CDM","58322","CPT","0761","RC","","","","outpatient","","","450.00","337.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","444.20","439.84","444.20","42","165.93","1234.13","other","ASC "
"Insemination Artificial Uterine","PX-76001385","CDM","58322","CPT","0761","RC","","","","outpatient","","","450.00","337.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","370.02","370.02","370.02","1 through 10","165.93","1234.13","other","Multiple Surgery"
"Insemination Artificial Uterine","PX-76001385","CDM","58322","CPT","0761","RC","","","","outpatient","","","450.00","337.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","244.01","244.01","244.01","1 through 10","165.93","1234.13","other","Multiple Surgery"
"Insemination of Oocytes","PX-30000131","CDM","89268","CPT","0300","RC","","","","both","","","631.00","473.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","501.65","79.5","","323.14","323.14","323.14","1 through 10","195.61","599.45","percent of total billed charges",""
"Insemination of Oocytes","PX-30000131","CDM","89268","CPT","0300","RC","","","","both","","","631.00","473.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","336.32","53.3","","481.64","323.14","481.64","1 through 10","195.61","599.45","percent of total billed charges",""
"Insemination of Oocytes","PX-30000131","CDM","89268","CPT","0300","RC","","","","both","","","631.00","473.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","270.70","42.9","","489.23","489.23","489.23","1 through 10","195.61","599.45","percent of total billed charges",""
"Insemination of Oocytes","PX-30000131","CDM","89268","CPT","0300","RC","","","","both","","","631.00","473.25","WELLPOINT [1015]","HB AMC WELLPOINT","465.55","73.78","","1067.63","455.63","1067.63","1 through 10","195.61","599.45","percent of total billed charges",""
"Insemination of Oocytes","PX-30000131","CDM","89268","CPT","0300","RC","","","","outpatient","","","631.00","473.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","515.65","81.72","","269.10","269.10","489.23","1 through 10","329.51","887.19","percent of total billed charges",""
"INSERT 90DEG OBLIQUE L PLATE MATRIXORTHOGNATHIC SYSTEM","SUP-ITM-10079788","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.75","326.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","346.42","79.5","","800.18","480.96","1887.97","195","135.08","346.42","percent of total billed charges",""
"INSERT 90DEG OBLIQUE L PLATE MATRIXORTHOGNATHIC SYSTEM","SUP-ITM-10079788","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.75","326.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","232.25","53.3","","813.12","216.42","1444.50","81","135.08","346.42","percent of total billed charges",""
"INSERT 90DEG OBLIQUE L PLATE MATRIXORTHOGNATHIC SYSTEM","SUP-ITM-10079788","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.75","326.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","135.08","31","","432.60","432.60","432.60","1 through 10","135.08","346.42","percent of total billed charges",""
"INSERT 90DEG OBLIQUE L PLATE MATRIXORTHOGNATHIC SYSTEM","SUP-ITM-10079788","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.75","326.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","159.05","36.5","","148.37","54.89","631.39","94","135.08","346.42","percent of total billed charges",""
"INSERT 90DEG OBLIQUE L PLATE MATRIXORTHOGNATHIC SYSTEM","SUP-ITM-10079788","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.75","326.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","166.89","38.3","","279.30","91.72","1116.77","266","135.08","346.42","percent of total billed charges",""
"INSERT 90DEG OBLIQUE L PLATE MATRIXORTHOGNATHIC SYSTEM","SUP-ITM-10079788","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.75","326.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.94","42.9","","731.00","63.70","731.00","1 through 10","135.08","346.42","percent of total billed charges",""
"INSERT 90DEG OBLIQUE L PLATE MATRIXORTHOGNATHIC SYSTEM","SUP-ITM-10079788","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.75","326.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.94","42.9","","384.74","384.74","384.74","1 through 10","135.08","346.42","percent of total billed charges",""
"INSERT 90DEG OBLIQUE L PLATE MATRIXORTHOGNATHIC SYSTEM","SUP-ITM-10079788","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.75","326.81","WELLPOINT [1015]","HB AMC WELLPOINT","321.50","73.78","","286.63","119.22","1107.45","105","135.08","346.42","percent of total billed charges",""
"INSERT 90DEG OBLIQUE L PLATE MATRIXORTHOGNATHIC SYSTEM","SUP-ITM-10079788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.75","326.81","AETNA [1001]","HB AMC AETNA HMO","304.15","69.8","","675.31","184.75","1721.50","286","227.72","356.09","percent of total billed charges",""
"INSERT 90DEG OBLIQUE L PLATE MATRIXORTHOGNATHIC SYSTEM","SUP-ITM-10079788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.75","326.81","AETNA [1001]","HB AMC AETNA PPO","350.34","80.4","","1261.44","103.12","1514.10","21","227.72","356.09","percent of total billed charges",""
"INSERT 90DEG OBLIQUE L PLATE MATRIXORTHOGNATHIC SYSTEM","SUP-ITM-10079788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.75","326.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","350.34","80.4","","1365.00","1365.00","1365.00","1 through 10","227.72","356.09","percent of total billed charges",""
"INSERT 90DEG OBLIQUE L PLATE MATRIXORTHOGNATHIC SYSTEM","SUP-ITM-10079788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.75","326.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","356.09","81.72","","5157.68","5157.68","5157.68","1 through 10","227.72","356.09","percent of total billed charges",""
"INSERT 90DEG OBLIQUE L PLATE MATRIXORTHOGNATHIC SYSTEM","SUP-ITM-10079788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.75","326.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","356.09","81.72","","431.26","71.26","1459.57","88","227.72","356.09","percent of total billed charges",""
"Insert Afamelanotide Biodegradable Drug Implant","PX-76002736","CDM","17999","CPT","0761","RC","","","","both","","","573.00","429.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4490.63","3878.56","4490.63","1 through 10","177.63","455.54","other","OPPS APC"
"Insert Afamelanotide Biodegradable Drug Implant","PX-76002736","CDM","17999","CPT","0761","RC","","","","outpatient","","","573.00","429.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","299.22","52.22","","467.73","465.00","467.73","1 through 10","286.5","700.33","percent of total billed charges",""
"Insert Afamelanotide Biodegradable Drug Implant","PX-98302039","CDM","17999","CPT","0983","RC","","","","both","","","454.00","340.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4490.63","3878.56","4490.63","1 through 10","140.74","360.93","other","OPPS APC"
"Insert Afamelanotide Biodegradable Drug Implant","PX-98302039","CDM","17999","CPT","0983","RC","","","","outpatient","","","454.00","340.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","237.08","52.22","","467.73","465.00","467.73","1 through 10","227","700.33","percent of total billed charges",""
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3849.59","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3846.25","3579.77","6883.73","1 through 10","938.06","4671.83","other","OPPS APC"
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3678.04","2025.51","3678.04","1 through 10","938.06","4671.83","other","OPPS APC"
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1966.90","65","","2309.06","1549.15","2309.06","1 through 10","938.06","4671.83","percent of total billed charges",""
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2118.20","70","","1936.45","1058.83","2934.00","19","938.06","4671.83","percent of total billed charges",""
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2405.67","79.5","","1907.10","1549.15","2309.06","1 through 10","938.06","4671.83","percent of total billed charges",""
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3674.83","3674.83","3674.83","1 through 10","938.06","4671.83","other","OPPS APC"
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1966.90","65","","1851.20","1851.20","1851.20","1 through 10","938.06","4671.83","percent of total billed charges",""
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3663.09","3663.09","3672.59","1 through 10","938.06","4671.83","other","OPPS APC"
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","MEDICARE [2001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3478.89","3737.85","67","938.06","4671.83","other","OPPS APC"
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","938.06","31","","906.61","906.61","906.61","1 through 10","938.06","4671.83","percent of total billed charges",""
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3665.59","3665.59","3665.59","1 through 10","938.06","4671.83","other","OPPS APC"
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","TRICARE [160005]","HB BWH TRICARE","3550.95","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3737.85","3737.85","3737.85","1 through 10","938.06","4671.83","other","Tricare OPPS"
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3670.49","3409.31","3678.04","1 through 10","938.06","4671.83","other","OPPS APC"
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3737.85","3478.89","3737.85","1 through 10","938.06","4671.83","other","OPPS APC"
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","both","","","3026.00","2269.50","WELLPOINT [1015]","HB AMC WELLPOINT","2232.58","73.78","","2184.36","2184.36","2184.36","1 through 10","938.06","4671.83","percent of total billed charges",""
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","outpatient","","","3026.00","2269.50","AETNA [1001]","HB AMC AETNA HMO","2112.15","69.8","","1986.32","1986.32","1986.32","1 through 10","1093.63","2472.85","percent of total billed charges",""
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","outpatient","","","3026.00","2269.50","AETNA [1001]","HB AMC AETNA PPO","2432.90","80.4","","2288.52","2288.52","2288.52","1 through 10","1093.63","2472.85","percent of total billed charges",""
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","outpatient","","","3026.00","2269.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2512.52","2512.52","2558.79","18","1093.63","2472.85","other","ASC"
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","outpatient","","","3026.00","2269.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2898.96","2898.96","2927.72","51","1093.63","2472.85","other","ASC "
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","outpatient","","","3026.00","2269.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1093.63","","Case rate ($1,093.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2537.22","2537.22","2537.22","1 through 10","1093.63","2472.85","other","Multiple Surgery"
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","outpatient","","","3026.00","2269.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1093.63","","Case rate ($1,093.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5140.06","2345.44","5140.06","1 through 10","1093.63","2472.85","other","Multiple Surgery"
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","outpatient","","","3026.00","2269.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2472.85","81.72","","2345.44","2345.44","2345.44","1 through 10","1093.63","2472.85","percent of total billed charges",""
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","both","","","7503.00","5627.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","5252.10","70","","4034.95","395.00","4034.95","1 through 10","2325.93","5964.89","percent of total billed charges",""
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","both","","","7503.00","5627.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","4671.83","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","450.00","450.00","450.00","1 through 10","2325.93","5964.89","other","OPPS APC"
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","both","","","7503.00","5627.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5964.89","79.5","","4729.40","4729.40","4729.40","1 through 10","2325.93","5964.89","percent of total billed charges",""
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","both","","","7503.00","5627.25","MEDICARE [2001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3478.89","3478.89","3478.89","1 through 10","2325.93","5964.89","other","OPPS APC"
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","both","","","7503.00","5627.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3663.10","3663.10","3663.10","1 through 10","2325.93","5964.89","other","OPPS APC"
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","outpatient","","","7503.00","5627.25","AETNA [1001]","HB AMC AETNA HMO","5237.09","69.8","","4925.85","4925.85","4925.85","1 through 10","2377.37","6131.45","percent of total billed charges",""
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","3153.00","2364.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1815.28","1815.28","1815.28","1 through 10","977.43","2506.64","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","3153.00","2364.75","HUMANA [1012]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1810.40","1810.40","1810.40","1 through 10","977.43","2506.64","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","3153.00","2364.75","MEDICARE [2001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1844.80","1844.80","1 through 10","977.43","2506.64","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","outpatient","","","3153.00","2364.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2898.96","2898.96","2898.96","1 through 10","1093.63","5545.35","other","ASC "
"Insert Cath Pleural Indwel/Tunl W/","PX-76000826","CDM","32550","CPT","0761","RC","","","","both","","","8859.00","6644.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4123.91","4123.91","4123.91","1 through 10","2746.29","7042.91","other","OPPS APC"
"Insert Cath Pleural Indwel/Tunl W/","PX-76000826","CDM","32550","CPT","0761","RC","","","","both","","","8859.00","6644.25","MEDICARE [2001]","HB BWH MEDICARE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","4190.97","4190.97","1 through 10","2746.29","7042.91","other","OPPS APC"
"Insert Cath Pleural Indwel/Tunl W/","PX-76000826","CDM","32550","CPT","0761","RC","","","","both","","","8859.00","6644.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3393.00","38.3","","3260.94","3260.94","3260.94","1 through 10","2746.29","7042.91","percent of total billed charges",""
"Insert Cath Pleural Indwel/Tunl W/","PX-76000826","CDM","32550","CPT","0761","RC","","","","both","","","8859.00","6644.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4106.74","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4123.91","4114.55","4123.91","1 through 10","2746.29","7042.91","other","OPPS APC"
"Insert Cath Pleural Indwel/Tunl W/","PX-76000826","CDM","32550","CPT","0761","RC","","","","both","","","8859.00","6644.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4106.74","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4123.92","4123.92","4123.92","1 through 10","2746.29","7042.91","other","OPPS APC"
"Insert Cath Pleural Indwel/Tunl W/","PX-76000826","CDM","32550","CPT","0761","RC","","","","outpatient","","","8859.00","6644.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3370.43","","Case rate ($3,370.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6771.19","6771.19","6771.19","1 through 10","2652.59","7239.57","other","ASC"
"Insert Cath Pleural Indwel/Tunl W/","PX-76000826","CDM","32550","CPT","0761","RC","","","","outpatient","","","8859.00","6644.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3370.43","","Case rate ($3,370.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7890.18","7812.66","7890.18","1 through 10","2652.59","7239.57","other","ASC "
"Insert Cath Pleural Indwel/Tunl W/","PX-76000826","CDM","32550","CPT","0761","RC","","","","outpatient","","","8859.00","6644.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7239.57","81.72","","9835.02","9835.02","9835.02","1 through 10","2652.59","7239.57","percent of total billed charges",""
"Insert Cath Pleural Indwel/Tunl W/|BILATERAL PROCEDURE","PX-76000826","CDM","32550","CPT","0761","RC","","","50","both","","","8859.00","6644.25","HUMANA [1012]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6100.87","6100.87","6100.87","1 through 10","6715.85","8835.76","other","OPPS APC"
"Insert Cath Pleural Indwel/Tunl W/|BILATERAL PROCEDURE","PX-76000826","CDM","32550","CPT","0761","RC","","","50","both","","","8859.00","6644.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6927.23","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6929.93","6929.93","6929.93","1 through 10","6715.85","8835.76","other","OPPS APC"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","both","","","11331.00","8498.25","ELDER SERVICES [1037]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","243.05","243.05","243.05","1 through 10","3512.61","9008.15","other","OPPS APC"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","both","","","11331.00","8498.25","MEDICARE [2001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3478.89","3478.89","3478.89","1 through 10","3512.61","9008.15","other","OPPS APC"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","both","","","11331.00","8498.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3670.50","3663.10","3671.00","42","3512.61","9008.15","other","OPPS APC"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","outpatient","","","11331.00","8498.25","AETNA [1001]","HB AMC AETNA HMO","7909.04","69.8","","7438.88","7438.88","11012.08","1 through 10","2377.37","9259.69","percent of total billed charges",""
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","outpatient","","","11331.00","8498.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2377.37","","Case rate ($2,377.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6894.37","6894.37","6894.37","1 through 10","2377.37","9259.69","other","Multiple Surgery"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","outpatient","","","11331.00","8498.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2377.37","","Case rate ($2,377.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","5515.50","5515.50","5515.50","1 through 10","2377.37","9259.69","other","Multiple Surgery"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","outpatient","","","11331.00","8498.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2377.37","","Case rate ($2,377.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5800.78","5586.82","5800.78","1 through 10","2377.37","9259.69","other","Multiple Surgery"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","outpatient","","","11331.00","8498.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2377.37","","Case rate ($2,377.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","6894.37","6894.37","6894.37","1 through 10","2377.37","9259.69","other","Multiple Surgery"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","outpatient","","","11331.00","8498.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2377.37","","Case rate ($2,377.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","6086.07","5848.33","6894.37","1 through 10","2377.37","9259.69","other","Multiple Surgery"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","outpatient","","","11331.00","8498.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2377.37","","Case rate ($2,377.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","5848.33","5848.33","5848.33","1 through 10","2377.37","9259.69","other","Multiple Surgery"
"Insert Drug Implant Device - 11981","PX-76000104","CDM","11981","CPT","0761","RC","","","","both","","","511.00","383.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","406.25","79.5","","833.19","277.73","1275.01","12","145.42","406.25","percent of total billed charges",""
"Insert Drug Implant Device - 11981","PX-76000104","CDM","11981","CPT","0761","RC","","","","both","","","511.00","383.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","272.36","53.3","","413.96","413.96","413.96","1 through 10","145.42","406.25","percent of total billed charges",""
"Insert Drug Implant Device - 11981","PX-76000104","CDM","11981","CPT","0761","RC","","","","both","","","511.00","383.25","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","139.42","153.08","1 through 10","145.42","406.25","other","OPPS APC"
"Insert Drug Implant Device - 11981","PX-76000104","CDM","11981","CPT","0761","RC","","","","both","","","511.00","383.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","186.52","36.5","","333.48","190.41","588.60","1 through 10","145.42","406.25","percent of total billed charges",""
"Insert Drug Implant Device - 11981","PX-76000104","CDM","11981","CPT","0761","RC","","","","both","","","511.00","383.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","195.71","38.3","","411.34","205.67","617.01","21","145.42","406.25","percent of total billed charges",""
"Insert Drug Implant Device - 11981","PX-76000104","CDM","11981","CPT","0761","RC","","","","both","","","511.00","383.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","219.22","42.9","","239.33","239.33","239.33","1 through 10","145.42","406.25","percent of total billed charges",""
"Insert Drug Implant Device - 11981","PX-76000104","CDM","11981","CPT","0761","RC","","","","both","","","511.00","383.25","WELLPOINT [1015]","HB AMC WELLPOINT","377.02","73.78","","391.61","391.61","391.61","1 through 10","145.42","406.25","percent of total billed charges",""
"Insert Drug Implant Device - 11981","PX-76000104","CDM","11981","CPT","0761","RC","","","","outpatient","","","511.00","383.25","AETNA [1001]","HB AMC AETNA PPO","410.84","80.4","","410.28","410.28","410.28","1 through 10","121.77","700.33","percent of total billed charges",""
"Insert Drug Implant Device - 11981","PX-76000104","CDM","11981","CPT","0761","RC","","","","outpatient","","","511.00","383.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","244.64","244.64","249.14","15","121.77","700.33","other","ASC"
"Insert Drug Implant Device - 11981","PX-76000104","CDM","11981","CPT","0761","RC","","","","outpatient","","","511.00","383.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","285.06","282.26","285.06","50","121.77","700.33","other","ASC "
"Insert Drug Implant Device - 11981","PX-76000104","CDM","11981","CPT","0761","RC","","","","outpatient","","","511.00","383.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","417.59","81.72","","546.57","420.48","546.57","1 through 10","121.77","700.33","percent of total billed charges",""
"Insert Drug Implant Device - 11981","PX-76000104","CDM","11981","CPT","0761","RC","","","","outpatient","","","511.00","383.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","417.59","81.72","","420.48","231.28","420.48","1 through 10","121.77","700.33","percent of total billed charges",""
"Insert Gastrostomy Tube Undr Fluoro","PX-75000298","CDM","49440","CPT","0361","RC","","","","both","","","3861.00","2895.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3069.50","79.5","","9682.46","9682.46","9682.46","1 through 10","1196.91","3069.5","percent of total billed charges",""
"Insert Gastrostomy Tube Undr Fluoro","PX-75000298","CDM","49440","CPT","0361","RC","","","","both","","","3861.00","2895.75","MEDICARE [2001]","HB BWH MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1196.91","3069.5","other","OPPS APC"
"Insert Gastrostomy Tube Undr Fluoro","PX-75000298","CDM","49440","CPT","0361","RC","","","","outpatient","","","3861.00","2895.75","AETNA [1001]","HB AMC AETNA HMO","2694.98","69.8","","11012.08","11012.08","11012.08","1 through 10","1335.02","3155.21","percent of total billed charges",""
"Insert Gastrostomy Tube Undr Fluoro","PX-75000298","CDM","49440","CPT","0361","RC","","","","outpatient","","","3861.00","2895.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3932.02","3932.02","3932.02","1 through 10","1335.02","3155.21","other","ASC "
"INSERT HINGE SIZE 3 11MM TRIATHLON","SUP-ITM-10322093","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2811.79","52.26","","1113.10","1113.10","1113.10","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 3 11MM TRIATHLON","SUP-ITM-10322093","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4277.40","79.5","","1293.60","1148.53","1603.80","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 3 11MM TRIATHLON","SUP-ITM-10322093","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1963.84","36.5","","1023.42","771.29","2068.67","33","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 3 11MM TRIATHLON","SUP-ITM-10322093","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2060.69","38.3","","850.52","759.78","1211.25","66","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 3 11MM TRIATHLON","SUP-ITM-10322093","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2308.18","42.9","","2548.09","2548.09","2548.09","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 3 11MM TRIATHLON","SUP-ITM-10322093","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2308.18","42.9","","956.46","956.46","956.46","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 3 11MM TRIATHLON","SUP-ITM-10322093","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","WELLPOINT [1015]","HB AMC WELLPOINT","3969.64","73.78","","2344.73","1619.47","2530.35","16","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 3 11MM TRIATHLON","SUP-ITM-10322093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","AETNA [1001]","HB AMC AETNA HMO","3755.51","69.8","","1523.63","988.41","4330.26","39","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 3 11MM TRIATHLON","SUP-ITM-10322093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","AETNA [1001]","HB AMC AETNA PPO","4325.83","80.4","","1670.25","1670.25","1670.25","1 through 10","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 3 11MM TRIATHLON","SUP-ITM-10322093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2811.79","52.26","","1113.10","1113.10","1113.10","1 through 10","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 3 11MM TRIATHLON","SUP-ITM-10322093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4396.85","81.72","","1738.90","1484.65","2716.94","38","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 4 16MM TRIATHLON","SUP-ITM-10322086","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2811.79","52.26","","1113.10","1113.10","1113.10","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 4 16MM TRIATHLON","SUP-ITM-10322086","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4277.40","79.5","","1293.60","1148.53","1603.80","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 4 16MM TRIATHLON","SUP-ITM-10322086","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1963.84","36.5","","1023.42","771.29","2068.67","33","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 4 16MM TRIATHLON","SUP-ITM-10322086","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2060.69","38.3","","850.52","759.78","1211.25","66","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 4 16MM TRIATHLON","SUP-ITM-10322086","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2308.18","42.9","","2548.09","2548.09","2548.09","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 4 16MM TRIATHLON","SUP-ITM-10322086","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2308.18","42.9","","956.46","956.46","956.46","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 4 16MM TRIATHLON","SUP-ITM-10322086","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","WELLPOINT [1015]","HB AMC WELLPOINT","3969.64","73.78","","2344.73","1619.47","2530.35","16","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 4 16MM TRIATHLON","SUP-ITM-10322086","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","AETNA [1001]","HB AMC AETNA HMO","3755.51","69.8","","1523.63","988.41","4330.26","39","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 4 16MM TRIATHLON","SUP-ITM-10322086","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","AETNA [1001]","HB AMC AETNA PPO","4325.83","80.4","","1670.25","1670.25","1670.25","1 through 10","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 4 16MM TRIATHLON","SUP-ITM-10322086","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2811.79","52.26","","1113.10","1113.10","1113.10","1 through 10","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 4 16MM TRIATHLON","SUP-ITM-10322086","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4396.85","81.72","","1738.90","1484.65","2716.94","38","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 6 11MM TRIATHLON","SUP-ITM-10322078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2811.79","52.26","","1113.10","1113.10","1113.10","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 11MM TRIATHLON","SUP-ITM-10322078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4277.40","79.5","","1293.60","1148.53","1603.80","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 11MM TRIATHLON","SUP-ITM-10322078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1963.84","36.5","","1023.42","771.29","2068.67","33","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 11MM TRIATHLON","SUP-ITM-10322078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2060.69","38.3","","850.52","759.78","1211.25","66","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 11MM TRIATHLON","SUP-ITM-10322078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2308.18","42.9","","2548.09","2548.09","2548.09","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 11MM TRIATHLON","SUP-ITM-10322078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2308.18","42.9","","956.46","956.46","956.46","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 11MM TRIATHLON","SUP-ITM-10322078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","WELLPOINT [1015]","HB AMC WELLPOINT","3969.64","73.78","","2344.73","1619.47","2530.35","16","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 11MM TRIATHLON","SUP-ITM-10322078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","AETNA [1001]","HB AMC AETNA HMO","3755.51","69.8","","1523.63","988.41","4330.26","39","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 6 11MM TRIATHLON","SUP-ITM-10322078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","AETNA [1001]","HB AMC AETNA PPO","4325.83","80.4","","1670.25","1670.25","1670.25","1 through 10","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 6 11MM TRIATHLON","SUP-ITM-10322078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2811.79","52.26","","1113.10","1113.10","1113.10","1 through 10","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 6 11MM TRIATHLON","SUP-ITM-10322078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4396.85","81.72","","1738.90","1484.65","2716.94","38","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 6 13MM TRIATHLON","SUP-ITM-10322077","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2811.79","52.26","","1113.10","1113.10","1113.10","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 13MM TRIATHLON","SUP-ITM-10322077","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4277.40","79.5","","1293.60","1148.53","1603.80","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 13MM TRIATHLON","SUP-ITM-10322077","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1963.84","36.5","","1023.42","771.29","2068.67","33","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 13MM TRIATHLON","SUP-ITM-10322077","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2060.69","38.3","","850.52","759.78","1211.25","66","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 13MM TRIATHLON","SUP-ITM-10322077","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2308.18","42.9","","2548.09","2548.09","2548.09","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 13MM TRIATHLON","SUP-ITM-10322077","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2308.18","42.9","","956.46","956.46","956.46","1 through 10","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 13MM TRIATHLON","SUP-ITM-10322077","CDM","C1776","HCPCS","0278","RC","","","","both","","","5380.38","4035.28","WELLPOINT [1015]","HB AMC WELLPOINT","3969.64","73.78","","2344.73","1619.47","2530.35","16","1667.92","4277.4","percent of total billed charges",""
"INSERT HINGE SIZE 6 13MM TRIATHLON","SUP-ITM-10322077","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","AETNA [1001]","HB AMC AETNA HMO","3755.51","69.8","","1523.63","988.41","4330.26","39","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 6 13MM TRIATHLON","SUP-ITM-10322077","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","AETNA [1001]","HB AMC AETNA PPO","4325.83","80.4","","1670.25","1670.25","1670.25","1 through 10","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 6 13MM TRIATHLON","SUP-ITM-10322077","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2811.79","52.26","","1113.10","1113.10","1113.10","1 through 10","2811.79","4396.85","percent of total billed charges",""
"INSERT HINGE SIZE 6 13MM TRIATHLON","SUP-ITM-10322077","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5380.38","4035.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4396.85","81.72","","1738.90","1484.65","2716.94","38","2811.79","4396.85","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","363.00","272.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","288.59","79.5","","277.03","185.86","831.07","33","112.53","344.85","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","363.00","272.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","193.48","53.3","","831.07","411.88","7386.00","1 through 10","112.53","344.85","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","363.00","272.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","279.51","77","","502.04","502.04","502.04","1 through 10","112.53","344.85","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","363.00","272.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","112.53","31","","217.54","217.54","217.54","1 through 10","112.53","344.85","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","363.00","272.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","132.50","36.5","","254.85","131.30","393.90","56","112.53","344.85","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","363.00","272.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","139.03","38.3","","401.28","137.63","412.89","223","112.53","344.85","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","363.00","272.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.73","42.9","","1865.96","154.77","1897.35","1 through 10","112.53","344.85","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","363.00","272.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.73","42.9","","154.77","154.77","154.77","1 through 10","112.53","344.85","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","363.00","272.25","WELLPOINT [1015]","HB AMC WELLPOINT","267.82","73.78","","614.06","262.06","7274.57","1 through 10","112.53","344.85","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","363.00","272.25","AETNA [1001]","HB AMC AETNA HMO","253.37","69.8","","238.30","168.26","821.37","43","89.94","700.33","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","363.00","272.25","AETNA [1001]","HB AMC AETNA PPO","291.85","80.4","","274.56","274.56","4798.16","1 through 10","89.94","700.33","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","363.00","272.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","202.92","55.9","","368.90","368.90","368.90","1 through 10","89.94","700.33","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","363.00","272.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","89.94","","Case rate ($89.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","180.69","90.35","184.02","115","89.94","700.33","other","ASC"
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","363.00","272.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","89.94","","Case rate ($89.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","208.48","104.24","210.55","298","89.94","700.33","other","ASC "
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","363.00","272.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","291.85","80.4","","274.56","274.56","274.56","1 through 10","89.94","700.33","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","363.00","272.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","296.64","81.72","","281.39","154.77","2223.67","22","89.94","700.33","percent of total billed charges",""
"INSERT PLATE TI 5MM SCREW HOLE","SUP-ITM-10007491","CDM","C1713","HCPCS","0278","RC","","","","both","","","251.23","188.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","199.73","79.5","","800.18","480.96","1887.97","195","77.88","199.73","percent of total billed charges",""
"INSERT PLATE TI 5MM SCREW HOLE","SUP-ITM-10007491","CDM","C1713","HCPCS","0278","RC","","","","both","","","251.23","188.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","133.91","53.3","","813.12","216.42","1444.50","81","77.88","199.73","percent of total billed charges",""
"INSERT PLATE TI 5MM SCREW HOLE","SUP-ITM-10007491","CDM","C1713","HCPCS","0278","RC","","","","both","","","251.23","188.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","77.88","31","","432.60","432.60","432.60","1 through 10","77.88","199.73","percent of total billed charges",""
"INSERT PLATE TI 5MM SCREW HOLE","SUP-ITM-10007491","CDM","C1713","HCPCS","0278","RC","","","","both","","","251.23","188.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91.70","36.5","","148.37","54.89","631.39","94","77.88","199.73","percent of total billed charges",""
"INSERT PLATE TI 5MM SCREW HOLE","SUP-ITM-10007491","CDM","C1713","HCPCS","0278","RC","","","","both","","","251.23","188.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.22","38.3","","279.30","91.72","1116.77","266","77.88","199.73","percent of total billed charges",""
"INSERT PLATE TI 5MM SCREW HOLE","SUP-ITM-10007491","CDM","C1713","HCPCS","0278","RC","","","","both","","","251.23","188.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","107.78","42.9","","731.00","63.70","731.00","1 through 10","77.88","199.73","percent of total billed charges",""
"INSERT PLATE TI 5MM SCREW HOLE","SUP-ITM-10007491","CDM","C1713","HCPCS","0278","RC","","","","both","","","251.23","188.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","107.78","42.9","","384.74","384.74","384.74","1 through 10","77.88","199.73","percent of total billed charges",""
"INSERT PLATE TI 5MM SCREW HOLE","SUP-ITM-10007491","CDM","C1713","HCPCS","0278","RC","","","","both","","","251.23","188.42","WELLPOINT [1015]","HB AMC WELLPOINT","185.36","73.78","","286.63","119.22","1107.45","105","77.88","199.73","percent of total billed charges",""
"INSERT PLATE TI 5MM SCREW HOLE","SUP-ITM-10007491","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","251.23","188.42","AETNA [1001]","HB AMC AETNA HMO","175.36","69.8","","675.31","184.75","1721.50","286","131.29","205.31","percent of total billed charges",""
"INSERT PLATE TI 5MM SCREW HOLE","SUP-ITM-10007491","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","251.23","188.42","AETNA [1001]","HB AMC AETNA PPO","201.99","80.4","","1261.44","103.12","1514.10","21","131.29","205.31","percent of total billed charges",""
"INSERT PLATE TI 5MM SCREW HOLE","SUP-ITM-10007491","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","251.23","188.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","201.99","80.4","","1365.00","1365.00","1365.00","1 through 10","131.29","205.31","percent of total billed charges",""
"INSERT PLATE TI 5MM SCREW HOLE","SUP-ITM-10007491","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","251.23","188.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","205.31","81.72","","5157.68","5157.68","5157.68","1 through 10","131.29","205.31","percent of total billed charges",""
"INSERT PLATE TI 5MM SCREW HOLE","SUP-ITM-10007491","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","251.23","188.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","205.31","81.72","","431.26","71.26","1459.57","88","131.29","205.31","percent of total billed charges",""
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","both","","","9212.00","6909.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4316.26","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4319.21","4319.21","4319.21","1 through 10","2855.72","7323.54","other","OPPS APC"
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","both","","","9212.00","6909.00","MEDICARE [2001]","HB BWH MEDICARE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","3775.96","4190.97","1 through 10","2855.72","7323.54","other","OPPS APC"
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","both","","","9212.00","6909.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3362.38","36.5","","2831.76","2831.76","2831.76","1 through 10","2855.72","7323.54","percent of total billed charges",""
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","outpatient","","","9212.00","6909.00","AETNA [1001]","HB AMC AETNA HMO","6429.98","69.8","","6729.05","6047.64","6967.74","1 through 10","2384.07","7528.05","percent of total billed charges",""
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","outpatient","","","9212.00","6909.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3370.43","","Case rate ($3,370.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6771.19","6771.19","6895.90","1 through 10","2384.07","7528.05","other","ASC"
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","outpatient","","","9212.00","6909.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3370.43","","Case rate ($3,370.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7890.18","7812.66","7890.18","1 through 10","2384.07","7528.05","other","ASC "
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","outpatient","","","9212.00","6909.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2652.59","","Case rate ($2,652.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6154.01","6154.01","6154.01","1 through 10","2384.07","7528.05","other","Multiple Surgery"
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","outpatient","","","9212.00","6909.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2652.59","","Case rate ($2,652.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6472.32","6472.32","6472.32","1 through 10","2384.07","7528.05","other","Multiple Surgery"
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","outpatient","","","9212.00","6909.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2652.59","","Case rate ($2,652.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","7692.51","7692.51","7692.51","1 through 10","2384.07","7528.05","other","Multiple Surgery"
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","outpatient","","","9212.00","6909.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2652.59","","Case rate ($2,652.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","6790.63","6790.63","6790.63","1 through 10","2384.07","7528.05","other","Multiple Surgery"
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","outpatient","","","9212.00","6909.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7528.05","81.72","","3927.84","3927.84","3927.84","1 through 10","2384.07","7528.05","percent of total billed charges",""
"Insert Uterine Tandem/Vaginal Ovoid","PX-76001350","CDM","57155","CPT","0761","RC","","","","outpatient","","","4886.00","3664.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5424.80","5424.80","5424.80","1 through 10","2125.14","3992.84","other","ASC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","372.04","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","371.71","371.71","371.71","18","249.55","639.98","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","355.46","355.46","355.46","13","249.55","639.98","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","639.98","79.5","","614.65","614.65","614.65","1 through 10","249.55","639.98","percent of total billed charges",""
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","ELDER SERVICES [1037]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","361.24","361.24","1 through 10","249.55","639.98","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","HUMANA [1012]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","359.92","359.92","359.92","1 through 10","249.55","639.98","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","361.24","1083.72","66","249.55","639.98","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","293.83","36.5","","291.31","291.31","291.31","1 through 10","249.55","639.98","percent of total billed charges",""
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","308.32","38.3","","305.37","305.37","916.11","18","249.55","639.98","percent of total billed charges",""
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","354.02","354.02","354.02","1 through 10","249.55","639.98","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","MOLINA [1014]","HB BWH MOLINA","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","361.24","361.24","361.24","1 through 10","249.55","639.98","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1029.39","686.26","1029.39","1 through 10","249.55","639.98","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","354.02","343.13","354.02","1 through 10","249.55","639.98","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","345.35","42.9","","343.41","343.41","343.41","1 through 10","249.55","639.98","percent of total billed charges",""
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","805.00","603.75","WELLPOINT [1015]","HB AMC WELLPOINT","593.93","73.78","","581.45","581.45","581.45","1 through 10","249.55","639.98","percent of total billed charges",""
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","outpatient","","","805.00","603.75","AETNA [1001]","HB AMC AETNA HMO","561.89","69.8","","528.74","528.74","528.74","1 through 10","273","1234.13","percent of total billed charges",""
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","outpatient","","","805.00","603.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","627.19","627.19","638.74","15","273","1234.13","other","ASC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","outpatient","","","805.00","603.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","730.84","723.66","730.84","17","273","1234.13","other","ASC "
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","outpatient","","","805.00","603.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","633.36","633.36","633.36","24","273","1234.13","other","Multiple Surgery"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","outpatient","","","805.00","603.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","698.88","698.88","698.88","1 through 10","273","1234.13","other","Multiple Surgery"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","outpatient","","","805.00","603.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","657.85","81.72","","624.33","624.33","624.33","11","273","1234.13","percent of total billed charges",""
"Insertion Aria Cv Pa Balloon Dev","PX-48000544","CDM","93799","CPT","0481","RC","","","","both","","","13332.00","9999.00","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","10598.94","other","OPPS APC"
"Insertion Aria Cv Pa Balloon Dev","PX-48000544","CDM","93799","CPT","0481","RC","","","","outpatient","","","13332.00","9999.00","AETNA [1001]","HB AMC AETNA HMO","9305.74","69.8","","2022.70","2022.70","2022.70","1 through 10","454","10998.9","percent of total billed charges",""
"Insertion Aria Cv Pa Balloon Dev","PX-48000544","CDM","93799","CPT","0481","RC","","","","outpatient","","","13332.00","9999.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","8072.53","60.55","","318.03","318.03","2439.77","1 through 10","454","10998.9","percent of total billed charges",""
"Insertion Aria Cv Pa Balloon Dev","PX-48000544","CDM","93799","CPT","0481","RC","","","","outpatient","","","13332.00","9999.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6961.97","52.22","","360.38","360.38","4023.00","1 through 10","454","10998.9","percent of total billed charges",""
"Insertion Aria Cv Pa Balloon Dev","PX-48000544","CDM","93799","CPT","0481","RC","","","","outpatient","","","13332.00","9999.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","7332.60","55","","13080.03","13080.03","13080.03","1 through 10","454","10998.9","percent of total billed charges",""
"Insertion Carotid Stent Non-Atherosclerotic","PX-76002963","CDM","37799","CPT","0761","RC","","","","outpatient","","","25231.00","18923.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","13175.63","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","20815.58","percent of total billed charges",""
"Insertion Carotid Stent Non-Atherosclerotic","PX-76002963","CDM","37799","CPT","0761","RC","","","","outpatient","","","25231.00","18923.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","13246.28","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","20815.58","percent of total billed charges",""
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","both","","","737.00","552.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","585.92","79.5","","377.52","377.52","539.11","1 through 10","228.47","585.92","percent of total billed charges",""
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","both","","","737.00","552.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","355.46","355.46","355.46","1 through 10","228.47","585.92","other","OPPS APC"
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","both","","","737.00","552.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","585.92","79.5","","539.11","539.11","539.11","1 through 10","228.47","585.92","percent of total billed charges",""
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","both","","","737.00","552.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","269.01","36.5","","266.70","266.70","266.70","1 through 10","228.47","585.92","percent of total billed charges",""
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","both","","","737.00","552.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","282.27","38.3","","279.57","271.70","279.57","1 through 10","228.47","585.92","percent of total billed charges",""
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","both","","","737.00","552.75","WELLPOINT [1015]","HB AMC WELLPOINT","543.76","73.78","","532.32","532.32","532.32","1 through 10","228.47","585.92","percent of total billed charges",""
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","outpatient","","","737.00","552.75","AETNA [1001]","HB AMC AETNA HMO","514.43","69.8","","341.77","341.77","484.06","1 through 10","273","700.33","percent of total billed charges",""
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","outpatient","","","737.00","552.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","638.74","627.19","638.74","1 through 10","273","700.33","other","ASC"
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","outpatient","","","737.00","552.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","723.66","723.66","730.84","1 through 10","273","700.33","other","ASC "
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","outpatient","","","737.00","552.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","633.36","633.36","633.36","1 through 10","273","700.33","other","Multiple Surgery"
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","outpatient","","","737.00","552.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","698.88","698.88","698.88","1 through 10","273","700.33","other","Multiple Surgery"
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","outpatient","","","737.00","552.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","602.28","81.72","","571.57","571.57","571.57","1 through 10","273","700.33","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-76002767","CDM","11981","CPT","0761","RC","","","","both","","","542.00","406.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","430.89","79.5","","833.19","277.73","1275.01","12","145.42","430.89","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-76002767","CDM","11981","CPT","0761","RC","","","","both","","","542.00","406.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","288.89","53.3","","413.96","413.96","413.96","1 through 10","145.42","430.89","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-76002767","CDM","11981","CPT","0761","RC","","","","both","","","542.00","406.50","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","139.42","153.08","1 through 10","145.42","430.89","other","OPPS APC"
"Insertion Drug Delivery Implant","PX-76002767","CDM","11981","CPT","0761","RC","","","","both","","","542.00","406.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","197.83","36.5","","333.48","190.41","588.60","1 through 10","145.42","430.89","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-76002767","CDM","11981","CPT","0761","RC","","","","both","","","542.00","406.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","207.59","38.3","","411.34","205.67","617.01","21","145.42","430.89","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-76002767","CDM","11981","CPT","0761","RC","","","","both","","","542.00","406.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","232.52","42.9","","239.33","239.33","239.33","1 through 10","145.42","430.89","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-76002767","CDM","11981","CPT","0761","RC","","","","both","","","542.00","406.50","WELLPOINT [1015]","HB AMC WELLPOINT","399.89","73.78","","391.61","391.61","391.61","1 through 10","145.42","430.89","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-76002767","CDM","11981","CPT","0761","RC","","","","outpatient","","","542.00","406.50","AETNA [1001]","HB AMC AETNA PPO","435.77","80.4","","410.28","410.28","410.28","1 through 10","121.77","700.33","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-76002767","CDM","11981","CPT","0761","RC","","","","outpatient","","","542.00","406.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","244.64","244.64","249.14","15","121.77","700.33","other","ASC"
"Insertion Drug Delivery Implant","PX-76002767","CDM","11981","CPT","0761","RC","","","","outpatient","","","542.00","406.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","285.06","282.26","285.06","50","121.77","700.33","other","ASC "
"Insertion Drug Delivery Implant","PX-76002767","CDM","11981","CPT","0761","RC","","","","outpatient","","","542.00","406.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","442.92","81.72","","546.57","420.48","546.57","1 through 10","121.77","700.33","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-76002767","CDM","11981","CPT","0761","RC","","","","outpatient","","","542.00","406.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","442.92","81.72","","420.48","231.28","420.48","1 through 10","121.77","700.33","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-98302093","CDM","11981","CPT","0983","RC","","","","both","","","437.00","327.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","347.42","79.5","","833.19","277.73","1275.01","12","135.47","347.42","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-98302093","CDM","11981","CPT","0983","RC","","","","both","","","437.00","327.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","232.92","53.3","","413.96","413.96","413.96","1 through 10","135.47","347.42","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-98302093","CDM","11981","CPT","0983","RC","","","","both","","","437.00","327.75","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","139.42","153.08","1 through 10","135.47","347.42","other","OPPS APC"
"Insertion Drug Delivery Implant","PX-98302093","CDM","11981","CPT","0983","RC","","","","both","","","437.00","327.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","159.51","36.5","","333.48","190.41","588.60","1 through 10","135.47","347.42","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-98302093","CDM","11981","CPT","0983","RC","","","","both","","","437.00","327.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","167.37","38.3","","411.34","205.67","617.01","21","135.47","347.42","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-98302093","CDM","11981","CPT","0983","RC","","","","both","","","437.00","327.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.47","42.9","","239.33","239.33","239.33","1 through 10","135.47","347.42","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-98302093","CDM","11981","CPT","0983","RC","","","","both","","","437.00","327.75","WELLPOINT [1015]","HB AMC WELLPOINT","322.42","73.78","","391.61","391.61","391.61","1 through 10","135.47","347.42","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-98302093","CDM","11981","CPT","0983","RC","","","","outpatient","","","437.00","327.75","AETNA [1001]","HB AMC AETNA PPO","351.35","80.4","","410.28","410.28","410.28","1 through 10","178.48","700.33","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-98302093","CDM","11981","CPT","0983","RC","","","","outpatient","","","437.00","327.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","357.12","81.72","","546.57","420.48","546.57","1 through 10","178.48","700.33","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-98302093","CDM","11981","CPT","0983","RC","","","","outpatient","","","437.00","327.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","357.12","81.72","","420.48","231.28","420.48","1 through 10","178.48","700.33","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","both","","","3966.00","2974.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1899.96","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1898.30","1799.34","1899.10","1 through 10","1229.46","3152.97","other","OPPS APC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","both","","","3966.00","2974.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1815.28","1815.28","1815.28","1 through 10","1229.46","3152.97","other","OPPS APC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","both","","","3966.00","2974.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2776.20","70","","2048.32","1653.78","2048.32","1 through 10","1229.46","3152.97","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","both","","","3966.00","2974.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1809.00","1807.90","1809.00","1 through 10","1229.46","3152.97","other","OPPS APC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","both","","","3966.00","2974.50","MEDICARE [2001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1753.34","1844.80","18","1229.46","3152.97","other","OPPS APC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","both","","","3966.00","2974.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1807.72","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1815.70","1815.70","1815.70","1 through 10","1229.46","3152.97","other","OPPS APC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","both","","","3966.00","2974.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1807.72","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1844.80","1807.90","1844.80","1 through 10","1229.46","3152.97","other","OPPS APC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","both","","","3966.00","2974.50","WELLPOINT [1015]","HB AMC WELLPOINT","2926.11","73.78","","2863.35","2863.35","2863.35","1 through 10","1229.46","3152.97","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","outpatient","","","3966.00","2974.50","AETNA [1001]","HB AMC AETNA HMO","2768.27","69.8","","1838.39","1838.39","1838.39","1 through 10","1093.63","5545.35","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","outpatient","","","3966.00","2974.50","AETNA [1001]","HB AMC AETNA PPO","3188.66","80.4","","2403.20","2403.20","2403.20","1 through 10","1093.63","5545.35","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","outpatient","","","3966.00","2974.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2558.79","2512.52","2558.79","1 through 10","1093.63","5545.35","other","ASC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","outpatient","","","3966.00","2974.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2898.96","2898.96","2927.72","12","1093.63","5545.35","other","ASC "
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","outpatient","","","3966.00","2974.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1093.63","","Case rate ($1,093.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2537.22","2438.79","2537.22","1 through 10","1093.63","5545.35","other","Multiple Surgery"
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","outpatient","","","3966.00","2974.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1093.63","","Case rate ($1,093.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2799.69","2799.69","2799.69","1 through 10","1093.63","5545.35","other","Multiple Surgery"
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","outpatient","","","3966.00","2974.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3241.02","81.72","","3074.48","3074.48","3074.48","1 through 10","1093.63","5545.35","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","both","","","499.00","374.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1899.96","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1898.30","1799.34","1899.10","1 through 10","154.69","2305.77","other","OPPS APC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","both","","","499.00","374.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1815.28","1815.28","1815.28","1 through 10","154.69","2305.77","other","OPPS APC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","both","","","499.00","374.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","349.30","70","","2048.32","1653.78","2048.32","1 through 10","154.69","2305.77","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","both","","","499.00","374.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1809.00","1807.90","1809.00","1 through 10","154.69","2305.77","other","OPPS APC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","both","","","499.00","374.25","MEDICARE [2001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1753.34","1844.80","18","154.69","2305.77","other","OPPS APC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","both","","","499.00","374.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1807.72","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1815.70","1815.70","1815.70","1 through 10","154.69","2305.77","other","OPPS APC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","both","","","499.00","374.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1807.72","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1844.80","1807.90","1844.80","1 through 10","154.69","2305.77","other","OPPS APC"
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","both","","","499.00","374.25","WELLPOINT [1015]","HB AMC WELLPOINT","368.16","73.78","","2863.35","2863.35","2863.35","1 through 10","154.69","2305.77","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","outpatient","","","499.00","374.25","AETNA [1001]","HB AMC AETNA HMO","348.30","69.8","","1838.39","1838.39","1838.39","1 through 10","219.26","5545.35","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","outpatient","","","499.00","374.25","AETNA [1001]","HB AMC AETNA PPO","401.20","80.4","","2403.20","2403.20","2403.20","1 through 10","219.26","5545.35","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","outpatient","","","499.00","374.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1093.63","","Case rate ($1,093.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2537.22","2438.79","2537.22","1 through 10","219.26","5545.35","other","Multiple Surgery"
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","outpatient","","","499.00","374.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1093.63","","Case rate ($1,093.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2799.69","2799.69","2799.69","1 through 10","219.26","5545.35","other","Multiple Surgery"
"Insertion Picc W/Rs&I 5 Yr/>","PX-98301824","CDM","36573","CPT","0983","RC","","","","outpatient","","","499.00","374.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","407.78","81.72","","3074.48","3074.48","3074.48","1 through 10","219.26","5545.35","percent of total billed charges",""
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","25054.00","18790.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10122.05","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","10122.86","10113.24","10128.44","1 through 10","7766.74","19917.93","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","25054.00","18790.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9827.23","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9670.97","3531.27","9670.97","1 through 10","7766.74","19917.93","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","25054.00","18790.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","19917.93","79.5","","19120.95","19120.95","19120.95","1 through 10","7766.74","19917.93","percent of total billed charges",""
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","25054.00","18790.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13353.78","53.3","","12828.29","10968.67","12828.29","1 through 10","7766.74","19917.93","percent of total billed charges",""
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","25054.00","18790.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","9827.23","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9151.84","9151.84","9151.84","1 through 10","7766.74","19917.93","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","25054.00","18790.50","MEDICARE [2001]","HB BWH MEDICARE","9827.23","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9828.22","9828.22","9828.22","64","7766.74","19917.93","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","25054.00","18790.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9144.71","36.5","","7701.83","7701.83","7701.83","1 through 10","7766.74","19917.93","percent of total billed charges",""
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","25054.00","18790.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9595.68","38.3","","9499.74","9232.48","9499.74","11","7766.74","19917.93","percent of total billed charges",""
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","25054.00","18790.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","9827.23","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9635.66","9635.66","9635.66","1 through 10","7766.74","19917.93","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","25054.00","18790.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9630.69","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28917.18","9633.66","36538.95","11","7766.74","19917.93","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","25054.00","18790.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9630.69","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9639.56","9632.06","9639.56","1 through 10","7766.74","19917.93","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","25054.00","18790.50","WELLPOINT [1015]","HB AMC WELLPOINT","18484.84","73.78","","18088.37","18088.37","18088.37","1 through 10","7766.74","19917.93","percent of total billed charges",""
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","25054.00","18790.50","AETNA [1001]","HB AMC AETNA HMO","17487.69","69.8","","16448.39","11613.49","24296.00","1 through 10","4812.67","20474.13","percent of total billed charges",""
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","25054.00","18790.50","AETNA [1001]","HB AMC AETNA PPO","20143.42","80.4","","18950.88","18950.88","18950.88","1 through 10","4812.67","20474.13","percent of total billed charges",""
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","25054.00","18790.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","8467.02","","Case rate ($8,467.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","17010.24","8661.76","17323.52","1 through 10","4812.67","20474.13","other","ASC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","25054.00","18790.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","8467.02","","Case rate ($8,467.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","19626.55","9910.65","19821.29","23","4812.67","20474.13","other","ASC "
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","25054.00","18790.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4812.67","","Case rate ($4,812.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","11165.39","11165.39","33496.17","15","4812.67","20474.13","other","Multiple Surgery"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","25054.00","18790.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4812.67","","Case rate ($4,812.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","11742.91","5654.89","11742.91","1 through 10","4812.67","20474.13","other","Multiple Surgery"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","25054.00","18790.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","4812.67","","Case rate ($4,812.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","12320.44","11839.17","12320.44","1 through 10","4812.67","20474.13","other","Multiple Surgery"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","25054.00","18790.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","20143.42","80.4","","17785.35","17785.35","17785.35","1 through 10","4812.67","20474.13","percent of total billed charges",""
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","25054.00","18790.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","20474.13","81.72","","19422.22","19422.22","19422.22","1 through 10","4812.67","20474.13","percent of total billed charges",""
"Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices,MAJOR","176","DRG","","","","","","","","inpatient","","","134836.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","96625.21","","Standard inlier is a Case rate ($96,625.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $86,788, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,716.53) for the length of stay and the standard reimbursement.","108632.77","108632.77","108632.77","1 through 10","29268.56","179923.82","case rate",""
"Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices,MAJOR","176","DRG","","","","","","","","inpatient","","","134836.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","108632.77","","Standard inlier is a Case rate ($108,632.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $86,788, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($15,419.52) for the length of stay and the standard reimbursement.","12569.25","12569.25","108632.77","1 through 10","29268.56","179923.82","case rate",""
"Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices,MAJOR","176","DRG","","","","","","","","inpatient","","","134836.10","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","102426.02","","Fee schedule rate ($102,426.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","87062.11","87062.11","87062.11","1 through 10","29268.56","179923.82","case rate",""
"INSIGNIA ACP 2-LEVEL 32MM","SUP-ITM-10322561","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1641.68","79.5","","800.18","480.96","1887.97","195","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 32MM","SUP-ITM-10322561","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1100.65","53.3","","813.12","216.42","1444.50","81","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 32MM","SUP-ITM-10322561","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","640.15","31","","432.60","432.60","432.60","1 through 10","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 32MM","SUP-ITM-10322561","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","753.73","36.5","","148.37","54.89","631.39","94","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 32MM","SUP-ITM-10322561","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","790.90","38.3","","279.30","91.72","1116.77","266","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 32MM","SUP-ITM-10322561","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.89","42.9","","731.00","63.70","731.00","1 through 10","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 32MM","SUP-ITM-10322561","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.89","42.9","","384.74","384.74","384.74","1 through 10","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 32MM","SUP-ITM-10322561","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","WELLPOINT [1015]","HB AMC WELLPOINT","1523.56","73.78","","286.63","119.22","1107.45","105","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 32MM","SUP-ITM-10322561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","AETNA [1001]","HB AMC AETNA HMO","1441.37","69.8","","675.31","184.75","1721.50","286","1079.17","1687.52","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 32MM","SUP-ITM-10322561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","AETNA [1001]","HB AMC AETNA PPO","1660.26","80.4","","1261.44","103.12","1514.10","21","1079.17","1687.52","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 32MM","SUP-ITM-10322561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1660.26","80.4","","1365.00","1365.00","1365.00","1 through 10","1079.17","1687.52","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 32MM","SUP-ITM-10322561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1687.52","81.72","","5157.68","5157.68","5157.68","1 through 10","1079.17","1687.52","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 32MM","SUP-ITM-10322561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1687.52","81.72","","431.26","71.26","1459.57","88","1079.17","1687.52","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 36MM","SUP-ITM-10322559","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1641.68","79.5","","800.18","480.96","1887.97","195","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 36MM","SUP-ITM-10322559","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1100.65","53.3","","813.12","216.42","1444.50","81","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 36MM","SUP-ITM-10322559","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","640.15","31","","432.60","432.60","432.60","1 through 10","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 36MM","SUP-ITM-10322559","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","753.73","36.5","","148.37","54.89","631.39","94","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 36MM","SUP-ITM-10322559","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","790.90","38.3","","279.30","91.72","1116.77","266","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 36MM","SUP-ITM-10322559","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.89","42.9","","731.00","63.70","731.00","1 through 10","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 36MM","SUP-ITM-10322559","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.89","42.9","","384.74","384.74","384.74","1 through 10","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 36MM","SUP-ITM-10322559","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","WELLPOINT [1015]","HB AMC WELLPOINT","1523.56","73.78","","286.63","119.22","1107.45","105","640.15","1641.68","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 36MM","SUP-ITM-10322559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","AETNA [1001]","HB AMC AETNA HMO","1441.37","69.8","","675.31","184.75","1721.50","286","1079.17","1687.52","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 36MM","SUP-ITM-10322559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","AETNA [1001]","HB AMC AETNA PPO","1660.26","80.4","","1261.44","103.12","1514.10","21","1079.17","1687.52","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 36MM","SUP-ITM-10322559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1660.26","80.4","","1365.00","1365.00","1365.00","1 through 10","1079.17","1687.52","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 36MM","SUP-ITM-10322559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1687.52","81.72","","5157.68","5157.68","5157.68","1 through 10","1079.17","1687.52","percent of total billed charges",""
"INSIGNIA ACP 2-LEVEL 36MM","SUP-ITM-10322559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1687.52","81.72","","431.26","71.26","1459.57","88","1079.17","1687.52","percent of total billed charges",""
"Insj 1 Transvns Eltrd Perm Pacemaker/Impltbl Dfb","PX-48000052","CDM","33216","CPT","0361","RC","","","","both","","","11075.00","8306.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10122.05","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","10121.49","10121.49","10121.49","1 through 10","3433.25","12284.04","other","OPPS APC"
"Insj 1 Transvns Eltrd Perm Pacemaker/Impltbl Dfb","PX-48000052","CDM","33216","CPT","0361","RC","","","","both","","","11075.00","8306.25","MEDICARE [2001]","HB BWH MEDICARE","9827.23","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9828.22","9828.22","9828.22","1 through 10","3433.25","12284.04","other","OPPS APC"
"Insj/Rplcmt Icds W/Substernal Electrode","PX-48000528","CDM","0571T","CPT","0480","RC","","","","outpatient","","","20529.00","15396.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","10720.24","52.22","","10716.48","10716.48","10716.48","1 through 10","8211.6","16776.3","percent of total billed charges",""
"Insj/Rplcmt Spi Npgr Dir/Induxive Coupling","PX-98301699","CDM","63685","CPT","0983","RC","","","","both","","","3325.00","2493.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1772.23","53.3","","24224.86","24224.86","24224.86","1 through 10","1426.43","2643.38","percent of total billed charges",""
"INSPIRE V IMPLANTABLE PULSE GENERATOR","SUP-ITM-10331441","CDM","C1767","HCPCS","0278","RC","","","","both","","","54000.00","40500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19710.00","36.5","","18081.90","16994.81","18081.90","1 through 10","16740","42930","percent of total billed charges",""
"INSPIRE V IMPLANTABLE PULSE GENERATOR","SUP-ITM-10331441","CDM","C1767","HCPCS","0278","RC","","","","both","","","54000.00","40500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20682.00","38.3","","17814.94","17448.38","17814.94","1 through 10","16740","42930","percent of total billed charges",""
"INSPIRE V IMPLANTABLE PULSE GENERATOR","SUP-ITM-10331441","CDM","C1767","HCPCS","0278","RC","","","","both","","","54000.00","40500.00","WELLPOINT [1015]","HB AMC WELLPOINT","39841.20","73.78","","33921.28","33921.28","33921.28","1 through 10","16740","42930","percent of total billed charges",""
"Insrt/Place Neurostim Gener Spinal","PX-76001495","CDM","63685","CPT","0761","RC","","","","both","","","10380.00","7785.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5532.54","53.3","","24224.86","24224.86","24224.86","1 through 10","4453.02","8252.1","percent of total billed charges",""
"Instill Anticarcinogen Agnt Bladder","PX-76001263","CDM","51720","CPT","0761","RC","","","","both","","","735.00","551.25","MOLINA [1014]","HB BWH MOLINA","683.40","","APC Price ($697.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4684.53","4684.53","4684.53","1 through 10","227.85","871.68","other","OPPS APC"
"Instill Anticarcinogen Agnt Bladder","PX-76001263","CDM","51720","CPT","0761","RC","","","","outpatient","","","735.00","551.25","AETNA [1001]","HB AMC AETNA HMO","513.03","69.8","","5506.04","5506.04","5506.04","1 through 10","231.42","1701.73","percent of total billed charges",""
"Instill Anticarcinogen Agnt Bladder","PX-76001263","CDM","51720","CPT","0761","RC","","","","outpatient","","","735.00","551.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","306.72","306.72","306.72","1 through 10","231.42","1701.73","other","ASC "
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-76002201","CDM","99177","CPT","0510","RC","","","","both","","","39.00","29.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14.24","36.5","","8.58","8.58","8.58","1 through 10","12.09","37.05","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-76002201","CDM","99177","CPT","0510","RC","","","","both","","","39.00","29.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.94","38.3","","8.99","8.74","14.86","1 through 10","12.09","37.05","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-76002201","CDM","99177","CPT","0510","RC","","","","both","","","39.00","29.25","WELLPOINT [1015]","HB AMC WELLPOINT","28.77","73.78","","17.12","17.12","17.12","1 through 10","12.09","37.05","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-76002201","CDM","99177","CPT","0510","RC","","","","outpatient","","","39.00","29.25","AETNA [1001]","HB AMC AETNA HMO","27.22","69.8","","41.30","29.15","41.30","1 through 10","13.3","938.96","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-76002201","CDM","99177","CPT","0510","RC","","","","outpatient","","","39.00","29.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13.30","34.1","","20.84","20.84","20.84","1 through 10","13.3","938.96","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-76002201","CDM","99177","CPT","0510","RC","","","","outpatient","","","39.00","29.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","19.50","50","","19.91","12.05","36.15","22","13.3","938.96","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-76002201","CDM","99177","CPT","0510","RC","","","","outpatient","","","39.00","29.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","20.48","52.5","","14.90","12.65","20.90","1 through 10","13.3","938.96","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-76002201","CDM","99177","CPT","0510","RC","","","","outpatient","","","39.00","29.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","31.87","81.72","","48.77","48.77","48.77","1 through 10","13.3","938.96","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-98302466","CDM","99177","CPT","0983","RC","","","","both","","","24.00","18.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","19.08","79.5","","20.84","20.84","20.84","1 through 10","7.44","22.8","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-98302466","CDM","99177","CPT","0983","RC","","","","both","","","24.00","18.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.76","36.5","","8.58","8.58","8.58","1 through 10","7.44","22.8","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-98302466","CDM","99177","CPT","0983","RC","","","","both","","","24.00","18.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9.19","38.3","","8.99","8.74","14.86","1 through 10","7.44","22.8","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-98302466","CDM","99177","CPT","0983","RC","","","","both","","","24.00","18.00","WELLPOINT [1015]","HB AMC WELLPOINT","17.71","73.78","","17.12","17.12","17.12","1 through 10","7.44","22.8","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-98302466","CDM","99177","CPT","0983","RC","","","","outpatient","","","24.00","18.00","AETNA [1001]","HB AMC AETNA HMO","16.75","69.8","","41.30","29.15","41.30","1 through 10","12","938.96","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-98302466","CDM","99177","CPT","0983","RC","","","","outpatient","","","24.00","18.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12.00","50","","19.91","12.05","36.15","22","12","938.96","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-98302466","CDM","99177","CPT","0983","RC","","","","outpatient","","","24.00","18.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12.60","52.5","","14.90","12.65","20.90","1 through 10","12","938.96","percent of total billed charges",""
"Instrument Based Ocular Scr Bi W/Onsite Analysis","PX-98302466","CDM","99177","CPT","0983","RC","","","","outpatient","","","24.00","18.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","19.61","81.72","","48.77","48.77","48.77","1 through 10","12","938.96","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","700.00","525.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","365.82","52.26","","1113.10","1113.10","1113.10","1 through 10","217","556.5","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","1293.60","1148.53","1603.80","1 through 10","217","556.5","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","1023.42","771.29","2068.67","33","217","556.5","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","850.52","759.78","1211.25","66","217","556.5","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","2548.09","2548.09","2548.09","1 through 10","217","556.5","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","956.46","956.46","956.46","1 through 10","217","556.5","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","2344.73","1619.47","2530.35","16","217","556.5","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","1523.63","988.41","4330.26","39","365.82","572.04","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA PPO","562.80","80.4","","1670.25","1670.25","1670.25","1 through 10","365.82","572.04","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","365.82","52.26","","1113.10","1113.10","1113.10","1 through 10","365.82","572.04","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","1738.90","1484.65","2716.94","38","365.82","572.04","percent of total billed charges",""
"INSTRUMENT SPEEDBOAT RS2 CUTTING/INJECTION BX/5EA","SUP-ITM-10295787","CDM","C1889","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2726.85","79.5","","1309.77","674.56","6049.93","26","1063.3","2726.85","percent of total billed charges",""
"INSTRUMENT SPEEDBOAT RS2 CUTTING/INJECTION BX/5EA","SUP-ITM-10295787","CDM","C1889","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1828.19","53.3","","1901.83","1901.83","2962.25","1 through 10","1063.3","2726.85","percent of total billed charges",""
"INSTRUMENT SPEEDBOAT RS2 CUTTING/INJECTION BX/5EA","SUP-ITM-10295787","CDM","C1889","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1251.95","36.5","","1620.31","1620.31","19908.88","1 through 10","1063.3","2726.85","percent of total billed charges",""
"INSTRUMENT SPEEDBOAT RS2 CUTTING/INJECTION BX/5EA","SUP-ITM-10295787","CDM","C1889","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1313.69","38.3","","352.91","352.91","2046.30","1 through 10","1063.3","2726.85","percent of total billed charges",""
"INSTRUMENT SPEEDBOAT RS2 CUTTING/INJECTION BX/5EA","SUP-ITM-10295787","CDM","C1889","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1471.47","42.9","","9668.75","9668.75","9668.75","1 through 10","1063.3","2726.85","percent of total billed charges",""
"INSTRUMENT SPEEDBOAT RS2 CUTTING/INJECTION BX/5EA","SUP-ITM-10295787","CDM","C1889","HCPCS","0272","RC","","","","both","","","3430.00","2572.50","WELLPOINT [1015]","HB AMC WELLPOINT","2530.65","73.78","","699.88","384.10","3443.31","33","1063.3","2726.85","percent of total billed charges",""
"INSTRUMENT SPEEDBOAT RS2 CUTTING/INJECTION BX/5EA","SUP-ITM-10295787","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","3430.00","2572.50","AETNA [1001]","HB AMC AETNA HMO","2394.14","69.8","","1421.24","264.50","4933.46","29","1792.52","2803","percent of total billed charges",""
"INSTRUMENT SPEEDBOAT RS2 CUTTING/INJECTION BX/5EA","SUP-ITM-10295787","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","3430.00","2572.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2757.72","80.4","","1022.97","1022.97","3607.50","1 through 10","1792.52","2803","percent of total billed charges",""
"INSTRUMENT SPEEDBOAT RS2 CUTTING/INJECTION BX/5EA","SUP-ITM-10295787","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","3430.00","2572.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2803.00","81.72","","3010.54","693.88","5019.88","35","1792.52","2803","percent of total billed charges",""
"Insulin (Any) per 5u","PX-63600136","CDM","J1815","HCPCS","0636","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.88","0.58","2.64","960","0.31","0.8","percent of total billed charges",""
"Insulin (Any) per 5u","PX-63600136","CDM","J1815","HCPCS","0636","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.41","0.32","0.58","440","0.31","0.8","percent of total billed charges",""
"Insulin (Any) per 5u","PX-63600136","CDM","J1815","HCPCS","0636","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","78.65","78.65","78.65","1 through 10","0.31","0.8","percent of total billed charges",""
"Insulin (Any) per 5u","PX-63600136","CDM","J1815","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","0.47","0.12","1.21","981","0.31","0.8","percent of total billed charges",""
"Insulin (Any) per 5u","PX-63600136","CDM","J1815","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","0.49","0.19","1.50","3196","0.31","0.8","percent of total billed charges",""
"Insulin (Any) per 5u","PX-63600136","CDM","J1815","HCPCS","0636","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","2.34","1.25","2.34","240","0.31","0.8","percent of total billed charges",""
"Insulin (Any) per 5u","PX-63600136","CDM","J1815","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","0.46","0.46","0.46","60","0.52","1.2","percent of total billed charges",""
"Insulin (Any) per 5u","PX-63600136","CDM","J1815","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","0.99","0.99","0.99","60","0.52","1.2","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","both","","","275.00","206.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","218.63","79.5","","210.13","210.13","210.13","1 through 10","20.98","261.25","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","both","","","275.00","206.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","146.58","53.3","","140.98","140.98","210.13","1 through 10","20.98","261.25","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","both","","","275.00","206.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.38","36.5","","99.59","84.64","99.59","1 through 10","20.98","261.25","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","both","","","275.00","206.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.33","38.3","","104.40","104.40","104.40","11","20.98","261.25","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","both","","","275.00","206.25","TRICARE [160005]","HB BWH TRICARE","261.25","95","","25.80","25.80","25.80","1 through 10","20.98","261.25","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","outpatient","","","275.00","206.25","AETNA [1001]","HB AMC AETNA HMO","191.95","69.8","","180.76","127.63","208.26","1 through 10","22.08","224.73","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","outpatient","","","275.00","206.25","AETNA [1001]","HB AMC AETNA PPO","221.10","80.4","","416.52","416.52","416.52","1 through 10","22.08","224.73","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","outpatient","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","224.73","81.72","","213.44","117.40","213.44","1 through 10","22.08","224.73","percent of total billed charges",""
"Insulin Injection","PX-63601025","CDM","J1815","HCPCS","0636","RC","","","","both","","","13.00","9.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10.34","79.5","","0.88","0.58","2.64","960","4.03","10.34","percent of total billed charges",""
"Insulin Injection","PX-63601025","CDM","J1815","HCPCS","0636","RC","","","","both","","","13.00","9.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6.93","53.3","","0.41","0.32","0.58","440","4.03","10.34","percent of total billed charges",""
"Insulin Injection","PX-63601025","CDM","J1815","HCPCS","0636","RC","","","","both","","","13.00","9.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8.45","65","","78.65","78.65","78.65","1 through 10","4.03","10.34","percent of total billed charges",""
"Insulin Injection","PX-63601025","CDM","J1815","HCPCS","0636","RC","","","","both","","","13.00","9.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4.75","36.5","","0.47","0.12","1.21","981","4.03","10.34","percent of total billed charges",""
"Insulin Injection","PX-63601025","CDM","J1815","HCPCS","0636","RC","","","","both","","","13.00","9.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4.98","38.3","","0.49","0.19","1.50","3196","4.03","10.34","percent of total billed charges",""
"Insulin Injection","PX-63601025","CDM","J1815","HCPCS","0636","RC","","","","both","","","13.00","9.75","WELLPOINT [1015]","HB AMC WELLPOINT","9.59","73.78","","2.34","1.25","2.34","240","4.03","10.34","percent of total billed charges",""
"Insulin Injection","PX-63601025","CDM","J1815","HCPCS","0636","RC","","","","outpatient","","","13.00","9.75","AETNA [1001]","HB AMC AETNA HMO","9.07","69.8","","0.46","0.46","0.46","60","1.2","10.45","percent of total billed charges",""
"Insulin Injection","PX-63601025","CDM","J1815","HCPCS","0636","RC","","","","outpatient","","","13.00","9.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10.45","80.4","","0.99","0.99","0.99","60","1.2","10.45","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","both","","","138.00","103.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","109.71","79.5","","105.46","70.75","105.46","41","11.2","131.1","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","both","","","138.00","103.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","73.55","53.3","","70.75","70.75","70.75","11","11.2","131.1","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.37","36.5","","49.98","42.48","97.02","15","11.2","131.1","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.85","38.3","","52.39","50.92","52.40","68","11.2","131.1","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","both","","","138.00","103.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","106.26","77","","105.46","105.46","105.46","1 through 10","11.2","131.1","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","both","","","138.00","103.50","TRICARE [160005]","HB BWH TRICARE","131.10","95","","13.08","13.08","13.08","1 through 10","11.2","131.1","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","both","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.20","42.9","","58.92","58.92","107.12","1 through 10","11.2","131.1","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","138.00","103.50","AETNA [1001]","HB AMC AETNA HMO","96.32","69.8","","90.72","64.05","104.52","31","11.79","112.77","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","138.00","103.50","AETNA [1001]","HB AMC AETNA PPO","110.95","80.4","","104.52","70.22","209.04","1 through 10","11.79","112.77","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","138.00","103.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","110.95","80.4","","104.52","104.52","104.52","1 through 10","11.79","112.77","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","112.77","81.72","","107.12","107.12","107.12","1 through 10","11.79","112.77","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","112.77","81.72","","107.12","58.92","107.12","17","11.79","112.77","percent of total billed charges",""
"Integra Bilayer Matrix Wound Dress 2"X 2" (26 Sq Cm)","PX-27001064","CDM","Q4104","HCPCS","0636","RC","","","","outpatient","","","201.03","150.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","140.52","69.9","","137.95","137.95","137.95","26","94.28","161.63","percent of total billed charges",""
"Integra Bilayer Matrix Wound Dress 4"X 10" (258 Sq Cm)","PX-27000596","CDM","Q4104","HCPCS","0636","RC","","","","outpatient","","","47.88","35.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33.47","69.9","","137.95","137.95","137.95","26","22.46","115.58","percent of total billed charges",""
"Integra Bilayer Matrix Wound Dress 4"X 5" (129 Sq Cm)","PX-27001066","CDM","Q4104","HCPCS","0636","RC","","","","outpatient","","","58.89","44.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","41.16","69.9","","137.95","137.95","137.95","26","27.62","115.58","percent of total billed charges",""
"Integra Bilayer Matrix Wound Dress 40 Sq Cm Tier3","PX-27001065","CDM","Q4104","HCPCS","0636","RC","","","","outpatient","","","6994.35","5245.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4889.05","69.9","","137.95","137.95","137.95","26","115.58","5623.46","percent of total billed charges",""
"Integra Bilayer Matrix Wound Dress 516 Sq Cm Tier3","PX-27001067","CDM","Q4104","HCPCS","0636","RC","","","","outpatient","","","9703.95","7277.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6783.06","69.9","","137.95","137.95","137.95","26","115.58","7801.98","percent of total billed charges",""
"Integra Bmwd","PX-63601040","CDM","Q4104","HCPCS","0636","RC","","","","outpatient","","","4486.00","3364.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3135.71","69.9","","137.95","137.95","137.95","26","115.58","3606.74","percent of total billed charges",""
"Integra Bmwd","PX-63601041","CDM","Q4104","HCPCS","0636","RC","","","","outpatient","","","5127.00","3845.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3583.77","69.9","","137.95","137.95","137.95","26","115.58","4122.11","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","707.51","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","706.89","706.89","709.78","53","652.62","4645.98","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","675.98","632.20","675.98","150","652.62","4645.98","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3798.60","65","","4459.93","4459.93","4459.93","1 through 10","652.62","4645.98","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4090.80","70","","2436.81","2436.81","4533.60","21","652.62","4645.98","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4645.98","79.5","","4459.93","2992.18","4459.93","121","652.62","4645.98","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","CIGNA [1006]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","634.77","634.77","634.77","1 through 10","652.62","4645.98","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3114.85","53.3","","2992.18","2861.84","4459.93","71","652.62","4645.98","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","675.98","673.23","675.98","40","652.62","4645.98","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1751.81","1751.81","1751.81","1 through 10","652.62","4645.98","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","4499.88","77","","4236.54","4236.54","4236.54","25","652.62","4645.98","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","HUMANA [1012]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","677.35","677.35","677.35","1 through 10","652.62","4645.98","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","4645.98","79.5","","7724.81","3576.30","11873.32","18","652.62","4645.98","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","MEDICARE [2001]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","686.97","686.97","686.97","1399","652.62","4645.98","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2133.06","36.5","","2113.79","2113.79","2113.79","72","652.62","4645.98","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2238.25","38.3","","2215.80","2215.80","2215.80","98","652.62","4645.98","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","674.43","673.23","674.43","33","652.62","4645.98","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","MOLINA [1014]","HB BWH MOLINA","673.16","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1362.95","1360.20","1362.95","38","652.62","4645.98","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4499.88","77","","623.37","623.37","623.37","1 through 10","652.62","4645.98","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","673.16","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","673.23","673.23","2019.69","198","652.62","4645.98","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","5844.00","4383.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","673.16","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","673.24","673.23","675.98","442","652.62","4645.98","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","outpatient","","","5844.00","4383.00","AETNA [1001]","HB AMC AETNA HMO","4079.11","69.8","","3836.56","2708.83","4420.26","194","1413.99","4775.72","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","outpatient","","","5844.00","4383.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4698.58","80.4","","3683.55","3683.55","4604.44","33","1413.99","4775.72","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","outpatient","","","5844.00","4383.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4775.72","81.72","","4530.20","4530.20","4530.20","148","1413.99","4775.72","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","707.51","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","707.09","706.89","709.78","440","652.62","4454.39","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","675.98","675.98","675.98","572","652.62","4454.39","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4454.39","79.5","","4275.77","2868.62","4275.77","151","652.62","4454.39","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2986.40","53.3","","2868.62","2868.62","4275.77","149","652.62","4454.39","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","675.98","569.21","675.98","52","652.62","4454.39","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","FALLON HEALTH [1008]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.63","629.63","629.63","12","652.62","4454.39","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","HUMANA [1012]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","677.35","677.35","677.35","45","652.62","4454.39","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","MEDICARE [2001]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","686.97","686.97","686.97","3345","652.62","4454.39","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1736.93","31","","1678.80","1678.80","1678.80","1 through 10","652.62","4454.39","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2045.10","36.5","","2026.51","1722.26","2026.51","152","652.62","4454.39","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2145.95","38.3","","2124.30","2124.30","2124.30","126","652.62","4454.39","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","MOLINA [1014]","HB BWH MOLINA","673.16","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1362.95","1362.95","1362.95","129","652.62","4454.39","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","673.16","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","674.43","673.23","2023.29","263","652.62","4454.39","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","673.16","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1249.59","1249.59","1249.59","20","652.62","4454.39","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","673.16","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","673.24","630.84","675.98","832","652.62","4454.39","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","5603.00","4202.25","WELLSENSE [1003]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","693.84","693.84","693.84","23","652.62","4454.39","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","outpatient","","","5603.00","4202.25","AETNA [1001]","HB AMC AETNA HMO","3910.89","69.8","","3678.14","2596.97","3678.14","140","1413.99","4578.77","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","outpatient","","","5603.00","4202.25","AETNA [1001]","HB AMC AETNA PPO","4504.81","80.4","","4237.74","4237.74","4237.74","1 through 10","1413.99","4578.77","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","outpatient","","","5603.00","4202.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2928.13","52.26","","2565.18","2565.18","2565.18","20","1413.99","4578.77","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","outpatient","","","5603.00","4202.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4504.81","80.4","","4237.74","4237.74","4237.74","1 through 10","1413.99","4578.77","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","outpatient","","","5603.00","4202.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4578.77","81.72","","4343.14","2388.89","4343.14","207","1413.99","4578.77","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1598.89","1598.89","1624.89","123","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","13611.00","65","","15980.82","15980.82","15980.82","1 through 10","1543.65","16647.3","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","14658.00","70","","20306.00","8731.58","20306.00","1 through 10","1543.65","16647.3","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICAID REPLACEMENT","2030.91","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","1543.65","1543.65","1543.65","1 through 10","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","16647.30","79.5","","15980.82","10721.57","15980.82","33","1543.65","16647.3","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11161.02","53.3","","10721.57","10721.57","32164.71","23","1543.65","16647.3","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1598.89","1346.37","1598.89","19","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","ELDER SERVICES [1037]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1512.30","403.27","1512.30","1 through 10","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","FALLON HEALTH [1008]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4874.67","1592.39","4874.67","15","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5182.24","1605.39","5182.24","1 through 10","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","16123.80","77","","15635.62","15180.55","15635.62","1 through 10","1543.65","16647.3","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1592.39","1592.39","1598.89","1 through 10","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","HUMANA [1012]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1598.89","1592.39","1602.14","11","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1602.14","1592.39","1602.14","1 through 10","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","MEDICARE [2001]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1624.89","1624.89","1624.89","1218","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","6491.40","31","","6274.55","6274.55","6274.55","1 through 10","1543.65","16647.3","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7643.10","36.5","","7574.14","7574.14","7574.14","25","1543.65","16647.3","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8020.02","38.3","","7939.65","7716.28","7939.65","33","1543.65","16647.3","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1592.39","1482.05","1592.39","14","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","MOLINA [1014]","HB BWH MOLINA","1592.23","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3223.78","3000.40","3223.78","12","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","16123.80","77","","15980.82","2233.66","15980.82","1 through 10","1543.65","16647.3","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","TRICARE [160005]","HB BWH TRICARE","1543.65","","APC Price ($1,624.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1543.65","1543.65","1543.65","1 through 10","1543.65","16647.3","other","Tricare OPPS"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","1543.65","","APC Price ($1,624.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1624.89","1624.89","1624.89","1 through 10","1543.65","16647.3","other","Tricare OPPS"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1592.23","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1592.39","1592.39","4777.17","86","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","1592.23","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4670.38","4670.38","4670.38","1 through 10","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1592.23","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1592.40","1482.06","1624.89","148","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","20940.00","15705.00","WELLSENSE [1003]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1641.14","1641.14","1641.14","1 through 10","1543.65","16647.3","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","outpatient","","","20940.00","15705.00","AETNA [1001]","HB AMC AETNA HMO","14616.12","69.8","","13747.16","9706.27","13747.16","11","3242.02","17112.17","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","outpatient","","","20940.00","15705.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","10943.24","52.26","","5881.47","5881.47","5881.47","1 through 10","3242.02","17112.17","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","outpatient","","","20940.00","15705.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","17112.17","81.72","","15441.70","15441.70","15441.70","1 through 10","3242.02","17112.17","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","outpatient","","","20940.00","15705.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","17112.17","81.72","","16232.62","8928.55","16232.62","42","3242.02","17112.17","percent of total billed charges",""
"Intentional Self-Harm And Attempted Suicide,EXTREME","817","DRG","","","","","","","","inpatient","","","95918.81","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","50773.10","","Standard inlier is a Case rate ($50,773.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,768, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,206.82) for the length of stay and the standard reimbursement.","50773.10","50773.10","50773.10","1 through 10","6639.43","50773.1","case rate",""
"Intentional Self-Harm And Attempted Suicide,EXTREME","817","DRG","","","","","","","","inpatient","","","95918.81","","MASSHEALTH [3001]","HB BWH MEDICAID","20604.86","","Case rate ($22,782.21). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,212.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,543.11 and the sum of the standard inlier and any outlier amount.","22776.62","22776.62","22776.62","1 through 10","6639.43","50773.1","case rate",""
"Intentional Self-Harm And Attempted Suicide,MAJOR","817","DRG","","","","","","","","inpatient","","","60171.68","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","12371.82","","Case rate ($13,679.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,109.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,127.40 and the sum of the standard inlier and any outlier amount.","2085.87","2085.87","2085.87","1 through 10","6639.43","50773.1","case rate",""
"Intentional Self-Harm And Attempted Suicide,MAJOR","817","DRG","","","","","","","","inpatient","","","60171.68","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12371.82","","Case rate ($13,679.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,109.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,127.40 and the sum of the standard inlier and any outlier amount.","1071.70","1071.70","8507.51","1 through 10","6639.43","50773.1","case rate",""
"Intentional Self-Harm And Attempted Suicide,MINOR","817","DRG","","","","","","","","inpatient","","","44193.68","","MASSHEALTH [3001]","HB BWH MEDICAID","6639.43","","Case rate ($7,341.03). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,771.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,141.68 and the sum of the standard inlier and any outlier amount.","2282.81","2282.81","2282.81","1 through 10","6639.43","50773.1","case rate",""
"Intentional Self-Harm And Attempted Suicide,MODERATE","817","DRG","","","","","","","","inpatient","","","31745.90","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","17212.82","","Standard inlier is a Case rate ($17,212.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,553, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,443.22) for the length of stay and the standard reimbursement.","17212.82","17212.82","17212.82","1 through 10","6639.43","50773.1","case rate",""
"Intentional Self-Harm And Attempted Suicide,MODERATE","817","DRG","","","","","","","","inpatient","","","31745.90","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8949.30","","Case rate ($9,894.98). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,324.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,538.88 and the sum of the standard inlier and any outlier amount.","6154.00","6154.00","6154.00","1 through 10","6639.43","50773.1","case rate",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Interleukin 1b","PX-30003742","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Interleukin 2","PX-30003743","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Internal Cervical Carotid Stent for Dissection","PX-76002962","CDM","37799","CPT","0761","RC","","","","outpatient","","","25231.00","18923.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","13175.63","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","20815.58","percent of total billed charges",""
"Internal Cervical Carotid Stent for Dissection","PX-76002962","CDM","37799","CPT","0761","RC","","","","outpatient","","","25231.00","18923.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","13246.28","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","20815.58","percent of total billed charges",""
"Interrog Dev Eval Implant Loop Rec","PX-48000017","CDM","93291","CPT","0480","RC","","","","both","","","1054.00","790.50","MEDICARE [2001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","1 through 10","27.63","837.93","other","OPPS APC"
"Interrog Dev Eval Implant Loop Rec","PX-48000017","CDM","93291","CPT","0480","RC","","","","both","","","1054.00","790.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","403.68","38.3","","1198.80","776.72","1198.80","1 through 10","27.63","837.93","percent of total billed charges",""
"Interrog Dev Eval Implant Loop Rec","PX-48000017","CDM","93291","CPT","0480","RC","","","","outpatient","","","1054.00","790.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","847.42","80.4","","797.16","797.16","797.16","1 through 10","39.44","861.33","percent of total billed charges",""
"Interrog Dev Eval Implant Loop Rec","PX-48000017","CDM","93291","CPT","0480","RC","","","","outpatient","","","1054.00","790.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","861.33","81.72","","816.99","449.37","816.99","1 through 10","39.44","861.33","percent of total billed charges",""
"Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb","PX-48000015","CDM","93289","CPT","0480","RC","","","","both","","","1686.00","1264.50","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1 through 10","42.07","1340.37","other","OPPS APC"
"Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb","PX-48000015","CDM","93289","CPT","0480","RC","","","","both","","","1686.00","1264.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","615.39","36.5","","609.86","609.86","609.86","1 through 10","42.07","1340.37","percent of total billed charges",""
"Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb","PX-48000015","CDM","93289","CPT","0480","RC","","","","both","","","1686.00","1264.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","645.74","38.3","","639.29","639.29","639.29","1 through 10","42.07","1340.37","percent of total billed charges",""
"Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb","PX-48000015","CDM","93289","CPT","0480","RC","","","","outpatient","","","1686.00","1264.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1377.80","81.72","","1307.02","718.91","1307.02","1 through 10","85.36","1377.8","percent of total billed charges",""
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","112.26","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","112.27","112.17","113.07","1 through 10","103.56","349.01","other","OPPS APC"
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.27","38.35","426.00","1 through 10","103.56","349.01","other","OPPS APC"
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","285.35","65","","830.70","276.90","1124.65","13","103.56","349.01","percent of total billed charges",""
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","307.30","70","","306.72","306.72","920.16","1 through 10","103.56","349.01","percent of total billed charges",""
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","136.24","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","108.60","107.33","109.01","1 through 10","103.56","349.01","other","OPPS APC"
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","349.01","79.5","","276.90","276.90","276.90","1 through 10","103.56","349.01","percent of total billed charges",""
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","233.99","53.3","","553.80","553.80","553.80","1 through 10","103.56","349.01","percent of total billed charges",""
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.75","90.75","90.75","1 through 10","103.56","349.01","other","OPPS APC"
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","MEDICARE [2001]","HB BWH MEDICARE","109.00","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.01","105.65","327.03","135","103.56","349.01","other","OPPS APC"
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","168.14","38.3","","499.71","166.57","499.71","1 through 10","103.56","349.01","percent of total billed charges",""
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","MOLINA [1014]","HB BWH MOLINA","106.82","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","216.28","216.28","216.99","1 through 10","103.56","349.01","other","OPPS APC"
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","106.82","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","213.66","106.83","320.49","13","103.56","349.01","other","OPPS APC"
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","106.82","","APC Price ($109.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.83","106.83","109.01","12","103.56","349.01","other","OPPS APC"
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","both","","","439.00","329.25","WELLPOINT [1015]","HB AMC WELLPOINT","323.89","73.78","","317.16","317.16","317.16","1 through 10","103.56","349.01","percent of total billed charges",""
"Interrog Vad With Phys/ Qual Analys","PX-48000028","CDM","93750","CPT","0480","RC","","","","outpatient","","","439.00","329.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","358.75","81.72","","187.31","187.31","187.31","1 through 10","229.42","762.52","percent of total billed charges",""
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","1105.00","828.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","1 through 10","42.07","878.48","other","OPPS APC"
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","1105.00","828.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","55.35","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","40.34","40.34","40.34","1 through 10","42.07","878.48","other","OPPS APC"
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","1105.00","828.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","588.97","53.3","","843.66","843.66","843.66","1 through 10","42.07","878.48","percent of total billed charges",""
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","1105.00","828.75","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","44","42.07","878.48","other","OPPS APC"
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","1105.00","828.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","403.33","36.5","","399.86","399.86","399.86","1 through 10","42.07","878.48","percent of total billed charges",""
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","1105.00","828.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","423.22","38.3","","419.15","419.15","419.15","1 through 10","42.07","878.48","percent of total billed charges",""
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","1105.00","828.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.40","43.39","43.49","1 through 10","42.07","878.48","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","45.61","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","46.35","45.56","46.46","233","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","310","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","55.35","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","43.90","41.16","44.28","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","810.90","79.5","","778.34","522.19","778.34","68","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","CIGNA [1006]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","130.89","130.89","130.89","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","543.66","53.3","","522.19","522.19","778.34","36","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","35.36","43.57","60","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","ELDER SERVICES [1037]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","40.34","44.28","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","FALLON HEALTH [1008]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","43.39","132.84","14","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.15","41.15","41.15","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.39","43.39","43.75","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","785.40","77","","761.53","761.53","761.53","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","HUMANA [1012]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.66","43.39","44.28","13","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","810.90","79.5","","778.34","778.34","778.34","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.39","43.39","43.39","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","4595","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","316.20","31","","305.60","305.60","305.60","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","372.30","36.5","","368.90","313.51","410.79","69","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","390.66","38.3","","386.70","386.70","386.70","116","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.79","40.74","43.79","70","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MOLINA [1014]","HB BWH MOLINA","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","87.85","82.32","154.55","30","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","785.40","77","","124.00","57.62","124.00","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","TRICARE [160005]","HB BWH TRICARE","42.07","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","44.28","42.07","44.28","12","42.07","810.9","other","Tricare OPPS"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.79","43.39","131.37","308","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","437.58","42.9","","790.61","434.86","790.61","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.60","41.14","44.28","584","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","WELLSENSE NH [1050]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.75","43.75","43.75","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","AETNA [1001]","HB AMC AETNA HMO","711.96","69.8","","669.55","472.74","669.55","91","85.36","833.54","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","820.08","80.4","","642.85","370.87","771.42","1 through 10","85.36","833.54","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","833.54","81.72","","790.61","790.61","790.61","1 through 10","85.36","833.54","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","833.54","81.72","","434.86","434.86","790.61","1 through 10","85.36","833.54","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Greater 90 Days","PX-48000432","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","833.54","81.72","","790.61","434.86","790.61","106","85.36","833.54","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","45.61","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","46.35","45.56","46.46","233","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","310","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","55.35","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","43.90","41.16","44.28","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","810.90","79.5","","778.34","522.19","778.34","68","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","CIGNA [1006]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","130.89","130.89","130.89","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","543.66","53.3","","522.19","522.19","778.34","36","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","35.36","43.57","60","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","ELDER SERVICES [1037]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","40.34","44.28","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","FALLON HEALTH [1008]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","43.39","132.84","14","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.15","41.15","41.15","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.39","43.39","43.75","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","785.40","77","","761.53","761.53","761.53","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","HUMANA [1012]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.66","43.39","44.28","13","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","810.90","79.5","","778.34","778.34","778.34","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.39","43.39","43.39","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","4595","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","316.20","31","","305.60","305.60","305.60","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","372.30","36.5","","368.90","313.51","410.79","69","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","390.66","38.3","","386.70","386.70","386.70","116","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.79","40.74","43.79","70","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MOLINA [1014]","HB BWH MOLINA","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","87.85","82.32","154.55","30","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","785.40","77","","124.00","57.62","124.00","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","TRICARE [160005]","HB BWH TRICARE","42.07","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","44.28","42.07","44.28","12","42.07","810.9","other","Tricare OPPS"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.79","43.39","131.37","308","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","437.58","42.9","","790.61","434.86","790.61","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.60","41.14","44.28","584","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","WELLSENSE NH [1050]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.75","43.75","43.75","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","AETNA [1001]","HB AMC AETNA HMO","711.96","69.8","","669.55","472.74","669.55","91","85.36","833.54","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","820.08","80.4","","642.85","370.87","771.42","1 through 10","85.36","833.54","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","833.54","81.72","","790.61","790.61","790.61","1 through 10","85.36","833.54","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","833.54","81.72","","434.86","434.86","790.61","1 through 10","85.36","833.54","percent of total billed charges",""
"Interrogation Device Eval Receipt of Transmission Less Than 90 Days","PX-48000431","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","833.54","81.72","","790.61","434.86","790.61","106","85.36","833.54","percent of total billed charges",""
"Interrogation Eval F2f Implant Subq Lead Defib","PX-48000422","CDM","93261","CPT","0480","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","767.58","767.58","767.58","1 through 10","42.07","417.38","percent of total billed charges",""
"Interrogation Eval F2f Implant Subq Lead Defib","PX-48000422","CDM","93261","CPT","0480","RC","","","","both","","","525.00","393.75","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1 through 10","42.07","417.38","other","OPPS APC"
"Interrogation Eval F2f Implant Subq Lead Defib","PX-48000422","CDM","93261","CPT","0480","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","386.84","193.42","386.84","1 through 10","42.07","417.38","percent of total billed charges",""
"Interrogation Eval F2f Implant Subq Lead Defib","PX-48000422","CDM","93261","CPT","0480","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.90","43.39","43.90","1 through 10","42.07","417.38","other","OPPS APC"
"Interrogation Eval F2f Implant Subq Lead Defib","PX-48000422","CDM","93261","CPT","0480","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","406.90","406.90","406.90","1 through 10","82.5","429.03","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","45.61","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","46.35","45.56","46.46","233","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","310","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","55.35","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","43.90","41.16","44.28","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","810.90","79.5","","778.34","522.19","778.34","68","42.07","810.9","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","CIGNA [1006]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","130.89","130.89","130.89","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","543.66","53.3","","522.19","522.19","778.34","36","42.07","810.9","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","35.36","43.57","60","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","ELDER SERVICES [1037]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","40.34","44.28","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","FALLON HEALTH [1008]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","43.39","132.84","14","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.15","41.15","41.15","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.39","43.39","43.75","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","785.40","77","","761.53","761.53","761.53","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","HUMANA [1012]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.66","43.39","44.28","13","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","810.90","79.5","","778.34","778.34","778.34","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.39","43.39","43.39","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","4595","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","316.20","31","","305.60","305.60","305.60","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","372.30","36.5","","368.90","313.51","410.79","69","42.07","810.9","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","390.66","38.3","","386.70","386.70","386.70","116","42.07","810.9","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.79","40.74","43.79","70","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","MOLINA [1014]","HB BWH MOLINA","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","87.85","82.32","154.55","30","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","785.40","77","","124.00","57.62","124.00","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","TRICARE [160005]","HB BWH TRICARE","42.07","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","44.28","42.07","44.28","12","42.07","810.9","other","Tricare OPPS"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.79","43.39","131.37","308","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","437.58","42.9","","790.61","434.86","790.61","1 through 10","42.07","810.9","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.60","41.14","44.28","584","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","1020.00","765.00","WELLSENSE NH [1050]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.75","43.75","43.75","1 through 10","42.07","810.9","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","AETNA [1001]","HB AMC AETNA HMO","711.96","69.8","","669.55","472.74","669.55","91","85.36","833.54","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","820.08","80.4","","642.85","370.87","771.42","1 through 10","85.36","833.54","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","833.54","81.72","","790.61","790.61","790.61","1 through 10","85.36","833.54","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","833.54","81.72","","434.86","434.86","790.61","1 through 10","85.36","833.54","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","outpatient","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","833.54","81.72","","790.61","434.86","790.61","106","85.36","833.54","percent of total billed charges",""
"Interspinous Process Distration Device T3","PX-27000143","CDM","C1821","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5962.50","79.5","","9828.00","9828.00","9828.00","1 through 10","2325","7125","percent of total billed charges",""
"Interspinous Process Distration Device T3","PX-27000143","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6129.00","81.72","","1958.53","1886.75","1958.53","1 through 10","3919.5","6129","percent of total billed charges",""
"Interstitial And Alveolar Lung Diseases,EXTREME","142","DRG","","","","","","","","inpatient","","","115587.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","52969.25","","Standard inlier is a Case rate ($52,969.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,287, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,518.54) for the length of stay and the standard reimbursement.","52969.24","52969.24","52969.24","1 through 10","6015.7","92947.76","case rate",""
"Interstitial And Alveolar Lung Diseases,EXTREME","142","DRG","","","","","","","","inpatient","","","115587.86","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14800.2439","","Fee schedule rate ($56,331.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14800.2439","56331.28","56331.28","1 through 10","6015.7","92947.76","case rate",""
"Interstitial And Alveolar Lung Diseases,EXTREME","142","DRG","","","","","","","","inpatient","","","115587.86","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","69498.01","","Fee schedule rate ($69,498.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","67699.80","67699.80","67699.80","1 through 10","6015.7","92947.76","case rate",""
"Interstitial And Alveolar Lung Diseases,EXTREME","142","DRG","","","","","","","","inpatient","","","115587.86","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","16580.30","","Case rate ($18,332.37). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,762.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","36283.93","36283.93","36283.93","1 through 10","6015.7","92947.76","case rate",""
"Interstitial And Alveolar Lung Diseases,MAJOR","142","DRG","","","","","","","","inpatient","","","71957.94","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35131.03","","Standard inlier is a Case rate ($35,131.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,948, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,986.56) for the length of stay and the standard reimbursement.","37539.53","35131.03","83298.48","1 through 10","6015.7","92947.76","case rate",""
"Interstitial And Alveolar Lung Diseases,MAJOR","142","DRG","","","","","","","","inpatient","","","71957.94","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","14289.19","14289.19","14289.19","1 through 10","6015.7","92947.76","percent of total billed charges",""
"Interstitial And Alveolar Lung Diseases,MAJOR","142","DRG","","","","","","","","inpatient","","","71957.94","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14800.2439","","Fee schedule rate ($32,069.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14800.2439","32069.80","32069.80","1 through 10","6015.7","92947.76","case rate",""
"Interstitial And Alveolar Lung Diseases,MAJOR","142","DRG","","","","","","","","inpatient","","","71957.94","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","15540.6862","","Fee schedule rate ($33,674.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15540.6862","33674.23","33674.23","1 through 10","6015.7","92947.76","case rate",""
"Interstitial And Alveolar Lung Diseases,MAJOR","142","DRG","","","","","","","","inpatient","","","71957.94","","MASSHEALTH [3001]","HB BWH MEDICAID","10678.84","","Case rate ($11,807.29). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,237.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12512.66","12512.66","12512.66","1 through 10","6015.7","92947.76","case rate",""
"Interstitial And Alveolar Lung Diseases,MODERATE","142","DRG","","","","","","","","inpatient","","","64480.83","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","23078.54","","Standard inlier is a Case rate ($23,078.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,594, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,276.14) for the length of stay and the standard reimbursement.","23078.53","23078.53","23078.53","1 through 10","6015.7","92947.76","case rate",""
"Interstitial Brachy Cplx","PX-33000066","CDM","77778","CPT","0333","RC","","","","both","","","7330.00","5497.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","5131.00","70","","7108.00","7108.00","7108.00","1 through 10","782.74","5827.35","percent of total billed charges",""
"Interstitial Brachy Cplx","PX-33000066","CDM","77778","CPT","0333","RC","","","","both","","","7330.00","5497.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5827.35","79.5","","3753.02","3753.02","3753.02","1 through 10","782.74","5827.35","percent of total billed charges",""
"Interstitial Brachy Cplx","PX-33000066","CDM","77778","CPT","0333","RC","","","","both","","","7330.00","5497.50","MEDICARE [2001]","HB BWH MEDICARE","823.86","","APC Price ($823.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","782.53","782.53","782.53","1 through 10","782.74","5827.35","other","OPPS APC"
"Interstitial Brachy Cplx","PX-33000066","CDM","77778","CPT","0333","RC","","","","outpatient","","","7330.00","5497.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5990.08","81.72","","3125.39","3125.39","3125.39","1 through 10","1916.84","5990.08","percent of total billed charges",""
"Interstitial Dev Plmt Radiation Therapy 1/Mlt","PX-75000288","CDM","49411","CPT","0761","RC","","","","both","","","3682.00","2761.50","MEDICARE [2001]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1624.89","1624.89","1624.89","1 through 10","1141.42","2927.19","other","OPPS APC"
"Interstitial Dev Plmt Radiation Therapy 1/Mlt","PX-75000288","CDM","49411","CPT","0761","RC","","","","both","","","3682.00","2761.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1592.23","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4793.37","4793.37","4793.37","1 through 10","1141.42","2927.19","other","OPPS APC"
"Interstitial Dev Plmt Radiation Therapy 1/Mlt","PX-75000288","CDM","49411","CPT","0761","RC","","","","outpatient","","","3682.00","2761.50","AETNA [1001]","HB AMC AETNA PPO","2960.33","80.4","","2785.38","2785.38","2785.38","1 through 10","1363.03","5545.35","percent of total billed charges",""
"Interstitial Dev Plmt Radiation Therapy 1/Mlt","PX-75000288","CDM","49411","CPT","0761","RC","","","","outpatient","","","3682.00","2761.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1363.03","","Case rate ($1,363.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1369.17","1369.17","1369.17","1 through 10","1363.03","5545.35","other","ASC"
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","","","","inpatient","","","71957.94","53968.45","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","11804.39","11804.39","11804.39","1 through 10","8856.88","14866.7","case rate",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","","","","inpatient","","","71957.94","53968.45","MEDICARE [2001]","HB BWH MEDICARE","9037.63","","Case rate ($9,037.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,802.11, add-ons for qualifying new technology services are included. If operating cost exceeds $56,446.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,203.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,894.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,422.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.70. The transfer capital threshold is the transfer adjustment factor * $763.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11949.53","11949.53","11967.00","1 through 10","8856.88","14866.7","other","Inpatient Replacement Plans DRG"
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","","","","inpatient","","","71957.94","53968.45","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8856.88","","Case rate ($9,037.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,802.11, add-ons for qualifying new technology services are included. If operating cost exceeds $56,446.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,203.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,894.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,422.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.70. The transfer capital threshold is the transfer adjustment factor * $763.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9098.89","9098.89","9098.89","1 through 10","8856.88","14866.7","other","Inpatient DRG"
"Interstitial Lung Disease With McC","196","MS-DRG","","","","","","","","inpatient","","","87778.82","65834.11","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","18122.93","","Case rate ($17,595.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,103.59, add-ons for qualifying new technology services are included. If operating cost exceeds $66,748.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,958.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,696.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,723.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.55. The transfer capital threshold is the transfer adjustment factor * $1,518.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17957.52","17957.52","17957.52","1 through 10","17243.18","29561.1","other","Inpatient DRG"
"Interstitial Lung Disease With McC","196","MS-DRG","","","","","","","","inpatient","","","87778.82","65834.11","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","17595.08","","Case rate ($17,595.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,103.59, add-ons for qualifying new technology services are included. If operating cost exceeds $66,748.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,958.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,696.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,723.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.55. The transfer capital threshold is the transfer adjustment factor * $1,518.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17127.75","17127.75","17127.75","1 through 10","17243.18","29561.1","other","Inpatient DRG"
"Interstitial Lung Disease With McC","196","MS-DRG","","","","","","","","inpatient","","","87778.82","65834.11","MEDICARE [2001]","HB BWH MEDICARE","22722.26","","Case rate ($22,722.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,103.59, add-ons for qualifying new technology services are included. If operating cost exceeds $66,748.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,958.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $20,823.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,723.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.55. The transfer capital threshold is the transfer adjustment factor * $1,518.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22490.23","0.03","22523.46","28","17243.18","29561.1","other","Inpatient DRG"
"Interstitial Lung Disease With McC","196","MS-DRG","","","","","","","","inpatient","","","87778.82","65834.11","MOLINA [1014]","HB BWH MOLINA","17243.18","","Case rate ($17,595.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,103.59, add-ons for qualifying new technology services are included. If operating cost exceeds $66,748.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,958.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,696.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,723.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.55. The transfer capital threshold is the transfer adjustment factor * $1,518.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","32889.58","32889.58","32889.58","1 through 10","17243.18","29561.1","other","Inpatient DRG"
"Interstitial Lung Disease With McC","196","MS-DRG","","","","","","","","inpatient","","","87778.82","65834.11","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","17243.18","","Case rate ($17,595.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,103.59, add-ons for qualifying new technology services are included. If operating cost exceeds $66,748.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,958.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,696.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,723.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.55. The transfer capital threshold is the transfer adjustment factor * $1,518.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17154.17","17154.17","17154.17","1 through 10","17243.18","29561.1","other","Inpatient DRG"
"Interstitial Lung Disease With McC","196","MS-DRG","","","","","","","","inpatient","","","87778.82","65834.11","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17243.18","","Case rate ($17,595.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,103.59, add-ons for qualifying new technology services are included. If operating cost exceeds $66,748.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,958.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,696.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,723.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.55. The transfer capital threshold is the transfer adjustment factor * $1,518.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17098.79","17055.79","17141.52","1 through 10","17243.18","29561.1","other","Inpatient DRG"
"Interstitial Lung Disease With McC","196","MS-DRG","","","","","","","","inpatient","","","87778.82","65834.11","WELLSENSE [1003]","HB BWH MEDICARE","22722.26","","Case rate ($22,722.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,103.59, add-ons for qualifying new technology services are included. If operating cost exceeds $66,748.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,958.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $20,823.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,723.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,518.55. The transfer capital threshold is the transfer adjustment factor * $1,518.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17617.52","17617.52","17617.52","1 through 10","17243.18","29561.1","other","Inpatient DRG"
"Interstitial Lung Disease Without Cc/McC","198","MS-DRG","","","","","","","","inpatient","","","39922.40","29941.80","MEDICARE [2001]","HB BWH MEDICARE","6913.09","","Case rate ($6,913.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,244.59, add-ons for qualifying new technology services are included. If operating cost exceeds $53,889.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,016.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,956.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,864.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $576.30. The transfer capital threshold is the transfer adjustment factor * $576.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8535.42","8535.42","8535.42","1 through 10","6774.83","10569.7364","other","Inpatient Replacement Plans DRG"
"Intestinal Obstruction,EXTREME","247","DRG","","","","","","","","inpatient","","","113411.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","29006.64","","Standard inlier is a Case rate ($29,006.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,205, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,117.67) for the length of stay and the standard reimbursement.","53511.41","53511.41","60161.25","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,EXTREME","247","DRG","","","","","","","","inpatient","","","113411.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32611.28","","Standard inlier is a Case rate ($32,611.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,205, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,628.90) for the length of stay and the standard reimbursement.","6960.90","6960.90","6960.90","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,EXTREME","247","DRG","","","","","","","","inpatient","","","113411.65","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11248.3643","","Fee schedule rate ($67,512.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11248.3643","67512.56","67512.56","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,EXTREME","247","DRG","","","","","","","","inpatient","","","113411.65","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11811.1094","","Fee schedule rate ($70,890.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11811.1094","70890.16","70890.16","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,EXTREME","247","DRG","","","","","","","","inpatient","","","113411.65","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58448.77","","Fee schedule rate ($58,448.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","58448.77","58448.77","58448.77","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,EXTREME","247","DRG","","","","","","","","inpatient","","","113411.65","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61372.17","","Fee schedule rate ($61,372.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61372.17","61372.17","61372.17","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MAJOR","247","DRG","","","","","","","","inpatient","","","63084.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","29006.64","","Standard inlier is a Case rate ($29,006.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,205, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,117.67) for the length of stay and the standard reimbursement.","26444.42","26440.61","29006.64","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MAJOR","247","DRG","","","","","","","","inpatient","","","63084.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","32611.28","","Standard inlier is a Case rate ($32,611.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,205, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,628.90) for the length of stay and the standard reimbursement.","29793.22","29793.22","29793.22","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MAJOR","247","DRG","","","","","","","","inpatient","","","63084.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32611.28","","Standard inlier is a Case rate ($32,611.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,205, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,628.90) for the length of stay and the standard reimbursement.","32963.69","29793.22","61458.85","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MAJOR","247","DRG","","","","","","","","inpatient","","","63084.03","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11248.3643","","Fee schedule rate ($26,370.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11248.3643","26370.68","75730.20","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MAJOR","247","DRG","","","","","","","","inpatient","","","63084.03","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11811.1094","","Fee schedule rate ($27,689.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11811.1094","26621.84","26621.84","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MAJOR","247","DRG","","","","","","","","inpatient","","","63084.03","","MASSHEALTH [3001]","HB BWH MEDICAID","9919.16","","Case rate ($10,967.34). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,397.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10964.64","10964.64","10964.64","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MAJOR","247","DRG","","","","","","","","inpatient","","","63084.03","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28440.07","","Fee schedule rate ($28,440.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28440.07","28440.07","28440.07","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MAJOR","247","DRG","","","","","","","","inpatient","","","63084.03","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29862.54","","Fee schedule rate ($29,862.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29862.54","29862.54","29862.54","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MAJOR","247","DRG","","","","","","","","inpatient","","","63084.03","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9919.16","","Case rate ($10,967.34). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,397.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10964.65","10964.65","27473.98","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","19355.13","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","14977.12","","Standard inlier is a Case rate ($14,977.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,295, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,126.09) for the length of stay and the standard reimbursement.","14977.11","14977.11","14977.11","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","19355.13","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","16838.32","","Standard inlier is a Case rate ($16,838.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,295, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,390.06) for the length of stay and the standard reimbursement.","16838.31","15383.25","16838.31","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","19355.13","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11811.1094","","Fee schedule rate ($16,038.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11811.1094","11355.48","11355.48","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","19355.13","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","16802.07","","Fee schedule rate ($16,802.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12373.36","12373.36","12373.36","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","19355.13","","MASSHEALTH [3001]","HB BWH MEDICAID","4082.82","","Case rate ($4,514.26). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,944.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","817.86","817.86","4513.14","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","19355.13","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15656.35","","Fee schedule rate ($15,656.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15656.35","15656.35","15656.35","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","29879.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19404.60","","Standard inlier is a Case rate ($19,404.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,739, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,754.60) for the length of stay and the standard reimbursement.","19404.60","17689.25","19404.60","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","29879.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21816.00","","Standard inlier is a Case rate ($21,816). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,739, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,096.60) for the length of stay and the standard reimbursement.","21816.00","21816.00","21816.00","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","29879.72","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11248.3643","","Fee schedule rate ($15,274.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11248.3643","15274.44","15274.44","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","29879.72","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11811.1094","","Fee schedule rate ($16,038.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11811.1094","16038.60","16038.60","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","29879.72","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","16802.07","","Fee schedule rate ($16,802.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16154.68","16154.68","16154.68","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","29879.72","","MASSHEALTH [3001]","HB BWH MEDICAID","5542.76","","Case rate ($6,128.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,558.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6126.97","6126.97","6126.97","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","29879.72","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20208.24","","Fee schedule rate ($20,208.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19619.48","19619.48","19619.48","1 through 10","4082.82","111397.07","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","29879.72","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5542.76","","Case rate ($6,128.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,558.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1020.93","1020.93","6494.59","1 through 10","4082.82","111397.07","case rate",""
"Intra Uterine Fetal Surgery","PX-36000147","CDM","59897","CPT","0761","RC","","","","both","","","6855.00","5141.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3653.72","53.3","","3658.50","3658.50","3658.50","1 through 10","226.96","5449.73","percent of total billed charges",""
"Intra Uterine Fetal Surgery","PX-36000147","CDM","59897","CPT","0761","RC","","","","outpatient","","","6855.00","5141.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5601.91","81.72","","6095.22","6095.22","6095.22","1 through 10","1234.13","5655.38","percent of total billed charges",""
"Intracerebral Stent Insert Non-Atherosclerotic","PX-76002960","CDM","37799","CPT","0761","RC","","","","outpatient","","","9008.00","6756.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4703.98","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","7431.6","percent of total billed charges",""
"Intracerebral Stent Insert Non-Atherosclerotic","PX-76002960","CDM","37799","CPT","0761","RC","","","","outpatient","","","9008.00","6756.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4729.20","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","7431.6","percent of total billed charges",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","60853.84","45640.38","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","9883.79","","Case rate ($9,595.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,474.16, add-ons for qualifying new technology services are included. If operating cost exceeds $57,118.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,253.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,403.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,094.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $812.95. The transfer capital threshold is the transfer adjustment factor * $812.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9801.26","9801.26","9801.26","1 through 10","9403.99","15825.34","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","60853.84","45640.38","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12340.71","","Case rate ($12,340.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,474.16, add-ons for qualifying new technology services are included. If operating cost exceeds $57,118.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,253.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,147.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,094.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $812.95. The transfer capital threshold is the transfer adjustment factor * $812.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9576.79","9409.12","12137.48","1 through 10","9403.99","15825.34","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","60853.84","45640.38","HUMANA [1012]","HB BWH MEDICARE","12340.71","","Case rate ($12,340.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,474.16, add-ons for qualifying new technology services are included. If operating cost exceeds $57,118.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,253.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,147.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,094.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $812.95. The transfer capital threshold is the transfer adjustment factor * $812.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9357.42","9357.42","9357.42","1 through 10","9403.99","15825.34","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","60853.84","45640.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","","65","","23252.00","23252.00","23252.00","1 through 10","9403.99","15825.34","percent of total billed charges",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","60853.84","45640.38","MEDICARE [2001]","HB BWH MEDICARE","12340.71","","Case rate ($12,340.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,474.16, add-ons for qualifying new technology services are included. If operating cost exceeds $57,118.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,253.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,147.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,094.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $812.95. The transfer capital threshold is the transfer adjustment factor * $812.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12266.68","0.03","12284.61","89","9403.99","15825.34","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","60853.84","45640.38","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","12340.71","","Case rate ($12,340.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,474.16, add-ons for qualifying new technology services are included. If operating cost exceeds $57,118.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,253.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,147.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,094.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $812.95. The transfer capital threshold is the transfer adjustment factor * $812.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9348.00","9348.00","9348.00","1 through 10","9403.99","15825.34","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","60853.84","45640.38","MOLINA [1014]","HB BWH MOLINA","9403.99","","Case rate ($9,595.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,474.16, add-ons for qualifying new technology services are included. If operating cost exceeds $57,118.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,253.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,403.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,094.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $812.95. The transfer capital threshold is the transfer adjustment factor * $812.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19072.23","19072.23","19072.23","1 through 10","9403.99","15825.34","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","60853.84","45640.38","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9403.99","","Case rate ($9,595.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,474.16, add-ons for qualifying new technology services are included. If operating cost exceeds $57,118.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,253.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,403.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,094.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $812.95. The transfer capital threshold is the transfer adjustment factor * $812.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9341.01","9327.00","9392.30","1 through 10","9403.99","15825.34","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","60853.84","45640.38","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9403.99","","Case rate ($9,595.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,474.16, add-ons for qualifying new technology services are included. If operating cost exceeds $57,118.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,253.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,403.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,094.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $812.95. The transfer capital threshold is the transfer adjustment factor * $812.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9432.22","9318.30","14947.41","1 through 10","9403.99","15825.34","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","80896.71","60672.53","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","19286.12","","Case rate ($18,724.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,463.06, add-ons for qualifying new technology services are included. If operating cost exceeds $68,107.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,058.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,726.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,083.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,618.17. The transfer capital threshold is the transfer adjustment factor * $1,618.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","18930.58","18906.81","18940.51","1 through 10","18349.9","31500.3","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","80896.71","60672.53","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","24187.91","","Case rate ($24,187.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,463.06, add-ons for qualifying new technology services are included. If operating cost exceeds $68,107.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,058.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $22,189.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,083.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,618.17. The transfer capital threshold is the transfer adjustment factor * $1,618.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18135.55","18038.03","27878.43","1 through 10","18349.9","31500.3","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","80896.71","60672.53","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","","65.6","","18865.31","18865.31","18865.31","1 through 10","18349.9","31500.3","percent of total billed charges",""
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","80896.71","60672.53","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","18724.39","","Case rate ($18,724.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,463.06, add-ons for qualifying new technology services are included. If operating cost exceeds $68,107.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,058.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,726.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,083.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,618.17. The transfer capital threshold is the transfer adjustment factor * $1,618.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18218.85","18218.85","18218.85","1 through 10","18349.9","31500.3","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","80896.71","60672.53","HUMANA [1012]","HB BWH MEDICARE","24187.91","","Case rate ($24,187.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,463.06, add-ons for qualifying new technology services are included. If operating cost exceeds $68,107.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,058.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $22,189.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,083.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,618.17. The transfer capital threshold is the transfer adjustment factor * $1,618.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17997.44","17997.44","17997.44","1 through 10","18349.9","31500.3","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","80896.71","60672.53","MEDICARE [2001]","HB BWH MEDICARE","24187.91","","Case rate ($24,187.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,463.06, add-ons for qualifying new technology services are included. If operating cost exceeds $68,107.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,058.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $22,189.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,083.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,618.17. The transfer capital threshold is the transfer adjustment factor * $1,618.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23729.27","0.03","23764.34","149","18349.9","31500.3","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","80896.71","60672.53","MOLINA [1014]","HB BWH MOLINA","18349.90","","Case rate ($18,724.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,463.06, add-ons for qualifying new technology services are included. If operating cost exceeds $68,107.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,058.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,726.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,083.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,618.17. The transfer capital threshold is the transfer adjustment factor * $1,618.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","36698.39","36300.63","37710.47","1 through 10","18349.9","31500.3","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","80896.71","60672.53","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","18349.90","","Case rate ($18,724.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,463.06, add-ons for qualifying new technology services are included. If operating cost exceeds $68,107.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,058.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,726.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,083.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,618.17. The transfer capital threshold is the transfer adjustment factor * $1,618.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17991.45","17966.94","23630.64","1 through 10","18349.9","31500.3","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","80896.71","60672.53","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","18349.90","","Case rate ($18,724.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,463.06, add-ons for qualifying new technology services are included. If operating cost exceeds $68,107.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,058.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,726.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,083.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,618.17. The transfer capital threshold is the transfer adjustment factor * $1,618.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","52362.52","52362.52","52362.52","1 through 10","18349.9","31500.3","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","80896.71","60672.53","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","18349.90","","Case rate ($18,724.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,463.06, add-ons for qualifying new technology services are included. If operating cost exceeds $68,107.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,058.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,726.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,083.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,618.17. The transfer capital threshold is the transfer adjustment factor * $1,618.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18035.82","17966.97","22239.83","17","18349.9","31500.3","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","43719.91","32789.93","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","6623.01","","Case rate ($6,623.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,895.39, add-ons for qualifying new technology services are included. If operating cost exceeds $53,539.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,990.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,692.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,515.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $550.71. The transfer capital threshold is the transfer adjustment factor * $550.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6454.31","6454.31","6454.31","1 through 10","6490.55","10720.44","other","Inpatient Replacement Plans DRG"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","43719.91","32789.93","HUMANA [1012]","HB BWH MEDICARE","6623.01","","Case rate ($6,623.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,895.39, add-ons for qualifying new technology services are included. If operating cost exceeds $53,539.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,990.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,692.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,515.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $550.71. The transfer capital threshold is the transfer adjustment factor * $550.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6545.78","6545.78","6545.78","1 through 10","6490.55","10720.44","other","Inpatient Replacement Plans DRG"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","43719.91","32789.93","MEDICARE [2001]","HB BWH MEDICARE","6623.01","","Case rate ($6,623.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,895.39, add-ons for qualifying new technology services are included. If operating cost exceeds $53,539.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,990.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,692.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,515.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $550.71. The transfer capital threshold is the transfer adjustment factor * $550.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8404.89","978.30","8404.89","1 through 10","6490.55","10720.44","other","Inpatient Replacement Plans DRG"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","43719.91","32789.93","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6490.55","","Case rate ($6,623.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,895.39, add-ons for qualifying new technology services are included. If operating cost exceeds $53,539.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,990.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,692.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,515.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $550.71. The transfer capital threshold is the transfer adjustment factor * $550.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6411.51","6411.51","6411.51","1 through 10","6490.55","10720.44","other","Inpatient DRG"
"Intracranial Hemorrhage,EXTREME","044","DRG","","","","","","","","inpatient","","","105028.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","47237.26","","Standard inlier is a Case rate ($47,237.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,381, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,705.61) for the length of stay and the standard reimbursement.","47237.26","47237.26","47237.26","1 through 10","6974.14","76261.07","case rate",""
"Intracranial Hemorrhage,EXTREME","044","DRG","","","","","","","","inpatient","","","105028.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","53107.42","","Standard inlier is a Case rate ($53,107.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,381, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,538.16) for the length of stay and the standard reimbursement.","107784.05","92760.97","412007.03","1 through 10","6974.14","76261.07","case rate",""
"Intracranial Hemorrhage,EXTREME","044","DRG","","","","","","","","inpatient","","","105028.43","","MASSHEALTH [3001]","HB BWH MEDICAID","23806.91","","Case rate ($26,322.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $68,752.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","26316.17","26316.17","125609.51","1 through 10","6974.14","76261.07","case rate",""
"Intracranial Hemorrhage,EXTREME","044","DRG","","","","","","","","inpatient","","","105028.43","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76261.07","","Fee schedule rate ($76,261.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","76261.07","76261.07","76261.07","1 through 10","6974.14","76261.07","case rate",""
"Intracranial Hemorrhage,EXTREME","044","DRG","","","","","","","","inpatient","","","105028.43","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","23806.91","","Case rate ($26,322.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $68,752.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","26316.17","26316.17","26316.17","1 through 10","6974.14","76261.07","case rate",""
"Intracranial Hemorrhage,MAJOR","044","DRG","","","","","","","","inpatient","","","92954.27","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","42395.82","","Standard inlier is a Case rate ($42,395.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $44,617, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,018.34) for the length of stay and the standard reimbursement.","71956.17","38645.33","146774.57","1 through 10","6974.14","76261.07","case rate",""
"Intracranial Hemorrhage,MAJOR","044","DRG","","","","","","","","inpatient","","","92954.27","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","47664.32","","Standard inlier is a Case rate ($47,664.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $44,617, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,765.55) for the length of stay and the standard reimbursement.","47664.32","46327.50","65285.92","1 through 10","6974.14","76261.07","case rate",""
"Intracranial Hemorrhage,MAJOR","044","DRG","","","","","","","","inpatient","","","92954.27","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Per diem ($10,685). If length of stay < 7, first 1 days paid at a per diem of $21,370 instead.","21695.99","44740.72","44740.72","1 through 10","6974.14","76261.07","per diem","Estimated amount calculated based on 3 day length of stay."
"Intracranial Hemorrhage,MAJOR","044","DRG","","","","","","","","inpatient","","","92954.27","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","23051.4302","","Per diem ($10,685). If length of stay < 7, first 1 days paid at a per diem of $21,370 instead.","23051.4302","44740.72","44740.72","1 through 10","6974.14","76261.07","per diem","Estimated amount calculated based on 3 day length of stay."
"Intracranial Hemorrhage,MAJOR","044","DRG","","","","","","","","inpatient","","","92954.27","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22781.42","","Per diem ($11,220). If length of stay < 7, first 1 days paid at a per diem of $22,440 instead.","22781.42","46979.04","46979.04","1 through 10","6974.14","76261.07","per diem","Estimated amount calculated based on 3 day length of stay."
"Intracranial Hemorrhage,MAJOR","044","DRG","","","","","","","","inpatient","","","92954.27","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","24204.6716","","Per diem ($11,220). If length of stay < 7, first 1 days paid at a per diem of $22,440 instead.","24204.6716","46979.04","46979.04","1 through 10","6974.14","76261.07","per diem","Estimated amount calculated based on 3 day length of stay."
"Intracranial Hemorrhage,MAJOR","044","DRG","","","","","","","","inpatient","","","92954.27","","MASSHEALTH [3001]","HB BWH MEDICAID","15455.07","","Case rate ($17,088.24). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,518.24, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,699.56 and the sum of the standard inlier and any outlier amount.","17084.05","17084.05","32782.77","1 through 10","6974.14","76261.07","case rate",""
"Intracranial Hemorrhage,MAJOR","044","DRG","","","","","","","","inpatient","","","92954.27","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9217.00","","Per diem ($9,217). If length of stay < 4.9, first 1 days paid at a per diem of $18,434 instead.","54811.28","54811.28","54811.28","1 through 10","6974.14","76261.07","per diem","Estimated amount calculated based on 3 day length of stay."
"Intracranial Hemorrhage,MAJOR","044","DRG","","","","","","","","inpatient","","","92954.27","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15455.07","","Case rate ($17,088.24). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,518.24, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,699.56 and the sum of the standard inlier and any outlier amount.","30167.00","30167.00","30167.00","1 through 10","6974.14","76261.07","case rate",""
"Intracranial Hemorrhage,MINOR","044","DRG","","","","","","","","inpatient","","","15658.91","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","23130.28","","Standard inlier is a Case rate ($23,130.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,635, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,283.48) for the length of stay and the standard reimbursement.","23130.28","23130.28","23130.28","1 through 10","6974.14","76261.07","case rate",""
"Intracranial Hemorrhage,MODERATE","044","DRG","","","","","","","","inpatient","","","31454.38","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","32376.58","","Standard inlier is a Case rate ($32,376.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,824, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,596.05) for the length of stay and the standard reimbursement.","32376.57","32376.57","32376.57","1 through 10","6974.14","76261.07","case rate",""
"Intracranial Hemorrhage,MODERATE","044","DRG","","","","","","","","inpatient","","","31454.38","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","36400.00","","Standard inlier is a Case rate ($36,400.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,824, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,166.68) for the length of stay and the standard reimbursement.","33254.53","33254.53","33254.53","1 through 10","6974.14","76261.07","case rate",""
"Intracranial Hemorrhage,MODERATE","044","DRG","","","","","","","","inpatient","","","31454.38","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38374.06","","Fee schedule rate ($38,374.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37256.16","37256.16","37256.16","1 through 10","6974.14","76261.07","case rate",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","","","","inpatient","","","260164.53","195123.40","MEDICARE [2001]","HB BWH MEDICARE","48670.44","","Case rate ($48,670.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,512.20, add-ons for qualifying new technology services are included. If operating cost exceeds $104,156.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,699.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $44,030.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $58,132.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,259.70. The transfer capital threshold is the transfer adjustment factor * $4,259.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","65537.95","65537.95","65537.95","1 through 10","47697.03","82922.08","other","Inpatient Replacement Plans DRG"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","","","","inpatient","","","260164.53","195123.40","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","47697.03","","Case rate ($48,670.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,512.20, add-ons for qualifying new technology services are included. If operating cost exceeds $104,156.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,699.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $44,030.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $58,132.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,259.70. The transfer capital threshold is the transfer adjustment factor * $4,259.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","64419.69","64419.69","64419.69","1 through 10","47697.03","82922.08","other","Inpatient DRG"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With McC","020","MS-DRG","","","","","","","","inpatient","","","273751.28","205313.46","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","74324.66","","Case rate ($72,159.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $86,788.84, add-ons for qualifying new technology services are included. If operating cost exceeds $132,433.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,771.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $65,448.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $86,409.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,331.70. The transfer capital threshold is the transfer adjustment factor * $6,331.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","121229.40","121229.40","121229.40","1 through 10","70716.66","123256.88","other","Inpatient DRG"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With McC","020","MS-DRG","","","","","","","","inpatient","","","273751.28","205313.46","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","72159.86","","Case rate ($72,159.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $86,788.84, add-ons for qualifying new technology services are included. If operating cost exceeds $132,433.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,771.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $65,448.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $86,409.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,331.70. The transfer capital threshold is the transfer adjustment factor * $6,331.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","72657.30","72657.30","72657.30","1 through 10","70716.66","123256.88","other","Inpatient Replacement Plans DRG"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With McC","020","MS-DRG","","","","","","","","inpatient","","","273751.28","205313.46","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","90199.83","","Case rate ($72,159.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $86,788.84, add-ons for qualifying new technology services are included. If operating cost exceeds $132,433.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,771.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $65,448.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $86,409.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,331.70. The transfer capital threshold is the transfer adjustment factor * $6,331.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","82975.90","82975.90","82975.90","1 through 10","70716.66","123256.88","other","Inpatient DRG"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With McC","020","MS-DRG","","","","","","","","inpatient","","","273751.28","205313.46","MARTIN'S POINT [160007]","HB BWH MEDICARE","72159.86","","Case rate ($72,159.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $86,788.84, add-ons for qualifying new technology services are included. If operating cost exceeds $132,433.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,771.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $65,448.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $86,409.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,331.70. The transfer capital threshold is the transfer adjustment factor * $6,331.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","72030.03","72030.03","72030.03","1 through 10","70716.66","123256.88","other","Inpatient Replacement Plans DRG"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With McC","020","MS-DRG","","","","","","","","inpatient","","","273751.28","205313.46","MEDICARE [2001]","HB BWH MEDICARE","72159.86","","Case rate ($72,159.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $86,788.84, add-ons for qualifying new technology services are included. If operating cost exceeds $132,433.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,771.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $65,448.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $86,409.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,331.70. The transfer capital threshold is the transfer adjustment factor * $6,331.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","95453.99","95311.84","146260.77","1 through 10","70716.66","123256.88","other","Inpatient Replacement Plans DRG"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With McC","020","MS-DRG","","","","","","","","inpatient","","","273751.28","205313.46","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","70716.66","","Case rate ($72,159.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $86,788.84, add-ons for qualifying new technology services are included. If operating cost exceeds $132,433.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,771.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $65,448.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $86,409.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,331.70. The transfer capital threshold is the transfer adjustment factor * $6,331.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","95655.08","95655.08","95655.08","1 through 10","70716.66","123256.88","other","Inpatient DRG"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/McC","022","MS-DRG","","","","","","","","inpatient","","","154354.89","115766.17","MEDICARE [2001]","HB BWH MEDICARE","29364.41","","Case rate ($29,364.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $80,915.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,996.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $26,427.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,891.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,556.72. The transfer capital threshold is the transfer adjustment factor * $2,556.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","41898.72","41898.72","41898.72","1 through 10","28777.12","49770.79","other","Inpatient Replacement Plans DRG"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/McC","022","MS-DRG","","","","","","","","inpatient","","","154354.89","115766.17","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28777.12","","Case rate ($29,364.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,271.55, add-ons for qualifying new technology services are included. If operating cost exceeds $80,915.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,996.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $26,427.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,891.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,556.72. The transfer capital threshold is the transfer adjustment factor * $2,556.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","42270.71","42270.71","42270.71","1 through 10","28777.12","49770.79","other","Inpatient DRG"
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","both","","","1972.00","1479.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","611.32","1567.74","other","OPPS APC"
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","both","","","1972.00","1479.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","611.32","1567.74","other","OPPS APC"
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","both","","","1972.00","1479.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1567.74","79.5","","2814.50","2346.50","2814.50","1 through 10","611.32","1567.74","percent of total billed charges",""
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","both","","","1972.00","1479.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","611.32","1567.74","other","OPPS APC"
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","both","","","1972.00","1479.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","611.32","1567.74","other","OPPS APC"
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","both","","","1972.00","1479.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","719.78","36.5","","2677.58","1482.13","2910.89","1 through 10","611.32","1567.74","percent of total billed charges",""
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","both","","","1972.00","1479.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","755.28","38.3","","2723.31","1555.62","2741.61","12","611.32","1567.74","percent of total billed charges",""
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","both","","","1972.00","1479.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","611.32","1567.74","other","OPPS APC"
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","both","","","1972.00","1479.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","611.32","1567.74","other","OPPS APC"
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","both","","","1972.00","1479.00","WELLPOINT [1015]","HB AMC WELLPOINT","1454.94","73.78","","2687.65","2687.64","3224.43","1 through 10","611.32","1567.74","percent of total billed charges",""
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","outpatient","","","1972.00","1479.00","AETNA [1001]","HB AMC AETNA PPO","1585.49","80.4","","1163.76","1163.76","1163.76","1 through 10","986","2384.07","percent of total billed charges",""
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","outpatient","","","1972.00","1479.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1194.05","60.55","","1781.82","1492.00","4331.00","1 through 10","986","2384.07","percent of total billed charges",""
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","outpatient","","","1972.00","1479.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1029.78","52.22","","3144.00","1492.00","3610.00","13","986","2384.07","percent of total billed charges",""
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","outpatient","","","1972.00","1479.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1035.30","52.5","","1182.28","1182.28","1182.28","1 through 10","986","2384.07","percent of total billed charges",""
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","outpatient","","","1972.00","1479.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","986.00","50","","3610.00","2269.44","3610.00","1 through 10","986","2384.07","percent of total billed charges",""
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","outpatient","","","1972.00","1479.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1035.30","52.5","","3610.00","2382.05","4331.00","1 through 10","986","2384.07","percent of total billed charges",""
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","outpatient","","","1972.00","1479.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1084.60","55","","4810.75","3363.17","4810.75","1 through 10","986","2384.07","percent of total billed charges",""
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","outpatient","","","1972.00","1479.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1611.52","81.72","","8894.69","8894.69","8894.69","1 through 10","986","2384.07","percent of total billed charges",""
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","outpatient","","","1972.00","1479.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1611.52","81.72","","2885.83","2132.00","3462.21","1 through 10","986","2384.07","percent of total billed charges",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","both","","","1032.00","774.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","820.44","79.5","","13620.68","7708.80","13620.68","1 through 10","442.73","820.44","percent of total billed charges",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","both","","","1032.00","774.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","550.06","53.3","","13328.94","13328.94","13328.94","1 through 10","442.73","820.44","percent of total billed charges",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","outpatient","","","1032.00","774.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","843.35","81.72","","10837.47","4915.49","15367.27","1 through 10","843.35","843.35","percent of total billed charges",""
"Intraperitoneal Fibrinolysis and Paracentesis","PX-36000360","CDM","49999","CPT","0361","RC","","","","both","","","3046.00","2284.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","944.26","2421.57","other","OPPS APC"
"Intraperitoneal Fibrinolysis and Paracentesis","PX-36000360","CDM","49999","CPT","0361","RC","","","","both","","","3046.00","2284.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","944.26","2421.57","other","OPPS APC"
"Intraperitoneal Fibrinolysis and Paracentesis","PX-36000360","CDM","49999","CPT","0361","RC","","","","both","","","3046.00","2284.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","944.26","2421.57","other","OPPS APC"
"Intraperitoneal Fibrinolysis and Paracentesis","PX-36000360","CDM","49999","CPT","0361","RC","","","","outpatient","","","3046.00","2284.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1523.00","50","","14640.00","14640.00","14640.00","1 through 10","1523","8899.59","percent of total billed charges",""
"Intravascular US Noncoronary Rs&I Intial Vessel","PX-40000142","CDM","37252","CPT","0402","RC","","","","both","","","2443.00","1832.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","935.67","38.3","","926.28","926.28","926.28","1 through 10","757.33","1942.19","percent of total billed charges",""
"Intrinsic Factor Antibody","PX-30000842","CDM","86340","CPT","0302","RC","","","","both","","","180.00","135.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","143.10","79.5","","137.73","137.73","137.73","1 through 10","14.78","171","percent of total billed charges",""
"Intrinsic Factor Antibody","PX-30000842","CDM","86340","CPT","0302","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.70","36.5","","65.28","55.48","130.56","1 through 10","14.78","171","percent of total billed charges",""
"Intrinsic Factor Antibody","PX-30000842","CDM","86340","CPT","0302","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.94","38.3","","68.43","68.43","68.43","15","14.78","171","percent of total billed charges",""
"Intrinsic Factor Antibody","PX-30000842","CDM","86340","CPT","0302","RC","","","","outpatient","","","180.00","135.00","AETNA [1001]","HB AMC AETNA HMO","125.64","69.8","","83.65","83.65","118.48","1 through 10","15.54","147.1","percent of total billed charges",""
"Intrinsic Factor Antibody","PX-30000842","CDM","86340","CPT","0302","RC","","","","outpatient","","","180.00","135.00","AETNA [1001]","HB AMC AETNA PPO","144.72","80.4","","136.50","136.50","136.50","1 through 10","15.54","147.1","percent of total billed charges",""
"Intrinsic Factor Antibody","PX-30000842","CDM","86340","CPT","0302","RC","","","","outpatient","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","147.10","81.72","","139.89","76.95","139.90","1 through 10","15.54","147.1","percent of total billed charges",""
"Intro Cath Artery Heart/Pulm","PX-76001034","CDM","36013","CPT","0361","RC","","","","both","","","3682.00","2761.50","WELLPOINT [1015]","HB AMC WELLPOINT","2716.58","73.78","","2658.61","2658.61","2658.61","1 through 10","1141.42","2927.19","percent of total billed charges",""
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","3812.00","2859.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2477.80","65","","105.95","105.95","105.95","1 through 10","1181.72","3030.54","percent of total billed charges",""
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","outpatient","","","3812.00","2859.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1093.63","","Case rate ($1,093.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1268.61","1268.61","1268.61","1 through 10","1093.63","4183.73","other","Multiple Surgery"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","15343.00","11507.25","MEDICARE [2001]","HB BWH MEDICARE","6770.21","","APC Price ($6,770.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20312.70","20312.70","20312.70","12","4756.33","12197.69","other","OPPS APC"
"Intro Cath Vena Cava Infer/Super","PX-76001031","CDM","36010","CPT","0361","RC","","","","both","","","3334.00","2500.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2650.53","79.5","","9152.55","9152.55","9152.55","1 through 10","1033.54","2650.53","percent of total billed charges",""
"Intro Needle/Cath Extremity","PX-76001039","CDM","36140","CPT","0361","RC","","","","both","","","2728.00","2046.00","WELLPOINT [1015]","HB AMC WELLPOINT","2012.72","73.78","","1969.20","1969.20","1969.20","1 through 10","845.68","2168.76","percent of total billed charges",""
"Intro Needle/Cath Extremity","PX-76001039","CDM","36140","CPT","0361","RC","","","","outpatient","","","2728.00","2046.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","2229.32","81.72","","1988.15","1988.15","1988.15","1 through 10","151.9","2229.32","percent of total billed charges",""
"Intro Tube GI Long","PX-75000165","CDM","44500","CPT","0750","RC","","","","outpatient","","","1703.00","1277.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2018.70","2018.70","2018.70","1 through 10","761.55","2384.07","other","ASC "
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3853.50","2890.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2013.84","52.26","","16.24","16.24","54.15","1 through 10","1194.59","3063.53","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3853.50","2890.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2766.81","71.8","","86.33","32.67","86.33","1 through 10","1194.59","3063.53","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3853.50","2890.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2697.45","70","","113.68","63.00","177.34","40","1194.59","3063.53","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3853.50","2890.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3063.53","79.5","","50.70","21.76","168.00","12","1194.59","3063.53","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3853.50","2890.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2053.92","53.3","","89.31","89.31","99.75","1 through 10","1194.59","3063.53","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3853.50","2890.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2504.78","65","","94.41","17.06","2275.00","1 through 10","1194.59","3063.53","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3853.50","2890.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1194.59","31","","35.13","35.13","35.13","1 through 10","1194.59","3063.53","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3853.50","2890.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1406.53","36.5","","40.08","12.40","86.17","108","1194.59","3063.53","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3853.50","2890.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1475.89","38.3","","33.25","10.27","68.43","169","1194.59","3063.53","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3853.50","2890.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1653.15","42.9","","25.48","14.86","90.88","1 through 10","1194.59","3063.53","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3853.50","2890.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1653.15","42.9","","90.88","90.88","90.88","1 through 10","1194.59","3063.53","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","both","","","3853.50","2890.12","WELLPOINT [1015]","HB AMC WELLPOINT","2843.11","73.78","","84.63","19.55","140.02","123","1194.59","3063.53","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3853.50","2890.12","AETNA [1001]","HB AMC AETNA HMO","2689.74","69.8","","76.96","17.77","113.68","14","2013.84","3149.08","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3853.50","2890.12","AETNA [1001]","HB AMC AETNA PPO","3098.21","80.4","","57.31","57.31","57.31","1 through 10","2013.84","3149.08","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3853.50","2890.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2013.84","52.26","","16.24","16.24","54.15","1 through 10","2013.84","3149.08","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3853.50","2890.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3098.21","80.4","","68.25","68.25","87.50","1 through 10","2013.84","3149.08","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3853.50","2890.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","3149.08","81.72","","156.19","156.19","156.19","1 through 10","2013.84","3149.08","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3853.50","2890.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3149.08","81.72","","82.70","12.06","98.97","13","2013.84","3149.08","percent of total billed charges",""
"INTRODUCER ACCESS SIZE 3 BONE OSTEO KYPHON ONE STEP TROCAR DIAMOND TIP","SUP-ITM-10028150","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3853.50","2890.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3149.08","81.72","","50.47","25.30","134.30","140","2013.84","3149.08","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","709.69","52.26","","16.24","16.24","54.15","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","975.04","71.8","","86.33","32.67","86.33","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","950.60","70","","113.68","63.00","177.34","40","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1079.61","79.5","","50.70","21.76","168.00","12","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","723.81","53.3","","89.31","89.31","99.75","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","882.70","65","","94.41","17.06","2275.00","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","420.98","31","","35.13","35.13","35.13","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","495.67","36.5","","40.08","12.40","86.17","108","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","520.11","38.3","","33.25","10.27","68.43","169","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","582.58","42.9","","25.48","14.86","90.88","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","582.58","42.9","","90.88","90.88","90.88","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","WELLPOINT [1015]","HB AMC WELLPOINT","1001.93","73.78","","84.63","19.55","140.02","123","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","AETNA [1001]","HB AMC AETNA HMO","947.88","69.8","","76.96","17.77","113.68","14","709.69","1109.76","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","AETNA [1001]","HB AMC AETNA PPO","1091.83","80.4","","57.31","57.31","57.31","1 through 10","709.69","1109.76","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","709.69","52.26","","16.24","16.24","54.15","1 through 10","709.69","1109.76","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1091.83","80.4","","68.25","68.25","87.50","1 through 10","709.69","1109.76","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1109.76","81.72","","156.19","156.19","156.19","1 through 10","709.69","1109.76","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1109.76","81.72","","82.70","12.06","98.97","13","709.69","1109.76","percent of total billed charges",""
"INTRODUCER CHECK-FLO 20FR 40CM .035IN 56CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10074826","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1109.76","81.72","","50.47","25.30","134.30","140","709.69","1109.76","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","709.69","52.26","","16.24","16.24","54.15","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","975.04","71.8","","86.33","32.67","86.33","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","950.60","70","","113.68","63.00","177.34","40","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1079.61","79.5","","50.70","21.76","168.00","12","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","723.81","53.3","","89.31","89.31","99.75","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","882.70","65","","94.41","17.06","2275.00","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","420.98","31","","35.13","35.13","35.13","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","495.67","36.5","","40.08","12.40","86.17","108","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","520.11","38.3","","33.25","10.27","68.43","169","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","582.58","42.9","","25.48","14.86","90.88","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","582.58","42.9","","90.88","90.88","90.88","1 through 10","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","both","","","1358.00","1018.50","WELLPOINT [1015]","HB AMC WELLPOINT","1001.93","73.78","","84.63","19.55","140.02","123","420.98","1079.61","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","AETNA [1001]","HB AMC AETNA HMO","947.88","69.8","","76.96","17.77","113.68","14","709.69","1109.76","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","AETNA [1001]","HB AMC AETNA PPO","1091.83","80.4","","57.31","57.31","57.31","1 through 10","709.69","1109.76","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","709.69","52.26","","16.24","16.24","54.15","1 through 10","709.69","1109.76","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1091.83","80.4","","68.25","68.25","87.50","1 through 10","709.69","1109.76","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1109.76","81.72","","156.19","156.19","156.19","1 through 10","709.69","1109.76","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1109.76","81.72","","82.70","12.06","98.97","13","709.69","1109.76","percent of total billed charges",""
"INTRODUCER CHECK-FLO 22FR 25CM .035IN 41CM DILATOR EXTRA LARGE VASCULAR ADULT","SUP-ITM-10007759","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1358.00","1018.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1109.76","81.72","","50.47","25.30","134.30","140","709.69","1109.76","percent of total billed charges",""
"INTRODUCER DI LOCK 9FR 14CM .038IN GUIDING DILATOR PEEL AWAY SHEATH BX/5EA","SUP-ITM-10007481","CDM","C1892","HCPCS","0272","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30.66","36.5","","66.97","66.97","66.97","1 through 10","26.04","66.78","percent of total billed charges",""
"INTRODUCER DI LOCK 9FR 14CM .038IN GUIDING DILATOR PEEL AWAY SHEATH BX/5EA","SUP-ITM-10007481","CDM","C1892","HCPCS","0272","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.17","38.3","","70.21","44.61","70.21","1 through 10","26.04","66.78","percent of total billed charges",""
"INTRODUCER DI LOCK 9FR 14CM .038IN GUIDING DILATOR PEEL AWAY SHEATH BX/5EA","SUP-ITM-10007481","CDM","C1892","HCPCS","0272","RC","","","","both","","","84.00","63.00","WELLPOINT [1015]","HB AMC WELLPOINT","61.98","73.78","","84.95","84.95","84.95","1 through 10","26.04","66.78","percent of total billed charges",""
"INTRODUCER DI LOCK 9FR 14CM .038IN GUIDING DILATOR PEEL AWAY SHEATH BX/5EA","SUP-ITM-10007481","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","68.64","81.72","","91.21","50.17","91.21","1 through 10","43.9","68.64","percent of total billed charges",""
"INTRODUCER DI LOCK 9FR 14CM .038IN GUIDING DILATOR PEEL AWAY SHEATH BX/5EA","SUP-ITM-10007481","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","68.64","81.72","","50.17","50.17","50.17","1 through 10","43.9","68.64","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","339.47","254.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","177.41","52.26","","16.24","16.24","54.15","1 through 10","105.24","269.88","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","339.47","254.60","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","243.74","71.8","","86.33","32.67","86.33","1 through 10","105.24","269.88","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","339.47","254.60","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","237.63","70","","113.68","63.00","177.34","40","105.24","269.88","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","339.47","254.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","269.88","79.5","","50.70","21.76","168.00","12","105.24","269.88","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","339.47","254.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","180.94","53.3","","89.31","89.31","99.75","1 through 10","105.24","269.88","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","339.47","254.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","220.66","65","","94.41","17.06","2275.00","1 through 10","105.24","269.88","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","339.47","254.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","105.24","31","","35.13","35.13","35.13","1 through 10","105.24","269.88","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","339.47","254.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.91","36.5","","40.08","12.40","86.17","108","105.24","269.88","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","339.47","254.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","130.02","38.3","","33.25","10.27","68.43","169","105.24","269.88","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","339.47","254.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.63","42.9","","25.48","14.86","90.88","1 through 10","105.24","269.88","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","339.47","254.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.63","42.9","","90.88","90.88","90.88","1 through 10","105.24","269.88","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","339.47","254.60","WELLPOINT [1015]","HB AMC WELLPOINT","250.46","73.78","","84.63","19.55","140.02","123","105.24","269.88","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","339.47","254.60","AETNA [1001]","HB AMC AETNA HMO","236.95","69.8","","76.96","17.77","113.68","14","177.41","277.41","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","339.47","254.60","AETNA [1001]","HB AMC AETNA PPO","272.93","80.4","","57.31","57.31","57.31","1 through 10","177.41","277.41","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","339.47","254.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","177.41","52.26","","16.24","16.24","54.15","1 through 10","177.41","277.41","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","339.47","254.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","272.93","80.4","","68.25","68.25","87.50","1 through 10","177.41","277.41","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","339.47","254.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","277.41","81.72","","156.19","156.19","156.19","1 through 10","177.41","277.41","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","339.47","254.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","277.41","81.72","","82.70","12.06","98.97","13","177.41","277.41","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","339.47","254.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","277.41","81.72","","50.47","25.30","134.30","140","177.41","277.41","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","137.17","52.26","","16.24","16.24","54.15","1 through 10","81.37","208.66","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","188.45","71.8","","86.33","32.67","86.33","1 through 10","81.37","208.66","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","183.73","70","","113.68","63.00","177.34","40","81.37","208.66","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","208.66","79.5","","50.70","21.76","168.00","12","81.37","208.66","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.90","53.3","","89.31","89.31","99.75","1 through 10","81.37","208.66","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","170.61","65","","94.41","17.06","2275.00","1 through 10","81.37","208.66","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","81.37","31","","35.13","35.13","35.13","1 through 10","81.37","208.66","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.80","36.5","","40.08","12.40","86.17","108","81.37","208.66","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.53","38.3","","33.25","10.27","68.43","169","81.37","208.66","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.60","42.9","","25.48","14.86","90.88","1 through 10","81.37","208.66","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.60","42.9","","90.88","90.88","90.88","1 through 10","81.37","208.66","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","WELLPOINT [1015]","HB AMC WELLPOINT","193.65","73.78","","84.63","19.55","140.02","123","81.37","208.66","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","AETNA [1001]","HB AMC AETNA HMO","183.20","69.8","","76.96","17.77","113.68","14","137.17","214.49","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","AETNA [1001]","HB AMC AETNA PPO","211.03","80.4","","57.31","57.31","57.31","1 through 10","137.17","214.49","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","137.17","52.26","","16.24","16.24","54.15","1 through 10","137.17","214.49","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","211.03","80.4","","68.25","68.25","87.50","1 through 10","137.17","214.49","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","214.49","81.72","","156.19","156.19","156.19","1 through 10","137.17","214.49","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","214.49","81.72","","82.70","12.06","98.97","13","137.17","214.49","percent of total billed charges",""
"INTRODUCER FLEXOR 12FR 4.1MM 40CM .038IN CHECK-FLO VASCULAR MINIMUM ORDER - 5EA","SUP-ITM-10022991","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.49","81.72","","50.47","25.30","134.30","140","137.17","214.49","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","both","","","251.97","188.98","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","131.68","52.26","","16.24","16.24","54.15","1 through 10","78.11","200.32","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","both","","","251.97","188.98","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","180.91","71.8","","86.33","32.67","86.33","1 through 10","78.11","200.32","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","both","","","251.97","188.98","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","176.38","70","","113.68","63.00","177.34","40","78.11","200.32","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","both","","","251.97","188.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","200.32","79.5","","50.70","21.76","168.00","12","78.11","200.32","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","both","","","251.97","188.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","134.30","53.3","","89.31","89.31","99.75","1 through 10","78.11","200.32","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","both","","","251.97","188.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","163.78","65","","94.41","17.06","2275.00","1 through 10","78.11","200.32","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","both","","","251.97","188.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","78.11","31","","35.13","35.13","35.13","1 through 10","78.11","200.32","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","both","","","251.97","188.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91.97","36.5","","40.08","12.40","86.17","108","78.11","200.32","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","both","","","251.97","188.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.50","38.3","","33.25","10.27","68.43","169","78.11","200.32","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","both","","","251.97","188.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.10","42.9","","25.48","14.86","90.88","1 through 10","78.11","200.32","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","both","","","251.97","188.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.10","42.9","","90.88","90.88","90.88","1 through 10","78.11","200.32","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","both","","","251.97","188.98","WELLPOINT [1015]","HB AMC WELLPOINT","185.90","73.78","","84.63","19.55","140.02","123","78.11","200.32","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","251.97","188.98","AETNA [1001]","HB AMC AETNA HMO","175.88","69.8","","76.96","17.77","113.68","14","131.68","205.91","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","251.97","188.98","AETNA [1001]","HB AMC AETNA PPO","202.58","80.4","","57.31","57.31","57.31","1 through 10","131.68","205.91","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","251.97","188.98","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","131.68","52.26","","16.24","16.24","54.15","1 through 10","131.68","205.91","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","251.97","188.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","202.58","80.4","","68.25","68.25","87.50","1 through 10","131.68","205.91","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","251.97","188.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","205.91","81.72","","156.19","156.19","156.19","1 through 10","131.68","205.91","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","251.97","188.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","205.91","81.72","","82.70","12.06","98.97","13","131.68","205.91","percent of total billed charges",""
"INTRODUCER FLEXOR 5.5FR 2.1MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007039","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","251.97","188.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","205.91","81.72","","50.47","25.30","134.30","140","131.68","205.91","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","250.57","52.26","","16.24","16.24","54.15","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","344.26","71.8","","86.33","32.67","86.33","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","335.63","70","","113.68","63.00","177.34","40","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","381.18","79.5","","50.70","21.76","168.00","12","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","255.56","53.3","","89.31","89.31","99.75","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","311.66","65","","94.41","17.06","2275.00","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","148.64","31","","35.13","35.13","35.13","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","175.01","36.5","","40.08","12.40","86.17","108","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","183.64","38.3","","33.25","10.27","68.43","169","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.69","42.9","","25.48","14.86","90.88","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.69","42.9","","90.88","90.88","90.88","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","WELLPOINT [1015]","HB AMC WELLPOINT","353.75","73.78","","84.63","19.55","140.02","123","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","AETNA [1001]","HB AMC AETNA HMO","334.67","69.8","","76.96","17.77","113.68","14","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","AETNA [1001]","HB AMC AETNA PPO","385.49","80.4","","57.31","57.31","57.31","1 through 10","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","250.57","52.26","","16.24","16.24","54.15","1 through 10","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","385.49","80.4","","68.25","68.25","87.50","1 through 10","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","391.82","81.72","","156.19","156.19","156.19","1 through 10","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","391.82","81.72","","82.70","12.06","98.97","13","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 110CM .018IN/.035IN SHUTTLE-SL GUIDING SHEATH VASCULAR TIBIAL INFRAPOPLITEAL ACCESS","SUP-ITM-10087125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","391.82","81.72","","50.47","25.30","134.30","140","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","139.00","52.26","","16.24","16.24","54.15","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","190.97","71.8","","86.33","32.67","86.33","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","186.18","70","","113.68","63.00","177.34","40","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","211.45","79.5","","50.70","21.76","168.00","12","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","141.76","53.3","","89.31","89.31","99.75","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","172.88","65","","94.41","17.06","2275.00","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","82.45","31","","35.13","35.13","35.13","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.08","36.5","","40.08","12.40","86.17","108","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","101.87","38.3","","33.25","10.27","68.43","169","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.10","42.9","","25.48","14.86","90.88","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.10","42.9","","90.88","90.88","90.88","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","WELLPOINT [1015]","HB AMC WELLPOINT","196.23","73.78","","84.63","19.55","140.02","123","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","AETNA [1001]","HB AMC AETNA HMO","185.65","69.8","","76.96","17.77","113.68","14","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","AETNA [1001]","HB AMC AETNA PPO","213.84","80.4","","57.31","57.31","57.31","1 through 10","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","139.00","52.26","","16.24","16.24","54.15","1 through 10","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","213.84","80.4","","68.25","68.25","87.50","1 through 10","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","217.35","81.72","","156.19","156.19","156.19","1 through 10","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","217.35","81.72","","82.70","12.06","98.97","13","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10018906","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","217.35","81.72","","50.47","25.30","134.30","140","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.53","52.26","","16.24","16.24","54.15","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","168.35","71.8","","86.33","32.67","86.33","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","164.13","70","","113.68","63.00","177.34","40","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.40","79.5","","50.70","21.76","168.00","12","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.97","53.3","","89.31","89.31","99.75","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","152.41","65","","94.41","17.06","2275.00","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.69","31","","35.13","35.13","35.13","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.58","36.5","","40.08","12.40","86.17","108","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.80","38.3","","33.25","10.27","68.43","169","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.59","42.9","","25.48","14.86","90.88","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.59","42.9","","90.88","90.88","90.88","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","WELLPOINT [1015]","HB AMC WELLPOINT","172.99","73.78","","84.63","19.55","140.02","123","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","AETNA [1001]","HB AMC AETNA HMO","163.66","69.8","","76.96","17.77","113.68","14","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","AETNA [1001]","HB AMC AETNA PPO","188.51","80.4","","57.31","57.31","57.31","1 through 10","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.53","52.26","","16.24","16.24","54.15","1 through 10","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","188.51","80.4","","68.25","68.25","87.50","1 through 10","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","191.61","81.72","","156.19","156.19","156.19","1 through 10","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.61","81.72","","82.70","12.06","98.97","13","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 70CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10009720","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.61","81.72","","50.47","25.30","134.30","140","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.15","380.36","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","265.04","52.26","","16.24","16.24","54.15","1 through 10","157.22","403.18","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.15","380.36","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","364.13","71.8","","86.33","32.67","86.33","1 through 10","157.22","403.18","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.15","380.36","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","355.01","70","","113.68","63.00","177.34","40","157.22","403.18","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.15","380.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.18","79.5","","50.70","21.76","168.00","12","157.22","403.18","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.15","380.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.31","53.3","","89.31","89.31","99.75","1 through 10","157.22","403.18","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.15","380.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","329.65","65","","94.41","17.06","2275.00","1 through 10","157.22","403.18","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.15","380.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","157.22","31","","35.13","35.13","35.13","1 through 10","157.22","403.18","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.15","380.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.11","36.5","","40.08","12.40","86.17","108","157.22","403.18","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.15","380.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.24","38.3","","33.25","10.27","68.43","169","157.22","403.18","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.15","380.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.57","42.9","","25.48","14.86","90.88","1 through 10","157.22","403.18","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.15","380.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.57","42.9","","90.88","90.88","90.88","1 through 10","157.22","403.18","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.15","380.36","WELLPOINT [1015]","HB AMC WELLPOINT","374.18","73.78","","84.63","19.55","140.02","123","157.22","403.18","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.15","380.36","AETNA [1001]","HB AMC AETNA HMO","353.99","69.8","","76.96","17.77","113.68","14","265.04","414.44","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.15","380.36","AETNA [1001]","HB AMC AETNA PPO","407.75","80.4","","57.31","57.31","57.31","1 through 10","265.04","414.44","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.15","380.36","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","265.04","52.26","","16.24","16.24","54.15","1 through 10","265.04","414.44","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.15","380.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","407.75","80.4","","68.25","68.25","87.50","1 through 10","265.04","414.44","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.15","380.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","414.44","81.72","","156.19","156.19","156.19","1 through 10","265.04","414.44","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.15","380.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","414.44","81.72","","82.70","12.06","98.97","13","265.04","414.44","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .038IN SHUTTLE SELECT CAROTID ACCESS VASCULAR","SUP-ITM-10012398","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.15","380.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","414.44","81.72","","50.47","25.30","134.30","140","265.04","414.44","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","139.00","52.26","","16.24","16.24","54.15","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","190.97","71.8","","86.33","32.67","86.33","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","186.18","70","","113.68","63.00","177.34","40","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","211.45","79.5","","50.70","21.76","168.00","12","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","141.76","53.3","","89.31","89.31","99.75","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","172.88","65","","94.41","17.06","2275.00","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","82.45","31","","35.13","35.13","35.13","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.08","36.5","","40.08","12.40","86.17","108","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","101.87","38.3","","33.25","10.27","68.43","169","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.10","42.9","","25.48","14.86","90.88","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.10","42.9","","90.88","90.88","90.88","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","WELLPOINT [1015]","HB AMC WELLPOINT","196.23","73.78","","84.63","19.55","140.02","123","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","AETNA [1001]","HB AMC AETNA HMO","185.65","69.8","","76.96","17.77","113.68","14","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","AETNA [1001]","HB AMC AETNA PPO","213.84","80.4","","57.31","57.31","57.31","1 through 10","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","139.00","52.26","","16.24","16.24","54.15","1 through 10","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","213.84","80.4","","68.25","68.25","87.50","1 through 10","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","217.35","81.72","","156.19","156.19","156.19","1 through 10","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","217.35","81.72","","82.70","12.06","98.97","13","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER MULTIPURPOSE TIP","SUP-ITM-10087077","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","217.35","81.72","","50.47","25.30","134.30","140","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","139.00","52.26","","16.24","16.24","54.15","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","190.97","71.8","","86.33","32.67","86.33","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","186.18","70","","113.68","63.00","177.34","40","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","211.45","79.5","","50.70","21.76","168.00","12","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","141.76","53.3","","89.31","89.31","99.75","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","172.88","65","","94.41","17.06","2275.00","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","82.45","31","","35.13","35.13","35.13","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.08","36.5","","40.08","12.40","86.17","108","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","101.87","38.3","","33.25","10.27","68.43","169","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.10","42.9","","25.48","14.86","90.88","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.10","42.9","","90.88","90.88","90.88","1 through 10","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","both","","","265.97","199.48","WELLPOINT [1015]","HB AMC WELLPOINT","196.23","73.78","","84.63","19.55","140.02","123","82.45","211.45","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","AETNA [1001]","HB AMC AETNA HMO","185.65","69.8","","76.96","17.77","113.68","14","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","AETNA [1001]","HB AMC AETNA PPO","213.84","80.4","","57.31","57.31","57.31","1 through 10","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","139.00","52.26","","16.24","16.24","54.15","1 through 10","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","213.84","80.4","","68.25","68.25","87.50","1 through 10","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","217.35","81.72","","156.19","156.19","156.19","1 through 10","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","217.35","81.72","","82.70","12.06","98.97","13","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .018IN/.038IN ANSEL GUIDING SHEATH TUOHY-BORST SIDEARM ADAPTER RENAL DOUBLE TIP","SUP-ITM-10012384","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","265.97","199.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","217.35","81.72","","50.47","25.30","134.30","140","139","217.35","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.53","52.26","","16.24","16.24","54.15","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","168.35","71.8","","86.33","32.67","86.33","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","164.13","70","","113.68","63.00","177.34","40","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.40","79.5","","50.70","21.76","168.00","12","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.97","53.3","","89.31","89.31","99.75","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","152.41","65","","94.41","17.06","2275.00","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.69","31","","35.13","35.13","35.13","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.58","36.5","","40.08","12.40","86.17","108","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.80","38.3","","33.25","10.27","68.43","169","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.59","42.9","","25.48","14.86","90.88","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.59","42.9","","90.88","90.88","90.88","1 through 10","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","both","","","234.47","175.85","WELLPOINT [1015]","HB AMC WELLPOINT","172.99","73.78","","84.63","19.55","140.02","123","72.69","186.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","AETNA [1001]","HB AMC AETNA HMO","163.66","69.8","","76.96","17.77","113.68","14","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","AETNA [1001]","HB AMC AETNA PPO","188.51","80.4","","57.31","57.31","57.31","1 through 10","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.53","52.26","","16.24","16.24","54.15","1 through 10","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","188.51","80.4","","68.25","68.25","87.50","1 through 10","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","191.61","81.72","","156.19","156.19","156.19","1 through 10","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.61","81.72","","82.70","12.06","98.97","13","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10026157","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","234.47","175.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.61","81.72","","50.47","25.30","134.30","140","122.53","191.61","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","164.60","52.26","","16.24","16.24","54.15","1 through 10","97.64","250.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","226.15","71.8","","86.33","32.67","86.33","1 through 10","97.64","250.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","220.48","70","","113.68","63.00","177.34","40","97.64","250.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.40","79.5","","50.70","21.76","168.00","12","97.64","250.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.88","53.3","","89.31","89.31","99.75","1 through 10","97.64","250.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","204.73","65","","94.41","17.06","2275.00","1 through 10","97.64","250.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","97.64","31","","35.13","35.13","35.13","1 through 10","97.64","250.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.96","36.5","","40.08","12.40","86.17","108","97.64","250.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.63","38.3","","33.25","10.27","68.43","169","97.64","250.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.12","42.9","","25.48","14.86","90.88","1 through 10","97.64","250.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.12","42.9","","90.88","90.88","90.88","1 through 10","97.64","250.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","WELLPOINT [1015]","HB AMC WELLPOINT","232.38","73.78","","84.63","19.55","140.02","123","97.64","250.4","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","AETNA [1001]","HB AMC AETNA HMO","219.85","69.8","","76.96","17.77","113.68","14","164.6","257.39","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","AETNA [1001]","HB AMC AETNA PPO","253.24","80.4","","57.31","57.31","57.31","1 through 10","164.6","257.39","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","164.60","52.26","","16.24","16.24","54.15","1 through 10","164.6","257.39","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.24","80.4","","68.25","68.25","87.50","1 through 10","164.6","257.39","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","257.39","81.72","","156.19","156.19","156.19","1 through 10","164.6","257.39","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","257.39","81.72","","82.70","12.06","98.97","13","164.6","257.39","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 70CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087194","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.39","81.72","","50.47","25.30","134.30","140","164.6","257.39","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","both","","","248.47","186.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","129.85","52.26","","16.24","16.24","54.15","1 through 10","77.03","197.53","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","both","","","248.47","186.35","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","178.40","71.8","","86.33","32.67","86.33","1 through 10","77.03","197.53","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","both","","","248.47","186.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","173.93","70","","113.68","63.00","177.34","40","77.03","197.53","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","both","","","248.47","186.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","197.53","79.5","","50.70","21.76","168.00","12","77.03","197.53","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","both","","","248.47","186.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","132.43","53.3","","89.31","89.31","99.75","1 through 10","77.03","197.53","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","both","","","248.47","186.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","161.51","65","","94.41","17.06","2275.00","1 through 10","77.03","197.53","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","both","","","248.47","186.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","77.03","31","","35.13","35.13","35.13","1 through 10","77.03","197.53","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","both","","","248.47","186.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","90.69","36.5","","40.08","12.40","86.17","108","77.03","197.53","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","both","","","248.47","186.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","95.16","38.3","","33.25","10.27","68.43","169","77.03","197.53","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","both","","","248.47","186.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.59","42.9","","25.48","14.86","90.88","1 through 10","77.03","197.53","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","both","","","248.47","186.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.59","42.9","","90.88","90.88","90.88","1 through 10","77.03","197.53","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","both","","","248.47","186.35","WELLPOINT [1015]","HB AMC WELLPOINT","183.32","73.78","","84.63","19.55","140.02","123","77.03","197.53","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","248.47","186.35","AETNA [1001]","HB AMC AETNA HMO","173.43","69.8","","76.96","17.77","113.68","14","129.85","203.05","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","248.47","186.35","AETNA [1001]","HB AMC AETNA PPO","199.77","80.4","","57.31","57.31","57.31","1 through 10","129.85","203.05","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","248.47","186.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","129.85","52.26","","16.24","16.24","54.15","1 through 10","129.85","203.05","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","248.47","186.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","199.77","80.4","","68.25","68.25","87.50","1 through 10","129.85","203.05","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","248.47","186.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","203.05","81.72","","156.19","156.19","156.19","1 through 10","129.85","203.05","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","248.47","186.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","203.05","81.72","","82.70","12.06","98.97","13","129.85","203.05","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008714","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","248.47","186.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","203.05","81.72","","50.47","25.30","134.30","140","129.85","203.05","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","250.57","52.26","","16.24","16.24","54.15","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","344.26","71.8","","86.33","32.67","86.33","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","335.63","70","","113.68","63.00","177.34","40","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","381.18","79.5","","50.70","21.76","168.00","12","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","255.56","53.3","","89.31","89.31","99.75","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","311.66","65","","94.41","17.06","2275.00","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","148.64","31","","35.13","35.13","35.13","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","175.01","36.5","","40.08","12.40","86.17","108","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","183.64","38.3","","33.25","10.27","68.43","169","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.69","42.9","","25.48","14.86","90.88","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.69","42.9","","90.88","90.88","90.88","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","WELLPOINT [1015]","HB AMC WELLPOINT","353.75","73.78","","84.63","19.55","140.02","123","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","AETNA [1001]","HB AMC AETNA HMO","334.67","69.8","","76.96","17.77","113.68","14","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","AETNA [1001]","HB AMC AETNA PPO","385.49","80.4","","57.31","57.31","57.31","1 through 10","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","250.57","52.26","","16.24","16.24","54.15","1 through 10","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","385.49","80.4","","68.25","68.25","87.50","1 through 10","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","391.82","81.72","","156.19","156.19","156.19","1 through 10","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","391.82","81.72","","82.70","12.06","98.97","13","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10022711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","391.82","81.72","","50.47","25.30","134.30","140","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","144.48","52.26","","16.24","16.24","54.15","1 through 10","85.71","219.79","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","198.51","71.8","","86.33","32.67","86.33","1 through 10","85.71","219.79","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","193.53","70","","113.68","63.00","177.34","40","85.71","219.79","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","219.79","79.5","","50.70","21.76","168.00","12","85.71","219.79","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.36","53.3","","89.31","89.31","99.75","1 through 10","85.71","219.79","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","179.71","65","","94.41","17.06","2275.00","1 through 10","85.71","219.79","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.71","31","","35.13","35.13","35.13","1 through 10","85.71","219.79","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.91","36.5","","40.08","12.40","86.17","108","85.71","219.79","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.89","38.3","","33.25","10.27","68.43","169","85.71","219.79","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.61","42.9","","25.48","14.86","90.88","1 through 10","85.71","219.79","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.61","42.9","","90.88","90.88","90.88","1 through 10","85.71","219.79","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","WELLPOINT [1015]","HB AMC WELLPOINT","203.98","73.78","","84.63","19.55","140.02","123","85.71","219.79","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","AETNA [1001]","HB AMC AETNA HMO","192.98","69.8","","76.96","17.77","113.68","14","144.48","225.93","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","AETNA [1001]","HB AMC AETNA PPO","222.28","80.4","","57.31","57.31","57.31","1 through 10","144.48","225.93","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","144.48","52.26","","16.24","16.24","54.15","1 through 10","144.48","225.93","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","222.28","80.4","","68.25","68.25","87.50","1 through 10","144.48","225.93","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","225.93","81.72","","156.19","156.19","156.19","1 through 10","144.48","225.93","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","225.93","81.72","","82.70","12.06","98.97","13","144.48","225.93","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087140","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","225.93","81.72","","50.47","25.30","134.30","140","144.48","225.93","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","250.57","52.26","","16.24","16.24","54.15","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","344.26","71.8","","86.33","32.67","86.33","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","335.63","70","","113.68","63.00","177.34","40","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","381.18","79.5","","50.70","21.76","168.00","12","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","255.56","53.3","","89.31","89.31","99.75","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","311.66","65","","94.41","17.06","2275.00","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","148.64","31","","35.13","35.13","35.13","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","175.01","36.5","","40.08","12.40","86.17","108","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","183.64","38.3","","33.25","10.27","68.43","169","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.69","42.9","","25.48","14.86","90.88","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.69","42.9","","90.88","90.88","90.88","1 through 10","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","both","","","479.47","359.60","WELLPOINT [1015]","HB AMC WELLPOINT","353.75","73.78","","84.63","19.55","140.02","123","148.64","381.18","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","AETNA [1001]","HB AMC AETNA HMO","334.67","69.8","","76.96","17.77","113.68","14","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","AETNA [1001]","HB AMC AETNA PPO","385.49","80.4","","57.31","57.31","57.31","1 through 10","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","250.57","52.26","","16.24","16.24","54.15","1 through 10","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","385.49","80.4","","68.25","68.25","87.50","1 through 10","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","391.82","81.72","","156.19","156.19","156.19","1 through 10","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","391.82","81.72","","82.70","12.06","98.97","13","250.57","391.82","percent of total billed charges",""
"INTRODUCER FLEXOR 8FR 2.9MM 90CM .038IN SHUTTLE GUIDING SHEATH VASCULAR","SUP-ITM-10007038","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","479.47","359.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","391.82","81.72","","50.47","25.30","134.30","140","250.57","391.82","percent of total billed charges",""
"INTRODUCER FUSION OASIS 9FR 195CM .035IN STENT BILIARY RADIOPAQUE BAND","SUP-ITM-10026254","CDM","C1876","HCPCS","0278","RC","","","","both","","","469.00","351.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","307.66","65.6","","751.18","751.18","751.18","1 through 10","145.39","372.86","percent of total billed charges",""
"INTRODUCER FUSION OASIS 9FR 195CM .035IN STENT BILIARY RADIOPAQUE BAND","SUP-ITM-10026254","CDM","C1876","HCPCS","0278","RC","","","","both","","","469.00","351.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","372.86","79.5","","4820.38","3211.27","4820.38","1 through 10","145.39","372.86","percent of total billed charges",""
"INTRODUCER FUSION OASIS 9FR 195CM .035IN STENT BILIARY RADIOPAQUE BAND","SUP-ITM-10026254","CDM","C1876","HCPCS","0278","RC","","","","both","","","469.00","351.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","171.19","36.5","","641.00","641.00","641.00","1 through 10","145.39","372.86","percent of total billed charges",""
"INTRODUCER FUSION OASIS 9FR 195CM .035IN STENT BILIARY RADIOPAQUE BAND","SUP-ITM-10026254","CDM","C1876","HCPCS","0278","RC","","","","both","","","469.00","351.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.63","38.3","","1098.43","1098.43","1098.43","1 through 10","145.39","372.86","percent of total billed charges",""
"INTRODUCER FUSION OASIS 9FR 195CM .035IN STENT BILIARY RADIOPAQUE BAND","SUP-ITM-10026254","CDM","C1876","HCPCS","0278","RC","","","","both","","","469.00","351.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.20","42.9","","4896.33","4896.33","4896.33","1 through 10","145.39","372.86","percent of total billed charges",""
"INTRODUCER FUSION OASIS 9FR 195CM .035IN STENT BILIARY RADIOPAQUE BAND","SUP-ITM-10026254","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","469.00","351.75","AETNA [1001]","HB AMC AETNA HMO","327.36","69.8","","175.60","163.11","1063.91","1 through 10","245.1","383.27","percent of total billed charges",""
"INTRODUCER FUSION OASIS 9FR 195CM .035IN STENT BILIARY RADIOPAQUE BAND","SUP-ITM-10026254","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","469.00","351.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","383.27","81.72","","105.94","85.10","105.94","1 through 10","245.1","383.27","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","171.02","52.26","","25.34","25.34","25.34","1 through 10","101.45","260.16","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","234.97","71.8","","105.81","105.81","366.90","1 through 10","101.45","260.16","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","229.08","70","","512.90","74.70","612.85","1 through 10","101.45","260.16","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","260.16","79.5","","200.27","182.80","200.27","1 through 10","101.45","260.16","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","174.42","53.3","","37.73","37.73","169.33","1 through 10","101.45","260.16","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","212.71","65","","100.27","8.48","494.52","1 through 10","101.45","260.16","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","212.71","65","","160.19","160.19","160.19","1 through 10","101.45","260.16","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","101.45","31","","28.12","28.12","28.12","1 through 10","101.45","260.16","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","119.45","36.5","","101.66","28.85","502.70","121","101.45","260.16","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","125.34","38.3","","61.58","25.32","328.44","138","101.45","260.16","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.39","42.9","","71.66","71.66","71.66","1 through 10","101.45","260.16","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","WELLPOINT [1015]","HB AMC WELLPOINT","241.45","73.78","","74.75","27.97","425.28","93","101.45","260.16","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","327.25","245.44","AETNA [1001]","HB AMC AETNA HMO","228.42","69.8","","52.67","14.36","414.90","1 through 10","171.02","267.43","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","327.25","245.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","171.02","52.26","","25.34","25.34","25.34","1 through 10","171.02","267.43","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","327.25","245.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","263.11","80.4","","478.02","107.84","478.02","1 through 10","171.02","267.43","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","327.25","245.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","267.43","81.72","","32.74","12.33","122.05","1 through 10","171.02","267.43","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","327.25","245.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","267.43","81.72","","144.95","32.78","676.91","104","171.02","267.43","percent of total billed charges",""
"Introducer Guiding Other Than Peel-Away T1","PX-27000184","CDM","C1893","HCPCS","0272","RC","","","","both","","","622.20","466.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","238.30","38.3","","218.28","218.28","218.28","1 through 10","192.88","494.65","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","80.46","52.26","","16.24","16.24","54.15","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","110.55","71.8","","86.33","32.67","86.33","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","107.78","70","","113.68","63.00","177.34","40","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","122.41","79.5","","50.70","21.76","168.00","12","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","82.07","53.3","","89.31","89.31","99.75","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","100.08","65","","94.41","17.06","2275.00","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","47.73","31","","35.13","35.13","35.13","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56.20","36.5","","40.08","12.40","86.17","108","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.97","38.3","","33.25","10.27","68.43","169","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.05","42.9","","25.48","14.86","90.88","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.05","42.9","","90.88","90.88","90.88","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","WELLPOINT [1015]","HB AMC WELLPOINT","113.60","73.78","","84.63","19.55","140.02","123","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","AETNA [1001]","HB AMC AETNA HMO","107.47","69.8","","76.96","17.77","113.68","14","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","AETNA [1001]","HB AMC AETNA PPO","123.79","80.4","","57.31","57.31","57.31","1 through 10","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","80.46","52.26","","16.24","16.24","54.15","1 through 10","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","123.79","80.4","","68.25","68.25","87.50","1 through 10","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","125.82","81.72","","156.19","156.19","156.19","1 through 10","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","125.82","81.72","","82.70","12.06","98.97","13","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 15FR .038IN VASCULAR SHEATH STERILE DISPOSABLE","SUP-ITM-10011464","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.82","81.72","","50.47","25.30","134.30","140","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 20FR 13CM .038IN VASCULAR SHEATH VESSEL DILATOR","SUP-ITM-10001350","CDM","C1892","HCPCS","0272","RC","","","","both","","","153.97","115.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56.20","36.5","","66.97","66.97","66.97","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 20FR 13CM .038IN VASCULAR SHEATH VESSEL DILATOR","SUP-ITM-10001350","CDM","C1892","HCPCS","0272","RC","","","","both","","","153.97","115.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.97","38.3","","70.21","44.61","70.21","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 20FR 13CM .038IN VASCULAR SHEATH VESSEL DILATOR","SUP-ITM-10001350","CDM","C1892","HCPCS","0272","RC","","","","both","","","153.97","115.48","WELLPOINT [1015]","HB AMC WELLPOINT","113.60","73.78","","84.95","84.95","84.95","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 20FR 13CM .038IN VASCULAR SHEATH VESSEL DILATOR","SUP-ITM-10001350","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","125.82","81.72","","91.21","50.17","91.21","1 through 10","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 20FR 13CM .038IN VASCULAR SHEATH VESSEL DILATOR","SUP-ITM-10001350","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.82","81.72","","50.17","50.17","50.17","1 through 10","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 22FR 13CM .038IN VASCULAR SHEATH VESSEL DILATOR","SUP-ITM-10015812","CDM","C1892","HCPCS","0272","RC","","","","both","","","153.97","115.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56.20","36.5","","66.97","66.97","66.97","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 22FR 13CM .038IN VASCULAR SHEATH VESSEL DILATOR","SUP-ITM-10015812","CDM","C1892","HCPCS","0272","RC","","","","both","","","153.97","115.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.97","38.3","","70.21","44.61","70.21","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 22FR 13CM .038IN VASCULAR SHEATH VESSEL DILATOR","SUP-ITM-10015812","CDM","C1892","HCPCS","0272","RC","","","","both","","","153.97","115.48","WELLPOINT [1015]","HB AMC WELLPOINT","113.60","73.78","","84.95","84.95","84.95","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 22FR 13CM .038IN VASCULAR SHEATH VESSEL DILATOR","SUP-ITM-10015812","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","125.82","81.72","","91.21","50.17","91.21","1 through 10","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 22FR 13CM .038IN VASCULAR SHEATH VESSEL DILATOR","SUP-ITM-10015812","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.82","81.72","","50.17","50.17","50.17","1 through 10","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","80.46","52.26","","16.24","16.24","54.15","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","110.55","71.8","","86.33","32.67","86.33","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","107.78","70","","113.68","63.00","177.34","40","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","122.41","79.5","","50.70","21.76","168.00","12","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","82.07","53.3","","89.31","89.31","99.75","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","100.08","65","","94.41","17.06","2275.00","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","47.73","31","","35.13","35.13","35.13","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56.20","36.5","","40.08","12.40","86.17","108","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.97","38.3","","33.25","10.27","68.43","169","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.05","42.9","","25.48","14.86","90.88","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.05","42.9","","90.88","90.88","90.88","1 through 10","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","both","","","153.97","115.48","WELLPOINT [1015]","HB AMC WELLPOINT","113.60","73.78","","84.63","19.55","140.02","123","47.73","122.41","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","AETNA [1001]","HB AMC AETNA HMO","107.47","69.8","","76.96","17.77","113.68","14","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","AETNA [1001]","HB AMC AETNA PPO","123.79","80.4","","57.31","57.31","57.31","1 through 10","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","80.46","52.26","","16.24","16.24","54.15","1 through 10","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","123.79","80.4","","68.25","68.25","87.50","1 through 10","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","125.82","81.72","","156.19","156.19","156.19","1 through 10","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","125.82","81.72","","82.70","12.06","98.97","13","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 6FR 15.5CM .035IN 20CM DILATOR SHEATH STERILE DISPOSABLE","SUP-ITM-10013814","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","153.97","115.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.82","81.72","","50.47","25.30","134.30","140","80.46","125.82","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","119.79","52.26","","16.24","16.24","54.15","1 through 10","71.06","182.23","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","164.58","71.8","","86.33","32.67","86.33","1 through 10","71.06","182.23","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","160.45","70","","113.68","63.00","177.34","40","71.06","182.23","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","182.23","79.5","","50.70","21.76","168.00","12","71.06","182.23","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","122.17","53.3","","89.31","89.31","99.75","1 through 10","71.06","182.23","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","148.99","65","","94.41","17.06","2275.00","1 through 10","71.06","182.23","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","71.06","31","","35.13","35.13","35.13","1 through 10","71.06","182.23","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.67","36.5","","40.08","12.40","86.17","108","71.06","182.23","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.79","38.3","","33.25","10.27","68.43","169","71.06","182.23","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.34","42.9","","25.48","14.86","90.88","1 through 10","71.06","182.23","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.34","42.9","","90.88","90.88","90.88","1 through 10","71.06","182.23","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","WELLPOINT [1015]","HB AMC WELLPOINT","169.12","73.78","","84.63","19.55","140.02","123","71.06","182.23","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","AETNA [1001]","HB AMC AETNA HMO","160.00","69.8","","76.96","17.77","113.68","14","119.79","187.32","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","AETNA [1001]","HB AMC AETNA PPO","184.29","80.4","","57.31","57.31","57.31","1 through 10","119.79","187.32","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","119.79","52.26","","16.24","16.24","54.15","1 through 10","119.79","187.32","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","184.29","80.4","","68.25","68.25","87.50","1 through 10","119.79","187.32","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","187.32","81.72","","156.19","156.19","156.19","1 through 10","119.79","187.32","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","187.32","81.72","","82.70","12.06","98.97","13","119.79","187.32","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 7FR 30CM .038IN SHEATH MULTIPURPOSE STRAIGHT ACCESS GUIDEWIRE NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087323","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","187.32","81.72","","50.47","25.30","134.30","140","119.79","187.32","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","both","","","325.47","244.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","170.09","52.26","","16.24","16.24","54.15","1 through 10","100.9","258.75","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","both","","","325.47","244.10","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","233.69","71.8","","86.33","32.67","86.33","1 through 10","100.9","258.75","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","both","","","325.47","244.10","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","227.83","70","","113.68","63.00","177.34","40","100.9","258.75","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","both","","","325.47","244.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.75","79.5","","50.70","21.76","168.00","12","100.9","258.75","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","both","","","325.47","244.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.48","53.3","","89.31","89.31","99.75","1 through 10","100.9","258.75","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","both","","","325.47","244.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","211.56","65","","94.41","17.06","2275.00","1 through 10","100.9","258.75","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","both","","","325.47","244.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","100.90","31","","35.13","35.13","35.13","1 through 10","100.9","258.75","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","both","","","325.47","244.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.80","36.5","","40.08","12.40","86.17","108","100.9","258.75","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","both","","","325.47","244.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.66","38.3","","33.25","10.27","68.43","169","100.9","258.75","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","both","","","325.47","244.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","139.63","42.9","","25.48","14.86","90.88","1 through 10","100.9","258.75","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","both","","","325.47","244.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","139.63","42.9","","90.88","90.88","90.88","1 through 10","100.9","258.75","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","both","","","325.47","244.10","WELLPOINT [1015]","HB AMC WELLPOINT","240.13","73.78","","84.63","19.55","140.02","123","100.9","258.75","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","325.47","244.10","AETNA [1001]","HB AMC AETNA HMO","227.18","69.8","","76.96","17.77","113.68","14","170.09","265.97","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","325.47","244.10","AETNA [1001]","HB AMC AETNA PPO","261.68","80.4","","57.31","57.31","57.31","1 through 10","170.09","265.97","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","325.47","244.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","170.09","52.26","","16.24","16.24","54.15","1 through 10","170.09","265.97","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","325.47","244.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","261.68","80.4","","68.25","68.25","87.50","1 through 10","170.09","265.97","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","325.47","244.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","265.97","81.72","","156.19","156.19","156.19","1 through 10","170.09","265.97","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","325.47","244.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","265.97","81.72","","82.70","12.06","98.97","13","170.09","265.97","percent of total billed charges",""
"INTRODUCER PERFORMER 11FR 3.6MM 70CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","325.47","244.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","265.97","81.72","","50.47","25.30","134.30","140","170.09","265.97","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.47","202.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","140.83","52.26","","16.24","16.24","54.15","1 through 10","83.54","214.23","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.47","202.10","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","193.48","71.8","","86.33","32.67","86.33","1 through 10","83.54","214.23","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.47","202.10","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","188.63","70","","113.68","63.00","177.34","40","83.54","214.23","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.47","202.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","214.23","79.5","","50.70","21.76","168.00","12","83.54","214.23","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.47","202.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","143.63","53.3","","89.31","89.31","99.75","1 through 10","83.54","214.23","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.47","202.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","175.16","65","","94.41","17.06","2275.00","1 through 10","83.54","214.23","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.47","202.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","83.54","31","","35.13","35.13","35.13","1 through 10","83.54","214.23","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.47","202.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","98.36","36.5","","40.08","12.40","86.17","108","83.54","214.23","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.47","202.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","103.21","38.3","","33.25","10.27","68.43","169","83.54","214.23","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.47","202.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","115.60","42.9","","25.48","14.86","90.88","1 through 10","83.54","214.23","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.47","202.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","115.60","42.9","","90.88","90.88","90.88","1 through 10","83.54","214.23","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.47","202.10","WELLPOINT [1015]","HB AMC WELLPOINT","198.81","73.78","","84.63","19.55","140.02","123","83.54","214.23","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","269.47","202.10","AETNA [1001]","HB AMC AETNA HMO","188.09","69.8","","76.96","17.77","113.68","14","140.83","220.21","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","269.47","202.10","AETNA [1001]","HB AMC AETNA PPO","216.65","80.4","","57.31","57.31","57.31","1 through 10","140.83","220.21","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","269.47","202.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","140.83","52.26","","16.24","16.24","54.15","1 through 10","140.83","220.21","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","269.47","202.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","216.65","80.4","","68.25","68.25","87.50","1 through 10","140.83","220.21","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","269.47","202.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","220.21","81.72","","156.19","156.19","156.19","1 through 10","140.83","220.21","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","269.47","202.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","220.21","81.72","","82.70","12.06","98.97","13","140.83","220.21","percent of total billed charges",""
"INTRODUCER PERFORMER 12FR 4MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011774","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","269.47","202.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","220.21","81.72","","50.47","25.30","134.30","140","140.83","220.21","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","both","","","419.97","314.98","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","219.48","52.26","","16.24","16.24","54.15","1 through 10","130.19","333.88","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","both","","","419.97","314.98","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","301.54","71.8","","86.33","32.67","86.33","1 through 10","130.19","333.88","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","both","","","419.97","314.98","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","293.98","70","","113.68","63.00","177.34","40","130.19","333.88","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","both","","","419.97","314.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","333.88","79.5","","50.70","21.76","168.00","12","130.19","333.88","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","both","","","419.97","314.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","223.84","53.3","","89.31","89.31","99.75","1 through 10","130.19","333.88","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","both","","","419.97","314.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","272.98","65","","94.41","17.06","2275.00","1 through 10","130.19","333.88","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","both","","","419.97","314.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","130.19","31","","35.13","35.13","35.13","1 through 10","130.19","333.88","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","both","","","419.97","314.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","153.29","36.5","","40.08","12.40","86.17","108","130.19","333.88","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","both","","","419.97","314.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","160.85","38.3","","33.25","10.27","68.43","169","130.19","333.88","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","both","","","419.97","314.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.17","42.9","","25.48","14.86","90.88","1 through 10","130.19","333.88","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","both","","","419.97","314.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.17","42.9","","90.88","90.88","90.88","1 through 10","130.19","333.88","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","both","","","419.97","314.98","WELLPOINT [1015]","HB AMC WELLPOINT","309.85","73.78","","84.63","19.55","140.02","123","130.19","333.88","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","419.97","314.98","AETNA [1001]","HB AMC AETNA HMO","293.14","69.8","","76.96","17.77","113.68","14","219.48","343.2","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","419.97","314.98","AETNA [1001]","HB AMC AETNA PPO","337.66","80.4","","57.31","57.31","57.31","1 through 10","219.48","343.2","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","419.97","314.98","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","219.48","52.26","","16.24","16.24","54.15","1 through 10","219.48","343.2","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","419.97","314.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","337.66","80.4","","68.25","68.25","87.50","1 through 10","219.48","343.2","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","419.97","314.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","343.20","81.72","","156.19","156.19","156.19","1 through 10","219.48","343.2","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","419.97","314.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","343.20","81.72","","82.70","12.06","98.97","13","219.48","343.2","percent of total billed charges",""
"INTRODUCER PERFORMER 14FR 4.6MM 30CM RADIOPAQUE BAND LG VALVE ASSEMBLY CHECK FLO VASCULAR","SUP-ITM-10011744","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","419.97","314.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","343.20","81.72","","50.47","25.30","134.30","140","219.48","343.2","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","217.65","52.26","","16.24","16.24","54.15","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","299.03","71.8","","86.33","32.67","86.33","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","291.53","70","","113.68","63.00","177.34","40","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","331.09","79.5","","50.70","21.76","168.00","12","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","221.98","53.3","","89.31","89.31","99.75","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","270.71","65","","94.41","17.06","2275.00","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","129.11","31","","35.13","35.13","35.13","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","152.01","36.5","","40.08","12.40","86.17","108","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","159.51","38.3","","33.25","10.27","68.43","169","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.67","42.9","","25.48","14.86","90.88","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.67","42.9","","90.88","90.88","90.88","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","WELLPOINT [1015]","HB AMC WELLPOINT","307.27","73.78","","84.63","19.55","140.02","123","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","AETNA [1001]","HB AMC AETNA HMO","290.70","69.8","","76.96","17.77","113.68","14","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","AETNA [1001]","HB AMC AETNA PPO","334.84","80.4","","57.31","57.31","57.31","1 through 10","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","217.65","52.26","","16.24","16.24","54.15","1 through 10","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","334.84","80.4","","68.25","68.25","87.50","1 through 10","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","340.34","81.72","","156.19","156.19","156.19","1 through 10","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","340.34","81.72","","82.70","12.06","98.97","13","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10011190","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","340.34","81.72","","50.47","25.30","134.30","140","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","217.65","52.26","","16.24","16.24","54.15","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","299.03","71.8","","86.33","32.67","86.33","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","291.53","70","","113.68","63.00","177.34","40","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","331.09","79.5","","50.70","21.76","168.00","12","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","221.98","53.3","","89.31","89.31","99.75","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","270.71","65","","94.41","17.06","2275.00","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","129.11","31","","35.13","35.13","35.13","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","152.01","36.5","","40.08","12.40","86.17","108","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","159.51","38.3","","33.25","10.27","68.43","169","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.67","42.9","","25.48","14.86","90.88","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.67","42.9","","90.88","90.88","90.88","1 through 10","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","both","","","416.47","312.35","WELLPOINT [1015]","HB AMC WELLPOINT","307.27","73.78","","84.63","19.55","140.02","123","129.11","331.09","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","AETNA [1001]","HB AMC AETNA HMO","290.70","69.8","","76.96","17.77","113.68","14","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","AETNA [1001]","HB AMC AETNA PPO","334.84","80.4","","57.31","57.31","57.31","1 through 10","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","217.65","52.26","","16.24","16.24","54.15","1 through 10","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","334.84","80.4","","68.25","68.25","87.50","1 through 10","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","340.34","81.72","","156.19","156.19","156.19","1 through 10","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","340.34","81.72","","82.70","12.06","98.97","13","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 18FR 5.9MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008893","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","416.47","312.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","340.34","81.72","","50.47","25.30","134.30","140","217.65","340.34","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","55.77","52.26","","16.24","16.24","54.15","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","76.62","71.8","","86.33","32.67","86.33","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","74.70","70","","113.68","63.00","177.34","40","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","84.84","79.5","","50.70","21.76","168.00","12","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","56.88","53.3","","89.31","89.31","99.75","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","69.37","65","","94.41","17.06","2275.00","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","33.08","31","","35.13","35.13","35.13","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.95","36.5","","40.08","12.40","86.17","108","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.87","38.3","","33.25","10.27","68.43","169","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.78","42.9","","25.48","14.86","90.88","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.78","42.9","","90.88","90.88","90.88","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","WELLPOINT [1015]","HB AMC WELLPOINT","78.74","73.78","","84.63","19.55","140.02","123","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","AETNA [1001]","HB AMC AETNA HMO","74.49","69.8","","76.96","17.77","113.68","14","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","AETNA [1001]","HB AMC AETNA PPO","85.80","80.4","","57.31","57.31","57.31","1 through 10","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","55.77","52.26","","16.24","16.24","54.15","1 through 10","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","85.80","80.4","","68.25","68.25","87.50","1 through 10","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","87.21","81.72","","156.19","156.19","156.19","1 through 10","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","87.21","81.72","","82.70","12.06","98.97","13","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 6FR 2MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10008243","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.21","81.72","","50.47","25.30","134.30","140","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","55.77","52.26","","16.24","16.24","54.15","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","76.62","71.8","","86.33","32.67","86.33","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","74.70","70","","113.68","63.00","177.34","40","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","84.84","79.5","","50.70","21.76","168.00","12","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","56.88","53.3","","89.31","89.31","99.75","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","69.37","65","","94.41","17.06","2275.00","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","33.08","31","","35.13","35.13","35.13","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.95","36.5","","40.08","12.40","86.17","108","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.87","38.3","","33.25","10.27","68.43","169","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.78","42.9","","25.48","14.86","90.88","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.78","42.9","","90.88","90.88","90.88","1 through 10","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","both","","","106.72","80.04","WELLPOINT [1015]","HB AMC WELLPOINT","78.74","73.78","","84.63","19.55","140.02","123","33.08","84.84","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","AETNA [1001]","HB AMC AETNA HMO","74.49","69.8","","76.96","17.77","113.68","14","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","AETNA [1001]","HB AMC AETNA PPO","85.80","80.4","","57.31","57.31","57.31","1 through 10","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","55.77","52.26","","16.24","16.24","54.15","1 through 10","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","85.80","80.4","","68.25","68.25","87.50","1 through 10","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","87.21","81.72","","156.19","156.19","156.19","1 through 10","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","87.21","81.72","","82.70","12.06","98.97","13","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 30CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10024622","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","106.72","80.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.21","81.72","","50.47","25.30","134.30","140","55.77","87.21","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","both","","","293.97","220.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","153.63","52.26","","16.24","16.24","54.15","1 through 10","91.13","233.71","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","both","","","293.97","220.48","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","211.07","71.8","","86.33","32.67","86.33","1 through 10","91.13","233.71","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","both","","","293.97","220.48","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","205.78","70","","113.68","63.00","177.34","40","91.13","233.71","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","both","","","293.97","220.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","233.71","79.5","","50.70","21.76","168.00","12","91.13","233.71","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","both","","","293.97","220.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","156.69","53.3","","89.31","89.31","99.75","1 through 10","91.13","233.71","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","both","","","293.97","220.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","191.08","65","","94.41","17.06","2275.00","1 through 10","91.13","233.71","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","both","","","293.97","220.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","91.13","31","","35.13","35.13","35.13","1 through 10","91.13","233.71","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","both","","","293.97","220.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","107.30","36.5","","40.08","12.40","86.17","108","91.13","233.71","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","both","","","293.97","220.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","112.59","38.3","","33.25","10.27","68.43","169","91.13","233.71","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","both","","","293.97","220.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.11","42.9","","25.48","14.86","90.88","1 through 10","91.13","233.71","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","both","","","293.97","220.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.11","42.9","","90.88","90.88","90.88","1 through 10","91.13","233.71","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","both","","","293.97","220.48","WELLPOINT [1015]","HB AMC WELLPOINT","216.89","73.78","","84.63","19.55","140.02","123","91.13","233.71","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","293.97","220.48","AETNA [1001]","HB AMC AETNA HMO","205.19","69.8","","76.96","17.77","113.68","14","153.63","240.23","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","293.97","220.48","AETNA [1001]","HB AMC AETNA PPO","236.35","80.4","","57.31","57.31","57.31","1 through 10","153.63","240.23","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","293.97","220.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","153.63","52.26","","16.24","16.24","54.15","1 through 10","153.63","240.23","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","293.97","220.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","236.35","80.4","","68.25","68.25","87.50","1 through 10","153.63","240.23","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","293.97","220.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","240.23","81.72","","156.19","156.19","156.19","1 through 10","153.63","240.23","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","293.97","220.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","240.23","81.72","","82.70","12.06","98.97","13","153.63","240.23","percent of total billed charges",""
"INTRODUCER PERFORMER 8FR 2.6MM 63CM .038IN GUIDING SHEATH MULLINS RADIOPAQUE CHECK FLO VASCULAR","SUP-ITM-10012228","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","293.97","220.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","240.23","81.72","","50.47","25.30","134.30","140","153.63","240.23","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.97","136.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","95.10","52.26","","16.24","16.24","54.15","1 through 10","56.41","144.67","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.97","136.48","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","130.65","71.8","","86.33","32.67","86.33","1 through 10","56.41","144.67","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.97","136.48","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","127.38","70","","113.68","63.00","177.34","40","56.41","144.67","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.97","136.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","144.67","79.5","","50.70","21.76","168.00","12","56.41","144.67","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.97","136.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","96.99","53.3","","89.31","89.31","99.75","1 through 10","56.41","144.67","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.97","136.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","118.28","65","","94.41","17.06","2275.00","1 through 10","56.41","144.67","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.97","136.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","56.41","31","","35.13","35.13","35.13","1 through 10","56.41","144.67","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.97","136.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","66.42","36.5","","40.08","12.40","86.17","108","56.41","144.67","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.97","136.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","69.69","38.3","","33.25","10.27","68.43","169","56.41","144.67","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.97","136.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.07","42.9","","25.48","14.86","90.88","1 through 10","56.41","144.67","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.97","136.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.07","42.9","","90.88","90.88","90.88","1 through 10","56.41","144.67","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.97","136.48","WELLPOINT [1015]","HB AMC WELLPOINT","134.26","73.78","","84.63","19.55","140.02","123","56.41","144.67","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.97","136.48","AETNA [1001]","HB AMC AETNA HMO","127.02","69.8","","76.96","17.77","113.68","14","95.1","148.71","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.97","136.48","AETNA [1001]","HB AMC AETNA PPO","146.30","80.4","","57.31","57.31","57.31","1 through 10","95.1","148.71","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.97","136.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","95.10","52.26","","16.24","16.24","54.15","1 through 10","95.1","148.71","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.97","136.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","146.30","80.4","","68.25","68.25","87.50","1 through 10","95.1","148.71","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.97","136.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","148.71","81.72","","156.19","156.19","156.19","1 through 10","95.1","148.71","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.97","136.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","148.71","81.72","","82.70","12.06","98.97","13","95.1","148.71","percent of total billed charges",""
"INTRODUCER PERFORMER SET 12FR 4MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 8FR 10FR 12FR DILATORS VASCULAR","SUP-ITM-10000191","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.97","136.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","148.71","81.72","","50.47","25.30","134.30","140","95.1","148.71","percent of total billed charges",""
"INTRODUCER SAFESHEATH II 11FR 23CM LONG SYSTEM HEMOSTATIC PEEL-AWAY VALVED W/SIDE PORT YELLOW HUB BX/5EA","SUP-ITM-10115589","CDM","C1892","HCPCS","0272","RC","","","","both","","","173.60","130.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.36","36.5","","66.97","66.97","66.97","1 through 10","53.82","138.01","percent of total billed charges",""
"INTRODUCER SAFESHEATH II 11FR 23CM LONG SYSTEM HEMOSTATIC PEEL-AWAY VALVED W/SIDE PORT YELLOW HUB BX/5EA","SUP-ITM-10115589","CDM","C1892","HCPCS","0272","RC","","","","both","","","173.60","130.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.49","38.3","","70.21","44.61","70.21","1 through 10","53.82","138.01","percent of total billed charges",""
"INTRODUCER SAFESHEATH II 11FR 23CM LONG SYSTEM HEMOSTATIC PEEL-AWAY VALVED W/SIDE PORT YELLOW HUB BX/5EA","SUP-ITM-10115589","CDM","C1892","HCPCS","0272","RC","","","","both","","","173.60","130.20","WELLPOINT [1015]","HB AMC WELLPOINT","128.08","73.78","","84.95","84.95","84.95","1 through 10","53.82","138.01","percent of total billed charges",""
"INTRODUCER SAFESHEATH II 11FR 23CM LONG SYSTEM HEMOSTATIC PEEL-AWAY VALVED W/SIDE PORT YELLOW HUB BX/5EA","SUP-ITM-10115589","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","173.60","130.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","141.87","81.72","","91.21","50.17","91.21","1 through 10","90.72","141.87","percent of total billed charges",""
"INTRODUCER SAFESHEATH II 11FR 23CM LONG SYSTEM HEMOSTATIC PEEL-AWAY VALVED W/SIDE PORT YELLOW HUB BX/5EA","SUP-ITM-10115589","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","173.60","130.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","141.87","81.72","","50.17","50.17","50.17","1 through 10","90.72","141.87","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","both","","","52.50","39.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","27.44","52.26","","16.24","16.24","54.15","1 through 10","16.28","41.74","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","both","","","52.50","39.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","37.70","71.8","","86.33","32.67","86.33","1 through 10","16.28","41.74","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","both","","","52.50","39.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","36.75","70","","113.68","63.00","177.34","40","16.28","41.74","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","both","","","52.50","39.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","41.74","79.5","","50.70","21.76","168.00","12","16.28","41.74","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","both","","","52.50","39.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","27.98","53.3","","89.31","89.31","99.75","1 through 10","16.28","41.74","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","both","","","52.50","39.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","34.13","65","","94.41","17.06","2275.00","1 through 10","16.28","41.74","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","both","","","52.50","39.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","16.28","31","","35.13","35.13","35.13","1 through 10","16.28","41.74","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","both","","","52.50","39.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19.16","36.5","","40.08","12.40","86.17","108","16.28","41.74","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","both","","","52.50","39.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20.11","38.3","","33.25","10.27","68.43","169","16.28","41.74","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","both","","","52.50","39.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","22.52","42.9","","25.48","14.86","90.88","1 through 10","16.28","41.74","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","both","","","52.50","39.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","22.52","42.9","","90.88","90.88","90.88","1 through 10","16.28","41.74","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","both","","","52.50","39.37","WELLPOINT [1015]","HB AMC WELLPOINT","38.73","73.78","","84.63","19.55","140.02","123","16.28","41.74","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","AETNA [1001]","HB AMC AETNA HMO","36.65","69.8","","76.96","17.77","113.68","14","27.44","42.9","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","AETNA [1001]","HB AMC AETNA PPO","42.21","80.4","","57.31","57.31","57.31","1 through 10","27.44","42.9","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","27.44","52.26","","16.24","16.24","54.15","1 through 10","27.44","42.9","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","42.21","80.4","","68.25","68.25","87.50","1 through 10","27.44","42.9","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","42.90","81.72","","156.19","156.19","156.19","1 through 10","27.44","42.9","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","42.90","81.72","","82.70","12.06","98.97","13","27.44","42.9","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000512","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","52.50","39.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","42.90","81.72","","50.47","25.30","134.30","140","27.44","42.9","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","both","","","49.00","36.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","25.61","52.26","","16.24","16.24","54.15","1 through 10","15.19","38.96","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","both","","","49.00","36.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","35.18","71.8","","86.33","32.67","86.33","1 through 10","15.19","38.96","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","both","","","49.00","36.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","34.30","70","","113.68","63.00","177.34","40","15.19","38.96","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","both","","","49.00","36.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","38.96","79.5","","50.70","21.76","168.00","12","15.19","38.96","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","both","","","49.00","36.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","26.12","53.3","","89.31","89.31","99.75","1 through 10","15.19","38.96","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","both","","","49.00","36.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","31.85","65","","94.41","17.06","2275.00","1 through 10","15.19","38.96","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","both","","","49.00","36.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","15.19","31","","35.13","35.13","35.13","1 through 10","15.19","38.96","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","both","","","49.00","36.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17.89","36.5","","40.08","12.40","86.17","108","15.19","38.96","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","both","","","49.00","36.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18.77","38.3","","33.25","10.27","68.43","169","15.19","38.96","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","both","","","49.00","36.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21.02","42.9","","25.48","14.86","90.88","1 through 10","15.19","38.96","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","both","","","49.00","36.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21.02","42.9","","90.88","90.88","90.88","1 through 10","15.19","38.96","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","both","","","49.00","36.75","WELLPOINT [1015]","HB AMC WELLPOINT","36.15","73.78","","84.63","19.55","140.02","123","15.19","38.96","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","49.00","36.75","AETNA [1001]","HB AMC AETNA HMO","34.20","69.8","","76.96","17.77","113.68","14","25.61","40.04","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","49.00","36.75","AETNA [1001]","HB AMC AETNA PPO","39.40","80.4","","57.31","57.31","57.31","1 through 10","25.61","40.04","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","49.00","36.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","25.61","52.26","","16.24","16.24","54.15","1 through 10","25.61","40.04","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","49.00","36.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","39.40","80.4","","68.25","68.25","87.50","1 through 10","25.61","40.04","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","49.00","36.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","40.04","81.72","","156.19","156.19","156.19","1 through 10","25.61","40.04","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","49.00","36.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","40.04","81.72","","82.70","12.06","98.97","13","25.61","40.04","percent of total billed charges",""
"INTRODUCER SHEATH 14FR 12CM .038IN FAST-CATH LG LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT BX/10EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10006617","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","49.00","36.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","40.04","81.72","","50.47","25.30","134.30","140","25.61","40.04","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1110.26","52.26","","16.24","16.24","54.15","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1525.39","71.8","","86.33","32.67","86.33","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1487.15","70","","113.68","63.00","177.34","40","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1688.98","79.5","","50.70","21.76","168.00","12","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1132.36","53.3","","89.31","89.31","99.75","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1380.93","65","","94.41","17.06","2275.00","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","658.60","31","","35.13","35.13","35.13","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","775.44","36.5","","40.08","12.40","86.17","108","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","813.68","38.3","","33.25","10.27","68.43","169","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.41","42.9","","25.48","14.86","90.88","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.41","42.9","","90.88","90.88","90.88","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","WELLPOINT [1015]","HB AMC WELLPOINT","1567.46","73.78","","84.63","19.55","140.02","123","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","AETNA [1001]","HB AMC AETNA HMO","1482.90","69.8","","76.96","17.77","113.68","14","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","AETNA [1001]","HB AMC AETNA PPO","1708.10","80.4","","57.31","57.31","57.31","1 through 10","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1110.26","52.26","","16.24","16.24","54.15","1 through 10","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1708.10","80.4","","68.25","68.25","87.50","1 through 10","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1736.14","81.72","","156.19","156.19","156.19","1 through 10","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1736.14","81.72","","82.70","12.06","98.97","13","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 20FR 6.7X33CM DRYSEAL FLEX","SUP-ITM-10169116","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1736.14","81.72","","50.47","25.30","134.30","140","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1110.26","52.26","","16.24","16.24","54.15","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1525.39","71.8","","86.33","32.67","86.33","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1487.15","70","","113.68","63.00","177.34","40","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1688.98","79.5","","50.70","21.76","168.00","12","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1132.36","53.3","","89.31","89.31","99.75","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1380.93","65","","94.41","17.06","2275.00","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","658.60","31","","35.13","35.13","35.13","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","775.44","36.5","","40.08","12.40","86.17","108","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","813.68","38.3","","33.25","10.27","68.43","169","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.41","42.9","","25.48","14.86","90.88","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.41","42.9","","90.88","90.88","90.88","1 through 10","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","WELLPOINT [1015]","HB AMC WELLPOINT","1567.46","73.78","","84.63","19.55","140.02","123","658.6","1688.98","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","AETNA [1001]","HB AMC AETNA HMO","1482.90","69.8","","76.96","17.77","113.68","14","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","AETNA [1001]","HB AMC AETNA PPO","1708.10","80.4","","57.31","57.31","57.31","1 through 10","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1110.26","52.26","","16.24","16.24","54.15","1 through 10","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1708.10","80.4","","68.25","68.25","87.50","1 through 10","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1736.14","81.72","","156.19","156.19","156.19","1 through 10","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1736.14","81.72","","82.70","12.06","98.97","13","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 24FR 8X33CM DRYSEAL FLEX","SUP-ITM-10169120","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1736.14","81.72","","50.47","25.30","134.30","140","1110.26","1736.14","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","18.25","52.26","","16.24","16.24","54.15","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","25.08","71.8","","86.33","32.67","86.33","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","24.45","70","","113.68","63.00","177.34","40","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","27.77","79.5","","50.70","21.76","168.00","12","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","18.62","53.3","","89.31","89.31","99.75","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","22.70","65","","94.41","17.06","2275.00","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","10.83","31","","35.13","35.13","35.13","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12.75","36.5","","40.08","12.40","86.17","108","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","13.38","38.3","","33.25","10.27","68.43","169","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.98","42.9","","25.48","14.86","90.88","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.98","42.9","","90.88","90.88","90.88","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","WELLPOINT [1015]","HB AMC WELLPOINT","25.77","73.78","","84.63","19.55","140.02","123","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","AETNA [1001]","HB AMC AETNA HMO","24.38","69.8","","76.96","17.77","113.68","14","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","AETNA [1001]","HB AMC AETNA PPO","28.08","80.4","","57.31","57.31","57.31","1 through 10","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","18.25","52.26","","16.24","16.24","54.15","1 through 10","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","28.08","80.4","","68.25","68.25","87.50","1 through 10","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","28.54","81.72","","156.19","156.19","156.19","1 through 10","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","28.54","81.72","","82.70","12.06","98.97","13","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 25MM 11CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE RED BX/5EA","SUP-ITM-10013727","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","28.54","81.72","","50.47","25.30","134.30","140","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","both","","","77.00","57.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","40.24","52.26","","16.24","16.24","54.15","1 through 10","23.87","61.22","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","both","","","77.00","57.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","55.29","71.8","","86.33","32.67","86.33","1 through 10","23.87","61.22","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","both","","","77.00","57.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","53.90","70","","113.68","63.00","177.34","40","23.87","61.22","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","both","","","77.00","57.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","61.22","79.5","","50.70","21.76","168.00","12","23.87","61.22","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","both","","","77.00","57.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","41.04","53.3","","89.31","89.31","99.75","1 through 10","23.87","61.22","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","both","","","77.00","57.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","50.05","65","","94.41","17.06","2275.00","1 through 10","23.87","61.22","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","both","","","77.00","57.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","23.87","31","","35.13","35.13","35.13","1 through 10","23.87","61.22","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","both","","","77.00","57.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28.11","36.5","","40.08","12.40","86.17","108","23.87","61.22","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","both","","","77.00","57.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.49","38.3","","33.25","10.27","68.43","169","23.87","61.22","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","both","","","77.00","57.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.03","42.9","","25.48","14.86","90.88","1 through 10","23.87","61.22","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","both","","","77.00","57.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.03","42.9","","90.88","90.88","90.88","1 through 10","23.87","61.22","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","both","","","77.00","57.75","WELLPOINT [1015]","HB AMC WELLPOINT","56.81","73.78","","84.63","19.55","140.02","123","23.87","61.22","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","77.00","57.75","AETNA [1001]","HB AMC AETNA HMO","53.75","69.8","","76.96","17.77","113.68","14","40.24","62.92","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","77.00","57.75","AETNA [1001]","HB AMC AETNA PPO","61.91","80.4","","57.31","57.31","57.31","1 through 10","40.24","62.92","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","77.00","57.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","40.24","52.26","","16.24","16.24","54.15","1 through 10","40.24","62.92","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","77.00","57.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","61.91","80.4","","68.25","68.25","87.50","1 through 10","40.24","62.92","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","77.00","57.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","62.92","81.72","","156.19","156.19","156.19","1 through 10","40.24","62.92","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","77.00","57.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","62.92","81.72","","82.70","12.06","98.97","13","40.24","62.92","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10008784","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","77.00","57.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","62.92","81.72","","50.47","25.30","134.30","140","40.24","62.92","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","48.02","52.26","","16.24","16.24","54.15","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","65.97","71.8","","86.33","32.67","86.33","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","64.32","70","","113.68","63.00","177.34","40","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","73.04","79.5","","50.70","21.76","168.00","12","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.97","53.3","","89.31","89.31","99.75","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","59.72","65","","94.41","17.06","2275.00","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","28.48","31","","35.13","35.13","35.13","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.54","36.5","","40.08","12.40","86.17","108","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35.19","38.3","","33.25","10.27","68.43","169","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.42","42.9","","25.48","14.86","90.88","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.42","42.9","","90.88","90.88","90.88","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","WELLPOINT [1015]","HB AMC WELLPOINT","67.79","73.78","","84.63","19.55","140.02","123","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","AETNA [1001]","HB AMC AETNA HMO","64.13","69.8","","76.96","17.77","113.68","14","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","AETNA [1001]","HB AMC AETNA PPO","73.87","80.4","","57.31","57.31","57.31","1 through 10","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","48.02","52.26","","16.24","16.24","54.15","1 through 10","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","73.87","80.4","","68.25","68.25","87.50","1 through 10","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","75.08","81.72","","156.19","156.19","156.19","1 through 10","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","75.08","81.72","","82.70","12.06","98.97","13","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 5FR 25MM 23CM .035IN BRITE TIP RADIOPAQUE NO MINI-WIRE GREY BX/5EA","SUP-ITM-10277234","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","75.08","81.72","","50.47","25.30","134.30","140","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","both","","","33.25","24.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","17.38","52.26","","16.24","16.24","54.15","1 through 10","10.31","26.43","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","both","","","33.25","24.94","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","23.87","71.8","","86.33","32.67","86.33","1 through 10","10.31","26.43","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","both","","","33.25","24.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","23.28","70","","113.68","63.00","177.34","40","10.31","26.43","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","both","","","33.25","24.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","26.43","79.5","","50.70","21.76","168.00","12","10.31","26.43","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","both","","","33.25","24.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","17.72","53.3","","89.31","89.31","99.75","1 through 10","10.31","26.43","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","both","","","33.25","24.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","21.61","65","","94.41","17.06","2275.00","1 through 10","10.31","26.43","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","both","","","33.25","24.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","10.31","31","","35.13","35.13","35.13","1 through 10","10.31","26.43","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","both","","","33.25","24.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12.14","36.5","","40.08","12.40","86.17","108","10.31","26.43","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","both","","","33.25","24.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12.73","38.3","","33.25","10.27","68.43","169","10.31","26.43","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","both","","","33.25","24.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.26","42.9","","25.48","14.86","90.88","1 through 10","10.31","26.43","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","both","","","33.25","24.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.26","42.9","","90.88","90.88","90.88","1 through 10","10.31","26.43","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","both","","","33.25","24.94","WELLPOINT [1015]","HB AMC WELLPOINT","24.53","73.78","","84.63","19.55","140.02","123","10.31","26.43","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","33.25","24.94","AETNA [1001]","HB AMC AETNA HMO","23.21","69.8","","76.96","17.77","113.68","14","17.38","27.17","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","33.25","24.94","AETNA [1001]","HB AMC AETNA PPO","26.73","80.4","","57.31","57.31","57.31","1 through 10","17.38","27.17","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","33.25","24.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","17.38","52.26","","16.24","16.24","54.15","1 through 10","17.38","27.17","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","33.25","24.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","26.73","80.4","","68.25","68.25","87.50","1 through 10","17.38","27.17","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","33.25","24.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","27.17","81.72","","156.19","156.19","156.19","1 through 10","17.38","27.17","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","33.25","24.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","27.17","81.72","","82.70","12.06","98.97","13","17.38","27.17","percent of total billed charges",""
"INTRODUCER SHEATH 6.5FR 11CM .038IN AVANTI PLUS VASCULAR WITH MINI-WIRE STANDARD LIGHT GREEN BX/5EA","SUP-ITM-10029970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","33.25","24.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","27.17","81.72","","50.47","25.30","134.30","140","17.38","27.17","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","both","","","73.50","55.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","38.41","52.26","","16.24","16.24","54.15","1 through 10","22.79","58.43","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","both","","","73.50","55.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","52.77","71.8","","86.33","32.67","86.33","1 through 10","22.79","58.43","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","both","","","73.50","55.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","51.45","70","","113.68","63.00","177.34","40","22.79","58.43","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","both","","","73.50","55.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","58.43","79.5","","50.70","21.76","168.00","12","22.79","58.43","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","both","","","73.50","55.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39.18","53.3","","89.31","89.31","99.75","1 through 10","22.79","58.43","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","both","","","73.50","55.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","47.78","65","","94.41","17.06","2275.00","1 through 10","22.79","58.43","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","both","","","73.50","55.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","22.79","31","","35.13","35.13","35.13","1 through 10","22.79","58.43","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","both","","","73.50","55.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.83","36.5","","40.08","12.40","86.17","108","22.79","58.43","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","both","","","73.50","55.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.15","38.3","","33.25","10.27","68.43","169","22.79","58.43","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","both","","","73.50","55.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.53","42.9","","25.48","14.86","90.88","1 through 10","22.79","58.43","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","both","","","73.50","55.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.53","42.9","","90.88","90.88","90.88","1 through 10","22.79","58.43","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","both","","","73.50","55.12","WELLPOINT [1015]","HB AMC WELLPOINT","54.23","73.78","","84.63","19.55","140.02","123","22.79","58.43","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","73.50","55.12","AETNA [1001]","HB AMC AETNA HMO","51.30","69.8","","76.96","17.77","113.68","14","38.41","60.06","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","73.50","55.12","AETNA [1001]","HB AMC AETNA PPO","59.09","80.4","","57.31","57.31","57.31","1 through 10","38.41","60.06","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","73.50","55.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","38.41","52.26","","16.24","16.24","54.15","1 through 10","38.41","60.06","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","73.50","55.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","59.09","80.4","","68.25","68.25","87.50","1 through 10","38.41","60.06","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","73.50","55.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","60.06","81.72","","156.19","156.19","156.19","1 through 10","38.41","60.06","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","73.50","55.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","60.06","81.72","","82.70","12.06","98.97","13","38.41","60.06","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 12CM .038IN FAST-CATH LUER LOCK HEMOSTASIS VALVE SIDEPORT DILATOR DOUBLE DISTAL GUIDEWIRE BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10011481","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","73.50","55.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","60.06","81.72","","50.47","25.30","134.30","140","38.41","60.06","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","48.02","52.26","","16.24","16.24","54.15","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","65.97","71.8","","86.33","32.67","86.33","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","64.32","70","","113.68","63.00","177.34","40","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","73.04","79.5","","50.70","21.76","168.00","12","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.97","53.3","","89.31","89.31","99.75","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","59.72","65","","94.41","17.06","2275.00","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","28.48","31","","35.13","35.13","35.13","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.54","36.5","","40.08","12.40","86.17","108","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35.19","38.3","","33.25","10.27","68.43","169","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.42","42.9","","25.48","14.86","90.88","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.42","42.9","","90.88","90.88","90.88","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","WELLPOINT [1015]","HB AMC WELLPOINT","67.79","73.78","","84.63","19.55","140.02","123","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","AETNA [1001]","HB AMC AETNA HMO","64.13","69.8","","76.96","17.77","113.68","14","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","AETNA [1001]","HB AMC AETNA PPO","73.87","80.4","","57.31","57.31","57.31","1 through 10","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","48.02","52.26","","16.24","16.24","54.15","1 through 10","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","73.87","80.4","","68.25","68.25","87.50","1 through 10","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","75.08","81.72","","156.19","156.19","156.19","1 through 10","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","75.08","81.72","","82.70","12.06","98.97","13","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","75.08","81.72","","50.47","25.30","134.30","140","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","18.25","52.26","","16.24","16.24","54.15","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","25.08","71.8","","86.33","32.67","86.33","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","24.45","70","","113.68","63.00","177.34","40","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","27.77","79.5","","50.70","21.76","168.00","12","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","18.62","53.3","","89.31","89.31","99.75","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","22.70","65","","94.41","17.06","2275.00","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","10.83","31","","35.13","35.13","35.13","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12.75","36.5","","40.08","12.40","86.17","108","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","13.38","38.3","","33.25","10.27","68.43","169","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.98","42.9","","25.48","14.86","90.88","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.98","42.9","","90.88","90.88","90.88","1 through 10","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","34.93","26.20","WELLPOINT [1015]","HB AMC WELLPOINT","25.77","73.78","","84.63","19.55","140.02","123","10.83","27.77","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","AETNA [1001]","HB AMC AETNA HMO","24.38","69.8","","76.96","17.77","113.68","14","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","AETNA [1001]","HB AMC AETNA PPO","28.08","80.4","","57.31","57.31","57.31","1 through 10","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","18.25","52.26","","16.24","16.24","54.15","1 through 10","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","28.08","80.4","","68.25","68.25","87.50","1 through 10","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","28.54","81.72","","156.19","156.19","156.19","1 through 10","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","28.54","81.72","","82.70","12.06","98.97","13","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","34.93","26.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","28.54","81.72","","50.47","25.30","134.30","140","18.25","28.54","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","48.02","52.26","","16.24","16.24","54.15","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","65.97","71.8","","86.33","32.67","86.33","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","64.32","70","","113.68","63.00","177.34","40","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","73.04","79.5","","50.70","21.76","168.00","12","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.97","53.3","","89.31","89.31","99.75","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","59.72","65","","94.41","17.06","2275.00","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","28.48","31","","35.13","35.13","35.13","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.54","36.5","","40.08","12.40","86.17","108","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35.19","38.3","","33.25","10.27","68.43","169","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.42","42.9","","25.48","14.86","90.88","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.42","42.9","","90.88","90.88","90.88","1 through 10","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","both","","","91.88","68.91","WELLPOINT [1015]","HB AMC WELLPOINT","67.79","73.78","","84.63","19.55","140.02","123","28.48","73.04","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","AETNA [1001]","HB AMC AETNA HMO","64.13","69.8","","76.96","17.77","113.68","14","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","AETNA [1001]","HB AMC AETNA PPO","73.87","80.4","","57.31","57.31","57.31","1 through 10","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","48.02","52.26","","16.24","16.24","54.15","1 through 10","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","73.87","80.4","","68.25","68.25","87.50","1 through 10","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","75.08","81.72","","156.19","156.19","156.19","1 through 10","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","75.08","81.72","","82.70","12.06","98.97","13","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX23CM MED VASCULAR BRITE TIP SILICONE COATED DILATOR MINI ORANGE BX/5EA","SUP-ITM-10283573","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","91.88","68.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","75.08","81.72","","50.47","25.30","134.30","140","48.02","75.08","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","997.50","748.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","521.29","52.26","","16.24","16.24","54.15","1 through 10","309.23","793.01","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","997.50","748.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","716.21","71.8","","86.33","32.67","86.33","1 through 10","309.23","793.01","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","997.50","748.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","698.25","70","","113.68","63.00","177.34","40","309.23","793.01","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","997.50","748.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","793.01","79.5","","50.70","21.76","168.00","12","309.23","793.01","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","997.50","748.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","531.67","53.3","","89.31","89.31","99.75","1 through 10","309.23","793.01","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","997.50","748.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","648.38","65","","94.41","17.06","2275.00","1 through 10","309.23","793.01","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","997.50","748.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","309.23","31","","35.13","35.13","35.13","1 through 10","309.23","793.01","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","997.50","748.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","364.09","36.5","","40.08","12.40","86.17","108","309.23","793.01","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","997.50","748.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","382.04","38.3","","33.25","10.27","68.43","169","309.23","793.01","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","997.50","748.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.93","42.9","","25.48","14.86","90.88","1 through 10","309.23","793.01","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","997.50","748.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.93","42.9","","90.88","90.88","90.88","1 through 10","309.23","793.01","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","997.50","748.12","WELLPOINT [1015]","HB AMC WELLPOINT","735.96","73.78","","84.63","19.55","140.02","123","309.23","793.01","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","997.50","748.12","AETNA [1001]","HB AMC AETNA HMO","696.26","69.8","","76.96","17.77","113.68","14","521.29","815.16","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","997.50","748.12","AETNA [1001]","HB AMC AETNA PPO","801.99","80.4","","57.31","57.31","57.31","1 through 10","521.29","815.16","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","997.50","748.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","521.29","52.26","","16.24","16.24","54.15","1 through 10","521.29","815.16","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","997.50","748.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","801.99","80.4","","68.25","68.25","87.50","1 through 10","521.29","815.16","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","997.50","748.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","815.16","81.72","","156.19","156.19","156.19","1 through 10","521.29","815.16","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","997.50","748.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","815.16","81.72","","82.70","12.06","98.97","13","521.29","815.16","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","997.50","748.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","815.16","81.72","","50.47","25.30","134.30","140","521.29","815.16","percent of total billed charges",""
"INTRODUCER SHEATH AGILIS 8.5FR 71CM .032IN 16.8MM CURL DUAL REACH STEERABLE BIDIRECTIONAL NXT","SUP-ITM-10016204","CDM","C1766","HCPCS","0272","RC","","","","both","","","3253.25","2439.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1700.15","52.26","","2815.54","2815.54","2815.54","1 through 10","1008.51","2586.33","percent of total billed charges",""
"INTRODUCER SHEATH AGILIS 8.5FR 71CM .032IN 16.8MM CURL DUAL REACH STEERABLE BIDIRECTIONAL NXT","SUP-ITM-10016204","CDM","C1766","HCPCS","0272","RC","","","","both","","","3253.25","2439.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2586.33","79.5","","3771.60","3771.60","3771.60","1 through 10","1008.51","2586.33","percent of total billed charges",""
"INTRODUCER SHEATH AGILIS 8.5FR 71CM .032IN 16.8MM CURL DUAL REACH STEERABLE BIDIRECTIONAL NXT","SUP-ITM-10016204","CDM","C1766","HCPCS","0272","RC","","","","both","","","3253.25","2439.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2114.61","65","","2161.25","2161.25","2161.25","1 through 10","1008.51","2586.33","percent of total billed charges",""
"INTRODUCER SHEATH AGILIS 8.5FR 71CM .032IN 16.8MM CURL DUAL REACH STEERABLE BIDIRECTIONAL NXT","SUP-ITM-10016204","CDM","C1766","HCPCS","0272","RC","","","","both","","","3253.25","2439.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1187.44","36.5","","1697.15","370.76","3720.69","1 through 10","1008.51","2586.33","percent of total billed charges",""
"INTRODUCER SHEATH AGILIS 8.5FR 71CM .032IN 16.8MM CURL DUAL REACH STEERABLE BIDIRECTIONAL NXT","SUP-ITM-10016204","CDM","C1766","HCPCS","0272","RC","","","","both","","","3253.25","2439.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1245.99","38.3","","1779.05","1263.50","3458.00","16","1008.51","2586.33","percent of total billed charges",""
"INTRODUCER SHEATH AGILIS 8.5FR 71CM .032IN 16.8MM CURL DUAL REACH STEERABLE BIDIRECTIONAL NXT","SUP-ITM-10016204","CDM","C1766","HCPCS","0272","RC","","","","both","","","3253.25","2439.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1395.64","42.9","","1512.88","1512.88","1512.88","1 through 10","1008.51","2586.33","percent of total billed charges",""
"INTRODUCER SHEATH AGILIS 8.5FR 71CM .032IN 16.8MM CURL DUAL REACH STEERABLE BIDIRECTIONAL NXT","SUP-ITM-10016204","CDM","C1766","HCPCS","0272","RC","","","","both","","","3253.25","2439.94","WELLPOINT [1015]","HB AMC WELLPOINT","2400.25","73.78","","3387.48","2475.46","3387.48","1 through 10","1008.51","2586.33","percent of total billed charges",""
"INTRODUCER SHEATH AGILIS 8.5FR 71CM .032IN 16.8MM CURL DUAL REACH STEERABLE BIDIRECTIONAL NXT","SUP-ITM-10016204","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","3253.25","2439.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1700.15","52.26","","2815.54","2815.54","2815.54","1 through 10","1700.15","2658.56","percent of total billed charges",""
"INTRODUCER SHEATH AGILIS 8.5FR 71CM .032IN 16.8MM CURL DUAL REACH STEERABLE BIDIRECTIONAL NXT","SUP-ITM-10016204","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","3253.25","2439.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2658.56","81.72","","3637.27","2000.64","3637.27","1 through 10","1700.15","2658.56","percent of total billed charges",""
"INTRODUCER SHEATH AGILIS 8.5FR 71CM .032IN 16.8MM CURL DUAL REACH STEERABLE BIDIRECTIONAL NXT","SUP-ITM-10016204","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","3253.25","2439.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2658.56","81.72","","2658.01","2000.64","3637.27","17","1700.15","2658.56","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","both","","","42.00","31.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","21.95","52.26","","16.24","16.24","54.15","1 through 10","13.02","33.39","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","both","","","42.00","31.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","30.16","71.8","","86.33","32.67","86.33","1 through 10","13.02","33.39","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","both","","","42.00","31.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","29.40","70","","113.68","63.00","177.34","40","13.02","33.39","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","both","","","42.00","31.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33.39","79.5","","50.70","21.76","168.00","12","13.02","33.39","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","both","","","42.00","31.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22.39","53.3","","89.31","89.31","99.75","1 through 10","13.02","33.39","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","both","","","42.00","31.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","27.30","65","","94.41","17.06","2275.00","1 through 10","13.02","33.39","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","both","","","42.00","31.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","13.02","31","","35.13","35.13","35.13","1 through 10","13.02","33.39","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","both","","","42.00","31.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15.33","36.5","","40.08","12.40","86.17","108","13.02","33.39","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","both","","","42.00","31.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.09","38.3","","33.25","10.27","68.43","169","13.02","33.39","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","both","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.02","42.9","","25.48","14.86","90.88","1 through 10","13.02","33.39","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","both","","","42.00","31.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.02","42.9","","90.88","90.88","90.88","1 through 10","13.02","33.39","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","both","","","42.00","31.50","WELLPOINT [1015]","HB AMC WELLPOINT","30.99","73.78","","84.63","19.55","140.02","123","13.02","33.39","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","42.00","31.50","AETNA [1001]","HB AMC AETNA HMO","29.32","69.8","","76.96","17.77","113.68","14","21.95","34.32","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","42.00","31.50","AETNA [1001]","HB AMC AETNA PPO","33.77","80.4","","57.31","57.31","57.31","1 through 10","21.95","34.32","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","42.00","31.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","21.95","52.26","","16.24","16.24","54.15","1 through 10","21.95","34.32","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","42.00","31.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","33.77","80.4","","68.25","68.25","87.50","1 through 10","21.95","34.32","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","42.00","31.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","34.32","81.72","","156.19","156.19","156.19","1 through 10","21.95","34.32","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","34.32","81.72","","82.70","12.06","98.97","13","21.95","34.32","percent of total billed charges",""
"INTRODUCER SHEATH ENGAGE 4FR 12CM .035IN VASCULAR FEMORAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10124285","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34.32","81.72","","50.47","25.30","134.30","140","21.95","34.32","percent of total billed charges",""
"INTRODUCER SHEATH FAST-CATH 8FR 63CM .038IN SWARTZ SR0 CURVE HEMOSTASIS VALVE SIDEPORT DILATOR","SUP-ITM-10000430","CDM","C1893","HCPCS","0272","RC","","","","both","","","558.25","418.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","213.81","38.3","","218.28","218.28","218.28","1 through 10","173.06","443.81","percent of total billed charges",""
"INTRODUCER SHEATH FLEXCATH 12FR 81CM ADVANCE CATHETER VASCULAR COPOLYMER BARIUM SULFATE ABLATION","SUP-ITM-10114987","CDM","C1766","HCPCS","0272","RC","","","","both","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","2815.54","2815.54","2815.54","1 through 10","1193.5","3060.75","percent of total billed charges",""
"INTRODUCER SHEATH FLEXCATH 12FR 81CM ADVANCE CATHETER VASCULAR COPOLYMER BARIUM SULFATE ABLATION","SUP-ITM-10114987","CDM","C1766","HCPCS","0272","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","3771.60","3771.60","3771.60","1 through 10","1193.5","3060.75","percent of total billed charges",""
"INTRODUCER SHEATH FLEXCATH 12FR 81CM ADVANCE CATHETER VASCULAR COPOLYMER BARIUM SULFATE ABLATION","SUP-ITM-10114987","CDM","C1766","HCPCS","0272","RC","","","","both","","","3850.00","2887.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2502.50","65","","2161.25","2161.25","2161.25","1 through 10","1193.5","3060.75","percent of total billed charges",""
"INTRODUCER SHEATH FLEXCATH 12FR 81CM ADVANCE CATHETER VASCULAR COPOLYMER BARIUM SULFATE ABLATION","SUP-ITM-10114987","CDM","C1766","HCPCS","0272","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","1697.15","370.76","3720.69","1 through 10","1193.5","3060.75","percent of total billed charges",""
"INTRODUCER SHEATH FLEXCATH 12FR 81CM ADVANCE CATHETER VASCULAR COPOLYMER BARIUM SULFATE ABLATION","SUP-ITM-10114987","CDM","C1766","HCPCS","0272","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","1779.05","1263.50","3458.00","16","1193.5","3060.75","percent of total billed charges",""
"INTRODUCER SHEATH FLEXCATH 12FR 81CM ADVANCE CATHETER VASCULAR COPOLYMER BARIUM SULFATE ABLATION","SUP-ITM-10114987","CDM","C1766","HCPCS","0272","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","1512.88","1512.88","1512.88","1 through 10","1193.5","3060.75","percent of total billed charges",""
"INTRODUCER SHEATH FLEXCATH 12FR 81CM ADVANCE CATHETER VASCULAR COPOLYMER BARIUM SULFATE ABLATION","SUP-ITM-10114987","CDM","C1766","HCPCS","0272","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","3387.48","2475.46","3387.48","1 through 10","1193.5","3060.75","percent of total billed charges",""
"INTRODUCER SHEATH FLEXCATH 12FR 81CM ADVANCE CATHETER VASCULAR COPOLYMER BARIUM SULFATE ABLATION","SUP-ITM-10114987","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","2815.54","2815.54","2815.54","1 through 10","2012.01","3146.22","percent of total billed charges",""
"INTRODUCER SHEATH FLEXCATH 12FR 81CM ADVANCE CATHETER VASCULAR COPOLYMER BARIUM SULFATE ABLATION","SUP-ITM-10114987","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3146.22","81.72","","3637.27","2000.64","3637.27","1 through 10","2012.01","3146.22","percent of total billed charges",""
"INTRODUCER SHEATH FLEXCATH 12FR 81CM ADVANCE CATHETER VASCULAR COPOLYMER BARIUM SULFATE ABLATION","SUP-ITM-10114987","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","2658.01","2000.64","3637.27","17","2012.01","3146.22","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 10.5FR 25CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE LIGHT FUSCIA BX/5EA","SUP-ITM-10148326","CDM","C1892","HCPCS","0272","RC","","","","both","","","163.80","122.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","59.79","36.5","","66.97","66.97","66.97","1 through 10","50.78","130.22","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 10.5FR 25CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE LIGHT FUSCIA BX/5EA","SUP-ITM-10148326","CDM","C1892","HCPCS","0272","RC","","","","both","","","163.80","122.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.74","38.3","","70.21","44.61","70.21","1 through 10","50.78","130.22","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 10.5FR 25CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE LIGHT FUSCIA BX/5EA","SUP-ITM-10148326","CDM","C1892","HCPCS","0272","RC","","","","both","","","163.80","122.85","WELLPOINT [1015]","HB AMC WELLPOINT","120.85","73.78","","84.95","84.95","84.95","1 through 10","50.78","130.22","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 10.5FR 25CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE LIGHT FUSCIA BX/5EA","SUP-ITM-10148326","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","163.80","122.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","133.86","81.72","","91.21","50.17","91.21","1 through 10","85.6","133.86","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 10.5FR 25CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE LIGHT FUSCIA BX/5EA","SUP-ITM-10148326","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","163.80","122.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","133.86","81.72","","50.17","50.17","50.17","1 through 10","85.6","133.86","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 10FR 13CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE FUSCIA BX/5EA","SUP-ITM-10148316","CDM","C1892","HCPCS","0272","RC","","","","both","","","129.15","96.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","47.14","36.5","","66.97","66.97","66.97","1 through 10","40.04","102.67","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 10FR 13CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE FUSCIA BX/5EA","SUP-ITM-10148316","CDM","C1892","HCPCS","0272","RC","","","","both","","","129.15","96.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","49.46","38.3","","70.21","44.61","70.21","1 through 10","40.04","102.67","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 10FR 13CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE FUSCIA BX/5EA","SUP-ITM-10148316","CDM","C1892","HCPCS","0272","RC","","","","both","","","129.15","96.86","WELLPOINT [1015]","HB AMC WELLPOINT","95.29","73.78","","84.95","84.95","84.95","1 through 10","40.04","102.67","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 10FR 13CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE FUSCIA BX/5EA","SUP-ITM-10148316","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","129.15","96.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","105.54","81.72","","91.21","50.17","91.21","1 through 10","67.49","105.54","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 10FR 13CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE FUSCIA BX/5EA","SUP-ITM-10148316","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","129.15","96.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","105.54","81.72","","50.17","50.17","50.17","1 through 10","67.49","105.54","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 6FR 13CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE GREEN BX/5EA","SUP-ITM-10148310","CDM","C1892","HCPCS","0272","RC","","","","both","","","114.10","85.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.65","36.5","","66.97","66.97","66.97","1 through 10","35.37","90.71","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 6FR 13CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE GREEN BX/5EA","SUP-ITM-10148310","CDM","C1892","HCPCS","0272","RC","","","","both","","","114.10","85.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.70","38.3","","70.21","44.61","70.21","1 through 10","35.37","90.71","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 6FR 13CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE GREEN BX/5EA","SUP-ITM-10148310","CDM","C1892","HCPCS","0272","RC","","","","both","","","114.10","85.57","WELLPOINT [1015]","HB AMC WELLPOINT","84.18","73.78","","84.95","84.95","84.95","1 through 10","35.37","90.71","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 6FR 13CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE GREEN BX/5EA","SUP-ITM-10148310","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","114.10","85.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","93.24","81.72","","91.21","50.17","91.21","1 through 10","59.63","93.24","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 6FR 13CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE GREEN BX/5EA","SUP-ITM-10148310","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","114.10","85.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.24","81.72","","50.17","50.17","50.17","1 through 10","59.63","93.24","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 6FR 25CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE GREEN BX/5EA","SUP-ITM-10148321","CDM","C1892","HCPCS","0272","RC","","","","both","","","165.55","124.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.43","36.5","","66.97","66.97","66.97","1 through 10","51.32","131.61","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 6FR 25CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE GREEN BX/5EA","SUP-ITM-10148321","CDM","C1892","HCPCS","0272","RC","","","","both","","","165.55","124.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.41","38.3","","70.21","44.61","70.21","1 through 10","51.32","131.61","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 6FR 25CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE GREEN BX/5EA","SUP-ITM-10148321","CDM","C1892","HCPCS","0272","RC","","","","both","","","165.55","124.16","WELLPOINT [1015]","HB AMC WELLPOINT","122.14","73.78","","84.95","84.95","84.95","1 through 10","51.32","131.61","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 6FR 25CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE GREEN BX/5EA","SUP-ITM-10148321","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","165.55","124.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","135.29","81.72","","91.21","50.17","91.21","1 through 10","86.52","135.29","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 6FR 25CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE GREEN BX/5EA","SUP-ITM-10148321","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","165.55","124.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","135.29","81.72","","50.17","50.17","50.17","1 through 10","86.52","135.29","percent of total billed charges",""
"INTRODUCER SILHOUETTE 13FR 30CM .038IN TRANSITIONLESS PEEL AWAY SHEATH","SUP-ITM-10017710","CDM","C1892","HCPCS","0272","RC","","","","both","","","227.47","170.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.03","36.5","","66.97","66.97","66.97","1 through 10","70.52","180.84","percent of total billed charges",""
"INTRODUCER SILHOUETTE 13FR 30CM .038IN TRANSITIONLESS PEEL AWAY SHEATH","SUP-ITM-10017710","CDM","C1892","HCPCS","0272","RC","","","","both","","","227.47","170.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.12","38.3","","70.21","44.61","70.21","1 through 10","70.52","180.84","percent of total billed charges",""
"INTRODUCER SILHOUETTE 13FR 30CM .038IN TRANSITIONLESS PEEL AWAY SHEATH","SUP-ITM-10017710","CDM","C1892","HCPCS","0272","RC","","","","both","","","227.47","170.60","WELLPOINT [1015]","HB AMC WELLPOINT","167.83","73.78","","84.95","84.95","84.95","1 through 10","70.52","180.84","percent of total billed charges",""
"INTRODUCER SILHOUETTE 13FR 30CM .038IN TRANSITIONLESS PEEL AWAY SHEATH","SUP-ITM-10017710","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","227.47","170.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","185.89","81.72","","91.21","50.17","91.21","1 through 10","118.88","185.89","percent of total billed charges",""
"INTRODUCER SILHOUETTE 13FR 30CM .038IN TRANSITIONLESS PEEL AWAY SHEATH","SUP-ITM-10017710","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","227.47","170.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","185.89","81.72","","50.17","50.17","50.17","1 through 10","118.88","185.89","percent of total billed charges",""
"INTRODUCER SILHOUETTE 15FR 30CM .038IN TRANSITIONLESS PEEL AWAY SHEATH -ORDER IN MULTIPLE OF 5","SUP-ITM-10017711","CDM","C1892","HCPCS","0272","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","209.51","36.5","","66.97","66.97","66.97","1 through 10","177.94","456.33","percent of total billed charges",""
"INTRODUCER SILHOUETTE 15FR 30CM .038IN TRANSITIONLESS PEEL AWAY SHEATH -ORDER IN MULTIPLE OF 5","SUP-ITM-10017711","CDM","C1892","HCPCS","0272","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","219.84","38.3","","70.21","44.61","70.21","1 through 10","177.94","456.33","percent of total billed charges",""
"INTRODUCER SILHOUETTE 15FR 30CM .038IN TRANSITIONLESS PEEL AWAY SHEATH -ORDER IN MULTIPLE OF 5","SUP-ITM-10017711","CDM","C1892","HCPCS","0272","RC","","","","both","","","574.00","430.50","WELLPOINT [1015]","HB AMC WELLPOINT","423.50","73.78","","84.95","84.95","84.95","1 through 10","177.94","456.33","percent of total billed charges",""
"INTRODUCER SILHOUETTE 15FR 30CM .038IN TRANSITIONLESS PEEL AWAY SHEATH -ORDER IN MULTIPLE OF 5","SUP-ITM-10017711","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","469.07","81.72","","91.21","50.17","91.21","1 through 10","299.97","469.07","percent of total billed charges",""
"INTRODUCER SILHOUETTE 15FR 30CM .038IN TRANSITIONLESS PEEL AWAY SHEATH -ORDER IN MULTIPLE OF 5","SUP-ITM-10017711","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","469.07","81.72","","50.17","50.17","50.17","1 through 10","299.97","469.07","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.50","380.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","265.22","52.26","","16.24","16.24","54.15","1 through 10","157.33","403.46","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.50","380.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","364.39","71.8","","86.33","32.67","86.33","1 through 10","157.33","403.46","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.50","380.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","355.25","70","","113.68","63.00","177.34","40","157.33","403.46","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.50","380.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.46","79.5","","50.70","21.76","168.00","12","157.33","403.46","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.50","380.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.50","53.3","","89.31","89.31","99.75","1 through 10","157.33","403.46","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.50","380.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","329.88","65","","94.41","17.06","2275.00","1 through 10","157.33","403.46","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","157.33","31","","35.13","35.13","35.13","1 through 10","157.33","403.46","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.24","36.5","","40.08","12.40","86.17","108","157.33","403.46","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.37","38.3","","33.25","10.27","68.43","169","157.33","403.46","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.72","42.9","","25.48","14.86","90.88","1 through 10","157.33","403.46","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.50","380.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.72","42.9","","90.88","90.88","90.88","1 through 10","157.33","403.46","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","both","","","507.50","380.62","WELLPOINT [1015]","HB AMC WELLPOINT","374.43","73.78","","84.63","19.55","140.02","123","157.33","403.46","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.50","380.62","AETNA [1001]","HB AMC AETNA HMO","354.24","69.8","","76.96","17.77","113.68","14","265.22","414.73","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.50","380.62","AETNA [1001]","HB AMC AETNA PPO","408.03","80.4","","57.31","57.31","57.31","1 through 10","265.22","414.73","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.50","380.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","265.22","52.26","","16.24","16.24","54.15","1 through 10","265.22","414.73","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.50","380.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","408.03","80.4","","68.25","68.25","87.50","1 through 10","265.22","414.73","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.50","380.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","414.73","81.72","","156.19","156.19","156.19","1 through 10","265.22","414.73","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","414.73","81.72","","82.70","12.06","98.97","13","265.22","414.73","percent of total billed charges",""
"INTRODUCER TRANSCAROTID 4FR 21GA GALT MICRO BX/10EA","SUP-ITM-10188822","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","414.73","81.72","","50.47","25.30","134.30","140","265.22","414.73","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","16.24","16.24","54.15","1 through 10","27.13","69.56","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","62.83","71.8","","86.33","32.67","86.33","1 through 10","27.13","69.56","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","61.25","70","","113.68","63.00","177.34","40","27.13","69.56","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","50.70","21.76","168.00","12","27.13","69.56","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.64","53.3","","89.31","89.31","99.75","1 through 10","27.13","69.56","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","56.88","65","","94.41","17.06","2275.00","1 through 10","27.13","69.56","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.13","31","","35.13","35.13","35.13","1 through 10","27.13","69.56","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","40.08","12.40","86.17","108","27.13","69.56","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","33.25","10.27","68.43","169","27.13","69.56","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","25.48","14.86","90.88","1 through 10","27.13","69.56","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","90.88","90.88","90.88","1 through 10","27.13","69.56","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","84.63","19.55","140.02","123","27.13","69.56","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","76.96","17.77","113.68","14","45.73","71.51","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","57.31","57.31","57.31","1 through 10","45.73","71.51","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","16.24","16.24","54.15","1 through 10","45.73","71.51","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","70.35","80.4","","68.25","68.25","87.50","1 through 10","45.73","71.51","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","71.51","81.72","","156.19","156.19","156.19","1 through 10","45.73","71.51","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","71.51","81.72","","82.70","12.06","98.97","13","45.73","71.51","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","50.47","25.30","134.30","140","45.73","71.51","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","both","","","63.00","47.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","32.92","52.26","","16.24","16.24","54.15","1 through 10","19.53","50.09","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","both","","","63.00","47.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","45.23","71.8","","86.33","32.67","86.33","1 through 10","19.53","50.09","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","both","","","63.00","47.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","44.10","70","","113.68","63.00","177.34","40","19.53","50.09","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","both","","","63.00","47.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","50.09","79.5","","50.70","21.76","168.00","12","19.53","50.09","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","both","","","63.00","47.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33.58","53.3","","89.31","89.31","99.75","1 through 10","19.53","50.09","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","both","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","40.95","65","","94.41","17.06","2275.00","1 through 10","19.53","50.09","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","19.53","31","","35.13","35.13","35.13","1 through 10","19.53","50.09","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.00","36.5","","40.08","12.40","86.17","108","19.53","50.09","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.13","38.3","","33.25","10.27","68.43","169","19.53","50.09","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.03","42.9","","25.48","14.86","90.88","1 through 10","19.53","50.09","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.03","42.9","","90.88","90.88","90.88","1 through 10","19.53","50.09","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","both","","","63.00","47.25","WELLPOINT [1015]","HB AMC WELLPOINT","46.48","73.78","","84.63","19.55","140.02","123","19.53","50.09","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","63.00","47.25","AETNA [1001]","HB AMC AETNA HMO","43.97","69.8","","76.96","17.77","113.68","14","32.92","51.48","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","63.00","47.25","AETNA [1001]","HB AMC AETNA PPO","50.65","80.4","","57.31","57.31","57.31","1 through 10","32.92","51.48","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","63.00","47.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","32.92","52.26","","16.24","16.24","54.15","1 through 10","32.92","51.48","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","50.65","80.4","","68.25","68.25","87.50","1 through 10","32.92","51.48","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","51.48","81.72","","156.19","156.19","156.19","1 through 10","32.92","51.48","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","51.48","81.72","","82.70","12.06","98.97","13","32.92","51.48","percent of total billed charges",""
"INTRODUCER VASCULAR 5FRX40CM SS SOFT TIP SMOOTH NEEDLE REG DILATOR BX/10EA","SUP-ITM-10152676","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","51.48","81.72","","50.47","25.30","134.30","140","32.92","51.48","percent of total billed charges",""
"INTRODUCER VASCULAR 9.5FRX13CM SAFESHEATH II TEAR AWAY VALVED SHEATH 3WAY STOPCOCK SIDE PORT HEMOSTATIC LIGHT BLACK BX/5EA","SUP-ITM-10012093","CDM","C1892","HCPCS","0272","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.43","36.5","","66.97","66.97","66.97","1 through 10","75.95","194.78","percent of total billed charges",""
"INTRODUCER VASCULAR 9.5FRX13CM SAFESHEATH II TEAR AWAY VALVED SHEATH 3WAY STOPCOCK SIDE PORT HEMOSTATIC LIGHT BLACK BX/5EA","SUP-ITM-10012093","CDM","C1892","HCPCS","0272","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.84","38.3","","70.21","44.61","70.21","1 through 10","75.95","194.78","percent of total billed charges",""
"INTRODUCER VASCULAR 9.5FRX13CM SAFESHEATH II TEAR AWAY VALVED SHEATH 3WAY STOPCOCK SIDE PORT HEMOSTATIC LIGHT BLACK BX/5EA","SUP-ITM-10012093","CDM","C1892","HCPCS","0272","RC","","","","both","","","245.00","183.75","WELLPOINT [1015]","HB AMC WELLPOINT","180.76","73.78","","84.95","84.95","84.95","1 through 10","75.95","194.78","percent of total billed charges",""
"INTRODUCER VASCULAR 9.5FRX13CM SAFESHEATH II TEAR AWAY VALVED SHEATH 3WAY STOPCOCK SIDE PORT HEMOSTATIC LIGHT BLACK BX/5EA","SUP-ITM-10012093","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","200.21","81.72","","91.21","50.17","91.21","1 through 10","128.04","200.21","percent of total billed charges",""
"INTRODUCER VASCULAR 9.5FRX13CM SAFESHEATH II TEAR AWAY VALVED SHEATH 3WAY STOPCOCK SIDE PORT HEMOSTATIC LIGHT BLACK BX/5EA","SUP-ITM-10012093","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","200.21","81.72","","50.17","50.17","50.17","1 through 10","128.04","200.21","percent of total billed charges",""
"Intubation Endotracheal","PX-76000762","CDM","31500","CPT","0761","RC","","","","outpatient","","","787.00","590.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","476.53","60.55","","473.58","473.58","473.58","1 through 10","314.8","643.14","percent of total billed charges",""
"Invitae Breast and Gyn Cancers Panel","PX-31000760","CDM","81479","CPT","0310","RC","","","","both","","","2497.00","1872.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1985.12","79.5","","0.65","0.65","0.65","1 through 10","774.07","2372.15","percent of total billed charges",""
"Invitae Breast and Gyn Cancers Panel","PX-31000760","CDM","81479","CPT","0310","RC","","","","both","","","2497.00","1872.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1330.90","53.3","","0.79","0.79","0.79","1 through 10","774.07","2372.15","percent of total billed charges",""
"Invitae Breast and Gyn Cancers Panel","PX-31000760","CDM","81479","CPT","0310","RC","","","","outpatient","","","2497.00","1872.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1248.50","50","","1.00","1.00","1.00","1 through 10","156.55","2060.03","percent of total billed charges",""
"Invitae Breast and Gyn Cancers Panel","PX-31000760","CDM","81479","CPT","0310","RC","","","","outpatient","","","2497.00","1872.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1310.93","52.5","","1.00","0.53","1.00","1 through 10","156.55","2060.03","percent of total billed charges",""
"Iodixanol Vl 270mg/Ml 1ml","PX-25500038","CDM","Q9966","HCPCS","0255","RC","","","","both","","","2.25","1.69","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1.58","70","","2.71","2.71","2.71","105","0.7","1.73","percent of total billed charges",""
"Iodixanol Vl 270mg/Ml 1ml","PX-25500038","CDM","Q9966","HCPCS","0255","RC","","","","both","","","2.25","1.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1.46","65","","1.74","1.74","1.74","501","0.7","1.73","percent of total billed charges",""
"Iodixanol Vl 270mg/Ml 1ml","PX-25500038","CDM","Q9966","HCPCS","0255","RC","","","","both","","","2.25","1.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.70","31","","0.12","0.12","0.12","201","0.7","1.73","percent of total billed charges",""
"Iodixanol Vl 270mg/Ml 1ml","PX-25500038","CDM","Q9966","HCPCS","0255","RC","","","","both","","","2.25","1.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.82","36.5","","1.00","0.85","10.31","3510","0.7","1.73","percent of total billed charges",""
"Iodixanol Vl 270mg/Ml 1ml","PX-25500038","CDM","Q9966","HCPCS","0255","RC","","","","both","","","2.25","1.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.86","38.3","","1.06","0.24","1.19","1286","0.7","1.73","percent of total billed charges",""
"Iodixanol Vl 270mg/Ml 1ml","PX-25500038","CDM","Q9966","HCPCS","0255","RC","","","","outpatient","","","2.25","1.69","AETNA [1001]","HB AMC AETNA HMO","1.57","69.8","","1.81","1.31","2.10","1374","0.97","1.81","percent of total billed charges",""
"Iodixanol Vl 270mg/Ml 1ml","PX-25500038","CDM","Q9966","HCPCS","0255","RC","","","","outpatient","","","2.25","1.69","AETNA [1001]","HB AMC AETNA PPO","1.81","80.4","","2.38","2.38","2.38","50","0.97","1.81","percent of total billed charges",""
"Iodixanol Vl 270mg/Ml 1ml","PX-25500038","CDM","Q9966","HCPCS","0636","RC","","","","outpatient","","","2.25","1.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.57","69.9","","2.32","2.32","144.15","1 through 10","1.06","1.57","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.48","1.86","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1.78","71.8","","2.83","2.83","2.83","50","0.32","1.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.48","1.86","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1.63","65.6","","2.45","1.73","3.07","426","0.32","1.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.48","1.86","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1.74","70","","2.87","1.69","7.83","859","0.32","1.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.48","1.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1.61","65","","256.09","192.07","1790.10","1 through 10","0.32","1.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.48","1.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.77","31","","1.12","0.11","3.36","780","0.32","1.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.48","1.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.91","36.5","","1.35","1.15","2.60","22835","0.32","1.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.48","1.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.95","38.3","","1.42","1.38","1.54","53934","0.32","1.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0255","RC","","","","both","","","2.48","1.86","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1.91","77","","2.83","2.83","2.83","83","0.32","1.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","2.48","1.86","AETNA [1001]","HB AMC AETNA HMO","1.73","69.8","","1.88","0.17","2.83","37600","0.32","1.99","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","2.48","1.86","AETNA [1001]","HB AMC AETNA PPO","1.99","80.4","","2.83","0.28","3.80","3073","0.32","1.99","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","2.48","1.86","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1.30","52.26","","2.24","2.24","2.24","305","0.32","1.99","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","2.48","1.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1.99","80.4","","2.83","2.83","2.83","269","0.32","1.99","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","2.48","1.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.73","69.9","","2.51","1.94","2.78","794","1.16","1.73","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500037","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","2.48","1.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1.16","46.9","","1.68","0.01","1.68","269","1.16","1.73","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0255","RC","","","","both","","","86.40","64.80","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","62.04","71.8","","2.83","2.83","2.83","50","0.32","66.53","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0255","RC","","","","both","","","86.40","64.80","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","56.68","65.6","","2.45","1.73","3.07","426","0.32","66.53","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0255","RC","","","","both","","","86.40","64.80","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.48","70","","2.87","1.69","7.83","859","0.32","66.53","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0255","RC","","","","both","","","86.40","64.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","56.16","65","","256.09","192.07","1790.10","1 through 10","0.32","66.53","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0255","RC","","","","both","","","86.40","64.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.78","31","","1.12","0.11","3.36","780","0.32","66.53","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0255","RC","","","","both","","","86.40","64.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.54","36.5","","1.35","1.15","2.60","22835","0.32","66.53","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0255","RC","","","","both","","","86.40","64.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.09","38.3","","1.42","1.38","1.54","53934","0.32","66.53","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0255","RC","","","","both","","","86.40","64.80","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","66.53","77","","2.83","2.83","2.83","83","0.32","66.53","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","86.40","64.80","AETNA [1001]","HB AMC AETNA HMO","60.31","69.8","","1.88","0.17","2.83","37600","0.32","69.47","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","86.40","64.80","AETNA [1001]","HB AMC AETNA PPO","69.47","80.4","","2.83","0.28","3.80","3073","0.32","69.47","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","86.40","64.80","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.15","52.26","","2.24","2.24","2.24","305","0.32","69.47","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","86.40","64.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","69.47","80.4","","2.83","2.83","2.83","269","0.32","69.47","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","86.40","64.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","60.39","69.9","","2.51","1.94","2.78","794","40.52","60.39","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 150ml","PX-25500030","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","86.40","64.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","40.52","46.9","","1.68","0.01","1.68","269","40.52","60.39","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.90","0.67","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.65","71.8","","2.83","2.83","2.83","50","0.28","0.69","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.90","0.67","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.59","65.6","","2.45","1.73","3.07","426","0.28","0.69","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.90","0.67","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.63","70","","2.87","1.69","7.83","859","0.28","0.69","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.90","0.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.59","65","","256.09","192.07","1790.10","1 through 10","0.28","0.69","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.90","0.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.28","31","","1.12","0.11","3.36","780","0.28","0.69","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.90","0.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.33","36.5","","1.35","1.15","2.60","22835","0.28","0.69","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.90","0.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.34","38.3","","1.42","1.38","1.54","53934","0.28","0.69","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.90","0.67","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.69","77","","2.83","2.83","2.83","83","0.28","0.69","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.90","0.67","AETNA [1001]","HB AMC AETNA HMO","0.63","69.8","","1.88","0.17","2.83","37600","0.32","0.72","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.90","0.67","AETNA [1001]","HB AMC AETNA PPO","0.72","80.4","","2.83","0.28","3.80","3073","0.32","0.72","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.90","0.67","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","0.47","52.26","","2.24","2.24","2.24","305","0.32","0.72","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.90","0.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.63","69.9","","2.51","1.94","2.78","794","0.32","0.72","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.90","0.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.42","46.9","","1.68","0.01","1.68","269","0.32","0.72","percent of total billed charges",""
"Iopamidol Vl 76% 370mg/Ml 1ml","PX-25500041","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.90","0.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.72","80.4","","2.83","2.83","2.83","269","0.32","0.72","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.41","0.31","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.29","71.8","","2.83","2.83","2.83","50","0.13","0.32","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.41","0.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.27","65.6","","2.45","1.73","3.07","426","0.13","0.32","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.41","0.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.29","70","","2.87","1.69","7.83","859","0.13","0.32","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.41","0.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.27","65","","256.09","192.07","1790.10","1 through 10","0.13","0.32","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.41","0.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.13","31","","1.12","0.11","3.36","780","0.13","0.32","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.41","0.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.15","36.5","","1.35","1.15","2.60","22835","0.13","0.32","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.41","0.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.16","38.3","","1.42","1.38","1.54","53934","0.13","0.32","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0255","RC","","","","both","","","0.41","0.31","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.32","77","","2.83","2.83","2.83","83","0.13","0.32","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","0.41","0.31","AETNA [1001]","HB AMC AETNA HMO","0.29","69.8","","1.88","0.17","2.83","37600","0.21","0.33","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","0.41","0.31","AETNA [1001]","HB AMC AETNA PPO","0.33","80.4","","2.83","0.28","3.80","3073","0.21","0.33","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","0.41","0.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","0.21","52.26","","2.24","2.24","2.24","305","0.21","0.33","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","0.41","0.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.33","80.4","","2.83","2.83","2.83","269","0.21","0.33","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.41","0.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.29","69.9","","2.51","1.94","2.78","794","0.19","0.29","percent of total billed charges",""
"Iopromide Vl 300mg/Ml Iodine 1ml","PX-25500044","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.41","0.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.19","46.9","","1.68","0.01","1.68","269","0.19","0.29","percent of total billed charges",""
"Iothalamate Meg Vl 17.2% 1ml","PX-25500045","CDM","Q9958","HCPCS","0255","RC","","","","both","","","0.09","0.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.06","65","","0.19","0.19","0.19","300","0.03","0.19","percent of total billed charges",""
"Iothalamate Meg Vl 17.2% 1ml","PX-25500045","CDM","Q9958","HCPCS","0255","RC","","","","both","","","0.09","0.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.03","36.5","","0.11","0.11","0.11","300","0.03","0.19","percent of total billed charges",""
"Iothalamate Meg Vl 17.2% 1ml","PX-25500045","CDM","Q9958","HCPCS","0255","RC","","","","outpatient","","","0.09","0.07","AETNA [1001]","HB AMC AETNA HMO","0.06","69.8","","0.23","0.14","0.23","600","0.05","0.15","percent of total billed charges",""
"Iothalamate Meg Vl 17.2% 1ml","PX-25500045","CDM","Q9958","HCPCS","0255","RC","","","","outpatient","","","0.09","0.07","AETNA [1001]","HB AMC AETNA PPO","0.07","80.4","","0.23","0.23","0.23","300","0.05","0.15","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","58.88","71.8","","57.44","5.71","172.32","16","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","53.30","65","","52.00","42.24","52.00","1 through 10","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","57.40","70","","57.60","34.40","80.00","20","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","65.19","79.5","","62.96","42.24","62.96","470","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","43.71","53.3","","42.24","42.24","126.72","271","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","63.14","77","","77.77","61.60","184.80","1 through 10","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","53.30","65","","89.38","10.40","102.70","1 through 10","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","65.19","79.5","","62.96","40.00","62.96","1 through 10","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","25.42","31","","24.72","24.72","74.16","18","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29.93","36.5","","29.84","25.36","76.08","564","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31.41","38.3","","31.28","31.28","91.20","1639","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","MOLINA [1014]","HB BWH MOLINA","28.70","35","","12.84","12.68","12.84","1 through 10","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","63.14","77","","62.39","62.39","62.39","1 through 10","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","TRICARE [160005]","HB BWH TRICARE","77.90","95","","7.80","7.41","15.60","29","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.18","42.9","","63.95","35.18","63.95","26","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","82.00","61.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.18","42.9","","35.18","35.18","63.95","1 through 10","6.34","77.9","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","82.00","61.50","AETNA [1001]","HB AMC AETNA HMO","57.24","69.8","","54.16","38.24","62.40","644","6.67","67.01","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","82.00","61.50","AETNA [1001]","HB AMC AETNA PPO","65.93","80.4","","62.40","41.92","62.40","61","6.67","67.01","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","82.00","61.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","45.84","55.9","","41.92","41.92","41.92","1 through 10","6.67","67.01","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","82.00","61.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","42.85","52.26","","22.68","22.68","49.51","13","6.67","67.01","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","82.00","61.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","65.93","80.4","","40.00","40.00","62.40","1 through 10","6.67","67.01","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","82.00","61.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","67.01","81.72","","63.95","63.95","63.95","1 through 10","6.67","67.01","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","67.01","81.72","","63.95","35.18","63.95","20","6.67","67.01","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","67.01","81.72","","63.95","35.18","63.95","456","6.67","67.01","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","75.39","71.8","","73.24","7.71","219.72","16","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","68.25","65","","66.30","53.86","66.30","1 through 10","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","73.50","70","","73.44","43.86","102.00","20","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","83.48","79.5","","80.27","53.86","80.27","459","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","55.97","53.3","","53.86","53.86","161.58","261","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","80.85","77","","104.72","78.54","235.62","1 through 10","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","68.25","65","","86.45","37.70","317.20","1 through 10","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","83.48","79.5","","80.27","51.00","80.27","1 through 10","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","32.55","31","","31.52","31.52","94.56","18","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.33","36.5","","38.05","32.33","96.99","558","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.22","38.3","","39.88","39.88","116.28","1612","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","MOLINA [1014]","HB BWH MOLINA","36.75","35","","17.34","17.14","17.34","1 through 10","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","80.85","77","","79.55","79.55","79.55","1 through 10","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","TRICARE [160005]","HB BWH TRICARE","99.75","95","","10.53","10.00","21.06","29","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.05","42.9","","81.54","44.85","81.54","26","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.05","42.9","","44.85","44.85","81.54","1 through 10","8.57","99.75","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","105.00","78.75","AETNA [1001]","HB AMC AETNA HMO","73.29","69.8","","69.05","48.76","79.56","636","9.02","85.81","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","105.00","78.75","AETNA [1001]","HB AMC AETNA PPO","84.42","80.4","","79.56","53.45","79.56","61","9.02","85.81","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","105.00","78.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","58.70","55.9","","53.45","53.45","53.45","1 through 10","9.02","85.81","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","105.00","78.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","54.87","52.26","","30.92","30.92","63.12","13","9.02","85.81","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","84.42","80.4","","51.00","51.00","79.56","1 through 10","9.02","85.81","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","85.81","81.72","","81.54","81.54","81.54","1 through 10","9.02","85.81","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","85.81","81.72","","81.54","44.85","81.54","19","9.02","85.81","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","85.81","81.72","","81.54","44.85","81.54","446","9.02","85.81","percent of total billed charges",""
"Iron Dextran Vl 50mg/Ml 1ml","PX-63600134","CDM","J1750","HCPCS","0636","RC","","","","both","","","39.31","29.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14.35","36.5","","13.57","11.54","27.32","1 through 10","12.19","42.7","percent of total billed charges",""
"Iron Dextran Vl 50mg/Ml 1ml","PX-63600134","CDM","J1750","HCPCS","0636","RC","","","","both","","","39.31","29.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15.06","38.3","","14.13","14.09","14.23","1 through 10","12.19","42.7","percent of total billed charges",""
"Iron Dextran Vl 50mg/Ml 1ml","PX-63600134","CDM","J1750","HCPCS","0636","RC","","","","both","","","39.31","29.48","TRICARE [160005]","HB BWH TRICARE","17.13","","APC Price ($18.03). Final payment is multiplied by 95%.","34.90","34.90","34.90","22","12.19","42.7","other","Tricare OPPS"
"Iron Dextran Vl 50mg/Ml 1ml","PX-63600134","CDM","J1750","HCPCS","0636","RC","","","","both","","","39.31","29.48","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17.74","","APC Price ($18.11). Final payment is multiplied by 98%.","50.67","50.67","50.67","22","12.19","42.7","other","OPPS APC"
"Iron Dextran Vl 50mg/Ml 1ml","PX-63600134","CDM","J1750","HCPCS","0636","RC","","","","outpatient","","","39.31","29.48","AETNA [1001]","HB AMC AETNA HMO","27.44","69.8","","1015.33","17.27","1066.06","14","18.44","38.76","percent of total billed charges",""
"Iron Dextran Vl 50mg/Ml 1ml","PX-63600134","CDM","J1750","HCPCS","0636","RC","","","","outpatient","","","39.31","29.48","AETNA [1001]","HB AMC AETNA PPO","31.61","80.4","","28.11","28.11","28.11","1 through 10","18.44","38.76","percent of total billed charges",""
"Iron Dextran Vl 50mg/Ml 1ml","PX-63600134","CDM","J1750","HCPCS","0636","RC","","","","outpatient","","","39.31","29.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","27.48","69.9","","16.88","16.77","24.98","1 through 10","18.44","38.76","percent of total billed charges",""
"Iron Dextran Vl 50mg/Ml 1ml","PX-63600134","CDM","J1750","HCPCS","0636","RC","","","","outpatient","","","39.31","29.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","18.44","46.9","","16.88","16.88","16.88","1 through 10","18.44","38.76","percent of total billed charges",""
"Iron Sucrose Vl 20mg/Ml 0.05ml","PX-63600135","CDM","J1756","HCPCS","0636","RC","","","","outpatient","","","1.67","1.25","AETNA [1001]","HB AMC AETNA HMO","1.17","69.8","","187.75","187.75","188.98","1 through 10","0.47","1.34","percent of total billed charges",""
"Iron Sucrose Vl 20mg/Ml 0.05ml","PX-63600135","CDM","J1756","HCPCS","0636","RC","","","","outpatient","","","1.67","1.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1.34","80.4","","139.57","139.57","139.57","1 through 10","0.47","1.34","percent of total billed charges",""
"Irreversible Electroporation Ablation of Lymph Node","PX-76002337","CDM","38999","CPT","0761","RC","","","","outpatient","","","6323.00","4742.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3301.87","52.22","","512.50","512.50","512.50","1 through 10","1234.13","5216.48","percent of total billed charges",""
"Irreversible Electroporation Ablation of Lymph Node","PX-76002337","CDM","38999","CPT","0761","RC","","","","outpatient","","","6323.00","4742.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3161.50","50","","6776.11","6776.11","6776.11","1 through 10","1234.13","5216.48","percent of total billed charges",""
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","both","","","750.00","562.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","265.42","265.42","265.42","1 through 10","232.5","596.25","other","OPPS APC"
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","both","","","750.00","562.50","FALLON HEALTH [1008]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","269.74","269.74","269.74","1 through 10","232.5","596.25","other","OPPS APC"
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","both","","","750.00","562.50","MEDICARE [2001]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","288.83","288.83","26","232.5","596.25","other","OPPS APC"
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","287.25","38.3","","284.26","284.26","284.26","1 through 10","232.5","596.25","percent of total billed charges",""
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","283.02","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","283.05","283.05","283.06","1 through 10","232.5","596.25","other","OPPS APC"
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","outpatient","","","750.00","562.50","AETNA [1001]","HB AMC AETNA HMO","523.50","69.8","","567.06","567.06","567.06","1 through 10","231.42","1120.45","percent of total billed charges",""
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","outpatient","","","750.00","562.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","541.45","531.66","541.45","1 through 10","231.42","1120.45","other","ASC"
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","outpatient","","","750.00","562.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","619.52","613.44","619.52","35","231.42","1120.45","other","ASC "
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","outpatient","","","750.00","562.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","592.44","592.44","592.44","1 through 10","231.42","1120.45","other","Multiple Surgery"
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","outpatient","","","750.00","562.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1548.21","1548.21","1548.21","1 through 10","231.42","1120.45","other","Multiple Surgery"
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","outpatient","","","750.00","562.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","564.66","564.66","564.66","1 through 10","231.42","1120.45","other","Multiple Surgery"
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","outpatient","","","750.00","562.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","592.44","592.44","592.44","1 through 10","231.42","1120.45","other","Multiple Surgery"
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","outpatient","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","603.00","80.4","","363.50","363.50","363.50","1 through 10","231.42","1120.45","percent of total billed charges",""
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","612.90","81.72","","319.66","319.66","581.16","1 through 10","231.42","1120.45","percent of total billed charges",""
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","382.00","286.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.13","69.13","69.13","1 through 10","67.01","303.69","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","382.00","286.50","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","70.54","70.54","1 through 10","67.01","303.69","other","OPPS APC"
"Irrigation/Appl Medicment Vagina","PX-76001349","CDM","57150","CPT","0761","RC","","","","both","","","440.00","330.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","87.13","87.13","87.13","1 through 10","67.01","349.8","other","OPPS APC"
"Irrigation/Appl Medicment Vagina","PX-76001349","CDM","57150","CPT","0761","RC","","","","both","","","440.00","330.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","315.92","71.8","","306.59","306.59","306.59","1 through 10","67.01","349.8","percent of total billed charges",""
"Irrigation/Appl Medicment Vagina","PX-76001349","CDM","57150","CPT","0761","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","168.52","38.3","","166.96","166.96","166.96","1 through 10","67.01","349.8","percent of total billed charges",""
"Irrigation/Appl Medicment Vagina","PX-76001349","CDM","57150","CPT","0761","RC","","","","outpatient","","","440.00","330.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","249.14","244.64","249.14","1 through 10","106.48","880.53","other","ASC"
"Irrigation/Appl Medicment Vagina","PX-76001349","CDM","57150","CPT","0761","RC","","","","outpatient","","","440.00","330.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","282.26","282.26","285.06","11","106.48","880.53","other","ASC "
"Irrigation/Appl Medicment Vagina","PX-76001349","CDM","57150","CPT","0761","RC","","","","outpatient","","","440.00","330.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","106.48","","Case rate ($106.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","272.59","272.59","272.59","1 through 10","106.48","880.53","other","Multiple Surgery"
"Irrigation/Appl Medicment Vagina","PX-76001349","CDM","57150","CPT","0761","RC","","","","outpatient","","","440.00","330.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","106.48","","Case rate ($106.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","247.03","247.03","247.03","1 through 10","106.48","880.53","other","Multiple Surgery"
"Isavuconazole (Cresemba) Lc-Ms/Ms","PX-30003278","CDM","80299","CPT","0301","RC","","","","both","","","259.00","194.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","205.91","79.5","","106.25","71.28","106.25","1 through 10","14.12","246.05","percent of total billed charges",""
"Isavuconazole (Cresemba) Lc-Ms/Ms","PX-30003278","CDM","80299","CPT","0301","RC","","","","both","","","259.00","194.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","138.05","53.3","","106.25","71.28","106.25","1 through 10","14.12","246.05","percent of total billed charges",""
"Isavuconazole (Cresemba) Lc-Ms/Ms","PX-30003278","CDM","80299","CPT","0301","RC","","","","both","","","259.00","194.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","94.54","36.5","","50.36","42.80","92.50","13","14.12","246.05","percent of total billed charges",""
"Isavuconazole (Cresemba) Lc-Ms/Ms","PX-30003278","CDM","80299","CPT","0301","RC","","","","both","","","259.00","194.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","99.20","38.3","","52.79","44.55","158.37","30","14.12","246.05","percent of total billed charges",""
"Isavuconazole (Cresemba) Lc-Ms/Ms","PX-30003278","CDM","80299","CPT","0301","RC","","","","outpatient","","","259.00","194.25","AETNA [1001]","HB AMC AETNA HMO","180.78","69.8","","91.40","64.53","105.30","14","14.12","211.65","percent of total billed charges",""
"Isavuconazole (Cresemba) Lc-Ms/Ms","PX-30003278","CDM","80299","CPT","0301","RC","","","","outpatient","","","259.00","194.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","208.24","80.4","","105.30","105.30","105.30","1 through 10","14.12","211.65","percent of total billed charges",""
"Isavuconazole (Cresemba) Lc-Ms/Ms","PX-30003278","CDM","80299","CPT","0301","RC","","","","outpatient","","","259.00","194.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","211.65","81.72","","59.36","15.50","59.36","1 through 10","14.12","211.65","percent of total billed charges",""
"Isavuconazole Lc-Ms/Ms","PX-31000847","CDM","80299","CPT","0310","RC","","","","both","","","412.00","309.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","327.54","79.5","","106.25","71.28","106.25","1 through 10","18.27","391.4","percent of total billed charges",""
"Isavuconazole Lc-Ms/Ms","PX-31000847","CDM","80299","CPT","0310","RC","","","","both","","","412.00","309.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","219.60","53.3","","106.25","71.28","106.25","1 through 10","18.27","391.4","percent of total billed charges",""
"Isavuconazole Lc-Ms/Ms","PX-31000847","CDM","80299","CPT","0310","RC","","","","both","","","412.00","309.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","150.38","36.5","","50.36","42.80","92.50","13","18.27","391.4","percent of total billed charges",""
"Isavuconazole Lc-Ms/Ms","PX-31000847","CDM","80299","CPT","0310","RC","","","","both","","","412.00","309.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.80","38.3","","52.79","44.55","158.37","30","18.27","391.4","percent of total billed charges",""
"Isavuconazole Lc-Ms/Ms","PX-31000847","CDM","80299","CPT","0310","RC","","","","outpatient","","","412.00","309.00","AETNA [1001]","HB AMC AETNA HMO","287.58","69.8","","91.40","64.53","105.30","14","53.62","336.69","percent of total billed charges",""
"Isavuconazole Lc-Ms/Ms","PX-31000847","CDM","80299","CPT","0310","RC","","","","outpatient","","","412.00","309.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","331.25","80.4","","105.30","105.30","105.30","1 through 10","53.62","336.69","percent of total billed charges",""
"Isavuconazole Lc-Ms/Ms","PX-31000847","CDM","80299","CPT","0310","RC","","","","outpatient","","","412.00","309.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","336.69","81.72","","59.36","15.50","59.36","1 through 10","53.62","336.69","percent of total billed charges",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","","","","inpatient","","","113682.83","85262.12","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","16901.48","","Case rate ($16,409.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,676.04, add-ons for qualifying new technology services are included. If operating cost exceeds $65,320.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,854.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $14,615.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,296.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,413.95. The transfer capital threshold is the transfer adjustment factor * $1,413.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","16982.40","16982.40","16982.40","1 through 10","16081.02","27524.78","other","Inpatient DRG"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","","","","inpatient","","","113682.83","85262.12","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16081.02","","Case rate ($16,409.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,676.04, add-ons for qualifying new technology services are included. If operating cost exceeds $65,320.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,854.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $14,615.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,296.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,413.95. The transfer capital threshold is the transfer adjustment factor * $1,413.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16159.40","16159.40","16159.40","1 through 10","16081.02","27524.78","other","Inpatient DRG"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC","061","MS-DRG","","","","","","","","inpatient","","","142852.84","107139.63","MEDICARE [2001]","HB BWH MEDICARE","33020.94","","Case rate ($33,020.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,656.15, add-ons for qualifying new technology services are included. If operating cost exceeds $76,300.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,658.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $30,422.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,276.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,218.52. The transfer capital threshold is the transfer adjustment factor * $2,218.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","32196.74","32186.69","64685.94","1 through 10","25019.79","40797.0094","other","Inpatient DRG"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC","061","MS-DRG","","","","","","","","inpatient","","","142852.84","107139.63","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","25019.79","","Case rate ($25,530.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,656.15, add-ons for qualifying new technology services are included. If operating cost exceeds $76,300.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,658.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $22,932.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,276.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,218.52. The transfer capital threshold is the transfer adjustment factor * $2,218.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","24423.27","24423.27","24423.27","1 through 10","25019.79","40797.0094","other","Inpatient DRG"
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","both","","","261.00","195.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","207.50","79.5","","199.11","199.11","597.33","25","20.4","247.95","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","both","","","261.00","195.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.11","53.3","","199.11","133.58","199.11","1 through 10","20.4","247.95","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","both","","","261.00","195.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","200.97","77","","194.81","194.81","194.81","1 through 10","20.4","247.95","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","both","","","261.00","195.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","80.91","31","","91.59","91.59","91.59","1 through 10","20.4","247.95","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","both","","","261.00","195.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.27","36.5","","94.37","80.20","283.11","29","20.4","247.95","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","both","","","261.00","195.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","99.96","38.3","","98.92","98.92","98.93","77","20.4","247.95","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","both","","","261.00","195.75","MOLINA [1014]","HB BWH MOLINA","91.35","35","","46.76","46.76","46.76","1 through 10","20.4","247.95","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","both","","","261.00","195.75","TRICARE [160005]","HB BWH TRICARE","247.95","95","","26.98","26.98","56.80","1 through 10","20.4","247.95","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","both","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","111.97","42.9","","202.25","202.25","202.25","1 through 10","20.4","247.95","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","outpatient","","","261.00","195.75","AETNA [1001]","HB AMC AETNA HMO","182.18","69.8","","171.28","120.93","197.34","36","20.4","213.29","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","outpatient","","","261.00","195.75","AETNA [1001]","HB AMC AETNA PPO","209.84","80.4","","394.68","197.34","394.68","1 through 10","20.4","213.29","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","outpatient","","","261.00","195.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","136.40","52.26","","60.37","60.37","60.37","1 through 10","20.4","213.29","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","outpatient","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","213.29","81.72","","202.25","111.25","404.49","23","20.4","213.29","percent of total billed charges",""
"Isoproterenol Challenge Test","PX-48000500","CDM","93799","CPT","0481","RC","","","","both","","","3668.00","2751.00","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","2916.06","other","OPPS APC"
"Isoproterenol Challenge Test","PX-48000500","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","AETNA [1001]","HB AMC AETNA HMO","2560.26","69.8","","2022.70","2022.70","2022.70","1 through 10","454","3026.1","percent of total billed charges",""
"Isoproterenol Challenge Test","PX-48000500","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2220.97","60.55","","318.03","318.03","2439.77","1 through 10","454","3026.1","percent of total billed charges",""
"Isoproterenol Challenge Test","PX-48000500","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1915.43","52.22","","360.38","360.38","4023.00","1 through 10","454","3026.1","percent of total billed charges",""
"Isoproterenol Challenge Test","PX-48000500","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2017.40","55","","13080.03","13080.03","13080.03","1 through 10","454","3026.1","percent of total billed charges",""
"Itraconazole, Serum","PX-30003358","CDM","80299","CPT","0310","RC","","","","both","","","102.00","76.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","81.09","79.5","","106.25","71.28","106.25","1 through 10","18.27","96.9","percent of total billed charges",""
"Itraconazole, Serum","PX-30003358","CDM","80299","CPT","0310","RC","","","","both","","","102.00","76.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","54.37","53.3","","106.25","71.28","106.25","1 through 10","18.27","96.9","percent of total billed charges",""
"Itraconazole, Serum","PX-30003358","CDM","80299","CPT","0310","RC","","","","both","","","102.00","76.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37.23","36.5","","50.36","42.80","92.50","13","18.27","96.9","percent of total billed charges",""
"Itraconazole, Serum","PX-30003358","CDM","80299","CPT","0310","RC","","","","both","","","102.00","76.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39.07","38.3","","52.79","44.55","158.37","30","18.27","96.9","percent of total billed charges",""
"Itraconazole, Serum","PX-30003358","CDM","80299","CPT","0310","RC","","","","outpatient","","","102.00","76.50","AETNA [1001]","HB AMC AETNA HMO","71.20","69.8","","91.40","64.53","105.30","14","53.31","114.26","percent of total billed charges",""
"Itraconazole, Serum","PX-30003358","CDM","80299","CPT","0310","RC","","","","outpatient","","","102.00","76.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","82.01","80.4","","105.30","105.30","105.30","1 through 10","53.31","114.26","percent of total billed charges",""
"Itraconazole, Serum","PX-30003358","CDM","80299","CPT","0310","RC","","","","outpatient","","","102.00","76.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","83.35","81.72","","59.36","15.50","59.36","1 through 10","53.31","114.26","percent of total billed charges",""
"Iud Insertion for Ein","PX-76002850","CDM","58999","CPT","0761","RC","","","","both","","","357.00","267.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","255.84","","APC Price ($255.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2891.02","2891.02","2891.02","1 through 10","110.67","319.8","other","OPPS APC"
"Iud Insertion for Ein","PX-76002850","CDM","58999","CPT","0761","RC","","","","outpatient","","","357.00","267.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","216.16","60.55","","28155.00","28155.00","28155.00","1 through 10","178.5","700.33","percent of total billed charges",""
"Iud Insertion for Ein","PX-76002850","CDM","58999","CPT","0761","RC","","","","outpatient","","","357.00","267.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","186.43","52.22","","8340.00","222.09","8340.00","1 through 10","178.5","700.33","percent of total billed charges",""
"Iud Insertion for Ein","PX-98302433","CDM","58999","CPT","0983","RC","","","","both","","","242.00","181.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","255.84","","APC Price ($255.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2891.02","2891.02","2891.02","1 through 10","75.02","319.8","other","OPPS APC"
"Iud Insertion for Ein","PX-98302433","CDM","58999","CPT","0983","RC","","","","outpatient","","","242.00","181.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","146.53","60.55","","28155.00","28155.00","28155.00","1 through 10","121","700.33","percent of total billed charges",""
"Iud Insertion for Ein","PX-98302433","CDM","58999","CPT","0983","RC","","","","outpatient","","","242.00","181.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","126.37","52.22","","8340.00","222.09","8340.00","1 through 10","121","700.33","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","14","52.05","263.94","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","14","52.05","263.94","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","232.40","70","","322.00","322.00","322.00","1 through 10","52.05","263.94","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","263.94","79.5","","253.41","236.00","3906.67","86","52.05","263.94","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","176.96","53.3","","253.42","170.02","340.03","37","52.05","263.94","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","1 through 10","52.05","263.94","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","HUMANA [1012]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","52.05","263.94","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","103.69","506","52.05","263.94","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","102.92","31","","99.50","99.50","99.50","1 through 10","52.05","263.94","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.18","36.5","","120.11","102.07","120.11","133","52.05","263.94","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.16","38.3","","125.90","125.90","477.01","227","52.05","263.94","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","50.81","50.81","50.81","1 through 10","52.05","263.94","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","MOLINA [1014]","HB BWH MOLINA","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","108.49","108.49","108.49","1 through 10","52.05","263.94","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","255.64","77","","251.16","251.16","251.16","1 through 10","52.05","263.94","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","TRICARE [160005]","HB BWH TRICARE","52.05","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","54.79","54.79","54.79","1 through 10","52.05","263.94","other","Tricare OPPS"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","53.69","53.70","1 through 10","52.05","263.94","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","74.06","74.06","74.06","1 through 10","52.05","263.94","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.91","50.82","54.79","76","52.05","263.94","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.43","42.9","","9997.13","9997.13","9997.13","1 through 10","52.05","263.94","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","332.00","249.00","WELLPOINT [1015]","HB AMC WELLPOINT","244.95","73.78","","239.73","239.73","239.73","48","52.05","263.94","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","inpatient","","","332.00","249.00","AETNA [1001]","HB AMC AETNA PPO","263.94","79.5","","168.73","168.73","168.73","1 through 10","183.6","263.94","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","332.00","249.00","AETNA [1001]","HB AMC AETNA HMO","231.74","69.8","","217.99","153.92","435.99","71","87.03","271.31","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","332.00","249.00","AETNA [1001]","HB AMC AETNA PPO","266.93","80.4","","251.16","168.73","251.16","25","87.03","271.31","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","332.00","249.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","271.31","81.72","","1205.21","1205.21","1205.21","1 through 10","87.03","271.31","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","332.00","249.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","271.31","81.72","","141.58","141.58","141.58","1 through 10","87.03","271.31","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","332.00","249.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","271.31","81.72","","257.41","141.58","3625.46","93","87.03","271.31","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","257.69","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","257.47","257.47","258.17","1 through 10","223.15","656.67","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.21","246.21","246.21","11","223.15","656.67","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","578.20","70","","305.00","305.00","305.00","1 through 10","223.15","656.67","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","312.73","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","131.81","131.81","131.81","1 through 10","223.15","656.67","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","656.67","79.5","","630.39","587.11","1891.17","12","223.15","656.67","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","440.26","53.3","","630.39","422.93","668.46","1 through 10","223.15","656.67","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","MEDICARE [2001]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.21","250.21","750.63","84","223.15","656.67","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","301.49","36.5","","253.92","253.92","507.84","11","223.15","656.67","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","316.36","38.3","","313.19","304.38","313.19","82","223.15","656.67","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","245.21","245.21","245.21","1 through 10","223.15","656.67","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","TRICARE [160005]","HB BWH TRICARE","237.70","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","250.21","250.21","250.21","1 through 10","223.15","656.67","other","Tricare OPPS"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","735.63","245.21","735.63","1 through 10","223.15","656.67","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","184.23","184.23","184.23","1 through 10","223.15","656.67","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","250.21","180.41","1047.21","31","223.15","656.67","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","826.00","619.50","AETNA [1001]","HB AMC AETNA HMO","576.55","69.8","","542.28","382.88","542.28","14","430.03","716.9","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","826.00","619.50","AETNA [1001]","HB AMC AETNA PPO","664.10","80.4","","624.78","624.78","624.78","1 through 10","430.03","716.9","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","826.00","619.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","431.67","52.26","","496.17","495.66","496.17","1 through 10","430.03","716.9","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","675.01","81.72","","640.32","640.32","640.32","1 through 10","430.03","716.9","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","675.01","81.72","","640.32","640.32","640.32","13","430.03","716.9","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","491.00","368.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","352.54","71.8","","341.77","341.77","341.77","1 through 10","80.29","390.35","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","491.00","368.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","390.35","79.5","","348.35","348.35","366.42","1 through 10","80.29","390.35","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","491.00","368.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","261.70","53.3","","251.33","251.33","251.33","1 through 10","80.29","390.35","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","491.00","368.25","HUMANA [1012]","HB BWH MEDICARE","84.51","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","75.35","75.35","75.35","1 through 10","80.29","390.35","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","491.00","368.25","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","461.34","32","80.29","390.35","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","491.00","368.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","152.21","31","","147.08","147.08","147.08","1 through 10","80.29","390.35","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","491.00","368.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","179.22","36.5","","177.55","150.89","177.55","1 through 10","80.29","390.35","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","491.00","368.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","188.05","38.3","","186.12","180.88","558.36","15","80.29","390.35","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","491.00","368.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","248.49","150.70","248.49","1 through 10","80.29","390.35","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","491.00","368.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","109.48","109.48","109.48","1 through 10","80.29","390.35","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","491.00","368.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","82.83","83.85","1 through 10","80.29","390.35","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","491.00","368.25","WELLPOINT [1015]","HB AMC WELLPOINT","362.26","73.78","","354.38","354.38","354.38","1 through 10","80.29","390.35","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","outpatient","","","491.00","368.25","AETNA [1001]","HB AMC AETNA HMO","342.72","69.8","","227.53","227.53","302.61","1 through 10","137.27","401.25","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","outpatient","","","491.00","368.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","401.25","81.72","","355.79","209.30","380.51","1 through 10","137.27","401.25","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","257.69","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","257.47","257.47","258.37","155","237.7","809.31","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.21","243.54","246.21","269","237.7","809.31","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","730.92","71.8","","708.67","708.67","708.67","15","237.7","809.31","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","661.70","65","","776.77","776.77","776.77","1 through 10","237.7","809.31","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","712.60","70","","987.00","433.80","987.00","1 through 10","237.7","809.31","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","312.73","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","250.21","246.32","516.87","1 through 10","237.7","809.31","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","CHAMPVA [160001]","HB BWH TRICARE","237.70","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","250.21","241.35","250.21","1 through 10","237.7","809.31","other","Tricare OPPS"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","809.31","79.5","","776.77","521.14","964.92","330","237.7","809.31","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","542.59","53.3","","776.77","521.14","1819.05","197","237.7","809.31","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.21","230.19","246.21","142","237.7","809.31","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","498.62","498.62","498.62","1 through 10","237.7","809.31","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","783.86","77","","759.99","759.99","759.99","1 through 10","237.7","809.31","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","HUMANA [1012]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.45","245.21","250.21","1 through 10","237.7","809.31","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","MEDICARE [2001]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.21","250.21","250.21","4888","237.7","809.31","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","315.58","31","","304.98","304.98","304.98","1 through 10","237.7","809.31","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","371.57","36.5","","368.15","312.88","625.76","217","237.7","809.31","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","389.89","38.3","","385.92","375.06","385.92","797","237.7","809.31","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","245.21","229.25","245.21","159","237.7","809.31","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","MOLINA [1014]","HB BWH MOLINA","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","467.86","464.12","500.42","1 through 10","237.7","809.31","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","783.86","77","","769.85","769.85","776.77","1 through 10","237.7","809.31","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","TRICARE [160005]","HB BWH TRICARE","237.70","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","237.70","222.23","250.21","26","237.7","809.31","other","Tricare OPPS"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","237.70","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","250.21","250.21","701.79","1 through 10","237.7","809.31","other","Tricare OPPS"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","245.21","245.21","738.63","141","237.7","809.31","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","227.01","227.01","227.01","1 through 10","237.7","809.31","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","436.72","42.9","","449.09","433.98","789.01","17","237.7","809.31","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1018.00","763.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","246.21","233.93","250.21","417","237.7","809.31","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","1018.00","763.50","AETNA [1001]","HB AMC AETNA HMO","710.56","69.8","","668.20","471.79","769.86","296","430.03","1177.23","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","1018.00","763.50","AETNA [1001]","HB AMC AETNA PPO","818.47","80.4","","769.86","517.19","769.86","20","430.03","1177.23","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","1018.00","763.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","532.01","52.26","","496.17","496.17","496.17","1 through 10","430.03","1177.23","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","1018.00","763.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","818.47","80.4","","769.86","769.86","769.86","1 through 10","430.03","1177.23","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","1018.00","763.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","831.91","81.72","","789.01","737.76","789.01","1 through 10","430.03","1177.23","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","1018.00","763.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","831.91","81.72","","433.98","433.98","789.01","20","430.03","1177.23","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","1018.00","763.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","831.91","81.72","","789.01","433.98","789.01","406","430.03","1177.23","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","53.69","56.43","72","52.05","325.16","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","84.15","72","52.05","325.16","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","286.30","70","","397.00","193.72","397.00","12","52.05","325.16","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","325.16","79.5","","312.44","209.62","397.00","249","52.05","325.16","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","218.00","53.3","","312.44","209.62","730.41","99","52.05","325.16","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","51.23","53.92","38","52.05","325.16","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","97.54","97.54","97.54","1 through 10","52.05","325.16","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","HUMANA [1012]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.82","54.02","15","52.05","325.16","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","54.79","164.38","2438","52.05","325.16","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","126.79","31","","122.68","122.68","122.68","1 through 10","52.05","325.16","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","149.29","36.5","","148.08","125.85","559.03","230","52.05","325.16","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","156.65","38.3","","155.23","155.23","452.58","609","52.05","325.16","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.70","50.81","53.70","63","52.05","325.16","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","314.93","77","","309.66","309.66","309.66","15","52.05","325.16","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","TRICARE [160005]","HB BWH TRICARE","52.05","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","54.79","27.39","54.79","1 through 10","52.05","325.16","other","Tricare OPPS"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.91","53.69","161.73","59","52.05","325.16","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","91.31","91.31","91.31","1 through 10","52.05","325.16","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","175.46","42.9","","317.36","317.36","317.36","1 through 10","52.05","325.16","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.91","50.82","54.79","125","52.05","325.16","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","409.00","306.75","WELLPOINT [1015]","HB AMC WELLPOINT","301.76","73.78","","295.57","295.57","295.57","164","52.05","325.16","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","409.00","306.75","AETNA [1001]","HB AMC AETNA HMO","285.48","69.8","","268.77","189.77","379.54","92","87.03","334.23","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","409.00","306.75","AETNA [1001]","HB AMC AETNA PPO","328.84","80.4","","189.77","92.43","309.66","1 through 10","87.03","334.23","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","409.00","306.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","334.23","81.72","","397.00","397.00","397.00","1 through 10","87.03","334.23","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","409.00","306.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","334.23","81.72","","174.56","174.56","317.36","1 through 10","87.03","334.23","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","409.00","306.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","334.23","81.72","","317.36","174.56","317.36","159","87.03","334.23","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","both","","","280.00","210.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","196.00","70","","272.00","272.00","272.00","1 through 10","86.8","222.6","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","both","","","280.00","210.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","149.24","53.3","","143.62","143.62","143.62","1 through 10","86.8","222.6","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","102.20","36.5","","101.46","86.22","101.46","1 through 10","86.8","222.6","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","107.24","38.3","","106.35","106.35","319.05","1 through 10","86.8","222.6","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","outpatient","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","228.82","81.72","","119.60","119.60","119.60","1 through 10","146.33","228.82","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","outpatient","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","228.82","81.72","","119.60","119.60","119.60","1 through 10","146.33","228.82","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","257.69","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","258.17","257.47","258.37","36","110.41","681.32","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.21","230.19","246.21","29","110.41","681.32","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","615.33","71.8","","596.66","596.66","596.66","1 through 10","110.41","681.32","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","599.90","70","","598.32","598.32","598.32","1 through 10","110.41","681.32","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","312.73","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","246.30","125.00","250.21","1 through 10","110.41","681.32","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","681.32","79.5","","654.00","438.77","1253.14","55","110.41","681.32","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","456.78","53.3","","654.00","438.77","1047.56","36","110.41","681.32","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.21","230.19","248.56","1 through 10","110.41","681.32","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","ELDER SERVICES [1037]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.93","233.93","233.93","1 through 10","110.41","681.32","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","FALLON HEALTH [1008]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1251.05","233.93","1251.05","1 through 10","110.41","681.32","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","659.89","77","","639.87","639.87","639.87","1 through 10","110.41","681.32","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","HUMANA [1012]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","245.41","245.41","245.41","1 through 10","110.41","681.32","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","MEDICARE [2001]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.21","250.21","250.21","387","110.41","681.32","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","312.81","36.5","","309.96","263.43","1549.80","43","110.41","681.32","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","328.23","38.3","","324.92","324.92","974.76","207","110.41","681.32","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","245.21","245.21","490.42","18","110.41","681.32","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","TRICARE [160005]","HB BWH TRICARE","237.70","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","250.21","57.21","831.00","1 through 10","110.41","681.32","other","Tricare OPPS"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","237.70","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","250.21","250.21","250.21","1 through 10","110.41","681.32","other","Tricare OPPS"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","245.21","229.25","735.63","1 through 10","110.41","681.32","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","191.13","191.13","191.13","1 through 10","110.41","681.32","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","367.65","42.9","","664.30","664.30","664.30","1 through 10","110.41","681.32","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","245.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","245.21","229.26","250.21","95","110.41","681.32","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","857.00","642.75","WELLSENSE [1003]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1263.55","1263.55","1263.55","1 through 10","110.41","681.32","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","857.00","642.75","AETNA [1001]","HB AMC AETNA HMO","598.19","69.8","","562.59","397.22","959.81","73","315.07","716.9","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","857.00","642.75","AETNA [1001]","HB AMC AETNA PPO","689.03","80.4","","648.18","435.44","1296.36","13","315.07","716.9","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","857.00","642.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","689.03","80.4","","648.18","648.18","648.18","1 through 10","315.07","716.9","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","857.00","642.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","700.34","81.72","","664.30","365.39","664.30","1 through 10","315.07","716.9","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","857.00","642.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","700.34","81.72","","664.30","365.39","5675.40","40","315.07","716.9","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","343.00","257.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","272.69","79.5","","262.07","261.64","262.07","17","106.33","272.69","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","343.00","257.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","182.82","53.3","","336.33","175.82","336.33","11","106.33","272.69","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","106.33","31","","102.90","102.90","102.90","1 through 10","106.33","272.69","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","125.20","36.5","","124.21","105.56","124.21","43","106.33","272.69","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","131.37","38.3","","130.20","126.54","390.62","99","106.33","272.69","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","343.00","257.25","WELLPOINT [1015]","HB AMC WELLPOINT","253.07","73.78","","247.92","247.92","580.92","34","106.33","272.69","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","343.00","257.25","AETNA [1001]","HB AMC AETNA HMO","239.41","69.8","","225.44","159.17","259.74","26","179.25","280.3","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","343.00","257.25","AETNA [1001]","HB AMC AETNA PPO","275.77","80.4","","174.49","174.49","259.74","1 through 10","179.25","280.3","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","343.00","257.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","280.30","81.72","","266.20","266.20","266.20","1 through 10","179.25","280.3","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","280.30","81.72","","146.42","146.42","146.42","1 through 10","179.25","280.3","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","280.30","81.72","","146.42","146.42","266.20","28","179.25","280.3","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.68","68","52.05","281.43","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.92","82","52.05","281.43","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","254.17","71.8","","246.27","246.27","246.27","1 through 10","52.05","281.43","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","232.22","65.6","","232.21","232.21","232.21","1 through 10","52.05","281.43","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","247.80","70","","343.00","343.00","343.00","1 through 10","52.05","281.43","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","281.43","79.5","","269.94","181.10","809.82","182","52.05","281.43","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","188.68","53.3","","269.94","181.10","543.30","86","52.05","281.43","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","51.02","53.92","52","52.05","281.43","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","HUMANA [1012]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.69","54.79","1 through 10","52.05","281.43","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","54.79","155.55","1350","52.05","281.43","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","109.74","31","","105.99","105.99","317.97","1 through 10","52.05","281.43","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","129.21","36.5","","127.94","108.73","483.52","149","52.05","281.43","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","135.58","38.3","","134.11","130.34","402.34","444","52.05","281.43","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.81","53.69","28","52.05","281.43","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","TRICARE [160005]","HB BWH TRICARE","52.05","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","54.79","49.25","343.00","1 through 10","52.05","281.43","other","Tricare OPPS"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","53.69","161.07","28","52.05","281.43","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","78.89","78.89","78.89","1 through 10","52.05","281.43","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.87","42.9","","274.19","274.19","274.20","1 through 10","52.05","281.43","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","50.82","54.79","148","52.05","281.43","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","354.00","265.50","WELLPOINT [1015]","HB AMC WELLPOINT","261.18","73.78","","255.36","255.36","255.37","158","52.05","281.43","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","inpatient","","","354.00","265.50","AETNA [1001]","HB AMC AETNA PPO","281.43","79.5","","179.73","179.73","179.73","1 through 10","195.76","281.43","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","354.00","265.50","AETNA [1001]","HB AMC AETNA HMO","247.09","69.8","","232.21","163.95","267.54","128","87.03","315.07","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","354.00","265.50","AETNA [1001]","HB AMC AETNA PPO","284.62","80.4","","179.73","92.43","802.62","1 through 10","87.03","315.07","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","354.00","265.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","197.89","55.9","","179.73","179.73","179.73","1 through 10","87.03","315.07","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","354.00","265.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","289.29","81.72","","548.39","548.39","548.39","1 through 10","87.03","315.07","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","354.00","265.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","289.29","81.72","","274.19","150.82","274.20","1 through 10","87.03","315.07","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","354.00","265.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","289.29","81.72","","274.19","150.82","548.39","138","87.03","315.07","percent of total billed charges",""
"J-Tube Change Without Imaging","PX-76002542","CDM","44799","CPT","0761","RC","","","","both","","","368.00","276.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","114.08","1391.62","other","OPPS APC"
"J-Tube Change Without Imaging","PX-76002542","CDM","44799","CPT","0761","RC","","","","both","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","114.08","1391.62","other","OPPS APC"
"J-Tube Change Without Imaging","PX-76002542","CDM","44799","CPT","0761","RC","","","","both","","","368.00","276.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","114.08","1391.62","other","OPPS APC"
"J-Tube Change Without Imaging","PX-76002542","CDM","44799","CPT","0761","RC","","","","both","","","368.00","276.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","114.08","1391.62","other","OPPS APC"
"J-Tube Change Without Imaging","PX-76002542","CDM","44799","CPT","0761","RC","","","","both","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.87","42.9","","1932.92","1932.92","1932.92","1 through 10","114.08","1391.62","percent of total billed charges",""
"J-Tube Change Without Imaging","PX-76002542","CDM","44799","CPT","0761","RC","","","","both","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","114.08","1391.62","other","OPPS APC"
"J-Tube Change Without Imaging","PX-76002542","CDM","44799","CPT","0761","RC","","","","both","","","368.00","276.00","WELLPOINT [1015]","HB AMC WELLPOINT","271.51","73.78","","2222.33","2222.33","2222.33","1 through 10","114.08","1391.62","percent of total billed charges",""
"J-Tube Change Without Imaging","PX-76002542","CDM","44799","CPT","0761","RC","","","","outpatient","","","368.00","276.00","AETNA [1001]","HB AMC AETNA HMO","256.86","69.8","","2238.60","2238.60","2238.60","1 through 10","184","8899.59","percent of total billed charges",""
"J-Tube Change Without Imaging","PX-76002542","CDM","44799","CPT","0761","RC","","","","outpatient","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","222.82","60.55","","3144.00","2870.00","3286.00","1 through 10","184","8899.59","percent of total billed charges",""
"J-Tube Change Without Imaging","PX-76002542","CDM","44799","CPT","0761","RC","","","","outpatient","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","192.32","52.26","","1775.96","1775.96","1775.96","1 through 10","184","8899.59","percent of total billed charges",""
"J-Tube Change Without Imaging","PX-76002542","CDM","44799","CPT","0761","RC","","","","outpatient","","","368.00","276.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","192.17","52.22","","3286.00","2018.70","5898.00","1 through 10","184","8899.59","percent of total billed charges",""
"J-Tube Change Without Imaging","PX-76002542","CDM","44799","CPT","0761","RC","","","","outpatient","","","368.00","276.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","193.20","52.5","","8340.00","8340.00","8340.00","1 through 10","184","8899.59","percent of total billed charges",""
"J-Tube Change Without Imaging","PX-76002542","CDM","44799","CPT","0761","RC","","","","outpatient","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","300.73","81.72","","2294.28","682.69","2294.28","1 through 10","184","8899.59","percent of total billed charges",""
"Jada Hemostatic Suction Catheter","PX-27002386","CDM","C2628","HCPCS","0272","RC","","","","both","","","4375.00","3281.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3478.13","79.5","","518.94","518.94","518.94","1 through 10","1356.25","3478.13","percent of total billed charges",""
"Jada Hemostatic Suction Catheter","PX-27002386","CDM","C2628","HCPCS","0272","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2843.75","65","","429.02","429.02","429.02","1 through 10","1356.25","3478.13","percent of total billed charges",""
"Jada Hemostatic Suction Catheter","PX-27002386","CDM","C2628","HCPCS","0272","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1596.88","36.5","","4636.13","4636.13","4636.13","1 through 10","1356.25","3478.13","percent of total billed charges",""
"Jada Hemostatic Suction Catheter","PX-27002386","CDM","C2628","HCPCS","0272","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB AMC WELLPOINT","3227.88","73.78","","491.39","491.39","491.39","1 through 10","1356.25","3478.13","percent of total billed charges",""
"Jada Hemostatic Suction Catheter","PX-27002386","CDM","C2628","HCPCS","0272","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3575.25","81.72","","290.22","290.22","290.22","1 through 10","2286.38","3575.25","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"JOINT COMPONENT 7X45MM SACROILIAC IFUSE-3D TI TPS COAT POROUS TRIANGULAR","SUP-ITM-10209206","CDM","C1713","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6161.25","79.5","","800.18","480.96","1887.97","195","2402.5","6161.25","percent of total billed charges",""
"JOINT COMPONENT 7X45MM SACROILIAC IFUSE-3D TI TPS COAT POROUS TRIANGULAR","SUP-ITM-10209206","CDM","C1713","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4130.75","53.3","","813.12","216.42","1444.50","81","2402.5","6161.25","percent of total billed charges",""
"JOINT COMPONENT 7X45MM SACROILIAC IFUSE-3D TI TPS COAT POROUS TRIANGULAR","SUP-ITM-10209206","CDM","C1713","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2402.50","31","","432.60","432.60","432.60","1 through 10","2402.5","6161.25","percent of total billed charges",""
"JOINT COMPONENT 7X45MM SACROILIAC IFUSE-3D TI TPS COAT POROUS TRIANGULAR","SUP-ITM-10209206","CDM","C1713","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2828.75","36.5","","148.37","54.89","631.39","94","2402.5","6161.25","percent of total billed charges",""
"JOINT COMPONENT 7X45MM SACROILIAC IFUSE-3D TI TPS COAT POROUS TRIANGULAR","SUP-ITM-10209206","CDM","C1713","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2968.25","38.3","","279.30","91.72","1116.77","266","2402.5","6161.25","percent of total billed charges",""
"JOINT COMPONENT 7X45MM SACROILIAC IFUSE-3D TI TPS COAT POROUS TRIANGULAR","SUP-ITM-10209206","CDM","C1713","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3324.75","42.9","","731.00","63.70","731.00","1 through 10","2402.5","6161.25","percent of total billed charges",""
"JOINT COMPONENT 7X45MM SACROILIAC IFUSE-3D TI TPS COAT POROUS TRIANGULAR","SUP-ITM-10209206","CDM","C1713","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3324.75","42.9","","384.74","384.74","384.74","1 through 10","2402.5","6161.25","percent of total billed charges",""
"JOINT COMPONENT 7X45MM SACROILIAC IFUSE-3D TI TPS COAT POROUS TRIANGULAR","SUP-ITM-10209206","CDM","C1713","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","WELLPOINT [1015]","HB AMC WELLPOINT","5717.95","73.78","","286.63","119.22","1107.45","105","2402.5","6161.25","percent of total billed charges",""
"JOINT COMPONENT 7X45MM SACROILIAC IFUSE-3D TI TPS COAT POROUS TRIANGULAR","SUP-ITM-10209206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","AETNA [1001]","HB AMC AETNA HMO","5409.50","69.8","","675.31","184.75","1721.50","286","4050.15","6333.3","percent of total billed charges",""
"JOINT COMPONENT 7X45MM SACROILIAC IFUSE-3D TI TPS COAT POROUS TRIANGULAR","SUP-ITM-10209206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","AETNA [1001]","HB AMC AETNA PPO","6231.00","80.4","","1261.44","103.12","1514.10","21","4050.15","6333.3","percent of total billed charges",""
"JOINT COMPONENT 7X45MM SACROILIAC IFUSE-3D TI TPS COAT POROUS TRIANGULAR","SUP-ITM-10209206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6231.00","80.4","","1365.00","1365.00","1365.00","1 through 10","4050.15","6333.3","percent of total billed charges",""
"JOINT COMPONENT 7X45MM SACROILIAC IFUSE-3D TI TPS COAT POROUS TRIANGULAR","SUP-ITM-10209206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6333.30","81.72","","5157.68","5157.68","5157.68","1 through 10","4050.15","6333.3","percent of total billed charges",""
"JOINT COMPONENT 7X45MM SACROILIAC IFUSE-3D TI TPS COAT POROUS TRIANGULAR","SUP-ITM-10209206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6333.30","81.72","","431.26","71.26","1459.57","88","4050.15","6333.3","percent of total billed charges",""
"Jynneos Smallpox&Monkeypox Vacc 0.5ml Dos for Subq Use","PX-63601366","CDM","90611","CPT","0636","RC","","","","both","","","540.00","405.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","206.82","38.3","","540.00","540.00","540.00","1 through 10","0.01","415.8","percent of total billed charges",""
"Jynneos Smallpox&Monkeypox Vacc 0.5ml Dos for Subq Use","PX-63601366","CDM","90611","CPT","0636","RC","","","","outpatient","","","540.00","405.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","377.46","69.9","","1122.66","374.22","1122.66","1 through 10","0.01","657.4","percent of total billed charges",""
"Jynneos Smallpox&Monkeypox Vacc 0.5ml Dos for Subq Use","PX-63601366","CDM","90611","CPT","0636","RC","","","","outpatient","","","540.00","405.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","297.00","55","","209.10","209.10","209.10","1 through 10","0.01","657.4","percent of total billed charges",""
"K-WIRE 1.1MM 20MM SINGLE TROCAR THREADED","SUP-ITM-10276016","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.51","79.5","","800.18","480.96","1887.97","195","92.23","236.51","percent of total billed charges",""
"K-WIRE 1.1MM 20MM SINGLE TROCAR THREADED","SUP-ITM-10276016","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.57","53.3","","813.12","216.42","1444.50","81","92.23","236.51","percent of total billed charges",""
"K-WIRE 1.1MM 20MM SINGLE TROCAR THREADED","SUP-ITM-10276016","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","92.23","31","","432.60","432.60","432.60","1 through 10","92.23","236.51","percent of total billed charges",""
"K-WIRE 1.1MM 20MM SINGLE TROCAR THREADED","SUP-ITM-10276016","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.59","36.5","","148.37","54.89","631.39","94","92.23","236.51","percent of total billed charges",""
"K-WIRE 1.1MM 20MM SINGLE TROCAR THREADED","SUP-ITM-10276016","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.94","38.3","","279.30","91.72","1116.77","266","92.23","236.51","percent of total billed charges",""
"K-WIRE 1.1MM 20MM SINGLE TROCAR THREADED","SUP-ITM-10276016","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.63","42.9","","731.00","63.70","731.00","1 through 10","92.23","236.51","percent of total billed charges",""
"K-WIRE 1.1MM 20MM SINGLE TROCAR THREADED","SUP-ITM-10276016","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.63","42.9","","384.74","384.74","384.74","1 through 10","92.23","236.51","percent of total billed charges",""
"K-WIRE 1.1MM 20MM SINGLE TROCAR THREADED","SUP-ITM-10276016","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","WELLPOINT [1015]","HB AMC WELLPOINT","219.50","73.78","","286.63","119.22","1107.45","105","92.23","236.51","percent of total billed charges",""
"K-WIRE 1.1MM 20MM SINGLE TROCAR THREADED","SUP-ITM-10276016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","AETNA [1001]","HB AMC AETNA HMO","207.66","69.8","","675.31","184.75","1721.50","286","155.47","243.12","percent of total billed charges",""
"K-WIRE 1.1MM 20MM SINGLE TROCAR THREADED","SUP-ITM-10276016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","AETNA [1001]","HB AMC AETNA PPO","239.19","80.4","","1261.44","103.12","1514.10","21","155.47","243.12","percent of total billed charges",""
"K-WIRE 1.1MM 20MM SINGLE TROCAR THREADED","SUP-ITM-10276016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","239.19","80.4","","1365.00","1365.00","1365.00","1 through 10","155.47","243.12","percent of total billed charges",""
"K-WIRE 1.1MM 20MM SINGLE TROCAR THREADED","SUP-ITM-10276016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","243.12","81.72","","5157.68","5157.68","5157.68","1 through 10","155.47","243.12","percent of total billed charges",""
"K-WIRE 1.1MM 20MM SINGLE TROCAR THREADED","SUP-ITM-10276016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","243.12","81.72","","431.26","71.26","1459.57","88","155.47","243.12","percent of total billed charges",""
"K-WIRE 1.1MM SINGLE TROCAR SMOOTH","SUP-ITM-10276017","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.50","144.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","153.04","79.5","","800.18","480.96","1887.97","195","59.68","153.04","percent of total billed charges",""
"K-WIRE 1.1MM SINGLE TROCAR SMOOTH","SUP-ITM-10276017","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.50","144.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","102.60","53.3","","813.12","216.42","1444.50","81","59.68","153.04","percent of total billed charges",""
"K-WIRE 1.1MM SINGLE TROCAR SMOOTH","SUP-ITM-10276017","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.50","144.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","59.68","31","","432.60","432.60","432.60","1 through 10","59.68","153.04","percent of total billed charges",""
"K-WIRE 1.1MM SINGLE TROCAR SMOOTH","SUP-ITM-10276017","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.50","144.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70.26","36.5","","148.37","54.89","631.39","94","59.68","153.04","percent of total billed charges",""
"K-WIRE 1.1MM SINGLE TROCAR SMOOTH","SUP-ITM-10276017","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.50","144.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.73","38.3","","279.30","91.72","1116.77","266","59.68","153.04","percent of total billed charges",""
"K-WIRE 1.1MM SINGLE TROCAR SMOOTH","SUP-ITM-10276017","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.50","144.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.58","42.9","","731.00","63.70","731.00","1 through 10","59.68","153.04","percent of total billed charges",""
"K-WIRE 1.1MM SINGLE TROCAR SMOOTH","SUP-ITM-10276017","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.50","144.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.58","42.9","","384.74","384.74","384.74","1 through 10","59.68","153.04","percent of total billed charges",""
"K-WIRE 1.1MM SINGLE TROCAR SMOOTH","SUP-ITM-10276017","CDM","C1713","HCPCS","0278","RC","","","","both","","","192.50","144.37","WELLPOINT [1015]","HB AMC WELLPOINT","142.03","73.78","","286.63","119.22","1107.45","105","59.68","153.04","percent of total billed charges",""
"K-WIRE 1.1MM SINGLE TROCAR SMOOTH","SUP-ITM-10276017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","192.50","144.37","AETNA [1001]","HB AMC AETNA HMO","134.37","69.8","","675.31","184.75","1721.50","286","100.6","157.31","percent of total billed charges",""
"K-WIRE 1.1MM SINGLE TROCAR SMOOTH","SUP-ITM-10276017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","192.50","144.37","AETNA [1001]","HB AMC AETNA PPO","154.77","80.4","","1261.44","103.12","1514.10","21","100.6","157.31","percent of total billed charges",""
"K-WIRE 1.1MM SINGLE TROCAR SMOOTH","SUP-ITM-10276017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","192.50","144.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","154.77","80.4","","1365.00","1365.00","1365.00","1 through 10","100.6","157.31","percent of total billed charges",""
"K-WIRE 1.1MM SINGLE TROCAR SMOOTH","SUP-ITM-10276017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","192.50","144.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","157.31","81.72","","5157.68","5157.68","5157.68","1 through 10","100.6","157.31","percent of total billed charges",""
"K-WIRE 1.1MM SINGLE TROCAR SMOOTH","SUP-ITM-10276017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","192.50","144.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","157.31","81.72","","431.26","71.26","1459.57","88","100.6","157.31","percent of total billed charges",""
"K-WIRE 1.4MM 150MM THREADED TROCAR TIP","SUP-ITM-10277918","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.00","57.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","61.22","79.5","","800.18","480.96","1887.97","195","23.87","61.22","percent of total billed charges",""
"K-WIRE 1.4MM 150MM THREADED TROCAR TIP","SUP-ITM-10277918","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.00","57.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","41.04","53.3","","813.12","216.42","1444.50","81","23.87","61.22","percent of total billed charges",""
"K-WIRE 1.4MM 150MM THREADED TROCAR TIP","SUP-ITM-10277918","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.00","57.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","23.87","31","","432.60","432.60","432.60","1 through 10","23.87","61.22","percent of total billed charges",""
"K-WIRE 1.4MM 150MM THREADED TROCAR TIP","SUP-ITM-10277918","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.00","57.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28.11","36.5","","148.37","54.89","631.39","94","23.87","61.22","percent of total billed charges",""
"K-WIRE 1.4MM 150MM THREADED TROCAR TIP","SUP-ITM-10277918","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.00","57.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.49","38.3","","279.30","91.72","1116.77","266","23.87","61.22","percent of total billed charges",""
"K-WIRE 1.4MM 150MM THREADED TROCAR TIP","SUP-ITM-10277918","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.00","57.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.03","42.9","","731.00","63.70","731.00","1 through 10","23.87","61.22","percent of total billed charges",""
"K-WIRE 1.4MM 150MM THREADED TROCAR TIP","SUP-ITM-10277918","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.00","57.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.03","42.9","","384.74","384.74","384.74","1 through 10","23.87","61.22","percent of total billed charges",""
"K-WIRE 1.4MM 150MM THREADED TROCAR TIP","SUP-ITM-10277918","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.00","57.75","WELLPOINT [1015]","HB AMC WELLPOINT","56.81","73.78","","286.63","119.22","1107.45","105","23.87","61.22","percent of total billed charges",""
"K-WIRE 1.4MM 150MM THREADED TROCAR TIP","SUP-ITM-10277918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.00","57.75","AETNA [1001]","HB AMC AETNA HMO","53.75","69.8","","675.31","184.75","1721.50","286","40.24","62.92","percent of total billed charges",""
"K-WIRE 1.4MM 150MM THREADED TROCAR TIP","SUP-ITM-10277918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.00","57.75","AETNA [1001]","HB AMC AETNA PPO","61.91","80.4","","1261.44","103.12","1514.10","21","40.24","62.92","percent of total billed charges",""
"K-WIRE 1.4MM 150MM THREADED TROCAR TIP","SUP-ITM-10277918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.00","57.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","61.91","80.4","","1365.00","1365.00","1365.00","1 through 10","40.24","62.92","percent of total billed charges",""
"K-WIRE 1.4MM 150MM THREADED TROCAR TIP","SUP-ITM-10277918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.00","57.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","62.92","81.72","","5157.68","5157.68","5157.68","1 through 10","40.24","62.92","percent of total billed charges",""
"K-WIRE 1.4MM 150MM THREADED TROCAR TIP","SUP-ITM-10277918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.00","57.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","62.92","81.72","","431.26","71.26","1459.57","88","40.24","62.92","percent of total billed charges",""
"K-WIRE 1.6MM 150MM THREADED TROCAR TIP","SUP-ITM-10277946","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.87","79.5","","800.18","480.96","1887.97","195","45.57","116.87","percent of total billed charges",""
"K-WIRE 1.6MM 150MM THREADED TROCAR TIP","SUP-ITM-10277946","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.35","53.3","","813.12","216.42","1444.50","81","45.57","116.87","percent of total billed charges",""
"K-WIRE 1.6MM 150MM THREADED TROCAR TIP","SUP-ITM-10277946","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.57","31","","432.60","432.60","432.60","1 through 10","45.57","116.87","percent of total billed charges",""
"K-WIRE 1.6MM 150MM THREADED TROCAR TIP","SUP-ITM-10277946","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.66","36.5","","148.37","54.89","631.39","94","45.57","116.87","percent of total billed charges",""
"K-WIRE 1.6MM 150MM THREADED TROCAR TIP","SUP-ITM-10277946","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.30","38.3","","279.30","91.72","1116.77","266","45.57","116.87","percent of total billed charges",""
"K-WIRE 1.6MM 150MM THREADED TROCAR TIP","SUP-ITM-10277946","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.06","42.9","","731.00","63.70","731.00","1 through 10","45.57","116.87","percent of total billed charges",""
"K-WIRE 1.6MM 150MM THREADED TROCAR TIP","SUP-ITM-10277946","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.06","42.9","","384.74","384.74","384.74","1 through 10","45.57","116.87","percent of total billed charges",""
"K-WIRE 1.6MM 150MM THREADED TROCAR TIP","SUP-ITM-10277946","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","WELLPOINT [1015]","HB AMC WELLPOINT","108.46","73.78","","286.63","119.22","1107.45","105","45.57","116.87","percent of total billed charges",""
"K-WIRE 1.6MM 150MM THREADED TROCAR TIP","SUP-ITM-10277946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA HMO","102.61","69.8","","675.31","184.75","1721.50","286","76.82","120.13","percent of total billed charges",""
"K-WIRE 1.6MM 150MM THREADED TROCAR TIP","SUP-ITM-10277946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA PPO","118.19","80.4","","1261.44","103.12","1514.10","21","76.82","120.13","percent of total billed charges",""
"K-WIRE 1.6MM 150MM THREADED TROCAR TIP","SUP-ITM-10277946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","118.19","80.4","","1365.00","1365.00","1365.00","1 through 10","76.82","120.13","percent of total billed charges",""
"K-WIRE 1.6MM 150MM THREADED TROCAR TIP","SUP-ITM-10277946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","120.13","81.72","","5157.68","5157.68","5157.68","1 through 10","76.82","120.13","percent of total billed charges",""
"K-WIRE 1.6MM 150MM THREADED TROCAR TIP","SUP-ITM-10277946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","120.13","81.72","","431.26","71.26","1459.57","88","76.82","120.13","percent of total billed charges",""
"K-WIRE 1.6MMX15CM","SUP-ITM-10115030","CDM","C1713","HCPCS","0278","RC","","","","both","","","45.50","34.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","36.17","79.5","","800.18","480.96","1887.97","195","14.11","36.17","percent of total billed charges",""
"K-WIRE 1.6MMX15CM","SUP-ITM-10115030","CDM","C1713","HCPCS","0278","RC","","","","both","","","45.50","34.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","24.25","53.3","","813.12","216.42","1444.50","81","14.11","36.17","percent of total billed charges",""
"K-WIRE 1.6MMX15CM","SUP-ITM-10115030","CDM","C1713","HCPCS","0278","RC","","","","both","","","45.50","34.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","14.11","31","","432.60","432.60","432.60","1 through 10","14.11","36.17","percent of total billed charges",""
"K-WIRE 1.6MMX15CM","SUP-ITM-10115030","CDM","C1713","HCPCS","0278","RC","","","","both","","","45.50","34.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16.61","36.5","","148.37","54.89","631.39","94","14.11","36.17","percent of total billed charges",""
"K-WIRE 1.6MMX15CM","SUP-ITM-10115030","CDM","C1713","HCPCS","0278","RC","","","","both","","","45.50","34.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17.43","38.3","","279.30","91.72","1116.77","266","14.11","36.17","percent of total billed charges",""
"K-WIRE 1.6MMX15CM","SUP-ITM-10115030","CDM","C1713","HCPCS","0278","RC","","","","both","","","45.50","34.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19.52","42.9","","731.00","63.70","731.00","1 through 10","14.11","36.17","percent of total billed charges",""
"K-WIRE 1.6MMX15CM","SUP-ITM-10115030","CDM","C1713","HCPCS","0278","RC","","","","both","","","45.50","34.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19.52","42.9","","384.74","384.74","384.74","1 through 10","14.11","36.17","percent of total billed charges",""
"K-WIRE 1.6MMX15CM","SUP-ITM-10115030","CDM","C1713","HCPCS","0278","RC","","","","both","","","45.50","34.12","WELLPOINT [1015]","HB AMC WELLPOINT","33.57","73.78","","286.63","119.22","1107.45","105","14.11","36.17","percent of total billed charges",""
"K-WIRE 1.6MMX15CM","SUP-ITM-10115030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","45.50","34.12","AETNA [1001]","HB AMC AETNA HMO","31.76","69.8","","675.31","184.75","1721.50","286","23.78","37.18","percent of total billed charges",""
"K-WIRE 1.6MMX15CM","SUP-ITM-10115030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","45.50","34.12","AETNA [1001]","HB AMC AETNA PPO","36.58","80.4","","1261.44","103.12","1514.10","21","23.78","37.18","percent of total billed charges",""
"K-WIRE 1.6MMX15CM","SUP-ITM-10115030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","45.50","34.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","36.58","80.4","","1365.00","1365.00","1365.00","1 through 10","23.78","37.18","percent of total billed charges",""
"K-WIRE 1.6MMX15CM","SUP-ITM-10115030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","45.50","34.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","37.18","81.72","","5157.68","5157.68","5157.68","1 through 10","23.78","37.18","percent of total billed charges",""
"K-WIRE 1.6MMX15CM","SUP-ITM-10115030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","45.50","34.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","37.18","81.72","","431.26","71.26","1459.57","88","23.78","37.18","percent of total billed charges",""
"K-WIRE 13.5IN .062 MAXCESS","SUP-ITM-10088583","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","102.95","79.5","","800.18","480.96","1887.97","195","40.15","102.95","percent of total billed charges",""
"K-WIRE 13.5IN .062 MAXCESS","SUP-ITM-10088583","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","69.02","53.3","","813.12","216.42","1444.50","81","40.15","102.95","percent of total billed charges",""
"K-WIRE 13.5IN .062 MAXCESS","SUP-ITM-10088583","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","40.15","31","","432.60","432.60","432.60","1 through 10","40.15","102.95","percent of total billed charges",""
"K-WIRE 13.5IN .062 MAXCESS","SUP-ITM-10088583","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","47.27","36.5","","148.37","54.89","631.39","94","40.15","102.95","percent of total billed charges",""
"K-WIRE 13.5IN .062 MAXCESS","SUP-ITM-10088583","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","49.60","38.3","","279.30","91.72","1116.77","266","40.15","102.95","percent of total billed charges",""
"K-WIRE 13.5IN .062 MAXCESS","SUP-ITM-10088583","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.56","42.9","","731.00","63.70","731.00","1 through 10","40.15","102.95","percent of total billed charges",""
"K-WIRE 13.5IN .062 MAXCESS","SUP-ITM-10088583","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.56","42.9","","384.74","384.74","384.74","1 through 10","40.15","102.95","percent of total billed charges",""
"K-WIRE 13.5IN .062 MAXCESS","SUP-ITM-10088583","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","WELLPOINT [1015]","HB AMC WELLPOINT","95.55","73.78","","286.63","119.22","1107.45","105","40.15","102.95","percent of total billed charges",""
"K-WIRE 13.5IN .062 MAXCESS","SUP-ITM-10088583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","AETNA [1001]","HB AMC AETNA HMO","90.39","69.8","","675.31","184.75","1721.50","286","67.68","105.83","percent of total billed charges",""
"K-WIRE 13.5IN .062 MAXCESS","SUP-ITM-10088583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","AETNA [1001]","HB AMC AETNA PPO","104.12","80.4","","1261.44","103.12","1514.10","21","67.68","105.83","percent of total billed charges",""
"K-WIRE 13.5IN .062 MAXCESS","SUP-ITM-10088583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","104.12","80.4","","1365.00","1365.00","1365.00","1 through 10","67.68","105.83","percent of total billed charges",""
"K-WIRE 13.5IN .062 MAXCESS","SUP-ITM-10088583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","105.83","81.72","","5157.68","5157.68","5157.68","1 through 10","67.68","105.83","percent of total billed charges",""
"K-WIRE 13.5IN .062 MAXCESS","SUP-ITM-10088583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","105.83","81.72","","431.26","71.26","1459.57","88","67.68","105.83","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","131.08","98.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","68.50","52.26","","25.34","25.34","25.34","1 through 10","40.63","104.21","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","131.08","98.31","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","94.12","71.8","","105.81","105.81","366.90","1 through 10","40.63","104.21","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","131.08","98.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","91.76","70","","512.90","74.70","612.85","1 through 10","40.63","104.21","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","131.08","98.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","104.21","79.5","","200.27","182.80","200.27","1 through 10","40.63","104.21","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","131.08","98.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","69.87","53.3","","37.73","37.73","169.33","1 through 10","40.63","104.21","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","131.08","98.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","85.20","65","","100.27","8.48","494.52","1 through 10","40.63","104.21","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","131.08","98.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","85.20","65","","160.19","160.19","160.19","1 through 10","40.63","104.21","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","131.08","98.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","40.63","31","","28.12","28.12","28.12","1 through 10","40.63","104.21","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","131.08","98.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","47.84","36.5","","101.66","28.85","502.70","121","40.63","104.21","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","131.08","98.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","50.20","38.3","","61.58","25.32","328.44","138","40.63","104.21","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","131.08","98.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.23","42.9","","71.66","71.66","71.66","1 through 10","40.63","104.21","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","131.08","98.31","WELLPOINT [1015]","HB AMC WELLPOINT","96.71","73.78","","74.75","27.97","425.28","93","40.63","104.21","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","131.08","98.31","AETNA [1001]","HB AMC AETNA HMO","91.49","69.8","","52.67","14.36","414.90","1 through 10","68.5","107.12","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","131.08","98.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","68.50","52.26","","25.34","25.34","25.34","1 through 10","68.5","107.12","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","131.08","98.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","105.39","80.4","","478.02","107.84","478.02","1 through 10","68.5","107.12","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","131.08","98.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","107.12","81.72","","32.74","12.33","122.05","1 through 10","68.5","107.12","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","131.08","98.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","107.12","81.72","","144.95","32.78","676.91","104","68.5","107.12","percent of total billed charges",""
"K-WIRE 2.5 X 320MM DRILL TIP","SUP-ITM-10326879","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","233.73","79.5","","800.18","480.96","1887.97","195","91.14","233.73","percent of total billed charges",""
"K-WIRE 2.5 X 320MM DRILL TIP","SUP-ITM-10326879","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","156.70","53.3","","813.12","216.42","1444.50","81","91.14","233.73","percent of total billed charges",""
"K-WIRE 2.5 X 320MM DRILL TIP","SUP-ITM-10326879","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","91.14","31","","432.60","432.60","432.60","1 through 10","91.14","233.73","percent of total billed charges",""
"K-WIRE 2.5 X 320MM DRILL TIP","SUP-ITM-10326879","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","107.31","36.5","","148.37","54.89","631.39","94","91.14","233.73","percent of total billed charges",""
"K-WIRE 2.5 X 320MM DRILL TIP","SUP-ITM-10326879","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","112.60","38.3","","279.30","91.72","1116.77","266","91.14","233.73","percent of total billed charges",""
"K-WIRE 2.5 X 320MM DRILL TIP","SUP-ITM-10326879","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.13","42.9","","731.00","63.70","731.00","1 through 10","91.14","233.73","percent of total billed charges",""
"K-WIRE 2.5 X 320MM DRILL TIP","SUP-ITM-10326879","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.13","42.9","","384.74","384.74","384.74","1 through 10","91.14","233.73","percent of total billed charges",""
"K-WIRE 2.5 X 320MM DRILL TIP","SUP-ITM-10326879","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","WELLPOINT [1015]","HB AMC WELLPOINT","216.91","73.78","","286.63","119.22","1107.45","105","91.14","233.73","percent of total billed charges",""
"K-WIRE 2.5 X 320MM DRILL TIP","SUP-ITM-10326879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","AETNA [1001]","HB AMC AETNA HMO","205.21","69.8","","675.31","184.75","1721.50","286","153.64","240.26","percent of total billed charges",""
"K-WIRE 2.5 X 320MM DRILL TIP","SUP-ITM-10326879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","AETNA [1001]","HB AMC AETNA PPO","236.38","80.4","","1261.44","103.12","1514.10","21","153.64","240.26","percent of total billed charges",""
"K-WIRE 2.5 X 320MM DRILL TIP","SUP-ITM-10326879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","236.38","80.4","","1365.00","1365.00","1365.00","1 through 10","153.64","240.26","percent of total billed charges",""
"K-WIRE 2.5 X 320MM DRILL TIP","SUP-ITM-10326879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","240.26","81.72","","5157.68","5157.68","5157.68","1 through 10","153.64","240.26","percent of total billed charges",""
"K-WIRE 2.5 X 320MM DRILL TIP","SUP-ITM-10326879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","240.26","81.72","","431.26","71.26","1459.57","88","153.64","240.26","percent of total billed charges",""
"K-WIRE 2.5X200MM DRILL TIP","SUP-ITM-10326880","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","150.26","79.5","","800.18","480.96","1887.97","195","58.59","150.26","percent of total billed charges",""
"K-WIRE 2.5X200MM DRILL TIP","SUP-ITM-10326880","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.74","53.3","","813.12","216.42","1444.50","81","58.59","150.26","percent of total billed charges",""
"K-WIRE 2.5X200MM DRILL TIP","SUP-ITM-10326880","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","58.59","31","","432.60","432.60","432.60","1 through 10","58.59","150.26","percent of total billed charges",""
"K-WIRE 2.5X200MM DRILL TIP","SUP-ITM-10326880","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.99","36.5","","148.37","54.89","631.39","94","58.59","150.26","percent of total billed charges",""
"K-WIRE 2.5X200MM DRILL TIP","SUP-ITM-10326880","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.39","38.3","","279.30","91.72","1116.77","266","58.59","150.26","percent of total billed charges",""
"K-WIRE 2.5X200MM DRILL TIP","SUP-ITM-10326880","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","731.00","63.70","731.00","1 through 10","58.59","150.26","percent of total billed charges",""
"K-WIRE 2.5X200MM DRILL TIP","SUP-ITM-10326880","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","384.74","384.74","384.74","1 through 10","58.59","150.26","percent of total billed charges",""
"K-WIRE 2.5X200MM DRILL TIP","SUP-ITM-10326880","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","WELLPOINT [1015]","HB AMC WELLPOINT","139.44","73.78","","286.63","119.22","1107.45","105","58.59","150.26","percent of total billed charges",""
"K-WIRE 2.5X200MM DRILL TIP","SUP-ITM-10326880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA HMO","131.92","69.8","","675.31","184.75","1721.50","286","98.77","154.45","percent of total billed charges",""
"K-WIRE 2.5X200MM DRILL TIP","SUP-ITM-10326880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA PPO","151.96","80.4","","1261.44","103.12","1514.10","21","98.77","154.45","percent of total billed charges",""
"K-WIRE 2.5X200MM DRILL TIP","SUP-ITM-10326880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","151.96","80.4","","1365.00","1365.00","1365.00","1 through 10","98.77","154.45","percent of total billed charges",""
"K-WIRE 2.5X200MM DRILL TIP","SUP-ITM-10326880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","154.45","81.72","","5157.68","5157.68","5157.68","1 through 10","98.77","154.45","percent of total billed charges",""
"K-WIRE 2.5X200MM DRILL TIP","SUP-ITM-10326880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","154.45","81.72","","431.26","71.26","1459.57","88","98.77","154.45","percent of total billed charges",""
"K-WIRE 2.5X200MM TROCAR TIP","SUP-ITM-10326881","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","800.18","480.96","1887.97","195","48.83","125.21","percent of total billed charges",""
"K-WIRE 2.5X200MM TROCAR TIP","SUP-ITM-10326881","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","813.12","216.42","1444.50","81","48.83","125.21","percent of total billed charges",""
"K-WIRE 2.5X200MM TROCAR TIP","SUP-ITM-10326881","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.83","31","","432.60","432.60","432.60","1 through 10","48.83","125.21","percent of total billed charges",""
"K-WIRE 2.5X200MM TROCAR TIP","SUP-ITM-10326881","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","148.37","54.89","631.39","94","48.83","125.21","percent of total billed charges",""
"K-WIRE 2.5X200MM TROCAR TIP","SUP-ITM-10326881","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","279.30","91.72","1116.77","266","48.83","125.21","percent of total billed charges",""
"K-WIRE 2.5X200MM TROCAR TIP","SUP-ITM-10326881","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","731.00","63.70","731.00","1 through 10","48.83","125.21","percent of total billed charges",""
"K-WIRE 2.5X200MM TROCAR TIP","SUP-ITM-10326881","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","384.74","384.74","384.74","1 through 10","48.83","125.21","percent of total billed charges",""
"K-WIRE 2.5X200MM TROCAR TIP","SUP-ITM-10326881","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","286.63","119.22","1107.45","105","48.83","125.21","percent of total billed charges",""
"K-WIRE 2.5X200MM TROCAR TIP","SUP-ITM-10326881","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","675.31","184.75","1721.50","286","82.31","128.71","percent of total billed charges",""
"K-WIRE 2.5X200MM TROCAR TIP","SUP-ITM-10326881","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA PPO","126.63","80.4","","1261.44","103.12","1514.10","21","82.31","128.71","percent of total billed charges",""
"K-WIRE 2.5X200MM TROCAR TIP","SUP-ITM-10326881","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","1365.00","1365.00","1365.00","1 through 10","82.31","128.71","percent of total billed charges",""
"K-WIRE 2.5X200MM TROCAR TIP","SUP-ITM-10326881","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.71","81.72","","5157.68","5157.68","5157.68","1 through 10","82.31","128.71","percent of total billed charges",""
"K-WIRE 2.5X200MM TROCAR TIP","SUP-ITM-10326881","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","431.26","71.26","1459.57","88","82.31","128.71","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.68","559.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","592.82","79.5","","800.18","480.96","1887.97","195","231.16","592.82","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.68","559.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","397.45","53.3","","813.12","216.42","1444.50","81","231.16","592.82","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.68","559.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","231.16","31","","432.60","432.60","432.60","1 through 10","231.16","592.82","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.68","559.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","272.17","36.5","","148.37","54.89","631.39","94","231.16","592.82","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.68","559.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","285.60","38.3","","279.30","91.72","1116.77","266","231.16","592.82","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.68","559.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","319.90","42.9","","731.00","63.70","731.00","1 through 10","231.16","592.82","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.68","559.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","319.90","42.9","","384.74","384.74","384.74","1 through 10","231.16","592.82","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.68","559.26","WELLPOINT [1015]","HB AMC WELLPOINT","550.16","73.78","","286.63","119.22","1107.45","105","231.16","592.82","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.68","559.26","AETNA [1001]","HB AMC AETNA HMO","520.48","69.8","","675.31","184.75","1721.50","286","389.69","609.37","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.68","559.26","AETNA [1001]","HB AMC AETNA PPO","599.53","80.4","","1261.44","103.12","1514.10","21","389.69","609.37","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.68","559.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","599.53","80.4","","1365.00","1365.00","1365.00","1 through 10","389.69","609.37","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.68","559.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","609.37","81.72","","5157.68","5157.68","5157.68","1 through 10","389.69","609.37","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.68","559.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","609.37","81.72","","431.26","71.26","1459.57","88","389.69","609.37","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","158.55","79.5","","800.18","480.96","1887.97","195","61.82","158.55","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.30","53.3","","813.12","216.42","1444.50","81","61.82","158.55","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","61.82","31","","432.60","432.60","432.60","1 through 10","61.82","158.55","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.79","36.5","","148.37","54.89","631.39","94","61.82","158.55","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.38","38.3","","279.30","91.72","1116.77","266","61.82","158.55","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.56","42.9","","731.00","63.70","731.00","1 through 10","61.82","158.55","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.56","42.9","","384.74","384.74","384.74","1 through 10","61.82","158.55","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","WELLPOINT [1015]","HB AMC WELLPOINT","147.14","73.78","","286.63","119.22","1107.45","105","61.82","158.55","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.43","149.57","AETNA [1001]","HB AMC AETNA HMO","139.20","69.8","","675.31","184.75","1721.50","286","104.22","162.97","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.43","149.57","AETNA [1001]","HB AMC AETNA PPO","160.34","80.4","","1261.44","103.12","1514.10","21","104.22","162.97","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.43","149.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","160.34","80.4","","1365.00","1365.00","1365.00","1 through 10","104.22","162.97","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.43","149.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","162.97","81.72","","5157.68","5157.68","5157.68","1 through 10","104.22","162.97","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.43","149.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","162.97","81.72","","431.26","71.26","1459.57","88","104.22","162.97","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","134.89","101.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","70.49","52.26","","25.34","25.34","25.34","1 through 10","41.82","107.24","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","134.89","101.17","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","96.85","71.8","","105.81","105.81","366.90","1 through 10","41.82","107.24","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","134.89","101.17","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","94.42","70","","512.90","74.70","612.85","1 through 10","41.82","107.24","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","134.89","101.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","107.24","79.5","","200.27","182.80","200.27","1 through 10","41.82","107.24","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","134.89","101.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","71.90","53.3","","37.73","37.73","169.33","1 through 10","41.82","107.24","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","134.89","101.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","87.68","65","","100.27","8.48","494.52","1 through 10","41.82","107.24","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","134.89","101.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","87.68","65","","160.19","160.19","160.19","1 through 10","41.82","107.24","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","134.89","101.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","41.82","31","","28.12","28.12","28.12","1 through 10","41.82","107.24","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","134.89","101.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","49.23","36.5","","101.66","28.85","502.70","121","41.82","107.24","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","134.89","101.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","51.66","38.3","","61.58","25.32","328.44","138","41.82","107.24","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","134.89","101.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.87","42.9","","71.66","71.66","71.66","1 through 10","41.82","107.24","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","134.89","101.17","WELLPOINT [1015]","HB AMC WELLPOINT","99.52","73.78","","74.75","27.97","425.28","93","41.82","107.24","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","134.89","101.17","AETNA [1001]","HB AMC AETNA HMO","94.15","69.8","","52.67","14.36","414.90","1 through 10","70.49","110.23","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","134.89","101.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","70.49","52.26","","25.34","25.34","25.34","1 through 10","70.49","110.23","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","134.89","101.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","108.45","80.4","","478.02","107.84","478.02","1 through 10","70.49","110.23","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","134.89","101.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","110.23","81.72","","32.74","12.33","122.05","1 through 10","70.49","110.23","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","134.89","101.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","110.23","81.72","","144.95","32.78","676.91","104","70.49","110.23","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","49.86","79.5","","800.18","480.96","1887.97","195","19.44","49.86","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33.43","53.3","","813.12","216.42","1444.50","81","19.44","49.86","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","19.44","31","","432.60","432.60","432.60","1 through 10","19.44","49.86","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22.89","36.5","","148.37","54.89","631.39","94","19.44","49.86","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.02","38.3","","279.30","91.72","1116.77","266","19.44","49.86","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.91","42.9","","731.00","63.70","731.00","1 through 10","19.44","49.86","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.91","42.9","","384.74","384.74","384.74","1 through 10","19.44","49.86","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.72","47.04","WELLPOINT [1015]","HB AMC WELLPOINT","46.27","73.78","","286.63","119.22","1107.45","105","19.44","49.86","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.72","47.04","AETNA [1001]","HB AMC AETNA HMO","43.78","69.8","","675.31","184.75","1721.50","286","32.78","51.25","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.72","47.04","AETNA [1001]","HB AMC AETNA PPO","50.43","80.4","","1261.44","103.12","1514.10","21","32.78","51.25","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.72","47.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","50.43","80.4","","1365.00","1365.00","1365.00","1 through 10","32.78","51.25","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.72","47.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","51.25","81.72","","5157.68","5157.68","5157.68","1 through 10","32.78","51.25","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.72","47.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","51.25","81.72","","431.26","71.26","1459.57","88","32.78","51.25","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.20","50.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","53.42","79.5","","800.18","480.96","1887.97","195","20.83","53.42","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.20","50.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","35.82","53.3","","813.12","216.42","1444.50","81","20.83","53.42","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.20","50.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","20.83","31","","432.60","432.60","432.60","1 through 10","20.83","53.42","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.20","50.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24.53","36.5","","148.37","54.89","631.39","94","20.83","53.42","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.20","50.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25.74","38.3","","279.30","91.72","1116.77","266","20.83","53.42","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.20","50.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.83","42.9","","731.00","63.70","731.00","1 through 10","20.83","53.42","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.20","50.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.83","42.9","","384.74","384.74","384.74","1 through 10","20.83","53.42","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.20","50.40","WELLPOINT [1015]","HB AMC WELLPOINT","49.58","73.78","","286.63","119.22","1107.45","105","20.83","53.42","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","67.20","50.40","AETNA [1001]","HB AMC AETNA HMO","46.91","69.8","","675.31","184.75","1721.50","286","35.12","54.92","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","67.20","50.40","AETNA [1001]","HB AMC AETNA PPO","54.03","80.4","","1261.44","103.12","1514.10","21","35.12","54.92","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","67.20","50.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","54.03","80.4","","1365.00","1365.00","1365.00","1 through 10","35.12","54.92","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","67.20","50.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","54.92","81.72","","5157.68","5157.68","5157.68","1 through 10","35.12","54.92","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","67.20","50.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","54.92","81.72","","431.26","71.26","1459.57","88","35.12","54.92","percent of total billed charges",""
"K-WIRE BONE 1.1X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024574","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.93","85.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","90.57","79.5","","800.18","480.96","1887.97","195","35.32","90.57","percent of total billed charges",""
"K-WIRE BONE 1.1X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024574","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.93","85.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","60.72","53.3","","813.12","216.42","1444.50","81","35.32","90.57","percent of total billed charges",""
"K-WIRE BONE 1.1X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024574","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.93","85.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","35.32","31","","432.60","432.60","432.60","1 through 10","35.32","90.57","percent of total billed charges",""
"K-WIRE BONE 1.1X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024574","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.93","85.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.58","36.5","","148.37","54.89","631.39","94","35.32","90.57","percent of total billed charges",""
"K-WIRE BONE 1.1X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024574","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.93","85.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.64","38.3","","279.30","91.72","1116.77","266","35.32","90.57","percent of total billed charges",""
"K-WIRE BONE 1.1X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024574","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.93","85.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.88","42.9","","731.00","63.70","731.00","1 through 10","35.32","90.57","percent of total billed charges",""
"K-WIRE BONE 1.1X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024574","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.93","85.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.88","42.9","","384.74","384.74","384.74","1 through 10","35.32","90.57","percent of total billed charges",""
"K-WIRE BONE 1.1X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024574","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.93","85.45","WELLPOINT [1015]","HB AMC WELLPOINT","84.06","73.78","","286.63","119.22","1107.45","105","35.32","90.57","percent of total billed charges",""
"K-WIRE BONE 1.1X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.93","85.45","AETNA [1001]","HB AMC AETNA HMO","79.52","69.8","","675.31","184.75","1721.50","286","59.54","93.1","percent of total billed charges",""
"K-WIRE BONE 1.1X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.93","85.45","AETNA [1001]","HB AMC AETNA PPO","91.60","80.4","","1261.44","103.12","1514.10","21","59.54","93.1","percent of total billed charges",""
"K-WIRE BONE 1.1X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.93","85.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","91.60","80.4","","1365.00","1365.00","1365.00","1 through 10","59.54","93.1","percent of total billed charges",""
"K-WIRE BONE 1.1X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.93","85.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","93.10","81.72","","5157.68","5157.68","5157.68","1 through 10","59.54","93.1","percent of total billed charges",""
"K-WIRE BONE 1.1X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.93","85.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.10","81.72","","431.26","71.26","1459.57","88","59.54","93.1","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","939.96","79.5","","800.18","480.96","1887.97","195","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","630.19","53.3","","813.12","216.42","1444.50","81","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","366.53","31","","432.60","432.60","432.60","1 through 10","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","431.55","36.5","","148.37","54.89","631.39","94","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","452.84","38.3","","279.30","91.72","1116.77","266","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","507.22","42.9","","731.00","63.70","731.00","1 through 10","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","507.22","42.9","","384.74","384.74","384.74","1 through 10","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","WELLPOINT [1015]","HB AMC WELLPOINT","872.33","73.78","","286.63","119.22","1107.45","105","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1182.34","886.75","AETNA [1001]","HB AMC AETNA HMO","825.27","69.8","","675.31","184.75","1721.50","286","617.89","966.21","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1182.34","886.75","AETNA [1001]","HB AMC AETNA PPO","950.60","80.4","","1261.44","103.12","1514.10","21","617.89","966.21","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1182.34","886.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","950.60","80.4","","1365.00","1365.00","1365.00","1 through 10","617.89","966.21","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1182.34","886.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","966.21","81.72","","5157.68","5157.68","5157.68","1 through 10","617.89","966.21","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1182.34","886.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","966.21","81.72","","431.26","71.26","1459.57","88","617.89","966.21","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","171.02","52.26","","25.34","25.34","25.34","1 through 10","101.45","260.16","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","234.97","71.8","","105.81","105.81","366.90","1 through 10","101.45","260.16","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","229.08","70","","512.90","74.70","612.85","1 through 10","101.45","260.16","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","260.16","79.5","","200.27","182.80","200.27","1 through 10","101.45","260.16","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","174.42","53.3","","37.73","37.73","169.33","1 through 10","101.45","260.16","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","212.71","65","","100.27","8.48","494.52","1 through 10","101.45","260.16","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","212.71","65","","160.19","160.19","160.19","1 through 10","101.45","260.16","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","101.45","31","","28.12","28.12","28.12","1 through 10","101.45","260.16","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","119.45","36.5","","101.66","28.85","502.70","121","101.45","260.16","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","125.34","38.3","","61.58","25.32","328.44","138","101.45","260.16","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.39","42.9","","71.66","71.66","71.66","1 through 10","101.45","260.16","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","327.25","245.44","WELLPOINT [1015]","HB AMC WELLPOINT","241.45","73.78","","74.75","27.97","425.28","93","101.45","260.16","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","327.25","245.44","AETNA [1001]","HB AMC AETNA HMO","228.42","69.8","","52.67","14.36","414.90","1 through 10","171.02","267.43","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","327.25","245.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","171.02","52.26","","25.34","25.34","25.34","1 through 10","171.02","267.43","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","327.25","245.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","263.11","80.4","","478.02","107.84","478.02","1 through 10","171.02","267.43","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","327.25","245.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","267.43","81.72","","32.74","12.33","122.05","1 through 10","171.02","267.43","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","327.25","245.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","267.43","81.72","","144.95","32.78","676.91","104","171.02","267.43","percent of total billed charges",""
"K-WIRE BONE 1.4X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024575","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.17","96.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","101.90","79.5","","800.18","480.96","1887.97","195","39.73","101.9","percent of total billed charges",""
"K-WIRE BONE 1.4X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024575","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.17","96.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","68.31","53.3","","813.12","216.42","1444.50","81","39.73","101.9","percent of total billed charges",""
"K-WIRE BONE 1.4X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024575","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.17","96.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","39.73","31","","432.60","432.60","432.60","1 through 10","39.73","101.9","percent of total billed charges",""
"K-WIRE BONE 1.4X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024575","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.17","96.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","46.78","36.5","","148.37","54.89","631.39","94","39.73","101.9","percent of total billed charges",""
"K-WIRE BONE 1.4X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024575","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.17","96.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","49.09","38.3","","279.30","91.72","1116.77","266","39.73","101.9","percent of total billed charges",""
"K-WIRE BONE 1.4X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024575","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.17","96.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.98","42.9","","731.00","63.70","731.00","1 through 10","39.73","101.9","percent of total billed charges",""
"K-WIRE BONE 1.4X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024575","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.17","96.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.98","42.9","","384.74","384.74","384.74","1 through 10","39.73","101.9","percent of total billed charges",""
"K-WIRE BONE 1.4X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024575","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.17","96.13","WELLPOINT [1015]","HB AMC WELLPOINT","94.56","73.78","","286.63","119.22","1107.45","105","39.73","101.9","percent of total billed charges",""
"K-WIRE BONE 1.4X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","128.17","96.13","AETNA [1001]","HB AMC AETNA HMO","89.46","69.8","","675.31","184.75","1721.50","286","66.98","104.74","percent of total billed charges",""
"K-WIRE BONE 1.4X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","128.17","96.13","AETNA [1001]","HB AMC AETNA PPO","103.05","80.4","","1261.44","103.12","1514.10","21","66.98","104.74","percent of total billed charges",""
"K-WIRE BONE 1.4X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","128.17","96.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","103.05","80.4","","1365.00","1365.00","1365.00","1 through 10","66.98","104.74","percent of total billed charges",""
"K-WIRE BONE 1.4X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","128.17","96.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","104.74","81.72","","5157.68","5157.68","5157.68","1 through 10","66.98","104.74","percent of total billed charges",""
"K-WIRE BONE 1.4X4MM UNIVERSAL2 FIXATION","SUP-ITM-10024575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","128.17","96.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","104.74","81.72","","431.26","71.26","1459.57","88","66.98","104.74","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.89","48.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","51.59","79.5","","800.18","480.96","1887.97","195","20.12","51.59","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.89","48.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","34.59","53.3","","813.12","216.42","1444.50","81","20.12","51.59","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.89","48.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","20.12","31","","432.60","432.60","432.60","1 through 10","20.12","51.59","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.89","48.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.68","36.5","","148.37","54.89","631.39","94","20.12","51.59","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.89","48.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.85","38.3","","279.30","91.72","1116.77","266","20.12","51.59","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.89","48.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.84","42.9","","731.00","63.70","731.00","1 through 10","20.12","51.59","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.89","48.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.84","42.9","","384.74","384.74","384.74","1 through 10","20.12","51.59","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.89","48.67","WELLPOINT [1015]","HB AMC WELLPOINT","47.88","73.78","","286.63","119.22","1107.45","105","20.12","51.59","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","64.89","48.67","AETNA [1001]","HB AMC AETNA HMO","45.29","69.8","","675.31","184.75","1721.50","286","33.91","53.03","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","64.89","48.67","AETNA [1001]","HB AMC AETNA PPO","52.17","80.4","","1261.44","103.12","1514.10","21","33.91","53.03","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","64.89","48.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","52.17","80.4","","1365.00","1365.00","1365.00","1 through 10","33.91","53.03","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","64.89","48.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","53.03","81.72","","5157.68","5157.68","5157.68","1 through 10","33.91","53.03","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","64.89","48.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","53.03","81.72","","431.26","71.26","1459.57","88","33.91","53.03","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.13","67.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","47.10","52.26","","25.34","25.34","25.34","1 through 10","27.94","71.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.13","67.60","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","64.71","71.8","","105.81","105.81","366.90","1 through 10","27.94","71.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.13","67.60","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","63.09","70","","512.90","74.70","612.85","1 through 10","27.94","71.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.13","67.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","71.65","79.5","","200.27","182.80","200.27","1 through 10","27.94","71.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.13","67.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.04","53.3","","37.73","37.73","169.33","1 through 10","27.94","71.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.13","67.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","58.58","65","","100.27","8.48","494.52","1 through 10","27.94","71.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.13","67.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","58.58","65","","160.19","160.19","160.19","1 through 10","27.94","71.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.13","67.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.94","31","","28.12","28.12","28.12","1 through 10","27.94","71.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.13","67.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","32.90","36.5","","101.66","28.85","502.70","121","27.94","71.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.13","67.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.52","38.3","","61.58","25.32","328.44","138","27.94","71.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.13","67.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","38.67","42.9","","71.66","71.66","71.66","1 through 10","27.94","71.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.13","67.60","WELLPOINT [1015]","HB AMC WELLPOINT","66.50","73.78","","74.75","27.97","425.28","93","27.94","71.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","90.13","67.60","AETNA [1001]","HB AMC AETNA HMO","62.91","69.8","","52.67","14.36","414.90","1 through 10","47.1","73.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","90.13","67.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","47.10","52.26","","25.34","25.34","25.34","1 through 10","47.1","73.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","90.13","67.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","72.46","80.4","","478.02","107.84","478.02","1 through 10","47.1","73.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","90.13","67.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","73.65","81.72","","32.74","12.33","122.05","1 through 10","47.1","73.65","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","90.13","67.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","73.65","81.72","","144.95","32.78","676.91","104","47.1","73.65","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","939.96","79.5","","800.18","480.96","1887.97","195","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","630.19","53.3","","813.12","216.42","1444.50","81","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","366.53","31","","432.60","432.60","432.60","1 through 10","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","431.55","36.5","","148.37","54.89","631.39","94","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","452.84","38.3","","279.30","91.72","1116.77","266","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","507.22","42.9","","731.00","63.70","731.00","1 through 10","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","507.22","42.9","","384.74","384.74","384.74","1 through 10","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1182.34","886.75","WELLPOINT [1015]","HB AMC WELLPOINT","872.33","73.78","","286.63","119.22","1107.45","105","366.53","939.96","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1182.34","886.75","AETNA [1001]","HB AMC AETNA HMO","825.27","69.8","","675.31","184.75","1721.50","286","617.89","966.21","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1182.34","886.75","AETNA [1001]","HB AMC AETNA PPO","950.60","80.4","","1261.44","103.12","1514.10","21","617.89","966.21","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1182.34","886.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","950.60","80.4","","1365.00","1365.00","1365.00","1 through 10","617.89","966.21","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1182.34","886.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","966.21","81.72","","5157.68","5157.68","5157.68","1 through 10","617.89","966.21","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1182.34","886.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","966.21","81.72","","431.26","71.26","1459.57","88","617.89","966.21","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.86","32.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","34.07","79.5","","800.18","480.96","1887.97","195","13.29","34.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.86","32.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22.84","53.3","","813.12","216.42","1444.50","81","13.29","34.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.86","32.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","13.29","31","","432.60","432.60","432.60","1 through 10","13.29","34.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.86","32.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15.64","36.5","","148.37","54.89","631.39","94","13.29","34.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.86","32.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.42","38.3","","279.30","91.72","1116.77","266","13.29","34.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.86","32.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.39","42.9","","731.00","63.70","731.00","1 through 10","13.29","34.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.86","32.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.39","42.9","","384.74","384.74","384.74","1 through 10","13.29","34.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.86","32.14","WELLPOINT [1015]","HB AMC WELLPOINT","31.62","73.78","","286.63","119.22","1107.45","105","13.29","34.07","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.86","32.14","AETNA [1001]","HB AMC AETNA HMO","29.92","69.8","","675.31","184.75","1721.50","286","22.4","35.03","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.86","32.14","AETNA [1001]","HB AMC AETNA PPO","34.46","80.4","","1261.44","103.12","1514.10","21","22.4","35.03","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.86","32.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","34.46","80.4","","1365.00","1365.00","1365.00","1 through 10","22.4","35.03","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.86","32.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","35.03","81.72","","5157.68","5157.68","5157.68","1 through 10","22.4","35.03","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.86","32.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","35.03","81.72","","431.26","71.26","1459.57","88","22.4","35.03","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","50.09","79.5","","800.18","480.96","1887.97","195","19.53","50.09","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33.58","53.3","","813.12","216.42","1444.50","81","19.53","50.09","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","19.53","31","","432.60","432.60","432.60","1 through 10","19.53","50.09","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.00","36.5","","148.37","54.89","631.39","94","19.53","50.09","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.13","38.3","","279.30","91.72","1116.77","266","19.53","50.09","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.03","42.9","","731.00","63.70","731.00","1 through 10","19.53","50.09","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.03","42.9","","384.74","384.74","384.74","1 through 10","19.53","50.09","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","WELLPOINT [1015]","HB AMC WELLPOINT","46.48","73.78","","286.63","119.22","1107.45","105","19.53","50.09","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.00","47.25","AETNA [1001]","HB AMC AETNA HMO","43.97","69.8","","675.31","184.75","1721.50","286","32.92","51.48","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.00","47.25","AETNA [1001]","HB AMC AETNA PPO","50.65","80.4","","1261.44","103.12","1514.10","21","32.92","51.48","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","50.65","80.4","","1365.00","1365.00","1365.00","1 through 10","32.92","51.48","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","51.48","81.72","","5157.68","5157.68","5157.68","1 through 10","32.92","51.48","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","51.48","81.72","","431.26","71.26","1459.57","88","32.92","51.48","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.25","105.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.50","79.5","","800.18","480.96","1887.97","195","43.48","111.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.25","105.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.75","53.3","","813.12","216.42","1444.50","81","43.48","111.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.25","105.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","43.48","31","","432.60","432.60","432.60","1 through 10","43.48","111.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.25","105.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.19","36.5","","148.37","54.89","631.39","94","43.48","111.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.25","105.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.72","38.3","","279.30","91.72","1116.77","266","43.48","111.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.25","105.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.17","42.9","","731.00","63.70","731.00","1 through 10","43.48","111.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.25","105.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.17","42.9","","384.74","384.74","384.74","1 through 10","43.48","111.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.25","105.19","WELLPOINT [1015]","HB AMC WELLPOINT","103.48","73.78","","286.63","119.22","1107.45","105","43.48","111.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.25","105.19","AETNA [1001]","HB AMC AETNA HMO","97.89","69.8","","675.31","184.75","1721.50","286","73.29","114.61","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.25","105.19","AETNA [1001]","HB AMC AETNA PPO","112.76","80.4","","1261.44","103.12","1514.10","21","73.29","114.61","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.25","105.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.76","80.4","","1365.00","1365.00","1365.00","1 through 10","73.29","114.61","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.25","105.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.61","81.72","","5157.68","5157.68","5157.68","1 through 10","73.29","114.61","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.25","105.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.61","81.72","","431.26","71.26","1459.57","88","73.29","114.61","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","52.47","39.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","41.71","79.5","","800.18","480.96","1887.97","195","16.27","41.71","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","52.47","39.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","27.97","53.3","","813.12","216.42","1444.50","81","16.27","41.71","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","52.47","39.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","16.27","31","","432.60","432.60","432.60","1 through 10","16.27","41.71","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","52.47","39.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19.15","36.5","","148.37","54.89","631.39","94","16.27","41.71","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","52.47","39.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20.10","38.3","","279.30","91.72","1116.77","266","16.27","41.71","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","52.47","39.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","22.51","42.9","","731.00","63.70","731.00","1 through 10","16.27","41.71","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","52.47","39.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","22.51","42.9","","384.74","384.74","384.74","1 through 10","16.27","41.71","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","52.47","39.35","WELLPOINT [1015]","HB AMC WELLPOINT","38.71","73.78","","286.63","119.22","1107.45","105","16.27","41.71","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","52.47","39.35","AETNA [1001]","HB AMC AETNA HMO","36.62","69.8","","675.31","184.75","1721.50","286","27.42","42.88","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","52.47","39.35","AETNA [1001]","HB AMC AETNA PPO","42.19","80.4","","1261.44","103.12","1514.10","21","27.42","42.88","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","52.47","39.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","42.19","80.4","","1365.00","1365.00","1365.00","1 through 10","27.42","42.88","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","52.47","39.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","42.88","81.72","","5157.68","5157.68","5157.68","1 through 10","27.42","42.88","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","52.47","39.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","42.88","81.72","","431.26","71.26","1459.57","88","27.42","42.88","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.46","15.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","16.27","79.5","","800.18","480.96","1887.97","195","6.34","16.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.46","15.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10.91","53.3","","813.12","216.42","1444.50","81","6.34","16.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.46","15.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","6.34","31","","432.60","432.60","432.60","1 through 10","6.34","16.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.46","15.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7.47","36.5","","148.37","54.89","631.39","94","6.34","16.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.46","15.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7.84","38.3","","279.30","91.72","1116.77","266","6.34","16.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.46","15.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8.78","42.9","","731.00","63.70","731.00","1 through 10","6.34","16.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.46","15.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8.78","42.9","","384.74","384.74","384.74","1 through 10","6.34","16.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.46","15.34","WELLPOINT [1015]","HB AMC WELLPOINT","15.10","73.78","","286.63","119.22","1107.45","105","6.34","16.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.46","15.34","AETNA [1001]","HB AMC AETNA HMO","14.28","69.8","","675.31","184.75","1721.50","286","10.69","16.72","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.46","15.34","AETNA [1001]","HB AMC AETNA PPO","16.45","80.4","","1261.44","103.12","1514.10","21","10.69","16.72","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.46","15.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","16.45","80.4","","1365.00","1365.00","1365.00","1 through 10","10.69","16.72","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.46","15.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","16.72","81.72","","5157.68","5157.68","5157.68","1 through 10","10.69","16.72","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.46","15.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16.72","81.72","","431.26","71.26","1459.57","88","10.69","16.72","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","72.35","79.5","","800.18","480.96","1887.97","195","28.21","72.35","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.50","53.3","","813.12","216.42","1444.50","81","28.21","72.35","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","28.21","31","","432.60","432.60","432.60","1 through 10","28.21","72.35","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.22","36.5","","148.37","54.89","631.39","94","28.21","72.35","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.85","38.3","","279.30","91.72","1116.77","266","28.21","72.35","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.04","42.9","","731.00","63.70","731.00","1 through 10","28.21","72.35","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.04","42.9","","384.74","384.74","384.74","1 through 10","28.21","72.35","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","WELLPOINT [1015]","HB AMC WELLPOINT","67.14","73.78","","286.63","119.22","1107.45","105","28.21","72.35","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA HMO","63.52","69.8","","675.31","184.75","1721.50","286","47.56","74.37","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA PPO","73.16","80.4","","1261.44","103.12","1514.10","21","47.56","74.37","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","73.16","80.4","","1365.00","1365.00","1365.00","1 through 10","47.56","74.37","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","74.37","81.72","","5157.68","5157.68","5157.68","1 through 10","47.56","74.37","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","74.37","81.72","","431.26","71.26","1459.57","88","47.56","74.37","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","95.58","79.5","","800.18","480.96","1887.97","195","37.27","95.58","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","64.08","53.3","","813.12","216.42","1444.50","81","37.27","95.58","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","37.27","31","","432.60","432.60","432.60","1 through 10","37.27","95.58","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","43.88","36.5","","148.37","54.89","631.39","94","37.27","95.58","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.05","38.3","","279.30","91.72","1116.77","266","37.27","95.58","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","51.58","42.9","","731.00","63.70","731.00","1 through 10","37.27","95.58","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","51.58","42.9","","384.74","384.74","384.74","1 through 10","37.27","95.58","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","WELLPOINT [1015]","HB AMC WELLPOINT","88.71","73.78","","286.63","119.22","1107.45","105","37.27","95.58","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.23","90.17","AETNA [1001]","HB AMC AETNA HMO","83.92","69.8","","675.31","184.75","1721.50","286","62.83","98.25","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.23","90.17","AETNA [1001]","HB AMC AETNA PPO","96.66","80.4","","1261.44","103.12","1514.10","21","62.83","98.25","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.23","90.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","96.66","80.4","","1365.00","1365.00","1365.00","1 through 10","62.83","98.25","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.23","90.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","98.25","81.72","","5157.68","5157.68","5157.68","1 through 10","62.83","98.25","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.23","90.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","98.25","81.72","","431.26","71.26","1459.57","88","62.83","98.25","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.56","101.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","107.77","79.5","","800.18","480.96","1887.97","195","42.02","107.77","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.56","101.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","72.25","53.3","","813.12","216.42","1444.50","81","42.02","107.77","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.56","101.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","42.02","31","","432.60","432.60","432.60","1 through 10","42.02","107.77","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.56","101.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","49.48","36.5","","148.37","54.89","631.39","94","42.02","107.77","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.56","101.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","51.92","38.3","","279.30","91.72","1116.77","266","42.02","107.77","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.56","101.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.16","42.9","","731.00","63.70","731.00","1 through 10","42.02","107.77","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.56","101.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.16","42.9","","384.74","384.74","384.74","1 through 10","42.02","107.77","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.56","101.67","WELLPOINT [1015]","HB AMC WELLPOINT","100.02","73.78","","286.63","119.22","1107.45","105","42.02","107.77","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.56","101.67","AETNA [1001]","HB AMC AETNA HMO","94.62","69.8","","675.31","184.75","1721.50","286","70.84","110.78","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.56","101.67","AETNA [1001]","HB AMC AETNA PPO","108.99","80.4","","1261.44","103.12","1514.10","21","70.84","110.78","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.56","101.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","108.99","80.4","","1365.00","1365.00","1365.00","1 through 10","70.84","110.78","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.56","101.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","110.78","81.72","","5157.68","5157.68","5157.68","1 through 10","70.84","110.78","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.56","101.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","110.78","81.72","","431.26","71.26","1459.57","88","70.84","110.78","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.50","55.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","38.41","52.26","","25.34","25.34","25.34","1 through 10","22.79","58.43","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.50","55.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","52.77","71.8","","105.81","105.81","366.90","1 through 10","22.79","58.43","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.50","55.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","51.45","70","","512.90","74.70","612.85","1 through 10","22.79","58.43","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.50","55.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","58.43","79.5","","200.27","182.80","200.27","1 through 10","22.79","58.43","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.50","55.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39.18","53.3","","37.73","37.73","169.33","1 through 10","22.79","58.43","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.50","55.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","47.78","65","","100.27","8.48","494.52","1 through 10","22.79","58.43","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.50","55.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","47.78","65","","160.19","160.19","160.19","1 through 10","22.79","58.43","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.50","55.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","22.79","31","","28.12","28.12","28.12","1 through 10","22.79","58.43","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.50","55.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.83","36.5","","101.66","28.85","502.70","121","22.79","58.43","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.50","55.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.15","38.3","","61.58","25.32","328.44","138","22.79","58.43","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.50","55.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.53","42.9","","71.66","71.66","71.66","1 through 10","22.79","58.43","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.50","55.12","WELLPOINT [1015]","HB AMC WELLPOINT","54.23","73.78","","74.75","27.97","425.28","93","22.79","58.43","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.50","55.12","AETNA [1001]","HB AMC AETNA HMO","51.30","69.8","","52.67","14.36","414.90","1 through 10","38.41","60.06","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.50","55.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","38.41","52.26","","25.34","25.34","25.34","1 through 10","38.41","60.06","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.50","55.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","59.09","80.4","","478.02","107.84","478.02","1 through 10","38.41","60.06","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.50","55.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","60.06","81.72","","32.74","12.33","122.05","1 through 10","38.41","60.06","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.50","55.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","60.06","81.72","","144.95","32.78","676.91","104","38.41","60.06","percent of total billed charges",""
"K-WIRE BONE 2.0X285MM SS DRILL TIP","SUP-ITM-10145362","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.81","446.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","473.67","79.5","","800.18","480.96","1887.97","195","184.7","473.67","percent of total billed charges",""
"K-WIRE BONE 2.0X285MM SS DRILL TIP","SUP-ITM-10145362","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.81","446.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","317.57","53.3","","813.12","216.42","1444.50","81","184.7","473.67","percent of total billed charges",""
"K-WIRE BONE 2.0X285MM SS DRILL TIP","SUP-ITM-10145362","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.81","446.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","184.70","31","","432.60","432.60","432.60","1 through 10","184.7","473.67","percent of total billed charges",""
"K-WIRE BONE 2.0X285MM SS DRILL TIP","SUP-ITM-10145362","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.81","446.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","217.47","36.5","","148.37","54.89","631.39","94","184.7","473.67","percent of total billed charges",""
"K-WIRE BONE 2.0X285MM SS DRILL TIP","SUP-ITM-10145362","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.81","446.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","228.20","38.3","","279.30","91.72","1116.77","266","184.7","473.67","percent of total billed charges",""
"K-WIRE BONE 2.0X285MM SS DRILL TIP","SUP-ITM-10145362","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.81","446.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.60","42.9","","731.00","63.70","731.00","1 through 10","184.7","473.67","percent of total billed charges",""
"K-WIRE BONE 2.0X285MM SS DRILL TIP","SUP-ITM-10145362","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.81","446.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.60","42.9","","384.74","384.74","384.74","1 through 10","184.7","473.67","percent of total billed charges",""
"K-WIRE BONE 2.0X285MM SS DRILL TIP","SUP-ITM-10145362","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.81","446.86","WELLPOINT [1015]","HB AMC WELLPOINT","439.59","73.78","","286.63","119.22","1107.45","105","184.7","473.67","percent of total billed charges",""
"K-WIRE BONE 2.0X285MM SS DRILL TIP","SUP-ITM-10145362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.81","446.86","AETNA [1001]","HB AMC AETNA HMO","415.88","69.8","","675.31","184.75","1721.50","286","311.37","486.9","percent of total billed charges",""
"K-WIRE BONE 2.0X285MM SS DRILL TIP","SUP-ITM-10145362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.81","446.86","AETNA [1001]","HB AMC AETNA PPO","479.03","80.4","","1261.44","103.12","1514.10","21","311.37","486.9","percent of total billed charges",""
"K-WIRE BONE 2.0X285MM SS DRILL TIP","SUP-ITM-10145362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.81","446.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","479.03","80.4","","1365.00","1365.00","1365.00","1 through 10","311.37","486.9","percent of total billed charges",""
"K-WIRE BONE 2.0X285MM SS DRILL TIP","SUP-ITM-10145362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.81","446.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","486.90","81.72","","5157.68","5157.68","5157.68","1 through 10","311.37","486.9","percent of total billed charges",""
"K-WIRE BONE 2.0X285MM SS DRILL TIP","SUP-ITM-10145362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.81","446.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","486.90","81.72","","431.26","71.26","1459.57","88","311.37","486.9","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.22","275.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","291.94","79.5","","800.18","480.96","1887.97","195","113.84","291.94","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.22","275.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","195.73","53.3","","813.12","216.42","1444.50","81","113.84","291.94","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.22","275.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","113.84","31","","432.60","432.60","432.60","1 through 10","113.84","291.94","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.22","275.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","134.04","36.5","","148.37","54.89","631.39","94","113.84","291.94","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.22","275.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","140.65","38.3","","279.30","91.72","1116.77","266","113.84","291.94","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.22","275.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.54","42.9","","731.00","63.70","731.00","1 through 10","113.84","291.94","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.22","275.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.54","42.9","","384.74","384.74","384.74","1 through 10","113.84","291.94","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.22","275.41","WELLPOINT [1015]","HB AMC WELLPOINT","270.93","73.78","","286.63","119.22","1107.45","105","113.84","291.94","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.22","275.41","AETNA [1001]","HB AMC AETNA HMO","256.32","69.8","","675.31","184.75","1721.50","286","191.91","300.09","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.22","275.41","AETNA [1001]","HB AMC AETNA PPO","295.24","80.4","","1261.44","103.12","1514.10","21","191.91","300.09","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.22","275.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","295.24","80.4","","1365.00","1365.00","1365.00","1 through 10","191.91","300.09","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.22","275.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","300.09","81.72","","5157.68","5157.68","5157.68","1 through 10","191.91","300.09","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.22","275.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","300.09","81.72","","431.26","71.26","1459.57","88","191.91","300.09","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.68","354.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","375.78","79.5","","800.18","480.96","1887.97","195","146.53","375.78","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.68","354.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","251.94","53.3","","813.12","216.42","1444.50","81","146.53","375.78","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.68","354.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","146.53","31","","432.60","432.60","432.60","1 through 10","146.53","375.78","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.68","354.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","172.53","36.5","","148.37","54.89","631.39","94","146.53","375.78","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.68","354.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","181.04","38.3","","279.30","91.72","1116.77","266","146.53","375.78","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.68","354.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.78","42.9","","731.00","63.70","731.00","1 through 10","146.53","375.78","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.68","354.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.78","42.9","","384.74","384.74","384.74","1 through 10","146.53","375.78","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.68","354.51","WELLPOINT [1015]","HB AMC WELLPOINT","348.74","73.78","","286.63","119.22","1107.45","105","146.53","375.78","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.68","354.51","AETNA [1001]","HB AMC AETNA HMO","329.93","69.8","","675.31","184.75","1721.50","286","247.02","386.27","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.68","354.51","AETNA [1001]","HB AMC AETNA PPO","380.03","80.4","","1261.44","103.12","1514.10","21","247.02","386.27","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.68","354.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","380.03","80.4","","1365.00","1365.00","1365.00","1 through 10","247.02","386.27","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.68","354.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","386.27","81.72","","5157.68","5157.68","5157.68","1 through 10","247.02","386.27","percent of total billed charges",""
"K-WIRE BONE 2.5X150MM FIXATION SS TROCAR POINT THREADED CS/10PK/10EA","SUP-ITM-10004540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.68","354.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","386.27","81.72","","431.26","71.26","1459.57","88","247.02","386.27","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","286.20","214.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","227.53","79.5","","800.18","480.96","1887.97","195","88.72","227.53","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","286.20","214.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","152.54","53.3","","813.12","216.42","1444.50","81","88.72","227.53","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","286.20","214.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","88.72","31","","432.60","432.60","432.60","1 through 10","88.72","227.53","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","286.20","214.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","104.46","36.5","","148.37","54.89","631.39","94","88.72","227.53","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","286.20","214.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","109.61","38.3","","279.30","91.72","1116.77","266","88.72","227.53","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","286.20","214.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","122.78","42.9","","731.00","63.70","731.00","1 through 10","88.72","227.53","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","286.20","214.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","122.78","42.9","","384.74","384.74","384.74","1 through 10","88.72","227.53","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","286.20","214.65","WELLPOINT [1015]","HB AMC WELLPOINT","211.16","73.78","","286.63","119.22","1107.45","105","88.72","227.53","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","286.20","214.65","AETNA [1001]","HB AMC AETNA HMO","199.77","69.8","","675.31","184.75","1721.50","286","149.57","233.88","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","286.20","214.65","AETNA [1001]","HB AMC AETNA PPO","230.10","80.4","","1261.44","103.12","1514.10","21","149.57","233.88","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","286.20","214.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","230.10","80.4","","1365.00","1365.00","1365.00","1 through 10","149.57","233.88","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","286.20","214.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","233.88","81.72","","5157.68","5157.68","5157.68","1 through 10","149.57","233.88","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","286.20","214.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","233.88","81.72","","431.26","71.26","1459.57","88","149.57","233.88","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.04","77.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","81.92","79.5","","800.18","480.96","1887.97","195","31.94","81.92","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.04","77.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","54.92","53.3","","813.12","216.42","1444.50","81","31.94","81.92","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.04","77.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","31.94","31","","432.60","432.60","432.60","1 through 10","31.94","81.92","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.04","77.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37.61","36.5","","148.37","54.89","631.39","94","31.94","81.92","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.04","77.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39.46","38.3","","279.30","91.72","1116.77","266","31.94","81.92","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.04","77.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.20","42.9","","731.00","63.70","731.00","1 through 10","31.94","81.92","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.04","77.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.20","42.9","","384.74","384.74","384.74","1 through 10","31.94","81.92","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.04","77.28","WELLPOINT [1015]","HB AMC WELLPOINT","76.02","73.78","","286.63","119.22","1107.45","105","31.94","81.92","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.04","77.28","AETNA [1001]","HB AMC AETNA HMO","71.92","69.8","","675.31","184.75","1721.50","286","53.85","84.2","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.04","77.28","AETNA [1001]","HB AMC AETNA PPO","82.84","80.4","","1261.44","103.12","1514.10","21","53.85","84.2","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.04","77.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","82.84","80.4","","1365.00","1365.00","1365.00","1 through 10","53.85","84.2","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.04","77.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","84.20","81.72","","5157.68","5157.68","5157.68","1 through 10","53.85","84.2","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.04","77.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","84.20","81.72","","431.26","71.26","1459.57","88","53.85","84.2","percent of total billed charges",""
"K-WIRE BONE 220X3.2MM OPEN REDUCTION INTERNAL FIXATION RETRACTOR","SUP-ITM-10185862","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.39","362.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","384.30","79.5","","800.18","480.96","1887.97","195","149.85","384.3","percent of total billed charges",""
"K-WIRE BONE 220X3.2MM OPEN REDUCTION INTERNAL FIXATION RETRACTOR","SUP-ITM-10185862","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.39","362.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","257.65","53.3","","813.12","216.42","1444.50","81","149.85","384.3","percent of total billed charges",""
"K-WIRE BONE 220X3.2MM OPEN REDUCTION INTERNAL FIXATION RETRACTOR","SUP-ITM-10185862","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.39","362.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","149.85","31","","432.60","432.60","432.60","1 through 10","149.85","384.3","percent of total billed charges",""
"K-WIRE BONE 220X3.2MM OPEN REDUCTION INTERNAL FIXATION RETRACTOR","SUP-ITM-10185862","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.39","362.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","176.44","36.5","","148.37","54.89","631.39","94","149.85","384.3","percent of total billed charges",""
"K-WIRE BONE 220X3.2MM OPEN REDUCTION INTERNAL FIXATION RETRACTOR","SUP-ITM-10185862","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.39","362.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","185.14","38.3","","279.30","91.72","1116.77","266","149.85","384.3","percent of total billed charges",""
"K-WIRE BONE 220X3.2MM OPEN REDUCTION INTERNAL FIXATION RETRACTOR","SUP-ITM-10185862","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.39","362.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","207.37","42.9","","731.00","63.70","731.00","1 through 10","149.85","384.3","percent of total billed charges",""
"K-WIRE BONE 220X3.2MM OPEN REDUCTION INTERNAL FIXATION RETRACTOR","SUP-ITM-10185862","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.39","362.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","207.37","42.9","","384.74","384.74","384.74","1 through 10","149.85","384.3","percent of total billed charges",""
"K-WIRE BONE 220X3.2MM OPEN REDUCTION INTERNAL FIXATION RETRACTOR","SUP-ITM-10185862","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.39","362.54","WELLPOINT [1015]","HB AMC WELLPOINT","356.65","73.78","","286.63","119.22","1107.45","105","149.85","384.3","percent of total billed charges",""
"K-WIRE BONE 220X3.2MM OPEN REDUCTION INTERNAL FIXATION RETRACTOR","SUP-ITM-10185862","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.39","362.54","AETNA [1001]","HB AMC AETNA HMO","337.41","69.8","","675.31","184.75","1721.50","286","252.62","395.03","percent of total billed charges",""
"K-WIRE BONE 220X3.2MM OPEN REDUCTION INTERNAL FIXATION RETRACTOR","SUP-ITM-10185862","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.39","362.54","AETNA [1001]","HB AMC AETNA PPO","388.65","80.4","","1261.44","103.12","1514.10","21","252.62","395.03","percent of total billed charges",""
"K-WIRE BONE 220X3.2MM OPEN REDUCTION INTERNAL FIXATION RETRACTOR","SUP-ITM-10185862","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.39","362.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","388.65","80.4","","1365.00","1365.00","1365.00","1 through 10","252.62","395.03","percent of total billed charges",""
"K-WIRE BONE 220X3.2MM OPEN REDUCTION INTERNAL FIXATION RETRACTOR","SUP-ITM-10185862","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.39","362.54","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","395.03","81.72","","5157.68","5157.68","5157.68","1 through 10","252.62","395.03","percent of total billed charges",""
"K-WIRE BONE 220X3.2MM OPEN REDUCTION INTERNAL FIXATION RETRACTOR","SUP-ITM-10185862","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.39","362.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","395.03","81.72","","431.26","71.26","1459.57","88","252.62","395.03","percent of total billed charges",""
"K-WIRE BONE 2MM SS STOP","SUP-ITM-10114777","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","414.07","79.5","","800.18","480.96","1887.97","195","161.46","414.07","percent of total billed charges",""
"K-WIRE BONE 2MM SS STOP","SUP-ITM-10114777","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","277.61","53.3","","813.12","216.42","1444.50","81","161.46","414.07","percent of total billed charges",""
"K-WIRE BONE 2MM SS STOP","SUP-ITM-10114777","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","161.46","31","","432.60","432.60","432.60","1 through 10","161.46","414.07","percent of total billed charges",""
"K-WIRE BONE 2MM SS STOP","SUP-ITM-10114777","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","190.11","36.5","","148.37","54.89","631.39","94","161.46","414.07","percent of total billed charges",""
"K-WIRE BONE 2MM SS STOP","SUP-ITM-10114777","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","199.48","38.3","","279.30","91.72","1116.77","266","161.46","414.07","percent of total billed charges",""
"K-WIRE BONE 2MM SS STOP","SUP-ITM-10114777","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","223.44","42.9","","731.00","63.70","731.00","1 through 10","161.46","414.07","percent of total billed charges",""
"K-WIRE BONE 2MM SS STOP","SUP-ITM-10114777","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","223.44","42.9","","384.74","384.74","384.74","1 through 10","161.46","414.07","percent of total billed charges",""
"K-WIRE BONE 2MM SS STOP","SUP-ITM-10114777","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","WELLPOINT [1015]","HB AMC WELLPOINT","384.28","73.78","","286.63","119.22","1107.45","105","161.46","414.07","percent of total billed charges",""
"K-WIRE BONE 2MM SS STOP","SUP-ITM-10114777","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.84","390.63","AETNA [1001]","HB AMC AETNA HMO","363.55","69.8","","675.31","184.75","1721.50","286","272.19","425.63","percent of total billed charges",""
"K-WIRE BONE 2MM SS STOP","SUP-ITM-10114777","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.84","390.63","AETNA [1001]","HB AMC AETNA PPO","418.76","80.4","","1261.44","103.12","1514.10","21","272.19","425.63","percent of total billed charges",""
"K-WIRE BONE 2MM SS STOP","SUP-ITM-10114777","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.84","390.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","418.76","80.4","","1365.00","1365.00","1365.00","1 through 10","272.19","425.63","percent of total billed charges",""
"K-WIRE BONE 2MM SS STOP","SUP-ITM-10114777","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.84","390.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","425.63","81.72","","5157.68","5157.68","5157.68","1 through 10","272.19","425.63","percent of total billed charges",""
"K-WIRE BONE 2MM SS STOP","SUP-ITM-10114777","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.84","390.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","425.63","81.72","","431.26","71.26","1459.57","88","272.19","425.63","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.05","17.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18.32","79.5","","800.18","480.96","1887.97","195","7.15","18.32","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.05","17.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12.29","53.3","","813.12","216.42","1444.50","81","7.15","18.32","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.05","17.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","7.15","31","","432.60","432.60","432.60","1 through 10","7.15","18.32","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.05","17.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.41","36.5","","148.37","54.89","631.39","94","7.15","18.32","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.05","17.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8.83","38.3","","279.30","91.72","1116.77","266","7.15","18.32","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.05","17.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.89","42.9","","731.00","63.70","731.00","1 through 10","7.15","18.32","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.05","17.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.89","42.9","","384.74","384.74","384.74","1 through 10","7.15","18.32","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","23.05","17.29","WELLPOINT [1015]","HB AMC WELLPOINT","17.01","73.78","","286.63","119.22","1107.45","105","7.15","18.32","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","23.05","17.29","AETNA [1001]","HB AMC AETNA HMO","16.09","69.8","","675.31","184.75","1721.50","286","12.05","18.84","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","23.05","17.29","AETNA [1001]","HB AMC AETNA PPO","18.53","80.4","","1261.44","103.12","1514.10","21","12.05","18.84","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","23.05","17.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","18.53","80.4","","1365.00","1365.00","1365.00","1 through 10","12.05","18.84","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","23.05","17.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","18.84","81.72","","5157.68","5157.68","5157.68","1 through 10","12.05","18.84","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","23.05","17.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18.84","81.72","","431.26","71.26","1459.57","88","12.05","18.84","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.55","19.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21.11","79.5","","800.18","480.96","1887.97","195","8.23","21.11","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.55","19.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14.15","53.3","","813.12","216.42","1444.50","81","8.23","21.11","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.55","19.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","8.23","31","","432.60","432.60","432.60","1 through 10","8.23","21.11","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.55","19.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9.69","36.5","","148.37","54.89","631.39","94","8.23","21.11","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.55","19.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10.17","38.3","","279.30","91.72","1116.77","266","8.23","21.11","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.55","19.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11.39","42.9","","731.00","63.70","731.00","1 through 10","8.23","21.11","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.55","19.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11.39","42.9","","384.74","384.74","384.74","1 through 10","8.23","21.11","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","26.55","19.91","WELLPOINT [1015]","HB AMC WELLPOINT","19.59","73.78","","286.63","119.22","1107.45","105","8.23","21.11","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","26.55","19.91","AETNA [1001]","HB AMC AETNA HMO","18.53","69.8","","675.31","184.75","1721.50","286","13.88","21.7","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","26.55","19.91","AETNA [1001]","HB AMC AETNA PPO","21.35","80.4","","1261.44","103.12","1514.10","21","13.88","21.7","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","26.55","19.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","21.35","80.4","","1365.00","1365.00","1365.00","1 through 10","13.88","21.7","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","26.55","19.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","21.70","81.72","","5157.68","5157.68","5157.68","1 through 10","13.88","21.7","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","26.55","19.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21.70","81.72","","431.26","71.26","1459.57","88","13.88","21.7","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.24","64.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.56","79.5","","800.18","480.96","1887.97","195","26.73","68.56","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.24","64.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.97","53.3","","813.12","216.42","1444.50","81","26.73","68.56","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.24","64.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.73","31","","432.60","432.60","432.60","1 through 10","26.73","68.56","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.24","64.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.48","36.5","","148.37","54.89","631.39","94","26.73","68.56","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.24","64.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.03","38.3","","279.30","91.72","1116.77","266","26.73","68.56","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.24","64.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.00","42.9","","731.00","63.70","731.00","1 through 10","26.73","68.56","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.24","64.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.00","42.9","","384.74","384.74","384.74","1 through 10","26.73","68.56","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.24","64.68","WELLPOINT [1015]","HB AMC WELLPOINT","63.63","73.78","","286.63","119.22","1107.45","105","26.73","68.56","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","86.24","64.68","AETNA [1001]","HB AMC AETNA HMO","60.20","69.8","","675.31","184.75","1721.50","286","45.07","70.48","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","86.24","64.68","AETNA [1001]","HB AMC AETNA PPO","69.34","80.4","","1261.44","103.12","1514.10","21","45.07","70.48","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","86.24","64.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","69.34","80.4","","1365.00","1365.00","1365.00","1 through 10","45.07","70.48","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","86.24","64.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.48","81.72","","5157.68","5157.68","5157.68","1 through 10","45.07","70.48","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","86.24","64.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.48","81.72","","431.26","71.26","1459.57","88","45.07","70.48","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.72","68.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","72.12","79.5","","800.18","480.96","1887.97","195","28.12","72.12","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.72","68.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.35","53.3","","813.12","216.42","1444.50","81","28.12","72.12","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.72","68.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","28.12","31","","432.60","432.60","432.60","1 through 10","28.12","72.12","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.72","68.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.11","36.5","","148.37","54.89","631.39","94","28.12","72.12","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.72","68.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.75","38.3","","279.30","91.72","1116.77","266","28.12","72.12","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.72","68.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","38.92","42.9","","731.00","63.70","731.00","1 through 10","28.12","72.12","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.72","68.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","38.92","42.9","","384.74","384.74","384.74","1 through 10","28.12","72.12","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.72","68.04","WELLPOINT [1015]","HB AMC WELLPOINT","66.93","73.78","","286.63","119.22","1107.45","105","28.12","72.12","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","90.72","68.04","AETNA [1001]","HB AMC AETNA HMO","63.32","69.8","","675.31","184.75","1721.50","286","47.41","74.14","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","90.72","68.04","AETNA [1001]","HB AMC AETNA PPO","72.94","80.4","","1261.44","103.12","1514.10","21","47.41","74.14","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","90.72","68.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","72.94","80.4","","1365.00","1365.00","1365.00","1 through 10","47.41","74.14","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","90.72","68.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","74.14","81.72","","5157.68","5157.68","5157.68","1 through 10","47.41","74.14","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","90.72","68.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","74.14","81.72","","431.26","71.26","1459.57","88","47.41","74.14","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.77","65.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.98","79.5","","800.18","480.96","1887.97","195","26.9","68.98","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.77","65.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.25","53.3","","813.12","216.42","1444.50","81","26.9","68.98","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.77","65.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.90","31","","432.60","432.60","432.60","1 through 10","26.9","68.98","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.77","65.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.67","36.5","","148.37","54.89","631.39","94","26.9","68.98","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.77","65.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.23","38.3","","279.30","91.72","1116.77","266","26.9","68.98","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.77","65.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.22","42.9","","731.00","63.70","731.00","1 through 10","26.9","68.98","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.77","65.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.22","42.9","","384.74","384.74","384.74","1 through 10","26.9","68.98","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","86.77","65.08","WELLPOINT [1015]","HB AMC WELLPOINT","64.02","73.78","","286.63","119.22","1107.45","105","26.9","68.98","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","86.77","65.08","AETNA [1001]","HB AMC AETNA HMO","60.57","69.8","","675.31","184.75","1721.50","286","45.35","70.91","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","86.77","65.08","AETNA [1001]","HB AMC AETNA PPO","69.76","80.4","","1261.44","103.12","1514.10","21","45.35","70.91","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","86.77","65.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","69.76","80.4","","1365.00","1365.00","1365.00","1 through 10","45.35","70.91","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","86.77","65.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.91","81.72","","5157.68","5157.68","5157.68","1 through 10","45.35","70.91","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","86.77","65.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.91","81.72","","431.26","71.26","1459.57","88","45.35","70.91","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.19","79.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","84.42","79.5","","800.18","480.96","1887.97","195","32.92","84.42","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.19","79.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","56.60","53.3","","813.12","216.42","1444.50","81","32.92","84.42","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.19","79.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","32.92","31","","432.60","432.60","432.60","1 through 10","32.92","84.42","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.19","79.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.76","36.5","","148.37","54.89","631.39","94","32.92","84.42","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.19","79.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.67","38.3","","279.30","91.72","1116.77","266","32.92","84.42","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.19","79.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.56","42.9","","731.00","63.70","731.00","1 through 10","32.92","84.42","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.19","79.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.56","42.9","","384.74","384.74","384.74","1 through 10","32.92","84.42","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.19","79.64","WELLPOINT [1015]","HB AMC WELLPOINT","78.35","73.78","","286.63","119.22","1107.45","105","32.92","84.42","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","106.19","79.64","AETNA [1001]","HB AMC AETNA HMO","74.12","69.8","","675.31","184.75","1721.50","286","55.49","86.78","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","106.19","79.64","AETNA [1001]","HB AMC AETNA PPO","85.38","80.4","","1261.44","103.12","1514.10","21","55.49","86.78","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","106.19","79.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","85.38","80.4","","1365.00","1365.00","1365.00","1 through 10","55.49","86.78","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","106.19","79.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","86.78","81.72","","5157.68","5157.68","5157.68","1 through 10","55.49","86.78","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","106.19","79.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","86.78","81.72","","431.26","71.26","1459.57","88","55.49","86.78","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.32","152.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","161.64","79.5","","800.18","480.96","1887.97","195","63.03","161.64","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.32","152.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","108.37","53.3","","813.12","216.42","1444.50","81","63.03","161.64","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.32","152.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","63.03","31","","432.60","432.60","432.60","1 through 10","63.03","161.64","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.32","152.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.21","36.5","","148.37","54.89","631.39","94","63.03","161.64","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.32","152.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.87","38.3","","279.30","91.72","1116.77","266","63.03","161.64","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.32","152.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.22","42.9","","731.00","63.70","731.00","1 through 10","63.03","161.64","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.32","152.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.22","42.9","","384.74","384.74","384.74","1 through 10","63.03","161.64","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.32","152.49","WELLPOINT [1015]","HB AMC WELLPOINT","150.01","73.78","","286.63","119.22","1107.45","105","63.03","161.64","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.32","152.49","AETNA [1001]","HB AMC AETNA HMO","141.92","69.8","","675.31","184.75","1721.50","286","106.26","166.15","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.32","152.49","AETNA [1001]","HB AMC AETNA PPO","163.47","80.4","","1261.44","103.12","1514.10","21","106.26","166.15","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.32","152.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","163.47","80.4","","1365.00","1365.00","1365.00","1 through 10","106.26","166.15","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.32","152.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","166.15","81.72","","5157.68","5157.68","5157.68","1 through 10","106.26","166.15","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.32","152.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","166.15","81.72","","431.26","71.26","1459.57","88","106.26","166.15","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.78","470.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","498.29","79.5","","800.18","480.96","1887.97","195","194.3","498.29","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.78","470.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","334.07","53.3","","813.12","216.42","1444.50","81","194.3","498.29","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.78","470.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","194.30","31","","432.60","432.60","432.60","1 through 10","194.3","498.29","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.78","470.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.77","36.5","","148.37","54.89","631.39","94","194.3","498.29","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.78","470.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","240.06","38.3","","279.30","91.72","1116.77","266","194.3","498.29","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.78","470.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.89","42.9","","731.00","63.70","731.00","1 through 10","194.3","498.29","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.78","470.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.89","42.9","","384.74","384.74","384.74","1 through 10","194.3","498.29","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.78","470.08","WELLPOINT [1015]","HB AMC WELLPOINT","462.44","73.78","","286.63","119.22","1107.45","105","194.3","498.29","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.78","470.08","AETNA [1001]","HB AMC AETNA HMO","437.49","69.8","","675.31","184.75","1721.50","286","327.56","512.2","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.78","470.08","AETNA [1001]","HB AMC AETNA PPO","503.93","80.4","","1261.44","103.12","1514.10","21","327.56","512.2","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.78","470.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","503.93","80.4","","1365.00","1365.00","1365.00","1 through 10","327.56","512.2","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.78","470.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","512.20","81.72","","5157.68","5157.68","5157.68","1 through 10","327.56","512.2","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.78","470.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","512.20","81.72","","431.26","71.26","1459.57","88","327.56","512.2","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.96","522.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","554.08","79.5","","800.18","480.96","1887.97","195","216.06","554.08","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.96","522.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","371.48","53.3","","813.12","216.42","1444.50","81","216.06","554.08","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.96","522.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","216.06","31","","432.60","432.60","432.60","1 through 10","216.06","554.08","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.96","522.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","254.39","36.5","","148.37","54.89","631.39","94","216.06","554.08","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.96","522.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","266.94","38.3","","279.30","91.72","1116.77","266","216.06","554.08","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.96","522.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","299.00","42.9","","731.00","63.70","731.00","1 through 10","216.06","554.08","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.96","522.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","299.00","42.9","","384.74","384.74","384.74","1 through 10","216.06","554.08","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.96","522.72","WELLPOINT [1015]","HB AMC WELLPOINT","514.22","73.78","","286.63","119.22","1107.45","105","216.06","554.08","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.96","522.72","AETNA [1001]","HB AMC AETNA HMO","486.48","69.8","","675.31","184.75","1721.50","286","364.23","569.56","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.96","522.72","AETNA [1001]","HB AMC AETNA PPO","560.36","80.4","","1261.44","103.12","1514.10","21","364.23","569.56","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.96","522.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","560.36","80.4","","1365.00","1365.00","1365.00","1 through 10","364.23","569.56","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.96","522.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","569.56","81.72","","5157.68","5157.68","5157.68","1 through 10","364.23","569.56","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.96","522.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","569.56","81.72","","431.26","71.26","1459.57","88","364.23","569.56","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","231.07","52.26","","25.34","25.34","25.34","1 through 10","137.07","351.52","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","317.47","71.8","","105.81","105.81","366.90","1 through 10","137.07","351.52","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","309.51","70","","512.90","74.70","612.85","1 through 10","137.07","351.52","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","351.52","79.5","","200.27","182.80","200.27","1 through 10","137.07","351.52","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","235.67","53.3","","37.73","37.73","169.33","1 through 10","137.07","351.52","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","287.40","65","","100.27","8.48","494.52","1 through 10","137.07","351.52","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","287.40","65","","160.19","160.19","160.19","1 through 10","137.07","351.52","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","137.07","31","","28.12","28.12","28.12","1 through 10","137.07","351.52","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","161.39","36.5","","101.66","28.85","502.70","121","137.07","351.52","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","169.35","38.3","","61.58","25.32","328.44","138","137.07","351.52","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.69","42.9","","71.66","71.66","71.66","1 through 10","137.07","351.52","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","both","","","442.16","331.62","WELLPOINT [1015]","HB AMC WELLPOINT","326.23","73.78","","74.75","27.97","425.28","93","137.07","351.52","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","442.16","331.62","AETNA [1001]","HB AMC AETNA HMO","308.63","69.8","","52.67","14.36","414.90","1 through 10","231.07","361.33","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","442.16","331.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","231.07","52.26","","25.34","25.34","25.34","1 through 10","231.07","361.33","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","442.16","331.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","355.50","80.4","","478.02","107.84","478.02","1 through 10","231.07","361.33","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","442.16","331.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","361.33","81.72","","32.74","12.33","122.05","1 through 10","231.07","361.33","percent of total billed charges",""
"K-WIRE BONE 4.0X1.4 150MM ASNIS III TITANIUM THREADED","SUP-ITM-10145107","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","442.16","331.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","361.33","81.72","","144.95","32.78","676.91","104","231.07","361.33","percent of total billed charges",""
"K-WIRE BONE 4IN 0.028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10003998","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.12","6.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6.46","79.5","","800.18","480.96","1887.97","195","2.52","6.46","percent of total billed charges",""
"K-WIRE BONE 4IN 0.028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10003998","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.12","6.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4.33","53.3","","813.12","216.42","1444.50","81","2.52","6.46","percent of total billed charges",""
"K-WIRE BONE 4IN 0.028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10003998","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.12","6.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2.52","31","","432.60","432.60","432.60","1 through 10","2.52","6.46","percent of total billed charges",""
"K-WIRE BONE 4IN 0.028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10003998","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.12","6.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2.96","36.5","","148.37","54.89","631.39","94","2.52","6.46","percent of total billed charges",""
"K-WIRE BONE 4IN 0.028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10003998","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.12","6.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3.11","38.3","","279.30","91.72","1116.77","266","2.52","6.46","percent of total billed charges",""
"K-WIRE BONE 4IN 0.028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10003998","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.12","6.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3.48","42.9","","731.00","63.70","731.00","1 through 10","2.52","6.46","percent of total billed charges",""
"K-WIRE BONE 4IN 0.028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10003998","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.12","6.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3.48","42.9","","384.74","384.74","384.74","1 through 10","2.52","6.46","percent of total billed charges",""
"K-WIRE BONE 4IN 0.028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10003998","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.12","6.09","WELLPOINT [1015]","HB AMC WELLPOINT","5.99","73.78","","286.63","119.22","1107.45","105","2.52","6.46","percent of total billed charges",""
"K-WIRE BONE 4IN 0.028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10003998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8.12","6.09","AETNA [1001]","HB AMC AETNA HMO","5.67","69.8","","675.31","184.75","1721.50","286","4.24","6.64","percent of total billed charges",""
"K-WIRE BONE 4IN 0.028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10003998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8.12","6.09","AETNA [1001]","HB AMC AETNA PPO","6.53","80.4","","1261.44","103.12","1514.10","21","4.24","6.64","percent of total billed charges",""
"K-WIRE BONE 4IN 0.028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10003998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8.12","6.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6.53","80.4","","1365.00","1365.00","1365.00","1 through 10","4.24","6.64","percent of total billed charges",""
"K-WIRE BONE 4IN 0.028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10003998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8.12","6.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6.64","81.72","","5157.68","5157.68","5157.68","1 through 10","4.24","6.64","percent of total billed charges",""
"K-WIRE BONE 4IN 0.028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10003998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8.12","6.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6.64","81.72","","431.26","71.26","1459.57","88","4.24","6.64","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.88","11.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11.83","79.5","","800.18","480.96","1887.97","195","4.61","11.83","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.88","11.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7.93","53.3","","813.12","216.42","1444.50","81","4.61","11.83","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.88","11.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4.61","31","","432.60","432.60","432.60","1 through 10","4.61","11.83","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.88","11.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5.43","36.5","","148.37","54.89","631.39","94","4.61","11.83","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.88","11.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5.70","38.3","","279.30","91.72","1116.77","266","4.61","11.83","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.88","11.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.38","42.9","","731.00","63.70","731.00","1 through 10","4.61","11.83","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.88","11.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.38","42.9","","384.74","384.74","384.74","1 through 10","4.61","11.83","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","both","","","14.88","11.16","WELLPOINT [1015]","HB AMC WELLPOINT","10.98","73.78","","286.63","119.22","1107.45","105","4.61","11.83","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.88","11.16","AETNA [1001]","HB AMC AETNA HMO","10.39","69.8","","675.31","184.75","1721.50","286","7.78","12.16","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.88","11.16","AETNA [1001]","HB AMC AETNA PPO","11.96","80.4","","1261.44","103.12","1514.10","21","7.78","12.16","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.88","11.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11.96","80.4","","1365.00","1365.00","1365.00","1 through 10","7.78","12.16","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.88","11.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","12.16","81.72","","5157.68","5157.68","5157.68","1 through 10","7.78","12.16","percent of total billed charges",""
"K-WIRE BONE 4IN 0.045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14.88","11.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12.16","81.72","","431.26","71.26","1459.57","88","7.78","12.16","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.87","10.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11.03","79.5","","800.18","480.96","1887.97","195","4.3","11.03","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.87","10.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7.39","53.3","","813.12","216.42","1444.50","81","4.3","11.03","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.87","10.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4.30","31","","432.60","432.60","432.60","1 through 10","4.3","11.03","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.87","10.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5.06","36.5","","148.37","54.89","631.39","94","4.3","11.03","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.87","10.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5.31","38.3","","279.30","91.72","1116.77","266","4.3","11.03","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.87","10.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.95","42.9","","731.00","63.70","731.00","1 through 10","4.3","11.03","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.87","10.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.95","42.9","","384.74","384.74","384.74","1 through 10","4.3","11.03","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.87","10.40","WELLPOINT [1015]","HB AMC WELLPOINT","10.23","73.78","","286.63","119.22","1107.45","105","4.3","11.03","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13.87","10.40","AETNA [1001]","HB AMC AETNA HMO","9.68","69.8","","675.31","184.75","1721.50","286","7.25","11.33","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13.87","10.40","AETNA [1001]","HB AMC AETNA PPO","11.15","80.4","","1261.44","103.12","1514.10","21","7.25","11.33","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13.87","10.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11.15","80.4","","1365.00","1365.00","1365.00","1 through 10","7.25","11.33","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13.87","10.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","11.33","81.72","","5157.68","5157.68","5157.68","1 through 10","7.25","11.33","percent of total billed charges",""
"K-WIRE BONE 4IN 0.054 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10004001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13.87","10.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11.33","81.72","","431.26","71.26","1459.57","88","7.25","11.33","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","74.52","79.5","","800.18","480.96","1887.97","195","29.06","74.52","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","49.96","53.3","","813.12","216.42","1444.50","81","29.06","74.52","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","29.06","31","","432.60","432.60","432.60","1 through 10","29.06","74.52","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34.21","36.5","","148.37","54.89","631.39","94","29.06","74.52","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35.90","38.3","","279.30","91.72","1116.77","266","29.06","74.52","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.21","42.9","","731.00","63.70","731.00","1 through 10","29.06","74.52","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.21","42.9","","384.74","384.74","384.74","1 through 10","29.06","74.52","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","WELLPOINT [1015]","HB AMC WELLPOINT","69.15","73.78","","286.63","119.22","1107.45","105","29.06","74.52","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","AETNA [1001]","HB AMC AETNA HMO","65.42","69.8","","675.31","184.75","1721.50","286","48.98","76.6","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","AETNA [1001]","HB AMC AETNA PPO","75.36","80.4","","1261.44","103.12","1514.10","21","48.98","76.6","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","75.36","80.4","","1365.00","1365.00","1365.00","1 through 10","48.98","76.6","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","76.60","81.72","","5157.68","5157.68","5157.68","1 through 10","48.98","76.6","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","76.60","81.72","","431.26","71.26","1459.57","88","48.98","76.6","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.20","134.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","142.46","79.5","","800.18","480.96","1887.97","195","55.55","142.46","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.20","134.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.51","53.3","","813.12","216.42","1444.50","81","55.55","142.46","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.20","134.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","55.55","31","","432.60","432.60","432.60","1 through 10","55.55","142.46","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.20","134.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.41","36.5","","148.37","54.89","631.39","94","55.55","142.46","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.20","134.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.63","38.3","","279.30","91.72","1116.77","266","55.55","142.46","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.20","134.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.88","42.9","","731.00","63.70","731.00","1 through 10","55.55","142.46","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.20","134.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.88","42.9","","384.74","384.74","384.74","1 through 10","55.55","142.46","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.20","134.40","WELLPOINT [1015]","HB AMC WELLPOINT","132.21","73.78","","286.63","119.22","1107.45","105","55.55","142.46","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.20","134.40","AETNA [1001]","HB AMC AETNA HMO","125.08","69.8","","675.31","184.75","1721.50","286","93.65","146.44","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.20","134.40","AETNA [1001]","HB AMC AETNA PPO","144.08","80.4","","1261.44","103.12","1514.10","21","93.65","146.44","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.20","134.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","144.08","80.4","","1365.00","1365.00","1365.00","1 through 10","93.65","146.44","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.20","134.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","146.44","81.72","","5157.68","5157.68","5157.68","1 through 10","93.65","146.44","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.20","134.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","146.44","81.72","","431.26","71.26","1459.57","88","93.65","146.44","percent of total billed charges",""
"K-WIRE BONE DIA 6IN 0.062IN SS SMOOTH TROCAR POINT DUEL END PK/6EA","SUP-ITM-10170701","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.66","31.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33.91","79.5","","800.18","480.96","1887.97","195","13.22","33.91","percent of total billed charges",""
"K-WIRE BONE DIA 6IN 0.062IN SS SMOOTH TROCAR POINT DUEL END PK/6EA","SUP-ITM-10170701","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.66","31.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22.74","53.3","","813.12","216.42","1444.50","81","13.22","33.91","percent of total billed charges",""
"K-WIRE BONE DIA 6IN 0.062IN SS SMOOTH TROCAR POINT DUEL END PK/6EA","SUP-ITM-10170701","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.66","31.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","13.22","31","","432.60","432.60","432.60","1 through 10","13.22","33.91","percent of total billed charges",""
"K-WIRE BONE DIA 6IN 0.062IN SS SMOOTH TROCAR POINT DUEL END PK/6EA","SUP-ITM-10170701","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.66","31.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15.57","36.5","","148.37","54.89","631.39","94","13.22","33.91","percent of total billed charges",""
"K-WIRE BONE DIA 6IN 0.062IN SS SMOOTH TROCAR POINT DUEL END PK/6EA","SUP-ITM-10170701","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.66","31.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.34","38.3","","279.30","91.72","1116.77","266","13.22","33.91","percent of total billed charges",""
"K-WIRE BONE DIA 6IN 0.062IN SS SMOOTH TROCAR POINT DUEL END PK/6EA","SUP-ITM-10170701","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.66","31.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.30","42.9","","731.00","63.70","731.00","1 through 10","13.22","33.91","percent of total billed charges",""
"K-WIRE BONE DIA 6IN 0.062IN SS SMOOTH TROCAR POINT DUEL END PK/6EA","SUP-ITM-10170701","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.66","31.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.30","42.9","","384.74","384.74","384.74","1 through 10","13.22","33.91","percent of total billed charges",""
"K-WIRE BONE DIA 6IN 0.062IN SS SMOOTH TROCAR POINT DUEL END PK/6EA","SUP-ITM-10170701","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.66","31.99","WELLPOINT [1015]","HB AMC WELLPOINT","31.47","73.78","","286.63","119.22","1107.45","105","13.22","33.91","percent of total billed charges",""
"K-WIRE BONE DIA 6IN 0.062IN SS SMOOTH TROCAR POINT DUEL END PK/6EA","SUP-ITM-10170701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.66","31.99","AETNA [1001]","HB AMC AETNA HMO","29.78","69.8","","675.31","184.75","1721.50","286","22.29","34.86","percent of total billed charges",""
"K-WIRE BONE DIA 6IN 0.062IN SS SMOOTH TROCAR POINT DUEL END PK/6EA","SUP-ITM-10170701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.66","31.99","AETNA [1001]","HB AMC AETNA PPO","34.30","80.4","","1261.44","103.12","1514.10","21","22.29","34.86","percent of total billed charges",""
"K-WIRE BONE DIA 6IN 0.062IN SS SMOOTH TROCAR POINT DUEL END PK/6EA","SUP-ITM-10170701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.66","31.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","34.30","80.4","","1365.00","1365.00","1365.00","1 through 10","22.29","34.86","percent of total billed charges",""
"K-WIRE BONE DIA 6IN 0.062IN SS SMOOTH TROCAR POINT DUEL END PK/6EA","SUP-ITM-10170701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.66","31.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","34.86","81.72","","5157.68","5157.68","5157.68","1 through 10","22.29","34.86","percent of total billed charges",""
"K-WIRE BONE DIA 6IN 0.062IN SS SMOOTH TROCAR POINT DUEL END PK/6EA","SUP-ITM-10170701","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.66","31.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34.86","81.72","","431.26","71.26","1459.57","88","22.29","34.86","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.30","79.5","","800.18","480.96","1887.97","195","43.4","111.3","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.62","53.3","","813.12","216.42","1444.50","81","43.4","111.3","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","43.40","31","","432.60","432.60","432.60","1 through 10","43.4","111.3","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.10","36.5","","148.37","54.89","631.39","94","43.4","111.3","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.62","38.3","","279.30","91.72","1116.77","266","43.4","111.3","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.06","42.9","","731.00","63.70","731.00","1 through 10","43.4","111.3","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.06","42.9","","384.74","384.74","384.74","1 through 10","43.4","111.3","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","WELLPOINT [1015]","HB AMC WELLPOINT","103.29","73.78","","286.63","119.22","1107.45","105","43.4","111.3","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA HMO","97.72","69.8","","675.31","184.75","1721.50","286","73.16","114.41","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA PPO","112.56","80.4","","1261.44","103.12","1514.10","21","73.16","114.41","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.56","80.4","","1365.00","1365.00","1365.00","1 through 10","73.16","114.41","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.41","81.72","","5157.68","5157.68","5157.68","1 through 10","73.16","114.41","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.41","81.72","","431.26","71.26","1459.57","88","73.16","114.41","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.20","9.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10.49","79.5","","800.18","480.96","1887.97","195","4.09","10.49","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.20","9.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7.04","53.3","","813.12","216.42","1444.50","81","4.09","10.49","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.20","9.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4.09","31","","432.60","432.60","432.60","1 through 10","4.09","10.49","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.20","9.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4.82","36.5","","148.37","54.89","631.39","94","4.09","10.49","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.20","9.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5.06","38.3","","279.30","91.72","1116.77","266","4.09","10.49","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.20","9.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.66","42.9","","731.00","63.70","731.00","1 through 10","4.09","10.49","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.20","9.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.66","42.9","","384.74","384.74","384.74","1 through 10","4.09","10.49","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.20","9.90","WELLPOINT [1015]","HB AMC WELLPOINT","9.74","73.78","","286.63","119.22","1107.45","105","4.09","10.49","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13.20","9.90","AETNA [1001]","HB AMC AETNA HMO","9.21","69.8","","675.31","184.75","1721.50","286","6.9","10.79","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13.20","9.90","AETNA [1001]","HB AMC AETNA PPO","10.61","80.4","","1261.44","103.12","1514.10","21","6.9","10.79","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13.20","9.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10.61","80.4","","1365.00","1365.00","1365.00","1 through 10","6.9","10.79","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13.20","9.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","10.79","81.72","","5157.68","5157.68","5157.68","1 through 10","6.9","10.79","percent of total billed charges",""
"K-WIRE GUIDE 4IN 0.035 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10003999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13.20","9.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10.79","81.72","","431.26","71.26","1459.57","88","6.9","10.79","percent of total billed charges",""
"K-WIRE GUIDE ORTHOPEDIC SPINAL ES2 NITINOL BLUNT","SUP-ITM-10152797","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.30","79.5","","800.18","480.96","1887.97","195","43.4","111.3","percent of total billed charges",""
"K-WIRE GUIDE ORTHOPEDIC SPINAL ES2 NITINOL BLUNT","SUP-ITM-10152797","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.62","53.3","","813.12","216.42","1444.50","81","43.4","111.3","percent of total billed charges",""
"K-WIRE GUIDE ORTHOPEDIC SPINAL ES2 NITINOL BLUNT","SUP-ITM-10152797","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","43.40","31","","432.60","432.60","432.60","1 through 10","43.4","111.3","percent of total billed charges",""
"K-WIRE GUIDE ORTHOPEDIC SPINAL ES2 NITINOL BLUNT","SUP-ITM-10152797","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.10","36.5","","148.37","54.89","631.39","94","43.4","111.3","percent of total billed charges",""
"K-WIRE GUIDE ORTHOPEDIC SPINAL ES2 NITINOL BLUNT","SUP-ITM-10152797","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.62","38.3","","279.30","91.72","1116.77","266","43.4","111.3","percent of total billed charges",""
"K-WIRE GUIDE ORTHOPEDIC SPINAL ES2 NITINOL BLUNT","SUP-ITM-10152797","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.06","42.9","","731.00","63.70","731.00","1 through 10","43.4","111.3","percent of total billed charges",""
"K-WIRE GUIDE ORTHOPEDIC SPINAL ES2 NITINOL BLUNT","SUP-ITM-10152797","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.06","42.9","","384.74","384.74","384.74","1 through 10","43.4","111.3","percent of total billed charges",""
"K-WIRE GUIDE ORTHOPEDIC SPINAL ES2 NITINOL BLUNT","SUP-ITM-10152797","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","WELLPOINT [1015]","HB AMC WELLPOINT","103.29","73.78","","286.63","119.22","1107.45","105","43.4","111.3","percent of total billed charges",""
"K-WIRE GUIDE ORTHOPEDIC SPINAL ES2 NITINOL BLUNT","SUP-ITM-10152797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA HMO","97.72","69.8","","675.31","184.75","1721.50","286","73.16","114.41","percent of total billed charges",""
"K-WIRE GUIDE ORTHOPEDIC SPINAL ES2 NITINOL BLUNT","SUP-ITM-10152797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA PPO","112.56","80.4","","1261.44","103.12","1514.10","21","73.16","114.41","percent of total billed charges",""
"K-WIRE GUIDE ORTHOPEDIC SPINAL ES2 NITINOL BLUNT","SUP-ITM-10152797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.56","80.4","","1365.00","1365.00","1365.00","1 through 10","73.16","114.41","percent of total billed charges",""
"K-WIRE GUIDE ORTHOPEDIC SPINAL ES2 NITINOL BLUNT","SUP-ITM-10152797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.41","81.72","","5157.68","5157.68","5157.68","1 through 10","73.16","114.41","percent of total billed charges",""
"K-WIRE GUIDE ORTHOPEDIC SPINAL ES2 NITINOL BLUNT","SUP-ITM-10152797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.41","81.72","","431.26","71.26","1459.57","88","73.16","114.41","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.00","73.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","77.91","79.5","","800.18","480.96","1887.97","195","30.38","77.91","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.00","73.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","52.23","53.3","","813.12","216.42","1444.50","81","30.38","77.91","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.00","73.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","30.38","31","","432.60","432.60","432.60","1 through 10","30.38","77.91","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.00","73.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","35.77","36.5","","148.37","54.89","631.39","94","30.38","77.91","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.00","73.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37.53","38.3","","279.30","91.72","1116.77","266","30.38","77.91","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.04","42.9","","731.00","63.70","731.00","1 through 10","30.38","77.91","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.00","73.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.04","42.9","","384.74","384.74","384.74","1 through 10","30.38","77.91","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.00","73.50","WELLPOINT [1015]","HB AMC WELLPOINT","72.30","73.78","","286.63","119.22","1107.45","105","30.38","77.91","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.00","73.50","AETNA [1001]","HB AMC AETNA HMO","68.40","69.8","","675.31","184.75","1721.50","286","51.21","80.09","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.00","73.50","AETNA [1001]","HB AMC AETNA PPO","78.79","80.4","","1261.44","103.12","1514.10","21","51.21","80.09","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","78.79","80.4","","1365.00","1365.00","1365.00","1 through 10","51.21","80.09","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","80.09","81.72","","5157.68","5157.68","5157.68","1 through 10","51.21","80.09","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","80.09","81.72","","431.26","71.26","1459.57","88","51.21","80.09","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","91.82","79.5","","800.18","480.96","1887.97","195","35.81","91.82","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","61.56","53.3","","813.12","216.42","1444.50","81","35.81","91.82","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","35.81","31","","432.60","432.60","432.60","1 through 10","35.81","91.82","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","42.16","36.5","","148.37","54.89","631.39","94","35.81","91.82","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44.24","38.3","","279.30","91.72","1116.77","266","35.81","91.82","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.55","42.9","","731.00","63.70","731.00","1 through 10","35.81","91.82","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.55","42.9","","384.74","384.74","384.74","1 through 10","35.81","91.82","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","WELLPOINT [1015]","HB AMC WELLPOINT","85.22","73.78","","286.63","119.22","1107.45","105","35.81","91.82","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.50","86.62","AETNA [1001]","HB AMC AETNA HMO","80.62","69.8","","675.31","184.75","1721.50","286","60.36","94.39","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.50","86.62","AETNA [1001]","HB AMC AETNA PPO","92.86","80.4","","1261.44","103.12","1514.10","21","60.36","94.39","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.50","86.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","92.86","80.4","","1365.00","1365.00","1365.00","1 through 10","60.36","94.39","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.50","86.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","94.39","81.72","","5157.68","5157.68","5157.68","1 through 10","60.36","94.39","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.50","86.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","94.39","81.72","","431.26","71.26","1459.57","88","60.36","94.39","percent of total billed charges",""
"K-WIRE STEINMAN 4MMX9IN PK/6EA","SUP-ITM-10147983","CDM","C1713","HCPCS","0278","RC","","","","both","","","24.96","18.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","19.84","79.5","","800.18","480.96","1887.97","195","7.74","19.84","percent of total billed charges",""
"K-WIRE STEINMAN 4MMX9IN PK/6EA","SUP-ITM-10147983","CDM","C1713","HCPCS","0278","RC","","","","both","","","24.96","18.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13.30","53.3","","813.12","216.42","1444.50","81","7.74","19.84","percent of total billed charges",""
"K-WIRE STEINMAN 4MMX9IN PK/6EA","SUP-ITM-10147983","CDM","C1713","HCPCS","0278","RC","","","","both","","","24.96","18.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","7.74","31","","432.60","432.60","432.60","1 through 10","7.74","19.84","percent of total billed charges",""
"K-WIRE STEINMAN 4MMX9IN PK/6EA","SUP-ITM-10147983","CDM","C1713","HCPCS","0278","RC","","","","both","","","24.96","18.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9.11","36.5","","148.37","54.89","631.39","94","7.74","19.84","percent of total billed charges",""
"K-WIRE STEINMAN 4MMX9IN PK/6EA","SUP-ITM-10147983","CDM","C1713","HCPCS","0278","RC","","","","both","","","24.96","18.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9.56","38.3","","279.30","91.72","1116.77","266","7.74","19.84","percent of total billed charges",""
"K-WIRE STEINMAN 4MMX9IN PK/6EA","SUP-ITM-10147983","CDM","C1713","HCPCS","0278","RC","","","","both","","","24.96","18.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.71","42.9","","731.00","63.70","731.00","1 through 10","7.74","19.84","percent of total billed charges",""
"K-WIRE STEINMAN 4MMX9IN PK/6EA","SUP-ITM-10147983","CDM","C1713","HCPCS","0278","RC","","","","both","","","24.96","18.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.71","42.9","","384.74","384.74","384.74","1 through 10","7.74","19.84","percent of total billed charges",""
"K-WIRE STEINMAN 4MMX9IN PK/6EA","SUP-ITM-10147983","CDM","C1713","HCPCS","0278","RC","","","","both","","","24.96","18.72","WELLPOINT [1015]","HB AMC WELLPOINT","18.42","73.78","","286.63","119.22","1107.45","105","7.74","19.84","percent of total billed charges",""
"K-WIRE STEINMAN 4MMX9IN PK/6EA","SUP-ITM-10147983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","24.96","18.72","AETNA [1001]","HB AMC AETNA HMO","17.42","69.8","","675.31","184.75","1721.50","286","13.04","20.4","percent of total billed charges",""
"K-WIRE STEINMAN 4MMX9IN PK/6EA","SUP-ITM-10147983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","24.96","18.72","AETNA [1001]","HB AMC AETNA PPO","20.07","80.4","","1261.44","103.12","1514.10","21","13.04","20.4","percent of total billed charges",""
"K-WIRE STEINMAN 4MMX9IN PK/6EA","SUP-ITM-10147983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","24.96","18.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","20.07","80.4","","1365.00","1365.00","1365.00","1 through 10","13.04","20.4","percent of total billed charges",""
"K-WIRE STEINMAN 4MMX9IN PK/6EA","SUP-ITM-10147983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","24.96","18.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","20.40","81.72","","5157.68","5157.68","5157.68","1 through 10","13.04","20.4","percent of total billed charges",""
"K-WIRE STEINMAN 4MMX9IN PK/6EA","SUP-ITM-10147983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","24.96","18.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","20.40","81.72","","431.26","71.26","1459.57","88","13.04","20.4","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","67.20","50.40","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","35.12","52.26","","25.34","25.34","25.34","1 through 10","20.83","53.42","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","67.20","50.40","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","48.25","71.8","","105.81","105.81","366.90","1 through 10","20.83","53.42","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","67.20","50.40","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","47.04","70","","512.90","74.70","612.85","1 through 10","20.83","53.42","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","67.20","50.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","53.42","79.5","","200.27","182.80","200.27","1 through 10","20.83","53.42","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","67.20","50.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","35.82","53.3","","37.73","37.73","169.33","1 through 10","20.83","53.42","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","67.20","50.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","43.68","65","","100.27","8.48","494.52","1 through 10","20.83","53.42","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","67.20","50.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","43.68","65","","160.19","160.19","160.19","1 through 10","20.83","53.42","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","67.20","50.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","20.83","31","","28.12","28.12","28.12","1 through 10","20.83","53.42","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","67.20","50.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24.53","36.5","","101.66","28.85","502.70","121","20.83","53.42","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","67.20","50.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25.74","38.3","","61.58","25.32","328.44","138","20.83","53.42","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","67.20","50.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.83","42.9","","71.66","71.66","71.66","1 through 10","20.83","53.42","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","67.20","50.40","WELLPOINT [1015]","HB AMC WELLPOINT","49.58","73.78","","74.75","27.97","425.28","93","20.83","53.42","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","67.20","50.40","AETNA [1001]","HB AMC AETNA HMO","46.91","69.8","","52.67","14.36","414.90","1 through 10","35.12","54.92","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","67.20","50.40","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","35.12","52.26","","25.34","25.34","25.34","1 through 10","35.12","54.92","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","67.20","50.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","54.03","80.4","","478.02","107.84","478.02","1 through 10","35.12","54.92","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","67.20","50.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","54.92","81.72","","32.74","12.33","122.05","1 through 10","35.12","54.92","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","67.20","50.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","54.92","81.72","","144.95","32.78","676.91","104","35.12","54.92","percent of total billed charges",""
"K-WIRE THREADED BLUNT","SUP-ITM-10312779","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","800.18","480.96","1887.97","195","97.65","250.43","percent of total billed charges",""
"K-WIRE THREADED BLUNT","SUP-ITM-10312779","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","813.12","216.42","1444.50","81","97.65","250.43","percent of total billed charges",""
"K-WIRE THREADED BLUNT","SUP-ITM-10312779","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","97.65","31","","432.60","432.60","432.60","1 through 10","97.65","250.43","percent of total billed charges",""
"K-WIRE THREADED BLUNT","SUP-ITM-10312779","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","148.37","54.89","631.39","94","97.65","250.43","percent of total billed charges",""
"K-WIRE THREADED BLUNT","SUP-ITM-10312779","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","279.30","91.72","1116.77","266","97.65","250.43","percent of total billed charges",""
"K-WIRE THREADED BLUNT","SUP-ITM-10312779","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","731.00","63.70","731.00","1 through 10","97.65","250.43","percent of total billed charges",""
"K-WIRE THREADED BLUNT","SUP-ITM-10312779","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","384.74","384.74","384.74","1 through 10","97.65","250.43","percent of total billed charges",""
"K-WIRE THREADED BLUNT","SUP-ITM-10312779","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB AMC WELLPOINT","232.41","73.78","","286.63","119.22","1107.45","105","97.65","250.43","percent of total billed charges",""
"K-WIRE THREADED BLUNT","SUP-ITM-10312779","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","675.31","184.75","1721.50","286","164.62","257.42","percent of total billed charges",""
"K-WIRE THREADED BLUNT","SUP-ITM-10312779","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA PPO","253.26","80.4","","1261.44","103.12","1514.10","21","164.62","257.42","percent of total billed charges",""
"K-WIRE THREADED BLUNT","SUP-ITM-10312779","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","1365.00","1365.00","1365.00","1 through 10","164.62","257.42","percent of total billed charges",""
"K-WIRE THREADED BLUNT","SUP-ITM-10312779","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","257.42","81.72","","5157.68","5157.68","5157.68","1 through 10","164.62","257.42","percent of total billed charges",""
"K-WIRE THREADED BLUNT","SUP-ITM-10312779","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","431.26","71.26","1459.57","88","164.62","257.42","percent of total billed charges",""
"Kcl Inj of Ectopic Pregnancy (Incl Img Guidance)","PX-76002994","CDM","59897","CPT","0761","RC","","","","both","","","4025.00","3018.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2145.33","53.3","","3658.50","3658.50","3658.50","1 through 10","226.96","3199.88","percent of total billed charges",""
"Kcl Inj of Ectopic Pregnancy (Incl Img Guidance)","PX-76002994","CDM","59897","CPT","0761","RC","","","","outpatient","","","4025.00","3018.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3289.23","81.72","","6095.22","6095.22","6095.22","1 through 10","1234.13","3320.63","percent of total billed charges",""
"Kcl Intracardiac Inj of Fetus (Incl Img Guidance), Other Than Mpr","PX-36000499","CDM","59897","CPT","0361","RC","","","","both","","","4137.00","3102.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2205.02","53.3","","3658.50","3658.50","3658.50","1 through 10","226.96","3288.92","percent of total billed charges",""
"Kcl Intracardiac Inj of Fetus (Incl Img Guidance), Other Than Mpr","PX-36000499","CDM","59897","CPT","0361","RC","","","","outpatient","","","4137.00","3102.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3380.76","81.72","","6095.22","6095.22","6095.22","1 through 10","1234.13","3413.03","percent of total billed charges",""
"Ketone Body Metabolism Deficiency Nextgen Dna Sequencing Panel (8 Genes)","PX-31000809","CDM","81479","CPT","0310","RC","","","","both","","","1922.00","1441.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1527.99","79.5","","0.65","0.65","0.65","1 through 10","595.82","1825.9","percent of total billed charges",""
"Ketone Body Metabolism Deficiency Nextgen Dna Sequencing Panel (8 Genes)","PX-31000809","CDM","81479","CPT","0310","RC","","","","both","","","1922.00","1441.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1024.43","53.3","","0.79","0.79","0.79","1 through 10","595.82","1825.9","percent of total billed charges",""
"Ketone Body Metabolism Deficiency Nextgen Dna Sequencing Panel (8 Genes)","PX-31000809","CDM","81479","CPT","0310","RC","","","","outpatient","","","1922.00","1441.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","961.00","50","","1.00","1.00","1.00","1 through 10","156.55","1585.65","percent of total billed charges",""
"Ketone Body Metabolism Deficiency Nextgen Dna Sequencing Panel (8 Genes)","PX-31000809","CDM","81479","CPT","0310","RC","","","","outpatient","","","1922.00","1441.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1009.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","1585.65","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.27","2.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2.13","65","","1.70","1.38","1.72","1 through 10","0.3","2.52","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.27","2.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1.25","38.3","","1.08","0.85","4.08","20","0.3","2.52","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.27","2.45","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2.52","77","","1.81","1.81","1.81","1 through 10","0.3","2.52","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.27","2.45","TRICARE [160005]","HB BWH TRICARE","0.33","","APC Price ($0.35). Final payment is multiplied by 95%.","0.50","0.35","0.75","24","0.3","2.52","other","Tricare OPPS"
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.27","2.45","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","0.30","","APC Price ($0.30). Final payment is multiplied by 98%.","0.49","0.34","0.74","121","0.3","2.52","other","OPPS APC"
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","outpatient","","","3.27","2.45","AETNA [1001]","HB AMC AETNA HMO","2.28","69.8","","2.83","1.19","7.10","22","0.57","2.63","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","outpatient","","","3.27","2.45","AETNA [1001]","HB AMC AETNA PPO","2.63","80.4","","1.07","1.03","1.07","1 through 10","0.57","2.63","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","outpatient","","","3.27","2.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2.29","69.9","","1.82","1.40","1.96","1 through 10","0.57","2.63","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","outpatient","","","3.27","2.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2.63","80.4","","2.03","1.31","2.06","1 through 10","0.57","2.63","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","outpatient","","","3.27","2.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2.29","69.9","","2.06","0.22","2.06","1 through 10","0.57","2.63","percent of total billed charges",""
"Ketosteroids (17-Ks) Total","PX-30000535","CDM","83586","CPT","0301","RC","","","","outpatient","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","152.82","81.72","","144.69","144.69","144.69","1 through 10","13.2","152.82","percent of total billed charges",""
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","92902.55","69676.91","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","17585.50","","Case rate ($17,073.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,475.47, add-ons for qualifying new technology services are included. If operating cost exceeds $66,119.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,912.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $15,220.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,095.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,472.53. The transfer capital threshold is the transfer adjustment factor * $1,472.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17400.04","17392.17","17404.04","1 through 10","16731.83","27587.8571","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","92902.55","69676.91","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","17073.30","","Case rate ($17,073.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,475.47, add-ons for qualifying new technology services are included. If operating cost exceeds $66,119.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,912.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $15,220.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,095.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,472.53. The transfer capital threshold is the transfer adjustment factor * $1,472.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16725.03","16674.73","21522.66","1 through 10","16731.83","27587.8571","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","92902.55","69676.91","FALLON HEALTH [1008]","HB BWH MEDICARE","17073.30","","Case rate ($17,073.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,475.47, add-ons for qualifying new technology services are included. If operating cost exceeds $66,119.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,912.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $15,220.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,095.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,472.53. The transfer capital threshold is the transfer adjustment factor * $1,472.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16871.35","16871.35","16871.35","1 through 10","16731.83","27587.8571","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","92902.55","69676.91","HUMANA [1012]","HB BWH MEDICARE","17073.30","","Case rate ($17,073.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,475.47, add-ons for qualifying new technology services are included. If operating cost exceeds $66,119.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,912.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $15,220.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,095.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,472.53. The transfer capital threshold is the transfer adjustment factor * $1,472.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16618.74","16618.74","16618.74","1 through 10","16731.83","27587.8571","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","92902.55","69676.91","MEDICARE [2001]","HB BWH MEDICARE","17073.30","","Case rate ($17,073.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,475.47, add-ons for qualifying new technology services are included. If operating cost exceeds $66,119.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,912.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $15,220.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,095.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,472.53. The transfer capital threshold is the transfer adjustment factor * $1,472.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21830.02","21830.02","21862.26","33","16731.83","27587.8571","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","92902.55","69676.91","MOLINA [1014]","HB BWH MOLINA","16731.83","","Case rate ($17,073.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,475.47, add-ons for qualifying new technology services are included. If operating cost exceeds $66,119.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,912.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $15,220.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,095.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,472.53. The transfer capital threshold is the transfer adjustment factor * $1,472.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","33513.74","33513.74","33513.74","1 through 10","16731.83","27587.8571","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","92902.55","69676.91","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16731.83","","Case rate ($17,073.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,475.47, add-ons for qualifying new technology services are included. If operating cost exceeds $66,119.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,912.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $15,220.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,095.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,472.53. The transfer capital threshold is the transfer adjustment factor * $1,472.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16561.57","16557.93","16578.03","1 through 10","16731.83","27587.8571","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","92902.55","69676.91","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16731.83","","Case rate ($17,073.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,475.47, add-ons for qualifying new technology services are included. If operating cost exceeds $66,119.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,912.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $15,220.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,095.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,472.53. The transfer capital threshold is the transfer adjustment factor * $1,472.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16619.21","16619.21","16620.99","1 through 10","16731.83","27587.8571","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm With McC","656","MS-DRG","","","","","","","","inpatient","","","189338.36","142003.77","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","30305.48","","Case rate ($29,422.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,341.84, add-ons for qualifying new technology services are included. If operating cost exceeds $80,986.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,002.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $26,481.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,962.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,561.87. The transfer capital threshold is the transfer adjustment factor * $2,561.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","30799.17","30799.17","30799.17","1 through 10","28834.34","49166.478","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm With McC","656","MS-DRG","","","","","","","","inpatient","","","189338.36","142003.77","MEDICARE [2001]","HB BWH MEDICARE","29422.80","","Case rate ($29,422.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,341.84, add-ons for qualifying new technology services are included. If operating cost exceeds $80,986.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,002.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $26,481.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,962.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,561.87. The transfer capital threshold is the transfer adjustment factor * $2,561.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38732.68","0.03","38744.80","1 through 10","28834.34","49166.478","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Neoplasm With McC","656","MS-DRG","","","","","","","","inpatient","","","189338.36","142003.77","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28834.34","","Case rate ($29,422.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,341.84, add-ons for qualifying new technology services are included. If operating cost exceeds $80,986.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,002.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $26,481.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,962.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,561.87. The transfer capital threshold is the transfer adjustment factor * $2,561.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","29286.69","29286.69","29286.69","1 through 10","28834.34","49166.478","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm With McC","656","MS-DRG","","","","","","","","inpatient","","","189338.36","142003.77","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28834.34","","Case rate ($29,422.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,341.84, add-ons for qualifying new technology services are included. If operating cost exceeds $80,986.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,002.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $26,481.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,962.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,561.87. The transfer capital threshold is the transfer adjustment factor * $2,561.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","29374.98","29374.98","29374.98","1 through 10","28834.34","49166.478","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm Without Cc/McC","658","MS-DRG","","","","","","","","inpatient","","","83784.80","62838.60","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","14971.59","","Case rate ($14,535.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,420.49, add-ons for qualifying new technology services are included. If operating cost exceeds $63,064.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,688.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $12,907.01 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,040.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,248.67. The transfer capital threshold is the transfer adjustment factor * $1,248.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14357.02","14357.02","14357.02","1 through 10","14244.81","22696.864","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm Without Cc/McC","658","MS-DRG","","","","","","","","inpatient","","","83784.80","62838.60","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","18751.48","","Case rate ($18,751.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,420.49, add-ons for qualifying new technology services are included. If operating cost exceeds $63,064.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,688.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $17,122.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,040.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,248.67. The transfer capital threshold is the transfer adjustment factor * $1,248.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13778.75","13778.75","13778.75","1 through 10","14244.81","22696.864","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm Without Cc/McC","658","MS-DRG","","","","","","","","inpatient","","","83784.80","62838.60","MEDICARE [2001]","HB BWH MEDICARE","18751.48","","Case rate ($18,751.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,420.49, add-ons for qualifying new technology services are included. If operating cost exceeds $63,064.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,688.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $17,122.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,040.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,248.67. The transfer capital threshold is the transfer adjustment factor * $1,248.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18009.17","18009.17","18035.69","13","14244.81","22696.864","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm Without Cc/McC","658","MS-DRG","","","","","","","","inpatient","","","83784.80","62838.60","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","18751.48","","Case rate ($18,751.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,420.49, add-ons for qualifying new technology services are included. If operating cost exceeds $63,064.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,688.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $17,122.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,040.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,248.67. The transfer capital threshold is the transfer adjustment factor * $1,248.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13676.21","13676.21","13676.21","1 through 10","14244.81","22696.864","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm Without Cc/McC","658","MS-DRG","","","","","","","","inpatient","","","83784.80","62838.60","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14244.81","","Case rate ($14,535.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,420.49, add-ons for qualifying new technology services are included. If operating cost exceeds $63,064.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,688.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $12,907.01 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,040.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,248.67. The transfer capital threshold is the transfer adjustment factor * $1,248.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18362.94","18362.94","18362.94","1 through 10","14244.81","22696.864","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","75437.01","56577.76","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","12809.62","","Case rate ($12,436.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,893.71, add-ons for qualifying new technology services are included. If operating cost exceeds $60,538.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,503.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,993.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,513.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,063.52. The transfer capital threshold is the transfer adjustment factor * $1,063.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12820.14","12820.14","12820.14","1 through 10","12187.79","20221.94","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","75437.01","56577.76","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","16027.34","","Case rate ($16,027.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,893.71, add-ons for qualifying new technology services are included. If operating cost exceeds $60,538.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,503.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $14,583.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,513.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,063.52. The transfer capital threshold is the transfer adjustment factor * $1,063.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12306.13","12306.13","12306.13","1 through 10","12187.79","20221.94","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","75437.01","56577.76","MEDICARE [2001]","HB BWH MEDICARE","16027.34","","Case rate ($16,027.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,893.71, add-ons for qualifying new technology services are included. If operating cost exceeds $60,538.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,503.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $14,583.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,513.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,063.52. The transfer capital threshold is the transfer adjustment factor * $1,063.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16075.74","0.03","16099.37","34","12187.79","20221.94","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","75437.01","56577.76","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12187.79","","Case rate ($12,436.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,893.71, add-ons for qualifying new technology services are included. If operating cost exceeds $60,538.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,503.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $10,993.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,513.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,063.52. The transfer capital threshold is the transfer adjustment factor * $1,063.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12192.26","12192.22","12302.75","1 through 10","12187.79","20221.94","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","96645.23","72483.92","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","24264.93","","Case rate ($23,558.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,282.01, add-ons for qualifying new technology services are included. If operating cost exceeds $73,926.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,484.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $21,133.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,902.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,044.56. The transfer capital threshold is the transfer adjustment factor * $2,044.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","16986.47","16986.47","16986.47","1 through 10","23087.02","38999.6713","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","96645.23","72483.92","FALLON HEALTH [1008]","HB BWH MEDICARE","23558.18","","Case rate ($23,558.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,282.01, add-ons for qualifying new technology services are included. If operating cost exceeds $73,926.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,484.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $21,133.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,902.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,044.56. The transfer capital threshold is the transfer adjustment factor * $2,044.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23767.59","23767.59","23767.59","1 through 10","23087.02","38999.6713","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","96645.23","72483.92","HUMANA [1012]","HB BWH MEDICARE","23558.18","","Case rate ($23,558.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,282.01, add-ons for qualifying new technology services are included. If operating cost exceeds $73,926.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,484.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $21,133.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,902.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,044.56. The transfer capital threshold is the transfer adjustment factor * $2,044.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23282.85","23282.85","23282.85","1 through 10","23087.02","38999.6713","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","96645.23","72483.92","MEDICARE [2001]","HB BWH MEDICARE","23558.18","","Case rate ($23,558.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,282.01, add-ons for qualifying new technology services are included. If operating cost exceeds $73,926.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,484.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $21,133.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,902.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,044.56. The transfer capital threshold is the transfer adjustment factor * $2,044.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30744.99","0.03","30790.56","22","23087.02","38999.6713","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","96645.23","72483.92","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","23087.02","","Case rate ($23,558.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,282.01, add-ons for qualifying new technology services are included. If operating cost exceeds $73,926.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,484.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $21,133.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,902.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,044.56. The transfer capital threshold is the transfer adjustment factor * $2,044.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","206115.77","206115.77","206115.77","1 through 10","23087.02","38999.6713","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","96645.23","72483.92","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","23087.02","","Case rate ($23,558.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,282.01, add-ons for qualifying new technology services are included. If operating cost exceeds $73,926.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,484.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $21,133.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,902.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,044.56. The transfer capital threshold is the transfer adjustment factor * $2,044.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19302.83","19302.83","19302.83","1 through 10","23087.02","38999.6713","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","96645.23","72483.92","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","23087.02","","Case rate ($23,558.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,282.01, add-ons for qualifying new technology services are included. If operating cost exceeds $73,926.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,484.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $21,133.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,902.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,044.56. The transfer capital threshold is the transfer adjustment factor * $2,044.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","23260.46","23260.46","72873.80","1 through 10","23087.02","38999.6713","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC","661","MS-DRG","","","","","","","","inpatient","","","62535.51","46901.63","MEDICARE [2001]","HB BWH MEDICARE","9824.87","","Case rate ($9,824.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,749.80, add-ons for qualifying new technology services are included. If operating cost exceeds $57,394.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,273.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,611.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,369.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.14. The transfer capital threshold is the transfer adjustment factor * $833.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6037.10","1142.35","12381.03","1 through 10","9628.37","15492.4206","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC","661","MS-DRG","","","","","","","","inpatient","","","62535.51","46901.63","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","9824.87","","Case rate ($9,824.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,749.80, add-ons for qualifying new technology services are included. If operating cost exceeds $57,394.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,273.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,611.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,369.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.14. The transfer capital threshold is the transfer adjustment factor * $833.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9422.09","9422.09","9422.09","1 through 10","9628.37","15492.4206","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC","661","MS-DRG","","","","","","","","inpatient","","","62535.51","46901.63","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9628.37","","Case rate ($9,824.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,749.80, add-ons for qualifying new technology services are included. If operating cost exceeds $57,394.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,273.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,611.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,369.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $833.14. The transfer capital threshold is the transfer adjustment factor * $833.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9448.51","9448.51","9448.51","1 through 10","9628.37","15492.4206","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","60621.66","45466.24","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","10964.21","","Case rate ($10,964.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,121.35, add-ons for qualifying new technology services are included. If operating cost exceeds $58,765.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,373.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,650.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,741.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $933.65. The transfer capital threshold is the transfer adjustment factor * $933.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13858.31","13858.31","13858.31","1 through 10","10744.93","17660.9973","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","60621.66","45466.24","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","8748.48","8748.48","8748.48","1 through 10","10744.93","17660.9973","case rate",""
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","60621.66","45466.24","HUMANA [1012]","HB BWH MEDICARE","10964.21","","Case rate ($10,964.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,121.35, add-ons for qualifying new technology services are included. If operating cost exceeds $58,765.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,373.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,650.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,741.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $933.65. The transfer capital threshold is the transfer adjustment factor * $933.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10730.12","10730.12","10730.12","1 through 10","10744.93","17660.9973","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","60621.66","45466.24","MEDICARE [2001]","HB BWH MEDICARE","10964.21","","Case rate ($10,964.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,121.35, add-ons for qualifying new technology services are included. If operating cost exceeds $58,765.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,373.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,650.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,741.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $933.65. The transfer capital threshold is the transfer adjustment factor * $933.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14075.13","0.03","14095.77","55","10744.93","17660.9973","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","60621.66","45466.24","MOLINA [1014]","HB BWH MOLINA","10744.93","","Case rate ($10,964.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,121.35, add-ons for qualifying new technology services are included. If operating cost exceeds $58,765.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,373.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,650.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,741.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $933.65. The transfer capital threshold is the transfer adjustment factor * $933.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","147120.87","147120.87","147120.87","1 through 10","10744.93","17660.9973","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","60621.66","45466.24","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","10744.93","","Case rate ($10,964.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,121.35, add-ons for qualifying new technology services are included. If operating cost exceeds $58,765.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,373.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,650.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,741.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $933.65. The transfer capital threshold is the transfer adjustment factor * $933.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","35418.19","35418.19","35418.19","1 through 10","10744.93","17660.9973","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","60621.66","45466.24","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10744.93","","Case rate ($10,964.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,121.35, add-ons for qualifying new technology services are included. If operating cost exceeds $58,765.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,373.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,650.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,741.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $933.65. The transfer capital threshold is the transfer adjustment factor * $933.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10789.16","10743.87","10824.75","1 through 10","10744.93","17660.9973","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","36975.54","27731.65","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7997.11","","Case rate ($7,764.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,269.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,913.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,091.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,732.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,889.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.37. The transfer capital threshold is the transfer adjustment factor * $651.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7800.09","7800.09","7822.20","1 through 10","7608.9","12680.01","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","36975.54","27731.65","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9963.45","","Case rate ($9,963.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,269.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,913.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,091.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,932.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,889.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.37. The transfer capital threshold is the transfer adjustment factor * $651.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7597.18","7597.18","7597.18","1 through 10","7608.9","12680.01","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","36975.54","27731.65","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","9705.23","","Case rate ($7,764.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,269.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,913.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,091.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,732.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,889.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.37. The transfer capital threshold is the transfer adjustment factor * $651.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","7597.18","7597.18","7597.18","1 through 10","7608.9","12680.01","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","36975.54","27731.65","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7764.18","","Case rate ($7,764.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,269.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,913.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,091.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,732.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,889.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.37. The transfer capital threshold is the transfer adjustment factor * $651.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7445.50","7445.50","7476.40","1 through 10","7608.9","12680.01","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","36975.54","27731.65","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","9963.45","","Case rate ($9,963.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,269.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,913.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,091.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,932.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,889.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.37. The transfer capital threshold is the transfer adjustment factor * $651.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","58281.13","58281.13","58281.13","1 through 10","7608.9","12680.01","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","36975.54","27731.65","HUMANA [1012]","HB BWH MEDICARE","9963.45","","Case rate ($9,963.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,269.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,913.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,091.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,932.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,889.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.37. The transfer capital threshold is the transfer adjustment factor * $651.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7449.36","7449.36","7449.36","1 through 10","7608.9","12680.01","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","36975.54","27731.65","MEDICARE [2001]","HB BWH MEDICARE","9963.45","","Case rate ($9,963.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,269.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,913.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,091.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,932.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,889.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.37. The transfer capital threshold is the transfer adjustment factor * $651.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9740.27","0.03","9754.43","81","7608.9","12680.01","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","36975.54","27731.65","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7608.90","","Case rate ($7,764.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,269.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,913.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,091.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,732.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,889.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.37. The transfer capital threshold is the transfer adjustment factor * $651.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7435.65","7425.99","7499.77","1 through 10","7608.9","12680.01","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","36975.54","27731.65","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7608.90","","Case rate ($7,764.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,269.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,913.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,091.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,732.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,889.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $651.37. The transfer capital threshold is the transfer adjustment factor * $651.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7437.45","7411.98","7470.97","1 through 10","7608.9","12680.01","other","Inpatient DRG"
"Kidney And Urinary Tract Infections,EXTREME","463","DRG","","","","","","","","inpatient","","","97708.01","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","38957.97","","Standard inlier is a Case rate ($38,957.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,942, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,530.32) for the length of stay and the standard reimbursement.","38957.96","38957.96","38957.96","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,EXTREME","463","DRG","","","","","","","","inpatient","","","97708.01","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","43799.26","","Standard inlier is a Case rate ($43,799.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,942, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,216.94) for the length of stay and the standard reimbursement.","28153.54","28153.54","28153.54","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,EXTREME","463","DRG","","","","","","","","inpatient","","","97708.01","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11337.8323","","Fee schedule rate ($44,586.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11337.8323","44586.36","44586.36","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,EXTREME","463","DRG","","","","","","","","inpatient","","","97708.01","","MASSHEALTH [3001]","HB BWH MEDICAID","13863.75","","Case rate ($15,328.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,758.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8748.48","8748.48","8748.48","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","43631.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","18647.82","","Standard inlier is a Case rate ($18,647.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,149, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,647.17) for the length of stay and the standard reimbursement.","25041.63","25041.63","25041.63","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","43631.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","20965.18","","Standard inlier is a Case rate ($20,965.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,149, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,975.83) for the length of stay and the standard reimbursement.","28153.54","28153.54","50025.48","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","43631.44","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","11905.0534","","Fee schedule rate ($22,959.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11905.0534","19382.66","19382.66","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","43631.44","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11337.8323","","Fee schedule rate ($21,865.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11337.8323","21865.96","21865.98","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","43631.44","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11905.0534","","Fee schedule rate ($22,959.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11905.0534","22959.92","22959.92","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","43631.44","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","26976.87","","Fee schedule rate ($26,976.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27332.72","27332.72","27332.72","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","43631.44","","MASSHEALTH [3001]","HB BWH MEDICAID","5227.47","","Case rate ($5,779.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,209.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8748.48","1201.70","8748.48","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","43631.44","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","5227.47","","Case rate ($5,779.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,209.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","43631.44","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17548.89","","Fee schedule rate ($17,548.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17548.89","17548.89","17548.89","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","43631.44","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18426.39","","Fee schedule rate ($18,426.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18426.39","18426.39","18426.39","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","43631.44","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5227.47","","Case rate ($5,779.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,209.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8748.48","8748.48","8748.48","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MINOR","463","DRG","","","","","","","","inpatient","","","33168.86","","MASSHEALTH [3001]","HB BWH MEDICAID","4162.78","","Case rate ($4,602.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,032.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4601.54","4601.54","4601.54","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MINOR","463","DRG","","","","","","","","inpatient","","","33168.86","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16754.58","","Fee schedule rate ($16,754.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2396), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11709.59","11709.59","11709.59","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MINOR","463","DRG","","","","","","","","inpatient","","","33168.86","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4162.78","","Case rate ($4,602.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,032.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4877.63","4877.63","4877.63","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","36062.18","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","18647.82","","Standard inlier is a Case rate ($18,647.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,149, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,647.17) for the length of stay and the standard reimbursement.","16998.16","14918.25","18647.82","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","36062.18","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","20965.18","","Standard inlier is a Case rate ($20,965.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,149, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,975.83) for the length of stay and the standard reimbursement.","19153.49","19153.49","25720.69","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","36062.18","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","6564.66","6564.66","6564.66","1 through 10","4162.78","73568.42","percent of total billed charges",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","36062.18","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11337.8323","","Fee schedule rate ($14,292.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11337.8323","21865.96","21865.96","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","36062.18","","MASSHEALTH [3001]","HB BWH MEDICAID","5227.47","","Case rate ($5,779.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,209.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5778.45","5778.45","6012.58","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","36062.18","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14352.64","","Fee schedule rate ($14,352.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14352.64","14352.64","14352.64","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","36062.18","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5227.47","","Case rate ($5,779.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,209.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5778.44","5778.44","5778.44","1 through 10","4162.78","73568.42","case rate",""
"Kidney And Urinary Tract Malignancy,MAJOR","461","DRG","","","","","","","","inpatient","","","41932.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","26386.45","","Standard inlier is a Case rate ($26,386.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,900, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,745.34) for the length of stay and the standard reimbursement.","38188.91","38188.91","38188.91","1 through 10","6430.38","99332.5","case rate",""
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","","","","inpatient","","","41932.46","31449.34","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9937.98","","Case rate ($9,937.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,885.95, add-ons for qualifying new technology services are included. If operating cost exceeds $57,530.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,283.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,715.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,506.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $843.12. The transfer capital threshold is the transfer adjustment factor * $843.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9746.90","9746.90","9746.90","1 through 10","9739.22","15886.2957","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","","","","inpatient","","","41932.46","31449.34","MEDICARE [2001]","HB BWH MEDICARE","9937.98","","Case rate ($9,937.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,885.95, add-ons for qualifying new technology services are included. If operating cost exceeds $57,530.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,283.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,715.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,506.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $843.12. The transfer capital threshold is the transfer adjustment factor * $843.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12688.73","12688.73","12688.73","1 through 10","9739.22","15886.2957","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","","","","inpatient","","","41932.46","31449.34","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9739.22","","Case rate ($9,937.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,885.95, add-ons for qualifying new technology services are included. If operating cost exceeds $57,530.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,283.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,715.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,506.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $843.12. The transfer capital threshold is the transfer adjustment factor * $843.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9681.81","9681.81","9681.81","1 through 10","9739.22","15886.2957","other","Inpatient DRG"
"Kidney And Urinary Tract Neoplasms With McC","686","MS-DRG","","","","","","","","inpatient","","","116575.28","87431.46","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","16833.38","","Case rate ($16,833.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,186.66, add-ons for qualifying new technology services are included. If operating cost exceeds $65,831.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,891.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,002.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,806.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.36. The transfer capital threshold is the transfer adjustment factor * $1,451.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","80934.15","80934.15","80934.15","1 through 10","16496.71","28253.16","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Neoplasms With McC","686","MS-DRG","","","","","","","","inpatient","","","116575.28","87431.46","MEDICARE [2001]","HB BWH MEDICARE","16833.38","","Case rate ($16,833.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,186.66, add-ons for qualifying new technology services are included. If operating cost exceeds $65,831.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,891.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,002.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,806.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.36. The transfer capital threshold is the transfer adjustment factor * $1,451.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22542.34","0.03","22542.34","1 through 10","16496.71","28253.16","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Neoplasms With McC","686","MS-DRG","","","","","","","","inpatient","","","116575.28","87431.46","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16496.71","","Case rate ($16,833.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,186.66, add-ons for qualifying new technology services are included. If operating cost exceeds $65,831.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,891.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,002.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,806.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.36. The transfer capital threshold is the transfer adjustment factor * $1,451.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17046.42","17046.42","17046.42","1 through 10","16496.71","28253.16","other","Inpatient DRG"
"Kidney And Urinary Tract Procedures For Malignancy,EXTREME","442","DRG","","","","","","","","inpatient","","","232534.69","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","129642.13","","Standard inlier is a Case rate ($129,642.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $112,463, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,403.48) for the length of stay and the standard reimbursement.","129642.13","129642.13","129642.13","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,EXTREME","442","DRG","","","","","","","","inpatient","","","232534.69","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","145752.70","","Standard inlier is a Case rate ($145,752.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $112,463, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,688.38) for the length of stay and the standard reimbursement.","133157.67","133157.67","133157.67","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MAJOR","442","DRG","","","","","","","","inpatient","","","150020.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","73999.44","","Standard inlier is a Case rate ($73,999.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $69,191, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,504.67) for the length of stay and the standard reimbursement.","75547.10","75547.10","75547.10","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MAJOR","442","DRG","","","","","","","","inpatient","","","150020.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","83195.32","","Standard inlier is a Case rate ($83,195.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $69,191, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,808.88) for the length of stay and the standard reimbursement.","76006.10","76006.10","83195.31","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MAJOR","442","DRG","","","","","","","","inpatient","","","150020.06","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","21009.25","","Case rate ($23,229.34). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,659.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21167.79","21167.79","21167.79","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MAJOR","442","DRG","","","","","","","","inpatient","","","150020.06","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","29363.3976","","Fee schedule rate ($63,658.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29363.3976","63658.72","63658.72","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MAJOR","442","DRG","","","","","","","","inpatient","","","150020.06","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","30832.4208","","Fee schedule rate ($66,843.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30832.4208","66843.52","66843.52","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MAJOR","442","DRG","","","","","","","","inpatient","","","150020.06","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","70025.44","","Fee schedule rate ($70,025.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","67327.34","67327.34","67327.34","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MAJOR","442","DRG","","","","","","","","inpatient","","","150020.06","","MASSHEALTH [3001]","HB BWH MEDICAID","21009.25","","Case rate ($23,229.34). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,659.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23223.64","23223.64","23223.64","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MINOR","442","DRG","","","","","","","","inpatient","","","90147.87","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","43860.86","","Standard inlier is a Case rate ($43,860.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,755, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,226.31) for the length of stay and the standard reimbursement.","43860.86","39980.77","43860.86","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MINOR","442","DRG","","","","","","","","inpatient","","","90147.87","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","49311.43","","Standard inlier is a Case rate ($49,311.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,755, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,999.35) for the length of stay and the standard reimbursement.","49311.43","49311.43","49311.43","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MINOR","442","DRG","","","","","","","","inpatient","","","90147.87","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","29363.3976","","Fee schedule rate ($29,363.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29363.3976","29363.40","35829.68","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MINOR","442","DRG","","","","","","","","inpatient","","","90147.87","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","30832.4208","","Fee schedule rate ($30,832.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30832.4208","30832.44","30832.44","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MINOR","442","DRG","","","","","","","","inpatient","","","90147.87","","MASSHEALTH [3001]","HB BWH MEDICAID","10746.24","","Case rate ($11,881.81). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,311.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11878.89","11878.89","11878.89","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MINOR","442","DRG","","","","","","","","inpatient","","","90147.87","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10746.24","","Case rate ($11,881.81). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,311.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16108.42","16108.42","16108.42","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MODERATE","442","DRG","","","","","","","","inpatient","","","87726.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","50933.84","","Standard inlier is a Case rate ($50,933.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $51,256, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,230.37) for the length of stay and the standard reimbursement.","46428.05","46428.05","50933.84","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MODERATE","442","DRG","","","","","","","","inpatient","","","87726.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","57263.36","","Standard inlier is a Case rate ($57,263.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $51,256, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,128.06) for the length of stay and the standard reimbursement.","52315.02","52315.02","57263.36","13","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MODERATE","442","DRG","","","","","","","","inpatient","","","87726.44","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","29363.3976","","Fee schedule rate ($63,658.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29363.3976","35829.68","35829.68","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MODERATE","442","DRG","","","","","","","","inpatient","","","87726.44","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","30832.4208","","Fee schedule rate ($66,843.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30832.4208","37622.24","37622.24","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MODERATE","442","DRG","","","","","","","","inpatient","","","87726.44","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74126.61","","Fee schedule rate ($74,126.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","49953.41","49953.41","49953.41","1 through 10","10746.24","262386.9","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,EXTREME","443","DRG","","","","","","","","inpatient","","","431869.52","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24766.9791","","Fee schedule rate ($128,077.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24766.9791","128077.92","128077.92","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MAJOR","443","DRG","","","","","","","","inpatient","","","96645.23","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","70676.57","","Standard inlier is a Case rate ($70,676.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $60,533, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,031.95) for the length of stay and the standard reimbursement.","12069.52","12069.52","12069.52","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MAJOR","443","DRG","","","","","","","","inpatient","","","96645.23","","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","","38.3","","73394.60","73394.60","73394.60","1 through 10","7718.97","211331.14","percent of total billed charges",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MAJOR","443","DRG","","","","","","","","inpatient","","","96645.23","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24766.9791","","Fee schedule rate ($53,938.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24766.9791","53938.04","53938.04","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MAJOR","443","DRG","","","","","","","","inpatient","","","96645.23","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","26006.0478","","Fee schedule rate ($56,636.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26006.0478","56636.48","56636.48","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MAJOR","443","DRG","","","","","","","","inpatient","","","96645.23","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","59332.55","","Fee schedule rate ($59,332.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","59332.55","59332.55","59332.55","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MAJOR","443","DRG","","","","","","","","inpatient","","","96645.23","","MASSHEALTH [3001]","HB BWH MEDICAID","20395.80","","Case rate ($22,551.07). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,981.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23459.03","23459.03","23459.03","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MINOR","443","DRG","","","","","","","","inpatient","","","88886.12","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","36920.49","","Standard inlier is a Case rate ($36,920.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,359, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,241.09) for the length of stay and the standard reimbursement.","33654.36","33654.36","33654.36","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MINOR","443","DRG","","","","","","","","inpatient","","","88886.12","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","41508.58","","Standard inlier is a Case rate ($41,508.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,359, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,891.80) for the length of stay and the standard reimbursement.","37921.66","37921.66","37921.66","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MINOR","443","DRG","","","","","","","","inpatient","","","88886.12","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","26006.05","","Fee schedule rate ($26,006.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26006.05","26006.05","26006.05","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MINOR","443","DRG","","","","","","","","inpatient","","","88886.12","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","27244.01","","Fee schedule rate ($27,244.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27244.01","27244.01","27244.01","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MINOR","443","DRG","","","","","","","","inpatient","","","88886.12","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10216.18","","Case rate ($11,295.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,725.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11292.97","11292.97","11292.97","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MODERATE","443","DRG","","","","","","","","inpatient","","","89217.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31839.71","","Standard inlier is a Case rate ($31,839.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,408, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,519.84) for the length of stay and the standard reimbursement.","128.35","128.35","38966.66","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MODERATE","443","DRG","","","","","","","","inpatient","","","89217.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35796.42","","Standard inlier is a Case rate ($35,796.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,408, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,081.00) for the length of stay and the standard reimbursement.","209.88","209.88","209.88","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MODERATE","443","DRG","","","","","","","","inpatient","","","89217.21","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24766.9791","","Fee schedule rate ($27,864.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24766.9791","27864.80","27864.80","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MODERATE","443","DRG","","","","","","","","inpatient","","","89217.21","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","26006.0478","","Fee schedule rate ($29,258.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26006.0478","29258.84","29258.84","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MODERATE","443","DRG","","","","","","","","inpatient","","","89217.21","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","34377.85","","Fee schedule rate ($34,377.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34831.32","34831.32","34831.32","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MODERATE","443","DRG","","","","","","","","inpatient","","","89217.21","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","50231.90","","Fee schedule rate ($50,231.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","46682.59","46682.59","46682.59","1 through 10","7718.97","211331.14","case rate",""
"Kidney And Urinary Tract Signs And Symptoms With McC","695","MS-DRG","","","","","","","","inpatient","","","41405.76","31054.32","MEDICARE [2001]","HB BWH MEDICARE","10813.70","","Case rate ($10,813.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,940.15, add-ons for qualifying new technology services are included. If operating cost exceeds $58,584.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,360.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,513.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,560.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.37. The transfer capital threshold is the transfer adjustment factor * $920.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13574.09","13574.09","13574.09","1 through 10","10597.43","17019.6298","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Signs And Symptoms Without McC","696","MS-DRG","","","","","","","","inpatient","","","19326.27","14494.70","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8536.86","","Case rate ($8,536.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,945.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,590.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,994.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,602.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,566.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $554.41. The transfer capital threshold is the transfer adjustment factor * $554.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6502.32","6502.32","6502.32","1 through 10","6531.67","10439.9538","other","Inpatient DRG"
"Kidney And Urinary Tract Signs And Symptoms Without McC","696","MS-DRG","","","","","","","","inpatient","","","19326.27","14494.70","MEDICARE [2001]","HB BWH MEDICARE","8536.86","","Case rate ($8,536.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,945.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,590.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,994.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,602.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,566.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $554.41. The transfer capital threshold is the transfer adjustment factor * $554.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8446.21","8446.21","8446.21","1 through 10","6531.67","10439.9538","other","Inpatient DRG"
"Kidney And Urinary Tract Signs And Symptoms Without McC","696","MS-DRG","","","","","","","","inpatient","","","19326.27","14494.70","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6531.67","","Case rate ($6,664.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,945.90, add-ons for qualifying new technology services are included. If operating cost exceeds $53,590.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,994.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,730.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,566.06 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $554.41. The transfer capital threshold is the transfer adjustment factor * $554.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6484.00","6484.00","6484.00","1 through 10","6531.67","10439.9538","other","Inpatient DRG"
"Kidney Transplant","652","MS-DRG","","","","","","","","inpatient","","","353890.33","265417.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","","","Payment is accumulated by days. Day 1 - 20, Case rate ($70,000). Day 21 - 9999, Per diem ($2,000).","234786.12","234786.12","478802.93","1 through 10","29242.9","85000","other","Kidney Transplant (Cadaver)"
"Kidney Transplant","652","MS-DRG","","","","","","","","inpatient","","","353890.33","265417.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","37299.61","","Case rate ($29,839.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,843.68, add-ons for qualifying new technology services are included. If operating cost exceeds $81,488.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,038.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $26,861.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,463.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,598.65. The transfer capital threshold is the transfer adjustment factor * $2,598.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","28226.80","28226.80","28226.80","1 through 10","29242.9","85000","other","Inpatient DRG"
"Kidney Transplant","652","MS-DRG","","","","","","","","inpatient","","","353890.33","265417.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","85000.00","","Case rate ($85,000). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($283,322), then multiplying the difference by the percent of outlier that is reimbursed (60%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","170520.86","170520.86","170520.86","1 through 10","29242.9","85000","case rate",""
"Kidney Transplant","652","MS-DRG","","","","","","","","inpatient","","","353890.33","265417.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","","65","","175998.87","175998.87","175998.87","1 through 10","29242.9","85000","percent of total billed charges",""
"Kidney Transplant","652","MS-DRG","","","","","","","","inpatient","","","353890.33","265417.75","MEDICARE [2001]","HB BWH MEDICARE","38613.66","","Case rate ($38,613.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,843.68, add-ons for qualifying new technology services are included. If operating cost exceeds $81,488.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,038.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $35,635.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,463.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,598.65. The transfer capital threshold is the transfer adjustment factor * $2,598.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36541.65","36487.50","37706.61","1 through 10","29242.9","85000","other","Inpatient DRG"
"Kidney Transplant","652","MS-DRG","","","","","","","","inpatient","","","353890.33","265417.75","WELLPOINT [1015]","HB AMC WELLPOINT","46350.4974","","Fee schedule rate ($50,586.89).","46350.4974","205037.13","205037.13","1 through 10","29242.9","85000","case rate",""
"Kidney Transplant With Hemodialysis With McC","650","MS-DRG","","","","","","","","inpatient","","","443572.24","332679.18","MEDICARE [2001]","HB BWH MEDICARE","43266.50","","Case rate ($43,266.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $52,006.93, add-ons for qualifying new technology services are included. If operating cost exceeds $97,651.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,223.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $39,103.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,627.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,783.02. The transfer capital threshold is the transfer adjustment factor * $3,783.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","54675.70","54594.46","128783.70","1 through 10","42401.17","69528.7643","other","Inpatient Replacement Plans DRG"
"Kidney Transplant With Hemodialysis Without McC","651","MS-DRG","","","","","","","","inpatient","","","302533.35","226900.01","MEDICARE [2001]","HB BWH MEDICARE","44252.53","","Case rate ($44,252.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,074.03, add-ons for qualifying new technology services are included. If operating cost exceeds $86,718.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,422.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $40,890.79 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $40,694.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,981.90. The transfer capital threshold is the transfer adjustment factor * $2,981.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","41216.13","41216.13","41216.13","1 through 10","33500.85","52403.4975","other","Inpatient DRG"
"Kidney Transplant,EXTREME","440","DRG","","","","","","","","inpatient","","","746689.54","","MASSHEALTH [3001]","HB BWH MEDICAID","107144.79","","Case rate ($118,466.99). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $160,896.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","166953.61","166953.61","166953.61","1 through 10","79243.64","306652.97","case rate",""
"Kidney Transplant,MAJOR","440","DRG","","","","","","","","inpatient","","","400961.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","179790.09","","Standard inlier is a Case rate ($179,790.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $151,461, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($25,522.29) for the length of stay and the standard reimbursement.","179790.08","179790.08","179790.08","1 through 10","79243.64","306652.97","case rate",""
"Kidney Transplant,MAJOR","440","DRG","","","","","","","","inpatient","","","400961.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","202132.51","","Standard inlier is a Case rate ($202,132.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $151,461, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($28,691.03) for the length of stay and the standard reimbursement.","202132.51","184665.50","589059.97","1 through 10","79243.64","306652.97","case rate",""
"Kidney Transplant,MAJOR","440","DRG","","","","","","","","inpatient","","","400961.09","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","79251.00","","Case rate ($79,251). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($142,587), then multiplying the difference by the percent of outlier that is reimbursed (60%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","198523.45","198523.45","198523.45","1 through 10","79243.64","306652.97","case rate",""
"Kidney Transplant,MAJOR","440","DRG","","","","","","","","inpatient","","","400961.09","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112564.00","","Case rate ($112,564). Includes reimbursement for any outliers.","186914.88","186914.88","186914.88","1 through 10","79243.64","306652.97","case rate",""
"Kidney Transplant,MAJOR","440","DRG","","","","","","","","inpatient","","","400961.09","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","157265.00","","Case rate ($157,265). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($357,727), then multiplying the difference by the percent of outlier that is reimbursed (49.7%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","157265.00","157265.00","157265.00","1 through 10","79243.64","306652.97","case rate",""
"Kidney Transplant,MAJOR","440","DRG","","","","","","","","inpatient","","","400961.09","","MASSHEALTH [3001]","HB BWH MEDICAID","83366.44","","Case rate ($92,175.94). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $134,605.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","92153.31","92153.31","92153.31","1 through 10","79243.64","306652.97","case rate",""
"Kidney Transplant,MODERATE","440","DRG","","","","","","","","inpatient","","","348418.70","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","173360.84","","Standard inlier is a Case rate ($173,360.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $131,559, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($24,607.13) for the length of stay and the standard reimbursement.","158380.10","158380.10","158380.10","1 through 10","79243.64","306652.97","case rate",""
"Kidney Transplant,MODERATE","440","DRG","","","","","","","","inpatient","","","348418.70","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","103294.00","","Case rate ($103,294). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($208,971), then multiplying the difference by the percent of outlier that is reimbursed (43%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","144532.92","144532.92","144532.92","1 through 10","79243.64","306652.97","case rate",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","56250.00","42187.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","44718.75","79.5","","1309.77","674.56","6049.93","26","17437.5","44718.75","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","56250.00","42187.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","29981.25","53.3","","1901.83","1901.83","2962.25","1 through 10","17437.5","44718.75","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","56250.00","42187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20531.25","36.5","","1620.31","1620.31","19908.88","1 through 10","17437.5","44718.75","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","56250.00","42187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21543.75","38.3","","352.91","352.91","2046.30","1 through 10","17437.5","44718.75","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","56250.00","42187.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24131.25","42.9","","9668.75","9668.75","9668.75","1 through 10","17437.5","44718.75","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","56250.00","42187.50","WELLPOINT [1015]","HB AMC WELLPOINT","41501.25","73.78","","699.88","384.10","3443.31","33","17437.5","44718.75","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","56250.00","42187.50","AETNA [1001]","HB AMC AETNA HMO","39262.50","69.8","","1421.24","264.50","4933.46","29","29396.25","45967.5","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","56250.00","42187.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","45225.00","80.4","","1022.97","1022.97","3607.50","1 through 10","29396.25","45967.5","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","56250.00","42187.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","45967.50","81.72","","3010.54","693.88","5019.88","35","29396.25","45967.5","percent of total billed charges",""
"KIT 20CM EXTENSION NEUROSTIMULATOR STRETCH COIL SINGLE QUADRIPOLAR","SUP-ITM-10020718","CDM","C1883","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","760.11","36.5","","1073.15","1073.15","1073.15","1 through 10","645.58","1655.59","percent of total billed charges",""
"KIT 20CM EXTENSION NEUROSTIMULATOR STRETCH COIL SINGLE QUADRIPOLAR","SUP-ITM-10020718","CDM","C1883","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","797.60","38.3","","1808.38","1642.20","1808.38","1 through 10","645.58","1655.59","percent of total billed charges",""
"KIT 20CM EXTENSION NEUROSTIMULATOR STRETCH COIL SINGLE QUADRIPOLAR","SUP-ITM-10020718","CDM","C1883","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","WELLPOINT [1015]","HB AMC WELLPOINT","1536.47","73.78","","625.38","625.38","625.38","1 through 10","645.58","1655.59","percent of total billed charges",""
"KIT 3D MANDIBLE MIDFACE TRUMATCH TI PRINT ORBITAL WITHOUT PLAN","SUP-ITM-10284842","CDM","C1713","HCPCS","0278","RC","","","","both","","","10048.50","7536.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7988.56","79.5","","800.18","480.96","1887.97","195","3115.04","7988.56","percent of total billed charges",""
"KIT 3D MANDIBLE MIDFACE TRUMATCH TI PRINT ORBITAL WITHOUT PLAN","SUP-ITM-10284842","CDM","C1713","HCPCS","0278","RC","","","","both","","","10048.50","7536.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5355.85","53.3","","813.12","216.42","1444.50","81","3115.04","7988.56","percent of total billed charges",""
"KIT 3D MANDIBLE MIDFACE TRUMATCH TI PRINT ORBITAL WITHOUT PLAN","SUP-ITM-10284842","CDM","C1713","HCPCS","0278","RC","","","","both","","","10048.50","7536.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3115.04","31","","432.60","432.60","432.60","1 through 10","3115.04","7988.56","percent of total billed charges",""
"KIT 3D MANDIBLE MIDFACE TRUMATCH TI PRINT ORBITAL WITHOUT PLAN","SUP-ITM-10284842","CDM","C1713","HCPCS","0278","RC","","","","both","","","10048.50","7536.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3667.70","36.5","","148.37","54.89","631.39","94","3115.04","7988.56","percent of total billed charges",""
"KIT 3D MANDIBLE MIDFACE TRUMATCH TI PRINT ORBITAL WITHOUT PLAN","SUP-ITM-10284842","CDM","C1713","HCPCS","0278","RC","","","","both","","","10048.50","7536.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3848.58","38.3","","279.30","91.72","1116.77","266","3115.04","7988.56","percent of total billed charges",""
"KIT 3D MANDIBLE MIDFACE TRUMATCH TI PRINT ORBITAL WITHOUT PLAN","SUP-ITM-10284842","CDM","C1713","HCPCS","0278","RC","","","","both","","","10048.50","7536.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4310.81","42.9","","731.00","63.70","731.00","1 through 10","3115.04","7988.56","percent of total billed charges",""
"KIT 3D MANDIBLE MIDFACE TRUMATCH TI PRINT ORBITAL WITHOUT PLAN","SUP-ITM-10284842","CDM","C1713","HCPCS","0278","RC","","","","both","","","10048.50","7536.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4310.81","42.9","","384.74","384.74","384.74","1 through 10","3115.04","7988.56","percent of total billed charges",""
"KIT 3D MANDIBLE MIDFACE TRUMATCH TI PRINT ORBITAL WITHOUT PLAN","SUP-ITM-10284842","CDM","C1713","HCPCS","0278","RC","","","","both","","","10048.50","7536.37","WELLPOINT [1015]","HB AMC WELLPOINT","7413.78","73.78","","286.63","119.22","1107.45","105","3115.04","7988.56","percent of total billed charges",""
"KIT 3D MANDIBLE MIDFACE TRUMATCH TI PRINT ORBITAL WITHOUT PLAN","SUP-ITM-10284842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10048.50","7536.37","AETNA [1001]","HB AMC AETNA HMO","7013.85","69.8","","675.31","184.75","1721.50","286","5251.35","8211.63","percent of total billed charges",""
"KIT 3D MANDIBLE MIDFACE TRUMATCH TI PRINT ORBITAL WITHOUT PLAN","SUP-ITM-10284842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10048.50","7536.37","AETNA [1001]","HB AMC AETNA PPO","8078.99","80.4","","1261.44","103.12","1514.10","21","5251.35","8211.63","percent of total billed charges",""
"KIT 3D MANDIBLE MIDFACE TRUMATCH TI PRINT ORBITAL WITHOUT PLAN","SUP-ITM-10284842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10048.50","7536.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8078.99","80.4","","1365.00","1365.00","1365.00","1 through 10","5251.35","8211.63","percent of total billed charges",""
"KIT 3D MANDIBLE MIDFACE TRUMATCH TI PRINT ORBITAL WITHOUT PLAN","SUP-ITM-10284842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10048.50","7536.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8211.63","81.72","","5157.68","5157.68","5157.68","1 through 10","5251.35","8211.63","percent of total billed charges",""
"KIT 3D MANDIBLE MIDFACE TRUMATCH TI PRINT ORBITAL WITHOUT PLAN","SUP-ITM-10284842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10048.50","7536.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8211.63","81.72","","431.26","71.26","1459.57","88","5251.35","8211.63","percent of total billed charges",""
"KIT 60CM EXTENSION NEUROSTIMULATOR ACTIVA DISTAL QUADRIPOLAR PROXIMALIMAL OCTAPOLAR CONNECTOR","SUP-ITM-10079668","CDM","C1883","HCPCS","0278","RC","","","","both","","","2359.00","1769.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","861.04","36.5","","1073.15","1073.15","1073.15","1 through 10","731.29","1875.41","percent of total billed charges",""
"KIT 60CM EXTENSION NEUROSTIMULATOR ACTIVA DISTAL QUADRIPOLAR PROXIMALIMAL OCTAPOLAR CONNECTOR","SUP-ITM-10079668","CDM","C1883","HCPCS","0278","RC","","","","both","","","2359.00","1769.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","903.50","38.3","","1808.38","1642.20","1808.38","1 through 10","731.29","1875.41","percent of total billed charges",""
"KIT 60CM EXTENSION NEUROSTIMULATOR ACTIVA DISTAL QUADRIPOLAR PROXIMALIMAL OCTAPOLAR CONNECTOR","SUP-ITM-10079668","CDM","C1883","HCPCS","0278","RC","","","","both","","","2359.00","1769.25","WELLPOINT [1015]","HB AMC WELLPOINT","1740.47","73.78","","625.38","625.38","625.38","1 through 10","731.29","1875.41","percent of total billed charges",""
"KIT 60CM EXTENSION NEUROSTIMULATOR STRETCH COIL BIFURCATED QUADRIPOLAR","SUP-ITM-10018213","CDM","C1883","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1481.90","36.5","","1073.15","1073.15","1073.15","1 through 10","1258.6","3227.7","percent of total billed charges",""
"KIT 60CM EXTENSION NEUROSTIMULATOR STRETCH COIL BIFURCATED QUADRIPOLAR","SUP-ITM-10018213","CDM","C1883","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1554.98","38.3","","1808.38","1642.20","1808.38","1 through 10","1258.6","3227.7","percent of total billed charges",""
"KIT 60CM EXTENSION NEUROSTIMULATOR STRETCH COIL BIFURCATED QUADRIPOLAR","SUP-ITM-10018213","CDM","C1883","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","WELLPOINT [1015]","HB AMC WELLPOINT","2995.47","73.78","","625.38","625.38","625.38","1 through 10","1258.6","3227.7","percent of total billed charges",""
"KIT ACCESS ENDOAVF HYDROPHILIC SHEATH BX/5EA","SUP-ITM-10267944","CDM","C1892","HCPCS","0272","RC","","","","both","","","276.50","207.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.92","36.5","","66.97","66.97","66.97","1 through 10","85.72","219.82","percent of total billed charges",""
"KIT ACCESS ENDOAVF HYDROPHILIC SHEATH BX/5EA","SUP-ITM-10267944","CDM","C1892","HCPCS","0272","RC","","","","both","","","276.50","207.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.90","38.3","","70.21","44.61","70.21","1 through 10","85.72","219.82","percent of total billed charges",""
"KIT ACCESS ENDOAVF HYDROPHILIC SHEATH BX/5EA","SUP-ITM-10267944","CDM","C1892","HCPCS","0272","RC","","","","both","","","276.50","207.37","WELLPOINT [1015]","HB AMC WELLPOINT","204.00","73.78","","84.95","84.95","84.95","1 through 10","85.72","219.82","percent of total billed charges",""
"KIT ACCESS ENDOAVF HYDROPHILIC SHEATH BX/5EA","SUP-ITM-10267944","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","276.50","207.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","225.96","81.72","","91.21","50.17","91.21","1 through 10","144.5","225.96","percent of total billed charges",""
"KIT ACCESS ENDOAVF HYDROPHILIC SHEATH BX/5EA","SUP-ITM-10267944","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","276.50","207.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","225.96","81.72","","50.17","50.17","50.17","1 through 10","144.5","225.96","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","16.24","16.24","54.15","1 through 10","27.13","69.56","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","62.83","71.8","","86.33","32.67","86.33","1 through 10","27.13","69.56","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","61.25","70","","113.68","63.00","177.34","40","27.13","69.56","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","50.70","21.76","168.00","12","27.13","69.56","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.64","53.3","","89.31","89.31","99.75","1 through 10","27.13","69.56","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","56.88","65","","94.41","17.06","2275.00","1 through 10","27.13","69.56","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.13","31","","35.13","35.13","35.13","1 through 10","27.13","69.56","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","40.08","12.40","86.17","108","27.13","69.56","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","33.25","10.27","68.43","169","27.13","69.56","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","25.48","14.86","90.88","1 through 10","27.13","69.56","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","90.88","90.88","90.88","1 through 10","27.13","69.56","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","84.63","19.55","140.02","123","27.13","69.56","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","76.96","17.77","113.68","14","45.73","71.51","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","57.31","57.31","57.31","1 through 10","45.73","71.51","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","16.24","16.24","54.15","1 through 10","45.73","71.51","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","70.35","80.4","","68.25","68.25","87.50","1 through 10","45.73","71.51","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","71.51","81.72","","156.19","156.19","156.19","1 through 10","45.73","71.51","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","71.51","81.72","","82.70","12.06","98.97","13","45.73","71.51","percent of total billed charges",""
"KIT ACCESS MAK 5FR 40CM 7CM NITINOL TIP VASCULAR COAXIAL DILATOR GUIDEWIRE NON ECHOGENIC NEEDLE BX/10EA","SUP-ITM-10115666","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","50.47","25.30","134.30","140","45.73","71.51","percent of total billed charges",""
"KIT ACCESS UNIVERSAL BWF CS/5EA","SUP-ITM-10114456","CDM","C1751","HCPCS","0272","RC","","","","both","","","342.83","257.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","239.98","70","","1389.50","602.17","3167.85","27","106.28","272.55","percent of total billed charges",""
"KIT ACCESS UNIVERSAL BWF CS/5EA","SUP-ITM-10114456","CDM","C1751","HCPCS","0272","RC","","","","both","","","342.83","257.12","WELLPOINT [1015]","HB AMC WELLPOINT","252.94","73.78","","1089.20","218.86","1089.20","1 through 10","106.28","272.55","percent of total billed charges",""
"KIT ACCESS UNIVERSAL BWF CS/5EA","SUP-ITM-10114456","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","342.83","257.12","AETNA [1001]","HB AMC AETNA HMO","239.30","69.8","","1389.50","940.69","1389.50","1 through 10","179.16","280.16","percent of total billed charges",""
"KIT ACCESS UNIVERSAL BWF CS/5EA","SUP-ITM-10114456","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","342.83","257.12","AETNA [1001]","HB AMC AETNA PPO","275.64","80.4","","190.26","190.26","190.26","1 through 10","179.16","280.16","percent of total billed charges",""
"KIT ACCESS UNIVERSAL BWF CS/5EA","SUP-ITM-10114456","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","342.83","257.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","280.16","81.72","","1110.77","235.00","1169.52","1 through 10","179.16","280.16","percent of total billed charges",""
"KIT ACCESSORY 1X4 8 NEUROSTIMULATOR ANCHOR BOOT","SUP-ITM-10012055","CDM","C1883","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","1073.15","1073.15","1073.15","1 through 10","54.25","139.13","percent of total billed charges",""
"KIT ACCESSORY 1X4 8 NEUROSTIMULATOR ANCHOR BOOT","SUP-ITM-10012055","CDM","C1883","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","1808.38","1642.20","1808.38","1 through 10","54.25","139.13","percent of total billed charges",""
"KIT ACCESSORY 1X4 8 NEUROSTIMULATOR ANCHOR BOOT","SUP-ITM-10012055","CDM","C1883","HCPCS","0278","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","625.38","625.38","625.38","1 through 10","54.25","139.13","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","both","","","1015.00","761.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","530.44","52.26","","16.24","16.24","54.15","1 through 10","314.65","806.93","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","both","","","1015.00","761.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","728.77","71.8","","86.33","32.67","86.33","1 through 10","314.65","806.93","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","both","","","1015.00","761.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","710.50","70","","113.68","63.00","177.34","40","314.65","806.93","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","both","","","1015.00","761.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","806.93","79.5","","50.70","21.76","168.00","12","314.65","806.93","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","both","","","1015.00","761.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","541.00","53.3","","89.31","89.31","99.75","1 through 10","314.65","806.93","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","both","","","1015.00","761.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","659.75","65","","94.41","17.06","2275.00","1 through 10","314.65","806.93","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","314.65","31","","35.13","35.13","35.13","1 through 10","314.65","806.93","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","370.48","36.5","","40.08","12.40","86.17","108","314.65","806.93","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","388.75","38.3","","33.25","10.27","68.43","169","314.65","806.93","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","both","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","435.44","42.9","","25.48","14.86","90.88","1 through 10","314.65","806.93","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","both","","","1015.00","761.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","435.44","42.9","","90.88","90.88","90.88","1 through 10","314.65","806.93","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","both","","","1015.00","761.25","WELLPOINT [1015]","HB AMC WELLPOINT","748.87","73.78","","84.63","19.55","140.02","123","314.65","806.93","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1015.00","761.25","AETNA [1001]","HB AMC AETNA HMO","708.47","69.8","","76.96","17.77","113.68","14","530.44","829.46","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1015.00","761.25","AETNA [1001]","HB AMC AETNA PPO","816.06","80.4","","57.31","57.31","57.31","1 through 10","530.44","829.46","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1015.00","761.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","530.44","52.26","","16.24","16.24","54.15","1 through 10","530.44","829.46","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1015.00","761.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","816.06","80.4","","68.25","68.25","87.50","1 through 10","530.44","829.46","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1015.00","761.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","829.46","81.72","","156.19","156.19","156.19","1 through 10","530.44","829.46","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","829.46","81.72","","82.70","12.06","98.97","13","530.44","829.46","percent of total billed charges",""
"KIT ACCESSORY BRIDGE OCCLUSION BALLOON CATHETER PC/1EA","SUP-ITM-10212935","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","829.46","81.72","","50.47","25.30","134.30","140","530.44","829.46","percent of total billed charges",""
"KIT ACCESSORY CORD STIMULATOR SPINE A","SUP-ITM-10020900","CDM","C1883","HCPCS","0278","RC","","","","both","","","1137.50","853.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","415.19","36.5","","1073.15","1073.15","1073.15","1 through 10","352.63","904.31","percent of total billed charges",""
"KIT ACCESSORY CORD STIMULATOR SPINE A","SUP-ITM-10020900","CDM","C1883","HCPCS","0278","RC","","","","both","","","1137.50","853.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","435.66","38.3","","1808.38","1642.20","1808.38","1 through 10","352.63","904.31","percent of total billed charges",""
"KIT ACCESSORY CORD STIMULATOR SPINE A","SUP-ITM-10020900","CDM","C1883","HCPCS","0278","RC","","","","both","","","1137.50","853.12","WELLPOINT [1015]","HB AMC WELLPOINT","839.25","73.78","","625.38","625.38","625.38","1 through 10","352.63","904.31","percent of total billed charges",""
"KIT ACCESSORY PUMP AMS 700 TENACIO","SUP-ITM-10335089","CDM","C1813","HCPCS","0278","RC","","","","both","","","3071.25","2303.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1176.29","38.3","","12613.42","12613.42","12613.42","1 through 10","952.09","2441.64","percent of total billed charges",""
"KIT ACCESSORY PUMP AMS 700 TENACIO","SUP-ITM-10335089","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","3071.25","2303.44","AETNA [1001]","HB AMC AETNA HMO","2143.73","69.8","","34275.85","34275.85","50471.26","19","1605.04","2509.83","percent of total billed charges",""
"KIT ADAPTER 1.0X4.0IN POCKET 16 ELECTRODE NEUROSTIMULATORS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10050560","CDM","C1883","HCPCS","0278","RC","","","","both","","","1519.00","1139.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","554.44","36.5","","1073.15","1073.15","1073.15","1 through 10","470.89","1207.61","percent of total billed charges",""
"KIT ADAPTER 1.0X4.0IN POCKET 16 ELECTRODE NEUROSTIMULATORS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10050560","CDM","C1883","HCPCS","0278","RC","","","","both","","","1519.00","1139.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","581.78","38.3","","1808.38","1642.20","1808.38","1 through 10","470.89","1207.61","percent of total billed charges",""
"KIT ADAPTER 1.0X4.0IN POCKET 16 ELECTRODE NEUROSTIMULATORS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10050560","CDM","C1883","HCPCS","0278","RC","","","","both","","","1519.00","1139.25","WELLPOINT [1015]","HB AMC WELLPOINT","1120.72","73.78","","625.38","625.38","625.38","1 through 10","470.89","1207.61","percent of total billed charges",""
"KIT ADAPTER 2X4 27.4CM POCKET FOR SPINAL CORD STIMULATION - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10074337","CDM","C1883","HCPCS","0278","RC","","","","both","","","3038.00","2278.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1108.87","36.5","","1073.15","1073.15","1073.15","1 through 10","941.78","2415.21","percent of total billed charges",""
"KIT ADAPTER 2X4 27.4CM POCKET FOR SPINAL CORD STIMULATION - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10074337","CDM","C1883","HCPCS","0278","RC","","","","both","","","3038.00","2278.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1163.55","38.3","","1808.38","1642.20","1808.38","1 through 10","941.78","2415.21","percent of total billed charges",""
"KIT ADAPTER 2X4 27.4CM POCKET FOR SPINAL CORD STIMULATION - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10074337","CDM","C1883","HCPCS","0278","RC","","","","both","","","3038.00","2278.50","WELLPOINT [1015]","HB AMC WELLPOINT","2241.44","73.78","","625.38","625.38","625.38","1 through 10","941.78","2415.21","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","857.85","52.26","","1113.10","1113.10","1113.10","1 through 10","508.87","1304.99","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1304.99","79.5","","1293.60","1148.53","1603.80","1 through 10","508.87","1304.99","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","599.15","36.5","","1023.42","771.29","2068.67","33","508.87","1304.99","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","628.69","38.3","","850.52","759.78","1211.25","66","508.87","1304.99","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","704.20","42.9","","2548.09","2548.09","2548.09","1 through 10","508.87","1304.99","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","704.20","42.9","","956.46","956.46","956.46","1 through 10","508.87","1304.99","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1641.50","1231.12","WELLPOINT [1015]","HB AMC WELLPOINT","1211.10","73.78","","2344.73","1619.47","2530.35","16","508.87","1304.99","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1641.50","1231.12","AETNA [1001]","HB AMC AETNA HMO","1145.77","69.8","","1523.63","988.41","4330.26","39","857.85","1341.43","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1641.50","1231.12","AETNA [1001]","HB AMC AETNA PPO","1319.77","80.4","","1670.25","1670.25","1670.25","1 through 10","857.85","1341.43","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1641.50","1231.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","857.85","52.26","","1113.10","1113.10","1113.10","1 through 10","857.85","1341.43","percent of total billed charges",""
"KIT ASSEMBLY 11MM FEMORAL CEMENTED KNEE HINGE IMPLANT BOLT SLEEVE LEGION","SUP-ITM-10100577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1641.50","1231.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1341.43","81.72","","1738.90","1484.65","2716.94","38","857.85","1341.43","percent of total billed charges",""
"KIT ASSEMBLY 30CM ACCESSORY PENILE PROSTHESIS CONNECTOR BLUNT NEEDLE CURVED KEITH TUBING INSERTION CLOSING TOOL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10075282","CDM","C1813","HCPCS","0278","RC","","","","both","","","2383.50","1787.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","912.88","38.3","","12613.42","12613.42","12613.42","1 through 10","738.89","1894.88","percent of total billed charges",""
"KIT ASSEMBLY 30CM ACCESSORY PENILE PROSTHESIS CONNECTOR BLUNT NEEDLE CURVED KEITH TUBING INSERTION CLOSING TOOL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10075282","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","2383.50","1787.62","AETNA [1001]","HB AMC AETNA HMO","1663.68","69.8","","34275.85","34275.85","50471.26","19","1245.62","1947.8","percent of total billed charges",""
"KIT ASSEMBLY TITAN","SUP-ITM-10319940","CDM","C1813","HCPCS","0278","RC","","","","both","","","2733.50","2050.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1046.93","38.3","","12613.42","12613.42","12613.42","1 through 10","847.39","2173.13","percent of total billed charges",""
"KIT ASSEMBLY TITAN","SUP-ITM-10319940","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","2733.50","2050.12","AETNA [1001]","HB AMC AETNA HMO","1907.98","69.8","","34275.85","34275.85","50471.26","19","1428.53","2233.82","percent of total billed charges",""
"KIT BALLOON PROSTHESIS PENILE AMS 800 CUFF SIZER TUBE PROTECTIVE HEMOSTAT CONNECTOR COLLET","SUP-ITM-10025939","CDM","C1815","HCPCS","0278","RC","","","","both","","","4354.35","3265.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3461.71","79.5","","18938.70","18113.72","18938.70","1 through 10","1349.85","3461.71","percent of total billed charges",""
"KIT BALLOON PROSTHESIS PENILE AMS 800 CUFF SIZER TUBE PROTECTIVE HEMOSTAT CONNECTOR COLLET","SUP-ITM-10025939","CDM","C1815","HCPCS","0278","RC","","","","both","","","4354.35","3265.76","WELLPOINT [1015]","HB AMC WELLPOINT","3212.64","73.78","","27772.46","27772.46","27772.46","1 through 10","1349.85","3461.71","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","6392.50","4794.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3340.72","52.26","","1113.10","1113.10","1113.10","1 through 10","1981.68","5082.04","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","6392.50","4794.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5082.04","79.5","","1293.60","1148.53","1603.80","1 through 10","1981.68","5082.04","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","6392.50","4794.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2333.26","36.5","","1023.42","771.29","2068.67","33","1981.68","5082.04","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","6392.50","4794.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2448.33","38.3","","850.52","759.78","1211.25","66","1981.68","5082.04","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","6392.50","4794.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2742.38","42.9","","2548.09","2548.09","2548.09","1 through 10","1981.68","5082.04","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","6392.50","4794.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2742.38","42.9","","956.46","956.46","956.46","1 through 10","1981.68","5082.04","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","6392.50","4794.37","WELLPOINT [1015]","HB AMC WELLPOINT","4716.39","73.78","","2344.73","1619.47","2530.35","16","1981.68","5082.04","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6392.50","4794.37","AETNA [1001]","HB AMC AETNA HMO","4461.97","69.8","","1523.63","988.41","4330.26","39","3340.72","5223.95","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6392.50","4794.37","AETNA [1001]","HB AMC AETNA PPO","5139.57","80.4","","1670.25","1670.25","1670.25","1 through 10","3340.72","5223.95","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6392.50","4794.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3340.72","52.26","","1113.10","1113.10","1113.10","1 through 10","3340.72","5223.95","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6392.50","4794.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5223.95","81.72","","1738.90","1484.65","2716.94","38","3340.72","5223.95","percent of total billed charges",""
"KIT BIOPSY 11GX10CM 13GX14.8CM BONE LESION TREK BX/5EA","SUP-ITM-10318618","CDM","C1830","HCPCS","0272","RC","","","","both","","","1272.18","954.13","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","890.53","70","","2532.60","2532.60","2532.60","1 through 10","394.38","1011.38","percent of total billed charges",""
"KIT BIOPSY 11GX10CM 13GX14.8CM BONE LESION TREK BX/5EA","SUP-ITM-10318618","CDM","C1830","HCPCS","0272","RC","","","","both","","","1272.18","954.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","487.24","38.3","","497.42","497.42","497.42","1 through 10","394.38","1011.38","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","both","","","8717.50","6538.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6930.41","79.5","","1309.77","674.56","6049.93","26","2702.43","6930.41","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","both","","","8717.50","6538.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4646.43","53.3","","1901.83","1901.83","2962.25","1 through 10","2702.43","6930.41","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","both","","","8717.50","6538.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3181.89","36.5","","1620.31","1620.31","19908.88","1 through 10","2702.43","6930.41","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","both","","","8717.50","6538.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3338.80","38.3","","352.91","352.91","2046.30","1 through 10","2702.43","6930.41","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","both","","","8717.50","6538.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3739.81","42.9","","9668.75","9668.75","9668.75","1 through 10","2702.43","6930.41","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","both","","","8717.50","6538.12","WELLPOINT [1015]","HB AMC WELLPOINT","6431.77","73.78","","699.88","384.10","3443.31","33","2702.43","6930.41","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8717.50","6538.12","AETNA [1001]","HB AMC AETNA HMO","6084.82","69.8","","1421.24","264.50","4933.46","29","4555.77","7123.94","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8717.50","6538.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7008.87","80.4","","1022.97","1022.97","3607.50","1 through 10","4555.77","7123.94","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8717.50","6538.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7123.94","81.72","","3010.54","693.88","5019.88","35","4555.77","7123.94","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","both","","","5807.50","4355.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4616.96","79.5","","1309.77","674.56","6049.93","26","1800.33","4616.96","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","both","","","5807.50","4355.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3095.40","53.3","","1901.83","1901.83","2962.25","1 through 10","1800.33","4616.96","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","both","","","5807.50","4355.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2119.74","36.5","","1620.31","1620.31","19908.88","1 through 10","1800.33","4616.96","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","both","","","5807.50","4355.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2224.27","38.3","","352.91","352.91","2046.30","1 through 10","1800.33","4616.96","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","both","","","5807.50","4355.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2491.42","42.9","","9668.75","9668.75","9668.75","1 through 10","1800.33","4616.96","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","both","","","5807.50","4355.62","WELLPOINT [1015]","HB AMC WELLPOINT","4284.77","73.78","","699.88","384.10","3443.31","33","1800.33","4616.96","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5807.50","4355.62","AETNA [1001]","HB AMC AETNA HMO","4053.64","69.8","","1421.24","264.50","4933.46","29","3035","4745.89","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5807.50","4355.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4669.23","80.4","","1022.97","1022.97","3607.50","1 through 10","3035","4745.89","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5807.50","4355.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4745.89","81.72","","3010.54","693.88","5019.88","35","3035","4745.89","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","800.18","480.96","1887.97","195","1534.5","3935.25","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2638.35","53.3","","813.12","216.42","1444.50","81","1534.5","3935.25","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1534.50","31","","432.60","432.60","432.60","1 through 10","1534.5","3935.25","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","148.37","54.89","631.39","94","1534.5","3935.25","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","279.30","91.72","1116.77","266","1534.5","3935.25","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","731.00","63.70","731.00","1 through 10","1534.5","3935.25","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","384.74","384.74","384.74","1 through 10","1534.5","3935.25","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","286.63","119.22","1107.45","105","1534.5","3935.25","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","675.31","184.75","1721.50","286","2586.87","4045.14","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA PPO","3979.80","80.4","","1261.44","103.12","1514.10","21","2586.87","4045.14","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3979.80","80.4","","1365.00","1365.00","1365.00","1 through 10","2586.87","4045.14","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4045.14","81.72","","5157.68","5157.68","5157.68","1 through 10","2586.87","4045.14","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","431.26","71.26","1459.57","88","2586.87","4045.14","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","973.88","79.5","","800.18","480.96","1887.97","195","379.75","973.88","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","652.93","53.3","","813.12","216.42","1444.50","81","379.75","973.88","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","379.75","31","","432.60","432.60","432.60","1 through 10","379.75","973.88","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","447.13","36.5","","148.37","54.89","631.39","94","379.75","973.88","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","469.18","38.3","","279.30","91.72","1116.77","266","379.75","973.88","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","525.53","42.9","","731.00","63.70","731.00","1 through 10","379.75","973.88","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","525.53","42.9","","384.74","384.74","384.74","1 through 10","379.75","973.88","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","WELLPOINT [1015]","HB AMC WELLPOINT","903.81","73.78","","286.63","119.22","1107.45","105","379.75","973.88","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","AETNA [1001]","HB AMC AETNA HMO","855.05","69.8","","675.31","184.75","1721.50","286","640.19","1001.07","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","AETNA [1001]","HB AMC AETNA PPO","984.90","80.4","","1261.44","103.12","1514.10","21","640.19","1001.07","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","984.90","80.4","","1365.00","1365.00","1365.00","1 through 10","640.19","1001.07","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1001.07","81.72","","5157.68","5157.68","5157.68","1 through 10","640.19","1001.07","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1001.07","81.72","","431.26","71.26","1459.57","88","640.19","1001.07","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","both","","","2074.66","1555.99","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1489.61","71.8","","162.24","51.52","162.24","1 through 10","643.14","1649.35","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","both","","","2074.66","1555.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","757.25","36.5","","94.34","22.19","146.22","26","643.14","1649.35","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","both","","","2074.66","1555.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","794.59","38.3","","51.52","27.37","51.52","26","643.14","1649.35","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","both","","","2074.66","1555.99","WELLPOINT [1015]","HB AMC WELLPOINT","1530.68","73.78","","207.21","122.12","216.28","14","643.14","1649.35","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","2074.66","1555.99","AETNA [1001]","HB AMC AETNA HMO","1448.11","69.8","","155.96","47.39","155.96","1 through 10","1084.22","1695.41","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","2074.66","1555.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1695.41","81.72","","57.36","51.76","232.23","35","1084.22","1695.41","percent of total billed charges",""
"KIT CATHETER 15.5FR PLUERX DRAINAGE PERITONEAL LIDOCAINE","SUP-ITM-10317687","CDM","C1729","HCPCS","0272","RC","","","","both","","","2044.00","1533.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1467.59","71.8","","162.24","51.52","162.24","1 through 10","633.64","1624.98","percent of total billed charges",""
"KIT CATHETER 15.5FR PLUERX DRAINAGE PERITONEAL LIDOCAINE","SUP-ITM-10317687","CDM","C1729","HCPCS","0272","RC","","","","both","","","2044.00","1533.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","746.06","36.5","","94.34","22.19","146.22","26","633.64","1624.98","percent of total billed charges",""
"KIT CATHETER 15.5FR PLUERX DRAINAGE PERITONEAL LIDOCAINE","SUP-ITM-10317687","CDM","C1729","HCPCS","0272","RC","","","","both","","","2044.00","1533.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","782.85","38.3","","51.52","27.37","51.52","26","633.64","1624.98","percent of total billed charges",""
"KIT CATHETER 15.5FR PLUERX DRAINAGE PERITONEAL LIDOCAINE","SUP-ITM-10317687","CDM","C1729","HCPCS","0272","RC","","","","both","","","2044.00","1533.00","WELLPOINT [1015]","HB AMC WELLPOINT","1508.06","73.78","","207.21","122.12","216.28","14","633.64","1624.98","percent of total billed charges",""
"KIT CATHETER 15.5FR PLUERX DRAINAGE PERITONEAL LIDOCAINE","SUP-ITM-10317687","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","2044.00","1533.00","AETNA [1001]","HB AMC AETNA HMO","1426.71","69.8","","155.96","47.39","155.96","1 through 10","1068.19","1670.36","percent of total billed charges",""
"KIT CATHETER 15.5FR PLUERX DRAINAGE PERITONEAL LIDOCAINE","SUP-ITM-10317687","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","2044.00","1533.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1670.36","81.72","","57.36","51.76","232.23","35","1068.19","1670.36","percent of total billed charges",""
"KIT CATHETER 7.5FR 40CC 6IN BALLOON INTRAAORTIC SENSATION PLUS FIBEROPTIC INSERTION INTRODUCER STATLOCK","SUP-ITM-10319505","CDM","C1887","HCPCS","0272","RC","","","","both","","","3384.68","2538.51","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2430.20","71.8","","28.28","27.13","28.28","1 through 10","1049.25","2690.82","percent of total billed charges",""
"KIT CATHETER 7.5FR 40CC 6IN BALLOON INTRAAORTIC SENSATION PLUS FIBEROPTIC INSERTION INTRODUCER STATLOCK","SUP-ITM-10319505","CDM","C1887","HCPCS","0272","RC","","","","both","","","3384.68","2538.51","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2369.28","70","","44.63","35.78","44.63","1 through 10","1049.25","2690.82","percent of total billed charges",""
"KIT CATHETER 7.5FR 40CC 6IN BALLOON INTRAAORTIC SENSATION PLUS FIBEROPTIC INSERTION INTRODUCER STATLOCK","SUP-ITM-10319505","CDM","C1887","HCPCS","0272","RC","","","","both","","","3384.68","2538.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2690.82","79.5","","1342.89","271.64","6954.67","1 through 10","1049.25","2690.82","percent of total billed charges",""
"KIT CATHETER 7.5FR 40CC 6IN BALLOON INTRAAORTIC SENSATION PLUS FIBEROPTIC INSERTION INTRODUCER STATLOCK","SUP-ITM-10319505","CDM","C1887","HCPCS","0272","RC","","","","both","","","3384.68","2538.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1804.03","53.3","","4550.00","30.49","4550.00","1 through 10","1049.25","2690.82","percent of total billed charges",""
"KIT CATHETER 7.5FR 40CC 6IN BALLOON INTRAAORTIC SENSATION PLUS FIBEROPTIC INSERTION INTRODUCER STATLOCK","SUP-ITM-10319505","CDM","C1887","HCPCS","0272","RC","","","","both","","","3384.68","2538.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2200.04","65","","42.09","0.04","5453.50","1 through 10","1049.25","2690.82","percent of total billed charges",""
"KIT CATHETER 7.5FR 40CC 6IN BALLOON INTRAAORTIC SENSATION PLUS FIBEROPTIC INSERTION INTRODUCER STATLOCK","SUP-ITM-10319505","CDM","C1887","HCPCS","0272","RC","","","","both","","","3384.68","2538.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1235.41","36.5","","310.94","18.54","1259.30","62","1049.25","2690.82","percent of total billed charges",""
"KIT CATHETER 7.5FR 40CC 6IN BALLOON INTRAAORTIC SENSATION PLUS FIBEROPTIC INSERTION INTRODUCER STATLOCK","SUP-ITM-10319505","CDM","C1887","HCPCS","0272","RC","","","","both","","","3384.68","2538.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1296.33","38.3","","146.86","22.58","1753.45","65","1049.25","2690.82","percent of total billed charges",""
"KIT CATHETER 7.5FR 40CC 6IN BALLOON INTRAAORTIC SENSATION PLUS FIBEROPTIC INSERTION INTRODUCER STATLOCK","SUP-ITM-10319505","CDM","C1887","HCPCS","0272","RC","","","","both","","","3384.68","2538.51","WELLPOINT [1015]","HB AMC WELLPOINT","2497.22","73.78","","247.29","33.09","909.09","53","1049.25","2690.82","percent of total billed charges",""
"KIT CATHETER 7.5FR 40CC 6IN BALLOON INTRAAORTIC SENSATION PLUS FIBEROPTIC INSERTION INTRODUCER STATLOCK","SUP-ITM-10319505","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3384.68","2538.51","AETNA [1001]","HB AMC AETNA HMO","2362.51","69.8","","30.69","30.21","30.69","1 through 10","1768.83","2765.96","percent of total billed charges",""
"KIT CATHETER 7.5FR 40CC 6IN BALLOON INTRAAORTIC SENSATION PLUS FIBEROPTIC INSERTION INTRODUCER STATLOCK","SUP-ITM-10319505","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3384.68","2538.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2721.28","80.4","","82.69","82.69","82.69","1 through 10","1768.83","2765.96","percent of total billed charges",""
"KIT CATHETER 7.5FR 40CC 6IN BALLOON INTRAAORTIC SENSATION PLUS FIBEROPTIC INSERTION INTRODUCER STATLOCK","SUP-ITM-10319505","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3384.68","2538.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2765.96","81.72","","751.01","74.72","751.01","1 through 10","1768.83","2765.96","percent of total billed charges",""
"KIT CATHETER 7.5FR 40CC 6IN BALLOON INTRAAORTIC SENSATION PLUS FIBEROPTIC INSERTION INTRODUCER STATLOCK","SUP-ITM-10319505","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3384.68","2538.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2765.96","81.72","","328.92","46.17","2701.97","59","1768.83","2765.96","percent of total billed charges",""
"KIT CATHETER ARGYLE 13.5CM DIALYSIS ARGYLE PRESTERNAL PERITONEALPRE-CURVED SHAFT POLYURETHANE LF DISPOSABLE PK/5EA","SUP-ITM-10267634","CDM","C1750","HCPCS","0278","RC","","","","both","","","1759.66","1319.74","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","919.60","52.26","","154.36","154.36","154.36","1 through 10","545.49","1398.93","percent of total billed charges",""
"KIT CATHETER ARGYLE 13.5CM DIALYSIS ARGYLE PRESTERNAL PERITONEALPRE-CURVED SHAFT POLYURETHANE LF DISPOSABLE PK/5EA","SUP-ITM-10267634","CDM","C1750","HCPCS","0278","RC","","","","both","","","1759.66","1319.74","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1143.78","65","","1371.74","196.32","1371.74","1 through 10","545.49","1398.93","percent of total billed charges",""
"KIT CATHETER ARGYLE 13.5CM DIALYSIS ARGYLE PRESTERNAL PERITONEALPRE-CURVED SHAFT POLYURETHANE LF DISPOSABLE PK/5EA","SUP-ITM-10267634","CDM","C1750","HCPCS","0278","RC","","","","both","","","1759.66","1319.74","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1231.76","70","","249.45","107.26","1254.96","14","545.49","1398.93","percent of total billed charges",""
"KIT CATHETER ARGYLE 13.5CM DIALYSIS ARGYLE PRESTERNAL PERITONEALPRE-CURVED SHAFT POLYURETHANE LF DISPOSABLE PK/5EA","SUP-ITM-10267634","CDM","C1750","HCPCS","0278","RC","","","","both","","","1759.66","1319.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1398.93","79.5","","196.32","85.01","196.32","1 through 10","545.49","1398.93","percent of total billed charges",""
"KIT CATHETER ARGYLE 13.5CM DIALYSIS ARGYLE PRESTERNAL PERITONEALPRE-CURVED SHAFT POLYURETHANE LF DISPOSABLE PK/5EA","SUP-ITM-10267634","CDM","C1750","HCPCS","0278","RC","","","","both","","","1759.66","1319.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","937.90","53.3","","1132.95","1132.95","1132.95","1 through 10","545.49","1398.93","percent of total billed charges",""
"KIT CATHETER ARGYLE 13.5CM DIALYSIS ARGYLE PRESTERNAL PERITONEALPRE-CURVED SHAFT POLYURETHANE LF DISPOSABLE PK/5EA","SUP-ITM-10267634","CDM","C1750","HCPCS","0278","RC","","","","both","","","1759.66","1319.74","WELLPOINT [1015]","HB AMC WELLPOINT","1298.28","73.78","","1297.66","185.72","1297.66","1 through 10","545.49","1398.93","percent of total billed charges",""
"KIT CATHETER ARGYLE 13.5CM DIALYSIS ARGYLE PRESTERNAL PERITONEALPRE-CURVED SHAFT POLYURETHANE LF DISPOSABLE PK/5EA","SUP-ITM-10267634","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1759.66","1319.74","AETNA [1001]","HB AMC AETNA HMO","1228.24","69.8","","76.96","76.96","76.96","1 through 10","919.6","1437.99","percent of total billed charges",""
"KIT CATHETER ARGYLE 13.5CM DIALYSIS ARGYLE PRESTERNAL PERITONEALPRE-CURVED SHAFT POLYURETHANE LF DISPOSABLE PK/5EA","SUP-ITM-10267634","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1759.66","1319.74","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","919.60","52.26","","154.36","154.36","154.36","1 through 10","919.6","1437.99","percent of total billed charges",""
"KIT CATHETER ARGYLE 13.5CM DIALYSIS ARGYLE PRESTERNAL PERITONEALPRE-CURVED SHAFT POLYURETHANE LF DISPOSABLE PK/5EA","SUP-ITM-10267634","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1759.66","1319.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1437.99","81.72","","199.41","199.41","199.41","1 through 10","919.6","1437.99","percent of total billed charges",""
"KIT CATHETER II CODMAN EDS3 LUMBAR DRAINAGE EXTERNAL","SUP-ITM-10114889","CDM","C1729","HCPCS","0272","RC","","","","both","","","1614.34","1210.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1159.10","71.8","","162.24","51.52","162.24","1 through 10","500.45","1283.4","percent of total billed charges",""
"KIT CATHETER II CODMAN EDS3 LUMBAR DRAINAGE EXTERNAL","SUP-ITM-10114889","CDM","C1729","HCPCS","0272","RC","","","","both","","","1614.34","1210.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","589.23","36.5","","94.34","22.19","146.22","26","500.45","1283.4","percent of total billed charges",""
"KIT CATHETER II CODMAN EDS3 LUMBAR DRAINAGE EXTERNAL","SUP-ITM-10114889","CDM","C1729","HCPCS","0272","RC","","","","both","","","1614.34","1210.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","618.29","38.3","","51.52","27.37","51.52","26","500.45","1283.4","percent of total billed charges",""
"KIT CATHETER II CODMAN EDS3 LUMBAR DRAINAGE EXTERNAL","SUP-ITM-10114889","CDM","C1729","HCPCS","0272","RC","","","","both","","","1614.34","1210.75","WELLPOINT [1015]","HB AMC WELLPOINT","1191.06","73.78","","207.21","122.12","216.28","14","500.45","1283.4","percent of total billed charges",""
"KIT CATHETER II CODMAN EDS3 LUMBAR DRAINAGE EXTERNAL","SUP-ITM-10114889","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1614.34","1210.75","AETNA [1001]","HB AMC AETNA HMO","1126.81","69.8","","155.96","47.39","155.96","1 through 10","843.65","1319.24","percent of total billed charges",""
"KIT CATHETER II CODMAN EDS3 LUMBAR DRAINAGE EXTERNAL","SUP-ITM-10114889","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1614.34","1210.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1319.24","81.72","","57.36","51.76","232.23","35","843.65","1319.24","percent of total billed charges",""
"KIT CATHETER L 40CM 8.3FR PERICARDIOCENTESIS PIGTAIL TIP 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294830","CDM","C1729","HCPCS","0272","RC","","","","both","","","448.00","336.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","321.66","71.8","","162.24","51.52","162.24","1 through 10","138.88","356.16","percent of total billed charges",""
"KIT CATHETER L 40CM 8.3FR PERICARDIOCENTESIS PIGTAIL TIP 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294830","CDM","C1729","HCPCS","0272","RC","","","","both","","","448.00","336.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","163.52","36.5","","94.34","22.19","146.22","26","138.88","356.16","percent of total billed charges",""
"KIT CATHETER L 40CM 8.3FR PERICARDIOCENTESIS PIGTAIL TIP 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294830","CDM","C1729","HCPCS","0272","RC","","","","both","","","448.00","336.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","171.58","38.3","","51.52","27.37","51.52","26","138.88","356.16","percent of total billed charges",""
"KIT CATHETER L 40CM 8.3FR PERICARDIOCENTESIS PIGTAIL TIP 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294830","CDM","C1729","HCPCS","0272","RC","","","","both","","","448.00","336.00","WELLPOINT [1015]","HB AMC WELLPOINT","330.53","73.78","","207.21","122.12","216.28","14","138.88","356.16","percent of total billed charges",""
"KIT CATHETER L 40CM 8.3FR PERICARDIOCENTESIS PIGTAIL TIP 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294830","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","448.00","336.00","AETNA [1001]","HB AMC AETNA HMO","312.70","69.8","","155.96","47.39","155.96","1 through 10","234.12","366.11","percent of total billed charges",""
"KIT CATHETER L 40CM 8.3FR PERICARDIOCENTESIS PIGTAIL TIP 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294830","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","448.00","336.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","366.11","81.72","","57.36","51.76","232.23","35","234.12","366.11","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 40CM 23CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET LF HEMODIALYSIS PK/5EA","SUP-ITM-10267585","CDM","C1750","HCPCS","0278","RC","","","","both","","","1032.50","774.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","539.58","52.26","","154.36","154.36","154.36","1 through 10","320.08","820.84","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 40CM 23CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET LF HEMODIALYSIS PK/5EA","SUP-ITM-10267585","CDM","C1750","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","671.13","65","","1371.74","196.32","1371.74","1 through 10","320.08","820.84","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 40CM 23CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET LF HEMODIALYSIS PK/5EA","SUP-ITM-10267585","CDM","C1750","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","722.75","70","","249.45","107.26","1254.96","14","320.08","820.84","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 40CM 23CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET LF HEMODIALYSIS PK/5EA","SUP-ITM-10267585","CDM","C1750","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","820.84","79.5","","196.32","85.01","196.32","1 through 10","320.08","820.84","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 40CM 23CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET LF HEMODIALYSIS PK/5EA","SUP-ITM-10267585","CDM","C1750","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","550.32","53.3","","1132.95","1132.95","1132.95","1 through 10","320.08","820.84","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 40CM 23CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET LF HEMODIALYSIS PK/5EA","SUP-ITM-10267585","CDM","C1750","HCPCS","0278","RC","","","","both","","","1032.50","774.37","WELLPOINT [1015]","HB AMC WELLPOINT","761.78","73.78","","1297.66","185.72","1297.66","1 through 10","320.08","820.84","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 40CM 23CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET LF HEMODIALYSIS PK/5EA","SUP-ITM-10267585","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","AETNA [1001]","HB AMC AETNA HMO","720.69","69.8","","76.96","76.96","76.96","1 through 10","539.58","843.76","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 40CM 23CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET LF HEMODIALYSIS PK/5EA","SUP-ITM-10267585","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","539.58","52.26","","154.36","154.36","154.36","1 through 10","539.58","843.76","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 40CM 23CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET LF HEMODIALYSIS PK/5EA","SUP-ITM-10267585","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","843.76","81.72","","199.41","199.41","199.41","1 through 10","539.58","843.76","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 45CM 28CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET HEMODIALYSIS LF PK/5EA","SUP-ITM-10267586","CDM","C1750","HCPCS","0278","RC","","","","both","","","1032.50","774.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","539.58","52.26","","154.36","154.36","154.36","1 through 10","320.08","820.84","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 45CM 28CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET HEMODIALYSIS LF PK/5EA","SUP-ITM-10267586","CDM","C1750","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","671.13","65","","1371.74","196.32","1371.74","1 through 10","320.08","820.84","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 45CM 28CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET HEMODIALYSIS LF PK/5EA","SUP-ITM-10267586","CDM","C1750","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","722.75","70","","249.45","107.26","1254.96","14","320.08","820.84","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 45CM 28CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET HEMODIALYSIS LF PK/5EA","SUP-ITM-10267586","CDM","C1750","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","820.84","79.5","","196.32","85.01","196.32","1 through 10","320.08","820.84","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 45CM 28CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET HEMODIALYSIS LF PK/5EA","SUP-ITM-10267586","CDM","C1750","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","550.32","53.3","","1132.95","1132.95","1132.95","1 through 10","320.08","820.84","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 45CM 28CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET HEMODIALYSIS LF PK/5EA","SUP-ITM-10267586","CDM","C1750","HCPCS","0278","RC","","","","both","","","1032.50","774.37","WELLPOINT [1015]","HB AMC WELLPOINT","761.78","73.78","","1297.66","185.72","1297.66","1 through 10","320.08","820.84","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 45CM 28CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET HEMODIALYSIS LF PK/5EA","SUP-ITM-10267586","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","AETNA [1001]","HB AMC AETNA HMO","720.69","69.8","","76.96","76.96","76.96","1 through 10","539.58","843.76","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 45CM 28CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET HEMODIALYSIS LF PK/5EA","SUP-ITM-10267586","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","539.58","52.26","","154.36","154.36","154.36","1 through 10","539.58","843.76","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 45CM 28CM .038IN SYMMETRSYMMETRIC TIP DOUBLE LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE VENATRAC INSERTION STYLET HEMODIALYSIS LF PK/5EA","SUP-ITM-10267586","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","843.76","81.72","","199.41","199.41","199.41","1 through 10","539.58","843.76","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 72CM 55CM .038INSYMMETRIC TIP DUAL LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE HEMODIALYSIS LF PK/5EA","SUP-ITM-10267583","CDM","C1750","HCPCS","0278","RC","","","","both","","","1288.74","966.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","673.50","52.26","","154.36","154.36","154.36","1 through 10","399.51","1024.55","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 72CM 55CM .038INSYMMETRIC TIP DUAL LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE HEMODIALYSIS LF PK/5EA","SUP-ITM-10267583","CDM","C1750","HCPCS","0278","RC","","","","both","","","1288.74","966.55","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","837.68","65","","1371.74","196.32","1371.74","1 through 10","399.51","1024.55","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 72CM 55CM .038INSYMMETRIC TIP DUAL LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE HEMODIALYSIS LF PK/5EA","SUP-ITM-10267583","CDM","C1750","HCPCS","0278","RC","","","","both","","","1288.74","966.55","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","902.12","70","","249.45","107.26","1254.96","14","399.51","1024.55","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 72CM 55CM .038INSYMMETRIC TIP DUAL LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE HEMODIALYSIS LF PK/5EA","SUP-ITM-10267583","CDM","C1750","HCPCS","0278","RC","","","","both","","","1288.74","966.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1024.55","79.5","","196.32","85.01","196.32","1 through 10","399.51","1024.55","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 72CM 55CM .038INSYMMETRIC TIP DUAL LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE HEMODIALYSIS LF PK/5EA","SUP-ITM-10267583","CDM","C1750","HCPCS","0278","RC","","","","both","","","1288.74","966.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","686.90","53.3","","1132.95","1132.95","1132.95","1 through 10","399.51","1024.55","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 72CM 55CM .038INSYMMETRIC TIP DUAL LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE HEMODIALYSIS LF PK/5EA","SUP-ITM-10267583","CDM","C1750","HCPCS","0278","RC","","","","both","","","1288.74","966.55","WELLPOINT [1015]","HB AMC WELLPOINT","950.83","73.78","","1297.66","185.72","1297.66","1 through 10","399.51","1024.55","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 72CM 55CM .038INSYMMETRIC TIP DUAL LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE HEMODIALYSIS LF PK/5EA","SUP-ITM-10267583","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1288.74","966.55","AETNA [1001]","HB AMC AETNA HMO","899.54","69.8","","76.96","76.96","76.96","1 through 10","673.5","1053.16","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 72CM 55CM .038INSYMMETRIC TIP DUAL LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE HEMODIALYSIS LF PK/5EA","SUP-ITM-10267583","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1288.74","966.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","673.50","52.26","","154.36","154.36","154.36","1 through 10","673.5","1053.16","percent of total billed charges",""
"KIT CATHETER PALINDROME 14.5FR 16FR 72CM 55CM .038INSYMMETRIC TIP DUAL LUMEN SAFETY SHEATH TISSUE DILATOR INTRODUCER NEEDLE GUIDEWIRE HEMODIALYSIS LF PK/5EA","SUP-ITM-10267583","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1288.74","966.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1053.16","81.72","","199.41","199.41","199.41","1 through 10","673.5","1053.16","percent of total billed charges",""
"KIT CATHETER PALINDROME 44CM PRECISION CHRONIC PK/5EA","SUP-ITM-10267070","CDM","C1750","HCPCS","0278","RC","","","","both","","","1288.74","966.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","673.50","52.26","","154.36","154.36","154.36","1 through 10","399.51","1024.55","percent of total billed charges",""
"KIT CATHETER PALINDROME 44CM PRECISION CHRONIC PK/5EA","SUP-ITM-10267070","CDM","C1750","HCPCS","0278","RC","","","","both","","","1288.74","966.55","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","837.68","65","","1371.74","196.32","1371.74","1 through 10","399.51","1024.55","percent of total billed charges",""
"KIT CATHETER PALINDROME 44CM PRECISION CHRONIC PK/5EA","SUP-ITM-10267070","CDM","C1750","HCPCS","0278","RC","","","","both","","","1288.74","966.55","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","902.12","70","","249.45","107.26","1254.96","14","399.51","1024.55","percent of total billed charges",""
"KIT CATHETER PALINDROME 44CM PRECISION CHRONIC PK/5EA","SUP-ITM-10267070","CDM","C1750","HCPCS","0278","RC","","","","both","","","1288.74","966.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1024.55","79.5","","196.32","85.01","196.32","1 through 10","399.51","1024.55","percent of total billed charges",""
"KIT CATHETER PALINDROME 44CM PRECISION CHRONIC PK/5EA","SUP-ITM-10267070","CDM","C1750","HCPCS","0278","RC","","","","both","","","1288.74","966.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","686.90","53.3","","1132.95","1132.95","1132.95","1 through 10","399.51","1024.55","percent of total billed charges",""
"KIT CATHETER PALINDROME 44CM PRECISION CHRONIC PK/5EA","SUP-ITM-10267070","CDM","C1750","HCPCS","0278","RC","","","","both","","","1288.74","966.55","WELLPOINT [1015]","HB AMC WELLPOINT","950.83","73.78","","1297.66","185.72","1297.66","1 through 10","399.51","1024.55","percent of total billed charges",""
"KIT CATHETER PALINDROME 44CM PRECISION CHRONIC PK/5EA","SUP-ITM-10267070","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1288.74","966.55","AETNA [1001]","HB AMC AETNA HMO","899.54","69.8","","76.96","76.96","76.96","1 through 10","673.5","1053.16","percent of total billed charges",""
"KIT CATHETER PALINDROME 44CM PRECISION CHRONIC PK/5EA","SUP-ITM-10267070","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1288.74","966.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","673.50","52.26","","154.36","154.36","154.36","1 through 10","673.5","1053.16","percent of total billed charges",""
"KIT CATHETER PALINDROME 44CM PRECISION CHRONIC PK/5EA","SUP-ITM-10267070","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1288.74","966.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1053.16","81.72","","199.41","199.41","199.41","1 through 10","673.5","1053.16","percent of total billed charges",""
"KIT CATHETER PALINDROME14.5FR 40CM PRECISION CHRONIC SYMMETRICAL TIP TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267305","CDM","C1750","HCPCS","0278","RC","","","","both","","","1513.17","1134.88","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","790.78","52.26","","154.36","154.36","154.36","1 through 10","469.08","1202.97","percent of total billed charges",""
"KIT CATHETER PALINDROME14.5FR 40CM PRECISION CHRONIC SYMMETRICAL TIP TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267305","CDM","C1750","HCPCS","0278","RC","","","","both","","","1513.17","1134.88","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","983.56","65","","1371.74","196.32","1371.74","1 through 10","469.08","1202.97","percent of total billed charges",""
"KIT CATHETER PALINDROME14.5FR 40CM PRECISION CHRONIC SYMMETRICAL TIP TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267305","CDM","C1750","HCPCS","0278","RC","","","","both","","","1513.17","1134.88","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1059.22","70","","249.45","107.26","1254.96","14","469.08","1202.97","percent of total billed charges",""
"KIT CATHETER PALINDROME14.5FR 40CM PRECISION CHRONIC SYMMETRICAL TIP TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267305","CDM","C1750","HCPCS","0278","RC","","","","both","","","1513.17","1134.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1202.97","79.5","","196.32","85.01","196.32","1 through 10","469.08","1202.97","percent of total billed charges",""
"KIT CATHETER PALINDROME14.5FR 40CM PRECISION CHRONIC SYMMETRICAL TIP TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267305","CDM","C1750","HCPCS","0278","RC","","","","both","","","1513.17","1134.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","806.52","53.3","","1132.95","1132.95","1132.95","1 through 10","469.08","1202.97","percent of total billed charges",""
"KIT CATHETER PALINDROME14.5FR 40CM PRECISION CHRONIC SYMMETRICAL TIP TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267305","CDM","C1750","HCPCS","0278","RC","","","","both","","","1513.17","1134.88","WELLPOINT [1015]","HB AMC WELLPOINT","1116.42","73.78","","1297.66","185.72","1297.66","1 through 10","469.08","1202.97","percent of total billed charges",""
"KIT CATHETER PALINDROME14.5FR 40CM PRECISION CHRONIC SYMMETRICAL TIP TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267305","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1513.17","1134.88","AETNA [1001]","HB AMC AETNA HMO","1056.19","69.8","","76.96","76.96","76.96","1 through 10","790.78","1236.56","percent of total billed charges",""
"KIT CATHETER PALINDROME14.5FR 40CM PRECISION CHRONIC SYMMETRICAL TIP TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267305","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1513.17","1134.88","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","790.78","52.26","","154.36","154.36","154.36","1 through 10","790.78","1236.56","percent of total billed charges",""
"KIT CATHETER PALINDROME14.5FR 40CM PRECISION CHRONIC SYMMETRICAL TIP TAL VENATRAC STYLET PK/5EA","SUP-ITM-10267305","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1513.17","1134.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1236.56","81.72","","199.41","199.41","199.41","1 through 10","790.78","1236.56","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2031.23","79.5","","800.18","480.96","1887.97","195","792.05","2031.23","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1361.82","53.3","","813.12","216.42","1444.50","81","792.05","2031.23","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","792.05","31","","432.60","432.60","432.60","1 through 10","792.05","2031.23","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","932.58","36.5","","148.37","54.89","631.39","94","792.05","2031.23","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","978.57","38.3","","279.30","91.72","1116.77","266","792.05","2031.23","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1096.10","42.9","","731.00","63.70","731.00","1 through 10","792.05","2031.23","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1096.10","42.9","","384.74","384.74","384.74","1 through 10","792.05","2031.23","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2555.00","1916.25","WELLPOINT [1015]","HB AMC WELLPOINT","1885.08","73.78","","286.63","119.22","1107.45","105","792.05","2031.23","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","AETNA [1001]","HB AMC AETNA HMO","1783.39","69.8","","675.31","184.75","1721.50","286","1335.24","2087.95","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","AETNA [1001]","HB AMC AETNA PPO","2054.22","80.4","","1261.44","103.12","1514.10","21","1335.24","2087.95","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2054.22","80.4","","1365.00","1365.00","1365.00","1 through 10","1335.24","2087.95","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2087.95","81.72","","5157.68","5157.68","5157.68","1 through 10","1335.24","2087.95","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2087.95","81.72","","431.26","71.26","1459.57","88","1335.24","2087.95","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.00","2677.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2838.15","79.5","","800.18","480.96","1887.97","195","1106.7","2838.15","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.00","2677.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1902.81","53.3","","813.12","216.42","1444.50","81","1106.7","2838.15","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.00","2677.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1106.70","31","","432.60","432.60","432.60","1 through 10","1106.7","2838.15","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.00","2677.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1303.05","36.5","","148.37","54.89","631.39","94","1106.7","2838.15","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.00","2677.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1367.31","38.3","","279.30","91.72","1116.77","266","1106.7","2838.15","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.00","2677.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1531.53","42.9","","731.00","63.70","731.00","1 through 10","1106.7","2838.15","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.00","2677.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1531.53","42.9","","384.74","384.74","384.74","1 through 10","1106.7","2838.15","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3570.00","2677.50","WELLPOINT [1015]","HB AMC WELLPOINT","2633.95","73.78","","286.63","119.22","1107.45","105","1106.7","2838.15","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3570.00","2677.50","AETNA [1001]","HB AMC AETNA HMO","2491.86","69.8","","675.31","184.75","1721.50","286","1865.68","2917.4","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3570.00","2677.50","AETNA [1001]","HB AMC AETNA PPO","2870.28","80.4","","1261.44","103.12","1514.10","21","1865.68","2917.4","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3570.00","2677.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2870.28","80.4","","1365.00","1365.00","1365.00","1 through 10","1865.68","2917.4","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3570.00","2677.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2917.40","81.72","","5157.68","5157.68","5157.68","1 through 10","1865.68","2917.4","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3570.00","2677.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2917.40","81.72","","431.26","71.26","1459.57","88","1865.68","2917.4","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3965.06","79.5","","800.18","480.96","1887.97","195","1546.13","3965.06","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2658.34","53.3","","813.12","216.42","1444.50","81","1546.13","3965.06","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1546.13","31","","432.60","432.60","432.60","1 through 10","1546.13","3965.06","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1820.44","36.5","","148.37","54.89","631.39","94","1546.13","3965.06","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1910.21","38.3","","279.30","91.72","1116.77","266","1546.13","3965.06","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2139.64","42.9","","731.00","63.70","731.00","1 through 10","1546.13","3965.06","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2139.64","42.9","","384.74","384.74","384.74","1 through 10","1546.13","3965.06","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","WELLPOINT [1015]","HB AMC WELLPOINT","3679.78","73.78","","286.63","119.22","1107.45","105","1546.13","3965.06","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4987.50","3740.62","AETNA [1001]","HB AMC AETNA HMO","3481.28","69.8","","675.31","184.75","1721.50","286","2606.47","4075.79","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4987.50","3740.62","AETNA [1001]","HB AMC AETNA PPO","4009.95","80.4","","1261.44","103.12","1514.10","21","2606.47","4075.79","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4987.50","3740.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4009.95","80.4","","1365.00","1365.00","1365.00","1 through 10","2606.47","4075.79","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4987.50","3740.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4075.79","81.72","","5157.68","5157.68","5157.68","1 through 10","2606.47","4075.79","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4987.50","3740.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4075.79","81.72","","431.26","71.26","1459.57","88","2606.47","4075.79","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","904.31","79.5","","800.18","480.96","1887.97","195","352.63","904.31","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","606.29","53.3","","813.12","216.42","1444.50","81","352.63","904.31","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","352.63","31","","432.60","432.60","432.60","1 through 10","352.63","904.31","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","415.19","36.5","","148.37","54.89","631.39","94","352.63","904.31","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","435.66","38.3","","279.30","91.72","1116.77","266","352.63","904.31","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","487.99","42.9","","731.00","63.70","731.00","1 through 10","352.63","904.31","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","487.99","42.9","","384.74","384.74","384.74","1 through 10","352.63","904.31","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.50","853.12","WELLPOINT [1015]","HB AMC WELLPOINT","839.25","73.78","","286.63","119.22","1107.45","105","352.63","904.31","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.50","853.12","AETNA [1001]","HB AMC AETNA HMO","793.98","69.8","","675.31","184.75","1721.50","286","594.46","929.57","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.50","853.12","AETNA [1001]","HB AMC AETNA PPO","914.55","80.4","","1261.44","103.12","1514.10","21","594.46","929.57","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.50","853.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","914.55","80.4","","1365.00","1365.00","1365.00","1 through 10","594.46","929.57","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.50","853.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","929.57","81.72","","5157.68","5157.68","5157.68","1 through 10","594.46","929.57","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.50","853.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","929.57","81.72","","431.26","71.26","1459.57","88","594.46","929.57","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","1309.77","674.56","6049.93","26","162.75","417.38","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","1901.83","1901.83","2962.25","1 through 10","162.75","417.38","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","1620.31","1620.31","19908.88","1 through 10","162.75","417.38","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","352.91","352.91","2046.30","1 through 10","162.75","417.38","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","9668.75","9668.75","9668.75","1 through 10","162.75","417.38","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","699.88","384.10","3443.31","33","162.75","417.38","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","1421.24","264.50","4933.46","29","274.37","429.03","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1022.97","1022.97","3607.50","1 through 10","274.37","429.03","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","3010.54","693.88","5019.88","35","274.37","429.03","percent of total billed charges",""
"KIT CONTROLLER LVAD EMERGENCY BATTERY BACKUP HEARTMATE","SUP-ITM-10194529","CDM","Q0481","HCPCS","0274","RC","","","","both","","","12375.00","9281.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8043.75","65","","21937.50","21937.50","21937.50","1 through 10","3836.25","35551.59","percent of total billed charges",""
"KIT COVER XSM ELBOW HUMERAL THO DISY CONDYLE ALIGNMENT","SUP-ITM-10061727","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1077.34","52.26","","1113.10","1113.10","1113.10","1 through 10","639.07","1638.89","percent of total billed charges",""
"KIT COVER XSM ELBOW HUMERAL THO DISY CONDYLE ALIGNMENT","SUP-ITM-10061727","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1638.89","79.5","","1293.60","1148.53","1603.80","1 through 10","639.07","1638.89","percent of total billed charges",""
"KIT COVER XSM ELBOW HUMERAL THO DISY CONDYLE ALIGNMENT","SUP-ITM-10061727","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","752.45","36.5","","1023.42","771.29","2068.67","33","639.07","1638.89","percent of total billed charges",""
"KIT COVER XSM ELBOW HUMERAL THO DISY CONDYLE ALIGNMENT","SUP-ITM-10061727","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","789.55","38.3","","850.52","759.78","1211.25","66","639.07","1638.89","percent of total billed charges",""
"KIT COVER XSM ELBOW HUMERAL THO DISY CONDYLE ALIGNMENT","SUP-ITM-10061727","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","884.38","42.9","","2548.09","2548.09","2548.09","1 through 10","639.07","1638.89","percent of total billed charges",""
"KIT COVER XSM ELBOW HUMERAL THO DISY CONDYLE ALIGNMENT","SUP-ITM-10061727","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","884.38","42.9","","956.46","956.46","956.46","1 through 10","639.07","1638.89","percent of total billed charges",""
"KIT COVER XSM ELBOW HUMERAL THO DISY CONDYLE ALIGNMENT","SUP-ITM-10061727","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","WELLPOINT [1015]","HB AMC WELLPOINT","1520.97","73.78","","2344.73","1619.47","2530.35","16","639.07","1638.89","percent of total billed charges",""
"KIT COVER XSM ELBOW HUMERAL THO DISY CONDYLE ALIGNMENT","SUP-ITM-10061727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2061.50","1546.12","AETNA [1001]","HB AMC AETNA HMO","1438.93","69.8","","1523.63","988.41","4330.26","39","1077.34","1684.66","percent of total billed charges",""
"KIT COVER XSM ELBOW HUMERAL THO DISY CONDYLE ALIGNMENT","SUP-ITM-10061727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2061.50","1546.12","AETNA [1001]","HB AMC AETNA PPO","1657.45","80.4","","1670.25","1670.25","1670.25","1 through 10","1077.34","1684.66","percent of total billed charges",""
"KIT COVER XSM ELBOW HUMERAL THO DISY CONDYLE ALIGNMENT","SUP-ITM-10061727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2061.50","1546.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1077.34","52.26","","1113.10","1113.10","1113.10","1 through 10","1077.34","1684.66","percent of total billed charges",""
"KIT COVER XSM ELBOW HUMERAL THO DISY CONDYLE ALIGNMENT","SUP-ITM-10061727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2061.50","1546.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1684.66","81.72","","1738.90","1484.65","2716.94","38","1077.34","1684.66","percent of total billed charges",""
"KIT CRANIAL MEDPOR CUSTOMIZED IMPLANT SM","SUP-ITM-10272784","CDM","C1713","HCPCS","0278","RC","","","","both","","","30075.76","22556.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","23910.23","79.5","","800.18","480.96","1887.97","195","9323.49","23910.23","percent of total billed charges",""
"KIT CRANIAL MEDPOR CUSTOMIZED IMPLANT SM","SUP-ITM-10272784","CDM","C1713","HCPCS","0278","RC","","","","both","","","30075.76","22556.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16030.38","53.3","","813.12","216.42","1444.50","81","9323.49","23910.23","percent of total billed charges",""
"KIT CRANIAL MEDPOR CUSTOMIZED IMPLANT SM","SUP-ITM-10272784","CDM","C1713","HCPCS","0278","RC","","","","both","","","30075.76","22556.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","9323.49","31","","432.60","432.60","432.60","1 through 10","9323.49","23910.23","percent of total billed charges",""
"KIT CRANIAL MEDPOR CUSTOMIZED IMPLANT SM","SUP-ITM-10272784","CDM","C1713","HCPCS","0278","RC","","","","both","","","30075.76","22556.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10977.65","36.5","","148.37","54.89","631.39","94","9323.49","23910.23","percent of total billed charges",""
"KIT CRANIAL MEDPOR CUSTOMIZED IMPLANT SM","SUP-ITM-10272784","CDM","C1713","HCPCS","0278","RC","","","","both","","","30075.76","22556.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11519.02","38.3","","279.30","91.72","1116.77","266","9323.49","23910.23","percent of total billed charges",""
"KIT CRANIAL MEDPOR CUSTOMIZED IMPLANT SM","SUP-ITM-10272784","CDM","C1713","HCPCS","0278","RC","","","","both","","","30075.76","22556.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12902.50","42.9","","731.00","63.70","731.00","1 through 10","9323.49","23910.23","percent of total billed charges",""
"KIT CRANIAL MEDPOR CUSTOMIZED IMPLANT SM","SUP-ITM-10272784","CDM","C1713","HCPCS","0278","RC","","","","both","","","30075.76","22556.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12902.50","42.9","","384.74","384.74","384.74","1 through 10","9323.49","23910.23","percent of total billed charges",""
"KIT CRANIAL MEDPOR CUSTOMIZED IMPLANT SM","SUP-ITM-10272784","CDM","C1713","HCPCS","0278","RC","","","","both","","","30075.76","22556.82","WELLPOINT [1015]","HB AMC WELLPOINT","22189.90","73.78","","286.63","119.22","1107.45","105","9323.49","23910.23","percent of total billed charges",""
"KIT CRANIAL MEDPOR CUSTOMIZED IMPLANT SM","SUP-ITM-10272784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","30075.76","22556.82","AETNA [1001]","HB AMC AETNA HMO","20992.88","69.8","","675.31","184.75","1721.50","286","15717.59","24577.91","percent of total billed charges",""
"KIT CRANIAL MEDPOR CUSTOMIZED IMPLANT SM","SUP-ITM-10272784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","30075.76","22556.82","AETNA [1001]","HB AMC AETNA PPO","24180.91","80.4","","1261.44","103.12","1514.10","21","15717.59","24577.91","percent of total billed charges",""
"KIT CRANIAL MEDPOR CUSTOMIZED IMPLANT SM","SUP-ITM-10272784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","30075.76","22556.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","24180.91","80.4","","1365.00","1365.00","1365.00","1 through 10","15717.59","24577.91","percent of total billed charges",""
"KIT CRANIAL MEDPOR CUSTOMIZED IMPLANT SM","SUP-ITM-10272784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","30075.76","22556.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","24577.91","81.72","","5157.68","5157.68","5157.68","1 through 10","15717.59","24577.91","percent of total billed charges",""
"KIT CRANIAL MEDPOR CUSTOMIZED IMPLANT SM","SUP-ITM-10272784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","30075.76","22556.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24577.91","81.72","","431.26","71.26","1459.57","88","15717.59","24577.91","percent of total billed charges",""
"KIT CRYOGEN CRYOTHERAPY TRUFREEZE LF LIQUID NITROGEN SPRAY CATHETER SUCTION TUBING STERILE DISPOSABLE BX/5EA","SUP-ITM-10148265","CDM","C1886","HCPCS","0272","RC","","","","both","","","4737.50","3553.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3401.53","71.8","","4399.55","4399.55","4399.55","1 through 10","1468.63","3766.31","percent of total billed charges",""
"KIT CRYOGEN CRYOTHERAPY TRUFREEZE LF LIQUID NITROGEN SPRAY CATHETER SUCTION TUBING STERILE DISPOSABLE BX/5EA","SUP-ITM-10148265","CDM","C1886","HCPCS","0272","RC","","","","both","","","4737.50","3553.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1729.19","36.5","","1413.19","621.27","1413.19","1 through 10","1468.63","3766.31","percent of total billed charges",""
"KIT CRYOGEN CRYOTHERAPY TRUFREEZE LF LIQUID NITROGEN SPRAY CATHETER SUCTION TUBING STERILE DISPOSABLE BX/5EA","SUP-ITM-10148265","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","4737.50","3553.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3871.49","81.72","","8168.27","2209.17","8168.27","1 through 10","2475.82","3871.49","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.410","SUP-ITM-10091667","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10440.34","79.5","","800.18","480.96","1887.97","195","4071.08","10440.34","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.410","SUP-ITM-10091667","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6999.62","53.3","","813.12","216.42","1444.50","81","4071.08","10440.34","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.410","SUP-ITM-10091667","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4071.08","31","","432.60","432.60","432.60","1 through 10","4071.08","10440.34","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.410","SUP-ITM-10091667","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4793.36","36.5","","148.37","54.89","631.39","94","4071.08","10440.34","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.410","SUP-ITM-10091667","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5029.75","38.3","","279.30","91.72","1116.77","266","4071.08","10440.34","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.410","SUP-ITM-10091667","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5633.84","42.9","","731.00","63.70","731.00","1 through 10","4071.08","10440.34","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.410","SUP-ITM-10091667","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5633.84","42.9","","384.74","384.74","384.74","1 through 10","4071.08","10440.34","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.410","SUP-ITM-10091667","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","WELLPOINT [1015]","HB AMC WELLPOINT","9689.16","73.78","","286.63","119.22","1107.45","105","4071.08","10440.34","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.410","SUP-ITM-10091667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","AETNA [1001]","HB AMC AETNA HMO","9166.49","69.8","","675.31","184.75","1721.50","286","6863.04","10731.88","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.410","SUP-ITM-10091667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","AETNA [1001]","HB AMC AETNA PPO","10558.53","80.4","","1261.44","103.12","1514.10","21","6863.04","10731.88","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.410","SUP-ITM-10091667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10558.53","80.4","","1365.00","1365.00","1365.00","1 through 10","6863.04","10731.88","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.410","SUP-ITM-10091667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","10731.88","81.72","","5157.68","5157.68","5157.68","1 through 10","6863.04","10731.88","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.410","SUP-ITM-10091667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10731.88","81.72","","431.26","71.26","1459.57","88","6863.04","10731.88","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.540","SUP-ITM-10079664","CDM","C1713","HCPCS","0278","RC","","","","both","","","14156.83","10617.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11254.68","79.5","","800.18","480.96","1887.97","195","4388.62","11254.68","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.540","SUP-ITM-10079664","CDM","C1713","HCPCS","0278","RC","","","","both","","","14156.83","10617.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7545.59","53.3","","813.12","216.42","1444.50","81","4388.62","11254.68","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.540","SUP-ITM-10079664","CDM","C1713","HCPCS","0278","RC","","","","both","","","14156.83","10617.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4388.62","31","","432.60","432.60","432.60","1 through 10","4388.62","11254.68","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.540","SUP-ITM-10079664","CDM","C1713","HCPCS","0278","RC","","","","both","","","14156.83","10617.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5167.24","36.5","","148.37","54.89","631.39","94","4388.62","11254.68","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.540","SUP-ITM-10079664","CDM","C1713","HCPCS","0278","RC","","","","both","","","14156.83","10617.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5422.07","38.3","","279.30","91.72","1116.77","266","4388.62","11254.68","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.540","SUP-ITM-10079664","CDM","C1713","HCPCS","0278","RC","","","","both","","","14156.83","10617.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6073.28","42.9","","731.00","63.70","731.00","1 through 10","4388.62","11254.68","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.540","SUP-ITM-10079664","CDM","C1713","HCPCS","0278","RC","","","","both","","","14156.83","10617.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6073.28","42.9","","384.74","384.74","384.74","1 through 10","4388.62","11254.68","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.540","SUP-ITM-10079664","CDM","C1713","HCPCS","0278","RC","","","","both","","","14156.83","10617.62","WELLPOINT [1015]","HB AMC WELLPOINT","10444.91","73.78","","286.63","119.22","1107.45","105","4388.62","11254.68","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.540","SUP-ITM-10079664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14156.83","10617.62","AETNA [1001]","HB AMC AETNA HMO","9881.47","69.8","","675.31","184.75","1721.50","286","7398.36","11568.96","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.540","SUP-ITM-10079664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14156.83","10617.62","AETNA [1001]","HB AMC AETNA PPO","11382.09","80.4","","1261.44","103.12","1514.10","21","7398.36","11568.96","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.540","SUP-ITM-10079664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14156.83","10617.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11382.09","80.4","","1365.00","1365.00","1365.00","1 through 10","7398.36","11568.96","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.540","SUP-ITM-10079664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14156.83","10617.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","11568.96","81.72","","5157.68","5157.68","5157.68","1 through 10","7398.36","11568.96","percent of total billed charges",""
"KIT CUSTOM CRANIOMAXILLOFACIAL PEEK SD800.540","SUP-ITM-10079664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14156.83","10617.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11568.96","81.72","","431.26","71.26","1459.57","88","7398.36","11568.96","percent of total billed charges",""
"KIT CUSTOM SEAL US","SUP-ITM-10138483","CDM","C1874","HCPCS","0278","RC","","","","both","","","2467.50","1850.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1603.88","65","","6652.80","6652.80","6652.80","1 through 10","764.93","1961.66","percent of total billed charges",""
"KIT CUSTOM SEAL US","SUP-ITM-10138483","CDM","C1874","HCPCS","0278","RC","","","","both","","","2467.50","1850.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1961.66","79.5","","2612.61","795.38","2612.61","1 through 10","764.93","1961.66","percent of total billed charges",""
"KIT CUSTOM SEAL US","SUP-ITM-10138483","CDM","C1874","HCPCS","0278","RC","","","","both","","","2467.50","1850.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1315.18","53.3","","1101.80","1101.80","1101.80","1 through 10","764.93","1961.66","percent of total billed charges",""
"KIT CUSTOM SEAL US","SUP-ITM-10138483","CDM","C1874","HCPCS","0278","RC","","","","both","","","2467.50","1850.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1603.88","65","","1820.00","910.00","1820.00","1 through 10","764.93","1961.66","percent of total billed charges",""
"KIT CUSTOM SEAL US","SUP-ITM-10138483","CDM","C1874","HCPCS","0278","RC","","","","both","","","2467.50","1850.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","900.64","36.5","","1257.80","693.44","2424.50","1 through 10","764.93","1961.66","percent of total billed charges",""
"KIT CUSTOM SEAL US","SUP-ITM-10138483","CDM","C1874","HCPCS","0278","RC","","","","both","","","2467.50","1850.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","945.05","38.3","","1950.11","547.40","2346.00","1 through 10","764.93","1961.66","percent of total billed charges",""
"KIT CUSTOM SEAL US","SUP-ITM-10138483","CDM","C1874","HCPCS","0278","RC","","","","both","","","2467.50","1850.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1058.56","42.9","","5096.18","5096.18","5096.18","1 through 10","764.93","1961.66","percent of total billed charges",""
"KIT CUSTOM SEAL US","SUP-ITM-10138483","CDM","C1874","HCPCS","0278","RC","","","","both","","","2467.50","1850.62","WELLPOINT [1015]","HB AMC WELLPOINT","1820.52","73.78","","1172.59","1172.59","4829.94","1 through 10","764.93","1961.66","percent of total billed charges",""
"KIT CUSTOM SEAL US","SUP-ITM-10138483","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2467.50","1850.62","AETNA [1001]","HB AMC AETNA HMO","1722.32","69.8","","1806.84","947.80","5091.72","1 through 10","1289.52","2016.44","percent of total billed charges",""
"KIT CUSTOM SEAL US","SUP-ITM-10138483","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2467.50","1850.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2016.44","81.72","","1259.05","615.58","4586.56","1 through 10","1289.52","2016.44","percent of total billed charges",""
"KIT ELECTRODE ABLATION ENDOMETRIAL NOVASURE BIPOLAR HANDPIECE CORD CONTROLLER BX/3EA","SUP-ITM-10015957","CDM","C1886","HCPCS","0272","RC","","","","both","","","3605.00","2703.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2588.39","71.8","","4399.55","4399.55","4399.55","1 through 10","1117.55","2865.98","percent of total billed charges",""
"KIT ELECTRODE ABLATION ENDOMETRIAL NOVASURE BIPOLAR HANDPIECE CORD CONTROLLER BX/3EA","SUP-ITM-10015957","CDM","C1886","HCPCS","0272","RC","","","","both","","","3605.00","2703.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1315.83","36.5","","1413.19","621.27","1413.19","1 through 10","1117.55","2865.98","percent of total billed charges",""
"KIT ELECTRODE ABLATION ENDOMETRIAL NOVASURE BIPOLAR HANDPIECE CORD CONTROLLER BX/3EA","SUP-ITM-10015957","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","3605.00","2703.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2946.01","81.72","","8168.27","2209.17","8168.27","1 through 10","1883.97","2946.01","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","800.18","480.96","1887.97","195","271.25","695.63","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","813.12","216.42","1444.50","81","271.25","695.63","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.25","31","","432.60","432.60","432.60","1 through 10","271.25","695.63","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","148.37","54.89","631.39","94","271.25","695.63","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","279.30","91.72","1116.77","266","271.25","695.63","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","731.00","63.70","731.00","1 through 10","271.25","695.63","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","384.74","384.74","384.74","1 through 10","271.25","695.63","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","286.63","119.22","1107.45","105","271.25","695.63","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","675.31","184.75","1721.50","286","457.28","715.05","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA PPO","703.50","80.4","","1261.44","103.12","1514.10","21","457.28","715.05","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1365.00","1365.00","1365.00","1 through 10","457.28","715.05","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","715.05","81.72","","5157.68","5157.68","5157.68","1 through 10","457.28","715.05","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","431.26","71.26","1459.57","88","457.28","715.05","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","both","","","15625.00","11718.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12421.88","79.5","","1309.77","674.56","6049.93","26","4843.75","12421.88","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","both","","","15625.00","11718.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8328.13","53.3","","1901.83","1901.83","2962.25","1 through 10","4843.75","12421.88","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","both","","","15625.00","11718.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5703.13","36.5","","1620.31","1620.31","19908.88","1 through 10","4843.75","12421.88","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","both","","","15625.00","11718.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5984.38","38.3","","352.91","352.91","2046.30","1 through 10","4843.75","12421.88","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","both","","","15625.00","11718.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6703.13","42.9","","9668.75","9668.75","9668.75","1 through 10","4843.75","12421.88","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","both","","","15625.00","11718.75","WELLPOINT [1015]","HB AMC WELLPOINT","11528.13","73.78","","699.88","384.10","3443.31","33","4843.75","12421.88","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","15625.00","11718.75","AETNA [1001]","HB AMC AETNA HMO","10906.25","69.8","","1421.24","264.50","4933.46","29","8165.63","12768.75","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","15625.00","11718.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","12562.50","80.4","","1022.97","1022.97","3607.50","1 through 10","8165.63","12768.75","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","15625.00","11718.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12768.75","81.72","","3010.54","693.88","5019.88","35","8165.63","12768.75","percent of total billed charges",""
"KIT EXTENDER EXTENSION PERCUTANEOUS INLINE CONNECTOR QUADRIPOLAR LEADTUNNELING GUIDE TIP PASSING STRAW","SUP-ITM-10022715","CDM","C1883","HCPCS","0278","RC","","","","both","","","626.50","469.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.67","36.5","","1073.15","1073.15","1073.15","1 through 10","194.22","498.07","percent of total billed charges",""
"KIT EXTENDER EXTENSION PERCUTANEOUS INLINE CONNECTOR QUADRIPOLAR LEADTUNNELING GUIDE TIP PASSING STRAW","SUP-ITM-10022715","CDM","C1883","HCPCS","0278","RC","","","","both","","","626.50","469.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.95","38.3","","1808.38","1642.20","1808.38","1 through 10","194.22","498.07","percent of total billed charges",""
"KIT EXTENDER EXTENSION PERCUTANEOUS INLINE CONNECTOR QUADRIPOLAR LEADTUNNELING GUIDE TIP PASSING STRAW","SUP-ITM-10022715","CDM","C1883","HCPCS","0278","RC","","","","both","","","626.50","469.87","WELLPOINT [1015]","HB AMC WELLPOINT","462.23","73.78","","625.38","625.38","625.38","1 through 10","194.22","498.07","percent of total billed charges",""
"KIT EXTENSION 4.32MM PERCUTANEOUS FOR INTERSTIM SURESCAN MRI LEAD","SUP-ITM-10277216","CDM","C1883","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","1073.15","1073.15","1073.15","1 through 10","260.4","667.8","percent of total billed charges",""
"KIT EXTENSION 4.32MM PERCUTANEOUS FOR INTERSTIM SURESCAN MRI LEAD","SUP-ITM-10277216","CDM","C1883","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","1808.38","1642.20","1808.38","1 through 10","260.4","667.8","percent of total billed charges",""
"KIT EXTENSION 4.32MM PERCUTANEOUS FOR INTERSTIM SURESCAN MRI LEAD","SUP-ITM-10277216","CDM","C1883","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","625.38","625.38","625.38","1 through 10","260.4","667.8","percent of total billed charges",""
"KIT EXTENSION 55CM 8 CONTACT","SUP-ITM-10241026","CDM","C1883","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","1073.15","1073.15","1073.15","1 through 10","542.5","1391.25","percent of total billed charges",""
"KIT EXTENSION 55CM 8 CONTACT","SUP-ITM-10241026","CDM","C1883","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","1808.38","1642.20","1808.38","1 through 10","542.5","1391.25","percent of total billed charges",""
"KIT EXTENSION 55CM 8 CONTACT","SUP-ITM-10241026","CDM","C1883","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","625.38","625.38","625.38","1 through 10","542.5","1391.25","percent of total billed charges",""
"KIT FILTER OPTIONELITE 6.5FR 30MM 70CM FEMORAL OR JUGULAR ACCESS APEX STABLE BASE RETEN ANCHOR PATTERN VENA CAVA","SUP-ITM-10118029","CDM","C1880","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","WELLPOINT [1015]","HB AMC WELLPOINT","2711.42","73.78","","2616.17","2616.17","2616.17","1 through 10","1139.25","2921.63","percent of total billed charges",""
"Kit Gene Analysis D816 Variant(S)","PX-31000696","CDM","81273","CPT","0310","RC","","","","both","","","856.00","642.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","680.52","79.5","","653.21","653.21","653.21","1 through 10","122.37","813.2","percent of total billed charges",""
"Kit Gene Analysis D816 Variant(S)","PX-31000696","CDM","81273","CPT","0310","RC","","","","both","","","856.00","642.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","312.44","36.5","","309.59","263.11","309.59","1 through 10","122.37","813.2","percent of total billed charges",""
"Kit Gene Analysis D816 Variant(S)","PX-31000696","CDM","81273","CPT","0310","RC","","","","both","","","856.00","642.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","327.85","38.3","","324.53","315.40","324.53","1 through 10","122.37","813.2","percent of total billed charges",""
"Kit Gene Analysis D816 Variant(S)","PX-31000696","CDM","81273","CPT","0310","RC","","","","outpatient","","","856.00","642.00","AETNA [1001]","HB AMC AETNA HMO","597.49","69.8","","561.91","561.91","647.40","1 through 10","254.23","765.45","percent of total billed charges",""
"Kit Gene Analysis D816 Variant(S)","PX-31000696","CDM","81273","CPT","0310","RC","","","","outpatient","","","856.00","642.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","518.31","60.55","","356.76","356.76","356.76","1 through 10","254.23","765.45","percent of total billed charges",""
"Kit Gene Analysis D816 Variant(S)","PX-31000696","CDM","81273","CPT","0310","RC","","","","outpatient","","","856.00","642.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","447.00","52.22","","356.76","356.76","356.76","15","254.23","765.45","percent of total billed charges",""
"Kit Gene Analysis D816 Variant(S)","PX-31000696","CDM","81273","CPT","0310","RC","","","","outpatient","","","856.00","642.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","699.52","81.72","","663.50","364.95","663.50","1 through 10","254.23","765.45","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","18028.95","13521.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","14333.02","79.5","","800.18","480.96","1887.97","195","5588.97","14333.02","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","18028.95","13521.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9609.43","53.3","","813.12","216.42","1444.50","81","5588.97","14333.02","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","18028.95","13521.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","5588.97","31","","432.60","432.60","432.60","1 through 10","5588.97","14333.02","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","18028.95","13521.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6580.57","36.5","","148.37","54.89","631.39","94","5588.97","14333.02","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","18028.95","13521.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6905.09","38.3","","279.30","91.72","1116.77","266","5588.97","14333.02","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","18028.95","13521.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7734.42","42.9","","731.00","63.70","731.00","1 through 10","5588.97","14333.02","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","18028.95","13521.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7734.42","42.9","","384.74","384.74","384.74","1 through 10","5588.97","14333.02","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","18028.95","13521.71","WELLPOINT [1015]","HB AMC WELLPOINT","13301.76","73.78","","286.63","119.22","1107.45","105","5588.97","14333.02","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18028.95","13521.71","AETNA [1001]","HB AMC AETNA HMO","12584.21","69.8","","675.31","184.75","1721.50","286","9421.93","14733.26","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18028.95","13521.71","AETNA [1001]","HB AMC AETNA PPO","14495.28","80.4","","1261.44","103.12","1514.10","21","9421.93","14733.26","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18028.95","13521.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","14495.28","80.4","","1365.00","1365.00","1365.00","1 through 10","9421.93","14733.26","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18028.95","13521.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","14733.26","81.72","","5157.68","5157.68","5157.68","1 through 10","9421.93","14733.26","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","18028.95","13521.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14733.26","81.72","","431.26","71.26","1459.57","88","9421.93","14733.26","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","16191.80","12143.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12872.48","79.5","","800.18","480.96","1887.97","195","5019.46","12872.48","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","16191.80","12143.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8630.23","53.3","","813.12","216.42","1444.50","81","5019.46","12872.48","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","16191.80","12143.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","5019.46","31","","432.60","432.60","432.60","1 through 10","5019.46","12872.48","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","16191.80","12143.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5910.01","36.5","","148.37","54.89","631.39","94","5019.46","12872.48","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","16191.80","12143.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6201.46","38.3","","279.30","91.72","1116.77","266","5019.46","12872.48","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","16191.80","12143.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6946.28","42.9","","731.00","63.70","731.00","1 through 10","5019.46","12872.48","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","16191.80","12143.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6946.28","42.9","","384.74","384.74","384.74","1 through 10","5019.46","12872.48","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","16191.80","12143.85","WELLPOINT [1015]","HB AMC WELLPOINT","11946.31","73.78","","286.63","119.22","1107.45","105","5019.46","12872.48","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16191.80","12143.85","AETNA [1001]","HB AMC AETNA HMO","11301.88","69.8","","675.31","184.75","1721.50","286","8461.83","13231.94","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16191.80","12143.85","AETNA [1001]","HB AMC AETNA PPO","13018.21","80.4","","1261.44","103.12","1514.10","21","8461.83","13231.94","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16191.80","12143.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","13018.21","80.4","","1365.00","1365.00","1365.00","1 through 10","8461.83","13231.94","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16191.80","12143.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","13231.94","81.72","","5157.68","5157.68","5157.68","1 through 10","8461.83","13231.94","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16191.80","12143.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13231.94","81.72","","431.26","71.26","1459.57","88","8461.83","13231.94","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1744.63","79.5","","800.18","480.96","1887.97","195","680.3","1744.63","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1169.67","53.3","","813.12","216.42","1444.50","81","680.3","1744.63","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","680.30","31","","432.60","432.60","432.60","1 through 10","680.3","1744.63","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","800.99","36.5","","148.37","54.89","631.39","94","680.3","1744.63","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","840.49","38.3","","279.30","91.72","1116.77","266","680.3","1744.63","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","941.44","42.9","","731.00","63.70","731.00","1 through 10","680.3","1744.63","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","941.44","42.9","","384.74","384.74","384.74","1 through 10","680.3","1744.63","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2194.50","1645.87","WELLPOINT [1015]","HB AMC WELLPOINT","1619.10","73.78","","286.63","119.22","1107.45","105","680.3","1744.63","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2194.50","1645.87","AETNA [1001]","HB AMC AETNA HMO","1531.76","69.8","","675.31","184.75","1721.50","286","1146.85","1793.35","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2194.50","1645.87","AETNA [1001]","HB AMC AETNA PPO","1764.38","80.4","","1261.44","103.12","1514.10","21","1146.85","1793.35","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2194.50","1645.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1764.38","80.4","","1365.00","1365.00","1365.00","1 through 10","1146.85","1793.35","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2194.50","1645.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1793.35","81.72","","5157.68","5157.68","5157.68","1 through 10","1146.85","1793.35","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2194.50","1645.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1793.35","81.72","","431.26","71.26","1459.57","88","1146.85","1793.35","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","11827.30","8870.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9402.70","79.5","","800.18","480.96","1887.97","195","3666.46","9402.7","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","11827.30","8870.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6303.95","53.3","","813.12","216.42","1444.50","81","3666.46","9402.7","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","11827.30","8870.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3666.46","31","","432.60","432.60","432.60","1 through 10","3666.46","9402.7","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","11827.30","8870.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4316.96","36.5","","148.37","54.89","631.39","94","3666.46","9402.7","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","11827.30","8870.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4529.86","38.3","","279.30","91.72","1116.77","266","3666.46","9402.7","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","11827.30","8870.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5073.91","42.9","","731.00","63.70","731.00","1 through 10","3666.46","9402.7","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","11827.30","8870.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5073.91","42.9","","384.74","384.74","384.74","1 through 10","3666.46","9402.7","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","11827.30","8870.47","WELLPOINT [1015]","HB AMC WELLPOINT","8726.18","73.78","","286.63","119.22","1107.45","105","3666.46","9402.7","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11827.30","8870.47","AETNA [1001]","HB AMC AETNA HMO","8255.46","69.8","","675.31","184.75","1721.50","286","6180.95","9665.27","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11827.30","8870.47","AETNA [1001]","HB AMC AETNA PPO","9509.15","80.4","","1261.44","103.12","1514.10","21","6180.95","9665.27","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11827.30","8870.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9509.15","80.4","","1365.00","1365.00","1365.00","1 through 10","6180.95","9665.27","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11827.30","8870.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","9665.27","81.72","","5157.68","5157.68","5157.68","1 through 10","6180.95","9665.27","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11827.30","8870.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9665.27","81.72","","431.26","71.26","1459.57","88","6180.95","9665.27","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","both","","","574.00","430.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","299.97","52.26","","25.34","25.34","25.34","1 through 10","177.94","456.33","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","both","","","574.00","430.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","412.13","71.8","","105.81","105.81","366.90","1 through 10","177.94","456.33","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","both","","","574.00","430.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","401.80","70","","512.90","74.70","612.85","1 through 10","177.94","456.33","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","both","","","574.00","430.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","456.33","79.5","","200.27","182.80","200.27","1 through 10","177.94","456.33","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","both","","","574.00","430.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","305.94","53.3","","37.73","37.73","169.33","1 through 10","177.94","456.33","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","both","","","574.00","430.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","373.10","65","","100.27","8.48","494.52","1 through 10","177.94","456.33","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","both","","","574.00","430.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","373.10","65","","160.19","160.19","160.19","1 through 10","177.94","456.33","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","177.94","31","","28.12","28.12","28.12","1 through 10","177.94","456.33","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","209.51","36.5","","101.66","28.85","502.70","121","177.94","456.33","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","219.84","38.3","","61.58","25.32","328.44","138","177.94","456.33","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","both","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","246.25","42.9","","71.66","71.66","71.66","1 through 10","177.94","456.33","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","both","","","574.00","430.50","WELLPOINT [1015]","HB AMC WELLPOINT","423.50","73.78","","74.75","27.97","425.28","93","177.94","456.33","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","574.00","430.50","AETNA [1001]","HB AMC AETNA HMO","400.65","69.8","","52.67","14.36","414.90","1 through 10","299.97","469.07","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","574.00","430.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","299.97","52.26","","25.34","25.34","25.34","1 through 10","299.97","469.07","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","574.00","430.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","461.50","80.4","","478.02","107.84","478.02","1 through 10","299.97","469.07","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","469.07","81.72","","32.74","12.33","122.05","1 through 10","299.97","469.07","percent of total billed charges",""
"KIT GUIDEWIRE 210CM VASCULAR ACCESS AVALON ELITE SS NONCOATED J TIP BX/5EA","SUP-ITM-10115498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","469.07","81.72","","144.95","32.78","676.91","104","299.97","469.07","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","765.19","79.5","","800.18","480.96","1887.97","195","298.38","765.19","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","513.01","53.3","","813.12","216.42","1444.50","81","298.38","765.19","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","298.38","31","","432.60","432.60","432.60","1 through 10","298.38","765.19","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","351.31","36.5","","148.37","54.89","631.39","94","298.38","765.19","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","368.64","38.3","","279.30","91.72","1116.77","266","298.38","765.19","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","731.00","63.70","731.00","1 through 10","298.38","765.19","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","384.74","384.74","384.74","1 through 10","298.38","765.19","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","WELLPOINT [1015]","HB AMC WELLPOINT","710.13","73.78","","286.63","119.22","1107.45","105","298.38","765.19","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA HMO","671.83","69.8","","675.31","184.75","1721.50","286","503","786.56","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA PPO","773.85","80.4","","1261.44","103.12","1514.10","21","503","786.56","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","773.85","80.4","","1365.00","1365.00","1365.00","1 through 10","503","786.56","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","786.56","81.72","","5157.68","5157.68","5157.68","1 through 10","503","786.56","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","786.56","81.72","","431.26","71.26","1459.57","88","503","786.56","percent of total billed charges",""
"KIT HINGE 13MM FEMORAL NEXGEN KNEE SEGMENTAL SERVICE SIZE C","SUP-ITM-10076773","CDM","C1776","HCPCS","0278","RC","","","","both","","","6126.75","4595.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3201.84","52.26","","1113.10","1113.10","1113.10","1 through 10","1899.29","4870.77","percent of total billed charges",""
"KIT HINGE 13MM FEMORAL NEXGEN KNEE SEGMENTAL SERVICE SIZE C","SUP-ITM-10076773","CDM","C1776","HCPCS","0278","RC","","","","both","","","6126.75","4595.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4870.77","79.5","","1293.60","1148.53","1603.80","1 through 10","1899.29","4870.77","percent of total billed charges",""
"KIT HINGE 13MM FEMORAL NEXGEN KNEE SEGMENTAL SERVICE SIZE C","SUP-ITM-10076773","CDM","C1776","HCPCS","0278","RC","","","","both","","","6126.75","4595.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2236.26","36.5","","1023.42","771.29","2068.67","33","1899.29","4870.77","percent of total billed charges",""
"KIT HINGE 13MM FEMORAL NEXGEN KNEE SEGMENTAL SERVICE SIZE C","SUP-ITM-10076773","CDM","C1776","HCPCS","0278","RC","","","","both","","","6126.75","4595.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2346.55","38.3","","850.52","759.78","1211.25","66","1899.29","4870.77","percent of total billed charges",""
"KIT HINGE 13MM FEMORAL NEXGEN KNEE SEGMENTAL SERVICE SIZE C","SUP-ITM-10076773","CDM","C1776","HCPCS","0278","RC","","","","both","","","6126.75","4595.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2628.38","42.9","","2548.09","2548.09","2548.09","1 through 10","1899.29","4870.77","percent of total billed charges",""
"KIT HINGE 13MM FEMORAL NEXGEN KNEE SEGMENTAL SERVICE SIZE C","SUP-ITM-10076773","CDM","C1776","HCPCS","0278","RC","","","","both","","","6126.75","4595.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2628.38","42.9","","956.46","956.46","956.46","1 through 10","1899.29","4870.77","percent of total billed charges",""
"KIT HINGE 13MM FEMORAL NEXGEN KNEE SEGMENTAL SERVICE SIZE C","SUP-ITM-10076773","CDM","C1776","HCPCS","0278","RC","","","","both","","","6126.75","4595.06","WELLPOINT [1015]","HB AMC WELLPOINT","4520.32","73.78","","2344.73","1619.47","2530.35","16","1899.29","4870.77","percent of total billed charges",""
"KIT HINGE 13MM FEMORAL NEXGEN KNEE SEGMENTAL SERVICE SIZE C","SUP-ITM-10076773","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6126.75","4595.06","AETNA [1001]","HB AMC AETNA HMO","4276.47","69.8","","1523.63","988.41","4330.26","39","3201.84","5006.78","percent of total billed charges",""
"KIT HINGE 13MM FEMORAL NEXGEN KNEE SEGMENTAL SERVICE SIZE C","SUP-ITM-10076773","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6126.75","4595.06","AETNA [1001]","HB AMC AETNA PPO","4925.91","80.4","","1670.25","1670.25","1670.25","1 through 10","3201.84","5006.78","percent of total billed charges",""
"KIT HINGE 13MM FEMORAL NEXGEN KNEE SEGMENTAL SERVICE SIZE C","SUP-ITM-10076773","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6126.75","4595.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3201.84","52.26","","1113.10","1113.10","1113.10","1 through 10","3201.84","5006.78","percent of total billed charges",""
"KIT HINGE 13MM FEMORAL NEXGEN KNEE SEGMENTAL SERVICE SIZE C","SUP-ITM-10076773","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6126.75","4595.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5006.78","81.72","","1738.90","1484.65","2716.94","38","3201.84","5006.78","percent of total billed charges",""
"KIT IMPLANT 13X12X12MM SPEED COMPRESSION","SUP-ITM-10212945","CDM","C1776","HCPCS","0278","RC","","","","both","","","1929.55","1447.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1008.38","52.26","","1113.10","1113.10","1113.10","1 through 10","598.16","1533.99","percent of total billed charges",""
"KIT IMPLANT 13X12X12MM SPEED COMPRESSION","SUP-ITM-10212945","CDM","C1776","HCPCS","0278","RC","","","","both","","","1929.55","1447.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1533.99","79.5","","1293.60","1148.53","1603.80","1 through 10","598.16","1533.99","percent of total billed charges",""
"KIT IMPLANT 13X12X12MM SPEED COMPRESSION","SUP-ITM-10212945","CDM","C1776","HCPCS","0278","RC","","","","both","","","1929.55","1447.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","704.29","36.5","","1023.42","771.29","2068.67","33","598.16","1533.99","percent of total billed charges",""
"KIT IMPLANT 13X12X12MM SPEED COMPRESSION","SUP-ITM-10212945","CDM","C1776","HCPCS","0278","RC","","","","both","","","1929.55","1447.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","739.02","38.3","","850.52","759.78","1211.25","66","598.16","1533.99","percent of total billed charges",""
"KIT IMPLANT 13X12X12MM SPEED COMPRESSION","SUP-ITM-10212945","CDM","C1776","HCPCS","0278","RC","","","","both","","","1929.55","1447.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","827.78","42.9","","2548.09","2548.09","2548.09","1 through 10","598.16","1533.99","percent of total billed charges",""
"KIT IMPLANT 13X12X12MM SPEED COMPRESSION","SUP-ITM-10212945","CDM","C1776","HCPCS","0278","RC","","","","both","","","1929.55","1447.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","827.78","42.9","","956.46","956.46","956.46","1 through 10","598.16","1533.99","percent of total billed charges",""
"KIT IMPLANT 13X12X12MM SPEED COMPRESSION","SUP-ITM-10212945","CDM","C1776","HCPCS","0278","RC","","","","both","","","1929.55","1447.16","WELLPOINT [1015]","HB AMC WELLPOINT","1423.62","73.78","","2344.73","1619.47","2530.35","16","598.16","1533.99","percent of total billed charges",""
"KIT IMPLANT 13X12X12MM SPEED COMPRESSION","SUP-ITM-10212945","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1929.55","1447.16","AETNA [1001]","HB AMC AETNA HMO","1346.83","69.8","","1523.63","988.41","4330.26","39","1008.38","1576.83","percent of total billed charges",""
"KIT IMPLANT 13X12X12MM SPEED COMPRESSION","SUP-ITM-10212945","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1929.55","1447.16","AETNA [1001]","HB AMC AETNA PPO","1551.36","80.4","","1670.25","1670.25","1670.25","1 through 10","1008.38","1576.83","percent of total billed charges",""
"KIT IMPLANT 13X12X12MM SPEED COMPRESSION","SUP-ITM-10212945","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1929.55","1447.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1008.38","52.26","","1113.10","1113.10","1113.10","1 through 10","1008.38","1576.83","percent of total billed charges",""
"KIT IMPLANT 13X12X12MM SPEED COMPRESSION","SUP-ITM-10212945","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1929.55","1447.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1576.83","81.72","","1738.90","1484.65","2716.94","38","1008.38","1576.83","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1396.17","52.26","","1113.10","1113.10","1113.10","1 through 10","828.19","2123.91","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2123.91","79.5","","1293.60","1148.53","1603.80","1 through 10","828.19","2123.91","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","975.13","36.5","","1023.42","771.29","2068.67","33","828.19","2123.91","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1023.22","38.3","","850.52","759.78","1211.25","66","828.19","2123.91","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1146.11","42.9","","2548.09","2548.09","2548.09","1 through 10","828.19","2123.91","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1146.11","42.9","","956.46","956.46","956.46","1 through 10","828.19","2123.91","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","WELLPOINT [1015]","HB AMC WELLPOINT","1971.10","73.78","","2344.73","1619.47","2530.35","16","828.19","2123.91","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2671.59","2003.69","AETNA [1001]","HB AMC AETNA HMO","1864.77","69.8","","1523.63","988.41","4330.26","39","1396.17","2183.22","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2671.59","2003.69","AETNA [1001]","HB AMC AETNA PPO","2147.96","80.4","","1670.25","1670.25","1670.25","1 through 10","1396.17","2183.22","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2671.59","2003.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1396.17","52.26","","1113.10","1113.10","1113.10","1 through 10","1396.17","2183.22","percent of total billed charges",""
"KIT IMPLANT 15X12X12MM SPEED COMPRESSION","SUP-ITM-10211720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2671.59","2003.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2183.22","81.72","","1738.90","1484.65","2716.94","38","1396.17","2183.22","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3440.82","2580.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2735.45","79.5","","800.18","480.96","1887.97","195","1066.65","2735.45","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3440.82","2580.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1833.96","53.3","","813.12","216.42","1444.50","81","1066.65","2735.45","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3440.82","2580.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1066.65","31","","432.60","432.60","432.60","1 through 10","1066.65","2735.45","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3440.82","2580.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1255.90","36.5","","148.37","54.89","631.39","94","1066.65","2735.45","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3440.82","2580.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1317.83","38.3","","279.30","91.72","1116.77","266","1066.65","2735.45","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3440.82","2580.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1476.11","42.9","","731.00","63.70","731.00","1 through 10","1066.65","2735.45","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3440.82","2580.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1476.11","42.9","","384.74","384.74","384.74","1 through 10","1066.65","2735.45","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3440.82","2580.61","WELLPOINT [1015]","HB AMC WELLPOINT","2538.64","73.78","","286.63","119.22","1107.45","105","1066.65","2735.45","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3440.82","2580.61","AETNA [1001]","HB AMC AETNA HMO","2401.69","69.8","","675.31","184.75","1721.50","286","1798.17","2811.84","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3440.82","2580.61","AETNA [1001]","HB AMC AETNA PPO","2766.42","80.4","","1261.44","103.12","1514.10","21","1798.17","2811.84","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3440.82","2580.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2766.42","80.4","","1365.00","1365.00","1365.00","1 through 10","1798.17","2811.84","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3440.82","2580.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2811.84","81.72","","5157.68","5157.68","5157.68","1 through 10","1798.17","2811.84","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3440.82","2580.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2811.84","81.72","","431.26","71.26","1459.57","88","1798.17","2811.84","percent of total billed charges",""
"KIT IMPLANT HIP CUSTOM FEMORAL","SUP-ITM-10287221","CDM","C1776","HCPCS","0278","RC","","","","both","","","70000.00","52500.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","36582.00","52.26","","1113.10","1113.10","1113.10","1 through 10","21700","55650","percent of total billed charges",""
"KIT IMPLANT HIP CUSTOM FEMORAL","SUP-ITM-10287221","CDM","C1776","HCPCS","0278","RC","","","","both","","","70000.00","52500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","55650.00","79.5","","1293.60","1148.53","1603.80","1 through 10","21700","55650","percent of total billed charges",""
"KIT IMPLANT HIP CUSTOM FEMORAL","SUP-ITM-10287221","CDM","C1776","HCPCS","0278","RC","","","","both","","","70000.00","52500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25550.00","36.5","","1023.42","771.29","2068.67","33","21700","55650","percent of total billed charges",""
"KIT IMPLANT HIP CUSTOM FEMORAL","SUP-ITM-10287221","CDM","C1776","HCPCS","0278","RC","","","","both","","","70000.00","52500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26810.00","38.3","","850.52","759.78","1211.25","66","21700","55650","percent of total billed charges",""
"KIT IMPLANT HIP CUSTOM FEMORAL","SUP-ITM-10287221","CDM","C1776","HCPCS","0278","RC","","","","both","","","70000.00","52500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30030.00","42.9","","2548.09","2548.09","2548.09","1 through 10","21700","55650","percent of total billed charges",""
"KIT IMPLANT HIP CUSTOM FEMORAL","SUP-ITM-10287221","CDM","C1776","HCPCS","0278","RC","","","","both","","","70000.00","52500.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30030.00","42.9","","956.46","956.46","956.46","1 through 10","21700","55650","percent of total billed charges",""
"KIT IMPLANT HIP CUSTOM FEMORAL","SUP-ITM-10287221","CDM","C1776","HCPCS","0278","RC","","","","both","","","70000.00","52500.00","WELLPOINT [1015]","HB AMC WELLPOINT","51646.00","73.78","","2344.73","1619.47","2530.35","16","21700","55650","percent of total billed charges",""
"KIT IMPLANT HIP CUSTOM FEMORAL","SUP-ITM-10287221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","70000.00","52500.00","AETNA [1001]","HB AMC AETNA HMO","48860.00","69.8","","1523.63","988.41","4330.26","39","36582","57204","percent of total billed charges",""
"KIT IMPLANT HIP CUSTOM FEMORAL","SUP-ITM-10287221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","70000.00","52500.00","AETNA [1001]","HB AMC AETNA PPO","56280.00","80.4","","1670.25","1670.25","1670.25","1 through 10","36582","57204","percent of total billed charges",""
"KIT IMPLANT HIP CUSTOM FEMORAL","SUP-ITM-10287221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","70000.00","52500.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","36582.00","52.26","","1113.10","1113.10","1113.10","1 through 10","36582","57204","percent of total billed charges",""
"KIT IMPLANT HIP CUSTOM FEMORAL","SUP-ITM-10287221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","70000.00","52500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","57204.00","81.72","","1738.90","1484.65","2716.94","38","36582","57204","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","8990.00","6742.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4698.17","52.26","","1113.10","1113.10","1113.10","1 through 10","2786.9","7147.05","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","8990.00","6742.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7147.05","79.5","","1293.60","1148.53","1603.80","1 through 10","2786.9","7147.05","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","8990.00","6742.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3281.35","36.5","","1023.42","771.29","2068.67","33","2786.9","7147.05","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","8990.00","6742.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3443.17","38.3","","850.52","759.78","1211.25","66","2786.9","7147.05","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","8990.00","6742.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3856.71","42.9","","2548.09","2548.09","2548.09","1 through 10","2786.9","7147.05","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","8990.00","6742.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3856.71","42.9","","956.46","956.46","956.46","1 through 10","2786.9","7147.05","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","8990.00","6742.50","WELLPOINT [1015]","HB AMC WELLPOINT","6632.82","73.78","","2344.73","1619.47","2530.35","16","2786.9","7147.05","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8990.00","6742.50","AETNA [1001]","HB AMC AETNA HMO","6275.02","69.8","","1523.63","988.41","4330.26","39","4698.17","7346.63","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8990.00","6742.50","AETNA [1001]","HB AMC AETNA PPO","7227.96","80.4","","1670.25","1670.25","1670.25","1 through 10","4698.17","7346.63","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8990.00","6742.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4698.17","52.26","","1113.10","1113.10","1113.10","1 through 10","4698.17","7346.63","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8990.00","6742.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7346.63","81.72","","1738.90","1484.65","2716.94","38","4698.17","7346.63","percent of total billed charges",""
"KIT IMPLANT VOCAL 1CC INJECTABLE X2 PLUS CATHETER - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10287703","CDM","C1878","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","1991.51","1991.51","1991.51","1 through 10","759.5","1947.75","percent of total billed charges",""
"KIT IMPLANT VOCAL 1CC INJECTABLE X2 PLUS CATHETER - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10287703","CDM","C1878","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","650.52","650.52","650.52","1 through 10","759.5","1947.75","percent of total billed charges",""
"KIT IMPLANTABLE PULSE GENERATOR P16 VERCISE GENUS PRIMARY","SUP-ITM-10282133","CDM","C1820","HCPCS","0278","RC","","","","both","","","43750.00","32812.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23318.75","53.3","","54287.50","54287.50","54287.50","1 through 10","13562.5","34781.25","percent of total billed charges",""
"KIT IMPLANTABLE PULSE GENERATOR P16 VERCISE GENUS PRIMARY","SUP-ITM-10282133","CDM","C1820","HCPCS","0278","RC","","","","both","","","43750.00","32812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15968.75","36.5","","10467.31","10467.31","10467.31","1 through 10","13562.5","34781.25","percent of total billed charges",""
"KIT IMPLANTABLE PULSE GENERATOR P16 VERCISE GENUS PRIMARY","SUP-ITM-10282133","CDM","C1820","HCPCS","0278","RC","","","","both","","","43750.00","32812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16756.25","38.3","","21505.00","21505.00","21505.00","1 through 10","13562.5","34781.25","percent of total billed charges",""
"KIT IMPLANTABLE PULSE GENERATOR P16 VERCISE GENUS PRIMARY","SUP-ITM-10282133","CDM","C1820","HCPCS","0278","RC","","","","both","","","43750.00","32812.50","WELLPOINT [1015]","HB AMC WELLPOINT","32278.75","73.78","","40016.88","40016.88","40016.88","1 through 10","13562.5","34781.25","percent of total billed charges",""
"KIT IMPLANTABLE PULSE GENERATOR R16 VERCISE GENUS RECHARGEABLE","SUP-ITM-10282132","CDM","C1820","HCPCS","0278","RC","","","","both","","","55000.00","41250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","29315.00","53.3","","54287.50","54287.50","54287.50","1 through 10","17050","43725","percent of total billed charges",""
"KIT IMPLANTABLE PULSE GENERATOR R16 VERCISE GENUS RECHARGEABLE","SUP-ITM-10282132","CDM","C1820","HCPCS","0278","RC","","","","both","","","55000.00","41250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20075.00","36.5","","10467.31","10467.31","10467.31","1 through 10","17050","43725","percent of total billed charges",""
"KIT IMPLANTABLE PULSE GENERATOR R16 VERCISE GENUS RECHARGEABLE","SUP-ITM-10282132","CDM","C1820","HCPCS","0278","RC","","","","both","","","55000.00","41250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21065.00","38.3","","21505.00","21505.00","21505.00","1 through 10","17050","43725","percent of total billed charges",""
"KIT IMPLANTABLE PULSE GENERATOR R16 VERCISE GENUS RECHARGEABLE","SUP-ITM-10282132","CDM","C1820","HCPCS","0278","RC","","","","both","","","55000.00","41250.00","WELLPOINT [1015]","HB AMC WELLPOINT","40579.00","73.78","","40016.88","40016.88","40016.88","1 through 10","17050","43725","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","210.00","157.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","109.75","52.26","","16.24","16.24","54.15","1 through 10","65.1","166.95","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","210.00","157.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","150.78","71.8","","86.33","32.67","86.33","1 through 10","65.1","166.95","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","210.00","157.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","147.00","70","","113.68","63.00","177.34","40","65.1","166.95","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","210.00","157.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.95","79.5","","50.70","21.76","168.00","12","65.1","166.95","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","210.00","157.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.93","53.3","","89.31","89.31","99.75","1 through 10","65.1","166.95","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","136.50","65","","94.41","17.06","2275.00","1 through 10","65.1","166.95","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","65.10","31","","35.13","35.13","35.13","1 through 10","65.1","166.95","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.65","36.5","","40.08","12.40","86.17","108","65.1","166.95","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.43","38.3","","33.25","10.27","68.43","169","65.1","166.95","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","25.48","14.86","90.88","1 through 10","65.1","166.95","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","90.88","90.88","90.88","1 through 10","65.1","166.95","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB AMC WELLPOINT","154.94","73.78","","84.63","19.55","140.02","123","65.1","166.95","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA HMO","146.58","69.8","","76.96","17.77","113.68","14","109.75","171.61","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA PPO","168.84","80.4","","57.31","57.31","57.31","1 through 10","109.75","171.61","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","210.00","157.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","109.75","52.26","","16.24","16.24","54.15","1 through 10","109.75","171.61","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","168.84","80.4","","68.25","68.25","87.50","1 through 10","109.75","171.61","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","171.61","81.72","","156.19","156.19","156.19","1 through 10","109.75","171.61","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","171.61","81.72","","82.70","12.06","98.97","13","109.75","171.61","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.61","81.72","","50.47","25.30","134.30","140","109.75","171.61","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","both","","","876.65","657.49","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","458.14","52.26","","16.24","16.24","54.15","1 through 10","271.76","696.94","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","both","","","876.65","657.49","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","629.43","71.8","","86.33","32.67","86.33","1 through 10","271.76","696.94","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","both","","","876.65","657.49","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","613.66","70","","113.68","63.00","177.34","40","271.76","696.94","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","both","","","876.65","657.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","696.94","79.5","","50.70","21.76","168.00","12","271.76","696.94","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","both","","","876.65","657.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","467.25","53.3","","89.31","89.31","99.75","1 through 10","271.76","696.94","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","both","","","876.65","657.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","569.82","65","","94.41","17.06","2275.00","1 through 10","271.76","696.94","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","both","","","876.65","657.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.76","31","","35.13","35.13","35.13","1 through 10","271.76","696.94","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","both","","","876.65","657.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.98","36.5","","40.08","12.40","86.17","108","271.76","696.94","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","both","","","876.65","657.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.76","38.3","","33.25","10.27","68.43","169","271.76","696.94","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","both","","","876.65","657.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","376.08","42.9","","25.48","14.86","90.88","1 through 10","271.76","696.94","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","both","","","876.65","657.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","376.08","42.9","","90.88","90.88","90.88","1 through 10","271.76","696.94","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","both","","","876.65","657.49","WELLPOINT [1015]","HB AMC WELLPOINT","646.79","73.78","","84.63","19.55","140.02","123","271.76","696.94","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","876.65","657.49","AETNA [1001]","HB AMC AETNA HMO","611.90","69.8","","76.96","17.77","113.68","14","458.14","716.4","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","876.65","657.49","AETNA [1001]","HB AMC AETNA PPO","704.83","80.4","","57.31","57.31","57.31","1 through 10","458.14","716.4","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","876.65","657.49","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","458.14","52.26","","16.24","16.24","54.15","1 through 10","458.14","716.4","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","876.65","657.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","704.83","80.4","","68.25","68.25","87.50","1 through 10","458.14","716.4","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","876.65","657.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","716.40","81.72","","156.19","156.19","156.19","1 through 10","458.14","716.4","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","876.65","657.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","716.40","81.72","","82.70","12.06","98.97","13","458.14","716.4","percent of total billed charges",""
"KIT INTRODUCER 16FR 18GA .035IN MIC-KEY LAPAROSCOPY DILATOR","SUP-ITM-10164745","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","876.65","657.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","716.40","81.72","","50.47","25.30","134.30","140","458.14","716.4","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","980.00","735.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","512.15","52.26","","16.24","16.24","54.15","1 through 10","303.8","779.1","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","980.00","735.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","703.64","71.8","","86.33","32.67","86.33","1 through 10","303.8","779.1","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","980.00","735.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","686.00","70","","113.68","63.00","177.34","40","303.8","779.1","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","980.00","735.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","779.10","79.5","","50.70","21.76","168.00","12","303.8","779.1","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","980.00","735.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","522.34","53.3","","89.31","89.31","99.75","1 through 10","303.8","779.1","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","980.00","735.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","637.00","65","","94.41","17.06","2275.00","1 through 10","303.8","779.1","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","303.80","31","","35.13","35.13","35.13","1 through 10","303.8","779.1","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","357.70","36.5","","40.08","12.40","86.17","108","303.8","779.1","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","375.34","38.3","","33.25","10.27","68.43","169","303.8","779.1","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.42","42.9","","25.48","14.86","90.88","1 through 10","303.8","779.1","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","980.00","735.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.42","42.9","","90.88","90.88","90.88","1 through 10","303.8","779.1","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","980.00","735.00","WELLPOINT [1015]","HB AMC WELLPOINT","723.04","73.78","","84.63","19.55","140.02","123","303.8","779.1","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","980.00","735.00","AETNA [1001]","HB AMC AETNA HMO","684.04","69.8","","76.96","17.77","113.68","14","512.15","800.86","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","980.00","735.00","AETNA [1001]","HB AMC AETNA PPO","787.92","80.4","","57.31","57.31","57.31","1 through 10","512.15","800.86","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","980.00","735.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","512.15","52.26","","16.24","16.24","54.15","1 through 10","512.15","800.86","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","980.00","735.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","787.92","80.4","","68.25","68.25","87.50","1 through 10","512.15","800.86","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","980.00","735.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","800.86","81.72","","156.19","156.19","156.19","1 through 10","512.15","800.86","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","800.86","81.72","","82.70","12.06","98.97","13","512.15","800.86","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","800.86","81.72","","50.47","25.30","134.30","140","512.15","800.86","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","808.89","606.67","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","422.73","52.26","","16.24","16.24","54.15","1 through 10","250.76","643.07","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","808.89","606.67","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","580.78","71.8","","86.33","32.67","86.33","1 through 10","250.76","643.07","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","808.89","606.67","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","566.22","70","","113.68","63.00","177.34","40","250.76","643.07","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","808.89","606.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","643.07","79.5","","50.70","21.76","168.00","12","250.76","643.07","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","808.89","606.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","431.14","53.3","","89.31","89.31","99.75","1 through 10","250.76","643.07","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","808.89","606.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","525.78","65","","94.41","17.06","2275.00","1 through 10","250.76","643.07","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","808.89","606.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","250.76","31","","35.13","35.13","35.13","1 through 10","250.76","643.07","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","808.89","606.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","295.24","36.5","","40.08","12.40","86.17","108","250.76","643.07","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","808.89","606.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","309.80","38.3","","33.25","10.27","68.43","169","250.76","643.07","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","808.89","606.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","347.01","42.9","","25.48","14.86","90.88","1 through 10","250.76","643.07","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","808.89","606.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","347.01","42.9","","90.88","90.88","90.88","1 through 10","250.76","643.07","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","both","","","808.89","606.67","WELLPOINT [1015]","HB AMC WELLPOINT","596.80","73.78","","84.63","19.55","140.02","123","250.76","643.07","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","808.89","606.67","AETNA [1001]","HB AMC AETNA HMO","564.61","69.8","","76.96","17.77","113.68","14","422.73","661.02","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","808.89","606.67","AETNA [1001]","HB AMC AETNA PPO","650.35","80.4","","57.31","57.31","57.31","1 through 10","422.73","661.02","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","808.89","606.67","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","422.73","52.26","","16.24","16.24","54.15","1 through 10","422.73","661.02","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","808.89","606.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","650.35","80.4","","68.25","68.25","87.50","1 through 10","422.73","661.02","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","808.89","606.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","661.02","81.72","","156.19","156.19","156.19","1 through 10","422.73","661.02","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","808.89","606.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","661.02","81.72","","82.70","12.06","98.97","13","422.73","661.02","percent of total billed charges",""
"KIT INTRODUCER 22FR TUBE FEEDING MIC-KEY-JJT","SUP-ITM-10158866","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","808.89","606.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","661.02","81.72","","50.47","25.30","134.30","140","422.73","661.02","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","713.35","52.26","","16.24","16.24","54.15","1 through 10","423.15","1085.18","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","980.07","71.8","","86.33","32.67","86.33","1 through 10","423.15","1085.18","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","955.50","70","","113.68","63.00","177.34","40","423.15","1085.18","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1085.18","79.5","","50.70","21.76","168.00","12","423.15","1085.18","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","727.55","53.3","","89.31","89.31","99.75","1 through 10","423.15","1085.18","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","887.25","65","","94.41","17.06","2275.00","1 through 10","423.15","1085.18","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","423.15","31","","35.13","35.13","35.13","1 through 10","423.15","1085.18","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","498.23","36.5","","40.08","12.40","86.17","108","423.15","1085.18","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","522.80","38.3","","33.25","10.27","68.43","169","423.15","1085.18","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","25.48","14.86","90.88","1 through 10","423.15","1085.18","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","90.88","90.88","90.88","1 through 10","423.15","1085.18","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB AMC WELLPOINT","1007.10","73.78","","84.63","19.55","140.02","123","423.15","1085.18","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA HMO","952.77","69.8","","76.96","17.77","113.68","14","713.35","1115.48","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA PPO","1097.46","80.4","","57.31","57.31","57.31","1 through 10","713.35","1115.48","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1365.00","1023.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","713.35","52.26","","16.24","16.24","54.15","1 through 10","713.35","1115.48","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1097.46","80.4","","68.25","68.25","87.50","1 through 10","713.35","1115.48","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1115.48","81.72","","156.19","156.19","156.19","1 through 10","713.35","1115.48","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1115.48","81.72","","82.70","12.06","98.97","13","713.35","1115.48","percent of total billed charges",""
"KIT INTRODUCER 25F ID 50CM FOR LEADLESS AVEIR PM - MUST ORDER 2 PER PO TO GET DISCOUNT","SUP-ITM-10309369","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1115.48","81.72","","50.47","25.30","134.30","140","713.35","1115.48","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.50","196.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","137.18","52.26","","16.24","16.24","54.15","1 through 10","81.38","208.69","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.50","196.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","188.48","71.8","","86.33","32.67","86.33","1 through 10","81.38","208.69","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.50","196.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","183.75","70","","113.68","63.00","177.34","40","81.38","208.69","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.50","196.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","208.69","79.5","","50.70","21.76","168.00","12","81.38","208.69","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.50","196.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.91","53.3","","89.31","89.31","99.75","1 through 10","81.38","208.69","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.50","196.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","170.63","65","","94.41","17.06","2275.00","1 through 10","81.38","208.69","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","81.38","31","","35.13","35.13","35.13","1 through 10","81.38","208.69","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.81","36.5","","40.08","12.40","86.17","108","81.38","208.69","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.54","38.3","","33.25","10.27","68.43","169","81.38","208.69","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.61","42.9","","25.48","14.86","90.88","1 through 10","81.38","208.69","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.50","196.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.61","42.9","","90.88","90.88","90.88","1 through 10","81.38","208.69","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.50","196.87","WELLPOINT [1015]","HB AMC WELLPOINT","193.67","73.78","","84.63","19.55","140.02","123","81.38","208.69","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.50","196.87","AETNA [1001]","HB AMC AETNA HMO","183.23","69.8","","76.96","17.77","113.68","14","137.18","214.52","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.50","196.87","AETNA [1001]","HB AMC AETNA PPO","211.05","80.4","","57.31","57.31","57.31","1 through 10","137.18","214.52","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.50","196.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","137.18","52.26","","16.24","16.24","54.15","1 through 10","137.18","214.52","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.50","196.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","211.05","80.4","","68.25","68.25","87.50","1 through 10","137.18","214.52","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.50","196.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","214.52","81.72","","156.19","156.19","156.19","1 through 10","137.18","214.52","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","214.52","81.72","","82.70","12.06","98.97","13","137.18","214.52","percent of total billed charges",""
"KIT INTRODUCER 6.5FR 2.17MM LEGEND LEAD PERCUTANEOUS","SUP-ITM-10021686","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.52","81.72","","50.47","25.30","134.30","140","137.18","214.52","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","136.43","102.32","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","71.30","52.26","","16.24","16.24","54.15","1 through 10","42.29","108.46","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","136.43","102.32","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","97.96","71.8","","86.33","32.67","86.33","1 through 10","42.29","108.46","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","136.43","102.32","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","95.50","70","","113.68","63.00","177.34","40","42.29","108.46","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","136.43","102.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","108.46","79.5","","50.70","21.76","168.00","12","42.29","108.46","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","136.43","102.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","72.72","53.3","","89.31","89.31","99.75","1 through 10","42.29","108.46","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","136.43","102.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","88.68","65","","94.41","17.06","2275.00","1 through 10","42.29","108.46","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","136.43","102.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","42.29","31","","35.13","35.13","35.13","1 through 10","42.29","108.46","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","136.43","102.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","49.80","36.5","","40.08","12.40","86.17","108","42.29","108.46","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","136.43","102.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.25","38.3","","33.25","10.27","68.43","169","42.29","108.46","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","136.43","102.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.53","42.9","","25.48","14.86","90.88","1 through 10","42.29","108.46","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","136.43","102.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.53","42.9","","90.88","90.88","90.88","1 through 10","42.29","108.46","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","136.43","102.32","WELLPOINT [1015]","HB AMC WELLPOINT","100.66","73.78","","84.63","19.55","140.02","123","42.29","108.46","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","136.43","102.32","AETNA [1001]","HB AMC AETNA HMO","95.23","69.8","","76.96","17.77","113.68","14","71.3","111.49","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","136.43","102.32","AETNA [1001]","HB AMC AETNA PPO","109.69","80.4","","57.31","57.31","57.31","1 through 10","71.3","111.49","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","136.43","102.32","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","71.30","52.26","","16.24","16.24","54.15","1 through 10","71.3","111.49","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","136.43","102.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","109.69","80.4","","68.25","68.25","87.50","1 through 10","71.3","111.49","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","136.43","102.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","111.49","81.72","","156.19","156.19","156.19","1 through 10","71.3","111.49","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","136.43","102.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","111.49","81.72","","82.70","12.06","98.97","13","71.3","111.49","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","136.43","102.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","111.49","81.72","","50.47","25.30","134.30","140","71.3","111.49","percent of total billed charges",""
"KIT INTRODUCER DI LOCK 7FR 23CM 3MM 80CM J TIP VASCULAR SHEATH ACCESS PEEL AWAY DILATOR GUIDEWIRE","SUP-ITM-10019214","CDM","C1892","HCPCS","0272","RC","","","","both","","","173.25","129.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.24","36.5","","66.97","66.97","66.97","1 through 10","53.71","137.73","percent of total billed charges",""
"KIT INTRODUCER DI LOCK 7FR 23CM 3MM 80CM J TIP VASCULAR SHEATH ACCESS PEEL AWAY DILATOR GUIDEWIRE","SUP-ITM-10019214","CDM","C1892","HCPCS","0272","RC","","","","both","","","173.25","129.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.35","38.3","","70.21","44.61","70.21","1 through 10","53.71","137.73","percent of total billed charges",""
"KIT INTRODUCER DI LOCK 7FR 23CM 3MM 80CM J TIP VASCULAR SHEATH ACCESS PEEL AWAY DILATOR GUIDEWIRE","SUP-ITM-10019214","CDM","C1892","HCPCS","0272","RC","","","","both","","","173.25","129.94","WELLPOINT [1015]","HB AMC WELLPOINT","127.82","73.78","","84.95","84.95","84.95","1 through 10","53.71","137.73","percent of total billed charges",""
"KIT INTRODUCER DI LOCK 7FR 23CM 3MM 80CM J TIP VASCULAR SHEATH ACCESS PEEL AWAY DILATOR GUIDEWIRE","SUP-ITM-10019214","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","173.25","129.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","141.58","81.72","","91.21","50.17","91.21","1 through 10","90.54","141.58","percent of total billed charges",""
"KIT INTRODUCER DI LOCK 7FR 23CM 3MM 80CM J TIP VASCULAR SHEATH ACCESS PEEL AWAY DILATOR GUIDEWIRE","SUP-ITM-10019214","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","173.25","129.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","141.58","81.72","","50.17","50.17","50.17","1 through 10","90.54","141.58","percent of total billed charges",""
"KIT INTRODUCER DI LOCK 9FR 14CM 3MM 50CM J TIP VASCULAR ACCESS PEEL AWAY DILATOR SHEATH GUIDEWIRE","SUP-ITM-10000299","CDM","C1892","HCPCS","0272","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.33","36.5","","66.97","66.97","66.97","1 through 10","32.55","83.48","percent of total billed charges",""
"KIT INTRODUCER DI LOCK 9FR 14CM 3MM 50CM J TIP VASCULAR ACCESS PEEL AWAY DILATOR SHEATH GUIDEWIRE","SUP-ITM-10000299","CDM","C1892","HCPCS","0272","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.22","38.3","","70.21","44.61","70.21","1 through 10","32.55","83.48","percent of total billed charges",""
"KIT INTRODUCER DI LOCK 9FR 14CM 3MM 50CM J TIP VASCULAR ACCESS PEEL AWAY DILATOR SHEATH GUIDEWIRE","SUP-ITM-10000299","CDM","C1892","HCPCS","0272","RC","","","","both","","","105.00","78.75","WELLPOINT [1015]","HB AMC WELLPOINT","77.47","73.78","","84.95","84.95","84.95","1 through 10","32.55","83.48","percent of total billed charges",""
"KIT INTRODUCER DI LOCK 9FR 14CM 3MM 50CM J TIP VASCULAR ACCESS PEEL AWAY DILATOR SHEATH GUIDEWIRE","SUP-ITM-10000299","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","85.81","81.72","","91.21","50.17","91.21","1 through 10","54.87","85.81","percent of total billed charges",""
"KIT INTRODUCER DI LOCK 9FR 14CM 3MM 50CM J TIP VASCULAR ACCESS PEEL AWAY DILATOR SHEATH GUIDEWIRE","SUP-ITM-10000299","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","85.81","81.72","","50.17","50.17","50.17","1 through 10","54.87","85.81","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","both","","","231.00","173.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","120.72","52.26","","16.24","16.24","54.15","1 through 10","71.61","183.65","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","both","","","231.00","173.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","165.86","71.8","","86.33","32.67","86.33","1 through 10","71.61","183.65","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","both","","","231.00","173.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","161.70","70","","113.68","63.00","177.34","40","71.61","183.65","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","both","","","231.00","173.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","183.65","79.5","","50.70","21.76","168.00","12","71.61","183.65","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","both","","","231.00","173.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","123.12","53.3","","89.31","89.31","99.75","1 through 10","71.61","183.65","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","both","","","231.00","173.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","150.15","65","","94.41","17.06","2275.00","1 through 10","71.61","183.65","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","71.61","31","","35.13","35.13","35.13","1 through 10","71.61","183.65","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","84.32","36.5","","40.08","12.40","86.17","108","71.61","183.65","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","88.47","38.3","","33.25","10.27","68.43","169","71.61","183.65","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","both","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.10","42.9","","25.48","14.86","90.88","1 through 10","71.61","183.65","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","both","","","231.00","173.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.10","42.9","","90.88","90.88","90.88","1 through 10","71.61","183.65","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","both","","","231.00","173.25","WELLPOINT [1015]","HB AMC WELLPOINT","170.43","73.78","","84.63","19.55","140.02","123","71.61","183.65","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","231.00","173.25","AETNA [1001]","HB AMC AETNA HMO","161.24","69.8","","76.96","17.77","113.68","14","120.72","188.77","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","231.00","173.25","AETNA [1001]","HB AMC AETNA PPO","185.72","80.4","","57.31","57.31","57.31","1 through 10","120.72","188.77","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","231.00","173.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","120.72","52.26","","16.24","16.24","54.15","1 through 10","120.72","188.77","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","231.00","173.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","185.72","80.4","","68.25","68.25","87.50","1 through 10","120.72","188.77","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","231.00","173.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","188.77","81.72","","156.19","156.19","156.19","1 through 10","120.72","188.77","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","188.77","81.72","","82.70","12.06","98.97","13","120.72","188.77","percent of total billed charges",""
"KIT INTRODUCER MAK-NV 6FR 60CM 15CM .018IN NONVASCULAR TROCAR STYLET NEEDLE BX/10EA","SUP-ITM-10049581","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","188.77","81.72","","50.47","25.30","134.30","140","120.72","188.77","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","both","","","796.92","597.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","416.47","52.26","","16.24","16.24","54.15","1 through 10","247.05","633.55","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","both","","","796.92","597.69","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","572.19","71.8","","86.33","32.67","86.33","1 through 10","247.05","633.55","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","both","","","796.92","597.69","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","557.84","70","","113.68","63.00","177.34","40","247.05","633.55","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","both","","","796.92","597.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","633.55","79.5","","50.70","21.76","168.00","12","247.05","633.55","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","both","","","796.92","597.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","424.76","53.3","","89.31","89.31","99.75","1 through 10","247.05","633.55","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","both","","","796.92","597.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","518.00","65","","94.41","17.06","2275.00","1 through 10","247.05","633.55","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","both","","","796.92","597.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","247.05","31","","35.13","35.13","35.13","1 through 10","247.05","633.55","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","both","","","796.92","597.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","290.88","36.5","","40.08","12.40","86.17","108","247.05","633.55","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","both","","","796.92","597.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","305.22","38.3","","33.25","10.27","68.43","169","247.05","633.55","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","both","","","796.92","597.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","341.88","42.9","","25.48","14.86","90.88","1 through 10","247.05","633.55","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","both","","","796.92","597.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","341.88","42.9","","90.88","90.88","90.88","1 through 10","247.05","633.55","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","both","","","796.92","597.69","WELLPOINT [1015]","HB AMC WELLPOINT","587.97","73.78","","84.63","19.55","140.02","123","247.05","633.55","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","796.92","597.69","AETNA [1001]","HB AMC AETNA HMO","556.25","69.8","","76.96","17.77","113.68","14","416.47","651.24","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","796.92","597.69","AETNA [1001]","HB AMC AETNA PPO","640.72","80.4","","57.31","57.31","57.31","1 through 10","416.47","651.24","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","796.92","597.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","416.47","52.26","","16.24","16.24","54.15","1 through 10","416.47","651.24","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","796.92","597.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","640.72","80.4","","68.25","68.25","87.50","1 through 10","416.47","651.24","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","796.92","597.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","651.24","81.72","","156.19","156.19","156.19","1 through 10","416.47","651.24","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","796.92","597.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","651.24","81.72","","82.70","12.06","98.97","13","416.47","651.24","percent of total billed charges",""
"KIT INTRODUCER MIC-KEY 16FR .035IN 18G NEEDLE J-TIP GUIDEWIRE HEMOSTAT ANCHOR SET W/4 SAF-T-PEXY T-FASTENERS DILATOR OTW STOMA MEASURING DEVICE 12ML SYRINGE","SUP-ITM-10050460","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","796.92","597.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","651.24","81.72","","50.47","25.30","134.30","140","416.47","651.24","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4449.94","52.26","","1113.10","1113.10","1113.10","1 through 10","2639.65","6769.43","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6769.43","79.5","","1293.60","1148.53","1603.80","1 through 10","2639.65","6769.43","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3107.98","36.5","","1023.42","771.29","2068.67","33","2639.65","6769.43","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3261.25","38.3","","850.52","759.78","1211.25","66","2639.65","6769.43","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3652.94","42.9","","2548.09","2548.09","2548.09","1 through 10","2639.65","6769.43","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3652.94","42.9","","956.46","956.46","956.46","1 through 10","2639.65","6769.43","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","WELLPOINT [1015]","HB AMC WELLPOINT","6282.37","73.78","","2344.73","1619.47","2530.35","16","2639.65","6769.43","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8515.00","6386.25","AETNA [1001]","HB AMC AETNA HMO","5943.47","69.8","","1523.63","988.41","4330.26","39","4449.94","6958.46","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8515.00","6386.25","AETNA [1001]","HB AMC AETNA PPO","6846.06","80.4","","1670.25","1670.25","1670.25","1 through 10","4449.94","6958.46","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8515.00","6386.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4449.94","52.26","","1113.10","1113.10","1113.10","1 through 10","4449.94","6958.46","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8515.00","6386.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6958.46","81.72","","1738.90","1484.65","2716.94","38","4449.94","6958.46","percent of total billed charges",""
"KIT LABORATORY BONE TAMP KYPHON KEX102NB AF E2 10X10/2IN","SUP-ITM-10133159","CDM","C1889","HCPCS","0278","RC","","","","both","","","5717.50","4288.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4545.41","79.5","","1309.77","674.56","6049.93","26","1772.43","4545.41","percent of total billed charges",""
"KIT LABORATORY BONE TAMP KYPHON KEX102NB AF E2 10X10/2IN","SUP-ITM-10133159","CDM","C1889","HCPCS","0278","RC","","","","both","","","5717.50","4288.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3047.43","53.3","","1901.83","1901.83","2962.25","1 through 10","1772.43","4545.41","percent of total billed charges",""
"KIT LABORATORY BONE TAMP KYPHON KEX102NB AF E2 10X10/2IN","SUP-ITM-10133159","CDM","C1889","HCPCS","0278","RC","","","","both","","","5717.50","4288.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2086.89","36.5","","1620.31","1620.31","19908.88","1 through 10","1772.43","4545.41","percent of total billed charges",""
"KIT LABORATORY BONE TAMP KYPHON KEX102NB AF E2 10X10/2IN","SUP-ITM-10133159","CDM","C1889","HCPCS","0278","RC","","","","both","","","5717.50","4288.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2189.80","38.3","","352.91","352.91","2046.30","1 through 10","1772.43","4545.41","percent of total billed charges",""
"KIT LABORATORY BONE TAMP KYPHON KEX102NB AF E2 10X10/2IN","SUP-ITM-10133159","CDM","C1889","HCPCS","0278","RC","","","","both","","","5717.50","4288.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2452.81","42.9","","9668.75","9668.75","9668.75","1 through 10","1772.43","4545.41","percent of total billed charges",""
"KIT LABORATORY BONE TAMP KYPHON KEX102NB AF E2 10X10/2IN","SUP-ITM-10133159","CDM","C1889","HCPCS","0278","RC","","","","both","","","5717.50","4288.12","WELLPOINT [1015]","HB AMC WELLPOINT","4218.37","73.78","","699.88","384.10","3443.31","33","1772.43","4545.41","percent of total billed charges",""
"KIT LABORATORY BONE TAMP KYPHON KEX102NB AF E2 10X10/2IN","SUP-ITM-10133159","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5717.50","4288.12","AETNA [1001]","HB AMC AETNA HMO","3990.82","69.8","","1421.24","264.50","4933.46","29","2987.97","4672.34","percent of total billed charges",""
"KIT LABORATORY BONE TAMP KYPHON KEX102NB AF E2 10X10/2IN","SUP-ITM-10133159","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5717.50","4288.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4596.87","80.4","","1022.97","1022.97","3607.50","1 through 10","2987.97","4672.34","percent of total billed charges",""
"KIT LABORATORY BONE TAMP KYPHON KEX102NB AF E2 10X10/2IN","SUP-ITM-10133159","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5717.50","4288.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4672.34","81.72","","3010.54","693.88","5019.88","35","2987.97","4672.34","percent of total billed charges",""
"KIT LABORATORY CORTICAL STRIP LEAD 25CMX10MM","SUP-ITM-10130421","CDM","C1778","HCPCS","0278","RC","","","","both","","","11675.00","8756.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6222.78","53.3","","5279.78","5279.78","5279.78","1 through 10","3619.25","9281.63","percent of total billed charges",""
"KIT LABORATORY CORTICAL STRIP LEAD 25CMX10MM","SUP-ITM-10130421","CDM","C1778","HCPCS","0278","RC","","","","both","","","11675.00","8756.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","9281.63","79.5","","15789.05","15789.05","15789.05","1 through 10","3619.25","9281.63","percent of total billed charges",""
"KIT LABORATORY CORTICAL STRIP LEAD 25CMX10MM","SUP-ITM-10130421","CDM","C1778","HCPCS","0278","RC","","","","both","","","11675.00","8756.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4261.38","36.5","","2482.78","1657.12","2482.78","1 through 10","3619.25","9281.63","percent of total billed charges",""
"KIT LABORATORY CORTICAL STRIP LEAD 25CMX10MM","SUP-ITM-10130421","CDM","C1778","HCPCS","0278","RC","","","","both","","","11675.00","8756.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4471.53","38.3","","2602.60","2602.60","2602.60","1 through 10","3619.25","9281.63","percent of total billed charges",""
"KIT LABORATORY CORTICAL STRIP LEAD 25CMX10MM","SUP-ITM-10130421","CDM","C1778","HCPCS","0278","RC","","","","both","","","11675.00","8756.25","WELLPOINT [1015]","HB AMC WELLPOINT","8613.82","73.78","","4955.58","3845.35","9119.37","1 through 10","3619.25","9281.63","percent of total billed charges",""
"KIT LABORATORY CORTICAL STRIP LEAD 25CMX10MM","SUP-ITM-10130421","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","11675.00","8756.25","AETNA [1001]","HB AMC AETNA HMO","8149.15","69.8","","8631.75","8631.75","8631.75","1 through 10","6101.36","9540.81","percent of total billed charges",""
"KIT LABORATORY LEAD EXT SENSA 60CM","SUP-ITM-10158045","CDM","C1883","HCPCS","0278","RC","","","","both","","","2772.00","2079.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1011.78","36.5","","1073.15","1073.15","1073.15","1 through 10","859.32","2203.74","percent of total billed charges",""
"KIT LABORATORY LEAD EXT SENSA 60CM","SUP-ITM-10158045","CDM","C1883","HCPCS","0278","RC","","","","both","","","2772.00","2079.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1061.68","38.3","","1808.38","1642.20","1808.38","1 through 10","859.32","2203.74","percent of total billed charges",""
"KIT LABORATORY LEAD EXT SENSA 60CM","SUP-ITM-10158045","CDM","C1883","HCPCS","0278","RC","","","","both","","","2772.00","2079.00","WELLPOINT [1015]","HB AMC WELLPOINT","2045.18","73.78","","625.38","625.38","625.38","1 through 10","859.32","2203.74","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","both","","","149.21","111.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","77.98","52.26","","25.34","25.34","25.34","1 through 10","46.26","118.62","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","both","","","149.21","111.91","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","107.13","71.8","","105.81","105.81","366.90","1 through 10","46.26","118.62","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","both","","","149.21","111.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","104.45","70","","512.90","74.70","612.85","1 through 10","46.26","118.62","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","both","","","149.21","111.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","118.62","79.5","","200.27","182.80","200.27","1 through 10","46.26","118.62","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","both","","","149.21","111.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","79.53","53.3","","37.73","37.73","169.33","1 through 10","46.26","118.62","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","both","","","149.21","111.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","96.99","65","","100.27","8.48","494.52","1 through 10","46.26","118.62","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","both","","","149.21","111.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","96.99","65","","160.19","160.19","160.19","1 through 10","46.26","118.62","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","both","","","149.21","111.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","46.26","31","","28.12","28.12","28.12","1 through 10","46.26","118.62","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","both","","","149.21","111.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54.46","36.5","","101.66","28.85","502.70","121","46.26","118.62","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","both","","","149.21","111.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.15","38.3","","61.58","25.32","328.44","138","46.26","118.62","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","both","","","149.21","111.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.01","42.9","","71.66","71.66","71.66","1 through 10","46.26","118.62","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","both","","","149.21","111.91","WELLPOINT [1015]","HB AMC WELLPOINT","110.09","73.78","","74.75","27.97","425.28","93","46.26","118.62","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","149.21","111.91","AETNA [1001]","HB AMC AETNA HMO","104.15","69.8","","52.67","14.36","414.90","1 through 10","77.98","121.93","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","149.21","111.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","77.98","52.26","","25.34","25.34","25.34","1 through 10","77.98","121.93","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","149.21","111.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","119.96","80.4","","478.02","107.84","478.02","1 through 10","77.98","121.93","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","149.21","111.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","121.93","81.72","","32.74","12.33","122.05","1 through 10","77.98","121.93","percent of total billed charges",""
"KIT LABORATORY LINE ARTERIAL ACCESS CS/5EA","SUP-ITM-10137049","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","149.21","111.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","121.93","81.72","","144.95","32.78","676.91","104","77.98","121.93","percent of total billed charges",""
"KIT LABORATORY PROSTHESIS PENILE EXTENDER SNAP CONE TIP","SUP-ITM-10027737","CDM","C1813","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","627.35","38.3","","12613.42","12613.42","12613.42","1 through 10","507.78","1302.21","percent of total billed charges",""
"KIT LABORATORY PROSTHESIS PENILE EXTENDER SNAP CONE TIP","SUP-ITM-10027737","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","AETNA [1001]","HB AMC AETNA HMO","1143.32","69.8","","34275.85","34275.85","50471.26","19","856.02","1338.57","percent of total billed charges",""
"KIT LABORATORY THORACOSTOMY CLOSED CS/19EA","SUP-ITM-10006077","CDM","C1729","HCPCS","0272","RC","","","","both","","","124.81","93.61","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","89.61","71.8","","162.24","51.52","162.24","1 through 10","38.69","99.22","percent of total billed charges",""
"KIT LABORATORY THORACOSTOMY CLOSED CS/19EA","SUP-ITM-10006077","CDM","C1729","HCPCS","0272","RC","","","","both","","","124.81","93.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","45.56","36.5","","94.34","22.19","146.22","26","38.69","99.22","percent of total billed charges",""
"KIT LABORATORY THORACOSTOMY CLOSED CS/19EA","SUP-ITM-10006077","CDM","C1729","HCPCS","0272","RC","","","","both","","","124.81","93.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","47.80","38.3","","51.52","27.37","51.52","26","38.69","99.22","percent of total billed charges",""
"KIT LABORATORY THORACOSTOMY CLOSED CS/19EA","SUP-ITM-10006077","CDM","C1729","HCPCS","0272","RC","","","","both","","","124.81","93.61","WELLPOINT [1015]","HB AMC WELLPOINT","92.08","73.78","","207.21","122.12","216.28","14","38.69","99.22","percent of total billed charges",""
"KIT LABORATORY THORACOSTOMY CLOSED CS/19EA","SUP-ITM-10006077","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","124.81","93.61","AETNA [1001]","HB AMC AETNA HMO","87.12","69.8","","155.96","47.39","155.96","1 through 10","65.23","101.99","percent of total billed charges",""
"KIT LABORATORY THORACOSTOMY CLOSED CS/19EA","SUP-ITM-10006077","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","124.81","93.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","101.99","81.72","","57.36","51.76","232.23","35","65.23","101.99","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","both","","","3400.15","2550.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2703.12","79.5","","1632.15","1632.15","1632.15","1 through 10","1054.05","2703.12","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","both","","","3400.15","2550.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1812.28","53.3","","9709.13","9709.13","9709.13","1 through 10","1054.05","2703.12","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","both","","","3400.15","2550.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2210.10","65","","2685.95","2190.09","2685.96","1 through 10","1054.05","2703.12","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","both","","","3400.15","2550.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1241.05","36.5","","1495.87","1455.73","1541.33","1 through 10","1054.05","2703.12","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","both","","","3400.15","2550.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1302.26","38.3","","1615.71","1615.71","1615.71","1 through 10","1054.05","2703.12","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","both","","","3400.15","2550.11","WELLPOINT [1015]","HB AMC WELLPOINT","2508.63","73.78","","3076.44","3076.44","3076.44","1 through 10","1054.05","2703.12","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3400.15","2550.11","AETNA [1001]","HB AMC AETNA HMO","2373.30","69.8","","4568.79","2411.14","4568.79","1 through 10","1776.92","2778.6","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3400.15","2550.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2733.72","80.4","","2411.14","1545.60","3223.14","1 through 10","1776.92","2778.6","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3400.15","2550.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2778.60","81.72","","1816.95","1816.95","1816.95","1 through 10","1776.92","2778.6","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3400.15","2550.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2778.60","81.72","","3303.30","3303.30","3303.30","1 through 10","1776.92","2778.6","percent of total billed charges",""
"KIT LEAD 1.5X0.5MM 40CM NEUROSTIMULATOR DBS 4 ELECTRODE","SUP-ITM-10022762","CDM","C1778","HCPCS","0278","RC","","","","both","","","7130.00","5347.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3800.29","53.3","","5279.78","5279.78","5279.78","1 through 10","2210.3","5668.35","percent of total billed charges",""
"KIT LEAD 1.5X0.5MM 40CM NEUROSTIMULATOR DBS 4 ELECTRODE","SUP-ITM-10022762","CDM","C1778","HCPCS","0278","RC","","","","both","","","7130.00","5347.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","5668.35","79.5","","15789.05","15789.05","15789.05","1 through 10","2210.3","5668.35","percent of total billed charges",""
"KIT LEAD 1.5X0.5MM 40CM NEUROSTIMULATOR DBS 4 ELECTRODE","SUP-ITM-10022762","CDM","C1778","HCPCS","0278","RC","","","","both","","","7130.00","5347.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2602.45","36.5","","2482.78","1657.12","2482.78","1 through 10","2210.3","5668.35","percent of total billed charges",""
"KIT LEAD 1.5X0.5MM 40CM NEUROSTIMULATOR DBS 4 ELECTRODE","SUP-ITM-10022762","CDM","C1778","HCPCS","0278","RC","","","","both","","","7130.00","5347.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2730.79","38.3","","2602.60","2602.60","2602.60","1 through 10","2210.3","5668.35","percent of total billed charges",""
"KIT LEAD 1.5X0.5MM 40CM NEUROSTIMULATOR DBS 4 ELECTRODE","SUP-ITM-10022762","CDM","C1778","HCPCS","0278","RC","","","","both","","","7130.00","5347.50","WELLPOINT [1015]","HB AMC WELLPOINT","5260.51","73.78","","4955.58","3845.35","9119.37","1 through 10","2210.3","5668.35","percent of total billed charges",""
"KIT LEAD 1.5X0.5MM 40CM NEUROSTIMULATOR DBS 4 ELECTRODE","SUP-ITM-10022762","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","7130.00","5347.50","AETNA [1001]","HB AMC AETNA HMO","4976.74","69.8","","8631.75","8631.75","8631.75","1 through 10","3726.14","5826.64","percent of total billed charges",""
"KIT LEAD 1X8 3 12 4 7 52MM 75CM NEUROSTIMULATOR COMPACT ELEC - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10018212","CDM","C1778","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","5279.78","5279.78","5279.78","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KIT LEAD 1X8 3 12 4 7 52MM 75CM NEUROSTIMULATOR COMPACT ELEC - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10018212","CDM","C1778","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","15789.05","15789.05","15789.05","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KIT LEAD 1X8 3 12 4 7 52MM 75CM NEUROSTIMULATOR COMPACT ELEC - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10018212","CDM","C1778","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","2482.78","1657.12","2482.78","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KIT LEAD 1X8 3 12 4 7 52MM 75CM NEUROSTIMULATOR COMPACT ELEC - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10018212","CDM","C1778","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","2602.60","2602.60","2602.60","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KIT LEAD 1X8 3 12 4 7 52MM 75CM NEUROSTIMULATOR COMPACT ELEC - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10018212","CDM","C1778","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","4955.58","3845.35","9119.37","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KIT LEAD 1X8 3 12 4 7 52MM 75CM NEUROSTIMULATOR COMPACT ELEC - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10018212","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","8631.75","8631.75","8631.75","1 through 10","2743.65","4290.3","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","both","","","5227.50","3920.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2786.26","53.3","","5279.78","5279.78","5279.78","1 through 10","1620.53","4155.86","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","both","","","5227.50","3920.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","4155.86","79.5","","15789.05","15789.05","15789.05","1 through 10","1620.53","4155.86","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","both","","","5227.50","3920.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1908.04","36.5","","2482.78","1657.12","2482.78","1 through 10","1620.53","4155.86","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","both","","","5227.50","3920.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2002.13","38.3","","2602.60","2602.60","2602.60","1 through 10","1620.53","4155.86","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","both","","","5227.50","3920.62","WELLPOINT [1015]","HB AMC WELLPOINT","3856.85","73.78","","4955.58","3845.35","9119.37","1 through 10","1620.53","4155.86","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5227.50","3920.62","AETNA [1001]","HB AMC AETNA HMO","3648.80","69.8","","8631.75","8631.75","8631.75","1 through 10","2731.89","4271.91","percent of total billed charges",""
"KIT LEAD 2.16MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277209","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4730.38","53.3","","5279.78","5279.78","5279.78","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 2.16MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277209","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","7055.63","79.5","","15789.05","15789.05","15789.05","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 2.16MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277209","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3239.38","36.5","","2482.78","1657.12","2482.78","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 2.16MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277209","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3399.13","38.3","","2602.60","2602.60","2602.60","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 2.16MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277209","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","WELLPOINT [1015]","HB AMC WELLPOINT","6547.98","73.78","","4955.58","3845.35","9119.37","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 2.16MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277209","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","8875.00","6656.25","AETNA [1001]","HB AMC AETNA HMO","6194.75","69.8","","8631.75","8631.75","8631.75","1 through 10","4638.08","7252.65","percent of total billed charges",""
"KIT LEAD 4.32MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277206","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4730.38","53.3","","5279.78","5279.78","5279.78","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 4.32MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277206","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","7055.63","79.5","","15789.05","15789.05","15789.05","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 4.32MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277206","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3239.38","36.5","","2482.78","1657.12","2482.78","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 4.32MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277206","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3399.13","38.3","","2602.60","2602.60","2602.60","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 4.32MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277206","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","WELLPOINT [1015]","HB AMC WELLPOINT","6547.98","73.78","","4955.58","3845.35","9119.37","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 4.32MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277206","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","8875.00","6656.25","AETNA [1001]","HB AMC AETNA HMO","6194.75","69.8","","8631.75","8631.75","8631.75","1 through 10","4638.08","7252.65","percent of total billed charges",""
"KIT LEAD 4.32MM 33CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277205","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4730.38","53.3","","5279.78","5279.78","5279.78","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 4.32MM 33CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277205","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","7055.63","79.5","","15789.05","15789.05","15789.05","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 4.32MM 33CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277205","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3239.38","36.5","","2482.78","1657.12","2482.78","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 4.32MM 33CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277205","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3399.13","38.3","","2602.60","2602.60","2602.60","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 4.32MM 33CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277205","CDM","C1778","HCPCS","0278","RC","","","","both","","","8875.00","6656.25","WELLPOINT [1015]","HB AMC WELLPOINT","6547.98","73.78","","4955.58","3845.35","9119.37","1 through 10","2751.25","7055.63","percent of total billed charges",""
"KIT LEAD 4.32MM 33CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277205","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","8875.00","6656.25","AETNA [1001]","HB AMC AETNA HMO","6194.75","69.8","","8631.75","8631.75","8631.75","1 through 10","4638.08","7252.65","percent of total billed charges",""
"KIT LEAD 45CM CARTESIA VERCISE DBS DIRECTIONAL 8 CONTACT","SUP-ITM-10241015","CDM","C1778","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3731.00","53.3","","5279.78","5279.78","5279.78","1 through 10","2170","5565","percent of total billed charges",""
"KIT LEAD 45CM CARTESIA VERCISE DBS DIRECTIONAL 8 CONTACT","SUP-ITM-10241015","CDM","C1778","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","5565.00","79.5","","15789.05","15789.05","15789.05","1 through 10","2170","5565","percent of total billed charges",""
"KIT LEAD 45CM CARTESIA VERCISE DBS DIRECTIONAL 8 CONTACT","SUP-ITM-10241015","CDM","C1778","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2555.00","36.5","","2482.78","1657.12","2482.78","1 through 10","2170","5565","percent of total billed charges",""
"KIT LEAD 45CM CARTESIA VERCISE DBS DIRECTIONAL 8 CONTACT","SUP-ITM-10241015","CDM","C1778","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2681.00","38.3","","2602.60","2602.60","2602.60","1 through 10","2170","5565","percent of total billed charges",""
"KIT LEAD 45CM CARTESIA VERCISE DBS DIRECTIONAL 8 CONTACT","SUP-ITM-10241015","CDM","C1778","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","WELLPOINT [1015]","HB AMC WELLPOINT","5164.60","73.78","","4955.58","3845.35","9119.37","1 through 10","2170","5565","percent of total billed charges",""
"KIT LEAD 45CM CARTESIA VERCISE DBS DIRECTIONAL 8 CONTACT","SUP-ITM-10241015","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","AETNA [1001]","HB AMC AETNA HMO","4886.00","69.8","","8631.75","8631.75","8631.75","1 through 10","3658.2","5720.4","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING LEAD1058-70B","SUP-ITM-10158049","CDM","C1778","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2638.35","53.3","","5279.78","5279.78","5279.78","1 through 10","1534.5","3935.25","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING LEAD1058-70B","SUP-ITM-10158049","CDM","C1778","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","15789.05","15789.05","15789.05","1 through 10","1534.5","3935.25","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING LEAD1058-70B","SUP-ITM-10158049","CDM","C1778","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","2482.78","1657.12","2482.78","1 through 10","1534.5","3935.25","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING LEAD1058-70B","SUP-ITM-10158049","CDM","C1778","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","2602.60","2602.60","2602.60","1 through 10","1534.5","3935.25","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING LEAD1058-70B","SUP-ITM-10158049","CDM","C1778","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","4955.58","3845.35","9119.37","1 through 10","1534.5","3935.25","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING LEAD1058-70B","SUP-ITM-10158049","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","8631.75","8631.75","8631.75","1 through 10","2586.87","4045.14","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING TLEAD1058-70B","SUP-ITM-10158039","CDM","C1897","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","WELLPOINT [1015]","HB AMC WELLPOINT","1678.50","73.78","","2260.50","2260.50","2260.50","1 through 10","705.25","1808.63","percent of total billed charges",""
"KIT LEAD 50CM AXIUM IMPLANT SLIMTIP PERI OP DEVICES NEUROMODULATION","SUP-ITM-10174960","CDM","C1778","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3864.25","53.3","","5279.78","5279.78","5279.78","1 through 10","2247.5","5763.75","percent of total billed charges",""
"KIT LEAD 50CM AXIUM IMPLANT SLIMTIP PERI OP DEVICES NEUROMODULATION","SUP-ITM-10174960","CDM","C1778","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","5763.75","79.5","","15789.05","15789.05","15789.05","1 through 10","2247.5","5763.75","percent of total billed charges",""
"KIT LEAD 50CM AXIUM IMPLANT SLIMTIP PERI OP DEVICES NEUROMODULATION","SUP-ITM-10174960","CDM","C1778","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2646.25","36.5","","2482.78","1657.12","2482.78","1 through 10","2247.5","5763.75","percent of total billed charges",""
"KIT LEAD 50CM AXIUM IMPLANT SLIMTIP PERI OP DEVICES NEUROMODULATION","SUP-ITM-10174960","CDM","C1778","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2776.75","38.3","","2602.60","2602.60","2602.60","1 through 10","2247.5","5763.75","percent of total billed charges",""
"KIT LEAD 50CM AXIUM IMPLANT SLIMTIP PERI OP DEVICES NEUROMODULATION","SUP-ITM-10174960","CDM","C1778","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","WELLPOINT [1015]","HB AMC WELLPOINT","5349.05","73.78","","4955.58","3845.35","9119.37","1 through 10","2247.5","5763.75","percent of total billed charges",""
"KIT LEAD 50CM AXIUM IMPLANT SLIMTIP PERI OP DEVICES NEUROMODULATION","SUP-ITM-10174960","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","AETNA [1001]","HB AMC AETNA HMO","5060.50","69.8","","8631.75","8631.75","8631.75","1 through 10","3788.85","5924.7","percent of total billed charges",""
"KIT LEAD 50CM INFINION CX NHPL PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10191387","CDM","C1778","HCPCS","0278","RC","","","","both","","","8250.00","6187.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4397.25","53.3","","5279.78","5279.78","5279.78","1 through 10","2557.5","6558.75","percent of total billed charges",""
"KIT LEAD 50CM INFINION CX NHPL PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10191387","CDM","C1778","HCPCS","0278","RC","","","","both","","","8250.00","6187.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","6558.75","79.5","","15789.05","15789.05","15789.05","1 through 10","2557.5","6558.75","percent of total billed charges",""
"KIT LEAD 50CM INFINION CX NHPL PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10191387","CDM","C1778","HCPCS","0278","RC","","","","both","","","8250.00","6187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3011.25","36.5","","2482.78","1657.12","2482.78","1 through 10","2557.5","6558.75","percent of total billed charges",""
"KIT LEAD 50CM INFINION CX NHPL PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10191387","CDM","C1778","HCPCS","0278","RC","","","","both","","","8250.00","6187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3159.75","38.3","","2602.60","2602.60","2602.60","1 through 10","2557.5","6558.75","percent of total billed charges",""
"KIT LEAD 50CM INFINION CX NHPL PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10191387","CDM","C1778","HCPCS","0278","RC","","","","both","","","8250.00","6187.50","WELLPOINT [1015]","HB AMC WELLPOINT","6086.85","73.78","","4955.58","3845.35","9119.37","1 through 10","2557.5","6558.75","percent of total billed charges",""
"KIT LEAD 50CM INFINION CX NHPL PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10191387","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","8250.00","6187.50","AETNA [1001]","HB AMC AETNA HMO","5758.50","69.8","","8631.75","8631.75","8631.75","1 through 10","4311.45","6741.9","percent of total billed charges",""
"KIT LEAD 55CM 2X8 SURGICAL DBS DUAL EXTENSION CONTACT","SUP-ITM-10307628","CDM","C1883","HCPCS","0278","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1688.13","36.5","","1073.15","1073.15","1073.15","1 through 10","1433.75","3676.88","percent of total billed charges",""
"KIT LEAD 55CM 2X8 SURGICAL DBS DUAL EXTENSION CONTACT","SUP-ITM-10307628","CDM","C1883","HCPCS","0278","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1771.38","38.3","","1808.38","1642.20","1808.38","1 through 10","1433.75","3676.88","percent of total billed charges",""
"KIT LEAD 55CM 2X8 SURGICAL DBS DUAL EXTENSION CONTACT","SUP-ITM-10307628","CDM","C1883","HCPCS","0278","RC","","","","both","","","4625.00","3468.75","WELLPOINT [1015]","HB AMC WELLPOINT","3412.33","73.78","","625.38","625.38","625.38","1 through 10","1433.75","3676.88","percent of total billed charges",""
"KIT LEAD 56CM AVISTA MRI PERCUTANEOUS 8 CONTACT","SUP-ITM-10174950","CDM","C1778","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3064.75","53.3","","5279.78","5279.78","5279.78","1 through 10","1782.5","4571.25","percent of total billed charges",""
"KIT LEAD 56CM AVISTA MRI PERCUTANEOUS 8 CONTACT","SUP-ITM-10174950","CDM","C1778","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","4571.25","79.5","","15789.05","15789.05","15789.05","1 through 10","1782.5","4571.25","percent of total billed charges",""
"KIT LEAD 56CM AVISTA MRI PERCUTANEOUS 8 CONTACT","SUP-ITM-10174950","CDM","C1778","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2098.75","36.5","","2482.78","1657.12","2482.78","1 through 10","1782.5","4571.25","percent of total billed charges",""
"KIT LEAD 56CM AVISTA MRI PERCUTANEOUS 8 CONTACT","SUP-ITM-10174950","CDM","C1778","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2202.25","38.3","","2602.60","2602.60","2602.60","1 through 10","1782.5","4571.25","percent of total billed charges",""
"KIT LEAD 56CM AVISTA MRI PERCUTANEOUS 8 CONTACT","SUP-ITM-10174950","CDM","C1778","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","WELLPOINT [1015]","HB AMC WELLPOINT","4242.35","73.78","","4955.58","3845.35","9119.37","1 through 10","1782.5","4571.25","percent of total billed charges",""
"KIT LEAD 56CM AVISTA MRI PERCUTANEOUS 8 CONTACT","SUP-ITM-10174950","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5750.00","4312.50","AETNA [1001]","HB AMC AETNA HMO","4013.50","69.8","","8631.75","8631.75","8631.75","1 through 10","3004.95","4698.9","percent of total billed charges",""
"KIT LEAD 70CM .014IN STIMULATOR PRECISION SPINAL CORD TRIAL","SUP-ITM-10077201","CDM","C1897","HCPCS","0278","RC","","","","both","","","2940.00","2205.00","WELLPOINT [1015]","HB AMC WELLPOINT","2169.13","73.78","","2260.50","2260.50","2260.50","1 through 10","911.4","2337.3","percent of total billed charges",""
"KIT LEAD EXTENSION 60CM CERVICAL 60CM","SUP-ITM-10019637","CDM","C1883","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1143.36","36.5","","1073.15","1073.15","1073.15","1 through 10","971.08","2490.34","percent of total billed charges",""
"KIT LEAD EXTENSION 60CM CERVICAL 60CM","SUP-ITM-10019637","CDM","C1883","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1199.75","38.3","","1808.38","1642.20","1808.38","1 through 10","971.08","2490.34","percent of total billed charges",""
"KIT LEAD EXTENSION 60CM CERVICAL 60CM","SUP-ITM-10019637","CDM","C1883","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","WELLPOINT [1015]","HB AMC WELLPOINT","2311.16","73.78","","625.38","625.38","625.38","1 through 10","971.08","2490.34","percent of total billed charges",""
"KIT LEAD TRIAL 60CM CAP12 EVOKE 12 ELECTRODES 4MM SPACING","SUP-ITM-10317729","CDM","C1897","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2260.50","2260.50","2260.50","1 through 10","1302","3339","percent of total billed charges",""
"KIT MICROCATHETER RENEGADE 3FR 20CM 165CM HI FLO STRAIGHT TRANSEND-18 STEERABLE GUIDEWIRE","SUP-ITM-10012721","CDM","C1887","HCPCS","0272","RC","","","","both","","","1525.37","1144.03","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1095.22","71.8","","28.28","27.13","28.28","1 through 10","472.86","1212.67","percent of total billed charges",""
"KIT MICROCATHETER RENEGADE 3FR 20CM 165CM HI FLO STRAIGHT TRANSEND-18 STEERABLE GUIDEWIRE","SUP-ITM-10012721","CDM","C1887","HCPCS","0272","RC","","","","both","","","1525.37","1144.03","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1067.76","70","","44.63","35.78","44.63","1 through 10","472.86","1212.67","percent of total billed charges",""
"KIT MICROCATHETER RENEGADE 3FR 20CM 165CM HI FLO STRAIGHT TRANSEND-18 STEERABLE GUIDEWIRE","SUP-ITM-10012721","CDM","C1887","HCPCS","0272","RC","","","","both","","","1525.37","1144.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1212.67","79.5","","1342.89","271.64","6954.67","1 through 10","472.86","1212.67","percent of total billed charges",""
"KIT MICROCATHETER RENEGADE 3FR 20CM 165CM HI FLO STRAIGHT TRANSEND-18 STEERABLE GUIDEWIRE","SUP-ITM-10012721","CDM","C1887","HCPCS","0272","RC","","","","both","","","1525.37","1144.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","813.02","53.3","","4550.00","30.49","4550.00","1 through 10","472.86","1212.67","percent of total billed charges",""
"KIT MICROCATHETER RENEGADE 3FR 20CM 165CM HI FLO STRAIGHT TRANSEND-18 STEERABLE GUIDEWIRE","SUP-ITM-10012721","CDM","C1887","HCPCS","0272","RC","","","","both","","","1525.37","1144.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","991.49","65","","42.09","0.04","5453.50","1 through 10","472.86","1212.67","percent of total billed charges",""
"KIT MICROCATHETER RENEGADE 3FR 20CM 165CM HI FLO STRAIGHT TRANSEND-18 STEERABLE GUIDEWIRE","SUP-ITM-10012721","CDM","C1887","HCPCS","0272","RC","","","","both","","","1525.37","1144.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","556.76","36.5","","310.94","18.54","1259.30","62","472.86","1212.67","percent of total billed charges",""
"KIT MICROCATHETER RENEGADE 3FR 20CM 165CM HI FLO STRAIGHT TRANSEND-18 STEERABLE GUIDEWIRE","SUP-ITM-10012721","CDM","C1887","HCPCS","0272","RC","","","","both","","","1525.37","1144.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","584.22","38.3","","146.86","22.58","1753.45","65","472.86","1212.67","percent of total billed charges",""
"KIT MICROCATHETER RENEGADE 3FR 20CM 165CM HI FLO STRAIGHT TRANSEND-18 STEERABLE GUIDEWIRE","SUP-ITM-10012721","CDM","C1887","HCPCS","0272","RC","","","","both","","","1525.37","1144.03","WELLPOINT [1015]","HB AMC WELLPOINT","1125.42","73.78","","247.29","33.09","909.09","53","472.86","1212.67","percent of total billed charges",""
"KIT MICROCATHETER RENEGADE 3FR 20CM 165CM HI FLO STRAIGHT TRANSEND-18 STEERABLE GUIDEWIRE","SUP-ITM-10012721","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1525.37","1144.03","AETNA [1001]","HB AMC AETNA HMO","1064.71","69.8","","30.69","30.21","30.69","1 through 10","797.16","1246.53","percent of total billed charges",""
"KIT MICROCATHETER RENEGADE 3FR 20CM 165CM HI FLO STRAIGHT TRANSEND-18 STEERABLE GUIDEWIRE","SUP-ITM-10012721","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1525.37","1144.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1226.40","80.4","","82.69","82.69","82.69","1 through 10","797.16","1246.53","percent of total billed charges",""
"KIT MICROCATHETER RENEGADE 3FR 20CM 165CM HI FLO STRAIGHT TRANSEND-18 STEERABLE GUIDEWIRE","SUP-ITM-10012721","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1525.37","1144.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1246.53","81.72","","751.01","74.72","751.01","1 through 10","797.16","1246.53","percent of total billed charges",""
"KIT MICROCATHETER RENEGADE 3FR 20CM 165CM HI FLO STRAIGHT TRANSEND-18 STEERABLE GUIDEWIRE","SUP-ITM-10012721","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1525.37","1144.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1246.53","81.72","","328.92","46.17","2701.97","59","797.16","1246.53","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","473.03","79.5","","800.18","480.96","1887.97","195","184.45","473.03","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","317.14","53.3","","813.12","216.42","1444.50","81","184.45","473.03","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","184.45","31","","432.60","432.60","432.60","1 through 10","184.45","473.03","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","217.18","36.5","","148.37","54.89","631.39","94","184.45","473.03","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","227.89","38.3","","279.30","91.72","1116.77","266","184.45","473.03","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.26","42.9","","731.00","63.70","731.00","1 through 10","184.45","473.03","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.26","42.9","","384.74","384.74","384.74","1 through 10","184.45","473.03","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","WELLPOINT [1015]","HB AMC WELLPOINT","438.99","73.78","","286.63","119.22","1107.45","105","184.45","473.03","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","AETNA [1001]","HB AMC AETNA HMO","415.31","69.8","","675.31","184.75","1721.50","286","310.95","486.23","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","AETNA [1001]","HB AMC AETNA PPO","478.38","80.4","","1261.44","103.12","1514.10","21","310.95","486.23","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","478.38","80.4","","1365.00","1365.00","1365.00","1 through 10","310.95","486.23","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","486.23","81.72","","5157.68","5157.68","5157.68","1 through 10","310.95","486.23","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","486.23","81.72","","431.26","71.26","1459.57","88","310.95","486.23","percent of total billed charges",""
"KIT MIXING VERTECEM II CEMENT","SUP-ITM-10169043","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","800.18","480.96","1887.97","195","217","556.5","percent of total billed charges",""
"KIT MIXING VERTECEM II CEMENT","SUP-ITM-10169043","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","813.12","216.42","1444.50","81","217","556.5","percent of total billed charges",""
"KIT MIXING VERTECEM II CEMENT","SUP-ITM-10169043","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","217.00","31","","432.60","432.60","432.60","1 through 10","217","556.5","percent of total billed charges",""
"KIT MIXING VERTECEM II CEMENT","SUP-ITM-10169043","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","148.37","54.89","631.39","94","217","556.5","percent of total billed charges",""
"KIT MIXING VERTECEM II CEMENT","SUP-ITM-10169043","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","279.30","91.72","1116.77","266","217","556.5","percent of total billed charges",""
"KIT MIXING VERTECEM II CEMENT","SUP-ITM-10169043","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","731.00","63.70","731.00","1 through 10","217","556.5","percent of total billed charges",""
"KIT MIXING VERTECEM II CEMENT","SUP-ITM-10169043","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","384.74","384.74","384.74","1 through 10","217","556.5","percent of total billed charges",""
"KIT MIXING VERTECEM II CEMENT","SUP-ITM-10169043","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","286.63","119.22","1107.45","105","217","556.5","percent of total billed charges",""
"KIT MIXING VERTECEM II CEMENT","SUP-ITM-10169043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","675.31","184.75","1721.50","286","365.82","572.04","percent of total billed charges",""
"KIT MIXING VERTECEM II CEMENT","SUP-ITM-10169043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA PPO","562.80","80.4","","1261.44","103.12","1514.10","21","365.82","572.04","percent of total billed charges",""
"KIT MIXING VERTECEM II CEMENT","SUP-ITM-10169043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","562.80","80.4","","1365.00","1365.00","1365.00","1 through 10","365.82","572.04","percent of total billed charges",""
"KIT MIXING VERTECEM II CEMENT","SUP-ITM-10169043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","572.04","81.72","","5157.68","5157.68","5157.68","1 through 10","365.82","572.04","percent of total billed charges",""
"KIT MIXING VERTECEM II CEMENT","SUP-ITM-10169043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","431.26","71.26","1459.57","88","365.82","572.04","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","8995.73","6746.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7151.61","79.5","","800.18","480.96","1887.97","195","2788.68","7151.61","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","8995.73","6746.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4794.72","53.3","","813.12","216.42","1444.50","81","2788.68","7151.61","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","8995.73","6746.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2788.68","31","","432.60","432.60","432.60","1 through 10","2788.68","7151.61","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","8995.73","6746.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3283.44","36.5","","148.37","54.89","631.39","94","2788.68","7151.61","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","8995.73","6746.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3445.36","38.3","","279.30","91.72","1116.77","266","2788.68","7151.61","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","8995.73","6746.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3859.17","42.9","","731.00","63.70","731.00","1 through 10","2788.68","7151.61","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","8995.73","6746.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3859.17","42.9","","384.74","384.74","384.74","1 through 10","2788.68","7151.61","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","8995.73","6746.80","WELLPOINT [1015]","HB AMC WELLPOINT","6637.05","73.78","","286.63","119.22","1107.45","105","2788.68","7151.61","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8995.73","6746.80","AETNA [1001]","HB AMC AETNA HMO","6279.02","69.8","","675.31","184.75","1721.50","286","4701.17","7351.31","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8995.73","6746.80","AETNA [1001]","HB AMC AETNA PPO","7232.57","80.4","","1261.44","103.12","1514.10","21","4701.17","7351.31","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8995.73","6746.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7232.57","80.4","","1365.00","1365.00","1365.00","1 through 10","4701.17","7351.31","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8995.73","6746.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7351.31","81.72","","5157.68","5157.68","5157.68","1 through 10","4701.17","7351.31","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8995.73","6746.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7351.31","81.72","","431.26","71.26","1459.57","88","4701.17","7351.31","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","5438.65","4078.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4323.73","79.5","","800.18","480.96","1887.97","195","1685.98","4323.73","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","5438.65","4078.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2898.80","53.3","","813.12","216.42","1444.50","81","1685.98","4323.73","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","5438.65","4078.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1685.98","31","","432.60","432.60","432.60","1 through 10","1685.98","4323.73","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","5438.65","4078.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1985.11","36.5","","148.37","54.89","631.39","94","1685.98","4323.73","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","5438.65","4078.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2083.00","38.3","","279.30","91.72","1116.77","266","1685.98","4323.73","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","5438.65","4078.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2333.18","42.9","","731.00","63.70","731.00","1 through 10","1685.98","4323.73","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","5438.65","4078.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2333.18","42.9","","384.74","384.74","384.74","1 through 10","1685.98","4323.73","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","5438.65","4078.99","WELLPOINT [1015]","HB AMC WELLPOINT","4012.64","73.78","","286.63","119.22","1107.45","105","1685.98","4323.73","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5438.65","4078.99","AETNA [1001]","HB AMC AETNA HMO","3796.18","69.8","","675.31","184.75","1721.50","286","2842.24","4444.46","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5438.65","4078.99","AETNA [1001]","HB AMC AETNA PPO","4372.67","80.4","","1261.44","103.12","1514.10","21","2842.24","4444.46","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5438.65","4078.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4372.67","80.4","","1365.00","1365.00","1365.00","1 through 10","2842.24","4444.46","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5438.65","4078.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4444.46","81.72","","5157.68","5157.68","5157.68","1 through 10","2842.24","4444.46","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5438.65","4078.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4444.46","81.72","","431.26","71.26","1459.57","88","2842.24","4444.46","percent of total billed charges",""
"KIT NEEDLE 1.5MM 90DEG CRYOABLATION ICEPHERE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10092393","CDM","C2618","HCPCS","0272","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1838.40","38.3","","1876.80","640.73","1876.80","1 through 10","1488","3816","percent of total billed charges",""
"KIT NEEDLE 1.5MM 90DEG CRYOABLATION ICEPHERE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10092393","CDM","C2618","HCPCS","0272","RC","","","","both","","","4800.00","3600.00","WELLPOINT [1015]","HB AMC WELLPOINT","3541.44","73.78","","2802.54","1220.01","4020.30","1 through 10","1488","3816","percent of total billed charges",""
"KIT NEEDLE 1.5MM 90DEG CRYOABLATION ICEPHERE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10092393","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA HMO","3350.40","69.8","","2175.20","2175.20","2175.20","1 through 10","2508.48","3922.56","percent of total billed charges",""
"KIT NEEDLE 1.5MM 90DEG CRYOABLATION ICEPHERE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10092393","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3922.56","81.72","","4750.00","720.54","7250.00","11","2508.48","3922.56","percent of total billed charges",""
"KIT OSTEOCOOL PROBE 17G 10MM RF DUAL ABLATION","SUP-ITM-10159469","CDM","C1886","HCPCS","0272","RC","","","","both","","","11080.00","8310.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","7955.44","71.8","","4399.55","4399.55","4399.55","1 through 10","3434.8","8808.6","percent of total billed charges",""
"KIT OSTEOCOOL PROBE 17G 10MM RF DUAL ABLATION","SUP-ITM-10159469","CDM","C1886","HCPCS","0272","RC","","","","both","","","11080.00","8310.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4044.20","36.5","","1413.19","621.27","1413.19","1 through 10","3434.8","8808.6","percent of total billed charges",""
"KIT OSTEOCOOL PROBE 17G 10MM RF DUAL ABLATION","SUP-ITM-10159469","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","11080.00","8310.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9054.58","81.72","","8168.27","2209.17","8168.27","1 through 10","5790.41","9054.58","percent of total billed charges",""
"KIT OSTEOCOOL PROBE 17G 7MM RF DUAL ABLATION","SUP-ITM-10159470","CDM","C1886","HCPCS","0272","RC","","","","both","","","11080.00","8310.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","7955.44","71.8","","4399.55","4399.55","4399.55","1 through 10","3434.8","8808.6","percent of total billed charges",""
"KIT OSTEOCOOL PROBE 17G 7MM RF DUAL ABLATION","SUP-ITM-10159470","CDM","C1886","HCPCS","0272","RC","","","","both","","","11080.00","8310.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4044.20","36.5","","1413.19","621.27","1413.19","1 through 10","3434.8","8808.6","percent of total billed charges",""
"KIT OSTEOCOOL PROBE 17G 7MM RF DUAL ABLATION","SUP-ITM-10159470","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","11080.00","8310.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9054.58","81.72","","8168.27","2209.17","8168.27","1 through 10","5790.41","9054.58","percent of total billed charges",""
"KIT PERICARDIOCENTESIS PERIVAC 8.3FR STRAIGHT CATHETER PLUS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010440","CDM","C1729","HCPCS","0272","RC","","","","both","","","456.17","342.13","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","327.53","71.8","","162.24","51.52","162.24","1 through 10","141.41","362.66","percent of total billed charges",""
"KIT PERICARDIOCENTESIS PERIVAC 8.3FR STRAIGHT CATHETER PLUS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010440","CDM","C1729","HCPCS","0272","RC","","","","both","","","456.17","342.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.50","36.5","","94.34","22.19","146.22","26","141.41","362.66","percent of total billed charges",""
"KIT PERICARDIOCENTESIS PERIVAC 8.3FR STRAIGHT CATHETER PLUS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010440","CDM","C1729","HCPCS","0272","RC","","","","both","","","456.17","342.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.71","38.3","","51.52","27.37","51.52","26","141.41","362.66","percent of total billed charges",""
"KIT PERICARDIOCENTESIS PERIVAC 8.3FR STRAIGHT CATHETER PLUS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010440","CDM","C1729","HCPCS","0272","RC","","","","both","","","456.17","342.13","WELLPOINT [1015]","HB AMC WELLPOINT","336.56","73.78","","207.21","122.12","216.28","14","141.41","362.66","percent of total billed charges",""
"KIT PERICARDIOCENTESIS PERIVAC 8.3FR STRAIGHT CATHETER PLUS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010440","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","456.17","342.13","AETNA [1001]","HB AMC AETNA HMO","318.41","69.8","","155.96","47.39","155.96","1 through 10","238.39","372.78","percent of total billed charges",""
"KIT PERICARDIOCENTESIS PERIVAC 8.3FR STRAIGHT CATHETER PLUS - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010440","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","456.17","342.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","372.78","81.72","","57.36","51.76","232.23","35","238.39","372.78","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","800.18","480.96","1887.97","195","217","556.5","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","813.12","216.42","1444.50","81","217","556.5","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","217.00","31","","432.60","432.60","432.60","1 through 10","217","556.5","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","148.37","54.89","631.39","94","217","556.5","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","279.30","91.72","1116.77","266","217","556.5","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","731.00","63.70","731.00","1 through 10","217","556.5","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","384.74","384.74","384.74","1 through 10","217","556.5","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","286.63","119.22","1107.45","105","217","556.5","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","675.31","184.75","1721.50","286","365.82","572.04","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA PPO","562.80","80.4","","1261.44","103.12","1514.10","21","365.82","572.04","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","562.80","80.4","","1365.00","1365.00","1365.00","1 through 10","365.82","572.04","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","572.04","81.72","","5157.68","5157.68","5157.68","1 through 10","365.82","572.04","percent of total billed charges",""
"KIT PIN 3.3MM BONE RIGIDFIX ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION","SUP-ITM-10007418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","431.26","71.26","1459.57","88","365.82","572.04","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","2164.58","1623.43","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1131.21","52.26","","1113.10","1113.10","1113.10","1 through 10","671.02","1720.84","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","2164.58","1623.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1720.84","79.5","","1293.60","1148.53","1603.80","1 through 10","671.02","1720.84","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","2164.58","1623.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","790.07","36.5","","1023.42","771.29","2068.67","33","671.02","1720.84","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","2164.58","1623.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","829.03","38.3","","850.52","759.78","1211.25","66","671.02","1720.84","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","2164.58","1623.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","928.60","42.9","","2548.09","2548.09","2548.09","1 through 10","671.02","1720.84","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","2164.58","1623.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","928.60","42.9","","956.46","956.46","956.46","1 through 10","671.02","1720.84","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","2164.58","1623.43","WELLPOINT [1015]","HB AMC WELLPOINT","1597.03","73.78","","2344.73","1619.47","2530.35","16","671.02","1720.84","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2164.58","1623.43","AETNA [1001]","HB AMC AETNA HMO","1510.88","69.8","","1523.63","988.41","4330.26","39","1131.21","1768.89","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2164.58","1623.43","AETNA [1001]","HB AMC AETNA PPO","1740.32","80.4","","1670.25","1670.25","1670.25","1 through 10","1131.21","1768.89","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2164.58","1623.43","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1131.21","52.26","","1113.10","1113.10","1113.10","1 through 10","1131.21","1768.89","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2164.58","1623.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1768.89","81.72","","1738.90","1484.65","2716.94","38","1131.21","1768.89","percent of total billed charges",""
"KIT PLAN INSTRUMENT IMT BASIC MADIBLE RECONSTRUCTION CUSTOM","SUP-ITM-10113813","CDM","C1713","HCPCS","0278","RC","","","","both","","","4729.63","3547.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3760.06","79.5","","800.18","480.96","1887.97","195","1466.19","3760.06","percent of total billed charges",""
"KIT PLAN INSTRUMENT IMT BASIC MADIBLE RECONSTRUCTION CUSTOM","SUP-ITM-10113813","CDM","C1713","HCPCS","0278","RC","","","","both","","","4729.63","3547.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2520.89","53.3","","813.12","216.42","1444.50","81","1466.19","3760.06","percent of total billed charges",""
"KIT PLAN INSTRUMENT IMT BASIC MADIBLE RECONSTRUCTION CUSTOM","SUP-ITM-10113813","CDM","C1713","HCPCS","0278","RC","","","","both","","","4729.63","3547.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1466.19","31","","432.60","432.60","432.60","1 through 10","1466.19","3760.06","percent of total billed charges",""
"KIT PLAN INSTRUMENT IMT BASIC MADIBLE RECONSTRUCTION CUSTOM","SUP-ITM-10113813","CDM","C1713","HCPCS","0278","RC","","","","both","","","4729.63","3547.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1726.31","36.5","","148.37","54.89","631.39","94","1466.19","3760.06","percent of total billed charges",""
"KIT PLAN INSTRUMENT IMT BASIC MADIBLE RECONSTRUCTION CUSTOM","SUP-ITM-10113813","CDM","C1713","HCPCS","0278","RC","","","","both","","","4729.63","3547.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1811.45","38.3","","279.30","91.72","1116.77","266","1466.19","3760.06","percent of total billed charges",""
"KIT PLAN INSTRUMENT IMT BASIC MADIBLE RECONSTRUCTION CUSTOM","SUP-ITM-10113813","CDM","C1713","HCPCS","0278","RC","","","","both","","","4729.63","3547.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2029.01","42.9","","731.00","63.70","731.00","1 through 10","1466.19","3760.06","percent of total billed charges",""
"KIT PLAN INSTRUMENT IMT BASIC MADIBLE RECONSTRUCTION CUSTOM","SUP-ITM-10113813","CDM","C1713","HCPCS","0278","RC","","","","both","","","4729.63","3547.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2029.01","42.9","","384.74","384.74","384.74","1 through 10","1466.19","3760.06","percent of total billed charges",""
"KIT PLAN INSTRUMENT IMT BASIC MADIBLE RECONSTRUCTION CUSTOM","SUP-ITM-10113813","CDM","C1713","HCPCS","0278","RC","","","","both","","","4729.63","3547.22","WELLPOINT [1015]","HB AMC WELLPOINT","3489.52","73.78","","286.63","119.22","1107.45","105","1466.19","3760.06","percent of total billed charges",""
"KIT PLAN INSTRUMENT IMT BASIC MADIBLE RECONSTRUCTION CUSTOM","SUP-ITM-10113813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4729.63","3547.22","AETNA [1001]","HB AMC AETNA HMO","3301.28","69.8","","675.31","184.75","1721.50","286","2471.7","3865.05","percent of total billed charges",""
"KIT PLAN INSTRUMENT IMT BASIC MADIBLE RECONSTRUCTION CUSTOM","SUP-ITM-10113813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4729.63","3547.22","AETNA [1001]","HB AMC AETNA PPO","3802.62","80.4","","1261.44","103.12","1514.10","21","2471.7","3865.05","percent of total billed charges",""
"KIT PLAN INSTRUMENT IMT BASIC MADIBLE RECONSTRUCTION CUSTOM","SUP-ITM-10113813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4729.63","3547.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3802.62","80.4","","1365.00","1365.00","1365.00","1 through 10","2471.7","3865.05","percent of total billed charges",""
"KIT PLAN INSTRUMENT IMT BASIC MADIBLE RECONSTRUCTION CUSTOM","SUP-ITM-10113813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4729.63","3547.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3865.05","81.72","","5157.68","5157.68","5157.68","1 through 10","2471.7","3865.05","percent of total billed charges",""
"KIT PLAN INSTRUMENT IMT BASIC MADIBLE RECONSTRUCTION CUSTOM","SUP-ITM-10113813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4729.63","3547.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3865.05","81.72","","431.26","71.26","1459.57","88","2471.7","3865.05","percent of total billed charges",""
"KIT PLAN RECONSTRUCTION PRO CMF MANDIBLE MIDFACE PATIENT SPECIFIC CUSTOM","SUP-ITM-10114549","CDM","C1713","HCPCS","0278","RC","","","","both","","","7119.88","5339.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5660.30","79.5","","800.18","480.96","1887.97","195","2207.16","5660.3","percent of total billed charges",""
"KIT PLAN RECONSTRUCTION PRO CMF MANDIBLE MIDFACE PATIENT SPECIFIC CUSTOM","SUP-ITM-10114549","CDM","C1713","HCPCS","0278","RC","","","","both","","","7119.88","5339.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3794.90","53.3","","813.12","216.42","1444.50","81","2207.16","5660.3","percent of total billed charges",""
"KIT PLAN RECONSTRUCTION PRO CMF MANDIBLE MIDFACE PATIENT SPECIFIC CUSTOM","SUP-ITM-10114549","CDM","C1713","HCPCS","0278","RC","","","","both","","","7119.88","5339.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2207.16","31","","432.60","432.60","432.60","1 through 10","2207.16","5660.3","percent of total billed charges",""
"KIT PLAN RECONSTRUCTION PRO CMF MANDIBLE MIDFACE PATIENT SPECIFIC CUSTOM","SUP-ITM-10114549","CDM","C1713","HCPCS","0278","RC","","","","both","","","7119.88","5339.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2598.76","36.5","","148.37","54.89","631.39","94","2207.16","5660.3","percent of total billed charges",""
"KIT PLAN RECONSTRUCTION PRO CMF MANDIBLE MIDFACE PATIENT SPECIFIC CUSTOM","SUP-ITM-10114549","CDM","C1713","HCPCS","0278","RC","","","","both","","","7119.88","5339.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2726.91","38.3","","279.30","91.72","1116.77","266","2207.16","5660.3","percent of total billed charges",""
"KIT PLAN RECONSTRUCTION PRO CMF MANDIBLE MIDFACE PATIENT SPECIFIC CUSTOM","SUP-ITM-10114549","CDM","C1713","HCPCS","0278","RC","","","","both","","","7119.88","5339.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3054.43","42.9","","731.00","63.70","731.00","1 through 10","2207.16","5660.3","percent of total billed charges",""
"KIT PLAN RECONSTRUCTION PRO CMF MANDIBLE MIDFACE PATIENT SPECIFIC CUSTOM","SUP-ITM-10114549","CDM","C1713","HCPCS","0278","RC","","","","both","","","7119.88","5339.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3054.43","42.9","","384.74","384.74","384.74","1 through 10","2207.16","5660.3","percent of total billed charges",""
"KIT PLAN RECONSTRUCTION PRO CMF MANDIBLE MIDFACE PATIENT SPECIFIC CUSTOM","SUP-ITM-10114549","CDM","C1713","HCPCS","0278","RC","","","","both","","","7119.88","5339.91","WELLPOINT [1015]","HB AMC WELLPOINT","5253.05","73.78","","286.63","119.22","1107.45","105","2207.16","5660.3","percent of total billed charges",""
"KIT PLAN RECONSTRUCTION PRO CMF MANDIBLE MIDFACE PATIENT SPECIFIC CUSTOM","SUP-ITM-10114549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7119.88","5339.91","AETNA [1001]","HB AMC AETNA HMO","4969.68","69.8","","675.31","184.75","1721.50","286","3720.85","5818.37","percent of total billed charges",""
"KIT PLAN RECONSTRUCTION PRO CMF MANDIBLE MIDFACE PATIENT SPECIFIC CUSTOM","SUP-ITM-10114549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7119.88","5339.91","AETNA [1001]","HB AMC AETNA PPO","5724.38","80.4","","1261.44","103.12","1514.10","21","3720.85","5818.37","percent of total billed charges",""
"KIT PLAN RECONSTRUCTION PRO CMF MANDIBLE MIDFACE PATIENT SPECIFIC CUSTOM","SUP-ITM-10114549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7119.88","5339.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5724.38","80.4","","1365.00","1365.00","1365.00","1 through 10","3720.85","5818.37","percent of total billed charges",""
"KIT PLAN RECONSTRUCTION PRO CMF MANDIBLE MIDFACE PATIENT SPECIFIC CUSTOM","SUP-ITM-10114549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7119.88","5339.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5818.37","81.72","","5157.68","5157.68","5157.68","1 through 10","3720.85","5818.37","percent of total billed charges",""
"KIT PLAN RECONSTRUCTION PRO CMF MANDIBLE MIDFACE PATIENT SPECIFIC CUSTOM","SUP-ITM-10114549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7119.88","5339.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5818.37","81.72","","431.26","71.26","1459.57","88","3720.85","5818.37","percent of total billed charges",""
"KIT PLUG 29CM ACCESSORY NEUROSTIMULATION OCTOPOLAR INLINE LOW PROFILE CLOSED BOOT KT/1EA","SUP-ITM-10018141","CDM","C1778","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","5279.78","5279.78","5279.78","1 through 10","162.75","417.38","percent of total billed charges",""
"KIT PLUG 29CM ACCESSORY NEUROSTIMULATION OCTOPOLAR INLINE LOW PROFILE CLOSED BOOT KT/1EA","SUP-ITM-10018141","CDM","C1778","HCPCS","0278","RC","","","","both","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","417.38","79.5","","15789.05","15789.05","15789.05","1 through 10","162.75","417.38","percent of total billed charges",""
"KIT PLUG 29CM ACCESSORY NEUROSTIMULATION OCTOPOLAR INLINE LOW PROFILE CLOSED BOOT KT/1EA","SUP-ITM-10018141","CDM","C1778","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","2482.78","1657.12","2482.78","1 through 10","162.75","417.38","percent of total billed charges",""
"KIT PLUG 29CM ACCESSORY NEUROSTIMULATION OCTOPOLAR INLINE LOW PROFILE CLOSED BOOT KT/1EA","SUP-ITM-10018141","CDM","C1778","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","2602.60","2602.60","2602.60","1 through 10","162.75","417.38","percent of total billed charges",""
"KIT PLUG 29CM ACCESSORY NEUROSTIMULATION OCTOPOLAR INLINE LOW PROFILE CLOSED BOOT KT/1EA","SUP-ITM-10018141","CDM","C1778","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","4955.58","3845.35","9119.37","1 through 10","162.75","417.38","percent of total billed charges",""
"KIT PLUG 29CM ACCESSORY NEUROSTIMULATION OCTOPOLAR INLINE LOW PROFILE CLOSED BOOT KT/1EA","SUP-ITM-10018141","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","8631.75","8631.75","8631.75","1 through 10","274.37","429.03","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","201.60","151.20","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","105.36","52.26","","1113.10","1113.10","1113.10","1 through 10","62.5","160.27","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","201.60","151.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.27","79.5","","1293.60","1148.53","1603.80","1 through 10","62.5","160.27","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","201.60","151.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.58","36.5","","1023.42","771.29","2068.67","33","62.5","160.27","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","201.60","151.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.21","38.3","","850.52","759.78","1211.25","66","62.5","160.27","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","201.60","151.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.49","42.9","","2548.09","2548.09","2548.09","1 through 10","62.5","160.27","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","201.60","151.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.49","42.9","","956.46","956.46","956.46","1 through 10","62.5","160.27","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","201.60","151.20","WELLPOINT [1015]","HB AMC WELLPOINT","148.74","73.78","","2344.73","1619.47","2530.35","16","62.5","160.27","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","201.60","151.20","AETNA [1001]","HB AMC AETNA HMO","140.72","69.8","","1523.63","988.41","4330.26","39","105.36","164.75","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","201.60","151.20","AETNA [1001]","HB AMC AETNA PPO","162.09","80.4","","1670.25","1670.25","1670.25","1 through 10","105.36","164.75","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","201.60","151.20","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","105.36","52.26","","1113.10","1113.10","1113.10","1 through 10","105.36","164.75","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","201.60","151.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","164.75","81.72","","1738.90","1484.65","2716.94","38","105.36","164.75","percent of total billed charges",""
"KIT PROBE L 75X17 17GA ELECTROSURGICAL INTRODUCER SINERGY SACROILIAC JOINT SYNDROME CS/1EA","SUP-ITM-10082902","CDM","C1886","HCPCS","0272","RC","","","","both","","","2625.00","1968.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1884.75","71.8","","4399.55","4399.55","4399.55","1 through 10","813.75","2086.88","percent of total billed charges",""
"KIT PROBE L 75X17 17GA ELECTROSURGICAL INTRODUCER SINERGY SACROILIAC JOINT SYNDROME CS/1EA","SUP-ITM-10082902","CDM","C1886","HCPCS","0272","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","958.13","36.5","","1413.19","621.27","1413.19","1 through 10","813.75","2086.88","percent of total billed charges",""
"KIT PROBE L 75X17 17GA ELECTROSURGICAL INTRODUCER SINERGY SACROILIAC JOINT SYNDROME CS/1EA","SUP-ITM-10082902","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2145.15","81.72","","8168.27","2209.17","8168.27","1 through 10","1371.83","2145.15","percent of total billed charges",""
"KIT PROCEDURE EM A-TUBE APIREASSIST","SUP-ITM-10192389","CDM","C1729","HCPCS","0272","RC","","","","both","","","4537.50","3403.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3257.93","71.8","","162.24","51.52","162.24","1 through 10","1406.63","3607.31","percent of total billed charges",""
"KIT PROCEDURE EM A-TUBE APIREASSIST","SUP-ITM-10192389","CDM","C1729","HCPCS","0272","RC","","","","both","","","4537.50","3403.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1656.19","36.5","","94.34","22.19","146.22","26","1406.63","3607.31","percent of total billed charges",""
"KIT PROCEDURE EM A-TUBE APIREASSIST","SUP-ITM-10192389","CDM","C1729","HCPCS","0272","RC","","","","both","","","4537.50","3403.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1737.86","38.3","","51.52","27.37","51.52","26","1406.63","3607.31","percent of total billed charges",""
"KIT PROCEDURE EM A-TUBE APIREASSIST","SUP-ITM-10192389","CDM","C1729","HCPCS","0272","RC","","","","both","","","4537.50","3403.12","WELLPOINT [1015]","HB AMC WELLPOINT","3347.77","73.78","","207.21","122.12","216.28","14","1406.63","3607.31","percent of total billed charges",""
"KIT PROCEDURE EM A-TUBE APIREASSIST","SUP-ITM-10192389","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","4537.50","3403.12","AETNA [1001]","HB AMC AETNA HMO","3167.18","69.8","","155.96","47.39","155.96","1 through 10","2371.3","3708.05","percent of total billed charges",""
"KIT PROCEDURE EM A-TUBE APIREASSIST","SUP-ITM-10192389","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","4537.50","3403.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3708.05","81.72","","57.36","51.76","232.23","35","2371.3","3708.05","percent of total billed charges",""
"KIT PROCEDURE EM FIRST YEAR ASPIREASSIST","SUP-ITM-10192390","CDM","C1729","HCPCS","0272","RC","","","","both","","","6422.50","4816.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","4611.36","71.8","","162.24","51.52","162.24","1 through 10","1990.98","5105.89","percent of total billed charges",""
"KIT PROCEDURE EM FIRST YEAR ASPIREASSIST","SUP-ITM-10192390","CDM","C1729","HCPCS","0272","RC","","","","both","","","6422.50","4816.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2344.21","36.5","","94.34","22.19","146.22","26","1990.98","5105.89","percent of total billed charges",""
"KIT PROCEDURE EM FIRST YEAR ASPIREASSIST","SUP-ITM-10192390","CDM","C1729","HCPCS","0272","RC","","","","both","","","6422.50","4816.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2459.82","38.3","","51.52","27.37","51.52","26","1990.98","5105.89","percent of total billed charges",""
"KIT PROCEDURE EM FIRST YEAR ASPIREASSIST","SUP-ITM-10192390","CDM","C1729","HCPCS","0272","RC","","","","both","","","6422.50","4816.87","WELLPOINT [1015]","HB AMC WELLPOINT","4738.52","73.78","","207.21","122.12","216.28","14","1990.98","5105.89","percent of total billed charges",""
"KIT PROCEDURE EM FIRST YEAR ASPIREASSIST","SUP-ITM-10192390","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","6422.50","4816.87","AETNA [1001]","HB AMC AETNA HMO","4482.91","69.8","","155.96","47.39","155.96","1 through 10","3356.4","5248.47","percent of total billed charges",""
"KIT PROCEDURE EM FIRST YEAR ASPIREASSIST","SUP-ITM-10192390","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","6422.50","4816.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5248.47","81.72","","57.36","51.76","232.23","35","3356.4","5248.47","percent of total billed charges",""
"KIT PROGRAMMER PRECISION SPECTRA CONTROL REMOTE STIMULATION SPINAL CORD","SUP-ITM-10126495","CDM","C1787","HCPCS","0270","RC","","","","both","","","2800.00","2100.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1492.40","53.3","","3163.82","3163.82","3163.82","1 through 10","868","2226","percent of total billed charges",""
"KIT PROGRAMMER PRECISION SPECTRA CONTROL REMOTE STIMULATION SPINAL CORD","SUP-ITM-10126495","CDM","C1787","HCPCS","0270","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","1639.86","1566.60","1745.64","1 through 10","868","2226","percent of total billed charges",""
"KIT PROGRAMMER PRECISION SPECTRA CONTROL REMOTE STIMULATION SPINAL CORD","SUP-ITM-10126495","CDM","C1787","HCPCS","0270","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","1642.20","1642.20","1642.20","1 through 10","868","2226","percent of total billed charges",""
"KIT PROGRAMMER PRECISION SPECTRA CONTROL REMOTE STIMULATION SPINAL CORD","SUP-ITM-10126495","CDM","C1787","HCPCS","0270","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","2332.15","846.87","3126.90","1 through 10","868","2226","percent of total billed charges",""
"KIT PULSE GENERATOR WAVEWRITER ALPHA IMPLANTABLE","SUP-ITM-10282803","CDM","C1767","HCPCS","0278","RC","","","","both","","","44625.00","33468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16288.13","36.5","","18081.90","16994.81","18081.90","1 through 10","13833.75","35476.88","percent of total billed charges",""
"KIT PULSE GENERATOR WAVEWRITER ALPHA IMPLANTABLE","SUP-ITM-10282803","CDM","C1767","HCPCS","0278","RC","","","","both","","","44625.00","33468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17091.38","38.3","","17814.94","17448.38","17814.94","1 through 10","13833.75","35476.88","percent of total billed charges",""
"KIT PULSE GENERATOR WAVEWRITER ALPHA IMPLANTABLE","SUP-ITM-10282803","CDM","C1767","HCPCS","0278","RC","","","","both","","","44625.00","33468.75","WELLPOINT [1015]","HB AMC WELLPOINT","32924.33","73.78","","33921.28","33921.28","33921.28","1 through 10","13833.75","35476.88","percent of total billed charges",""
"KIT PUMP REVISION SEGMENT STRAIN RELIEF SLEEVE CONNECTOR PIN RULER LITERATURE","SUP-ITM-10036224","CDM","C1772","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","22036.00","22036.00","22036.00","1 through 10","434","1113","percent of total billed charges",""
"KIT PUMP REVISION SEGMENT STRAIN RELIEF SLEEVE CONNECTOR PIN RULER LITERATURE","SUP-ITM-10036224","CDM","C1772","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","14140.00","14140.00","14140.00","1 through 10","434","1113","percent of total billed charges",""
"KIT PUMP REVISION SEGMENT STRAIN RELIEF SLEEVE CONNECTOR PIN RULER LITERATURE","SUP-ITM-10036224","CDM","C1772","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","13384.00","13272.00","13384.00","1 through 10","731.64","1144.08","percent of total billed charges",""
"KIT PUMP REVISION SEGMENT STRAIN RELIEF SLEEVE CONNECTOR PIN RULER LITERATURE","SUP-ITM-10036224","CDM","C1772","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","22383.20","22383.20","22383.20","1 through 10","731.64","1144.08","percent of total billed charges",""
"KIT REMOTE CONTROL NEVRO SENZA PATIENT PROGRAMMER EXTERNAL","SUP-ITM-10158042","CDM","C1787","HCPCS","0270","RC","","","","both","","","4158.00","3118.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2216.21","53.3","","3163.82","3163.82","3163.82","1 through 10","1288.98","3305.61","percent of total billed charges",""
"KIT REMOTE CONTROL NEVRO SENZA PATIENT PROGRAMMER EXTERNAL","SUP-ITM-10158042","CDM","C1787","HCPCS","0270","RC","","","","both","","","4158.00","3118.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1517.67","36.5","","1639.86","1566.60","1745.64","1 through 10","1288.98","3305.61","percent of total billed charges",""
"KIT REMOTE CONTROL NEVRO SENZA PATIENT PROGRAMMER EXTERNAL","SUP-ITM-10158042","CDM","C1787","HCPCS","0270","RC","","","","both","","","4158.00","3118.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1592.51","38.3","","1642.20","1642.20","1642.20","1 through 10","1288.98","3305.61","percent of total billed charges",""
"KIT REMOTE CONTROL NEVRO SENZA PATIENT PROGRAMMER EXTERNAL","SUP-ITM-10158042","CDM","C1787","HCPCS","0270","RC","","","","both","","","4158.00","3118.50","WELLPOINT [1015]","HB AMC WELLPOINT","3067.77","73.78","","2332.15","846.87","3126.90","1 through 10","1288.98","3305.61","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1637.04","52.26","","1113.10","1113.10","1113.10","1 through 10","971.08","2490.34","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2490.34","79.5","","1293.60","1148.53","1603.80","1 through 10","971.08","2490.34","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1143.36","36.5","","1023.42","771.29","2068.67","33","971.08","2490.34","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1199.75","38.3","","850.52","759.78","1211.25","66","971.08","2490.34","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1343.84","42.9","","2548.09","2548.09","2548.09","1 through 10","971.08","2490.34","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1343.84","42.9","","956.46","956.46","956.46","1 through 10","971.08","2490.34","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","WELLPOINT [1015]","HB AMC WELLPOINT","2311.16","73.78","","2344.73","1619.47","2530.35","16","971.08","2490.34","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","AETNA [1001]","HB AMC AETNA HMO","2186.49","69.8","","1523.63","988.41","4330.26","39","1637.04","2559.88","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","AETNA [1001]","HB AMC AETNA PPO","2518.53","80.4","","1670.25","1670.25","1670.25","1 through 10","1637.04","2559.88","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1637.04","52.26","","1113.10","1113.10","1113.10","1 through 10","1637.04","2559.88","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2559.88","81.72","","1738.90","1484.65","2716.94","38","1637.04","2559.88","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","both","","","3852.80","2889.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3062.98","79.5","","800.18","480.96","1887.97","195","1194.37","3062.98","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","both","","","3852.80","2889.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2053.54","53.3","","813.12","216.42","1444.50","81","1194.37","3062.98","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","both","","","3852.80","2889.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1194.37","31","","432.60","432.60","432.60","1 through 10","1194.37","3062.98","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","both","","","3852.80","2889.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1406.27","36.5","","148.37","54.89","631.39","94","1194.37","3062.98","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","both","","","3852.80","2889.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1475.62","38.3","","279.30","91.72","1116.77","266","1194.37","3062.98","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","both","","","3852.80","2889.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1652.85","42.9","","731.00","63.70","731.00","1 through 10","1194.37","3062.98","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","both","","","3852.80","2889.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1652.85","42.9","","384.74","384.74","384.74","1 through 10","1194.37","3062.98","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","both","","","3852.80","2889.60","WELLPOINT [1015]","HB AMC WELLPOINT","2842.60","73.78","","286.63","119.22","1107.45","105","1194.37","3062.98","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3852.80","2889.60","AETNA [1001]","HB AMC AETNA HMO","2689.25","69.8","","675.31","184.75","1721.50","286","2013.47","3148.51","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3852.80","2889.60","AETNA [1001]","HB AMC AETNA PPO","3097.65","80.4","","1261.44","103.12","1514.10","21","2013.47","3148.51","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3852.80","2889.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3097.65","80.4","","1365.00","1365.00","1365.00","1 through 10","2013.47","3148.51","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3852.80","2889.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3148.51","81.72","","5157.68","5157.68","5157.68","1 through 10","2013.47","3148.51","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3852.80","2889.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3148.51","81.72","","431.26","71.26","1459.57","88","2013.47","3148.51","percent of total billed charges",""
"KIT REPAIR SUTURE GUIDEWIRE CANNULATED DRILL BIT MINI TIGHTROPE","SUP-ITM-10030202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1460.81","79.5","","800.18","480.96","1887.97","195","569.63","1460.81","percent of total billed charges",""
"KIT REPAIR SUTURE GUIDEWIRE CANNULATED DRILL BIT MINI TIGHTROPE","SUP-ITM-10030202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","979.39","53.3","","813.12","216.42","1444.50","81","569.63","1460.81","percent of total billed charges",""
"KIT REPAIR SUTURE GUIDEWIRE CANNULATED DRILL BIT MINI TIGHTROPE","SUP-ITM-10030202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","569.63","31","","432.60","432.60","432.60","1 through 10","569.63","1460.81","percent of total billed charges",""
"KIT REPAIR SUTURE GUIDEWIRE CANNULATED DRILL BIT MINI TIGHTROPE","SUP-ITM-10030202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","670.69","36.5","","148.37","54.89","631.39","94","569.63","1460.81","percent of total billed charges",""
"KIT REPAIR SUTURE GUIDEWIRE CANNULATED DRILL BIT MINI TIGHTROPE","SUP-ITM-10030202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","703.76","38.3","","279.30","91.72","1116.77","266","569.63","1460.81","percent of total billed charges",""
"KIT REPAIR SUTURE GUIDEWIRE CANNULATED DRILL BIT MINI TIGHTROPE","SUP-ITM-10030202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","788.29","42.9","","731.00","63.70","731.00","1 through 10","569.63","1460.81","percent of total billed charges",""
"KIT REPAIR SUTURE GUIDEWIRE CANNULATED DRILL BIT MINI TIGHTROPE","SUP-ITM-10030202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","788.29","42.9","","384.74","384.74","384.74","1 through 10","569.63","1460.81","percent of total billed charges",""
"KIT REPAIR SUTURE GUIDEWIRE CANNULATED DRILL BIT MINI TIGHTROPE","SUP-ITM-10030202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","WELLPOINT [1015]","HB AMC WELLPOINT","1355.71","73.78","","286.63","119.22","1107.45","105","569.63","1460.81","percent of total billed charges",""
"KIT REPAIR SUTURE GUIDEWIRE CANNULATED DRILL BIT MINI TIGHTROPE","SUP-ITM-10030202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","AETNA [1001]","HB AMC AETNA HMO","1282.58","69.8","","675.31","184.75","1721.50","286","960.28","1501.61","percent of total billed charges",""
"KIT REPAIR SUTURE GUIDEWIRE CANNULATED DRILL BIT MINI TIGHTROPE","SUP-ITM-10030202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","AETNA [1001]","HB AMC AETNA PPO","1477.35","80.4","","1261.44","103.12","1514.10","21","960.28","1501.61","percent of total billed charges",""
"KIT REPAIR SUTURE GUIDEWIRE CANNULATED DRILL BIT MINI TIGHTROPE","SUP-ITM-10030202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1477.35","80.4","","1365.00","1365.00","1365.00","1 through 10","960.28","1501.61","percent of total billed charges",""
"KIT REPAIR SUTURE GUIDEWIRE CANNULATED DRILL BIT MINI TIGHTROPE","SUP-ITM-10030202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1501.61","81.72","","5157.68","5157.68","5157.68","1 through 10","960.28","1501.61","percent of total billed charges",""
"KIT REPAIR SUTURE GUIDEWIRE CANNULATED DRILL BIT MINI TIGHTROPE","SUP-ITM-10030202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1501.61","81.72","","431.26","71.26","1459.57","88","960.28","1501.61","percent of total billed charges",""
"KIT REVISION LEAD","SUP-ITM-10138416","CDM","C1883","HCPCS","0278","RC","","","","both","","","38125.00","28593.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13915.63","36.5","","1073.15","1073.15","1073.15","1 through 10","11818.75","30309.38","percent of total billed charges",""
"KIT REVISION LEAD","SUP-ITM-10138416","CDM","C1883","HCPCS","0278","RC","","","","both","","","38125.00","28593.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14601.88","38.3","","1808.38","1642.20","1808.38","1 through 10","11818.75","30309.38","percent of total billed charges",""
"KIT REVISION LEAD","SUP-ITM-10138416","CDM","C1883","HCPCS","0278","RC","","","","both","","","38125.00","28593.75","WELLPOINT [1015]","HB AMC WELLPOINT","28128.63","73.78","","625.38","625.38","625.38","1 through 10","11818.75","30309.38","percent of total billed charges",""
"KIT SEAL 8FR THORACENTESIS PLEURA SHARPS SAFETY CS/10EA","SUP-ITM-10006103","CDM","C1729","HCPCS","0272","RC","","","","both","","","139.27","104.45","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","100.00","71.8","","162.24","51.52","162.24","1 through 10","43.17","110.72","percent of total billed charges",""
"KIT SEAL 8FR THORACENTESIS PLEURA SHARPS SAFETY CS/10EA","SUP-ITM-10006103","CDM","C1729","HCPCS","0272","RC","","","","both","","","139.27","104.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.83","36.5","","94.34","22.19","146.22","26","43.17","110.72","percent of total billed charges",""
"KIT SEAL 8FR THORACENTESIS PLEURA SHARPS SAFETY CS/10EA","SUP-ITM-10006103","CDM","C1729","HCPCS","0272","RC","","","","both","","","139.27","104.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.34","38.3","","51.52","27.37","51.52","26","43.17","110.72","percent of total billed charges",""
"KIT SEAL 8FR THORACENTESIS PLEURA SHARPS SAFETY CS/10EA","SUP-ITM-10006103","CDM","C1729","HCPCS","0272","RC","","","","both","","","139.27","104.45","WELLPOINT [1015]","HB AMC WELLPOINT","102.75","73.78","","207.21","122.12","216.28","14","43.17","110.72","percent of total billed charges",""
"KIT SEAL 8FR THORACENTESIS PLEURA SHARPS SAFETY CS/10EA","SUP-ITM-10006103","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","139.27","104.45","AETNA [1001]","HB AMC AETNA HMO","97.21","69.8","","155.96","47.39","155.96","1 through 10","72.78","113.81","percent of total billed charges",""
"KIT SEAL 8FR THORACENTESIS PLEURA SHARPS SAFETY CS/10EA","SUP-ITM-10006103","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","139.27","104.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.81","81.72","","57.36","51.76","232.23","35","72.78","113.81","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","36.58","27.43","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","19.12","52.26","","16.24","16.24","54.15","1 through 10","11.34","29.08","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","36.58","27.43","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","26.26","71.8","","86.33","32.67","86.33","1 through 10","11.34","29.08","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","36.58","27.43","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","25.61","70","","113.68","63.00","177.34","40","11.34","29.08","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","36.58","27.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","29.08","79.5","","50.70","21.76","168.00","12","11.34","29.08","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","36.58","27.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19.50","53.3","","89.31","89.31","99.75","1 through 10","11.34","29.08","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","36.58","27.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","23.78","65","","94.41","17.06","2275.00","1 through 10","11.34","29.08","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","36.58","27.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","11.34","31","","35.13","35.13","35.13","1 through 10","11.34","29.08","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","36.58","27.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13.35","36.5","","40.08","12.40","86.17","108","11.34","29.08","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","36.58","27.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.01","38.3","","33.25","10.27","68.43","169","11.34","29.08","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","36.58","27.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.69","42.9","","25.48","14.86","90.88","1 through 10","11.34","29.08","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","36.58","27.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.69","42.9","","90.88","90.88","90.88","1 through 10","11.34","29.08","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","36.58","27.43","WELLPOINT [1015]","HB AMC WELLPOINT","26.99","73.78","","84.63","19.55","140.02","123","11.34","29.08","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","36.58","27.43","AETNA [1001]","HB AMC AETNA HMO","25.53","69.8","","76.96","17.77","113.68","14","19.12","29.89","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","36.58","27.43","AETNA [1001]","HB AMC AETNA PPO","29.41","80.4","","57.31","57.31","57.31","1 through 10","19.12","29.89","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","36.58","27.43","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","19.12","52.26","","16.24","16.24","54.15","1 through 10","19.12","29.89","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","36.58","27.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","29.41","80.4","","68.25","68.25","87.50","1 through 10","19.12","29.89","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","36.58","27.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","29.89","81.72","","156.19","156.19","156.19","1 through 10","19.12","29.89","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","36.58","27.43","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","29.89","81.72","","82.70","12.06","98.97","13","19.12","29.89","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","36.58","27.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","29.89","81.72","","50.47","25.30","134.30","140","19.12","29.89","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3269.44","79.5","","800.18","480.96","1887.97","195","1274.88","3269.44","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2191.96","53.3","","813.12","216.42","1444.50","81","1274.88","3269.44","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1274.88","31","","432.60","432.60","432.60","1 through 10","1274.88","3269.44","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1501.06","36.5","","148.37","54.89","631.39","94","1274.88","3269.44","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1575.09","38.3","","279.30","91.72","1116.77","266","1274.88","3269.44","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1764.26","42.9","","731.00","63.70","731.00","1 through 10","1274.88","3269.44","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1764.26","42.9","","384.74","384.74","384.74","1 through 10","1274.88","3269.44","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","WELLPOINT [1015]","HB AMC WELLPOINT","3034.20","73.78","","286.63","119.22","1107.45","105","1274.88","3269.44","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4112.50","3084.37","AETNA [1001]","HB AMC AETNA HMO","2870.53","69.8","","675.31","184.75","1721.50","286","2149.19","3360.74","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4112.50","3084.37","AETNA [1001]","HB AMC AETNA PPO","3306.45","80.4","","1261.44","103.12","1514.10","21","2149.19","3360.74","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4112.50","3084.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3306.45","80.4","","1365.00","1365.00","1365.00","1 through 10","2149.19","3360.74","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4112.50","3084.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3360.74","81.72","","5157.68","5157.68","5157.68","1 through 10","2149.19","3360.74","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4112.50","3084.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3360.74","81.72","","431.26","71.26","1459.57","88","2149.19","3360.74","percent of total billed charges",""
"KIT SHEATH 22CM DELIVERY BIG CURVE","SUP-ITM-10211776","CDM","C1893","HCPCS","0272","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","218.28","218.28","218.28","1 through 10","434","1113","percent of total billed charges",""
"KIT SHEATH GLIDELIGHT 12FR 50CM LASER POLYMER S/S COATED BEVEL PC/1EA","SUP-ITM-10100544","CDM","C2629","HCPCS","0272","RC","","","","both","","","7862.50","5896.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2869.81","36.5","","8098.77","8098.77","8098.77","1 through 10","2437.38","6250.69","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","both","","","3458.00","2593.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2749.11","79.5","","1632.15","1632.15","1632.15","1 through 10","1071.98","2749.11","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","both","","","3458.00","2593.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1843.11","53.3","","9709.13","9709.13","9709.13","1 through 10","1071.98","2749.11","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","both","","","3458.00","2593.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2247.70","65","","2685.95","2190.09","2685.96","1 through 10","1071.98","2749.11","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","both","","","3458.00","2593.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1262.17","36.5","","1495.87","1455.73","1541.33","1 through 10","1071.98","2749.11","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","both","","","3458.00","2593.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1324.41","38.3","","1615.71","1615.71","1615.71","1 through 10","1071.98","2749.11","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","both","","","3458.00","2593.50","WELLPOINT [1015]","HB AMC WELLPOINT","2551.31","73.78","","3076.44","3076.44","3076.44","1 through 10","1071.98","2749.11","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3458.00","2593.50","AETNA [1001]","HB AMC AETNA HMO","2413.68","69.8","","4568.79","2411.14","4568.79","1 through 10","1807.15","2825.88","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3458.00","2593.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2780.23","80.4","","2411.14","1545.60","3223.14","1 through 10","1807.15","2825.88","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3458.00","2593.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2825.88","81.72","","1816.95","1816.95","1816.95","1 through 10","1807.15","2825.88","percent of total billed charges",""
"KIT SLING L 60CM 1 W LONG TRANSOBTURATOR MIDURETHRAL ARIS KNIT POLYPROPYLENE FLAT CURVED HELICAL INTRODUCER","SUP-ITM-10016202","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3458.00","2593.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2825.88","81.72","","3303.30","3303.30","3303.30","1 through 10","1807.15","2825.88","percent of total billed charges",""
"KIT SMALL IMPLANT ELBOW HUMERAL PIN BUSHING REPLACEMENT COONRAD MORREY SET REGULAR","SUP-ITM-10006959","CDM","C1889","HCPCS","0278","RC","","","","both","","","2164.58","1623.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1720.84","79.5","","1309.77","674.56","6049.93","26","671.02","1720.84","percent of total billed charges",""
"KIT SMALL IMPLANT ELBOW HUMERAL PIN BUSHING REPLACEMENT COONRAD MORREY SET REGULAR","SUP-ITM-10006959","CDM","C1889","HCPCS","0278","RC","","","","both","","","2164.58","1623.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1153.72","53.3","","1901.83","1901.83","2962.25","1 through 10","671.02","1720.84","percent of total billed charges",""
"KIT SMALL IMPLANT ELBOW HUMERAL PIN BUSHING REPLACEMENT COONRAD MORREY SET REGULAR","SUP-ITM-10006959","CDM","C1889","HCPCS","0278","RC","","","","both","","","2164.58","1623.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","790.07","36.5","","1620.31","1620.31","19908.88","1 through 10","671.02","1720.84","percent of total billed charges",""
"KIT SMALL IMPLANT ELBOW HUMERAL PIN BUSHING REPLACEMENT COONRAD MORREY SET REGULAR","SUP-ITM-10006959","CDM","C1889","HCPCS","0278","RC","","","","both","","","2164.58","1623.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","829.03","38.3","","352.91","352.91","2046.30","1 through 10","671.02","1720.84","percent of total billed charges",""
"KIT SMALL IMPLANT ELBOW HUMERAL PIN BUSHING REPLACEMENT COONRAD MORREY SET REGULAR","SUP-ITM-10006959","CDM","C1889","HCPCS","0278","RC","","","","both","","","2164.58","1623.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","928.60","42.9","","9668.75","9668.75","9668.75","1 through 10","671.02","1720.84","percent of total billed charges",""
"KIT SMALL IMPLANT ELBOW HUMERAL PIN BUSHING REPLACEMENT COONRAD MORREY SET REGULAR","SUP-ITM-10006959","CDM","C1889","HCPCS","0278","RC","","","","both","","","2164.58","1623.43","WELLPOINT [1015]","HB AMC WELLPOINT","1597.03","73.78","","699.88","384.10","3443.31","33","671.02","1720.84","percent of total billed charges",""
"KIT SMALL IMPLANT ELBOW HUMERAL PIN BUSHING REPLACEMENT COONRAD MORREY SET REGULAR","SUP-ITM-10006959","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2164.58","1623.43","AETNA [1001]","HB AMC AETNA HMO","1510.88","69.8","","1421.24","264.50","4933.46","29","1131.21","1768.89","percent of total billed charges",""
"KIT SMALL IMPLANT ELBOW HUMERAL PIN BUSHING REPLACEMENT COONRAD MORREY SET REGULAR","SUP-ITM-10006959","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2164.58","1623.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1740.32","80.4","","1022.97","1022.97","3607.50","1 through 10","1131.21","1768.89","percent of total billed charges",""
"KIT SMALL IMPLANT ELBOW HUMERAL PIN BUSHING REPLACEMENT COONRAD MORREY SET REGULAR","SUP-ITM-10006959","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2164.58","1623.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1768.89","81.72","","3010.54","693.88","5019.88","35","1131.21","1768.89","percent of total billed charges",""
"KIT SNARE 12 20MMX120CM ATRIEVE VASCULAR 12","SUP-ITM-10080219","CDM","C1773","HCPCS","0272","RC","","","","both","","","1046.50","784.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","381.97","36.5","","114.30","97.14","114.30","1 through 10","324.42","831.97","percent of total billed charges",""
"KIT SNARE 12 20MMX120CM ATRIEVE VASCULAR 12","SUP-ITM-10080219","CDM","C1773","HCPCS","0272","RC","","","","both","","","1046.50","784.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","400.81","38.3","","119.81","116.44","359.43","20","324.42","831.97","percent of total billed charges",""
"KIT SNARE 12 20MMX120CM ATRIEVE VASCULAR 12","SUP-ITM-10080219","CDM","C1773","HCPCS","0272","RC","","","","both","","","1046.50","784.87","WELLPOINT [1015]","HB AMC WELLPOINT","772.11","73.78","","875.53","228.13","875.53","1 through 10","324.42","831.97","percent of total billed charges",""
"KIT SNARE 12 20MMX120CM ATRIEVE VASCULAR 12","SUP-ITM-10080219","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1046.50","784.87","AETNA [1001]","HB AMC AETNA HMO","730.46","69.8","","207.45","207.45","207.45","1 through 10","546.9","855.2","percent of total billed charges",""
"KIT SNARE 12 20MMX120CM ATRIEVE VASCULAR 12","SUP-ITM-10080219","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1046.50","784.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","855.20","81.72","","244.96","134.74","244.96","1 through 10","546.9","855.2","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 15MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000132","CDM","C1773","HCPCS","0272","RC","","","","both","","","780.50","585.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","284.88","36.5","","114.30","97.14","114.30","1 through 10","241.96","620.5","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 15MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000132","CDM","C1773","HCPCS","0272","RC","","","","both","","","780.50","585.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","298.93","38.3","","119.81","116.44","359.43","20","241.96","620.5","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 15MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000132","CDM","C1773","HCPCS","0272","RC","","","","both","","","780.50","585.37","WELLPOINT [1015]","HB AMC WELLPOINT","575.85","73.78","","875.53","228.13","875.53","1 through 10","241.96","620.5","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 15MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000132","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","780.50","585.37","AETNA [1001]","HB AMC AETNA HMO","544.79","69.8","","207.45","207.45","207.45","1 through 10","407.89","637.82","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 15MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000132","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","780.50","585.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","637.82","81.72","","244.96","134.74","244.96","1 through 10","407.89","637.82","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 25MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000268","CDM","C1773","HCPCS","0272","RC","","","","both","","","780.50","585.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","284.88","36.5","","114.30","97.14","114.30","1 through 10","241.96","620.5","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 25MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000268","CDM","C1773","HCPCS","0272","RC","","","","both","","","780.50","585.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","298.93","38.3","","119.81","116.44","359.43","20","241.96","620.5","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 25MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000268","CDM","C1773","HCPCS","0272","RC","","","","both","","","780.50","585.37","WELLPOINT [1015]","HB AMC WELLPOINT","575.85","73.78","","875.53","228.13","875.53","1 through 10","241.96","620.5","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 25MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000268","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","780.50","585.37","AETNA [1001]","HB AMC AETNA HMO","544.79","69.8","","207.45","207.45","207.45","1 through 10","407.89","637.82","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 25MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000268","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","780.50","585.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","637.82","81.72","","244.96","134.74","244.96","1 through 10","407.89","637.82","percent of total billed charges",""
"KIT SPRAY 16FR TRUFREEZE RAPIDAV CATHETER BX/5EA","SUP-ITM-10295646","CDM","C1886","HCPCS","0272","RC","","","","both","","","4987.50","3740.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3581.03","71.8","","4399.55","4399.55","4399.55","1 through 10","1546.13","3965.06","percent of total billed charges",""
"KIT SPRAY 16FR TRUFREEZE RAPIDAV CATHETER BX/5EA","SUP-ITM-10295646","CDM","C1886","HCPCS","0272","RC","","","","both","","","4987.50","3740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1820.44","36.5","","1413.19","621.27","1413.19","1 through 10","1546.13","3965.06","percent of total billed charges",""
"KIT SPRAY 16FR TRUFREEZE RAPIDAV CATHETER BX/5EA","SUP-ITM-10295646","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","4987.50","3740.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4075.79","81.72","","8168.27","2209.17","8168.27","1 through 10","2606.47","4075.79","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","594.16","445.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","472.36","79.5","","304.65","204.39","304.65","1 through 10","184.19","472.36","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","594.16","445.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","316.69","53.3","","204.39","204.39","304.65","1 through 10","184.19","472.36","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","594.16","445.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","216.87","36.5","","144.39","122.71","144.39","1 through 10","184.19","472.36","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","594.16","445.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","227.56","38.3","","151.36","147.10","454.08","13","184.19","472.36","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","594.16","445.62","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","457.50","77","","304.65","304.65","304.65","1 through 10","184.19","472.36","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","594.16","445.62","WELLPOINT [1015]","HB AMC WELLPOINT","438.37","73.78","","675.30","288.20","675.30","1 through 10","184.19","472.36","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","594.16","445.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","485.55","81.72","","183.26","154.72","309.45","1 through 10","310.51","485.55","percent of total billed charges",""
"KIT STENT 5FRX24CM UNIVERSAL UROLOGICAL PIGTAIL FLEXIBLE TIP TETHER PERCUFLEX POSITIONER RADIOPAQUE Y","SUP-ITM-10047636","CDM","C2617","HCPCS","0278","RC","","","","both","","","325.50","244.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.77","79.5","","304.65","204.39","304.65","1 through 10","100.91","258.77","percent of total billed charges",""
"KIT STENT 5FRX24CM UNIVERSAL UROLOGICAL PIGTAIL FLEXIBLE TIP TETHER PERCUFLEX POSITIONER RADIOPAQUE Y","SUP-ITM-10047636","CDM","C2617","HCPCS","0278","RC","","","","both","","","325.50","244.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.49","53.3","","204.39","204.39","304.65","1 through 10","100.91","258.77","percent of total billed charges",""
"KIT STENT 5FRX24CM UNIVERSAL UROLOGICAL PIGTAIL FLEXIBLE TIP TETHER PERCUFLEX POSITIONER RADIOPAQUE Y","SUP-ITM-10047636","CDM","C2617","HCPCS","0278","RC","","","","both","","","325.50","244.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.81","36.5","","144.39","122.71","144.39","1 through 10","100.91","258.77","percent of total billed charges",""
"KIT STENT 5FRX24CM UNIVERSAL UROLOGICAL PIGTAIL FLEXIBLE TIP TETHER PERCUFLEX POSITIONER RADIOPAQUE Y","SUP-ITM-10047636","CDM","C2617","HCPCS","0278","RC","","","","both","","","325.50","244.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.67","38.3","","151.36","147.10","454.08","13","100.91","258.77","percent of total billed charges",""
"KIT STENT 5FRX24CM UNIVERSAL UROLOGICAL PIGTAIL FLEXIBLE TIP TETHER PERCUFLEX POSITIONER RADIOPAQUE Y","SUP-ITM-10047636","CDM","C2617","HCPCS","0278","RC","","","","both","","","325.50","244.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","250.64","77","","304.65","304.65","304.65","1 through 10","100.91","258.77","percent of total billed charges",""
"KIT STENT 5FRX24CM UNIVERSAL UROLOGICAL PIGTAIL FLEXIBLE TIP TETHER PERCUFLEX POSITIONER RADIOPAQUE Y","SUP-ITM-10047636","CDM","C2617","HCPCS","0278","RC","","","","both","","","325.50","244.12","WELLPOINT [1015]","HB AMC WELLPOINT","240.15","73.78","","675.30","288.20","675.30","1 through 10","100.91","258.77","percent of total billed charges",""
"KIT STENT 5FRX24CM UNIVERSAL UROLOGICAL PIGTAIL FLEXIBLE TIP TETHER PERCUFLEX POSITIONER RADIOPAQUE Y","SUP-ITM-10047636","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","325.50","244.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","266.00","81.72","","183.26","154.72","309.45","1 through 10","170.11","266","percent of total billed charges",""
"KIT STENT 6.0FR 12CM URETERAL DOUBLE J CLOSED TIP ATTACHED SUTURE PUSH CATHETER KIDNEY","SUP-ITM-10015117","CDM","C2625","HCPCS","0278","RC","","","","both","","","696.29","522.22","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","487.40","70","","470.75","470.75","470.75","1 through 10","215.85","553.55","percent of total billed charges",""
"KIT STENT 6.0FR 12CM URETERAL DOUBLE J CLOSED TIP ATTACHED SUTURE PUSH CATHETER KIDNEY","SUP-ITM-10015117","CDM","C2625","HCPCS","0278","RC","","","","both","","","696.29","522.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","266.68","38.3","","184.07","124.37","184.07","1 through 10","215.85","553.55","percent of total billed charges",""
"KIT STENT 6.0FR 12CM URETERAL DOUBLE J CLOSED TIP ATTACHED SUTURE PUSH CATHETER KIDNEY","SUP-ITM-10015117","CDM","C2625","HCPCS","0278","RC","","","","both","","","696.29","522.22","WELLPOINT [1015]","HB AMC WELLPOINT","513.72","73.78","","243.67","243.67","243.67","1 through 10","215.85","553.55","percent of total billed charges",""
"KIT STENT 6.0FR 12CM URETERAL DOUBLE J CLOSED TIP ATTACHED SUTURE PUSH CATHETER KIDNEY","SUP-ITM-10015117","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","696.29","522.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","569.01","81.72","","376.32","376.32","376.32","1 through 10","363.88","569.01","percent of total billed charges",""
"KIT STENT 6.0FR 26CM URETERAL RESONANCE METALLIC SHEATH CATHETER COIL DESIGN PIGTAIL RADIOPAQUE TIP","SUP-ITM-10025365","CDM","C2625","HCPCS","0278","RC","","","","both","","","4000.85","3000.64","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2800.60","70","","470.75","470.75","470.75","1 through 10","1240.26","3180.68","percent of total billed charges",""
"KIT STENT 6.0FR 26CM URETERAL RESONANCE METALLIC SHEATH CATHETER COIL DESIGN PIGTAIL RADIOPAQUE TIP","SUP-ITM-10025365","CDM","C2625","HCPCS","0278","RC","","","","both","","","4000.85","3000.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1532.33","38.3","","184.07","124.37","184.07","1 through 10","1240.26","3180.68","percent of total billed charges",""
"KIT STENT 6.0FR 26CM URETERAL RESONANCE METALLIC SHEATH CATHETER COIL DESIGN PIGTAIL RADIOPAQUE TIP","SUP-ITM-10025365","CDM","C2625","HCPCS","0278","RC","","","","both","","","4000.85","3000.64","WELLPOINT [1015]","HB AMC WELLPOINT","2951.83","73.78","","243.67","243.67","243.67","1 through 10","1240.26","3180.68","percent of total billed charges",""
"KIT STENT 6.0FR 26CM URETERAL RESONANCE METALLIC SHEATH CATHETER COIL DESIGN PIGTAIL RADIOPAQUE TIP","SUP-ITM-10025365","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","4000.85","3000.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3269.49","81.72","","376.32","376.32","376.32","1 through 10","2090.84","3269.49","percent of total billed charges",""
"KIT STENT 7FRX20CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10057364","CDM","C2625","HCPCS","0278","RC","","","","both","","","649.88","487.41","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","454.92","70","","470.75","470.75","470.75","1 through 10","201.46","516.65","percent of total billed charges",""
"KIT STENT 7FRX20CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10057364","CDM","C2625","HCPCS","0278","RC","","","","both","","","649.88","487.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","248.90","38.3","","184.07","124.37","184.07","1 through 10","201.46","516.65","percent of total billed charges",""
"KIT STENT 7FRX20CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10057364","CDM","C2625","HCPCS","0278","RC","","","","both","","","649.88","487.41","WELLPOINT [1015]","HB AMC WELLPOINT","479.48","73.78","","243.67","243.67","243.67","1 through 10","201.46","516.65","percent of total billed charges",""
"KIT STENT 7FRX20CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10057364","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","649.88","487.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","531.08","81.72","","376.32","376.32","376.32","1 through 10","339.63","531.08","percent of total billed charges",""
"KIT STENT 8.5FRX28CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10000329","CDM","C2617","HCPCS","0278","RC","","","","both","","","649.88","487.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","516.65","79.5","","304.65","204.39","304.65","1 through 10","201.46","516.65","percent of total billed charges",""
"KIT STENT 8.5FRX28CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10000329","CDM","C2617","HCPCS","0278","RC","","","","both","","","649.88","487.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","346.39","53.3","","204.39","204.39","304.65","1 through 10","201.46","516.65","percent of total billed charges",""
"KIT STENT 8.5FRX28CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10000329","CDM","C2617","HCPCS","0278","RC","","","","both","","","649.88","487.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","237.21","36.5","","144.39","122.71","144.39","1 through 10","201.46","516.65","percent of total billed charges",""
"KIT STENT 8.5FRX28CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10000329","CDM","C2617","HCPCS","0278","RC","","","","both","","","649.88","487.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","248.90","38.3","","151.36","147.10","454.08","13","201.46","516.65","percent of total billed charges",""
"KIT STENT 8.5FRX28CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10000329","CDM","C2617","HCPCS","0278","RC","","","","both","","","649.88","487.41","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","500.41","77","","304.65","304.65","304.65","1 through 10","201.46","516.65","percent of total billed charges",""
"KIT STENT 8.5FRX28CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10000329","CDM","C2617","HCPCS","0278","RC","","","","both","","","649.88","487.41","WELLPOINT [1015]","HB AMC WELLPOINT","479.48","73.78","","675.30","288.20","675.30","1 through 10","201.46","516.65","percent of total billed charges",""
"KIT STENT 8.5FRX28CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10000329","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","649.88","487.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","531.08","81.72","","183.26","154.72","309.45","1 through 10","339.63","531.08","percent of total billed charges",""
"KIT STENT 90CMX8.5FR 2 .028 URETERAL SILICONE GUIDEWIRE PTFE COAT SINGLE J DIVERSION","SUP-ITM-10020620","CDM","C2617","HCPCS","0278","RC","","","","both","","","1154.09","865.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","917.50","79.5","","304.65","204.39","304.65","1 through 10","357.77","917.5","percent of total billed charges",""
"KIT STENT 90CMX8.5FR 2 .028 URETERAL SILICONE GUIDEWIRE PTFE COAT SINGLE J DIVERSION","SUP-ITM-10020620","CDM","C2617","HCPCS","0278","RC","","","","both","","","1154.09","865.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","615.13","53.3","","204.39","204.39","304.65","1 through 10","357.77","917.5","percent of total billed charges",""
"KIT STENT 90CMX8.5FR 2 .028 URETERAL SILICONE GUIDEWIRE PTFE COAT SINGLE J DIVERSION","SUP-ITM-10020620","CDM","C2617","HCPCS","0278","RC","","","","both","","","1154.09","865.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","421.24","36.5","","144.39","122.71","144.39","1 through 10","357.77","917.5","percent of total billed charges",""
"KIT STENT 90CMX8.5FR 2 .028 URETERAL SILICONE GUIDEWIRE PTFE COAT SINGLE J DIVERSION","SUP-ITM-10020620","CDM","C2617","HCPCS","0278","RC","","","","both","","","1154.09","865.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","442.02","38.3","","151.36","147.10","454.08","13","357.77","917.5","percent of total billed charges",""
"KIT STENT 90CMX8.5FR 2 .028 URETERAL SILICONE GUIDEWIRE PTFE COAT SINGLE J DIVERSION","SUP-ITM-10020620","CDM","C2617","HCPCS","0278","RC","","","","both","","","1154.09","865.57","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","888.65","77","","304.65","304.65","304.65","1 through 10","357.77","917.5","percent of total billed charges",""
"KIT STENT 90CMX8.5FR 2 .028 URETERAL SILICONE GUIDEWIRE PTFE COAT SINGLE J DIVERSION","SUP-ITM-10020620","CDM","C2617","HCPCS","0278","RC","","","","both","","","1154.09","865.57","WELLPOINT [1015]","HB AMC WELLPOINT","851.49","73.78","","675.30","288.20","675.30","1 through 10","357.77","917.5","percent of total billed charges",""
"KIT STENT 90CMX8.5FR 2 .028 URETERAL SILICONE GUIDEWIRE PTFE COAT SINGLE J DIVERSION","SUP-ITM-10020620","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1154.09","865.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","943.12","81.72","","183.26","154.72","309.45","1 through 10","603.13","943.12","percent of total billed charges",""
"KIT STIMULATOR 1.5 XMM 40CM LD DEEP BRAIN WITH STIMLOC CAP","SUP-ITM-10022761","CDM","C1778","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3677.70","53.3","","5279.78","5279.78","5279.78","1 through 10","2139","5485.5","percent of total billed charges",""
"KIT STIMULATOR 1.5 XMM 40CM LD DEEP BRAIN WITH STIMLOC CAP","SUP-ITM-10022761","CDM","C1778","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","5485.50","79.5","","15789.05","15789.05","15789.05","1 through 10","2139","5485.5","percent of total billed charges",""
"KIT STIMULATOR 1.5 XMM 40CM LD DEEP BRAIN WITH STIMLOC CAP","SUP-ITM-10022761","CDM","C1778","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2518.50","36.5","","2482.78","1657.12","2482.78","1 through 10","2139","5485.5","percent of total billed charges",""
"KIT STIMULATOR 1.5 XMM 40CM LD DEEP BRAIN WITH STIMLOC CAP","SUP-ITM-10022761","CDM","C1778","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2642.70","38.3","","2602.60","2602.60","2602.60","1 through 10","2139","5485.5","percent of total billed charges",""
"KIT STIMULATOR 1.5 XMM 40CM LD DEEP BRAIN WITH STIMLOC CAP","SUP-ITM-10022761","CDM","C1778","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","WELLPOINT [1015]","HB AMC WELLPOINT","5090.82","73.78","","4955.58","3845.35","9119.37","1 through 10","2139","5485.5","percent of total billed charges",""
"KIT STIMULATOR 1.5 XMM 40CM LD DEEP BRAIN WITH STIMLOC CAP","SUP-ITM-10022761","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","6900.00","5175.00","AETNA [1001]","HB AMC AETNA HMO","4816.20","69.8","","8631.75","8631.75","8631.75","1 through 10","3605.94","5638.68","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","765.19","79.5","","800.18","480.96","1887.97","195","298.38","765.19","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","513.01","53.3","","813.12","216.42","1444.50","81","298.38","765.19","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","298.38","31","","432.60","432.60","432.60","1 through 10","298.38","765.19","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","351.31","36.5","","148.37","54.89","631.39","94","298.38","765.19","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","368.64","38.3","","279.30","91.72","1116.77","266","298.38","765.19","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","731.00","63.70","731.00","1 through 10","298.38","765.19","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","384.74","384.74","384.74","1 through 10","298.38","765.19","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","WELLPOINT [1015]","HB AMC WELLPOINT","710.13","73.78","","286.63","119.22","1107.45","105","298.38","765.19","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA HMO","671.83","69.8","","675.31","184.75","1721.50","286","503","786.56","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA PPO","773.85","80.4","","1261.44","103.12","1514.10","21","503","786.56","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","773.85","80.4","","1365.00","1365.00","1365.00","1 through 10","503","786.56","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","786.56","81.72","","5157.68","5157.68","5157.68","1 through 10","503","786.56","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","786.56","81.72","","431.26","71.26","1459.57","88","503","786.56","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","both","","","5717.50","4288.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4545.41","79.5","","1309.77","674.56","6049.93","26","1772.43","4545.41","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","both","","","5717.50","4288.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3047.43","53.3","","1901.83","1901.83","2962.25","1 through 10","1772.43","4545.41","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","both","","","5717.50","4288.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2086.89","36.5","","1620.31","1620.31","19908.88","1 through 10","1772.43","4545.41","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","both","","","5717.50","4288.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2189.80","38.3","","352.91","352.91","2046.30","1 through 10","1772.43","4545.41","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","both","","","5717.50","4288.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2452.81","42.9","","9668.75","9668.75","9668.75","1 through 10","1772.43","4545.41","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","both","","","5717.50","4288.12","WELLPOINT [1015]","HB AMC WELLPOINT","4218.37","73.78","","699.88","384.10","3443.31","33","1772.43","4545.41","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5717.50","4288.12","AETNA [1001]","HB AMC AETNA HMO","3990.82","69.8","","1421.24","264.50","4933.46","29","2987.97","4672.34","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5717.50","4288.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4596.87","80.4","","1022.97","1022.97","3607.50","1 through 10","2987.97","4672.34","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5717.50","4288.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4672.34","81.72","","3010.54","693.88","5019.88","35","2987.97","4672.34","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","both","","","5807.50","4355.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4616.96","79.5","","1309.77","674.56","6049.93","26","1800.33","4616.96","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","both","","","5807.50","4355.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3095.40","53.3","","1901.83","1901.83","2962.25","1 through 10","1800.33","4616.96","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","both","","","5807.50","4355.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2119.74","36.5","","1620.31","1620.31","19908.88","1 through 10","1800.33","4616.96","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","both","","","5807.50","4355.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2224.27","38.3","","352.91","352.91","2046.30","1 through 10","1800.33","4616.96","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","both","","","5807.50","4355.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2491.42","42.9","","9668.75","9668.75","9668.75","1 through 10","1800.33","4616.96","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","both","","","5807.50","4355.62","WELLPOINT [1015]","HB AMC WELLPOINT","4284.77","73.78","","699.88","384.10","3443.31","33","1800.33","4616.96","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5807.50","4355.62","AETNA [1001]","HB AMC AETNA HMO","4053.64","69.8","","1421.24","264.50","4933.46","29","3035","4745.89","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5807.50","4355.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4669.23","80.4","","1022.97","1022.97","3607.50","1 through 10","3035","4745.89","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10019401","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5807.50","4355.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4745.89","81.72","","3010.54","693.88","5019.88","35","3035","4745.89","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","both","","","8717.50","6538.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6930.41","79.5","","1309.77","674.56","6049.93","26","2702.43","6930.41","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","both","","","8717.50","6538.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4646.43","53.3","","1901.83","1901.83","2962.25","1 through 10","2702.43","6930.41","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","both","","","8717.50","6538.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3181.89","36.5","","1620.31","1620.31","19908.88","1 through 10","2702.43","6930.41","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","both","","","8717.50","6538.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3338.80","38.3","","352.91","352.91","2046.30","1 through 10","2702.43","6930.41","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","both","","","8717.50","6538.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3739.81","42.9","","9668.75","9668.75","9668.75","1 through 10","2702.43","6930.41","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","both","","","8717.50","6538.12","WELLPOINT [1015]","HB AMC WELLPOINT","6431.77","73.78","","699.88","384.10","3443.31","33","2702.43","6930.41","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","8717.50","6538.12","AETNA [1001]","HB AMC AETNA HMO","6084.82","69.8","","1421.24","264.50","4933.46","29","4555.77","7123.94","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","8717.50","6538.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7008.87","80.4","","1022.97","1022.97","3607.50","1 through 10","4555.77","7123.94","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","8717.50","6538.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7123.94","81.72","","3010.54","693.88","5019.88","35","4555.77","7123.94","percent of total billed charges",""
"KIT TRAY 15X3MM BONE KYPHOPLASTY KYPHOPAK XPANDER ONE STEP OSTEO INTRODUCER FIRST FRACTURE","SUP-ITM-10016760","CDM","C1889","HCPCS","0272","RC","","","","both","","","8542.50","6406.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6791.29","79.5","","1309.77","674.56","6049.93","26","2648.18","6791.29","percent of total billed charges",""
"KIT TRAY 15X3MM BONE KYPHOPLASTY KYPHOPAK XPANDER ONE STEP OSTEO INTRODUCER FIRST FRACTURE","SUP-ITM-10016760","CDM","C1889","HCPCS","0272","RC","","","","both","","","8542.50","6406.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4553.15","53.3","","1901.83","1901.83","2962.25","1 through 10","2648.18","6791.29","percent of total billed charges",""
"KIT TRAY 15X3MM BONE KYPHOPLASTY KYPHOPAK XPANDER ONE STEP OSTEO INTRODUCER FIRST FRACTURE","SUP-ITM-10016760","CDM","C1889","HCPCS","0272","RC","","","","both","","","8542.50","6406.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3118.01","36.5","","1620.31","1620.31","19908.88","1 through 10","2648.18","6791.29","percent of total billed charges",""
"KIT TRAY 15X3MM BONE KYPHOPLASTY KYPHOPAK XPANDER ONE STEP OSTEO INTRODUCER FIRST FRACTURE","SUP-ITM-10016760","CDM","C1889","HCPCS","0272","RC","","","","both","","","8542.50","6406.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3271.78","38.3","","352.91","352.91","2046.30","1 through 10","2648.18","6791.29","percent of total billed charges",""
"KIT TRAY 15X3MM BONE KYPHOPLASTY KYPHOPAK XPANDER ONE STEP OSTEO INTRODUCER FIRST FRACTURE","SUP-ITM-10016760","CDM","C1889","HCPCS","0272","RC","","","","both","","","8542.50","6406.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3664.73","42.9","","9668.75","9668.75","9668.75","1 through 10","2648.18","6791.29","percent of total billed charges",""
"KIT TRAY 15X3MM BONE KYPHOPLASTY KYPHOPAK XPANDER ONE STEP OSTEO INTRODUCER FIRST FRACTURE","SUP-ITM-10016760","CDM","C1889","HCPCS","0272","RC","","","","both","","","8542.50","6406.87","WELLPOINT [1015]","HB AMC WELLPOINT","6302.66","73.78","","699.88","384.10","3443.31","33","2648.18","6791.29","percent of total billed charges",""
"KIT TRAY 15X3MM BONE KYPHOPLASTY KYPHOPAK XPANDER ONE STEP OSTEO INTRODUCER FIRST FRACTURE","SUP-ITM-10016760","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","8542.50","6406.87","AETNA [1001]","HB AMC AETNA HMO","5962.67","69.8","","1421.24","264.50","4933.46","29","4464.31","6980.93","percent of total billed charges",""
"KIT TRAY 15X3MM BONE KYPHOPLASTY KYPHOPAK XPANDER ONE STEP OSTEO INTRODUCER FIRST FRACTURE","SUP-ITM-10016760","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","8542.50","6406.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6868.17","80.4","","1022.97","1022.97","3607.50","1 through 10","4464.31","6980.93","percent of total billed charges",""
"KIT TRAY 15X3MM BONE KYPHOPLASTY KYPHOPAK XPANDER ONE STEP OSTEO INTRODUCER FIRST FRACTURE","SUP-ITM-10016760","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","8542.50","6406.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6980.93","81.72","","3010.54","693.88","5019.88","35","4464.31","6980.93","percent of total billed charges",""
"KIT TRIAL 50CM AXIUM LEAD SLIMTIP PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10174962","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2665.00","53.3","","5279.78","5279.78","5279.78","1 through 10","1550","3975","percent of total billed charges",""
"KIT TRIAL 50CM AXIUM LEAD SLIMTIP PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10174962","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","15789.05","15789.05","15789.05","1 through 10","1550","3975","percent of total billed charges",""
"KIT TRIAL 50CM AXIUM LEAD SLIMTIP PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10174962","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","2482.78","1657.12","2482.78","1 through 10","1550","3975","percent of total billed charges",""
"KIT TRIAL 50CM AXIUM LEAD SLIMTIP PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10174962","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","2602.60","2602.60","2602.60","1 through 10","1550","3975","percent of total billed charges",""
"KIT TRIAL 50CM AXIUM LEAD SLIMTIP PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10174962","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","4955.58","3845.35","9119.37","1 through 10","1550","3975","percent of total billed charges",""
"KIT TRIAL 50CM AXIUM LEAD SLIMTIP PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10174962","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","8631.75","8631.75","8631.75","1 through 10","2613","4086","percent of total billed charges",""
"KIT TRUMATCH ORTHOGNATHICS BASIC MANDIBULAR","SUP-ITM-10239684","CDM","C1713","HCPCS","0278","RC","","","","both","","","9424.80","7068.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7492.72","79.5","","800.18","480.96","1887.97","195","2921.69","7492.72","percent of total billed charges",""
"KIT TRUMATCH ORTHOGNATHICS BASIC MANDIBULAR","SUP-ITM-10239684","CDM","C1713","HCPCS","0278","RC","","","","both","","","9424.80","7068.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5023.42","53.3","","813.12","216.42","1444.50","81","2921.69","7492.72","percent of total billed charges",""
"KIT TRUMATCH ORTHOGNATHICS BASIC MANDIBULAR","SUP-ITM-10239684","CDM","C1713","HCPCS","0278","RC","","","","both","","","9424.80","7068.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2921.69","31","","432.60","432.60","432.60","1 through 10","2921.69","7492.72","percent of total billed charges",""
"KIT TRUMATCH ORTHOGNATHICS BASIC MANDIBULAR","SUP-ITM-10239684","CDM","C1713","HCPCS","0278","RC","","","","both","","","9424.80","7068.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3440.05","36.5","","148.37","54.89","631.39","94","2921.69","7492.72","percent of total billed charges",""
"KIT TRUMATCH ORTHOGNATHICS BASIC MANDIBULAR","SUP-ITM-10239684","CDM","C1713","HCPCS","0278","RC","","","","both","","","9424.80","7068.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3609.70","38.3","","279.30","91.72","1116.77","266","2921.69","7492.72","percent of total billed charges",""
"KIT TRUMATCH ORTHOGNATHICS BASIC MANDIBULAR","SUP-ITM-10239684","CDM","C1713","HCPCS","0278","RC","","","","both","","","9424.80","7068.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4043.24","42.9","","731.00","63.70","731.00","1 through 10","2921.69","7492.72","percent of total billed charges",""
"KIT TRUMATCH ORTHOGNATHICS BASIC MANDIBULAR","SUP-ITM-10239684","CDM","C1713","HCPCS","0278","RC","","","","both","","","9424.80","7068.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4043.24","42.9","","384.74","384.74","384.74","1 through 10","2921.69","7492.72","percent of total billed charges",""
"KIT TRUMATCH ORTHOGNATHICS BASIC MANDIBULAR","SUP-ITM-10239684","CDM","C1713","HCPCS","0278","RC","","","","both","","","9424.80","7068.60","WELLPOINT [1015]","HB AMC WELLPOINT","6953.62","73.78","","286.63","119.22","1107.45","105","2921.69","7492.72","percent of total billed charges",""
"KIT TRUMATCH ORTHOGNATHICS BASIC MANDIBULAR","SUP-ITM-10239684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9424.80","7068.60","AETNA [1001]","HB AMC AETNA HMO","6578.51","69.8","","675.31","184.75","1721.50","286","4925.4","7701.95","percent of total billed charges",""
"KIT TRUMATCH ORTHOGNATHICS BASIC MANDIBULAR","SUP-ITM-10239684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9424.80","7068.60","AETNA [1001]","HB AMC AETNA PPO","7577.54","80.4","","1261.44","103.12","1514.10","21","4925.4","7701.95","percent of total billed charges",""
"KIT TRUMATCH ORTHOGNATHICS BASIC MANDIBULAR","SUP-ITM-10239684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9424.80","7068.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7577.54","80.4","","1365.00","1365.00","1365.00","1 through 10","4925.4","7701.95","percent of total billed charges",""
"KIT TRUMATCH ORTHOGNATHICS BASIC MANDIBULAR","SUP-ITM-10239684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9424.80","7068.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7701.95","81.72","","5157.68","5157.68","5157.68","1 through 10","4925.4","7701.95","percent of total billed charges",""
"KIT TRUMATCH ORTHOGNATHICS BASIC MANDIBULAR","SUP-ITM-10239684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9424.80","7068.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7701.95","81.72","","431.26","71.26","1459.57","88","4925.4","7701.95","percent of total billed charges",""
"KIT X RX 9FR MULTI LUMEN PSI CS/5EA","SUP-ITM-10215199","CDM","C1751","HCPCS","0272","RC","","","","both","","","348.85","261.64","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","244.20","70","","1389.50","602.17","3167.85","27","108.14","277.34","percent of total billed charges",""
"KIT X RX 9FR MULTI LUMEN PSI CS/5EA","SUP-ITM-10215199","CDM","C1751","HCPCS","0272","RC","","","","both","","","348.85","261.64","WELLPOINT [1015]","HB AMC WELLPOINT","257.38","73.78","","1089.20","218.86","1089.20","1 through 10","108.14","277.34","percent of total billed charges",""
"KIT X RX 9FR MULTI LUMEN PSI CS/5EA","SUP-ITM-10215199","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","348.85","261.64","AETNA [1001]","HB AMC AETNA HMO","243.50","69.8","","1389.50","940.69","1389.50","1 through 10","182.31","285.08","percent of total billed charges",""
"KIT X RX 9FR MULTI LUMEN PSI CS/5EA","SUP-ITM-10215199","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","348.85","261.64","AETNA [1001]","HB AMC AETNA PPO","280.48","80.4","","190.26","190.26","190.26","1 through 10","182.31","285.08","percent of total billed charges",""
"KIT X RX 9FR MULTI LUMEN PSI CS/5EA","SUP-ITM-10215199","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","348.85","261.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","285.08","81.72","","1110.77","235.00","1169.52","1 through 10","182.31","285.08","percent of total billed charges",""
"KIT ZYGOMATIC TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239690","CDM","C1713","HCPCS","0278","RC","","","","both","","","13446.98","10085.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10690.35","79.5","","800.18","480.96","1887.97","195","4168.56","10690.35","percent of total billed charges",""
"KIT ZYGOMATIC TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239690","CDM","C1713","HCPCS","0278","RC","","","","both","","","13446.98","10085.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7167.24","53.3","","813.12","216.42","1444.50","81","4168.56","10690.35","percent of total billed charges",""
"KIT ZYGOMATIC TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239690","CDM","C1713","HCPCS","0278","RC","","","","both","","","13446.98","10085.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4168.56","31","","432.60","432.60","432.60","1 through 10","4168.56","10690.35","percent of total billed charges",""
"KIT ZYGOMATIC TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239690","CDM","C1713","HCPCS","0278","RC","","","","both","","","13446.98","10085.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4908.15","36.5","","148.37","54.89","631.39","94","4168.56","10690.35","percent of total billed charges",""
"KIT ZYGOMATIC TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239690","CDM","C1713","HCPCS","0278","RC","","","","both","","","13446.98","10085.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5150.19","38.3","","279.30","91.72","1116.77","266","4168.56","10690.35","percent of total billed charges",""
"KIT ZYGOMATIC TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239690","CDM","C1713","HCPCS","0278","RC","","","","both","","","13446.98","10085.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5768.75","42.9","","731.00","63.70","731.00","1 through 10","4168.56","10690.35","percent of total billed charges",""
"KIT ZYGOMATIC TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239690","CDM","C1713","HCPCS","0278","RC","","","","both","","","13446.98","10085.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5768.75","42.9","","384.74","384.74","384.74","1 through 10","4168.56","10690.35","percent of total billed charges",""
"KIT ZYGOMATIC TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239690","CDM","C1713","HCPCS","0278","RC","","","","both","","","13446.98","10085.23","WELLPOINT [1015]","HB AMC WELLPOINT","9921.18","73.78","","286.63","119.22","1107.45","105","4168.56","10690.35","percent of total billed charges",""
"KIT ZYGOMATIC TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13446.98","10085.23","AETNA [1001]","HB AMC AETNA HMO","9385.99","69.8","","675.31","184.75","1721.50","286","7027.39","10988.87","percent of total billed charges",""
"KIT ZYGOMATIC TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13446.98","10085.23","AETNA [1001]","HB AMC AETNA PPO","10811.37","80.4","","1261.44","103.12","1514.10","21","7027.39","10988.87","percent of total billed charges",""
"KIT ZYGOMATIC TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13446.98","10085.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10811.37","80.4","","1365.00","1365.00","1365.00","1 through 10","7027.39","10988.87","percent of total billed charges",""
"KIT ZYGOMATIC TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13446.98","10085.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","10988.87","81.72","","5157.68","5157.68","5157.68","1 through 10","7027.39","10988.87","percent of total billed charges",""
"KIT ZYGOMATIC TRUMATCH MIDFACE MANDIBLE","SUP-ITM-10239690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13446.98","10085.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10988.87","81.72","","431.26","71.26","1459.57","88","7027.39","10988.87","percent of total billed charges",""
"Klippel-Feil Syndrome 1 / 2 / 3","PX-31000762","CDM","81479","CPT","0310","RC","","","","both","","","418.00","313.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","332.31","79.5","","0.65","0.65","0.65","1 through 10","129.58","397.1","percent of total billed charges",""
"Klippel-Feil Syndrome 1 / 2 / 3","PX-31000762","CDM","81479","CPT","0310","RC","","","","both","","","418.00","313.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","222.79","53.3","","0.79","0.79","0.79","1 through 10","129.58","397.1","percent of total billed charges",""
"Klippel-Feil Syndrome 1 / 2 / 3","PX-31000762","CDM","81479","CPT","0310","RC","","","","outpatient","","","418.00","313.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","209.00","50","","1.00","1.00","1.00","1 through 10","156.55","344.85","percent of total billed charges",""
"Klippel-Feil Syndrome 1 / 2 / 3","PX-31000762","CDM","81479","CPT","0310","RC","","","","outpatient","","","418.00","313.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","219.45","52.5","","1.00","0.53","1.00","1 through 10","156.55","344.85","percent of total billed charges",""
"KNEE 5850 30 17MM ART SURFACE W/SEG HINGE POST SZ C 08 ONC 06 NC","SUP-ITM-10025557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1924.40","52.26","","1113.10","1113.10","1113.10","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE 5850 30 17MM ART SURFACE W/SEG HINGE POST SZ C 08 ONC 06 NC","SUP-ITM-10025557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2927.47","79.5","","1293.60","1148.53","1603.80","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE 5850 30 17MM ART SURFACE W/SEG HINGE POST SZ C 08 ONC 06 NC","SUP-ITM-10025557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1344.06","36.5","","1023.42","771.29","2068.67","33","1141.53","2927.47","percent of total billed charges",""
"KNEE 5850 30 17MM ART SURFACE W/SEG HINGE POST SZ C 08 ONC 06 NC","SUP-ITM-10025557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1410.34","38.3","","850.52","759.78","1211.25","66","1141.53","2927.47","percent of total billed charges",""
"KNEE 5850 30 17MM ART SURFACE W/SEG HINGE POST SZ C 08 ONC 06 NC","SUP-ITM-10025557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1579.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE 5850 30 17MM ART SURFACE W/SEG HINGE POST SZ C 08 ONC 06 NC","SUP-ITM-10025557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1579.73","42.9","","956.46","956.46","956.46","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE 5850 30 17MM ART SURFACE W/SEG HINGE POST SZ C 08 ONC 06 NC","SUP-ITM-10025557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","WELLPOINT [1015]","HB AMC WELLPOINT","2716.84","73.78","","2344.73","1619.47","2530.35","16","1141.53","2927.47","percent of total billed charges",""
"KNEE 5850 30 17MM ART SURFACE W/SEG HINGE POST SZ C 08 ONC 06 NC","SUP-ITM-10025557","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","AETNA [1001]","HB AMC AETNA HMO","2570.28","69.8","","1523.63","988.41","4330.26","39","1924.4","3009.22","percent of total billed charges",""
"KNEE 5850 30 17MM ART SURFACE W/SEG HINGE POST SZ C 08 ONC 06 NC","SUP-ITM-10025557","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","AETNA [1001]","HB AMC AETNA PPO","2960.61","80.4","","1670.25","1670.25","1670.25","1 through 10","1924.4","3009.22","percent of total billed charges",""
"KNEE 5850 30 17MM ART SURFACE W/SEG HINGE POST SZ C 08 ONC 06 NC","SUP-ITM-10025557","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1924.40","52.26","","1113.10","1113.10","1113.10","1 through 10","1924.4","3009.22","percent of total billed charges",""
"KNEE 5850 30 17MM ART SURFACE W/SEG HINGE POST SZ C 08 ONC 06 NC","SUP-ITM-10025557","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3009.22","81.72","","1738.90","1484.65","2716.94","38","1924.4","3009.22","percent of total billed charges",""
"Knee And Lower Leg Procedures Except Foot,EXTREME","313","DRG","","","","","","","","inpatient","","","299595.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","123801.35","","Standard inlier is a Case rate ($123,801.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $107,919, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,574.35) for the length of stay and the standard reimbursement.","112849.44","112849.44","112849.44","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,EXTREME","313","DRG","","","","","","","","inpatient","","","299595.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","139186.08","","Standard inlier is a Case rate ($139,186.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $107,919, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($19,756.31) for the length of stay and the standard reimbursement.","139186.08","139186.08","139186.08","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,EXTREME","313","DRG","","","","","","","","inpatient","","","299595.19","","MASSHEALTH [3001]","HB BWH MEDICAID","45470.74","","Case rate ($50,275.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $92,705.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31564.25","31564.25","122403.39","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,EXTREME","313","DRG","","","","","","","","inpatient","","","299595.19","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","45470.74","","Case rate ($50,275.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $92,705.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,EXTREME","313","DRG","","","","","","","","inpatient","","","299595.19","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","45470.74","","Case rate ($50,275.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $92,705.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","50263.38","50263.38","69479.97","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MAJOR","313","DRG","","","","","","","","inpatient","","","130993.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","79507.11","","Standard inlier is a Case rate ($79,507.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $73,476, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,286.51) for the length of stay and the standard reimbursement.","89387.42","89387.42","89387.42","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MAJOR","313","DRG","","","","","","","","inpatient","","","130993.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","89387.42","","Standard inlier is a Case rate ($89,387.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $73,476, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,687.80) for the length of stay and the standard reimbursement.","89387.42","81663.13","89387.42","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MAJOR","313","DRG","","","","","","","","inpatient","","","130993.26","","MASSHEALTH [3001]","HB BWH MEDICAID","24380.38","","Case rate ($26,956.70). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $69,386.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $5,359.18 and the sum of the standard inlier and any outlier amount.","26950.08","26950.08","26950.08","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MAJOR","313","DRG","","","","","","","","inpatient","","","130993.26","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71926.11","","Fee schedule rate ($71,926.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","71926.11","71926.11","71926.11","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","101456.14","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","41393.25","","Standard inlier is a Case rate ($41,393.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,837, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,876.02) for the length of stay and the standard reimbursement.","41393.24","41393.24","41393.24","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","101456.14","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","46537.16","","Standard inlier is a Case rate ($46,537.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,837, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,605.56) for the length of stay and the standard reimbursement.","46537.16","46537.16","46537.16","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","101456.14","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","26739.63","","Fee schedule rate ($26,739.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26739.64","26739.64","26739.64","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","101456.14","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39798.81","","Fee schedule rate ($39,798.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","39798.81","39798.81","39798.81","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","101456.14","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12046.25","","Case rate ($13,319.20). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,749.20, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13638.57","13638.57","13638.57","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","128387.23","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","54494.59","","Standard inlier is a Case rate ($54,494.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,025, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,735.84) for the length of stay and the standard reimbursement.","54494.58","54494.58","54494.58","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","128387.23","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","61266.60","","Standard inlier is a Case rate ($61,266.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,025, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,696.29) for the length of stay and the standard reimbursement.","55980.33","55972.33","68444.47","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","128387.23","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24308.4556","","Fee schedule rate ($37,343.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24308.4556","37343.96","37343.96","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","128387.23","","MASSHEALTH [3001]","HB BWH MEDICAID","17667.83","","Case rate ($19,534.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,964.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20367.16","19530.03","20701.84","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","128387.23","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","17667.83","","Case rate ($19,534.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,964.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4171.74","4171.74","4171.74","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","128387.23","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","49996.04","","Fee schedule rate ($49,996.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","49996.04","49996.04","49996.04","1 through 10","12046.25","139186.08","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","128387.23","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","17667.83","","Case rate ($19,534.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,964.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19530.03","19530.03","19530.03","1 through 10","12046.25","139186.08","case rate",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","854.19","52.26","","1113.10","1113.10","1113.10","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1299.43","79.5","","1293.60","1148.53","1603.80","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","596.59","36.5","","1023.42","771.29","2068.67","33","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","626.01","38.3","","850.52","759.78","1211.25","66","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","2548.09","2548.09","2548.09","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","956.46","956.46","956.46","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","WELLPOINT [1015]","HB AMC WELLPOINT","1205.93","73.78","","2344.73","1619.47","2530.35","16","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA HMO","1140.88","69.8","","1523.63","988.41","4330.26","39","854.19","1335.71","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA PPO","1314.14","80.4","","1670.25","1670.25","1670.25","1 through 10","854.19","1335.71","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","854.19","52.26","","1113.10","1113.10","1113.10","1 through 10","854.19","1335.71","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1335.71","81.72","","1738.90","1484.65","2716.94","38","854.19","1335.71","percent of total billed charges",""
"KNEE AUGMENT 5MM BLOCK L S-ROM NOILES ROTATING HINGE DISTAL","SUP-ITM-10015333","CDM","C1776","HCPCS","0278","RC","","","","both","","","4469.50","3352.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2335.76","52.26","","1113.10","1113.10","1113.10","1 through 10","1385.55","3553.25","percent of total billed charges",""
"KNEE AUGMENT 5MM BLOCK L S-ROM NOILES ROTATING HINGE DISTAL","SUP-ITM-10015333","CDM","C1776","HCPCS","0278","RC","","","","both","","","4469.50","3352.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3553.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1385.55","3553.25","percent of total billed charges",""
"KNEE AUGMENT 5MM BLOCK L S-ROM NOILES ROTATING HINGE DISTAL","SUP-ITM-10015333","CDM","C1776","HCPCS","0278","RC","","","","both","","","4469.50","3352.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1631.37","36.5","","1023.42","771.29","2068.67","33","1385.55","3553.25","percent of total billed charges",""
"KNEE AUGMENT 5MM BLOCK L S-ROM NOILES ROTATING HINGE DISTAL","SUP-ITM-10015333","CDM","C1776","HCPCS","0278","RC","","","","both","","","4469.50","3352.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1711.82","38.3","","850.52","759.78","1211.25","66","1385.55","3553.25","percent of total billed charges",""
"KNEE AUGMENT 5MM BLOCK L S-ROM NOILES ROTATING HINGE DISTAL","SUP-ITM-10015333","CDM","C1776","HCPCS","0278","RC","","","","both","","","4469.50","3352.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1917.42","42.9","","2548.09","2548.09","2548.09","1 through 10","1385.55","3553.25","percent of total billed charges",""
"KNEE AUGMENT 5MM BLOCK L S-ROM NOILES ROTATING HINGE DISTAL","SUP-ITM-10015333","CDM","C1776","HCPCS","0278","RC","","","","both","","","4469.50","3352.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1917.42","42.9","","956.46","956.46","956.46","1 through 10","1385.55","3553.25","percent of total billed charges",""
"KNEE AUGMENT 5MM BLOCK L S-ROM NOILES ROTATING HINGE DISTAL","SUP-ITM-10015333","CDM","C1776","HCPCS","0278","RC","","","","both","","","4469.50","3352.12","WELLPOINT [1015]","HB AMC WELLPOINT","3297.60","73.78","","2344.73","1619.47","2530.35","16","1385.55","3553.25","percent of total billed charges",""
"KNEE AUGMENT 5MM BLOCK L S-ROM NOILES ROTATING HINGE DISTAL","SUP-ITM-10015333","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4469.50","3352.12","AETNA [1001]","HB AMC AETNA HMO","3119.71","69.8","","1523.63","988.41","4330.26","39","2335.76","3652.48","percent of total billed charges",""
"KNEE AUGMENT 5MM BLOCK L S-ROM NOILES ROTATING HINGE DISTAL","SUP-ITM-10015333","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4469.50","3352.12","AETNA [1001]","HB AMC AETNA PPO","3593.48","80.4","","1670.25","1670.25","1670.25","1 through 10","2335.76","3652.48","percent of total billed charges",""
"KNEE AUGMENT 5MM BLOCK L S-ROM NOILES ROTATING HINGE DISTAL","SUP-ITM-10015333","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4469.50","3352.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2335.76","52.26","","1113.10","1113.10","1113.10","1 through 10","2335.76","3652.48","percent of total billed charges",""
"KNEE AUGMENT 5MM BLOCK L S-ROM NOILES ROTATING HINGE DISTAL","SUP-ITM-10015333","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4469.50","3352.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3652.48","81.72","","1738.90","1484.65","2716.94","38","2335.76","3652.48","percent of total billed charges",""
"KNEE AUGMENT 9MM SIZE 5.0 7DEG TIBIAL FULL WEDGE NXGN 20","SUP-ITM-10065865","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","854.19","52.26","","1113.10","1113.10","1113.10","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 9MM SIZE 5.0 7DEG TIBIAL FULL WEDGE NXGN 20","SUP-ITM-10065865","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1299.43","79.5","","1293.60","1148.53","1603.80","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 9MM SIZE 5.0 7DEG TIBIAL FULL WEDGE NXGN 20","SUP-ITM-10065865","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","596.59","36.5","","1023.42","771.29","2068.67","33","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 9MM SIZE 5.0 7DEG TIBIAL FULL WEDGE NXGN 20","SUP-ITM-10065865","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","626.01","38.3","","850.52","759.78","1211.25","66","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 9MM SIZE 5.0 7DEG TIBIAL FULL WEDGE NXGN 20","SUP-ITM-10065865","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","2548.09","2548.09","2548.09","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 9MM SIZE 5.0 7DEG TIBIAL FULL WEDGE NXGN 20","SUP-ITM-10065865","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","956.46","956.46","956.46","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 9MM SIZE 5.0 7DEG TIBIAL FULL WEDGE NXGN 20","SUP-ITM-10065865","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","WELLPOINT [1015]","HB AMC WELLPOINT","1205.93","73.78","","2344.73","1619.47","2530.35","16","506.7","1299.43","percent of total billed charges",""
"KNEE AUGMENT 9MM SIZE 5.0 7DEG TIBIAL FULL WEDGE NXGN 20","SUP-ITM-10065865","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA HMO","1140.88","69.8","","1523.63","988.41","4330.26","39","854.19","1335.71","percent of total billed charges",""
"KNEE AUGMENT 9MM SIZE 5.0 7DEG TIBIAL FULL WEDGE NXGN 20","SUP-ITM-10065865","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA PPO","1314.14","80.4","","1670.25","1670.25","1670.25","1 through 10","854.19","1335.71","percent of total billed charges",""
"KNEE AUGMENT 9MM SIZE 5.0 7DEG TIBIAL FULL WEDGE NXGN 20","SUP-ITM-10065865","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","854.19","52.26","","1113.10","1113.10","1113.10","1 through 10","854.19","1335.71","percent of total billed charges",""
"KNEE AUGMENT 9MM SIZE 5.0 7DEG TIBIAL FULL WEDGE NXGN 20","SUP-ITM-10065865","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1335.71","81.72","","1738.90","1484.65","2716.94","38","854.19","1335.71","percent of total billed charges",""
"KNEE AUGMENT SZ 8 8MM FEMORAL REVISION DISTAL","SUP-ITM-10268446","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","1113.10","1113.10","1113.10","1 through 10","542.5","1391.25","percent of total billed charges",""
"KNEE AUGMENT SZ 8 8MM FEMORAL REVISION DISTAL","SUP-ITM-10268446","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","1293.60","1148.53","1603.80","1 through 10","542.5","1391.25","percent of total billed charges",""
"KNEE AUGMENT SZ 8 8MM FEMORAL REVISION DISTAL","SUP-ITM-10268446","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","1023.42","771.29","2068.67","33","542.5","1391.25","percent of total billed charges",""
"KNEE AUGMENT SZ 8 8MM FEMORAL REVISION DISTAL","SUP-ITM-10268446","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","850.52","759.78","1211.25","66","542.5","1391.25","percent of total billed charges",""
"KNEE AUGMENT SZ 8 8MM FEMORAL REVISION DISTAL","SUP-ITM-10268446","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","2548.09","2548.09","2548.09","1 through 10","542.5","1391.25","percent of total billed charges",""
"KNEE AUGMENT SZ 8 8MM FEMORAL REVISION DISTAL","SUP-ITM-10268446","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","956.46","956.46","956.46","1 through 10","542.5","1391.25","percent of total billed charges",""
"KNEE AUGMENT SZ 8 8MM FEMORAL REVISION DISTAL","SUP-ITM-10268446","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","2344.73","1619.47","2530.35","16","542.5","1391.25","percent of total billed charges",""
"KNEE AUGMENT SZ 8 8MM FEMORAL REVISION DISTAL","SUP-ITM-10268446","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","1523.63","988.41","4330.26","39","914.55","1430.1","percent of total billed charges",""
"KNEE AUGMENT SZ 8 8MM FEMORAL REVISION DISTAL","SUP-ITM-10268446","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1670.25","1670.25","1670.25","1 through 10","914.55","1430.1","percent of total billed charges",""
"KNEE AUGMENT SZ 8 8MM FEMORAL REVISION DISTAL","SUP-ITM-10268446","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","1113.10","1113.10","1113.10","1 through 10","914.55","1430.1","percent of total billed charges",""
"KNEE AUGMENT SZ 8 8MM FEMORAL REVISION DISTAL","SUP-ITM-10268446","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","1738.90","1484.65","2716.94","38","914.55","1430.1","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 3 GENESIS II ALL POLYETHYLENE CRUCIATE RETAINING TIBIA RT","SUP-ITM-10100517","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","834.07","52.26","","1113.10","1113.10","1113.10","1 through 10","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 3 GENESIS II ALL POLYETHYLENE CRUCIATE RETAINING TIBIA RT","SUP-ITM-10100517","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1268.82","79.5","","1293.60","1148.53","1603.80","1 through 10","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 3 GENESIS II ALL POLYETHYLENE CRUCIATE RETAINING TIBIA RT","SUP-ITM-10100517","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","582.54","36.5","","1023.42","771.29","2068.67","33","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 3 GENESIS II ALL POLYETHYLENE CRUCIATE RETAINING TIBIA RT","SUP-ITM-10100517","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","611.27","38.3","","850.52","759.78","1211.25","66","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 3 GENESIS II ALL POLYETHYLENE CRUCIATE RETAINING TIBIA RT","SUP-ITM-10100517","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","684.68","42.9","","2548.09","2548.09","2548.09","1 through 10","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 3 GENESIS II ALL POLYETHYLENE CRUCIATE RETAINING TIBIA RT","SUP-ITM-10100517","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","684.68","42.9","","956.46","956.46","956.46","1 through 10","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 3 GENESIS II ALL POLYETHYLENE CRUCIATE RETAINING TIBIA RT","SUP-ITM-10100517","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","WELLPOINT [1015]","HB AMC WELLPOINT","1177.53","73.78","","2344.73","1619.47","2530.35","16","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 3 GENESIS II ALL POLYETHYLENE CRUCIATE RETAINING TIBIA RT","SUP-ITM-10100517","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1596.00","1197.00","AETNA [1001]","HB AMC AETNA HMO","1114.01","69.8","","1523.63","988.41","4330.26","39","834.07","1304.25","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 3 GENESIS II ALL POLYETHYLENE CRUCIATE RETAINING TIBIA RT","SUP-ITM-10100517","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1596.00","1197.00","AETNA [1001]","HB AMC AETNA PPO","1283.18","80.4","","1670.25","1670.25","1670.25","1 through 10","834.07","1304.25","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 3 GENESIS II ALL POLYETHYLENE CRUCIATE RETAINING TIBIA RT","SUP-ITM-10100517","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1596.00","1197.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","834.07","52.26","","1113.10","1113.10","1113.10","1 through 10","834.07","1304.25","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 3 GENESIS II ALL POLYETHYLENE CRUCIATE RETAINING TIBIA RT","SUP-ITM-10100517","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1596.00","1197.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1304.25","81.72","","1738.90","1484.65","2716.94","38","834.07","1304.25","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1752.98","79.5","","800.18","480.96","1887.97","195","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1175.27","53.3","","813.12","216.42","1444.50","81","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","683.55","31","","432.60","432.60","432.60","1 through 10","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","804.83","36.5","","148.37","54.89","631.39","94","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","844.52","38.3","","279.30","91.72","1116.77","266","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","945.95","42.9","","731.00","63.70","731.00","1 through 10","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","945.95","42.9","","384.74","384.74","384.74","1 through 10","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","WELLPOINT [1015]","HB AMC WELLPOINT","1626.85","73.78","","286.63","119.22","1107.45","105","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","AETNA [1001]","HB AMC AETNA HMO","1539.09","69.8","","675.31","184.75","1721.50","286","1152.33","1801.93","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","AETNA [1001]","HB AMC AETNA PPO","1772.82","80.4","","1261.44","103.12","1514.10","21","1152.33","1801.93","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1772.82","80.4","","1365.00","1365.00","1365.00","1 through 10","1152.33","1801.93","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1801.93","81.72","","5157.68","5157.68","5157.68","1 through 10","1152.33","1801.93","percent of total billed charges",""
"KNEE BASEPLATE 25X44MM SZ 2 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10020239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1801.93","81.72","","431.26","71.26","1459.57","88","1152.33","1801.93","percent of total billed charges",""
"KNEE BASEPLATE 42.5X22MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX RT MEDIAL LT LATERAL SIZE B","SUP-ITM-10017049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE BASEPLATE 42.5X22MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX RT MEDIAL LT LATERAL SIZE B","SUP-ITM-10017049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE BASEPLATE 42.5X22MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX RT MEDIAL LT LATERAL SIZE B","SUP-ITM-10017049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","1023.42","771.29","2068.67","33","1193.5","3060.75","percent of total billed charges",""
"KNEE BASEPLATE 42.5X22MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX RT MEDIAL LT LATERAL SIZE B","SUP-ITM-10017049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","850.52","759.78","1211.25","66","1193.5","3060.75","percent of total billed charges",""
"KNEE BASEPLATE 42.5X22MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX RT MEDIAL LT LATERAL SIZE B","SUP-ITM-10017049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","2548.09","2548.09","2548.09","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE BASEPLATE 42.5X22MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX RT MEDIAL LT LATERAL SIZE B","SUP-ITM-10017049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","956.46","956.46","956.46","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE BASEPLATE 42.5X22MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX RT MEDIAL LT LATERAL SIZE B","SUP-ITM-10017049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","2344.73","1619.47","2530.35","16","1193.5","3060.75","percent of total billed charges",""
"KNEE BASEPLATE 42.5X22MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX RT MEDIAL LT LATERAL SIZE B","SUP-ITM-10017049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA HMO","2687.30","69.8","","1523.63","988.41","4330.26","39","2012.01","3146.22","percent of total billed charges",""
"KNEE BASEPLATE 42.5X22MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX RT MEDIAL LT LATERAL SIZE B","SUP-ITM-10017049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA PPO","3095.40","80.4","","1670.25","1670.25","1670.25","1 through 10","2012.01","3146.22","percent of total billed charges",""
"KNEE BASEPLATE 42.5X22MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX RT MEDIAL LT LATERAL SIZE B","SUP-ITM-10017049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","2012.01","3146.22","percent of total billed charges",""
"KNEE BASEPLATE 42.5X22MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX RT MEDIAL LT LATERAL SIZE B","SUP-ITM-10017049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","1738.90","1484.65","2716.94","38","2012.01","3146.22","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1840.62","79.5","","800.18","480.96","1887.97","195","717.73","1840.62","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1234.03","53.3","","813.12","216.42","1444.50","81","717.73","1840.62","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","717.73","31","","432.60","432.60","432.60","1 through 10","717.73","1840.62","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","845.07","36.5","","148.37","54.89","631.39","94","717.73","1840.62","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","886.74","38.3","","279.30","91.72","1116.77","266","717.73","1840.62","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.24","42.9","","731.00","63.70","731.00","1 through 10","717.73","1840.62","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.24","42.9","","384.74","384.74","384.74","1 through 10","717.73","1840.62","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","WELLPOINT [1015]","HB AMC WELLPOINT","1708.19","73.78","","286.63","119.22","1107.45","105","717.73","1840.62","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","AETNA [1001]","HB AMC AETNA HMO","1616.04","69.8","","675.31","184.75","1721.50","286","1209.95","1892.02","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","AETNA [1001]","HB AMC AETNA PPO","1861.46","80.4","","1261.44","103.12","1514.10","21","1209.95","1892.02","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1861.46","80.4","","1365.00","1365.00","1365.00","1 through 10","1209.95","1892.02","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1892.02","81.72","","5157.68","5157.68","5157.68","1 through 10","1209.95","1892.02","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1892.02","81.72","","431.26","71.26","1459.57","88","1209.95","1892.02","percent of total billed charges",""
"KNEE BASEPLATE 67MM TIBIAL OSS MODULAR","SUP-ITM-10122023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3636.71","52.26","","1113.10","1113.10","1113.10","1 through 10","2157.25","5532.31","percent of total billed charges",""
"KNEE BASEPLATE 67MM TIBIAL OSS MODULAR","SUP-ITM-10122023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5532.31","79.5","","1293.60","1148.53","1603.80","1 through 10","2157.25","5532.31","percent of total billed charges",""
"KNEE BASEPLATE 67MM TIBIAL OSS MODULAR","SUP-ITM-10122023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2539.99","36.5","","1023.42","771.29","2068.67","33","2157.25","5532.31","percent of total billed charges",""
"KNEE BASEPLATE 67MM TIBIAL OSS MODULAR","SUP-ITM-10122023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2665.25","38.3","","850.52","759.78","1211.25","66","2157.25","5532.31","percent of total billed charges",""
"KNEE BASEPLATE 67MM TIBIAL OSS MODULAR","SUP-ITM-10122023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2985.36","42.9","","2548.09","2548.09","2548.09","1 through 10","2157.25","5532.31","percent of total billed charges",""
"KNEE BASEPLATE 67MM TIBIAL OSS MODULAR","SUP-ITM-10122023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2985.36","42.9","","956.46","956.46","956.46","1 through 10","2157.25","5532.31","percent of total billed charges",""
"KNEE BASEPLATE 67MM TIBIAL OSS MODULAR","SUP-ITM-10122023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","WELLPOINT [1015]","HB AMC WELLPOINT","5134.26","73.78","","2344.73","1619.47","2530.35","16","2157.25","5532.31","percent of total billed charges",""
"KNEE BASEPLATE 67MM TIBIAL OSS MODULAR","SUP-ITM-10122023","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","AETNA [1001]","HB AMC AETNA HMO","4857.30","69.8","","1523.63","988.41","4330.26","39","3636.71","5686.8","percent of total billed charges",""
"KNEE BASEPLATE 67MM TIBIAL OSS MODULAR","SUP-ITM-10122023","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","AETNA [1001]","HB AMC AETNA PPO","5594.94","80.4","","1670.25","1670.25","1670.25","1 through 10","3636.71","5686.8","percent of total billed charges",""
"KNEE BASEPLATE 67MM TIBIAL OSS MODULAR","SUP-ITM-10122023","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3636.71","52.26","","1113.10","1113.10","1113.10","1 through 10","3636.71","5686.8","percent of total billed charges",""
"KNEE BASEPLATE 67MM TIBIAL OSS MODULAR","SUP-ITM-10122023","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5686.80","81.72","","1738.90","1484.65","2716.94","38","3636.71","5686.8","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 4 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121217","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","834.07","52.26","","1113.10","1113.10","1113.10","1 through 10","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 4 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121217","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1268.82","79.5","","1293.60","1148.53","1603.80","1 through 10","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 4 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121217","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","582.54","36.5","","1023.42","771.29","2068.67","33","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 4 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121217","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","611.27","38.3","","850.52","759.78","1211.25","66","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 4 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121217","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","684.68","42.9","","2548.09","2548.09","2548.09","1 through 10","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 4 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121217","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","684.68","42.9","","956.46","956.46","956.46","1 through 10","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 4 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121217","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","WELLPOINT [1015]","HB AMC WELLPOINT","1177.53","73.78","","2344.73","1619.47","2530.35","16","494.76","1268.82","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 4 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121217","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1596.00","1197.00","AETNA [1001]","HB AMC AETNA HMO","1114.01","69.8","","1523.63","988.41","4330.26","39","834.07","1304.25","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 4 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121217","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1596.00","1197.00","AETNA [1001]","HB AMC AETNA PPO","1283.18","80.4","","1670.25","1670.25","1670.25","1 through 10","834.07","1304.25","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 4 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121217","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1596.00","1197.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","834.07","52.26","","1113.10","1113.10","1113.10","1 through 10","834.07","1304.25","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 4 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121217","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1596.00","1197.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1304.25","81.72","","1738.90","1484.65","2716.94","38","834.07","1304.25","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","800.18","480.96","1887.97","195","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1865.50","53.3","","813.12","216.42","1444.50","81","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1085.00","31","","432.60","432.60","432.60","1 through 10","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","148.37","54.89","631.39","94","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","279.30","91.72","1116.77","266","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","731.00","63.70","731.00","1 through 10","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","384.74","384.74","384.74","1 through 10","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","286.63","119.22","1107.45","105","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","675.31","184.75","1721.50","286","1829.1","2860.2","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1261.44","103.12","1514.10","21","1829.1","2860.2","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2814.00","80.4","","1365.00","1365.00","1365.00","1 through 10","1829.1","2860.2","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2860.20","81.72","","5157.68","5157.68","5157.68","1 through 10","1829.1","2860.2","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","431.26","71.26","1459.57","88","1829.1","2860.2","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1152.33","52.26","","1113.10","1113.10","1113.10","1 through 10","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1752.98","79.5","","1293.60","1148.53","1603.80","1 through 10","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","804.83","36.5","","1023.42","771.29","2068.67","33","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","844.52","38.3","","850.52","759.78","1211.25","66","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","945.95","42.9","","2548.09","2548.09","2548.09","1 through 10","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","945.95","42.9","","956.46","956.46","956.46","1 through 10","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","WELLPOINT [1015]","HB AMC WELLPOINT","1626.85","73.78","","2344.73","1619.47","2530.35","16","683.55","1752.98","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","AETNA [1001]","HB AMC AETNA HMO","1539.09","69.8","","1523.63","988.41","4330.26","39","1152.33","1801.93","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","AETNA [1001]","HB AMC AETNA PPO","1772.82","80.4","","1670.25","1670.25","1670.25","1 through 10","1152.33","1801.93","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1152.33","52.26","","1113.10","1113.10","1113.10","1 through 10","1152.33","1801.93","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1801.93","81.72","","1738.90","1484.65","2716.94","38","1152.33","1801.93","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2033.96","52.26","","1113.10","1113.10","1113.10","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3094.14","79.5","","1293.60","1148.53","1603.80","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1420.58","36.5","","1023.42","771.29","2068.67","33","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1490.64","38.3","","850.52","759.78","1211.25","66","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.67","42.9","","2548.09","2548.09","2548.09","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.67","42.9","","956.46","956.46","956.46","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","WELLPOINT [1015]","HB AMC WELLPOINT","2871.52","73.78","","2344.73","1619.47","2530.35","16","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","AETNA [1001]","HB AMC AETNA HMO","2716.62","69.8","","1523.63","988.41","4330.26","39","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","AETNA [1001]","HB AMC AETNA PPO","3129.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2033.96","52.26","","1113.10","1113.10","1113.10","1 through 10","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3180.54","81.72","","1738.90","1484.65","2716.94","38","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3094.14","79.5","","800.18","480.96","1887.97","195","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2074.44","53.3","","813.12","216.42","1444.50","81","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1206.52","31","","432.60","432.60","432.60","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1420.58","36.5","","148.37","54.89","631.39","94","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1490.64","38.3","","279.30","91.72","1116.77","266","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.67","42.9","","731.00","63.70","731.00","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.67","42.9","","384.74","384.74","384.74","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","WELLPOINT [1015]","HB AMC WELLPOINT","2871.52","73.78","","286.63","119.22","1107.45","105","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","AETNA [1001]","HB AMC AETNA HMO","2716.62","69.8","","675.31","184.75","1721.50","286","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","AETNA [1001]","HB AMC AETNA PPO","3129.17","80.4","","1261.44","103.12","1514.10","21","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3129.17","80.4","","1365.00","1365.00","1365.00","1 through 10","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3180.54","81.72","","5157.68","5157.68","5157.68","1 through 10","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3180.54","81.72","","431.26","71.26","1459.57","88","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2033.96","52.26","","1113.10","1113.10","1113.10","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3094.14","79.5","","1293.60","1148.53","1603.80","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1420.58","36.5","","1023.42","771.29","2068.67","33","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1490.64","38.3","","850.52","759.78","1211.25","66","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.67","42.9","","2548.09","2548.09","2548.09","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.67","42.9","","956.46","956.46","956.46","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","WELLPOINT [1015]","HB AMC WELLPOINT","2871.52","73.78","","2344.73","1619.47","2530.35","16","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","AETNA [1001]","HB AMC AETNA HMO","2716.62","69.8","","1523.63","988.41","4330.26","39","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","AETNA [1001]","HB AMC AETNA PPO","3129.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2033.96","52.26","","1113.10","1113.10","1113.10","1 through 10","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3180.54","81.72","","1738.90","1484.65","2716.94","38","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10082292","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3094.14","79.5","","800.18","480.96","1887.97","195","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10082292","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2074.44","53.3","","813.12","216.42","1444.50","81","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10082292","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1206.52","31","","432.60","432.60","432.60","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10082292","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1420.58","36.5","","148.37","54.89","631.39","94","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10082292","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1490.64","38.3","","279.30","91.72","1116.77","266","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10082292","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.67","42.9","","731.00","63.70","731.00","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10082292","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.67","42.9","","384.74","384.74","384.74","1 through 10","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10082292","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","WELLPOINT [1015]","HB AMC WELLPOINT","2871.52","73.78","","286.63","119.22","1107.45","105","1206.52","3094.14","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10082292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","AETNA [1001]","HB AMC AETNA HMO","2716.62","69.8","","675.31","184.75","1721.50","286","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10082292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","AETNA [1001]","HB AMC AETNA PPO","3129.17","80.4","","1261.44","103.12","1514.10","21","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10082292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3129.17","80.4","","1365.00","1365.00","1365.00","1 through 10","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10082292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3180.54","81.72","","5157.68","5157.68","5157.68","1 through 10","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10082292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3180.54","81.72","","431.26","71.26","1459.57","88","2033.96","3180.54","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1463.28","52.26","","1113.10","1113.10","1113.10","1 through 10","868","2226","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","1293.60","1148.53","1603.80","1 through 10","868","2226","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","1023.42","771.29","2068.67","33","868","2226","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","850.52","759.78","1211.25","66","868","2226","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","2548.09","2548.09","2548.09","1 through 10","868","2226","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","956.46","956.46","956.46","1 through 10","868","2226","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","2344.73","1619.47","2530.35","16","868","2226","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA HMO","1954.40","69.8","","1523.63","988.41","4330.26","39","1463.28","2288.16","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA PPO","2251.20","80.4","","1670.25","1670.25","1670.25","1 through 10","1463.28","2288.16","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1463.28","52.26","","1113.10","1113.10","1113.10","1 through 10","1463.28","2288.16","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","1738.90","1484.65","2716.94","38","1463.28","2288.16","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1023.42","771.29","2068.67","33","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","850.52","759.78","1211.25","66","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","956.46","956.46","956.46","1 through 10","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2344.73","1619.47","2530.35","16","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1523.63","988.41","4330.26","39","1829.1","2860.2","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1829.1","2860.2","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1829.1","2860.2","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","1738.90","1484.65","2716.94","38","1829.1","2860.2","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1023.42","771.29","2068.67","33","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","850.52","759.78","1211.25","66","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","956.46","956.46","956.46","1 through 10","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2344.73","1619.47","2530.35","16","1085","2782.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1523.63","988.41","4330.26","39","1829.1","2860.2","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1829.1","2860.2","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1829.1","2860.2","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","1738.90","1484.65","2716.94","38","1829.1","2860.2","percent of total billed charges",""
"KNEE BEARING 12X63 TO 67MM VANGUARD SSK 185062","SUP-ITM-10117922","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1530.68","52.26","","1113.10","1113.10","1113.10","1 through 10","907.98","2328.54","percent of total billed charges",""
"KNEE BEARING 12X63 TO 67MM VANGUARD SSK 185062","SUP-ITM-10117922","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2328.54","79.5","","1293.60","1148.53","1603.80","1 through 10","907.98","2328.54","percent of total billed charges",""
"KNEE BEARING 12X63 TO 67MM VANGUARD SSK 185062","SUP-ITM-10117922","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1069.08","36.5","","1023.42","771.29","2068.67","33","907.98","2328.54","percent of total billed charges",""
"KNEE BEARING 12X63 TO 67MM VANGUARD SSK 185062","SUP-ITM-10117922","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1121.80","38.3","","850.52","759.78","1211.25","66","907.98","2328.54","percent of total billed charges",""
"KNEE BEARING 12X63 TO 67MM VANGUARD SSK 185062","SUP-ITM-10117922","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.53","42.9","","2548.09","2548.09","2548.09","1 through 10","907.98","2328.54","percent of total billed charges",""
"KNEE BEARING 12X63 TO 67MM VANGUARD SSK 185062","SUP-ITM-10117922","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.53","42.9","","956.46","956.46","956.46","1 through 10","907.98","2328.54","percent of total billed charges",""
"KNEE BEARING 12X63 TO 67MM VANGUARD SSK 185062","SUP-ITM-10117922","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","WELLPOINT [1015]","HB AMC WELLPOINT","2161.00","73.78","","2344.73","1619.47","2530.35","16","907.98","2328.54","percent of total billed charges",""
"KNEE BEARING 12X63 TO 67MM VANGUARD SSK 185062","SUP-ITM-10117922","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2928.98","2196.73","AETNA [1001]","HB AMC AETNA HMO","2044.43","69.8","","1523.63","988.41","4330.26","39","1530.68","2393.56","percent of total billed charges",""
"KNEE BEARING 12X63 TO 67MM VANGUARD SSK 185062","SUP-ITM-10117922","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2928.98","2196.73","AETNA [1001]","HB AMC AETNA PPO","2354.90","80.4","","1670.25","1670.25","1670.25","1 through 10","1530.68","2393.56","percent of total billed charges",""
"KNEE BEARING 12X63 TO 67MM VANGUARD SSK 185062","SUP-ITM-10117922","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2928.98","2196.73","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1530.68","52.26","","1113.10","1113.10","1113.10","1 through 10","1530.68","2393.56","percent of total billed charges",""
"KNEE BEARING 12X63 TO 67MM VANGUARD SSK 185062","SUP-ITM-10117922","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2928.98","2196.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2393.56","81.72","","1738.90","1484.65","2716.94","38","1530.68","2393.56","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.18","52.26","","1113.10","1113.10","1113.10","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1390.69","79.5","","1293.60","1148.53","1603.80","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.49","36.5","","1023.42","771.29","2068.67","33","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","669.98","38.3","","850.52","759.78","1211.25","66","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.45","42.9","","2548.09","2548.09","2548.09","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.45","42.9","","956.46","956.46","956.46","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","WELLPOINT [1015]","HB AMC WELLPOINT","1290.63","73.78","","2344.73","1619.47","2530.35","16","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","AETNA [1001]","HB AMC AETNA HMO","1221.01","69.8","","1523.63","988.41","4330.26","39","914.18","1429.53","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","AETNA [1001]","HB AMC AETNA PPO","1406.44","80.4","","1670.25","1670.25","1670.25","1 through 10","914.18","1429.53","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.18","52.26","","1113.10","1113.10","1113.10","1 through 10","914.18","1429.53","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1429.53","81.72","","1738.90","1484.65","2716.94","38","914.18","1429.53","percent of total billed charges",""
"KNEE BEARING C4 LEFT LATERAL FIXED OXFORD","SUP-ITM-10239041","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2124.13","52.26","","1113.10","1113.10","1113.10","1 through 10","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING C4 LEFT LATERAL FIXED OXFORD","SUP-ITM-10239041","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3231.32","79.5","","1293.60","1148.53","1603.80","1 through 10","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING C4 LEFT LATERAL FIXED OXFORD","SUP-ITM-10239041","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1483.56","36.5","","1023.42","771.29","2068.67","33","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING C4 LEFT LATERAL FIXED OXFORD","SUP-ITM-10239041","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1556.72","38.3","","850.52","759.78","1211.25","66","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING C4 LEFT LATERAL FIXED OXFORD","SUP-ITM-10239041","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1743.69","42.9","","2548.09","2548.09","2548.09","1 through 10","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING C4 LEFT LATERAL FIXED OXFORD","SUP-ITM-10239041","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1743.69","42.9","","956.46","956.46","956.46","1 through 10","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING C4 LEFT LATERAL FIXED OXFORD","SUP-ITM-10239041","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","WELLPOINT [1015]","HB AMC WELLPOINT","2998.82","73.78","","2344.73","1619.47","2530.35","16","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING C4 LEFT LATERAL FIXED OXFORD","SUP-ITM-10239041","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4064.55","3048.41","AETNA [1001]","HB AMC AETNA HMO","2837.06","69.8","","1523.63","988.41","4330.26","39","2124.13","3321.55","percent of total billed charges",""
"KNEE BEARING C4 LEFT LATERAL FIXED OXFORD","SUP-ITM-10239041","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4064.55","3048.41","AETNA [1001]","HB AMC AETNA PPO","3267.90","80.4","","1670.25","1670.25","1670.25","1 through 10","2124.13","3321.55","percent of total billed charges",""
"KNEE BEARING C4 LEFT LATERAL FIXED OXFORD","SUP-ITM-10239041","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4064.55","3048.41","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2124.13","52.26","","1113.10","1113.10","1113.10","1 through 10","2124.13","3321.55","percent of total billed charges",""
"KNEE BEARING C4 LEFT LATERAL FIXED OXFORD","SUP-ITM-10239041","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4064.55","3048.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3321.55","81.72","","1738.90","1484.65","2716.94","38","2124.13","3321.55","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D4 RIGHT TIBIAL","SUP-ITM-10236848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2124.13","52.26","","1113.10","1113.10","1113.10","1 through 10","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D4 RIGHT TIBIAL","SUP-ITM-10236848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3231.32","79.5","","1293.60","1148.53","1603.80","1 through 10","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D4 RIGHT TIBIAL","SUP-ITM-10236848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1483.56","36.5","","1023.42","771.29","2068.67","33","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D4 RIGHT TIBIAL","SUP-ITM-10236848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1556.72","38.3","","850.52","759.78","1211.25","66","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D4 RIGHT TIBIAL","SUP-ITM-10236848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1743.69","42.9","","2548.09","2548.09","2548.09","1 through 10","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D4 RIGHT TIBIAL","SUP-ITM-10236848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1743.69","42.9","","956.46","956.46","956.46","1 through 10","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D4 RIGHT TIBIAL","SUP-ITM-10236848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4064.55","3048.41","WELLPOINT [1015]","HB AMC WELLPOINT","2998.82","73.78","","2344.73","1619.47","2530.35","16","1260.01","3231.32","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D4 RIGHT TIBIAL","SUP-ITM-10236848","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4064.55","3048.41","AETNA [1001]","HB AMC AETNA HMO","2837.06","69.8","","1523.63","988.41","4330.26","39","2124.13","3321.55","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D4 RIGHT TIBIAL","SUP-ITM-10236848","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4064.55","3048.41","AETNA [1001]","HB AMC AETNA PPO","3267.90","80.4","","1670.25","1670.25","1670.25","1 through 10","2124.13","3321.55","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D4 RIGHT TIBIAL","SUP-ITM-10236848","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4064.55","3048.41","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2124.13","52.26","","1113.10","1113.10","1113.10","1 through 10","2124.13","3321.55","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D4 RIGHT TIBIAL","SUP-ITM-10236848","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4064.55","3048.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3321.55","81.72","","1738.90","1484.65","2716.94","38","2124.13","3321.55","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.18","52.26","","1113.10","1113.10","1113.10","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1390.69","79.5","","1293.60","1148.53","1603.80","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.49","36.5","","1023.42","771.29","2068.67","33","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","669.98","38.3","","850.52","759.78","1211.25","66","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.45","42.9","","2548.09","2548.09","2548.09","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.45","42.9","","956.46","956.46","956.46","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","WELLPOINT [1015]","HB AMC WELLPOINT","1290.63","73.78","","2344.73","1619.47","2530.35","16","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","AETNA [1001]","HB AMC AETNA HMO","1221.01","69.8","","1523.63","988.41","4330.26","39","914.18","1429.53","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","AETNA [1001]","HB AMC AETNA PPO","1406.44","80.4","","1670.25","1670.25","1670.25","1 through 10","914.18","1429.53","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.18","52.26","","1113.10","1113.10","1113.10","1 through 10","914.18","1429.53","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1429.53","81.72","","1738.90","1484.65","2716.94","38","914.18","1429.53","percent of total billed charges",""
"KNEE BEARING SM SIZE 6 TIBIAL OXFORD ANATOMIC POLYETHYLENE LT MEDIAL","SUP-ITM-10029418","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.18","52.26","","1113.10","1113.10","1113.10","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING SM SIZE 6 TIBIAL OXFORD ANATOMIC POLYETHYLENE LT MEDIAL","SUP-ITM-10029418","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1390.69","79.5","","1293.60","1148.53","1603.80","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING SM SIZE 6 TIBIAL OXFORD ANATOMIC POLYETHYLENE LT MEDIAL","SUP-ITM-10029418","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.49","36.5","","1023.42","771.29","2068.67","33","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING SM SIZE 6 TIBIAL OXFORD ANATOMIC POLYETHYLENE LT MEDIAL","SUP-ITM-10029418","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","669.98","38.3","","850.52","759.78","1211.25","66","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING SM SIZE 6 TIBIAL OXFORD ANATOMIC POLYETHYLENE LT MEDIAL","SUP-ITM-10029418","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.45","42.9","","2548.09","2548.09","2548.09","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING SM SIZE 6 TIBIAL OXFORD ANATOMIC POLYETHYLENE LT MEDIAL","SUP-ITM-10029418","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.45","42.9","","956.46","956.46","956.46","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING SM SIZE 6 TIBIAL OXFORD ANATOMIC POLYETHYLENE LT MEDIAL","SUP-ITM-10029418","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","WELLPOINT [1015]","HB AMC WELLPOINT","1290.63","73.78","","2344.73","1619.47","2530.35","16","542.28","1390.69","percent of total billed charges",""
"KNEE BEARING SM SIZE 6 TIBIAL OXFORD ANATOMIC POLYETHYLENE LT MEDIAL","SUP-ITM-10029418","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","AETNA [1001]","HB AMC AETNA HMO","1221.01","69.8","","1523.63","988.41","4330.26","39","914.18","1429.53","percent of total billed charges",""
"KNEE BEARING SM SIZE 6 TIBIAL OXFORD ANATOMIC POLYETHYLENE LT MEDIAL","SUP-ITM-10029418","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","AETNA [1001]","HB AMC AETNA PPO","1406.44","80.4","","1670.25","1670.25","1670.25","1 through 10","914.18","1429.53","percent of total billed charges",""
"KNEE BEARING SM SIZE 6 TIBIAL OXFORD ANATOMIC POLYETHYLENE LT MEDIAL","SUP-ITM-10029418","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.18","52.26","","1113.10","1113.10","1113.10","1 through 10","914.18","1429.53","percent of total billed charges",""
"KNEE BEARING SM SIZE 6 TIBIAL OXFORD ANATOMIC POLYETHYLENE LT MEDIAL","SUP-ITM-10029418","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1429.53","81.72","","1738.90","1484.65","2716.94","38","914.18","1429.53","percent of total billed charges",""
"KNEE CAGE 7CM FEMORAL FINN SALVAGE MODULAR PROXIMALIMAL","SUP-ITM-10114884","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5963.33","52.26","","1113.10","1113.10","1113.10","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE CAGE 7CM FEMORAL FINN SALVAGE MODULAR PROXIMALIMAL","SUP-ITM-10114884","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9071.65","79.5","","1293.60","1148.53","1603.80","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE CAGE 7CM FEMORAL FINN SALVAGE MODULAR PROXIMALIMAL","SUP-ITM-10114884","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4164.97","36.5","","1023.42","771.29","2068.67","33","3537.37","9071.65","percent of total billed charges",""
"KNEE CAGE 7CM FEMORAL FINN SALVAGE MODULAR PROXIMALIMAL","SUP-ITM-10114884","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4370.37","38.3","","850.52","759.78","1211.25","66","3537.37","9071.65","percent of total billed charges",""
"KNEE CAGE 7CM FEMORAL FINN SALVAGE MODULAR PROXIMALIMAL","SUP-ITM-10114884","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4895.27","42.9","","2548.09","2548.09","2548.09","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE CAGE 7CM FEMORAL FINN SALVAGE MODULAR PROXIMALIMAL","SUP-ITM-10114884","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4895.27","42.9","","956.46","956.46","956.46","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE CAGE 7CM FEMORAL FINN SALVAGE MODULAR PROXIMALIMAL","SUP-ITM-10114884","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","WELLPOINT [1015]","HB AMC WELLPOINT","8418.95","73.78","","2344.73","1619.47","2530.35","16","3537.37","9071.65","percent of total billed charges",""
"KNEE CAGE 7CM FEMORAL FINN SALVAGE MODULAR PROXIMALIMAL","SUP-ITM-10114884","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","AETNA [1001]","HB AMC AETNA HMO","7964.79","69.8","","1523.63","988.41","4330.26","39","5963.33","9324.97","percent of total billed charges",""
"KNEE CAGE 7CM FEMORAL FINN SALVAGE MODULAR PROXIMALIMAL","SUP-ITM-10114884","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","AETNA [1001]","HB AMC AETNA PPO","9174.35","80.4","","1670.25","1670.25","1670.25","1 through 10","5963.33","9324.97","percent of total billed charges",""
"KNEE CAGE 7CM FEMORAL FINN SALVAGE MODULAR PROXIMALIMAL","SUP-ITM-10114884","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5963.33","52.26","","1113.10","1113.10","1113.10","1 through 10","5963.33","9324.97","percent of total billed charges",""
"KNEE CAGE 7CM FEMORAL FINN SALVAGE MODULAR PROXIMALIMAL","SUP-ITM-10114884","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9324.97","81.72","","1738.90","1484.65","2716.94","38","5963.33","9324.97","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","512.15","52.26","","1113.10","1113.10","1113.10","1 through 10","303.8","779.1","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","779.10","79.5","","1293.60","1148.53","1603.80","1 through 10","303.8","779.1","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","357.70","36.5","","1023.42","771.29","2068.67","33","303.8","779.1","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","375.34","38.3","","850.52","759.78","1211.25","66","303.8","779.1","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.42","42.9","","2548.09","2548.09","2548.09","1 through 10","303.8","779.1","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.42","42.9","","956.46","956.46","956.46","1 through 10","303.8","779.1","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","WELLPOINT [1015]","HB AMC WELLPOINT","723.04","73.78","","2344.73","1619.47","2530.35","16","303.8","779.1","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","AETNA [1001]","HB AMC AETNA HMO","684.04","69.8","","1523.63","988.41","4330.26","39","512.15","800.86","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","AETNA [1001]","HB AMC AETNA PPO","787.92","80.4","","1670.25","1670.25","1670.25","1 through 10","512.15","800.86","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","512.15","52.26","","1113.10","1113.10","1113.10","1 through 10","512.15","800.86","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","800.86","81.72","","1738.90","1484.65","2716.94","38","512.15","800.86","percent of total billed charges",""
"KNEE COMPONENT 63MM TIBIAL CONDYLE OSS COATED 161088","SUP-ITM-10122135","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3636.71","52.26","","1113.10","1113.10","1113.10","1 through 10","2157.25","5532.31","percent of total billed charges",""
"KNEE COMPONENT 63MM TIBIAL CONDYLE OSS COATED 161088","SUP-ITM-10122135","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5532.31","79.5","","1293.60","1148.53","1603.80","1 through 10","2157.25","5532.31","percent of total billed charges",""
"KNEE COMPONENT 63MM TIBIAL CONDYLE OSS COATED 161088","SUP-ITM-10122135","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2539.99","36.5","","1023.42","771.29","2068.67","33","2157.25","5532.31","percent of total billed charges",""
"KNEE COMPONENT 63MM TIBIAL CONDYLE OSS COATED 161088","SUP-ITM-10122135","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2665.25","38.3","","850.52","759.78","1211.25","66","2157.25","5532.31","percent of total billed charges",""
"KNEE COMPONENT 63MM TIBIAL CONDYLE OSS COATED 161088","SUP-ITM-10122135","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2985.36","42.9","","2548.09","2548.09","2548.09","1 through 10","2157.25","5532.31","percent of total billed charges",""
"KNEE COMPONENT 63MM TIBIAL CONDYLE OSS COATED 161088","SUP-ITM-10122135","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2985.36","42.9","","956.46","956.46","956.46","1 through 10","2157.25","5532.31","percent of total billed charges",""
"KNEE COMPONENT 63MM TIBIAL CONDYLE OSS COATED 161088","SUP-ITM-10122135","CDM","C1776","HCPCS","0278","RC","","","","both","","","6958.88","5219.16","WELLPOINT [1015]","HB AMC WELLPOINT","5134.26","73.78","","2344.73","1619.47","2530.35","16","2157.25","5532.31","percent of total billed charges",""
"KNEE COMPONENT 63MM TIBIAL CONDYLE OSS COATED 161088","SUP-ITM-10122135","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","AETNA [1001]","HB AMC AETNA HMO","4857.30","69.8","","1523.63","988.41","4330.26","39","3636.71","5686.8","percent of total billed charges",""
"KNEE COMPONENT 63MM TIBIAL CONDYLE OSS COATED 161088","SUP-ITM-10122135","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","AETNA [1001]","HB AMC AETNA PPO","5594.94","80.4","","1670.25","1670.25","1670.25","1 through 10","3636.71","5686.8","percent of total billed charges",""
"KNEE COMPONENT 63MM TIBIAL CONDYLE OSS COATED 161088","SUP-ITM-10122135","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3636.71","52.26","","1113.10","1113.10","1113.10","1 through 10","3636.71","5686.8","percent of total billed charges",""
"KNEE COMPONENT 63MM TIBIAL CONDYLE OSS COATED 161088","SUP-ITM-10122135","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6958.88","5219.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5686.80","81.72","","1738.90","1484.65","2716.94","38","3636.71","5686.8","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4580.59","52.26","","1113.10","1113.10","1113.10","1 through 10","2717.15","6968.18","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6968.18","79.5","","1293.60","1148.53","1603.80","1 through 10","2717.15","6968.18","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3199.23","36.5","","1023.42","771.29","2068.67","33","2717.15","6968.18","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3357.00","38.3","","850.52","759.78","1211.25","66","2717.15","6968.18","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3760.19","42.9","","2548.09","2548.09","2548.09","1 through 10","2717.15","6968.18","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3760.19","42.9","","956.46","956.46","956.46","1 through 10","2717.15","6968.18","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","WELLPOINT [1015]","HB AMC WELLPOINT","6466.82","73.78","","2344.73","1619.47","2530.35","16","2717.15","6968.18","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8765.00","6573.75","AETNA [1001]","HB AMC AETNA HMO","6117.97","69.8","","1523.63","988.41","4330.26","39","4580.59","7162.76","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8765.00","6573.75","AETNA [1001]","HB AMC AETNA PPO","7047.06","80.4","","1670.25","1670.25","1670.25","1 through 10","4580.59","7162.76","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8765.00","6573.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4580.59","52.26","","1113.10","1113.10","1113.10","1 through 10","4580.59","7162.76","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8765.00","6573.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7162.76","81.72","","1738.90","1484.65","2716.94","38","4580.59","7162.76","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3100.32","52.26","","1113.10","1113.10","1113.10","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4716.34","79.5","","1293.60","1148.53","1603.80","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2165.36","36.5","","1023.42","771.29","2068.67","33","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2272.15","38.3","","850.52","759.78","1211.25","66","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2545.04","42.9","","2548.09","2548.09","2548.09","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2545.04","42.9","","956.46","956.46","956.46","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","WELLPOINT [1015]","HB AMC WELLPOINT","4377.00","73.78","","2344.73","1619.47","2530.35","16","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","AETNA [1001]","HB AMC AETNA HMO","4140.89","69.8","","1523.63","988.41","4330.26","39","3100.32","4848.04","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","AETNA [1001]","HB AMC AETNA PPO","4769.73","80.4","","1670.25","1670.25","1670.25","1 through 10","3100.32","4848.04","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3100.32","52.26","","1113.10","1113.10","1113.10","1 through 10","3100.32","4848.04","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4848.04","81.72","","1738.90","1484.65","2716.94","38","3100.32","4848.04","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3100.32","52.26","","1113.10","1113.10","1113.10","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4716.34","79.5","","1293.60","1148.53","1603.80","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2165.36","36.5","","1023.42","771.29","2068.67","33","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2272.15","38.3","","850.52","759.78","1211.25","66","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2545.04","42.9","","2548.09","2548.09","2548.09","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2545.04","42.9","","956.46","956.46","956.46","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","WELLPOINT [1015]","HB AMC WELLPOINT","4377.00","73.78","","2344.73","1619.47","2530.35","16","1839.08","4716.34","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","AETNA [1001]","HB AMC AETNA HMO","4140.89","69.8","","1523.63","988.41","4330.26","39","3100.32","4848.04","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","AETNA [1001]","HB AMC AETNA PPO","4769.73","80.4","","1670.25","1670.25","1670.25","1 through 10","3100.32","4848.04","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3100.32","52.26","","1113.10","1113.10","1113.10","1 through 10","3100.32","4848.04","percent of total billed charges",""
"KNEE COMPONENT SZ 7 L FEMORAL REV CCR PERSONA STD","SUP-ITM-10267963","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4848.04","81.72","","1738.90","1484.65","2716.94","38","3100.32","4848.04","percent of total billed charges",""
"KNEE COMPONENT SZ C FEMORAL RIGHT","SUP-ITM-10025554","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8587.62","52.26","","1113.10","1113.10","1113.10","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE COMPONENT SZ C FEMORAL RIGHT","SUP-ITM-10025554","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13063.84","79.5","","1293.60","1148.53","1603.80","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE COMPONENT SZ C FEMORAL RIGHT","SUP-ITM-10025554","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5997.86","36.5","","1023.42","771.29","2068.67","33","5094.08","13063.84","percent of total billed charges",""
"KNEE COMPONENT SZ C FEMORAL RIGHT","SUP-ITM-10025554","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6293.65","38.3","","850.52","759.78","1211.25","66","5094.08","13063.84","percent of total billed charges",""
"KNEE COMPONENT SZ C FEMORAL RIGHT","SUP-ITM-10025554","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7049.54","42.9","","2548.09","2548.09","2548.09","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE COMPONENT SZ C FEMORAL RIGHT","SUP-ITM-10025554","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7049.54","42.9","","956.46","956.46","956.46","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE COMPONENT SZ C FEMORAL RIGHT","SUP-ITM-10025554","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","WELLPOINT [1015]","HB AMC WELLPOINT","12123.90","73.78","","2344.73","1619.47","2530.35","16","5094.08","13063.84","percent of total billed charges",""
"KNEE COMPONENT SZ C FEMORAL RIGHT","SUP-ITM-10025554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","AETNA [1001]","HB AMC AETNA HMO","11469.89","69.8","","1523.63","988.41","4330.26","39","8587.62","13428.64","percent of total billed charges",""
"KNEE COMPONENT SZ C FEMORAL RIGHT","SUP-ITM-10025554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","AETNA [1001]","HB AMC AETNA PPO","13211.73","80.4","","1670.25","1670.25","1670.25","1 through 10","8587.62","13428.64","percent of total billed charges",""
"KNEE COMPONENT SZ C FEMORAL RIGHT","SUP-ITM-10025554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8587.62","52.26","","1113.10","1113.10","1113.10","1 through 10","8587.62","13428.64","percent of total billed charges",""
"KNEE COMPONENT SZ C FEMORAL RIGHT","SUP-ITM-10025554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13428.64","81.72","","1738.90","1484.65","2716.94","38","8587.62","13428.64","percent of total billed charges",""
"KNEE CONE 26MM TIBIAL SHORT LEGION","SUP-ITM-10198688","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2381.75","52.26","","1113.10","1113.10","1113.10","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE CONE 26MM TIBIAL SHORT LEGION","SUP-ITM-10198688","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3623.21","79.5","","1293.60","1148.53","1603.80","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE CONE 26MM TIBIAL SHORT LEGION","SUP-ITM-10198688","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1663.49","36.5","","1023.42","771.29","2068.67","33","1412.83","3623.21","percent of total billed charges",""
"KNEE CONE 26MM TIBIAL SHORT LEGION","SUP-ITM-10198688","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1745.52","38.3","","850.52","759.78","1211.25","66","1412.83","3623.21","percent of total billed charges",""
"KNEE CONE 26MM TIBIAL SHORT LEGION","SUP-ITM-10198688","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.17","42.9","","2548.09","2548.09","2548.09","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE CONE 26MM TIBIAL SHORT LEGION","SUP-ITM-10198688","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.17","42.9","","956.46","956.46","956.46","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE CONE 26MM TIBIAL SHORT LEGION","SUP-ITM-10198688","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","WELLPOINT [1015]","HB AMC WELLPOINT","3362.52","73.78","","2344.73","1619.47","2530.35","16","1412.83","3623.21","percent of total billed charges",""
"KNEE CONE 26MM TIBIAL SHORT LEGION","SUP-ITM-10198688","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","AETNA [1001]","HB AMC AETNA HMO","3181.14","69.8","","1523.63","988.41","4330.26","39","2381.75","3724.39","percent of total billed charges",""
"KNEE CONE 26MM TIBIAL SHORT LEGION","SUP-ITM-10198688","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","AETNA [1001]","HB AMC AETNA PPO","3664.23","80.4","","1670.25","1670.25","1670.25","1 through 10","2381.75","3724.39","percent of total billed charges",""
"KNEE CONE 26MM TIBIAL SHORT LEGION","SUP-ITM-10198688","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2381.75","52.26","","1113.10","1113.10","1113.10","1 through 10","2381.75","3724.39","percent of total billed charges",""
"KNEE CONE 26MM TIBIAL SHORT LEGION","SUP-ITM-10198688","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3724.39","81.72","","1738.90","1484.65","2716.94","38","2381.75","3724.39","percent of total billed charges",""
"KNEE CONE SIZE 1-2 FEMORAL CENTRAL AUGMENT TRIATHLON TRITANIUM LEFT","SUP-ITM-10267721","CDM","C1776","HCPCS","0278","RC","","","","both","","","10381.25","7785.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5425.24","52.26","","1113.10","1113.10","1113.10","1 through 10","3218.19","8253.09","percent of total billed charges",""
"KNEE CONE SIZE 1-2 FEMORAL CENTRAL AUGMENT TRIATHLON TRITANIUM LEFT","SUP-ITM-10267721","CDM","C1776","HCPCS","0278","RC","","","","both","","","10381.25","7785.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8253.09","79.5","","1293.60","1148.53","1603.80","1 through 10","3218.19","8253.09","percent of total billed charges",""
"KNEE CONE SIZE 1-2 FEMORAL CENTRAL AUGMENT TRIATHLON TRITANIUM LEFT","SUP-ITM-10267721","CDM","C1776","HCPCS","0278","RC","","","","both","","","10381.25","7785.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3789.16","36.5","","1023.42","771.29","2068.67","33","3218.19","8253.09","percent of total billed charges",""
"KNEE CONE SIZE 1-2 FEMORAL CENTRAL AUGMENT TRIATHLON TRITANIUM LEFT","SUP-ITM-10267721","CDM","C1776","HCPCS","0278","RC","","","","both","","","10381.25","7785.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3976.02","38.3","","850.52","759.78","1211.25","66","3218.19","8253.09","percent of total billed charges",""
"KNEE CONE SIZE 1-2 FEMORAL CENTRAL AUGMENT TRIATHLON TRITANIUM LEFT","SUP-ITM-10267721","CDM","C1776","HCPCS","0278","RC","","","","both","","","10381.25","7785.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4453.56","42.9","","2548.09","2548.09","2548.09","1 through 10","3218.19","8253.09","percent of total billed charges",""
"KNEE CONE SIZE 1-2 FEMORAL CENTRAL AUGMENT TRIATHLON TRITANIUM LEFT","SUP-ITM-10267721","CDM","C1776","HCPCS","0278","RC","","","","both","","","10381.25","7785.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4453.56","42.9","","956.46","956.46","956.46","1 through 10","3218.19","8253.09","percent of total billed charges",""
"KNEE CONE SIZE 1-2 FEMORAL CENTRAL AUGMENT TRIATHLON TRITANIUM LEFT","SUP-ITM-10267721","CDM","C1776","HCPCS","0278","RC","","","","both","","","10381.25","7785.94","WELLPOINT [1015]","HB AMC WELLPOINT","7659.29","73.78","","2344.73","1619.47","2530.35","16","3218.19","8253.09","percent of total billed charges",""
"KNEE CONE SIZE 1-2 FEMORAL CENTRAL AUGMENT TRIATHLON TRITANIUM LEFT","SUP-ITM-10267721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10381.25","7785.94","AETNA [1001]","HB AMC AETNA HMO","7246.11","69.8","","1523.63","988.41","4330.26","39","5425.24","8483.56","percent of total billed charges",""
"KNEE CONE SIZE 1-2 FEMORAL CENTRAL AUGMENT TRIATHLON TRITANIUM LEFT","SUP-ITM-10267721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10381.25","7785.94","AETNA [1001]","HB AMC AETNA PPO","8346.53","80.4","","1670.25","1670.25","1670.25","1 through 10","5425.24","8483.56","percent of total billed charges",""
"KNEE CONE SIZE 1-2 FEMORAL CENTRAL AUGMENT TRIATHLON TRITANIUM LEFT","SUP-ITM-10267721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10381.25","7785.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5425.24","52.26","","1113.10","1113.10","1113.10","1 through 10","5425.24","8483.56","percent of total billed charges",""
"KNEE CONE SIZE 1-2 FEMORAL CENTRAL AUGMENT TRIATHLON TRITANIUM LEFT","SUP-ITM-10267721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10381.25","7785.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8483.56","81.72","","1738.90","1484.65","2716.94","38","5425.24","8483.56","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3966.53","52.26","","1113.10","1113.10","1113.10","1 through 10","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6034.05","79.5","","1293.60","1148.53","1603.80","1 through 10","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2770.35","36.5","","1023.42","771.29","2068.67","33","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2906.97","38.3","","850.52","759.78","1211.25","66","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3256.11","42.9","","2548.09","2548.09","2548.09","1 through 10","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3256.11","42.9","","956.46","956.46","956.46","1 through 10","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","WELLPOINT [1015]","HB AMC WELLPOINT","5599.90","73.78","","2344.73","1619.47","2530.35","16","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7590.00","5692.50","AETNA [1001]","HB AMC AETNA HMO","5297.82","69.8","","1523.63","988.41","4330.26","39","3966.53","6202.55","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7590.00","5692.50","AETNA [1001]","HB AMC AETNA PPO","6102.36","80.4","","1670.25","1670.25","1670.25","1 through 10","3966.53","6202.55","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7590.00","5692.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3966.53","52.26","","1113.10","1113.10","1113.10","1 through 10","3966.53","6202.55","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7590.00","5692.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6202.55","81.72","","1738.90","1484.65","2716.94","38","3966.53","6202.55","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3966.53","52.26","","1113.10","1113.10","1113.10","1 through 10","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6034.05","79.5","","1293.60","1148.53","1603.80","1 through 10","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2770.35","36.5","","1023.42","771.29","2068.67","33","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2906.97","38.3","","850.52","759.78","1211.25","66","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3256.11","42.9","","2548.09","2548.09","2548.09","1 through 10","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3256.11","42.9","","956.46","956.46","956.46","1 through 10","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","WELLPOINT [1015]","HB AMC WELLPOINT","5599.90","73.78","","2344.73","1619.47","2530.35","16","2352.9","6034.05","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7590.00","5692.50","AETNA [1001]","HB AMC AETNA HMO","5297.82","69.8","","1523.63","988.41","4330.26","39","3966.53","6202.55","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7590.00","5692.50","AETNA [1001]","HB AMC AETNA PPO","6102.36","80.4","","1670.25","1670.25","1670.25","1 through 10","3966.53","6202.55","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7590.00","5692.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3966.53","52.26","","1113.10","1113.10","1113.10","1 through 10","3966.53","6202.55","percent of total billed charges",""
"KNEE CONE SZ D 20MM TIBIAL IMPLANT","SUP-ITM-10170118","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7590.00","5692.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6202.55","81.72","","1738.90","1484.65","2716.94","38","3966.53","6202.55","percent of total billed charges",""
"KNEE FEMORAL LT SZ 7 LEGION CEMENTED","SUP-ITM-10238930","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5432.43","52.26","","1113.10","1113.10","1113.10","1 through 10","3222.45","8264.03","percent of total billed charges",""
"KNEE FEMORAL LT SZ 7 LEGION CEMENTED","SUP-ITM-10238930","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8264.03","79.5","","1293.60","1148.53","1603.80","1 through 10","3222.45","8264.03","percent of total billed charges",""
"KNEE FEMORAL LT SZ 7 LEGION CEMENTED","SUP-ITM-10238930","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3794.18","36.5","","1023.42","771.29","2068.67","33","3222.45","8264.03","percent of total billed charges",""
"KNEE FEMORAL LT SZ 7 LEGION CEMENTED","SUP-ITM-10238930","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3981.29","38.3","","850.52","759.78","1211.25","66","3222.45","8264.03","percent of total billed charges",""
"KNEE FEMORAL LT SZ 7 LEGION CEMENTED","SUP-ITM-10238930","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4459.46","42.9","","2548.09","2548.09","2548.09","1 through 10","3222.45","8264.03","percent of total billed charges",""
"KNEE FEMORAL LT SZ 7 LEGION CEMENTED","SUP-ITM-10238930","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4459.46","42.9","","956.46","956.46","956.46","1 through 10","3222.45","8264.03","percent of total billed charges",""
"KNEE FEMORAL LT SZ 7 LEGION CEMENTED","SUP-ITM-10238930","CDM","C1776","HCPCS","0278","RC","","","","both","","","10395.00","7796.25","WELLPOINT [1015]","HB AMC WELLPOINT","7669.43","73.78","","2344.73","1619.47","2530.35","16","3222.45","8264.03","percent of total billed charges",""
"KNEE FEMORAL LT SZ 7 LEGION CEMENTED","SUP-ITM-10238930","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10395.00","7796.25","AETNA [1001]","HB AMC AETNA HMO","7255.71","69.8","","1523.63","988.41","4330.26","39","5432.43","8494.79","percent of total billed charges",""
"KNEE FEMORAL LT SZ 7 LEGION CEMENTED","SUP-ITM-10238930","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10395.00","7796.25","AETNA [1001]","HB AMC AETNA PPO","8357.58","80.4","","1670.25","1670.25","1670.25","1 through 10","5432.43","8494.79","percent of total billed charges",""
"KNEE FEMORAL LT SZ 7 LEGION CEMENTED","SUP-ITM-10238930","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10395.00","7796.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5432.43","52.26","","1113.10","1113.10","1113.10","1 through 10","5432.43","8494.79","percent of total billed charges",""
"KNEE FEMORAL LT SZ 7 LEGION CEMENTED","SUP-ITM-10238930","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10395.00","7796.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8494.79","81.72","","1738.90","1484.65","2716.94","38","5432.43","8494.79","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1182.56","79.5","","800.18","480.96","1887.97","195","461.13","1182.56","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","792.84","53.3","","813.12","216.42","1444.50","81","461.13","1182.56","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","461.13","31","","432.60","432.60","432.60","1 through 10","461.13","1182.56","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","542.94","36.5","","148.37","54.89","631.39","94","461.13","1182.56","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","569.71","38.3","","279.30","91.72","1116.77","266","461.13","1182.56","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","638.14","42.9","","731.00","63.70","731.00","1 through 10","461.13","1182.56","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","638.14","42.9","","384.74","384.74","384.74","1 through 10","461.13","1182.56","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","WELLPOINT [1015]","HB AMC WELLPOINT","1097.48","73.78","","286.63","119.22","1107.45","105","461.13","1182.56","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","AETNA [1001]","HB AMC AETNA HMO","1038.28","69.8","","675.31","184.75","1721.50","286","777.37","1215.59","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","AETNA [1001]","HB AMC AETNA PPO","1195.95","80.4","","1261.44","103.12","1514.10","21","777.37","1215.59","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1195.95","80.4","","1365.00","1365.00","1365.00","1 through 10","777.37","1215.59","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1215.59","81.72","","5157.68","5157.68","5157.68","1 through 10","777.37","1215.59","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1215.59","81.72","","431.26","71.26","1459.57","88","777.37","1215.59","percent of total billed charges",""
"KNEE HEAD MD AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020613","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"KNEE HEAD MD AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020613","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"KNEE HEAD MD AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020613","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"KNEE HEAD MD AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020613","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"KNEE HEAD MD AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020613","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"KNEE HEAD MD AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020613","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"KNEE HEAD MD AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020613","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"KNEE HEAD MD AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020613","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"KNEE HEAD MD AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020613","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"KNEE HEAD MD AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020613","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"KNEE HEAD MD AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020613","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"KNEE IMPLANT 1 2 20MM COMPONENT ARTICULAR SURFACE NEXGEN POLYETHYLENE CRUCIATE RETAINING ANTERIOR CONSTRAINED","SUP-ITM-10079051","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.18","52.26","","1113.10","1113.10","1113.10","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 1 2 20MM COMPONENT ARTICULAR SURFACE NEXGEN POLYETHYLENE CRUCIATE RETAINING ANTERIOR CONSTRAINED","SUP-ITM-10079051","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1390.69","79.5","","1293.60","1148.53","1603.80","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 1 2 20MM COMPONENT ARTICULAR SURFACE NEXGEN POLYETHYLENE CRUCIATE RETAINING ANTERIOR CONSTRAINED","SUP-ITM-10079051","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.49","36.5","","1023.42","771.29","2068.67","33","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 1 2 20MM COMPONENT ARTICULAR SURFACE NEXGEN POLYETHYLENE CRUCIATE RETAINING ANTERIOR CONSTRAINED","SUP-ITM-10079051","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","669.98","38.3","","850.52","759.78","1211.25","66","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 1 2 20MM COMPONENT ARTICULAR SURFACE NEXGEN POLYETHYLENE CRUCIATE RETAINING ANTERIOR CONSTRAINED","SUP-ITM-10079051","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.45","42.9","","2548.09","2548.09","2548.09","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 1 2 20MM COMPONENT ARTICULAR SURFACE NEXGEN POLYETHYLENE CRUCIATE RETAINING ANTERIOR CONSTRAINED","SUP-ITM-10079051","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.45","42.9","","956.46","956.46","956.46","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 1 2 20MM COMPONENT ARTICULAR SURFACE NEXGEN POLYETHYLENE CRUCIATE RETAINING ANTERIOR CONSTRAINED","SUP-ITM-10079051","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","WELLPOINT [1015]","HB AMC WELLPOINT","1290.63","73.78","","2344.73","1619.47","2530.35","16","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 1 2 20MM COMPONENT ARTICULAR SURFACE NEXGEN POLYETHYLENE CRUCIATE RETAINING ANTERIOR CONSTRAINED","SUP-ITM-10079051","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","AETNA [1001]","HB AMC AETNA HMO","1221.01","69.8","","1523.63","988.41","4330.26","39","914.18","1429.53","percent of total billed charges",""
"KNEE IMPLANT 1 2 20MM COMPONENT ARTICULAR SURFACE NEXGEN POLYETHYLENE CRUCIATE RETAINING ANTERIOR CONSTRAINED","SUP-ITM-10079051","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","AETNA [1001]","HB AMC AETNA PPO","1406.44","80.4","","1670.25","1670.25","1670.25","1 through 10","914.18","1429.53","percent of total billed charges",""
"KNEE IMPLANT 1 2 20MM COMPONENT ARTICULAR SURFACE NEXGEN POLYETHYLENE CRUCIATE RETAINING ANTERIOR CONSTRAINED","SUP-ITM-10079051","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.18","52.26","","1113.10","1113.10","1113.10","1 through 10","914.18","1429.53","percent of total billed charges",""
"KNEE IMPLANT 1 2 20MM COMPONENT ARTICULAR SURFACE NEXGEN POLYETHYLENE CRUCIATE RETAINING ANTERIOR CONSTRAINED","SUP-ITM-10079051","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1429.53","81.72","","1738.90","1484.65","2716.94","38","914.18","1429.53","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1914.80","52.26","","1113.10","1113.10","1113.10","1 through 10","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2912.86","79.5","","1293.60","1148.53","1603.80","1 through 10","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1337.35","36.5","","1023.42","771.29","2068.67","33","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1403.30","38.3","","850.52","759.78","1211.25","66","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1571.85","42.9","","2548.09","2548.09","2548.09","1 through 10","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1571.85","42.9","","956.46","956.46","956.46","1 through 10","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","WELLPOINT [1015]","HB AMC WELLPOINT","2703.28","73.78","","2344.73","1619.47","2530.35","16","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3663.98","2747.98","AETNA [1001]","HB AMC AETNA HMO","2557.46","69.8","","1523.63","988.41","4330.26","39","1914.8","2994.2","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3663.98","2747.98","AETNA [1001]","HB AMC AETNA PPO","2945.84","80.4","","1670.25","1670.25","1670.25","1 through 10","1914.8","2994.2","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3663.98","2747.98","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1914.80","52.26","","1113.10","1113.10","1113.10","1 through 10","1914.8","2994.2","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3663.98","2747.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2994.20","81.72","","1738.90","1484.65","2716.94","38","1914.8","2994.2","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120486","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1914.80","52.26","","1113.10","1113.10","1113.10","1 through 10","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120486","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2912.86","79.5","","1293.60","1148.53","1603.80","1 through 10","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120486","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1337.35","36.5","","1023.42","771.29","2068.67","33","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120486","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1403.30","38.3","","850.52","759.78","1211.25","66","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120486","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1571.85","42.9","","2548.09","2548.09","2548.09","1 through 10","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120486","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1571.85","42.9","","956.46","956.46","956.46","1 through 10","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120486","CDM","C1776","HCPCS","0278","RC","","","","both","","","3663.98","2747.98","WELLPOINT [1015]","HB AMC WELLPOINT","2703.28","73.78","","2344.73","1619.47","2530.35","16","1135.83","2912.86","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3663.98","2747.98","AETNA [1001]","HB AMC AETNA HMO","2557.46","69.8","","1523.63","988.41","4330.26","39","1914.8","2994.2","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3663.98","2747.98","AETNA [1001]","HB AMC AETNA PPO","2945.84","80.4","","1670.25","1670.25","1670.25","1 through 10","1914.8","2994.2","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3663.98","2747.98","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1914.80","52.26","","1113.10","1113.10","1113.10","1 through 10","1914.8","2994.2","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3663.98","2747.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2994.20","81.72","","1738.90","1484.65","2716.94","38","1914.8","2994.2","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","873.86","52.26","","1113.10","1113.10","1113.10","1 through 10","518.36","1329.34","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1329.34","79.5","","1293.60","1148.53","1603.80","1 through 10","518.36","1329.34","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","610.33","36.5","","1023.42","771.29","2068.67","33","518.36","1329.34","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","640.43","38.3","","850.52","759.78","1211.25","66","518.36","1329.34","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","717.34","42.9","","2548.09","2548.09","2548.09","1 through 10","518.36","1329.34","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","717.34","42.9","","956.46","956.46","956.46","1 through 10","518.36","1329.34","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","WELLPOINT [1015]","HB AMC WELLPOINT","1233.70","73.78","","2344.73","1619.47","2530.35","16","518.36","1329.34","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1672.13","1254.10","AETNA [1001]","HB AMC AETNA HMO","1167.15","69.8","","1523.63","988.41","4330.26","39","873.86","1366.46","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1672.13","1254.10","AETNA [1001]","HB AMC AETNA PPO","1344.39","80.4","","1670.25","1670.25","1670.25","1 through 10","873.86","1366.46","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1672.13","1254.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","873.86","52.26","","1113.10","1113.10","1113.10","1 through 10","873.86","1366.46","percent of total billed charges",""
"KNEE IMPLANT 10X35MM PATELLA NEXGEN UHMWPE POROUS TRABECULAR METAL BACK","SUP-ITM-10042577","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1672.13","1254.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1366.46","81.72","","1738.90","1484.65","2716.94","38","873.86","1366.46","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3070.28","52.26","","1113.10","1113.10","1113.10","1 through 10","1821.25","4670.63","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4670.63","79.5","","1293.60","1148.53","1603.80","1 through 10","1821.25","4670.63","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2144.38","36.5","","1023.42","771.29","2068.67","33","1821.25","4670.63","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2250.13","38.3","","850.52","759.78","1211.25","66","1821.25","4670.63","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2520.38","42.9","","2548.09","2548.09","2548.09","1 through 10","1821.25","4670.63","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2520.38","42.9","","956.46","956.46","956.46","1 through 10","1821.25","4670.63","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","WELLPOINT [1015]","HB AMC WELLPOINT","4334.58","73.78","","2344.73","1619.47","2530.35","16","1821.25","4670.63","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5875.00","4406.25","AETNA [1001]","HB AMC AETNA HMO","4100.75","69.8","","1523.63","988.41","4330.26","39","3070.28","4801.05","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5875.00","4406.25","AETNA [1001]","HB AMC AETNA PPO","4723.50","80.4","","1670.25","1670.25","1670.25","1 through 10","3070.28","4801.05","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5875.00","4406.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3070.28","52.26","","1113.10","1113.10","1113.10","1 through 10","3070.28","4801.05","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5875.00","4406.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4801.05","81.72","","1738.90","1484.65","2716.94","38","3070.28","4801.05","percent of total billed charges",""
"KNEE IMPLANT 13CM FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036220","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3581.84","52.26","","1113.10","1113.10","1113.10","1 through 10","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 13CM FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036220","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5448.83","79.5","","1293.60","1148.53","1603.80","1 through 10","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 13CM FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036220","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2501.67","36.5","","1023.42","771.29","2068.67","33","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 13CM FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036220","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2625.04","38.3","","850.52","759.78","1211.25","66","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 13CM FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036220","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2940.31","42.9","","2548.09","2548.09","2548.09","1 through 10","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 13CM FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036220","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2940.31","42.9","","956.46","956.46","956.46","1 through 10","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 13CM FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036220","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","WELLPOINT [1015]","HB AMC WELLPOINT","5056.79","73.78","","2344.73","1619.47","2530.35","16","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 13CM FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036220","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","AETNA [1001]","HB AMC AETNA HMO","4784.01","69.8","","1523.63","988.41","4330.26","39","3581.84","5600.99","percent of total billed charges",""
"KNEE IMPLANT 13CM FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036220","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","AETNA [1001]","HB AMC AETNA PPO","5510.52","80.4","","1670.25","1670.25","1670.25","1 through 10","3581.84","5600.99","percent of total billed charges",""
"KNEE IMPLANT 13CM FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036220","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3581.84","52.26","","1113.10","1113.10","1113.10","1 through 10","3581.84","5600.99","percent of total billed charges",""
"KNEE IMPLANT 13CM FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036220","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5600.99","81.72","","1738.90","1484.65","2716.94","38","3581.84","5600.99","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE SEGMENTAL SIZE B","SUP-ITM-10082322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2927.47","79.5","","800.18","480.96","1887.97","195","1141.53","2927.47","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE SEGMENTAL SIZE B","SUP-ITM-10082322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1962.69","53.3","","813.12","216.42","1444.50","81","1141.53","2927.47","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE SEGMENTAL SIZE B","SUP-ITM-10082322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1141.53","31","","432.60","432.60","432.60","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE SEGMENTAL SIZE B","SUP-ITM-10082322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1344.06","36.5","","148.37","54.89","631.39","94","1141.53","2927.47","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE SEGMENTAL SIZE B","SUP-ITM-10082322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1410.34","38.3","","279.30","91.72","1116.77","266","1141.53","2927.47","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE SEGMENTAL SIZE B","SUP-ITM-10082322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1579.73","42.9","","731.00","63.70","731.00","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE SEGMENTAL SIZE B","SUP-ITM-10082322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1579.73","42.9","","384.74","384.74","384.74","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE SEGMENTAL SIZE B","SUP-ITM-10082322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","WELLPOINT [1015]","HB AMC WELLPOINT","2716.84","73.78","","286.63","119.22","1107.45","105","1141.53","2927.47","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE SEGMENTAL SIZE B","SUP-ITM-10082322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","AETNA [1001]","HB AMC AETNA HMO","2570.28","69.8","","675.31","184.75","1721.50","286","1924.4","3009.22","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE SEGMENTAL SIZE B","SUP-ITM-10082322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","AETNA [1001]","HB AMC AETNA PPO","2960.61","80.4","","1261.44","103.12","1514.10","21","1924.4","3009.22","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE SEGMENTAL SIZE B","SUP-ITM-10082322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2960.61","80.4","","1365.00","1365.00","1365.00","1 through 10","1924.4","3009.22","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE SEGMENTAL SIZE B","SUP-ITM-10082322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3009.22","81.72","","5157.68","5157.68","5157.68","1 through 10","1924.4","3009.22","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE SEGMENTAL SIZE B","SUP-ITM-10082322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3009.22","81.72","","431.26","71.26","1459.57","88","1924.4","3009.22","percent of total billed charges",""
"KNEE IMPLANT 2.0X2.5MM COMPONENT FEMORAL HEMICAP COCR TROCHLEAR ARTICULAR OFFSET P202-2025-W","SUP-ITM-10042546","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5226.00","52.26","","1113.10","1113.10","1113.10","1 through 10","3100","7950","percent of total billed charges",""
"KNEE IMPLANT 2.0X2.5MM COMPONENT FEMORAL HEMICAP COCR TROCHLEAR ARTICULAR OFFSET P202-2025-W","SUP-ITM-10042546","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7950.00","79.5","","1293.60","1148.53","1603.80","1 through 10","3100","7950","percent of total billed charges",""
"KNEE IMPLANT 2.0X2.5MM COMPONENT FEMORAL HEMICAP COCR TROCHLEAR ARTICULAR OFFSET P202-2025-W","SUP-ITM-10042546","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3650.00","36.5","","1023.42","771.29","2068.67","33","3100","7950","percent of total billed charges",""
"KNEE IMPLANT 2.0X2.5MM COMPONENT FEMORAL HEMICAP COCR TROCHLEAR ARTICULAR OFFSET P202-2025-W","SUP-ITM-10042546","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3830.00","38.3","","850.52","759.78","1211.25","66","3100","7950","percent of total billed charges",""
"KNEE IMPLANT 2.0X2.5MM COMPONENT FEMORAL HEMICAP COCR TROCHLEAR ARTICULAR OFFSET P202-2025-W","SUP-ITM-10042546","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4290.00","42.9","","2548.09","2548.09","2548.09","1 through 10","3100","7950","percent of total billed charges",""
"KNEE IMPLANT 2.0X2.5MM COMPONENT FEMORAL HEMICAP COCR TROCHLEAR ARTICULAR OFFSET P202-2025-W","SUP-ITM-10042546","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4290.00","42.9","","956.46","956.46","956.46","1 through 10","3100","7950","percent of total billed charges",""
"KNEE IMPLANT 2.0X2.5MM COMPONENT FEMORAL HEMICAP COCR TROCHLEAR ARTICULAR OFFSET P202-2025-W","SUP-ITM-10042546","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB AMC WELLPOINT","7378.00","73.78","","2344.73","1619.47","2530.35","16","3100","7950","percent of total billed charges",""
"KNEE IMPLANT 2.0X2.5MM COMPONENT FEMORAL HEMICAP COCR TROCHLEAR ARTICULAR OFFSET P202-2025-W","SUP-ITM-10042546","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA HMO","6980.00","69.8","","1523.63","988.41","4330.26","39","5226","8172","percent of total billed charges",""
"KNEE IMPLANT 2.0X2.5MM COMPONENT FEMORAL HEMICAP COCR TROCHLEAR ARTICULAR OFFSET P202-2025-W","SUP-ITM-10042546","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA PPO","8040.00","80.4","","1670.25","1670.25","1670.25","1 through 10","5226","8172","percent of total billed charges",""
"KNEE IMPLANT 2.0X2.5MM COMPONENT FEMORAL HEMICAP COCR TROCHLEAR ARTICULAR OFFSET P202-2025-W","SUP-ITM-10042546","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5226.00","52.26","","1113.10","1113.10","1113.10","1 through 10","5226","8172","percent of total billed charges",""
"KNEE IMPLANT 2.0X2.5MM COMPONENT FEMORAL HEMICAP COCR TROCHLEAR ARTICULAR OFFSET P202-2025-W","SUP-ITM-10042546","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8172.00","81.72","","1738.90","1484.65","2716.94","38","5226","8172","percent of total billed charges",""
"KNEE IMPLANT 3 4 23MM SIZE EF COMPONENT ARTICULAR SURFACE NEXGEN LPS FLEX FIXED POLYETHYLENE","SUP-ITM-10079018","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.18","52.26","","1113.10","1113.10","1113.10","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 3 4 23MM SIZE EF COMPONENT ARTICULAR SURFACE NEXGEN LPS FLEX FIXED POLYETHYLENE","SUP-ITM-10079018","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1390.69","79.5","","1293.60","1148.53","1603.80","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 3 4 23MM SIZE EF COMPONENT ARTICULAR SURFACE NEXGEN LPS FLEX FIXED POLYETHYLENE","SUP-ITM-10079018","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.49","36.5","","1023.42","771.29","2068.67","33","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 3 4 23MM SIZE EF COMPONENT ARTICULAR SURFACE NEXGEN LPS FLEX FIXED POLYETHYLENE","SUP-ITM-10079018","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","669.98","38.3","","850.52","759.78","1211.25","66","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 3 4 23MM SIZE EF COMPONENT ARTICULAR SURFACE NEXGEN LPS FLEX FIXED POLYETHYLENE","SUP-ITM-10079018","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.45","42.9","","2548.09","2548.09","2548.09","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 3 4 23MM SIZE EF COMPONENT ARTICULAR SURFACE NEXGEN LPS FLEX FIXED POLYETHYLENE","SUP-ITM-10079018","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.45","42.9","","956.46","956.46","956.46","1 through 10","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 3 4 23MM SIZE EF COMPONENT ARTICULAR SURFACE NEXGEN LPS FLEX FIXED POLYETHYLENE","SUP-ITM-10079018","CDM","C1776","HCPCS","0278","RC","","","","both","","","1749.30","1311.97","WELLPOINT [1015]","HB AMC WELLPOINT","1290.63","73.78","","2344.73","1619.47","2530.35","16","542.28","1390.69","percent of total billed charges",""
"KNEE IMPLANT 3 4 23MM SIZE EF COMPONENT ARTICULAR SURFACE NEXGEN LPS FLEX FIXED POLYETHYLENE","SUP-ITM-10079018","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","AETNA [1001]","HB AMC AETNA HMO","1221.01","69.8","","1523.63","988.41","4330.26","39","914.18","1429.53","percent of total billed charges",""
"KNEE IMPLANT 3 4 23MM SIZE EF COMPONENT ARTICULAR SURFACE NEXGEN LPS FLEX FIXED POLYETHYLENE","SUP-ITM-10079018","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","AETNA [1001]","HB AMC AETNA PPO","1406.44","80.4","","1670.25","1670.25","1670.25","1 through 10","914.18","1429.53","percent of total billed charges",""
"KNEE IMPLANT 3 4 23MM SIZE EF COMPONENT ARTICULAR SURFACE NEXGEN LPS FLEX FIXED POLYETHYLENE","SUP-ITM-10079018","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.18","52.26","","1113.10","1113.10","1113.10","1 through 10","914.18","1429.53","percent of total billed charges",""
"KNEE IMPLANT 3 4 23MM SIZE EF COMPONENT ARTICULAR SURFACE NEXGEN LPS FLEX FIXED POLYETHYLENE","SUP-ITM-10079018","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1749.30","1311.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1429.53","81.72","","1738.90","1484.65","2716.94","38","914.18","1429.53","percent of total billed charges",""
"KNEE IMPLANT 3.0CM FEMORAL RESURFACING ELLIPTICAL SEGMENTAL OSS RIGHT","SUP-ITM-10122085","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8178.69","52.26","","1113.10","1113.10","1113.10","1 through 10","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT 3.0CM FEMORAL RESURFACING ELLIPTICAL SEGMENTAL OSS RIGHT","SUP-ITM-10122085","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12441.75","79.5","","1293.60","1148.53","1603.80","1 through 10","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT 3.0CM FEMORAL RESURFACING ELLIPTICAL SEGMENTAL OSS RIGHT","SUP-ITM-10122085","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5712.25","36.5","","1023.42","771.29","2068.67","33","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT 3.0CM FEMORAL RESURFACING ELLIPTICAL SEGMENTAL OSS RIGHT","SUP-ITM-10122085","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5993.95","38.3","","850.52","759.78","1211.25","66","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT 3.0CM FEMORAL RESURFACING ELLIPTICAL SEGMENTAL OSS RIGHT","SUP-ITM-10122085","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6713.85","42.9","","2548.09","2548.09","2548.09","1 through 10","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT 3.0CM FEMORAL RESURFACING ELLIPTICAL SEGMENTAL OSS RIGHT","SUP-ITM-10122085","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6713.85","42.9","","956.46","956.46","956.46","1 through 10","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT 3.0CM FEMORAL RESURFACING ELLIPTICAL SEGMENTAL OSS RIGHT","SUP-ITM-10122085","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","WELLPOINT [1015]","HB AMC WELLPOINT","11546.57","73.78","","2344.73","1619.47","2530.35","16","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT 3.0CM FEMORAL RESURFACING ELLIPTICAL SEGMENTAL OSS RIGHT","SUP-ITM-10122085","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","AETNA [1001]","HB AMC AETNA HMO","10923.70","69.8","","1523.63","988.41","4330.26","39","8178.69","12789.18","percent of total billed charges",""
"KNEE IMPLANT 3.0CM FEMORAL RESURFACING ELLIPTICAL SEGMENTAL OSS RIGHT","SUP-ITM-10122085","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","AETNA [1001]","HB AMC AETNA PPO","12582.60","80.4","","1670.25","1670.25","1670.25","1 through 10","8178.69","12789.18","percent of total billed charges",""
"KNEE IMPLANT 3.0CM FEMORAL RESURFACING ELLIPTICAL SEGMENTAL OSS RIGHT","SUP-ITM-10122085","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8178.69","52.26","","1113.10","1113.10","1113.10","1 through 10","8178.69","12789.18","percent of total billed charges",""
"KNEE IMPLANT 3.0CM FEMORAL RESURFACING ELLIPTICAL SEGMENTAL OSS RIGHT","SUP-ITM-10122085","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12789.18","81.72","","1738.90","1484.65","2716.94","38","8178.69","12789.18","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","512.15","52.26","","1113.10","1113.10","1113.10","1 through 10","303.8","779.1","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","779.10","79.5","","1293.60","1148.53","1603.80","1 through 10","303.8","779.1","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","357.70","36.5","","1023.42","771.29","2068.67","33","303.8","779.1","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","375.34","38.3","","850.52","759.78","1211.25","66","303.8","779.1","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.42","42.9","","2548.09","2548.09","2548.09","1 through 10","303.8","779.1","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.42","42.9","","956.46","956.46","956.46","1 through 10","303.8","779.1","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","980.00","735.00","WELLPOINT [1015]","HB AMC WELLPOINT","723.04","73.78","","2344.73","1619.47","2530.35","16","303.8","779.1","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","AETNA [1001]","HB AMC AETNA HMO","684.04","69.8","","1523.63","988.41","4330.26","39","512.15","800.86","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","AETNA [1001]","HB AMC AETNA PPO","787.92","80.4","","1670.25","1670.25","1670.25","1 through 10","512.15","800.86","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","512.15","52.26","","1113.10","1113.10","1113.10","1 through 10","512.15","800.86","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","800.86","81.72","","1738.90","1484.65","2716.94","38","512.15","800.86","percent of total billed charges",""
"KNEE IMPLANT 38MM COMPONENT FEMORAL ORTHOPEDIC SEGMENTAL SYSTEM OFFSET PROXIMALIMAL","SUP-ITM-10159064","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8587.62","52.26","","1113.10","1113.10","1113.10","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 38MM COMPONENT FEMORAL ORTHOPEDIC SEGMENTAL SYSTEM OFFSET PROXIMALIMAL","SUP-ITM-10159064","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13063.84","79.5","","1293.60","1148.53","1603.80","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 38MM COMPONENT FEMORAL ORTHOPEDIC SEGMENTAL SYSTEM OFFSET PROXIMALIMAL","SUP-ITM-10159064","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5997.86","36.5","","1023.42","771.29","2068.67","33","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 38MM COMPONENT FEMORAL ORTHOPEDIC SEGMENTAL SYSTEM OFFSET PROXIMALIMAL","SUP-ITM-10159064","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6293.65","38.3","","850.52","759.78","1211.25","66","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 38MM COMPONENT FEMORAL ORTHOPEDIC SEGMENTAL SYSTEM OFFSET PROXIMALIMAL","SUP-ITM-10159064","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7049.54","42.9","","2548.09","2548.09","2548.09","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 38MM COMPONENT FEMORAL ORTHOPEDIC SEGMENTAL SYSTEM OFFSET PROXIMALIMAL","SUP-ITM-10159064","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7049.54","42.9","","956.46","956.46","956.46","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 38MM COMPONENT FEMORAL ORTHOPEDIC SEGMENTAL SYSTEM OFFSET PROXIMALIMAL","SUP-ITM-10159064","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","WELLPOINT [1015]","HB AMC WELLPOINT","12123.90","73.78","","2344.73","1619.47","2530.35","16","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 38MM COMPONENT FEMORAL ORTHOPEDIC SEGMENTAL SYSTEM OFFSET PROXIMALIMAL","SUP-ITM-10159064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","AETNA [1001]","HB AMC AETNA HMO","11469.89","69.8","","1523.63","988.41","4330.26","39","8587.62","13428.64","percent of total billed charges",""
"KNEE IMPLANT 38MM COMPONENT FEMORAL ORTHOPEDIC SEGMENTAL SYSTEM OFFSET PROXIMALIMAL","SUP-ITM-10159064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","AETNA [1001]","HB AMC AETNA PPO","13211.73","80.4","","1670.25","1670.25","1670.25","1 through 10","8587.62","13428.64","percent of total billed charges",""
"KNEE IMPLANT 38MM COMPONENT FEMORAL ORTHOPEDIC SEGMENTAL SYSTEM OFFSET PROXIMALIMAL","SUP-ITM-10159064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8587.62","52.26","","1113.10","1113.10","1113.10","1 through 10","8587.62","13428.64","percent of total billed charges",""
"KNEE IMPLANT 38MM COMPONENT FEMORAL ORTHOPEDIC SEGMENTAL SYSTEM OFFSET PROXIMALIMAL","SUP-ITM-10159064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13428.64","81.72","","1738.90","1484.65","2716.94","38","8587.62","13428.64","percent of total billed charges",""
"KNEE IMPLANT 41MM PATELLA ATTUNE POLYETHYLENE AOX ANTIOXIDANT MEDIALIZED CEMENTED","SUP-ITM-10285199","CDM","C1776","HCPCS","0278","RC","","","","both","","","2585.98","1939.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1351.43","52.26","","1113.10","1113.10","1113.10","1 through 10","801.65","2055.85","percent of total billed charges",""
"KNEE IMPLANT 41MM PATELLA ATTUNE POLYETHYLENE AOX ANTIOXIDANT MEDIALIZED CEMENTED","SUP-ITM-10285199","CDM","C1776","HCPCS","0278","RC","","","","both","","","2585.98","1939.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2055.85","79.5","","1293.60","1148.53","1603.80","1 through 10","801.65","2055.85","percent of total billed charges",""
"KNEE IMPLANT 41MM PATELLA ATTUNE POLYETHYLENE AOX ANTIOXIDANT MEDIALIZED CEMENTED","SUP-ITM-10285199","CDM","C1776","HCPCS","0278","RC","","","","both","","","2585.98","1939.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","943.88","36.5","","1023.42","771.29","2068.67","33","801.65","2055.85","percent of total billed charges",""
"KNEE IMPLANT 41MM PATELLA ATTUNE POLYETHYLENE AOX ANTIOXIDANT MEDIALIZED CEMENTED","SUP-ITM-10285199","CDM","C1776","HCPCS","0278","RC","","","","both","","","2585.98","1939.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","990.43","38.3","","850.52","759.78","1211.25","66","801.65","2055.85","percent of total billed charges",""
"KNEE IMPLANT 41MM PATELLA ATTUNE POLYETHYLENE AOX ANTIOXIDANT MEDIALIZED CEMENTED","SUP-ITM-10285199","CDM","C1776","HCPCS","0278","RC","","","","both","","","2585.98","1939.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1109.39","42.9","","2548.09","2548.09","2548.09","1 through 10","801.65","2055.85","percent of total billed charges",""
"KNEE IMPLANT 41MM PATELLA ATTUNE POLYETHYLENE AOX ANTIOXIDANT MEDIALIZED CEMENTED","SUP-ITM-10285199","CDM","C1776","HCPCS","0278","RC","","","","both","","","2585.98","1939.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1109.39","42.9","","956.46","956.46","956.46","1 through 10","801.65","2055.85","percent of total billed charges",""
"KNEE IMPLANT 41MM PATELLA ATTUNE POLYETHYLENE AOX ANTIOXIDANT MEDIALIZED CEMENTED","SUP-ITM-10285199","CDM","C1776","HCPCS","0278","RC","","","","both","","","2585.98","1939.48","WELLPOINT [1015]","HB AMC WELLPOINT","1907.94","73.78","","2344.73","1619.47","2530.35","16","801.65","2055.85","percent of total billed charges",""
"KNEE IMPLANT 41MM PATELLA ATTUNE POLYETHYLENE AOX ANTIOXIDANT MEDIALIZED CEMENTED","SUP-ITM-10285199","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2585.98","1939.48","AETNA [1001]","HB AMC AETNA HMO","1805.01","69.8","","1523.63","988.41","4330.26","39","1351.43","2113.26","percent of total billed charges",""
"KNEE IMPLANT 41MM PATELLA ATTUNE POLYETHYLENE AOX ANTIOXIDANT MEDIALIZED CEMENTED","SUP-ITM-10285199","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2585.98","1939.48","AETNA [1001]","HB AMC AETNA PPO","2079.13","80.4","","1670.25","1670.25","1670.25","1 through 10","1351.43","2113.26","percent of total billed charges",""
"KNEE IMPLANT 41MM PATELLA ATTUNE POLYETHYLENE AOX ANTIOXIDANT MEDIALIZED CEMENTED","SUP-ITM-10285199","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2585.98","1939.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1351.43","52.26","","1113.10","1113.10","1113.10","1 through 10","1351.43","2113.26","percent of total billed charges",""
"KNEE IMPLANT 41MM PATELLA ATTUNE POLYETHYLENE AOX ANTIOXIDANT MEDIALIZED CEMENTED","SUP-ITM-10285199","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2585.98","1939.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2113.26","81.72","","1738.90","1484.65","2716.94","38","1351.43","2113.26","percent of total billed charges",""
"KNEE IMPLANT 43CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10122065","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5963.33","52.26","","1113.10","1113.10","1113.10","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE IMPLANT 43CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10122065","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9071.65","79.5","","1293.60","1148.53","1603.80","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE IMPLANT 43CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10122065","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4164.97","36.5","","1023.42","771.29","2068.67","33","3537.37","9071.65","percent of total billed charges",""
"KNEE IMPLANT 43CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10122065","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4370.37","38.3","","850.52","759.78","1211.25","66","3537.37","9071.65","percent of total billed charges",""
"KNEE IMPLANT 43CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10122065","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4895.27","42.9","","2548.09","2548.09","2548.09","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE IMPLANT 43CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10122065","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4895.27","42.9","","956.46","956.46","956.46","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE IMPLANT 43CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10122065","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","WELLPOINT [1015]","HB AMC WELLPOINT","8418.95","73.78","","2344.73","1619.47","2530.35","16","3537.37","9071.65","percent of total billed charges",""
"KNEE IMPLANT 43CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10122065","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","AETNA [1001]","HB AMC AETNA HMO","7964.79","69.8","","1523.63","988.41","4330.26","39","5963.33","9324.97","percent of total billed charges",""
"KNEE IMPLANT 43CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10122065","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","AETNA [1001]","HB AMC AETNA PPO","9174.35","80.4","","1670.25","1670.25","1670.25","1 through 10","5963.33","9324.97","percent of total billed charges",""
"KNEE IMPLANT 43CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10122065","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5963.33","52.26","","1113.10","1113.10","1113.10","1 through 10","5963.33","9324.97","percent of total billed charges",""
"KNEE IMPLANT 43CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10122065","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9324.97","81.72","","1738.90","1484.65","2716.94","38","5963.33","9324.97","percent of total billed charges",""
"KNEE IMPLANT 5.0CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10118238","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5448.83","79.5","","800.18","480.96","1887.97","195","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 5.0CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10118238","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3653.12","53.3","","813.12","216.42","1444.50","81","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 5.0CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10118238","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2124.70","31","","432.60","432.60","432.60","1 through 10","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 5.0CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10118238","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2501.67","36.5","","148.37","54.89","631.39","94","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 5.0CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10118238","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2625.04","38.3","","279.30","91.72","1116.77","266","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 5.0CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10118238","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2940.31","42.9","","731.00","63.70","731.00","1 through 10","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 5.0CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10118238","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2940.31","42.9","","384.74","384.74","384.74","1 through 10","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 5.0CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10118238","CDM","C1713","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","WELLPOINT [1015]","HB AMC WELLPOINT","5056.79","73.78","","286.63","119.22","1107.45","105","2124.7","5448.83","percent of total billed charges",""
"KNEE IMPLANT 5.0CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10118238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","AETNA [1001]","HB AMC AETNA HMO","4784.01","69.8","","675.31","184.75","1721.50","286","3581.84","5600.99","percent of total billed charges",""
"KNEE IMPLANT 5.0CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10118238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","AETNA [1001]","HB AMC AETNA PPO","5510.52","80.4","","1261.44","103.12","1514.10","21","3581.84","5600.99","percent of total billed charges",""
"KNEE IMPLANT 5.0CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10118238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5510.52","80.4","","1365.00","1365.00","1365.00","1 through 10","3581.84","5600.99","percent of total billed charges",""
"KNEE IMPLANT 5.0CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10118238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5600.99","81.72","","5157.68","5157.68","5157.68","1 through 10","3581.84","5600.99","percent of total billed charges",""
"KNEE IMPLANT 5.0CM COMPONENT FEMORAL OSS DIAPHYSEAL SEGMENT","SUP-ITM-10118238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5600.99","81.72","","431.26","71.26","1459.57","88","3581.84","5600.99","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","1023.42","771.29","2068.67","33","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","850.52","759.78","1211.25","66","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","2548.09","2548.09","2548.09","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","956.46","956.46","956.46","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","2344.73","1619.47","2530.35","16","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA HMO","2687.30","69.8","","1523.63","988.41","4330.26","39","2012.01","3146.22","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA PPO","3095.40","80.4","","1670.25","1670.25","1670.25","1 through 10","2012.01","3146.22","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","2012.01","3146.22","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","1738.90","1484.65","2716.94","38","2012.01","3146.22","percent of total billed charges",""
"KNEE IMPLANT 72.5MM 360DEG COMPONENT FEMORAL VANGUARD SUPER STABILIZED RIGHT","SUP-ITM-10117742","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3100.32","52.26","","1113.10","1113.10","1113.10","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE IMPLANT 72.5MM 360DEG COMPONENT FEMORAL VANGUARD SUPER STABILIZED RIGHT","SUP-ITM-10117742","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4716.34","79.5","","1293.60","1148.53","1603.80","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE IMPLANT 72.5MM 360DEG COMPONENT FEMORAL VANGUARD SUPER STABILIZED RIGHT","SUP-ITM-10117742","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2165.36","36.5","","1023.42","771.29","2068.67","33","1839.08","4716.34","percent of total billed charges",""
"KNEE IMPLANT 72.5MM 360DEG COMPONENT FEMORAL VANGUARD SUPER STABILIZED RIGHT","SUP-ITM-10117742","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2272.15","38.3","","850.52","759.78","1211.25","66","1839.08","4716.34","percent of total billed charges",""
"KNEE IMPLANT 72.5MM 360DEG COMPONENT FEMORAL VANGUARD SUPER STABILIZED RIGHT","SUP-ITM-10117742","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2545.04","42.9","","2548.09","2548.09","2548.09","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE IMPLANT 72.5MM 360DEG COMPONENT FEMORAL VANGUARD SUPER STABILIZED RIGHT","SUP-ITM-10117742","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2545.04","42.9","","956.46","956.46","956.46","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE IMPLANT 72.5MM 360DEG COMPONENT FEMORAL VANGUARD SUPER STABILIZED RIGHT","SUP-ITM-10117742","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","WELLPOINT [1015]","HB AMC WELLPOINT","4377.00","73.78","","2344.73","1619.47","2530.35","16","1839.08","4716.34","percent of total billed charges",""
"KNEE IMPLANT 72.5MM 360DEG COMPONENT FEMORAL VANGUARD SUPER STABILIZED RIGHT","SUP-ITM-10117742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","AETNA [1001]","HB AMC AETNA HMO","4140.89","69.8","","1523.63","988.41","4330.26","39","3100.32","4848.04","percent of total billed charges",""
"KNEE IMPLANT 72.5MM 360DEG COMPONENT FEMORAL VANGUARD SUPER STABILIZED RIGHT","SUP-ITM-10117742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","AETNA [1001]","HB AMC AETNA PPO","4769.73","80.4","","1670.25","1670.25","1670.25","1 through 10","3100.32","4848.04","percent of total billed charges",""
"KNEE IMPLANT 72.5MM 360DEG COMPONENT FEMORAL VANGUARD SUPER STABILIZED RIGHT","SUP-ITM-10117742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3100.32","52.26","","1113.10","1113.10","1113.10","1 through 10","3100.32","4848.04","percent of total billed charges",""
"KNEE IMPLANT 72.5MM 360DEG COMPONENT FEMORAL VANGUARD SUPER STABILIZED RIGHT","SUP-ITM-10117742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4848.04","81.72","","1738.90","1484.65","2716.94","38","3100.32","4848.04","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL OSS RESURFACING SS ELLIPTICAL REVISION RIGHT","SUP-ITM-10121973","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8587.62","52.26","","1113.10","1113.10","1113.10","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL OSS RESURFACING SS ELLIPTICAL REVISION RIGHT","SUP-ITM-10121973","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13063.84","79.5","","1293.60","1148.53","1603.80","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL OSS RESURFACING SS ELLIPTICAL REVISION RIGHT","SUP-ITM-10121973","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5997.86","36.5","","1023.42","771.29","2068.67","33","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL OSS RESURFACING SS ELLIPTICAL REVISION RIGHT","SUP-ITM-10121973","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6293.65","38.3","","850.52","759.78","1211.25","66","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL OSS RESURFACING SS ELLIPTICAL REVISION RIGHT","SUP-ITM-10121973","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7049.54","42.9","","2548.09","2548.09","2548.09","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL OSS RESURFACING SS ELLIPTICAL REVISION RIGHT","SUP-ITM-10121973","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7049.54","42.9","","956.46","956.46","956.46","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL OSS RESURFACING SS ELLIPTICAL REVISION RIGHT","SUP-ITM-10121973","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","WELLPOINT [1015]","HB AMC WELLPOINT","12123.90","73.78","","2344.73","1619.47","2530.35","16","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL OSS RESURFACING SS ELLIPTICAL REVISION RIGHT","SUP-ITM-10121973","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","AETNA [1001]","HB AMC AETNA HMO","11469.89","69.8","","1523.63","988.41","4330.26","39","8587.62","13428.64","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL OSS RESURFACING SS ELLIPTICAL REVISION RIGHT","SUP-ITM-10121973","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","AETNA [1001]","HB AMC AETNA PPO","13211.73","80.4","","1670.25","1670.25","1670.25","1 through 10","8587.62","13428.64","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL OSS RESURFACING SS ELLIPTICAL REVISION RIGHT","SUP-ITM-10121973","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8587.62","52.26","","1113.10","1113.10","1113.10","1 through 10","8587.62","13428.64","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL OSS RESURFACING SS ELLIPTICAL REVISION RIGHT","SUP-ITM-10121973","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13428.64","81.72","","1738.90","1484.65","2716.94","38","8587.62","13428.64","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL VANGUARD SEGMENTAL MODULAR RIGHT","SUP-ITM-10118239","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8587.62","52.26","","1113.10","1113.10","1113.10","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL VANGUARD SEGMENTAL MODULAR RIGHT","SUP-ITM-10118239","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13063.84","79.5","","1293.60","1148.53","1603.80","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL VANGUARD SEGMENTAL MODULAR RIGHT","SUP-ITM-10118239","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5997.86","36.5","","1023.42","771.29","2068.67","33","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL VANGUARD SEGMENTAL MODULAR RIGHT","SUP-ITM-10118239","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6293.65","38.3","","850.52","759.78","1211.25","66","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL VANGUARD SEGMENTAL MODULAR RIGHT","SUP-ITM-10118239","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7049.54","42.9","","2548.09","2548.09","2548.09","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL VANGUARD SEGMENTAL MODULAR RIGHT","SUP-ITM-10118239","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7049.54","42.9","","956.46","956.46","956.46","1 through 10","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL VANGUARD SEGMENTAL MODULAR RIGHT","SUP-ITM-10118239","CDM","C1776","HCPCS","0278","RC","","","","both","","","16432.50","12324.37","WELLPOINT [1015]","HB AMC WELLPOINT","12123.90","73.78","","2344.73","1619.47","2530.35","16","5094.08","13063.84","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL VANGUARD SEGMENTAL MODULAR RIGHT","SUP-ITM-10118239","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","AETNA [1001]","HB AMC AETNA HMO","11469.89","69.8","","1523.63","988.41","4330.26","39","8587.62","13428.64","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL VANGUARD SEGMENTAL MODULAR RIGHT","SUP-ITM-10118239","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","AETNA [1001]","HB AMC AETNA PPO","13211.73","80.4","","1670.25","1670.25","1670.25","1 through 10","8587.62","13428.64","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL VANGUARD SEGMENTAL MODULAR RIGHT","SUP-ITM-10118239","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8587.62","52.26","","1113.10","1113.10","1113.10","1 through 10","8587.62","13428.64","percent of total billed charges",""
"KNEE IMPLANT 7CM COMPONENT FEMORAL VANGUARD SEGMENTAL MODULAR RIGHT","SUP-ITM-10118239","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16432.50","12324.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13428.64","81.72","","1738.90","1484.65","2716.94","38","8587.62","13428.64","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","15597.50","11698.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8151.25","52.26","","1113.10","1113.10","1113.10","1 through 10","4835.23","12400.01","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","15597.50","11698.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12400.01","79.5","","1293.60","1148.53","1603.80","1 through 10","4835.23","12400.01","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","15597.50","11698.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5693.09","36.5","","1023.42","771.29","2068.67","33","4835.23","12400.01","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","15597.50","11698.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5973.84","38.3","","850.52","759.78","1211.25","66","4835.23","12400.01","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","15597.50","11698.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6691.33","42.9","","2548.09","2548.09","2548.09","1 through 10","4835.23","12400.01","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","15597.50","11698.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6691.33","42.9","","956.46","956.46","956.46","1 through 10","4835.23","12400.01","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","15597.50","11698.12","WELLPOINT [1015]","HB AMC WELLPOINT","11507.84","73.78","","2344.73","1619.47","2530.35","16","4835.23","12400.01","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15597.50","11698.12","AETNA [1001]","HB AMC AETNA HMO","10887.06","69.8","","1523.63","988.41","4330.26","39","8151.25","12746.28","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15597.50","11698.12","AETNA [1001]","HB AMC AETNA PPO","12540.39","80.4","","1670.25","1670.25","1670.25","1 through 10","8151.25","12746.28","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15597.50","11698.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8151.25","52.26","","1113.10","1113.10","1113.10","1 through 10","8151.25","12746.28","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15597.50","11698.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12746.28","81.72","","1738.90","1484.65","2716.94","38","8151.25","12746.28","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","548.73","52.26","","1113.10","1113.10","1113.10","1 through 10","325.5","834.75","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","834.75","79.5","","1293.60","1148.53","1603.80","1 through 10","325.5","834.75","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","1023.42","771.29","2068.67","33","325.5","834.75","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","850.52","759.78","1211.25","66","325.5","834.75","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","2548.09","2548.09","2548.09","1 through 10","325.5","834.75","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","956.46","956.46","956.46","1 through 10","325.5","834.75","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB AMC WELLPOINT","774.69","73.78","","2344.73","1619.47","2530.35","16","325.5","834.75","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA HMO","732.90","69.8","","1523.63","988.41","4330.26","39","548.73","858.06","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA PPO","844.20","80.4","","1670.25","1670.25","1670.25","1 through 10","548.73","858.06","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","548.73","52.26","","1113.10","1113.10","1113.10","1 through 10","548.73","858.06","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","858.06","81.72","","1738.90","1484.65","2716.94","38","548.73","858.06","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","11010.00","8257.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5753.83","52.26","","1113.10","1113.10","1113.10","1 through 10","3413.1","8752.95","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","11010.00","8257.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8752.95","79.5","","1293.60","1148.53","1603.80","1 through 10","3413.1","8752.95","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","11010.00","8257.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4018.65","36.5","","1023.42","771.29","2068.67","33","3413.1","8752.95","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","11010.00","8257.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4216.83","38.3","","850.52","759.78","1211.25","66","3413.1","8752.95","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","11010.00","8257.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4723.29","42.9","","2548.09","2548.09","2548.09","1 through 10","3413.1","8752.95","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","11010.00","8257.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4723.29","42.9","","956.46","956.46","956.46","1 through 10","3413.1","8752.95","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","11010.00","8257.50","WELLPOINT [1015]","HB AMC WELLPOINT","8123.18","73.78","","2344.73","1619.47","2530.35","16","3413.1","8752.95","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11010.00","8257.50","AETNA [1001]","HB AMC AETNA HMO","7684.98","69.8","","1523.63","988.41","4330.26","39","5753.83","8997.37","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11010.00","8257.50","AETNA [1001]","HB AMC AETNA PPO","8852.04","80.4","","1670.25","1670.25","1670.25","1 through 10","5753.83","8997.37","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11010.00","8257.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5753.83","52.26","","1113.10","1113.10","1113.10","1 through 10","5753.83","8997.37","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11010.00","8257.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8997.37","81.72","","1738.90","1484.65","2716.94","38","5753.83","8997.37","percent of total billed charges",""
"KNEE IMPLANT CEMENT STEM 14MMX160 FEMORAL LEGION COBALT ED","SUP-ITM-10121554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","552.39","52.26","","1113.10","1113.10","1113.10","1 through 10","327.67","840.32","percent of total billed charges",""
"KNEE IMPLANT CEMENT STEM 14MMX160 FEMORAL LEGION COBALT ED","SUP-ITM-10121554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","840.32","79.5","","1293.60","1148.53","1603.80","1 through 10","327.67","840.32","percent of total billed charges",""
"KNEE IMPLANT CEMENT STEM 14MMX160 FEMORAL LEGION COBALT ED","SUP-ITM-10121554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","385.81","36.5","","1023.42","771.29","2068.67","33","327.67","840.32","percent of total billed charges",""
"KNEE IMPLANT CEMENT STEM 14MMX160 FEMORAL LEGION COBALT ED","SUP-ITM-10121554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","404.83","38.3","","850.52","759.78","1211.25","66","327.67","840.32","percent of total billed charges",""
"KNEE IMPLANT CEMENT STEM 14MMX160 FEMORAL LEGION COBALT ED","SUP-ITM-10121554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.45","42.9","","2548.09","2548.09","2548.09","1 through 10","327.67","840.32","percent of total billed charges",""
"KNEE IMPLANT CEMENT STEM 14MMX160 FEMORAL LEGION COBALT ED","SUP-ITM-10121554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.45","42.9","","956.46","956.46","956.46","1 through 10","327.67","840.32","percent of total billed charges",""
"KNEE IMPLANT CEMENT STEM 14MMX160 FEMORAL LEGION COBALT ED","SUP-ITM-10121554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","WELLPOINT [1015]","HB AMC WELLPOINT","779.85","73.78","","2344.73","1619.47","2530.35","16","327.67","840.32","percent of total billed charges",""
"KNEE IMPLANT CEMENT STEM 14MMX160 FEMORAL LEGION COBALT ED","SUP-ITM-10121554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1057.00","792.75","AETNA [1001]","HB AMC AETNA HMO","737.79","69.8","","1523.63","988.41","4330.26","39","552.39","863.78","percent of total billed charges",""
"KNEE IMPLANT CEMENT STEM 14MMX160 FEMORAL LEGION COBALT ED","SUP-ITM-10121554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1057.00","792.75","AETNA [1001]","HB AMC AETNA PPO","849.83","80.4","","1670.25","1670.25","1670.25","1 through 10","552.39","863.78","percent of total billed charges",""
"KNEE IMPLANT CEMENT STEM 14MMX160 FEMORAL LEGION COBALT ED","SUP-ITM-10121554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1057.00","792.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","552.39","52.26","","1113.10","1113.10","1113.10","1 through 10","552.39","863.78","percent of total billed charges",""
"KNEE IMPLANT CEMENT STEM 14MMX160 FEMORAL LEGION COBALT ED","SUP-ITM-10121554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1057.00","792.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","863.78","81.72","","1738.90","1484.65","2716.94","38","552.39","863.78","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2883.45","52.26","","1113.10","1113.10","1113.10","1 through 10","1710.43","4386.41","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4386.41","79.5","","1293.60","1148.53","1603.80","1 through 10","1710.43","4386.41","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2013.89","36.5","","1023.42","771.29","2068.67","33","1710.43","4386.41","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2113.20","38.3","","850.52","759.78","1211.25","66","1710.43","4386.41","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2367.01","42.9","","2548.09","2548.09","2548.09","1 through 10","1710.43","4386.41","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2367.01","42.9","","956.46","956.46","956.46","1 through 10","1710.43","4386.41","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","WELLPOINT [1015]","HB AMC WELLPOINT","4070.81","73.78","","2344.73","1619.47","2530.35","16","1710.43","4386.41","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5517.50","4138.12","AETNA [1001]","HB AMC AETNA HMO","3851.22","69.8","","1523.63","988.41","4330.26","39","2883.45","4508.9","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5517.50","4138.12","AETNA [1001]","HB AMC AETNA PPO","4436.07","80.4","","1670.25","1670.25","1670.25","1 through 10","2883.45","4508.9","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5517.50","4138.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2883.45","52.26","","1113.10","1113.10","1113.10","1 through 10","2883.45","4508.9","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5517.50","4138.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4508.90","81.72","","1738.90","1484.65","2716.94","38","2883.45","4508.9","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 1.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101418","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 1.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101418","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3213.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 1.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101418","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.51","36.5","","1023.42","771.29","2068.67","33","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 1.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101418","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.28","38.3","","850.52","759.78","1211.25","66","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 1.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101418","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 1.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101418","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","956.46","956.46","956.46","1 through 10","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 1.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101418","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","WELLPOINT [1015]","HB AMC WELLPOINT","2982.56","73.78","","2344.73","1619.47","2530.35","16","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 1.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101418","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA HMO","2821.67","69.8","","1523.63","988.41","4330.26","39","2112.61","3303.53","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 1.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101418","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA PPO","3250.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2112.61","3303.53","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 1.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101418","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","2112.61","3303.53","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 1.0 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101418","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.53","81.72","","1738.90","1484.65","2716.94","38","2112.61","3303.53","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3213.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.51","36.5","","1023.42","771.29","2068.67","33","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.28","38.3","","850.52","759.78","1211.25","66","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","956.46","956.46","956.46","1 through 10","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","WELLPOINT [1015]","HB AMC WELLPOINT","2982.56","73.78","","2344.73","1619.47","2530.35","16","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA HMO","2821.67","69.8","","1523.63","988.41","4330.26","39","2112.61","3303.53","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA PPO","3250.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2112.61","3303.53","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","2112.61","3303.53","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.53","81.72","","1738.90","1484.65","2716.94","38","2112.61","3303.53","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1494.37","52.26","","1113.10","1113.10","1113.10","1 through 10","886.45","2273.3","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2273.30","79.5","","1293.60","1148.53","1603.80","1 through 10","886.45","2273.3","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1043.72","36.5","","1023.42","771.29","2068.67","33","886.45","2273.3","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1095.19","38.3","","850.52","759.78","1211.25","66","886.45","2273.3","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1226.73","42.9","","2548.09","2548.09","2548.09","1 through 10","886.45","2273.3","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1226.73","42.9","","956.46","956.46","956.46","1 through 10","886.45","2273.3","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2859.50","2144.62","WELLPOINT [1015]","HB AMC WELLPOINT","2109.74","73.78","","2344.73","1619.47","2530.35","16","886.45","2273.3","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2859.50","2144.62","AETNA [1001]","HB AMC AETNA HMO","1995.93","69.8","","1523.63","988.41","4330.26","39","1494.37","2336.78","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2859.50","2144.62","AETNA [1001]","HB AMC AETNA PPO","2299.04","80.4","","1670.25","1670.25","1670.25","1 through 10","1494.37","2336.78","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2859.50","2144.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1494.37","52.26","","1113.10","1113.10","1113.10","1 through 10","1494.37","2336.78","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2859.50","2144.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2336.78","81.72","","1738.90","1484.65","2716.94","38","1494.37","2336.78","percent of total billed charges",""
"KNEE IMPLANT SIZE 5 COMPONENT FEMORAL SIGMA POROCOAT CRUCIATE RETAINING RIGHT","SUP-ITM-10025848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SIZE 5 COMPONENT FEMORAL SIGMA POROCOAT CRUCIATE RETAINING RIGHT","SUP-ITM-10025848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SIZE 5 COMPONENT FEMORAL SIGMA POROCOAT CRUCIATE RETAINING RIGHT","SUP-ITM-10025848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SIZE 5 COMPONENT FEMORAL SIGMA POROCOAT CRUCIATE RETAINING RIGHT","SUP-ITM-10025848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SIZE 5 COMPONENT FEMORAL SIGMA POROCOAT CRUCIATE RETAINING RIGHT","SUP-ITM-10025848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SIZE 5 COMPONENT FEMORAL SIGMA POROCOAT CRUCIATE RETAINING RIGHT","SUP-ITM-10025848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SIZE 5 COMPONENT FEMORAL SIGMA POROCOAT CRUCIATE RETAINING RIGHT","SUP-ITM-10025848","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SIZE 5 COMPONENT FEMORAL SIGMA POROCOAT CRUCIATE RETAINING RIGHT","SUP-ITM-10025848","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"KNEE IMPLANT SIZE 5 COMPONENT FEMORAL SIGMA POROCOAT CRUCIATE RETAINING RIGHT","SUP-ITM-10025848","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"KNEE IMPLANT SIZE 5 COMPONENT FEMORAL SIGMA POROCOAT CRUCIATE RETAINING RIGHT","SUP-ITM-10025848","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"KNEE IMPLANT SIZE 5 COMPONENT FEMORAL SIGMA POROCOAT CRUCIATE RETAINING RIGHT","SUP-ITM-10025848","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8178.69","52.26","","1113.10","1113.10","1113.10","1 through 10","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12441.75","79.5","","1293.60","1148.53","1603.80","1 through 10","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5712.25","36.5","","1023.42","771.29","2068.67","33","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5993.95","38.3","","850.52","759.78","1211.25","66","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6713.85","42.9","","2548.09","2548.09","2548.09","1 through 10","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6713.85","42.9","","956.46","956.46","956.46","1 through 10","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","15650.00","11737.50","WELLPOINT [1015]","HB AMC WELLPOINT","11546.57","73.78","","2344.73","1619.47","2530.35","16","4851.5","12441.75","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","AETNA [1001]","HB AMC AETNA HMO","10923.70","69.8","","1523.63","988.41","4330.26","39","8178.69","12789.18","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","AETNA [1001]","HB AMC AETNA PPO","12582.60","80.4","","1670.25","1670.25","1670.25","1 through 10","8178.69","12789.18","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","8178.69","52.26","","1113.10","1113.10","1113.10","1 through 10","8178.69","12789.18","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15650.00","11737.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12789.18","81.72","","1738.90","1484.65","2716.94","38","8178.69","12789.18","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2304.67","52.26","","1113.10","1113.10","1113.10","1 through 10","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3505.95","79.5","","1293.60","1148.53","1603.80","1 through 10","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1609.65","36.5","","1023.42","771.29","2068.67","33","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1689.03","38.3","","850.52","759.78","1211.25","66","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.89","42.9","","2548.09","2548.09","2548.09","1 through 10","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.89","42.9","","956.46","956.46","956.46","1 through 10","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","WELLPOINT [1015]","HB AMC WELLPOINT","3253.70","73.78","","2344.73","1619.47","2530.35","16","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","AETNA [1001]","HB AMC AETNA HMO","3078.18","69.8","","1523.63","988.41","4330.26","39","2304.67","3603.85","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","AETNA [1001]","HB AMC AETNA PPO","3545.64","80.4","","1670.25","1670.25","1670.25","1 through 10","2304.67","3603.85","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2304.67","52.26","","1113.10","1113.10","1113.10","1 through 10","2304.67","3603.85","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3603.85","81.72","","1738.90","1484.65","2716.94","38","2304.67","3603.85","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2304.67","52.26","","1113.10","1113.10","1113.10","1 through 10","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3505.95","79.5","","1293.60","1148.53","1603.80","1 through 10","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1609.65","36.5","","1023.42","771.29","2068.67","33","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1689.03","38.3","","850.52","759.78","1211.25","66","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.89","42.9","","2548.09","2548.09","2548.09","1 through 10","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1891.89","42.9","","956.46","956.46","956.46","1 through 10","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4410.00","3307.50","WELLPOINT [1015]","HB AMC WELLPOINT","3253.70","73.78","","2344.73","1619.47","2530.35","16","1367.1","3505.95","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","AETNA [1001]","HB AMC AETNA HMO","3078.18","69.8","","1523.63","988.41","4330.26","39","2304.67","3603.85","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","AETNA [1001]","HB AMC AETNA PPO","3545.64","80.4","","1670.25","1670.25","1670.25","1 through 10","2304.67","3603.85","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2304.67","52.26","","1113.10","1113.10","1113.10","1 through 10","2304.67","3603.85","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4410.00","3307.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3603.85","81.72","","1738.90","1484.65","2716.94","38","2304.67","3603.85","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2508.48","52.26","","1113.10","1113.10","1113.10","1 through 10","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3816.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1752.00","36.5","","1023.42","771.29","2068.67","33","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1838.40","38.3","","850.52","759.78","1211.25","66","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","2548.09","2548.09","2548.09","1 through 10","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","956.46","956.46","956.46","1 through 10","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","WELLPOINT [1015]","HB AMC WELLPOINT","3541.44","73.78","","2344.73","1619.47","2530.35","16","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA HMO","3350.40","69.8","","1523.63","988.41","4330.26","39","2508.48","3922.56","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA PPO","3859.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2508.48","3922.56","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2508.48","52.26","","1113.10","1113.10","1113.10","1 through 10","2508.48","3922.56","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3922.56","81.72","","1738.90","1484.65","2716.94","38","2508.48","3922.56","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2508.48","52.26","","1113.10","1113.10","1113.10","1 through 10","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3816.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1752.00","36.5","","1023.42","771.29","2068.67","33","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1838.40","38.3","","850.52","759.78","1211.25","66","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","2548.09","2548.09","2548.09","1 through 10","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","956.46","956.46","956.46","1 through 10","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","WELLPOINT [1015]","HB AMC WELLPOINT","3541.44","73.78","","2344.73","1619.47","2530.35","16","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA HMO","3350.40","69.8","","1523.63","988.41","4330.26","39","2508.48","3922.56","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA PPO","3859.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2508.48","3922.56","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2508.48","52.26","","1113.10","1113.10","1113.10","1 through 10","2508.48","3922.56","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3922.56","81.72","","1738.90","1484.65","2716.94","38","2508.48","3922.56","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1023.42","771.29","2068.67","33","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","850.52","759.78","1211.25","66","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","2548.09","2548.09","2548.09","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","956.46","956.46","956.46","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","2344.73","1619.47","2530.35","16","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1523.63","988.41","4330.26","39","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA PPO","4221.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","1738.90","1484.65","2716.94","38","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","1023.42","771.29","2068.67","33","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","850.52","759.78","1211.25","66","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","2548.09","2548.09","2548.09","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","956.46","956.46","956.46","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","2344.73","1619.47","2530.35","16","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA HMO","2687.30","69.8","","1523.63","988.41","4330.26","39","2012.01","3146.22","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA PPO","3095.40","80.4","","1670.25","1670.25","1670.25","1 through 10","2012.01","3146.22","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","2012.01","3146.22","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","1738.90","1484.65","2716.94","38","2012.01","3146.22","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","800.18","480.96","1887.97","195","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","813.12","216.42","1444.50","81","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1627.50","31","","432.60","432.60","432.60","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","148.37","54.89","631.39","94","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","279.30","91.72","1116.77","266","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","731.00","63.70","731.00","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","384.74","384.74","384.74","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","286.63","119.22","1107.45","105","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","675.31","184.75","1721.50","286","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA PPO","4221.00","80.4","","1261.44","103.12","1514.10","21","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4221.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4290.30","81.72","","5157.68","5157.68","5157.68","1 through 10","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","431.26","71.26","1459.57","88","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2508.48","52.26","","1113.10","1113.10","1113.10","1 through 10","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3816.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1752.00","36.5","","1023.42","771.29","2068.67","33","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1838.40","38.3","","850.52","759.78","1211.25","66","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","2548.09","2548.09","2548.09","1 through 10","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","956.46","956.46","956.46","1 through 10","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","WELLPOINT [1015]","HB AMC WELLPOINT","3541.44","73.78","","2344.73","1619.47","2530.35","16","1488","3816","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA HMO","3350.40","69.8","","1523.63","988.41","4330.26","39","2508.48","3922.56","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA PPO","3859.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2508.48","3922.56","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2508.48","52.26","","1113.10","1113.10","1113.10","1 through 10","2508.48","3922.56","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3922.56","81.72","","1738.90","1484.65","2716.94","38","2508.48","3922.56","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1023.42","771.29","2068.67","33","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","850.52","759.78","1211.25","66","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","2548.09","2548.09","2548.09","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","956.46","956.46","956.46","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","2344.73","1619.47","2530.35","16","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1523.63","988.41","4330.26","39","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA PPO","4221.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","1738.90","1484.65","2716.94","38","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3244.37","52.26","","1113.10","1113.10","1113.10","1 through 10","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4935.46","79.5","","1293.60","1148.53","1603.80","1 through 10","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2265.97","36.5","","1023.42","771.29","2068.67","33","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2377.71","38.3","","850.52","759.78","1211.25","66","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2663.29","42.9","","2548.09","2548.09","2548.09","1 through 10","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2663.29","42.9","","956.46","956.46","956.46","1 through 10","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","WELLPOINT [1015]","HB AMC WELLPOINT","4580.36","73.78","","2344.73","1619.47","2530.35","16","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6208.13","4656.10","AETNA [1001]","HB AMC AETNA HMO","4333.27","69.8","","1523.63","988.41","4330.26","39","3244.37","5073.28","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6208.13","4656.10","AETNA [1001]","HB AMC AETNA PPO","4991.34","80.4","","1670.25","1670.25","1670.25","1 through 10","3244.37","5073.28","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6208.13","4656.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3244.37","52.26","","1113.10","1113.10","1113.10","1 through 10","3244.37","5073.28","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6208.13","4656.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5073.28","81.72","","1738.90","1484.65","2716.94","38","3244.37","5073.28","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","800.18","480.96","1887.97","195","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2052.05","53.3","","813.12","216.42","1444.50","81","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1193.50","31","","432.60","432.60","432.60","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","148.37","54.89","631.39","94","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","279.30","91.72","1116.77","266","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","731.00","63.70","731.00","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","384.74","384.74","384.74","1 through 10","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","286.63","119.22","1107.45","105","1193.5","3060.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA HMO","2687.30","69.8","","675.31","184.75","1721.50","286","2012.01","3146.22","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA PPO","3095.40","80.4","","1261.44","103.12","1514.10","21","2012.01","3146.22","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3095.40","80.4","","1365.00","1365.00","1365.00","1 through 10","2012.01","3146.22","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3146.22","81.72","","5157.68","5157.68","5157.68","1 through 10","2012.01","3146.22","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","431.26","71.26","1459.57","88","2012.01","3146.22","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1023.42","771.29","2068.67","33","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","850.52","759.78","1211.25","66","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","2548.09","2548.09","2548.09","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","956.46","956.46","956.46","1 through 10","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","2344.73","1619.47","2530.35","16","1627.5","4173.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1523.63","988.41","4330.26","39","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA PPO","4221.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2743.65","52.26","","1113.10","1113.10","1113.10","1 through 10","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","1738.90","1484.65","2716.94","38","2743.65","4290.3","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3244.37","52.26","","1113.10","1113.10","1113.10","1 through 10","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4935.46","79.5","","1293.60","1148.53","1603.80","1 through 10","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2265.97","36.5","","1023.42","771.29","2068.67","33","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2377.71","38.3","","850.52","759.78","1211.25","66","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2663.29","42.9","","2548.09","2548.09","2548.09","1 through 10","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2663.29","42.9","","956.46","956.46","956.46","1 through 10","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","6208.13","4656.10","WELLPOINT [1015]","HB AMC WELLPOINT","4580.36","73.78","","2344.73","1619.47","2530.35","16","1924.52","4935.46","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6208.13","4656.10","AETNA [1001]","HB AMC AETNA HMO","4333.27","69.8","","1523.63","988.41","4330.26","39","3244.37","5073.28","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6208.13","4656.10","AETNA [1001]","HB AMC AETNA PPO","4991.34","80.4","","1670.25","1670.25","1670.25","1 through 10","3244.37","5073.28","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6208.13","4656.10","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3244.37","52.26","","1113.10","1113.10","1113.10","1 through 10","3244.37","5073.28","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6208.13","4656.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5073.28","81.72","","1738.90","1484.65","2716.94","38","3244.37","5073.28","percent of total billed charges",""
"KNEE IMPLANT SZ C FEMORAL COMPONENT NEXGEN PRECOAT RT 02","SUP-ITM-10022838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT SZ C FEMORAL COMPONENT NEXGEN PRECOAT RT 02","SUP-ITM-10022838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3213.79","79.5","","1293.60","1148.53","1603.80","1 through 10","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT SZ C FEMORAL COMPONENT NEXGEN PRECOAT RT 02","SUP-ITM-10022838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.51","36.5","","1023.42","771.29","2068.67","33","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT SZ C FEMORAL COMPONENT NEXGEN PRECOAT RT 02","SUP-ITM-10022838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.28","38.3","","850.52","759.78","1211.25","66","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT SZ C FEMORAL COMPONENT NEXGEN PRECOAT RT 02","SUP-ITM-10022838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","2548.09","2548.09","2548.09","1 through 10","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT SZ C FEMORAL COMPONENT NEXGEN PRECOAT RT 02","SUP-ITM-10022838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.23","42.9","","956.46","956.46","956.46","1 through 10","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT SZ C FEMORAL COMPONENT NEXGEN PRECOAT RT 02","SUP-ITM-10022838","CDM","C1776","HCPCS","0278","RC","","","","both","","","4042.50","3031.87","WELLPOINT [1015]","HB AMC WELLPOINT","2982.56","73.78","","2344.73","1619.47","2530.35","16","1253.18","3213.79","percent of total billed charges",""
"KNEE IMPLANT SZ C FEMORAL COMPONENT NEXGEN PRECOAT RT 02","SUP-ITM-10022838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA HMO","2821.67","69.8","","1523.63","988.41","4330.26","39","2112.61","3303.53","percent of total billed charges",""
"KNEE IMPLANT SZ C FEMORAL COMPONENT NEXGEN PRECOAT RT 02","SUP-ITM-10022838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","AETNA [1001]","HB AMC AETNA PPO","3250.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2112.61","3303.53","percent of total billed charges",""
"KNEE IMPLANT SZ C FEMORAL COMPONENT NEXGEN PRECOAT RT 02","SUP-ITM-10022838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2112.61","52.26","","1113.10","1113.10","1113.10","1 through 10","2112.61","3303.53","percent of total billed charges",""
"KNEE IMPLANT SZ C FEMORAL COMPONENT NEXGEN PRECOAT RT 02","SUP-ITM-10022838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4042.50","3031.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.53","81.72","","1738.90","1484.65","2716.94","38","2112.61","3303.53","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2509.82","79.5","","1293.60","1148.53","1603.80","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1152.31","36.5","","1023.42","771.29","2068.67","33","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1209.13","38.3","","850.52","759.78","1211.25","66","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","2548.09","2548.09","2548.09","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","956.46","956.46","956.46","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","WELLPOINT [1015]","HB AMC WELLPOINT","2329.23","73.78","","2344.73","1619.47","2530.35","16","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA HMO","2203.59","69.8","","1523.63","988.41","4330.26","39","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA PPO","2538.23","80.4","","1670.25","1670.25","1670.25","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2579.90","81.72","","1738.90","1484.65","2716.94","38","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1293.60","1148.53","1603.80","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1023.42","771.29","2068.67","33","651","1669.5","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","850.52","759.78","1211.25","66","651","1669.5","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","2548.09","2548.09","2548.09","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","956.46","956.46","956.46","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","2344.73","1619.47","2530.35","16","651","1669.5","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1523.63","988.41","4330.26","39","1097.46","1716.12","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1670.25","1670.25","1670.25","1 through 10","1097.46","1716.12","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1097.46","1716.12","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1738.90","1484.65","2716.94","38","1097.46","1716.12","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1832.76","52.26","","1113.10","1113.10","1113.10","1 through 10","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2788.07","79.5","","1293.60","1148.53","1603.80","1 through 10","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1280.06","36.5","","1023.42","771.29","2068.67","33","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1343.18","38.3","","850.52","759.78","1211.25","66","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1504.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1504.50","42.9","","956.46","956.46","956.46","1 through 10","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","WELLPOINT [1015]","HB AMC WELLPOINT","2587.46","73.78","","2344.73","1619.47","2530.35","16","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","AETNA [1001]","HB AMC AETNA HMO","2447.89","69.8","","1523.63","988.41","4330.26","39","1832.76","2865.92","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","AETNA [1001]","HB AMC AETNA PPO","2819.63","80.4","","1670.25","1670.25","1670.25","1 through 10","1832.76","2865.92","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1832.76","52.26","","1113.10","1113.10","1113.10","1 through 10","1832.76","2865.92","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2865.92","81.72","","1738.90","1484.65","2716.94","38","1832.76","2865.92","percent of total billed charges",""
"KNEE INSERT 12MM IMPLANT TIBIAL BRING OSS POLY ONC 06","SUP-ITM-10036218","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1924.40","52.26","","1113.10","1113.10","1113.10","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 12MM IMPLANT TIBIAL BRING OSS POLY ONC 06","SUP-ITM-10036218","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2927.47","79.5","","1293.60","1148.53","1603.80","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 12MM IMPLANT TIBIAL BRING OSS POLY ONC 06","SUP-ITM-10036218","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1344.06","36.5","","1023.42","771.29","2068.67","33","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 12MM IMPLANT TIBIAL BRING OSS POLY ONC 06","SUP-ITM-10036218","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1410.34","38.3","","850.52","759.78","1211.25","66","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 12MM IMPLANT TIBIAL BRING OSS POLY ONC 06","SUP-ITM-10036218","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1579.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 12MM IMPLANT TIBIAL BRING OSS POLY ONC 06","SUP-ITM-10036218","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1579.73","42.9","","956.46","956.46","956.46","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 12MM IMPLANT TIBIAL BRING OSS POLY ONC 06","SUP-ITM-10036218","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","WELLPOINT [1015]","HB AMC WELLPOINT","2716.84","73.78","","2344.73","1619.47","2530.35","16","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 12MM IMPLANT TIBIAL BRING OSS POLY ONC 06","SUP-ITM-10036218","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","AETNA [1001]","HB AMC AETNA HMO","2570.28","69.8","","1523.63","988.41","4330.26","39","1924.4","3009.22","percent of total billed charges",""
"KNEE INSERT 12MM IMPLANT TIBIAL BRING OSS POLY ONC 06","SUP-ITM-10036218","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","AETNA [1001]","HB AMC AETNA PPO","2960.61","80.4","","1670.25","1670.25","1670.25","1 through 10","1924.4","3009.22","percent of total billed charges",""
"KNEE INSERT 12MM IMPLANT TIBIAL BRING OSS POLY ONC 06","SUP-ITM-10036218","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1924.40","52.26","","1113.10","1113.10","1113.10","1 through 10","1924.4","3009.22","percent of total billed charges",""
"KNEE INSERT 12MM IMPLANT TIBIAL BRING OSS POLY ONC 06","SUP-ITM-10036218","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3009.22","81.72","","1738.90","1484.65","2716.94","38","1924.4","3009.22","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2 3 SCREW BONE LOCKING RT INCLUDED LEGION HK GUIDED MOTION ARTICULAR ONC 06","SUP-ITM-10100908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2788.07","79.5","","800.18","480.96","1887.97","195","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2 3 SCREW BONE LOCKING RT INCLUDED LEGION HK GUIDED MOTION ARTICULAR ONC 06","SUP-ITM-10100908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1869.23","53.3","","813.12","216.42","1444.50","81","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2 3 SCREW BONE LOCKING RT INCLUDED LEGION HK GUIDED MOTION ARTICULAR ONC 06","SUP-ITM-10100908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1087.17","31","","432.60","432.60","432.60","1 through 10","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2 3 SCREW BONE LOCKING RT INCLUDED LEGION HK GUIDED MOTION ARTICULAR ONC 06","SUP-ITM-10100908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1280.06","36.5","","148.37","54.89","631.39","94","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2 3 SCREW BONE LOCKING RT INCLUDED LEGION HK GUIDED MOTION ARTICULAR ONC 06","SUP-ITM-10100908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1343.18","38.3","","279.30","91.72","1116.77","266","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2 3 SCREW BONE LOCKING RT INCLUDED LEGION HK GUIDED MOTION ARTICULAR ONC 06","SUP-ITM-10100908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1504.50","42.9","","731.00","63.70","731.00","1 through 10","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2 3 SCREW BONE LOCKING RT INCLUDED LEGION HK GUIDED MOTION ARTICULAR ONC 06","SUP-ITM-10100908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1504.50","42.9","","384.74","384.74","384.74","1 through 10","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2 3 SCREW BONE LOCKING RT INCLUDED LEGION HK GUIDED MOTION ARTICULAR ONC 06","SUP-ITM-10100908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","WELLPOINT [1015]","HB AMC WELLPOINT","2587.46","73.78","","286.63","119.22","1107.45","105","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2 3 SCREW BONE LOCKING RT INCLUDED LEGION HK GUIDED MOTION ARTICULAR ONC 06","SUP-ITM-10100908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","AETNA [1001]","HB AMC AETNA HMO","2447.89","69.8","","675.31","184.75","1721.50","286","1832.76","2865.92","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2 3 SCREW BONE LOCKING RT INCLUDED LEGION HK GUIDED MOTION ARTICULAR ONC 06","SUP-ITM-10100908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","AETNA [1001]","HB AMC AETNA PPO","2819.63","80.4","","1261.44","103.12","1514.10","21","1832.76","2865.92","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2 3 SCREW BONE LOCKING RT INCLUDED LEGION HK GUIDED MOTION ARTICULAR ONC 06","SUP-ITM-10100908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2819.63","80.4","","1365.00","1365.00","1365.00","1 through 10","1832.76","2865.92","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2 3 SCREW BONE LOCKING RT INCLUDED LEGION HK GUIDED MOTION ARTICULAR ONC 06","SUP-ITM-10100908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2865.92","81.72","","5157.68","5157.68","5157.68","1 through 10","1832.76","2865.92","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2 3 SCREW BONE LOCKING RT INCLUDED LEGION HK GUIDED MOTION ARTICULAR ONC 06","SUP-ITM-10100908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2865.92","81.72","","431.26","71.26","1459.57","88","1832.76","2865.92","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2509.82","79.5","","800.18","480.96","1887.97","195","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1682.68","53.3","","813.12","216.42","1444.50","81","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","978.67","31","","432.60","432.60","432.60","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1152.31","36.5","","148.37","54.89","631.39","94","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1209.13","38.3","","279.30","91.72","1116.77","266","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","731.00","63.70","731.00","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","384.74","384.74","384.74","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","WELLPOINT [1015]","HB AMC WELLPOINT","2329.23","73.78","","286.63","119.22","1107.45","105","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA HMO","2203.59","69.8","","675.31","184.75","1721.50","286","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA PPO","2538.23","80.4","","1261.44","103.12","1514.10","21","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2538.23","80.4","","1365.00","1365.00","1365.00","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2579.90","81.72","","5157.68","5157.68","5157.68","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2579.90","81.72","","431.26","71.26","1459.57","88","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1324.47","79.5","","1293.60","1148.53","1603.80","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","608.09","36.5","","1023.42","771.29","2068.67","33","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","638.08","38.3","","850.52","759.78","1211.25","66","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","2548.09","2548.09","2548.09","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","956.46","956.46","956.46","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","WELLPOINT [1015]","HB AMC WELLPOINT","1229.17","73.78","","2344.73","1619.47","2530.35","16","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA HMO","1162.87","69.8","","1523.63","988.41","4330.26","39","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA PPO","1339.46","80.4","","1670.25","1670.25","1670.25","1 through 10","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1361.46","81.72","","1738.90","1484.65","2716.94","38","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2509.82","79.5","","1293.60","1148.53","1603.80","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1152.31","36.5","","1023.42","771.29","2068.67","33","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1209.13","38.3","","850.52","759.78","1211.25","66","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","2548.09","2548.09","2548.09","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","956.46","956.46","956.46","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","WELLPOINT [1015]","HB AMC WELLPOINT","2329.23","73.78","","2344.73","1619.47","2530.35","16","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA HMO","2203.59","69.8","","1523.63","988.41","4330.26","39","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA PPO","2538.23","80.4","","1670.25","1670.25","1670.25","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2579.90","81.72","","1738.90","1484.65","2716.94","38","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1774.50","1330.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","927.35","52.26","","1113.10","1113.10","1113.10","1 through 10","550.1","1410.73","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1774.50","1330.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1410.73","79.5","","1293.60","1148.53","1603.80","1 through 10","550.1","1410.73","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1774.50","1330.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","647.69","36.5","","1023.42","771.29","2068.67","33","550.1","1410.73","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1774.50","1330.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","679.63","38.3","","850.52","759.78","1211.25","66","550.1","1410.73","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1774.50","1330.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","761.26","42.9","","2548.09","2548.09","2548.09","1 through 10","550.1","1410.73","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1774.50","1330.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","761.26","42.9","","956.46","956.46","956.46","1 through 10","550.1","1410.73","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1774.50","1330.87","WELLPOINT [1015]","HB AMC WELLPOINT","1309.23","73.78","","2344.73","1619.47","2530.35","16","550.1","1410.73","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1774.50","1330.87","AETNA [1001]","HB AMC AETNA HMO","1238.60","69.8","","1523.63","988.41","4330.26","39","927.35","1450.12","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1774.50","1330.87","AETNA [1001]","HB AMC AETNA PPO","1426.70","80.4","","1670.25","1670.25","1670.25","1 through 10","927.35","1450.12","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1774.50","1330.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","927.35","52.26","","1113.10","1113.10","1113.10","1 through 10","927.35","1450.12","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1774.50","1330.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1450.12","81.72","","1738.90","1484.65","2716.94","38","927.35","1450.12","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1457.79","52.26","","1113.10","1113.10","1113.10","1 through 10","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2217.65","79.5","","1293.60","1148.53","1603.80","1 through 10","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1018.17","36.5","","1023.42","771.29","2068.67","33","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1068.38","38.3","","850.52","759.78","1211.25","66","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1196.70","42.9","","2548.09","2548.09","2548.09","1 through 10","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1196.70","42.9","","956.46","956.46","956.46","1 through 10","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","WELLPOINT [1015]","HB AMC WELLPOINT","2058.09","73.78","","2344.73","1619.47","2530.35","16","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2789.50","2092.12","AETNA [1001]","HB AMC AETNA HMO","1947.07","69.8","","1523.63","988.41","4330.26","39","1457.79","2279.58","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2789.50","2092.12","AETNA [1001]","HB AMC AETNA PPO","2242.76","80.4","","1670.25","1670.25","1670.25","1 through 10","1457.79","2279.58","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2789.50","2092.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1457.79","52.26","","1113.10","1113.10","1113.10","1 through 10","1457.79","2279.58","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2789.50","2092.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2279.58","81.72","","1738.90","1484.65","2716.94","38","1457.79","2279.58","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1324.47","79.5","","800.18","480.96","1887.97","195","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","887.98","53.3","","813.12","216.42","1444.50","81","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","516.46","31","","432.60","432.60","432.60","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","608.09","36.5","","148.37","54.89","631.39","94","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","638.08","38.3","","279.30","91.72","1116.77","266","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","731.00","63.70","731.00","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","384.74","384.74","384.74","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","WELLPOINT [1015]","HB AMC WELLPOINT","1229.17","73.78","","286.63","119.22","1107.45","105","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA HMO","1162.87","69.8","","675.31","184.75","1721.50","286","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA PPO","1339.46","80.4","","1261.44","103.12","1514.10","21","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1339.46","80.4","","1365.00","1365.00","1365.00","1 through 10","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1361.46","81.72","","5157.68","5157.68","5157.68","1 through 10","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1361.46","81.72","","431.26","71.26","1459.57","88","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 17MM SURFACE FEMORAL ARTICULAR SEGMENTAL SIZE D","SUP-ITM-10200134","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1924.40","52.26","","1113.10","1113.10","1113.10","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 17MM SURFACE FEMORAL ARTICULAR SEGMENTAL SIZE D","SUP-ITM-10200134","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2927.47","79.5","","1293.60","1148.53","1603.80","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 17MM SURFACE FEMORAL ARTICULAR SEGMENTAL SIZE D","SUP-ITM-10200134","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1344.06","36.5","","1023.42","771.29","2068.67","33","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 17MM SURFACE FEMORAL ARTICULAR SEGMENTAL SIZE D","SUP-ITM-10200134","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1410.34","38.3","","850.52","759.78","1211.25","66","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 17MM SURFACE FEMORAL ARTICULAR SEGMENTAL SIZE D","SUP-ITM-10200134","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1579.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 17MM SURFACE FEMORAL ARTICULAR SEGMENTAL SIZE D","SUP-ITM-10200134","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1579.73","42.9","","956.46","956.46","956.46","1 through 10","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 17MM SURFACE FEMORAL ARTICULAR SEGMENTAL SIZE D","SUP-ITM-10200134","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","WELLPOINT [1015]","HB AMC WELLPOINT","2716.84","73.78","","2344.73","1619.47","2530.35","16","1141.53","2927.47","percent of total billed charges",""
"KNEE INSERT 17MM SURFACE FEMORAL ARTICULAR SEGMENTAL SIZE D","SUP-ITM-10200134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","AETNA [1001]","HB AMC AETNA HMO","2570.28","69.8","","1523.63","988.41","4330.26","39","1924.4","3009.22","percent of total billed charges",""
"KNEE INSERT 17MM SURFACE FEMORAL ARTICULAR SEGMENTAL SIZE D","SUP-ITM-10200134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","AETNA [1001]","HB AMC AETNA PPO","2960.61","80.4","","1670.25","1670.25","1670.25","1 through 10","1924.4","3009.22","percent of total billed charges",""
"KNEE INSERT 17MM SURFACE FEMORAL ARTICULAR SEGMENTAL SIZE D","SUP-ITM-10200134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1924.40","52.26","","1113.10","1113.10","1113.10","1 through 10","1924.4","3009.22","percent of total billed charges",""
"KNEE INSERT 17MM SURFACE FEMORAL ARTICULAR SEGMENTAL SIZE D","SUP-ITM-10200134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3009.22","81.72","","1738.90","1484.65","2716.94","38","1924.4","3009.22","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1457.79","52.26","","1113.10","1113.10","1113.10","1 through 10","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2217.65","79.5","","1293.60","1148.53","1603.80","1 through 10","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1018.17","36.5","","1023.42","771.29","2068.67","33","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1068.38","38.3","","850.52","759.78","1211.25","66","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1196.70","42.9","","2548.09","2548.09","2548.09","1 through 10","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1196.70","42.9","","956.46","956.46","956.46","1 through 10","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","WELLPOINT [1015]","HB AMC WELLPOINT","2058.09","73.78","","2344.73","1619.47","2530.35","16","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2789.50","2092.12","AETNA [1001]","HB AMC AETNA HMO","1947.07","69.8","","1523.63","988.41","4330.26","39","1457.79","2279.58","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2789.50","2092.12","AETNA [1001]","HB AMC AETNA PPO","2242.76","80.4","","1670.25","1670.25","1670.25","1 through 10","1457.79","2279.58","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2789.50","2092.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1457.79","52.26","","1113.10","1113.10","1113.10","1 through 10","1457.79","2279.58","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2789.50","2092.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2279.58","81.72","","1738.90","1484.65","2716.94","38","1457.79","2279.58","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1324.47","79.5","","1293.60","1148.53","1603.80","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","608.09","36.5","","1023.42","771.29","2068.67","33","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","638.08","38.3","","850.52","759.78","1211.25","66","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","2548.09","2548.09","2548.09","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","956.46","956.46","956.46","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","WELLPOINT [1015]","HB AMC WELLPOINT","1229.17","73.78","","2344.73","1619.47","2530.35","16","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA HMO","1162.87","69.8","","1523.63","988.41","4330.26","39","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA PPO","1339.46","80.4","","1670.25","1670.25","1670.25","1 through 10","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1361.46","81.72","","1738.90","1484.65","2716.94","38","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2509.82","79.5","","1293.60","1148.53","1603.80","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1152.31","36.5","","1023.42","771.29","2068.67","33","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1209.13","38.3","","850.52","759.78","1211.25","66","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","2548.09","2548.09","2548.09","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","956.46","956.46","956.46","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","WELLPOINT [1015]","HB AMC WELLPOINT","2329.23","73.78","","2344.73","1619.47","2530.35","16","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA HMO","2203.59","69.8","","1523.63","988.41","4330.26","39","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA PPO","2538.23","80.4","","1670.25","1670.25","1670.25","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2579.90","81.72","","1738.90","1484.65","2716.94","38","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 200MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10159260","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3429.56","52.26","","1113.10","1113.10","1113.10","1 through 10","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 200MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10159260","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5217.19","79.5","","1293.60","1148.53","1603.80","1 through 10","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 200MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10159260","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2395.31","36.5","","1023.42","771.29","2068.67","33","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 200MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10159260","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2513.44","38.3","","850.52","759.78","1211.25","66","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 200MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10159260","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2815.31","42.9","","2548.09","2548.09","2548.09","1 through 10","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 200MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10159260","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2815.31","42.9","","956.46","956.46","956.46","1 through 10","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 200MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10159260","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","WELLPOINT [1015]","HB AMC WELLPOINT","4841.81","73.78","","2344.73","1619.47","2530.35","16","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 200MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10159260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","AETNA [1001]","HB AMC AETNA HMO","4580.63","69.8","","1523.63","988.41","4330.26","39","3429.56","5362.88","percent of total billed charges",""
"KNEE INSERT 200MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10159260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","AETNA [1001]","HB AMC AETNA PPO","5276.25","80.4","","1670.25","1670.25","1670.25","1 through 10","3429.56","5362.88","percent of total billed charges",""
"KNEE INSERT 200MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10159260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3429.56","52.26","","1113.10","1113.10","1113.10","1 through 10","3429.56","5362.88","percent of total billed charges",""
"KNEE INSERT 200MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10159260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5362.88","81.72","","1738.90","1484.65","2716.94","38","3429.56","5362.88","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2509.82","79.5","","1293.60","1148.53","1603.80","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1152.31","36.5","","1023.42","771.29","2068.67","33","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1209.13","38.3","","850.52","759.78","1211.25","66","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","2548.09","2548.09","2548.09","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","956.46","956.46","956.46","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","WELLPOINT [1015]","HB AMC WELLPOINT","2329.23","73.78","","2344.73","1619.47","2530.35","16","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA HMO","2203.59","69.8","","1523.63","988.41","4330.26","39","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA PPO","2538.23","80.4","","1670.25","1670.25","1670.25","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2579.90","81.72","","1738.90","1484.65","2716.94","38","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2509.82","79.5","","1293.60","1148.53","1603.80","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1152.31","36.5","","1023.42","771.29","2068.67","33","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1209.13","38.3","","850.52","759.78","1211.25","66","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","2548.09","2548.09","2548.09","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","956.46","956.46","956.46","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","WELLPOINT [1015]","HB AMC WELLPOINT","2329.23","73.78","","2344.73","1619.47","2530.35","16","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA HMO","2203.59","69.8","","1523.63","988.41","4330.26","39","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA PPO","2538.23","80.4","","1670.25","1670.25","1670.25","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2579.90","81.72","","1738.90","1484.65","2716.94","38","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1832.76","52.26","","1113.10","1113.10","1113.10","1 through 10","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2788.07","79.5","","1293.60","1148.53","1603.80","1 through 10","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1280.06","36.5","","1023.42","771.29","2068.67","33","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1343.18","38.3","","850.52","759.78","1211.25","66","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1504.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1504.50","42.9","","956.46","956.46","956.46","1 through 10","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3507.00","2630.25","WELLPOINT [1015]","HB AMC WELLPOINT","2587.46","73.78","","2344.73","1619.47","2530.35","16","1087.17","2788.07","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","AETNA [1001]","HB AMC AETNA HMO","2447.89","69.8","","1523.63","988.41","4330.26","39","1832.76","2865.92","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","AETNA [1001]","HB AMC AETNA PPO","2819.63","80.4","","1670.25","1670.25","1670.25","1 through 10","1832.76","2865.92","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1832.76","52.26","","1113.10","1113.10","1113.10","1 through 10","1832.76","2865.92","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3507.00","2630.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2865.92","81.72","","1738.90","1484.65","2716.94","38","1832.76","2865.92","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2509.82","79.5","","1293.60","1148.53","1603.80","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1152.31","36.5","","1023.42","771.29","2068.67","33","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1209.13","38.3","","850.52","759.78","1211.25","66","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","2548.09","2548.09","2548.09","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","956.46","956.46","956.46","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","WELLPOINT [1015]","HB AMC WELLPOINT","2329.23","73.78","","2344.73","1619.47","2530.35","16","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA HMO","2203.59","69.8","","1523.63","988.41","4330.26","39","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA PPO","2538.23","80.4","","1670.25","1670.25","1670.25","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2579.90","81.72","","1738.90","1484.65","2716.94","38","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2509.82","79.5","","1293.60","1148.53","1603.80","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1152.31","36.5","","1023.42","771.29","2068.67","33","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1209.13","38.3","","850.52","759.78","1211.25","66","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","2548.09","2548.09","2548.09","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1354.35","42.9","","956.46","956.46","956.46","1 through 10","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","3157.00","2367.75","WELLPOINT [1015]","HB AMC WELLPOINT","2329.23","73.78","","2344.73","1619.47","2530.35","16","978.67","2509.82","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA HMO","2203.59","69.8","","1523.63","988.41","4330.26","39","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","AETNA [1001]","HB AMC AETNA PPO","2538.23","80.4","","1670.25","1670.25","1670.25","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1649.85","52.26","","1113.10","1113.10","1113.10","1 through 10","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3157.00","2367.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2579.90","81.72","","1738.90","1484.65","2716.94","38","1649.85","2579.9","percent of total billed charges",""
"KNEE INSERT 4 8MM SIZE 3 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022194","CDM","C1776","HCPCS","0278","RC","","","","both","","","1561.00","1170.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","815.78","52.26","","1113.10","1113.10","1113.10","1 through 10","483.91","1241","percent of total billed charges",""
"KNEE INSERT 4 8MM SIZE 3 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022194","CDM","C1776","HCPCS","0278","RC","","","","both","","","1561.00","1170.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1241.00","79.5","","1293.60","1148.53","1603.80","1 through 10","483.91","1241","percent of total billed charges",""
"KNEE INSERT 4 8MM SIZE 3 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022194","CDM","C1776","HCPCS","0278","RC","","","","both","","","1561.00","1170.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","569.77","36.5","","1023.42","771.29","2068.67","33","483.91","1241","percent of total billed charges",""
"KNEE INSERT 4 8MM SIZE 3 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022194","CDM","C1776","HCPCS","0278","RC","","","","both","","","1561.00","1170.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","597.86","38.3","","850.52","759.78","1211.25","66","483.91","1241","percent of total billed charges",""
"KNEE INSERT 4 8MM SIZE 3 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022194","CDM","C1776","HCPCS","0278","RC","","","","both","","","1561.00","1170.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","669.67","42.9","","2548.09","2548.09","2548.09","1 through 10","483.91","1241","percent of total billed charges",""
"KNEE INSERT 4 8MM SIZE 3 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022194","CDM","C1776","HCPCS","0278","RC","","","","both","","","1561.00","1170.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","669.67","42.9","","956.46","956.46","956.46","1 through 10","483.91","1241","percent of total billed charges",""
"KNEE INSERT 4 8MM SIZE 3 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022194","CDM","C1776","HCPCS","0278","RC","","","","both","","","1561.00","1170.75","WELLPOINT [1015]","HB AMC WELLPOINT","1151.71","73.78","","2344.73","1619.47","2530.35","16","483.91","1241","percent of total billed charges",""
"KNEE INSERT 4 8MM SIZE 3 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022194","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1561.00","1170.75","AETNA [1001]","HB AMC AETNA HMO","1089.58","69.8","","1523.63","988.41","4330.26","39","815.78","1275.65","percent of total billed charges",""
"KNEE INSERT 4 8MM SIZE 3 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022194","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1561.00","1170.75","AETNA [1001]","HB AMC AETNA PPO","1255.04","80.4","","1670.25","1670.25","1670.25","1 through 10","815.78","1275.65","percent of total billed charges",""
"KNEE INSERT 4 8MM SIZE 3 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022194","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1561.00","1170.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","815.78","52.26","","1113.10","1113.10","1113.10","1 through 10","815.78","1275.65","percent of total billed charges",""
"KNEE INSERT 4 8MM SIZE 3 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022194","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1561.00","1170.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1275.65","81.72","","1738.90","1484.65","2716.94","38","815.78","1275.65","percent of total billed charges",""
"KNEE INSERT 5 6F 12MM SURFACE NEXGEN COMPLETE ROTATING HINGE POST EXTENSION PLATE SIZE","SUP-ITM-10130325","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2444.59","52.26","","1113.10","1113.10","1113.10","1 through 10","1450.1","3718.81","percent of total billed charges",""
"KNEE INSERT 5 6F 12MM SURFACE NEXGEN COMPLETE ROTATING HINGE POST EXTENSION PLATE SIZE","SUP-ITM-10130325","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3718.81","79.5","","1293.60","1148.53","1603.80","1 through 10","1450.1","3718.81","percent of total billed charges",""
"KNEE INSERT 5 6F 12MM SURFACE NEXGEN COMPLETE ROTATING HINGE POST EXTENSION PLATE SIZE","SUP-ITM-10130325","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1707.38","36.5","","1023.42","771.29","2068.67","33","1450.1","3718.81","percent of total billed charges",""
"KNEE INSERT 5 6F 12MM SURFACE NEXGEN COMPLETE ROTATING HINGE POST EXTENSION PLATE SIZE","SUP-ITM-10130325","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1791.58","38.3","","850.52","759.78","1211.25","66","1450.1","3718.81","percent of total billed charges",""
"KNEE INSERT 5 6F 12MM SURFACE NEXGEN COMPLETE ROTATING HINGE POST EXTENSION PLATE SIZE","SUP-ITM-10130325","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2006.75","42.9","","2548.09","2548.09","2548.09","1 through 10","1450.1","3718.81","percent of total billed charges",""
"KNEE INSERT 5 6F 12MM SURFACE NEXGEN COMPLETE ROTATING HINGE POST EXTENSION PLATE SIZE","SUP-ITM-10130325","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2006.75","42.9","","956.46","956.46","956.46","1 through 10","1450.1","3718.81","percent of total billed charges",""
"KNEE INSERT 5 6F 12MM SURFACE NEXGEN COMPLETE ROTATING HINGE POST EXTENSION PLATE SIZE","SUP-ITM-10130325","CDM","C1776","HCPCS","0278","RC","","","","both","","","4677.75","3508.31","WELLPOINT [1015]","HB AMC WELLPOINT","3451.24","73.78","","2344.73","1619.47","2530.35","16","1450.1","3718.81","percent of total billed charges",""
"KNEE INSERT 5 6F 12MM SURFACE NEXGEN COMPLETE ROTATING HINGE POST EXTENSION PLATE SIZE","SUP-ITM-10130325","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4677.75","3508.31","AETNA [1001]","HB AMC AETNA HMO","3265.07","69.8","","1523.63","988.41","4330.26","39","2444.59","3822.66","percent of total billed charges",""
"KNEE INSERT 5 6F 12MM SURFACE NEXGEN COMPLETE ROTATING HINGE POST EXTENSION PLATE SIZE","SUP-ITM-10130325","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4677.75","3508.31","AETNA [1001]","HB AMC AETNA PPO","3760.91","80.4","","1670.25","1670.25","1670.25","1 through 10","2444.59","3822.66","percent of total billed charges",""
"KNEE INSERT 5 6F 12MM SURFACE NEXGEN COMPLETE ROTATING HINGE POST EXTENSION PLATE SIZE","SUP-ITM-10130325","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4677.75","3508.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2444.59","52.26","","1113.10","1113.10","1113.10","1 through 10","2444.59","3822.66","percent of total billed charges",""
"KNEE INSERT 5 6F 12MM SURFACE NEXGEN COMPLETE ROTATING HINGE POST EXTENSION PLATE SIZE","SUP-ITM-10130325","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4677.75","3508.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3822.66","81.72","","1738.90","1484.65","2716.94","38","2444.59","3822.66","percent of total billed charges",""
"KNEE INSERT 6 13MM SIZE 5 LEGION PS POLYETHYLENE STABILIZING CONSTRAINED","SUP-ITM-10026907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 6 13MM SIZE 5 LEGION PS POLYETHYLENE STABILIZING CONSTRAINED","SUP-ITM-10026907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1324.47","79.5","","1293.60","1148.53","1603.80","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 6 13MM SIZE 5 LEGION PS POLYETHYLENE STABILIZING CONSTRAINED","SUP-ITM-10026907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","608.09","36.5","","1023.42","771.29","2068.67","33","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 6 13MM SIZE 5 LEGION PS POLYETHYLENE STABILIZING CONSTRAINED","SUP-ITM-10026907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","638.08","38.3","","850.52","759.78","1211.25","66","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 6 13MM SIZE 5 LEGION PS POLYETHYLENE STABILIZING CONSTRAINED","SUP-ITM-10026907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","2548.09","2548.09","2548.09","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 6 13MM SIZE 5 LEGION PS POLYETHYLENE STABILIZING CONSTRAINED","SUP-ITM-10026907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","956.46","956.46","956.46","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 6 13MM SIZE 5 LEGION PS POLYETHYLENE STABILIZING CONSTRAINED","SUP-ITM-10026907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","WELLPOINT [1015]","HB AMC WELLPOINT","1229.17","73.78","","2344.73","1619.47","2530.35","16","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT 6 13MM SIZE 5 LEGION PS POLYETHYLENE STABILIZING CONSTRAINED","SUP-ITM-10026907","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA HMO","1162.87","69.8","","1523.63","988.41","4330.26","39","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 6 13MM SIZE 5 LEGION PS POLYETHYLENE STABILIZING CONSTRAINED","SUP-ITM-10026907","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA PPO","1339.46","80.4","","1670.25","1670.25","1670.25","1 through 10","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 6 13MM SIZE 5 LEGION PS POLYETHYLENE STABILIZING CONSTRAINED","SUP-ITM-10026907","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 6 13MM SIZE 5 LEGION PS POLYETHYLENE STABILIZING CONSTRAINED","SUP-ITM-10026907","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1361.46","81.72","","1738.90","1484.65","2716.94","38","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT 80MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10082670","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3429.56","52.26","","1113.10","1113.10","1113.10","1 through 10","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 80MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10082670","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5217.19","79.5","","1293.60","1148.53","1603.80","1 through 10","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 80MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10082670","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2395.31","36.5","","1023.42","771.29","2068.67","33","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 80MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10082670","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2513.44","38.3","","850.52","759.78","1211.25","66","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 80MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10082670","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2815.31","42.9","","2548.09","2548.09","2548.09","1 through 10","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 80MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10082670","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2815.31","42.9","","956.46","956.46","956.46","1 through 10","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 80MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10082670","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","WELLPOINT [1015]","HB AMC WELLPOINT","4841.81","73.78","","2344.73","1619.47","2530.35","16","2034.38","5217.19","percent of total billed charges",""
"KNEE INSERT 80MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10082670","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","AETNA [1001]","HB AMC AETNA HMO","4580.63","69.8","","1523.63","988.41","4330.26","39","3429.56","5362.88","percent of total billed charges",""
"KNEE INSERT 80MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10082670","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","AETNA [1001]","HB AMC AETNA PPO","5276.25","80.4","","1670.25","1670.25","1670.25","1 through 10","3429.56","5362.88","percent of total billed charges",""
"KNEE INSERT 80MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10082670","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3429.56","52.26","","1113.10","1113.10","1113.10","1 through 10","3429.56","5362.88","percent of total billed charges",""
"KNEE INSERT 80MM SEGMENTAL ARTICULAR SURFACE FIBULAR POROUS TIBIAL MALE FEMALE","SUP-ITM-10082670","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5362.88","81.72","","1738.90","1484.65","2716.94","38","3429.56","5362.88","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 2PC IPOLY XE","SUP-ITM-10261430","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4580.59","52.26","","1113.10","1113.10","1113.10","1 through 10","2717.15","6968.18","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 2PC IPOLY XE","SUP-ITM-10261430","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6968.18","79.5","","1293.60","1148.53","1603.80","1 through 10","2717.15","6968.18","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 2PC IPOLY XE","SUP-ITM-10261430","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3199.23","36.5","","1023.42","771.29","2068.67","33","2717.15","6968.18","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 2PC IPOLY XE","SUP-ITM-10261430","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3357.00","38.3","","850.52","759.78","1211.25","66","2717.15","6968.18","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 2PC IPOLY XE","SUP-ITM-10261430","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3760.19","42.9","","2548.09","2548.09","2548.09","1 through 10","2717.15","6968.18","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 2PC IPOLY XE","SUP-ITM-10261430","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3760.19","42.9","","956.46","956.46","956.46","1 through 10","2717.15","6968.18","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 2PC IPOLY XE","SUP-ITM-10261430","CDM","C1776","HCPCS","0278","RC","","","","both","","","8765.00","6573.75","WELLPOINT [1015]","HB AMC WELLPOINT","6466.82","73.78","","2344.73","1619.47","2530.35","16","2717.15","6968.18","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 2PC IPOLY XE","SUP-ITM-10261430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8765.00","6573.75","AETNA [1001]","HB AMC AETNA HMO","6117.97","69.8","","1523.63","988.41","4330.26","39","4580.59","7162.76","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 2PC IPOLY XE","SUP-ITM-10261430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8765.00","6573.75","AETNA [1001]","HB AMC AETNA PPO","7047.06","80.4","","1670.25","1670.25","1670.25","1 through 10","4580.59","7162.76","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 2PC IPOLY XE","SUP-ITM-10261430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8765.00","6573.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4580.59","52.26","","1113.10","1113.10","1113.10","1 through 10","4580.59","7162.76","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 2PC IPOLY XE","SUP-ITM-10261430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8765.00","6573.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7162.76","81.72","","1738.90","1484.65","2716.94","38","4580.59","7162.76","percent of total billed charges",""
"KNEE INSERT LG 9MM TIBIAL LEFT","SUP-ITM-10126468","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1457.79","52.26","","1113.10","1113.10","1113.10","1 through 10","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT LG 9MM TIBIAL LEFT","SUP-ITM-10126468","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2217.65","79.5","","1293.60","1148.53","1603.80","1 through 10","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT LG 9MM TIBIAL LEFT","SUP-ITM-10126468","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1018.17","36.5","","1023.42","771.29","2068.67","33","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT LG 9MM TIBIAL LEFT","SUP-ITM-10126468","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1068.38","38.3","","850.52","759.78","1211.25","66","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT LG 9MM TIBIAL LEFT","SUP-ITM-10126468","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1196.70","42.9","","2548.09","2548.09","2548.09","1 through 10","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT LG 9MM TIBIAL LEFT","SUP-ITM-10126468","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1196.70","42.9","","956.46","956.46","956.46","1 through 10","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT LG 9MM TIBIAL LEFT","SUP-ITM-10126468","CDM","C1776","HCPCS","0278","RC","","","","both","","","2789.50","2092.12","WELLPOINT [1015]","HB AMC WELLPOINT","2058.09","73.78","","2344.73","1619.47","2530.35","16","864.75","2217.65","percent of total billed charges",""
"KNEE INSERT LG 9MM TIBIAL LEFT","SUP-ITM-10126468","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2789.50","2092.12","AETNA [1001]","HB AMC AETNA HMO","1947.07","69.8","","1523.63","988.41","4330.26","39","1457.79","2279.58","percent of total billed charges",""
"KNEE INSERT LG 9MM TIBIAL LEFT","SUP-ITM-10126468","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2789.50","2092.12","AETNA [1001]","HB AMC AETNA PPO","2242.76","80.4","","1670.25","1670.25","1670.25","1 through 10","1457.79","2279.58","percent of total billed charges",""
"KNEE INSERT LG 9MM TIBIAL LEFT","SUP-ITM-10126468","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2789.50","2092.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1457.79","52.26","","1113.10","1113.10","1113.10","1 through 10","1457.79","2279.58","percent of total billed charges",""
"KNEE INSERT LG 9MM TIBIAL LEFT","SUP-ITM-10126468","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2789.50","2092.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2279.58","81.72","","1738.90","1484.65","2716.94","38","1457.79","2279.58","percent of total billed charges",""
"KNEE INSERT SZ 2 18MM TIBIAL UC BKS- E-VITALIZE","SUP-ITM-10286284","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1371.83","52.26","","1113.10","1113.10","1113.10","1 through 10","813.75","2086.88","percent of total billed charges",""
"KNEE INSERT SZ 2 18MM TIBIAL UC BKS- E-VITALIZE","SUP-ITM-10286284","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2086.88","79.5","","1293.60","1148.53","1603.80","1 through 10","813.75","2086.88","percent of total billed charges",""
"KNEE INSERT SZ 2 18MM TIBIAL UC BKS- E-VITALIZE","SUP-ITM-10286284","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","958.13","36.5","","1023.42","771.29","2068.67","33","813.75","2086.88","percent of total billed charges",""
"KNEE INSERT SZ 2 18MM TIBIAL UC BKS- E-VITALIZE","SUP-ITM-10286284","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1005.38","38.3","","850.52","759.78","1211.25","66","813.75","2086.88","percent of total billed charges",""
"KNEE INSERT SZ 2 18MM TIBIAL UC BKS- E-VITALIZE","SUP-ITM-10286284","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1126.13","42.9","","2548.09","2548.09","2548.09","1 through 10","813.75","2086.88","percent of total billed charges",""
"KNEE INSERT SZ 2 18MM TIBIAL UC BKS- E-VITALIZE","SUP-ITM-10286284","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1126.13","42.9","","956.46","956.46","956.46","1 through 10","813.75","2086.88","percent of total billed charges",""
"KNEE INSERT SZ 2 18MM TIBIAL UC BKS- E-VITALIZE","SUP-ITM-10286284","CDM","C1776","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","WELLPOINT [1015]","HB AMC WELLPOINT","1936.73","73.78","","2344.73","1619.47","2530.35","16","813.75","2086.88","percent of total billed charges",""
"KNEE INSERT SZ 2 18MM TIBIAL UC BKS- E-VITALIZE","SUP-ITM-10286284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","AETNA [1001]","HB AMC AETNA HMO","1832.25","69.8","","1523.63","988.41","4330.26","39","1371.83","2145.15","percent of total billed charges",""
"KNEE INSERT SZ 2 18MM TIBIAL UC BKS- E-VITALIZE","SUP-ITM-10286284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","AETNA [1001]","HB AMC AETNA PPO","2110.50","80.4","","1670.25","1670.25","1670.25","1 through 10","1371.83","2145.15","percent of total billed charges",""
"KNEE INSERT SZ 2 18MM TIBIAL UC BKS- E-VITALIZE","SUP-ITM-10286284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1371.83","52.26","","1113.10","1113.10","1113.10","1 through 10","1371.83","2145.15","percent of total billed charges",""
"KNEE INSERT SZ 2 18MM TIBIAL UC BKS- E-VITALIZE","SUP-ITM-10286284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2145.15","81.72","","1738.90","1484.65","2716.94","38","1371.83","2145.15","percent of total billed charges",""
"KNEE INSERT SZ B FEMORAL SEGMENTED POLYETHYLENE","SUP-ITM-10077260","CDM","C1776","HCPCS","0278","RC","","","","both","","","1675.80","1256.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","875.77","52.26","","1113.10","1113.10","1113.10","1 through 10","519.5","1332.26","percent of total billed charges",""
"KNEE INSERT SZ B FEMORAL SEGMENTED POLYETHYLENE","SUP-ITM-10077260","CDM","C1776","HCPCS","0278","RC","","","","both","","","1675.80","1256.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1332.26","79.5","","1293.60","1148.53","1603.80","1 through 10","519.5","1332.26","percent of total billed charges",""
"KNEE INSERT SZ B FEMORAL SEGMENTED POLYETHYLENE","SUP-ITM-10077260","CDM","C1776","HCPCS","0278","RC","","","","both","","","1675.80","1256.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","611.67","36.5","","1023.42","771.29","2068.67","33","519.5","1332.26","percent of total billed charges",""
"KNEE INSERT SZ B FEMORAL SEGMENTED POLYETHYLENE","SUP-ITM-10077260","CDM","C1776","HCPCS","0278","RC","","","","both","","","1675.80","1256.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","641.83","38.3","","850.52","759.78","1211.25","66","519.5","1332.26","percent of total billed charges",""
"KNEE INSERT SZ B FEMORAL SEGMENTED POLYETHYLENE","SUP-ITM-10077260","CDM","C1776","HCPCS","0278","RC","","","","both","","","1675.80","1256.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","718.92","42.9","","2548.09","2548.09","2548.09","1 through 10","519.5","1332.26","percent of total billed charges",""
"KNEE INSERT SZ B FEMORAL SEGMENTED POLYETHYLENE","SUP-ITM-10077260","CDM","C1776","HCPCS","0278","RC","","","","both","","","1675.80","1256.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","718.92","42.9","","956.46","956.46","956.46","1 through 10","519.5","1332.26","percent of total billed charges",""
"KNEE INSERT SZ B FEMORAL SEGMENTED POLYETHYLENE","SUP-ITM-10077260","CDM","C1776","HCPCS","0278","RC","","","","both","","","1675.80","1256.85","WELLPOINT [1015]","HB AMC WELLPOINT","1236.41","73.78","","2344.73","1619.47","2530.35","16","519.5","1332.26","percent of total billed charges",""
"KNEE INSERT SZ B FEMORAL SEGMENTED POLYETHYLENE","SUP-ITM-10077260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1675.80","1256.85","AETNA [1001]","HB AMC AETNA HMO","1169.71","69.8","","1523.63","988.41","4330.26","39","875.77","1369.46","percent of total billed charges",""
"KNEE INSERT SZ B FEMORAL SEGMENTED POLYETHYLENE","SUP-ITM-10077260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1675.80","1256.85","AETNA [1001]","HB AMC AETNA PPO","1347.34","80.4","","1670.25","1670.25","1670.25","1 through 10","875.77","1369.46","percent of total billed charges",""
"KNEE INSERT SZ B FEMORAL SEGMENTED POLYETHYLENE","SUP-ITM-10077260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1675.80","1256.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","875.77","52.26","","1113.10","1113.10","1113.10","1 through 10","875.77","1369.46","percent of total billed charges",""
"KNEE INSERT SZ B FEMORAL SEGMENTED POLYETHYLENE","SUP-ITM-10077260","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1675.80","1256.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1369.46","81.72","","1738.90","1484.65","2716.94","38","875.77","1369.46","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1324.47","79.5","","1293.60","1148.53","1603.80","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","608.09","36.5","","1023.42","771.29","2068.67","33","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","638.08","38.3","","850.52","759.78","1211.25","66","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","2548.09","2548.09","2548.09","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","956.46","956.46","956.46","1 through 10","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","WELLPOINT [1015]","HB AMC WELLPOINT","1229.17","73.78","","2344.73","1619.47","2530.35","16","516.46","1324.47","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA HMO","1162.87","69.8","","1523.63","988.41","4330.26","39","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA PPO","1339.46","80.4","","1670.25","1670.25","1670.25","1 through 10","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1361.46","81.72","","1738.90","1484.65","2716.94","38","870.65","1361.46","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","198.45","148.84","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","103.71","52.26","","1113.10","1113.10","1113.10","1 through 10","61.52","157.77","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","198.45","148.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","157.77","79.5","","1293.60","1148.53","1603.80","1 through 10","61.52","157.77","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","198.45","148.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.43","36.5","","1023.42","771.29","2068.67","33","61.52","157.77","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","198.45","148.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.01","38.3","","850.52","759.78","1211.25","66","61.52","157.77","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","198.45","148.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.14","42.9","","2548.09","2548.09","2548.09","1 through 10","61.52","157.77","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","198.45","148.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.14","42.9","","956.46","956.46","956.46","1 through 10","61.52","157.77","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","198.45","148.84","WELLPOINT [1015]","HB AMC WELLPOINT","146.42","73.78","","2344.73","1619.47","2530.35","16","61.52","157.77","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","198.45","148.84","AETNA [1001]","HB AMC AETNA HMO","138.52","69.8","","1523.63","988.41","4330.26","39","103.71","162.17","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","198.45","148.84","AETNA [1001]","HB AMC AETNA PPO","159.55","80.4","","1670.25","1670.25","1670.25","1 through 10","103.71","162.17","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","198.45","148.84","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","103.71","52.26","","1113.10","1113.10","1113.10","1 through 10","103.71","162.17","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","198.45","148.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","162.17","81.72","","1738.90","1484.65","2716.94","38","103.71","162.17","percent of total billed charges",""
"Knee Joint Replacement,MAJOR","302","DRG","","","","","","","","inpatient","","","131346.01","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","44033.9129","","Fee schedule rate ($48,813.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","44033.9129","60786.80","60786.80","1 through 10","32447.48","100299.44","case rate",""
"Knee Joint Replacement,MAJOR","302","DRG","","","","","","","","inpatient","","","131346.01","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54849.96","","Fee schedule rate ($54,849.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","53252.10","53252.10","53252.10","1 through 10","32447.48","100299.44","case rate",""
"Knee Joint Replacement,MODERATE","302","DRG","","","","","","","","inpatient","","","103167.20","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","44033.9129","","Fee schedule rate ($48,813.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","44033.9129","48813.76","119663.36","1 through 10","32447.48","100299.44","case rate",""
"Knee Joint Replacement,MODERATE","302","DRG","","","","","","","","inpatient","","","103167.20","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","46236.8882","","Fee schedule rate ($51,255.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","46236.8882","51255.84","51255.84","1 through 10","32447.48","100299.44","case rate",""
"Knee Joint Replacement,MODERATE","302","DRG","","","","","","","","inpatient","","","103167.20","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","53695.77","","Fee schedule rate ($53,695.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","53695.77","53695.77","53695.77","1 through 10","32447.48","100299.44","case rate",""
"Knee Joint Replacement,MODERATE","302","DRG","","","","","","","","inpatient","","","103167.20","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","42827.29","","Fee schedule rate ($42,827.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42827.29","42827.29","42827.29","1 through 10","32447.48","100299.44","case rate",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4277.35","52.26","","1113.10","1113.10","1113.10","1 through 10","2537.27","6506.88","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6506.88","79.5","","1293.60","1148.53","1603.80","1 through 10","2537.27","6506.88","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2987.43","36.5","","1023.42","771.29","2068.67","33","2537.27","6506.88","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3134.76","38.3","","850.52","759.78","1211.25","66","2537.27","6506.88","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3511.26","42.9","","2548.09","2548.09","2548.09","1 through 10","2537.27","6506.88","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3511.26","42.9","","956.46","956.46","956.46","1 through 10","2537.27","6506.88","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","WELLPOINT [1015]","HB AMC WELLPOINT","6038.71","73.78","","2344.73","1619.47","2530.35","16","2537.27","6506.88","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8184.75","6138.56","AETNA [1001]","HB AMC AETNA HMO","5712.96","69.8","","1523.63","988.41","4330.26","39","4277.35","6688.58","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8184.75","6138.56","AETNA [1001]","HB AMC AETNA PPO","6580.54","80.4","","1670.25","1670.25","1670.25","1 through 10","4277.35","6688.58","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8184.75","6138.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4277.35","52.26","","1113.10","1113.10","1113.10","1 through 10","4277.35","6688.58","percent of total billed charges",""
"KNEE LT SIZE 3 COMPONENT TROCHLEA GENDER SOLLUTIONS PATELLO FEMORAL PRECOAT 18","SUP-ITM-10082638","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8184.75","6138.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6688.58","81.72","","1738.90","1484.65","2716.94","38","4277.35","6688.58","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3112.26","79.5","","800.18","480.96","1887.97","195","1213.58","3112.26","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2086.58","53.3","","813.12","216.42","1444.50","81","1213.58","3112.26","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1213.58","31","","432.60","432.60","432.60","1 through 10","1213.58","3112.26","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1428.90","36.5","","148.37","54.89","631.39","94","1213.58","3112.26","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1499.36","38.3","","279.30","91.72","1116.77","266","1213.58","3112.26","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1679.44","42.9","","731.00","63.70","731.00","1 through 10","1213.58","3112.26","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1679.44","42.9","","384.74","384.74","384.74","1 through 10","1213.58","3112.26","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","WELLPOINT [1015]","HB AMC WELLPOINT","2888.33","73.78","","286.63","119.22","1107.45","105","1213.58","3112.26","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","AETNA [1001]","HB AMC AETNA HMO","2732.52","69.8","","675.31","184.75","1721.50","286","2045.87","3199.17","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","AETNA [1001]","HB AMC AETNA PPO","3147.49","80.4","","1261.44","103.12","1514.10","21","2045.87","3199.17","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3147.49","80.4","","1365.00","1365.00","1365.00","1 through 10","2045.87","3199.17","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3199.17","81.72","","5157.68","5157.68","5157.68","1 through 10","2045.87","3199.17","percent of total billed charges",""
"KNEE PLATE 118MM 5 HOLE TIBIAL SS BUTTRESS LATERAL HEAD DCP LT","SUP-ITM-10001768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3199.17","81.72","","431.26","71.26","1459.57","88","2045.87","3199.17","percent of total billed charges",""
"KNEE PLATE 3.5X131MM 6 HOLE TIBIAL LCP STAINLESS POSTERIOR MEDIAL PROXIMAL","SUP-ITM-10074536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3350.17","2512.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2663.39","79.5","","800.18","480.96","1887.97","195","1038.55","2663.39","percent of total billed charges",""
"KNEE PLATE 3.5X131MM 6 HOLE TIBIAL LCP STAINLESS POSTERIOR MEDIAL PROXIMAL","SUP-ITM-10074536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3350.17","2512.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1785.64","53.3","","813.12","216.42","1444.50","81","1038.55","2663.39","percent of total billed charges",""
"KNEE PLATE 3.5X131MM 6 HOLE TIBIAL LCP STAINLESS POSTERIOR MEDIAL PROXIMAL","SUP-ITM-10074536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3350.17","2512.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1038.55","31","","432.60","432.60","432.60","1 through 10","1038.55","2663.39","percent of total billed charges",""
"KNEE PLATE 3.5X131MM 6 HOLE TIBIAL LCP STAINLESS POSTERIOR MEDIAL PROXIMAL","SUP-ITM-10074536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3350.17","2512.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1222.81","36.5","","148.37","54.89","631.39","94","1038.55","2663.39","percent of total billed charges",""
"KNEE PLATE 3.5X131MM 6 HOLE TIBIAL LCP STAINLESS POSTERIOR MEDIAL PROXIMAL","SUP-ITM-10074536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3350.17","2512.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1283.12","38.3","","279.30","91.72","1116.77","266","1038.55","2663.39","percent of total billed charges",""
"KNEE PLATE 3.5X131MM 6 HOLE TIBIAL LCP STAINLESS POSTERIOR MEDIAL PROXIMAL","SUP-ITM-10074536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3350.17","2512.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1437.22","42.9","","731.00","63.70","731.00","1 through 10","1038.55","2663.39","percent of total billed charges",""
"KNEE PLATE 3.5X131MM 6 HOLE TIBIAL LCP STAINLESS POSTERIOR MEDIAL PROXIMAL","SUP-ITM-10074536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3350.17","2512.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1437.22","42.9","","384.74","384.74","384.74","1 through 10","1038.55","2663.39","percent of total billed charges",""
"KNEE PLATE 3.5X131MM 6 HOLE TIBIAL LCP STAINLESS POSTERIOR MEDIAL PROXIMAL","SUP-ITM-10074536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3350.17","2512.63","WELLPOINT [1015]","HB AMC WELLPOINT","2471.76","73.78","","286.63","119.22","1107.45","105","1038.55","2663.39","percent of total billed charges",""
"KNEE PLATE 3.5X131MM 6 HOLE TIBIAL LCP STAINLESS POSTERIOR MEDIAL PROXIMAL","SUP-ITM-10074536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3350.17","2512.63","AETNA [1001]","HB AMC AETNA HMO","2338.42","69.8","","675.31","184.75","1721.50","286","1750.8","2737.76","percent of total billed charges",""
"KNEE PLATE 3.5X131MM 6 HOLE TIBIAL LCP STAINLESS POSTERIOR MEDIAL PROXIMAL","SUP-ITM-10074536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3350.17","2512.63","AETNA [1001]","HB AMC AETNA PPO","2693.54","80.4","","1261.44","103.12","1514.10","21","1750.8","2737.76","percent of total billed charges",""
"KNEE PLATE 3.5X131MM 6 HOLE TIBIAL LCP STAINLESS POSTERIOR MEDIAL PROXIMAL","SUP-ITM-10074536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3350.17","2512.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2693.54","80.4","","1365.00","1365.00","1365.00","1 through 10","1750.8","2737.76","percent of total billed charges",""
"KNEE PLATE 3.5X131MM 6 HOLE TIBIAL LCP STAINLESS POSTERIOR MEDIAL PROXIMAL","SUP-ITM-10074536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3350.17","2512.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2737.76","81.72","","5157.68","5157.68","5157.68","1 through 10","1750.8","2737.76","percent of total billed charges",""
"KNEE PLATE 3.5X131MM 6 HOLE TIBIAL LCP STAINLESS POSTERIOR MEDIAL PROXIMAL","SUP-ITM-10074536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3350.17","2512.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2737.76","81.72","","431.26","71.26","1459.57","88","1750.8","2737.76","percent of total billed charges",""
"KNEE PLATE 3.5X157MM 8 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10092313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3486.14","2614.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2771.48","79.5","","800.18","480.96","1887.97","195","1080.7","2771.48","percent of total billed charges",""
"KNEE PLATE 3.5X157MM 8 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10092313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3486.14","2614.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1858.11","53.3","","813.12","216.42","1444.50","81","1080.7","2771.48","percent of total billed charges",""
"KNEE PLATE 3.5X157MM 8 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10092313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3486.14","2614.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1080.70","31","","432.60","432.60","432.60","1 through 10","1080.7","2771.48","percent of total billed charges",""
"KNEE PLATE 3.5X157MM 8 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10092313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3486.14","2614.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1272.44","36.5","","148.37","54.89","631.39","94","1080.7","2771.48","percent of total billed charges",""
"KNEE PLATE 3.5X157MM 8 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10092313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3486.14","2614.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1335.19","38.3","","279.30","91.72","1116.77","266","1080.7","2771.48","percent of total billed charges",""
"KNEE PLATE 3.5X157MM 8 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10092313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3486.14","2614.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1495.55","42.9","","731.00","63.70","731.00","1 through 10","1080.7","2771.48","percent of total billed charges",""
"KNEE PLATE 3.5X157MM 8 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10092313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3486.14","2614.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1495.55","42.9","","384.74","384.74","384.74","1 through 10","1080.7","2771.48","percent of total billed charges",""
"KNEE PLATE 3.5X157MM 8 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10092313","CDM","C1713","HCPCS","0278","RC","","","","both","","","3486.14","2614.60","WELLPOINT [1015]","HB AMC WELLPOINT","2572.07","73.78","","286.63","119.22","1107.45","105","1080.7","2771.48","percent of total billed charges",""
"KNEE PLATE 3.5X157MM 8 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10092313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3486.14","2614.60","AETNA [1001]","HB AMC AETNA HMO","2433.33","69.8","","675.31","184.75","1721.50","286","1821.86","2848.87","percent of total billed charges",""
"KNEE PLATE 3.5X157MM 8 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10092313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3486.14","2614.60","AETNA [1001]","HB AMC AETNA PPO","2802.86","80.4","","1261.44","103.12","1514.10","21","1821.86","2848.87","percent of total billed charges",""
"KNEE PLATE 3.5X157MM 8 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10092313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3486.14","2614.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2802.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1821.86","2848.87","percent of total billed charges",""
"KNEE PLATE 3.5X157MM 8 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10092313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3486.14","2614.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2848.87","81.72","","5157.68","5157.68","5157.68","1 through 10","1821.86","2848.87","percent of total billed charges",""
"KNEE PLATE 3.5X157MM 8 HOLE LCP STAINLESS POSTERIOR MEDIAL PROXIMAL TIBIAL","SUP-ITM-10092313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3486.14","2614.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2848.87","81.72","","431.26","71.26","1459.57","88","1821.86","2848.87","percent of total billed charges",""
"KNEE PLATE SIZE 6 FEMORAL EVOLUTION MP CRUCIATE SUBSTITUTION RETAINING NONPORUS PRIMARY LEFT","SUP-ITM-10123978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","800.18","480.96","1887.97","195","1302","3339","percent of total billed charges",""
"KNEE PLATE SIZE 6 FEMORAL EVOLUTION MP CRUCIATE SUBSTITUTION RETAINING NONPORUS PRIMARY LEFT","SUP-ITM-10123978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2238.60","53.3","","813.12","216.42","1444.50","81","1302","3339","percent of total billed charges",""
"KNEE PLATE SIZE 6 FEMORAL EVOLUTION MP CRUCIATE SUBSTITUTION RETAINING NONPORUS PRIMARY LEFT","SUP-ITM-10123978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1302.00","31","","432.60","432.60","432.60","1 through 10","1302","3339","percent of total billed charges",""
"KNEE PLATE SIZE 6 FEMORAL EVOLUTION MP CRUCIATE SUBSTITUTION RETAINING NONPORUS PRIMARY LEFT","SUP-ITM-10123978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","148.37","54.89","631.39","94","1302","3339","percent of total billed charges",""
"KNEE PLATE SIZE 6 FEMORAL EVOLUTION MP CRUCIATE SUBSTITUTION RETAINING NONPORUS PRIMARY LEFT","SUP-ITM-10123978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","279.30","91.72","1116.77","266","1302","3339","percent of total billed charges",""
"KNEE PLATE SIZE 6 FEMORAL EVOLUTION MP CRUCIATE SUBSTITUTION RETAINING NONPORUS PRIMARY LEFT","SUP-ITM-10123978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","731.00","63.70","731.00","1 through 10","1302","3339","percent of total billed charges",""
"KNEE PLATE SIZE 6 FEMORAL EVOLUTION MP CRUCIATE SUBSTITUTION RETAINING NONPORUS PRIMARY LEFT","SUP-ITM-10123978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","384.74","384.74","384.74","1 through 10","1302","3339","percent of total billed charges",""
"KNEE PLATE SIZE 6 FEMORAL EVOLUTION MP CRUCIATE SUBSTITUTION RETAINING NONPORUS PRIMARY LEFT","SUP-ITM-10123978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","286.63","119.22","1107.45","105","1302","3339","percent of total billed charges",""
"KNEE PLATE SIZE 6 FEMORAL EVOLUTION MP CRUCIATE SUBSTITUTION RETAINING NONPORUS PRIMARY LEFT","SUP-ITM-10123978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","675.31","184.75","1721.50","286","2194.92","3432.24","percent of total billed charges",""
"KNEE PLATE SIZE 6 FEMORAL EVOLUTION MP CRUCIATE SUBSTITUTION RETAINING NONPORUS PRIMARY LEFT","SUP-ITM-10123978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1261.44","103.12","1514.10","21","2194.92","3432.24","percent of total billed charges",""
"KNEE PLATE SIZE 6 FEMORAL EVOLUTION MP CRUCIATE SUBSTITUTION RETAINING NONPORUS PRIMARY LEFT","SUP-ITM-10123978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3376.80","80.4","","1365.00","1365.00","1365.00","1 through 10","2194.92","3432.24","percent of total billed charges",""
"KNEE PLATE SIZE 6 FEMORAL EVOLUTION MP CRUCIATE SUBSTITUTION RETAINING NONPORUS PRIMARY LEFT","SUP-ITM-10123978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3432.24","81.72","","5157.68","5157.68","5157.68","1 through 10","2194.92","3432.24","percent of total billed charges",""
"KNEE PLATE SIZE 6 FEMORAL EVOLUTION MP CRUCIATE SUBSTITUTION RETAINING NONPORUS PRIMARY LEFT","SUP-ITM-10123978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","431.26","71.26","1459.57","88","2194.92","3432.24","percent of total billed charges",""
"KNEE PLATE SIZE 8.0 TIBIAL NEXGEN STEMMED PRECOAT TIVANIUM","SUP-ITM-10017147","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.66","52.26","","1113.10","1113.10","1113.10","1 through 10","1266.85","3248.85","percent of total billed charges",""
"KNEE PLATE SIZE 8.0 TIBIAL NEXGEN STEMMED PRECOAT TIVANIUM","SUP-ITM-10017147","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3248.85","79.5","","1293.60","1148.53","1603.80","1 through 10","1266.85","3248.85","percent of total billed charges",""
"KNEE PLATE SIZE 8.0 TIBIAL NEXGEN STEMMED PRECOAT TIVANIUM","SUP-ITM-10017147","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1491.61","36.5","","1023.42","771.29","2068.67","33","1266.85","3248.85","percent of total billed charges",""
"KNEE PLATE SIZE 8.0 TIBIAL NEXGEN STEMMED PRECOAT TIVANIUM","SUP-ITM-10017147","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1565.17","38.3","","850.52","759.78","1211.25","66","1266.85","3248.85","percent of total billed charges",""
"KNEE PLATE SIZE 8.0 TIBIAL NEXGEN STEMMED PRECOAT TIVANIUM","SUP-ITM-10017147","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.15","42.9","","2548.09","2548.09","2548.09","1 through 10","1266.85","3248.85","percent of total billed charges",""
"KNEE PLATE SIZE 8.0 TIBIAL NEXGEN STEMMED PRECOAT TIVANIUM","SUP-ITM-10017147","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.15","42.9","","956.46","956.46","956.46","1 through 10","1266.85","3248.85","percent of total billed charges",""
"KNEE PLATE SIZE 8.0 TIBIAL NEXGEN STEMMED PRECOAT TIVANIUM","SUP-ITM-10017147","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","WELLPOINT [1015]","HB AMC WELLPOINT","3015.09","73.78","","2344.73","1619.47","2530.35","16","1266.85","3248.85","percent of total billed charges",""
"KNEE PLATE SIZE 8.0 TIBIAL NEXGEN STEMMED PRECOAT TIVANIUM","SUP-ITM-10017147","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","AETNA [1001]","HB AMC AETNA HMO","2852.45","69.8","","1523.63","988.41","4330.26","39","2135.66","3339.57","percent of total billed charges",""
"KNEE PLATE SIZE 8.0 TIBIAL NEXGEN STEMMED PRECOAT TIVANIUM","SUP-ITM-10017147","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","AETNA [1001]","HB AMC AETNA PPO","3285.63","80.4","","1670.25","1670.25","1670.25","1 through 10","2135.66","3339.57","percent of total billed charges",""
"KNEE PLATE SIZE 8.0 TIBIAL NEXGEN STEMMED PRECOAT TIVANIUM","SUP-ITM-10017147","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.66","52.26","","1113.10","1113.10","1113.10","1 through 10","2135.66","3339.57","percent of total billed charges",""
"KNEE PLATE SIZE 8.0 TIBIAL NEXGEN STEMMED PRECOAT TIVANIUM","SUP-ITM-10017147","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3339.57","81.72","","1738.90","1484.65","2716.94","38","2135.66","3339.57","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4073.67","52.26","","1113.10","1113.10","1113.10","1 through 10","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6197.03","79.5","","1293.60","1148.53","1603.80","1 through 10","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2845.18","36.5","","1023.42","771.29","2068.67","33","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2985.49","38.3","","850.52","759.78","1211.25","66","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3344.06","42.9","","2548.09","2548.09","2548.09","1 through 10","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3344.06","42.9","","956.46","956.46","956.46","1 through 10","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","WELLPOINT [1015]","HB AMC WELLPOINT","5751.15","73.78","","2344.73","1619.47","2530.35","16","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7795.00","5846.25","AETNA [1001]","HB AMC AETNA HMO","5440.91","69.8","","1523.63","988.41","4330.26","39","4073.67","6370.07","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7795.00","5846.25","AETNA [1001]","HB AMC AETNA PPO","6267.18","80.4","","1670.25","1670.25","1670.25","1 through 10","4073.67","6370.07","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7795.00","5846.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4073.67","52.26","","1113.10","1113.10","1113.10","1 through 10","4073.67","6370.07","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7795.00","5846.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6370.07","81.72","","1738.90","1484.65","2716.94","38","4073.67","6370.07","percent of total billed charges",""
"KNEE POST 54.3MM LG COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG 6430-0-300","SUP-ITM-10020048","CDM","C1713","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6197.03","79.5","","800.18","480.96","1887.97","195","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 54.3MM LG COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG 6430-0-300","SUP-ITM-10020048","CDM","C1713","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4154.74","53.3","","813.12","216.42","1444.50","81","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 54.3MM LG COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG 6430-0-300","SUP-ITM-10020048","CDM","C1713","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2416.45","31","","432.60","432.60","432.60","1 through 10","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 54.3MM LG COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG 6430-0-300","SUP-ITM-10020048","CDM","C1713","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2845.18","36.5","","148.37","54.89","631.39","94","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 54.3MM LG COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG 6430-0-300","SUP-ITM-10020048","CDM","C1713","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2985.49","38.3","","279.30","91.72","1116.77","266","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 54.3MM LG COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG 6430-0-300","SUP-ITM-10020048","CDM","C1713","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3344.06","42.9","","731.00","63.70","731.00","1 through 10","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 54.3MM LG COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG 6430-0-300","SUP-ITM-10020048","CDM","C1713","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3344.06","42.9","","384.74","384.74","384.74","1 through 10","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 54.3MM LG COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG 6430-0-300","SUP-ITM-10020048","CDM","C1713","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","WELLPOINT [1015]","HB AMC WELLPOINT","5751.15","73.78","","286.63","119.22","1107.45","105","2416.45","6197.03","percent of total billed charges",""
"KNEE POST 54.3MM LG COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG 6430-0-300","SUP-ITM-10020048","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7795.00","5846.25","AETNA [1001]","HB AMC AETNA HMO","5440.91","69.8","","675.31","184.75","1721.50","286","4073.67","6370.07","percent of total billed charges",""
"KNEE POST 54.3MM LG COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG 6430-0-300","SUP-ITM-10020048","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7795.00","5846.25","AETNA [1001]","HB AMC AETNA PPO","6267.18","80.4","","1261.44","103.12","1514.10","21","4073.67","6370.07","percent of total billed charges",""
"KNEE POST 54.3MM LG COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG 6430-0-300","SUP-ITM-10020048","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7795.00","5846.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6267.18","80.4","","1365.00","1365.00","1365.00","1 through 10","4073.67","6370.07","percent of total billed charges",""
"KNEE POST 54.3MM LG COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG 6430-0-300","SUP-ITM-10020048","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7795.00","5846.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6370.07","81.72","","5157.68","5157.68","5157.68","1 through 10","4073.67","6370.07","percent of total billed charges",""
"KNEE POST 54.3MM LG COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG 6430-0-300","SUP-ITM-10020048","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7795.00","5846.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6370.07","81.72","","431.26","71.26","1459.57","88","4073.67","6370.07","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","740.79","52.26","","1113.10","1113.10","1113.10","1 through 10","439.43","1126.91","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1126.91","79.5","","1293.60","1148.53","1603.80","1 through 10","439.43","1126.91","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","517.39","36.5","","1023.42","771.29","2068.67","33","439.43","1126.91","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","542.90","38.3","","850.52","759.78","1211.25","66","439.43","1126.91","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","608.11","42.9","","2548.09","2548.09","2548.09","1 through 10","439.43","1126.91","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","608.11","42.9","","956.46","956.46","956.46","1 through 10","439.43","1126.91","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1417.50","1063.12","WELLPOINT [1015]","HB AMC WELLPOINT","1045.83","73.78","","2344.73","1619.47","2530.35","16","439.43","1126.91","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","AETNA [1001]","HB AMC AETNA HMO","989.42","69.8","","1523.63","988.41","4330.26","39","740.79","1158.38","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","AETNA [1001]","HB AMC AETNA PPO","1139.67","80.4","","1670.25","1670.25","1670.25","1 through 10","740.79","1158.38","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","740.79","52.26","","1113.10","1113.10","1113.10","1 through 10","740.79","1158.38","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1417.50","1063.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1158.38","81.72","","1738.90","1484.65","2716.94","38","740.79","1158.38","percent of total billed charges",""
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","","","","inpatient","","","106578.88","79934.16","MEDICARE [2001]","HB BWH MEDICARE","25136.21","","Case rate ($25,136.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,342.66, add-ons for qualifying new technology services are included. If operating cost exceeds $68,987.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,122.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $23,073.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,962.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,682.62. The transfer capital threshold is the transfer adjustment factor * $1,682.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25281.90","25281.90","25281.90","1 through 10","19065.97","32006.5019","other","Inpatient DRG"
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","","","","inpatient","","","106578.88","79934.16","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19065.97","","Case rate ($19,455.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,342.66, add-ons for qualifying new technology services are included. If operating cost exceeds $68,987.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,122.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,392.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,962.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,682.62. The transfer capital threshold is the transfer adjustment factor * $1,682.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19138.52","19138.52","19138.52","1 through 10","19065.97","32006.5019","other","Inpatient DRG"
"Knee Procedures With Principal Diagnosis Of Infection With McC","485","MS-DRG","","","","","","","","inpatient","","","197199.46","147899.59","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","38585.24","","Case rate ($38,585.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,817.33, add-ons for qualifying new technology services are included. If operating cost exceeds $81,461.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,036.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $35,608.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,437.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,596.71. The transfer capital threshold is the transfer adjustment factor * $2,596.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","125523.57","125523.57","125523.57","1 through 10","29221.43","48582.4563","other","Inpatient DRG"
"Knee Procedures With Principal Diagnosis Of Infection With McC","485","MS-DRG","","","","","","","","inpatient","","","197199.46","147899.59","MEDICARE [2001]","HB BWH MEDICARE","38585.24","","Case rate ($38,585.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,817.33, add-ons for qualifying new technology services are included. If operating cost exceeds $81,461.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,036.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $35,608.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,437.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,596.71. The transfer capital threshold is the transfer adjustment factor * $2,596.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38287.86","38231.09","38287.86","1 through 10","29221.43","48582.4563","other","Inpatient DRG"
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/McC","487","MS-DRG","","","","","","","","inpatient","","","85437.91","64078.43","MEDICARE [2001]","HB BWH MEDICARE","18921.96","","Case rate ($18,921.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,578.62, add-ons for qualifying new technology services are included. If operating cost exceeds $63,223.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,700.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $17,281.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,198.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,260.26. The transfer capital threshold is the transfer adjustment factor * $1,260.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18935.38","18935.38","18935.38","1 through 10","14373.54","23846.7982","other","Inpatient DRG"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC","488","MS-DRG","","","","","","","","inpatient","","","147972.38","110979.28","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","21321.71","","Case rate ($21,321.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,804.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,448.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,863.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $19,518.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,424.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,423.36. The transfer capital threshold is the transfer adjustment factor * $1,423.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23098.66","23098.66","23098.66","1 through 10","16185.61","27708.05","other","Inpatient DRG"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC","488","MS-DRG","","","","","","","","inpatient","","","147972.38","110979.28","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","16515.93","","Case rate ($16,515.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,804.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,448.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,863.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,712.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,424.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,423.36. The transfer capital threshold is the transfer adjustment factor * $1,423.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17844.13","17844.13","17844.13","1 through 10","16185.61","27708.05","other","Inpatient DRG"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC","488","MS-DRG","","","","","","","","inpatient","","","147972.38","110979.28","MEDICARE [2001]","HB BWH MEDICARE","21321.71","","Case rate ($21,321.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,804.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,448.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,863.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $19,518.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,424.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,423.36. The transfer capital threshold is the transfer adjustment factor * $1,423.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23476.03","0.03","23483.34","1 through 10","16185.61","27708.05","other","Inpatient DRG"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC","488","MS-DRG","","","","","","","","inpatient","","","147972.38","110979.28","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","21321.71","","Case rate ($21,321.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,804.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,448.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,863.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $19,518.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,424.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,423.36. The transfer capital threshold is the transfer adjustment factor * $1,423.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17807.28","17807.28","17807.28","1 through 10","16185.61","27708.05","other","Inpatient DRG"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC","488","MS-DRG","","","","","","","","inpatient","","","147972.38","110979.28","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16185.61","","Case rate ($16,515.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,804.51, add-ons for qualifying new technology services are included. If operating cost exceeds $65,448.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,863.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $14,712.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,424.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,423.36. The transfer capital threshold is the transfer adjustment factor * $1,423.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17844.48","17844.48","17844.48","1 through 10","16185.61","27708.05","other","Inpatient DRG"
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC","489","MS-DRG","","","","","","","","inpatient","","","119715.45","89786.59","MEDICARE [2001]","HB BWH MEDICARE","10567.40","","Case rate ($10,567.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,643.66, add-ons for qualifying new technology services are included. If operating cost exceeds $58,288.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,338.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,288.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,263.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $898.64. The transfer capital threshold is the transfer adjustment factor * $898.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14899.81","14899.81","14899.81","1 through 10","10356.05","17493.56","other","Inpatient Replacement Plans DRG"
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","537.76","52.26","","1113.10","1113.10","1113.10","1 through 10","318.99","818.06","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","818.06","79.5","","1293.60","1148.53","1603.80","1 through 10","318.99","818.06","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","375.59","36.5","","1023.42","771.29","2068.67","33","318.99","818.06","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","394.11","38.3","","850.52","759.78","1211.25","66","318.99","818.06","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","441.44","42.9","","2548.09","2548.09","2548.09","1 through 10","318.99","818.06","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","441.44","42.9","","956.46","956.46","956.46","1 through 10","318.99","818.06","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","1029.00","771.75","WELLPOINT [1015]","HB AMC WELLPOINT","759.20","73.78","","2344.73","1619.47","2530.35","16","318.99","818.06","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","AETNA [1001]","HB AMC AETNA HMO","718.24","69.8","","1523.63","988.41","4330.26","39","537.76","840.9","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","AETNA [1001]","HB AMC AETNA PPO","827.32","80.4","","1670.25","1670.25","1670.25","1 through 10","537.76","840.9","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","537.76","52.26","","1113.10","1113.10","1113.10","1 through 10","537.76","840.9","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","840.90","81.72","","1738.90","1484.65","2716.94","38","537.76","840.9","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2103.47","52.26","","1113.10","1113.10","1113.10","1 through 10","1247.75","3199.88","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3199.88","79.5","","1293.60","1148.53","1603.80","1 through 10","1247.75","3199.88","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1469.13","36.5","","1023.42","771.29","2068.67","33","1247.75","3199.88","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1541.58","38.3","","850.52","759.78","1211.25","66","1247.75","3199.88","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1247.75","3199.88","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.73","42.9","","956.46","956.46","956.46","1 through 10","1247.75","3199.88","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","WELLPOINT [1015]","HB AMC WELLPOINT","2969.65","73.78","","2344.73","1619.47","2530.35","16","1247.75","3199.88","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","AETNA [1001]","HB AMC AETNA HMO","2809.45","69.8","","1523.63","988.41","4330.26","39","2103.47","3289.23","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","AETNA [1001]","HB AMC AETNA PPO","3236.10","80.4","","1670.25","1670.25","1670.25","1 through 10","2103.47","3289.23","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2103.47","52.26","","1113.10","1113.10","1113.10","1 through 10","2103.47","3289.23","percent of total billed charges",""
"KNEE SPACER MOLD 70MM STAGEONE SILICONE AGC STYLE FEMORAL","SUP-ITM-10018188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3289.23","81.72","","1738.90","1484.65","2716.94","38","2103.47","3289.23","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1006.01","52.26","","1113.10","1113.10","1113.10","1 through 10","596.75","1530.38","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1530.38","79.5","","1293.60","1148.53","1603.80","1 through 10","596.75","1530.38","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","702.63","36.5","","1023.42","771.29","2068.67","33","596.75","1530.38","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","737.28","38.3","","850.52","759.78","1211.25","66","596.75","1530.38","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","2548.09","2548.09","2548.09","1 through 10","596.75","1530.38","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","956.46","956.46","956.46","1 through 10","596.75","1530.38","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","WELLPOINT [1015]","HB AMC WELLPOINT","1420.27","73.78","","2344.73","1619.47","2530.35","16","596.75","1530.38","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA HMO","1343.65","69.8","","1523.63","988.41","4330.26","39","1006.01","1573.11","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA PPO","1547.70","80.4","","1670.25","1670.25","1670.25","1 through 10","1006.01","1573.11","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1006.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1006.01","1573.11","percent of total billed charges",""
"KNEE SPACER MOLD TEMPORARY 70MM STAGEONE SILICONE AGC STYLE TIBIAL","SUP-ITM-10018187","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1573.11","81.72","","1738.90","1484.65","2716.94","38","1006.01","1573.11","percent of total billed charges",""
"KNEE SPACER SIZE E FEMORAL COMPONENT NEXGEN CR POROUS LEFT","SUP-ITM-10001819","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2298.39","52.26","","1113.10","1113.10","1113.10","1 through 10","1363.38","3496.41","percent of total billed charges",""
"KNEE SPACER SIZE E FEMORAL COMPONENT NEXGEN CR POROUS LEFT","SUP-ITM-10001819","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3496.41","79.5","","1293.60","1148.53","1603.80","1 through 10","1363.38","3496.41","percent of total billed charges",""
"KNEE SPACER SIZE E FEMORAL COMPONENT NEXGEN CR POROUS LEFT","SUP-ITM-10001819","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1605.27","36.5","","1023.42","771.29","2068.67","33","1363.38","3496.41","percent of total billed charges",""
"KNEE SPACER SIZE E FEMORAL COMPONENT NEXGEN CR POROUS LEFT","SUP-ITM-10001819","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1684.43","38.3","","850.52","759.78","1211.25","66","1363.38","3496.41","percent of total billed charges",""
"KNEE SPACER SIZE E FEMORAL COMPONENT NEXGEN CR POROUS LEFT","SUP-ITM-10001819","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1886.74","42.9","","2548.09","2548.09","2548.09","1 through 10","1363.38","3496.41","percent of total billed charges",""
"KNEE SPACER SIZE E FEMORAL COMPONENT NEXGEN CR POROUS LEFT","SUP-ITM-10001819","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1886.74","42.9","","956.46","956.46","956.46","1 through 10","1363.38","3496.41","percent of total billed charges",""
"KNEE SPACER SIZE E FEMORAL COMPONENT NEXGEN CR POROUS LEFT","SUP-ITM-10001819","CDM","C1776","HCPCS","0278","RC","","","","both","","","4398.00","3298.50","WELLPOINT [1015]","HB AMC WELLPOINT","3244.84","73.78","","2344.73","1619.47","2530.35","16","1363.38","3496.41","percent of total billed charges",""
"KNEE SPACER SIZE E FEMORAL COMPONENT NEXGEN CR POROUS LEFT","SUP-ITM-10001819","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4398.00","3298.50","AETNA [1001]","HB AMC AETNA HMO","3069.80","69.8","","1523.63","988.41","4330.26","39","2298.39","3594.05","percent of total billed charges",""
"KNEE SPACER SIZE E FEMORAL COMPONENT NEXGEN CR POROUS LEFT","SUP-ITM-10001819","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4398.00","3298.50","AETNA [1001]","HB AMC AETNA PPO","3535.99","80.4","","1670.25","1670.25","1670.25","1 through 10","2298.39","3594.05","percent of total billed charges",""
"KNEE SPACER SIZE E FEMORAL COMPONENT NEXGEN CR POROUS LEFT","SUP-ITM-10001819","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4398.00","3298.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2298.39","52.26","","1113.10","1113.10","1113.10","1 through 10","2298.39","3594.05","percent of total billed charges",""
"KNEE SPACER SIZE E FEMORAL COMPONENT NEXGEN CR POROUS LEFT","SUP-ITM-10001819","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4398.00","3298.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3594.05","81.72","","1738.90","1484.65","2716.94","38","2298.39","3594.05","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2939.63","52.26","","1113.10","1113.10","1113.10","1 through 10","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4471.88","79.5","","1293.60","1148.53","1603.80","1 through 10","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2053.13","36.5","","1023.42","771.29","2068.67","33","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2154.38","38.3","","850.52","759.78","1211.25","66","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2413.13","42.9","","2548.09","2548.09","2548.09","1 through 10","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2413.13","42.9","","956.46","956.46","956.46","1 through 10","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","WELLPOINT [1015]","HB AMC WELLPOINT","4150.13","73.78","","2344.73","1619.47","2530.35","16","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","AETNA [1001]","HB AMC AETNA HMO","3926.25","69.8","","1523.63","988.41","4330.26","39","2939.63","4596.75","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","AETNA [1001]","HB AMC AETNA PPO","4522.50","80.4","","1670.25","1670.25","1670.25","1 through 10","2939.63","4596.75","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2939.63","52.26","","1113.10","1113.10","1113.10","1 through 10","2939.63","4596.75","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4596.75","81.72","","1738.90","1484.65","2716.94","38","2939.63","4596.75","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2939.63","52.26","","1113.10","1113.10","1113.10","1 through 10","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4471.88","79.5","","1293.60","1148.53","1603.80","1 through 10","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2053.13","36.5","","1023.42","771.29","2068.67","33","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2154.38","38.3","","850.52","759.78","1211.25","66","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2413.13","42.9","","2548.09","2548.09","2548.09","1 through 10","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2413.13","42.9","","956.46","956.46","956.46","1 through 10","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","WELLPOINT [1015]","HB AMC WELLPOINT","4150.13","73.78","","2344.73","1619.47","2530.35","16","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","AETNA [1001]","HB AMC AETNA HMO","3926.25","69.8","","1523.63","988.41","4330.26","39","2939.63","4596.75","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","AETNA [1001]","HB AMC AETNA PPO","4522.50","80.4","","1670.25","1670.25","1670.25","1 through 10","2939.63","4596.75","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2939.63","52.26","","1113.10","1113.10","1113.10","1 through 10","2939.63","4596.75","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4596.75","81.72","","1738.90","1484.65","2716.94","38","2939.63","4596.75","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","7793.75","5845.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4073.01","52.26","","1113.10","1113.10","1113.10","1 through 10","2416.06","6196.03","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","7793.75","5845.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6196.03","79.5","","1293.60","1148.53","1603.80","1 through 10","2416.06","6196.03","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","7793.75","5845.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2844.72","36.5","","1023.42","771.29","2068.67","33","2416.06","6196.03","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","7793.75","5845.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2985.01","38.3","","850.52","759.78","1211.25","66","2416.06","6196.03","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","7793.75","5845.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3343.52","42.9","","2548.09","2548.09","2548.09","1 through 10","2416.06","6196.03","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","7793.75","5845.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3343.52","42.9","","956.46","956.46","956.46","1 through 10","2416.06","6196.03","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","7793.75","5845.31","WELLPOINT [1015]","HB AMC WELLPOINT","5750.23","73.78","","2344.73","1619.47","2530.35","16","2416.06","6196.03","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7793.75","5845.31","AETNA [1001]","HB AMC AETNA HMO","5440.04","69.8","","1523.63","988.41","4330.26","39","4073.01","6369.05","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7793.75","5845.31","AETNA [1001]","HB AMC AETNA PPO","6266.18","80.4","","1670.25","1670.25","1670.25","1 through 10","4073.01","6369.05","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7793.75","5845.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4073.01","52.26","","1113.10","1113.10","1113.10","1 through 10","4073.01","6369.05","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7793.75","5845.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6369.05","81.72","","1738.90","1484.65","2716.94","38","4073.01","6369.05","percent of total billed charges",""
"KNEE STEM 120MM OD 14 EXTENDER SMOOTH IMPL VANGUARD 360","SUP-ITM-10121875","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1338.63","52.26","","1113.10","1113.10","1113.10","1 through 10","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 120MM OD 14 EXTENDER SMOOTH IMPL VANGUARD 360","SUP-ITM-10121875","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2036.38","79.5","","1293.60","1148.53","1603.80","1 through 10","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 120MM OD 14 EXTENDER SMOOTH IMPL VANGUARD 360","SUP-ITM-10121875","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","934.94","36.5","","1023.42","771.29","2068.67","33","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 120MM OD 14 EXTENDER SMOOTH IMPL VANGUARD 360","SUP-ITM-10121875","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","981.05","38.3","","850.52","759.78","1211.25","66","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 120MM OD 14 EXTENDER SMOOTH IMPL VANGUARD 360","SUP-ITM-10121875","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1098.87","42.9","","2548.09","2548.09","2548.09","1 through 10","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 120MM OD 14 EXTENDER SMOOTH IMPL VANGUARD 360","SUP-ITM-10121875","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1098.87","42.9","","956.46","956.46","956.46","1 through 10","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 120MM OD 14 EXTENDER SMOOTH IMPL VANGUARD 360","SUP-ITM-10121875","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","WELLPOINT [1015]","HB AMC WELLPOINT","1889.86","73.78","","2344.73","1619.47","2530.35","16","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 120MM OD 14 EXTENDER SMOOTH IMPL VANGUARD 360","SUP-ITM-10121875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2561.48","1921.11","AETNA [1001]","HB AMC AETNA HMO","1787.91","69.8","","1523.63","988.41","4330.26","39","1338.63","2093.24","percent of total billed charges",""
"KNEE STEM 120MM OD 14 EXTENDER SMOOTH IMPL VANGUARD 360","SUP-ITM-10121875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2561.48","1921.11","AETNA [1001]","HB AMC AETNA PPO","2059.43","80.4","","1670.25","1670.25","1670.25","1 through 10","1338.63","2093.24","percent of total billed charges",""
"KNEE STEM 120MM OD 14 EXTENDER SMOOTH IMPL VANGUARD 360","SUP-ITM-10121875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2561.48","1921.11","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1338.63","52.26","","1113.10","1113.10","1113.10","1 through 10","1338.63","2093.24","percent of total billed charges",""
"KNEE STEM 120MM OD 14 EXTENDER SMOOTH IMPL VANGUARD 360","SUP-ITM-10121875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2561.48","1921.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2093.24","81.72","","1738.90","1484.65","2716.94","38","1338.63","2093.24","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","552.39","52.26","","1113.10","1113.10","1113.10","1 through 10","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","840.32","79.5","","1293.60","1148.53","1603.80","1 through 10","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","385.81","36.5","","1023.42","771.29","2068.67","33","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","404.83","38.3","","850.52","759.78","1211.25","66","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.45","42.9","","2548.09","2548.09","2548.09","1 through 10","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.45","42.9","","956.46","956.46","956.46","1 through 10","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","WELLPOINT [1015]","HB AMC WELLPOINT","779.85","73.78","","2344.73","1619.47","2530.35","16","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1057.00","792.75","AETNA [1001]","HB AMC AETNA HMO","737.79","69.8","","1523.63","988.41","4330.26","39","552.39","863.78","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1057.00","792.75","AETNA [1001]","HB AMC AETNA PPO","849.83","80.4","","1670.25","1670.25","1670.25","1 through 10","552.39","863.78","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1057.00","792.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","552.39","52.26","","1113.10","1113.10","1113.10","1 through 10","552.39","863.78","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1057.00","792.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","863.78","81.72","","1738.90","1484.65","2716.94","38","552.39","863.78","percent of total billed charges",""
"KNEE STEM 12X120MM FEMORAL LEGION TITANIUM PRESS FIT NON SLOTTED","SUP-ITM-10042183","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 12X120MM FEMORAL LEGION TITANIUM PRESS FIT NON SLOTTED","SUP-ITM-10042183","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1293.60","1148.53","1603.80","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 12X120MM FEMORAL LEGION TITANIUM PRESS FIT NON SLOTTED","SUP-ITM-10042183","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1023.42","771.29","2068.67","33","651","1669.5","percent of total billed charges",""
"KNEE STEM 12X120MM FEMORAL LEGION TITANIUM PRESS FIT NON SLOTTED","SUP-ITM-10042183","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","850.52","759.78","1211.25","66","651","1669.5","percent of total billed charges",""
"KNEE STEM 12X120MM FEMORAL LEGION TITANIUM PRESS FIT NON SLOTTED","SUP-ITM-10042183","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","2548.09","2548.09","2548.09","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 12X120MM FEMORAL LEGION TITANIUM PRESS FIT NON SLOTTED","SUP-ITM-10042183","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","956.46","956.46","956.46","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 12X120MM FEMORAL LEGION TITANIUM PRESS FIT NON SLOTTED","SUP-ITM-10042183","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","2344.73","1619.47","2530.35","16","651","1669.5","percent of total billed charges",""
"KNEE STEM 12X120MM FEMORAL LEGION TITANIUM PRESS FIT NON SLOTTED","SUP-ITM-10042183","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1523.63","988.41","4330.26","39","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 12X120MM FEMORAL LEGION TITANIUM PRESS FIT NON SLOTTED","SUP-ITM-10042183","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1670.25","1670.25","1670.25","1 through 10","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 12X120MM FEMORAL LEGION TITANIUM PRESS FIT NON SLOTTED","SUP-ITM-10042183","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 12X120MM FEMORAL LEGION TITANIUM PRESS FIT NON SLOTTED","SUP-ITM-10042183","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1738.90","1484.65","2716.94","38","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","552.39","52.26","","1113.10","1113.10","1113.10","1 through 10","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","840.32","79.5","","1293.60","1148.53","1603.80","1 through 10","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","385.81","36.5","","1023.42","771.29","2068.67","33","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","404.83","38.3","","850.52","759.78","1211.25","66","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.45","42.9","","2548.09","2548.09","2548.09","1 through 10","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.45","42.9","","956.46","956.46","956.46","1 through 10","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1057.00","792.75","WELLPOINT [1015]","HB AMC WELLPOINT","779.85","73.78","","2344.73","1619.47","2530.35","16","327.67","840.32","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1057.00","792.75","AETNA [1001]","HB AMC AETNA HMO","737.79","69.8","","1523.63","988.41","4330.26","39","552.39","863.78","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1057.00","792.75","AETNA [1001]","HB AMC AETNA PPO","849.83","80.4","","1670.25","1670.25","1670.25","1 through 10","552.39","863.78","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1057.00","792.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","552.39","52.26","","1113.10","1113.10","1113.10","1 through 10","552.39","863.78","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1057.00","792.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","863.78","81.72","","1738.90","1484.65","2716.94","38","552.39","863.78","percent of total billed charges",""
"KNEE STEM 130MM OD 15 UNIVERSAL EXTENDER POROUS PRIMARY CEMENTED SMOOTH VARIABLE STIFFNESS SEGMENTAL SY STRAIGHT IMPL","SUP-ITM-10082321","CDM","C1713","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8514.45","79.5","","800.18","480.96","1887.97","195","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 15 UNIVERSAL EXTENDER POROUS PRIMARY CEMENTED SMOOTH VARIABLE STIFFNESS SEGMENTAL SY STRAIGHT IMPL","SUP-ITM-10082321","CDM","C1713","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5708.43","53.3","","813.12","216.42","1444.50","81","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 15 UNIVERSAL EXTENDER POROUS PRIMARY CEMENTED SMOOTH VARIABLE STIFFNESS SEGMENTAL SY STRAIGHT IMPL","SUP-ITM-10082321","CDM","C1713","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3320.10","31","","432.60","432.60","432.60","1 through 10","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 15 UNIVERSAL EXTENDER POROUS PRIMARY CEMENTED SMOOTH VARIABLE STIFFNESS SEGMENTAL SY STRAIGHT IMPL","SUP-ITM-10082321","CDM","C1713","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3909.15","36.5","","148.37","54.89","631.39","94","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 15 UNIVERSAL EXTENDER POROUS PRIMARY CEMENTED SMOOTH VARIABLE STIFFNESS SEGMENTAL SY STRAIGHT IMPL","SUP-ITM-10082321","CDM","C1713","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4101.93","38.3","","279.30","91.72","1116.77","266","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 15 UNIVERSAL EXTENDER POROUS PRIMARY CEMENTED SMOOTH VARIABLE STIFFNESS SEGMENTAL SY STRAIGHT IMPL","SUP-ITM-10082321","CDM","C1713","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","731.00","63.70","731.00","1 through 10","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 15 UNIVERSAL EXTENDER POROUS PRIMARY CEMENTED SMOOTH VARIABLE STIFFNESS SEGMENTAL SY STRAIGHT IMPL","SUP-ITM-10082321","CDM","C1713","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","384.74","384.74","384.74","1 through 10","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 15 UNIVERSAL EXTENDER POROUS PRIMARY CEMENTED SMOOTH VARIABLE STIFFNESS SEGMENTAL SY STRAIGHT IMPL","SUP-ITM-10082321","CDM","C1713","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","WELLPOINT [1015]","HB AMC WELLPOINT","7901.84","73.78","","286.63","119.22","1107.45","105","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 15 UNIVERSAL EXTENDER POROUS PRIMARY CEMENTED SMOOTH VARIABLE STIFFNESS SEGMENTAL SY STRAIGHT IMPL","SUP-ITM-10082321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA HMO","7475.58","69.8","","675.31","184.75","1721.50","286","5597.05","8752.21","percent of total billed charges",""
"KNEE STEM 130MM OD 15 UNIVERSAL EXTENDER POROUS PRIMARY CEMENTED SMOOTH VARIABLE STIFFNESS SEGMENTAL SY STRAIGHT IMPL","SUP-ITM-10082321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA PPO","8610.84","80.4","","1261.44","103.12","1514.10","21","5597.05","8752.21","percent of total billed charges",""
"KNEE STEM 130MM OD 15 UNIVERSAL EXTENDER POROUS PRIMARY CEMENTED SMOOTH VARIABLE STIFFNESS SEGMENTAL SY STRAIGHT IMPL","SUP-ITM-10082321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8610.84","80.4","","1365.00","1365.00","1365.00","1 through 10","5597.05","8752.21","percent of total billed charges",""
"KNEE STEM 130MM OD 15 UNIVERSAL EXTENDER POROUS PRIMARY CEMENTED SMOOTH VARIABLE STIFFNESS SEGMENTAL SY STRAIGHT IMPL","SUP-ITM-10082321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8752.21","81.72","","5157.68","5157.68","5157.68","1 through 10","5597.05","8752.21","percent of total billed charges",""
"KNEE STEM 130MM OD 15 UNIVERSAL EXTENDER POROUS PRIMARY CEMENTED SMOOTH VARIABLE STIFFNESS SEGMENTAL SY STRAIGHT IMPL","SUP-ITM-10082321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8752.21","81.72","","431.26","71.26","1459.57","88","5597.05","8752.21","percent of total billed charges",""
"KNEE STEM 130MM OD 19 EXTENDER TRABECULAR METAL POROUS PRIMARY CEMENTED FLUTED PRECOAT ROD SMOOTH SEGMENTAL SY STRAIGHT IM","SUP-ITM-10046666","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5597.05","52.26","","1113.10","1113.10","1113.10","1 through 10","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 19 EXTENDER TRABECULAR METAL POROUS PRIMARY CEMENTED FLUTED PRECOAT ROD SMOOTH SEGMENTAL SY STRAIGHT IM","SUP-ITM-10046666","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8514.45","79.5","","1293.60","1148.53","1603.80","1 through 10","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 19 EXTENDER TRABECULAR METAL POROUS PRIMARY CEMENTED FLUTED PRECOAT ROD SMOOTH SEGMENTAL SY STRAIGHT IM","SUP-ITM-10046666","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3909.15","36.5","","1023.42","771.29","2068.67","33","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 19 EXTENDER TRABECULAR METAL POROUS PRIMARY CEMENTED FLUTED PRECOAT ROD SMOOTH SEGMENTAL SY STRAIGHT IM","SUP-ITM-10046666","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4101.93","38.3","","850.52","759.78","1211.25","66","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 19 EXTENDER TRABECULAR METAL POROUS PRIMARY CEMENTED FLUTED PRECOAT ROD SMOOTH SEGMENTAL SY STRAIGHT IM","SUP-ITM-10046666","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","2548.09","2548.09","2548.09","1 through 10","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 19 EXTENDER TRABECULAR METAL POROUS PRIMARY CEMENTED FLUTED PRECOAT ROD SMOOTH SEGMENTAL SY STRAIGHT IM","SUP-ITM-10046666","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","956.46","956.46","956.46","1 through 10","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 19 EXTENDER TRABECULAR METAL POROUS PRIMARY CEMENTED FLUTED PRECOAT ROD SMOOTH SEGMENTAL SY STRAIGHT IM","SUP-ITM-10046666","CDM","C1776","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","WELLPOINT [1015]","HB AMC WELLPOINT","7901.84","73.78","","2344.73","1619.47","2530.35","16","3320.1","8514.45","percent of total billed charges",""
"KNEE STEM 130MM OD 19 EXTENDER TRABECULAR METAL POROUS PRIMARY CEMENTED FLUTED PRECOAT ROD SMOOTH SEGMENTAL SY STRAIGHT IM","SUP-ITM-10046666","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA HMO","7475.58","69.8","","1523.63","988.41","4330.26","39","5597.05","8752.21","percent of total billed charges",""
"KNEE STEM 130MM OD 19 EXTENDER TRABECULAR METAL POROUS PRIMARY CEMENTED FLUTED PRECOAT ROD SMOOTH SEGMENTAL SY STRAIGHT IM","SUP-ITM-10046666","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA PPO","8610.84","80.4","","1670.25","1670.25","1670.25","1 through 10","5597.05","8752.21","percent of total billed charges",""
"KNEE STEM 130MM OD 19 EXTENDER TRABECULAR METAL POROUS PRIMARY CEMENTED FLUTED PRECOAT ROD SMOOTH SEGMENTAL SY STRAIGHT IM","SUP-ITM-10046666","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5597.05","52.26","","1113.10","1113.10","1113.10","1 through 10","5597.05","8752.21","percent of total billed charges",""
"KNEE STEM 130MM OD 19 EXTENDER TRABECULAR METAL POROUS PRIMARY CEMENTED FLUTED PRECOAT ROD SMOOTH SEGMENTAL SY STRAIGHT IM","SUP-ITM-10046666","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8752.21","81.72","","1738.90","1484.65","2716.94","38","5597.05","8752.21","percent of total billed charges",""
"KNEE STEM 13X220MM FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT SLOTTED","SUP-ITM-10018354","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","800.18","480.96","1887.97","195","651","1669.5","percent of total billed charges",""
"KNEE STEM 13X220MM FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT SLOTTED","SUP-ITM-10018354","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1119.30","53.3","","813.12","216.42","1444.50","81","651","1669.5","percent of total billed charges",""
"KNEE STEM 13X220MM FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT SLOTTED","SUP-ITM-10018354","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","651.00","31","","432.60","432.60","432.60","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 13X220MM FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT SLOTTED","SUP-ITM-10018354","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","148.37","54.89","631.39","94","651","1669.5","percent of total billed charges",""
"KNEE STEM 13X220MM FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT SLOTTED","SUP-ITM-10018354","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","279.30","91.72","1116.77","266","651","1669.5","percent of total billed charges",""
"KNEE STEM 13X220MM FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT SLOTTED","SUP-ITM-10018354","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","731.00","63.70","731.00","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 13X220MM FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT SLOTTED","SUP-ITM-10018354","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","384.74","384.74","384.74","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 13X220MM FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT SLOTTED","SUP-ITM-10018354","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","286.63","119.22","1107.45","105","651","1669.5","percent of total billed charges",""
"KNEE STEM 13X220MM FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT SLOTTED","SUP-ITM-10018354","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","675.31","184.75","1721.50","286","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 13X220MM FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT SLOTTED","SUP-ITM-10018354","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1261.44","103.12","1514.10","21","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 13X220MM FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT SLOTTED","SUP-ITM-10018354","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1688.40","80.4","","1365.00","1365.00","1365.00","1 through 10","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 13X220MM FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT SLOTTED","SUP-ITM-10018354","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1716.12","81.72","","5157.68","5157.68","5157.68","1 through 10","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 13X220MM FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT SLOTTED","SUP-ITM-10018354","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","431.26","71.26","1459.57","88","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2939.63","52.26","","1113.10","1113.10","1113.10","1 through 10","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4471.88","79.5","","1293.60","1148.53","1603.80","1 through 10","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2053.13","36.5","","1023.42","771.29","2068.67","33","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2154.38","38.3","","850.52","759.78","1211.25","66","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2413.13","42.9","","2548.09","2548.09","2548.09","1 through 10","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2413.13","42.9","","956.46","956.46","956.46","1 through 10","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","WELLPOINT [1015]","HB AMC WELLPOINT","4150.13","73.78","","2344.73","1619.47","2530.35","16","1743.75","4471.88","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","AETNA [1001]","HB AMC AETNA HMO","3926.25","69.8","","1523.63","988.41","4330.26","39","2939.63","4596.75","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","AETNA [1001]","HB AMC AETNA PPO","4522.50","80.4","","1670.25","1670.25","1670.25","1 through 10","2939.63","4596.75","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2939.63","52.26","","1113.10","1113.10","1113.10","1 through 10","2939.63","4596.75","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4596.75","81.72","","1738.90","1484.65","2716.94","38","2939.63","4596.75","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1338.63","52.26","","1113.10","1113.10","1113.10","1 through 10","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2036.38","79.5","","1293.60","1148.53","1603.80","1 through 10","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","934.94","36.5","","1023.42","771.29","2068.67","33","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","981.05","38.3","","850.52","759.78","1211.25","66","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1098.87","42.9","","2548.09","2548.09","2548.09","1 through 10","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1098.87","42.9","","956.46","956.46","956.46","1 through 10","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","both","","","2561.48","1921.11","WELLPOINT [1015]","HB AMC WELLPOINT","1889.86","73.78","","2344.73","1619.47","2530.35","16","794.06","2036.38","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2561.48","1921.11","AETNA [1001]","HB AMC AETNA HMO","1787.91","69.8","","1523.63","988.41","4330.26","39","1338.63","2093.24","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2561.48","1921.11","AETNA [1001]","HB AMC AETNA PPO","2059.43","80.4","","1670.25","1670.25","1670.25","1 through 10","1338.63","2093.24","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2561.48","1921.11","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1338.63","52.26","","1113.10","1113.10","1113.10","1 through 10","1338.63","2093.24","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 18 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2561.48","1921.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2093.24","81.72","","1738.90","1484.65","2716.94","38","1338.63","2093.24","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1006.01","52.26","","1113.10","1113.10","1113.10","1 through 10","596.75","1530.38","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1530.38","79.5","","1293.60","1148.53","1603.80","1 through 10","596.75","1530.38","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","702.63","36.5","","1023.42","771.29","2068.67","33","596.75","1530.38","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","737.28","38.3","","850.52","759.78","1211.25","66","596.75","1530.38","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","2548.09","2548.09","2548.09","1 through 10","596.75","1530.38","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","956.46","956.46","956.46","1 through 10","596.75","1530.38","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","WELLPOINT [1015]","HB AMC WELLPOINT","1420.27","73.78","","2344.73","1619.47","2530.35","16","596.75","1530.38","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA HMO","1343.65","69.8","","1523.63","988.41","4330.26","39","1006.01","1573.11","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA PPO","1547.70","80.4","","1670.25","1670.25","1670.25","1 through 10","1006.01","1573.11","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1006.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1006.01","1573.11","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1573.11","81.72","","1738.90","1484.65","2716.94","38","1006.01","1573.11","percent of total billed charges",""
"KNEE STEM 152MMX13.5 MODULAR FEMORAL 11","SUP-ITM-10126500","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2594.71","52.26","","1113.10","1113.10","1113.10","1 through 10","1539.15","3947.18","percent of total billed charges",""
"KNEE STEM 152MMX13.5 MODULAR FEMORAL 11","SUP-ITM-10126500","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3947.18","79.5","","1293.60","1148.53","1603.80","1 through 10","1539.15","3947.18","percent of total billed charges",""
"KNEE STEM 152MMX13.5 MODULAR FEMORAL 11","SUP-ITM-10126500","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1812.23","36.5","","1023.42","771.29","2068.67","33","1539.15","3947.18","percent of total billed charges",""
"KNEE STEM 152MMX13.5 MODULAR FEMORAL 11","SUP-ITM-10126500","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1901.60","38.3","","850.52","759.78","1211.25","66","1539.15","3947.18","percent of total billed charges",""
"KNEE STEM 152MMX13.5 MODULAR FEMORAL 11","SUP-ITM-10126500","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2129.99","42.9","","2548.09","2548.09","2548.09","1 through 10","1539.15","3947.18","percent of total billed charges",""
"KNEE STEM 152MMX13.5 MODULAR FEMORAL 11","SUP-ITM-10126500","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2129.99","42.9","","956.46","956.46","956.46","1 through 10","1539.15","3947.18","percent of total billed charges",""
"KNEE STEM 152MMX13.5 MODULAR FEMORAL 11","SUP-ITM-10126500","CDM","C1776","HCPCS","0278","RC","","","","both","","","4965.00","3723.75","WELLPOINT [1015]","HB AMC WELLPOINT","3663.18","73.78","","2344.73","1619.47","2530.35","16","1539.15","3947.18","percent of total billed charges",""
"KNEE STEM 152MMX13.5 MODULAR FEMORAL 11","SUP-ITM-10126500","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4965.00","3723.75","AETNA [1001]","HB AMC AETNA HMO","3465.57","69.8","","1523.63","988.41","4330.26","39","2594.71","4057.4","percent of total billed charges",""
"KNEE STEM 152MMX13.5 MODULAR FEMORAL 11","SUP-ITM-10126500","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4965.00","3723.75","AETNA [1001]","HB AMC AETNA PPO","3991.86","80.4","","1670.25","1670.25","1670.25","1 through 10","2594.71","4057.4","percent of total billed charges",""
"KNEE STEM 152MMX13.5 MODULAR FEMORAL 11","SUP-ITM-10126500","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4965.00","3723.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2594.71","52.26","","1113.10","1113.10","1113.10","1 through 10","2594.71","4057.4","percent of total billed charges",""
"KNEE STEM 152MMX13.5 MODULAR FEMORAL 11","SUP-ITM-10126500","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4965.00","3723.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4057.40","81.72","","1738.90","1484.65","2716.94","38","2594.71","4057.4","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1293.60","1148.53","1603.80","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1023.42","771.29","2068.67","33","651","1669.5","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","850.52","759.78","1211.25","66","651","1669.5","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","2548.09","2548.09","2548.09","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","956.46","956.46","956.46","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","2344.73","1619.47","2530.35","16","651","1669.5","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1523.63","988.41","4330.26","39","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1670.25","1670.25","1670.25","1 through 10","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1738.90","1484.65","2716.94","38","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 16MMX120 FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT","SUP-ITM-10021615","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 16MMX120 FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT","SUP-ITM-10021615","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1293.60","1148.53","1603.80","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 16MMX120 FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT","SUP-ITM-10021615","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1023.42","771.29","2068.67","33","651","1669.5","percent of total billed charges",""
"KNEE STEM 16MMX120 FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT","SUP-ITM-10021615","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","850.52","759.78","1211.25","66","651","1669.5","percent of total billed charges",""
"KNEE STEM 16MMX120 FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT","SUP-ITM-10021615","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","2548.09","2548.09","2548.09","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 16MMX120 FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT","SUP-ITM-10021615","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","956.46","956.46","956.46","1 through 10","651","1669.5","percent of total billed charges",""
"KNEE STEM 16MMX120 FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT","SUP-ITM-10021615","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","2344.73","1619.47","2530.35","16","651","1669.5","percent of total billed charges",""
"KNEE STEM 16MMX120 FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT","SUP-ITM-10021615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1523.63","988.41","4330.26","39","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 16MMX120 FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT","SUP-ITM-10021615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1670.25","1670.25","1670.25","1 through 10","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 16MMX120 FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT","SUP-ITM-10021615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 16MMX120 FEMORAL LEGION TITANIUM PRESS FIT STRAIGHT","SUP-ITM-10021615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1738.90","1484.65","2716.94","38","1097.46","1716.12","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1766.91","52.26","","1113.10","1113.10","1113.10","1 through 10","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2687.90","79.5","","1293.60","1148.53","1603.80","1 through 10","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1234.07","36.5","","1023.42","771.29","2068.67","33","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1294.92","38.3","","850.52","759.78","1211.25","66","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1450.45","42.9","","2548.09","2548.09","2548.09","1 through 10","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1450.45","42.9","","956.46","956.46","956.46","1 through 10","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","WELLPOINT [1015]","HB AMC WELLPOINT","2494.50","73.78","","2344.73","1619.47","2530.35","16","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3381.00","2535.75","AETNA [1001]","HB AMC AETNA HMO","2359.94","69.8","","1523.63","988.41","4330.26","39","1766.91","2762.95","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3381.00","2535.75","AETNA [1001]","HB AMC AETNA PPO","2718.32","80.4","","1670.25","1670.25","1670.25","1 through 10","1766.91","2762.95","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3381.00","2535.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1766.91","52.26","","1113.10","1113.10","1113.10","1 through 10","1766.91","2762.95","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3381.00","2535.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2762.95","81.72","","1738.90","1484.65","2716.94","38","1766.91","2762.95","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1766.91","52.26","","1113.10","1113.10","1113.10","1 through 10","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2687.90","79.5","","1293.60","1148.53","1603.80","1 through 10","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1234.07","36.5","","1023.42","771.29","2068.67","33","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1294.92","38.3","","850.52","759.78","1211.25","66","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1450.45","42.9","","2548.09","2548.09","2548.09","1 through 10","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1450.45","42.9","","956.46","956.46","956.46","1 through 10","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","3381.00","2535.75","WELLPOINT [1015]","HB AMC WELLPOINT","2494.50","73.78","","2344.73","1619.47","2530.35","16","1048.11","2687.9","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3381.00","2535.75","AETNA [1001]","HB AMC AETNA HMO","2359.94","69.8","","1523.63","988.41","4330.26","39","1766.91","2762.95","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3381.00","2535.75","AETNA [1001]","HB AMC AETNA PPO","2718.32","80.4","","1670.25","1670.25","1670.25","1 through 10","1766.91","2762.95","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3381.00","2535.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1766.91","52.26","","1113.10","1113.10","1113.10","1 through 10","1766.91","2762.95","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3381.00","2535.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2762.95","81.72","","1738.90","1484.65","2716.94","38","1766.91","2762.95","percent of total billed charges",""
"KNEE STEM 3CM IMPLANT FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036221","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3581.84","52.26","","1113.10","1113.10","1113.10","1 through 10","2124.7","5448.83","percent of total billed charges",""
"KNEE STEM 3CM IMPLANT FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036221","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5448.83","79.5","","1293.60","1148.53","1603.80","1 through 10","2124.7","5448.83","percent of total billed charges",""
"KNEE STEM 3CM IMPLANT FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036221","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2501.67","36.5","","1023.42","771.29","2068.67","33","2124.7","5448.83","percent of total billed charges",""
"KNEE STEM 3CM IMPLANT FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036221","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2625.04","38.3","","850.52","759.78","1211.25","66","2124.7","5448.83","percent of total billed charges",""
"KNEE STEM 3CM IMPLANT FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036221","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2940.31","42.9","","2548.09","2548.09","2548.09","1 through 10","2124.7","5448.83","percent of total billed charges",""
"KNEE STEM 3CM IMPLANT FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036221","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2940.31","42.9","","956.46","956.46","956.46","1 through 10","2124.7","5448.83","percent of total billed charges",""
"KNEE STEM 3CM IMPLANT FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036221","CDM","C1776","HCPCS","0278","RC","","","","both","","","6853.88","5140.41","WELLPOINT [1015]","HB AMC WELLPOINT","5056.79","73.78","","2344.73","1619.47","2530.35","16","2124.7","5448.83","percent of total billed charges",""
"KNEE STEM 3CM IMPLANT FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","AETNA [1001]","HB AMC AETNA HMO","4784.01","69.8","","1523.63","988.41","4330.26","39","3581.84","5600.99","percent of total billed charges",""
"KNEE STEM 3CM IMPLANT FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","AETNA [1001]","HB AMC AETNA PPO","5510.52","80.4","","1670.25","1670.25","1670.25","1 through 10","3581.84","5600.99","percent of total billed charges",""
"KNEE STEM 3CM IMPLANT FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3581.84","52.26","","1113.10","1113.10","1113.10","1 through 10","3581.84","5600.99","percent of total billed charges",""
"KNEE STEM 3CM IMPLANT FEMORAL COMPONENT SEGMENT DIAPHYSL OSS WITH SCREW ONC 03","SUP-ITM-10036221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6853.88","5140.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5600.99","81.72","","1738.90","1484.65","2716.94","38","3581.84","5600.99","percent of total billed charges",""
"KNEE STEM 65MM VANGUARD SSK 360 REVISION SY RIGHT","SUP-ITM-10117687","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3100.32","52.26","","1113.10","1113.10","1113.10","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE STEM 65MM VANGUARD SSK 360 REVISION SY RIGHT","SUP-ITM-10117687","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4716.34","79.5","","1293.60","1148.53","1603.80","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE STEM 65MM VANGUARD SSK 360 REVISION SY RIGHT","SUP-ITM-10117687","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2165.36","36.5","","1023.42","771.29","2068.67","33","1839.08","4716.34","percent of total billed charges",""
"KNEE STEM 65MM VANGUARD SSK 360 REVISION SY RIGHT","SUP-ITM-10117687","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2272.15","38.3","","850.52","759.78","1211.25","66","1839.08","4716.34","percent of total billed charges",""
"KNEE STEM 65MM VANGUARD SSK 360 REVISION SY RIGHT","SUP-ITM-10117687","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2545.04","42.9","","2548.09","2548.09","2548.09","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE STEM 65MM VANGUARD SSK 360 REVISION SY RIGHT","SUP-ITM-10117687","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2545.04","42.9","","956.46","956.46","956.46","1 through 10","1839.08","4716.34","percent of total billed charges",""
"KNEE STEM 65MM VANGUARD SSK 360 REVISION SY RIGHT","SUP-ITM-10117687","CDM","C1776","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","WELLPOINT [1015]","HB AMC WELLPOINT","4377.00","73.78","","2344.73","1619.47","2530.35","16","1839.08","4716.34","percent of total billed charges",""
"KNEE STEM 65MM VANGUARD SSK 360 REVISION SY RIGHT","SUP-ITM-10117687","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","AETNA [1001]","HB AMC AETNA HMO","4140.89","69.8","","1523.63","988.41","4330.26","39","3100.32","4848.04","percent of total billed charges",""
"KNEE STEM 65MM VANGUARD SSK 360 REVISION SY RIGHT","SUP-ITM-10117687","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","AETNA [1001]","HB AMC AETNA PPO","4769.73","80.4","","1670.25","1670.25","1670.25","1 through 10","3100.32","4848.04","percent of total billed charges",""
"KNEE STEM 65MM VANGUARD SSK 360 REVISION SY RIGHT","SUP-ITM-10117687","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3100.32","52.26","","1113.10","1113.10","1113.10","1 through 10","3100.32","4848.04","percent of total billed charges",""
"KNEE STEM 65MM VANGUARD SSK 360 REVISION SY RIGHT","SUP-ITM-10117687","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4848.04","81.72","","1738.90","1484.65","2716.94","38","3100.32","4848.04","percent of total billed charges",""
"KNEE STEM 6MM 16X135MM EXTENSION PERSONA REV OFFSET","SUP-ITM-10268393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1855.26","52.26","","1113.10","1113.10","1113.10","1 through 10","1100.52","2822.29","percent of total billed charges",""
"KNEE STEM 6MM 16X135MM EXTENSION PERSONA REV OFFSET","SUP-ITM-10268393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2822.29","79.5","","1293.60","1148.53","1603.80","1 through 10","1100.52","2822.29","percent of total billed charges",""
"KNEE STEM 6MM 16X135MM EXTENSION PERSONA REV OFFSET","SUP-ITM-10268393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1295.77","36.5","","1023.42","771.29","2068.67","33","1100.52","2822.29","percent of total billed charges",""
"KNEE STEM 6MM 16X135MM EXTENSION PERSONA REV OFFSET","SUP-ITM-10268393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1359.67","38.3","","850.52","759.78","1211.25","66","1100.52","2822.29","percent of total billed charges",""
"KNEE STEM 6MM 16X135MM EXTENSION PERSONA REV OFFSET","SUP-ITM-10268393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1522.97","42.9","","2548.09","2548.09","2548.09","1 through 10","1100.52","2822.29","percent of total billed charges",""
"KNEE STEM 6MM 16X135MM EXTENSION PERSONA REV OFFSET","SUP-ITM-10268393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1522.97","42.9","","956.46","956.46","956.46","1 through 10","1100.52","2822.29","percent of total billed charges",""
"KNEE STEM 6MM 16X135MM EXTENSION PERSONA REV OFFSET","SUP-ITM-10268393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","WELLPOINT [1015]","HB AMC WELLPOINT","2619.23","73.78","","2344.73","1619.47","2530.35","16","1100.52","2822.29","percent of total billed charges",""
"KNEE STEM 6MM 16X135MM EXTENSION PERSONA REV OFFSET","SUP-ITM-10268393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3550.05","2662.54","AETNA [1001]","HB AMC AETNA HMO","2477.93","69.8","","1523.63","988.41","4330.26","39","1855.26","2901.1","percent of total billed charges",""
"KNEE STEM 6MM 16X135MM EXTENSION PERSONA REV OFFSET","SUP-ITM-10268393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3550.05","2662.54","AETNA [1001]","HB AMC AETNA PPO","2854.24","80.4","","1670.25","1670.25","1670.25","1 through 10","1855.26","2901.1","percent of total billed charges",""
"KNEE STEM 6MM 16X135MM EXTENSION PERSONA REV OFFSET","SUP-ITM-10268393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3550.05","2662.54","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1855.26","52.26","","1113.10","1113.10","1113.10","1 through 10","1855.26","2901.1","percent of total billed charges",""
"KNEE STEM 6MM 16X135MM EXTENSION PERSONA REV OFFSET","SUP-ITM-10268393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3550.05","2662.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2901.10","81.72","","1738.90","1484.65","2716.94","38","1855.26","2901.1","percent of total billed charges",""
"KNEE STEM 8MM SIZE 3 COMPONENT FEMORAL NEXGEN TIBIAL ALL POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX RT LATERAL LT MEDIAL","SUP-ITM-10016574","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","834.07","52.26","","1113.10","1113.10","1113.10","1 through 10","494.76","1268.82","percent of total billed charges",""
"KNEE STEM 8MM SIZE 3 COMPONENT FEMORAL NEXGEN TIBIAL ALL POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX RT LATERAL LT MEDIAL","SUP-ITM-10016574","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1268.82","79.5","","1293.60","1148.53","1603.80","1 through 10","494.76","1268.82","percent of total billed charges",""
"KNEE STEM 8MM SIZE 3 COMPONENT FEMORAL NEXGEN TIBIAL ALL POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX RT LATERAL LT MEDIAL","SUP-ITM-10016574","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","582.54","36.5","","1023.42","771.29","2068.67","33","494.76","1268.82","percent of total billed charges",""
"KNEE STEM 8MM SIZE 3 COMPONENT FEMORAL NEXGEN TIBIAL ALL POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX RT LATERAL LT MEDIAL","SUP-ITM-10016574","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","611.27","38.3","","850.52","759.78","1211.25","66","494.76","1268.82","percent of total billed charges",""
"KNEE STEM 8MM SIZE 3 COMPONENT FEMORAL NEXGEN TIBIAL ALL POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX RT LATERAL LT MEDIAL","SUP-ITM-10016574","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","684.68","42.9","","2548.09","2548.09","2548.09","1 through 10","494.76","1268.82","percent of total billed charges",""
"KNEE STEM 8MM SIZE 3 COMPONENT FEMORAL NEXGEN TIBIAL ALL POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX RT LATERAL LT MEDIAL","SUP-ITM-10016574","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","684.68","42.9","","956.46","956.46","956.46","1 through 10","494.76","1268.82","percent of total billed charges",""
"KNEE STEM 8MM SIZE 3 COMPONENT FEMORAL NEXGEN TIBIAL ALL POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX RT LATERAL LT MEDIAL","SUP-ITM-10016574","CDM","C1776","HCPCS","0278","RC","","","","both","","","1596.00","1197.00","WELLPOINT [1015]","HB AMC WELLPOINT","1177.53","73.78","","2344.73","1619.47","2530.35","16","494.76","1268.82","percent of total billed charges",""
"KNEE STEM 8MM SIZE 3 COMPONENT FEMORAL NEXGEN TIBIAL ALL POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX RT LATERAL LT MEDIAL","SUP-ITM-10016574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1596.00","1197.00","AETNA [1001]","HB AMC AETNA HMO","1114.01","69.8","","1523.63","988.41","4330.26","39","834.07","1304.25","percent of total billed charges",""
"KNEE STEM 8MM SIZE 3 COMPONENT FEMORAL NEXGEN TIBIAL ALL POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX RT LATERAL LT MEDIAL","SUP-ITM-10016574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1596.00","1197.00","AETNA [1001]","HB AMC AETNA PPO","1283.18","80.4","","1670.25","1670.25","1670.25","1 through 10","834.07","1304.25","percent of total billed charges",""
"KNEE STEM 8MM SIZE 3 COMPONENT FEMORAL NEXGEN TIBIAL ALL POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX RT LATERAL LT MEDIAL","SUP-ITM-10016574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1596.00","1197.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","834.07","52.26","","1113.10","1113.10","1113.10","1 through 10","834.07","1304.25","percent of total billed charges",""
"KNEE STEM 8MM SIZE 3 COMPONENT FEMORAL NEXGEN TIBIAL ALL POLYETHYLENE UNICOMPARTMENTAL HIGH FLEX RT LATERAL LT MEDIAL","SUP-ITM-10016574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1596.00","1197.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1304.25","81.72","","1738.90","1484.65","2716.94","38","834.07","1304.25","percent of total billed charges",""
"KNEE STEM COLLAR 16MMX30 TRABECULAR SEGMENTAL METAL DISTAL LESS THAN","SUP-ITM-10025558","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2790.29","52.26","","1113.10","1113.10","1113.10","1 through 10","1655.17","4244.7","percent of total billed charges",""
"KNEE STEM COLLAR 16MMX30 TRABECULAR SEGMENTAL METAL DISTAL LESS THAN","SUP-ITM-10025558","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4244.70","79.5","","1293.60","1148.53","1603.80","1 through 10","1655.17","4244.7","percent of total billed charges",""
"KNEE STEM COLLAR 16MMX30 TRABECULAR SEGMENTAL METAL DISTAL LESS THAN","SUP-ITM-10025558","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1948.83","36.5","","1023.42","771.29","2068.67","33","1655.17","4244.7","percent of total billed charges",""
"KNEE STEM COLLAR 16MMX30 TRABECULAR SEGMENTAL METAL DISTAL LESS THAN","SUP-ITM-10025558","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2044.93","38.3","","850.52","759.78","1211.25","66","1655.17","4244.7","percent of total billed charges",""
"KNEE STEM COLLAR 16MMX30 TRABECULAR SEGMENTAL METAL DISTAL LESS THAN","SUP-ITM-10025558","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","2548.09","2548.09","2548.09","1 through 10","1655.17","4244.7","percent of total billed charges",""
"KNEE STEM COLLAR 16MMX30 TRABECULAR SEGMENTAL METAL DISTAL LESS THAN","SUP-ITM-10025558","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","956.46","956.46","956.46","1 through 10","1655.17","4244.7","percent of total billed charges",""
"KNEE STEM COLLAR 16MMX30 TRABECULAR SEGMENTAL METAL DISTAL LESS THAN","SUP-ITM-10025558","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","WELLPOINT [1015]","HB AMC WELLPOINT","3939.30","73.78","","2344.73","1619.47","2530.35","16","1655.17","4244.7","percent of total billed charges",""
"KNEE STEM COLLAR 16MMX30 TRABECULAR SEGMENTAL METAL DISTAL LESS THAN","SUP-ITM-10025558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA HMO","3726.80","69.8","","1523.63","988.41","4330.26","39","2790.29","4363.24","percent of total billed charges",""
"KNEE STEM COLLAR 16MMX30 TRABECULAR SEGMENTAL METAL DISTAL LESS THAN","SUP-ITM-10025558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA PPO","4292.76","80.4","","1670.25","1670.25","1670.25","1 through 10","2790.29","4363.24","percent of total billed charges",""
"KNEE STEM COLLAR 16MMX30 TRABECULAR SEGMENTAL METAL DISTAL LESS THAN","SUP-ITM-10025558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2790.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2790.29","4363.24","percent of total billed charges",""
"KNEE STEM COLLAR 16MMX30 TRABECULAR SEGMENTAL METAL DISTAL LESS THAN","SUP-ITM-10025558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4363.24","81.72","","1738.90","1484.65","2716.94","38","2790.29","4363.24","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE LEFT","SUP-ITM-10202201","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5963.33","52.26","","1113.10","1113.10","1113.10","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE LEFT","SUP-ITM-10202201","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9071.65","79.5","","1293.60","1148.53","1603.80","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE LEFT","SUP-ITM-10202201","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4164.97","36.5","","1023.42","771.29","2068.67","33","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE LEFT","SUP-ITM-10202201","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4370.37","38.3","","850.52","759.78","1211.25","66","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE LEFT","SUP-ITM-10202201","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4895.27","42.9","","2548.09","2548.09","2548.09","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE LEFT","SUP-ITM-10202201","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4895.27","42.9","","956.46","956.46","956.46","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE LEFT","SUP-ITM-10202201","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","WELLPOINT [1015]","HB AMC WELLPOINT","8418.95","73.78","","2344.73","1619.47","2530.35","16","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE LEFT","SUP-ITM-10202201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","AETNA [1001]","HB AMC AETNA HMO","7964.79","69.8","","1523.63","988.41","4330.26","39","5963.33","9324.97","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE LEFT","SUP-ITM-10202201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","AETNA [1001]","HB AMC AETNA PPO","9174.35","80.4","","1670.25","1670.25","1670.25","1 through 10","5963.33","9324.97","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE LEFT","SUP-ITM-10202201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5963.33","52.26","","1113.10","1113.10","1113.10","1 through 10","5963.33","9324.97","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE LEFT","SUP-ITM-10202201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9324.97","81.72","","1738.90","1484.65","2716.94","38","5963.33","9324.97","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE RIGHT","SUP-ITM-10202200","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5963.33","52.26","","1113.10","1113.10","1113.10","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE RIGHT","SUP-ITM-10202200","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9071.65","79.5","","1293.60","1148.53","1603.80","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE RIGHT","SUP-ITM-10202200","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4164.97","36.5","","1023.42","771.29","2068.67","33","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE RIGHT","SUP-ITM-10202200","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4370.37","38.3","","850.52","759.78","1211.25","66","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE RIGHT","SUP-ITM-10202200","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4895.27","42.9","","2548.09","2548.09","2548.09","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE RIGHT","SUP-ITM-10202200","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4895.27","42.9","","956.46","956.46","956.46","1 through 10","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE RIGHT","SUP-ITM-10202200","CDM","C1776","HCPCS","0278","RC","","","","both","","","11410.88","8558.16","WELLPOINT [1015]","HB AMC WELLPOINT","8418.95","73.78","","2344.73","1619.47","2530.35","16","3537.37","9071.65","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE RIGHT","SUP-ITM-10202200","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","AETNA [1001]","HB AMC AETNA HMO","7964.79","69.8","","1523.63","988.41","4330.26","39","5963.33","9324.97","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE RIGHT","SUP-ITM-10202200","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","AETNA [1001]","HB AMC AETNA PPO","9174.35","80.4","","1670.25","1670.25","1670.25","1 through 10","5963.33","9324.97","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE RIGHT","SUP-ITM-10202200","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5963.33","52.26","","1113.10","1113.10","1113.10","1 through 10","5963.33","9324.97","percent of total billed charges",""
"KNEE STEM FEMORAL LOW OSS PROFILE RIGHT","SUP-ITM-10202200","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11410.88","8558.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9324.97","81.72","","1738.90","1484.65","2716.94","38","5963.33","9324.97","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5112.33","52.26","","1113.10","1113.10","1113.10","1 through 10","3032.58","7777.09","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7777.09","79.5","","1293.60","1148.53","1603.80","1 through 10","3032.58","7777.09","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3570.61","36.5","","1023.42","771.29","2068.67","33","3032.58","7777.09","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3746.70","38.3","","850.52","759.78","1211.25","66","3032.58","7777.09","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4196.69","42.9","","2548.09","2548.09","2548.09","1 through 10","3032.58","7777.09","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4196.69","42.9","","956.46","956.46","956.46","1 through 10","3032.58","7777.09","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","9782.50","7336.87","WELLPOINT [1015]","HB AMC WELLPOINT","7217.53","73.78","","2344.73","1619.47","2530.35","16","3032.58","7777.09","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9782.50","7336.87","AETNA [1001]","HB AMC AETNA HMO","6828.19","69.8","","1523.63","988.41","4330.26","39","5112.33","7994.26","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9782.50","7336.87","AETNA [1001]","HB AMC AETNA PPO","7865.13","80.4","","1670.25","1670.25","1670.25","1 through 10","5112.33","7994.26","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9782.50","7336.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5112.33","52.26","","1113.10","1113.10","1113.10","1 through 10","5112.33","7994.26","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9782.50","7336.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7994.26","81.72","","1738.90","1484.65","2716.94","38","5112.33","7994.26","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.66","52.26","","1113.10","1113.10","1113.10","1 through 10","1266.85","3248.85","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3248.85","79.5","","1293.60","1148.53","1603.80","1 through 10","1266.85","3248.85","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1491.61","36.5","","1023.42","771.29","2068.67","33","1266.85","3248.85","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1565.17","38.3","","850.52","759.78","1211.25","66","1266.85","3248.85","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.15","42.9","","2548.09","2548.09","2548.09","1 through 10","1266.85","3248.85","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.15","42.9","","956.46","956.46","956.46","1 through 10","1266.85","3248.85","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","WELLPOINT [1015]","HB AMC WELLPOINT","3015.09","73.78","","2344.73","1619.47","2530.35","16","1266.85","3248.85","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","AETNA [1001]","HB AMC AETNA HMO","2852.45","69.8","","1523.63","988.41","4330.26","39","2135.66","3339.57","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","AETNA [1001]","HB AMC AETNA PPO","3285.63","80.4","","1670.25","1670.25","1670.25","1 through 10","2135.66","3339.57","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.66","52.26","","1113.10","1113.10","1113.10","1 through 10","2135.66","3339.57","percent of total billed charges",""
"KNEE TRAY 71MM TIBIAL VANGUARD INTERLOK MODULAR COBALT STEMMED AUGMENTABLE","SUP-ITM-10076973","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3339.57","81.72","","1738.90","1484.65","2716.94","38","2135.66","3339.57","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1840.62","79.5","","800.18","480.96","1887.97","195","717.73","1840.62","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1234.03","53.3","","813.12","216.42","1444.50","81","717.73","1840.62","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","717.73","31","","432.60","432.60","432.60","1 through 10","717.73","1840.62","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","845.07","36.5","","148.37","54.89","631.39","94","717.73","1840.62","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","886.74","38.3","","279.30","91.72","1116.77","266","717.73","1840.62","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.24","42.9","","731.00","63.70","731.00","1 through 10","717.73","1840.62","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.24","42.9","","384.74","384.74","384.74","1 through 10","717.73","1840.62","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","WELLPOINT [1015]","HB AMC WELLPOINT","1708.19","73.78","","286.63","119.22","1107.45","105","717.73","1840.62","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","AETNA [1001]","HB AMC AETNA HMO","1616.04","69.8","","675.31","184.75","1721.50","286","1209.95","1892.02","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","AETNA [1001]","HB AMC AETNA PPO","1861.46","80.4","","1261.44","103.12","1514.10","21","1209.95","1892.02","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1861.46","80.4","","1365.00","1365.00","1365.00","1 through 10","1209.95","1892.02","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1892.02","81.72","","5157.68","5157.68","5157.68","1 through 10","1209.95","1892.02","percent of total billed charges",""
"KNEE TRAY 71MM VANGUARD MODULAR COBALT FINNED CEMENTED","SUP-ITM-10016624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1892.02","81.72","","431.26","71.26","1459.57","88","1209.95","1892.02","percent of total billed charges",""
"KNEE WEDGE 10MM SIZE 6 HINGE LEGION","SUP-ITM-10121496","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1139.53","52.26","","1113.10","1113.10","1113.10","1 through 10","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 10MM SIZE 6 HINGE LEGION","SUP-ITM-10121496","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1733.50","79.5","","1293.60","1148.53","1603.80","1 through 10","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 10MM SIZE 6 HINGE LEGION","SUP-ITM-10121496","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","795.88","36.5","","1023.42","771.29","2068.67","33","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 10MM SIZE 6 HINGE LEGION","SUP-ITM-10121496","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","835.13","38.3","","850.52","759.78","1211.25","66","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 10MM SIZE 6 HINGE LEGION","SUP-ITM-10121496","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","935.43","42.9","","2548.09","2548.09","2548.09","1 through 10","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 10MM SIZE 6 HINGE LEGION","SUP-ITM-10121496","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","935.43","42.9","","956.46","956.46","956.46","1 through 10","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 10MM SIZE 6 HINGE LEGION","SUP-ITM-10121496","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","WELLPOINT [1015]","HB AMC WELLPOINT","1608.77","73.78","","2344.73","1619.47","2530.35","16","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 10MM SIZE 6 HINGE LEGION","SUP-ITM-10121496","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","AETNA [1001]","HB AMC AETNA HMO","1521.99","69.8","","1523.63","988.41","4330.26","39","1139.53","1781.9","percent of total billed charges",""
"KNEE WEDGE 10MM SIZE 6 HINGE LEGION","SUP-ITM-10121496","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","AETNA [1001]","HB AMC AETNA PPO","1753.12","80.4","","1670.25","1670.25","1670.25","1 through 10","1139.53","1781.9","percent of total billed charges",""
"KNEE WEDGE 10MM SIZE 6 HINGE LEGION","SUP-ITM-10121496","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1139.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1139.53","1781.9","percent of total billed charges",""
"KNEE WEDGE 10MM SIZE 6 HINGE LEGION","SUP-ITM-10121496","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1781.90","81.72","","1738.90","1484.65","2716.94","38","1139.53","1781.9","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","854.19","52.26","","1113.10","1113.10","1113.10","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1299.43","79.5","","1293.60","1148.53","1603.80","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","596.59","36.5","","1023.42","771.29","2068.67","33","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","626.01","38.3","","850.52","759.78","1211.25","66","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","2548.09","2548.09","2548.09","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","956.46","956.46","956.46","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","WELLPOINT [1015]","HB AMC WELLPOINT","1205.93","73.78","","2344.73","1619.47","2530.35","16","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA HMO","1140.88","69.8","","1523.63","988.41","4330.26","39","854.19","1335.71","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA PPO","1314.14","80.4","","1670.25","1670.25","1670.25","1 through 10","854.19","1335.71","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","854.19","52.26","","1113.10","1113.10","1113.10","1 through 10","854.19","1335.71","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1335.71","81.72","","1738.90","1484.65","2716.94","38","854.19","1335.71","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 4 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10121429","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","854.19","52.26","","1113.10","1113.10","1113.10","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 4 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10121429","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1299.43","79.5","","1293.60","1148.53","1603.80","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 4 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10121429","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","596.59","36.5","","1023.42","771.29","2068.67","33","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 4 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10121429","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","626.01","38.3","","850.52","759.78","1211.25","66","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 4 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10121429","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","2548.09","2548.09","2548.09","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 4 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10121429","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","956.46","956.46","956.46","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 4 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10121429","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","WELLPOINT [1015]","HB AMC WELLPOINT","1205.93","73.78","","2344.73","1619.47","2530.35","16","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 4 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10121429","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA HMO","1140.88","69.8","","1523.63","988.41","4330.26","39","854.19","1335.71","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 4 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10121429","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA PPO","1314.14","80.4","","1670.25","1670.25","1670.25","1 through 10","854.19","1335.71","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 4 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10121429","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","854.19","52.26","","1113.10","1113.10","1113.10","1 through 10","854.19","1335.71","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 4 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10121429","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1335.71","81.72","","1738.90","1484.65","2716.94","38","854.19","1335.71","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","800.18","480.96","1887.97","195","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2398.50","53.3","","813.12","216.42","1444.50","81","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1395.00","31","","432.60","432.60","432.60","1 through 10","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","148.37","54.89","631.39","94","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","279.30","91.72","1116.77","266","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","731.00","63.70","731.00","1 through 10","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","384.74","384.74","384.74","1 through 10","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","286.63","119.22","1107.45","105","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","675.31","184.75","1721.50","286","2351.7","3677.4","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA PPO","3618.00","80.4","","1261.44","103.12","1514.10","21","2351.7","3677.4","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3618.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2351.7","3677.4","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3677.40","81.72","","5157.68","5157.68","5157.68","1 through 10","2351.7","3677.4","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","431.26","71.26","1459.57","88","2351.7","3677.4","percent of total billed charges",""
"KNEE WEDGE 20MM SIZE 3 HK LEGION E SZ ONC 09","SUP-ITM-10121486","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1139.53","52.26","","1113.10","1113.10","1113.10","1 through 10","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 20MM SIZE 3 HK LEGION E SZ ONC 09","SUP-ITM-10121486","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1733.50","79.5","","1293.60","1148.53","1603.80","1 through 10","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 20MM SIZE 3 HK LEGION E SZ ONC 09","SUP-ITM-10121486","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","795.88","36.5","","1023.42","771.29","2068.67","33","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 20MM SIZE 3 HK LEGION E SZ ONC 09","SUP-ITM-10121486","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","835.13","38.3","","850.52","759.78","1211.25","66","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 20MM SIZE 3 HK LEGION E SZ ONC 09","SUP-ITM-10121486","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","935.43","42.9","","2548.09","2548.09","2548.09","1 through 10","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 20MM SIZE 3 HK LEGION E SZ ONC 09","SUP-ITM-10121486","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","935.43","42.9","","956.46","956.46","956.46","1 through 10","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 20MM SIZE 3 HK LEGION E SZ ONC 09","SUP-ITM-10121486","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","WELLPOINT [1015]","HB AMC WELLPOINT","1608.77","73.78","","2344.73","1619.47","2530.35","16","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE 20MM SIZE 3 HK LEGION E SZ ONC 09","SUP-ITM-10121486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","AETNA [1001]","HB AMC AETNA HMO","1521.99","69.8","","1523.63","988.41","4330.26","39","1139.53","1781.9","percent of total billed charges",""
"KNEE WEDGE 20MM SIZE 3 HK LEGION E SZ ONC 09","SUP-ITM-10121486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","AETNA [1001]","HB AMC AETNA PPO","1753.12","80.4","","1670.25","1670.25","1670.25","1 through 10","1139.53","1781.9","percent of total billed charges",""
"KNEE WEDGE 20MM SIZE 3 HK LEGION E SZ ONC 09","SUP-ITM-10121486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1139.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1139.53","1781.9","percent of total billed charges",""
"KNEE WEDGE 20MM SIZE 3 HK LEGION E SZ ONC 09","SUP-ITM-10121486","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1781.90","81.72","","1738.90","1484.65","2716.94","38","1139.53","1781.9","percent of total billed charges",""
"KNEE WEDGE 24MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198668","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2381.75","52.26","","1113.10","1113.10","1113.10","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 24MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198668","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3623.21","79.5","","1293.60","1148.53","1603.80","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 24MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198668","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1663.49","36.5","","1023.42","771.29","2068.67","33","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 24MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198668","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1745.52","38.3","","850.52","759.78","1211.25","66","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 24MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198668","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.17","42.9","","2548.09","2548.09","2548.09","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 24MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198668","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.17","42.9","","956.46","956.46","956.46","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 24MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198668","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","WELLPOINT [1015]","HB AMC WELLPOINT","3362.52","73.78","","2344.73","1619.47","2530.35","16","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 24MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198668","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","AETNA [1001]","HB AMC AETNA HMO","3181.14","69.8","","1523.63","988.41","4330.26","39","2381.75","3724.39","percent of total billed charges",""
"KNEE WEDGE 24MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198668","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","AETNA [1001]","HB AMC AETNA PPO","3664.23","80.4","","1670.25","1670.25","1670.25","1 through 10","2381.75","3724.39","percent of total billed charges",""
"KNEE WEDGE 24MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198668","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2381.75","52.26","","1113.10","1113.10","1113.10","1 through 10","2381.75","3724.39","percent of total billed charges",""
"KNEE WEDGE 24MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198668","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3724.39","81.72","","1738.90","1484.65","2716.94","38","2381.75","3724.39","percent of total billed charges",""
"KNEE WEDGE 30MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198665","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2381.75","52.26","","1113.10","1113.10","1113.10","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 30MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198665","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3623.21","79.5","","1293.60","1148.53","1603.80","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 30MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198665","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1663.49","36.5","","1023.42","771.29","2068.67","33","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 30MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198665","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1745.52","38.3","","850.52","759.78","1211.25","66","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 30MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198665","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.17","42.9","","2548.09","2548.09","2548.09","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 30MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198665","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.17","42.9","","956.46","956.46","956.46","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 30MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198665","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","WELLPOINT [1015]","HB AMC WELLPOINT","3362.52","73.78","","2344.73","1619.47","2530.35","16","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE 30MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198665","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","AETNA [1001]","HB AMC AETNA HMO","3181.14","69.8","","1523.63","988.41","4330.26","39","2381.75","3724.39","percent of total billed charges",""
"KNEE WEDGE 30MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198665","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","AETNA [1001]","HB AMC AETNA PPO","3664.23","80.4","","1670.25","1670.25","1670.25","1 through 10","2381.75","3724.39","percent of total billed charges",""
"KNEE WEDGE 30MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198665","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2381.75","52.26","","1113.10","1113.10","1113.10","1 through 10","2381.75","3724.39","percent of total billed charges",""
"KNEE WEDGE 30MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198665","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3724.39","81.72","","1738.90","1484.65","2716.94","38","2381.75","3724.39","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","1309.77","674.56","6049.93","26","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2398.50","53.3","","1901.83","1901.83","2962.25","1 through 10","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","1620.31","1620.31","19908.88","1 through 10","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","352.91","352.91","2046.30","1 through 10","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","9668.75","9668.75","9668.75","1 through 10","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","699.88","384.10","3443.31","33","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","1421.24","264.50","4933.46","29","2351.7","3677.4","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3618.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2351.7","3677.4","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","3010.54","693.88","5019.88","35","2351.7","3677.4","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","854.19","52.26","","1113.10","1113.10","1113.10","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1299.43","79.5","","1293.60","1148.53","1603.80","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","596.59","36.5","","1023.42","771.29","2068.67","33","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","626.01","38.3","","850.52","759.78","1211.25","66","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","2548.09","2548.09","2548.09","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","956.46","956.46","956.46","1 through 10","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","WELLPOINT [1015]","HB AMC WELLPOINT","1205.93","73.78","","2344.73","1619.47","2530.35","16","506.7","1299.43","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA HMO","1140.88","69.8","","1523.63","988.41","4330.26","39","854.19","1335.71","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA PPO","1314.14","80.4","","1670.25","1670.25","1670.25","1 through 10","854.19","1335.71","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","854.19","52.26","","1113.10","1113.10","1113.10","1 through 10","854.19","1335.71","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1335.71","81.72","","1738.90","1484.65","2716.94","38","854.19","1335.71","percent of total billed charges",""
"KNEE WEDGE LONG 20MM TIBIAL CONE LEGION","SUP-ITM-10198684","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2381.75","52.26","","1113.10","1113.10","1113.10","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE LONG 20MM TIBIAL CONE LEGION","SUP-ITM-10198684","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3623.21","79.5","","1293.60","1148.53","1603.80","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE LONG 20MM TIBIAL CONE LEGION","SUP-ITM-10198684","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1663.49","36.5","","1023.42","771.29","2068.67","33","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE LONG 20MM TIBIAL CONE LEGION","SUP-ITM-10198684","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1745.52","38.3","","850.52","759.78","1211.25","66","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE LONG 20MM TIBIAL CONE LEGION","SUP-ITM-10198684","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.17","42.9","","2548.09","2548.09","2548.09","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE LONG 20MM TIBIAL CONE LEGION","SUP-ITM-10198684","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.17","42.9","","956.46","956.46","956.46","1 through 10","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE LONG 20MM TIBIAL CONE LEGION","SUP-ITM-10198684","CDM","C1776","HCPCS","0278","RC","","","","both","","","4557.50","3418.12","WELLPOINT [1015]","HB AMC WELLPOINT","3362.52","73.78","","2344.73","1619.47","2530.35","16","1412.83","3623.21","percent of total billed charges",""
"KNEE WEDGE LONG 20MM TIBIAL CONE LEGION","SUP-ITM-10198684","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","AETNA [1001]","HB AMC AETNA HMO","3181.14","69.8","","1523.63","988.41","4330.26","39","2381.75","3724.39","percent of total billed charges",""
"KNEE WEDGE LONG 20MM TIBIAL CONE LEGION","SUP-ITM-10198684","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","AETNA [1001]","HB AMC AETNA PPO","3664.23","80.4","","1670.25","1670.25","1670.25","1 through 10","2381.75","3724.39","percent of total billed charges",""
"KNEE WEDGE LONG 20MM TIBIAL CONE LEGION","SUP-ITM-10198684","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2381.75","52.26","","1113.10","1113.10","1113.10","1 through 10","2381.75","3724.39","percent of total billed charges",""
"KNEE WEDGE LONG 20MM TIBIAL CONE LEGION","SUP-ITM-10198684","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4557.50","3418.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3724.39","81.72","","1738.90","1484.65","2716.94","38","2381.75","3724.39","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3248.85","79.5","","800.18","480.96","1887.97","195","1266.85","3248.85","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2178.16","53.3","","813.12","216.42","1444.50","81","1266.85","3248.85","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1266.85","31","","432.60","432.60","432.60","1 through 10","1266.85","3248.85","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1491.61","36.5","","148.37","54.89","631.39","94","1266.85","3248.85","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1565.17","38.3","","279.30","91.72","1116.77","266","1266.85","3248.85","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.15","42.9","","731.00","63.70","731.00","1 through 10","1266.85","3248.85","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.15","42.9","","384.74","384.74","384.74","1 through 10","1266.85","3248.85","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","WELLPOINT [1015]","HB AMC WELLPOINT","3015.09","73.78","","286.63","119.22","1107.45","105","1266.85","3248.85","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","AETNA [1001]","HB AMC AETNA HMO","2852.45","69.8","","675.31","184.75","1721.50","286","2135.66","3339.57","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","AETNA [1001]","HB AMC AETNA PPO","3285.63","80.4","","1261.44","103.12","1514.10","21","2135.66","3339.57","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3285.63","80.4","","1365.00","1365.00","1365.00","1 through 10","2135.66","3339.57","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3339.57","81.72","","5157.68","5157.68","5157.68","1 through 10","2135.66","3339.57","percent of total billed charges",""
"KNEE WEDGE SIZE 3 PLATE BONE TIBIAL STEMMED NEXGEN PRECOAT 03C CS/1BX/1EA","SUP-ITM-10009686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3339.57","81.72","","431.26","71.26","1459.57","88","2135.66","3339.57","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","1023.42","771.29","2068.67","33","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","850.52","759.78","1211.25","66","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","956.46","956.46","956.46","1 through 10","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","2344.73","1619.47","2530.35","16","1395","3577.5","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","1523.63","988.41","4330.26","39","2351.7","3677.4","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA PPO","3618.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2351.7","3677.4","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","2351.7","3677.4","percent of total billed charges",""
"KNEE WEDGE SZ 3-15MM STEP CEMENTED MBT REVISION TIBIAL AUGMENT","SUP-ITM-10018513","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","1738.90","1484.65","2716.94","38","2351.7","3677.4","percent of total billed charges",""
"KNEE WEDGE SZ 5 10MM DISTAL LEGION","SUP-ITM-10113419","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1139.53","52.26","","1113.10","1113.10","1113.10","1 through 10","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE SZ 5 10MM DISTAL LEGION","SUP-ITM-10113419","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1733.50","79.5","","1293.60","1148.53","1603.80","1 through 10","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE SZ 5 10MM DISTAL LEGION","SUP-ITM-10113419","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","795.88","36.5","","1023.42","771.29","2068.67","33","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE SZ 5 10MM DISTAL LEGION","SUP-ITM-10113419","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","835.13","38.3","","850.52","759.78","1211.25","66","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE SZ 5 10MM DISTAL LEGION","SUP-ITM-10113419","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","935.43","42.9","","2548.09","2548.09","2548.09","1 through 10","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE SZ 5 10MM DISTAL LEGION","SUP-ITM-10113419","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","935.43","42.9","","956.46","956.46","956.46","1 through 10","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE SZ 5 10MM DISTAL LEGION","SUP-ITM-10113419","CDM","C1776","HCPCS","0278","RC","","","","both","","","2180.50","1635.37","WELLPOINT [1015]","HB AMC WELLPOINT","1608.77","73.78","","2344.73","1619.47","2530.35","16","675.96","1733.5","percent of total billed charges",""
"KNEE WEDGE SZ 5 10MM DISTAL LEGION","SUP-ITM-10113419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","AETNA [1001]","HB AMC AETNA HMO","1521.99","69.8","","1523.63","988.41","4330.26","39","1139.53","1781.9","percent of total billed charges",""
"KNEE WEDGE SZ 5 10MM DISTAL LEGION","SUP-ITM-10113419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","AETNA [1001]","HB AMC AETNA PPO","1753.12","80.4","","1670.25","1670.25","1670.25","1 through 10","1139.53","1781.9","percent of total billed charges",""
"KNEE WEDGE SZ 5 10MM DISTAL LEGION","SUP-ITM-10113419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1139.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1139.53","1781.9","percent of total billed charges",""
"KNEE WEDGE SZ 5 10MM DISTAL LEGION","SUP-ITM-10113419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2180.50","1635.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1781.90","81.72","","1738.90","1484.65","2716.94","38","1139.53","1781.9","percent of total billed charges",""
"KNIFE ELECTROSURGICAL .4MM 4.5MM TRIANGLE TIP WATER JET FUNCTION","SUP-ITM-10273896","CDM","C1889","HCPCS","0272","RC","","","","both","","","3738.70","2804.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2972.27","79.5","","1309.77","674.56","6049.93","26","1159","2972.27","percent of total billed charges",""
"KNIFE ELECTROSURGICAL .4MM 4.5MM TRIANGLE TIP WATER JET FUNCTION","SUP-ITM-10273896","CDM","C1889","HCPCS","0272","RC","","","","both","","","3738.70","2804.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1992.73","53.3","","1901.83","1901.83","2962.25","1 through 10","1159","2972.27","percent of total billed charges",""
"KNIFE ELECTROSURGICAL .4MM 4.5MM TRIANGLE TIP WATER JET FUNCTION","SUP-ITM-10273896","CDM","C1889","HCPCS","0272","RC","","","","both","","","3738.70","2804.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1364.63","36.5","","1620.31","1620.31","19908.88","1 through 10","1159","2972.27","percent of total billed charges",""
"KNIFE ELECTROSURGICAL .4MM 4.5MM TRIANGLE TIP WATER JET FUNCTION","SUP-ITM-10273896","CDM","C1889","HCPCS","0272","RC","","","","both","","","3738.70","2804.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1431.92","38.3","","352.91","352.91","2046.30","1 through 10","1159","2972.27","percent of total billed charges",""
"KNIFE ELECTROSURGICAL .4MM 4.5MM TRIANGLE TIP WATER JET FUNCTION","SUP-ITM-10273896","CDM","C1889","HCPCS","0272","RC","","","","both","","","3738.70","2804.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1603.90","42.9","","9668.75","9668.75","9668.75","1 through 10","1159","2972.27","percent of total billed charges",""
"KNIFE ELECTROSURGICAL .4MM 4.5MM TRIANGLE TIP WATER JET FUNCTION","SUP-ITM-10273896","CDM","C1889","HCPCS","0272","RC","","","","both","","","3738.70","2804.02","WELLPOINT [1015]","HB AMC WELLPOINT","2758.41","73.78","","699.88","384.10","3443.31","33","1159","2972.27","percent of total billed charges",""
"KNIFE ELECTROSURGICAL .4MM 4.5MM TRIANGLE TIP WATER JET FUNCTION","SUP-ITM-10273896","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","3738.70","2804.02","AETNA [1001]","HB AMC AETNA HMO","2609.61","69.8","","1421.24","264.50","4933.46","29","1953.84","3055.27","percent of total billed charges",""
"KNIFE ELECTROSURGICAL .4MM 4.5MM TRIANGLE TIP WATER JET FUNCTION","SUP-ITM-10273896","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","3738.70","2804.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3005.91","80.4","","1022.97","1022.97","3607.50","1 through 10","1953.84","3055.27","percent of total billed charges",""
"KNIFE ELECTROSURGICAL .4MM 4.5MM TRIANGLE TIP WATER JET FUNCTION","SUP-ITM-10273896","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","3738.70","2804.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3055.27","81.72","","3010.54","693.88","5019.88","35","1953.84","3055.27","percent of total billed charges",""
"Known Familial Mutation (Kfmiv)","PX-31000680","CDM","81479","CPT","0310","RC","","","","both","","","344.00","258.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","273.48","79.5","","0.65","0.65","0.65","1 through 10","106.64","326.8","percent of total billed charges",""
"Known Familial Mutation (Kfmiv)","PX-31000680","CDM","81479","CPT","0310","RC","","","","both","","","344.00","258.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","183.35","53.3","","0.79","0.79","0.79","1 through 10","106.64","326.8","percent of total billed charges",""
"Known Familial Mutation (Kfmiv)","PX-31000680","CDM","81479","CPT","0310","RC","","","","outpatient","","","344.00","258.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","172.00","50","","1.00","1.00","1.00","1 through 10","156.55","283.8","percent of total billed charges",""
"Known Familial Mutation (Kfmiv)","PX-31000680","CDM","81479","CPT","0310","RC","","","","outpatient","","","344.00","258.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","180.60","52.5","","1.00","0.53","1.00","1 through 10","156.55","283.8","percent of total billed charges",""
"Ko Immobil Knee Prefab Ots T1","PX-27000328","CDM","L1830","HCPCS","0274","RC","","","","outpatient","","","49.81","37.36","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","26.15","52.5","","73.75","73.75","73.75","1 through 10","24.91","204.66","percent of total billed charges",""
"Kyleena Iud 19.5 Mg Levonorgestrel","PX-27002137","CDM","J7296","HCPCS","0270","RC","","","","both","","","4247.00","3185.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1550.16","36.5","","3850.98","1925.49","3850.98","1 through 10","1316.57","3270.19","percent of total billed charges",""
"Kyleena Iud 19.5 Mg Levonorgestrel","PX-27002137","CDM","J7296","HCPCS","0270","RC","","","","both","","","4247.00","3185.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1626.60","38.3","","4036.82","1868.22","5766.90","32","1316.57","3270.19","percent of total billed charges",""
"Kyleena Iud 19.5 Mg Levonorgestrel","PX-27002137","CDM","J7296","HCPCS","0270","RC","","","","both","","","4247.00","3185.25","WELLPOINT [1015]","HB AMC WELLPOINT","3133.44","73.78","","9005.42","9005.42","9005.42","1 through 10","1316.57","3270.19","percent of total billed charges",""
"Kyleena Iud 19.5 Mg Levonorgestrel","PX-27002137","CDM","J7296","HCPCS","0270","RC","","","","outpatient","","","4247.00","3185.25","AETNA [1001]","HB AMC AETNA HMO","2964.41","69.8","","3494.80","2467.52","5162.18","1 through 10","1419.97","3414.59","percent of total billed charges",""
"Kyleena Iud 19.5 Mg Levonorgestrel","PX-27002137","CDM","J7296","HCPCS","0270","RC","","","","outpatient","","","4247.00","3185.25","AETNA [1001]","HB AMC AETNA PPO","3414.59","80.4","","2576.17","2576.17","2576.17","1 through 10","1419.97","3414.59","percent of total billed charges",""
"Kyleena Iud 19.5 Mg Levonorgestrel","PX-27002137","CDM","J7296","HCPCS","0270","RC","","","","outpatient","","","4247.00","3185.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2968.65","69.9","","7315.45","3407.04","10732.17","1 through 10","1419.97","3414.59","percent of total billed charges",""
"Kyleena Iud 19.5 Mg Levonorgestrel","PX-27002137","CDM","J7296","HCPCS","0270","RC","","","","outpatient","","","4247.00","3185.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1991.84","46.9","","2482.76","2482.76","2482.76","1 through 10","1419.97","3414.59","percent of total billed charges",""
"L-PLATE","SUP-ITM-10317508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1460.81","79.5","","800.18","480.96","1887.97","195","569.63","1460.81","percent of total billed charges",""
"L-PLATE","SUP-ITM-10317508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","979.39","53.3","","813.12","216.42","1444.50","81","569.63","1460.81","percent of total billed charges",""
"L-PLATE","SUP-ITM-10317508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","569.63","31","","432.60","432.60","432.60","1 through 10","569.63","1460.81","percent of total billed charges",""
"L-PLATE","SUP-ITM-10317508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","670.69","36.5","","148.37","54.89","631.39","94","569.63","1460.81","percent of total billed charges",""
"L-PLATE","SUP-ITM-10317508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","703.76","38.3","","279.30","91.72","1116.77","266","569.63","1460.81","percent of total billed charges",""
"L-PLATE","SUP-ITM-10317508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","788.29","42.9","","731.00","63.70","731.00","1 through 10","569.63","1460.81","percent of total billed charges",""
"L-PLATE","SUP-ITM-10317508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","788.29","42.9","","384.74","384.74","384.74","1 through 10","569.63","1460.81","percent of total billed charges",""
"L-PLATE","SUP-ITM-10317508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1837.50","1378.12","WELLPOINT [1015]","HB AMC WELLPOINT","1355.71","73.78","","286.63","119.22","1107.45","105","569.63","1460.81","percent of total billed charges",""
"L-PLATE","SUP-ITM-10317508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","AETNA [1001]","HB AMC AETNA HMO","1282.58","69.8","","675.31","184.75","1721.50","286","960.28","1501.61","percent of total billed charges",""
"L-PLATE","SUP-ITM-10317508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","AETNA [1001]","HB AMC AETNA PPO","1477.35","80.4","","1261.44","103.12","1514.10","21","960.28","1501.61","percent of total billed charges",""
"L-PLATE","SUP-ITM-10317508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1477.35","80.4","","1365.00","1365.00","1365.00","1 through 10","960.28","1501.61","percent of total billed charges",""
"L-PLATE","SUP-ITM-10317508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1501.61","81.72","","5157.68","5157.68","5157.68","1 through 10","960.28","1501.61","percent of total billed charges",""
"L-PLATE","SUP-ITM-10317508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1837.50","1378.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1501.61","81.72","","431.26","71.26","1459.57","88","960.28","1501.61","percent of total billed charges",""
"La Press Measure via Transeptal Allay Hf Trial","PX-48000547","CDM","93799","CPT","0481","RC","","","","both","","","8032.00","6024.00","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","6385.44","other","OPPS APC"
"La Press Measure via Transeptal Allay Hf Trial","PX-48000547","CDM","93799","CPT","0481","RC","","","","outpatient","","","8032.00","6024.00","AETNA [1001]","HB AMC AETNA HMO","5606.34","69.8","","2022.70","2022.70","2022.70","1 through 10","454","6626.4","percent of total billed charges",""
"La Press Measure via Transeptal Allay Hf Trial","PX-48000547","CDM","93799","CPT","0481","RC","","","","outpatient","","","8032.00","6024.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4863.38","60.55","","318.03","318.03","2439.77","1 through 10","454","6626.4","percent of total billed charges",""
"La Press Measure via Transeptal Allay Hf Trial","PX-48000547","CDM","93799","CPT","0481","RC","","","","outpatient","","","8032.00","6024.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4194.31","52.22","","360.38","360.38","4023.00","1 through 10","454","6626.4","percent of total billed charges",""
"La Press Measure via Transeptal Allay Hf Trial","PX-48000547","CDM","93799","CPT","0481","RC","","","","outpatient","","","8032.00","6024.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","4417.60","55","","13080.03","13080.03","13080.03","1 through 10","454","6626.4","percent of total billed charges",""
"La Press Measure via Transeptal W/Ra Pressures","PX-48000548","CDM","93799","CPT","0481","RC","","","","both","","","40873.00","30654.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","32494.04","other","OPPS APC"
"La Press Measure via Transeptal W/Ra Pressures","PX-48000548","CDM","93799","CPT","0481","RC","","","","outpatient","","","40873.00","30654.75","AETNA [1001]","HB AMC AETNA HMO","28529.35","69.8","","2022.70","2022.70","2022.70","1 through 10","454","33720.23","percent of total billed charges",""
"La Press Measure via Transeptal W/Ra Pressures","PX-48000548","CDM","93799","CPT","0481","RC","","","","outpatient","","","40873.00","30654.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24748.60","60.55","","318.03","318.03","2439.77","1 through 10","454","33720.23","percent of total billed charges",""
"La Press Measure via Transeptal W/Ra Pressures","PX-48000548","CDM","93799","CPT","0481","RC","","","","outpatient","","","40873.00","30654.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21343.88","52.22","","360.38","360.38","4023.00","1 through 10","454","33720.23","percent of total billed charges",""
"La Press Measure via Transeptal W/Ra Pressures","PX-48000548","CDM","93799","CPT","0481","RC","","","","outpatient","","","40873.00","30654.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","22480.15","55","","13080.03","13080.03","13080.03","1 through 10","454","33720.23","percent of total billed charges",""
"Labcore, 510200 Prenatal Direct Snp Microarray Dirsnp","PX-31001277","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2946.27","79.5","","2828.48","1814.97","2828.48","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Labcore, 510200 Prenatal Direct Snp Microarray Dirsnp","PX-31001277","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1975.30","53.3","","1814.97","1761.95","1814.97","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Labcore, 510200 Prenatal Direct Snp Microarray Dirsnp","PX-31001277","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1352.69","36.5","","1340.56","1340.56","1340.56","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Labcore, 510200 Prenatal Direct Snp Microarray Dirsnp","PX-31001277","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1419.40","38.3","","1405.25","1405.25","1405.25","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Labcore, 510200 Prenatal Direct Snp Microarray Dirsnp","PX-31001277","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","WELLPOINT [1015]","HB AMC WELLPOINT","2734.29","73.78","","6269.73","2675.73","7188.00","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Labcore, 510200 Prenatal Direct Snp Microarray Dirsnp","PX-31001277","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","AETNA [1001]","HB AMC AETNA HMO","2586.79","69.8","","2433.14","2433.14","2433.14","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Labcore, 510200 Prenatal Direct Snp Microarray Dirsnp","PX-31001277","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2979.62","80.4","","2803.32","2803.32","2803.32","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Labcore, 510200 Prenatal Direct Snp Microarray Dirsnp","PX-31001277","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3028.54","81.72","","2873.04","1533.07","3526.61","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Labcore, 511590 Chromosome 5 Cell Count Microarray Chr5ce","PX-31001293","CDM","81268","CPT","0310","RC","","","","both","","","1601.00","1200.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1272.80","79.5","","1222.21","1222.21","1222.21","1 through 10","255.57","1520.95","percent of total billed charges",""
"Labcorp, 604734 Hazelnut Ige Allergen With Reflex to Hazelnut Components","PX-31001381","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","both","","","226.00","169.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","179.67","79.5","","106.25","71.28","106.25","1 through 10","14.12","214.7","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","both","","","226.00","169.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","120.46","53.3","","106.25","71.28","106.25","1 through 10","14.12","214.7","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","both","","","226.00","169.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","82.49","36.5","","50.36","42.80","92.50","13","14.12","214.7","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","both","","","226.00","169.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","86.56","38.3","","52.79","44.55","158.37","30","14.12","214.7","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","outpatient","","","226.00","169.50","AETNA [1001]","HB AMC AETNA HMO","157.75","69.8","","91.40","64.53","105.30","14","14.12","184.69","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","outpatient","","","226.00","169.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","181.70","80.4","","105.30","105.30","105.30","1 through 10","14.12","184.69","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","outpatient","","","226.00","169.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","184.69","81.72","","59.36","15.50","59.36","1 through 10","14.12","184.69","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","75.39","71.8","","73.24","73.24","73.24","1 through 10","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","68.88","65.6","","6.21","6.21","6.21","1 through 10","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","68.25","65","","200.20","66.30","269.30","16","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","73.50","70","","102.00","73.44","306.00","14","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","83.48","79.5","","80.27","53.86","161.58","111","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","55.97","53.3","","80.27","53.86","161.58","48","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","80.85","77","","235.62","235.62","235.62","1 through 10","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","32.55","31","","31.52","31.52","31.52","1 through 10","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.33","36.5","","38.05","32.33","38.05","45","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.22","38.3","","39.88","39.88","119.64","286","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","80.85","77","","10.12","10.12","10.12","1 through 10","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","TRICARE [160005]","HB BWH TRICARE","99.75","95","","7.28","6.92","7.28","1 through 10","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.05","42.9","","81.54","44.85","81.54","1 through 10","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.05","42.9","","44.85","44.85","44.85","1 through 10","5.92","99.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","105.00","78.75","AETNA [1001]","HB AMC AETNA HMO","73.29","69.8","","64.85","48.76","79.56","140","6.23","85.81","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","105.00","78.75","AETNA [1001]","HB AMC AETNA PPO","84.42","80.4","","79.56","48.76","160.35","15","6.23","85.81","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","105.00","78.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","54.87","52.26","","63.12","63.12","63.12","1 through 10","6.23","85.81","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","85.81","81.72","","81.54","81.54","81.54","1 through 10","6.23","85.81","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","85.81","81.72","","81.54","44.85","81.54","1 through 10","6.23","85.81","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","85.81","81.72","","81.54","44.85","81.54","90","6.23","85.81","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","both","","","179.00","134.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","128.52","71.8","","124.93","124.93","124.93","1 through 10","11.01","170.05","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","both","","","179.00","134.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","125.30","70","","174.00","125.28","174.00","1 through 10","11.01","170.05","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","both","","","179.00","134.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","142.31","79.5","","136.94","136.71","382.17","58","11.01","170.05","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","both","","","179.00","134.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.41","53.3","","91.87","86.38","175.74","14","11.01","170.05","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","both","","","179.00","134.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","116.35","65","","90.35","90.35","90.35","1 through 10","11.01","170.05","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","both","","","179.00","134.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","128.88","72","","125.28","125.28","125.28","1 through 10","11.01","170.05","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.34","36.5","","64.90","55.16","324.50","27","11.01","170.05","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.56","38.3","","68.03","68.03","68.04","74","11.01","170.05","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","179.00","134.25","AETNA [1001]","HB AMC AETNA HMO","124.94","69.8","","117.80","117.80","200.97","21","11.01","146.28","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","179.00","134.25","AETNA [1001]","HB AMC AETNA PPO","143.92","80.4","","265.18","135.72","265.18","1 through 10","11.01","146.28","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","179.00","134.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","93.55","52.26","","107.67","107.67","107.67","1 through 10","11.01","146.28","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","179.00","134.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","146.28","81.72","","1046.72","1046.72","1046.72","1 through 10","11.01","146.28","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","179.00","134.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","146.28","81.72","","76.51","76.51","76.51","1 through 10","11.01","146.28","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","179.00","134.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","146.28","81.72","","139.10","76.51","139.10","27","11.01","146.28","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","both","","","391.00","293.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","142.72","36.5","","141.37","120.14","141.37","1 through 10","121.21","371.45","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","both","","","391.00","293.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","149.75","38.3","","148.19","148.19","148.19","65","121.21","371.45","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","both","","","391.00","293.25","WELLPOINT [1015]","HB AMC WELLPOINT","288.48","73.78","","282.17","282.17","282.17","1 through 10","121.21","371.45","percent of total billed charges",""
"Lactoferrin Fecal Ql","PX-30000540","CDM","83630","CPT","0301","RC","","","","both","","","251.00","188.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","199.55","79.5","","191.24","191.24","191.24","1 through 10","19.31","238.45","percent of total billed charges",""
"Lactoferrin Fecal Ql","PX-30000540","CDM","83630","CPT","0301","RC","","","","both","","","251.00","188.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91.62","36.5","","90.64","77.03","90.64","1 through 10","19.31","238.45","percent of total billed charges",""
"Lactoferrin Fecal Ql","PX-30000540","CDM","83630","CPT","0301","RC","","","","both","","","251.00","188.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.13","38.3","","95.01","95.01","95.01","1 through 10","19.31","238.45","percent of total billed charges",""
"Lactoferrin Fecal Ql","PX-30000540","CDM","83630","CPT","0301","RC","","","","outpatient","","","251.00","188.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","205.12","81.72","","194.25","106.85","194.25","1 through 10","20.24","205.12","percent of total billed charges",""
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","93864.23","70398.17","MEDICARE [2001]","HB BWH MEDICARE","20406.56","","Case rate ($20,406.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,955.66, add-ons for qualifying new technology services are included. If operating cost exceeds $64,600.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,801.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $18,665.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,575.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.16. The transfer capital threshold is the transfer adjustment factor * $1,361.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19829.42","0.03","19858.67","16","15494.57","25026.9144","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","93864.23","70398.17","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","15494.57","","Case rate ($15,810.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,955.66, add-ons for qualifying new technology services are included. If operating cost exceeds $64,600.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,801.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $14,069.79 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,575.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.16. The transfer capital threshold is the transfer adjustment factor * $1,361.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20496.09","20496.09","20496.09","1 through 10","15494.57","25026.9144","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","93864.23","70398.17","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15494.57","","Case rate ($15,810.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,955.66, add-ons for qualifying new technology services are included. If operating cost exceeds $64,600.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,801.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $14,069.79 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,575.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,361.16. The transfer capital threshold is the transfer adjustment factor * $1,361.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15122.77","15122.77","15122.77","1 through 10","15494.57","25026.9144","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With McC","417","MS-DRG","","","","","","","","inpatient","","","113025.12","84768.84","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","22148.83","","Case rate ($22,148.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,585.41, add-ons for qualifying new technology services are included. If operating cost exceeds $72,229.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,360.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,848.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,205.57 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,920.24. The transfer capital threshold is the transfer adjustment factor * $1,920.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21608.98","21608.98","21608.98","1 through 10","21705.85","35863.7615","other","Inpatient Replacement Plans DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With McC","417","MS-DRG","","","","","","","","inpatient","","","113025.12","84768.84","MEDICARE [2001]","HB BWH MEDICARE","22148.83","","Case rate ($22,148.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,585.41, add-ons for qualifying new technology services are included. If operating cost exceeds $72,229.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,360.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,848.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,205.57 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,920.24. The transfer capital threshold is the transfer adjustment factor * $1,920.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28337.12","28295.20","33340.31","1 through 10","21705.85","35863.7615","other","Inpatient Replacement Plans DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With McC","417","MS-DRG","","","","","","","","inpatient","","","113025.12","84768.84","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","21705.85","","Case rate ($22,148.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,585.41, add-ons for qualifying new technology services are included. If operating cost exceeds $72,229.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,360.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,848.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,205.57 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,920.24. The transfer capital threshold is the transfer adjustment factor * $1,920.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21544.94","21544.94","21544.94","1 through 10","21705.85","35863.7615","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With McC","417","MS-DRG","","","","","","","","inpatient","","","113025.12","84768.84","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","21705.85","","Case rate ($22,148.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,585.41, add-ons for qualifying new technology services are included. If operating cost exceeds $72,229.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,360.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,848.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,205.57 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,920.24. The transfer capital threshold is the transfer adjustment factor * $1,920.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21434.53","21434.53","21434.53","1 through 10","21705.85","35863.7615","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With McC","417","MS-DRG","","","","","","","","inpatient","","","113025.12","84768.84","WELLPOINT [1015]","HB AMC WELLPOINT","35863.7615","","Fee schedule rate ($37,380.57).","35863.7615","35863.76","35863.76","1 through 10","21705.85","35863.7615","case rate",""
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC","419","MS-DRG","","","","","","","","inpatient","","","83475.02","62606.26","MEDICARE [2001]","HB BWH MEDICARE","12838.81","","Case rate ($12,838.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,377.98, add-ons for qualifying new technology services are included. If operating cost exceeds $61,022.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,539.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $11,359.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,998.15 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,099.00. The transfer capital threshold is the transfer adjustment factor * $1,099.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6929.40","4518.11","15834.91","1 through 10","12582.03","19883.9016","other","Inpatient Replacement Plans DRG"
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC","419","MS-DRG","","","","","","","","inpatient","","","83475.02","62606.26","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12582.03","","Case rate ($12,838.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,377.98, add-ons for qualifying new technology services are included. If operating cost exceeds $61,022.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,539.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $11,359.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,998.15 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,099.00. The transfer capital threshold is the transfer adjustment factor * $1,099.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12055.93","12055.93","12055.93","1 through 10","12582.03","19883.9016","other","Inpatient DRG"
"Laparoscopy Surg Rpr Initial Inguinal Hernia","PX-36000437","CDM","49650","CPT","0361","RC","","","","both","","","8094.00","6070.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7271.44","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6797.98","6171.55","6797.98","1 through 10","2509.14","9274.8","other","OPPS APC"
"Laparoscopy Surg Rpr Initial Inguinal Hernia|BILATERAL PROCEDURE","PX-36000437","CDM","49650","CPT","0361","RC","","","50","outpatient","","","8094.00","6070.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","7883.43","","Case rate ($7,883.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","16129.50","15837.81","16129.50","1 through 10","7883.43","23762.87","other","ASC"
"Laparoscopy W/Lysis of Adhesions","PX-36000517","CDM","58660","CPT","0361","RC","","","","both","","","5739.00","4304.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2094.74","36.5","","45118.10","45118.10","45118.10","1 through 10","1779.09","9274.8","percent of total billed charges",""
"Laparoscopy W/Lysis of Adhesions","PX-36000517","CDM","58660","CPT","0361","RC","","","","outpatient","","","5739.00","4304.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5255.62","","Case rate ($5,255.62). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","12182.53","12182.53","12182.53","1 through 10","2999.2","9843.6","other","ASC "
"Laryngoscopy","PX-76000766","CDM","31525","CPT","0761","RC","","","","both","","","4320.00","3240.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3434.40","79.5","","7960.11","7960.11","7960.11","1 through 10","165.85","3434.4","percent of total billed charges",""
"Laryngoscopy","PX-76000766","CDM","31525","CPT","0761","RC","","","","outpatient","","","4320.00","3240.00","AETNA [1001]","HB AMC AETNA HMO","3015.36","69.8","","12213.42","10871.94","12213.42","1 through 10","1232.36","3530.3","percent of total billed charges",""
"Laryngoscopy","PX-76000766","CDM","31525","CPT","0761","RC","","","","outpatient","","","4320.00","3240.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1832.84","1814.83","1832.84","1 through 10","1232.36","3530.3","other","ASC "
"Laryngoscopy","PX-76000766","CDM","31525","CPT","0761","RC","","","","outpatient","","","4320.00","3240.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3530.30","81.72","","7800.07","7800.07","7800.07","1 through 10","1232.36","3530.3","percent of total billed charges",""
"Laryngoscopy Direct With Biopsy","PX-76002335","CDM","31535","CPT","0761","RC","","","","both","","","5271.00","3953.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4190.45","79.5","","12801.34","4294.22","12801.34","1 through 10","1634.01","4190.45","percent of total billed charges",""
"Laryngoscopy Direct With Biopsy","PX-76002335","CDM","31535","CPT","0761","RC","","","","both","","","5271.00","3953.25","WELLPOINT [1015]","HB AMC WELLPOINT","3888.94","73.78","","10480.70","10480.70","10480.70","1 through 10","1634.01","4190.45","percent of total billed charges",""
"Laryngoscopy Direct With Biopsy","PX-76002335","CDM","31535","CPT","0761","RC","","","","outpatient","","","5271.00","3953.25","AETNA [1001]","HB AMC AETNA PPO","4237.88","80.4","","18869.76","18869.76","18869.76","1 through 10","2108.4","4307.46","percent of total billed charges",""
"Laryngoscopy Direct With Biopsy","PX-76002335","CDM","31535","CPT","0761","RC","","","","outpatient","","","5271.00","3953.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3191.59","60.55","","6296.41","3206.19","6412.37","1 through 10","2108.4","4307.46","percent of total billed charges",""
"Laryngoscopy Direct With Biopsy","PX-76002335","CDM","31535","CPT","0761","RC","","","","outpatient","","","5271.00","3953.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2752.52","52.22","","7264.84","7264.84","7336.93","1 through 10","2108.4","4307.46","percent of total billed charges",""
"Laryngoscopy Direct With Biopsy","PX-76002335","CDM","31535","CPT","0761","RC","","","","outpatient","","","5271.00","3953.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4307.46","81.72","","19339.08","19339.08","19339.08","1 through 10","2108.4","4307.46","percent of total billed charges",""
"Laryngoscopy Direct With Dilation Initial","PX-76002336","CDM","31528","CPT","0761","RC","","","","both","","","5168.00","3876.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1979.34","38.3","","5123.86","5123.86","5123.86","1 through 10","149.68","4159.55","percent of total billed charges",""
"Laryngoscopy Direct With Dilation Initial","PX-76002336","CDM","31528","CPT","0761","RC","","","","outpatient","","","5168.00","3876.00","AETNA [1001]","HB AMC AETNA HMO","3607.26","69.8","","6505.20","2940.42","6505.20","1 through 10","2466.59","5545.35","percent of total billed charges",""
"Laryngoscopy Direct With Dilation Initial","PX-76002336","CDM","31528","CPT","0761","RC","","","","outpatient","","","5168.00","3876.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7264.84","7264.84","7264.84","1 through 10","2466.59","5545.35","other","ASC "
"Laryngoscopy Direct With Dilation Initial","PX-76002336","CDM","31528","CPT","0761","RC","","","","outpatient","","","5168.00","3876.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4223.29","81.72","","2223.67","2223.67","2223.67","1 through 10","2466.59","5545.35","percent of total billed charges",""
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","both","","","540.00","405.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","429.30","79.5","","410.61","410.61","410.61","1 through 10","73.25","429.3","percent of total billed charges",""
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","both","","","540.00","405.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","206.82","38.3","","204.88","204.88","204.88","1 through 10","73.25","429.3","percent of total billed charges",""
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","outpatient","","","540.00","405.00","AETNA [1001]","HB AMC AETNA HMO","376.92","69.8","","354.75","354.75","354.75","1 through 10","163.97","700.33","percent of total billed charges",""
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","outpatient","","","540.00","405.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","187.51","","Case rate ($187.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","434.65","434.65","434.65","1 through 10","163.97","700.33","other","ASC "
"Laryngoscopy Flexible Therapeutic Injection Uni","PX-76002404","CDM","31573","CPT","0761","RC","","","","both","","","1175.00","881.25","MEDICARE [2001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1852.43","1852.43","1852.43","1 through 10","364.25","2559.63","other","OPPS APC"
"Laryngoscopy Flexible Therapeutic Injection Uni","PX-76002404","CDM","31573","CPT","0761","RC","","","","both","","","1175.00","881.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","428.88","36.5","","2643.78","2643.78","2643.78","1 through 10","364.25","2559.63","percent of total billed charges",""
"Laryngoscopy Flexible Therapeutic Injection Uni","PX-76002404","CDM","31573","CPT","0761","RC","","","","both","","","1175.00","881.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","450.03","38.3","","2929.56","2929.56","2929.56","1 through 10","364.25","2559.63","percent of total billed charges",""
"Laryngoscopy Flexible Therapeutic Injection Uni","PX-76002404","CDM","31573","CPT","0761","RC","","","","both","","","1175.00","881.25","WELLPOINT [1015]","HB AMC WELLPOINT","866.92","73.78","","847.99","847.99","847.99","1 through 10","364.25","2559.63","percent of total billed charges",""
"Laryngoscopy OP Remove FB","PX-76000768","CDM","31530","CPT","0761","RC","","","","both","","","4235.00","3176.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1545.78","36.5","","2643.78","2643.78","2643.78","1 through 10","1312.85","3366.83","percent of total billed charges",""
"Laryngoscopy OP Remove FB","PX-76000768","CDM","31530","CPT","0761","RC","","","","outpatient","","","4235.00","3176.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2211.52","52.22","","937.00","937.00","937.00","1 through 10","1694","3460.84","percent of total billed charges",""
"Laryngoscopy OP W/Inj Cord","PX-76000769","CDM","31570","CPT","0761","RC","","","","both","","","4362.00","3271.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1592.13","36.5","","2643.78","2643.78","2643.78","1 through 10","235.86","4159.55","percent of total billed charges",""
"Laryngoscopy OP W/Inj Cord","PX-76000769","CDM","31570","CPT","0761","RC","","","","outpatient","","","4362.00","3271.50","AETNA [1001]","HB AMC AETNA HMO","3044.68","69.8","","5646.18","5646.18","5646.18","1 through 10","2279.58","5545.35","percent of total billed charges",""
"Laryngoscopy OP W/Inj Cord","PX-76000769","CDM","31570","CPT","0761","RC","","","","outpatient","","","4362.00","3271.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6412.37","6412.37","6412.37","1 through 10","2279.58","5545.35","other","ASC"
"Laryngoscopy OP W/Inj Cord","PX-76000769","CDM","31570","CPT","0761","RC","","","","outpatient","","","4362.00","3271.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7336.93","7336.93","7336.93","1 through 10","2279.58","5545.35","other","ASC "
"Laryngoscopy OP W/Inj Cord W/Mic/Te","PX-76000770","CDM","31571","CPT","0761","RC","","","","both","","","6548.00","4911.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4509.37","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4512.44","4512.44","4512.44","1 through 10","2029.88","5472.54","other","OPPS APC"
"Laryngoscopy OP W/Inj Cord W/Mic/Te","PX-76000770","CDM","31571","CPT","0761","RC","","","","both","","","6548.00","4911.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5205.66","79.5","","14373.37","12801.34","14373.37","1 through 10","2029.88","5472.54","percent of total billed charges",""
"Laryngoscopy OP W/Inj Cord W/Mic/Te","PX-76000770","CDM","31571","CPT","0761","RC","","","","both","","","6548.00","4911.00","MEDICARE [2001]","HB BWH MEDICARE","4378.03","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4378.47","4087.20","4378.47","1 through 10","2029.88","5472.54","other","OPPS APC"
"Laryngoscopy OP W/Inj Cord W/Mic/Te","PX-76000770","CDM","31571","CPT","0761","RC","","","","both","","","6548.00","4911.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2390.02","36.5","","6412.59","2643.78","6412.59","1 through 10","2029.88","5472.54","percent of total billed charges",""
"Laryngoscopy OP W/Inj Cord W/Mic/Te","PX-76000770","CDM","31571","CPT","0761","RC","","","","both","","","6548.00","4911.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2507.88","38.3","","2929.56","2929.56","2929.56","1 through 10","2029.88","5472.54","percent of total billed charges",""
"Laryngoscopy OP W/Inj Cord W/Mic/Te","PX-76000770","CDM","31571","CPT","0761","RC","","","","both","","","6548.00","4911.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","14983.33","14983.33","14983.33","1 through 10","2029.88","5472.54","other","OPPS APC"
"Laryngoscopy OP W/Inj Cord W/Mic/Te","PX-76000770","CDM","31571","CPT","0761","RC","","","","both","","","6548.00","4911.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4290.47","","APC Price ($4,378.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4298.81","4298.41","4298.81","1 through 10","2029.88","5472.54","other","OPPS APC"
"Laryngoscopy OP W/Inj Cord W/Mic/Te","PX-76000770","CDM","31571","CPT","0761","RC","","","","outpatient","","","6548.00","4911.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6296.41","3148.21","6412.37","1 through 10","2466.59","5545.35","other","ASC"
"Laryngoscopy OP W/Inj Cord W/Mic/Te","PX-76000770","CDM","31571","CPT","0761","RC","","","","outpatient","","","6548.00","4911.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7264.84","3632.42","7336.93","1 through 10","2466.59","5545.35","other","ASC "
"Laryngoscopy OP W/Inj Cord W/Mic/Te","PX-76000770","CDM","31571","CPT","0761","RC","","","","outpatient","","","6548.00","4911.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2861.25","2750.25","5722.49","1 through 10","2466.59","5545.35","other","Multiple Surgery"
"Laryngoscopy OP W/Inj Cord W/Mic/Te","PX-76000770","CDM","31571","CPT","0761","RC","","","","outpatient","","","6548.00","4911.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2466.59","","Case rate ($2,466.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6018.48","6018.48","6018.48","1 through 10","2466.59","5545.35","other","Multiple Surgery"
"Laryngoscopy OP W/Inj Cord W/Mic/Te","PX-76000770","CDM","31571","CPT","0761","RC","","","","outpatient","","","6548.00","4911.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5351.03","81.72","","8085.53","2223.67","8085.53","1 through 10","2466.59","5545.35","percent of total billed charges",""
"Laryngoscopy W/WO Tracheoscopy Dx Except Newborn","PX-98301021","CDM","31525","CPT","0983","RC","","","","both","","","823.00","617.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","654.29","79.5","","7960.11","7960.11","7960.11","1 through 10","165.85","1945.52","percent of total billed charges",""
"Laryngoscopy W/WO Tracheoscopy Dx Except Newborn","PX-98301021","CDM","31525","CPT","0983","RC","","","","outpatient","","","823.00","617.25","AETNA [1001]","HB AMC AETNA HMO","574.45","69.8","","12213.42","10871.94","12213.42","1 through 10","460.06","2384.07","percent of total billed charges",""
"Laryngoscopy W/WO Tracheoscopy Dx Except Newborn","PX-98301021","CDM","31525","CPT","0983","RC","","","","outpatient","","","823.00","617.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","672.56","81.72","","7800.07","7800.07","7800.07","1 through 10","460.06","2384.07","percent of total billed charges",""
"Laser Hair Removal","PX-76002704","CDM","17999","CPT","0761","RC","","","","both","","","480.00","360.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4490.63","3878.56","4490.63","1 through 10","148.8","381.6","other","OPPS APC"
"Laser Hair Removal","PX-76002704","CDM","17999","CPT","0761","RC","","","","outpatient","","","480.00","360.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","250.66","52.22","","467.73","465.00","467.73","1 through 10","240","700.33","percent of total billed charges",""
"Laser Skin Disease Psoriasis Tot Area <250 Sq C","PX-76001688","CDM","96920","CPT","0761","RC","","","","both","","","869.00","651.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","218.50","235.97","51","224.17","690.86","other","OPPS APC"
"Laser Skin Disease Psoriasis Tot Area <250 Sq C","PX-76001688","CDM","96920","CPT","0761","RC","","","","both","","","869.00","651.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","317.19","36.5","","314.44","314.44","314.44","11","224.17","690.86","percent of total billed charges",""
"Laser Skin Disease Psoriasis Tot Area <250 Sq C","PX-76001688","CDM","96920","CPT","0761","RC","","","","both","","","869.00","651.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","235.97","231.25","235.97","39","224.17","690.86","other","OPPS APC"
"Laser Skin Disease Psoriasis Tot Area <250 Sq C","PX-76001688","CDM","96920","CPT","0761","RC","","","","outpatient","","","869.00","651.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","710.15","81.72","","673.89","673.89","673.89","17","176.45","722.59","percent of total billed charges",""
"LATERAL PLATE 140.0MM 5 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037602","CDM","C1713","HCPCS","0278","RC","","","","both","","","3782.70","2837.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3007.25","79.5","","800.18","480.96","1887.97","195","1172.64","3007.25","percent of total billed charges",""
"LATERAL PLATE 140.0MM 5 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037602","CDM","C1713","HCPCS","0278","RC","","","","both","","","3782.70","2837.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2016.18","53.3","","813.12","216.42","1444.50","81","1172.64","3007.25","percent of total billed charges",""
"LATERAL PLATE 140.0MM 5 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037602","CDM","C1713","HCPCS","0278","RC","","","","both","","","3782.70","2837.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1172.64","31","","432.60","432.60","432.60","1 through 10","1172.64","3007.25","percent of total billed charges",""
"LATERAL PLATE 140.0MM 5 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037602","CDM","C1713","HCPCS","0278","RC","","","","both","","","3782.70","2837.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1380.69","36.5","","148.37","54.89","631.39","94","1172.64","3007.25","percent of total billed charges",""
"LATERAL PLATE 140.0MM 5 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037602","CDM","C1713","HCPCS","0278","RC","","","","both","","","3782.70","2837.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1448.77","38.3","","279.30","91.72","1116.77","266","1172.64","3007.25","percent of total billed charges",""
"LATERAL PLATE 140.0MM 5 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037602","CDM","C1713","HCPCS","0278","RC","","","","both","","","3782.70","2837.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1622.78","42.9","","731.00","63.70","731.00","1 through 10","1172.64","3007.25","percent of total billed charges",""
"LATERAL PLATE 140.0MM 5 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037602","CDM","C1713","HCPCS","0278","RC","","","","both","","","3782.70","2837.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1622.78","42.9","","384.74","384.74","384.74","1 through 10","1172.64","3007.25","percent of total billed charges",""
"LATERAL PLATE 140.0MM 5 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037602","CDM","C1713","HCPCS","0278","RC","","","","both","","","3782.70","2837.02","WELLPOINT [1015]","HB AMC WELLPOINT","2790.88","73.78","","286.63","119.22","1107.45","105","1172.64","3007.25","percent of total billed charges",""
"LATERAL PLATE 140.0MM 5 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3782.70","2837.02","AETNA [1001]","HB AMC AETNA HMO","2640.32","69.8","","675.31","184.75","1721.50","286","1976.84","3091.22","percent of total billed charges",""
"LATERAL PLATE 140.0MM 5 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3782.70","2837.02","AETNA [1001]","HB AMC AETNA PPO","3041.29","80.4","","1261.44","103.12","1514.10","21","1976.84","3091.22","percent of total billed charges",""
"LATERAL PLATE 140.0MM 5 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3782.70","2837.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3041.29","80.4","","1365.00","1365.00","1365.00","1 through 10","1976.84","3091.22","percent of total billed charges",""
"LATERAL PLATE 140.0MM 5 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3782.70","2837.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3091.22","81.72","","5157.68","5157.68","5157.68","1 through 10","1976.84","3091.22","percent of total billed charges",""
"LATERAL PLATE 140.0MM 5 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3782.70","2837.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3091.22","81.72","","431.26","71.26","1459.57","88","1976.84","3091.22","percent of total billed charges",""
"LATERAL PLATE 147MM 6 HOLE BONE AXSOS TITANIUM PROXIMALIMAL RIGHT","SUP-ITM-10144620","CDM","C1713","HCPCS","0278","RC","","","","both","","","6758.18","5068.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5372.75","79.5","","800.18","480.96","1887.97","195","2095.04","5372.75","percent of total billed charges",""
"LATERAL PLATE 147MM 6 HOLE BONE AXSOS TITANIUM PROXIMALIMAL RIGHT","SUP-ITM-10144620","CDM","C1713","HCPCS","0278","RC","","","","both","","","6758.18","5068.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3602.11","53.3","","813.12","216.42","1444.50","81","2095.04","5372.75","percent of total billed charges",""
"LATERAL PLATE 147MM 6 HOLE BONE AXSOS TITANIUM PROXIMALIMAL RIGHT","SUP-ITM-10144620","CDM","C1713","HCPCS","0278","RC","","","","both","","","6758.18","5068.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2095.04","31","","432.60","432.60","432.60","1 through 10","2095.04","5372.75","percent of total billed charges",""
"LATERAL PLATE 147MM 6 HOLE BONE AXSOS TITANIUM PROXIMALIMAL RIGHT","SUP-ITM-10144620","CDM","C1713","HCPCS","0278","RC","","","","both","","","6758.18","5068.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2466.74","36.5","","148.37","54.89","631.39","94","2095.04","5372.75","percent of total billed charges",""
"LATERAL PLATE 147MM 6 HOLE BONE AXSOS TITANIUM PROXIMALIMAL RIGHT","SUP-ITM-10144620","CDM","C1713","HCPCS","0278","RC","","","","both","","","6758.18","5068.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2588.38","38.3","","279.30","91.72","1116.77","266","2095.04","5372.75","percent of total billed charges",""
"LATERAL PLATE 147MM 6 HOLE BONE AXSOS TITANIUM PROXIMALIMAL RIGHT","SUP-ITM-10144620","CDM","C1713","HCPCS","0278","RC","","","","both","","","6758.18","5068.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2899.26","42.9","","731.00","63.70","731.00","1 through 10","2095.04","5372.75","percent of total billed charges",""
"LATERAL PLATE 147MM 6 HOLE BONE AXSOS TITANIUM PROXIMALIMAL RIGHT","SUP-ITM-10144620","CDM","C1713","HCPCS","0278","RC","","","","both","","","6758.18","5068.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2899.26","42.9","","384.74","384.74","384.74","1 through 10","2095.04","5372.75","percent of total billed charges",""
"LATERAL PLATE 147MM 6 HOLE BONE AXSOS TITANIUM PROXIMALIMAL RIGHT","SUP-ITM-10144620","CDM","C1713","HCPCS","0278","RC","","","","both","","","6758.18","5068.63","WELLPOINT [1015]","HB AMC WELLPOINT","4986.19","73.78","","286.63","119.22","1107.45","105","2095.04","5372.75","percent of total billed charges",""
"LATERAL PLATE 147MM 6 HOLE BONE AXSOS TITANIUM PROXIMALIMAL RIGHT","SUP-ITM-10144620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6758.18","5068.63","AETNA [1001]","HB AMC AETNA HMO","4717.21","69.8","","675.31","184.75","1721.50","286","3531.82","5522.78","percent of total billed charges",""
"LATERAL PLATE 147MM 6 HOLE BONE AXSOS TITANIUM PROXIMALIMAL RIGHT","SUP-ITM-10144620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6758.18","5068.63","AETNA [1001]","HB AMC AETNA PPO","5433.58","80.4","","1261.44","103.12","1514.10","21","3531.82","5522.78","percent of total billed charges",""
"LATERAL PLATE 147MM 6 HOLE BONE AXSOS TITANIUM PROXIMALIMAL RIGHT","SUP-ITM-10144620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6758.18","5068.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5433.58","80.4","","1365.00","1365.00","1365.00","1 through 10","3531.82","5522.78","percent of total billed charges",""
"LATERAL PLATE 147MM 6 HOLE BONE AXSOS TITANIUM PROXIMALIMAL RIGHT","SUP-ITM-10144620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6758.18","5068.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5522.78","81.72","","5157.68","5157.68","5157.68","1 through 10","3531.82","5522.78","percent of total billed charges",""
"LATERAL PLATE 147MM 6 HOLE BONE AXSOS TITANIUM PROXIMALIMAL RIGHT","SUP-ITM-10144620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6758.18","5068.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5522.78","81.72","","431.26","71.26","1459.57","88","3531.82","5522.78","percent of total billed charges",""
"LATERAL PLATE 180.0MM 7 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037606","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3067.98","79.5","","800.18","480.96","1887.97","195","1196.32","3067.98","percent of total billed charges",""
"LATERAL PLATE 180.0MM 7 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037606","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2056.90","53.3","","813.12","216.42","1444.50","81","1196.32","3067.98","percent of total billed charges",""
"LATERAL PLATE 180.0MM 7 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037606","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1196.32","31","","432.60","432.60","432.60","1 through 10","1196.32","3067.98","percent of total billed charges",""
"LATERAL PLATE 180.0MM 7 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037606","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1408.57","36.5","","148.37","54.89","631.39","94","1196.32","3067.98","percent of total billed charges",""
"LATERAL PLATE 180.0MM 7 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037606","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1478.04","38.3","","279.30","91.72","1116.77","266","1196.32","3067.98","percent of total billed charges",""
"LATERAL PLATE 180.0MM 7 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037606","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1655.55","42.9","","731.00","63.70","731.00","1 through 10","1196.32","3067.98","percent of total billed charges",""
"LATERAL PLATE 180.0MM 7 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037606","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1655.55","42.9","","384.74","384.74","384.74","1 through 10","1196.32","3067.98","percent of total billed charges",""
"LATERAL PLATE 180.0MM 7 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037606","CDM","C1713","HCPCS","0278","RC","","","","both","","","3859.10","2894.32","WELLPOINT [1015]","HB AMC WELLPOINT","2847.24","73.78","","286.63","119.22","1107.45","105","1196.32","3067.98","percent of total billed charges",""
"LATERAL PLATE 180.0MM 7 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3859.10","2894.32","AETNA [1001]","HB AMC AETNA HMO","2693.65","69.8","","675.31","184.75","1721.50","286","2016.77","3153.66","percent of total billed charges",""
"LATERAL PLATE 180.0MM 7 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3859.10","2894.32","AETNA [1001]","HB AMC AETNA PPO","3102.72","80.4","","1261.44","103.12","1514.10","21","2016.77","3153.66","percent of total billed charges",""
"LATERAL PLATE 180.0MM 7 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3859.10","2894.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3102.72","80.4","","1365.00","1365.00","1365.00","1 through 10","2016.77","3153.66","percent of total billed charges",""
"LATERAL PLATE 180.0MM 7 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3859.10","2894.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3153.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2016.77","3153.66","percent of total billed charges",""
"LATERAL PLATE 180.0MM 7 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3859.10","2894.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3153.66","81.72","","431.26","71.26","1459.57","88","2016.77","3153.66","percent of total billed charges",""
"LATERAL PLATE 260.0MM 11 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.09","3012.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3193.59","79.5","","800.18","480.96","1887.97","195","1245.3","3193.59","percent of total billed charges",""
"LATERAL PLATE 260.0MM 11 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.09","3012.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2141.11","53.3","","813.12","216.42","1444.50","81","1245.3","3193.59","percent of total billed charges",""
"LATERAL PLATE 260.0MM 11 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.09","3012.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1245.30","31","","432.60","432.60","432.60","1 through 10","1245.3","3193.59","percent of total billed charges",""
"LATERAL PLATE 260.0MM 11 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.09","3012.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1466.24","36.5","","148.37","54.89","631.39","94","1245.3","3193.59","percent of total billed charges",""
"LATERAL PLATE 260.0MM 11 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.09","3012.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1538.55","38.3","","279.30","91.72","1116.77","266","1245.3","3193.59","percent of total billed charges",""
"LATERAL PLATE 260.0MM 11 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.09","3012.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1723.33","42.9","","731.00","63.70","731.00","1 through 10","1245.3","3193.59","percent of total billed charges",""
"LATERAL PLATE 260.0MM 11 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.09","3012.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1723.33","42.9","","384.74","384.74","384.74","1 through 10","1245.3","3193.59","percent of total billed charges",""
"LATERAL PLATE 260.0MM 11 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.09","3012.82","WELLPOINT [1015]","HB AMC WELLPOINT","2963.81","73.78","","286.63","119.22","1107.45","105","1245.3","3193.59","percent of total billed charges",""
"LATERAL PLATE 260.0MM 11 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037614","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4017.09","3012.82","AETNA [1001]","HB AMC AETNA HMO","2803.93","69.8","","675.31","184.75","1721.50","286","2099.33","3282.77","percent of total billed charges",""
"LATERAL PLATE 260.0MM 11 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037614","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4017.09","3012.82","AETNA [1001]","HB AMC AETNA PPO","3229.74","80.4","","1261.44","103.12","1514.10","21","2099.33","3282.77","percent of total billed charges",""
"LATERAL PLATE 260.0MM 11 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037614","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4017.09","3012.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3229.74","80.4","","1365.00","1365.00","1365.00","1 through 10","2099.33","3282.77","percent of total billed charges",""
"LATERAL PLATE 260.0MM 11 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037614","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4017.09","3012.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3282.77","81.72","","5157.68","5157.68","5157.68","1 through 10","2099.33","3282.77","percent of total billed charges",""
"LATERAL PLATE 260.0MM 11 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037614","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4017.09","3012.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3282.77","81.72","","431.26","71.26","1459.57","88","2099.33","3282.77","percent of total billed charges",""
"LATERAL PLATE 300.0MM 13 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4094.79","3071.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3255.36","79.5","","800.18","480.96","1887.97","195","1269.38","3255.36","percent of total billed charges",""
"LATERAL PLATE 300.0MM 13 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4094.79","3071.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2182.52","53.3","","813.12","216.42","1444.50","81","1269.38","3255.36","percent of total billed charges",""
"LATERAL PLATE 300.0MM 13 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4094.79","3071.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1269.38","31","","432.60","432.60","432.60","1 through 10","1269.38","3255.36","percent of total billed charges",""
"LATERAL PLATE 300.0MM 13 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4094.79","3071.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1494.60","36.5","","148.37","54.89","631.39","94","1269.38","3255.36","percent of total billed charges",""
"LATERAL PLATE 300.0MM 13 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4094.79","3071.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1568.30","38.3","","279.30","91.72","1116.77","266","1269.38","3255.36","percent of total billed charges",""
"LATERAL PLATE 300.0MM 13 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4094.79","3071.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1756.66","42.9","","731.00","63.70","731.00","1 through 10","1269.38","3255.36","percent of total billed charges",""
"LATERAL PLATE 300.0MM 13 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4094.79","3071.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1756.66","42.9","","384.74","384.74","384.74","1 through 10","1269.38","3255.36","percent of total billed charges",""
"LATERAL PLATE 300.0MM 13 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037618","CDM","C1713","HCPCS","0278","RC","","","","both","","","4094.79","3071.09","WELLPOINT [1015]","HB AMC WELLPOINT","3021.14","73.78","","286.63","119.22","1107.45","105","1269.38","3255.36","percent of total billed charges",""
"LATERAL PLATE 300.0MM 13 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4094.79","3071.09","AETNA [1001]","HB AMC AETNA HMO","2858.16","69.8","","675.31","184.75","1721.50","286","2139.94","3346.26","percent of total billed charges",""
"LATERAL PLATE 300.0MM 13 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4094.79","3071.09","AETNA [1001]","HB AMC AETNA PPO","3292.21","80.4","","1261.44","103.12","1514.10","21","2139.94","3346.26","percent of total billed charges",""
"LATERAL PLATE 300.0MM 13 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4094.79","3071.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3292.21","80.4","","1365.00","1365.00","1365.00","1 through 10","2139.94","3346.26","percent of total billed charges",""
"LATERAL PLATE 300.0MM 13 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4094.79","3071.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3346.26","81.72","","5157.68","5157.68","5157.68","1 through 10","2139.94","3346.26","percent of total billed charges",""
"LATERAL PLATE 300.0MM 13 HOLE BONE LCP SS RT PROXIMALIMAL TIBIA","SUP-ITM-10037618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4094.79","3071.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3346.26","81.72","","431.26","71.26","1459.57","88","2139.94","3346.26","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2675.10","79.5","","800.18","480.96","1887.97","195","1043.12","2675.1","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1793.49","53.3","","813.12","216.42","1444.50","81","1043.12","2675.1","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1043.12","31","","432.60","432.60","432.60","1 through 10","1043.12","2675.1","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1228.19","36.5","","148.37","54.89","631.39","94","1043.12","2675.1","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1288.76","38.3","","279.30","91.72","1116.77","266","1043.12","2675.1","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1443.54","42.9","","731.00","63.70","731.00","1 through 10","1043.12","2675.1","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1443.54","42.9","","384.74","384.74","384.74","1 through 10","1043.12","2675.1","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.90","2523.67","WELLPOINT [1015]","HB AMC WELLPOINT","2482.62","73.78","","286.63","119.22","1107.45","105","1043.12","2675.1","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.90","2523.67","AETNA [1001]","HB AMC AETNA HMO","2348.70","69.8","","675.31","184.75","1721.50","286","1758.5","2749.8","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.90","2523.67","AETNA [1001]","HB AMC AETNA PPO","2705.38","80.4","","1261.44","103.12","1514.10","21","1758.5","2749.8","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.90","2523.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2705.38","80.4","","1365.00","1365.00","1365.00","1 through 10","1758.5","2749.8","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.90","2523.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2749.80","81.72","","5157.68","5157.68","5157.68","1 through 10","1758.5","2749.8","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.90","2523.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2749.80","81.72","","431.26","71.26","1459.57","88","1758.5","2749.8","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","both","","","146.00","109.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.07","79.5","","111.75","111.75","335.25","21","11.87","138.7","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","both","","","146.00","109.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.82","53.3","","74.98","74.98","111.75","1 through 10","11.87","138.7","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","both","","","146.00","109.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","116.07","79.5","","111.75","111.75","111.75","1 through 10","11.87","138.7","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.29","36.5","","52.97","45.01","52.97","35","11.87","138.7","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.92","38.3","","55.52","55.52","107.92","126","11.87","138.7","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","both","","","146.00","109.50","TRICARE [160005]","HB BWH TRICARE","138.70","95","","29.18","13.86","142.00","1 through 10","11.87","138.7","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","both","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.63","42.9","","113.51","113.51","113.51","1 through 10","11.87","138.7","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA HMO","101.91","69.8","","96.13","67.88","110.76","16","12.49","119.31","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA PPO","117.38","80.4","","110.76","110.76","110.76","1 through 10","12.49","119.31","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","146.00","109.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","76.30","52.26","","42.28","42.28","42.28","1 through 10","12.49","119.31","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","119.31","81.72","","62.44","62.44","62.44","1 through 10","12.49","119.31","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","119.31","81.72","","113.51","62.44","113.52","18","12.49","119.31","percent of total billed charges",""
"LEAD ACUITY 80CM PACING SPIRAL STEERABLE IS-1","SUP-ITM-10030193","CDM","C1900","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2145.33","53.3","","2692.80","2257.20","2692.80","1 through 10","1247.75","3199.88","percent of total billed charges",""
"LEAD ACUITY 80CM PACING SPIRAL STEERABLE IS-1","SUP-ITM-10030193","CDM","C1900","HCPCS","0278","RC","","","","both","","","4025.00","3018.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1541.58","38.3","","1671.53","1671.53","1671.53","1 through 10","1247.75","3199.88","percent of total billed charges",""
"LEAD ACUITY 80CM PACING SPIRAL STEERABLE IS-1","SUP-ITM-10030193","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","AETNA [1001]","HB AMC AETNA HMO","2809.45","69.8","","1935.90","1935.90","1935.90","1 through 10","2103.47","3289.23","percent of total billed charges",""
"LEAD ACUITY 80CM PACING SPIRAL STEERABLE IS-1","SUP-ITM-10030193","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","4025.00","3018.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3289.23","81.72","","1769.79","1769.79","1769.79","1 through 10","2103.47","3289.23","percent of total billed charges",""
"LEAD ATTAIN STABILITY QUAD MRI SURESCAN","SUP-ITM-10272934","CDM","C1900","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2718.30","53.3","","2692.80","2257.20","2692.80","1 through 10","1581","4054.5","percent of total billed charges",""
"LEAD ATTAIN STABILITY QUAD MRI SURESCAN","SUP-ITM-10272934","CDM","C1900","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1953.30","38.3","","1671.53","1671.53","1671.53","1 through 10","1581","4054.5","percent of total billed charges",""
"LEAD ATTAIN STABILITY QUAD MRI SURESCAN","SUP-ITM-10272934","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","AETNA [1001]","HB AMC AETNA HMO","3559.80","69.8","","1935.90","1935.90","1935.90","1 through 10","2665.26","4167.72","percent of total billed charges",""
"LEAD ATTAIN STABILITY QUAD MRI SURESCAN","SUP-ITM-10272934","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4167.72","81.72","","1769.79","1769.79","1769.79","1 through 10","2665.26","4167.72","percent of total billed charges",""
"LEAD CARDIOVERTER 50CM MED DEFIBRILLATOR TRANSVENE SILICONE EPICARDIAL PATCH SUTURE DF 1","SUP-ITM-10272900","CDM","C1896","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","7540.00","7540.00","7540.00","1 through 10","868","2226","percent of total billed charges",""
"LEAD CARDIOVERTER 50CM MED DEFIBRILLATOR TRANSVENE SILICONE EPICARDIAL PATCH SUTURE DF 1","SUP-ITM-10272900","CDM","C1896","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1820.00","65","","6500.00","6500.00","6500.00","1 through 10","868","2226","percent of total billed charges",""
"LEAD CARDIOVERTER 50CM MED DEFIBRILLATOR TRANSVENE SILICONE EPICARDIAL PATCH SUTURE DF 1","SUP-ITM-10272900","CDM","C1896","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","11190.00","11190.00","11190.00","1 through 10","868","2226","percent of total billed charges",""
"LEAD CARDIOVERTER 50CM MED DEFIBRILLATOR TRANSVENE SILICONE EPICARDIAL PATCH SUTURE DF 1","SUP-ITM-10272900","CDM","C1896","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA HMO","1954.40","69.8","","17800.00","17800.00","17800.00","1 through 10","1463.28","2288.16","percent of total billed charges",""
"LEAD CARDIOVERTER 59CM DEFIBRILLATOR ENDOTAK RELIANCE 4-SITE GORE STEROID ELUTING 1 COIL ACTIVE","SUP-ITM-10093889","CDM","C1777","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","AETNA [1001]","HB AMC AETNA HMO","3926.25","69.8","","3892.75","3808.13","3892.75","1 through 10","2939.63","4596.75","percent of total billed charges",""
"LEAD CARDIOVERTER 59CM DEFIBRILLATOR ENDOTAK RELIANCE 4-SITE GORE STEROID ELUTING 1 COIL ACTIVE","SUP-ITM-10093889","CDM","C1777","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4596.75","81.72","","4496.63","2473.31","4496.63","1 through 10","2939.63","4596.75","percent of total billed charges",""
"LEAD CARDIOVERTER 59CM DEFIBRILLATOR ENDOTAK RELIANCE 4-SITE GORE STEROID ELUTING 1 COIL ACTIVE","SUP-ITM-10093889","CDM","C1777","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4596.75","81.72","","2473.31","2473.31","2473.31","1 through 10","2939.63","4596.75","percent of total billed charges",""
"LEAD CARDIOVERTER 59CM DEFIBRILLATOR ENDOTAK RELIANCE 4-SITE GORE STEROID ELUTING 2 COIL ACTIVE","SUP-ITM-10093891","CDM","C1895","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2998.13","53.3","","3630.00","3630.00","3630.00","1 through 10","1743.75","4471.88","percent of total billed charges",""
"Lead Coronary Venous System T1","PX-27000194","CDM","C1900","HCPCS","0278","RC","","","","both","","","3395.00","2546.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1809.54","53.3","","2692.80","2257.20","2692.80","1 through 10","1052.45","2699.03","percent of total billed charges",""
"Lead Coronary Venous System T1","PX-27000194","CDM","C1900","HCPCS","0278","RC","","","","both","","","3395.00","2546.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1300.29","38.3","","1671.53","1671.53","1671.53","1 through 10","1052.45","2699.03","percent of total billed charges",""
"Lead Coronary Venous System T1","PX-27000194","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","3395.00","2546.25","AETNA [1001]","HB AMC AETNA HMO","2369.71","69.8","","1935.90","1935.90","1935.90","1 through 10","1774.23","2774.39","percent of total billed charges",""
"Lead Coronary Venous System T1","PX-27000194","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","3395.00","2546.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2774.39","81.72","","1769.79","1769.79","1769.79","1 through 10","1774.23","2774.39","percent of total billed charges",""
"Lead Coronary Venous System T2","PX-27000195","CDM","C1900","HCPCS","0278","RC","","","","both","","","4793.01","3594.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2554.67","53.3","","2692.80","2257.20","2692.80","1 through 10","1485.83","3810.44","percent of total billed charges",""
"Lead Coronary Venous System T2","PX-27000195","CDM","C1900","HCPCS","0278","RC","","","","both","","","4793.01","3594.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1835.72","38.3","","1671.53","1671.53","1671.53","1 through 10","1485.83","3810.44","percent of total billed charges",""
"Lead Coronary Venous System T2","PX-27000195","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","4793.01","3594.76","AETNA [1001]","HB AMC AETNA HMO","3345.52","69.8","","1935.90","1935.90","1935.90","1 through 10","2504.83","3916.85","percent of total billed charges",""
"Lead Coronary Venous System T2","PX-27000195","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","4793.01","3594.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3916.85","81.72","","1769.79","1769.79","1769.79","1 through 10","2504.83","3916.85","percent of total billed charges",""
"Lead Coronary Venous System T3","PX-27000196","CDM","C1900","HCPCS","0278","RC","","","","both","","","5812.50","4359.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3098.06","53.3","","2692.80","2257.20","2692.80","1 through 10","1801.88","4620.94","percent of total billed charges",""
"Lead Coronary Venous System T3","PX-27000196","CDM","C1900","HCPCS","0278","RC","","","","both","","","5812.50","4359.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2226.19","38.3","","1671.53","1671.53","1671.53","1 through 10","1801.88","4620.94","percent of total billed charges",""
"Lead Coronary Venous System T3","PX-27000196","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","5812.50","4359.37","AETNA [1001]","HB AMC AETNA HMO","4057.13","69.8","","1935.90","1935.90","1935.90","1 through 10","3037.61","4749.98","percent of total billed charges",""
"Lead Coronary Venous System T3","PX-27000196","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","5812.50","4359.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4749.98","81.72","","1769.79","1769.79","1769.79","1 through 10","3037.61","4749.98","percent of total billed charges",""
"LEAD DEFIBRILLATOR 7.5FR 58CM SUBCUTANEOUS UNIPOLAR SILICONE","SUP-ITM-10011053","CDM","C1896","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","7540.00","7540.00","7540.00","1 through 10","1395","3577.5","percent of total billed charges",""
"LEAD DEFIBRILLATOR 7.5FR 58CM SUBCUTANEOUS UNIPOLAR SILICONE","SUP-ITM-10011053","CDM","C1896","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2925.00","65","","6500.00","6500.00","6500.00","1 through 10","1395","3577.5","percent of total billed charges",""
"LEAD DEFIBRILLATOR 7.5FR 58CM SUBCUTANEOUS UNIPOLAR SILICONE","SUP-ITM-10011053","CDM","C1896","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","11190.00","11190.00","11190.00","1 through 10","1395","3577.5","percent of total billed charges",""
"LEAD DEFIBRILLATOR 7.5FR 58CM SUBCUTANEOUS UNIPOLAR SILICONE","SUP-ITM-10011053","CDM","C1896","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","17800.00","17800.00","17800.00","1 through 10","2351.7","3677.4","percent of total billed charges",""
"LEAD DIRECTIONAL 40CM 1 3 16350045 16350029 8 CH DBS KIT 1 SPACE 1.5","SUP-ITM-10174941","CDM","C1778","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4930.25","53.3","","5279.78","5279.78","5279.78","1 through 10","2867.5","7353.75","percent of total billed charges",""
"LEAD DIRECTIONAL 40CM 1 3 16350045 16350029 8 CH DBS KIT 1 SPACE 1.5","SUP-ITM-10174941","CDM","C1778","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","7353.75","79.5","","15789.05","15789.05","15789.05","1 through 10","2867.5","7353.75","percent of total billed charges",""
"LEAD DIRECTIONAL 40CM 1 3 16350045 16350029 8 CH DBS KIT 1 SPACE 1.5","SUP-ITM-10174941","CDM","C1778","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3376.25","36.5","","2482.78","1657.12","2482.78","1 through 10","2867.5","7353.75","percent of total billed charges",""
"LEAD DIRECTIONAL 40CM 1 3 16350045 16350029 8 CH DBS KIT 1 SPACE 1.5","SUP-ITM-10174941","CDM","C1778","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3542.75","38.3","","2602.60","2602.60","2602.60","1 through 10","2867.5","7353.75","percent of total billed charges",""
"LEAD DIRECTIONAL 40CM 1 3 16350045 16350029 8 CH DBS KIT 1 SPACE 1.5","SUP-ITM-10174941","CDM","C1778","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","WELLPOINT [1015]","HB AMC WELLPOINT","6824.65","73.78","","4955.58","3845.35","9119.37","1 through 10","2867.5","7353.75","percent of total billed charges",""
"LEAD DIRECTIONAL 40CM 1 3 16350045 16350029 8 CH DBS KIT 1 SPACE 1.5","SUP-ITM-10174941","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","9250.00","6937.50","AETNA [1001]","HB AMC AETNA HMO","6456.50","69.8","","8631.75","8631.75","8631.75","1 through 10","4834.05","7559.1","percent of total billed charges",""
"LEAD DIRECTIONAL 40CM 8 CH DBS KIT 1 3 1 SPACE 0.5","SUP-ITM-10174940","CDM","C1778","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4930.25","53.3","","5279.78","5279.78","5279.78","1 through 10","2867.5","7353.75","percent of total billed charges",""
"LEAD DIRECTIONAL 40CM 8 CH DBS KIT 1 3 1 SPACE 0.5","SUP-ITM-10174940","CDM","C1778","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","7353.75","79.5","","15789.05","15789.05","15789.05","1 through 10","2867.5","7353.75","percent of total billed charges",""
"LEAD DIRECTIONAL 40CM 8 CH DBS KIT 1 3 1 SPACE 0.5","SUP-ITM-10174940","CDM","C1778","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3376.25","36.5","","2482.78","1657.12","2482.78","1 through 10","2867.5","7353.75","percent of total billed charges",""
"LEAD DIRECTIONAL 40CM 8 CH DBS KIT 1 3 1 SPACE 0.5","SUP-ITM-10174940","CDM","C1778","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3542.75","38.3","","2602.60","2602.60","2602.60","1 through 10","2867.5","7353.75","percent of total billed charges",""
"LEAD DIRECTIONAL 40CM 8 CH DBS KIT 1 3 1 SPACE 0.5","SUP-ITM-10174940","CDM","C1778","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","WELLPOINT [1015]","HB AMC WELLPOINT","6824.65","73.78","","4955.58","3845.35","9119.37","1 through 10","2867.5","7353.75","percent of total billed charges",""
"LEAD DIRECTIONAL 40CM 8 CH DBS KIT 1 3 1 SPACE 0.5","SUP-ITM-10174940","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","9250.00","6937.50","AETNA [1001]","HB AMC AETNA HMO","6456.50","69.8","","8631.75","8631.75","8631.75","1 through 10","4834.05","7559.1","percent of total billed charges",""
"LEAD DURATA 7FR 65CM DEFIBRILLATION SINGLE COIL OPTIM INSULATION EXT/REX HELIX DF4 CONNECTOR 7122Q/65","SUP-ITM-10050527","CDM","C1777","HCPCS","0278","RC","","","","outpatient","","","8100.00","6075.00","AETNA [1001]","HB AMC AETNA HMO","5653.80","69.8","","3892.75","3808.13","3892.75","1 through 10","4233.06","6619.32","percent of total billed charges",""
"LEAD DURATA 7FR 65CM DEFIBRILLATION SINGLE COIL OPTIM INSULATION EXT/REX HELIX DF4 CONNECTOR 7122Q/65","SUP-ITM-10050527","CDM","C1777","HCPCS","0278","RC","","","","outpatient","","","8100.00","6075.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6619.32","81.72","","4496.63","2473.31","4496.63","1 through 10","4233.06","6619.32","percent of total billed charges",""
"LEAD DURATA 7FR 65CM DEFIBRILLATION SINGLE COIL OPTIM INSULATION EXT/REX HELIX DF4 CONNECTOR 7122Q/65","SUP-ITM-10050527","CDM","C1777","HCPCS","0278","RC","","","","outpatient","","","8100.00","6075.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6619.32","81.72","","2473.31","2473.31","2473.31","1 through 10","4233.06","6619.32","percent of total billed charges",""
"LEAD ELECTRODE 52MMX60CM TRIAL OCTRODE 8 NEUROSTIMULATOR","SUP-ITM-10018946","CDM","C1897","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2260.50","2260.50","2260.50","1 through 10","1085","2782.5","percent of total billed charges",""
"LEAD ELECTRODE 8CH SLIM LAMITRODE","SUP-ITM-10094003","CDM","C1778","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4130.75","53.3","","5279.78","5279.78","5279.78","1 through 10","2402.5","6161.25","percent of total billed charges",""
"LEAD ELECTRODE 8CH SLIM LAMITRODE","SUP-ITM-10094003","CDM","C1778","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","6161.25","79.5","","15789.05","15789.05","15789.05","1 through 10","2402.5","6161.25","percent of total billed charges",""
"LEAD ELECTRODE 8CH SLIM LAMITRODE","SUP-ITM-10094003","CDM","C1778","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2828.75","36.5","","2482.78","1657.12","2482.78","1 through 10","2402.5","6161.25","percent of total billed charges",""
"LEAD ELECTRODE 8CH SLIM LAMITRODE","SUP-ITM-10094003","CDM","C1778","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2968.25","38.3","","2602.60","2602.60","2602.60","1 through 10","2402.5","6161.25","percent of total billed charges",""
"LEAD ELECTRODE 8CH SLIM LAMITRODE","SUP-ITM-10094003","CDM","C1778","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","WELLPOINT [1015]","HB AMC WELLPOINT","5717.95","73.78","","4955.58","3845.35","9119.37","1 through 10","2402.5","6161.25","percent of total billed charges",""
"LEAD ELECTRODE 8CH SLIM LAMITRODE","SUP-ITM-10094003","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","AETNA [1001]","HB AMC AETNA HMO","5409.50","69.8","","8631.75","8631.75","8631.75","1 through 10","4050.15","6333.3","percent of total billed charges",""
"LEAD EXTENSION 30CM NEUROSTIMULATOR SINGLE 8","SUP-ITM-10020901","CDM","C1883","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1143.36","36.5","","1073.15","1073.15","1073.15","1 through 10","971.08","2490.34","percent of total billed charges",""
"LEAD EXTENSION 30CM NEUROSTIMULATOR SINGLE 8","SUP-ITM-10020901","CDM","C1883","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1199.75","38.3","","1808.38","1642.20","1808.38","1 through 10","971.08","2490.34","percent of total billed charges",""
"LEAD EXTENSION 30CM NEUROSTIMULATOR SINGLE 8","SUP-ITM-10020901","CDM","C1883","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","WELLPOINT [1015]","HB AMC WELLPOINT","2311.16","73.78","","625.38","625.38","625.38","1 through 10","971.08","2490.34","percent of total billed charges",""
"LEAD EXTENTION 50CM NEUROSTIMULATION INFININTY RIGHT","SUP-ITM-10174942","CDM","C1883","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1341.38","36.5","","1073.15","1073.15","1073.15","1 through 10","1139.25","2921.63","percent of total billed charges",""
"LEAD EXTENTION 50CM NEUROSTIMULATION INFININTY RIGHT","SUP-ITM-10174942","CDM","C1883","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1407.53","38.3","","1808.38","1642.20","1808.38","1 through 10","1139.25","2921.63","percent of total billed charges",""
"LEAD EXTENTION 50CM NEUROSTIMULATION INFININTY RIGHT","SUP-ITM-10174942","CDM","C1883","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","WELLPOINT [1015]","HB AMC WELLPOINT","2711.42","73.78","","625.38","625.38","625.38","1 through 10","1139.25","2921.63","percent of total billed charges",""
"LEAD GREATBATCH 35CM PACING INNOMEDICA MYOCARDIAL BIPOLAR IS1 SCREW FIXATION","SUP-ITM-10010884","CDM","C1898","HCPCS","0278","RC","","","","both","","","1015.00","761.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","541.00","53.3","","679.14","679.14","679.14","1 through 10","314.65","806.93","percent of total billed charges",""
"LEAD GREATBATCH 35CM PACING INNOMEDICA MYOCARDIAL BIPOLAR IS1 SCREW FIXATION","SUP-ITM-10010884","CDM","C1898","HCPCS","0278","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","370.48","36.5","","479.77","479.77","479.77","1 through 10","314.65","806.93","percent of total billed charges",""
"LEAD GREATBATCH 35CM PACING INNOMEDICA MYOCARDIAL BIPOLAR IS1 SCREW FIXATION","SUP-ITM-10010884","CDM","C1898","HCPCS","0278","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","388.75","38.3","","502.93","502.93","502.93","1 through 10","314.65","806.93","percent of total billed charges",""
"LEAD GREATBATCH 35CM PACING INNOMEDICA MYOCARDIAL BIPOLAR IS1 SCREW FIXATION","SUP-ITM-10010884","CDM","C1898","HCPCS","0278","RC","","","","both","","","1015.00","761.25","WELLPOINT [1015]","HB AMC WELLPOINT","748.87","73.78","","957.62","957.62","957.62","1 through 10","314.65","806.93","percent of total billed charges",""
"LEAD GREATBATCH 35CM PACING INNOMEDICA MYOCARDIAL BIPOLAR IS1 SCREW FIXATION","SUP-ITM-10010884","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","AETNA [1001]","HB AMC AETNA HMO","708.47","69.8","","916.33","669.20","916.33","1 through 10","530.44","829.46","percent of total billed charges",""
"LEAD GREATBATCH 35CM PACING INNOMEDICA MYOCARDIAL BIPOLAR IS1 SCREW FIXATION","SUP-ITM-10010884","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","829.46","81.72","","811.39","811.39","811.39","1 through 10","530.44","829.46","percent of total billed charges",""
"LEAD GREATBATCH 35CM PACING INNOMEDICA MYOCARDIAL BIPOLAR IS1 SCREW FIXATION","SUP-ITM-10010884","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","829.46","81.72","","446.30","446.30","446.30","1 through 10","530.44","829.46","percent of total billed charges",""
"Lead Icd Device Single Coil T3","PX-27000113","CDM","C1777","HCPCS","0278","RC","","","","outpatient","","","9446.88","7085.16","AETNA [1001]","HB AMC AETNA HMO","6593.92","69.8","","3892.75","3808.13","3892.75","1 through 10","4936.94","7719.99","percent of total billed charges",""
"Lead Icd Device Single Coil T3","PX-27000113","CDM","C1777","HCPCS","0278","RC","","","","outpatient","","","9446.88","7085.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7719.99","81.72","","4496.63","2473.31","4496.63","1 through 10","4936.94","7719.99","percent of total billed charges",""
"Lead Icd Device Single Coil T3","PX-27000113","CDM","C1777","HCPCS","0278","RC","","","","outpatient","","","9446.88","7085.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7719.99","81.72","","2473.31","2473.31","2473.31","1 through 10","4936.94","7719.99","percent of total billed charges",""
"LEAD ICD PLEXA DF4 65CM PROMRI S 65 SINGLE COIL","SUP-ITM-10185757","CDM","C1777","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","AETNA [1001]","HB AMC AETNA HMO","4188.00","69.8","","3892.75","3808.13","3892.75","1 through 10","3135.6","4903.2","percent of total billed charges",""
"LEAD ICD PLEXA DF4 65CM PROMRI S 65 SINGLE COIL","SUP-ITM-10185757","CDM","C1777","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4903.20","81.72","","4496.63","2473.31","4496.63","1 through 10","3135.6","4903.2","percent of total billed charges",""
"LEAD ICD PLEXA DF4 65CM PROMRI S 65 SINGLE COIL","SUP-ITM-10185757","CDM","C1777","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4903.20","81.72","","2473.31","2473.31","2473.31","1 through 10","3135.6","4903.2","percent of total billed charges",""
"LEAD IMPLANTABLE 45CM REACTIV8","SUP-ITM-10283220","CDM","C1778","HCPCS","0278","RC","","","","both","","","11540.38","8655.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6151.02","53.3","","5279.78","5279.78","5279.78","1 through 10","3577.52","9174.6","percent of total billed charges",""
"LEAD IMPLANTABLE 45CM REACTIV8","SUP-ITM-10283220","CDM","C1778","HCPCS","0278","RC","","","","both","","","11540.38","8655.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","9174.60","79.5","","15789.05","15789.05","15789.05","1 through 10","3577.52","9174.6","percent of total billed charges",""
"LEAD IMPLANTABLE 45CM REACTIV8","SUP-ITM-10283220","CDM","C1778","HCPCS","0278","RC","","","","both","","","11540.38","8655.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4212.24","36.5","","2482.78","1657.12","2482.78","1 through 10","3577.52","9174.6","percent of total billed charges",""
"LEAD IMPLANTABLE 45CM REACTIV8","SUP-ITM-10283220","CDM","C1778","HCPCS","0278","RC","","","","both","","","11540.38","8655.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4419.97","38.3","","2602.60","2602.60","2602.60","1 through 10","3577.52","9174.6","percent of total billed charges",""
"LEAD IMPLANTABLE 45CM REACTIV8","SUP-ITM-10283220","CDM","C1778","HCPCS","0278","RC","","","","both","","","11540.38","8655.28","WELLPOINT [1015]","HB AMC WELLPOINT","8514.49","73.78","","4955.58","3845.35","9119.37","1 through 10","3577.52","9174.6","percent of total billed charges",""
"LEAD IMPLANTABLE 45CM REACTIV8","SUP-ITM-10283220","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","11540.38","8655.28","AETNA [1001]","HB AMC AETNA HMO","8055.19","69.8","","8631.75","8631.75","8631.75","1 through 10","6031","9430.8","percent of total billed charges",""
"LEAD LV SENTUS PROMRI OTW QP L-85/49 QUADRIPOLAR","SUP-ITM-10191337","CDM","C1883","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1073.15","1073.15","1073.15","1 through 10","1302","3339","percent of total billed charges",""
"LEAD LV SENTUS PROMRI OTW QP L-85/49 QUADRIPOLAR","SUP-ITM-10191337","CDM","C1883","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","1808.38","1642.20","1808.38","1 through 10","1302","3339","percent of total billed charges",""
"LEAD LV SENTUS PROMRI OTW QP L-85/49 QUADRIPOLAR","SUP-ITM-10191337","CDM","C1883","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","625.38","625.38","625.38","1 through 10","1302","3339","percent of total billed charges",""
"LEAD LV SENTUS PROMRI OTW QP S-85/49 QUADRIPOLAR","SUP-ITM-10191335","CDM","C1900","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2238.60","53.3","","2692.80","2257.20","2692.80","1 through 10","1302","3339","percent of total billed charges",""
"LEAD LV SENTUS PROMRI OTW QP S-85/49 QUADRIPOLAR","SUP-ITM-10191335","CDM","C1900","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","1671.53","1671.53","1671.53","1 through 10","1302","3339","percent of total billed charges",""
"LEAD LV SENTUS PROMRI OTW QP S-85/49 QUADRIPOLAR","SUP-ITM-10191335","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1935.90","1935.90","1935.90","1 through 10","2194.92","3432.24","percent of total billed charges",""
"LEAD LV SENTUS PROMRI OTW QP S-85/49 QUADRIPOLAR","SUP-ITM-10191335","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1769.79","1769.79","1769.79","1 through 10","2194.92","3432.24","percent of total billed charges",""
"LEAD MRI 74CM SAFE AVISTA","SUP-ITM-10191385","CDM","C1778","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3064.75","53.3","","5279.78","5279.78","5279.78","1 through 10","1782.5","4571.25","percent of total billed charges",""
"LEAD MRI 74CM SAFE AVISTA","SUP-ITM-10191385","CDM","C1778","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","4571.25","79.5","","15789.05","15789.05","15789.05","1 through 10","1782.5","4571.25","percent of total billed charges",""
"LEAD MRI 74CM SAFE AVISTA","SUP-ITM-10191385","CDM","C1778","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2098.75","36.5","","2482.78","1657.12","2482.78","1 through 10","1782.5","4571.25","percent of total billed charges",""
"LEAD MRI 74CM SAFE AVISTA","SUP-ITM-10191385","CDM","C1778","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2202.25","38.3","","2602.60","2602.60","2602.60","1 through 10","1782.5","4571.25","percent of total billed charges",""
"LEAD MRI 74CM SAFE AVISTA","SUP-ITM-10191385","CDM","C1778","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","WELLPOINT [1015]","HB AMC WELLPOINT","4242.35","73.78","","4955.58","3845.35","9119.37","1 through 10","1782.5","4571.25","percent of total billed charges",""
"LEAD MRI 74CM SAFE AVISTA","SUP-ITM-10191385","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5750.00","4312.50","AETNA [1001]","HB AMC AETNA HMO","4013.50","69.8","","8631.75","8631.75","8631.75","1 through 10","3004.95","4698.9","percent of total billed charges",""
"LEAD NEUROMODULATION 1.0X16 50CM SPINAL INFINEON PERCUTANEOUS TRIAL","SUP-ITM-10126480","CDM","C1778","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2052.05","53.3","","5279.78","5279.78","5279.78","1 through 10","1193.5","3060.75","percent of total billed charges",""
"LEAD NEUROMODULATION 1.0X16 50CM SPINAL INFINEON PERCUTANEOUS TRIAL","SUP-ITM-10126480","CDM","C1778","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","15789.05","15789.05","15789.05","1 through 10","1193.5","3060.75","percent of total billed charges",""
"LEAD NEUROMODULATION 1.0X16 50CM SPINAL INFINEON PERCUTANEOUS TRIAL","SUP-ITM-10126480","CDM","C1778","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","2482.78","1657.12","2482.78","1 through 10","1193.5","3060.75","percent of total billed charges",""
"LEAD NEUROMODULATION 1.0X16 50CM SPINAL INFINEON PERCUTANEOUS TRIAL","SUP-ITM-10126480","CDM","C1778","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","2602.60","2602.60","2602.60","1 through 10","1193.5","3060.75","percent of total billed charges",""
"LEAD NEUROMODULATION 1.0X16 50CM SPINAL INFINEON PERCUTANEOUS TRIAL","SUP-ITM-10126480","CDM","C1778","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","4955.58","3845.35","9119.37","1 through 10","1193.5","3060.75","percent of total billed charges",""
"LEAD NEUROMODULATION 1.0X16 50CM SPINAL INFINEON PERCUTANEOUS TRIAL","SUP-ITM-10126480","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA HMO","2687.30","69.8","","8631.75","8631.75","8631.75","1 through 10","2012.01","3146.22","percent of total billed charges",""
"LEAD NEUROMODULATION 70CM SPINAL PRECISION LINEAR 8 CONTACT ENHANCED","SUP-ITM-10077213","CDM","C1778","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2398.50","53.3","","5279.78","5279.78","5279.78","1 through 10","1395","3577.5","percent of total billed charges",""
"LEAD NEUROMODULATION 70CM SPINAL PRECISION LINEAR 8 CONTACT ENHANCED","SUP-ITM-10077213","CDM","C1778","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","15789.05","15789.05","15789.05","1 through 10","1395","3577.5","percent of total billed charges",""
"LEAD NEUROMODULATION 70CM SPINAL PRECISION LINEAR 8 CONTACT ENHANCED","SUP-ITM-10077213","CDM","C1778","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","2482.78","1657.12","2482.78","1 through 10","1395","3577.5","percent of total billed charges",""
"LEAD NEUROMODULATION 70CM SPINAL PRECISION LINEAR 8 CONTACT ENHANCED","SUP-ITM-10077213","CDM","C1778","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","2602.60","2602.60","2602.60","1 through 10","1395","3577.5","percent of total billed charges",""
"LEAD NEUROMODULATION 70CM SPINAL PRECISION LINEAR 8 CONTACT ENHANCED","SUP-ITM-10077213","CDM","C1778","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","4955.58","3845.35","9119.37","1 through 10","1395","3577.5","percent of total billed charges",""
"LEAD NEUROMODULATION 70CM SPINAL PRECISION LINEAR 8 CONTACT ENHANCED","SUP-ITM-10077213","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","8631.75","8631.75","8631.75","1 through 10","2351.7","3677.4","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 2MM VAGUS NERVE BIPOLAR HELICAL","SUP-ITM-10082057","CDM","C1778","HCPCS","0278","RC","","","","both","","","21892.75","16419.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11668.84","53.3","","5279.78","5279.78","5279.78","1 through 10","6786.75","17404.74","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 2MM VAGUS NERVE BIPOLAR HELICAL","SUP-ITM-10082057","CDM","C1778","HCPCS","0278","RC","","","","both","","","21892.75","16419.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","17404.74","79.5","","15789.05","15789.05","15789.05","1 through 10","6786.75","17404.74","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 2MM VAGUS NERVE BIPOLAR HELICAL","SUP-ITM-10082057","CDM","C1778","HCPCS","0278","RC","","","","both","","","21892.75","16419.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7990.85","36.5","","2482.78","1657.12","2482.78","1 through 10","6786.75","17404.74","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 2MM VAGUS NERVE BIPOLAR HELICAL","SUP-ITM-10082057","CDM","C1778","HCPCS","0278","RC","","","","both","","","21892.75","16419.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8384.92","38.3","","2602.60","2602.60","2602.60","1 through 10","6786.75","17404.74","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 2MM VAGUS NERVE BIPOLAR HELICAL","SUP-ITM-10082057","CDM","C1778","HCPCS","0278","RC","","","","both","","","21892.75","16419.56","WELLPOINT [1015]","HB AMC WELLPOINT","16152.47","73.78","","4955.58","3845.35","9119.37","1 through 10","6786.75","17404.74","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 2MM VAGUS NERVE BIPOLAR HELICAL","SUP-ITM-10082057","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","21892.75","16419.56","AETNA [1001]","HB AMC AETNA HMO","15281.14","69.8","","8631.75","8631.75","8631.75","1 through 10","11441.15","17890.76","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 3.0X12 6.0 9.0 66MM 45CM STANDARD ELECTRODE PERCUTANEOUS","SUP-ITM-10016455","CDM","C1778","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","5279.78","5279.78","5279.78","1 through 10","1627.5","4173.75","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 3.0X12 6.0 9.0 66MM 45CM STANDARD ELECTRODE PERCUTANEOUS","SUP-ITM-10016455","CDM","C1778","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","15789.05","15789.05","15789.05","1 through 10","1627.5","4173.75","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 3.0X12 6.0 9.0 66MM 45CM STANDARD ELECTRODE PERCUTANEOUS","SUP-ITM-10016455","CDM","C1778","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","2482.78","1657.12","2482.78","1 through 10","1627.5","4173.75","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 3.0X12 6.0 9.0 66MM 45CM STANDARD ELECTRODE PERCUTANEOUS","SUP-ITM-10016455","CDM","C1778","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","2602.60","2602.60","2602.60","1 through 10","1627.5","4173.75","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 3.0X12 6.0 9.0 66MM 45CM STANDARD ELECTRODE PERCUTANEOUS","SUP-ITM-10016455","CDM","C1778","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","4955.58","3845.35","9119.37","1 through 10","1627.5","4173.75","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 3.0X12 6.0 9.0 66MM 45CM STANDARD ELECTRODE PERCUTANEOUS","SUP-ITM-10016455","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","8631.75","8631.75","8631.75","1 through 10","2743.65","4290.3","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 3X12 6 9 30MM 56CM PISCES PERCUTANEOUS STANDARD 4 ELECTRODE","SUP-ITM-10022001","CDM","C1778","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2163.98","53.3","","5279.78","5279.78","5279.78","1 through 10","1258.6","3227.7","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 3X12 6 9 30MM 56CM PISCES PERCUTANEOUS STANDARD 4 ELECTRODE","SUP-ITM-10022001","CDM","C1778","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3227.70","79.5","","15789.05","15789.05","15789.05","1 through 10","1258.6","3227.7","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 3X12 6 9 30MM 56CM PISCES PERCUTANEOUS STANDARD 4 ELECTRODE","SUP-ITM-10022001","CDM","C1778","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1481.90","36.5","","2482.78","1657.12","2482.78","1 through 10","1258.6","3227.7","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 3X12 6 9 30MM 56CM PISCES PERCUTANEOUS STANDARD 4 ELECTRODE","SUP-ITM-10022001","CDM","C1778","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1554.98","38.3","","2602.60","2602.60","2602.60","1 through 10","1258.6","3227.7","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 3X12 6 9 30MM 56CM PISCES PERCUTANEOUS STANDARD 4 ELECTRODE","SUP-ITM-10022001","CDM","C1778","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","WELLPOINT [1015]","HB AMC WELLPOINT","2995.47","73.78","","4955.58","3845.35","9119.37","1 through 10","1258.6","3227.7","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 3X12 6 9 30MM 56CM PISCES PERCUTANEOUS STANDARD 4 ELECTRODE","SUP-ITM-10022001","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4060.00","3045.00","AETNA [1001]","HB AMC AETNA HMO","2833.88","69.8","","8631.75","8631.75","8631.75","1 through 10","2121.76","3317.83","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 60CM LAMITRODE TRIPOLE 16 LEAD","SUP-ITM-10050561","CDM","C1778","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5330.00","53.3","","5279.78","5279.78","5279.78","1 through 10","3100","7950","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 60CM LAMITRODE TRIPOLE 16 LEAD","SUP-ITM-10050561","CDM","C1778","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","7950.00","79.5","","15789.05","15789.05","15789.05","1 through 10","3100","7950","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 60CM LAMITRODE TRIPOLE 16 LEAD","SUP-ITM-10050561","CDM","C1778","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3650.00","36.5","","2482.78","1657.12","2482.78","1 through 10","3100","7950","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 60CM LAMITRODE TRIPOLE 16 LEAD","SUP-ITM-10050561","CDM","C1778","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3830.00","38.3","","2602.60","2602.60","2602.60","1 through 10","3100","7950","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 60CM LAMITRODE TRIPOLE 16 LEAD","SUP-ITM-10050561","CDM","C1778","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB AMC WELLPOINT","7378.00","73.78","","4955.58","3845.35","9119.37","1 through 10","3100","7950","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 60CM LAMITRODE TRIPOLE 16 LEAD","SUP-ITM-10050561","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA HMO","6980.00","69.8","","8631.75","8631.75","8631.75","1 through 10","5226","8172","percent of total billed charges",""
"Lead Neurostimulator T1","PX-27000114","CDM","C1778","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1865.50","53.3","","5279.78","5279.78","5279.78","1 through 10","1085","2782.5","percent of total billed charges",""
"Lead Neurostimulator T1","PX-27000114","CDM","C1778","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","15789.05","15789.05","15789.05","1 through 10","1085","2782.5","percent of total billed charges",""
"Lead Neurostimulator T1","PX-27000114","CDM","C1778","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","2482.78","1657.12","2482.78","1 through 10","1085","2782.5","percent of total billed charges",""
"Lead Neurostimulator T1","PX-27000114","CDM","C1778","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","2602.60","2602.60","2602.60","1 through 10","1085","2782.5","percent of total billed charges",""
"Lead Neurostimulator T1","PX-27000114","CDM","C1778","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","4955.58","3845.35","9119.37","1 through 10","1085","2782.5","percent of total billed charges",""
"Lead Neurostimulator T1","PX-27000114","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","8631.75","8631.75","8631.75","1 through 10","1829.1","2860.2","percent of total billed charges",""
"Lead Neurostimulator T2","PX-27000115","CDM","C1778","HCPCS","0278","RC","","","","both","","","4993.50","3745.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2661.54","53.3","","5279.78","5279.78","5279.78","1 through 10","1547.99","3969.83","percent of total billed charges",""
"Lead Neurostimulator T2","PX-27000115","CDM","C1778","HCPCS","0278","RC","","","","both","","","4993.50","3745.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3969.83","79.5","","15789.05","15789.05","15789.05","1 through 10","1547.99","3969.83","percent of total billed charges",""
"Lead Neurostimulator T2","PX-27000115","CDM","C1778","HCPCS","0278","RC","","","","both","","","4993.50","3745.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1822.63","36.5","","2482.78","1657.12","2482.78","1 through 10","1547.99","3969.83","percent of total billed charges",""
"Lead Neurostimulator T2","PX-27000115","CDM","C1778","HCPCS","0278","RC","","","","both","","","4993.50","3745.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1912.51","38.3","","2602.60","2602.60","2602.60","1 through 10","1547.99","3969.83","percent of total billed charges",""
"Lead Neurostimulator T2","PX-27000115","CDM","C1778","HCPCS","0278","RC","","","","both","","","4993.50","3745.12","WELLPOINT [1015]","HB AMC WELLPOINT","3684.20","73.78","","4955.58","3845.35","9119.37","1 through 10","1547.99","3969.83","percent of total billed charges",""
"Lead Neurostimulator T2","PX-27000115","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4993.50","3745.12","AETNA [1001]","HB AMC AETNA HMO","3485.46","69.8","","8631.75","8631.75","8631.75","1 through 10","2609.6","4080.69","percent of total billed charges",""
"Lead Neurostimulator T3","PX-27000116","CDM","C1778","HCPCS","0278","RC","","","","both","","","7399.33","5549.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3943.84","53.3","","5279.78","5279.78","5279.78","1 through 10","2293.79","5882.47","percent of total billed charges",""
"Lead Neurostimulator T3","PX-27000116","CDM","C1778","HCPCS","0278","RC","","","","both","","","7399.33","5549.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","5882.47","79.5","","15789.05","15789.05","15789.05","1 through 10","2293.79","5882.47","percent of total billed charges",""
"Lead Neurostimulator T3","PX-27000116","CDM","C1778","HCPCS","0278","RC","","","","both","","","7399.33","5549.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2700.76","36.5","","2482.78","1657.12","2482.78","1 through 10","2293.79","5882.47","percent of total billed charges",""
"Lead Neurostimulator T3","PX-27000116","CDM","C1778","HCPCS","0278","RC","","","","both","","","7399.33","5549.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2833.94","38.3","","2602.60","2602.60","2602.60","1 through 10","2293.79","5882.47","percent of total billed charges",""
"Lead Neurostimulator T3","PX-27000116","CDM","C1778","HCPCS","0278","RC","","","","both","","","7399.33","5549.50","WELLPOINT [1015]","HB AMC WELLPOINT","5459.23","73.78","","4955.58","3845.35","9119.37","1 through 10","2293.79","5882.47","percent of total billed charges",""
"Lead Neurostimulator T3","PX-27000116","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","7399.33","5549.50","AETNA [1001]","HB AMC AETNA HMO","5164.73","69.8","","8631.75","8631.75","8631.75","1 through 10","3866.89","6046.73","percent of total billed charges",""
"Lead Neurostimulator Test Kit T1","PX-27000191","CDM","C1897","HCPCS","0278","RC","","","","both","","","2919.53","2189.65","WELLPOINT [1015]","HB AMC WELLPOINT","2154.03","73.78","","2260.50","2260.50","2260.50","1 through 10","905.05","2321.03","percent of total billed charges",""
"Lead Neurostimulator Test Kit T3","PX-27002377","CDM","C1897","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","2260.50","2260.50","2260.50","1 through 10","1550","3975","percent of total billed charges",""
"LEAD OCTRODE 60CM NEUROSTIMULATOR","SUP-ITM-10019318","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2665.00","53.3","","5279.78","5279.78","5279.78","1 through 10","1550","3975","percent of total billed charges",""
"LEAD OCTRODE 60CM NEUROSTIMULATOR","SUP-ITM-10019318","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","15789.05","15789.05","15789.05","1 through 10","1550","3975","percent of total billed charges",""
"LEAD OCTRODE 60CM NEUROSTIMULATOR","SUP-ITM-10019318","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","2482.78","1657.12","2482.78","1 through 10","1550","3975","percent of total billed charges",""
"LEAD OCTRODE 60CM NEUROSTIMULATOR","SUP-ITM-10019318","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","2602.60","2602.60","2602.60","1 through 10","1550","3975","percent of total billed charges",""
"LEAD OCTRODE 60CM NEUROSTIMULATOR","SUP-ITM-10019318","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","4955.58","3845.35","9119.37","1 through 10","1550","3975","percent of total billed charges",""
"LEAD OCTRODE 60CM NEUROSTIMULATOR","SUP-ITM-10019318","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","8631.75","8631.75","8631.75","1 through 10","2613","4086","percent of total billed charges",""
"LEAD OCTRODE 90CM KIT RECHARGEABLE","SUP-ITM-10046831","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2665.00","53.3","","5279.78","5279.78","5279.78","1 through 10","1550","3975","percent of total billed charges",""
"LEAD OCTRODE 90CM KIT RECHARGEABLE","SUP-ITM-10046831","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","15789.05","15789.05","15789.05","1 through 10","1550","3975","percent of total billed charges",""
"LEAD OCTRODE 90CM KIT RECHARGEABLE","SUP-ITM-10046831","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","2482.78","1657.12","2482.78","1 through 10","1550","3975","percent of total billed charges",""
"LEAD OCTRODE 90CM KIT RECHARGEABLE","SUP-ITM-10046831","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","2602.60","2602.60","2602.60","1 through 10","1550","3975","percent of total billed charges",""
"LEAD OCTRODE 90CM KIT RECHARGEABLE","SUP-ITM-10046831","CDM","C1778","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","4955.58","3845.35","9119.37","1 through 10","1550","3975","percent of total billed charges",""
"LEAD OCTRODE 90CM KIT RECHARGEABLE","SUP-ITM-10046831","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","8631.75","8631.75","8631.75","1 through 10","2613","4086","percent of total billed charges",""
"LEAD PACEMAKER 53CM ADULT MYOCARDIAL BIPOLAR TEMPORARY STREAMLINE PK/6EA","SUP-ITM-10007163","CDM","C1898","HCPCS","0278","RC","","","","both","","","116.67","87.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","62.19","53.3","","679.14","679.14","679.14","1 through 10","36.17","92.75","percent of total billed charges",""
"LEAD PACEMAKER 53CM ADULT MYOCARDIAL BIPOLAR TEMPORARY STREAMLINE PK/6EA","SUP-ITM-10007163","CDM","C1898","HCPCS","0278","RC","","","","both","","","116.67","87.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","42.58","36.5","","479.77","479.77","479.77","1 through 10","36.17","92.75","percent of total billed charges",""
"LEAD PACEMAKER 53CM ADULT MYOCARDIAL BIPOLAR TEMPORARY STREAMLINE PK/6EA","SUP-ITM-10007163","CDM","C1898","HCPCS","0278","RC","","","","both","","","116.67","87.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44.68","38.3","","502.93","502.93","502.93","1 through 10","36.17","92.75","percent of total billed charges",""
"LEAD PACEMAKER 53CM ADULT MYOCARDIAL BIPOLAR TEMPORARY STREAMLINE PK/6EA","SUP-ITM-10007163","CDM","C1898","HCPCS","0278","RC","","","","both","","","116.67","87.50","WELLPOINT [1015]","HB AMC WELLPOINT","86.08","73.78","","957.62","957.62","957.62","1 through 10","36.17","92.75","percent of total billed charges",""
"LEAD PACEMAKER 53CM ADULT MYOCARDIAL BIPOLAR TEMPORARY STREAMLINE PK/6EA","SUP-ITM-10007163","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","116.67","87.50","AETNA [1001]","HB AMC AETNA HMO","81.44","69.8","","916.33","669.20","916.33","1 through 10","60.97","95.34","percent of total billed charges",""
"LEAD PACEMAKER 53CM ADULT MYOCARDIAL BIPOLAR TEMPORARY STREAMLINE PK/6EA","SUP-ITM-10007163","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","116.67","87.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","95.34","81.72","","811.39","811.39","811.39","1 through 10","60.97","95.34","percent of total billed charges",""
"LEAD PACEMAKER 53CM ADULT MYOCARDIAL BIPOLAR TEMPORARY STREAMLINE PK/6EA","SUP-ITM-10007163","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","116.67","87.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","95.34","81.72","","446.30","446.30","446.30","1 through 10","60.97","95.34","percent of total billed charges",""
"Lead Pacemaker Single T1","PX-27000117","CDM","C1779","HCPCS","0278","RC","","","","outpatient","","","1231.72","923.79","AETNA [1001]","HB AMC AETNA HMO","859.74","69.8","","6441.05","6441.05","6441.05","1 through 10","643.7","1006.56","percent of total billed charges",""
"Lead Pacemaker Single T1","PX-27000117","CDM","C1779","HCPCS","0278","RC","","","","outpatient","","","1231.72","923.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1006.56","81.72","","10771.92","10771.92","10771.92","1 through 10","643.7","1006.56","percent of total billed charges",""
"LEAD PACING 6.6FR 35CM PACEMAKER MYOCARDIAL SILICONE FIXED SCREW IS 1 UNIVERSAL","SUP-ITM-10010975","CDM","C1898","HCPCS","0278","RC","","","","both","","","1286.25","964.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","685.57","53.3","","679.14","679.14","679.14","1 through 10","398.74","1022.57","percent of total billed charges",""
"LEAD PACING 6.6FR 35CM PACEMAKER MYOCARDIAL SILICONE FIXED SCREW IS 1 UNIVERSAL","SUP-ITM-10010975","CDM","C1898","HCPCS","0278","RC","","","","both","","","1286.25","964.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","469.48","36.5","","479.77","479.77","479.77","1 through 10","398.74","1022.57","percent of total billed charges",""
"LEAD PACING 6.6FR 35CM PACEMAKER MYOCARDIAL SILICONE FIXED SCREW IS 1 UNIVERSAL","SUP-ITM-10010975","CDM","C1898","HCPCS","0278","RC","","","","both","","","1286.25","964.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","492.63","38.3","","502.93","502.93","502.93","1 through 10","398.74","1022.57","percent of total billed charges",""
"LEAD PACING 6.6FR 35CM PACEMAKER MYOCARDIAL SILICONE FIXED SCREW IS 1 UNIVERSAL","SUP-ITM-10010975","CDM","C1898","HCPCS","0278","RC","","","","both","","","1286.25","964.69","WELLPOINT [1015]","HB AMC WELLPOINT","949.00","73.78","","957.62","957.62","957.62","1 through 10","398.74","1022.57","percent of total billed charges",""
"LEAD PACING 6.6FR 35CM PACEMAKER MYOCARDIAL SILICONE FIXED SCREW IS 1 UNIVERSAL","SUP-ITM-10010975","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1286.25","964.69","AETNA [1001]","HB AMC AETNA HMO","897.80","69.8","","916.33","669.20","916.33","1 through 10","672.19","1051.12","percent of total billed charges",""
"LEAD PACING 6.6FR 35CM PACEMAKER MYOCARDIAL SILICONE FIXED SCREW IS 1 UNIVERSAL","SUP-ITM-10010975","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1286.25","964.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1051.12","81.72","","811.39","811.39","811.39","1 through 10","672.19","1051.12","percent of total billed charges",""
"LEAD PACING 6.6FR 35CM PACEMAKER MYOCARDIAL SILICONE FIXED SCREW IS 1 UNIVERSAL","SUP-ITM-10010975","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1286.25","964.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1051.12","81.72","","446.30","446.30","446.30","1 through 10","672.19","1051.12","percent of total billed charges",""
"LEAD PACING ATTAIN 78CM ABILITY POLYURETHANE STERIOID ELUTING LT VENTRICLE DOUBLE CURVE IS 1 BI","SUP-ITM-10051548","CDM","C1900","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2118.68","53.3","","2692.80","2257.20","2692.80","1 through 10","1232.25","3160.13","percent of total billed charges",""
"LEAD PACING ATTAIN 78CM ABILITY POLYURETHANE STERIOID ELUTING LT VENTRICLE DOUBLE CURVE IS 1 BI","SUP-ITM-10051548","CDM","C1900","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1522.43","38.3","","1671.53","1671.53","1671.53","1 through 10","1232.25","3160.13","percent of total billed charges",""
"LEAD PACING ATTAIN 78CM ABILITY POLYURETHANE STERIOID ELUTING LT VENTRICLE DOUBLE CURVE IS 1 BI","SUP-ITM-10051548","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","3975.00","2981.25","AETNA [1001]","HB AMC AETNA HMO","2774.55","69.8","","1935.90","1935.90","1935.90","1 through 10","2077.34","3248.37","percent of total billed charges",""
"LEAD PACING ATTAIN 78CM ABILITY POLYURETHANE STERIOID ELUTING LT VENTRICLE DOUBLE CURVE IS 1 BI","SUP-ITM-10051548","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","3975.00","2981.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3248.37","81.72","","1769.79","1769.79","1769.79","1 through 10","2077.34","3248.37","percent of total billed charges",""
"LEAD PACING ATTAIN 88CM ABILITY LV POLYURETHANE STEROID ELUTING LT VENTRICLE DISTAL DOUBLE CURVE IS 1 BI","SUP-ITM-10135388","CDM","C1900","HCPCS","0278","RC","","","","both","","","4275.00","3206.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2278.58","53.3","","2692.80","2257.20","2692.80","1 through 10","1325.25","3398.63","percent of total billed charges",""
"LEAD PACING ATTAIN 88CM ABILITY LV POLYURETHANE STEROID ELUTING LT VENTRICLE DISTAL DOUBLE CURVE IS 1 BI","SUP-ITM-10135388","CDM","C1900","HCPCS","0278","RC","","","","both","","","4275.00","3206.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1637.33","38.3","","1671.53","1671.53","1671.53","1 through 10","1325.25","3398.63","percent of total billed charges",""
"LEAD PACING ATTAIN 88CM ABILITY LV POLYURETHANE STEROID ELUTING LT VENTRICLE DISTAL DOUBLE CURVE IS 1 BI","SUP-ITM-10135388","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","4275.00","3206.25","AETNA [1001]","HB AMC AETNA HMO","2983.95","69.8","","1935.90","1935.90","1935.90","1 through 10","2234.12","3493.53","percent of total billed charges",""
"LEAD PACING ATTAIN 88CM ABILITY LV POLYURETHANE STEROID ELUTING LT VENTRICLE DISTAL DOUBLE CURVE IS 1 BI","SUP-ITM-10135388","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","4275.00","3206.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3493.53","81.72","","1769.79","1769.79","1769.79","1 through 10","2234.12","3493.53","percent of total billed charges",""
"LEAD PACING L 53CM ADULT TEMPORARY STREAMLINE MYOCARDIAL UNIPOLAR PK/12EA","SUP-ITM-10001461","CDM","C1898","HCPCS","0278","RC","","","","both","","","58.33","43.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","31.09","53.3","","679.14","679.14","679.14","1 through 10","18.08","46.37","percent of total billed charges",""
"LEAD PACING L 53CM ADULT TEMPORARY STREAMLINE MYOCARDIAL UNIPOLAR PK/12EA","SUP-ITM-10001461","CDM","C1898","HCPCS","0278","RC","","","","both","","","58.33","43.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21.29","36.5","","479.77","479.77","479.77","1 through 10","18.08","46.37","percent of total billed charges",""
"LEAD PACING L 53CM ADULT TEMPORARY STREAMLINE MYOCARDIAL UNIPOLAR PK/12EA","SUP-ITM-10001461","CDM","C1898","HCPCS","0278","RC","","","","both","","","58.33","43.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22.34","38.3","","502.93","502.93","502.93","1 through 10","18.08","46.37","percent of total billed charges",""
"LEAD PACING L 53CM ADULT TEMPORARY STREAMLINE MYOCARDIAL UNIPOLAR PK/12EA","SUP-ITM-10001461","CDM","C1898","HCPCS","0278","RC","","","","both","","","58.33","43.75","WELLPOINT [1015]","HB AMC WELLPOINT","43.04","73.78","","957.62","957.62","957.62","1 through 10","18.08","46.37","percent of total billed charges",""
"LEAD PACING L 53CM ADULT TEMPORARY STREAMLINE MYOCARDIAL UNIPOLAR PK/12EA","SUP-ITM-10001461","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","58.33","43.75","AETNA [1001]","HB AMC AETNA HMO","40.71","69.8","","916.33","669.20","916.33","1 through 10","30.48","47.67","percent of total billed charges",""
"LEAD PACING L 53CM ADULT TEMPORARY STREAMLINE MYOCARDIAL UNIPOLAR PK/12EA","SUP-ITM-10001461","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","58.33","43.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","47.67","81.72","","811.39","811.39","811.39","1 through 10","30.48","47.67","percent of total billed charges",""
"LEAD PACING L 53CM ADULT TEMPORARY STREAMLINE MYOCARDIAL UNIPOLAR PK/12EA","SUP-ITM-10001461","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","58.33","43.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","47.67","81.72","","446.30","446.30","446.30","1 through 10","30.48","47.67","percent of total billed charges",""
"LEAD PACING SELECTSECURE 4FR 59CM BRADYCARDIA STEROID ELUTING FIXED SCREW BIPOLAR","SUP-ITM-10018070","CDM","C1779","HCPCS","0278","RC","","","","outpatient","","","1286.25","964.69","AETNA [1001]","HB AMC AETNA HMO","897.80","69.8","","6441.05","6441.05","6441.05","1 through 10","672.19","1051.12","percent of total billed charges",""
"LEAD PACING SELECTSECURE 4FR 59CM BRADYCARDIA STEROID ELUTING FIXED SCREW BIPOLAR","SUP-ITM-10018070","CDM","C1779","HCPCS","0278","RC","","","","outpatient","","","1286.25","964.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1051.12","81.72","","10771.92","10771.92","10771.92","1 through 10","672.19","1051.12","percent of total billed charges",""
"LEAD PACING SOLIA 53CM STEROID ELUTING RA IS 1 BIPOLAR PROMRI BRADY","SUP-ITM-10169064","CDM","C1898","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","559.65","53.3","","679.14","679.14","679.14","1 through 10","325.5","834.75","percent of total billed charges",""
"LEAD PACING SOLIA 53CM STEROID ELUTING RA IS 1 BIPOLAR PROMRI BRADY","SUP-ITM-10169064","CDM","C1898","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","479.77","479.77","479.77","1 through 10","325.5","834.75","percent of total billed charges",""
"LEAD PACING SOLIA 53CM STEROID ELUTING RA IS 1 BIPOLAR PROMRI BRADY","SUP-ITM-10169064","CDM","C1898","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","502.93","502.93","502.93","1 through 10","325.5","834.75","percent of total billed charges",""
"LEAD PACING SOLIA 53CM STEROID ELUTING RA IS 1 BIPOLAR PROMRI BRADY","SUP-ITM-10169064","CDM","C1898","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB AMC WELLPOINT","774.69","73.78","","957.62","957.62","957.62","1 through 10","325.5","834.75","percent of total billed charges",""
"LEAD PACING SOLIA 53CM STEROID ELUTING RA IS 1 BIPOLAR PROMRI BRADY","SUP-ITM-10169064","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA HMO","732.90","69.8","","916.33","669.20","916.33","1 through 10","548.73","858.06","percent of total billed charges",""
"LEAD PACING SOLIA 53CM STEROID ELUTING RA IS 1 BIPOLAR PROMRI BRADY","SUP-ITM-10169064","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","858.06","81.72","","811.39","811.39","811.39","1 through 10","548.73","858.06","percent of total billed charges",""
"LEAD PACING SOLIA 53CM STEROID ELUTING RA IS 1 BIPOLAR PROMRI BRADY","SUP-ITM-10169064","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","858.06","81.72","","446.30","446.30","446.30","1 through 10","548.73","858.06","percent of total billed charges",""
"LEAD PADDLE 2X8 65CM MRI SURGICAL NOTE NEW CHANGES","SUP-ITM-10073304","CDM","C1778","HCPCS","0278","RC","","","","both","","","12500.00","9375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6662.50","53.3","","5279.78","5279.78","5279.78","1 through 10","3875","9937.5","percent of total billed charges",""
"LEAD PADDLE 2X8 65CM MRI SURGICAL NOTE NEW CHANGES","SUP-ITM-10073304","CDM","C1778","HCPCS","0278","RC","","","","both","","","12500.00","9375.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","9937.50","79.5","","15789.05","15789.05","15789.05","1 through 10","3875","9937.5","percent of total billed charges",""
"LEAD PADDLE 2X8 65CM MRI SURGICAL NOTE NEW CHANGES","SUP-ITM-10073304","CDM","C1778","HCPCS","0278","RC","","","","both","","","12500.00","9375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4562.50","36.5","","2482.78","1657.12","2482.78","1 through 10","3875","9937.5","percent of total billed charges",""
"LEAD PADDLE 2X8 65CM MRI SURGICAL NOTE NEW CHANGES","SUP-ITM-10073304","CDM","C1778","HCPCS","0278","RC","","","","both","","","12500.00","9375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4787.50","38.3","","2602.60","2602.60","2602.60","1 through 10","3875","9937.5","percent of total billed charges",""
"LEAD PADDLE 2X8 65CM MRI SURGICAL NOTE NEW CHANGES","SUP-ITM-10073304","CDM","C1778","HCPCS","0278","RC","","","","both","","","12500.00","9375.00","WELLPOINT [1015]","HB AMC WELLPOINT","9222.50","73.78","","4955.58","3845.35","9119.37","1 through 10","3875","9937.5","percent of total billed charges",""
"LEAD PADDLE 2X8 65CM MRI SURGICAL NOTE NEW CHANGES","SUP-ITM-10073304","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","12500.00","9375.00","AETNA [1001]","HB AMC AETNA HMO","8725.00","69.8","","8631.75","8631.75","8631.75","1 through 10","6532.5","10215","percent of total billed charges",""
"LEAD PADDLE 50CM NEUROSTIMULATOR","SUP-ITM-10203891","CDM","C1778","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5729.75","53.3","","5279.78","5279.78","5279.78","1 through 10","3332.5","8546.25","percent of total billed charges",""
"LEAD PADDLE 50CM NEUROSTIMULATOR","SUP-ITM-10203891","CDM","C1778","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","8546.25","79.5","","15789.05","15789.05","15789.05","1 through 10","3332.5","8546.25","percent of total billed charges",""
"LEAD PADDLE 50CM NEUROSTIMULATOR","SUP-ITM-10203891","CDM","C1778","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3923.75","36.5","","2482.78","1657.12","2482.78","1 through 10","3332.5","8546.25","percent of total billed charges",""
"LEAD PADDLE 50CM NEUROSTIMULATOR","SUP-ITM-10203891","CDM","C1778","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4117.25","38.3","","2602.60","2602.60","2602.60","1 through 10","3332.5","8546.25","percent of total billed charges",""
"LEAD PADDLE 50CM NEUROSTIMULATOR","SUP-ITM-10203891","CDM","C1778","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","WELLPOINT [1015]","HB AMC WELLPOINT","7931.35","73.78","","4955.58","3845.35","9119.37","1 through 10","3332.5","8546.25","percent of total billed charges",""
"LEAD PADDLE 50CM NEUROSTIMULATOR","SUP-ITM-10203891","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","10750.00","8062.50","AETNA [1001]","HB AMC AETNA HMO","7503.50","69.8","","8631.75","8631.75","8631.75","1 through 10","5617.95","8784.9","percent of total billed charges",""
"LEAD PAMIRA S DX 65/17 RV AND ATRIAL SENSING","SUP-ITM-10319247","CDM","C1895","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3198.00","53.3","","3630.00","3630.00","3630.00","1 through 10","1860","4770","percent of total billed charges",""
"Lead Ppm Not Transvenous T1","PX-27000192","CDM","C1898","HCPCS","0278","RC","","","","both","","","1686.02","1264.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","898.65","53.3","","679.14","679.14","679.14","1 through 10","522.67","1340.39","percent of total billed charges",""
"Lead Ppm Not Transvenous T1","PX-27000192","CDM","C1898","HCPCS","0278","RC","","","","both","","","1686.02","1264.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","615.40","36.5","","479.77","479.77","479.77","1 through 10","522.67","1340.39","percent of total billed charges",""
"Lead Ppm Not Transvenous T1","PX-27000192","CDM","C1898","HCPCS","0278","RC","","","","both","","","1686.02","1264.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","645.75","38.3","","502.93","502.93","502.93","1 through 10","522.67","1340.39","percent of total billed charges",""
"Lead Ppm Not Transvenous T1","PX-27000192","CDM","C1898","HCPCS","0278","RC","","","","both","","","1686.02","1264.51","WELLPOINT [1015]","HB AMC WELLPOINT","1243.95","73.78","","957.62","957.62","957.62","1 through 10","522.67","1340.39","percent of total billed charges",""
"Lead Ppm Not Transvenous T1","PX-27000192","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1686.02","1264.51","AETNA [1001]","HB AMC AETNA HMO","1176.84","69.8","","916.33","669.20","916.33","1 through 10","881.11","1377.82","percent of total billed charges",""
"Lead Ppm Not Transvenous T1","PX-27000192","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1686.02","1264.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1377.82","81.72","","811.39","811.39","811.39","1 through 10","881.11","1377.82","percent of total billed charges",""
"Lead Ppm Not Transvenous T1","PX-27000192","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1686.02","1264.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1377.82","81.72","","446.30","446.30","446.30","1 through 10","881.11","1377.82","percent of total billed charges",""
"LEAD QUARTET LV 4.7FR 40MM 86CM SMALL-S 8 CURVE LEFT HEART OPTIM INSULATION IS4-LLLL CONNECTOR","SUP-ITM-10166474","CDM","C1900","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2590.38","53.3","","2692.80","2257.20","2692.80","1 through 10","1506.6","3863.7","percent of total billed charges",""
"LEAD QUARTET LV 4.7FR 40MM 86CM SMALL-S 8 CURVE LEFT HEART OPTIM INSULATION IS4-LLLL CONNECTOR","SUP-ITM-10166474","CDM","C1900","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1861.38","38.3","","1671.53","1671.53","1671.53","1 through 10","1506.6","3863.7","percent of total billed charges",""
"LEAD QUARTET LV 4.7FR 40MM 86CM SMALL-S 8 CURVE LEFT HEART OPTIM INSULATION IS4-LLLL CONNECTOR","SUP-ITM-10166474","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","4860.00","3645.00","AETNA [1001]","HB AMC AETNA HMO","3392.28","69.8","","1935.90","1935.90","1935.90","1 through 10","2539.84","3971.59","percent of total billed charges",""
"LEAD QUARTET LV 4.7FR 40MM 86CM SMALL-S 8 CURVE LEFT HEART OPTIM INSULATION IS4-LLLL CONNECTOR","SUP-ITM-10166474","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","4860.00","3645.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3971.59","81.72","","1769.79","1769.79","1769.79","1 through 10","2539.84","3971.59","percent of total billed charges",""
"LEAD QUARTET LV 4.7FR 47MM 75CM TRADITIONAL S 16 CURVE LEFT HEART OPTIM INSULATION IS4-LLLL CONNECTOR","SUP-ITM-10093887","CDM","C1900","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2590.38","53.3","","2692.80","2257.20","2692.80","1 through 10","1506.6","3863.7","percent of total billed charges",""
"LEAD QUARTET LV 4.7FR 47MM 75CM TRADITIONAL S 16 CURVE LEFT HEART OPTIM INSULATION IS4-LLLL CONNECTOR","SUP-ITM-10093887","CDM","C1900","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1861.38","38.3","","1671.53","1671.53","1671.53","1 through 10","1506.6","3863.7","percent of total billed charges",""
"LEAD QUARTET LV 4.7FR 47MM 75CM TRADITIONAL S 16 CURVE LEFT HEART OPTIM INSULATION IS4-LLLL CONNECTOR","SUP-ITM-10093887","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","4860.00","3645.00","AETNA [1001]","HB AMC AETNA HMO","3392.28","69.8","","1935.90","1935.90","1935.90","1 through 10","2539.84","3971.59","percent of total billed charges",""
"LEAD QUARTET LV 4.7FR 47MM 75CM TRADITIONAL S 16 CURVE LEFT HEART OPTIM INSULATION IS4-LLLL CONNECTOR","SUP-ITM-10093887","CDM","C1900","HCPCS","0278","RC","","","","outpatient","","","4860.00","3645.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3971.59","81.72","","1769.79","1769.79","1769.79","1 through 10","2539.84","3971.59","percent of total billed charges",""
"LEAD RESPIRATORY SENSING","SUP-ITM-10237951","CDM","C1778","HCPCS","0278","RC","","","","both","","","8437.50","6328.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4497.19","53.3","","5279.78","5279.78","5279.78","1 through 10","2615.63","6707.81","percent of total billed charges",""
"LEAD RESPIRATORY SENSING","SUP-ITM-10237951","CDM","C1778","HCPCS","0278","RC","","","","both","","","8437.50","6328.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","6707.81","79.5","","15789.05","15789.05","15789.05","1 through 10","2615.63","6707.81","percent of total billed charges",""
"LEAD RESPIRATORY SENSING","SUP-ITM-10237951","CDM","C1778","HCPCS","0278","RC","","","","both","","","8437.50","6328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3079.69","36.5","","2482.78","1657.12","2482.78","1 through 10","2615.63","6707.81","percent of total billed charges",""
"LEAD RESPIRATORY SENSING","SUP-ITM-10237951","CDM","C1778","HCPCS","0278","RC","","","","both","","","8437.50","6328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3231.56","38.3","","2602.60","2602.60","2602.60","1 through 10","2615.63","6707.81","percent of total billed charges",""
"LEAD RESPIRATORY SENSING","SUP-ITM-10237951","CDM","C1778","HCPCS","0278","RC","","","","both","","","8437.50","6328.12","WELLPOINT [1015]","HB AMC WELLPOINT","6225.19","73.78","","4955.58","3845.35","9119.37","1 through 10","2615.63","6707.81","percent of total billed charges",""
"LEAD RESPIRATORY SENSING","SUP-ITM-10237951","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","8437.50","6328.12","AETNA [1001]","HB AMC AETNA HMO","5889.38","69.8","","8631.75","8631.75","8631.75","1 through 10","4409.44","6895.13","percent of total billed charges",""
"LEAD SPRINT QUATTRO 65CM CARDIOVERTER DEFIBRILLATOR SECURE SILICONE ENDO RV ACTIVE SCREW IS 1 BI","SUP-ITM-10042808","CDM","C1895","HCPCS","0278","RC","","","","both","","","6875.00","5156.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3664.38","53.3","","3630.00","3630.00","3630.00","1 through 10","2131.25","5465.63","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2598.38","53.3","","5279.78","5279.78","5279.78","1 through 10","1511.25","3875.63","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3875.63","79.5","","15789.05","15789.05","15789.05","1 through 10","1511.25","3875.63","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1779.38","36.5","","2482.78","1657.12","2482.78","1 through 10","1511.25","3875.63","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1867.13","38.3","","2602.60","2602.60","2602.60","1 through 10","1511.25","3875.63","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","WELLPOINT [1015]","HB AMC WELLPOINT","3596.78","73.78","","4955.58","3845.35","9119.37","1 through 10","1511.25","3875.63","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4875.00","3656.25","AETNA [1001]","HB AMC AETNA HMO","3402.75","69.8","","8631.75","8631.75","8631.75","1 through 10","2547.68","3983.85","percent of total billed charges",""
"LEAD STIMULATOR 60CM LAMITRODE 16CH 5 COLUMN PENTA","SUP-ITM-10086854","CDM","C1778","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5996.25","53.3","","5279.78","5279.78","5279.78","1 through 10","3487.5","8943.75","percent of total billed charges",""
"LEAD STIMULATOR 60CM LAMITRODE 16CH 5 COLUMN PENTA","SUP-ITM-10086854","CDM","C1778","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","8943.75","79.5","","15789.05","15789.05","15789.05","1 through 10","3487.5","8943.75","percent of total billed charges",""
"LEAD STIMULATOR 60CM LAMITRODE 16CH 5 COLUMN PENTA","SUP-ITM-10086854","CDM","C1778","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4106.25","36.5","","2482.78","1657.12","2482.78","1 through 10","3487.5","8943.75","percent of total billed charges",""
"LEAD STIMULATOR 60CM LAMITRODE 16CH 5 COLUMN PENTA","SUP-ITM-10086854","CDM","C1778","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4308.75","38.3","","2602.60","2602.60","2602.60","1 through 10","3487.5","8943.75","percent of total billed charges",""
"LEAD STIMULATOR 60CM LAMITRODE 16CH 5 COLUMN PENTA","SUP-ITM-10086854","CDM","C1778","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","WELLPOINT [1015]","HB AMC WELLPOINT","8300.25","73.78","","4955.58","3845.35","9119.37","1 through 10","3487.5","8943.75","percent of total billed charges",""
"LEAD STIMULATOR 60CM LAMITRODE 16CH 5 COLUMN PENTA","SUP-ITM-10086854","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","11250.00","8437.50","AETNA [1001]","HB AMC AETNA HMO","7852.50","69.8","","8631.75","8631.75","8631.75","1 through 10","5879.25","9193.5","percent of total billed charges",""
"LEAD SUBSTERNAL 52CM EPSILA EV","SUP-ITM-10330336","CDM","C1896","HCPCS","0278","RC","","","","both","","","13475.00","10106.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10712.63","79.5","","7540.00","7540.00","7540.00","1 through 10","4177.25","10712.63","percent of total billed charges",""
"LEAD SUBSTERNAL 52CM EPSILA EV","SUP-ITM-10330336","CDM","C1896","HCPCS","0278","RC","","","","both","","","13475.00","10106.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8758.75","65","","6500.00","6500.00","6500.00","1 through 10","4177.25","10712.63","percent of total billed charges",""
"LEAD SUBSTERNAL 52CM EPSILA EV","SUP-ITM-10330336","CDM","C1896","HCPCS","0278","RC","","","","both","","","13475.00","10106.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4918.38","36.5","","11190.00","11190.00","11190.00","1 through 10","4177.25","10712.63","percent of total billed charges",""
"LEAD SUBSTERNAL 52CM EPSILA EV","SUP-ITM-10330336","CDM","C1896","HCPCS","0278","RC","","","","outpatient","","","13475.00","10106.25","AETNA [1001]","HB AMC AETNA HMO","9405.55","69.8","","17800.00","17800.00","17800.00","1 through 10","7042.04","11011.77","percent of total billed charges",""
"LEAD SUBSTERNAL 63CM EPSILA EV","SUP-ITM-10330337","CDM","C1779","HCPCS","0278","RC","","","","outpatient","","","13475.00","10106.25","AETNA [1001]","HB AMC AETNA HMO","9405.55","69.8","","6441.05","6441.05","6441.05","1 through 10","7042.04","11011.77","percent of total billed charges",""
"LEAD SUBSTERNAL 63CM EPSILA EV","SUP-ITM-10330337","CDM","C1779","HCPCS","0278","RC","","","","outpatient","","","13475.00","10106.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11011.77","81.72","","10771.92","10771.92","10771.92","1 through 10","7042.04","11011.77","percent of total billed charges",""
"LEAD SURGICAL 70CM COVERAGE","SUP-ITM-10166130","CDM","C1778","HCPCS","0278","RC","","","","both","","","11000.00","8250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5863.00","53.3","","5279.78","5279.78","5279.78","1 through 10","3410","8745","percent of total billed charges",""
"LEAD SURGICAL 70CM COVERAGE","SUP-ITM-10166130","CDM","C1778","HCPCS","0278","RC","","","","both","","","11000.00","8250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","8745.00","79.5","","15789.05","15789.05","15789.05","1 through 10","3410","8745","percent of total billed charges",""
"LEAD SURGICAL 70CM COVERAGE","SUP-ITM-10166130","CDM","C1778","HCPCS","0278","RC","","","","both","","","11000.00","8250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4015.00","36.5","","2482.78","1657.12","2482.78","1 through 10","3410","8745","percent of total billed charges",""
"LEAD SURGICAL 70CM COVERAGE","SUP-ITM-10166130","CDM","C1778","HCPCS","0278","RC","","","","both","","","11000.00","8250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4213.00","38.3","","2602.60","2602.60","2602.60","1 through 10","3410","8745","percent of total billed charges",""
"LEAD SURGICAL 70CM COVERAGE","SUP-ITM-10166130","CDM","C1778","HCPCS","0278","RC","","","","both","","","11000.00","8250.00","WELLPOINT [1015]","HB AMC WELLPOINT","8115.80","73.78","","4955.58","3845.35","9119.37","1 through 10","3410","8745","percent of total billed charges",""
"LEAD SURGICAL 70CM COVERAGE","SUP-ITM-10166130","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","11000.00","8250.00","AETNA [1001]","HB AMC AETNA HMO","7678.00","69.8","","8631.75","8631.75","8631.75","1 through 10","5748.6","8989.2","percent of total billed charges",""
"LEAD TENDRIL MRI 8FR 58CM PACING OPTIM INSULATION EXT/REL HELIX IS-1 BIPOLAR CONNECTOR","SUP-ITM-10183339","CDM","C1898","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","679.14","679.14","679.14","1 through 10","542.5","1391.25","percent of total billed charges",""
"LEAD TENDRIL MRI 8FR 58CM PACING OPTIM INSULATION EXT/REL HELIX IS-1 BIPOLAR CONNECTOR","SUP-ITM-10183339","CDM","C1898","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","479.77","479.77","479.77","1 through 10","542.5","1391.25","percent of total billed charges",""
"LEAD TENDRIL MRI 8FR 58CM PACING OPTIM INSULATION EXT/REL HELIX IS-1 BIPOLAR CONNECTOR","SUP-ITM-10183339","CDM","C1898","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","502.93","502.93","502.93","1 through 10","542.5","1391.25","percent of total billed charges",""
"LEAD TENDRIL MRI 8FR 58CM PACING OPTIM INSULATION EXT/REL HELIX IS-1 BIPOLAR CONNECTOR","SUP-ITM-10183339","CDM","C1898","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","957.62","957.62","957.62","1 through 10","542.5","1391.25","percent of total billed charges",""
"LEAD TENDRIL MRI 8FR 58CM PACING OPTIM INSULATION EXT/REL HELIX IS-1 BIPOLAR CONNECTOR","SUP-ITM-10183339","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","916.33","669.20","916.33","1 through 10","914.55","1430.1","percent of total billed charges",""
"LEAD TENDRIL MRI 8FR 58CM PACING OPTIM INSULATION EXT/REL HELIX IS-1 BIPOLAR CONNECTOR","SUP-ITM-10183339","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1430.10","81.72","","811.39","811.39","811.39","1 through 10","914.55","1430.1","percent of total billed charges",""
"LEAD TENDRIL MRI 8FR 58CM PACING OPTIM INSULATION EXT/REL HELIX IS-1 BIPOLAR CONNECTOR","SUP-ITM-10183339","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","446.30","446.30","446.30","1 through 10","914.55","1430.1","percent of total billed charges",""
"LEAD TENDRIL STS 6FR 65CM PACING OPTIM INSULATION EXT/RET HELIX SILICONE TIP IS-1 BIPOLAR CONNECTOR","SUP-ITM-10124574","CDM","C1898","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","783.51","53.3","","679.14","679.14","679.14","1 through 10","455.7","1168.65","percent of total billed charges",""
"LEAD TENDRIL STS 6FR 65CM PACING OPTIM INSULATION EXT/RET HELIX SILICONE TIP IS-1 BIPOLAR CONNECTOR","SUP-ITM-10124574","CDM","C1898","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","536.55","36.5","","479.77","479.77","479.77","1 through 10","455.7","1168.65","percent of total billed charges",""
"LEAD TENDRIL STS 6FR 65CM PACING OPTIM INSULATION EXT/RET HELIX SILICONE TIP IS-1 BIPOLAR CONNECTOR","SUP-ITM-10124574","CDM","C1898","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","563.01","38.3","","502.93","502.93","502.93","1 through 10","455.7","1168.65","percent of total billed charges",""
"LEAD TENDRIL STS 6FR 65CM PACING OPTIM INSULATION EXT/RET HELIX SILICONE TIP IS-1 BIPOLAR CONNECTOR","SUP-ITM-10124574","CDM","C1898","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB AMC WELLPOINT","1084.57","73.78","","957.62","957.62","957.62","1 through 10","455.7","1168.65","percent of total billed charges",""
"LEAD TENDRIL STS 6FR 65CM PACING OPTIM INSULATION EXT/RET HELIX SILICONE TIP IS-1 BIPOLAR CONNECTOR","SUP-ITM-10124574","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA HMO","1026.06","69.8","","916.33","669.20","916.33","1 through 10","768.22","1201.28","percent of total billed charges",""
"LEAD TENDRIL STS 6FR 65CM PACING OPTIM INSULATION EXT/RET HELIX SILICONE TIP IS-1 BIPOLAR CONNECTOR","SUP-ITM-10124574","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1201.28","81.72","","811.39","811.39","811.39","1 through 10","768.22","1201.28","percent of total billed charges",""
"LEAD TENDRIL STS 6FR 65CM PACING OPTIM INSULATION EXT/RET HELIX SILICONE TIP IS-1 BIPOLAR CONNECTOR","SUP-ITM-10124574","CDM","C1898","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1201.28","81.72","","446.30","446.30","446.30","1 through 10","768.22","1201.28","percent of total billed charges",""
"LEAD TRIAL NEUROSTIMULATOR 1X16 70CM INFINION","SUP-ITM-10280226","CDM","C1778","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2052.05","53.3","","5279.78","5279.78","5279.78","1 through 10","1193.5","3060.75","percent of total billed charges",""
"LEAD TRIAL NEUROSTIMULATOR 1X16 70CM INFINION","SUP-ITM-10280226","CDM","C1778","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","15789.05","15789.05","15789.05","1 through 10","1193.5","3060.75","percent of total billed charges",""
"LEAD TRIAL NEUROSTIMULATOR 1X16 70CM INFINION","SUP-ITM-10280226","CDM","C1778","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","2482.78","1657.12","2482.78","1 through 10","1193.5","3060.75","percent of total billed charges",""
"LEAD TRIAL NEUROSTIMULATOR 1X16 70CM INFINION","SUP-ITM-10280226","CDM","C1778","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","2602.60","2602.60","2602.60","1 through 10","1193.5","3060.75","percent of total billed charges",""
"LEAD TRIAL NEUROSTIMULATOR 1X16 70CM INFINION","SUP-ITM-10280226","CDM","C1778","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","4955.58","3845.35","9119.37","1 through 10","1193.5","3060.75","percent of total billed charges",""
"LEAD TRIAL NEUROSTIMULATOR 1X16 70CM INFINION","SUP-ITM-10280226","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA HMO","2687.30","69.8","","8631.75","8631.75","8631.75","1 through 10","2012.01","3146.22","percent of total billed charges",""
"LEAD WIRE 1X8 3 12 4 52MM 45CM NEUROSTIMULATOR TEMPORARY TES - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020637","CDM","C1897","HCPCS","0278","RC","","","","both","","","3073.00","2304.75","WELLPOINT [1015]","HB AMC WELLPOINT","2267.26","73.78","","2260.50","2260.50","2260.50","1 through 10","952.63","2443.04","percent of total billed charges",""
"LEAD WIRE 6X24 12 18 60MM 45CM NEUROSTIMULATOR PISCES PLUS 4 ELECTRODE","SUP-ITM-10022067","CDM","C1778","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2163.98","53.3","","5279.78","5279.78","5279.78","1 through 10","1258.6","3227.7","percent of total billed charges",""
"LEAD WIRE 6X24 12 18 60MM 45CM NEUROSTIMULATOR PISCES PLUS 4 ELECTRODE","SUP-ITM-10022067","CDM","C1778","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3227.70","79.5","","15789.05","15789.05","15789.05","1 through 10","1258.6","3227.7","percent of total billed charges",""
"LEAD WIRE 6X24 12 18 60MM 45CM NEUROSTIMULATOR PISCES PLUS 4 ELECTRODE","SUP-ITM-10022067","CDM","C1778","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1481.90","36.5","","2482.78","1657.12","2482.78","1 through 10","1258.6","3227.7","percent of total billed charges",""
"LEAD WIRE 6X24 12 18 60MM 45CM NEUROSTIMULATOR PISCES PLUS 4 ELECTRODE","SUP-ITM-10022067","CDM","C1778","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1554.98","38.3","","2602.60","2602.60","2602.60","1 through 10","1258.6","3227.7","percent of total billed charges",""
"LEAD WIRE 6X24 12 18 60MM 45CM NEUROSTIMULATOR PISCES PLUS 4 ELECTRODE","SUP-ITM-10022067","CDM","C1778","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","WELLPOINT [1015]","HB AMC WELLPOINT","2995.47","73.78","","4955.58","3845.35","9119.37","1 through 10","1258.6","3227.7","percent of total billed charges",""
"LEAD WIRE 6X24 12 18 60MM 45CM NEUROSTIMULATOR PISCES PLUS 4 ELECTRODE","SUP-ITM-10022067","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4060.00","3045.00","AETNA [1001]","HB AMC AETNA HMO","2833.88","69.8","","8631.75","8631.75","8631.75","1 through 10","2121.76","3317.83","percent of total billed charges",""
"LEADWIRE NEUROSTIMULATOR 1X8 3 12 6 66MM 60CM TEMPORARY TEST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10082688","CDM","C1897","HCPCS","0278","RC","","","","both","","","3073.00","2304.75","WELLPOINT [1015]","HB AMC WELLPOINT","2267.26","73.78","","2260.50","2260.50","2260.50","1 through 10","952.63","2443.04","percent of total billed charges",""
"Left Heart Artery/Graft Angio","PX-48000124","CDM","93459","CPT","0481","RC","","","","both","","","31499.00","23624.25","MEDICARE [2001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3819.68","3819.68","6770.90","1 through 10","3628.7","25041.71","other","OPPS APC"
"Left Heart Artery/Graft Angio","PX-48000124","CDM","93459","CPT","0481","RC","","","","both","","","31499.00","23624.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3750.93","3750.93","3750.93","1 through 10","3628.7","25041.71","other","OPPS APC"
"Legionella Ag Urine (Infec Agent)","PX-30002770","CDM","87899","CPT","0306","RC","","","","both","","","206.00","154.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","147.91","71.8","","14.17","14.17","14.17","1 through 10","11.81","195.7","percent of total billed charges",""
"Legionella Ag Urine (Infec Agent)","PX-30002770","CDM","87899","CPT","0306","RC","","","","both","","","206.00","154.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","144.20","70","","393.00","393.00","393.00","1 through 10","11.81","195.7","percent of total billed charges",""
"Legionella Ag Urine (Infec Agent)","PX-30002770","CDM","87899","CPT","0306","RC","","","","both","","","206.00","154.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.80","53.3","","166.91","166.91","166.91","1 through 10","11.81","195.7","percent of total billed charges",""
"Legionella Ag Urine (Infec Agent)","PX-30002770","CDM","87899","CPT","0306","RC","","","","both","","","206.00","154.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.90","38.3","","153.66","78.20","153.66","1 through 10","11.81","195.7","percent of total billed charges",""
"Legionella Ag Urine (Infec Agent)","PX-30002770","CDM","87899","CPT","0306","RC","","","","outpatient","","","206.00","154.50","AETNA [1001]","HB AMC AETNA HMO","143.79","69.8","","187.85","95.60","306.54","1 through 10","11.81","168.34","percent of total billed charges",""
"Legionella Ag Urine (Infec Agent)","PX-30002770","CDM","87899","CPT","0306","RC","","","","outpatient","","","206.00","154.50","AETNA [1001]","HB AMC AETNA PPO","165.62","80.4","","306.54","306.54","306.54","1 through 10","11.81","168.34","percent of total billed charges",""
"Legionella Ag Urine (Infec Agent)","PX-30002770","CDM","87899","CPT","0306","RC","","","","outpatient","","","206.00","154.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","168.34","81.72","","314.16","314.16","314.16","1 through 10","11.81","168.34","percent of total billed charges",""
"Leptospira Antibody","PX-30000967","CDM","86720","CPT","0302","RC","","","","both","","","142.00","106.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","112.89","79.5","","108.61","108.61","108.61","1 through 10","8.97","134.9","percent of total billed charges",""
"Leptospira Antibody","PX-30000967","CDM","86720","CPT","0302","RC","","","","both","","","142.00","106.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","75.69","53.3","","69.69","69.69","69.69","1 through 10","8.97","134.9","percent of total billed charges",""
"Leptospira Antibody","PX-30000967","CDM","86720","CPT","0302","RC","","","","both","","","142.00","106.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.39","38.3","","161.88","161.88","161.88","1 through 10","8.97","134.9","percent of total billed charges",""
"Leukocyte Antibody ID","PX-30000778","CDM","86021","CPT","0302","RC","","","","both","","","253.00","189.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","177.10","70","","107.73","107.73","107.73","1 through 10","14.75","240.35","percent of total billed charges",""
"Leukocyte Antibody ID","PX-30000778","CDM","86021","CPT","0302","RC","","","","both","","","253.00","189.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","201.14","79.5","","129.36","129.36","192.82","1 through 10","14.75","240.35","percent of total billed charges",""
"Leukocyte Antibody ID","PX-30000778","CDM","86021","CPT","0302","RC","","","","both","","","253.00","189.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","92.35","36.5","","91.39","91.39","91.39","1 through 10","14.75","240.35","percent of total billed charges",""
"Leukocyte Antibody ID","PX-30000778","CDM","86021","CPT","0302","RC","","","","both","","","253.00","189.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.90","38.3","","95.80","95.80","95.80","1 through 10","14.75","240.35","percent of total billed charges",""
"Leukocyte Antibody ID","PX-30000778","CDM","86021","CPT","0302","RC","","","","outpatient","","","253.00","189.75","AETNA [1001]","HB AMC AETNA HMO","176.59","69.8","","165.87","117.11","191.10","1 through 10","15.53","206.75","percent of total billed charges",""
"Leukocyte Antibody ID","PX-30000778","CDM","86021","CPT","0302","RC","","","","outpatient","","","253.00","189.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","206.75","81.72","","195.85","107.73","195.85","1 through 10","15.53","206.75","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","both","","","73.00","54.75","CHAMPVA [160001]","HB BWH TRICARE","69.35","95","","5.15","5.15","5.15","1 through 10","4.18","69.35","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","both","","","73.00","54.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","58.04","79.5","","55.88","52.03","55.88","1 through 10","4.18","69.35","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","both","","","73.00","54.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","38.91","53.3","","37.49","37.49","37.49","1 through 10","4.18","69.35","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","both","","","73.00","54.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.65","36.5","","26.48","26.48","26.48","1 through 10","4.18","69.35","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","both","","","73.00","54.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27.96","38.3","","27.76","26.98","83.28","1 through 10","4.18","69.35","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","both","","","73.00","54.75","TRICARE [160005]","HB BWH TRICARE","69.35","95","","5.15","5.15","5.15","1 through 10","4.18","69.35","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","outpatient","","","73.00","54.75","AETNA [1001]","HB AMC AETNA HMO","50.95","69.8","","48.07","33.94","55.38","1 through 10","4.4","59.66","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","outpatient","","","73.00","54.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","59.66","81.72","","31.22","31.22","31.22","1 through 10","4.4","59.66","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","outpatient","","","73.00","54.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","59.66","81.72","","56.76","56.76","56.76","1 through 10","4.4","59.66","percent of total billed charges",""
"Leuprolide Depot Kit 3.75mg","PX-63600142","CDM","J1950","HCPCS","0636","RC","","","","both","","","1514.96","1136.22","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1695.72","","APC Price ($1,730.32). Final payment is multiplied by 98%.","1709.30","1617.65","1709.30","1 through 10","469.64","3738.94","other","OPPS APC"
"Levofloxacin Vl 250mg","PX-63600143","CDM","J1956","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.47","46.9","","3.65","3.65","3.65","1 through 10","0.47","4.21","percent of total billed charges",""
"Levonorgestrel Liletta Iud 52mg 3 Yr","PX-27001389","CDM","J7297","HCPCS","0636","RC","","","","both","","","3592.00","2694.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1375.74","38.3","","1548.31","990.92","1548.31","1 through 10","1113.52","3412.4","percent of total billed charges",""
"Levonorgestrel Mirena Iud 52mg 5 Yr","PX-27001390","CDM","J7298","HCPCS","0636","RC","","","","both","","","4247.00","3185.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1316.57","31","","3038.32","3038.32","3038.32","1 through 10","1316.57","4034.65","percent of total billed charges",""
"Levonorgestrel Mirena Iud 52mg 5 Yr","PX-27001390","CDM","J7298","HCPCS","0636","RC","","","","both","","","4247.00","3185.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1550.16","36.5","","3559.44","1833.80","5776.47","31","1316.57","4034.65","percent of total billed charges",""
"Levonorgestrel Mirena Iud 52mg 5 Yr","PX-27001390","CDM","J7298","HCPCS","0636","RC","","","","both","","","4247.00","3185.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1626.60","38.3","","5604.66","2018.41","6055.23","133","1316.57","4034.65","percent of total billed charges",""
"Levonorgestrel Mirena Iud 52mg 5 Yr","PX-27001390","CDM","J7298","HCPCS","0636","RC","","","","both","","","4247.00","3185.25","TRICARE [160005]","HB BWH TRICARE","4034.65","95","","4916.36","4916.36","4916.36","1 through 10","1316.57","4034.65","percent of total billed charges",""
"Levonorgestrel Mirena Iud 52mg 5 Yr","PX-27001390","CDM","J7298","HCPCS","0636","RC","","","","both","","","4247.00","3185.25","WELLPOINT [1015]","HB AMC WELLPOINT","3133.44","73.78","","8576.59","3843.24","9005.42","1 through 10","1316.57","4034.65","percent of total billed charges",""
"Levonorgestrel Mirena Iud 52mg 5 Yr","PX-27001390","CDM","J7298","HCPCS","0636","RC","","","","outpatient","","","4247.00","3185.25","AETNA [1001]","HB AMC AETNA HMO","2964.41","69.8","","3494.80","2350.02","5162.18","22","1351.89","3414.59","percent of total billed charges",""
"Levonorgestrel Mirena Iud 52mg 5 Yr","PX-27001390","CDM","J7298","HCPCS","0636","RC","","","","outpatient","","","4247.00","3185.25","AETNA [1001]","HB AMC AETNA PPO","3414.59","80.4","","4026.50","2576.17","4026.50","1 through 10","1351.89","3414.59","percent of total billed charges",""
"Levonorgestrel Mirena Iud 52mg 5 Yr","PX-27001390","CDM","J7298","HCPCS","0636","RC","","","","outpatient","","","4247.00","3185.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","2374.07","55.9","","5409.96","5409.96","5409.96","1 through 10","1351.89","3414.59","percent of total billed charges",""
"Levonorgestrel Mirena Iud 52mg 5 Yr","PX-27001390","CDM","J7298","HCPCS","0636","RC","","","","outpatient","","","4247.00","3185.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2968.65","69.9","","3577.39","2281.19","10732.17","14","1351.89","3414.59","percent of total billed charges",""
"Levonorgestrel Mirena Iud 52mg 5 Yr","PX-27001390","CDM","J7298","HCPCS","0636","RC","","","","outpatient","","","4247.00","3185.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1991.84","46.9","","3577.39","3407.04","3577.39","1 through 10","1351.89","3414.59","percent of total billed charges",""
"Levonorgestrel Mirena Iud 52mg 5 Yr","PX-27001390","CDM","J7298","HCPCS","0636","RC","","","","outpatient","","","4247.00","3185.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3414.59","80.4","","3834.76","3834.76","3834.76","1 through 10","1351.89","3414.59","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","both","","","2.17","1.63","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1.67","77","","0.28","0.28","0.28","40","0.06","2.06","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","both","","","2.17","1.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1.41","65","","2.38","2.38","2.38","1 through 10","0.06","2.06","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","both","","","2.17","1.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.83","38.3","","0.14","0.09","1.25","66","0.06","2.06","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","outpatient","","","2.17","1.63","AETNA [1001]","HB AMC AETNA HMO","1.51","69.8","","0.89","0.12","1.31","57","1.02","1.77","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","outpatient","","","2.17","1.63","AETNA [1001]","HB AMC AETNA PPO","1.74","80.4","","1.58","1.58","5.71","1 through 10","1.02","1.77","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","outpatient","","","2.17","1.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.52","69.9","","0.24","0.24","0.24","40","1.02","1.77","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","outpatient","","","2.17","1.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1.02","46.9","","0.11","0.11","0.11","80","1.02","1.77","percent of total billed charges",""
"Life/Disability Eval","PX-51000093","CDM","99450","CPT","0510","RC","","","","both","","","168.00","126.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","58.80","35","","163.00","163.00","163.00","1 through 10","52.08","159.6","percent of total billed charges",""
"Life/Disability Evaluation","PX-98302119","CDM","99450","CPT","0983","RC","","","","both","","","424.00","318.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","148.40","35","","163.00","163.00","163.00","1 through 10","131.44","402.8","percent of total billed charges",""
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","both","","","9766.00","7324.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3737.85","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3678.04","3678.04","3678.04","1 through 10","3027.46","7763.97","other","OPPS APC"
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","both","","","9766.00","7324.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","4672.31","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","3678.04","3678.04","3678.04","1 through 10","3027.46","7763.97","other","OPPS APC"
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","both","","","9766.00","7324.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3737.85","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3678.04","3678.04","3678.04","1 through 10","3027.46","7763.97","other","OPPS APC"
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","both","","","9766.00","7324.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6347.90","65","","2.76","2.76","2.76","1 through 10","3027.46","7763.97","percent of total billed charges",""
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","both","","","9766.00","7324.50","MEDICARE [2001]","HB BWH MEDICARE","3737.85","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11213.55","3737.85","11213.55","27","3027.46","7763.97","other","OPPS APC"
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","both","","","9766.00","7324.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3663.09","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3663.50","3663.09","3663.50","1 through 10","3027.46","7763.97","other","OPPS APC"
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","outpatient","","","9766.00","7324.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6068.65","3034.33","6068.65","1 through 10","2377.37","7980.78","other","ASC"
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","outpatient","","","9766.00","7324.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7071.53","7071.53","7071.53","1 through 10","2377.37","7980.78","other","ASC "
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","outpatient","","","9766.00","7324.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2377.37","","Case rate ($2,377.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","5515.50","5515.50","5515.50","1 through 10","2377.37","7980.78","other","Multiple Surgery"
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","outpatient","","","9766.00","7324.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7980.78","81.72","","33321.39","33321.39","33321.39","1 through 10","2377.37","7980.78","percent of total billed charges",""
"Ligate/Biopsy Artery Temporal","PX-76001167","CDM","37609","CPT","0761","RC","","","","outpatient","","","5019.00","3764.25","AETNA [1001]","HB AMC AETNA HMO","3503.26","69.8","","1942.99","1942.99","1942.99","1 through 10","1237.95","5545.35","percent of total billed charges",""
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","","","","inpatient","","","172439.51","129329.63","MEDICARE [2001]","HB BWH MEDICARE","44929.71","","Case rate ($44,929.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,702.15, add-ons for qualifying new technology services are included. If operating cost exceeds $87,346.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,468.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $41,521.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,322.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,027.93. The transfer capital threshold is the transfer adjustment factor * $3,027.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","45408.56","36675.83","81969.17","1 through 10","34012.19","57683.8384","other","Inpatient DRG"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","","","","inpatient","","","172439.51","129329.63","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","34012.19","","Case rate ($34,706.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,702.15, add-ons for qualifying new technology services are included. If operating cost exceeds $87,346.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,468.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $31,298.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,322.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,027.93. The transfer capital threshold is the transfer adjustment factor * $3,027.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","34277.54","34277.54","34277.54","1 through 10","34012.19","57683.8384","other","Inpatient DRG"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","","","","inpatient","","","172439.51","129329.63","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","34012.19","","Case rate ($34,706.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,702.15, add-ons for qualifying new technology services are included. If operating cost exceeds $87,346.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,468.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $31,298.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,322.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,027.93. The transfer capital threshold is the transfer adjustment factor * $3,027.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","33298.11","33298.11","33298.11","1 through 10","34012.19","57683.8384","other","Inpatient DRG"
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","115.00","86.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","80.50","70","","80.64","80.64","80.64","1 through 10","6.75","109.25","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","115.00","86.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","91.43","79.5","","88.14","59.14","88.14","100","6.75","109.25","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","115.00","86.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","61.30","53.3","","59.14","59.14","113.12","70","6.75","109.25","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","35.65","31","","34.61","34.61","103.83","1 through 10","6.75","109.25","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.98","36.5","","41.78","35.50","125.34","109","6.75","109.25","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44.05","38.3","","43.79","42.56","43.79","256","6.75","109.25","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","115.00","86.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","88.55","77","","84.45","84.45","84.45","1 through 10","6.75","109.25","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.34","42.9","","89.53","31.21","112.00","1 through 10","6.75","109.25","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","115.00","86.25","AETNA [1001]","HB AMC AETNA HMO","80.27","69.8","","75.82","53.54","87.36","147","7.1","93.98","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","115.00","86.25","AETNA [1001]","HB AMC AETNA PPO","92.46","80.4","","87.36","53.54","170.69","17","7.1","93.98","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","115.00","86.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","60.10","52.26","","69.31","24.75","69.31","1 through 10","7.1","93.98","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","115.00","86.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","93.98","81.72","","89.53","89.53","89.53","1 through 10","7.1","93.98","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","93.98","81.72","","89.53","29.87","112.00","1 through 10","7.1","93.98","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.98","81.72","","89.53","49.25","89.53","92","7.1","93.98","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","119.19","71.8","","115.60","11.89","346.80","38","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","108.90","65.6","","109.00","109.00","125.58","1 through 10","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","107.90","65","","104.65","85.01","104.65","1 through 10","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","116.20","70","","161.00","115.92","347.76","24","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","CHAMPVA [160001]","HB BWH TRICARE","157.70","95","","16.13","16.13","16.13","1 through 10","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","131.97","79.5","","126.71","85.01","126.71","1436","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","88.48","53.3","","85.01","85.01","255.03","873","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","127.82","77","","123.97","123.97","323.40","1 through 10","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","107.90","65","","104.65","103.35","136.50","15","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","131.97","79.5","","126.71","64.03","126.71","1 through 10","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","107.90","65","","15841.15","15841.15","15841.15","1 through 10","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","51.46","31","","49.75","49.75","149.25","75","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.59","36.5","","60.05","51.04","174.84","1701","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.58","38.3","","62.95","62.95","188.85","5664","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","MOLINA [1014]","HB BWH MOLINA","58.10","35","","26.57","26.57","79.71","43","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","127.82","77","","125.58","19.21","158.34","13","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","TRICARE [160005]","HB BWH TRICARE","157.70","95","","15.32","15.32","16.13","92","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","157.70","95","","13.39","13.39","13.39","1 through 10","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.21","42.9","","128.70","70.79","128.70","75","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","166.00","124.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.21","42.9","","70.79","70.79","128.70","19","13.12","157.7","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","166.00","124.50","AETNA [1001]","HB AMC AETNA HMO","115.87","69.8","","109.00","76.96","125.58","2138","13.81","135.66","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","166.00","124.50","AETNA [1001]","HB AMC AETNA PPO","133.46","80.4","","125.58","76.96","125.58","181","13.81","135.66","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","166.00","124.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","92.79","55.9","","84.36","84.36","168.72","1 through 10","13.81","135.66","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","166.00","124.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","86.75","52.26","","16.42","13.38","99.63","35","13.81","135.66","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","166.00","124.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","133.46","80.4","","80.50","80.50","125.58","15","13.81","135.66","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","166.00","124.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","135.66","81.72","","128.70","128.70","161.72","1 through 10","13.81","135.66","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","166.00","124.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","135.66","81.72","","128.70","70.79","128.70","73","13.81","135.66","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","166.00","124.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","135.66","81.72","","128.70","70.79","128.70","1363","13.81","135.66","percent of total billed charges",""
"Lipoprotein Electrophoresis Bld Qn","PX-30000555","CDM","83700","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.62","36.5","","57.69","57.69","57.69","1 through 10","11.03","178.6","percent of total billed charges",""
"Lipoprotein Electrophoresis Bld Qn","PX-30000555","CDM","83700","CPT","0301","RC","","","","outpatient","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","153.63","81.72","","145.49","145.49","145.49","1 through 10","11.62","153.63","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","both","","","109.00","81.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","86.66","79.5","","83.42","55.97","83.42","15","6.48","103.55","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","both","","","109.00","81.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","58.10","53.3","","55.97","55.97","55.97","1 through 10","6.48","103.55","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","both","","","109.00","81.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","39.79","36.5","","39.54","33.60","39.54","1 through 10","6.48","103.55","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","both","","","109.00","81.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","41.75","38.3","","41.45","41.45","124.35","47","6.48","103.55","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","both","","","109.00","81.75","TRICARE [160005]","HB BWH TRICARE","103.55","95","","7.57","7.57","7.97","1 through 10","6.48","103.55","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","outpatient","","","109.00","81.75","AETNA [1001]","HB AMC AETNA HMO","76.08","69.8","","71.76","50.67","82.68","14","6.82","89.07","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","outpatient","","","109.00","81.75","AETNA [1001]","HB AMC AETNA PPO","87.64","80.4","","82.68","82.68","82.68","1 through 10","6.82","89.07","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","outpatient","","","109.00","81.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","89.07","81.72","","84.74","35.47","84.74","11","6.82","89.07","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","167.00","182.84","19","53.32","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","111.80","65","","108.55","88.18","108.55","1 through 10","53.32","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","120.40","70","","120.24","120.24","120.24","1 through 10","53.32","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","232.23","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","163.66","163.66","163.66","1 through 10","53.32","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","136.74","79.5","","131.43","88.18","131.49","30","53.32","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","91.68","53.3","","88.18","88.18","131.43","19","53.32","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","164.33","145.85","182.76","1 through 10","53.32","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","132.44","77","","128.59","128.59","128.59","1 through 10","53.32","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","111.80","65","","90.35","90.35","90.35","1 through 10","53.32","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","136.74","79.5","","131.43","131.43","131.43","1 through 10","53.32","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","166","53.32","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","53.32","31","","51.60","51.60","51.60","1 through 10","53.32","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","62.78","36.5","","62.29","52.94","62.29","34","53.32","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","65.88","38.3","","65.30","65.30","65.30","97","53.32","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","182.09","554.11","1 through 10","53.32","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","546.87","182.09","546.87","1 through 10","53.32","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","73.79","42.9","","133.50","73.43","133.50","1 through 10","53.32","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.84","182.09","185.44","47","53.32","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","both","","","172.00","129.00","WELLPOINT [1015]","HB AMC WELLPOINT","126.90","73.78","","124.33","124.33","124.33","22","53.32","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","outpatient","","","172.00","129.00","AETNA [1001]","HB AMC AETNA HMO","120.06","69.8","","113.06","79.83","113.06","1 through 10","89.89","520.69","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","outpatient","","","172.00","129.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","89.89","52.26","","103.34","103.34","103.34","1 through 10","89.89","520.69","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","outpatient","","","172.00","129.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","138.29","80.4","","83.50","83.50","83.50","1 through 10","89.89","520.69","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","outpatient","","","172.00","129.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","140.56","81.72","","133.50","133.50","133.50","1 through 10","89.89","520.69","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-75000428","CDM","91200","CPT","0750","RC","","","","outpatient","","","172.00","129.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","140.56","81.72","","133.50","73.43","133.50","24","89.89","520.69","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","167.00","182.84","19","19.84","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","41.60","65","","108.55","88.18","108.55","1 through 10","19.84","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","44.80","70","","120.24","120.24","120.24","1 through 10","19.84","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","232.23","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","163.66","163.66","163.66","1 through 10","19.84","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","50.88","79.5","","131.43","88.18","131.49","30","19.84","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","34.11","53.3","","88.18","88.18","131.43","19","19.84","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","164.33","145.85","182.76","1 through 10","19.84","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","49.28","77","","128.59","128.59","128.59","1 through 10","19.84","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","41.60","65","","90.35","90.35","90.35","1 through 10","19.84","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","50.88","79.5","","131.43","131.43","131.43","1 through 10","19.84","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","166","19.84","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","19.84","31","","51.60","51.60","51.60","1 through 10","19.84","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.36","36.5","","62.29","52.94","62.29","34","19.84","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.51","38.3","","65.30","65.30","65.30","97","19.84","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","182.09","554.11","1 through 10","19.84","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","546.87","182.09","546.87","1 through 10","19.84","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.46","42.9","","133.50","73.43","133.50","1 through 10","19.84","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.84","182.09","185.44","47","19.84","232.23","other","OPPS APC"
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","both","","","64.00","48.00","WELLPOINT [1015]","HB AMC WELLPOINT","47.22","73.78","","124.33","124.33","124.33","22","19.84","232.23","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","outpatient","","","64.00","48.00","AETNA [1001]","HB AMC AETNA HMO","44.67","69.8","","113.06","79.83","113.06","1 through 10","35.78","520.69","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","outpatient","","","64.00","48.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","51.46","80.4","","83.50","83.50","83.50","1 through 10","35.78","520.69","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","outpatient","","","64.00","48.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","52.30","81.72","","133.50","133.50","133.50","1 through 10","35.78","520.69","percent of total billed charges",""
"Liver Elastography W/O Imag W/I&R","PX-98302350","CDM","91200","CPT","0983","RC","","","","outpatient","","","64.00","48.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","52.30","81.72","","133.50","73.43","133.50","24","35.78","520.69","percent of total billed charges",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","","","","inpatient","","","108363.37","81272.53","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","21736.08","","Case rate ($21,736.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,188.86, add-ons for qualifying new technology services are included. If operating cost exceeds $65,833.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,891.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,904.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,809.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.52. The transfer capital threshold is the transfer adjustment factor * $1,451.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36295.06","36295.06","36295.06","1 through 10","16498.51","28256.29","other","Inpatient DRG"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","","","","inpatient","","","108363.37","81272.53","MEDICARE [2001]","HB BWH MEDICARE","21736.08","","Case rate ($21,736.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,188.86, add-ons for qualifying new technology services are included. If operating cost exceeds $65,833.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,891.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,904.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,809.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.52. The transfer capital threshold is the transfer adjustment factor * $1,451.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23538.29","22846.28","23573.08","1 through 10","16498.51","28256.29","other","Inpatient DRG"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","","","","inpatient","","","108363.37","81272.53","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16498.51","","Case rate ($16,835.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,188.86, add-ons for qualifying new technology services are included. If operating cost exceeds $65,833.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,891.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,003.84 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,809.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.52. The transfer capital threshold is the transfer adjustment factor * $1,451.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25570.18","25570.18","25570.18","1 through 10","16498.51","28256.29","other","Inpatient DRG"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With McC","495","MS-DRG","","","","","","","","inpatient","","","130237.21","97677.91","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","34457.50","","Case rate ($33,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,194.44, add-ons for qualifying new technology services are included. If operating cost exceeds $85,838.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,357.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $30,156.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,814.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,917.45. The transfer capital threshold is the transfer adjustment factor * $2,917.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","33168.44","33168.44","33168.44","1 through 10","32784.8","53129.3746","other","Inpatient DRG"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With McC","495","MS-DRG","","","","","","","","inpatient","","","130237.21","97677.91","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","33453.88","","Case rate ($33,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,194.44, add-ons for qualifying new technology services are included. If operating cost exceeds $85,838.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,357.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $30,156.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,814.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,917.45. The transfer capital threshold is the transfer adjustment factor * $2,917.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","32386.86","32386.86","32386.86","1 through 10","32784.8","53129.3746","other","Inpatient Replacement Plans DRG"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With McC","495","MS-DRG","","","","","","","","inpatient","","","130237.21","97677.91","MEDICARE [2001]","HB BWH MEDICARE","33453.88","","Case rate ($33,453.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,194.44, add-ons for qualifying new technology services are included. If operating cost exceeds $85,838.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,357.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $30,156.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,814.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,917.45. The transfer capital threshold is the transfer adjustment factor * $2,917.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","41845.25","41845.25","41845.25","1 through 10","32784.8","53129.3746","other","Inpatient Replacement Plans DRG"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/McC","497","MS-DRG","","","","","","","","inpatient","","","89258.00","66943.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11174.05","","Case rate ($11,402.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,648.44, add-ons for qualifying new technology services are included. If operating cost exceeds $59,292.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,412.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,049.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,268.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $972.27. The transfer capital threshold is the transfer adjustment factor * $972.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12231.94","12231.94","12231.94","1 through 10","11174.05","18926.81","other","Inpatient DRG"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/McC","498","MS-DRG","","","","","","","","inpatient","","","136503.49","102377.62","MEDICARE [2001]","HB BWH MEDICARE","36095.50","","Case rate ($36,095.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $33,507.97, add-ons for qualifying new technology services are included. If operating cost exceeds $79,152.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,867.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $33,288.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $33,128.13 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,427.49. The transfer capital threshold is the transfer adjustment factor * $2,427.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30044.73","0.03","115387.51","1 through 10","27341.41","38103.2659","other","Inpatient DRG"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/McC","499","MS-DRG","","","","","","","","inpatient","","","90407.22","67805.41","MEDICARE [2001]","HB BWH MEDICARE","24232.90","","Case rate ($24,232.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,504.80, add-ons for qualifying new technology services are included. If operating cost exceeds $68,149.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,061.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $22,231.84 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,124.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,621.23. The transfer capital threshold is the transfer adjustment factor * $1,621.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7101.07","7101.07","7101.07","1 through 10","17517.6328","24232.9","other","Inpatient DRG"
"LOCKING SCREW 4.5 X 14MM BLUNT TIP COCR","SUP-ITM-10326968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","834.75","79.5","","800.18","480.96","1887.97","195","325.5","834.75","percent of total billed charges",""
"LOCKING SCREW 4.5 X 14MM BLUNT TIP COCR","SUP-ITM-10326968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","559.65","53.3","","813.12","216.42","1444.50","81","325.5","834.75","percent of total billed charges",""
"LOCKING SCREW 4.5 X 14MM BLUNT TIP COCR","SUP-ITM-10326968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","325.50","31","","432.60","432.60","432.60","1 through 10","325.5","834.75","percent of total billed charges",""
"LOCKING SCREW 4.5 X 14MM BLUNT TIP COCR","SUP-ITM-10326968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","148.37","54.89","631.39","94","325.5","834.75","percent of total billed charges",""
"LOCKING SCREW 4.5 X 14MM BLUNT TIP COCR","SUP-ITM-10326968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","279.30","91.72","1116.77","266","325.5","834.75","percent of total billed charges",""
"LOCKING SCREW 4.5 X 14MM BLUNT TIP COCR","SUP-ITM-10326968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","731.00","63.70","731.00","1 through 10","325.5","834.75","percent of total billed charges",""
"LOCKING SCREW 4.5 X 14MM BLUNT TIP COCR","SUP-ITM-10326968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","384.74","384.74","384.74","1 through 10","325.5","834.75","percent of total billed charges",""
"LOCKING SCREW 4.5 X 14MM BLUNT TIP COCR","SUP-ITM-10326968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB AMC WELLPOINT","774.69","73.78","","286.63","119.22","1107.45","105","325.5","834.75","percent of total billed charges",""
"LOCKING SCREW 4.5 X 14MM BLUNT TIP COCR","SUP-ITM-10326968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA HMO","732.90","69.8","","675.31","184.75","1721.50","286","548.73","858.06","percent of total billed charges",""
"LOCKING SCREW 4.5 X 14MM BLUNT TIP COCR","SUP-ITM-10326968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA PPO","844.20","80.4","","1261.44","103.12","1514.10","21","548.73","858.06","percent of total billed charges",""
"LOCKING SCREW 4.5 X 14MM BLUNT TIP COCR","SUP-ITM-10326968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","844.20","80.4","","1365.00","1365.00","1365.00","1 through 10","548.73","858.06","percent of total billed charges",""
"LOCKING SCREW 4.5 X 14MM BLUNT TIP COCR","SUP-ITM-10326968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","858.06","81.72","","5157.68","5157.68","5157.68","1 through 10","548.73","858.06","percent of total billed charges",""
"LOCKING SCREW 4.5 X 14MM BLUNT TIP COCR","SUP-ITM-10326968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","858.06","81.72","","431.26","71.26","1459.57","88","548.73","858.06","percent of total billed charges",""
"LOCKING SCREW 4.5 X 42MM COCR","SUP-ITM-10326984","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","800.18","480.96","1887.97","195","260.4","667.8","percent of total billed charges",""
"LOCKING SCREW 4.5 X 42MM COCR","SUP-ITM-10326984","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","813.12","216.42","1444.50","81","260.4","667.8","percent of total billed charges",""
"LOCKING SCREW 4.5 X 42MM COCR","SUP-ITM-10326984","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","260.40","31","","432.60","432.60","432.60","1 through 10","260.4","667.8","percent of total billed charges",""
"LOCKING SCREW 4.5 X 42MM COCR","SUP-ITM-10326984","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","148.37","54.89","631.39","94","260.4","667.8","percent of total billed charges",""
"LOCKING SCREW 4.5 X 42MM COCR","SUP-ITM-10326984","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","279.30","91.72","1116.77","266","260.4","667.8","percent of total billed charges",""
"LOCKING SCREW 4.5 X 42MM COCR","SUP-ITM-10326984","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","731.00","63.70","731.00","1 through 10","260.4","667.8","percent of total billed charges",""
"LOCKING SCREW 4.5 X 42MM COCR","SUP-ITM-10326984","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","384.74","384.74","384.74","1 through 10","260.4","667.8","percent of total billed charges",""
"LOCKING SCREW 4.5 X 42MM COCR","SUP-ITM-10326984","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","286.63","119.22","1107.45","105","260.4","667.8","percent of total billed charges",""
"LOCKING SCREW 4.5 X 42MM COCR","SUP-ITM-10326984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","675.31","184.75","1721.50","286","438.98","686.45","percent of total billed charges",""
"LOCKING SCREW 4.5 X 42MM COCR","SUP-ITM-10326984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA PPO","675.36","80.4","","1261.44","103.12","1514.10","21","438.98","686.45","percent of total billed charges",""
"LOCKING SCREW 4.5 X 42MM COCR","SUP-ITM-10326984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1365.00","1365.00","1365.00","1 through 10","438.98","686.45","percent of total billed charges",""
"LOCKING SCREW 4.5 X 42MM COCR","SUP-ITM-10326984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","686.45","81.72","","5157.68","5157.68","5157.68","1 through 10","438.98","686.45","percent of total billed charges",""
"LOCKING SCREW 4.5 X 42MM COCR","SUP-ITM-10326984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","431.26","71.26","1459.57","88","438.98","686.45","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml","PX-63601202","CDM","Q9966","HCPCS","0636","RC","","","","both","","","1.40","1.05","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.98","70","","2.71","2.71","2.71","105","0.43","1.08","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml","PX-63601202","CDM","Q9966","HCPCS","0636","RC","","","","both","","","1.40","1.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.91","65","","1.74","1.74","1.74","501","0.43","1.08","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml","PX-63601202","CDM","Q9966","HCPCS","0636","RC","","","","both","","","1.40","1.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.43","31","","0.12","0.12","0.12","201","0.43","1.08","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml","PX-63601202","CDM","Q9966","HCPCS","0636","RC","","","","both","","","1.40","1.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.51","36.5","","1.00","0.85","10.31","3510","0.43","1.08","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml","PX-63601202","CDM","Q9966","HCPCS","0636","RC","","","","both","","","1.40","1.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.54","38.3","","1.06","0.24","1.19","1286","0.43","1.08","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml","PX-63601202","CDM","Q9966","HCPCS","0636","RC","","","","outpatient","","","1.40","1.05","AETNA [1001]","HB AMC AETNA HMO","0.98","69.8","","1.81","1.31","2.10","1374","0.66","1.13","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml","PX-63601202","CDM","Q9966","HCPCS","0636","RC","","","","outpatient","","","1.40","1.05","AETNA [1001]","HB AMC AETNA PPO","1.13","80.4","","2.38","2.38","2.38","50","0.66","1.13","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml","PX-63601202","CDM","Q9966","HCPCS","0636","RC","","","","outpatient","","","1.40","1.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.98","69.9","","2.32","2.32","144.15","1 through 10","0.66","1.13","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml (Newborn Referral)","PX-63601198","CDM","Q9966","HCPCS","0636","RC","","","","both","","","10.00","7.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","7.00","70","","2.71","2.71","2.71","105","1","7.7","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml (Newborn Referral)","PX-63601198","CDM","Q9966","HCPCS","0636","RC","","","","both","","","10.00","7.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6.50","65","","1.74","1.74","1.74","501","1","7.7","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml (Newborn Referral)","PX-63601198","CDM","Q9966","HCPCS","0636","RC","","","","both","","","10.00","7.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3.10","31","","0.12","0.12","0.12","201","1","7.7","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml (Newborn Referral)","PX-63601198","CDM","Q9966","HCPCS","0636","RC","","","","both","","","10.00","7.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3.65","36.5","","1.00","0.85","10.31","3510","1","7.7","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml (Newborn Referral)","PX-63601198","CDM","Q9966","HCPCS","0636","RC","","","","both","","","10.00","7.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3.83","38.3","","1.06","0.24","1.19","1286","1","7.7","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml (Newborn Referral)","PX-63601198","CDM","Q9966","HCPCS","0636","RC","","","","outpatient","","","10.00","7.50","AETNA [1001]","HB AMC AETNA HMO","6.98","69.8","","1.81","1.31","2.10","1374","0.97","8.04","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml (Newborn Referral)","PX-63601198","CDM","Q9966","HCPCS","0636","RC","","","","outpatient","","","10.00","7.50","AETNA [1001]","HB AMC AETNA PPO","8.04","80.4","","2.38","2.38","2.38","50","0.97","8.04","percent of total billed charges",""
"Locm 200-299mg/Ml Iodine,1ml (Newborn Referral)","PX-63601198","CDM","Q9966","HCPCS","0636","RC","","","","outpatient","","","10.00","7.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6.99","69.9","","2.32","2.32","144.15","1 through 10","0.97","8.04","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.67","0.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.48","71.8","","2.83","2.83","2.83","50","0.21","0.52","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.67","0.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.44","65.6","","2.45","1.73","3.07","426","0.21","0.52","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.67","0.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.47","70","","2.87","1.69","7.83","859","0.21","0.52","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.67","0.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.44","65","","256.09","192.07","1790.10","1 through 10","0.21","0.52","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.67","0.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.21","31","","1.12","0.11","3.36","780","0.21","0.52","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.67","0.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.24","36.5","","1.35","1.15","2.60","22835","0.21","0.52","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.67","0.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.26","38.3","","1.42","1.38","1.54","53934","0.21","0.52","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","both","","","0.67","0.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.52","77","","2.83","2.83","2.83","83","0.21","0.52","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.67","0.50","AETNA [1001]","HB AMC AETNA HMO","0.47","69.8","","1.88","0.17","2.83","37600","0.31","0.54","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.67","0.50","AETNA [1001]","HB AMC AETNA PPO","0.54","80.4","","2.83","0.28","3.80","3073","0.31","0.54","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.67","0.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","0.35","52.26","","2.24","2.24","2.24","305","0.31","0.54","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.67","0.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.47","69.9","","2.51","1.94","2.78","794","0.31","0.54","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.67","0.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.31","46.9","","1.68","0.01","1.68","269","0.31","0.54","percent of total billed charges",""
"Locm 300-399mg/Ml Iodine,1ml","PX-63601097","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","0.67","0.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.54","80.4","","2.83","2.83","2.83","269","0.31","0.54","percent of total billed charges",""
"Lorazepam Vl 2mg/Ml 1ml","PX-63600145","CDM","J2060","HCPCS","0636","RC","","","","both","","","3.10","2.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2.02","65","","2.71","2.71","2.71","1 through 10","0.96","2.48","percent of total billed charges",""
"Lorazepam Vl 2mg/Ml 1ml","PX-63600145","CDM","J2060","HCPCS","0636","RC","","","","both","","","3.10","2.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1.19","38.3","","0.76","0.76","0.76","1 through 10","0.96","2.48","percent of total billed charges",""
"Lorazepam Vl 2mg/Ml 1ml","PX-63600145","CDM","J2060","HCPCS","0636","RC","","","","outpatient","","","3.10","2.32","AETNA [1001]","HB AMC AETNA HMO","2.16","69.8","","0.98","0.93","0.98","1 through 10","1.45","2.84","percent of total billed charges",""
"Lorazepam Vl 2mg/Ml 1ml","PX-63600145","CDM","J2060","HCPCS","0636","RC","","","","outpatient","","","3.10","2.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2.17","69.9","","0.68","0.68","0.68","1 through 10","1.45","2.84","percent of total billed charges",""
"Lorazepam Vl 2mg/Ml 1ml","PX-63600145","CDM","J2060","HCPCS","0636","RC","","","","outpatient","","","3.10","2.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1.45","46.9","","2.62","2.62","2.62","1 through 10","1.45","2.84","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","130.06","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","129.95","129.95","129.95","57","119.97","727.65","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","44","119.97","727.65","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","661.50","70","","649.00","649.00","649.00","1 through 10","119.97","727.65","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","104.21","123.76","13","119.97","727.65","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","117.59","123.76","1 through 10","119.97","727.65","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","185","119.97","727.65","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","344.93","36.5","","341.67","290.37","341.67","1 through 10","119.97","727.65","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","361.94","38.3","","358.16","358.16","358.16","40","119.97","727.65","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","117.59","376.34","29","119.97","727.65","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","MOLINA [1014]","HB BWH MOLINA","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","250.05","250.05","250.05","1 through 10","119.97","727.65","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","372.42","17","119.97","727.65","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","123.76","123.77","126","119.97","727.65","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","WELLPOINT [1015]","HB AMC WELLPOINT","697.22","73.78","","681.96","681.96","681.96","16","119.97","727.65","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","945.00","708.75","WELLSENSE [1003]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","127.55","127.55","127.55","1 through 10","119.97","727.65","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","945.00","708.75","AETNA [1001]","HB AMC AETNA HMO","659.61","69.8","","437.85","437.85","714.48","31","296.54","779.63","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","945.00","708.75","AETNA [1001]","HB AMC AETNA PPO","759.78","80.4","","437.85","437.85","437.85","1 through 10","296.54","779.63","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","945.00","708.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","493.86","52.26","","337.13","337.13","337.13","1 through 10","296.54","779.63","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","945.00","708.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","496.13","52.5","","599.98","599.98","599.98","1 through 10","296.54","779.63","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","945.00","708.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","472.50","50","","479.98","479.98","904.09","40","296.54","779.63","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","945.00","708.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","496.13","52.5","","949.89","484.56","949.89","1 through 10","296.54","779.63","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","945.00","708.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","519.75","55","","527.62","507.46","527.62","1 through 10","296.54","779.63","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","296.54","31.38","","281.21","281.21","402.77","1 through 10","296.54","779.63","percent of total billed charges",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","130743.65","98057.74","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","24219.84","","Case rate ($23,514.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,229.31, add-ons for qualifying new technology services are included. If operating cost exceeds $73,873.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,480.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,093.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,849.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,040.69. The transfer capital threshold is the transfer adjustment factor * $2,040.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","22794.77","22794.77","22794.77","1 through 10","23044.12","36233.491","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","130743.65","98057.74","MEDICARE [2001]","HB BWH MEDICARE","23514.41","","Case rate ($23,514.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,229.31, add-ons for qualifying new technology services are included. If operating cost exceeds $73,873.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,480.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,093.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,849.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,040.69. The transfer capital threshold is the transfer adjustment factor * $2,040.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28584.04","24575.42","28626.37","15","23044.12","36233.491","other","Inpatient Replacement Plans DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","130743.65","98057.74","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","23044.12","","Case rate ($23,514.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,229.31, add-ons for qualifying new technology services are included. If operating cost exceeds $73,873.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,480.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,093.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,849.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,040.69. The transfer capital threshold is the transfer adjustment factor * $2,040.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21630.01","21630.01","21630.01","1 through 10","23044.12","36233.491","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","130743.65","98057.74","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","23044.12","","Case rate ($23,514.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,229.31, add-ons for qualifying new technology services are included. If operating cost exceeds $73,873.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,480.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,093.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,849.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,040.69. The transfer capital threshold is the transfer adjustment factor * $2,040.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","30006.12","30006.12","39903.52","1 through 10","23044.12","36233.491","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","130743.65","98057.74","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","23044.12","","Case rate ($23,514.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,229.31, add-ons for qualifying new technology services are included. If operating cost exceeds $73,873.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,480.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,093.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,849.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,040.69. The transfer capital threshold is the transfer adjustment factor * $2,040.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21698.48","21698.48","21728.30","1 through 10","23044.12","36233.491","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","130743.65","98057.74","WELLPOINT [1015]","HB AMC WELLPOINT","36233.491","","Fee schedule rate ($39,725.47).","36233.491","75325.35","75325.35","1 through 10","23044.12","36233.491","case rate",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With McC","492","MS-DRG","","","","","","","","inpatient","","","176651.01","132488.26","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","42340.71","","Case rate ($33,872.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,698.48, add-ons for qualifying new technology services are included. If operating cost exceeds $86,342.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,394.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $30,538.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $40,318.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,954.38. The transfer capital threshold is the transfer adjustment factor * $2,954.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","37038.15","37038.15","37038.15","1 through 10","33195.12","53591.1592","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With McC","492","MS-DRG","","","","","","","","inpatient","","","176651.01","132488.26","MEDICARE [2001]","HB BWH MEDICARE","33872.57","","Case rate ($33,872.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,698.48, add-ons for qualifying new technology services are included. If operating cost exceeds $86,342.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,394.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $30,538.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $40,318.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,954.38. The transfer capital threshold is the transfer adjustment factor * $2,954.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","42143.94","33896.39","42206.55","13","33195.12","53591.1592","other","Inpatient Replacement Plans DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With McC","492","MS-DRG","","","","","","","","inpatient","","","176651.01","132488.26","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","33195.12","","Case rate ($33,872.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,698.48, add-ons for qualifying new technology services are included. If operating cost exceeds $86,342.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,394.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $30,538.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $40,318.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,954.38. The transfer capital threshold is the transfer adjustment factor * $2,954.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","32123.06","32123.06","32154.22","1 through 10","33195.12","53591.1592","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/McC","494","MS-DRG","","","","","","","","inpatient","","","104886.86","78665.14","MEDICARE [2001]","HB BWH MEDICARE","18683.35","","Case rate ($18,683.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,413.65, add-ons for qualifying new technology services are included. If operating cost exceeds $68,058.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,054.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,688.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,033.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,614.55. The transfer capital threshold is the transfer adjustment factor * $1,614.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22505.54","0.03","22505.54","1 through 10","18309.68","31429.82","other","Inpatient Replacement Plans DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/McC","494","MS-DRG","","","","","","","","inpatient","","","104886.86","78665.14","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","18309.68","","Case rate ($18,683.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,413.65, add-ons for qualifying new technology services are included. If operating cost exceeds $68,058.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,054.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,688.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,033.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,614.55. The transfer capital threshold is the transfer adjustment factor * $1,614.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17113.01","17113.01","17113.01","1 through 10","18309.68","31429.82","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/McC","494","MS-DRG","","","","","","","","inpatient","","","104886.86","78665.14","WELLPOINT [1015]","HB AMC WELLPOINT","31429.82","","Fee schedule rate ($31,429.82).","58111.14","58111.14","58111.14","1 through 10","18309.68","31429.82","case rate",""
"Lower Vascular Procedures,EXTREME","181","DRG","","","","","","","","inpatient","","","329883.73","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","162904.85","","Standard inlier is a Case rate ($162,904.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $138,329, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($23,125.33) for the length of stay and the standard reimbursement.","162904.85","162904.85","162904.85","1 through 10","15555.6","221645.95","case rate",""
"Lower Vascular Procedures,EXTREME","181","DRG","","","","","","","","inpatient","","","329883.73","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","53201.13","","Case rate ($58,822.99). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $101,252.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","130.74","130.74","130.74","1 through 10","15555.6","221645.95","case rate",""
"Lower Vascular Procedures,MAJOR","181","DRG","","","","","","","","inpatient","","","190847.48","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","104487.30","","Standard inlier is a Case rate ($104,487.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $92,902, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,832.60) for the length of stay and the standard reimbursement.","104487.30","104487.30","104487.30","1 through 10","15555.6","221645.95","case rate",""
"Lower Vascular Procedures,MAJOR","181","DRG","","","","","","","","inpatient","","","190847.48","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","117471.89","","Standard inlier is a Case rate ($117,471.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $92,902, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,674.16) for the length of stay and the standard reimbursement.","117471.88","117471.88","117471.88","1 through 10","15555.6","221645.95","case rate",""
"Lower Vascular Procedures,MAJOR","181","DRG","","","","","","","","inpatient","","","190847.48","","MASSHEALTH [3001]","HB BWH MEDICAID","31416.21","","Case rate ($34,736.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $77,166.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22191.64","22191.64","22191.64","1 through 10","15555.6","221645.95","case rate",""
"Lower Vascular Procedures,MINOR","181","DRG","","","","","","","","inpatient","","","90412.41","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","48650.57","","Standard inlier is a Case rate ($48,650.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,480, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,906.24) for the length of stay and the standard reimbursement.","48650.56","48650.56","48650.56","1 through 10","15555.6","221645.95","case rate",""
"Lower Vascular Procedures,MINOR","181","DRG","","","","","","","","inpatient","","","90412.41","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","54696.35","","Standard inlier is a Case rate ($54,696.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,480, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,763.69) for the length of stay and the standard reimbursement.","49969.83","49969.83","54696.34","1 through 10","15555.6","221645.95","case rate",""
"Lower Vascular Procedures,MODERATE","181","DRG","","","","","","","","inpatient","","","102157.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","67233.70","","Standard inlier is a Case rate ($67,233.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,932, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,544.23) for the length of stay and the standard reimbursement.","67233.70","67233.70","67233.70","1 through 10","15555.6","221645.95","case rate",""
"Lower Vascular Procedures,MODERATE","181","DRG","","","","","","","","inpatient","","","102157.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","75588.80","","Standard inlier is a Case rate ($75,588.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,932, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,729.20) for the length of stay and the standard reimbursement.","75588.80","75588.80","75588.80","1 through 10","15555.6","221645.95","case rate",""
"Lso Belt Lumbosacral Ots T1","PX-27000279","CDM","L0625","HCPCS","0274","RC","","","","both","","","159.92","119.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.25","38.3","","62.53","62.53","62.53","1 through 10","40.84","151.92","percent of total billed charges",""
"Lso Belt Lumbosacral Ots T1","PX-27000279","CDM","L0625","HCPCS","0274","RC","","","","outpatient","","","159.92","119.94","AETNA [1001]","HB AMC AETNA HMO","111.62","69.8","","75.80","75.80","75.80","1 through 10","79.96","134.49","percent of total billed charges",""
"Lso Belt Lumbosacral Ots T1","PX-27000279","CDM","L0625","HCPCS","0274","RC","","","","outpatient","","","159.92","119.94","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","79.96","50","","83.80","83.80","83.80","1 through 10","79.96","134.49","percent of total billed charges",""
"Lso Belt Lumbosacral Ots T1","PX-27000279","CDM","L0625","HCPCS","0274","RC","","","","outpatient","","","159.92","119.94","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","83.96","52.5","","87.96","87.96","87.96","1 through 10","79.96","134.49","percent of total billed charges",""
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","31145.00","23358.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3758.57","3758.57","6662.57","1 through 10","3628.7","24760.28","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","31145.00","23358.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","22362.11","71.8","","3067.56","3067.56","3067.56","1 through 10","3628.7","24760.28","percent of total billed charges",""
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","31145.00","23358.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24760.28","79.5","","25643.75","23769.76","25643.75","1 through 10","3628.7","24760.28","percent of total billed charges",""
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","31145.00","23358.75","MEDICARE [2001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3819.68","3819.68","6770.90","25","3628.7","24760.28","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","31145.00","23358.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11367.93","36.5","","11265.72","11265.72","11265.72","1 through 10","3628.7","24760.28","percent of total billed charges",""
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","31145.00","23358.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11928.54","38.3","","11809.37","11477.14","11809.37","1 through 10","3628.7","24760.28","percent of total billed charges",""
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","31145.00","23358.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3743.29","3485.74","3743.29","1 through 10","3628.7","24760.28","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","31145.00","23358.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","19907.64","19907.64","19907.64","1 through 10","3628.7","24760.28","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","31145.00","23358.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3750.99","3743.29","6642.99","1 through 10","3628.7","24760.28","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","outpatient","","","31145.00","23358.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","11281.00","11281.00","11281.00","1 through 10","2529.37","25451.69","other","Multiple Surgery"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","outpatient","","","31145.00","23358.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","6475.19","6475.19","6475.19","1 through 10","2529.37","25451.69","other","Multiple Surgery"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","outpatient","","","31145.00","23358.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","25451.69","81.72","","24144.28","24144.28","24144.28","1 through 10","2529.37","25451.69","percent of total billed charges",""
"Lucentad P-Tau 217","PX-30003879","CDM","84393","CPT","0300","RC","","","","both","","","608.00","456.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","483.36","79.5","","1652.70","1652.70","1652.70","1 through 10","188.48","577.6","percent of total billed charges",""
"Lucentad P-Tau 217","PX-30003879","CDM","84393","CPT","0300","RC","","","","outpatient","","","608.00","456.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","380.00","62.5","","455.00","455.00","455.00","1 through 10","243.2","501.6","percent of total billed charges",""
"LUMBAR CAGE 17X14 5MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086906","CDM","C1713","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3875.63","79.5","","800.18","480.96","1887.97","195","1511.25","3875.63","percent of total billed charges",""
"LUMBAR CAGE 17X14 5MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086906","CDM","C1713","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2598.38","53.3","","813.12","216.42","1444.50","81","1511.25","3875.63","percent of total billed charges",""
"LUMBAR CAGE 17X14 5MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086906","CDM","C1713","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1511.25","31","","432.60","432.60","432.60","1 through 10","1511.25","3875.63","percent of total billed charges",""
"LUMBAR CAGE 17X14 5MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086906","CDM","C1713","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1779.38","36.5","","148.37","54.89","631.39","94","1511.25","3875.63","percent of total billed charges",""
"LUMBAR CAGE 17X14 5MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086906","CDM","C1713","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1867.13","38.3","","279.30","91.72","1116.77","266","1511.25","3875.63","percent of total billed charges",""
"LUMBAR CAGE 17X14 5MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086906","CDM","C1713","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2091.38","42.9","","731.00","63.70","731.00","1 through 10","1511.25","3875.63","percent of total billed charges",""
"LUMBAR CAGE 17X14 5MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086906","CDM","C1713","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2091.38","42.9","","384.74","384.74","384.74","1 through 10","1511.25","3875.63","percent of total billed charges",""
"LUMBAR CAGE 17X14 5MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086906","CDM","C1713","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","WELLPOINT [1015]","HB AMC WELLPOINT","3596.78","73.78","","286.63","119.22","1107.45","105","1511.25","3875.63","percent of total billed charges",""
"LUMBAR CAGE 17X14 5MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4875.00","3656.25","AETNA [1001]","HB AMC AETNA HMO","3402.75","69.8","","675.31","184.75","1721.50","286","2547.68","3983.85","percent of total billed charges",""
"LUMBAR CAGE 17X14 5MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4875.00","3656.25","AETNA [1001]","HB AMC AETNA PPO","3919.50","80.4","","1261.44","103.12","1514.10","21","2547.68","3983.85","percent of total billed charges",""
"LUMBAR CAGE 17X14 5MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4875.00","3656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3919.50","80.4","","1365.00","1365.00","1365.00","1 through 10","2547.68","3983.85","percent of total billed charges",""
"LUMBAR CAGE 17X14 5MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4875.00","3656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3983.85","81.72","","5157.68","5157.68","5157.68","1 through 10","2547.68","3983.85","percent of total billed charges",""
"LUMBAR CAGE 17X14 5MM COROENT PEEK LORDOTIC SI","SUP-ITM-10086906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4875.00","3656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3983.85","81.72","","431.26","71.26","1459.57","88","2547.68","3983.85","percent of total billed charges",""
"LUMBAR PLATE 21MM AEGIS TITANIUM","SUP-ITM-10168038","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1309.77","674.56","6049.93","26","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 21MM AEGIS TITANIUM","SUP-ITM-10168038","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","1901.83","1901.83","2962.25","1 through 10","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 21MM AEGIS TITANIUM","SUP-ITM-10168038","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1620.31","1620.31","19908.88","1 through 10","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 21MM AEGIS TITANIUM","SUP-ITM-10168038","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","352.91","352.91","2046.30","1 through 10","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 21MM AEGIS TITANIUM","SUP-ITM-10168038","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","9668.75","9668.75","9668.75","1 through 10","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 21MM AEGIS TITANIUM","SUP-ITM-10168038","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","699.88","384.10","3443.31","33","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 21MM AEGIS TITANIUM","SUP-ITM-10168038","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1421.24","264.50","4933.46","29","2743.65","4290.3","percent of total billed charges",""
"LUMBAR PLATE 21MM AEGIS TITANIUM","SUP-ITM-10168038","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4221.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2743.65","4290.3","percent of total billed charges",""
"LUMBAR PLATE 21MM AEGIS TITANIUM","SUP-ITM-10168038","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","3010.54","693.88","5019.88","35","2743.65","4290.3","percent of total billed charges",""
"LUMBAR PLATE 25MM AEGIS TITANIUM","SUP-ITM-10179292","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","800.18","480.96","1887.97","195","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 25MM AEGIS TITANIUM","SUP-ITM-10179292","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","813.12","216.42","1444.50","81","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 25MM AEGIS TITANIUM","SUP-ITM-10179292","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1627.50","31","","432.60","432.60","432.60","1 through 10","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 25MM AEGIS TITANIUM","SUP-ITM-10179292","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","148.37","54.89","631.39","94","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 25MM AEGIS TITANIUM","SUP-ITM-10179292","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","279.30","91.72","1116.77","266","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 25MM AEGIS TITANIUM","SUP-ITM-10179292","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","731.00","63.70","731.00","1 through 10","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 25MM AEGIS TITANIUM","SUP-ITM-10179292","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","384.74","384.74","384.74","1 through 10","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 25MM AEGIS TITANIUM","SUP-ITM-10179292","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","286.63","119.22","1107.45","105","1627.5","4173.75","percent of total billed charges",""
"LUMBAR PLATE 25MM AEGIS TITANIUM","SUP-ITM-10179292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","675.31","184.75","1721.50","286","2743.65","4290.3","percent of total billed charges",""
"LUMBAR PLATE 25MM AEGIS TITANIUM","SUP-ITM-10179292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA PPO","4221.00","80.4","","1261.44","103.12","1514.10","21","2743.65","4290.3","percent of total billed charges",""
"LUMBAR PLATE 25MM AEGIS TITANIUM","SUP-ITM-10179292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4221.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2743.65","4290.3","percent of total billed charges",""
"LUMBAR PLATE 25MM AEGIS TITANIUM","SUP-ITM-10179292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4290.30","81.72","","5157.68","5157.68","5157.68","1 through 10","2743.65","4290.3","percent of total billed charges",""
"LUMBAR PLATE 25MM AEGIS TITANIUM","SUP-ITM-10179292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","431.26","71.26","1459.57","88","2743.65","4290.3","percent of total billed charges",""
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","1261.00","945.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","635.10","634.70","635.10","1 through 10","390.91","1027.91","other","OPPS APC"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","1261.00","945.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","606.94","606.94","606.94","1 through 10","390.91","1027.91","other","OPPS APC"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","1261.00","945.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1002.50","79.5","","4262.39","645.74","4262.39","1 through 10","390.91","1027.91","percent of total billed charges",""
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","1261.00","945.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","672.11","53.3","","645.74","645.74","962.50","1 through 10","390.91","1027.91","percent of total billed charges",""
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","1261.00","945.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","806.96","806.96","806.96","1 through 10","390.91","1027.91","other","OPPS APC"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","1261.00","945.75","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","616.81","2467.23","22","390.91","1027.91","other","OPPS APC"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","1261.00","945.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","460.27","36.5","","456.18","387.69","456.18","1 through 10","390.91","1027.91","percent of total billed charges",""
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","1261.00","945.75","TRICARE [160005]","HB BWH TRICARE","781.29","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","585.97","585.97","585.97","1 through 10","390.91","1027.91","other","Tricare OPPS"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","1261.00","945.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","605.48","605.48","605.48","1 through 10","390.91","1027.91","other","OPPS APC"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","1261.00","945.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","616.81","608.40","822.41","1 through 10","390.91","1027.91","other","OPPS APC"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","1261.00","945.75","WELLPOINT [1015]","HB AMC WELLPOINT","930.37","73.78","","2133.52","2133.52","2133.52","1 through 10","390.91","1027.91","percent of total billed charges",""
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","outpatient","","","1261.00","945.75","AETNA [1001]","HB AMC AETNA HMO","880.18","69.8","","953.94","953.94","1655.94","1 through 10","598.81","2384.07","percent of total billed charges",""
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","outpatient","","","1261.00","945.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","700.52","687.85","1401.04","12","598.81","2384.07","other","ASC"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","outpatient","","","1261.00","945.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","801.53","793.65","1603.05","41","598.81","2384.07","other","ASC "
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","outpatient","","","1261.00","945.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1389.24","1389.24","1389.24","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","outpatient","","","1261.00","945.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1461.10","1461.10","1461.10","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","outpatient","","","1261.00","945.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","766.48","766.48","766.48","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","outpatient","","","1261.00","945.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1030.49","81.72","","1955.33","977.67","1955.33","1 through 10","598.81","2384.07","percent of total billed charges",""
"Lumbar Puncture Drain CSF Thrputic","PX-76001463","CDM","62272","CPT","0761","RC","","","","both","","","1258.00","943.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1000.11","79.5","","960.14","960.14","960.14","1 through 10","389.98","1027.91","percent of total billed charges",""
"Lumbar Puncture Drain CSF Thrputic","PX-76001463","CDM","62272","CPT","0761","RC","","","","both","","","1258.00","943.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","814.96","814.96","814.96","1 through 10","389.98","1027.91","other","OPPS APC"
"Lumbar Puncture Drain CSF Thrputic","PX-76001463","CDM","62272","CPT","0761","RC","","","","both","","","1258.00","943.50","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","616.81","822.41","13","389.98","1027.91","other","OPPS APC"
"Lumbar Puncture Drain CSF Thrputic","PX-76001463","CDM","62272","CPT","0761","RC","","","","both","","","1258.00","943.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.87","813.87","813.87","1 through 10","389.98","1027.91","other","OPPS APC"
"Lumbar Puncture Drain CSF Thrputic","PX-76001463","CDM","62272","CPT","0761","RC","","","","outpatient","","","1258.00","943.50","AETNA [1001]","HB AMC AETNA HMO","878.08","69.8","","825.94","825.94","825.94","1 through 10","598.81","2384.07","percent of total billed charges",""
"Lumbar Puncture Drain CSF Thrputic","PX-76001463","CDM","62272","CPT","0761","RC","","","","outpatient","","","1258.00","943.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1587.30","1587.30","1603.05","1 through 10","598.81","2384.07","other","ASC "
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","both","","","770.00","577.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","612.15","79.5","","1309.77","674.56","6049.93","26","238.7","612.15","percent of total billed charges",""
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","both","","","770.00","577.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","410.41","53.3","","1901.83","1901.83","2962.25","1 through 10","238.7","612.15","percent of total billed charges",""
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","281.05","36.5","","1620.31","1620.31","19908.88","1 through 10","238.7","612.15","percent of total billed charges",""
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","294.91","38.3","","352.91","352.91","2046.30","1 through 10","238.7","612.15","percent of total billed charges",""
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","both","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","330.33","42.9","","9668.75","9668.75","9668.75","1 through 10","238.7","612.15","percent of total billed charges",""
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","both","","","770.00","577.50","WELLPOINT [1015]","HB AMC WELLPOINT","568.11","73.78","","699.88","384.10","3443.31","33","238.7","612.15","percent of total billed charges",""
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","AETNA [1001]","HB AMC AETNA HMO","537.46","69.8","","1421.24","264.50","4933.46","29","402.4","629.24","percent of total billed charges",""
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","619.08","80.4","","1022.97","1022.97","3607.50","1 through 10","402.4","629.24","percent of total billed charges",""
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","629.24","81.72","","3010.54","693.88","5019.88","35","402.4","629.24","percent of total billed charges",""
"LUMBAR ROD 5.5X50MM SEXTANT TITANIUM PREBENT","SUP-ITM-10025374","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","1309.77","674.56","6049.93","26","260.4","667.8","percent of total billed charges",""
"LUMBAR ROD 5.5X50MM SEXTANT TITANIUM PREBENT","SUP-ITM-10025374","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","1901.83","1901.83","2962.25","1 through 10","260.4","667.8","percent of total billed charges",""
"LUMBAR ROD 5.5X50MM SEXTANT TITANIUM PREBENT","SUP-ITM-10025374","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","1620.31","1620.31","19908.88","1 through 10","260.4","667.8","percent of total billed charges",""
"LUMBAR ROD 5.5X50MM SEXTANT TITANIUM PREBENT","SUP-ITM-10025374","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","352.91","352.91","2046.30","1 through 10","260.4","667.8","percent of total billed charges",""
"LUMBAR ROD 5.5X50MM SEXTANT TITANIUM PREBENT","SUP-ITM-10025374","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","9668.75","9668.75","9668.75","1 through 10","260.4","667.8","percent of total billed charges",""
"LUMBAR ROD 5.5X50MM SEXTANT TITANIUM PREBENT","SUP-ITM-10025374","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","699.88","384.10","3443.31","33","260.4","667.8","percent of total billed charges",""
"LUMBAR ROD 5.5X50MM SEXTANT TITANIUM PREBENT","SUP-ITM-10025374","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","1421.24","264.50","4933.46","29","438.98","686.45","percent of total billed charges",""
"LUMBAR ROD 5.5X50MM SEXTANT TITANIUM PREBENT","SUP-ITM-10025374","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1022.97","1022.97","3607.50","1 through 10","438.98","686.45","percent of total billed charges",""
"LUMBAR ROD 5.5X50MM SEXTANT TITANIUM PREBENT","SUP-ITM-10025374","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","3010.54","693.88","5019.88","35","438.98","686.45","percent of total billed charges",""
"LUMBAR ROD 5.5X60MM TITANIUM PRECUT STRAIGHT","SUP-ITM-10045776","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","1309.77","674.56","6049.93","26","162.75","417.38","percent of total billed charges",""
"LUMBAR ROD 5.5X60MM TITANIUM PRECUT STRAIGHT","SUP-ITM-10045776","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","1901.83","1901.83","2962.25","1 through 10","162.75","417.38","percent of total billed charges",""
"LUMBAR ROD 5.5X60MM TITANIUM PRECUT STRAIGHT","SUP-ITM-10045776","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","1620.31","1620.31","19908.88","1 through 10","162.75","417.38","percent of total billed charges",""
"LUMBAR ROD 5.5X60MM TITANIUM PRECUT STRAIGHT","SUP-ITM-10045776","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","352.91","352.91","2046.30","1 through 10","162.75","417.38","percent of total billed charges",""
"LUMBAR ROD 5.5X60MM TITANIUM PRECUT STRAIGHT","SUP-ITM-10045776","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","9668.75","9668.75","9668.75","1 through 10","162.75","417.38","percent of total billed charges",""
"LUMBAR ROD 5.5X60MM TITANIUM PRECUT STRAIGHT","SUP-ITM-10045776","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","699.88","384.10","3443.31","33","162.75","417.38","percent of total billed charges",""
"LUMBAR ROD 5.5X60MM TITANIUM PRECUT STRAIGHT","SUP-ITM-10045776","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","1421.24","264.50","4933.46","29","274.37","429.03","percent of total billed charges",""
"LUMBAR ROD 5.5X60MM TITANIUM PRECUT STRAIGHT","SUP-ITM-10045776","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1022.97","1022.97","3607.50","1 through 10","274.37","429.03","percent of total billed charges",""
"LUMBAR ROD 5.5X60MM TITANIUM PRECUT STRAIGHT","SUP-ITM-10045776","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","3010.54","693.88","5019.88","35","274.37","429.03","percent of total billed charges",""
"LUMBAR SPACER 10X45MM 6DEG CLYDESDALE IB PEEK DISPOSABE","SUP-ITM-10058894","CDM","C1889","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7403.44","79.5","","1309.77","674.56","6049.93","26","2886.88","7403.44","percent of total billed charges",""
"LUMBAR SPACER 10X45MM 6DEG CLYDESDALE IB PEEK DISPOSABE","SUP-ITM-10058894","CDM","C1889","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4963.56","53.3","","1901.83","1901.83","2962.25","1 through 10","2886.88","7403.44","percent of total billed charges",""
"LUMBAR SPACER 10X45MM 6DEG CLYDESDALE IB PEEK DISPOSABE","SUP-ITM-10058894","CDM","C1889","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3399.06","36.5","","1620.31","1620.31","19908.88","1 through 10","2886.88","7403.44","percent of total billed charges",""
"LUMBAR SPACER 10X45MM 6DEG CLYDESDALE IB PEEK DISPOSABE","SUP-ITM-10058894","CDM","C1889","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3566.69","38.3","","352.91","352.91","2046.30","1 through 10","2886.88","7403.44","percent of total billed charges",""
"LUMBAR SPACER 10X45MM 6DEG CLYDESDALE IB PEEK DISPOSABE","SUP-ITM-10058894","CDM","C1889","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3995.06","42.9","","9668.75","9668.75","9668.75","1 through 10","2886.88","7403.44","percent of total billed charges",""
"LUMBAR SPACER 10X45MM 6DEG CLYDESDALE IB PEEK DISPOSABE","SUP-ITM-10058894","CDM","C1889","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","WELLPOINT [1015]","HB AMC WELLPOINT","6870.76","73.78","","699.88","384.10","3443.31","33","2886.88","7403.44","percent of total billed charges",""
"LUMBAR SPACER 10X45MM 6DEG CLYDESDALE IB PEEK DISPOSABE","SUP-ITM-10058894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9312.50","6984.37","AETNA [1001]","HB AMC AETNA HMO","6500.13","69.8","","1421.24","264.50","4933.46","29","4866.71","7610.18","percent of total billed charges",""
"LUMBAR SPACER 10X45MM 6DEG CLYDESDALE IB PEEK DISPOSABE","SUP-ITM-10058894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9312.50","6984.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7487.25","80.4","","1022.97","1022.97","3607.50","1 through 10","4866.71","7610.18","percent of total billed charges",""
"LUMBAR SPACER 10X45MM 6DEG CLYDESDALE IB PEEK DISPOSABE","SUP-ITM-10058894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9312.50","6984.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7610.18","81.72","","3010.54","693.88","5019.88","35","4866.71","7610.18","percent of total billed charges",""
"LUMBAR SPACER 11X27 32 21 26MM ALLOGRAFT ALIF FREEZE DRIED","SUP-ITM-10048784","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.25","8674.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9195.17","79.5","","1309.77","674.56","6049.93","26","3585.54","9195.17","percent of total billed charges",""
"LUMBAR SPACER 11X27 32 21 26MM ALLOGRAFT ALIF FREEZE DRIED","SUP-ITM-10048784","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.25","8674.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6164.81","53.3","","1901.83","1901.83","2962.25","1 through 10","3585.54","9195.17","percent of total billed charges",""
"LUMBAR SPACER 11X27 32 21 26MM ALLOGRAFT ALIF FREEZE DRIED","SUP-ITM-10048784","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.25","8674.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4221.68","36.5","","1620.31","1620.31","19908.88","1 through 10","3585.54","9195.17","percent of total billed charges",""
"LUMBAR SPACER 11X27 32 21 26MM ALLOGRAFT ALIF FREEZE DRIED","SUP-ITM-10048784","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.25","8674.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4429.87","38.3","","352.91","352.91","2046.30","1 through 10","3585.54","9195.17","percent of total billed charges",""
"LUMBAR SPACER 11X27 32 21 26MM ALLOGRAFT ALIF FREEZE DRIED","SUP-ITM-10048784","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.25","8674.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4961.92","42.9","","9668.75","9668.75","9668.75","1 through 10","3585.54","9195.17","percent of total billed charges",""
"LUMBAR SPACER 11X27 32 21 26MM ALLOGRAFT ALIF FREEZE DRIED","SUP-ITM-10048784","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.25","8674.69","WELLPOINT [1015]","HB AMC WELLPOINT","8533.58","73.78","","699.88","384.10","3443.31","33","3585.54","9195.17","percent of total billed charges",""
"LUMBAR SPACER 11X27 32 21 26MM ALLOGRAFT ALIF FREEZE DRIED","SUP-ITM-10048784","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11566.25","8674.69","AETNA [1001]","HB AMC AETNA HMO","8073.24","69.8","","1421.24","264.50","4933.46","29","6044.52","9451.94","percent of total billed charges",""
"LUMBAR SPACER 11X27 32 21 26MM ALLOGRAFT ALIF FREEZE DRIED","SUP-ITM-10048784","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11566.25","8674.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9299.27","80.4","","1022.97","1022.97","3607.50","1 through 10","6044.52","9451.94","percent of total billed charges",""
"LUMBAR SPACER 11X27 32 21 26MM ALLOGRAFT ALIF FREEZE DRIED","SUP-ITM-10048784","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11566.25","8674.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9451.94","81.72","","3010.54","693.88","5019.88","35","6044.52","9451.94","percent of total billed charges",""
"LUMBAR SPACER 27 32X21 26 15MM ALLOGRAFT FROZEN","SUP-ITM-10048786","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.25","8674.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9195.17","79.5","","1309.77","674.56","6049.93","26","3585.54","9195.17","percent of total billed charges",""
"LUMBAR SPACER 27 32X21 26 15MM ALLOGRAFT FROZEN","SUP-ITM-10048786","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.25","8674.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6164.81","53.3","","1901.83","1901.83","2962.25","1 through 10","3585.54","9195.17","percent of total billed charges",""
"LUMBAR SPACER 27 32X21 26 15MM ALLOGRAFT FROZEN","SUP-ITM-10048786","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.25","8674.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4221.68","36.5","","1620.31","1620.31","19908.88","1 through 10","3585.54","9195.17","percent of total billed charges",""
"LUMBAR SPACER 27 32X21 26 15MM ALLOGRAFT FROZEN","SUP-ITM-10048786","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.25","8674.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4429.87","38.3","","352.91","352.91","2046.30","1 through 10","3585.54","9195.17","percent of total billed charges",""
"LUMBAR SPACER 27 32X21 26 15MM ALLOGRAFT FROZEN","SUP-ITM-10048786","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.25","8674.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4961.92","42.9","","9668.75","9668.75","9668.75","1 through 10","3585.54","9195.17","percent of total billed charges",""
"LUMBAR SPACER 27 32X21 26 15MM ALLOGRAFT FROZEN","SUP-ITM-10048786","CDM","C1889","HCPCS","0278","RC","","","","both","","","11566.25","8674.69","WELLPOINT [1015]","HB AMC WELLPOINT","8533.58","73.78","","699.88","384.10","3443.31","33","3585.54","9195.17","percent of total billed charges",""
"LUMBAR SPACER 27 32X21 26 15MM ALLOGRAFT FROZEN","SUP-ITM-10048786","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11566.25","8674.69","AETNA [1001]","HB AMC AETNA HMO","8073.24","69.8","","1421.24","264.50","4933.46","29","6044.52","9451.94","percent of total billed charges",""
"LUMBAR SPACER 27 32X21 26 15MM ALLOGRAFT FROZEN","SUP-ITM-10048786","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11566.25","8674.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9299.27","80.4","","1022.97","1022.97","3607.50","1 through 10","6044.52","9451.94","percent of total billed charges",""
"LUMBAR SPACER 27 32X21 26 15MM ALLOGRAFT FROZEN","SUP-ITM-10048786","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11566.25","8674.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9451.94","81.72","","3010.54","693.88","5019.88","35","6044.52","9451.94","percent of total billed charges",""
"LUMBAR SPACER 8X8.6 11 22MM ALLOGRAFT INTERBODY FUSION FREEZE DRIED","SUP-ITM-10048793","CDM","C1889","HCPCS","0278","RC","","","","both","","","5333.35","4000.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4240.01","79.5","","1309.77","674.56","6049.93","26","1653.34","4240.01","percent of total billed charges",""
"LUMBAR SPACER 8X8.6 11 22MM ALLOGRAFT INTERBODY FUSION FREEZE DRIED","SUP-ITM-10048793","CDM","C1889","HCPCS","0278","RC","","","","both","","","5333.35","4000.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2842.68","53.3","","1901.83","1901.83","2962.25","1 through 10","1653.34","4240.01","percent of total billed charges",""
"LUMBAR SPACER 8X8.6 11 22MM ALLOGRAFT INTERBODY FUSION FREEZE DRIED","SUP-ITM-10048793","CDM","C1889","HCPCS","0278","RC","","","","both","","","5333.35","4000.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1946.67","36.5","","1620.31","1620.31","19908.88","1 through 10","1653.34","4240.01","percent of total billed charges",""
"LUMBAR SPACER 8X8.6 11 22MM ALLOGRAFT INTERBODY FUSION FREEZE DRIED","SUP-ITM-10048793","CDM","C1889","HCPCS","0278","RC","","","","both","","","5333.35","4000.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2042.67","38.3","","352.91","352.91","2046.30","1 through 10","1653.34","4240.01","percent of total billed charges",""
"LUMBAR SPACER 8X8.6 11 22MM ALLOGRAFT INTERBODY FUSION FREEZE DRIED","SUP-ITM-10048793","CDM","C1889","HCPCS","0278","RC","","","","both","","","5333.35","4000.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2288.01","42.9","","9668.75","9668.75","9668.75","1 through 10","1653.34","4240.01","percent of total billed charges",""
"LUMBAR SPACER 8X8.6 11 22MM ALLOGRAFT INTERBODY FUSION FREEZE DRIED","SUP-ITM-10048793","CDM","C1889","HCPCS","0278","RC","","","","both","","","5333.35","4000.01","WELLPOINT [1015]","HB AMC WELLPOINT","3934.95","73.78","","699.88","384.10","3443.31","33","1653.34","4240.01","percent of total billed charges",""
"LUMBAR SPACER 8X8.6 11 22MM ALLOGRAFT INTERBODY FUSION FREEZE DRIED","SUP-ITM-10048793","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5333.35","4000.01","AETNA [1001]","HB AMC AETNA HMO","3722.68","69.8","","1421.24","264.50","4933.46","29","2787.21","4358.41","percent of total billed charges",""
"LUMBAR SPACER 8X8.6 11 22MM ALLOGRAFT INTERBODY FUSION FREEZE DRIED","SUP-ITM-10048793","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5333.35","4000.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4288.01","80.4","","1022.97","1022.97","3607.50","1 through 10","2787.21","4358.41","percent of total billed charges",""
"LUMBAR SPACER 8X8.6 11 22MM ALLOGRAFT INTERBODY FUSION FREEZE DRIED","SUP-ITM-10048793","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5333.35","4000.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4358.41","81.72","","3010.54","693.88","5019.88","35","2787.21","4358.41","percent of total billed charges",""
"Lung Transplant","007","MS-DRG","","","","","","","","inpatient","","","802777.06","602082.79","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","122068.31","","Case rate ($118,512.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $142,588.79, add-ons for qualifying new technology services are included. If operating cost exceeds $188,233.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,860.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 19.7. The base transfer operating payment is the transfer adjustment factor * $107,712.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $142,208.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $10,420.49. The transfer capital threshold is the transfer adjustment factor * $10,420.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","334714.60","334714.60","334714.60","1 through 10","116142.66","202851.93","other","Inpatient DRG"
"Lung Transplant","007","MS-DRG","","","","","","","","inpatient","","","802777.06","602082.79","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","118512.92","","Case rate ($118,512.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $142,588.79, add-ons for qualifying new technology services are included. If operating cost exceeds $188,233.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,860.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 19.7. The base transfer operating payment is the transfer adjustment factor * $107,712.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $142,208.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $10,420.49. The transfer capital threshold is the transfer adjustment factor * $10,420.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","750050.49","750050.49","750050.49","1 through 10","116142.66","202851.93","other","Inpatient Replacement Plans DRG"
"Lung Transplant","007","MS-DRG","","","","","","","","inpatient","","","802777.06","602082.79","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","148141.15","","Case rate ($118,512.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $142,588.79, add-ons for qualifying new technology services are included. If operating cost exceeds $188,233.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,860.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 19.7. The base transfer operating payment is the transfer adjustment factor * $107,712.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $142,208.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $10,420.49. The transfer capital threshold is the transfer adjustment factor * $10,420.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","303499.61","303499.61","303615.26","1 through 10","116142.66","202851.93","other","Inpatient DRG"
"Lung Transplant","007","MS-DRG","","","","","","","","inpatient","","","802777.06","602082.79","MEDICARE [2001]","HB BWH MEDICARE","118512.92","","Case rate ($118,512.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $142,588.79, add-ons for qualifying new technology services are included. If operating cost exceeds $188,233.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,860.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 19.7. The base transfer operating payment is the transfer adjustment factor * $107,712.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $142,208.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $10,420.49. The transfer capital threshold is the transfer adjustment factor * $10,420.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","154578.85","154348.40","154578.85","12","116142.66","202851.93","other","Inpatient Replacement Plans DRG"
"Lung Transplant","007","MS-DRG","","","","","","","","inpatient","","","802777.06","602082.79","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","118512.92","","Case rate ($118,512.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $142,588.79, add-ons for qualifying new technology services are included. If operating cost exceeds $188,233.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,860.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 19.7. The base transfer operating payment is the transfer adjustment factor * $107,712.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $142,208.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $10,420.49. The transfer capital threshold is the transfer adjustment factor * $10,420.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","285318.16","285318.16","285318.16","1 through 10","116142.66","202851.93","other","Inpatient Replacement Plans DRG"
"Lung Transplant","007","MS-DRG","","","","","","","","inpatient","","","802777.06","602082.79","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","116142.66","","Case rate ($118,512.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $142,588.79, add-ons for qualifying new technology services are included. If operating cost exceeds $188,233.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,860.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 19.7. The base transfer operating payment is the transfer adjustment factor * $107,712.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $142,208.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $10,420.49. The transfer capital threshold is the transfer adjustment factor * $10,420.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","116527.56","116527.56","116527.56","1 through 10","116142.66","202851.93","other","Inpatient DRG"
"Lung Transplant","007","MS-DRG","","","","","","","","inpatient","","","802777.06","602082.79","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","116142.66","","Case rate ($118,512.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $142,588.79, add-ons for qualifying new technology services are included. If operating cost exceeds $188,233.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $12,860.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 19.7. The base transfer operating payment is the transfer adjustment factor * $107,712.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $142,208.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $10,420.49. The transfer capital threshold is the transfer adjustment factor * $10,420.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17094.23","17094.23","17094.23","1 through 10","116142.66","202851.93","other","Inpatient DRG"
"Lung Transplant","007","MS-DRG","","","","","","","","inpatient","","","802777.06","602082.79","WELLPOINT [1015]","HB AMC WELLPOINT","202851.93","","Fee schedule rate ($202,851.93).","613057.18","613057.18","613057.18","1 through 10","116142.66","202851.93","case rate",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","315.00","236.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","206.64","65.6","","206.49","206.49","206.49","1 through 10","18.15","299.25","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","315.00","236.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","220.50","70","","305.00","305.00","305.00","1 through 10","18.15","299.25","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","315.00","236.25","CHAMPVA [160001]","HB BWH TRICARE","299.25","95","","22.32","22.32","22.32","1 through 10","18.15","299.25","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","240.04","161.04","240.04","229","18.15","299.25","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","161.04","161.04","240.04","82","18.15","299.25","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","250.43","79.5","","240.04","240.04","240.04","1 through 10","18.15","299.25","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","97.65","31","","94.25","94.25","94.25","1 through 10","18.15","299.25","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","113.77","96.69","341.31","109","18.15","299.25","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","119.26","115.90","119.26","320","18.15","299.25","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","315.00","236.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","242.55","77","","240.04","240.04","240.04","1 through 10","18.15","299.25","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","315.00","236.25","TRICARE [160005]","HB BWH TRICARE","299.25","95","","21.20","21.20","22.32","1 through 10","18.15","299.25","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","243.82","134.11","243.82","1 through 10","18.15","299.25","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","243.82","243.82","243.82","1 through 10","18.15","299.25","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","206.49","145.79","237.90","242","19.09","257.42","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA PPO","253.26","80.4","","237.90","155.10","237.90","31","19.09","257.42","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","176.09","55.9","","159.82","159.82","159.82","1 through 10","19.09","257.42","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","315.00","236.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","164.62","52.26","","64.96","64.96","64.96","1 through 10","19.09","257.42","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","237.90","237.90","237.90","1 through 10","19.09","257.42","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","257.42","81.72","","243.82","243.82","243.82","1 through 10","19.09","257.42","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","243.82","134.11","243.82","137","19.09","257.42","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","239.00","179.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","171.60","71.8","","15.02","15.02","15.02","1 through 10","14.72","227.05","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","239.00","179.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","190.01","79.5","","182.58","122.50","192.28","87","14.72","227.05","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","239.00","179.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","127.39","53.3","","122.50","122.50","462.01","45","14.72","227.05","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","239.00","179.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","74.09","31","","464.00","71.69","464.00","1 through 10","14.72","227.05","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","239.00","179.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.24","36.5","","86.54","73.54","86.54","68","14.72","227.05","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","239.00","179.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.54","38.3","","90.71","88.16","90.71","197","14.72","227.05","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","239.00","179.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","184.03","77","","157.06","16.69","157.06","1 through 10","14.72","227.05","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","239.00","179.25","TRICARE [160005]","HB BWH TRICARE","227.05","95","","20.52","19.49","20.52","1 through 10","14.72","227.05","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","239.00","179.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.53","42.9","","185.46","105.56","185.46","1 through 10","14.72","227.05","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","239.00","179.25","AETNA [1001]","HB AMC AETNA HMO","166.82","69.8","","157.06","110.90","180.96","88","14.72","195.31","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","239.00","179.25","AETNA [1001]","HB AMC AETNA PPO","192.16","80.4","","180.96","180.96","243.14","11","14.72","195.31","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","239.00","179.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","124.90","52.26","","59.80","59.80","59.80","1 through 10","14.72","195.31","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","239.00","179.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","192.16","80.4","","116.00","116.00","116.00","1 through 10","14.72","195.31","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","239.00","179.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","195.31","81.72","","232.00","232.00","232.00","1 through 10","14.72","195.31","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","239.00","179.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","195.31","81.72","","185.46","102.01","185.46","1 through 10","14.72","195.31","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","239.00","179.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","195.31","81.72","","185.46","102.01","185.46","96","14.72","195.31","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","both","","","185.00","138.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","147.08","79.5","","140.88","94.51","140.88","30","15.18","175.75","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","both","","","185.00","138.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","98.61","53.3","","94.51","94.51","189.02","1 through 10","15.18","175.75","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","both","","","185.00","138.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","57.35","31","","179.00","179.00","179.00","1 through 10","15.18","175.75","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","both","","","185.00","138.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.53","36.5","","66.77","56.75","66.77","22","15.18","175.75","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","both","","","185.00","138.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.86","38.3","","69.99","69.99","209.97","64","15.18","175.75","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","outpatient","","","185.00","138.75","AETNA [1001]","HB AMC AETNA HMO","129.13","69.8","","121.19","85.56","139.62","25","15.98","151.18","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","outpatient","","","185.00","138.75","AETNA [1001]","HB AMC AETNA PPO","148.74","80.4","","139.62","93.80","139.62","1 through 10","15.98","151.18","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","outpatient","","","185.00","138.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","151.18","81.72","","143.10","78.71","143.10","19","15.98","151.18","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Lyme Disease, Molecular Detection, Pcr, Varies","PX-30003700","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,EXTREME","694","DRG","","","","","","","","inpatient","","","84936.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","61257.09","","Standard inlier is a Case rate ($61,257.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,695.81) for the length of stay and the standard reimbursement.","55838.06","55838.06","55838.06","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,EXTREME","694","DRG","","","","","","","","inpatient","","","84936.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","68869.48","","Standard inlier is a Case rate ($68,869.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,775.45) for the length of stay and the standard reimbursement.","62918.21","62918.21","68869.47","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,EXTREME","694","DRG","","","","","","","","inpatient","","","84936.36","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15299.028","","Fee schedule rate ($86,240.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15299.028","86240.44","86240.44","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,EXTREME","694","DRG","","","","","","","","inpatient","","","84936.36","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","22335.6862","","Fee schedule rate ($86,240.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22335.6862","86240.44","86240.44","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,EXTREME","694","DRG","","","","","","","","inpatient","","","84936.36","","MASSHEALTH [3001]","HB BWH MEDICAID","22167.61","","Case rate ($24,510.11). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,940.11, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","28481.33","28481.33","28481.33","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,EXTREME","694","DRG","","","","","","","","inpatient","","","84936.36","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","74741.38","","Fee schedule rate ($74,741.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","74741.38","74741.38","74741.38","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,EXTREME","694","DRG","","","","","","","","inpatient","","","84936.36","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","22167.61","","Case rate ($24,510.11). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,940.11, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","34743.86","849.43","88748.79","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,MAJOR","694","DRG","","","","","","","","inpatient","","","61526.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","39868.74","","Standard inlier is a Case rate ($39,868.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,225, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,659.04) for the length of stay and the standard reimbursement.","36423.53","36423.53","39868.74","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,MAJOR","694","DRG","","","","","","","","inpatient","","","61526.51","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12235.88","","Case rate ($13,528.87). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,958.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13525.55","13525.55","13525.55","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,MINOR","694","DRG","","","","","","","","inpatient","","","26162.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21677.83","","Standard inlier is a Case rate ($21,677.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,642, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,076.99) for the length of stay and the standard reimbursement.","33918.89","33918.89","33918.89","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,MINOR","694","DRG","","","","","","","","inpatient","","","26162.65","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5826.07","","Case rate ($6,441.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,871.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6440.14","6440.14","6440.14","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,MODERATE","694","DRG","","","","","","","","inpatient","","","64763.96","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","27128.20","","Standard inlier is a Case rate ($27,128.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,412, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,850.62) for the length of stay and the standard reimbursement.","24784.78","24784.78","24784.78","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,MODERATE","694","DRG","","","","","","","","inpatient","","","64763.96","","MASSHEALTH [3001]","HB BWH MEDICAID","7820.64","","Case rate ($8,647.06). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,077.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8644.94","8644.94","8644.94","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic And Other Malignancies And Neoplasms Of Uncertain Behavior,MODERATE","694","DRG","","","","","","","","inpatient","","","64763.96","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27144.24","","Fee schedule rate ($27,144.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27144.24","27144.24","27144.24","1 through 10","5826.07","142298.46","case rate",""
"Lymphatic Malf Sclerotherapy","PX-76001994","CDM","38999","CPT","0761","RC","","","","outpatient","","","10488.00","7866.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5476.83","52.22","","512.50","512.50","512.50","1 through 10","1234.13","8652.6","percent of total billed charges",""
"Lymphatic Malf Sclerotherapy","PX-76001994","CDM","38999","CPT","0761","RC","","","","outpatient","","","10488.00","7866.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5244.00","50","","6776.11","6776.11","6776.11","1 through 10","1234.13","8652.6","percent of total billed charges",""
"Lymphocyte Transformation Mitogen","PX-30000847","CDM","86353","CPT","0302","RC","","","","both","","","692.00","519.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","550.14","79.5","","1584.23","1584.23","1584.23","1 through 10","48.05","657.4","percent of total billed charges",""
"Lymphocyte Transformation Mitogen","PX-30000847","CDM","86353","CPT","0302","RC","","","","both","","","692.00","519.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","368.84","53.3","","1584.23","528.08","1584.23","1 through 10","48.05","657.4","percent of total billed charges",""
"Lymphocyte Transformation Mitogen","PX-30000847","CDM","86353","CPT","0302","RC","","","","both","","","692.00","519.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","252.58","36.5","","212.71","212.71","212.71","1 through 10","48.05","657.4","percent of total billed charges",""
"Lymphocyte Transformation Mitogen","PX-30000847","CDM","86353","CPT","0302","RC","","","","both","","","692.00","519.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","265.04","38.3","","787.08","787.08","787.08","1 through 10","48.05","657.4","percent of total billed charges",""
"Lymphocyte Transformation Mitogen","PX-30000847","CDM","86353","CPT","0302","RC","","","","outpatient","","","692.00","519.00","AETNA [1001]","HB AMC AETNA HMO","483.02","69.8","","454.27","454.27","454.27","1 through 10","50.56","565.5","percent of total billed charges",""
"Lymphocyte Transformation Mitogen","PX-30000847","CDM","86353","CPT","0302","RC","","","","outpatient","","","692.00","519.00","AETNA [1001]","HB AMC AETNA PPO","556.37","80.4","","1054.82","351.61","1054.82","1 through 10","50.56","565.5","percent of total billed charges",""
"Lymphocyte Transformation Mitogen","PX-30000847","CDM","86353","CPT","0302","RC","","","","outpatient","","","692.00","519.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","565.50","81.72","","536.40","295.04","536.40","1 through 10","50.56","565.5","percent of total billed charges",""
"Lymphocytotoxicity W/Titer","PX-30001016","CDM","86805","CPT","0302","RC","","","","both","","","896.00","672.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","643.33","71.8","","1871.83","623.94","1871.83","51","53.92","851.2","percent of total billed charges",""
"Lymphocytotoxicity W/Titer","PX-30001016","CDM","86805","CPT","0302","RC","","","","both","","","896.00","672.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","587.78","65.6","","588.31","195.01","588.31","11","53.92","851.2","percent of total billed charges",""
"Lymphocytotoxicity W/Titer","PX-30001016","CDM","86805","CPT","0302","RC","","","","both","","","896.00","672.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","582.40","65","","564.85","564.85","683.91","17","53.92","851.2","percent of total billed charges",""
"Lymphocytotoxicity W/Titer","PX-30001016","CDM","86805","CPT","0302","RC","","","","both","","","896.00","672.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","627.20","70","","714.17","596.40","869.00","43","53.92","851.2","percent of total billed charges",""
"Lymphocytotoxicity W/Titer","PX-30001016","CDM","86805","CPT","0302","RC","","","","both","","","896.00","672.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","712.32","79.5","","2051.71","546.00","2051.71","15","53.92","851.2","percent of total billed charges",""
"Lymphocytotoxicity W/Titer","PX-30001016","CDM","86805","CPT","0302","RC","","","","both","","","896.00","672.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","582.40","65","","564.85","564.85","1694.55","22","53.92","851.2","percent of total billed charges",""
"Lymphocytotoxicity W/Titer","PX-30001016","CDM","86805","CPT","0302","RC","","","","both","","","896.00","672.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","582.40","65","","1431.30","1431.30","1431.30","1 through 10","53.92","851.2","percent of total billed charges",""
"Lymphocytotoxicity W/Titer","PX-30001016","CDM","86805","CPT","0302","RC","","","","both","","","896.00","672.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","327.04","36.5","","623.94","530.35","623.94","1 through 10","53.92","851.2","percent of total billed charges",""
"Lymphocytotoxicity W/Titer","PX-30001016","CDM","86805","CPT","0302","RC","","","","both","","","896.00","672.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","343.17","38.3","","1871.83","1871.83","1871.83","18","53.92","851.2","percent of total billed charges",""
"Lymphocytotoxicity W/Titer","PX-30001016","CDM","86805","CPT","0302","RC","","","","outpatient","","","896.00","672.00","AETNA [1001]","HB AMC AETNA HMO","625.41","69.8","","677.82","588.32","677.82","11","53.92","1161.7","percent of total billed charges",""
"Lymphocytotoxicity W/Titer","PX-30001016","CDM","86805","CPT","0302","RC","","","","outpatient","","","896.00","672.00","AETNA [1001]","HB AMC AETNA PPO","720.38","80.4","","677.82","677.82","677.82","1 through 10","53.92","1161.7","percent of total billed charges",""
"Lymphocytotoxicity W/Titer","PX-30001016","CDM","86805","CPT","0302","RC","","","","outpatient","","","896.00","672.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","720.38","80.4","","677.82","434.50","1303.50","1 through 10","53.92","1161.7","percent of total billed charges",""
"Lymphocytotoxicity W/Titer","PX-30001016","CDM","86805","CPT","0302","RC","","","","outpatient","","","896.00","672.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","732.21","81.72","","2083.93","694.68","2084.04","1 through 10","53.92","1161.7","percent of total billed charges",""
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","","","","inpatient","","","115297.19","86472.89","HUMANA [1012]","HB BWH MEDICARE","20800.58","","Case rate ($20,800.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,962.39, add-ons for qualifying new technology services are included. If operating cost exceeds $70,606.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,241.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,619.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,582.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,801.31. The transfer capital threshold is the transfer adjustment factor * $1,801.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","45387.63","45387.63","45387.63","1 through 10","20384.57","35065.43","other","Inpatient Replacement Plans DRG"
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","","","","inpatient","","","115297.19","86472.89","MEDICARE [2001]","HB BWH MEDICARE","20800.58","","Case rate ($20,800.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,962.39, add-ons for qualifying new technology services are included. If operating cost exceeds $70,606.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,241.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,619.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,582.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,801.31. The transfer capital threshold is the transfer adjustment factor * $1,801.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26596.40","26491.50","26635.78","13","20384.57","35065.43","other","Inpatient Replacement Plans DRG"
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","","","","inpatient","","","115297.19","86472.89","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","20384.57","","Case rate ($20,800.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,962.39, add-ons for qualifying new technology services are included. If operating cost exceeds $70,606.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,241.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,619.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,582.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,801.31. The transfer capital threshold is the transfer adjustment factor * $1,801.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20134.24","20134.24","20134.24","1 through 10","20384.57","35065.43","other","Inpatient DRG"
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","","","","inpatient","","","115297.19","86472.89","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20384.57","","Case rate ($20,800.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,962.39, add-ons for qualifying new technology services are included. If operating cost exceeds $70,606.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,241.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,619.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,582.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,801.31. The transfer capital threshold is the transfer adjustment factor * $1,801.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20130.28","20130.28","20130.28","1 through 10","20384.57","35065.43","other","Inpatient DRG"
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","TRIS-DRG","","","","","","","","inpatient","","","450647.18","","TRICARE [160005]","HB BWH TRICARE","25662.46","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($45,077.56). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $88,804.57 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($10,483.15), capped at $32,443.91. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $88,804.57 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","42757.59","42757.59","42757.59","1 through 10","25662.46","25662.46","other","Inpatient DRGs"
"Lymphoma And Leukemia With Major O.R. Procedures With McC","820","MS-DRG","","","","","","","","inpatient","","","338597.81","253948.36","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","69812.75","","Case rate ($69,812.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $64,782.47, add-ons for qualifying new technology services are included. If operating cost exceeds $110,426.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,159.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $64,713.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $64,402.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,719.16. The transfer capital threshold is the transfer adjustment factor * $4,719.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","56119.73","56119.73","56119.73","1 through 10","52801.57","91866.23","other","Inpatient DRG"
"Lymphoma And Leukemia With Major O.R. Procedures With McC","820","MS-DRG","","","","","","","","inpatient","","","338597.81","253948.36","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","53879.15","","Case rate ($53,879.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $64,782.47, add-ons for qualifying new technology services are included. If operating cost exceeds $110,426.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,159.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $48,780.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $64,402.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,719.16. The transfer capital threshold is the transfer adjustment factor * $4,719.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","52113.42","52113.42","52113.42","1 through 10","52801.57","91866.23","other","Inpatient DRG"
"Lymphoma And Leukemia With Major O.R. Procedures With McC","820","MS-DRG","","","","","","","","inpatient","","","338597.81","253948.36","MEDICARE [2001]","HB BWH MEDICARE","69812.75","","Case rate ($69,812.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $64,782.47, add-ons for qualifying new technology services are included. If operating cost exceeds $110,426.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,159.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $64,713.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $64,402.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,719.16. The transfer capital threshold is the transfer adjustment factor * $4,719.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","68918.27","0.03","262043.55","1 through 10","52801.57","91866.23","other","Inpatient DRG"
"Lymphoma And Leukemia With Major O.R. Procedures With McC","820","MS-DRG","","","","","","","","inpatient","","","338597.81","253948.36","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","52801.57","","Case rate ($53,879.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $64,782.47, add-ons for qualifying new technology services are included. If operating cost exceeds $110,426.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,159.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.7. The base transfer operating payment is the transfer adjustment factor * $48,780.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $64,402.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,719.16. The transfer capital threshold is the transfer adjustment factor * $4,719.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","52531.35","52531.35","52531.35","1 through 10","52801.57","91866.23","other","Inpatient DRG"
"Lymphoma And Leukemia With Major O.R. Procedures With McC","820","TRIS-DRG","","","","","","","","inpatient","","","126418.58","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","71322.46","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($125,281.89). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $169,008.89 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($13,471.17), capped at $90,169.78. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $169,008.89 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","28482.36","28482.36","28482.36","1 through 10","71322.46","71322.46","other","Inpatient DRGs"
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/McC","822","MS-DRG","","","","","","","","inpatient","","","87239.93","65429.95","HUMANA [1012]","HB BWH MEDICARE","11362.87","","Case rate ($11,362.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,601.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,245.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,408.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,014.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,221.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $968.81. The transfer capital threshold is the transfer adjustment factor * $968.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10534.19","10534.19","10534.19","1 through 10","11135.61","17259.5767","other","Inpatient Replacement Plans DRG"
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/McC","822","MS-DRG","","","","","","","","inpatient","","","87239.93","65429.95","MEDICARE [2001]","HB BWH MEDICARE","11362.87","","Case rate ($11,362.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,601.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,245.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,408.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,014.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,221.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $968.81. The transfer capital threshold is the transfer adjustment factor * $968.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13761.54","13761.54","13781.70","1 through 10","11135.61","17259.5767","other","Inpatient Replacement Plans DRG"
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/McC","822","MS-DRG","","","","","","","","inpatient","","","87239.93","65429.95","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","11362.87","","Case rate ($11,362.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,601.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,245.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,408.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,014.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,221.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $968.81. The transfer capital threshold is the transfer adjustment factor * $968.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10462.01","10462.01","10462.01","1 through 10","11135.61","17259.5767","other","Inpatient Replacement Plans DRG"
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/McC","822","MS-DRG","","","","","","","","inpatient","","","87239.93","65429.95","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11135.61","","Case rate ($11,362.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,601.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,245.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,408.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,014.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,221.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $968.81. The transfer capital threshold is the transfer adjustment factor * $968.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10477.41","10477.41","10477.41","1 through 10","11135.61","17259.5767","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","","","","inpatient","","","81633.96","61225.47","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15719.50","","Case rate ($15,261.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,294.60, add-ons for qualifying new technology services are included. If operating cost exceeds $63,939.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,752.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,569.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,914.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,312.72. The transfer capital threshold is the transfer adjustment factor * $1,312.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14968.22","14968.22","14968.22","1 through 10","14956.42","23662.688","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","","","","inpatient","","","81633.96","61225.47","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","15261.65","","Case rate ($15,261.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,294.60, add-ons for qualifying new technology services are included. If operating cost exceeds $63,939.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,752.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,569.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,914.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,312.72. The transfer capital threshold is the transfer adjustment factor * $1,312.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14353.45","14353.45","14353.45","1 through 10","14956.42","23662.688","other","Inpatient Replacement Plans DRG"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","","","","inpatient","","","81633.96","61225.47","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15261.65","","Case rate ($15,261.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,294.60, add-ons for qualifying new technology services are included. If operating cost exceeds $63,939.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,752.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,569.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,914.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,312.72. The transfer capital threshold is the transfer adjustment factor * $1,312.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14226.64","14226.64","14226.64","1 through 10","14956.42","23662.688","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","","","","inpatient","","","81633.96","61225.47","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","15683.63","15683.63","15683.63","1 through 10","14956.42","23662.688","case rate",""
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","","","","inpatient","","","81633.96","61225.47","HUMANA [1012]","HB BWH MEDICARE","15261.65","","Case rate ($15,261.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,294.60, add-ons for qualifying new technology services are included. If operating cost exceeds $63,939.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,752.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,569.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,914.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,312.72. The transfer capital threshold is the transfer adjustment factor * $1,312.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14323.78","14323.78","14323.78","1 through 10","14956.42","23662.688","other","Inpatient Replacement Plans DRG"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","","","","inpatient","","","81633.96","61225.47","MEDICARE [2001]","HB BWH MEDICARE","15261.65","","Case rate ($15,261.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,294.60, add-ons for qualifying new technology services are included. If operating cost exceeds $63,939.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,752.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,569.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,914.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,312.72. The transfer capital threshold is the transfer adjustment factor * $1,312.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18763.67","0.03","18791.32","32","14956.42","23662.688","other","Inpatient Replacement Plans DRG"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","","","","inpatient","","","81633.96","61225.47","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14956.42","","Case rate ($15,261.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,294.60, add-ons for qualifying new technology services are included. If operating cost exceeds $63,939.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,752.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,569.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,914.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,312.72. The transfer capital threshold is the transfer adjustment factor * $1,312.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14270.35","14270.35","21121.27","1 through 10","14956.42","23662.688","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","139581.72","104686.29","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","30785.60","","Case rate ($29,888.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,902.97, add-ons for qualifying new technology services are included. If operating cost exceeds $81,547.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,043.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $26,906.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,523.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,602.99. The transfer capital threshold is the transfer adjustment factor * $2,602.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","30112.52","30112.52","30112.52","1 through 10","29291.15","48125.199","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","139581.72","104686.29","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","38677.57","","Case rate ($38,677.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,902.97, add-ons for qualifying new technology services are included. If operating cost exceeds $81,547.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,043.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $35,694.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,523.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,602.99. The transfer capital threshold is the transfer adjustment factor * $2,602.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29343.39","29343.39","29343.39","1 through 10","29291.15","48125.199","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","139581.72","104686.29","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","29888.93","","Case rate ($29,888.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,902.97, add-ons for qualifying new technology services are included. If operating cost exceeds $81,547.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,043.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $26,906.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,523.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,602.99. The transfer capital threshold is the transfer adjustment factor * $2,602.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28639.46","28639.46","28639.46","1 through 10","29291.15","48125.199","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","139581.72","104686.29","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","44613.73","44613.73","44613.73","1 through 10","29291.15","48125.199","case rate",""
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","139581.72","104686.29","MEDICARE [2001]","HB BWH MEDICARE","38677.57","","Case rate ($38,677.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,902.97, add-ons for qualifying new technology services are included. If operating cost exceeds $81,547.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,043.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $35,694.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,523.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,602.99. The transfer capital threshold is the transfer adjustment factor * $2,602.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","37873.89","0.03","40434.52","62","29291.15","48125.199","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","139581.72","104686.29","MOLINA [1014]","HB BWH MOLINA","29291.15","","Case rate ($29,888.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,902.97, add-ons for qualifying new technology services are included. If operating cost exceeds $81,547.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,043.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $26,906.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,523.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,602.99. The transfer capital threshold is the transfer adjustment factor * $2,602.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","65801.67","65801.67","65801.67","1 through 10","29291.15","48125.199","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","139581.72","104686.29","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","29291.15","","Case rate ($29,888.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,902.97, add-ons for qualifying new technology services are included. If operating cost exceeds $81,547.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,043.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $26,906.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,523.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,602.99. The transfer capital threshold is the transfer adjustment factor * $2,602.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","28717.57","28717.57","28717.57","1 through 10","29291.15","48125.199","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","139581.72","104686.29","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","29291.15","","Case rate ($29,888.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,902.97, add-ons for qualifying new technology services are included. If operating cost exceeds $81,547.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,043.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $26,906.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,523.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,602.99. The transfer capital threshold is the transfer adjustment factor * $2,602.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","29387.55","28663.06","128925.41","1 through 10","29291.15","48125.199","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","139581.72","104686.29","WELLPOINT [1015]","HB AMC WELLPOINT","48125.199","","Fee schedule rate ($50,671.47).","48125.199","48125.19","48125.19","1 through 10","29291.15","48125.199","case rate",""
"Lymphoma And Non-Acute Leukemia With McC","840","TRIS-DRG","","","","","","","","inpatient","","","45761.57","","TRICARE [160005]","HB BWH TRICARE","26226.96","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($46,069.13). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $6,581.30, and the first day is paid a rate of $13,162.61. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $6,581.30, and the first day is paid a rate of $13,162.61. The transfer payment is capped at $33,157.57. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $89,796.13 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 7). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($8,945.46), capped at $33,157.57. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $6,581.30, and the first day is paid a rate of $13,162.61. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $6,581.30, and the first day is paid a rate of $13,162.61. The transfer payment is capped at $33,157.57. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $89,796.13 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 7). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","9598.79","9598.79","9598.79","1 through 10","26226.96","26226.96","other","Inpatient DRGs"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","","","","inpatient","","","88600.63","66450.47","HUMANA [1012]","HB BWH MEDICARE","21046.89","","Case rate ($21,046.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,258.89, add-ons for qualifying new technology services are included. If operating cost exceeds $70,903.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,263.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $18,844.01 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,879.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,823.03. The transfer capital threshold is the transfer adjustment factor * $1,823.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","40253.00","40253.00","40253.00","1 through 10","20625.95","33191.1454","other","Inpatient Replacement Plans DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","","","","inpatient","","","88600.63","66450.47","MEDICARE [2001]","HB BWH MEDICARE","21046.89","","Case rate ($21,046.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,258.89, add-ons for qualifying new technology services are included. If operating cost exceeds $70,903.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,263.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $18,844.01 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,879.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,823.03. The transfer capital threshold is the transfer adjustment factor * $1,823.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26237.97","26207.35","26246.14","1 through 10","20625.95","33191.1454","other","Inpatient Replacement Plans DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","","","","inpatient","","","88600.63","66450.47","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","20625.95","","Case rate ($21,046.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,258.89, add-ons for qualifying new technology services are included. If operating cost exceeds $70,903.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,263.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $18,844.01 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,879.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,823.03. The transfer capital threshold is the transfer adjustment factor * $1,823.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20006.39","20006.39","20006.39","1 through 10","20625.95","33191.1454","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","","","","inpatient","","","88600.63","66450.47","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20625.95","","Case rate ($21,046.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,258.89, add-ons for qualifying new technology services are included. If operating cost exceeds $70,903.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,263.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $18,844.01 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,879.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,823.03. The transfer capital threshold is the transfer adjustment factor * $1,823.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","42047.24","42047.24","42047.24","1 through 10","20625.95","33191.1454","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures With McC","823","MS-DRG","","","","","","","","inpatient","","","211878.78","158909.08","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","43468.94","","Case rate ($42,202.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,726.51, add-ons for qualifying new technology services are included. If operating cost exceeds $96,370.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,129.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $38,133.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,346.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,689.20. The transfer capital threshold is the transfer adjustment factor * $3,689.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","78008.94","78008.94","78008.94","1 through 10","41358.79","70618.3345","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures With McC","823","MS-DRG","","","","","","","","inpatient","","","211878.78","158909.08","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54658.92","","Case rate ($54,658.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,726.51, add-ons for qualifying new technology services are included. If operating cost exceeds $96,370.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,129.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $50,589.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,346.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,689.20. The transfer capital threshold is the transfer adjustment factor * $3,689.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","54709.42","54709.42","54709.42","1 through 10","41358.79","70618.3345","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures With McC","823","MS-DRG","","","","","","","","inpatient","","","211878.78","158909.08","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","69538.33","69538.33","69538.33","1 through 10","41358.79","70618.3345","case rate",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With McC","823","MS-DRG","","","","","","","","inpatient","","","211878.78","158909.08","MEDICARE [2001]","HB BWH MEDICARE","54658.92","","Case rate ($54,658.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,726.51, add-ons for qualifying new technology services are included. If operating cost exceeds $96,370.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,129.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $50,589.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,346.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,689.20. The transfer capital threshold is the transfer adjustment factor * $3,689.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","55510.76","55445.64","55528.16","11","41358.79","70618.3345","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures With McC","823","MS-DRG","","","","","","","","inpatient","","","211878.78","158909.08","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","41358.79","","Case rate ($42,202.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,726.51, add-ons for qualifying new technology services are included. If operating cost exceeds $96,370.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,129.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $38,133.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,346.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,689.20. The transfer capital threshold is the transfer adjustment factor * $3,689.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","41897.59","41897.59","41935.12","1 through 10","41358.79","70618.3345","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/McC","825","MS-DRG","","","","","","","","inpatient","","","76785.70","57589.27","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12689.21","","Case rate ($12,689.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,197.90, add-ons for qualifying new technology services are included. If operating cost exceeds $60,842.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,525.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $11,223.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,818.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.81. The transfer capital threshold is the transfer adjustment factor * $1,085.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","47970.00","47970.00","47970.00","1 through 10","12435.43","21137","other","Inpatient Replacement Plans DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/McC","825","MS-DRG","","","","","","","","inpatient","","","76785.70","57589.27","MEDICARE [2001]","HB BWH MEDICARE","12689.21","","Case rate ($12,689.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,197.90, add-ons for qualifying new technology services are included. If operating cost exceeds $60,842.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,525.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $11,223.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,818.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.81. The transfer capital threshold is the transfer adjustment factor * $1,085.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14810.08","14810.08","14810.08","1 through 10","12435.43","21137","other","Inpatient Replacement Plans DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/McC","825","MS-DRG","","","","","","","","inpatient","","","76785.70","57589.27","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","12689.21","","Case rate ($12,689.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,197.90, add-ons for qualifying new technology services are included. If operating cost exceeds $60,842.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,525.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $11,223.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,818.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.81. The transfer capital threshold is the transfer adjustment factor * $1,085.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11266.53","11266.53","11266.53","1 through 10","12435.43","21137","other","Inpatient Replacement Plans DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/McC","825","MS-DRG","","","","","","","","inpatient","","","76785.70","57589.27","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12435.43","","Case rate ($12,689.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,197.90, add-ons for qualifying new technology services are included. If operating cost exceeds $60,842.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,525.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $11,223.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,818.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.81. The transfer capital threshold is the transfer adjustment factor * $1,085.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11270.49","11270.49","11270.49","1 through 10","12435.43","21137","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia Without Cc/McC","842","MS-DRG","","","","","","","","inpatient","","","52680.22","39510.16","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","9884.71","","Case rate ($9,596.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,475.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,119.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,253.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,403.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,095.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $813.03. The transfer capital threshold is the transfer adjustment factor * $813.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10160.56","10160.56","10160.56","1 through 10","9404.87","15826.91","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia Without Cc/McC","842","MS-DRG","","","","","","","","inpatient","","","52680.22","39510.16","FALLON HEALTH [1008]","HB BWH MEDICARE","12341.88","","Case rate ($12,341.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,475.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,119.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,253.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $11,149.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,095.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $813.03. The transfer capital threshold is the transfer adjustment factor * $813.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28690.59","28690.59","28690.59","1 through 10","9404.87","15826.91","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia Without Cc/McC","842","MS-DRG","","","","","","","","inpatient","","","52680.22","39510.16","MEDICARE [2001]","HB BWH MEDICARE","12341.88","","Case rate ($12,341.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,475.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,119.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,253.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $11,149.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,095.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $813.03. The transfer capital threshold is the transfer adjustment factor * $813.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","66.76","0.03","12697.84","1 through 10","9404.87","15826.91","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia Without Cc/McC","842","MS-DRG","","","","","","","","inpatient","","","52680.22","39510.16","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9404.87","","Case rate ($9,596.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,475.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,119.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,253.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,403.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,095.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $813.03. The transfer capital threshold is the transfer adjustment factor * $813.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9653.24","9653.24","9653.24","1 through 10","9404.87","15826.91","other","Inpatient DRG"
"Lymphoma, Myeloma And Non-Acute Leukemia,EXTREME","691","DRG","","","","","","","","inpatient","","","220909.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","53058.64","","Standard inlier is a Case rate ($53,058.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,909, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,531.99) for the length of stay and the standard reimbursement.","110379.77","98717.66","160819.45","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,EXTREME","691","DRG","","","","","","","","inpatient","","","220909.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","59652.22","","Standard inlier is a Case rate ($59,652.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,909, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,467.14) for the length of stay and the standard reimbursement.","101394.62","101394.62","117216.00","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,EXTREME","691","DRG","","","","","","","","inpatient","","","220909.22","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","366929.49","366929.49","366929.49","1 through 10","10756.52","234508.11","percent of total billed charges",""
"Lymphoma, Myeloma And Non-Acute Leukemia,EXTREME","691","DRG","","","","","","","","inpatient","","","220909.22","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","20324.8929","","Fee schedule rate ($142,124.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20324.8929","136647.08","136647.08","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,EXTREME","691","DRG","","","","","","","","inpatient","","","220909.22","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","21341.7282","","Fee schedule rate ($149,234.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21341.7282","149234.76","149234.76","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,EXTREME","691","DRG","","","","","","","","inpatient","","","220909.22","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","120686.99","","Fee schedule rate ($120,686.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","102583.94","102583.94","102583.94","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,EXTREME","691","DRG","","","","","","","","inpatient","","","220909.22","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","126723.33","","Fee schedule rate ($126,723.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","126723.33","126723.33","126723.33","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MAJOR","691","DRG","","","","","","","","inpatient","","","145925.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","53058.64","","Standard inlier is a Case rate ($53,058.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,909, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,531.99) for the length of stay and the standard reimbursement.","84134.48","53058.64","112957.79","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MAJOR","691","DRG","","","","","","","","inpatient","","","145925.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","59652.22","","Standard inlier is a Case rate ($59,652.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,909, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,467.14) for the length of stay and the standard reimbursement.","59652.21","54497.45","59652.21","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MAJOR","691","DRG","","","","","","","","inpatient","","","145925.72","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","","65","","14039.90","14039.90","14039.90","1 through 10","10756.52","234508.11","percent of total billed charges",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MAJOR","691","DRG","","","","","","","","inpatient","","","145925.72","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","20324.8929","","Fee schedule rate ($142,124.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20324.8929","30167.21","30167.21","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MAJOR","691","DRG","","","","","","","","inpatient","","","145925.72","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","21341.7282","","Fee schedule rate ($149,234.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21341.7282","62155.68","62155.68","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MAJOR","691","DRG","","","","","","","","inpatient","","","145925.72","","MASSHEALTH [3001]","HB BWH MEDICAID","21667.26","","Case rate ($23,956.88). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,386.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23951.00","3106.43","36279.04","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MAJOR","691","DRG","","","","","","","","inpatient","","","145925.72","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","21667.26","","Case rate ($23,956.88). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,386.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MAJOR","691","DRG","","","","","","","","inpatient","","","145925.72","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","126723.33","","Fee schedule rate ($126,723.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61255.80","61255.80","61255.80","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MAJOR","691","DRG","","","","","","","","inpatient","","","145925.72","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","21667.26","","Case rate ($23,956.88). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,386.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23951.00","23951.00","40128.21","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MINOR","691","DRG","","","","","","","","inpatient","","","103232.83","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","30724.20","","Standard inlier is a Case rate ($30,724.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,899, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,361.05) for the length of stay and the standard reimbursement.","28069.21","28069.21","28069.21","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MINOR","691","DRG","","","","","","","","inpatient","","","103232.83","","MASSHEALTH [3001]","HB BWH MEDICAID","10756.52","","Case rate ($11,893.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,323.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11890.27","11890.27","11890.27","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MODERATE","691","DRG","","","","","","","","inpatient","","","68023.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","35419.86","","Standard inlier is a Case rate ($35,419.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,191, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,028.06) for the length of stay and the standard reimbursement.","32286.49","32286.49","32286.49","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MODERATE","691","DRG","","","","","","","","inpatient","","","68023.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","39821.47","","Standard inlier is a Case rate ($39,821.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,191, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,652.33) for the length of stay and the standard reimbursement.","39821.47","39821.47","39821.47","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MODERATE","691","DRG","","","","","","","","inpatient","","","68023.86","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","","65","","70527.32","70527.32","70527.32","1 through 10","10756.52","234508.11","percent of total billed charges",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MODERATE","691","DRG","","","","","","","","inpatient","","","68023.86","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","20324.8929","","Fee schedule rate ($31,376.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20324.8929","31376.44","31376.44","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MODERATE","691","DRG","","","","","","","","inpatient","","","68023.86","","MASSHEALTH [3001]","HB BWH MEDICAID","14188.19","","Case rate ($15,687.48). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,117.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15683.62","15683.62","15683.62","1 through 10","10756.52","234508.11","case rate",""
"Lymphoma, Myeloma And Non-Acute Leukemia,MODERATE","691","DRG","","","","","","","","inpatient","","","68023.86","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14188.19","","Case rate ($15,687.48). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,117.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15683.63","15683.63","15683.63","1 through 10","10756.52","234508.11","case rate",""
"Lysis Labial Adhesions","PX-98301131","CDM","56441","CPT","0983","RC","","","","both","","","702.00","526.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","374.17","53.3","","11078.99","11078.99","11078.99","1 through 10","217.62","4719.38","percent of total billed charges",""
"Lysis Labial Adhesions","PX-98301131","CDM","56441","CPT","0983","RC","","","","both","","","702.00","526.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.87","38.3","","1959.69","1959.69","1959.69","1 through 10","217.62","4719.38","percent of total billed charges",""
"Lysis of Labial Lesion(S)","PX-76002266","CDM","56441","CPT","0761","RC","","","","both","","","5168.00","3876.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2754.54","53.3","","11078.99","11078.99","11078.99","1 through 10","1602.08","4719.38","percent of total billed charges",""
"Lysis of Labial Lesion(S)","PX-76002266","CDM","56441","CPT","0761","RC","","","","both","","","5168.00","3876.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1979.34","38.3","","1959.69","1959.69","1959.69","1 through 10","1602.08","4719.38","percent of total billed charges",""
"M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb","PX-31000497","CDM","88377","CPT","0310","RC","","","","both","","","1105.00","828.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","403.33","36.5","","388.06","388.06","388.06","1 through 10","193.33","878.48","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","200.24","39.82","203.50","30","156.86","402.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","328.90","65","","319.15","319.15","319.15","1 through 10","156.86","402.27","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","354.20","70","","353.52","343.44","491.00","1 through 10","156.86","402.27","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","402.27","79.5","","386.42","259.25","1159.25","45","156.86","402.27","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","269.70","53.3","","259.25","247.96","386.42","11","156.86","402.27","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","182.69","199.43","1 through 10","156.86","402.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","ELDER SERVICES [1037]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.42","186.42","186.42","1 through 10","156.86","402.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","FALLON HEALTH [1008]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","598.29","93.21","598.29","1 through 10","156.86","402.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.67","201.06","325.67","1 through 10","156.86","402.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","389.62","77","","378.07","378.07","378.07","1 through 10","156.86","402.27","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","HUMANA [1012]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","99.72","199.43","1 through 10","156.86","402.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","328.90","65","","319.15","319.15","319.15","1 through 10","156.86","402.27","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","328.90","65","","319.15","319.15","319.15","1 through 10","156.86","402.27","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.53","91.35","199.53","1 through 10","156.86","402.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","MEDICARE [2001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","67.83","203.50","270","156.86","402.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","156.86","31","","151.72","151.72","151.72","1 through 10","156.86","402.27","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","184.69","36.5","","183.14","155.65","710.96","37","156.86","402.27","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","193.80","38.3","","191.98","186.58","575.94","70","156.86","402.27","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","182.69","199.43","1 through 10","156.86","402.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","389.62","77","","386.42","386.42","386.42","1 through 10","156.86","402.27","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","TRICARE [160005]","HB BWH TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","193.33","193.33","193.33","1 through 10","156.86","402.27","other","Tricare OPPS"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","203.50","186.42","203.50","1 through 10","156.86","402.27","other","Tricare OPPS"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","99.72","199.43","12","156.86","402.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","112.93","112.93","112.93","1 through 10","156.86","402.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.07","42.9","","491.00","215.89","491.00","1 through 10","156.86","402.27","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","66.48","199.43","49","156.86","402.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","WELLPOINT [1015]","HB AMC WELLPOINT","373.33","73.78","","1838.55","365.55","2820.55","83","156.86","402.27","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","506.00","379.50","WELLSENSE [1003]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","68.51","68.51","68.51","1 through 10","156.86","402.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","506.00","379.50","AETNA [1001]","HB AMC AETNA HMO","353.19","69.8","","332.41","226.10","332.41","1 through 10","264.44","887.19","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","506.00","379.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","264.44","52.26","","303.83","303.83","303.83","1 through 10","264.44","887.19","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","506.00","379.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","406.82","80.4","","382.98","245.50","491.00","1 through 10","264.44","887.19","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","506.00","379.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","413.50","81.72","","1177.52","1177.52","1177.52","1 through 10","264.44","887.19","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","506.00","379.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","413.50","81.72","","215.89","199.43","392.51","1 through 10","264.44","887.19","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","506.00","379.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","413.50","81.72","","392.51","215.89","785.01","89","264.44","887.19","percent of total billed charges",""
"Machaon Diagnostics, P3346 Ahus Genetic 3rdp Panel 12 Genes Ngs","PX-31001327","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Machaon, P3346 Ahus Genetic 3rdp Panel 12 Genes Ngs","PX-31001351","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Machaon, P3346 Ahus Genetic 3rdp Panel 12 Genes Ngs","PX-31001351","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0300","RC","","","","inpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","84.11","78.61","","45.26","45.26","45.26","1 through 10","59.17","85.07","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","76.83","71.8","","74.67","17.73","224.01","103","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","70.19","65.6","","70.41","49.71","70.41","1 through 10","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","69.55","65","","67.60","54.91","274.55","119","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","74.90","70","","104.00","44.72","224.64","82","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","54.91","245.55","316","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","57.03","53.3","","81.85","54.91","245.55","197","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","82.39","77","","80.08","80.08","158.62","11","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","69.55","65","","67.60","67.60","67.60","16","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","33.17","31","","32.14","32.14","32.97","11","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","39.06","36.5","","38.79","32.97","98.91","329","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.98","38.3","","40.66","39.52","121.98","925","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","MOLINA [1014]","HB BWH MOLINA","37.45","35","","13.29","13.29","13.29","1 through 10","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","82.39","77","","81.12","78.42","85.28","1 through 10","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","TRICARE [160005]","HB BWH TRICARE","101.65","95","","8.07","7.67","104.00","12","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","83.14","45.73","83.14","15","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","137.19","45.73","137.19","1 through 10","6.57","101.65","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","107.00","80.25","AETNA [1001]","HB AMC AETNA HMO","74.69","69.8","","70.41","49.71","81.12","486","6.9","87.44","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","107.00","80.25","AETNA [1001]","HB AMC AETNA PPO","86.03","80.4","","81.12","49.71","158.50","46","6.9","87.44","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","107.00","80.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","55.92","52.26","","64.36","23.72","64.36","1 through 10","6.9","87.44","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","86.03","80.4","","81.12","52.00","81.12","1 through 10","6.9","87.44","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","87.44","81.72","","83.14","79.32","104.00","1 through 10","6.9","87.44","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","87.44","81.72","","45.73","45.73","91.46","20","6.9","87.44","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","83.14","45.73","83.14","340","6.9","87.44","percent of total billed charges",""
"Magnesium Sulf Inj 500mg","PX-63600196","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1.56","70","","7.68","2.41","12.27","24","0.69","1.87","percent of total billed charges",""
"Magnesium Sulf Inj 500mg","PX-63600196","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1.72","77","","2.62","2.62","2.62","1 through 10","0.69","1.87","percent of total billed charges",""
"Magnesium Sulf Inj 500mg","PX-63600196","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1.45","65","","1.41","1.41","5.64","1 through 10","0.69","1.87","percent of total billed charges",""
"Magnesium Sulf Inj 500mg","PX-63600196","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.69","31","","1.05","1.05","1.05","1 through 10","0.69","1.87","percent of total billed charges",""
"Magnesium Sulf Inj 500mg","PX-63600196","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.81","36.5","","2.12","0.77","3.80","112","0.69","1.87","percent of total billed charges",""
"Magnesium Sulf Inj 500mg","PX-63600196","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.85","38.3","","3.07","0.17","3.62","672","0.69","1.87","percent of total billed charges",""
"Magnesium Sulf Inj 500mg","PX-63600196","CDM","J3475","HCPCS","0636","RC","","","","both","","","2.23","1.67","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1.72","77","","1.64","1.64","1.64","1 through 10","0.69","1.87","percent of total billed charges",""
"Magnesium Sulf Inj 500mg","PX-63600196","CDM","J3475","HCPCS","0636","RC","","","","outpatient","","","2.23","1.67","AETNA [1001]","HB AMC AETNA HMO","1.56","69.8","","2.30","1.63","3.20","79","1.05","1.79","percent of total billed charges",""
"Magnesium Sulf Inj 500mg","PX-63600196","CDM","J3475","HCPCS","0636","RC","","","","outpatient","","","2.23","1.67","AETNA [1001]","HB AMC AETNA PPO","1.79","80.4","","3.25","1.62","3.25","13","1.05","1.79","percent of total billed charges",""
"Magnesium Sulf Inj 500mg","PX-63600196","CDM","J3475","HCPCS","0636","RC","","","","outpatient","","","2.23","1.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.56","69.9","","1.63","0.29","2.56","134","1.05","1.79","percent of total billed charges",""
"Magnesium Sulf Inj 500mg","PX-63600196","CDM","J3475","HCPCS","0636","RC","","","","outpatient","","","2.23","1.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1.05","46.9","","1.58","1.43","5.15","56","1.05","1.79","percent of total billed charges",""
"Magnesium Sulf Inj 500mg","PX-63600196","CDM","J3475","HCPCS","0636","RC","","","","outpatient","","","2.23","1.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1.79","80.4","","1.69","1.69","4.33","11","1.05","1.79","percent of total billed charges",""
"Magnesium Sulf Inj 500mg","PX-63600196","CDM","J3475","HCPCS","0636","RC","","","","outpatient","","","2.23","1.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1.56","69.9","","6.82","6.82","6.82","1 through 10","1.05","1.79","percent of total billed charges",""
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","both","","","1468.00","1101.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","295.64","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","982.05","980.05","982.05","1 through 10","272.7","1130.36","other","OPPS APC"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","both","","","1468.00","1101.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","358.78","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","208.43","208.43","208.43","1 through 10","272.7","1130.36","other","OPPS APC"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","both","","","1468.00","1101.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","998.92","818.15","998.92","1 through 10","272.7","1130.36","other","OPPS APC"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","both","","","1468.00","1101.00","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1000.95","1000.95","1000.95","1 through 10","272.7","1130.36","other","OPPS APC"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","both","","","1468.00","1101.00","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","952.43","1015.16","58","272.7","1130.36","other","OPPS APC"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","both","","","1468.00","1101.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","455.08","31","","440.02","440.02","440.02","1 through 10","272.7","1130.36","percent of total billed charges",""
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","both","","","1468.00","1101.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","535.82","36.5","","531.15","451.41","531.15","1 through 10","272.7","1130.36","percent of total billed charges",""
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","both","","","1468.00","1101.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","562.24","38.3","","556.78","556.78","556.78","12","272.7","1130.36","percent of total billed charges",""
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","both","","","1468.00","1101.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","998.06","997.86","998.06","1 through 10","272.7","1130.36","other","OPPS APC"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","both","","","1468.00","1101.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2992.98","994.86","2992.98","1 through 10","272.7","1130.36","other","OPPS APC"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","both","","","1468.00","1101.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","994.86","586.78","998.92","1 through 10","272.7","1130.36","other","OPPS APC"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","both","","","1468.00","1101.00","WELLPOINT [1015]","HB AMC WELLPOINT","1083.09","73.78","","1060.17","1060.17","1060.17","1 through 10","272.7","1130.36","percent of total billed charges",""
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","outpatient","","","1468.00","1101.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","936.26","","Case rate ($936.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","468.13","453.83","468.13","24","230.56","1393.31","other","Multiple Imaging"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","outpatient","","","1468.00","1101.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","936.26","","Case rate ($936.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","468.13","453.83","468.13","36","230.56","1393.31","other","Multiple Imaging"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","outpatient","","","1468.00","1101.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","344.69","344.69","391.95","1 through 10","230.56","1393.31","other","Multiple Radiology"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","outpatient","","","1468.00","1101.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","627.12","627.12","1 through 10","230.56","1393.31","other","Multiple Radiology"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","outpatient","","","1468.00","1101.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","689.37","1 through 10","230.56","1393.31","other","Multiple Radiology"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","outpatient","","","1468.00","1101.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","783.90","783.90","783.90","1 through 10","230.56","1393.31","other","Multiple Radiology"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","outpatient","","","1468.00","1101.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","664.01","344.69","1424.00","1 through 10","230.56","1393.31","other","Multiple Radiology"
"Magnetic Resonance Elastography","PX-61000155","CDM","76391","CPT","0610","RC","","","","outpatient","","","1468.00","1101.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","460.66","31.38","","437.17","437.17","626.13","1 through 10","230.56","1393.31","percent of total billed charges",""
"Major Abdominal Vascular Procedures,EXTREME","169","DRG","","","","","","","","inpatient","","","406577.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","197027.84","","Standard inlier is a Case rate ($197,027.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $164,863, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($27,969.29) for the length of stay and the standard reimbursement.","179598.05","179598.05","197027.84","1 through 10","23660.68","284142.98","case rate",""
"Major Abdominal Vascular Procedures,EXTREME","169","DRG","","","","","","","","inpatient","","","406577.55","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","41224.6177","","Fee schedule rate ($172,205.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","41224.6177","165569.16","165569.16","1 through 10","23660.68","284142.98","case rate",""
"Major Abdominal Vascular Procedures,EXTREME","169","DRG","","","","","","","","inpatient","","","406577.55","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","43287.0466","","Fee schedule rate ($180,821.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","43287.0466","180821.08","285400.49","1 through 10","23660.68","284142.98","case rate",""
"Major Abdominal Vascular Procedures,EXTREME","169","DRG","","","","","","","","inpatient","","","406577.55","","MASSHEALTH [3001]","HB BWH MEDICAID","62848.41","","Case rate ($69,489.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $111,919.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","85892.32","85892.32","85892.32","1 through 10","23660.68","284142.98","case rate",""
"Major Abdominal Vascular Procedures,EXTREME","169","DRG","","","","","","","","inpatient","","","406577.55","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","62848.41","","Case rate ($69,489.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $111,919.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","75280.41","75280.41","75280.41","1 through 10","23660.68","284142.98","case rate",""
"Major Abdominal Vascular Procedures,MAJOR","169","DRG","","","","","","","","inpatient","","","291746.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","136160.93","","Standard inlier is a Case rate ($136,160.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $105,827, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($19,326.91) for the length of stay and the standard reimbursement.","135793.34","124394.76","136160.92","1 through 10","23660.68","284142.98","case rate",""
"Major Abdominal Vascular Procedures,MAJOR","169","DRG","","","","","","","","inpatient","","","291746.06","","MASSHEALTH [3001]","HB BWH MEDICAID","37367.93","","Case rate ($41,316.68). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $83,746.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","65515.84","65515.84","65515.84","1 through 10","23660.68","284142.98","case rate",""
"Major Abdominal Vascular Procedures,MINOR","169","DRG","","","","","","","","inpatient","","","237285.71","","MASSHEALTH [3001]","HB BWH MEDICAID","23660.68","","Case rate ($26,160.95). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $68,590.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27123.63","27123.63","27123.63","1 through 10","23660.68","284142.98","case rate",""
"Major Abdominal Vascular Procedures,MODERATE","169","DRG","","","","","","","","inpatient","","","141613.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","104200.49","","Standard inlier is a Case rate ($104,200.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $83,721, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,790.39) for the length of stay and the standard reimbursement.","111291.49","111291.49","111291.49","1 through 10","23660.68","284142.98","case rate",""
"Major Abdominal Vascular Procedures,MODERATE","169","DRG","","","","","","","","inpatient","","","141613.33","","MASSHEALTH [3001]","HB BWH MEDICAID","31095.20","","Case rate ($34,381.09). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,811.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","34372.65","34372.65","34372.65","1 through 10","23660.68","284142.98","case rate",""
"Major Abdominal Vascular Procedures,MODERATE","169","DRG","","","","","","","","inpatient","","","141613.33","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82502.42","","Fee schedule rate ($82,502.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","80098.76","80098.76","80098.76","1 through 10","23660.68","284142.98","case rate",""
"Major Abdominal Vascular Procedures,MODERATE","169","DRG","","","","","","","","inpatient","","","141613.33","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","31095.20","","Case rate ($34,381.09). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,811.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27214.26","27214.26","27214.26","1 through 10","23660.68","284142.98","case rate",""
"Major Biliary Tract Procedures,MAJOR","261","DRG","","","","","","","","inpatient","","","82787.99","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","38207.09","","Standard inlier is a Case rate ($38,207.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,075, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,423.18) for the length of stay and the standard reimbursement.","86041.26","86041.26","86041.26","1 through 10","10886.75","124982.17","case rate",""
"Major Biliary Tract Procedures,MAJOR","261","DRG","","","","","","","","inpatient","","","82787.99","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","32602.1392","","Fee schedule rate ($75,745.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32602.1392","75745.84","75745.84","1 through 10","10886.75","124982.17","case rate",""
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","","","","inpatient","","","161514.83","121136.12","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","33520.54","","Case rate ($33,520.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,119.55, add-ons for qualifying new technology services are included. If operating cost exceeds $76,763.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,692.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $30,888.22 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,739.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,252.48. The transfer capital threshold is the transfer adjustment factor * $2,252.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25614.46","25614.46","33070.37","1 through 10","25397.04","43848.24","other","Inpatient DRG"
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","","","","inpatient","","","161514.83","121136.12","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","25915.35","","Case rate ($25,915.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,119.55, add-ons for qualifying new technology services are included. If operating cost exceeds $76,763.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,692.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $23,283.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,739.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,252.48. The transfer capital threshold is the transfer adjustment factor * $2,252.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25449.43","25449.43","25511.76","1 through 10","25397.04","43848.24","other","Inpatient DRG"
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","","","","inpatient","","","161514.83","121136.12","MARTIN'S POINT [160007]","HB BWH MEDICARE","33520.54","","Case rate ($33,520.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,119.55, add-ons for qualifying new technology services are included. If operating cost exceeds $76,763.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,692.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $30,888.22 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,739.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,252.48. The transfer capital threshold is the transfer adjustment factor * $2,252.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25512.62","25512.62","25512.62","1 through 10","25397.04","43848.24","other","Inpatient DRG"
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","","","","inpatient","","","161514.83","121136.12","MEDICARE [2001]","HB BWH MEDICARE","33520.54","","Case rate ($33,520.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,119.55, add-ons for qualifying new technology services are included. If operating cost exceeds $76,763.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,692.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $30,888.22 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,739.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,252.48. The transfer capital threshold is the transfer adjustment factor * $2,252.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","33548.45","0.03","33598.23","58","25397.04","43848.24","other","Inpatient DRG"
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","","","","inpatient","","","161514.83","121136.12","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","25397.04","","Case rate ($25,915.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,119.55, add-ons for qualifying new technology services are included. If operating cost exceeds $76,763.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,692.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $23,283.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,739.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,252.48. The transfer capital threshold is the transfer adjustment factor * $2,252.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","23985.28","23985.28","23985.28","1 through 10","25397.04","43848.24","other","Inpatient DRG"
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","","","","inpatient","","","161514.83","121136.12","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","25397.04","","Case rate ($25,915.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,119.55, add-ons for qualifying new technology services are included. If operating cost exceeds $76,763.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,692.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $23,283.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,739.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,252.48. The transfer capital threshold is the transfer adjustment factor * $2,252.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25480.60","24050.43","35408.40","11","25397.04","43848.24","other","Inpatient DRG"
"Major Bladder Procedures With McC","653","MS-DRG","","","","","","","","inpatient","","","180118.63","135088.97","FALLON HEALTH [1008]","HB BWH MEDICARE","61899.62","","Case rate ($61,899.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $57,442.63, add-ons for qualifying new technology services are included. If operating cost exceeds $103,087.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,621.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $57,338.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,062.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,181.33. The transfer capital threshold is the transfer adjustment factor * $4,181.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","49967.25","49967.25","49967.25","1 through 10","46826.3","81396.41","other","Inpatient DRG"
"Major Bladder Procedures With McC","653","MS-DRG","","","","","","","","inpatient","","","180118.63","135088.97","MEDICARE [2001]","HB BWH MEDICARE","61899.62","","Case rate ($61,899.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $57,442.63, add-ons for qualifying new technology services are included. If operating cost exceeds $103,087.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,621.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $57,338.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,062.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,181.33. The transfer capital threshold is the transfer adjustment factor * $4,181.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","58910.35","0.03","66096.41","11","46826.3","81396.41","other","Inpatient DRG"
"Major Bladder Procedures With McC","653","MS-DRG","","","","","","","","inpatient","","","180118.63","135088.97","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","61899.62","","Case rate ($61,899.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $57,442.63, add-ons for qualifying new technology services are included. If operating cost exceeds $103,087.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,621.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $57,338.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,062.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,181.33. The transfer capital threshold is the transfer adjustment factor * $4,181.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34697.93","34697.93","34697.93","1 through 10","46826.3","81396.41","other","Inpatient DRG"
"Major Bladder Procedures With McC","653","MS-DRG","","","","","","","","inpatient","","","180118.63","135088.97","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","46826.30","","Case rate ($47,781.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $57,442.63, add-ons for qualifying new technology services are included. If operating cost exceeds $103,087.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,621.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. The base transfer operating payment is the transfer adjustment factor * $43,220.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,062.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,181.33. The transfer capital threshold is the transfer adjustment factor * $4,181.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","50139.06","50139.06","72420.56","1 through 10","46826.3","81396.41","other","Inpatient DRG"
"Major Bladder Procedures Without Cc/McC","655","MS-DRG","","","","","","","","inpatient","","","147485.87","110614.40","FALLON HEALTH [1008]","HB BWH MEDICARE","19687.69","","Case rate ($19,687.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,622.68, add-ons for qualifying new technology services are included. If operating cost exceeds $69,267.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,143.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $17,604.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,242.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,703.14. The transfer capital threshold is the transfer adjustment factor * $1,703.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19151.66","19151.66","19151.66","1 through 10","19293.94","33154.42","other","Inpatient Replacement Plans DRG"
"Major Bladder Procedures Without Cc/McC","655","MS-DRG","","","","","","","","inpatient","","","147485.87","110614.40","MEDICARE [2001]","HB BWH MEDICARE","19687.69","","Case rate ($19,687.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,622.68, add-ons for qualifying new technology services are included. If operating cost exceeds $69,267.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,143.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $17,604.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,242.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,703.14. The transfer capital threshold is the transfer adjustment factor * $1,703.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24767.91","11523.70","24804.53","1 through 10","19293.94","33154.42","other","Inpatient Replacement Plans DRG"
"Major Bladder Procedures Without Cc/McC","655","MS-DRG","","","","","","","","inpatient","","","147485.87","110614.40","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19293.94","","Case rate ($19,687.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,622.68, add-ons for qualifying new technology services are included. If operating cost exceeds $69,267.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,143.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $17,604.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,242.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,703.14. The transfer capital threshold is the transfer adjustment factor * $1,703.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18829.36","18829.36","18829.36","1 through 10","19293.94","33154.42","other","Inpatient DRG"
"Major Bladder Procedures,MAJOR","441","DRG","","","","","","","","inpatient","","","173192.80","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","93307.02","","Standard inlier is a Case rate ($93,307.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $84,208, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,245.49) for the length of stay and the standard reimbursement.","85052.74","85052.74","85052.74","1 through 10","10746.24","122018.62","case rate",""
"Major Bladder Procedures,MAJOR","441","DRG","","","","","","","","inpatient","","","173192.80","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","104902.24","","Standard inlier is a Case rate ($104,902.24). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $84,208, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,890.00) for the length of stay and the standard reimbursement.","104902.23","95837.25","104902.23","1 through 10","10746.24","122018.62","case rate",""
"Major Bladder Procedures,MAJOR","441","DRG","","","","","","","","inpatient","","","173192.80","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33879.2949","","Fee schedule rate ($73,949.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33879.2949","73949.76","73949.76","1 through 10","10746.24","122018.62","case rate",""
"Major Bladder Procedures,MAJOR","441","DRG","","","","","","","","inpatient","","","173192.80","","MASSHEALTH [3001]","HB BWH MEDICAID","27342.53","","Case rate ($30,231.87). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $72,661.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31449.08","31449.08","31449.08","1 through 10","10746.24","122018.62","case rate",""
"Major Bladder Procedures,MAJOR","441","DRG","","","","","","","","inpatient","","","173192.80","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","27342.53","","Case rate ($30,231.87). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $72,661.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","30224.45","30224.45","30224.45","1 through 10","10746.24","122018.62","case rate",""
"Major Bladder Procedures,MODERATE","441","DRG","","","","","","","","inpatient","","","153558.24","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","71360.42","","Standard inlier is a Case rate ($71,360.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $67,139, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,130.04) for the length of stay and the standard reimbursement.","71360.41","71360.41","71360.41","1 through 10","10746.24","122018.62","case rate",""
"Major Bladder Procedures,MODERATE","441","DRG","","","","","","","","inpatient","","","153558.24","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","80228.34","","Standard inlier is a Case rate ($80,228.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $67,139, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,387.75) for the length of stay and the standard reimbursement.","80228.34","80228.34","80228.34","1 through 10","10746.24","122018.62","case rate",""
"Major Bladder Procedures,MODERATE","441","DRG","","","","","","","","inpatient","","","153558.24","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35574.2442","","Fee schedule rate ($56,631.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35574.2442","60124.34","60124.34","1 through 10","10746.24","122018.62","case rate",""
"Major Bladder Procedures,MODERATE","441","DRG","","","","","","","","inpatient","","","153558.24","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72758.32","","Fee schedule rate ($72,758.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","72758.32","72758.32","72758.32","1 through 10","10746.24","122018.62","case rate",""
"Major Cardiothoracic Repair Of Heart Anomaly,EXTREME","160","DRG","","","","","","","","inpatient","","","614564.17","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","318419.78","","Standard inlier is a Case rate ($318,419.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $259,264, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($45,201.61) for the length of stay and the standard reimbursement.","318419.78","318419.78","318419.78","1 through 10","57990.929","394971.45","case rate",""
"Major Cardiothoracic Repair Of Heart Anomaly,EXTREME","160","DRG","","","","","","","","inpatient","","","614564.17","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","357989.65","","Standard inlier is a Case rate ($357,989.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $259,264, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($50,813.66) for the length of stay and the standard reimbursement.","1398038.78","1398038.78","1398038.78","1 through 10","57990.929","394971.45","case rate",""
"Major Cardiothoracic Repair Of Heart Anomaly,EXTREME","160","DRG","","","","","","","","inpatient","","","614564.17","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","60312.6155","","Fee schedule rate ($218,169.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","60312.6155","218169.96","218169.96","1 through 10","57990.929","394971.45","case rate",""
"Major Cardiothoracic Repair Of Heart Anomaly,EXTREME","160","DRG","","","","","","","","inpatient","","","614564.17","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","63329.999","","Fee schedule rate ($229,084.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","63329.999","337443.96","337443.96","1 through 10","57990.929","394971.45","case rate",""
"Major Cardiothoracic Repair Of Heart Anomaly,MAJOR","160","DRG","","","","","","","","inpatient","","","363457.20","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","192169.87","","Standard inlier is a Case rate ($192,169.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $144,570, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($27,276.92) for the length of stay and the standard reimbursement.","192169.87","192169.87","192169.87","1 through 10","57990.929","394971.45","case rate",""
"Major Cardiothoracic Repair Of Heart Anomaly,MAJOR","160","DRG","","","","","","","","inpatient","","","363457.20","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","60312.6155","","Fee schedule rate ($93,189.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","60312.6155","93189.88","93189.88","1 through 10","57990.929","394971.45","case rate",""
"Major Chest And Respiratory Trauma,EXTREME","135","DRG","","","","","","","","inpatient","","","93726.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","69407.60","","Standard inlier is a Case rate ($69,407.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,655, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,851.83) for the length of stay and the standard reimbursement.","63409.84","63409.84","63409.84","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,EXTREME","135","DRG","","","","","","","","inpatient","","","93726.32","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","18220.74","","Case rate ($20,146.16). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,576.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20141.21","20141.21","20141.21","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MAJOR","135","DRG","","","","","","","","inpatient","","","51965.56","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","41199.52","","Standard inlier is a Case rate ($41,199.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,145, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,847.93) for the length of stay and the standard reimbursement.","6860.92","6860.92","6860.92","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MAJOR","135","DRG","","","","","","","","inpatient","","","51965.56","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12538.9402","","Fee schedule rate ($29,191.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12538.9402","29191.16","29191.16","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MAJOR","135","DRG","","","","","","","","inpatient","","","51965.56","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($29,191.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","29191.16","29191.16","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MINOR","135","DRG","","","","","","","","inpatient","","","32645.99","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24681.17","","Standard inlier is a Case rate ($24,681.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,718, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,503.29) for the length of stay and the standard reimbursement.","24681.16","24681.16","24681.16","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MINOR","135","DRG","","","","","","","","inpatient","","","32645.99","","MASSHEALTH [3001]","HB BWH MEDICAID","5606.73","","Case rate ($6,199.21). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,629.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6448.80","6448.80","6448.80","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MINOR","135","DRG","","","","","","","","inpatient","","","32645.99","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24335.18","","Fee schedule rate ($24,335.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24335.18","24335.18","24335.18","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MINOR","135","DRG","","","","","","","","inpatient","","","32645.99","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25552.34","","Fee schedule rate ($25,552.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24807.89","24807.89","24807.89","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MODERATE","135","DRG","","","","","","","","inpatient","","","34099.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","25546.16","","Standard inlier is a Case rate ($25,546.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,513, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,626.43) for the length of stay and the standard reimbursement.","23286.25","23286.25","23286.25","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MODERATE","135","DRG","","","","","","","","inpatient","","","34099.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","28720.76","","Standard inlier is a Case rate ($28,720.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,513, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,076.67) for the length of stay and the standard reimbursement.","28720.76","28720.76","28720.76","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MODERATE","135","DRG","","","","","","","","inpatient","","","34099.71","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12538.9402","","Fee schedule rate ($29,191.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12538.9402","17195.76","17195.76","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MODERATE","135","DRG","","","","","","","","inpatient","","","34099.71","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($29,191.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","17195.76","17195.76","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MODERATE","135","DRG","","","","","","","","inpatient","","","34099.71","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","6601.73","","Case rate ($7,299.35). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,729.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MODERATE","135","DRG","","","","","","","","inpatient","","","34099.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38299.42","","Fee schedule rate ($38,299.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26653.39","26653.39","26653.39","1 through 10","5606.73","83444.47","case rate",""
"Major Chest And Respiratory Trauma,MODERATE","135","DRG","","","","","","","","inpatient","","","34099.71","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6601.73","","Case rate ($7,299.35). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,729.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7297.56","7297.56","7297.56","1 through 10","5606.73","83444.47","case rate",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","24106.16","","Case rate ($23,404.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,096.43, add-ons for qualifying new technology services are included. If operating cost exceeds $73,740.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,471.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $20,993.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,716.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.96. The transfer capital threshold is the transfer adjustment factor * $2,030.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","23831.44","20483.18","23869.80","13","22935.96","39535.94","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","30261.29","","Case rate ($30,261.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,096.43, add-ons for qualifying new technology services are included. If operating cost exceeds $73,740.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,471.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $27,850.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,716.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.96. The transfer capital threshold is the transfer adjustment factor * $2,030.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22874.85","19645.17","23219.51","20","22935.96","39535.94","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","23404.04","","Case rate ($23,404.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,096.43, add-ons for qualifying new technology services are included. If operating cost exceeds $73,740.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,471.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $20,993.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,716.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.96. The transfer capital threshold is the transfer adjustment factor * $2,030.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22741.89","22741.89","112482.14","1 through 10","22935.96","39535.94","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","22659.18","22659.18","22659.18","1 through 10","22935.96","39535.94","case rate",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","FALLON HEALTH [1008]","HB BWH MEDICARE","30261.29","","Case rate ($30,261.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,096.43, add-ons for qualifying new technology services are included. If operating cost exceeds $73,740.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,471.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $27,850.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,716.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.96. The transfer capital threshold is the transfer adjustment factor * $2,030.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23146.55","23146.55","23146.55","1 through 10","22935.96","39535.94","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","HUMANA [1012]","HB BWH MEDICARE","30261.29","","Case rate ($30,261.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,096.43, add-ons for qualifying new technology services are included. If operating cost exceeds $73,740.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,471.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $27,850.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,716.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.96. The transfer capital threshold is the transfer adjustment factor * $2,030.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10500.43","10500.43","10500.43","1 through 10","22935.96","39535.94","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","MARTIN'S POINT [160007]","HB BWH MEDICARE","30261.29","","Case rate ($30,261.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,096.43, add-ons for qualifying new technology services are included. If operating cost exceeds $73,740.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,471.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $27,850.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,716.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.96. The transfer capital threshold is the transfer adjustment factor * $2,030.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22716.16","22716.16","22799.83","1 through 10","22935.96","39535.94","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","MEDICARE [2001]","HB BWH MEDICARE","30261.29","","Case rate ($30,261.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,096.43, add-ons for qualifying new technology services are included. If operating cost exceeds $73,740.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,471.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $27,850.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,716.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.96. The transfer capital threshold is the transfer adjustment factor * $2,030.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29951.57","0.03","29995.95","202","22935.96","39535.94","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","30261.29","","Case rate ($30,261.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,096.43, add-ons for qualifying new technology services are included. If operating cost exceeds $73,740.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,471.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $27,850.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,716.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.96. The transfer capital threshold is the transfer adjustment factor * $2,030.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22692.79","22692.79","22704.62","1 through 10","22935.96","39535.94","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","MOLINA [1014]","HB BWH MOLINA","22935.96","","Case rate ($23,404.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,096.43, add-ons for qualifying new technology services are included. If operating cost exceeds $73,740.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,471.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $20,993.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,716.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.96. The transfer capital threshold is the transfer adjustment factor * $2,030.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","45786.17","45786.17","45945.19","1 through 10","22935.96","39535.94","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","22935.96","","Case rate ($23,404.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,096.43, add-ons for qualifying new technology services are included. If operating cost exceeds $73,740.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,471.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $20,993.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,716.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.96. The transfer capital threshold is the transfer adjustment factor * $2,030.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22731.75","22667.82","22755.12","1 through 10","22935.96","39535.94","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","22935.96","","Case rate ($23,404.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,096.43, add-ons for qualifying new technology services are included. If operating cost exceeds $73,740.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,471.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $20,993.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,716.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.96. The transfer capital threshold is the transfer adjustment factor * $2,030.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","23128.74","23128.74","23128.74","1 through 10","22935.96","39535.94","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","22935.96","","Case rate ($23,404.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,096.43, add-ons for qualifying new technology services are included. If operating cost exceeds $73,740.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,471.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $20,993.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $27,716.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,030.96. The transfer capital threshold is the transfer adjustment factor * $2,030.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22709.15","13085.31","22808.21","26","22935.96","39535.94","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","113855.42","85391.56","WELLPOINT [1015]","HB AMC WELLPOINT","39535.94","","Fee schedule rate ($39,535.94).","37984.04","37984.04","84021.35","1 through 10","22935.96","39535.94","case rate",""
"Major Chest Procedures With McC","163","MS-DRG","","","","","","","","inpatient","","","196726.03","147544.52","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","42501.20","","Case rate ($41,263.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,595.46, add-ons for qualifying new technology services are included. If operating cost exceeds $95,239.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,046.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $37,277.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,215.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,606.32. The transfer capital threshold is the transfer adjustment factor * $3,606.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","43442.85","43442.82","43444.95","1 through 10","40438.03","70202.92","other","Inpatient DRG"
"Major Chest Procedures With McC","163","MS-DRG","","","","","","","","inpatient","","","196726.03","147544.52","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","53439.54","","Case rate ($53,439.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,595.46, add-ons for qualifying new technology services are included. If operating cost exceeds $95,239.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,046.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $49,453.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,215.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,606.32. The transfer capital threshold is the transfer adjustment factor * $3,606.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36794.28","31173.88","53969.35","1 through 10","40438.03","70202.92","other","Inpatient DRG"
"Major Chest Procedures With McC","163","MS-DRG","","","","","","","","inpatient","","","196726.03","147544.52","FALLON HEALTH [1008]","HB BWH MEDICARE","53439.54","","Case rate ($53,439.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,595.46, add-ons for qualifying new technology services are included. If operating cost exceeds $95,239.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,046.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $49,453.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,215.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,606.32. The transfer capital threshold is the transfer adjustment factor * $3,606.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","37245.67","37245.67","37245.67","1 through 10","40438.03","70202.92","other","Inpatient DRG"
"Major Chest Procedures With McC","163","MS-DRG","","","","","","","","inpatient","","","196726.03","147544.52","HUMANA [1012]","HB BWH MEDICARE","53439.54","","Case rate ($53,439.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,595.46, add-ons for qualifying new technology services are included. If operating cost exceeds $95,239.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,046.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $49,453.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,215.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,606.32. The transfer capital threshold is the transfer adjustment factor * $3,606.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10721.60","10721.60","10721.60","1 through 10","40438.03","70202.92","other","Inpatient DRG"
"Major Chest Procedures With McC","163","MS-DRG","","","","","","","","inpatient","","","196726.03","147544.52","MEDICARE [2001]","HB BWH MEDICARE","53439.54","","Case rate ($53,439.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,595.46, add-ons for qualifying new technology services are included. If operating cost exceeds $95,239.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,046.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $49,453.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,215.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,606.32. The transfer capital threshold is the transfer adjustment factor * $3,606.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","54616.86","0.03","58539.28","65","40438.03","70202.92","other","Inpatient DRG"
"Major Chest Procedures With McC","163","MS-DRG","","","","","","","","inpatient","","","196726.03","147544.52","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","53439.54","","Case rate ($53,439.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,595.46, add-ons for qualifying new technology services are included. If operating cost exceeds $95,239.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,046.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $49,453.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,215.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,606.32. The transfer capital threshold is the transfer adjustment factor * $3,606.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","41349.97","41349.97","41349.97","1 through 10","40438.03","70202.92","other","Inpatient DRG"
"Major Chest Procedures With McC","163","MS-DRG","","","","","","","","inpatient","","","196726.03","147544.52","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","40438.03","","Case rate ($41,263.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,595.46, add-ons for qualifying new technology services are included. If operating cost exceeds $95,239.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,046.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $37,277.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,215.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,606.32. The transfer capital threshold is the transfer adjustment factor * $3,606.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","41399.10","41399.10","41500.39","1 through 10","40438.03","70202.92","other","Inpatient DRG"
"Major Chest Procedures With McC","163","MS-DRG","","","","","","","","inpatient","","","196726.03","147544.52","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","40438.03","","Case rate ($41,263.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,595.46, add-ons for qualifying new technology services are included. If operating cost exceeds $95,239.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,046.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $37,277.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,215.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,606.32. The transfer capital threshold is the transfer adjustment factor * $3,606.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","41374.53","22771.14","79054.39","14","40438.03","70202.92","other","Inpatient DRG"
"Major Chest Procedures Without Cc/McC","165","MS-DRG","","","","","","","","inpatient","","","87742.11","65806.58","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","18376.62","","Case rate ($17,841.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,400.09, add-ons for qualifying new technology services are included. If operating cost exceeds $67,044.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,980.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $15,921.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,020.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.28. The transfer capital threshold is the transfer adjustment factor * $1,540.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17720.04","17713.44","23802.06","1 through 10","17484.55","28129.624","other","Inpatient DRG"
"Major Chest Procedures Without Cc/McC","165","MS-DRG","","","","","","","","inpatient","","","87742.11","65806.58","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","23041.92","","Case rate ($23,041.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,400.09, add-ons for qualifying new technology services are included. If operating cost exceeds $67,044.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,980.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $21,121.79 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,020.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.28. The transfer capital threshold is the transfer adjustment factor * $1,540.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17011.34","17011.31","21913.98","1 through 10","17484.55","28129.624","other","Inpatient DRG"
"Major Chest Procedures Without Cc/McC","165","MS-DRG","","","","","","","","inpatient","","","87742.11","65806.58","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","17841.38","","Case rate ($17,841.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,400.09, add-ons for qualifying new technology services are included. If operating cost exceeds $67,044.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,980.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $15,921.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,020.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.28. The transfer capital threshold is the transfer adjustment factor * $1,540.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16884.01","16884.01","17015.12","1 through 10","17484.55","28129.624","other","Inpatient DRG"
"Major Chest Procedures Without Cc/McC","165","MS-DRG","","","","","","","","inpatient","","","87742.11","65806.58","MEDICARE [2001]","HB BWH MEDICARE","23041.92","","Case rate ($23,041.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,400.09, add-ons for qualifying new technology services are included. If operating cost exceeds $67,044.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,980.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $21,121.79 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,020.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.28. The transfer capital threshold is the transfer adjustment factor * $1,540.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22253.26","0.03","22286.13","59","17484.55","28129.624","other","Inpatient DRG"
"Major Chest Procedures Without Cc/McC","165","MS-DRG","","","","","","","","inpatient","","","87742.11","65806.58","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","17484.55","","Case rate ($17,841.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,400.09, add-ons for qualifying new technology services are included. If operating cost exceeds $67,044.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,980.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $15,921.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,020.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.28. The transfer capital threshold is the transfer adjustment factor * $1,540.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16887.22","16887.22","16918.53","1 through 10","17484.55","28129.624","other","Inpatient DRG"
"Major Chest Procedures Without Cc/McC","165","MS-DRG","","","","","","","","inpatient","","","87742.11","65806.58","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17484.55","","Case rate ($17,841.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,400.09, add-ons for qualifying new technology services are included. If operating cost exceeds $67,044.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,980.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $15,921.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,020.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.28. The transfer capital threshold is the transfer adjustment factor * $1,540.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16891.91","16867.94","22618.98","1 through 10","17484.55","28129.624","other","Inpatient DRG"
"Major Chest Procedures Without Cc/McC","165","TRIS-DRG","","","","","","","","inpatient","","","71802.49","","CHAMPVA [160001]","HB BWH TRICARE","13986.78","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($24,568.58). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $9,449.45, and the first day is paid a rate of $18,898.91. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $9,449.45, and the first day is paid a rate of $18,898.91. The transfer payment is capped at $17,682.87. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $68,295.58 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.59999990463257). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($15,355.36), capped at $17,682.87. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $9,449.45, and the first day is paid a rate of $18,898.91. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $9,449.45, and the first day is paid a rate of $18,898.91. The transfer payment is capped at $17,682.87. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $68,295.58 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.59999990463257). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","31360.15","31360.15","31360.15","1 through 10","13986.78","13986.78","other","Inpatient DRGs"
"Major Chest Procedures Without Cc/McC","165","TRIS-DRG","","","","","","","","inpatient","","","71802.49","","TRICARE [160005]","HB BWH TRICARE","13986.78","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($24,568.58). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $9,449.45, and the first day is paid a rate of $18,898.91. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $9,449.45, and the first day is paid a rate of $18,898.91. The transfer payment is capped at $17,682.87. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $68,295.58 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.59999990463257). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($15,355.36), capped at $17,682.87. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $9,449.45, and the first day is paid a rate of $18,898.91. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $9,449.45, and the first day is paid a rate of $18,898.91. The transfer payment is capped at $17,682.87. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $68,295.58 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.59999990463257). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","17818.25","17818.25","17818.25","1 through 10","13986.78","13986.78","other","Inpatient DRGs"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","45532.45","34149.34","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10389.28","","Case rate ($10,086.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,064.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,709.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,296.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,850.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,685.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $856.24. The transfer capital threshold is the transfer adjustment factor * $856.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10262.32","10262.32","10262.32","1 through 10","9884.95","16668.06","other","Inpatient DRG"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","45532.45","34149.34","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","10086.68","","Case rate ($10,086.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,064.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,709.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,296.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,850.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,685.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $856.24. The transfer capital threshold is the transfer adjustment factor * $856.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9773.76","9773.76","9773.76","1 through 10","9884.95","16668.06","other","Inpatient DRG"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","45532.45","34149.34","MEDICARE [2001]","HB BWH MEDICARE","12977.65","","Case rate ($12,977.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,064.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,709.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,296.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $11,741.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,685.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $856.24. The transfer capital threshold is the transfer adjustment factor * $856.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12870.26","0.03","12889.11","32","9884.95","16668.06","other","Inpatient DRG"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","45532.45","34149.34","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","12977.65","","Case rate ($12,977.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,064.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,709.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,296.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $11,741.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,685.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $856.24. The transfer capital threshold is the transfer adjustment factor * $856.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9800.75","9800.75","9800.75","1 through 10","9884.95","16668.06","other","Inpatient DRG"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","45532.45","34149.34","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9884.95","","Case rate ($10,086.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,064.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,709.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,296.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,850.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,685.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $856.24. The transfer capital threshold is the transfer adjustment factor * $856.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9868.52","9868.52","14969.22","1 through 10","9884.95","16668.06","other","Inpatient DRG"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","45532.45","34149.34","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9884.95","","Case rate ($10,086.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,064.96, add-ons for qualifying new technology services are included. If operating cost exceeds $57,709.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,296.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,850.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,685.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $856.24. The transfer capital threshold is the transfer adjustment factor * $856.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9833.53","9817.94","84719.26","1 through 10","9884.95","16668.06","other","Inpatient DRG"
"Major Chest Trauma With Cc","184","TRIS-DRG","","","","","","","","inpatient","","","20276.35","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","7725.77","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($13,570.75). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $57,297.75 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($10,052.41), capped at $9,767.35. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $57,297.75 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","14004.64","14004.64","14004.64","1 through 10","7725.77","7725.77","other","Inpatient DRGs"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","70701.91","53026.43","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","18492.21","","Case rate ($18,492.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,180, add-ons for qualifying new technology services are included. If operating cost exceeds $62,824.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,671.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $16,881.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,800.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.05. The transfer capital threshold is the transfer adjustment factor * $1,231.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14803.10","14803.10","14803.10","1 through 10","14049.04","23964.35","other","Inpatient DRG"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","70701.91","53026.43","MEDICARE [2001]","HB BWH MEDICARE","18492.21","","Case rate ($18,492.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,180, add-ons for qualifying new technology services are included. If operating cost exceeds $62,824.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,671.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $16,881.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,800.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.05. The transfer capital threshold is the transfer adjustment factor * $1,231.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18991.21","0.03","19019.20","18","14049.04","23964.35","other","Inpatient DRG"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","70701.91","53026.43","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14049.04","","Case rate ($14,335.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,180, add-ons for qualifying new technology services are included. If operating cost exceeds $62,824.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,671.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $12,724.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,800.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.05. The transfer capital threshold is the transfer adjustment factor * $1,231.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14509.16","14509.16","14509.16","1 through 10","14049.04","23964.35","other","Inpatient DRG"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","70701.91","53026.43","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14049.04","","Case rate ($14,335.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,180, add-ons for qualifying new technology services are included. If operating cost exceeds $62,824.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,671.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $12,724.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,800.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.05. The transfer capital threshold is the transfer adjustment factor * $1,231.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14495.79","14495.79","14495.79","1 through 10","14049.04","23964.35","other","Inpatient DRG"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","70701.91","53026.43","WELLSENSE [1003]","HB BWH MEDICARE","18492.21","","Case rate ($18,492.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,180, add-ons for qualifying new technology services are included. If operating cost exceeds $62,824.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,671.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $16,881.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,800.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,231.05. The transfer capital threshold is the transfer adjustment factor * $1,231.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14900.88","14900.88","14900.88","1 through 10","14049.04","23964.35","other","Inpatient DRG"
"Major Chest Trauma Without Cc/McC","185","MS-DRG","","","","","","","","inpatient","","","23974.05","17980.54","MEDICARE [2001]","HB BWH MEDICARE","7554.37","","Case rate ($7,554.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,016.57, add-ons for qualifying new technology services are included. If operating cost exceeds $54,661.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,073.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,541.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,636.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $632.86. The transfer capital threshold is the transfer adjustment factor * $632.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1250.86","730.49","9446.70","1 through 10","7403.28","11736.2707","other","Inpatient Replacement Plans DRG"
"Major Cranial Or Facial Bone Procedures,MAJOR","089","DRG","","","","","","","","inpatient","","","336153.27","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","135059.22","","Standard inlier is a Case rate ($135,059.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $105,067, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($19,170.53) for the length of stay and the standard reimbursement.","135059.22","135059.22","135059.22","1 through 10","14426.94","279673.67","case rate",""
"Major Cranial Or Facial Bone Procedures,MAJOR","089","DRG","","","","","","","","inpatient","","","336153.27","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","32993.1328","","Fee schedule rate ($79,974.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32993.1328","83781.54","83781.54","1 through 10","14426.94","279673.67","case rate",""
"Major Cranial Or Facial Bone Procedures,MAJOR","089","DRG","","","","","","","","inpatient","","","336153.27","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","31421.1616","","Fee schedule rate ($76,164.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31421.1616","76164.12","76164.12","1 through 10","14426.94","279673.67","case rate",""
"Major Cranial Or Facial Bone Procedures,MAJOR","089","DRG","","","","","","","","inpatient","","","336153.27","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119973.82","","Fee schedule rate ($119,973.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","119973.82","119973.82","119973.82","1 through 10","14426.94","279673.67","case rate",""
"Major Cranial Or Facial Bone Procedures,MINOR","089","DRG","","","","","","","","inpatient","","","41019.93","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","49132.45","","Standard inlier is a Case rate ($49,132.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,855, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,974.65) for the length of stay and the standard reimbursement.","49132.44","49132.44","49132.44","1 through 10","14426.94","279673.67","case rate",""
"Major Cranial Or Facial Bone Procedures,MINOR","089","DRG","","","","","","","","inpatient","","","41019.93","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","34563.70","","Fee schedule rate ($34,563.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34563.70","34563.70","34563.70","1 through 10","14426.94","279673.67","case rate",""
"Major Cranial Or Facial Bone Procedures,MINOR","089","DRG","","","","","","","","inpatient","","","41019.93","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61040.96","","Fee schedule rate ($61,040.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61040.96","61040.96","61040.96","1 through 10","14426.94","279673.67","case rate",""
"Major Cranial Or Facial Bone Procedures,MODERATE","089","DRG","","","","","","","","inpatient","","","98105.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","65762.19","","Standard inlier is a Case rate ($65,762.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $62,788, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,335.34) for the length of stay and the standard reimbursement.","65762.18","65762.18","65762.18","1 through 10","14426.94","279673.67","case rate",""
"Major Cranial Or Facial Bone Procedures,MODERATE","089","DRG","","","","","","","","inpatient","","","98105.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","73934.42","","Standard inlier is a Case rate ($73,934.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $62,788, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,494.38) for the length of stay and the standard reimbursement.","73934.42","73934.42","73934.42","1 through 10","14426.94","279673.67","case rate",""
"Major Cranial Or Facial Bone Procedures,MODERATE","089","DRG","","","","","","","","inpatient","","","98105.74","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","32993.1328","","Fee schedule rate ($49,057.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32993.1328","49057.56","49057.56","1 through 10","14426.94","279673.67","case rate",""
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","","","","inpatient","","","54202.28","40651.71","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9503.77","","Case rate ($9,503.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,363.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,007.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,244.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,319.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,983.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.82. The transfer capital threshold is the transfer adjustment factor * $804.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9415.39","9415.39","9415.39","1 through 10","9313.69","15094.0182","other","Inpatient Replacement Plans DRG"
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","","","","inpatient","","","54202.28","40651.71","MEDICARE [2001]","HB BWH MEDICARE","9503.77","","Case rate ($9,503.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,363.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,007.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,244.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,319.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,983.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $804.82. The transfer capital threshold is the transfer adjustment factor * $804.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12274.94","12274.94","12274.94","1 through 10","9313.69","15094.0182","other","Inpatient Replacement Plans DRG"
"Major Esophageal Disorders With McC","368","MS-DRG","","","","","","","","inpatient","","","77389.73","58042.30","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","14901.32","","Case rate ($14,901.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,860.85, add-ons for qualifying new technology services are included. If operating cost exceeds $63,505.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,721.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,240.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,481.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,280.94. The transfer capital threshold is the transfer adjustment factor * $1,280.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15558.72","15558.72","15558.72","1 through 10","14603.29","24935.52","other","Inpatient DRG"
"Major Esophageal Disorders With McC","368","MS-DRG","","","","","","","","inpatient","","","77389.73","58042.30","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","26616.71","26616.71","26616.71","1 through 10","14603.29","24935.52","case rate",""
"Major Esophageal Disorders With McC","368","MS-DRG","","","","","","","","inpatient","","","77389.73","58042.30","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","14901.32","","Case rate ($14,901.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,860.85, add-ons for qualifying new technology services are included. If operating cost exceeds $63,505.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,721.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,240.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,481.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,280.94. The transfer capital threshold is the transfer adjustment factor * $1,280.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15240.93","15240.93","15240.93","1 through 10","14603.29","24935.52","other","Inpatient Replacement Plans DRG"
"Major Esophageal Disorders With McC","368","MS-DRG","","","","","","","","inpatient","","","77389.73","58042.30","MEDICARE [2001]","HB BWH MEDICARE","14901.32","","Case rate ($14,901.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,860.85, add-ons for qualifying new technology services are included. If operating cost exceeds $63,505.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,721.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,240.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,481.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,280.94. The transfer capital threshold is the transfer adjustment factor * $1,280.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19995.62","0.03","177932.56","1 through 10","14603.29","24935.52","other","Inpatient Replacement Plans DRG"
"Major Esophageal Disorders With McC","368","MS-DRG","","","","","","","","inpatient","","","77389.73","58042.30","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14603.29","","Case rate ($14,901.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,860.85, add-ons for qualifying new technology services are included. If operating cost exceeds $63,505.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,721.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,240.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,481.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,280.94. The transfer capital threshold is the transfer adjustment factor * $1,280.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15127.83","15127.83","15127.83","1 through 10","14603.29","24935.52","other","Inpatient DRG"
"Major Esophageal Disorders,EXTREME","242","DRG","","","","","","","","inpatient","","","215784.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","74541.64","","Standard inlier is a Case rate ($74,541.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,208, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,580.57) for the length of stay and the standard reimbursement.","74541.63","74541.63","74541.63","1 through 10","6442.94","126945.57","case rate",""
"Major Esophageal Disorders,EXTREME","242","DRG","","","","","","","","inpatient","","","215784.03","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72101.88","","Fee schedule rate ($72,101.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61286.60","61286.60","61286.60","1 through 10","6442.94","126945.57","case rate",""
"Major Esophageal Disorders,MAJOR","242","DRG","","","","","","","","inpatient","","","63226.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","32308.66","","Standard inlier is a Case rate ($32,308.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,771, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,586.41) for the length of stay and the standard reimbursement.","33235.66","33235.66","33235.66","1 through 10","6442.94","126945.57","case rate",""
"Major Esophageal Disorders,MAJOR","242","DRG","","","","","","","","inpatient","","","63226.36","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","13100.4908","","Fee schedule rate ($31,776.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13100.4908","31776.56","31776.56","1 through 10","6442.94","126945.57","case rate",""
"Major Esophageal Disorders,MAJOR","242","DRG","","","","","","","","inpatient","","","63226.36","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10155.63","","Case rate ($11,228.80). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,658.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11226.04","11226.04","11226.04","1 through 10","6442.94","126945.57","case rate",""
"Major Esophageal Disorders,MODERATE","242","DRG","","","","","","","","inpatient","","","24011.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25328.38","","Standard inlier is a Case rate ($25,328.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,167, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,595.15) for the length of stay and the standard reimbursement.","25328.37","25328.37","25328.37","1 through 10","6442.94","126945.57","case rate",""
"Major Gastrointestinal And Peritoneal Infections,EXTREME","248","DRG","","","","","","","","inpatient","","","120522.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","57997.12","","Standard inlier is a Case rate ($57,997.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,748, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,233.04) for the length of stay and the standard reimbursement.","57997.11","57997.11","57997.11","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,EXTREME","248","DRG","","","","","","","","inpatient","","","120522.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","65204.39","","Standard inlier is a Case rate ($65,204.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,748, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,255.22) for the length of stay and the standard reimbursement.","65204.38","65204.38","65204.38","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,EXTREME","248","DRG","","","","","","","","inpatient","","","120522.22","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13679.6572","","Fee schedule rate ($68,749.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13679.6572","75730.20","75730.20","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","57266.47","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31907.63","","Standard inlier is a Case rate ($31,907.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,460, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,529.48) for the length of stay and the standard reimbursement.","29084.96","29084.96","29084.96","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","57266.47","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35872.78","","Standard inlier is a Case rate ($35,872.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,460, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,091.84) for the length of stay and the standard reimbursement.","32772.87","32772.87","35872.77","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","57266.47","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13679.6572","","Fee schedule rate ($20,114.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13679.6572","32293.48","32293.48","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","57266.47","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","14364.0376","","Fee schedule rate ($21,120.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14364.0376","33909.08","33909.08","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","57266.47","","MASSHEALTH [3001]","HB BWH MEDICAID","10610.30","","Case rate ($11,731.51). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,161.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11728.62","11728.62","11728.62","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","57266.47","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23043.62","","Fee schedule rate ($23,043.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26398.71","26398.71","26398.71","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","57266.47","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24196.17","","Fee schedule rate ($24,196.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32610.68","32610.68","32610.68","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","57266.47","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10610.30","","Case rate ($11,731.51). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,161.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11728.63","11728.63","11728.63","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MINOR","248","DRG","","","","","","","","inpatient","","","28332.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","16497.14","","Standard inlier is a Case rate ($16,497.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,477, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,341.87) for the length of stay and the standard reimbursement.","16497.14","16497.14","16497.14","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MINOR","248","DRG","","","","","","","","inpatient","","","28332.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18547.24","","Standard inlier is a Case rate ($18,547.24). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,477, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,632.63) for the length of stay and the standard reimbursement.","13555.60","13555.60","13555.60","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MINOR","248","DRG","","","","","","","","inpatient","","","28332.21","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13679.6572","","Fee schedule rate ($13,679.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13679.6572","13679.64","13679.64","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MINOR","248","DRG","","","","","","","","inpatient","","","28332.21","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","14364.0376","","Fee schedule rate ($14,364.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14364.0376","14364.04","14364.04","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","37556.75","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21720.22","","Standard inlier is a Case rate ($21,720.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,538, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,083.32) for the length of stay and the standard reimbursement.","21720.21","21720.21","21720.21","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","37556.75","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24419.38","","Standard inlier is a Case rate ($24,419.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,538, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,466.13) for the length of stay and the standard reimbursement.","22309.20","22309.20","24419.37","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","37556.75","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13679.6572","","Fee schedule rate ($20,114.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13679.6572","20114.64","20114.64","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","37556.75","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","14364.0376","","Fee schedule rate ($21,120.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14364.0376","21120.96","21120.96","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","37556.75","","MASSHEALTH [3001]","HB BWH MEDICAID","6778.80","","Case rate ($7,495.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,925.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7493.29","7493.29","7493.29","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","37556.75","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23043.62","","Fee schedule rate ($23,043.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23043.62","23043.62","23043.62","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","37556.75","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24196.17","","Fee schedule rate ($24,196.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24196.17","24196.17","24196.17","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","37556.75","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6778.80","","Case rate ($7,495.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,925.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7493.29","7493.29","7493.29","1 through 10","4675.7","113437.97","case rate",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","45457.73","34093.30","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","20318.00","20318.00","20318.00","1 through 10","9499.62","15533.1663","case rate",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","45457.73","34093.30","MEDICARE [2001]","HB BWH MEDICARE","9693.49","","Case rate ($9,693.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,591.65, add-ons for qualifying new technology services are included. If operating cost exceeds $57,236.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,261.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,492.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,211.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $821.56. The transfer capital threshold is the transfer adjustment factor * $821.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12412.85","0.03","12431.00","21","9499.62","15533.1663","other","Inpatient Replacement Plans DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","45457.73","34093.30","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9499.62","","Case rate ($9,693.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,591.65, add-ons for qualifying new technology services are included. If operating cost exceeds $57,236.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,261.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,492.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,211.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $821.56. The transfer capital threshold is the transfer adjustment factor * $821.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9464.54","9462.01","13900.81","1 through 10","9499.62","15533.1663","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","79305.28","59478.96","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","20692.83","","Case rate ($16,554.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,850.63, add-ons for qualifying new technology services are included. If operating cost exceeds $65,495.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,866.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $14,747.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,470.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,426.74. The transfer capital threshold is the transfer adjustment factor * $1,426.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","16246.47","16246.47","16246.47","1 through 10","16223.17","27773.84","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","79305.28","59478.96","MEDICARE [2001]","HB BWH MEDICARE","21371.45","","Case rate ($21,371.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,850.63, add-ons for qualifying new technology services are included. If operating cost exceeds $65,495.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,866.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $19,564.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,470.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,426.74. The transfer capital threshold is the transfer adjustment factor * $1,426.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20885.72","0.03","20916.55","28","16223.17","27773.84","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","79305.28","59478.96","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16223.17","","Case rate ($16,554.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,850.63, add-ons for qualifying new technology services are included. If operating cost exceeds $65,495.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,866.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $14,747.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,470.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,426.74. The transfer capital threshold is the transfer adjustment factor * $1,426.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15923.23","15923.23","24245.05","1 through 10","16223.17","27773.84","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC","373","MS-DRG","","","","","","","","inpatient","","","33868.96","25401.72","MEDICARE [2001]","HB BWH MEDICARE","7015.27","","Case rate ($7,015.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,367.57, add-ons for qualifying new technology services are included. If operating cost exceeds $54,012.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,025.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,050.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,987.74 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.31. The transfer capital threshold is the transfer adjustment factor * $585.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8842.91","8842.91","8842.91","1 through 10","6874.96","10947.0114","other","Inpatient Replacement Plans DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC","373","MS-DRG","","","","","","","","inpatient","","","33868.96","25401.72","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6874.96","","Case rate ($7,015.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,367.57, add-ons for qualifying new technology services are included. If operating cost exceeds $54,012.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,025.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,050.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,987.74 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $585.31. The transfer capital threshold is the transfer adjustment factor * $585.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15010.62","15010.62","15010.62","1 through 10","6874.96","10947.0114","other","Inpatient DRG"
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","","","","inpatient","","","121020.70","90765.52","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","26201.72","","Case rate ($26,201.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,330.97, add-ons for qualifying new technology services are included. If operating cost exceeds $69,975.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,195.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $24,066.84 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,951.13 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,755.04. The transfer capital threshold is the transfer adjustment factor * $1,755.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","25231.09","25231.09","25231.09","1 through 10","19870.54","34164.75","other","Inpatient DRG"
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","","","","inpatient","","","121020.70","90765.52","MEDICARE [2001]","HB BWH MEDICARE","26201.72","","Case rate ($26,201.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,330.97, add-ons for qualifying new technology services are included. If operating cost exceeds $69,975.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,195.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $24,066.84 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,951.13 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,755.04. The transfer capital threshold is the transfer adjustment factor * $1,755.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","25607.27","8171.88","25645.15","14","19870.54","34164.75","other","Inpatient DRG"
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","","","","inpatient","","","121020.70","90765.52","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19870.54","","Case rate ($20,276.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,330.97, add-ons for qualifying new technology services are included. If operating cost exceeds $69,975.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,195.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $18,141.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,951.13 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,755.04. The transfer capital threshold is the transfer adjustment factor * $1,755.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","19499.92","19499.92","19499.92","1 through 10","19870.54","34164.75","other","Inpatient DRG"
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","","","","inpatient","","","121020.70","90765.52","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19870.54","","Case rate ($20,276.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,330.97, add-ons for qualifying new technology services are included. If operating cost exceeds $69,975.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,195.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $18,141.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,951.13 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,755.04. The transfer capital threshold is the transfer adjustment factor * $1,755.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","19425.69","19425.69","19425.69","1 through 10","19870.54","34164.75","other","Inpatient DRG"
"Major Head And Neck Procedures With McC","140","MS-DRG","","","","","","","","inpatient","","","141939.72","106454.79","MEDICARE [2001]","HB BWH MEDICARE","50876.40","","Case rate ($50,876.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $47,218.02, add-ons for qualifying new technology services are included. If operating cost exceeds $92,862.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,872.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $47,064.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,838.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,432.11. The transfer capital threshold is the transfer adjustment factor * $3,432.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","50136.97","50136.97","50136.97","1 through 10","38502.58","63822.8572","other","Inpatient DRG"
"Major Head And Neck Procedures Without Cc/McC","142","MS-DRG","","","","","","","","inpatient","","","93195.06","69896.29","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","15203.77","15203.77","15203.77","1 through 10","14643.52","23729.0884","case rate",""
"Major Head And Neck Procedures Without Cc/McC","142","MS-DRG","","","","","","","","inpatient","","","93195.06","69896.29","MEDICARE [2001]","HB BWH MEDICARE","19279.50","","Case rate ($19,279.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,910.25, add-ons for qualifying new technology services are included. If operating cost exceeds $63,554.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,724.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $17,615.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,530.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,284.56. The transfer capital threshold is the transfer adjustment factor * $1,284.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","18815.55","7025.20","18843.29","1 through 10","14643.52","23729.0884","other","Inpatient DRG"
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,EXTREME","660","DRG","","","","","","","","inpatient","","","150317.57","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","76289.18","","Standard inlier is a Case rate ($76,289.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $70,973, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,829.71) for the length of stay and the standard reimbursement.","76289.18","69540.37","276182.28","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,EXTREME","660","DRG","","","","","","","","inpatient","","","150317.57","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","85769.60","","Standard inlier is a Case rate ($85,769.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $70,973, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,174.28) for the length of stay and the standard reimbursement.","78357.94","78357.94","162420.09","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,EXTREME","660","DRG","","","","","","","","inpatient","","","150317.57","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","99505.32","99505.32","114766.87","1 through 10","10011.7","232744","percent of total billed charges",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,EXTREME","660","DRG","","","","","","","","inpatient","","","150317.57","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","141055.25","","Fee schedule rate ($141,055.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","141055.24","141055.24","141055.24","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,EXTREME","660","DRG","","","","","","","","inpatient","","","150317.57","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","148112.11","","Fee schedule rate ($148,112.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","148112.12","148112.12","148112.12","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,EXTREME","660","DRG","","","","","","","","inpatient","","","150317.57","","MASSHEALTH [3001]","HB BWH MEDICAID","42418.33","","Case rate ($46,900.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $89,330.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","525713.44","525713.44","525713.44","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,EXTREME","660","DRG","","","","","","","","inpatient","","","150317.57","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","42418.33","","Case rate ($46,900.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $89,330.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","476948.65","476948.65","476948.65","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","65847.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","34963.86","","Standard inlier is a Case rate ($34,963.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,838, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,963.33) for the length of stay and the standard reimbursement.","34963.85","34963.85","108553.42","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","65847.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","39308.80","","Standard inlier is a Case rate ($39,308.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,838, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,579.56) for the length of stay and the standard reimbursement.","39308.79","35911.97","47547.82","15","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","65847.65","","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","","38.3","","8843.41","8843.41","8843.41","1 through 10","10011.7","232744","percent of total billed charges",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","65847.65","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","","65","","67500.51","67500.51","67500.51","1 through 10","10011.7","232744","percent of total billed charges",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","65847.65","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","21330.87","21330.87","21330.87","1 through 10","10011.7","232744","percent of total billed charges",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","65847.65","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","14758.23","","Case rate ($16,317.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,747.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8047.49","8047.49","8047.49","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","65847.65","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","40374.78","","Fee schedule rate ($40,374.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42296.74","42296.74","42296.74","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","65847.65","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","38451.11","","Fee schedule rate ($38,451.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38451.12","38451.12","41245.53","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","65847.65","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","40374.78","","Fee schedule rate ($40,374.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40374.80","40374.80","42296.72","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","65847.65","","MASSHEALTH [3001]","HB BWH MEDICAID","14758.23","","Case rate ($16,317.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,747.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","58589.85","58589.85","58589.85","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","65847.65","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","42900.54","","Fee schedule rate ($42,900.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42900.54","42900.54","42900.54","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MAJOR","660","DRG","","","","","","","","inpatient","","","65847.65","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14758.23","","Case rate ($16,317.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,747.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16313.75","16313.75","16313.75","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MODERATE","660","DRG","","","","","","","","inpatient","","","37219.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22428.48","","Standard inlier is a Case rate ($22,428.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,089, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,183.86) for the length of stay and the standard reimbursement.","22428.48","22428.48","22428.48","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MODERATE","660","DRG","","","","","","","","inpatient","","","37219.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25215.66","","Standard inlier is a Case rate ($25,215.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,089, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,579.15) for the length of stay and the standard reimbursement.","25215.66","23037.62","25215.66","13","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MODERATE","660","DRG","","","","","","","","inpatient","","","37219.31","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","20982.48","","Fee schedule rate ($20,982.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20982.48","20982.48","20982.48","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MODERATE","660","DRG","","","","","","","","inpatient","","","37219.31","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22032.22","","Fee schedule rate ($22,032.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22032.20","22032.20","22032.20","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MODERATE","660","DRG","","","","","","","","inpatient","","","37219.31","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27515.08","","Fee schedule rate ($27,515.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31515.08","31515.08","31515.08","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MODERATE","660","DRG","","","","","","","","inpatient","","","37219.31","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28891.29","","Fee schedule rate ($28,891.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28891.29","28891.29","28891.29","1 through 10","10011.7","232744","case rate",""
"Major Hematologic Or Immunologic Diagnoses Except Sickle Cell Crisis And Coagulation,MODERATE","660","DRG","","","","","","","","inpatient","","","37219.31","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10011.70","","Case rate ($11,069.65). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,499.65, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","170474.90","170474.90","170474.90","1 through 10","10011.7","232744","case rate",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","51288.40","38466.30","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","11927.51","","Case rate ($11,927.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,280.96, add-ons for qualifying new technology services are included. If operating cost exceeds $59,925.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,458.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,529.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,901.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,018.62. The transfer capital threshold is the transfer adjustment factor * $1,018.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11394.75","11394.75","14682.99","1 through 10","11688.96","18690.2035","other","Inpatient Replacement Plans DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","51288.40","38466.30","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","11927.51","","Case rate ($11,927.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,280.96, add-ons for qualifying new technology services are included. If operating cost exceeds $59,925.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,458.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,529.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,901.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,018.62. The transfer capital threshold is the transfer adjustment factor * $1,018.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11415.15","11415.15","11415.15","1 through 10","11688.96","18690.2035","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","51288.40","38466.30","HUMANA [1012]","HB BWH MEDICARE","11927.51","","Case rate ($11,927.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,280.96, add-ons for qualifying new technology services are included. If operating cost exceeds $59,925.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,458.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,529.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,901.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,018.62. The transfer capital threshold is the transfer adjustment factor * $1,018.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11530.71","11530.71","11530.71","1 through 10","11688.96","18690.2035","other","Inpatient Replacement Plans DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","51288.40","38466.30","MEDICARE [2001]","HB BWH MEDICARE","11927.51","","Case rate ($11,927.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,280.96, add-ons for qualifying new technology services are included. If operating cost exceeds $59,925.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,458.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,529.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,901.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,018.62. The transfer capital threshold is the transfer adjustment factor * $1,018.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14879.14","14879.14","14900.98","40","11688.96","18690.2035","other","Inpatient Replacement Plans DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","51288.40","38466.30","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","11927.51","","Case rate ($11,927.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,280.96, add-ons for qualifying new technology services are included. If operating cost exceeds $59,925.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,458.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,529.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,901.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,018.62. The transfer capital threshold is the transfer adjustment factor * $1,018.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11313.57","11313.57","11313.57","1 through 10","11688.96","18690.2035","other","Inpatient Replacement Plans DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","51288.40","38466.30","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","11688.96","","Case rate ($11,927.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,280.96, add-ons for qualifying new technology services are included. If operating cost exceeds $59,925.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,458.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,529.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,901.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,018.62. The transfer capital threshold is the transfer adjustment factor * $1,018.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11327.38","11327.38","11338.12","1 through 10","11688.96","18690.2035","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","51288.40","38466.30","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11688.96","","Case rate ($11,927.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,280.96, add-ons for qualifying new technology services are included. If operating cost exceeds $59,925.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,458.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,529.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,901.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,018.62. The transfer capital threshold is the transfer adjustment factor * $1,018.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11374.73","11374.73","11378.56","1 through 10","11688.96","18690.2035","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC","808","MS-DRG","","","","","","","","inpatient","","","119119.04","89339.28","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","21136.15","","Case rate ($20,520.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,625.27, add-ons for qualifying new technology services are included. If operating cost exceeds $70,269.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,216.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $18,364.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,245.43 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,776.61. The transfer capital threshold is the transfer adjustment factor * $1,776.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","21707.12","21707.12","21707.12","1 through 10","20110.12","34584.55","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC","808","MS-DRG","","","","","","","","inpatient","","","119119.04","89339.28","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","20520.53","","Case rate ($20,520.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,625.27, add-ons for qualifying new technology services are included. If operating cost exceeds $70,269.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,216.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $18,364.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,245.43 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,776.61. The transfer capital threshold is the transfer adjustment factor * $1,776.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21119.23","21119.23","26901.20","1 through 10","20110.12","34584.55","other","Inpatient Replacement Plans DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC","808","MS-DRG","","","","","","","","inpatient","","","119119.04","89339.28","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","25650.66","","Case rate ($20,520.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,625.27, add-ons for qualifying new technology services are included. If operating cost exceeds $70,269.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,216.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $18,364.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,245.43 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,776.61. The transfer capital threshold is the transfer adjustment factor * $1,776.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","20681.26","20681.26","20681.26","1 through 10","20110.12","34584.55","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC","808","MS-DRG","","","","","","","","inpatient","","","119119.04","89339.28","FALLON HEALTH [1008]","HB BWH MEDICARE","20520.53","","Case rate ($20,520.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,625.27, add-ons for qualifying new technology services are included. If operating cost exceeds $70,269.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,216.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $18,364.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,245.43 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,776.61. The transfer capital threshold is the transfer adjustment factor * $1,776.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21086.86","21086.86","21086.86","1 through 10","20110.12","34584.55","other","Inpatient Replacement Plans DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC","808","MS-DRG","","","","","","","","inpatient","","","119119.04","89339.28","MEDICARE [2001]","HB BWH MEDICARE","20520.53","","Case rate ($20,520.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,625.27, add-ons for qualifying new technology services are included. If operating cost exceeds $70,269.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,216.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $18,364.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,245.43 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,776.61. The transfer capital threshold is the transfer adjustment factor * $1,776.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27278.98","27278.98","27319.36","37","20110.12","34584.55","other","Inpatient Replacement Plans DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC","808","MS-DRG","","","","","","","","inpatient","","","119119.04","89339.28","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20110.12","","Case rate ($20,520.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,625.27, add-ons for qualifying new technology services are included. If operating cost exceeds $70,269.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,216.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $18,364.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,245.43 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,776.61. The transfer capital threshold is the transfer adjustment factor * $1,776.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20752.23","20654.17","20828.83","1 through 10","20110.12","34584.55","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC","810","MS-DRG","","","","","","","","inpatient","","","33731.44","25298.58","FALLON HEALTH [1008]","HB BWH MEDICARE","9927.03","","Case rate ($9,927.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,872.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,517.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,282.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,705.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,492.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.16. The transfer capital threshold is the transfer adjustment factor * $842.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8766.40","8766.40","8766.40","1 through 10","9728.49","14363.6138","other","Inpatient Replacement Plans DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC","810","MS-DRG","","","","","","","","inpatient","","","33731.44","25298.58","HUMANA [1012]","HB BWH MEDICARE","9927.03","","Case rate ($9,927.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,872.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,517.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,282.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,705.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,492.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.16. The transfer capital threshold is the transfer adjustment factor * $842.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","170655.77","170655.77","170655.77","1 through 10","9728.49","14363.6138","other","Inpatient Replacement Plans DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC","810","MS-DRG","","","","","","","","inpatient","","","33731.44","25298.58","MEDICARE [2001]","HB BWH MEDICARE","9927.03","","Case rate ($9,927.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,872.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,517.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,282.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,705.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,492.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.16. The transfer capital threshold is the transfer adjustment factor * $842.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11499.19","11499.19","11499.19","1 through 10","9728.49","14363.6138","other","Inpatient Replacement Plans DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC","810","MS-DRG","","","","","","","","inpatient","","","33731.44","25298.58","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9728.49","","Case rate ($9,927.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,872.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,517.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,282.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,705.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,492.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.16. The transfer capital threshold is the transfer adjustment factor * $842.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","218973.20","218973.20","218973.20","1 through 10","9728.49","14363.6138","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement","469","MS-DRG","","","","","","","","inpatient","","","119012.68","89259.51","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","28890.49","","Case rate ($28,049.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $33,688.06, add-ons for qualifying new technology services are included. If operating cost exceeds $79,332.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,880.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $25,228.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $33,308.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,440.69. The transfer capital threshold is the transfer adjustment factor * $2,440.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","30905.39","30905.39","30905.39","1 through 10","27488.04","47512.04","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement","469","MS-DRG","","","","","","","","inpatient","","","119012.68","89259.51","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","28049.02","","Case rate ($28,049.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $33,688.06, add-ons for qualifying new technology services are included. If operating cost exceeds $79,332.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,880.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $25,228.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $33,308.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,440.69. The transfer capital threshold is the transfer adjustment factor * $2,440.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","38234.40","38234.40","38234.40","1 through 10","27488.04","47512.04","other","Inpatient Replacement Plans DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement","469","MS-DRG","","","","","","","","inpatient","","","119012.68","89259.51","MEDICARE [2001]","HB BWH MEDICARE","28049.02","","Case rate ($28,049.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $33,688.06, add-ons for qualifying new technology services are included. If operating cost exceeds $79,332.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,880.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $25,228.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $33,308.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,440.69. The transfer capital threshold is the transfer adjustment factor * $2,440.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","38813.50","33306.81","38871.15","1 through 10","27488.04","47512.04","other","Inpatient Replacement Plans DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement","469","MS-DRG","","","","","","","","inpatient","","","119012.68","89259.51","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","27488.04","","Case rate ($28,049.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $33,688.06, add-ons for qualifying new technology services are included. If operating cost exceeds $79,332.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,880.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $25,228.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $33,308.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,440.69. The transfer capital threshold is the transfer adjustment factor * $2,440.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","29451.32","29446.40","29465.01","1 through 10","27488.04","47512.04","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","85101.46","63826.09","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","23215.95","","Case rate ($23,215.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,561.51, add-ons for qualifying new technology services are included. If operating cost exceeds $67,205.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,992.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $21,284.00 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,181.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,552.11. The transfer capital threshold is the transfer adjustment factor * $1,552.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","17204.40","17204.40","17204.40","1 through 10","17615.97","30214.29","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","85101.46","63826.09","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","17975.48","","Case rate ($17,975.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,561.51, add-ons for qualifying new technology services are included. If operating cost exceeds $67,205.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,992.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $16,043.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,181.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,552.11. The transfer capital threshold is the transfer adjustment factor * $1,552.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","17109.06","17109.06","17135.96","1 through 10","17615.97","30214.29","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","85101.46","63826.09","FALLON HEALTH [1008]","HB BWH MEDICARE","23215.95","","Case rate ($23,215.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,561.51, add-ons for qualifying new technology services are included. If operating cost exceeds $67,205.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,992.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $21,284.00 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,181.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,552.11. The transfer capital threshold is the transfer adjustment factor * $1,552.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","17090.88","17090.88","17090.88","1 through 10","17615.97","30214.29","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","85101.46","63826.09","HUMANA [1012]","HB BWH MEDICARE","23215.95","","Case rate ($23,215.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,561.51, add-ons for qualifying new technology services are included. If operating cost exceeds $67,205.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,992.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $21,284.00 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,181.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,552.11. The transfer capital threshold is the transfer adjustment factor * $1,552.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","10549.81","10549.81","10549.81","1 through 10","17615.97","30214.29","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","85101.46","63826.09","MEDICARE [2001]","HB BWH MEDICARE","23215.95","","Case rate ($23,215.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,561.51, add-ons for qualifying new technology services are included. If operating cost exceeds $67,205.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,992.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $21,284.00 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,181.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,552.11. The transfer capital threshold is the transfer adjustment factor * $1,552.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","22506.75","0.03","22539.99","142","17615.97","30214.29","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","85101.46","63826.09","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","23215.95","","Case rate ($23,215.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,561.51, add-ons for qualifying new technology services are included. If operating cost exceeds $67,205.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,992.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $21,284.00 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,181.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,552.11. The transfer capital threshold is the transfer adjustment factor * $1,552.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","17081.72","17069.88","17082.72","1 through 10","17615.97","30214.29","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","85101.46","63826.09","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","17615.97","","Case rate ($17,975.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,561.51, add-ons for qualifying new technology services are included. If operating cost exceeds $67,205.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,992.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $16,043.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,181.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,552.11. The transfer capital threshold is the transfer adjustment factor * $1,552.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","17112.12","17055.53","17116.85","11","17615.97","30214.29","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","85101.46","63826.09","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17615.97","","Case rate ($17,975.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,561.51, add-ons for qualifying new technology services are included. If operating cost exceeds $67,205.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,992.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $16,043.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,181.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,552.11. The transfer capital threshold is the transfer adjustment factor * $1,552.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","17113.63","17084.07","22878.74","1 through 10","17615.97","30214.29","other","Inpatient DRG"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","","","","inpatient","","","115597.55","86698.16","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","26435.36","","Case rate ($25,665.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,818.67, add-ons for qualifying new technology services are included. If operating cost exceeds $76,463.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,670.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $23,055.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,438.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,230.43. The transfer capital threshold is the transfer adjustment factor * $2,230.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","24135.07","24135.07","24135.07","1 through 10","25152.09","43419.04","other","Inpatient DRG"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","","","","inpatient","","","115597.55","86698.16","HUMANA [1012]","HB BWH MEDICARE","33196.15","","Case rate ($33,196.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,818.67, add-ons for qualifying new technology services are included. If operating cost exceeds $76,463.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,670.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $30,585.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,438.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,230.43. The transfer capital threshold is the transfer adjustment factor * $2,230.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23111.37","23111.37","23111.37","1 through 10","25152.09","43419.04","other","Inpatient DRG"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","","","","inpatient","","","115597.55","86698.16","MEDICARE [2001]","HB BWH MEDICARE","33196.15","","Case rate ($33,196.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,818.67, add-ons for qualifying new technology services are included. If operating cost exceeds $76,463.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,670.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $30,585.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,438.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,230.43. The transfer capital threshold is the transfer adjustment factor * $2,230.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30364.35","30319.41","30364.35","15","25152.09","43419.04","other","Inpatient DRG"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","","","","inpatient","","","115597.55","86698.16","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","25152.09","","Case rate ($25,665.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,818.67, add-ons for qualifying new technology services are included. If operating cost exceeds $76,463.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,670.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $23,055.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,438.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,230.43. The transfer capital threshold is the transfer adjustment factor * $2,230.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22992.31","22992.31","22992.31","1 through 10","25152.09","43419.04","other","Inpatient DRG"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","","","","inpatient","","","115597.55","86698.16","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","25152.09","","Case rate ($25,665.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,818.67, add-ons for qualifying new technology services are included. If operating cost exceeds $76,463.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,670.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $23,055.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,438.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,230.43. The transfer capital threshold is the transfer adjustment factor * $2,230.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","53166.60","53166.60","53166.60","1 through 10","25152.09","43419.04","other","Inpatient DRG"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","","","","inpatient","","","115597.55","86698.16","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","25152.09","","Case rate ($25,665.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,818.67, add-ons for qualifying new technology services are included. If operating cost exceeds $76,463.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,670.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $23,055.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,438.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,230.43. The transfer capital threshold is the transfer adjustment factor * $2,230.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","23049.19","23049.19","23049.19","1 through 10","25152.09","43419.04","other","Inpatient DRG"
"Major Large Bowel Procedures,EXTREME","231","DRG","","","","","","","","inpatient","","","164187.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","154410.01","","Standard inlier is a Case rate ($154,410.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $118,451, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($21,917.22) for the length of stay and the standard reimbursement.","160818.38","160818.38","160818.38","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MAJOR","231","DRG","","","","","","","","inpatient","","","147871.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","83766.42","","Standard inlier is a Case rate ($83,766.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $76,789, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,891.15) for the length of stay and the standard reimbursement.","76356.14","76356.14","83766.42","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MAJOR","231","DRG","","","","","","","","inpatient","","","147871.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","94176.04","","Standard inlier is a Case rate ($94,176.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $76,789, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,367.51) for the length of stay and the standard reimbursement.","94176.03","86037.94","96270.05","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MAJOR","231","DRG","","","","","","","","inpatient","","","147871.25","","MASSHEALTH [3001]","HB BWH MEDICAID","23465.34","","Case rate ($25,944.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $68,374.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25938.60","25938.60","25938.60","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MAJOR","231","DRG","","","","","","","","inpatient","","","147871.25","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","23465.34","","Case rate ($25,944.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $68,374.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2737.24","2737.24","2737.24","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MINOR","231","DRG","","","","","","","","inpatient","","","75543.89","","MASSHEALTH [3001]","HB BWH MEDICAID","11841.77","","Case rate ($13,093.11). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,523.11, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13089.89","13089.89","13089.89","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MINOR","231","DRG","","","","","","","","inpatient","","","75543.89","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44279.89","","Fee schedule rate ($44,279.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42989.70","42989.70","44279.89","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MINOR","231","DRG","","","","","","","","inpatient","","","75543.89","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46494.61","","Fee schedule rate ($46,494.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","46494.61","46494.61","46494.61","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MINOR","231","DRG","","","","","","","","inpatient","","","75545.59","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","47725.61","","Standard inlier is a Case rate ($47,725.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,761, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,774.94) for the length of stay and the standard reimbursement.","43503.63","43503.63","47725.61","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MINOR","231","DRG","","","","","","","","inpatient","","","75545.59","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","53656.45","","Standard inlier is a Case rate ($53,656.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,761, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,616.09) for the length of stay and the standard reimbursement.","53656.45","49019.80","53656.45","11","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","90818.18","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","58601.89","","Standard inlier is a Case rate ($58,601.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,219, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,318.89) for the length of stay and the standard reimbursement.","58601.89","6780.50","62639.76","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","90818.18","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","65884.32","","Standard inlier is a Case rate ($65,884.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,219, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,351.73) for the length of stay and the standard reimbursement.","60191.01","60191.01","65884.32","30","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","90818.18","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","14953.57","","Case rate ($16,533.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,963.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15358.78","15358.78","15358.78","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","90818.18","","MASSHEALTH [3001]","HB BWH MEDICAID","14953.57","","Case rate ($16,533.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,963.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16529.68","16529.68","16529.68","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","90818.18","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54237.32","","Fee schedule rate ($54,237.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","54237.32","54237.32","54237.32","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","90818.18","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56950.08","","Fee schedule rate ($56,950.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","55290.87","55290.87","56950.08","1 through 10","11841.77","156411.31","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","90818.18","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14953.57","","Case rate ($16,533.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,963.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16529.69","16529.69","16529.69","1 through 10","11841.77","156411.31","case rate",""
"Major Larynx & Trachea Procedures,MAJOR","090","DRG","","","","","","","","inpatient","","","204501.39","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","131754.14","131754.14","131754.14","1 through 10","17318.7818","171369.32","percent of total billed charges",""
"Major Larynx & Trachea Procedures,MAJOR","090","DRG","","","","","","","","inpatient","","","204501.39","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18012.1451","","Fee schedule rate ($103,858.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18012.1451","103858.92","103858.92","1 through 10","17318.7818","171369.32","case rate",""
"Major Male Pelvic Procedures With Cc/McC","707","MS-DRG","","","","","","","","inpatient","","","91237.44","68428.08","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","18626.80","","Case rate ($18,626.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,345.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,990.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,049.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $16,637.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,965.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,609.56. The transfer capital threshold is the transfer adjustment factor * $1,609.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17699.16","17699.16","17699.16","1 through 10","18254.26","31332.7","other","Inpatient Replacement Plans DRG"
"Major Male Pelvic Procedures With Cc/McC","707","MS-DRG","","","","","","","","inpatient","","","91237.44","68428.08","MEDICARE [2001]","HB BWH MEDICARE","18626.80","","Case rate ($18,626.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,345.57, add-ons for qualifying new technology services are included. If operating cost exceeds $67,990.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,049.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $16,637.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,965.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,609.56. The transfer capital threshold is the transfer adjustment factor * $1,609.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23156.33","0.03","23190.54","11","18254.26","31332.7","other","Inpatient Replacement Plans DRG"
"Major Male Pelvic Procedures Without Cc/McC","708","MS-DRG","","","","","","","","inpatient","","","82634.66","61975.99","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","14806.23","","Case rate ($14,374.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,227.22, add-ons for qualifying new technology services are included. If operating cost exceeds $62,871.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,674.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $12,760.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,847.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,234.51. The transfer capital threshold is the transfer adjustment factor * $1,234.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14140.67","14140.67","14140.67","1 through 10","14087.48","22372.4075","other","Inpatient DRG"
"Major Male Pelvic Procedures Without Cc/McC","708","MS-DRG","","","","","","","","inpatient","","","82634.66","61975.99","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14374.98","","Case rate ($14,374.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,227.22, add-ons for qualifying new technology services are included. If operating cost exceeds $62,871.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,674.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $12,760.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,847.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,234.51. The transfer capital threshold is the transfer adjustment factor * $1,234.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13585.72","13585.72","13585.72","1 through 10","14087.48","22372.4075","other","Inpatient Replacement Plans DRG"
"Major Male Pelvic Procedures Without Cc/McC","708","MS-DRG","","","","","","","","inpatient","","","82634.66","61975.99","MEDICARE [2001]","HB BWH MEDICARE","14374.98","","Case rate ($14,374.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,227.22, add-ons for qualifying new technology services are included. If operating cost exceeds $62,871.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,674.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $12,760.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,847.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,234.51. The transfer capital threshold is the transfer adjustment factor * $1,234.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17755.72","0.03","17781.85","1 through 10","14087.48","22372.4075","other","Inpatient Replacement Plans DRG"
"Major Male Pelvic Procedures Without Cc/McC","708","MS-DRG","","","","","","","","inpatient","","","82634.66","61975.99","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14087.48","","Case rate ($14,374.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,227.22, add-ons for qualifying new technology services are included. If operating cost exceeds $62,871.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,674.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $12,760.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,847.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,234.51. The transfer capital threshold is the transfer adjustment factor * $1,234.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13500.57","13500.57","13500.57","1 through 10","14087.48","22372.4075","other","Inpatient DRG"
"Major Male Pelvic Procedures Without Cc/McC","708","TRIS-DRG","","","","","","","","inpatient","","","90310.60","","TRICARE [160005]","HB BWH TRICARE","15263.63","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($26,811.43). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $70,538.43 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($41,248.36), capped at $19,297.13. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $70,538.43 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","34414.44","34414.44","34414.44","1 through 10","15263.63","15263.63","other","Inpatient DRGs"
"Major Male Pelvic Procedures,EXTREME","480","DRG","","","","","","","","inpatient","","","191458.34","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24760.269","","Fee schedule rate ($58,266.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24760.269","58266.04","58266.04","1 through 10","9912.31","192558.92","case rate",""
"Major Male Pelvic Procedures,MAJOR","480","DRG","","","","","","","","inpatient","","","91429.08","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","47395.74","","Standard inlier is a Case rate ($47,395.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,505, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,728.11) for the length of stay and the standard reimbursement.","7454.74","7454.74","7454.74","1 through 10","9912.31","192558.92","case rate",""
"Major Male Pelvic Procedures,MINOR","480","DRG","","","","","","","","inpatient","","","80836.18","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","41238.01","","Standard inlier is a Case rate ($41,238.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,716, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,853.98) for the length of stay and the standard reimbursement.","41238.00","37589.94","41238.00","1 through 10","9912.31","192558.92","case rate",""
"Major Male Pelvic Procedures,MINOR","480","DRG","","","","","","","","inpatient","","","80836.18","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","46362.64","","Standard inlier is a Case rate ($46,362.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,716, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,580.79) for the length of stay and the standard reimbursement.","46362.63","46362.63","46362.63","1 through 10","9912.31","192558.92","case rate",""
"Major Male Pelvic Procedures,MINOR","480","DRG","","","","","","","","inpatient","","","80836.18","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","27236.63","","Fee schedule rate ($27,236.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27236.64","27236.64","27236.64","1 through 10","9912.31","192558.92","case rate",""
"Major Male Pelvic Procedures,MODERATE","480","DRG","","","","","","","","inpatient","","","83953.62","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","47395.74","","Standard inlier is a Case rate ($47,395.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,505, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,728.11) for the length of stay and the standard reimbursement.","47395.73","47395.73","47395.73","1 through 10","9912.31","192558.92","case rate",""
"Major Male Pelvic Procedures,MODERATE","480","DRG","","","","","","","","inpatient","","","83953.62","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","55839.05","55839.05","55839.05","1 through 10","9912.31","192558.92","percent of total billed charges",""
"Major Male Pelvic Procedures,MODERATE","480","DRG","","","","","","","","inpatient","","","83953.62","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24760.269","","Fee schedule rate ($28,640.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24760.269","28640.96","28640.96","1 through 10","9912.31","192558.92","case rate",""
"Major Male Pelvic Procedures,MODERATE","480","DRG","","","","","","","","inpatient","","","83953.62","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43701.71","","Fee schedule rate ($43,701.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42428.49","42428.49","42428.49","1 through 10","9912.31","192558.92","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","680","DRG","","","","","","","","inpatient","","","475124.99","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","205811.66","","Standard inlier is a Case rate ($205,811.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $171,696, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($29,216.21) for the length of stay and the standard reimbursement.","205811.65","205811.65","205811.65","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","680","DRG","","","","","","","","inpatient","","","475124.99","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231387.77","","Standard inlier is a Case rate ($231,387.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $171,696, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($32,843.57) for the length of stay and the standard reimbursement.","231387.76","231387.76","231387.76","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","680","DRG","","","","","","","","inpatient","","","475124.99","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","253599.64","253599.64","253599.64","1 through 10","13934.58","439484.03","percent of total billed charges",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","680","DRG","","","","","","","","inpatient","","","475124.99","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","22335.6862","","Fee schedule rate ($266,350.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22335.6862","266350.72","266350.72","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","680","DRG","","","","","","","","inpatient","","","475124.99","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","30504.1146","","Fee schedule rate ($266,350.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30504.1146","266350.72","266350.72","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","680","DRG","","","","","","","","inpatient","","","475124.99","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","23453.1196","","Fee schedule rate ($279,675.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23453.1196","268887.16","268887.16","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","680","DRG","","","","","","","","inpatient","","","475124.99","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","32030.2068","","Fee schedule rate ($279,675.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32030.2068","268887.16","268887.16","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","680","DRG","","","","","","","","inpatient","","","475124.99","","MASSHEALTH [3001]","HB BWH MEDICAID","91329.88","","Case rate ($100,980.88). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $143,410.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","49314.14","49314.14","49314.14","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","680","DRG","","","","","","","","inpatient","","","160159.52","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","107430.33","","Standard inlier is a Case rate ($107,430.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $95,190, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($15,250.38) for the length of stay and the standard reimbursement.","97926.66","97926.66","97926.66","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","680","DRG","","","","","","","","inpatient","","","160159.52","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","120780.65","","Standard inlier is a Case rate ($120,780.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $95,190, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,143.81) for the length of stay and the standard reimbursement.","120780.64","110343.55","120780.64","11","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","680","DRG","","","","","","","","inpatient","","","160159.52","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","22335.6862","","Fee schedule rate ($93,614.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22335.6862","93614.84","93614.84","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","680","DRG","","","","","","","","inpatient","","","160159.52","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","30504.1146","","Fee schedule rate ($93,614.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30504.1146","93614.84","93614.84","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","680","DRG","","","","","","","","inpatient","","","160159.52","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","23453.1196","","Fee schedule rate ($98,298.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23453.1196","98298.32","98298.32","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","680","DRG","","","","","","","","inpatient","","","160159.52","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","32030.2068","","Fee schedule rate ($98,298.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32030.2068","98298.32","98298.32","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","680","DRG","","","","","","","","inpatient","","","160159.52","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","109155.81","","Fee schedule rate ($109,155.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","109155.81","109155.81","109155.81","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","680","DRG","","","","","","","","inpatient","","","160159.52","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","35688.66","","Case rate ($39,459.94). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $81,889.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","39450.26","39450.26","42331.97","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MINOR","680","DRG","","","","","","","","inpatient","","","99546.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","55659.89","","Standard inlier is a Case rate ($55,659.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,146, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,900.46) for the length of stay and the standard reimbursement.","55659.88","55659.88","61045.19","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MINOR","680","DRG","","","","","","","","inpatient","","","99546.36","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","22335.6862","","Fee schedule rate ($30,504.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22335.6862","30504.12","30504.12","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MINOR","680","DRG","","","","","","","","inpatient","","","99546.36","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","30504.1146","","Fee schedule rate ($30,504.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30504.1146","30504.12","30504.12","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MINOR","680","DRG","","","","","","","","inpatient","","","99546.36","","MASSHEALTH [3001]","HB BWH MEDICAID","13934.58","","Case rate ($15,407.07). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,837.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15403.29","15403.29","15403.29","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MINOR","680","DRG","","","","","","","","inpatient","","","99546.36","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","27919.8574","","Fee schedule rate ($37,634.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27919.8574","36660.31","36660.31","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MINOR","680","DRG","","","","","","","","inpatient","","","99546.36","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","38130.4842","","Fee schedule rate ($37,634.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38130.4842","36660.31","36660.31","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MINOR","680","DRG","","","","","","","","inpatient","","","99546.36","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","13934.58","","Case rate ($15,407.07). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,837.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15403.29","15403.29","15403.29","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","680","DRG","","","","","","","","inpatient","","","113986.89","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","65322.35","","Fee schedule rate ($65,322.35). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($7,558.09) multiplied by length of stay and the outlier percent (100%).","67093.71","65322.35","154522.76","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","680","DRG","","","","","","","","inpatient","","","113986.89","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","73439.93","","Fee schedule rate ($73,439.93). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($8,497.30) multiplied by length of stay and the outlier percent (100%).","73439.92","7762.09","73439.92","12","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","680","DRG","","","","","","","","inpatient","","","113986.89","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","22335.6862","","Fee schedule rate ($49,786.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22335.6862","49786.72","49786.72","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","680","DRG","","","","","","","","inpatient","","","113986.89","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","30504.1146","","Fee schedule rate ($49,786.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30504.1146","49786.72","49786.72","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","680","DRG","","","","","","","","inpatient","","","113986.89","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","23453.1196","","Fee schedule rate ($52,277.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23453.1196","52277.48","52277.48","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","680","DRG","","","","","","","","inpatient","","","113986.89","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","32030.2068","","Fee schedule rate ($52,277.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32030.2068","52277.48","52277.48","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","680","DRG","","","","","","","","inpatient","","","113986.89","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","54766.04","","Fee schedule rate ($54,766.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","54766.04","54766.04","54766.04","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","680","DRG","","","","","","","","inpatient","","","113986.89","","MASSHEALTH [3001]","HB BWH MEDICAID","19056.95","","Case rate ($21,070.73). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,500.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21065.56","21065.56","21065.56","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","680","DRG","","","","","","","","inpatient","","","113986.89","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65690.93","","Fee schedule rate ($65,690.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","65690.93","65690.93","65690.93","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","680","DRG","","","","","","","","inpatient","","","113986.89","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68976.55","","Fee schedule rate ($68,976.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","68976.55","68976.55","68976.55","1 through 10","13934.58","439484.03","case rate",""
"Major O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","680","DRG","","","","","","","","inpatient","","","113986.89","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","19056.95","","Case rate ($21,070.73). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,500.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21065.56","21065.56","21065.56","1 through 10","13934.58","439484.03","case rate",""
"Major Pancreas, Liver And Shunt Procedures,EXTREME","260","DRG","","","","","","","","inpatient","","","480671.54","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","96146.56","","Standard inlier is a Case rate ($96,146.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $86,415, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,648.58) for the length of stay and the standard reimbursement.","181526.79","181526.79","181526.79","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,EXTREME","260","DRG","","","","","","","","inpatient","","","480671.54","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","108094.64","","Standard inlier is a Case rate ($108,094.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $86,415, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($15,343.14) for the length of stay and the standard reimbursement.","251425.88","251425.88","402844.33","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,EXTREME","260","DRG","","","","","","","","inpatient","","","480671.54","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","","65","","387278.94","387278.94","387278.94","1 through 10","16913.87","308644.88","percent of total billed charges",""
"Major Pancreas, Liver And Shunt Procedures,EXTREME","260","DRG","","","","","","","","inpatient","","","480671.54","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","34246.1137","","Fee schedule rate ($187,055.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34246.1137","187055.24","187055.24","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,EXTREME","260","DRG","","","","","","","","inpatient","","","480671.54","","MASSHEALTH [3001]","HB BWH MEDICAID","30915.85","","Case rate ($34,182.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,612.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","34620.72","34620.72","34620.72","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,EXTREME","260","DRG","","","","","","","","inpatient","","","480671.54","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","30915.85","","Case rate ($34,182.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,612.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","195226.37","195226.37","195226.37","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MAJOR","260","DRG","","","","","","","","inpatient","","","184717.79","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","96146.56","","Standard inlier is a Case rate ($96,146.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $86,415, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,648.58) for the length of stay and the standard reimbursement.","96146.55","96146.55","96146.55","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MAJOR","260","DRG","","","","","","","","inpatient","","","184717.79","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","108094.64","","Standard inlier is a Case rate ($108,094.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $86,415, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($15,343.14) for the length of stay and the standard reimbursement.","108094.64","98753.79","108094.64","12","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MAJOR","260","DRG","","","","","","","","inpatient","","","184717.79","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","34246.1137","","Fee schedule rate ($78,908.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34246.1137","78908.52","78908.52","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MAJOR","260","DRG","","","","","","","","inpatient","","","184717.79","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35959.4146","","Fee schedule rate ($82,856.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35959.4146","156405.07","156405.07","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MAJOR","260","DRG","","","","","","","","inpatient","","","184717.79","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","86800.45","","Fee schedule rate ($86,800.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","86800.45","86800.45","86800.45","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MAJOR","260","DRG","","","","","","","","inpatient","","","184717.79","","MASSHEALTH [3001]","HB BWH MEDICAID","30915.85","","Case rate ($34,182.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,612.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","34174.40","34174.40","34174.40","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MAJOR","260","DRG","","","","","","","","inpatient","","","184717.79","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","104680.93","","Fee schedule rate ($104,680.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","104680.93","104680.93","104680.93","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MAJOR","260","DRG","","","","","","","","inpatient","","","184717.79","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","30915.85","","Case rate ($34,182.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,612.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","34174.40","34174.40","49327.68","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MINOR","260","DRG","","","","","","","","inpatient","","","90394.90","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","62215.60","","Standard inlier is a Case rate ($62,215.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,681, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,830.99) for the length of stay and the standard reimbursement.","56839.31","56839.31","62215.59","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MINOR","260","DRG","","","","","","","","inpatient","","","90394.90","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63601.12","","Fee schedule rate ($63,601.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61748.13","61748.13","61748.13","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MODERATE","260","DRG","","","","","","","","inpatient","","","137050.52","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","70150.86","","Standard inlier is a Case rate ($70,150.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $66,200, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,958.34) for the length of stay and the standard reimbursement.","63945.06","63945.06","70150.86","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MODERATE","260","DRG","","","","","","","","inpatient","","","137050.52","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","78868.48","","Standard inlier is a Case rate ($78,868.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $66,200, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,194.73) for the length of stay and the standard reimbursement.","72061.82","72053.16","78868.47","12","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MODERATE","260","DRG","","","","","","","","inpatient","","","137050.52","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","34246.1137","","Fee schedule rate ($45,910.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34246.1137","45910.52","45910.52","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MODERATE","260","DRG","","","","","","","","inpatient","","","137050.52","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35959.4146","","Fee schedule rate ($48,207.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35959.4146","46347.72","48207.36","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MODERATE","260","DRG","","","","","","","","inpatient","","","137050.52","","MASSHEALTH [3001]","HB BWH MEDICAID","21008.11","","Case rate ($23,228.08). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23222.38","23222.38","23222.38","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MODERATE","260","DRG","","","","","","","","inpatient","","","137050.52","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77489.53","","Fee schedule rate ($77,489.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","77489.53","77489.53","77489.53","1 through 10","16913.87","308644.88","case rate",""
"Major Pancreas, Liver And Shunt Procedures,MODERATE","260","DRG","","","","","","","","inpatient","","","137050.52","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","21008.11","","Case rate ($23,228.08). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23222.38","23222.38","23222.38","1 through 10","16913.87","308644.88","case rate",""
"Major Respiratory And Chest Procedures,EXTREME","120","DRG","","","","","","","","inpatient","","","481366.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","180145.62","","Standard inlier is a Case rate ($180,145.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $136,251, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($25,570.17) for the length of stay and the standard reimbursement.","243826.79","243826.79","243826.79","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,EXTREME","120","DRG","","","","","","","","inpatient","","","481366.03","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","38169.2855","","Fee schedule rate ($154,898.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38169.2855","148928.56","148928.56","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,EXTREME","120","DRG","","","","","","","","inpatient","","","481366.03","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","150012.32","","Fee schedule rate ($150,012.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","96880.37","96880.37","96880.37","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,EXTREME","120","DRG","","","","","","","","inpatient","","","481366.03","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157513.57","","Fee schedule rate ($157,513.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","203407.21","203407.21","203407.21","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MAJOR","120","DRG","","","","","","","","inpatient","","","174156.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","71273.10","","Standard inlier is a Case rate ($71,273.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $67,072, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,117.65) for the length of stay and the standard reimbursement.","94184.02","88233.64","96796.61","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MAJOR","120","DRG","","","","","","","","inpatient","","","174156.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","80130.17","","Standard inlier is a Case rate ($80,130.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $67,072, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,373.81) for the length of stay and the standard reimbursement.","108825.48","99421.47","108825.48","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MAJOR","120","DRG","","","","","","","","inpatient","","","174156.31","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","38169.2855","","Fee schedule rate ($83,780.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38169.2855","80551.28","83780.08","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MAJOR","120","DRG","","","","","","","","inpatient","","","174156.31","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","40078.859","","Fee schedule rate ($87,971.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40078.859","146471.57","146471.57","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MAJOR","120","DRG","","","","","","","","inpatient","","","174156.31","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","92159.20","","Fee schedule rate ($92,159.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","88608.28","88608.28","88608.28","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MAJOR","120","DRG","","","","","","","","inpatient","","","174156.31","","MASSHEALTH [3001]","HB BWH MEDICAID","20498.62","","Case rate ($22,664.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,094.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","42576.22","42576.22","42576.22","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MAJOR","120","DRG","","","","","","","","inpatient","","","174156.31","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","101725.98","","Fee schedule rate ($101,725.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","101725.98","101725.98","101725.98","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MAJOR","120","DRG","","","","","","","","inpatient","","","174156.31","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","20498.62","","Case rate ($22,664.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,094.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","95754.19","95754.19","95754.19","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MINOR","120","DRG","","","","","","","","inpatient","","","105774.52","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","58048.86","","Standard inlier is a Case rate ($58,048.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,788, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,240.39) for the length of stay and the standard reimbursement.","58048.86","58048.86","58048.86","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MINOR","120","DRG","","","","","","","","inpatient","","","105774.52","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","65262.56","","Standard inlier is a Case rate ($65,262.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,788, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,263.48) for the length of stay and the standard reimbursement.","65262.56","59622.98","95957.97","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MINOR","120","DRG","","","","","","","","inpatient","","","105774.52","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","38169.2855","","Fee schedule rate ($38,169.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38169.2855","38169.28","50934.12","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MINOR","120","DRG","","","","","","","","inpatient","","","105774.52","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","40078.859","","Fee schedule rate ($40,078.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40078.859","40078.84","40078.84","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MINOR","120","DRG","","","","","","","","inpatient","","","105774.52","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15468.78","","Case rate ($17,103.39). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,533.39, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17099.20","17099.20","17099.20","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MODERATE","120","DRG","","","","","","","","inpatient","","","124776.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","71273.10","","Standard inlier is a Case rate ($71,273.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $67,072, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,117.65) for the length of stay and the standard reimbursement.","71273.09","71273.09","71273.09","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MODERATE","120","DRG","","","","","","","","inpatient","","","124776.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","80130.17","","Standard inlier is a Case rate ($80,130.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $67,072, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,373.81) for the length of stay and the standard reimbursement.","80130.16","73205.82","80130.16","13","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MODERATE","120","DRG","","","","","","","","inpatient","","","124776.60","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","40078.859","","Fee schedule rate ($53,482.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40078.859","53869.44","53869.44","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MODERATE","120","DRG","","","","","","","","inpatient","","","124776.60","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","38169.2855","","Fee schedule rate ($50,934.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38169.2855","50934.12","83780.08","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MODERATE","120","DRG","","","","","","","","inpatient","","","124776.60","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","40078.859","","Fee schedule rate ($53,482.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40078.859","53482.32","53482.32","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MODERATE","120","DRG","","","","","","","","inpatient","","","124776.60","","MASSHEALTH [3001]","HB BWH MEDICAID","20498.62","","Case rate ($22,664.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,094.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22659.18","22659.18","22659.18","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MODERATE","120","DRG","","","","","","","","inpatient","","","124776.60","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72261.79","","Fee schedule rate ($72,261.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","72261.79","72261.79","72261.79","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory And Chest Procedures,MODERATE","120","DRG","","","","","","","","inpatient","","","124776.60","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","20498.62","","Case rate ($22,664.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,094.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22659.18","22659.18","22659.18","1 through 10","15468.78","255585.12","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","96168.77","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","33861.03","","Standard inlier is a Case rate ($33,861.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,980, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,806.78) for the length of stay and the standard reimbursement.","44585.55","44585.55","48912.52","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","96168.77","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","38068.92","","Standard inlier is a Case rate ($38,068.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,980, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,403.57) for the length of stay and the standard reimbursement.","50238.90","50238.90","78022.84","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","96168.77","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14475.9224","","Fee schedule rate ($61,851.47). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14475.9224","61851.48","61851.48","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","96168.77","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","23809.6715","","Fee schedule rate ($61,851.47). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23809.6715","61851.48","61851.48","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","96168.77","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","68037.44","","Fee schedule rate ($68,037.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","68037.44","68037.44","68037.44","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","96168.77","","MASSHEALTH [3001]","HB BWH MEDICAID","8346.13","","Case rate ($9,228.08). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15873.04","4384.02","147428.37","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","96168.77","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","8346.13","","Case rate ($9,228.08). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2781.16","2781.16","2781.16","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","96168.77","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8346.13","","Case rate ($9,228.08). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15873.04","15873.04","15873.04","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","56548.40","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14475.9224","","Fee schedule rate ($31,706.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14475.9224","37301.44","37301.44","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","56548.40","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","23809.6715","","Fee schedule rate ($31,706.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23809.6715","37301.44","37301.44","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","56548.40","","MASSHEALTH [3001]","HB BWH MEDICAID","8346.13","","Case rate ($9,228.08). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9225.82","9225.82","9225.82","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","56548.40","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31340.65","","Fee schedule rate ($31,340.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2396), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35797.41","35797.41","35797.41","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","56548.40","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8346.13","","Case rate ($9,228.08). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9225.81","9225.81","9225.81","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,MINOR","137","DRG","","","","","","","","inpatient","","","51264.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19491.92","","Standard inlier is a Case rate ($19,491.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,806, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,767.00) for the length of stay and the standard reimbursement.","19491.92","19491.92","19491.92","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,MINOR","137","DRG","","","","","","","","inpatient","","","51264.35","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5034.41","","Case rate ($5,566.40). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,996.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5565.04","5565.04","5565.04","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,MODERATE","137","DRG","","","","","","","","inpatient","","","43883.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24841.12","","Standard inlier is a Case rate ($24,841.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,965, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,526.35) for the length of stay and the standard reimbursement.","24841.12","24841.12","24841.12","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,MODERATE","137","DRG","","","","","","","","inpatient","","","43883.25","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14475.9224","","Fee schedule rate ($25,950.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14475.9224","25950.20","25950.20","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,MODERATE","137","DRG","","","","","","","","inpatient","","","43883.25","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","23809.6715","","Fee schedule rate ($25,950.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23809.6715","25950.20","25950.20","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,MODERATE","137","DRG","","","","","","","","inpatient","","","43883.25","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","28545.56","","Fee schedule rate ($28,545.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28545.56","28545.56","28545.56","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,MODERATE","137","DRG","","","","","","","","inpatient","","","43883.25","","MASSHEALTH [3001]","HB BWH MEDICAID","6895.32","","Case rate ($7,623.96). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,053.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7622.09","7622.09","7622.09","1 through 10","5034.41","102056.16","case rate",""
"Major Respiratory Infections And Inflammations,MODERATE","137","DRG","","","","","","","","inpatient","","","43883.25","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26483.31","","Fee schedule rate ($26,483.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25711.73","25711.73","25711.73","1 through 10","5034.41","102056.16","case rate",""
"Major Skin Disorders With McC","595","MS-DRG","","","","","","","","inpatient","","","169246.51","126934.88","MEDICARE [2001]","HB BWH MEDICARE","19725.08","","Case rate ($19,725.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,667.70, add-ons for qualifying new technology services are included. If operating cost exceeds $69,312.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,146.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $17,638.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,287.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,706.44. The transfer capital threshold is the transfer adjustment factor * $1,706.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25213.52","25213.52","25250.83","1 through 10","19330.58","31918.9741","other","Inpatient Replacement Plans DRG"
"Major Skin Disorders Without McC","596","MS-DRG","","","","","","","","inpatient","","","46781.16","35085.87","MEDICARE [2001]","HB BWH MEDICARE","10254.52","","Case rate ($10,254.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,267.01, add-ons for qualifying new technology services are included. If operating cost exceeds $57,911.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,311.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,003.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,887.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $871.04. The transfer capital threshold is the transfer adjustment factor * $871.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13042.60","0.03","13042.60","1 through 10","10049.43","16314.8801","other","Inpatient Replacement Plans DRG"
"Major Skin Disorders Without McC","596","MS-DRG","","","","","","","","inpatient","","","46781.16","35085.87","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","10049.43","","Case rate ($10,254.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,267.01, add-ons for qualifying new technology services are included. If operating cost exceeds $57,911.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,311.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,003.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,887.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $871.04. The transfer capital threshold is the transfer adjustment factor * $871.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9895.34","9895.34","9895.34","1 through 10","10049.43","16314.8801","other","Inpatient DRG"
"Major Skin Disorders,EXTREME","381","DRG","","","","","","","","inpatient","","","458830.70","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","76382.97","","Standard inlier is a Case rate ($76,382.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,046, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,843.02) for the length of stay and the standard reimbursement.","184975.40","184975.40","184975.40","1 through 10","4746.53","254946.65","case rate",""
"Major Skin Disorders,EXTREME","381","DRG","","","","","","","","inpatient","","","458830.70","","MASSHEALTH [3001]","HB BWH MEDICAID","43353.93","","Case rate ($47,935.22). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $90,365.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","75812.41","75812.41","75812.41","1 through 10","4746.53","254946.65","case rate",""
"Major Skin Disorders,EXTREME","381","DRG","","","","","","","","inpatient","","","458830.70","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","43353.93","","Case rate ($47,935.22). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $90,365.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","74469.35","74469.35","74469.35","1 through 10","4746.53","254946.65","case rate",""
"Major Skin Disorders,MAJOR","381","DRG","","","","","","","","inpatient","","","89928.47","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","43613.82","","Standard inlier is a Case rate ($43,613.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,814, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,190.62) for the length of stay and the standard reimbursement.","43613.82","43613.82","43613.82","1 through 10","4746.53","254946.65","case rate",""
"Major Skin Disorders,MAJOR","381","DRG","","","","","","","","inpatient","","","89928.47","","MASSHEALTH [3001]","HB BWH MEDICAID","14939.86","","Case rate ($16,518.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,948.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22748.91","22748.91","22748.91","1 through 10","4746.53","254946.65","case rate",""
"Major Skin Disorders,MAJOR","381","DRG","","","","","","","","inpatient","","","89928.47","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38879.17","","Fee schedule rate ($38,879.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38879.17","38879.17","38879.17","1 through 10","4746.53","254946.65","case rate",""
"Major Skin Disorders,MAJOR","381","DRG","","","","","","","","inpatient","","","89928.47","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14939.86","","Case rate ($16,518.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,948.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16514.53","16514.53","16514.53","1 through 10","4746.53","254946.65","case rate",""
"Major Skin Disorders,MINOR","381","DRG","","","","","","","","inpatient","","","32743.48","","MASSHEALTH [3001]","HB BWH MEDICAID","4746.53","","Case rate ($5,248.11). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,678.11, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5246.82","5246.82","5246.82","1 through 10","4746.53","254946.65","case rate",""
"Major Skin Disorders,MODERATE","381","DRG","","","","","","","","inpatient","","","43347.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21692.38","","Standard inlier is a Case rate ($21,692.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,652, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,079.05) for the length of stay and the standard reimbursement.","21692.37","21692.37","21692.37","1 through 10","4746.53","254946.65","case rate",""
"Major Small & Large Bowel Procedures,EXTREME","221","DRG","","","","","","","","inpatient","","","282633.18","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33349.197","","Fee schedule rate ($158,606.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33349.197","158606.64","158606.64","1 through 10","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,EXTREME","221","DRG","","","","","","","","inpatient","","","282633.18","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35017.626","","Fee schedule rate ($166,541.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35017.626","166541.56","166541.56","1 through 10","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,EXTREME","221","DRG","","","","","","","","inpatient","","","282633.18","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","174469.42","","Fee schedule rate ($174,469.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","174469.44","174469.44","174469.44","1 through 10","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,MAJOR","221","DRG","","","","","","","","inpatient","","","119067.82","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33349.197","","Fee schedule rate ($73,578.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33349.197","73578.48","73578.48","12","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,MAJOR","221","DRG","","","","","","","","inpatient","","","119067.82","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35017.626","","Fee schedule rate ($77,259.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35017.626","77259.56","77259.56","1 through 10","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,MAJOR","221","DRG","","","","","","","","inpatient","","","119067.82","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","80937.32","","Fee schedule rate ($80,937.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","77818.78","77818.78","77818.78","1 through 10","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,MAJOR","221","DRG","","","","","","","","inpatient","","","119067.82","","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","35017.626","","Fee schedule rate ($77,259.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35017.626","77818.78","77818.78","1 through 10","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,MINOR","221","DRG","","","","","","","","inpatient","","","74152.21","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","35017.626","","Fee schedule rate ($35,017.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35017.626","36684.56","36684.56","1 through 10","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,MINOR","221","DRG","","","","","","","","inpatient","","","74152.21","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33349.197","","Fee schedule rate ($33,349.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33349.197","33349.20","43528.40","1 through 10","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,MINOR","221","DRG","","","","","","","","inpatient","","","74152.21","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35017.626","","Fee schedule rate ($35,017.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35017.626","35017.64","68063.49","1 through 10","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,MINOR","221","DRG","","","","","","","","inpatient","","","74152.21","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","36684.564","","Fee schedule rate ($36,684.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","36684.564","35271.10","35271.10","1 through 10","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,MODERATE","221","DRG","","","","","","","","inpatient","","","96414.98","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33349.197","","Fee schedule rate ($43,528.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33349.197","43528.40","43528.40","14","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,MODERATE","221","DRG","","","","","","","","inpatient","","","96414.98","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35017.626","","Fee schedule rate ($45,706.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35017.626","43942.92","122167.13","1 through 10","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,MODERATE","221","DRG","","","","","","","","inpatient","","","96414.98","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","47881.84","","Fee schedule rate ($47,881.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","47881.84","47881.84","47881.84","1 through 10","32065.446","261704.14","case rate",""
"Major Small & Large Bowel Procedures,MODERATE","221","DRG","","","","","","","","inpatient","","","96414.98","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","68089.45","68089.45","68089.45","1 through 10","32065.446","261704.14","percent of total billed charges",""
"Major Small & Large Bowel Procedures,MODERATE","221","DRG","","","","","","","","inpatient","","","96414.98","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","36684.564","","Fee schedule rate ($47,881.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","36684.564","46036.94","46036.94","1 through 10","32065.446","261704.14","case rate",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","97964.20","73473.15","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","22914.77","","Case rate ($22,247.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,704.01, add-ons for qualifying new technology services are included. If operating cost exceeds $72,348.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,369.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,938.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,324.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.93. The transfer capital threshold is the transfer adjustment factor * $1,928.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","22401.56","21352.90","22433.26","1 through 10","21802.4","37549.74","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","97964.20","73473.15","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","22247.35","","Case rate ($22,247.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,704.01, add-ons for qualifying new technology services are included. If operating cost exceeds $72,348.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,369.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,938.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,324.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.93. The transfer capital threshold is the transfer adjustment factor * $1,928.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21498.32","17599.35","21873.84","1 through 10","21802.4","37549.74","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","97964.20","73473.15","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","22247.35","","Case rate ($22,247.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,704.01, add-ons for qualifying new technology services are included. If operating cost exceeds $72,348.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,369.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,938.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,324.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.93. The transfer capital threshold is the transfer adjustment factor * $1,928.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21298.19","21298.19","21489.22","1 through 10","21802.4","37549.74","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","97964.20","73473.15","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","22247.35","","Case rate ($22,247.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,704.01, add-ons for qualifying new technology services are included. If operating cost exceeds $72,348.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,369.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,938.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,324.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.93. The transfer capital threshold is the transfer adjustment factor * $1,928.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21455.16","21455.16","21455.16","1 through 10","21802.4","37549.74","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","97964.20","73473.15","HUMANA [1012]","HB BWH MEDICARE","22247.35","","Case rate ($22,247.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,704.01, add-ons for qualifying new technology services are included. If operating cost exceeds $72,348.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,369.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,938.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,324.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.93. The transfer capital threshold is the transfer adjustment factor * $1,928.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21391.49","21391.49","21391.49","1 through 10","21802.4","37549.74","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","97964.20","73473.15","MARTIN'S POINT [160007]","HB BWH MEDICARE","22247.35","","Case rate ($22,247.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,704.01, add-ons for qualifying new technology services are included. If operating cost exceeds $72,348.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,369.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,938.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,324.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.93. The transfer capital threshold is the transfer adjustment factor * $1,928.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21419.04","21419.04","21444.92","1 through 10","21802.4","37549.74","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","97964.20","73473.15","MEDICARE [2001]","HB BWH MEDICARE","22247.35","","Case rate ($22,247.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,704.01, add-ons for qualifying new technology services are included. If operating cost exceeds $72,348.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,369.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,938.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,324.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.93. The transfer capital threshold is the transfer adjustment factor * $1,928.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28144.31","0.03","28144.31","128","21802.4","37549.74","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","97964.20","73473.15","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","21802.40","","Case rate ($22,247.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,704.01, add-ons for qualifying new technology services are included. If operating cost exceeds $72,348.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,369.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,938.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,324.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.93. The transfer capital threshold is the transfer adjustment factor * $1,928.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21324.67","17499.44","21380.04","1 through 10","21802.4","37549.74","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","97964.20","73473.15","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","21802.40","","Case rate ($22,247.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,704.01, add-ons for qualifying new technology services are included. If operating cost exceeds $72,348.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,369.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,938.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,324.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.93. The transfer capital threshold is the transfer adjustment factor * $1,928.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21382.40","13157.52","28518.84","21","21802.4","37549.74","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","97964.20","73473.15","WELLSENSE NH [1050]","HB BWH MEDICARE","22247.35","","Case rate ($22,247.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,704.01, add-ons for qualifying new technology services are included. If operating cost exceeds $72,348.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,369.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,938.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,324.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,928.93. The transfer capital threshold is the transfer adjustment factor * $1,928.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21482.25","21482.25","21482.25","1 through 10","21802.4","37549.74","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","178284.00","133713.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","43578.89","","Case rate ($42,309.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,855, add-ons for qualifying new technology services are included. If operating cost exceeds $96,499.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,138.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $38,231.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,475.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,698.61. The transfer capital threshold is the transfer adjustment factor * $3,698.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","43174.49","40598.95","43254.03","1 through 10","41463.41","71999.58","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","178284.00","133713.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","42309.60","","Case rate ($42,309.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,855, add-ons for qualifying new technology services are included. If operating cost exceeds $96,499.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,138.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $38,231.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,475.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,698.61. The transfer capital threshold is the transfer adjustment factor * $3,698.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","41507.95","41507.95","42015.20","1 through 10","41463.41","71999.58","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","178284.00","133713.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","52887.00","","Case rate ($42,309.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,855, add-ons for qualifying new technology services are included. If operating cost exceeds $96,499.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,138.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $38,231.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,475.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,698.61. The transfer capital threshold is the transfer adjustment factor * $3,698.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","41998.12","41998.12","41998.12","1 through 10","41463.41","71999.58","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","178284.00","133713.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","42309.60","","Case rate ($42,309.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,855, add-ons for qualifying new technology services are included. If operating cost exceeds $96,499.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,138.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $38,231.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,475.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,698.61. The transfer capital threshold is the transfer adjustment factor * $3,698.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","41291.76","41291.76","41291.76","1 through 10","41463.41","71999.58","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","178284.00","133713.00","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","4232.00","4232.00","4232.00","1 through 10","41463.41","71999.58","case rate",""
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","178284.00","133713.00","MEDICARE [2001]","HB BWH MEDICARE","42309.60","","Case rate ($42,309.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,855, add-ons for qualifying new technology services are included. If operating cost exceeds $96,499.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,138.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $38,231.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,475.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,698.61. The transfer capital threshold is the transfer adjustment factor * $3,698.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","54412.89","0.03","54493.87","58","41463.41","71999.58","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","178284.00","133713.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","41463.41","","Case rate ($42,309.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,855, add-ons for qualifying new technology services are included. If operating cost exceeds $96,499.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,138.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $38,231.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,475.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,698.61. The transfer capital threshold is the transfer adjustment factor * $3,698.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","41151.94","38684.84","41442.00","1 through 10","41463.41","71999.58","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","178284.00","133713.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","41463.41","","Case rate ($42,309.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,855, add-ons for qualifying new technology services are included. If operating cost exceeds $96,499.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,138.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $38,231.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $50,475.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,698.61. The transfer capital threshold is the transfer adjustment factor * $3,698.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","41278.22","34345.90","125229.80","1 through 10","41463.41","71999.58","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","178284.00","133713.00","WELLPOINT [1015]","HB AMC WELLPOINT","71999.58","","Fee schedule rate ($71,999.58).","200570.02","200570.02","200570.02","1 through 10","41463.41","71999.58","case rate",""
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75450.22","56587.66","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","16203.37","","Case rate ($15,731.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,860.13, add-ons for qualifying new technology services are included. If operating cost exceeds $64,504.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,794.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,997.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,480.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.16. The transfer capital threshold is the transfer adjustment factor * $1,354.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15735.79","15735.79","15735.79","1 through 10","15416.8","24915.241","other","Inpatient DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75450.22","56587.66","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","15731.43","","Case rate ($15,731.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,860.13, add-ons for qualifying new technology services are included. If operating cost exceeds $64,504.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,794.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,997.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,480.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.16. The transfer capital threshold is the transfer adjustment factor * $1,354.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15098.75","15098.75","15098.75","1 through 10","15416.8","24915.241","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75450.22","56587.66","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","37578.43","37578.43","37578.43","1 through 10","15416.8","24915.241","case rate",""
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75450.22","56587.66","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","15731.43","","Case rate ($15,731.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,860.13, add-ons for qualifying new technology services are included. If operating cost exceeds $64,504.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,794.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,997.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,480.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.16. The transfer capital threshold is the transfer adjustment factor * $1,354.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15020.31","15020.31","15020.31","1 through 10","15416.8","24915.241","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75450.22","56587.66","MARTIN'S POINT [160007]","HB BWH MEDICARE","15731.43","","Case rate ($15,731.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,860.13, add-ons for qualifying new technology services are included. If operating cost exceeds $64,504.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,794.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,997.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,480.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.16. The transfer capital threshold is the transfer adjustment factor * $1,354.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15022.71","15022.71","15022.71","1 through 10","15416.8","24915.241","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75450.22","56587.66","MEDICARE [2001]","HB BWH MEDICARE","15731.43","","Case rate ($15,731.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,860.13, add-ons for qualifying new technology services are included. If operating cost exceeds $64,504.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,794.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,997.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,480.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.16. The transfer capital threshold is the transfer adjustment factor * $1,354.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19742.16","14202.14","19771.30","33","15416.8","24915.241","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75450.22","56587.66","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","15416.80","","Case rate ($15,731.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,860.13, add-ons for qualifying new technology services are included. If operating cost exceeds $64,504.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,794.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,997.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,480.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.16. The transfer capital threshold is the transfer adjustment factor * $1,354.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15004.49","15004.49","15095.97","1 through 10","15416.8","24915.241","other","Inpatient DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75450.22","56587.66","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15416.80","","Case rate ($15,731.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,860.13, add-ons for qualifying new technology services are included. If operating cost exceeds $64,504.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,794.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $13,997.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,480.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,354.16. The transfer capital threshold is the transfer adjustment factor * $1,354.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14992.10","14992.10","14992.10","1 through 10","15416.8","24915.241","other","Inpatient DRG"
"Major Small Bowel Procedures,EXTREME","230","DRG","","","","","","","","inpatient","","","337762.78","","MASSHEALTH [3001]","HB BWH MEDICAID","57566.11","","Case rate ($63,649.23). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $106,079.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","63633.61","63633.61","63633.61","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,EXTREME","230","DRG","","","","","","","","inpatient","","","337762.78","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","174344.60","","Fee schedule rate ($174,344.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","174344.60","174344.60","174344.60","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,EXTREME","230","DRG","","","","","","","","inpatient","","","337788.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","156093.84","","Standard inlier is a Case rate ($156,093.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $133,033, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($22,158.46) for the length of stay and the standard reimbursement.","142285.22","142285.22","142307.41","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,EXTREME","230","DRG","","","","","","","","inpatient","","","337788.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","175491.54","","Standard inlier is a Case rate ($175,491.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $133,033, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($24,909.57) for the length of stay and the standard reimbursement.","175491.54","175491.54","175491.54","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,EXTREME","230","DRG","","","","","","","","inpatient","","","337788.28","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","57566.11","","Case rate ($63,649.23). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $106,079.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","100226.46","100226.46","100226.46","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MAJOR","230","DRG","","","","","","","","inpatient","","","164700.70","","MASSHEALTH [3001]","HB BWH MEDICAID","26946.13","","Case rate ($29,793.58). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $72,223.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29786.26","29786.26","29786.26","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MAJOR","230","DRG","","","","","","","","inpatient","","","164700.70","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","86675.71","","Fee schedule rate ($86,675.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","86675.71","86675.71","86675.71","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MAJOR","230","DRG","","","","","","","","inpatient","","","164700.70","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91010.92","","Fee schedule rate ($91,010.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","91010.92","91010.92","91010.92","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MAJOR","230","DRG","","","","","","","","inpatient","","","164777.20","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","84840.15","","Standard inlier is a Case rate ($84,840.15). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $77,622, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,043.57) for the length of stay and the standard reimbursement.","84840.14","84840.14","96568.22","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MAJOR","230","DRG","","","","","","","","inpatient","","","164777.20","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","95383.19","","Standard inlier is a Case rate ($95,383.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $77,622, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,538.85) for the length of stay and the standard reimbursement.","95383.18","87140.78","98897.46","19","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MAJOR","230","DRG","","","","","","","","inpatient","","","164777.20","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","26946.13","","Case rate ($29,793.58). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $72,223.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","51582.27","51582.27","51582.27","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MINOR","230","DRG","","","","","","","","inpatient","","","56211.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","41781.34","","Standard inlier is a Case rate ($41,781.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $44,139, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,931.11) for the length of stay and the standard reimbursement.","41781.33","41781.33","41781.33","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MINOR","230","DRG","","","","","","","","inpatient","","","56211.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","46973.48","","Standard inlier is a Case rate ($46,973.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $44,139, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,667.50) for the length of stay and the standard reimbursement.","42914.33","4964.77","46973.48","11","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MINOR","230","DRG","","","","","","","","inpatient","","","56211.28","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56389.94","","Fee schedule rate ($56,389.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","43444.42","43444.42","43444.42","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MINOR","230","DRG","","","","","","","","inpatient","","","56211.28","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","59210.36","","Fee schedule rate ($59,210.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","45617.35","45617.35","45617.35","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MINOR","230","DRG","","","","","","","","inpatient","","","56211.28","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11688.69","","Case rate ($12,923.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,353.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12920.68","12920.68","12920.68","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MINOR","230","DRG","","","","","","","","inpatient","","","56211.28","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","11688.69","","Case rate ($12,923.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,353.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16549.68","16549.68","16549.68","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MODERATE","230","DRG","","","","","","","","inpatient","","","87480.21","","MASSHEALTH [3001]","HB BWH MEDICAID","17180.04","","Case rate ($18,995.49). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,425.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19760.30","19760.30","24065.81","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MODERATE","230","DRG","","","","","","","","inpatient","","","87480.21","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","17180.04","","Case rate ($18,995.49). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,425.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5565.37","5565.37","5565.37","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MODERATE","230","DRG","","","","","","","","inpatient","","","87480.21","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","59210.36","","Fee schedule rate ($59,210.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","59210.36","59210.36","59210.36","1 through 10","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MODERATE","230","DRG","","","","","","","","inpatient","","","87531.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","57288.85","","Standard inlier is a Case rate ($57,288.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,197, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,132.50) for the length of stay and the standard reimbursement.","57288.84","52220.87","57288.84","16","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MODERATE","230","DRG","","","","","","","","inpatient","","","87531.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","64408.10","","Standard inlier is a Case rate ($64,408.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,197, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,142.20) for the length of stay and the standard reimbursement.","58842.36","58842.36","64408.10","28","11688.69","183064.7","case rate",""
"Major Small Bowel Procedures,MODERATE","230","DRG","","","","","","","","inpatient","","","87531.21","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","17180.04","","Case rate ($18,995.49). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,425.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18990.83","18990.83","18990.83","1 through 10","11688.69","183064.7","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,EXTREME","220","DRG","","","","","","","","inpatient","","","465245.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","195798.60","","Standard inlier is a Case rate ($195,798.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $147,080, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($27,791.99) for the length of stay and the standard reimbursement.","200378.15","200378.15","200378.15","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,EXTREME","220","DRG","","","","","","","","inpatient","","","465245.19","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","29658.1208","","Fee schedule rate ($187,063.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29658.1208","158682.00","158682.00","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,EXTREME","220","DRG","","","","","","","","inpatient","","","465245.19","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","243101.17","","Fee schedule rate ($243,101.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","243101.17","243101.17","243101.17","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,EXTREME","220","DRG","","","","","","","","inpatient","","","465245.19","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","98142.95","","Case rate ($108,513.90). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $150,943.90, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","134595.05","134595.05","134595.05","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MAJOR","220","DRG","","","","","","","","inpatient","","","224821.24","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","97508.12","","Standard inlier is a Case rate ($97,508.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $87,473, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,841.87) for the length of stay and the standard reimbursement.","97508.11","88882.20","100152.27","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MAJOR","220","DRG","","","","","","","","inpatient","","","224821.24","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","109625.40","","Standard inlier is a Case rate ($109,625.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $87,473, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($15,560.42) for the length of stay and the standard reimbursement.","100152.27","23173.29","110662.57","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MAJOR","220","DRG","","","","","","","","inpatient","","","224821.24","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28245.0476","","Fee schedule rate ($65,600.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28245.0476","81708.88","81708.88","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MAJOR","220","DRG","","","","","","","","inpatient","","","224821.24","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","68882.09","","Fee schedule rate ($68,882.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","82487.00","82487.00","82487.00","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MAJOR","220","DRG","","","","","","","","inpatient","","","224821.24","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","120295.27","","Fee schedule rate ($120,295.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","120295.27","120295.27","120295.27","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MAJOR","220","DRG","","","","","","","","inpatient","","","224821.24","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","126308.75","","Fee schedule rate ($126,308.75). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","126308.75","126308.75","126308.75","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MAJOR","220","DRG","","","","","","","","inpatient","","","224821.24","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","36034.79","","Case rate ($39,842.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $82,272.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","813.16","813.16","813.16","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","89293.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","44617.64","","Standard inlier is a Case rate ($44,617.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,343, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,333.74) for the length of stay and the standard reimbursement.","44617.64","40670.60","58364.50","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","89293.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","50162.26","","Standard inlier is a Case rate ($50,162.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,343, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,120.12) for the length of stay and the standard reimbursement.","50162.25","45827.55","50162.25","18","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","89293.71","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28245.0476","","Fee schedule rate ($28,245.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28245.0476","28245.04","28245.04","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","89293.71","","MASSHEALTH [3001]","HB BWH MEDICAID","10892.46","","Case rate ($12,043.49). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,473.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12040.53","12040.53","66116.52","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","89293.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54550.34","","Fee schedule rate ($54,550.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","54550.34","54550.34","54550.34","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","89293.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57277.28","","Fee schedule rate ($57,277.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","57277.28","57277.28","57277.28","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","89293.71","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10892.46","","Case rate ($12,043.49). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,473.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12040.53","12040.53","12040.53","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MODERATE","220","DRG","","","","","","","","inpatient","","","102067.68","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","64028.71","","Standard inlier is a Case rate ($64,028.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $61,439, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,089.26) for the length of stay and the standard reimbursement.","64028.71","64028.71","64028.71","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MODERATE","220","DRG","","","","","","","","inpatient","","","102067.68","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28245.0476","","Fee schedule rate ($45,259.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28245.0476","53940.24","81708.88","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MODERATE","220","DRG","","","","","","","","inpatient","","","102067.68","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","29658.1208","","Fee schedule rate ($47,523.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29658.1208","47523.92","47523.92","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MODERATE","220","DRG","","","","","","","","inpatient","","","102067.68","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78853.56","","Fee schedule rate ($78,853.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","67025.53","67025.53","67025.53","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MODERATE","220","DRG","","","","","","","","inpatient","","","102067.68","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82795.40","","Fee schedule rate ($82,795.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32154.15","32154.15","32154.15","1 through 10","10892.46","293952.6","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MODERATE","220","DRG","","","","","","","","inpatient","","","102067.68","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","18998.69","","Case rate ($21,006.32). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,436.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21001.16","21001.16","21001.16","1 through 10","10892.46","293952.6","case rate",""
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","","","","inpatient","","","41464.61","31098.46","MEDICARE [2001]","HB BWH MEDICARE","16352.91","","Case rate ($16,352.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,195.69, add-ons for qualifying new technology services are included. If operating cost exceeds $60,840.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,525.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $14,887.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,815.86 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.65. The transfer capital threshold is the transfer adjustment factor * $1,085.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17951.41","17951.41","17951.41","1 through 10","12433.63","21133.87","other","Inpatient DRG"
"Male Reproductive System Diagnoses Except Malignancy,MAJOR","501","DRG","","","","","","","","inpatient","","","45464.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","31491.40","","Standard inlier is a Case rate ($31,491.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,429, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,469.94) for the length of stay and the standard reimbursement.","28770.10","28770.10","28770.10","1 through 10","6004.28","69608.41","case rate",""
"Male Reproductive System Diagnoses Except Malignancy,MAJOR","501","DRG","","","","","","","","inpatient","","","45464.35","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","29723.96","29723.96","29723.96","1 through 10","6004.28","69608.41","percent of total billed charges",""
"Male Reproductive System Diagnoses Except Malignancy,MODERATE","501","DRG","","","","","","","","inpatient","","","31240.43","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6004.28","","Case rate ($6,638.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,068.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8879.04","8879.04","8879.04","1 through 10","6004.28","69608.41","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,EXTREME","252","DRG","","","","","","","","inpatient","","","93516.67","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","60002.26","","Standard inlier is a Case rate ($60,002.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $58,308, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,517.68) for the length of stay and the standard reimbursement.","130589.02","130589.02","130589.02","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,EXTREME","252","DRG","","","","","","","","inpatient","","","93516.67","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","67458.71","","Standard inlier is a Case rate ($67,458.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $58,308, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,575.20) for the length of stay and the standard reimbursement.","67458.70","67458.70","67458.70","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,EXTREME","252","DRG","","","","","","","","inpatient","","","93516.67","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12673.1422","","Fee schedule rate ($60,616.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12673.1422","60616.80","60616.80","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,EXTREME","252","DRG","","","","","","","","inpatient","","","93516.67","","MASSHEALTH [3001]","HB BWH MEDICAID","31202.58","","Case rate ($34,499.82). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,929.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18916.65","3240.41","34491.35","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,EXTREME","252","DRG","","","","","","","","inpatient","","","93516.67","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","31202.58","","Case rate ($34,499.82). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,929.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1020.93","1020.93","13723.81","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MAJOR","252","DRG","","","","","","","","inpatient","","","54295.82","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31532.48","","Standard inlier is a Case rate ($31,532.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,169, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,476.23) for the length of stay and the standard reimbursement.","28743.00","28743.00","31532.47","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MAJOR","252","DRG","","","","","","","","inpatient","","","54295.82","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35451.00","","Standard inlier is a Case rate ($35,451). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,169, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,031.98) for the length of stay and the standard reimbursement.","32387.55","32387.55","35451.00","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MAJOR","252","DRG","","","","","","","","inpatient","","","54295.82","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","","65","","16535.27","16535.27","16535.27","1 through 10","6544.61","100018.95","percent of total billed charges",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MAJOR","252","DRG","","","","","","","","inpatient","","","54295.82","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12673.1422","","Fee schedule rate ($28,842.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12673.1422","28842.24","28842.24","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MAJOR","252","DRG","","","","","","","","inpatient","","","54295.82","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","13307.1676","","Fee schedule rate ($30,285.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13307.1676","31726.84","31726.84","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MAJOR","252","DRG","","","","","","","","inpatient","","","54295.82","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34853.05","","Fee schedule rate ($34,853.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34853.05","34853.05","34853.05","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MAJOR","252","DRG","","","","","","","","inpatient","","","54295.82","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12415.23","","Case rate ($13,727.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,157.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13723.81","1349.64","13723.81","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MINOR","252","DRG","","","","","","","","inpatient","","","34039.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","17920.15","","Standard inlier is a Case rate ($17,920.15). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,583, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,543.87) for the length of stay and the standard reimbursement.","16335.61","16335.61","16335.61","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MINOR","252","DRG","","","","","","","","inpatient","","","34039.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","20147.08","","Standard inlier is a Case rate ($20,147.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,583, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,859.71) for the length of stay and the standard reimbursement.","18406.09","18406.09","18406.09","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MINOR","252","DRG","","","","","","","","inpatient","","","34039.98","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23354.79","","Fee schedule rate ($23,354.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18695.76","18695.76","18695.76","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MINOR","252","DRG","","","","","","","","inpatient","","","34039.98","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6544.61","","Case rate ($7,236.20). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,666.20, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7234.42","268.45","7234.42","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MODERATE","252","DRG","","","","","","","","inpatient","","","27692.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22182.69","","Standard inlier is a Case rate ($22,182.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,899, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,148.97) for the length of stay and the standard reimbursement.","20220.33","20220.33","22182.69","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MODERATE","252","DRG","","","","","","","","inpatient","","","27692.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24939.32","","Standard inlier is a Case rate ($24,939.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,899, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,539.93) for the length of stay and the standard reimbursement.","22784.22","22784.22","22784.22","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MODERATE","252","DRG","","","","","","","","inpatient","","","27692.28","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","13307.1676","","Fee schedule rate ($47,523.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13307.1676","16885.32","16885.32","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MODERATE","252","DRG","","","","","","","","inpatient","","","27692.28","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24522.91","","Fee schedule rate ($24,522.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24522.91","24522.91","24522.91","1 through 10","6544.61","100018.95","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,EXTREME","206","DRG","","","","","","","","inpatient","","","102521.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","60600.57","","Standard inlier is a Case rate ($60,600.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $58,773, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,602.62) for the length of stay and the standard reimbursement.","60600.56","60600.56","60600.56","1 through 10","7693.84","116896.06","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,EXTREME","206","DRG","","","","","","","","inpatient","","","102521.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","68131.37","","Standard inlier is a Case rate ($68,131.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $58,773, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,670.68) for the length of stay and the standard reimbursement.","68131.36","68131.36","68131.36","1 through 10","7693.84","116896.06","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,EXTREME","206","DRG","","","","","","","","inpatient","","","102521.43","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","20283.85","","Case rate ($22,427.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,857.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","34723.65","34723.65","34723.65","1 through 10","7693.84","116896.06","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MAJOR","206","DRG","","","","","","","","inpatient","","","62813.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","30601.05","","Standard inlier is a Case rate ($30,601.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,443, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,344.00) for the length of stay and the standard reimbursement.","27893.97","3540.68","30601.05","1 through 10","7693.84","116896.06","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MAJOR","206","DRG","","","","","","","","inpatient","","","62813.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","34403.83","","Standard inlier is a Case rate ($34,403.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,443, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,883.34) for the length of stay and the standard reimbursement.","34403.83","31430.87","62155.12","1 through 10","7693.84","116896.06","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MAJOR","206","DRG","","","","","","","","inpatient","","","62813.60","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","19910.03","19910.03","19910.03","1 through 10","7693.84","116896.06","percent of total billed charges",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MAJOR","206","DRG","","","","","","","","inpatient","","","62813.60","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33702.5956","","Fee schedule rate ($29,783.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33702.5956","29783.88","29783.88","1 through 10","7693.84","116896.06","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MAJOR","206","DRG","","","","","","","","inpatient","","","62813.60","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9691.6211","","Fee schedule rate ($29,783.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9691.6211","29783.88","29783.88","1 through 10","7693.84","116896.06","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MAJOR","206","DRG","","","","","","","","inpatient","","","62813.60","","MASSHEALTH [3001]","HB BWH MEDICAID","12345.55","","Case rate ($13,650.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,080.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","24547.75","24547.75","96153.77","1 through 10","7693.84","116896.06","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MAJOR","206","DRG","","","","","","","","inpatient","","","62813.60","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36040.28","","Fee schedule rate ($36,040.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34990.17","34990.17","34990.17","1 through 10","7693.84","116896.06","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MAJOR","206","DRG","","","","","","","","inpatient","","","62813.60","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12345.55","","Case rate ($13,650.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,080.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13646.78","13646.78","13646.78","1 through 10","7693.84","116896.06","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MODERATE","206","DRG","","","","","","","","inpatient","","","32336.45","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20410.41","","Standard inlier is a Case rate ($20,410.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,520, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,897.38) for the length of stay and the standard reimbursement.","20410.40","20410.40","20410.40","1 through 10","7693.84","116896.06","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MODERATE","206","DRG","","","","","","","","inpatient","","","32336.45","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22946.80","","Standard inlier is a Case rate ($22,946.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,520, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,257.11) for the length of stay and the standard reimbursement.","22946.79","20963.87","22946.79","1 through 10","7693.84","116896.06","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MODERATE","206","DRG","","","","","","","","inpatient","","","32336.45","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26082.85","","Fee schedule rate ($26,082.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22170.42","22170.42","22170.42","1 through 10","7693.84","116896.06","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,EXTREME","466","DRG","","","","","","","","inpatient","","","87948.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","45710.77","","Standard inlier is a Case rate ($45,710.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,194, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,488.92) for the length of stay and the standard reimbursement.","45710.76","45710.76","45710.76","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,EXTREME","466","DRG","","","","","","","","inpatient","","","87948.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","51391.22","","Standard inlier is a Case rate ($51,391.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,194, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,294.56) for the length of stay and the standard reimbursement.","51391.22","51391.22","51391.22","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,EXTREME","466","DRG","","","","","","","","inpatient","","","87948.86","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9691.6211","","Fee schedule rate ($58,610.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9691.6211","58610.48","58610.48","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,EXTREME","466","DRG","","","","","","","","inpatient","","","87948.86","","MASSHEALTH [3001]","HB BWH MEDICAID","14811.92","","Case rate ($16,377.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,807.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15330.62","4067.78","19955.40","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,EXTREME","466","DRG","","","","","","","","inpatient","","","87948.86","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14811.92","","Case rate ($16,377.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,807.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27909.53","27909.53","27909.53","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","47780.08","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","27299.04","","Standard inlier is a Case rate ($27,299.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,876, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,875.26) for the length of stay and the standard reimbursement.","27299.03","3158.62","30483.57","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","47780.08","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","30691.48","","Standard inlier is a Case rate ($30,691.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,876, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,356.40) for the length of stay and the standard reimbursement.","28041.33","28039.31","30691.47","13","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","47780.08","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","52798.26","52798.26","52798.26","1 through 10","4537.48","96708.48","percent of total billed charges",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","47780.08","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10176.4838","","Fee schedule rate ($28,981.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10176.4838","28981.72","28981.72","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","47780.08","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","34052.23","","Fee schedule rate ($34,052.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34501.41","34501.41","34501.41","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","47780.08","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","59511.69","59511.69","59511.69","1 through 10","4537.48","96708.48","percent of total billed charges",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","47780.08","","MASSHEALTH [3001]","HB BWH MEDICAID","8702.54","","Case rate ($9,622.16). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,052.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6033.52","1912.28","9619.80","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","47780.08","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22527.38","","Fee schedule rate ($22,527.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25531.03","25531.03","25531.03","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","47780.08","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23653.82","","Fee schedule rate ($23,653.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23653.82","23653.82","23653.82","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","47780.08","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8702.54","","Case rate ($9,622.16). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,052.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9619.80","9619.80","9619.80","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MINOR","466","DRG","","","","","","","","inpatient","","","24082.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","13411.81","","Standard inlier is a Case rate ($13,411.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,077, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,903.89) for the length of stay and the standard reimbursement.","12225.35","12225.35","12225.35","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MINOR","466","DRG","","","","","","","","inpatient","","","24082.49","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9691.6211","","Fee schedule rate ($15,473.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9691.6211","9691.64","9691.64","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MODERATE","466","DRG","","","","","","","","inpatient","","","32045.81","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19210.55","","Standard inlier is a Case rate ($19,210.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,586, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,727.05) for the length of stay and the standard reimbursement.","17512.10","17512.10","17512.10","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MODERATE","466","DRG","","","","","","","","inpatient","","","32045.81","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10176.4838","","Fee schedule rate ($16,247.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10176.4838","16247.61","16247.61","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MODERATE","466","DRG","","","","","","","","inpatient","","","32045.81","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","16247.61","","Fee schedule rate ($16,247.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16247.61","16247.61","16247.61","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MODERATE","466","DRG","","","","","","","","inpatient","","","32045.81","","MASSHEALTH [3001]","HB BWH MEDICAID","5458.22","","Case rate ($6,035.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,465.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6033.52","1596.62","8798.29","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MODERATE","466","DRG","","","","","","","","inpatient","","","32045.81","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5458.22","","Case rate ($6,035.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,465.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6033.52","1245.92","6033.52","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MODERATE","466","DRG","","","","","","","","inpatient","","","32045.81","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","5458.22","","Case rate ($6,035.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,465.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7140.93","7140.93","7140.93","1 through 10","4537.48","96708.48","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MAJOR","349","DRG","","","","","","","","inpatient","","","94334.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","33793.11","","Standard inlier is a Case rate ($33,793.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,926, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,797.14) for the length of stay and the standard reimbursement.","30803.65","30803.65","30803.65","1 through 10","5035.55","62352.69","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MAJOR","349","DRG","","","","","","","","inpatient","","","94334.09","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","41568.46","","Fee schedule rate ($41,568.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","39966.81","39966.81","39966.81","1 through 10","5035.55","62352.69","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MAJOR","349","DRG","","","","","","","","inpatient","","","94334.09","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11600.73","","Case rate ($12,826.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,256.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9938.66","619.20","12823.45","1 through 10","5035.55","62352.69","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MINOR","349","DRG","","","","","","","","inpatient","","","33537.75","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","16613.57","","Standard inlier is a Case rate ($16,613.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,568, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,358.40) for the length of stay and the standard reimbursement.","15143.87","15143.87","15143.87","1 through 10","5035.55","62352.69","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MODERATE","349","DRG","","","","","","","","inpatient","","","54421.52","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12090.5928","","Fee schedule rate ($20,439.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12090.5928","20439.88","20439.88","1 through 10","5035.55","62352.69","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MODERATE","349","DRG","","","","","","","","inpatient","","","54421.52","","MASSHEALTH [3001]","HB BWH MEDICAID","7002.70","","Case rate ($7,742.69). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,172.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7740.79","7740.79","7740.79","1 through 10","5035.55","62352.69","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MODERATE","349","DRG","","","","","","","","inpatient","","","54421.52","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","7002.70","","Case rate ($7,742.69). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,172.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","5035.55","62352.69","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MODERATE","349","DRG","","","","","","","","inpatient","","","54421.52","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7002.70","","Case rate ($7,742.69). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,172.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16525.25","320.88","91038.25","1 through 10","5035.55","62352.69","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,EXTREME","281","DRG","","","","","","","","inpatient","","","93977.27","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","33983.92","","Standard inlier is a Case rate ($33,983.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,075, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,824.22) for the length of stay and the standard reimbursement.","61424.45","61424.45","61424.45","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,EXTREME","281","DRG","","","","","","","","inpatient","","","93977.27","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","38207.09","","Standard inlier is a Case rate ($38,207.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,075, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,423.18) for the length of stay and the standard reimbursement.","56172.56","51318.48","109672.15","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,EXTREME","281","DRG","","","","","","","","inpatient","","","93977.27","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17229.3001","","Fee schedule rate ($59,628.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17229.3001","59628.20","59628.20","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,EXTREME","281","DRG","","","","","","","","inpatient","","","93977.27","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","18091.2658","","Fee schedule rate ($62,611.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18091.2658","97840.50","97840.50","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,EXTREME","281","DRG","","","","","","","","inpatient","","","93977.27","","MASSHEALTH [3001]","HB BWH MEDICAID","12011.98","","Case rate ($13,281.31). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,711.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20512.47","20512.47","20512.47","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,EXTREME","281","DRG","","","","","","","","inpatient","","","93977.27","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58951.76","","Fee schedule rate ($58,951.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","58951.76","58951.76","58951.76","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,EXTREME","281","DRG","","","","","","","","inpatient","","","93977.27","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12011.98","","Case rate ($13,281.31). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,711.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","98383.59","98383.59","98383.59","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MAJOR","281","DRG","","","","","","","","inpatient","","","70255.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","33983.92","","Standard inlier is a Case rate ($33,983.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,075, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,824.22) for the length of stay and the standard reimbursement.","33983.92","33983.92","59595.26","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MAJOR","281","DRG","","","","","","","","inpatient","","","70255.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","38207.09","","Standard inlier is a Case rate ($38,207.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,075, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,423.18) for the length of stay and the standard reimbursement.","34905.47","34905.47","38207.08","11","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MAJOR","281","DRG","","","","","","","","inpatient","","","70255.46","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17229.3001","","Fee schedule rate ($32,973.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17229.3001","59628.20","59628.20","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MAJOR","281","DRG","","","","","","","","inpatient","","","70255.46","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","18091.2658","","Fee schedule rate ($34,623.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18091.2658","34623.08","34623.08","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MAJOR","281","DRG","","","","","","","","inpatient","","","70255.46","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12011.98","","Case rate ($13,281.31). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,711.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13278.05","13278.05","13278.05","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MINOR","281","DRG","","","","","","","","inpatient","","","70397.19","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17229.3001","","Fee schedule rate ($14,644.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17229.3001","17229.30","17229.30","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MODERATE","281","DRG","","","","","","","","inpatient","","","42446.42","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","26115.36","","Standard inlier is a Case rate ($26,115.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,955, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,707.23) for the length of stay and the standard reimbursement.","26115.35","26115.35","26115.35","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MODERATE","281","DRG","","","","","","","","inpatient","","","42446.42","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","29360.70","","Standard inlier is a Case rate ($29,360.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,955, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,167.51) for the length of stay and the standard reimbursement.","29360.70","29360.70","29360.70","1 through 10","7119.22","98387.71","case rate",""
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","","","","inpatient","","","47485.69","35614.27","MEDICARE [2001]","HB BWH MEDICARE","13770.85","","Case rate ($13,770.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,800.69, add-ons for qualifying new technology services are included. If operating cost exceeds $58,445.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,350.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $12,480.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,420.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $910.15. The transfer capital threshold is the transfer adjustment factor * $910.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13572.92","0.03","13592.80","1 through 10","10483.9","17717.55","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","","","","inpatient","","","47485.69","35614.27","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10483.90","","Case rate ($10,697.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,800.69, add-ons for qualifying new technology services are included. If operating cost exceeds $58,445.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,350.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,407.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,420.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $910.15. The transfer capital threshold is the transfer adjustment factor * $910.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10317.67","10317.67","10317.67","1 through 10","10483.9","17717.55","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","TRIS-DRG","","","","","","","","inpatient","","","30649.87","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","8936.38","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($15,697.27). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $59,424.27 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($7,848.63), capped at $11,297.88. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $59,424.27 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","13314.90","13314.90","13314.90","1 through 10","8936.38","8936.38","other","Inpatient DRGs"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","77630.38","58222.78","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","17648.44","","Case rate ($17,134.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,549.03, add-ons for qualifying new technology services are included. If operating cost exceeds $66,193.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,918.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,276.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,169.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,477.92. The transfer capital threshold is the transfer adjustment factor * $1,477.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17398.94","17398.94","22992.81","1 through 10","16791.72","27535.0386","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","77630.38","58222.78","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","17134.41","","Case rate ($17,134.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,549.03, add-ons for qualifying new technology services are included. If operating cost exceeds $66,193.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,918.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,276.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,169.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,477.92. The transfer capital threshold is the transfer adjustment factor * $1,477.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16839.59","16657.55","21473.69","1 through 10","16791.72","27535.0386","other","Inpatient Replacement Plans DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","77630.38","58222.78","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","17134.41","","Case rate ($17,134.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,549.03, add-ons for qualifying new technology services are included. If operating cost exceeds $66,193.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,918.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,276.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,169.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,477.92. The transfer capital threshold is the transfer adjustment factor * $1,477.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16502.95","16502.95","16502.95","1 through 10","16791.72","27535.0386","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","77630.38","58222.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","","65","","59500.31","59500.31","59500.31","1 through 10","16791.72","27535.0386","percent of total billed charges",""
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","77630.38","58222.78","MARTIN'S POINT [160007]","HB BWH MEDICARE","17134.41","","Case rate ($17,134.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,549.03, add-ons for qualifying new technology services are included. If operating cost exceeds $66,193.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,918.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,276.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,169.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,477.92. The transfer capital threshold is the transfer adjustment factor * $1,477.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16587.67","1835.59","23490.00","1 through 10","16791.72","27535.0386","other","Inpatient Replacement Plans DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","77630.38","58222.78","MEDICARE [2001]","HB BWH MEDICARE","17134.41","","Case rate ($17,134.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,549.03, add-ons for qualifying new technology services are included. If operating cost exceeds $66,193.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,918.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,276.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,169.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,477.92. The transfer capital threshold is the transfer adjustment factor * $1,477.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21788.78","0.03","21820.94","43","16791.72","27535.0386","other","Inpatient Replacement Plans DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","77630.38","58222.78","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16791.72","","Case rate ($17,134.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,549.03, add-ons for qualifying new technology services are included. If operating cost exceeds $66,193.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,918.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,276.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,169.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,477.92. The transfer capital threshold is the transfer adjustment factor * $1,477.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16618.76","16537.95","16669.63","1 through 10","16791.72","27535.0386","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","77630.38","58222.78","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16791.72","","Case rate ($17,134.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,549.03, add-ons for qualifying new technology services are included. If operating cost exceeds $66,193.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,918.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,276.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,169.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,477.92. The transfer capital threshold is the transfer adjustment factor * $1,477.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16586.23","16533.05","17247.78","11","16791.72","27535.0386","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/McC","437","MS-DRG","","","","","","","","inpatient","","","42446.42","31834.81","HUMANA [1012]","HB BWH MEDICARE","8163.73","","Case rate ($8,163.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,750.11, add-ons for qualifying new technology services are included. If operating cost exceeds $55,394.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,126.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,097.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,370.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.62. The transfer capital threshold is the transfer adjustment factor * $686.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5243.94","5243.94","5243.94","1 through 10","8000.46","11849.4532","other","Inpatient Replacement Plans DRG"
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/McC","437","MS-DRG","","","","","","","","inpatient","","","42446.42","31834.81","MEDICARE [2001]","HB BWH MEDICARE","8163.73","","Case rate ($8,163.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,750.11, add-ons for qualifying new technology services are included. If operating cost exceeds $55,394.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,126.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,097.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,370.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.62. The transfer capital threshold is the transfer adjustment factor * $686.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9535.12","9535.12","9535.12","1 through 10","8000.46","11849.4532","other","Inpatient Replacement Plans DRG"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","85759.54","64319.65","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10611.95","","Case rate ($10,302.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,325.21, add-ons for qualifying new technology services are included. If operating cost exceeds $57,969.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,315.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,047.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,945.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $875.31. The transfer capital threshold is the transfer adjustment factor * $875.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10677.62","10677.62","10677.62","1 through 10","10096.8","16752.5191","other","Inpatient DRG"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","85759.54","64319.65","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","10302.86","","Case rate ($10,302.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,325.21, add-ons for qualifying new technology services are included. If operating cost exceeds $57,969.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,315.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,047.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,945.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $875.31. The transfer capital threshold is the transfer adjustment factor * $875.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10220.89","10220.89","10220.89","1 through 10","10096.8","16752.5191","other","Inpatient DRG"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","85759.54","64319.65","ELDER SERVICES [1037]","HB BWH MEDICARE","10302.86","","Case rate ($10,302.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,325.21, add-ons for qualifying new technology services are included. If operating cost exceeds $57,969.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,315.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,047.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,945.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $875.31. The transfer capital threshold is the transfer adjustment factor * $875.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","68982.59","68982.59","68982.59","1 through 10","10096.8","16752.5191","other","Inpatient Replacement Plans DRG"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","85759.54","64319.65","FALLON HEALTH [1008]","HB BWH MEDICARE","10302.86","","Case rate ($10,302.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,325.21, add-ons for qualifying new technology services are included. If operating cost exceeds $57,969.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,315.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,047.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,945.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $875.31. The transfer capital threshold is the transfer adjustment factor * $875.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10364.14","10364.14","10364.14","1 through 10","10096.8","16752.5191","other","Inpatient Replacement Plans DRG"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","85759.54","64319.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","","65","","3559.40","3559.40","3559.40","1 through 10","10096.8","16752.5191","percent of total billed charges",""
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","85759.54","64319.65","MEDICARE [2001]","HB BWH MEDICARE","10302.86","","Case rate ($10,302.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,325.21, add-ons for qualifying new technology services are included. If operating cost exceeds $57,969.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,315.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,047.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,945.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $875.31. The transfer capital threshold is the transfer adjustment factor * $875.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13385.00","13365.43","13385.00","1 through 10","10096.8","16752.5191","other","Inpatient Replacement Plans DRG"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","85759.54","64319.65","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","10096.80","","Case rate ($10,302.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,325.21, add-ons for qualifying new technology services are included. If operating cost exceeds $57,969.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,315.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,047.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,945.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $875.31. The transfer capital threshold is the transfer adjustment factor * $875.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10147.24","10147.24","10147.24","1 through 10","10096.8","16752.5191","other","Inpatient DRG"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","85759.54","64319.65","WELLPOINT [1015]","HB AMC WELLPOINT","16752.5191","","Fee schedule rate ($17,039.30).","16752.5191","16752.51","16752.51","1 through 10","10096.8","16752.5191","case rate",""
"Malignancy, Female Reproductive System With McC","754","MS-DRG","","","","","","","","inpatient","","","107095.74","80321.80","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","17695.42","","Case rate ($17,180.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,603.95, add-ons for qualifying new technology services are included. If operating cost exceeds $66,248.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,922.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,318.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,224.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,481.94. The transfer capital threshold is the transfer adjustment factor * $1,481.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17263.74","17263.74","17263.74","1 through 10","16836.42","27304.1463","other","Inpatient DRG"
"Malignancy, Female Reproductive System With McC","754","MS-DRG","","","","","","","","inpatient","","","107095.74","80321.80","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","17180.02","","Case rate ($17,180.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,603.95, add-ons for qualifying new technology services are included. If operating cost exceeds $66,248.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,922.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,318.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,224.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,481.94. The transfer capital threshold is the transfer adjustment factor * $1,481.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16408.73","16408.73","16408.73","1 through 10","16836.42","27304.1463","other","Inpatient Replacement Plans DRG"
"Malignancy, Female Reproductive System With McC","754","MS-DRG","","","","","","","","inpatient","","","107095.74","80321.80","MEDICARE [2001]","HB BWH MEDICARE","17180.02","","Case rate ($17,180.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,603.95, add-ons for qualifying new technology services are included. If operating cost exceeds $66,248.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,922.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,318.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,224.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,481.94. The transfer capital threshold is the transfer adjustment factor * $1,481.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21608.40","21608.40","21640.30","14","16836.42","27304.1463","other","Inpatient Replacement Plans DRG"
"Malignancy, Female Reproductive System With McC","754","MS-DRG","","","","","","","","inpatient","","","107095.74","80321.80","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16836.42","","Case rate ($17,180.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,603.95, add-ons for qualifying new technology services are included. If operating cost exceeds $66,248.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,922.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,318.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,224.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,481.94. The transfer capital threshold is the transfer adjustment factor * $1,481.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16374.70","16374.70","16374.70","1 through 10","16836.42","27304.1463","other","Inpatient DRG"
"Malignancy, Female Reproductive System With McC","754","MS-DRG","","","","","","","","inpatient","","","107095.74","80321.80","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16836.42","","Case rate ($17,180.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,603.95, add-ons for qualifying new technology services are included. If operating cost exceeds $66,248.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,922.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,318.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,224.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,481.94. The transfer capital threshold is the transfer adjustment factor * $1,481.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16420.15","16420.15","16420.15","1 through 10","16836.42","27304.1463","other","Inpatient DRG"
"Malignancy, Female Reproductive System Without Cc/McC","756","MS-DRG","","","","","","","","inpatient","","","119990.16","89992.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","","65","","48179.21","8399.95","78456.22","1 through 10","8958.8","14411.905","percent of total billed charges",""
"Malignancy, Female Reproductive System Without Cc/McC","756","MS-DRG","","","","","","","","inpatient","","","119990.16","89992.62","MEDICARE [2001]","HB BWH MEDICARE","9141.63","","Case rate ($9,141.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,927.30, add-ons for qualifying new technology services are included. If operating cost exceeds $56,571.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,213.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,988.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,547.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $772.87. The transfer capital threshold is the transfer adjustment factor * $772.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11536.91","11536.91","11553.76","1 through 10","8958.8","14411.905","other","Inpatient Replacement Plans DRG"
"Malignancy, Female Reproductive System Without Cc/McC","756","MS-DRG","","","","","","","","inpatient","","","119990.16","89992.62","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8958.80","","Case rate ($9,141.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,927.30, add-ons for qualifying new technology services are included. If operating cost exceeds $56,571.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,213.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,988.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,547.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $772.87. The transfer capital threshold is the transfer adjustment factor * $772.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8832.21","8832.21","8832.21","1 through 10","8958.8","14411.905","other","Inpatient DRG"
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","","","","inpatient","","","46732.08","35049.06","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","11127.78","","Case rate ($10,803.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,928.08, add-ons for qualifying new technology services are included. If operating cost exceeds $58,572.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,359.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,504.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,548.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $919.48. The transfer capital threshold is the transfer adjustment factor * $919.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10828.24","10828.24","10828.24","1 through 10","10587.6","16945.6839","other","Inpatient DRG"
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","","","","inpatient","","","46732.08","35049.06","MEDICARE [2001]","HB BWH MEDICARE","10803.67","","Case rate ($10,803.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,928.08, add-ons for qualifying new technology services are included. If operating cost exceeds $58,572.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,359.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,504.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,548.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $919.48. The transfer capital threshold is the transfer adjustment factor * $919.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13516.31","13516.31","13536.11","1 through 10","10587.6","16945.6839","other","Inpatient Replacement Plans DRG"
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","","","","inpatient","","","46732.08","35049.06","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10587.60","","Case rate ($10,803.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,928.08, add-ons for qualifying new technology services are included. If operating cost exceeds $58,572.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,359.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,504.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,548.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $919.48. The transfer capital threshold is the transfer adjustment factor * $919.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10345.02","10345.02","76805.81","1 through 10","10587.6","16945.6839","other","Inpatient DRG"
"Malignancy, Male Reproductive System With McC","722","MS-DRG","","","","","","","","inpatient","","","108189.19","81141.89","MEDICARE [2001]","HB BWH MEDICARE","21804.74","","Case rate ($21,804.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,252.55, add-ons for qualifying new technology services are included. If operating cost exceeds $65,896.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,896.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,968.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,872.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.19. The transfer capital threshold is the transfer adjustment factor * $1,456.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20691.03","20691.03","20691.03","1 through 10","16550.35","26090.8299","other","Inpatient DRG"
"Malignancy, Male Reproductive System With McC","722","MS-DRG","","","","","","","","inpatient","","","108189.19","81141.89","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16550.35","","Case rate ($16,888.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,252.55, add-ons for qualifying new technology services are included. If operating cost exceeds $65,896.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,896.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,052.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,872.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.19. The transfer capital threshold is the transfer adjustment factor * $1,456.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","24323.02","24323.02","24323.02","1 through 10","16550.35","26090.8299","other","Inpatient DRG"
"Malignancy, Male Reproductive System,MAJOR","500","DRG","","","","","","","","inpatient","","","111596.80","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","37105.38","","Standard inlier is a Case rate ($37,105.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,313, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,266.80) for the length of stay and the standard reimbursement.","37105.38","37105.38","37105.38","1 through 10","5997.42","47627.19","case rate",""
"Malignancy, Male Reproductive System,MAJOR","500","DRG","","","","","","","","inpatient","","","111596.80","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12279.483","","Fee schedule rate ($28,864.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12279.483","28864.60","28864.60","1 through 10","5997.42","47627.19","case rate",""
"Malignancy, Male Reproductive System,MAJOR","500","DRG","","","","","","","","inpatient","","","111596.80","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","13064.10","","Case rate ($14,444.61). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,874.61, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18012.90","18012.90","18012.90","1 through 10","5997.42","47627.19","case rate",""
"Malignancy, Male Reproductive System,MINOR","500","DRG","","","","","","","","inpatient","","","10100.22","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5997.42","","Case rate ($6,631.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,061.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6629.55","6629.55","6629.55","1 through 10","5997.42","47627.19","case rate",""
"Malignancy, Male Reproductive System,MODERATE","500","DRG","","","","","","","","inpatient","","","147708.77","","MASSHEALTH [3001]","HB BWH MEDICAID","8350.70","","Case rate ($9,233.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,663.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9230.86","9230.86","9230.86","1 through 10","5997.42","47627.19","case rate",""
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","","","","inpatient","","","39771.69","29828.77","MEDICARE [2001]","HB BWH MEDICARE","13773.22","","Case rate ($13,773.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,802.89, add-ons for qualifying new technology services are included. If operating cost exceeds $58,447.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,350.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $12,483.07 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,423.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $910.31. The transfer capital threshold is the transfer adjustment factor * $910.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12997.59","12997.59","12997.59","1 through 10","10485.69","17720.68","other","Inpatient DRG"
"Malignant Breast Disorders With McC","597","MS-DRG","","","","","","","","inpatient","","","72795.14","54596.35","MEDICARE [2001]","HB BWH MEDICARE","15587.31","","Case rate ($15,587.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,686.63, add-ons for qualifying new technology services are included. If operating cost exceeds $64,331.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,781.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $13,866.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,306.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,341.45. The transfer capital threshold is the transfer adjustment factor * $1,341.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21019.26","21019.26","21019.26","1 through 10","15275.56","26113.45","other","Inpatient Replacement Plans DRG"
"Malignant Breast Disorders,EXTREME","382","DRG","","","","","","","","inpatient","","","72795.14","","MASSHEALTH [3001]","HB BWH MEDICAID","21201.17","","Case rate ($23,441.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,871.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23435.79","23435.79","23435.79","1 through 10","8067.39","121129.18","case rate",""
"Malignant Breast Disorders,MAJOR","382","DRG","","","","","","","","inpatient","","","63237.32","","MASSHEALTH [3001]","HB BWH MEDICAID","11445.36","","Case rate ($12,654.82). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,084.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","261.79","261.79","261.79","1 through 10","8067.39","121129.18","case rate",""
"Malignant Breast Disorders,MAJOR","382","DRG","","","","","","","","inpatient","","","63237.32","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11445.36","","Case rate ($12,654.82). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,084.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12651.71","12651.71","12651.71","1 through 10","8067.39","121129.18","case rate",""
"Malignant Breast Disorders,MODERATE","382","DRG","","","","","","","","inpatient","","","35397.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24637.54","","Standard inlier is a Case rate ($24,637.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,689, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,497.09) for the length of stay and the standard reimbursement.","22508.51","22508.51","22508.51","1 through 10","8067.39","121129.18","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,EXTREME","421","DRG","","","","","","","","inpatient","","","96985.01","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","54872.97","","Standard inlier is a Case rate ($54,872.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,319, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,789.55) for the length of stay and the standard reimbursement.","54872.97","54872.97","54872.97","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,EXTREME","421","DRG","","","","","","","","inpatient","","","96985.01","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","61692.01","","Standard inlier is a Case rate ($61,692.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,319, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,756.67) for the length of stay and the standard reimbursement.","63232.34","63232.34","63232.34","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,EXTREME","421","DRG","","","","","","","","inpatient","","","96985.01","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13617.0296","","Fee schedule rate ($88,962.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13617.0296","85534.00","85534.00","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,EXTREME","421","DRG","","","","","","","","inpatient","","","96985.01","","MASSHEALTH [3001]","HB BWH MEDICAID","25955.70","","Case rate ($28,698.49). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $71,128.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,651.21 and the sum of the standard inlier and any outlier amount.","2179.00","2179.00","2179.00","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","63852.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","31985.89","","Standard inlier is a Case rate ($31,985.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,772, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,540.13) for the length of stay and the standard reimbursement.","42417.18","31985.89","50937.12","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","63852.22","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","14298.2768","","Fee schedule rate ($32,319.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14298.2768","31072.32","31072.32","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","63852.22","","MASSHEALTH [3001]","HB BWH MEDICAID","15493.91","","Case rate ($17,131.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,561.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8716.02","8716.02","17126.98","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","63852.22","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33252.54","","Fee schedule rate ($33,252.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33252.54","33252.54","33252.54","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","63852.22","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34915.72","","Fee schedule rate ($34,915.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34915.72","34915.72","34915.72","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","63852.22","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15493.91","","Case rate ($17,131.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,561.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23752.79","6537.01","199872.78","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MINOR","421","DRG","","","","","","","","inpatient","","","19513.59","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","14298.2768","","Fee schedule rate ($36,126.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14298.2768","14298.28","14298.28","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MINOR","421","DRG","","","","","","","","inpatient","","","19513.59","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21368.41","","Fee schedule rate ($21,368.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15038.45","15038.45","15038.45","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MINOR","421","DRG","","","","","","","","inpatient","","","19513.59","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22437.19","","Fee schedule rate ($22,437.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15790.62","15790.62","15790.62","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MINOR","421","DRG","","","","","","","","inpatient","","","19513.59","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6798.22","","Case rate ($7,516.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,946.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7514.76","7514.76","7514.76","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MODERATE","421","DRG","","","","","","","","inpatient","","","24412.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","18773.95","","Standard inlier is a Case rate ($18,773.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,246, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,665.08) for the length of stay and the standard reimbursement.","17113.14","17113.14","17113.14","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MODERATE","421","DRG","","","","","","","","inpatient","","","24412.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21106.98","","Standard inlier is a Case rate ($21,106.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,246, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,995.96) for the length of stay and the standard reimbursement.","21106.98","21106.98","21106.98","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MODERATE","421","DRG","","","","","","","","inpatient","","","24412.85","","MASSHEALTH [3001]","HB BWH MEDICAID","9302.29","","Case rate ($10,285.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,715.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14199.51","14199.51","14199.51","1 through 10","6798.22","146789.92","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MODERATE","421","DRG","","","","","","","","inpatient","","","24412.85","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9302.29","","Case rate ($10,285.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,715.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31104.20","31104.20","31104.20","1 through 10","6798.22","146789.92","case rate",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","483.93","71.8","","215.82","215.82","215.82","1 through 10","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","471.80","70","","353.20","105.01","353.20","1 through 10","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","CHAMPVA [160001]","HB BWH TRICARE","640.30","95","","110.27","107.15","110.27","1 through 10","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","535.83","79.5","","514.70","345.31","514.70","431","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","359.24","53.3","","345.31","345.31","514.70","221","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","438.10","65","","425.10","425.10","425.10","1 through 10","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","535.83","79.5","","514.70","514.70","514.70","1 through 10","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","208.94","31","","202.09","202.09","202.09","14","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","246.01","36.5","","243.94","207.32","243.94","286","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","258.14","38.3","","255.71","248.52","255.71","1145","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","518.98","77","","354.24","199.06","514.70","13","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","TRICARE [160005]","HB BWH TRICARE","640.30","95","","107.15","101.79","110.27","27","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.15","42.9","","522.81","287.56","522.81","22","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","674.00","505.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.15","42.9","","287.56","287.56","287.56","1 through 10","105.01","640.3","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","674.00","505.50","AETNA [1001]","HB AMC AETNA HMO","470.45","69.8","","442.76","312.61","442.76","49","270.56","845.49","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","674.00","505.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","318.83","","Case rate ($318.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","318.83","318.83","318.83","1074","270.56","845.49","other","Multiple Imaging"
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","674.00","505.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","352.23","52.26","","318.83","318.83","404.70","15","270.56","845.49","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","674.00","505.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","318.83","","Case rate ($318.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","318.83","318.83","318.83","2333","270.56","845.49","other","Multiple Imaging"
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","674.00","505.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","550.79","81.72","","522.81","522.81","522.81","1 through 10","270.56","845.49","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","674.00","505.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","550.79","81.72","","287.56","287.56","522.81","11","270.56","845.49","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","674.00","505.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","550.79","81.72","","522.81","287.56","522.81","271","270.56","845.49","percent of total billed charges",""
"Man Palmar Fascial Sgl Cord","PX-76000487","CDM","26341","CPT","0761","RC","","","","both","","","582.00","436.50","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","180.42","462.69","other","OPPS APC"
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT FULL","SUP-ITM-10025213","CDM","C1889","HCPCS","0278","RC","","","","both","","","1281.07","960.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1018.45","79.5","","1309.77","674.56","6049.93","26","397.13","1018.45","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT FULL","SUP-ITM-10025213","CDM","C1889","HCPCS","0278","RC","","","","both","","","1281.07","960.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","682.81","53.3","","1901.83","1901.83","2962.25","1 through 10","397.13","1018.45","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT FULL","SUP-ITM-10025213","CDM","C1889","HCPCS","0278","RC","","","","both","","","1281.07","960.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","467.59","36.5","","1620.31","1620.31","19908.88","1 through 10","397.13","1018.45","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT FULL","SUP-ITM-10025213","CDM","C1889","HCPCS","0278","RC","","","","both","","","1281.07","960.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","490.65","38.3","","352.91","352.91","2046.30","1 through 10","397.13","1018.45","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT FULL","SUP-ITM-10025213","CDM","C1889","HCPCS","0278","RC","","","","both","","","1281.07","960.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","549.58","42.9","","9668.75","9668.75","9668.75","1 through 10","397.13","1018.45","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT FULL","SUP-ITM-10025213","CDM","C1889","HCPCS","0278","RC","","","","both","","","1281.07","960.80","WELLPOINT [1015]","HB AMC WELLPOINT","945.17","73.78","","699.88","384.10","3443.31","33","397.13","1018.45","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT FULL","SUP-ITM-10025213","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1281.07","960.80","AETNA [1001]","HB AMC AETNA HMO","894.19","69.8","","1421.24","264.50","4933.46","29","669.49","1046.89","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT FULL","SUP-ITM-10025213","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1281.07","960.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1029.98","80.4","","1022.97","1022.97","3607.50","1 through 10","669.49","1046.89","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT FULL","SUP-ITM-10025213","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1281.07","960.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1046.89","81.72","","3010.54","693.88","5019.88","35","669.49","1046.89","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT RAMUS FULL","SUP-ITM-10030885","CDM","C1713","HCPCS","0278","RC","","","","both","","","1498.91","1124.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1191.63","79.5","","800.18","480.96","1887.97","195","464.66","1191.63","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT RAMUS FULL","SUP-ITM-10030885","CDM","C1713","HCPCS","0278","RC","","","","both","","","1498.91","1124.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","798.92","53.3","","813.12","216.42","1444.50","81","464.66","1191.63","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT RAMUS FULL","SUP-ITM-10030885","CDM","C1713","HCPCS","0278","RC","","","","both","","","1498.91","1124.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","464.66","31","","432.60","432.60","432.60","1 through 10","464.66","1191.63","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT RAMUS FULL","SUP-ITM-10030885","CDM","C1713","HCPCS","0278","RC","","","","both","","","1498.91","1124.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","547.10","36.5","","148.37","54.89","631.39","94","464.66","1191.63","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT RAMUS FULL","SUP-ITM-10030885","CDM","C1713","HCPCS","0278","RC","","","","both","","","1498.91","1124.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","574.08","38.3","","279.30","91.72","1116.77","266","464.66","1191.63","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT RAMUS FULL","SUP-ITM-10030885","CDM","C1713","HCPCS","0278","RC","","","","both","","","1498.91","1124.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","643.03","42.9","","731.00","63.70","731.00","1 through 10","464.66","1191.63","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT RAMUS FULL","SUP-ITM-10030885","CDM","C1713","HCPCS","0278","RC","","","","both","","","1498.91","1124.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","643.03","42.9","","384.74","384.74","384.74","1 through 10","464.66","1191.63","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT RAMUS FULL","SUP-ITM-10030885","CDM","C1713","HCPCS","0278","RC","","","","both","","","1498.91","1124.18","WELLPOINT [1015]","HB AMC WELLPOINT","1105.90","73.78","","286.63","119.22","1107.45","105","464.66","1191.63","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT RAMUS FULL","SUP-ITM-10030885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1498.91","1124.18","AETNA [1001]","HB AMC AETNA HMO","1046.24","69.8","","675.31","184.75","1721.50","286","783.33","1224.91","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT RAMUS FULL","SUP-ITM-10030885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1498.91","1124.18","AETNA [1001]","HB AMC AETNA PPO","1205.12","80.4","","1261.44","103.12","1514.10","21","783.33","1224.91","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT RAMUS FULL","SUP-ITM-10030885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1498.91","1124.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1205.12","80.4","","1365.00","1365.00","1365.00","1 through 10","783.33","1224.91","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT RAMUS FULL","SUP-ITM-10030885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1498.91","1124.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1224.91","81.72","","5157.68","5157.68","5157.68","1 through 10","783.33","1224.91","percent of total billed charges",""
"MANDIBLE ROD 4.0MM EXTERNAL FIXATION TITANIUM CONNECTING PREBENT RAMUS FULL","SUP-ITM-10030885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1498.91","1124.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1224.91","81.72","","431.26","71.26","1459.57","88","783.33","1224.91","percent of total billed charges",""
"MANDIBULAR IMPLANT 79X32X5MM LEFT","SUP-ITM-10001708","CDM","C1713","HCPCS","0278","RC","","","","both","","","2231.46","1673.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1774.01","79.5","","800.18","480.96","1887.97","195","691.75","1774.01","percent of total billed charges",""
"MANDIBULAR IMPLANT 79X32X5MM LEFT","SUP-ITM-10001708","CDM","C1713","HCPCS","0278","RC","","","","both","","","2231.46","1673.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1189.37","53.3","","813.12","216.42","1444.50","81","691.75","1774.01","percent of total billed charges",""
"MANDIBULAR IMPLANT 79X32X5MM LEFT","SUP-ITM-10001708","CDM","C1713","HCPCS","0278","RC","","","","both","","","2231.46","1673.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","691.75","31","","432.60","432.60","432.60","1 through 10","691.75","1774.01","percent of total billed charges",""
"MANDIBULAR IMPLANT 79X32X5MM LEFT","SUP-ITM-10001708","CDM","C1713","HCPCS","0278","RC","","","","both","","","2231.46","1673.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","814.48","36.5","","148.37","54.89","631.39","94","691.75","1774.01","percent of total billed charges",""
"MANDIBULAR IMPLANT 79X32X5MM LEFT","SUP-ITM-10001708","CDM","C1713","HCPCS","0278","RC","","","","both","","","2231.46","1673.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","854.65","38.3","","279.30","91.72","1116.77","266","691.75","1774.01","percent of total billed charges",""
"MANDIBULAR IMPLANT 79X32X5MM LEFT","SUP-ITM-10001708","CDM","C1713","HCPCS","0278","RC","","","","both","","","2231.46","1673.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","957.30","42.9","","731.00","63.70","731.00","1 through 10","691.75","1774.01","percent of total billed charges",""
"MANDIBULAR IMPLANT 79X32X5MM LEFT","SUP-ITM-10001708","CDM","C1713","HCPCS","0278","RC","","","","both","","","2231.46","1673.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","957.30","42.9","","384.74","384.74","384.74","1 through 10","691.75","1774.01","percent of total billed charges",""
"MANDIBULAR IMPLANT 79X32X5MM LEFT","SUP-ITM-10001708","CDM","C1713","HCPCS","0278","RC","","","","both","","","2231.46","1673.59","WELLPOINT [1015]","HB AMC WELLPOINT","1646.37","73.78","","286.63","119.22","1107.45","105","691.75","1774.01","percent of total billed charges",""
"MANDIBULAR IMPLANT 79X32X5MM LEFT","SUP-ITM-10001708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2231.46","1673.59","AETNA [1001]","HB AMC AETNA HMO","1557.56","69.8","","675.31","184.75","1721.50","286","1166.16","1823.55","percent of total billed charges",""
"MANDIBULAR IMPLANT 79X32X5MM LEFT","SUP-ITM-10001708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2231.46","1673.59","AETNA [1001]","HB AMC AETNA PPO","1794.09","80.4","","1261.44","103.12","1514.10","21","1166.16","1823.55","percent of total billed charges",""
"MANDIBULAR IMPLANT 79X32X5MM LEFT","SUP-ITM-10001708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2231.46","1673.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1794.09","80.4","","1365.00","1365.00","1365.00","1 through 10","1166.16","1823.55","percent of total billed charges",""
"MANDIBULAR IMPLANT 79X32X5MM LEFT","SUP-ITM-10001708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2231.46","1673.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1823.55","81.72","","5157.68","5157.68","5157.68","1 through 10","1166.16","1823.55","percent of total billed charges",""
"MANDIBULAR IMPLANT 79X32X5MM LEFT","SUP-ITM-10001708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2231.46","1673.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1823.55","81.72","","431.26","71.26","1459.57","88","1166.16","1823.55","percent of total billed charges",""
"Manganese","PX-30000566","CDM","83785","CPT","0301","RC","","","","both","","","409.00","306.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","156.65","38.3","","155.23","155.23","155.23","1 through 10","25.36","388.55","percent of total billed charges",""
"Manganese","PX-30000566","CDM","83785","CPT","0301","RC","","","","outpatient","","","409.00","306.75","AETNA [1001]","HB AMC AETNA HMO","285.48","69.8","","268.77","268.77","268.77","1 through 10","25.36","334.23","percent of total billed charges",""
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","both","","","1904.00","1428.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","369.81","1 through 10","351.32","1513.68","other","OPPS APC"
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","both","","","1904.00","1428.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1332.80","70","","1476.80","1476.80","1476.80","1 through 10","351.32","1513.68","percent of total billed charges",""
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","both","","","1904.00","1428.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1513.68","79.5","","1452.80","974.69","1452.80","1 through 10","351.32","1513.68","percent of total billed charges",""
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","both","","","1904.00","1428.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","369.77","","APC Price ($369.77). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","1 through 10","351.32","1513.68","other","OPPS APC"
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","both","","","1904.00","1428.00","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","369.81","33","351.32","1513.68","other","OPPS APC"
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","both","","","1904.00","1428.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","694.96","36.5","","688.56","688.56","688.56","1 through 10","351.32","1513.68","percent of total billed charges",""
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","both","","","1904.00","1428.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","729.23","38.3","","701.48","701.48","721.79","1 through 10","351.32","1513.68","percent of total billed charges",""
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","both","","","1904.00","1428.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","362.41","362.41","1 through 10","351.32","1513.68","other","OPPS APC"
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","both","","","1904.00","1428.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.41","335.72","369.81","1 through 10","351.32","1513.68","other","OPPS APC"
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","both","","","1904.00","1428.00","WELLPOINT [1015]","HB AMC WELLPOINT","1404.77","73.78","","1374.35","1374.35","1374.35","1 through 10","351.32","1513.68","percent of total billed charges",""
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","outpatient","","","1904.00","1428.00","AETNA [1001]","HB AMC AETNA HMO","1328.99","69.8","","1249.74","1249.74","1249.74","1 through 10","231.42","1555.95","percent of total billed charges",""
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","outpatient","","","1904.00","1428.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","995.03","52.26","","1142.30","1142.30","1142.30","1 through 10","231.42","1555.95","percent of total billed charges",""
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","outpatient","","","1904.00","1428.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","671.12","671.12","671.12","1 through 10","231.42","1555.95","other","Multiple Surgery"
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","outpatient","","","1904.00","1428.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","536.89","516.07","536.89","1 through 10","231.42","1555.95","other","Multiple Surgery"
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","outpatient","","","1904.00","1428.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","564.66","543.84","564.66","1 through 10","231.42","1555.95","other","Multiple Surgery"
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","outpatient","","","1904.00","1428.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","671.12","671.12","671.12","1 through 10","231.42","1555.95","other","Multiple Surgery"
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","outpatient","","","1904.00","1428.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","592.44","592.44","592.44","1 through 10","231.42","1555.95","other","Multiple Surgery"
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","outpatient","","","1904.00","1428.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1555.95","81.72","","811.69","811.69","811.69","1 through 10","231.42","1555.95","percent of total billed charges",""
"Manometry Test Anorectal","PX-75000324","CDM","91122","CPT","0750","RC","","","","outpatient","","","1904.00","1428.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1555.95","81.72","","1475.69","1475.69","1475.69","1 through 10","231.42","1555.95","percent of total billed charges",""
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","both","","","31654.00","23740.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","25164.93","other","OPPS APC"
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","both","","","31654.00","23740.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","25164.93","other","OPPS APC"
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","both","","","31654.00","23740.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16871.58","53.3","","477.31","477.31","477.31","1 through 10","333.03","25164.93","percent of total billed charges",""
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","both","","","31654.00","23740.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","25164.93","other","OPPS APC"
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","both","","","31654.00","23740.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","25164.93","other","OPPS APC"
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","both","","","31654.00","23740.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11553.71","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","25164.93","percent of total billed charges",""
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","both","","","31654.00","23740.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12123.48","38.3","","343.52","323.76","353.46","1 through 10","333.03","25164.93","percent of total billed charges",""
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","both","","","31654.00","23740.50","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","25164.93","other","Tricare OPPS"
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","both","","","31654.00","23740.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","25164.93","other","OPPS APC"
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","both","","","31654.00","23740.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","25164.93","other","OPPS APC"
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","both","","","31654.00","23740.50","WELLPOINT [1015]","HB AMC WELLPOINT","23354.32","73.78","","673.03","673.03","673.03","1 through 10","333.03","25164.93","percent of total billed charges",""
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","outpatient","","","31654.00","23740.50","AETNA [1001]","HB AMC AETNA HMO","22094.49","69.8","","612.01","612.01","1224.02","1 through 10","700.33","26114.55","percent of total billed charges",""
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","outpatient","","","31654.00","23740.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19166.50","60.55","","579.04","568.57","904.00","30","700.33","26114.55","percent of total billed charges",""
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","outpatient","","","31654.00","23740.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","16529.72","52.22","","904.00","656.02","2938.00","26","700.33","26114.55","percent of total billed charges",""
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","outpatient","","","31654.00","23740.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15827.00","50","","1421.10","875.08","2368.50","15","700.33","26114.55","percent of total billed charges",""
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","outpatient","","","31654.00","23740.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","16618.35","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","26114.55","percent of total billed charges",""
"Manual Test Occlusion Common Carotid Artery","PX-76002868","CDM","64999","CPT","0761","RC","","","","outpatient","","","31654.00","23740.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","25867.65","81.72","","722.66","722.66","17449.00","1 through 10","700.33","26114.55","percent of total billed charges",""
"MARKER FIDUCIAL 1.2MM 3MM 17GA 20CM SOFT TISSUE GOLD SEED PRELOADED NEEDLE PK/3EA","SUP-ITM-10025615","CDM","A4648","HCPCS","0278","RC","","","","both","","","149.33","112.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","118.72","79.5","","454.50","151.50","454.50","21","46.29","123.2","percent of total billed charges",""
"MARKER FIDUCIAL 1.2MM 3MM 17GA 20CM SOFT TISSUE GOLD SEED PRELOADED NEEDLE PK/3EA","SUP-ITM-10025615","CDM","A4648","HCPCS","0278","RC","","","","both","","","149.33","112.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","79.59","53.3","","304.92","207.96","485.88","1 through 10","46.29","123.2","percent of total billed charges",""
"MARKER FIDUCIAL 1.2MM 3MM 17GA 20CM SOFT TISSUE GOLD SEED PRELOADED NEEDLE PK/3EA","SUP-ITM-10025615","CDM","A4648","HCPCS","0278","RC","","","","both","","","149.33","112.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54.51","36.5","","183.06","183.06","183.06","1 through 10","46.29","123.2","percent of total billed charges",""
"MARKER FIDUCIAL 1.2MM 3MM 17GA 20CM SOFT TISSUE GOLD SEED PRELOADED NEEDLE PK/3EA","SUP-ITM-10025615","CDM","A4648","HCPCS","0278","RC","","","","both","","","149.33","112.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.19","38.3","","225.81","149.00","234.60","19","46.29","123.2","percent of total billed charges",""
"MARKER FIDUCIAL 1.2MM 3MM 17GA 20CM SOFT TISSUE GOLD SEED PRELOADED NEEDLE PK/3EA","SUP-ITM-10025615","CDM","A4648","HCPCS","0278","RC","","","","both","","","149.33","112.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.06","42.9","","153.88","90.49","192.50","1 through 10","46.29","123.2","percent of total billed charges",""
"MARKER FIDUCIAL 1.2MM 3MM 17GA 20CM SOFT TISSUE GOLD SEED PRELOADED NEEDLE PK/3EA","SUP-ITM-10025615","CDM","A4648","HCPCS","0278","RC","","","","both","","","149.33","112.00","WELLPOINT [1015]","HB AMC WELLPOINT","110.18","73.78","","335.82","153.22","335.82","1 through 10","46.29","123.2","percent of total billed charges",""
"MARKER FIDUCIAL 1.2MM 3MM 17GA 20CM SOFT TISSUE GOLD SEED PRELOADED NEEDLE PK/3EA","SUP-ITM-10025615","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","149.33","112.00","AETNA [1001]","HB AMC AETNA HMO","104.23","69.8","","98.37","92.02","150.15","11","74.67","123.2","percent of total billed charges",""
"MARKER FIDUCIAL 1.2MM 3MM 17GA 20CM SOFT TISSUE GOLD SEED PRELOADED NEEDLE PK/3EA","SUP-ITM-10025615","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","149.33","112.00","AETNA [1001]","HB AMC AETNA PPO","120.06","80.4","","333.06","160.52","333.06","1 through 10","74.67","123.2","percent of total billed charges",""
"MARKER FIDUCIAL 1.2MM 3MM 17GA 20CM SOFT TISSUE GOLD SEED PRELOADED NEEDLE PK/3EA","SUP-ITM-10025615","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","149.33","112.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","122.03","81.72","","153.88","84.64","170.39","1 through 10","74.67","123.2","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","both","","","264.25","198.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","210.08","79.5","","454.50","151.50","454.50","21","81.92","210.08","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","both","","","264.25","198.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","140.85","53.3","","304.92","207.96","485.88","1 through 10","81.92","210.08","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","both","","","264.25","198.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","96.45","36.5","","183.06","183.06","183.06","1 through 10","81.92","210.08","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","both","","","264.25","198.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","101.21","38.3","","225.81","149.00","234.60","19","81.92","210.08","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","both","","","264.25","198.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","113.36","42.9","","153.88","90.49","192.50","1 through 10","81.92","210.08","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","both","","","264.25","198.19","WELLPOINT [1015]","HB AMC WELLPOINT","194.96","73.78","","335.82","153.22","335.82","1 through 10","81.92","210.08","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","264.25","198.19","AETNA [1001]","HB AMC AETNA HMO","184.45","69.8","","98.37","92.02","150.15","11","132.13","218.01","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","264.25","198.19","AETNA [1001]","HB AMC AETNA PPO","212.46","80.4","","333.06","160.52","333.06","1 through 10","132.13","218.01","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","264.25","198.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","215.95","81.72","","153.88","84.64","170.39","1 through 10","132.13","218.01","percent of total billed charges",""
"Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea","PX-30003058","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea","PX-30003058","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea","PX-30003058","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea","PX-30003058","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea","PX-30003058","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea","PX-30003058","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea","PX-30003058","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Mastectomy For Malignancy With Cc/McC","582","MS-DRG","","","","","","","","inpatient","","","266764.43","200073.32","MEDICARE [2001]","HB BWH MEDICARE","17954.48","","Case rate ($17,954.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,536.24, add-ons for qualifying new technology services are included. If operating cost exceeds $67,180.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,990.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $16,024.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,156.41 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,550.26. The transfer capital threshold is the transfer adjustment factor * $1,550.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26046.48","26046.48","74599.43","1 through 10","17595.39","26427.3592","other","Inpatient Replacement Plans DRG"
"Mastectomy For Malignancy Without Cc/McC","583","MS-DRG","","","","","","","","inpatient","","","264699.99","198524.99","WELLPOINT [1015]","HB AMC WELLPOINT","27011.00","","Fee schedule rate ($27,011.00).","62372.16","62372.16","62372.16","1 through 10","15787.79","27011","case rate",""
"Mastectomy Procedures,MINOR","362","DRG","","","","","","","","inpatient","","","196236.61","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","40151.35","","Standard inlier is a Case rate ($40,151.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $42,872, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,699.73) for the length of stay and the standard reimbursement.","40221.57","40221.57","40221.57","1 through 10","12177.62","64997.14","case rate",""
"Mastectomy Procedures,MINOR","362","DRG","","","","","","","","inpatient","","","196236.61","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","45140.94","","Standard inlier is a Case rate ($45,140.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $42,872, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,407.38) for the length of stay and the standard reimbursement.","50289.52","50289.52","50289.52","1 through 10","12177.62","64997.14","case rate",""
"Mastectomy Procedures,MINOR","362","DRG","","","","","","","","inpatient","","","196236.61","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","28145.62","","Fee schedule rate ($28,145.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28145.64","28145.64","28145.64","1 through 10","12177.62","64997.14","case rate",""
"Mastectomy Procedures,MINOR","362","DRG","","","","","","","","inpatient","","","196236.61","","MASSHEALTH [3001]","HB BWH MEDICAID","12177.62","","Case rate ($13,464.45). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,894.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","28560.46","28560.46","28560.46","1 through 10","12177.62","64997.14","case rate",""
"Mastectomy Procedures,MINOR","362","DRG","","","","","","","","inpatient","","","196236.61","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38630.63","","Fee schedule rate ($38,630.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38630.63","38630.63","38630.63","1 through 10","12177.62","64997.14","case rate",""
"Mastectomy Procedures,MODERATE","362","DRG","","","","","","","","inpatient","","","278516.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","57812.77","","Standard inlier is a Case rate ($57,812.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,604, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,206.87) for the length of stay and the standard reimbursement.","77889.32","77889.32","77889.32","1 through 10","12177.62","64997.14","case rate",""
"Mastectomy Procedures,MODERATE","362","DRG","","","","","","","","inpatient","","","278516.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","64997.14","","Standard inlier is a Case rate ($64,997.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,604, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,225.80) for the length of stay and the standard reimbursement.","77270.54","69595.27","83787.31","17","12177.62","64997.14","case rate",""
"Mastectomy Procedures,MODERATE","362","DRG","","","","","","","","inpatient","","","278516.35","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","39014.76","","Fee schedule rate ($39,014.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","39014.76","39014.76","39014.76","1 through 10","12177.62","64997.14","case rate",""
"Mastectomy Procedures,MODERATE","362","DRG","","","","","","","","inpatient","","","278516.35","","MASSHEALTH [3001]","HB BWH MEDICAID","19636.13","","Case rate ($21,711.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,141.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27984.55","27984.55","27984.55","1 through 10","12177.62","64997.14","case rate",""
"Mastectomy Procedures,MODERATE","362","DRG","","","","","","","","inpatient","","","278516.35","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","43533.93","","Fee schedule rate ($43,533.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37003.84","37003.84","43533.93","1 through 10","12177.62","64997.14","case rate",""
"Mastectomy Procedures,MODERATE","362","DRG","","","","","","","","inpatient","","","278516.35","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","19636.13","","Case rate ($21,711.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,141.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21705.79","21705.79","21705.79","1 through 10","12177.62","64997.14","case rate",""
"Maternal Cell Contamination","PX-30003659","CDM","81265","CPT","0300","RC","","","","outpatient","","","1341.00","1005.75","AETNA [1001]","HB AMC AETNA HMO","936.02","69.8","","880.10","880.10","880.10","1 through 10","221.75","1464.7","percent of total billed charges",""
"MATRIX AUTOLOGOUS CHONDROCYTE IMPLANT","SUP-ITM-10176318","CDM","J7330","HCPCS","0278","RC","","","","both","","","0.04","0.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.02","38.3","","0.76","0.76","0.76","1 through 10","0.01","161386.05","percent of total billed charges",""
"MATRIX AUTOLOGOUS CHONDROCYTE IMPLANT","SUP-ITM-10176318","CDM","J7330","HCPCS","0278","RC","","","","both","","","0.04","0.03","TRICARE [160005]","HB BWH TRICARE","0.04","95","","0.04","0.04","0.04","1 through 10","0.01","161386.05","percent of total billed charges",""
"MATRIX AUTOLOGOUS CHONDROCYTE IMPLANT","SUP-ITM-10176318","CDM","J7330","HCPCS","0278","RC","","","","outpatient","","","0.04","0.03","AETNA [1001]","HB AMC AETNA HMO","0.03","69.8","","1.00","1.00","1.00","1 through 10","0.02","169820.76","percent of total billed charges",""
"MATRIX AUTOLOGOUS CHONDROCYTE IMPLANT","SUP-ITM-10176318","CDM","J7330","HCPCS","0278","RC","","","","outpatient","","","0.04","0.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.03","69.9","","0.03","0.03","0.03","1 through 10","0.02","169820.76","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4300.43","79.5","","1309.77","674.56","6049.93","26","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2883.18","53.3","","1901.83","1901.83","2962.25","1 through 10","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1974.41","36.5","","1620.31","1620.31","19908.88","1 through 10","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2071.78","38.3","","352.91","352.91","2046.30","1 through 10","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2320.61","42.9","","9668.75","9668.75","9668.75","1 through 10","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","WELLPOINT [1015]","HB AMC WELLPOINT","3991.02","73.78","","699.88","384.10","3443.31","33","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5409.35","4057.01","AETNA [1001]","HB AMC AETNA HMO","3775.73","69.8","","1421.24","264.50","4933.46","29","2826.93","4420.52","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5409.35","4057.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4349.12","80.4","","1022.97","1022.97","3607.50","1 through 10","2826.93","4420.52","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5409.35","4057.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4420.52","81.72","","3010.54","693.88","5019.88","35","2826.93","4420.52","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10327578","CDM","C1713","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4300.43","79.5","","800.18","480.96","1887.97","195","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10327578","CDM","C1713","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2883.18","53.3","","813.12","216.42","1444.50","81","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10327578","CDM","C1713","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1676.90","31","","432.60","432.60","432.60","1 through 10","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10327578","CDM","C1713","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1974.41","36.5","","148.37","54.89","631.39","94","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10327578","CDM","C1713","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2071.78","38.3","","279.30","91.72","1116.77","266","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10327578","CDM","C1713","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2320.61","42.9","","731.00","63.70","731.00","1 through 10","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10327578","CDM","C1713","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2320.61","42.9","","384.74","384.74","384.74","1 through 10","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10327578","CDM","C1713","HCPCS","0278","RC","","","","both","","","5409.35","4057.01","WELLPOINT [1015]","HB AMC WELLPOINT","3991.02","73.78","","286.63","119.22","1107.45","105","1676.9","4300.43","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10327578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5409.35","4057.01","AETNA [1001]","HB AMC AETNA HMO","3775.73","69.8","","675.31","184.75","1721.50","286","2826.93","4420.52","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10327578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5409.35","4057.01","AETNA [1001]","HB AMC AETNA PPO","4349.12","80.4","","1261.44","103.12","1514.10","21","2826.93","4420.52","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10327578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5409.35","4057.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4349.12","80.4","","1365.00","1365.00","1365.00","1 through 10","2826.93","4420.52","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10327578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5409.35","4057.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4420.52","81.72","","5157.68","5157.68","5157.68","1 through 10","2826.93","4420.52","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10327578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5409.35","4057.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4420.52","81.72","","431.26","71.26","1459.57","88","2826.93","4420.52","percent of total billed charges",""
"MATRIX DERMAL 10 XCM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN SQUARE CA/1EA","SUP-ITM-10028524","CDM","C1781","HCPCS","0278","RC","","","","both","","","6470.55","4852.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4529.39","70","","134.04","134.04","134.04","1 through 10","2005.87","5144.09","percent of total billed charges",""
"MATRIX DERMAL 10 XCM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN SQUARE CA/1EA","SUP-ITM-10028524","CDM","C1781","HCPCS","0278","RC","","","","both","","","6470.55","4852.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5144.09","79.5","","948.87","198.19","1805.30","1 through 10","2005.87","5144.09","percent of total billed charges",""
"MATRIX DERMAL 10 XCM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN SQUARE CA/1EA","SUP-ITM-10028524","CDM","C1781","HCPCS","0278","RC","","","","both","","","6470.55","4852.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3448.80","53.3","","462.00","170.45","3253.37","1 through 10","2005.87","5144.09","percent of total billed charges",""
"MATRIX DERMAL 10 XCM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN SQUARE CA/1EA","SUP-ITM-10028524","CDM","C1781","HCPCS","0278","RC","","","","both","","","6470.55","4852.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2361.75","36.5","","245.50","107.19","1371.45","1 through 10","2005.87","5144.09","percent of total billed charges",""
"MATRIX DERMAL 10 XCM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN SQUARE CA/1EA","SUP-ITM-10028524","CDM","C1781","HCPCS","0278","RC","","","","both","","","6470.55","4852.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2478.22","38.3","","200.79","72.79","355.81","22","2005.87","5144.09","percent of total billed charges",""
"MATRIX DERMAL 10 XCM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN SQUARE CA/1EA","SUP-ITM-10028524","CDM","C1781","HCPCS","0278","RC","","","","both","","","6470.55","4852.91","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4982.32","77","","477.18","477.18","477.18","1 through 10","2005.87","5144.09","percent of total billed charges",""
"MATRIX DERMAL 10 XCM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN SQUARE CA/1EA","SUP-ITM-10028524","CDM","C1781","HCPCS","0278","RC","","","","both","","","6470.55","4852.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2775.87","42.9","","1045.91","1045.91","1045.91","1 through 10","2005.87","5144.09","percent of total billed charges",""
"MATRIX DERMAL 10 XCM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN SQUARE CA/1EA","SUP-ITM-10028524","CDM","C1781","HCPCS","0278","RC","","","","both","","","6470.55","4852.91","WELLPOINT [1015]","HB AMC WELLPOINT","4773.97","73.78","","1726.50","1726.50","1726.50","1 through 10","2005.87","5144.09","percent of total billed charges",""
"MATRIX DERMAL 10 XCM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN SQUARE CA/1EA","SUP-ITM-10028524","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6470.55","4852.91","AETNA [1001]","HB AMC AETNA HMO","4516.44","69.8","","915.80","263.76","2881.00","1 through 10","3381.51","5287.73","percent of total billed charges",""
"MATRIX DERMAL 10 XCM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN SQUARE CA/1EA","SUP-ITM-10028524","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6470.55","4852.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5287.73","81.72","","1531.57","410.52","8841.36","1 through 10","3381.51","5287.73","percent of total billed charges",""
"MATRIX DERMAL 10X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10036237","CDM","C1781","HCPCS","0278","RC","","","","both","","","9704.43","7278.32","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","6793.10","70","","134.04","134.04","134.04","1 through 10","3008.37","7715.02","percent of total billed charges",""
"MATRIX DERMAL 10X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10036237","CDM","C1781","HCPCS","0278","RC","","","","both","","","9704.43","7278.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7715.02","79.5","","948.87","198.19","1805.30","1 through 10","3008.37","7715.02","percent of total billed charges",""
"MATRIX DERMAL 10X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10036237","CDM","C1781","HCPCS","0278","RC","","","","both","","","9704.43","7278.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5172.46","53.3","","462.00","170.45","3253.37","1 through 10","3008.37","7715.02","percent of total billed charges",""
"MATRIX DERMAL 10X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10036237","CDM","C1781","HCPCS","0278","RC","","","","both","","","9704.43","7278.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3542.12","36.5","","245.50","107.19","1371.45","1 through 10","3008.37","7715.02","percent of total billed charges",""
"MATRIX DERMAL 10X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10036237","CDM","C1781","HCPCS","0278","RC","","","","both","","","9704.43","7278.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3716.80","38.3","","200.79","72.79","355.81","22","3008.37","7715.02","percent of total billed charges",""
"MATRIX DERMAL 10X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10036237","CDM","C1781","HCPCS","0278","RC","","","","both","","","9704.43","7278.32","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","7472.41","77","","477.18","477.18","477.18","1 through 10","3008.37","7715.02","percent of total billed charges",""
"MATRIX DERMAL 10X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10036237","CDM","C1781","HCPCS","0278","RC","","","","both","","","9704.43","7278.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4163.20","42.9","","1045.91","1045.91","1045.91","1 through 10","3008.37","7715.02","percent of total billed charges",""
"MATRIX DERMAL 10X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10036237","CDM","C1781","HCPCS","0278","RC","","","","both","","","9704.43","7278.32","WELLPOINT [1015]","HB AMC WELLPOINT","7159.93","73.78","","1726.50","1726.50","1726.50","1 through 10","3008.37","7715.02","percent of total billed charges",""
"MATRIX DERMAL 10X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10036237","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9704.43","7278.32","AETNA [1001]","HB AMC AETNA HMO","6773.69","69.8","","915.80","263.76","2881.00","1 through 10","5071.54","7930.46","percent of total billed charges",""
"MATRIX DERMAL 10X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10036237","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9704.43","7278.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7930.46","81.72","","1531.57","410.52","8841.36","1 through 10","5071.54","7930.46","percent of total billed charges",""
"MATRIX DERMAL 13X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10028523","CDM","C1781","HCPCS","0278","RC","","","","both","","","12622.25","9466.69","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","8835.58","70","","134.04","134.04","134.04","1 through 10","3912.9","10034.69","percent of total billed charges",""
"MATRIX DERMAL 13X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10028523","CDM","C1781","HCPCS","0278","RC","","","","both","","","12622.25","9466.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10034.69","79.5","","948.87","198.19","1805.30","1 through 10","3912.9","10034.69","percent of total billed charges",""
"MATRIX DERMAL 13X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10028523","CDM","C1781","HCPCS","0278","RC","","","","both","","","12622.25","9466.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6727.66","53.3","","462.00","170.45","3253.37","1 through 10","3912.9","10034.69","percent of total billed charges",""
"MATRIX DERMAL 13X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10028523","CDM","C1781","HCPCS","0278","RC","","","","both","","","12622.25","9466.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4607.12","36.5","","245.50","107.19","1371.45","1 through 10","3912.9","10034.69","percent of total billed charges",""
"MATRIX DERMAL 13X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10028523","CDM","C1781","HCPCS","0278","RC","","","","both","","","12622.25","9466.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4834.32","38.3","","200.79","72.79","355.81","22","3912.9","10034.69","percent of total billed charges",""
"MATRIX DERMAL 13X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10028523","CDM","C1781","HCPCS","0278","RC","","","","both","","","12622.25","9466.69","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","9719.13","77","","477.18","477.18","477.18","1 through 10","3912.9","10034.69","percent of total billed charges",""
"MATRIX DERMAL 13X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10028523","CDM","C1781","HCPCS","0278","RC","","","","both","","","12622.25","9466.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5414.95","42.9","","1045.91","1045.91","1045.91","1 through 10","3912.9","10034.69","percent of total billed charges",""
"MATRIX DERMAL 13X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10028523","CDM","C1781","HCPCS","0278","RC","","","","both","","","12622.25","9466.69","WELLPOINT [1015]","HB AMC WELLPOINT","9312.70","73.78","","1726.50","1726.50","1726.50","1 through 10","3912.9","10034.69","percent of total billed charges",""
"MATRIX DERMAL 13X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10028523","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","12622.25","9466.69","AETNA [1001]","HB AMC AETNA HMO","8810.33","69.8","","915.80","263.76","2881.00","1 through 10","6596.39","10314.9","percent of total billed charges",""
"MATRIX DERMAL 13X15CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR CA/1EA","SUP-ITM-10028523","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","12622.25","9466.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10314.90","81.72","","1531.57","410.52","8841.36","1 through 10","6596.39","10314.9","percent of total billed charges",""
"MATRIX DERMAL 6.0X16CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR XW CA/1EA","SUP-ITM-10072525","CDM","C1781","HCPCS","0278","RC","","","","both","","","6781.90","5086.42","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4747.33","70","","134.04","134.04","134.04","1 through 10","2102.39","5391.61","percent of total billed charges",""
"MATRIX DERMAL 6.0X16CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR XW CA/1EA","SUP-ITM-10072525","CDM","C1781","HCPCS","0278","RC","","","","both","","","6781.90","5086.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5391.61","79.5","","948.87","198.19","1805.30","1 through 10","2102.39","5391.61","percent of total billed charges",""
"MATRIX DERMAL 6.0X16CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR XW CA/1EA","SUP-ITM-10072525","CDM","C1781","HCPCS","0278","RC","","","","both","","","6781.90","5086.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3614.75","53.3","","462.00","170.45","3253.37","1 through 10","2102.39","5391.61","percent of total billed charges",""
"MATRIX DERMAL 6.0X16CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR XW CA/1EA","SUP-ITM-10072525","CDM","C1781","HCPCS","0278","RC","","","","both","","","6781.90","5086.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2475.39","36.5","","245.50","107.19","1371.45","1 through 10","2102.39","5391.61","percent of total billed charges",""
"MATRIX DERMAL 6.0X16CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR XW CA/1EA","SUP-ITM-10072525","CDM","C1781","HCPCS","0278","RC","","","","both","","","6781.90","5086.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2597.47","38.3","","200.79","72.79","355.81","22","2102.39","5391.61","percent of total billed charges",""
"MATRIX DERMAL 6.0X16CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR XW CA/1EA","SUP-ITM-10072525","CDM","C1781","HCPCS","0278","RC","","","","both","","","6781.90","5086.42","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","5222.06","77","","477.18","477.18","477.18","1 through 10","2102.39","5391.61","percent of total billed charges",""
"MATRIX DERMAL 6.0X16CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR XW CA/1EA","SUP-ITM-10072525","CDM","C1781","HCPCS","0278","RC","","","","both","","","6781.90","5086.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2909.44","42.9","","1045.91","1045.91","1045.91","1 through 10","2102.39","5391.61","percent of total billed charges",""
"MATRIX DERMAL 6.0X16CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR XW CA/1EA","SUP-ITM-10072525","CDM","C1781","HCPCS","0278","RC","","","","both","","","6781.90","5086.42","WELLPOINT [1015]","HB AMC WELLPOINT","5003.69","73.78","","1726.50","1726.50","1726.50","1 through 10","2102.39","5391.61","percent of total billed charges",""
"MATRIX DERMAL 6.0X16CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR XW CA/1EA","SUP-ITM-10072525","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6781.90","5086.42","AETNA [1001]","HB AMC AETNA HMO","4733.77","69.8","","915.80","263.76","2881.00","1 through 10","3544.22","5542.17","percent of total billed charges",""
"MATRIX DERMAL 6.0X16CM GRAFT TISSUE ALLOMAX ACELLULAR COLLAGEN RECTANGULAR XW CA/1EA","SUP-ITM-10072525","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6781.90","5086.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5542.17","81.72","","1531.57","410.52","8841.36","1 through 10","3544.22","5542.17","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","both","","","6704.63","5028.47","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4693.24","70","","134.04","134.04","134.04","1 through 10","2078.44","5330.18","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","both","","","6704.63","5028.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5330.18","79.5","","948.87","198.19","1805.30","1 through 10","2078.44","5330.18","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","both","","","6704.63","5028.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3573.57","53.3","","462.00","170.45","3253.37","1 through 10","2078.44","5330.18","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","both","","","6704.63","5028.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2447.19","36.5","","245.50","107.19","1371.45","1 through 10","2078.44","5330.18","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","both","","","6704.63","5028.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2567.87","38.3","","200.79","72.79","355.81","22","2078.44","5330.18","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","both","","","6704.63","5028.47","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","5162.57","77","","477.18","477.18","477.18","1 through 10","2078.44","5330.18","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","both","","","6704.63","5028.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2876.29","42.9","","1045.91","1045.91","1045.91","1 through 10","2078.44","5330.18","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","both","","","6704.63","5028.47","WELLPOINT [1015]","HB AMC WELLPOINT","4946.68","73.78","","1726.50","1726.50","1726.50","1 through 10","2078.44","5330.18","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6704.63","5028.47","AETNA [1001]","HB AMC AETNA HMO","4679.83","69.8","","915.80","263.76","2881.00","1 through 10","3503.84","5479.02","percent of total billed charges",""
"MATRIX GRAFT 5X6CM COLLAGEN SOFT TISSUE TISSUEMEND ACELLULAR MEMBRANE","SUP-ITM-10012338","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6704.63","5028.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5479.02","81.72","","1531.57","410.52","8841.36","1 through 10","3503.84","5479.02","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7677.47","79.5","","1309.77","674.56","6049.93","26","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5147.29","53.3","","1901.83","1901.83","2962.25","1 through 10","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3524.88","36.5","","1620.31","1620.31","19908.88","1 through 10","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3698.71","38.3","","352.91","352.91","2046.30","1 through 10","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4142.94","42.9","","9668.75","9668.75","9668.75","1 through 10","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","WELLPOINT [1015]","HB AMC WELLPOINT","7125.08","73.78","","699.88","384.10","3443.31","33","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9657.20","7242.90","AETNA [1001]","HB AMC AETNA HMO","6740.73","69.8","","1421.24","264.50","4933.46","29","5046.85","7891.86","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9657.20","7242.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7764.39","80.4","","1022.97","1022.97","3607.50","1 through 10","5046.85","7891.86","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9657.20","7242.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7891.86","81.72","","3010.54","693.88","5019.88","35","5046.85","7891.86","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10327579","CDM","C1713","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7677.47","79.5","","800.18","480.96","1887.97","195","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10327579","CDM","C1713","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5147.29","53.3","","813.12","216.42","1444.50","81","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10327579","CDM","C1713","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2993.73","31","","432.60","432.60","432.60","1 through 10","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10327579","CDM","C1713","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3524.88","36.5","","148.37","54.89","631.39","94","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10327579","CDM","C1713","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3698.71","38.3","","279.30","91.72","1116.77","266","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10327579","CDM","C1713","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4142.94","42.9","","731.00","63.70","731.00","1 through 10","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10327579","CDM","C1713","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4142.94","42.9","","384.74","384.74","384.74","1 through 10","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10327579","CDM","C1713","HCPCS","0278","RC","","","","both","","","9657.20","7242.90","WELLPOINT [1015]","HB AMC WELLPOINT","7125.08","73.78","","286.63","119.22","1107.45","105","2993.73","7677.47","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10327579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9657.20","7242.90","AETNA [1001]","HB AMC AETNA HMO","6740.73","69.8","","675.31","184.75","1721.50","286","5046.85","7891.86","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10327579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9657.20","7242.90","AETNA [1001]","HB AMC AETNA PPO","7764.39","80.4","","1261.44","103.12","1514.10","21","5046.85","7891.86","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10327579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9657.20","7242.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7764.39","80.4","","1365.00","1365.00","1365.00","1 through 10","5046.85","7891.86","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10327579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9657.20","7242.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7891.86","81.72","","5157.68","5157.68","5157.68","1 through 10","5046.85","7891.86","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10327579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9657.20","7242.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7891.86","81.72","","431.26","71.26","1459.57","88","5046.85","7891.86","percent of total billed charges",""
"MATRIX SYNTHECEL 10CMX12 4 5 DURA SUBSTITUTE","SUP-ITM-10168178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","800.18","480.96","1887.97","195","868","2226","percent of total billed charges",""
"MATRIX SYNTHECEL 10CMX12 4 5 DURA SUBSTITUTE","SUP-ITM-10168178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1492.40","53.3","","813.12","216.42","1444.50","81","868","2226","percent of total billed charges",""
"MATRIX SYNTHECEL 10CMX12 4 5 DURA SUBSTITUTE","SUP-ITM-10168178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","868.00","31","","432.60","432.60","432.60","1 through 10","868","2226","percent of total billed charges",""
"MATRIX SYNTHECEL 10CMX12 4 5 DURA SUBSTITUTE","SUP-ITM-10168178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","148.37","54.89","631.39","94","868","2226","percent of total billed charges",""
"MATRIX SYNTHECEL 10CMX12 4 5 DURA SUBSTITUTE","SUP-ITM-10168178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","279.30","91.72","1116.77","266","868","2226","percent of total billed charges",""
"MATRIX SYNTHECEL 10CMX12 4 5 DURA SUBSTITUTE","SUP-ITM-10168178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","731.00","63.70","731.00","1 through 10","868","2226","percent of total billed charges",""
"MATRIX SYNTHECEL 10CMX12 4 5 DURA SUBSTITUTE","SUP-ITM-10168178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","384.74","384.74","384.74","1 through 10","868","2226","percent of total billed charges",""
"MATRIX SYNTHECEL 10CMX12 4 5 DURA SUBSTITUTE","SUP-ITM-10168178","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","286.63","119.22","1107.45","105","868","2226","percent of total billed charges",""
"MATRIX SYNTHECEL 10CMX12 4 5 DURA SUBSTITUTE","SUP-ITM-10168178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA HMO","1954.40","69.8","","675.31","184.75","1721.50","286","1463.28","2288.16","percent of total billed charges",""
"MATRIX SYNTHECEL 10CMX12 4 5 DURA SUBSTITUTE","SUP-ITM-10168178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA PPO","2251.20","80.4","","1261.44","103.12","1514.10","21","1463.28","2288.16","percent of total billed charges",""
"MATRIX SYNTHECEL 10CMX12 4 5 DURA SUBSTITUTE","SUP-ITM-10168178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2251.20","80.4","","1365.00","1365.00","1365.00","1 through 10","1463.28","2288.16","percent of total billed charges",""
"MATRIX SYNTHECEL 10CMX12 4 5 DURA SUBSTITUTE","SUP-ITM-10168178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2288.16","81.72","","5157.68","5157.68","5157.68","1 through 10","1463.28","2288.16","percent of total billed charges",""
"MATRIX SYNTHECEL 10CMX12 4 5 DURA SUBSTITUTE","SUP-ITM-10168178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","431.26","71.26","1459.57","88","1463.28","2288.16","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX1 DURA SUBSTITUTE","SUP-ITM-10168182","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.22","506.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","536.80","79.5","","800.18","480.96","1887.97","195","209.32","536.8","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX1 DURA SUBSTITUTE","SUP-ITM-10168182","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.22","506.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","359.89","53.3","","813.12","216.42","1444.50","81","209.32","536.8","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX1 DURA SUBSTITUTE","SUP-ITM-10168182","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.22","506.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","209.32","31","","432.60","432.60","432.60","1 through 10","209.32","536.8","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX1 DURA SUBSTITUTE","SUP-ITM-10168182","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.22","506.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","246.46","36.5","","148.37","54.89","631.39","94","209.32","536.8","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX1 DURA SUBSTITUTE","SUP-ITM-10168182","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.22","506.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","258.61","38.3","","279.30","91.72","1116.77","266","209.32","536.8","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX1 DURA SUBSTITUTE","SUP-ITM-10168182","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.22","506.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.67","42.9","","731.00","63.70","731.00","1 through 10","209.32","536.8","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX1 DURA SUBSTITUTE","SUP-ITM-10168182","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.22","506.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.67","42.9","","384.74","384.74","384.74","1 through 10","209.32","536.8","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX1 DURA SUBSTITUTE","SUP-ITM-10168182","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.22","506.41","WELLPOINT [1015]","HB AMC WELLPOINT","498.18","73.78","","286.63","119.22","1107.45","105","209.32","536.8","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX1 DURA SUBSTITUTE","SUP-ITM-10168182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.22","506.41","AETNA [1001]","HB AMC AETNA HMO","471.30","69.8","","675.31","184.75","1721.50","286","352.87","551.79","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX1 DURA SUBSTITUTE","SUP-ITM-10168182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.22","506.41","AETNA [1001]","HB AMC AETNA PPO","542.88","80.4","","1261.44","103.12","1514.10","21","352.87","551.79","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX1 DURA SUBSTITUTE","SUP-ITM-10168182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.22","506.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","542.88","80.4","","1365.00","1365.00","1365.00","1 through 10","352.87","551.79","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX1 DURA SUBSTITUTE","SUP-ITM-10168182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.22","506.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","551.79","81.72","","5157.68","5157.68","5157.68","1 through 10","352.87","551.79","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX1 DURA SUBSTITUTE","SUP-ITM-10168182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.22","506.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","551.79","81.72","","431.26","71.26","1459.57","88","352.87","551.79","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX7.5 1 3 DURA SUBSTITUTE","SUP-ITM-10168181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.70","866.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","918.78","79.5","","800.18","480.96","1887.97","195","358.27","918.78","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX7.5 1 3 DURA SUBSTITUTE","SUP-ITM-10168181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.70","866.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","615.99","53.3","","813.12","216.42","1444.50","81","358.27","918.78","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX7.5 1 3 DURA SUBSTITUTE","SUP-ITM-10168181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.70","866.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","358.27","31","","432.60","432.60","432.60","1 through 10","358.27","918.78","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX7.5 1 3 DURA SUBSTITUTE","SUP-ITM-10168181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.70","866.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","421.83","36.5","","148.37","54.89","631.39","94","358.27","918.78","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX7.5 1 3 DURA SUBSTITUTE","SUP-ITM-10168181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.70","866.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","442.63","38.3","","279.30","91.72","1116.77","266","358.27","918.78","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX7.5 1 3 DURA SUBSTITUTE","SUP-ITM-10168181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.70","866.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","495.80","42.9","","731.00","63.70","731.00","1 through 10","358.27","918.78","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX7.5 1 3 DURA SUBSTITUTE","SUP-ITM-10168181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.70","866.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","495.80","42.9","","384.74","384.74","384.74","1 through 10","358.27","918.78","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX7.5 1 3 DURA SUBSTITUTE","SUP-ITM-10168181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.70","866.77","WELLPOINT [1015]","HB AMC WELLPOINT","852.68","73.78","","286.63","119.22","1107.45","105","358.27","918.78","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX7.5 1 3 DURA SUBSTITUTE","SUP-ITM-10168181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.70","866.77","AETNA [1001]","HB AMC AETNA HMO","806.68","69.8","","675.31","184.75","1721.50","286","603.97","944.44","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX7.5 1 3 DURA SUBSTITUTE","SUP-ITM-10168181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.70","866.77","AETNA [1001]","HB AMC AETNA PPO","929.18","80.4","","1261.44","103.12","1514.10","21","603.97","944.44","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX7.5 1 3 DURA SUBSTITUTE","SUP-ITM-10168181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.70","866.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","929.18","80.4","","1365.00","1365.00","1365.00","1 through 10","603.97","944.44","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX7.5 1 3 DURA SUBSTITUTE","SUP-ITM-10168181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.70","866.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","944.44","81.72","","5157.68","5157.68","5157.68","1 through 10","603.97","944.44","percent of total billed charges",""
"MATRIX SYNTHECEL 2.5CMX7.5 1 3 DURA SUBSTITUTE","SUP-ITM-10168181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.70","866.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","944.44","81.72","","431.26","71.26","1459.57","88","603.97","944.44","percent of total billed charges",""
"MATRIX SYNTHECEL 5CMX2 DURA SUBSTITUTE","SUP-ITM-10168180","CDM","C1713","HCPCS","0278","RC","","","","both","","","1279.46","959.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1017.17","79.5","","800.18","480.96","1887.97","195","396.63","1017.17","percent of total billed charges",""
"MATRIX SYNTHECEL 5CMX2 DURA SUBSTITUTE","SUP-ITM-10168180","CDM","C1713","HCPCS","0278","RC","","","","both","","","1279.46","959.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","681.95","53.3","","813.12","216.42","1444.50","81","396.63","1017.17","percent of total billed charges",""
"MATRIX SYNTHECEL 5CMX2 DURA SUBSTITUTE","SUP-ITM-10168180","CDM","C1713","HCPCS","0278","RC","","","","both","","","1279.46","959.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","396.63","31","","432.60","432.60","432.60","1 through 10","396.63","1017.17","percent of total billed charges",""
"MATRIX SYNTHECEL 5CMX2 DURA SUBSTITUTE","SUP-ITM-10168180","CDM","C1713","HCPCS","0278","RC","","","","both","","","1279.46","959.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","467.00","36.5","","148.37","54.89","631.39","94","396.63","1017.17","percent of total billed charges",""
"MATRIX SYNTHECEL 5CMX2 DURA SUBSTITUTE","SUP-ITM-10168180","CDM","C1713","HCPCS","0278","RC","","","","both","","","1279.46","959.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","490.03","38.3","","279.30","91.72","1116.77","266","396.63","1017.17","percent of total billed charges",""
"MATRIX SYNTHECEL 5CMX2 DURA SUBSTITUTE","SUP-ITM-10168180","CDM","C1713","HCPCS","0278","RC","","","","both","","","1279.46","959.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","548.89","42.9","","731.00","63.70","731.00","1 through 10","396.63","1017.17","percent of total billed charges",""
"MATRIX SYNTHECEL 5CMX2 DURA SUBSTITUTE","SUP-ITM-10168180","CDM","C1713","HCPCS","0278","RC","","","","both","","","1279.46","959.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","548.89","42.9","","384.74","384.74","384.74","1 through 10","396.63","1017.17","percent of total billed charges",""
"MATRIX SYNTHECEL 5CMX2 DURA SUBSTITUTE","SUP-ITM-10168180","CDM","C1713","HCPCS","0278","RC","","","","both","","","1279.46","959.59","WELLPOINT [1015]","HB AMC WELLPOINT","943.99","73.78","","286.63","119.22","1107.45","105","396.63","1017.17","percent of total billed charges",""
"MATRIX SYNTHECEL 5CMX2 DURA SUBSTITUTE","SUP-ITM-10168180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1279.46","959.59","AETNA [1001]","HB AMC AETNA HMO","893.06","69.8","","675.31","184.75","1721.50","286","668.65","1045.57","percent of total billed charges",""
"MATRIX SYNTHECEL 5CMX2 DURA SUBSTITUTE","SUP-ITM-10168180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1279.46","959.59","AETNA [1001]","HB AMC AETNA PPO","1028.69","80.4","","1261.44","103.12","1514.10","21","668.65","1045.57","percent of total billed charges",""
"MATRIX SYNTHECEL 5CMX2 DURA SUBSTITUTE","SUP-ITM-10168180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1279.46","959.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1028.69","80.4","","1365.00","1365.00","1365.00","1 through 10","668.65","1045.57","percent of total billed charges",""
"MATRIX SYNTHECEL 5CMX2 DURA SUBSTITUTE","SUP-ITM-10168180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1279.46","959.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1045.57","81.72","","5157.68","5157.68","5157.68","1 through 10","668.65","1045.57","percent of total billed charges",""
"MATRIX SYNTHECEL 5CMX2 DURA SUBSTITUTE","SUP-ITM-10168180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1279.46","959.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1045.57","81.72","","431.26","71.26","1459.57","88","668.65","1045.57","percent of total billed charges",""
"MATRIX SYNTHECEL 7.5CMX3 DURA SUBSTITUTE","SUP-ITM-10168179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1960.00","1470.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1558.20","79.5","","800.18","480.96","1887.97","195","607.6","1558.2","percent of total billed charges",""
"MATRIX SYNTHECEL 7.5CMX3 DURA SUBSTITUTE","SUP-ITM-10168179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1960.00","1470.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1044.68","53.3","","813.12","216.42","1444.50","81","607.6","1558.2","percent of total billed charges",""
"MATRIX SYNTHECEL 7.5CMX3 DURA SUBSTITUTE","SUP-ITM-10168179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1960.00","1470.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","607.60","31","","432.60","432.60","432.60","1 through 10","607.6","1558.2","percent of total billed charges",""
"MATRIX SYNTHECEL 7.5CMX3 DURA SUBSTITUTE","SUP-ITM-10168179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1960.00","1470.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","715.40","36.5","","148.37","54.89","631.39","94","607.6","1558.2","percent of total billed charges",""
"MATRIX SYNTHECEL 7.5CMX3 DURA SUBSTITUTE","SUP-ITM-10168179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1960.00","1470.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","750.68","38.3","","279.30","91.72","1116.77","266","607.6","1558.2","percent of total billed charges",""
"MATRIX SYNTHECEL 7.5CMX3 DURA SUBSTITUTE","SUP-ITM-10168179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1960.00","1470.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","840.84","42.9","","731.00","63.70","731.00","1 through 10","607.6","1558.2","percent of total billed charges",""
"MATRIX SYNTHECEL 7.5CMX3 DURA SUBSTITUTE","SUP-ITM-10168179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1960.00","1470.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","840.84","42.9","","384.74","384.74","384.74","1 through 10","607.6","1558.2","percent of total billed charges",""
"MATRIX SYNTHECEL 7.5CMX3 DURA SUBSTITUTE","SUP-ITM-10168179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1960.00","1470.00","WELLPOINT [1015]","HB AMC WELLPOINT","1446.09","73.78","","286.63","119.22","1107.45","105","607.6","1558.2","percent of total billed charges",""
"MATRIX SYNTHECEL 7.5CMX3 DURA SUBSTITUTE","SUP-ITM-10168179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1960.00","1470.00","AETNA [1001]","HB AMC AETNA HMO","1368.08","69.8","","675.31","184.75","1721.50","286","1024.3","1601.71","percent of total billed charges",""
"MATRIX SYNTHECEL 7.5CMX3 DURA SUBSTITUTE","SUP-ITM-10168179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1960.00","1470.00","AETNA [1001]","HB AMC AETNA PPO","1575.84","80.4","","1261.44","103.12","1514.10","21","1024.3","1601.71","percent of total billed charges",""
"MATRIX SYNTHECEL 7.5CMX3 DURA SUBSTITUTE","SUP-ITM-10168179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1960.00","1470.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1575.84","80.4","","1365.00","1365.00","1365.00","1 through 10","1024.3","1601.71","percent of total billed charges",""
"MATRIX SYNTHECEL 7.5CMX3 DURA SUBSTITUTE","SUP-ITM-10168179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1960.00","1470.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1601.71","81.72","","5157.68","5157.68","5157.68","1 through 10","1024.3","1601.71","percent of total billed charges",""
"MATRIX SYNTHECEL 7.5CMX3 DURA SUBSTITUTE","SUP-ITM-10168179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1960.00","1470.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1601.71","81.72","","431.26","71.26","1459.57","88","1024.3","1601.71","percent of total billed charges",""
"MATRIX TISSUE 10X20CM REINFORCED OVITEX PRS LONG TERM RESORBABLE CONTOUR","SUP-ITM-10321643","CDM","C1781","HCPCS","0278","RC","","","","both","","","9570.00","7177.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","6699.00","70","","134.04","134.04","134.04","1 through 10","2966.7","7608.15","percent of total billed charges",""
"MATRIX TISSUE 10X20CM REINFORCED OVITEX PRS LONG TERM RESORBABLE CONTOUR","SUP-ITM-10321643","CDM","C1781","HCPCS","0278","RC","","","","both","","","9570.00","7177.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7608.15","79.5","","948.87","198.19","1805.30","1 through 10","2966.7","7608.15","percent of total billed charges",""
"MATRIX TISSUE 10X20CM REINFORCED OVITEX PRS LONG TERM RESORBABLE CONTOUR","SUP-ITM-10321643","CDM","C1781","HCPCS","0278","RC","","","","both","","","9570.00","7177.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5100.81","53.3","","462.00","170.45","3253.37","1 through 10","2966.7","7608.15","percent of total billed charges",""
"MATRIX TISSUE 10X20CM REINFORCED OVITEX PRS LONG TERM RESORBABLE CONTOUR","SUP-ITM-10321643","CDM","C1781","HCPCS","0278","RC","","","","both","","","9570.00","7177.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3493.05","36.5","","245.50","107.19","1371.45","1 through 10","2966.7","7608.15","percent of total billed charges",""
"MATRIX TISSUE 10X20CM REINFORCED OVITEX PRS LONG TERM RESORBABLE CONTOUR","SUP-ITM-10321643","CDM","C1781","HCPCS","0278","RC","","","","both","","","9570.00","7177.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3665.31","38.3","","200.79","72.79","355.81","22","2966.7","7608.15","percent of total billed charges",""
"MATRIX TISSUE 10X20CM REINFORCED OVITEX PRS LONG TERM RESORBABLE CONTOUR","SUP-ITM-10321643","CDM","C1781","HCPCS","0278","RC","","","","both","","","9570.00","7177.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","7368.90","77","","477.18","477.18","477.18","1 through 10","2966.7","7608.15","percent of total billed charges",""
"MATRIX TISSUE 10X20CM REINFORCED OVITEX PRS LONG TERM RESORBABLE CONTOUR","SUP-ITM-10321643","CDM","C1781","HCPCS","0278","RC","","","","both","","","9570.00","7177.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4105.53","42.9","","1045.91","1045.91","1045.91","1 through 10","2966.7","7608.15","percent of total billed charges",""
"MATRIX TISSUE 10X20CM REINFORCED OVITEX PRS LONG TERM RESORBABLE CONTOUR","SUP-ITM-10321643","CDM","C1781","HCPCS","0278","RC","","","","both","","","9570.00","7177.50","WELLPOINT [1015]","HB AMC WELLPOINT","7060.75","73.78","","1726.50","1726.50","1726.50","1 through 10","2966.7","7608.15","percent of total billed charges",""
"MATRIX TISSUE 10X20CM REINFORCED OVITEX PRS LONG TERM RESORBABLE CONTOUR","SUP-ITM-10321643","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9570.00","7177.50","AETNA [1001]","HB AMC AETNA HMO","6679.86","69.8","","915.80","263.76","2881.00","1 through 10","5001.28","7820.6","percent of total billed charges",""
"MATRIX TISSUE 10X20CM REINFORCED OVITEX PRS LONG TERM RESORBABLE CONTOUR","SUP-ITM-10321643","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9570.00","7177.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7820.60","81.72","","1531.57","410.52","8841.36","1 through 10","5001.28","7820.6","percent of total billed charges",""
"MATRIX TISSUE 4X7CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10286279","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2663.50","1997.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","972.18","36.5","","23.35","23.35","23.35","264","825.69","2050.9","percent of total billed charges",""
"MATRIX TISSUE 4X7CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10286279","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2663.50","1997.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1020.12","38.3","","350.11","350.11","350.11","1108","825.69","2050.9","percent of total billed charges",""
"MATRIX TISSUE 4X7CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10286279","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2663.50","1997.62","WELLPOINT [1015]","HB AMC WELLPOINT","1965.13","73.78","","77.77","77.77","77.77","528","825.69","2050.9","percent of total billed charges",""
"MATRIX TISSUE 4X7CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10286279","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2663.50","1997.62","AETNA [1001]","HB AMC AETNA HMO","1859.12","69.8","","35.22","35.22","35.22","397","1249.18","2141.45","percent of total billed charges",""
"MATRIX TISSUE 4X7CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10286279","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2663.50","1997.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1861.79","69.9","","34.18","34.18","34.18","1057","1249.18","2141.45","percent of total billed charges",""
"MATRIX TISSUE 4X7CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10286279","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2663.50","1997.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1249.18","46.9","","34.18","34.18","34.18","528","1249.18","2141.45","percent of total billed charges",""
"MAXILLAE PLATE 10MM 0.8 CRANIAL MATRIXORTHOGNATHIC TITANIUM PREBENT LT MAXILLARY","SUP-ITM-10077332","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","800.22","79.5","","800.18","480.96","1887.97","195","312.04","800.22","percent of total billed charges",""
"MAXILLAE PLATE 10MM 0.8 CRANIAL MATRIXORTHOGNATHIC TITANIUM PREBENT LT MAXILLARY","SUP-ITM-10077332","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","536.50","53.3","","813.12","216.42","1444.50","81","312.04","800.22","percent of total billed charges",""
"MAXILLAE PLATE 10MM 0.8 CRANIAL MATRIXORTHOGNATHIC TITANIUM PREBENT LT MAXILLARY","SUP-ITM-10077332","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","312.04","31","","432.60","432.60","432.60","1 through 10","312.04","800.22","percent of total billed charges",""
"MAXILLAE PLATE 10MM 0.8 CRANIAL MATRIXORTHOGNATHIC TITANIUM PREBENT LT MAXILLARY","SUP-ITM-10077332","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","367.40","36.5","","148.37","54.89","631.39","94","312.04","800.22","percent of total billed charges",""
"MAXILLAE PLATE 10MM 0.8 CRANIAL MATRIXORTHOGNATHIC TITANIUM PREBENT LT MAXILLARY","SUP-ITM-10077332","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","385.52","38.3","","279.30","91.72","1116.77","266","312.04","800.22","percent of total billed charges",""
"MAXILLAE PLATE 10MM 0.8 CRANIAL MATRIXORTHOGNATHIC TITANIUM PREBENT LT MAXILLARY","SUP-ITM-10077332","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","431.82","42.9","","731.00","63.70","731.00","1 through 10","312.04","800.22","percent of total billed charges",""
"MAXILLAE PLATE 10MM 0.8 CRANIAL MATRIXORTHOGNATHIC TITANIUM PREBENT LT MAXILLARY","SUP-ITM-10077332","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","431.82","42.9","","384.74","384.74","384.74","1 through 10","312.04","800.22","percent of total billed charges",""
"MAXILLAE PLATE 10MM 0.8 CRANIAL MATRIXORTHOGNATHIC TITANIUM PREBENT LT MAXILLARY","SUP-ITM-10077332","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","WELLPOINT [1015]","HB AMC WELLPOINT","742.65","73.78","","286.63","119.22","1107.45","105","312.04","800.22","percent of total billed charges",""
"MAXILLAE PLATE 10MM 0.8 CRANIAL MATRIXORTHOGNATHIC TITANIUM PREBENT LT MAXILLARY","SUP-ITM-10077332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1006.57","754.93","AETNA [1001]","HB AMC AETNA HMO","702.59","69.8","","675.31","184.75","1721.50","286","526.03","822.57","percent of total billed charges",""
"MAXILLAE PLATE 10MM 0.8 CRANIAL MATRIXORTHOGNATHIC TITANIUM PREBENT LT MAXILLARY","SUP-ITM-10077332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1006.57","754.93","AETNA [1001]","HB AMC AETNA PPO","809.28","80.4","","1261.44","103.12","1514.10","21","526.03","822.57","percent of total billed charges",""
"MAXILLAE PLATE 10MM 0.8 CRANIAL MATRIXORTHOGNATHIC TITANIUM PREBENT LT MAXILLARY","SUP-ITM-10077332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1006.57","754.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","809.28","80.4","","1365.00","1365.00","1365.00","1 through 10","526.03","822.57","percent of total billed charges",""
"MAXILLAE PLATE 10MM 0.8 CRANIAL MATRIXORTHOGNATHIC TITANIUM PREBENT LT MAXILLARY","SUP-ITM-10077332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1006.57","754.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","822.57","81.72","","5157.68","5157.68","5157.68","1 through 10","526.03","822.57","percent of total billed charges",""
"MAXILLAE PLATE 10MM 0.8 CRANIAL MATRIXORTHOGNATHIC TITANIUM PREBENT LT MAXILLARY","SUP-ITM-10077332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1006.57","754.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","822.57","81.72","","431.26","71.26","1459.57","88","526.03","822.57","percent of total billed charges",""
"Mayo Ahusp Hemolytic Uremic Syndrome Panel","PX-31001166","CDM","81479","CPT","0310","RC","","","","both","","","6356.00","4767.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5053.02","79.5","","0.65","0.65","0.65","1 through 10","1970.36","6038.2","percent of total billed charges",""
"Mayo Ahusp Hemolytic Uremic Syndrome Panel","PX-31001166","CDM","81479","CPT","0310","RC","","","","both","","","6356.00","4767.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3387.75","53.3","","0.79","0.79","0.79","1 through 10","1970.36","6038.2","percent of total billed charges",""
"Mayo Ahusp Hemolytic Uremic Syndrome Panel","PX-31001166","CDM","81479","CPT","0310","RC","","","","outpatient","","","6356.00","4767.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3178.00","50","","1.00","1.00","1.00","1 through 10","156.55","5243.7","percent of total billed charges",""
"Mayo Ahusp Hemolytic Uremic Syndrome Panel","PX-31001166","CDM","81479","CPT","0310","RC","","","","outpatient","","","6356.00","4767.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3336.90","52.5","","1.00","0.53","1.00","1 through 10","156.55","5243.7","percent of total billed charges",""
"Mayo Bpgm Full Gene Sequencing","PX-31001183","CDM","81479","CPT","0310","RC","","","","both","","","1369.00","1026.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1088.36","79.5","","0.65","0.65","0.65","1 through 10","424.39","1300.55","percent of total billed charges",""
"Mayo Bpgm Full Gene Sequencing","PX-31001183","CDM","81479","CPT","0310","RC","","","","both","","","1369.00","1026.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","729.68","53.3","","0.79","0.79","0.79","1 through 10","424.39","1300.55","percent of total billed charges",""
"Mayo Bpgm Full Gene Sequencing","PX-31001183","CDM","81479","CPT","0310","RC","","","","outpatient","","","1369.00","1026.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","684.50","50","","1.00","1.00","1.00","1 through 10","156.55","1129.43","percent of total billed charges",""
"Mayo Bpgm Full Gene Sequencing","PX-31001183","CDM","81479","CPT","0310","RC","","","","outpatient","","","1369.00","1026.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","718.73","52.5","","1.00","0.53","1.00","1 through 10","156.55","1129.43","percent of total billed charges",""
"Mayo F13a1 and B Genes","PX-31001159","CDM","81479","CPT","0310","RC","","","","both","","","3572.00","2679.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2839.74","79.5","","0.65","0.65","0.65","1 through 10","1107.32","3393.4","percent of total billed charges",""
"Mayo F13a1 and B Genes","PX-31001159","CDM","81479","CPT","0310","RC","","","","both","","","3572.00","2679.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1903.88","53.3","","0.79","0.79","0.79","1 through 10","1107.32","3393.4","percent of total billed charges",""
"Mayo F13a1 and B Genes","PX-31001159","CDM","81479","CPT","0310","RC","","","","outpatient","","","3572.00","2679.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1786.00","50","","1.00","1.00","1.00","1 through 10","156.55","2946.9","percent of total billed charges",""
"Mayo F13a1 and B Genes","PX-31001159","CDM","81479","CPT","0310","RC","","","","outpatient","","","3572.00","2679.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1875.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","2946.9","percent of total billed charges",""
"Mayo Gamma Globin Full Gene Sequencing Wgseq","PX-31001248","CDM","81479","CPT","0310","RC","","","","both","","","1342.00","1006.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1066.89","79.5","","0.65","0.65","0.65","1 through 10","416.02","1274.9","percent of total billed charges",""
"Mayo Gamma Globin Full Gene Sequencing Wgseq","PX-31001248","CDM","81479","CPT","0310","RC","","","","both","","","1342.00","1006.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","715.29","53.3","","0.79","0.79","0.79","1 through 10","416.02","1274.9","percent of total billed charges",""
"Mayo Gamma Globin Full Gene Sequencing Wgseq","PX-31001248","CDM","81479","CPT","0310","RC","","","","outpatient","","","1342.00","1006.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","671.00","50","","1.00","1.00","1.00","1 through 10","156.55","1107.15","percent of total billed charges",""
"Mayo Gamma Globin Full Gene Sequencing Wgseq","PX-31001248","CDM","81479","CPT","0310","RC","","","","outpatient","","","1342.00","1006.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","704.55","52.5","","1.00","0.53","1.00","1 through 10","156.55","1107.15","percent of total billed charges",""
"MAYO Glycine receptor alpha1 IgG, serum","PX-30003830","CDM","0431U","CPT","0302","RC","","","","both","","","1059.00","794.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","841.91","79.5","","2424.75","2424.75","2424.75","1 through 10","35.84","1006.05","percent of total billed charges",""
"Mayo Pera Preeclampsia Sflt-1/Pigf Placenta Growth Factor Ratio, Seru","PX-30003833","CDM","0482U","CPT","0300","RC","","","","both","","","722.00","541.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","573.99","79.5","","369.60","369.60","550.90","1 through 10","126.24","685.9","percent of total billed charges",""
"Mayo Pera Preeclampsia Sflt-1/Pigf Placenta Growth Factor Ratio, Seru","PX-30003833","CDM","0482U","CPT","0300","RC","","","","both","","","722.00","541.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","384.83","53.3","","369.60","369.60","550.90","1 through 10","126.24","685.9","percent of total billed charges",""
"Mayo Pera Preeclampsia Sflt-1/Pigf Placenta Growth Factor Ratio, Seru","PX-30003833","CDM","0482U","CPT","0300","RC","","","","both","","","722.00","541.50","WELLPOINT [1015]","HB AMC WELLPOINT","532.69","73.78","","521.15","521.15","521.15","1 through 10","126.24","685.9","percent of total billed charges",""
"Mayo Pera Preeclampsia Sflt-1/Pigf Placenta Growth Factor Ratio, Seru","PX-30003833","CDM","0482U","CPT","0300","RC","","","","outpatient","","","722.00","541.50","AETNA [1001]","HB AMC AETNA HMO","503.96","69.8","","473.90","334.60","473.90","1 through 10","288.8","595.65","percent of total billed charges",""
"Mayo Pera Preeclampsia Sflt-1/Pigf Placenta Growth Factor Ratio, Seru","PX-30003833","CDM","0482U","CPT","0300","RC","","","","outpatient","","","722.00","541.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","377.03","52.22","","700.00","483.84","700.00","1 through 10","288.8","595.65","percent of total billed charges",""
"Mayo Pera Preeclampsia Sflt-1/Pigf Placenta Growth Factor Ratio, Seru","PX-30003833","CDM","0482U","CPT","0300","RC","","","","outpatient","","","722.00","541.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","590.02","81.72","","559.58","559.58","559.58","1 through 10","288.8","595.65","percent of total billed charges",""
"Mayo Tcall Receptor Excision Circles Analysis","PX-31001168","CDM","81479","CPT","0310","RC","","","","both","","","2235.00","1676.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1776.83","79.5","","0.65","0.65","0.65","1 through 10","692.85","2123.25","percent of total billed charges",""
"Mayo Tcall Receptor Excision Circles Analysis","PX-31001168","CDM","81479","CPT","0310","RC","","","","both","","","2235.00","1676.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1191.26","53.3","","0.79","0.79","0.79","1 through 10","692.85","2123.25","percent of total billed charges",""
"Mayo Tcall Receptor Excision Circles Analysis","PX-31001168","CDM","81479","CPT","0310","RC","","","","outpatient","","","2235.00","1676.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1117.50","50","","1.00","1.00","1.00","1 through 10","156.55","1843.88","percent of total billed charges",""
"Mayo Tcall Receptor Excision Circles Analysis","PX-31001168","CDM","81479","CPT","0310","RC","","","","outpatient","","","2235.00","1676.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1173.38","52.5","","1.00","0.53","1.00","1 through 10","156.55","1843.88","percent of total billed charges",""
"Mayo Uba1 Mutation, Quant, Ddpcr, Varies","PX-31001240","CDM","81479","CPT","0310","RC","","","","both","","","2660.00","1995.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2114.70","79.5","","0.65","0.65","0.65","1 through 10","824.6","2527","percent of total billed charges",""
"Mayo Uba1 Mutation, Quant, Ddpcr, Varies","PX-31001240","CDM","81479","CPT","0310","RC","","","","both","","","2660.00","1995.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1417.78","53.3","","0.79","0.79","0.79","1 through 10","824.6","2527","percent of total billed charges",""
"Mayo Uba1 Mutation, Quant, Ddpcr, Varies","PX-31001240","CDM","81479","CPT","0310","RC","","","","outpatient","","","2660.00","1995.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1330.00","50","","1.00","1.00","1.00","1 through 10","156.55","2194.5","percent of total billed charges",""
"Mayo Uba1 Mutation, Quant, Ddpcr, Varies","PX-31001240","CDM","81479","CPT","0310","RC","","","","outpatient","","","2660.00","1995.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1396.50","52.5","","1.00","0.53","1.00","1 through 10","156.55","2194.5","percent of total billed charges",""
"Mayo, 88898 Microarray Array Comparative Genomic Hybridization Acgh","PX-31001273","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2946.27","79.5","","2828.48","1814.97","2828.48","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Mayo, 88898 Microarray Array Comparative Genomic Hybridization Acgh","PX-31001273","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1975.30","53.3","","1814.97","1761.95","1814.97","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Mayo, 88898 Microarray Array Comparative Genomic Hybridization Acgh","PX-31001273","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1352.69","36.5","","1340.56","1340.56","1340.56","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Mayo, 88898 Microarray Array Comparative Genomic Hybridization Acgh","PX-31001273","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1419.40","38.3","","1405.25","1405.25","1405.25","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Mayo, 88898 Microarray Array Comparative Genomic Hybridization Acgh","PX-31001273","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","WELLPOINT [1015]","HB AMC WELLPOINT","2734.29","73.78","","6269.73","2675.73","7188.00","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Mayo, 88898 Microarray Array Comparative Genomic Hybridization Acgh","PX-31001273","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","AETNA [1001]","HB AMC AETNA HMO","2586.79","69.8","","2433.14","2433.14","2433.14","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Mayo, 88898 Microarray Array Comparative Genomic Hybridization Acgh","PX-31001273","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2979.62","80.4","","2803.32","2803.32","2803.32","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Mayo, 88898 Microarray Array Comparative Genomic Hybridization Acgh","PX-31001273","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3028.54","81.72","","2873.04","1533.07","3526.61","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Mayo, 89436 Methylmalonic Aciduria Homocystinuria Gene Seq Mmacfull Gene Seq","PX-31001318","CDM","81403","CPT","0310","RC","","","","outpatient","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","864.60","81.72","","820.18","820.18","820.18","1 through 10","512.07","1135.28","percent of total billed charges",""
"Mayo, Apol1 Genotyping","PX-31001211","CDM","81479","CPT","0310","RC","","","","both","","","1282.00","961.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1019.19","79.5","","0.65","0.65","0.65","1 through 10","397.42","1217.9","percent of total billed charges",""
"Mayo, Apol1 Genotyping","PX-31001211","CDM","81479","CPT","0310","RC","","","","both","","","1282.00","961.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","683.31","53.3","","0.79","0.79","0.79","1 through 10","397.42","1217.9","percent of total billed charges",""
"Mayo, Apol1 Genotyping","PX-31001211","CDM","81479","CPT","0310","RC","","","","outpatient","","","1282.00","961.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","641.00","50","","1.00","1.00","1.00","1 through 10","156.55","1057.65","percent of total billed charges",""
"Mayo, Apol1 Genotyping","PX-31001211","CDM","81479","CPT","0310","RC","","","","outpatient","","","1282.00","961.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","673.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","1057.65","percent of total billed charges",""
"Mayo, Casrz Casr Full Gene Seq Csrsp","PX-31001354","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Mayo, Casrz Casr Full Gene Seq Csrsp","PX-31001354","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Mayo, Fabrz Fabry Disease Full Gene Analysis","PX-31001356","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Mayo, Fabrz Fabry Disease Full Gene Analysis","PX-31001356","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Mayo, Galz Galactosemia Galt Gene Full Gene Analysis Varies Galz","PX-31001380","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Mayo, Hexaz Hexa Full Gene Analysis Tay Sachs Disease","PX-31001383","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Mayo, Hpanp Hereditary Pancreatitis Panel","PX-31001360","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Mayo, Hpanp Hereditary Pancreatitis Panel","PX-31001360","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Mayo, Hpanp Hereditary Pancreatitis Panel Hppan","PX-31001340","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Mayo, Kelch-Like Protein 11 Antibody, Cell Binding Assay, Serum","PX-30003828","CDM","0432U","CPT","0300","RC","","","","both","","","1059.00","794.25","WELLPOINT [1015]","HB AMC WELLPOINT","781.33","73.78","","764.60","764.60","764.60","1 through 10","35.84","1006.05","percent of total billed charges",""
"Mayo, Kelch-Like Protein 11 Antibody, Cell Binding Assay, Serum","PX-30003828","CDM","0432U","CPT","0300","RC","","","","outpatient","","","1059.00","794.25","AETNA [1001]","HB AMC AETNA HMO","739.18","69.8","","801.06","801.06","801.06","1 through 10","423.6","873.68","percent of total billed charges",""
"Mayo, Kelch-Like Protein 11 Antibody, Cell Binding Assay, Serum","PX-30003828","CDM","0432U","CPT","0300","RC","","","","outpatient","","","1059.00","794.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","553.01","52.22","","709.86","552.84","709.87","1 through 10","423.6","873.68","percent of total billed charges",""
"Mayo, Kelch-Like Protein 11 Antibody, Cell Binding Assay, Serum","PX-30003828","CDM","0432U","CPT","0300","RC","","","","outpatient","","","1059.00","794.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","865.41","81.72","","820.98","820.98","820.98","1 through 10","423.6","873.68","percent of total billed charges",""
"Mayo, Men2a Multiple Endocrine Neoplasia Type 2a Medullary Thyroid Carcinoma Retseq 80573","PX-31001363","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Mayo, Men2a Multiple Endocrine Neoplasia Type 2a Medullary Thyroid Carcinoma Retseq 80573","PX-31001363","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Mayo, Microarray Array Comparative Genomic Hybridization Acgh Ad708 Ad709 105k Baylor Microarray","PX-31001280","CDM","81265","CPT","0310","RC","","","","outpatient","","","1341.00","1005.75","AETNA [1001]","HB AMC AETNA HMO","936.02","69.8","","880.10","880.10","880.10","1 through 10","648.65","1464.7","percent of total billed charges",""
"Mayo, Pardp Inherited Parkinson Disease Gene Panel","PX-31001388","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Mayo, Pardp Inherited Parkinson Disease Gene Panel Pardp","PX-31001344","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Mayo, Pardp Inherited Parkinson Disease Gene Panel Pardp","PX-31001362","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Mayo, Pardp Inherited Parkinson Disease Gene Panel Pardp","PX-31001362","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","both","","","111.00","83.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","77.70","70","","484.00","212.81","484.00","1 through 10","34.41","194.41","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","both","","","111.00","83.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","88.25","79.5","","380.91","255.55","1142.73","14","34.41","194.41","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","both","","","111.00","83.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","59.16","53.3","","766.65","255.55","1319.02","16","34.41","194.41","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","both","","","111.00","83.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","85.47","77","","1118.04","1118.04","1118.04","1 through 10","34.41","194.41","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","both","","","111.00","83.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","72.15","65","","314.60","304.20","314.60","1 through 10","34.41","194.41","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","40.52","36.5","","541.59","180.53","1263.71","21","34.41","194.41","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","42.51","38.3","","551.76","189.24","919.60","40","34.41","194.41","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","outpatient","","","111.00","83.25","AETNA [1001]","HB AMC AETNA HMO","77.48","69.8","","327.67","231.35","377.52","16","58.01","402.68","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","90.71","81.72","","386.91","212.81","386.91","1 through 10","58.01","402.68","percent of total billed charges",""
"Mayo, Retzz Ret Full Gene Seq Retz","PX-31001390","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Mayo, Ttrz Ttr Full Gene Analysis Transthyretin Seq Amyloidosis","PX-31001329","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Mayo, Ugtfz Ugt1a1 Full Gene Seq Udp-Glucuronosyl Transferase 1a1","PX-31001346","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Mayo, Vhle Reflex Vhl Gene Erythrocytosis Mutations Mvhle","PX-31001343","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Mayo, Wndz Wilson Disease Atp7b Wilson Disease Full Gene Seq","PX-31001391","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"MAYO, ZW210 GENETIC RENAL DNA PANEL HUS aHUS TTP ASSAYS INCLUDES CFH CFI MCP CFB CFHR5 C3 THBD","PX-31001357","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"MAYO, ZW210 GENETIC RENAL DNA PANEL HUS aHUS TTP ASSAYS INCLUDES CFH CFI MCP CFB CFHR5 C3 THBD","PX-31001357","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"MAYO, ZW210 GENETIC RENAL DNA PANEL HUS aHUS TTP ASSAYS INCLUDES CFH CFI MCP CFB CFHR5 C3 THBD ADAMTS13 PLG DGKE","PX-31001338","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Mcg Chrom Insitu 3-5","PX-31000131","CDM","88272","CPT","0311","RC","","","","both","","","486.00","364.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","186.14","38.3","","175.68","175.68","175.68","1 through 10","39.89","461.7","percent of total billed charges",""
"Mcg Chrom Insitu 3-5","PX-31000131","CDM","88272","CPT","0311","RC","","","","outpatient","","","486.00","364.50","AETNA [1001]","HB AMC AETNA PPO","390.74","80.4","","367.38","367.38","367.38","1 through 10","116.51","397.16","percent of total billed charges",""
"Mcg Dna Probe","PX-31000129","CDM","88271","CPT","0311","RC","","","","both","","","351.00","263.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","228.15","65","","602.55","602.55","602.55","1 through 10","20.99","333.45","percent of total billed charges",""
"Mcg Dna Probe","PX-31000129","CDM","88271","CPT","0311","RC","","","","both","","","351.00","263.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","279.05","79.5","","267.58","179.52","720.89","80","20.99","333.45","percent of total billed charges",""
"Mcg Dna Probe","PX-31000129","CDM","88271","CPT","0311","RC","","","","both","","","351.00","263.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","187.08","53.3","","1795.73","267.58","1795.73","32","20.99","333.45","percent of total billed charges",""
"Mcg Dna Probe","PX-31000129","CDM","88271","CPT","0311","RC","","","","both","","","351.00","263.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","128.12","36.5","","380.46","107.78","380.46","30","20.99","333.45","percent of total billed charges",""
"Mcg Dna Probe","PX-31000129","CDM","88271","CPT","0311","RC","","","","both","","","351.00","263.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","134.43","38.3","","265.88","129.20","398.82","114","20.99","333.45","percent of total billed charges",""
"Mcg Dna Probe","PX-31000129","CDM","88271","CPT","0311","RC","","","","outpatient","","","351.00","263.25","AETNA [1001]","HB AMC AETNA HMO","245.00","69.8","","265.20","230.18","265.20","23","75.28","286.84","percent of total billed charges",""
"Mcg Dna Probe","PX-31000129","CDM","88271","CPT","0311","RC","","","","outpatient","","","351.00","263.25","AETNA [1001]","HB AMC AETNA PPO","282.20","80.4","","265.20","265.20","265.20","1 through 10","75.28","286.84","percent of total billed charges",""
"Mcg Dna Probe","PX-31000129","CDM","88271","CPT","0311","RC","","","","outpatient","","","351.00","263.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","183.43","52.26","","210.39","210.39","210.39","1 through 10","75.28","286.84","percent of total billed charges",""
"Mcg Dna Probe","PX-31000129","CDM","88271","CPT","0311","RC","","","","outpatient","","","351.00","263.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","286.84","81.72","","271.80","271.80","271.80","11","75.28","286.84","percent of total billed charges",""
"Mcg Interphase Insitu 100","PX-31000135","CDM","88275","CPT","0311","RC","","","","both","","","666.00","499.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","529.47","79.5","","508.40","341.09","646.00","1 through 10","50.17","632.7","percent of total billed charges",""
"Mcg Interphase Insitu 100","PX-31000135","CDM","88275","CPT","0311","RC","","","","both","","","666.00","499.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","354.98","53.3","","1359.08","508.40","1359.08","14","50.17","632.7","percent of total billed charges",""
"Mcg Interphase Insitu 100","PX-31000135","CDM","88275","CPT","0311","RC","","","","both","","","666.00","499.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","243.09","36.5","","722.88","204.78","722.88","1 through 10","50.17","632.7","percent of total billed charges",""
"Mcg Interphase Insitu 100","PX-31000135","CDM","88275","CPT","0311","RC","","","","both","","","666.00","499.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","255.08","38.3","","505.17","245.48","505.17","13","50.17","632.7","percent of total billed charges",""
"Mcg Interphase Insitu 100","PX-31000135","CDM","88275","CPT","0311","RC","","","","outpatient","","","666.00","499.50","AETNA [1001]","HB AMC AETNA HMO","464.87","69.8","","503.88","308.79","503.88","1 through 10","146.41","544.26","percent of total billed charges",""
"Mcg Interphase Insitu 100","PX-31000135","CDM","88275","CPT","0311","RC","","","","outpatient","","","666.00","499.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","348.05","52.26","","399.74","399.74","399.74","1 through 10","146.41","544.26","percent of total billed charges",""
"Mcg Interphase Insitu 100","PX-31000135","CDM","88275","CPT","0311","RC","","","","outpatient","","","666.00","499.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","544.26","81.72","","516.41","516.41","516.41","1 through 10","146.41","544.26","percent of total billed charges",""
"Mcg Interphase Insitu 25","PX-31000134","CDM","88274","CPT","0311","RC","","","","both","","","601.00","450.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","390.65","65","","911.30","911.30","911.30","20","41.53","570.95","percent of total billed charges",""
"Mcg Interphase Insitu 25","PX-31000134","CDM","88274","CPT","0311","RC","","","","both","","","601.00","450.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","477.80","79.5","","1318.74","458.82","1574.79","12","41.53","570.95","percent of total billed charges",""
"Mcg Interphase Insitu 25","PX-31000134","CDM","88274","CPT","0311","RC","","","","both","","","601.00","450.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","219.37","36.5","","217.46","217.46","217.46","1 through 10","41.53","570.95","percent of total billed charges",""
"Mcg Interphase Insitu 25","PX-31000134","CDM","88274","CPT","0311","RC","","","","both","","","601.00","450.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","230.18","38.3","","455.90","227.95","683.85","1 through 10","41.53","570.95","percent of total billed charges",""
"Mcg Interphase Insitu 25","PX-31000134","CDM","88274","CPT","0311","RC","","","","outpatient","","","601.00","450.75","AETNA [1001]","HB AMC AETNA HMO","419.50","69.8","","394.69","394.69","394.69","1 through 10","122.71","491.14","percent of total billed charges",""
"Mcg Interphase Insitu 25","PX-31000134","CDM","88274","CPT","0311","RC","","","","outpatient","","","601.00","450.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","491.14","81.72","","466.05","466.05","466.05","1 through 10","122.71","491.14","percent of total billed charges",""
"Measles Mumps Rubella Virus Vaccine Live Subq","PX-63600317","CDM","90707","CPT","0636","RC","","","","both","","","16.14","12.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5.89","36.5","","6.02","6.02","6.02","1 through 10","5","12.43","percent of total billed charges",""
"Measles Mumps Rubella Virus Vaccine Live Subq","PX-63600317","CDM","90707","CPT","0636","RC","","","","both","","","16.14","12.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6.18","38.3","","6.31","6.31","6.31","1 through 10","5","12.43","percent of total billed charges",""
"Measles Mumps Rubella Virus Vaccine Live Subq","PX-63600317","CDM","90707","CPT","0636","RC","","","","outpatient","","","16.14","12.10","AETNA [1001]","HB AMC AETNA HMO","11.27","69.8","","10.93","10.93","10.93","1 through 10","7.57","13.19","percent of total billed charges",""
"Measles Mumps Rubella Virus Vaccine Live Subq","PX-63600317","CDM","90707","CPT","0636","RC","","","","outpatient","","","16.14","12.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11.28","69.9","","7.49","7.49","7.49","1 through 10","7.57","13.19","percent of total billed charges",""
"Measure Post-Void Urine by US","PX-76001275","CDM","51798","CPT","0761","RC","","","","both","","","205.00","153.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.27","53.3","","105.07","105.07","105.07","1 through 10","63.55","162.98","percent of total billed charges",""
"Measure Post-Void Urine by US","PX-76001275","CDM","51798","CPT","0761","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.83","36.5","","63.08","63.08","63.08","1 through 10","63.55","162.98","percent of total billed charges",""
"Measure Post-Void Urine by US","PX-76001275","CDM","51798","CPT","0761","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.52","38.3","","77.81","77.81","77.81","1 through 10","63.55","162.98","percent of total billed charges",""
"Measure Post-Void Urine by US","PX-76001275","CDM","51798","CPT","0761","RC","","","","both","","","205.00","153.75","WELLPOINT [1015]","HB AMC WELLPOINT","151.25","73.78","","148.16","148.16","148.16","1 through 10","63.55","162.98","percent of total billed charges",""
"Measure Post-Void Urine by US","PX-76001275","CDM","51798","CPT","0761","RC","","","","outpatient","","","205.00","153.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","63.92","","Case rate ($63.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","128.42","128.42","130.78","1 through 10","63.92","363.34","other","ASC"
"Measure Post-Void Urine by US","PX-76001275","CDM","51798","CPT","0761","RC","","","","outpatient","","","205.00","153.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","63.92","","Case rate ($63.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","148.17","148.17","149.64","1 through 10","63.92","363.34","other","ASC "
"Measure Post-Void Urine by US","PX-76001275","CDM","51798","CPT","0761","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","167.53","81.72","","159.08","159.08","159.08","1 through 10","63.92","363.34","percent of total billed charges",""
"Meat Fibers Feces","PX-30000115","CDM","89160","CPT","0300","RC","","","","outpatient","","","63.00","47.25","AETNA [1001]","HB AMC AETNA PPO","50.65","80.4","","47.58","47.58","47.58","1 through 10","3.8","51.48","percent of total billed charges",""
"Mech Removal Fibrin Sheath Same Access Not Through Cvc","PX-76002631","CDM","37799","CPT","0761","RC","","","","outpatient","","","2342.00","1756.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1222.99","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","1932.15","percent of total billed charges",""
"Mech Removal Fibrin Sheath Same Access Not Through Cvc","PX-76002631","CDM","37799","CPT","0761","RC","","","","outpatient","","","2342.00","1756.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1229.55","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","1932.15","percent of total billed charges",""
"Mechanical Chest Wall Oscillation Lung Function","PX-41000021","CDM","94669","CPT","0410","RC","","","","both","","","1021.00","765.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","811.70","79.5","","895.68","779.13","895.68","1 through 10","67.25","811.7","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","AETNA [1001]","HB AMC AETNA HMO","436.25","69.8","","410.26","289.67","472.68","45","60.9","593.75","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","448.75","71.8","","1305.33","435.11","1305.33","1 through 10","60.9","593.75","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","410.00","65.6","","410.26","410.26","410.26","1 through 10","60.9","593.75","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","406.25","65","","1181.70","393.90","1181.70","1 through 10","60.9","593.75","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","437.50","70","","436.32","260.58","436.32","1 through 10","60.9","593.75","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","496.88","79.5","","476.92","319.97","1430.76","27","60.9","593.75","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","333.13","53.3","","319.97","306.03","1430.76","23","60.9","593.75","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","193.75","31","","187.25","187.25","187.25","1 through 10","60.9","593.75","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.13","36.5","","226.04","190.28","226.04","42","60.9","593.75","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.38","38.3","","236.95","230.28","710.85","80","60.9","593.75","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","outpatient","","","625.00","468.75","AETNA [1001]","HB AMC AETNA PPO","502.50","80.4","","472.68","317.54","923.54","1 through 10","205.18","594.32","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","outpatient","","","625.00","468.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","326.63","52.26","","205.18","205.18","205.18","1 through 10","205.18","594.32","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","outpatient","","","625.00","468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","510.75","81.72","","484.44","266.46","484.44","1 through 10","205.18","594.32","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","outpatient","","","625.00","468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","510.75","81.72","","484.44","266.46","484.44","33","205.18","594.32","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","both","","","474.00","355.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","173.01","36.5","","171.58","145.82","514.74","138","146.94","450.3","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","both","","","474.00","355.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","181.54","38.3","","179.86","179.86","539.58","344","146.94","450.3","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","AETNA [1001]","HB AMC AETNA HMO","330.85","69.8","","311.42","219.88","622.84","37","40.19","391.05","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","161.63","34.1","","362.02","242.88","1261.56","36","40.19","391.05","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","248.85","52.5","","301.30","301.30","301.30","1 through 10","40.19","391.05","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","237.00","50","","723.12","241.04","723.12","24","40.19","391.05","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","248.85","52.5","","482.08","202.40","759.00","22","40.19","391.05","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","260.70","55","","423.94","211.97","635.90","24","40.19","391.05","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","381.10","80.4","","358.80","358.80","358.80","1 through 10","40.19","391.05","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","248.85","52.5","","496.83","496.83","496.83","1 through 10","40.19","391.05","percent of total billed charges",""
"Med Genetics&Genetic Counseling Svcs Each 30 Min","PX-51000649","CDM","96041","CPT","0510","RC","","","","outpatient","","","474.00","355.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","387.35","81.72","","367.72","317.95","397.44","25","40.19","391.05","percent of total billed charges",""
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","64647.96","48485.97","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","20223.05","","Case rate ($20,223.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,785.45, add-ons for qualifying new technology services are included. If operating cost exceeds $64,429.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,788.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $18,494.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,405.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,348.69. The transfer capital threshold is the transfer adjustment factor * $1,348.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","55727.65","55727.65","55727.65","1 through 10","15356","26254.43","other","Inpatient DRG"
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","64647.96","48485.97","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15669.39","","Case rate ($15,669.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,785.45, add-ons for qualifying new technology services are included. If operating cost exceeds $64,429.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,788.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,940.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,405.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,348.69. The transfer capital threshold is the transfer adjustment factor * $1,348.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19410.67","19410.67","19410.67","1 through 10","15356","26254.43","other","Inpatient DRG"
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","64647.96","48485.97","MEDICARE [2001]","HB BWH MEDICARE","20223.05","","Case rate ($20,223.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,785.45, add-ons for qualifying new technology services are included. If operating cost exceeds $64,429.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,788.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $18,494.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,405.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,348.69. The transfer capital threshold is the transfer adjustment factor * $1,348.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20395.28","17772.04","20425.38","37","15356","26254.43","other","Inpatient DRG"
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","64647.96","48485.97","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","15356.00","","Case rate ($15,669.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,785.45, add-ons for qualifying new technology services are included. If operating cost exceeds $64,429.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,788.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,940.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,405.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,348.69. The transfer capital threshold is the transfer adjustment factor * $1,348.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15491.40","15491.40","15491.40","1 through 10","15356","26254.43","other","Inpatient DRG"
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","64647.96","48485.97","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15356.00","","Case rate ($15,669.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,785.45, add-ons for qualifying new technology services are included. If operating cost exceeds $64,429.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,788.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,940.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,405.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,348.69. The transfer capital threshold is the transfer adjustment factor * $1,348.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15581.48","15451.40","54856.62","1 through 10","15356","26254.43","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","50702.46","38026.84","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","9423.39","","Case rate ($9,148.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,936.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,580.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,995.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,556.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.52. The transfer capital threshold is the transfer adjustment factor * $773.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9360.94","9360.94","9360.94","1 through 10","8965.94","15057.8","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","50702.46","38026.84","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9148.92","","Case rate ($9,148.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,936.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,580.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,995.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,556.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.52. The transfer capital threshold is the transfer adjustment factor * $773.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11479.55","11479.55","11479.55","1 through 10","8965.94","15057.8","other","Inpatient Replacement Plans DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","50702.46","38026.84","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9148.92","","Case rate ($9,148.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,936.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,580.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,995.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,556.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.52. The transfer capital threshold is the transfer adjustment factor * $773.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8896.68","8879.36","8929.42","1 through 10","8965.94","15057.8","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","50702.46","38026.84","MARTIN'S POINT [160007]","HB BWH MEDICARE","9148.92","","Case rate ($9,148.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,936.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,580.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,995.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,556.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.52. The transfer capital threshold is the transfer adjustment factor * $773.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8901.20","8901.20","8901.20","1 through 10","8965.94","15057.8","other","Inpatient Replacement Plans DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","50702.46","38026.84","MEDICARE [2001]","HB BWH MEDICARE","9148.92","","Case rate ($9,148.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,936.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,580.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,995.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,556.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.52. The transfer capital threshold is the transfer adjustment factor * $773.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11640.65","0.03","11657.65","55","8965.94","15057.8","other","Inpatient Replacement Plans DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","50702.46","38026.84","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","9148.92","","Case rate ($9,148.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,936.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,580.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,995.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,556.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.52. The transfer capital threshold is the transfer adjustment factor * $773.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8871.72","8871.72","8871.72","1 through 10","8965.94","15057.8","other","Inpatient Replacement Plans DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","50702.46","38026.84","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8965.94","","Case rate ($9,148.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,936.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,580.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,995.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,556.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.52. The transfer capital threshold is the transfer adjustment factor * $773.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8912.26","8896.68","8940.04","1 through 10","8965.94","15057.8","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","50702.46","38026.84","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8965.94","","Case rate ($9,148.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,936.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,580.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,213.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,995.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,556.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.52. The transfer capital threshold is the transfer adjustment factor * $773.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8888.88","8888.88","8903.60","1 through 10","8965.94","15057.8","other","Inpatient DRG"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","162.39","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","162.24","162.24","162.90","108","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.15","145.72","155.15","155","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","916.43","65.6","","1355.00","1355.00","1355.00","1 through 10","149.79","1110.62","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","908.05","65","","1066.39","1066.39","1066.39","1 through 10","149.79","1110.62","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","977.90","70","","975.60","582.65","1355.00","14","149.79","1110.62","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1110.62","79.5","","1066.39","715.44","1066.39","59","149.79","1110.62","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","744.60","53.3","","715.44","684.28","1066.39","49","149.79","1110.62","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.15","154.52","155.15","21","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","ELDER SERVICES [1037]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","145.13","145.13","145.13","1 through 10","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","FALLON HEALTH [1008]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","145.13","145.13","154.52","1 through 10","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","401.76","401.76","401.76","1 through 10","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1075.69","77","","1013.32","1013.32","1013.32","1 through 10","149.79","1110.62","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","HUMANA [1012]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.46","154.52","155.46","11","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1110.62","79.5","","1847.66","1847.66","1847.66","1 through 10","149.79","1110.62","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","154.52","154.52","155.46","1 through 10","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","MEDICARE [2001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","157.67","157.67","157.67","1120","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","433.07","31","","418.70","418.70","418.70","1 through 10","149.79","1110.62","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","509.91","36.5","","505.42","490.51","505.42","49","149.79","1110.62","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","535.05","38.3","","529.81","529.81","529.81","49","149.79","1110.62","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.72","146.33","155.72","1 through 10","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","MOLINA [1014]","HB BWH MOLINA","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","312.82","312.19","312.82","39","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1075.69","77","","149.05","149.05","149.05","1 through 10","149.79","1110.62","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","149.79","","APC Price ($157.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","473.01","473.01","473.01","1 through 10","149.79","1110.62","other","Tricare OPPS"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","154.52","145.13","463.56","109","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","311.65","311.65","311.65","1 through 10","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","154.52","145.73","156.12","313","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1397.00","1047.75","WELLSENSE [1003]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","159.25","159.25","477.75","1 through 10","149.79","1110.62","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","outpatient","","","1397.00","1047.75","AETNA [1001]","HB AMC AETNA HMO","975.11","69.8","","917.34","647.69","1056.90","74","336.65","1141.63","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","outpatient","","","1397.00","1047.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","730.07","52.26","","610.75","610.75","610.75","1 through 10","336.65","1141.63","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","outpatient","","","1397.00","1047.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1123.19","80.4","","1056.90","677.50","1141.08","1 through 10","336.65","1141.63","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","outpatient","","","1397.00","1047.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1141.63","81.72","","1083.19","1083.19","1083.19","1 through 10","336.65","1141.63","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","outpatient","","","1397.00","1047.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1141.63","81.72","","1083.19","595.79","1083.19","79","336.65","1141.63","percent of total billed charges",""
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","1146.00","859.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","162.39","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","162.90","162.90","162.90","1 through 10","149.79","911.07","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","1146.00","859.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.15","145.72","155.15","1 through 10","149.79","911.07","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","1146.00","859.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.15","155.15","155.15","1 through 10","149.79","911.07","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","1146.00","859.50","FALLON HEALTH [1008]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","157.67","148.09","157.67","1 through 10","149.79","911.07","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","1146.00","859.50","HUMANA [1012]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","154.52","154.52","154.52","1 through 10","149.79","911.07","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","1146.00","859.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","825.12","72","","799.92","799.92","799.92","1 through 10","149.79","911.07","percent of total billed charges",""
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","1146.00","859.50","MEDICARE [2001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","157.67","157.67","157.67","51","149.79","911.07","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","1146.00","859.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","418.29","36.5","","414.40","414.40","414.40","1 through 10","149.79","911.07","percent of total billed charges",""
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","1146.00","859.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","438.92","38.3","","434.40","434.40","434.40","1 through 10","149.79","911.07","percent of total billed charges",""
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","1146.00","859.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","154.52","154.52","154.52","1 through 10","149.79","911.07","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","1146.00","859.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","148.09","145.13","157.67","1 through 10","149.79","911.07","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","outpatient","","","1146.00","859.50","AETNA [1001]","HB AMC AETNA HMO","799.91","69.8","","752.15","531.06","866.58","1 through 10","336.65","936.51","percent of total billed charges",""
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","outpatient","","","1146.00","859.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","936.51","81.72","","888.13","888.13","888.13","1 through 10","336.65","936.51","percent of total billed charges",""
"Medium Chain Acyl Coa Dehydrogenase Deficiency","PX-31000641","CDM","81479","CPT","0310","RC","","","","both","","","1310.00","982.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1041.45","79.5","","0.65","0.65","0.65","1 through 10","406.1","1244.5","percent of total billed charges",""
"Medium Chain Acyl Coa Dehydrogenase Deficiency","PX-31000641","CDM","81479","CPT","0310","RC","","","","both","","","1310.00","982.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","698.23","53.3","","0.79","0.79","0.79","1 through 10","406.1","1244.5","percent of total billed charges",""
"Medium Chain Acyl Coa Dehydrogenase Deficiency","PX-31000641","CDM","81479","CPT","0310","RC","","","","outpatient","","","1310.00","982.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","655.00","50","","1.00","1.00","1.00","1 through 10","156.55","1080.75","percent of total billed charges",""
"Medium Chain Acyl Coa Dehydrogenase Deficiency","PX-31000641","CDM","81479","CPT","0310","RC","","","","outpatient","","","1310.00","982.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","687.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","1080.75","percent of total billed charges",""
"Mee Prothesis (L8509)","PX-27001343","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","483.00","362.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","241.50","50","","492.94","492.94","492.94","1 through 10","213.03","398.48","percent of total billed charges",""
"Mee Tep BS Advantage","PX-27002043","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","711.00","533.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","355.50","50","","492.94","492.94","492.94","1 through 10","213.03","586.58","percent of total billed charges",""
"Mee Tep BS Classic","PX-27002045","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","526.00","394.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","263.00","50","","492.94","492.94","492.94","1 through 10","213.03","433.95","percent of total billed charges",""
"Mee Tep BS Duckbill","PX-27002041","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","128.00","96.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","64.00","50","","492.94","492.94","492.94","1 through 10","64","267.2","percent of total billed charges",""
"Mee Tep BS Low Pressure","PX-27002040","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","181.00","135.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","90.50","50","","492.94","492.94","492.94","1 through 10","90.5","267.2","percent of total billed charges",""
"Mee Tep BS Low Pressure - Special Order","PX-27002042","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","268.00","201.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","134.00","50","","492.94","492.94","492.94","1 through 10","134","267.2","percent of total billed charges",""
"Mee Tep BS Special Order","PX-27002046","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","636.00","477.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","318.00","50","","492.94","492.94","492.94","1 through 10","213.03","524.7","percent of total billed charges",""
"Mee Tep Provox Activalve","PX-27002037","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","2725.00","2043.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1362.50","50","","492.94","492.94","492.94","1 through 10","213.03","2248.13","percent of total billed charges",""
"Mee Tep Provox II","PX-27002034","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","588.00","441.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","294.00","50","","492.94","492.94","492.94","1 through 10","213.03","485.1","percent of total billed charges",""
"Mee Tep Provox Nid","PX-27002039","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","217.00","162.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","108.50","50","","492.94","492.94","492.94","1 through 10","108.5","267.2","percent of total billed charges",""
"Mee Tep Provox Vega","PX-27002035","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","547.00","410.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.50","50","","492.94","492.94","492.94","1 through 10","213.03","451.28","percent of total billed charges",""
"Mee Tep Provox Vega Xtraseal","PX-27002036","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","632.00","474.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","316.00","50","","492.94","492.94","492.94","1 through 10","213.03","521.4","percent of total billed charges",""
"Mee Tep vs Dual Valve","PX-27002044","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","848.00","636.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","424.00","50","","492.94","492.94","492.94","1 through 10","213.03","699.6","percent of total billed charges",""
"Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use","PX-63601304","CDM","90619","CPT","0636","RC","","","","both","","","203.88","152.91","WELLPOINT [1015]","HB AMC WELLPOINT","150.42","73.78","","0.01","0.01","0.01","1 through 10","63.2","193.69","percent of total billed charges",""
"Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use","PX-63601304","CDM","90619","CPT","0636","RC","","","","outpatient","","","203.88","152.91","AETNA [1001]","HB AMC AETNA PPO","163.92","80.4","","0.01","0.01","0.01","1 through 10","0.01","168.2","percent of total billed charges",""
"Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use","PX-63601304","CDM","90619","CPT","0636","RC","","","","outpatient","","","203.88","152.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","142.51","69.9","","0.01","0.01","0.01","1 through 10","0.01","168.2","percent of total billed charges",""
"Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use","PX-63601304","CDM","90619","CPT","0636","RC","","","","outpatient","","","203.88","152.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.62","46.9","","0.01","0.01","0.01","1 through 10","0.01","168.2","percent of total billed charges",""
"Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use","PX-63601304","CDM","90619","CPT","0636","RC","","","","outpatient","","","203.88","152.91","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","101.94","50","","0.01","0.01","0.01","23","0.01","168.2","percent of total billed charges",""
"Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use","PX-63601304","CDM","90619","CPT","0636","RC","","","","outpatient","","","203.88","152.91","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","107.04","52.5","","0.01","0.01","0.02","1 through 10","0.01","168.2","percent of total billed charges",""
"Menacwy-Tt Conj Vacc Serogroups Acwy for Im Use","PX-63601304","CDM","90619","CPT","0636","RC","","","","outpatient","","","203.88","152.91","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.13","55","","0.01","0.01","0.02","1 through 10","0.01","168.2","percent of total billed charges",""
"Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use","PX-63600324","CDM","90734","CPT","0636","RC","","","","both","","","264.16","198.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","96.42","36.5","","98.53","98.53","98.53","1 through 10","81.89","250.95","percent of total billed charges",""
"Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use","PX-63600324","CDM","90734","CPT","0636","RC","","","","both","","","264.16","198.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","101.17","38.3","","103.29","103.29","301.14","1 through 10","81.89","250.95","percent of total billed charges",""
"Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use","PX-63600324","CDM","90734","CPT","0636","RC","","","","both","","","264.16","198.12","WELLPOINT [1015]","HB AMC WELLPOINT","194.90","73.78","","518.94","254.78","518.94","1 through 10","81.89","250.95","percent of total billed charges",""
"Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use","PX-63600324","CDM","90734","CPT","0636","RC","","","","outpatient","","","264.16","198.12","AETNA [1001]","HB AMC AETNA HMO","184.38","69.8","","178.84","178.84","178.84","1 through 10","123.89","405.7","percent of total billed charges",""
"Menacwyd/Menacwy-CRM Conj Vacc Grps Acwy Im Use","PX-63600324","CDM","90734","CPT","0636","RC","","","","outpatient","","","264.16","198.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","184.65","69.9","","122.57","122.57","122.57","1 through 10","123.89","405.7","percent of total billed charges",""
"Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im","PX-63601155","CDM","90620","CPT","0636","RC","","","","both","","","304.28","228.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","111.06","36.5","","113.50","96.46","218.47","1 through 10","94.33","289.07","percent of total billed charges",""
"Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im","PX-63601155","CDM","90620","CPT","0636","RC","","","","both","","","304.28","228.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","116.54","38.3","","118.97","115.63","118.97","12","94.33","289.07","percent of total billed charges",""
"Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im","PX-63601155","CDM","90620","CPT","0636","RC","","","","both","","","304.28","228.21","WELLPOINT [1015]","HB AMC WELLPOINT","224.50","73.78","","530.82","530.82","530.82","1 through 10","94.33","289.07","percent of total billed charges",""
"Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im","PX-63601155","CDM","90620","CPT","0636","RC","","","","outpatient","","","304.28","228.21","AETNA [1001]","HB AMC AETNA HMO","212.39","69.8","","145.45","145.45","145.45","1 through 10","142.71","577.05","percent of total billed charges",""
"Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im","PX-63601155","CDM","90620","CPT","0636","RC","","","","outpatient","","","304.28","228.21","AETNA [1001]","HB AMC AETNA PPO","244.64","80.4","","159.44","159.44","159.44","1 through 10","142.71","577.05","percent of total billed charges",""
"Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im","PX-63601155","CDM","90620","CPT","0636","RC","","","","outpatient","","","304.28","228.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","212.69","69.9","","210.87","210.87","210.87","1 through 10","142.71","577.05","percent of total billed charges",""
"Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im","PX-63601155","CDM","90620","CPT","0636","RC","","","","outpatient","","","304.28","228.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","142.71","46.9","","141.19","141.19","141.19","1 through 10","142.71","577.05","percent of total billed charges",""
"Menb-4c Recombnt Prot & Outer Memb Vesic Vacc Im","PX-63601155","CDM","90620","CPT","0636","RC","","","","outpatient","","","304.28","228.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","248.66","81.72","","535.67","535.67","535.67","1 through 10","142.71","577.05","percent of total billed charges",""
"Menstrual And Other Female Reproductive System Disorders With Cc/McC","760","MS-DRG","","","","","","","","inpatient","","","38566.14","28924.60","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12307.57","","Case rate ($12,307.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,443.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,087.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,250.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,117.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,063.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.69. The transfer capital threshold is the transfer adjustment factor * $810.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9123.86","9123.86","9123.86","1 through 10","9378.96","14873.6896","other","Inpatient DRG"
"Menstrual And Other Female Reproductive System Disorders With Cc/McC","760","MS-DRG","","","","","","","","inpatient","","","38566.14","28924.60","MEDICARE [2001]","HB BWH MEDICARE","12307.57","","Case rate ($12,307.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,443.42, add-ons for qualifying new technology services are included. If operating cost exceeds $57,087.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,250.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,117.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,063.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $810.69. The transfer capital threshold is the transfer adjustment factor * $810.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11911.38","11897.65","11915.04","1 through 10","9378.96","14873.6896","other","Inpatient DRG"
"Menstrual And Other Female Reproductive System Disorders Without Cc/McC","761","MS-DRG","","","","","","","","inpatient","","","33072.86","24804.64","MEDICARE [2001]","HB BWH MEDICARE","5584.00","","Case rate ($5,584). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,644.63, add-ons for qualifying new technology services are included. If operating cost exceeds $52,289.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,899.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,745.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,264.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $459.06. The transfer capital threshold is the transfer adjustment factor * $459.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7751.44","7751.44","7751.44","1 through 10","5472.32","8936.31","other","Inpatient Replacement Plans DRG"
"Menstrual And Other Female Reproductive System Disorders,MAJOR","532","DRG","","","","","","","","inpatient","","","48723.56","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","25339.17","","Standard inlier is a Case rate ($25,339.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,351, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,597.05) for the length of stay and the standard reimbursement.","25339.17","25339.17","25339.17","1 through 10","3972.01","40770.06","case rate",""
"Menstrual And Other Female Reproductive System Disorders,MINOR","532","DRG","","","","","","","","inpatient","","","27919.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","12852.31","","Standard inlier is a Case rate ($12,852.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $21,642, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,824.46) for the length of stay and the standard reimbursement.","12852.31","12852.31","12852.31","1 through 10","3972.01","40770.06","case rate",""
"Menstrual And Other Female Reproductive System Disorders,MINOR","532","DRG","","","","","","","","inpatient","","","27919.51","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9228.6242","","Fee schedule rate ($11,577.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9228.6242","9228.64","9228.64","1 through 10","3972.01","40770.06","case rate",""
"Menstrual And Other Female Reproductive System Disorders,MODERATE","532","DRG","","","","","","","","inpatient","","","25684.89","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","16112.29","","Standard inlier is a Case rate ($16,112.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,178, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,287.24) for the length of stay and the standard reimbursement.","16112.28","16112.28","16112.28","1 through 10","3972.01","40770.06","case rate",""
"Menstrual And Other Female Reproductive System Disorders,MODERATE","532","DRG","","","","","","","","inpatient","","","25684.89","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18114.55","","Standard inlier is a Case rate ($18,114.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,178, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,571.21) for the length of stay and the standard reimbursement.","18114.55","18114.55","18114.55","1 through 10","3972.01","40770.06","case rate",""
"Menstrual And Other Female Reproductive System Disorders,MODERATE","532","DRG","","","","","","","","inpatient","","","25684.89","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","5069.82","","Case rate ($5,605.56). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,035.56, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","3972.01","40770.06","case rate",""
"Menstrual And Other Female Reproductive System Disorders,MODERATE","532","DRG","","","","","","","","inpatient","","","25684.89","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18171.75","","Fee schedule rate ($18,171.75). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18171.75","18171.75","18171.75","1 through 10","3972.01","40770.06","case rate",""
"Mental Illness Diagnosis With O.R. Procedure,MINOR","740","DRG","","","","","","","","inpatient","","","158889.02","","MASSHEALTH [3001]","HB BWH MEDICAID","16744.80","","Case rate ($18,514.26). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,944.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31478.63","31478.63","31478.63","1 through 10","954.59","89784.55","case rate",""
"Mental Illness Diagnosis With O.R. Procedure,MINOR","740","DRG","","","","","","","","inpatient","","","158889.02","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38712.93","","Fee schedule rate ($38,712.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31947.21","31947.21","31947.21","1 through 10","954.59","89784.55","case rate",""
"Mental Illness Diagnosis With O.R. Procedure,MODERATE","740","DRG","","","","","","","","inpatient","","","134691.93","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","19800.63","","Case rate ($21,893). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,323, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18097.43","18097.43","18097.43","1 through 10","954.59","89784.55","case rate",""
"Mental Illness Diagnosis With O.R. Procedure,MODERATE","740","DRG","","","","","","","","inpatient","","","134691.93","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","45169.77","","Fee schedule rate ($45,169.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","45169.77","45169.77","45169.77","1 through 10","954.59","89784.55","case rate",""
"Meperidine Hydrochl /100 Mg","PX-63601077","CDM","J2175","HCPCS","0636","RC","","","","both","","","3.78","2.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1.45","38.3","","13.86","4.68","34.79","28","1.17","16.55","percent of total billed charges",""
"Meperidine Inj 100mg/Ml 1ml","PX-63600146","CDM","J2175","HCPCS","0636","RC","","","","both","","","3.78","2.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1.45","38.3","","13.86","4.68","34.79","28","1.17","16.55","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","152.68","102.43","458.04","1 through 10","15.93","190","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","both","","","200.00","150.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.60","53.3","","102.43","102.43","102.43","1 through 10","15.93","190","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","72.36","61.50","72.36","1 through 10","15.93","190","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","73.72","75.85","19","15.93","190","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","155.08","155.08","1 through 10","15.93","190","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","151.32","151.32","151.32","1 through 10","16.76","163.44","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA PPO","160.80","80.4","","151.32","151.32","151.32","1 through 10","16.76","163.44","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","163.44","81.72","","85.30","85.30","85.30","1 through 10","16.76","163.44","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","85.30","155.08","1 through 10","16.76","163.44","percent of total billed charges",""
"MESH ARC 0.6MM SM MATRIXNEURO CRANIOMAXILLOFACIAL TI CONTOUR CRESCENT EXTRA RIGID","SUP-ITM-10077383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1673.21","1254.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1330.20","79.5","","800.18","480.96","1887.97","195","518.7","1330.2","percent of total billed charges",""
"MESH ARC 0.6MM SM MATRIXNEURO CRANIOMAXILLOFACIAL TI CONTOUR CRESCENT EXTRA RIGID","SUP-ITM-10077383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1673.21","1254.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","891.82","53.3","","813.12","216.42","1444.50","81","518.7","1330.2","percent of total billed charges",""
"MESH ARC 0.6MM SM MATRIXNEURO CRANIOMAXILLOFACIAL TI CONTOUR CRESCENT EXTRA RIGID","SUP-ITM-10077383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1673.21","1254.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","518.70","31","","432.60","432.60","432.60","1 through 10","518.7","1330.2","percent of total billed charges",""
"MESH ARC 0.6MM SM MATRIXNEURO CRANIOMAXILLOFACIAL TI CONTOUR CRESCENT EXTRA RIGID","SUP-ITM-10077383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1673.21","1254.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","610.72","36.5","","148.37","54.89","631.39","94","518.7","1330.2","percent of total billed charges",""
"MESH ARC 0.6MM SM MATRIXNEURO CRANIOMAXILLOFACIAL TI CONTOUR CRESCENT EXTRA RIGID","SUP-ITM-10077383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1673.21","1254.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","640.84","38.3","","279.30","91.72","1116.77","266","518.7","1330.2","percent of total billed charges",""
"MESH ARC 0.6MM SM MATRIXNEURO CRANIOMAXILLOFACIAL TI CONTOUR CRESCENT EXTRA RIGID","SUP-ITM-10077383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1673.21","1254.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","717.81","42.9","","731.00","63.70","731.00","1 through 10","518.7","1330.2","percent of total billed charges",""
"MESH ARC 0.6MM SM MATRIXNEURO CRANIOMAXILLOFACIAL TI CONTOUR CRESCENT EXTRA RIGID","SUP-ITM-10077383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1673.21","1254.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","717.81","42.9","","384.74","384.74","384.74","1 through 10","518.7","1330.2","percent of total billed charges",""
"MESH ARC 0.6MM SM MATRIXNEURO CRANIOMAXILLOFACIAL TI CONTOUR CRESCENT EXTRA RIGID","SUP-ITM-10077383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1673.21","1254.91","WELLPOINT [1015]","HB AMC WELLPOINT","1234.49","73.78","","286.63","119.22","1107.45","105","518.7","1330.2","percent of total billed charges",""
"MESH ARC 0.6MM SM MATRIXNEURO CRANIOMAXILLOFACIAL TI CONTOUR CRESCENT EXTRA RIGID","SUP-ITM-10077383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1673.21","1254.91","AETNA [1001]","HB AMC AETNA HMO","1167.90","69.8","","675.31","184.75","1721.50","286","874.42","1367.35","percent of total billed charges",""
"MESH ARC 0.6MM SM MATRIXNEURO CRANIOMAXILLOFACIAL TI CONTOUR CRESCENT EXTRA RIGID","SUP-ITM-10077383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1673.21","1254.91","AETNA [1001]","HB AMC AETNA PPO","1345.26","80.4","","1261.44","103.12","1514.10","21","874.42","1367.35","percent of total billed charges",""
"MESH ARC 0.6MM SM MATRIXNEURO CRANIOMAXILLOFACIAL TI CONTOUR CRESCENT EXTRA RIGID","SUP-ITM-10077383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1673.21","1254.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1345.26","80.4","","1365.00","1365.00","1365.00","1 through 10","874.42","1367.35","percent of total billed charges",""
"MESH ARC 0.6MM SM MATRIXNEURO CRANIOMAXILLOFACIAL TI CONTOUR CRESCENT EXTRA RIGID","SUP-ITM-10077383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1673.21","1254.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1367.35","81.72","","5157.68","5157.68","5157.68","1 through 10","874.42","1367.35","percent of total billed charges",""
"MESH ARC 0.6MM SM MATRIXNEURO CRANIOMAXILLOFACIAL TI CONTOUR CRESCENT EXTRA RIGID","SUP-ITM-10077383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1673.21","1254.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1367.35","81.72","","431.26","71.26","1459.57","88","874.42","1367.35","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238430","CDM","C1781","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2793.00","70","","134.04","134.04","134.04","1 through 10","1236.9","3172.05","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238430","CDM","C1781","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3172.05","79.5","","948.87","198.19","1805.30","1 through 10","1236.9","3172.05","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238430","CDM","C1781","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2126.67","53.3","","462.00","170.45","3253.37","1 through 10","1236.9","3172.05","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238430","CDM","C1781","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1456.35","36.5","","245.50","107.19","1371.45","1 through 10","1236.9","3172.05","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238430","CDM","C1781","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1528.17","38.3","","200.79","72.79","355.81","22","1236.9","3172.05","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238430","CDM","C1781","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3072.30","77","","477.18","477.18","477.18","1 through 10","1236.9","3172.05","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238430","CDM","C1781","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1711.71","42.9","","1045.91","1045.91","1045.91","1 through 10","1236.9","3172.05","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238430","CDM","C1781","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","WELLPOINT [1015]","HB AMC WELLPOINT","2943.82","73.78","","1726.50","1726.50","1726.50","1 through 10","1236.9","3172.05","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238430","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","AETNA [1001]","HB AMC AETNA HMO","2785.02","69.8","","915.80","263.76","2881.00","1 through 10","2085.17","3260.63","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238430","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3260.63","81.72","","1531.57","410.52","8841.36","1 through 10","2085.17","3260.63","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238436","CDM","C1781","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3402.00","70","","134.04","134.04","134.04","1 through 10","1506.6","3863.7","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238436","CDM","C1781","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3863.70","79.5","","948.87","198.19","1805.30","1 through 10","1506.6","3863.7","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238436","CDM","C1781","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2590.38","53.3","","462.00","170.45","3253.37","1 through 10","1506.6","3863.7","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238436","CDM","C1781","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1773.90","36.5","","245.50","107.19","1371.45","1 through 10","1506.6","3863.7","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238436","CDM","C1781","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1861.38","38.3","","200.79","72.79","355.81","22","1506.6","3863.7","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238436","CDM","C1781","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3742.20","77","","477.18","477.18","477.18","1 through 10","1506.6","3863.7","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238436","CDM","C1781","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2084.94","42.9","","1045.91","1045.91","1045.91","1 through 10","1506.6","3863.7","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238436","CDM","C1781","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","WELLPOINT [1015]","HB AMC WELLPOINT","3585.71","73.78","","1726.50","1726.50","1726.50","1 through 10","1506.6","3863.7","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238436","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4860.00","3645.00","AETNA [1001]","HB AMC AETNA HMO","3392.28","69.8","","915.80","263.76","2881.00","1 through 10","2539.84","3971.59","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 12CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238436","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4860.00","3645.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3971.59","81.72","","1531.57","410.52","8841.36","1 through 10","2539.84","3971.59","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238431","CDM","C1781","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3325.00","70","","134.04","134.04","134.04","1 through 10","1472.5","3776.25","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238431","CDM","C1781","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3776.25","79.5","","948.87","198.19","1805.30","1 through 10","1472.5","3776.25","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238431","CDM","C1781","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2531.75","53.3","","462.00","170.45","3253.37","1 through 10","1472.5","3776.25","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238431","CDM","C1781","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1733.75","36.5","","245.50","107.19","1371.45","1 through 10","1472.5","3776.25","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238431","CDM","C1781","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1819.25","38.3","","200.79","72.79","355.81","22","1472.5","3776.25","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238431","CDM","C1781","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3657.50","77","","477.18","477.18","477.18","1 through 10","1472.5","3776.25","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238431","CDM","C1781","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2037.75","42.9","","1045.91","1045.91","1045.91","1 through 10","1472.5","3776.25","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238431","CDM","C1781","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","WELLPOINT [1015]","HB AMC WELLPOINT","3504.55","73.78","","1726.50","1726.50","1726.50","1 through 10","1472.5","3776.25","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238431","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4750.00","3562.50","AETNA [1001]","HB AMC AETNA HMO","3315.50","69.8","","915.80","263.76","2881.00","1 through 10","2482.35","3881.7","percent of total billed charges",""
"MESH BIOSCAFFOLD 10CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238431","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4750.00","3562.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3881.70","81.72","","1531.57","410.52","8841.36","1 through 10","2482.35","3881.7","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238432","CDM","C1781","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","5320.00","70","","134.04","134.04","134.04","1 through 10","2356","6042","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238432","CDM","C1781","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6042.00","79.5","","948.87","198.19","1805.30","1 through 10","2356","6042","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238432","CDM","C1781","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4050.80","53.3","","462.00","170.45","3253.37","1 through 10","2356","6042","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238432","CDM","C1781","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2774.00","36.5","","245.50","107.19","1371.45","1 through 10","2356","6042","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238432","CDM","C1781","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2910.80","38.3","","200.79","72.79","355.81","22","2356","6042","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238432","CDM","C1781","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","5852.00","77","","477.18","477.18","477.18","1 through 10","2356","6042","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238432","CDM","C1781","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3260.40","42.9","","1045.91","1045.91","1045.91","1 through 10","2356","6042","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238432","CDM","C1781","HCPCS","0278","RC","","","","both","","","7600.00","5700.00","WELLPOINT [1015]","HB AMC WELLPOINT","5607.28","73.78","","1726.50","1726.50","1726.50","1 through 10","2356","6042","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238432","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","7600.00","5700.00","AETNA [1001]","HB AMC AETNA HMO","5304.80","69.8","","915.80","263.76","2881.00","1 through 10","3971.76","6210.72","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT","SUP-ITM-10238432","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","7600.00","5700.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6210.72","81.72","","1531.57","410.52","8841.36","1 through 10","3971.76","6210.72","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238438","CDM","C1781","HCPCS","0278","RC","","","","both","","","12960.00","9720.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","9072.00","70","","134.04","134.04","134.04","1 through 10","4017.6","10303.2","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238438","CDM","C1781","HCPCS","0278","RC","","","","both","","","12960.00","9720.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10303.20","79.5","","948.87","198.19","1805.30","1 through 10","4017.6","10303.2","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238438","CDM","C1781","HCPCS","0278","RC","","","","both","","","12960.00","9720.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6907.68","53.3","","462.00","170.45","3253.37","1 through 10","4017.6","10303.2","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238438","CDM","C1781","HCPCS","0278","RC","","","","both","","","12960.00","9720.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4730.40","36.5","","245.50","107.19","1371.45","1 through 10","4017.6","10303.2","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238438","CDM","C1781","HCPCS","0278","RC","","","","both","","","12960.00","9720.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4963.68","38.3","","200.79","72.79","355.81","22","4017.6","10303.2","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238438","CDM","C1781","HCPCS","0278","RC","","","","both","","","12960.00","9720.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","9979.20","77","","477.18","477.18","477.18","1 through 10","4017.6","10303.2","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238438","CDM","C1781","HCPCS","0278","RC","","","","both","","","12960.00","9720.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5559.84","42.9","","1045.91","1045.91","1045.91","1 through 10","4017.6","10303.2","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238438","CDM","C1781","HCPCS","0278","RC","","","","both","","","12960.00","9720.00","WELLPOINT [1015]","HB AMC WELLPOINT","9561.89","73.78","","1726.50","1726.50","1726.50","1 through 10","4017.6","10303.2","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238438","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","12960.00","9720.00","AETNA [1001]","HB AMC AETNA HMO","9046.08","69.8","","915.80","263.76","2881.00","1 through 10","6772.9","10590.91","percent of total billed charges",""
"MESH BIOSCAFFOLD 16CM 20CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238438","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","12960.00","9720.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10590.91","81.72","","1531.57","410.52","8841.36","1 through 10","6772.9","10590.91","percent of total billed charges",""
"MESH BIOSCAFFOLD 18CM 22CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238439","CDM","C1781","HCPCS","0278","RC","","","","both","","","16037.50","12028.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","11226.25","70","","134.04","134.04","134.04","1 through 10","4971.63","12749.81","percent of total billed charges",""
"MESH BIOSCAFFOLD 18CM 22CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238439","CDM","C1781","HCPCS","0278","RC","","","","both","","","16037.50","12028.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12749.81","79.5","","948.87","198.19","1805.30","1 through 10","4971.63","12749.81","percent of total billed charges",""
"MESH BIOSCAFFOLD 18CM 22CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238439","CDM","C1781","HCPCS","0278","RC","","","","both","","","16037.50","12028.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8547.99","53.3","","462.00","170.45","3253.37","1 through 10","4971.63","12749.81","percent of total billed charges",""
"MESH BIOSCAFFOLD 18CM 22CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238439","CDM","C1781","HCPCS","0278","RC","","","","both","","","16037.50","12028.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5853.69","36.5","","245.50","107.19","1371.45","1 through 10","4971.63","12749.81","percent of total billed charges",""
"MESH BIOSCAFFOLD 18CM 22CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238439","CDM","C1781","HCPCS","0278","RC","","","","both","","","16037.50","12028.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6142.36","38.3","","200.79","72.79","355.81","22","4971.63","12749.81","percent of total billed charges",""
"MESH BIOSCAFFOLD 18CM 22CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238439","CDM","C1781","HCPCS","0278","RC","","","","both","","","16037.50","12028.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","12348.88","77","","477.18","477.18","477.18","1 through 10","4971.63","12749.81","percent of total billed charges",""
"MESH BIOSCAFFOLD 18CM 22CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238439","CDM","C1781","HCPCS","0278","RC","","","","both","","","16037.50","12028.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6880.09","42.9","","1045.91","1045.91","1045.91","1 through 10","4971.63","12749.81","percent of total billed charges",""
"MESH BIOSCAFFOLD 18CM 22CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238439","CDM","C1781","HCPCS","0278","RC","","","","both","","","16037.50","12028.12","WELLPOINT [1015]","HB AMC WELLPOINT","11832.47","73.78","","1726.50","1726.50","1726.50","1 through 10","4971.63","12749.81","percent of total billed charges",""
"MESH BIOSCAFFOLD 18CM 22CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238439","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","16037.50","12028.12","AETNA [1001]","HB AMC AETNA HMO","11194.18","69.8","","915.80","263.76","2881.00","1 through 10","8381.2","13105.85","percent of total billed charges",""
"MESH BIOSCAFFOLD 18CM 22CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238439","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","16037.50","12028.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13105.85","81.72","","1531.57","410.52","8841.36","1 through 10","8381.2","13105.85","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK PERMANENT 2S","SUP-ITM-10238445","CDM","C1781","HCPCS","0278","RC","","","","both","","","20400.00","15300.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","14280.00","70","","134.04","134.04","134.04","1 through 10","6324","16218","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK PERMANENT 2S","SUP-ITM-10238445","CDM","C1781","HCPCS","0278","RC","","","","both","","","20400.00","15300.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","16218.00","79.5","","948.87","198.19","1805.30","1 through 10","6324","16218","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK PERMANENT 2S","SUP-ITM-10238445","CDM","C1781","HCPCS","0278","RC","","","","both","","","20400.00","15300.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10873.20","53.3","","462.00","170.45","3253.37","1 through 10","6324","16218","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK PERMANENT 2S","SUP-ITM-10238445","CDM","C1781","HCPCS","0278","RC","","","","both","","","20400.00","15300.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7446.00","36.5","","245.50","107.19","1371.45","1 through 10","6324","16218","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK PERMANENT 2S","SUP-ITM-10238445","CDM","C1781","HCPCS","0278","RC","","","","both","","","20400.00","15300.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7813.20","38.3","","200.79","72.79","355.81","22","6324","16218","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK PERMANENT 2S","SUP-ITM-10238445","CDM","C1781","HCPCS","0278","RC","","","","both","","","20400.00","15300.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","15708.00","77","","477.18","477.18","477.18","1 through 10","6324","16218","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK PERMANENT 2S","SUP-ITM-10238445","CDM","C1781","HCPCS","0278","RC","","","","both","","","20400.00","15300.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8751.60","42.9","","1045.91","1045.91","1045.91","1 through 10","6324","16218","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK PERMANENT 2S","SUP-ITM-10238445","CDM","C1781","HCPCS","0278","RC","","","","both","","","20400.00","15300.00","WELLPOINT [1015]","HB AMC WELLPOINT","15051.12","73.78","","1726.50","1726.50","1726.50","1 through 10","6324","16218","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK PERMANENT 2S","SUP-ITM-10238445","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","20400.00","15300.00","AETNA [1001]","HB AMC AETNA HMO","14239.20","69.8","","915.80","263.76","2881.00","1 through 10","10661.04","16670.88","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK PERMANENT 2S","SUP-ITM-10238445","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","20400.00","15300.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16670.88","81.72","","1531.57","410.52","8841.36","1 through 10","10661.04","16670.88","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK RESORBABLE 1S","SUP-ITM-10238454","CDM","C1781","HCPCS","0278","RC","","","","both","","","16200.00","12150.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","11340.00","70","","134.04","134.04","134.04","1 through 10","5022","12879","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK RESORBABLE 1S","SUP-ITM-10238454","CDM","C1781","HCPCS","0278","RC","","","","both","","","16200.00","12150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12879.00","79.5","","948.87","198.19","1805.30","1 through 10","5022","12879","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK RESORBABLE 1S","SUP-ITM-10238454","CDM","C1781","HCPCS","0278","RC","","","","both","","","16200.00","12150.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8634.60","53.3","","462.00","170.45","3253.37","1 through 10","5022","12879","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK RESORBABLE 1S","SUP-ITM-10238454","CDM","C1781","HCPCS","0278","RC","","","","both","","","16200.00","12150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5913.00","36.5","","245.50","107.19","1371.45","1 through 10","5022","12879","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK RESORBABLE 1S","SUP-ITM-10238454","CDM","C1781","HCPCS","0278","RC","","","","both","","","16200.00","12150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6204.60","38.3","","200.79","72.79","355.81","22","5022","12879","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK RESORBABLE 1S","SUP-ITM-10238454","CDM","C1781","HCPCS","0278","RC","","","","both","","","16200.00","12150.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","12474.00","77","","477.18","477.18","477.18","1 through 10","5022","12879","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK RESORBABLE 1S","SUP-ITM-10238454","CDM","C1781","HCPCS","0278","RC","","","","both","","","16200.00","12150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6949.80","42.9","","1045.91","1045.91","1045.91","1 through 10","5022","12879","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK RESORBABLE 1S","SUP-ITM-10238454","CDM","C1781","HCPCS","0278","RC","","","","both","","","16200.00","12150.00","WELLPOINT [1015]","HB AMC WELLPOINT","11952.36","73.78","","1726.50","1726.50","1726.50","1 through 10","5022","12879","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK RESORBABLE 1S","SUP-ITM-10238454","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","16200.00","12150.00","AETNA [1001]","HB AMC AETNA HMO","11307.60","69.8","","915.80","263.76","2881.00","1 through 10","8466.12","13238.64","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 20CM REINFORCED OVITEK RESORBABLE 1S","SUP-ITM-10238454","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","16200.00","12150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13238.64","81.72","","1531.57","410.52","8841.36","1 through 10","8466.12","13238.64","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 30CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319432","CDM","C1781","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","11375.00","70","","134.04","134.04","134.04","1 through 10","5037.5","12918.75","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 30CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319432","CDM","C1781","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12918.75","79.5","","948.87","198.19","1805.30","1 through 10","5037.5","12918.75","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 30CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319432","CDM","C1781","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8661.25","53.3","","462.00","170.45","3253.37","1 through 10","5037.5","12918.75","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 30CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319432","CDM","C1781","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5931.25","36.5","","245.50","107.19","1371.45","1 through 10","5037.5","12918.75","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 30CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319432","CDM","C1781","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6223.75","38.3","","200.79","72.79","355.81","22","5037.5","12918.75","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 30CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319432","CDM","C1781","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","12512.50","77","","477.18","477.18","477.18","1 through 10","5037.5","12918.75","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 30CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319432","CDM","C1781","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6971.25","42.9","","1045.91","1045.91","1045.91","1 through 10","5037.5","12918.75","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 30CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319432","CDM","C1781","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","WELLPOINT [1015]","HB AMC WELLPOINT","11989.25","73.78","","1726.50","1726.50","1726.50","1 through 10","5037.5","12918.75","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 30CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319432","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","16250.00","12187.50","AETNA [1001]","HB AMC AETNA HMO","11342.50","69.8","","915.80","263.76","2881.00","1 through 10","8492.25","13279.5","percent of total billed charges",""
"MESH BIOSCAFFOLD 20CM 30CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319432","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","16250.00","12187.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13279.50","81.72","","1531.57","410.52","8841.36","1 through 10","8492.25","13279.5","percent of total billed charges",""
"MESH BIOSCAFFOLD 6CM 10CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238435","CDM","C1781","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2381.40","70","","134.04","134.04","134.04","1 through 10","1054.62","2704.59","percent of total billed charges",""
"MESH BIOSCAFFOLD 6CM 10CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238435","CDM","C1781","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2704.59","79.5","","948.87","198.19","1805.30","1 through 10","1054.62","2704.59","percent of total billed charges",""
"MESH BIOSCAFFOLD 6CM 10CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238435","CDM","C1781","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1813.27","53.3","","462.00","170.45","3253.37","1 through 10","1054.62","2704.59","percent of total billed charges",""
"MESH BIOSCAFFOLD 6CM 10CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238435","CDM","C1781","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1241.73","36.5","","245.50","107.19","1371.45","1 through 10","1054.62","2704.59","percent of total billed charges",""
"MESH BIOSCAFFOLD 6CM 10CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238435","CDM","C1781","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1302.97","38.3","","200.79","72.79","355.81","22","1054.62","2704.59","percent of total billed charges",""
"MESH BIOSCAFFOLD 6CM 10CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238435","CDM","C1781","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2619.54","77","","477.18","477.18","477.18","1 through 10","1054.62","2704.59","percent of total billed charges",""
"MESH BIOSCAFFOLD 6CM 10CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238435","CDM","C1781","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1459.46","42.9","","1045.91","1045.91","1045.91","1 through 10","1054.62","2704.59","percent of total billed charges",""
"MESH BIOSCAFFOLD 6CM 10CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238435","CDM","C1781","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","WELLPOINT [1015]","HB AMC WELLPOINT","2510.00","73.78","","1726.50","1726.50","1726.50","1 through 10","1054.62","2704.59","percent of total billed charges",""
"MESH BIOSCAFFOLD 6CM 10CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238435","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3402.00","2551.50","AETNA [1001]","HB AMC AETNA HMO","2374.60","69.8","","915.80","263.76","2881.00","1 through 10","1777.89","2780.11","percent of total billed charges",""
"MESH BIOSCAFFOLD 6CM 10CM REINFORCED OVITEK PERMANENT 1S","SUP-ITM-10238435","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3402.00","2551.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2780.11","81.72","","1531.57","410.52","8841.36","1 through 10","1777.89","2780.11","percent of total billed charges",""
"MESH BIOSCAFFOLD LPR 9CM 9CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319883","CDM","C1781","HCPCS","0278","RC","","","","both","","","4007.50","3005.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2805.25","70","","134.04","134.04","134.04","1 through 10","1242.33","3185.96","percent of total billed charges",""
"MESH BIOSCAFFOLD LPR 9CM 9CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319883","CDM","C1781","HCPCS","0278","RC","","","","both","","","4007.50","3005.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3185.96","79.5","","948.87","198.19","1805.30","1 through 10","1242.33","3185.96","percent of total billed charges",""
"MESH BIOSCAFFOLD LPR 9CM 9CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319883","CDM","C1781","HCPCS","0278","RC","","","","both","","","4007.50","3005.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2136.00","53.3","","462.00","170.45","3253.37","1 through 10","1242.33","3185.96","percent of total billed charges",""
"MESH BIOSCAFFOLD LPR 9CM 9CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319883","CDM","C1781","HCPCS","0278","RC","","","","both","","","4007.50","3005.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1462.74","36.5","","245.50","107.19","1371.45","1 through 10","1242.33","3185.96","percent of total billed charges",""
"MESH BIOSCAFFOLD LPR 9CM 9CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319883","CDM","C1781","HCPCS","0278","RC","","","","both","","","4007.50","3005.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1534.87","38.3","","200.79","72.79","355.81","22","1242.33","3185.96","percent of total billed charges",""
"MESH BIOSCAFFOLD LPR 9CM 9CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319883","CDM","C1781","HCPCS","0278","RC","","","","both","","","4007.50","3005.62","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3085.78","77","","477.18","477.18","477.18","1 through 10","1242.33","3185.96","percent of total billed charges",""
"MESH BIOSCAFFOLD LPR 9CM 9CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319883","CDM","C1781","HCPCS","0278","RC","","","","both","","","4007.50","3005.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1719.22","42.9","","1045.91","1045.91","1045.91","1 through 10","1242.33","3185.96","percent of total billed charges",""
"MESH BIOSCAFFOLD LPR 9CM 9CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319883","CDM","C1781","HCPCS","0278","RC","","","","both","","","4007.50","3005.62","WELLPOINT [1015]","HB AMC WELLPOINT","2956.73","73.78","","1726.50","1726.50","1726.50","1 through 10","1242.33","3185.96","percent of total billed charges",""
"MESH BIOSCAFFOLD LPR 9CM 9CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319883","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4007.50","3005.62","AETNA [1001]","HB AMC AETNA HMO","2797.24","69.8","","915.80","263.76","2881.00","1 through 10","2094.32","3274.93","percent of total billed charges",""
"MESH BIOSCAFFOLD LPR 9CM 9CM REINFORCED OVITEK PERMANENT","SUP-ITM-10319883","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4007.50","3005.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3274.93","81.72","","1531.57","410.52","8841.36","1 through 10","2094.32","3274.93","percent of total billed charges",""
"MESH FRONTAL 109MM DIAX78 CRANIAL MATRIXNEURO TI","SUP-ITM-10158753","CDM","C1713","HCPCS","0278","RC","","","","both","","","10862.50","8146.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8635.69","79.5","","800.18","480.96","1887.97","195","3367.38","8635.69","percent of total billed charges",""
"MESH FRONTAL 109MM DIAX78 CRANIAL MATRIXNEURO TI","SUP-ITM-10158753","CDM","C1713","HCPCS","0278","RC","","","","both","","","10862.50","8146.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5789.71","53.3","","813.12","216.42","1444.50","81","3367.38","8635.69","percent of total billed charges",""
"MESH FRONTAL 109MM DIAX78 CRANIAL MATRIXNEURO TI","SUP-ITM-10158753","CDM","C1713","HCPCS","0278","RC","","","","both","","","10862.50","8146.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3367.38","31","","432.60","432.60","432.60","1 through 10","3367.38","8635.69","percent of total billed charges",""
"MESH FRONTAL 109MM DIAX78 CRANIAL MATRIXNEURO TI","SUP-ITM-10158753","CDM","C1713","HCPCS","0278","RC","","","","both","","","10862.50","8146.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3964.81","36.5","","148.37","54.89","631.39","94","3367.38","8635.69","percent of total billed charges",""
"MESH FRONTAL 109MM DIAX78 CRANIAL MATRIXNEURO TI","SUP-ITM-10158753","CDM","C1713","HCPCS","0278","RC","","","","both","","","10862.50","8146.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4160.34","38.3","","279.30","91.72","1116.77","266","3367.38","8635.69","percent of total billed charges",""
"MESH FRONTAL 109MM DIAX78 CRANIAL MATRIXNEURO TI","SUP-ITM-10158753","CDM","C1713","HCPCS","0278","RC","","","","both","","","10862.50","8146.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4660.01","42.9","","731.00","63.70","731.00","1 through 10","3367.38","8635.69","percent of total billed charges",""
"MESH FRONTAL 109MM DIAX78 CRANIAL MATRIXNEURO TI","SUP-ITM-10158753","CDM","C1713","HCPCS","0278","RC","","","","both","","","10862.50","8146.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4660.01","42.9","","384.74","384.74","384.74","1 through 10","3367.38","8635.69","percent of total billed charges",""
"MESH FRONTAL 109MM DIAX78 CRANIAL MATRIXNEURO TI","SUP-ITM-10158753","CDM","C1713","HCPCS","0278","RC","","","","both","","","10862.50","8146.87","WELLPOINT [1015]","HB AMC WELLPOINT","8014.35","73.78","","286.63","119.22","1107.45","105","3367.38","8635.69","percent of total billed charges",""
"MESH FRONTAL 109MM DIAX78 CRANIAL MATRIXNEURO TI","SUP-ITM-10158753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10862.50","8146.87","AETNA [1001]","HB AMC AETNA HMO","7582.03","69.8","","675.31","184.75","1721.50","286","5676.74","8876.84","percent of total billed charges",""
"MESH FRONTAL 109MM DIAX78 CRANIAL MATRIXNEURO TI","SUP-ITM-10158753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10862.50","8146.87","AETNA [1001]","HB AMC AETNA PPO","8733.45","80.4","","1261.44","103.12","1514.10","21","5676.74","8876.84","percent of total billed charges",""
"MESH FRONTAL 109MM DIAX78 CRANIAL MATRIXNEURO TI","SUP-ITM-10158753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10862.50","8146.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8733.45","80.4","","1365.00","1365.00","1365.00","1 through 10","5676.74","8876.84","percent of total billed charges",""
"MESH FRONTAL 109MM DIAX78 CRANIAL MATRIXNEURO TI","SUP-ITM-10158753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10862.50","8146.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8876.84","81.72","","5157.68","5157.68","5157.68","1 through 10","5676.74","8876.84","percent of total billed charges",""
"MESH FRONTAL 109MM DIAX78 CRANIAL MATRIXNEURO TI","SUP-ITM-10158753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10862.50","8146.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8876.84","81.72","","431.26","71.26","1459.57","88","5676.74","8876.84","percent of total billed charges",""
"MESH FRONTOTEMPORAL 151MM DIAX125 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158751","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10440.34","79.5","","800.18","480.96","1887.97","195","4071.08","10440.34","percent of total billed charges",""
"MESH FRONTOTEMPORAL 151MM DIAX125 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158751","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6999.62","53.3","","813.12","216.42","1444.50","81","4071.08","10440.34","percent of total billed charges",""
"MESH FRONTOTEMPORAL 151MM DIAX125 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158751","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4071.08","31","","432.60","432.60","432.60","1 through 10","4071.08","10440.34","percent of total billed charges",""
"MESH FRONTOTEMPORAL 151MM DIAX125 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158751","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4793.36","36.5","","148.37","54.89","631.39","94","4071.08","10440.34","percent of total billed charges",""
"MESH FRONTOTEMPORAL 151MM DIAX125 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158751","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5029.75","38.3","","279.30","91.72","1116.77","266","4071.08","10440.34","percent of total billed charges",""
"MESH FRONTOTEMPORAL 151MM DIAX125 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158751","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5633.84","42.9","","731.00","63.70","731.00","1 through 10","4071.08","10440.34","percent of total billed charges",""
"MESH FRONTOTEMPORAL 151MM DIAX125 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158751","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5633.84","42.9","","384.74","384.74","384.74","1 through 10","4071.08","10440.34","percent of total billed charges",""
"MESH FRONTOTEMPORAL 151MM DIAX125 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158751","CDM","C1713","HCPCS","0278","RC","","","","both","","","13132.50","9849.37","WELLPOINT [1015]","HB AMC WELLPOINT","9689.16","73.78","","286.63","119.22","1107.45","105","4071.08","10440.34","percent of total billed charges",""
"MESH FRONTOTEMPORAL 151MM DIAX125 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","AETNA [1001]","HB AMC AETNA HMO","9166.49","69.8","","675.31","184.75","1721.50","286","6863.04","10731.88","percent of total billed charges",""
"MESH FRONTOTEMPORAL 151MM DIAX125 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","AETNA [1001]","HB AMC AETNA PPO","10558.53","80.4","","1261.44","103.12","1514.10","21","6863.04","10731.88","percent of total billed charges",""
"MESH FRONTOTEMPORAL 151MM DIAX125 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10558.53","80.4","","1365.00","1365.00","1365.00","1 through 10","6863.04","10731.88","percent of total billed charges",""
"MESH FRONTOTEMPORAL 151MM DIAX125 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","10731.88","81.72","","5157.68","5157.68","5157.68","1 through 10","6863.04","10731.88","percent of total billed charges",""
"MESH FRONTOTEMPORAL 151MM DIAX125 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13132.50","9849.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10731.88","81.72","","431.26","71.26","1459.57","88","6863.04","10731.88","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2388.75","70","","134.04","134.04","134.04","1 through 10","1057.88","2712.94","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2712.94","79.5","","948.87","198.19","1805.30","1 through 10","1057.88","2712.94","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1818.86","53.3","","462.00","170.45","3253.37","1 through 10","1057.88","2712.94","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1245.56","36.5","","245.50","107.19","1371.45","1 through 10","1057.88","2712.94","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1306.99","38.3","","200.79","72.79","355.81","22","1057.88","2712.94","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2627.63","77","","477.18","477.18","477.18","1 through 10","1057.88","2712.94","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1463.96","42.9","","1045.91","1045.91","1045.91","1 through 10","1057.88","2712.94","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","WELLPOINT [1015]","HB AMC WELLPOINT","2517.74","73.78","","1726.50","1726.50","1726.50","1 through 10","1057.88","2712.94","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3412.50","2559.37","AETNA [1001]","HB AMC AETNA HMO","2381.93","69.8","","915.80","263.76","2881.00","1 through 10","1783.37","2788.7","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3412.50","2559.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2788.70","81.72","","1531.57","410.52","8841.36","1 through 10","1783.37","2788.7","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","770.89","578.17","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","539.62","70","","134.04","134.04","134.04","1 through 10","238.98","612.86","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","770.89","578.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","612.86","79.5","","948.87","198.19","1805.30","1 through 10","238.98","612.86","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","770.89","578.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","410.88","53.3","","462.00","170.45","3253.37","1 through 10","238.98","612.86","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","770.89","578.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","281.37","36.5","","245.50","107.19","1371.45","1 through 10","238.98","612.86","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","770.89","578.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","295.25","38.3","","200.79","72.79","355.81","22","238.98","612.86","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","770.89","578.17","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","593.59","77","","477.18","477.18","477.18","1 through 10","238.98","612.86","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","770.89","578.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","330.71","42.9","","1045.91","1045.91","1045.91","1 through 10","238.98","612.86","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","770.89","578.17","WELLPOINT [1015]","HB AMC WELLPOINT","568.76","73.78","","1726.50","1726.50","1726.50","1 through 10","238.98","612.86","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","770.89","578.17","AETNA [1001]","HB AMC AETNA HMO","538.08","69.8","","915.80","263.76","2881.00","1 through 10","402.87","629.97","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","770.89","578.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","629.97","81.72","","1531.57","410.52","8841.36","1 through 10","402.87","629.97","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","both","","","778.00","583.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","544.60","70","","134.04","134.04","134.04","1 through 10","241.18","618.51","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","both","","","778.00","583.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","618.51","79.5","","948.87","198.19","1805.30","1 through 10","241.18","618.51","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","both","","","778.00","583.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","414.67","53.3","","462.00","170.45","3253.37","1 through 10","241.18","618.51","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","both","","","778.00","583.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","283.97","36.5","","245.50","107.19","1371.45","1 through 10","241.18","618.51","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","both","","","778.00","583.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","297.97","38.3","","200.79","72.79","355.81","22","241.18","618.51","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","both","","","778.00","583.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","599.06","77","","477.18","477.18","477.18","1 through 10","241.18","618.51","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","both","","","778.00","583.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.76","42.9","","1045.91","1045.91","1045.91","1 through 10","241.18","618.51","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","both","","","778.00","583.50","WELLPOINT [1015]","HB AMC WELLPOINT","574.01","73.78","","1726.50","1726.50","1726.50","1 through 10","241.18","618.51","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","778.00","583.50","AETNA [1001]","HB AMC AETNA HMO","543.04","69.8","","915.80","263.76","2881.00","1 through 10","406.58","635.78","percent of total billed charges",""
"MESH GRAFT 1.6X1.9IN 4.1 4.8CM LG PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003519","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","778.00","583.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","635.78","81.72","","1531.57","410.52","8841.36","1 through 10","406.58","635.78","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","both","","","1302.00","976.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","911.40","70","","134.04","134.04","134.04","1 through 10","403.62","1035.09","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","both","","","1302.00","976.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1035.09","79.5","","948.87","198.19","1805.30","1 through 10","403.62","1035.09","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","both","","","1302.00","976.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","693.97","53.3","","462.00","170.45","3253.37","1 through 10","403.62","1035.09","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","both","","","1302.00","976.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","475.23","36.5","","245.50","107.19","1371.45","1 through 10","403.62","1035.09","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","both","","","1302.00","976.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","498.67","38.3","","200.79","72.79","355.81","22","403.62","1035.09","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","both","","","1302.00","976.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1002.54","77","","477.18","477.18","477.18","1 through 10","403.62","1035.09","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","both","","","1302.00","976.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","558.56","42.9","","1045.91","1045.91","1045.91","1 through 10","403.62","1035.09","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","both","","","1302.00","976.50","WELLPOINT [1015]","HB AMC WELLPOINT","960.62","73.78","","1726.50","1726.50","1726.50","1 through 10","403.62","1035.09","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1302.00","976.50","AETNA [1001]","HB AMC AETNA HMO","908.80","69.8","","915.80","263.76","2881.00","1 through 10","680.43","1063.99","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1302.00","976.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1063.99","81.72","","1531.57","410.52","8841.36","1 through 10","680.43","1063.99","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1540.32","1155.24","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1078.22","70","","134.04","134.04","134.04","1 through 10","477.5","1224.55","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1540.32","1155.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1224.55","79.5","","948.87","198.19","1805.30","1 through 10","477.5","1224.55","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1540.32","1155.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","820.99","53.3","","462.00","170.45","3253.37","1 through 10","477.5","1224.55","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1540.32","1155.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","562.22","36.5","","245.50","107.19","1371.45","1 through 10","477.5","1224.55","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1540.32","1155.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","589.94","38.3","","200.79","72.79","355.81","22","477.5","1224.55","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1540.32","1155.24","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1186.05","77","","477.18","477.18","477.18","1 through 10","477.5","1224.55","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1540.32","1155.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","660.80","42.9","","1045.91","1045.91","1045.91","1 through 10","477.5","1224.55","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1540.32","1155.24","WELLPOINT [1015]","HB AMC WELLPOINT","1136.45","73.78","","1726.50","1726.50","1726.50","1 through 10","477.5","1224.55","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1540.32","1155.24","AETNA [1001]","HB AMC AETNA HMO","1075.14","69.8","","915.80","263.76","2881.00","1 through 10","804.97","1258.75","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1540.32","1155.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1258.75","81.72","","1531.57","410.52","8841.36","1 through 10","804.97","1258.75","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1205.68","904.26","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","843.98","70","","134.04","134.04","134.04","1 through 10","373.76","958.52","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1205.68","904.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","958.52","79.5","","948.87","198.19","1805.30","1 through 10","373.76","958.52","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1205.68","904.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","642.63","53.3","","462.00","170.45","3253.37","1 through 10","373.76","958.52","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1205.68","904.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","440.07","36.5","","245.50","107.19","1371.45","1 through 10","373.76","958.52","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1205.68","904.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","461.78","38.3","","200.79","72.79","355.81","22","373.76","958.52","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1205.68","904.26","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","928.37","77","","477.18","477.18","477.18","1 through 10","373.76","958.52","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1205.68","904.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","517.24","42.9","","1045.91","1045.91","1045.91","1 through 10","373.76","958.52","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1205.68","904.26","WELLPOINT [1015]","HB AMC WELLPOINT","889.55","73.78","","1726.50","1726.50","1726.50","1 through 10","373.76","958.52","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1205.68","904.26","AETNA [1001]","HB AMC AETNA HMO","841.56","69.8","","915.80","263.76","2881.00","1 through 10","630.09","985.28","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1205.68","904.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","985.28","81.72","","1531.57","410.52","8841.36","1 through 10","630.09","985.28","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","both","","","41500.00","31125.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","29050.00","70","","134.04","134.04","134.04","1 through 10","12865","32992.5","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","both","","","41500.00","31125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","32992.50","79.5","","948.87","198.19","1805.30","1 through 10","12865","32992.5","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","both","","","41500.00","31125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22119.50","53.3","","462.00","170.45","3253.37","1 through 10","12865","32992.5","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","both","","","41500.00","31125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15147.50","36.5","","245.50","107.19","1371.45","1 through 10","12865","32992.5","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","both","","","41500.00","31125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15894.50","38.3","","200.79","72.79","355.81","22","12865","32992.5","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","both","","","41500.00","31125.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","31955.00","77","","477.18","477.18","477.18","1 through 10","12865","32992.5","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","both","","","41500.00","31125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17803.50","42.9","","1045.91","1045.91","1045.91","1 through 10","12865","32992.5","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","both","","","41500.00","31125.00","WELLPOINT [1015]","HB AMC WELLPOINT","30618.70","73.78","","1726.50","1726.50","1726.50","1 through 10","12865","32992.5","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","41500.00","31125.00","AETNA [1001]","HB AMC AETNA HMO","28967.00","69.8","","915.80","263.76","2881.00","1 through 10","21687.9","33913.8","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","41500.00","31125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","33913.80","81.72","","1531.57","410.52","8841.36","1 through 10","21687.9","33913.8","percent of total billed charges",""
"MESH GRAFT 20CM TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE CA/1EA","SUP-ITM-10107408","CDM","C1781","HCPCS","0278","RC","","","","both","","","32125.00","24093.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","22487.50","70","","134.04","134.04","134.04","1 through 10","9958.75","25539.38","percent of total billed charges",""
"MESH GRAFT 20CM TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE CA/1EA","SUP-ITM-10107408","CDM","C1781","HCPCS","0278","RC","","","","both","","","32125.00","24093.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","25539.38","79.5","","948.87","198.19","1805.30","1 through 10","9958.75","25539.38","percent of total billed charges",""
"MESH GRAFT 20CM TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE CA/1EA","SUP-ITM-10107408","CDM","C1781","HCPCS","0278","RC","","","","both","","","32125.00","24093.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","17122.63","53.3","","462.00","170.45","3253.37","1 through 10","9958.75","25539.38","percent of total billed charges",""
"MESH GRAFT 20CM TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE CA/1EA","SUP-ITM-10107408","CDM","C1781","HCPCS","0278","RC","","","","both","","","32125.00","24093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11725.63","36.5","","245.50","107.19","1371.45","1 through 10","9958.75","25539.38","percent of total billed charges",""
"MESH GRAFT 20CM TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE CA/1EA","SUP-ITM-10107408","CDM","C1781","HCPCS","0278","RC","","","","both","","","32125.00","24093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12303.88","38.3","","200.79","72.79","355.81","22","9958.75","25539.38","percent of total billed charges",""
"MESH GRAFT 20CM TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE CA/1EA","SUP-ITM-10107408","CDM","C1781","HCPCS","0278","RC","","","","both","","","32125.00","24093.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","24736.25","77","","477.18","477.18","477.18","1 through 10","9958.75","25539.38","percent of total billed charges",""
"MESH GRAFT 20CM TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE CA/1EA","SUP-ITM-10107408","CDM","C1781","HCPCS","0278","RC","","","","both","","","32125.00","24093.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13781.63","42.9","","1045.91","1045.91","1045.91","1 through 10","9958.75","25539.38","percent of total billed charges",""
"MESH GRAFT 20CM TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE CA/1EA","SUP-ITM-10107408","CDM","C1781","HCPCS","0278","RC","","","","both","","","32125.00","24093.75","WELLPOINT [1015]","HB AMC WELLPOINT","23701.83","73.78","","1726.50","1726.50","1726.50","1 through 10","9958.75","25539.38","percent of total billed charges",""
"MESH GRAFT 20CM TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE CA/1EA","SUP-ITM-10107408","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","32125.00","24093.75","AETNA [1001]","HB AMC AETNA HMO","22423.25","69.8","","915.80","263.76","2881.00","1 through 10","16788.53","26252.55","percent of total billed charges",""
"MESH GRAFT 20CM TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE CA/1EA","SUP-ITM-10107408","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","32125.00","24093.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","26252.55","81.72","","1531.57","410.52","8841.36","1 through 10","16788.53","26252.55","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2842.00","70","","134.04","134.04","134.04","1 through 10","1258.6","3227.7","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3227.70","79.5","","948.87","198.19","1805.30","1 through 10","1258.6","3227.7","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2163.98","53.3","","462.00","170.45","3253.37","1 through 10","1258.6","3227.7","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1481.90","36.5","","245.50","107.19","1371.45","1 through 10","1258.6","3227.7","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1554.98","38.3","","200.79","72.79","355.81","22","1258.6","3227.7","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3126.20","77","","477.18","477.18","477.18","1 through 10","1258.6","3227.7","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1741.74","42.9","","1045.91","1045.91","1045.91","1 through 10","1258.6","3227.7","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","WELLPOINT [1015]","HB AMC WELLPOINT","2995.47","73.78","","1726.50","1726.50","1726.50","1 through 10","1258.6","3227.7","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4060.00","3045.00","AETNA [1001]","HB AMC AETNA HMO","2833.88","69.8","","915.80","263.76","2881.00","1 through 10","2121.76","3317.83","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4060.00","3045.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3317.83","81.72","","1531.57","410.52","8841.36","1 through 10","2121.76","3317.83","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","5025.00","3768.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3517.50","70","","134.04","134.04","134.04","1 through 10","1557.75","3994.88","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","5025.00","3768.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3994.88","79.5","","948.87","198.19","1805.30","1 through 10","1557.75","3994.88","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","5025.00","3768.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2678.33","53.3","","462.00","170.45","3253.37","1 through 10","1557.75","3994.88","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","5025.00","3768.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1834.13","36.5","","245.50","107.19","1371.45","1 through 10","1557.75","3994.88","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","5025.00","3768.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1924.58","38.3","","200.79","72.79","355.81","22","1557.75","3994.88","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","5025.00","3768.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3869.25","77","","477.18","477.18","477.18","1 through 10","1557.75","3994.88","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","5025.00","3768.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2155.73","42.9","","1045.91","1045.91","1045.91","1 through 10","1557.75","3994.88","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","5025.00","3768.75","WELLPOINT [1015]","HB AMC WELLPOINT","3707.45","73.78","","1726.50","1726.50","1726.50","1 through 10","1557.75","3994.88","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5025.00","3768.75","AETNA [1001]","HB AMC AETNA HMO","3507.45","69.8","","915.80","263.76","2881.00","1 through 10","2626.07","4106.43","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5025.00","3768.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4106.43","81.72","","1531.57","410.52","8841.36","1 through 10","2626.07","4106.43","percent of total billed charges",""
"MESH GRAFT 25X20MM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED HERNIA","SUP-ITM-10012847","CDM","C1781","HCPCS","0278","RC","","","","both","","","2869.20","2151.90","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2008.44","70","","134.04","134.04","134.04","1 through 10","889.45","2281.01","percent of total billed charges",""
"MESH GRAFT 25X20MM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED HERNIA","SUP-ITM-10012847","CDM","C1781","HCPCS","0278","RC","","","","both","","","2869.20","2151.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2281.01","79.5","","948.87","198.19","1805.30","1 through 10","889.45","2281.01","percent of total billed charges",""
"MESH GRAFT 25X20MM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED HERNIA","SUP-ITM-10012847","CDM","C1781","HCPCS","0278","RC","","","","both","","","2869.20","2151.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1529.28","53.3","","462.00","170.45","3253.37","1 through 10","889.45","2281.01","percent of total billed charges",""
"MESH GRAFT 25X20MM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED HERNIA","SUP-ITM-10012847","CDM","C1781","HCPCS","0278","RC","","","","both","","","2869.20","2151.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1047.26","36.5","","245.50","107.19","1371.45","1 through 10","889.45","2281.01","percent of total billed charges",""
"MESH GRAFT 25X20MM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED HERNIA","SUP-ITM-10012847","CDM","C1781","HCPCS","0278","RC","","","","both","","","2869.20","2151.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1098.90","38.3","","200.79","72.79","355.81","22","889.45","2281.01","percent of total billed charges",""
"MESH GRAFT 25X20MM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED HERNIA","SUP-ITM-10012847","CDM","C1781","HCPCS","0278","RC","","","","both","","","2869.20","2151.90","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2209.28","77","","477.18","477.18","477.18","1 through 10","889.45","2281.01","percent of total billed charges",""
"MESH GRAFT 25X20MM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED HERNIA","SUP-ITM-10012847","CDM","C1781","HCPCS","0278","RC","","","","both","","","2869.20","2151.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1230.89","42.9","","1045.91","1045.91","1045.91","1 through 10","889.45","2281.01","percent of total billed charges",""
"MESH GRAFT 25X20MM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED HERNIA","SUP-ITM-10012847","CDM","C1781","HCPCS","0278","RC","","","","both","","","2869.20","2151.90","WELLPOINT [1015]","HB AMC WELLPOINT","2116.90","73.78","","1726.50","1726.50","1726.50","1 through 10","889.45","2281.01","percent of total billed charges",""
"MESH GRAFT 25X20MM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED HERNIA","SUP-ITM-10012847","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2869.20","2151.90","AETNA [1001]","HB AMC AETNA HMO","2002.70","69.8","","915.80","263.76","2881.00","1 through 10","1499.44","2344.71","percent of total billed charges",""
"MESH GRAFT 25X20MM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED HERNIA","SUP-ITM-10012847","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2869.20","2151.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2344.71","81.72","","1531.57","410.52","8841.36","1 through 10","1499.44","2344.71","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","6225.00","4668.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4357.50","70","","134.04","134.04","134.04","1 through 10","1929.75","4948.88","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","6225.00","4668.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4948.88","79.5","","948.87","198.19","1805.30","1 through 10","1929.75","4948.88","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","6225.00","4668.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3317.93","53.3","","462.00","170.45","3253.37","1 through 10","1929.75","4948.88","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","6225.00","4668.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2272.13","36.5","","245.50","107.19","1371.45","1 through 10","1929.75","4948.88","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","6225.00","4668.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2384.18","38.3","","200.79","72.79","355.81","22","1929.75","4948.88","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","6225.00","4668.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4793.25","77","","477.18","477.18","477.18","1 through 10","1929.75","4948.88","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","6225.00","4668.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2670.53","42.9","","1045.91","1045.91","1045.91","1 through 10","1929.75","4948.88","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","6225.00","4668.75","WELLPOINT [1015]","HB AMC WELLPOINT","4592.81","73.78","","1726.50","1726.50","1726.50","1 through 10","1929.75","4948.88","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6225.00","4668.75","AETNA [1001]","HB AMC AETNA HMO","4345.05","69.8","","915.80","263.76","2881.00","1 through 10","3253.19","5087.07","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6225.00","4668.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5087.07","81.72","","1531.57","410.52","8841.36","1 through 10","3253.19","5087.07","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","both","","","1802.50","1351.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1261.75","70","","134.04","134.04","134.04","1 through 10","558.78","1432.99","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","both","","","1802.50","1351.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1432.99","79.5","","948.87","198.19","1805.30","1 through 10","558.78","1432.99","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","both","","","1802.50","1351.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","960.73","53.3","","462.00","170.45","3253.37","1 through 10","558.78","1432.99","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","both","","","1802.50","1351.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","657.91","36.5","","245.50","107.19","1371.45","1 through 10","558.78","1432.99","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","both","","","1802.50","1351.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","690.36","38.3","","200.79","72.79","355.81","22","558.78","1432.99","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","both","","","1802.50","1351.87","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1387.93","77","","477.18","477.18","477.18","1 through 10","558.78","1432.99","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","both","","","1802.50","1351.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","773.27","42.9","","1045.91","1045.91","1045.91","1 through 10","558.78","1432.99","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","both","","","1802.50","1351.87","WELLPOINT [1015]","HB AMC WELLPOINT","1329.88","73.78","","1726.50","1726.50","1726.50","1 through 10","558.78","1432.99","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1802.50","1351.87","AETNA [1001]","HB AMC AETNA HMO","1258.15","69.8","","915.80","263.76","2881.00","1 through 10","941.99","1473","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1802.50","1351.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1473.00","81.72","","1531.57","410.52","8841.36","1 through 10","941.99","1473","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","858.10","643.57","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","600.67","70","","134.04","134.04","134.04","1 through 10","266.01","682.19","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","858.10","643.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","682.19","79.5","","948.87","198.19","1805.30","1 through 10","266.01","682.19","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","858.10","643.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","457.37","53.3","","462.00","170.45","3253.37","1 through 10","266.01","682.19","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","858.10","643.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","313.21","36.5","","245.50","107.19","1371.45","1 through 10","266.01","682.19","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","858.10","643.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","328.65","38.3","","200.79","72.79","355.81","22","266.01","682.19","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","858.10","643.57","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","660.74","77","","477.18","477.18","477.18","1 through 10","266.01","682.19","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","858.10","643.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","368.12","42.9","","1045.91","1045.91","1045.91","1 through 10","266.01","682.19","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","858.10","643.57","WELLPOINT [1015]","HB AMC WELLPOINT","633.11","73.78","","1726.50","1726.50","1726.50","1 through 10","266.01","682.19","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","858.10","643.57","AETNA [1001]","HB AMC AETNA HMO","598.95","69.8","","915.80","263.76","2881.00","1 through 10","448.44","701.24","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","858.10","643.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","701.24","81.72","","1531.57","410.52","8841.36","1 through 10","448.44","701.24","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1176.81","882.61","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","823.77","70","","134.04","134.04","134.04","1 through 10","364.81","935.56","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1176.81","882.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","935.56","79.5","","948.87","198.19","1805.30","1 through 10","364.81","935.56","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1176.81","882.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","627.24","53.3","","462.00","170.45","3253.37","1 through 10","364.81","935.56","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1176.81","882.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","429.54","36.5","","245.50","107.19","1371.45","1 through 10","364.81","935.56","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1176.81","882.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","450.72","38.3","","200.79","72.79","355.81","22","364.81","935.56","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1176.81","882.61","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","906.14","77","","477.18","477.18","477.18","1 through 10","364.81","935.56","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1176.81","882.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","504.85","42.9","","1045.91","1045.91","1045.91","1 through 10","364.81","935.56","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1176.81","882.61","WELLPOINT [1015]","HB AMC WELLPOINT","868.25","73.78","","1726.50","1726.50","1726.50","1 through 10","364.81","935.56","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1176.81","882.61","AETNA [1001]","HB AMC AETNA HMO","821.41","69.8","","915.80","263.76","2881.00","1 through 10","615","961.69","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1176.81","882.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","961.69","81.72","","1531.57","410.52","8841.36","1 through 10","615","961.69","percent of total billed charges",""
"MESH HERNIA 2.0MMX10 15CM DUAL BIOMATERIAL OVAL","SUP-ITM-10005093","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2315.25","70","","134.04","134.04","134.04","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH HERNIA 2.0MMX10 15CM DUAL BIOMATERIAL OVAL","SUP-ITM-10005093","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2629.46","79.5","","948.87","198.19","1805.30","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH HERNIA 2.0MMX10 15CM DUAL BIOMATERIAL OVAL","SUP-ITM-10005093","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1762.90","53.3","","462.00","170.45","3253.37","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH HERNIA 2.0MMX10 15CM DUAL BIOMATERIAL OVAL","SUP-ITM-10005093","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1207.24","36.5","","245.50","107.19","1371.45","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH HERNIA 2.0MMX10 15CM DUAL BIOMATERIAL OVAL","SUP-ITM-10005093","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1266.77","38.3","","200.79","72.79","355.81","22","1025.33","2629.46","percent of total billed charges",""
"MESH HERNIA 2.0MMX10 15CM DUAL BIOMATERIAL OVAL","SUP-ITM-10005093","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2546.78","77","","477.18","477.18","477.18","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH HERNIA 2.0MMX10 15CM DUAL BIOMATERIAL OVAL","SUP-ITM-10005093","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1418.92","42.9","","1045.91","1045.91","1045.91","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH HERNIA 2.0MMX10 15CM DUAL BIOMATERIAL OVAL","SUP-ITM-10005093","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","WELLPOINT [1015]","HB AMC WELLPOINT","2440.27","73.78","","1726.50","1726.50","1726.50","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH HERNIA 2.0MMX10 15CM DUAL BIOMATERIAL OVAL","SUP-ITM-10005093","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","AETNA [1001]","HB AMC AETNA HMO","2308.64","69.8","","915.80","263.76","2881.00","1 through 10","1728.5","2702.89","percent of total billed charges",""
"MESH HERNIA 2.0MMX10 15CM DUAL BIOMATERIAL OVAL","SUP-ITM-10005093","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2702.89","81.72","","1531.57","410.52","8841.36","1 through 10","1728.5","2702.89","percent of total billed charges",""
"MESH HERNIA 2.25X5IN PROLENE POLYPROPYLENE EXTENDED BX/3EA","SUP-ITM-10012077","CDM","C1781","HCPCS","0278","RC","","","","both","","","844.00","633.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","590.80","70","","134.04","134.04","134.04","1 through 10","261.64","670.98","percent of total billed charges",""
"MESH HERNIA 2.25X5IN PROLENE POLYPROPYLENE EXTENDED BX/3EA","SUP-ITM-10012077","CDM","C1781","HCPCS","0278","RC","","","","both","","","844.00","633.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","670.98","79.5","","948.87","198.19","1805.30","1 through 10","261.64","670.98","percent of total billed charges",""
"MESH HERNIA 2.25X5IN PROLENE POLYPROPYLENE EXTENDED BX/3EA","SUP-ITM-10012077","CDM","C1781","HCPCS","0278","RC","","","","both","","","844.00","633.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","449.85","53.3","","462.00","170.45","3253.37","1 through 10","261.64","670.98","percent of total billed charges",""
"MESH HERNIA 2.25X5IN PROLENE POLYPROPYLENE EXTENDED BX/3EA","SUP-ITM-10012077","CDM","C1781","HCPCS","0278","RC","","","","both","","","844.00","633.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","308.06","36.5","","245.50","107.19","1371.45","1 through 10","261.64","670.98","percent of total billed charges",""
"MESH HERNIA 2.25X5IN PROLENE POLYPROPYLENE EXTENDED BX/3EA","SUP-ITM-10012077","CDM","C1781","HCPCS","0278","RC","","","","both","","","844.00","633.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","323.25","38.3","","200.79","72.79","355.81","22","261.64","670.98","percent of total billed charges",""
"MESH HERNIA 2.25X5IN PROLENE POLYPROPYLENE EXTENDED BX/3EA","SUP-ITM-10012077","CDM","C1781","HCPCS","0278","RC","","","","both","","","844.00","633.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","649.88","77","","477.18","477.18","477.18","1 through 10","261.64","670.98","percent of total billed charges",""
"MESH HERNIA 2.25X5IN PROLENE POLYPROPYLENE EXTENDED BX/3EA","SUP-ITM-10012077","CDM","C1781","HCPCS","0278","RC","","","","both","","","844.00","633.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","362.08","42.9","","1045.91","1045.91","1045.91","1 through 10","261.64","670.98","percent of total billed charges",""
"MESH HERNIA 2.25X5IN PROLENE POLYPROPYLENE EXTENDED BX/3EA","SUP-ITM-10012077","CDM","C1781","HCPCS","0278","RC","","","","both","","","844.00","633.00","WELLPOINT [1015]","HB AMC WELLPOINT","622.70","73.78","","1726.50","1726.50","1726.50","1 through 10","261.64","670.98","percent of total billed charges",""
"MESH HERNIA 2.25X5IN PROLENE POLYPROPYLENE EXTENDED BX/3EA","SUP-ITM-10012077","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","844.00","633.00","AETNA [1001]","HB AMC AETNA HMO","589.11","69.8","","915.80","263.76","2881.00","1 through 10","441.07","689.72","percent of total billed charges",""
"MESH HERNIA 2.25X5IN PROLENE POLYPROPYLENE EXTENDED BX/3EA","SUP-ITM-10012077","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","844.00","633.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","689.72","81.72","","1531.57","410.52","8841.36","1 through 10","441.07","689.72","percent of total billed charges",""
"MESH HERNIA 20.0CMX30.0 1.0MM DUAL BIOMATERIAL SOFT TISSUE","SUP-ITM-10076194","CDM","C1781","HCPCS","0278","RC","","","","both","","","4535.00","3401.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3174.50","70","","134.04","134.04","134.04","1 through 10","1405.85","3605.33","percent of total billed charges",""
"MESH HERNIA 20.0CMX30.0 1.0MM DUAL BIOMATERIAL SOFT TISSUE","SUP-ITM-10076194","CDM","C1781","HCPCS","0278","RC","","","","both","","","4535.00","3401.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3605.33","79.5","","948.87","198.19","1805.30","1 through 10","1405.85","3605.33","percent of total billed charges",""
"MESH HERNIA 20.0CMX30.0 1.0MM DUAL BIOMATERIAL SOFT TISSUE","SUP-ITM-10076194","CDM","C1781","HCPCS","0278","RC","","","","both","","","4535.00","3401.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2417.16","53.3","","462.00","170.45","3253.37","1 through 10","1405.85","3605.33","percent of total billed charges",""
"MESH HERNIA 20.0CMX30.0 1.0MM DUAL BIOMATERIAL SOFT TISSUE","SUP-ITM-10076194","CDM","C1781","HCPCS","0278","RC","","","","both","","","4535.00","3401.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1655.28","36.5","","245.50","107.19","1371.45","1 through 10","1405.85","3605.33","percent of total billed charges",""
"MESH HERNIA 20.0CMX30.0 1.0MM DUAL BIOMATERIAL SOFT TISSUE","SUP-ITM-10076194","CDM","C1781","HCPCS","0278","RC","","","","both","","","4535.00","3401.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1736.91","38.3","","200.79","72.79","355.81","22","1405.85","3605.33","percent of total billed charges",""
"MESH HERNIA 20.0CMX30.0 1.0MM DUAL BIOMATERIAL SOFT TISSUE","SUP-ITM-10076194","CDM","C1781","HCPCS","0278","RC","","","","both","","","4535.00","3401.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3491.95","77","","477.18","477.18","477.18","1 through 10","1405.85","3605.33","percent of total billed charges",""
"MESH HERNIA 20.0CMX30.0 1.0MM DUAL BIOMATERIAL SOFT TISSUE","SUP-ITM-10076194","CDM","C1781","HCPCS","0278","RC","","","","both","","","4535.00","3401.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1945.52","42.9","","1045.91","1045.91","1045.91","1 through 10","1405.85","3605.33","percent of total billed charges",""
"MESH HERNIA 20.0CMX30.0 1.0MM DUAL BIOMATERIAL SOFT TISSUE","SUP-ITM-10076194","CDM","C1781","HCPCS","0278","RC","","","","both","","","4535.00","3401.25","WELLPOINT [1015]","HB AMC WELLPOINT","3345.92","73.78","","1726.50","1726.50","1726.50","1 through 10","1405.85","3605.33","percent of total billed charges",""
"MESH HERNIA 20.0CMX30.0 1.0MM DUAL BIOMATERIAL SOFT TISSUE","SUP-ITM-10076194","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4535.00","3401.25","AETNA [1001]","HB AMC AETNA HMO","3165.43","69.8","","915.80","263.76","2881.00","1 through 10","2369.99","3706","percent of total billed charges",""
"MESH HERNIA 20.0CMX30.0 1.0MM DUAL BIOMATERIAL SOFT TISSUE","SUP-ITM-10076194","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4535.00","3401.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3706.00","81.72","","1531.57","410.52","8841.36","1 through 10","2369.99","3706","percent of total billed charges",""
"MESH HERNIA 25X30CM OVITEX 1S PERMANENT","SUP-ITM-10321647","CDM","C1781","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","18375.00","70","","134.04","134.04","134.04","1 through 10","8137.5","20868.75","percent of total billed charges",""
"MESH HERNIA 25X30CM OVITEX 1S PERMANENT","SUP-ITM-10321647","CDM","C1781","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20868.75","79.5","","948.87","198.19","1805.30","1 through 10","8137.5","20868.75","percent of total billed charges",""
"MESH HERNIA 25X30CM OVITEX 1S PERMANENT","SUP-ITM-10321647","CDM","C1781","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13991.25","53.3","","462.00","170.45","3253.37","1 through 10","8137.5","20868.75","percent of total billed charges",""
"MESH HERNIA 25X30CM OVITEX 1S PERMANENT","SUP-ITM-10321647","CDM","C1781","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9581.25","36.5","","245.50","107.19","1371.45","1 through 10","8137.5","20868.75","percent of total billed charges",""
"MESH HERNIA 25X30CM OVITEX 1S PERMANENT","SUP-ITM-10321647","CDM","C1781","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10053.75","38.3","","200.79","72.79","355.81","22","8137.5","20868.75","percent of total billed charges",""
"MESH HERNIA 25X30CM OVITEX 1S PERMANENT","SUP-ITM-10321647","CDM","C1781","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","20212.50","77","","477.18","477.18","477.18","1 through 10","8137.5","20868.75","percent of total billed charges",""
"MESH HERNIA 25X30CM OVITEX 1S PERMANENT","SUP-ITM-10321647","CDM","C1781","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11261.25","42.9","","1045.91","1045.91","1045.91","1 through 10","8137.5","20868.75","percent of total billed charges",""
"MESH HERNIA 25X30CM OVITEX 1S PERMANENT","SUP-ITM-10321647","CDM","C1781","HCPCS","0278","RC","","","","both","","","26250.00","19687.50","WELLPOINT [1015]","HB AMC WELLPOINT","19367.25","73.78","","1726.50","1726.50","1726.50","1 through 10","8137.5","20868.75","percent of total billed charges",""
"MESH HERNIA 25X30CM OVITEX 1S PERMANENT","SUP-ITM-10321647","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","26250.00","19687.50","AETNA [1001]","HB AMC AETNA HMO","18322.50","69.8","","915.80","263.76","2881.00","1 through 10","13718.25","21451.5","percent of total billed charges",""
"MESH HERNIA 25X30CM OVITEX 1S PERMANENT","SUP-ITM-10321647","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","26250.00","19687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21451.50","81.72","","1531.57","410.52","8841.36","1 through 10","13718.25","21451.5","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2266.25","70","","134.04","134.04","134.04","1 through 10","1003.63","2573.81","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2573.81","79.5","","948.87","198.19","1805.30","1 through 10","1003.63","2573.81","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1725.59","53.3","","462.00","170.45","3253.37","1 through 10","1003.63","2573.81","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1181.69","36.5","","245.50","107.19","1371.45","1 through 10","1003.63","2573.81","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1239.96","38.3","","200.79","72.79","355.81","22","1003.63","2573.81","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2492.88","77","","477.18","477.18","477.18","1 through 10","1003.63","2573.81","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1388.89","42.9","","1045.91","1045.91","1045.91","1 through 10","1003.63","2573.81","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","WELLPOINT [1015]","HB AMC WELLPOINT","2388.63","73.78","","1726.50","1726.50","1726.50","1 through 10","1003.63","2573.81","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","AETNA [1001]","HB AMC AETNA HMO","2259.78","69.8","","915.80","263.76","2881.00","1 through 10","1691.92","2645.69","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2645.69","81.72","","1531.57","410.52","8841.36","1 through 10","1691.92","2645.69","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1441.65","1081.24","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1009.16","70","","134.04","134.04","134.04","1 through 10","446.91","1146.11","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1441.65","1081.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1146.11","79.5","","948.87","198.19","1805.30","1 through 10","446.91","1146.11","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1441.65","1081.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","768.40","53.3","","462.00","170.45","3253.37","1 through 10","446.91","1146.11","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1441.65","1081.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","526.20","36.5","","245.50","107.19","1371.45","1 through 10","446.91","1146.11","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1441.65","1081.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","552.15","38.3","","200.79","72.79","355.81","22","446.91","1146.11","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1441.65","1081.24","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1110.07","77","","477.18","477.18","477.18","1 through 10","446.91","1146.11","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1441.65","1081.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","618.47","42.9","","1045.91","1045.91","1045.91","1 through 10","446.91","1146.11","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1441.65","1081.24","WELLPOINT [1015]","HB AMC WELLPOINT","1063.65","73.78","","1726.50","1726.50","1726.50","1 through 10","446.91","1146.11","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1441.65","1081.24","AETNA [1001]","HB AMC AETNA HMO","1006.27","69.8","","915.80","263.76","2881.00","1 through 10","753.41","1178.12","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1441.65","1081.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1178.12","81.72","","1531.57","410.52","8841.36","1 through 10","753.41","1178.12","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3465.00","70","","134.04","134.04","134.04","1 through 10","1534.5","3935.25","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","948.87","198.19","1805.30","1 through 10","1534.5","3935.25","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2638.35","53.3","","462.00","170.45","3253.37","1 through 10","1534.5","3935.25","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","245.50","107.19","1371.45","1 through 10","1534.5","3935.25","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","200.79","72.79","355.81","22","1534.5","3935.25","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3811.50","77","","477.18","477.18","477.18","1 through 10","1534.5","3935.25","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","1045.91","1045.91","1045.91","1 through 10","1534.5","3935.25","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","1726.50","1726.50","1726.50","1 through 10","1534.5","3935.25","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","915.80","263.76","2881.00","1 through 10","2586.87","4045.14","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","1531.57","410.52","8841.36","1 through 10","2586.87","4045.14","percent of total billed charges",""
"MESH OVITEX 25X30CM 2S PERMANANENT","SUP-ITM-10310275","CDM","C1781","HCPCS","0278","RC","","","","both","","","32500.00","24375.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","22750.00","70","","134.04","134.04","134.04","1 through 10","10075","25837.5","percent of total billed charges",""
"MESH OVITEX 25X30CM 2S PERMANANENT","SUP-ITM-10310275","CDM","C1781","HCPCS","0278","RC","","","","both","","","32500.00","24375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","25837.50","79.5","","948.87","198.19","1805.30","1 through 10","10075","25837.5","percent of total billed charges",""
"MESH OVITEX 25X30CM 2S PERMANANENT","SUP-ITM-10310275","CDM","C1781","HCPCS","0278","RC","","","","both","","","32500.00","24375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","17322.50","53.3","","462.00","170.45","3253.37","1 through 10","10075","25837.5","percent of total billed charges",""
"MESH OVITEX 25X30CM 2S PERMANANENT","SUP-ITM-10310275","CDM","C1781","HCPCS","0278","RC","","","","both","","","32500.00","24375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11862.50","36.5","","245.50","107.19","1371.45","1 through 10","10075","25837.5","percent of total billed charges",""
"MESH OVITEX 25X30CM 2S PERMANANENT","SUP-ITM-10310275","CDM","C1781","HCPCS","0278","RC","","","","both","","","32500.00","24375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12447.50","38.3","","200.79","72.79","355.81","22","10075","25837.5","percent of total billed charges",""
"MESH OVITEX 25X30CM 2S PERMANANENT","SUP-ITM-10310275","CDM","C1781","HCPCS","0278","RC","","","","both","","","32500.00","24375.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","25025.00","77","","477.18","477.18","477.18","1 through 10","10075","25837.5","percent of total billed charges",""
"MESH OVITEX 25X30CM 2S PERMANANENT","SUP-ITM-10310275","CDM","C1781","HCPCS","0278","RC","","","","both","","","32500.00","24375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13942.50","42.9","","1045.91","1045.91","1045.91","1 through 10","10075","25837.5","percent of total billed charges",""
"MESH OVITEX 25X30CM 2S PERMANANENT","SUP-ITM-10310275","CDM","C1781","HCPCS","0278","RC","","","","both","","","32500.00","24375.00","WELLPOINT [1015]","HB AMC WELLPOINT","23978.50","73.78","","1726.50","1726.50","1726.50","1 through 10","10075","25837.5","percent of total billed charges",""
"MESH OVITEX 25X30CM 2S PERMANANENT","SUP-ITM-10310275","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","32500.00","24375.00","AETNA [1001]","HB AMC AETNA HMO","22685.00","69.8","","915.80","263.76","2881.00","1 through 10","16984.5","26559","percent of total billed charges",""
"MESH OVITEX 25X30CM 2S PERMANANENT","SUP-ITM-10310275","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","32500.00","24375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","26559.00","81.72","","1531.57","410.52","8841.36","1 through 10","16984.5","26559","percent of total billed charges",""
"MESH PARIETEX 20X30CM 8X12IN OPTIMIZED COMPOSITE RECTANGLE","SUP-ITM-10013251","CDM","C1781","HCPCS","0278","RC","","","","both","","","3922.66","2941.99","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2745.86","70","","134.04","134.04","134.04","1 through 10","1216.02","3118.51","percent of total billed charges",""
"MESH PARIETEX 20X30CM 8X12IN OPTIMIZED COMPOSITE RECTANGLE","SUP-ITM-10013251","CDM","C1781","HCPCS","0278","RC","","","","both","","","3922.66","2941.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3118.51","79.5","","948.87","198.19","1805.30","1 through 10","1216.02","3118.51","percent of total billed charges",""
"MESH PARIETEX 20X30CM 8X12IN OPTIMIZED COMPOSITE RECTANGLE","SUP-ITM-10013251","CDM","C1781","HCPCS","0278","RC","","","","both","","","3922.66","2941.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2090.78","53.3","","462.00","170.45","3253.37","1 through 10","1216.02","3118.51","percent of total billed charges",""
"MESH PARIETEX 20X30CM 8X12IN OPTIMIZED COMPOSITE RECTANGLE","SUP-ITM-10013251","CDM","C1781","HCPCS","0278","RC","","","","both","","","3922.66","2941.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1431.77","36.5","","245.50","107.19","1371.45","1 through 10","1216.02","3118.51","percent of total billed charges",""
"MESH PARIETEX 20X30CM 8X12IN OPTIMIZED COMPOSITE RECTANGLE","SUP-ITM-10013251","CDM","C1781","HCPCS","0278","RC","","","","both","","","3922.66","2941.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1502.38","38.3","","200.79","72.79","355.81","22","1216.02","3118.51","percent of total billed charges",""
"MESH PARIETEX 20X30CM 8X12IN OPTIMIZED COMPOSITE RECTANGLE","SUP-ITM-10013251","CDM","C1781","HCPCS","0278","RC","","","","both","","","3922.66","2941.99","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3020.45","77","","477.18","477.18","477.18","1 through 10","1216.02","3118.51","percent of total billed charges",""
"MESH PARIETEX 20X30CM 8X12IN OPTIMIZED COMPOSITE RECTANGLE","SUP-ITM-10013251","CDM","C1781","HCPCS","0278","RC","","","","both","","","3922.66","2941.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1682.82","42.9","","1045.91","1045.91","1045.91","1 through 10","1216.02","3118.51","percent of total billed charges",""
"MESH PARIETEX 20X30CM 8X12IN OPTIMIZED COMPOSITE RECTANGLE","SUP-ITM-10013251","CDM","C1781","HCPCS","0278","RC","","","","both","","","3922.66","2941.99","WELLPOINT [1015]","HB AMC WELLPOINT","2894.14","73.78","","1726.50","1726.50","1726.50","1 through 10","1216.02","3118.51","percent of total billed charges",""
"MESH PARIETEX 20X30CM 8X12IN OPTIMIZED COMPOSITE RECTANGLE","SUP-ITM-10013251","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3922.66","2941.99","AETNA [1001]","HB AMC AETNA HMO","2738.02","69.8","","915.80","263.76","2881.00","1 through 10","2049.98","3205.6","percent of total billed charges",""
"MESH PARIETEX 20X30CM 8X12IN OPTIMIZED COMPOSITE RECTANGLE","SUP-ITM-10013251","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3922.66","2941.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3205.60","81.72","","1531.57","410.52","8841.36","1 through 10","2049.98","3205.6","percent of total billed charges",""
"MESH PARIETEX 28X37CM 11X15.5IN OPTIMIZED COMPOSITE RECTANGLE - DISCONTINUED PER MFG","SUP-ITM-10025247","CDM","C1781","HCPCS","0278","RC","","","","both","","","3992.76","2994.57","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2794.93","70","","134.04","134.04","134.04","1 through 10","1237.76","3174.24","percent of total billed charges",""
"MESH PARIETEX 28X37CM 11X15.5IN OPTIMIZED COMPOSITE RECTANGLE - DISCONTINUED PER MFG","SUP-ITM-10025247","CDM","C1781","HCPCS","0278","RC","","","","both","","","3992.76","2994.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3174.24","79.5","","948.87","198.19","1805.30","1 through 10","1237.76","3174.24","percent of total billed charges",""
"MESH PARIETEX 28X37CM 11X15.5IN OPTIMIZED COMPOSITE RECTANGLE - DISCONTINUED PER MFG","SUP-ITM-10025247","CDM","C1781","HCPCS","0278","RC","","","","both","","","3992.76","2994.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2128.14","53.3","","462.00","170.45","3253.37","1 through 10","1237.76","3174.24","percent of total billed charges",""
"MESH PARIETEX 28X37CM 11X15.5IN OPTIMIZED COMPOSITE RECTANGLE - DISCONTINUED PER MFG","SUP-ITM-10025247","CDM","C1781","HCPCS","0278","RC","","","","both","","","3992.76","2994.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1457.36","36.5","","245.50","107.19","1371.45","1 through 10","1237.76","3174.24","percent of total billed charges",""
"MESH PARIETEX 28X37CM 11X15.5IN OPTIMIZED COMPOSITE RECTANGLE - DISCONTINUED PER MFG","SUP-ITM-10025247","CDM","C1781","HCPCS","0278","RC","","","","both","","","3992.76","2994.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1529.23","38.3","","200.79","72.79","355.81","22","1237.76","3174.24","percent of total billed charges",""
"MESH PARIETEX 28X37CM 11X15.5IN OPTIMIZED COMPOSITE RECTANGLE - DISCONTINUED PER MFG","SUP-ITM-10025247","CDM","C1781","HCPCS","0278","RC","","","","both","","","3992.76","2994.57","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3074.43","77","","477.18","477.18","477.18","1 through 10","1237.76","3174.24","percent of total billed charges",""
"MESH PARIETEX 28X37CM 11X15.5IN OPTIMIZED COMPOSITE RECTANGLE - DISCONTINUED PER MFG","SUP-ITM-10025247","CDM","C1781","HCPCS","0278","RC","","","","both","","","3992.76","2994.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1712.89","42.9","","1045.91","1045.91","1045.91","1 through 10","1237.76","3174.24","percent of total billed charges",""
"MESH PARIETEX 28X37CM 11X15.5IN OPTIMIZED COMPOSITE RECTANGLE - DISCONTINUED PER MFG","SUP-ITM-10025247","CDM","C1781","HCPCS","0278","RC","","","","both","","","3992.76","2994.57","WELLPOINT [1015]","HB AMC WELLPOINT","2945.86","73.78","","1726.50","1726.50","1726.50","1 through 10","1237.76","3174.24","percent of total billed charges",""
"MESH PARIETEX 28X37CM 11X15.5IN OPTIMIZED COMPOSITE RECTANGLE - DISCONTINUED PER MFG","SUP-ITM-10025247","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3992.76","2994.57","AETNA [1001]","HB AMC AETNA HMO","2786.95","69.8","","915.80","263.76","2881.00","1 through 10","2086.62","3262.88","percent of total billed charges",""
"MESH PARIETEX 28X37CM 11X15.5IN OPTIMIZED COMPOSITE RECTANGLE - DISCONTINUED PER MFG","SUP-ITM-10025247","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3992.76","2994.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3262.88","81.72","","1531.57","410.52","8841.36","1 through 10","2086.62","3262.88","percent of total billed charges",""
"MESH PATCH 15CMX8 2MM SYNTHETIC ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE THICK POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013732","CDM","C1781","HCPCS","0278","RC","","","","both","","","986.90","740.17","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","690.83","70","","134.04","134.04","134.04","1 through 10","305.94","784.59","percent of total billed charges",""
"MESH PATCH 15CMX8 2MM SYNTHETIC ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE THICK POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013732","CDM","C1781","HCPCS","0278","RC","","","","both","","","986.90","740.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","784.59","79.5","","948.87","198.19","1805.30","1 through 10","305.94","784.59","percent of total billed charges",""
"MESH PATCH 15CMX8 2MM SYNTHETIC ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE THICK POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013732","CDM","C1781","HCPCS","0278","RC","","","","both","","","986.90","740.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","526.02","53.3","","462.00","170.45","3253.37","1 through 10","305.94","784.59","percent of total billed charges",""
"MESH PATCH 15CMX8 2MM SYNTHETIC ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE THICK POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013732","CDM","C1781","HCPCS","0278","RC","","","","both","","","986.90","740.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","360.22","36.5","","245.50","107.19","1371.45","1 through 10","305.94","784.59","percent of total billed charges",""
"MESH PATCH 15CMX8 2MM SYNTHETIC ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE THICK POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013732","CDM","C1781","HCPCS","0278","RC","","","","both","","","986.90","740.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","377.98","38.3","","200.79","72.79","355.81","22","305.94","784.59","percent of total billed charges",""
"MESH PATCH 15CMX8 2MM SYNTHETIC ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE THICK POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013732","CDM","C1781","HCPCS","0278","RC","","","","both","","","986.90","740.17","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","759.91","77","","477.18","477.18","477.18","1 through 10","305.94","784.59","percent of total billed charges",""
"MESH PATCH 15CMX8 2MM SYNTHETIC ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE THICK POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013732","CDM","C1781","HCPCS","0278","RC","","","","both","","","986.90","740.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","423.38","42.9","","1045.91","1045.91","1045.91","1 through 10","305.94","784.59","percent of total billed charges",""
"MESH PATCH 15CMX8 2MM SYNTHETIC ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE THICK POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013732","CDM","C1781","HCPCS","0278","RC","","","","both","","","986.90","740.17","WELLPOINT [1015]","HB AMC WELLPOINT","728.13","73.78","","1726.50","1726.50","1726.50","1 through 10","305.94","784.59","percent of total billed charges",""
"MESH PATCH 15CMX8 2MM SYNTHETIC ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE THICK POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013732","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","986.90","740.17","AETNA [1001]","HB AMC AETNA HMO","688.86","69.8","","915.80","263.76","2881.00","1 through 10","515.75","806.49","percent of total billed charges",""
"MESH PATCH 15CMX8 2MM SYNTHETIC ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE THICK POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013732","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","986.90","740.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","806.49","81.72","","1531.57","410.52","8841.36","1 through 10","515.75","806.49","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3724.00","2793.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2606.80","70","","134.04","134.04","134.04","1 through 10","1154.44","2960.58","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3724.00","2793.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2960.58","79.5","","948.87","198.19","1805.30","1 through 10","1154.44","2960.58","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3724.00","2793.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1984.89","53.3","","462.00","170.45","3253.37","1 through 10","1154.44","2960.58","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3724.00","2793.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1359.26","36.5","","245.50","107.19","1371.45","1 through 10","1154.44","2960.58","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3724.00","2793.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1426.29","38.3","","200.79","72.79","355.81","22","1154.44","2960.58","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3724.00","2793.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2867.48","77","","477.18","477.18","477.18","1 through 10","1154.44","2960.58","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3724.00","2793.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1597.60","42.9","","1045.91","1045.91","1045.91","1 through 10","1154.44","2960.58","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3724.00","2793.00","WELLPOINT [1015]","HB AMC WELLPOINT","2747.57","73.78","","1726.50","1726.50","1726.50","1 through 10","1154.44","2960.58","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3724.00","2793.00","AETNA [1001]","HB AMC AETNA HMO","2599.35","69.8","","915.80","263.76","2881.00","1 through 10","1946.16","3043.25","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3724.00","2793.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3043.25","81.72","","1531.57","410.52","8841.36","1 through 10","1946.16","3043.25","percent of total billed charges",""
"MESH RECON 100MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.54","3238.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3432.44","79.5","","800.18","480.96","1887.97","195","1338.44","3432.44","percent of total billed charges",""
"MESH RECON 100MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.54","3238.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2301.25","53.3","","813.12","216.42","1444.50","81","1338.44","3432.44","percent of total billed charges",""
"MESH RECON 100MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.54","3238.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1338.44","31","","432.60","432.60","432.60","1 through 10","1338.44","3432.44","percent of total billed charges",""
"MESH RECON 100MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.54","3238.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1575.90","36.5","","148.37","54.89","631.39","94","1338.44","3432.44","percent of total billed charges",""
"MESH RECON 100MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.54","3238.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1653.62","38.3","","279.30","91.72","1116.77","266","1338.44","3432.44","percent of total billed charges",""
"MESH RECON 100MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.54","3238.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1852.22","42.9","","731.00","63.70","731.00","1 through 10","1338.44","3432.44","percent of total billed charges",""
"MESH RECON 100MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.54","3238.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1852.22","42.9","","384.74","384.74","384.74","1 through 10","1338.44","3432.44","percent of total billed charges",""
"MESH RECON 100MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.54","3238.15","WELLPOINT [1015]","HB AMC WELLPOINT","3185.48","73.78","","286.63","119.22","1107.45","105","1338.44","3432.44","percent of total billed charges",""
"MESH RECON 100MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.54","3238.15","AETNA [1001]","HB AMC AETNA HMO","3013.64","69.8","","675.31","184.75","1721.50","286","2256.35","3528.29","percent of total billed charges",""
"MESH RECON 100MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.54","3238.15","AETNA [1001]","HB AMC AETNA PPO","3471.30","80.4","","1261.44","103.12","1514.10","21","2256.35","3528.29","percent of total billed charges",""
"MESH RECON 100MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.54","3238.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3471.30","80.4","","1365.00","1365.00","1365.00","1 through 10","2256.35","3528.29","percent of total billed charges",""
"MESH RECON 100MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.54","3238.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3528.29","81.72","","5157.68","5157.68","5157.68","1 through 10","2256.35","3528.29","percent of total billed charges",""
"MESH RECON 100MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.54","3238.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3528.29","81.72","","431.26","71.26","1459.57","88","2256.35","3528.29","percent of total billed charges",""
"MESH RECON 150MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158745","CDM","C1713","HCPCS","0278","RC","","","","both","","","8887.50","6665.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7065.56","79.5","","800.18","480.96","1887.97","195","2755.13","7065.56","percent of total billed charges",""
"MESH RECON 150MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158745","CDM","C1713","HCPCS","0278","RC","","","","both","","","8887.50","6665.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4737.04","53.3","","813.12","216.42","1444.50","81","2755.13","7065.56","percent of total billed charges",""
"MESH RECON 150MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158745","CDM","C1713","HCPCS","0278","RC","","","","both","","","8887.50","6665.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2755.13","31","","432.60","432.60","432.60","1 through 10","2755.13","7065.56","percent of total billed charges",""
"MESH RECON 150MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158745","CDM","C1713","HCPCS","0278","RC","","","","both","","","8887.50","6665.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3243.94","36.5","","148.37","54.89","631.39","94","2755.13","7065.56","percent of total billed charges",""
"MESH RECON 150MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158745","CDM","C1713","HCPCS","0278","RC","","","","both","","","8887.50","6665.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3403.91","38.3","","279.30","91.72","1116.77","266","2755.13","7065.56","percent of total billed charges",""
"MESH RECON 150MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158745","CDM","C1713","HCPCS","0278","RC","","","","both","","","8887.50","6665.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3812.74","42.9","","731.00","63.70","731.00","1 through 10","2755.13","7065.56","percent of total billed charges",""
"MESH RECON 150MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158745","CDM","C1713","HCPCS","0278","RC","","","","both","","","8887.50","6665.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3812.74","42.9","","384.74","384.74","384.74","1 through 10","2755.13","7065.56","percent of total billed charges",""
"MESH RECON 150MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158745","CDM","C1713","HCPCS","0278","RC","","","","both","","","8887.50","6665.62","WELLPOINT [1015]","HB AMC WELLPOINT","6557.20","73.78","","286.63","119.22","1107.45","105","2755.13","7065.56","percent of total billed charges",""
"MESH RECON 150MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8887.50","6665.62","AETNA [1001]","HB AMC AETNA HMO","6203.48","69.8","","675.31","184.75","1721.50","286","4644.61","7262.87","percent of total billed charges",""
"MESH RECON 150MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8887.50","6665.62","AETNA [1001]","HB AMC AETNA PPO","7145.55","80.4","","1261.44","103.12","1514.10","21","4644.61","7262.87","percent of total billed charges",""
"MESH RECON 150MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8887.50","6665.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7145.55","80.4","","1365.00","1365.00","1365.00","1 through 10","4644.61","7262.87","percent of total billed charges",""
"MESH RECON 150MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8887.50","6665.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7262.87","81.72","","5157.68","5157.68","5157.68","1 through 10","4644.61","7262.87","percent of total billed charges",""
"MESH RECON 150MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8887.50","6665.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7262.87","81.72","","431.26","71.26","1459.57","88","4644.61","7262.87","percent of total billed charges",""
"MESH RECON 200MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158746","CDM","C1713","HCPCS","0278","RC","","","","both","","","11850.00","8887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9420.75","79.5","","800.18","480.96","1887.97","195","3673.5","9420.75","percent of total billed charges",""
"MESH RECON 200MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158746","CDM","C1713","HCPCS","0278","RC","","","","both","","","11850.00","8887.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6316.05","53.3","","813.12","216.42","1444.50","81","3673.5","9420.75","percent of total billed charges",""
"MESH RECON 200MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158746","CDM","C1713","HCPCS","0278","RC","","","","both","","","11850.00","8887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3673.50","31","","432.60","432.60","432.60","1 through 10","3673.5","9420.75","percent of total billed charges",""
"MESH RECON 200MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158746","CDM","C1713","HCPCS","0278","RC","","","","both","","","11850.00","8887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4325.25","36.5","","148.37","54.89","631.39","94","3673.5","9420.75","percent of total billed charges",""
"MESH RECON 200MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158746","CDM","C1713","HCPCS","0278","RC","","","","both","","","11850.00","8887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4538.55","38.3","","279.30","91.72","1116.77","266","3673.5","9420.75","percent of total billed charges",""
"MESH RECON 200MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158746","CDM","C1713","HCPCS","0278","RC","","","","both","","","11850.00","8887.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5083.65","42.9","","731.00","63.70","731.00","1 through 10","3673.5","9420.75","percent of total billed charges",""
"MESH RECON 200MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158746","CDM","C1713","HCPCS","0278","RC","","","","both","","","11850.00","8887.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5083.65","42.9","","384.74","384.74","384.74","1 through 10","3673.5","9420.75","percent of total billed charges",""
"MESH RECON 200MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158746","CDM","C1713","HCPCS","0278","RC","","","","both","","","11850.00","8887.50","WELLPOINT [1015]","HB AMC WELLPOINT","8742.93","73.78","","286.63","119.22","1107.45","105","3673.5","9420.75","percent of total billed charges",""
"MESH RECON 200MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11850.00","8887.50","AETNA [1001]","HB AMC AETNA HMO","8271.30","69.8","","675.31","184.75","1721.50","286","6192.81","9683.82","percent of total billed charges",""
"MESH RECON 200MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11850.00","8887.50","AETNA [1001]","HB AMC AETNA PPO","9527.40","80.4","","1261.44","103.12","1514.10","21","6192.81","9683.82","percent of total billed charges",""
"MESH RECON 200MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11850.00","8887.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9527.40","80.4","","1365.00","1365.00","1365.00","1 through 10","6192.81","9683.82","percent of total billed charges",""
"MESH RECON 200MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11850.00","8887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","9683.82","81.72","","5157.68","5157.68","5157.68","1 through 10","6192.81","9683.82","percent of total billed charges",""
"MESH RECON 200MMXTI MATRIXNEURO PLATE / PERI OP ORTHO CMF","SUP-ITM-10158746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11850.00","8887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9683.82","81.72","","431.26","71.26","1459.57","88","6192.81","9683.82","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","1309.77","674.56","6049.93","26","162.75","417.38","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","1901.83","1901.83","2962.25","1 through 10","162.75","417.38","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","1620.31","1620.31","19908.88","1 through 10","162.75","417.38","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","352.91","352.91","2046.30","1 through 10","162.75","417.38","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","9668.75","9668.75","9668.75","1 through 10","162.75","417.38","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","699.88","384.10","3443.31","33","162.75","417.38","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","1421.24","264.50","4933.46","29","274.37","429.03","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1022.97","1022.97","3607.50","1 through 10","274.37","429.03","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","3010.54","693.88","5019.88","35","274.37","429.03","percent of total billed charges",""
"MESH SOFT 25CM 40CM TISSUE PHASIX RESORBABLE","SUP-ITM-10191765","CDM","C1781","HCPCS","0278","RC","","","","both","","","59428.75","44571.56","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","41600.13","70","","134.04","134.04","134.04","1 through 10","18422.91","47245.86","percent of total billed charges",""
"MESH SOFT 25CM 40CM TISSUE PHASIX RESORBABLE","SUP-ITM-10191765","CDM","C1781","HCPCS","0278","RC","","","","both","","","59428.75","44571.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","47245.86","79.5","","948.87","198.19","1805.30","1 through 10","18422.91","47245.86","percent of total billed charges",""
"MESH SOFT 25CM 40CM TISSUE PHASIX RESORBABLE","SUP-ITM-10191765","CDM","C1781","HCPCS","0278","RC","","","","both","","","59428.75","44571.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","31675.52","53.3","","462.00","170.45","3253.37","1 through 10","18422.91","47245.86","percent of total billed charges",""
"MESH SOFT 25CM 40CM TISSUE PHASIX RESORBABLE","SUP-ITM-10191765","CDM","C1781","HCPCS","0278","RC","","","","both","","","59428.75","44571.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21691.49","36.5","","245.50","107.19","1371.45","1 through 10","18422.91","47245.86","percent of total billed charges",""
"MESH SOFT 25CM 40CM TISSUE PHASIX RESORBABLE","SUP-ITM-10191765","CDM","C1781","HCPCS","0278","RC","","","","both","","","59428.75","44571.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22761.21","38.3","","200.79","72.79","355.81","22","18422.91","47245.86","percent of total billed charges",""
"MESH SOFT 25CM 40CM TISSUE PHASIX RESORBABLE","SUP-ITM-10191765","CDM","C1781","HCPCS","0278","RC","","","","both","","","59428.75","44571.56","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","45760.14","77","","477.18","477.18","477.18","1 through 10","18422.91","47245.86","percent of total billed charges",""
"MESH SOFT 25CM 40CM TISSUE PHASIX RESORBABLE","SUP-ITM-10191765","CDM","C1781","HCPCS","0278","RC","","","","both","","","59428.75","44571.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25494.93","42.9","","1045.91","1045.91","1045.91","1 through 10","18422.91","47245.86","percent of total billed charges",""
"MESH SOFT 25CM 40CM TISSUE PHASIX RESORBABLE","SUP-ITM-10191765","CDM","C1781","HCPCS","0278","RC","","","","both","","","59428.75","44571.56","WELLPOINT [1015]","HB AMC WELLPOINT","43846.53","73.78","","1726.50","1726.50","1726.50","1 through 10","18422.91","47245.86","percent of total billed charges",""
"MESH SOFT 25CM 40CM TISSUE PHASIX RESORBABLE","SUP-ITM-10191765","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","59428.75","44571.56","AETNA [1001]","HB AMC AETNA HMO","41481.27","69.8","","915.80","263.76","2881.00","1 through 10","31057.46","48565.17","percent of total billed charges",""
"MESH SOFT 25CM 40CM TISSUE PHASIX RESORBABLE","SUP-ITM-10191765","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","59428.75","44571.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","48565.17","81.72","","1531.57","410.52","8841.36","1 through 10","31057.46","48565.17","percent of total billed charges",""
"MESH SURGICAL 1 3/8IN 3.5CM HERNIA PROLENE 3D POLYPROPYLENE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010067","CDM","C1781","HCPCS","0278","RC","","","","both","","","764.09","573.07","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","534.86","70","","134.04","134.04","134.04","1 through 10","236.87","607.45","percent of total billed charges",""
"MESH SURGICAL 1 3/8IN 3.5CM HERNIA PROLENE 3D POLYPROPYLENE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010067","CDM","C1781","HCPCS","0278","RC","","","","both","","","764.09","573.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","607.45","79.5","","948.87","198.19","1805.30","1 through 10","236.87","607.45","percent of total billed charges",""
"MESH SURGICAL 1 3/8IN 3.5CM HERNIA PROLENE 3D POLYPROPYLENE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010067","CDM","C1781","HCPCS","0278","RC","","","","both","","","764.09","573.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","407.26","53.3","","462.00","170.45","3253.37","1 through 10","236.87","607.45","percent of total billed charges",""
"MESH SURGICAL 1 3/8IN 3.5CM HERNIA PROLENE 3D POLYPROPYLENE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010067","CDM","C1781","HCPCS","0278","RC","","","","both","","","764.09","573.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","278.89","36.5","","245.50","107.19","1371.45","1 through 10","236.87","607.45","percent of total billed charges",""
"MESH SURGICAL 1 3/8IN 3.5CM HERNIA PROLENE 3D POLYPROPYLENE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010067","CDM","C1781","HCPCS","0278","RC","","","","both","","","764.09","573.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","292.65","38.3","","200.79","72.79","355.81","22","236.87","607.45","percent of total billed charges",""
"MESH SURGICAL 1 3/8IN 3.5CM HERNIA PROLENE 3D POLYPROPYLENE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010067","CDM","C1781","HCPCS","0278","RC","","","","both","","","764.09","573.07","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","588.35","77","","477.18","477.18","477.18","1 through 10","236.87","607.45","percent of total billed charges",""
"MESH SURGICAL 1 3/8IN 3.5CM HERNIA PROLENE 3D POLYPROPYLENE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010067","CDM","C1781","HCPCS","0278","RC","","","","both","","","764.09","573.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","327.79","42.9","","1045.91","1045.91","1045.91","1 through 10","236.87","607.45","percent of total billed charges",""
"MESH SURGICAL 1 3/8IN 3.5CM HERNIA PROLENE 3D POLYPROPYLENE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010067","CDM","C1781","HCPCS","0278","RC","","","","both","","","764.09","573.07","WELLPOINT [1015]","HB AMC WELLPOINT","563.75","73.78","","1726.50","1726.50","1726.50","1 through 10","236.87","607.45","percent of total billed charges",""
"MESH SURGICAL 1 3/8IN 3.5CM HERNIA PROLENE 3D POLYPROPYLENE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010067","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","764.09","573.07","AETNA [1001]","HB AMC AETNA HMO","533.33","69.8","","915.80","263.76","2881.00","1 through 10","399.31","624.41","percent of total billed charges",""
"MESH SURGICAL 1 3/8IN 3.5CM HERNIA PROLENE 3D POLYPROPYLENE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010067","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","764.09","573.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","624.41","81.72","","1531.57","410.52","8841.36","1 through 10","399.31","624.41","percent of total billed charges",""
"MESH SURGICAL 10 XCM PHASIX ST RESORBABLE SQUARE CS/1EA","SUP-ITM-10159305","CDM","C1781","HCPCS","0278","RC","","","","both","","","8186.00","6139.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","5730.20","70","","134.04","134.04","134.04","1 through 10","2537.66","6507.87","percent of total billed charges",""
"MESH SURGICAL 10 XCM PHASIX ST RESORBABLE SQUARE CS/1EA","SUP-ITM-10159305","CDM","C1781","HCPCS","0278","RC","","","","both","","","8186.00","6139.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6507.87","79.5","","948.87","198.19","1805.30","1 through 10","2537.66","6507.87","percent of total billed charges",""
"MESH SURGICAL 10 XCM PHASIX ST RESORBABLE SQUARE CS/1EA","SUP-ITM-10159305","CDM","C1781","HCPCS","0278","RC","","","","both","","","8186.00","6139.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4363.14","53.3","","462.00","170.45","3253.37","1 through 10","2537.66","6507.87","percent of total billed charges",""
"MESH SURGICAL 10 XCM PHASIX ST RESORBABLE SQUARE CS/1EA","SUP-ITM-10159305","CDM","C1781","HCPCS","0278","RC","","","","both","","","8186.00","6139.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2987.89","36.5","","245.50","107.19","1371.45","1 through 10","2537.66","6507.87","percent of total billed charges",""
"MESH SURGICAL 10 XCM PHASIX ST RESORBABLE SQUARE CS/1EA","SUP-ITM-10159305","CDM","C1781","HCPCS","0278","RC","","","","both","","","8186.00","6139.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3135.24","38.3","","200.79","72.79","355.81","22","2537.66","6507.87","percent of total billed charges",""
"MESH SURGICAL 10 XCM PHASIX ST RESORBABLE SQUARE CS/1EA","SUP-ITM-10159305","CDM","C1781","HCPCS","0278","RC","","","","both","","","8186.00","6139.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","6303.22","77","","477.18","477.18","477.18","1 through 10","2537.66","6507.87","percent of total billed charges",""
"MESH SURGICAL 10 XCM PHASIX ST RESORBABLE SQUARE CS/1EA","SUP-ITM-10159305","CDM","C1781","HCPCS","0278","RC","","","","both","","","8186.00","6139.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3511.79","42.9","","1045.91","1045.91","1045.91","1 through 10","2537.66","6507.87","percent of total billed charges",""
"MESH SURGICAL 10 XCM PHASIX ST RESORBABLE SQUARE CS/1EA","SUP-ITM-10159305","CDM","C1781","HCPCS","0278","RC","","","","both","","","8186.00","6139.50","WELLPOINT [1015]","HB AMC WELLPOINT","6039.63","73.78","","1726.50","1726.50","1726.50","1 through 10","2537.66","6507.87","percent of total billed charges",""
"MESH SURGICAL 10 XCM PHASIX ST RESORBABLE SQUARE CS/1EA","SUP-ITM-10159305","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8186.00","6139.50","AETNA [1001]","HB AMC AETNA HMO","5713.83","69.8","","915.80","263.76","2881.00","1 through 10","4278","6689.6","percent of total billed charges",""
"MESH SURGICAL 10 XCM PHASIX ST RESORBABLE SQUARE CS/1EA","SUP-ITM-10159305","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8186.00","6139.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6689.60","81.72","","1531.57","410.52","8841.36","1 through 10","4278","6689.6","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1926.09","1444.57","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1348.26","70","","134.04","134.04","134.04","1 through 10","597.09","1531.24","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1926.09","1444.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1531.24","79.5","","948.87","198.19","1805.30","1 through 10","597.09","1531.24","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1926.09","1444.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1026.61","53.3","","462.00","170.45","3253.37","1 through 10","597.09","1531.24","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1926.09","1444.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","703.02","36.5","","245.50","107.19","1371.45","1 through 10","597.09","1531.24","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1926.09","1444.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","737.69","38.3","","200.79","72.79","355.81","22","597.09","1531.24","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1926.09","1444.57","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1483.09","77","","477.18","477.18","477.18","1 through 10","597.09","1531.24","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1926.09","1444.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","826.29","42.9","","1045.91","1045.91","1045.91","1 through 10","597.09","1531.24","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1926.09","1444.57","WELLPOINT [1015]","HB AMC WELLPOINT","1421.07","73.78","","1726.50","1726.50","1726.50","1 through 10","597.09","1531.24","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1926.09","1444.57","AETNA [1001]","HB AMC AETNA HMO","1344.41","69.8","","915.80","263.76","2881.00","1 through 10","1006.57","1574","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1926.09","1444.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1574.00","81.72","","1531.57","410.52","8841.36","1 through 10","1006.57","1574","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","both","","","54978.75","41234.06","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","38485.13","70","","134.04","134.04","134.04","1 through 10","17043.41","43708.11","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","both","","","54978.75","41234.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","43708.11","79.5","","948.87","198.19","1805.30","1 through 10","17043.41","43708.11","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","both","","","54978.75","41234.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","29303.67","53.3","","462.00","170.45","3253.37","1 through 10","17043.41","43708.11","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","both","","","54978.75","41234.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20067.24","36.5","","245.50","107.19","1371.45","1 through 10","17043.41","43708.11","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","both","","","54978.75","41234.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21056.86","38.3","","200.79","72.79","355.81","22","17043.41","43708.11","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","both","","","54978.75","41234.06","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","42333.64","77","","477.18","477.18","477.18","1 through 10","17043.41","43708.11","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","both","","","54978.75","41234.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23585.88","42.9","","1045.91","1045.91","1045.91","1 through 10","17043.41","43708.11","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","both","","","54978.75","41234.06","WELLPOINT [1015]","HB AMC WELLPOINT","40563.32","73.78","","1726.50","1726.50","1726.50","1 through 10","17043.41","43708.11","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","54978.75","41234.06","AETNA [1001]","HB AMC AETNA HMO","38375.17","69.8","","915.80","263.76","2881.00","1 through 10","28731.89","44928.63","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","54978.75","41234.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","44928.63","81.72","","1531.57","410.52","8841.36","1 through 10","28731.89","44928.63","percent of total billed charges",""
"MESH SURGICAL 10MMX15 PYRA ROUND TITANIUM","SUP-ITM-10019661","CDM","C1889","HCPCS","0278","RC","","","","both","","","5582.50","4186.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4438.09","79.5","","1309.77","674.56","6049.93","26","1730.58","4438.09","percent of total billed charges",""
"MESH SURGICAL 10MMX15 PYRA ROUND TITANIUM","SUP-ITM-10019661","CDM","C1889","HCPCS","0278","RC","","","","both","","","5582.50","4186.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2975.47","53.3","","1901.83","1901.83","2962.25","1 through 10","1730.58","4438.09","percent of total billed charges",""
"MESH SURGICAL 10MMX15 PYRA ROUND TITANIUM","SUP-ITM-10019661","CDM","C1889","HCPCS","0278","RC","","","","both","","","5582.50","4186.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2037.61","36.5","","1620.31","1620.31","19908.88","1 through 10","1730.58","4438.09","percent of total billed charges",""
"MESH SURGICAL 10MMX15 PYRA ROUND TITANIUM","SUP-ITM-10019661","CDM","C1889","HCPCS","0278","RC","","","","both","","","5582.50","4186.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2138.10","38.3","","352.91","352.91","2046.30","1 through 10","1730.58","4438.09","percent of total billed charges",""
"MESH SURGICAL 10MMX15 PYRA ROUND TITANIUM","SUP-ITM-10019661","CDM","C1889","HCPCS","0278","RC","","","","both","","","5582.50","4186.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2394.89","42.9","","9668.75","9668.75","9668.75","1 through 10","1730.58","4438.09","percent of total billed charges",""
"MESH SURGICAL 10MMX15 PYRA ROUND TITANIUM","SUP-ITM-10019661","CDM","C1889","HCPCS","0278","RC","","","","both","","","5582.50","4186.87","WELLPOINT [1015]","HB AMC WELLPOINT","4118.77","73.78","","699.88","384.10","3443.31","33","1730.58","4438.09","percent of total billed charges",""
"MESH SURGICAL 10MMX15 PYRA ROUND TITANIUM","SUP-ITM-10019661","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5582.50","4186.87","AETNA [1001]","HB AMC AETNA HMO","3896.59","69.8","","1421.24","264.50","4933.46","29","2917.41","4562.02","percent of total billed charges",""
"MESH SURGICAL 10MMX15 PYRA ROUND TITANIUM","SUP-ITM-10019661","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5582.50","4186.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4488.33","80.4","","1022.97","1022.97","3607.50","1 through 10","2917.41","4562.02","percent of total billed charges",""
"MESH SURGICAL 10MMX15 PYRA ROUND TITANIUM","SUP-ITM-10019661","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5582.50","4186.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4562.02","81.72","","3010.54","693.88","5019.88","35","2917.41","4562.02","percent of total billed charges",""
"MESH SURGICAL 10X15CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285806","CDM","C1781","HCPCS","0278","RC","","","","both","","","13029.50","9772.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","9120.65","70","","134.04","134.04","134.04","1 through 10","4039.15","10358.45","percent of total billed charges",""
"MESH SURGICAL 10X15CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285806","CDM","C1781","HCPCS","0278","RC","","","","both","","","13029.50","9772.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10358.45","79.5","","948.87","198.19","1805.30","1 through 10","4039.15","10358.45","percent of total billed charges",""
"MESH SURGICAL 10X15CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285806","CDM","C1781","HCPCS","0278","RC","","","","both","","","13029.50","9772.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6944.72","53.3","","462.00","170.45","3253.37","1 through 10","4039.15","10358.45","percent of total billed charges",""
"MESH SURGICAL 10X15CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285806","CDM","C1781","HCPCS","0278","RC","","","","both","","","13029.50","9772.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4755.77","36.5","","245.50","107.19","1371.45","1 through 10","4039.15","10358.45","percent of total billed charges",""
"MESH SURGICAL 10X15CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285806","CDM","C1781","HCPCS","0278","RC","","","","both","","","13029.50","9772.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4990.30","38.3","","200.79","72.79","355.81","22","4039.15","10358.45","percent of total billed charges",""
"MESH SURGICAL 10X15CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285806","CDM","C1781","HCPCS","0278","RC","","","","both","","","13029.50","9772.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","10032.72","77","","477.18","477.18","477.18","1 through 10","4039.15","10358.45","percent of total billed charges",""
"MESH SURGICAL 10X15CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285806","CDM","C1781","HCPCS","0278","RC","","","","both","","","13029.50","9772.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5589.66","42.9","","1045.91","1045.91","1045.91","1 through 10","4039.15","10358.45","percent of total billed charges",""
"MESH SURGICAL 10X15CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285806","CDM","C1781","HCPCS","0278","RC","","","","both","","","13029.50","9772.12","WELLPOINT [1015]","HB AMC WELLPOINT","9613.17","73.78","","1726.50","1726.50","1726.50","1 through 10","4039.15","10358.45","percent of total billed charges",""
"MESH SURGICAL 10X15CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285806","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","13029.50","9772.12","AETNA [1001]","HB AMC AETNA HMO","9094.59","69.8","","915.80","263.76","2881.00","1 through 10","6809.22","10647.71","percent of total billed charges",""
"MESH SURGICAL 10X15CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285806","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","13029.50","9772.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10647.71","81.72","","1531.57","410.52","8841.36","1 through 10","6809.22","10647.71","percent of total billed charges",""
"MESH SURGICAL 11CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM CIRCLE","SUP-ITM-10285805","CDM","C1781","HCPCS","0278","RC","","","","both","","","9234.00","6925.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","6463.80","70","","134.04","134.04","134.04","1 through 10","2862.54","7341.03","percent of total billed charges",""
"MESH SURGICAL 11CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM CIRCLE","SUP-ITM-10285805","CDM","C1781","HCPCS","0278","RC","","","","both","","","9234.00","6925.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7341.03","79.5","","948.87","198.19","1805.30","1 through 10","2862.54","7341.03","percent of total billed charges",""
"MESH SURGICAL 11CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM CIRCLE","SUP-ITM-10285805","CDM","C1781","HCPCS","0278","RC","","","","both","","","9234.00","6925.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4921.72","53.3","","462.00","170.45","3253.37","1 through 10","2862.54","7341.03","percent of total billed charges",""
"MESH SURGICAL 11CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM CIRCLE","SUP-ITM-10285805","CDM","C1781","HCPCS","0278","RC","","","","both","","","9234.00","6925.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3370.41","36.5","","245.50","107.19","1371.45","1 through 10","2862.54","7341.03","percent of total billed charges",""
"MESH SURGICAL 11CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM CIRCLE","SUP-ITM-10285805","CDM","C1781","HCPCS","0278","RC","","","","both","","","9234.00","6925.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3536.62","38.3","","200.79","72.79","355.81","22","2862.54","7341.03","percent of total billed charges",""
"MESH SURGICAL 11CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM CIRCLE","SUP-ITM-10285805","CDM","C1781","HCPCS","0278","RC","","","","both","","","9234.00","6925.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","7110.18","77","","477.18","477.18","477.18","1 through 10","2862.54","7341.03","percent of total billed charges",""
"MESH SURGICAL 11CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM CIRCLE","SUP-ITM-10285805","CDM","C1781","HCPCS","0278","RC","","","","both","","","9234.00","6925.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3961.39","42.9","","1045.91","1045.91","1045.91","1 through 10","2862.54","7341.03","percent of total billed charges",""
"MESH SURGICAL 11CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM CIRCLE","SUP-ITM-10285805","CDM","C1781","HCPCS","0278","RC","","","","both","","","9234.00","6925.50","WELLPOINT [1015]","HB AMC WELLPOINT","6812.85","73.78","","1726.50","1726.50","1726.50","1 through 10","2862.54","7341.03","percent of total billed charges",""
"MESH SURGICAL 11CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM CIRCLE","SUP-ITM-10285805","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9234.00","6925.50","AETNA [1001]","HB AMC AETNA HMO","6445.33","69.8","","915.80","263.76","2881.00","1 through 10","4825.69","7546.02","percent of total billed charges",""
"MESH SURGICAL 11CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM CIRCLE","SUP-ITM-10285805","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9234.00","6925.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7546.02","81.72","","1531.57","410.52","8841.36","1 through 10","4825.69","7546.02","percent of total billed charges",""
"MESH SURGICAL 12X88MM SPINE SYN ROUND THORACOLUMBAR HEIGHT CONTOURED TI","SUP-ITM-10032892","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1309.77","674.56","6049.93","26","1627.5","4173.75","percent of total billed charges",""
"MESH SURGICAL 12X88MM SPINE SYN ROUND THORACOLUMBAR HEIGHT CONTOURED TI","SUP-ITM-10032892","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","1901.83","1901.83","2962.25","1 through 10","1627.5","4173.75","percent of total billed charges",""
"MESH SURGICAL 12X88MM SPINE SYN ROUND THORACOLUMBAR HEIGHT CONTOURED TI","SUP-ITM-10032892","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1620.31","1620.31","19908.88","1 through 10","1627.5","4173.75","percent of total billed charges",""
"MESH SURGICAL 12X88MM SPINE SYN ROUND THORACOLUMBAR HEIGHT CONTOURED TI","SUP-ITM-10032892","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","352.91","352.91","2046.30","1 through 10","1627.5","4173.75","percent of total billed charges",""
"MESH SURGICAL 12X88MM SPINE SYN ROUND THORACOLUMBAR HEIGHT CONTOURED TI","SUP-ITM-10032892","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","9668.75","9668.75","9668.75","1 through 10","1627.5","4173.75","percent of total billed charges",""
"MESH SURGICAL 12X88MM SPINE SYN ROUND THORACOLUMBAR HEIGHT CONTOURED TI","SUP-ITM-10032892","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","699.88","384.10","3443.31","33","1627.5","4173.75","percent of total billed charges",""
"MESH SURGICAL 12X88MM SPINE SYN ROUND THORACOLUMBAR HEIGHT CONTOURED TI","SUP-ITM-10032892","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1421.24","264.50","4933.46","29","2743.65","4290.3","percent of total billed charges",""
"MESH SURGICAL 12X88MM SPINE SYN ROUND THORACOLUMBAR HEIGHT CONTOURED TI","SUP-ITM-10032892","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4221.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2743.65","4290.3","percent of total billed charges",""
"MESH SURGICAL 12X88MM SPINE SYN ROUND THORACOLUMBAR HEIGHT CONTOURED TI","SUP-ITM-10032892","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","3010.54","693.88","5019.88","35","2743.65","4290.3","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","203.93","152.95","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","142.75","70","","134.04","134.04","134.04","1 through 10","63.22","162.12","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","203.93","152.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","162.12","79.5","","948.87","198.19","1805.30","1 through 10","63.22","162.12","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","203.93","152.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","108.69","53.3","","462.00","170.45","3253.37","1 through 10","63.22","162.12","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","203.93","152.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.43","36.5","","245.50","107.19","1371.45","1 through 10","63.22","162.12","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","203.93","152.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.11","38.3","","200.79","72.79","355.81","22","63.22","162.12","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","203.93","152.95","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","157.03","77","","477.18","477.18","477.18","1 through 10","63.22","162.12","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","203.93","152.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.49","42.9","","1045.91","1045.91","1045.91","1 through 10","63.22","162.12","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","203.93","152.95","WELLPOINT [1015]","HB AMC WELLPOINT","150.46","73.78","","1726.50","1726.50","1726.50","1 through 10","63.22","162.12","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","203.93","152.95","AETNA [1001]","HB AMC AETNA HMO","142.34","69.8","","915.80","263.76","2881.00","1 through 10","106.57","166.65","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","203.93","152.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","166.65","81.72","","1531.57","410.52","8841.36","1 through 10","106.57","166.65","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2315.25","70","","134.04","134.04","134.04","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2629.46","79.5","","948.87","198.19","1805.30","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1762.90","53.3","","462.00","170.45","3253.37","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1207.24","36.5","","245.50","107.19","1371.45","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1266.77","38.3","","200.79","72.79","355.81","22","1025.33","2629.46","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2546.78","77","","477.18","477.18","477.18","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1418.92","42.9","","1045.91","1045.91","1045.91","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","both","","","3307.50","2480.62","WELLPOINT [1015]","HB AMC WELLPOINT","2440.27","73.78","","1726.50","1726.50","1726.50","1 through 10","1025.33","2629.46","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","AETNA [1001]","HB AMC AETNA HMO","2308.64","69.8","","915.80","263.76","2881.00","1 through 10","1728.5","2702.89","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3307.50","2480.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2702.89","81.72","","1531.57","410.52","8841.36","1 through 10","1728.5","2702.89","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285652","CDM","C1781","HCPCS","0278","RC","","","","both","","","24671.00","18503.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","17269.70","70","","134.04","134.04","134.04","1 through 10","7648.01","19613.45","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285652","CDM","C1781","HCPCS","0278","RC","","","","both","","","24671.00","18503.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","19613.45","79.5","","948.87","198.19","1805.30","1 through 10","7648.01","19613.45","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285652","CDM","C1781","HCPCS","0278","RC","","","","both","","","24671.00","18503.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13149.64","53.3","","462.00","170.45","3253.37","1 through 10","7648.01","19613.45","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285652","CDM","C1781","HCPCS","0278","RC","","","","both","","","24671.00","18503.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9004.92","36.5","","245.50","107.19","1371.45","1 through 10","7648.01","19613.45","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285652","CDM","C1781","HCPCS","0278","RC","","","","both","","","24671.00","18503.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9448.99","38.3","","200.79","72.79","355.81","22","7648.01","19613.45","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285652","CDM","C1781","HCPCS","0278","RC","","","","both","","","24671.00","18503.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","18996.67","77","","477.18","477.18","477.18","1 through 10","7648.01","19613.45","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285652","CDM","C1781","HCPCS","0278","RC","","","","both","","","24671.00","18503.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10583.86","42.9","","1045.91","1045.91","1045.91","1 through 10","7648.01","19613.45","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285652","CDM","C1781","HCPCS","0278","RC","","","","both","","","24671.00","18503.25","WELLPOINT [1015]","HB AMC WELLPOINT","18202.26","73.78","","1726.50","1726.50","1726.50","1 through 10","7648.01","19613.45","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285652","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","24671.00","18503.25","AETNA [1001]","HB AMC AETNA HMO","17220.36","69.8","","915.80","263.76","2881.00","1 through 10","12893.06","20161.14","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285652","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","24671.00","18503.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","20161.14","81.72","","1531.57","410.52","8841.36","1 through 10","12893.06","20161.14","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","both","","","22433.50","16825.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","15703.45","70","","134.04","134.04","134.04","1 through 10","6954.39","17834.63","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","both","","","22433.50","16825.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","17834.63","79.5","","948.87","198.19","1805.30","1 through 10","6954.39","17834.63","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","both","","","22433.50","16825.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11957.06","53.3","","462.00","170.45","3253.37","1 through 10","6954.39","17834.63","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","both","","","22433.50","16825.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8188.23","36.5","","245.50","107.19","1371.45","1 through 10","6954.39","17834.63","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","both","","","22433.50","16825.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8592.03","38.3","","200.79","72.79","355.81","22","6954.39","17834.63","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","both","","","22433.50","16825.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","17273.80","77","","477.18","477.18","477.18","1 through 10","6954.39","17834.63","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","both","","","22433.50","16825.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9623.97","42.9","","1045.91","1045.91","1045.91","1 through 10","6954.39","17834.63","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","both","","","22433.50","16825.12","WELLPOINT [1015]","HB AMC WELLPOINT","16551.44","73.78","","1726.50","1726.50","1726.50","1 through 10","6954.39","17834.63","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","22433.50","16825.12","AETNA [1001]","HB AMC AETNA HMO","15658.58","69.8","","915.80","263.76","2881.00","1 through 10","11723.75","18332.66","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","22433.50","16825.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18332.66","81.72","","1531.57","410.52","8841.36","1 through 10","11723.75","18332.66","percent of total billed charges",""
"MESH SURGICAL 15X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285807","CDM","C1781","HCPCS","0278","RC","","","","both","","","36765.75","27574.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","25736.03","70","","134.04","134.04","134.04","1 through 10","11397.38","29228.77","percent of total billed charges",""
"MESH SURGICAL 15X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285807","CDM","C1781","HCPCS","0278","RC","","","","both","","","36765.75","27574.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","29228.77","79.5","","948.87","198.19","1805.30","1 through 10","11397.38","29228.77","percent of total billed charges",""
"MESH SURGICAL 15X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285807","CDM","C1781","HCPCS","0278","RC","","","","both","","","36765.75","27574.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19596.14","53.3","","462.00","170.45","3253.37","1 through 10","11397.38","29228.77","percent of total billed charges",""
"MESH SURGICAL 15X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285807","CDM","C1781","HCPCS","0278","RC","","","","both","","","36765.75","27574.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13419.50","36.5","","245.50","107.19","1371.45","1 through 10","11397.38","29228.77","percent of total billed charges",""
"MESH SURGICAL 15X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285807","CDM","C1781","HCPCS","0278","RC","","","","both","","","36765.75","27574.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14081.28","38.3","","200.79","72.79","355.81","22","11397.38","29228.77","percent of total billed charges",""
"MESH SURGICAL 15X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285807","CDM","C1781","HCPCS","0278","RC","","","","both","","","36765.75","27574.31","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","28309.63","77","","477.18","477.18","477.18","1 through 10","11397.38","29228.77","percent of total billed charges",""
"MESH SURGICAL 15X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285807","CDM","C1781","HCPCS","0278","RC","","","","both","","","36765.75","27574.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15772.51","42.9","","1045.91","1045.91","1045.91","1 through 10","11397.38","29228.77","percent of total billed charges",""
"MESH SURGICAL 15X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285807","CDM","C1781","HCPCS","0278","RC","","","","both","","","36765.75","27574.31","WELLPOINT [1015]","HB AMC WELLPOINT","27125.77","73.78","","1726.50","1726.50","1726.50","1 through 10","11397.38","29228.77","percent of total billed charges",""
"MESH SURGICAL 15X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285807","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","36765.75","27574.31","AETNA [1001]","HB AMC AETNA HMO","25662.49","69.8","","915.80","263.76","2881.00","1 through 10","19213.78","30044.97","percent of total billed charges",""
"MESH SURGICAL 15X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285807","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","36765.75","27574.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","30044.97","81.72","","1531.57","410.52","8841.36","1 through 10","19213.78","30044.97","percent of total billed charges",""
"MESH SURGICAL 2.0MMX20 30CM HERNIA DUAL BIOMATERIAL","SUP-ITM-10005037","CDM","C1781","HCPCS","0278","RC","","","","both","","","8122.50","6091.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","5685.75","70","","134.04","134.04","134.04","1 through 10","2517.98","6457.39","percent of total billed charges",""
"MESH SURGICAL 2.0MMX20 30CM HERNIA DUAL BIOMATERIAL","SUP-ITM-10005037","CDM","C1781","HCPCS","0278","RC","","","","both","","","8122.50","6091.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6457.39","79.5","","948.87","198.19","1805.30","1 through 10","2517.98","6457.39","percent of total billed charges",""
"MESH SURGICAL 2.0MMX20 30CM HERNIA DUAL BIOMATERIAL","SUP-ITM-10005037","CDM","C1781","HCPCS","0278","RC","","","","both","","","8122.50","6091.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4329.29","53.3","","462.00","170.45","3253.37","1 through 10","2517.98","6457.39","percent of total billed charges",""
"MESH SURGICAL 2.0MMX20 30CM HERNIA DUAL BIOMATERIAL","SUP-ITM-10005037","CDM","C1781","HCPCS","0278","RC","","","","both","","","8122.50","6091.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2964.71","36.5","","245.50","107.19","1371.45","1 through 10","2517.98","6457.39","percent of total billed charges",""
"MESH SURGICAL 2.0MMX20 30CM HERNIA DUAL BIOMATERIAL","SUP-ITM-10005037","CDM","C1781","HCPCS","0278","RC","","","","both","","","8122.50","6091.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3110.92","38.3","","200.79","72.79","355.81","22","2517.98","6457.39","percent of total billed charges",""
"MESH SURGICAL 2.0MMX20 30CM HERNIA DUAL BIOMATERIAL","SUP-ITM-10005037","CDM","C1781","HCPCS","0278","RC","","","","both","","","8122.50","6091.87","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","6254.33","77","","477.18","477.18","477.18","1 through 10","2517.98","6457.39","percent of total billed charges",""
"MESH SURGICAL 2.0MMX20 30CM HERNIA DUAL BIOMATERIAL","SUP-ITM-10005037","CDM","C1781","HCPCS","0278","RC","","","","both","","","8122.50","6091.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3484.55","42.9","","1045.91","1045.91","1045.91","1 through 10","2517.98","6457.39","percent of total billed charges",""
"MESH SURGICAL 2.0MMX20 30CM HERNIA DUAL BIOMATERIAL","SUP-ITM-10005037","CDM","C1781","HCPCS","0278","RC","","","","both","","","8122.50","6091.87","WELLPOINT [1015]","HB AMC WELLPOINT","5992.78","73.78","","1726.50","1726.50","1726.50","1 through 10","2517.98","6457.39","percent of total billed charges",""
"MESH SURGICAL 2.0MMX20 30CM HERNIA DUAL BIOMATERIAL","SUP-ITM-10005037","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8122.50","6091.87","AETNA [1001]","HB AMC AETNA HMO","5669.51","69.8","","915.80","263.76","2881.00","1 through 10","4244.82","6637.71","percent of total billed charges",""
"MESH SURGICAL 2.0MMX20 30CM HERNIA DUAL BIOMATERIAL","SUP-ITM-10005037","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8122.50","6091.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6637.71","81.72","","1531.57","410.52","8841.36","1 through 10","4244.82","6637.71","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285808","CDM","C1781","HCPCS","0278","RC","","","","both","","","40561.50","30421.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","28393.05","70","","134.04","134.04","134.04","1 through 10","12574.07","32246.39","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285808","CDM","C1781","HCPCS","0278","RC","","","","both","","","40561.50","30421.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","32246.39","79.5","","948.87","198.19","1805.30","1 through 10","12574.07","32246.39","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285808","CDM","C1781","HCPCS","0278","RC","","","","both","","","40561.50","30421.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","21619.28","53.3","","462.00","170.45","3253.37","1 through 10","12574.07","32246.39","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285808","CDM","C1781","HCPCS","0278","RC","","","","both","","","40561.50","30421.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14804.95","36.5","","245.50","107.19","1371.45","1 through 10","12574.07","32246.39","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285808","CDM","C1781","HCPCS","0278","RC","","","","both","","","40561.50","30421.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15535.05","38.3","","200.79","72.79","355.81","22","12574.07","32246.39","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285808","CDM","C1781","HCPCS","0278","RC","","","","both","","","40561.50","30421.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","31232.36","77","","477.18","477.18","477.18","1 through 10","12574.07","32246.39","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285808","CDM","C1781","HCPCS","0278","RC","","","","both","","","40561.50","30421.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17400.88","42.9","","1045.91","1045.91","1045.91","1 through 10","12574.07","32246.39","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285808","CDM","C1781","HCPCS","0278","RC","","","","both","","","40561.50","30421.12","WELLPOINT [1015]","HB AMC WELLPOINT","29926.27","73.78","","1726.50","1726.50","1726.50","1 through 10","12574.07","32246.39","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285808","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","40561.50","30421.12","AETNA [1001]","HB AMC AETNA HMO","28311.93","69.8","","915.80","263.76","2881.00","1 through 10","21197.44","33146.86","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285808","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","40561.50","30421.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","33146.86","81.72","","1531.57","410.52","8841.36","1 through 10","21197.44","33146.86","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","both","","","36879.25","27659.44","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","25815.48","70","","134.04","134.04","134.04","1 through 10","11432.57","29319","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","both","","","36879.25","27659.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","29319.00","79.5","","948.87","198.19","1805.30","1 through 10","11432.57","29319","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","both","","","36879.25","27659.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19656.64","53.3","","462.00","170.45","3253.37","1 through 10","11432.57","29319","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","both","","","36879.25","27659.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13460.93","36.5","","245.50","107.19","1371.45","1 through 10","11432.57","29319","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","both","","","36879.25","27659.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14124.75","38.3","","200.79","72.79","355.81","22","11432.57","29319","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","both","","","36879.25","27659.44","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","28397.02","77","","477.18","477.18","477.18","1 through 10","11432.57","29319","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","both","","","36879.25","27659.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15821.20","42.9","","1045.91","1045.91","1045.91","1 through 10","11432.57","29319","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","both","","","36879.25","27659.44","WELLPOINT [1015]","HB AMC WELLPOINT","27209.51","73.78","","1726.50","1726.50","1726.50","1 through 10","11432.57","29319","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","36879.25","27659.44","AETNA [1001]","HB AMC AETNA HMO","25741.72","69.8","","915.80","263.76","2881.00","1 through 10","19273.1","30137.72","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","36879.25","27659.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","30137.72","81.72","","1531.57","410.52","8841.36","1 through 10","19273.1","30137.72","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","11060.00","8295.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","7742.00","70","","134.04","134.04","134.04","1 through 10","3428.6","8792.7","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","11060.00","8295.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8792.70","79.5","","948.87","198.19","1805.30","1 through 10","3428.6","8792.7","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","11060.00","8295.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5894.98","53.3","","462.00","170.45","3253.37","1 through 10","3428.6","8792.7","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","11060.00","8295.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4036.90","36.5","","245.50","107.19","1371.45","1 through 10","3428.6","8792.7","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","11060.00","8295.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4235.98","38.3","","200.79","72.79","355.81","22","3428.6","8792.7","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","11060.00","8295.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","8516.20","77","","477.18","477.18","477.18","1 through 10","3428.6","8792.7","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","11060.00","8295.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4744.74","42.9","","1045.91","1045.91","1045.91","1 through 10","3428.6","8792.7","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","11060.00","8295.00","WELLPOINT [1015]","HB AMC WELLPOINT","8160.07","73.78","","1726.50","1726.50","1726.50","1 through 10","3428.6","8792.7","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","11060.00","8295.00","AETNA [1001]","HB AMC AETNA HMO","7719.88","69.8","","915.80","263.76","2881.00","1 through 10","5779.96","9038.23","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","11060.00","8295.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9038.23","81.72","","1531.57","410.52","8841.36","1 through 10","5779.96","9038.23","percent of total billed charges",""
"MESH SURGICAL 22X28X88MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007246","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1309.77","674.56","6049.93","26","1627.5","4173.75","percent of total billed charges",""
"MESH SURGICAL 22X28X88MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007246","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","1901.83","1901.83","2962.25","1 through 10","1627.5","4173.75","percent of total billed charges",""
"MESH SURGICAL 22X28X88MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007246","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1620.31","1620.31","19908.88","1 through 10","1627.5","4173.75","percent of total billed charges",""
"MESH SURGICAL 22X28X88MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007246","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","352.91","352.91","2046.30","1 through 10","1627.5","4173.75","percent of total billed charges",""
"MESH SURGICAL 22X28X88MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007246","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","9668.75","9668.75","9668.75","1 through 10","1627.5","4173.75","percent of total billed charges",""
"MESH SURGICAL 22X28X88MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007246","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","699.88","384.10","3443.31","33","1627.5","4173.75","percent of total billed charges",""
"MESH SURGICAL 22X28X88MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007246","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1421.24","264.50","4933.46","29","2743.65","4290.3","percent of total billed charges",""
"MESH SURGICAL 22X28X88MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007246","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4221.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2743.65","4290.3","percent of total billed charges",""
"MESH SURGICAL 22X28X88MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007246","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","3010.54","693.88","5019.88","35","2743.65","4290.3","percent of total billed charges",""
"MESH SURGICAL 25X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285809","CDM","C1781","HCPCS","0278","RC","","","","both","","","60474.00","45355.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","42331.80","70","","134.04","134.04","134.04","1 through 10","18746.94","48076.83","percent of total billed charges",""
"MESH SURGICAL 25X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285809","CDM","C1781","HCPCS","0278","RC","","","","both","","","60474.00","45355.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","48076.83","79.5","","948.87","198.19","1805.30","1 through 10","18746.94","48076.83","percent of total billed charges",""
"MESH SURGICAL 25X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285809","CDM","C1781","HCPCS","0278","RC","","","","both","","","60474.00","45355.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","32232.64","53.3","","462.00","170.45","3253.37","1 through 10","18746.94","48076.83","percent of total billed charges",""
"MESH SURGICAL 25X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285809","CDM","C1781","HCPCS","0278","RC","","","","both","","","60474.00","45355.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22073.01","36.5","","245.50","107.19","1371.45","1 through 10","18746.94","48076.83","percent of total billed charges",""
"MESH SURGICAL 25X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285809","CDM","C1781","HCPCS","0278","RC","","","","both","","","60474.00","45355.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23161.54","38.3","","200.79","72.79","355.81","22","18746.94","48076.83","percent of total billed charges",""
"MESH SURGICAL 25X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285809","CDM","C1781","HCPCS","0278","RC","","","","both","","","60474.00","45355.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","46564.98","77","","477.18","477.18","477.18","1 through 10","18746.94","48076.83","percent of total billed charges",""
"MESH SURGICAL 25X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285809","CDM","C1781","HCPCS","0278","RC","","","","both","","","60474.00","45355.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25943.35","42.9","","1045.91","1045.91","1045.91","1 through 10","18746.94","48076.83","percent of total billed charges",""
"MESH SURGICAL 25X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285809","CDM","C1781","HCPCS","0278","RC","","","","both","","","60474.00","45355.50","WELLPOINT [1015]","HB AMC WELLPOINT","44617.72","73.78","","1726.50","1726.50","1726.50","1 through 10","18746.94","48076.83","percent of total billed charges",""
"MESH SURGICAL 25X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285809","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","60474.00","45355.50","AETNA [1001]","HB AMC AETNA HMO","42210.85","69.8","","915.80","263.76","2881.00","1 through 10","31603.71","49419.35","percent of total billed charges",""
"MESH SURGICAL 25X30CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285809","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","60474.00","45355.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","49419.35","81.72","","1531.57","410.52","8841.36","1 through 10","31603.71","49419.35","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2477.59","1858.19","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1734.31","70","","134.04","134.04","134.04","1 through 10","768.05","1969.68","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2477.59","1858.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1969.68","79.5","","948.87","198.19","1805.30","1 through 10","768.05","1969.68","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2477.59","1858.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1320.56","53.3","","462.00","170.45","3253.37","1 through 10","768.05","1969.68","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2477.59","1858.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","904.32","36.5","","245.50","107.19","1371.45","1 through 10","768.05","1969.68","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2477.59","1858.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","948.92","38.3","","200.79","72.79","355.81","22","768.05","1969.68","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2477.59","1858.19","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1907.74","77","","477.18","477.18","477.18","1 through 10","768.05","1969.68","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2477.59","1858.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1062.89","42.9","","1045.91","1045.91","1045.91","1 through 10","768.05","1969.68","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2477.59","1858.19","WELLPOINT [1015]","HB AMC WELLPOINT","1827.97","73.78","","1726.50","1726.50","1726.50","1 through 10","768.05","1969.68","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2477.59","1858.19","AETNA [1001]","HB AMC AETNA HMO","1729.36","69.8","","915.80","263.76","2881.00","1 through 10","1294.79","2024.69","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2477.59","1858.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2024.69","81.72","","1531.57","410.52","8841.36","1 through 10","1294.79","2024.69","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285810","CDM","C1781","HCPCS","0278","RC","","","","both","","","83700.50","62775.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","58590.35","70","","134.04","134.04","134.04","1 through 10","25947.16","66541.9","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285810","CDM","C1781","HCPCS","0278","RC","","","","both","","","83700.50","62775.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","66541.90","79.5","","948.87","198.19","1805.30","1 through 10","25947.16","66541.9","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285810","CDM","C1781","HCPCS","0278","RC","","","","both","","","83700.50","62775.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","44612.37","53.3","","462.00","170.45","3253.37","1 through 10","25947.16","66541.9","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285810","CDM","C1781","HCPCS","0278","RC","","","","both","","","83700.50","62775.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30550.68","36.5","","245.50","107.19","1371.45","1 through 10","25947.16","66541.9","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285810","CDM","C1781","HCPCS","0278","RC","","","","both","","","83700.50","62775.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32057.29","38.3","","200.79","72.79","355.81","22","25947.16","66541.9","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285810","CDM","C1781","HCPCS","0278","RC","","","","both","","","83700.50","62775.37","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","64449.39","77","","477.18","477.18","477.18","1 through 10","25947.16","66541.9","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285810","CDM","C1781","HCPCS","0278","RC","","","","both","","","83700.50","62775.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35907.51","42.9","","1045.91","1045.91","1045.91","1 through 10","25947.16","66541.9","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285810","CDM","C1781","HCPCS","0278","RC","","","","both","","","83700.50","62775.37","WELLPOINT [1015]","HB AMC WELLPOINT","61754.23","73.78","","1726.50","1726.50","1726.50","1 through 10","25947.16","66541.9","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285810","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","83700.50","62775.37","AETNA [1001]","HB AMC AETNA HMO","58422.95","69.8","","915.80","263.76","2881.00","1 through 10","43741.88","68400.05","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST POCKETED BIORESORBABLE OPEN POSITIONING SYSTEM OVAL","SUP-ITM-10285810","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","83700.50","62775.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","68400.05","81.72","","1531.57","410.52","8841.36","1 through 10","43741.88","68400.05","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159310","CDM","C1781","HCPCS","0278","RC","","","","both","","","76081.00","57060.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","53256.70","70","","134.04","134.04","134.04","1 through 10","23585.11","60484.4","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159310","CDM","C1781","HCPCS","0278","RC","","","","both","","","76081.00","57060.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","60484.40","79.5","","948.87","198.19","1805.30","1 through 10","23585.11","60484.4","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159310","CDM","C1781","HCPCS","0278","RC","","","","both","","","76081.00","57060.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","40551.17","53.3","","462.00","170.45","3253.37","1 through 10","23585.11","60484.4","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159310","CDM","C1781","HCPCS","0278","RC","","","","both","","","76081.00","57060.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27769.57","36.5","","245.50","107.19","1371.45","1 through 10","23585.11","60484.4","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159310","CDM","C1781","HCPCS","0278","RC","","","","both","","","76081.00","57060.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29139.02","38.3","","200.79","72.79","355.81","22","23585.11","60484.4","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159310","CDM","C1781","HCPCS","0278","RC","","","","both","","","76081.00","57060.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","58582.37","77","","477.18","477.18","477.18","1 through 10","23585.11","60484.4","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159310","CDM","C1781","HCPCS","0278","RC","","","","both","","","76081.00","57060.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32638.75","42.9","","1045.91","1045.91","1045.91","1 through 10","23585.11","60484.4","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159310","CDM","C1781","HCPCS","0278","RC","","","","both","","","76081.00","57060.75","WELLPOINT [1015]","HB AMC WELLPOINT","56132.56","73.78","","1726.50","1726.50","1726.50","1 through 10","23585.11","60484.4","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159310","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","76081.00","57060.75","AETNA [1001]","HB AMC AETNA HMO","53104.54","69.8","","915.80","263.76","2881.00","1 through 10","39759.93","62173.39","percent of total billed charges",""
"MESH SURGICAL 30X35CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159310","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","76081.00","57060.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","62173.39","81.72","","1531.57","410.52","8841.36","1 through 10","39759.93","62173.39","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","22562.50","16921.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","15793.75","70","","134.04","134.04","134.04","1 through 10","6994.38","17937.19","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","22562.50","16921.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","17937.19","79.5","","948.87","198.19","1805.30","1 through 10","6994.38","17937.19","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","22562.50","16921.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12025.81","53.3","","462.00","170.45","3253.37","1 through 10","6994.38","17937.19","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","22562.50","16921.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8235.31","36.5","","245.50","107.19","1371.45","1 through 10","6994.38","17937.19","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","22562.50","16921.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8641.44","38.3","","200.79","72.79","355.81","22","6994.38","17937.19","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","22562.50","16921.87","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","17373.13","77","","477.18","477.18","477.18","1 through 10","6994.38","17937.19","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","22562.50","16921.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9679.31","42.9","","1045.91","1045.91","1045.91","1 through 10","6994.38","17937.19","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","22562.50","16921.87","WELLPOINT [1015]","HB AMC WELLPOINT","16646.61","73.78","","1726.50","1726.50","1726.50","1 through 10","6994.38","17937.19","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","22562.50","16921.87","AETNA [1001]","HB AMC AETNA HMO","15748.63","69.8","","915.80","263.76","2881.00","1 through 10","11791.16","18438.08","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","22562.50","16921.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18438.08","81.72","","1531.57","410.52","8841.36","1 through 10","11791.16","18438.08","percent of total billed charges",""
"MESH SURGICAL 4.5IN CIRCLE 11CM PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10320476","CDM","C1781","HCPCS","0278","RC","","","","both","","","9423.00","7067.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","6596.10","70","","134.04","134.04","134.04","1 through 10","2921.13","7491.29","percent of total billed charges",""
"MESH SURGICAL 4.5IN CIRCLE 11CM PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10320476","CDM","C1781","HCPCS","0278","RC","","","","both","","","9423.00","7067.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7491.29","79.5","","948.87","198.19","1805.30","1 through 10","2921.13","7491.29","percent of total billed charges",""
"MESH SURGICAL 4.5IN CIRCLE 11CM PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10320476","CDM","C1781","HCPCS","0278","RC","","","","both","","","9423.00","7067.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5022.46","53.3","","462.00","170.45","3253.37","1 through 10","2921.13","7491.29","percent of total billed charges",""
"MESH SURGICAL 4.5IN CIRCLE 11CM PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10320476","CDM","C1781","HCPCS","0278","RC","","","","both","","","9423.00","7067.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3439.40","36.5","","245.50","107.19","1371.45","1 through 10","2921.13","7491.29","percent of total billed charges",""
"MESH SURGICAL 4.5IN CIRCLE 11CM PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10320476","CDM","C1781","HCPCS","0278","RC","","","","both","","","9423.00","7067.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3609.01","38.3","","200.79","72.79","355.81","22","2921.13","7491.29","percent of total billed charges",""
"MESH SURGICAL 4.5IN CIRCLE 11CM PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10320476","CDM","C1781","HCPCS","0278","RC","","","","both","","","9423.00","7067.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","7255.71","77","","477.18","477.18","477.18","1 through 10","2921.13","7491.29","percent of total billed charges",""
"MESH SURGICAL 4.5IN CIRCLE 11CM PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10320476","CDM","C1781","HCPCS","0278","RC","","","","both","","","9423.00","7067.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4042.47","42.9","","1045.91","1045.91","1045.91","1 through 10","2921.13","7491.29","percent of total billed charges",""
"MESH SURGICAL 4.5IN CIRCLE 11CM PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10320476","CDM","C1781","HCPCS","0278","RC","","","","both","","","9423.00","7067.25","WELLPOINT [1015]","HB AMC WELLPOINT","6952.29","73.78","","1726.50","1726.50","1726.50","1 through 10","2921.13","7491.29","percent of total billed charges",""
"MESH SURGICAL 4.5IN CIRCLE 11CM PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10320476","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9423.00","7067.25","AETNA [1001]","HB AMC AETNA HMO","6577.25","69.8","","915.80","263.76","2881.00","1 through 10","4924.46","7700.48","percent of total billed charges",""
"MESH SURGICAL 4.5IN CIRCLE 11CM PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10320476","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9423.00","7067.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7700.48","81.72","","1531.57","410.52","8841.36","1 through 10","4924.46","7700.48","percent of total billed charges",""
"MESH SURGICAL 4IN X 6IN (10CMX15CM) PHASIX ST WITH ECHO 2 POSITIONING SYSTEM ELLIPSE","SUP-ITM-10337331","CDM","C1781","HCPCS","0278","RC","","","","both","","","12652.00","9489.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","8856.40","70","","134.04","134.04","134.04","1 through 10","3922.12","10058.34","percent of total billed charges",""
"MESH SURGICAL 4IN X 6IN (10CMX15CM) PHASIX ST WITH ECHO 2 POSITIONING SYSTEM ELLIPSE","SUP-ITM-10337331","CDM","C1781","HCPCS","0278","RC","","","","both","","","12652.00","9489.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10058.34","79.5","","948.87","198.19","1805.30","1 through 10","3922.12","10058.34","percent of total billed charges",""
"MESH SURGICAL 4IN X 6IN (10CMX15CM) PHASIX ST WITH ECHO 2 POSITIONING SYSTEM ELLIPSE","SUP-ITM-10337331","CDM","C1781","HCPCS","0278","RC","","","","both","","","12652.00","9489.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6743.52","53.3","","462.00","170.45","3253.37","1 through 10","3922.12","10058.34","percent of total billed charges",""
"MESH SURGICAL 4IN X 6IN (10CMX15CM) PHASIX ST WITH ECHO 2 POSITIONING SYSTEM ELLIPSE","SUP-ITM-10337331","CDM","C1781","HCPCS","0278","RC","","","","both","","","12652.00","9489.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4617.98","36.5","","245.50","107.19","1371.45","1 through 10","3922.12","10058.34","percent of total billed charges",""
"MESH SURGICAL 4IN X 6IN (10CMX15CM) PHASIX ST WITH ECHO 2 POSITIONING SYSTEM ELLIPSE","SUP-ITM-10337331","CDM","C1781","HCPCS","0278","RC","","","","both","","","12652.00","9489.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4845.72","38.3","","200.79","72.79","355.81","22","3922.12","10058.34","percent of total billed charges",""
"MESH SURGICAL 4IN X 6IN (10CMX15CM) PHASIX ST WITH ECHO 2 POSITIONING SYSTEM ELLIPSE","SUP-ITM-10337331","CDM","C1781","HCPCS","0278","RC","","","","both","","","12652.00","9489.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","9742.04","77","","477.18","477.18","477.18","1 through 10","3922.12","10058.34","percent of total billed charges",""
"MESH SURGICAL 4IN X 6IN (10CMX15CM) PHASIX ST WITH ECHO 2 POSITIONING SYSTEM ELLIPSE","SUP-ITM-10337331","CDM","C1781","HCPCS","0278","RC","","","","both","","","12652.00","9489.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5427.71","42.9","","1045.91","1045.91","1045.91","1 through 10","3922.12","10058.34","percent of total billed charges",""
"MESH SURGICAL 4IN X 6IN (10CMX15CM) PHASIX ST WITH ECHO 2 POSITIONING SYSTEM ELLIPSE","SUP-ITM-10337331","CDM","C1781","HCPCS","0278","RC","","","","both","","","12652.00","9489.00","WELLPOINT [1015]","HB AMC WELLPOINT","9334.65","73.78","","1726.50","1726.50","1726.50","1 through 10","3922.12","10058.34","percent of total billed charges",""
"MESH SURGICAL 4IN X 6IN (10CMX15CM) PHASIX ST WITH ECHO 2 POSITIONING SYSTEM ELLIPSE","SUP-ITM-10337331","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","12652.00","9489.00","AETNA [1001]","HB AMC AETNA HMO","8831.10","69.8","","915.80","263.76","2881.00","1 through 10","6611.94","10339.21","percent of total billed charges",""
"MESH SURGICAL 4IN X 6IN (10CMX15CM) PHASIX ST WITH ECHO 2 POSITIONING SYSTEM ELLIPSE","SUP-ITM-10337331","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","12652.00","9489.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10339.21","81.72","","1531.57","410.52","8841.36","1 through 10","6611.94","10339.21","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","831.58","623.68","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","582.11","70","","134.04","134.04","134.04","1 through 10","257.79","661.11","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","831.58","623.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","661.11","79.5","","948.87","198.19","1805.30","1 through 10","257.79","661.11","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","831.58","623.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","443.23","53.3","","462.00","170.45","3253.37","1 through 10","257.79","661.11","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","831.58","623.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","303.53","36.5","","245.50","107.19","1371.45","1 through 10","257.79","661.11","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","831.58","623.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","318.50","38.3","","200.79","72.79","355.81","22","257.79","661.11","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","831.58","623.68","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","640.32","77","","477.18","477.18","477.18","1 through 10","257.79","661.11","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","831.58","623.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","356.75","42.9","","1045.91","1045.91","1045.91","1 through 10","257.79","661.11","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","831.58","623.68","WELLPOINT [1015]","HB AMC WELLPOINT","613.54","73.78","","1726.50","1726.50","1726.50","1 through 10","257.79","661.11","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","831.58","623.68","AETNA [1001]","HB AMC AETNA HMO","580.44","69.8","","915.80","263.76","2881.00","1 through 10","434.58","679.57","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","831.58","623.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","679.57","81.72","","1531.57","410.52","8841.36","1 through 10","434.58","679.57","percent of total billed charges",""
"MESH SURGICAL 6IN CIRCLE PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10318477","CDM","C1781","HCPCS","0278","RC","","","","both","","","16292.00","12219.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","11404.40","70","","134.04","134.04","134.04","1 through 10","5050.52","12952.14","percent of total billed charges",""
"MESH SURGICAL 6IN CIRCLE PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10318477","CDM","C1781","HCPCS","0278","RC","","","","both","","","16292.00","12219.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12952.14","79.5","","948.87","198.19","1805.30","1 through 10","5050.52","12952.14","percent of total billed charges",""
"MESH SURGICAL 6IN CIRCLE PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10318477","CDM","C1781","HCPCS","0278","RC","","","","both","","","16292.00","12219.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8683.64","53.3","","462.00","170.45","3253.37","1 through 10","5050.52","12952.14","percent of total billed charges",""
"MESH SURGICAL 6IN CIRCLE PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10318477","CDM","C1781","HCPCS","0278","RC","","","","both","","","16292.00","12219.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5946.58","36.5","","245.50","107.19","1371.45","1 through 10","5050.52","12952.14","percent of total billed charges",""
"MESH SURGICAL 6IN CIRCLE PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10318477","CDM","C1781","HCPCS","0278","RC","","","","both","","","16292.00","12219.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6239.84","38.3","","200.79","72.79","355.81","22","5050.52","12952.14","percent of total billed charges",""
"MESH SURGICAL 6IN CIRCLE PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10318477","CDM","C1781","HCPCS","0278","RC","","","","both","","","16292.00","12219.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","12544.84","77","","477.18","477.18","477.18","1 through 10","5050.52","12952.14","percent of total billed charges",""
"MESH SURGICAL 6IN CIRCLE PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10318477","CDM","C1781","HCPCS","0278","RC","","","","both","","","16292.00","12219.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6989.27","42.9","","1045.91","1045.91","1045.91","1 through 10","5050.52","12952.14","percent of total billed charges",""
"MESH SURGICAL 6IN CIRCLE PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10318477","CDM","C1781","HCPCS","0278","RC","","","","both","","","16292.00","12219.00","WELLPOINT [1015]","HB AMC WELLPOINT","12020.24","73.78","","1726.50","1726.50","1726.50","1 through 10","5050.52","12952.14","percent of total billed charges",""
"MESH SURGICAL 6IN CIRCLE PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10318477","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","16292.00","12219.00","AETNA [1001]","HB AMC AETNA HMO","11371.82","69.8","","915.80","263.76","2881.00","1 through 10","8514.2","13313.82","percent of total billed charges",""
"MESH SURGICAL 6IN CIRCLE PHASIX ST ECHO 2 POSITIONING SYSTEM","SUP-ITM-10318477","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","16292.00","12219.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13313.82","81.72","","1531.57","410.52","8841.36","1 through 10","8514.2","13313.82","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","5948.25","4461.19","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4163.78","70","","134.04","134.04","134.04","1 through 10","1843.96","4728.86","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","5948.25","4461.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4728.86","79.5","","948.87","198.19","1805.30","1 through 10","1843.96","4728.86","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","5948.25","4461.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3170.42","53.3","","462.00","170.45","3253.37","1 through 10","1843.96","4728.86","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","5948.25","4461.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2171.11","36.5","","245.50","107.19","1371.45","1 through 10","1843.96","4728.86","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","5948.25","4461.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2278.18","38.3","","200.79","72.79","355.81","22","1843.96","4728.86","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","5948.25","4461.19","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4580.15","77","","477.18","477.18","477.18","1 through 10","1843.96","4728.86","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","5948.25","4461.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2551.80","42.9","","1045.91","1045.91","1045.91","1 through 10","1843.96","4728.86","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","5948.25","4461.19","WELLPOINT [1015]","HB AMC WELLPOINT","4388.62","73.78","","1726.50","1726.50","1726.50","1 through 10","1843.96","4728.86","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5948.25","4461.19","AETNA [1001]","HB AMC AETNA HMO","4151.88","69.8","","915.80","263.76","2881.00","1 through 10","3108.56","4860.91","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5948.25","4461.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4860.91","81.72","","1531.57","410.52","8841.36","1 through 10","3108.56","4860.91","percent of total billed charges",""
"MESH SURGICAL 8.0X12IN SEPRA POLYPROPYLENE HERNIA REPAIR IP COMPOSITE RECTANGLE CS/1BX/1EA","SUP-ITM-10014510","CDM","C1781","HCPCS","0278","RC","","","","both","","","4197.00","3147.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2937.90","70","","134.04","134.04","134.04","1 through 10","1301.07","3336.62","percent of total billed charges",""
"MESH SURGICAL 8.0X12IN SEPRA POLYPROPYLENE HERNIA REPAIR IP COMPOSITE RECTANGLE CS/1BX/1EA","SUP-ITM-10014510","CDM","C1781","HCPCS","0278","RC","","","","both","","","4197.00","3147.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3336.62","79.5","","948.87","198.19","1805.30","1 through 10","1301.07","3336.62","percent of total billed charges",""
"MESH SURGICAL 8.0X12IN SEPRA POLYPROPYLENE HERNIA REPAIR IP COMPOSITE RECTANGLE CS/1BX/1EA","SUP-ITM-10014510","CDM","C1781","HCPCS","0278","RC","","","","both","","","4197.00","3147.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2237.00","53.3","","462.00","170.45","3253.37","1 through 10","1301.07","3336.62","percent of total billed charges",""
"MESH SURGICAL 8.0X12IN SEPRA POLYPROPYLENE HERNIA REPAIR IP COMPOSITE RECTANGLE CS/1BX/1EA","SUP-ITM-10014510","CDM","C1781","HCPCS","0278","RC","","","","both","","","4197.00","3147.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1531.91","36.5","","245.50","107.19","1371.45","1 through 10","1301.07","3336.62","percent of total billed charges",""
"MESH SURGICAL 8.0X12IN SEPRA POLYPROPYLENE HERNIA REPAIR IP COMPOSITE RECTANGLE CS/1BX/1EA","SUP-ITM-10014510","CDM","C1781","HCPCS","0278","RC","","","","both","","","4197.00","3147.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1607.45","38.3","","200.79","72.79","355.81","22","1301.07","3336.62","percent of total billed charges",""
"MESH SURGICAL 8.0X12IN SEPRA POLYPROPYLENE HERNIA REPAIR IP COMPOSITE RECTANGLE CS/1BX/1EA","SUP-ITM-10014510","CDM","C1781","HCPCS","0278","RC","","","","both","","","4197.00","3147.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3231.69","77","","477.18","477.18","477.18","1 through 10","1301.07","3336.62","percent of total billed charges",""
"MESH SURGICAL 8.0X12IN SEPRA POLYPROPYLENE HERNIA REPAIR IP COMPOSITE RECTANGLE CS/1BX/1EA","SUP-ITM-10014510","CDM","C1781","HCPCS","0278","RC","","","","both","","","4197.00","3147.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1800.51","42.9","","1045.91","1045.91","1045.91","1 through 10","1301.07","3336.62","percent of total billed charges",""
"MESH SURGICAL 8.0X12IN SEPRA POLYPROPYLENE HERNIA REPAIR IP COMPOSITE RECTANGLE CS/1BX/1EA","SUP-ITM-10014510","CDM","C1781","HCPCS","0278","RC","","","","both","","","4197.00","3147.75","WELLPOINT [1015]","HB AMC WELLPOINT","3096.55","73.78","","1726.50","1726.50","1726.50","1 through 10","1301.07","3336.62","percent of total billed charges",""
"MESH SURGICAL 8.0X12IN SEPRA POLYPROPYLENE HERNIA REPAIR IP COMPOSITE RECTANGLE CS/1BX/1EA","SUP-ITM-10014510","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4197.00","3147.75","AETNA [1001]","HB AMC AETNA HMO","2929.51","69.8","","915.80","263.76","2881.00","1 through 10","2193.35","3429.79","percent of total billed charges",""
"MESH SURGICAL 8.0X12IN SEPRA POLYPROPYLENE HERNIA REPAIR IP COMPOSITE RECTANGLE CS/1BX/1EA","SUP-ITM-10014510","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4197.00","3147.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3429.79","81.72","","1531.57","410.52","8841.36","1 through 10","2193.35","3429.79","percent of total billed charges",""
"MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE ABSORBABLE FLAT 6.0 X 6.0IN BX/3EA","SUP-ITM-10337420","CDM","C1781","HCPCS","0278","RC","","","","both","","","421.74","316.30","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","295.22","70","","134.04","134.04","134.04","1 through 10","130.74","335.28","percent of total billed charges",""
"MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE ABSORBABLE FLAT 6.0 X 6.0IN BX/3EA","SUP-ITM-10337420","CDM","C1781","HCPCS","0278","RC","","","","both","","","421.74","316.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","335.28","79.5","","948.87","198.19","1805.30","1 through 10","130.74","335.28","percent of total billed charges",""
"MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE ABSORBABLE FLAT 6.0 X 6.0IN BX/3EA","SUP-ITM-10337420","CDM","C1781","HCPCS","0278","RC","","","","both","","","421.74","316.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","224.79","53.3","","462.00","170.45","3253.37","1 through 10","130.74","335.28","percent of total billed charges",""
"MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE ABSORBABLE FLAT 6.0 X 6.0IN BX/3EA","SUP-ITM-10337420","CDM","C1781","HCPCS","0278","RC","","","","both","","","421.74","316.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","153.94","36.5","","245.50","107.19","1371.45","1 through 10","130.74","335.28","percent of total billed charges",""
"MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE ABSORBABLE FLAT 6.0 X 6.0IN BX/3EA","SUP-ITM-10337420","CDM","C1781","HCPCS","0278","RC","","","","both","","","421.74","316.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","161.53","38.3","","200.79","72.79","355.81","22","130.74","335.28","percent of total billed charges",""
"MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE ABSORBABLE FLAT 6.0 X 6.0IN BX/3EA","SUP-ITM-10337420","CDM","C1781","HCPCS","0278","RC","","","","both","","","421.74","316.30","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","324.74","77","","477.18","477.18","477.18","1 through 10","130.74","335.28","percent of total billed charges",""
"MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE ABSORBABLE FLAT 6.0 X 6.0IN BX/3EA","SUP-ITM-10337420","CDM","C1781","HCPCS","0278","RC","","","","both","","","421.74","316.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.93","42.9","","1045.91","1045.91","1045.91","1 through 10","130.74","335.28","percent of total billed charges",""
"MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE ABSORBABLE FLAT 6.0 X 6.0IN BX/3EA","SUP-ITM-10337420","CDM","C1781","HCPCS","0278","RC","","","","both","","","421.74","316.30","WELLPOINT [1015]","HB AMC WELLPOINT","311.16","73.78","","1726.50","1726.50","1726.50","1 through 10","130.74","335.28","percent of total billed charges",""
"MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE ABSORBABLE FLAT 6.0 X 6.0IN BX/3EA","SUP-ITM-10337420","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","421.74","316.30","AETNA [1001]","HB AMC AETNA HMO","294.37","69.8","","915.80","263.76","2881.00","1 through 10","220.4","344.65","percent of total billed charges",""
"MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE ABSORBABLE FLAT 6.0 X 6.0IN BX/3EA","SUP-ITM-10337420","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","421.74","316.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","344.65","81.72","","1531.57","410.52","8841.36","1 through 10","220.4","344.65","percent of total billed charges",""
"MESH SURGICAL POSITIONING Y SHAPED FLAT SUTURING SURFACE MULTI DIRECTIONAL VAGINAL UPSYLON COLPASSIST IMPLANTABLE SACRAL COLPOPE","SUP-ITM-10118315","CDM","C1763","HCPCS","0278","RC","","","","both","","","3120.36","2340.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2028.23","65","","2028.23","1653.70","2028.23","1 through 10","967.31","2480.69","percent of total billed charges",""
"MESH SURGICAL POSITIONING Y SHAPED FLAT SUTURING SURFACE MULTI DIRECTIONAL VAGINAL UPSYLON COLPASSIST IMPLANTABLE SACRAL COLPOPE","SUP-ITM-10118315","CDM","C1763","HCPCS","0278","RC","","","","both","","","3120.36","2340.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1138.93","36.5","","1163.89","1163.89","1163.89","1 through 10","967.31","2480.69","percent of total billed charges",""
"MESH SURGICAL POSITIONING Y SHAPED FLAT SUTURING SURFACE MULTI DIRECTIONAL VAGINAL UPSYLON COLPASSIST IMPLANTABLE SACRAL COLPOPE","SUP-ITM-10118315","CDM","C1763","HCPCS","0278","RC","","","","both","","","3120.36","2340.27","WELLPOINT [1015]","HB AMC WELLPOINT","2302.20","73.78","","4280.87","4280.87","4280.87","1 through 10","967.31","2480.69","percent of total billed charges",""
"MESH SYNTHETIC 0.6MM LG PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CRESCENT RIGID TI","SUP-ITM-10131077","CDM","C1713","HCPCS","0278","RC","","","","both","","","2863.11","2147.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2276.17","79.5","","800.18","480.96","1887.97","195","887.56","2276.17","percent of total billed charges",""
"MESH SYNTHETIC 0.6MM LG PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CRESCENT RIGID TI","SUP-ITM-10131077","CDM","C1713","HCPCS","0278","RC","","","","both","","","2863.11","2147.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1526.04","53.3","","813.12","216.42","1444.50","81","887.56","2276.17","percent of total billed charges",""
"MESH SYNTHETIC 0.6MM LG PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CRESCENT RIGID TI","SUP-ITM-10131077","CDM","C1713","HCPCS","0278","RC","","","","both","","","2863.11","2147.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","887.56","31","","432.60","432.60","432.60","1 through 10","887.56","2276.17","percent of total billed charges",""
"MESH SYNTHETIC 0.6MM LG PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CRESCENT RIGID TI","SUP-ITM-10131077","CDM","C1713","HCPCS","0278","RC","","","","both","","","2863.11","2147.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1045.04","36.5","","148.37","54.89","631.39","94","887.56","2276.17","percent of total billed charges",""
"MESH SYNTHETIC 0.6MM LG PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CRESCENT RIGID TI","SUP-ITM-10131077","CDM","C1713","HCPCS","0278","RC","","","","both","","","2863.11","2147.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1096.57","38.3","","279.30","91.72","1116.77","266","887.56","2276.17","percent of total billed charges",""
"MESH SYNTHETIC 0.6MM LG PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CRESCENT RIGID TI","SUP-ITM-10131077","CDM","C1713","HCPCS","0278","RC","","","","both","","","2863.11","2147.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1228.27","42.9","","731.00","63.70","731.00","1 through 10","887.56","2276.17","percent of total billed charges",""
"MESH SYNTHETIC 0.6MM LG PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CRESCENT RIGID TI","SUP-ITM-10131077","CDM","C1713","HCPCS","0278","RC","","","","both","","","2863.11","2147.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1228.27","42.9","","384.74","384.74","384.74","1 through 10","887.56","2276.17","percent of total billed charges",""
"MESH SYNTHETIC 0.6MM LG PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CRESCENT RIGID TI","SUP-ITM-10131077","CDM","C1713","HCPCS","0278","RC","","","","both","","","2863.11","2147.33","WELLPOINT [1015]","HB AMC WELLPOINT","2112.40","73.78","","286.63","119.22","1107.45","105","887.56","2276.17","percent of total billed charges",""
"MESH SYNTHETIC 0.6MM LG PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CRESCENT RIGID TI","SUP-ITM-10131077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2863.11","2147.33","AETNA [1001]","HB AMC AETNA HMO","1998.45","69.8","","675.31","184.75","1721.50","286","1496.26","2339.73","percent of total billed charges",""
"MESH SYNTHETIC 0.6MM LG PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CRESCENT RIGID TI","SUP-ITM-10131077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2863.11","2147.33","AETNA [1001]","HB AMC AETNA PPO","2301.94","80.4","","1261.44","103.12","1514.10","21","1496.26","2339.73","percent of total billed charges",""
"MESH SYNTHETIC 0.6MM LG PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CRESCENT RIGID TI","SUP-ITM-10131077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2863.11","2147.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2301.94","80.4","","1365.00","1365.00","1365.00","1 through 10","1496.26","2339.73","percent of total billed charges",""
"MESH SYNTHETIC 0.6MM LG PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CRESCENT RIGID TI","SUP-ITM-10131077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2863.11","2147.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2339.73","81.72","","5157.68","5157.68","5157.68","1 through 10","1496.26","2339.73","percent of total billed charges",""
"MESH SYNTHETIC 0.6MM LG PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CRESCENT RIGID TI","SUP-ITM-10131077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2863.11","2147.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2339.73","81.72","","431.26","71.26","1459.57","88","1496.26","2339.73","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10082411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3607.31","2705.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2867.81","79.5","","800.18","480.96","1887.97","195","1118.27","2867.81","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10082411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3607.31","2705.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1922.70","53.3","","813.12","216.42","1444.50","81","1118.27","2867.81","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10082411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3607.31","2705.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1118.27","31","","432.60","432.60","432.60","1 through 10","1118.27","2867.81","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10082411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3607.31","2705.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1316.67","36.5","","148.37","54.89","631.39","94","1118.27","2867.81","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10082411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3607.31","2705.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1381.60","38.3","","279.30","91.72","1116.77","266","1118.27","2867.81","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10082411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3607.31","2705.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1547.54","42.9","","731.00","63.70","731.00","1 through 10","1118.27","2867.81","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10082411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3607.31","2705.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1547.54","42.9","","384.74","384.74","384.74","1 through 10","1118.27","2867.81","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10082411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3607.31","2705.48","WELLPOINT [1015]","HB AMC WELLPOINT","2661.47","73.78","","286.63","119.22","1107.45","105","1118.27","2867.81","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10082411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3607.31","2705.48","AETNA [1001]","HB AMC AETNA HMO","2517.90","69.8","","675.31","184.75","1721.50","286","1885.18","2947.89","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10082411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3607.31","2705.48","AETNA [1001]","HB AMC AETNA PPO","2900.28","80.4","","1261.44","103.12","1514.10","21","1885.18","2947.89","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10082411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3607.31","2705.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2900.28","80.4","","1365.00","1365.00","1365.00","1 through 10","1885.18","2947.89","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10082411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3607.31","2705.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2947.89","81.72","","5157.68","5157.68","5157.68","1 through 10","1885.18","2947.89","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10082411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3607.31","2705.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2947.89","81.72","","431.26","71.26","1459.57","88","1885.18","2947.89","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077385","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.68","3324.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3523.98","79.5","","800.18","480.96","1887.97","195","1374.13","3523.98","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077385","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.68","3324.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2362.62","53.3","","813.12","216.42","1444.50","81","1374.13","3523.98","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077385","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.68","3324.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1374.13","31","","432.60","432.60","432.60","1 through 10","1374.13","3523.98","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077385","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.68","3324.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1617.93","36.5","","148.37","54.89","631.39","94","1374.13","3523.98","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077385","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.68","3324.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1697.72","38.3","","279.30","91.72","1116.77","266","1374.13","3523.98","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077385","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.68","3324.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1901.62","42.9","","731.00","63.70","731.00","1 through 10","1374.13","3523.98","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077385","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.68","3324.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1901.62","42.9","","384.74","384.74","384.74","1 through 10","1374.13","3523.98","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077385","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.68","3324.51","WELLPOINT [1015]","HB AMC WELLPOINT","3270.43","73.78","","286.63","119.22","1107.45","105","1374.13","3523.98","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4432.68","3324.51","AETNA [1001]","HB AMC AETNA HMO","3094.01","69.8","","675.31","184.75","1721.50","286","2316.52","3622.39","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4432.68","3324.51","AETNA [1001]","HB AMC AETNA PPO","3563.87","80.4","","1261.44","103.12","1514.10","21","2316.52","3622.39","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4432.68","3324.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3563.87","80.4","","1365.00","1365.00","1365.00","1 through 10","2316.52","3622.39","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4432.68","3324.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3622.39","81.72","","5157.68","5157.68","5157.68","1 through 10","2316.52","3622.39","percent of total billed charges",""
"MESH SYNTHETIC 0.6X100MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4432.68","3324.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3622.39","81.72","","431.26","71.26","1459.57","88","2316.52","3622.39","percent of total billed charges",""
"MESH SYNTHETIC 0.6X200MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077386","CDM","C1713","HCPCS","0278","RC","","","","both","","","9688.80","7266.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7702.60","79.5","","800.18","480.96","1887.97","195","3003.53","7702.6","percent of total billed charges",""
"MESH SYNTHETIC 0.6X200MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077386","CDM","C1713","HCPCS","0278","RC","","","","both","","","9688.80","7266.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5164.13","53.3","","813.12","216.42","1444.50","81","3003.53","7702.6","percent of total billed charges",""
"MESH SYNTHETIC 0.6X200MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077386","CDM","C1713","HCPCS","0278","RC","","","","both","","","9688.80","7266.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3003.53","31","","432.60","432.60","432.60","1 through 10","3003.53","7702.6","percent of total billed charges",""
"MESH SYNTHETIC 0.6X200MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077386","CDM","C1713","HCPCS","0278","RC","","","","both","","","9688.80","7266.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3536.41","36.5","","148.37","54.89","631.39","94","3003.53","7702.6","percent of total billed charges",""
"MESH SYNTHETIC 0.6X200MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077386","CDM","C1713","HCPCS","0278","RC","","","","both","","","9688.80","7266.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3710.81","38.3","","279.30","91.72","1116.77","266","3003.53","7702.6","percent of total billed charges",""
"MESH SYNTHETIC 0.6X200MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077386","CDM","C1713","HCPCS","0278","RC","","","","both","","","9688.80","7266.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4156.50","42.9","","731.00","63.70","731.00","1 through 10","3003.53","7702.6","percent of total billed charges",""
"MESH SYNTHETIC 0.6X200MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077386","CDM","C1713","HCPCS","0278","RC","","","","both","","","9688.80","7266.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4156.50","42.9","","384.74","384.74","384.74","1 through 10","3003.53","7702.6","percent of total billed charges",""
"MESH SYNTHETIC 0.6X200MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077386","CDM","C1713","HCPCS","0278","RC","","","","both","","","9688.80","7266.60","WELLPOINT [1015]","HB AMC WELLPOINT","7148.40","73.78","","286.63","119.22","1107.45","105","3003.53","7702.6","percent of total billed charges",""
"MESH SYNTHETIC 0.6X200MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9688.80","7266.60","AETNA [1001]","HB AMC AETNA HMO","6762.78","69.8","","675.31","184.75","1721.50","286","5063.37","7917.69","percent of total billed charges",""
"MESH SYNTHETIC 0.6X200MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9688.80","7266.60","AETNA [1001]","HB AMC AETNA PPO","7789.80","80.4","","1261.44","103.12","1514.10","21","5063.37","7917.69","percent of total billed charges",""
"MESH SYNTHETIC 0.6X200MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9688.80","7266.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7789.80","80.4","","1365.00","1365.00","1365.00","1 through 10","5063.37","7917.69","percent of total billed charges",""
"MESH SYNTHETIC 0.6X200MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9688.80","7266.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7917.69","81.72","","5157.68","5157.68","5157.68","1 through 10","5063.37","7917.69","percent of total billed charges",""
"MESH SYNTHETIC 0.6X200MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9688.80","7266.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7917.69","81.72","","431.26","71.26","1459.57","88","5063.37","7917.69","percent of total billed charges",""
"MESH SYNTHETIC 0.6X38 45MM PLATE CRANIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.74","2135.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2263.95","79.5","","800.18","480.96","1887.97","195","882.8","2263.95","percent of total billed charges",""
"MESH SYNTHETIC 0.6X38 45MM PLATE CRANIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.74","2135.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1517.85","53.3","","813.12","216.42","1444.50","81","882.8","2263.95","percent of total billed charges",""
"MESH SYNTHETIC 0.6X38 45MM PLATE CRANIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.74","2135.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","882.80","31","","432.60","432.60","432.60","1 through 10","882.8","2263.95","percent of total billed charges",""
"MESH SYNTHETIC 0.6X38 45MM PLATE CRANIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.74","2135.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1039.43","36.5","","148.37","54.89","631.39","94","882.8","2263.95","percent of total billed charges",""
"MESH SYNTHETIC 0.6X38 45MM PLATE CRANIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.74","2135.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1090.68","38.3","","279.30","91.72","1116.77","266","882.8","2263.95","percent of total billed charges",""
"MESH SYNTHETIC 0.6X38 45MM PLATE CRANIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.74","2135.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1221.68","42.9","","731.00","63.70","731.00","1 through 10","882.8","2263.95","percent of total billed charges",""
"MESH SYNTHETIC 0.6X38 45MM PLATE CRANIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.74","2135.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1221.68","42.9","","384.74","384.74","384.74","1 through 10","882.8","2263.95","percent of total billed charges",""
"MESH SYNTHETIC 0.6X38 45MM PLATE CRANIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.74","2135.80","WELLPOINT [1015]","HB AMC WELLPOINT","2101.06","73.78","","286.63","119.22","1107.45","105","882.8","2263.95","percent of total billed charges",""
"MESH SYNTHETIC 0.6X38 45MM PLATE CRANIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2847.74","2135.80","AETNA [1001]","HB AMC AETNA HMO","1987.72","69.8","","675.31","184.75","1721.50","286","1488.23","2327.17","percent of total billed charges",""
"MESH SYNTHETIC 0.6X38 45MM PLATE CRANIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2847.74","2135.80","AETNA [1001]","HB AMC AETNA PPO","2289.58","80.4","","1261.44","103.12","1514.10","21","1488.23","2327.17","percent of total billed charges",""
"MESH SYNTHETIC 0.6X38 45MM PLATE CRANIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2847.74","2135.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2289.58","80.4","","1365.00","1365.00","1365.00","1 through 10","1488.23","2327.17","percent of total billed charges",""
"MESH SYNTHETIC 0.6X38 45MM PLATE CRANIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2847.74","2135.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2327.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1488.23","2327.17","percent of total billed charges",""
"MESH SYNTHETIC 0.6X38 45MM PLATE CRANIAL MATRIXNEURO CONTOUR EXTRA RIGID TI","SUP-ITM-10077382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2847.74","2135.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2327.17","81.72","","431.26","71.26","1459.57","88","1488.23","2327.17","percent of total billed charges",""
"MESH SYNTHETIC 0.6X70MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10077384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.98","2170.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2300.71","79.5","","800.18","480.96","1887.97","195","897.13","2300.71","percent of total billed charges",""
"MESH SYNTHETIC 0.6X70MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10077384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.98","2170.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1542.49","53.3","","813.12","216.42","1444.50","81","897.13","2300.71","percent of total billed charges",""
"MESH SYNTHETIC 0.6X70MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10077384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.98","2170.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","897.13","31","","432.60","432.60","432.60","1 through 10","897.13","2300.71","percent of total billed charges",""
"MESH SYNTHETIC 0.6X70MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10077384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.98","2170.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1056.30","36.5","","148.37","54.89","631.39","94","897.13","2300.71","percent of total billed charges",""
"MESH SYNTHETIC 0.6X70MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10077384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.98","2170.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1108.39","38.3","","279.30","91.72","1116.77","266","897.13","2300.71","percent of total billed charges",""
"MESH SYNTHETIC 0.6X70MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10077384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.98","2170.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1241.52","42.9","","731.00","63.70","731.00","1 through 10","897.13","2300.71","percent of total billed charges",""
"MESH SYNTHETIC 0.6X70MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10077384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.98","2170.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1241.52","42.9","","384.74","384.74","384.74","1 through 10","897.13","2300.71","percent of total billed charges",""
"MESH SYNTHETIC 0.6X70MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10077384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.98","2170.48","WELLPOINT [1015]","HB AMC WELLPOINT","2135.18","73.78","","286.63","119.22","1107.45","105","897.13","2300.71","percent of total billed charges",""
"MESH SYNTHETIC 0.6X70MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10077384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2893.98","2170.48","AETNA [1001]","HB AMC AETNA HMO","2020.00","69.8","","675.31","184.75","1721.50","286","1512.39","2364.96","percent of total billed charges",""
"MESH SYNTHETIC 0.6X70MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10077384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2893.98","2170.48","AETNA [1001]","HB AMC AETNA PPO","2326.76","80.4","","1261.44","103.12","1514.10","21","1512.39","2364.96","percent of total billed charges",""
"MESH SYNTHETIC 0.6X70MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10077384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2893.98","2170.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2326.76","80.4","","1365.00","1365.00","1365.00","1 through 10","1512.39","2364.96","percent of total billed charges",""
"MESH SYNTHETIC 0.6X70MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10077384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2893.98","2170.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2364.96","81.72","","5157.68","5157.68","5157.68","1 through 10","1512.39","2364.96","percent of total billed charges",""
"MESH SYNTHETIC 0.6X70MM PLATE CRANIOMAXILLOFACIAL MATRIXNEURO CONTOUR CIRCULAR EXTRA RIGID TI","SUP-ITM-10077384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2893.98","2170.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2364.96","81.72","","431.26","71.26","1459.57","88","1512.39","2364.96","percent of total billed charges",""
"MESH SYNTHETIC 20CMX15 ABDOMINAL COLLAGEN COATED ELLIPTICAL POLYESTER PARIETEX","SUP-ITM-10012796","CDM","C1781","HCPCS","0278","RC","","","","both","","","1887.83","1415.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1321.48","70","","134.04","134.04","134.04","1 through 10","585.23","1500.82","percent of total billed charges",""
"MESH SYNTHETIC 20CMX15 ABDOMINAL COLLAGEN COATED ELLIPTICAL POLYESTER PARIETEX","SUP-ITM-10012796","CDM","C1781","HCPCS","0278","RC","","","","both","","","1887.83","1415.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1500.82","79.5","","948.87","198.19","1805.30","1 through 10","585.23","1500.82","percent of total billed charges",""
"MESH SYNTHETIC 20CMX15 ABDOMINAL COLLAGEN COATED ELLIPTICAL POLYESTER PARIETEX","SUP-ITM-10012796","CDM","C1781","HCPCS","0278","RC","","","","both","","","1887.83","1415.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1006.21","53.3","","462.00","170.45","3253.37","1 through 10","585.23","1500.82","percent of total billed charges",""
"MESH SYNTHETIC 20CMX15 ABDOMINAL COLLAGEN COATED ELLIPTICAL POLYESTER PARIETEX","SUP-ITM-10012796","CDM","C1781","HCPCS","0278","RC","","","","both","","","1887.83","1415.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","689.06","36.5","","245.50","107.19","1371.45","1 through 10","585.23","1500.82","percent of total billed charges",""
"MESH SYNTHETIC 20CMX15 ABDOMINAL COLLAGEN COATED ELLIPTICAL POLYESTER PARIETEX","SUP-ITM-10012796","CDM","C1781","HCPCS","0278","RC","","","","both","","","1887.83","1415.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","723.04","38.3","","200.79","72.79","355.81","22","585.23","1500.82","percent of total billed charges",""
"MESH SYNTHETIC 20CMX15 ABDOMINAL COLLAGEN COATED ELLIPTICAL POLYESTER PARIETEX","SUP-ITM-10012796","CDM","C1781","HCPCS","0278","RC","","","","both","","","1887.83","1415.87","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1453.63","77","","477.18","477.18","477.18","1 through 10","585.23","1500.82","percent of total billed charges",""
"MESH SYNTHETIC 20CMX15 ABDOMINAL COLLAGEN COATED ELLIPTICAL POLYESTER PARIETEX","SUP-ITM-10012796","CDM","C1781","HCPCS","0278","RC","","","","both","","","1887.83","1415.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","809.88","42.9","","1045.91","1045.91","1045.91","1 through 10","585.23","1500.82","percent of total billed charges",""
"MESH SYNTHETIC 20CMX15 ABDOMINAL COLLAGEN COATED ELLIPTICAL POLYESTER PARIETEX","SUP-ITM-10012796","CDM","C1781","HCPCS","0278","RC","","","","both","","","1887.83","1415.87","WELLPOINT [1015]","HB AMC WELLPOINT","1392.84","73.78","","1726.50","1726.50","1726.50","1 through 10","585.23","1500.82","percent of total billed charges",""
"MESH SYNTHETIC 20CMX15 ABDOMINAL COLLAGEN COATED ELLIPTICAL POLYESTER PARIETEX","SUP-ITM-10012796","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1887.83","1415.87","AETNA [1001]","HB AMC AETNA HMO","1317.71","69.8","","915.80","263.76","2881.00","1 through 10","986.58","1542.73","percent of total billed charges",""
"MESH SYNTHETIC 20CMX15 ABDOMINAL COLLAGEN COATED ELLIPTICAL POLYESTER PARIETEX","SUP-ITM-10012796","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1887.83","1415.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1542.73","81.72","","1531.57","410.52","8841.36","1 through 10","986.58","1542.73","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","338.15","253.61","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","236.71","70","","134.04","134.04","134.04","1 through 10","104.83","268.83","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","338.15","253.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","268.83","79.5","","948.87","198.19","1805.30","1 through 10","104.83","268.83","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","338.15","253.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","180.23","53.3","","462.00","170.45","3253.37","1 through 10","104.83","268.83","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","338.15","253.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.42","36.5","","245.50","107.19","1371.45","1 through 10","104.83","268.83","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","338.15","253.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","129.51","38.3","","200.79","72.79","355.81","22","104.83","268.83","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","338.15","253.61","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","260.38","77","","477.18","477.18","477.18","1 through 10","104.83","268.83","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","338.15","253.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.07","42.9","","1045.91","1045.91","1045.91","1 through 10","104.83","268.83","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","338.15","253.61","WELLPOINT [1015]","HB AMC WELLPOINT","249.49","73.78","","1726.50","1726.50","1726.50","1 through 10","104.83","268.83","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","338.15","253.61","AETNA [1001]","HB AMC AETNA HMO","236.03","69.8","","915.80","263.76","2881.00","1 through 10","176.72","276.34","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","338.15","253.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","276.34","81.72","","1531.57","410.52","8841.36","1 through 10","176.72","276.34","percent of total billed charges",""
"MESH SYNTHETIC 30CMX5 ABDOMINAL NON ABSORBABLE RECTANGLE POLYPROPYLENE BX/6EA","SUP-ITM-10010433","CDM","C1781","HCPCS","0278","RC","","","","both","","","199.44","149.58","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","139.61","70","","134.04","134.04","134.04","1 through 10","61.83","158.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMX5 ABDOMINAL NON ABSORBABLE RECTANGLE POLYPROPYLENE BX/6EA","SUP-ITM-10010433","CDM","C1781","HCPCS","0278","RC","","","","both","","","199.44","149.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","158.55","79.5","","948.87","198.19","1805.30","1 through 10","61.83","158.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMX5 ABDOMINAL NON ABSORBABLE RECTANGLE POLYPROPYLENE BX/6EA","SUP-ITM-10010433","CDM","C1781","HCPCS","0278","RC","","","","both","","","199.44","149.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.30","53.3","","462.00","170.45","3253.37","1 through 10","61.83","158.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMX5 ABDOMINAL NON ABSORBABLE RECTANGLE POLYPROPYLENE BX/6EA","SUP-ITM-10010433","CDM","C1781","HCPCS","0278","RC","","","","both","","","199.44","149.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.80","36.5","","245.50","107.19","1371.45","1 through 10","61.83","158.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMX5 ABDOMINAL NON ABSORBABLE RECTANGLE POLYPROPYLENE BX/6EA","SUP-ITM-10010433","CDM","C1781","HCPCS","0278","RC","","","","both","","","199.44","149.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.39","38.3","","200.79","72.79","355.81","22","61.83","158.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMX5 ABDOMINAL NON ABSORBABLE RECTANGLE POLYPROPYLENE BX/6EA","SUP-ITM-10010433","CDM","C1781","HCPCS","0278","RC","","","","both","","","199.44","149.58","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","153.57","77","","477.18","477.18","477.18","1 through 10","61.83","158.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMX5 ABDOMINAL NON ABSORBABLE RECTANGLE POLYPROPYLENE BX/6EA","SUP-ITM-10010433","CDM","C1781","HCPCS","0278","RC","","","","both","","","199.44","149.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.56","42.9","","1045.91","1045.91","1045.91","1 through 10","61.83","158.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMX5 ABDOMINAL NON ABSORBABLE RECTANGLE POLYPROPYLENE BX/6EA","SUP-ITM-10010433","CDM","C1781","HCPCS","0278","RC","","","","both","","","199.44","149.58","WELLPOINT [1015]","HB AMC WELLPOINT","147.15","73.78","","1726.50","1726.50","1726.50","1 through 10","61.83","158.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMX5 ABDOMINAL NON ABSORBABLE RECTANGLE POLYPROPYLENE BX/6EA","SUP-ITM-10010433","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","199.44","149.58","AETNA [1001]","HB AMC AETNA HMO","139.21","69.8","","915.80","263.76","2881.00","1 through 10","104.23","162.98","percent of total billed charges",""
"MESH SYNTHETIC 30CMX5 ABDOMINAL NON ABSORBABLE RECTANGLE POLYPROPYLENE BX/6EA","SUP-ITM-10010433","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","199.44","149.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","162.98","81.72","","1531.57","410.52","8841.36","1 through 10","104.23","162.98","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","467.71","350.78","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","327.40","70","","134.04","134.04","134.04","1 through 10","144.99","371.83","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","467.71","350.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","371.83","79.5","","948.87","198.19","1805.30","1 through 10","144.99","371.83","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","467.71","350.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","249.29","53.3","","462.00","170.45","3253.37","1 through 10","144.99","371.83","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","467.71","350.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","170.71","36.5","","245.50","107.19","1371.45","1 through 10","144.99","371.83","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","467.71","350.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.13","38.3","","200.79","72.79","355.81","22","144.99","371.83","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","467.71","350.78","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","360.14","77","","477.18","477.18","477.18","1 through 10","144.99","371.83","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","467.71","350.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.65","42.9","","1045.91","1045.91","1045.91","1 through 10","144.99","371.83","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","467.71","350.78","WELLPOINT [1015]","HB AMC WELLPOINT","345.08","73.78","","1726.50","1726.50","1726.50","1 through 10","144.99","371.83","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","467.71","350.78","AETNA [1001]","HB AMC AETNA HMO","326.46","69.8","","915.80","263.76","2881.00","1 through 10","244.43","382.21","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","467.71","350.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","382.21","81.72","","1531.57","410.52","8841.36","1 through 10","244.43","382.21","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","862.33","646.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","603.63","70","","134.04","134.04","134.04","1 through 10","267.32","685.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","862.33","646.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","685.55","79.5","","948.87","198.19","1805.30","1 through 10","267.32","685.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","862.33","646.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","459.62","53.3","","462.00","170.45","3253.37","1 through 10","267.32","685.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","862.33","646.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","314.75","36.5","","245.50","107.19","1371.45","1 through 10","267.32","685.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","862.33","646.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","330.27","38.3","","200.79","72.79","355.81","22","267.32","685.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","862.33","646.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","663.99","77","","477.18","477.18","477.18","1 through 10","267.32","685.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","862.33","646.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","369.94","42.9","","1045.91","1045.91","1045.91","1 through 10","267.32","685.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","862.33","646.75","WELLPOINT [1015]","HB AMC WELLPOINT","636.23","73.78","","1726.50","1726.50","1726.50","1 through 10","267.32","685.55","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","862.33","646.75","AETNA [1001]","HB AMC AETNA HMO","601.91","69.8","","915.80","263.76","2881.00","1 through 10","450.65","704.7","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","862.33","646.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","704.70","81.72","","1531.57","410.52","8841.36","1 through 10","450.65","704.7","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","225.66","169.24","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","157.96","70","","134.04","134.04","134.04","1 through 10","69.95","179.4","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","225.66","169.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","179.40","79.5","","948.87","198.19","1805.30","1 through 10","69.95","179.4","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","225.66","169.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","120.28","53.3","","462.00","170.45","3253.37","1 through 10","69.95","179.4","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","225.66","169.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","82.37","36.5","","245.50","107.19","1371.45","1 through 10","69.95","179.4","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","225.66","169.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","86.43","38.3","","200.79","72.79","355.81","22","69.95","179.4","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","225.66","169.24","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","173.76","77","","477.18","477.18","477.18","1 through 10","69.95","179.4","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","225.66","169.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.81","42.9","","1045.91","1045.91","1045.91","1 through 10","69.95","179.4","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","225.66","169.24","WELLPOINT [1015]","HB AMC WELLPOINT","166.49","73.78","","1726.50","1726.50","1726.50","1 through 10","69.95","179.4","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","225.66","169.24","AETNA [1001]","HB AMC AETNA HMO","157.51","69.8","","915.80","263.76","2881.00","1 through 10","117.93","184.41","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","225.66","169.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","184.41","81.72","","1531.57","410.52","8841.36","1 through 10","117.93","184.41","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2606.87","1955.15","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1824.81","70","","134.04","134.04","134.04","1 through 10","808.13","2072.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2606.87","1955.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2072.46","79.5","","948.87","198.19","1805.30","1 through 10","808.13","2072.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2606.87","1955.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1389.46","53.3","","462.00","170.45","3253.37","1 through 10","808.13","2072.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2606.87","1955.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","951.51","36.5","","245.50","107.19","1371.45","1 through 10","808.13","2072.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2606.87","1955.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","998.43","38.3","","200.79","72.79","355.81","22","808.13","2072.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2606.87","1955.15","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2007.29","77","","477.18","477.18","477.18","1 through 10","808.13","2072.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2606.87","1955.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1118.35","42.9","","1045.91","1045.91","1045.91","1 through 10","808.13","2072.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2606.87","1955.15","WELLPOINT [1015]","HB AMC WELLPOINT","1923.35","73.78","","1726.50","1726.50","1726.50","1 through 10","808.13","2072.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2606.87","1955.15","AETNA [1001]","HB AMC AETNA HMO","1819.60","69.8","","915.80","263.76","2881.00","1 through 10","1362.35","2130.33","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2606.87","1955.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2130.33","81.72","","1531.57","410.52","8841.36","1 through 10","1362.35","2130.33","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1303.16","977.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","912.21","70","","134.04","134.04","134.04","1 through 10","403.98","1036.01","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1303.16","977.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1036.01","79.5","","948.87","198.19","1805.30","1 through 10","403.98","1036.01","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1303.16","977.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","694.58","53.3","","462.00","170.45","3253.37","1 through 10","403.98","1036.01","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1303.16","977.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","475.65","36.5","","245.50","107.19","1371.45","1 through 10","403.98","1036.01","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1303.16","977.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","499.11","38.3","","200.79","72.79","355.81","22","403.98","1036.01","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1303.16","977.37","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1003.43","77","","477.18","477.18","477.18","1 through 10","403.98","1036.01","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1303.16","977.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","559.06","42.9","","1045.91","1045.91","1045.91","1 through 10","403.98","1036.01","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1303.16","977.37","WELLPOINT [1015]","HB AMC WELLPOINT","961.47","73.78","","1726.50","1726.50","1726.50","1 through 10","403.98","1036.01","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1303.16","977.37","AETNA [1001]","HB AMC AETNA HMO","909.61","69.8","","915.80","263.76","2881.00","1 through 10","681.03","1064.94","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1303.16","977.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1064.94","81.72","","1531.57","410.52","8841.36","1 through 10","681.03","1064.94","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","4056.27","3042.20","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2839.39","70","","134.04","134.04","134.04","1 through 10","1257.44","3224.73","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","4056.27","3042.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3224.73","79.5","","948.87","198.19","1805.30","1 through 10","1257.44","3224.73","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","4056.27","3042.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2161.99","53.3","","462.00","170.45","3253.37","1 through 10","1257.44","3224.73","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","4056.27","3042.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1480.54","36.5","","245.50","107.19","1371.45","1 through 10","1257.44","3224.73","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","4056.27","3042.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1553.55","38.3","","200.79","72.79","355.81","22","1257.44","3224.73","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","4056.27","3042.20","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3123.33","77","","477.18","477.18","477.18","1 through 10","1257.44","3224.73","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","4056.27","3042.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1740.14","42.9","","1045.91","1045.91","1045.91","1 through 10","1257.44","3224.73","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","4056.27","3042.20","WELLPOINT [1015]","HB AMC WELLPOINT","2992.72","73.78","","1726.50","1726.50","1726.50","1 through 10","1257.44","3224.73","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4056.27","3042.20","AETNA [1001]","HB AMC AETNA HMO","2831.28","69.8","","915.80","263.76","2881.00","1 through 10","2119.81","3314.78","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4056.27","3042.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3314.78","81.72","","1531.57","410.52","8841.36","1 through 10","2119.81","3314.78","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","5286.13","3964.60","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3700.29","70","","134.04","134.04","134.04","1 through 10","1638.7","4202.47","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","5286.13","3964.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4202.47","79.5","","948.87","198.19","1805.30","1 through 10","1638.7","4202.47","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","5286.13","3964.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2817.51","53.3","","462.00","170.45","3253.37","1 through 10","1638.7","4202.47","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","5286.13","3964.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1929.44","36.5","","245.50","107.19","1371.45","1 through 10","1638.7","4202.47","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","5286.13","3964.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2024.59","38.3","","200.79","72.79","355.81","22","1638.7","4202.47","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","5286.13","3964.60","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4070.32","77","","477.18","477.18","477.18","1 through 10","1638.7","4202.47","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","5286.13","3964.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2267.75","42.9","","1045.91","1045.91","1045.91","1 through 10","1638.7","4202.47","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","5286.13","3964.60","WELLPOINT [1015]","HB AMC WELLPOINT","3900.11","73.78","","1726.50","1726.50","1726.50","1 through 10","1638.7","4202.47","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5286.13","3964.60","AETNA [1001]","HB AMC AETNA HMO","3689.72","69.8","","915.80","263.76","2881.00","1 through 10","2762.53","4319.83","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5286.13","3964.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4319.83","81.72","","1531.57","410.52","8841.36","1 through 10","2762.53","4319.83","percent of total billed charges",""
"MESH TEMPORAL 99MM DIAX66 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158749","CDM","C1713","HCPCS","0278","RC","","","","both","","","7900.00","5925.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6280.50","79.5","","800.18","480.96","1887.97","195","2449","6280.5","percent of total billed charges",""
"MESH TEMPORAL 99MM DIAX66 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158749","CDM","C1713","HCPCS","0278","RC","","","","both","","","7900.00","5925.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4210.70","53.3","","813.12","216.42","1444.50","81","2449","6280.5","percent of total billed charges",""
"MESH TEMPORAL 99MM DIAX66 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158749","CDM","C1713","HCPCS","0278","RC","","","","both","","","7900.00","5925.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2449.00","31","","432.60","432.60","432.60","1 through 10","2449","6280.5","percent of total billed charges",""
"MESH TEMPORAL 99MM DIAX66 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158749","CDM","C1713","HCPCS","0278","RC","","","","both","","","7900.00","5925.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2883.50","36.5","","148.37","54.89","631.39","94","2449","6280.5","percent of total billed charges",""
"MESH TEMPORAL 99MM DIAX66 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158749","CDM","C1713","HCPCS","0278","RC","","","","both","","","7900.00","5925.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3025.70","38.3","","279.30","91.72","1116.77","266","2449","6280.5","percent of total billed charges",""
"MESH TEMPORAL 99MM DIAX66 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158749","CDM","C1713","HCPCS","0278","RC","","","","both","","","7900.00","5925.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3389.10","42.9","","731.00","63.70","731.00","1 through 10","2449","6280.5","percent of total billed charges",""
"MESH TEMPORAL 99MM DIAX66 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158749","CDM","C1713","HCPCS","0278","RC","","","","both","","","7900.00","5925.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3389.10","42.9","","384.74","384.74","384.74","1 through 10","2449","6280.5","percent of total billed charges",""
"MESH TEMPORAL 99MM DIAX66 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158749","CDM","C1713","HCPCS","0278","RC","","","","both","","","7900.00","5925.00","WELLPOINT [1015]","HB AMC WELLPOINT","5828.62","73.78","","286.63","119.22","1107.45","105","2449","6280.5","percent of total billed charges",""
"MESH TEMPORAL 99MM DIAX66 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7900.00","5925.00","AETNA [1001]","HB AMC AETNA HMO","5514.20","69.8","","675.31","184.75","1721.50","286","4128.54","6455.88","percent of total billed charges",""
"MESH TEMPORAL 99MM DIAX66 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7900.00","5925.00","AETNA [1001]","HB AMC AETNA PPO","6351.60","80.4","","1261.44","103.12","1514.10","21","4128.54","6455.88","percent of total billed charges",""
"MESH TEMPORAL 99MM DIAX66 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7900.00","5925.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6351.60","80.4","","1365.00","1365.00","1365.00","1 through 10","4128.54","6455.88","percent of total billed charges",""
"MESH TEMPORAL 99MM DIAX66 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7900.00","5925.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6455.88","81.72","","5157.68","5157.68","5157.68","1 through 10","4128.54","6455.88","percent of total billed charges",""
"MESH TEMPORAL 99MM DIAX66 CRANIAL MATRIXNEURO TI LEFT","SUP-ITM-10158749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7900.00","5925.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6455.88","81.72","","431.26","71.26","1459.57","88","4128.54","6455.88","percent of total billed charges",""
"MESH VENTRALIGHT 10X15CM 4X6IN ELLIPSE ECHO 2","SUP-ITM-10279167","CDM","C1781","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2474.50","70","","134.04","134.04","134.04","1 through 10","1095.85","2810.33","percent of total billed charges",""
"MESH VENTRALIGHT 10X15CM 4X6IN ELLIPSE ECHO 2","SUP-ITM-10279167","CDM","C1781","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2810.33","79.5","","948.87","198.19","1805.30","1 through 10","1095.85","2810.33","percent of total billed charges",""
"MESH VENTRALIGHT 10X15CM 4X6IN ELLIPSE ECHO 2","SUP-ITM-10279167","CDM","C1781","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1884.16","53.3","","462.00","170.45","3253.37","1 through 10","1095.85","2810.33","percent of total billed charges",""
"MESH VENTRALIGHT 10X15CM 4X6IN ELLIPSE ECHO 2","SUP-ITM-10279167","CDM","C1781","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1290.28","36.5","","245.50","107.19","1371.45","1 through 10","1095.85","2810.33","percent of total billed charges",""
"MESH VENTRALIGHT 10X15CM 4X6IN ELLIPSE ECHO 2","SUP-ITM-10279167","CDM","C1781","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1353.91","38.3","","200.79","72.79","355.81","22","1095.85","2810.33","percent of total billed charges",""
"MESH VENTRALIGHT 10X15CM 4X6IN ELLIPSE ECHO 2","SUP-ITM-10279167","CDM","C1781","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2721.95","77","","477.18","477.18","477.18","1 through 10","1095.85","2810.33","percent of total billed charges",""
"MESH VENTRALIGHT 10X15CM 4X6IN ELLIPSE ECHO 2","SUP-ITM-10279167","CDM","C1781","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1516.52","42.9","","1045.91","1045.91","1045.91","1 through 10","1095.85","2810.33","percent of total billed charges",""
"MESH VENTRALIGHT 10X15CM 4X6IN ELLIPSE ECHO 2","SUP-ITM-10279167","CDM","C1781","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","WELLPOINT [1015]","HB AMC WELLPOINT","2608.12","73.78","","1726.50","1726.50","1726.50","1 through 10","1095.85","2810.33","percent of total billed charges",""
"MESH VENTRALIGHT 10X15CM 4X6IN ELLIPSE ECHO 2","SUP-ITM-10279167","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3535.00","2651.25","AETNA [1001]","HB AMC AETNA HMO","2467.43","69.8","","915.80","263.76","2881.00","1 through 10","1847.39","2888.8","percent of total billed charges",""
"MESH VENTRALIGHT 10X15CM 4X6IN ELLIPSE ECHO 2","SUP-ITM-10279167","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3535.00","2651.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2888.80","81.72","","1531.57","410.52","8841.36","1 through 10","1847.39","2888.8","percent of total billed charges",""
"MESH VENTRALIGHT 11.4CM 4.5IN ST CIRCLE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277648","CDM","C1781","HCPCS","0278","RC","","","","both","","","4462.50","3346.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3123.75","70","","134.04","134.04","134.04","1 through 10","1383.38","3547.69","percent of total billed charges",""
"MESH VENTRALIGHT 11.4CM 4.5IN ST CIRCLE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277648","CDM","C1781","HCPCS","0278","RC","","","","both","","","4462.50","3346.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3547.69","79.5","","948.87","198.19","1805.30","1 through 10","1383.38","3547.69","percent of total billed charges",""
"MESH VENTRALIGHT 11.4CM 4.5IN ST CIRCLE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277648","CDM","C1781","HCPCS","0278","RC","","","","both","","","4462.50","3346.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2378.51","53.3","","462.00","170.45","3253.37","1 through 10","1383.38","3547.69","percent of total billed charges",""
"MESH VENTRALIGHT 11.4CM 4.5IN ST CIRCLE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277648","CDM","C1781","HCPCS","0278","RC","","","","both","","","4462.50","3346.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1628.81","36.5","","245.50","107.19","1371.45","1 through 10","1383.38","3547.69","percent of total billed charges",""
"MESH VENTRALIGHT 11.4CM 4.5IN ST CIRCLE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277648","CDM","C1781","HCPCS","0278","RC","","","","both","","","4462.50","3346.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1709.14","38.3","","200.79","72.79","355.81","22","1383.38","3547.69","percent of total billed charges",""
"MESH VENTRALIGHT 11.4CM 4.5IN ST CIRCLE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277648","CDM","C1781","HCPCS","0278","RC","","","","both","","","4462.50","3346.87","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3436.13","77","","477.18","477.18","477.18","1 through 10","1383.38","3547.69","percent of total billed charges",""
"MESH VENTRALIGHT 11.4CM 4.5IN ST CIRCLE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277648","CDM","C1781","HCPCS","0278","RC","","","","both","","","4462.50","3346.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1914.41","42.9","","1045.91","1045.91","1045.91","1 through 10","1383.38","3547.69","percent of total billed charges",""
"MESH VENTRALIGHT 11.4CM 4.5IN ST CIRCLE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277648","CDM","C1781","HCPCS","0278","RC","","","","both","","","4462.50","3346.87","WELLPOINT [1015]","HB AMC WELLPOINT","3292.43","73.78","","1726.50","1726.50","1726.50","1 through 10","1383.38","3547.69","percent of total billed charges",""
"MESH VENTRALIGHT 11.4CM 4.5IN ST CIRCLE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277648","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4462.50","3346.87","AETNA [1001]","HB AMC AETNA HMO","3114.83","69.8","","915.80","263.76","2881.00","1 through 10","2332.1","3646.76","percent of total billed charges",""
"MESH VENTRALIGHT 11.4CM 4.5IN ST CIRCLE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277648","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4462.50","3346.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3646.76","81.72","","1531.57","410.52","8841.36","1 through 10","2332.1","3646.76","percent of total billed charges",""
"MESH VENTRALIGHT 15CM 6IN CIRCLE ECHO 2 CS/1EA","SUP-ITM-10279168","CDM","C1781","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3171.00","70","","134.04","134.04","134.04","1 through 10","1404.3","3601.35","percent of total billed charges",""
"MESH VENTRALIGHT 15CM 6IN CIRCLE ECHO 2 CS/1EA","SUP-ITM-10279168","CDM","C1781","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3601.35","79.5","","948.87","198.19","1805.30","1 through 10","1404.3","3601.35","percent of total billed charges",""
"MESH VENTRALIGHT 15CM 6IN CIRCLE ECHO 2 CS/1EA","SUP-ITM-10279168","CDM","C1781","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2414.49","53.3","","462.00","170.45","3253.37","1 through 10","1404.3","3601.35","percent of total billed charges",""
"MESH VENTRALIGHT 15CM 6IN CIRCLE ECHO 2 CS/1EA","SUP-ITM-10279168","CDM","C1781","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1653.45","36.5","","245.50","107.19","1371.45","1 through 10","1404.3","3601.35","percent of total billed charges",""
"MESH VENTRALIGHT 15CM 6IN CIRCLE ECHO 2 CS/1EA","SUP-ITM-10279168","CDM","C1781","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1734.99","38.3","","200.79","72.79","355.81","22","1404.3","3601.35","percent of total billed charges",""
"MESH VENTRALIGHT 15CM 6IN CIRCLE ECHO 2 CS/1EA","SUP-ITM-10279168","CDM","C1781","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3488.10","77","","477.18","477.18","477.18","1 through 10","1404.3","3601.35","percent of total billed charges",""
"MESH VENTRALIGHT 15CM 6IN CIRCLE ECHO 2 CS/1EA","SUP-ITM-10279168","CDM","C1781","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1943.37","42.9","","1045.91","1045.91","1045.91","1 through 10","1404.3","3601.35","percent of total billed charges",""
"MESH VENTRALIGHT 15CM 6IN CIRCLE ECHO 2 CS/1EA","SUP-ITM-10279168","CDM","C1781","HCPCS","0278","RC","","","","both","","","4530.00","3397.50","WELLPOINT [1015]","HB AMC WELLPOINT","3342.23","73.78","","1726.50","1726.50","1726.50","1 through 10","1404.3","3601.35","percent of total billed charges",""
"MESH VENTRALIGHT 15CM 6IN CIRCLE ECHO 2 CS/1EA","SUP-ITM-10279168","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","AETNA [1001]","HB AMC AETNA HMO","3161.94","69.8","","915.80","263.76","2881.00","1 through 10","2367.38","3701.92","percent of total billed charges",""
"MESH VENTRALIGHT 15CM 6IN CIRCLE ECHO 2 CS/1EA","SUP-ITM-10279168","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4530.00","3397.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3701.92","81.72","","1531.57","410.52","8841.36","1 through 10","2367.38","3701.92","percent of total billed charges",""
"MESH VENTRALIGHT 15CMX25CM 6X10IN ST ELLIPSE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277317","CDM","C1781","HCPCS","0278","RC","","","","both","","","5247.50","3935.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3673.25","70","","134.04","134.04","134.04","1 through 10","1626.73","4171.76","percent of total billed charges",""
"MESH VENTRALIGHT 15CMX25CM 6X10IN ST ELLIPSE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277317","CDM","C1781","HCPCS","0278","RC","","","","both","","","5247.50","3935.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4171.76","79.5","","948.87","198.19","1805.30","1 through 10","1626.73","4171.76","percent of total billed charges",""
"MESH VENTRALIGHT 15CMX25CM 6X10IN ST ELLIPSE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277317","CDM","C1781","HCPCS","0278","RC","","","","both","","","5247.50","3935.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2796.92","53.3","","462.00","170.45","3253.37","1 through 10","1626.73","4171.76","percent of total billed charges",""
"MESH VENTRALIGHT 15CMX25CM 6X10IN ST ELLIPSE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277317","CDM","C1781","HCPCS","0278","RC","","","","both","","","5247.50","3935.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1915.34","36.5","","245.50","107.19","1371.45","1 through 10","1626.73","4171.76","percent of total billed charges",""
"MESH VENTRALIGHT 15CMX25CM 6X10IN ST ELLIPSE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277317","CDM","C1781","HCPCS","0278","RC","","","","both","","","5247.50","3935.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2009.79","38.3","","200.79","72.79","355.81","22","1626.73","4171.76","percent of total billed charges",""
"MESH VENTRALIGHT 15CMX25CM 6X10IN ST ELLIPSE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277317","CDM","C1781","HCPCS","0278","RC","","","","both","","","5247.50","3935.62","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4040.58","77","","477.18","477.18","477.18","1 through 10","1626.73","4171.76","percent of total billed charges",""
"MESH VENTRALIGHT 15CMX25CM 6X10IN ST ELLIPSE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277317","CDM","C1781","HCPCS","0278","RC","","","","both","","","5247.50","3935.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2251.18","42.9","","1045.91","1045.91","1045.91","1 through 10","1626.73","4171.76","percent of total billed charges",""
"MESH VENTRALIGHT 15CMX25CM 6X10IN ST ELLIPSE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277317","CDM","C1781","HCPCS","0278","RC","","","","both","","","5247.50","3935.62","WELLPOINT [1015]","HB AMC WELLPOINT","3871.61","73.78","","1726.50","1726.50","1726.50","1 through 10","1626.73","4171.76","percent of total billed charges",""
"MESH VENTRALIGHT 15CMX25CM 6X10IN ST ELLIPSE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277317","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5247.50","3935.62","AETNA [1001]","HB AMC AETNA HMO","3662.76","69.8","","915.80","263.76","2881.00","1 through 10","2742.34","4288.26","percent of total billed charges",""
"MESH VENTRALIGHT 15CMX25CM 6X10IN ST ELLIPSE WITH ECHO 2 POSITIONING SYSTEM CS/1EA","SUP-ITM-10277317","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5247.50","3935.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4288.26","81.72","","1531.57","410.52","8841.36","1 through 10","2742.34","4288.26","percent of total billed charges",""
"MESH VENTRALIGHT 18X23CM 7X9IN ELLIPSE ECHO 2","SUP-ITM-10279169","CDM","C1781","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4025.00","70","","134.04","134.04","134.04","1 through 10","1782.5","4571.25","percent of total billed charges",""
"MESH VENTRALIGHT 18X23CM 7X9IN ELLIPSE ECHO 2","SUP-ITM-10279169","CDM","C1781","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4571.25","79.5","","948.87","198.19","1805.30","1 through 10","1782.5","4571.25","percent of total billed charges",""
"MESH VENTRALIGHT 18X23CM 7X9IN ELLIPSE ECHO 2","SUP-ITM-10279169","CDM","C1781","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3064.75","53.3","","462.00","170.45","3253.37","1 through 10","1782.5","4571.25","percent of total billed charges",""
"MESH VENTRALIGHT 18X23CM 7X9IN ELLIPSE ECHO 2","SUP-ITM-10279169","CDM","C1781","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2098.75","36.5","","245.50","107.19","1371.45","1 through 10","1782.5","4571.25","percent of total billed charges",""
"MESH VENTRALIGHT 18X23CM 7X9IN ELLIPSE ECHO 2","SUP-ITM-10279169","CDM","C1781","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2202.25","38.3","","200.79","72.79","355.81","22","1782.5","4571.25","percent of total billed charges",""
"MESH VENTRALIGHT 18X23CM 7X9IN ELLIPSE ECHO 2","SUP-ITM-10279169","CDM","C1781","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4427.50","77","","477.18","477.18","477.18","1 through 10","1782.5","4571.25","percent of total billed charges",""
"MESH VENTRALIGHT 18X23CM 7X9IN ELLIPSE ECHO 2","SUP-ITM-10279169","CDM","C1781","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2466.75","42.9","","1045.91","1045.91","1045.91","1 through 10","1782.5","4571.25","percent of total billed charges",""
"MESH VENTRALIGHT 18X23CM 7X9IN ELLIPSE ECHO 2","SUP-ITM-10279169","CDM","C1781","HCPCS","0278","RC","","","","both","","","5750.00","4312.50","WELLPOINT [1015]","HB AMC WELLPOINT","4242.35","73.78","","1726.50","1726.50","1726.50","1 through 10","1782.5","4571.25","percent of total billed charges",""
"MESH VENTRALIGHT 18X23CM 7X9IN ELLIPSE ECHO 2","SUP-ITM-10279169","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5750.00","4312.50","AETNA [1001]","HB AMC AETNA HMO","4013.50","69.8","","915.80","263.76","2881.00","1 through 10","3004.95","4698.9","percent of total billed charges",""
"MESH VENTRALIGHT 18X23CM 7X9IN ELLIPSE ECHO 2","SUP-ITM-10279169","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5750.00","4312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4698.90","81.72","","1531.57","410.52","8841.36","1 through 10","3004.95","4698.9","percent of total billed charges",""
"MESH VENTRALIGHT 20CM 8IN CIRCLE ECHO 2","SUP-ITM-10279170","CDM","C1781","HCPCS","0278","RC","","","","both","","","6100.00","4575.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4270.00","70","","134.04","134.04","134.04","1 through 10","1891","4849.5","percent of total billed charges",""
"MESH VENTRALIGHT 20CM 8IN CIRCLE ECHO 2","SUP-ITM-10279170","CDM","C1781","HCPCS","0278","RC","","","","both","","","6100.00","4575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4849.50","79.5","","948.87","198.19","1805.30","1 through 10","1891","4849.5","percent of total billed charges",""
"MESH VENTRALIGHT 20CM 8IN CIRCLE ECHO 2","SUP-ITM-10279170","CDM","C1781","HCPCS","0278","RC","","","","both","","","6100.00","4575.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3251.30","53.3","","462.00","170.45","3253.37","1 through 10","1891","4849.5","percent of total billed charges",""
"MESH VENTRALIGHT 20CM 8IN CIRCLE ECHO 2","SUP-ITM-10279170","CDM","C1781","HCPCS","0278","RC","","","","both","","","6100.00","4575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2226.50","36.5","","245.50","107.19","1371.45","1 through 10","1891","4849.5","percent of total billed charges",""
"MESH VENTRALIGHT 20CM 8IN CIRCLE ECHO 2","SUP-ITM-10279170","CDM","C1781","HCPCS","0278","RC","","","","both","","","6100.00","4575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2336.30","38.3","","200.79","72.79","355.81","22","1891","4849.5","percent of total billed charges",""
"MESH VENTRALIGHT 20CM 8IN CIRCLE ECHO 2","SUP-ITM-10279170","CDM","C1781","HCPCS","0278","RC","","","","both","","","6100.00","4575.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4697.00","77","","477.18","477.18","477.18","1 through 10","1891","4849.5","percent of total billed charges",""
"MESH VENTRALIGHT 20CM 8IN CIRCLE ECHO 2","SUP-ITM-10279170","CDM","C1781","HCPCS","0278","RC","","","","both","","","6100.00","4575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2616.90","42.9","","1045.91","1045.91","1045.91","1 through 10","1891","4849.5","percent of total billed charges",""
"MESH VENTRALIGHT 20CM 8IN CIRCLE ECHO 2","SUP-ITM-10279170","CDM","C1781","HCPCS","0278","RC","","","","both","","","6100.00","4575.00","WELLPOINT [1015]","HB AMC WELLPOINT","4500.58","73.78","","1726.50","1726.50","1726.50","1 through 10","1891","4849.5","percent of total billed charges",""
"MESH VENTRALIGHT 20CM 8IN CIRCLE ECHO 2","SUP-ITM-10279170","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6100.00","4575.00","AETNA [1001]","HB AMC AETNA HMO","4257.80","69.8","","915.80","263.76","2881.00","1 through 10","3187.86","4984.92","percent of total billed charges",""
"MESH VENTRALIGHT 20CM 8IN CIRCLE ECHO 2","SUP-ITM-10279170","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6100.00","4575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4984.92","81.72","","1531.57","410.52","8841.36","1 through 10","3187.86","4984.92","percent of total billed charges",""
"MESH VENTRALIGHT 25X33CM 10X13IN ELLIPSE ECHO 2","SUP-ITM-10279171","CDM","C1781","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","6123.25","70","","134.04","134.04","134.04","1 through 10","2711.73","6954.26","percent of total billed charges",""
"MESH VENTRALIGHT 25X33CM 10X13IN ELLIPSE ECHO 2","SUP-ITM-10279171","CDM","C1781","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6954.26","79.5","","948.87","198.19","1805.30","1 through 10","2711.73","6954.26","percent of total billed charges",""
"MESH VENTRALIGHT 25X33CM 10X13IN ELLIPSE ECHO 2","SUP-ITM-10279171","CDM","C1781","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4662.42","53.3","","462.00","170.45","3253.37","1 through 10","2711.73","6954.26","percent of total billed charges",""
"MESH VENTRALIGHT 25X33CM 10X13IN ELLIPSE ECHO 2","SUP-ITM-10279171","CDM","C1781","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3192.84","36.5","","245.50","107.19","1371.45","1 through 10","2711.73","6954.26","percent of total billed charges",""
"MESH VENTRALIGHT 25X33CM 10X13IN ELLIPSE ECHO 2","SUP-ITM-10279171","CDM","C1781","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3350.29","38.3","","200.79","72.79","355.81","22","2711.73","6954.26","percent of total billed charges",""
"MESH VENTRALIGHT 25X33CM 10X13IN ELLIPSE ECHO 2","SUP-ITM-10279171","CDM","C1781","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","6735.58","77","","477.18","477.18","477.18","1 through 10","2711.73","6954.26","percent of total billed charges",""
"MESH VENTRALIGHT 25X33CM 10X13IN ELLIPSE ECHO 2","SUP-ITM-10279171","CDM","C1781","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3752.68","42.9","","1045.91","1045.91","1045.91","1 through 10","2711.73","6954.26","percent of total billed charges",""
"MESH VENTRALIGHT 25X33CM 10X13IN ELLIPSE ECHO 2","SUP-ITM-10279171","CDM","C1781","HCPCS","0278","RC","","","","both","","","8747.50","6560.62","WELLPOINT [1015]","HB AMC WELLPOINT","6453.91","73.78","","1726.50","1726.50","1726.50","1 through 10","2711.73","6954.26","percent of total billed charges",""
"MESH VENTRALIGHT 25X33CM 10X13IN ELLIPSE ECHO 2","SUP-ITM-10279171","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8747.50","6560.62","AETNA [1001]","HB AMC AETNA HMO","6105.76","69.8","","915.80","263.76","2881.00","1 through 10","4571.44","7148.46","percent of total billed charges",""
"MESH VENTRALIGHT 25X33CM 10X13IN ELLIPSE ECHO 2","SUP-ITM-10279171","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8747.50","6560.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7148.46","81.72","","1531.57","410.52","8841.36","1 through 10","4571.44","7148.46","percent of total billed charges",""
"MESH VENTRALIGHT 30X35CM 12X14IN ELLIPSE ECHO 2","SUP-ITM-10279172","CDM","C1781","HCPCS","0278","RC","","","","both","","","9200.00","6900.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","6440.00","70","","134.04","134.04","134.04","1 through 10","2852","7314","percent of total billed charges",""
"MESH VENTRALIGHT 30X35CM 12X14IN ELLIPSE ECHO 2","SUP-ITM-10279172","CDM","C1781","HCPCS","0278","RC","","","","both","","","9200.00","6900.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7314.00","79.5","","948.87","198.19","1805.30","1 through 10","2852","7314","percent of total billed charges",""
"MESH VENTRALIGHT 30X35CM 12X14IN ELLIPSE ECHO 2","SUP-ITM-10279172","CDM","C1781","HCPCS","0278","RC","","","","both","","","9200.00","6900.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4903.60","53.3","","462.00","170.45","3253.37","1 through 10","2852","7314","percent of total billed charges",""
"MESH VENTRALIGHT 30X35CM 12X14IN ELLIPSE ECHO 2","SUP-ITM-10279172","CDM","C1781","HCPCS","0278","RC","","","","both","","","9200.00","6900.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3358.00","36.5","","245.50","107.19","1371.45","1 through 10","2852","7314","percent of total billed charges",""
"MESH VENTRALIGHT 30X35CM 12X14IN ELLIPSE ECHO 2","SUP-ITM-10279172","CDM","C1781","HCPCS","0278","RC","","","","both","","","9200.00","6900.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3523.60","38.3","","200.79","72.79","355.81","22","2852","7314","percent of total billed charges",""
"MESH VENTRALIGHT 30X35CM 12X14IN ELLIPSE ECHO 2","SUP-ITM-10279172","CDM","C1781","HCPCS","0278","RC","","","","both","","","9200.00","6900.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","7084.00","77","","477.18","477.18","477.18","1 through 10","2852","7314","percent of total billed charges",""
"MESH VENTRALIGHT 30X35CM 12X14IN ELLIPSE ECHO 2","SUP-ITM-10279172","CDM","C1781","HCPCS","0278","RC","","","","both","","","9200.00","6900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3946.80","42.9","","1045.91","1045.91","1045.91","1 through 10","2852","7314","percent of total billed charges",""
"MESH VENTRALIGHT 30X35CM 12X14IN ELLIPSE ECHO 2","SUP-ITM-10279172","CDM","C1781","HCPCS","0278","RC","","","","both","","","9200.00","6900.00","WELLPOINT [1015]","HB AMC WELLPOINT","6787.76","73.78","","1726.50","1726.50","1726.50","1 through 10","2852","7314","percent of total billed charges",""
"MESH VENTRALIGHT 30X35CM 12X14IN ELLIPSE ECHO 2","SUP-ITM-10279172","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9200.00","6900.00","AETNA [1001]","HB AMC AETNA HMO","6421.60","69.8","","915.80","263.76","2881.00","1 through 10","4807.92","7518.24","percent of total billed charges",""
"MESH VENTRALIGHT 30X35CM 12X14IN ELLIPSE ECHO 2","SUP-ITM-10279172","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9200.00","6900.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7518.24","81.72","","1531.57","410.52","8841.36","1 through 10","4807.92","7518.24","percent of total billed charges",""
"MESH VENTRALIGHT 8X10IN 20X25CM ELLIPSE ECHO 2","SUP-ITM-10212175","CDM","C1781","HCPCS","0278","RC","","","","both","","","6975.00","5231.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4882.50","70","","134.04","134.04","134.04","1 through 10","2162.25","5545.13","percent of total billed charges",""
"MESH VENTRALIGHT 8X10IN 20X25CM ELLIPSE ECHO 2","SUP-ITM-10212175","CDM","C1781","HCPCS","0278","RC","","","","both","","","6975.00","5231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5545.13","79.5","","948.87","198.19","1805.30","1 through 10","2162.25","5545.13","percent of total billed charges",""
"MESH VENTRALIGHT 8X10IN 20X25CM ELLIPSE ECHO 2","SUP-ITM-10212175","CDM","C1781","HCPCS","0278","RC","","","","both","","","6975.00","5231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3717.68","53.3","","462.00","170.45","3253.37","1 through 10","2162.25","5545.13","percent of total billed charges",""
"MESH VENTRALIGHT 8X10IN 20X25CM ELLIPSE ECHO 2","SUP-ITM-10212175","CDM","C1781","HCPCS","0278","RC","","","","both","","","6975.00","5231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2545.88","36.5","","245.50","107.19","1371.45","1 through 10","2162.25","5545.13","percent of total billed charges",""
"MESH VENTRALIGHT 8X10IN 20X25CM ELLIPSE ECHO 2","SUP-ITM-10212175","CDM","C1781","HCPCS","0278","RC","","","","both","","","6975.00","5231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2671.43","38.3","","200.79","72.79","355.81","22","2162.25","5545.13","percent of total billed charges",""
"MESH VENTRALIGHT 8X10IN 20X25CM ELLIPSE ECHO 2","SUP-ITM-10212175","CDM","C1781","HCPCS","0278","RC","","","","both","","","6975.00","5231.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","5370.75","77","","477.18","477.18","477.18","1 through 10","2162.25","5545.13","percent of total billed charges",""
"MESH VENTRALIGHT 8X10IN 20X25CM ELLIPSE ECHO 2","SUP-ITM-10212175","CDM","C1781","HCPCS","0278","RC","","","","both","","","6975.00","5231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2992.28","42.9","","1045.91","1045.91","1045.91","1 through 10","2162.25","5545.13","percent of total billed charges",""
"MESH VENTRALIGHT 8X10IN 20X25CM ELLIPSE ECHO 2","SUP-ITM-10212175","CDM","C1781","HCPCS","0278","RC","","","","both","","","6975.00","5231.25","WELLPOINT [1015]","HB AMC WELLPOINT","5146.16","73.78","","1726.50","1726.50","1726.50","1 through 10","2162.25","5545.13","percent of total billed charges",""
"MESH VENTRALIGHT 8X10IN 20X25CM ELLIPSE ECHO 2","SUP-ITM-10212175","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6975.00","5231.25","AETNA [1001]","HB AMC AETNA HMO","4868.55","69.8","","915.80","263.76","2881.00","1 through 10","3645.14","5699.97","percent of total billed charges",""
"MESH VENTRALIGHT 8X10IN 20X25CM ELLIPSE ECHO 2","SUP-ITM-10212175","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6975.00","5231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5699.97","81.72","","1531.57","410.52","8841.36","1 through 10","3645.14","5699.97","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","both","","","283.00","212.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","224.99","79.5","","215.64","137.00","215.64","1 through 10","16.6","268.85","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","both","","","283.00","212.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","150.84","53.3","","144.67","144.67","215.64","12","16.6","268.85","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","both","","","283.00","212.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","103.30","36.5","","102.20","86.86","204.40","16","16.6","268.85","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","both","","","283.00","212.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","108.39","38.3","","107.13","107.13","107.14","31","16.6","268.85","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","both","","","283.00","212.25","TRICARE [160005]","HB BWH TRICARE","268.85","95","","19.39","19.39","19.39","1 through 10","16.6","268.85","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","outpatient","","","283.00","212.25","AETNA [1001]","HB AMC AETNA HMO","197.53","69.8","","185.50","130.97","213.72","24","17.47","231.27","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","outpatient","","","283.00","212.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","147.90","52.26","","169.55","169.55","169.55","1 through 10","17.47","231.27","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","outpatient","","","283.00","212.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","231.27","81.72","","120.48","16.61","219.04","27","17.47","231.27","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2212.09","79.5","","800.18","480.96","1887.97","195","862.58","2212.09","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1483.07","53.3","","813.12","216.42","1444.50","81","862.58","2212.09","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","862.58","31","","432.60","432.60","432.60","1 through 10","862.58","2212.09","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1015.61","36.5","","148.37","54.89","631.39","94","862.58","2212.09","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1065.70","38.3","","279.30","91.72","1116.77","266","862.58","2212.09","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.69","42.9","","731.00","63.70","731.00","1 through 10","862.58","2212.09","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.69","42.9","","384.74","384.74","384.74","1 through 10","862.58","2212.09","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","WELLPOINT [1015]","HB AMC WELLPOINT","2052.93","73.78","","286.63","119.22","1107.45","105","862.58","2212.09","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","AETNA [1001]","HB AMC AETNA HMO","1942.19","69.8","","675.31","184.75","1721.50","286","1454.13","2273.86","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","AETNA [1001]","HB AMC AETNA PPO","2237.13","80.4","","1261.44","103.12","1514.10","21","1454.13","2273.86","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2237.13","80.4","","1365.00","1365.00","1365.00","1 through 10","1454.13","2273.86","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2273.86","81.72","","5157.68","5157.68","5157.68","1 through 10","1454.13","2273.86","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2273.86","81.72","","431.26","71.26","1459.57","88","1454.13","2273.86","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3308.39","79.5","","800.18","480.96","1887.97","195","1290.07","3308.39","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2218.08","53.3","","813.12","216.42","1444.50","81","1290.07","3308.39","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1290.07","31","","432.60","432.60","432.60","1 through 10","1290.07","3308.39","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1518.95","36.5","","148.37","54.89","631.39","94","1290.07","3308.39","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1593.85","38.3","","279.30","91.72","1116.77","266","1290.07","3308.39","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1785.28","42.9","","731.00","63.70","731.00","1 through 10","1290.07","3308.39","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1785.28","42.9","","384.74","384.74","384.74","1 through 10","1290.07","3308.39","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","WELLPOINT [1015]","HB AMC WELLPOINT","3070.35","73.78","","286.63","119.22","1107.45","105","1290.07","3308.39","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","AETNA [1001]","HB AMC AETNA HMO","2904.73","69.8","","675.31","184.75","1721.50","286","2174.8","3400.78","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","AETNA [1001]","HB AMC AETNA PPO","3345.85","80.4","","1261.44","103.12","1514.10","21","2174.8","3400.78","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3345.85","80.4","","1365.00","1365.00","1365.00","1 through 10","2174.8","3400.78","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3400.78","81.72","","5157.68","5157.68","5157.68","1 through 10","2174.8","3400.78","percent of total billed charges",""
"METATARSO PLATE MD 0.0DEG BONE ORTHOLOC 3DI HALLUX TITANIUM METATARSALPHALANGEAL FUSION LEFT","SUP-ITM-10124489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3400.78","81.72","","431.26","71.26","1459.57","88","2174.8","3400.78","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2490.34","79.5","","800.18","480.96","1887.97","195","971.08","2490.34","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1669.62","53.3","","813.12","216.42","1444.50","81","971.08","2490.34","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","971.08","31","","432.60","432.60","432.60","1 through 10","971.08","2490.34","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1143.36","36.5","","148.37","54.89","631.39","94","971.08","2490.34","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1199.75","38.3","","279.30","91.72","1116.77","266","971.08","2490.34","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1343.84","42.9","","731.00","63.70","731.00","1 through 10","971.08","2490.34","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1343.84","42.9","","384.74","384.74","384.74","1 through 10","971.08","2490.34","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.50","2349.37","WELLPOINT [1015]","HB AMC WELLPOINT","2311.16","73.78","","286.63","119.22","1107.45","105","971.08","2490.34","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","AETNA [1001]","HB AMC AETNA HMO","2186.49","69.8","","675.31","184.75","1721.50","286","1637.04","2559.88","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","AETNA [1001]","HB AMC AETNA PPO","2518.53","80.4","","1261.44","103.12","1514.10","21","1637.04","2559.88","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2518.53","80.4","","1365.00","1365.00","1365.00","1 through 10","1637.04","2559.88","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2559.88","81.72","","5157.68","5157.68","5157.68","1 through 10","1637.04","2559.88","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3132.50","2349.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2559.88","81.72","","431.26","71.26","1459.57","88","1637.04","2559.88","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","800.18","480.96","1887.97","195","868","2226","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1492.40","53.3","","813.12","216.42","1444.50","81","868","2226","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","868.00","31","","432.60","432.60","432.60","1 through 10","868","2226","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","148.37","54.89","631.39","94","868","2226","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","279.30","91.72","1116.77","266","868","2226","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","731.00","63.70","731.00","1 through 10","868","2226","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","384.74","384.74","384.74","1 through 10","868","2226","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","286.63","119.22","1107.45","105","868","2226","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA HMO","1954.40","69.8","","675.31","184.75","1721.50","286","1463.28","2288.16","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA PPO","2251.20","80.4","","1261.44","103.12","1514.10","21","1463.28","2288.16","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2251.20","80.4","","1365.00","1365.00","1365.00","1 through 10","1463.28","2288.16","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2288.16","81.72","","5157.68","5157.68","5157.68","1 through 10","1463.28","2288.16","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","431.26","71.26","1459.57","88","1463.28","2288.16","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE LG FIRST FUSION A.L.P.S. RIGHT","SUP-ITM-10126733","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.89","2948.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3125.06","79.5","","800.18","480.96","1887.97","195","1218.58","3125.06","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE LG FIRST FUSION A.L.P.S. RIGHT","SUP-ITM-10126733","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.89","2948.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2095.16","53.3","","813.12","216.42","1444.50","81","1218.58","3125.06","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE LG FIRST FUSION A.L.P.S. RIGHT","SUP-ITM-10126733","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.89","2948.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1218.58","31","","432.60","432.60","432.60","1 through 10","1218.58","3125.06","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE LG FIRST FUSION A.L.P.S. RIGHT","SUP-ITM-10126733","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.89","2948.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1434.77","36.5","","148.37","54.89","631.39","94","1218.58","3125.06","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE LG FIRST FUSION A.L.P.S. RIGHT","SUP-ITM-10126733","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.89","2948.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1505.53","38.3","","279.30","91.72","1116.77","266","1218.58","3125.06","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE LG FIRST FUSION A.L.P.S. RIGHT","SUP-ITM-10126733","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.89","2948.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1686.35","42.9","","731.00","63.70","731.00","1 through 10","1218.58","3125.06","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE LG FIRST FUSION A.L.P.S. RIGHT","SUP-ITM-10126733","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.89","2948.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1686.35","42.9","","384.74","384.74","384.74","1 through 10","1218.58","3125.06","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE LG FIRST FUSION A.L.P.S. RIGHT","SUP-ITM-10126733","CDM","C1713","HCPCS","0278","RC","","","","both","","","3930.89","2948.17","WELLPOINT [1015]","HB AMC WELLPOINT","2900.21","73.78","","286.63","119.22","1107.45","105","1218.58","3125.06","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE LG FIRST FUSION A.L.P.S. RIGHT","SUP-ITM-10126733","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3930.89","2948.17","AETNA [1001]","HB AMC AETNA HMO","2743.76","69.8","","675.31","184.75","1721.50","286","2054.28","3212.32","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE LG FIRST FUSION A.L.P.S. RIGHT","SUP-ITM-10126733","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3930.89","2948.17","AETNA [1001]","HB AMC AETNA PPO","3160.44","80.4","","1261.44","103.12","1514.10","21","2054.28","3212.32","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE LG FIRST FUSION A.L.P.S. RIGHT","SUP-ITM-10126733","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3930.89","2948.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3160.44","80.4","","1365.00","1365.00","1365.00","1 through 10","2054.28","3212.32","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE LG FIRST FUSION A.L.P.S. RIGHT","SUP-ITM-10126733","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3930.89","2948.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3212.32","81.72","","5157.68","5157.68","5157.68","1 through 10","2054.28","3212.32","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE LG FIRST FUSION A.L.P.S. RIGHT","SUP-ITM-10126733","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3930.89","2948.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3212.32","81.72","","431.26","71.26","1459.57","88","2054.28","3212.32","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM 25MM LOCKING","SUP-ITM-10030556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3797.50","2848.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3019.01","79.5","","800.18","480.96","1887.97","195","1177.23","3019.01","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM 25MM LOCKING","SUP-ITM-10030556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3797.50","2848.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2024.07","53.3","","813.12","216.42","1444.50","81","1177.23","3019.01","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM 25MM LOCKING","SUP-ITM-10030556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3797.50","2848.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1177.23","31","","432.60","432.60","432.60","1 through 10","1177.23","3019.01","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM 25MM LOCKING","SUP-ITM-10030556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3797.50","2848.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1386.09","36.5","","148.37","54.89","631.39","94","1177.23","3019.01","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM 25MM LOCKING","SUP-ITM-10030556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3797.50","2848.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1454.44","38.3","","279.30","91.72","1116.77","266","1177.23","3019.01","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM 25MM LOCKING","SUP-ITM-10030556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3797.50","2848.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1629.13","42.9","","731.00","63.70","731.00","1 through 10","1177.23","3019.01","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM 25MM LOCKING","SUP-ITM-10030556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3797.50","2848.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1629.13","42.9","","384.74","384.74","384.74","1 through 10","1177.23","3019.01","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM 25MM LOCKING","SUP-ITM-10030556","CDM","C1713","HCPCS","0278","RC","","","","both","","","3797.50","2848.12","WELLPOINT [1015]","HB AMC WELLPOINT","2801.80","73.78","","286.63","119.22","1107.45","105","1177.23","3019.01","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM 25MM LOCKING","SUP-ITM-10030556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3797.50","2848.12","AETNA [1001]","HB AMC AETNA HMO","2650.66","69.8","","675.31","184.75","1721.50","286","1984.57","3103.32","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM 25MM LOCKING","SUP-ITM-10030556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3797.50","2848.12","AETNA [1001]","HB AMC AETNA PPO","3053.19","80.4","","1261.44","103.12","1514.10","21","1984.57","3103.32","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM 25MM LOCKING","SUP-ITM-10030556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3797.50","2848.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3053.19","80.4","","1365.00","1365.00","1365.00","1 through 10","1984.57","3103.32","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM 25MM LOCKING","SUP-ITM-10030556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3797.50","2848.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3103.32","81.72","","5157.68","5157.68","5157.68","1 through 10","1984.57","3103.32","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM 25MM LOCKING","SUP-ITM-10030556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3797.50","2848.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3103.32","81.72","","431.26","71.26","1459.57","88","1984.57","3103.32","percent of total billed charges",""
"METATARSUS PLATE 35MM SM 5 HOLE BONE ORTHOLOC 3DI FIRST RAY TITANIUM LOCKING FIXED LOW PROFILE COMPRESSION CONTOURED METATARSAL","SUP-ITM-10132302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3556.00","2667.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2827.02","79.5","","800.18","480.96","1887.97","195","1102.36","2827.02","percent of total billed charges",""
"METATARSUS PLATE 35MM SM 5 HOLE BONE ORTHOLOC 3DI FIRST RAY TITANIUM LOCKING FIXED LOW PROFILE COMPRESSION CONTOURED METATARSAL","SUP-ITM-10132302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3556.00","2667.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1895.35","53.3","","813.12","216.42","1444.50","81","1102.36","2827.02","percent of total billed charges",""
"METATARSUS PLATE 35MM SM 5 HOLE BONE ORTHOLOC 3DI FIRST RAY TITANIUM LOCKING FIXED LOW PROFILE COMPRESSION CONTOURED METATARSAL","SUP-ITM-10132302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3556.00","2667.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1102.36","31","","432.60","432.60","432.60","1 through 10","1102.36","2827.02","percent of total billed charges",""
"METATARSUS PLATE 35MM SM 5 HOLE BONE ORTHOLOC 3DI FIRST RAY TITANIUM LOCKING FIXED LOW PROFILE COMPRESSION CONTOURED METATARSAL","SUP-ITM-10132302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3556.00","2667.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1297.94","36.5","","148.37","54.89","631.39","94","1102.36","2827.02","percent of total billed charges",""
"METATARSUS PLATE 35MM SM 5 HOLE BONE ORTHOLOC 3DI FIRST RAY TITANIUM LOCKING FIXED LOW PROFILE COMPRESSION CONTOURED METATARSAL","SUP-ITM-10132302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3556.00","2667.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1361.95","38.3","","279.30","91.72","1116.77","266","1102.36","2827.02","percent of total billed charges",""
"METATARSUS PLATE 35MM SM 5 HOLE BONE ORTHOLOC 3DI FIRST RAY TITANIUM LOCKING FIXED LOW PROFILE COMPRESSION CONTOURED METATARSAL","SUP-ITM-10132302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3556.00","2667.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1525.52","42.9","","731.00","63.70","731.00","1 through 10","1102.36","2827.02","percent of total billed charges",""
"METATARSUS PLATE 35MM SM 5 HOLE BONE ORTHOLOC 3DI FIRST RAY TITANIUM LOCKING FIXED LOW PROFILE COMPRESSION CONTOURED METATARSAL","SUP-ITM-10132302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3556.00","2667.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1525.52","42.9","","384.74","384.74","384.74","1 through 10","1102.36","2827.02","percent of total billed charges",""
"METATARSUS PLATE 35MM SM 5 HOLE BONE ORTHOLOC 3DI FIRST RAY TITANIUM LOCKING FIXED LOW PROFILE COMPRESSION CONTOURED METATARSAL","SUP-ITM-10132302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3556.00","2667.00","WELLPOINT [1015]","HB AMC WELLPOINT","2623.62","73.78","","286.63","119.22","1107.45","105","1102.36","2827.02","percent of total billed charges",""
"METATARSUS PLATE 35MM SM 5 HOLE BONE ORTHOLOC 3DI FIRST RAY TITANIUM LOCKING FIXED LOW PROFILE COMPRESSION CONTOURED METATARSAL","SUP-ITM-10132302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3556.00","2667.00","AETNA [1001]","HB AMC AETNA HMO","2482.09","69.8","","675.31","184.75","1721.50","286","1858.37","2905.96","percent of total billed charges",""
"METATARSUS PLATE 35MM SM 5 HOLE BONE ORTHOLOC 3DI FIRST RAY TITANIUM LOCKING FIXED LOW PROFILE COMPRESSION CONTOURED METATARSAL","SUP-ITM-10132302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3556.00","2667.00","AETNA [1001]","HB AMC AETNA PPO","2859.02","80.4","","1261.44","103.12","1514.10","21","1858.37","2905.96","percent of total billed charges",""
"METATARSUS PLATE 35MM SM 5 HOLE BONE ORTHOLOC 3DI FIRST RAY TITANIUM LOCKING FIXED LOW PROFILE COMPRESSION CONTOURED METATARSAL","SUP-ITM-10132302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3556.00","2667.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2859.02","80.4","","1365.00","1365.00","1365.00","1 through 10","1858.37","2905.96","percent of total billed charges",""
"METATARSUS PLATE 35MM SM 5 HOLE BONE ORTHOLOC 3DI FIRST RAY TITANIUM LOCKING FIXED LOW PROFILE COMPRESSION CONTOURED METATARSAL","SUP-ITM-10132302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3556.00","2667.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2905.96","81.72","","5157.68","5157.68","5157.68","1 through 10","1858.37","2905.96","percent of total billed charges",""
"METATARSUS PLATE 35MM SM 5 HOLE BONE ORTHOLOC 3DI FIRST RAY TITANIUM LOCKING FIXED LOW PROFILE COMPRESSION CONTOURED METATARSAL","SUP-ITM-10132302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3556.00","2667.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2905.96","81.72","","431.26","71.26","1459.57","88","1858.37","2905.96","percent of total billed charges",""
"Methacholine Inh Pwdr 1mg","PX-63600234","CDM","J7674","HCPCS","0636","RC","","","","both","","","1.55","1.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.57","36.5","","3.19","3.19","3.19","64","0.48","2.12","percent of total billed charges",""
"Methacholine Inh Pwdr 1mg","PX-63600234","CDM","J7674","HCPCS","0636","RC","","","","both","","","1.55","1.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.59","38.3","","3.35","3.26","3.35","576","0.48","2.12","percent of total billed charges",""
"Methacholine Inh Pwdr 1mg","PX-63600234","CDM","J7674","HCPCS","0636","RC","","","","outpatient","","","1.55","1.16","AETNA [1001]","HB AMC AETNA HMO","1.08","69.8","","5.80","5.80","5.80","64","0.73","3.72","percent of total billed charges",""
"Methacholine Inh Pwdr 1mg","PX-63600234","CDM","J7674","HCPCS","0636","RC","","","","outpatient","","","1.55","1.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.73","46.9","","0.63","0.63","0.63","64","0.73","3.72","percent of total billed charges",""
"Methemoglobin Qn","PX-30000500","CDM","83050","CPT","0301","RC","","","","both","","","90.00","67.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","71.55","79.5","","99.61","68.47","99.61","44","7.56","85.5","percent of total billed charges",""
"Methemoglobin Qn","PX-30000500","CDM","83050","CPT","0301","RC","","","","both","","","90.00","67.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","32.85","36.5","","97.35","97.35","97.35","1 through 10","7.56","85.5","percent of total billed charges",""
"Methemoglobin Qn","PX-30000500","CDM","83050","CPT","0301","RC","","","","both","","","90.00","67.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.47","38.3","","34.02","34.02","34.02","50","7.56","85.5","percent of total billed charges",""
"Methemoglobin Qn","PX-30000500","CDM","83050","CPT","0301","RC","","","","outpatient","","","90.00","67.50","AETNA [1001]","HB AMC AETNA HMO","62.82","69.8","","58.90","41.59","67.86","1 through 10","7.56","73.55","percent of total billed charges",""
"Methemoglobin Qn","PX-30000500","CDM","83050","CPT","0301","RC","","","","outpatient","","","90.00","67.50","AETNA [1001]","HB AMC AETNA PPO","72.36","80.4","","45.59","45.59","45.59","1 through 10","7.56","73.55","percent of total billed charges",""
"Methemoglobin Qn","PX-30000500","CDM","83050","CPT","0301","RC","","","","outpatient","","","90.00","67.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","73.55","81.72","","1235.62","1235.62","1235.62","1 through 10","7.56","73.55","percent of total billed charges",""
"Methemoglobin Qn","PX-30000500","CDM","83050","CPT","0301","RC","","","","outpatient","","","90.00","67.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","73.55","81.72","","69.55","69.55","69.55","1 through 10","7.56","73.55","percent of total billed charges",""
"Methylene Blue Injection Non-Sentinel","PX-76002682","CDM","38999","CPT","0761","RC","","","","outpatient","","","813.00","609.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","424.55","52.22","","512.50","512.50","512.50","1 through 10","406.5","1234.13","percent of total billed charges",""
"Methylene Blue Injection Non-Sentinel","PX-76002682","CDM","38999","CPT","0761","RC","","","","outpatient","","","813.00","609.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","406.50","50","","6776.11","6776.11","6776.11","1 through 10","406.5","1234.13","percent of total billed charges",""
"Methylpred Na Vl 40mg","PX-63600177","CDM","J2920","HCPCS","0636","RC","","","","both","","","7.99","5.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2.92","36.5","","27.84","27.84","27.84","1 through 10","2.48","8.42","percent of total billed charges",""
"Methylpred Na Vl 40mg","PX-63600177","CDM","J2920","HCPCS","0636","RC","","","","both","","","7.99","5.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3.06","38.3","","7.32","7.30","7.32","1 through 10","2.48","8.42","percent of total billed charges",""
"Metoclopramide Inj 10mg","PX-63600168","CDM","J2765","HCPCS","0636","RC","","","","outpatient","","","3.83","2.87","AETNA [1001]","HB AMC AETNA HMO","2.67","69.8","","1.50","1.50","1.50","1 through 10","1.8","3.08","percent of total billed charges",""
"Metoclopramide Inj 10mg","PX-63600168","CDM","J2765","HCPCS","0636","RC","","","","outpatient","","","3.83","2.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3.08","80.4","","2.47","2.08","2.47","1 through 10","1.8","3.08","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.55","1.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1.67","65.6","","0.96","0.96","0.96","1 through 10","0.79","2.03","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.55","1.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1.79","70","","4.45","1.98","14.99","1 through 10","0.79","2.03","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.55","1.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2.03","79.5","","414.25","7.38","1891.33","1713","0.79","2.03","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.55","1.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1.36","53.3","","6.50","1.93","26.16","91","0.79","2.03","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.55","1.91","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1.96","77","","4.84","4.84","4.84","1 through 10","0.79","2.03","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.55","1.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1.66","65","","11.15","6.10","14.62","1 through 10","0.79","2.03","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.55","1.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2.03","79.5","","0.59","0.59","1.48","1 through 10","0.79","2.03","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.55","1.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.79","31","","0.83","0.83","0.83","1 through 10","0.79","2.03","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.55","1.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.93","36.5","","2.33","0.78","11.19","64","0.79","2.03","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.55","1.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.98","38.3","","3.61","0.89","16.20","213","0.79","2.03","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.55","1.91","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1.96","77","","9.22","3.56","12.86","1 through 10","0.79","2.03","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.55","1.91","WELLPOINT [1015]","HB AMC WELLPOINT","1.88","73.78","","5.23","1.33","24.91","47","0.79","2.03","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","AETNA [1001]","HB AMC AETNA HMO","1.78","69.8","","6.04","1.31","22.28","143","1.28","2.1","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","AETNA [1001]","HB AMC AETNA PPO","2.05","80.4","","4.95","1.52","30.51","1 through 10","1.28","2.1","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1.34","52.5","","533.60","0.69","533.60","1 through 10","1.28","2.1","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1.28","50","","4.92","1.04","22.14","217","1.28","2.1","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1.34","52.5","","11.25","1.46","33.02","97","1.28","2.1","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1.59","62.5","","4.81","4.81","4.81","1 through 10","1.28","2.1","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1.40","55","","9.85","1.05","154.76","17","1.28","2.1","percent of total billed charges",""
"Metoprolol (IV) per 5mg","PX-63601108","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.55","1.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2.05","80.4","","8.31","5.24","14.69","13","1.28","2.1","percent of total billed charges",""
"Mgh .Nzym Activ Bld Cells/Tis Nrdc","PX-30001994","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh .Nzym Activ Bld Cells/Tis Nrdc","PX-30001994","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002248","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","102.43","102.43","102.43","1 through 10","11.74","190","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002248","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","61.50","61.50","61.50","1 through 10","11.74","190","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002248","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","75.85","75.86","1 through 10","11.74","190","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002248","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","155.08","155.08","1 through 10","11.74","190","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002248","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","131.34","92.73","185.46","17","11.81","163.44","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002248","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","60.38","194.00","1 through 10","11.81","163.44","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002252","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","102.43","102.43","102.43","1 through 10","11.74","190","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002252","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","61.50","61.50","61.50","1 through 10","11.74","190","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002252","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","75.85","75.86","1 through 10","11.74","190","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002252","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","155.08","155.08","1 through 10","11.74","190","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002252","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","131.34","92.73","185.46","17","11.81","163.44","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002252","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","60.38","194.00","1 through 10","11.81","163.44","percent of total billed charges",""
"Mgh Ab Protozoa Not Elsewhere Spec","PX-30002237","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","108.58","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Ab Protozoa Not Elsewhere Spec","PX-30002237","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.55","53.3","","78.14","78.14","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Ab Protozoa Not Elsewhere Spec","PX-30002237","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.85","36.5","","165.60","55.20","165.60","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Ab Protozoa Not Elsewhere Spec","PX-30002237","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","57.87","57.87","57.87","14","9.6","145.35","percent of total billed charges",""
"Mgh Ab Protozoa Not Elsewhere Spec","PX-30002237","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","TRICARE [160005]","HB BWH TRICARE","145.35","95","","14.93","14.18","14.93","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Ab Protozoa Not Elsewhere Spec","PX-30002237","CDM","86753","CPT","0302","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","141.48","70.74","200.40","1 through 10","9.6","125.03","percent of total billed charges",""
"Mgh Ab Protozoa Not Elsewhere Spec","PX-30002237","CDM","86753","CPT","0302","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","118.31","65.08","118.31","13","9.6","125.03","percent of total billed charges",""
"Mgh Acad9 Sequence Analysis","PX-31000554","CDM","81479","CPT","0310","RC","","","","both","","","3250.00","2437.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2583.75","79.5","","0.65","0.65","0.65","1 through 10","1007.5","3087.5","percent of total billed charges",""
"Mgh Acad9 Sequence Analysis","PX-31000554","CDM","81479","CPT","0310","RC","","","","both","","","3250.00","2437.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1732.25","53.3","","0.79","0.79","0.79","1 through 10","1007.5","3087.5","percent of total billed charges",""
"Mgh Acad9 Sequence Analysis","PX-31000554","CDM","81479","CPT","0310","RC","","","","outpatient","","","3250.00","2437.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1625.00","50","","1.00","1.00","1.00","1 through 10","156.55","2681.25","percent of total billed charges",""
"Mgh Acad9 Sequence Analysis","PX-31000554","CDM","81479","CPT","0310","RC","","","","outpatient","","","3250.00","2437.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1706.25","52.5","","1.00","0.53","1.00","1 through 10","156.55","2681.25","percent of total billed charges",""
"Mgh Acetabuloplasty Procedure","PX-76001893","CDM","27299","CPT","0761","RC","","","","both","","","6447.00","4835.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","5125.37","other","OPPS APC"
"Mgh Acsf3 Sequence Analysis","PX-31000515","CDM","81479","CPT","0310","RC","","","","both","","","4334.00","3250.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3445.53","79.5","","0.65","0.65","0.65","1 through 10","1343.54","4117.3","percent of total billed charges",""
"Mgh Acsf3 Sequence Analysis","PX-31000515","CDM","81479","CPT","0310","RC","","","","both","","","4334.00","3250.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2310.02","53.3","","0.79","0.79","0.79","1 through 10","1343.54","4117.3","percent of total billed charges",""
"Mgh Acsf3 Sequence Analysis","PX-31000515","CDM","81479","CPT","0310","RC","","","","outpatient","","","4334.00","3250.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2167.00","50","","1.00","1.00","1.00","1 through 10","156.55","3575.55","percent of total billed charges",""
"Mgh Acsf3 Sequence Analysis","PX-31000515","CDM","81479","CPT","0310","RC","","","","outpatient","","","4334.00","3250.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2275.35","52.5","","1.00","0.53","1.00","1 through 10","156.55","3575.55","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002054","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Actin Igg Ab","PX-30002084","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Ada Gene Sequencing","PX-31000270","CDM","81479","CPT","0310","RC","","","","both","","","4600.00","3450.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3657.00","79.5","","0.65","0.65","0.65","1 through 10","1426","4370","percent of total billed charges",""
"Mgh Ada Gene Sequencing","PX-31000270","CDM","81479","CPT","0310","RC","","","","both","","","4600.00","3450.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2451.80","53.3","","0.79","0.79","0.79","1 through 10","1426","4370","percent of total billed charges",""
"Mgh Ada Gene Sequencing","PX-31000270","CDM","81479","CPT","0310","RC","","","","outpatient","","","4600.00","3450.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2300.00","50","","1.00","1.00","1.00","1 through 10","156.55","3795","percent of total billed charges",""
"Mgh Ada Gene Sequencing","PX-31000270","CDM","81479","CPT","0310","RC","","","","outpatient","","","4600.00","3450.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2415.00","52.5","","1.00","0.53","1.00","1 through 10","156.55","3795","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Adeno Virus Quant","PX-30001629","CDM","87799","CPT","0301","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Adenovirus Dna Pcr","PX-30002280","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Adenovirus Pcr","PX-30002281","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Adiponectin","PX-30002050","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Adiponectin","PX-30002081","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Admark® App Dna Sequencing Test and Duplication Test","PX-31000720","CDM","81479","CPT","0310","RC","","","","both","","","3103.00","2327.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2466.89","79.5","","0.65","0.65","0.65","1 through 10","961.93","2947.85","percent of total billed charges",""
"Mgh Admark® App Dna Sequencing Test and Duplication Test","PX-31000720","CDM","81479","CPT","0310","RC","","","","both","","","3103.00","2327.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1653.90","53.3","","0.79","0.79","0.79","1 through 10","961.93","2947.85","percent of total billed charges",""
"Mgh Admark® App Dna Sequencing Test and Duplication Test","PX-31000720","CDM","81479","CPT","0310","RC","","","","outpatient","","","3103.00","2327.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1551.50","50","","1.00","1.00","1.00","1 through 10","156.55","2559.98","percent of total billed charges",""
"Mgh Admark® App Dna Sequencing Test and Duplication Test","PX-31000720","CDM","81479","CPT","0310","RC","","","","outpatient","","","3103.00","2327.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1629.08","52.5","","1.00","0.53","1.00","1 through 10","156.55","2559.98","percent of total billed charges",""
"Mgh Ags Panel","PX-31000484","CDM","81479","CPT","0310","RC","","","","both","","","10112.00","7584.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8039.04","79.5","","0.65","0.65","0.65","1 through 10","3134.72","9606.4","percent of total billed charges",""
"Mgh Ags Panel","PX-31000484","CDM","81479","CPT","0310","RC","","","","both","","","10112.00","7584.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5389.70","53.3","","0.79","0.79","0.79","1 through 10","3134.72","9606.4","percent of total billed charges",""
"Mgh Ags Panel","PX-31000484","CDM","81479","CPT","0310","RC","","","","outpatient","","","10112.00","7584.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5056.00","50","","1.00","1.00","1.00","1 through 10","156.55","8342.4","percent of total billed charges",""
"Mgh Ags Panel","PX-31000484","CDM","81479","CPT","0310","RC","","","","outpatient","","","10112.00","7584.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","5308.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","8342.4","percent of total billed charges",""
"Mgh Ags Tier 1","PX-31000582","CDM","81479","CPT","0310","RC","","","","both","","","1986.00","1489.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1578.87","79.5","","0.65","0.65","0.65","1 through 10","615.66","1886.7","percent of total billed charges",""
"Mgh Ags Tier 1","PX-31000582","CDM","81479","CPT","0310","RC","","","","both","","","1986.00","1489.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1058.54","53.3","","0.79","0.79","0.79","1 through 10","615.66","1886.7","percent of total billed charges",""
"Mgh Ags Tier 1","PX-31000582","CDM","81479","CPT","0310","RC","","","","outpatient","","","1986.00","1489.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","993.00","50","","1.00","1.00","1.00","1 through 10","156.55","1638.45","percent of total billed charges",""
"Mgh Ags Tier 1","PX-31000582","CDM","81479","CPT","0310","RC","","","","outpatient","","","1986.00","1489.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1042.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","1638.45","percent of total billed charges",""
"Mgh Aicardi Goutieres Pnl","PX-31000636","CDM","81479","CPT","0310","RC","","","","both","","","1509.00","1131.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1199.66","79.5","","0.65","0.65","0.65","1 through 10","467.79","1433.55","percent of total billed charges",""
"Mgh Aicardi Goutieres Pnl","PX-31000636","CDM","81479","CPT","0310","RC","","","","both","","","1509.00","1131.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","804.30","53.3","","0.79","0.79","0.79","1 through 10","467.79","1433.55","percent of total billed charges",""
"Mgh Aicardi Goutieres Pnl","PX-31000636","CDM","81479","CPT","0310","RC","","","","outpatient","","","1509.00","1131.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","754.50","50","","1.00","1.00","1.00","1 through 10","156.55","1244.93","percent of total billed charges",""
"Mgh Aicardi Goutieres Pnl","PX-31000636","CDM","81479","CPT","0310","RC","","","","outpatient","","","1509.00","1131.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","792.23","52.5","","1.00","0.53","1.00","1 through 10","156.55","1244.93","percent of total billed charges",""
"Mgh Aicardi-Goutieres Panel","PX-31000600","CDM","81479","CPT","0310","RC","","","","both","","","1582.00","1186.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1257.69","79.5","","0.65","0.65","0.65","1 through 10","490.42","1502.9","percent of total billed charges",""
"Mgh Aicardi-Goutieres Panel","PX-31000600","CDM","81479","CPT","0310","RC","","","","both","","","1582.00","1186.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","843.21","53.3","","0.79","0.79","0.79","1 through 10","490.42","1502.9","percent of total billed charges",""
"Mgh Aicardi-Goutieres Panel","PX-31000600","CDM","81479","CPT","0310","RC","","","","outpatient","","","1582.00","1186.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","791.00","50","","1.00","1.00","1.00","1 through 10","156.55","1305.15","percent of total billed charges",""
"Mgh Aicardi-Goutieres Panel","PX-31000600","CDM","81479","CPT","0310","RC","","","","outpatient","","","1582.00","1186.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","830.55","52.5","","1.00","0.53","1.00","1 through 10","156.55","1305.15","percent of total billed charges",""
"Mgh Aicda Gene Sequencing","PX-31000731","CDM","81479","CPT","0310","RC","","","","both","","","1330.00","997.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1057.35","79.5","","0.65","0.65","0.65","1 through 10","412.3","1263.5","percent of total billed charges",""
"Mgh Aicda Gene Sequencing","PX-31000731","CDM","81479","CPT","0310","RC","","","","both","","","1330.00","997.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","708.89","53.3","","0.79","0.79","0.79","1 through 10","412.3","1263.5","percent of total billed charges",""
"Mgh Aicda Gene Sequencing","PX-31000731","CDM","81479","CPT","0310","RC","","","","outpatient","","","1330.00","997.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","665.00","50","","1.00","1.00","1.00","1 through 10","156.55","1097.25","percent of total billed charges",""
"Mgh Aicda Gene Sequencing","PX-31000731","CDM","81479","CPT","0310","RC","","","","outpatient","","","1330.00","997.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","698.25","52.5","","1.00","0.53","1.00","1 through 10","156.55","1097.25","percent of total billed charges",""
"Mgh Ala D and Porpho Deam RBC","PX-30001995","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Ala D and Porpho Deam RBC","PX-30001995","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Ala D and Porpho Deam RBC","PX-30002006","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Ala D and Porpho Deam RBC","PX-30002006","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Alagille Syndrome (Algs2)","PX-31000373","CDM","81479","CPT","0310","RC","","","","both","","","5089.00","3816.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4045.76","79.5","","0.65","0.65","0.65","1 through 10","1577.59","4834.55","percent of total billed charges",""
"Mgh Alagille Syndrome (Algs2)","PX-31000373","CDM","81479","CPT","0310","RC","","","","both","","","5089.00","3816.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2712.44","53.3","","0.79","0.79","0.79","1 through 10","1577.59","4834.55","percent of total billed charges",""
"Mgh Alagille Syndrome (Algs2)","PX-31000373","CDM","81479","CPT","0310","RC","","","","outpatient","","","5089.00","3816.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2544.50","50","","1.00","1.00","1.00","1 through 10","156.55","4198.43","percent of total billed charges",""
"Mgh Alagille Syndrome (Algs2)","PX-31000373","CDM","81479","CPT","0310","RC","","","","outpatient","","","5089.00","3816.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2671.73","52.5","","1.00","0.53","1.00","1 through 10","156.55","4198.43","percent of total billed charges",""
"Mgh Aldh3a2 Gene Sequencing","PX-31000581","CDM","81479","CPT","0310","RC","","","","both","","","2816.00","2112.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2238.72","79.5","","0.65","0.65","0.65","1 through 10","872.96","2675.2","percent of total billed charges",""
"Mgh Aldh3a2 Gene Sequencing","PX-31000581","CDM","81479","CPT","0310","RC","","","","both","","","2816.00","2112.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1500.93","53.3","","0.79","0.79","0.79","1 through 10","872.96","2675.2","percent of total billed charges",""
"Mgh Aldh3a2 Gene Sequencing","PX-31000581","CDM","81479","CPT","0310","RC","","","","outpatient","","","2816.00","2112.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1408.00","50","","1.00","1.00","1.00","1 through 10","156.55","2323.2","percent of total billed charges",""
"Mgh Aldh3a2 Gene Sequencing","PX-31000581","CDM","81479","CPT","0310","RC","","","","outpatient","","","2816.00","2112.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1478.40","52.5","","1.00","0.53","1.00","1 through 10","156.55","2323.2","percent of total billed charges",""
"Mgh Aldob Gene","PX-31000325","CDM","81479","CPT","0310","RC","","","","both","","","3572.00","2679.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2839.74","79.5","","0.65","0.65","0.65","1 through 10","1107.32","3393.4","percent of total billed charges",""
"Mgh Aldob Gene","PX-31000325","CDM","81479","CPT","0310","RC","","","","both","","","3572.00","2679.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1903.88","53.3","","0.79","0.79","0.79","1 through 10","1107.32","3393.4","percent of total billed charges",""
"Mgh Aldob Gene","PX-31000325","CDM","81479","CPT","0310","RC","","","","outpatient","","","3572.00","2679.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1786.00","50","","1.00","1.00","1.00","1 through 10","156.55","2946.9","percent of total billed charges",""
"Mgh Aldob Gene","PX-31000325","CDM","81479","CPT","0310","RC","","","","outpatient","","","3572.00","2679.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1875.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","2946.9","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Allergen Test 86003","PX-30002188","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Alpha 2 Macroglobulin","PX-30001873","CDM","83883","CPT","0300","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Alpha 2 Macroglobulin","PX-30001873","CDM","83883","CPT","0300","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002049","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Alpha Beta Tryptase","PX-30002080","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Alpha D Glucosidase","PX-30001996","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Alpha D Glucosidase","PX-30001996","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Alpha D Glucosidase","PX-30002007","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Alpha D Glucosidase","PX-30002007","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Alpha-Thalassemia X-Linked Intellectual Disability (Atr-X) Seq","PX-31000620","CDM","81479","CPT","0310","RC","","","","both","","","3796.00","2847.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3017.82","79.5","","0.65","0.65","0.65","1 through 10","1176.76","3606.2","percent of total billed charges",""
"Mgh Alpha-Thalassemia X-Linked Intellectual Disability (Atr-X) Seq","PX-31000620","CDM","81479","CPT","0310","RC","","","","both","","","3796.00","2847.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2023.27","53.3","","0.79","0.79","0.79","1 through 10","1176.76","3606.2","percent of total billed charges",""
"Mgh Alpha-Thalassemia X-Linked Intellectual Disability (Atr-X) Seq","PX-31000620","CDM","81479","CPT","0310","RC","","","","outpatient","","","3796.00","2847.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1898.00","50","","1.00","1.00","1.00","1 through 10","156.55","3131.7","percent of total billed charges",""
"Mgh Alpha-Thalassemia X-Linked Intellectual Disability (Atr-X) Seq","PX-31000620","CDM","81479","CPT","0310","RC","","","","outpatient","","","3796.00","2847.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1992.90","52.5","","1.00","0.53","1.00","1 through 10","156.55","3131.7","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Alternaria Tenuis 86003","PX-30002197","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Alx4 Gene Sequence","PX-31000285","CDM","81479","CPT","0310","RC","","","","both","","","2305.00","1728.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1832.48","79.5","","0.65","0.65","0.65","1 through 10","714.55","2189.75","percent of total billed charges",""
"Mgh Alx4 Gene Sequence","PX-31000285","CDM","81479","CPT","0310","RC","","","","both","","","2305.00","1728.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1228.57","53.3","","0.79","0.79","0.79","1 through 10","714.55","2189.75","percent of total billed charges",""
"Mgh Alx4 Gene Sequence","PX-31000285","CDM","81479","CPT","0310","RC","","","","outpatient","","","2305.00","1728.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1152.50","50","","1.00","1.00","1.00","1 through 10","156.55","1901.63","percent of total billed charges",""
"Mgh Alx4 Gene Sequence","PX-31000285","CDM","81479","CPT","0310","RC","","","","outpatient","","","2305.00","1728.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1210.13","52.5","","1.00","0.53","1.00","1 through 10","156.55","1901.63","percent of total billed charges",""
"Mgh Amidarone","PX-30001530","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Mgh Amidarone","PX-30001530","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Mgh Amidarone","PX-30001530","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","50.36","42.80","92.50","13","14.12","299.25","percent of total billed charges",""
"Mgh Amidarone","PX-30001530","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","52.79","44.55","158.37","30","14.12","299.25","percent of total billed charges",""
"Mgh Amidarone","PX-30001530","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","91.40","64.53","105.30","14","14.12","257.42","percent of total billed charges",""
"Mgh Amidarone","PX-30001530","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","105.30","105.30","105.30","1 through 10","14.12","257.42","percent of total billed charges",""
"Mgh Amidarone","PX-30001530","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","59.36","15.50","59.36","1 through 10","14.12","257.42","percent of total billed charges",""
"Mgh Ampd1 Deficiency: Ampd1 Two Mutation Panel","PX-31000656","CDM","81479","CPT","0310","RC","","","","both","","","862.00","646.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","685.29","79.5","","0.65","0.65","0.65","1 through 10","267.22","818.9","percent of total billed charges",""
"Mgh Ampd1 Deficiency: Ampd1 Two Mutation Panel","PX-31000656","CDM","81479","CPT","0310","RC","","","","both","","","862.00","646.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","459.45","53.3","","0.79","0.79","0.79","1 through 10","267.22","818.9","percent of total billed charges",""
"Mgh Ampd1 Deficiency: Ampd1 Two Mutation Panel","PX-31000656","CDM","81479","CPT","0310","RC","","","","outpatient","","","862.00","646.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","431.00","50","","1.00","1.00","1.00","1 through 10","156.55","711.15","percent of total billed charges",""
"Mgh Ampd1 Deficiency: Ampd1 Two Mutation Panel","PX-31000656","CDM","81479","CPT","0310","RC","","","","outpatient","","","862.00","646.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","452.55","52.5","","1.00","0.53","1.00","1 through 10","156.55","711.15","percent of total billed charges",""
"Mgh Ampd1 Full Gene Sequencing Analysis","PX-31000572","CDM","81479","CPT","0310","RC","","","","both","","","541.00","405.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","430.10","79.5","","0.65","0.65","0.65","1 through 10","167.71","513.95","percent of total billed charges",""
"Mgh Ampd1 Full Gene Sequencing Analysis","PX-31000572","CDM","81479","CPT","0310","RC","","","","both","","","541.00","405.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","288.35","53.3","","0.79","0.79","0.79","1 through 10","167.71","513.95","percent of total billed charges",""
"Mgh Ampd1 Full Gene Sequencing Analysis","PX-31000572","CDM","81479","CPT","0310","RC","","","","outpatient","","","541.00","405.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","270.50","50","","1.00","1.00","1.00","1 through 10","156.55","446.33","percent of total billed charges",""
"Mgh Ampd1 Full Gene Sequencing Analysis","PX-31000572","CDM","81479","CPT","0310","RC","","","","outpatient","","","541.00","405.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","284.03","52.5","","1.00","0.53","1.00","1 through 10","156.55","446.33","percent of total billed charges",""
"Mgh Ampd1 Sequencing by Massively Parallel Sequencing (Bcm-Ngssm","PX-31000569","CDM","81479","CPT","0310","RC","","","","both","","","2439.00","1829.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1939.01","79.5","","0.65","0.65","0.65","1 through 10","756.09","2317.05","percent of total billed charges",""
"Mgh Ampd1 Sequencing by Massively Parallel Sequencing (Bcm-Ngssm","PX-31000569","CDM","81479","CPT","0310","RC","","","","both","","","2439.00","1829.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1299.99","53.3","","0.79","0.79","0.79","1 through 10","756.09","2317.05","percent of total billed charges",""
"Mgh Ampd1 Sequencing by Massively Parallel Sequencing (Bcm-Ngssm","PX-31000569","CDM","81479","CPT","0310","RC","","","","outpatient","","","2439.00","1829.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1219.50","50","","1.00","1.00","1.00","1 through 10","156.55","2012.18","percent of total billed charges",""
"Mgh Ampd1 Sequencing by Massively Parallel Sequencing (Bcm-Ngssm","PX-31000569","CDM","81479","CPT","0310","RC","","","","outpatient","","","2439.00","1829.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1280.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","2012.18","percent of total billed charges",""
"Mgh Ampd1 Sequencing by Massively Parallel Sequencing (Bcm-Ngssm)","PX-31000555","CDM","81479","CPT","0310","RC","","","","both","","","2439.00","1829.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1939.01","79.5","","0.65","0.65","0.65","1 through 10","756.09","2317.05","percent of total billed charges",""
"Mgh Ampd1 Sequencing by Massively Parallel Sequencing (Bcm-Ngssm)","PX-31000555","CDM","81479","CPT","0310","RC","","","","both","","","2439.00","1829.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1299.99","53.3","","0.79","0.79","0.79","1 through 10","756.09","2317.05","percent of total billed charges",""
"Mgh Ampd1 Sequencing by Massively Parallel Sequencing (Bcm-Ngssm)","PX-31000555","CDM","81479","CPT","0310","RC","","","","outpatient","","","2439.00","1829.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1219.50","50","","1.00","1.00","1.00","1 through 10","156.55","2012.18","percent of total billed charges",""
"Mgh Ampd1 Sequencing by Massively Parallel Sequencing (Bcm-Ngssm)","PX-31000555","CDM","81479","CPT","0310","RC","","","","outpatient","","","2439.00","1829.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1280.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","2012.18","percent of total billed charges",""
"Mgh Angelman/Prader-Willi Syn Methylation & Deletion/Dup Analysis","PX-31000591","CDM","81479","CPT","0310","RC","","","","both","","","992.00","744.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","788.64","79.5","","0.65","0.65","0.65","1 through 10","307.52","942.4","percent of total billed charges",""
"Mgh Angelman/Prader-Willi Syn Methylation & Deletion/Dup Analysis","PX-31000591","CDM","81479","CPT","0310","RC","","","","both","","","992.00","744.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","528.74","53.3","","0.79","0.79","0.79","1 through 10","307.52","942.4","percent of total billed charges",""
"Mgh Angelman/Prader-Willi Syn Methylation & Deletion/Dup Analysis","PX-31000591","CDM","81479","CPT","0310","RC","","","","outpatient","","","992.00","744.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","496.00","50","","1.00","1.00","1.00","1 through 10","156.55","818.4","percent of total billed charges",""
"Mgh Angelman/Prader-Willi Syn Methylation & Deletion/Dup Analysis","PX-31000591","CDM","81479","CPT","0310","RC","","","","outpatient","","","992.00","744.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","520.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","818.4","percent of total billed charges",""
"Mgh Antb Fungus Nes","PX-30002180","CDM","86671","CPT","0301","RC","","","","both","","","168.00","126.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","133.56","79.5","","128.28","128.28","128.28","1 through 10","10.07","159.6","percent of total billed charges",""
"Mgh Antb Fungus Nes","PX-30002216","CDM","86671","CPT","0302","RC","","","","both","","","168.00","126.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","133.56","79.5","","128.28","128.28","128.28","1 through 10","10.07","159.6","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002182","CDM","86753","CPT","0301","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","108.58","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002182","CDM","86753","CPT","0301","RC","","","","both","","","153.00","114.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.55","53.3","","78.14","78.14","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002182","CDM","86753","CPT","0301","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.85","36.5","","165.60","55.20","165.60","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002182","CDM","86753","CPT","0301","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","57.87","57.87","57.87","14","9.6","145.35","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002182","CDM","86753","CPT","0301","RC","","","","both","","","153.00","114.75","TRICARE [160005]","HB BWH TRICARE","145.35","95","","14.93","14.18","14.93","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002182","CDM","86753","CPT","0301","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","141.48","70.74","200.40","1 through 10","9.6","125.03","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002182","CDM","86753","CPT","0301","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","118.31","65.08","118.31","13","9.6","125.03","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002236","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","108.58","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002236","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.55","53.3","","78.14","78.14","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002236","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.85","36.5","","165.60","55.20","165.60","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002236","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","57.87","57.87","57.87","14","9.6","145.35","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002236","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","TRICARE [160005]","HB BWH TRICARE","145.35","95","","14.93","14.18","14.93","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002236","CDM","86753","CPT","0302","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","141.48","70.74","200.40","1 through 10","9.6","125.03","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002236","CDM","86753","CPT","0302","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","118.31","65.08","118.31","13","9.6","125.03","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002184","CDM","86790","CPT","0301","RC","","","","both","","","157.00","117.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.82","79.5","","119.62","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002184","CDM","86790","CPT","0301","RC","","","","both","","","157.00","117.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.68","53.3","","80.26","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002184","CDM","86790","CPT","0301","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.31","36.5","","56.70","40.57","143.19","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002184","CDM","86790","CPT","0301","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.13","38.3","","59.43","57.76","178.29","54","9.6","149.15","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002184","CDM","86790","CPT","0301","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA HMO","109.59","69.8","","102.90","72.66","175.56","43","9.6","128.3","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002184","CDM","86790","CPT","0301","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA PPO","126.23","80.4","","72.66","72.66","118.56","1 through 10","9.6","128.3","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002184","CDM","86790","CPT","0301","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.30","81.72","","121.51","66.83","121.51","11","9.6","128.3","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002245","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.82","79.5","","119.62","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002245","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.68","53.3","","80.26","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002245","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.31","36.5","","56.70","40.57","143.19","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002245","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.13","38.3","","59.43","57.76","178.29","54","9.6","149.15","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002245","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA HMO","109.59","69.8","","102.90","72.66","175.56","43","9.6","128.3","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002245","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA PPO","126.23","80.4","","72.66","72.66","118.56","1 through 10","9.6","128.3","percent of total billed charges",""
"Mgh Antb Virus Nes","PX-30002245","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.30","81.72","","121.51","66.83","121.51","11","9.6","128.3","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002044","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Histone Antibody","PX-30002077","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002070","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Iga Abs","PX-30002100","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002046","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Assoc Quant","PX-30002079","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002055","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Myelin Basic Protein","PX-30002085","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002045","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti Neuronal Nuclear","PX-30002078","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Anti-Neuronal Nuclear","PX-30001869","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Apert Syndrome Fgfr2 Dna","PX-31000606","CDM","81479","CPT","0310","RC","","","","both","","","544.00","408.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","432.48","79.5","","0.65","0.65","0.65","1 through 10","168.64","516.8","percent of total billed charges",""
"Mgh Apert Syndrome Fgfr2 Dna","PX-31000606","CDM","81479","CPT","0310","RC","","","","both","","","544.00","408.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","289.95","53.3","","0.79","0.79","0.79","1 through 10","168.64","516.8","percent of total billed charges",""
"Mgh Apert Syndrome Fgfr2 Dna","PX-31000606","CDM","81479","CPT","0310","RC","","","","outpatient","","","544.00","408.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","272.00","50","","1.00","1.00","1.00","1 through 10","156.55","448.8","percent of total billed charges",""
"Mgh Apert Syndrome Fgfr2 Dna","PX-31000606","CDM","81479","CPT","0310","RC","","","","outpatient","","","544.00","408.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","285.60","52.5","","1.00","0.53","1.00","1 through 10","156.55","448.8","percent of total billed charges",""
"Mgh Arbovirus Ab Panel I 86790","PX-30002239","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.82","79.5","","119.62","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Arbovirus Ab Panel I 86790","PX-30002239","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.68","53.3","","80.26","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Arbovirus Ab Panel I 86790","PX-30002239","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.31","36.5","","56.70","40.57","143.19","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Arbovirus Ab Panel I 86790","PX-30002239","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.13","38.3","","59.43","57.76","178.29","54","9.6","149.15","percent of total billed charges",""
"Mgh Arbovirus Ab Panel I 86790","PX-30002239","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA HMO","109.59","69.8","","102.90","72.66","175.56","43","9.6","128.3","percent of total billed charges",""
"Mgh Arbovirus Ab Panel I 86790","PX-30002239","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA PPO","126.23","80.4","","72.66","72.66","118.56","1 through 10","9.6","128.3","percent of total billed charges",""
"Mgh Arbovirus Ab Panel I 86790","PX-30002239","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.30","81.72","","121.51","66.83","121.51","11","9.6","128.3","percent of total billed charges",""
"Mgh Arbovirus Ab Panel II 86790","PX-30002240","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.82","79.5","","119.62","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Arbovirus Ab Panel II 86790","PX-30002240","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.68","53.3","","80.26","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Arbovirus Ab Panel II 86790","PX-30002240","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.31","36.5","","56.70","40.57","143.19","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Arbovirus Ab Panel II 86790","PX-30002240","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.13","38.3","","59.43","57.76","178.29","54","9.6","149.15","percent of total billed charges",""
"Mgh Arbovirus Ab Panel II 86790","PX-30002240","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA HMO","109.59","69.8","","102.90","72.66","175.56","43","9.6","128.3","percent of total billed charges",""
"Mgh Arbovirus Ab Panel II 86790","PX-30002240","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA PPO","126.23","80.4","","72.66","72.66","118.56","1 through 10","9.6","128.3","percent of total billed charges",""
"Mgh Arbovirus Ab Panel II 86790","PX-30002240","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.30","81.72","","121.51","66.83","121.51","11","9.6","128.3","percent of total billed charges",""
"Mgh Argininosuccinate Lyase","PX-30001999","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Argininosuccinate Lyase","PX-30001999","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Argininosuccinate Lyase","PX-30002009","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Argininosuccinate Lyase","PX-30002009","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001971","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001971","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001971","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001971","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001971","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001971","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001971","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001971","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001971","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001981","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001981","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001981","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001981","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001981","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001981","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001981","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001981","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Aripiprazole","PX-30001981","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Arup Non-Alcoh Fatty Liver Disease Suscept (Pnpla3) Genotype","PX-31001045","CDM","81479","CPT","0310","RC","","","","both","","","465.00","348.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","369.68","79.5","","0.65","0.65","0.65","1 through 10","144.15","441.75","percent of total billed charges",""
"Mgh Arup Non-Alcoh Fatty Liver Disease Suscept (Pnpla3) Genotype","PX-31001045","CDM","81479","CPT","0310","RC","","","","both","","","465.00","348.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","247.85","53.3","","0.79","0.79","0.79","1 through 10","144.15","441.75","percent of total billed charges",""
"Mgh Arup Non-Alcoh Fatty Liver Disease Suscept (Pnpla3) Genotype","PX-31001045","CDM","81479","CPT","0310","RC","","","","outpatient","","","465.00","348.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","232.50","50","","1.00","1.00","1.00","1 through 10","156.55","383.63","percent of total billed charges",""
"Mgh Arup Non-Alcoh Fatty Liver Disease Suscept (Pnpla3) Genotype","PX-31001045","CDM","81479","CPT","0310","RC","","","","outpatient","","","465.00","348.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","244.13","52.5","","1.00","0.53","1.00","1 through 10","156.55","383.63","percent of total billed charges",""
"Mgh Arvc Sequence Panel","PX-31000286","CDM","81479","CPT","0310","RC","","","","both","","","10048.00","7536.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7988.16","79.5","","0.65","0.65","0.65","1 through 10","3114.88","9545.6","percent of total billed charges",""
"Mgh Arvc Sequence Panel","PX-31000286","CDM","81479","CPT","0310","RC","","","","both","","","10048.00","7536.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5355.58","53.3","","0.79","0.79","0.79","1 through 10","3114.88","9545.6","percent of total billed charges",""
"Mgh Arvc Sequence Panel","PX-31000286","CDM","81479","CPT","0310","RC","","","","outpatient","","","10048.00","7536.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5024.00","50","","1.00","1.00","1.00","1 through 10","156.55","8289.6","percent of total billed charges",""
"Mgh Arvc Sequence Panel","PX-31000286","CDM","81479","CPT","0310","RC","","","","outpatient","","","10048.00","7536.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","5275.20","52.5","","1.00","0.53","1.00","1 through 10","156.55","8289.6","percent of total billed charges",""
"Mgh Arylsulfatase","PX-30002154","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Arylsulfatase","PX-30002154","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Arylsulfatase","PX-30002154","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Arylsulfatase","PX-30002165","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Arylsulfatase","PX-30002165","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Arylsulfatase","PX-30002165","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Asp Galactomannan Ag","PX-30002250","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","102.43","102.43","102.43","1 through 10","11.74","190","percent of total billed charges",""
"Mgh Asp Galactomannan Ag","PX-30002250","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","61.50","61.50","61.50","1 through 10","11.74","190","percent of total billed charges",""
"Mgh Asp Galactomannan Ag","PX-30002250","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","75.85","75.86","1 through 10","11.74","190","percent of total billed charges",""
"Mgh Asp Galactomannan Ag","PX-30002250","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","155.08","155.08","1 through 10","11.74","190","percent of total billed charges",""
"Mgh Asp Galactomannan Ag","PX-30002250","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","131.34","92.73","185.46","17","11.81","163.44","percent of total billed charges",""
"Mgh Asp Galactomannan Ag","PX-30002250","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","60.38","194.00","1 through 10","11.81","163.44","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","34.39","354.35","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","34.39","354.35","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","34.39","354.35","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","34.39","354.35","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","34.39","354.35","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","34.39","354.35","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","34.39","354.35","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","34.39","354.35","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","34.39","354.35","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","34.39","354.35","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","123.73","304.82","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","123.73","304.82","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","123.73","304.82","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","123.73","304.82","percent of total billed charges",""
"Mgh Aspergillus Dna, Qualitative Real-Time Pcr","PX-30003015","CDM","87798","CPT","0310","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","123.73","304.82","percent of total billed charges",""
"Mgh Assay-Serum Concentration Levofloxacin","PX-30003643","CDM","80299","CPT","0301","RC","","","","both","","","147.00","110.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.87","79.5","","106.25","71.28","106.25","1 through 10","14.12","139.65","percent of total billed charges",""
"Mgh Assay-Serum Concentration Levofloxacin","PX-30003643","CDM","80299","CPT","0301","RC","","","","both","","","147.00","110.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.35","53.3","","106.25","71.28","106.25","1 through 10","14.12","139.65","percent of total billed charges",""
"Mgh Assay-Serum Concentration Levofloxacin","PX-30003643","CDM","80299","CPT","0301","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.66","36.5","","50.36","42.80","92.50","13","14.12","139.65","percent of total billed charges",""
"Mgh Assay-Serum Concentration Levofloxacin","PX-30003643","CDM","80299","CPT","0301","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.30","38.3","","52.79","44.55","158.37","30","14.12","139.65","percent of total billed charges",""
"Mgh Assay-Serum Concentration Levofloxacin","PX-30003643","CDM","80299","CPT","0301","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA HMO","102.61","69.8","","91.40","64.53","105.30","14","14.12","120.13","percent of total billed charges",""
"Mgh Assay-Serum Concentration Levofloxacin","PX-30003643","CDM","80299","CPT","0301","RC","","","","outpatient","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","118.19","80.4","","105.30","105.30","105.30","1 through 10","14.12","120.13","percent of total billed charges",""
"Mgh Assay-Serum Concentration Levofloxacin","PX-30003643","CDM","80299","CPT","0301","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","120.13","81.72","","59.36","15.50","59.36","1 through 10","14.12","120.13","percent of total billed charges",""
"Mgh Assay-Serum Concentration Rifampin","PX-30003642","CDM","80299","CPT","0301","RC","","","","both","","","147.00","110.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.87","79.5","","106.25","71.28","106.25","1 through 10","14.12","139.65","percent of total billed charges",""
"Mgh Assay-Serum Concentration Rifampin","PX-30003642","CDM","80299","CPT","0301","RC","","","","both","","","147.00","110.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.35","53.3","","106.25","71.28","106.25","1 through 10","14.12","139.65","percent of total billed charges",""
"Mgh Assay-Serum Concentration Rifampin","PX-30003642","CDM","80299","CPT","0301","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.66","36.5","","50.36","42.80","92.50","13","14.12","139.65","percent of total billed charges",""
"Mgh Assay-Serum Concentration Rifampin","PX-30003642","CDM","80299","CPT","0301","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.30","38.3","","52.79","44.55","158.37","30","14.12","139.65","percent of total billed charges",""
"Mgh Assay-Serum Concentration Rifampin","PX-30003642","CDM","80299","CPT","0301","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA HMO","102.61","69.8","","91.40","64.53","105.30","14","14.12","120.13","percent of total billed charges",""
"Mgh Assay-Serum Concentration Rifampin","PX-30003642","CDM","80299","CPT","0301","RC","","","","outpatient","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","118.19","80.4","","105.30","105.30","105.30","1 through 10","14.12","120.13","percent of total billed charges",""
"Mgh Assay-Serum Concentration Rifampin","PX-30003642","CDM","80299","CPT","0301","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","120.13","81.72","","59.36","15.50","59.36","1 through 10","14.12","120.13","percent of total billed charges",""
"Mgh Ataxia Disorder Dna Seq","PX-31000234","CDM","81479","CPT","0310","RC","","","","both","","","4600.00","3450.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3657.00","79.5","","0.65","0.65","0.65","1 through 10","1426","4370","percent of total billed charges",""
"Mgh Ataxia Disorder Dna Seq","PX-31000234","CDM","81479","CPT","0310","RC","","","","both","","","4600.00","3450.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2451.80","53.3","","0.79","0.79","0.79","1 through 10","1426","4370","percent of total billed charges",""
"Mgh Ataxia Disorder Dna Seq","PX-31000234","CDM","81479","CPT","0310","RC","","","","outpatient","","","4600.00","3450.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2300.00","50","","1.00","1.00","1.00","1 through 10","156.55","3795","percent of total billed charges",""
"Mgh Ataxia Disorder Dna Seq","PX-31000234","CDM","81479","CPT","0310","RC","","","","outpatient","","","4600.00","3450.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2415.00","52.5","","1.00","0.53","1.00","1 through 10","156.55","3795","percent of total billed charges",""
"Mgh Atenolol Tenormin","PX-30001551","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Atenolol Tenormin","PX-30001551","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Atenolol Tenormin","PX-30001551","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Atenolol Tenormin","PX-30001551","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Atenolol Tenormin","PX-30001551","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Atenolol Tenormin","PX-30001551","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Atenolol Tenormin","PX-30001551","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001973","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001973","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001973","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001973","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001973","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001973","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001973","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001973","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001973","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001983","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001983","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001983","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001983","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001983","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001983","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001983","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001983","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Atomoxetine","PX-30001983","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Axillaryulnar Bypass Grft Vein","PX-36000191","CDM","37799","CPT","0361","RC","","","","outpatient","","","25944.00","19458.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","13547.96","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","21403.8","percent of total billed charges",""
"Mgh Axillaryulnar Bypass Grft Vein","PX-36000191","CDM","37799","CPT","0361","RC","","","","outpatient","","","25944.00","19458.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","13620.60","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","21403.8","percent of total billed charges",""
"Mgh Azathioprine","PX-30001537","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Azathioprine","PX-30001537","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Azathioprine","PX-30001537","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Azathioprine","PX-30001537","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Azathioprine","PX-30001537","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Azathioprine","PX-30001537","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Azathioprine","PX-30001537","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Azithromycin","PX-30001520","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.38","79.5","","106.25","71.28","106.25","1 through 10","14.12","308.75","percent of total billed charges",""
"Mgh Azithromycin","PX-30001520","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.23","53.3","","106.25","71.28","106.25","1 through 10","14.12","308.75","percent of total billed charges",""
"Mgh Azithromycin","PX-30001520","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.63","36.5","","50.36","42.80","92.50","13","14.12","308.75","percent of total billed charges",""
"Mgh Azithromycin","PX-30001520","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.48","38.3","","52.79","44.55","158.37","30","14.12","308.75","percent of total billed charges",""
"Mgh Azithromycin","PX-30001520","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","AETNA [1001]","HB AMC AETNA HMO","226.85","69.8","","91.40","64.53","105.30","14","14.12","265.59","percent of total billed charges",""
"Mgh Azithromycin","PX-30001520","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","261.30","80.4","","105.30","105.30","105.30","1 through 10","14.12","265.59","percent of total billed charges",""
"Mgh Azithromycin","PX-30001520","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","265.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","265.59","percent of total billed charges",""
"Mgh Baclofen","PX-30001550","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Baclofen","PX-30001550","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Baclofen","PX-30001550","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Baclofen","PX-30001550","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Baclofen","PX-30001550","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Baclofen","PX-30001550","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Baclofen","PX-30001550","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Basal Cell Nevus Syndrome Ngs Panel","PX-30003430","CDM","81479","CPT","0310","RC","","","","both","","","487.00","365.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","387.17","79.5","","0.65","0.65","0.65","1 through 10","150.97","462.65","percent of total billed charges",""
"Mgh Basal Cell Nevus Syndrome Ngs Panel","PX-30003430","CDM","81479","CPT","0310","RC","","","","both","","","487.00","365.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","259.57","53.3","","0.79","0.79","0.79","1 through 10","150.97","462.65","percent of total billed charges",""
"Mgh Basal Cell Nevus Syndrome Ngs Panel","PX-30003430","CDM","81479","CPT","0310","RC","","","","outpatient","","","487.00","365.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","243.50","50","","1.00","1.00","1.00","1 through 10","156.55","401.78","percent of total billed charges",""
"Mgh Basal Cell Nevus Syndrome Ngs Panel","PX-30003430","CDM","81479","CPT","0310","RC","","","","outpatient","","","487.00","365.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","255.68","52.5","","1.00","0.53","1.00","1 through 10","156.55","401.78","percent of total billed charges",""
"Mgh Basic Fibrosis Panel","PX-31000513","CDM","81479","CPT","0310","RC","","","","both","","","7225.00","5418.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5743.88","79.5","","0.65","0.65","0.65","1 through 10","2239.75","6863.75","percent of total billed charges",""
"Mgh Basic Fibrosis Panel","PX-31000513","CDM","81479","CPT","0310","RC","","","","both","","","7225.00","5418.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3850.93","53.3","","0.79","0.79","0.79","1 through 10","2239.75","6863.75","percent of total billed charges",""
"Mgh Basic Fibrosis Panel","PX-31000513","CDM","81479","CPT","0310","RC","","","","outpatient","","","7225.00","5418.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3612.50","50","","1.00","1.00","1.00","1 through 10","156.55","5960.63","percent of total billed charges",""
"Mgh Basic Fibrosis Panel","PX-31000513","CDM","81479","CPT","0310","RC","","","","outpatient","","","7225.00","5418.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3793.13","52.5","","1.00","0.53","1.00","1 through 10","156.55","5960.63","percent of total billed charges",""
"Mgh Bcw Autosomal Dominant Thrombocytopenia Panel","PX-31001049","CDM","81479","CPT","0310","RC","","","","both","","","3109.00","2331.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2471.66","79.5","","0.65","0.65","0.65","1 through 10","963.79","2953.55","percent of total billed charges",""
"Mgh Bcw Autosomal Dominant Thrombocytopenia Panel","PX-31001049","CDM","81479","CPT","0310","RC","","","","both","","","3109.00","2331.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1657.10","53.3","","0.79","0.79","0.79","1 through 10","963.79","2953.55","percent of total billed charges",""
"Mgh Bcw Autosomal Dominant Thrombocytopenia Panel","PX-31001049","CDM","81479","CPT","0310","RC","","","","outpatient","","","3109.00","2331.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1554.50","50","","1.00","1.00","1.00","1 through 10","156.55","2564.93","percent of total billed charges",""
"Mgh Bcw Autosomal Dominant Thrombocytopenia Panel","PX-31001049","CDM","81479","CPT","0310","RC","","","","outpatient","","","3109.00","2331.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1632.23","52.5","","1.00","0.53","1.00","1 through 10","156.55","2564.93","percent of total billed charges",""
"Mgh Benign Hereditary Chorea Seq","PX-31000471","CDM","81479","CPT","0310","RC","","","","both","","","2549.00","1911.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2026.46","79.5","","0.65","0.65","0.65","1 through 10","790.19","2421.55","percent of total billed charges",""
"Mgh Benign Hereditary Chorea Seq","PX-31000471","CDM","81479","CPT","0310","RC","","","","both","","","2549.00","1911.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1358.62","53.3","","0.79","0.79","0.79","1 through 10","790.19","2421.55","percent of total billed charges",""
"Mgh Benign Hereditary Chorea Seq","PX-31000471","CDM","81479","CPT","0310","RC","","","","outpatient","","","2549.00","1911.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1274.50","50","","1.00","1.00","1.00","1 through 10","156.55","2102.93","percent of total billed charges",""
"Mgh Benign Hereditary Chorea Seq","PX-31000471","CDM","81479","CPT","0310","RC","","","","outpatient","","","2549.00","1911.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1338.23","52.5","","1.00","0.53","1.00","1 through 10","156.55","2102.93","percent of total billed charges",""
"Mgh Beta Galactosidase","PX-30002155","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Beta Galactosidase","PX-30002155","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Beta Galactosidase","PX-30002155","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Beta Galactosidase","PX-30002166","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Beta Galactosidase","PX-30002166","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Beta Galactosidase","PX-30002166","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Beta Mannosidase","PX-30002159","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Beta Mannosidase","PX-30002159","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Beta Mannosidase","PX-30002159","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Beta Mannosidase","PX-30002169","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Beta Mannosidase","PX-30002169","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Beta Mannosidase","PX-30002169","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Bile Acids (Serum) 83789","PX-30002106","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Bile Acids (Serum) 83789","PX-30002106","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Bile Acids (Serum) 83789","PX-30002106","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Bile Acids (Serum) 83789","PX-30002106","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Bile Acids (Serum) 83789","PX-30002106","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Bile Acids (Serum) 83789","PX-30002106","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Bile Acids (Serum) 83789","PX-30002106","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Biopsy Gingiva","PX-51000152","CDM","41899","CPT","0512","RC","","","","outpatient","","","2928.00","2196.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1772.90","60.55","","481.00","481.00","481.00","1 through 10","700.33","2415.6","percent of total billed charges",""
"Mgh Birt Hogg Dube Syndrome","PX-31000719","CDM","81479","CPT","0310","RC","","","","both","","","2472.00","1854.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1965.24","79.5","","0.65","0.65","0.65","1 through 10","766.32","2348.4","percent of total billed charges",""
"Mgh Birt Hogg Dube Syndrome","PX-31000719","CDM","81479","CPT","0310","RC","","","","both","","","2472.00","1854.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1317.58","53.3","","0.79","0.79","0.79","1 through 10","766.32","2348.4","percent of total billed charges",""
"Mgh Birt Hogg Dube Syndrome","PX-31000719","CDM","81479","CPT","0310","RC","","","","outpatient","","","2472.00","1854.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1236.00","50","","1.00","1.00","1.00","1 through 10","156.55","2039.4","percent of total billed charges",""
"Mgh Birt Hogg Dube Syndrome","PX-31000719","CDM","81479","CPT","0310","RC","","","","outpatient","","","2472.00","1854.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1297.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","2039.4","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Bk Virus Pcr Quant","PX-30002283","CDM","87799","CPT","0300","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"Mgh Blm Gene Sanger Sequencing","PX-31000389","CDM","81479","CPT","0310","RC","","","","both","","","3930.00","2947.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3124.35","79.5","","0.65","0.65","0.65","1 through 10","1218.3","3733.5","percent of total billed charges",""
"Mgh Blm Gene Sanger Sequencing","PX-31000389","CDM","81479","CPT","0310","RC","","","","both","","","3930.00","2947.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2094.69","53.3","","0.79","0.79","0.79","1 through 10","1218.3","3733.5","percent of total billed charges",""
"Mgh Blm Gene Sanger Sequencing","PX-31000389","CDM","81479","CPT","0310","RC","","","","outpatient","","","3930.00","2947.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1965.00","50","","1.00","1.00","1.00","1 through 10","156.55","3242.25","percent of total billed charges",""
"Mgh Blm Gene Sanger Sequencing","PX-31000389","CDM","81479","CPT","0310","RC","","","","outpatient","","","3930.00","2947.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2063.25","52.5","","1.00","0.53","1.00","1 through 10","156.55","3242.25","percent of total billed charges",""
"Mgh Branchiootorenal Syndrome Nextgen Sequencing (Ngs) Panel","PX-31000865","CDM","81479","CPT","0310","RC","","","","both","","","825.00","618.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","655.88","79.5","","0.65","0.65","0.65","1 through 10","255.75","783.75","percent of total billed charges",""
"Mgh Branchiootorenal Syndrome Nextgen Sequencing (Ngs) Panel","PX-31000865","CDM","81479","CPT","0310","RC","","","","both","","","825.00","618.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","439.73","53.3","","0.79","0.79","0.79","1 through 10","255.75","783.75","percent of total billed charges",""
"Mgh Branchiootorenal Syndrome Nextgen Sequencing (Ngs) Panel","PX-31000865","CDM","81479","CPT","0310","RC","","","","outpatient","","","825.00","618.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","412.50","50","","1.00","1.00","1.00","1 through 10","156.55","680.63","percent of total billed charges",""
"Mgh Branchiootorenal Syndrome Nextgen Sequencing (Ngs) Panel","PX-31000865","CDM","81479","CPT","0310","RC","","","","outpatient","","","825.00","618.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","433.13","52.5","","1.00","0.53","1.00","1 through 10","156.55","680.63","percent of total billed charges",""
"Mgh Bromides 84311","PX-30002153","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Bromides 84311","PX-30002153","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Bromides 84311","PX-30002153","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Bronchiectasis (16 Genes)","PX-31000337","CDM","81479","CPT","0310","RC","","","","both","","","75.00","56.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59.63","79.5","","0.65","0.65","0.65","1 through 10","23.25","71.25","percent of total billed charges",""
"Mgh Bronchiectasis (16 Genes)","PX-31000337","CDM","81479","CPT","0310","RC","","","","both","","","75.00","56.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39.98","53.3","","0.79","0.79","0.79","1 through 10","23.25","71.25","percent of total billed charges",""
"Mgh Bronchiectasis (16 Genes)","PX-31000337","CDM","81479","CPT","0310","RC","","","","outpatient","","","75.00","56.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37.50","50","","1.00","1.00","1.00","1 through 10","36.3","156.55","percent of total billed charges",""
"Mgh Bronchiectasis (16 Genes)","PX-31000337","CDM","81479","CPT","0310","RC","","","","outpatient","","","75.00","56.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","39.38","52.5","","1.00","0.53","1.00","1 through 10","36.3","156.55","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002312","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002312","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002312","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002312","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002312","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002312","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002312","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002313","CDM","80299","CPT","0301","RC","","","","both","","","450.00","337.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","357.75","79.5","","106.25","71.28","106.25","1 through 10","14.12","427.5","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002313","CDM","80299","CPT","0301","RC","","","","both","","","450.00","337.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","239.85","53.3","","106.25","71.28","106.25","1 through 10","14.12","427.5","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002313","CDM","80299","CPT","0301","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","164.25","36.5","","50.36","42.80","92.50","13","14.12","427.5","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002313","CDM","80299","CPT","0301","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","172.35","38.3","","52.79","44.55","158.37","30","14.12","427.5","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002313","CDM","80299","CPT","0301","RC","","","","outpatient","","","450.00","337.50","AETNA [1001]","HB AMC AETNA HMO","314.10","69.8","","91.40","64.53","105.30","14","14.12","367.74","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002313","CDM","80299","CPT","0301","RC","","","","outpatient","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","361.80","80.4","","105.30","105.30","105.30","1 through 10","14.12","367.74","percent of total billed charges",""
"Mgh Bupivacaine","PX-30002313","CDM","80299","CPT","0301","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","367.74","81.72","","59.36","15.50","59.36","1 through 10","14.12","367.74","percent of total billed charges",""
"Mgh Buproprion Level 80299","PX-30001566","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Buproprion Level 80299","PX-30001566","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Buproprion Level 80299","PX-30001566","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Buproprion Level 80299","PX-30001566","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Buproprion Level 80299","PX-30001566","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Buproprion Level 80299","PX-30001566","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Buproprion Level 80299","PX-30001566","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Buproprion Oh Buprop","PX-30001538","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Buproprion Oh Buprop","PX-30001538","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Buproprion Oh Buprop","PX-30001538","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Buproprion Oh Buprop","PX-30001538","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Buproprion Oh Buprop","PX-30001538","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Buproprion Oh Buprop","PX-30001538","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Buproprion Oh Buprop","PX-30001538","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh C Histoplasma Cap Ag","PX-30002249","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","102.43","102.43","102.43","1 through 10","11.74","190","percent of total billed charges",""
"Mgh C Histoplasma Cap Ag","PX-30002249","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","61.50","61.50","61.50","1 through 10","11.74","190","percent of total billed charges",""
"Mgh C Histoplasma Cap Ag","PX-30002249","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","75.85","75.86","1 through 10","11.74","190","percent of total billed charges",""
"Mgh C Histoplasma Cap Ag","PX-30002249","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","155.08","155.08","1 through 10","11.74","190","percent of total billed charges",""
"Mgh C Histoplasma Cap Ag","PX-30002249","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","131.34","92.73","185.46","17","11.81","163.44","percent of total billed charges",""
"Mgh C Histoplasma Cap Ag","PX-30002249","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","60.38","194.00","1 through 10","11.81","163.44","percent of total billed charges",""
"Mgh C Histoplasma Cap Ag","PX-30002253","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","102.43","102.43","102.43","1 through 10","11.74","190","percent of total billed charges",""
"Mgh C Histoplasma Cap Ag","PX-30002253","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","61.50","61.50","61.50","1 through 10","11.74","190","percent of total billed charges",""
"Mgh C Histoplasma Cap Ag","PX-30002253","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","75.85","75.86","1 through 10","11.74","190","percent of total billed charges",""
"Mgh C Histoplasma Cap Ag","PX-30002253","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","155.08","155.08","1 through 10","11.74","190","percent of total billed charges",""
"Mgh C Histoplasma Cap Ag","PX-30002253","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","131.34","92.73","185.46","17","11.81","163.44","percent of total billed charges",""
"Mgh C Histoplasma Cap Ag","PX-30002253","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","60.38","194.00","1 through 10","11.81","163.44","percent of total billed charges",""
"Mgh C Htlv1 and 2 Pcr","PX-30001649","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","298.48","65.6","","298.56","298.56","298.56","1 through 10","141.05","361.73","percent of total billed charges",""
"Mgh C Htlv1 and 2 Pcr","PX-30001649","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","295.75","65","","286.65","286.65","347.07","11","141.05","361.73","percent of total billed charges",""
"Mgh C Htlv1 and 2 Pcr","PX-30001649","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","318.50","70","","317.52","189.63","317.52","1 through 10","141.05","361.73","percent of total billed charges",""
"Mgh C Htlv1 and 2 Pcr","PX-30001649","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","295.75","65","","286.65","270.40","286.65","12","141.05","361.73","percent of total billed charges",""
"Mgh C Htlv1 and 2 Pcr","PX-30001649","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","295.75","65","","286.65","286.65","286.65","1 through 10","141.05","361.73","percent of total billed charges",""
"Mgh C Htlv1 and 2 Pcr","PX-30001649","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","WELLPOINT [1015]","HB AMC WELLPOINT","335.70","73.78","","328.32","306.01","328.32","1 through 10","141.05","361.73","percent of total billed charges",""
"Mgh C Htlv1 and 2 Pcr","PX-30001649","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","298.56","298.56","343.98","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh C Htlv1 and 2 Pcr","PX-30001649","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA PPO","365.82","80.4","","343.98","343.98","343.98","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh C Htlv1 and 2 Pcr","PX-30001649","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","227.50","50","","441.00","441.00","441.00","12","227.5","375.38","percent of total billed charges",""
"Mgh C Htlv1 and 2 Pcr","PX-30001649","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","238.88","52.5","","441.00","441.00","441.00","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh C Htlv1 and 2 Pcr","PX-30001649","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","250.25","55","","254.02","254.02","254.02","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh C Htlv1 and 2 Pcr","PX-30001649","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","365.82","80.4","","343.98","343.98","343.98","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh C Htlv1 and 2 Pcr","PX-30001649","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","284.38","62.5","","288.86","277.39","288.86","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh C1 Inhibitor Functional","PX-30002071","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh C9orf72 (Ftd) Dna Test","PX-31000544","CDM","81479","CPT","0310","RC","","","","both","","","1166.00","874.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","926.97","79.5","","0.65","0.65","0.65","1 through 10","361.46","1107.7","percent of total billed charges",""
"Mgh C9orf72 (Ftd) Dna Test","PX-31000544","CDM","81479","CPT","0310","RC","","","","both","","","1166.00","874.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","621.48","53.3","","0.79","0.79","0.79","1 through 10","361.46","1107.7","percent of total billed charges",""
"Mgh C9orf72 (Ftd) Dna Test","PX-31000544","CDM","81479","CPT","0310","RC","","","","outpatient","","","1166.00","874.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","583.00","50","","1.00","1.00","1.00","1 through 10","156.55","961.95","percent of total billed charges",""
"Mgh C9orf72 (Ftd) Dna Test","PX-31000544","CDM","81479","CPT","0310","RC","","","","outpatient","","","1166.00","874.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","612.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","961.95","percent of total billed charges",""
"Mgh Cacna1a Full Gene Seq Analysis","PX-31000299","CDM","81479","CPT","0310","RC","","","","both","","","3304.00","2478.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2626.68","79.5","","0.65","0.65","0.65","1 through 10","1024.24","3138.8","percent of total billed charges",""
"Mgh Cacna1a Full Gene Seq Analysis","PX-31000299","CDM","81479","CPT","0310","RC","","","","both","","","3304.00","2478.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1761.03","53.3","","0.79","0.79","0.79","1 through 10","1024.24","3138.8","percent of total billed charges",""
"Mgh Cacna1a Full Gene Seq Analysis","PX-31000299","CDM","81479","CPT","0310","RC","","","","outpatient","","","3304.00","2478.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1652.00","50","","1.00","1.00","1.00","1 through 10","156.55","2725.8","percent of total billed charges",""
"Mgh Cacna1a Full Gene Seq Analysis","PX-31000299","CDM","81479","CPT","0310","RC","","","","outpatient","","","3304.00","2478.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1734.60","52.5","","1.00","0.53","1.00","1 through 10","156.55","2725.8","percent of total billed charges",""
"Mgh Cact Sequencing","PX-31000240","CDM","81479","CPT","0310","RC","","","","both","","","2882.00","2161.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2291.19","79.5","","0.65","0.65","0.65","1 through 10","893.42","2737.9","percent of total billed charges",""
"Mgh Cact Sequencing","PX-31000240","CDM","81479","CPT","0310","RC","","","","both","","","2882.00","2161.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1536.11","53.3","","0.79","0.79","0.79","1 through 10","893.42","2737.9","percent of total billed charges",""
"Mgh Cact Sequencing","PX-31000240","CDM","81479","CPT","0310","RC","","","","outpatient","","","2882.00","2161.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1441.00","50","","1.00","1.00","1.00","1 through 10","156.55","2377.65","percent of total billed charges",""
"Mgh Cact Sequencing","PX-31000240","CDM","81479","CPT","0310","RC","","","","outpatient","","","2882.00","2161.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1513.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","2377.65","percent of total billed charges",""
"Mgh Caffeine 80299","PX-30001567","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Caffeine 80299","PX-30001567","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Caffeine 80299","PX-30001567","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Caffeine 80299","PX-30001567","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Caffeine 80299","PX-30001567","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Caffeine 80299","PX-30001567","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Caffeine 80299","PX-30001567","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Calr Mutation Analysis","PX-31000627","CDM","81479","CPT","0310","RC","","","","both","","","813.00","609.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","646.34","79.5","","0.65","0.65","0.65","1 through 10","252.03","772.35","percent of total billed charges",""
"Mgh Calr Mutation Analysis","PX-31000627","CDM","81479","CPT","0310","RC","","","","both","","","813.00","609.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","433.33","53.3","","0.79","0.79","0.79","1 through 10","252.03","772.35","percent of total billed charges",""
"Mgh Calr Mutation Analysis","PX-31000627","CDM","81479","CPT","0310","RC","","","","outpatient","","","813.00","609.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","406.50","50","","1.00","1.00","1.00","1 through 10","156.55","670.73","percent of total billed charges",""
"Mgh Calr Mutation Analysis","PX-31000627","CDM","81479","CPT","0310","RC","","","","outpatient","","","813.00","609.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","426.83","52.5","","1.00","0.53","1.00","1 through 10","156.55","670.73","percent of total billed charges",""
"Mgh Campomelic Dysplasia Sox9 Sequence","PX-31000607","CDM","81479","CPT","0310","RC","","","","both","","","1629.00","1221.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1295.06","79.5","","0.65","0.65","0.65","1 through 10","504.99","1547.55","percent of total billed charges",""
"Mgh Campomelic Dysplasia Sox9 Sequence","PX-31000607","CDM","81479","CPT","0310","RC","","","","both","","","1629.00","1221.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","868.26","53.3","","0.79","0.79","0.79","1 through 10","504.99","1547.55","percent of total billed charges",""
"Mgh Campomelic Dysplasia Sox9 Sequence","PX-31000607","CDM","81479","CPT","0310","RC","","","","outpatient","","","1629.00","1221.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","814.50","50","","1.00","1.00","1.00","1 through 10","156.55","1343.93","percent of total billed charges",""
"Mgh Campomelic Dysplasia Sox9 Sequence","PX-31000607","CDM","81479","CPT","0310","RC","","","","outpatient","","","1629.00","1221.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","855.23","52.5","","1.00","0.53","1.00","1 through 10","156.55","1343.93","percent of total billed charges",""
"Mgh Canavan (Aspa Gene Sequence Reflex Deletion / Duplication)","PX-31000547","CDM","81479","CPT","0310","RC","","","","both","","","580.00","435.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","461.10","79.5","","0.65","0.65","0.65","1 through 10","179.8","551","percent of total billed charges",""
"Mgh Canavan (Aspa Gene Sequence Reflex Deletion / Duplication)","PX-31000547","CDM","81479","CPT","0310","RC","","","","both","","","580.00","435.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","309.14","53.3","","0.79","0.79","0.79","1 through 10","179.8","551","percent of total billed charges",""
"Mgh Canavan (Aspa Gene Sequence Reflex Deletion / Duplication)","PX-31000547","CDM","81479","CPT","0310","RC","","","","outpatient","","","580.00","435.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","290.00","50","","1.00","1.00","1.00","1 through 10","156.55","478.5","percent of total billed charges",""
"Mgh Canavan (Aspa Gene Sequence Reflex Deletion / Duplication)","PX-31000547","CDM","81479","CPT","0310","RC","","","","outpatient","","","580.00","435.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","304.50","52.5","","1.00","0.53","1.00","1 through 10","156.55","478.5","percent of total billed charges",""
"Mgh Carrier/Mutation-Specific Test","PX-31000276","CDM","81479","CPT","0310","RC","","","","both","","","1071.00","803.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","851.45","79.5","","0.65","0.65","0.65","1 through 10","332.01","1017.45","percent of total billed charges",""
"Mgh Carrier/Mutation-Specific Test","PX-31000276","CDM","81479","CPT","0310","RC","","","","both","","","1071.00","803.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","570.84","53.3","","0.79","0.79","0.79","1 through 10","332.01","1017.45","percent of total billed charges",""
"Mgh Carrier/Mutation-Specific Test","PX-31000276","CDM","81479","CPT","0310","RC","","","","outpatient","","","1071.00","803.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","535.50","50","","1.00","1.00","1.00","1 through 10","156.55","883.58","percent of total billed charges",""
"Mgh Carrier/Mutation-Specific Test","PX-31000276","CDM","81479","CPT","0310","RC","","","","outpatient","","","1071.00","803.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","562.28","52.5","","1.00","0.53","1.00","1 through 10","156.55","883.58","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Cat Epithelium Ige 86003","PX-30002194","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Ccm Panel","PX-31000326","CDM","81479","CPT","0310","RC","","","","both","","","8929.00","6696.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7098.56","79.5","","0.65","0.65","0.65","1 through 10","2767.99","8482.55","percent of total billed charges",""
"Mgh Ccm Panel","PX-31000326","CDM","81479","CPT","0310","RC","","","","both","","","8929.00","6696.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4759.16","53.3","","0.79","0.79","0.79","1 through 10","2767.99","8482.55","percent of total billed charges",""
"Mgh Ccm Panel","PX-31000326","CDM","81479","CPT","0310","RC","","","","outpatient","","","8929.00","6696.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4464.50","50","","1.00","1.00","1.00","1 through 10","156.55","7366.43","percent of total billed charges",""
"Mgh Ccm Panel","PX-31000326","CDM","81479","CPT","0310","RC","","","","outpatient","","","8929.00","6696.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4687.73","52.5","","1.00","0.53","1.00","1 through 10","156.55","7366.43","percent of total billed charges",""
"Mgh Ccm Sanger Panel","PX-31000354","CDM","81479","CPT","0310","RC","","","","both","","","6399.00","4799.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5087.21","79.5","","0.65","0.65","0.65","1 through 10","1983.69","6079.05","percent of total billed charges",""
"Mgh Ccm Sanger Panel","PX-31000354","CDM","81479","CPT","0310","RC","","","","both","","","6399.00","4799.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3410.67","53.3","","0.79","0.79","0.79","1 through 10","1983.69","6079.05","percent of total billed charges",""
"Mgh Ccm Sanger Panel","PX-31000354","CDM","81479","CPT","0310","RC","","","","outpatient","","","6399.00","4799.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3199.50","50","","1.00","1.00","1.00","1 through 10","156.55","5279.18","percent of total billed charges",""
"Mgh Ccm Sanger Panel","PX-31000354","CDM","81479","CPT","0310","RC","","","","outpatient","","","6399.00","4799.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3359.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","5279.18","percent of total billed charges",""
"Mgh Cd40 Gene Sequencing","PX-31000730","CDM","81479","CPT","0310","RC","","","","both","","","2074.00","1555.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1648.83","79.5","","0.65","0.65","0.65","1 through 10","642.94","1970.3","percent of total billed charges",""
"Mgh Cd40 Gene Sequencing","PX-31000730","CDM","81479","CPT","0310","RC","","","","both","","","2074.00","1555.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1105.44","53.3","","0.79","0.79","0.79","1 through 10","642.94","1970.3","percent of total billed charges",""
"Mgh Cd40 Gene Sequencing","PX-31000730","CDM","81479","CPT","0310","RC","","","","outpatient","","","2074.00","1555.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1037.00","50","","1.00","1.00","1.00","1 through 10","156.55","1711.05","percent of total billed charges",""
"Mgh Cd40 Gene Sequencing","PX-31000730","CDM","81479","CPT","0310","RC","","","","outpatient","","","2074.00","1555.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1088.85","52.5","","1.00","0.53","1.00","1 through 10","156.55","1711.05","percent of total billed charges",""
"Mgh Cda5 Gene Panel","PX-31000504","CDM","81479","CPT","0310","RC","","","","both","","","388.00","291.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","308.46","79.5","","0.65","0.65","0.65","1 through 10","120.28","368.6","percent of total billed charges",""
"Mgh Cda5 Gene Panel","PX-31000504","CDM","81479","CPT","0310","RC","","","","both","","","388.00","291.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","206.80","53.3","","0.79","0.79","0.79","1 through 10","120.28","368.6","percent of total billed charges",""
"Mgh Cda5 Gene Panel","PX-31000504","CDM","81479","CPT","0310","RC","","","","outpatient","","","388.00","291.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","194.00","50","","1.00","1.00","1.00","1 through 10","156.55","320.1","percent of total billed charges",""
"Mgh Cda5 Gene Panel","PX-31000504","CDM","81479","CPT","0310","RC","","","","outpatient","","","388.00","291.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","203.70","52.5","","1.00","0.53","1.00","1 through 10","156.55","320.1","percent of total billed charges",""
"Mgh Cdc73 (Hrpt2) Gene Sequencing","PX-31000588","CDM","81479","CPT","0310","RC","","","","both","","","3886.00","2914.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3089.37","79.5","","0.65","0.65","0.65","1 through 10","1204.66","3691.7","percent of total billed charges",""
"Mgh Cdc73 (Hrpt2) Gene Sequencing","PX-31000588","CDM","81479","CPT","0310","RC","","","","both","","","3886.00","2914.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2071.24","53.3","","0.79","0.79","0.79","1 through 10","1204.66","3691.7","percent of total billed charges",""
"Mgh Cdc73 (Hrpt2) Gene Sequencing","PX-31000588","CDM","81479","CPT","0310","RC","","","","outpatient","","","3886.00","2914.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1943.00","50","","1.00","1.00","1.00","1 through 10","156.55","3205.95","percent of total billed charges",""
"Mgh Cdc73 (Hrpt2) Gene Sequencing","PX-31000588","CDM","81479","CPT","0310","RC","","","","outpatient","","","3886.00","2914.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2040.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","3205.95","percent of total billed charges",""
"Mgh Cdc73 Gene Sequencing","PX-31000239","CDM","81479","CPT","0310","RC","","","","both","","","6592.00","4944.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5240.64","79.5","","0.65","0.65","0.65","1 through 10","2043.52","6262.4","percent of total billed charges",""
"Mgh Cdc73 Gene Sequencing","PX-31000239","CDM","81479","CPT","0310","RC","","","","both","","","6592.00","4944.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3513.54","53.3","","0.79","0.79","0.79","1 through 10","2043.52","6262.4","percent of total billed charges",""
"Mgh Cdc73 Gene Sequencing","PX-31000239","CDM","81479","CPT","0310","RC","","","","outpatient","","","6592.00","4944.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3296.00","50","","1.00","1.00","1.00","1 through 10","156.55","5438.4","percent of total billed charges",""
"Mgh Cdc73 Gene Sequencing","PX-31000239","CDM","81479","CPT","0310","RC","","","","outpatient","","","6592.00","4944.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3460.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","5438.4","percent of total billed charges",""
"Mgh Cdgia","PX-31000327","CDM","81479","CPT","0310","RC","","","","both","","","2978.00","2233.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2367.51","79.5","","0.65","0.65","0.65","1 through 10","923.18","2829.1","percent of total billed charges",""
"Mgh Cdgia","PX-31000327","CDM","81479","CPT","0310","RC","","","","both","","","2978.00","2233.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1587.27","53.3","","0.79","0.79","0.79","1 through 10","923.18","2829.1","percent of total billed charges",""
"Mgh Cdgia","PX-31000327","CDM","81479","CPT","0310","RC","","","","outpatient","","","2978.00","2233.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1489.00","50","","1.00","1.00","1.00","1 through 10","156.55","2456.85","percent of total billed charges",""
"Mgh Cdgia","PX-31000327","CDM","81479","CPT","0310","RC","","","","outpatient","","","2978.00","2233.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1563.45","52.5","","1.00","0.53","1.00","1 through 10","156.55","2456.85","percent of total billed charges",""
"Mgh Cdkl5 Deletion/Duplication","PX-31000232","CDM","81479","CPT","0310","RC","","","","both","","","1256.00","942.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","998.52","79.5","","0.65","0.65","0.65","1 through 10","389.36","1193.2","percent of total billed charges",""
"Mgh Cdkl5 Deletion/Duplication","PX-31000232","CDM","81479","CPT","0310","RC","","","","both","","","1256.00","942.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","669.45","53.3","","0.79","0.79","0.79","1 through 10","389.36","1193.2","percent of total billed charges",""
"Mgh Cdkl5 Deletion/Duplication","PX-31000232","CDM","81479","CPT","0310","RC","","","","outpatient","","","1256.00","942.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","628.00","50","","1.00","1.00","1.00","1 through 10","156.55","1036.2","percent of total billed charges",""
"Mgh Cdkl5 Deletion/Duplication","PX-31000232","CDM","81479","CPT","0310","RC","","","","outpatient","","","1256.00","942.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","659.40","52.5","","1.00","0.53","1.00","1 through 10","156.55","1036.2","percent of total billed charges",""
"Mgh Cdkl5 Deletion/Duplication","PX-31000238","CDM","81479","CPT","0310","RC","","","","both","","","1256.00","942.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","998.52","79.5","","0.65","0.65","0.65","1 through 10","389.36","1193.2","percent of total billed charges",""
"Mgh Cdkl5 Deletion/Duplication","PX-31000238","CDM","81479","CPT","0310","RC","","","","both","","","1256.00","942.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","669.45","53.3","","0.79","0.79","0.79","1 through 10","389.36","1193.2","percent of total billed charges",""
"Mgh Cdkl5 Deletion/Duplication","PX-31000238","CDM","81479","CPT","0310","RC","","","","outpatient","","","1256.00","942.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","628.00","50","","1.00","1.00","1.00","1 through 10","156.55","1036.2","percent of total billed charges",""
"Mgh Cdkl5 Deletion/Duplication","PX-31000238","CDM","81479","CPT","0310","RC","","","","outpatient","","","1256.00","942.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","659.40","52.5","","1.00","0.53","1.00","1 through 10","156.55","1036.2","percent of total billed charges",""
"Mgh Ceftriaxone Level Ba","PX-30001521","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","224.99","79.5","","106.25","71.28","106.25","1 through 10","14.12","268.85","percent of total billed charges",""
"Mgh Ceftriaxone Level Ba","PX-30001521","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","150.84","53.3","","106.25","71.28","106.25","1 through 10","14.12","268.85","percent of total billed charges",""
"Mgh Ceftriaxone Level Ba","PX-30001521","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","103.30","36.5","","50.36","42.80","92.50","13","14.12","268.85","percent of total billed charges",""
"Mgh Ceftriaxone Level Ba","PX-30001521","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","108.39","38.3","","52.79","44.55","158.37","30","14.12","268.85","percent of total billed charges",""
"Mgh Ceftriaxone Level Ba","PX-30001521","CDM","80299","CPT","0301","RC","","","","outpatient","","","283.00","212.25","AETNA [1001]","HB AMC AETNA HMO","197.53","69.8","","91.40","64.53","105.30","14","14.12","231.27","percent of total billed charges",""
"Mgh Ceftriaxone Level Ba","PX-30001521","CDM","80299","CPT","0301","RC","","","","outpatient","","","283.00","212.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","227.53","80.4","","105.30","105.30","105.30","1 through 10","14.12","231.27","percent of total billed charges",""
"Mgh Ceftriaxone Level Ba","PX-30001521","CDM","80299","CPT","0301","RC","","","","outpatient","","","283.00","212.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","231.27","81.72","","59.36","15.50","59.36","1 through 10","14.12","231.27","percent of total billed charges",""
"Mgh Cerebral Cavernous Malformation Panel","PX-31000597","CDM","81479","CPT","0310","RC","","","","both","","","5419.00","4064.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4308.11","79.5","","0.65","0.65","0.65","1 through 10","1679.89","5148.05","percent of total billed charges",""
"Mgh Cerebral Cavernous Malformation Panel","PX-31000597","CDM","81479","CPT","0310","RC","","","","both","","","5419.00","4064.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2888.33","53.3","","0.79","0.79","0.79","1 through 10","1679.89","5148.05","percent of total billed charges",""
"Mgh Cerebral Cavernous Malformation Panel","PX-31000597","CDM","81479","CPT","0310","RC","","","","outpatient","","","5419.00","4064.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2709.50","50","","1.00","1.00","1.00","1 through 10","156.55","4470.68","percent of total billed charges",""
"Mgh Cerebral Cavernous Malformation Panel","PX-31000597","CDM","81479","CPT","0310","RC","","","","outpatient","","","5419.00","4064.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2844.98","52.5","","1.00","0.53","1.00","1 through 10","156.55","4470.68","percent of total billed charges",""
"Mgh Ch Dna Extraction and Storage (Molecular Genetics)","PX-31001044","CDM","81479","CPT","0310","RC","","","","both","","","148.00","111.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","117.66","79.5","","0.65","0.65","0.65","1 through 10","45.88","140.6","percent of total billed charges",""
"Mgh Ch Dna Extraction and Storage (Molecular Genetics)","PX-31001044","CDM","81479","CPT","0310","RC","","","","both","","","148.00","111.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.88","53.3","","0.79","0.79","0.79","1 through 10","45.88","140.6","percent of total billed charges",""
"Mgh Ch Dna Extraction and Storage (Molecular Genetics)","PX-31001044","CDM","81479","CPT","0310","RC","","","","outpatient","","","148.00","111.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","74.00","50","","1.00","1.00","1.00","1 through 10","71.63","156.55","percent of total billed charges",""
"Mgh Ch Dna Extraction and Storage (Molecular Genetics)","PX-31001044","CDM","81479","CPT","0310","RC","","","","outpatient","","","148.00","111.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","77.70","52.5","","1.00","0.53","1.00","1 through 10","71.63","156.55","percent of total billed charges",""
"Mgh Chagas Disease Ab Igg 86753","PX-30002234","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","108.58","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Chagas Disease Ab Igg 86753","PX-30002234","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.55","53.3","","78.14","78.14","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Chagas Disease Ab Igg 86753","PX-30002234","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.85","36.5","","165.60","55.20","165.60","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Chagas Disease Ab Igg 86753","PX-30002234","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","57.87","57.87","57.87","14","9.6","145.35","percent of total billed charges",""
"Mgh Chagas Disease Ab Igg 86753","PX-30002234","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","TRICARE [160005]","HB BWH TRICARE","145.35","95","","14.93","14.18","14.93","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Chagas Disease Ab Igg 86753","PX-30002234","CDM","86753","CPT","0302","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","141.48","70.74","200.40","1 through 10","9.6","125.03","percent of total billed charges",""
"Mgh Chagas Disease Ab Igg 86753","PX-30002234","CDM","86753","CPT","0302","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","118.31","65.08","118.31","13","9.6","125.03","percent of total billed charges",""
"Mgh Chagas Disease Ab Igm 86753","PX-30002235","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","108.58","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Chagas Disease Ab Igm 86753","PX-30002235","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.55","53.3","","78.14","78.14","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Chagas Disease Ab Igm 86753","PX-30002235","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.85","36.5","","165.60","55.20","165.60","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Chagas Disease Ab Igm 86753","PX-30002235","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","57.87","57.87","57.87","14","9.6","145.35","percent of total billed charges",""
"Mgh Chagas Disease Ab Igm 86753","PX-30002235","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","TRICARE [160005]","HB BWH TRICARE","145.35","95","","14.93","14.18","14.93","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Chagas Disease Ab Igm 86753","PX-30002235","CDM","86753","CPT","0302","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","141.48","70.74","200.40","1 through 10","9.6","125.03","percent of total billed charges",""
"Mgh Chagas Disease Ab Igm 86753","PX-30002235","CDM","86753","CPT","0302","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","118.31","65.08","118.31","13","9.6","125.03","percent of total billed charges",""
"Mgh Charcot Marie Tooth Disease Panel","PX-30002984","CDM","81479","CPT","0301","RC","","","","both","","","5346.00","4009.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4250.07","79.5","","0.65","0.65","0.65","1 through 10","1657.26","5078.7","percent of total billed charges",""
"Mgh Charcot Marie Tooth Disease Panel","PX-30002984","CDM","81479","CPT","0301","RC","","","","both","","","5346.00","4009.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2849.42","53.3","","0.79","0.79","0.79","1 through 10","1657.26","5078.7","percent of total billed charges",""
"Mgh Charcot Marie Tooth Disease Panel","PX-30002984","CDM","81479","CPT","0301","RC","","","","outpatient","","","5346.00","4009.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2673.00","50","","1.00","1.00","1.00","1 through 10","156.55","4410.45","percent of total billed charges",""
"Mgh Charcot Marie Tooth Disease Panel","PX-30002984","CDM","81479","CPT","0301","RC","","","","outpatient","","","5346.00","4009.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2806.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","4410.45","percent of total billed charges",""
"Mgh Chn1 Sequencing","PX-31000488","CDM","81479","CPT","0310","RC","","","","both","","","4970.00","3727.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3951.15","79.5","","0.65","0.65","0.65","1 through 10","1540.7","4721.5","percent of total billed charges",""
"Mgh Chn1 Sequencing","PX-31000488","CDM","81479","CPT","0310","RC","","","","both","","","4970.00","3727.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2649.01","53.3","","0.79","0.79","0.79","1 through 10","1540.7","4721.5","percent of total billed charges",""
"Mgh Chn1 Sequencing","PX-31000488","CDM","81479","CPT","0310","RC","","","","outpatient","","","4970.00","3727.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2485.00","50","","1.00","1.00","1.00","1 through 10","156.55","4100.25","percent of total billed charges",""
"Mgh Chn1 Sequencing","PX-31000488","CDM","81479","CPT","0310","RC","","","","outpatient","","","4970.00","3727.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2609.25","52.5","","1.00","0.53","1.00","1 through 10","156.55","4100.25","percent of total billed charges",""
"Mgh Cholestanol","PX-30001976","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cholestanol","PX-30001976","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cholestanol","PX-30001976","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cholestanol","PX-30001976","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Cholestanol","PX-30001976","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cholestanol","PX-30001976","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Cholestanol","PX-30001976","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cholestanol","PX-30001976","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cholestanol","PX-30001976","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cholestanol","PX-30001986","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cholestanol","PX-30001986","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cholestanol","PX-30001986","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cholestanol","PX-30001986","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Cholestanol","PX-30001986","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cholestanol","PX-30001986","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Cholestanol","PX-30001986","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cholestanol","PX-30001986","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cholestanol","PX-30001986","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Ciliopathies Panel","PX-31000573","CDM","81479","CPT","0310","RC","","","","both","","","2710.00","2032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2154.45","79.5","","0.65","0.65","0.65","1 through 10","840.1","2574.5","percent of total billed charges",""
"Mgh Ciliopathies Panel","PX-31000573","CDM","81479","CPT","0310","RC","","","","both","","","2710.00","2032.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1444.43","53.3","","0.79","0.79","0.79","1 through 10","840.1","2574.5","percent of total billed charges",""
"Mgh Ciliopathies Panel","PX-31000573","CDM","81479","CPT","0310","RC","","","","outpatient","","","2710.00","2032.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1355.00","50","","1.00","1.00","1.00","1 through 10","156.55","2235.75","percent of total billed charges",""
"Mgh Ciliopathies Panel","PX-31000573","CDM","81479","CPT","0310","RC","","","","outpatient","","","2710.00","2032.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1422.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","2235.75","percent of total billed charges",""
"Mgh Cimetidine","PX-30001560","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Cimetidine","PX-30001560","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Cimetidine","PX-30001560","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Cimetidine","PX-30001560","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Cimetidine","PX-30001560","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Cimetidine","PX-30001560","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Cimetidine","PX-30001560","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Ciprofloxacin Level Ba","PX-30001522","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","224.99","79.5","","106.25","71.28","106.25","1 through 10","14.12","268.85","percent of total billed charges",""
"Mgh Ciprofloxacin Level Ba","PX-30001522","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","150.84","53.3","","106.25","71.28","106.25","1 through 10","14.12","268.85","percent of total billed charges",""
"Mgh Ciprofloxacin Level Ba","PX-30001522","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","103.30","36.5","","50.36","42.80","92.50","13","14.12","268.85","percent of total billed charges",""
"Mgh Ciprofloxacin Level Ba","PX-30001522","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","108.39","38.3","","52.79","44.55","158.37","30","14.12","268.85","percent of total billed charges",""
"Mgh Ciprofloxacin Level Ba","PX-30001522","CDM","80299","CPT","0301","RC","","","","outpatient","","","283.00","212.25","AETNA [1001]","HB AMC AETNA HMO","197.53","69.8","","91.40","64.53","105.30","14","14.12","231.27","percent of total billed charges",""
"Mgh Ciprofloxacin Level Ba","PX-30001522","CDM","80299","CPT","0301","RC","","","","outpatient","","","283.00","212.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","227.53","80.4","","105.30","105.30","105.30","1 through 10","14.12","231.27","percent of total billed charges",""
"Mgh Ciprofloxacin Level Ba","PX-30001522","CDM","80299","CPT","0301","RC","","","","outpatient","","","283.00","212.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","231.27","81.72","","59.36","15.50","59.36","1 through 10","14.12","231.27","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Cladosporium Ige 86003","PX-30002196","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Clarithromycin","PX-30001523","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.38","79.5","","106.25","71.28","106.25","1 through 10","14.12","308.75","percent of total billed charges",""
"Mgh Clarithromycin","PX-30001523","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.23","53.3","","106.25","71.28","106.25","1 through 10","14.12","308.75","percent of total billed charges",""
"Mgh Clarithromycin","PX-30001523","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.63","36.5","","50.36","42.80","92.50","13","14.12","308.75","percent of total billed charges",""
"Mgh Clarithromycin","PX-30001523","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.48","38.3","","52.79","44.55","158.37","30","14.12","308.75","percent of total billed charges",""
"Mgh Clarithromycin","PX-30001523","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","AETNA [1001]","HB AMC AETNA HMO","226.85","69.8","","91.40","64.53","105.30","14","14.12","265.59","percent of total billed charges",""
"Mgh Clarithromycin","PX-30001523","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","261.30","80.4","","105.30","105.30","105.30","1 through 10","14.12","265.59","percent of total billed charges",""
"Mgh Clarithromycin","PX-30001523","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","265.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","265.59","percent of total billed charges",""
"Mgh Cleiocranial Dysplasia","PX-31000489","CDM","81479","CPT","0310","RC","","","","both","","","2485.00","1863.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1975.58","79.5","","0.65","0.65","0.65","1 through 10","770.35","2360.75","percent of total billed charges",""
"Mgh Cleiocranial Dysplasia","PX-31000489","CDM","81479","CPT","0310","RC","","","","both","","","2485.00","1863.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1324.51","53.3","","0.79","0.79","0.79","1 through 10","770.35","2360.75","percent of total billed charges",""
"Mgh Cleiocranial Dysplasia","PX-31000489","CDM","81479","CPT","0310","RC","","","","outpatient","","","2485.00","1863.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1242.50","50","","1.00","1.00","1.00","1 through 10","156.55","2050.13","percent of total billed charges",""
"Mgh Cleiocranial Dysplasia","PX-31000489","CDM","81479","CPT","0310","RC","","","","outpatient","","","2485.00","1863.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1304.63","52.5","","1.00","0.53","1.00","1 through 10","156.55","2050.13","percent of total billed charges",""
"Mgh Clofazimine","PX-31000850","CDM","80299","CPT","0310","RC","","","","both","","","267.00","200.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","212.27","79.5","","106.25","71.28","106.25","1 through 10","18.27","253.65","percent of total billed charges",""
"Mgh Clofazimine","PX-31000850","CDM","80299","CPT","0310","RC","","","","both","","","267.00","200.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","142.31","53.3","","106.25","71.28","106.25","1 through 10","18.27","253.65","percent of total billed charges",""
"Mgh Clofazimine","PX-31000850","CDM","80299","CPT","0310","RC","","","","both","","","267.00","200.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.46","36.5","","50.36","42.80","92.50","13","18.27","253.65","percent of total billed charges",""
"Mgh Clofazimine","PX-31000850","CDM","80299","CPT","0310","RC","","","","both","","","267.00","200.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","102.26","38.3","","52.79","44.55","158.37","30","18.27","253.65","percent of total billed charges",""
"Mgh Clofazimine","PX-31000850","CDM","80299","CPT","0310","RC","","","","outpatient","","","267.00","200.25","AETNA [1001]","HB AMC AETNA HMO","186.37","69.8","","91.40","64.53","105.30","14","53.62","218.19","percent of total billed charges",""
"Mgh Clofazimine","PX-31000850","CDM","80299","CPT","0310","RC","","","","outpatient","","","267.00","200.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","214.67","80.4","","105.30","105.30","105.30","1 through 10","53.62","218.19","percent of total billed charges",""
"Mgh Clofazimine","PX-31000850","CDM","80299","CPT","0310","RC","","","","outpatient","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","218.19","81.72","","59.36","15.50","59.36","1 through 10","53.62","218.19","percent of total billed charges",""
"Mgh Clomipramine","PX-30001531","CDM","80299","CPT","0301","RC","","","","both","","","240.00","180.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","190.80","79.5","","106.25","71.28","106.25","1 through 10","14.12","228","percent of total billed charges",""
"Mgh Clomipramine","PX-30001531","CDM","80299","CPT","0301","RC","","","","both","","","240.00","180.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","127.92","53.3","","106.25","71.28","106.25","1 through 10","14.12","228","percent of total billed charges",""
"Mgh Clomipramine","PX-30001531","CDM","80299","CPT","0301","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.60","36.5","","50.36","42.80","92.50","13","14.12","228","percent of total billed charges",""
"Mgh Clomipramine","PX-30001531","CDM","80299","CPT","0301","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.92","38.3","","52.79","44.55","158.37","30","14.12","228","percent of total billed charges",""
"Mgh Clomipramine","PX-30001531","CDM","80299","CPT","0301","RC","","","","outpatient","","","240.00","180.00","AETNA [1001]","HB AMC AETNA HMO","167.52","69.8","","91.40","64.53","105.30","14","14.12","196.13","percent of total billed charges",""
"Mgh Clomipramine","PX-30001531","CDM","80299","CPT","0301","RC","","","","outpatient","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","192.96","80.4","","105.30","105.30","105.30","1 through 10","14.12","196.13","percent of total billed charges",""
"Mgh Clomipramine","PX-30001531","CDM","80299","CPT","0301","RC","","","","outpatient","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","196.13","81.72","","59.36","15.50","59.36","1 through 10","14.12","196.13","percent of total billed charges",""
"Mgh Cmt Adv Eval Rec Panl","PX-31000655","CDM","81479","CPT","0310","RC","","","","both","","","1846.00","1384.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1467.57","79.5","","0.65","0.65","0.65","1 through 10","572.26","1753.7","percent of total billed charges",""
"Mgh Cmt Adv Eval Rec Panl","PX-31000655","CDM","81479","CPT","0310","RC","","","","both","","","1846.00","1384.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","983.92","53.3","","0.79","0.79","0.79","1 through 10","572.26","1753.7","percent of total billed charges",""
"Mgh Cmt Adv Eval Rec Panl","PX-31000655","CDM","81479","CPT","0310","RC","","","","outpatient","","","1846.00","1384.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","923.00","50","","1.00","1.00","1.00","1 through 10","156.55","1522.95","percent of total billed charges",""
"Mgh Cmt Adv Eval Rec Panl","PX-31000655","CDM","81479","CPT","0310","RC","","","","outpatient","","","1846.00","1384.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","969.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","1522.95","percent of total billed charges",""
"Mgh Cmt Advanced Eval","PX-31000283","CDM","81479","CPT","0310","RC","","","","both","","","148.00","111.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","117.66","79.5","","0.65","0.65","0.65","1 through 10","45.88","140.6","percent of total billed charges",""
"Mgh Cmt Advanced Eval","PX-31000283","CDM","81479","CPT","0310","RC","","","","both","","","148.00","111.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.88","53.3","","0.79","0.79","0.79","1 through 10","45.88","140.6","percent of total billed charges",""
"Mgh Cmt Advanced Eval","PX-31000283","CDM","81479","CPT","0310","RC","","","","outpatient","","","148.00","111.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","74.00","50","","1.00","1.00","1.00","1 through 10","71.63","156.55","percent of total billed charges",""
"Mgh Cmt Advanced Eval","PX-31000283","CDM","81479","CPT","0310","RC","","","","outpatient","","","148.00","111.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","77.70","52.5","","1.00","0.53","1.00","1 through 10","71.63","156.55","percent of total billed charges",""
"Mgh Cmt Advanced Evaluation - Comprehensive","PX-31000541","CDM","81479","CPT","0310","RC","","","","both","","","1432.00","1074.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1138.44","79.5","","0.65","0.65","0.65","1 through 10","443.92","1360.4","percent of total billed charges",""
"Mgh Cmt Advanced Evaluation - Comprehensive","PX-31000541","CDM","81479","CPT","0310","RC","","","","both","","","1432.00","1074.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","763.26","53.3","","0.79","0.79","0.79","1 through 10","443.92","1360.4","percent of total billed charges",""
"Mgh Cmt Advanced Evaluation - Comprehensive","PX-31000541","CDM","81479","CPT","0310","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","716.00","50","","1.00","1.00","1.00","1 through 10","156.55","1181.4","percent of total billed charges",""
"Mgh Cmt Advanced Evaluation - Comprehensive","PX-31000541","CDM","81479","CPT","0310","RC","","","","outpatient","","","1432.00","1074.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","751.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","1181.4","percent of total billed charges",""
"Mgh Cmt Advanced Evaluation - Dominant, Axonal","PX-31000542","CDM","81479","CPT","0310","RC","","","","both","","","1286.00","964.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1022.37","79.5","","0.65","0.65","0.65","1 through 10","398.66","1221.7","percent of total billed charges",""
"Mgh Cmt Advanced Evaluation - Dominant, Axonal","PX-31000542","CDM","81479","CPT","0310","RC","","","","both","","","1286.00","964.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","685.44","53.3","","0.79","0.79","0.79","1 through 10","398.66","1221.7","percent of total billed charges",""
"Mgh Cmt Advanced Evaluation - Dominant, Axonal","PX-31000542","CDM","81479","CPT","0310","RC","","","","outpatient","","","1286.00","964.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","643.00","50","","1.00","1.00","1.00","1 through 10","156.55","1060.95","percent of total billed charges",""
"Mgh Cmt Advanced Evaluation - Dominant, Axonal","PX-31000542","CDM","81479","CPT","0310","RC","","","","outpatient","","","1286.00","964.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","675.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","1060.95","percent of total billed charges",""
"Mgh Cnbp Repeat Analysis","PX-31000602","CDM","81479","CPT","0310","RC","","","","both","","","903.00","677.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","717.89","79.5","","0.65","0.65","0.65","1 through 10","279.93","857.85","percent of total billed charges",""
"Mgh Cnbp Repeat Analysis","PX-31000602","CDM","81479","CPT","0310","RC","","","","both","","","903.00","677.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","481.30","53.3","","0.79","0.79","0.79","1 through 10","279.93","857.85","percent of total billed charges",""
"Mgh Cnbp Repeat Analysis","PX-31000602","CDM","81479","CPT","0310","RC","","","","outpatient","","","903.00","677.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","451.50","50","","1.00","1.00","1.00","1 through 10","156.55","744.98","percent of total billed charges",""
"Mgh Cnbp Repeat Analysis","PX-31000602","CDM","81479","CPT","0310","RC","","","","outpatient","","","903.00","677.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","474.08","52.5","","1.00","0.53","1.00","1 through 10","156.55","744.98","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002109","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002109","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002109","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002109","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002109","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002109","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002109","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002112","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002112","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002112","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002112","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002112","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002112","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002112","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002114","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002114","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002114","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002114","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002114","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002114","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cobalt Blood","PX-30002114","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Cogm1 Quattro","PX-30002048","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Col3a1 Dna Sequence","PX-31000646","CDM","81479","CPT","0310","RC","","","","both","","","2377.00","1782.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1889.72","79.5","","0.65","0.65","0.65","1 through 10","736.87","2258.15","percent of total billed charges",""
"Mgh Col3a1 Dna Sequence","PX-31000646","CDM","81479","CPT","0310","RC","","","","both","","","2377.00","1782.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1266.94","53.3","","0.79","0.79","0.79","1 through 10","736.87","2258.15","percent of total billed charges",""
"Mgh Col3a1 Dna Sequence","PX-31000646","CDM","81479","CPT","0310","RC","","","","outpatient","","","2377.00","1782.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1188.50","50","","1.00","1.00","1.00","1 through 10","156.55","1961.03","percent of total billed charges",""
"Mgh Col3a1 Dna Sequence","PX-31000646","CDM","81479","CPT","0310","RC","","","","outpatient","","","2377.00","1782.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1247.93","52.5","","1.00","0.53","1.00","1 through 10","156.55","1961.03","percent of total billed charges",""
"Mgh Col5a1 Gene Sequencing","PX-31000482","CDM","81479","CPT","0310","RC","","","","both","","","3757.00","2817.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2986.82","79.5","","0.65","0.65","0.65","1 through 10","1164.67","3569.15","percent of total billed charges",""
"Mgh Col5a1 Gene Sequencing","PX-31000482","CDM","81479","CPT","0310","RC","","","","both","","","3757.00","2817.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2002.48","53.3","","0.79","0.79","0.79","1 through 10","1164.67","3569.15","percent of total billed charges",""
"Mgh Col5a1 Gene Sequencing","PX-31000482","CDM","81479","CPT","0310","RC","","","","outpatient","","","3757.00","2817.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1878.50","50","","1.00","1.00","1.00","1 through 10","156.55","3099.53","percent of total billed charges",""
"Mgh Col5a1 Gene Sequencing","PX-31000482","CDM","81479","CPT","0310","RC","","","","outpatient","","","3757.00","2817.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1972.43","52.5","","1.00","0.53","1.00","1 through 10","156.55","3099.53","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001978","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001978","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001978","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001978","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001978","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001978","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001978","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001978","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001978","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001979","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001979","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001979","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001979","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001979","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001979","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001979","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001979","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Colchr Ms Quan 1 Statnry&Mobl","PX-30001979","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002056","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Collagen Ab Type II","PX-30002086","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Common Short Ragweed 86003","PX-30002192","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Comp Neonatal Diabetes Mutation Analysis","PX-31000882","CDM","81479","CPT","0310","RC","","","","both","","","4992.00","3744.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3968.64","79.5","","0.65","0.65","0.65","1 through 10","1547.52","4742.4","percent of total billed charges",""
"Mgh Comp Neonatal Diabetes Mutation Analysis","PX-31000882","CDM","81479","CPT","0310","RC","","","","both","","","4992.00","3744.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2660.74","53.3","","0.79","0.79","0.79","1 through 10","1547.52","4742.4","percent of total billed charges",""
"Mgh Comp Neonatal Diabetes Mutation Analysis","PX-31000882","CDM","81479","CPT","0310","RC","","","","outpatient","","","4992.00","3744.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2496.00","50","","1.00","1.00","1.00","1 through 10","156.55","4118.4","percent of total billed charges",""
"Mgh Comp Neonatal Diabetes Mutation Analysis","PX-31000882","CDM","81479","CPT","0310","RC","","","","outpatient","","","4992.00","3744.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2620.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","4118.4","percent of total billed charges",""
"Mgh Complete Cerebrl Cavernous Mal","PX-31000260","CDM","81479","CPT","0310","RC","","","","both","","","9181.00","6885.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7298.90","79.5","","0.65","0.65","0.65","1 through 10","2846.11","8721.95","percent of total billed charges",""
"Mgh Complete Cerebrl Cavernous Mal","PX-31000260","CDM","81479","CPT","0310","RC","","","","both","","","9181.00","6885.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4893.47","53.3","","0.79","0.79","0.79","1 through 10","2846.11","8721.95","percent of total billed charges",""
"Mgh Complete Cerebrl Cavernous Mal","PX-31000260","CDM","81479","CPT","0310","RC","","","","outpatient","","","9181.00","6885.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4590.50","50","","1.00","1.00","1.00","1 through 10","156.55","7574.33","percent of total billed charges",""
"Mgh Complete Cerebrl Cavernous Mal","PX-31000260","CDM","81479","CPT","0310","RC","","","","outpatient","","","9181.00","6885.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4820.03","52.5","","1.00","0.53","1.00","1 through 10","156.55","7574.33","percent of total billed charges",""
"Mgh Cong Hypovent Syn Panel","PX-31000336","CDM","81479","CPT","0310","RC","","","","both","","","4712.00","3534.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3746.04","79.5","","0.65","0.65","0.65","1 through 10","1460.72","4476.4","percent of total billed charges",""
"Mgh Cong Hypovent Syn Panel","PX-31000336","CDM","81479","CPT","0310","RC","","","","both","","","4712.00","3534.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2511.50","53.3","","0.79","0.79","0.79","1 through 10","1460.72","4476.4","percent of total billed charges",""
"Mgh Cong Hypovent Syn Panel","PX-31000336","CDM","81479","CPT","0310","RC","","","","outpatient","","","4712.00","3534.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2356.00","50","","1.00","1.00","1.00","1 through 10","156.55","3887.4","percent of total billed charges",""
"Mgh Cong Hypovent Syn Panel","PX-31000336","CDM","81479","CPT","0310","RC","","","","outpatient","","","4712.00","3534.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2473.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","3887.4","percent of total billed charges",""
"Mgh Congenital Contractural Arachnodactyly (Cca)","PX-31000576","CDM","81479","CPT","0310","RC","","","","both","","","4170.00","3127.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3315.15","79.5","","0.65","0.65","0.65","1 through 10","1292.7","3961.5","percent of total billed charges",""
"Mgh Congenital Contractural Arachnodactyly (Cca)","PX-31000576","CDM","81479","CPT","0310","RC","","","","both","","","4170.00","3127.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2222.61","53.3","","0.79","0.79","0.79","1 through 10","1292.7","3961.5","percent of total billed charges",""
"Mgh Congenital Contractural Arachnodactyly (Cca)","PX-31000576","CDM","81479","CPT","0310","RC","","","","outpatient","","","4170.00","3127.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2085.00","50","","1.00","1.00","1.00","1 through 10","156.55","3440.25","percent of total billed charges",""
"Mgh Congenital Contractural Arachnodactyly (Cca)","PX-31000576","CDM","81479","CPT","0310","RC","","","","outpatient","","","4170.00","3127.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2189.25","52.5","","1.00","0.53","1.00","1 through 10","156.55","3440.25","percent of total billed charges",""
"Mgh Congenital Myasthenic Syn Pan by Mass Parallel Seq (Bcm-Ngssm)","PX-31000723","CDM","81479","CPT","0310","RC","","","","both","","","325.00","243.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.38","79.5","","0.65","0.65","0.65","1 through 10","100.75","308.75","percent of total billed charges",""
"Mgh Congenital Myasthenic Syn Pan by Mass Parallel Seq (Bcm-Ngssm)","PX-31000723","CDM","81479","CPT","0310","RC","","","","both","","","325.00","243.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.23","53.3","","0.79","0.79","0.79","1 through 10","100.75","308.75","percent of total billed charges",""
"Mgh Congenital Myasthenic Syn Pan by Mass Parallel Seq (Bcm-Ngssm)","PX-31000723","CDM","81479","CPT","0310","RC","","","","outpatient","","","325.00","243.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","162.50","50","","1.00","1.00","1.00","1 through 10","156.55","268.13","percent of total billed charges",""
"Mgh Congenital Myasthenic Syn Pan by Mass Parallel Seq (Bcm-Ngssm)","PX-31000723","CDM","81479","CPT","0310","RC","","","","outpatient","","","325.00","243.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","170.63","52.5","","1.00","0.53","1.00","1 through 10","156.55","268.13","percent of total billed charges",""
"Mgh Congenital Myasthenic Syndrome Nextgen Sequencing (Ngs) Panel","PX-31000529","CDM","81479","CPT","0310","RC","","","","both","","","1679.00","1259.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1334.81","79.5","","0.65","0.65","0.65","1 through 10","520.49","1595.05","percent of total billed charges",""
"Mgh Congenital Myasthenic Syndrome Nextgen Sequencing (Ngs) Panel","PX-31000529","CDM","81479","CPT","0310","RC","","","","both","","","1679.00","1259.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","894.91","53.3","","0.79","0.79","0.79","1 through 10","520.49","1595.05","percent of total billed charges",""
"Mgh Congenital Myasthenic Syndrome Nextgen Sequencing (Ngs) Panel","PX-31000529","CDM","81479","CPT","0310","RC","","","","outpatient","","","1679.00","1259.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","839.50","50","","1.00","1.00","1.00","1 through 10","156.55","1385.18","percent of total billed charges",""
"Mgh Congenital Myasthenic Syndrome Nextgen Sequencing (Ngs) Panel","PX-31000529","CDM","81479","CPT","0310","RC","","","","outpatient","","","1679.00","1259.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","881.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","1385.18","percent of total billed charges",""
"Mgh Connective Tissue Gene","PX-31000281","CDM","81479","CPT","0310","RC","","","","both","","","6873.00","5154.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5464.04","79.5","","0.65","0.65","0.65","1 through 10","2130.63","6529.35","percent of total billed charges",""
"Mgh Connective Tissue Gene","PX-31000281","CDM","81479","CPT","0310","RC","","","","both","","","6873.00","5154.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3663.31","53.3","","0.79","0.79","0.79","1 through 10","2130.63","6529.35","percent of total billed charges",""
"Mgh Connective Tissue Gene","PX-31000281","CDM","81479","CPT","0310","RC","","","","outpatient","","","6873.00","5154.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3436.50","50","","1.00","1.00","1.00","1 through 10","156.55","5670.23","percent of total billed charges",""
"Mgh Connective Tissue Gene","PX-31000281","CDM","81479","CPT","0310","RC","","","","outpatient","","","6873.00","5154.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3608.33","52.5","","1.00","0.53","1.00","1 through 10","156.55","5670.23","percent of total billed charges",""
"Mgh Cornelia De Lange Syn Panel","PX-31000347","CDM","81479","CPT","0310","RC","","","","both","","","12588.00","9441.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10007.46","79.5","","0.65","0.65","0.65","1 through 10","3902.28","11958.6","percent of total billed charges",""
"Mgh Cornelia De Lange Syn Panel","PX-31000347","CDM","81479","CPT","0310","RC","","","","both","","","12588.00","9441.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6709.40","53.3","","0.79","0.79","0.79","1 through 10","3902.28","11958.6","percent of total billed charges",""
"Mgh Cornelia De Lange Syn Panel","PX-31000347","CDM","81479","CPT","0310","RC","","","","outpatient","","","12588.00","9441.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6294.00","50","","1.00","1.00","1.00","1 through 10","156.55","10385.1","percent of total billed charges",""
"Mgh Cornelia De Lange Syn Panel","PX-31000347","CDM","81479","CPT","0310","RC","","","","outpatient","","","12588.00","9441.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6608.70","52.5","","1.00","0.53","1.00","1 through 10","156.55","10385.1","percent of total billed charges",""
"Mgh Cornelia De Lange Syndrome via the Hdac8 Gene","PX-31000534","CDM","81479","CPT","0310","RC","","","","both","","","1462.00","1096.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1162.29","79.5","","0.65","0.65","0.65","1 through 10","453.22","1388.9","percent of total billed charges",""
"Mgh Cornelia De Lange Syndrome via the Hdac8 Gene","PX-31000534","CDM","81479","CPT","0310","RC","","","","both","","","1462.00","1096.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","779.25","53.3","","0.79","0.79","0.79","1 through 10","453.22","1388.9","percent of total billed charges",""
"Mgh Cornelia De Lange Syndrome via the Hdac8 Gene","PX-31000534","CDM","81479","CPT","0310","RC","","","","outpatient","","","1462.00","1096.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","731.00","50","","1.00","1.00","1.00","1 through 10","156.55","1206.15","percent of total billed charges",""
"Mgh Cornelia De Lange Syndrome via the Hdac8 Gene","PX-31000534","CDM","81479","CPT","0310","RC","","","","outpatient","","","1462.00","1096.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","767.55","52.5","","1.00","0.53","1.00","1 through 10","156.55","1206.15","percent of total billed charges",""
"Mgh Cornelia De Lange Syndrome via the Rad21 Gene","PX-31000533","CDM","81479","CPT","0310","RC","","","","both","","","1970.00","1477.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1566.15","79.5","","0.65","0.65","0.65","1 through 10","610.7","1871.5","percent of total billed charges",""
"Mgh Cornelia De Lange Syndrome via the Rad21 Gene","PX-31000533","CDM","81479","CPT","0310","RC","","","","both","","","1970.00","1477.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1050.01","53.3","","0.79","0.79","0.79","1 through 10","610.7","1871.5","percent of total billed charges",""
"Mgh Cornelia De Lange Syndrome via the Rad21 Gene","PX-31000533","CDM","81479","CPT","0310","RC","","","","outpatient","","","1970.00","1477.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","985.00","50","","1.00","1.00","1.00","1 through 10","156.55","1625.25","percent of total billed charges",""
"Mgh Cornelia De Lange Syndrome via the Rad21 Gene","PX-31000533","CDM","81479","CPT","0310","RC","","","","outpatient","","","1970.00","1477.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1034.25","52.5","","1.00","0.53","1.00","1 through 10","156.55","1625.25","percent of total billed charges",""
"Mgh Cornelia De Lange Syndrome via the Smc3 Gene","PX-31000532","CDM","81479","CPT","0310","RC","","","","both","","","2765.00","2073.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2198.18","79.5","","0.65","0.65","0.65","1 through 10","857.15","2626.75","percent of total billed charges",""
"Mgh Cornelia De Lange Syndrome via the Smc3 Gene","PX-31000532","CDM","81479","CPT","0310","RC","","","","both","","","2765.00","2073.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1473.75","53.3","","0.79","0.79","0.79","1 through 10","857.15","2626.75","percent of total billed charges",""
"Mgh Cornelia De Lange Syndrome via the Smc3 Gene","PX-31000532","CDM","81479","CPT","0310","RC","","","","outpatient","","","2765.00","2073.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1382.50","50","","1.00","1.00","1.00","1 through 10","156.55","2281.13","percent of total billed charges",""
"Mgh Cornelia De Lange Syndrome via the Smc3 Gene","PX-31000532","CDM","81479","CPT","0310","RC","","","","outpatient","","","2765.00","2073.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1451.63","52.5","","1.00","0.53","1.00","1 through 10","156.55","2281.13","percent of total billed charges",""
"Mgh Craniosynostosis, Type 1 (Crs1)","PX-31000574","CDM","81479","CPT","0310","RC","","","","both","","","804.00","603.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","639.18","79.5","","0.65","0.65","0.65","1 through 10","249.24","763.8","percent of total billed charges",""
"Mgh Craniosynostosis, Type 1 (Crs1)","PX-31000574","CDM","81479","CPT","0310","RC","","","","both","","","804.00","603.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","428.53","53.3","","0.79","0.79","0.79","1 through 10","249.24","763.8","percent of total billed charges",""
"Mgh Craniosynostosis, Type 1 (Crs1)","PX-31000574","CDM","81479","CPT","0310","RC","","","","outpatient","","","804.00","603.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","402.00","50","","1.00","1.00","1.00","1 through 10","156.55","663.3","percent of total billed charges",""
"Mgh Craniosynostosis, Type 1 (Crs1)","PX-31000574","CDM","81479","CPT","0310","RC","","","","outpatient","","","804.00","603.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","422.10","52.5","","1.00","0.53","1.00","1 through 10","156.55","663.3","percent of total billed charges",""
"Mgh Cryoablation of Chest Tumor","PX-76001899","CDM","32999","CPT","0761","RC","","","","both","","","2955.00","2216.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2349.23","79.5","","0.89","0.89","0.89","1 through 10","697.51","2349.23","percent of total billed charges",""
"Mgh Cryoablation of Chest Tumor","PX-76002001","CDM","32999","CPT","0761","RC","","","","both","","","2955.00","2216.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2349.23","79.5","","0.89","0.89","0.89","1 through 10","697.51","2349.23","percent of total billed charges",""
"Mgh Cryoablation of Ms Tumor","PX-76001884","CDM","20999","CPT","0761","RC","","","","outpatient","","","3035.00","2276.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1584.88","52.22","","596.65","596.65","596.65","1 through 10","1517.5","8899.59","percent of total billed charges",""
"Mgh Cryoablation of Ms Tumor","PX-76001884","CDM","20999","CPT","0761","RC","","","","outpatient","","","3035.00","2276.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1593.38","52.5","","1695.17","1695.17","1695.17","1 through 10","1517.5","8899.59","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Cysticercs Abelisa","PX-30002225","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Cysticercus Ab Elisa","PX-30002222","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Myd88 L265p Mutn","PX-31000629","CDM","81479","CPT","0310","RC","","","","both","","","323.00","242.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","256.79","79.5","","0.65","0.65","0.65","1 through 10","100.13","306.85","percent of total billed charges",""
"Mgh CSF Myd88 L265p Mutn","PX-31000629","CDM","81479","CPT","0310","RC","","","","both","","","323.00","242.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","172.16","53.3","","0.79","0.79","0.79","1 through 10","100.13","306.85","percent of total billed charges",""
"Mgh CSF Myd88 L265p Mutn","PX-31000629","CDM","81479","CPT","0310","RC","","","","outpatient","","","323.00","242.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","161.50","50","","1.00","1.00","1.00","1 through 10","156.33","266.48","percent of total billed charges",""
"Mgh CSF Myd88 L265p Mutn","PX-31000629","CDM","81479","CPT","0310","RC","","","","outpatient","","","323.00","242.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","169.58","52.5","","1.00","0.53","1.00","1 through 10","156.33","266.48","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002223","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Schistosom Igg Ab","PX-30002226","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh CSF Sporothrix Ab","PX-30002218","CDM","86671","CPT","0302","RC","","","","both","","","168.00","126.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","133.56","79.5","","128.28","128.28","128.28","1 through 10","10.07","159.6","percent of total billed charges",""
"Mgh Csf3r Mutational Analysis","PX-31000479","CDM","81479","CPT","0310","RC","","","","both","","","6223.00","4667.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4947.29","79.5","","0.65","0.65","0.65","1 through 10","1929.13","5911.85","percent of total billed charges",""
"Mgh Csf3r Mutational Analysis","PX-31000479","CDM","81479","CPT","0310","RC","","","","both","","","6223.00","4667.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3316.86","53.3","","0.79","0.79","0.79","1 through 10","1929.13","5911.85","percent of total billed charges",""
"Mgh Csf3r Mutational Analysis","PX-31000479","CDM","81479","CPT","0310","RC","","","","outpatient","","","6223.00","4667.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3111.50","50","","1.00","1.00","1.00","1 through 10","156.55","5133.98","percent of total billed charges",""
"Mgh Csf3r Mutational Analysis","PX-31000479","CDM","81479","CPT","0310","RC","","","","outpatient","","","6223.00","4667.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3267.08","52.5","","1.00","0.53","1.00","1 through 10","156.55","5133.98","percent of total billed charges",""
"Mgh CT Lung Ablation","PX-76001900","CDM","32999","CPT","0761","RC","","","","both","","","8946.00","6709.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7112.07","79.5","","0.89","0.89","0.89","1 through 10","697.51","7112.07","percent of total billed charges",""
"Mgh CT Lung Ablation","PX-76002002","CDM","32999","CPT","0761","RC","","","","both","","","8946.00","6709.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7112.07","79.5","","0.89","0.89","0.89","1 through 10","697.51","7112.07","percent of total billed charges",""
"Mgh Ctgt Lissencephaly and Related Disorders Ngs Panel","PX-31001051","CDM","81479","CPT","0310","RC","","","","both","","","2524.00","1893.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2006.58","79.5","","0.65","0.65","0.65","1 through 10","782.44","2397.8","percent of total billed charges",""
"Mgh Ctgt Lissencephaly and Related Disorders Ngs Panel","PX-31001051","CDM","81479","CPT","0310","RC","","","","both","","","2524.00","1893.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1345.29","53.3","","0.79","0.79","0.79","1 through 10","782.44","2397.8","percent of total billed charges",""
"Mgh Ctgt Lissencephaly and Related Disorders Ngs Panel","PX-31001051","CDM","81479","CPT","0310","RC","","","","outpatient","","","2524.00","1893.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1262.00","50","","1.00","1.00","1.00","1 through 10","156.55","2082.3","percent of total billed charges",""
"Mgh Ctgt Lissencephaly and Related Disorders Ngs Panel","PX-31001051","CDM","81479","CPT","0310","RC","","","","outpatient","","","2524.00","1893.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1325.10","52.5","","1.00","0.53","1.00","1 through 10","156.55","2082.3","percent of total billed charges",""
"Mgh Cybb Gene Sequencing","PX-31000583","CDM","81479","CPT","0310","RC","","","","both","","","2980.00","2235.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2369.10","79.5","","0.65","0.65","0.65","1 through 10","923.8","2831","percent of total billed charges",""
"Mgh Cybb Gene Sequencing","PX-31000583","CDM","81479","CPT","0310","RC","","","","both","","","2980.00","2235.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1588.34","53.3","","0.79","0.79","0.79","1 through 10","923.8","2831","percent of total billed charges",""
"Mgh Cybb Gene Sequencing","PX-31000583","CDM","81479","CPT","0310","RC","","","","outpatient","","","2980.00","2235.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1490.00","50","","1.00","1.00","1.00","1 through 10","156.55","2458.5","percent of total billed charges",""
"Mgh Cybb Gene Sequencing","PX-31000583","CDM","81479","CPT","0310","RC","","","","outpatient","","","2980.00","2235.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1564.50","52.5","","1.00","0.53","1.00","1 through 10","156.55","2458.5","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Cyclic Citrullinatd Pep Ab","PX-30001872","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Cyp7b1 Spg5a Dna Sequencing","PX-31000256","CDM","81479","CPT","0310","RC","","","","both","","","1886.00","1414.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1499.37","79.5","","0.65","0.65","0.65","1 through 10","584.66","1791.7","percent of total billed charges",""
"Mgh Cyp7b1 Spg5a Dna Sequencing","PX-31000256","CDM","81479","CPT","0310","RC","","","","both","","","1886.00","1414.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1005.24","53.3","","0.79","0.79","0.79","1 through 10","584.66","1791.7","percent of total billed charges",""
"Mgh Cyp7b1 Spg5a Dna Sequencing","PX-31000256","CDM","81479","CPT","0310","RC","","","","outpatient","","","1886.00","1414.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","943.00","50","","1.00","1.00","1.00","1 through 10","156.55","1555.95","percent of total billed charges",""
"Mgh Cyp7b1 Spg5a Dna Sequencing","PX-31000256","CDM","81479","CPT","0310","RC","","","","outpatient","","","1886.00","1414.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","990.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","1555.95","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercosis Ab 86682","PX-30002220","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercosis Igg Ab Wba","PX-30002228","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002224","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cysticercus Ab Serum Elisa","PX-30002227","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Cytochrome P450 1a2 Genotype","PX-31000279","CDM","81479","CPT","0310","RC","","","","both","","","1155.00","866.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","918.23","79.5","","0.65","0.65","0.65","1 through 10","358.05","1097.25","percent of total billed charges",""
"Mgh Cytochrome P450 1a2 Genotype","PX-31000279","CDM","81479","CPT","0310","RC","","","","both","","","1155.00","866.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","615.62","53.3","","0.79","0.79","0.79","1 through 10","358.05","1097.25","percent of total billed charges",""
"Mgh Cytochrome P450 1a2 Genotype","PX-31000279","CDM","81479","CPT","0310","RC","","","","outpatient","","","1155.00","866.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","577.50","50","","1.00","1.00","1.00","1 through 10","156.55","952.88","percent of total billed charges",""
"Mgh Cytochrome P450 1a2 Genotype","PX-31000279","CDM","81479","CPT","0310","RC","","","","outpatient","","","1155.00","866.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","606.38","52.5","","1.00","0.53","1.00","1 through 10","156.55","952.88","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh D. Farinae Igg 86003","PX-30002198","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Deletion/Duplication Analysis by Array-Cgh","PX-31000562","CDM","81479","CPT","0310","RC","","","","both","","","2790.00","2092.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2218.05","79.5","","0.65","0.65","0.65","1 through 10","864.9","2650.5","percent of total billed charges",""
"Mgh Deletion/Duplication Analysis by Array-Cgh","PX-31000562","CDM","81479","CPT","0310","RC","","","","both","","","2790.00","2092.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1487.07","53.3","","0.79","0.79","0.79","1 through 10","864.9","2650.5","percent of total billed charges",""
"Mgh Deletion/Duplication Analysis by Array-Cgh","PX-31000562","CDM","81479","CPT","0310","RC","","","","outpatient","","","2790.00","2092.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1395.00","50","","1.00","1.00","1.00","1 through 10","156.55","2301.75","percent of total billed charges",""
"Mgh Deletion/Duplication Analysis by Array-Cgh","PX-31000562","CDM","81479","CPT","0310","RC","","","","outpatient","","","2790.00","2092.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1464.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","2301.75","percent of total billed charges",""
"Mgh Deletion/Duplication via Acgh","PX-31000252","CDM","81479","CPT","0310","RC","","","","both","","","3034.00","2275.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2412.03","79.5","","0.65","0.65","0.65","1 through 10","940.54","2882.3","percent of total billed charges",""
"Mgh Deletion/Duplication via Acgh","PX-31000252","CDM","81479","CPT","0310","RC","","","","both","","","3034.00","2275.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1617.12","53.3","","0.79","0.79","0.79","1 through 10","940.54","2882.3","percent of total billed charges",""
"Mgh Deletion/Duplication via Acgh","PX-31000252","CDM","81479","CPT","0310","RC","","","","outpatient","","","3034.00","2275.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1517.00","50","","1.00","1.00","1.00","1 through 10","156.55","2503.05","percent of total billed charges",""
"Mgh Deletion/Duplication via Acgh","PX-31000252","CDM","81479","CPT","0310","RC","","","","outpatient","","","3034.00","2275.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1592.85","52.5","","1.00","0.53","1.00","1 through 10","156.55","2503.05","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Demyelinating Neuropathy Panel","PX-30003004","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Detect Agent Nos Dna Quant","PX-30002285","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"Mgh Detect Agnt Mult Dna Ampli","PX-30002286","CDM","87801","CPT","0302","RC","","","","both","","","747.00","560.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","286.10","38.3","","283.08","283.08","283.08","1 through 10","53.71","709.65","percent of total billed charges",""
"Mgh Detect Agnt Mult Dna Ampli","PX-30002286","CDM","87801","CPT","0302","RC","","","","outpatient","","","747.00","560.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","610.45","81.72","","578.77","578.77","578.77","1 through 10","53.71","610.45","percent of total billed charges",""
"Mgh Digitoxin 80299","PX-30001568","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Digitoxin 80299","PX-30001568","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Digitoxin 80299","PX-30001568","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Digitoxin 80299","PX-30001568","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Digitoxin 80299","PX-30001568","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Digitoxin 80299","PX-30001568","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Digitoxin 80299","PX-30001568","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Diltiazem","PX-30001539","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Diltiazem","PX-30001539","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Diltiazem","PX-30001539","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Diltiazem","PX-30001539","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Diltiazem","PX-30001539","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Diltiazem","PX-30001539","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Diltiazem","PX-30001539","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Diphenhydramine 25mg Minitb","PX-63601105","CDM","Q0163","HCPCS","0636","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.70","70","","0.92","0.92","0.92","1 through 10","0.31","0.77","percent of total billed charges",""
"Mgh Diphenhydramine 25mg Minitb","PX-63601105","CDM","Q0163","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.70","69.9","","0.57","0.57","0.57","1 through 10","0.47","2.84","percent of total billed charges",""
"Mgh Disopyramide","PX-30001557","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Disopyramide","PX-30001557","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Disopyramide","PX-30001557","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Disopyramide","PX-30001557","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Disopyramide","PX-30001557","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Disopyramide","PX-30001557","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Disopyramide","PX-30001557","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Distal Myopathy Advanced Sequencing Evaluation","PX-31000616","CDM","81479","CPT","0310","RC","","","","both","","","599.00","449.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","476.21","79.5","","0.65","0.65","0.65","1 through 10","185.69","569.05","percent of total billed charges",""
"Mgh Distal Myopathy Advanced Sequencing Evaluation","PX-31000616","CDM","81479","CPT","0310","RC","","","","both","","","599.00","449.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","319.27","53.3","","0.79","0.79","0.79","1 through 10","185.69","569.05","percent of total billed charges",""
"Mgh Distal Myopathy Advanced Sequencing Evaluation","PX-31000616","CDM","81479","CPT","0310","RC","","","","outpatient","","","599.00","449.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","299.50","50","","1.00","1.00","1.00","1 through 10","156.55","494.18","percent of total billed charges",""
"Mgh Distal Myopathy Advanced Sequencing Evaluation","PX-31000616","CDM","81479","CPT","0310","RC","","","","outpatient","","","599.00","449.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","494.18","percent of total billed charges",""
"Mgh Dkc1 Gene Sequencing","PX-31000578","CDM","81479","CPT","0310","RC","","","","both","","","3430.00","2572.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2726.85","79.5","","0.65","0.65","0.65","1 through 10","1063.3","3258.5","percent of total billed charges",""
"Mgh Dkc1 Gene Sequencing","PX-31000578","CDM","81479","CPT","0310","RC","","","","both","","","3430.00","2572.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1828.19","53.3","","0.79","0.79","0.79","1 through 10","1063.3","3258.5","percent of total billed charges",""
"Mgh Dkc1 Gene Sequencing","PX-31000578","CDM","81479","CPT","0310","RC","","","","outpatient","","","3430.00","2572.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1715.00","50","","1.00","1.00","1.00","1 through 10","156.55","2829.75","percent of total billed charges",""
"Mgh Dkc1 Gene Sequencing","PX-31000578","CDM","81479","CPT","0310","RC","","","","outpatient","","","3430.00","2572.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1800.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","2829.75","percent of total billed charges",""
"Mgh Dnm2 Dna Sequencing Test","PX-31000267","CDM","81479","CPT","0310","RC","","","","both","","","4581.00","3435.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3641.90","79.5","","0.65","0.65","0.65","1 through 10","1420.11","4351.95","percent of total billed charges",""
"Mgh Dnm2 Dna Sequencing Test","PX-31000267","CDM","81479","CPT","0310","RC","","","","both","","","4581.00","3435.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2441.67","53.3","","0.79","0.79","0.79","1 through 10","1420.11","4351.95","percent of total billed charges",""
"Mgh Dnm2 Dna Sequencing Test","PX-31000267","CDM","81479","CPT","0310","RC","","","","outpatient","","","4581.00","3435.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2290.50","50","","1.00","1.00","1.00","1 through 10","156.55","3779.33","percent of total billed charges",""
"Mgh Dnm2 Dna Sequencing Test","PX-31000267","CDM","81479","CPT","0310","RC","","","","outpatient","","","4581.00","3435.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2405.03","52.5","","1.00","0.53","1.00","1 through 10","156.55","3779.33","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Dog Dander Ige 86003","PX-30002195","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Doxycycline Level Ba","PX-30001524","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","224.99","79.5","","106.25","71.28","106.25","1 through 10","14.12","268.85","percent of total billed charges",""
"Mgh Doxycycline Level Ba","PX-30001524","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","150.84","53.3","","106.25","71.28","106.25","1 through 10","14.12","268.85","percent of total billed charges",""
"Mgh Doxycycline Level Ba","PX-30001524","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","103.30","36.5","","50.36","42.80","92.50","13","14.12","268.85","percent of total billed charges",""
"Mgh Doxycycline Level Ba","PX-30001524","CDM","80299","CPT","0301","RC","","","","both","","","283.00","212.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","108.39","38.3","","52.79","44.55","158.37","30","14.12","268.85","percent of total billed charges",""
"Mgh Doxycycline Level Ba","PX-30001524","CDM","80299","CPT","0301","RC","","","","outpatient","","","283.00","212.25","AETNA [1001]","HB AMC AETNA HMO","197.53","69.8","","91.40","64.53","105.30","14","14.12","231.27","percent of total billed charges",""
"Mgh Doxycycline Level Ba","PX-30001524","CDM","80299","CPT","0301","RC","","","","outpatient","","","283.00","212.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","227.53","80.4","","105.30","105.30","105.30","1 through 10","14.12","231.27","percent of total billed charges",""
"Mgh Doxycycline Level Ba","PX-30001524","CDM","80299","CPT","0301","RC","","","","outpatient","","","283.00","212.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","231.27","81.72","","59.36","15.50","59.36","1 through 10","14.12","231.27","percent of total billed charges",""
"Mgh Doxycycline Serum","PX-30001540","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Doxycycline Serum","PX-30001540","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Doxycycline Serum","PX-30001540","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Doxycycline Serum","PX-30001540","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Doxycycline Serum","PX-30001540","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Doxycycline Serum","PX-30001540","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Doxycycline Serum","PX-30001540","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Duchenne/Becker Muscular Dystrophy: Dmd Gene Sequencing","PX-31000538","CDM","81479","CPT","0310","RC","","","","both","","","5599.00","4199.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4451.21","79.5","","0.65","0.65","0.65","1 through 10","1735.69","5319.05","percent of total billed charges",""
"Mgh Duchenne/Becker Muscular Dystrophy: Dmd Gene Sequencing","PX-31000538","CDM","81479","CPT","0310","RC","","","","both","","","5599.00","4199.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2984.27","53.3","","0.79","0.79","0.79","1 through 10","1735.69","5319.05","percent of total billed charges",""
"Mgh Duchenne/Becker Muscular Dystrophy: Dmd Gene Sequencing","PX-31000538","CDM","81479","CPT","0310","RC","","","","outpatient","","","5599.00","4199.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2799.50","50","","1.00","1.00","1.00","1 through 10","156.55","4619.18","percent of total billed charges",""
"Mgh Duchenne/Becker Muscular Dystrophy: Dmd Gene Sequencing","PX-31000538","CDM","81479","CPT","0310","RC","","","","outpatient","","","5599.00","4199.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2939.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","4619.18","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001974","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001974","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001974","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001974","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001974","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001974","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001974","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001974","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001974","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001984","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001984","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001984","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001984","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001984","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001984","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001984","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001984","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Duloxetine Serum","PX-30001984","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Dyphylline","PX-30001561","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Dyphylline","PX-30001561","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Dyphylline","PX-30001561","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Dyphylline","PX-30001561","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Dyphylline","PX-30001561","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Dyphylline","PX-30001561","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Dyphylline","PX-30001561","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Ebv Pcr Qual","PX-30002287","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Echinococcus Ab Igg","PX-30002229","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Ectodermal Dysplasia Sanger Sequencing Panel","PX-31000667","CDM","81479","CPT","0310","RC","","","","both","","","1120.00","840.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","890.40","79.5","","0.65","0.65","0.65","1 through 10","347.2","1064","percent of total billed charges",""
"Mgh Ectodermal Dysplasia Sanger Sequencing Panel","PX-31000667","CDM","81479","CPT","0310","RC","","","","both","","","1120.00","840.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","596.96","53.3","","0.79","0.79","0.79","1 through 10","347.2","1064","percent of total billed charges",""
"Mgh Ectodermal Dysplasia Sanger Sequencing Panel","PX-31000667","CDM","81479","CPT","0310","RC","","","","outpatient","","","1120.00","840.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","560.00","50","","1.00","1.00","1.00","1 through 10","156.55","924","percent of total billed charges",""
"Mgh Ectodermal Dysplasia Sanger Sequencing Panel","PX-31000667","CDM","81479","CPT","0310","RC","","","","outpatient","","","1120.00","840.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","588.00","52.5","","1.00","0.53","1.00","1 through 10","156.55","924","percent of total billed charges",""
"Mgh Eds Viia / Viib","PX-31000289","CDM","81479","CPT","0310","RC","","","","both","","","1021.00","765.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","811.70","79.5","","0.65","0.65","0.65","1 through 10","316.51","969.95","percent of total billed charges",""
"Mgh Eds Viia / Viib","PX-31000289","CDM","81479","CPT","0310","RC","","","","both","","","1021.00","765.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","544.19","53.3","","0.79","0.79","0.79","1 through 10","316.51","969.95","percent of total billed charges",""
"Mgh Eds Viia / Viib","PX-31000289","CDM","81479","CPT","0310","RC","","","","outpatient","","","1021.00","765.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","510.50","50","","1.00","1.00","1.00","1 through 10","156.55","842.33","percent of total billed charges",""
"Mgh Eds Viia / Viib","PX-31000289","CDM","81479","CPT","0310","RC","","","","outpatient","","","1021.00","765.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","536.03","52.5","","1.00","0.53","1.00","1 through 10","156.55","842.33","percent of total billed charges",""
"Mgh Efavirenz","PX-30001541","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Efavirenz","PX-30001541","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Efavirenz","PX-30001541","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Efavirenz","PX-30001541","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Efavirenz","PX-30001541","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Efavirenz","PX-30001541","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Efavirenz","PX-30001541","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Ehlers-Danlos Syndrome, Type IV (Eds IV)","PX-31000561","CDM","81479","CPT","0310","RC","","","","both","","","1715.00","1286.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1363.43","79.5","","0.65","0.65","0.65","1 through 10","531.65","1629.25","percent of total billed charges",""
"Mgh Ehlers-Danlos Syndrome, Type IV (Eds IV)","PX-31000561","CDM","81479","CPT","0310","RC","","","","both","","","1715.00","1286.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","914.10","53.3","","0.79","0.79","0.79","1 through 10","531.65","1629.25","percent of total billed charges",""
"Mgh Ehlers-Danlos Syndrome, Type IV (Eds IV)","PX-31000561","CDM","81479","CPT","0310","RC","","","","outpatient","","","1715.00","1286.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","857.50","50","","1.00","1.00","1.00","1 through 10","156.55","1414.88","percent of total billed charges",""
"Mgh Ehlers-Danlos Syndrome, Type IV (Eds IV)","PX-31000561","CDM","81479","CPT","0310","RC","","","","outpatient","","","1715.00","1286.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","900.38","52.5","","1.00","0.53","1.00","1 through 10","156.55","1414.88","percent of total billed charges",""
"Mgh Ehlers-Danlos Syndrome, Type VI (Eds VI)","PX-31000575","CDM","81479","CPT","0310","RC","","","","both","","","2601.00","1950.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2067.80","79.5","","0.65","0.65","0.65","1 through 10","806.31","2470.95","percent of total billed charges",""
"Mgh Ehlers-Danlos Syndrome, Type VI (Eds VI)","PX-31000575","CDM","81479","CPT","0310","RC","","","","both","","","2601.00","1950.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1386.33","53.3","","0.79","0.79","0.79","1 through 10","806.31","2470.95","percent of total billed charges",""
"Mgh Ehlers-Danlos Syndrome, Type VI (Eds VI)","PX-31000575","CDM","81479","CPT","0310","RC","","","","outpatient","","","2601.00","1950.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1300.50","50","","1.00","1.00","1.00","1 through 10","156.55","2145.83","percent of total billed charges",""
"Mgh Ehlers-Danlos Syndrome, Type VI (Eds VI)","PX-31000575","CDM","81479","CPT","0310","RC","","","","outpatient","","","2601.00","1950.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1365.53","52.5","","1.00","0.53","1.00","1 through 10","156.55","2145.83","percent of total billed charges",""
"Mgh Ela2 Gene Kn Cogn Np","PX-31000635","CDM","81479","CPT","0310","RC","","","","both","","","1328.00","996.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1055.76","79.5","","0.65","0.65","0.65","1 through 10","411.68","1261.6","percent of total billed charges",""
"Mgh Ela2 Gene Kn Cogn Np","PX-31000635","CDM","81479","CPT","0310","RC","","","","both","","","1328.00","996.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","707.82","53.3","","0.79","0.79","0.79","1 through 10","411.68","1261.6","percent of total billed charges",""
"Mgh Ela2 Gene Kn Cogn Np","PX-31000635","CDM","81479","CPT","0310","RC","","","","outpatient","","","1328.00","996.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","664.00","50","","1.00","1.00","1.00","1 through 10","156.55","1095.6","percent of total billed charges",""
"Mgh Ela2 Gene Kn Cogn Np","PX-31000635","CDM","81479","CPT","0310","RC","","","","outpatient","","","1328.00","996.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","697.20","52.5","","1.00","0.53","1.00","1 through 10","156.55","1095.6","percent of total billed charges",""
"Mgh Ela2 Gene Sequencing","PX-31000481","CDM","81479","CPT","0310","RC","","","","both","","","2224.00","1668.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1768.08","79.5","","0.65","0.65","0.65","1 through 10","689.44","2112.8","percent of total billed charges",""
"Mgh Ela2 Gene Sequencing","PX-31000481","CDM","81479","CPT","0310","RC","","","","both","","","2224.00","1668.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1185.39","53.3","","0.79","0.79","0.79","1 through 10","689.44","2112.8","percent of total billed charges",""
"Mgh Ela2 Gene Sequencing","PX-31000481","CDM","81479","CPT","0310","RC","","","","outpatient","","","2224.00","1668.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1112.00","50","","1.00","1.00","1.00","1 through 10","156.55","1834.8","percent of total billed charges",""
"Mgh Ela2 Gene Sequencing","PX-31000481","CDM","81479","CPT","0310","RC","","","","outpatient","","","2224.00","1668.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1167.60","52.5","","1.00","0.53","1.00","1 through 10","156.55","1834.8","percent of total billed charges",""
"Mgh Elane (Ela2) Gene Sequencing","PX-31000584","CDM","81479","CPT","0310","RC","","","","both","","","1390.00","1042.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1105.05","79.5","","0.65","0.65","0.65","1 through 10","430.9","1320.5","percent of total billed charges",""
"Mgh Elane (Ela2) Gene Sequencing","PX-31000584","CDM","81479","CPT","0310","RC","","","","both","","","1390.00","1042.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","740.87","53.3","","0.79","0.79","0.79","1 through 10","430.9","1320.5","percent of total billed charges",""
"Mgh Elane (Ela2) Gene Sequencing","PX-31000584","CDM","81479","CPT","0310","RC","","","","outpatient","","","1390.00","1042.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","695.00","50","","1.00","1.00","1.00","1 through 10","156.55","1146.75","percent of total billed charges",""
"Mgh Elane (Ela2) Gene Sequencing","PX-31000584","CDM","81479","CPT","0310","RC","","","","outpatient","","","1390.00","1042.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","729.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","1146.75","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Enterovirus Rna Rt Pcr Ql","PX-30002288","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Enterovirus Rt Pcr","PX-30002289","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Entrovirs Rna Rt Pcr Ql","PX-30002290","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Enzym Asa Nonradoact Ea","PX-30002010","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Enzym Asa Nonradoact Ea","PX-30002010","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Enzyme Assay Nonradioactive Ea","PX-30002000","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Enzyme Assay Nonradioactive Ea","PX-30002000","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Epidermolysis Bullosa Dystrophica, Autosomal Dom & Rec","PX-30003434","CDM","81479","CPT","0310","RC","","","","both","","","1274.00","955.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1012.83","79.5","","0.65","0.65","0.65","1 through 10","394.94","1210.3","percent of total billed charges",""
"Mgh Epidermolysis Bullosa Dystrophica, Autosomal Dom & Rec","PX-30003434","CDM","81479","CPT","0310","RC","","","","both","","","1274.00","955.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","679.04","53.3","","0.79","0.79","0.79","1 through 10","394.94","1210.3","percent of total billed charges",""
"Mgh Epidermolysis Bullosa Dystrophica, Autosomal Dom & Rec","PX-30003434","CDM","81479","CPT","0310","RC","","","","outpatient","","","1274.00","955.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","637.00","50","","1.00","1.00","1.00","1 through 10","156.55","1051.05","percent of total billed charges",""
"Mgh Epidermolysis Bullosa Dystrophica, Autosomal Dom & Rec","PX-30003434","CDM","81479","CPT","0310","RC","","","","outpatient","","","1274.00","955.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","668.85","52.5","","1.00","0.53","1.00","1 through 10","156.55","1051.05","percent of total billed charges",""
"Mgh Epidermolysis Bullosa Dystrophica,Autosomal Dominant&Recess","PX-30003413","CDM","81479","CPT","0310","RC","","","","both","","","1307.00","980.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1039.07","79.5","","0.65","0.65","0.65","1 through 10","405.17","1241.65","percent of total billed charges",""
"Mgh Epidermolysis Bullosa Dystrophica,Autosomal Dominant&Recess","PX-30003413","CDM","81479","CPT","0310","RC","","","","both","","","1307.00","980.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","696.63","53.3","","0.79","0.79","0.79","1 through 10","405.17","1241.65","percent of total billed charges",""
"Mgh Epidermolysis Bullosa Dystrophica,Autosomal Dominant&Recess","PX-30003413","CDM","81479","CPT","0310","RC","","","","outpatient","","","1307.00","980.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","653.50","50","","1.00","1.00","1.00","1 through 10","156.55","1078.28","percent of total billed charges",""
"Mgh Epidermolysis Bullosa Dystrophica,Autosomal Dominant&Recess","PX-30003413","CDM","81479","CPT","0310","RC","","","","outpatient","","","1307.00","980.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","686.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","1078.28","percent of total billed charges",""
"Mgh Epilepsy Advanced Sequencing Eval - Epilepsy With Migraine","PX-31000658","CDM","81479","CPT","0310","RC","","","","both","","","752.00","564.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","597.84","79.5","","0.65","0.65","0.65","1 through 10","233.12","714.4","percent of total billed charges",""
"Mgh Epilepsy Advanced Sequencing Eval - Epilepsy With Migraine","PX-31000658","CDM","81479","CPT","0310","RC","","","","both","","","752.00","564.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","400.82","53.3","","0.79","0.79","0.79","1 through 10","233.12","714.4","percent of total billed charges",""
"Mgh Epilepsy Advanced Sequencing Eval - Epilepsy With Migraine","PX-31000658","CDM","81479","CPT","0310","RC","","","","outpatient","","","752.00","564.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","376.00","50","","1.00","1.00","1.00","1 through 10","156.55","620.4","percent of total billed charges",""
"Mgh Epilepsy Advanced Sequencing Eval - Epilepsy With Migraine","PX-31000658","CDM","81479","CPT","0310","RC","","","","outpatient","","","752.00","564.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","394.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","620.4","percent of total billed charges",""
"Mgh Epilepsy Advanced Sequencing Evaluation","PX-31000611","CDM","81479","CPT","0310","RC","","","","both","","","486.00","364.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","386.37","79.5","","0.65","0.65","0.65","1 through 10","150.66","461.7","percent of total billed charges",""
"Mgh Epilepsy Advanced Sequencing Evaluation","PX-31000611","CDM","81479","CPT","0310","RC","","","","both","","","486.00","364.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","259.04","53.3","","0.79","0.79","0.79","1 through 10","150.66","461.7","percent of total billed charges",""
"Mgh Epilepsy Advanced Sequencing Evaluation","PX-31000611","CDM","81479","CPT","0310","RC","","","","outpatient","","","486.00","364.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","243.00","50","","1.00","1.00","1.00","1 through 10","156.55","400.95","percent of total billed charges",""
"Mgh Epilepsy Advanced Sequencing Evaluation","PX-31000611","CDM","81479","CPT","0310","RC","","","","outpatient","","","486.00","364.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","255.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","400.95","percent of total billed charges",""
"Mgh Epilepsy Sequencing Eval","PX-31000371","CDM","81479","CPT","0310","RC","","","","both","","","75.00","56.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59.63","79.5","","0.65","0.65","0.65","1 through 10","23.25","71.25","percent of total billed charges",""
"Mgh Epilepsy Sequencing Eval","PX-31000371","CDM","81479","CPT","0310","RC","","","","both","","","75.00","56.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39.98","53.3","","0.79","0.79","0.79","1 through 10","23.25","71.25","percent of total billed charges",""
"Mgh Epilepsy Sequencing Eval","PX-31000371","CDM","81479","CPT","0310","RC","","","","outpatient","","","75.00","56.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37.50","50","","1.00","1.00","1.00","1 through 10","36.3","156.55","percent of total billed charges",""
"Mgh Epilepsy Sequencing Eval","PX-31000371","CDM","81479","CPT","0310","RC","","","","outpatient","","","75.00","56.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","39.38","52.5","","1.00","0.53","1.00","1 through 10","36.3","156.55","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Epstein Barr Pcr Quant","PX-30002292","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Mgh Epstein Barr Virus Quant Pcr","PX-30002293","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"Mgh Everolimus","PX-30001529","CDM","80299","CPT","0301","RC","","","","both","","","129.00","96.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","102.56","79.5","","106.25","71.28","106.25","1 through 10","14.12","122.55","percent of total billed charges",""
"Mgh Everolimus","PX-30001529","CDM","80299","CPT","0301","RC","","","","both","","","129.00","96.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","68.76","53.3","","106.25","71.28","106.25","1 through 10","14.12","122.55","percent of total billed charges",""
"Mgh Everolimus","PX-30001529","CDM","80299","CPT","0301","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","47.09","36.5","","50.36","42.80","92.50","13","14.12","122.55","percent of total billed charges",""
"Mgh Everolimus","PX-30001529","CDM","80299","CPT","0301","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","49.41","38.3","","52.79","44.55","158.37","30","14.12","122.55","percent of total billed charges",""
"Mgh Everolimus","PX-30001529","CDM","80299","CPT","0301","RC","","","","outpatient","","","129.00","96.75","AETNA [1001]","HB AMC AETNA HMO","90.04","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Everolimus","PX-30001529","CDM","80299","CPT","0301","RC","","","","outpatient","","","129.00","96.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","103.72","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Everolimus","PX-30001529","CDM","80299","CPT","0301","RC","","","","outpatient","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","105.42","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Exact Metabolic Test","PX-46000059","CDM","94799","CPT","0460","RC","","","","both","","","934.00","700.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","754.00","71.74","754.00","1 through 10","176.52","742.53","other","OPPS APC"
"Mgh Exact Metabolic Test","PX-46000059","CDM","94799","CPT","0460","RC","","","","both","","","934.00","700.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","742.53","79.5","","398.11","398.11","398.11","1 through 10","176.52","742.53","percent of total billed charges",""
"Mgh Exact Metabolic Test","PX-46000059","CDM","94799","CPT","0460","RC","","","","both","","","934.00","700.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","607.10","65","","399.62","399.62","399.62","1 through 10","176.52","742.53","percent of total billed charges",""
"Mgh Exact Metabolic Test","PX-46000059","CDM","94799","CPT","0460","RC","","","","both","","","934.00","700.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","357.72","38.3","","294.81","294.81","294.81","1 through 10","176.52","742.53","percent of total billed charges",""
"Mgh Exact Metabolic Test","PX-46000059","CDM","94799","CPT","0460","RC","","","","outpatient","","","934.00","700.50","AETNA [1001]","HB AMC AETNA HMO","651.93","69.8","","510.46","510.46","510.46","1 through 10","304.03","770.55","percent of total billed charges",""
"Mgh Exact Metabolic Test","PX-46000059","CDM","94799","CPT","0460","RC","","","","outpatient","","","934.00","700.50","AETNA [1001]","HB AMC AETNA PPO","750.94","80.4","","588.12","588.12","588.12","1 through 10","304.03","770.55","percent of total billed charges",""
"Mgh Exact Metabolic Test","PX-46000059","CDM","94799","CPT","0460","RC","","","","outpatient","","","934.00","700.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","565.54","60.55","","363.93","312.34","754.00","1 through 10","304.03","770.55","percent of total billed charges",""
"Mgh Exact Metabolic Test","PX-46000059","CDM","94799","CPT","0460","RC","","","","outpatient","","","934.00","700.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","487.73","52.22","","363.93","360.37","754.00","1 through 10","304.03","770.55","percent of total billed charges",""
"Mgh Exact Metabolic Test","PX-46000059","CDM","94799","CPT","0460","RC","","","","outpatient","","","934.00","700.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","467.00","50","","754.00","754.00","754.00","1 through 10","304.03","770.55","percent of total billed charges",""
"Mgh Exact Metabolic Test","PX-46000059","CDM","94799","CPT","0460","RC","","","","outpatient","","","934.00","700.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","490.35","52.5","","754.00","414.70","754.00","1 through 10","304.03","770.55","percent of total billed charges",""
"Mgh Exact Metabolic Test","PX-46000059","CDM","94799","CPT","0460","RC","","","","outpatient","","","934.00","700.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","513.70","55","","434.30","434.30","434.30","1 through 10","304.03","770.55","percent of total billed charges",""
"Mgh Exact Metabolic Test","PX-46000059","CDM","94799","CPT","0460","RC","","","","outpatient","","","934.00","700.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","763.26","81.72","","602.75","602.75","602.75","1 through 10","304.03","770.55","percent of total billed charges",""
"Mgh Exostoses Multi Type I","PX-31000338","CDM","81479","CPT","0310","RC","","","","both","","","2323.00","1742.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1846.79","79.5","","0.65","0.65","0.65","1 through 10","720.13","2206.85","percent of total billed charges",""
"Mgh Exostoses Multi Type I","PX-31000338","CDM","81479","CPT","0310","RC","","","","both","","","2323.00","1742.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1238.16","53.3","","0.79","0.79","0.79","1 through 10","720.13","2206.85","percent of total billed charges",""
"Mgh Exostoses Multi Type I","PX-31000338","CDM","81479","CPT","0310","RC","","","","outpatient","","","2323.00","1742.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1161.50","50","","1.00","1.00","1.00","1 through 10","156.55","1916.48","percent of total billed charges",""
"Mgh Exostoses Multi Type I","PX-31000338","CDM","81479","CPT","0310","RC","","","","outpatient","","","2323.00","1742.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1219.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","1916.48","percent of total billed charges",""
"Mgh Exostoses, Multiple, Type I & II","PX-30003428","CDM","81479","CPT","0310","RC","","","","both","","","803.00","602.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","638.39","79.5","","0.65","0.65","0.65","1 through 10","248.93","762.85","percent of total billed charges",""
"Mgh Exostoses, Multiple, Type I & II","PX-30003428","CDM","81479","CPT","0310","RC","","","","both","","","803.00","602.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","428.00","53.3","","0.79","0.79","0.79","1 through 10","248.93","762.85","percent of total billed charges",""
"Mgh Exostoses, Multiple, Type I & II","PX-30003428","CDM","81479","CPT","0310","RC","","","","outpatient","","","803.00","602.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","401.50","50","","1.00","1.00","1.00","1 through 10","156.55","662.48","percent of total billed charges",""
"Mgh Exostoses, Multiple, Type I & II","PX-30003428","CDM","81479","CPT","0310","RC","","","","outpatient","","","803.00","602.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","421.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","662.48","percent of total billed charges",""
"Mgh Expanded Rasopathy Panel (14 Genes) Test","PX-31000563","CDM","81479","CPT","0310","RC","","","","both","","","338.00","253.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","268.71","79.5","","0.65","0.65","0.65","1 through 10","104.78","321.1","percent of total billed charges",""
"Mgh Expanded Rasopathy Panel (14 Genes) Test","PX-31000563","CDM","81479","CPT","0310","RC","","","","both","","","338.00","253.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","180.15","53.3","","0.79","0.79","0.79","1 through 10","104.78","321.1","percent of total billed charges",""
"Mgh Expanded Rasopathy Panel (14 Genes) Test","PX-31000563","CDM","81479","CPT","0310","RC","","","","outpatient","","","338.00","253.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","169.00","50","","1.00","1.00","1.00","1 through 10","156.55","278.85","percent of total billed charges",""
"Mgh Expanded Rasopathy Panel (14 Genes) Test","PX-31000563","CDM","81479","CPT","0310","RC","","","","outpatient","","","338.00","253.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","177.45","52.5","","1.00","0.53","1.00","1 through 10","156.55","278.85","percent of total billed charges",""
"Mgh Expedited Tma Panel","PX-31000296","CDM","81479","CPT","0310","RC","","","","both","","","1351.00","1013.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1074.05","79.5","","0.65","0.65","0.65","1 through 10","418.81","1283.45","percent of total billed charges",""
"Mgh Expedited Tma Panel","PX-31000296","CDM","81479","CPT","0310","RC","","","","both","","","1351.00","1013.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","720.08","53.3","","0.79","0.79","0.79","1 through 10","418.81","1283.45","percent of total billed charges",""
"Mgh Expedited Tma Panel","PX-31000296","CDM","81479","CPT","0310","RC","","","","outpatient","","","1351.00","1013.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","675.50","50","","1.00","1.00","1.00","1 through 10","156.55","1114.58","percent of total billed charges",""
"Mgh Expedited Tma Panel","PX-31000296","CDM","81479","CPT","0310","RC","","","","outpatient","","","1351.00","1013.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","709.28","52.5","","1.00","0.53","1.00","1 through 10","156.55","1114.58","percent of total billed charges",""
"Mgh F Adenosine Deaminase","PX-30002158","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh F Adenosine Deaminase","PX-30002158","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh F Adenosine Deaminase","PX-30002158","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh F Adenosine Deaminase","PX-30002168","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh F Adenosine Deaminase","PX-30002168","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh F Adenosine Deaminase","PX-30002168","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Factor X11 Snp Analysis","PX-31000241","CDM","81479","CPT","0310","RC","","","","both","","","400.00","300.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","318.00","79.5","","0.65","0.65","0.65","1 through 10","124","380","percent of total billed charges",""
"Mgh Factor X11 Snp Analysis","PX-31000241","CDM","81479","CPT","0310","RC","","","","both","","","400.00","300.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","213.20","53.3","","0.79","0.79","0.79","1 through 10","124","380","percent of total billed charges",""
"Mgh Factor X11 Snp Analysis","PX-31000241","CDM","81479","CPT","0310","RC","","","","outpatient","","","400.00","300.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","200.00","50","","1.00","1.00","1.00","1 through 10","156.55","330","percent of total billed charges",""
"Mgh Factor X11 Snp Analysis","PX-31000241","CDM","81479","CPT","0310","RC","","","","outpatient","","","400.00","300.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","210.00","52.5","","1.00","0.53","1.00","1 through 10","156.55","330","percent of total billed charges",""
"Mgh Familial Dysautonomia via the Ikbkap Gene - Full Gene Seq","PX-31000599","CDM","81479","CPT","0310","RC","","","","both","","","2980.00","2235.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2369.10","79.5","","0.65","0.65","0.65","1 through 10","923.8","2831","percent of total billed charges",""
"Mgh Familial Dysautonomia via the Ikbkap Gene - Full Gene Seq","PX-31000599","CDM","81479","CPT","0310","RC","","","","both","","","2980.00","2235.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1588.34","53.3","","0.79","0.79","0.79","1 through 10","923.8","2831","percent of total billed charges",""
"Mgh Familial Dysautonomia via the Ikbkap Gene - Full Gene Seq","PX-31000599","CDM","81479","CPT","0310","RC","","","","outpatient","","","2980.00","2235.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1490.00","50","","1.00","1.00","1.00","1 through 10","156.55","2458.5","percent of total billed charges",""
"Mgh Familial Dysautonomia via the Ikbkap Gene - Full Gene Seq","PX-31000599","CDM","81479","CPT","0310","RC","","","","outpatient","","","2980.00","2235.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1564.50","52.5","","1.00","0.53","1.00","1 through 10","156.55","2458.5","percent of total billed charges",""
"Mgh Familial Hemiplegic Migraine","PX-31000861","CDM","81479","CPT","0310","RC","","","","both","","","686.00","514.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","545.37","79.5","","0.65","0.65","0.65","1 through 10","212.66","651.7","percent of total billed charges",""
"Mgh Familial Hemiplegic Migraine","PX-31000861","CDM","81479","CPT","0310","RC","","","","both","","","686.00","514.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","365.64","53.3","","0.79","0.79","0.79","1 through 10","212.66","651.7","percent of total billed charges",""
"Mgh Familial Hemiplegic Migraine","PX-31000861","CDM","81479","CPT","0310","RC","","","","outpatient","","","686.00","514.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","343.00","50","","1.00","1.00","1.00","1 through 10","156.55","565.95","percent of total billed charges",""
"Mgh Familial Hemiplegic Migraine","PX-31000861","CDM","81479","CPT","0310","RC","","","","outpatient","","","686.00","514.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","360.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","565.95","percent of total billed charges",""
"Mgh Fbn1 Del/Dup Test","PX-31000335","CDM","81479","CPT","0310","RC","","","","both","","","1638.00","1228.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1302.21","79.5","","0.65","0.65","0.65","1 through 10","507.78","1556.1","percent of total billed charges",""
"Mgh Fbn1 Del/Dup Test","PX-31000335","CDM","81479","CPT","0310","RC","","","","both","","","1638.00","1228.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","873.05","53.3","","0.79","0.79","0.79","1 through 10","507.78","1556.1","percent of total billed charges",""
"Mgh Fbn1 Del/Dup Test","PX-31000335","CDM","81479","CPT","0310","RC","","","","outpatient","","","1638.00","1228.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","819.00","50","","1.00","1.00","1.00","1 through 10","156.55","1351.35","percent of total billed charges",""
"Mgh Fbn1 Del/Dup Test","PX-31000335","CDM","81479","CPT","0310","RC","","","","outpatient","","","1638.00","1228.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","859.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","1351.35","percent of total billed charges",""
"Mgh Fbn1 Gene Sequencing & Del/Dup","PX-31000665","CDM","81479","CPT","0310","RC","","","","both","","","1986.00","1489.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1578.87","79.5","","0.65","0.65","0.65","1 through 10","615.66","1886.7","percent of total billed charges",""
"Mgh Fbn1 Gene Sequencing & Del/Dup","PX-31000665","CDM","81479","CPT","0310","RC","","","","both","","","1986.00","1489.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1058.54","53.3","","0.79","0.79","0.79","1 through 10","615.66","1886.7","percent of total billed charges",""
"Mgh Fbn1 Gene Sequencing & Del/Dup","PX-31000665","CDM","81479","CPT","0310","RC","","","","outpatient","","","1986.00","1489.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","993.00","50","","1.00","1.00","1.00","1 through 10","156.55","1638.45","percent of total billed charges",""
"Mgh Fbn1 Gene Sequencing & Del/Dup","PX-31000665","CDM","81479","CPT","0310","RC","","","","outpatient","","","1986.00","1489.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1042.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","1638.45","percent of total billed charges",""
"Mgh Felbamate","PX-30001534","CDM","80299","CPT","0301","RC","","","","both","","","269.00","201.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","213.86","79.5","","106.25","71.28","106.25","1 through 10","14.12","255.55","percent of total billed charges",""
"Mgh Felbamate","PX-30001534","CDM","80299","CPT","0301","RC","","","","both","","","269.00","201.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","143.38","53.3","","106.25","71.28","106.25","1 through 10","14.12","255.55","percent of total billed charges",""
"Mgh Felbamate","PX-30001534","CDM","80299","CPT","0301","RC","","","","both","","","269.00","201.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","98.19","36.5","","50.36","42.80","92.50","13","14.12","255.55","percent of total billed charges",""
"Mgh Felbamate","PX-30001534","CDM","80299","CPT","0301","RC","","","","both","","","269.00","201.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","103.03","38.3","","52.79","44.55","158.37","30","14.12","255.55","percent of total billed charges",""
"Mgh Felbamate","PX-30001534","CDM","80299","CPT","0301","RC","","","","outpatient","","","269.00","201.75","AETNA [1001]","HB AMC AETNA HMO","187.76","69.8","","91.40","64.53","105.30","14","14.12","219.83","percent of total billed charges",""
"Mgh Felbamate","PX-30001534","CDM","80299","CPT","0301","RC","","","","outpatient","","","269.00","201.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","216.28","80.4","","105.30","105.30","105.30","1 through 10","14.12","219.83","percent of total billed charges",""
"Mgh Felbamate","PX-30001534","CDM","80299","CPT","0301","RC","","","","outpatient","","","269.00","201.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","219.83","81.72","","59.36","15.50","59.36","1 through 10","14.12","219.83","percent of total billed charges",""
"Mgh Fenfluramine","PX-30001564","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Fenfluramine","PX-30001564","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Fenfluramine","PX-30001564","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Fenfluramine","PX-30001564","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Fenfluramine","PX-30001564","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Fenfluramine","PX-30001564","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Fenfluramine","PX-30001564","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Fetal Akinesia Seq/Lethal Mtpl Pterygium Syn Nextgen Seq (Ngs)","PX-31000727","CDM","81479","CPT","0310","RC","","","","both","","","226.00","169.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","179.67","79.5","","0.65","0.65","0.65","1 through 10","70.06","214.7","percent of total billed charges",""
"Mgh Fetal Akinesia Seq/Lethal Mtpl Pterygium Syn Nextgen Seq (Ngs)","PX-31000727","CDM","81479","CPT","0310","RC","","","","both","","","226.00","169.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","120.46","53.3","","0.79","0.79","0.79","1 through 10","70.06","214.7","percent of total billed charges",""
"Mgh Fetal Akinesia Seq/Lethal Mtpl Pterygium Syn Nextgen Seq (Ngs)","PX-31000727","CDM","81479","CPT","0310","RC","","","","outpatient","","","226.00","169.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","113.00","50","","1.00","1.00","1.00","1 through 10","109.38","186.45","percent of total billed charges",""
"Mgh Fetal Akinesia Seq/Lethal Mtpl Pterygium Syn Nextgen Seq (Ngs)","PX-31000727","CDM","81479","CPT","0310","RC","","","","outpatient","","","226.00","169.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","118.65","52.5","","1.00","0.53","1.00","1 through 10","109.38","186.45","percent of total billed charges",""
"Mgh Fgd1 Sanger Sequencing","PX-31000478","CDM","81479","CPT","0310","RC","","","","both","","","2716.00","2037.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2159.22","79.5","","0.65","0.65","0.65","1 through 10","841.96","2580.2","percent of total billed charges",""
"Mgh Fgd1 Sanger Sequencing","PX-31000478","CDM","81479","CPT","0310","RC","","","","both","","","2716.00","2037.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1447.63","53.3","","0.79","0.79","0.79","1 through 10","841.96","2580.2","percent of total billed charges",""
"Mgh Fgd1 Sanger Sequencing","PX-31000478","CDM","81479","CPT","0310","RC","","","","outpatient","","","2716.00","2037.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1358.00","50","","1.00","1.00","1.00","1 through 10","156.55","2240.7","percent of total billed charges",""
"Mgh Fgd1 Sanger Sequencing","PX-31000478","CDM","81479","CPT","0310","RC","","","","outpatient","","","2716.00","2037.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1425.90","52.5","","1.00","0.53","1.00","1 through 10","156.55","2240.7","percent of total billed charges",""
"Mgh Fgfr3-Related Disorders via the Fgfr3 Gene","PX-31000840","CDM","81479","CPT","0310","RC","","","","both","","","1616.00","1212.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1284.72","79.5","","0.65","0.65","0.65","1 through 10","500.96","1535.2","percent of total billed charges",""
"Mgh Fgfr3-Related Disorders via the Fgfr3 Gene","PX-31000840","CDM","81479","CPT","0310","RC","","","","both","","","1616.00","1212.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","861.33","53.3","","0.79","0.79","0.79","1 through 10","500.96","1535.2","percent of total billed charges",""
"Mgh Fgfr3-Related Disorders via the Fgfr3 Gene","PX-31000840","CDM","81479","CPT","0310","RC","","","","outpatient","","","1616.00","1212.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","808.00","50","","1.00","1.00","1.00","1 through 10","156.55","1333.2","percent of total billed charges",""
"Mgh Fgfr3-Related Disorders via the Fgfr3 Gene","PX-31000840","CDM","81479","CPT","0310","RC","","","","outpatient","","","1616.00","1212.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","848.40","52.5","","1.00","0.53","1.00","1 through 10","156.55","1333.2","percent of total billed charges",""
"Mgh Fh/Adh Genetic Reflex Panel","PX-31000351","CDM","81479","CPT","0310","RC","","","","both","","","1104.00","828.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","877.68","79.5","","0.65","0.65","0.65","1 through 10","342.24","1048.8","percent of total billed charges",""
"Mgh Fh/Adh Genetic Reflex Panel","PX-31000351","CDM","81479","CPT","0310","RC","","","","both","","","1104.00","828.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","588.43","53.3","","0.79","0.79","0.79","1 through 10","342.24","1048.8","percent of total billed charges",""
"Mgh Fh/Adh Genetic Reflex Panel","PX-31000351","CDM","81479","CPT","0310","RC","","","","outpatient","","","1104.00","828.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","552.00","50","","1.00","1.00","1.00","1 through 10","156.55","910.8","percent of total billed charges",""
"Mgh Fh/Adh Genetic Reflex Panel","PX-31000351","CDM","81479","CPT","0310","RC","","","","outpatient","","","1104.00","828.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.60","52.5","","1.00","0.53","1.00","1 through 10","156.55","910.8","percent of total billed charges",""
"Mgh Fkbp10 Mutation Analysis","PX-31000391","CDM","81479","CPT","0310","RC","","","","both","","","1506.00","1129.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1197.27","79.5","","0.65","0.65","0.65","1 through 10","466.86","1430.7","percent of total billed charges",""
"Mgh Fkbp10 Mutation Analysis","PX-31000391","CDM","81479","CPT","0310","RC","","","","both","","","1506.00","1129.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","802.70","53.3","","0.79","0.79","0.79","1 through 10","466.86","1430.7","percent of total billed charges",""
"Mgh Fkbp10 Mutation Analysis","PX-31000391","CDM","81479","CPT","0310","RC","","","","outpatient","","","1506.00","1129.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","753.00","50","","1.00","1.00","1.00","1 through 10","156.55","1242.45","percent of total billed charges",""
"Mgh Fkbp10 Mutation Analysis","PX-31000391","CDM","81479","CPT","0310","RC","","","","outpatient","","","1506.00","1129.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","790.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","1242.45","percent of total billed charges",""
"Mgh Flna Sequencing and Del/Dup","PX-31000243","CDM","81479","CPT","0310","RC","","","","both","","","11145.00","8358.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8860.28","79.5","","0.65","0.65","0.65","1 through 10","3454.95","10587.75","percent of total billed charges",""
"Mgh Flna Sequencing and Del/Dup","PX-31000243","CDM","81479","CPT","0310","RC","","","","both","","","11145.00","8358.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5940.29","53.3","","0.79","0.79","0.79","1 through 10","3454.95","10587.75","percent of total billed charges",""
"Mgh Flna Sequencing and Del/Dup","PX-31000243","CDM","81479","CPT","0310","RC","","","","outpatient","","","11145.00","8358.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5572.50","50","","1.00","1.00","1.00","1 through 10","156.55","9194.63","percent of total billed charges",""
"Mgh Flna Sequencing and Del/Dup","PX-31000243","CDM","81479","CPT","0310","RC","","","","outpatient","","","11145.00","8358.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","5851.13","52.5","","1.00","0.53","1.00","1 through 10","156.55","9194.63","percent of total billed charges",""
"Mgh Flna-Related Disorders, Sequencing","PX-31000863","CDM","81479","CPT","0310","RC","","","","both","","","4825.00","3618.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3835.88","79.5","","0.65","0.65","0.65","1 through 10","1495.75","4583.75","percent of total billed charges",""
"Mgh Flna-Related Disorders, Sequencing","PX-31000863","CDM","81479","CPT","0310","RC","","","","both","","","4825.00","3618.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2571.73","53.3","","0.79","0.79","0.79","1 through 10","1495.75","4583.75","percent of total billed charges",""
"Mgh Flna-Related Disorders, Sequencing","PX-31000863","CDM","81479","CPT","0310","RC","","","","outpatient","","","4825.00","3618.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2412.50","50","","1.00","1.00","1.00","1 through 10","156.55","3980.63","percent of total billed charges",""
"Mgh Flna-Related Disorders, Sequencing","PX-31000863","CDM","81479","CPT","0310","RC","","","","outpatient","","","4825.00","3618.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2533.13","52.5","","1.00","0.53","1.00","1 through 10","156.55","3980.63","percent of total billed charges",""
"Mgh Fluid Ph","PX-30002148","CDM","83986","CPT","0301","RC","","","","both","","","59.00","44.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46.91","79.5","","44.86","44.86","44.86","1 through 10","3.51","56.05","percent of total billed charges",""
"Mgh Fluid Ph","PX-30002148","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","AETNA [1001]","HB AMC AETNA PPO","47.44","80.4","","44.46","44.46","44.46","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Fluid Ph","PX-30002148","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","48.21","81.72","","45.57","45.57","45.57","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Fluid Ph","PX-30002150","CDM","83986","CPT","0301","RC","","","","both","","","59.00","44.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46.91","79.5","","44.86","44.86","44.86","1 through 10","3.51","56.05","percent of total billed charges",""
"Mgh Fluid Ph","PX-30002150","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","AETNA [1001]","HB AMC AETNA PPO","47.44","80.4","","44.46","44.46","44.46","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Fluid Ph","PX-30002150","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","48.21","81.72","","45.57","45.57","45.57","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Fluoxetine","PX-30001532","CDM","80299","CPT","0301","RC","","","","both","","","240.00","180.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","190.80","79.5","","106.25","71.28","106.25","1 through 10","14.12","228","percent of total billed charges",""
"Mgh Fluoxetine","PX-30001532","CDM","80299","CPT","0301","RC","","","","both","","","240.00","180.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","127.92","53.3","","106.25","71.28","106.25","1 through 10","14.12","228","percent of total billed charges",""
"Mgh Fluoxetine","PX-30001532","CDM","80299","CPT","0301","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.60","36.5","","50.36","42.80","92.50","13","14.12","228","percent of total billed charges",""
"Mgh Fluoxetine","PX-30001532","CDM","80299","CPT","0301","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.92","38.3","","52.79","44.55","158.37","30","14.12","228","percent of total billed charges",""
"Mgh Fluoxetine","PX-30001532","CDM","80299","CPT","0301","RC","","","","outpatient","","","240.00","180.00","AETNA [1001]","HB AMC AETNA HMO","167.52","69.8","","91.40","64.53","105.30","14","14.12","196.13","percent of total billed charges",""
"Mgh Fluoxetine","PX-30001532","CDM","80299","CPT","0301","RC","","","","outpatient","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","192.96","80.4","","105.30","105.30","105.30","1 through 10","14.12","196.13","percent of total billed charges",""
"Mgh Fluoxetine","PX-30001532","CDM","80299","CPT","0301","RC","","","","outpatient","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","196.13","81.72","","59.36","15.50","59.36","1 through 10","14.12","196.13","percent of total billed charges",""
"Mgh Foxc2 Sanger Sequencing","PX-31000333","CDM","81479","CPT","0310","RC","","","","both","","","1667.00","1250.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1325.27","79.5","","0.65","0.65","0.65","1 through 10","516.77","1583.65","percent of total billed charges",""
"Mgh Foxc2 Sanger Sequencing","PX-31000333","CDM","81479","CPT","0310","RC","","","","both","","","1667.00","1250.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","888.51","53.3","","0.79","0.79","0.79","1 through 10","516.77","1583.65","percent of total billed charges",""
"Mgh Foxc2 Sanger Sequencing","PX-31000333","CDM","81479","CPT","0310","RC","","","","outpatient","","","1667.00","1250.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","833.50","50","","1.00","1.00","1.00","1 through 10","156.55","1375.28","percent of total billed charges",""
"Mgh Foxc2 Sanger Sequencing","PX-31000333","CDM","81479","CPT","0310","RC","","","","outpatient","","","1667.00","1250.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","875.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","1375.28","percent of total billed charges",""
"Mgh Fract Bile Acids 83789","PX-30002107","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Fract Bile Acids 83789","PX-30002107","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Fract Bile Acids 83789","PX-30002107","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Fract Bile Acids 83789","PX-30002107","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Fract Bile Acids 83789","PX-30002107","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Fract Bile Acids 83789","PX-30002107","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Fract Bile Acids 83789","PX-30002107","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Fragile X Syndrome via the Fmr1 Gene","PX-30003415","CDM","81479","CPT","0310","RC","","","","both","","","1882.00","1411.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1496.19","79.5","","0.65","0.65","0.65","1 through 10","583.42","1787.9","percent of total billed charges",""
"Mgh Fragile X Syndrome via the Fmr1 Gene","PX-30003415","CDM","81479","CPT","0310","RC","","","","both","","","1882.00","1411.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1003.11","53.3","","0.79","0.79","0.79","1 through 10","583.42","1787.9","percent of total billed charges",""
"Mgh Fragile X Syndrome via the Fmr1 Gene","PX-30003415","CDM","81479","CPT","0310","RC","","","","outpatient","","","1882.00","1411.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","941.00","50","","1.00","1.00","1.00","1 through 10","156.55","1552.65","percent of total billed charges",""
"Mgh Fragile X Syndrome via the Fmr1 Gene","PX-30003415","CDM","81479","CPT","0310","RC","","","","outpatient","","","1882.00","1411.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","988.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","1552.65","percent of total billed charges",""
"Mgh Free Kappa/Lambda 5 83883","PX-30002120","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Free Kappa/Lambda 5 83883","PX-30002120","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Free Kappa/Lambda UR 83883","PX-30002121","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Free Kappa/Lambda UR 83883","PX-30002121","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Free Sialic Acid Urine","PX-30001554","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Free Sialic Acid Urine","PX-30001554","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Free Sialic Acid Urine","PX-30001554","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Free Sialic Acid Urine","PX-30001554","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Free Sialic Acid Urine","PX-30001554","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Free Sialic Acid Urine","PX-30001554","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Free Sialic Acid Urine","PX-30001554","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Fungal Serology Test","PX-30002217","CDM","86671","CPT","0302","RC","","","","both","","","168.00","126.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","133.56","79.5","","128.28","128.28","128.28","1 through 10","10.07","159.6","percent of total billed charges",""
"Mgh G030036 Anaconda Stent Graft","PX-62400004","CDM","C1874","HCPCS","0624","RC","","","","both","","","25000.00","18750.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","16250.00","65","","6652.80","6652.80","6652.80","1 through 10","7750","19875","percent of total billed charges",""
"Mgh G030036 Anaconda Stent Graft","PX-62400004","CDM","C1874","HCPCS","0624","RC","","","","both","","","25000.00","18750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","19875.00","79.5","","2612.61","795.38","2612.61","1 through 10","7750","19875","percent of total billed charges",""
"Mgh G030036 Anaconda Stent Graft","PX-62400004","CDM","C1874","HCPCS","0624","RC","","","","both","","","25000.00","18750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13325.00","53.3","","1101.80","1101.80","1101.80","1 through 10","7750","19875","percent of total billed charges",""
"Mgh G030036 Anaconda Stent Graft","PX-62400004","CDM","C1874","HCPCS","0624","RC","","","","both","","","25000.00","18750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","16250.00","65","","1820.00","910.00","1820.00","1 through 10","7750","19875","percent of total billed charges",""
"Mgh G030036 Anaconda Stent Graft","PX-62400004","CDM","C1874","HCPCS","0624","RC","","","","both","","","25000.00","18750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9125.00","36.5","","1257.80","693.44","2424.50","1 through 10","7750","19875","percent of total billed charges",""
"Mgh G030036 Anaconda Stent Graft","PX-62400004","CDM","C1874","HCPCS","0624","RC","","","","both","","","25000.00","18750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9575.00","38.3","","1950.11","547.40","2346.00","1 through 10","7750","19875","percent of total billed charges",""
"Mgh G030036 Anaconda Stent Graft","PX-62400004","CDM","C1874","HCPCS","0624","RC","","","","both","","","25000.00","18750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10725.00","42.9","","5096.18","5096.18","5096.18","1 through 10","7750","19875","percent of total billed charges",""
"Mgh G030036 Anaconda Stent Graft","PX-62400004","CDM","C1874","HCPCS","0624","RC","","","","both","","","25000.00","18750.00","WELLPOINT [1015]","HB AMC WELLPOINT","18445.00","73.78","","1172.59","1172.59","4829.94","1 through 10","7750","19875","percent of total billed charges",""
"Mgh G030036 Anaconda Stent Graft","PX-62400004","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","25000.00","18750.00","AETNA [1001]","HB AMC AETNA HMO","17450.00","69.8","","1806.84","947.80","5091.72","1 through 10","13065","20430","percent of total billed charges",""
"Mgh G030036 Anaconda Stent Graft","PX-62400004","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","25000.00","18750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","20430.00","81.72","","1259.05","615.58","4586.56","1 through 10","13065","20430","percent of total billed charges",""
"Mgh G030126 Neuropace Neurostim","PX-62400015","CDM","C1767","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","18081.90","16994.81","18081.90","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G030126 Neuropace Neurostim","PX-62400015","CDM","C1767","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","17814.94","17448.38","17814.94","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G030126 Neuropace Neurostim","PX-62400015","CDM","C1767","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","33921.28","33921.28","33921.28","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G030159 Cryoabl Catheter","PX-62400056","CDM","C2630","HCPCS","0624","RC","","","","both","","","11250.00","8437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4308.75","38.3","","3714.50","3714.50","3714.50","1 through 10","3487.5","8943.75","percent of total billed charges",""
"Mgh G030159 Cryobalation Cath Cap","PX-62400062","CDM","C2630","HCPCS","0624","RC","","","","both","","","11250.00","8437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4308.75","38.3","","3714.50","3714.50","3714.50","1 through 10","3487.5","8943.75","percent of total billed charges",""
"Mgh G030249 Endeavor Zotarlimus St","PX-62400031","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.65","65","","6652.80","6652.80","6652.80","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G030249 Endeavor Zotarlimus St","PX-62400031","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","2612.61","795.38","2612.61","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G030249 Endeavor Zotarlimus St","PX-62400031","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1101.80","1101.80","1101.80","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G030249 Endeavor Zotarlimus St","PX-62400031","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1820.00","910.00","1820.00","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G030249 Endeavor Zotarlimus St","PX-62400031","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1257.80","693.44","2424.50","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G030249 Endeavor Zotarlimus St","PX-62400031","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1950.11","547.40","2346.00","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G030249 Endeavor Zotarlimus St","PX-62400031","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","5096.18","5096.18","5096.18","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G030249 Endeavor Zotarlimus St","PX-62400031","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","1172.59","1172.59","4829.94","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G030249 Endeavor Zotarlimus St","PX-62400031","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1806.84","947.80","5091.72","1 through 10","0.52","0.82","percent of total billed charges",""
"Mgh G030249 Endeavor Zotarlimus St","PX-62400031","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","1259.05","615.58","4586.56","1 through 10","0.52","0.82","percent of total billed charges",""
"Mgh G040145 Act1 Carotid Stent Sys","PX-62400051","CDM","C1876","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.66","65.6","","751.18","751.18","751.18","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G040145 Act1 Carotid Stent Sys","PX-62400051","CDM","C1876","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","4820.38","3211.27","4820.38","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G040145 Act1 Carotid Stent Sys","PX-62400051","CDM","C1876","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","641.00","641.00","641.00","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G040145 Act1 Carotid Stent Sys","PX-62400051","CDM","C1876","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1098.43","1098.43","1098.43","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G040145 Act1 Carotid Stent Sys","PX-62400051","CDM","C1876","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","4896.33","4896.33","4896.33","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G040145 Act1 Carotid Stent Sys","PX-62400051","CDM","C1876","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","175.60","163.11","1063.91","1 through 10","0.52","0.82","percent of total billed charges",""
"Mgh G040145 Act1 Carotid Stent Sys","PX-62400051","CDM","C1876","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","105.94","85.10","105.94","1 through 10","0.52","0.82","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400058","CDM","C2630","HCPCS","0624","RC","","","","both","","","12998.00","9748.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4978.23","38.3","","3714.50","3714.50","3714.50","1 through 10","4029.38","10333.41","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400059","CDM","C1732","HCPCS","0624","RC","","","","both","","","12998.00","9748.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8448.70","65","","2222.68","2222.68","2222.68","1 through 10","4029.38","10333.41","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400059","CDM","C1732","HCPCS","0624","RC","","","","both","","","12998.00","9748.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4744.27","36.5","","4681.38","1275.47","8371.80","20","4029.38","10333.41","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400059","CDM","C1732","HCPCS","0624","RC","","","","both","","","12998.00","9748.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4978.23","38.3","","1663.12","1287.53","2528.21","1 through 10","4029.38","10333.41","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400059","CDM","C1732","HCPCS","0624","RC","","","","both","","","12998.00","9748.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5576.14","42.9","","1935.35","1935.35","1935.35","1 through 10","4029.38","10333.41","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400059","CDM","C1732","HCPCS","0624","RC","","","","both","","","12998.00","9748.50","WELLPOINT [1015]","HB AMC WELLPOINT","9589.92","73.78","","4813.94","2545.82","7082.06","1 through 10","4029.38","10333.41","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400059","CDM","C1732","HCPCS","0624","RC","","","","outpatient","","","12998.00","9748.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10621.97","81.72","","2733.55","2433.63","5168.92","14","6792.75","10621.97","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400060","CDM","C1733","HCPCS","0624","RC","","","","both","","","12998.00","9748.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10333.41","79.5","","17511.01","17511.01","17511.01","1 through 10","4029.38","10333.41","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400060","CDM","C1733","HCPCS","0624","RC","","","","both","","","12998.00","9748.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6927.93","53.3","","21125.00","21125.00","21125.00","1 through 10","4029.38","10333.41","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400060","CDM","C1733","HCPCS","0624","RC","","","","both","","","12998.00","9748.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4744.27","36.5","","7879.63","7879.63","7879.63","1 through 10","4029.38","10333.41","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400060","CDM","C1733","HCPCS","0624","RC","","","","both","","","12998.00","9748.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4978.23","38.3","","8259.88","8259.88","16055.00","1 through 10","4029.38","10333.41","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400060","CDM","C1733","HCPCS","0624","RC","","","","both","","","12998.00","9748.50","WELLPOINT [1015]","HB AMC WELLPOINT","9589.92","73.78","","15727.56","15727.56","20473.75","1 through 10","4029.38","10333.41","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400060","CDM","C1733","HCPCS","0624","RC","","","","outpatient","","","12998.00","9748.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","10621.97","81.72","","16887.32","9288.66","16887.32","1 through 10","6792.75","10621.97","percent of total billed charges",""
"Mgh G050233 Cabana Ablation Device","PX-62400060","CDM","C1733","HCPCS","0624","RC","","","","outpatient","","","12998.00","9748.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10621.97","81.72","","16887.33","11641.27","21983.50","1 through 10","6792.75","10621.97","percent of total billed charges",""
"Mgh G070013 Protege Stent","PX-62400034","CDM","C1876","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.66","65.6","","751.18","751.18","751.18","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070013 Protege Stent","PX-62400034","CDM","C1876","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","4820.38","3211.27","4820.38","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070013 Protege Stent","PX-62400034","CDM","C1876","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","641.00","641.00","641.00","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070013 Protege Stent","PX-62400034","CDM","C1876","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1098.43","1098.43","1098.43","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070013 Protege Stent","PX-62400034","CDM","C1876","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","4896.33","4896.33","4896.33","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070013 Protege Stent","PX-62400034","CDM","C1876","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","175.60","163.11","1063.91","1 through 10","0.52","0.82","percent of total billed charges",""
"Mgh G070013 Protege Stent","PX-62400034","CDM","C1876","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","105.94","85.10","105.94","1 through 10","0.52","0.82","percent of total billed charges",""
"Mgh G070239 Superb Nitinol Stent","PX-62400045","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.65","65","","6652.80","6652.80","6652.80","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Nitinol Stent","PX-62400045","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","2612.61","795.38","2612.61","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Nitinol Stent","PX-62400045","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1101.80","1101.80","1101.80","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Nitinol Stent","PX-62400045","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1820.00","910.00","1820.00","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Nitinol Stent","PX-62400045","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1257.80","693.44","2424.50","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Nitinol Stent","PX-62400045","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1950.11","547.40","2346.00","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Nitinol Stent","PX-62400045","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","5096.18","5096.18","5096.18","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Nitinol Stent","PX-62400045","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","1172.59","1172.59","4829.94","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Nitinol Stent","PX-62400045","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1806.84","947.80","5091.72","1 through 10","0.52","0.82","percent of total billed charges",""
"Mgh G070239 Superb Nitinol Stent","PX-62400045","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","1259.05","615.58","4586.56","1 through 10","0.52","0.82","percent of total billed charges",""
"Mgh G070239 Superb Stent System","PX-62400033","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.65","65","","6652.80","6652.80","6652.80","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Stent System","PX-62400033","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","2612.61","795.38","2612.61","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Stent System","PX-62400033","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1101.80","1101.80","1101.80","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Stent System","PX-62400033","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1820.00","910.00","1820.00","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Stent System","PX-62400033","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1257.80","693.44","2424.50","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Stent System","PX-62400033","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1950.11","547.40","2346.00","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Stent System","PX-62400033","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","5096.18","5096.18","5096.18","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Stent System","PX-62400033","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","1172.59","1172.59","4829.94","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G070239 Superb Stent System","PX-62400033","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1806.84","947.80","5091.72","1 through 10","0.52","0.82","percent of total billed charges",""
"Mgh G070239 Superb Stent System","PX-62400033","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","1259.05","615.58","4586.56","1 through 10","0.52","0.82","percent of total billed charges",""
"Mgh G080067 Biotronik Crt-D Device","PX-62400068","CDM","C1882","HCPCS","0624","RC","","","","both","","","43250.00","32437.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23052.25","53.3","","25132.80","25132.80","25132.80","1 through 10","13407.5","34383.75","percent of total billed charges",""
"Mgh G080067 Biotronik Crt-D Device","PX-62400068","CDM","C1882","HCPCS","0624","RC","","","","both","","","43250.00","32437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16564.75","38.3","","18611.60","13196.25","18611.60","1 through 10","13407.5","34383.75","percent of total billed charges",""
"Mgh G080067 Biotronik Crt-D Device","PX-62400068","CDM","C1882","HCPCS","0624","RC","","","","outpatient","","","43250.00","32437.50","AETNA [1001]","HB AMC AETNA HMO","30188.50","69.8","","23525.75","23525.75","23525.75","1 through 10","22602.45","35343.9","percent of total billed charges",""
"Mgh G080067 Biotronik Crt-D Device","PX-62400068","CDM","C1882","HCPCS","0624","RC","","","","outpatient","","","43250.00","32437.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","35343.90","81.72","","14745.34","14745.34","14745.34","1 through 10","22602.45","35343.9","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","both","","","1103.00","827.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","791.95","71.8","","86.33","32.67","86.33","1 through 10","341.93","876.89","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","both","","","1103.00","827.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","772.10","70","","113.68","63.00","177.34","40","341.93","876.89","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","both","","","1103.00","827.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","876.89","79.5","","50.70","21.76","168.00","12","341.93","876.89","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","both","","","1103.00","827.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","587.90","53.3","","89.31","89.31","99.75","1 through 10","341.93","876.89","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","both","","","1103.00","827.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","716.95","65","","94.41","17.06","2275.00","1 through 10","341.93","876.89","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","both","","","1103.00","827.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","341.93","31","","35.13","35.13","35.13","1 through 10","341.93","876.89","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","both","","","1103.00","827.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","402.60","36.5","","40.08","12.40","86.17","108","341.93","876.89","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","both","","","1103.00","827.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","422.45","38.3","","33.25","10.27","68.43","169","341.93","876.89","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","both","","","1103.00","827.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","473.19","42.9","","25.48","14.86","90.88","1 through 10","341.93","876.89","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","both","","","1103.00","827.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","473.19","42.9","","90.88","90.88","90.88","1 through 10","341.93","876.89","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","both","","","1103.00","827.25","WELLPOINT [1015]","HB AMC WELLPOINT","813.79","73.78","","84.63","19.55","140.02","123","341.93","876.89","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","outpatient","","","1103.00","827.25","AETNA [1001]","HB AMC AETNA HMO","769.89","69.8","","76.96","17.77","113.68","14","576.43","901.37","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","outpatient","","","1103.00","827.25","AETNA [1001]","HB AMC AETNA PPO","886.81","80.4","","57.31","57.31","57.31","1 through 10","576.43","901.37","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","outpatient","","","1103.00","827.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","576.43","52.26","","16.24","16.24","54.15","1 through 10","576.43","901.37","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","outpatient","","","1103.00","827.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","886.81","80.4","","68.25","68.25","87.50","1 through 10","576.43","901.37","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","outpatient","","","1103.00","827.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","901.37","81.72","","156.19","156.19","156.19","1 through 10","576.43","901.37","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","outpatient","","","1103.00","827.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","901.37","81.72","","82.70","12.06","98.97","13","576.43","901.37","percent of total billed charges",""
"Mgh G090010 Gore Intro Sheath","PX-62400006","CDM","C1894","HCPCS","0624","RC","","","","outpatient","","","1103.00","827.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","901.37","81.72","","50.47","25.30","134.30","140","576.43","901.37","percent of total billed charges",""
"Mgh G090084 Laptop Crt-D W/Coil","PX-62400064","CDM","C1882","HCPCS","0624","RC","","","","both","","","53475.00","40106.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","28502.18","53.3","","25132.80","25132.80","25132.80","1 through 10","16577.25","42512.63","percent of total billed charges",""
"Mgh G090084 Laptop Crt-D W/Coil","PX-62400064","CDM","C1882","HCPCS","0624","RC","","","","both","","","53475.00","40106.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20480.93","38.3","","18611.60","13196.25","18611.60","1 through 10","16577.25","42512.63","percent of total billed charges",""
"Mgh G090084 Laptop Crt-D W/Coil","PX-62400064","CDM","C1882","HCPCS","0624","RC","","","","outpatient","","","53475.00","40106.25","AETNA [1001]","HB AMC AETNA HMO","37325.55","69.8","","23525.75","23525.75","23525.75","1 through 10","27946.04","43699.77","percent of total billed charges",""
"Mgh G090084 Laptop Crt-D W/Coil","PX-62400064","CDM","C1882","HCPCS","0624","RC","","","","outpatient","","","53475.00","40106.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","43699.77","81.72","","14745.34","14745.34","14745.34","1 through 10","27946.04","43699.77","percent of total billed charges",""
"Mgh G090084 Laptop-Hf Leads","PX-62400065","CDM","C1883","HCPCS","0624","RC","","","","both","","","39180.00","29385.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14300.70","36.5","","1073.15","1073.15","1073.15","1 through 10","12145.8","31148.1","percent of total billed charges",""
"Mgh G090084 Laptop-Hf Leads","PX-62400065","CDM","C1883","HCPCS","0624","RC","","","","both","","","39180.00","29385.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15005.94","38.3","","1808.38","1642.20","1808.38","1 through 10","12145.8","31148.1","percent of total billed charges",""
"Mgh G090084 Laptop-Hf Leads","PX-62400065","CDM","C1883","HCPCS","0624","RC","","","","both","","","39180.00","29385.00","WELLPOINT [1015]","HB AMC WELLPOINT","28907.00","73.78","","625.38","625.38","625.38","1 through 10","12145.8","31148.1","percent of total billed charges",""
"Mgh G090226 Doxorubicin Study Drug","PX-62400002","CDM","J9000","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","6.07","6.07","6.07","1 through 10","0.31","6.58","percent of total billed charges",""
"Mgh G090226 Hepasphere Study","PX-62400001","CDM","C2616","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.70","70","","18772.47","18772.47","18772.47","1 through 10","0.31","21856.38","percent of total billed charges",""
"Mgh G090226 Hepasphere Study","PX-62400001","CDM","C2616","HCPCS","0624","RC","","","","both","","","1.00","0.75","MEDICARE [2001]","HB BWH MEDICARE","17485.10","","APC Price ($17,485.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","17485.10","17177.01","17485.10","1 through 10","0.31","21856.38","other","OPPS APC"
"Mgh G090226 Hepasphere Study","PX-62400001","CDM","C2616","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17135.40","","APC Price ($17,485.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","17205.34","17205.34","17205.34","1 through 10","0.31","21856.38","other","OPPS APC"
"Mgh G090226 Hepasphere Study","PX-62400001","CDM","C2616","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","34144.63","34144.63","34144.63","1 through 10","0.31","21856.38","percent of total billed charges",""
"Mgh G100002 Bioflex Astron Stent","PX-62400048","CDM","C1876","HCPCS","0624","RC","","","","both","","","5085.00","3813.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3335.76","65.6","","751.18","751.18","751.18","1 through 10","1576.35","4042.58","percent of total billed charges",""
"Mgh G100002 Bioflex Astron Stent","PX-62400048","CDM","C1876","HCPCS","0624","RC","","","","both","","","5085.00","3813.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4042.58","79.5","","4820.38","3211.27","4820.38","1 through 10","1576.35","4042.58","percent of total billed charges",""
"Mgh G100002 Bioflex Astron Stent","PX-62400048","CDM","C1876","HCPCS","0624","RC","","","","both","","","5085.00","3813.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1856.03","36.5","","641.00","641.00","641.00","1 through 10","1576.35","4042.58","percent of total billed charges",""
"Mgh G100002 Bioflex Astron Stent","PX-62400048","CDM","C1876","HCPCS","0624","RC","","","","both","","","5085.00","3813.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1947.56","38.3","","1098.43","1098.43","1098.43","1 through 10","1576.35","4042.58","percent of total billed charges",""
"Mgh G100002 Bioflex Astron Stent","PX-62400048","CDM","C1876","HCPCS","0624","RC","","","","both","","","5085.00","3813.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2181.47","42.9","","4896.33","4896.33","4896.33","1 through 10","1576.35","4042.58","percent of total billed charges",""
"Mgh G100002 Bioflex Astron Stent","PX-62400048","CDM","C1876","HCPCS","0624","RC","","","","outpatient","","","5085.00","3813.75","AETNA [1001]","HB AMC AETNA HMO","3549.33","69.8","","175.60","163.11","1063.91","1 through 10","2657.42","4155.46","percent of total billed charges",""
"Mgh G100002 Bioflex Astron Stent","PX-62400048","CDM","C1876","HCPCS","0624","RC","","","","outpatient","","","5085.00","3813.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4155.46","81.72","","105.94","85.10","105.94","1 through 10","2657.42","4155.46","percent of total billed charges",""
"Mgh G100002 Bioflx Astrn Pulsr Stn","PX-62400049","CDM","C1876","HCPCS","0624","RC","","","","both","","","5988.00","4491.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3928.13","65.6","","751.18","751.18","751.18","1 through 10","1856.28","4760.46","percent of total billed charges",""
"Mgh G100002 Bioflx Astrn Pulsr Stn","PX-62400049","CDM","C1876","HCPCS","0624","RC","","","","both","","","5988.00","4491.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4760.46","79.5","","4820.38","3211.27","4820.38","1 through 10","1856.28","4760.46","percent of total billed charges",""
"Mgh G100002 Bioflx Astrn Pulsr Stn","PX-62400049","CDM","C1876","HCPCS","0624","RC","","","","both","","","5988.00","4491.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2185.62","36.5","","641.00","641.00","641.00","1 through 10","1856.28","4760.46","percent of total billed charges",""
"Mgh G100002 Bioflx Astrn Pulsr Stn","PX-62400049","CDM","C1876","HCPCS","0624","RC","","","","both","","","5988.00","4491.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2293.40","38.3","","1098.43","1098.43","1098.43","1 through 10","1856.28","4760.46","percent of total billed charges",""
"Mgh G100002 Bioflx Astrn Pulsr Stn","PX-62400049","CDM","C1876","HCPCS","0624","RC","","","","both","","","5988.00","4491.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2568.85","42.9","","4896.33","4896.33","4896.33","1 through 10","1856.28","4760.46","percent of total billed charges",""
"Mgh G100002 Bioflx Astrn Pulsr Stn","PX-62400049","CDM","C1876","HCPCS","0624","RC","","","","outpatient","","","5988.00","4491.00","AETNA [1001]","HB AMC AETNA HMO","4179.62","69.8","","175.60","163.11","1063.91","1 through 10","3129.33","4893.39","percent of total billed charges",""
"Mgh G100002 Bioflx Astrn Pulsr Stn","PX-62400049","CDM","C1876","HCPCS","0624","RC","","","","outpatient","","","5988.00","4491.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4893.39","81.72","","105.94","85.10","105.94","1 through 10","3129.33","4893.39","percent of total billed charges",""
"Mgh G110030 Thermocool Ablate Cath","PX-62400067","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","2222.68","2222.68","2222.68","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G110030 Thermocool Ablate Cath","PX-62400067","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","4681.38","1275.47","8371.80","20","0.31","0.8","percent of total billed charges",""
"Mgh G110030 Thermocool Ablate Cath","PX-62400067","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1663.12","1287.53","2528.21","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G110030 Thermocool Ablate Cath","PX-62400067","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","1935.35","1935.35","1935.35","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G110030 Thermocool Ablate Cath","PX-62400067","CDM","C1732","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","4813.94","2545.82","7082.06","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G110030 Thermocool Ablate Cath","PX-62400067","CDM","C1732","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","2733.55","2433.63","5168.92","14","0.52","0.82","percent of total billed charges",""
"Mgh G110030thermocoolcath 2ndphase","PX-62400070","CDM","C1732","HCPCS","0624","RC","","","","both","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3250.00","65","","2222.68","2222.68","2222.68","1 through 10","1550","3975","percent of total billed charges",""
"Mgh G110030thermocoolcath 2ndphase","PX-62400070","CDM","C1732","HCPCS","0624","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","4681.38","1275.47","8371.80","20","1550","3975","percent of total billed charges",""
"Mgh G110030thermocoolcath 2ndphase","PX-62400070","CDM","C1732","HCPCS","0624","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","1663.12","1287.53","2528.21","1 through 10","1550","3975","percent of total billed charges",""
"Mgh G110030thermocoolcath 2ndphase","PX-62400070","CDM","C1732","HCPCS","0624","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","1935.35","1935.35","1935.35","1 through 10","1550","3975","percent of total billed charges",""
"Mgh G110030thermocoolcath 2ndphase","PX-62400070","CDM","C1732","HCPCS","0624","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","4813.94","2545.82","7082.06","1 through 10","1550","3975","percent of total billed charges",""
"Mgh G110030thermocoolcath 2ndphase","PX-62400070","CDM","C1732","HCPCS","0624","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","2733.55","2433.63","5168.92","14","2613","4086","percent of total billed charges",""
"Mgh G110031 Xience Prime Stent","PX-62400053","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2973.75","65","","6652.80","6652.80","6652.80","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience Prime Stent","PX-62400053","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3637.13","79.5","","2612.61","795.38","2612.61","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience Prime Stent","PX-62400053","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2438.48","53.3","","1101.80","1101.80","1101.80","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience Prime Stent","PX-62400053","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2973.75","65","","1820.00","910.00","1820.00","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience Prime Stent","PX-62400053","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1669.88","36.5","","1257.80","693.44","2424.50","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience Prime Stent","PX-62400053","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1752.23","38.3","","1950.11","547.40","2346.00","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience Prime Stent","PX-62400053","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1962.68","42.9","","5096.18","5096.18","5096.18","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience Prime Stent","PX-62400053","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","WELLPOINT [1015]","HB AMC WELLPOINT","3375.44","73.78","","1172.59","1172.59","4829.94","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience Prime Stent","PX-62400053","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","4575.00","3431.25","AETNA [1001]","HB AMC AETNA HMO","3193.35","69.8","","1806.84","947.80","5091.72","1 through 10","2390.9","3738.69","percent of total billed charges",""
"Mgh G110031 Xience Prime Stent","PX-62400053","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","4575.00","3431.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3738.69","81.72","","1259.05","615.58","4586.56","1 through 10","2390.9","3738.69","percent of total billed charges",""
"Mgh G110031 Xience V Stent","PX-62400052","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2973.75","65","","6652.80","6652.80","6652.80","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience V Stent","PX-62400052","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3637.13","79.5","","2612.61","795.38","2612.61","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience V Stent","PX-62400052","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2438.48","53.3","","1101.80","1101.80","1101.80","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience V Stent","PX-62400052","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2973.75","65","","1820.00","910.00","1820.00","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience V Stent","PX-62400052","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1669.88","36.5","","1257.80","693.44","2424.50","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience V Stent","PX-62400052","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1752.23","38.3","","1950.11","547.40","2346.00","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience V Stent","PX-62400052","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1962.68","42.9","","5096.18","5096.18","5096.18","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience V Stent","PX-62400052","CDM","C1874","HCPCS","0624","RC","","","","both","","","4575.00","3431.25","WELLPOINT [1015]","HB AMC WELLPOINT","3375.44","73.78","","1172.59","1172.59","4829.94","1 through 10","1418.25","3637.13","percent of total billed charges",""
"Mgh G110031 Xience V Stent","PX-62400052","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","4575.00","3431.25","AETNA [1001]","HB AMC AETNA HMO","3193.35","69.8","","1806.84","947.80","5091.72","1 through 10","2390.9","3738.69","percent of total billed charges",""
"Mgh G110031 Xience V Stent","PX-62400052","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","4575.00","3431.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3738.69","81.72","","1259.05","615.58","4586.56","1 through 10","2390.9","3738.69","percent of total billed charges",""
"Mgh G110194 Icast Stent Systm","PX-62400054","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.65","65","","6652.80","6652.80","6652.80","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G110194 Icast Stent Systm","PX-62400054","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","2612.61","795.38","2612.61","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G110194 Icast Stent Systm","PX-62400054","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","1101.80","1101.80","1101.80","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G110194 Icast Stent Systm","PX-62400054","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1820.00","910.00","1820.00","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G110194 Icast Stent Systm","PX-62400054","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1257.80","693.44","2424.50","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G110194 Icast Stent Systm","PX-62400054","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1950.11","547.40","2346.00","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G110194 Icast Stent Systm","PX-62400054","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","0.43","42.9","","5096.18","5096.18","5096.18","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G110194 Icast Stent Systm","PX-62400054","CDM","C1874","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","1172.59","1172.59","4829.94","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh G110194 Icast Stent Systm","PX-62400054","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1806.84","947.80","5091.72","1 through 10","0.52","0.82","percent of total billed charges",""
"Mgh G110194 Icast Stent Systm","PX-62400054","CDM","C1874","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","1259.05","615.58","4586.56","1 through 10","0.52","0.82","percent of total billed charges",""
"Mgh G6pd Gene Sequencing","PX-31000469","CDM","81479","CPT","0310","RC","","","","both","","","580.00","435.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","461.10","79.5","","0.65","0.65","0.65","1 through 10","179.8","551","percent of total billed charges",""
"Mgh G6pd Gene Sequencing","PX-31000469","CDM","81479","CPT","0310","RC","","","","both","","","580.00","435.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","309.14","53.3","","0.79","0.79","0.79","1 through 10","179.8","551","percent of total billed charges",""
"Mgh G6pd Gene Sequencing","PX-31000469","CDM","81479","CPT","0310","RC","","","","outpatient","","","580.00","435.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","290.00","50","","1.00","1.00","1.00","1 through 10","156.55","478.5","percent of total billed charges",""
"Mgh G6pd Gene Sequencing","PX-31000469","CDM","81479","CPT","0310","RC","","","","outpatient","","","580.00","435.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","304.50","52.5","","1.00","0.53","1.00","1 through 10","156.55","478.5","percent of total billed charges",""
"Mgh Gabapentin","PX-30001542","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Gabapentin","PX-30001542","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Gabapentin","PX-30001542","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Gabapentin","PX-30001542","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Gabapentin","PX-30001542","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Gabapentin","PX-30001542","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Gabapentin","PX-30001542","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Galactosylceramide","PX-30001876","CDM","84311","CPT","0300","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Galactosylceramide","PX-30001876","CDM","84311","CPT","0300","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Galactosylceramide","PX-30001876","CDM","84311","CPT","0300","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Galactosylceramide","PX-30001880","CDM","84311","CPT","0300","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Galactosylceramide","PX-30001880","CDM","84311","CPT","0300","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Galactosylceramide","PX-30001880","CDM","84311","CPT","0300","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Ganciclovir, Serum","PX-31000657","CDM","80299","CPT","0310","RC","","","","both","","","112.00","84.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","89.04","79.5","","106.25","71.28","106.25","1 through 10","18.27","106.4","percent of total billed charges",""
"Mgh Ganciclovir, Serum","PX-31000657","CDM","80299","CPT","0310","RC","","","","both","","","112.00","84.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","59.70","53.3","","106.25","71.28","106.25","1 through 10","18.27","106.4","percent of total billed charges",""
"Mgh Ganciclovir, Serum","PX-31000657","CDM","80299","CPT","0310","RC","","","","both","","","112.00","84.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","40.88","36.5","","50.36","42.80","92.50","13","18.27","106.4","percent of total billed charges",""
"Mgh Ganciclovir, Serum","PX-31000657","CDM","80299","CPT","0310","RC","","","","both","","","112.00","84.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","42.90","38.3","","52.79","44.55","158.37","30","18.27","106.4","percent of total billed charges",""
"Mgh Ganciclovir, Serum","PX-31000657","CDM","80299","CPT","0310","RC","","","","outpatient","","","112.00","84.00","AETNA [1001]","HB AMC AETNA HMO","78.18","69.8","","91.40","64.53","105.30","14","53.62","114.26","percent of total billed charges",""
"Mgh Ganciclovir, Serum","PX-31000657","CDM","80299","CPT","0310","RC","","","","outpatient","","","112.00","84.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","90.05","80.4","","105.30","105.30","105.30","1 through 10","53.62","114.26","percent of total billed charges",""
"Mgh Ganciclovir, Serum","PX-31000657","CDM","80299","CPT","0310","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","91.53","81.72","","59.36","15.50","59.36","1 through 10","53.62","114.26","percent of total billed charges",""
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","both","","","2685.00","2013.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","832.35","2134.58","other","OPPS APC"
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","both","","","2685.00","2013.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","832.35","2134.58","other","OPPS APC"
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","both","","","2685.00","2013.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2134.58","79.5","","2814.50","2346.50","2814.50","1 through 10","832.35","2134.58","percent of total billed charges",""
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","both","","","2685.00","2013.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","832.35","2134.58","other","OPPS APC"
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","both","","","2685.00","2013.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","832.35","2134.58","other","OPPS APC"
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","980.03","36.5","","2677.58","1482.13","2910.89","1 through 10","832.35","2134.58","percent of total billed charges",""
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1028.36","38.3","","2723.31","1555.62","2741.61","12","832.35","2134.58","percent of total billed charges",""
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","832.35","2134.58","other","OPPS APC"
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","both","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","832.35","2134.58","other","OPPS APC"
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","both","","","2685.00","2013.75","WELLPOINT [1015]","HB AMC WELLPOINT","1980.99","73.78","","2687.65","2687.64","3224.43","1 through 10","832.35","2134.58","percent of total billed charges",""
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","outpatient","","","2685.00","2013.75","AETNA [1001]","HB AMC AETNA PPO","2158.74","80.4","","1163.76","1163.76","1163.76","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","outpatient","","","2685.00","2013.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1625.77","60.55","","1781.82","1492.00","4331.00","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","outpatient","","","2685.00","2013.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1402.11","52.22","","3144.00","1492.00","3610.00","13","1342.5","2384.07","percent of total billed charges",""
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","outpatient","","","2685.00","2013.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1409.63","52.5","","1182.28","1182.28","1182.28","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","outpatient","","","2685.00","2013.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1342.50","50","","3610.00","2269.44","3610.00","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","outpatient","","","2685.00","2013.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1409.63","52.5","","3610.00","2382.05","4331.00","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","outpatient","","","2685.00","2013.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1476.75","55","","4810.75","3363.17","4810.75","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","outpatient","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2194.18","81.72","","8894.69","8894.69","8894.69","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Mgh Gastric Fistula Plug Placement","PX-76001915","CDM","43999","CPT","0761","RC","","","","outpatient","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2194.18","81.72","","2885.83","2132.00","3462.21","1 through 10","1342.5","2384.07","percent of total billed charges",""
"Mgh Gata1 Sequencing","PX-31000367","CDM","81479","CPT","0310","RC","","","","both","","","2411.00","1808.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1916.75","79.5","","0.65","0.65","0.65","1 through 10","747.41","2290.45","percent of total billed charges",""
"Mgh Gata1 Sequencing","PX-31000367","CDM","81479","CPT","0310","RC","","","","both","","","2411.00","1808.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1285.06","53.3","","0.79","0.79","0.79","1 through 10","747.41","2290.45","percent of total billed charges",""
"Mgh Gata1 Sequencing","PX-31000367","CDM","81479","CPT","0310","RC","","","","outpatient","","","2411.00","1808.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1205.50","50","","1.00","1.00","1.00","1 through 10","156.55","1989.08","percent of total billed charges",""
"Mgh Gata1 Sequencing","PX-31000367","CDM","81479","CPT","0310","RC","","","","outpatient","","","2411.00","1808.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1265.78","52.5","","1.00","0.53","1.00","1 through 10","156.55","1989.08","percent of total billed charges",""
"Mgh Gata2 Gene Sequencing","PX-31000487","CDM","81479","CPT","0310","RC","","","","both","","","1965.00","1473.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1562.18","79.5","","0.65","0.65","0.65","1 through 10","609.15","1866.75","percent of total billed charges",""
"Mgh Gata2 Gene Sequencing","PX-31000487","CDM","81479","CPT","0310","RC","","","","both","","","1965.00","1473.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1047.35","53.3","","0.79","0.79","0.79","1 through 10","609.15","1866.75","percent of total billed charges",""
"Mgh Gata2 Gene Sequencing","PX-31000487","CDM","81479","CPT","0310","RC","","","","outpatient","","","1965.00","1473.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","982.50","50","","1.00","1.00","1.00","1 through 10","156.55","1621.13","percent of total billed charges",""
"Mgh Gata2 Gene Sequencing","PX-31000487","CDM","81479","CPT","0310","RC","","","","outpatient","","","1965.00","1473.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1031.63","52.5","","1.00","0.53","1.00","1 through 10","156.55","1621.13","percent of total billed charges",""
"Mgh Gaucher Disease, Full Gene Analysis","PX-31000510","CDM","81479","CPT","0310","RC","","","","both","","","2883.00","2162.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2291.99","79.5","","0.65","0.65","0.65","1 through 10","893.73","2738.85","percent of total billed charges",""
"Mgh Gaucher Disease, Full Gene Analysis","PX-31000510","CDM","81479","CPT","0310","RC","","","","both","","","2883.00","2162.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1536.64","53.3","","0.79","0.79","0.79","1 through 10","893.73","2738.85","percent of total billed charges",""
"Mgh Gaucher Disease, Full Gene Analysis","PX-31000510","CDM","81479","CPT","0310","RC","","","","outpatient","","","2883.00","2162.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1441.50","50","","1.00","1.00","1.00","1 through 10","156.55","2378.48","percent of total billed charges",""
"Mgh Gaucher Disease, Full Gene Analysis","PX-31000510","CDM","81479","CPT","0310","RC","","","","outpatient","","","2883.00","2162.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1513.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","2378.48","percent of total billed charges",""
"Mgh Gch1 Gene Sequencing & Del/Dup","PX-30003432","CDM","81479","CPT","0310","RC","","","","both","","","1136.00","852.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","903.12","79.5","","0.65","0.65","0.65","1 through 10","352.16","1079.2","percent of total billed charges",""
"Mgh Gch1 Gene Sequencing & Del/Dup","PX-30003432","CDM","81479","CPT","0310","RC","","","","both","","","1136.00","852.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","605.49","53.3","","0.79","0.79","0.79","1 through 10","352.16","1079.2","percent of total billed charges",""
"Mgh Gch1 Gene Sequencing & Del/Dup","PX-30003432","CDM","81479","CPT","0310","RC","","","","outpatient","","","1136.00","852.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","568.00","50","","1.00","1.00","1.00","1 through 10","156.55","937.2","percent of total billed charges",""
"Mgh Gch1 Gene Sequencing & Del/Dup","PX-30003432","CDM","81479","CPT","0310","RC","","","","outpatient","","","1136.00","852.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","596.40","52.5","","1.00","0.53","1.00","1 through 10","156.55","937.2","percent of total billed charges",""
"Mgh Genetic Renal Panel Testing","PX-31000609","CDM","81479","CPT","0310","RC","","","","both","","","2710.00","2032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2154.45","79.5","","0.65","0.65","0.65","1 through 10","840.1","2574.5","percent of total billed charges",""
"Mgh Genetic Renal Panel Testing","PX-31000609","CDM","81479","CPT","0310","RC","","","","both","","","2710.00","2032.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1444.43","53.3","","0.79","0.79","0.79","1 through 10","840.1","2574.5","percent of total billed charges",""
"Mgh Genetic Renal Panel Testing","PX-31000609","CDM","81479","CPT","0310","RC","","","","outpatient","","","2710.00","2032.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1355.00","50","","1.00","1.00","1.00","1 through 10","156.55","2235.75","percent of total billed charges",""
"Mgh Genetic Renal Panel Testing","PX-31000609","CDM","81479","CPT","0310","RC","","","","outpatient","","","2710.00","2032.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1422.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","2235.75","percent of total billed charges",""
"Mgh Gfgfr3 Gene, Exon 10","PX-31000370","CDM","81479","CPT","0310","RC","","","","both","","","952.00","714.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","756.84","79.5","","0.65","0.65","0.65","1 through 10","295.12","904.4","percent of total billed charges",""
"Mgh Gfgfr3 Gene, Exon 10","PX-31000370","CDM","81479","CPT","0310","RC","","","","both","","","952.00","714.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","507.42","53.3","","0.79","0.79","0.79","1 through 10","295.12","904.4","percent of total billed charges",""
"Mgh Gfgfr3 Gene, Exon 10","PX-31000370","CDM","81479","CPT","0310","RC","","","","outpatient","","","952.00","714.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","476.00","50","","1.00","1.00","1.00","1 through 10","156.55","785.4","percent of total billed charges",""
"Mgh Gfgfr3 Gene, Exon 10","PX-31000370","CDM","81479","CPT","0310","RC","","","","outpatient","","","952.00","714.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","499.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","785.4","percent of total billed charges",""
"Mgh Ggc Lysosomal Storage Disease Sequencing Panel","PX-31001050","CDM","81479","CPT","0310","RC","","","","both","","","5523.00","4142.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4390.79","79.5","","0.65","0.65","0.65","1 through 10","1712.13","5246.85","percent of total billed charges",""
"Mgh Ggc Lysosomal Storage Disease Sequencing Panel","PX-31001050","CDM","81479","CPT","0310","RC","","","","both","","","5523.00","4142.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2943.76","53.3","","0.79","0.79","0.79","1 through 10","1712.13","5246.85","percent of total billed charges",""
"Mgh Ggc Lysosomal Storage Disease Sequencing Panel","PX-31001050","CDM","81479","CPT","0310","RC","","","","outpatient","","","5523.00","4142.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2761.50","50","","1.00","1.00","1.00","1 through 10","156.55","4556.48","percent of total billed charges",""
"Mgh Ggc Lysosomal Storage Disease Sequencing Panel","PX-31001050","CDM","81479","CPT","0310","RC","","","","outpatient","","","5523.00","4142.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2899.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","4556.48","percent of total billed charges",""
"Mgh Gjb6 (Connexin 30) Gene Sequencing","PX-31000560","CDM","81479","CPT","0310","RC","","","","both","","","722.00","541.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","573.99","79.5","","0.65","0.65","0.65","1 through 10","223.82","685.9","percent of total billed charges",""
"Mgh Gjb6 (Connexin 30) Gene Sequencing","PX-31000560","CDM","81479","CPT","0310","RC","","","","both","","","722.00","541.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","384.83","53.3","","0.79","0.79","0.79","1 through 10","223.82","685.9","percent of total billed charges",""
"Mgh Gjb6 (Connexin 30) Gene Sequencing","PX-31000560","CDM","81479","CPT","0310","RC","","","","outpatient","","","722.00","541.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","361.00","50","","1.00","1.00","1.00","1 through 10","156.55","595.65","percent of total billed charges",""
"Mgh Gjb6 (Connexin 30) Gene Sequencing","PX-31000560","CDM","81479","CPT","0310","RC","","","","outpatient","","","722.00","541.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","379.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","595.65","percent of total billed charges",""
"Mgh Gli3 Exons Sequencing","PX-31000506","CDM","81479","CPT","0310","RC","","","","both","","","2889.00","2166.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2296.76","79.5","","0.65","0.65","0.65","1 through 10","895.59","2744.55","percent of total billed charges",""
"Mgh Gli3 Exons Sequencing","PX-31000506","CDM","81479","CPT","0310","RC","","","","both","","","2889.00","2166.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1539.84","53.3","","0.79","0.79","0.79","1 through 10","895.59","2744.55","percent of total billed charges",""
"Mgh Gli3 Exons Sequencing","PX-31000506","CDM","81479","CPT","0310","RC","","","","outpatient","","","2889.00","2166.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1444.50","50","","1.00","1.00","1.00","1 through 10","156.55","2383.43","percent of total billed charges",""
"Mgh Gli3 Exons Sequencing","PX-31000506","CDM","81479","CPT","0310","RC","","","","outpatient","","","2889.00","2166.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1516.73","52.5","","1.00","0.53","1.00","1 through 10","156.55","2383.43","percent of total billed charges",""
"Mgh Gli3 Sanger Sequencing","PX-31000363","CDM","81479","CPT","0310","RC","","","","both","","","3035.00","2276.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2412.83","79.5","","0.65","0.65","0.65","1 through 10","940.85","2883.25","percent of total billed charges",""
"Mgh Gli3 Sanger Sequencing","PX-31000363","CDM","81479","CPT","0310","RC","","","","both","","","3035.00","2276.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1617.66","53.3","","0.79","0.79","0.79","1 through 10","940.85","2883.25","percent of total billed charges",""
"Mgh Gli3 Sanger Sequencing","PX-31000363","CDM","81479","CPT","0310","RC","","","","outpatient","","","3035.00","2276.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1517.50","50","","1.00","1.00","1.00","1 through 10","156.55","2503.88","percent of total billed charges",""
"Mgh Gli3 Sanger Sequencing","PX-31000363","CDM","81479","CPT","0310","RC","","","","outpatient","","","3035.00","2276.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1593.38","52.5","","1.00","0.53","1.00","1 through 10","156.55","2503.88","percent of total billed charges",""
"Mgh Gli3 Select Exons Sequencing","PX-31000603","CDM","81479","CPT","0310","RC","","","","both","","","1807.00","1355.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1436.57","79.5","","0.65","0.65","0.65","1 through 10","560.17","1716.65","percent of total billed charges",""
"Mgh Gli3 Select Exons Sequencing","PX-31000603","CDM","81479","CPT","0310","RC","","","","both","","","1807.00","1355.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","963.13","53.3","","0.79","0.79","0.79","1 through 10","560.17","1716.65","percent of total billed charges",""
"Mgh Gli3 Select Exons Sequencing","PX-31000603","CDM","81479","CPT","0310","RC","","","","outpatient","","","1807.00","1355.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","903.50","50","","1.00","1.00","1.00","1 through 10","156.55","1490.78","percent of total billed charges",""
"Mgh Gli3 Select Exons Sequencing","PX-31000603","CDM","81479","CPT","0310","RC","","","","outpatient","","","1807.00","1355.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","948.68","52.5","","1.00","0.53","1.00","1 through 10","156.55","1490.78","percent of total billed charges",""
"Mgh Glycogen Storage Disease Type IV via Gbe1 Gene","PX-30003423","CDM","81479","CPT","0310","RC","","","","both","","","1607.00","1205.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1277.57","79.5","","0.65","0.65","0.65","1 through 10","498.17","1526.65","percent of total billed charges",""
"Mgh Glycogen Storage Disease Type IV via Gbe1 Gene","PX-30003423","CDM","81479","CPT","0310","RC","","","","both","","","1607.00","1205.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","856.53","53.3","","0.79","0.79","0.79","1 through 10","498.17","1526.65","percent of total billed charges",""
"Mgh Glycogen Storage Disease Type IV via Gbe1 Gene","PX-30003423","CDM","81479","CPT","0310","RC","","","","outpatient","","","1607.00","1205.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","803.50","50","","1.00","1.00","1.00","1 through 10","156.55","1325.78","percent of total billed charges",""
"Mgh Glycogen Storage Disease Type IV via Gbe1 Gene","PX-30003423","CDM","81479","CPT","0310","RC","","","","outpatient","","","1607.00","1205.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","843.68","52.5","","1.00","0.53","1.00","1 through 10","156.55","1325.78","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test","PX-30002028","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Gm1 Autoantibody Test 83520","PX-30002032","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Gsd Liver Pnl by Massively Parallel Seq (Bcm-Mitomengssm)","PX-31000614","CDM","81479","CPT","0310","RC","","","","both","","","1083.00","812.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","860.99","79.5","","0.65","0.65","0.65","1 through 10","335.73","1028.85","percent of total billed charges",""
"Mgh Gsd Liver Pnl by Massively Parallel Seq (Bcm-Mitomengssm)","PX-31000614","CDM","81479","CPT","0310","RC","","","","both","","","1083.00","812.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","577.24","53.3","","0.79","0.79","0.79","1 through 10","335.73","1028.85","percent of total billed charges",""
"Mgh Gsd Liver Pnl by Massively Parallel Seq (Bcm-Mitomengssm)","PX-31000614","CDM","81479","CPT","0310","RC","","","","outpatient","","","1083.00","812.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","541.50","50","","1.00","1.00","1.00","1 through 10","156.55","893.48","percent of total billed charges",""
"Mgh Gsd Liver Pnl by Massively Parallel Seq (Bcm-Mitomengssm)","PX-31000614","CDM","81479","CPT","0310","RC","","","","outpatient","","","1083.00","812.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","568.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","893.48","percent of total billed charges",""
"Mgh Gsd Muscle Panel Massive Parallel Sequenc (Bcm-Mitomengssm)","PX-31000552","CDM","81479","CPT","0310","RC","","","","both","","","1300.00","975.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1033.50","79.5","","0.65","0.65","0.65","1 through 10","403","1235","percent of total billed charges",""
"Mgh Gsd Muscle Panel Massive Parallel Sequenc (Bcm-Mitomengssm)","PX-31000552","CDM","81479","CPT","0310","RC","","","","both","","","1300.00","975.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","692.90","53.3","","0.79","0.79","0.79","1 through 10","403","1235","percent of total billed charges",""
"Mgh Gsd Muscle Panel Massive Parallel Sequenc (Bcm-Mitomengssm)","PX-31000552","CDM","81479","CPT","0310","RC","","","","outpatient","","","1300.00","975.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","650.00","50","","1.00","1.00","1.00","1 through 10","156.55","1072.5","percent of total billed charges",""
"Mgh Gsd Muscle Panel Massive Parallel Sequenc (Bcm-Mitomengssm)","PX-31000552","CDM","81479","CPT","0310","RC","","","","outpatient","","","1300.00","975.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","682.50","52.5","","1.00","0.53","1.00","1 through 10","156.55","1072.5","percent of total billed charges",""
"Mgh Gx Cornelia De Lange Syndrome Panel","PX-31001047","CDM","81479","CPT","0310","RC","","","","both","","","4735.00","3551.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3764.33","79.5","","0.65","0.65","0.65","1 through 10","1467.85","4498.25","percent of total billed charges",""
"Mgh Gx Cornelia De Lange Syndrome Panel","PX-31001047","CDM","81479","CPT","0310","RC","","","","both","","","4735.00","3551.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2523.76","53.3","","0.79","0.79","0.79","1 through 10","1467.85","4498.25","percent of total billed charges",""
"Mgh Gx Cornelia De Lange Syndrome Panel","PX-31001047","CDM","81479","CPT","0310","RC","","","","outpatient","","","4735.00","3551.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2367.50","50","","1.00","1.00","1.00","1 through 10","156.55","3906.38","percent of total billed charges",""
"Mgh Gx Cornelia De Lange Syndrome Panel","PX-31001047","CDM","81479","CPT","0310","RC","","","","outpatient","","","4735.00","3551.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2485.88","52.5","","1.00","0.53","1.00","1 through 10","156.55","3906.38","percent of total billed charges",""
"Mgh Gx Flcn Gene Sequencing and Del/Dup","PX-31001048","CDM","81479","CPT","0310","RC","","","","both","","","3395.00","2546.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2699.03","79.5","","0.65","0.65","0.65","1 through 10","1052.45","3225.25","percent of total billed charges",""
"Mgh Gx Flcn Gene Sequencing and Del/Dup","PX-31001048","CDM","81479","CPT","0310","RC","","","","both","","","3395.00","2546.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1809.54","53.3","","0.79","0.79","0.79","1 through 10","1052.45","3225.25","percent of total billed charges",""
"Mgh Gx Flcn Gene Sequencing and Del/Dup","PX-31001048","CDM","81479","CPT","0310","RC","","","","outpatient","","","3395.00","2546.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1697.50","50","","1.00","1.00","1.00","1 through 10","156.55","2800.88","percent of total billed charges",""
"Mgh Gx Flcn Gene Sequencing and Del/Dup","PX-31001048","CDM","81479","CPT","0310","RC","","","","outpatient","","","3395.00","2546.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1782.38","52.5","","1.00","0.53","1.00","1 through 10","156.55","2800.88","percent of total billed charges",""
"Mgh Gx Fumarate Hydratase Gene Analysis","PX-31001161","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Mgh Gx Fumarate Hydratase Gene Analysis","PX-31001161","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Mgh Gx Fumarate Hydratase Gene Analysis","PX-31001161","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Mgh Gx Fumarate Hydratase Gene Analysis","PX-31001161","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Mgh Gys2 Full Gene Sequencing Analysis","PX-31000543","CDM","81479","CPT","0310","RC","","","","both","","","541.00","405.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","430.10","79.5","","0.65","0.65","0.65","1 through 10","167.71","513.95","percent of total billed charges",""
"Mgh Gys2 Full Gene Sequencing Analysis","PX-31000543","CDM","81479","CPT","0310","RC","","","","both","","","541.00","405.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","288.35","53.3","","0.79","0.79","0.79","1 through 10","167.71","513.95","percent of total billed charges",""
"Mgh Gys2 Full Gene Sequencing Analysis","PX-31000543","CDM","81479","CPT","0310","RC","","","","outpatient","","","541.00","405.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","270.50","50","","1.00","1.00","1.00","1 through 10","156.55","446.33","percent of total billed charges",""
"Mgh Gys2 Full Gene Sequencing Analysis","PX-31000543","CDM","81479","CPT","0310","RC","","","","outpatient","","","541.00","405.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","284.03","52.5","","1.00","0.53","1.00","1 through 10","156.55","446.33","percent of total billed charges",""
"Mgh Hantavirus Antibody 86790","PX-30002241","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.82","79.5","","119.62","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Hantavirus Antibody 86790","PX-30002241","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.68","53.3","","80.26","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Hantavirus Antibody 86790","PX-30002241","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.31","36.5","","56.70","40.57","143.19","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Hantavirus Antibody 86790","PX-30002241","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.13","38.3","","59.43","57.76","178.29","54","9.6","149.15","percent of total billed charges",""
"Mgh Hantavirus Antibody 86790","PX-30002241","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA HMO","109.59","69.8","","102.90","72.66","175.56","43","9.6","128.3","percent of total billed charges",""
"Mgh Hantavirus Antibody 86790","PX-30002241","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA PPO","126.23","80.4","","72.66","72.66","118.56","1 through 10","9.6","128.3","percent of total billed charges",""
"Mgh Hantavirus Antibody 86790","PX-30002241","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.30","81.72","","121.51","66.83","121.51","11","9.6","128.3","percent of total billed charges",""
"Mgh Hax1 Gene Sequencing","PX-31000851","CDM","81479","CPT","0310","RC","","","","both","","","1482.00","1111.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1178.19","79.5","","0.65","0.65","0.65","1 through 10","459.42","1407.9","percent of total billed charges",""
"Mgh Hax1 Gene Sequencing","PX-31000851","CDM","81479","CPT","0310","RC","","","","both","","","1482.00","1111.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","789.91","53.3","","0.79","0.79","0.79","1 through 10","459.42","1407.9","percent of total billed charges",""
"Mgh Hax1 Gene Sequencing","PX-31000851","CDM","81479","CPT","0310","RC","","","","outpatient","","","1482.00","1111.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","741.00","50","","1.00","1.00","1.00","1 through 10","156.55","1222.65","percent of total billed charges",""
"Mgh Hax1 Gene Sequencing","PX-31000851","CDM","81479","CPT","0310","RC","","","","outpatient","","","1482.00","1111.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","778.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","1222.65","percent of total billed charges",""
"Mgh Hbd","PX-30001562","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Hbd","PX-30001562","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Hbd","PX-30001562","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Hbd","PX-30001562","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Hbd","PX-30001562","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Hbd","PX-30001562","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Hbd","PX-30001562","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Hcv Fibrosure Nephelome 83883","PX-30002122","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Hcv Fibrosure Nephelome 83883","PX-30002122","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Hemophagocytic Lymphohistiocytosis","PX-31000507","CDM","81479","CPT","0310","RC","","","","both","","","231.00","173.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","183.65","79.5","","0.65","0.65","0.65","1 through 10","71.61","219.45","percent of total billed charges",""
"Mgh Hemophagocytic Lymphohistiocytosis","PX-31000507","CDM","81479","CPT","0310","RC","","","","both","","","231.00","173.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","123.12","53.3","","0.79","0.79","0.79","1 through 10","71.61","219.45","percent of total billed charges",""
"Mgh Hemophagocytic Lymphohistiocytosis","PX-31000507","CDM","81479","CPT","0310","RC","","","","outpatient","","","231.00","173.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","115.50","50","","1.00","1.00","1.00","1 through 10","111.8","190.58","percent of total billed charges",""
"Mgh Hemophagocytic Lymphohistiocytosis","PX-31000507","CDM","81479","CPT","0310","RC","","","","outpatient","","","231.00","173.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","121.28","52.5","","1.00","0.53","1.00","1 through 10","111.8","190.58","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Hep C Rna by Pcr 4","PX-30002295","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Hep D Virus Rna Pcr","PX-30002296","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Hereditary Hemochromatosis","PX-31000546","CDM","81479","CPT","0310","RC","","","","both","","","2710.00","2032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2154.45","79.5","","0.65","0.65","0.65","1 through 10","840.1","2574.5","percent of total billed charges",""
"Mgh Hereditary Hemochromatosis","PX-31000546","CDM","81479","CPT","0310","RC","","","","both","","","2710.00","2032.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1444.43","53.3","","0.79","0.79","0.79","1 through 10","840.1","2574.5","percent of total billed charges",""
"Mgh Hereditary Hemochromatosis","PX-31000546","CDM","81479","CPT","0310","RC","","","","outpatient","","","2710.00","2032.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1355.00","50","","1.00","1.00","1.00","1 through 10","156.55","2235.75","percent of total billed charges",""
"Mgh Hereditary Hemochromatosis","PX-31000546","CDM","81479","CPT","0310","RC","","","","outpatient","","","2710.00","2032.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1422.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","2235.75","percent of total billed charges",""
"Mgh Hereditary Hemorrhagic Telangiectasia (Hht) Testing","PX-31000669","CDM","81479","CPT","0310","RC","","","","both","","","461.00","345.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","366.50","79.5","","0.65","0.65","0.65","1 through 10","142.91","437.95","percent of total billed charges",""
"Mgh Hereditary Hemorrhagic Telangiectasia (Hht) Testing","PX-31000669","CDM","81479","CPT","0310","RC","","","","both","","","461.00","345.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","245.71","53.3","","0.79","0.79","0.79","1 through 10","142.91","437.95","percent of total billed charges",""
"Mgh Hereditary Hemorrhagic Telangiectasia (Hht) Testing","PX-31000669","CDM","81479","CPT","0310","RC","","","","outpatient","","","461.00","345.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.50","50","","1.00","1.00","1.00","1 through 10","156.55","380.33","percent of total billed charges",""
"Mgh Hereditary Hemorrhagic Telangiectasia (Hht) Testing","PX-31000669","CDM","81479","CPT","0310","RC","","","","outpatient","","","461.00","345.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","242.03","52.5","","1.00","0.53","1.00","1 through 10","156.55","380.33","percent of total billed charges",""
"Mgh Hereditary Osteodystrophy","PX-31000280","CDM","81479","CPT","0310","RC","","","","both","","","1418.00","1063.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1127.31","79.5","","0.65","0.65","0.65","1 through 10","439.58","1347.1","percent of total billed charges",""
"Mgh Hereditary Osteodystrophy","PX-31000280","CDM","81479","CPT","0310","RC","","","","both","","","1418.00","1063.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","755.79","53.3","","0.79","0.79","0.79","1 through 10","439.58","1347.1","percent of total billed charges",""
"Mgh Hereditary Osteodystrophy","PX-31000280","CDM","81479","CPT","0310","RC","","","","outpatient","","","1418.00","1063.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","709.00","50","","1.00","1.00","1.00","1 through 10","156.55","1169.85","percent of total billed charges",""
"Mgh Hereditary Osteodystrophy","PX-31000280","CDM","81479","CPT","0310","RC","","","","outpatient","","","1418.00","1063.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","744.45","52.5","","1.00","0.53","1.00","1 through 10","156.55","1169.85","percent of total billed charges",""
"Mgh Hereditary Pancreatitis Panel","PX-31000649","CDM","81479","CPT","0310","RC","","","","both","","","754.00","565.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","599.43","79.5","","0.65","0.65","0.65","1 through 10","233.74","716.3","percent of total billed charges",""
"Mgh Hereditary Pancreatitis Panel","PX-31000649","CDM","81479","CPT","0310","RC","","","","both","","","754.00","565.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","401.88","53.3","","0.79","0.79","0.79","1 through 10","233.74","716.3","percent of total billed charges",""
"Mgh Hereditary Pancreatitis Panel","PX-31000649","CDM","81479","CPT","0310","RC","","","","outpatient","","","754.00","565.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","377.00","50","","1.00","1.00","1.00","1 through 10","156.55","622.05","percent of total billed charges",""
"Mgh Hereditary Pancreatitis Panel","PX-31000649","CDM","81479","CPT","0310","RC","","","","outpatient","","","754.00","565.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","395.85","52.5","","1.00","0.53","1.00","1 through 10","156.55","622.05","percent of total billed charges",""
"Mgh Hermansky Pudlak Syn 20 Genes","PX-31000290","CDM","81479","CPT","0310","RC","","","","both","","","2257.00","1692.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1794.32","79.5","","0.65","0.65","0.65","1 through 10","699.67","2144.15","percent of total billed charges",""
"Mgh Hermansky Pudlak Syn 20 Genes","PX-31000290","CDM","81479","CPT","0310","RC","","","","both","","","2257.00","1692.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1202.98","53.3","","0.79","0.79","0.79","1 through 10","699.67","2144.15","percent of total billed charges",""
"Mgh Hermansky Pudlak Syn 20 Genes","PX-31000290","CDM","81479","CPT","0310","RC","","","","outpatient","","","2257.00","1692.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1128.50","50","","1.00","1.00","1.00","1 through 10","156.55","1862.03","percent of total billed charges",""
"Mgh Hermansky Pudlak Syn 20 Genes","PX-31000290","CDM","81479","CPT","0310","RC","","","","outpatient","","","2257.00","1692.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1184.93","52.5","","1.00","0.53","1.00","1 through 10","156.55","1862.03","percent of total billed charges",""
"Mgh Hermansky Pudlak Syndrome Pnel","PX-31000249","CDM","81479","CPT","0310","RC","","","","both","","","4600.00","3450.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3657.00","79.5","","0.65","0.65","0.65","1 through 10","1426","4370","percent of total billed charges",""
"Mgh Hermansky Pudlak Syndrome Pnel","PX-31000249","CDM","81479","CPT","0310","RC","","","","both","","","4600.00","3450.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2451.80","53.3","","0.79","0.79","0.79","1 through 10","1426","4370","percent of total billed charges",""
"Mgh Hermansky Pudlak Syndrome Pnel","PX-31000249","CDM","81479","CPT","0310","RC","","","","outpatient","","","4600.00","3450.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2300.00","50","","1.00","1.00","1.00","1 through 10","156.55","3795","percent of total billed charges",""
"Mgh Hermansky Pudlak Syndrome Pnel","PX-31000249","CDM","81479","CPT","0310","RC","","","","outpatient","","","4600.00","3450.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2415.00","52.5","","1.00","0.53","1.00","1 through 10","156.55","3795","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Herpes Virus 8 Dna Pcr","PX-30002298","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Hexb Gene","PX-31000251","CDM","81479","CPT","0310","RC","","","","both","","","2574.00","1930.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2046.33","79.5","","0.65","0.65","0.65","1 through 10","797.94","2445.3","percent of total billed charges",""
"Mgh Hexb Gene","PX-31000251","CDM","81479","CPT","0310","RC","","","","both","","","2574.00","1930.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1371.94","53.3","","0.79","0.79","0.79","1 through 10","797.94","2445.3","percent of total billed charges",""
"Mgh Hexb Gene","PX-31000251","CDM","81479","CPT","0310","RC","","","","outpatient","","","2574.00","1930.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1287.00","50","","1.00","1.00","1.00","1 through 10","156.55","2123.55","percent of total billed charges",""
"Mgh Hexb Gene","PX-31000251","CDM","81479","CPT","0310","RC","","","","outpatient","","","2574.00","1930.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1351.35","52.5","","1.00","0.53","1.00","1 through 10","156.55","2123.55","percent of total billed charges",""
"Mgh Hirschsprung Disease Seq","PX-31000352","CDM","81479","CPT","0310","RC","","","","both","","","1607.00","1205.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1277.57","79.5","","0.65","0.65","0.65","1 through 10","498.17","1526.65","percent of total billed charges",""
"Mgh Hirschsprung Disease Seq","PX-31000352","CDM","81479","CPT","0310","RC","","","","both","","","1607.00","1205.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","856.53","53.3","","0.79","0.79","0.79","1 through 10","498.17","1526.65","percent of total billed charges",""
"Mgh Hirschsprung Disease Seq","PX-31000352","CDM","81479","CPT","0310","RC","","","","outpatient","","","1607.00","1205.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","803.50","50","","1.00","1.00","1.00","1 through 10","156.55","1325.78","percent of total billed charges",""
"Mgh Hirschsprung Disease Seq","PX-31000352","CDM","81479","CPT","0310","RC","","","","outpatient","","","1607.00","1205.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","843.68","52.5","","1.00","0.53","1.00","1 through 10","156.55","1325.78","percent of total billed charges",""
"Mgh Hpe Panel","PX-31000356","CDM","81479","CPT","0310","RC","","","","both","","","4464.00","3348.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3548.88","79.5","","0.65","0.65","0.65","1 through 10","1383.84","4240.8","percent of total billed charges",""
"Mgh Hpe Panel","PX-31000356","CDM","81479","CPT","0310","RC","","","","both","","","4464.00","3348.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2379.31","53.3","","0.79","0.79","0.79","1 through 10","1383.84","4240.8","percent of total billed charges",""
"Mgh Hpe Panel","PX-31000356","CDM","81479","CPT","0310","RC","","","","outpatient","","","4464.00","3348.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2232.00","50","","1.00","1.00","1.00","1 through 10","156.55","3682.8","percent of total billed charges",""
"Mgh Hpe Panel","PX-31000356","CDM","81479","CPT","0310","RC","","","","outpatient","","","4464.00","3348.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2343.60","52.5","","1.00","0.53","1.00","1 through 10","156.55","3682.8","percent of total billed charges",""
"Mgh Hsp, Complete Recessive Evaluation","PX-30003426","CDM","81479","CPT","0310","RC","","","","both","","","3471.00","2603.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2759.45","79.5","","0.65","0.65","0.65","1 through 10","1076.01","3297.45","percent of total billed charges",""
"Mgh Hsp, Complete Recessive Evaluation","PX-30003426","CDM","81479","CPT","0310","RC","","","","both","","","3471.00","2603.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1850.04","53.3","","0.79","0.79","0.79","1 through 10","1076.01","3297.45","percent of total billed charges",""
"Mgh Hsp, Complete Recessive Evaluation","PX-30003426","CDM","81479","CPT","0310","RC","","","","outpatient","","","3471.00","2603.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1735.50","50","","1.00","1.00","1.00","1 through 10","156.55","2863.58","percent of total billed charges",""
"Mgh Hsp, Complete Recessive Evaluation","PX-30003426","CDM","81479","CPT","0310","RC","","","","outpatient","","","3471.00","2603.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1822.28","52.5","","1.00","0.53","1.00","1 through 10","156.55","2863.58","percent of total billed charges",""
"Mgh Hspb8 Dna Sequencing Test","PX-31000265","CDM","81479","CPT","0310","RC","","","","both","","","4581.00","3435.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3641.90","79.5","","0.65","0.65","0.65","1 through 10","1420.11","4351.95","percent of total billed charges",""
"Mgh Hspb8 Dna Sequencing Test","PX-31000265","CDM","81479","CPT","0310","RC","","","","both","","","4581.00","3435.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2441.67","53.3","","0.79","0.79","0.79","1 through 10","1420.11","4351.95","percent of total billed charges",""
"Mgh Hspb8 Dna Sequencing Test","PX-31000265","CDM","81479","CPT","0310","RC","","","","outpatient","","","4581.00","3435.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2290.50","50","","1.00","1.00","1.00","1 through 10","156.55","3779.33","percent of total billed charges",""
"Mgh Hspb8 Dna Sequencing Test","PX-31000265","CDM","81479","CPT","0310","RC","","","","outpatient","","","4581.00","3435.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2405.03","52.5","","1.00","0.53","1.00","1 through 10","156.55","3779.33","percent of total billed charges",""
"Mgh Hydroxychloroquine","PX-30002116","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Hydroxychloroquine","PX-30002116","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Hydroxychloroquine","PX-30002116","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Hydroxychloroquine","PX-30002116","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Hydroxychloroquine","PX-30002116","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Hydroxychloroquine","PX-30002116","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Hydroxychloroquine","PX-30002116","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Hyper-Igd Syndrome","PX-31000277","CDM","81479","CPT","0310","RC","","","","both","","","2762.00","2071.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2195.79","79.5","","0.65","0.65","0.65","1 through 10","856.22","2623.9","percent of total billed charges",""
"Mgh Hyper-Igd Syndrome","PX-31000277","CDM","81479","CPT","0310","RC","","","","both","","","2762.00","2071.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1472.15","53.3","","0.79","0.79","0.79","1 through 10","856.22","2623.9","percent of total billed charges",""
"Mgh Hyper-Igd Syndrome","PX-31000277","CDM","81479","CPT","0310","RC","","","","outpatient","","","2762.00","2071.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1381.00","50","","1.00","1.00","1.00","1 through 10","156.55","2278.65","percent of total billed charges",""
"Mgh Hyper-Igd Syndrome","PX-31000277","CDM","81479","CPT","0310","RC","","","","outpatient","","","2762.00","2071.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1450.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","2278.65","percent of total billed charges",""
"Mgh Hyperekplexia Full Gene Sequencing Analysis Panel (5 Genes)","PX-31000589","CDM","81479","CPT","0310","RC","","","","both","","","1129.00","846.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","897.56","79.5","","0.65","0.65","0.65","1 through 10","349.99","1072.55","percent of total billed charges",""
"Mgh Hyperekplexia Full Gene Sequencing Analysis Panel (5 Genes)","PX-31000589","CDM","81479","CPT","0310","RC","","","","both","","","1129.00","846.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","601.76","53.3","","0.79","0.79","0.79","1 through 10","349.99","1072.55","percent of total billed charges",""
"Mgh Hyperekplexia Full Gene Sequencing Analysis Panel (5 Genes)","PX-31000589","CDM","81479","CPT","0310","RC","","","","outpatient","","","1129.00","846.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","564.50","50","","1.00","1.00","1.00","1 through 10","156.55","931.43","percent of total billed charges",""
"Mgh Hyperekplexia Full Gene Sequencing Analysis Panel (5 Genes)","PX-31000589","CDM","81479","CPT","0310","RC","","","","outpatient","","","1129.00","846.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","592.73","52.5","","1.00","0.53","1.00","1 through 10","156.55","931.43","percent of total billed charges",""
"Mgh Hypocalcemia Auto Dom (Adh)","PX-31000269","CDM","81479","CPT","0310","RC","","","","both","","","5393.00","4044.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4287.44","79.5","","0.65","0.65","0.65","1 through 10","1671.83","5123.35","percent of total billed charges",""
"Mgh Hypocalcemia Auto Dom (Adh)","PX-31000269","CDM","81479","CPT","0310","RC","","","","both","","","5393.00","4044.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2874.47","53.3","","0.79","0.79","0.79","1 through 10","1671.83","5123.35","percent of total billed charges",""
"Mgh Hypocalcemia Auto Dom (Adh)","PX-31000269","CDM","81479","CPT","0310","RC","","","","outpatient","","","5393.00","4044.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2696.50","50","","1.00","1.00","1.00","1 through 10","156.55","4449.23","percent of total billed charges",""
"Mgh Hypocalcemia Auto Dom (Adh)","PX-31000269","CDM","81479","CPT","0310","RC","","","","outpatient","","","5393.00","4044.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2831.33","52.5","","1.00","0.53","1.00","1 through 10","156.55","4449.23","percent of total billed charges",""
"Mgh Hypophosphatasia, Infantile, Childhood & Adult Types","PX-31000661","CDM","81479","CPT","0310","RC","","","","both","","","1310.00","982.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1041.45","79.5","","0.65","0.65","0.65","1 through 10","406.1","1244.5","percent of total billed charges",""
"Mgh Hypophosphatasia, Infantile, Childhood & Adult Types","PX-31000661","CDM","81479","CPT","0310","RC","","","","both","","","1310.00","982.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","698.23","53.3","","0.79","0.79","0.79","1 through 10","406.1","1244.5","percent of total billed charges",""
"Mgh Hypophosphatasia, Infantile, Childhood & Adult Types","PX-31000661","CDM","81479","CPT","0310","RC","","","","outpatient","","","1310.00","982.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","655.00","50","","1.00","1.00","1.00","1 through 10","156.55","1080.75","percent of total billed charges",""
"Mgh Hypophosphatasia, Infantile, Childhood & Adult Types","PX-31000661","CDM","81479","CPT","0310","RC","","","","outpatient","","","1310.00","982.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","687.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","1080.75","percent of total billed charges",""
"Mgh Iaad Eia Mult Meth Nos Eo","PX-30002246","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","102.43","102.43","102.43","1 through 10","11.74","190","percent of total billed charges",""
"Mgh Iaad Eia Mult Meth Nos Eo","PX-30002246","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","61.50","61.50","61.50","1 through 10","11.74","190","percent of total billed charges",""
"Mgh Iaad Eia Mult Meth Nos Eo","PX-30002246","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","75.85","75.86","1 through 10","11.74","190","percent of total billed charges",""
"Mgh Iaad Eia Mult Meth Nos Eo","PX-30002246","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","155.08","155.08","1 through 10","11.74","190","percent of total billed charges",""
"Mgh Iaad Eia Mult Meth Nos Eo","PX-30002246","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","131.34","92.73","185.46","17","11.81","163.44","percent of total billed charges",""
"Mgh Iaad Eia Mult Meth Nos Eo","PX-30002246","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","60.38","194.00","1 through 10","11.81","163.44","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001625","CDM","87798","CPT","0301","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Prb Ea Org","PX-30001655","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Iadna Nos Amp Probe Ea Orgnsm","PX-30001656","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Ifitms Mutation Analysis","PX-31000392","CDM","81479","CPT","0310","RC","","","","both","","","800.00","600.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","636.00","79.5","","0.65","0.65","0.65","1 through 10","248","760","percent of total billed charges",""
"Mgh Ifitms Mutation Analysis","PX-31000392","CDM","81479","CPT","0310","RC","","","","both","","","800.00","600.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","426.40","53.3","","0.79","0.79","0.79","1 through 10","248","760","percent of total billed charges",""
"Mgh Ifitms Mutation Analysis","PX-31000392","CDM","81479","CPT","0310","RC","","","","outpatient","","","800.00","600.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","400.00","50","","1.00","1.00","1.00","1 through 10","156.55","660","percent of total billed charges",""
"Mgh Ifitms Mutation Analysis","PX-31000392","CDM","81479","CPT","0310","RC","","","","outpatient","","","800.00","600.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","420.00","52.5","","1.00","0.53","1.00","1 through 10","156.55","660","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Igfbp3 83520","PX-30002042","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Ighmbp2 Dna Sequencing Test","PX-31000284","CDM","81479","CPT","0310","RC","","","","both","","","3615.00","2711.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2873.93","79.5","","0.65","0.65","0.65","1 through 10","1120.65","3434.25","percent of total billed charges",""
"Mgh Ighmbp2 Dna Sequencing Test","PX-31000284","CDM","81479","CPT","0310","RC","","","","both","","","3615.00","2711.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1926.80","53.3","","0.79","0.79","0.79","1 through 10","1120.65","3434.25","percent of total billed charges",""
"Mgh Ighmbp2 Dna Sequencing Test","PX-31000284","CDM","81479","CPT","0310","RC","","","","outpatient","","","3615.00","2711.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1807.50","50","","1.00","1.00","1.00","1 through 10","156.55","2982.38","percent of total billed charges",""
"Mgh Ighmbp2 Dna Sequencing Test","PX-31000284","CDM","81479","CPT","0310","RC","","","","outpatient","","","3615.00","2711.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1897.88","52.5","","1.00","0.53","1.00","1 through 10","156.55","2982.38","percent of total billed charges",""
"Mgh Ikbkg (Nemo) Gene Sequencing (IP)","PX-31000619","CDM","81479","CPT","0310","RC","","","","both","","","2986.00","2239.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2373.87","79.5","","0.65","0.65","0.65","1 through 10","925.66","2836.7","percent of total billed charges",""
"Mgh Ikbkg (Nemo) Gene Sequencing (IP)","PX-31000619","CDM","81479","CPT","0310","RC","","","","both","","","2986.00","2239.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1591.54","53.3","","0.79","0.79","0.79","1 through 10","925.66","2836.7","percent of total billed charges",""
"Mgh Ikbkg (Nemo) Gene Sequencing (IP)","PX-31000619","CDM","81479","CPT","0310","RC","","","","outpatient","","","2986.00","2239.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1493.00","50","","1.00","1.00","1.00","1 through 10","156.55","2463.45","percent of total billed charges",""
"Mgh Ikbkg (Nemo) Gene Sequencing (IP)","PX-31000619","CDM","81479","CPT","0310","RC","","","","outpatient","","","2986.00","2239.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1567.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","2463.45","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Immunoassay Analyte","PX-30002043","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Implantation La Press Monitor","PX-48000402","CDM","93799","CPT","0480","RC","","","","outpatient","","","14627.00","10970.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","8044.85","55","","13080.03","13080.03","13080.03","1 through 10","7313.5","12067.28","percent of total billed charges",""
"Mgh Implantation La Press Monitor","PX-48000402","CDM","93799","CPT","0481","RC","","","","both","","","14627.00","10970.25","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","11628.47","other","OPPS APC"
"Mgh Implantation La Press Monitor","PX-48000402","CDM","93799","CPT","0481","RC","","","","outpatient","","","14627.00","10970.25","AETNA [1001]","HB AMC AETNA HMO","10209.65","69.8","","2022.70","2022.70","2022.70","1 through 10","454","11953.18","percent of total billed charges",""
"Mgh Implantation La Press Monitor","PX-48000402","CDM","93799","CPT","0481","RC","","","","outpatient","","","14627.00","10970.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","8856.65","60.55","","318.03","318.03","2439.77","1 through 10","454","11953.18","percent of total billed charges",""
"Mgh Implantation La Press Monitor","PX-48000402","CDM","93799","CPT","0481","RC","","","","outpatient","","","14627.00","10970.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","7638.22","52.22","","360.38","360.38","4023.00","1 through 10","454","11953.18","percent of total billed charges",""
"Mgh Implantation Watchman Device","PX-48000401","CDM","93799","CPT","0480","RC","","","","outpatient","","","29247.00","21935.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","16085.85","55","","13080.03","13080.03","13080.03","1 through 10","14623.5","24128.78","percent of total billed charges",""
"Mgh Implantation Watchman Device","PX-48000401","CDM","93799","CPT","0481","RC","","","","both","","","29247.00","21935.25","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","23251.37","other","OPPS APC"
"Mgh Implantation Watchman Device","PX-48000401","CDM","93799","CPT","0481","RC","","","","outpatient","","","29247.00","21935.25","AETNA [1001]","HB AMC AETNA HMO","20414.41","69.8","","2022.70","2022.70","2022.70","1 through 10","454","23900.65","percent of total billed charges",""
"Mgh Implantation Watchman Device","PX-48000401","CDM","93799","CPT","0481","RC","","","","outpatient","","","29247.00","21935.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","17709.06","60.55","","318.03","318.03","2439.77","1 through 10","454","23900.65","percent of total billed charges",""
"Mgh Implantation Watchman Device","PX-48000401","CDM","93799","CPT","0481","RC","","","","outpatient","","","29247.00","21935.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","15272.78","52.22","","360.38","360.38","4023.00","1 through 10","454","23900.65","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Imunoassay Analyte Quant Nos","PX-30002030","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Infliximab Concentration and Anti-Infliximab Antibody","PX-30003003","CDM","80299","CPT","0301","RC","","","","both","","","691.00","518.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","549.35","79.5","","106.25","71.28","106.25","1 through 10","14.12","656.45","percent of total billed charges",""
"Mgh Infliximab Concentration and Anti-Infliximab Antibody","PX-30003003","CDM","80299","CPT","0301","RC","","","","both","","","691.00","518.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","368.30","53.3","","106.25","71.28","106.25","1 through 10","14.12","656.45","percent of total billed charges",""
"Mgh Infliximab Concentration and Anti-Infliximab Antibody","PX-30003003","CDM","80299","CPT","0301","RC","","","","both","","","691.00","518.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","252.22","36.5","","50.36","42.80","92.50","13","14.12","656.45","percent of total billed charges",""
"Mgh Infliximab Concentration and Anti-Infliximab Antibody","PX-30003003","CDM","80299","CPT","0301","RC","","","","both","","","691.00","518.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","264.65","38.3","","52.79","44.55","158.37","30","14.12","656.45","percent of total billed charges",""
"Mgh Infliximab Concentration and Anti-Infliximab Antibody","PX-30003003","CDM","80299","CPT","0301","RC","","","","outpatient","","","691.00","518.25","AETNA [1001]","HB AMC AETNA HMO","482.32","69.8","","91.40","64.53","105.30","14","14.12","564.69","percent of total billed charges",""
"Mgh Infliximab Concentration and Anti-Infliximab Antibody","PX-30003003","CDM","80299","CPT","0301","RC","","","","outpatient","","","691.00","518.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","555.56","80.4","","105.30","105.30","105.30","1 through 10","14.12","564.69","percent of total billed charges",""
"Mgh Infliximab Concentration and Anti-Infliximab Antibody","PX-30003003","CDM","80299","CPT","0301","RC","","","","outpatient","","","691.00","518.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","564.69","81.72","","59.36","15.50","59.36","1 through 10","14.12","564.69","percent of total billed charges",""
"Mgh Infliximab Quantitation, Serum","PX-30003009","CDM","80299","CPT","0301","RC","","","","both","","","276.00","207.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","219.42","79.5","","106.25","71.28","106.25","1 through 10","14.12","262.2","percent of total billed charges",""
"Mgh Infliximab Quantitation, Serum","PX-30003009","CDM","80299","CPT","0301","RC","","","","both","","","276.00","207.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.11","53.3","","106.25","71.28","106.25","1 through 10","14.12","262.2","percent of total billed charges",""
"Mgh Infliximab Quantitation, Serum","PX-30003009","CDM","80299","CPT","0301","RC","","","","both","","","276.00","207.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.74","36.5","","50.36","42.80","92.50","13","14.12","262.2","percent of total billed charges",""
"Mgh Infliximab Quantitation, Serum","PX-30003009","CDM","80299","CPT","0301","RC","","","","both","","","276.00","207.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.71","38.3","","52.79","44.55","158.37","30","14.12","262.2","percent of total billed charges",""
"Mgh Infliximab Quantitation, Serum","PX-30003009","CDM","80299","CPT","0301","RC","","","","outpatient","","","276.00","207.00","AETNA [1001]","HB AMC AETNA HMO","192.65","69.8","","91.40","64.53","105.30","14","14.12","225.55","percent of total billed charges",""
"Mgh Infliximab Quantitation, Serum","PX-30003009","CDM","80299","CPT","0301","RC","","","","outpatient","","","276.00","207.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","221.90","80.4","","105.30","105.30","105.30","1 through 10","14.12","225.55","percent of total billed charges",""
"Mgh Infliximab Quantitation, Serum","PX-30003009","CDM","80299","CPT","0301","RC","","","","outpatient","","","276.00","207.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","225.55","81.72","","59.36","15.50","59.36","1 through 10","14.12","225.55","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.80","2.10","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1.84","65.6","","0.96","0.96","0.96","1 through 10","0.87","2.23","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.80","2.10","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1.96","70","","4.45","1.98","14.99","1 through 10","0.87","2.23","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.80","2.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2.23","79.5","","414.25","7.38","1891.33","1713","0.87","2.23","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.80","2.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1.49","53.3","","6.50","1.93","26.16","91","0.87","2.23","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.80","2.10","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","2.16","77","","4.84","4.84","4.84","1 through 10","0.87","2.23","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.80","2.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1.82","65","","11.15","6.10","14.62","1 through 10","0.87","2.23","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.80","2.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2.23","79.5","","0.59","0.59","1.48","1 through 10","0.87","2.23","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.80","2.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.87","31","","0.83","0.83","0.83","1 through 10","0.87","2.23","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.80","2.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1.02","36.5","","2.33","0.78","11.19","64","0.87","2.23","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.80","2.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1.07","38.3","","3.61","0.89","16.20","213","0.87","2.23","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.80","2.10","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2.16","77","","9.22","3.56","12.86","1 through 10","0.87","2.23","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.80","2.10","WELLPOINT [1015]","HB AMC WELLPOINT","2.07","73.78","","5.23","1.33","24.91","47","0.87","2.23","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.80","2.10","AETNA [1001]","HB AMC AETNA HMO","1.95","69.8","","6.04","1.31","22.28","143","1.4","2.31","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.80","2.10","AETNA [1001]","HB AMC AETNA PPO","2.25","80.4","","4.95","1.52","30.51","1 through 10","1.4","2.31","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.80","2.10","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1.47","52.5","","533.60","0.69","533.60","1 through 10","1.4","2.31","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.80","2.10","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1.40","50","","4.92","1.04","22.14","217","1.4","2.31","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.80","2.10","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1.47","52.5","","11.25","1.46","33.02","97","1.4","2.31","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.80","2.10","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1.75","62.5","","4.81","4.81","4.81","1 through 10","1.4","2.31","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.80","2.10","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1.54","55","","9.85","1.05","154.76","17","1.4","2.31","percent of total billed charges",""
"Mgh Inj Doxycycline 5mg","PX-63601134","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.80","2.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2.25","80.4","","8.31","5.24","14.69","13","1.4","2.31","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","both","","","4.50","3.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2.95","65.6","","0.96","0.96","0.96","1 through 10","1.4","3.58","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","both","","","4.50","3.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3.15","70","","4.45","1.98","14.99","1 through 10","1.4","3.58","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","both","","","4.50","3.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3.58","79.5","","414.25","7.38","1891.33","1713","1.4","3.58","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","both","","","4.50","3.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2.40","53.3","","6.50","1.93","26.16","91","1.4","3.58","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","both","","","4.50","3.37","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","3.47","77","","4.84","4.84","4.84","1 through 10","1.4","3.58","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","both","","","4.50","3.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2.93","65","","11.15","6.10","14.62","1 through 10","1.4","3.58","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","both","","","4.50","3.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","3.58","79.5","","0.59","0.59","1.48","1 through 10","1.4","3.58","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","both","","","4.50","3.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1.40","31","","0.83","0.83","0.83","1 through 10","1.4","3.58","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","both","","","4.50","3.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1.64","36.5","","2.33","0.78","11.19","64","1.4","3.58","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","both","","","4.50","3.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1.72","38.3","","3.61","0.89","16.20","213","1.4","3.58","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","both","","","4.50","3.37","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3.47","77","","9.22","3.56","12.86","1 through 10","1.4","3.58","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","both","","","4.50","3.37","WELLPOINT [1015]","HB AMC WELLPOINT","3.32","73.78","","5.23","1.33","24.91","47","1.4","3.58","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","4.50","3.37","AETNA [1001]","HB AMC AETNA HMO","3.14","69.8","","6.04","1.31","22.28","143","2.25","3.71","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","4.50","3.37","AETNA [1001]","HB AMC AETNA PPO","3.62","80.4","","4.95","1.52","30.51","1 through 10","2.25","3.71","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","4.50","3.37","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2.36","52.5","","533.60","0.69","533.60","1 through 10","2.25","3.71","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","4.50","3.37","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2.25","50","","4.92","1.04","22.14","217","2.25","3.71","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","4.50","3.37","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2.36","52.5","","11.25","1.46","33.02","97","2.25","3.71","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","4.50","3.37","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2.81","62.5","","4.81","4.81","4.81","1 through 10","2.25","3.71","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","4.50","3.37","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2.48","55","","9.85","1.05","154.76","17","2.25","3.71","percent of total billed charges",""
"Mgh Inj Metronidazole 500mg","PX-63601135","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","4.50","3.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3.62","80.4","","8.31","5.24","14.69","13","2.25","3.71","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.56","1.92","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1.68","65.6","","0.96","0.96","0.96","1 through 10","0.79","2.04","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.56","1.92","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1.79","70","","4.45","1.98","14.99","1 through 10","0.79","2.04","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.56","1.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2.04","79.5","","414.25","7.38","1891.33","1713","0.79","2.04","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.56","1.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1.36","53.3","","6.50","1.93","26.16","91","0.79","2.04","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.56","1.92","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1.97","77","","4.84","4.84","4.84","1 through 10","0.79","2.04","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.56","1.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1.66","65","","11.15","6.10","14.62","1 through 10","0.79","2.04","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.56","1.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","2.04","79.5","","0.59","0.59","1.48","1 through 10","0.79","2.04","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.56","1.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.79","31","","0.83","0.83","0.83","1 through 10","0.79","2.04","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.56","1.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.93","36.5","","2.33","0.78","11.19","64","0.79","2.04","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.56","1.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.98","38.3","","3.61","0.89","16.20","213","0.79","2.04","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.56","1.92","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1.97","77","","9.22","3.56","12.86","1 through 10","0.79","2.04","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","both","","","2.56","1.92","WELLPOINT [1015]","HB AMC WELLPOINT","1.89","73.78","","5.23","1.33","24.91","47","0.79","2.04","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.56","1.92","AETNA [1001]","HB AMC AETNA HMO","1.79","69.8","","6.04","1.31","22.28","143","1.28","2.11","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.56","1.92","AETNA [1001]","HB AMC AETNA PPO","2.06","80.4","","4.95","1.52","30.51","1 through 10","1.28","2.11","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.56","1.92","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1.34","52.5","","533.60","0.69","533.60","1 through 10","1.28","2.11","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.56","1.92","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1.28","50","","4.92","1.04","22.14","217","1.28","2.11","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.56","1.92","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1.34","52.5","","11.25","1.46","33.02","97","1.28","2.11","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.56","1.92","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1.60","62.5","","4.81","4.81","4.81","1 through 10","1.28","2.11","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.56","1.92","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1.41","55","","9.85","1.05","154.76","17","1.28","2.11","percent of total billed charges",""
"Mgh Inj Nitroglycerin 5mg","PX-63601133","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2.56","1.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2.06","80.4","","8.31","5.24","14.69","13","1.28","2.11","percent of total billed charges",""
"Mgh Inj Vedolizumab 300mg","PX-63601113","CDM","J3590","HCPCS","0636","RC","","","","outpatient","","","20480.75","15360.56","AETNA [1001]","HB AMC AETNA HMO","14295.56","69.8","","428.01","428.01","428.01","1 through 10","0.01","16896.62","percent of total billed charges",""
"Mgh Injection Mesna 200mg","PX-63601193","CDM","J9209","HCPCS","0636","RC","","","","outpatient","","","87.55","65.66","AETNA [1001]","HB AMC AETNA HMO","61.11","69.8","","1.99","1.99","1.99","1 through 10","2.86","70.39","percent of total billed charges",""
"Mgh Injection Mesna 200mg","PX-63601193","CDM","J9209","HCPCS","0636","RC","","","","outpatient","","","87.55","65.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","61.20","69.9","","23.29","23.29","23.29","1 through 10","2.86","70.39","percent of total billed charges",""
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","both","","","3375.00","2531.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","2683.13","other","OPPS APC"
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","both","","","3375.00","2531.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","2683.13","other","OPPS APC"
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","both","","","3375.00","2531.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1798.88","53.3","","477.31","477.31","477.31","1 through 10","333.03","2683.13","percent of total billed charges",""
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","both","","","3375.00","2531.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","2683.13","other","OPPS APC"
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","both","","","3375.00","2531.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","2683.13","other","OPPS APC"
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1231.88","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","2683.13","percent of total billed charges",""
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1292.63","38.3","","343.52","323.76","353.46","1 through 10","333.03","2683.13","percent of total billed charges",""
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","both","","","3375.00","2531.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","2683.13","other","Tricare OPPS"
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","both","","","3375.00","2531.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","2683.13","other","OPPS APC"
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","both","","","3375.00","2531.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","2683.13","other","OPPS APC"
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","both","","","3375.00","2531.25","WELLPOINT [1015]","HB AMC WELLPOINT","2490.08","73.78","","673.03","673.03","673.03","1 through 10","333.03","2683.13","percent of total billed charges",""
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","outpatient","","","3375.00","2531.25","AETNA [1001]","HB AMC AETNA HMO","2355.75","69.8","","612.01","612.01","1224.02","1 through 10","700.33","2784.38","percent of total billed charges",""
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","outpatient","","","3375.00","2531.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2043.56","60.55","","579.04","568.57","904.00","30","700.33","2784.38","percent of total billed charges",""
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","outpatient","","","3375.00","2531.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1762.43","52.22","","904.00","656.02","2938.00","26","700.33","2784.38","percent of total billed charges",""
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","outpatient","","","3375.00","2531.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1687.50","50","","1421.10","875.08","2368.50","15","700.33","2784.38","percent of total billed charges",""
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","outpatient","","","3375.00","2531.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1771.88","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","2784.38","percent of total billed charges",""
"Mgh Injection Tx Cerebl Vasospasm","PX-76002006","CDM","64999","CPT","0761","RC","","","","outpatient","","","3375.00","2531.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2758.05","81.72","","722.66","722.66","17449.00","1 through 10","700.33","2784.38","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0250","RC","","","","inpatient","","","0.47","0.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.25","53.3","","0.17","0.17","0.17","30","0.2","0.37","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","both","","","0.47","0.35","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.34","71.8","","0.24","0.24","0.27","90","0.15","0.36","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","both","","","0.47","0.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.31","65.6","","0.50","0.50","0.50","54","0.15","0.36","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","both","","","0.47","0.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.31","65","","0.51","0.24","1.04","477","0.15","0.36","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","both","","","0.47","0.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.33","70","","0.34","0.24","0.37","487","0.15","0.36","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","both","","","0.47","0.35","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","0.36","77","","0.29","0.25","0.29","179","0.15","0.36","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","both","","","0.47","0.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.31","65","","0.24","0.24","0.26","264","0.15","0.36","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","both","","","0.47","0.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.15","31","","0.31","0.10","1.49","1018","0.15","0.36","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","both","","","0.47","0.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.17","36.5","","0.14","0.12","0.43","19571","0.15","0.36","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","both","","","0.47","0.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.18","38.3","","0.14","0.13","0.72","50701","0.15","0.36","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","both","","","0.47","0.35","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.36","77","","0.26","0.26","0.28","181","0.15","0.36","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","outpatient","","","0.47","0.35","AETNA [1001]","HB AMC AETNA HMO","0.33","69.8","","0.25","0.18","0.40","28810","0.19","0.38","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","outpatient","","","0.47","0.35","AETNA [1001]","HB AMC AETNA PPO","0.38","80.4","","0.29","0.19","0.39","3788","0.19","0.38","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","outpatient","","","0.47","0.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.33","69.9","","0.27","0.17","0.82","21573","0.19","0.38","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","outpatient","","","0.47","0.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.22","46.9","","0.27","0.17","4.77","13873","0.19","0.38","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","outpatient","","","0.47","0.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.38","80.4","","0.29","0.28","0.29","646","0.19","0.38","percent of total billed charges",""
"Mgh Injection, Propofol, 10 Mg","PX-63601127","CDM","J2704","HCPCS","0636","RC","","","","outpatient","","","0.47","0.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","0.33","69.9","","0.27","0.26","0.27","210","0.19","0.38","percent of total billed charges",""
"Mgh Insr Sequencing","PX-31000394","CDM","81479","CPT","0310","RC","","","","both","","","2257.00","1692.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1794.32","79.5","","0.65","0.65","0.65","1 through 10","699.67","2144.15","percent of total billed charges",""
"Mgh Insr Sequencing","PX-31000394","CDM","81479","CPT","0310","RC","","","","both","","","2257.00","1692.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1202.98","53.3","","0.79","0.79","0.79","1 through 10","699.67","2144.15","percent of total billed charges",""
"Mgh Insr Sequencing","PX-31000394","CDM","81479","CPT","0310","RC","","","","outpatient","","","2257.00","1692.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1128.50","50","","1.00","1.00","1.00","1 through 10","156.55","1862.03","percent of total billed charges",""
"Mgh Insr Sequencing","PX-31000394","CDM","81479","CPT","0310","RC","","","","outpatient","","","2257.00","1692.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1184.93","52.5","","1.00","0.53","1.00","1 through 10","156.55","1862.03","percent of total billed charges",""
"Mgh Intellectual Disability (Idnext)","PX-31000818","CDM","81479","CPT","0310","RC","","","","both","","","233.00","174.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","185.24","79.5","","0.65","0.65","0.65","1 through 10","72.23","221.35","percent of total billed charges",""
"Mgh Intellectual Disability (Idnext)","PX-31000818","CDM","81479","CPT","0310","RC","","","","both","","","233.00","174.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.19","53.3","","0.79","0.79","0.79","1 through 10","72.23","221.35","percent of total billed charges",""
"Mgh Intellectual Disability (Idnext)","PX-31000818","CDM","81479","CPT","0310","RC","","","","outpatient","","","233.00","174.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","116.50","50","","1.00","1.00","1.00","1 through 10","112.77","192.23","percent of total billed charges",""
"Mgh Intellectual Disability (Idnext)","PX-31000818","CDM","81479","CPT","0310","RC","","","","outpatient","","","233.00","174.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","122.33","52.5","","1.00","0.53","1.00","1 through 10","112.77","192.23","percent of total billed charges",""
"Mgh Interleukin","PX-31000230","CDM","81479","CPT","0310","RC","","","","both","","","5020.00","3765.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3990.90","79.5","","0.65","0.65","0.65","1 through 10","1556.2","4769","percent of total billed charges",""
"Mgh Interleukin","PX-31000230","CDM","81479","CPT","0310","RC","","","","both","","","5020.00","3765.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2675.66","53.3","","0.79","0.79","0.79","1 through 10","1556.2","4769","percent of total billed charges",""
"Mgh Interleukin","PX-31000230","CDM","81479","CPT","0310","RC","","","","outpatient","","","5020.00","3765.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2510.00","50","","1.00","1.00","1.00","1 through 10","156.55","4141.5","percent of total billed charges",""
"Mgh Interleukin","PX-31000230","CDM","81479","CPT","0310","RC","","","","outpatient","","","5020.00","3765.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2635.50","52.5","","1.00","0.53","1.00","1 through 10","156.55","4141.5","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30001870","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002057","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 10","PX-30002087","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30001871","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002058","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 12","PX-30002088","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002059","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Interleukin 5","PX-30002089","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Irak4 Gene Sequence","PX-31000631","CDM","81479","CPT","0310","RC","","","","both","","","2589.00","1941.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2058.26","79.5","","0.65","0.65","0.65","1 through 10","802.59","2459.55","percent of total billed charges",""
"Mgh Irak4 Gene Sequence","PX-31000631","CDM","81479","CPT","0310","RC","","","","both","","","2589.00","1941.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1379.94","53.3","","0.79","0.79","0.79","1 through 10","802.59","2459.55","percent of total billed charges",""
"Mgh Irak4 Gene Sequence","PX-31000631","CDM","81479","CPT","0310","RC","","","","outpatient","","","2589.00","1941.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1294.50","50","","1.00","1.00","1.00","1 through 10","156.55","2135.93","percent of total billed charges",""
"Mgh Irak4 Gene Sequence","PX-31000631","CDM","81479","CPT","0310","RC","","","","outpatient","","","2589.00","1941.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1359.23","52.5","","1.00","0.53","1.00","1 through 10","156.55","2135.93","percent of total billed charges",""
"Mgh Irak4 Gene Sequencing","PX-31000253","CDM","81479","CPT","0310","RC","","","","both","","","4600.00","3450.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3657.00","79.5","","0.65","0.65","0.65","1 through 10","1426","4370","percent of total billed charges",""
"Mgh Irak4 Gene Sequencing","PX-31000253","CDM","81479","CPT","0310","RC","","","","both","","","4600.00","3450.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2451.80","53.3","","0.79","0.79","0.79","1 through 10","1426","4370","percent of total billed charges",""
"Mgh Irak4 Gene Sequencing","PX-31000253","CDM","81479","CPT","0310","RC","","","","outpatient","","","4600.00","3450.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2300.00","50","","1.00","1.00","1.00","1 through 10","156.55","3795","percent of total billed charges",""
"Mgh Irak4 Gene Sequencing","PX-31000253","CDM","81479","CPT","0310","RC","","","","outpatient","","","4600.00","3450.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2415.00","52.5","","1.00","0.53","1.00","1 through 10","156.55","3795","percent of total billed charges",""
"Mgh Jak3 Gene Sequence","PX-31000632","CDM","81479","CPT","0310","RC","","","","both","","","4745.00","3558.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3772.28","79.5","","0.65","0.65","0.65","1 through 10","1470.95","4507.75","percent of total billed charges",""
"Mgh Jak3 Gene Sequence","PX-31000632","CDM","81479","CPT","0310","RC","","","","both","","","4745.00","3558.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2529.09","53.3","","0.79","0.79","0.79","1 through 10","1470.95","4507.75","percent of total billed charges",""
"Mgh Jak3 Gene Sequence","PX-31000632","CDM","81479","CPT","0310","RC","","","","outpatient","","","4745.00","3558.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2372.50","50","","1.00","1.00","1.00","1 through 10","156.55","3914.63","percent of total billed charges",""
"Mgh Jak3 Gene Sequence","PX-31000632","CDM","81479","CPT","0310","RC","","","","outpatient","","","4745.00","3558.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2491.13","52.5","","1.00","0.53","1.00","1 through 10","156.55","3914.63","percent of total billed charges",""
"Mgh Jak3 Gene Sequencing","PX-31000255","CDM","81479","CPT","0310","RC","","","","both","","","8429.00","6321.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6701.06","79.5","","0.65","0.65","0.65","1 through 10","2612.99","8007.55","percent of total billed charges",""
"Mgh Jak3 Gene Sequencing","PX-31000255","CDM","81479","CPT","0310","RC","","","","both","","","8429.00","6321.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4492.66","53.3","","0.79","0.79","0.79","1 through 10","2612.99","8007.55","percent of total billed charges",""
"Mgh Jak3 Gene Sequencing","PX-31000255","CDM","81479","CPT","0310","RC","","","","outpatient","","","8429.00","6321.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4214.50","50","","1.00","1.00","1.00","1 through 10","156.55","6953.93","percent of total billed charges",""
"Mgh Jak3 Gene Sequencing","PX-31000255","CDM","81479","CPT","0310","RC","","","","outpatient","","","8429.00","6321.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4425.23","52.5","","1.00","0.53","1.00","1 through 10","156.55","6953.93","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Jc Bk Virus Detect Pcr","PX-30002300","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh June/Kent Blue Grass Ige 86003","PX-30002191","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh K/K Antigen Genotyping (Kell)","PX-31000624","CDM","81479","CPT","0310","RC","","","","both","","","144.00","108.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","114.48","79.5","","0.65","0.65","0.65","1 through 10","44.64","136.8","percent of total billed charges",""
"Mgh K/K Antigen Genotyping (Kell)","PX-31000624","CDM","81479","CPT","0310","RC","","","","both","","","144.00","108.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","76.75","53.3","","0.79","0.79","0.79","1 through 10","44.64","136.8","percent of total billed charges",""
"Mgh K/K Antigen Genotyping (Kell)","PX-31000624","CDM","81479","CPT","0310","RC","","","","outpatient","","","144.00","108.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","72.00","50","","1.00","1.00","1.00","1 through 10","69.7","156.55","percent of total billed charges",""
"Mgh K/K Antigen Genotyping (Kell)","PX-31000624","CDM","81479","CPT","0310","RC","","","","outpatient","","","144.00","108.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","75.60","52.5","","1.00","0.53","1.00","1 through 10","69.7","156.55","percent of total billed charges",""
"Mgh Kabuki Syndrome Nextgen Sequencing (Ngs) Panel","PX-31000548","CDM","81479","CPT","0310","RC","","","","both","","","1844.00","1383.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1465.98","79.5","","0.65","0.65","0.65","1 through 10","571.64","1751.8","percent of total billed charges",""
"Mgh Kabuki Syndrome Nextgen Sequencing (Ngs) Panel","PX-31000548","CDM","81479","CPT","0310","RC","","","","both","","","1844.00","1383.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","982.85","53.3","","0.79","0.79","0.79","1 through 10","571.64","1751.8","percent of total billed charges",""
"Mgh Kabuki Syndrome Nextgen Sequencing (Ngs) Panel","PX-31000548","CDM","81479","CPT","0310","RC","","","","outpatient","","","1844.00","1383.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","922.00","50","","1.00","1.00","1.00","1 through 10","156.55","1521.3","percent of total billed charges",""
"Mgh Kabuki Syndrome Nextgen Sequencing (Ngs) Panel","PX-31000548","CDM","81479","CPT","0310","RC","","","","outpatient","","","1844.00","1383.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","968.10","52.5","","1.00","0.53","1.00","1 through 10","156.55","1521.3","percent of total billed charges",""
"Mgh Kartageners Syndrome Panel","PX-31000474","CDM","81479","CPT","0310","RC","","","","both","","","4752.00","3564.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3777.84","79.5","","0.65","0.65","0.65","1 through 10","1473.12","4514.4","percent of total billed charges",""
"Mgh Kartageners Syndrome Panel","PX-31000474","CDM","81479","CPT","0310","RC","","","","both","","","4752.00","3564.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2532.82","53.3","","0.79","0.79","0.79","1 through 10","1473.12","4514.4","percent of total billed charges",""
"Mgh Kartageners Syndrome Panel","PX-31000474","CDM","81479","CPT","0310","RC","","","","outpatient","","","4752.00","3564.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2376.00","50","","1.00","1.00","1.00","1 through 10","156.55","3920.4","percent of total billed charges",""
"Mgh Kartageners Syndrome Panel","PX-31000474","CDM","81479","CPT","0310","RC","","","","outpatient","","","4752.00","3564.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2494.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","3920.4","percent of total billed charges",""
"Mgh Kfm Double Exon Seq","PX-31000642","CDM","81479","CPT","0310","RC","","","","both","","","639.00","479.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","508.01","79.5","","0.65","0.65","0.65","1 through 10","198.09","607.05","percent of total billed charges",""
"Mgh Kfm Double Exon Seq","PX-31000642","CDM","81479","CPT","0310","RC","","","","both","","","639.00","479.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","340.59","53.3","","0.79","0.79","0.79","1 through 10","198.09","607.05","percent of total billed charges",""
"Mgh Kfm Double Exon Seq","PX-31000642","CDM","81479","CPT","0310","RC","","","","outpatient","","","639.00","479.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","319.50","50","","1.00","1.00","1.00","1 through 10","156.55","527.18","percent of total billed charges",""
"Mgh Kfm Double Exon Seq","PX-31000642","CDM","81479","CPT","0310","RC","","","","outpatient","","","639.00","479.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","335.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","527.18","percent of total billed charges",""
"Mgh Kif5a Spg10 Dna Sequencing","PX-31000257","CDM","81479","CPT","0310","RC","","","","both","","","4015.00","3011.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3191.93","79.5","","0.65","0.65","0.65","1 through 10","1244.65","3814.25","percent of total billed charges",""
"Mgh Kif5a Spg10 Dna Sequencing","PX-31000257","CDM","81479","CPT","0310","RC","","","","both","","","4015.00","3011.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2140.00","53.3","","0.79","0.79","0.79","1 through 10","1244.65","3814.25","percent of total billed charges",""
"Mgh Kif5a Spg10 Dna Sequencing","PX-31000257","CDM","81479","CPT","0310","RC","","","","outpatient","","","4015.00","3011.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2007.50","50","","1.00","1.00","1.00","1 through 10","156.55","3312.38","percent of total billed charges",""
"Mgh Kif5a Spg10 Dna Sequencing","PX-31000257","CDM","81479","CPT","0310","RC","","","","outpatient","","","4015.00","3011.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2107.88","52.5","","1.00","0.53","1.00","1 through 10","156.55","3312.38","percent of total billed charges",""
"Mgh Kleefstra Syndrome via the Ehmt1 Gene","PX-31000531","CDM","81479","CPT","0310","RC","","","","both","","","2418.00","1813.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1922.31","79.5","","0.65","0.65","0.65","1 through 10","749.58","2297.1","percent of total billed charges",""
"Mgh Kleefstra Syndrome via the Ehmt1 Gene","PX-31000531","CDM","81479","CPT","0310","RC","","","","both","","","2418.00","1813.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1288.79","53.3","","0.79","0.79","0.79","1 through 10","749.58","2297.1","percent of total billed charges",""
"Mgh Kleefstra Syndrome via the Ehmt1 Gene","PX-31000531","CDM","81479","CPT","0310","RC","","","","outpatient","","","2418.00","1813.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1209.00","50","","1.00","1.00","1.00","1 through 10","156.55","1994.85","percent of total billed charges",""
"Mgh Kleefstra Syndrome via the Ehmt1 Gene","PX-31000531","CDM","81479","CPT","0310","RC","","","","outpatient","","","2418.00","1813.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1269.45","52.5","","1.00","0.53","1.00","1 through 10","156.55","1994.85","percent of total billed charges",""
"Mgh Klippel-Feil Syndrome","PX-31000464","CDM","81479","CPT","0310","RC","","","","both","","","1456.00","1092.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1157.52","79.5","","0.65","0.65","0.65","1 through 10","451.36","1383.2","percent of total billed charges",""
"Mgh Klippel-Feil Syndrome","PX-31000464","CDM","81479","CPT","0310","RC","","","","both","","","1456.00","1092.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","776.05","53.3","","0.79","0.79","0.79","1 through 10","451.36","1383.2","percent of total billed charges",""
"Mgh Klippel-Feil Syndrome","PX-31000464","CDM","81479","CPT","0310","RC","","","","outpatient","","","1456.00","1092.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","728.00","50","","1.00","1.00","1.00","1 through 10","156.55","1201.2","percent of total billed charges",""
"Mgh Klippel-Feil Syndrome","PX-31000464","CDM","81479","CPT","0310","RC","","","","outpatient","","","1456.00","1092.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","764.40","52.5","","1.00","0.53","1.00","1 through 10","156.55","1201.2","percent of total billed charges",""
"Mgh Known Familiar Mutation","PX-31000237","CDM","81479","CPT","0310","RC","","","","both","","","1071.00","803.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","851.45","79.5","","0.65","0.65","0.65","1 through 10","332.01","1017.45","percent of total billed charges",""
"Mgh Known Familiar Mutation","PX-31000237","CDM","81479","CPT","0310","RC","","","","both","","","1071.00","803.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","570.84","53.3","","0.79","0.79","0.79","1 through 10","332.01","1017.45","percent of total billed charges",""
"Mgh Known Familiar Mutation","PX-31000237","CDM","81479","CPT","0310","RC","","","","outpatient","","","1071.00","803.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","535.50","50","","1.00","1.00","1.00","1 through 10","156.55","883.58","percent of total billed charges",""
"Mgh Known Familiar Mutation","PX-31000237","CDM","81479","CPT","0310","RC","","","","outpatient","","","1071.00","803.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","562.28","52.5","","1.00","0.53","1.00","1 through 10","156.55","883.58","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Lamb's Quarters Ige 86003","PX-30002193","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Lambert Eaton Syn Panel 1b","PX-30001647","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","298.48","65.6","","298.56","298.56","298.56","1 through 10","141.05","361.73","percent of total billed charges",""
"Mgh Lambert Eaton Syn Panel 1b","PX-30001647","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","295.75","65","","286.65","286.65","347.07","11","141.05","361.73","percent of total billed charges",""
"Mgh Lambert Eaton Syn Panel 1b","PX-30001647","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","318.50","70","","317.52","189.63","317.52","1 through 10","141.05","361.73","percent of total billed charges",""
"Mgh Lambert Eaton Syn Panel 1b","PX-30001647","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","295.75","65","","286.65","270.40","286.65","12","141.05","361.73","percent of total billed charges",""
"Mgh Lambert Eaton Syn Panel 1b","PX-30001647","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","295.75","65","","286.65","286.65","286.65","1 through 10","141.05","361.73","percent of total billed charges",""
"Mgh Lambert Eaton Syn Panel 1b","PX-30001647","CDM","86849","CPT","0302","RC","","","","both","","","455.00","341.25","WELLPOINT [1015]","HB AMC WELLPOINT","335.70","73.78","","328.32","306.01","328.32","1 through 10","141.05","361.73","percent of total billed charges",""
"Mgh Lambert Eaton Syn Panel 1b","PX-30001647","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","298.56","298.56","343.98","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh Lambert Eaton Syn Panel 1b","PX-30001647","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA PPO","365.82","80.4","","343.98","343.98","343.98","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh Lambert Eaton Syn Panel 1b","PX-30001647","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","227.50","50","","441.00","441.00","441.00","12","227.5","375.38","percent of total billed charges",""
"Mgh Lambert Eaton Syn Panel 1b","PX-30001647","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","238.88","52.5","","441.00","441.00","441.00","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh Lambert Eaton Syn Panel 1b","PX-30001647","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","250.25","55","","254.02","254.02","254.02","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh Lambert Eaton Syn Panel 1b","PX-30001647","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","365.82","80.4","","343.98","343.98","343.98","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh Lambert Eaton Syn Panel 1b","PX-30001647","CDM","86849","CPT","0302","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","284.38","62.5","","288.86","277.39","288.86","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh Larsen Syndrome, Autosomal Dominant (Lrs1)","PX-31000525","CDM","81479","CPT","0310","RC","","","","both","","","4112.00","3084.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3269.04","79.5","","0.65","0.65","0.65","1 through 10","1274.72","3906.4","percent of total billed charges",""
"Mgh Larsen Syndrome, Autosomal Dominant (Lrs1)","PX-31000525","CDM","81479","CPT","0310","RC","","","","both","","","4112.00","3084.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2191.70","53.3","","0.79","0.79","0.79","1 through 10","1274.72","3906.4","percent of total billed charges",""
"Mgh Larsen Syndrome, Autosomal Dominant (Lrs1)","PX-31000525","CDM","81479","CPT","0310","RC","","","","outpatient","","","4112.00","3084.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2056.00","50","","1.00","1.00","1.00","1 through 10","156.55","3392.4","percent of total billed charges",""
"Mgh Larsen Syndrome, Autosomal Dominant (Lrs1)","PX-31000525","CDM","81479","CPT","0310","RC","","","","outpatient","","","4112.00","3084.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2158.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","3392.4","percent of total billed charges",""
"Mgh Larsen Syndrome, Autosomal Dominant (Lrs1)","PX-31000537","CDM","81479","CPT","0310","RC","","","","both","","","4112.00","3084.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3269.04","79.5","","0.65","0.65","0.65","1 through 10","1274.72","3906.4","percent of total billed charges",""
"Mgh Larsen Syndrome, Autosomal Dominant (Lrs1)","PX-31000537","CDM","81479","CPT","0310","RC","","","","both","","","4112.00","3084.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2191.70","53.3","","0.79","0.79","0.79","1 through 10","1274.72","3906.4","percent of total billed charges",""
"Mgh Larsen Syndrome, Autosomal Dominant (Lrs1)","PX-31000537","CDM","81479","CPT","0310","RC","","","","outpatient","","","4112.00","3084.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2056.00","50","","1.00","1.00","1.00","1 through 10","156.55","3392.4","percent of total billed charges",""
"Mgh Larsen Syndrome, Autosomal Dominant (Lrs1)","PX-31000537","CDM","81479","CPT","0310","RC","","","","outpatient","","","4112.00","3084.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2158.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","3392.4","percent of total billed charges",""
"Mgh Laser Treatment","PX-36000197","CDM","31599","CPT","0361","RC","","","","outpatient","","","3729.00","2796.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1947.28","52.22","","551.84","275.91","28155.00","1 through 10","1491.6","3047.34","percent of total billed charges",""
"Mgh Laser Treatment","PX-36000197","CDM","31599","CPT","0361","RC","","","","outpatient","","","3729.00","2796.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3047.34","81.72","","14421.58","14421.58","14421.58","1 through 10","1491.6","3047.34","percent of total billed charges",""
"Mgh Late Onset Hsan Eval","PX-31000247","CDM","81479","CPT","0310","RC","","","","both","","","3358.00","2518.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2669.61","79.5","","0.65","0.65","0.65","1 through 10","1040.98","3190.1","percent of total billed charges",""
"Mgh Late Onset Hsan Eval","PX-31000247","CDM","81479","CPT","0310","RC","","","","both","","","3358.00","2518.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1789.81","53.3","","0.79","0.79","0.79","1 through 10","1040.98","3190.1","percent of total billed charges",""
"Mgh Late Onset Hsan Eval","PX-31000247","CDM","81479","CPT","0310","RC","","","","outpatient","","","3358.00","2518.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1679.00","50","","1.00","1.00","1.00","1 through 10","156.55","2770.35","percent of total billed charges",""
"Mgh Late Onset Hsan Eval","PX-31000247","CDM","81479","CPT","0310","RC","","","","outpatient","","","3358.00","2518.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1762.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","2770.35","percent of total billed charges",""
"Mgh Late Onset Hsan Eval Part II","PX-31000248","CDM","81479","CPT","0310","RC","","","","both","","","3358.00","2518.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2669.61","79.5","","0.65","0.65","0.65","1 through 10","1040.98","3190.1","percent of total billed charges",""
"Mgh Late Onset Hsan Eval Part II","PX-31000248","CDM","81479","CPT","0310","RC","","","","both","","","3358.00","2518.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1789.81","53.3","","0.79","0.79","0.79","1 through 10","1040.98","3190.1","percent of total billed charges",""
"Mgh Late Onset Hsan Eval Part II","PX-31000248","CDM","81479","CPT","0310","RC","","","","outpatient","","","3358.00","2518.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1679.00","50","","1.00","1.00","1.00","1 through 10","156.55","2770.35","percent of total billed charges",""
"Mgh Late Onset Hsan Eval Part II","PX-31000248","CDM","81479","CPT","0310","RC","","","","outpatient","","","3358.00","2518.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1762.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","2770.35","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Latex Rast","PX-30002200","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Latex Rast","PX-30002204","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Laukodystrophy Seq 39 Genes","PX-31000300","CDM","81479","CPT","0310","RC","","","","both","","","7439.00","5579.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5914.01","79.5","","0.65","0.65","0.65","1 through 10","2306.09","7067.05","percent of total billed charges",""
"Mgh Laukodystrophy Seq 39 Genes","PX-31000300","CDM","81479","CPT","0310","RC","","","","both","","","7439.00","5579.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3964.99","53.3","","0.79","0.79","0.79","1 through 10","2306.09","7067.05","percent of total billed charges",""
"Mgh Laukodystrophy Seq 39 Genes","PX-31000300","CDM","81479","CPT","0310","RC","","","","outpatient","","","7439.00","5579.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3719.50","50","","1.00","1.00","1.00","1 through 10","156.55","6137.18","percent of total billed charges",""
"Mgh Laukodystrophy Seq 39 Genes","PX-31000300","CDM","81479","CPT","0310","RC","","","","outpatient","","","7439.00","5579.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3905.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","6137.18","percent of total billed charges",""
"Mgh Laukodystrophy Seq 52 Genes","PX-31000297","CDM","81479","CPT","0310","RC","","","","both","","","6845.00","5133.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5441.78","79.5","","0.65","0.65","0.65","1 through 10","2121.95","6502.75","percent of total billed charges",""
"Mgh Laukodystrophy Seq 52 Genes","PX-31000297","CDM","81479","CPT","0310","RC","","","","both","","","6845.00","5133.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3648.39","53.3","","0.79","0.79","0.79","1 through 10","2121.95","6502.75","percent of total billed charges",""
"Mgh Laukodystrophy Seq 52 Genes","PX-31000297","CDM","81479","CPT","0310","RC","","","","outpatient","","","6845.00","5133.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3422.50","50","","1.00","1.00","1.00","1 through 10","156.55","5647.13","percent of total billed charges",""
"Mgh Laukodystrophy Seq 52 Genes","PX-31000297","CDM","81479","CPT","0310","RC","","","","outpatient","","","6845.00","5133.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3593.63","52.5","","1.00","0.53","1.00","1 through 10","156.55","5647.13","percent of total billed charges",""
"Mgh Laukodystrophy Seq 84 Genes","PX-31000293","CDM","81479","CPT","0310","RC","","","","both","","","7439.00","5579.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5914.01","79.5","","0.65","0.65","0.65","1 through 10","2306.09","7067.05","percent of total billed charges",""
"Mgh Laukodystrophy Seq 84 Genes","PX-31000293","CDM","81479","CPT","0310","RC","","","","both","","","7439.00","5579.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3964.99","53.3","","0.79","0.79","0.79","1 through 10","2306.09","7067.05","percent of total billed charges",""
"Mgh Laukodystrophy Seq 84 Genes","PX-31000293","CDM","81479","CPT","0310","RC","","","","outpatient","","","7439.00","5579.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3719.50","50","","1.00","1.00","1.00","1 through 10","156.55","6137.18","percent of total billed charges",""
"Mgh Laukodystrophy Seq 84 Genes","PX-31000293","CDM","81479","CPT","0310","RC","","","","outpatient","","","7439.00","5579.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3905.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","6137.18","percent of total billed charges",""
"Mgh Lds3 Gene Sequencing","PX-31000470","CDM","81479","CPT","0310","RC","","","","both","","","1994.00","1495.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1585.23","79.5","","0.65","0.65","0.65","1 through 10","618.14","1894.3","percent of total billed charges",""
"Mgh Lds3 Gene Sequencing","PX-31000470","CDM","81479","CPT","0310","RC","","","","both","","","1994.00","1495.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1062.80","53.3","","0.79","0.79","0.79","1 through 10","618.14","1894.3","percent of total billed charges",""
"Mgh Lds3 Gene Sequencing","PX-31000470","CDM","81479","CPT","0310","RC","","","","outpatient","","","1994.00","1495.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","997.00","50","","1.00","1.00","1.00","1 through 10","156.55","1645.05","percent of total billed charges",""
"Mgh Lds3 Gene Sequencing","PX-31000470","CDM","81479","CPT","0310","RC","","","","outpatient","","","1994.00","1495.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1046.85","52.5","","1.00","0.53","1.00","1 through 10","156.55","1645.05","percent of total billed charges",""
"Mgh Leflunomide","PX-30001972","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Leflunomide","PX-30001972","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Leflunomide","PX-30001972","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Leflunomide","PX-30001972","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Leflunomide","PX-30001972","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Leflunomide","PX-30001972","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Leflunomide","PX-30001972","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Leflunomide","PX-30001972","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Leflunomide","PX-30001972","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Leflunomide","PX-30001982","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Leflunomide","PX-30001982","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Leflunomide","PX-30001982","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Leflunomide","PX-30001982","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Leflunomide","PX-30001982","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Leflunomide","PX-30001982","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Leflunomide","PX-30001982","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Leflunomide","PX-30001982","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Leflunomide","PX-30001982","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Lemd3 Del/Dup Analysis","PX-31000467","CDM","81479","CPT","0310","RC","","","","both","","","3572.00","2679.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2839.74","79.5","","0.65","0.65","0.65","1 through 10","1107.32","3393.4","percent of total billed charges",""
"Mgh Lemd3 Del/Dup Analysis","PX-31000467","CDM","81479","CPT","0310","RC","","","","both","","","3572.00","2679.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1903.88","53.3","","0.79","0.79","0.79","1 through 10","1107.32","3393.4","percent of total billed charges",""
"Mgh Lemd3 Del/Dup Analysis","PX-31000467","CDM","81479","CPT","0310","RC","","","","outpatient","","","3572.00","2679.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1786.00","50","","1.00","1.00","1.00","1 through 10","156.55","2946.9","percent of total billed charges",""
"Mgh Lemd3 Del/Dup Analysis","PX-31000467","CDM","81479","CPT","0310","RC","","","","outpatient","","","3572.00","2679.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1875.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","2946.9","percent of total billed charges",""
"Mgh Lep Sequence Analysis","PX-31000465","CDM","81479","CPT","0310","RC","","","","both","","","923.00","692.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","733.79","79.5","","0.65","0.65","0.65","1 through 10","286.13","876.85","percent of total billed charges",""
"Mgh Lep Sequence Analysis","PX-31000465","CDM","81479","CPT","0310","RC","","","","both","","","923.00","692.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","491.96","53.3","","0.79","0.79","0.79","1 through 10","286.13","876.85","percent of total billed charges",""
"Mgh Lep Sequence Analysis","PX-31000465","CDM","81479","CPT","0310","RC","","","","outpatient","","","923.00","692.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","461.50","50","","1.00","1.00","1.00","1 through 10","156.55","761.48","percent of total billed charges",""
"Mgh Lep Sequence Analysis","PX-31000465","CDM","81479","CPT","0310","RC","","","","outpatient","","","923.00","692.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","484.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","761.48","percent of total billed charges",""
"Mgh Leukoencephalopathy With Vanishing White Matter","PX-31000628","CDM","81479","CPT","0310","RC","","","","both","","","1857.00","1392.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1476.32","79.5","","0.65","0.65","0.65","1 through 10","575.67","1764.15","percent of total billed charges",""
"Mgh Leukoencephalopathy With Vanishing White Matter","PX-31000628","CDM","81479","CPT","0310","RC","","","","both","","","1857.00","1392.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","989.78","53.3","","0.79","0.79","0.79","1 through 10","575.67","1764.15","percent of total billed charges",""
"Mgh Leukoencephalopathy With Vanishing White Matter","PX-31000628","CDM","81479","CPT","0310","RC","","","","outpatient","","","1857.00","1392.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","928.50","50","","1.00","1.00","1.00","1 through 10","156.55","1532.03","percent of total billed charges",""
"Mgh Leukoencephalopathy With Vanishing White Matter","PX-31000628","CDM","81479","CPT","0310","RC","","","","outpatient","","","1857.00","1392.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","974.93","52.5","","1.00","0.53","1.00","1 through 10","156.55","1532.03","percent of total billed charges",""
"Mgh Levetiracetam","PX-30001543","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Levetiracetam","PX-30001543","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Levetiracetam","PX-30001543","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Levetiracetam","PX-30001543","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Levetiracetam","PX-30001543","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Levetiracetam","PX-30001543","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Levetiracetam","PX-30001543","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Levofloxacin","PX-30003654","CDM","80299","CPT","0300","RC","","","","both","","","147.00","110.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.87","79.5","","106.25","71.28","106.25","1 through 10","14.12","139.65","percent of total billed charges",""
"Mgh Levofloxacin","PX-30003654","CDM","80299","CPT","0300","RC","","","","both","","","147.00","110.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.35","53.3","","106.25","71.28","106.25","1 through 10","14.12","139.65","percent of total billed charges",""
"Mgh Levofloxacin","PX-30003654","CDM","80299","CPT","0300","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.66","36.5","","50.36","42.80","92.50","13","14.12","139.65","percent of total billed charges",""
"Mgh Levofloxacin","PX-30003654","CDM","80299","CPT","0300","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.30","38.3","","52.79","44.55","158.37","30","14.12","139.65","percent of total billed charges",""
"Mgh Levofloxacin","PX-30003654","CDM","80299","CPT","0300","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA HMO","102.61","69.8","","91.40","64.53","105.30","14","14.12","120.13","percent of total billed charges",""
"Mgh Levofloxacin","PX-30003654","CDM","80299","CPT","0300","RC","","","","outpatient","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","118.19","80.4","","105.30","105.30","105.30","1 through 10","14.12","120.13","percent of total billed charges",""
"Mgh Levofloxacin","PX-30003654","CDM","80299","CPT","0300","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","120.13","81.72","","59.36","15.50","59.36","1 through 10","14.12","120.13","percent of total billed charges",""
"Mgh Linezolid","PX-31000849","CDM","80299","CPT","0310","RC","","","","both","","","134.00","100.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","106.53","79.5","","106.25","71.28","106.25","1 through 10","18.27","127.3","percent of total billed charges",""
"Mgh Linezolid","PX-31000849","CDM","80299","CPT","0310","RC","","","","both","","","134.00","100.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","71.42","53.3","","106.25","71.28","106.25","1 through 10","18.27","127.3","percent of total billed charges",""
"Mgh Linezolid","PX-31000849","CDM","80299","CPT","0310","RC","","","","both","","","134.00","100.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.91","36.5","","50.36","42.80","92.50","13","18.27","127.3","percent of total billed charges",""
"Mgh Linezolid","PX-31000849","CDM","80299","CPT","0310","RC","","","","both","","","134.00","100.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","51.32","38.3","","52.79","44.55","158.37","30","18.27","127.3","percent of total billed charges",""
"Mgh Linezolid","PX-31000849","CDM","80299","CPT","0310","RC","","","","outpatient","","","134.00","100.50","AETNA [1001]","HB AMC AETNA HMO","93.53","69.8","","91.40","64.53","105.30","14","53.62","114.26","percent of total billed charges",""
"Mgh Linezolid","PX-31000849","CDM","80299","CPT","0310","RC","","","","outpatient","","","134.00","100.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","107.74","80.4","","105.30","105.30","105.30","1 through 10","53.62","114.26","percent of total billed charges",""
"Mgh Linezolid","PX-31000849","CDM","80299","CPT","0310","RC","","","","outpatient","","","134.00","100.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","109.50","81.72","","59.36","15.50","59.36","1 through 10","53.62","114.26","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Lipoprot Assoc Phospholip A2","PX-30002051","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Lipprot Asoc Phospholip A2","PX-30002082","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Lpin1 Sanger Sequencing","PX-31000291","CDM","81479","CPT","0310","RC","","","","both","","","3215.00","2411.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2555.93","79.5","","0.65","0.65","0.65","1 through 10","996.65","3054.25","percent of total billed charges",""
"Mgh Lpin1 Sanger Sequencing","PX-31000291","CDM","81479","CPT","0310","RC","","","","both","","","3215.00","2411.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1713.60","53.3","","0.79","0.79","0.79","1 through 10","996.65","3054.25","percent of total billed charges",""
"Mgh Lpin1 Sanger Sequencing","PX-31000291","CDM","81479","CPT","0310","RC","","","","outpatient","","","3215.00","2411.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1607.50","50","","1.00","1.00","1.00","1 through 10","156.55","2652.38","percent of total billed charges",""
"Mgh Lpin1 Sanger Sequencing","PX-31000291","CDM","81479","CPT","0310","RC","","","","outpatient","","","3215.00","2411.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1687.88","52.5","","1.00","0.53","1.00","1 through 10","156.55","2652.38","percent of total billed charges",""
"Mgh Lsd Confirmation, Urine","PX-31000512","CDM","80299","CPT","0310","RC","","","","both","","","233.00","174.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","185.24","79.5","","106.25","71.28","106.25","1 through 10","18.27","221.35","percent of total billed charges",""
"Mgh Lsd Confirmation, Urine","PX-31000512","CDM","80299","CPT","0310","RC","","","","both","","","233.00","174.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.19","53.3","","106.25","71.28","106.25","1 through 10","18.27","221.35","percent of total billed charges",""
"Mgh Lsd Confirmation, Urine","PX-31000512","CDM","80299","CPT","0310","RC","","","","both","","","233.00","174.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.05","36.5","","50.36","42.80","92.50","13","18.27","221.35","percent of total billed charges",""
"Mgh Lsd Confirmation, Urine","PX-31000512","CDM","80299","CPT","0310","RC","","","","both","","","233.00","174.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.24","38.3","","52.79","44.55","158.37","30","18.27","221.35","percent of total billed charges",""
"Mgh Lsd Confirmation, Urine","PX-31000512","CDM","80299","CPT","0310","RC","","","","outpatient","","","233.00","174.75","AETNA [1001]","HB AMC AETNA HMO","162.63","69.8","","91.40","64.53","105.30","14","53.62","190.41","percent of total billed charges",""
"Mgh Lsd Confirmation, Urine","PX-31000512","CDM","80299","CPT","0310","RC","","","","outpatient","","","233.00","174.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","187.33","80.4","","105.30","105.30","105.30","1 through 10","53.62","190.41","percent of total billed charges",""
"Mgh Lsd Confirmation, Urine","PX-31000512","CDM","80299","CPT","0310","RC","","","","outpatient","","","233.00","174.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","190.41","81.72","","59.36","15.50","59.36","1 through 10","53.62","190.41","percent of total billed charges",""
"Mgh Ludiomil","PX-30001563","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Ludiomil","PX-30001563","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Ludiomil","PX-30001563","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Ludiomil","PX-30001563","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Ludiomil","PX-30001563","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Ludiomil","PX-30001563","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Ludiomil","PX-30001563","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Lymphoma Assay on CSF","PX-31000480","CDM","81479","CPT","0310","RC","","","","both","","","1892.00","1419.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1504.14","79.5","","0.65","0.65","0.65","1 through 10","586.52","1797.4","percent of total billed charges",""
"Mgh Lymphoma Assay on CSF","PX-31000480","CDM","81479","CPT","0310","RC","","","","both","","","1892.00","1419.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1008.44","53.3","","0.79","0.79","0.79","1 through 10","586.52","1797.4","percent of total billed charges",""
"Mgh Lymphoma Assay on CSF","PX-31000480","CDM","81479","CPT","0310","RC","","","","outpatient","","","1892.00","1419.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","946.00","50","","1.00","1.00","1.00","1 through 10","156.55","1560.9","percent of total billed charges",""
"Mgh Lymphoma Assay on CSF","PX-31000480","CDM","81479","CPT","0310","RC","","","","outpatient","","","1892.00","1419.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","993.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","1560.9","percent of total billed charges",""
"Mgh Lysosomal Enzyme Scr","PX-30002003","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Lysosomal Enzyme Scr","PX-30002003","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Lysosomal Enzyme Scr","PX-30002013","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Lysosomal Enzyme Scr","PX-30002013","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II","PX-30002029","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mag Dual Antigen Part II 83520","PX-30002033","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Malignant Hyperthermia Susceptibility Nextgen Seq (Ngs) Panel","PX-31000622","CDM","81479","CPT","0301","RC","","","","both","","","955.00","716.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","759.23","79.5","","0.65","0.65","0.65","1 through 10","296.05","907.25","percent of total billed charges",""
"Mgh Malignant Hyperthermia Susceptibility Nextgen Seq (Ngs) Panel","PX-31000622","CDM","81479","CPT","0301","RC","","","","both","","","955.00","716.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","509.02","53.3","","0.79","0.79","0.79","1 through 10","296.05","907.25","percent of total billed charges",""
"Mgh Malignant Hyperthermia Susceptibility Nextgen Seq (Ngs) Panel","PX-31000622","CDM","81479","CPT","0301","RC","","","","outpatient","","","955.00","716.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","477.50","50","","1.00","1.00","1.00","1 through 10","156.55","787.88","percent of total billed charges",""
"Mgh Malignant Hyperthermia Susceptibility Nextgen Seq (Ngs) Panel","PX-31000622","CDM","81479","CPT","0301","RC","","","","outpatient","","","955.00","716.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","501.38","52.5","","1.00","0.53","1.00","1 through 10","156.55","787.88","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002052","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Lectin","PX-30002083","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002090","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Marfan, Loeys-Dietz Panel","PX-31000509","CDM","81479","CPT","0310","RC","","","","both","","","198.00","148.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","157.41","79.5","","0.65","0.65","0.65","1 through 10","61.38","188.1","percent of total billed charges",""
"Mgh Marfan, Loeys-Dietz Panel","PX-31000509","CDM","81479","CPT","0310","RC","","","","both","","","198.00","148.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","105.53","53.3","","0.79","0.79","0.79","1 through 10","61.38","188.1","percent of total billed charges",""
"Mgh Marfan, Loeys-Dietz Panel","PX-31000509","CDM","81479","CPT","0310","RC","","","","outpatient","","","198.00","148.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","99.00","50","","1.00","1.00","1.00","1 through 10","95.83","163.35","percent of total billed charges",""
"Mgh Marfan, Loeys-Dietz Panel","PX-31000509","CDM","81479","CPT","0310","RC","","","","outpatient","","","198.00","148.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","103.95","52.5","","1.00","0.53","1.00","1 through 10","95.83","163.35","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002111","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002111","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002111","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002111","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002111","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002111","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002111","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002117","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002117","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002117","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002117","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002117","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002117","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Mas Spctndm Mas Spectanal Quan","PX-30002117","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Mcals Mccune Albright Syndrome Mas St Francis","PX-31000645","CDM","81479","CPT","0310","RC","","","","both","","","1122.00","841.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","891.99","79.5","","0.65","0.65","0.65","1 through 10","347.82","1065.9","percent of total billed charges",""
"Mgh Mcals Mccune Albright Syndrome Mas St Francis","PX-31000645","CDM","81479","CPT","0310","RC","","","","both","","","1122.00","841.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","598.03","53.3","","0.79","0.79","0.79","1 through 10","347.82","1065.9","percent of total billed charges",""
"Mgh Mcals Mccune Albright Syndrome Mas St Francis","PX-31000645","CDM","81479","CPT","0310","RC","","","","outpatient","","","1122.00","841.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","561.00","50","","1.00","1.00","1.00","1 through 10","156.55","925.65","percent of total billed charges",""
"Mgh Mcals Mccune Albright Syndrome Mas St Francis","PX-31000645","CDM","81479","CPT","0310","RC","","","","outpatient","","","1122.00","841.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","589.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","925.65","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Mec a Gene for Pcr","PX-30002302","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Med12 Sanger Sequencing","PX-31000298","CDM","81479","CPT","0310","RC","","","","both","","","5507.00","4130.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4378.07","79.5","","0.65","0.65","0.65","1 through 10","1707.17","5231.65","percent of total billed charges",""
"Mgh Med12 Sanger Sequencing","PX-31000298","CDM","81479","CPT","0310","RC","","","","both","","","5507.00","4130.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2935.23","53.3","","0.79","0.79","0.79","1 through 10","1707.17","5231.65","percent of total billed charges",""
"Mgh Med12 Sanger Sequencing","PX-31000298","CDM","81479","CPT","0310","RC","","","","outpatient","","","5507.00","4130.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2753.50","50","","1.00","1.00","1.00","1 through 10","156.55","4543.28","percent of total billed charges",""
"Mgh Med12 Sanger Sequencing","PX-31000298","CDM","81479","CPT","0310","RC","","","","outpatient","","","5507.00","4130.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2891.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","4543.28","percent of total billed charges",""
"Mgh Meningiomatosis/Multiple Meningioma Ngs Panel (Men-Ng)","PX-30003416","CDM","81479","CPT","0310","RC","","","","both","","","1037.00","777.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","824.42","79.5","","0.65","0.65","0.65","1 through 10","321.47","985.15","percent of total billed charges",""
"Mgh Meningiomatosis/Multiple Meningioma Ngs Panel (Men-Ng)","PX-30003416","CDM","81479","CPT","0310","RC","","","","both","","","1037.00","777.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","552.72","53.3","","0.79","0.79","0.79","1 through 10","321.47","985.15","percent of total billed charges",""
"Mgh Meningiomatosis/Multiple Meningioma Ngs Panel (Men-Ng)","PX-30003416","CDM","81479","CPT","0310","RC","","","","outpatient","","","1037.00","777.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","518.50","50","","1.00","1.00","1.00","1 through 10","156.55","855.53","percent of total billed charges",""
"Mgh Meningiomatosis/Multiple Meningioma Ngs Panel (Men-Ng)","PX-30003416","CDM","81479","CPT","0310","RC","","","","outpatient","","","1037.00","777.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","544.43","52.5","","1.00","0.53","1.00","1 through 10","156.55","855.53","percent of total billed charges",""
"Mgh Meningiomatosis/Multiple Meningiomas Panel by Ngs","PX-30003436","CDM","81479","CPT","0310","RC","","","","both","","","542.00","406.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","430.89","79.5","","0.65","0.65","0.65","1 through 10","168.02","514.9","percent of total billed charges",""
"Mgh Meningiomatosis/Multiple Meningiomas Panel by Ngs","PX-30003436","CDM","81479","CPT","0310","RC","","","","both","","","542.00","406.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","288.89","53.3","","0.79","0.79","0.79","1 through 10","168.02","514.9","percent of total billed charges",""
"Mgh Meningiomatosis/Multiple Meningiomas Panel by Ngs","PX-30003436","CDM","81479","CPT","0310","RC","","","","outpatient","","","542.00","406.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","271.00","50","","1.00","1.00","1.00","1 through 10","156.55","447.15","percent of total billed charges",""
"Mgh Meningiomatosis/Multiple Meningiomas Panel by Ngs","PX-30003436","CDM","81479","CPT","0310","RC","","","","outpatient","","","542.00","406.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","284.55","52.5","","1.00","0.53","1.00","1 through 10","156.55","447.15","percent of total billed charges",""
"Mgh Meningiomatosis/Multiple Meningiomas Panel by Ngs (91)","PX-30003437","CDM","81479","CPT","0310","RC","","","","both","","","496.00","372.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","394.32","79.5","","0.65","0.65","0.65","1 through 10","153.76","471.2","percent of total billed charges",""
"Mgh Meningiomatosis/Multiple Meningiomas Panel by Ngs (91)","PX-30003437","CDM","81479","CPT","0310","RC","","","","both","","","496.00","372.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","264.37","53.3","","0.79","0.79","0.79","1 through 10","153.76","471.2","percent of total billed charges",""
"Mgh Meningiomatosis/Multiple Meningiomas Panel by Ngs (91)","PX-30003437","CDM","81479","CPT","0310","RC","","","","outpatient","","","496.00","372.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","248.00","50","","1.00","1.00","1.00","1 through 10","156.55","409.2","percent of total billed charges",""
"Mgh Meningiomatosis/Multiple Meningiomas Panel by Ngs (91)","PX-30003437","CDM","81479","CPT","0310","RC","","","","outpatient","","","496.00","372.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","260.40","52.5","","1.00","0.53","1.00","1 through 10","156.55","409.2","percent of total billed charges",""
"Mgh Meox1 Gene","PX-31000369","CDM","81479","CPT","0310","RC","","","","both","","","1815.00","1361.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1442.93","79.5","","0.65","0.65","0.65","1 through 10","562.65","1724.25","percent of total billed charges",""
"Mgh Meox1 Gene","PX-31000369","CDM","81479","CPT","0310","RC","","","","both","","","1815.00","1361.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","967.40","53.3","","0.79","0.79","0.79","1 through 10","562.65","1724.25","percent of total billed charges",""
"Mgh Meox1 Gene","PX-31000369","CDM","81479","CPT","0310","RC","","","","outpatient","","","1815.00","1361.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","907.50","50","","1.00","1.00","1.00","1 through 10","156.55","1497.38","percent of total billed charges",""
"Mgh Meox1 Gene","PX-31000369","CDM","81479","CPT","0310","RC","","","","outpatient","","","1815.00","1361.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","952.88","52.5","","1.00","0.53","1.00","1 through 10","156.55","1497.38","percent of total billed charges",""
"Mgh Mephenytoin 80299","PX-30001569","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Mephenytoin 80299","PX-30001569","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Mephenytoin 80299","PX-30001569","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Mephenytoin 80299","PX-30001569","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Mephenytoin 80299","PX-30001569","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Mephenytoin 80299","PX-30001569","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Mephenytoin 80299","PX-30001569","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Mertazapine Remeron","PX-30001544","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Mertazapine Remeron","PX-30001544","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Mertazapine Remeron","PX-30001544","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Mertazapine Remeron","PX-30001544","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Mertazapine Remeron","PX-30001544","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Mertazapine Remeron","PX-30001544","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Mertazapine Remeron","PX-30001544","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Metabolism Related Disorders Panel, Sequencing and Delete/Dup","PX-31000653","CDM","81479","CPT","0310","RC","","","","both","","","519.00","389.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","412.61","79.5","","0.65","0.65","0.65","1 through 10","160.89","493.05","percent of total billed charges",""
"Mgh Metabolism Related Disorders Panel, Sequencing and Delete/Dup","PX-31000653","CDM","81479","CPT","0310","RC","","","","both","","","519.00","389.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","276.63","53.3","","0.79","0.79","0.79","1 through 10","160.89","493.05","percent of total billed charges",""
"Mgh Metabolism Related Disorders Panel, Sequencing and Delete/Dup","PX-31000653","CDM","81479","CPT","0310","RC","","","","outpatient","","","519.00","389.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","259.50","50","","1.00","1.00","1.00","1 through 10","156.55","428.18","percent of total billed charges",""
"Mgh Metabolism Related Disorders Panel, Sequencing and Delete/Dup","PX-31000653","CDM","81479","CPT","0310","RC","","","","outpatient","","","519.00","389.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","272.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","428.18","percent of total billed charges",""
"Mgh Metachromatic Leukodystrophy: Arsa","PX-31000558","CDM","81479","CPT","0310","RC","","","","both","","","1265.00","948.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1005.68","79.5","","0.65","0.65","0.65","1 through 10","392.15","1201.75","percent of total billed charges",""
"Mgh Metachromatic Leukodystrophy: Arsa","PX-31000558","CDM","81479","CPT","0310","RC","","","","both","","","1265.00","948.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","674.25","53.3","","0.79","0.79","0.79","1 through 10","392.15","1201.75","percent of total billed charges",""
"Mgh Metachromatic Leukodystrophy: Arsa","PX-31000558","CDM","81479","CPT","0310","RC","","","","outpatient","","","1265.00","948.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","632.50","50","","1.00","1.00","1.00","1 through 10","156.55","1043.63","percent of total billed charges",""
"Mgh Metachromatic Leukodystrophy: Arsa","PX-31000558","CDM","81479","CPT","0310","RC","","","","outpatient","","","1265.00","948.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","664.13","52.5","","1.00","0.53","1.00","1 through 10","156.55","1043.63","percent of total billed charges",""
"Mgh Methotrexate","PX-30001533","CDM","80299","CPT","0301","RC","","","","both","","","376.00","282.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","298.92","79.5","","106.25","71.28","106.25","1 through 10","14.12","357.2","percent of total billed charges",""
"Mgh Methotrexate","PX-30001533","CDM","80299","CPT","0301","RC","","","","both","","","376.00","282.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","200.41","53.3","","106.25","71.28","106.25","1 through 10","14.12","357.2","percent of total billed charges",""
"Mgh Methotrexate","PX-30001533","CDM","80299","CPT","0301","RC","","","","both","","","376.00","282.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","137.24","36.5","","50.36","42.80","92.50","13","14.12","357.2","percent of total billed charges",""
"Mgh Methotrexate","PX-30001533","CDM","80299","CPT","0301","RC","","","","both","","","376.00","282.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","144.01","38.3","","52.79","44.55","158.37","30","14.12","357.2","percent of total billed charges",""
"Mgh Methotrexate","PX-30001533","CDM","80299","CPT","0301","RC","","","","outpatient","","","376.00","282.00","AETNA [1001]","HB AMC AETNA HMO","262.45","69.8","","91.40","64.53","105.30","14","14.12","307.27","percent of total billed charges",""
"Mgh Methotrexate","PX-30001533","CDM","80299","CPT","0301","RC","","","","outpatient","","","376.00","282.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","302.30","80.4","","105.30","105.30","105.30","1 through 10","14.12","307.27","percent of total billed charges",""
"Mgh Methotrexate","PX-30001533","CDM","80299","CPT","0301","RC","","","","outpatient","","","376.00","282.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","307.27","81.72","","59.36","15.50","59.36","1 through 10","14.12","307.27","percent of total billed charges",""
"Mgh Methotrexate 80299","PX-30001570","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Methotrexate 80299","PX-30001570","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Methotrexate 80299","PX-30001570","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Methotrexate 80299","PX-30001570","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Methotrexate 80299","PX-30001570","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Methotrexate 80299","PX-30001570","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Methotrexate 80299","PX-30001570","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Methylmalonic Acid Analysis","PX-30001878","CDM","84311","CPT","0300","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Methylmalonic Acid Analysis","PX-30001878","CDM","84311","CPT","0300","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Methylmalonic Acid Analysis","PX-30001878","CDM","84311","CPT","0300","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Methylmalonic Acid Analysis","PX-30001879","CDM","84311","CPT","0300","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Methylmalonic Acid Analysis","PX-30001879","CDM","84311","CPT","0300","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Methylmalonic Acid Analysis","PX-30001879","CDM","84311","CPT","0300","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001970","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001970","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001970","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001970","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001970","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001970","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001970","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001970","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001970","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001980","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001980","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001980","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001980","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001980","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001980","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001980","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001980","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Methylphenidate","PX-30001980","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Mexilitine Level 80299","PX-30001571","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Mexilitine Level 80299","PX-30001571","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Mexilitine Level 80299","PX-30001571","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Mexilitine Level 80299","PX-30001571","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Mexilitine Level 80299","PX-30001571","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Mexilitine Level 80299","PX-30001571","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Mexilitine Level 80299","PX-30001571","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Mhpg 80299","PX-30001572","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Mhpg 80299","PX-30001572","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Mhpg 80299","PX-30001572","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Mhpg 80299","PX-30001572","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Mhpg 80299","PX-30001572","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Mhpg 80299","PX-30001572","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Mhpg 80299","PX-30001572","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Mito Dna Parallel Sequencing","PX-30001781","CDM","81479","CPT","0301","RC","","","","both","","","6188.00","4641.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4919.46","79.5","","0.65","0.65","0.65","1 through 10","1918.28","5878.6","percent of total billed charges",""
"Mgh Mito Dna Parallel Sequencing","PX-30001781","CDM","81479","CPT","0301","RC","","","","both","","","6188.00","4641.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3298.20","53.3","","0.79","0.79","0.79","1 through 10","1918.28","5878.6","percent of total billed charges",""
"Mgh Mito Dna Parallel Sequencing","PX-30001781","CDM","81479","CPT","0301","RC","","","","outpatient","","","6188.00","4641.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3094.00","50","","1.00","1.00","1.00","1 through 10","156.55","5105.1","percent of total billed charges",""
"Mgh Mito Dna Parallel Sequencing","PX-30001781","CDM","81479","CPT","0301","RC","","","","outpatient","","","6188.00","4641.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3248.70","52.5","","1.00","0.53","1.00","1 through 10","156.55","5105.1","percent of total billed charges",""
"Mgh Mito Genome Seq&Del","PX-31000353","CDM","81479","CPT","0310","RC","","","","both","","","4464.00","3348.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3548.88","79.5","","0.65","0.65","0.65","1 through 10","1383.84","4240.8","percent of total billed charges",""
"Mgh Mito Genome Seq&Del","PX-31000353","CDM","81479","CPT","0310","RC","","","","both","","","4464.00","3348.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2379.31","53.3","","0.79","0.79","0.79","1 through 10","1383.84","4240.8","percent of total billed charges",""
"Mgh Mito Genome Seq&Del","PX-31000353","CDM","81479","CPT","0310","RC","","","","outpatient","","","4464.00","3348.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2232.00","50","","1.00","1.00","1.00","1 through 10","156.55","3682.8","percent of total billed charges",""
"Mgh Mito Genome Seq&Del","PX-31000353","CDM","81479","CPT","0310","RC","","","","outpatient","","","4464.00","3348.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2343.60","52.5","","1.00","0.53","1.00","1 through 10","156.55","3682.8","percent of total billed charges",""
"Mgh Mito. Enz. Defic. Pro","PX-30002156","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Mito. Enz. Defic. Pro","PX-30002156","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Mito. Enz. Defic. Pro","PX-30002156","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Mitochondria Respiratory Chain","PX-31000262","CDM","81479","CPT","0310","RC","","","","both","","","921.00","690.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","732.20","79.5","","0.65","0.65","0.65","1 through 10","285.51","874.95","percent of total billed charges",""
"Mgh Mitochondria Respiratory Chain","PX-31000262","CDM","81479","CPT","0310","RC","","","","both","","","921.00","690.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","490.89","53.3","","0.79","0.79","0.79","1 through 10","285.51","874.95","percent of total billed charges",""
"Mgh Mitochondria Respiratory Chain","PX-31000262","CDM","81479","CPT","0310","RC","","","","outpatient","","","921.00","690.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","460.50","50","","1.00","1.00","1.00","1 through 10","156.55","759.83","percent of total billed charges",""
"Mgh Mitochondria Respiratory Chain","PX-31000262","CDM","81479","CPT","0310","RC","","","","outpatient","","","921.00","690.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","483.53","52.5","","1.00","0.53","1.00","1 through 10","156.55","759.83","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Mitochondrial M2 Ab Igg","PX-30002053","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Mitomet Plus Acgh Analysis","PX-31000346","CDM","81479","CPT","0310","RC","","","","both","","","3572.00","2679.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2839.74","79.5","","0.65","0.65","0.65","1 through 10","1107.32","3393.4","percent of total billed charges",""
"Mgh Mitomet Plus Acgh Analysis","PX-31000346","CDM","81479","CPT","0310","RC","","","","both","","","3572.00","2679.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1903.88","53.3","","0.79","0.79","0.79","1 through 10","1107.32","3393.4","percent of total billed charges",""
"Mgh Mitomet Plus Acgh Analysis","PX-31000346","CDM","81479","CPT","0310","RC","","","","outpatient","","","3572.00","2679.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1786.00","50","","1.00","1.00","1.00","1 through 10","156.55","2946.9","percent of total billed charges",""
"Mgh Mitomet Plus Acgh Analysis","PX-31000346","CDM","81479","CPT","0310","RC","","","","outpatient","","","3572.00","2679.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1875.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","2946.9","percent of total billed charges",""
"Mgh Mng Non Mitochondrial Comprehensive Ophthalmoplegia Syndromes","PX-31001052","CDM","81479","CPT","0310","RC","","","","both","","","3148.00","2361.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2502.66","79.5","","0.65","0.65","0.65","1 through 10","975.88","2990.6","percent of total billed charges",""
"Mgh Mng Non Mitochondrial Comprehensive Ophthalmoplegia Syndromes","PX-31001052","CDM","81479","CPT","0310","RC","","","","both","","","3148.00","2361.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1677.88","53.3","","0.79","0.79","0.79","1 through 10","975.88","2990.6","percent of total billed charges",""
"Mgh Mng Non Mitochondrial Comprehensive Ophthalmoplegia Syndromes","PX-31001052","CDM","81479","CPT","0310","RC","","","","outpatient","","","3148.00","2361.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1574.00","50","","1.00","1.00","1.00","1 through 10","156.55","2597.1","percent of total billed charges",""
"Mgh Mng Non Mitochondrial Comprehensive Ophthalmoplegia Syndromes","PX-31001052","CDM","81479","CPT","0310","RC","","","","outpatient","","","3148.00","2361.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1652.70","52.5","","1.00","0.53","1.00","1 through 10","156.55","2597.1","percent of total billed charges",""
"Mgh Mpn, Calr Gene Mutation Analysis","PX-31000477","CDM","81479","CPT","0310","RC","","","","both","","","943.00","707.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","749.69","79.5","","0.65","0.65","0.65","1 through 10","292.33","895.85","percent of total billed charges",""
"Mgh Mpn, Calr Gene Mutation Analysis","PX-31000477","CDM","81479","CPT","0310","RC","","","","both","","","943.00","707.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","502.62","53.3","","0.79","0.79","0.79","1 through 10","292.33","895.85","percent of total billed charges",""
"Mgh Mpn, Calr Gene Mutation Analysis","PX-31000477","CDM","81479","CPT","0310","RC","","","","outpatient","","","943.00","707.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","471.50","50","","1.00","1.00","1.00","1 through 10","156.55","777.98","percent of total billed charges",""
"Mgh Mpn, Calr Gene Mutation Analysis","PX-31000477","CDM","81479","CPT","0310","RC","","","","outpatient","","","943.00","707.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","495.08","52.5","","1.00","0.53","1.00","1 through 10","156.55","777.98","percent of total billed charges",""
"Mgh Mtdna Point Mutations","PX-31000328","CDM","81479","CPT","0310","RC","","","","both","","","983.00","737.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","781.49","79.5","","0.65","0.65","0.65","1 through 10","304.73","933.85","percent of total billed charges",""
"Mgh Mtdna Point Mutations","PX-31000328","CDM","81479","CPT","0310","RC","","","","both","","","983.00","737.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","523.94","53.3","","0.79","0.79","0.79","1 through 10","304.73","933.85","percent of total billed charges",""
"Mgh Mtdna Point Mutations","PX-31000328","CDM","81479","CPT","0310","RC","","","","outpatient","","","983.00","737.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","491.50","50","","1.00","1.00","1.00","1 through 10","156.55","810.98","percent of total billed charges",""
"Mgh Mtdna Point Mutations","PX-31000328","CDM","81479","CPT","0310","RC","","","","outpatient","","","983.00","737.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","516.08","52.5","","1.00","0.53","1.00","1 through 10","156.55","810.98","percent of total billed charges",""
"Mgh Mucopolysaccharidosis Type Iiia","PX-30003370","CDM","81479","CPT","0310","RC","","","","both","","","1166.00","874.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","926.97","79.5","","0.65","0.65","0.65","1 through 10","361.46","1107.7","percent of total billed charges",""
"Mgh Mucopolysaccharidosis Type Iiia","PX-30003370","CDM","81479","CPT","0310","RC","","","","both","","","1166.00","874.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","621.48","53.3","","0.79","0.79","0.79","1 through 10","361.46","1107.7","percent of total billed charges",""
"Mgh Mucopolysaccharidosis Type Iiia","PX-30003370","CDM","81479","CPT","0310","RC","","","","outpatient","","","1166.00","874.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","583.00","50","","1.00","1.00","1.00","1 through 10","156.55","961.95","percent of total billed charges",""
"Mgh Mucopolysaccharidosis Type Iiia","PX-30003370","CDM","81479","CPT","0310","RC","","","","outpatient","","","1166.00","874.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","612.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","961.95","percent of total billed charges",""
"Mgh Multiple Epiphyseal Dysplasia","PX-31000864","CDM","81479","CPT","0310","RC","","","","both","","","1647.00","1235.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1309.37","79.5","","0.65","0.65","0.65","1 through 10","510.57","1564.65","percent of total billed charges",""
"Mgh Multiple Epiphyseal Dysplasia","PX-31000864","CDM","81479","CPT","0310","RC","","","","both","","","1647.00","1235.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","877.85","53.3","","0.79","0.79","0.79","1 through 10","510.57","1564.65","percent of total billed charges",""
"Mgh Multiple Epiphyseal Dysplasia","PX-31000864","CDM","81479","CPT","0310","RC","","","","outpatient","","","1647.00","1235.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","823.50","50","","1.00","1.00","1.00","1 through 10","156.55","1358.78","percent of total billed charges",""
"Mgh Multiple Epiphyseal Dysplasia","PX-31000864","CDM","81479","CPT","0310","RC","","","","outpatient","","","1647.00","1235.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","864.68","52.5","","1.00","0.53","1.00","1 through 10","156.55","1358.78","percent of total billed charges",""
"Mgh Multiplex Rt-Pcr Fusion Detection in Ph-Like B-All","PX-31000594","CDM","81479","CPT","0310","RC","","","","both","","","980.00","735.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","779.10","79.5","","0.65","0.65","0.65","1 through 10","303.8","931","percent of total billed charges",""
"Mgh Multiplex Rt-Pcr Fusion Detection in Ph-Like B-All","PX-31000594","CDM","81479","CPT","0310","RC","","","","both","","","980.00","735.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","522.34","53.3","","0.79","0.79","0.79","1 through 10","303.8","931","percent of total billed charges",""
"Mgh Multiplex Rt-Pcr Fusion Detection in Ph-Like B-All","PX-31000594","CDM","81479","CPT","0310","RC","","","","outpatient","","","980.00","735.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","490.00","50","","1.00","1.00","1.00","1 through 10","156.55","808.5","percent of total billed charges",""
"Mgh Multiplex Rt-Pcr Fusion Detection in Ph-Like B-All","PX-31000594","CDM","81479","CPT","0310","RC","","","","outpatient","","","980.00","735.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","514.50","52.5","","1.00","0.53","1.00","1 through 10","156.55","808.5","percent of total billed charges",""
"Mgh Muscular Dystrophy Advance Eval","PX-30003367","CDM","81479","CPT","0310","RC","","","","both","","","235.00","176.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.83","79.5","","0.65","0.65","0.65","1 through 10","72.85","223.25","percent of total billed charges",""
"Mgh Muscular Dystrophy Advance Eval","PX-30003367","CDM","81479","CPT","0310","RC","","","","both","","","235.00","176.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","125.26","53.3","","0.79","0.79","0.79","1 through 10","72.85","223.25","percent of total billed charges",""
"Mgh Muscular Dystrophy Advance Eval","PX-30003367","CDM","81479","CPT","0310","RC","","","","outpatient","","","235.00","176.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","117.50","50","","1.00","1.00","1.00","1 through 10","113.74","193.88","percent of total billed charges",""
"Mgh Muscular Dystrophy Advance Eval","PX-30003367","CDM","81479","CPT","0310","RC","","","","outpatient","","","235.00","176.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","123.38","52.5","","1.00","0.53","1.00","1 through 10","113.74","193.88","percent of total billed charges",""
"Mgh Muscular Dystrophy/Myopathy Panel","PX-31000374","CDM","81479","CPT","0310","RC","","","","both","","","6845.00","5133.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5441.78","79.5","","0.65","0.65","0.65","1 through 10","2121.95","6502.75","percent of total billed charges",""
"Mgh Muscular Dystrophy/Myopathy Panel","PX-31000374","CDM","81479","CPT","0310","RC","","","","both","","","6845.00","5133.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3648.39","53.3","","0.79","0.79","0.79","1 through 10","2121.95","6502.75","percent of total billed charges",""
"Mgh Muscular Dystrophy/Myopathy Panel","PX-31000374","CDM","81479","CPT","0310","RC","","","","outpatient","","","6845.00","5133.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3422.50","50","","1.00","1.00","1.00","1 through 10","156.55","5647.13","percent of total billed charges",""
"Mgh Muscular Dystrophy/Myopathy Panel","PX-31000374","CDM","81479","CPT","0310","RC","","","","outpatient","","","6845.00","5133.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3593.63","52.5","","1.00","0.53","1.00","1 through 10","156.55","5647.13","percent of total billed charges",""
"Mgh Mvk Select Exons Sequencing","PX-31000595","CDM","81479","CPT","0310","RC","","","","both","","","992.00","744.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","788.64","79.5","","0.65","0.65","0.65","1 through 10","307.52","942.4","percent of total billed charges",""
"Mgh Mvk Select Exons Sequencing","PX-31000595","CDM","81479","CPT","0310","RC","","","","both","","","992.00","744.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","528.74","53.3","","0.79","0.79","0.79","1 through 10","307.52","942.4","percent of total billed charges",""
"Mgh Mvk Select Exons Sequencing","PX-31000595","CDM","81479","CPT","0310","RC","","","","outpatient","","","992.00","744.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","496.00","50","","1.00","1.00","1.00","1 through 10","156.55","818.4","percent of total billed charges",""
"Mgh Mvk Select Exons Sequencing","PX-31000595","CDM","81479","CPT","0310","RC","","","","outpatient","","","992.00","744.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","520.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","818.4","percent of total billed charges",""
"Mgh Mycophenolic Acid","PX-30001556","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Mycophenolic Acid","PX-30001556","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Mycophenolic Acid","PX-30001556","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Mycophenolic Acid","PX-30001556","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Mycophenolic Acid","PX-30001556","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Mycophenolic Acid","PX-30001556","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Mycophenolic Acid","PX-30001556","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Myh9 Sequence Analysis","PX-31000557","CDM","81479","CPT","0310","RC","","","","both","","","1444.00","1083.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1147.98","79.5","","0.65","0.65","0.65","1 through 10","447.64","1371.8","percent of total billed charges",""
"Mgh Myh9 Sequence Analysis","PX-31000557","CDM","81479","CPT","0310","RC","","","","both","","","1444.00","1083.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","769.65","53.3","","0.79","0.79","0.79","1 through 10","447.64","1371.8","percent of total billed charges",""
"Mgh Myh9 Sequence Analysis","PX-31000557","CDM","81479","CPT","0310","RC","","","","outpatient","","","1444.00","1083.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","722.00","50","","1.00","1.00","1.00","1 through 10","156.55","1191.3","percent of total billed charges",""
"Mgh Myh9 Sequence Analysis","PX-31000557","CDM","81479","CPT","0310","RC","","","","outpatient","","","1444.00","1083.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","758.10","52.5","","1.00","0.53","1.00","1 through 10","156.55","1191.3","percent of total billed charges",""
"Mgh Myotonic Syndrome Advanced Evaluation","PX-31000650","CDM","81479","CPT","0310","RC","","","","both","","","1293.00","969.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1027.94","79.5","","0.65","0.65","0.65","1 through 10","400.83","1228.35","percent of total billed charges",""
"Mgh Myotonic Syndrome Advanced Evaluation","PX-31000650","CDM","81479","CPT","0310","RC","","","","both","","","1293.00","969.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","689.17","53.3","","0.79","0.79","0.79","1 through 10","400.83","1228.35","percent of total billed charges",""
"Mgh Myotonic Syndrome Advanced Evaluation","PX-31000650","CDM","81479","CPT","0310","RC","","","","outpatient","","","1293.00","969.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","646.50","50","","1.00","1.00","1.00","1 through 10","156.55","1066.73","percent of total billed charges",""
"Mgh Myotonic Syndrome Advanced Evaluation","PX-31000650","CDM","81479","CPT","0310","RC","","","","outpatient","","","1293.00","969.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","678.83","52.5","","1.00","0.53","1.00","1 through 10","156.55","1066.73","percent of total billed charges",""
"Mgh Nait-Patella Syndrome","PX-31000334","CDM","81479","CPT","0310","RC","","","","both","","","2946.00","2209.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2342.07","79.5","","0.65","0.65","0.65","1 through 10","913.26","2798.7","percent of total billed charges",""
"Mgh Nait-Patella Syndrome","PX-31000334","CDM","81479","CPT","0310","RC","","","","both","","","2946.00","2209.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1570.22","53.3","","0.79","0.79","0.79","1 through 10","913.26","2798.7","percent of total billed charges",""
"Mgh Nait-Patella Syndrome","PX-31000334","CDM","81479","CPT","0310","RC","","","","outpatient","","","2946.00","2209.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1473.00","50","","1.00","1.00","1.00","1 through 10","156.55","2430.45","percent of total billed charges",""
"Mgh Nait-Patella Syndrome","PX-31000334","CDM","81479","CPT","0310","RC","","","","outpatient","","","2946.00","2209.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1546.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","2430.45","percent of total billed charges",""
"Mgh Nash Fibrosure","PX-30003019","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Nash Fibrosure","PX-30003019","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Nbk Virus Dna Pcr Ser","PX-30002303","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Nbn Sanger Sequencing","PX-31000476","CDM","81479","CPT","0310","RC","","","","both","","","3065.00","2298.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2436.68","79.5","","0.65","0.65","0.65","1 through 10","950.15","2911.75","percent of total billed charges",""
"Mgh Nbn Sanger Sequencing","PX-31000476","CDM","81479","CPT","0310","RC","","","","both","","","3065.00","2298.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1633.65","53.3","","0.79","0.79","0.79","1 through 10","950.15","2911.75","percent of total billed charges",""
"Mgh Nbn Sanger Sequencing","PX-31000476","CDM","81479","CPT","0310","RC","","","","outpatient","","","3065.00","2298.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1532.50","50","","1.00","1.00","1.00","1 through 10","156.55","2528.63","percent of total billed charges",""
"Mgh Nbn Sanger Sequencing","PX-31000476","CDM","81479","CPT","0310","RC","","","","outpatient","","","3065.00","2298.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1609.13","52.5","","1.00","0.53","1.00","1 through 10","156.55","2528.63","percent of total billed charges",""
"Mgh Ndrg1 Dna Sequencing","PX-31000282","CDM","81479","CPT","0310","RC","","","","both","","","4450.00","3337.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3537.75","79.5","","0.65","0.65","0.65","1 through 10","1379.5","4227.5","percent of total billed charges",""
"Mgh Ndrg1 Dna Sequencing","PX-31000282","CDM","81479","CPT","0310","RC","","","","both","","","4450.00","3337.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2371.85","53.3","","0.79","0.79","0.79","1 through 10","1379.5","4227.5","percent of total billed charges",""
"Mgh Ndrg1 Dna Sequencing","PX-31000282","CDM","81479","CPT","0310","RC","","","","outpatient","","","4450.00","3337.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2225.00","50","","1.00","1.00","1.00","1 through 10","156.55","3671.25","percent of total billed charges",""
"Mgh Ndrg1 Dna Sequencing","PX-31000282","CDM","81479","CPT","0310","RC","","","","outpatient","","","4450.00","3337.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2336.25","52.5","","1.00","0.53","1.00","1 through 10","156.55","3671.25","percent of total billed charges",""
"Mgh Neonatal Alloimmune Neutropenia (Nan) Panel - Mother","PX-31000721","CDM","81479","CPT","0310","RC","","","","both","","","197.00","147.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","156.62","79.5","","0.65","0.65","0.65","1 through 10","61.07","187.15","percent of total billed charges",""
"Mgh Neonatal Alloimmune Neutropenia (Nan) Panel - Mother","PX-31000721","CDM","81479","CPT","0310","RC","","","","both","","","197.00","147.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","105.00","53.3","","0.79","0.79","0.79","1 through 10","61.07","187.15","percent of total billed charges",""
"Mgh Neonatal Alloimmune Neutropenia (Nan) Panel - Mother","PX-31000721","CDM","81479","CPT","0310","RC","","","","outpatient","","","197.00","147.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","98.50","50","","1.00","1.00","1.00","1 through 10","95.35","162.53","percent of total billed charges",""
"Mgh Neonatal Alloimmune Neutropenia (Nan) Panel - Mother","PX-31000721","CDM","81479","CPT","0310","RC","","","","outpatient","","","197.00","147.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","103.43","52.5","","1.00","0.53","1.00","1 through 10","95.35","162.53","percent of total billed charges",""
"Mgh Nephlmtry Ea Anal Nes","PX-30002131","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Nephlmtry Ea Anal Nes","PX-30002131","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Nephlmtry Ea Anal Nes","PX-30002132","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Nephlmtry Ea Anal Nes","PX-30002132","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Nephlmtry Ea Anal Nes","PX-30002134","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Nephlmtry Ea Anal Nes","PX-30002134","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Nephlmtry Ea Anal Nes","PX-30002135","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Nephlmtry Ea Anal Nes","PX-30002135","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002065","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Neuron Specific Enolase","PX-30002095","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Neuronal Ceroid Lipofuscinosis","PX-30001998","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Neuronal Ceroid Lipofuscinosis","PX-30001998","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Neuronal Ceroid Lipofuscinosis","PX-30002002","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Neuronal Ceroid Lipofuscinosis","PX-30002002","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Neuronl Cerod Lipofuscnosi","PX-30002008","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Neuronl Cerod Lipofuscnosi","PX-30002008","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Neurotransmitter Enz Activ","PX-30001997","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Neurotransmitter Enz Activ","PX-30001997","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Nevirapine","PX-30001525","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.38","79.5","","106.25","71.28","106.25","1 through 10","14.12","308.75","percent of total billed charges",""
"Mgh Nevirapine","PX-30001525","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.23","53.3","","106.25","71.28","106.25","1 through 10","14.12","308.75","percent of total billed charges",""
"Mgh Nevirapine","PX-30001525","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.63","36.5","","50.36","42.80","92.50","13","14.12","308.75","percent of total billed charges",""
"Mgh Nevirapine","PX-30001525","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.48","38.3","","52.79","44.55","158.37","30","14.12","308.75","percent of total billed charges",""
"Mgh Nevirapine","PX-30001525","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","AETNA [1001]","HB AMC AETNA HMO","226.85","69.8","","91.40","64.53","105.30","14","14.12","265.59","percent of total billed charges",""
"Mgh Nevirapine","PX-30001525","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","261.30","80.4","","105.30","105.30","105.30","1 through 10","14.12","265.59","percent of total billed charges",""
"Mgh Nevirapine","PX-30001525","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","265.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","265.59","percent of total billed charges",""
"Mgh Ngs Connective Tissue Panel","PX-31000592","CDM","81479","CPT","0310","RC","","","","both","","","6321.00","4740.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5025.20","79.5","","0.65","0.65","0.65","1 through 10","1959.51","6004.95","percent of total billed charges",""
"Mgh Ngs Connective Tissue Panel","PX-31000592","CDM","81479","CPT","0310","RC","","","","both","","","6321.00","4740.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3369.09","53.3","","0.79","0.79","0.79","1 through 10","1959.51","6004.95","percent of total billed charges",""
"Mgh Ngs Connective Tissue Panel","PX-31000592","CDM","81479","CPT","0310","RC","","","","outpatient","","","6321.00","4740.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3160.50","50","","1.00","1.00","1.00","1 through 10","156.55","5214.83","percent of total billed charges",""
"Mgh Ngs Connective Tissue Panel","PX-31000592","CDM","81479","CPT","0310","RC","","","","outpatient","","","6321.00","4740.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3318.53","52.5","","1.00","0.53","1.00","1 through 10","156.55","5214.83","percent of total billed charges",""
"Mgh Ngs Non-Immune Hydrops Panel","PX-31000878","CDM","81479","CPT","0310","RC","","","","both","","","5826.00","4369.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4631.67","79.5","","0.65","0.65","0.65","1 through 10","1806.06","5534.7","percent of total billed charges",""
"Mgh Ngs Non-Immune Hydrops Panel","PX-31000878","CDM","81479","CPT","0310","RC","","","","both","","","5826.00","4369.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3105.26","53.3","","0.79","0.79","0.79","1 through 10","1806.06","5534.7","percent of total billed charges",""
"Mgh Ngs Non-Immune Hydrops Panel","PX-31000878","CDM","81479","CPT","0310","RC","","","","outpatient","","","5826.00","4369.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2913.00","50","","1.00","1.00","1.00","1 through 10","156.55","4806.45","percent of total billed charges",""
"Mgh Ngs Non-Immune Hydrops Panel","PX-31000878","CDM","81479","CPT","0310","RC","","","","outpatient","","","5826.00","4369.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3058.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","4806.45","percent of total billed charges",""
"Mgh Ngs Panel","PX-31000472","CDM","81479","CPT","0310","RC","","","","both","","","3899.00","2924.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3099.71","79.5","","0.65","0.65","0.65","1 through 10","1208.69","3704.05","percent of total billed charges",""
"Mgh Ngs Panel","PX-31000472","CDM","81479","CPT","0310","RC","","","","both","","","3899.00","2924.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2078.17","53.3","","0.79","0.79","0.79","1 through 10","1208.69","3704.05","percent of total billed charges",""
"Mgh Ngs Panel","PX-31000472","CDM","81479","CPT","0310","RC","","","","outpatient","","","3899.00","2924.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1949.50","50","","1.00","1.00","1.00","1 through 10","156.55","3216.68","percent of total billed charges",""
"Mgh Ngs Panel","PX-31000472","CDM","81479","CPT","0310","RC","","","","outpatient","","","3899.00","2924.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2046.98","52.5","","1.00","0.53","1.00","1 through 10","156.55","3216.68","percent of total billed charges",""
"Mgh Niemann Pick Type a/B","PX-31000630","CDM","81479","CPT","0310","RC","","","","both","","","1747.00","1310.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1388.87","79.5","","0.65","0.65","0.65","1 through 10","541.57","1659.65","percent of total billed charges",""
"Mgh Niemann Pick Type a/B","PX-31000630","CDM","81479","CPT","0310","RC","","","","both","","","1747.00","1310.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","931.15","53.3","","0.79","0.79","0.79","1 through 10","541.57","1659.65","percent of total billed charges",""
"Mgh Niemann Pick Type a/B","PX-31000630","CDM","81479","CPT","0310","RC","","","","outpatient","","","1747.00","1310.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","873.50","50","","1.00","1.00","1.00","1 through 10","156.55","1441.28","percent of total billed charges",""
"Mgh Niemann Pick Type a/B","PX-31000630","CDM","81479","CPT","0310","RC","","","","outpatient","","","1747.00","1310.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","917.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","1441.28","percent of total billed charges",""
"Mgh Nogastar Stemcell Inj Procedur","PX-48000398","CDM","93799","CPT","0480","RC","","","","outpatient","","","24310.00","18232.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","13370.50","55","","13080.03","13080.03","13080.03","1 through 10","12155","20055.75","percent of total billed charges",""
"Mgh Nogastar Stemcell Inj Procedur","PX-48000398","CDM","93799","CPT","0481","RC","","","","both","","","24310.00","18232.50","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","19326.45","other","OPPS APC"
"Mgh Nogastar Stemcell Inj Procedur","PX-48000398","CDM","93799","CPT","0481","RC","","","","outpatient","","","24310.00","18232.50","AETNA [1001]","HB AMC AETNA HMO","16968.38","69.8","","2022.70","2022.70","2022.70","1 through 10","454","19866.13","percent of total billed charges",""
"Mgh Nogastar Stemcell Inj Procedur","PX-48000398","CDM","93799","CPT","0481","RC","","","","outpatient","","","24310.00","18232.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","14719.71","60.55","","318.03","318.03","2439.77","1 through 10","454","19866.13","percent of total billed charges",""
"Mgh Nogastar Stemcell Inj Procedur","PX-48000398","CDM","93799","CPT","0481","RC","","","","outpatient","","","24310.00","18232.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","12694.68","52.22","","360.38","360.38","4023.00","1 through 10","454","19866.13","percent of total billed charges",""
"Mgh Non-Ketotic Hyperglycinemia","PX-31000275","CDM","81479","CPT","0310","RC","","","","both","","","1532.00","1149.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1217.94","79.5","","0.65","0.65","0.65","1 through 10","474.92","1455.4","percent of total billed charges",""
"Mgh Non-Ketotic Hyperglycinemia","PX-31000275","CDM","81479","CPT","0310","RC","","","","both","","","1532.00","1149.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","816.56","53.3","","0.79","0.79","0.79","1 through 10","474.92","1455.4","percent of total billed charges",""
"Mgh Non-Ketotic Hyperglycinemia","PX-31000275","CDM","81479","CPT","0310","RC","","","","outpatient","","","1532.00","1149.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","766.00","50","","1.00","1.00","1.00","1 through 10","156.55","1263.9","percent of total billed charges",""
"Mgh Non-Ketotic Hyperglycinemia","PX-31000275","CDM","81479","CPT","0310","RC","","","","outpatient","","","1532.00","1149.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","804.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","1263.9","percent of total billed charges",""
"Mgh Non-Mitochondrial Leukodystrophy/Leukoencephalopathy","PX-30003369","CDM","81479","CPT","0310","RC","","","","both","","","3319.00","2489.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2638.61","79.5","","0.65","0.65","0.65","1 through 10","1028.89","3153.05","percent of total billed charges",""
"Mgh Non-Mitochondrial Leukodystrophy/Leukoencephalopathy","PX-30003369","CDM","81479","CPT","0310","RC","","","","both","","","3319.00","2489.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1769.03","53.3","","0.79","0.79","0.79","1 through 10","1028.89","3153.05","percent of total billed charges",""
"Mgh Non-Mitochondrial Leukodystrophy/Leukoencephalopathy","PX-30003369","CDM","81479","CPT","0310","RC","","","","outpatient","","","3319.00","2489.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1659.50","50","","1.00","1.00","1.00","1 through 10","156.55","2738.18","percent of total billed charges",""
"Mgh Non-Mitochondrial Leukodystrophy/Leukoencephalopathy","PX-30003369","CDM","81479","CPT","0310","RC","","","","outpatient","","","3319.00","2489.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1742.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","2738.18","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Nonvirus Rna Rt Pcr","PX-30002304","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Noonan Spectrum Disorder Panel","PX-31000254","CDM","81479","CPT","0310","RC","","","","both","","","3677.00","2757.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2923.22","79.5","","0.65","0.65","0.65","1 through 10","1139.87","3493.15","percent of total billed charges",""
"Mgh Noonan Spectrum Disorder Panel","PX-31000254","CDM","81479","CPT","0310","RC","","","","both","","","3677.00","2757.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1959.84","53.3","","0.79","0.79","0.79","1 through 10","1139.87","3493.15","percent of total billed charges",""
"Mgh Noonan Spectrum Disorder Panel","PX-31000254","CDM","81479","CPT","0310","RC","","","","outpatient","","","3677.00","2757.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1838.50","50","","1.00","1.00","1.00","1 through 10","156.55","3033.53","percent of total billed charges",""
"Mgh Noonan Spectrum Disorder Panel","PX-31000254","CDM","81479","CPT","0310","RC","","","","outpatient","","","3677.00","2757.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1930.43","52.5","","1.00","0.53","1.00","1 through 10","156.55","3033.53","percent of total billed charges",""
"Mgh Notch1 C.7541_7542 Del CT (Pcr)","PX-31000726","CDM","81479","CPT","0310","RC","","","","both","","","1141.00","855.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","907.10","79.5","","0.65","0.65","0.65","1 through 10","353.71","1083.95","percent of total billed charges",""
"Mgh Notch1 C.7541_7542 Del CT (Pcr)","PX-31000726","CDM","81479","CPT","0310","RC","","","","both","","","1141.00","855.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","608.15","53.3","","0.79","0.79","0.79","1 through 10","353.71","1083.95","percent of total billed charges",""
"Mgh Notch1 C.7541_7542 Del CT (Pcr)","PX-31000726","CDM","81479","CPT","0310","RC","","","","outpatient","","","1141.00","855.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","570.50","50","","1.00","1.00","1.00","1 through 10","156.55","941.33","percent of total billed charges",""
"Mgh Notch1 C.7541_7542 Del CT (Pcr)","PX-31000726","CDM","81479","CPT","0310","RC","","","","outpatient","","","1141.00","855.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","599.03","52.5","","1.00","0.53","1.00","1 through 10","156.55","941.33","percent of total billed charges",""
"Mgh Nuronl Crod Lipofuscnos","PX-30002012","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Nuronl Crod Lipofuscnos","PX-30002012","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Nzm Cels Tis Nonradct Sbstrt","PX-30002004","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Nzm Cels Tis Nonradct Sbstrt","PX-30002004","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Nzm Cels Tis Nonradct Sbstrt","PX-30002005","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Nzm Cels Tis Nonradct Sbstrt","PX-30002005","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Nzm Cels Tis Nonradct Sbstrt","PX-30002014","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Nzm Cels Tis Nonradct Sbstrt","PX-30002014","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Nzm Cels Tis Nonradct Sbstrt","PX-30002015","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Nzm Cels Tis Nonradct Sbstrt","PX-30002015","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Oak Tree Ige 86003","PX-30002189","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Ofd1 Gene","PX-31000368","CDM","81479","CPT","0310","RC","","","","both","","","3453.00","2589.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2745.14","79.5","","0.65","0.65","0.65","1 through 10","1070.43","3280.35","percent of total billed charges",""
"Mgh Ofd1 Gene","PX-31000368","CDM","81479","CPT","0310","RC","","","","both","","","3453.00","2589.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1840.45","53.3","","0.79","0.79","0.79","1 through 10","1070.43","3280.35","percent of total billed charges",""
"Mgh Ofd1 Gene","PX-31000368","CDM","81479","CPT","0310","RC","","","","outpatient","","","3453.00","2589.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1726.50","50","","1.00","1.00","1.00","1 through 10","156.55","2848.73","percent of total billed charges",""
"Mgh Ofd1 Gene","PX-31000368","CDM","81479","CPT","0310","RC","","","","outpatient","","","3453.00","2589.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1812.83","52.5","","1.00","0.53","1.00","1 through 10","156.55","2848.73","percent of total billed charges",""
"Mgh Olanzapine Zyprexa","PX-30001545","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Olanzapine Zyprexa","PX-30001545","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Olanzapine Zyprexa","PX-30001545","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Olanzapine Zyprexa","PX-30001545","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Olanzapine Zyprexa","PX-30001545","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Olanzapine Zyprexa","PX-30001545","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Olanzapine Zyprexa","PX-30001545","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Osteogenesis Imperfecta Ngs Panel - Dominant & Recessive","PX-31000550","CDM","81479","CPT","0310","RC","","","","both","","","1876.00","1407.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1491.42","79.5","","0.65","0.65","0.65","1 through 10","581.56","1782.2","percent of total billed charges",""
"Mgh Osteogenesis Imperfecta Ngs Panel - Dominant & Recessive","PX-31000550","CDM","81479","CPT","0310","RC","","","","both","","","1876.00","1407.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","999.91","53.3","","0.79","0.79","0.79","1 through 10","581.56","1782.2","percent of total billed charges",""
"Mgh Osteogenesis Imperfecta Ngs Panel - Dominant & Recessive","PX-31000550","CDM","81479","CPT","0310","RC","","","","outpatient","","","1876.00","1407.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","938.00","50","","1.00","1.00","1.00","1 through 10","156.55","1547.7","percent of total billed charges",""
"Mgh Osteogenesis Imperfecta Ngs Panel - Dominant & Recessive","PX-31000550","CDM","81479","CPT","0310","RC","","","","outpatient","","","1876.00","1407.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","984.90","52.5","","1.00","0.53","1.00","1 through 10","156.55","1547.7","percent of total billed charges",""
"Mgh Osteogenesis Imperfecta, Types I, II, III & IV","PX-30003000","CDM","81479","CPT","0301","RC","","","","both","","","6188.00","4641.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4919.46","79.5","","0.65","0.65","0.65","1 through 10","1918.28","5878.6","percent of total billed charges",""
"Mgh Osteogenesis Imperfecta, Types I, II, III & IV","PX-30003000","CDM","81479","CPT","0301","RC","","","","both","","","6188.00","4641.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3298.20","53.3","","0.79","0.79","0.79","1 through 10","1918.28","5878.6","percent of total billed charges",""
"Mgh Osteogenesis Imperfecta, Types I, II, III & IV","PX-30003000","CDM","81479","CPT","0301","RC","","","","outpatient","","","6188.00","4641.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3094.00","50","","1.00","1.00","1.00","1 through 10","156.55","5105.1","percent of total billed charges",""
"Mgh Osteogenesis Imperfecta, Types I, II, III & IV","PX-30003000","CDM","81479","CPT","0301","RC","","","","outpatient","","","6188.00","4641.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3248.70","52.5","","1.00","0.53","1.00","1 through 10","156.55","5105.1","percent of total billed charges",""
"Mgh Other Snapshot Gene Testing","PX-31000301","CDM","81479","CPT","0310","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","0.65","0.65","0.65","1 through 10","47.43","145.35","percent of total billed charges",""
"Mgh Other Snapshot Gene Testing","PX-31000301","CDM","81479","CPT","0310","RC","","","","both","","","153.00","114.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.55","53.3","","0.79","0.79","0.79","1 through 10","47.43","145.35","percent of total billed charges",""
"Mgh Other Snapshot Gene Testing","PX-31000301","CDM","81479","CPT","0310","RC","","","","outpatient","","","153.00","114.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","76.50","50","","1.00","1.00","1.00","1 through 10","74.05","156.55","percent of total billed charges",""
"Mgh Other Snapshot Gene Testing","PX-31000301","CDM","81479","CPT","0310","RC","","","","outpatient","","","153.00","114.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","80.33","52.5","","1.00","0.53","1.00","1 through 10","74.05","156.55","percent of total billed charges",""
"Mgh P Acadl Sequence Analysis","PX-31000556","CDM","81479","CPT","0310","RC","","","","both","","","2020.00","1515.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1605.90","79.5","","0.65","0.65","0.65","1 through 10","626.2","1919","percent of total billed charges",""
"Mgh P Acadl Sequence Analysis","PX-31000556","CDM","81479","CPT","0310","RC","","","","both","","","2020.00","1515.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1076.66","53.3","","0.79","0.79","0.79","1 through 10","626.2","1919","percent of total billed charges",""
"Mgh P Acadl Sequence Analysis","PX-31000556","CDM","81479","CPT","0310","RC","","","","outpatient","","","2020.00","1515.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1010.00","50","","1.00","1.00","1.00","1 through 10","156.55","1666.5","percent of total billed charges",""
"Mgh P Acadl Sequence Analysis","PX-31000556","CDM","81479","CPT","0310","RC","","","","outpatient","","","2020.00","1515.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1060.50","52.5","","1.00","0.53","1.00","1 through 10","156.55","1666.5","percent of total billed charges",""
"Mgh P001608 Nir Cath Infraredx","PX-62400050","CDM","C1753","HCPCS","0624","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1660.75","1660.75","1660.75","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh P001608 Nir Cath Infraredx","PX-62400050","CDM","C1753","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","1233.70","876.51","1905.76","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh P001608 Nir Cath Infraredx","PX-62400050","CDM","C1753","HCPCS","0624","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1026.38","999.01","1026.38","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh P001608 Nir Cath Infraredx","PX-62400050","CDM","C1753","HCPCS","0624","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","1902.20","1902.20","1902.20","1 through 10","0.31","0.8","percent of total billed charges",""
"Mgh P001608 Nir Cath Infraredx","PX-62400050","CDM","C1753","HCPCS","0624","RC","","","","outpatient","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","0.82","81.72","","2098.42","1123.43","2210.34","1 through 10","0.52","0.82","percent of total billed charges",""
"Mgh Parainfluenza Ab I 86790","PX-30002242","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.82","79.5","","119.62","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Parainfluenza Ab I 86790","PX-30002242","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.68","53.3","","80.26","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Parainfluenza Ab I 86790","PX-30002242","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.31","36.5","","56.70","40.57","143.19","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Parainfluenza Ab I 86790","PX-30002242","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.13","38.3","","59.43","57.76","178.29","54","9.6","149.15","percent of total billed charges",""
"Mgh Parainfluenza Ab I 86790","PX-30002242","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA HMO","109.59","69.8","","102.90","72.66","175.56","43","9.6","128.3","percent of total billed charges",""
"Mgh Parainfluenza Ab I 86790","PX-30002242","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA PPO","126.23","80.4","","72.66","72.66","118.56","1 through 10","9.6","128.3","percent of total billed charges",""
"Mgh Parainfluenza Ab I 86790","PX-30002242","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.30","81.72","","121.51","66.83","121.51","11","9.6","128.3","percent of total billed charges",""
"Mgh Parainfluenza Ab II 86790","PX-30002243","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.82","79.5","","119.62","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Parainfluenza Ab II 86790","PX-30002243","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.68","53.3","","80.26","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Parainfluenza Ab II 86790","PX-30002243","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.31","36.5","","56.70","40.57","143.19","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Parainfluenza Ab II 86790","PX-30002243","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.13","38.3","","59.43","57.76","178.29","54","9.6","149.15","percent of total billed charges",""
"Mgh Parainfluenza Ab II 86790","PX-30002243","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA HMO","109.59","69.8","","102.90","72.66","175.56","43","9.6","128.3","percent of total billed charges",""
"Mgh Parainfluenza Ab II 86790","PX-30002243","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA PPO","126.23","80.4","","72.66","72.66","118.56","1 through 10","9.6","128.3","percent of total billed charges",""
"Mgh Parainfluenza Ab II 86790","PX-30002243","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.30","81.72","","121.51","66.83","121.51","11","9.6","128.3","percent of total billed charges",""
"Mgh Parainfluenza Ab III 86790","PX-30002244","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.82","79.5","","119.62","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Parainfluenza Ab III 86790","PX-30002244","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.68","53.3","","80.26","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Parainfluenza Ab III 86790","PX-30002244","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.31","36.5","","56.70","40.57","143.19","1 through 10","9.6","149.15","percent of total billed charges",""
"Mgh Parainfluenza Ab III 86790","PX-30002244","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.13","38.3","","59.43","57.76","178.29","54","9.6","149.15","percent of total billed charges",""
"Mgh Parainfluenza Ab III 86790","PX-30002244","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA HMO","109.59","69.8","","102.90","72.66","175.56","43","9.6","128.3","percent of total billed charges",""
"Mgh Parainfluenza Ab III 86790","PX-30002244","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA PPO","126.23","80.4","","72.66","72.66","118.56","1 through 10","9.6","128.3","percent of total billed charges",""
"Mgh Parainfluenza Ab III 86790","PX-30002244","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.30","81.72","","121.51","66.83","121.51","11","9.6","128.3","percent of total billed charges",""
"Mgh Paravalvular Leak Closure","PX-48000438","CDM","93799","CPT","0481","RC","","","","both","","","28047.00","21035.25","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","22297.37","other","OPPS APC"
"Mgh Paravalvular Leak Closure","PX-48000438","CDM","93799","CPT","0481","RC","","","","outpatient","","","28047.00","21035.25","AETNA [1001]","HB AMC AETNA HMO","19576.81","69.8","","2022.70","2022.70","2022.70","1 through 10","454","23138.78","percent of total billed charges",""
"Mgh Paravalvular Leak Closure","PX-48000438","CDM","93799","CPT","0481","RC","","","","outpatient","","","28047.00","21035.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","16982.46","60.55","","318.03","318.03","2439.77","1 through 10","454","23138.78","percent of total billed charges",""
"Mgh Paravalvular Leak Closure","PX-48000438","CDM","93799","CPT","0481","RC","","","","outpatient","","","28047.00","21035.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","14646.14","52.22","","360.38","360.38","4023.00","1 through 10","454","23138.78","percent of total billed charges",""
"Mgh Paravalvular Leak Closure","PX-48000438","CDM","93799","CPT","0481","RC","","","","outpatient","","","28047.00","21035.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","15425.85","55","","13080.03","13080.03","13080.03","1 through 10","454","23138.78","percent of total billed charges",""
"Mgh Parkes Weber Syndrome","PX-31000364","CDM","81479","CPT","0310","RC","","","","both","","","3914.00","2935.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3111.63","79.5","","0.65","0.65","0.65","1 through 10","1213.34","3718.3","percent of total billed charges",""
"Mgh Parkes Weber Syndrome","PX-31000364","CDM","81479","CPT","0310","RC","","","","both","","","3914.00","2935.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2086.16","53.3","","0.79","0.79","0.79","1 through 10","1213.34","3718.3","percent of total billed charges",""
"Mgh Parkes Weber Syndrome","PX-31000364","CDM","81479","CPT","0310","RC","","","","outpatient","","","3914.00","2935.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1957.00","50","","1.00","1.00","1.00","1 through 10","156.55","3229.05","percent of total billed charges",""
"Mgh Parkes Weber Syndrome","PX-31000364","CDM","81479","CPT","0310","RC","","","","outpatient","","","3914.00","2935.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2054.85","52.5","","1.00","0.53","1.00","1 through 10","156.55","3229.05","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Parvo B19 Dna Pcr","PX-30002305","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Pax6 Gene Analysis","PX-31000638","CDM","81479","CPT","0310","RC","","","","both","","","1725.00","1293.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1371.38","79.5","","0.65","0.65","0.65","1 through 10","534.75","1638.75","percent of total billed charges",""
"Mgh Pax6 Gene Analysis","PX-31000638","CDM","81479","CPT","0310","RC","","","","both","","","1725.00","1293.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","919.43","53.3","","0.79","0.79","0.79","1 through 10","534.75","1638.75","percent of total billed charges",""
"Mgh Pax6 Gene Analysis","PX-31000638","CDM","81479","CPT","0310","RC","","","","outpatient","","","1725.00","1293.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","862.50","50","","1.00","1.00","1.00","1 through 10","156.55","1423.13","percent of total billed charges",""
"Mgh Pax6 Gene Analysis","PX-31000638","CDM","81479","CPT","0310","RC","","","","outpatient","","","1725.00","1293.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","905.63","52.5","","1.00","0.53","1.00","1 through 10","156.55","1423.13","percent of total billed charges",""
"Mgh Pax6 Gene Sequencing","PX-31000486","CDM","81479","CPT","0310","RC","","","","both","","","1807.00","1355.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1436.57","79.5","","0.65","0.65","0.65","1 through 10","560.17","1716.65","percent of total billed charges",""
"Mgh Pax6 Gene Sequencing","PX-31000486","CDM","81479","CPT","0310","RC","","","","both","","","1807.00","1355.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","963.13","53.3","","0.79","0.79","0.79","1 through 10","560.17","1716.65","percent of total billed charges",""
"Mgh Pax6 Gene Sequencing","PX-31000486","CDM","81479","CPT","0310","RC","","","","outpatient","","","1807.00","1355.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","903.50","50","","1.00","1.00","1.00","1 through 10","156.55","1490.78","percent of total billed charges",""
"Mgh Pax6 Gene Sequencing","PX-31000486","CDM","81479","CPT","0310","RC","","","","outpatient","","","1807.00","1355.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","948.68","52.5","","1.00","0.53","1.00","1 through 10","156.55","1490.78","percent of total billed charges",""
"Mgh Pca3 Assay","PX-31000350","CDM","81479","CPT","0310","RC","","","","both","","","1488.00","1116.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1182.96","79.5","","0.65","0.65","0.65","1 through 10","461.28","1413.6","percent of total billed charges",""
"Mgh Pca3 Assay","PX-31000350","CDM","81479","CPT","0310","RC","","","","both","","","1488.00","1116.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","793.10","53.3","","0.79","0.79","0.79","1 through 10","461.28","1413.6","percent of total billed charges",""
"Mgh Pca3 Assay","PX-31000350","CDM","81479","CPT","0310","RC","","","","outpatient","","","1488.00","1116.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","744.00","50","","1.00","1.00","1.00","1 through 10","156.55","1227.6","percent of total billed charges",""
"Mgh Pca3 Assay","PX-31000350","CDM","81479","CPT","0310","RC","","","","outpatient","","","1488.00","1116.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","781.20","52.5","","1.00","0.53","1.00","1 through 10","156.55","1227.6","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Pcr Toxoplasma Gondii 87798","PX-30002306","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Pdcd10 Ccm3 Deletion Analysis","PX-31000259","CDM","81479","CPT","0310","RC","","","","both","","","1686.00","1264.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1340.37","79.5","","0.65","0.65","0.65","1 through 10","522.66","1601.7","percent of total billed charges",""
"Mgh Pdcd10 Ccm3 Deletion Analysis","PX-31000259","CDM","81479","CPT","0310","RC","","","","both","","","1686.00","1264.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","898.64","53.3","","0.79","0.79","0.79","1 through 10","522.66","1601.7","percent of total billed charges",""
"Mgh Pdcd10 Ccm3 Deletion Analysis","PX-31000259","CDM","81479","CPT","0310","RC","","","","outpatient","","","1686.00","1264.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","843.00","50","","1.00","1.00","1.00","1 through 10","156.55","1390.95","percent of total billed charges",""
"Mgh Pdcd10 Ccm3 Deletion Analysis","PX-31000259","CDM","81479","CPT","0310","RC","","","","outpatient","","","1686.00","1264.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","885.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","1390.95","percent of total billed charges",""
"Mgh Pdgfrb Sanger Sequencing","PX-31000523","CDM","81479","CPT","0310","RC","","","","both","","","2365.00","1773.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1880.18","79.5","","0.65","0.65","0.65","1 through 10","733.15","2246.75","percent of total billed charges",""
"Mgh Pdgfrb Sanger Sequencing","PX-31000523","CDM","81479","CPT","0310","RC","","","","both","","","2365.00","1773.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1260.55","53.3","","0.79","0.79","0.79","1 through 10","733.15","2246.75","percent of total billed charges",""
"Mgh Pdgfrb Sanger Sequencing","PX-31000523","CDM","81479","CPT","0310","RC","","","","outpatient","","","2365.00","1773.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1182.50","50","","1.00","1.00","1.00","1 through 10","156.55","1951.13","percent of total billed charges",""
"Mgh Pdgfrb Sanger Sequencing","PX-31000523","CDM","81479","CPT","0310","RC","","","","outpatient","","","2365.00","1773.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1241.63","52.5","","1.00","0.53","1.00","1 through 10","156.55","1951.13","percent of total billed charges",""
"Mgh Peganone (Ethotoin) 80299","PX-30001573","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Peganone (Ethotoin) 80299","PX-30001573","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Peganone (Ethotoin) 80299","PX-30001573","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Peganone (Ethotoin) 80299","PX-30001573","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Peganone (Ethotoin) 80299","PX-30001573","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Peganone (Ethotoin) 80299","PX-30001573","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Peganone (Ethotoin) 80299","PX-30001573","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Peo Panel by Massively Parallel Sequencing (Bcm-Mitomengssm)","PX-31000539","CDM","81479","CPT","0310","RC","","","","both","","","813.00","609.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","646.34","79.5","","0.65","0.65","0.65","1 through 10","252.03","772.35","percent of total billed charges",""
"Mgh Peo Panel by Massively Parallel Sequencing (Bcm-Mitomengssm)","PX-31000539","CDM","81479","CPT","0310","RC","","","","both","","","813.00","609.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","433.33","53.3","","0.79","0.79","0.79","1 through 10","252.03","772.35","percent of total billed charges",""
"Mgh Peo Panel by Massively Parallel Sequencing (Bcm-Mitomengssm)","PX-31000539","CDM","81479","CPT","0310","RC","","","","outpatient","","","813.00","609.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","406.50","50","","1.00","1.00","1.00","1 through 10","156.55","670.73","percent of total billed charges",""
"Mgh Peo Panel by Massively Parallel Sequencing (Bcm-Mitomengssm)","PX-31000539","CDM","81479","CPT","0310","RC","","","","outpatient","","","813.00","609.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","426.83","52.5","","1.00","0.53","1.00","1 through 10","156.55","670.73","percent of total billed charges",""
"Mgh Perc a.V.Replace Transfemoral","PX-48000340","CDM","93799","CPT","0481","RC","","","","both","","","57333.00","42999.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","45579.74","other","OPPS APC"
"Mgh Perc a.V.Replace Transfemoral","PX-48000340","CDM","93799","CPT","0481","RC","","","","outpatient","","","57333.00","42999.75","AETNA [1001]","HB AMC AETNA HMO","40018.43","69.8","","2022.70","2022.70","2022.70","1 through 10","454","47299.73","percent of total billed charges",""
"Mgh Perc a.V.Replace Transfemoral","PX-48000340","CDM","93799","CPT","0481","RC","","","","outpatient","","","57333.00","42999.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","34715.13","60.55","","318.03","318.03","2439.77","1 through 10","454","47299.73","percent of total billed charges",""
"Mgh Perc a.V.Replace Transfemoral","PX-48000340","CDM","93799","CPT","0481","RC","","","","outpatient","","","57333.00","42999.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","29939.29","52.22","","360.38","360.38","4023.00","1 through 10","454","47299.73","percent of total billed charges",""
"Mgh Perc a.V.Replace Transfemoral","PX-48000340","CDM","93799","CPT","0481","RC","","","","outpatient","","","57333.00","42999.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","31533.15","55","","13080.03","13080.03","13080.03","1 through 10","454","47299.73","percent of total billed charges",""
"Mgh Perc a.V.Replace Transfemoral","PX-48000399","CDM","93799","CPT","0480","RC","","","","outpatient","","","57333.00","42999.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","31533.15","55","","13080.03","13080.03","13080.03","1 through 10","28666.5","47299.73","percent of total billed charges",""
"Mgh Perc a.V.Replace Transfemoral","PX-48000399","CDM","93799","CPT","0481","RC","","","","both","","","57333.00","42999.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","45579.74","other","OPPS APC"
"Mgh Perc a.V.Replace Transfemoral","PX-48000399","CDM","93799","CPT","0481","RC","","","","outpatient","","","57333.00","42999.75","AETNA [1001]","HB AMC AETNA HMO","40018.43","69.8","","2022.70","2022.70","2022.70","1 through 10","454","46852.53","percent of total billed charges",""
"Mgh Perc a.V.Replace Transfemoral","PX-48000399","CDM","93799","CPT","0481","RC","","","","outpatient","","","57333.00","42999.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","34715.13","60.55","","318.03","318.03","2439.77","1 through 10","454","46852.53","percent of total billed charges",""
"Mgh Perc a.V.Replace Transfemoral","PX-48000399","CDM","93799","CPT","0481","RC","","","","outpatient","","","57333.00","42999.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","29939.29","52.22","","360.38","360.38","4023.00","1 through 10","454","46852.53","percent of total billed charges",""
"Mgh Pg C9orf72 Gene Hexanucleotide","PX-31001046","CDM","81479","CPT","0310","RC","","","","both","","","395.00","296.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","314.03","79.5","","0.65","0.65","0.65","1 through 10","122.45","375.25","percent of total billed charges",""
"Mgh Pg C9orf72 Gene Hexanucleotide","PX-31001046","CDM","81479","CPT","0310","RC","","","","both","","","395.00","296.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","210.54","53.3","","0.79","0.79","0.79","1 through 10","122.45","375.25","percent of total billed charges",""
"Mgh Pg C9orf72 Gene Hexanucleotide","PX-31001046","CDM","81479","CPT","0310","RC","","","","outpatient","","","395.00","296.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","197.50","50","","1.00","1.00","1.00","1 through 10","156.55","325.88","percent of total billed charges",""
"Mgh Pg C9orf72 Gene Hexanucleotide","PX-31001046","CDM","81479","CPT","0310","RC","","","","outpatient","","","395.00","296.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","207.38","52.5","","1.00","0.53","1.00","1 through 10","156.55","325.88","percent of total billed charges",""
"Mgh Ph","PX-30002145","CDM","83986","CPT","0301","RC","","","","both","","","59.00","44.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46.91","79.5","","44.86","44.86","44.86","1 through 10","3.51","56.05","percent of total billed charges",""
"Mgh Ph","PX-30002145","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","AETNA [1001]","HB AMC AETNA PPO","47.44","80.4","","44.46","44.46","44.46","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Ph","PX-30002145","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","48.21","81.72","","45.57","45.57","45.57","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Ph Stool","PX-30002146","CDM","83986","CPT","0301","RC","","","","both","","","59.00","44.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46.91","79.5","","44.86","44.86","44.86","1 through 10","3.51","56.05","percent of total billed charges",""
"Mgh Ph Stool","PX-30002146","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","AETNA [1001]","HB AMC AETNA PPO","47.44","80.4","","44.46","44.46","44.46","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Ph Stool","PX-30002146","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","48.21","81.72","","45.57","45.57","45.57","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Ph Urine Test","PX-30002147","CDM","83986","CPT","0301","RC","","","","both","","","59.00","44.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46.91","79.5","","44.86","44.86","44.86","1 through 10","3.51","56.05","percent of total billed charges",""
"Mgh Ph Urine Test","PX-30002147","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","AETNA [1001]","HB AMC AETNA PPO","47.44","80.4","","44.46","44.46","44.46","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Ph Urine Test","PX-30002147","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","48.21","81.72","","45.57","45.57","45.57","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Phospholipids","PX-30002160","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Phospholipids","PX-30002160","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Phospholipids","PX-30002160","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Phospholipids","PX-30002170","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Phospholipids","PX-30002170","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Phospholipids","PX-30002170","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Php 1a and Spectrum","PX-31000292","CDM","81479","CPT","0310","RC","","","","both","","","1435.00","1076.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1140.83","79.5","","0.65","0.65","0.65","1 through 10","444.85","1363.25","percent of total billed charges",""
"Mgh Php 1a and Spectrum","PX-31000292","CDM","81479","CPT","0310","RC","","","","both","","","1435.00","1076.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","764.86","53.3","","0.79","0.79","0.79","1 through 10","444.85","1363.25","percent of total billed charges",""
"Mgh Php 1a and Spectrum","PX-31000292","CDM","81479","CPT","0310","RC","","","","outpatient","","","1435.00","1076.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","717.50","50","","1.00","1.00","1.00","1 through 10","156.55","1183.88","percent of total billed charges",""
"Mgh Php 1a and Spectrum","PX-31000292","CDM","81479","CPT","0310","RC","","","","outpatient","","","1435.00","1076.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","753.38","52.5","","1.00","0.53","1.00","1 through 10","156.55","1183.88","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Pivka II","PX-30002047","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Pkd Analysis","PX-31000245","CDM","81479","CPT","0310","RC","","","","both","","","5366.00","4024.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4265.97","79.5","","0.65","0.65","0.65","1 through 10","1663.46","5097.7","percent of total billed charges",""
"Mgh Pkd Analysis","PX-31000245","CDM","81479","CPT","0310","RC","","","","both","","","5366.00","4024.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2860.08","53.3","","0.79","0.79","0.79","1 through 10","1663.46","5097.7","percent of total billed charges",""
"Mgh Pkd Analysis","PX-31000245","CDM","81479","CPT","0310","RC","","","","outpatient","","","5366.00","4024.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2683.00","50","","1.00","1.00","1.00","1 through 10","156.55","4426.95","percent of total billed charges",""
"Mgh Pkd Analysis","PX-31000245","CDM","81479","CPT","0310","RC","","","","outpatient","","","5366.00","4024.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2817.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","4426.95","percent of total billed charges",""
"Mgh Plod2 Mutation Analysis","PX-31000390","CDM","81479","CPT","0310","RC","","","","both","","","2710.00","2032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2154.45","79.5","","0.65","0.65","0.65","1 through 10","840.1","2574.5","percent of total billed charges",""
"Mgh Plod2 Mutation Analysis","PX-31000390","CDM","81479","CPT","0310","RC","","","","both","","","2710.00","2032.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1444.43","53.3","","0.79","0.79","0.79","1 through 10","840.1","2574.5","percent of total billed charges",""
"Mgh Plod2 Mutation Analysis","PX-31000390","CDM","81479","CPT","0310","RC","","","","outpatient","","","2710.00","2032.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1355.00","50","","1.00","1.00","1.00","1 through 10","156.55","2235.75","percent of total billed charges",""
"Mgh Plod2 Mutation Analysis","PX-31000390","CDM","81479","CPT","0310","RC","","","","outpatient","","","2710.00","2032.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1422.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","2235.75","percent of total billed charges",""
"Mgh Polg Gene","PX-31000329","CDM","81479","CPT","0310","RC","","","","both","","","2978.00","2233.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2367.51","79.5","","0.65","0.65","0.65","1 through 10","923.18","2829.1","percent of total billed charges",""
"Mgh Polg Gene","PX-31000329","CDM","81479","CPT","0310","RC","","","","both","","","2978.00","2233.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1587.27","53.3","","0.79","0.79","0.79","1 through 10","923.18","2829.1","percent of total billed charges",""
"Mgh Polg Gene","PX-31000329","CDM","81479","CPT","0310","RC","","","","outpatient","","","2978.00","2233.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1489.00","50","","1.00","1.00","1.00","1 through 10","156.55","2456.85","percent of total billed charges",""
"Mgh Polg Gene","PX-31000329","CDM","81479","CPT","0310","RC","","","","outpatient","","","2978.00","2233.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1563.45","52.5","","1.00","0.53","1.00","1 through 10","156.55","2456.85","percent of total billed charges",""
"Mgh Pomc Sequence Analysis","PX-31000466","CDM","81479","CPT","0310","RC","","","","both","","","1220.00","915.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","969.90","79.5","","0.65","0.65","0.65","1 through 10","378.2","1159","percent of total billed charges",""
"Mgh Pomc Sequence Analysis","PX-31000466","CDM","81479","CPT","0310","RC","","","","both","","","1220.00","915.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","650.26","53.3","","0.79","0.79","0.79","1 through 10","378.2","1159","percent of total billed charges",""
"Mgh Pomc Sequence Analysis","PX-31000466","CDM","81479","CPT","0310","RC","","","","outpatient","","","1220.00","915.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","610.00","50","","1.00","1.00","1.00","1 through 10","156.55","1006.5","percent of total billed charges",""
"Mgh Pomc Sequence Analysis","PX-31000466","CDM","81479","CPT","0310","RC","","","","outpatient","","","1220.00","915.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","640.50","52.5","","1.00","0.53","1.00","1 through 10","156.55","1006.5","percent of total billed charges",""
"Mgh Porphyrins Total","PX-30002161","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Porphyrins Total","PX-30002161","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Porphyrins Total","PX-30002161","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Porphyrins Total","PX-30002171","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Porphyrins Total","PX-30002171","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Porphyrins Total","PX-30002171","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Posaconazole, Serum","PX-30002269","CDM","80299","CPT","0300","RC","","","","both","","","461.00","345.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","366.50","79.5","","106.25","71.28","106.25","1 through 10","14.12","437.95","percent of total billed charges",""
"Mgh Posaconazole, Serum","PX-30002269","CDM","80299","CPT","0300","RC","","","","both","","","461.00","345.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","245.71","53.3","","106.25","71.28","106.25","1 through 10","14.12","437.95","percent of total billed charges",""
"Mgh Posaconazole, Serum","PX-30002269","CDM","80299","CPT","0300","RC","","","","both","","","461.00","345.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","168.27","36.5","","50.36","42.80","92.50","13","14.12","437.95","percent of total billed charges",""
"Mgh Posaconazole, Serum","PX-30002269","CDM","80299","CPT","0300","RC","","","","both","","","461.00","345.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","176.56","38.3","","52.79","44.55","158.37","30","14.12","437.95","percent of total billed charges",""
"Mgh Posaconazole, Serum","PX-30002269","CDM","80299","CPT","0300","RC","","","","outpatient","","","461.00","345.75","AETNA [1001]","HB AMC AETNA HMO","321.78","69.8","","91.40","64.53","105.30","14","14.12","376.73","percent of total billed charges",""
"Mgh Posaconazole, Serum","PX-30002269","CDM","80299","CPT","0300","RC","","","","outpatient","","","461.00","345.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","370.64","80.4","","105.30","105.30","105.30","1 through 10","14.12","376.73","percent of total billed charges",""
"Mgh Posaconazole, Serum","PX-30002269","CDM","80299","CPT","0300","RC","","","","outpatient","","","461.00","345.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","376.73","81.72","","59.36","15.50","59.36","1 through 10","14.12","376.73","percent of total billed charges",""
"Mgh Post Transplantation Follow Up","PX-39000035","CDM","86849","CPT","0390","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","298.48","65.6","","298.56","298.56","298.56","1 through 10","141.05","361.73","percent of total billed charges",""
"Mgh Post Transplantation Follow Up","PX-39000035","CDM","86849","CPT","0390","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","295.75","65","","286.65","286.65","347.07","11","141.05","361.73","percent of total billed charges",""
"Mgh Post Transplantation Follow Up","PX-39000035","CDM","86849","CPT","0390","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","318.50","70","","317.52","189.63","317.52","1 through 10","141.05","361.73","percent of total billed charges",""
"Mgh Post Transplantation Follow Up","PX-39000035","CDM","86849","CPT","0390","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","295.75","65","","286.65","270.40","286.65","12","141.05","361.73","percent of total billed charges",""
"Mgh Post Transplantation Follow Up","PX-39000035","CDM","86849","CPT","0390","RC","","","","both","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","295.75","65","","286.65","286.65","286.65","1 through 10","141.05","361.73","percent of total billed charges",""
"Mgh Post Transplantation Follow Up","PX-39000035","CDM","86849","CPT","0390","RC","","","","both","","","455.00","341.25","WELLPOINT [1015]","HB AMC WELLPOINT","335.70","73.78","","328.32","306.01","328.32","1 through 10","141.05","361.73","percent of total billed charges",""
"Mgh Post Transplantation Follow Up","PX-39000035","CDM","86849","CPT","0390","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","298.56","298.56","343.98","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh Post Transplantation Follow Up","PX-39000035","CDM","86849","CPT","0390","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA PPO","365.82","80.4","","343.98","343.98","343.98","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh Post Transplantation Follow Up","PX-39000035","CDM","86849","CPT","0390","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","227.50","50","","441.00","441.00","441.00","12","227.5","375.38","percent of total billed charges",""
"Mgh Post Transplantation Follow Up","PX-39000035","CDM","86849","CPT","0390","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","238.88","52.5","","441.00","441.00","441.00","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh Post Transplantation Follow Up","PX-39000035","CDM","86849","CPT","0390","RC","","","","outpatient","","","455.00","341.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","250.25","55","","254.02","254.02","254.02","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh Post Transplantation Follow Up","PX-39000035","CDM","86849","CPT","0390","RC","","","","outpatient","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","365.82","80.4","","343.98","343.98","343.98","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh Post Transplantation Follow Up","PX-39000035","CDM","86849","CPT","0390","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","284.38","62.5","","288.86","277.39","288.86","1 through 10","227.5","375.38","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Preg Asoc Placntl Protn","PX-30002103","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Preg Assoc Placental Protein","PX-30002075","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Preop Plcmnt Ndle Loc Wire Msk","PX-76001883","CDM","20999","CPT","0761","RC","","","","outpatient","","","2426.00","1819.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1266.86","52.22","","596.65","596.65","596.65","1 through 10","1213","8899.59","percent of total billed charges",""
"Mgh Preop Plcmnt Ndle Loc Wire Msk","PX-76001883","CDM","20999","CPT","0761","RC","","","","outpatient","","","2426.00","1819.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1273.65","52.5","","1695.17","1695.17","1695.17","1 through 10","1213","8899.59","percent of total billed charges",""
"Mgh Preop Plcmnt Ndle Loc Wire Msk","PX-76001999","CDM","20999","CPT","0761","RC","","","","outpatient","","","2426.00","1819.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1266.86","52.22","","596.65","596.65","596.65","1 through 10","1213","8899.59","percent of total billed charges",""
"Mgh Preop Plcmnt Ndle Loc Wire Msk","PX-76001999","CDM","20999","CPT","0761","RC","","","","outpatient","","","2426.00","1819.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1273.65","52.5","","1695.17","1695.17","1695.17","1 through 10","1213","8899.59","percent of total billed charges",""
"Mgh Primary Carnitine Deficiency (Slc22a5) Deletion/Duplication","PX-31000545","CDM","81479","CPT","0310","RC","","","","both","","","968.00","726.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","769.56","79.5","","0.65","0.65","0.65","1 through 10","300.08","919.6","percent of total billed charges",""
"Mgh Primary Carnitine Deficiency (Slc22a5) Deletion/Duplication","PX-31000545","CDM","81479","CPT","0310","RC","","","","both","","","968.00","726.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","515.94","53.3","","0.79","0.79","0.79","1 through 10","300.08","919.6","percent of total billed charges",""
"Mgh Primary Carnitine Deficiency (Slc22a5) Deletion/Duplication","PX-31000545","CDM","81479","CPT","0310","RC","","","","outpatient","","","968.00","726.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","484.00","50","","1.00","1.00","1.00","1 through 10","156.55","798.6","percent of total billed charges",""
"Mgh Primary Carnitine Deficiency (Slc22a5) Deletion/Duplication","PX-31000545","CDM","81479","CPT","0310","RC","","","","outpatient","","","968.00","726.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","508.20","52.5","","1.00","0.53","1.00","1 through 10","156.55","798.6","percent of total billed charges",""
"Mgh Primary Ciliary Dyskinesia Sequencing","PX-31000570","CDM","81479","CPT","0310","RC","","","","both","","","581.00","435.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","461.90","79.5","","0.65","0.65","0.65","1 through 10","180.11","551.95","percent of total billed charges",""
"Mgh Primary Ciliary Dyskinesia Sequencing","PX-31000570","CDM","81479","CPT","0310","RC","","","","both","","","581.00","435.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","309.67","53.3","","0.79","0.79","0.79","1 through 10","180.11","551.95","percent of total billed charges",""
"Mgh Primary Ciliary Dyskinesia Sequencing","PX-31000570","CDM","81479","CPT","0310","RC","","","","outpatient","","","581.00","435.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","290.50","50","","1.00","1.00","1.00","1 through 10","156.55","479.33","percent of total billed charges",""
"Mgh Primary Ciliary Dyskinesia Sequencing","PX-31000570","CDM","81479","CPT","0310","RC","","","","outpatient","","","581.00","435.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","305.03","52.5","","1.00","0.53","1.00","1 through 10","156.55","479.33","percent of total billed charges",""
"Mgh Prkar1a Gene Sequencing","PX-31000366","CDM","81479","CPT","0310","RC","","","","both","","","4923.00","3692.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3913.79","79.5","","0.65","0.65","0.65","1 through 10","1526.13","4676.85","percent of total billed charges",""
"Mgh Prkar1a Gene Sequencing","PX-31000366","CDM","81479","CPT","0310","RC","","","","both","","","4923.00","3692.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2623.96","53.3","","0.79","0.79","0.79","1 through 10","1526.13","4676.85","percent of total billed charges",""
"Mgh Prkar1a Gene Sequencing","PX-31000366","CDM","81479","CPT","0310","RC","","","","outpatient","","","4923.00","3692.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2461.50","50","","1.00","1.00","1.00","1 through 10","156.55","4061.48","percent of total billed charges",""
"Mgh Prkar1a Gene Sequencing","PX-31000366","CDM","81479","CPT","0310","RC","","","","outpatient","","","4923.00","3692.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2584.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","4061.48","percent of total billed charges",""
"Mgh Proliferative Vasculopathy/Hydranencephaly-Hydrocephaly","PX-30003371","CDM","81479","CPT","0310","RC","","","","both","","","1328.00","996.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1055.76","79.5","","0.65","0.65","0.65","1 through 10","411.68","1261.6","percent of total billed charges",""
"Mgh Proliferative Vasculopathy/Hydranencephaly-Hydrocephaly","PX-30003371","CDM","81479","CPT","0310","RC","","","","both","","","1328.00","996.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","707.82","53.3","","0.79","0.79","0.79","1 through 10","411.68","1261.6","percent of total billed charges",""
"Mgh Proliferative Vasculopathy/Hydranencephaly-Hydrocephaly","PX-30003371","CDM","81479","CPT","0310","RC","","","","outpatient","","","1328.00","996.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","664.00","50","","1.00","1.00","1.00","1 through 10","156.55","1095.6","percent of total billed charges",""
"Mgh Proliferative Vasculopathy/Hydranencephaly-Hydrocephaly","PX-30003371","CDM","81479","CPT","0310","RC","","","","outpatient","","","1328.00","996.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","697.20","52.5","","1.00","0.53","1.00","1 through 10","156.55","1095.6","percent of total billed charges",""
"Mgh Protriptyline","PX-30001546","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Protriptyline","PX-30001546","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Protriptyline","PX-30001546","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Protriptyline","PX-30001546","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Protriptyline","PX-30001546","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Protriptyline","PX-30001546","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Protriptyline","PX-30001546","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Prps1-Related Disorders","PX-31000617","CDM","81479","CPT","0310","RC","","","","both","","","1227.00","920.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","975.47","79.5","","0.65","0.65","0.65","1 through 10","380.37","1165.65","percent of total billed charges",""
"Mgh Prps1-Related Disorders","PX-31000617","CDM","81479","CPT","0310","RC","","","","both","","","1227.00","920.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","653.99","53.3","","0.79","0.79","0.79","1 through 10","380.37","1165.65","percent of total billed charges",""
"Mgh Prps1-Related Disorders","PX-31000617","CDM","81479","CPT","0310","RC","","","","outpatient","","","1227.00","920.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","613.50","50","","1.00","1.00","1.00","1 through 10","156.55","1012.28","percent of total billed charges",""
"Mgh Prps1-Related Disorders","PX-31000617","CDM","81479","CPT","0310","RC","","","","outpatient","","","1227.00","920.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","644.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","1012.28","percent of total billed charges",""
"Mgh Prq Balloon Ocld Iliac Art Uni","PX-36000188","CDM","37799","CPT","0361","RC","","","","outpatient","","","9163.00","6872.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4784.92","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","7559.48","percent of total billed charges",""
"Mgh Prq Balloon Ocld Iliac Art Uni","PX-36000188","CDM","37799","CPT","0361","RC","","","","outpatient","","","9163.00","6872.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4810.58","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","7559.48","percent of total billed charges",""
"Mgh Prrt2 (Dyskinesia/Ic) Dna Sequencing Test","PX-31000568","CDM","81479","CPT","0310","RC","","","","both","","","2699.00","2024.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2145.71","79.5","","0.65","0.65","0.65","1 through 10","836.69","2564.05","percent of total billed charges",""
"Mgh Prrt2 (Dyskinesia/Ic) Dna Sequencing Test","PX-31000568","CDM","81479","CPT","0310","RC","","","","both","","","2699.00","2024.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1438.57","53.3","","0.79","0.79","0.79","1 through 10","836.69","2564.05","percent of total billed charges",""
"Mgh Prrt2 (Dyskinesia/Ic) Dna Sequencing Test","PX-31000568","CDM","81479","CPT","0310","RC","","","","outpatient","","","2699.00","2024.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1349.50","50","","1.00","1.00","1.00","1 through 10","156.55","2226.68","percent of total billed charges",""
"Mgh Prrt2 (Dyskinesia/Ic) Dna Sequencing Test","PX-31000568","CDM","81479","CPT","0310","RC","","","","outpatient","","","2699.00","2024.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1416.98","52.5","","1.00","0.53","1.00","1 through 10","156.55","2226.68","percent of total billed charges",""
"Mgh Prrt2 Gene Sequence","PX-31000634","CDM","81479","CPT","0310","RC","","","","both","","","1294.00","970.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1028.73","79.5","","0.65","0.65","0.65","1 through 10","401.14","1229.3","percent of total billed charges",""
"Mgh Prrt2 Gene Sequence","PX-31000634","CDM","81479","CPT","0310","RC","","","","both","","","1294.00","970.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","689.70","53.3","","0.79","0.79","0.79","1 through 10","401.14","1229.3","percent of total billed charges",""
"Mgh Prrt2 Gene Sequence","PX-31000634","CDM","81479","CPT","0310","RC","","","","outpatient","","","1294.00","970.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","647.00","50","","1.00","1.00","1.00","1 through 10","156.55","1067.55","percent of total billed charges",""
"Mgh Prrt2 Gene Sequence","PX-31000634","CDM","81479","CPT","0310","RC","","","","outpatient","","","1294.00","970.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","679.35","52.5","","1.00","0.53","1.00","1 through 10","156.55","1067.55","percent of total billed charges",""
"Mgh Prrt2 Gene Sequencing","PX-31000372","CDM","81479","CPT","0310","RC","","","","both","","","1353.00","1014.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1075.64","79.5","","0.65","0.65","0.65","1 through 10","419.43","1285.35","percent of total billed charges",""
"Mgh Prrt2 Gene Sequencing","PX-31000372","CDM","81479","CPT","0310","RC","","","","both","","","1353.00","1014.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","721.15","53.3","","0.79","0.79","0.79","1 through 10","419.43","1285.35","percent of total billed charges",""
"Mgh Prrt2 Gene Sequencing","PX-31000372","CDM","81479","CPT","0310","RC","","","","outpatient","","","1353.00","1014.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","676.50","50","","1.00","1.00","1.00","1 through 10","156.55","1116.23","percent of total billed charges",""
"Mgh Prrt2 Gene Sequencing","PX-31000372","CDM","81479","CPT","0310","RC","","","","outpatient","","","1353.00","1014.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","710.33","52.5","","1.00","0.53","1.00","1 through 10","156.55","1116.23","percent of total billed charges",""
"Mgh Pseudo Type 1a","PX-31000233","CDM","81479","CPT","0310","RC","","","","both","","","4531.00","3398.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3602.15","79.5","","0.65","0.65","0.65","1 through 10","1404.61","4304.45","percent of total billed charges",""
"Mgh Pseudo Type 1a","PX-31000233","CDM","81479","CPT","0310","RC","","","","both","","","4531.00","3398.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2415.02","53.3","","0.79","0.79","0.79","1 through 10","1404.61","4304.45","percent of total billed charges",""
"Mgh Pseudo Type 1a","PX-31000233","CDM","81479","CPT","0310","RC","","","","outpatient","","","4531.00","3398.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2265.50","50","","1.00","1.00","1.00","1 through 10","156.55","3738.08","percent of total billed charges",""
"Mgh Pseudo Type 1a","PX-31000233","CDM","81479","CPT","0310","RC","","","","outpatient","","","4531.00","3398.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2378.78","52.5","","1.00","0.53","1.00","1 through 10","156.55","3738.08","percent of total billed charges",""
"Mgh Pstpip1 Select Exons Sequencing","PX-31000604","CDM","81479","CPT","0310","RC","","","","both","","","903.00","677.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","717.89","79.5","","0.65","0.65","0.65","1 through 10","279.93","857.85","percent of total billed charges",""
"Mgh Pstpip1 Select Exons Sequencing","PX-31000604","CDM","81479","CPT","0310","RC","","","","both","","","903.00","677.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","481.30","53.3","","0.79","0.79","0.79","1 through 10","279.93","857.85","percent of total billed charges",""
"Mgh Pstpip1 Select Exons Sequencing","PX-31000604","CDM","81479","CPT","0310","RC","","","","outpatient","","","903.00","677.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","451.50","50","","1.00","1.00","1.00","1 through 10","156.55","744.98","percent of total billed charges",""
"Mgh Pstpip1 Select Exons Sequencing","PX-31000604","CDM","81479","CPT","0310","RC","","","","outpatient","","","903.00","677.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","474.08","52.5","","1.00","0.53","1.00","1 through 10","156.55","744.98","percent of total billed charges",""
"Mgh Pulmogene Panel (64 Genes) Test","PX-31000520","CDM","81479","CPT","0310","RC","","","","both","","","624.00","468.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","496.08","79.5","","0.65","0.65","0.65","1 through 10","193.44","592.8","percent of total billed charges",""
"Mgh Pulmogene Panel (64 Genes) Test","PX-31000520","CDM","81479","CPT","0310","RC","","","","both","","","624.00","468.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","332.59","53.3","","0.79","0.79","0.79","1 through 10","193.44","592.8","percent of total billed charges",""
"Mgh Pulmogene Panel (64 Genes) Test","PX-31000520","CDM","81479","CPT","0310","RC","","","","outpatient","","","624.00","468.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","312.00","50","","1.00","1.00","1.00","1 through 10","156.55","514.8","percent of total billed charges",""
"Mgh Pulmogene Panel (64 Genes) Test","PX-31000520","CDM","81479","CPT","0310","RC","","","","outpatient","","","624.00","468.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","327.60","52.5","","1.00","0.53","1.00","1 through 10","156.55","514.8","percent of total billed charges",""
"Mgh Pulmonary Fibrosis - Hermansky Pudlak Panel (21 Genes)","PX-31000559","CDM","81479","CPT","0310","RC","","","","both","","","5057.00","3792.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4020.32","79.5","","0.65","0.65","0.65","1 through 10","1567.67","4804.15","percent of total billed charges",""
"Mgh Pulmonary Fibrosis - Hermansky Pudlak Panel (21 Genes)","PX-31000559","CDM","81479","CPT","0310","RC","","","","both","","","5057.00","3792.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2695.38","53.3","","0.79","0.79","0.79","1 through 10","1567.67","4804.15","percent of total billed charges",""
"Mgh Pulmonary Fibrosis - Hermansky Pudlak Panel (21 Genes)","PX-31000559","CDM","81479","CPT","0310","RC","","","","outpatient","","","5057.00","3792.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2528.50","50","","1.00","1.00","1.00","1 through 10","156.55","4172.03","percent of total billed charges",""
"Mgh Pulmonary Fibrosis - Hermansky Pudlak Panel (21 Genes)","PX-31000559","CDM","81479","CPT","0310","RC","","","","outpatient","","","5057.00","3792.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2654.93","52.5","","1.00","0.53","1.00","1 through 10","156.55","4172.03","percent of total billed charges",""
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","931.74","other","OPPS APC"
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","931.74","other","OPPS APC"
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","624.68","53.3","","477.31","477.31","477.31","1 through 10","333.03","931.74","percent of total billed charges",""
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","931.74","other","OPPS APC"
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","931.74","other","OPPS APC"
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","427.78","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","931.74","percent of total billed charges",""
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","448.88","38.3","","343.52","323.76","353.46","1 through 10","333.03","931.74","percent of total billed charges",""
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","931.74","other","Tricare OPPS"
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","931.74","other","OPPS APC"
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","931.74","other","OPPS APC"
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","both","","","1172.00","879.00","WELLPOINT [1015]","HB AMC WELLPOINT","864.70","73.78","","673.03","673.03","673.03","1 through 10","333.03","931.74","percent of total billed charges",""
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","outpatient","","","1172.00","879.00","AETNA [1001]","HB AMC AETNA HMO","818.06","69.8","","612.01","612.01","1224.02","1 through 10","586","966.9","percent of total billed charges",""
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","outpatient","","","1172.00","879.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","709.65","60.55","","579.04","568.57","904.00","30","586","966.9","percent of total billed charges",""
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","outpatient","","","1172.00","879.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","612.02","52.22","","904.00","656.02","2938.00","26","586","966.9","percent of total billed charges",""
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","outpatient","","","1172.00","879.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","586.00","50","","1421.10","875.08","2368.50","15","586","966.9","percent of total billed charges",""
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","outpatient","","","1172.00","879.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","615.30","52.5","","2985.00","904.00","2985.00","1 through 10","586","966.9","percent of total billed charges",""
"Mgh Pulsed Radiofreq Ablation Pain","PX-98300615","CDM","64999","CPT","0983","RC","","","","outpatient","","","1172.00","879.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","957.76","81.72","","722.66","722.66","17449.00","1 through 10","586","966.9","percent of total billed charges",""
"Mgh Pyrazinamide","PX-30001526","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.38","79.5","","106.25","71.28","106.25","1 through 10","14.12","308.75","percent of total billed charges",""
"Mgh Pyrazinamide","PX-30001526","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.23","53.3","","106.25","71.28","106.25","1 through 10","14.12","308.75","percent of total billed charges",""
"Mgh Pyrazinamide","PX-30001526","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.63","36.5","","50.36","42.80","92.50","13","14.12","308.75","percent of total billed charges",""
"Mgh Pyrazinamide","PX-30001526","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.48","38.3","","52.79","44.55","158.37","30","14.12","308.75","percent of total billed charges",""
"Mgh Pyrazinamide","PX-30001526","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","AETNA [1001]","HB AMC AETNA HMO","226.85","69.8","","91.40","64.53","105.30","14","14.12","265.59","percent of total billed charges",""
"Mgh Pyrazinamide","PX-30001526","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","261.30","80.4","","105.30","105.30","105.30","1 through 10","14.12","265.59","percent of total billed charges",""
"Mgh Pyrazinamide","PX-30001526","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","265.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","265.59","percent of total billed charges",""
"Mgh Rag1/Rag2 Gene Sequencing","PX-31000268","CDM","81479","CPT","0310","RC","","","","both","","","6132.00","4599.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4874.94","79.5","","0.65","0.65","0.65","1 through 10","1900.92","5825.4","percent of total billed charges",""
"Mgh Rag1/Rag2 Gene Sequencing","PX-31000268","CDM","81479","CPT","0310","RC","","","","both","","","6132.00","4599.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3268.36","53.3","","0.79","0.79","0.79","1 through 10","1900.92","5825.4","percent of total billed charges",""
"Mgh Rag1/Rag2 Gene Sequencing","PX-31000268","CDM","81479","CPT","0310","RC","","","","outpatient","","","6132.00","4599.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3066.00","50","","1.00","1.00","1.00","1 through 10","156.55","5058.9","percent of total billed charges",""
"Mgh Rag1/Rag2 Gene Sequencing","PX-31000268","CDM","81479","CPT","0310","RC","","","","outpatient","","","6132.00","4599.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3219.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","5058.9","percent of total billed charges",""
"Mgh Raltegravin","PX-30001527","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.38","79.5","","106.25","71.28","106.25","1 through 10","14.12","308.75","percent of total billed charges",""
"Mgh Raltegravin","PX-30001527","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.23","53.3","","106.25","71.28","106.25","1 through 10","14.12","308.75","percent of total billed charges",""
"Mgh Raltegravin","PX-30001527","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.63","36.5","","50.36","42.80","92.50","13","14.12","308.75","percent of total billed charges",""
"Mgh Raltegravin","PX-30001527","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.48","38.3","","52.79","44.55","158.37","30","14.12","308.75","percent of total billed charges",""
"Mgh Raltegravin","PX-30001527","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","AETNA [1001]","HB AMC AETNA HMO","226.85","69.8","","91.40","64.53","105.30","14","14.12","265.59","percent of total billed charges",""
"Mgh Raltegravin","PX-30001527","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","261.30","80.4","","105.30","105.30","105.30","1 through 10","14.12","265.59","percent of total billed charges",""
"Mgh Raltegravin","PX-30001527","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","265.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","265.59","percent of total billed charges",""
"Mgh Ranbp2 Common Mutations Analysis","PX-31000618","CDM","81479","CPT","0310","RC","","","","both","","","2257.00","1692.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1794.32","79.5","","0.65","0.65","0.65","1 through 10","699.67","2144.15","percent of total billed charges",""
"Mgh Ranbp2 Common Mutations Analysis","PX-31000618","CDM","81479","CPT","0310","RC","","","","both","","","2257.00","1692.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1202.98","53.3","","0.79","0.79","0.79","1 through 10","699.67","2144.15","percent of total billed charges",""
"Mgh Ranbp2 Common Mutations Analysis","PX-31000618","CDM","81479","CPT","0310","RC","","","","outpatient","","","2257.00","1692.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1128.50","50","","1.00","1.00","1.00","1 through 10","156.55","1862.03","percent of total billed charges",""
"Mgh Ranbp2 Common Mutations Analysis","PX-31000618","CDM","81479","CPT","0310","RC","","","","outpatient","","","2257.00","1692.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1184.93","52.5","","1.00","0.53","1.00","1 through 10","156.55","1862.03","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002199","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost Is per Allergen","PX-30002203","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002201","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Rast Cost per Allergen","PX-30002205","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Rast Northeast 86005","PX-30002206","CDM","86005","CPT","0302","RC","","","","both","","","135.00","101.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","94.50","70","","104.80","104.80","104.80","1 through 10","7.81","128.25","percent of total billed charges",""
"Mgh Reep1 Spg31 Deletion Analysis","PX-31000258","CDM","81479","CPT","0310","RC","","","","both","","","1532.00","1149.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1217.94","79.5","","0.65","0.65","0.65","1 through 10","474.92","1455.4","percent of total billed charges",""
"Mgh Reep1 Spg31 Deletion Analysis","PX-31000258","CDM","81479","CPT","0310","RC","","","","both","","","1532.00","1149.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","816.56","53.3","","0.79","0.79","0.79","1 through 10","474.92","1455.4","percent of total billed charges",""
"Mgh Reep1 Spg31 Deletion Analysis","PX-31000258","CDM","81479","CPT","0310","RC","","","","outpatient","","","1532.00","1149.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","766.00","50","","1.00","1.00","1.00","1 through 10","156.55","1263.9","percent of total billed charges",""
"Mgh Reep1 Spg31 Deletion Analysis","PX-31000258","CDM","81479","CPT","0310","RC","","","","outpatient","","","1532.00","1149.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","804.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","1263.9","percent of total billed charges",""
"Mgh Relax Cpet Sress Test Protocol","PX-46000060","CDM","94799","CPT","0460","RC","","","","both","","","3186.00","2389.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","754.00","71.74","754.00","1 through 10","176.52","2532.87","other","OPPS APC"
"Mgh Relax Cpet Sress Test Protocol","PX-46000060","CDM","94799","CPT","0460","RC","","","","both","","","3186.00","2389.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2532.87","79.5","","398.11","398.11","398.11","1 through 10","176.52","2532.87","percent of total billed charges",""
"Mgh Relax Cpet Sress Test Protocol","PX-46000060","CDM","94799","CPT","0460","RC","","","","both","","","3186.00","2389.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2070.90","65","","399.62","399.62","399.62","1 through 10","176.52","2532.87","percent of total billed charges",""
"Mgh Relax Cpet Sress Test Protocol","PX-46000060","CDM","94799","CPT","0460","RC","","","","both","","","3186.00","2389.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1220.24","38.3","","294.81","294.81","294.81","1 through 10","176.52","2532.87","percent of total billed charges",""
"Mgh Relax Cpet Sress Test Protocol","PX-46000060","CDM","94799","CPT","0460","RC","","","","outpatient","","","3186.00","2389.50","AETNA [1001]","HB AMC AETNA HMO","2223.83","69.8","","510.46","510.46","510.46","1 through 10","304.03","2628.45","percent of total billed charges",""
"Mgh Relax Cpet Sress Test Protocol","PX-46000060","CDM","94799","CPT","0460","RC","","","","outpatient","","","3186.00","2389.50","AETNA [1001]","HB AMC AETNA PPO","2561.54","80.4","","588.12","588.12","588.12","1 through 10","304.03","2628.45","percent of total billed charges",""
"Mgh Relax Cpet Sress Test Protocol","PX-46000060","CDM","94799","CPT","0460","RC","","","","outpatient","","","3186.00","2389.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1929.12","60.55","","363.93","312.34","754.00","1 through 10","304.03","2628.45","percent of total billed charges",""
"Mgh Relax Cpet Sress Test Protocol","PX-46000060","CDM","94799","CPT","0460","RC","","","","outpatient","","","3186.00","2389.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1663.73","52.22","","363.93","360.37","754.00","1 through 10","304.03","2628.45","percent of total billed charges",""
"Mgh Relax Cpet Sress Test Protocol","PX-46000060","CDM","94799","CPT","0460","RC","","","","outpatient","","","3186.00","2389.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1593.00","50","","754.00","754.00","754.00","1 through 10","304.03","2628.45","percent of total billed charges",""
"Mgh Relax Cpet Sress Test Protocol","PX-46000060","CDM","94799","CPT","0460","RC","","","","outpatient","","","3186.00","2389.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1672.65","52.5","","754.00","414.70","754.00","1 through 10","304.03","2628.45","percent of total billed charges",""
"Mgh Relax Cpet Sress Test Protocol","PX-46000060","CDM","94799","CPT","0460","RC","","","","outpatient","","","3186.00","2389.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1752.30","55","","434.30","434.30","434.30","1 through 10","304.03","2628.45","percent of total billed charges",""
"Mgh Relax Cpet Sress Test Protocol","PX-46000060","CDM","94799","CPT","0460","RC","","","","outpatient","","","3186.00","2389.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2603.60","81.72","","602.75","602.75","602.75","1 through 10","304.03","2628.45","percent of total billed charges",""
"Mgh Retinol Binding Protein","PX-30002130","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Retinol Binding Protein","PX-30002130","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Retinol Binding Protein","PX-30002133","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Retinol Binding Protein","PX-30002133","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Revise Av Fistula,W/O Thrombectomy","PX-36000361","CDM","36832","CPT","0361","RC","","","","both","","","14656.00","10992.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","6418.94","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5901.79","5901.79","5901.79","1 through 10","4543.36","11651.52","other","OPPS APC"
"Mgh Revise Av Fistula,W/O Thrombectomy","PX-36000361","CDM","36832","CPT","0361","RC","","","","both","","","14656.00","10992.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","8023.68","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","5503.89","5503.89","5503.89","1 through 10","4543.36","11651.52","other","OPPS APC"
"Mgh Revise Av Fistula,W/O Thrombectomy","PX-36000361","CDM","36832","CPT","0361","RC","","","","both","","","14656.00","10992.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","6418.94","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6291.20","6291.20","6291.20","1 through 10","4543.36","11651.52","other","OPPS APC"
"Mgh Revise Av Fistula,W/O Thrombectomy","PX-36000361","CDM","36832","CPT","0361","RC","","","","both","","","14656.00","10992.00","MEDICARE [2001]","HB BWH MEDICARE","6418.94","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","19258.77","6419.59","32097.95","37","4543.36","11651.52","other","OPPS APC"
"Mgh Revise Av Fistula,W/O Thrombectomy","PX-36000361","CDM","36832","CPT","0361","RC","","","","both","","","14656.00","10992.00","MOLINA [1014]","HB BWH MOLINA","6290.57","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","12736.47","12736.47","12736.47","1 through 10","4543.36","11651.52","other","OPPS APC"
"Mgh Revise Av Fistula,W/O Thrombectomy","PX-36000361","CDM","36832","CPT","0361","RC","","","","both","","","14656.00","10992.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6290.57","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6291.20","6291.20","6291.20","1 through 10","4543.36","11651.52","other","OPPS APC"
"Mgh Revise Av Fistula,W/O Thrombectomy","PX-36000361","CDM","36832","CPT","0361","RC","","","","both","","","14656.00","10992.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6290.57","","APC Price ($6,418.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6298.20","5877.80","6298.70","1 through 10","4543.36","11651.52","other","OPPS APC"
"Mgh Revise Av Fistula,W/O Thrombectomy","PX-36000361","CDM","36832","CPT","0361","RC","","","","outpatient","","","14656.00","10992.00","AETNA [1001]","HB AMC AETNA HMO","10229.89","69.8","","3986.52","3986.52","3986.52","1 through 10","3938.87","11976.88","percent of total billed charges",""
"Mgh Revise Av Fistula,W/O Thrombectomy","PX-36000361","CDM","36832","CPT","0361","RC","","","","outpatient","","","14656.00","10992.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5004.80","","Case rate ($5,004.80). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","10054.64","10054.64","10054.64","1 through 10","3938.87","11976.88","other","ASC"
"Mgh Revise Av Fistula,W/O Thrombectomy","PX-36000361","CDM","36832","CPT","0361","RC","","","","outpatient","","","14656.00","10992.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3938.87","","Case rate ($3,938.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","9138.18","9138.18","9138.18","1 through 10","3938.87","11976.88","other","Multiple Surgery"
"Mgh Rf Ablation Musculoskl Tumor","PX-76002000","CDM","20999","CPT","0761","RC","","","","outpatient","","","10954.00","8215.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5720.18","52.22","","596.65","596.65","596.65","1 through 10","5477","9037.05","percent of total billed charges",""
"Mgh Rf Ablation Musculoskl Tumor","PX-76002000","CDM","20999","CPT","0761","RC","","","","outpatient","","","10954.00","8215.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","5750.85","52.5","","1695.17","1695.17","1695.17","1 through 10","5477","9037.05","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002068","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Ribosomal P Protein Ab","PX-30002098","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Risperidone","PX-30001547","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Risperidone","PX-30001547","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Risperidone","PX-30001547","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Risperidone","PX-30001547","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Risperidone","PX-30001547","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Risperidone","PX-30001547","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Risperidone","PX-30001547","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Risperidone 82542","PX-30001969","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Risperidone 82542","PX-30001969","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Risperidone 82542","PX-30001969","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Risperidone 82542","PX-30001969","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Risperidone 82542","PX-30001969","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Risperidone 82542","PX-30001969","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Risperidone 82542","PX-30001969","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Risperidone 82542","PX-30001969","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Risperidone 82542","PX-30001969","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Ritonavir","PX-30001528","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.38","79.5","","106.25","71.28","106.25","1 through 10","14.12","308.75","percent of total billed charges",""
"Mgh Ritonavir","PX-30001528","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.23","53.3","","106.25","71.28","106.25","1 through 10","14.12","308.75","percent of total billed charges",""
"Mgh Ritonavir","PX-30001528","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.63","36.5","","50.36","42.80","92.50","13","14.12","308.75","percent of total billed charges",""
"Mgh Ritonavir","PX-30001528","CDM","80299","CPT","0301","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.48","38.3","","52.79","44.55","158.37","30","14.12","308.75","percent of total billed charges",""
"Mgh Ritonavir","PX-30001528","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","AETNA [1001]","HB AMC AETNA HMO","226.85","69.8","","91.40","64.53","105.30","14","14.12","265.59","percent of total billed charges",""
"Mgh Ritonavir","PX-30001528","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","261.30","80.4","","105.30","105.30","105.30","1 through 10","14.12","265.59","percent of total billed charges",""
"Mgh Ritonavir","PX-30001528","CDM","80299","CPT","0301","RC","","","","outpatient","","","325.00","243.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","265.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","265.59","percent of total billed charges",""
"Mgh Sacs Sanger Sequencing","PX-31000324","CDM","81479","CPT","0310","RC","","","","both","","","5835.00","4376.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4638.83","79.5","","0.65","0.65","0.65","1 through 10","1808.85","5543.25","percent of total billed charges",""
"Mgh Sacs Sanger Sequencing","PX-31000324","CDM","81479","CPT","0310","RC","","","","both","","","5835.00","4376.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3110.06","53.3","","0.79","0.79","0.79","1 through 10","1808.85","5543.25","percent of total billed charges",""
"Mgh Sacs Sanger Sequencing","PX-31000324","CDM","81479","CPT","0310","RC","","","","outpatient","","","5835.00","4376.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2917.50","50","","1.00","1.00","1.00","1 through 10","156.55","4813.88","percent of total billed charges",""
"Mgh Sacs Sanger Sequencing","PX-31000324","CDM","81479","CPT","0310","RC","","","","outpatient","","","5835.00","4376.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3063.38","52.5","","1.00","0.53","1.00","1 through 10","156.55","4813.88","percent of total billed charges",""
"Mgh Sall4 Gene","PX-31000330","CDM","81479","CPT","0310","RC","","","","both","","","5699.00","4274.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4530.71","79.5","","0.65","0.65","0.65","1 through 10","1766.69","5414.05","percent of total billed charges",""
"Mgh Sall4 Gene","PX-31000330","CDM","81479","CPT","0310","RC","","","","both","","","5699.00","4274.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3037.57","53.3","","0.79","0.79","0.79","1 through 10","1766.69","5414.05","percent of total billed charges",""
"Mgh Sall4 Gene","PX-31000330","CDM","81479","CPT","0310","RC","","","","outpatient","","","5699.00","4274.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2849.50","50","","1.00","1.00","1.00","1 through 10","156.55","4701.68","percent of total billed charges",""
"Mgh Sall4 Gene","PX-31000330","CDM","81479","CPT","0310","RC","","","","outpatient","","","5699.00","4274.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2991.98","52.5","","1.00","0.53","1.00","1 through 10","156.55","4701.68","percent of total billed charges",""
"Mgh Sanger Seq Hdt Array Del/Dup","PX-31000355","CDM","81479","CPT","0310","RC","","","","both","","","75.00","56.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59.63","79.5","","0.65","0.65","0.65","1 through 10","23.25","71.25","percent of total billed charges",""
"Mgh Sanger Seq Hdt Array Del/Dup","PX-31000355","CDM","81479","CPT","0310","RC","","","","both","","","75.00","56.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39.98","53.3","","0.79","0.79","0.79","1 through 10","23.25","71.25","percent of total billed charges",""
"Mgh Sanger Seq Hdt Array Del/Dup","PX-31000355","CDM","81479","CPT","0310","RC","","","","outpatient","","","75.00","56.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37.50","50","","1.00","1.00","1.00","1 through 10","36.3","156.55","percent of total billed charges",""
"Mgh Sanger Seq Hdt Array Del/Dup","PX-31000355","CDM","81479","CPT","0310","RC","","","","outpatient","","","75.00","56.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","39.38","52.5","","1.00","0.53","1.00","1 through 10","36.3","156.55","percent of total billed charges",""
"Mgh Sanger/Del Dup Comprehensive","PX-31000526","CDM","81479","CPT","0310","RC","","","","both","","","1196.00","897.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","950.82","79.5","","0.65","0.65","0.65","1 through 10","370.76","1136.2","percent of total billed charges",""
"Mgh Sanger/Del Dup Comprehensive","PX-31000526","CDM","81479","CPT","0310","RC","","","","both","","","1196.00","897.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","637.47","53.3","","0.79","0.79","0.79","1 through 10","370.76","1136.2","percent of total billed charges",""
"Mgh Sanger/Del Dup Comprehensive","PX-31000526","CDM","81479","CPT","0310","RC","","","","outpatient","","","1196.00","897.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.00","50","","1.00","1.00","1.00","1 through 10","156.55","986.7","percent of total billed charges",""
"Mgh Sanger/Del Dup Comprehensive","PX-31000526","CDM","81479","CPT","0310","RC","","","","outpatient","","","1196.00","897.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","627.90","52.5","","1.00","0.53","1.00","1 through 10","156.55","986.7","percent of total billed charges",""
"Mgh Sbds Gene Sequencing","PX-31000586","CDM","81479","CPT","0310","RC","","","","both","","","1390.00","1042.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1105.05","79.5","","0.65","0.65","0.65","1 through 10","430.9","1320.5","percent of total billed charges",""
"Mgh Sbds Gene Sequencing","PX-31000586","CDM","81479","CPT","0310","RC","","","","both","","","1390.00","1042.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","740.87","53.3","","0.79","0.79","0.79","1 through 10","430.9","1320.5","percent of total billed charges",""
"Mgh Sbds Gene Sequencing","PX-31000586","CDM","81479","CPT","0310","RC","","","","outpatient","","","1390.00","1042.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","695.00","50","","1.00","1.00","1.00","1 through 10","156.55","1146.75","percent of total billed charges",""
"Mgh Sbds Gene Sequencing","PX-31000586","CDM","81479","CPT","0310","RC","","","","outpatient","","","1390.00","1042.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","729.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","1146.75","percent of total billed charges",""
"Mgh Sbds Sanger Sequencing","PX-31000524","CDM","81479","CPT","0310","RC","","","","both","","","795.00","596.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","632.03","79.5","","0.65","0.65","0.65","1 through 10","246.45","755.25","percent of total billed charges",""
"Mgh Sbds Sanger Sequencing","PX-31000524","CDM","81479","CPT","0310","RC","","","","both","","","795.00","596.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","423.74","53.3","","0.79","0.79","0.79","1 through 10","246.45","755.25","percent of total billed charges",""
"Mgh Sbds Sanger Sequencing","PX-31000524","CDM","81479","CPT","0310","RC","","","","outpatient","","","795.00","596.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","397.50","50","","1.00","1.00","1.00","1 through 10","156.55","655.88","percent of total billed charges",""
"Mgh Sbds Sanger Sequencing","PX-31000524","CDM","81479","CPT","0310","RC","","","","outpatient","","","795.00","596.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","417.38","52.5","","1.00","0.53","1.00","1 through 10","156.55","655.88","percent of total billed charges",""
"Mgh Sca7 Dna Test","PX-31000536","CDM","81479","CPT","0310","RC","","","","both","","","1382.00","1036.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1098.69","79.5","","0.65","0.65","0.65","1 through 10","428.42","1312.9","percent of total billed charges",""
"Mgh Sca7 Dna Test","PX-31000536","CDM","81479","CPT","0310","RC","","","","both","","","1382.00","1036.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","736.61","53.3","","0.79","0.79","0.79","1 through 10","428.42","1312.9","percent of total billed charges",""
"Mgh Sca7 Dna Test","PX-31000536","CDM","81479","CPT","0310","RC","","","","outpatient","","","1382.00","1036.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","691.00","50","","1.00","1.00","1.00","1 through 10","156.55","1140.15","percent of total billed charges",""
"Mgh Sca7 Dna Test","PX-31000536","CDM","81479","CPT","0310","RC","","","","outpatient","","","1382.00","1036.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","725.55","52.5","","1.00","0.53","1.00","1 through 10","156.55","1140.15","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Schistosoma Ab Igg","PX-30002230","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Schistosomiasis Ab 86682","PX-30002221","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 1 83520","PX-30002034","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 2 83520","PX-30002035","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 3 83520","PX-30002036","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sensory Neuropathy 4 83520","PX-30002037","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sentory Neuropathy 83520","PX-30002038","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Sepn1","PX-31000236","CDM","81479","CPT","0310","RC","","","","both","","","2546.00","1909.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2024.07","79.5","","0.65","0.65","0.65","1 through 10","789.26","2418.7","percent of total billed charges",""
"Mgh Sepn1","PX-31000236","CDM","81479","CPT","0310","RC","","","","both","","","2546.00","1909.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1357.02","53.3","","0.79","0.79","0.79","1 through 10","789.26","2418.7","percent of total billed charges",""
"Mgh Sepn1","PX-31000236","CDM","81479","CPT","0310","RC","","","","outpatient","","","2546.00","1909.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1273.00","50","","1.00","1.00","1.00","1 through 10","156.55","2100.45","percent of total billed charges",""
"Mgh Sepn1","PX-31000236","CDM","81479","CPT","0310","RC","","","","outpatient","","","2546.00","1909.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1336.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","2100.45","percent of total billed charges",""
"Mgh Sept9 Dna Sequencing Test","PX-31000244","CDM","81479","CPT","0310","RC","","","","both","","","2743.00","2057.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2180.69","79.5","","0.65","0.65","0.65","1 through 10","850.33","2605.85","percent of total billed charges",""
"Mgh Sept9 Dna Sequencing Test","PX-31000244","CDM","81479","CPT","0310","RC","","","","both","","","2743.00","2057.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1462.02","53.3","","0.79","0.79","0.79","1 through 10","850.33","2605.85","percent of total billed charges",""
"Mgh Sept9 Dna Sequencing Test","PX-31000244","CDM","81479","CPT","0310","RC","","","","outpatient","","","2743.00","2057.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1371.50","50","","1.00","1.00","1.00","1 through 10","156.55","2262.98","percent of total billed charges",""
"Mgh Sept9 Dna Sequencing Test","PX-31000244","CDM","81479","CPT","0310","RC","","","","outpatient","","","2743.00","2057.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1440.08","52.5","","1.00","0.53","1.00","1 through 10","156.55","2262.98","percent of total billed charges",""
"Mgh Serping1 (C1inh) Gene Sequencing & Del/Dup","PX-31000621","CDM","81479","CPT","0310","RC","","","","both","","","2889.00","2166.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2296.76","79.5","","0.65","0.65","0.65","1 through 10","895.59","2744.55","percent of total billed charges",""
"Mgh Serping1 (C1inh) Gene Sequencing & Del/Dup","PX-31000621","CDM","81479","CPT","0310","RC","","","","both","","","2889.00","2166.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1539.84","53.3","","0.79","0.79","0.79","1 through 10","895.59","2744.55","percent of total billed charges",""
"Mgh Serping1 (C1inh) Gene Sequencing & Del/Dup","PX-31000621","CDM","81479","CPT","0310","RC","","","","outpatient","","","2889.00","2166.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1444.50","50","","1.00","1.00","1.00","1 through 10","156.55","2383.43","percent of total billed charges",""
"Mgh Serping1 (C1inh) Gene Sequencing & Del/Dup","PX-31000621","CDM","81479","CPT","0310","RC","","","","outpatient","","","2889.00","2166.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1516.73","52.5","","1.00","0.53","1.00","1 through 10","156.55","2383.43","percent of total billed charges",""
"Mgh Serum Free Kappa L C","PX-30001874","CDM","83883","CPT","0300","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Serum Free Kappa L C","PX-30001874","CDM","83883","CPT","0300","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Serum Free Kappa L C","PX-30002128","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Serum Free Kappa L C","PX-30002128","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Serum Free Lambda L C","PX-30001875","CDM","83883","CPT","0300","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Serum Free Lambda L C","PX-30001875","CDM","83883","CPT","0300","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Serum Free Lambda L C","PX-30002129","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Serum Free Lambda L C","PX-30002129","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Serum Protein Electrophor","PX-30002123","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Serum Protein Electrophor","PX-30002123","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Shox-Dna-Dxtm","PX-31000274","CDM","81479","CPT","0310","RC","","","","both","","","1226.00","919.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","974.67","79.5","","0.65","0.65","0.65","1 through 10","380.06","1164.7","percent of total billed charges",""
"Mgh Shox-Dna-Dxtm","PX-31000274","CDM","81479","CPT","0310","RC","","","","both","","","1226.00","919.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","653.46","53.3","","0.79","0.79","0.79","1 through 10","380.06","1164.7","percent of total billed charges",""
"Mgh Shox-Dna-Dxtm","PX-31000274","CDM","81479","CPT","0310","RC","","","","outpatient","","","1226.00","919.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","613.00","50","","1.00","1.00","1.00","1 through 10","156.55","1011.45","percent of total billed charges",""
"Mgh Shox-Dna-Dxtm","PX-31000274","CDM","81479","CPT","0310","RC","","","","outpatient","","","1226.00","919.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","643.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","1011.45","percent of total billed charges",""
"Mgh Sinemet","PX-30001565","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Sinemet","PX-30001565","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Sinemet","PX-30001565","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Sinemet","PX-30001565","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Sinemet","PX-30001565","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Sinemet","PX-30001565","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Sinemet","PX-30001565","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Single Gene Seq","PX-31000881","CDM","81479","CPT","0310","RC","","","","both","","","1581.00","1185.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1256.90","79.5","","0.65","0.65","0.65","1 through 10","490.11","1501.95","percent of total billed charges",""
"Mgh Single Gene Seq","PX-31000881","CDM","81479","CPT","0310","RC","","","","both","","","1581.00","1185.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","842.67","53.3","","0.79","0.79","0.79","1 through 10","490.11","1501.95","percent of total billed charges",""
"Mgh Single Gene Seq","PX-31000881","CDM","81479","CPT","0310","RC","","","","outpatient","","","1581.00","1185.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","790.50","50","","1.00","1.00","1.00","1 through 10","156.55","1304.33","percent of total billed charges",""
"Mgh Single Gene Seq","PX-31000881","CDM","81479","CPT","0310","RC","","","","outpatient","","","1581.00","1185.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","830.03","52.5","","1.00","0.53","1.00","1 through 10","156.55","1304.33","percent of total billed charges",""
"Mgh Single Gene Test","PX-31000659","CDM","81479","CPT","0310","RC","","","","both","","","1036.00","777.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","823.62","79.5","","0.65","0.65","0.65","1 through 10","321.16","984.2","percent of total billed charges",""
"Mgh Single Gene Test","PX-31000659","CDM","81479","CPT","0310","RC","","","","both","","","1036.00","777.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","552.19","53.3","","0.79","0.79","0.79","1 through 10","321.16","984.2","percent of total billed charges",""
"Mgh Single Gene Test","PX-31000659","CDM","81479","CPT","0310","RC","","","","outpatient","","","1036.00","777.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","518.00","50","","1.00","1.00","1.00","1 through 10","156.55","854.7","percent of total billed charges",""
"Mgh Single Gene Test","PX-31000659","CDM","81479","CPT","0310","RC","","","","outpatient","","","1036.00","777.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","543.90","52.5","","1.00","0.53","1.00","1 through 10","156.55","854.7","percent of total billed charges",""
"Mgh Skeletal Dysplasia Core Ngs Panel","PX-31000521","CDM","81479","CPT","0310","RC","","","","both","","","449.00","336.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","356.96","79.5","","0.65","0.65","0.65","1 through 10","139.19","426.55","percent of total billed charges",""
"Mgh Skeletal Dysplasia Core Ngs Panel","PX-31000521","CDM","81479","CPT","0310","RC","","","","both","","","449.00","336.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","239.32","53.3","","0.79","0.79","0.79","1 through 10","139.19","426.55","percent of total billed charges",""
"Mgh Skeletal Dysplasia Core Ngs Panel","PX-31000521","CDM","81479","CPT","0310","RC","","","","outpatient","","","449.00","336.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","224.50","50","","1.00","1.00","1.00","1 through 10","156.55","370.43","percent of total billed charges",""
"Mgh Skeletal Dysplasia Core Ngs Panel","PX-31000521","CDM","81479","CPT","0310","RC","","","","outpatient","","","449.00","336.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","235.73","52.5","","1.00","0.53","1.00","1 through 10","156.55","370.43","percent of total billed charges",""
"Mgh Skeletal Muscle Analysis","PX-31000349","CDM","81479","CPT","0310","RC","","","","both","","","1876.00","1407.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1491.42","79.5","","0.65","0.65","0.65","1 through 10","581.56","1782.2","percent of total billed charges",""
"Mgh Skeletal Muscle Analysis","PX-31000349","CDM","81479","CPT","0310","RC","","","","both","","","1876.00","1407.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","999.91","53.3","","0.79","0.79","0.79","1 through 10","581.56","1782.2","percent of total billed charges",""
"Mgh Skeletal Muscle Analysis","PX-31000349","CDM","81479","CPT","0310","RC","","","","outpatient","","","1876.00","1407.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","938.00","50","","1.00","1.00","1.00","1 through 10","156.55","1547.7","percent of total billed charges",""
"Mgh Skeletal Muscle Analysis","PX-31000349","CDM","81479","CPT","0310","RC","","","","outpatient","","","1876.00","1407.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","984.90","52.5","","1.00","0.53","1.00","1 through 10","156.55","1547.7","percent of total billed charges",""
"Mgh Smchd1 Gene Sequencing","PX-31000483","CDM","81479","CPT","0310","RC","","","","both","","","6270.00","4702.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4984.65","79.5","","0.65","0.65","0.65","1 through 10","1943.7","5956.5","percent of total billed charges",""
"Mgh Smchd1 Gene Sequencing","PX-31000483","CDM","81479","CPT","0310","RC","","","","both","","","6270.00","4702.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3341.91","53.3","","0.79","0.79","0.79","1 through 10","1943.7","5956.5","percent of total billed charges",""
"Mgh Smchd1 Gene Sequencing","PX-31000483","CDM","81479","CPT","0310","RC","","","","outpatient","","","6270.00","4702.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3135.00","50","","1.00","1.00","1.00","1 through 10","156.55","5172.75","percent of total billed charges",""
"Mgh Smchd1 Gene Sequencing","PX-31000483","CDM","81479","CPT","0310","RC","","","","outpatient","","","6270.00","4702.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3291.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","5172.75","percent of total billed charges",""
"Mgh Smpd1 Gene Sequencing","PX-31000242","CDM","81479","CPT","0310","RC","","","","both","","","3105.00","2328.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2468.48","79.5","","0.65","0.65","0.65","1 through 10","962.55","2949.75","percent of total billed charges",""
"Mgh Smpd1 Gene Sequencing","PX-31000242","CDM","81479","CPT","0310","RC","","","","both","","","3105.00","2328.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1654.97","53.3","","0.79","0.79","0.79","1 through 10","962.55","2949.75","percent of total billed charges",""
"Mgh Smpd1 Gene Sequencing","PX-31000242","CDM","81479","CPT","0310","RC","","","","outpatient","","","3105.00","2328.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1552.50","50","","1.00","1.00","1.00","1 through 10","156.55","2561.63","percent of total billed charges",""
"Mgh Smpd1 Gene Sequencing","PX-31000242","CDM","81479","CPT","0310","RC","","","","outpatient","","","3105.00","2328.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1630.13","52.5","","1.00","0.53","1.00","1 through 10","156.55","2561.63","percent of total billed charges",""
"Mgh Snapshot Testing","PX-31000302","CDM","81479","CPT","0310","RC","","","","both","","","3831.00","2873.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3045.65","79.5","","0.65","0.65","0.65","1 through 10","1187.61","3639.45","percent of total billed charges",""
"Mgh Snapshot Testing","PX-31000302","CDM","81479","CPT","0310","RC","","","","both","","","3831.00","2873.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2041.92","53.3","","0.79","0.79","0.79","1 through 10","1187.61","3639.45","percent of total billed charges",""
"Mgh Snapshot Testing","PX-31000302","CDM","81479","CPT","0310","RC","","","","outpatient","","","3831.00","2873.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1915.50","50","","1.00","1.00","1.00","1 through 10","156.55","3160.58","percent of total billed charges",""
"Mgh Snapshot Testing","PX-31000302","CDM","81479","CPT","0310","RC","","","","outpatient","","","3831.00","2873.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2011.28","52.5","","1.00","0.53","1.00","1 through 10","156.55","3160.58","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Soluabl Livr Ag Cytokeratn","PX-30002099","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Soluable Liver Ag Cytokeratin","PX-30002069","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Solubl Transferrn Receptor","PX-30002091","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Soluble Il 2r Alpha","PX-30002092","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Soluble Transferrin Receptor","PX-30002061","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Spastic Para Nextgen Dna Seq","PX-31000271","CDM","81479","CPT","0310","RC","","","","both","","","5518.00","4138.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4386.81","79.5","","0.65","0.65","0.65","1 through 10","1710.58","5242.1","percent of total billed charges",""
"Mgh Spastic Para Nextgen Dna Seq","PX-31000271","CDM","81479","CPT","0310","RC","","","","both","","","5518.00","4138.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2941.09","53.3","","0.79","0.79","0.79","1 through 10","1710.58","5242.1","percent of total billed charges",""
"Mgh Spastic Para Nextgen Dna Seq","PX-31000271","CDM","81479","CPT","0310","RC","","","","outpatient","","","5518.00","4138.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2759.00","50","","1.00","1.00","1.00","1 through 10","156.55","4552.35","percent of total billed charges",""
"Mgh Spastic Para Nextgen Dna Seq","PX-31000271","CDM","81479","CPT","0310","RC","","","","outpatient","","","5518.00","4138.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2896.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","4552.35","percent of total billed charges",""
"Mgh Spastic Paraplegia Nextgen Dna Sequencing Panel (57 Genes)","PX-31000725","CDM","81479","CPT","0310","RC","","","","both","","","2415.00","1811.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1919.93","79.5","","0.65","0.65","0.65","1 through 10","748.65","2294.25","percent of total billed charges",""
"Mgh Spastic Paraplegia Nextgen Dna Sequencing Panel (57 Genes)","PX-31000725","CDM","81479","CPT","0310","RC","","","","both","","","2415.00","1811.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1287.20","53.3","","0.79","0.79","0.79","1 through 10","748.65","2294.25","percent of total billed charges",""
"Mgh Spastic Paraplegia Nextgen Dna Sequencing Panel (57 Genes)","PX-31000725","CDM","81479","CPT","0310","RC","","","","outpatient","","","2415.00","1811.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1207.50","50","","1.00","1.00","1.00","1 through 10","156.55","1992.38","percent of total billed charges",""
"Mgh Spastic Paraplegia Nextgen Dna Sequencing Panel (57 Genes)","PX-31000725","CDM","81479","CPT","0310","RC","","","","outpatient","","","2415.00","1811.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1267.88","52.5","","1.00","0.53","1.00","1 through 10","156.55","1992.38","percent of total billed charges",""
"Mgh Spctrophotomtry Anal Nes","PX-30002163","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Spctrophotomtry Anal Nes","PX-30002163","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Spctrophotomtry Anal Nes","PX-30002163","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Spctrophotomtry Anal Nes","PX-30002164","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Spctrophotomtry Anal Nes","PX-30002164","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Spctrophotomtry Anal Nes","PX-30002164","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Spctrophotomtry Anal Nes","PX-30002174","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Spctrophotomtry Anal Nes","PX-30002174","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Spctrophotomtry Anal Nes","PX-30002174","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002175","CDM","86003","CPT","0301","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Spec Ige Quan Semiquan Ea Allg","PX-30002202","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Spectrophotometry Analyte Ne","PX-30002172","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Spectrophotometry Analyte Ne","PX-30002172","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Spectrophotometry Analyte Ne","PX-30002172","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Spectrophotometry Analyte Nes","PX-30002173","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Spectrophotometry Analyte Nes","PX-30002173","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Spectrophotometry Analyte Nes","PX-30002173","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Spinal Muscular Atrophy Panel","PX-31000514","CDM","81479","CPT","0310","RC","","","","both","","","3467.00","2600.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2756.27","79.5","","0.65","0.65","0.65","1 through 10","1074.77","3293.65","percent of total billed charges",""
"Mgh Spinal Muscular Atrophy Panel","PX-31000514","CDM","81479","CPT","0310","RC","","","","both","","","3467.00","2600.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1847.91","53.3","","0.79","0.79","0.79","1 through 10","1074.77","3293.65","percent of total billed charges",""
"Mgh Spinal Muscular Atrophy Panel","PX-31000514","CDM","81479","CPT","0310","RC","","","","outpatient","","","3467.00","2600.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1733.50","50","","1.00","1.00","1.00","1 through 10","156.55","2860.28","percent of total billed charges",""
"Mgh Spinal Muscular Atrophy Panel","PX-31000514","CDM","81479","CPT","0310","RC","","","","outpatient","","","3467.00","2600.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1820.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","2860.28","percent of total billed charges",""
"Mgh Spinal Muscular Atrophy Testing (2 Genes - Smn1, Smn2)","PX-31000528","CDM","81479","CPT","0310","RC","","","","both","","","224.00","168.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","178.08","79.5","","0.65","0.65","0.65","1 through 10","69.44","212.8","percent of total billed charges",""
"Mgh Spinal Muscular Atrophy Testing (2 Genes - Smn1, Smn2)","PX-31000528","CDM","81479","CPT","0310","RC","","","","both","","","224.00","168.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","119.39","53.3","","0.79","0.79","0.79","1 through 10","69.44","212.8","percent of total billed charges",""
"Mgh Spinal Muscular Atrophy Testing (2 Genes - Smn1, Smn2)","PX-31000528","CDM","81479","CPT","0310","RC","","","","outpatient","","","224.00","168.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.00","50","","1.00","1.00","1.00","1 through 10","108.42","184.8","percent of total billed charges",""
"Mgh Spinal Muscular Atrophy Testing (2 Genes - Smn1, Smn2)","PX-31000528","CDM","81479","CPT","0310","RC","","","","outpatient","","","224.00","168.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","117.60","52.5","","1.00","0.53","1.00","1 through 10","108.42","184.8","percent of total billed charges",""
"Mgh Spink5 Gene Sequencing","PX-31000580","CDM","81479","CPT","0310","RC","","","","both","","","6953.00","5214.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5527.64","79.5","","0.65","0.65","0.65","1 through 10","2155.43","6605.35","percent of total billed charges",""
"Mgh Spink5 Gene Sequencing","PX-31000580","CDM","81479","CPT","0310","RC","","","","both","","","6953.00","5214.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3705.95","53.3","","0.79","0.79","0.79","1 through 10","2155.43","6605.35","percent of total billed charges",""
"Mgh Spink5 Gene Sequencing","PX-31000580","CDM","81479","CPT","0310","RC","","","","outpatient","","","6953.00","5214.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3476.50","50","","1.00","1.00","1.00","1 through 10","156.55","5736.23","percent of total billed charges",""
"Mgh Spink5 Gene Sequencing","PX-31000580","CDM","81479","CPT","0310","RC","","","","outpatient","","","6953.00","5214.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3650.33","52.5","","1.00","0.53","1.00","1 through 10","156.55","5736.23","percent of total billed charges",""
"Mgh Spinocerebellar Ataxia","PX-31000287","CDM","81479","CPT","0310","RC","","","","both","","","1934.00","1450.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1537.53","79.5","","0.65","0.65","0.65","1 through 10","599.54","1837.3","percent of total billed charges",""
"Mgh Spinocerebellar Ataxia","PX-31000287","CDM","81479","CPT","0310","RC","","","","both","","","1934.00","1450.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1030.82","53.3","","0.79","0.79","0.79","1 through 10","599.54","1837.3","percent of total billed charges",""
"Mgh Spinocerebellar Ataxia","PX-31000287","CDM","81479","CPT","0310","RC","","","","outpatient","","","1934.00","1450.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","967.00","50","","1.00","1.00","1.00","1 through 10","156.55","1595.55","percent of total billed charges",""
"Mgh Spinocerebellar Ataxia","PX-31000287","CDM","81479","CPT","0310","RC","","","","outpatient","","","1934.00","1450.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1015.35","52.5","","1.00","0.53","1.00","1 through 10","156.55","1595.55","percent of total billed charges",""
"Mgh Spinocerebellar Ataxia, Autosomal Recessive-8","PX-31000598","CDM","81479","CPT","0310","RC","","","","both","","","1175.00","881.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","934.13","79.5","","0.65","0.65","0.65","1 through 10","364.25","1116.25","percent of total billed charges",""
"Mgh Spinocerebellar Ataxia, Autosomal Recessive-8","PX-31000598","CDM","81479","CPT","0310","RC","","","","both","","","1175.00","881.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","626.28","53.3","","0.79","0.79","0.79","1 through 10","364.25","1116.25","percent of total billed charges",""
"Mgh Spinocerebellar Ataxia, Autosomal Recessive-8","PX-31000598","CDM","81479","CPT","0310","RC","","","","outpatient","","","1175.00","881.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","587.50","50","","1.00","1.00","1.00","1 through 10","156.55","969.38","percent of total billed charges",""
"Mgh Spinocerebellar Ataxia, Autosomal Recessive-8","PX-31000598","CDM","81479","CPT","0310","RC","","","","outpatient","","","1175.00","881.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","616.88","52.5","","1.00","0.53","1.00","1 through 10","156.55","969.38","percent of total billed charges",""
"Mgh Splint of Lux/Avuls/Tooth","PX-51000151","CDM","41899","CPT","0512","RC","","","","outpatient","","","1333.00","999.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","807.13","60.55","","481.00","481.00","481.00","1 through 10","454.55","1099.73","percent of total billed charges",""
"Mgh Spondylo-Epi-Metaphyseal Dysplasias Ngs Panel","PX-30003424","CDM","81479","CPT","0310","RC","","","","both","","","57.00","42.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","45.32","79.5","","0.65","0.65","0.65","1 through 10","17.67","54.15","percent of total billed charges",""
"Mgh Spondylo-Epi-Metaphyseal Dysplasias Ngs Panel","PX-30003424","CDM","81479","CPT","0310","RC","","","","both","","","57.00","42.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","30.38","53.3","","0.79","0.79","0.79","1 through 10","17.67","54.15","percent of total billed charges",""
"Mgh Spondylo-Epi-Metaphyseal Dysplasias Ngs Panel","PX-30003424","CDM","81479","CPT","0310","RC","","","","outpatient","","","57.00","42.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28.50","50","","1.00","1.00","1.00","1 through 10","27.59","156.55","percent of total billed charges",""
"Mgh Spondylo-Epi-Metaphyseal Dysplasias Ngs Panel","PX-30003424","CDM","81479","CPT","0310","RC","","","","outpatient","","","57.00","42.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","29.93","52.5","","1.00","0.53","1.00","1 through 10","27.59","156.55","percent of total billed charges",""
"Mgh Spondyloepiphyseal Displasia","PX-31000235","CDM","81479","CPT","0310","RC","","","","both","","","2882.00","2161.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2291.19","79.5","","0.65","0.65","0.65","1 through 10","893.42","2737.9","percent of total billed charges",""
"Mgh Spondyloepiphyseal Displasia","PX-31000235","CDM","81479","CPT","0310","RC","","","","both","","","2882.00","2161.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1536.11","53.3","","0.79","0.79","0.79","1 through 10","893.42","2737.9","percent of total billed charges",""
"Mgh Spondyloepiphyseal Displasia","PX-31000235","CDM","81479","CPT","0310","RC","","","","outpatient","","","2882.00","2161.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1441.00","50","","1.00","1.00","1.00","1 through 10","156.55","2377.65","percent of total billed charges",""
"Mgh Spondyloepiphyseal Displasia","PX-31000235","CDM","81479","CPT","0310","RC","","","","outpatient","","","2882.00","2161.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1513.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","2377.65","percent of total billed charges",""
"Mgh Sporothrix Ab","PX-30002219","CDM","86671","CPT","0302","RC","","","","both","","","168.00","126.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","133.56","79.5","","128.28","128.28","128.28","1 through 10","10.07","159.6","percent of total billed charges",""
"Mgh Stereotaxis Mapping System","PX-48000400","CDM","93799","CPT","0481","RC","","","","both","","","1106.00","829.50","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","879.27","other","OPPS APC"
"Mgh Stereotaxis Mapping System","PX-48000400","CDM","93799","CPT","0481","RC","","","","outpatient","","","1106.00","829.50","AETNA [1001]","HB AMC AETNA HMO","771.99","69.8","","2022.70","2022.70","2022.70","1 through 10","454","912.45","percent of total billed charges",""
"Mgh Stereotaxis Mapping System","PX-48000400","CDM","93799","CPT","0481","RC","","","","outpatient","","","1106.00","829.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","669.68","60.55","","318.03","318.03","2439.77","1 through 10","454","912.45","percent of total billed charges",""
"Mgh Stereotaxis Mapping System","PX-48000400","CDM","93799","CPT","0481","RC","","","","outpatient","","","1106.00","829.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","577.55","52.22","","360.38","360.38","4023.00","1 through 10","454","912.45","percent of total billed charges",""
"Mgh Stereotaxis Mapping System","PX-48000400","CDM","93799","CPT","0481","RC","","","","outpatient","","","1106.00","829.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","608.30","55","","13080.03","13080.03","13080.03","1 through 10","454","912.45","percent of total billed charges",""
"Mgh Stickler Syndrome Ngs Panel","PX-31000663","CDM","81479","CPT","0310","RC","","","","both","","","507.00","380.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.07","79.5","","0.65","0.65","0.65","1 through 10","157.17","481.65","percent of total billed charges",""
"Mgh Stickler Syndrome Ngs Panel","PX-31000663","CDM","81479","CPT","0310","RC","","","","both","","","507.00","380.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.23","53.3","","0.79","0.79","0.79","1 through 10","157.17","481.65","percent of total billed charges",""
"Mgh Stickler Syndrome Ngs Panel","PX-31000663","CDM","81479","CPT","0310","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","253.50","50","","1.00","1.00","1.00","1 through 10","156.55","418.28","percent of total billed charges",""
"Mgh Stickler Syndrome Ngs Panel","PX-31000663","CDM","81479","CPT","0310","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","266.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","418.28","percent of total billed charges",""
"Mgh Stickler Syndrome, Type I","PX-31000272","CDM","81479","CPT","0310","RC","","","","both","","","5978.00","4483.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4752.51","79.5","","0.65","0.65","0.65","1 through 10","1853.18","5679.1","percent of total billed charges",""
"Mgh Stickler Syndrome, Type I","PX-31000272","CDM","81479","CPT","0310","RC","","","","both","","","5978.00","4483.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3186.27","53.3","","0.79","0.79","0.79","1 through 10","1853.18","5679.1","percent of total billed charges",""
"Mgh Stickler Syndrome, Type I","PX-31000272","CDM","81479","CPT","0310","RC","","","","outpatient","","","5978.00","4483.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2989.00","50","","1.00","1.00","1.00","1 through 10","156.55","4931.85","percent of total billed charges",""
"Mgh Stickler Syndrome, Type I","PX-31000272","CDM","81479","CPT","0310","RC","","","","outpatient","","","5978.00","4483.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3138.45","52.5","","1.00","0.53","1.00","1 through 10","156.55","4931.85","percent of total billed charges",""
"Mgh Stickler Syndrome, Type II","PX-31000273","CDM","81479","CPT","0310","RC","","","","both","","","5731.00","4298.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4556.15","79.5","","0.65","0.65","0.65","1 through 10","1776.61","5444.45","percent of total billed charges",""
"Mgh Stickler Syndrome, Type II","PX-31000273","CDM","81479","CPT","0310","RC","","","","both","","","5731.00","4298.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3054.62","53.3","","0.79","0.79","0.79","1 through 10","1776.61","5444.45","percent of total billed charges",""
"Mgh Stickler Syndrome, Type II","PX-31000273","CDM","81479","CPT","0310","RC","","","","outpatient","","","5731.00","4298.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2865.50","50","","1.00","1.00","1.00","1 through 10","156.55","4728.08","percent of total billed charges",""
"Mgh Stickler Syndrome, Type II","PX-31000273","CDM","81479","CPT","0310","RC","","","","outpatient","","","5731.00","4298.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3008.78","52.5","","1.00","0.53","1.00","1 through 10","156.55","4728.08","percent of total billed charges",""
"Mgh Stool Ph","PX-30002149","CDM","83986","CPT","0301","RC","","","","both","","","59.00","44.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46.91","79.5","","44.86","44.86","44.86","1 through 10","3.51","56.05","percent of total billed charges",""
"Mgh Stool Ph","PX-30002149","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","AETNA [1001]","HB AMC AETNA PPO","47.44","80.4","","44.46","44.46","44.46","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Stool Ph","PX-30002149","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","48.21","81.72","","45.57","45.57","45.57","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Stool Ph","PX-30002151","CDM","83986","CPT","0301","RC","","","","both","","","59.00","44.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46.91","79.5","","44.86","44.86","44.86","1 through 10","3.51","56.05","percent of total billed charges",""
"Mgh Stool Ph","PX-30002151","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","AETNA [1001]","HB AMC AETNA PPO","47.44","80.4","","44.46","44.46","44.46","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Stool Ph","PX-30002151","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","48.21","81.72","","45.57","45.57","45.57","1 through 10","3.68","48.21","percent of total billed charges",""
"Mgh Streptomycin Level","PX-30001548","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Streptomycin Level","PX-30001548","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Streptomycin Level","PX-30001548","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Streptomycin Level","PX-30001548","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Streptomycin Level","PX-30001548","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Streptomycin Level","PX-30001548","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Streptomycin Level","PX-30001548","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Substance P","PX-30002066","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Substance P","PX-30002096","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Sulfametoxazole","PX-30001555","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Sulfametoxazole","PX-30001555","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Sulfametoxazole","PX-30001555","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Sulfametoxazole","PX-30001555","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Sulfametoxazole","PX-30001555","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Sulfametoxazole","PX-30001555","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Sulfametoxazole","PX-30001555","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Sulfatide 83520","PX-30002039","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Swab Herpes B Isolat","PX-31000288","CDM","81479","CPT","0310","RC","","","","both","","","223.00","167.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","177.29","79.5","","0.65","0.65","0.65","1 through 10","69.13","211.85","percent of total billed charges",""
"Mgh Swab Herpes B Isolat","PX-31000288","CDM","81479","CPT","0310","RC","","","","both","","","223.00","167.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","118.86","53.3","","0.79","0.79","0.79","1 through 10","69.13","211.85","percent of total billed charges",""
"Mgh Swab Herpes B Isolat","PX-31000288","CDM","81479","CPT","0310","RC","","","","outpatient","","","223.00","167.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","111.50","50","","1.00","1.00","1.00","1 through 10","107.93","183.98","percent of total billed charges",""
"Mgh Swab Herpes B Isolat","PX-31000288","CDM","81479","CPT","0310","RC","","","","outpatient","","","223.00","167.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","117.08","52.5","","1.00","0.53","1.00","1 through 10","107.93","183.98","percent of total billed charges",""
"Mgh Syndromic Macrocephaly/Overgrowth Panel","PX-31000651","CDM","81479","CPT","0310","RC","","","","both","","","486.00","364.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","386.37","79.5","","0.65","0.65","0.65","1 through 10","150.66","461.7","percent of total billed charges",""
"Mgh Syndromic Macrocephaly/Overgrowth Panel","PX-31000651","CDM","81479","CPT","0310","RC","","","","both","","","486.00","364.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","259.04","53.3","","0.79","0.79","0.79","1 through 10","150.66","461.7","percent of total billed charges",""
"Mgh Syndromic Macrocephaly/Overgrowth Panel","PX-31000651","CDM","81479","CPT","0310","RC","","","","outpatient","","","486.00","364.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","243.00","50","","1.00","1.00","1.00","1 through 10","156.55","400.95","percent of total billed charges",""
"Mgh Syndromic Macrocephaly/Overgrowth Panel","PX-31000651","CDM","81479","CPT","0310","RC","","","","outpatient","","","486.00","364.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","255.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","400.95","percent of total billed charges",""
"Mgh T-Cell Lymphoma Fish","PX-30003695","CDM","88377","CPT","0300","RC","","","","both","","","1105.00","828.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","403.33","36.5","","388.06","388.06","388.06","1 through 10","193.33","878.48","percent of total billed charges",""
"Mgh Targeted Mtdna Analysis by Massively Parallel Seq (Mitongssm)","PX-31000626","CDM","81479","CPT","0310","RC","","","","both","","","2710.00","2032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2154.45","79.5","","0.65","0.65","0.65","1 through 10","840.1","2574.5","percent of total billed charges",""
"Mgh Targeted Mtdna Analysis by Massively Parallel Seq (Mitongssm)","PX-31000626","CDM","81479","CPT","0310","RC","","","","both","","","2710.00","2032.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1444.43","53.3","","0.79","0.79","0.79","1 through 10","840.1","2574.5","percent of total billed charges",""
"Mgh Targeted Mtdna Analysis by Massively Parallel Seq (Mitongssm)","PX-31000626","CDM","81479","CPT","0310","RC","","","","outpatient","","","2710.00","2032.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1355.00","50","","1.00","1.00","1.00","1 through 10","156.55","2235.75","percent of total billed charges",""
"Mgh Targeted Mtdna Analysis by Massively Parallel Seq (Mitongssm)","PX-31000626","CDM","81479","CPT","0310","RC","","","","outpatient","","","2710.00","2032.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1422.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","2235.75","percent of total billed charges",""
"Mgh Telangiectasia Syndrome (Bmp9/Gdf2)Seq","PX-31000883","CDM","81479","CPT","0310","RC","","","","both","","","773.00","579.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","614.54","79.5","","0.65","0.65","0.65","1 through 10","239.63","734.35","percent of total billed charges",""
"Mgh Telangiectasia Syndrome (Bmp9/Gdf2)Seq","PX-31000883","CDM","81479","CPT","0310","RC","","","","both","","","773.00","579.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","412.01","53.3","","0.79","0.79","0.79","1 through 10","239.63","734.35","percent of total billed charges",""
"Mgh Telangiectasia Syndrome (Bmp9/Gdf2)Seq","PX-31000883","CDM","81479","CPT","0310","RC","","","","outpatient","","","773.00","579.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","386.50","50","","1.00","1.00","1.00","1 through 10","156.55","637.73","percent of total billed charges",""
"Mgh Telangiectasia Syndrome (Bmp9/Gdf2)Seq","PX-31000883","CDM","81479","CPT","0310","RC","","","","outpatient","","","773.00","579.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","405.83","52.5","","1.00","0.53","1.00","1 through 10","156.55","637.73","percent of total billed charges",""
"Mgh Tert Gene Sequencing","PX-31000294","CDM","81479","CPT","0310","RC","","","","both","","","5654.00","4240.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4494.93","79.5","","0.65","0.65","0.65","1 through 10","1752.74","5371.3","percent of total billed charges",""
"Mgh Tert Gene Sequencing","PX-31000294","CDM","81479","CPT","0310","RC","","","","both","","","5654.00","4240.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3013.58","53.3","","0.79","0.79","0.79","1 through 10","1752.74","5371.3","percent of total billed charges",""
"Mgh Tert Gene Sequencing","PX-31000294","CDM","81479","CPT","0310","RC","","","","outpatient","","","5654.00","4240.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2827.00","50","","1.00","1.00","1.00","1 through 10","156.55","4664.55","percent of total billed charges",""
"Mgh Tert Gene Sequencing","PX-31000294","CDM","81479","CPT","0310","RC","","","","outpatient","","","5654.00","4240.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2968.35","52.5","","1.00","0.53","1.00","1 through 10","156.55","4664.55","percent of total billed charges",""
"Mgh Tetrahydrocannabinol","PX-30001519","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Mgh Tetrahydrocannabinol","PX-30001519","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","106.25","71.28","106.25","1 through 10","14.12","299.25","percent of total billed charges",""
"Mgh Tetrahydrocannabinol","PX-30001519","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","50.36","42.80","92.50","13","14.12","299.25","percent of total billed charges",""
"Mgh Tetrahydrocannabinol","PX-30001519","CDM","80299","CPT","0301","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","52.79","44.55","158.37","30","14.12","299.25","percent of total billed charges",""
"Mgh Tetrahydrocannabinol","PX-30001519","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","91.40","64.53","105.30","14","14.12","257.42","percent of total billed charges",""
"Mgh Tetrahydrocannabinol","PX-30001519","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","105.30","105.30","105.30","1 through 10","14.12","257.42","percent of total billed charges",""
"Mgh Tetrahydrocannabinol","PX-30001519","CDM","80299","CPT","0301","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","59.36","15.50","59.36","1 through 10","14.12","257.42","percent of total billed charges",""
"Mgh Tgm1 Gene Sequencing","PX-31000587","CDM","81479","CPT","0310","RC","","","","both","","","2799.00","2099.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2225.21","79.5","","0.65","0.65","0.65","1 through 10","867.69","2659.05","percent of total billed charges",""
"Mgh Tgm1 Gene Sequencing","PX-31000587","CDM","81479","CPT","0310","RC","","","","both","","","2799.00","2099.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1491.87","53.3","","0.79","0.79","0.79","1 through 10","867.69","2659.05","percent of total billed charges",""
"Mgh Tgm1 Gene Sequencing","PX-31000587","CDM","81479","CPT","0310","RC","","","","outpatient","","","2799.00","2099.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1399.50","50","","1.00","1.00","1.00","1 through 10","156.55","2309.18","percent of total billed charges",""
"Mgh Tgm1 Gene Sequencing","PX-31000587","CDM","81479","CPT","0310","RC","","","","outpatient","","","2799.00","2099.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1469.48","52.5","","1.00","0.53","1.00","1 through 10","156.55","2309.18","percent of total billed charges",""
"Mgh Thioplasmin Act Inhib","PX-30002001","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Thioplasmin Act Inhib","PX-30002001","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Thioplasmin Act Inhib","PX-30002011","CDM","82657","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","231.38","231.38","231.38","1 through 10","18.62","287.85","percent of total billed charges",""
"Mgh Thioplasmin Act Inhib","PX-30002011","CDM","82657","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","1 through 10","18.62","247.61","percent of total billed charges",""
"Mgh Thiosulfate Spectrophotometric","PX-30001877","CDM","84311","CPT","0300","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Thiosulfate Spectrophotometric","PX-30001877","CDM","84311","CPT","0300","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Thiosulfate Spectrophotometric","PX-30001877","CDM","84311","CPT","0300","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Thosulf Spctrophotmetrc","PX-30001881","CDM","84311","CPT","0300","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Thosulf Spctrophotmetrc","PX-30001881","CDM","84311","CPT","0300","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Thosulf Spctrophotmetrc","PX-30001881","CDM","84311","CPT","0300","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002064","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Thrombin Antithrombin Cplx","PX-30002094","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Tiagabine","PX-30001552","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Tiagabine","PX-30001552","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Tiagabine","PX-30001552","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Tiagabine","PX-30001552","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Tiagabine","PX-30001552","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Tiagabine","PX-30001552","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Tiagabine","PX-30001552","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Mgh Timothy Grass Ige 86003","PX-30002190","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Mgh Tinf2 Exon 6 Sequence","PX-31000633","CDM","81479","CPT","0310","RC","","","","both","","","603.00","452.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","479.39","79.5","","0.65","0.65","0.65","1 through 10","186.93","572.85","percent of total billed charges",""
"Mgh Tinf2 Exon 6 Sequence","PX-31000633","CDM","81479","CPT","0310","RC","","","","both","","","603.00","452.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","321.40","53.3","","0.79","0.79","0.79","1 through 10","186.93","572.85","percent of total billed charges",""
"Mgh Tinf2 Exon 6 Sequence","PX-31000633","CDM","81479","CPT","0310","RC","","","","outpatient","","","603.00","452.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","301.50","50","","1.00","1.00","1.00","1 through 10","156.55","497.48","percent of total billed charges",""
"Mgh Tinf2 Exon 6 Sequence","PX-31000633","CDM","81479","CPT","0310","RC","","","","outpatient","","","603.00","452.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","316.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","497.48","percent of total billed charges",""
"Mgh Tinf2 Exon 6 Sequencing","PX-31000295","CDM","81479","CPT","0310","RC","","","","both","","","632.00","474.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","502.44","79.5","","0.65","0.65","0.65","1 through 10","195.92","600.4","percent of total billed charges",""
"Mgh Tinf2 Exon 6 Sequencing","PX-31000295","CDM","81479","CPT","0310","RC","","","","both","","","632.00","474.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","336.86","53.3","","0.79","0.79","0.79","1 through 10","195.92","600.4","percent of total billed charges",""
"Mgh Tinf2 Exon 6 Sequencing","PX-31000295","CDM","81479","CPT","0310","RC","","","","outpatient","","","632.00","474.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","316.00","50","","1.00","1.00","1.00","1 through 10","156.55","521.4","percent of total billed charges",""
"Mgh Tinf2 Exon 6 Sequencing","PX-31000295","CDM","81479","CPT","0310","RC","","","","outpatient","","","632.00","474.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","331.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","521.4","percent of total billed charges",""
"Mgh Total Iodine","PX-30002110","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Total Iodine","PX-30002110","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Total Iodine","PX-30002110","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Total Iodine","PX-30002110","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Total Iodine","PX-30002110","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Total Iodine","PX-30002110","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Total Iodine","PX-30002110","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","333.87","111.29","333.87","14","10.07","152","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","104.96","65.6","","120.90","120.90","120.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","100.75","100.75","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","155.00","106.50","155.00","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","121.99","81.84","365.97","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","81.84","81.84","81.84","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","100.75","97.50","100.75","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.60","31","","47.90","47.90","47.90","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.40","36.5","","57.82","49.14","173.46","12","10.07","152","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","60.61","60.61","333.87","28","10.07","152","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","both","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","123.91","123.91","123.91","1 through 10","10.07","152","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","104.94","74.09","104.94","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","120.90","120.90","241.80","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.64","80.4","","77.50","77.50","77.50","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Toxocara Ab Elisa","PX-30002232","CDM","86682","CPT","0302","RC","","","","outpatient","","","160.00","120.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","123.91","68.15","124.55","1 through 10","10.07","130.75","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Toxoplasma Dna Ql Pcr","PX-30002307","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Tp63 Select Exons Sequencing","PX-31000585","CDM","81479","CPT","0310","RC","","","","both","","","1751.00","1313.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1392.05","79.5","","0.65","0.65","0.65","1 through 10","542.81","1663.45","percent of total billed charges",""
"Mgh Tp63 Select Exons Sequencing","PX-31000585","CDM","81479","CPT","0310","RC","","","","both","","","1751.00","1313.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","933.28","53.3","","0.79","0.79","0.79","1 through 10","542.81","1663.45","percent of total billed charges",""
"Mgh Tp63 Select Exons Sequencing","PX-31000585","CDM","81479","CPT","0310","RC","","","","outpatient","","","1751.00","1313.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","875.50","50","","1.00","1.00","1.00","1 through 10","156.55","1444.58","percent of total billed charges",""
"Mgh Tp63 Select Exons Sequencing","PX-31000585","CDM","81479","CPT","0310","RC","","","","outpatient","","","1751.00","1313.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","919.28","52.5","","1.00","0.53","1.00","1 through 10","156.55","1444.58","percent of total billed charges",""
"Mgh Transketolase Whole Bld","PX-30002162","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Transketolase Whole Bld","PX-30002162","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Transketolase Whole Bld","PX-30002162","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Translocation Assays I","PX-31000303","CDM","81479","CPT","0310","RC","","","","both","","","1532.00","1149.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1217.94","79.5","","0.65","0.65","0.65","1 through 10","474.92","1455.4","percent of total billed charges",""
"Mgh Translocation Assays I","PX-31000303","CDM","81479","CPT","0310","RC","","","","both","","","1532.00","1149.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","816.56","53.3","","0.79","0.79","0.79","1 through 10","474.92","1455.4","percent of total billed charges",""
"Mgh Translocation Assays I","PX-31000303","CDM","81479","CPT","0310","RC","","","","outpatient","","","1532.00","1149.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","766.00","50","","1.00","1.00","1.00","1 through 10","156.55","1263.9","percent of total billed charges",""
"Mgh Translocation Assays I","PX-31000303","CDM","81479","CPT","0310","RC","","","","outpatient","","","1532.00","1149.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","804.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","1263.9","percent of total billed charges",""
"Mgh Translocation Assays II","PX-31000304","CDM","81479","CPT","0310","RC","","","","both","","","78.00","58.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","62.01","79.5","","0.65","0.65","0.65","1 through 10","24.18","74.1","percent of total billed charges",""
"Mgh Translocation Assays II","PX-31000304","CDM","81479","CPT","0310","RC","","","","both","","","78.00","58.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","41.57","53.3","","0.79","0.79","0.79","1 through 10","24.18","74.1","percent of total billed charges",""
"Mgh Translocation Assays II","PX-31000304","CDM","81479","CPT","0310","RC","","","","outpatient","","","78.00","58.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","39.00","50","","1.00","1.00","1.00","1 through 10","37.75","156.55","percent of total billed charges",""
"Mgh Translocation Assays II","PX-31000304","CDM","81479","CPT","0310","RC","","","","outpatient","","","78.00","58.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","40.95","52.5","","1.00","0.53","1.00","1 through 10","37.75","156.55","percent of total billed charges",""
"Mgh Trazodone Level 80299","PX-30001575","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Trazodone Level 80299","PX-30001575","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Trazodone Level 80299","PX-30001575","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Trazodone Level 80299","PX-30001575","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Trazodone Level 80299","PX-30001575","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Trazodone Level 80299","PX-30001575","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Trazodone Level 80299","PX-30001575","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Trex1 Gene Sequencing","PX-31000511","CDM","81479","CPT","0310","RC","","","","both","","","1431.00","1073.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1137.65","79.5","","0.65","0.65","0.65","1 through 10","443.61","1359.45","percent of total billed charges",""
"Mgh Trex1 Gene Sequencing","PX-31000511","CDM","81479","CPT","0310","RC","","","","both","","","1431.00","1073.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","762.72","53.3","","0.79","0.79","0.79","1 through 10","443.61","1359.45","percent of total billed charges",""
"Mgh Trex1 Gene Sequencing","PX-31000511","CDM","81479","CPT","0310","RC","","","","outpatient","","","1431.00","1073.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","715.50","50","","1.00","1.00","1.00","1 through 10","156.55","1180.58","percent of total billed charges",""
"Mgh Trex1 Gene Sequencing","PX-31000511","CDM","81479","CPT","0310","RC","","","","outpatient","","","1431.00","1073.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","751.28","52.5","","1.00","0.53","1.00","1 through 10","156.55","1180.58","percent of total billed charges",""
"Mgh Trips I/III","PX-31000340","CDM","81479","CPT","0310","RC","","","","both","","","2812.00","2109.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2235.54","79.5","","0.65","0.65","0.65","1 through 10","871.72","2671.4","percent of total billed charges",""
"Mgh Trips I/III","PX-31000340","CDM","81479","CPT","0310","RC","","","","both","","","2812.00","2109.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1498.80","53.3","","0.79","0.79","0.79","1 through 10","871.72","2671.4","percent of total billed charges",""
"Mgh Trips I/III","PX-31000340","CDM","81479","CPT","0310","RC","","","","outpatient","","","2812.00","2109.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1406.00","50","","1.00","1.00","1.00","1 through 10","156.55","2319.9","percent of total billed charges",""
"Mgh Trips I/III","PX-31000340","CDM","81479","CPT","0310","RC","","","","outpatient","","","2812.00","2109.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1476.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","2319.9","percent of total billed charges",""
"Mgh Trpv4 Dna Sequencing Test","PX-31000264","CDM","81479","CPT","0310","RC","","","","both","","","4581.00","3435.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3641.90","79.5","","0.65","0.65","0.65","1 through 10","1420.11","4351.95","percent of total billed charges",""
"Mgh Trpv4 Dna Sequencing Test","PX-31000264","CDM","81479","CPT","0310","RC","","","","both","","","4581.00","3435.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2441.67","53.3","","0.79","0.79","0.79","1 through 10","1420.11","4351.95","percent of total billed charges",""
"Mgh Trpv4 Dna Sequencing Test","PX-31000264","CDM","81479","CPT","0310","RC","","","","outpatient","","","4581.00","3435.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2290.50","50","","1.00","1.00","1.00","1 through 10","156.55","3779.33","percent of total billed charges",""
"Mgh Trpv4 Dna Sequencing Test","PX-31000264","CDM","81479","CPT","0310","RC","","","","outpatient","","","4581.00","3435.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2405.03","52.5","","1.00","0.53","1.00","1 through 10","156.55","3779.33","percent of total billed charges",""
"Mgh Trypanosoma Cruzi Ab Igg","PX-30002238","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","108.58","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Trypanosoma Cruzi Ab Igg","PX-30002238","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.55","53.3","","78.14","78.14","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Trypanosoma Cruzi Ab Igg","PX-30002238","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.85","36.5","","165.60","55.20","165.60","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Trypanosoma Cruzi Ab Igg","PX-30002238","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","57.87","57.87","57.87","14","9.6","145.35","percent of total billed charges",""
"Mgh Trypanosoma Cruzi Ab Igg","PX-30002238","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","TRICARE [160005]","HB BWH TRICARE","145.35","95","","14.93","14.18","14.93","1 through 10","9.6","145.35","percent of total billed charges",""
"Mgh Trypanosoma Cruzi Ab Igg","PX-30002238","CDM","86753","CPT","0302","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","141.48","70.74","200.40","1 through 10","9.6","125.03","percent of total billed charges",""
"Mgh Trypanosoma Cruzi Ab Igg","PX-30002238","CDM","86753","CPT","0302","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","118.31","65.08","118.31","13","9.6","125.03","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase","PX-30002067","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase","PX-30002097","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Tryptase Serum 83520","PX-30002041","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh Tsh Receptor 83520","PX-30002040","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002108","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002108","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002108","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002108","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002108","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002108","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002108","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002113","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002113","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002113","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002113","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002113","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002113","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Tu Cortisone","PX-30002113","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Two Known Mutations","PX-31000278","CDM","81479","CPT","0310","RC","","","","both","","","1488.00","1116.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1182.96","79.5","","0.65","0.65","0.65","1 through 10","461.28","1413.6","percent of total billed charges",""
"Mgh Two Known Mutations","PX-31000278","CDM","81479","CPT","0310","RC","","","","both","","","1488.00","1116.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","793.10","53.3","","0.79","0.79","0.79","1 through 10","461.28","1413.6","percent of total billed charges",""
"Mgh Two Known Mutations","PX-31000278","CDM","81479","CPT","0310","RC","","","","outpatient","","","1488.00","1116.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","744.00","50","","1.00","1.00","1.00","1 through 10","156.55","1227.6","percent of total billed charges",""
"Mgh Two Known Mutations","PX-31000278","CDM","81479","CPT","0310","RC","","","","outpatient","","","1488.00","1116.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","781.20","52.5","","1.00","0.53","1.00","1 through 10","156.55","1227.6","percent of total billed charges",""
"Mgh U Blastomyces Ag","PX-30002247","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","102.43","102.43","102.43","1 through 10","11.74","190","percent of total billed charges",""
"Mgh U Blastomyces Ag","PX-30002247","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","61.50","61.50","61.50","1 through 10","11.74","190","percent of total billed charges",""
"Mgh U Blastomyces Ag","PX-30002247","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","75.85","75.86","1 through 10","11.74","190","percent of total billed charges",""
"Mgh U Blastomyces Ag","PX-30002247","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","155.08","155.08","1 through 10","11.74","190","percent of total billed charges",""
"Mgh U Blastomyces Ag","PX-30002247","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","131.34","92.73","185.46","17","11.81","163.44","percent of total billed charges",""
"Mgh U Blastomyces Ag","PX-30002247","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","60.38","194.00","1 through 10","11.81","163.44","percent of total billed charges",""
"Mgh U Buprenorphine Screen","PX-30001535","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh U Buprenorphine Screen","PX-30001535","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh U Buprenorphine Screen","PX-30001535","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh U Buprenorphine Screen","PX-30001535","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh U Buprenorphine Screen","PX-30001535","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh U Buprenorphine Screen","PX-30001535","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh U Buprenorphine Screen","PX-30001535","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh U Iodine","PX-30001975","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh U Iodine","PX-30001975","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh U Iodine","PX-30001975","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh U Iodine","PX-30001975","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh U Iodine","PX-30001975","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh U Iodine","PX-30001975","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh U Iodine","PX-30001975","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh U Iodine","PX-30001975","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh U Iodine","PX-30001975","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh U Iodine","PX-30001985","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh U Iodine","PX-30001985","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh U Iodine","PX-30001985","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh U Iodine","PX-30001985","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh U Iodine","PX-30001985","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh U Iodine","PX-30001985","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh U Iodine","PX-30001985","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh U Iodine","PX-30001985","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh U Iodine","PX-30001985","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh U Psilocin","PX-30001536","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh U Psilocin","PX-30001536","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh U Psilocin","PX-30001536","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh U Psilocin","PX-30001536","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh U Psilocin","PX-30001536","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh U Psilocin","PX-30001536","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh U Psilocin","PX-30001536","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh U Sertraline by Gc","PX-30001549","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh U Sertraline by Gc","PX-30001549","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh U Sertraline by Gc","PX-30001549","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh U Sertraline by Gc","PX-30001549","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh U Sertraline by Gc","PX-30001549","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh U Sertraline by Gc","PX-30001549","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh U Sertraline by Gc","PX-30001549","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002074","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Mgh U-Cotinine","PX-30002102","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Mgh Ung Gene Sequencing","PX-31000729","CDM","81479","CPT","0310","RC","","","","both","","","1725.00","1293.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1371.38","79.5","","0.65","0.65","0.65","1 through 10","534.75","1638.75","percent of total billed charges",""
"Mgh Ung Gene Sequencing","PX-31000729","CDM","81479","CPT","0310","RC","","","","both","","","1725.00","1293.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","919.43","53.3","","0.79","0.79","0.79","1 through 10","534.75","1638.75","percent of total billed charges",""
"Mgh Ung Gene Sequencing","PX-31000729","CDM","81479","CPT","0310","RC","","","","outpatient","","","1725.00","1293.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","862.50","50","","1.00","1.00","1.00","1 through 10","156.55","1423.13","percent of total billed charges",""
"Mgh Ung Gene Sequencing","PX-31000729","CDM","81479","CPT","0310","RC","","","","outpatient","","","1725.00","1293.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","905.63","52.5","","1.00","0.53","1.00","1 through 10","156.55","1423.13","percent of total billed charges",""
"Mgh Urine Clonidine","PX-30002311","CDM","80299","CPT","0301","RC","","","","both","","","564.00","423.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","448.38","79.5","","106.25","71.28","106.25","1 through 10","14.12","535.8","percent of total billed charges",""
"Mgh Urine Clonidine","PX-30002311","CDM","80299","CPT","0301","RC","","","","both","","","564.00","423.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","300.61","53.3","","106.25","71.28","106.25","1 through 10","14.12","535.8","percent of total billed charges",""
"Mgh Urine Clonidine","PX-30002311","CDM","80299","CPT","0301","RC","","","","both","","","564.00","423.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","205.86","36.5","","50.36","42.80","92.50","13","14.12","535.8","percent of total billed charges",""
"Mgh Urine Clonidine","PX-30002311","CDM","80299","CPT","0301","RC","","","","both","","","564.00","423.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","216.01","38.3","","52.79","44.55","158.37","30","14.12","535.8","percent of total billed charges",""
"Mgh Urine Clonidine","PX-30002311","CDM","80299","CPT","0301","RC","","","","outpatient","","","564.00","423.00","AETNA [1001]","HB AMC AETNA HMO","393.67","69.8","","91.40","64.53","105.30","14","14.12","460.9","percent of total billed charges",""
"Mgh Urine Clonidine","PX-30002311","CDM","80299","CPT","0301","RC","","","","outpatient","","","564.00","423.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","453.46","80.4","","105.30","105.30","105.30","1 through 10","14.12","460.9","percent of total billed charges",""
"Mgh Urine Clonidine","PX-30002311","CDM","80299","CPT","0301","RC","","","","outpatient","","","564.00","423.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","460.90","81.72","","59.36","15.50","59.36","1 through 10","14.12","460.9","percent of total billed charges",""
"Mgh Urine Kappa Lc Qt","PX-30002124","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Urine Kappa Lc Qt","PX-30002124","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Urine Lambda Lc Qt","PX-30002125","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Mgh Urine Lambda Lc Qt","PX-30002125","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Mgh Uroporphyringn Decarbox RBC","PX-30002157","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Uroporphyringn Decarbox RBC","PX-30002157","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Uroporphyringn Decarbox RBC","PX-30002157","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Uroporphyringn Decarbx RBC","PX-30002167","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Uroporphyringn Decarbx RBC","PX-30002167","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Mgh Uroporphyringn Decarbx RBC","PX-30002167","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Mgh Vascular Malformations Pan, Seq and Del/Duplication, 14 Genes","PX-31000856","CDM","81479","CPT","0310","RC","","","","both","","","474.00","355.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","376.83","79.5","","0.65","0.65","0.65","1 through 10","146.94","450.3","percent of total billed charges",""
"Mgh Vascular Malformations Pan, Seq and Del/Duplication, 14 Genes","PX-31000856","CDM","81479","CPT","0310","RC","","","","both","","","474.00","355.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","252.64","53.3","","0.79","0.79","0.79","1 through 10","146.94","450.3","percent of total billed charges",""
"Mgh Vascular Malformations Pan, Seq and Del/Duplication, 14 Genes","PX-31000856","CDM","81479","CPT","0310","RC","","","","outpatient","","","474.00","355.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","237.00","50","","1.00","1.00","1.00","1 through 10","156.55","391.05","percent of total billed charges",""
"Mgh Vascular Malformations Pan, Seq and Del/Duplication, 14 Genes","PX-31000856","CDM","81479","CPT","0310","RC","","","","outpatient","","","474.00","355.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","248.85","52.5","","1.00","0.53","1.00","1 through 10","156.55","391.05","percent of total billed charges",""
"Mgh Vcp Dna Sequencing Test","PX-31000246","CDM","81479","CPT","0310","RC","","","","both","","","3203.00","2402.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2546.39","79.5","","0.65","0.65","0.65","1 through 10","992.93","3042.85","percent of total billed charges",""
"Mgh Vcp Dna Sequencing Test","PX-31000246","CDM","81479","CPT","0310","RC","","","","both","","","3203.00","2402.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1707.20","53.3","","0.79","0.79","0.79","1 through 10","992.93","3042.85","percent of total billed charges",""
"Mgh Vcp Dna Sequencing Test","PX-31000246","CDM","81479","CPT","0310","RC","","","","outpatient","","","3203.00","2402.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1601.50","50","","1.00","1.00","1.00","1 through 10","156.55","2642.48","percent of total billed charges",""
"Mgh Vcp Dna Sequencing Test","PX-31000246","CDM","81479","CPT","0310","RC","","","","outpatient","","","3203.00","2402.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1681.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","2642.48","percent of total billed charges",""
"Mgh Vedolizumab and Anti-Vedolizumab Antibodies, Serum","PX-31000879","CDM","80299","CPT","0310","RC","","","","both","","","212.00","159.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","168.54","79.5","","106.25","71.28","106.25","1 through 10","18.27","201.4","percent of total billed charges",""
"Mgh Vedolizumab and Anti-Vedolizumab Antibodies, Serum","PX-31000879","CDM","80299","CPT","0310","RC","","","","both","","","212.00","159.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","113.00","53.3","","106.25","71.28","106.25","1 through 10","18.27","201.4","percent of total billed charges",""
"Mgh Vedolizumab and Anti-Vedolizumab Antibodies, Serum","PX-31000879","CDM","80299","CPT","0310","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.38","36.5","","50.36","42.80","92.50","13","18.27","201.4","percent of total billed charges",""
"Mgh Vedolizumab and Anti-Vedolizumab Antibodies, Serum","PX-31000879","CDM","80299","CPT","0310","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.20","38.3","","52.79","44.55","158.37","30","18.27","201.4","percent of total billed charges",""
"Mgh Vedolizumab and Anti-Vedolizumab Antibodies, Serum","PX-31000879","CDM","80299","CPT","0310","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA HMO","147.98","69.8","","91.40","64.53","105.30","14","53.62","173.25","percent of total billed charges",""
"Mgh Vedolizumab and Anti-Vedolizumab Antibodies, Serum","PX-31000879","CDM","80299","CPT","0310","RC","","","","outpatient","","","212.00","159.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","170.45","80.4","","105.30","105.30","105.30","1 through 10","53.62","173.25","percent of total billed charges",""
"Mgh Vedolizumab and Anti-Vedolizumab Antibodies, Serum","PX-31000879","CDM","80299","CPT","0310","RC","","","","outpatient","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","173.25","81.72","","59.36","15.50","59.36","1 through 10","53.62","173.25","percent of total billed charges",""
"Mgh Voriconazole Level","PX-30002318","CDM","80299","CPT","0301","RC","","","","both","","","290.00","217.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","230.55","79.5","","106.25","71.28","106.25","1 through 10","14.12","275.5","percent of total billed charges",""
"Mgh Voriconazole Level","PX-30002318","CDM","80299","CPT","0301","RC","","","","both","","","290.00","217.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","154.57","53.3","","106.25","71.28","106.25","1 through 10","14.12","275.5","percent of total billed charges",""
"Mgh Voriconazole Level","PX-30002318","CDM","80299","CPT","0301","RC","","","","both","","","290.00","217.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.85","36.5","","50.36","42.80","92.50","13","14.12","275.5","percent of total billed charges",""
"Mgh Voriconazole Level","PX-30002318","CDM","80299","CPT","0301","RC","","","","both","","","290.00","217.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","111.07","38.3","","52.79","44.55","158.37","30","14.12","275.5","percent of total billed charges",""
"Mgh Voriconazole Level","PX-30002318","CDM","80299","CPT","0301","RC","","","","outpatient","","","290.00","217.50","AETNA [1001]","HB AMC AETNA HMO","202.42","69.8","","91.40","64.53","105.30","14","14.12","236.99","percent of total billed charges",""
"Mgh Voriconazole Level","PX-30002318","CDM","80299","CPT","0301","RC","","","","outpatient","","","290.00","217.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","233.16","80.4","","105.30","105.30","105.30","1 through 10","14.12","236.99","percent of total billed charges",""
"Mgh Voriconazole Level","PX-30002318","CDM","80299","CPT","0301","RC","","","","outpatient","","","290.00","217.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","236.99","81.72","","59.36","15.50","59.36","1 through 10","14.12","236.99","percent of total billed charges",""
"Mgh Vwd Platelet-Type Sequence Analysis","PX-31000565","CDM","81479","CPT","0310","RC","","","","both","","","1436.00","1077.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1141.62","79.5","","0.65","0.65","0.65","1 through 10","445.16","1364.2","percent of total billed charges",""
"Mgh Vwd Platelet-Type Sequence Analysis","PX-31000565","CDM","81479","CPT","0310","RC","","","","both","","","1436.00","1077.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","765.39","53.3","","0.79","0.79","0.79","1 through 10","445.16","1364.2","percent of total billed charges",""
"Mgh Vwd Platelet-Type Sequence Analysis","PX-31000565","CDM","81479","CPT","0310","RC","","","","outpatient","","","1436.00","1077.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","718.00","50","","1.00","1.00","1.00","1 through 10","156.55","1184.7","percent of total billed charges",""
"Mgh Vwd Platelet-Type Sequence Analysis","PX-31000565","CDM","81479","CPT","0310","RC","","","","outpatient","","","1436.00","1077.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","753.90","52.5","","1.00","0.53","1.00","1 through 10","156.55","1184.7","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Vzv Dna Pcr","PX-30002308","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Waardenburg Syndrome Pax3 Gene Types","PX-31000643","CDM","81479","CPT","0310","RC","","","","both","","","1763.00","1322.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1401.59","79.5","","0.65","0.65","0.65","1 through 10","546.53","1674.85","percent of total billed charges",""
"Mgh Waardenburg Syndrome Pax3 Gene Types","PX-31000643","CDM","81479","CPT","0310","RC","","","","both","","","1763.00","1322.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","939.68","53.3","","0.79","0.79","0.79","1 through 10","546.53","1674.85","percent of total billed charges",""
"Mgh Waardenburg Syndrome Pax3 Gene Types","PX-31000643","CDM","81479","CPT","0310","RC","","","","outpatient","","","1763.00","1322.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","881.50","50","","1.00","1.00","1.00","1 through 10","156.55","1454.48","percent of total billed charges",""
"Mgh Waardenburg Syndrome Pax3 Gene Types","PX-31000643","CDM","81479","CPT","0310","RC","","","","outpatient","","","1763.00","1322.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","925.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","1454.48","percent of total billed charges",""
"Mgh Warfarin","PX-30001553","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Warfarin","PX-30001553","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Mgh Warfarin","PX-30001553","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Mgh Warfarin","PX-30001553","CDM","80299","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Mgh Warfarin","PX-30001553","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Mgh Warfarin","PX-30001553","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh Warfarin","PX-30001553","CDM","80299","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh West Nile Virus Rt Pcr","PX-30002309","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Mgh Whipple Disease Pcr","PX-30002310","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Mgh Wnt10a Gene Sequencing","PX-31000579","CDM","81479","CPT","0310","RC","","","","both","","","1626.00","1219.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1292.67","79.5","","0.65","0.65","0.65","1 through 10","504.06","1544.7","percent of total billed charges",""
"Mgh Wnt10a Gene Sequencing","PX-31000579","CDM","81479","CPT","0310","RC","","","","both","","","1626.00","1219.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","866.66","53.3","","0.79","0.79","0.79","1 through 10","504.06","1544.7","percent of total billed charges",""
"Mgh Wnt10a Gene Sequencing","PX-31000579","CDM","81479","CPT","0310","RC","","","","outpatient","","","1626.00","1219.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","813.00","50","","1.00","1.00","1.00","1 through 10","156.55","1341.45","percent of total billed charges",""
"Mgh Wnt10a Gene Sequencing","PX-31000579","CDM","81479","CPT","0310","RC","","","","outpatient","","","1626.00","1219.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","853.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","1341.45","percent of total billed charges",""
"Mgh X?Adrenoleukodystrophy Abcd1 Mlpa","PX-31000605","CDM","81479","CPT","0310","RC","","","","both","","","979.00","734.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","778.31","79.5","","0.65","0.65","0.65","1 through 10","303.49","930.05","percent of total billed charges",""
"Mgh X?Adrenoleukodystrophy Abcd1 Mlpa","PX-31000605","CDM","81479","CPT","0310","RC","","","","both","","","979.00","734.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","521.81","53.3","","0.79","0.79","0.79","1 through 10","303.49","930.05","percent of total billed charges",""
"Mgh X?Adrenoleukodystrophy Abcd1 Mlpa","PX-31000605","CDM","81479","CPT","0310","RC","","","","outpatient","","","979.00","734.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","489.50","50","","1.00","1.00","1.00","1 through 10","156.55","807.68","percent of total billed charges",""
"Mgh X?Adrenoleukodystrophy Abcd1 Mlpa","PX-31000605","CDM","81479","CPT","0310","RC","","","","outpatient","","","979.00","734.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","513.98","52.5","","1.00","0.53","1.00","1 through 10","156.55","807.68","percent of total billed charges",""
"Mgh Xeroderma Pigmentosum Sequencing Panel","PX-30003418","CDM","81479","CPT","0310","RC","","","","both","","","394.00","295.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","313.23","79.5","","0.65","0.65","0.65","1 through 10","122.14","374.3","percent of total billed charges",""
"Mgh Xeroderma Pigmentosum Sequencing Panel","PX-30003418","CDM","81479","CPT","0310","RC","","","","both","","","394.00","295.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","210.00","53.3","","0.79","0.79","0.79","1 through 10","122.14","374.3","percent of total billed charges",""
"Mgh Xeroderma Pigmentosum Sequencing Panel","PX-30003418","CDM","81479","CPT","0310","RC","","","","outpatient","","","394.00","295.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","197.00","50","","1.00","1.00","1.00","1 through 10","156.55","325.05","percent of total billed charges",""
"Mgh Xeroderma Pigmentosum Sequencing Panel","PX-30003418","CDM","81479","CPT","0310","RC","","","","outpatient","","","394.00","295.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","206.85","52.5","","1.00","0.53","1.00","1 through 10","156.55","325.05","percent of total billed charges",""
"Mgh Xomedx (Whole Exome Sequencing","PX-31000250","CDM","81479","CPT","0310","RC","","","","both","","","7663.00","5747.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6092.09","79.5","","0.65","0.65","0.65","1 through 10","2375.53","7279.85","percent of total billed charges",""
"Mgh Xomedx (Whole Exome Sequencing","PX-31000250","CDM","81479","CPT","0310","RC","","","","both","","","7663.00","5747.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4084.38","53.3","","0.79","0.79","0.79","1 through 10","2375.53","7279.85","percent of total billed charges",""
"Mgh Xomedx (Whole Exome Sequencing","PX-31000250","CDM","81479","CPT","0310","RC","","","","outpatient","","","7663.00","5747.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3831.50","50","","1.00","1.00","1.00","1 through 10","156.55","6321.98","percent of total billed charges",""
"Mgh Xomedx (Whole Exome Sequencing","PX-31000250","CDM","81479","CPT","0310","RC","","","","outpatient","","","7663.00","5747.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4023.08","52.5","","1.00","0.53","1.00","1 through 10","156.55","6321.98","percent of total billed charges",""
"Mgh Xomedx Whole Exome Sequencing","PX-31000263","CDM","81479","CPT","0310","RC","","","","both","","","12260.00","9195.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9746.70","79.5","","0.65","0.65","0.65","1 through 10","3800.6","11647","percent of total billed charges",""
"Mgh Xomedx Whole Exome Sequencing","PX-31000263","CDM","81479","CPT","0310","RC","","","","both","","","12260.00","9195.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6534.58","53.3","","0.79","0.79","0.79","1 through 10","3800.6","11647","percent of total billed charges",""
"Mgh Xomedx Whole Exome Sequencing","PX-31000263","CDM","81479","CPT","0310","RC","","","","outpatient","","","12260.00","9195.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6130.00","50","","1.00","1.00","1.00","1 through 10","156.55","10114.5","percent of total billed charges",""
"Mgh Xomedx Whole Exome Sequencing","PX-31000263","CDM","81479","CPT","0310","RC","","","","outpatient","","","12260.00","9195.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6436.50","52.5","","1.00","0.53","1.00","1 through 10","156.55","10114.5","percent of total billed charges",""
"Mgh Yars Dna Sequencing Test","PX-31000266","CDM","81479","CPT","0310","RC","","","","both","","","4581.00","3435.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3641.90","79.5","","0.65","0.65","0.65","1 through 10","1420.11","4351.95","percent of total billed charges",""
"Mgh Yars Dna Sequencing Test","PX-31000266","CDM","81479","CPT","0310","RC","","","","both","","","4581.00","3435.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2441.67","53.3","","0.79","0.79","0.79","1 through 10","1420.11","4351.95","percent of total billed charges",""
"Mgh Yars Dna Sequencing Test","PX-31000266","CDM","81479","CPT","0310","RC","","","","outpatient","","","4581.00","3435.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2290.50","50","","1.00","1.00","1.00","1 through 10","156.55","3779.33","percent of total billed charges",""
"Mgh Yars Dna Sequencing Test","PX-31000266","CDM","81479","CPT","0310","RC","","","","outpatient","","","4581.00","3435.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2405.03","52.5","","1.00","0.53","1.00","1 through 10","156.55","3779.33","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001977","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001977","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001977","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001977","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001977","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001977","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001977","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001977","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001977","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001987","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001987","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001987","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001987","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001987","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001987","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001987","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001987","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Mgh Ziprasidone","PX-30001987","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Mghdrug Screen Quant Everolimus","PX-30002278","CDM","80169","CPT","0301","RC","","","","both","","","120.00","90.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","86.16","71.8","","83.29","12.11","83.29","36","7.52","114","percent of total billed charges",""
"Mghdrug Screen Quant Everolimus","PX-30002278","CDM","80169","CPT","0301","RC","","","","both","","","120.00","90.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","78.00","65","","75.40","75.40","75.40","1 through 10","7.52","114","percent of total billed charges",""
"Mghdrug Screen Quant Everolimus","PX-30002278","CDM","80169","CPT","0301","RC","","","","both","","","120.00","90.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","95.40","79.5","","91.29","91.29","91.29","1 through 10","7.52","114","percent of total billed charges",""
"Mghdrug Screen Quant Everolimus","PX-30002278","CDM","80169","CPT","0301","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","43.80","36.5","","36.77","36.77","43.27","1 through 10","7.52","114","percent of total billed charges",""
"Mghdrug Screen Quant Everolimus","PX-30002278","CDM","80169","CPT","0301","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","45.96","38.3","","45.36","43.27","45.36","11","7.52","114","percent of total billed charges",""
"Mghdrug Screen Quant Everolimus","PX-30002278","CDM","80169","CPT","0301","RC","","","","outpatient","","","120.00","90.00","AETNA [1001]","HB AMC AETNA HMO","83.76","69.8","","55.45","55.45","157.06","16","7.52","98.06","percent of total billed charges",""
"Mghdrug Screen Quant Everolimus","PX-30002278","CDM","80169","CPT","0301","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","98.06","81.72","","92.73","92.73","92.73","1 through 10","7.52","98.06","percent of total billed charges",""
"Mghterc Gene Sequencing","PX-31000577","CDM","81479","CPT","0310","RC","","","","both","","","632.00","474.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","502.44","79.5","","0.65","0.65","0.65","1 through 10","195.92","600.4","percent of total billed charges",""
"Mghterc Gene Sequencing","PX-31000577","CDM","81479","CPT","0310","RC","","","","both","","","632.00","474.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","336.86","53.3","","0.79","0.79","0.79","1 through 10","195.92","600.4","percent of total billed charges",""
"Mghterc Gene Sequencing","PX-31000577","CDM","81479","CPT","0310","RC","","","","outpatient","","","632.00","474.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","316.00","50","","1.00","1.00","1.00","1 through 10","156.55","521.4","percent of total billed charges",""
"Mghterc Gene Sequencing","PX-31000577","CDM","81479","CPT","0310","RC","","","","outpatient","","","632.00","474.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","331.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","521.4","percent of total billed charges",""
"Mgmt Methylation Analysis","PX-30001850","CDM","81287","CPT","0300","RC","","","","both","","","856.00","642.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","680.52","79.5","","419.15","419.15","419.15","1 through 10","122.15","813.2","percent of total billed charges",""
"Mgn Transcriptome Rna001","PX-31001162","CDM","81479","CPT","0310","RC","","","","both","","","4610.00","3457.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3664.95","79.5","","0.65","0.65","0.65","1 through 10","1429.1","4379.5","percent of total billed charges",""
"Mgn Transcriptome Rna001","PX-31001162","CDM","81479","CPT","0310","RC","","","","both","","","4610.00","3457.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2457.13","53.3","","0.79","0.79","0.79","1 through 10","1429.1","4379.5","percent of total billed charges",""
"Mgn Transcriptome Rna001","PX-31001162","CDM","81479","CPT","0310","RC","","","","outpatient","","","4610.00","3457.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2305.00","50","","1.00","1.00","1.00","1 through 10","156.55","3803.25","percent of total billed charges",""
"Mgn Transcriptome Rna001","PX-31001162","CDM","81479","CPT","0310","RC","","","","outpatient","","","4610.00","3457.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2420.25","52.5","","1.00","0.53","1.00","1 through 10","156.55","3803.25","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","65.34","71.8","","63.18","15.30","189.54","29","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","59.70","65.6","","59.58","59.58","59.58","1 through 10","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","59.15","65","","57.20","46.46","57.20","1 through 10","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","63.70","70","","63.36","37.84","88.00","13","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","CHAMPVA [160001]","HB BWH TRICARE","86.45","95","","6.96","6.96","6.96","1 through 10","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","72.35","79.5","","69.26","46.46","69.26","193","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.50","53.3","","46.46","46.46","69.26","76","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","70.07","77","","203.28","67.76","203.28","1 through 10","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","59.15","65","","57.20","55.25","57.20","1 through 10","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","72.35","79.5","","28.11","28.11","28.11","1 through 10","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","28.21","31","","27.19","27.19","27.19","13","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.22","36.5","","32.82","27.90","83.70","300","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.85","38.3","","34.41","33.44","103.23","815","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","MOLINA [1014]","HB BWH MOLINA","31.85","35","","11.47","11.47","11.47","1 through 10","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","70.07","77","","68.64","7.80","68.64","1 through 10","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","TRICARE [160005]","HB BWH TRICARE","86.45","95","","6.61","6.61","6.96","1 through 10","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.04","42.9","","70.35","38.69","70.35","1 through 10","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","91.00","68.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.04","42.9","","38.69","38.69","38.69","1 through 10","5.57","86.45","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA HMO","63.52","69.8","","59.58","42.06","68.64","285","5.57","74.37","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA PPO","73.16","80.4","","68.64","42.06","68.64","28","5.57","74.37","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","50.87","55.9","","46.11","46.11","46.11","1 through 10","5.57","74.37","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","91.00","68.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","47.56","52.26","","54.45","20.63","54.45","1 through 10","5.57","74.37","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","91.00","68.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","73.16","80.4","","68.64","44.00","68.64","1 through 10","5.57","74.37","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","91.00","68.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","74.37","81.72","","70.35","65.46","70.35","1 through 10","5.57","74.37","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","74.37","81.72","","70.35","38.69","70.35","16","5.57","74.37","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","74.37","81.72","","70.35","38.69","70.35","208","5.57","74.37","percent of total billed charges",""
"MICROCATHETER ECHELON 2.1-1.7FR 150CM .014IN STRAIGHT TIP RADIOPAQUE MARKER INFUSION","SUP-ITM-10016537","CDM","C1887","HCPCS","0272","RC","","","","both","","","2334.50","1750.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1676.17","71.8","","28.28","27.13","28.28","1 through 10","723.7","1855.93","percent of total billed charges",""
"MICROCATHETER ECHELON 2.1-1.7FR 150CM .014IN STRAIGHT TIP RADIOPAQUE MARKER INFUSION","SUP-ITM-10016537","CDM","C1887","HCPCS","0272","RC","","","","both","","","2334.50","1750.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1634.15","70","","44.63","35.78","44.63","1 through 10","723.7","1855.93","percent of total billed charges",""
"MICROCATHETER ECHELON 2.1-1.7FR 150CM .014IN STRAIGHT TIP RADIOPAQUE MARKER INFUSION","SUP-ITM-10016537","CDM","C1887","HCPCS","0272","RC","","","","both","","","2334.50","1750.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1855.93","79.5","","1342.89","271.64","6954.67","1 through 10","723.7","1855.93","percent of total billed charges",""
"MICROCATHETER ECHELON 2.1-1.7FR 150CM .014IN STRAIGHT TIP RADIOPAQUE MARKER INFUSION","SUP-ITM-10016537","CDM","C1887","HCPCS","0272","RC","","","","both","","","2334.50","1750.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1244.29","53.3","","4550.00","30.49","4550.00","1 through 10","723.7","1855.93","percent of total billed charges",""
"MICROCATHETER ECHELON 2.1-1.7FR 150CM .014IN STRAIGHT TIP RADIOPAQUE MARKER INFUSION","SUP-ITM-10016537","CDM","C1887","HCPCS","0272","RC","","","","both","","","2334.50","1750.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1517.43","65","","42.09","0.04","5453.50","1 through 10","723.7","1855.93","percent of total billed charges",""
"MICROCATHETER ECHELON 2.1-1.7FR 150CM .014IN STRAIGHT TIP RADIOPAQUE MARKER INFUSION","SUP-ITM-10016537","CDM","C1887","HCPCS","0272","RC","","","","both","","","2334.50","1750.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","852.09","36.5","","310.94","18.54","1259.30","62","723.7","1855.93","percent of total billed charges",""
"MICROCATHETER ECHELON 2.1-1.7FR 150CM .014IN STRAIGHT TIP RADIOPAQUE MARKER INFUSION","SUP-ITM-10016537","CDM","C1887","HCPCS","0272","RC","","","","both","","","2334.50","1750.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","894.11","38.3","","146.86","22.58","1753.45","65","723.7","1855.93","percent of total billed charges",""
"MICROCATHETER ECHELON 2.1-1.7FR 150CM .014IN STRAIGHT TIP RADIOPAQUE MARKER INFUSION","SUP-ITM-10016537","CDM","C1887","HCPCS","0272","RC","","","","both","","","2334.50","1750.87","WELLPOINT [1015]","HB AMC WELLPOINT","1722.39","73.78","","247.29","33.09","909.09","53","723.7","1855.93","percent of total billed charges",""
"MICROCATHETER ECHELON 2.1-1.7FR 150CM .014IN STRAIGHT TIP RADIOPAQUE MARKER INFUSION","SUP-ITM-10016537","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2334.50","1750.87","AETNA [1001]","HB AMC AETNA HMO","1629.48","69.8","","30.69","30.21","30.69","1 through 10","1220.01","1907.75","percent of total billed charges",""
"MICROCATHETER ECHELON 2.1-1.7FR 150CM .014IN STRAIGHT TIP RADIOPAQUE MARKER INFUSION","SUP-ITM-10016537","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2334.50","1750.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1876.94","80.4","","82.69","82.69","82.69","1 through 10","1220.01","1907.75","percent of total billed charges",""
"MICROCATHETER ECHELON 2.1-1.7FR 150CM .014IN STRAIGHT TIP RADIOPAQUE MARKER INFUSION","SUP-ITM-10016537","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2334.50","1750.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1907.75","81.72","","751.01","74.72","751.01","1 through 10","1220.01","1907.75","percent of total billed charges",""
"MICROCATHETER ECHELON 2.1-1.7FR 150CM .014IN STRAIGHT TIP RADIOPAQUE MARKER INFUSION","SUP-ITM-10016537","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2334.50","1750.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1907.75","81.72","","328.92","46.17","2701.97","59","1220.01","1907.75","percent of total billed charges",""
"MICROCATHETER HEADWAY 2.1TO1.6FR 156CM .0165IN INFUSION STRAIGHT 2 MARKER TIP SHAPING MANDREL INTRODUCER SHEATH DUO HYDROPHILIC","SUP-ITM-10115273","CDM","C1887","HCPCS","0272","RC","","","","both","","","3762.50","2821.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2701.48","71.8","","28.28","27.13","28.28","1 through 10","1166.38","2991.19","percent of total billed charges",""
"MICROCATHETER HEADWAY 2.1TO1.6FR 156CM .0165IN INFUSION STRAIGHT 2 MARKER TIP SHAPING MANDREL INTRODUCER SHEATH DUO HYDROPHILIC","SUP-ITM-10115273","CDM","C1887","HCPCS","0272","RC","","","","both","","","3762.50","2821.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2633.75","70","","44.63","35.78","44.63","1 through 10","1166.38","2991.19","percent of total billed charges",""
"MICROCATHETER HEADWAY 2.1TO1.6FR 156CM .0165IN INFUSION STRAIGHT 2 MARKER TIP SHAPING MANDREL INTRODUCER SHEATH DUO HYDROPHILIC","SUP-ITM-10115273","CDM","C1887","HCPCS","0272","RC","","","","both","","","3762.50","2821.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2991.19","79.5","","1342.89","271.64","6954.67","1 through 10","1166.38","2991.19","percent of total billed charges",""
"MICROCATHETER HEADWAY 2.1TO1.6FR 156CM .0165IN INFUSION STRAIGHT 2 MARKER TIP SHAPING MANDREL INTRODUCER SHEATH DUO HYDROPHILIC","SUP-ITM-10115273","CDM","C1887","HCPCS","0272","RC","","","","both","","","3762.50","2821.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2005.41","53.3","","4550.00","30.49","4550.00","1 through 10","1166.38","2991.19","percent of total billed charges",""
"MICROCATHETER HEADWAY 2.1TO1.6FR 156CM .0165IN INFUSION STRAIGHT 2 MARKER TIP SHAPING MANDREL INTRODUCER SHEATH DUO HYDROPHILIC","SUP-ITM-10115273","CDM","C1887","HCPCS","0272","RC","","","","both","","","3762.50","2821.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2445.63","65","","42.09","0.04","5453.50","1 through 10","1166.38","2991.19","percent of total billed charges",""
"MICROCATHETER HEADWAY 2.1TO1.6FR 156CM .0165IN INFUSION STRAIGHT 2 MARKER TIP SHAPING MANDREL INTRODUCER SHEATH DUO HYDROPHILIC","SUP-ITM-10115273","CDM","C1887","HCPCS","0272","RC","","","","both","","","3762.50","2821.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1373.31","36.5","","310.94","18.54","1259.30","62","1166.38","2991.19","percent of total billed charges",""
"MICROCATHETER HEADWAY 2.1TO1.6FR 156CM .0165IN INFUSION STRAIGHT 2 MARKER TIP SHAPING MANDREL INTRODUCER SHEATH DUO HYDROPHILIC","SUP-ITM-10115273","CDM","C1887","HCPCS","0272","RC","","","","both","","","3762.50","2821.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1441.04","38.3","","146.86","22.58","1753.45","65","1166.38","2991.19","percent of total billed charges",""
"MICROCATHETER HEADWAY 2.1TO1.6FR 156CM .0165IN INFUSION STRAIGHT 2 MARKER TIP SHAPING MANDREL INTRODUCER SHEATH DUO HYDROPHILIC","SUP-ITM-10115273","CDM","C1887","HCPCS","0272","RC","","","","both","","","3762.50","2821.87","WELLPOINT [1015]","HB AMC WELLPOINT","2775.97","73.78","","247.29","33.09","909.09","53","1166.38","2991.19","percent of total billed charges",""
"MICROCATHETER HEADWAY 2.1TO1.6FR 156CM .0165IN INFUSION STRAIGHT 2 MARKER TIP SHAPING MANDREL INTRODUCER SHEATH DUO HYDROPHILIC","SUP-ITM-10115273","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3762.50","2821.87","AETNA [1001]","HB AMC AETNA HMO","2626.23","69.8","","30.69","30.21","30.69","1 through 10","1966.28","3074.72","percent of total billed charges",""
"MICROCATHETER HEADWAY 2.1TO1.6FR 156CM .0165IN INFUSION STRAIGHT 2 MARKER TIP SHAPING MANDREL INTRODUCER SHEATH DUO HYDROPHILIC","SUP-ITM-10115273","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3762.50","2821.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3025.05","80.4","","82.69","82.69","82.69","1 through 10","1966.28","3074.72","percent of total billed charges",""
"MICROCATHETER HEADWAY 2.1TO1.6FR 156CM .0165IN INFUSION STRAIGHT 2 MARKER TIP SHAPING MANDREL INTRODUCER SHEATH DUO HYDROPHILIC","SUP-ITM-10115273","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3762.50","2821.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3074.72","81.72","","751.01","74.72","751.01","1 through 10","1966.28","3074.72","percent of total billed charges",""
"MICROCATHETER HEADWAY 2.1TO1.6FR 156CM .0165IN INFUSION STRAIGHT 2 MARKER TIP SHAPING MANDREL INTRODUCER SHEATH DUO HYDROPHILIC","SUP-ITM-10115273","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3762.50","2821.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3074.72","81.72","","328.92","46.17","2701.97","59","1966.28","3074.72","percent of total billed charges",""
"MICROCATHETER LANTERN 135CM .025IN 45DEGREE ANGLE","SUP-ITM-10170121","CDM","C1887","HCPCS","0272","RC","","","","both","","","2275.00","1706.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1633.45","71.8","","28.28","27.13","28.28","1 through 10","705.25","1808.63","percent of total billed charges",""
"MICROCATHETER LANTERN 135CM .025IN 45DEGREE ANGLE","SUP-ITM-10170121","CDM","C1887","HCPCS","0272","RC","","","","both","","","2275.00","1706.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1592.50","70","","44.63","35.78","44.63","1 through 10","705.25","1808.63","percent of total billed charges",""
"MICROCATHETER LANTERN 135CM .025IN 45DEGREE ANGLE","SUP-ITM-10170121","CDM","C1887","HCPCS","0272","RC","","","","both","","","2275.00","1706.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1808.63","79.5","","1342.89","271.64","6954.67","1 through 10","705.25","1808.63","percent of total billed charges",""
"MICROCATHETER LANTERN 135CM .025IN 45DEGREE ANGLE","SUP-ITM-10170121","CDM","C1887","HCPCS","0272","RC","","","","both","","","2275.00","1706.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1212.58","53.3","","4550.00","30.49","4550.00","1 through 10","705.25","1808.63","percent of total billed charges",""
"MICROCATHETER LANTERN 135CM .025IN 45DEGREE ANGLE","SUP-ITM-10170121","CDM","C1887","HCPCS","0272","RC","","","","both","","","2275.00","1706.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1478.75","65","","42.09","0.04","5453.50","1 through 10","705.25","1808.63","percent of total billed charges",""
"MICROCATHETER LANTERN 135CM .025IN 45DEGREE ANGLE","SUP-ITM-10170121","CDM","C1887","HCPCS","0272","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","830.38","36.5","","310.94","18.54","1259.30","62","705.25","1808.63","percent of total billed charges",""
"MICROCATHETER LANTERN 135CM .025IN 45DEGREE ANGLE","SUP-ITM-10170121","CDM","C1887","HCPCS","0272","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","871.33","38.3","","146.86","22.58","1753.45","65","705.25","1808.63","percent of total billed charges",""
"MICROCATHETER LANTERN 135CM .025IN 45DEGREE ANGLE","SUP-ITM-10170121","CDM","C1887","HCPCS","0272","RC","","","","both","","","2275.00","1706.25","WELLPOINT [1015]","HB AMC WELLPOINT","1678.50","73.78","","247.29","33.09","909.09","53","705.25","1808.63","percent of total billed charges",""
"MICROCATHETER LANTERN 135CM .025IN 45DEGREE ANGLE","SUP-ITM-10170121","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2275.00","1706.25","AETNA [1001]","HB AMC AETNA HMO","1587.95","69.8","","30.69","30.21","30.69","1 through 10","1188.92","1859.13","percent of total billed charges",""
"MICROCATHETER LANTERN 135CM .025IN 45DEGREE ANGLE","SUP-ITM-10170121","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2275.00","1706.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1829.10","80.4","","82.69","82.69","82.69","1 through 10","1188.92","1859.13","percent of total billed charges",""
"MICROCATHETER LANTERN 135CM .025IN 45DEGREE ANGLE","SUP-ITM-10170121","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1859.13","81.72","","751.01","74.72","751.01","1 through 10","1188.92","1859.13","percent of total billed charges",""
"MICROCATHETER LANTERN 135CM .025IN 45DEGREE ANGLE","SUP-ITM-10170121","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1859.13","81.72","","328.92","46.17","2701.97","59","1188.92","1859.13","percent of total billed charges",""
"MICROCATHETER MAESTRO 2.8X2.8FR 130CM .021IN SWAN NECK NON TAPERED INFUSION BX/1EA","SUP-ITM-10082086","CDM","C1887","HCPCS","0272","RC","","","","both","","","1073.80","805.35","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","770.99","71.8","","28.28","27.13","28.28","1 through 10","332.88","853.67","percent of total billed charges",""
"MICROCATHETER MAESTRO 2.8X2.8FR 130CM .021IN SWAN NECK NON TAPERED INFUSION BX/1EA","SUP-ITM-10082086","CDM","C1887","HCPCS","0272","RC","","","","both","","","1073.80","805.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","751.66","70","","44.63","35.78","44.63","1 through 10","332.88","853.67","percent of total billed charges",""
"MICROCATHETER MAESTRO 2.8X2.8FR 130CM .021IN SWAN NECK NON TAPERED INFUSION BX/1EA","SUP-ITM-10082086","CDM","C1887","HCPCS","0272","RC","","","","both","","","1073.80","805.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","853.67","79.5","","1342.89","271.64","6954.67","1 through 10","332.88","853.67","percent of total billed charges",""
"MICROCATHETER MAESTRO 2.8X2.8FR 130CM .021IN SWAN NECK NON TAPERED INFUSION BX/1EA","SUP-ITM-10082086","CDM","C1887","HCPCS","0272","RC","","","","both","","","1073.80","805.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","572.34","53.3","","4550.00","30.49","4550.00","1 through 10","332.88","853.67","percent of total billed charges",""
"MICROCATHETER MAESTRO 2.8X2.8FR 130CM .021IN SWAN NECK NON TAPERED INFUSION BX/1EA","SUP-ITM-10082086","CDM","C1887","HCPCS","0272","RC","","","","both","","","1073.80","805.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","697.97","65","","42.09","0.04","5453.50","1 through 10","332.88","853.67","percent of total billed charges",""
"MICROCATHETER MAESTRO 2.8X2.8FR 130CM .021IN SWAN NECK NON TAPERED INFUSION BX/1EA","SUP-ITM-10082086","CDM","C1887","HCPCS","0272","RC","","","","both","","","1073.80","805.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","391.94","36.5","","310.94","18.54","1259.30","62","332.88","853.67","percent of total billed charges",""
"MICROCATHETER MAESTRO 2.8X2.8FR 130CM .021IN SWAN NECK NON TAPERED INFUSION BX/1EA","SUP-ITM-10082086","CDM","C1887","HCPCS","0272","RC","","","","both","","","1073.80","805.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","411.27","38.3","","146.86","22.58","1753.45","65","332.88","853.67","percent of total billed charges",""
"MICROCATHETER MAESTRO 2.8X2.8FR 130CM .021IN SWAN NECK NON TAPERED INFUSION BX/1EA","SUP-ITM-10082086","CDM","C1887","HCPCS","0272","RC","","","","both","","","1073.80","805.35","WELLPOINT [1015]","HB AMC WELLPOINT","792.25","73.78","","247.29","33.09","909.09","53","332.88","853.67","percent of total billed charges",""
"MICROCATHETER MAESTRO 2.8X2.8FR 130CM .021IN SWAN NECK NON TAPERED INFUSION BX/1EA","SUP-ITM-10082086","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1073.80","805.35","AETNA [1001]","HB AMC AETNA HMO","749.51","69.8","","30.69","30.21","30.69","1 through 10","561.17","877.51","percent of total billed charges",""
"MICROCATHETER MAESTRO 2.8X2.8FR 130CM .021IN SWAN NECK NON TAPERED INFUSION BX/1EA","SUP-ITM-10082086","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1073.80","805.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","863.34","80.4","","82.69","82.69","82.69","1 through 10","561.17","877.51","percent of total billed charges",""
"MICROCATHETER MAESTRO 2.8X2.8FR 130CM .021IN SWAN NECK NON TAPERED INFUSION BX/1EA","SUP-ITM-10082086","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1073.80","805.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","877.51","81.72","","751.01","74.72","751.01","1 through 10","561.17","877.51","percent of total billed charges",""
"MICROCATHETER MAESTRO 2.8X2.8FR 130CM .021IN SWAN NECK NON TAPERED INFUSION BX/1EA","SUP-ITM-10082086","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1073.80","805.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","877.51","81.72","","328.92","46.17","2701.97","59","561.17","877.51","percent of total billed charges",""
"MICROCATHETER MARATHON 2.7-1.5FR 25CM 165CM .010IN FLOW DIRECT W/O STYLET","SUP-ITM-10134815","CDM","C1887","HCPCS","0272","RC","","","","both","","","2590.00","1942.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1859.62","71.8","","28.28","27.13","28.28","1 through 10","802.9","2059.05","percent of total billed charges",""
"MICROCATHETER MARATHON 2.7-1.5FR 25CM 165CM .010IN FLOW DIRECT W/O STYLET","SUP-ITM-10134815","CDM","C1887","HCPCS","0272","RC","","","","both","","","2590.00","1942.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1813.00","70","","44.63","35.78","44.63","1 through 10","802.9","2059.05","percent of total billed charges",""
"MICROCATHETER MARATHON 2.7-1.5FR 25CM 165CM .010IN FLOW DIRECT W/O STYLET","SUP-ITM-10134815","CDM","C1887","HCPCS","0272","RC","","","","both","","","2590.00","1942.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2059.05","79.5","","1342.89","271.64","6954.67","1 through 10","802.9","2059.05","percent of total billed charges",""
"MICROCATHETER MARATHON 2.7-1.5FR 25CM 165CM .010IN FLOW DIRECT W/O STYLET","SUP-ITM-10134815","CDM","C1887","HCPCS","0272","RC","","","","both","","","2590.00","1942.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1380.47","53.3","","4550.00","30.49","4550.00","1 through 10","802.9","2059.05","percent of total billed charges",""
"MICROCATHETER MARATHON 2.7-1.5FR 25CM 165CM .010IN FLOW DIRECT W/O STYLET","SUP-ITM-10134815","CDM","C1887","HCPCS","0272","RC","","","","both","","","2590.00","1942.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1683.50","65","","42.09","0.04","5453.50","1 through 10","802.9","2059.05","percent of total billed charges",""
"MICROCATHETER MARATHON 2.7-1.5FR 25CM 165CM .010IN FLOW DIRECT W/O STYLET","SUP-ITM-10134815","CDM","C1887","HCPCS","0272","RC","","","","both","","","2590.00","1942.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","945.35","36.5","","310.94","18.54","1259.30","62","802.9","2059.05","percent of total billed charges",""
"MICROCATHETER MARATHON 2.7-1.5FR 25CM 165CM .010IN FLOW DIRECT W/O STYLET","SUP-ITM-10134815","CDM","C1887","HCPCS","0272","RC","","","","both","","","2590.00","1942.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","991.97","38.3","","146.86","22.58","1753.45","65","802.9","2059.05","percent of total billed charges",""
"MICROCATHETER MARATHON 2.7-1.5FR 25CM 165CM .010IN FLOW DIRECT W/O STYLET","SUP-ITM-10134815","CDM","C1887","HCPCS","0272","RC","","","","both","","","2590.00","1942.50","WELLPOINT [1015]","HB AMC WELLPOINT","1910.90","73.78","","247.29","33.09","909.09","53","802.9","2059.05","percent of total billed charges",""
"MICROCATHETER MARATHON 2.7-1.5FR 25CM 165CM .010IN FLOW DIRECT W/O STYLET","SUP-ITM-10134815","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2590.00","1942.50","AETNA [1001]","HB AMC AETNA HMO","1807.82","69.8","","30.69","30.21","30.69","1 through 10","1353.53","2116.55","percent of total billed charges",""
"MICROCATHETER MARATHON 2.7-1.5FR 25CM 165CM .010IN FLOW DIRECT W/O STYLET","SUP-ITM-10134815","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2590.00","1942.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2082.36","80.4","","82.69","82.69","82.69","1 through 10","1353.53","2116.55","percent of total billed charges",""
"MICROCATHETER MARATHON 2.7-1.5FR 25CM 165CM .010IN FLOW DIRECT W/O STYLET","SUP-ITM-10134815","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2590.00","1942.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2116.55","81.72","","751.01","74.72","751.01","1 through 10","1353.53","2116.55","percent of total billed charges",""
"MICROCATHETER MARATHON 2.7-1.5FR 25CM 165CM .010IN FLOW DIRECT W/O STYLET","SUP-ITM-10134815","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2590.00","1942.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2116.55","81.72","","328.92","46.17","2701.97","59","1353.53","2116.55","percent of total billed charges",""
"MICROCATHETER PROGREAT 2.8FR 150CM 90CM HYDRO COAT DOUBLE RO MARKER BAND","SUP-ITM-10140579","CDM","C1887","HCPCS","0272","RC","","","","both","","","1149.75","862.31","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","825.52","71.8","","28.28","27.13","28.28","1 through 10","356.42","914.05","percent of total billed charges",""
"MICROCATHETER PROGREAT 2.8FR 150CM 90CM HYDRO COAT DOUBLE RO MARKER BAND","SUP-ITM-10140579","CDM","C1887","HCPCS","0272","RC","","","","both","","","1149.75","862.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","804.83","70","","44.63","35.78","44.63","1 through 10","356.42","914.05","percent of total billed charges",""
"MICROCATHETER PROGREAT 2.8FR 150CM 90CM HYDRO COAT DOUBLE RO MARKER BAND","SUP-ITM-10140579","CDM","C1887","HCPCS","0272","RC","","","","both","","","1149.75","862.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","914.05","79.5","","1342.89","271.64","6954.67","1 through 10","356.42","914.05","percent of total billed charges",""
"MICROCATHETER PROGREAT 2.8FR 150CM 90CM HYDRO COAT DOUBLE RO MARKER BAND","SUP-ITM-10140579","CDM","C1887","HCPCS","0272","RC","","","","both","","","1149.75","862.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","612.82","53.3","","4550.00","30.49","4550.00","1 through 10","356.42","914.05","percent of total billed charges",""
"MICROCATHETER PROGREAT 2.8FR 150CM 90CM HYDRO COAT DOUBLE RO MARKER BAND","SUP-ITM-10140579","CDM","C1887","HCPCS","0272","RC","","","","both","","","1149.75","862.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","747.34","65","","42.09","0.04","5453.50","1 through 10","356.42","914.05","percent of total billed charges",""
"MICROCATHETER PROGREAT 2.8FR 150CM 90CM HYDRO COAT DOUBLE RO MARKER BAND","SUP-ITM-10140579","CDM","C1887","HCPCS","0272","RC","","","","both","","","1149.75","862.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","419.66","36.5","","310.94","18.54","1259.30","62","356.42","914.05","percent of total billed charges",""
"MICROCATHETER PROGREAT 2.8FR 150CM 90CM HYDRO COAT DOUBLE RO MARKER BAND","SUP-ITM-10140579","CDM","C1887","HCPCS","0272","RC","","","","both","","","1149.75","862.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","440.35","38.3","","146.86","22.58","1753.45","65","356.42","914.05","percent of total billed charges",""
"MICROCATHETER PROGREAT 2.8FR 150CM 90CM HYDRO COAT DOUBLE RO MARKER BAND","SUP-ITM-10140579","CDM","C1887","HCPCS","0272","RC","","","","both","","","1149.75","862.31","WELLPOINT [1015]","HB AMC WELLPOINT","848.29","73.78","","247.29","33.09","909.09","53","356.42","914.05","percent of total billed charges",""
"MICROCATHETER PROGREAT 2.8FR 150CM 90CM HYDRO COAT DOUBLE RO MARKER BAND","SUP-ITM-10140579","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1149.75","862.31","AETNA [1001]","HB AMC AETNA HMO","802.53","69.8","","30.69","30.21","30.69","1 through 10","600.86","939.58","percent of total billed charges",""
"MICROCATHETER PROGREAT 2.8FR 150CM 90CM HYDRO COAT DOUBLE RO MARKER BAND","SUP-ITM-10140579","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1149.75","862.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","924.40","80.4","","82.69","82.69","82.69","1 through 10","600.86","939.58","percent of total billed charges",""
"MICROCATHETER PROGREAT 2.8FR 150CM 90CM HYDRO COAT DOUBLE RO MARKER BAND","SUP-ITM-10140579","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1149.75","862.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","939.58","81.72","","751.01","74.72","751.01","1 through 10","600.86","939.58","percent of total billed charges",""
"MICROCATHETER PROGREAT 2.8FR 150CM 90CM HYDRO COAT DOUBLE RO MARKER BAND","SUP-ITM-10140579","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1149.75","862.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","939.58","81.72","","328.92","46.17","2701.97","59","600.86","939.58","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STC-18 ANGLED","SUP-ITM-10094133","CDM","C1887","HCPCS","0272","RC","","","","both","","","1346.03","1009.52","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","966.45","71.8","","28.28","27.13","28.28","1 through 10","417.27","1070.09","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STC-18 ANGLED","SUP-ITM-10094133","CDM","C1887","HCPCS","0272","RC","","","","both","","","1346.03","1009.52","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","942.22","70","","44.63","35.78","44.63","1 through 10","417.27","1070.09","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STC-18 ANGLED","SUP-ITM-10094133","CDM","C1887","HCPCS","0272","RC","","","","both","","","1346.03","1009.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1070.09","79.5","","1342.89","271.64","6954.67","1 through 10","417.27","1070.09","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STC-18 ANGLED","SUP-ITM-10094133","CDM","C1887","HCPCS","0272","RC","","","","both","","","1346.03","1009.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","717.43","53.3","","4550.00","30.49","4550.00","1 through 10","417.27","1070.09","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STC-18 ANGLED","SUP-ITM-10094133","CDM","C1887","HCPCS","0272","RC","","","","both","","","1346.03","1009.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","874.92","65","","42.09","0.04","5453.50","1 through 10","417.27","1070.09","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STC-18 ANGLED","SUP-ITM-10094133","CDM","C1887","HCPCS","0272","RC","","","","both","","","1346.03","1009.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","491.30","36.5","","310.94","18.54","1259.30","62","417.27","1070.09","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STC-18 ANGLED","SUP-ITM-10094133","CDM","C1887","HCPCS","0272","RC","","","","both","","","1346.03","1009.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","515.53","38.3","","146.86","22.58","1753.45","65","417.27","1070.09","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STC-18 ANGLED","SUP-ITM-10094133","CDM","C1887","HCPCS","0272","RC","","","","both","","","1346.03","1009.52","WELLPOINT [1015]","HB AMC WELLPOINT","993.10","73.78","","247.29","33.09","909.09","53","417.27","1070.09","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STC-18 ANGLED","SUP-ITM-10094133","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1346.03","1009.52","AETNA [1001]","HB AMC AETNA HMO","939.53","69.8","","30.69","30.21","30.69","1 through 10","703.44","1099.98","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STC-18 ANGLED","SUP-ITM-10094133","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1346.03","1009.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1082.21","80.4","","82.69","82.69","82.69","1 through 10","703.44","1099.98","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STC-18 ANGLED","SUP-ITM-10094133","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1346.03","1009.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1099.98","81.72","","751.01","74.72","751.01","1 through 10","703.44","1099.98","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STC-18 ANGLED","SUP-ITM-10094133","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1346.03","1009.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1099.98","81.72","","328.92","46.17","2701.97","59","703.44","1099.98","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10022911","CDM","C1887","HCPCS","0272","RC","","","","both","","","1285.76","964.32","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","923.18","71.8","","28.28","27.13","28.28","1 through 10","398.59","1022.18","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10022911","CDM","C1887","HCPCS","0272","RC","","","","both","","","1285.76","964.32","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","900.03","70","","44.63","35.78","44.63","1 through 10","398.59","1022.18","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10022911","CDM","C1887","HCPCS","0272","RC","","","","both","","","1285.76","964.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1022.18","79.5","","1342.89","271.64","6954.67","1 through 10","398.59","1022.18","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10022911","CDM","C1887","HCPCS","0272","RC","","","","both","","","1285.76","964.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","685.31","53.3","","4550.00","30.49","4550.00","1 through 10","398.59","1022.18","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10022911","CDM","C1887","HCPCS","0272","RC","","","","both","","","1285.76","964.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","835.74","65","","42.09","0.04","5453.50","1 through 10","398.59","1022.18","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10022911","CDM","C1887","HCPCS","0272","RC","","","","both","","","1285.76","964.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","469.30","36.5","","310.94","18.54","1259.30","62","398.59","1022.18","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10022911","CDM","C1887","HCPCS","0272","RC","","","","both","","","1285.76","964.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","492.45","38.3","","146.86","22.58","1753.45","65","398.59","1022.18","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10022911","CDM","C1887","HCPCS","0272","RC","","","","both","","","1285.76","964.32","WELLPOINT [1015]","HB AMC WELLPOINT","948.63","73.78","","247.29","33.09","909.09","53","398.59","1022.18","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10022911","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1285.76","964.32","AETNA [1001]","HB AMC AETNA HMO","897.46","69.8","","30.69","30.21","30.69","1 through 10","671.94","1050.72","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10022911","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1285.76","964.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1033.75","80.4","","82.69","82.69","82.69","1 through 10","671.94","1050.72","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10022911","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1285.76","964.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1050.72","81.72","","751.01","74.72","751.01","1 through 10","671.94","1050.72","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 150CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10022911","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1285.76","964.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1050.72","81.72","","328.92","46.17","2701.97","59","671.94","1050.72","percent of total billed charges",""
"MICROCATHETER TRUSELECT 2FR 155CM SELECTIVE STRAIGHT TIP 1RO","SUP-ITM-10277388","CDM","C1887","HCPCS","0272","RC","","","","both","","","2397.50","1798.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1721.41","71.8","","28.28","27.13","28.28","1 through 10","743.23","1906.01","percent of total billed charges",""
"MICROCATHETER TRUSELECT 2FR 155CM SELECTIVE STRAIGHT TIP 1RO","SUP-ITM-10277388","CDM","C1887","HCPCS","0272","RC","","","","both","","","2397.50","1798.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1678.25","70","","44.63","35.78","44.63","1 through 10","743.23","1906.01","percent of total billed charges",""
"MICROCATHETER TRUSELECT 2FR 155CM SELECTIVE STRAIGHT TIP 1RO","SUP-ITM-10277388","CDM","C1887","HCPCS","0272","RC","","","","both","","","2397.50","1798.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1906.01","79.5","","1342.89","271.64","6954.67","1 through 10","743.23","1906.01","percent of total billed charges",""
"MICROCATHETER TRUSELECT 2FR 155CM SELECTIVE STRAIGHT TIP 1RO","SUP-ITM-10277388","CDM","C1887","HCPCS","0272","RC","","","","both","","","2397.50","1798.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1277.87","53.3","","4550.00","30.49","4550.00","1 through 10","743.23","1906.01","percent of total billed charges",""
"MICROCATHETER TRUSELECT 2FR 155CM SELECTIVE STRAIGHT TIP 1RO","SUP-ITM-10277388","CDM","C1887","HCPCS","0272","RC","","","","both","","","2397.50","1798.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1558.38","65","","42.09","0.04","5453.50","1 through 10","743.23","1906.01","percent of total billed charges",""
"MICROCATHETER TRUSELECT 2FR 155CM SELECTIVE STRAIGHT TIP 1RO","SUP-ITM-10277388","CDM","C1887","HCPCS","0272","RC","","","","both","","","2397.50","1798.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","875.09","36.5","","310.94","18.54","1259.30","62","743.23","1906.01","percent of total billed charges",""
"MICROCATHETER TRUSELECT 2FR 155CM SELECTIVE STRAIGHT TIP 1RO","SUP-ITM-10277388","CDM","C1887","HCPCS","0272","RC","","","","both","","","2397.50","1798.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","918.24","38.3","","146.86","22.58","1753.45","65","743.23","1906.01","percent of total billed charges",""
"MICROCATHETER TRUSELECT 2FR 155CM SELECTIVE STRAIGHT TIP 1RO","SUP-ITM-10277388","CDM","C1887","HCPCS","0272","RC","","","","both","","","2397.50","1798.12","WELLPOINT [1015]","HB AMC WELLPOINT","1768.88","73.78","","247.29","33.09","909.09","53","743.23","1906.01","percent of total billed charges",""
"MICROCATHETER TRUSELECT 2FR 155CM SELECTIVE STRAIGHT TIP 1RO","SUP-ITM-10277388","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2397.50","1798.12","AETNA [1001]","HB AMC AETNA HMO","1673.46","69.8","","30.69","30.21","30.69","1 through 10","1252.93","1959.24","percent of total billed charges",""
"MICROCATHETER TRUSELECT 2FR 155CM SELECTIVE STRAIGHT TIP 1RO","SUP-ITM-10277388","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2397.50","1798.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1927.59","80.4","","82.69","82.69","82.69","1 through 10","1252.93","1959.24","percent of total billed charges",""
"MICROCATHETER TRUSELECT 2FR 155CM SELECTIVE STRAIGHT TIP 1RO","SUP-ITM-10277388","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2397.50","1798.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1959.24","81.72","","751.01","74.72","751.01","1 through 10","1252.93","1959.24","percent of total billed charges",""
"MICROCATHETER TRUSELECT 2FR 155CM SELECTIVE STRAIGHT TIP 1RO","SUP-ITM-10277388","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2397.50","1798.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1959.24","81.72","","328.92","46.17","2701.97","59","1252.93","1959.24","percent of total billed charges",""
"Microdissection Manual","PX-31000059","CDM","88381","CPT","0310","RC","","","","both","","","527.00","395.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","418.97","79.5","","402.16","258.06","402.16","1 through 10","163.37","418.97","percent of total billed charges",""
"Microdissection Manual","PX-31000059","CDM","88381","CPT","0310","RC","","","","both","","","527.00","395.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","280.89","53.3","","269.81","269.81","402.16","1 through 10","163.37","418.97","percent of total billed charges",""
"Microdissection Manual","PX-31000059","CDM","88381","CPT","0310","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","192.36","36.5","","184.98","161.99","190.60","1 through 10","163.37","418.97","percent of total billed charges",""
"Microdissection Manual","PX-31000059","CDM","88381","CPT","0310","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.84","38.3","","199.80","199.80","199.80","1 through 10","163.37","418.97","percent of total billed charges",""
"Microdissection Manual","PX-31000059","CDM","88381","CPT","0310","RC","","","","both","","","527.00","395.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","405.79","77","","441.98","441.98","441.98","1 through 10","163.37","418.97","percent of total billed charges",""
"Microdissection Manual","PX-31000059","CDM","88381","CPT","0310","RC","","","","both","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.08","42.9","","232.51","232.51","232.51","1 through 10","163.37","418.97","percent of total billed charges",""
"Microdissection Manual","PX-31000059","CDM","88381","CPT","0310","RC","","","","both","","","527.00","395.25","WELLPOINT [1015]","HB AMC WELLPOINT","388.82","73.78","","380.44","380.44","891.44","1 through 10","163.37","418.97","percent of total billed charges",""
"Microdissection Manual","PX-31000059","CDM","88381","CPT","0310","RC","","","","outpatient","","","527.00","395.25","AETNA [1001]","HB AMC AETNA HMO","367.85","69.8","","244.26","244.26","244.26","1 through 10","275.2","430.66","percent of total billed charges",""
"Microdissection Manual","PX-31000059","CDM","88381","CPT","0310","RC","","","","outpatient","","","527.00","395.25","AETNA [1001]","HB AMC AETNA PPO","423.71","80.4","","1333.71","1333.71","1333.71","1 through 10","275.2","430.66","percent of total billed charges",""
"Microdissection Manual","PX-31000059","CDM","88381","CPT","0310","RC","","","","outpatient","","","527.00","395.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","275.20","52.22","","511.00","511.00","511.00","1 through 10","275.2","430.66","percent of total billed charges",""
"Microdissection Manual","PX-31000059","CDM","88381","CPT","0310","RC","","","","outpatient","","","527.00","395.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","423.71","80.4","","511.00","398.58","797.16","1 through 10","275.2","430.66","percent of total billed charges",""
"Microdissection Manual","PX-31000059","CDM","88381","CPT","0310","RC","","","","outpatient","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","430.66","81.72","","408.49","224.69","11067.56","1 through 10","275.2","430.66","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","173.00","129.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","124.21","71.8","","120.62","120.62","120.62","1 through 10","14.26","164.35","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","173.00","129.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","121.10","70","","362.88","362.88","362.88","1 through 10","14.26","164.35","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","173.00","129.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","137.54","79.5","","132.22","88.70","168.00","65","14.26","164.35","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","173.00","129.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","92.21","53.3","","88.70","88.70","266.10","29","14.26","164.35","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","137.54","79.5","","132.22","132.22","132.22","1 through 10","14.26","164.35","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","173.00","129.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","53.63","31","","51.91","51.91","51.91","1 through 10","14.26","164.35","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","173.00","129.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.15","36.5","","62.66","53.26","438.62","62","14.26","164.35","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","173.00","129.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.26","38.3","","65.69","63.84","191.52","186","14.26","164.35","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","173.00","129.75","TRICARE [160005]","HB BWH TRICARE","164.35","95","","17.53","16.65","168.00","1 through 10","14.26","164.35","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.22","42.9","","134.30","73.87","134.30","1 through 10","14.26","164.35","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.22","42.9","","73.87","73.87","73.87","1 through 10","14.26","164.35","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","173.00","129.75","AETNA [1001]","HB AMC AETNA HMO","120.75","69.8","","113.74","80.30","131.04","82","15.01","141.38","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","173.00","129.75","AETNA [1001]","HB AMC AETNA PPO","139.09","80.4","","131.04","131.04","176.06","13","15.01","141.38","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","173.00","129.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","90.41","52.26","","51.55","51.55","51.55","1 through 10","15.01","141.38","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","141.38","81.72","","134.30","73.87","134.30","1 through 10","15.01","141.38","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","141.38","81.72","","134.30","73.87","134.30","64","15.01","141.38","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 100UM 2ML EMBOZENE SYRINGE ORANGE","SUP-ITM-10046606","CDM","C1889","HCPCS","0278","RC","","","","both","","","717.50","538.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.41","79.5","","1309.77","674.56","6049.93","26","222.43","570.41","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 100UM 2ML EMBOZENE SYRINGE ORANGE","SUP-ITM-10046606","CDM","C1889","HCPCS","0278","RC","","","","both","","","717.50","538.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","382.43","53.3","","1901.83","1901.83","2962.25","1 through 10","222.43","570.41","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 100UM 2ML EMBOZENE SYRINGE ORANGE","SUP-ITM-10046606","CDM","C1889","HCPCS","0278","RC","","","","both","","","717.50","538.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","261.89","36.5","","1620.31","1620.31","19908.88","1 through 10","222.43","570.41","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 100UM 2ML EMBOZENE SYRINGE ORANGE","SUP-ITM-10046606","CDM","C1889","HCPCS","0278","RC","","","","both","","","717.50","538.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.80","38.3","","352.91","352.91","2046.30","1 through 10","222.43","570.41","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 100UM 2ML EMBOZENE SYRINGE ORANGE","SUP-ITM-10046606","CDM","C1889","HCPCS","0278","RC","","","","both","","","717.50","538.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.81","42.9","","9668.75","9668.75","9668.75","1 through 10","222.43","570.41","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 100UM 2ML EMBOZENE SYRINGE ORANGE","SUP-ITM-10046606","CDM","C1889","HCPCS","0278","RC","","","","both","","","717.50","538.12","WELLPOINT [1015]","HB AMC WELLPOINT","529.37","73.78","","699.88","384.10","3443.31","33","222.43","570.41","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 100UM 2ML EMBOZENE SYRINGE ORANGE","SUP-ITM-10046606","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","717.50","538.12","AETNA [1001]","HB AMC AETNA HMO","500.82","69.8","","1421.24","264.50","4933.46","29","374.97","586.34","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 100UM 2ML EMBOZENE SYRINGE ORANGE","SUP-ITM-10046606","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","717.50","538.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","576.87","80.4","","1022.97","1022.97","3607.50","1 through 10","374.97","586.34","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 100UM 2ML EMBOZENE SYRINGE ORANGE","SUP-ITM-10046606","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","717.50","538.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","586.34","81.72","","3010.54","693.88","5019.88","35","374.97","586.34","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 40UM 2ML EMBOZENE SYRINGE BLACK","SUP-ITM-10046605","CDM","C1889","HCPCS","0278","RC","","","","both","","","717.50","538.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.41","79.5","","1309.77","674.56","6049.93","26","222.43","570.41","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 40UM 2ML EMBOZENE SYRINGE BLACK","SUP-ITM-10046605","CDM","C1889","HCPCS","0278","RC","","","","both","","","717.50","538.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","382.43","53.3","","1901.83","1901.83","2962.25","1 through 10","222.43","570.41","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 40UM 2ML EMBOZENE SYRINGE BLACK","SUP-ITM-10046605","CDM","C1889","HCPCS","0278","RC","","","","both","","","717.50","538.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","261.89","36.5","","1620.31","1620.31","19908.88","1 through 10","222.43","570.41","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 40UM 2ML EMBOZENE SYRINGE BLACK","SUP-ITM-10046605","CDM","C1889","HCPCS","0278","RC","","","","both","","","717.50","538.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.80","38.3","","352.91","352.91","2046.30","1 through 10","222.43","570.41","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 40UM 2ML EMBOZENE SYRINGE BLACK","SUP-ITM-10046605","CDM","C1889","HCPCS","0278","RC","","","","both","","","717.50","538.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.81","42.9","","9668.75","9668.75","9668.75","1 through 10","222.43","570.41","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 40UM 2ML EMBOZENE SYRINGE BLACK","SUP-ITM-10046605","CDM","C1889","HCPCS","0278","RC","","","","both","","","717.50","538.12","WELLPOINT [1015]","HB AMC WELLPOINT","529.37","73.78","","699.88","384.10","3443.31","33","222.43","570.41","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 40UM 2ML EMBOZENE SYRINGE BLACK","SUP-ITM-10046605","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","717.50","538.12","AETNA [1001]","HB AMC AETNA HMO","500.82","69.8","","1421.24","264.50","4933.46","29","374.97","586.34","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 40UM 2ML EMBOZENE SYRINGE BLACK","SUP-ITM-10046605","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","717.50","538.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","576.87","80.4","","1022.97","1022.97","3607.50","1 through 10","374.97","586.34","percent of total billed charges",""
"MICROSPHERE EMBOLIZATION 40UM 2ML EMBOZENE SYRINGE BLACK","SUP-ITM-10046605","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","717.50","538.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","586.34","81.72","","3010.54","693.88","5019.88","35","374.97","586.34","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0250","RC","","","","inpatient","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.27","0.27","0.27","1 through 10","0.43","0.8","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.72","71.8","","0.95","0.41","0.95","1 through 10","0.31","0.77","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.66","65.6","","0.39","0.39","0.77","26","0.31","0.77","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.65","65","","0.40","0.27","0.86","34","0.31","0.77","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.70","70","","0.57","0.35","1.08","155","0.31","0.77","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","both","","","1.00","0.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","0.77","77","","4.34","4.34","4.34","1 through 10","0.31","0.77","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","both","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","0.65","65","","1.38","0.38","60.45","20","0.31","0.77","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.31","31","","0.18","0.18","0.54","33","0.31","0.77","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","0.22","0.18","0.65","1040","0.31","0.77","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","0.23","0.22","0.68","2746","0.31","0.77","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","both","","","1.00","0.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.77","77","","0.40","0.40","3.28","1 through 10","0.31","0.77","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","0.39","0.27","0.55","1316","0.34","0.8","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA PPO","0.80","80.4","","0.45","0.30","0.60","103","0.34","0.8","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.70","69.9","","0.81","0.33","1.62","2047","0.34","0.8","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.47","46.9","","0.59","0.27","0.82","885","0.34","0.8","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","0.80","80.4","","0.45","0.38","5.58","49","0.34","0.8","percent of total billed charges",""
"Midazolam Inj 1mg","PX-63600149","CDM","J2250","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","0.70","69.9","","0.45","0.45","0.47","13","0.34","0.8","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.07","1755.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1860.36","79.5","","800.18","480.96","1887.97","195","725.42","1860.36","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.07","1755.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1247.26","53.3","","813.12","216.42","1444.50","81","725.42","1860.36","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.07","1755.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","725.42","31","","432.60","432.60","432.60","1 through 10","725.42","1860.36","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.07","1755.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","854.13","36.5","","148.37","54.89","631.39","94","725.42","1860.36","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.07","1755.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","896.25","38.3","","279.30","91.72","1116.77","266","725.42","1860.36","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.07","1755.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1003.89","42.9","","731.00","63.70","731.00","1 through 10","725.42","1860.36","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.07","1755.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1003.89","42.9","","384.74","384.74","384.74","1 through 10","725.42","1860.36","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2340.07","1755.05","WELLPOINT [1015]","HB AMC WELLPOINT","1726.50","73.78","","286.63","119.22","1107.45","105","725.42","1860.36","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2340.07","1755.05","AETNA [1001]","HB AMC AETNA HMO","1633.37","69.8","","675.31","184.75","1721.50","286","1222.92","1912.31","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2340.07","1755.05","AETNA [1001]","HB AMC AETNA PPO","1881.42","80.4","","1261.44","103.12","1514.10","21","1222.92","1912.31","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2340.07","1755.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1881.42","80.4","","1365.00","1365.00","1365.00","1 through 10","1222.92","1912.31","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2340.07","1755.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1912.31","81.72","","5157.68","5157.68","5157.68","1 through 10","1222.92","1912.31","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX31 5 HOLE BONE SS HIND","SUP-ITM-10038057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2340.07","1755.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1912.31","81.72","","431.26","71.26","1459.57","88","1222.92","1912.31","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2417.77","1813.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1922.13","79.5","","800.18","480.96","1887.97","195","749.51","1922.13","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2417.77","1813.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1288.67","53.3","","813.12","216.42","1444.50","81","749.51","1922.13","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2417.77","1813.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","749.51","31","","432.60","432.60","432.60","1 through 10","749.51","1922.13","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2417.77","1813.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","882.49","36.5","","148.37","54.89","631.39","94","749.51","1922.13","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2417.77","1813.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","926.01","38.3","","279.30","91.72","1116.77","266","749.51","1922.13","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2417.77","1813.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1037.22","42.9","","731.00","63.70","731.00","1 through 10","749.51","1922.13","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2417.77","1813.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1037.22","42.9","","384.74","384.74","384.74","1 through 10","749.51","1922.13","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","both","","","2417.77","1813.33","WELLPOINT [1015]","HB AMC WELLPOINT","1783.83","73.78","","286.63","119.22","1107.45","105","749.51","1922.13","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2417.77","1813.33","AETNA [1001]","HB AMC AETNA HMO","1687.60","69.8","","675.31","184.75","1721.50","286","1263.53","1975.8","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2417.77","1813.33","AETNA [1001]","HB AMC AETNA PPO","1943.89","80.4","","1261.44","103.12","1514.10","21","1263.53","1975.8","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2417.77","1813.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1943.89","80.4","","1365.00","1365.00","1365.00","1 through 10","1263.53","1975.8","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2417.77","1813.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1975.80","81.72","","5157.68","5157.68","5157.68","1 through 10","1263.53","1975.8","percent of total billed charges",""
"MIDFOOT PLATE 2.7MMX45 8 HOLE BONE SS HIND","SUP-ITM-10038058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2417.77","1813.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1975.80","81.72","","431.26","71.26","1459.57","88","1263.53","1975.8","percent of total billed charges",""
"MIDFOOT PLATE 6HOLE T FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132132","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.00","2430.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2576.60","79.5","","800.18","480.96","1887.97","195","1004.71","2576.6","percent of total billed charges",""
"MIDFOOT PLATE 6HOLE T FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132132","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.00","2430.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1727.45","53.3","","813.12","216.42","1444.50","81","1004.71","2576.6","percent of total billed charges",""
"MIDFOOT PLATE 6HOLE T FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132132","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.00","2430.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1004.71","31","","432.60","432.60","432.60","1 through 10","1004.71","2576.6","percent of total billed charges",""
"MIDFOOT PLATE 6HOLE T FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132132","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.00","2430.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1182.97","36.5","","148.37","54.89","631.39","94","1004.71","2576.6","percent of total billed charges",""
"MIDFOOT PLATE 6HOLE T FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132132","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.00","2430.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1241.30","38.3","","279.30","91.72","1116.77","266","1004.71","2576.6","percent of total billed charges",""
"MIDFOOT PLATE 6HOLE T FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132132","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.00","2430.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1390.39","42.9","","731.00","63.70","731.00","1 through 10","1004.71","2576.6","percent of total billed charges",""
"MIDFOOT PLATE 6HOLE T FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132132","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.00","2430.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1390.39","42.9","","384.74","384.74","384.74","1 through 10","1004.71","2576.6","percent of total billed charges",""
"MIDFOOT PLATE 6HOLE T FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132132","CDM","C1713","HCPCS","0278","RC","","","","both","","","3241.00","2430.75","WELLPOINT [1015]","HB AMC WELLPOINT","2391.21","73.78","","286.63","119.22","1107.45","105","1004.71","2576.6","percent of total billed charges",""
"MIDFOOT PLATE 6HOLE T FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3241.00","2430.75","AETNA [1001]","HB AMC AETNA HMO","2262.22","69.8","","675.31","184.75","1721.50","286","1693.75","2648.55","percent of total billed charges",""
"MIDFOOT PLATE 6HOLE T FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3241.00","2430.75","AETNA [1001]","HB AMC AETNA PPO","2605.76","80.4","","1261.44","103.12","1514.10","21","1693.75","2648.55","percent of total billed charges",""
"MIDFOOT PLATE 6HOLE T FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3241.00","2430.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2605.76","80.4","","1365.00","1365.00","1365.00","1 through 10","1693.75","2648.55","percent of total billed charges",""
"MIDFOOT PLATE 6HOLE T FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3241.00","2430.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2648.55","81.72","","5157.68","5157.68","5157.68","1 through 10","1693.75","2648.55","percent of total billed charges",""
"MIDFOOT PLATE 6HOLE T FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3241.00","2430.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2648.55","81.72","","431.26","71.26","1459.57","88","1693.75","2648.55","percent of total billed charges",""
"MIDFOOT PLATE FUSION STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2999.50","2249.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2384.60","79.5","","800.18","480.96","1887.97","195","929.85","2384.6","percent of total billed charges",""
"MIDFOOT PLATE FUSION STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2999.50","2249.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1598.73","53.3","","813.12","216.42","1444.50","81","929.85","2384.6","percent of total billed charges",""
"MIDFOOT PLATE FUSION STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2999.50","2249.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","929.85","31","","432.60","432.60","432.60","1 through 10","929.85","2384.6","percent of total billed charges",""
"MIDFOOT PLATE FUSION STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2999.50","2249.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1094.82","36.5","","148.37","54.89","631.39","94","929.85","2384.6","percent of total billed charges",""
"MIDFOOT PLATE FUSION STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2999.50","2249.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1148.81","38.3","","279.30","91.72","1116.77","266","929.85","2384.6","percent of total billed charges",""
"MIDFOOT PLATE FUSION STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2999.50","2249.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1286.79","42.9","","731.00","63.70","731.00","1 through 10","929.85","2384.6","percent of total billed charges",""
"MIDFOOT PLATE FUSION STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2999.50","2249.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1286.79","42.9","","384.74","384.74","384.74","1 through 10","929.85","2384.6","percent of total billed charges",""
"MIDFOOT PLATE FUSION STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2999.50","2249.62","WELLPOINT [1015]","HB AMC WELLPOINT","2213.03","73.78","","286.63","119.22","1107.45","105","929.85","2384.6","percent of total billed charges",""
"MIDFOOT PLATE FUSION STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2999.50","2249.62","AETNA [1001]","HB AMC AETNA HMO","2093.65","69.8","","675.31","184.75","1721.50","286","1567.54","2451.19","percent of total billed charges",""
"MIDFOOT PLATE FUSION STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2999.50","2249.62","AETNA [1001]","HB AMC AETNA PPO","2411.60","80.4","","1261.44","103.12","1514.10","21","1567.54","2451.19","percent of total billed charges",""
"MIDFOOT PLATE FUSION STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2999.50","2249.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2411.60","80.4","","1365.00","1365.00","1365.00","1 through 10","1567.54","2451.19","percent of total billed charges",""
"MIDFOOT PLATE FUSION STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2999.50","2249.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2451.19","81.72","","5157.68","5157.68","5157.68","1 through 10","1567.54","2451.19","percent of total billed charges",""
"MIDFOOT PLATE FUSION STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2999.50","2249.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2451.19","81.72","","431.26","71.26","1459.57","88","1567.54","2451.19","percent of total billed charges",""
"MIDFOOT PLATE SM U FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132126","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3255.53","79.5","","800.18","480.96","1887.97","195","1269.45","3255.53","percent of total billed charges",""
"MIDFOOT PLATE SM U FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132126","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2182.64","53.3","","813.12","216.42","1444.50","81","1269.45","3255.53","percent of total billed charges",""
"MIDFOOT PLATE SM U FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132126","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1269.45","31","","432.60","432.60","432.60","1 through 10","1269.45","3255.53","percent of total billed charges",""
"MIDFOOT PLATE SM U FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132126","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1494.68","36.5","","148.37","54.89","631.39","94","1269.45","3255.53","percent of total billed charges",""
"MIDFOOT PLATE SM U FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132126","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1568.39","38.3","","279.30","91.72","1116.77","266","1269.45","3255.53","percent of total billed charges",""
"MIDFOOT PLATE SM U FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132126","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1756.76","42.9","","731.00","63.70","731.00","1 through 10","1269.45","3255.53","percent of total billed charges",""
"MIDFOOT PLATE SM U FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132126","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1756.76","42.9","","384.74","384.74","384.74","1 through 10","1269.45","3255.53","percent of total billed charges",""
"MIDFOOT PLATE SM U FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132126","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","WELLPOINT [1015]","HB AMC WELLPOINT","3021.29","73.78","","286.63","119.22","1107.45","105","1269.45","3255.53","percent of total billed charges",""
"MIDFOOT PLATE SM U FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4095.00","3071.25","AETNA [1001]","HB AMC AETNA HMO","2858.31","69.8","","675.31","184.75","1721.50","286","2140.05","3346.43","percent of total billed charges",""
"MIDFOOT PLATE SM U FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4095.00","3071.25","AETNA [1001]","HB AMC AETNA PPO","3292.38","80.4","","1261.44","103.12","1514.10","21","2140.05","3346.43","percent of total billed charges",""
"MIDFOOT PLATE SM U FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4095.00","3071.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3292.38","80.4","","1365.00","1365.00","1365.00","1 through 10","2140.05","3346.43","percent of total billed charges",""
"MIDFOOT PLATE SM U FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4095.00","3071.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3346.43","81.72","","5157.68","5157.68","5157.68","1 through 10","2140.05","3346.43","percent of total billed charges",""
"MIDFOOT PLATE SM U FUSION LT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4095.00","3071.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3346.43","81.72","","431.26","71.26","1459.57","88","2140.05","3346.43","percent of total billed charges",""
"Mifepristone, Oral, 200 Mg","PX-63601136","CDM","S0190","HCPCS","0636","RC","","","","both","","","382.50","286.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","139.61","36.5","","204.51","66.16","204.51","12","118.58","294.53","percent of total billed charges",""
"Mifepristone, Oral, 200 Mg","PX-63601136","CDM","S0190","HCPCS","0636","RC","","","","both","","","382.50","286.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","146.50","38.3","","208.35","71.46","357.30","31","118.58","294.53","percent of total billed charges",""
"Mifepristone, Oral, 200 Mg","PX-63601136","CDM","S0190","HCPCS","0636","RC","","","","both","","","382.50","286.87","WELLPOINT [1015]","HB AMC WELLPOINT","282.21","73.78","","342.86","160.11","342.86","1 through 10","118.58","294.53","percent of total billed charges",""
"Mifepristone, Oral, 200 Mg","PX-63601136","CDM","S0190","HCPCS","0636","RC","","","","outpatient","","","382.50","286.87","AETNA [1001]","HB AMC AETNA HMO","266.99","69.8","","123.72","87.35","182.84","1 through 10","76.96","307.53","percent of total billed charges",""
"Mifepristone, Oral, 200 Mg","PX-63601136","CDM","S0190","HCPCS","0636","RC","","","","outpatient","","","382.50","286.87","AETNA [1001]","HB AMC AETNA PPO","307.53","80.4","","191.52","191.52","191.52","1 through 10","76.96","307.53","percent of total billed charges",""
"Mifepristone, Oral, 200 Mg","PX-63601136","CDM","S0190","HCPCS","0636","RC","","","","outpatient","","","382.50","286.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","267.37","69.9","","213.98","84.80","379.95","1 through 10","76.96","307.53","percent of total billed charges",""
"Mifepristone, Oral, 200 Mg","PX-63601136","CDM","S0190","HCPCS","0636","RC","","","","outpatient","","","382.50","286.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","179.39","46.9","","126.65","84.80","126.65","1 through 10","76.96","307.53","percent of total billed charges",""
"Migraine And Other Headaches,MAJOR","054","DRG","","","","","","","","inpatient","","","44713.61","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","29280.71","","Standard inlier is a Case rate ($29,280.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,900, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,156.15) for the length of stay and the standard reimbursement.","29280.70","29280.70","29280.70","1 through 10","4391.25","29280.71","case rate",""
"Migraine And Other Headaches,MAJOR","054","DRG","","","","","","","","inpatient","","","44713.61","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8671.70","","Case rate ($9,588.06). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,018.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9585.70","9585.70","9585.70","1 through 10","4391.25","29280.71","case rate",""
"Migraine And Other Headaches,MINOR","054","DRG","","","","","","","","inpatient","","","41572.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","17186.01","","Standard inlier is a Case rate ($17,186.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,013, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,439.66) for the length of stay and the standard reimbursement.","17186.00","17186.00","17186.00","1 through 10","4391.25","29280.71","case rate",""
"Migraine And Other Headaches,MINOR","054","DRG","","","","","","","","inpatient","","","41572.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","19321.70","","Standard inlier is a Case rate ($19,321.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,013, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,742.56) for the length of stay and the standard reimbursement.","17652.04","17652.04","17652.04","1 through 10","4391.25","29280.71","case rate",""
"Migraine And Other Headaches,MINOR","054","DRG","","","","","","","","inpatient","","","41572.10","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10561.6542","","Fee schedule rate ($10,561.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10561.6542","13405.80","13405.80","1 through 10","4391.25","29280.71","case rate",""
"Migraine And Other Headaches,MINOR","054","DRG","","","","","","","","inpatient","","","41572.10","","MASSHEALTH [3001]","HB BWH MEDICAID","4391.25","","Case rate ($4,855.29). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,285.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5050.77","5050.77","5050.77","1 through 10","4391.25","29280.71","case rate",""
"Migraine And Other Headaches,MODERATE","054","DRG","","","","","","","","inpatient","","","40871.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20924.63","","Standard inlier is a Case rate ($20,924.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,920, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,970.38) for the length of stay and the standard reimbursement.","19073.56","19073.56","20924.62","1 through 10","4391.25","29280.71","case rate",""
"Migraine And Other Headaches,MODERATE","054","DRG","","","","","","","","inpatient","","","40871.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","23524.92","","Standard inlier is a Case rate ($23,524.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,920, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,339.17) for the length of stay and the standard reimbursement.","23524.92","21492.04","23524.92","1 through 10","4391.25","29280.71","case rate",""
"Migraine And Other Headaches,MODERATE","054","DRG","","","","","","","","inpatient","","","40871.21","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10058.4399","","Fee schedule rate ($12,767.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10058.4399","12767.08","12767.08","1 through 10","4391.25","29280.71","case rate",""
"Migraine And Other Headaches,MODERATE","054","DRG","","","","","","","","inpatient","","","40871.21","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21430.13","","Fee schedule rate ($21,430.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21430.13","21430.13","21430.13","1 through 10","4391.25","29280.71","case rate",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","294.02","71.8","","28.28","27.13","28.28","1 through 10","126.95","325.55","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","286.65","70","","44.63","35.78","44.63","1 through 10","126.95","325.55","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","325.55","79.5","","1342.89","271.64","6954.67","1 through 10","126.95","325.55","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","218.26","53.3","","4550.00","30.49","4550.00","1 through 10","126.95","325.55","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","266.18","65","","42.09","0.04","5453.50","1 through 10","126.95","325.55","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","149.47","36.5","","310.94","18.54","1259.30","62","126.95","325.55","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","156.84","38.3","","146.86","22.58","1753.45","65","126.95","325.55","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","both","","","409.50","307.12","WELLPOINT [1015]","HB AMC WELLPOINT","302.13","73.78","","247.29","33.09","909.09","53","126.95","325.55","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","409.50","307.12","AETNA [1001]","HB AMC AETNA HMO","285.83","69.8","","30.69","30.21","30.69","1 through 10","214","334.64","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","409.50","307.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","329.24","80.4","","82.69","82.69","82.69","1 through 10","214","334.64","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","409.50","307.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","334.64","81.72","","751.01","74.72","751.01","1 through 10","214","334.64","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","409.50","307.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","334.64","81.72","","328.92","46.17","2701.97","59","214","334.64","percent of total billed charges",""
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","","","","inpatient","","","81083.74","60812.80","MEDICARE [2001]","HB BWH MEDICARE","14247.27","","Case rate ($14,247.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,073.49, add-ons for qualifying new technology services are included. If operating cost exceeds $62,717.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,663.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,644.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,693.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,223.24. The transfer capital threshold is the transfer adjustment factor * $1,223.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18285.05","18285.05","18285.05","1 through 10","13962.32","23049.9934","other","Inpatient Replacement Plans DRG"
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","","","","inpatient","","","81083.74","60812.80","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13962.32","","Case rate ($14,247.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,073.49, add-ons for qualifying new technology services are included. If operating cost exceeds $62,717.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,663.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,644.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,693.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,223.24. The transfer capital threshold is the transfer adjustment factor * $1,223.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13916.93","13916.93","13916.93","1 through 10","13962.32","23049.9934","other","Inpatient DRG"
"Minor Bladder Procedures With McC","662","MS-DRG","","","","","","","","inpatient","","","87522.82","65642.11","MEDICARE [2001]","HB BWH MEDICARE","36624.70","","Case rate ($36,624.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $33,998.83, add-ons for qualifying new technology services are included. If operating cost exceeds $79,643.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,903.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $33,781.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $33,618.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,463.46. The transfer capital threshold is the transfer adjustment factor * $2,463.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34658.99","34658.99","34658.99","1 through 10","27741.02","47077.8836","other","Inpatient DRG"
"Minor Bladder Procedures Without Cc/McC","664","MS-DRG","","","","","","","","inpatient","","","58412.60","43809.45","MEDICARE [2001]","HB BWH MEDICARE","12774.02","","Case rate ($12,774.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,876.08, add-ons for qualifying new technology services are included. If operating cost exceeds $57,520.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,282.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $11,551.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,496.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $842.40. The transfer capital threshold is the transfer adjustment factor * $842.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13008.21","13008.21","13008.21","1 through 10","9731.18","16398.64","other","Inpatient DRG"
"Minor Skin Disorders With McC","606","MS-DRG","","","","","","","","inpatient","","","93431.29","70073.47","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","17729.26","","Case rate ($14,183.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,996.61, add-ons for qualifying new technology services are included. If operating cost exceeds $62,641.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,657.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,585.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,616.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.61. The transfer capital threshold is the transfer adjustment factor * $1,217.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","14986.25","14986.25","14986.25","1 through 10","13899.74","23702.76","other","Inpatient DRG"
"Minor Skin Disorders With McC","606","MS-DRG","","","","","","","","inpatient","","","93431.29","70073.47","MEDICARE [2001]","HB BWH MEDICARE","18294.50","","Case rate ($18,294.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,996.61, add-ons for qualifying new technology services are included. If operating cost exceeds $62,641.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,657.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $16,697.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,616.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.61. The transfer capital threshold is the transfer adjustment factor * $1,217.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19262.35","0.03","19290.76","1 through 10","13899.74","23702.76","other","Inpatient DRG"
"Minor Skin Disorders With McC","606","MS-DRG","","","","","","","","inpatient","","","93431.29","70073.47","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13899.74","","Case rate ($14,183.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,996.61, add-ons for qualifying new technology services are included. If operating cost exceeds $62,641.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,657.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,585.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,616.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,217.61. The transfer capital threshold is the transfer adjustment factor * $1,217.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14724.03","14724.03","14724.03","1 through 10","13899.74","23702.76","other","Inpatient DRG"
"Minor Skin Disorders Without McC","607","MS-DRG","","","","","","","","inpatient","","","45953.64","34465.23","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8648.11","","Case rate ($8,648.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,333.22, add-ons for qualifying new technology services are included. If operating cost exceeds $55,977.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,169.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,538.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,953.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.34. The transfer capital threshold is the transfer adjustment factor * $729.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8033.79","8033.79","8033.79","1 through 10","8475.15","14197.85","other","Inpatient Replacement Plans DRG"
"Minor Skin Disorders Without McC","607","MS-DRG","","","","","","","","inpatient","","","45953.64","34465.23","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8648.11","","Case rate ($8,648.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,333.22, add-ons for qualifying new technology services are included. If operating cost exceeds $55,977.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,169.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,538.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,953.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.34. The transfer capital threshold is the transfer adjustment factor * $729.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7959.96","7959.96","7959.96","1 through 10","8475.15","14197.85","other","Inpatient DRG"
"Minor Skin Disorders Without McC","607","MS-DRG","","","","","","","","inpatient","","","45953.64","34465.23","HUMANA [1012]","HB BWH MEDICARE","8648.11","","Case rate ($8,648.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,333.22, add-ons for qualifying new technology services are included. If operating cost exceeds $55,977.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,169.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,538.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,953.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.34. The transfer capital threshold is the transfer adjustment factor * $729.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7981.20","7981.20","7981.20","1 through 10","8475.15","14197.85","other","Inpatient Replacement Plans DRG"
"Minor Skin Disorders Without McC","607","MS-DRG","","","","","","","","inpatient","","","45953.64","34465.23","MEDICARE [2001]","HB BWH MEDICARE","8648.11","","Case rate ($8,648.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,333.22, add-ons for qualifying new technology services are included. If operating cost exceeds $55,977.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,169.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,538.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,953.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $729.34. The transfer capital threshold is the transfer adjustment factor * $729.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10466.47","10466.47","10481.71","18","8475.15","14197.85","other","Inpatient Replacement Plans DRG"
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","","","","inpatient","","","67931.07","50948.30","MARTIN'S POINT [160007]","HB BWH MEDICARE","18193.86","","Case rate ($18,193.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,903.28, add-ons for qualifying new technology services are included. If operating cost exceeds $62,547.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,650.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $16,603.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,523.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.77. The transfer capital threshold is the transfer adjustment factor * $1,210.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24407.19","24407.19","24407.19","1 through 10","13823.74","22465.9717","other","Inpatient DRG"
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","","","","inpatient","","","67931.07","50948.30","MEDICARE [2001]","HB BWH MEDICARE","18193.86","","Case rate ($18,193.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,903.28, add-ons for qualifying new technology services are included. If operating cost exceeds $62,547.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,650.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $16,603.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,523.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.77. The transfer capital threshold is the transfer adjustment factor * $1,210.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17849.50","17849.50","17849.50","1 through 10","13823.74","22465.9717","other","Inpatient DRG"
"Minor Small And Large Bowel Procedures With McC","344","MS-DRG","","","","","","","","inpatient","","","149808.40","112356.30","MEDICARE [2001]","HB BWH MEDICARE","23940.40","","Case rate ($23,940.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,742.12, add-ons for qualifying new technology services are included. If operating cost exceeds $74,386.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,518.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $21,482.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,362.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,078.27. The transfer capital threshold is the transfer adjustment factor * $2,078.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","32091.68","32091.68","32091.68","1 through 10","23461.59","40456.98","other","Inpatient Replacement Plans DRG"
"Minor Small And Large Bowel Procedures With McC","344","MS-DRG","","","","","","","","inpatient","","","149808.40","112356.30","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","23461.59","","Case rate ($23,940.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,742.12, add-ons for qualifying new technology services are included. If operating cost exceeds $74,386.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,518.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $21,482.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,362.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,078.27. The transfer capital threshold is the transfer adjustment factor * $2,078.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","24326.64","24326.64","24326.64","1 through 10","23461.59","40456.98","other","Inpatient DRG"
"Minor Small And Large Bowel Procedures With McC","344","MS-DRG","","","","","","","","inpatient","","","149808.40","112356.30","WELLPOINT [1015]","HB AMC WELLPOINT","40456.98","","Fee schedule rate ($40,456.98).","40662.69","40662.69","40662.69","1 through 10","23461.59","40456.98","case rate",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Age >17 With McC","640","TRIS-DRG","","","","","","","","inpatient","","","128285.97","","TRICARE [160005]","HB BWH TRICARE","8887.10","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($15,610.69). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $4,591.38, and the first day is paid a rate of $9,182.76. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $4,591.38, and the first day is paid a rate of $9,182.76. The transfer payment is capped at $11,235.56. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $59,337.69 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 3.40000009536743). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($6,121.84), capped at $11,235.56. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $4,591.38, and the first day is paid a rate of $9,182.76. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $4,591.38, and the first day is paid a rate of $9,182.76. The transfer payment is capped at $11,235.56. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $59,337.69 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 3.40000009536743). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","14627.37","14627.37","14627.37","1 through 10","8887.1","8887.1","other","Inpatient DRGs"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","63169.57","47377.18","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","12940.23","","Case rate ($12,563.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,046.35, add-ons for qualifying new technology services are included. If operating cost exceeds $60,690.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,514.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,108.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,666.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,074.70. The transfer capital threshold is the transfer adjustment factor * $1,074.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12756.42","12756.42","12756.42","1 through 10","12312.06","20040.848","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","63169.57","47377.18","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12563.33","","Case rate ($12,563.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,046.35, add-ons for qualifying new technology services are included. If operating cost exceeds $60,690.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,514.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,108.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,666.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,074.70. The transfer capital threshold is the transfer adjustment factor * $1,074.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12198.41","12198.41","12452.16","1 through 10","12312.06","20040.848","other","Inpatient Replacement Plans DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","63169.57","47377.18","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","15704.16","","Case rate ($12,563.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,046.35, add-ons for qualifying new technology services are included. If operating cost exceeds $60,690.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,514.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,108.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,666.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,074.70. The transfer capital threshold is the transfer adjustment factor * $1,074.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","12164.16","12164.16","12164.16","1 through 10","12312.06","20040.848","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","63169.57","47377.18","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","12563.33","","Case rate ($12,563.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,046.35, add-ons for qualifying new technology services are included. If operating cost exceeds $60,690.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,514.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,108.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,666.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,074.70. The transfer capital threshold is the transfer adjustment factor * $1,074.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12143.14","12085.47","16805.06","1 through 10","12312.06","20040.848","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","63169.57","47377.18","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10434.29","10434.29","10434.29","1 through 10","12312.06","20040.848","case rate",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","63169.57","47377.18","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","12563.33","","Case rate ($12,563.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,046.35, add-ons for qualifying new technology services are included. If operating cost exceeds $60,690.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,514.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,108.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,666.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,074.70. The transfer capital threshold is the transfer adjustment factor * $1,074.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24707.00","24707.00","24707.00","1 through 10","12312.06","20040.848","other","Inpatient Replacement Plans DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","63169.57","47377.18","MEDICARE [2001]","HB BWH MEDICARE","12563.33","","Case rate ($12,563.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,046.35, add-ons for qualifying new technology services are included. If operating cost exceeds $60,690.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,514.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,108.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,666.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,074.70. The transfer capital threshold is the transfer adjustment factor * $1,074.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15934.28","0.03","15957.70","81","12312.06","20040.848","other","Inpatient Replacement Plans DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","63169.57","47377.18","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12312.06","","Case rate ($12,563.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,046.35, add-ons for qualifying new technology services are included. If operating cost exceeds $60,690.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,514.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,108.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,666.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,074.70. The transfer capital threshold is the transfer adjustment factor * $1,074.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12119.03","12089.47","22351.75","1 through 10","12312.06","20040.848","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","63169.57","47377.18","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12312.06","","Case rate ($12,563.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,046.35, add-ons for qualifying new technology services are included. If operating cost exceeds $60,690.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,514.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,108.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,666.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,074.70. The transfer capital threshold is the transfer adjustment factor * $1,074.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12125.21","12085.49","12273.79","12","12312.06","20040.848","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","45252.95","33939.71","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7703.03","","Case rate ($7,478.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,925.43, add-ons for qualifying new technology services are included. If operating cost exceeds $54,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,066.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,472.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,545.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.19. The transfer capital threshold is the transfer adjustment factor * $626.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7614.45","7575.30","7628.38","1 through 10","7329.1","12189.72","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","45252.95","33939.71","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9592.90","","Case rate ($9,592.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,925.43, add-ons for qualifying new technology services are included. If operating cost exceeds $54,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,066.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,586.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,545.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.19. The transfer capital threshold is the transfer adjustment factor * $626.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9363.64","9355.25","9372.02","1 through 10","7329.1","12189.72","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","45252.95","33939.71","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7478.67","","Case rate ($7,478.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,925.43, add-ons for qualifying new technology services are included. If operating cost exceeds $54,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,066.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,472.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,545.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.19. The transfer capital threshold is the transfer adjustment factor * $626.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7349.86","7349.86","7349.86","1 through 10","7329.1","12189.72","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","45252.95","33939.71","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10434.29","4232.00","17126.98","1 through 10","7329.1","12189.72","case rate",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","45252.95","33939.71","HUMANA [1012]","HB BWH MEDICARE","9592.90","","Case rate ($9,592.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,925.43, add-ons for qualifying new technology services are included. If operating cost exceeds $54,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,066.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,586.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,545.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.19. The transfer capital threshold is the transfer adjustment factor * $626.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7317.69","7317.69","7317.69","1 through 10","7329.1","12189.72","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","45252.95","33939.71","MEDICARE [2001]","HB BWH MEDICARE","9592.90","","Case rate ($9,592.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,925.43, add-ons for qualifying new technology services are included. If operating cost exceeds $54,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,066.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,586.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,545.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.19. The transfer capital threshold is the transfer adjustment factor * $626.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9490.33","0.03","9504.09","75","7329.1","12189.72","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","45252.95","33939.71","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","9592.90","","Case rate ($9,592.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,925.43, add-ons for qualifying new technology services are included. If operating cost exceeds $54,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,066.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,586.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,545.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.19. The transfer capital threshold is the transfer adjustment factor * $626.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","197.02","197.02","197.02","1 through 10","7329.1","12189.72","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","45252.95","33939.71","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7329.10","","Case rate ($7,478.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,925.43, add-ons for qualifying new technology services are included. If operating cost exceeds $54,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,066.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,472.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,545.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.19. The transfer capital threshold is the transfer adjustment factor * $626.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7256.96","7256.96","7335.76","1 through 10","7329.1","12189.72","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","45252.95","33939.71","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","7329.10","","Case rate ($7,478.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,925.43, add-ons for qualifying new technology services are included. If operating cost exceeds $54,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,066.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,472.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,545.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.19. The transfer capital threshold is the transfer adjustment factor * $626.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9355.87","9355.87","9355.87","1 through 10","7329.1","12189.72","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","45252.95","33939.71","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7329.10","","Case rate ($7,478.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,925.43, add-ons for qualifying new technology services are included. If operating cost exceeds $54,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,066.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,472.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,545.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.19. The transfer capital threshold is the transfer adjustment factor * $626.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7325.04","7254.32","15194.14","1 through 10","7329.1","12189.72","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","45252.95","33939.71","WELLSENSE [1003]","HB BWH MEDICARE","9592.90","","Case rate ($9,592.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,925.43, add-ons for qualifying new technology services are included. If operating cost exceeds $54,569.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,066.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,586.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,545.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $626.19. The transfer capital threshold is the transfer adjustment factor * $626.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7502.59","7502.59","7502.59","1 through 10","7329.1","12189.72","other","Inpatient DRG"
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","302.00","226.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","240.09","79.5","","230.59","230.59","896.39","22","24.94","286.9","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","302.00","226.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","160.97","53.3","","230.59","154.70","230.59","1 through 10","24.94","286.9","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","302.00","226.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","110.23","36.5","","109.29","92.88","125.54","13","24.94","286.9","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","302.00","226.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","115.67","38.3","","114.56","111.34","343.68","46","24.94","286.9","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","302.00","226.50","TRICARE [160005]","HB BWH TRICARE","286.90","95","","30.67","30.67","293.00","1 through 10","24.94","286.9","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","302.00","226.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.56","42.9","","234.22","234.22","234.22","1 through 10","24.94","286.9","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","302.00","226.50","WELLPOINT [1015]","HB AMC WELLPOINT","222.82","73.78","","218.14","218.14","511.14","14","24.94","286.9","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","302.00","226.50","AETNA [1001]","HB AMC AETNA HMO","210.80","69.8","","396.72","198.36","396.72","1 through 10","74.12","249.15","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","302.00","226.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","158.55","52.5","","168.77","168.77","168.77","1 through 10","74.12","249.15","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","302.00","226.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","151.00","50","","153.53","153.53","289.19","41","74.12","249.15","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","302.00","226.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","158.55","52.5","","161.15","161.15","303.84","12","74.12","249.15","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","302.00","226.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","188.75","62.5","","191.92","191.92","191.92","1 through 10","74.12","249.15","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","302.00","226.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","158.55","52.5","","161.15","161.15","161.15","1 through 10","74.12","249.15","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","302.00","226.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","166.10","55","","168.77","136.83","168.77","1 through 10","74.12","249.15","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","302.00","226.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","246.79","81.72","","234.22","128.83","234.22","1 through 10","74.12","249.15","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","302.00","226.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","246.79","81.72","","234.22","128.83","234.22","17","74.12","249.15","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","302.00","226.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","166.10","55","","156.20","156.20","156.20","1 through 10","74.12","249.15","percent of total billed charges",""
"Mitraclip System Kit","PX-27001094","CDM","C1760","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","53850.00","71.8","","612.50","612.50","612.50","1 through 10","23250","59625","percent of total billed charges",""
"Mitraclip System Kit","PX-27001094","CDM","C1760","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","52500.00","70","","612.50","612.50","612.50","1 through 10","23250","59625","percent of total billed charges",""
"Mitraclip System Kit","PX-27001094","CDM","C1760","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59625.00","79.5","","742.96","323.40","1446.12","32","23250","59625","percent of total billed charges",""
"Mitraclip System Kit","PX-27001094","CDM","C1760","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39975.00","53.3","","323.40","323.40","550.90","13","23250","59625","percent of total billed charges",""
"Mitraclip System Kit","PX-27001094","CDM","C1760","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27375.00","36.5","","285.08","194.16","582.48","27","23250","59625","percent of total billed charges",""
"Mitraclip System Kit","PX-27001094","CDM","C1760","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28725.00","38.3","","239.49","233.98","600.08","52","23250","59625","percent of total billed charges",""
"Mitraclip System Kit","PX-27001094","CDM","C1760","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32175.00","42.9","","278.69","278.69","278.69","1 through 10","23250","59625","percent of total billed charges",""
"Mitraclip System Kit","PX-27001094","CDM","C1760","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","WELLPOINT [1015]","HB AMC WELLPOINT","55335.00","73.78","","456.01","456.01","456.01","33","23250","59625","percent of total billed charges",""
"Mitraclip System Kit","PX-27001094","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","75000.00","56250.00","AETNA [1001]","HB AMC AETNA HMO","52350.00","69.8","","290.33","290.33","1575.00","1 through 10","39195","61290","percent of total billed charges",""
"Mitraclip System Kit","PX-27001094","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","75000.00","56250.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","39195.00","52.26","","487.31","487.31","487.31","1 through 10","39195","61290","percent of total billed charges",""
"Mitraclip System Kit","PX-27001094","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","75000.00","56250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","61290.00","81.72","","489.63","489.63","489.63","1 through 10","39195","61290","percent of total billed charges",""
"Mitraclip System Kit","PX-27001094","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","75000.00","56250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","61290.00","81.72","","489.64","489.63","1888.58","19","39195","61290","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.77","427.77","434.73","134","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5814.90","65","","6827.23","6827.23","6827.23","1 through 10","412.99","7112.07","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","6262.20","70","","2368.80","560.32","6940.00","1 through 10","412.99","7112.07","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICAID REPLACEMENT","543.36","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","412.99","412.99","412.99","1 through 10","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7112.07","79.5","","6827.23","4580.40","6827.23","36","412.99","7112.07","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4768.22","53.3","","4580.40","4580.40","13741.20","23","412.99","7112.07","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.77","360.21","427.77","19","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","ELDER SERVICES [1037]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","403.27","403.27","1947.49","1 through 10","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","FALLON HEALTH [1008]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1304.19","426.04","1304.19","15","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1341.90","429.51","1341.90","1 through 10","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","6888.42","77","","6679.75","6484.94","6679.75","1 through 10","412.99","7112.07","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","426.04","426.04","427.77","1 through 10","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","HUMANA [1012]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.77","426.04","428.64","11","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","7112.07","79.5","","6350.19","6350.19","6350.19","1 through 10","412.99","7112.07","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","428.64","426.04","428.64","1 through 10","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","MEDICARE [2001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","434.73","434.73","434.73","1213","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2773.26","31","","2680.58","2680.58","2680.58","1 through 10","412.99","7112.07","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3265.29","36.5","","3235.78","3235.78","3235.78","25","412.99","7112.07","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3426.32","38.3","","3391.93","3296.50","3391.93","37","412.99","7112.07","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","426.04","395.20","426.04","14","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","MOLINA [1014]","HB BWH MOLINA","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","862.50","800.09","862.50","14","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","6888.42","77","","6827.23","954.25","6827.23","1 through 10","412.99","7112.07","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","TRICARE [160005]","HB BWH TRICARE","412.99","","APC Price ($434.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","434.73","412.99","434.73","1 through 10","412.99","7112.07","other","Tricare OPPS"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","412.99","","APC Price ($434.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","434.73","434.73","434.73","1 through 10","412.99","7112.07","other","Tricare OPPS"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","426.04","426.04","1278.12","87","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1995.25","1995.25","1995.25","1 through 10","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","426.04","395.21","434.73","169","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","8946.00","6709.50","WELLSENSE [1003]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","439.08","439.08","439.08","1 through 10","412.99","7112.07","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","outpatient","","","8946.00","6709.50","AETNA [1001]","HB AMC AETNA HMO","6244.31","69.8","","5872.98","4146.65","5872.98","11","875.35","7310.67","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","outpatient","","","8946.00","6709.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4675.18","52.26","","1588.01","1588.01","1588.01","1 through 10","875.35","7310.67","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","outpatient","","","8946.00","6709.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7310.67","81.72","","6934.80","3814.40","6934.80","33","875.35","7310.67","percent of total billed charges",""
"Mlh1 Gene Analysis Promoter Methylation Analysis","PX-30002896","CDM","81288","CPT","0301","RC","","","","both","","","1120.00","840.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","890.40","79.5","","818.84","818.84","818.84","1 through 10","188.47","1064","percent of total billed charges",""
"Mlh1 Gene Analysis Promoter Methylation Analysis","PX-30002896","CDM","81288","CPT","0301","RC","","","","both","","","1120.00","840.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","408.80","36.5","","405.08","405.08","405.08","1 through 10","188.47","1064","percent of total billed charges",""
"Mlh1 Gene Analysis Promoter Methylation Analysis","PX-30002896","CDM","81288","CPT","0301","RC","","","","outpatient","","","1120.00","840.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","900.48","80.4","","847.08","847.08","847.08","1 through 10","550.6","1178.92","percent of total billed charges",""
"Mlpa Assay","PX-30003063","CDM","81479","CPT","0300","RC","","","","both","","","1036.00","777.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","823.62","79.5","","0.65","0.65","0.65","1 through 10","321.16","984.2","percent of total billed charges",""
"Mlpa Assay","PX-30003063","CDM","81479","CPT","0300","RC","","","","both","","","1036.00","777.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","552.19","53.3","","0.79","0.79","0.79","1 through 10","321.16","984.2","percent of total billed charges",""
"Mlpa Assay","PX-30003063","CDM","81479","CPT","0300","RC","","","","outpatient","","","1036.00","777.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","518.00","50","","1.00","1.00","1.00","1 through 10","156.55","854.7","percent of total billed charges",""
"Mlpa Assay","PX-30003063","CDM","81479","CPT","0300","RC","","","","outpatient","","","1036.00","777.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","543.90","52.5","","1.00","0.53","1.00","1 through 10","156.55","854.7","percent of total billed charges",""
"Mmaknown Mutation","PX-31001317","CDM","81403","CPT","0310","RC","","","","outpatient","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","864.60","81.72","","820.18","820.18","820.18","1 through 10","512.07","1135.28","percent of total billed charges",""
"Mng Ataxia/Episodic Ataxia Disorders + Mtdna + Sca & Frda Repeat Expansion Analysis","PX-31001058","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Mng Ataxia/Episodic Ataxia Disorders + Mtdna + Sca & Frda Repeat Expansion Analysis","PX-31001058","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Mng Ataxia/Episodic Ataxia Disorders + Mtdna + Sca & Frda Repeat Expansion Analysis","PX-31001058","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Mng Ataxia/Episodic Ataxia Disorders + Mtdna + Sca & Frda Repeat Expansion Analysis","PX-31001058","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Mod Sed Endo Service Initial 15 Mins >5yrs","PX-37000034","CDM","G0500","HCPCS","0370","RC","","","","both","","","44.00","33.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","34.98","79.5","","22.70","22.70","22.70","1 through 10","13.64","34.98","percent of total billed charges",""
"Mod Sed Endo Service Initial 15 Mins >5yrs","PX-37000034","CDM","G0500","HCPCS","0370","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.88","42.9","","34.37","34.37","34.37","1 through 10","13.64","34.98","percent of total billed charges",""
"Mod Sed Endo Service Initial 15 Mins >5yrs","PX-37000034","CDM","G0500","HCPCS","0370","RC","","","","outpatient","","","44.00","33.00","AETNA [1001]","HB AMC AETNA HMO","30.71","69.8","","26.44","20.55","26.44","1 through 10","22.99","35.96","percent of total billed charges",""
"Mod Sed Endo Service Initial 15 Mins >5yrs","PX-37000034","CDM","G0500","HCPCS","0370","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","35.96","81.72","","34.37","34.37","34.37","1 through 10","22.99","35.96","percent of total billed charges",""
"Mod Sed Endo Service Initial 15 Mins >5yrs","PX-37000034","CDM","G0500","HCPCS","0370","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","35.96","81.72","","34.37","18.91","34.37","73","22.99","35.96","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","44.00","33.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","28.86","65.6","","29.11","20.55","33.54","13","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","44.00","33.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","28.60","65","","22.70","22.70","83.85","17","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","44.00","33.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","30.80","70","","43.00","29.52","67.08","77","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","44.00","33.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","34.98","79.5","","33.84","22.70","376.97","252","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","44.00","33.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23.45","53.3","","33.84","22.70","101.52","98","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","44.00","33.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","28.60","65","","27.95","26.65","111.80","13","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","44.00","33.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","13.64","31","","13.29","13.29","13.29","1 through 10","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","44.00","33.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16.06","36.5","","16.04","13.63","46.70","208","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","44.00","33.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.85","38.3","","16.81","16.81","49.02","341","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.88","42.9","","34.38","19.57","43.00","13","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.88","42.9","","34.38","34.38","34.38","1 through 10","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","44.00","33.00","WELLPOINT [1015]","HB AMC WELLPOINT","32.46","73.78","","32.01","30.16","32.02","178","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","44.00","33.00","AETNA [1001]","HB AMC AETNA HMO","30.71","69.8","","29.11","20.55","33.54","267","22.99","35.96","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","44.00","33.00","AETNA [1001]","HB AMC AETNA PPO","35.38","80.4","","33.54","33.54","33.54","1 through 10","22.99","35.96","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","44.00","33.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","22.99","52.26","","26.61","26.61","26.61","1 through 10","22.99","35.96","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","44.00","33.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","35.38","80.4","","33.54","33.54","33.54","14","22.99","35.96","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","35.96","81.72","","18.91","18.91","34.38","15","22.99","35.96","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","35.96","81.72","","34.37","18.91","34.38","257","22.99","35.96","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","both","","","57.00","42.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","37.39","65.6","","29.11","20.55","33.54","13","17.67","45.32","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","both","","","57.00","42.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","37.05","65","","22.70","22.70","83.85","17","17.67","45.32","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","both","","","57.00","42.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","39.90","70","","43.00","29.52","67.08","77","17.67","45.32","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","both","","","57.00","42.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","45.32","79.5","","33.84","22.70","376.97","252","17.67","45.32","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","both","","","57.00","42.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","30.38","53.3","","33.84","22.70","101.52","98","17.67","45.32","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","both","","","57.00","42.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","37.05","65","","27.95","26.65","111.80","13","17.67","45.32","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","both","","","57.00","42.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","17.67","31","","13.29","13.29","13.29","1 through 10","17.67","45.32","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","both","","","57.00","42.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20.81","36.5","","16.04","13.63","46.70","208","17.67","45.32","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","both","","","57.00","42.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21.83","38.3","","16.81","16.81","49.02","341","17.67","45.32","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","both","","","57.00","42.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.45","42.9","","34.38","19.57","43.00","13","17.67","45.32","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","both","","","57.00","42.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.45","42.9","","34.38","34.38","34.38","1 through 10","17.67","45.32","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","both","","","57.00","42.75","WELLPOINT [1015]","HB AMC WELLPOINT","42.05","73.78","","32.01","30.16","32.02","178","17.67","45.32","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","outpatient","","","57.00","42.75","AETNA [1001]","HB AMC AETNA HMO","39.79","69.8","","29.11","20.55","33.54","267","31.86","46.58","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","outpatient","","","57.00","42.75","AETNA [1001]","HB AMC AETNA PPO","45.83","80.4","","33.54","33.54","33.54","1 through 10","31.86","46.58","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","outpatient","","","57.00","42.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","45.83","80.4","","33.54","33.54","33.54","14","31.86","46.58","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","outpatient","","","57.00","42.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","46.58","81.72","","18.91","18.91","34.38","15","31.86","46.58","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-98301654","CDM","99153","CPT","0983","RC","","","","outpatient","","","57.00","42.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","46.58","81.72","","34.37","18.91","34.38","257","31.86","46.58","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","44.00","33.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","28.86","65.6","","29.11","20.55","33.54","1 through 10","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","44.00","33.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","28.60","65","","33.84","22.70","83.85","1 through 10","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","44.00","33.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","30.80","70","","43.00","29.52","80.41","43","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","44.00","33.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","34.98","79.5","","33.84","22.70","387.99","92","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","44.00","33.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23.45","53.3","","33.84","22.70","484.00","53","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","44.00","33.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","28.60","65","","27.95","26.65","27.95","1 through 10","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","44.00","33.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","13.64","31","","13.29","13.29","13.29","1 through 10","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","44.00","33.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16.06","36.5","","16.04","13.63","48.12","66","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","44.00","33.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.85","38.3","","16.81","16.34","50.43","101","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.88","42.9","","34.37","19.57","43.00","1 through 10","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.88","42.9","","34.37","34.37","34.37","1 through 10","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","44.00","33.00","WELLPOINT [1015]","HB AMC WELLPOINT","32.46","73.78","","32.01","32.01","75.01","77","13.64","34.98","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","44.00","33.00","AETNA [1001]","HB AMC AETNA HMO","30.71","69.8","","29.11","20.55","33.54","131","22.99","35.96","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","44.00","33.00","AETNA [1001]","HB AMC AETNA PPO","35.38","80.4","","33.54","33.54","33.54","1 through 10","22.99","35.96","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","44.00","33.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","22.99","52.26","","26.61","26.61","26.61","1 through 10","22.99","35.96","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","44.00","33.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","35.38","80.4","","33.54","21.50","33.54","1 through 10","22.99","35.96","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","35.96","81.72","","18.91","18.91","34.37","1 through 10","22.99","35.96","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","35.96","81.72","","34.37","18.91","34.37","73","22.99","35.96","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","both","","","56.00","42.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","36.74","65.6","","29.11","20.55","33.54","1 through 10","17.36","44.52","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","both","","","56.00","42.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","36.40","65","","33.84","22.70","83.85","1 through 10","17.36","44.52","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","both","","","56.00","42.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","39.20","70","","43.00","29.52","80.41","43","17.36","44.52","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","both","","","56.00","42.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","44.52","79.5","","33.84","22.70","387.99","92","17.36","44.52","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","both","","","56.00","42.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","29.85","53.3","","33.84","22.70","484.00","53","17.36","44.52","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","both","","","56.00","42.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","36.40","65","","27.95","26.65","27.95","1 through 10","17.36","44.52","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","both","","","56.00","42.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","17.36","31","","13.29","13.29","13.29","1 through 10","17.36","44.52","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","both","","","56.00","42.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20.44","36.5","","16.04","13.63","48.12","66","17.36","44.52","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","both","","","56.00","42.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21.45","38.3","","16.81","16.34","50.43","101","17.36","44.52","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","both","","","56.00","42.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.02","42.9","","34.37","19.57","43.00","1 through 10","17.36","44.52","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","both","","","56.00","42.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.02","42.9","","34.37","34.37","34.37","1 through 10","17.36","44.52","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","both","","","56.00","42.00","WELLPOINT [1015]","HB AMC WELLPOINT","41.32","73.78","","32.01","32.01","75.01","77","17.36","44.52","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","outpatient","","","56.00","42.00","AETNA [1001]","HB AMC AETNA HMO","39.09","69.8","","29.11","20.55","33.54","131","31.3","45.76","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","outpatient","","","56.00","42.00","AETNA [1001]","HB AMC AETNA PPO","45.02","80.4","","33.54","33.54","33.54","1 through 10","31.3","45.76","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","outpatient","","","56.00","42.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","45.02","80.4","","33.54","21.50","33.54","1 through 10","31.3","45.76","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","outpatient","","","56.00","42.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","45.76","81.72","","18.91","18.91","34.37","1 through 10","31.3","45.76","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-98301653","CDM","99152","CPT","0983","RC","","","","outpatient","","","56.00","42.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","45.76","81.72","","34.37","18.91","34.37","73","31.3","45.76","percent of total billed charges",""
"MODEL ANATOMICAL CHILD MANDIBLE THROUGH ORBITS ACRYLIC SD900.236","SUP-ITM-10114561","CDM","C1713","HCPCS","0278","RC","","","","both","","","5494.50","4120.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4368.13","79.5","","800.18","480.96","1887.97","195","1703.3","4368.13","percent of total billed charges",""
"MODEL ANATOMICAL CHILD MANDIBLE THROUGH ORBITS ACRYLIC SD900.236","SUP-ITM-10114561","CDM","C1713","HCPCS","0278","RC","","","","both","","","5494.50","4120.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2928.57","53.3","","813.12","216.42","1444.50","81","1703.3","4368.13","percent of total billed charges",""
"MODEL ANATOMICAL CHILD MANDIBLE THROUGH ORBITS ACRYLIC SD900.236","SUP-ITM-10114561","CDM","C1713","HCPCS","0278","RC","","","","both","","","5494.50","4120.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1703.30","31","","432.60","432.60","432.60","1 through 10","1703.3","4368.13","percent of total billed charges",""
"MODEL ANATOMICAL CHILD MANDIBLE THROUGH ORBITS ACRYLIC SD900.236","SUP-ITM-10114561","CDM","C1713","HCPCS","0278","RC","","","","both","","","5494.50","4120.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2005.49","36.5","","148.37","54.89","631.39","94","1703.3","4368.13","percent of total billed charges",""
"MODEL ANATOMICAL CHILD MANDIBLE THROUGH ORBITS ACRYLIC SD900.236","SUP-ITM-10114561","CDM","C1713","HCPCS","0278","RC","","","","both","","","5494.50","4120.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2104.39","38.3","","279.30","91.72","1116.77","266","1703.3","4368.13","percent of total billed charges",""
"MODEL ANATOMICAL CHILD MANDIBLE THROUGH ORBITS ACRYLIC SD900.236","SUP-ITM-10114561","CDM","C1713","HCPCS","0278","RC","","","","both","","","5494.50","4120.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2357.14","42.9","","731.00","63.70","731.00","1 through 10","1703.3","4368.13","percent of total billed charges",""
"MODEL ANATOMICAL CHILD MANDIBLE THROUGH ORBITS ACRYLIC SD900.236","SUP-ITM-10114561","CDM","C1713","HCPCS","0278","RC","","","","both","","","5494.50","4120.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2357.14","42.9","","384.74","384.74","384.74","1 through 10","1703.3","4368.13","percent of total billed charges",""
"MODEL ANATOMICAL CHILD MANDIBLE THROUGH ORBITS ACRYLIC SD900.236","SUP-ITM-10114561","CDM","C1713","HCPCS","0278","RC","","","","both","","","5494.50","4120.87","WELLPOINT [1015]","HB AMC WELLPOINT","4053.84","73.78","","286.63","119.22","1107.45","105","1703.3","4368.13","percent of total billed charges",""
"MODEL ANATOMICAL CHILD MANDIBLE THROUGH ORBITS ACRYLIC SD900.236","SUP-ITM-10114561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5494.50","4120.87","AETNA [1001]","HB AMC AETNA HMO","3835.16","69.8","","675.31","184.75","1721.50","286","2871.43","4490.11","percent of total billed charges",""
"MODEL ANATOMICAL CHILD MANDIBLE THROUGH ORBITS ACRYLIC SD900.236","SUP-ITM-10114561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5494.50","4120.87","AETNA [1001]","HB AMC AETNA PPO","4417.58","80.4","","1261.44","103.12","1514.10","21","2871.43","4490.11","percent of total billed charges",""
"MODEL ANATOMICAL CHILD MANDIBLE THROUGH ORBITS ACRYLIC SD900.236","SUP-ITM-10114561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5494.50","4120.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4417.58","80.4","","1365.00","1365.00","1365.00","1 through 10","2871.43","4490.11","percent of total billed charges",""
"MODEL ANATOMICAL CHILD MANDIBLE THROUGH ORBITS ACRYLIC SD900.236","SUP-ITM-10114561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5494.50","4120.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4490.11","81.72","","5157.68","5157.68","5157.68","1 through 10","2871.43","4490.11","percent of total billed charges",""
"MODEL ANATOMICAL CHILD MANDIBLE THROUGH ORBITS ACRYLIC SD900.236","SUP-ITM-10114561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5494.50","4120.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4490.11","81.72","","431.26","71.26","1459.57","88","2871.43","4490.11","percent of total billed charges",""
"MODEL PLANNED ADULT OUTCOME MAXILLA / ORBITS ACRYLIC","SUP-ITM-10130317","CDM","C1713","HCPCS","0278","RC","","","","both","","","4796.75","3597.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3813.42","79.5","","800.18","480.96","1887.97","195","1486.99","3813.42","percent of total billed charges",""
"MODEL PLANNED ADULT OUTCOME MAXILLA / ORBITS ACRYLIC","SUP-ITM-10130317","CDM","C1713","HCPCS","0278","RC","","","","both","","","4796.75","3597.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2556.67","53.3","","813.12","216.42","1444.50","81","1486.99","3813.42","percent of total billed charges",""
"MODEL PLANNED ADULT OUTCOME MAXILLA / ORBITS ACRYLIC","SUP-ITM-10130317","CDM","C1713","HCPCS","0278","RC","","","","both","","","4796.75","3597.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1486.99","31","","432.60","432.60","432.60","1 through 10","1486.99","3813.42","percent of total billed charges",""
"MODEL PLANNED ADULT OUTCOME MAXILLA / ORBITS ACRYLIC","SUP-ITM-10130317","CDM","C1713","HCPCS","0278","RC","","","","both","","","4796.75","3597.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1750.81","36.5","","148.37","54.89","631.39","94","1486.99","3813.42","percent of total billed charges",""
"MODEL PLANNED ADULT OUTCOME MAXILLA / ORBITS ACRYLIC","SUP-ITM-10130317","CDM","C1713","HCPCS","0278","RC","","","","both","","","4796.75","3597.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1837.16","38.3","","279.30","91.72","1116.77","266","1486.99","3813.42","percent of total billed charges",""
"MODEL PLANNED ADULT OUTCOME MAXILLA / ORBITS ACRYLIC","SUP-ITM-10130317","CDM","C1713","HCPCS","0278","RC","","","","both","","","4796.75","3597.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2057.81","42.9","","731.00","63.70","731.00","1 through 10","1486.99","3813.42","percent of total billed charges",""
"MODEL PLANNED ADULT OUTCOME MAXILLA / ORBITS ACRYLIC","SUP-ITM-10130317","CDM","C1713","HCPCS","0278","RC","","","","both","","","4796.75","3597.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2057.81","42.9","","384.74","384.74","384.74","1 through 10","1486.99","3813.42","percent of total billed charges",""
"MODEL PLANNED ADULT OUTCOME MAXILLA / ORBITS ACRYLIC","SUP-ITM-10130317","CDM","C1713","HCPCS","0278","RC","","","","both","","","4796.75","3597.56","WELLPOINT [1015]","HB AMC WELLPOINT","3539.04","73.78","","286.63","119.22","1107.45","105","1486.99","3813.42","percent of total billed charges",""
"MODEL PLANNED ADULT OUTCOME MAXILLA / ORBITS ACRYLIC","SUP-ITM-10130317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4796.75","3597.56","AETNA [1001]","HB AMC AETNA HMO","3348.13","69.8","","675.31","184.75","1721.50","286","2506.78","3919.9","percent of total billed charges",""
"MODEL PLANNED ADULT OUTCOME MAXILLA / ORBITS ACRYLIC","SUP-ITM-10130317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4796.75","3597.56","AETNA [1001]","HB AMC AETNA PPO","3856.59","80.4","","1261.44","103.12","1514.10","21","2506.78","3919.9","percent of total billed charges",""
"MODEL PLANNED ADULT OUTCOME MAXILLA / ORBITS ACRYLIC","SUP-ITM-10130317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4796.75","3597.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3856.59","80.4","","1365.00","1365.00","1365.00","1 through 10","2506.78","3919.9","percent of total billed charges",""
"MODEL PLANNED ADULT OUTCOME MAXILLA / ORBITS ACRYLIC","SUP-ITM-10130317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4796.75","3597.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3919.90","81.72","","5157.68","5157.68","5157.68","1 through 10","2506.78","3919.9","percent of total billed charges",""
"MODEL PLANNED ADULT OUTCOME MAXILLA / ORBITS ACRYLIC","SUP-ITM-10130317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4796.75","3597.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3919.90","81.72","","431.26","71.26","1459.57","88","2506.78","3919.9","percent of total billed charges",""
"MODEL STIMULATOR 11X55 60MM 44G CORD ITREL 4 SPINAL NEURO PRIMARY CELL BATTERY","SUP-ITM-10133220","CDM","C1778","HCPCS","0278","RC","","","","both","","","17670.00","13252.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9418.11","53.3","","5279.78","5279.78","5279.78","1 through 10","5477.7","14047.65","percent of total billed charges",""
"MODEL STIMULATOR 11X55 60MM 44G CORD ITREL 4 SPINAL NEURO PRIMARY CELL BATTERY","SUP-ITM-10133220","CDM","C1778","HCPCS","0278","RC","","","","both","","","17670.00","13252.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","14047.65","79.5","","15789.05","15789.05","15789.05","1 through 10","5477.7","14047.65","percent of total billed charges",""
"MODEL STIMULATOR 11X55 60MM 44G CORD ITREL 4 SPINAL NEURO PRIMARY CELL BATTERY","SUP-ITM-10133220","CDM","C1778","HCPCS","0278","RC","","","","both","","","17670.00","13252.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6449.55","36.5","","2482.78","1657.12","2482.78","1 through 10","5477.7","14047.65","percent of total billed charges",""
"MODEL STIMULATOR 11X55 60MM 44G CORD ITREL 4 SPINAL NEURO PRIMARY CELL BATTERY","SUP-ITM-10133220","CDM","C1778","HCPCS","0278","RC","","","","both","","","17670.00","13252.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6767.61","38.3","","2602.60","2602.60","2602.60","1 through 10","5477.7","14047.65","percent of total billed charges",""
"MODEL STIMULATOR 11X55 60MM 44G CORD ITREL 4 SPINAL NEURO PRIMARY CELL BATTERY","SUP-ITM-10133220","CDM","C1778","HCPCS","0278","RC","","","","both","","","17670.00","13252.50","WELLPOINT [1015]","HB AMC WELLPOINT","13036.93","73.78","","4955.58","3845.35","9119.37","1 through 10","5477.7","14047.65","percent of total billed charges",""
"MODEL STIMULATOR 11X55 60MM 44G CORD ITREL 4 SPINAL NEURO PRIMARY CELL BATTERY","SUP-ITM-10133220","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","17670.00","13252.50","AETNA [1001]","HB AMC AETNA HMO","12333.66","69.8","","8631.75","8631.75","8631.75","1 through 10","9234.34","14439.92","percent of total billed charges",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","951","DRG","","","","","","","","inpatient","","","212643.19","","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","","38.3","","12281.33","12281.33","23971.59","1 through 10","9493.06","254946.65","percent of total billed charges",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","951","DRG","","","","","","","","inpatient","","","212643.19","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","","65","","1237217.74","1237217.74","1237217.74","1 through 10","9493.06","254946.65","percent of total billed charges",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","951","DRG","","","","","","","","inpatient","","","212643.19","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($154,511.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","148556.56","154511.24","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","951","DRG","","","","","","","","inpatient","","","212643.19","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22781.42","","Fee schedule rate ($162,241.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22781.42","162241.28","162241.28","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","951","DRG","","","","","","","","inpatient","","","212643.19","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","169964.43","","Fee schedule rate ($169,964.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","163415.65","163415.65","169964.44","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","951","DRG","","","","","","","","inpatient","","","212643.19","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56377.15","","Fee schedule rate ($56,377.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","133671.00","133671.00","133671.00","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","951","DRG","","","","","","","","inpatient","","","212643.19","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9493.06","","Case rate ($10,496.21). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,926.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","50147.20","50147.20","50147.20","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","951","DRG","","","","","","","","inpatient","","","113916.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","71014.37","","Standard inlier is a Case rate ($71,014.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $66,870, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,080.92) for the length of stay and the standard reimbursement.","71014.36","71014.36","71014.36","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","951","DRG","","","","","","","","inpatient","","","113916.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","79839.29","","Standard inlier is a Case rate ($79,839.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $66,870, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,332.52) for the length of stay and the standard reimbursement.","79839.28","79839.28","92517.14","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","951","DRG","","","","","","","","inpatient","","","113916.49","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($154,511.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","65251.24","65251.24","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","951","DRG","","","","","","","","inpatient","","","113916.49","","MASSHEALTH [3001]","HB BWH MEDICAID","24721.94","","Case rate ($27,334.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $69,764.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29509.72","10530.89","43617.22","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","951","DRG","","","","","","","","inpatient","","","113916.49","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","24721.94","","Case rate ($27,334.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $69,764.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","951","DRG","","","","","","","","inpatient","","","113916.49","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","24721.94","","Case rate ($27,334.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $69,764.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","34306.45","34306.45","34306.45","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","951","DRG","","","","","","","","inpatient","","","113916.49","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","69508.95","","Fee schedule rate ($69,508.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","69508.95","69508.95","69508.95","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MINOR","951","DRG","","","","","","","","inpatient","","","77598.13","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","45613.75","","Standard inlier is a Case rate ($45,613.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,119, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,475.15) for the length of stay and the standard reimbursement.","31649.72","31649.72","31649.72","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MINOR","951","DRG","","","","","","","","inpatient","","","77598.13","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","51282.14","","Standard inlier is a Case rate ($51,282.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,119, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,279.07) for the length of stay and the standard reimbursement.","39036.09","39036.09","39036.09","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MINOR","951","DRG","","","","","","","","inpatient","","","77598.13","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($21,695.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","34404.92","34404.92","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MINOR","951","DRG","","","","","","","","inpatient","","","77598.13","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48956.30","","Fee schedule rate ($48,956.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35059.95","35059.95","35059.95","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","951","DRG","","","","","","","","inpatient","","","90289.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","47243.73","","Standard inlier is a Case rate ($47,243.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,386, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,706.53) for the length of stay and the standard reimbursement.","47243.73","47243.73","47243.73","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","951","DRG","","","","","","","","inpatient","","","90289.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","53114.69","","Standard inlier is a Case rate ($53,114.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $48,386, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,539.19) for the length of stay and the standard reimbursement.","53114.68","53114.68","53114.68","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","951","DRG","","","","","","","","inpatient","","","90289.44","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22781.42","","Fee schedule rate ($36,126.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22781.42","16732.56","16732.56","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","951","DRG","","","","","","","","inpatient","","","90289.44","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","45954.01","","Fee schedule rate ($45,954.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","45954.01","45954.01","45954.01","1 through 10","9493.06","254946.65","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,EXTREME","793","DRG","","","","","","","","inpatient","","","86081.40","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","135611.89","","Standard inlier is a Case rate ($135,611.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $105,449, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($19,248.98) for the length of stay and the standard reimbursement.","135611.89","135611.89","135611.89","1 through 10","9858.62","135956.9","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MAJOR","793","DRG","","","","","","","","inpatient","","","223426.68","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","69502.14","","Standard inlier is a Case rate ($69,502.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,720, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,865.25) for the length of stay and the standard reimbursement.","69502.14","69502.14","69502.14","1 through 10","9858.62","135956.9","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MAJOR","793","DRG","","","","","","","","inpatient","","","223426.68","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","21547.31","","Case rate ($23,824.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,254.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12328.87","12328.87","25087.24","1 through 10","9858.62","135956.9","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MAJOR","793","DRG","","","","","","","","inpatient","","","223426.68","","MASSHEALTH [3001]","HB BWH MEDICAID","21547.31","","Case rate ($23,824.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,254.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","48587.84","48587.84","48587.84","1 through 10","9858.62","135956.9","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MAJOR","793","DRG","","","","","","","","inpatient","","","223426.68","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","21547.31","","Case rate ($23,824.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,254.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","9858.62","135956.9","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MAJOR","793","DRG","","","","","","","","inpatient","","","223426.68","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","129480.74","","Fee schedule rate ($129,480.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","62941.55","62941.55","62941.55","1 through 10","9858.62","135956.9","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MAJOR","793","DRG","","","","","","","","inpatient","","","223426.68","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","135956.90","","Fee schedule rate ($135,956.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","66089.66","66089.66","66089.66","1 through 10","9858.62","135956.9","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MINOR","793","DRG","","","","","","","","inpatient","","","104246.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35360.10","","Standard inlier is a Case rate ($35,360.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,107, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,019.07) for the length of stay and the standard reimbursement.","35360.10","35360.10","35360.10","1 through 10","9858.62","135956.9","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MINOR","793","DRG","","","","","","","","inpatient","","","104246.25","","MASSHEALTH [3001]","HB BWH MEDICAID","9858.62","","Case rate ($10,900.40). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,330.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10897.73","10897.73","10897.73","1 through 10","9858.62","135956.9","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MINOR","793","DRG","","","","","","","","inpatient","","","104246.25","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9858.62","","Case rate ($10,900.40). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,330.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10897.72","10897.72","10897.72","1 through 10","9858.62","135956.9","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MODERATE","793","DRG","","","","","","","","inpatient","","","79787.50","","MASSHEALTH [3001]","HB BWH MEDICAID","13932.30","","Case rate ($15,404.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,834.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15400.76","15400.76","15400.76","1 through 10","9858.62","135956.9","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MODERATE","793","DRG","","","","","","","","inpatient","","","79787.50","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","40754.72","","Fee schedule rate ($40,754.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40754.72","40754.72","40754.72","1 through 10","9858.62","135956.9","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MODERATE","793","DRG","","","","","","","","inpatient","","","79789.20","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","46900.76","","Standard inlier is a Case rate ($46,900.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $44,088, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,657.17) for the length of stay and the standard reimbursement.","46900.76","46900.76","59391.94","1 through 10","9858.62","135956.9","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MODERATE","793","DRG","","","","","","","","inpatient","","","79789.20","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","13932.30","","Case rate ($15,404.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,834.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2567.80","2567.80","2567.80","1 through 10","9858.62","135956.9","case rate",""
"MODULE COMPACT MATRIXNEURO NEUROSURGERY SYSTEM","SUP-ITM-10075431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.45","2464.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2611.93","79.5","","800.18","480.96","1887.97","195","1018.49","2611.93","percent of total billed charges",""
"MODULE COMPACT MATRIXNEURO NEUROSURGERY SYSTEM","SUP-ITM-10075431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.45","2464.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1751.14","53.3","","813.12","216.42","1444.50","81","1018.49","2611.93","percent of total billed charges",""
"MODULE COMPACT MATRIXNEURO NEUROSURGERY SYSTEM","SUP-ITM-10075431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.45","2464.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1018.49","31","","432.60","432.60","432.60","1 through 10","1018.49","2611.93","percent of total billed charges",""
"MODULE COMPACT MATRIXNEURO NEUROSURGERY SYSTEM","SUP-ITM-10075431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.45","2464.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1199.19","36.5","","148.37","54.89","631.39","94","1018.49","2611.93","percent of total billed charges",""
"MODULE COMPACT MATRIXNEURO NEUROSURGERY SYSTEM","SUP-ITM-10075431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.45","2464.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1258.33","38.3","","279.30","91.72","1116.77","266","1018.49","2611.93","percent of total billed charges",""
"MODULE COMPACT MATRIXNEURO NEUROSURGERY SYSTEM","SUP-ITM-10075431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.45","2464.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1409.46","42.9","","731.00","63.70","731.00","1 through 10","1018.49","2611.93","percent of total billed charges",""
"MODULE COMPACT MATRIXNEURO NEUROSURGERY SYSTEM","SUP-ITM-10075431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.45","2464.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1409.46","42.9","","384.74","384.74","384.74","1 through 10","1018.49","2611.93","percent of total billed charges",""
"MODULE COMPACT MATRIXNEURO NEUROSURGERY SYSTEM","SUP-ITM-10075431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.45","2464.09","WELLPOINT [1015]","HB AMC WELLPOINT","2424.01","73.78","","286.63","119.22","1107.45","105","1018.49","2611.93","percent of total billed charges",""
"MODULE COMPACT MATRIXNEURO NEUROSURGERY SYSTEM","SUP-ITM-10075431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.45","2464.09","AETNA [1001]","HB AMC AETNA HMO","2293.24","69.8","","675.31","184.75","1721.50","286","1716.98","2684.87","percent of total billed charges",""
"MODULE COMPACT MATRIXNEURO NEUROSURGERY SYSTEM","SUP-ITM-10075431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.45","2464.09","AETNA [1001]","HB AMC AETNA PPO","2641.50","80.4","","1261.44","103.12","1514.10","21","1716.98","2684.87","percent of total billed charges",""
"MODULE COMPACT MATRIXNEURO NEUROSURGERY SYSTEM","SUP-ITM-10075431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.45","2464.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2641.50","80.4","","1365.00","1365.00","1365.00","1 through 10","1716.98","2684.87","percent of total billed charges",""
"MODULE COMPACT MATRIXNEURO NEUROSURGERY SYSTEM","SUP-ITM-10075431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.45","2464.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2684.87","81.72","","5157.68","5157.68","5157.68","1 through 10","1716.98","2684.87","percent of total billed charges",""
"MODULE COMPACT MATRIXNEURO NEUROSURGERY SYSTEM","SUP-ITM-10075431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.45","2464.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2684.87","81.72","","431.26","71.26","1459.57","88","1716.98","2684.87","percent of total billed charges",""
"MODULE DIAPHYSIS 3CM OSS TAPERED","SUP-ITM-10202203","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2790.29","52.26","","1113.10","1113.10","1113.10","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 3CM OSS TAPERED","SUP-ITM-10202203","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4244.70","79.5","","1293.60","1148.53","1603.80","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 3CM OSS TAPERED","SUP-ITM-10202203","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1948.83","36.5","","1023.42","771.29","2068.67","33","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 3CM OSS TAPERED","SUP-ITM-10202203","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2044.93","38.3","","850.52","759.78","1211.25","66","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 3CM OSS TAPERED","SUP-ITM-10202203","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","2548.09","2548.09","2548.09","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 3CM OSS TAPERED","SUP-ITM-10202203","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","956.46","956.46","956.46","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 3CM OSS TAPERED","SUP-ITM-10202203","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","WELLPOINT [1015]","HB AMC WELLPOINT","3939.30","73.78","","2344.73","1619.47","2530.35","16","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 3CM OSS TAPERED","SUP-ITM-10202203","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA HMO","3726.80","69.8","","1523.63","988.41","4330.26","39","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 3CM OSS TAPERED","SUP-ITM-10202203","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA PPO","4292.76","80.4","","1670.25","1670.25","1670.25","1 through 10","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 3CM OSS TAPERED","SUP-ITM-10202203","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2790.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 3CM OSS TAPERED","SUP-ITM-10202203","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4363.24","81.72","","1738.90","1484.65","2716.94","38","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 4CM OSS TAPERED","SUP-ITM-10202204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2790.29","52.26","","1113.10","1113.10","1113.10","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 4CM OSS TAPERED","SUP-ITM-10202204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4244.70","79.5","","1293.60","1148.53","1603.80","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 4CM OSS TAPERED","SUP-ITM-10202204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1948.83","36.5","","1023.42","771.29","2068.67","33","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 4CM OSS TAPERED","SUP-ITM-10202204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2044.93","38.3","","850.52","759.78","1211.25","66","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 4CM OSS TAPERED","SUP-ITM-10202204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","2548.09","2548.09","2548.09","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 4CM OSS TAPERED","SUP-ITM-10202204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","956.46","956.46","956.46","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 4CM OSS TAPERED","SUP-ITM-10202204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","WELLPOINT [1015]","HB AMC WELLPOINT","3939.30","73.78","","2344.73","1619.47","2530.35","16","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 4CM OSS TAPERED","SUP-ITM-10202204","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA HMO","3726.80","69.8","","1523.63","988.41","4330.26","39","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 4CM OSS TAPERED","SUP-ITM-10202204","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA PPO","4292.76","80.4","","1670.25","1670.25","1670.25","1 through 10","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 4CM OSS TAPERED","SUP-ITM-10202204","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2790.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 4CM OSS TAPERED","SUP-ITM-10202204","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4363.24","81.72","","1738.90","1484.65","2716.94","38","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 7CM OSS TAPERED","SUP-ITM-10202206","CDM","C1713","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4244.70","79.5","","800.18","480.96","1887.97","195","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 7CM OSS TAPERED","SUP-ITM-10202206","CDM","C1713","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2845.82","53.3","","813.12","216.42","1444.50","81","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 7CM OSS TAPERED","SUP-ITM-10202206","CDM","C1713","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1655.17","31","","432.60","432.60","432.60","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 7CM OSS TAPERED","SUP-ITM-10202206","CDM","C1713","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1948.83","36.5","","148.37","54.89","631.39","94","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 7CM OSS TAPERED","SUP-ITM-10202206","CDM","C1713","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2044.93","38.3","","279.30","91.72","1116.77","266","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 7CM OSS TAPERED","SUP-ITM-10202206","CDM","C1713","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","731.00","63.70","731.00","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 7CM OSS TAPERED","SUP-ITM-10202206","CDM","C1713","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","384.74","384.74","384.74","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 7CM OSS TAPERED","SUP-ITM-10202206","CDM","C1713","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","WELLPOINT [1015]","HB AMC WELLPOINT","3939.30","73.78","","286.63","119.22","1107.45","105","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 7CM OSS TAPERED","SUP-ITM-10202206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA HMO","3726.80","69.8","","675.31","184.75","1721.50","286","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 7CM OSS TAPERED","SUP-ITM-10202206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA PPO","4292.76","80.4","","1261.44","103.12","1514.10","21","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 7CM OSS TAPERED","SUP-ITM-10202206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4292.76","80.4","","1365.00","1365.00","1365.00","1 through 10","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 7CM OSS TAPERED","SUP-ITM-10202206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4363.24","81.72","","5157.68","5157.68","5157.68","1 through 10","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 7CM OSS TAPERED","SUP-ITM-10202206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4363.24","81.72","","431.26","71.26","1459.57","88","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 9CM OSS TAPERED","SUP-ITM-10202207","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2790.29","52.26","","1113.10","1113.10","1113.10","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 9CM OSS TAPERED","SUP-ITM-10202207","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4244.70","79.5","","1293.60","1148.53","1603.80","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 9CM OSS TAPERED","SUP-ITM-10202207","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1948.83","36.5","","1023.42","771.29","2068.67","33","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 9CM OSS TAPERED","SUP-ITM-10202207","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2044.93","38.3","","850.52","759.78","1211.25","66","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 9CM OSS TAPERED","SUP-ITM-10202207","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","2548.09","2548.09","2548.09","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 9CM OSS TAPERED","SUP-ITM-10202207","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2290.54","42.9","","956.46","956.46","956.46","1 through 10","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 9CM OSS TAPERED","SUP-ITM-10202207","CDM","C1776","HCPCS","0278","RC","","","","both","","","5339.25","4004.44","WELLPOINT [1015]","HB AMC WELLPOINT","3939.30","73.78","","2344.73","1619.47","2530.35","16","1655.17","4244.7","percent of total billed charges",""
"MODULE DIAPHYSIS 9CM OSS TAPERED","SUP-ITM-10202207","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA HMO","3726.80","69.8","","1523.63","988.41","4330.26","39","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 9CM OSS TAPERED","SUP-ITM-10202207","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","AETNA [1001]","HB AMC AETNA PPO","4292.76","80.4","","1670.25","1670.25","1670.25","1 through 10","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 9CM OSS TAPERED","SUP-ITM-10202207","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2790.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2790.29","4363.24","percent of total billed charges",""
"MODULE DIAPHYSIS 9CM OSS TAPERED","SUP-ITM-10202207","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5339.25","4004.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4363.24","81.72","","1738.90","1484.65","2716.94","38","2790.29","4363.24","percent of total billed charges",""
"MODULE INSTRUMENT STORAGE PLATE ORTHOGNATHIC","SUP-ITM-10075383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2271.64","1703.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1805.95","79.5","","800.18","480.96","1887.97","195","704.21","1805.95","percent of total billed charges",""
"MODULE INSTRUMENT STORAGE PLATE ORTHOGNATHIC","SUP-ITM-10075383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2271.64","1703.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1210.78","53.3","","813.12","216.42","1444.50","81","704.21","1805.95","percent of total billed charges",""
"MODULE INSTRUMENT STORAGE PLATE ORTHOGNATHIC","SUP-ITM-10075383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2271.64","1703.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","704.21","31","","432.60","432.60","432.60","1 through 10","704.21","1805.95","percent of total billed charges",""
"MODULE INSTRUMENT STORAGE PLATE ORTHOGNATHIC","SUP-ITM-10075383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2271.64","1703.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","829.15","36.5","","148.37","54.89","631.39","94","704.21","1805.95","percent of total billed charges",""
"MODULE INSTRUMENT STORAGE PLATE ORTHOGNATHIC","SUP-ITM-10075383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2271.64","1703.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","870.04","38.3","","279.30","91.72","1116.77","266","704.21","1805.95","percent of total billed charges",""
"MODULE INSTRUMENT STORAGE PLATE ORTHOGNATHIC","SUP-ITM-10075383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2271.64","1703.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","974.53","42.9","","731.00","63.70","731.00","1 through 10","704.21","1805.95","percent of total billed charges",""
"MODULE INSTRUMENT STORAGE PLATE ORTHOGNATHIC","SUP-ITM-10075383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2271.64","1703.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","974.53","42.9","","384.74","384.74","384.74","1 through 10","704.21","1805.95","percent of total billed charges",""
"MODULE INSTRUMENT STORAGE PLATE ORTHOGNATHIC","SUP-ITM-10075383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2271.64","1703.73","WELLPOINT [1015]","HB AMC WELLPOINT","1676.02","73.78","","286.63","119.22","1107.45","105","704.21","1805.95","percent of total billed charges",""
"MODULE INSTRUMENT STORAGE PLATE ORTHOGNATHIC","SUP-ITM-10075383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2271.64","1703.73","AETNA [1001]","HB AMC AETNA HMO","1585.60","69.8","","675.31","184.75","1721.50","286","1187.16","1856.38","percent of total billed charges",""
"MODULE INSTRUMENT STORAGE PLATE ORTHOGNATHIC","SUP-ITM-10075383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2271.64","1703.73","AETNA [1001]","HB AMC AETNA PPO","1826.40","80.4","","1261.44","103.12","1514.10","21","1187.16","1856.38","percent of total billed charges",""
"MODULE INSTRUMENT STORAGE PLATE ORTHOGNATHIC","SUP-ITM-10075383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2271.64","1703.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1826.40","80.4","","1365.00","1365.00","1365.00","1 through 10","1187.16","1856.38","percent of total billed charges",""
"MODULE INSTRUMENT STORAGE PLATE ORTHOGNATHIC","SUP-ITM-10075383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2271.64","1703.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1856.38","81.72","","5157.68","5157.68","5157.68","1 through 10","1187.16","1856.38","percent of total billed charges",""
"MODULE INSTRUMENT STORAGE PLATE ORTHOGNATHIC","SUP-ITM-10075383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2271.64","1703.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1856.38","81.72","","431.26","71.26","1459.57","88","1187.16","1856.38","percent of total billed charges",""
"Modulr Belt Sm/MD/Lg #104227/8","PX-27000878","CDM","Q0499","HCPCS","0274","RC","","","","outpatient","","","1207.50","905.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","630.56","52.22","","612.59","612.59","612.59","1 through 10","408.29","996.19","percent of total billed charges",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","both","","","143.00","107.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","113.69","79.5","","109.39","109.39","109.39","1 through 10","36.98","135.85","percent of total billed charges",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","both","","","143.00","107.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","76.22","53.3","","73.39","73.39","73.39","1 through 10","36.98","135.85","percent of total billed charges",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","both","","","143.00","107.25","TRICARE [160005]","HB BWH TRICARE","135.85","95","","43.19","43.19","43.19","1 through 10","36.98","135.85","percent of total billed charges",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","outpatient","","","143.00","107.25","AETNA [1001]","HB AMC AETNA HMO","99.81","69.8","","94.10","94.10","94.10","1 through 10","34.67","117.98","percent of total billed charges",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","outpatient","","","143.00","107.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","74.73","52.26","","29.85","29.85","29.85","1 through 10","34.67","117.98","percent of total billed charges",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","75.08","52.5","","91.05","91.05","91.05","1 through 10","34.67","117.98","percent of total billed charges",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","71.50","50","","72.84","72.84","137.20","1 through 10","34.67","117.98","percent of total billed charges",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","75.08","52.5","","76.45","76.45","76.45","1 through 10","34.67","117.98","percent of total billed charges",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","78.65","55","","80.06","80.06","80.06","1 through 10","34.67","117.98","percent of total billed charges",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","outpatient","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","116.86","81.72","","139.00","139.00","139.00","1 through 10","34.67","117.98","percent of total billed charges",""
"Mog-Igg1 Antibody Flow Cytometry Each","PX-30003770","CDM","86363","CPT","0302","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","116.86","81.72","","111.12","61.12","111.12","1 through 10","34.67","117.98","percent of total billed charges",""
"Mol074 - Pnpo Full Gene Sequencing Analysis","PX-31000687","CDM","81479","CPT","0310","RC","","","","both","","","1033.00","774.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","821.24","79.5","","0.65","0.65","0.65","1 through 10","320.23","981.35","percent of total billed charges",""
"Mol074 - Pnpo Full Gene Sequencing Analysis","PX-31000687","CDM","81479","CPT","0310","RC","","","","both","","","1033.00","774.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","550.59","53.3","","0.79","0.79","0.79","1 through 10","320.23","981.35","percent of total billed charges",""
"Mol074 - Pnpo Full Gene Sequencing Analysis","PX-31000687","CDM","81479","CPT","0310","RC","","","","outpatient","","","1033.00","774.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","516.50","50","","1.00","1.00","1.00","1 through 10","156.55","852.23","percent of total billed charges",""
"Mol074 - Pnpo Full Gene Sequencing Analysis","PX-31000687","CDM","81479","CPT","0310","RC","","","","outpatient","","","1033.00","774.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","542.33","52.5","","1.00","0.53","1.00","1 through 10","156.55","852.23","percent of total billed charges",""
"Molecular Path Procedure Level 2","PX-31000003","CDM","81401","CPT","0310","RC","","","","both","","","1457.00","1092.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1158.32","79.5","","1112.03","746.06","1112.03","1 through 10","134.26","1384.15","percent of total billed charges",""
"Molecular Path Procedure Level 2","PX-31000003","CDM","81401","CPT","0310","RC","","","","both","","","1457.00","1092.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","776.58","53.3","","1112.03","746.06","1112.03","1 through 10","134.26","1384.15","percent of total billed charges",""
"Molecular Path Procedure Level 4","PX-31000005","CDM","81403","CPT","0310","RC","","","","outpatient","","","1058.00","793.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.49","52.22","","1026.00","1026.00","1026.00","1 through 10","512.07","1135.28","percent of total billed charges",""
"Molecular Path Procedure Level 4","PX-31000005","CDM","81403","CPT","0310","RC","","","","outpatient","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","864.60","81.72","","820.18","820.18","820.18","1 through 10","512.07","1135.28","percent of total billed charges",""
"Molecular Path Procedure Level 5","PX-31000006","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Molecular Path Procedure Level 5","PX-31000006","CDM","81404","CPT","0310","RC","","","","outpatient","","","1916.00","1437.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1160.14","60.55","","1858.00","1858.00","1858.00","1 through 10","927.34","1684.71","percent of total billed charges",""
"Molecular Path Procedure Level 5","PX-31000006","CDM","81404","CPT","0310","RC","","","","outpatient","","","1916.00","1437.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1000.54","52.22","","786.73","786.73","786.73","1 through 10","927.34","1684.71","percent of total billed charges",""
"Molecular Path Procedure Level 6","PX-31000007","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Molecular Path Procedure Level 6","PX-31000007","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","1118.01","3319.47","percent of total billed charges",""
"Molecular Path Procedure Level 7","PX-31000008","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Molecular Pathology Procedure","PX-31000231","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Molecular Pathology Procedure","PX-31000231","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Molecular Pathology Procedure","PX-31000231","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Molecular Pathology Procedure","PX-31000231","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Molecule Nucleic Ampli Each","PX-31000750","CDM","81479","CPT","0310","RC","","","","both","","","1566.00","1174.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1244.97","79.5","","0.65","0.65","0.65","1 through 10","485.46","1487.7","percent of total billed charges",""
"Molecule Nucleic Ampli Each","PX-31000750","CDM","81479","CPT","0310","RC","","","","both","","","1566.00","1174.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","834.68","53.3","","0.79","0.79","0.79","1 through 10","485.46","1487.7","percent of total billed charges",""
"Molecule Nucleic Ampli Each","PX-31000750","CDM","81479","CPT","0310","RC","","","","outpatient","","","1566.00","1174.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","783.00","50","","1.00","1.00","1.00","1 through 10","156.55","1291.95","percent of total billed charges",""
"Molecule Nucleic Ampli Each","PX-31000750","CDM","81479","CPT","0310","RC","","","","outpatient","","","1566.00","1174.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","822.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","1291.95","percent of total billed charges",""
"Mon Glucose Continuous <72 Hrs","PX-51000064","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.59","150.59","150.59","1 through 10","145.39","863.17","other","OPPS APC"
"Mon Glucose Continuous <72 Hrs","PX-51000064","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","141.97","128.87","141.97","1 through 10","145.39","863.17","other","OPPS APC"
"Mon Glucose Continuous <72 Hrs","PX-51000064","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","FALLON HEALTH [1008]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.04","153.04","153.04","1 through 10","145.39","863.17","other","OPPS APC"
"Mon Glucose Continuous <72 Hrs","PX-51000064","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","MEDICARE [2001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.04","153.04","153.04","19","145.39","863.17","other","OPPS APC"
"Mon Glucose Continuous <72 Hrs","PX-51000064","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","409.17","36.5","","405.45","393.49","663.40","1 through 10","145.39","863.17","percent of total billed charges",""
"Mon Glucose Continuous <72 Hrs","PX-51000064","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","429.34","38.3","","425.02","425.02","425.02","1 through 10","145.39","863.17","percent of total billed charges",""
"Mon Glucose Continuous <72 Hrs","PX-51000064","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","149.98","149.98","149.98","1 through 10","145.39","863.17","other","OPPS APC"
"Mon Glucose Continuous <72 Hrs","PX-51000064","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.38","150.38","150.38","1 through 10","145.39","863.17","other","OPPS APC"
"Mon Glucose Continuous <72 Hrs","PX-51000064","CDM","95250","CPT","0510","RC","","","","both","","","1121.00","840.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","149.98","149.98","150.98","1 through 10","145.39","863.17","other","OPPS APC"
"Mon Glucose Continuous <72 Hrs","PX-51000064","CDM","95250","CPT","0510","RC","","","","outpatient","","","1121.00","840.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","382.26","34.1","","855.46","855.46","855.46","1 through 10","40.19","916.08","percent of total billed charges",""
"Mon Glucose Continuous <72 Hrs","PX-51000064","CDM","95250","CPT","0510","RC","","","","outpatient","","","1121.00","840.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","916.08","81.72","","868.95","868.95","868.95","1 through 10","40.19","916.08","percent of total billed charges",""
"MONITOR CARDIAC INJECTABLE BIOMONITOR IIIM","SUP-ITM-10278709","CDM","C1764","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7950.00","79.5","","8853.75","7870.00","8853.75","1 through 10","3100","7950","percent of total billed charges",""
"MONITOR CARDIAC INJECTABLE BIOMONITOR IIIM","SUP-ITM-10278709","CDM","C1764","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5330.00","53.3","","6996.00","5280.00","6996.00","1 through 10","3100","7950","percent of total billed charges",""
"MONITOR CARDIAC INJECTABLE BIOMONITOR IIIM","SUP-ITM-10278709","CDM","C1764","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3650.00","36.5","","4200.25","4200.25","4200.25","1 through 10","3100","7950","percent of total billed charges",""
"MONITOR CARDIAC INJECTABLE BIOMONITOR IIIM","SUP-ITM-10278709","CDM","C1764","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3830.00","38.3","","3910.00","3800.00","4398.75","11","3100","7950","percent of total billed charges",""
"MONITOR CARDIAC INJECTABLE BIOMONITOR IIIM","SUP-ITM-10278709","CDM","C1764","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB AMC WELLPOINT","7378.00","73.78","","8375.63","7445.00","8375.63","1 through 10","3100","7950","percent of total billed charges",""
"MONITOR CARDIAC INJECTABLE BIOMONITOR IIIM","SUP-ITM-10278709","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA HMO","6980.00","69.8","","7616.25","5377.50","11250.00","1 through 10","5226","8172","percent of total billed charges",""
"MONITOR CARDIAC INJECTABLE BIOMONITOR IIIM","SUP-ITM-10278709","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA PPO","8040.00","80.4","","7800.00","7800.00","7800.00","1 through 10","5226","8172","percent of total billed charges",""
"MONITOR CARDIAC INJECTABLE BIOMONITOR IIIM","SUP-ITM-10278709","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8040.00","80.4","","7540.00","7540.00","7540.00","1 through 10","5226","8172","percent of total billed charges",""
"MONITOR CARDIAC INJECTABLE BIOMONITOR IIIM","SUP-ITM-10278709","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8172.00","81.72","","8993.25","8993.25","8993.25","1 through 10","5226","8172","percent of total billed charges",""
"MONITOR CARDIAC INSERTABLE ASSERT IQ EL PLUS","SUP-ITM-10318499","CDM","C1764","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10533.75","79.5","","8853.75","7870.00","8853.75","1 through 10","4107.5","10533.75","percent of total billed charges",""
"MONITOR CARDIAC INSERTABLE ASSERT IQ EL PLUS","SUP-ITM-10318499","CDM","C1764","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7062.25","53.3","","6996.00","5280.00","6996.00","1 through 10","4107.5","10533.75","percent of total billed charges",""
"MONITOR CARDIAC INSERTABLE ASSERT IQ EL PLUS","SUP-ITM-10318499","CDM","C1764","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4836.25","36.5","","4200.25","4200.25","4200.25","1 through 10","4107.5","10533.75","percent of total billed charges",""
"MONITOR CARDIAC INSERTABLE ASSERT IQ EL PLUS","SUP-ITM-10318499","CDM","C1764","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5074.75","38.3","","3910.00","3800.00","4398.75","11","4107.5","10533.75","percent of total billed charges",""
"MONITOR CARDIAC INSERTABLE ASSERT IQ EL PLUS","SUP-ITM-10318499","CDM","C1764","HCPCS","0278","RC","","","","both","","","13250.00","9937.50","WELLPOINT [1015]","HB AMC WELLPOINT","9775.85","73.78","","8375.63","7445.00","8375.63","1 through 10","4107.5","10533.75","percent of total billed charges",""
"MONITOR CARDIAC INSERTABLE ASSERT IQ EL PLUS","SUP-ITM-10318499","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","13250.00","9937.50","AETNA [1001]","HB AMC AETNA HMO","9248.50","69.8","","7616.25","5377.50","11250.00","1 through 10","6924.45","10827.9","percent of total billed charges",""
"MONITOR CARDIAC INSERTABLE ASSERT IQ EL PLUS","SUP-ITM-10318499","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","13250.00","9937.50","AETNA [1001]","HB AMC AETNA PPO","10653.00","80.4","","7800.00","7800.00","7800.00","1 through 10","6924.45","10827.9","percent of total billed charges",""
"MONITOR CARDIAC INSERTABLE ASSERT IQ EL PLUS","SUP-ITM-10318499","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","13250.00","9937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10653.00","80.4","","7540.00","7540.00","7540.00","1 through 10","6924.45","10827.9","percent of total billed charges",""
"MONITOR CARDIAC INSERTABLE ASSERT IQ EL PLUS","SUP-ITM-10318499","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","13250.00","9937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10827.90","81.72","","8993.25","8993.25","8993.25","1 through 10","6924.45","10827.9","percent of total billed charges",""
"MONITOR CARDIAC REVEAL LOOP RECORDER SYSTEM","SUP-ITM-10132914","CDM","C1764","HCPCS","0278","RC","","","","both","","","11000.00","8250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8745.00","79.5","","8853.75","7870.00","8853.75","1 through 10","3410","8745","percent of total billed charges",""
"MONITOR CARDIAC REVEAL LOOP RECORDER SYSTEM","SUP-ITM-10132914","CDM","C1764","HCPCS","0278","RC","","","","both","","","11000.00","8250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5863.00","53.3","","6996.00","5280.00","6996.00","1 through 10","3410","8745","percent of total billed charges",""
"MONITOR CARDIAC REVEAL LOOP RECORDER SYSTEM","SUP-ITM-10132914","CDM","C1764","HCPCS","0278","RC","","","","both","","","11000.00","8250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4015.00","36.5","","4200.25","4200.25","4200.25","1 through 10","3410","8745","percent of total billed charges",""
"MONITOR CARDIAC REVEAL LOOP RECORDER SYSTEM","SUP-ITM-10132914","CDM","C1764","HCPCS","0278","RC","","","","both","","","11000.00","8250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4213.00","38.3","","3910.00","3800.00","4398.75","11","3410","8745","percent of total billed charges",""
"MONITOR CARDIAC REVEAL LOOP RECORDER SYSTEM","SUP-ITM-10132914","CDM","C1764","HCPCS","0278","RC","","","","both","","","11000.00","8250.00","WELLPOINT [1015]","HB AMC WELLPOINT","8115.80","73.78","","8375.63","7445.00","8375.63","1 through 10","3410","8745","percent of total billed charges",""
"MONITOR CARDIAC REVEAL LOOP RECORDER SYSTEM","SUP-ITM-10132914","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","11000.00","8250.00","AETNA [1001]","HB AMC AETNA HMO","7678.00","69.8","","7616.25","5377.50","11250.00","1 through 10","5748.6","8989.2","percent of total billed charges",""
"MONITOR CARDIAC REVEAL LOOP RECORDER SYSTEM","SUP-ITM-10132914","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","11000.00","8250.00","AETNA [1001]","HB AMC AETNA PPO","8844.00","80.4","","7800.00","7800.00","7800.00","1 through 10","5748.6","8989.2","percent of total billed charges",""
"MONITOR CARDIAC REVEAL LOOP RECORDER SYSTEM","SUP-ITM-10132914","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","11000.00","8250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8844.00","80.4","","7540.00","7540.00","7540.00","1 through 10","5748.6","8989.2","percent of total billed charges",""
"MONITOR CARDIAC REVEAL LOOP RECORDER SYSTEM","SUP-ITM-10132914","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","11000.00","8250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8989.20","81.72","","8993.25","8993.25","8993.25","1 through 10","5748.6","8989.2","percent of total billed charges",""
"Monkeypox Virus Vaccine Subq","PX-63601361","CDM","90749","CPT","0636","RC","","","","both","","","0.01","0.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.01","79.5","","0.01","0.01","0.01","1 through 10","0.01","0.01","percent of total billed charges",""
"Monkeypox Virus Vaccine Subq","PX-63601361","CDM","90749","CPT","0636","RC","","","","outpatient","","","0.01","0.01","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.01","50","","0.01","0.01","0.01","1 through 10","0.01","0.01","percent of total billed charges",""
"Monogenic Diabetes (Mody) 5-Gene Evaluation (Ad885)","PX-31000682","CDM","81479","CPT","0310","RC","","","","both","","","1037.00","777.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","824.42","79.5","","0.65","0.65","0.65","1 through 10","321.47","985.15","percent of total billed charges",""
"Monogenic Diabetes (Mody) 5-Gene Evaluation (Ad885)","PX-31000682","CDM","81479","CPT","0310","RC","","","","both","","","1037.00","777.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","552.72","53.3","","0.79","0.79","0.79","1 through 10","321.47","985.15","percent of total billed charges",""
"Monogenic Diabetes (Mody) 5-Gene Evaluation (Ad885)","PX-31000682","CDM","81479","CPT","0310","RC","","","","outpatient","","","1037.00","777.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","518.50","50","","1.00","1.00","1.00","1 through 10","156.55","855.53","percent of total billed charges",""
"Monogenic Diabetes (Mody) 5-Gene Evaluation (Ad885)","PX-31000682","CDM","81479","CPT","0310","RC","","","","outpatient","","","1037.00","777.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","544.43","52.5","","1.00","0.53","1.00","1 through 10","156.55","855.53","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","both","","","168.00","126.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","117.60","70","","163.00","121.38","163.00","1 through 10","11.33","159.6","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","both","","","168.00","126.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","133.56","79.5","","122.90","86.06","128.28","15","11.33","159.6","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","both","","","168.00","126.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","89.54","53.3","","128.28","82.32","128.28","1 through 10","11.33","159.6","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","52.08","31","","198.96","198.96","198.96","1 through 10","11.33","159.6","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","61.32","36.5","","60.80","51.67","155.01","28","11.33","159.6","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64.34","38.3","","63.73","63.73","191.19","60","11.33","159.6","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","both","","","168.00","126.00","TRICARE [160005]","HB BWH TRICARE","159.60","95","","30.66","30.66","30.66","1 through 10","11.33","159.6","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","both","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.07","42.9","","130.30","71.67","130.30","1 through 10","11.33","159.6","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","outpatient","","","168.00","126.00","AETNA [1001]","HB AMC AETNA HMO","117.26","69.8","","110.35","77.91","110.35","39","11.33","182.37","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","outpatient","","","168.00","126.00","AETNA [1001]","HB AMC AETNA PPO","135.07","80.4","","127.14","85.41","256.23","1 through 10","11.33","182.37","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","137.29","81.72","","130.30","71.67","163.00","1 through 10","11.33","182.37","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","137.29","81.72","","130.30","71.67","130.30","38","11.33","182.37","percent of total billed charges",""
"Mopath Level 4 for Dex Z","PX-31001319","CDM","81403","CPT","0310","RC","","","","outpatient","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","864.60","81.72","","820.18","820.18","820.18","1 through 10","512.07","1135.28","percent of total billed charges",""
"Mopath Level 5 for Dex Z","PX-31001342","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Mopath Level 6 for Dex Z","PX-31001361","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Mopath Level 6 for Dex Z","PX-31001361","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Mopath Level 7 for Dex Z","PX-31001387","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Morcellator T1","PX-27000122","CDM","C1782","HCPCS","0272","RC","","","","both","","","1378.13","1033.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1095.61","79.5","","3677.25","3677.25","3677.25","1 through 10","427.22","1095.61","percent of total billed charges",""
"Morphine Inj 10mg","PX-63600150","CDM","J2270","HCPCS","0636","RC","","","","both","","","8.84","6.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2.74","31","","3.02","3.02","3.02","1 through 10","2.74","10.59","percent of total billed charges",""
"Morphine Inj 10mg","PX-63600150","CDM","J2270","HCPCS","0636","RC","","","","both","","","8.84","6.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3.23","36.5","","6.08","2.66","7.91","42","2.74","10.59","percent of total billed charges",""
"Morphine Inj 10mg","PX-63600150","CDM","J2270","HCPCS","0636","RC","","","","both","","","8.84","6.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3.39","38.3","","3.83","3.72","11.46","20","2.74","10.59","percent of total billed charges",""
"Morphine Inj 10mg","PX-63600150","CDM","J2270","HCPCS","0636","RC","","","","outpatient","","","8.84","6.63","AETNA [1001]","HB AMC AETNA HMO","6.17","69.8","","6.58","4.65","6.62","23","4.15","9.78","percent of total billed charges",""
"Morphine Inj 10mg","PX-63600150","CDM","J2270","HCPCS","0636","RC","","","","outpatient","","","8.84","6.63","AETNA [1001]","HB AMC AETNA PPO","7.11","80.4","","3.82","3.82","3.82","1 through 10","4.15","9.78","percent of total billed charges",""
"Morphine Inj 10mg","PX-63600150","CDM","J2270","HCPCS","0636","RC","","","","outpatient","","","8.84","6.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6.18","69.9","","6.69","2.09","8.36","13","4.15","9.78","percent of total billed charges",""
"Morphine Inj 10mg","PX-63600150","CDM","J2270","HCPCS","0636","RC","","","","outpatient","","","8.84","6.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4.15","46.9","","9.88","3.36","9.88","1 through 10","4.15","9.78","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","229.41","630.12","13","598.61","1571.72","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1296.91","65.6","","1495.26","1495.26","1495.26","1 through 10","598.61","1571.72","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1383.90","70","","1883.17","1883.17","1883.17","1 through 10","598.61","1571.72","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","787.57","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","229.29","50.00","1846.61","1 through 10","598.61","1571.72","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1571.72","79.5","","1508.68","1012.18","1508.68","1 through 10","598.61","1571.72","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1053.74","53.3","","1508.68","1508.68","1508.68","1 through 10","598.61","1571.72","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","523.52","620.04","1 through 10","598.61","1571.72","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","MEDICARE [2001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","584.98","630.12","87","598.61","1571.72","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","612.87","31","","592.35","592.35","592.35","1 through 10","598.61","1571.72","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","721.61","36.5","","715.04","715.04","715.04","1 through 10","598.61","1571.72","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","757.19","38.3","","749.55","749.55","2248.65","1 through 10","598.61","1571.72","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","617.52","573.28","617.92","1 through 10","598.61","1571.72","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.92","617.92","617.92","1 through 10","598.61","1571.72","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","440.91","440.91","440.91","1 through 10","598.61","1571.72","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.72","573.28","618.52","16","598.61","1571.72","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","1977.00","1482.75","WELLPOINT [1015]","HB AMC WELLPOINT","1458.63","73.78","","1427.21","1427.21","1427.21","1 through 10","598.61","1571.72","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","outpatient","","","1977.00","1482.75","AETNA [1001]","HB AMC AETNA HMO","1379.95","69.8","","1297.81","1297.81","1297.81","1 through 10","1033.18","2051.09","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","outpatient","","","1977.00","1482.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1615.60","81.72","","1532.45","1165.49","1532.45","13","1033.18","2051.09","percent of total billed charges",""
"Mouth Procedures With Cc/McC","137","MS-DRG","","","","","","","","inpatient","","","50905.86","38179.39","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14000.96","","Case rate ($14,000.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,776.99, add-ons for qualifying new technology services are included. If operating cost exceeds $62,421.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,641.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $12,419.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,397.15 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,201.52. The transfer capital threshold is the transfer adjustment factor * $1,201.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12840.19","12840.19","12840.19","1 through 10","13720.94","21106.2726","other","Inpatient Replacement Plans DRG"
"Mouth Procedures With Cc/McC","137","MS-DRG","","","","","","","","inpatient","","","50905.86","38179.39","MEDICARE [2001]","HB BWH MEDICARE","14000.96","","Case rate ($14,000.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,776.99, add-ons for qualifying new technology services are included. If operating cost exceeds $62,421.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,641.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $12,419.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,397.15 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,201.52. The transfer capital threshold is the transfer adjustment factor * $1,201.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16766.59","16766.59","16766.59","1 through 10","13720.94","21106.2726","other","Inpatient Replacement Plans DRG"
"Mouth Procedures Without Cc/McC","138","MS-DRG","","","","","","","","inpatient","","","34836.26","26127.19","MEDICARE [2001]","HB BWH MEDICARE","8463.85","","Case rate ($8,463.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,111.40, add-ons for qualifying new technology services are included. If operating cost exceeds $55,755.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,153.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $7,370.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,731.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.09. The transfer capital threshold is the transfer adjustment factor * $713.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9883.10","9883.10","9883.10","1 through 10","8294.57","12276.5285","other","Inpatient Replacement Plans DRG"
"MR Quantitative Tissue Analysis Single Organ With Dx Exam","PX-61000169","CDM","0649T","CPT","0614","RC","","","","both","","","7036.00","5277.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1128.66","","APC Price ($1,128.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1110.72","1110.72","1110.72","1 through 10","1106.09","6684.2","other","OPPS APC"
"MR Quantitative Tissue Analysis Single Organ With Dx Exam","PX-61000169","CDM","0649T","CPT","0614","RC","","","","both","","","7036.00","5277.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","1410.83","","APC Price ($1,128.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","998.66","998.66","998.66","1 through 10","1106.09","6684.2","other","OPPS APC"
"MR Quantitative Tissue Analysis Single Organ With Dx Exam","PX-61000169","CDM","0649T","CPT","0614","RC","","","","both","","","7036.00","5277.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1128.66","","APC Price ($1,128.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1110.72","1110.72","1110.72","1 through 10","1106.09","6684.2","other","OPPS APC"
"MR Quantitative Tissue Analysis Single Organ With Dx Exam","PX-61000169","CDM","0649T","CPT","0614","RC","","","","both","","","7036.00","5277.00","MEDICARE [2001]","HB BWH MEDICARE","1128.66","","APC Price ($1,128.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1128.78","1088.80","1128.78","29","1106.09","6684.2","other","OPPS APC"
"MR Quantitative Tissue Analysis Single Organ With Dx Exam","PX-61000169","CDM","0649T","CPT","0614","RC","","","","both","","","7036.00","5277.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1128.66","","APC Price ($1,128.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1109.40","1109.40","1109.40","1 through 10","1106.09","6684.2","other","OPPS APC"
"MR Quantitative Tissue Analysis Single Organ With Dx Exam","PX-61000169","CDM","0649T","CPT","0614","RC","","","","both","","","7036.00","5277.00","TRICARE [160005]","HB BWH TRICARE","6684.20","95","","6823.00","6823.00","6823.00","1 through 10","1106.09","6684.2","percent of total billed charges",""
"MR Quantitative Tissue Analysis Single Organ With Dx Exam","PX-61000169","CDM","0649T","CPT","0614","RC","","","","both","","","7036.00","5277.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1106.09","","APC Price ($1,128.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1106.21","1067.03","1110.72","1 through 10","1106.09","6684.2","other","OPPS APC"
"MR Quantitative Tissue Analysis Single Organ With Dx Exam","PX-61000169","CDM","0649T","CPT","0614","RC","","","","both","","","7036.00","5277.00","WELLPOINT [1015]","HB AMC WELLPOINT","5191.16","73.78","","5079.72","5079.72","5079.72","1 through 10","1106.09","6684.2","percent of total billed charges",""
"MR Quantitative Tissue Analysis Single Organ With Dx Exam","PX-61000169","CDM","0649T","CPT","0614","RC","","","","outpatient","","","7036.00","5277.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3518.00","50","","3575.25","3575.25","3575.25","1 through 10","477.58","5804.7","percent of total billed charges",""
"MR Quantitative Tissue Analysis Single Organ With Dx Exam","PX-61000169","CDM","0649T","CPT","0614","RC","","","","outpatient","","","7036.00","5277.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","3869.80","55","","6823.00","6823.00","6823.00","1 through 10","477.58","5804.7","percent of total billed charges",""
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","both","","","5132.00","3849.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","463.54","1 through 10","402.91","3951.64","other","OPPS APC"
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","both","","","5132.00","3849.00","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","952.43","1015.16","44","402.91","3951.64","other","OPPS APC"
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","both","","","5132.00","3849.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","997.86","997.86","997.86","1 through 10","402.91","3951.64","other","OPPS APC"
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","both","","","5132.00","3849.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","997.66","997.66","997.66","1 through 10","402.91","3951.64","other","OPPS APC"
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","both","","","5132.00","3849.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","938.39","415.63","999.86","1 through 10","402.91","3951.64","other","OPPS APC"
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","both","","","5132.00","3849.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1610.42","31.38","","2188.39","2188.39","2188.39","1 through 10","402.91","3951.64","percent of total billed charges",""
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","outpatient","","","5132.00","3849.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1610.42","31.38","","1527.94","1527.94","2188.39","13","385.88","2681.98","percent of total billed charges",""
"Mra Abdomen W/O Contrast","PX-61000102","CDM","C8901","HCPCS","0618","RC","","","","both","","","3584.00","2688.00","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","2759.68","other","OPPS APC"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","both","","","4756.00","3567.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1735.94","36.5","","1856.42","1856.42","1856.42","1 through 10","292.92","4518.2","percent of total billed charges",""
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","both","","","4756.00","3567.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1821.55","38.3","","5838.03","1946.01","5838.03","11","292.92","4518.2","percent of total billed charges",""
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","both","","","4756.00","3567.00","TRICARE [160005]","HB BWH TRICARE","4518.20","95","","313.98","313.98","313.98","1 through 10","292.92","4518.2","percent of total billed charges",""
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","both","","","4756.00","3567.00","WELLPOINT [1015]","HB AMC WELLPOINT","3508.98","73.78","","3705.38","3705.38","3705.38","1 through 10","292.92","4518.2","percent of total billed charges",""
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4756.00","3567.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2021.29","","Case rate ($2,021.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","2021.29","1959.53","2021.29","14","385.88","2485.49","other","Multiple Imaging"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4756.00","3567.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2021.29","","Case rate ($2,021.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","2021.29","1959.53","2021.29","38","385.88","2485.49","other","Multiple Imaging"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4756.00","3567.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1153.78","576.89","1153.78","1 through 10","385.88","2485.49","other","Multiple Radiology"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4756.00","3567.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","524.79","524.79","1007.14","11","385.88","2485.49","other","Multiple Radiology"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4756.00","3567.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","549.88","549.88","549.88","1 through 10","385.88","2485.49","other","Multiple Radiology"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4756.00","3567.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1311.99","1311.99","1311.99","1 through 10","385.88","2485.49","other","Multiple Radiology"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4756.00","3567.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1153.78","1153.78","1153.78","1 through 10","385.88","2485.49","other","Multiple Radiology"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4756.00","3567.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","2488.50","2488.50","2488.50","1 through 10","385.88","2485.49","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Mra Chest W&W/O Contrast","PX-61000105","CDM","C8911","HCPCS","0618","RC","","","","both","","","6115.00","4586.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","5930.00","1 through 10","402.91","4708.55","other","OPPS APC"
"Mra Chest W&W/O Contrast","PX-61000105","CDM","C8911","HCPCS","0618","RC","","","","both","","","6115.00","4586.25","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","848.22","78","402.91","4708.55","other","OPPS APC"
"Mra Chest W&W/O Contrast","PX-61000105","CDM","C8911","HCPCS","0618","RC","","","","both","","","6115.00","4586.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.43","418.43","418.43","1 through 10","402.91","4708.55","other","OPPS APC"
"Mra Chest W&W/O Contrast","PX-61000105","CDM","C8911","HCPCS","0618","RC","","","","both","","","6115.00","4586.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.09","420.09","420.09","1 through 10","402.91","4708.55","other","OPPS APC"
"Mra Chest W&W/O Contrast","PX-61000105","CDM","C8911","HCPCS","0618","RC","","","","both","","","6115.00","4586.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.13","411.34","420.63","1 through 10","402.91","4708.55","other","OPPS APC"
"Mra Chest W&W/O Contrast","PX-61000105","CDM","C8911","HCPCS","0618","RC","","","","both","","","6115.00","4586.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1918.89","31.38","","2607.42","2607.42","2607.42","1 through 10","402.91","4708.55","percent of total billed charges",""
"Mra Chest W&W/O Contrast","PX-61000105","CDM","C8911","HCPCS","0618","RC","","","","outpatient","","","6115.00","4586.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1918.89","31.38","","1820.51","1820.51","2607.42","1 through 10","385.88","3195.7","percent of total billed charges",""
"Mra Chest W/O Contrast","PX-61000104","CDM","C8910","HCPCS","0618","RC","","","","both","","","3670.00","2752.50","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","2825.9","other","OPPS APC"
"Mra Head W&W/O Cont","PX-61000083","CDM","70546","CPT","0615","RC","","","","outpatient","","","5673.00","4254.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1049.59","1049.59","1 through 10","385.88","2964.71","other","Multiple Radiology"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4884.00","3663.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","267.44","263.16","267.44","1 through 10","272.7","3760.68","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4884.00","3663.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","263.16","263.16","263.16","1 through 10","272.7","3760.68","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4884.00","3663.00","FALLON HEALTH [1008]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1000.86","1000.86","1000.86","1 through 10","272.7","3760.68","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4884.00","3663.00","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","952.43","20","272.7","3760.68","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4884.00","3663.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1782.66","36.5","","1766.53","1501.31","1766.53","1 through 10","272.7","3760.68","percent of total billed charges",""
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4884.00","3663.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1870.57","38.3","","1851.78","1799.68","5555.34","1 through 10","272.7","3760.68","percent of total billed charges",""
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4884.00","3663.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","996.36","996.36","996.36","1 through 10","272.7","3760.68","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4884.00","3663.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","265.40","999.86","19","272.7","3760.68","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4884.00","3663.00","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3206.27","3206.27","3206.27","1 through 10","230.56","2552.38","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4884.00","3663.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","468.53","966.58","1 through 10","230.56","2552.38","other","Multiple Imaging"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4884.00","3663.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","483.29","966.58","18","230.56","2552.38","other","Multiple Imaging"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4884.00","3663.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","313.56","313.56","5363.12","13","230.56","2552.38","other","Multiple Radiology"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4884.00","3663.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","328.55","657.10","1 through 10","230.56","2552.38","other","Multiple Radiology"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4884.00","3663.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","344.69","332.00","665.62","11","230.56","2552.38","other","Multiple Radiology"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4884.00","3663.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1532.60","31.38","","1453.95","1453.95","2082.42","1 through 10","230.56","2552.38","percent of total billed charges",""
"Mra Lwr Ext W&W/O Cont","PX-61000092","CDM","C8914","HCPCS","0616","RC","","","","both","","","5998.00","4498.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","995.06","933.39","998.92","1 through 10","402.91","4618.46","other","OPPS APC"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","both","","","5670.00","4252.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","998.92","998.92","998.92","1 through 10","402.91","4365.9","other","OPPS APC"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","both","","","5670.00","4252.50","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","402.91","4365.9","other","OPPS APC"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","both","","","5670.00","4252.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2069.55","36.5","","1742.87","1742.87","2050.75","1 through 10","402.91","4365.9","percent of total billed charges",""
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","both","","","5670.00","4252.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2171.61","38.3","","2149.72","2149.72","2149.72","1 through 10","402.91","4365.9","percent of total billed charges",""
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","5670.00","4252.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3722.15","3722.15","3722.15","1 through 10","385.88","2963.14","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","5670.00","4252.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","808.87","784.16","1617.73","1 through 10","385.88","2963.14","other","Multiple Imaging"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","5670.00","4252.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","808.87","784.16","1617.73","25","385.88","2963.14","other","Multiple Imaging"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","5670.00","4252.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","524.79","7597.18","1 through 10","385.88","2963.14","other","Multiple Radiology"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","5670.00","4252.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","528.65","528.65","549.88","1 through 10","385.88","2963.14","other","Multiple Radiology"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","5670.00","4252.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1311.99","1311.99","1311.99","1 through 10","385.88","2963.14","other","Multiple Radiology"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","5670.00","4252.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1153.78","576.89","1153.78","1 through 10","385.88","2963.14","other","Multiple Radiology"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","5670.00","4252.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1779.25","31.38","","2417.47","2417.47","2417.47","1 through 10","385.88","2963.14","percent of total billed charges",""
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4963.00","3722.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","452.98","417.32","507.47","1 through 10","402.91","3821.51","other","OPPS APC"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4963.00","3722.25","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","402.91","3821.51","other","OPPS APC"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4963.00","3722.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1811.50","36.5","","1795.25","1525.72","5385.75","12","402.91","3821.51","percent of total billed charges",""
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4963.00","3722.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1900.83","38.3","","1881.88","1881.88","5645.64","17","402.91","3821.51","percent of total billed charges",""
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4963.00","3722.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.63","418.63","418.63","1 through 10","402.91","3821.51","other","OPPS APC"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4963.00","3722.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.13","417.13","417.13","1 through 10","402.91","3821.51","other","OPPS APC"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4963.00","3722.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1557.39","31.38","","1477.59","1477.59","1477.59","1 through 10","402.91","3821.51","percent of total billed charges",""
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4963.00","3722.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","415.63","415.63","415.63","1 through 10","402.91","3821.51","other","OPPS APC"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4963.00","3722.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","808.87","784.16","1568.31","14","385.88","2593.66","other","Multiple Imaging"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4963.00","3722.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","808.87","784.16","1617.73","38","385.88","2593.66","other","Multiple Imaging"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4963.00","3722.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","524.79","524.79","4673.00","1 through 10","385.88","2593.66","other","Multiple Radiology"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4963.00","3722.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","549.88","1099.76","1 through 10","385.88","2593.66","other","Multiple Radiology"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4963.00","3722.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","576.89","576.89","1153.78","1 through 10","385.88","2593.66","other","Multiple Radiology"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4963.00","3722.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1557.39","31.38","","2116.28","2116.28","2116.28","1 through 10","385.88","2593.66","percent of total billed charges",""
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4963.00","3722.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1557.39","31.38","","1477.59","1477.59","1477.59","1 through 10","385.88","2593.66","percent of total billed charges",""
"Mra Neck W/O Cont","PX-61000084","CDM","70547","CPT","0615","RC","","","","both","","","4697.00","3522.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","3616.69","other","OPPS APC"
"Mra Neck W/O Cont","PX-61000084","CDM","70547","CPT","0615","RC","","","","both","","","4697.00","3522.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1714.41","36.5","","1699.02","1443.94","1699.02","1 through 10","272.7","3616.69","percent of total billed charges",""
"Mra Neck W/O Cont","PX-61000084","CDM","70547","CPT","0615","RC","","","","both","","","4697.00","3522.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.52","284.52","284.52","1 through 10","272.7","3616.69","other","OPPS APC"
"Mra Neck W/O Cont","PX-61000084","CDM","70547","CPT","0615","RC","","","","outpatient","","","4697.00","3522.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","483.29","483.29","966.58","1 through 10","230.56","2454.65","other","Multiple Imaging"
"Mra Neck W/O Cont","PX-61000084","CDM","70547","CPT","0615","RC","","","","outpatient","","","4697.00","3522.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","483.29","468.53","483.29","1 through 10","230.56","2454.65","other","Multiple Imaging"
"Mra Neck W/O Cont","PX-61000084","CDM","70547","CPT","0615","RC","","","","outpatient","","","4697.00","3522.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","313.56","313.56","313.56","1 through 10","230.56","2454.65","other","Multiple Radiology"
"Mra Neck W/O Cont","PX-61000084","CDM","70547","CPT","0615","RC","","","","outpatient","","","4697.00","3522.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1263.47","328.55","1263.47","1 through 10","230.56","2454.65","other","Multiple Radiology"
"Mra Neck W/O Cont","PX-61000084","CDM","70547","CPT","0615","RC","","","","outpatient","","","4697.00","3522.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1473.92","31.38","","1398.39","1398.39","1398.39","1 through 10","230.56","2454.65","percent of total billed charges",""
"Mra Pelvis W&W/O Contrast","PX-61000109","CDM","C8920","HCPCS","0618","RC","","","","both","","","5973.00","4479.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","539.45","539.45","539.45","1 through 10","402.91","4599.21","other","OPPS APC"
"Mra Pelvis W&W/O Contrast","PX-61000109","CDM","C8920","HCPCS","0618","RC","","","","both","","","5973.00","4479.75","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","848.22","424.11","848.22","1 through 10","402.91","4599.21","other","OPPS APC"
"Mra Pelvis W&W/O Contrast","PX-61000109","CDM","C8920","HCPCS","0618","RC","","","","both","","","5973.00","4479.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1874.33","31.38","","2546.74","2546.74","2546.74","1 through 10","402.91","4599.21","percent of total billed charges",""
"Mra Pelvis W&W/O Contrast","PX-61000109","CDM","C8920","HCPCS","0618","RC","","","","outpatient","","","5973.00","4479.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1874.33","31.38","","1778.14","1778.14","2546.74","1 through 10","385.88","3121.49","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","998.92","160","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","4679.92","71.8","","4538.48","4538.48","4538.48","1 through 10","402.91","5018.86","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4275.81","65.6","","4279.32","4279.32","4279.32","1 through 10","402.91","5018.86","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4562.60","70","","4212.09","424.11","13653.36","1 through 10","402.91","5018.86","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","530.09","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","420.63","418.88","925.18","1 through 10","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","411.34","419.70","21","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","FALLON HEALTH [1008]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1264.89","1261.89","1272.33","1 through 10","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","385.53","417.32","1 through 10","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","5018.86","77","","4867.17","4867.17","4867.17","1 through 10","402.91","5018.86","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","421.63","421.63","421.63","1 through 10","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","HUMANA [1012]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.02","418.17","421.09","1 through 10","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4236.70","65","","4108.65","4108.65","4108.65","1 through 10","402.91","5018.86","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","418.17","418.17","1 through 10","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1025","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2020.58","31","","1953.19","1953.19","1953.19","1 through 10","402.91","5018.86","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2379.07","36.5","","2357.73","2003.76","2357.73","56","402.91","5018.86","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2496.39","38.3","","2471.51","2401.98","2471.51","176","402.91","5018.86","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.63","414.54","418.83","32","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","MOLINA [1014]","HB BWH MOLINA","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","841.43","832.74","841.43","16","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","5018.86","77","","1814.13","580.84","4930.38","1 through 10","402.91","5018.86","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","TRICARE [160005]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","402.90","402.90","424.11","1 through 10","402.91","5018.86","other","Tricare OPPS"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","419.73","424.11","1 through 10","402.91","5018.86","other","Tricare OPPS"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","415.63","1251.96","84","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1453.83","1453.83","1453.83","1 through 10","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2045.35","31.38","","1940.55","1940.55","2779.34","1 through 10","402.91","5018.86","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.23","415.63","420.63","226","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2045.35","31.38","","2779.34","2779.34","2779.34","1 through 10","402.91","5018.86","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","6518.00","4888.50","WELLSENSE [1003]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","428.35","428.35","428.35","1 through 10","402.91","5018.86","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","4279.32","4279.32","4279.32","11","385.88","3406.31","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1617.73","1568.31","1617.73","271","385.88","3406.31","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3406.31","52.26","","1617.73","1617.73","3911.44","1 through 10","385.88","3406.31","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1617.73","1568.31","1617.73","651","385.88","3406.31","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1311.99","1153.78","1311.99","11","385.88","3406.31","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","524.79","1049.59","174","385.88","3406.31","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","549.88","1099.76","67","385.88","3406.31","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1311.99","1311.99","1311.99","1 through 10","385.88","3406.31","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1057.31","1099.76","1 through 10","385.88","3406.31","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1153.78","576.89","1153.78","46","385.88","3406.31","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","4930.38","4930.38","4930.38","1 through 10","385.88","3406.31","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","2045.35","31.38","","1940.55","1940.55","1940.55","1 through 10","385.88","3406.31","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2045.35","31.38","","1940.55","1940.55","5053.02","1 through 10","385.88","3406.31","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","6518.00","4888.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2045.35","31.38","","1940.55","1940.55","2779.34","90","385.88","3406.31","percent of total billed charges",""
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","4330.00","3247.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","11","272.7","3334.1","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","4330.00","3247.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","3334.1","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","4330.00","3247.50","FALLON HEALTH [1008]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","3334.1","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","4330.00","3247.50","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","281.32","281.32","1 through 10","272.7","3334.1","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","4330.00","3247.50","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","2009.42","58","272.7","3334.1","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","4330.00","3247.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1342.30","31","","1297.49","1297.49","1297.49","1 through 10","272.7","3334.1","percent of total billed charges",""
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","4330.00","3247.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1658.39","38.3","","1641.81","1641.81","1641.81","1 through 10","272.7","3334.1","percent of total billed charges",""
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","4330.00","3247.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.52","281.32","284.52","1 through 10","272.7","3334.1","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","4330.00","3247.50","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","287.06","287.06","287.06","1 through 10","272.7","3334.1","other","Tricare OPPS"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","4330.00","3247.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","262.09","283.32","1 through 10","272.7","3334.1","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","4330.00","3247.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","262.10","286.32","17","272.7","3334.1","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","4330.00","3247.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","468.53","966.58","12","230.56","2262.86","other","Multiple Imaging"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","4330.00","3247.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","483.29","966.58","27","230.56","2262.86","other","Multiple Imaging"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","4330.00","3247.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","689.37","689.37","689.37","1 through 10","230.56","2262.86","other","Multiple Radiology"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","4330.00","3247.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","313.56","627.12","1 through 10","230.56","2262.86","other","Multiple Radiology"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","4330.00","3247.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","328.55","328.55","328.55","1 through 10","230.56","2262.86","other","Multiple Radiology"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","4330.00","3247.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","753.93","753.93","753.93","1 through 10","230.56","2262.86","other","Multiple Radiology"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","4330.00","3247.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1358.75","31.38","","1289.09","1289.09","1846.30","1 through 10","230.56","2262.86","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","998.92","235","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4251.54","65.6","","436.41","436.41","436.41","1 through 10","402.91","4990.37","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4536.70","70","","5091.18","4525.20","15335.40","17","402.91","4990.37","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","CHAMPVA [160001]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1015.16","1015.16","1015.16","1 through 10","402.91","4990.37","other","Tricare OPPS"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","CIGNA [1006]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","415.63","415.63","415.63","1 through 10","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","415.63","998.92","73","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","ELDER SERVICES [1037]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.73","419.73","419.73","1 through 10","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","FALLON HEALTH [1008]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1246.89","415.63","3045.48","21","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","337.52","419.02","1 through 10","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","4990.37","77","","4839.45","4839.45","4839.45","1 through 10","402.91","4990.37","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","420.63","415.63","421.63","1 through 10","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","HUMANA [1012]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","415.63","1583.97","24","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4212.65","65","","4085.25","4085.25","4085.25","1 through 10","402.91","4990.37","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","4666.32","72","","4525.20","4525.20","4525.20","1 through 10","402.91","4990.37","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","415.63","1000.95","1 through 10","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1272.33","1959","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2009.11","31","","1942.07","1942.07","5826.21","11","402.91","4990.37","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2365.57","36.5","","2344.31","1992.35","5977.05","144","402.91","4990.37","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2482.22","38.3","","2457.44","2457.44","4776.60","305","402.91","4990.37","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.83","414.54","998.06","46","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","MOLINA [1014]","HB BWH MOLINA","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","841.43","839.46","2101.22","27","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4990.37","77","","4902.30","1803.80","6285.00","1 through 10","402.91","4990.37","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","TRICARE [160005]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","402.90","964.40","24","402.91","4990.37","other","Tricare OPPS"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","402.91","4990.37","other","Tricare OPPS"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","415.63","1255.29","181","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1445.55","1445.55","1445.55","1 through 10","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2033.74","31.38","","2763.51","1929.50","2859.68","1 through 10","402.91","4990.37","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","415.14","937.19","401","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","6481.00","4860.75","WELLSENSE [1003]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","428.35","428.35","428.35","1 through 10","402.91","4990.37","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","4254.95","3004.23","4254.95","25","385.88","3386.97","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1617.73","1568.31","1617.73","614","385.88","3386.97","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3386.97","52.26","","3889.16","1617.73","3889.16","1 through 10","385.88","3386.97","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1617.73","1568.31","1617.73","1495","385.88","3386.97","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1311.99","1153.78","1311.99","20","385.88","3386.97","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1049.59","1049.59","412","385.88","3386.97","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1057.31","1099.76","128","385.88","3386.97","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1311.99","656.00","1311.99","15","385.88","3386.97","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","1 through 10","385.88","3386.97","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1153.78","1110.22","1153.78","97","385.88","3386.97","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","4902.30","4902.30","4902.30","1 through 10","385.88","3386.97","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","2033.74","31.38","","4699.16","1804.97","6285.00","1 through 10","385.88","3386.97","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1261.83","1261.83","1261.83","1 through 10","385.88","3386.97","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2033.74","31.38","","2763.51","1929.50","2763.51","14","385.88","3386.97","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2033.74","31.38","","1929.50","1929.50","2763.51","203","385.88","3386.97","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","6481.00","4860.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1111.33","1111.33","1153.78","1 through 10","385.88","3386.97","other","Multiple Radiology"
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","both","","","5693.00","4269.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","418.94","1 through 10","402.91","4383.61","other","OPPS APC"
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","both","","","5693.00","4269.75","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","11","402.91","4383.61","other","OPPS APC"
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","both","","","5693.00","4269.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2077.95","36.5","","6177.99","3891.36","6177.99","1 through 10","402.91","4383.61","percent of total billed charges",""
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","both","","","5693.00","4269.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2180.42","38.3","","6293.94","2097.98","6293.94","1 through 10","402.91","4383.61","percent of total billed charges",""
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","both","","","5693.00","4269.75","TRICARE [160005]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","402.90","402.90","402.90","1 through 10","402.91","4383.61","other","Tricare OPPS"
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","outpatient","","","5693.00","4269.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1568.31","1568.31","1617.73","1 through 10","385.88","2975.16","other","Multiple Imaging"
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","outpatient","","","5693.00","4269.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1617.73","1568.31","1617.73","24","385.88","2975.16","other","Multiple Imaging"
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","outpatient","","","5693.00","4269.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1007.15","1049.59","1 through 10","385.88","2975.16","other","Multiple Radiology"
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","outpatient","","","5693.00","4269.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","1 through 10","385.88","2975.16","other","Multiple Radiology"
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","outpatient","","","5693.00","4269.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1786.46","31.38","","2427.58","1694.95","2427.58","1 through 10","385.88","2975.16","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","631.33","95","272.7","3960.88","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3343.60","65","","3242.20","3242.20","3242.20","1 through 10","272.7","3960.88","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","631.33","25","272.7","3960.88","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","FALLON HEALTH [1008]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","802.32","287.06","802.32","1 through 10","272.7","3960.88","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","223.24","283.04","1 through 10","272.7","3960.88","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","3960.88","77","","3840.76","3840.76","3840.76","1 through 10","272.7","3960.88","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","637.47","287.06","1004.63","1 through 10","272.7","3960.88","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","263.70","283.04","1 through 10","272.7","3960.88","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","641.60","983","272.7","3960.88","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1594.64","31","","1541.29","1541.29","1541.29","1 through 10","272.7","3960.88","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1877.56","36.5","","1860.52","1581.20","1860.52","50","272.7","3960.88","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1970.15","38.3","","1950.31","1895.44","1950.31","117","272.7","3960.88","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.52","281.32","284.52","23","272.7","3960.88","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","MOLINA [1014]","HB BWH MOLINA","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","569.53","534.88","569.53","1 through 10","272.7","3960.88","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3960.88","77","","330.12","330.12","330.12","1 through 10","272.7","3960.88","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","272.71","272.71","609.52","11","272.7","3960.88","other","Tricare OPPS"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","267.44","267.44","287.06","1 through 10","272.7","3960.88","other","Tricare OPPS"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","286.32","282.47","858.96","56","272.7","3960.88","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1147.24","1147.24","1147.24","1 through 10","272.7","3960.88","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1614.19","31.38","","1531.32","1531.32","2269.54","1 through 10","272.7","3960.88","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","267.10","287.06","191","272.7","3960.88","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","5144.00","3858.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1614.19","31.38","","1531.32","1531.32","1531.32","1 through 10","272.7","3960.88","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3376.88","3376.88","3376.88","1 through 10","230.56","2688.25","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","AETNA [1001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","631.73","631.73","631.73","1 through 10","230.56","2688.25","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","966.58","937.05","966.58","259","230.56","2688.25","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2688.25","52.26","","3086.57","3086.57","3086.57","1 through 10","230.56","2688.25","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","966.58","937.05","966.58","523","230.56","2688.25","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","783.90","689.37","783.90","1 through 10","230.56","2688.25","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","627.12","627.12","120","230.56","2688.25","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","50","230.56","2688.25","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","783.90","783.90","1035.21","1 through 10","230.56","2688.25","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","230.56","2688.25","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","689.37","344.69","689.37","26","230.56","2688.25","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","3890.64","3890.64","3890.64","1 through 10","230.56","2688.25","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","753.93","376.97","1531.32","1 through 10","230.56","2688.25","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1614.19","31.38","","1531.32","1531.32","1531.32","1 through 10","230.56","2688.25","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1614.19","31.38","","1531.32","1531.32","2193.22","62","230.56","2688.25","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","5144.00","3858.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","689.37","689.37","689.37","1 through 10","230.56","2688.25","other","Multiple Radiology"
"MRI Brain W/O Cont|REDUCED SERVICES","PX-61000016","CDM","70551","CPT","0611","RC","","","52","both","","","5144.00","3858.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","141.23","141.23","141.23","1 through 10","272.7","358.78","other","OPPS APC"
"MRI Brain W/O Cont|REDUCED SERVICES","PX-61000016","CDM","70551","CPT","0611","RC","","","52","both","","","5144.00","3858.00","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.53","143.53","143.53","1 through 10","272.7","358.78","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","6480.00","4860.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","17","402.91","4989.6","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","6480.00","4860.00","CHAMPVA [160001]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","402.91","4989.6","other","Tricare OPPS"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","6480.00","4860.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","360.56","360.56","360.56","1 through 10","402.91","4989.6","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","6480.00","4860.00","HUMANA [1012]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.87","418.17","419.87","1 through 10","402.91","4989.6","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","6480.00","4860.00","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","147","402.91","4989.6","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","6480.00","4860.00","TRICARE [160005]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","848.22","402.90","848.22","1 through 10","402.91","4989.6","other","Tricare OPPS"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","6480.00","4860.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1246.89","417.13","1261.89","19","402.91","4989.6","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","6480.00","4860.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","413.01","424.11","44","402.91","4989.6","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","5526.00","4144.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","295.64","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","295.38","295.38","295.38","1 through 10","272.7","4255.02","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","5526.00","4144.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","4255.02","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","5526.00","4144.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","4255.02","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","5526.00","4144.50","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","13","272.7","4255.02","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","5526.00","4144.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2016.99","36.5","","1998.91","1939.96","1998.91","1 through 10","272.7","4255.02","percent of total billed charges",""
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","5526.00","4144.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2116.46","38.3","","2095.37","2036.42","2095.37","1 through 10","272.7","4255.02","percent of total billed charges",""
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","5526.00","4144.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4255.02","77","","5359.00","5359.00","5359.00","1 through 10","272.7","4255.02","percent of total billed charges",""
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","5526.00","4144.50","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","272.71","272.71","272.71","1 through 10","272.7","4255.02","other","Tricare OPPS"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","5526.00","4144.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","852.14","286.32","852.14","1 through 10","272.7","4255.02","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","5526.00","4144.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","281.32","287.06","1 through 10","272.7","4255.02","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","5526.00","4144.50","WELLPOINT [1015]","HB AMC WELLPOINT","4077.08","73.78","","3989.78","3989.78","3989.78","1 through 10","272.7","4255.02","percent of total billed charges",""
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","5526.00","4144.50","AETNA [1001]","HB AMC AETNA HMO","3857.15","69.8","","2561.60","2561.60","3628.04","1 through 10","230.56","4442.9","percent of total billed charges",""
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","5526.00","4144.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","937.05","966.58","1 through 10","230.56","4442.9","other","Multiple Imaging"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","5526.00","4144.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","937.05","966.58","32","230.56","4442.9","other","Multiple Imaging"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","5526.00","4144.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","627.12","1881.36","1 through 10","230.56","4442.9","other","Multiple Radiology"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","5526.00","4144.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","689.37","1 through 10","230.56","4442.9","other","Multiple Radiology"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","5526.00","4144.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","1035.21","1035.21","1035.21","1 through 10","230.56","4442.9","other","Multiple Radiology"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","5526.00","4144.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","689.37","689.37","689.37","1 through 10","230.56","4442.9","other","Multiple Radiology"
"MRI Breast Unilat W&W/O Cont","PX-61000080","CDM","C8905","HCPCS","0614","RC","","","","both","","","9216.00","6912.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8937.00","8937.00","8937.00","1 through 10","402.91","7096.32","other","OPPS APC"
"MRI Breast Unilat W&W/O Cont","PX-61000080","CDM","C8905","HCPCS","0614","RC","","","","both","","","9216.00","6912.00","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","402.91","7096.32","other","OPPS APC"
"MRI Breast Unilat W&W/O Cont","PX-61000080","CDM","C8905","HCPCS","0614","RC","","","","both","","","9216.00","6912.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","420.63","420.63","1 through 10","402.91","7096.32","other","OPPS APC"
"MRI Breast Unilat W&W/O Cont","PX-61000080","CDM","C8905","HCPCS","0614","RC","","","","outpatient","","","9216.00","6912.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2891.98","31.38","","2743.66","2743.66","2743.66","1 through 10","385.88","7409.66","percent of total billed charges",""
"MRI Breast Unilat W/O Cont","PX-61000079","CDM","77046","CPT","0614","RC","","","","both","","","5501.00","4125.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","287.06","1 through 10","272.7","4235.77","other","OPPS APC"
"MRI Breast Unilat W/O Cont","PX-61000079","CDM","77046","CPT","0614","RC","","","","both","","","5501.00","4125.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2106.88","38.3","","2085.99","2085.99","2085.99","1 through 10","272.7","4235.77","percent of total billed charges",""
"MRI Breast Unilat W/O Cont","PX-61000079","CDM","77046","CPT","0614","RC","","","","both","","","5501.00","4125.75","WELLPOINT [1015]","HB AMC WELLPOINT","4058.64","73.78","","3971.91","3971.91","3971.91","1 through 10","272.7","4235.77","percent of total billed charges",""
"MRI Breast Unilat W/O Cont","PX-61000079","CDM","77046","CPT","0614","RC","","","","outpatient","","","5501.00","4125.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","937.05","937.05","1 through 10","230.56","4422.8","other","Multiple Imaging"
"MRI Breast Unilat W/O Cont","PX-61000079","CDM","77046","CPT","0614","RC","","","","outpatient","","","5501.00","4125.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","627.12","627.12","1 through 10","230.56","4422.8","other","Multiple Radiology"
"MRI Breast Unilat W/O Cont","PX-61000079","CDM","77046","CPT","0614","RC","","","","outpatient","","","5501.00","4125.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1726.21","31.38","","1637.85","1637.85","1637.85","1 through 10","230.56","4422.8","percent of total billed charges",""
"MRI Breast W/Out&With Contrast W/Cad Unilateral","PX-61000158","CDM","77048","CPT","0610","RC","","","","both","","","2315.00","1736.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","886.65","38.3","","3570.61","3470.16","3570.61","1 through 10","274.43","2199.25","percent of total billed charges",""
"MRI Breast W/Out&With Contrast W/Cad Unilateral","PX-61000158","CDM","77048","CPT","0610","RC","","","","outpatient","","","2315.00","1736.25","AETNA [1001]","HB AMC AETNA HMO","1615.87","69.8","","6182.36","6182.36","6182.36","1 through 10","385.88","3658.87","percent of total billed charges",""
"MRI Breast W/Out&With Contrast W/Cad Unilateral","PX-61000158","CDM","77048","CPT","0610","RC","","","","outpatient","","","2315.00","1736.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1922.41","","Case rate ($1,922.41). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1922.41","1922.41","1922.41","1 through 10","385.88","3658.87","other","Multiple Imaging"
"MRI Breast W/Out&With Contrast W/Cad Unilateral","PX-61000158","CDM","77048","CPT","0610","RC","","","","outpatient","","","2315.00","1736.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1049.59","1049.59","1 through 10","385.88","3658.87","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2348.00","1761.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1643.60","70","","5012.59","5012.59","5012.59","1 through 10","271.02","2230.6","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2348.00","1761.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1807.96","77","","4988.83","4988.83","4988.83","1 through 10","271.02","2230.6","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2348.00","1761.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1526.20","65","","4211.35","4211.35","4211.35","1 through 10","271.02","2230.6","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2348.00","1761.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","727.88","31","","2002.01","2002.01","2002.01","1 through 10","271.02","2230.6","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2348.00","1761.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","857.02","36.5","","2416.67","2053.84","3642.57","33","271.02","2230.6","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2348.00","1761.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","899.28","38.3","","2533.29","2533.29","2533.29","118","271.02","2230.6","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2348.00","1761.00","WELLPOINT [1015]","HB AMC WELLPOINT","1732.35","73.78","","4823.62","4823.62","11302.62","43","271.02","2230.6","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","AETNA [1001]","HB AMC AETNA HMO","1638.90","69.8","","4386.28","3096.96","5053.62","88","385.88","4963.63","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","AETNA [1001]","HB AMC AETNA PPO","1887.79","80.4","","5053.62","3096.96","6712.11","1 through 10","385.88","4963.63","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1912.99","","Case rate ($1,912.99). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1912.99","1854.55","1912.99","215","385.88","4963.63","other","Multiple Imaging"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1227.06","52.26","","4009.21","4009.21","4009.21","1 through 10","385.88","4963.63","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1912.99","","Case rate ($1,912.99). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1912.99","1854.55","1912.99","460","385.88","4963.63","other","Multiple Imaging"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1311.99","1153.78","1311.99","1 through 10","385.88","4963.63","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1049.59","1049.59","121","385.88","4963.63","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","64","385.88","4963.63","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","1732.60","1732.60","1732.60","1 through 10","385.88","4963.63","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1311.99","1311.99","1311.99","1 through 10","385.88","4963.63","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1057.31","1099.76","1 through 10","385.88","4963.63","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1153.78","1142.06","1153.78","23","385.88","4963.63","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1887.79","80.4","","3239.50","3239.50","3239.50","1 through 10","385.88","4963.63","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","736.80","31.38","","1989.05","1989.05","1989.05","1 through 10","385.88","4963.63","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","736.80","31.38","","1989.05","1989.05","2848.82","1 through 10","385.88","4963.63","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1044.89","1044.89","1044.89","1 through 10","385.88","4963.63","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","736.80","31.38","","1989.05","1989.05","1989.05","1 through 10","385.88","4963.63","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","736.80","31.38","","1989.05","1989.05","2848.82","54","385.88","4963.63","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2348.00","1761.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1111.33","1111.33","1111.33","1 through 10","385.88","4963.63","other","Multiple Radiology"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","998.92","417.32","6259.00","1 through 10","402.91","4969.58","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4517.80","70","","4506.48","4506.48","4506.48","1 through 10","402.91","4969.58","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","937.19","417.32","998.92","1 through 10","402.91","4969.58","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","FALLON HEALTH [1008]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","1000.86","1015.16","1 through 10","402.91","4969.58","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","4969.58","77","","4819.43","4819.43","4819.43","1 through 10","402.91","4969.58","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","HUMANA [1012]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1002.98","1000.95","1002.98","1 through 10","402.91","4969.58","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4195.10","65","","4068.35","4068.35","4068.35","1 through 10","402.91","4969.58","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","424.11","1015.16","116","402.91","4969.58","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2000.74","31","","1934.03","1934.03","1934.03","1 through 10","402.91","4969.58","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2355.71","36.5","","2265.76","1984.10","2334.61","21","402.91","4969.58","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2471.88","38.3","","2447.27","2447.27","7341.81","46","402.91","4969.58","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.83","415.63","998.06","1 through 10","402.91","4969.58","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","TRICARE [160005]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","402.90","424.11","1 through 10","402.91","4969.58","other","Tricare OPPS"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2984.58","933.38","2984.58","12","402.91","4969.58","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1439.57","1439.57","1439.57","1 through 10","402.91","4969.58","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","6454.00","4840.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","938.39","415.63","998.56","18","402.91","4969.58","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","4237.34","2991.80","4237.34","1 through 10","385.88","3372.86","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","808.87","784.16","1617.73","106","385.88","3372.86","other","Multiple Imaging"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3372.86","52.26","","1936.54","1617.73","1936.54","1 through 10","385.88","3372.86","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","808.87","784.16","1617.73","250","385.88","3372.86","other","Multiple Imaging"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1153.78","576.89","1921.51","1 through 10","385.88","3372.86","other","Multiple Radiology"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","524.79","524.79","1049.59","61","385.88","3372.86","other","Multiple Radiology"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","549.88","549.88","3299.28","25","385.88","3372.86","other","Multiple Radiology"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","656.00","656.00","656.00","1 through 10","385.88","3372.86","other","Multiple Radiology"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1142.54","576.89","1153.78","17","385.88","3372.86","other","Multiple Radiology"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","2025.27","31.38","","6259.00","6259.00","6259.00","1 through 10","385.88","3372.86","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2025.27","31.38","","2752.08","1921.51","2752.08","1 through 10","385.88","3372.86","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2025.27","31.38","","1921.51","1921.51","1921.51","37","385.88","3372.86","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","630.92","630.92","630.92","1 through 10","385.88","3372.86","other","Multiple Radiology"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","6454.00","4840.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","555.67","555.67","555.67","1 through 10","385.88","3372.86","other","Multiple Radiology"
"MRI C-Spine W/Cont","PX-61000025","CDM","72142","CPT","0612","RC","","","","both","","","5367.00","4025.25","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","424.11","1015.16","1 through 10","402.91","4132.59","other","OPPS APC"
"MRI C-Spine W/Cont","PX-61000025","CDM","72142","CPT","0612","RC","","","","outpatient","","","5367.00","4025.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1568.31","784.16","1568.31","1 through 10","385.88","2804.79","other","Multiple Imaging"
"MRI C-Spine W/Cont","PX-61000025","CDM","72142","CPT","0612","RC","","","","outpatient","","","5367.00","4025.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","784.16","784.16","1617.73","1 through 10","385.88","2804.79","other","Multiple Imaging"
"MRI C-Spine W/Cont","PX-61000025","CDM","72142","CPT","0612","RC","","","","outpatient","","","5367.00","4025.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","524.79","524.79","524.79","1 through 10","385.88","2804.79","other","Multiple Radiology"
"MRI C-Spine W/Cont","PX-61000025","CDM","72142","CPT","0612","RC","","","","outpatient","","","5367.00","4025.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","549.88","549.88","549.88","1 through 10","385.88","2804.79","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","263.16","631.33","44","272.7","3398.01","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3089.10","70","","272.71","272.71","272.71","1 through 10","272.7","3398.01","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","CHAMPVA [160001]","HB BWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","287.06","287.06","287.06","1 through 10","272.7","3398.01","other","Tricare OPPS"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","237.85","631.33","18","272.7","3398.01","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","ELDER SERVICES [1037]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","3398.01","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","263.70","263.70","263.70","1 through 10","272.7","3398.01","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.28","287.06","629.28","1 through 10","272.7","3398.01","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","641.60","365","272.7","3398.01","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1368.03","31","","1322.21","1322.21","1322.21","1 through 10","272.7","3398.01","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1610.75","36.5","","1596.07","1356.44","1596.07","39","272.7","3398.01","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1690.18","38.3","","1673.09","1626.02","1673.09","135","272.7","3398.01","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.32","265.29","631.97","19","272.7","3398.01","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","MOLINA [1014]","HB BWH MOLINA","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1272.93","1272.93","1272.93","1 through 10","272.7","3398.01","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3398.01","77","","3294.83","283.20","3294.83","1 through 10","272.7","3398.01","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","272.71","272.71","272.71","1 through 10","272.7","3398.01","other","Tricare OPPS"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.12","267.44","852.36","17","272.7","3398.01","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1384.80","31.38","","1881.48","406.37","1946.95","1 through 10","272.7","3398.01","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4413.00","3309.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","283.72","265.90","631.33","74","272.7","3398.01","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2896.88","2045.36","2896.88","1 through 10","230.56","2306.23","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","AETNA [1001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","315.87","315.87","315.87","1 through 10","230.56","2306.23","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","483.29","468.53","966.58","198","230.56","2306.23","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2306.23","52.26","","1323.93","1323.93","1323.93","1 through 10","230.56","2306.23","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","483.29","468.53","966.58","391","230.56","2306.23","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","CIGNA ALTERNATE [1018]","HB AMC TUFTS CIGNA CARELINK HYBRID","1393.31","","Case rate ($1,393.31). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1346.20","1346.20","1346.20","1 through 10","230.56","2306.23","other","Multiple Imaging MRI / MRA"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","689.37","391.95","783.90","1 through 10","230.56","2306.23","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","313.56","627.12","119","230.56","2306.23","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","328.55","657.10","46","230.56","2306.23","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","783.90","517.61","783.90","1 through 10","230.56","2306.23","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","328.55","657.10","1 through 10","230.56","2306.23","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","344.69","344.69","689.37","23","230.56","2306.23","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","753.93","376.97","753.93","1 through 10","230.56","2306.23","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1384.80","31.38","","1881.48","1881.48","1881.48","1 through 10","230.56","2306.23","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1384.80","31.38","","1313.65","1313.65","1881.48","42","230.56","2306.23","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4413.00","3309.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","664.01","344.69","664.01","1 through 10","230.56","2306.23","other","Multiple Radiology"
"MRI C-Spine W/O Cont|REDUCED SERVICES","PX-61000024","CDM","72141","CPT","0612","RC","","","52","both","","","4413.00","3309.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4279.00","4279.00","4279.00","1 through 10","272.7","358.78","other","OPPS APC"
"MRI C-Spine W/O Cont|REDUCED SERVICES","PX-61000024","CDM","72141","CPT","0612","RC","","","52","both","","","4413.00","3309.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","118.93","118.93","118.93","1 through 10","272.7","358.78","other","OPPS APC"
"MRI C-Spine W/O Cont|REDUCED SERVICES","PX-61000024","CDM","72141","CPT","0612","RC","","","52","both","","","4413.00","3309.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.53","143.53","143.53","1 through 10","272.7","358.78","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","413.01","419.06","50","402.91","3536.61","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","360.56","417.32","1 through 10","402.91","3536.61","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","FALLON HEALTH [1008]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","415.63","424.11","1 through 10","402.91","3536.61","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","3536.61","77","","3429.58","3429.58","3429.58","1 through 10","402.91","3536.61","percent of total billed charges",""
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","HUMANA [1012]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","418.17","418.17","1 through 10","402.91","3536.61","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2985.45","65","","2895.10","2895.10","2895.10","1 through 10","402.91","3536.61","percent of total billed charges",""
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","417.32","418.17","1 through 10","402.91","3536.61","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","357","402.91","3536.61","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1676.45","36.5","","1661.34","1411.92","1661.34","26","402.91","3536.61","percent of total billed charges",""
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1759.12","38.3","","1741.51","1741.51","5077.56","67","402.91","3536.61","percent of total billed charges",""
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.43","414.34","418.83","1 through 10","402.91","3536.61","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","MOLINA [1014]","HB BWH MOLINA","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","841.43","841.43","841.43","1 through 10","402.91","3536.61","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3536.61","77","","3474.12","1278.30","3474.12","1 through 10","402.91","3536.61","percent of total billed charges",""
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","TRICARE [160005]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","402.90","424.11","1 through 10","402.91","3536.61","other","Tricare OPPS"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","417.13","1257.31","26","402.91","3536.61","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.03","415.63","420.63","61","402.91","3536.61","other","OPPS APC"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","both","","","4593.00","3444.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1441.28","31.38","","1958.42","1958.42","1958.42","1 through 10","402.91","3536.61","percent of total billed charges",""
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3015.36","2129.01","3015.36","1 through 10","385.88","2400.3","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1617.73","1568.31","1617.73","125","385.88","2400.3","other","Multiple Imaging"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1617.73","1568.31","1617.73","249","385.88","2400.3","other","Multiple Imaging"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1367.38","1367.38","1367.38","1 through 10","385.88","2400.3","other","Multiple Radiology"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1007.15","1049.59","65","385.88","2400.3","other","Multiple Radiology"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1057.31","1099.76","25","385.88","2400.3","other","Multiple Radiology"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","1732.60","1732.60","1732.60","1 through 10","385.88","2400.3","other","Multiple Radiology"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1311.99","1311.99","1311.99","1 through 10","385.88","2400.3","other","Multiple Radiology"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","1 through 10","385.88","2400.3","other","Multiple Radiology"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1137.60","1097.88","1153.78","21","385.88","2400.3","other","Multiple Radiology"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","3474.12","2227.00","3474.12","1 through 10","385.88","2400.3","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1441.28","31.38","","1958.42","1635.48","1958.42","1 through 10","385.88","2400.3","percent of total billed charges",""
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1441.28","31.38","","1367.38","1367.38","1958.42","29","385.88","2400.3","percent of total billed charges",""
"MRI Card W/O&W Con","PX-61000070","CDM","75561","CPT","0614","RC","","","","outpatient","","","4593.00","3444.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1111.33","1111.33","1111.33","1 through 10","385.88","2400.3","other","Multiple Radiology"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","both","","","5751.00","4313.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","938.15","","APC Price ($938.15). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","923.23","859.90","923.23","1 through 10","891.33","4428.27","other","OPPS APC"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","both","","","5751.00","4313.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3772.66","65.6","","3775.63","3775.63","3775.63","1 through 10","891.33","4428.27","percent of total billed charges",""
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","both","","","5751.00","4313.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","938.15","","APC Price ($938.15). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","923.23","923.23","923.23","1 through 10","891.33","4428.27","other","OPPS APC"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","both","","","5751.00","4313.25","FALLON HEALTH [1008]","HB BWH MEDICARE","938.15","","APC Price ($938.15). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2776.44","2776.44","2776.44","1 through 10","891.33","4428.27","other","OPPS APC"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","both","","","5751.00","4313.25","HUMANA [1012]","HB BWH MEDICARE","938.15","","APC Price ($938.15). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","925.10","925.10","925.10","1 through 10","891.33","4428.27","other","OPPS APC"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","both","","","5751.00","4313.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3738.15","65","","3625.05","3625.05","3625.05","1 through 10","891.33","4428.27","percent of total billed charges",""
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","both","","","5751.00","4313.25","MEDICARE [2001]","HB BWH MEDICARE","938.15","","APC Price ($938.15). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","938.24","938.24","938.24","49","891.33","4428.27","other","OPPS APC"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","both","","","5751.00","4313.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2099.12","36.5","","2018.87","1767.91","2080.22","1 through 10","891.33","4428.27","percent of total billed charges",""
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","both","","","5751.00","4313.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2202.63","38.3","","2180.61","2180.61","2180.61","1 through 10","891.33","4428.27","percent of total billed charges",""
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","both","","","5751.00","4313.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","938.15","","APC Price ($938.15). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","858.47","858.47","858.47","1 through 10","891.33","4428.27","other","OPPS APC"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","both","","","5751.00","4313.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","919.39","","APC Price ($938.15). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2773.44","922.28","2773.44","1 through 10","891.33","4428.27","other","OPPS APC"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","both","","","5751.00","4313.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","919.39","","APC Price ($938.15). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","922.48","856.41","924.48","1 through 10","891.33","4428.27","other","OPPS APC"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","outpatient","","","5751.00","4313.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2900.03","","Case rate ($2,900.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","2900.03","2811.43","8388.43","1 through 10","691.75","3005.47","other","Multiple Imaging"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","outpatient","","","5751.00","4313.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2900.03","","Case rate ($2,900.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","2900.03","2811.43","2900.03","27","691.75","3005.47","other","Multiple Imaging"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","outpatient","","","5751.00","4313.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","691.75","","Case rate ($691.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1881.56","1881.56","1881.56","1 through 10","691.75","3005.47","other","Multiple Radiology"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","outpatient","","","5751.00","4313.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","691.75","","Case rate ($691.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1971.49","1971.49","1971.49","1 through 10","691.75","3005.47","other","Multiple Radiology"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","outpatient","","","5751.00","4313.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","691.75","","Case rate ($691.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","2010.10","2010.10","2010.10","1 through 10","691.75","3005.47","other","Multiple Radiology"
"MRI Card W/O&W Con Stress Imag","PX-61000071","CDM","75563","CPT","0614","RC","","","","outpatient","","","5751.00","4313.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1804.66","31.38","","1712.14","1712.14","2452.21","1 through 10","691.75","3005.47","percent of total billed charges",""
"MRI Cardiac for Velocity Flow Mapp","PX-61000072","CDM","75565","CPT","0614","RC","","","","both","","","792.00","594.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","514.80","65","","499.20","499.20","499.20","1 through 10","245.52","609.84","percent of total billed charges",""
"MRI Cardiac for Velocity Flow Mapp","PX-61000072","CDM","75565","CPT","0614","RC","","","","both","","","792.00","594.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","289.08","36.5","","286.46","286.46","286.46","1 through 10","245.52","609.84","percent of total billed charges",""
"MRI Cardiac for Velocity Flow Mapp","PX-61000072","CDM","75565","CPT","0614","RC","","","","both","","","792.00","594.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","303.34","38.3","","300.29","300.29","875.52","1 through 10","245.52","609.84","percent of total billed charges",""
"MRI Cardiac for Velocity Flow Mapp","PX-61000072","CDM","75565","CPT","0614","RC","","","","both","","","792.00","594.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","609.84","77","","599.04","599.04","599.04","1 through 10","245.52","609.84","percent of total billed charges",""
"MRI Cardiac for Velocity Flow Mapp","PX-61000072","CDM","75565","CPT","0614","RC","","","","both","","","792.00","594.00","WELLPOINT [1015]","HB AMC WELLPOINT","584.34","73.78","","571.78","571.78","571.78","1 through 10","245.52","609.84","percent of total billed charges",""
"MRI Cardiac for Velocity Flow Mapp","PX-61000072","CDM","75565","CPT","0614","RC","","","","outpatient","","","792.00","594.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","636.77","80.4","","599.04","599.04","599.04","1 through 10","247.34","636.77","percent of total billed charges",""
"MRI Cardiac for Velocity Flow Mapp","PX-61000072","CDM","75565","CPT","0614","RC","","","","outpatient","","","792.00","594.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","248.53","31.38","","235.78","235.78","235.78","1 through 10","247.34","636.77","percent of total billed charges",""
"MRI Cardiac W/O Cont","PX-61000068","CDM","75557","CPT","0614","RC","","","","both","","","4416.00","3312.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4282.00","4282.00","4282.00","1 through 10","272.7","3400.32","other","OPPS APC"
"MRI Cardiac W/O Cont","PX-61000068","CDM","75557","CPT","0614","RC","","","","both","","","4416.00","3312.00","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","287.06","17","272.7","3400.32","other","OPPS APC"
"MRI Cardiac W/O Cont","PX-61000068","CDM","75557","CPT","0614","RC","","","","both","","","4416.00","3312.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1611.84","36.5","","1597.19","1597.19","1597.19","1 through 10","272.7","3400.32","percent of total billed charges",""
"MRI Cardiac W/O Cont","PX-61000068","CDM","75557","CPT","0614","RC","","","","both","","","4416.00","3312.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1691.33","38.3","","1674.26","1674.26","1674.26","1 through 10","272.7","3400.32","percent of total billed charges",""
"MRI Cardiac W/O Cont","PX-61000068","CDM","75557","CPT","0614","RC","","","","both","","","4416.00","3312.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","287.06","285.82","287.06","1 through 10","272.7","3400.32","other","OPPS APC"
"MRI Cardiac W/O Cont","PX-61000068","CDM","75557","CPT","0614","RC","","","","outpatient","","","4416.00","3312.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","966.58","937.05","966.58","1 through 10","230.56","2307.8","other","Multiple Imaging"
"MRI Cardiac W/O Cont","PX-61000068","CDM","75557","CPT","0614","RC","","","","outpatient","","","4416.00","3312.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","468.53","937.05","1 through 10","230.56","2307.8","other","Multiple Imaging"
"MRI Cardiac W/O Cont","PX-61000068","CDM","75557","CPT","0614","RC","","","","outpatient","","","4416.00","3312.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","689.37","689.37","689.37","1 through 10","230.56","2307.8","other","Multiple Radiology"
"MRI Cardiac W/O Cont","PX-61000068","CDM","75557","CPT","0614","RC","","","","outpatient","","","4416.00","3312.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","627.12","627.12","1 through 10","230.56","2307.8","other","Multiple Radiology"
"MRI Cardiac W/O Cont","PX-61000068","CDM","75557","CPT","0614","RC","","","","outpatient","","","4416.00","3312.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","230.56","2307.8","other","Multiple Radiology"
"MRI Cardiac W/O Cont","PX-61000068","CDM","75557","CPT","0614","RC","","","","outpatient","","","4416.00","3312.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1385.74","31.38","","1314.57","1314.57","1314.57","1 through 10","230.56","2307.8","percent of total billed charges",""
"MRI Cardiac W/O Cont|REDUCED SERVICES","PX-61000068","CDM","75557","CPT","0614","RC","","","52","both","","","4416.00","3312.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","141.23","141.23","141.23","1 through 10","272.7","358.78","other","OPPS APC"
"MRI Cardiac W/O Cont|REDUCED SERVICES","PX-61000068","CDM","75557","CPT","0614","RC","","","52","both","","","4416.00","3312.00","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.53","143.53","143.53","1 through 10","272.7","358.78","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","7719.00","5789.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","402.91","5943.63","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","7719.00","5789.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","5943.63","77","","5601.75","5601.75","5601.75","1 through 10","402.91","5943.63","percent of total billed charges",""
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","7719.00","5789.25","HUMANA [1012]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","422.13","422.13","422.13","1 through 10","402.91","5943.63","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","7719.00","5789.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","418.17","418.17","1 through 10","402.91","5943.63","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","7719.00","5789.25","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1015.16","36","402.91","5943.63","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","7719.00","5789.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2817.44","36.5","","2791.91","2372.75","2791.91","1 through 10","402.91","5943.63","percent of total billed charges",""
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","7719.00","5789.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2956.38","38.3","","2926.64","2926.64","8779.92","22","402.91","5943.63","percent of total billed charges",""
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","7719.00","5789.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.83","418.83","418.83","1 through 10","402.91","5943.63","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","7719.00","5789.25","MOLINA [1014]","HB BWH MOLINA","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1672.20","1672.20","1672.20","1 through 10","402.91","5943.63","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","7719.00","5789.25","TRICARE [160005]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","402.91","5943.63","other","Tricare OPPS"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","7719.00","5789.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","402.91","5943.63","other","Tricare OPPS"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","7719.00","5789.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.13","413.01","417.13","1 through 10","402.91","5943.63","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","7719.00","5789.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.63","414.64","424.11","1 through 10","402.91","5943.63","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","7719.00","5789.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1617.73","1568.31","1617.73","17","385.88","4033.95","other","Multiple Imaging"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","7719.00","5789.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4033.95","52.26","","4631.72","4631.72","4631.72","1 through 10","385.88","4033.95","percent of total billed charges",""
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","7719.00","5789.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1617.73","1568.31","1617.73","33","385.88","4033.95","other","Multiple Imaging"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","7719.00","5789.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","524.79","1049.59","1 through 10","385.88","4033.95","other","Multiple Radiology"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","7719.00","5789.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2422.22","31.38","","420.03","420.03","420.03","1 through 10","385.88","4033.95","percent of total billed charges",""
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","7719.00","5789.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2422.22","31.38","","2297.90","2297.90","3291.15","1 through 10","385.88","4033.95","percent of total billed charges",""
"MRI Chest W/Cont","PX-61000036","CDM","71551","CPT","0614","RC","","","","both","","","6110.00","4582.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2340.13","38.3","","2316.68","2316.68","2316.68","1 through 10","891.33","4704.7","percent of total billed charges",""
"MRI Chest W/Cont","PX-61000036","CDM","71551","CPT","0614","RC","","","","outpatient","","","6110.00","4582.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2900.03","","Case rate ($2,900.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","2811.43","2811.43","2811.43","1 through 10","691.75","3193.09","other","Multiple Imaging"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","both","","","5526.00","4144.50","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","641.60","1 through 10","272.7","4255.02","other","OPPS APC"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","both","","","5526.00","4144.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2116.46","38.3","","2095.37","2095.37","2095.37","1 through 10","272.7","4255.02","percent of total billed charges",""
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","both","","","5526.00","4144.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","287.06","281.32","287.06","1 through 10","272.7","4255.02","other","OPPS APC"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","outpatient","","","5526.00","4144.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","966.58","966.58","966.58","1 through 10","230.56","2887.89","other","Multiple Imaging"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","outpatient","","","5526.00","4144.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","937.05","966.58","1 through 10","230.56","2887.89","other","Multiple Imaging"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","outpatient","","","5526.00","4144.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","5832.76","627.12","5832.76","1 through 10","230.56","2887.89","other","Multiple Radiology"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","outpatient","","","5526.00","4144.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","783.90","783.90","783.90","1 through 10","230.56","2887.89","other","Multiple Radiology"
"MRI Chest W/O Cont|REDUCED SERVICES","PX-61000035","CDM","71550","CPT","0614","RC","","","52","both","","","5526.00","4144.50","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.53","143.53","143.53","1 through 10","272.7","358.78","other","OPPS APC"
"MRI Functional Brain by Technician","PX-61000019","CDM","70554","CPT","0611","RC","","","","both","","","5101.00","3825.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","3927.77","other","OPPS APC"
"MRI Functional Brain by Technician","PX-61000019","CDM","70554","CPT","0611","RC","","","","both","","","5101.00","3825.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","3927.77","other","OPPS APC"
"MRI Functional Brain by Technician","PX-61000019","CDM","70554","CPT","0611","RC","","","","both","","","5101.00","3825.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1953.68","38.3","","1934.28","1934.28","1934.28","1 through 10","272.7","3927.77","percent of total billed charges",""
"MRI Functional Brain by Technician","PX-61000019","CDM","70554","CPT","0611","RC","","","","both","","","5101.00","3825.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","267.09","267.09","267.09","1 through 10","272.7","3927.77","other","OPPS APC"
"MRI Functional Brain by Technician","PX-61000019","CDM","70554","CPT","0611","RC","","","","both","","","5101.00","3825.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.69","31.38","","1518.73","1518.73","1518.73","1 through 10","272.7","3927.77","percent of total billed charges",""
"MRI Functional Brain by Technician","PX-61000019","CDM","70554","CPT","0611","RC","","","","both","","","5101.00","3825.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","283.72","283.72","283.72","1 through 10","272.7","3927.77","other","OPPS APC"
"MRI Functional Brain by Technician","PX-61000019","CDM","70554","CPT","0611","RC","","","","outpatient","","","5101.00","3825.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","937.05","937.05","1 through 10","230.56","2665.78","other","Multiple Imaging"
"MRI Functional Brain by Technician","PX-61000019","CDM","70554","CPT","0611","RC","","","","outpatient","","","5101.00","3825.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1203.52","627.12","1203.52","1 through 10","230.56","2665.78","other","Multiple Radiology"
"MRI Functional Brain by Technician","PX-61000019","CDM","70554","CPT","0611","RC","","","","outpatient","","","5101.00","3825.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","230.56","2665.78","other","Multiple Radiology"
"MRI Functional Brain by Technician","PX-61000019","CDM","70554","CPT","0611","RC","","","","outpatient","","","5101.00","3825.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","689.37","689.37","689.37","1 through 10","230.56","2665.78","other","Multiple Radiology"
"MRI Functional Brain by Technician","PX-61000019","CDM","70554","CPT","0611","RC","","","","outpatient","","","5101.00","3825.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","3858.66","3858.66","3858.66","1 through 10","230.56","2665.78","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Functional Brain by Technician","PX-61000019","CDM","70554","CPT","0611","RC","","","","outpatient","","","5101.00","3825.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1600.69","31.38","","2175.20","1518.73","2175.20","1 through 10","230.56","2665.78","percent of total billed charges",""
"MRI Guide Needle Place","PX-61000003","CDM","77021","CPT","0610","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1343.18","38.3","","1329.79","1329.79","1329.79","1 through 10","1087.17","2700.39","percent of total billed charges",""
"MRI Guide Needle Place","PX-61000003","CDM","77021","CPT","0610","RC","","","","outpatient","","","3507.00","2630.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1100.50","31.38","","1044.11","1044.11","1044.11","1 through 10","1100.5","2819.63","percent of total billed charges",""
"MRI Guided Parenchymal Tissue Ablat","PX-61000004","CDM","77022","CPT","0610","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1280.06","36.5","","1268.57","1268.57","1268.57","1 through 10","1087.17","2700.39","percent of total billed charges",""
"MRI Guided Parenchymal Tissue Ablat","PX-61000004","CDM","77022","CPT","0610","RC","","","","both","","","3507.00","2630.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1343.18","38.3","","1329.79","1329.79","1329.79","1 through 10","1087.17","2700.39","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","413.01","998.92","16","402.91","4915.68","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4149.60","65","","1776.82","1776.82","1776.82","1 through 10","402.91","4915.68","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4468.80","70","","4457.52","4457.52","4457.52","1 through 10","402.91","4915.68","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","998.92","1 through 10","402.91","4915.68","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","4915.68","77","","4767.07","4767.07","4767.07","1 through 10","402.91","4915.68","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","HUMANA [1012]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","415.63","420.63","1 through 10","402.91","4915.68","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1015.16","139","402.91","4915.68","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1979.04","31","","1913.02","1913.02","1913.02","1 through 10","402.91","4915.68","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2330.16","36.5","","1962.55","1962.55","2309.24","1 through 10","402.91","4915.68","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2445.07","38.3","","2420.68","2352.58","2420.68","31","402.91","4915.68","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1243.62","414.54","1243.62","1 through 10","402.91","4915.68","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","MOLINA [1014]","HB BWH MOLINA","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","832.74","832.74","832.74","1 through 10","402.91","4915.68","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4915.68","77","","1776.82","1776.82","1776.82","1 through 10","402.91","4915.68","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","TRICARE [160005]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","848.22","402.90","848.22","1 through 10","402.91","4915.68","other","Tricare OPPS"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","402.91","4915.68","other","Tricare OPPS"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.63","417.13","997.66","1 through 10","402.91","4915.68","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1423.93","1423.93","1423.93","1 through 10","402.91","4915.68","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2003.30","31.38","","1900.64","1900.64","1900.64","1 through 10","402.91","4915.68","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","6384.00","4788.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.48","414.34","420.63","17","402.91","4915.68","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","6384.00","4788.00","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","4191.31","2959.30","4191.31","1 through 10","385.88","3336.28","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","6384.00","4788.00","AETNA [1001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","4828.98","4828.98","4828.98","1 through 10","385.88","3336.28","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","6384.00","4788.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","808.87","784.16","1617.73","42","385.88","3336.28","other","Multiple Imaging"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","6384.00","4788.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3336.28","52.26","","1915.50","1915.50","1915.50","1 through 10","385.88","3336.28","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","6384.00","4788.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","808.87","784.16","1617.73","142","385.88","3336.28","other","Multiple Imaging"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","6384.00","4788.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1311.99","1311.99","1311.99","1 through 10","385.88","3336.28","other","Multiple Radiology"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","6384.00","4788.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","524.79","524.79","1049.59","23","385.88","3336.28","other","Multiple Radiology"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","6384.00","4788.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","549.88","1099.76","13","385.88","3336.28","other","Multiple Radiology"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","6384.00","4788.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1103.32","555.66","1153.78","1 through 10","385.88","3336.28","other","Multiple Radiology"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","6384.00","4788.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","3095.50","1000.00","3095.50","1 through 10","385.88","3336.28","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","6384.00","4788.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2003.30","31.38","","2722.18","1900.64","2722.18","1 through 10","385.88","3336.28","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","6384.00","4788.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2003.30","31.38","","1900.64","1900.64","1900.64","21","385.88","3336.28","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","263.16","282.47","79","272.7","3368.75","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","CHAMPVA [160001]","HB BWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","267.44","267.44","267.44","1 through 10","272.7","3368.75","other","Tricare OPPS"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","229.73","282.47","24","272.7","3368.75","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.04","262.09","287.06","1 through 10","272.7","3368.75","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2843.75","65","","2757.95","2757.95","2757.95","1 through 10","272.7","3368.75","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","641.60","788","272.7","3368.75","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1356.25","31","","1311.09","1311.09","1311.09","1 through 10","272.7","3368.75","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1596.88","36.5","","1582.64","1345.03","4747.92","53","272.7","3368.75","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1675.63","38.3","","1659.01","1612.34","1659.01","179","272.7","3368.75","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.52","265.29","631.97","34","272.7","3368.75","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","MOLINA [1014]","HB BWH MOLINA","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","530.60","263.16","569.53","1 through 10","272.7","3368.75","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3368.75","77","","3309.54","313.27","3384.14","1 through 10","272.7","3368.75","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","287.06","272.71","609.52","1 through 10","272.7","3368.75","other","Tricare OPPS"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","267.44","267.44","267.44","1 through 10","272.7","3368.75","other","Tricare OPPS"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.12","281.32","851.92","50","272.7","3368.75","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","975.89","975.89","975.89","1 through 10","272.7","3368.75","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1372.88","31.38","","1865.65","402.95","3391.86","1 through 10","272.7","3368.75","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","281.32","286.47","206","272.7","3368.75","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1372.88","31.38","","1865.65","1302.60","1865.65","1 through 10","272.7","3368.75","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4375.00","3281.25","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2872.51","2028.15","2872.51","1 through 10","230.56","2286.38","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4375.00","3281.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","483.29","966.58","174","230.56","2286.38","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4375.00","3281.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2286.38","52.26","","966.58","966.58","966.58","1 through 10","230.56","2286.38","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4375.00","3281.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","483.29","966.58","382","230.56","2286.38","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4375.00","3281.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","783.90","344.69","783.90","1 through 10","230.56","2286.38","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4375.00","3281.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","601.76","627.12","100","230.56","2286.38","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4375.00","3281.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","328.55","657.10","49","230.56","2286.38","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4375.00","3281.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","391.95","391.95","391.95","1 through 10","230.56","2286.38","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4375.00","3281.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","230.56","2286.38","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4375.00","3281.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","689.37","344.69","689.37","29","230.56","2286.38","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","664.01","664.01","664.01","1 through 10","230.56","2286.38","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1372.88","31.38","","1865.65","408.09","1865.65","1 through 10","230.56","2286.38","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1372.88","31.38","","1302.60","1302.60","1865.65","38","230.56","2286.38","percent of total billed charges",""
"MRI L-Spine W/O Cont|REDUCED SERVICES","PX-61000028","CDM","72148","CPT","0612","RC","","","52","both","","","4375.00","3281.25","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.53","143.53","143.53","1 through 10","272.7","358.78","other","OPPS APC"
"MRI Lwr Ext Joint W&W/O Cont","PX-61000064","CDM","73723","CPT","0614","RC","","","","both","","","4508.00","3381.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.34","411.34","421.29","1 through 10","402.91","3471.16","other","OPPS APC"
"MRI Lwr Ext Joint W&W/O Cont","PX-61000064","CDM","73723","CPT","0614","RC","","","","outpatient","","","4508.00","3381.00","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2959.84","2959.84","2959.84","1 through 10","385.88","2435.86","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Lwr Ext Joint W&W/O Cont","PX-61000064","CDM","73723","CPT","0614","RC","","","","outpatient","","","4508.00","3381.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1139.23","555.66","1142.60","1 through 10","385.88","2435.86","other","Multiple Radiology"
"MRI Lwr Ext Joint W&W/O Cont","PX-61000064","CDM","73723","CPT","0614","RC","","","","outpatient","","","4508.00","3381.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1369.64","1369.64","1369.64","1 through 10","385.88","2435.86","other","Multiple Radiology"
"MRI Lwr Ext Joint W/Cont","PX-61000063","CDM","73722","CPT","0614","RC","","","","outpatient","","","3532.00","2649.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","691.75","","Case rate ($691.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","2068.33","2068.33","2068.33","1 through 10","691.75","2900.03","other","Multiple Radiology"
"MRI Lwr Ext Joint W/Cont","PX-61000063","CDM","73722","CPT","0614","RC","","","","outpatient","","","3532.00","2649.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1108.34","31.38","","1051.48","1051.48","1051.48","1 through 10","691.75","2900.03","percent of total billed charges",""
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","both","","","3332.00","2499.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","266.40","286.32","55","272.7","2565.64","other","OPPS APC"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","3332.00","2499.00","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2187.39","1544.42","2187.39","1 through 10","230.56","1741.3","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","3332.00","2499.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","937.05","937.05","1 through 10","230.56","1741.3","other","Multiple Imaging"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","3332.00","2499.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","627.12","627.12","1 through 10","230.56","1741.3","other","Multiple Radiology"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","3332.00","2499.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","631.73","1314.19","1 through 10","230.56","1741.3","other","Multiple Radiology"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","3332.00","2499.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","689.37","450.24","689.37","22","230.56","1741.3","other","Multiple Radiology"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","3332.00","2499.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1045.58","31.38","","689.37","689.37","689.37","1 through 10","230.56","1741.3","percent of total billed charges",""
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","3332.00","2499.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1045.58","31.38","","657.10","631.73","2810.97","1 through 10","230.56","1741.3","percent of total billed charges",""
"MRI Lwr Ext W&W/O Cont","PX-61000061","CDM","73720","CPT","0614","RC","","","","both","","","6494.00","4870.50","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","402.91","5000.38","other","OPPS APC"
"MRI Lwr Ext W&W/O Cont","PX-61000061","CDM","73720","CPT","0614","RC","","","","both","","","6494.00","4870.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.63","415.63","420.63","14","402.91","5000.38","other","OPPS APC"
"MRI Lwr Ext W&W/O Cont","PX-61000061","CDM","73720","CPT","0614","RC","","","","outpatient","","","6494.00","4870.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","4263.75","572.55","4263.75","1 through 10","385.88","3393.76","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Lwr Ext W&W/O Cont","PX-61000061","CDM","73720","CPT","0614","RC","","","","outpatient","","","6494.00","4870.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1057.31","1099.76","1 through 10","385.88","3393.76","other","Multiple Radiology"
"MRI Lwr Ext W&W/O Cont","PX-61000061","CDM","73720","CPT","0614","RC","","","","outpatient","","","6494.00","4870.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1141.93","1111.33","1153.78","1 through 10","385.88","3393.76","other","Multiple Radiology"
"MRI Lwr Ext W&W/O Cont|BILATERAL PROCEDURE","PX-61000061","CDM","73720","CPT","0614","RC","","","50","both","","","6494.00","4870.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","","","APC Price ($0.00). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","998.92","998.92","998.92","1 through 10","","","other","OPPS APC"
"MRI Lwr Ext W&W/O Cont|BILATERAL PROCEDURE","PX-61000061","CDM","73720","CPT","0614","RC","","","50","both","","","6494.00","4870.50","MEDICARE [2001]","HB BWH MEDICARE","","","APC Price ($0.00). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","1015.16","1015.16","1 through 10","","","other","OPPS APC"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","both","","","4838.00","3628.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","358.78","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","267.44","267.44","267.44","1 through 10","272.7","3725.26","other","OPPS APC"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","both","","","4838.00","3628.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3144.70","65","","3049.80","3049.80","3049.80","1 through 10","272.7","3725.26","percent of total billed charges",""
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","both","","","4838.00","3628.50","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","320.80","320.80","574.12","14","272.7","3725.26","other","OPPS APC"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","both","","","4838.00","3628.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","265.40","633.77","13","272.7","3725.26","other","OPPS APC"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","both","","","4838.00","3628.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1518.16","31.38","","2063.07","2063.07","2063.07","1 through 10","272.7","3725.26","percent of total billed charges",""
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","outpatient","","","4838.00","3628.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3176.48","3176.48","3176.48","1 through 10","230.56","2528.34","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","outpatient","","","4838.00","3628.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","689.37","689.37","689.37","1 through 10","230.56","2528.34","other","Multiple Radiology"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","outpatient","","","4838.00","3628.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1518.16","31.38","","1440.45","631.73","2880.88","1 through 10","230.56","2528.34","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","638.22","1 through 10","402.91","4191.11","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3810.10","70","","2905.49","2905.49","2905.49","1 through 10","402.91","4191.11","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","CIGNA [1006]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","414.69","414.69","414.69","1 through 10","402.91","4191.11","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","933.38","417.32","998.92","1 through 10","402.91","4191.11","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","ELDER SERVICES [1037]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","952.43","952.43","952.43","1 through 10","402.91","4191.11","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","386.94","386.94","386.94","1 through 10","402.91","4191.11","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","HUMANA [1012]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1000.95","420.88","1000.95","1 through 10","402.91","4191.11","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","418.17","418.17","1 through 10","402.91","4191.11","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1015.16","130","402.91","4191.11","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1986.70","36.5","","1968.69","1673.13","1968.69","1 through 10","402.91","4191.11","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2084.67","38.3","","2063.70","2063.70","2063.70","26","402.91","4191.11","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.83","411.34","994.86","1 through 10","402.91","4191.11","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","424.11","424.11","1 through 10","402.91","4191.11","other","Tricare OPPS"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","997.66","417.13","1246.89","1 through 10","402.91","4191.11","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1708.01","31.38","","2320.74","1620.35","2320.74","1 through 10","402.91","4191.11","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5443.00","4082.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.63","415.63","997.86","38","402.91","4191.11","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","5443.00","4082.25","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","1370.47","1370.47","1370.47","1 through 10","385.88","2844.51","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","5443.00","4082.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1568.31","784.16","1617.73","38","385.88","2844.51","other","Multiple Imaging"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","5443.00","4082.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1568.31","784.16","1617.73","78","385.88","2844.51","other","Multiple Imaging"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","5443.00","4082.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1153.78","1153.78","1153.78","1 through 10","385.88","2844.51","other","Multiple Radiology"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","5443.00","4082.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1049.59","5247.95","34","385.88","2844.51","other","Multiple Radiology"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","5443.00","4082.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1057.31","2114.62","12","385.88","2844.51","other","Multiple Radiology"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","5443.00","4082.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1311.99","1311.99","1311.99","1 through 10","385.88","2844.51","other","Multiple Radiology"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","5443.00","4082.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1111.33","1099.30","1977.51","1 through 10","385.88","2844.51","other","Multiple Radiology"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","5443.00","4082.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1708.01","31.38","","5278.00","5278.00","5278.00","1 through 10","385.88","2844.51","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","5443.00","4082.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1708.01","31.38","","2320.74","2320.74","2320.74","1 through 10","385.88","2844.51","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","5443.00","4082.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1708.01","31.38","","1620.35","1620.35","2320.74","1 through 10","385.88","2844.51","percent of total billed charges",""
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","both","","","4738.00","3553.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","263.16","263.16","263.16","1 through 10","272.7","3648.26","other","OPPS APC"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","both","","","4738.00","3553.50","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","641.60","1 through 10","272.7","3648.26","other","OPPS APC"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","both","","","4738.00","3553.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","631.57","631.57","631.57","1 through 10","272.7","3648.26","other","OPPS APC"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","outpatient","","","4738.00","3553.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","937.05","937.05","1 through 10","230.56","2476.08","other","Multiple Imaging"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","outpatient","","","4738.00","3553.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","483.29","468.53","937.05","1 through 10","230.56","2476.08","other","Multiple Imaging"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","outpatient","","","4738.00","3553.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","627.12","627.12","1 through 10","230.56","2476.08","other","Multiple Radiology"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","outpatient","","","4738.00","3553.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","230.56","2476.08","other","Multiple Radiology"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","outpatient","","","4738.00","3553.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","783.90","783.90","783.90","1 through 10","230.56","2476.08","other","Multiple Radiology"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","outpatient","","","4738.00","3553.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1486.78","31.38","","1410.67","1410.67","1410.67","1 through 10","230.56","2476.08","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","419.79","103","402.91","5008.85","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4553.50","70","","6308.00","6308.00","6308.00","1 through 10","402.91","5008.85","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","CHAMPVA [160001]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","419.73","419.73","424.11","1 through 10","402.91","5008.85","other","Tricare OPPS"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","360.56","998.92","19","402.91","5008.85","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","FALLON HEALTH [1008]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1000.86","421.63","1000.86","1 through 10","402.91","5008.85","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","383.98","418.17","1 through 10","402.91","5008.85","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","5008.85","77","","4857.16","4857.16","4857.16","1 through 10","402.91","5008.85","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","HUMANA [1012]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.33","418.17","996.86","1 through 10","402.91","5008.85","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4228.25","65","","4100.20","3980.60","4100.20","1 through 10","402.91","5008.85","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","418.17","418.17","1 through 10","402.91","5008.85","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1015.16","1104","402.91","5008.85","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2016.55","31","","1949.17","1949.17","1949.17","1 through 10","402.91","5008.85","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2374.33","36.5","","2352.88","1999.64","2352.88","80","402.91","5008.85","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2491.42","38.3","","2466.43","2466.43","2466.43","194","402.91","5008.85","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.83","415.63","998.06","34","402.91","5008.85","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","MOLINA [1014]","HB BWH MOLINA","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2010.02","212.05","2010.02","1 through 10","402.91","5008.85","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","5008.85","77","","1810.40","1810.40","6308.00","1 through 10","402.91","5008.85","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","TRICARE [160005]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","402.90","1015.16","15","402.91","5008.85","other","Tricare OPPS"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","415.63","1255.29","55","402.91","5008.85","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2041.27","31.38","","1936.56","1936.56","2773.63","1 through 10","402.91","5008.85","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","6505.00","4878.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.63","415.63","994.86","173","402.91","5008.85","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","4270.52","3015.22","4270.52","1 through 10","385.88","3399.51","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1568.31","808.87","1617.73","365","385.88","3399.51","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3399.51","52.26","","1951.70","1617.73","1951.70","1 through 10","385.88","3399.51","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1568.31","808.86","1617.73","772","385.88","3399.51","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1311.99","656.00","1311.99","11","385.88","3399.51","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1049.59","1049.59","208","385.88","3399.51","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1057.31","1099.76","94","385.88","3399.51","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1311.99","656.00","1311.99","1 through 10","385.88","3399.51","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","1 through 10","385.88","3399.51","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1140.23","576.89","1153.78","46","385.88","3399.51","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","3154.00","1033.87","4920.24","1 through 10","385.88","3399.51","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2041.27","31.38","","1936.56","1936.56","1936.56","1 through 10","385.88","3399.51","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2041.27","31.38","","1936.56","1936.55","2773.63","112","385.88","3399.51","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1057.31","1057.31","1057.31","1 through 10","385.88","3399.51","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","6505.00","4878.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1111.33","1111.33","1111.33","1 through 10","385.88","3399.51","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont|REDUCED SERVICES","PX-61000040","CDM","72197","CPT","0614","RC","","","52","both","","","6505.00","4878.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.67","208.67","208.67","1 through 10","402.91","530.09","other","OPPS APC"
"MRI Pelvis W/Cont","PX-61000039","CDM","72196","CPT","0614","RC","","","","outpatient","","","5241.00","3930.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1049.59","1049.59","1 through 10","385.88","2738.95","other","Multiple Radiology"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4913.00","3684.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","263.16","4764.00","1 through 10","272.7","3783.01","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4913.00","3684.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","358.78","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","282.22","267.44","282.22","1 through 10","272.7","3783.01","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4913.00","3684.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","229.73","512.25","1 through 10","272.7","3783.01","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4913.00","3684.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","641.60","84","272.7","3783.01","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4913.00","3684.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1793.25","36.5","","1776.97","1510.19","1776.97","1 through 10","272.7","3783.01","percent of total billed charges",""
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4913.00","3684.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1881.68","38.3","","1862.72","1862.72","1862.72","24","272.7","3783.01","percent of total billed charges",""
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4913.00","3684.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.52","284.52","284.52","1 through 10","272.7","3783.01","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4913.00","3684.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3783.01","77","","401.88","401.88","401.88","1 through 10","272.7","3783.01","percent of total billed charges",""
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4913.00","3684.75","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","267.44","267.44","267.44","1 through 10","272.7","3783.01","other","Tricare OPPS"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4913.00","3684.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","852.36","281.32","852.36","1 through 10","272.7","3783.01","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4913.00","3684.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","281.32","628.77","18","272.7","3783.01","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4913.00","3684.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1541.70","31.38","","2094.73","2094.73","2094.73","1 through 10","272.7","3783.01","percent of total billed charges",""
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4913.00","3684.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3225.23","3225.23","3225.23","1 through 10","230.56","2567.53","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4913.00","3684.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","966.58","937.05","966.58","27","230.56","2567.53","other","Multiple Imaging"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4913.00","3684.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","966.58","937.05","966.58","52","230.56","2567.53","other","Multiple Imaging"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4913.00","3684.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","783.90","783.90","783.90","1 through 10","230.56","2567.53","other","Multiple Radiology"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4913.00","3684.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","300.88","627.12","17","230.56","2567.53","other","Multiple Radiology"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4913.00","3684.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","1971.30","1 through 10","230.56","2567.53","other","Multiple Radiology"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4913.00","3684.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","1035.21","1035.21","1035.21","1 through 10","230.56","2567.53","other","Multiple Radiology"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4913.00","3684.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","783.90","376.97","783.90","1 through 10","230.56","2567.53","other","Multiple Radiology"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4913.00","3684.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","689.37","664.01","689.37","1 through 10","230.56","2567.53","other","Multiple Radiology"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4913.00","3684.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","3428.44","3428.44","3428.44","1 through 10","230.56","2567.53","other","Multiple Radiology"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4913.00","3684.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1541.70","31.38","","1462.55","1462.55","1462.55","11","230.56","2567.53","percent of total billed charges",""
"MRI Pelvis W/O Cont|REDUCED SERVICES","PX-61000038","CDM","72195","CPT","0614","RC","","","52","both","","","4913.00","3684.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","140.66","140.66","140.66","1 through 10","272.7","358.78","other","OPPS APC"
"MRI Spectroscopy","PX-61000001","CDM","76390","CPT","0610","RC","","","","both","","","3577.00","2682.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2325.05","65","","2254.85","2254.85","2254.85","1 through 10","99.34","2754.29","percent of total billed charges",""
"MRI Spectroscopy","PX-61000001","CDM","76390","CPT","0610","RC","","","","both","","","3577.00","2682.75","MEDICARE [2001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","297.54","14","99.34","2754.29","other","OPPS APC"
"MRI Spectroscopy","PX-61000001","CDM","76390","CPT","0610","RC","","","","both","","","3577.00","2682.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1305.61","36.5","","2742.82","2742.82","2742.82","1 through 10","99.34","2754.29","percent of total billed charges",""
"MRI Spectroscopy","PX-61000001","CDM","76390","CPT","0610","RC","","","","both","","","3577.00","2682.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1369.99","38.3","","1356.38","1356.38","1356.38","1 through 10","99.34","2754.29","percent of total billed charges",""
"MRI Spectroscopy","PX-61000001","CDM","76390","CPT","0610","RC","","","","both","","","3577.00","2682.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","104.56","104.56","104.56","1 through 10","99.34","2754.29","other","OPPS APC"
"MRI Spectroscopy","PX-61000001","CDM","76390","CPT","0610","RC","","","","outpatient","","","3577.00","2682.75","AETNA [1001]","HB AMC AETNA HMO","2496.75","69.8","","2348.51","2348.51","2348.51","1 through 10","1012.6","2875.91","percent of total billed charges",""
"MRI Spectroscopy","PX-61000001","CDM","76390","CPT","0610","RC","","","","outpatient","","","3577.00","2682.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1122.46","31.38","","1064.98","1064.98","1064.98","1 through 10","1012.6","2875.91","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","13","402.91","4583.81","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4167.10","70","","4156.56","4156.56","4678.36","1 through 10","402.91","4583.81","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","402.91","4583.81","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","FALLON HEALTH [1008]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","848.22","415.63","939.38","1 through 10","402.91","4583.81","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","4583.81","77","","4445.21","4445.21","4445.21","1 through 10","402.91","4583.81","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3869.45","65","","3752.45","3752.45","3752.45","1 through 10","402.91","4583.81","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1015.16","100","402.91","4583.81","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1845.43","31","","1783.86","1783.86","1783.86","1 through 10","402.91","4583.81","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2172.85","36.5","","2089.83","1830.04","6459.99","23","402.91","4583.81","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2280.00","38.3","","2257.24","2257.24","2257.24","41","402.91","4583.81","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","415.63","415.63","415.63","1 through 10","402.91","4583.81","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","TRICARE [160005]","HB BWH TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","402.90","402.90","402.90","1 through 10","402.91","4583.81","other","Tricare OPPS"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","415.63","420.63","1 through 10","402.91","4583.81","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1327.79","1327.79","1327.79","1 through 10","402.91","4583.81","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","933.38","415.63","998.92","13","402.91","4583.81","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5953.00","4464.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1868.05","31.38","","2538.39","2538.39","2538.39","1 through 10","402.91","4583.81","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3908.32","2759.49","3908.32","1 through 10","385.88","3111.04","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","808.87","784.16","808.87","82","385.88","3111.04","other","Multiple Imaging"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3111.04","52.26","","1786.17","808.87","1786.17","1 through 10","385.88","3111.04","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","808.87","784.16","1617.73","257","385.88","3111.04","other","Multiple Imaging"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1153.78","656.00","1772.31","1 through 10","385.88","3111.04","other","Multiple Radiology"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","524.79","524.79","1574.37","54","385.88","3111.04","other","Multiple Radiology"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","549.88","549.88","1649.64","22","385.88","3111.04","other","Multiple Radiology"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1311.99","1311.99","1311.99","1 through 10","385.88","3111.04","other","Multiple Radiology"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","576.89","555.66","1153.78","13","385.88","3111.04","other","Multiple Radiology"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","4502.94","2886.50","4502.94","1 through 10","385.88","3111.04","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1868.05","31.38","","5773.00","5773.00","5773.00","1 through 10","385.88","3111.04","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1868.05","31.38","","2538.39","1772.31","2538.39","1 through 10","385.88","3111.04","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1868.05","31.38","","1772.31","1772.31","2538.39","38","385.88","3111.04","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","5953.00","4464.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","1261.83","1261.83","1261.83","1 through 10","385.88","3111.04","other","Multiple Radiology"
"MRI T-Spine W/Cont","PX-61000027","CDM","72147","CPT","0612","RC","","","","outpatient","","","4922.00","3691.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","784.16","784.16","784.16","1 through 10","385.88","2572.24","other","Multiple Imaging"
"MRI T-Spine W/Cont","PX-61000027","CDM","72147","CPT","0612","RC","","","","outpatient","","","4922.00","3691.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1617.73","","Case rate ($1,617.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","784.16","784.16","808.87","1 through 10","385.88","2572.24","other","Multiple Imaging"
"MRI T-Spine W/Cont","PX-61000027","CDM","72147","CPT","0612","RC","","","","outpatient","","","4922.00","3691.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","524.79","524.79","524.79","1 through 10","385.88","2572.24","other","Multiple Radiology"
"MRI T-Spine W/Cont","PX-61000027","CDM","72147","CPT","0612","RC","","","","outpatient","","","4922.00","3691.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","549.88","549.88","549.88","1 through 10","385.88","2572.24","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4439.00","3329.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","631.33","282.47","631.33","17","272.7","3418.03","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4439.00","3329.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","237.85","631.33","1 through 10","272.7","3418.03","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4439.00","3329.25","FALLON HEALTH [1008]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1901.31","1901.31","1901.31","1 through 10","272.7","3418.03","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4439.00","3329.25","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","641.60","82","272.7","3418.03","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4439.00","3329.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1620.24","36.5","","1605.77","1364.69","1605.77","14","272.7","3418.03","percent of total billed charges",""
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4439.00","3329.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1700.14","38.3","","1683.26","1635.90","5049.78","58","272.7","3418.03","percent of total billed charges",""
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4439.00","3329.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","589.97","284.52","589.97","1 through 10","272.7","3418.03","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4439.00","3329.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3418.03","77","","284.92","284.92","284.92","1 through 10","272.7","3418.03","percent of total billed charges",""
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4439.00","3329.25","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","609.52","609.52","609.52","1 through 10","272.7","3418.03","other","Tricare OPPS"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4439.00","3329.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","631.57","281.32","851.92","1 through 10","272.7","3418.03","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4439.00","3329.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1392.96","31.38","","1321.64","408.83","3441.42","1 through 10","272.7","3418.03","percent of total billed charges",""
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4439.00","3329.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","287.06","281.82","633.77","20","272.7","3418.03","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2914.49","2914.49","2914.49","1 through 10","230.56","2319.82","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","AETNA [1001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","631.74","631.74","631.74","1 through 10","230.56","2319.82","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","483.29","468.53","966.58","117","230.56","2319.82","other","Multiple Imaging"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2319.82","52.26","","1331.97","1331.97","1331.97","1 through 10","230.56","2319.82","percent of total billed charges",""
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","483.29","468.53","966.58","218","230.56","2319.82","other","Multiple Imaging"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","689.37","391.95","689.37","1 through 10","230.56","2319.82","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","313.56","313.56","627.12","52","230.56","2319.82","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","328.55","328.55","657.10","20","230.56","2319.82","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","391.95","391.95","391.95","1 through 10","230.56","2319.82","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","328.55","328.55","328.55","1 through 10","230.56","2319.82","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","344.69","344.69","689.37","13","230.56","2319.82","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","376.97","376.97","376.97","1 through 10","230.56","2319.82","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1392.96","31.38","","1321.64","657.10","1892.91","22","230.56","2319.82","percent of total billed charges",""
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4439.00","3329.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","344.69","344.69","344.69","1 through 10","230.56","2319.82","other","Multiple Radiology"
"MRI T-Spine W/O Cont|REDUCED SERVICES","PX-61000026","CDM","72146","CPT","0612","RC","","","52","both","","","4439.00","3329.25","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.53","143.53","143.53","1 through 10","272.7","358.78","other","OPPS APC"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","both","","","4297.00","3222.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4167.00","631.33","4167.00","1 through 10","272.7","3308.69","other","OPPS APC"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","both","","","4297.00","3222.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","239.59","239.59","239.59","1 through 10","272.7","3308.69","other","OPPS APC"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","both","","","4297.00","3222.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","1015.16","1 through 10","272.7","3308.69","other","OPPS APC"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","both","","","4297.00","3222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1645.75","38.3","","1629.30","1629.30","4887.90","1 through 10","272.7","3308.69","percent of total billed charges",""
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","both","","","4297.00","3222.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","281.32","281.32","1 through 10","272.7","3308.69","other","OPPS APC"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","4297.00","3222.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","966.58","937.05","966.58","1 through 10","230.56","2245.61","other","Multiple Imaging"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","4297.00","3222.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","966.58","","Case rate ($966.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.05","937.05","966.58","14","230.56","2245.61","other","Multiple Imaging"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","4297.00","3222.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","627.12","627.12","1 through 10","230.56","2245.61","other","Multiple Radiology"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","4297.00","3222.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","230.56","2245.61","other","Multiple Radiology"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","4297.00","3222.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","783.90","783.90","783.90","1 through 10","230.56","2245.61","other","Multiple Radiology"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","4297.00","3222.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","344.69","344.69","344.69","1 through 10","230.56","2245.61","other","Multiple Radiology"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","4297.00","3222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1348.40","31.38","","1279.27","1279.27","1279.27","1 through 10","230.56","2245.61","percent of total billed charges",""
"MRI Upr Ext Joint W&W/O","PX-61000052","CDM","73223","CPT","0614","RC","","","","both","","","4692.00","3519.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.63","414.64","420.63","1 through 10","402.91","3612.84","other","OPPS APC"
"MRI Upr Ext Joint W&W/O","PX-61000052","CDM","73223","CPT","0614","RC","","","","outpatient","","","4692.00","3519.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","1099.93","555.66","1138.33","1 through 10","385.88","2452.04","other","Multiple Radiology"
"MRI Upr Ext Joint W/Cont","PX-61000051","CDM","73222","CPT","0614","RC","","","","both","","","3810.00","2857.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","919.39","","APC Price ($938.15). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","922.48","860.21","922.48","1 through 10","891.33","2933.7","other","OPPS APC"
"MRI Upr Ext Joint W/Cont","PX-61000051","CDM","73222","CPT","0614","RC","","","","outpatient","","","3810.00","2857.50","AETNA [1001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","2882.10","2882.10","2882.10","1 through 10","691.75","2900.03","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","both","","","3595.00","2696.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","283.72","265.10","286.32","44","272.7","2768.15","other","OPPS APC"
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","outpatient","","","3595.00","2696.25","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2360.02","2360.02","2360.02","1 through 10","230.56","1878.75","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","outpatient","","","3595.00","2696.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","631.73","1314.19","1 through 10","230.56","1878.75","other","Multiple Radiology"
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","outpatient","","","3595.00","2696.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","689.37","344.69","1378.75","1 through 10","230.56","1878.75","other","Multiple Radiology"
"MRI Upr Ext W&W/O Cont","PX-61000049","CDM","73220","CPT","0614","RC","","","","both","","","6504.00","4878.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.63","414.64","937.69","1 through 10","402.91","5008.08","other","OPPS APC"
"MRI Upr Ext W&W/O Cont","PX-61000049","CDM","73220","CPT","0614","RC","","","","outpatient","","","6504.00","4878.00","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","4269.84","4269.84","4269.84","1 through 10","385.88","3398.99","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Upr Ext W&W/O Cont","PX-61000049","CDM","73220","CPT","0614","RC","","","","outpatient","","","6504.00","4878.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","1049.59","1049.59","1049.59","1 through 10","385.88","3398.99","other","Multiple Radiology"
"MRI Upr Ext W&W/O Cont","PX-61000049","CDM","73220","CPT","0614","RC","","","","outpatient","","","6504.00","4878.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","1 through 10","385.88","3398.99","other","Multiple Radiology"
"MRI Upr Ext W/O Cont","PX-61000043","CDM","73218","CPT","0614","RC","","","","both","","","5020.00","3765.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","286.32","262.60","633.77","1 through 10","272.7","3865.4","other","OPPS APC"
"MRI, Joint Upper Extrem W/Contrast","PX-98301624","CDM","73222","CPT","0983","RC","","","","both","","","413.00","309.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","919.39","","APC Price ($938.15). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","922.48","860.21","922.48","1 through 10","128.03","1501.33","other","OPPS APC"
"MRI, Joint Upper Extrem W/Contrast","PX-98301624","CDM","73222","CPT","0983","RC","","","","outpatient","","","413.00","309.75","AETNA [1001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","2882.10","2882.10","2882.10","1 through 10","337.5","2900.03","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","366","TRIS-DRG","","","","","","","","inpatient","","","112882.53","","TRICARE [160005]","HB BWH TRICARE","","","If the length of stay is greater than 0, the reimbursement is as follows:  If the length of stay is less than or equal to 0, the reimbursement is as follows:  Final payment is multiplied by 95%.","77411.77","77411.77","77411.77","1 through 10","","","other","Inpatient DRGs"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","","","","inpatient","","","170946.72","128210.04","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","68215.54","","Case rate ($66,228.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $79,648.85, add-ons for qualifying new technology services are included. If operating cost exceeds $125,293.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,248.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,040.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $79,269.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,808.51. The transfer capital threshold is the transfer adjustment factor * $5,808.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","66664.37","66664.37","66664.37","1 through 10","64904.11","113072.15","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","","","","inpatient","","","170946.72","128210.04","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","85840.31","","Case rate ($85,840.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $79,648.85, add-ons for qualifying new technology services are included. If operating cost exceeds $125,293.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,248.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $79,651.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $79,269.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,808.51. The transfer capital threshold is the transfer adjustment factor * $5,808.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","64051.49","64051.46","64051.49","1 through 10","64904.11","113072.15","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","","","","inpatient","","","170946.72","128210.04","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","66228.68","","Case rate ($66,228.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $79,648.85, add-ons for qualifying new technology services are included. If operating cost exceeds $125,293.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,248.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,040.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $79,269.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,808.51. The transfer capital threshold is the transfer adjustment factor * $5,808.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","63669.64","63669.64","63669.64","1 through 10","64904.11","113072.15","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","","","","inpatient","","","170946.72","128210.04","HUMANA [1012]","HB BWH MEDICARE","85840.31","","Case rate ($85,840.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $79,648.85, add-ons for qualifying new technology services are included. If operating cost exceeds $125,293.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,248.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $79,651.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $79,269.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,808.51. The transfer capital threshold is the transfer adjustment factor * $5,808.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","63546.89","63546.89","63546.89","1 through 10","64904.11","113072.15","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","","","","inpatient","","","170946.72","128210.04","MEDICARE [2001]","HB BWH MEDICARE","85840.31","","Case rate ($85,840.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $79,648.85, add-ons for qualifying new technology services are included. If operating cost exceeds $125,293.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,248.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $79,651.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $79,269.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,808.51. The transfer capital threshold is the transfer adjustment factor * $5,808.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","84013.12","0.03","84138.38","72","64904.11","113072.15","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","","","","inpatient","","","170946.72","128210.04","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","85840.31","","Case rate ($85,840.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $79,648.85, add-ons for qualifying new technology services are included. If operating cost exceeds $125,293.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,248.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $79,651.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $79,269.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,808.51. The transfer capital threshold is the transfer adjustment factor * $5,808.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","63574.75","63574.75","63574.75","1 through 10","64904.11","113072.15","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","","","","inpatient","","","170946.72","128210.04","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","64904.11","","Case rate ($66,228.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $79,648.85, add-ons for qualifying new technology services are included. If operating cost exceeds $125,293.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,248.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,040.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $79,269.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,808.51. The transfer capital threshold is the transfer adjustment factor * $5,808.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","63619.98","63590.76","83821.94","1 through 10","64904.11","113072.15","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","","","","inpatient","","","170946.72","128210.04","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","64904.11","","Case rate ($66,228.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $79,648.85, add-ons for qualifying new technology services are included. If operating cost exceeds $125,293.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,248.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $60,040.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $79,269.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,808.51. The transfer capital threshold is the transfer adjustment factor * $5,808.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","63482.24","63452.28","63489.77","1 through 10","64904.11","113072.15","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","426","MS-DRG","","","","","","","","inpatient","","","275801.87","206851.40","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","103943.88","","Case rate ($100,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $121,406.02, add-ons for qualifying new technology services are included. If operating cost exceeds $167,050.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $11,308.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $91,668.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $121,026.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $8,868.30. The transfer capital threshold is the transfer adjustment factor * $8,868.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","98261.07","98261.07","98261.07","1 through 10","98898.06","158084.2614","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","426","MS-DRG","","","","","","","","inpatient","","","275801.87","206851.40","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","100916.39","","Case rate ($100,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $121,406.02, add-ons for qualifying new technology services are included. If operating cost exceeds $167,050.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $11,308.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $91,668.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $121,026.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $8,868.30. The transfer capital threshold is the transfer adjustment factor * $8,868.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","121877.85","121877.85","121877.85","1 through 10","98898.06","158084.2614","other","Inpatient Replacement Plans DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","426","MS-DRG","","","","","","","","inpatient","","","275801.87","206851.40","MEDICARE [2001]","HB BWH MEDICARE","100916.39","","Case rate ($100,916.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $121,406.02, add-ons for qualifying new technology services are included. If operating cost exceeds $167,050.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $11,308.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $91,668.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $121,026.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $8,868.30. The transfer capital threshold is the transfer adjustment factor * $8,868.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","123920.17","123774.40","123959.12","11","98898.06","158084.2614","other","Inpatient Replacement Plans DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/McC","428","MS-DRG","","","","","","","","inpatient","","","148103.88","111077.91","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","51664.32","","Case rate ($51,664.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $62,116.24, add-ons for qualifying new technology services are included. If operating cost exceeds $107,760.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,963.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $46,760.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $61,736.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,523.79. The transfer capital threshold is the transfer adjustment factor * $4,523.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","49468.06","49468.06","49468.06","1 through 10","50631.03","88063.01","other","Inpatient Replacement Plans DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/McC","428","MS-DRG","","","","","","","","inpatient","","","148103.88","111077.91","MEDICARE [2001]","HB BWH MEDICARE","51664.32","","Case rate ($51,664.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $62,116.24, add-ons for qualifying new technology services are included. If operating cost exceeds $107,760.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,963.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $46,760.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $61,736.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,523.79. The transfer capital threshold is the transfer adjustment factor * $4,523.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","65264.02","65166.96","65264.02","1 through 10","50631.03","88063.01","other","Inpatient Replacement Plans DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/McC","428","MS-DRG","","","","","","","","inpatient","","","148103.88","111077.91","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","50631.03","","Case rate ($51,664.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $62,116.24, add-ons for qualifying new technology services are included. If operating cost exceeds $107,760.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,963.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $46,760.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $61,736.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,523.79. The transfer capital threshold is the transfer adjustment factor * $4,523.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","49329.64","49329.64","49329.64","1 through 10","50631.03","88063.01","other","Inpatient DRG"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/McC","428","MS-DRG","","","","","","","","inpatient","","","148103.88","111077.91","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","50631.03","","Case rate ($51,664.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $62,116.24, add-ons for qualifying new technology services are included. If operating cost exceeds $107,760.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,963.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $46,760.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $61,736.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,523.79. The transfer capital threshold is the transfer adjustment factor * $4,523.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","49378.73","139.42","66654.92","1 through 10","50631.03","88063.01","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","447","MS-DRG","","","","","","","","inpatient","","","228518.56","171388.92","MEDICARE [2001]","HB BWH MEDICARE","79482.80","","Case rate ($79,482.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $73,751.93, add-ons for qualifying new technology services are included. If operating cost exceeds $119,396.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,816.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $73,726.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $73,372.10 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,376.41. The transfer capital threshold is the transfer adjustment factor * $5,376.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","79321.03","74380.86","121449.31","14","60103.5","104660.58","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","447","MS-DRG","","","","","","","","inpatient","","","228518.56","171388.92","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","60103.50","","Case rate ($61,330.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $73,751.93, add-ons for qualifying new technology services are included. If operating cost exceeds $119,396.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,816.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $55,573.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $73,372.10 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,376.41. The transfer capital threshold is the transfer adjustment factor * $5,376.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","52603.31","52603.31","52603.31","1 through 10","60103.5","104660.58","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","447","MS-DRG","","","","","","","","inpatient","","","228518.56","171388.92","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","60103.50","","Case rate ($61,330.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $73,751.93, add-ons for qualifying new technology services are included. If operating cost exceeds $119,396.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,816.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $55,573.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $73,372.10 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,376.41. The transfer capital threshold is the transfer adjustment factor * $5,376.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","59929.15","59929.15","59929.15","1 through 10","60103.5","104660.58","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","138048.12","103536.09","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","40236.83","","Case rate ($39,064.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,948.99, add-ons for qualifying new technology services are included. If operating cost exceeds $92,593.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,852.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,272.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,569.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,412.40. The transfer capital threshold is the transfer adjustment factor * $3,412.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","38509.22","38478.63","38552.11","1 through 10","38283.58","61624.0985","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","138048.12","103536.09","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","39064.88","","Case rate ($39,064.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,948.99, add-ons for qualifying new technology services are included. If operating cost exceeds $92,593.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,852.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,272.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,569.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,412.40. The transfer capital threshold is the transfer adjustment factor * $3,412.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36940.98","36940.98","47728.43","1 through 10","38283.58","61624.0985","other","Inpatient Replacement Plans DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","138048.12","103536.09","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","39064.88","","Case rate ($39,064.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,948.99, add-ons for qualifying new technology services are included. If operating cost exceeds $92,593.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,852.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,272.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,569.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,412.40. The transfer capital threshold is the transfer adjustment factor * $3,412.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36711.03","36711.03","36711.03","1 through 10","38283.58","61624.0985","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","138048.12","103536.09","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","31103.34","31103.34","31103.34","1 through 10","38283.58","61624.0985","case rate",""
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","138048.12","103536.09","FALLON HEALTH [1008]","HB BWH MEDICARE","39064.88","","Case rate ($39,064.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,948.99, add-ons for qualifying new technology services are included. If operating cost exceeds $92,593.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,852.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,272.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,569.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,412.40. The transfer capital threshold is the transfer adjustment factor * $3,412.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","37394.23","37394.23","37394.23","1 through 10","38283.58","61624.0985","other","Inpatient Replacement Plans DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","138048.12","103536.09","HUMANA [1012]","HB BWH MEDICARE","39064.88","","Case rate ($39,064.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,948.99, add-ons for qualifying new technology services are included. If operating cost exceeds $92,593.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,852.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,272.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,569.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,412.40. The transfer capital threshold is the transfer adjustment factor * $3,412.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36657.51","36657.51","36657.51","1 through 10","38283.58","61624.0985","other","Inpatient Replacement Plans DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","138048.12","103536.09","MARTIN'S POINT [160007]","HB BWH MEDICARE","39064.88","","Case rate ($39,064.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,948.99, add-ons for qualifying new technology services are included. If operating cost exceeds $92,593.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,852.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,272.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,569.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,412.40. The transfer capital threshold is the transfer adjustment factor * $3,412.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36767.82","36767.82","36767.82","1 through 10","38283.58","61624.0985","other","Inpatient Replacement Plans DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","138048.12","103536.09","MEDICARE [2001]","HB BWH MEDICARE","39064.88","","Case rate ($39,064.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,948.99, add-ons for qualifying new technology services are included. If operating cost exceeds $92,593.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,852.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,272.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,569.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,412.40. The transfer capital threshold is the transfer adjustment factor * $3,412.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","48419.29","0.03","48491.30","57","38283.58","61624.0985","other","Inpatient Replacement Plans DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","138048.12","103536.09","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","38283.58","","Case rate ($39,064.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,948.99, add-ons for qualifying new technology services are included. If operating cost exceeds $92,593.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,852.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,272.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,569.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,412.40. The transfer capital threshold is the transfer adjustment factor * $3,412.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","36596.07","36596.07","36596.07","1 through 10","38283.58","61624.0985","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","138048.12","103536.09","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","38283.58","","Case rate ($39,064.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,948.99, add-ons for qualifying new technology services are included. If operating cost exceeds $92,593.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,852.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,272.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,569.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,412.40. The transfer capital threshold is the transfer adjustment factor * $3,412.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","36693.09","36661.84","119040.78","1 through 10","38283.58","61624.0985","other","Inpatient DRG"
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","","","","inpatient","","","48922.81","36692.11","MEDICARE [2001]","HB BWH MEDICARE","11699.45","","Case rate ($11,699.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,006.42, add-ons for qualifying new technology services are included. If operating cost exceeds $59,650.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,438.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,321.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,626.59 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $998.50. The transfer capital threshold is the transfer adjustment factor * $998.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14703.50","14703.50","14703.50","1 through 10","11465.46","17916.0352","other","Inpatient Replacement Plans DRG"
"Multiple Sclerosis And Cerebellar Ataxia With McC","058","MS-DRG","","","","","","","","inpatient","","","53853.15","40389.86","MEDICARE [2001]","HB BWH MEDICARE","20618.48","","Case rate ($20,618.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,152.23, add-ons for qualifying new technology services are included. If operating cost exceeds $64,796.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,815.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $18,863.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,772.39 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,375.56. The transfer capital threshold is the transfer adjustment factor * $1,375.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22039.90","22039.90","22039.90","1 through 10","15654.6","26777.61","other","Inpatient DRG"
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC","060","MS-DRG","","","","","","","","inpatient","","","43719.19","32789.39","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8770.37","","Case rate ($8,770.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,480.37, add-ons for qualifying new technology services are included. If operating cost exceeds $56,124.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,180.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,650.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,100.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.13. The transfer capital threshold is the transfer adjustment factor * $740.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8278.64","8278.64","8278.64","1 through 10","8594.96","13467.2084","other","Inpatient DRG"
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC","060","MS-DRG","","","","","","","","inpatient","","","43719.19","32789.39","MEDICARE [2001]","HB BWH MEDICARE","8770.37","","Case rate ($8,770.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,480.37, add-ons for qualifying new technology services are included. If operating cost exceeds $56,124.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,180.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,650.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,100.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.13. The transfer capital threshold is the transfer adjustment factor * $740.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10814.67","10814.67","10814.67","1 through 10","8594.96","13467.2084","other","Inpatient Replacement Plans DRG"
"Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies,MAJOR","043","DRG","","","","","","","","inpatient","","","67267.34","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","16952.1948","","Fee schedule rate ($41,069.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16952.1948","41069.96","41069.96","1 through 10","8628.29","64537.52","case rate",""
"Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies,MINOR","043","DRG","","","","","","","","inpatient","","","49408.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","25420.03","","Standard inlier is a Case rate ($25,420.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,414, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,608.53) for the length of stay and the standard reimbursement.","23171.28","23171.28","23171.28","1 through 10","8628.29","64537.52","case rate",""
"Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies,MINOR","043","DRG","","","","","","","","inpatient","","","49408.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","28578.96","","Standard inlier is a Case rate ($28,578.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,414, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,056.55) for the length of stay and the standard reimbursement.","28578.96","28578.96","28578.96","1 through 10","8628.29","64537.52","case rate",""
"Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies,MINOR","043","DRG","","","","","","","","inpatient","","","49408.44","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8628.29","","Case rate ($9,540.06). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,970.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9537.72","9537.72","9537.72","1 through 10","8628.29","64537.52","case rate",""
"Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies,MODERATE","043","DRG","","","","","","","","inpatient","","","60726.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","34229.71","","Standard inlier is a Case rate ($34,229.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,266, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,859.11) for the length of stay and the standard reimbursement.","34229.71","34229.71","34229.71","1 through 10","8628.29","64537.52","case rate",""
"Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies,MODERATE","043","DRG","","","","","","","","inpatient","","","60726.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","38483.42","","Standard inlier is a Case rate ($38,483.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,266, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,462.40) for the length of stay and the standard reimbursement.","38483.42","38483.42","38518.98","1 through 10","8628.29","64537.52","case rate",""
"Multiple Significant Trauma Without O.R. Procedure,EXTREME","930","DRG","","","","","","","","inpatient","","","204772.30","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","88239.18","","Standard inlier is a Case rate ($88,239.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $80,265, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,526.08) for the length of stay and the standard reimbursement.","99857.03","99857.03","99857.03","1 through 10","8988.14","289715.79","case rate",""
"Multiple Significant Trauma Without O.R. Procedure,EXTREME","930","DRG","","","","","","","","inpatient","","","204772.30","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","28589.99","","Case rate ($31,611.15). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $74,041.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31603.39","31603.39","31603.39","1 through 10","8988.14","289715.79","case rate",""
"Multiple Significant Trauma Without O.R. Procedure,MAJOR","930","DRG","","","","","","","","inpatient","","","69083.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","45827.20","","Standard inlier is a Case rate ($45,827.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,505.45) for the length of stay and the standard reimbursement.","45827.19","45827.19","45827.19","1 through 10","8988.14","289715.79","case rate",""
"Multiple Significant Trauma Without O.R. Procedure,MAJOR","930","DRG","","","","","","","","inpatient","","","69083.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","51522.12","","Standard inlier is a Case rate ($51,522.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,313.14) for the length of stay and the standard reimbursement.","47069.90","47069.90","47069.90","1 through 10","8988.14","289715.79","case rate",""
"Multiple Significant Trauma Without O.R. Procedure,MAJOR","930","DRG","","","","","","","","inpatient","","","69083.84","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16153.4474","","Fee schedule rate ($39,681.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16153.4474","39681.28","39681.28","1 through 10","8988.14","289715.79","case rate",""
"Multiple Significant Trauma Without O.R. Procedure,MAJOR","930","DRG","","","","","","","","inpatient","","","69083.84","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","206.58","206.58","206.58","1 through 10","8988.14","289715.79","percent of total billed charges",""
"Multiple Significant Trauma Without O.R. Procedure,MAJOR","930","DRG","","","","","","","","inpatient","","","69083.84","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48105.90","","Fee schedule rate ($48,105.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","48105.90","48105.90","48105.90","1 through 10","8988.14","289715.79","case rate",""
"Multiple Significant Trauma Without O.R. Procedure,MAJOR","930","DRG","","","","","","","","inpatient","","","69083.84","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","13845.48","","Case rate ($15,308.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,738.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15304.80","15304.80","15304.80","1 through 10","8988.14","289715.79","case rate",""
"Multiple Significant Trauma Without O.R. Procedure,MODERATE","930","DRG","","","","","","","","inpatient","","","28276.01","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32738.54","","Standard inlier is a Case rate ($32,738.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,293, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,646.96) for the length of stay and the standard reimbursement.","32738.54","32738.54","32738.54","1 through 10","8988.14","289715.79","case rate",""
"Multiple Significant Trauma Without O.R. Procedure,MODERATE","930","DRG","","","","","","","","inpatient","","","28276.01","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16153.4474","","Fee schedule rate ($22,528.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16153.4474","22528.04","22528.04","1 through 10","8988.14","289715.79","case rate",""
"Multiple Sulfatase Deficiency/ Mucosulfatidosis via Sumf1 Gene","PX-31000927","CDM","81479","CPT","0310","RC","","","","both","","","1103.00","827.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","876.89","79.5","","0.65","0.65","0.65","1 through 10","341.93","1047.85","percent of total billed charges",""
"Multiple Sulfatase Deficiency/ Mucosulfatidosis via Sumf1 Gene","PX-31000927","CDM","81479","CPT","0310","RC","","","","both","","","1103.00","827.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","587.90","53.3","","0.79","0.79","0.79","1 through 10","341.93","1047.85","percent of total billed charges",""
"Multiple Sulfatase Deficiency/ Mucosulfatidosis via Sumf1 Gene","PX-31000927","CDM","81479","CPT","0310","RC","","","","outpatient","","","1103.00","827.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","551.50","50","","1.00","1.00","1.00","1 through 10","156.55","909.98","percent of total billed charges",""
"Multiple Sulfatase Deficiency/ Mucosulfatidosis via Sumf1 Gene","PX-31000927","CDM","81479","CPT","0310","RC","","","","outpatient","","","1103.00","827.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.08","52.5","","1.00","0.53","1.00","1 through 10","156.55","909.98","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","157.00","117.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","112.73","71.8","","327.42","109.14","327.42","15","12.79","149.15","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","157.00","117.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","102.05","65","","119.62","98.80","119.62","1 through 10","12.79","149.15","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","157.00","117.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","109.90","70","","152.00","109.44","152.00","1 through 10","12.79","149.15","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.82","79.5","","119.62","80.26","152.00","35","12.79","149.15","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.68","53.3","","80.26","80.26","119.62","1 through 10","12.79","149.15","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","157.00","117.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","120.89","77","","117.04","117.04","117.04","1 through 10","12.79","149.15","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","157.00","117.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","102.05","65","","98.80","98.80","98.80","1 through 10","12.79","149.15","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.31","36.5","","56.70","55.02","170.10","35","12.79","149.15","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.13","38.3","","59.43","57.76","178.29","108","12.79","149.15","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","157.00","117.75","TRICARE [160005]","HB BWH TRICARE","149.15","95","","15.73","15.73","15.73","1 through 10","12.79","149.15","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.35","42.9","","121.51","121.51","121.51","1 through 10","12.79","149.15","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","157.00","117.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.35","42.9","","66.83","66.83","66.83","1 through 10","12.79","149.15","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA HMO","109.59","69.8","","102.90","72.66","118.56","36","13.45","128.3","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA PPO","126.23","80.4","","118.56","79.65","159.30","1 through 10","13.45","128.3","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","157.00","117.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.23","80.4","","76.00","76.00","76.00","1 through 10","13.45","128.3","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.30","81.72","","66.83","66.83","66.83","1 through 10","13.45","128.3","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.30","81.72","","121.51","66.83","121.51","32","13.45","128.3","percent of total billed charges",""
"Muramidase","PX-30001111","CDM","85549","CPT","0305","RC","","","","both","","","244.00","183.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.06","36.5","","88.40","88.40","88.40","1 through 10","18.38","231.8","percent of total billed charges",""
"Muramidase","PX-30001111","CDM","85549","CPT","0305","RC","","","","both","","","244.00","183.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.45","38.3","","278.01","90.06","278.01","1 through 10","18.38","231.8","percent of total billed charges",""
"Muramidase","PX-30001111","CDM","85549","CPT","0305","RC","","","","outpatient","","","244.00","183.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","199.40","81.72","","189.46","189.46","189.46","1 through 10","19.35","199.4","percent of total billed charges",""
"Muscle-Specific Kinase Antibody","PX-30003823","CDM","86366","CPT","0302","RC","","","","both","","","224.00","168.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","81.76","36.5","","78.55","78.55","78.55","1 through 10","18.03","212.8","percent of total billed charges",""
"Muscle-Specific Kinase Antibody","PX-30003823","CDM","86366","CPT","0302","RC","","","","both","","","224.00","168.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","85.79","38.3","","254.55","84.85","254.55","1 through 10","18.03","212.8","percent of total billed charges",""
"Muscle-Specific Kinase Antibody","PX-30003823","CDM","86366","CPT","0302","RC","","","","both","","","224.00","168.00","WELLPOINT [1015]","HB AMC WELLPOINT","165.27","73.78","","378.56","155.21","595.56","1 through 10","18.03","212.8","percent of total billed charges",""
"Muscle-Specific Kinase Antibody","PX-30003823","CDM","86366","CPT","0302","RC","","","","outpatient","","","224.00","168.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.00","50","","113.71","113.71","113.71","1 through 10","53.55","184.8","percent of total billed charges",""
"Muscle-Specific Kinase Antibody","PX-30003823","CDM","86366","CPT","0302","RC","","","","outpatient","","","224.00","168.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","117.60","52.5","","119.35","119.35","119.35","1 through 10","53.55","184.8","percent of total billed charges",""
"Muscle-Specific Kinase Antibody","PX-30003823","CDM","86366","CPT","0302","RC","","","","outpatient","","","224.00","168.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","140.00","62.5","","142.14","142.14","142.14","1 through 10","53.55","184.8","percent of total billed charges",""
"Muscle-Specific Kinase Antibody","PX-30003823","CDM","86366","CPT","0302","RC","","","","outpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.05","81.72","","173.47","173.47","173.47","1 through 10","53.55","184.8","percent of total billed charges",""
"Musculoskeletal And Other Procedures For Multiple Significant Trauma,EXTREME","912","DRG","","","","","","","","inpatient","","","298591.00","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","29761.5302","","Fee schedule rate ($175,583.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29761.5302","175583.20","175583.20","1 through 10","25488.47","289715.79","case rate",""
"Musculoskeletal And Other Procedures For Multiple Significant Trauma,EXTREME","912","DRG","","","","","","","","inpatient","","","298591.00","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","50213.915","","Fee schedule rate ($175,583.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","50213.915","175583.20","175583.20","1 through 10","25488.47","289715.79","case rate",""
"Musculoskeletal And Other Procedures For Multiple Significant Trauma,EXTREME","912","DRG","","","","","","","","inpatient","","","298591.00","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","57308.7274","","Fee schedule rate ($175,583.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","57308.7274","175583.20","175583.20","1 through 10","25488.47","289715.79","case rate",""
"Musculoskeletal And Other Procedures For Multiple Significant Trauma,EXTREME","912","DRG","","","","","","","","inpatient","","","298591.00","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","57801.43","","Case rate ($63,909.42). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $106,339.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","63893.74","63893.74","63893.74","1 through 10","25488.47","289715.79","case rate",""
"Musculoskeletal And Other Procedures For Multiple Significant Trauma,MAJOR","912","DRG","","","","","","","","inpatient","","","184289.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","120867.91","","Standard inlier is a Case rate ($120,867.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $95,250, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,156.20) for the length of stay and the standard reimbursement.","110423.27","110423.27","110423.27","1 through 10","25488.47","289715.79","case rate",""
"Musculoskeletal And Other Procedures For Multiple Significant Trauma,MAJOR","912","DRG","","","","","","","","inpatient","","","184289.25","","MASSHEALTH [3001]","HB BWH MEDICAID","28998.96","","Case rate ($32,063.34). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $74,493.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,149.64 and the sum of the standard inlier and any outlier amount.","9446.60","9446.60","9446.60","1 through 10","25488.47","289715.79","case rate",""
"Musculoskeletal And Other Procedures For Multiple Significant Trauma,MINOR","912","DRG","","","","","","","","inpatient","","","114277.94","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58547.94","","Fee schedule rate ($58,547.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","58547.94","58547.94","58547.94","1 through 10","25488.47","289715.79","case rate",""
"Musculoskeletal And Other Procedures For Multiple Significant Trauma,MODERATE","912","DRG","","","","","","","","inpatient","","","130458.37","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","67796.44","","Standard inlier is a Case rate ($67,796.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $64,368, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,624.11) for the length of stay and the standard reimbursement.","67796.43","67796.43","67796.43","1 through 10","25488.47","289715.79","case rate",""
"Musculoskeletal And Other Procedures For Multiple Significant Trauma,MODERATE","912","DRG","","","","","","","","inpatient","","","130458.37","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","76221.47","","Standard inlier is a Case rate ($76,221.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $64,368, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,819.00) for the length of stay and the standard reimbursement.","69634.89","69634.89","69634.89","1 through 10","25488.47","289715.79","case rate",""
"Musculoskeletal And Other Procedures For Multiple Significant Trauma,MODERATE","912","DRG","","","","","","","","inpatient","","","130458.37","","MASSHEALTH [3001]","HB BWH MEDICAID","25570.72","","Case rate ($28,272.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,702.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29383.73","29383.73","29383.73","1 through 10","25488.47","289715.79","case rate",""
"Musculoskeletal And Other Procedures For Multiple Significant Trauma,MODERATE","912","DRG","","","","","","","","inpatient","","","130458.37","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","25570.72","","Case rate ($28,272.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,702.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","28265.89","28265.89","28265.89","1 through 10","25488.47","289715.79","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,EXTREME","343","DRG","","","","","","","","inpatient","","","215512.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22580.4862","","Standard inlier is a Case rate ($67,214.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,917, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,541.48) for the length of stay and the standard reimbursement.","22580.4862","61268.28","61268.28","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,EXTREME","343","DRG","","","","","","","","inpatient","","","215512.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25386.552","","Standard inlier is a Case rate ($75,566.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,917, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,726.11) for the length of stay and the standard reimbursement.","25386.552","203645.16","203645.16","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,EXTREME","343","DRG","","","","","","","","inpatient","","","215512.72","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18016.6185","","Fee schedule rate ($78,212.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18016.6185","78212.92","78212.92","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,EXTREME","343","DRG","","","","","","","","inpatient","","","215512.72","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","75145.38","","Fee schedule rate ($75,145.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","75145.38","75145.38","75145.38","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MAJOR","343","DRG","","","","","","","","inpatient","","","78603.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22580.4862","","Standard inlier is a Case rate ($41,509.67). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,928, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,892.55) for the length of stay and the standard reimbursement.","22580.4862","37837.58","41509.67","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MAJOR","343","DRG","","","","","","","","inpatient","","","78603.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25386.552","","Standard inlier is a Case rate ($46,668.06). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,928, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,624.14) for the length of stay and the standard reimbursement.","25386.552","42635.30","48775.78","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MAJOR","343","DRG","","","","","","","","inpatient","","","78603.88","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18016.6185","","Fee schedule rate ($43,318.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18016.6185","43318.16","43318.16","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MAJOR","343","DRG","","","","","","","","inpatient","","","78603.88","","MASSHEALTH [3001]","HB BWH MEDICAID","15920.01","","Case rate ($17,602.31). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,032.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2569.05","2569.05","2569.05","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MAJOR","343","DRG","","","","","","","","inpatient","","","78603.88","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44326.78","","Fee schedule rate ($44,326.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","44326.78","44326.78","44326.78","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MAJOR","343","DRG","","","","","","","","inpatient","","","78603.88","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15920.01","","Case rate ($17,602.31). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,032.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17597.99","17597.99","30731.10","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MINOR","343","DRG","","","","","","","","inpatient","","","48783.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22580.4862","","Standard inlier is a Case rate ($24,168.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,442, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,430.85) for the length of stay and the standard reimbursement.","22580.4862","24168.42","24168.42","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MINOR","343","DRG","","","","","","","","inpatient","","","48783.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25386.552","","Standard inlier is a Case rate ($27,171.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,442, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,856.82) for the length of stay and the standard reimbursement.","25386.552","27171.82","27171.82","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MINOR","343","DRG","","","","","","","","inpatient","","","48783.58","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18016.6185","","Fee schedule rate ($22,673.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18016.6185","18016.60","18016.60","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MINOR","343","DRG","","","","","","","","inpatient","","","48783.58","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31551.77","","Fee schedule rate ($31,551.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29058.14","29058.14","29058.14","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MODERATE","343","DRG","","","","","","","","inpatient","","","75059.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22580.4862","","Standard inlier is a Case rate ($28,405.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,737, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,032.28) for the length of stay and the standard reimbursement.","22580.4862","25892.28","25892.28","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MODERATE","343","DRG","","","","","","","","inpatient","","","75059.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25386.552","","Standard inlier is a Case rate ($31,934.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,737, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,532.91) for the length of stay and the standard reimbursement.","25386.552","31934.98","31934.98","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MODERATE","343","DRG","","","","","","","","inpatient","","","75059.88","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18016.6185","","Fee schedule rate ($43,318.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18016.6185","22673.44","22673.44","1 through 10","6472.65","129052.9","case rate",""
"Musculoskeletal Malignancy And Pathological Fracture Due To Musculoskeletal Malignancy,MODERATE","343","DRG","","","","","","","","inpatient","","","75059.88","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8103.94","","Case rate ($8,960.30). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,390.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8958.10","8958.10","8958.10","1 through 10","6472.65","129052.9","case rate",""
"Mutation Testing for Dex Z","PX-31001312","CDM","81403","CPT","0310","RC","","","","outpatient","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","864.60","81.72","","820.18","820.18","820.18","1 through 10","512.07","1135.28","percent of total billed charges",""
"Myc Gene Analysis","PX-31000778","CDM","81479","CPT","0310","RC","","","","both","","","10924.00","8193.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8684.58","79.5","","0.65","0.65","0.65","1 through 10","3386.44","10377.8","percent of total billed charges",""
"Myc Gene Analysis","PX-31000778","CDM","81479","CPT","0310","RC","","","","both","","","10924.00","8193.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5822.49","53.3","","0.79","0.79","0.79","1 through 10","3386.44","10377.8","percent of total billed charges",""
"Myc Gene Analysis","PX-31000778","CDM","81479","CPT","0310","RC","","","","outpatient","","","10924.00","8193.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","6614.48","60.55","","1.00","1.00","1.00","1 through 10","5287.22","9012.3","percent of total billed charges",""
"Myc Gene Analysis","PX-31000778","CDM","81479","CPT","0310","RC","","","","outpatient","","","10924.00","8193.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5704.51","52.22","","1.00","1.00","1.00","1 through 10","5287.22","9012.3","percent of total billed charges",""
"Myc Gene Analysis","PX-31000778","CDM","81479","CPT","0310","RC","","","","outpatient","","","10924.00","8193.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5462.00","50","","1.00","1.00","1.00","1 through 10","5287.22","9012.3","percent of total billed charges",""
"Myc Gene Analysis","PX-31000778","CDM","81479","CPT","0310","RC","","","","outpatient","","","10924.00","8193.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","5735.10","52.5","","1.00","0.53","1.00","1 through 10","5287.22","9012.3","percent of total billed charges",""
"Mycophenolate Cap 250mg","PX-63600225","CDM","J7517","HCPCS","0636","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.66","65.6","","0.37","0.37","0.37","12","0.31","0.77","percent of total billed charges",""
"Mycophenolate Cap 250mg","PX-63600225","CDM","J7517","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","0.66","0.19","3.79","30","0.31","0.77","percent of total billed charges",""
"Mycophenolate Cap 250mg","PX-63600225","CDM","J7517","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","1.96","1.96","1.96","1 through 10","0.34","0.8","percent of total billed charges",""
"Mycophenolate Cap 250mg","PX-63600225","CDM","J7517","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.47","46.9","","0.46","0.46","1.19","62","0.34","0.8","percent of total billed charges",""
"Mycoplasma Antibody","PX-30000975","CDM","86738","CPT","0302","RC","","","","both","","","144.00","108.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","76.75","53.3","","73.92","73.92","73.92","1 through 10","10.76","136.8","percent of total billed charges",""
"Mycoplasma Antibody","PX-30000975","CDM","86738","CPT","0302","RC","","","","both","","","144.00","108.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","52.56","36.5","","43.96","43.96","43.96","1 through 10","10.76","136.8","percent of total billed charges",""
"Mycoplasma Antibody","PX-30000975","CDM","86738","CPT","0302","RC","","","","both","","","144.00","108.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.15","38.3","","54.74","54.74","54.74","1 through 10","10.76","136.8","percent of total billed charges",""
"Mycoplasma Antibody","PX-30000975","CDM","86738","CPT","0302","RC","","","","outpatient","","","144.00","108.00","AETNA [1001]","HB AMC AETNA HMO","100.51","69.8","","66.92","66.92","66.92","1 through 10","10.76","117.68","percent of total billed charges",""
"Mycoplasma Antibody","PX-30000975","CDM","86738","CPT","0302","RC","","","","outpatient","","","144.00","108.00","AETNA [1001]","HB AMC AETNA PPO","115.78","80.4","","218.40","218.40","218.40","1 through 10","10.76","117.68","percent of total billed charges",""
"Mycoplasma Antibody","PX-30000975","CDM","86738","CPT","0302","RC","","","","outpatient","","","144.00","108.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","117.68","81.72","","61.56","61.56","111.92","1 through 10","10.76","117.68","percent of total billed charges",""
"Myd88 {Component} for Rhp - Abnormal/Spep","PX-31001042","CDM","81305","CPT","0310","RC","","","","both","","","1802.00","1351.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1432.59","79.5","","1374.89","1275.95","1374.89","1 through 10","171.89","1711.9","percent of total billed charges",""
"Myd88 {Component} for Rhp - Abnormal/Spep","PX-31001042","CDM","81305","CPT","0310","RC","","","","both","","","1802.00","1351.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","960.47","53.3","","1374.89","1374.89","1374.89","1 through 10","171.89","1711.9","percent of total billed charges",""
"Myd88 {Component} for Rhp - Abnormal/Spep","PX-31001042","CDM","81305","CPT","0310","RC","","","","both","","","1802.00","1351.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","657.73","36.5","","553.80","553.80","553.80","1 through 10","171.89","1711.9","percent of total billed charges",""
"Myd88 {Component} for Rhp - Abnormal/Spep","PX-31001042","CDM","81305","CPT","0310","RC","","","","outpatient","","","1802.00","1351.50","AETNA [1001]","HB AMC AETNA HMO","1257.80","69.8","","1182.72","1182.72","1182.72","1 through 10","650.73","1472.59","percent of total billed charges",""
"Myd88 {Component} for Rhp - Abnormal/Spep","PX-31001042","CDM","81305","CPT","0310","RC","","","","outpatient","","","1802.00","1351.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1091.11","60.55","","315.72","315.72","315.72","1 through 10","650.73","1472.59","percent of total billed charges",""
"Myd88 {Component} for Rhp - Abnormal/Spep","PX-31001042","CDM","81305","CPT","0310","RC","","","","outpatient","","","1802.00","1351.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","941.00","52.22","","315.72","315.72","315.72","11","650.73","1472.59","percent of total billed charges",""
"Myd88 {Component} for Rhp - Abnormal/Spep","PX-31001042","CDM","81305","CPT","0310","RC","","","","outpatient","","","1802.00","1351.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1472.59","81.72","","1396.55","1396.55","1396.55","1 through 10","650.73","1472.59","percent of total billed charges",""
"Myd88 Gene Analysis P.Leu265 (L265p) Variant","PX-31000985","CDM","81305","CPT","0310","RC","","","","both","","","1802.00","1351.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1432.59","79.5","","1374.89","1275.95","1374.89","1 through 10","171.89","1711.9","percent of total billed charges",""
"Myd88 Gene Analysis P.Leu265 (L265p) Variant","PX-31000985","CDM","81305","CPT","0310","RC","","","","both","","","1802.00","1351.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","960.47","53.3","","1374.89","1374.89","1374.89","1 through 10","171.89","1711.9","percent of total billed charges",""
"Myd88 Gene Analysis P.Leu265 (L265p) Variant","PX-31000985","CDM","81305","CPT","0310","RC","","","","both","","","1802.00","1351.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","657.73","36.5","","553.80","553.80","553.80","1 through 10","171.89","1711.9","percent of total billed charges",""
"Myd88 Gene Analysis P.Leu265 (L265p) Variant","PX-31000985","CDM","81305","CPT","0310","RC","","","","outpatient","","","1802.00","1351.50","AETNA [1001]","HB AMC AETNA HMO","1257.80","69.8","","1182.72","1182.72","1182.72","1 through 10","650.73","1472.59","percent of total billed charges",""
"Myd88 Gene Analysis P.Leu265 (L265p) Variant","PX-31000985","CDM","81305","CPT","0310","RC","","","","outpatient","","","1802.00","1351.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1091.11","60.55","","315.72","315.72","315.72","1 through 10","650.73","1472.59","percent of total billed charges",""
"Myd88 Gene Analysis P.Leu265 (L265p) Variant","PX-31000985","CDM","81305","CPT","0310","RC","","","","outpatient","","","1802.00","1351.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","941.00","52.22","","315.72","315.72","315.72","11","650.73","1472.59","percent of total billed charges",""
"Myd88 Gene Analysis P.Leu265 (L265p) Variant","PX-31000985","CDM","81305","CPT","0310","RC","","","","outpatient","","","1802.00","1351.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1472.59","81.72","","1396.55","1396.55","1396.55","1 through 10","650.73","1472.59","percent of total billed charges",""
"Myelography via Lumbar Inject Rs&I Lumbosacral","PX-36000349","CDM","62304","CPT","0361","RC","","","","outpatient","","","879.00","659.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","791.06","","Case rate ($791.06). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1833.68","1833.68","1833.68","1 through 10","459.37","2384.07","other","ASC "
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","","","","inpatient","","","136957.66","102718.24","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","22106.74","","Case rate ($21,462.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,759.62, add-ons for qualifying new technology services are included. If operating cost exceeds $71,404.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,299.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $19,223.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,379.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,859.73. The transfer capital threshold is the transfer adjustment factor * $1,859.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","22347.15","22347.15","22347.15","1 through 10","21033.59","36202.64","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","","","","inpatient","","","136957.66","102718.24","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","27741.96","","Case rate ($27,741.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,759.62, add-ons for qualifying new technology services are included. If operating cost exceeds $71,404.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,299.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $25,502.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,379.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,859.73. The transfer capital threshold is the transfer adjustment factor * $1,859.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21464.18","21464.18","27666.70","1 through 10","21033.59","36202.64","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","","","","inpatient","","","136957.66","102718.24","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","21462.85","","Case rate ($21,462.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,759.62, add-ons for qualifying new technology services are included. If operating cost exceeds $71,404.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,299.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $19,223.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,379.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,859.73. The transfer capital threshold is the transfer adjustment factor * $1,859.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21347.99","21347.99","21347.99","1 through 10","21033.59","36202.64","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","","","","inpatient","","","136957.66","102718.24","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","39450.26","39450.26","39450.26","1 through 10","21033.59","36202.64","case rate",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","","","","inpatient","","","136957.66","102718.24","FALLON HEALTH [1008]","HB BWH MEDICARE","27741.96","","Case rate ($27,741.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,759.62, add-ons for qualifying new technology services are included. If operating cost exceeds $71,404.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,299.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $25,502.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,379.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,859.73. The transfer capital threshold is the transfer adjustment factor * $1,859.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21316.82","21316.82","21316.82","1 through 10","21033.59","36202.64","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","","","","inpatient","","","136957.66","102718.24","MEDICARE [2001]","HB BWH MEDICARE","27741.96","","Case rate ($27,741.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,759.62, add-ons for qualifying new technology services are included. If operating cost exceeds $71,404.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,299.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $25,502.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,379.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,859.73. The transfer capital threshold is the transfer adjustment factor * $1,859.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28099.53","0.03","28141.13","23","21033.59","36202.64","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","","","","inpatient","","","136957.66","102718.24","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","21033.59","","Case rate ($21,462.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,759.62, add-ons for qualifying new technology services are included. If operating cost exceeds $71,404.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,299.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $19,223.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,379.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,859.73. The transfer capital threshold is the transfer adjustment factor * $1,859.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21272.36","21272.36","21272.36","1 through 10","21033.59","36202.64","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","","","","inpatient","","","136957.66","102718.24","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","21033.59","","Case rate ($21,462.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,759.62, add-ons for qualifying new technology services are included. If operating cost exceeds $71,404.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,299.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $19,223.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,379.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,859.73. The transfer capital threshold is the transfer adjustment factor * $1,859.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21375.20","21375.20","28471.52","1 through 10","21033.59","36202.64","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","","","","inpatient","","","136957.66","102718.24","WELLPOINT [1015]","HB AMC WELLPOINT","36202.64","","Fee schedule rate ($36,202.64).","35613.25","35613.25","35613.25","1 through 10","21033.59","36202.64","case rate",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC","826","MS-DRG","","","","","","","","inpatient","","","329222.59","246916.94","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","44342.77","","Case rate ($43,051.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,747.77, add-ons for qualifying new technology services are included. If operating cost exceeds $97,392.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,204.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $38,907.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,367.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,764.03. The transfer capital threshold is the transfer adjustment factor * $3,764.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","56612.21","56612.21","56612.21","1 through 10","42190.21","73273.06","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC","826","MS-DRG","","","","","","","","inpatient","","","329222.59","246916.94","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","43051.23","","Case rate ($43,051.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,747.77, add-ons for qualifying new technology services are included. If operating cost exceeds $97,392.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,204.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $38,907.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,367.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,764.03. The transfer capital threshold is the transfer adjustment factor * $3,764.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","55747.60","55747.60","55747.60","1 through 10","42190.21","73273.06","other","Inpatient Replacement Plans DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC","826","MS-DRG","","","","","","","","inpatient","","","329222.59","246916.94","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","15537.15","15537.15","15537.15","1 through 10","42190.21","73273.06","case rate",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC","826","MS-DRG","","","","","","","","inpatient","","","329222.59","246916.94","MARTIN'S POINT [160007]","HB BWH MEDICARE","43051.23","","Case rate ($43,051.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,747.77, add-ons for qualifying new technology services are included. If operating cost exceeds $97,392.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,204.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $38,907.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,367.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,764.03. The transfer capital threshold is the transfer adjustment factor * $3,764.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","42779.23","42779.23","42779.23","1 through 10","42190.21","73273.06","other","Inpatient Replacement Plans DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC","826","MS-DRG","","","","","","","","inpatient","","","329222.59","246916.94","MEDICARE [2001]","HB BWH MEDICARE","43051.23","","Case rate ($43,051.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,747.77, add-ons for qualifying new technology services are included. If operating cost exceeds $97,392.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,204.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $38,907.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,367.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,764.03. The transfer capital threshold is the transfer adjustment factor * $3,764.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","56661.60","56577.39","118300.43","1 through 10","42190.21","73273.06","other","Inpatient Replacement Plans DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC","826","MS-DRG","","","","","","","","inpatient","","","329222.59","246916.94","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","42190.21","","Case rate ($43,051.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $51,747.77, add-ons for qualifying new technology services are included. If operating cost exceeds $97,392.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,204.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $38,907.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $51,367.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,764.03. The transfer capital threshold is the transfer adjustment factor * $3,764.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","43023.22","43023.22","43023.22","1 through 10","42190.21","73273.06","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC","828","MS-DRG","","","","","","","","inpatient","","","94560.89","70920.67","MEDICARE [2001]","HB BWH MEDICARE","15922.08","","Case rate ($15,922.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,089.64, add-ons for qualifying new technology services are included. If operating cost exceeds $64,734.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,811.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $14,171.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,709.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,370.98. The transfer capital threshold is the transfer adjustment factor * $1,370.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19175.12","19175.12","19203.39","12","15603.64","24189.3639","other","Inpatient Replacement Plans DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC","828","MS-DRG","","","","","","","","inpatient","","","94560.89","70920.67","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15603.64","","Case rate ($15,922.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,089.64, add-ons for qualifying new technology services are included. If operating cost exceeds $64,734.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,811.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $14,171.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,709.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,370.98. The transfer capital threshold is the transfer adjustment factor * $1,370.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14571.42","14571.42","14597.58","1 through 10","15603.64","24189.3639","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC","828","MS-DRG","","","","","","","","inpatient","","","94560.89","70920.67","WELLPOINT [1015]","HB AMC WELLPOINT","24189.3639","","Fee schedule rate ($26,688.32).","24189.3639","219231.53","219231.53","1 through 10","15603.64","24189.3639","case rate",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC","829","MS-DRG","","","","","","","","inpatient","","","126391.04","94793.28","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","37790.84","","Case rate ($37,790.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,080.48, add-ons for qualifying new technology services are included. If operating cost exceeds $80,724.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,982.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $34,868.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,700.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,542.72. The transfer capital threshold is the transfer adjustment factor * $2,542.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28307.70","28307.70","28307.70","1 through 10","28621.58","46537.6258","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC","829","MS-DRG","","","","","","","","inpatient","","","126391.04","94793.28","MARTIN'S POINT [160007]","HB BWH MEDICARE","37790.84","","Case rate ($37,790.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,080.48, add-ons for qualifying new technology services are included. If operating cost exceeds $80,724.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,982.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $34,868.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,700.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,542.72. The transfer capital threshold is the transfer adjustment factor * $2,542.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27788.62","27788.62","27788.62","1 through 10","28621.58","46537.6258","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC","829","MS-DRG","","","","","","","","inpatient","","","126391.04","94793.28","MEDICARE [2001]","HB BWH MEDICARE","37790.84","","Case rate ($37,790.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,080.48, add-ons for qualifying new technology services are included. If operating cost exceeds $80,724.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,982.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $34,868.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,700.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,542.72. The transfer capital threshold is the transfer adjustment factor * $2,542.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36676.60","3513.96","36688.06","17","28621.58","46537.6258","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC","829","MS-DRG","","","","","","","","inpatient","","","126391.04","94793.28","MOLINA [1014]","HB BWH MOLINA","28621.58","","Case rate ($29,205.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,080.48, add-ons for qualifying new technology services are included. If operating cost exceeds $80,724.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,982.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $26,283.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,700.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,542.72. The transfer capital threshold is the transfer adjustment factor * $2,542.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14016.97","14016.97","14016.97","1 through 10","28621.58","46537.6258","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC","829","MS-DRG","","","","","","","","inpatient","","","126391.04","94793.28","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28621.58","","Case rate ($29,205.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,080.48, add-ons for qualifying new technology services are included. If operating cost exceeds $80,724.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,982.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $26,283.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,700.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,542.72. The transfer capital threshold is the transfer adjustment factor * $2,542.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","27976.56","27976.56","27976.56","1 through 10","28621.58","46537.6258","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/McC","830","MS-DRG","","","","","","","","inpatient","","","89313.30","66984.97","MEDICARE [2001]","HB BWH MEDICARE","18197.42","","Case rate ($18,197.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,906.57, add-ons for qualifying new technology services are included. If operating cost exceeds $62,551.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,651.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $16,606.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,526.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,211.01. The transfer capital threshold is the transfer adjustment factor * $1,211.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17545.71","17545.71","17545.71","1 through 10","13826.44","22070.5875","other","Inpatient DRG"
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","968.00","726.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","635.01","65.6","","732.42","635.70","732.42","1 through 10","300.08","769.56","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","968.00","726.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","629.20","65","","610.35","610.35","939.00","1 through 10","300.08","769.56","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","968.00","726.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","677.60","70","","676.08","143.95","751.20","12","300.08","769.56","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","968.00","726.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","769.56","79.5","","738.99","495.79","1831.05","35","300.08","769.56","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","968.00","726.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","515.94","53.3","","738.99","495.79","863.56","15","300.08","769.56","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","968.00","726.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","745.36","77","","723.03","723.03","723.03","1 through 10","300.08","769.56","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","968.00","726.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","629.20","65","","610.35","610.35","610.35","1 through 10","300.08","769.56","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","968.00","726.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","745.36","77","","811.68","811.68","811.68","1 through 10","300.08","769.56","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","968.00","726.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","415.27","42.9","","427.25","412.88","750.64","1 through 10","300.08","769.56","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","968.00","726.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","415.27","42.9","","750.64","750.64","750.64","1 through 10","300.08","769.56","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","968.00","726.00","WELLPOINT [1015]","HB AMC WELLPOINT","714.19","73.78","","699.09","699.09","1638.09","36","300.08","769.56","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","968.00","726.00","AETNA [1001]","HB AMC AETNA HMO","675.66","69.8","","635.70","448.84","635.70","57","505.88","791.05","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","968.00","726.00","AETNA [1001]","HB AMC AETNA PPO","778.27","80.4","","732.42","732.42","732.42","1 through 10","505.88","791.05","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","968.00","726.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","778.27","80.4","","732.42","732.42","751.20","1 through 10","505.88","791.05","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","968.00","726.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","791.05","81.72","","412.88","412.88","750.64","1 through 10","505.88","791.05","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","968.00","726.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","791.05","81.72","","750.64","412.88","750.64","74","505.88","791.05","percent of total billed charges",""
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1783.95","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1782.39","1756.99","1782.59","1 through 10","1645.55","4652.34","other","OPPS APC"
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1704.45","1680.16","5675.00","1 through 10","1645.55","4652.34","other","OPPS APC"
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3838.91","65.6","","2425.02","2425.02","2425.02","1 through 10","1645.55","4652.34","percent of total billed charges",""
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4652.34","79.5","","4466.23","2996.40","8011.25","1 through 10","1645.55","4652.34","percent of total billed charges",""
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1704.45","1680.16","1704.45","1 through 10","1645.55","4652.34","other","OPPS APC"
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","FALLON HEALTH [1008]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1703.52","1697.52","1703.52","1 through 10","1645.55","4652.34","other","OPPS APC"
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1704.45","1704.45","1704.45","1 through 10","1645.55","4652.34","other","OPPS APC"
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","MEDICARE [2001]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1732.16","1707.48","3464.32","88","1645.55","4652.34","other","OPPS APC"
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2135.98","36.5","","2116.78","2054.35","2116.78","1 through 10","1645.55","4652.34","percent of total billed charges",""
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2241.32","38.3","","2218.93","2218.93","6656.79","18","1645.55","4652.34","percent of total billed charges",""
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1697.52","1697.52","1697.52","1 through 10","1645.55","4652.34","other","OPPS APC"
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","MOLINA [1014]","HB BWH MOLINA","1697.35","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3436.61","3436.61","3436.61","1 through 10","1645.55","4652.34","other","OPPS APC"
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","1645.55","","APC Price ($1,732.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1732.16","1732.16","1732.16","1 through 10","1645.55","4652.34","other","Tricare OPPS"
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1697.35","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1700.32","1697.52","5092.56","1 through 10","1645.55","4652.34","other","OPPS APC"
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1697.35","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1697.52","1673.34","1704.45","11","1645.55","4652.34","other","OPPS APC"
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","both","","","5852.00","4389.00","WELLPOINT [1015]","HB AMC WELLPOINT","4317.61","73.78","","4225.04","4225.04","4225.04","1 through 10","1645.55","4652.34","percent of total billed charges",""
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","outpatient","","","5852.00","4389.00","AETNA [1001]","HB AMC AETNA HMO","4084.70","69.8","","3841.98","2712.65","5675.00","1 through 10","3058.26","6176.17","percent of total billed charges",""
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","outpatient","","","5852.00","4389.00","AETNA [1001]","HB AMC AETNA PPO","4705.01","80.4","","3841.98","3841.98","3841.98","1 through 10","3058.26","6176.17","percent of total billed charges",""
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","outpatient","","","5852.00","4389.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4782.25","81.72","","4536.60","4536.60","4536.60","1 through 10","3058.26","6176.17","percent of total billed charges",""
"Myocrd Img Pet Metab Eval Single Study Cncrnt CT","PX-40000167","CDM","78429","CPT","0404","RC","","","","outpatient","","","5852.00","4389.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4782.25","81.72","","4536.60","1309.50","4536.60","1 through 10","3058.26","6176.17","percent of total billed charges",""
"Myocrd Img Pet Prfuj 1std Rest/Stress Cncrnt CT","PX-40000168","CDM","78430","CPT","0404","RC","","","","both","","","8171.00","6128.25","MEDICARE [2001]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1732.16","1732.16","1732.16","1 through 10","1645.55","6495.95","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2752.50","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2751.01","2750.11","2760.01","31","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2672.33","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2629.84","2629.84","2629.84","41","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","5993.86","71.8","","5812.21","5812.21","5812.21","1 through 10","2538.97","6636.66","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","5476.29","65.6","","2751.01","2750.11","2751.01","1 through 10","2538.97","6636.66","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5426.20","65","","5261.75","5261.75","5261.75","1 through 10","2538.97","6636.66","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","5843.60","70","","6341.29","4541.16","6360.29","1 through 10","2538.97","6636.66","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","3340.42","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","2672.60","2577.95","2672.60","1 through 10","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6636.66","79.5","","6370.77","4274.16","6370.77","12","2538.97","6636.66","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4449.48","53.3","","4274.16","4274.16","6370.77","1 through 10","2538.97","6636.66","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2672.33","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2629.84","2629.84","2629.84","14","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","ELDER SERVICES [1037]","HB BWH MEDICARE","2672.33","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2672.60","2672.60","2672.60","1 through 10","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","2672.33","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2528.12","2526.39","2528.12","1 through 10","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","2672.33","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2526.39","2526.39","2526.39","1 through 10","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","HUMANA [1012]","HB BWH MEDICARE","2672.33","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2624.15","2624.15","2624.15","1 through 10","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5426.20","65","","5261.75","5261.75","5261.75","1 through 10","2538.97","6636.66","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","MEDICARE [2001]","HB BWH MEDICARE","2672.33","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2672.60","2672.60","2672.60","543","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3047.02","36.5","","3019.44","2930.39","3019.44","20","2538.97","6636.66","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3197.28","38.3","","3165.15","3165.15","9495.45","46","2538.97","6636.66","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2672.33","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2622.15","2619.15","2622.35","14","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","MOLINA [1014]","HB BWH MOLINA","2618.89","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5302.44","5302.44","5302.44","1 through 10","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","6427.96","77","","6103.63","6103.63","6103.63","1 through 10","2538.97","6636.66","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2618.89","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2624.15","2533.39","7865.85","35","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","2618.89","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5585.55","1861.85","5585.55","1 through 10","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2618.89","","APC Price ($2,672.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2619.55","2619.15","2624.50","108","2538.97","6636.66","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3581.29","42.9","","3559.37","3559.37","3559.37","1 through 10","2538.97","6636.66","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","8348.00","6261.00","WELLPOINT [1015]","HB AMC WELLPOINT","6159.15","73.78","","6026.73","6026.73","6026.73","1 through 10","2538.97","6636.66","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","outpatient","","","8348.00","6261.00","AETNA [1001]","HB AMC AETNA HMO","5826.90","69.8","","5480.32","3869.41","10960.64","19","3895.16","10104.75","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","outpatient","","","8348.00","6261.00","AETNA [1001]","HB AMC AETNA PPO","6711.79","80.4","","6314.10","6314.10","6314.10","1 through 10","3895.16","10104.75","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","outpatient","","","8348.00","6261.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4362.66","52.26","","5009.19","5009.19","5009.19","1 through 10","3895.16","10104.75","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","outpatient","","","8348.00","6261.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","6821.99","81.72","","6471.14","6471.14","6471.14","1 through 10","3895.16","10104.75","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","outpatient","","","8348.00","6261.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6821.99","81.72","","6471.14","3559.37","6471.14","22","3895.16","10104.75","percent of total billed charges",""
"Myocrd Img Pet Prfuj W/Metab 2rtracer Cncrnt CT","PX-40000170","CDM","78433","CPT","0404","RC","","","","both","","","11048.00","8286.00","MEDICARE [2001]","HB BWH MEDICARE","2316.10","","APC Price ($2,316.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2234.30","2234.30","2234.30","1 through 10","2200.52","8783.16","other","OPPS APC"
"Myocrd Symp Innervaj Img Plnr Qual&Quant W/Spect","PX-34000175","CDM","0332T","CPT","0341","RC","","","","both","","","1621.00","1215.75","MEDICARE [2001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1549.78","1549.78","1549.78","1 through 10","502.51","1937.72","other","OPPS APC"
"Myofibrillar Myopathy Advanced Sequencing Evaluation","PX-31000739","CDM","81479","CPT","0310","RC","","","","both","","","994.00","745.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","790.23","79.5","","0.65","0.65","0.65","1 through 10","308.14","944.3","percent of total billed charges",""
"Myofibrillar Myopathy Advanced Sequencing Evaluation","PX-31000739","CDM","81479","CPT","0310","RC","","","","both","","","994.00","745.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","529.80","53.3","","0.79","0.79","0.79","1 through 10","308.14","944.3","percent of total billed charges",""
"Myofibrillar Myopathy Advanced Sequencing Evaluation","PX-31000739","CDM","81479","CPT","0310","RC","","","","outpatient","","","994.00","745.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","497.00","50","","1.00","1.00","1.00","1 through 10","156.55","820.05","percent of total billed charges",""
"Myofibrillar Myopathy Advanced Sequencing Evaluation","PX-31000739","CDM","81479","CPT","0310","RC","","","","outpatient","","","994.00","745.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","521.85","52.5","","1.00","0.53","1.00","1 through 10","156.55","820.05","percent of total billed charges",""
"Myoglobin","PX-30000581","CDM","83874","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","167.63","167.63","1 through 10","12.66","209","percent of total billed charges",""
"Myoglobin","PX-30000581","CDM","83874","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","67.52","67.52","67.52","1 through 10","12.66","209","percent of total billed charges",""
"Myoglobin","PX-30000581","CDM","83874","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","15.57","15.57","15.57","1 through 10","12.66","209","percent of total billed charges",""
"Myoglobin","PX-30000581","CDM","83874","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","144.20","144.20","1 through 10","13.32","179.78","percent of total billed charges",""
"Myoglobin","PX-30000581","CDM","83874","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.32","179.78","percent of total billed charges",""
"Myomectomy <250grams Vag","PX-76001380","CDM","58145","CPT","0761","RC","","","","outpatient","","","8960.00","6720.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5425.28","60.55","","5524.71","5524.71","5524.71","1 through 10","3584","7322.11","percent of total billed charges",""
"Myomectomy 1-4 W/Tot 250gms/<Abd Apprch","PX-36000424","CDM","58140","CPT","0361","RC","","","","outpatient","","","4682.00","3511.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1541.62","","Case rate ($1,541.62). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3154.15","3154.15","3154.15","1 through 10","1541.62","11593.85","other","ASC"
"Myomectomy 1-4 W/Tot 250gms/<Abd Apprch","PX-36000424","CDM","58140","CPT","0361","RC","","","","outpatient","","","4682.00","3511.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1541.62","","Case rate ($1,541.62). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3608.93","3573.48","3608.93","1 through 10","1541.62","11593.85","other","ASC "
"Myopathy Comprehensive (163 Genes & Mtdna)","PX-31000718","CDM","81479","CPT","0310","RC","","","","both","","","5110.00","3832.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4062.45","79.5","","0.65","0.65","0.65","1 through 10","1584.1","4854.5","percent of total billed charges",""
"Myopathy Comprehensive (163 Genes & Mtdna)","PX-31000718","CDM","81479","CPT","0310","RC","","","","both","","","5110.00","3832.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2723.63","53.3","","0.79","0.79","0.79","1 through 10","1584.1","4854.5","percent of total billed charges",""
"Myopathy Comprehensive (163 Genes & Mtdna)","PX-31000718","CDM","81479","CPT","0310","RC","","","","outpatient","","","5110.00","3832.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2555.00","50","","1.00","1.00","1.00","1 through 10","156.55","4215.75","percent of total billed charges",""
"Myopathy Comprehensive (163 Genes & Mtdna)","PX-31000718","CDM","81479","CPT","0310","RC","","","","outpatient","","","5110.00","3832.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2682.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","4215.75","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1244.33","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1244.05","1174.22","1246.25","1 through 10","1147.8","6181.13","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1208.09","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1188.88","1122.86","1188.88","1 through 10","1147.8","6181.13","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","5100.40","65.6","","1184.05","1184.05","1184.05","1 through 10","1147.8","6181.13","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6181.13","79.5","","5933.98","5933.98","5933.98","1 through 10","1147.8","6181.13","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4144.08","53.3","","12597.55","12597.55","12597.55","1 through 10","1147.8","6181.13","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1208.09","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1188.88","1118.30","1188.88","1 through 10","1147.8","6181.13","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","FALLON HEALTH [1008]","HB BWH MEDICARE","1208.09","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1927.22","1927.22","1927.22","1 through 10","1147.8","6181.13","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","MEDICARE [2001]","HB BWH MEDICARE","1208.09","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1208.21","1208.21","1208.21","55","1147.8","6181.13","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2837.88","36.5","","7563.30","2812.42","7563.30","1 through 10","1147.8","6181.13","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2977.83","38.3","","27199.26","2948.14","27199.26","1 through 10","1147.8","6181.13","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1208.09","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1184.05","1184.05","1184.05","1 through 10","1147.8","6181.13","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1183.93","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1186.05","1184.05","1186.05","1 through 10","1147.8","6181.13","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1183.93","","APC Price ($1,208.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1184.55","1118.30","1185.05","1 through 10","1147.8","6181.13","other","OPPS APC"
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","both","","","7775.00","5831.25","WELLPOINT [1015]","HB AMC WELLPOINT","5736.40","73.78","","17763.03","17763.03","17763.03","1 through 10","1147.8","6181.13","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","outpatient","","","7775.00","5831.25","AETNA [1001]","HB AMC AETNA HMO","5426.95","69.8","","16152.54","5104.58","18610.02","1 through 10","1565.7","6414.38","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","outpatient","","","7775.00","5831.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3887.50","50","","3950.96","3950.96","3950.96","1 through 10","1565.7","6414.38","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","outpatient","","","7775.00","5831.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4081.88","52.5","","13122.45","12621.41","13122.45","1 through 10","1565.7","6414.38","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","outpatient","","","7775.00","5831.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","4276.25","55","","4343.04","4343.04","4343.04","1 through 10","1565.7","6414.38","percent of total billed charges",""
"N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp","PX-35000103","CDM","75580","CPT","0489","RC","","","","outpatient","","","7775.00","5831.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6353.73","81.72","","7324.71","6027.48","7324.71","1 through 10","1565.7","6414.38","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","both","","","674.70","506.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","536.39","79.5","","1309.77","674.56","6049.93","26","209.16","536.39","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","both","","","674.70","506.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","359.62","53.3","","1901.83","1901.83","2962.25","1 through 10","209.16","536.39","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","both","","","674.70","506.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","246.27","36.5","","1620.31","1620.31","19908.88","1 through 10","209.16","536.39","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","both","","","674.70","506.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","258.41","38.3","","352.91","352.91","2046.30","1 through 10","209.16","536.39","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","both","","","674.70","506.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.45","42.9","","9668.75","9668.75","9668.75","1 through 10","209.16","536.39","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","both","","","674.70","506.02","WELLPOINT [1015]","HB AMC WELLPOINT","497.79","73.78","","699.88","384.10","3443.31","33","209.16","536.39","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","674.70","506.02","AETNA [1001]","HB AMC AETNA HMO","470.94","69.8","","1421.24","264.50","4933.46","29","352.6","551.36","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","674.70","506.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","542.46","80.4","","1022.97","1022.97","3607.50","1 through 10","352.6","551.36","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","674.70","506.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","551.36","81.72","","3010.54","693.88","5019.88","35","352.6","551.36","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","515.82","79.5","","800.18","480.96","1887.97","195","201.14","515.82","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","345.83","53.3","","813.12","216.42","1444.50","81","201.14","515.82","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","201.14","31","","432.60","432.60","432.60","1 through 10","201.14","515.82","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","236.82","36.5","","148.37","54.89","631.39","94","201.14","515.82","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","248.50","38.3","","279.30","91.72","1116.77","266","201.14","515.82","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.35","42.9","","731.00","63.70","731.00","1 through 10","201.14","515.82","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.35","42.9","","384.74","384.74","384.74","1 through 10","201.14","515.82","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","WELLPOINT [1015]","HB AMC WELLPOINT","478.71","73.78","","286.63","119.22","1107.45","105","201.14","515.82","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.83","486.62","AETNA [1001]","HB AMC AETNA HMO","452.88","69.8","","675.31","184.75","1721.50","286","339.08","530.22","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.83","486.62","AETNA [1001]","HB AMC AETNA PPO","521.66","80.4","","1261.44","103.12","1514.10","21","339.08","530.22","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.83","486.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","521.66","80.4","","1365.00","1365.00","1365.00","1 through 10","339.08","530.22","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.83","486.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","530.22","81.72","","5157.68","5157.68","5157.68","1 through 10","339.08","530.22","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.83","486.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","530.22","81.72","","431.26","71.26","1459.57","88","339.08","530.22","percent of total billed charges",""
"NAIL BONE 10X170MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL","SUP-ITM-10009647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3021.21","79.5","","800.18","480.96","1887.97","195","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 10X170MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL","SUP-ITM-10009647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2025.54","53.3","","813.12","216.42","1444.50","81","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 10X170MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL","SUP-ITM-10009647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1178.08","31","","432.60","432.60","432.60","1 through 10","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 10X170MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL","SUP-ITM-10009647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1387.10","36.5","","148.37","54.89","631.39","94","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 10X170MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL","SUP-ITM-10009647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1455.50","38.3","","279.30","91.72","1116.77","266","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 10X170MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL","SUP-ITM-10009647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1630.32","42.9","","731.00","63.70","731.00","1 through 10","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 10X170MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL","SUP-ITM-10009647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1630.32","42.9","","384.74","384.74","384.74","1 through 10","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 10X170MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL","SUP-ITM-10009647","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","WELLPOINT [1015]","HB AMC WELLPOINT","2803.84","73.78","","286.63","119.22","1107.45","105","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 10X170MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL","SUP-ITM-10009647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3800.27","2850.20","AETNA [1001]","HB AMC AETNA HMO","2652.59","69.8","","675.31","184.75","1721.50","286","1986.02","3105.58","percent of total billed charges",""
"NAIL BONE 10X170MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL","SUP-ITM-10009647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3800.27","2850.20","AETNA [1001]","HB AMC AETNA PPO","3055.42","80.4","","1261.44","103.12","1514.10","21","1986.02","3105.58","percent of total billed charges",""
"NAIL BONE 10X170MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL","SUP-ITM-10009647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3800.27","2850.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3055.42","80.4","","1365.00","1365.00","1365.00","1 through 10","1986.02","3105.58","percent of total billed charges",""
"NAIL BONE 10X170MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL","SUP-ITM-10009647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3800.27","2850.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3105.58","81.72","","5157.68","5157.68","5157.68","1 through 10","1986.02","3105.58","percent of total billed charges",""
"NAIL BONE 10X170MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL","SUP-ITM-10009647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3800.27","2850.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3105.58","81.72","","431.26","71.26","1459.57","88","1986.02","3105.58","percent of total billed charges",""
"NAIL BONE 10X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3925.22","2943.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3120.55","79.5","","800.18","480.96","1887.97","195","1216.82","3120.55","percent of total billed charges",""
"NAIL BONE 10X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3925.22","2943.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2092.14","53.3","","813.12","216.42","1444.50","81","1216.82","3120.55","percent of total billed charges",""
"NAIL BONE 10X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3925.22","2943.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1216.82","31","","432.60","432.60","432.60","1 through 10","1216.82","3120.55","percent of total billed charges",""
"NAIL BONE 10X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3925.22","2943.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1432.71","36.5","","148.37","54.89","631.39","94","1216.82","3120.55","percent of total billed charges",""
"NAIL BONE 10X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3925.22","2943.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1503.36","38.3","","279.30","91.72","1116.77","266","1216.82","3120.55","percent of total billed charges",""
"NAIL BONE 10X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3925.22","2943.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.92","42.9","","731.00","63.70","731.00","1 through 10","1216.82","3120.55","percent of total billed charges",""
"NAIL BONE 10X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3925.22","2943.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.92","42.9","","384.74","384.74","384.74","1 through 10","1216.82","3120.55","percent of total billed charges",""
"NAIL BONE 10X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025908","CDM","C1713","HCPCS","0278","RC","","","","both","","","3925.22","2943.91","WELLPOINT [1015]","HB AMC WELLPOINT","2896.03","73.78","","286.63","119.22","1107.45","105","1216.82","3120.55","percent of total billed charges",""
"NAIL BONE 10X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3925.22","2943.91","AETNA [1001]","HB AMC AETNA HMO","2739.80","69.8","","675.31","184.75","1721.50","286","2051.32","3207.69","percent of total billed charges",""
"NAIL BONE 10X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3925.22","2943.91","AETNA [1001]","HB AMC AETNA PPO","3155.88","80.4","","1261.44","103.12","1514.10","21","2051.32","3207.69","percent of total billed charges",""
"NAIL BONE 10X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3925.22","2943.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3155.88","80.4","","1365.00","1365.00","1365.00","1 through 10","2051.32","3207.69","percent of total billed charges",""
"NAIL BONE 10X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3925.22","2943.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3207.69","81.72","","5157.68","5157.68","5157.68","1 through 10","2051.32","3207.69","percent of total billed charges",""
"NAIL BONE 10X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3925.22","2943.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3207.69","81.72","","431.26","71.26","1459.57","88","2051.32","3207.69","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3265.07","79.5","","800.18","480.96","1887.97","195","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2189.03","53.3","","813.12","216.42","1444.50","81","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1273.17","31","","432.60","432.60","432.60","1 through 10","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1499.06","36.5","","148.37","54.89","631.39","94","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1572.98","38.3","","279.30","91.72","1116.77","266","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1761.90","42.9","","731.00","63.70","731.00","1 through 10","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1761.90","42.9","","384.74","384.74","384.74","1 through 10","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","WELLPOINT [1015]","HB AMC WELLPOINT","3030.14","73.78","","286.63","119.22","1107.45","105","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","AETNA [1001]","HB AMC AETNA HMO","2866.69","69.8","","675.31","184.75","1721.50","286","2146.32","3356.24","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","AETNA [1001]","HB AMC AETNA PPO","3302.03","80.4","","1261.44","103.12","1514.10","21","2146.32","3356.24","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3302.03","80.4","","1365.00","1365.00","1365.00","1 through 10","2146.32","3356.24","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3356.24","81.72","","5157.68","5157.68","5157.68","1 through 10","2146.32","3356.24","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3356.24","81.72","","431.26","71.26","1459.57","88","2146.32","3356.24","percent of total billed charges",""
"NAIL BONE 11.5MMX65 INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10100894","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13733.63","79.5","","800.18","480.96","1887.97","195","5355.25","13733.63","percent of total billed charges",""
"NAIL BONE 11.5MMX65 INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10100894","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9207.58","53.3","","813.12","216.42","1444.50","81","5355.25","13733.63","percent of total billed charges",""
"NAIL BONE 11.5MMX65 INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10100894","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","5355.25","31","","432.60","432.60","432.60","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL BONE 11.5MMX65 INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10100894","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6305.38","36.5","","148.37","54.89","631.39","94","5355.25","13733.63","percent of total billed charges",""
"NAIL BONE 11.5MMX65 INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10100894","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6616.33","38.3","","279.30","91.72","1116.77","266","5355.25","13733.63","percent of total billed charges",""
"NAIL BONE 11.5MMX65 INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10100894","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7410.98","42.9","","731.00","63.70","731.00","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL BONE 11.5MMX65 INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10100894","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7410.98","42.9","","384.74","384.74","384.74","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL BONE 11.5MMX65 INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10100894","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","WELLPOINT [1015]","HB AMC WELLPOINT","12745.50","73.78","","286.63","119.22","1107.45","105","5355.25","13733.63","percent of total billed charges",""
"NAIL BONE 11.5MMX65 INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10100894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","AETNA [1001]","HB AMC AETNA HMO","12057.95","69.8","","675.31","184.75","1721.50","286","9027.92","14117.13","percent of total billed charges",""
"NAIL BONE 11.5MMX65 INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10100894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","AETNA [1001]","HB AMC AETNA PPO","13889.10","80.4","","1261.44","103.12","1514.10","21","9027.92","14117.13","percent of total billed charges",""
"NAIL BONE 11.5MMX65 INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10100894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","13889.10","80.4","","1365.00","1365.00","1365.00","1 through 10","9027.92","14117.13","percent of total billed charges",""
"NAIL BONE 11.5MMX65 INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10100894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","14117.13","81.72","","5157.68","5157.68","5157.68","1 through 10","9027.92","14117.13","percent of total billed charges",""
"NAIL BONE 11.5MMX65 INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10100894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14117.13","81.72","","431.26","71.26","1459.57","88","9027.92","14117.13","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033702","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20116.39","79.5","","800.18","480.96","1887.97","195","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033702","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13486.83","53.3","","813.12","216.42","1444.50","81","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033702","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","7844.13","31","","432.60","432.60","432.60","1 through 10","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033702","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9235.82","36.5","","148.37","54.89","631.39","94","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033702","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9691.29","38.3","","279.30","91.72","1116.77","266","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033702","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10855.26","42.9","","731.00","63.70","731.00","1 through 10","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033702","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10855.26","42.9","","384.74","384.74","384.74","1 through 10","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033702","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","WELLPOINT [1015]","HB AMC WELLPOINT","18669.02","73.78","","286.63","119.22","1107.45","105","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033702","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","AETNA [1001]","HB AMC AETNA HMO","17661.93","69.8","","675.31","184.75","1721.50","286","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033702","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","AETNA [1001]","HB AMC AETNA PPO","20344.12","80.4","","1261.44","103.12","1514.10","21","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033702","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","20344.12","80.4","","1365.00","1365.00","1365.00","1 through 10","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033702","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","20678.13","81.72","","5157.68","5157.68","5157.68","1 through 10","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033702","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","20678.13","81.72","","431.26","71.26","1459.57","88","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO RIGHT","SUP-ITM-10033709","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20116.39","79.5","","800.18","480.96","1887.97","195","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO RIGHT","SUP-ITM-10033709","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13486.83","53.3","","813.12","216.42","1444.50","81","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO RIGHT","SUP-ITM-10033709","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","7844.13","31","","432.60","432.60","432.60","1 through 10","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO RIGHT","SUP-ITM-10033709","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9235.82","36.5","","148.37","54.89","631.39","94","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO RIGHT","SUP-ITM-10033709","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9691.29","38.3","","279.30","91.72","1116.77","266","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO RIGHT","SUP-ITM-10033709","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10855.26","42.9","","731.00","63.70","731.00","1 through 10","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO RIGHT","SUP-ITM-10033709","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10855.26","42.9","","384.74","384.74","384.74","1 through 10","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO RIGHT","SUP-ITM-10033709","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","WELLPOINT [1015]","HB AMC WELLPOINT","18669.02","73.78","","286.63","119.22","1107.45","105","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO RIGHT","SUP-ITM-10033709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","AETNA [1001]","HB AMC AETNA HMO","17661.93","69.8","","675.31","184.75","1721.50","286","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO RIGHT","SUP-ITM-10033709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","AETNA [1001]","HB AMC AETNA PPO","20344.12","80.4","","1261.44","103.12","1514.10","21","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO RIGHT","SUP-ITM-10033709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","20344.12","80.4","","1365.00","1365.00","1365.00","1 through 10","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO RIGHT","SUP-ITM-10033709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","20678.13","81.72","","5157.68","5157.68","5157.68","1 through 10","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X660MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO RIGHT","SUP-ITM-10033709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","20678.13","81.72","","431.26","71.26","1459.57","88","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X700MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033703","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20116.39","79.5","","800.18","480.96","1887.97","195","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X700MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033703","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13486.83","53.3","","813.12","216.42","1444.50","81","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X700MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033703","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","7844.13","31","","432.60","432.60","432.60","1 through 10","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X700MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033703","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9235.82","36.5","","148.37","54.89","631.39","94","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X700MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033703","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9691.29","38.3","","279.30","91.72","1116.77","266","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X700MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033703","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10855.26","42.9","","731.00","63.70","731.00","1 through 10","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X700MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033703","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10855.26","42.9","","384.74","384.74","384.74","1 through 10","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X700MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033703","CDM","C1713","HCPCS","0278","RC","","","","both","","","25303.63","18977.72","WELLPOINT [1015]","HB AMC WELLPOINT","18669.02","73.78","","286.63","119.22","1107.45","105","7844.13","20116.39","percent of total billed charges",""
"NAIL BONE 11.5X700MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","AETNA [1001]","HB AMC AETNA HMO","17661.93","69.8","","675.31","184.75","1721.50","286","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X700MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","AETNA [1001]","HB AMC AETNA PPO","20344.12","80.4","","1261.44","103.12","1514.10","21","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X700MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","20344.12","80.4","","1365.00","1365.00","1365.00","1 through 10","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X700MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","20678.13","81.72","","5157.68","5157.68","5157.68","1 through 10","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11.5X700MM INTRAMEDULLARY HOWMEDICA T2 ARTHRO LEFT","SUP-ITM-10033703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25303.63","18977.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","20678.13","81.72","","431.26","71.26","1459.57","88","13223.68","20678.13","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3021.21","79.5","","800.18","480.96","1887.97","195","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2025.54","53.3","","813.12","216.42","1444.50","81","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1178.08","31","","432.60","432.60","432.60","1 through 10","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1387.10","36.5","","148.37","54.89","631.39","94","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1455.50","38.3","","279.30","91.72","1116.77","266","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1630.32","42.9","","731.00","63.70","731.00","1 through 10","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1630.32","42.9","","384.74","384.74","384.74","1 through 10","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3800.27","2850.20","WELLPOINT [1015]","HB AMC WELLPOINT","2803.84","73.78","","286.63","119.22","1107.45","105","1178.08","3021.21","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3800.27","2850.20","AETNA [1001]","HB AMC AETNA HMO","2652.59","69.8","","675.31","184.75","1721.50","286","1986.02","3105.58","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3800.27","2850.20","AETNA [1001]","HB AMC AETNA PPO","3055.42","80.4","","1261.44","103.12","1514.10","21","1986.02","3105.58","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3800.27","2850.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3055.42","80.4","","1365.00","1365.00","1365.00","1 through 10","1986.02","3105.58","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3800.27","2850.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3105.58","81.72","","5157.68","5157.68","5157.68","1 through 10","1986.02","3105.58","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3800.27","2850.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3105.58","81.72","","431.26","71.26","1459.57","88","1986.02","3105.58","percent of total billed charges",""
"NAIL BONE 11X300MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION RIGHT","SUP-ITM-10009650","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4148.35","79.5","","800.18","480.96","1887.97","195","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 11X300MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION RIGHT","SUP-ITM-10009650","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2781.22","53.3","","813.12","216.42","1444.50","81","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 11X300MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION RIGHT","SUP-ITM-10009650","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1617.60","31","","432.60","432.60","432.60","1 through 10","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 11X300MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION RIGHT","SUP-ITM-10009650","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1904.59","36.5","","148.37","54.89","631.39","94","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 11X300MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION RIGHT","SUP-ITM-10009650","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1998.51","38.3","","279.30","91.72","1116.77","266","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 11X300MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION RIGHT","SUP-ITM-10009650","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2238.54","42.9","","731.00","63.70","731.00","1 through 10","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 11X300MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION RIGHT","SUP-ITM-10009650","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2238.54","42.9","","384.74","384.74","384.74","1 through 10","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 11X300MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION RIGHT","SUP-ITM-10009650","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","WELLPOINT [1015]","HB AMC WELLPOINT","3849.88","73.78","","286.63","119.22","1107.45","105","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 11X300MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION RIGHT","SUP-ITM-10009650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5218.05","3913.54","AETNA [1001]","HB AMC AETNA HMO","3642.20","69.8","","675.31","184.75","1721.50","286","2726.95","4264.19","percent of total billed charges",""
"NAIL BONE 11X300MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION RIGHT","SUP-ITM-10009650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5218.05","3913.54","AETNA [1001]","HB AMC AETNA PPO","4195.31","80.4","","1261.44","103.12","1514.10","21","2726.95","4264.19","percent of total billed charges",""
"NAIL BONE 11X300MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION RIGHT","SUP-ITM-10009650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5218.05","3913.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4195.31","80.4","","1365.00","1365.00","1365.00","1 through 10","2726.95","4264.19","percent of total billed charges",""
"NAIL BONE 11X300MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION RIGHT","SUP-ITM-10009650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5218.05","3913.54","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4264.19","81.72","","5157.68","5157.68","5157.68","1 through 10","2726.95","4264.19","percent of total billed charges",""
"NAIL BONE 11X300MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION RIGHT","SUP-ITM-10009650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5218.05","3913.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4264.19","81.72","","431.26","71.26","1459.57","88","2726.95","4264.19","percent of total billed charges",""
"NAIL BONE 11X330MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018309","CDM","C1713","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4664.19","79.5","","800.18","480.96","1887.97","195","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 11X330MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018309","CDM","C1713","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3127.06","53.3","","813.12","216.42","1444.50","81","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 11X330MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018309","CDM","C1713","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1818.74","31","","432.60","432.60","432.60","1 through 10","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 11X330MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018309","CDM","C1713","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2141.42","36.5","","148.37","54.89","631.39","94","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 11X330MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018309","CDM","C1713","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2247.02","38.3","","279.30","91.72","1116.77","266","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 11X330MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018309","CDM","C1713","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2516.90","42.9","","731.00","63.70","731.00","1 through 10","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 11X330MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018309","CDM","C1713","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2516.90","42.9","","384.74","384.74","384.74","1 through 10","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 11X330MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018309","CDM","C1713","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","WELLPOINT [1015]","HB AMC WELLPOINT","4328.60","73.78","","286.63","119.22","1107.45","105","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 11X330MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5866.90","4400.17","AETNA [1001]","HB AMC AETNA HMO","4095.10","69.8","","675.31","184.75","1721.50","286","3066.04","4794.43","percent of total billed charges",""
"NAIL BONE 11X330MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5866.90","4400.17","AETNA [1001]","HB AMC AETNA PPO","4716.99","80.4","","1261.44","103.12","1514.10","21","3066.04","4794.43","percent of total billed charges",""
"NAIL BONE 11X330MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5866.90","4400.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4716.99","80.4","","1365.00","1365.00","1365.00","1 through 10","3066.04","4794.43","percent of total billed charges",""
"NAIL BONE 11X330MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5866.90","4400.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4794.43","81.72","","5157.68","5157.68","5157.68","1 through 10","3066.04","4794.43","percent of total billed charges",""
"NAIL BONE 11X330MM TIBIAL T2 TITANIUM INTRAMEDULLARY STANDARD","SUP-ITM-10018309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5866.90","4400.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4794.43","81.72","","431.26","71.26","1459.57","88","3066.04","4794.43","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3407.00","79.5","","800.18","480.96","1887.97","195","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2284.19","53.3","","813.12","216.42","1444.50","81","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1328.51","31","","432.60","432.60","432.60","1 through 10","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1564.22","36.5","","148.37","54.89","631.39","94","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1641.36","38.3","","279.30","91.72","1116.77","266","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1838.49","42.9","","731.00","63.70","731.00","1 through 10","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1838.49","42.9","","384.74","384.74","384.74","1 through 10","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","WELLPOINT [1015]","HB AMC WELLPOINT","3161.86","73.78","","286.63","119.22","1107.45","105","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4285.53","3214.15","AETNA [1001]","HB AMC AETNA HMO","2991.30","69.8","","675.31","184.75","1721.50","286","2239.62","3502.14","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4285.53","3214.15","AETNA [1001]","HB AMC AETNA PPO","3445.57","80.4","","1261.44","103.12","1514.10","21","2239.62","3502.14","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4285.53","3214.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3445.57","80.4","","1365.00","1365.00","1365.00","1 through 10","2239.62","3502.14","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4285.53","3214.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3502.14","81.72","","5157.68","5157.68","5157.68","1 through 10","2239.62","3502.14","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4285.53","3214.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3502.14","81.72","","431.26","71.26","1459.57","88","2239.62","3502.14","percent of total billed charges",""
"NAIL BONE 11X360MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL LEFT","SUP-ITM-10009657","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3407.00","79.5","","800.18","480.96","1887.97","195","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X360MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL LEFT","SUP-ITM-10009657","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2284.19","53.3","","813.12","216.42","1444.50","81","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X360MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL LEFT","SUP-ITM-10009657","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1328.51","31","","432.60","432.60","432.60","1 through 10","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X360MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL LEFT","SUP-ITM-10009657","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1564.22","36.5","","148.37","54.89","631.39","94","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X360MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL LEFT","SUP-ITM-10009657","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1641.36","38.3","","279.30","91.72","1116.77","266","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X360MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL LEFT","SUP-ITM-10009657","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1838.49","42.9","","731.00","63.70","731.00","1 through 10","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X360MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL LEFT","SUP-ITM-10009657","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1838.49","42.9","","384.74","384.74","384.74","1 through 10","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X360MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL LEFT","SUP-ITM-10009657","CDM","C1713","HCPCS","0278","RC","","","","both","","","4285.53","3214.15","WELLPOINT [1015]","HB AMC WELLPOINT","3161.86","73.78","","286.63","119.22","1107.45","105","1328.51","3407","percent of total billed charges",""
"NAIL BONE 11X360MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL LEFT","SUP-ITM-10009657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4285.53","3214.15","AETNA [1001]","HB AMC AETNA HMO","2991.30","69.8","","675.31","184.75","1721.50","286","2239.62","3502.14","percent of total billed charges",""
"NAIL BONE 11X360MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL LEFT","SUP-ITM-10009657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4285.53","3214.15","AETNA [1001]","HB AMC AETNA PPO","3445.57","80.4","","1261.44","103.12","1514.10","21","2239.62","3502.14","percent of total billed charges",""
"NAIL BONE 11X360MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL LEFT","SUP-ITM-10009657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4285.53","3214.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3445.57","80.4","","1365.00","1365.00","1365.00","1 through 10","2239.62","3502.14","percent of total billed charges",""
"NAIL BONE 11X360MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL LEFT","SUP-ITM-10009657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4285.53","3214.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3502.14","81.72","","5157.68","5157.68","5157.68","1 through 10","2239.62","3502.14","percent of total billed charges",""
"NAIL BONE 11X360MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL LEFT","SUP-ITM-10009657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4285.53","3214.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3502.14","81.72","","431.26","71.26","1459.57","88","2239.62","3502.14","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3867.78","79.5","","800.18","480.96","1887.97","195","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2593.11","53.3","","813.12","216.42","1444.50","81","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1508.19","31","","432.60","432.60","432.60","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1775.77","36.5","","148.37","54.89","631.39","94","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1863.34","38.3","","279.30","91.72","1116.77","266","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2087.14","42.9","","731.00","63.70","731.00","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2087.14","42.9","","384.74","384.74","384.74","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","WELLPOINT [1015]","HB AMC WELLPOINT","3589.49","73.78","","286.63","119.22","1107.45","105","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","AETNA [1001]","HB AMC AETNA HMO","3395.86","69.8","","675.31","184.75","1721.50","286","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","AETNA [1001]","HB AMC AETNA PPO","3911.56","80.4","","1261.44","103.12","1514.10","21","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3911.56","80.4","","1365.00","1365.00","1365.00","1 through 10","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3975.78","81.72","","5157.68","5157.68","5157.68","1 through 10","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3975.78","81.72","","431.26","71.26","1459.57","88","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4359.04","3269.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3465.44","79.5","","800.18","480.96","1887.97","195","1351.3","3465.44","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4359.04","3269.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2323.37","53.3","","813.12","216.42","1444.50","81","1351.3","3465.44","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4359.04","3269.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1351.30","31","","432.60","432.60","432.60","1 through 10","1351.3","3465.44","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4359.04","3269.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1591.05","36.5","","148.37","54.89","631.39","94","1351.3","3465.44","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4359.04","3269.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1669.51","38.3","","279.30","91.72","1116.77","266","1351.3","3465.44","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4359.04","3269.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1870.03","42.9","","731.00","63.70","731.00","1 through 10","1351.3","3465.44","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4359.04","3269.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1870.03","42.9","","384.74","384.74","384.74","1 through 10","1351.3","3465.44","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4359.04","3269.28","WELLPOINT [1015]","HB AMC WELLPOINT","3216.10","73.78","","286.63","119.22","1107.45","105","1351.3","3465.44","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4359.04","3269.28","AETNA [1001]","HB AMC AETNA HMO","3042.61","69.8","","675.31","184.75","1721.50","286","2278.03","3562.21","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4359.04","3269.28","AETNA [1001]","HB AMC AETNA PPO","3504.67","80.4","","1261.44","103.12","1514.10","21","2278.03","3562.21","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4359.04","3269.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3504.67","80.4","","1365.00","1365.00","1365.00","1 through 10","2278.03","3562.21","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4359.04","3269.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3562.21","81.72","","5157.68","5157.68","5157.68","1 through 10","2278.03","3562.21","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4359.04","3269.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3562.21","81.72","","431.26","71.26","1459.57","88","2278.03","3562.21","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3307.87","79.5","","800.18","480.96","1887.97","195","1289.86","3307.87","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2217.73","53.3","","813.12","216.42","1444.50","81","1289.86","3307.87","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1289.86","31","","432.60","432.60","432.60","1 through 10","1289.86","3307.87","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1518.71","36.5","","148.37","54.89","631.39","94","1289.86","3307.87","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1593.60","38.3","","279.30","91.72","1116.77","266","1289.86","3307.87","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1785.00","42.9","","731.00","63.70","731.00","1 through 10","1289.86","3307.87","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1785.00","42.9","","384.74","384.74","384.74","1 through 10","1289.86","3307.87","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","WELLPOINT [1015]","HB AMC WELLPOINT","3069.87","73.78","","286.63","119.22","1107.45","105","1289.86","3307.87","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4160.84","3120.63","AETNA [1001]","HB AMC AETNA HMO","2904.27","69.8","","675.31","184.75","1721.50","286","2174.45","3400.24","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4160.84","3120.63","AETNA [1001]","HB AMC AETNA PPO","3345.32","80.4","","1261.44","103.12","1514.10","21","2174.45","3400.24","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4160.84","3120.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3345.32","80.4","","1365.00","1365.00","1365.00","1 through 10","2174.45","3400.24","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4160.84","3120.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3400.24","81.72","","5157.68","5157.68","5157.68","1 through 10","2174.45","3400.24","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4160.84","3120.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3400.24","81.72","","431.26","71.26","1459.57","88","2174.45","3400.24","percent of total billed charges",""
"NAIL BONE 12X235MM 130DEG TFN ADVANCED FEMORAL NECK SHORT LEFT STERILE","SUP-ITM-10164000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3465.38","79.5","","800.18","480.96","1887.97","195","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 12X235MM 130DEG TFN ADVANCED FEMORAL NECK SHORT LEFT STERILE","SUP-ITM-10164000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2323.33","53.3","","813.12","216.42","1444.50","81","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 12X235MM 130DEG TFN ADVANCED FEMORAL NECK SHORT LEFT STERILE","SUP-ITM-10164000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1351.28","31","","432.60","432.60","432.60","1 through 10","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 12X235MM 130DEG TFN ADVANCED FEMORAL NECK SHORT LEFT STERILE","SUP-ITM-10164000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1591.02","36.5","","148.37","54.89","631.39","94","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 12X235MM 130DEG TFN ADVANCED FEMORAL NECK SHORT LEFT STERILE","SUP-ITM-10164000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1669.49","38.3","","279.30","91.72","1116.77","266","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 12X235MM 130DEG TFN ADVANCED FEMORAL NECK SHORT LEFT STERILE","SUP-ITM-10164000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1870.00","42.9","","731.00","63.70","731.00","1 through 10","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 12X235MM 130DEG TFN ADVANCED FEMORAL NECK SHORT LEFT STERILE","SUP-ITM-10164000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1870.00","42.9","","384.74","384.74","384.74","1 through 10","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 12X235MM 130DEG TFN ADVANCED FEMORAL NECK SHORT LEFT STERILE","SUP-ITM-10164000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","WELLPOINT [1015]","HB AMC WELLPOINT","3216.05","73.78","","286.63","119.22","1107.45","105","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 12X235MM 130DEG TFN ADVANCED FEMORAL NECK SHORT LEFT STERILE","SUP-ITM-10164000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","AETNA [1001]","HB AMC AETNA HMO","3042.56","69.8","","675.31","184.75","1721.50","286","2278","3562.15","percent of total billed charges",""
"NAIL BONE 12X235MM 130DEG TFN ADVANCED FEMORAL NECK SHORT LEFT STERILE","SUP-ITM-10164000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","AETNA [1001]","HB AMC AETNA PPO","3504.61","80.4","","1261.44","103.12","1514.10","21","2278","3562.15","percent of total billed charges",""
"NAIL BONE 12X235MM 130DEG TFN ADVANCED FEMORAL NECK SHORT LEFT STERILE","SUP-ITM-10164000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3504.61","80.4","","1365.00","1365.00","1365.00","1 through 10","2278","3562.15","percent of total billed charges",""
"NAIL BONE 12X235MM 130DEG TFN ADVANCED FEMORAL NECK SHORT LEFT STERILE","SUP-ITM-10164000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3562.15","81.72","","5157.68","5157.68","5157.68","1 through 10","2278","3562.15","percent of total billed charges",""
"NAIL BONE 12X235MM 130DEG TFN ADVANCED FEMORAL NECK SHORT LEFT STERILE","SUP-ITM-10164000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3562.15","81.72","","431.26","71.26","1459.57","88","2278","3562.15","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3265.07","79.5","","800.18","480.96","1887.97","195","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2189.03","53.3","","813.12","216.42","1444.50","81","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1273.17","31","","432.60","432.60","432.60","1 through 10","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1499.06","36.5","","148.37","54.89","631.39","94","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1572.98","38.3","","279.30","91.72","1116.77","266","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1761.90","42.9","","731.00","63.70","731.00","1 through 10","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1761.90","42.9","","384.74","384.74","384.74","1 through 10","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","WELLPOINT [1015]","HB AMC WELLPOINT","3030.14","73.78","","286.63","119.22","1107.45","105","1273.17","3265.07","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","AETNA [1001]","HB AMC AETNA HMO","2866.69","69.8","","675.31","184.75","1721.50","286","2146.32","3356.24","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","AETNA [1001]","HB AMC AETNA PPO","3302.03","80.4","","1261.44","103.12","1514.10","21","2146.32","3356.24","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3302.03","80.4","","1365.00","1365.00","1365.00","1 through 10","2146.32","3356.24","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3356.24","81.72","","5157.68","5157.68","5157.68","1 through 10","2146.32","3356.24","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3356.24","81.72","","431.26","71.26","1459.57","88","2146.32","3356.24","percent of total billed charges",""
"NAIL BONE 12X400MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10041001","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4148.35","79.5","","800.18","480.96","1887.97","195","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 12X400MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10041001","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2781.22","53.3","","813.12","216.42","1444.50","81","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 12X400MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10041001","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1617.60","31","","432.60","432.60","432.60","1 through 10","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 12X400MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10041001","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1904.59","36.5","","148.37","54.89","631.39","94","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 12X400MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10041001","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1998.51","38.3","","279.30","91.72","1116.77","266","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 12X400MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10041001","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2238.54","42.9","","731.00","63.70","731.00","1 through 10","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 12X400MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10041001","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2238.54","42.9","","384.74","384.74","384.74","1 through 10","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 12X400MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10041001","CDM","C1713","HCPCS","0278","RC","","","","both","","","5218.05","3913.54","WELLPOINT [1015]","HB AMC WELLPOINT","3849.88","73.78","","286.63","119.22","1107.45","105","1617.6","4148.35","percent of total billed charges",""
"NAIL BONE 12X400MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10041001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5218.05","3913.54","AETNA [1001]","HB AMC AETNA HMO","3642.20","69.8","","675.31","184.75","1721.50","286","2726.95","4264.19","percent of total billed charges",""
"NAIL BONE 12X400MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10041001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5218.05","3913.54","AETNA [1001]","HB AMC AETNA PPO","4195.31","80.4","","1261.44","103.12","1514.10","21","2726.95","4264.19","percent of total billed charges",""
"NAIL BONE 12X400MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10041001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5218.05","3913.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4195.31","80.4","","1365.00","1365.00","1365.00","1 through 10","2726.95","4264.19","percent of total billed charges",""
"NAIL BONE 12X400MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10041001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5218.05","3913.54","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4264.19","81.72","","5157.68","5157.68","5157.68","1 through 10","2726.95","4264.19","percent of total billed charges",""
"NAIL BONE 12X400MM 130DEG FEMORAL CANNULATED TITANIUM TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10041001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5218.05","3913.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4264.19","81.72","","431.26","71.26","1459.57","88","2726.95","4264.19","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3867.78","79.5","","800.18","480.96","1887.97","195","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2593.11","53.3","","813.12","216.42","1444.50","81","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1508.19","31","","432.60","432.60","432.60","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1775.77","36.5","","148.37","54.89","631.39","94","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1863.34","38.3","","279.30","91.72","1116.77","266","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2087.14","42.9","","731.00","63.70","731.00","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2087.14","42.9","","384.74","384.74","384.74","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","WELLPOINT [1015]","HB AMC WELLPOINT","3589.49","73.78","","286.63","119.22","1107.45","105","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","AETNA [1001]","HB AMC AETNA HMO","3395.86","69.8","","675.31","184.75","1721.50","286","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","AETNA [1001]","HB AMC AETNA PPO","3911.56","80.4","","1261.44","103.12","1514.10","21","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3911.56","80.4","","1365.00","1365.00","1365.00","1 through 10","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3975.78","81.72","","5157.68","5157.68","5157.68","1 through 10","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3975.78","81.72","","431.26","71.26","1459.57","88","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3465.38","79.5","","800.18","480.96","1887.97","195","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2323.33","53.3","","813.12","216.42","1444.50","81","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1351.28","31","","432.60","432.60","432.60","1 through 10","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1591.02","36.5","","148.37","54.89","631.39","94","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1669.49","38.3","","279.30","91.72","1116.77","266","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1870.00","42.9","","731.00","63.70","731.00","1 through 10","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1870.00","42.9","","384.74","384.74","384.74","1 through 10","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","4358.97","3269.23","WELLPOINT [1015]","HB AMC WELLPOINT","3216.05","73.78","","286.63","119.22","1107.45","105","1351.28","3465.38","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","AETNA [1001]","HB AMC AETNA HMO","3042.56","69.8","","675.31","184.75","1721.50","286","2278","3562.15","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","AETNA [1001]","HB AMC AETNA PPO","3504.61","80.4","","1261.44","103.12","1514.10","21","2278","3562.15","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3504.61","80.4","","1365.00","1365.00","1365.00","1 through 10","2278","3562.15","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3562.15","81.72","","5157.68","5157.68","5157.68","1 through 10","2278","3562.15","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4358.97","3269.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3562.15","81.72","","431.26","71.26","1459.57","88","2278","3562.15","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3210.06","79.5","","800.18","480.96","1887.97","195","1251.72","3210.06","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2152.15","53.3","","813.12","216.42","1444.50","81","1251.72","3210.06","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1251.72","31","","432.60","432.60","432.60","1 through 10","1251.72","3210.06","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1473.80","36.5","","148.37","54.89","631.39","94","1251.72","3210.06","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1546.48","38.3","","279.30","91.72","1116.77","266","1251.72","3210.06","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1732.22","42.9","","731.00","63.70","731.00","1 through 10","1251.72","3210.06","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1732.22","42.9","","384.74","384.74","384.74","1 through 10","1251.72","3210.06","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","WELLPOINT [1015]","HB AMC WELLPOINT","2979.10","73.78","","286.63","119.22","1107.45","105","1251.72","3210.06","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4037.81","3028.36","AETNA [1001]","HB AMC AETNA HMO","2818.39","69.8","","675.31","184.75","1721.50","286","2110.16","3299.7","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4037.81","3028.36","AETNA [1001]","HB AMC AETNA PPO","3246.40","80.4","","1261.44","103.12","1514.10","21","2110.16","3299.7","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4037.81","3028.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3246.40","80.4","","1365.00","1365.00","1365.00","1 through 10","2110.16","3299.7","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4037.81","3028.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3299.70","81.72","","5157.68","5157.68","5157.68","1 through 10","2110.16","3299.7","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4037.81","3028.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3299.70","81.72","","431.26","71.26","1459.57","88","2110.16","3299.7","percent of total billed charges",""
"NAIL BONE 14X320MM 130DEG CANNULATED TROCHANTERIC FIXATION RIGHT TITANIUM","SUP-ITM-10041031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3680.87","79.5","","800.18","480.96","1887.97","195","1435.31","3680.87","percent of total billed charges",""
"NAIL BONE 14X320MM 130DEG CANNULATED TROCHANTERIC FIXATION RIGHT TITANIUM","SUP-ITM-10041031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2467.81","53.3","","813.12","216.42","1444.50","81","1435.31","3680.87","percent of total billed charges",""
"NAIL BONE 14X320MM 130DEG CANNULATED TROCHANTERIC FIXATION RIGHT TITANIUM","SUP-ITM-10041031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1435.31","31","","432.60","432.60","432.60","1 through 10","1435.31","3680.87","percent of total billed charges",""
"NAIL BONE 14X320MM 130DEG CANNULATED TROCHANTERIC FIXATION RIGHT TITANIUM","SUP-ITM-10041031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1689.96","36.5","","148.37","54.89","631.39","94","1435.31","3680.87","percent of total billed charges",""
"NAIL BONE 14X320MM 130DEG CANNULATED TROCHANTERIC FIXATION RIGHT TITANIUM","SUP-ITM-10041031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1773.30","38.3","","279.30","91.72","1116.77","266","1435.31","3680.87","percent of total billed charges",""
"NAIL BONE 14X320MM 130DEG CANNULATED TROCHANTERIC FIXATION RIGHT TITANIUM","SUP-ITM-10041031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.28","42.9","","731.00","63.70","731.00","1 through 10","1435.31","3680.87","percent of total billed charges",""
"NAIL BONE 14X320MM 130DEG CANNULATED TROCHANTERIC FIXATION RIGHT TITANIUM","SUP-ITM-10041031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.28","42.9","","384.74","384.74","384.74","1 through 10","1435.31","3680.87","percent of total billed charges",""
"NAIL BONE 14X320MM 130DEG CANNULATED TROCHANTERIC FIXATION RIGHT TITANIUM","SUP-ITM-10041031","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","WELLPOINT [1015]","HB AMC WELLPOINT","3416.04","73.78","","286.63","119.22","1107.45","105","1435.31","3680.87","percent of total billed charges",""
"NAIL BONE 14X320MM 130DEG CANNULATED TROCHANTERIC FIXATION RIGHT TITANIUM","SUP-ITM-10041031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","AETNA [1001]","HB AMC AETNA HMO","3231.76","69.8","","675.31","184.75","1721.50","286","2419.65","3783.66","percent of total billed charges",""
"NAIL BONE 14X320MM 130DEG CANNULATED TROCHANTERIC FIXATION RIGHT TITANIUM","SUP-ITM-10041031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","AETNA [1001]","HB AMC AETNA PPO","3722.54","80.4","","1261.44","103.12","1514.10","21","2419.65","3783.66","percent of total billed charges",""
"NAIL BONE 14X320MM 130DEG CANNULATED TROCHANTERIC FIXATION RIGHT TITANIUM","SUP-ITM-10041031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3722.54","80.4","","1365.00","1365.00","1365.00","1 through 10","2419.65","3783.66","percent of total billed charges",""
"NAIL BONE 14X320MM 130DEG CANNULATED TROCHANTERIC FIXATION RIGHT TITANIUM","SUP-ITM-10041031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3783.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2419.65","3783.66","percent of total billed charges",""
"NAIL BONE 14X320MM 130DEG CANNULATED TROCHANTERIC FIXATION RIGHT TITANIUM","SUP-ITM-10041031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3783.66","81.72","","431.26","71.26","1459.57","88","2419.65","3783.66","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3867.78","79.5","","800.18","480.96","1887.97","195","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2593.11","53.3","","813.12","216.42","1444.50","81","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1508.19","31","","432.60","432.60","432.60","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1775.77","36.5","","148.37","54.89","631.39","94","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1863.34","38.3","","279.30","91.72","1116.77","266","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2087.14","42.9","","731.00","63.70","731.00","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2087.14","42.9","","384.74","384.74","384.74","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","WELLPOINT [1015]","HB AMC WELLPOINT","3589.49","73.78","","286.63","119.22","1107.45","105","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","AETNA [1001]","HB AMC AETNA HMO","3395.86","69.8","","675.31","184.75","1721.50","286","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","AETNA [1001]","HB AMC AETNA PPO","3911.56","80.4","","1261.44","103.12","1514.10","21","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3911.56","80.4","","1365.00","1365.00","1365.00","1 through 10","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3975.78","81.72","","5157.68","5157.68","5157.68","1 through 10","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3975.78","81.72","","431.26","71.26","1459.57","88","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 14X440MM 130DEG FEMORAL TFN ADVANCED DISTAL TI CANNULATED","SUP-ITM-10163960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3867.78","79.5","","800.18","480.96","1887.97","195","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X440MM 130DEG FEMORAL TFN ADVANCED DISTAL TI CANNULATED","SUP-ITM-10163960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2593.11","53.3","","813.12","216.42","1444.50","81","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X440MM 130DEG FEMORAL TFN ADVANCED DISTAL TI CANNULATED","SUP-ITM-10163960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1508.19","31","","432.60","432.60","432.60","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X440MM 130DEG FEMORAL TFN ADVANCED DISTAL TI CANNULATED","SUP-ITM-10163960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1775.77","36.5","","148.37","54.89","631.39","94","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X440MM 130DEG FEMORAL TFN ADVANCED DISTAL TI CANNULATED","SUP-ITM-10163960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1863.34","38.3","","279.30","91.72","1116.77","266","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X440MM 130DEG FEMORAL TFN ADVANCED DISTAL TI CANNULATED","SUP-ITM-10163960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2087.14","42.9","","731.00","63.70","731.00","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X440MM 130DEG FEMORAL TFN ADVANCED DISTAL TI CANNULATED","SUP-ITM-10163960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2087.14","42.9","","384.74","384.74","384.74","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X440MM 130DEG FEMORAL TFN ADVANCED DISTAL TI CANNULATED","SUP-ITM-10163960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","WELLPOINT [1015]","HB AMC WELLPOINT","3589.49","73.78","","286.63","119.22","1107.45","105","1508.19","3867.78","percent of total billed charges",""
"NAIL BONE 14X440MM 130DEG FEMORAL TFN ADVANCED DISTAL TI CANNULATED","SUP-ITM-10163960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","AETNA [1001]","HB AMC AETNA HMO","3395.86","69.8","","675.31","184.75","1721.50","286","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 14X440MM 130DEG FEMORAL TFN ADVANCED DISTAL TI CANNULATED","SUP-ITM-10163960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","AETNA [1001]","HB AMC AETNA PPO","3911.56","80.4","","1261.44","103.12","1514.10","21","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 14X440MM 130DEG FEMORAL TFN ADVANCED DISTAL TI CANNULATED","SUP-ITM-10163960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3911.56","80.4","","1365.00","1365.00","1365.00","1 through 10","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 14X440MM 130DEG FEMORAL TFN ADVANCED DISTAL TI CANNULATED","SUP-ITM-10163960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3975.78","81.72","","5157.68","5157.68","5157.68","1 through 10","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 14X440MM 130DEG FEMORAL TFN ADVANCED DISTAL TI CANNULATED","SUP-ITM-10163960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3975.78","81.72","","431.26","71.26","1459.57","88","2542.52","3975.78","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3791.76","2843.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3014.45","79.5","","800.18","480.96","1887.97","195","1175.45","3014.45","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3791.76","2843.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2021.01","53.3","","813.12","216.42","1444.50","81","1175.45","3014.45","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3791.76","2843.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1175.45","31","","432.60","432.60","432.60","1 through 10","1175.45","3014.45","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3791.76","2843.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1383.99","36.5","","148.37","54.89","631.39","94","1175.45","3014.45","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3791.76","2843.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1452.24","38.3","","279.30","91.72","1116.77","266","1175.45","3014.45","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3791.76","2843.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1626.67","42.9","","731.00","63.70","731.00","1 through 10","1175.45","3014.45","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3791.76","2843.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1626.67","42.9","","384.74","384.74","384.74","1 through 10","1175.45","3014.45","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3791.76","2843.82","WELLPOINT [1015]","HB AMC WELLPOINT","2797.56","73.78","","286.63","119.22","1107.45","105","1175.45","3014.45","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3791.76","2843.82","AETNA [1001]","HB AMC AETNA HMO","2646.65","69.8","","675.31","184.75","1721.50","286","1981.57","3098.63","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3791.76","2843.82","AETNA [1001]","HB AMC AETNA PPO","3048.58","80.4","","1261.44","103.12","1514.10","21","1981.57","3098.63","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3791.76","2843.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3048.58","80.4","","1365.00","1365.00","1365.00","1 through 10","1981.57","3098.63","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3791.76","2843.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3098.63","81.72","","5157.68","5157.68","5157.68","1 through 10","1981.57","3098.63","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3791.76","2843.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3098.63","81.72","","431.26","71.26","1459.57","88","1981.57","3098.63","percent of total billed charges",""
"NAIL BONE 2.4X16MM SMART BIOABSORBABLE","SUP-ITM-10086404","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","515.82","79.5","","800.18","480.96","1887.97","195","201.14","515.82","percent of total billed charges",""
"NAIL BONE 2.4X16MM SMART BIOABSORBABLE","SUP-ITM-10086404","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","345.83","53.3","","813.12","216.42","1444.50","81","201.14","515.82","percent of total billed charges",""
"NAIL BONE 2.4X16MM SMART BIOABSORBABLE","SUP-ITM-10086404","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","201.14","31","","432.60","432.60","432.60","1 through 10","201.14","515.82","percent of total billed charges",""
"NAIL BONE 2.4X16MM SMART BIOABSORBABLE","SUP-ITM-10086404","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","236.82","36.5","","148.37","54.89","631.39","94","201.14","515.82","percent of total billed charges",""
"NAIL BONE 2.4X16MM SMART BIOABSORBABLE","SUP-ITM-10086404","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","248.50","38.3","","279.30","91.72","1116.77","266","201.14","515.82","percent of total billed charges",""
"NAIL BONE 2.4X16MM SMART BIOABSORBABLE","SUP-ITM-10086404","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.35","42.9","","731.00","63.70","731.00","1 through 10","201.14","515.82","percent of total billed charges",""
"NAIL BONE 2.4X16MM SMART BIOABSORBABLE","SUP-ITM-10086404","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.35","42.9","","384.74","384.74","384.74","1 through 10","201.14","515.82","percent of total billed charges",""
"NAIL BONE 2.4X16MM SMART BIOABSORBABLE","SUP-ITM-10086404","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.83","486.62","WELLPOINT [1015]","HB AMC WELLPOINT","478.71","73.78","","286.63","119.22","1107.45","105","201.14","515.82","percent of total billed charges",""
"NAIL BONE 2.4X16MM SMART BIOABSORBABLE","SUP-ITM-10086404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.83","486.62","AETNA [1001]","HB AMC AETNA HMO","452.88","69.8","","675.31","184.75","1721.50","286","339.08","530.22","percent of total billed charges",""
"NAIL BONE 2.4X16MM SMART BIOABSORBABLE","SUP-ITM-10086404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.83","486.62","AETNA [1001]","HB AMC AETNA PPO","521.66","80.4","","1261.44","103.12","1514.10","21","339.08","530.22","percent of total billed charges",""
"NAIL BONE 2.4X16MM SMART BIOABSORBABLE","SUP-ITM-10086404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.83","486.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","521.66","80.4","","1365.00","1365.00","1365.00","1 through 10","339.08","530.22","percent of total billed charges",""
"NAIL BONE 2.4X16MM SMART BIOABSORBABLE","SUP-ITM-10086404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.83","486.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","530.22","81.72","","5157.68","5157.68","5157.68","1 through 10","339.08","530.22","percent of total billed charges",""
"NAIL BONE 2.4X16MM SMART BIOABSORBABLE","SUP-ITM-10086404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.83","486.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","530.22","81.72","","431.26","71.26","1459.57","88","339.08","530.22","percent of total billed charges",""
"NAIL BONE 2.4X25MM FIXATION SELF REINFORCED SMART","SUP-ITM-10086405","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.97","491.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","521.50","79.5","","800.18","480.96","1887.97","195","203.35","521.5","percent of total billed charges",""
"NAIL BONE 2.4X25MM FIXATION SELF REINFORCED SMART","SUP-ITM-10086405","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.97","491.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","349.63","53.3","","813.12","216.42","1444.50","81","203.35","521.5","percent of total billed charges",""
"NAIL BONE 2.4X25MM FIXATION SELF REINFORCED SMART","SUP-ITM-10086405","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.97","491.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","203.35","31","","432.60","432.60","432.60","1 through 10","203.35","521.5","percent of total billed charges",""
"NAIL BONE 2.4X25MM FIXATION SELF REINFORCED SMART","SUP-ITM-10086405","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.97","491.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","239.43","36.5","","148.37","54.89","631.39","94","203.35","521.5","percent of total billed charges",""
"NAIL BONE 2.4X25MM FIXATION SELF REINFORCED SMART","SUP-ITM-10086405","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.97","491.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","251.24","38.3","","279.30","91.72","1116.77","266","203.35","521.5","percent of total billed charges",""
"NAIL BONE 2.4X25MM FIXATION SELF REINFORCED SMART","SUP-ITM-10086405","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.97","491.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","281.41","42.9","","731.00","63.70","731.00","1 through 10","203.35","521.5","percent of total billed charges",""
"NAIL BONE 2.4X25MM FIXATION SELF REINFORCED SMART","SUP-ITM-10086405","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.97","491.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","281.41","42.9","","384.74","384.74","384.74","1 through 10","203.35","521.5","percent of total billed charges",""
"NAIL BONE 2.4X25MM FIXATION SELF REINFORCED SMART","SUP-ITM-10086405","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.97","491.98","WELLPOINT [1015]","HB AMC WELLPOINT","483.97","73.78","","286.63","119.22","1107.45","105","203.35","521.5","percent of total billed charges",""
"NAIL BONE 2.4X25MM FIXATION SELF REINFORCED SMART","SUP-ITM-10086405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","655.97","491.98","AETNA [1001]","HB AMC AETNA HMO","457.87","69.8","","675.31","184.75","1721.50","286","342.81","536.06","percent of total billed charges",""
"NAIL BONE 2.4X25MM FIXATION SELF REINFORCED SMART","SUP-ITM-10086405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","655.97","491.98","AETNA [1001]","HB AMC AETNA PPO","527.40","80.4","","1261.44","103.12","1514.10","21","342.81","536.06","percent of total billed charges",""
"NAIL BONE 2.4X25MM FIXATION SELF REINFORCED SMART","SUP-ITM-10086405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","655.97","491.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","527.40","80.4","","1365.00","1365.00","1365.00","1 through 10","342.81","536.06","percent of total billed charges",""
"NAIL BONE 2.4X25MM FIXATION SELF REINFORCED SMART","SUP-ITM-10086405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","655.97","491.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","536.06","81.72","","5157.68","5157.68","5157.68","1 through 10","342.81","536.06","percent of total billed charges",""
"NAIL BONE 2.4X25MM FIXATION SELF REINFORCED SMART","SUP-ITM-10086405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","655.97","491.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","536.06","81.72","","431.26","71.26","1459.57","88","342.81","536.06","percent of total billed charges",""
"NAIL BONE 8X280MM LONG PROXIMALIMAL HUMERAL T2 TITANIUM LEFT","SUP-ITM-10033809","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5717.44","79.5","","800.18","480.96","1887.97","195","2229.44","5717.44","percent of total billed charges",""
"NAIL BONE 8X280MM LONG PROXIMALIMAL HUMERAL T2 TITANIUM LEFT","SUP-ITM-10033809","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3833.20","53.3","","813.12","216.42","1444.50","81","2229.44","5717.44","percent of total billed charges",""
"NAIL BONE 8X280MM LONG PROXIMALIMAL HUMERAL T2 TITANIUM LEFT","SUP-ITM-10033809","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2229.44","31","","432.60","432.60","432.60","1 through 10","2229.44","5717.44","percent of total billed charges",""
"NAIL BONE 8X280MM LONG PROXIMALIMAL HUMERAL T2 TITANIUM LEFT","SUP-ITM-10033809","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2624.99","36.5","","148.37","54.89","631.39","94","2229.44","5717.44","percent of total billed charges",""
"NAIL BONE 8X280MM LONG PROXIMALIMAL HUMERAL T2 TITANIUM LEFT","SUP-ITM-10033809","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2754.44","38.3","","279.30","91.72","1116.77","266","2229.44","5717.44","percent of total billed charges",""
"NAIL BONE 8X280MM LONG PROXIMALIMAL HUMERAL T2 TITANIUM LEFT","SUP-ITM-10033809","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3085.26","42.9","","731.00","63.70","731.00","1 through 10","2229.44","5717.44","percent of total billed charges",""
"NAIL BONE 8X280MM LONG PROXIMALIMAL HUMERAL T2 TITANIUM LEFT","SUP-ITM-10033809","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3085.26","42.9","","384.74","384.74","384.74","1 through 10","2229.44","5717.44","percent of total billed charges",""
"NAIL BONE 8X280MM LONG PROXIMALIMAL HUMERAL T2 TITANIUM LEFT","SUP-ITM-10033809","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","WELLPOINT [1015]","HB AMC WELLPOINT","5306.07","73.78","","286.63","119.22","1107.45","105","2229.44","5717.44","percent of total billed charges",""
"NAIL BONE 8X280MM LONG PROXIMALIMAL HUMERAL T2 TITANIUM LEFT","SUP-ITM-10033809","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7191.75","5393.81","AETNA [1001]","HB AMC AETNA HMO","5019.84","69.8","","675.31","184.75","1721.50","286","3758.41","5877.1","percent of total billed charges",""
"NAIL BONE 8X280MM LONG PROXIMALIMAL HUMERAL T2 TITANIUM LEFT","SUP-ITM-10033809","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7191.75","5393.81","AETNA [1001]","HB AMC AETNA PPO","5782.17","80.4","","1261.44","103.12","1514.10","21","3758.41","5877.1","percent of total billed charges",""
"NAIL BONE 8X280MM LONG PROXIMALIMAL HUMERAL T2 TITANIUM LEFT","SUP-ITM-10033809","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7191.75","5393.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5782.17","80.4","","1365.00","1365.00","1365.00","1 through 10","3758.41","5877.1","percent of total billed charges",""
"NAIL BONE 8X280MM LONG PROXIMALIMAL HUMERAL T2 TITANIUM LEFT","SUP-ITM-10033809","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7191.75","5393.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5877.10","81.72","","5157.68","5157.68","5157.68","1 through 10","3758.41","5877.1","percent of total billed charges",""
"NAIL BONE 8X280MM LONG PROXIMALIMAL HUMERAL T2 TITANIUM LEFT","SUP-ITM-10033809","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7191.75","5393.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5877.10","81.72","","431.26","71.26","1459.57","88","3758.41","5877.1","percent of total billed charges",""
"NAIL BONE 8X300MM INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10028268","CDM","C1889","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4664.19","79.5","","1309.77","674.56","6049.93","26","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 8X300MM INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10028268","CDM","C1889","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3127.06","53.3","","1901.83","1901.83","2962.25","1 through 10","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 8X300MM INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10028268","CDM","C1889","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2141.42","36.5","","1620.31","1620.31","19908.88","1 through 10","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 8X300MM INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10028268","CDM","C1889","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2247.02","38.3","","352.91","352.91","2046.30","1 through 10","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 8X300MM INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10028268","CDM","C1889","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2516.90","42.9","","9668.75","9668.75","9668.75","1 through 10","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 8X300MM INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10028268","CDM","C1889","HCPCS","0278","RC","","","","both","","","5866.90","4400.17","WELLPOINT [1015]","HB AMC WELLPOINT","4328.60","73.78","","699.88","384.10","3443.31","33","1818.74","4664.19","percent of total billed charges",""
"NAIL BONE 8X300MM INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10028268","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5866.90","4400.17","AETNA [1001]","HB AMC AETNA HMO","4095.10","69.8","","1421.24","264.50","4933.46","29","3066.04","4794.43","percent of total billed charges",""
"NAIL BONE 8X300MM INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10028268","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5866.90","4400.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4716.99","80.4","","1022.97","1022.97","3607.50","1 through 10","3066.04","4794.43","percent of total billed charges",""
"NAIL BONE 8X300MM INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10028268","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5866.90","4400.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4794.43","81.72","","3010.54","693.88","5019.88","35","3066.04","4794.43","percent of total billed charges",""
"NAIL EXTENSION 15MM ENDCAP BONE TIBIAL SOLID TI","SUP-ITM-10004380","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.54","459.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","486.97","79.5","","800.18","480.96","1887.97","195","189.89","486.97","percent of total billed charges",""
"NAIL EXTENSION 15MM ENDCAP BONE TIBIAL SOLID TI","SUP-ITM-10004380","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.54","459.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","326.48","53.3","","813.12","216.42","1444.50","81","189.89","486.97","percent of total billed charges",""
"NAIL EXTENSION 15MM ENDCAP BONE TIBIAL SOLID TI","SUP-ITM-10004380","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.54","459.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","189.89","31","","432.60","432.60","432.60","1 through 10","189.89","486.97","percent of total billed charges",""
"NAIL EXTENSION 15MM ENDCAP BONE TIBIAL SOLID TI","SUP-ITM-10004380","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.54","459.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.58","36.5","","148.37","54.89","631.39","94","189.89","486.97","percent of total billed charges",""
"NAIL EXTENSION 15MM ENDCAP BONE TIBIAL SOLID TI","SUP-ITM-10004380","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.54","459.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.60","38.3","","279.30","91.72","1116.77","266","189.89","486.97","percent of total billed charges",""
"NAIL EXTENSION 15MM ENDCAP BONE TIBIAL SOLID TI","SUP-ITM-10004380","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.54","459.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","262.78","42.9","","731.00","63.70","731.00","1 through 10","189.89","486.97","percent of total billed charges",""
"NAIL EXTENSION 15MM ENDCAP BONE TIBIAL SOLID TI","SUP-ITM-10004380","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.54","459.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","262.78","42.9","","384.74","384.74","384.74","1 through 10","189.89","486.97","percent of total billed charges",""
"NAIL EXTENSION 15MM ENDCAP BONE TIBIAL SOLID TI","SUP-ITM-10004380","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.54","459.40","WELLPOINT [1015]","HB AMC WELLPOINT","451.93","73.78","","286.63","119.22","1107.45","105","189.89","486.97","percent of total billed charges",""
"NAIL EXTENSION 15MM ENDCAP BONE TIBIAL SOLID TI","SUP-ITM-10004380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.54","459.40","AETNA [1001]","HB AMC AETNA HMO","427.55","69.8","","675.31","184.75","1721.50","286","320.11","500.57","percent of total billed charges",""
"NAIL EXTENSION 15MM ENDCAP BONE TIBIAL SOLID TI","SUP-ITM-10004380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.54","459.40","AETNA [1001]","HB AMC AETNA PPO","492.48","80.4","","1261.44","103.12","1514.10","21","320.11","500.57","percent of total billed charges",""
"NAIL EXTENSION 15MM ENDCAP BONE TIBIAL SOLID TI","SUP-ITM-10004380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.54","459.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","492.48","80.4","","1365.00","1365.00","1365.00","1 through 10","320.11","500.57","percent of total billed charges",""
"NAIL EXTENSION 15MM ENDCAP BONE TIBIAL SOLID TI","SUP-ITM-10004380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.54","459.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","500.57","81.72","","5157.68","5157.68","5157.68","1 through 10","320.11","500.57","percent of total billed charges",""
"NAIL EXTENSION 15MM ENDCAP BONE TIBIAL SOLID TI","SUP-ITM-10004380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.54","459.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","500.57","81.72","","431.26","71.26","1459.57","88","320.11","500.57","percent of total billed charges",""
"NAIL FEMORAL 10X320MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3680.87","79.5","","800.18","480.96","1887.97","195","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X320MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2467.81","53.3","","813.12","216.42","1444.50","81","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X320MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1435.31","31","","432.60","432.60","432.60","1 through 10","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X320MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1689.96","36.5","","148.37","54.89","631.39","94","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X320MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1773.30","38.3","","279.30","91.72","1116.77","266","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X320MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.28","42.9","","731.00","63.70","731.00","1 through 10","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X320MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.28","42.9","","384.74","384.74","384.74","1 through 10","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X320MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","WELLPOINT [1015]","HB AMC WELLPOINT","3416.04","73.78","","286.63","119.22","1107.45","105","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X320MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","AETNA [1001]","HB AMC AETNA HMO","3231.76","69.8","","675.31","184.75","1721.50","286","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X320MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","AETNA [1001]","HB AMC AETNA PPO","3722.54","80.4","","1261.44","103.12","1514.10","21","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X320MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3722.54","80.4","","1365.00","1365.00","1365.00","1 through 10","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X320MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3783.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X320MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3783.66","81.72","","431.26","71.26","1459.57","88","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X320MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296629","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3986.31","79.5","","800.18","480.96","1887.97","195","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X320MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296629","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2672.58","53.3","","813.12","216.42","1444.50","81","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X320MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296629","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1554.41","31","","432.60","432.60","432.60","1 through 10","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X320MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296629","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1830.19","36.5","","148.37","54.89","631.39","94","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X320MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296629","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1920.45","38.3","","279.30","91.72","1116.77","266","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X320MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296629","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2151.10","42.9","","731.00","63.70","731.00","1 through 10","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X320MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296629","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2151.10","42.9","","384.74","384.74","384.74","1 through 10","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X320MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296629","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","WELLPOINT [1015]","HB AMC WELLPOINT","3699.50","73.78","","286.63","119.22","1107.45","105","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X320MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","AETNA [1001]","HB AMC AETNA HMO","3499.93","69.8","","675.31","184.75","1721.50","286","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 10X320MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","AETNA [1001]","HB AMC AETNA PPO","4031.44","80.4","","1261.44","103.12","1514.10","21","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 10X320MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4031.44","80.4","","1365.00","1365.00","1365.00","1 through 10","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 10X320MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4097.63","81.72","","5157.68","5157.68","5157.68","1 through 10","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 10X320MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4097.63","81.72","","431.26","71.26","1459.57","88","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","both","","","5163.87","3872.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4105.28","79.5","","800.18","480.96","1887.97","195","1600.8","4105.28","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","both","","","5163.87","3872.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2752.34","53.3","","813.12","216.42","1444.50","81","1600.8","4105.28","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","both","","","5163.87","3872.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1600.80","31","","432.60","432.60","432.60","1 through 10","1600.8","4105.28","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","both","","","5163.87","3872.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1884.81","36.5","","148.37","54.89","631.39","94","1600.8","4105.28","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","both","","","5163.87","3872.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1977.76","38.3","","279.30","91.72","1116.77","266","1600.8","4105.28","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","both","","","5163.87","3872.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2215.30","42.9","","731.00","63.70","731.00","1 through 10","1600.8","4105.28","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","both","","","5163.87","3872.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2215.30","42.9","","384.74","384.74","384.74","1 through 10","1600.8","4105.28","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","both","","","5163.87","3872.90","WELLPOINT [1015]","HB AMC WELLPOINT","3809.90","73.78","","286.63","119.22","1107.45","105","1600.8","4105.28","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5163.87","3872.90","AETNA [1001]","HB AMC AETNA HMO","3604.38","69.8","","675.31","184.75","1721.50","286","2698.64","4219.91","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5163.87","3872.90","AETNA [1001]","HB AMC AETNA PPO","4151.75","80.4","","1261.44","103.12","1514.10","21","2698.64","4219.91","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5163.87","3872.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4151.75","80.4","","1365.00","1365.00","1365.00","1 through 10","2698.64","4219.91","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5163.87","3872.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4219.91","81.72","","5157.68","5157.68","5157.68","1 through 10","2698.64","4219.91","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5163.87","3872.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4219.91","81.72","","431.26","71.26","1459.57","88","2698.64","4219.91","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3680.87","79.5","","800.18","480.96","1887.97","195","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2467.81","53.3","","813.12","216.42","1444.50","81","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1435.31","31","","432.60","432.60","432.60","1 through 10","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1689.96","36.5","","148.37","54.89","631.39","94","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1773.30","38.3","","279.30","91.72","1116.77","266","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.28","42.9","","731.00","63.70","731.00","1 through 10","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.28","42.9","","384.74","384.74","384.74","1 through 10","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","WELLPOINT [1015]","HB AMC WELLPOINT","3416.04","73.78","","286.63","119.22","1107.45","105","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","AETNA [1001]","HB AMC AETNA HMO","3231.76","69.8","","675.31","184.75","1721.50","286","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","AETNA [1001]","HB AMC AETNA PPO","3722.54","80.4","","1261.44","103.12","1514.10","21","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3722.54","80.4","","1365.00","1365.00","1365.00","1 through 10","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3783.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3783.66","81.72","","431.26","71.26","1459.57","88","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3680.87","79.5","","800.18","480.96","1887.97","195","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2467.81","53.3","","813.12","216.42","1444.50","81","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1435.31","31","","432.60","432.60","432.60","1 through 10","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1689.96","36.5","","148.37","54.89","631.39","94","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1773.30","38.3","","279.30","91.72","1116.77","266","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.28","42.9","","731.00","63.70","731.00","1 through 10","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.28","42.9","","384.74","384.74","384.74","1 through 10","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040914","CDM","C1713","HCPCS","0278","RC","","","","both","","","4630.03","3472.52","WELLPOINT [1015]","HB AMC WELLPOINT","3416.04","73.78","","286.63","119.22","1107.45","105","1435.31","3680.87","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","AETNA [1001]","HB AMC AETNA HMO","3231.76","69.8","","675.31","184.75","1721.50","286","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","AETNA [1001]","HB AMC AETNA PPO","3722.54","80.4","","1261.44","103.12","1514.10","21","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3722.54","80.4","","1365.00","1365.00","1365.00","1 through 10","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3783.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 130DEG CANNULATED TI TROCHANTERIC FIXATION INTRAMEDULLARY RIGHT","SUP-ITM-10040914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4630.03","3472.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3783.66","81.72","","431.26","71.26","1459.57","88","2419.65","3783.66","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3698.13","79.5","","800.18","480.96","1887.97","195","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2479.38","53.3","","813.12","216.42","1444.50","81","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1442.04","31","","432.60","432.60","432.60","1 through 10","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1697.89","36.5","","148.37","54.89","631.39","94","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1781.62","38.3","","279.30","91.72","1116.77","266","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1995.60","42.9","","731.00","63.70","731.00","1 through 10","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1995.60","42.9","","384.74","384.74","384.74","1 through 10","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","WELLPOINT [1015]","HB AMC WELLPOINT","3432.05","73.78","","286.63","119.22","1107.45","105","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","AETNA [1001]","HB AMC AETNA HMO","3246.91","69.8","","675.31","184.75","1721.50","286","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","AETNA [1001]","HB AMC AETNA PPO","3740.00","80.4","","1261.44","103.12","1514.10","21","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3740.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3801.40","81.72","","5157.68","5157.68","5157.68","1 through 10","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 10X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3801.40","81.72","","431.26","71.26","1459.57","88","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 10X400MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296621","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3986.31","79.5","","800.18","480.96","1887.97","195","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X400MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296621","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2672.58","53.3","","813.12","216.42","1444.50","81","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X400MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296621","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1554.41","31","","432.60","432.60","432.60","1 through 10","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X400MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296621","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1830.19","36.5","","148.37","54.89","631.39","94","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X400MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296621","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1920.45","38.3","","279.30","91.72","1116.77","266","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X400MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296621","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2151.10","42.9","","731.00","63.70","731.00","1 through 10","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X400MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296621","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2151.10","42.9","","384.74","384.74","384.74","1 through 10","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X400MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296621","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","WELLPOINT [1015]","HB AMC WELLPOINT","3699.50","73.78","","286.63","119.22","1107.45","105","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 10X400MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","AETNA [1001]","HB AMC AETNA HMO","3499.93","69.8","","675.31","184.75","1721.50","286","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 10X400MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","AETNA [1001]","HB AMC AETNA PPO","4031.44","80.4","","1261.44","103.12","1514.10","21","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 10X400MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4031.44","80.4","","1365.00","1365.00","1365.00","1 through 10","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 10X400MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4097.63","81.72","","5157.68","5157.68","5157.68","1 through 10","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 10X400MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4097.63","81.72","","431.26","71.26","1459.57","88","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3867.78","79.5","","800.18","480.96","1887.97","195","1508.19","3867.78","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2593.11","53.3","","813.12","216.42","1444.50","81","1508.19","3867.78","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1508.19","31","","432.60","432.60","432.60","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1775.77","36.5","","148.37","54.89","631.39","94","1508.19","3867.78","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1863.34","38.3","","279.30","91.72","1116.77","266","1508.19","3867.78","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2087.14","42.9","","731.00","63.70","731.00","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2087.14","42.9","","384.74","384.74","384.74","1 through 10","1508.19","3867.78","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4865.13","3648.85","WELLPOINT [1015]","HB AMC WELLPOINT","3589.49","73.78","","286.63","119.22","1107.45","105","1508.19","3867.78","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","AETNA [1001]","HB AMC AETNA HMO","3395.86","69.8","","675.31","184.75","1721.50","286","2542.52","3975.78","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","AETNA [1001]","HB AMC AETNA PPO","3911.56","80.4","","1261.44","103.12","1514.10","21","2542.52","3975.78","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3911.56","80.4","","1365.00","1365.00","1365.00","1 through 10","2542.52","3975.78","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3975.78","81.72","","5157.68","5157.68","5157.68","1 through 10","2542.52","3975.78","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4865.13","3648.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3975.78","81.72","","431.26","71.26","1459.57","88","2542.52","3975.78","percent of total billed charges",""
"NAIL FEMORAL 11X360MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296584","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3986.31","79.5","","800.18","480.96","1887.97","195","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 11X360MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296584","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2672.58","53.3","","813.12","216.42","1444.50","81","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 11X360MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296584","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1554.41","31","","432.60","432.60","432.60","1 through 10","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 11X360MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296584","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1830.19","36.5","","148.37","54.89","631.39","94","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 11X360MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296584","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1920.45","38.3","","279.30","91.72","1116.77","266","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 11X360MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296584","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2151.10","42.9","","731.00","63.70","731.00","1 through 10","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 11X360MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296584","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2151.10","42.9","","384.74","384.74","384.74","1 through 10","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 11X360MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296584","CDM","C1713","HCPCS","0278","RC","","","","both","","","5014.23","3760.67","WELLPOINT [1015]","HB AMC WELLPOINT","3699.50","73.78","","286.63","119.22","1107.45","105","1554.41","3986.31","percent of total billed charges",""
"NAIL FEMORAL 11X360MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","AETNA [1001]","HB AMC AETNA HMO","3499.93","69.8","","675.31","184.75","1721.50","286","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 11X360MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","AETNA [1001]","HB AMC AETNA PPO","4031.44","80.4","","1261.44","103.12","1514.10","21","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 11X360MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4031.44","80.4","","1365.00","1365.00","1365.00","1 through 10","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 11X360MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4097.63","81.72","","5157.68","5157.68","5157.68","1 through 10","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 11X360MM CANNULATED RECON TITANIUM GREATER TROCHANTER LT","SUP-ITM-10296584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5014.23","3760.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4097.63","81.72","","431.26","71.26","1459.57","88","2620.44","4097.63","percent of total billed charges",""
"NAIL FEMORAL 11X400MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020820","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3192.08","79.5","","800.18","480.96","1887.97","195","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X400MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020820","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2140.10","53.3","","813.12","216.42","1444.50","81","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X400MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020820","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1244.71","31","","432.60","432.60","432.60","1 through 10","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X400MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020820","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1465.55","36.5","","148.37","54.89","631.39","94","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X400MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020820","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1537.82","38.3","","279.30","91.72","1116.77","266","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X400MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020820","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1722.52","42.9","","731.00","63.70","731.00","1 through 10","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X400MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020820","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1722.52","42.9","","384.74","384.74","384.74","1 through 10","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X400MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020820","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","WELLPOINT [1015]","HB AMC WELLPOINT","2962.41","73.78","","286.63","119.22","1107.45","105","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X400MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","AETNA [1001]","HB AMC AETNA HMO","2802.61","69.8","","675.31","184.75","1721.50","286","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 11X400MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","AETNA [1001]","HB AMC AETNA PPO","3228.22","80.4","","1261.44","103.12","1514.10","21","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 11X400MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3228.22","80.4","","1365.00","1365.00","1365.00","1 through 10","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 11X400MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3281.22","81.72","","5157.68","5157.68","5157.68","1 through 10","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 11X400MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3281.22","81.72","","431.26","71.26","1459.57","88","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 11X460MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020823","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3192.08","79.5","","800.18","480.96","1887.97","195","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X460MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020823","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2140.10","53.3","","813.12","216.42","1444.50","81","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X460MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020823","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1244.71","31","","432.60","432.60","432.60","1 through 10","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X460MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020823","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1465.55","36.5","","148.37","54.89","631.39","94","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X460MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020823","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1537.82","38.3","","279.30","91.72","1116.77","266","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X460MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020823","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1722.52","42.9","","731.00","63.70","731.00","1 through 10","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X460MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020823","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1722.52","42.9","","384.74","384.74","384.74","1 through 10","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X460MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020823","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","WELLPOINT [1015]","HB AMC WELLPOINT","2962.41","73.78","","286.63","119.22","1107.45","105","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 11X460MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","AETNA [1001]","HB AMC AETNA HMO","2802.61","69.8","","675.31","184.75","1721.50","286","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 11X460MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","AETNA [1001]","HB AMC AETNA PPO","3228.22","80.4","","1261.44","103.12","1514.10","21","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 11X460MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3228.22","80.4","","1365.00","1365.00","1365.00","1 through 10","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 11X460MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3281.22","81.72","","5157.68","5157.68","5157.68","1 through 10","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 11X460MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3281.22","81.72","","431.26","71.26","1459.57","88","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 12X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296012","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3698.13","79.5","","800.18","480.96","1887.97","195","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296012","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2479.38","53.3","","813.12","216.42","1444.50","81","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296012","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1442.04","31","","432.60","432.60","432.60","1 through 10","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296012","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1697.89","36.5","","148.37","54.89","631.39","94","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296012","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1781.62","38.3","","279.30","91.72","1116.77","266","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296012","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1995.60","42.9","","731.00","63.70","731.00","1 through 10","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296012","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1995.60","42.9","","384.74","384.74","384.74","1 through 10","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296012","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","WELLPOINT [1015]","HB AMC WELLPOINT","3432.05","73.78","","286.63","119.22","1107.45","105","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","AETNA [1001]","HB AMC AETNA HMO","3246.91","69.8","","675.31","184.75","1721.50","286","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 12X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","AETNA [1001]","HB AMC AETNA PPO","3740.00","80.4","","1261.44","103.12","1514.10","21","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 12X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3740.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 12X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3801.40","81.72","","5157.68","5157.68","5157.68","1 through 10","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 12X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3801.40","81.72","","431.26","71.26","1459.57","88","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 12X400MM 5DEG BEND RETROGRADE","SUP-ITM-10296008","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3698.13","79.5","","800.18","480.96","1887.97","195","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X400MM 5DEG BEND RETROGRADE","SUP-ITM-10296008","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2479.38","53.3","","813.12","216.42","1444.50","81","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X400MM 5DEG BEND RETROGRADE","SUP-ITM-10296008","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1442.04","31","","432.60","432.60","432.60","1 through 10","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X400MM 5DEG BEND RETROGRADE","SUP-ITM-10296008","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1697.89","36.5","","148.37","54.89","631.39","94","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X400MM 5DEG BEND RETROGRADE","SUP-ITM-10296008","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1781.62","38.3","","279.30","91.72","1116.77","266","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X400MM 5DEG BEND RETROGRADE","SUP-ITM-10296008","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1995.60","42.9","","731.00","63.70","731.00","1 through 10","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X400MM 5DEG BEND RETROGRADE","SUP-ITM-10296008","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1995.60","42.9","","384.74","384.74","384.74","1 through 10","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X400MM 5DEG BEND RETROGRADE","SUP-ITM-10296008","CDM","C1713","HCPCS","0278","RC","","","","both","","","4651.74","3488.80","WELLPOINT [1015]","HB AMC WELLPOINT","3432.05","73.78","","286.63","119.22","1107.45","105","1442.04","3698.13","percent of total billed charges",""
"NAIL FEMORAL 12X400MM 5DEG BEND RETROGRADE","SUP-ITM-10296008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","AETNA [1001]","HB AMC AETNA HMO","3246.91","69.8","","675.31","184.75","1721.50","286","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 12X400MM 5DEG BEND RETROGRADE","SUP-ITM-10296008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","AETNA [1001]","HB AMC AETNA PPO","3740.00","80.4","","1261.44","103.12","1514.10","21","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 12X400MM 5DEG BEND RETROGRADE","SUP-ITM-10296008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3740.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 12X400MM 5DEG BEND RETROGRADE","SUP-ITM-10296008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3801.40","81.72","","5157.68","5157.68","5157.68","1 through 10","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 12X400MM 5DEG BEND RETROGRADE","SUP-ITM-10296008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4651.74","3488.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3801.40","81.72","","431.26","71.26","1459.57","88","2431","3801.4","percent of total billed charges",""
"NAIL FEMORAL 12X460MM EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3290.03","79.5","","800.18","480.96","1887.97","195","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 12X460MM EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2205.77","53.3","","813.12","216.42","1444.50","81","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 12X460MM EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1282.90","31","","432.60","432.60","432.60","1 through 10","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 12X460MM EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1510.52","36.5","","148.37","54.89","631.39","94","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 12X460MM EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1585.01","38.3","","279.30","91.72","1116.77","266","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 12X460MM EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1775.37","42.9","","731.00","63.70","731.00","1 through 10","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 12X460MM EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1775.37","42.9","","384.74","384.74","384.74","1 through 10","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 12X460MM EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020840","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","WELLPOINT [1015]","HB AMC WELLPOINT","3053.31","73.78","","286.63","119.22","1107.45","105","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 12X460MM EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.40","3103.80","AETNA [1001]","HB AMC AETNA HMO","2888.60","69.8","","675.31","184.75","1721.50","286","2162.73","3381.9","percent of total billed charges",""
"NAIL FEMORAL 12X460MM EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.40","3103.80","AETNA [1001]","HB AMC AETNA PPO","3327.27","80.4","","1261.44","103.12","1514.10","21","2162.73","3381.9","percent of total billed charges",""
"NAIL FEMORAL 12X460MM EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.40","3103.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3327.27","80.4","","1365.00","1365.00","1365.00","1 through 10","2162.73","3381.9","percent of total billed charges",""
"NAIL FEMORAL 12X460MM EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.40","3103.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3381.90","81.72","","5157.68","5157.68","5157.68","1 through 10","2162.73","3381.9","percent of total billed charges",""
"NAIL FEMORAL 12X460MM EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020840","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.40","3103.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3381.90","81.72","","431.26","71.26","1459.57","88","2162.73","3381.9","percent of total billed charges",""
"NAIL FEMORAL 13X160MM EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020842","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3290.03","79.5","","800.18","480.96","1887.97","195","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 13X160MM EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020842","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2205.77","53.3","","813.12","216.42","1444.50","81","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 13X160MM EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020842","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1282.90","31","","432.60","432.60","432.60","1 through 10","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 13X160MM EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020842","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1510.52","36.5","","148.37","54.89","631.39","94","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 13X160MM EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020842","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1585.01","38.3","","279.30","91.72","1116.77","266","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 13X160MM EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020842","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1775.37","42.9","","731.00","63.70","731.00","1 through 10","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 13X160MM EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020842","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1775.37","42.9","","384.74","384.74","384.74","1 through 10","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 13X160MM EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020842","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.40","3103.80","WELLPOINT [1015]","HB AMC WELLPOINT","3053.31","73.78","","286.63","119.22","1107.45","105","1282.9","3290.03","percent of total billed charges",""
"NAIL FEMORAL 13X160MM EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.40","3103.80","AETNA [1001]","HB AMC AETNA HMO","2888.60","69.8","","675.31","184.75","1721.50","286","2162.73","3381.9","percent of total billed charges",""
"NAIL FEMORAL 13X160MM EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.40","3103.80","AETNA [1001]","HB AMC AETNA PPO","3327.27","80.4","","1261.44","103.12","1514.10","21","2162.73","3381.9","percent of total billed charges",""
"NAIL FEMORAL 13X160MM EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.40","3103.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3327.27","80.4","","1365.00","1365.00","1365.00","1 through 10","2162.73","3381.9","percent of total billed charges",""
"NAIL FEMORAL 13X160MM EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.40","3103.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3381.90","81.72","","5157.68","5157.68","5157.68","1 through 10","2162.73","3381.9","percent of total billed charges",""
"NAIL FEMORAL 13X160MM EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.40","3103.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3381.90","81.72","","431.26","71.26","1459.57","88","2162.73","3381.9","percent of total billed charges",""
"NAIL FEMORAL 14X380MM 5DEG BEND RETROGRADE","SUP-ITM-10295990","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.93","3789.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4017.08","79.5","","800.18","480.96","1887.97","195","1566.41","4017.08","percent of total billed charges",""
"NAIL FEMORAL 14X380MM 5DEG BEND RETROGRADE","SUP-ITM-10295990","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.93","3789.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2693.21","53.3","","813.12","216.42","1444.50","81","1566.41","4017.08","percent of total billed charges",""
"NAIL FEMORAL 14X380MM 5DEG BEND RETROGRADE","SUP-ITM-10295990","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.93","3789.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1566.41","31","","432.60","432.60","432.60","1 through 10","1566.41","4017.08","percent of total billed charges",""
"NAIL FEMORAL 14X380MM 5DEG BEND RETROGRADE","SUP-ITM-10295990","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.93","3789.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1844.32","36.5","","148.37","54.89","631.39","94","1566.41","4017.08","percent of total billed charges",""
"NAIL FEMORAL 14X380MM 5DEG BEND RETROGRADE","SUP-ITM-10295990","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.93","3789.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1935.27","38.3","","279.30","91.72","1116.77","266","1566.41","4017.08","percent of total billed charges",""
"NAIL FEMORAL 14X380MM 5DEG BEND RETROGRADE","SUP-ITM-10295990","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.93","3789.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2167.71","42.9","","731.00","63.70","731.00","1 through 10","1566.41","4017.08","percent of total billed charges",""
"NAIL FEMORAL 14X380MM 5DEG BEND RETROGRADE","SUP-ITM-10295990","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.93","3789.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2167.71","42.9","","384.74","384.74","384.74","1 through 10","1566.41","4017.08","percent of total billed charges",""
"NAIL FEMORAL 14X380MM 5DEG BEND RETROGRADE","SUP-ITM-10295990","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.93","3789.70","WELLPOINT [1015]","HB AMC WELLPOINT","3728.05","73.78","","286.63","119.22","1107.45","105","1566.41","4017.08","percent of total billed charges",""
"NAIL FEMORAL 14X380MM 5DEG BEND RETROGRADE","SUP-ITM-10295990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5052.93","3789.70","AETNA [1001]","HB AMC AETNA HMO","3526.95","69.8","","675.31","184.75","1721.50","286","2640.66","4129.25","percent of total billed charges",""
"NAIL FEMORAL 14X380MM 5DEG BEND RETROGRADE","SUP-ITM-10295990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5052.93","3789.70","AETNA [1001]","HB AMC AETNA PPO","4062.56","80.4","","1261.44","103.12","1514.10","21","2640.66","4129.25","percent of total billed charges",""
"NAIL FEMORAL 14X380MM 5DEG BEND RETROGRADE","SUP-ITM-10295990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5052.93","3789.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4062.56","80.4","","1365.00","1365.00","1365.00","1 through 10","2640.66","4129.25","percent of total billed charges",""
"NAIL FEMORAL 14X380MM 5DEG BEND RETROGRADE","SUP-ITM-10295990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5052.93","3789.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4129.25","81.72","","5157.68","5157.68","5157.68","1 through 10","2640.66","4129.25","percent of total billed charges",""
"NAIL FEMORAL 14X380MM 5DEG BEND RETROGRADE","SUP-ITM-10295990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5052.93","3789.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4129.25","81.72","","431.26","71.26","1459.57","88","2640.66","4129.25","percent of total billed charges",""
"NAIL FEMORAL 8.2X280MM TI LATERAL ADOLESCENT RIGHT","SUP-ITM-10097411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3112.26","79.5","","800.18","480.96","1887.97","195","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 8.2X280MM TI LATERAL ADOLESCENT RIGHT","SUP-ITM-10097411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2086.58","53.3","","813.12","216.42","1444.50","81","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 8.2X280MM TI LATERAL ADOLESCENT RIGHT","SUP-ITM-10097411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1213.58","31","","432.60","432.60","432.60","1 through 10","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 8.2X280MM TI LATERAL ADOLESCENT RIGHT","SUP-ITM-10097411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1428.90","36.5","","148.37","54.89","631.39","94","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 8.2X280MM TI LATERAL ADOLESCENT RIGHT","SUP-ITM-10097411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1499.36","38.3","","279.30","91.72","1116.77","266","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 8.2X280MM TI LATERAL ADOLESCENT RIGHT","SUP-ITM-10097411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1679.44","42.9","","731.00","63.70","731.00","1 through 10","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 8.2X280MM TI LATERAL ADOLESCENT RIGHT","SUP-ITM-10097411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1679.44","42.9","","384.74","384.74","384.74","1 through 10","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 8.2X280MM TI LATERAL ADOLESCENT RIGHT","SUP-ITM-10097411","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","WELLPOINT [1015]","HB AMC WELLPOINT","2888.33","73.78","","286.63","119.22","1107.45","105","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 8.2X280MM TI LATERAL ADOLESCENT RIGHT","SUP-ITM-10097411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","AETNA [1001]","HB AMC AETNA HMO","2732.52","69.8","","675.31","184.75","1721.50","286","2045.87","3199.17","percent of total billed charges",""
"NAIL FEMORAL 8.2X280MM TI LATERAL ADOLESCENT RIGHT","SUP-ITM-10097411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","AETNA [1001]","HB AMC AETNA PPO","3147.49","80.4","","1261.44","103.12","1514.10","21","2045.87","3199.17","percent of total billed charges",""
"NAIL FEMORAL 8.2X280MM TI LATERAL ADOLESCENT RIGHT","SUP-ITM-10097411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3147.49","80.4","","1365.00","1365.00","1365.00","1 through 10","2045.87","3199.17","percent of total billed charges",""
"NAIL FEMORAL 8.2X280MM TI LATERAL ADOLESCENT RIGHT","SUP-ITM-10097411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3199.17","81.72","","5157.68","5157.68","5157.68","1 through 10","2045.87","3199.17","percent of total billed charges",""
"NAIL FEMORAL 8.2X280MM TI LATERAL ADOLESCENT RIGHT","SUP-ITM-10097411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3199.17","81.72","","431.26","71.26","1459.57","88","2045.87","3199.17","percent of total billed charges",""
"NAIL FEMORAL 9X160MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3400.44","79.5","","800.18","480.96","1887.97","195","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X160MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2279.79","53.3","","813.12","216.42","1444.50","81","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X160MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1325.96","31","","432.60","432.60","432.60","1 through 10","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X160MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1561.21","36.5","","148.37","54.89","631.39","94","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X160MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1638.20","38.3","","279.30","91.72","1116.77","266","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X160MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1834.95","42.9","","731.00","63.70","731.00","1 through 10","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X160MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1834.95","42.9","","384.74","384.74","384.74","1 through 10","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X160MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","WELLPOINT [1015]","HB AMC WELLPOINT","3155.78","73.78","","286.63","119.22","1107.45","105","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X160MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4277.28","3207.96","AETNA [1001]","HB AMC AETNA HMO","2985.54","69.8","","675.31","184.75","1721.50","286","2235.31","3495.39","percent of total billed charges",""
"NAIL FEMORAL 9X160MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4277.28","3207.96","AETNA [1001]","HB AMC AETNA PPO","3438.93","80.4","","1261.44","103.12","1514.10","21","2235.31","3495.39","percent of total billed charges",""
"NAIL FEMORAL 9X160MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4277.28","3207.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3438.93","80.4","","1365.00","1365.00","1365.00","1 through 10","2235.31","3495.39","percent of total billed charges",""
"NAIL FEMORAL 9X160MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4277.28","3207.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3495.39","81.72","","5157.68","5157.68","5157.68","1 through 10","2235.31","3495.39","percent of total billed charges",""
"NAIL FEMORAL 9X160MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4277.28","3207.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3495.39","81.72","","431.26","71.26","1459.57","88","2235.31","3495.39","percent of total billed charges",""
"NAIL FEMORAL 9X220MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020777","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3400.44","79.5","","800.18","480.96","1887.97","195","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X220MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020777","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2279.79","53.3","","813.12","216.42","1444.50","81","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X220MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020777","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1325.96","31","","432.60","432.60","432.60","1 through 10","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X220MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020777","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1561.21","36.5","","148.37","54.89","631.39","94","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X220MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020777","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1638.20","38.3","","279.30","91.72","1116.77","266","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X220MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020777","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1834.95","42.9","","731.00","63.70","731.00","1 through 10","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X220MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020777","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1834.95","42.9","","384.74","384.74","384.74","1 through 10","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X220MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020777","CDM","C1713","HCPCS","0278","RC","","","","both","","","4277.28","3207.96","WELLPOINT [1015]","HB AMC WELLPOINT","3155.78","73.78","","286.63","119.22","1107.45","105","1325.96","3400.44","percent of total billed charges",""
"NAIL FEMORAL 9X220MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020777","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4277.28","3207.96","AETNA [1001]","HB AMC AETNA HMO","2985.54","69.8","","675.31","184.75","1721.50","286","2235.31","3495.39","percent of total billed charges",""
"NAIL FEMORAL 9X220MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020777","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4277.28","3207.96","AETNA [1001]","HB AMC AETNA PPO","3438.93","80.4","","1261.44","103.12","1514.10","21","2235.31","3495.39","percent of total billed charges",""
"NAIL FEMORAL 9X220MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020777","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4277.28","3207.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3438.93","80.4","","1365.00","1365.00","1365.00","1 through 10","2235.31","3495.39","percent of total billed charges",""
"NAIL FEMORAL 9X220MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020777","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4277.28","3207.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3495.39","81.72","","5157.68","5157.68","5157.68","1 through 10","2235.31","3495.39","percent of total billed charges",""
"NAIL FEMORAL 9X220MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020777","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4277.28","3207.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3495.39","81.72","","431.26","71.26","1459.57","88","2235.31","3495.39","percent of total billed charges",""
"NAIL FEMORAL 9X280MM 5DEG BEND RETROGRADE","SUP-ITM-10295978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.69","3638.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3857.09","79.5","","800.18","480.96","1887.97","195","1504.02","3857.09","percent of total billed charges",""
"NAIL FEMORAL 9X280MM 5DEG BEND RETROGRADE","SUP-ITM-10295978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.69","3638.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2585.95","53.3","","813.12","216.42","1444.50","81","1504.02","3857.09","percent of total billed charges",""
"NAIL FEMORAL 9X280MM 5DEG BEND RETROGRADE","SUP-ITM-10295978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.69","3638.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1504.02","31","","432.60","432.60","432.60","1 through 10","1504.02","3857.09","percent of total billed charges",""
"NAIL FEMORAL 9X280MM 5DEG BEND RETROGRADE","SUP-ITM-10295978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.69","3638.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1770.87","36.5","","148.37","54.89","631.39","94","1504.02","3857.09","percent of total billed charges",""
"NAIL FEMORAL 9X280MM 5DEG BEND RETROGRADE","SUP-ITM-10295978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.69","3638.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1858.20","38.3","","279.30","91.72","1116.77","266","1504.02","3857.09","percent of total billed charges",""
"NAIL FEMORAL 9X280MM 5DEG BEND RETROGRADE","SUP-ITM-10295978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.69","3638.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2081.38","42.9","","731.00","63.70","731.00","1 through 10","1504.02","3857.09","percent of total billed charges",""
"NAIL FEMORAL 9X280MM 5DEG BEND RETROGRADE","SUP-ITM-10295978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.69","3638.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2081.38","42.9","","384.74","384.74","384.74","1 through 10","1504.02","3857.09","percent of total billed charges",""
"NAIL FEMORAL 9X280MM 5DEG BEND RETROGRADE","SUP-ITM-10295978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.69","3638.77","WELLPOINT [1015]","HB AMC WELLPOINT","3579.58","73.78","","286.63","119.22","1107.45","105","1504.02","3857.09","percent of total billed charges",""
"NAIL FEMORAL 9X280MM 5DEG BEND RETROGRADE","SUP-ITM-10295978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4851.69","3638.77","AETNA [1001]","HB AMC AETNA HMO","3386.48","69.8","","675.31","184.75","1721.50","286","2535.49","3964.8","percent of total billed charges",""
"NAIL FEMORAL 9X280MM 5DEG BEND RETROGRADE","SUP-ITM-10295978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4851.69","3638.77","AETNA [1001]","HB AMC AETNA PPO","3900.76","80.4","","1261.44","103.12","1514.10","21","2535.49","3964.8","percent of total billed charges",""
"NAIL FEMORAL 9X280MM 5DEG BEND RETROGRADE","SUP-ITM-10295978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4851.69","3638.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3900.76","80.4","","1365.00","1365.00","1365.00","1 through 10","2535.49","3964.8","percent of total billed charges",""
"NAIL FEMORAL 9X280MM 5DEG BEND RETROGRADE","SUP-ITM-10295978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4851.69","3638.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3964.80","81.72","","5157.68","5157.68","5157.68","1 through 10","2535.49","3964.8","percent of total billed charges",""
"NAIL FEMORAL 9X280MM 5DEG BEND RETROGRADE","SUP-ITM-10295978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4851.69","3638.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3964.80","81.72","","431.26","71.26","1459.57","88","2535.49","3964.8","percent of total billed charges",""
"NAIL FEMORAL 9X280MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4149.60","3112.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3298.93","79.5","","800.18","480.96","1887.97","195","1286.38","3298.93","percent of total billed charges",""
"NAIL FEMORAL 9X280MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4149.60","3112.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2211.74","53.3","","813.12","216.42","1444.50","81","1286.38","3298.93","percent of total billed charges",""
"NAIL FEMORAL 9X280MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4149.60","3112.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1286.38","31","","432.60","432.60","432.60","1 through 10","1286.38","3298.93","percent of total billed charges",""
"NAIL FEMORAL 9X280MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4149.60","3112.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1514.60","36.5","","148.37","54.89","631.39","94","1286.38","3298.93","percent of total billed charges",""
"NAIL FEMORAL 9X280MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4149.60","3112.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1589.30","38.3","","279.30","91.72","1116.77","266","1286.38","3298.93","percent of total billed charges",""
"NAIL FEMORAL 9X280MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4149.60","3112.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1780.18","42.9","","731.00","63.70","731.00","1 through 10","1286.38","3298.93","percent of total billed charges",""
"NAIL FEMORAL 9X280MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4149.60","3112.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1780.18","42.9","","384.74","384.74","384.74","1 through 10","1286.38","3298.93","percent of total billed charges",""
"NAIL FEMORAL 9X280MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020780","CDM","C1713","HCPCS","0278","RC","","","","both","","","4149.60","3112.20","WELLPOINT [1015]","HB AMC WELLPOINT","3061.57","73.78","","286.63","119.22","1107.45","105","1286.38","3298.93","percent of total billed charges",""
"NAIL FEMORAL 9X280MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4149.60","3112.20","AETNA [1001]","HB AMC AETNA HMO","2896.42","69.8","","675.31","184.75","1721.50","286","2168.58","3391.05","percent of total billed charges",""
"NAIL FEMORAL 9X280MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4149.60","3112.20","AETNA [1001]","HB AMC AETNA PPO","3336.28","80.4","","1261.44","103.12","1514.10","21","2168.58","3391.05","percent of total billed charges",""
"NAIL FEMORAL 9X280MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4149.60","3112.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3336.28","80.4","","1365.00","1365.00","1365.00","1 through 10","2168.58","3391.05","percent of total billed charges",""
"NAIL FEMORAL 9X280MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4149.60","3112.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3391.05","81.72","","5157.68","5157.68","5157.68","1 through 10","2168.58","3391.05","percent of total billed charges",""
"NAIL FEMORAL 9X280MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4149.60","3112.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3391.05","81.72","","431.26","71.26","1459.57","88","2168.58","3391.05","percent of total billed charges",""
"NAIL FEMORAL 9X300MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020781","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3192.08","79.5","","800.18","480.96","1887.97","195","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 9X300MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020781","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2140.10","53.3","","813.12","216.42","1444.50","81","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 9X300MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020781","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1244.71","31","","432.60","432.60","432.60","1 through 10","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 9X300MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020781","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1465.55","36.5","","148.37","54.89","631.39","94","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 9X300MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020781","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1537.82","38.3","","279.30","91.72","1116.77","266","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 9X300MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020781","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1722.52","42.9","","731.00","63.70","731.00","1 through 10","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 9X300MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020781","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1722.52","42.9","","384.74","384.74","384.74","1 through 10","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 9X300MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020781","CDM","C1713","HCPCS","0278","RC","","","","both","","","4015.20","3011.40","WELLPOINT [1015]","HB AMC WELLPOINT","2962.41","73.78","","286.63","119.22","1107.45","105","1244.71","3192.08","percent of total billed charges",""
"NAIL FEMORAL 9X300MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","AETNA [1001]","HB AMC AETNA HMO","2802.61","69.8","","675.31","184.75","1721.50","286","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 9X300MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","AETNA [1001]","HB AMC AETNA PPO","3228.22","80.4","","1261.44","103.12","1514.10","21","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 9X300MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3228.22","80.4","","1365.00","1365.00","1365.00","1 through 10","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 9X300MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3281.22","81.72","","5157.68","5157.68","5157.68","1 through 10","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 9X300MM NAIL-EX TITANIUM CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4015.20","3011.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3281.22","81.72","","431.26","71.26","1459.57","88","2098.34","3281.22","percent of total billed charges",""
"NAIL FEMORAL 9X380MM TITANIUM LATERAL ADOLESCENT RIGHT","SUP-ITM-10092048","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3112.26","79.5","","800.18","480.96","1887.97","195","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 9X380MM TITANIUM LATERAL ADOLESCENT RIGHT","SUP-ITM-10092048","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2086.58","53.3","","813.12","216.42","1444.50","81","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 9X380MM TITANIUM LATERAL ADOLESCENT RIGHT","SUP-ITM-10092048","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1213.58","31","","432.60","432.60","432.60","1 through 10","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 9X380MM TITANIUM LATERAL ADOLESCENT RIGHT","SUP-ITM-10092048","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1428.90","36.5","","148.37","54.89","631.39","94","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 9X380MM TITANIUM LATERAL ADOLESCENT RIGHT","SUP-ITM-10092048","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1499.36","38.3","","279.30","91.72","1116.77","266","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 9X380MM TITANIUM LATERAL ADOLESCENT RIGHT","SUP-ITM-10092048","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1679.44","42.9","","731.00","63.70","731.00","1 through 10","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 9X380MM TITANIUM LATERAL ADOLESCENT RIGHT","SUP-ITM-10092048","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1679.44","42.9","","384.74","384.74","384.74","1 through 10","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 9X380MM TITANIUM LATERAL ADOLESCENT RIGHT","SUP-ITM-10092048","CDM","C1713","HCPCS","0278","RC","","","","both","","","3914.79","2936.09","WELLPOINT [1015]","HB AMC WELLPOINT","2888.33","73.78","","286.63","119.22","1107.45","105","1213.58","3112.26","percent of total billed charges",""
"NAIL FEMORAL 9X380MM TITANIUM LATERAL ADOLESCENT RIGHT","SUP-ITM-10092048","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","AETNA [1001]","HB AMC AETNA HMO","2732.52","69.8","","675.31","184.75","1721.50","286","2045.87","3199.17","percent of total billed charges",""
"NAIL FEMORAL 9X380MM TITANIUM LATERAL ADOLESCENT RIGHT","SUP-ITM-10092048","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","AETNA [1001]","HB AMC AETNA PPO","3147.49","80.4","","1261.44","103.12","1514.10","21","2045.87","3199.17","percent of total billed charges",""
"NAIL FEMORAL 9X380MM TITANIUM LATERAL ADOLESCENT RIGHT","SUP-ITM-10092048","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3147.49","80.4","","1365.00","1365.00","1365.00","1 through 10","2045.87","3199.17","percent of total billed charges",""
"NAIL FEMORAL 9X380MM TITANIUM LATERAL ADOLESCENT RIGHT","SUP-ITM-10092048","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3199.17","81.72","","5157.68","5157.68","5157.68","1 through 10","2045.87","3199.17","percent of total billed charges",""
"NAIL FEMORAL 9X380MM TITANIUM LATERAL ADOLESCENT RIGHT","SUP-ITM-10092048","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3914.79","2936.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3199.17","81.72","","431.26","71.26","1459.57","88","2045.87","3199.17","percent of total billed charges",""
"NAIL FEMORAL ADOLESCENT 10MMX320MM PIP RIGHT","SUP-ITM-10270921","CDM","C1713","HCPCS","0278","RC","","","","both","","","8437.50","6328.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6707.81","79.5","","800.18","480.96","1887.97","195","2615.63","6707.81","percent of total billed charges",""
"NAIL FEMORAL ADOLESCENT 10MMX320MM PIP RIGHT","SUP-ITM-10270921","CDM","C1713","HCPCS","0278","RC","","","","both","","","8437.50","6328.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4497.19","53.3","","813.12","216.42","1444.50","81","2615.63","6707.81","percent of total billed charges",""
"NAIL FEMORAL ADOLESCENT 10MMX320MM PIP RIGHT","SUP-ITM-10270921","CDM","C1713","HCPCS","0278","RC","","","","both","","","8437.50","6328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2615.63","31","","432.60","432.60","432.60","1 through 10","2615.63","6707.81","percent of total billed charges",""
"NAIL FEMORAL ADOLESCENT 10MMX320MM PIP RIGHT","SUP-ITM-10270921","CDM","C1713","HCPCS","0278","RC","","","","both","","","8437.50","6328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3079.69","36.5","","148.37","54.89","631.39","94","2615.63","6707.81","percent of total billed charges",""
"NAIL FEMORAL ADOLESCENT 10MMX320MM PIP RIGHT","SUP-ITM-10270921","CDM","C1713","HCPCS","0278","RC","","","","both","","","8437.50","6328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3231.56","38.3","","279.30","91.72","1116.77","266","2615.63","6707.81","percent of total billed charges",""
"NAIL FEMORAL ADOLESCENT 10MMX320MM PIP RIGHT","SUP-ITM-10270921","CDM","C1713","HCPCS","0278","RC","","","","both","","","8437.50","6328.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3619.69","42.9","","731.00","63.70","731.00","1 through 10","2615.63","6707.81","percent of total billed charges",""
"NAIL FEMORAL ADOLESCENT 10MMX320MM PIP RIGHT","SUP-ITM-10270921","CDM","C1713","HCPCS","0278","RC","","","","both","","","8437.50","6328.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3619.69","42.9","","384.74","384.74","384.74","1 through 10","2615.63","6707.81","percent of total billed charges",""
"NAIL FEMORAL ADOLESCENT 10MMX320MM PIP RIGHT","SUP-ITM-10270921","CDM","C1713","HCPCS","0278","RC","","","","both","","","8437.50","6328.12","WELLPOINT [1015]","HB AMC WELLPOINT","6225.19","73.78","","286.63","119.22","1107.45","105","2615.63","6707.81","percent of total billed charges",""
"NAIL FEMORAL ADOLESCENT 10MMX320MM PIP RIGHT","SUP-ITM-10270921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8437.50","6328.12","AETNA [1001]","HB AMC AETNA HMO","5889.38","69.8","","675.31","184.75","1721.50","286","4409.44","6895.13","percent of total billed charges",""
"NAIL FEMORAL ADOLESCENT 10MMX320MM PIP RIGHT","SUP-ITM-10270921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8437.50","6328.12","AETNA [1001]","HB AMC AETNA PPO","6783.75","80.4","","1261.44","103.12","1514.10","21","4409.44","6895.13","percent of total billed charges",""
"NAIL FEMORAL ADOLESCENT 10MMX320MM PIP RIGHT","SUP-ITM-10270921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8437.50","6328.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6783.75","80.4","","1365.00","1365.00","1365.00","1 through 10","4409.44","6895.13","percent of total billed charges",""
"NAIL FEMORAL ADOLESCENT 10MMX320MM PIP RIGHT","SUP-ITM-10270921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8437.50","6328.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6895.13","81.72","","5157.68","5157.68","5157.68","1 through 10","4409.44","6895.13","percent of total billed charges",""
"NAIL FEMORAL ADOLESCENT 10MMX320MM PIP RIGHT","SUP-ITM-10270921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8437.50","6328.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6895.13","81.72","","431.26","71.26","1459.57","88","4409.44","6895.13","percent of total billed charges",""
"NAIL FEMORAL GT RIGHT D10XL340","SUP-ITM-10233226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8058.95","6044.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6406.87","79.5","","800.18","480.96","1887.97","195","2498.27","6406.87","percent of total billed charges",""
"NAIL FEMORAL GT RIGHT D10XL340","SUP-ITM-10233226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8058.95","6044.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4295.42","53.3","","813.12","216.42","1444.50","81","2498.27","6406.87","percent of total billed charges",""
"NAIL FEMORAL GT RIGHT D10XL340","SUP-ITM-10233226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8058.95","6044.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2498.27","31","","432.60","432.60","432.60","1 through 10","2498.27","6406.87","percent of total billed charges",""
"NAIL FEMORAL GT RIGHT D10XL340","SUP-ITM-10233226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8058.95","6044.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2941.52","36.5","","148.37","54.89","631.39","94","2498.27","6406.87","percent of total billed charges",""
"NAIL FEMORAL GT RIGHT D10XL340","SUP-ITM-10233226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8058.95","6044.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3086.58","38.3","","279.30","91.72","1116.77","266","2498.27","6406.87","percent of total billed charges",""
"NAIL FEMORAL GT RIGHT D10XL340","SUP-ITM-10233226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8058.95","6044.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3457.29","42.9","","731.00","63.70","731.00","1 through 10","2498.27","6406.87","percent of total billed charges",""
"NAIL FEMORAL GT RIGHT D10XL340","SUP-ITM-10233226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8058.95","6044.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3457.29","42.9","","384.74","384.74","384.74","1 through 10","2498.27","6406.87","percent of total billed charges",""
"NAIL FEMORAL GT RIGHT D10XL340","SUP-ITM-10233226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8058.95","6044.21","WELLPOINT [1015]","HB AMC WELLPOINT","5945.89","73.78","","286.63","119.22","1107.45","105","2498.27","6406.87","percent of total billed charges",""
"NAIL FEMORAL GT RIGHT D10XL340","SUP-ITM-10233226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8058.95","6044.21","AETNA [1001]","HB AMC AETNA HMO","5625.15","69.8","","675.31","184.75","1721.50","286","4211.61","6585.77","percent of total billed charges",""
"NAIL FEMORAL GT RIGHT D10XL340","SUP-ITM-10233226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8058.95","6044.21","AETNA [1001]","HB AMC AETNA PPO","6479.40","80.4","","1261.44","103.12","1514.10","21","4211.61","6585.77","percent of total billed charges",""
"NAIL FEMORAL GT RIGHT D10XL340","SUP-ITM-10233226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8058.95","6044.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6479.40","80.4","","1365.00","1365.00","1365.00","1 through 10","4211.61","6585.77","percent of total billed charges",""
"NAIL FEMORAL GT RIGHT D10XL340","SUP-ITM-10233226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8058.95","6044.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6585.77","81.72","","5157.68","5157.68","5157.68","1 through 10","4211.61","6585.77","percent of total billed charges",""
"NAIL FEMORAL GT RIGHT D10XL340","SUP-ITM-10233226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8058.95","6044.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6585.77","81.72","","431.26","71.26","1459.57","88","4211.61","6585.77","percent of total billed charges",""
"NAIL HINDFOOT 10MMX180 ARTHRODESIS TI CANNULATED RIGHT","SUP-ITM-10036911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3265.07","79.5","","800.18","480.96","1887.97","195","1273.17","3265.07","percent of total billed charges",""
"NAIL HINDFOOT 10MMX180 ARTHRODESIS TI CANNULATED RIGHT","SUP-ITM-10036911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2189.03","53.3","","813.12","216.42","1444.50","81","1273.17","3265.07","percent of total billed charges",""
"NAIL HINDFOOT 10MMX180 ARTHRODESIS TI CANNULATED RIGHT","SUP-ITM-10036911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1273.17","31","","432.60","432.60","432.60","1 through 10","1273.17","3265.07","percent of total billed charges",""
"NAIL HINDFOOT 10MMX180 ARTHRODESIS TI CANNULATED RIGHT","SUP-ITM-10036911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1499.06","36.5","","148.37","54.89","631.39","94","1273.17","3265.07","percent of total billed charges",""
"NAIL HINDFOOT 10MMX180 ARTHRODESIS TI CANNULATED RIGHT","SUP-ITM-10036911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1572.98","38.3","","279.30","91.72","1116.77","266","1273.17","3265.07","percent of total billed charges",""
"NAIL HINDFOOT 10MMX180 ARTHRODESIS TI CANNULATED RIGHT","SUP-ITM-10036911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1761.90","42.9","","731.00","63.70","731.00","1 through 10","1273.17","3265.07","percent of total billed charges",""
"NAIL HINDFOOT 10MMX180 ARTHRODESIS TI CANNULATED RIGHT","SUP-ITM-10036911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1761.90","42.9","","384.74","384.74","384.74","1 through 10","1273.17","3265.07","percent of total billed charges",""
"NAIL HINDFOOT 10MMX180 ARTHRODESIS TI CANNULATED RIGHT","SUP-ITM-10036911","CDM","C1713","HCPCS","0278","RC","","","","both","","","4107.00","3080.25","WELLPOINT [1015]","HB AMC WELLPOINT","3030.14","73.78","","286.63","119.22","1107.45","105","1273.17","3265.07","percent of total billed charges",""
"NAIL HINDFOOT 10MMX180 ARTHRODESIS TI CANNULATED RIGHT","SUP-ITM-10036911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","AETNA [1001]","HB AMC AETNA HMO","2866.69","69.8","","675.31","184.75","1721.50","286","2146.32","3356.24","percent of total billed charges",""
"NAIL HINDFOOT 10MMX180 ARTHRODESIS TI CANNULATED RIGHT","SUP-ITM-10036911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","AETNA [1001]","HB AMC AETNA PPO","3302.03","80.4","","1261.44","103.12","1514.10","21","2146.32","3356.24","percent of total billed charges",""
"NAIL HINDFOOT 10MMX180 ARTHRODESIS TI CANNULATED RIGHT","SUP-ITM-10036911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3302.03","80.4","","1365.00","1365.00","1365.00","1 through 10","2146.32","3356.24","percent of total billed charges",""
"NAIL HINDFOOT 10MMX180 ARTHRODESIS TI CANNULATED RIGHT","SUP-ITM-10036911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3356.24","81.72","","5157.68","5157.68","5157.68","1 through 10","2146.32","3356.24","percent of total billed charges",""
"NAIL HINDFOOT 10MMX180 ARTHRODESIS TI CANNULATED RIGHT","SUP-ITM-10036911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4107.00","3080.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3356.24","81.72","","431.26","71.26","1459.57","88","2146.32","3356.24","percent of total billed charges",""
"NAIL HUMERAL 260MM LONG TITANIUM PROXIMALIMAL T2 RIGHT","SUP-ITM-10033813","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5717.44","79.5","","800.18","480.96","1887.97","195","2229.44","5717.44","percent of total billed charges",""
"NAIL HUMERAL 260MM LONG TITANIUM PROXIMALIMAL T2 RIGHT","SUP-ITM-10033813","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3833.20","53.3","","813.12","216.42","1444.50","81","2229.44","5717.44","percent of total billed charges",""
"NAIL HUMERAL 260MM LONG TITANIUM PROXIMALIMAL T2 RIGHT","SUP-ITM-10033813","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2229.44","31","","432.60","432.60","432.60","1 through 10","2229.44","5717.44","percent of total billed charges",""
"NAIL HUMERAL 260MM LONG TITANIUM PROXIMALIMAL T2 RIGHT","SUP-ITM-10033813","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2624.99","36.5","","148.37","54.89","631.39","94","2229.44","5717.44","percent of total billed charges",""
"NAIL HUMERAL 260MM LONG TITANIUM PROXIMALIMAL T2 RIGHT","SUP-ITM-10033813","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2754.44","38.3","","279.30","91.72","1116.77","266","2229.44","5717.44","percent of total billed charges",""
"NAIL HUMERAL 260MM LONG TITANIUM PROXIMALIMAL T2 RIGHT","SUP-ITM-10033813","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3085.26","42.9","","731.00","63.70","731.00","1 through 10","2229.44","5717.44","percent of total billed charges",""
"NAIL HUMERAL 260MM LONG TITANIUM PROXIMALIMAL T2 RIGHT","SUP-ITM-10033813","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3085.26","42.9","","384.74","384.74","384.74","1 through 10","2229.44","5717.44","percent of total billed charges",""
"NAIL HUMERAL 260MM LONG TITANIUM PROXIMALIMAL T2 RIGHT","SUP-ITM-10033813","CDM","C1713","HCPCS","0278","RC","","","","both","","","7191.75","5393.81","WELLPOINT [1015]","HB AMC WELLPOINT","5306.07","73.78","","286.63","119.22","1107.45","105","2229.44","5717.44","percent of total billed charges",""
"NAIL HUMERAL 260MM LONG TITANIUM PROXIMALIMAL T2 RIGHT","SUP-ITM-10033813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7191.75","5393.81","AETNA [1001]","HB AMC AETNA HMO","5019.84","69.8","","675.31","184.75","1721.50","286","3758.41","5877.1","percent of total billed charges",""
"NAIL HUMERAL 260MM LONG TITANIUM PROXIMALIMAL T2 RIGHT","SUP-ITM-10033813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7191.75","5393.81","AETNA [1001]","HB AMC AETNA PPO","5782.17","80.4","","1261.44","103.12","1514.10","21","3758.41","5877.1","percent of total billed charges",""
"NAIL HUMERAL 260MM LONG TITANIUM PROXIMALIMAL T2 RIGHT","SUP-ITM-10033813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7191.75","5393.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5782.17","80.4","","1365.00","1365.00","1365.00","1 through 10","3758.41","5877.1","percent of total billed charges",""
"NAIL HUMERAL 260MM LONG TITANIUM PROXIMALIMAL T2 RIGHT","SUP-ITM-10033813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7191.75","5393.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5877.10","81.72","","5157.68","5157.68","5157.68","1 through 10","3758.41","5877.1","percent of total billed charges",""
"NAIL HUMERAL 260MM LONG TITANIUM PROXIMALIMAL T2 RIGHT","SUP-ITM-10033813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7191.75","5393.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5877.10","81.72","","431.26","71.26","1459.57","88","3758.41","5877.1","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3409.79","79.5","","800.18","480.96","1887.97","195","1329.6","3409.79","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2286.06","53.3","","813.12","216.42","1444.50","81","1329.6","3409.79","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1329.60","31","","432.60","432.60","432.60","1 through 10","1329.6","3409.79","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1565.50","36.5","","148.37","54.89","631.39","94","1329.6","3409.79","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1642.70","38.3","","279.30","91.72","1116.77","266","1329.6","3409.79","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1840.00","42.9","","731.00","63.70","731.00","1 through 10","1329.6","3409.79","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1840.00","42.9","","384.74","384.74","384.74","1 through 10","1329.6","3409.79","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","4289.04","3216.78","WELLPOINT [1015]","HB AMC WELLPOINT","3164.45","73.78","","286.63","119.22","1107.45","105","1329.6","3409.79","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4289.04","3216.78","AETNA [1001]","HB AMC AETNA HMO","2993.75","69.8","","675.31","184.75","1721.50","286","2241.45","3505","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4289.04","3216.78","AETNA [1001]","HB AMC AETNA PPO","3448.39","80.4","","1261.44","103.12","1514.10","21","2241.45","3505","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4289.04","3216.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3448.39","80.4","","1365.00","1365.00","1365.00","1 through 10","2241.45","3505","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4289.04","3216.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3505.00","81.72","","5157.68","5157.68","5157.68","1 through 10","2241.45","3505","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4289.04","3216.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3505.00","81.72","","431.26","71.26","1459.57","88","2241.45","3505","percent of total billed charges",""
"NAIL INTERMEDIATE 11X240MM 125DEG GAMMA 4 FEMORAL LEFT","SUP-ITM-10321001","CDM","C1713","HCPCS","0278","RC","","","","both","","","9992.08","7494.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7943.70","79.5","","800.18","480.96","1887.97","195","3097.54","7943.7","percent of total billed charges",""
"NAIL INTERMEDIATE 11X240MM 125DEG GAMMA 4 FEMORAL LEFT","SUP-ITM-10321001","CDM","C1713","HCPCS","0278","RC","","","","both","","","9992.08","7494.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5325.78","53.3","","813.12","216.42","1444.50","81","3097.54","7943.7","percent of total billed charges",""
"NAIL INTERMEDIATE 11X240MM 125DEG GAMMA 4 FEMORAL LEFT","SUP-ITM-10321001","CDM","C1713","HCPCS","0278","RC","","","","both","","","9992.08","7494.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3097.54","31","","432.60","432.60","432.60","1 through 10","3097.54","7943.7","percent of total billed charges",""
"NAIL INTERMEDIATE 11X240MM 125DEG GAMMA 4 FEMORAL LEFT","SUP-ITM-10321001","CDM","C1713","HCPCS","0278","RC","","","","both","","","9992.08","7494.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3647.11","36.5","","148.37","54.89","631.39","94","3097.54","7943.7","percent of total billed charges",""
"NAIL INTERMEDIATE 11X240MM 125DEG GAMMA 4 FEMORAL LEFT","SUP-ITM-10321001","CDM","C1713","HCPCS","0278","RC","","","","both","","","9992.08","7494.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3826.97","38.3","","279.30","91.72","1116.77","266","3097.54","7943.7","percent of total billed charges",""
"NAIL INTERMEDIATE 11X240MM 125DEG GAMMA 4 FEMORAL LEFT","SUP-ITM-10321001","CDM","C1713","HCPCS","0278","RC","","","","both","","","9992.08","7494.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4286.60","42.9","","731.00","63.70","731.00","1 through 10","3097.54","7943.7","percent of total billed charges",""
"NAIL INTERMEDIATE 11X240MM 125DEG GAMMA 4 FEMORAL LEFT","SUP-ITM-10321001","CDM","C1713","HCPCS","0278","RC","","","","both","","","9992.08","7494.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4286.60","42.9","","384.74","384.74","384.74","1 through 10","3097.54","7943.7","percent of total billed charges",""
"NAIL INTERMEDIATE 11X240MM 125DEG GAMMA 4 FEMORAL LEFT","SUP-ITM-10321001","CDM","C1713","HCPCS","0278","RC","","","","both","","","9992.08","7494.06","WELLPOINT [1015]","HB AMC WELLPOINT","7372.16","73.78","","286.63","119.22","1107.45","105","3097.54","7943.7","percent of total billed charges",""
"NAIL INTERMEDIATE 11X240MM 125DEG GAMMA 4 FEMORAL LEFT","SUP-ITM-10321001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9992.08","7494.06","AETNA [1001]","HB AMC AETNA HMO","6974.47","69.8","","675.31","184.75","1721.50","286","5221.86","8165.53","percent of total billed charges",""
"NAIL INTERMEDIATE 11X240MM 125DEG GAMMA 4 FEMORAL LEFT","SUP-ITM-10321001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9992.08","7494.06","AETNA [1001]","HB AMC AETNA PPO","8033.63","80.4","","1261.44","103.12","1514.10","21","5221.86","8165.53","percent of total billed charges",""
"NAIL INTERMEDIATE 11X240MM 125DEG GAMMA 4 FEMORAL LEFT","SUP-ITM-10321001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9992.08","7494.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8033.63","80.4","","1365.00","1365.00","1365.00","1 through 10","5221.86","8165.53","percent of total billed charges",""
"NAIL INTERMEDIATE 11X240MM 125DEG GAMMA 4 FEMORAL LEFT","SUP-ITM-10321001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9992.08","7494.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8165.53","81.72","","5157.68","5157.68","5157.68","1 through 10","5221.86","8165.53","percent of total billed charges",""
"NAIL INTERMEDIATE 11X240MM 125DEG GAMMA 4 FEMORAL LEFT","SUP-ITM-10321001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9992.08","7494.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8165.53","81.72","","431.26","71.26","1459.57","88","5221.86","8165.53","percent of total billed charges",""
"NAIL KNEE 11.5MMX75CM FUSION RIGHT","SUP-ITM-10139147","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9027.92","52.26","","1113.10","1113.10","1113.10","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 11.5MMX75CM FUSION RIGHT","SUP-ITM-10139147","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13733.63","79.5","","1293.60","1148.53","1603.80","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 11.5MMX75CM FUSION RIGHT","SUP-ITM-10139147","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6305.38","36.5","","1023.42","771.29","2068.67","33","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 11.5MMX75CM FUSION RIGHT","SUP-ITM-10139147","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6616.33","38.3","","850.52","759.78","1211.25","66","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 11.5MMX75CM FUSION RIGHT","SUP-ITM-10139147","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7410.98","42.9","","2548.09","2548.09","2548.09","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 11.5MMX75CM FUSION RIGHT","SUP-ITM-10139147","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7410.98","42.9","","956.46","956.46","956.46","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 11.5MMX75CM FUSION RIGHT","SUP-ITM-10139147","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","WELLPOINT [1015]","HB AMC WELLPOINT","12745.50","73.78","","2344.73","1619.47","2530.35","16","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 11.5MMX75CM FUSION RIGHT","SUP-ITM-10139147","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","AETNA [1001]","HB AMC AETNA HMO","12057.95","69.8","","1523.63","988.41","4330.26","39","9027.92","14117.13","percent of total billed charges",""
"NAIL KNEE 11.5MMX75CM FUSION RIGHT","SUP-ITM-10139147","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","AETNA [1001]","HB AMC AETNA PPO","13889.10","80.4","","1670.25","1670.25","1670.25","1 through 10","9027.92","14117.13","percent of total billed charges",""
"NAIL KNEE 11.5MMX75CM FUSION RIGHT","SUP-ITM-10139147","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9027.92","52.26","","1113.10","1113.10","1113.10","1 through 10","9027.92","14117.13","percent of total billed charges",""
"NAIL KNEE 11.5MMX75CM FUSION RIGHT","SUP-ITM-10139147","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14117.13","81.72","","1738.90","1484.65","2716.94","38","9027.92","14117.13","percent of total billed charges",""
"NAIL KNEE 13MMX65CM FUSION RIGHT","SUP-ITM-10139162","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9027.92","52.26","","1113.10","1113.10","1113.10","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 13MMX65CM FUSION RIGHT","SUP-ITM-10139162","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13733.63","79.5","","1293.60","1148.53","1603.80","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 13MMX65CM FUSION RIGHT","SUP-ITM-10139162","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6305.38","36.5","","1023.42","771.29","2068.67","33","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 13MMX65CM FUSION RIGHT","SUP-ITM-10139162","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6616.33","38.3","","850.52","759.78","1211.25","66","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 13MMX65CM FUSION RIGHT","SUP-ITM-10139162","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7410.98","42.9","","2548.09","2548.09","2548.09","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 13MMX65CM FUSION RIGHT","SUP-ITM-10139162","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7410.98","42.9","","956.46","956.46","956.46","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 13MMX65CM FUSION RIGHT","SUP-ITM-10139162","CDM","C1776","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","WELLPOINT [1015]","HB AMC WELLPOINT","12745.50","73.78","","2344.73","1619.47","2530.35","16","5355.25","13733.63","percent of total billed charges",""
"NAIL KNEE 13MMX65CM FUSION RIGHT","SUP-ITM-10139162","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","AETNA [1001]","HB AMC AETNA HMO","12057.95","69.8","","1523.63","988.41","4330.26","39","9027.92","14117.13","percent of total billed charges",""
"NAIL KNEE 13MMX65CM FUSION RIGHT","SUP-ITM-10139162","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","AETNA [1001]","HB AMC AETNA PPO","13889.10","80.4","","1670.25","1670.25","1670.25","1 through 10","9027.92","14117.13","percent of total billed charges",""
"NAIL KNEE 13MMX65CM FUSION RIGHT","SUP-ITM-10139162","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9027.92","52.26","","1113.10","1113.10","1113.10","1 through 10","9027.92","14117.13","percent of total billed charges",""
"NAIL KNEE 13MMX65CM FUSION RIGHT","SUP-ITM-10139162","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14117.13","81.72","","1738.90","1484.65","2716.94","38","9027.92","14117.13","percent of total billed charges",""
"NAIL NAIIL 11.5MMX55CM FEMORAL FUSION TRIGEN FAN TITANIUM ALLOY RT ANTEGRADE","SUP-ITM-10091562","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13733.63","79.5","","800.18","480.96","1887.97","195","5355.25","13733.63","percent of total billed charges",""
"NAIL NAIIL 11.5MMX55CM FEMORAL FUSION TRIGEN FAN TITANIUM ALLOY RT ANTEGRADE","SUP-ITM-10091562","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9207.58","53.3","","813.12","216.42","1444.50","81","5355.25","13733.63","percent of total billed charges",""
"NAIL NAIIL 11.5MMX55CM FEMORAL FUSION TRIGEN FAN TITANIUM ALLOY RT ANTEGRADE","SUP-ITM-10091562","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","5355.25","31","","432.60","432.60","432.60","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL NAIIL 11.5MMX55CM FEMORAL FUSION TRIGEN FAN TITANIUM ALLOY RT ANTEGRADE","SUP-ITM-10091562","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6305.38","36.5","","148.37","54.89","631.39","94","5355.25","13733.63","percent of total billed charges",""
"NAIL NAIIL 11.5MMX55CM FEMORAL FUSION TRIGEN FAN TITANIUM ALLOY RT ANTEGRADE","SUP-ITM-10091562","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6616.33","38.3","","279.30","91.72","1116.77","266","5355.25","13733.63","percent of total billed charges",""
"NAIL NAIIL 11.5MMX55CM FEMORAL FUSION TRIGEN FAN TITANIUM ALLOY RT ANTEGRADE","SUP-ITM-10091562","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7410.98","42.9","","731.00","63.70","731.00","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL NAIIL 11.5MMX55CM FEMORAL FUSION TRIGEN FAN TITANIUM ALLOY RT ANTEGRADE","SUP-ITM-10091562","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7410.98","42.9","","384.74","384.74","384.74","1 through 10","5355.25","13733.63","percent of total billed charges",""
"NAIL NAIIL 11.5MMX55CM FEMORAL FUSION TRIGEN FAN TITANIUM ALLOY RT ANTEGRADE","SUP-ITM-10091562","CDM","C1713","HCPCS","0278","RC","","","","both","","","17275.00","12956.25","WELLPOINT [1015]","HB AMC WELLPOINT","12745.50","73.78","","286.63","119.22","1107.45","105","5355.25","13733.63","percent of total billed charges",""
"NAIL NAIIL 11.5MMX55CM FEMORAL FUSION TRIGEN FAN TITANIUM ALLOY RT ANTEGRADE","SUP-ITM-10091562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","AETNA [1001]","HB AMC AETNA HMO","12057.95","69.8","","675.31","184.75","1721.50","286","9027.92","14117.13","percent of total billed charges",""
"NAIL NAIIL 11.5MMX55CM FEMORAL FUSION TRIGEN FAN TITANIUM ALLOY RT ANTEGRADE","SUP-ITM-10091562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","AETNA [1001]","HB AMC AETNA PPO","13889.10","80.4","","1261.44","103.12","1514.10","21","9027.92","14117.13","percent of total billed charges",""
"NAIL NAIIL 11.5MMX55CM FEMORAL FUSION TRIGEN FAN TITANIUM ALLOY RT ANTEGRADE","SUP-ITM-10091562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","13889.10","80.4","","1365.00","1365.00","1365.00","1 through 10","9027.92","14117.13","percent of total billed charges",""
"NAIL NAIIL 11.5MMX55CM FEMORAL FUSION TRIGEN FAN TITANIUM ALLOY RT ANTEGRADE","SUP-ITM-10091562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","14117.13","81.72","","5157.68","5157.68","5157.68","1 through 10","9027.92","14117.13","percent of total billed charges",""
"NAIL NAIIL 11.5MMX55CM FEMORAL FUSION TRIGEN FAN TITANIUM ALLOY RT ANTEGRADE","SUP-ITM-10091562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17275.00","12956.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14117.13","81.72","","431.26","71.26","1459.57","88","9027.92","14117.13","percent of total billed charges",""
"NAIL PLATE BONE WRIST DVR ANATOMIC TITANIUM DORSAL RIGHT","SUP-ITM-10072406","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.64","1857.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1968.93","79.5","","800.18","480.96","1887.97","195","767.76","1968.93","percent of total billed charges",""
"NAIL PLATE BONE WRIST DVR ANATOMIC TITANIUM DORSAL RIGHT","SUP-ITM-10072406","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.64","1857.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1320.05","53.3","","813.12","216.42","1444.50","81","767.76","1968.93","percent of total billed charges",""
"NAIL PLATE BONE WRIST DVR ANATOMIC TITANIUM DORSAL RIGHT","SUP-ITM-10072406","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.64","1857.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","767.76","31","","432.60","432.60","432.60","1 through 10","767.76","1968.93","percent of total billed charges",""
"NAIL PLATE BONE WRIST DVR ANATOMIC TITANIUM DORSAL RIGHT","SUP-ITM-10072406","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.64","1857.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","903.97","36.5","","148.37","54.89","631.39","94","767.76","1968.93","percent of total billed charges",""
"NAIL PLATE BONE WRIST DVR ANATOMIC TITANIUM DORSAL RIGHT","SUP-ITM-10072406","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.64","1857.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","948.55","38.3","","279.30","91.72","1116.77","266","767.76","1968.93","percent of total billed charges",""
"NAIL PLATE BONE WRIST DVR ANATOMIC TITANIUM DORSAL RIGHT","SUP-ITM-10072406","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.64","1857.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1062.48","42.9","","731.00","63.70","731.00","1 through 10","767.76","1968.93","percent of total billed charges",""
"NAIL PLATE BONE WRIST DVR ANATOMIC TITANIUM DORSAL RIGHT","SUP-ITM-10072406","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.64","1857.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1062.48","42.9","","384.74","384.74","384.74","1 through 10","767.76","1968.93","percent of total billed charges",""
"NAIL PLATE BONE WRIST DVR ANATOMIC TITANIUM DORSAL RIGHT","SUP-ITM-10072406","CDM","C1713","HCPCS","0278","RC","","","","both","","","2476.64","1857.48","WELLPOINT [1015]","HB AMC WELLPOINT","1827.26","73.78","","286.63","119.22","1107.45","105","767.76","1968.93","percent of total billed charges",""
"NAIL PLATE BONE WRIST DVR ANATOMIC TITANIUM DORSAL RIGHT","SUP-ITM-10072406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2476.64","1857.48","AETNA [1001]","HB AMC AETNA HMO","1728.69","69.8","","675.31","184.75","1721.50","286","1294.29","2023.91","percent of total billed charges",""
"NAIL PLATE BONE WRIST DVR ANATOMIC TITANIUM DORSAL RIGHT","SUP-ITM-10072406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2476.64","1857.48","AETNA [1001]","HB AMC AETNA PPO","1991.22","80.4","","1261.44","103.12","1514.10","21","1294.29","2023.91","percent of total billed charges",""
"NAIL PLATE BONE WRIST DVR ANATOMIC TITANIUM DORSAL RIGHT","SUP-ITM-10072406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2476.64","1857.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1991.22","80.4","","1365.00","1365.00","1365.00","1 through 10","1294.29","2023.91","percent of total billed charges",""
"NAIL PLATE BONE WRIST DVR ANATOMIC TITANIUM DORSAL RIGHT","SUP-ITM-10072406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2476.64","1857.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2023.91","81.72","","5157.68","5157.68","5157.68","1 through 10","1294.29","2023.91","percent of total billed charges",""
"NAIL PLATE BONE WRIST DVR ANATOMIC TITANIUM DORSAL RIGHT","SUP-ITM-10072406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2476.64","1857.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2023.91","81.72","","431.26","71.26","1459.57","88","1294.29","2023.91","percent of total billed charges",""
"NAIL SALVAGE 13.0MM 250MM PRECICE ANKLE","SUP-ITM-10330301","CDM","C1713","HCPCS","0278","RC","","","","both","","","66107.50","49580.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","52555.46","79.5","","800.18","480.96","1887.97","195","20493.33","52555.46","percent of total billed charges",""
"NAIL SALVAGE 13.0MM 250MM PRECICE ANKLE","SUP-ITM-10330301","CDM","C1713","HCPCS","0278","RC","","","","both","","","66107.50","49580.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","35235.30","53.3","","813.12","216.42","1444.50","81","20493.33","52555.46","percent of total billed charges",""
"NAIL SALVAGE 13.0MM 250MM PRECICE ANKLE","SUP-ITM-10330301","CDM","C1713","HCPCS","0278","RC","","","","both","","","66107.50","49580.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","20493.33","31","","432.60","432.60","432.60","1 through 10","20493.33","52555.46","percent of total billed charges",""
"NAIL SALVAGE 13.0MM 250MM PRECICE ANKLE","SUP-ITM-10330301","CDM","C1713","HCPCS","0278","RC","","","","both","","","66107.50","49580.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24129.24","36.5","","148.37","54.89","631.39","94","20493.33","52555.46","percent of total billed charges",""
"NAIL SALVAGE 13.0MM 250MM PRECICE ANKLE","SUP-ITM-10330301","CDM","C1713","HCPCS","0278","RC","","","","both","","","66107.50","49580.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25319.17","38.3","","279.30","91.72","1116.77","266","20493.33","52555.46","percent of total billed charges",""
"NAIL SALVAGE 13.0MM 250MM PRECICE ANKLE","SUP-ITM-10330301","CDM","C1713","HCPCS","0278","RC","","","","both","","","66107.50","49580.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28360.12","42.9","","731.00","63.70","731.00","1 through 10","20493.33","52555.46","percent of total billed charges",""
"NAIL SALVAGE 13.0MM 250MM PRECICE ANKLE","SUP-ITM-10330301","CDM","C1713","HCPCS","0278","RC","","","","both","","","66107.50","49580.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28360.12","42.9","","384.74","384.74","384.74","1 through 10","20493.33","52555.46","percent of total billed charges",""
"NAIL SALVAGE 13.0MM 250MM PRECICE ANKLE","SUP-ITM-10330301","CDM","C1713","HCPCS","0278","RC","","","","both","","","66107.50","49580.62","WELLPOINT [1015]","HB AMC WELLPOINT","48774.11","73.78","","286.63","119.22","1107.45","105","20493.33","52555.46","percent of total billed charges",""
"NAIL SALVAGE 13.0MM 250MM PRECICE ANKLE","SUP-ITM-10330301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66107.50","49580.62","AETNA [1001]","HB AMC AETNA HMO","46143.04","69.8","","675.31","184.75","1721.50","286","34547.78","54023.05","percent of total billed charges",""
"NAIL SALVAGE 13.0MM 250MM PRECICE ANKLE","SUP-ITM-10330301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66107.50","49580.62","AETNA [1001]","HB AMC AETNA PPO","53150.43","80.4","","1261.44","103.12","1514.10","21","34547.78","54023.05","percent of total billed charges",""
"NAIL SALVAGE 13.0MM 250MM PRECICE ANKLE","SUP-ITM-10330301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66107.50","49580.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","53150.43","80.4","","1365.00","1365.00","1365.00","1 through 10","34547.78","54023.05","percent of total billed charges",""
"NAIL SALVAGE 13.0MM 250MM PRECICE ANKLE","SUP-ITM-10330301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66107.50","49580.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","54023.05","81.72","","5157.68","5157.68","5157.68","1 through 10","34547.78","54023.05","percent of total billed charges",""
"NAIL SALVAGE 13.0MM 250MM PRECICE ANKLE","SUP-ITM-10330301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66107.50","49580.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","54023.05","81.72","","431.26","71.26","1459.57","88","34547.78","54023.05","percent of total billed charges",""
"NAIL TIBIAL 10X300MM ADVANCED","SUP-ITM-10296416","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3610.96","79.5","","800.18","480.96","1887.97","195","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X300MM ADVANCED","SUP-ITM-10296416","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2420.93","53.3","","813.12","216.42","1444.50","81","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X300MM ADVANCED","SUP-ITM-10296416","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1408.05","31","","432.60","432.60","432.60","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X300MM ADVANCED","SUP-ITM-10296416","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1657.86","36.5","","148.37","54.89","631.39","94","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X300MM ADVANCED","SUP-ITM-10296416","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1739.62","38.3","","279.30","91.72","1116.77","266","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X300MM ADVANCED","SUP-ITM-10296416","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","731.00","63.70","731.00","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X300MM ADVANCED","SUP-ITM-10296416","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","384.74","384.74","384.74","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X300MM ADVANCED","SUP-ITM-10296416","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","WELLPOINT [1015]","HB AMC WELLPOINT","3351.15","73.78","","286.63","119.22","1107.45","105","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X300MM ADVANCED","SUP-ITM-10296416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA HMO","3170.38","69.8","","675.31","184.75","1721.50","286","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X300MM ADVANCED","SUP-ITM-10296416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA PPO","3651.84","80.4","","1261.44","103.12","1514.10","21","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X300MM ADVANCED","SUP-ITM-10296416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3651.84","80.4","","1365.00","1365.00","1365.00","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X300MM ADVANCED","SUP-ITM-10296416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3711.80","81.72","","5157.68","5157.68","5157.68","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X300MM ADVANCED","SUP-ITM-10296416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3711.80","81.72","","431.26","71.26","1459.57","88","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3610.96","79.5","","800.18","480.96","1887.97","195","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2420.93","53.3","","813.12","216.42","1444.50","81","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1408.05","31","","432.60","432.60","432.60","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1657.86","36.5","","148.37","54.89","631.39","94","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1739.62","38.3","","279.30","91.72","1116.77","266","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","731.00","63.70","731.00","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","384.74","384.74","384.74","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","WELLPOINT [1015]","HB AMC WELLPOINT","3351.15","73.78","","286.63","119.22","1107.45","105","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA HMO","3170.38","69.8","","675.31","184.75","1721.50","286","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA PPO","3651.84","80.4","","1261.44","103.12","1514.10","21","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3651.84","80.4","","1365.00","1365.00","1365.00","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3711.80","81.72","","5157.68","5157.68","5157.68","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3711.80","81.72","","431.26","71.26","1459.57","88","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X375MM ADVANCED","SUP-ITM-10296411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3610.96","79.5","","800.18","480.96","1887.97","195","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X375MM ADVANCED","SUP-ITM-10296411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2420.93","53.3","","813.12","216.42","1444.50","81","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X375MM ADVANCED","SUP-ITM-10296411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1408.05","31","","432.60","432.60","432.60","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X375MM ADVANCED","SUP-ITM-10296411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1657.86","36.5","","148.37","54.89","631.39","94","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X375MM ADVANCED","SUP-ITM-10296411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1739.62","38.3","","279.30","91.72","1116.77","266","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X375MM ADVANCED","SUP-ITM-10296411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","731.00","63.70","731.00","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X375MM ADVANCED","SUP-ITM-10296411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","384.74","384.74","384.74","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X375MM ADVANCED","SUP-ITM-10296411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","WELLPOINT [1015]","HB AMC WELLPOINT","3351.15","73.78","","286.63","119.22","1107.45","105","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 10X375MM ADVANCED","SUP-ITM-10296411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA HMO","3170.38","69.8","","675.31","184.75","1721.50","286","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X375MM ADVANCED","SUP-ITM-10296411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA PPO","3651.84","80.4","","1261.44","103.12","1514.10","21","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X375MM ADVANCED","SUP-ITM-10296411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3651.84","80.4","","1365.00","1365.00","1365.00","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X375MM ADVANCED","SUP-ITM-10296411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3711.80","81.72","","5157.68","5157.68","5157.68","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 10X375MM ADVANCED","SUP-ITM-10296411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3711.80","81.72","","431.26","71.26","1459.57","88","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3104.02","79.5","","800.18","480.96","1887.97","195","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2081.06","53.3","","813.12","216.42","1444.50","81","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1210.37","31","","432.60","432.60","432.60","1 through 10","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1425.12","36.5","","148.37","54.89","631.39","94","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1495.40","38.3","","279.30","91.72","1116.77","266","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1675.00","42.9","","731.00","63.70","731.00","1 through 10","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1675.00","42.9","","384.74","384.74","384.74","1 through 10","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","WELLPOINT [1015]","HB AMC WELLPOINT","2880.69","73.78","","286.63","119.22","1107.45","105","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","AETNA [1001]","HB AMC AETNA HMO","2725.29","69.8","","675.31","184.75","1721.50","286","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","AETNA [1001]","HB AMC AETNA PPO","3139.16","80.4","","1261.44","103.12","1514.10","21","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3139.16","80.4","","1365.00","1365.00","1365.00","1 through 10","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3190.70","81.72","","5157.68","5157.68","5157.68","1 through 10","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3190.70","81.72","","431.26","71.26","1459.57","88","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 11X330MM ADVANCED","SUP-ITM-10296399","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3610.96","79.5","","800.18","480.96","1887.97","195","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X330MM ADVANCED","SUP-ITM-10296399","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2420.93","53.3","","813.12","216.42","1444.50","81","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X330MM ADVANCED","SUP-ITM-10296399","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1408.05","31","","432.60","432.60","432.60","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X330MM ADVANCED","SUP-ITM-10296399","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1657.86","36.5","","148.37","54.89","631.39","94","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X330MM ADVANCED","SUP-ITM-10296399","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1739.62","38.3","","279.30","91.72","1116.77","266","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X330MM ADVANCED","SUP-ITM-10296399","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","731.00","63.70","731.00","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X330MM ADVANCED","SUP-ITM-10296399","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","384.74","384.74","384.74","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X330MM ADVANCED","SUP-ITM-10296399","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","WELLPOINT [1015]","HB AMC WELLPOINT","3351.15","73.78","","286.63","119.22","1107.45","105","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X330MM ADVANCED","SUP-ITM-10296399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA HMO","3170.38","69.8","","675.31","184.75","1721.50","286","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 11X330MM ADVANCED","SUP-ITM-10296399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA PPO","3651.84","80.4","","1261.44","103.12","1514.10","21","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 11X330MM ADVANCED","SUP-ITM-10296399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3651.84","80.4","","1365.00","1365.00","1365.00","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 11X330MM ADVANCED","SUP-ITM-10296399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3711.80","81.72","","5157.68","5157.68","5157.68","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 11X330MM ADVANCED","SUP-ITM-10296399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3711.80","81.72","","431.26","71.26","1459.57","88","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 11X345MM ADVANCED","SUP-ITM-10296398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3610.96","79.5","","800.18","480.96","1887.97","195","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X345MM ADVANCED","SUP-ITM-10296398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2420.93","53.3","","813.12","216.42","1444.50","81","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X345MM ADVANCED","SUP-ITM-10296398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1408.05","31","","432.60","432.60","432.60","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X345MM ADVANCED","SUP-ITM-10296398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1657.86","36.5","","148.37","54.89","631.39","94","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X345MM ADVANCED","SUP-ITM-10296398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1739.62","38.3","","279.30","91.72","1116.77","266","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X345MM ADVANCED","SUP-ITM-10296398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","731.00","63.70","731.00","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X345MM ADVANCED","SUP-ITM-10296398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","384.74","384.74","384.74","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X345MM ADVANCED","SUP-ITM-10296398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","WELLPOINT [1015]","HB AMC WELLPOINT","3351.15","73.78","","286.63","119.22","1107.45","105","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 11X345MM ADVANCED","SUP-ITM-10296398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA HMO","3170.38","69.8","","675.31","184.75","1721.50","286","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 11X345MM ADVANCED","SUP-ITM-10296398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA PPO","3651.84","80.4","","1261.44","103.12","1514.10","21","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 11X345MM ADVANCED","SUP-ITM-10296398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3651.84","80.4","","1365.00","1365.00","1365.00","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 11X345MM ADVANCED","SUP-ITM-10296398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3711.80","81.72","","5157.68","5157.68","5157.68","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 11X345MM ADVANCED","SUP-ITM-10296398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3711.80","81.72","","431.26","71.26","1459.57","88","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 11X360MM INTRAMEDULLARY STERILE","SUP-ITM-10232917","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5398.27","79.5","","800.18","480.96","1887.97","195","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 11X360MM INTRAMEDULLARY STERILE","SUP-ITM-10232917","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3619.22","53.3","","813.12","216.42","1444.50","81","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 11X360MM INTRAMEDULLARY STERILE","SUP-ITM-10232917","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2104.99","31","","432.60","432.60","432.60","1 through 10","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 11X360MM INTRAMEDULLARY STERILE","SUP-ITM-10232917","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2478.45","36.5","","148.37","54.89","631.39","94","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 11X360MM INTRAMEDULLARY STERILE","SUP-ITM-10232917","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2600.68","38.3","","279.30","91.72","1116.77","266","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 11X360MM INTRAMEDULLARY STERILE","SUP-ITM-10232917","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2913.03","42.9","","731.00","63.70","731.00","1 through 10","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 11X360MM INTRAMEDULLARY STERILE","SUP-ITM-10232917","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2913.03","42.9","","384.74","384.74","384.74","1 through 10","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 11X360MM INTRAMEDULLARY STERILE","SUP-ITM-10232917","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","WELLPOINT [1015]","HB AMC WELLPOINT","5009.87","73.78","","286.63","119.22","1107.45","105","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 11X360MM INTRAMEDULLARY STERILE","SUP-ITM-10232917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6790.28","5092.71","AETNA [1001]","HB AMC AETNA HMO","4739.62","69.8","","675.31","184.75","1721.50","286","3548.6","5549.02","percent of total billed charges",""
"NAIL TIBIAL 11X360MM INTRAMEDULLARY STERILE","SUP-ITM-10232917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6790.28","5092.71","AETNA [1001]","HB AMC AETNA PPO","5459.39","80.4","","1261.44","103.12","1514.10","21","3548.6","5549.02","percent of total billed charges",""
"NAIL TIBIAL 11X360MM INTRAMEDULLARY STERILE","SUP-ITM-10232917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6790.28","5092.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5459.39","80.4","","1365.00","1365.00","1365.00","1 through 10","3548.6","5549.02","percent of total billed charges",""
"NAIL TIBIAL 11X360MM INTRAMEDULLARY STERILE","SUP-ITM-10232917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6790.28","5092.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5549.02","81.72","","5157.68","5157.68","5157.68","1 through 10","3548.6","5549.02","percent of total billed charges",""
"NAIL TIBIAL 11X360MM INTRAMEDULLARY STERILE","SUP-ITM-10232917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6790.28","5092.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5549.02","81.72","","431.26","71.26","1459.57","88","3548.6","5549.02","percent of total billed charges",""
"NAIL TIBIAL 12X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232905","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5398.27","79.5","","800.18","480.96","1887.97","195","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 12X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232905","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3619.22","53.3","","813.12","216.42","1444.50","81","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 12X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232905","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2104.99","31","","432.60","432.60","432.60","1 through 10","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 12X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232905","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2478.45","36.5","","148.37","54.89","631.39","94","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 12X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232905","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2600.68","38.3","","279.30","91.72","1116.77","266","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 12X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232905","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2913.03","42.9","","731.00","63.70","731.00","1 through 10","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 12X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232905","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2913.03","42.9","","384.74","384.74","384.74","1 through 10","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 12X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232905","CDM","C1713","HCPCS","0278","RC","","","","both","","","6790.28","5092.71","WELLPOINT [1015]","HB AMC WELLPOINT","5009.87","73.78","","286.63","119.22","1107.45","105","2104.99","5398.27","percent of total billed charges",""
"NAIL TIBIAL 12X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232905","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6790.28","5092.71","AETNA [1001]","HB AMC AETNA HMO","4739.62","69.8","","675.31","184.75","1721.50","286","3548.6","5549.02","percent of total billed charges",""
"NAIL TIBIAL 12X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232905","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6790.28","5092.71","AETNA [1001]","HB AMC AETNA PPO","5459.39","80.4","","1261.44","103.12","1514.10","21","3548.6","5549.02","percent of total billed charges",""
"NAIL TIBIAL 12X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232905","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6790.28","5092.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5459.39","80.4","","1365.00","1365.00","1365.00","1 through 10","3548.6","5549.02","percent of total billed charges",""
"NAIL TIBIAL 12X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232905","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6790.28","5092.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5549.02","81.72","","5157.68","5157.68","5157.68","1 through 10","3548.6","5549.02","percent of total billed charges",""
"NAIL TIBIAL 12X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232905","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6790.28","5092.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5549.02","81.72","","431.26","71.26","1459.57","88","3548.6","5549.02","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3104.02","79.5","","800.18","480.96","1887.97","195","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2081.06","53.3","","813.12","216.42","1444.50","81","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1210.37","31","","432.60","432.60","432.60","1 through 10","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1425.12","36.5","","148.37","54.89","631.39","94","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1495.40","38.3","","279.30","91.72","1116.77","266","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1675.00","42.9","","731.00","63.70","731.00","1 through 10","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1675.00","42.9","","384.74","384.74","384.74","1 through 10","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","WELLPOINT [1015]","HB AMC WELLPOINT","2880.69","73.78","","286.63","119.22","1107.45","105","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","AETNA [1001]","HB AMC AETNA HMO","2725.29","69.8","","675.31","184.75","1721.50","286","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","AETNA [1001]","HB AMC AETNA PPO","3139.16","80.4","","1261.44","103.12","1514.10","21","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3139.16","80.4","","1365.00","1365.00","1365.00","1 through 10","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3190.70","81.72","","5157.68","5157.68","5157.68","1 through 10","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3190.70","81.72","","431.26","71.26","1459.57","88","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 13X420MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10037028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3210.06","79.5","","800.18","480.96","1887.97","195","1251.72","3210.06","percent of total billed charges",""
"NAIL TIBIAL 13X420MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10037028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2152.15","53.3","","813.12","216.42","1444.50","81","1251.72","3210.06","percent of total billed charges",""
"NAIL TIBIAL 13X420MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10037028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1251.72","31","","432.60","432.60","432.60","1 through 10","1251.72","3210.06","percent of total billed charges",""
"NAIL TIBIAL 13X420MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10037028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1473.80","36.5","","148.37","54.89","631.39","94","1251.72","3210.06","percent of total billed charges",""
"NAIL TIBIAL 13X420MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10037028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1546.48","38.3","","279.30","91.72","1116.77","266","1251.72","3210.06","percent of total billed charges",""
"NAIL TIBIAL 13X420MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10037028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1732.22","42.9","","731.00","63.70","731.00","1 through 10","1251.72","3210.06","percent of total billed charges",""
"NAIL TIBIAL 13X420MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10037028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1732.22","42.9","","384.74","384.74","384.74","1 through 10","1251.72","3210.06","percent of total billed charges",""
"NAIL TIBIAL 13X420MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10037028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4037.81","3028.36","WELLPOINT [1015]","HB AMC WELLPOINT","2979.10","73.78","","286.63","119.22","1107.45","105","1251.72","3210.06","percent of total billed charges",""
"NAIL TIBIAL 13X420MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10037028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4037.81","3028.36","AETNA [1001]","HB AMC AETNA HMO","2818.39","69.8","","675.31","184.75","1721.50","286","2110.16","3299.7","percent of total billed charges",""
"NAIL TIBIAL 13X420MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10037028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4037.81","3028.36","AETNA [1001]","HB AMC AETNA PPO","3246.40","80.4","","1261.44","103.12","1514.10","21","2110.16","3299.7","percent of total billed charges",""
"NAIL TIBIAL 13X420MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10037028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4037.81","3028.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3246.40","80.4","","1365.00","1365.00","1365.00","1 through 10","2110.16","3299.7","percent of total billed charges",""
"NAIL TIBIAL 13X420MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10037028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4037.81","3028.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3299.70","81.72","","5157.68","5157.68","5157.68","1 through 10","2110.16","3299.7","percent of total billed charges",""
"NAIL TIBIAL 13X420MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10037028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4037.81","3028.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3299.70","81.72","","431.26","71.26","1459.57","88","2110.16","3299.7","percent of total billed charges",""
"NAIL TIBIAL 8X330MM ADVANCED","SUP-ITM-10296444","CDM","C1713","HCPCS","0278","RC","","","","both","","","4293.12","3219.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3413.03","79.5","","800.18","480.96","1887.97","195","1330.87","3413.03","percent of total billed charges",""
"NAIL TIBIAL 8X330MM ADVANCED","SUP-ITM-10296444","CDM","C1713","HCPCS","0278","RC","","","","both","","","4293.12","3219.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2288.23","53.3","","813.12","216.42","1444.50","81","1330.87","3413.03","percent of total billed charges",""
"NAIL TIBIAL 8X330MM ADVANCED","SUP-ITM-10296444","CDM","C1713","HCPCS","0278","RC","","","","both","","","4293.12","3219.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1330.87","31","","432.60","432.60","432.60","1 through 10","1330.87","3413.03","percent of total billed charges",""
"NAIL TIBIAL 8X330MM ADVANCED","SUP-ITM-10296444","CDM","C1713","HCPCS","0278","RC","","","","both","","","4293.12","3219.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1566.99","36.5","","148.37","54.89","631.39","94","1330.87","3413.03","percent of total billed charges",""
"NAIL TIBIAL 8X330MM ADVANCED","SUP-ITM-10296444","CDM","C1713","HCPCS","0278","RC","","","","both","","","4293.12","3219.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1644.26","38.3","","279.30","91.72","1116.77","266","1330.87","3413.03","percent of total billed charges",""
"NAIL TIBIAL 8X330MM ADVANCED","SUP-ITM-10296444","CDM","C1713","HCPCS","0278","RC","","","","both","","","4293.12","3219.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1841.75","42.9","","731.00","63.70","731.00","1 through 10","1330.87","3413.03","percent of total billed charges",""
"NAIL TIBIAL 8X330MM ADVANCED","SUP-ITM-10296444","CDM","C1713","HCPCS","0278","RC","","","","both","","","4293.12","3219.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1841.75","42.9","","384.74","384.74","384.74","1 through 10","1330.87","3413.03","percent of total billed charges",""
"NAIL TIBIAL 8X330MM ADVANCED","SUP-ITM-10296444","CDM","C1713","HCPCS","0278","RC","","","","both","","","4293.12","3219.84","WELLPOINT [1015]","HB AMC WELLPOINT","3167.46","73.78","","286.63","119.22","1107.45","105","1330.87","3413.03","percent of total billed charges",""
"NAIL TIBIAL 8X330MM ADVANCED","SUP-ITM-10296444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4293.12","3219.84","AETNA [1001]","HB AMC AETNA HMO","2996.60","69.8","","675.31","184.75","1721.50","286","2243.58","3508.34","percent of total billed charges",""
"NAIL TIBIAL 8X330MM ADVANCED","SUP-ITM-10296444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4293.12","3219.84","AETNA [1001]","HB AMC AETNA PPO","3451.67","80.4","","1261.44","103.12","1514.10","21","2243.58","3508.34","percent of total billed charges",""
"NAIL TIBIAL 8X330MM ADVANCED","SUP-ITM-10296444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4293.12","3219.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3451.67","80.4","","1365.00","1365.00","1365.00","1 through 10","2243.58","3508.34","percent of total billed charges",""
"NAIL TIBIAL 8X330MM ADVANCED","SUP-ITM-10296444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4293.12","3219.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3508.34","81.72","","5157.68","5157.68","5157.68","1 through 10","2243.58","3508.34","percent of total billed charges",""
"NAIL TIBIAL 8X330MM ADVANCED","SUP-ITM-10296444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4293.12","3219.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3508.34","81.72","","431.26","71.26","1459.57","88","2243.58","3508.34","percent of total billed charges",""
"NAIL TIBIAL 8X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036962","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.57","3017.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3198.74","79.5","","800.18","480.96","1887.97","195","1247.31","3198.74","percent of total billed charges",""
"NAIL TIBIAL 8X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036962","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.57","3017.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2144.56","53.3","","813.12","216.42","1444.50","81","1247.31","3198.74","percent of total billed charges",""
"NAIL TIBIAL 8X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036962","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.57","3017.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1247.31","31","","432.60","432.60","432.60","1 through 10","1247.31","3198.74","percent of total billed charges",""
"NAIL TIBIAL 8X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036962","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.57","3017.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1468.60","36.5","","148.37","54.89","631.39","94","1247.31","3198.74","percent of total billed charges",""
"NAIL TIBIAL 8X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036962","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.57","3017.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1541.03","38.3","","279.30","91.72","1116.77","266","1247.31","3198.74","percent of total billed charges",""
"NAIL TIBIAL 8X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036962","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.57","3017.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.11","42.9","","731.00","63.70","731.00","1 through 10","1247.31","3198.74","percent of total billed charges",""
"NAIL TIBIAL 8X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036962","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.57","3017.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.11","42.9","","384.74","384.74","384.74","1 through 10","1247.31","3198.74","percent of total billed charges",""
"NAIL TIBIAL 8X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036962","CDM","C1713","HCPCS","0278","RC","","","","both","","","4023.57","3017.68","WELLPOINT [1015]","HB AMC WELLPOINT","2968.59","73.78","","286.63","119.22","1107.45","105","1247.31","3198.74","percent of total billed charges",""
"NAIL TIBIAL 8X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4023.57","3017.68","AETNA [1001]","HB AMC AETNA HMO","2808.45","69.8","","675.31","184.75","1721.50","286","2102.72","3288.06","percent of total billed charges",""
"NAIL TIBIAL 8X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4023.57","3017.68","AETNA [1001]","HB AMC AETNA PPO","3234.95","80.4","","1261.44","103.12","1514.10","21","2102.72","3288.06","percent of total billed charges",""
"NAIL TIBIAL 8X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4023.57","3017.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3234.95","80.4","","1365.00","1365.00","1365.00","1 through 10","2102.72","3288.06","percent of total billed charges",""
"NAIL TIBIAL 8X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4023.57","3017.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3288.06","81.72","","5157.68","5157.68","5157.68","1 through 10","2102.72","3288.06","percent of total billed charges",""
"NAIL TIBIAL 8X405MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4023.57","3017.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3288.06","81.72","","431.26","71.26","1459.57","88","2102.72","3288.06","percent of total billed charges",""
"NAIL TIBIAL 9X255MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10036965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3307.87","79.5","","800.18","480.96","1887.97","195","1289.86","3307.87","percent of total billed charges",""
"NAIL TIBIAL 9X255MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10036965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2217.73","53.3","","813.12","216.42","1444.50","81","1289.86","3307.87","percent of total billed charges",""
"NAIL TIBIAL 9X255MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10036965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1289.86","31","","432.60","432.60","432.60","1 through 10","1289.86","3307.87","percent of total billed charges",""
"NAIL TIBIAL 9X255MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10036965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1518.71","36.5","","148.37","54.89","631.39","94","1289.86","3307.87","percent of total billed charges",""
"NAIL TIBIAL 9X255MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10036965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1593.60","38.3","","279.30","91.72","1116.77","266","1289.86","3307.87","percent of total billed charges",""
"NAIL TIBIAL 9X255MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10036965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1785.00","42.9","","731.00","63.70","731.00","1 through 10","1289.86","3307.87","percent of total billed charges",""
"NAIL TIBIAL 9X255MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10036965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1785.00","42.9","","384.74","384.74","384.74","1 through 10","1289.86","3307.87","percent of total billed charges",""
"NAIL TIBIAL 9X255MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10036965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4160.84","3120.63","WELLPOINT [1015]","HB AMC WELLPOINT","3069.87","73.78","","286.63","119.22","1107.45","105","1289.86","3307.87","percent of total billed charges",""
"NAIL TIBIAL 9X255MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10036965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4160.84","3120.63","AETNA [1001]","HB AMC AETNA HMO","2904.27","69.8","","675.31","184.75","1721.50","286","2174.45","3400.24","percent of total billed charges",""
"NAIL TIBIAL 9X255MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10036965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4160.84","3120.63","AETNA [1001]","HB AMC AETNA PPO","3345.32","80.4","","1261.44","103.12","1514.10","21","2174.45","3400.24","percent of total billed charges",""
"NAIL TIBIAL 9X255MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10036965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4160.84","3120.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3345.32","80.4","","1365.00","1365.00","1365.00","1 through 10","2174.45","3400.24","percent of total billed charges",""
"NAIL TIBIAL 9X255MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10036965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4160.84","3120.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3400.24","81.72","","5157.68","5157.68","5157.68","1 through 10","2174.45","3400.24","percent of total billed charges",""
"NAIL TIBIAL 9X255MM FX CANNULATED TITANIUM PROXIMALIMAL BEND","SUP-ITM-10036965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4160.84","3120.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3400.24","81.72","","431.26","71.26","1459.57","88","2174.45","3400.24","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3610.96","79.5","","800.18","480.96","1887.97","195","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2420.93","53.3","","813.12","216.42","1444.50","81","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1408.05","31","","432.60","432.60","432.60","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1657.86","36.5","","148.37","54.89","631.39","94","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1739.62","38.3","","279.30","91.72","1116.77","266","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","731.00","63.70","731.00","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","384.74","384.74","384.74","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","WELLPOINT [1015]","HB AMC WELLPOINT","3351.15","73.78","","286.63","119.22","1107.45","105","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA HMO","3170.38","69.8","","675.31","184.75","1721.50","286","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA PPO","3651.84","80.4","","1261.44","103.12","1514.10","21","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3651.84","80.4","","1365.00","1365.00","1365.00","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3711.80","81.72","","5157.68","5157.68","5157.68","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3711.80","81.72","","431.26","71.26","1459.57","88","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3610.96","79.5","","800.18","480.96","1887.97","195","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2420.93","53.3","","813.12","216.42","1444.50","81","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1408.05","31","","432.60","432.60","432.60","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1657.86","36.5","","148.37","54.89","631.39","94","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1739.62","38.3","","279.30","91.72","1116.77","266","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","731.00","63.70","731.00","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.56","42.9","","384.74","384.74","384.74","1 through 10","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.09","3406.57","WELLPOINT [1015]","HB AMC WELLPOINT","3351.15","73.78","","286.63","119.22","1107.45","105","1408.05","3610.96","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA HMO","3170.38","69.8","","675.31","184.75","1721.50","286","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","AETNA [1001]","HB AMC AETNA PPO","3651.84","80.4","","1261.44","103.12","1514.10","21","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3651.84","80.4","","1365.00","1365.00","1365.00","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3711.80","81.72","","5157.68","5157.68","5157.68","1 through 10","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.09","3406.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3711.80","81.72","","431.26","71.26","1459.57","88","2373.7","3711.8","percent of total billed charges",""
"NAIL TIBIAL 9X375MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3104.02","79.5","","800.18","480.96","1887.97","195","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 9X375MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2081.06","53.3","","813.12","216.42","1444.50","81","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 9X375MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1210.37","31","","432.60","432.60","432.60","1 through 10","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 9X375MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1425.12","36.5","","148.37","54.89","631.39","94","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 9X375MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1495.40","38.3","","279.30","91.72","1116.77","266","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 9X375MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1675.00","42.9","","731.00","63.70","731.00","1 through 10","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 9X375MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1675.00","42.9","","384.74","384.74","384.74","1 through 10","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 9X375MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036973","CDM","C1713","HCPCS","0278","RC","","","","both","","","3904.43","2928.32","WELLPOINT [1015]","HB AMC WELLPOINT","2880.69","73.78","","286.63","119.22","1107.45","105","1210.37","3104.02","percent of total billed charges",""
"NAIL TIBIAL 9X375MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036973","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","AETNA [1001]","HB AMC AETNA HMO","2725.29","69.8","","675.31","184.75","1721.50","286","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 9X375MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036973","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","AETNA [1001]","HB AMC AETNA PPO","3139.16","80.4","","1261.44","103.12","1514.10","21","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 9X375MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036973","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3139.16","80.4","","1365.00","1365.00","1365.00","1 through 10","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 9X375MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036973","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3190.70","81.72","","5157.68","5157.68","5157.68","1 through 10","2040.46","3190.7","percent of total billed charges",""
"NAIL TIBIAL 9X375MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036973","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3904.43","2928.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3190.70","81.72","","431.26","71.26","1459.57","88","2040.46","3190.7","percent of total billed charges",""
"Naltrexone Vl 1mg","PX-63600152","CDM","J2315","HCPCS","0636","RC","","","","both","","","14.53","10.90","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4.16","","APC Price ($4.24). Final payment is multiplied by 98%.","4.17","4.06","4.17","760","4.03","11.19","other","OPPS APC"
"Naltrexone Vl 1mg","PX-63600152","CDM","J2315","HCPCS","0636","RC","","","","outpatient","","","14.53","10.90","AETNA [1001]","HB AMC AETNA HMO","10.14","69.8","","4661.72","0.01","6885.85","1 through 10","0.01","11.68","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","340.33","71.8","","103.86","34.62","990.84","15","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","308.10","65","","736.45","299.00","1214.40","16","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","331.80","70","","410.60","331.20","993.60","16","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","376.83","79.5","","362.02","299.00","1086.06","54","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","252.64","53.3","","242.88","242.88","863.03","30","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","364.98","77","","354.20","354.20","822.36","1 through 10","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","308.10","65","","299.00","243.80","299.00","1 through 10","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","146.94","31","","426.42","142.14","426.42","1 through 10","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","173.01","36.5","","171.58","145.82","499.56","66","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","181.54","38.3","","179.86","179.86","539.58","224","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","364.98","77","","346.84","346.84","346.84","1 through 10","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","TRICARE [160005]","HB BWH TRICARE","450.30","95","","47.31","44.94","47.31","1 through 10","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","203.35","42.9","","209.30","202.26","367.74","1 through 10","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","474.00","355.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","203.35","42.9","","202.26","202.26","202.26","1 through 10","35.01","450.3","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","474.00","355.50","AETNA [1001]","HB AMC AETNA HMO","330.85","69.8","","311.42","219.88","358.80","92","35.01","387.35","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","474.00","355.50","AETNA [1001]","HB AMC AETNA PPO","381.10","80.4","","241.04","219.88","358.80","1 through 10","35.01","387.35","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","474.00","355.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","247.71","52.26","","284.65","119.61","284.65","1 through 10","35.01","387.35","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","474.00","355.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","381.10","80.4","","230.00","230.00","230.00","1 through 10","35.01","387.35","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","474.00","355.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","387.35","81.72","","411.23","367.72","411.23","1 through 10","35.01","387.35","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","474.00","355.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","387.35","81.72","","202.26","202.26","202.26","1 through 10","35.01","387.35","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","474.00","355.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","387.35","81.72","","367.72","202.26","367.72","54","35.01","387.35","percent of total billed charges",""
"Natural Killer (Nk) Cells, Total","PX-30000851","CDM","86357","CPT","0302","RC","","","","both","","","282.00","211.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","197.40","70","","273.00","171.03","273.00","1 through 10","11.81","267.9","percent of total billed charges",""
"Natural Killer (Nk) Cells, Total","PX-30000851","CDM","86357","CPT","0302","RC","","","","both","","","282.00","211.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","224.19","79.5","","214.85","144.14","214.85","1 through 10","11.81","267.9","percent of total billed charges",""
"Natural Killer (Nk) Cells, Total","PX-30000851","CDM","86357","CPT","0302","RC","","","","both","","","282.00","211.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","150.31","53.3","","214.85","214.85","214.85","1 through 10","11.81","267.9","percent of total billed charges",""
"Natural Killer (Nk) Cells, Total","PX-30000851","CDM","86357","CPT","0302","RC","","","","both","","","282.00","211.50","TRICARE [160005]","HB BWH TRICARE","267.90","95","","43.19","43.19","43.19","1 through 10","11.81","267.9","percent of total billed charges",""
"Natural Killer (Nk) Cells, Total","PX-30000851","CDM","86357","CPT","0302","RC","","","","both","","","282.00","211.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.98","42.9","","218.24","120.04","218.24","1 through 10","11.81","267.9","percent of total billed charges",""
"Natural Killer (Nk) Cells, Total","PX-30000851","CDM","86357","CPT","0302","RC","","","","outpatient","","","282.00","211.50","AETNA [1001]","HB AMC AETNA HMO","196.84","69.8","","184.82","130.49","184.82","28","11.81","256.97","percent of total billed charges",""
"Natural Killer (Nk) Cells, Total","PX-30000851","CDM","86357","CPT","0302","RC","","","","outpatient","","","282.00","211.50","AETNA [1001]","HB AMC AETNA PPO","226.73","80.4","","212.94","143.05","429.15","1 through 10","11.81","256.97","percent of total billed charges",""
"Natural Killer (Nk) Cells, Total","PX-30000851","CDM","86357","CPT","0302","RC","","","","outpatient","","","282.00","211.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","230.45","81.72","","218.24","120.04","218.24","28","11.81","256.97","percent of total billed charges",""
"Needle Aspirate/Biopsy Peritonsillar Collection","PX-76002634","CDM","42999","CPT","0761","RC","","","","both","","","1004.00","753.00","AETNA [1001]","HB AMC AETNA HMO","700.79","69.8","","659.40","659.40","659.40","1 through 10","261.99","807.22","percent of total billed charges",""
"Needle Aspirate/Biopsy Peritonsillar Collection","PX-76002634","CDM","42999","CPT","0761","RC","","","","outpatient","","","1004.00","753.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","524.29","52.22","","275.91","275.91","275.91","1 through 10","430.72","828.3","percent of total billed charges",""
"Needle Aspirate/Biopsy Peritonsillar Collection","PX-76002634","CDM","42999","CPT","0761","RC","","","","outpatient","","","1004.00","753.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","820.47","81.72","","19339.08","19339.08","19339.08","1 through 10","430.72","828.3","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","both","","","1225.70","919.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","974.43","79.5","","454.50","151.50","454.50","21","379.97","1011.2","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","both","","","1225.70","919.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","653.30","53.3","","304.92","207.96","485.88","1 through 10","379.97","1011.2","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","both","","","1225.70","919.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","447.38","36.5","","183.06","183.06","183.06","1 through 10","379.97","1011.2","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","both","","","1225.70","919.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","469.44","38.3","","225.81","149.00","234.60","19","379.97","1011.2","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","both","","","1225.70","919.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","525.83","42.9","","153.88","90.49","192.50","1 through 10","379.97","1011.2","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","both","","","1225.70","919.27","WELLPOINT [1015]","HB AMC WELLPOINT","904.32","73.78","","335.82","153.22","335.82","1 through 10","379.97","1011.2","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1225.70","919.27","AETNA [1001]","HB AMC AETNA HMO","855.54","69.8","","98.37","92.02","150.15","11","612.85","1011.2","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1225.70","919.27","AETNA [1001]","HB AMC AETNA PPO","985.46","80.4","","333.06","160.52","333.06","1 through 10","612.85","1011.2","percent of total billed charges",""
"NEEDLE BEACON 22G FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND BX/5EA","SUP-ITM-10165182","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1225.70","919.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1001.64","81.72","","153.88","84.64","170.39","1 through 10","612.85","1011.2","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 15CM KOPANS LESION LOCALIZER","SUP-ITM-10011855","CDM","A4648","HCPCS","0278","RC","","","","both","","","70.00","52.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","55.65","79.5","","454.50","151.50","454.50","21","21.7","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 15CM KOPANS LESION LOCALIZER","SUP-ITM-10011855","CDM","A4648","HCPCS","0278","RC","","","","both","","","70.00","52.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37.31","53.3","","304.92","207.96","485.88","1 through 10","21.7","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 15CM KOPANS LESION LOCALIZER","SUP-ITM-10011855","CDM","A4648","HCPCS","0278","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25.55","36.5","","183.06","183.06","183.06","1 through 10","21.7","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 15CM KOPANS LESION LOCALIZER","SUP-ITM-10011855","CDM","A4648","HCPCS","0278","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26.81","38.3","","225.81","149.00","234.60","19","21.7","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 15CM KOPANS LESION LOCALIZER","SUP-ITM-10011855","CDM","A4648","HCPCS","0278","RC","","","","both","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.03","42.9","","153.88","90.49","192.50","1 through 10","21.7","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 15CM KOPANS LESION LOCALIZER","SUP-ITM-10011855","CDM","A4648","HCPCS","0278","RC","","","","both","","","70.00","52.50","WELLPOINT [1015]","HB AMC WELLPOINT","51.65","73.78","","335.82","153.22","335.82","1 through 10","21.7","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 15CM KOPANS LESION LOCALIZER","SUP-ITM-10011855","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA HMO","48.86","69.8","","98.37","92.02","150.15","11","35","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 15CM KOPANS LESION LOCALIZER","SUP-ITM-10011855","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA PPO","56.28","80.4","","333.06","160.52","333.06","1 through 10","35","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 15CM KOPANS LESION LOCALIZER","SUP-ITM-10011855","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","57.20","81.72","","153.88","84.64","170.39","1 through 10","35","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 9CM LOCALIZATION KOPANS SPRING HOOK LESION MARKER","SUP-ITM-10114041","CDM","A4648","HCPCS","0278","RC","","","","both","","","70.00","52.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","55.65","79.5","","454.50","151.50","454.50","21","21.7","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 9CM LOCALIZATION KOPANS SPRING HOOK LESION MARKER","SUP-ITM-10114041","CDM","A4648","HCPCS","0278","RC","","","","both","","","70.00","52.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37.31","53.3","","304.92","207.96","485.88","1 through 10","21.7","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 9CM LOCALIZATION KOPANS SPRING HOOK LESION MARKER","SUP-ITM-10114041","CDM","A4648","HCPCS","0278","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25.55","36.5","","183.06","183.06","183.06","1 through 10","21.7","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 9CM LOCALIZATION KOPANS SPRING HOOK LESION MARKER","SUP-ITM-10114041","CDM","A4648","HCPCS","0278","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26.81","38.3","","225.81","149.00","234.60","19","21.7","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 9CM LOCALIZATION KOPANS SPRING HOOK LESION MARKER","SUP-ITM-10114041","CDM","A4648","HCPCS","0278","RC","","","","both","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.03","42.9","","153.88","90.49","192.50","1 through 10","21.7","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 9CM LOCALIZATION KOPANS SPRING HOOK LESION MARKER","SUP-ITM-10114041","CDM","A4648","HCPCS","0278","RC","","","","both","","","70.00","52.50","WELLPOINT [1015]","HB AMC WELLPOINT","51.65","73.78","","335.82","153.22","335.82","1 through 10","21.7","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 9CM LOCALIZATION KOPANS SPRING HOOK LESION MARKER","SUP-ITM-10114041","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA HMO","48.86","69.8","","98.37","92.02","150.15","11","35","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 9CM LOCALIZATION KOPANS SPRING HOOK LESION MARKER","SUP-ITM-10114041","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA PPO","56.28","80.4","","333.06","160.52","333.06","1 through 10","35","57.75","percent of total billed charges",""
"NEEDLE BIOPSY 21GA 9CM LOCALIZATION KOPANS SPRING HOOK LESION MARKER","SUP-ITM-10114041","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","57.20","81.72","","153.88","84.64","170.39","1 through 10","35","57.75","percent of total billed charges",""
"Needle Brachytherapy T1","PX-27000030","CDM","C1715","HCPCS","0272","RC","","","","both","","","1312.50","984.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.06","42.9","","577.11","577.11","577.11","22","406.88","1043.44","percent of total billed charges",""
"Needle Brachytherapy T1","PX-27000030","CDM","C1715","HCPCS","0272","RC","","","","outpatient","","","1312.50","984.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1072.58","81.72","","577.11","577.11","577.11","23","685.91","1072.58","percent of total billed charges",""
"Needle Bx Bone Marrow Powered T1","PX-27000144","CDM","C1830","HCPCS","0272","RC","","","","both","","","494.38","370.78","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","346.07","70","","2532.60","2532.60","2532.60","1 through 10","153.26","393.03","percent of total billed charges",""
"Needle Bx Bone Marrow Powered T1","PX-27000144","CDM","C1830","HCPCS","0272","RC","","","","both","","","494.38","370.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","189.35","38.3","","497.42","497.42","497.42","1 through 10","153.26","393.03","percent of total billed charges",""
"NEEDLE CRYOABLATION ICE SEED ECHOGENIC","SUP-ITM-10092392","CDM","C2618","HCPCS","0272","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1838.40","38.3","","1876.80","640.73","1876.80","1 through 10","1488","3816","percent of total billed charges",""
"NEEDLE CRYOABLATION ICE SEED ECHOGENIC","SUP-ITM-10092392","CDM","C2618","HCPCS","0272","RC","","","","both","","","4800.00","3600.00","WELLPOINT [1015]","HB AMC WELLPOINT","3541.44","73.78","","2802.54","1220.01","4020.30","1 through 10","1488","3816","percent of total billed charges",""
"NEEDLE CRYOABLATION ICE SEED ECHOGENIC","SUP-ITM-10092392","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA HMO","3350.40","69.8","","2175.20","2175.20","2175.20","1 through 10","2508.48","3922.56","percent of total billed charges",""
"NEEDLE CRYOABLATION ICE SEED ECHOGENIC","SUP-ITM-10092392","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3922.56","81.72","","4750.00","720.54","7250.00","11","2508.48","3922.56","percent of total billed charges",""
"Needle Insertion W/O Injection 1 or 2 Muscles","PX-42000118","CDM","20560","CPT","0421","RC","","","","both","","","126.00","94.50","WELLPOINT [1015]","HB AMC WELLPOINT","92.96","73.78","","90.83","90.83","90.83","1 through 10","28.5","119.7","percent of total billed charges",""
"Needle Insertion W/O Injection 1 or 2 Muscles","PX-43000124","CDM","20560","CPT","0431","RC","","","","both","","","126.00","94.50","WELLPOINT [1015]","HB AMC WELLPOINT","92.96","73.78","","90.83","90.83","90.83","1 through 10","28.5","119.7","percent of total billed charges",""
"Needle Insertion W/O Injection 1 or 2 Muscles","PX-76002659","CDM","20560","CPT","0761","RC","","","","both","","","126.00","94.50","WELLPOINT [1015]","HB AMC WELLPOINT","92.96","73.78","","90.83","90.83","90.83","1 through 10","28.5","119.7","percent of total billed charges",""
"Needle Insertion W/O Injection 1 or 2 Muscles","PX-98301895","CDM","20560","CPT","0983","RC","","","","both","","","65.00","48.75","WELLPOINT [1015]","HB AMC WELLPOINT","47.96","73.78","","90.83","90.83","90.83","1 through 10","20.15","61.75","percent of total billed charges",""
"NEEDLE PROCEDURE L 4.6IN 21GA OD CONCAVE SIDE OPENING SIDEKICK COAPTITE IMPLANT - DISCONTINUED PER SUPPLIER","SUP-ITM-10025146","CDM","L8606","HCPCS","0278","RC","","","","both","","","189.48","142.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.57","38.3","","1436.93","1436.93","1436.93","1 through 10","58.74","150.64","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","651.11","79.5","","800.18","480.96","1887.97","195","253.89","651.11","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","436.53","53.3","","813.12","216.42","1444.50","81","253.89","651.11","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","253.89","31","","432.60","432.60","432.60","1 through 10","253.89","651.11","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","298.94","36.5","","148.37","54.89","631.39","94","253.89","651.11","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","313.68","38.3","","279.30","91.72","1116.77","266","253.89","651.11","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.35","42.9","","731.00","63.70","731.00","1 through 10","253.89","651.11","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.35","42.9","","384.74","384.74","384.74","1 through 10","253.89","651.11","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","WELLPOINT [1015]","HB AMC WELLPOINT","604.26","73.78","","286.63","119.22","1107.45","105","253.89","651.11","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","AETNA [1001]","HB AMC AETNA HMO","571.66","69.8","","675.31","184.75","1721.50","286","428.01","669.29","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","AETNA [1001]","HB AMC AETNA PPO","658.48","80.4","","1261.44","103.12","1514.10","21","428.01","669.29","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","658.48","80.4","","1365.00","1365.00","1365.00","1 through 10","428.01","669.29","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","669.29","81.72","","5157.68","5157.68","5157.68","1 through 10","428.01","669.29","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","669.29","81.72","","431.26","71.26","1459.57","88","428.01","669.29","percent of total billed charges",""
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","both","","","188.00","141.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","149.46","79.5","","143.23","143.23","143.23","1 through 10","58.28","294.93","percent of total billed charges",""
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","outpatient","","","188.00","141.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1228.08","409.36","1228.08","1 through 10","98.25","483.52","other","Multiple Surgery"
"Negative Pressure Wound Therapy Dme </= 50 Sq Cm","PX-98301283","CDM","97605","CPT","0983","RC","","","","both","","","106.00","79.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","84.27","79.5","","143.23","143.23","143.23","1 through 10","32.86","294.93","percent of total billed charges",""
"Negative Pressure Wound Therapy Dme </= 50 Sq Cm","PX-98301283","CDM","97605","CPT","0983","RC","","","","outpatient","","","106.00","79.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1228.08","409.36","1228.08","1 through 10","59.25","483.52","other","Multiple Surgery"
"Nelfinavir, Level","PX-31000752","CDM","80299","CPT","0310","RC","","","","both","","","146.00","109.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.07","79.5","","106.25","71.28","106.25","1 through 10","18.27","138.7","percent of total billed charges",""
"Nelfinavir, Level","PX-31000752","CDM","80299","CPT","0310","RC","","","","both","","","146.00","109.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.82","53.3","","106.25","71.28","106.25","1 through 10","18.27","138.7","percent of total billed charges",""
"Nelfinavir, Level","PX-31000752","CDM","80299","CPT","0310","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.29","36.5","","50.36","42.80","92.50","13","18.27","138.7","percent of total billed charges",""
"Nelfinavir, Level","PX-31000752","CDM","80299","CPT","0310","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.92","38.3","","52.79","44.55","158.37","30","18.27","138.7","percent of total billed charges",""
"Nelfinavir, Level","PX-31000752","CDM","80299","CPT","0310","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA HMO","101.91","69.8","","91.40","64.53","105.30","14","53.62","119.31","percent of total billed charges",""
"Nelfinavir, Level","PX-31000752","CDM","80299","CPT","0310","RC","","","","outpatient","","","146.00","109.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","117.38","80.4","","105.30","105.30","105.30","1 through 10","53.62","119.31","percent of total billed charges",""
"Nelfinavir, Level","PX-31000752","CDM","80299","CPT","0310","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","119.31","81.72","","59.36","15.50","59.36","1 through 10","53.62","119.31","percent of total billed charges",""
"Neonatal Aftercare,EXTREME","863","DRG","","","","","","","","inpatient","","","628378.80","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","236707.24","","Standard inlier is a Case rate ($236,707.24). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $175,375, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($33,598.63) for the length of stay and the standard reimbursement.","236707.23","236707.23","236707.23","1 through 10","16484.349","330054.44","case rate",""
"Neonate Birth Weight < 1500 Grams With Major Procedure,EXTREME","588","DRG","","","","","","","","inpatient","","","1811180.20","","CIGNA ALTERNATE [1018]","HB AMC TUFTS CIGNA CARELINK HYBRID","443649.4246","","Fee schedule rate ($687,284.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.305), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($28,417), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","443649.4246","2172.29","2172.29","1 through 10","189493.39","951148.81","case rate",""
"Neonate Birth Weight < 1500 Grams With Major Procedure,EXTREME","588","DRG","","","","","","","","inpatient","","","1811180.20","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","461411.0797","","Fee schedule rate ($576,446.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","461411.0797","576446.80","576446.80","1 through 10","189493.39","951148.81","case rate",""
"Neonate Birth Weight < 1500 Grams With Major Procedure,EXTREME","588","DRG","","","","","","","","inpatient","","","1811180.20","","MASSHEALTH [3001]","HB BWH MEDICAID","189493.39","","Case rate ($209,517.52). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $251,947.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29990.32","29990.32","29990.32","1 through 10","189493.39","951148.81","case rate",""
"Neonate Birth Weight < 1500 Grams With Major Procedure,EXTREME","588","DRG","","","","","","","","inpatient","","","1811180.20","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","189493.39","","Case rate ($209,517.52). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $251,947.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","147607.87","147607.87","147607.87","1 through 10","189493.39","951148.81","case rate",""
"Neonate Birth Weight < 500 Grams, Or Birth Weight 500-999 Grams And Gestational Age <24 Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining Intervention,EXTREME","589","DRG","","","","","","","","inpatient","","","3401.00","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2153.91","","Standard inlier is a Case rate ($2,153.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $13,322, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($305.76) for the length of stay and the standard reimbursement.","1963.36","1963.36","1963.36","1 through 10","1562.76","951148.81","case rate",""
"Neonate Birth Weight < 500 Grams, Or Birth Weight 500-999 Grams And Gestational Age <24 Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining Intervention,EXTREME","589","DRG","","","","","","","","inpatient","","","3401.00","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2421.58","","Standard inlier is a Case rate ($2,421.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $13,322, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($343.72) for the length of stay and the standard reimbursement.","2421.57","2421.57","93850.73","1 through 10","1562.76","951148.81","case rate",""
"Neonate Birth Weight < 500 Grams, Or Birth Weight 500-999 Grams And Gestational Age <24 Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining Intervention,EXTREME","589","DRG","","","","","","","","inpatient","","","3401.00","","MASSHEALTH [3001]","HB BWH MEDICAID","1562.76","","Case rate ($1,727.90). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $44,157.90, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1831.12","1831.12","190905.83","1 through 10","1562.76","951148.81","case rate",""
"Neonate Birth Weight < 500 Grams, Or Birth Weight 500-999 Grams And Gestational Age <24 Weeks, Or Birth Weight 500-749 Grams With Major Anomaly Or Without Life Sustaining Intervention,MAJOR","589","DRG","","","","","","","","inpatient","","","2458507.18","","MASSHEALTH [3001]","HB BWH MEDICAID","73687.18","","Case rate ($81,473.84). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $123,903.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","113976.81","113976.81","113976.81","1 through 10","1562.76","951148.81","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,EXTREME","633","DRG","","","","","","","","inpatient","","","297334.96","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","172164.60","","Standard inlier is a Case rate ($172,164.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $130,731, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($24,437.34) for the length of stay and the standard reimbursement.","157287.23","157287.23","157287.23","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,EXTREME","633","DRG","","","","","","","","inpatient","","","297334.96","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","86985.46","","Case rate ($96,177.38). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $138,607.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","60339.85","60339.85","60339.85","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,EXTREME","633","DRG","","","","","","","","inpatient","","","297334.96","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6231.4462","","Fee schedule rate ($115,165.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6231.4462","115165.44","115165.44","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,EXTREME","633","DRG","","","","","","","","inpatient","","","297334.96","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","142083.90","","Fee schedule rate ($142,083.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","143958.10","143958.10","143958.10","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,EXTREME","633","DRG","","","","","","","","inpatient","","","297334.96","","MASSHEALTH [3001]","HB BWH MEDICAID","86985.46","","Case rate ($96,177.38). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $138,607.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","101923.00","101923.00","101923.00","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,EXTREME","633","DRG","","","","","","","","inpatient","","","297334.96","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11017.00","","Per diem ($11,017). If length of stay < 26.12, first 1 days paid at a per diem of $22,034 instead.","287768.13","287768.13","287768.13","1 through 10","3143.79","190025.3","per diem","Estimated amount calculated based on 15 day length of stay."
"Neonate Birth Weight > 2499 Grams With Major Anomaly,EXTREME","633","DRG","","","","","","","","inpatient","","","297334.96","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11568.00","","Per diem ($11,568). If length of stay < 26.12, first 1 days paid at a per diem of $23,136 instead.","302161.26","302161.26","302161.26","1 through 10","3143.79","190025.3","per diem","Estimated amount calculated based on 15 day length of stay."
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MAJOR","633","DRG","","","","","","","","inpatient","","","100985.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","59216.37","","Standard inlier is a Case rate ($59,216.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,406.12) for the length of stay and the standard reimbursement.","59216.37","59216.37","59216.37","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MAJOR","633","DRG","","","","","","","","inpatient","","","100985.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","66575.16","","Standard inlier is a Case rate ($66,575.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,449.79) for the length of stay and the standard reimbursement.","66575.16","15406.03","134456.97","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MAJOR","633","DRG","","","","","","","","inpatient","","","100985.98","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6231.4462","","Fee schedule rate ($44,727.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6231.4462","43003.56","43003.56","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MAJOR","633","DRG","","","","","","","","inpatient","","","100985.98","","MASSHEALTH [3001]","HB BWH MEDICAID","43170.01","","Case rate ($47,731.87). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $90,161.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","50583.36","36130.97","50583.36","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MAJOR","633","DRG","","","","","","","","inpatient","","","100985.98","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","43170.01","","Case rate ($47,731.87). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $90,161.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","50583.36","50583.36","239245.36","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","11610.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5869.89","","Standard inlier is a Case rate ($5,869.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $16,213, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($833.27) for the length of stay and the standard reimbursement.","5350.62","5350.62","6599.34","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","11610.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6599.34","","Standard inlier is a Case rate ($6,599.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $16,213, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($936.72) for the length of stay and the standard reimbursement.","6599.34","6029.06","7593.68","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","11610.71","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","6543.1996","","Fee schedule rate ($6,543.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6543.1996","6854.67","6854.67","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","11610.71","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6231.4462","","Fee schedule rate ($6,231.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6231.4462","6231.44","6231.44","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","11610.71","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6543.1996","","Fee schedule rate ($6,543.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6543.1996","6543.20","6543.20","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","11610.71","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","6854.67","","Fee schedule rate ($6,854.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6854.67","6854.67","6854.67","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","11610.71","","MASSHEALTH [3001]","HB BWH MEDICAID","3143.79","","Case rate ($3,476). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $45,906, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3683.65","3683.65","3683.65","12","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MINOR","633","DRG","","","","","","","","inpatient","","","11610.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18118.04","","Fee schedule rate ($18,118.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18118.04","18118.04","18118.04","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MODERATE","633","DRG","","","","","","","","inpatient","","","25327.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","16684.72","","Standard inlier is a Case rate ($16,684.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,622, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,368.50) for the length of stay and the standard reimbursement.","16684.72","16684.72","16684.72","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MODERATE","633","DRG","","","","","","","","inpatient","","","25327.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18758.12","","Standard inlier is a Case rate ($18,758.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,622, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,662.56) for the length of stay and the standard reimbursement.","18758.12","17137.16","18758.12","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MODERATE","633","DRG","","","","","","","","inpatient","","","25327.58","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6231.4462","","Fee schedule rate ($19,396.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6231.4462","19396.68","19396.68","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MODERATE","633","DRG","","","","","","","","inpatient","","","25327.58","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6543.1996","","Fee schedule rate ($20,367.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6543.1996","20367.04","20367.04","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MODERATE","633","DRG","","","","","","","","inpatient","","","25327.58","","MASSHEALTH [3001]","HB BWH MEDICAID","13069.81","","Case rate ($14,450.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,880.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15314.21","15314.21","24664.58","12","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MODERATE","633","DRG","","","","","","","","inpatient","","","25327.58","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52903.96","","Fee schedule rate ($52,903.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","51362.63","51362.63","51362.63","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Anomaly,MODERATE","633","DRG","","","","","","","","inpatient","","","25327.58","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","13069.81","","Case rate ($14,450.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,880.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","280402.24","280402.24","280402.24","1 through 10","3143.79","190025.3","case rate",""
"Neonate Birth Weight > 2499 Grams With Major Cardiovascular Procedure,MAJOR","630","DRG","","","","","","","","inpatient","","","34046.20","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","73486.7785","","Fee schedule rate ($138,243.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","73486.7785","138243.72","138243.72","1 through 10","19584.72","228104.91","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MAJOR","639","DRG","","","","","","","","inpatient","","","132901.02","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","54689.08","","Standard inlier is a Case rate ($54,689.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,475, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,762.66) for the length of stay and the standard reimbursement.","54689.07","54689.07","54689.07","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MAJOR","639","DRG","","","","","","","","inpatient","","","132901.02","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74962.08","","Fee schedule rate ($74,962.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","72777.90","72777.90","72777.90","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","10860.11","","Standard inlier is a Case rate ($10,860.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $20,094, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,541.66) for the length of stay and the standard reimbursement.","9899.38","9899.38","10860.10","11","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","12209.69","","Standard inlier is a Case rate ($12,209.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $20,094, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,733.06) for the length of stay and the standard reimbursement.","11155.96","11154.60","12209.68","34","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","11545.7176","","Fee schedule rate ($5,643.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11545.7176","12095.33","12095.33","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","3912.7676","","Fee schedule rate ($5,643.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3912.7676","12095.33","12095.33","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","6543.1996","","Fee schedule rate ($5,643.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6543.1996","12095.33","12095.33","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10995.6172","","Fee schedule rate ($5,374.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10995.6172","10995.60","10995.60","11","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3726.3422","","Fee schedule rate ($5,374.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3726.3422","10995.60","10995.60","11","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6231.4462","","Fee schedule rate ($5,374.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6231.4462","10995.60","10995.60","11","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11545.7176","","Fee schedule rate ($5,643.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11545.7176","11545.72","11545.72","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3912.7676","","Fee schedule rate ($5,643.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3912.7676","11545.72","11545.72","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6543.1996","","Fee schedule rate ($5,643.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6543.1996","11545.72","11545.72","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","5912.34","","Fee schedule rate ($5,912.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12095.33","12095.33","515506.39","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","MASSHEALTH [3001]","HB BWH MEDICAID","4921.31","","Case rate ($5,441.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,871.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5766.42","5766.42","5766.42","39","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4913.06","","Fee schedule rate ($4,913.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21830.47","21830.47","21830.47","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5780.09","","Fee schedule rate ($5,780.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26453.70","26453.70","26453.70","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6069.18","","Fee schedule rate ($6,069.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27776.81","26967.55","27776.81","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","11545.7176","","Fee schedule rate ($5,643.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11545.7176","5679.83","5679.83","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","3912.7676","","Fee schedule rate ($5,643.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3912.7676","5679.83","5679.83","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","6543.1996","","Fee schedule rate ($5,643.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6543.1996","5679.83","5679.83","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MINOR","639","DRG","","","","","","","","inpatient","","","16510.71","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4921.31","","Case rate ($5,441.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,871.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5766.42","5766.42","77852.42","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","40368.04","","Standard inlier is a Case rate ($40,368.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,039, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,730.49) for the length of stay and the standard reimbursement.","14854.22","13540.16","27229.82","11","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","45384.55","","Standard inlier is a Case rate ($45,384.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,039, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,441.96) for the length of stay and the standard reimbursement.","16700.14","15257.02","26430.76","15","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","19584.72","","Case rate ($21,654.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,084.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6234.81","6234.81","6234.81","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10995.6172","","Fee schedule rate ($28,356.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10995.6172","31138.37","122248.88","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3726.3422","","Fee schedule rate ($28,356.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3726.3422","31138.37","122248.88","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6231.4462","","Fee schedule rate ($28,356.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6231.4462","31138.37","122248.88","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11545.7176","","Fee schedule rate ($29,775.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11545.7176","29775.56","29775.56","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3912.7676","","Fee schedule rate ($29,775.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3912.7676","29775.56","29775.56","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6543.1996","","Fee schedule rate ($29,775.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6543.1996","29775.56","29775.56","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","34984.94","","Fee schedule rate ($34,984.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20865.03","20865.03","20865.03","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","MASSHEALTH [3001]","HB BWH MEDICAID","19584.72","","Case rate ($21,654.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,084.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13566.08","13566.08","13566.08","13","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73444.60","","Fee schedule rate ($73,444.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","47745.38","47745.38","47745.38","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77118.03","","Fee schedule rate ($77,118.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","48672.83","48672.83","50133.44","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Other Significant Condition,MODERATE","639","DRG","","","","","","","","inpatient","","","68198.62","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","19584.72","","Case rate ($21,654.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,084.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13566.09","13566.09","13566.09","1 through 10","3582.8996","78711.42","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,EXTREME","634","DRG","","","","","","","","inpatient","","","220938.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","117365.49","","Standard inlier is a Case rate ($117,365.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $102,917, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,660.74) for the length of stay and the standard reimbursement.","178074.45","178074.45","178074.45","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,EXTREME","634","DRG","","","","","","","","inpatient","","","220938.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","131950.44","","Standard inlier is a Case rate ($131,950.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $102,917, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,729.27) for the length of stay and the standard reimbursement.","131950.44","131950.44","131950.44","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,EXTREME","634","DRG","","","","","","","","inpatient","","","220938.50","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16240.6787","","Fee schedule rate ($91,899.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16240.6787","88357.60","88357.60","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,EXTREME","634","DRG","","","","","","","","inpatient","","","220938.50","","MASSHEALTH [3001]","HB BWH MEDICAID","47801.16","","Case rate ($52,852.40). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $95,282.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","56009.80","56009.80","56009.80","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,EXTREME","634","DRG","","","","","","","","inpatient","","","220938.50","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194102.02","","Fee schedule rate ($194,102.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","194102.02","188446.96","195146.96","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","120092.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","40368.04","","Standard inlier is a Case rate ($40,368.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,039, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,730.49) for the length of stay and the standard reimbursement.","40368.03","36802.70","88262.70","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","120092.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45384.55","","Standard inlier is a Case rate ($45,384.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,039, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,441.96) for the length of stay and the standard reimbursement.","79299.57","79299.57","79299.57","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","120092.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","45384.55","","Standard inlier is a Case rate ($45,384.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,039, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,441.96) for the length of stay and the standard reimbursement.","45384.55","41462.70","64112.07","27","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","120092.53","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","17053.1846","","Fee schedule rate ($46,302.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17053.1846","48506.79","48506.79","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","120092.53","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16240.6787","","Fee schedule rate ($44,096.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16240.6787","42397.12","44096.56","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","120092.53","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","17053.1846","","Fee schedule rate ($46,302.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17053.1846","44516.48","46302.64","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","120092.53","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","48506.79","","Fee schedule rate ($48,506.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","48506.79","48506.79","48506.79","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","120092.53","","MASSHEALTH [3001]","HB BWH MEDICAID","19584.72","","Case rate ($21,654.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,084.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22947.91","18549.12","22947.91","26","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","120092.53","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73444.60","","Fee schedule rate ($73,444.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","71304.63","71304.63","73444.60","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","120092.53","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77118.03","","Fee schedule rate ($77,118.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","74871.24","74871.24","77118.03","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","634","DRG","","","","","","","","inpatient","","","120092.53","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","19584.72","","Case rate ($21,654.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,084.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22947.90","22947.90","181652.56","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MINOR","634","DRG","","","","","","","","inpatient","","","45881.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","17428.56","","Standard inlier is a Case rate ($17,428.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,200, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,474.09) for the length of stay and the standard reimbursement.","17428.56","17428.56","17428.56","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MINOR","634","DRG","","","","","","","","inpatient","","","45881.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","19594.40","","Standard inlier is a Case rate ($19,594.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,200, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,781.26) for the length of stay and the standard reimbursement.","19594.40","17901.18","33806.04","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MINOR","634","DRG","","","","","","","","inpatient","","","45881.72","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","17053.1846","","Fee schedule rate ($17,053.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17053.1846","17864.96","17864.96","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MINOR","634","DRG","","","","","","","","inpatient","","","45881.72","","MASSHEALTH [3001]","HB BWH MEDICAID","9336.56","","Case rate ($10,323.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,753.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10939.87","10939.87","11383.14","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MINOR","634","DRG","","","","","","","","inpatient","","","45881.72","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28631.88","","Fee schedule rate ($28,631.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27797.63","27797.63","27797.63","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MINOR","634","DRG","","","","","","","","inpatient","","","45881.72","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30063.95","","Fee schedule rate ($30,063.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30063.95","30063.95","30063.95","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MODERATE","634","DRG","","","","","","","","inpatient","","","73738.69","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","40192.34","","Standard inlier is a Case rate ($40,192.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,449, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,704.97) for the length of stay and the standard reimbursement.","40192.34","36719.17","45853.77","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MODERATE","634","DRG","","","","","","","","inpatient","","","73738.69","","MASSHEALTH [3001]","HB BWH MEDICAID","18547.45","","Case rate ($20,507.40). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,937.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21732.51","21732.51","21732.51","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MODERATE","634","DRG","","","","","","","","inpatient","","","73738.69","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53105.37","","Fee schedule rate ($53,105.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","53105.37","53105.37","53105.37","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MODERATE","634","DRG","","","","","","","","inpatient","","","73738.69","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","18547.45","","Case rate ($20,507.40). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,937.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","94687.06","94687.06","94687.06","1 through 10","9336.56","194102.02","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","16270.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","8204.91","","Standard inlier is a Case rate ($8,204.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $18,028, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,164.74) for the length of stay and the standard reimbursement.","8204.91","7479.07","10860.10","34","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","16270.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","9224.53","","Standard inlier is a Case rate ($9,224.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $18,028, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,309.35) for the length of stay and the standard reimbursement.","9224.53","8427.40","9224.53","58","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","16270.58","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","5643.69","","Fee schedule rate ($5,643.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13448.55","13448.55","13448.55","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","16270.58","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5374.79","","Fee schedule rate ($5,374.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12225.80","12225.80","12225.80","13","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","16270.58","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","5643.69","","Fee schedule rate ($5,643.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12837.44","12342.24","12837.44","11","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","16270.58","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","6631.08","","Fee schedule rate ($6,631.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14693.15","14693.15","14693.15","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","16270.58","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","5912.34","","Fee schedule rate ($5,912.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13448.55","12930.36","13448.56","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","16270.58","","MASSHEALTH [3001]","HB BWH MEDICAID","4195.91","","Case rate ($4,639.30). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,069.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4916.45","4916.45","4916.45","78","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","16270.58","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","4195.91","","Case rate ($4,639.30). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,069.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27099.60","27099.60","27099.60","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","16270.58","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","12155.84","","Fee schedule rate ($12,155.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11801.68","11801.68","11801.68","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","16270.58","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14301.02","","Fee schedule rate ($14,301.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14301.02","13884.33","23499.71","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","16270.58","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15016.31","","Fee schedule rate ($15,016.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15016.31","14578.82","15016.31","24","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","640","DRG","","","","","","","","inpatient","","","16270.58","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4195.91","","Case rate ($4,639.30). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,069.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","217535.45","217535.45","217535.45","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3431.38","","Standard inlier is a Case rate ($3,431.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $14,316, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($487.11) for the length of stay and the standard reimbursement.","3431.38","3127.82","3431.38","349","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3857.80","","Standard inlier is a Case rate ($3,857.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $14,316, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($547.58) for the length of stay and the standard reimbursement.","3524.42","3524.42","3524.42","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3857.80","","Standard inlier is a Case rate ($3,857.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $14,316, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($547.58) for the length of stay and the standard reimbursement.","3857.79","3524.42","3857.79","805","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","3912.77","","Fee schedule rate ($3,912.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4099.03","4099.03","4657.97","17","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3726.34","","Fee schedule rate ($3,726.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3726.36","5991.28","3726.36","163","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3912.77","","Fee schedule rate ($3,912.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3912.76","3761.84","3912.76","109","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","4597.33","","Fee schedule rate ($4,597.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4657.97","4657.97","4657.97","12","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","3912.77","","Fee schedule rate ($3,912.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3912.77","3912.77","3912.77","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","4099.03","","Fee schedule rate ($4,099.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4099.03","3941.09","4099.04","69","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","MASSHEALTH [3001]","HB BWH MEDICAID","1562.76","","Case rate ($1,727.90). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $44,157.90, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1831.12","1831.12","1831.12","803","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3115.95","","Fee schedule rate ($3,115.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3025.17","3025.17","3025.17","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3665.84","","Fee schedule rate ($3,665.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3665.84","3115.96","3665.84","52","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3849.19","","Fee schedule rate ($3,849.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3849.19","3737.04","3849.19","243","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","3912.77","","Fee schedule rate ($3,912.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3941.09","3941.09","3941.09","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","3912.77","","Fee schedule rate ($3,912.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3761.83","3761.83","3761.83","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","640","DRG","","","","","","","","inpatient","","","8672.58","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","4099.03","","Fee schedule rate ($4,099.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3941.09","3941.09","3941.09","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4540.68","","Standard inlier is a Case rate ($4,540.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $15,179, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($644.58) for the length of stay and the standard reimbursement.","4540.67","4138.99","4540.67","105","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5104.94","","Standard inlier is a Case rate ($5,104.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $15,179, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($724.60) for the length of stay and the standard reimbursement.","5104.94","4663.80","5104.94","277","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","CIGNA ALTERNATE [1018]","HB AMC TUFTS CIGNA CARELINK HYBRID","6408.24","","Fee schedule rate ($6,408.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.305), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($28,417), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6191.53","6191.53","6191.53","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","5643.69","","Fee schedule rate ($5,643.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5912.34","5912.34","5912.34","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5374.79","","Fee schedule rate ($5,374.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5374.80","5374.80","5374.80","46","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","5643.69","","Fee schedule rate ($5,643.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5643.68","5425.96","5684.52","27","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","6631.08","","Fee schedule rate ($6,631.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6718.55","6718.55","6718.55","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","5912.34","","Fee schedule rate ($5,912.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5912.34","5912.34","5912.36","15","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","MASSHEALTH [3001]","HB BWH MEDICAID","1990.00","","Case rate ($2,200.29). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $44,630.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2331.73","2331.73","2331.73","248","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4913.06","","Fee schedule rate ($4,913.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4769.92","4769.92","4769.92","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5780.09","","Fee schedule rate ($5,780.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5780.09","4913.07","5780.09","13","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6069.18","","Fee schedule rate ($6,069.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6069.18","5892.36","6069.18","99","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","6631.08","","Fee schedule rate ($6,631.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6459.50","6459.50","6459.50","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight > 2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","640","DRG","","","","","","","","inpatient","","","10959.71","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","1990.00","","Case rate ($2,200.29). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $44,630.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2331.73","2331.73","2331.73","1 through 10","1562.76","15016.31","case rate",""
"Neonate Birth Weight 1000-1249 Grams With Or Without Significant Condition,MINOR","603","DRG","","","","","","","","inpatient","","","4331.00","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4809.11","","Standard inlier is a Case rate ($4,809.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $15,388, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($682.68) for the length of stay and the standard reimbursement.","4809.10","4809.10","4809.10","1 through 10","2803.37","272111.63","case rate",""
"Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,EXTREME","602","DRG","","","","","","","","inpatient","","","727347.78","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","367937.09","","Standard inlier is a Case rate ($367,937.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $297,770, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($52,230.89) for the length of stay and the standard reimbursement.","367937.08","367937.08","367937.08","1 through 10","119701.68","554001.1","case rate",""
"Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,EXTREME","602","DRG","","","","","","","","inpatient","","","727347.78","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","413660.45","","Standard inlier is a Case rate ($413,660.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $297,770, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($58,715.66) for the length of stay and the standard reimbursement.","413660.44","413660.44","413660.44","1 through 10","119701.68","554001.1","case rate",""
"Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,EXTREME","602","DRG","","","","","","","","inpatient","","","727347.78","","MASSHEALTH [3001]","HB BWH MEDICAID","139110.48","","Case rate ($153,810.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $196,240.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","162999.17","162999.17","162999.17","1 through 10","119701.68","554001.1","case rate",""
"Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,EXTREME","602","DRG","","","","","","","","inpatient","","","727347.78","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","139110.48","","Case rate ($153,810.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $196,240.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","169603.57","169603.57","169603.57","1 through 10","119701.68","554001.1","case rate",""
"Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","602","DRG","","","","","","","","inpatient","","","742003.68","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","290127.88","","Standard inlier is a Case rate ($290,127.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $237,264, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($41,185.40) for the length of stay and the standard reimbursement.","290127.87","290127.87","290127.87","1 through 10","119701.68","554001.1","case rate",""
"Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","602","DRG","","","","","","","","inpatient","","","742003.68","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","326181.92","","Standard inlier is a Case rate ($326,181.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $237,264, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($46,298.81) for the length of stay and the standard reimbursement.","297995.35","297995.35","297995.35","1 through 10","119701.68","554001.1","case rate",""
"Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","602","DRG","","","","","","","","inpatient","","","742003.68","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165187.0051","","Fee schedule rate ($246,249.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","165187.0051","246249.48","246249.48","1 through 10","119701.68","554001.1","case rate",""
"Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","602","DRG","","","","","","","","inpatient","","","742003.68","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","173451.1558","","Fee schedule rate ($258,569.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","173451.1558","258569.12","258569.12","1 through 10","119701.68","554001.1","case rate",""
"Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","602","DRG","","","","","","","","inpatient","","","742003.68","","MASSHEALTH [3001]","HB BWH MEDICAID","119701.68","","Case rate ($132,350.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $174,780.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","46475.25","46475.25","46475.25","1 through 10","119701.68","554001.1","case rate",""
"Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","602","DRG","","","","","","","","inpatient","","","742003.68","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","363915.21","","Fee schedule rate ($363,915.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","353311.76","353311.76","353311.76","1 through 10","119701.68","554001.1","case rate",""
"Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","602","DRG","","","","","","","","inpatient","","","742003.68","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","382116.95","","Fee schedule rate ($382,116.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","382116.95","382116.95","382116.95","1 through 10","119701.68","554001.1","case rate",""
"Neonate Birth Weight 1000-1249 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","602","DRG","","","","","","","","inpatient","","","742003.68","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","119701.68","","Case rate ($132,350.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $174,780.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","68489.84","68489.84","68489.84","1 through 10","119701.68","554001.1","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,EXTREME","607","DRG","","","","","","","","inpatient","","","746097.27","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","282608.59","","Standard inlier is a Case rate ($282,608.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $231,415, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($40,117.99) for the length of stay and the standard reimbursement.","312200.17","312200.17","312200.17","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,EXTREME","607","DRG","","","","","","","","inpatient","","","746097.27","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","131862.4118","","Fee schedule rate ($238,286.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","131862.4118","229103.52","229103.52","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,EXTREME","607","DRG","","","","","","","","inpatient","","","746097.27","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","96623.2033","","Fee schedule rate ($238,286.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","96623.2033","229103.52","229103.52","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,EXTREME","607","DRG","","","","","","","","inpatient","","","746097.27","","MASSHEALTH [3001]","HB BWH MEDICAID","151300.66","","Case rate ($167,288.90). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $209,718.90, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","60180.84","45135.63","182978.53","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,EXTREME","607","DRG","","","","","","","","inpatient","","","746097.27","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","151300.66","","Case rate ($167,288.90). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $209,718.90, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","161123.22","161123.22","358575.91","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","607","DRG","","","","","","","","inpatient","","","557006.08","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","219854.12","","Standard inlier is a Case rate ($219,854.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $182,616, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($31,209.62) for the length of stay and the standard reimbursement.","262611.32","262611.32","262611.32","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","607","DRG","","","","","","","","inpatient","","","557006.08","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","247175.28","","Standard inlier is a Case rate ($247,175.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $182,616, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($35,084.48) for the length of stay and the standard reimbursement.","247175.28","247175.28","267951.91","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","607","DRG","","","","","","","","inpatient","","","557006.08","","MASSHEALTH [3001]","HB BWH MEDICAID","65817.42","","Case rate ($72,772.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $115,202.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13089.65","13089.65","58903.45","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","607","DRG","","","","","","","","inpatient","","","557006.08","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","267162.72","","Fee schedule rate ($267,162.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","259378.36","259378.36","259378.36","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","607","DRG","","","","","","","","inpatient","","","557006.08","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","280525.24","","Fee schedule rate ($280,525.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","280525.24","280525.24","280525.24","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MAJOR","607","DRG","","","","","","","","inpatient","","","557006.08","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","65817.42","","Case rate ($72,772.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $115,202.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","223883.65","223883.65","341312.67","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MODERATE","607","DRG","","","","","","","","inpatient","","","494641.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","170239.79","","Standard inlier is a Case rate ($170,239.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $144,032, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($24,166.56) for the length of stay and the standard reimbursement.","170239.78","170239.78","170239.78","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MODERATE","607","DRG","","","","","","","","inpatient","","","494641.51","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","101457.1714","","Fee schedule rate ($166,830.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","101457.1714","166830.44","166830.44","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MODERATE","607","DRG","","","","","","","","inpatient","","","494641.51","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","138459.3644","","Fee schedule rate ($166,830.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","138459.3644","166830.44","166830.44","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1250-1499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition Or Major Anomaly,MODERATE","607","DRG","","","","","","","","inpatient","","","494641.51","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","51209.98","","Case rate ($56,621.44). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $99,051.44, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","400335.81","400335.81","400335.81","1 through 10","51209.98","434559.9","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Major Anomaly,EXTREME","611","DRG","","","","","","","","inpatient","","","406413.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","241448.58","","Standard inlier is a Case rate ($241,448.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $178,654, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($34,271.62) for the length of stay and the standard reimbursement.","15753.74","15753.74","15753.74","1 through 10","18069.95","391990.56","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Major Anomaly,EXTREME","611","DRG","","","","","","","","inpatient","","","406413.60","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","66995.8751","","Fee schedule rate ($181,689.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","66995.8751","181689.36","181689.36","1 through 10","18069.95","391990.56","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Major Anomaly,EXTREME","611","DRG","","","","","","","","inpatient","","","406413.60","","MASSHEALTH [3001]","HB BWH MEDICAID","100533.92","","Case rate ($111,157.53). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $153,587.53, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","117798.07","117798.07","117798.07","1 through 10","18069.95","391990.56","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Major Anomaly,MAJOR","611","DRG","","","","","","","","inpatient","","","426178.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","157264.27","","Standard inlier is a Case rate ($157,264.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $120,425, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($22,322.36) for the length of stay and the standard reimbursement.","36392.23","36392.23","36392.23","1 through 10","18069.95","391990.56","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Major Anomaly,MAJOR","611","DRG","","","","","","","","inpatient","","","426178.28","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","70347.6158","","Fee schedule rate ($136,876.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","70347.6158","45596.24","45596.24","1 through 10","18069.95","391990.56","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Major Anomaly,MAJOR","611","DRG","","","","","","","","inpatient","","","426178.28","","MASSHEALTH [3001]","HB BWH MEDICAID","66702.75","","Case rate ($73,751.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $116,181.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","51359.62","51359.62","51359.62","1 through 10","18069.95","391990.56","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Major Anomaly,MAJOR","611","DRG","","","","","","","","inpatient","","","426178.28","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","66702.75","","Case rate ($73,751.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $116,181.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","232467.92","232467.92","232467.92","1 through 10","18069.95","391990.56","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Major Anomaly,MINOR","611","DRG","","","","","","","","inpatient","","","46100.05","","MASSHEALTH [3001]","HB BWH MEDICAID","18069.95","","Case rate ($19,979.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,409.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21173.00","21173.00","21173.00","1 through 10","18069.95","391990.56","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Major Anomaly,MODERATE","611","DRG","","","","","","","","inpatient","","","94455.85","","MASSHEALTH [3001]","HB BWH MEDICAID","34360.08","","Case rate ($37,990.98). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,420.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","40260.56","40260.56","40260.56","1 through 10","18069.95","391990.56","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Major Anomaly,MODERATE","611","DRG","","","","","","","","inpatient","","","94455.85","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","34360.08","","Case rate ($37,990.98). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,420.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","42632.63","42632.63","42632.63","1 through 10","18069.95","391990.56","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MAJOR","614","DRG","","","","","","","","inpatient","","","789279.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","139651.49","","Standard inlier is a Case rate ($139,651.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $108,243, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($19,822.37) for the length of stay and the standard reimbursement.","244974.26","244974.26","244974.26","1 through 10","15421.94","203632.55","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MAJOR","614","DRG","","","","","","","","inpatient","","","789279.71","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","45708.4532","","Fee schedule rate ($129,586.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","45708.4532","126371.12","126371.12","1 through 10","15421.94","203632.55","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MINOR","614","DRG","","","","","","","","inpatient","","","122488.52","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","28094.63","","Standard inlier is a Case rate ($28,094.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,495, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,988.20) for the length of stay and the standard reimbursement.","28094.62","28094.62","28094.62","1 through 10","15421.94","203632.55","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MINOR","614","DRG","","","","","","","","inpatient","","","122488.52","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","31585.93","","Standard inlier is a Case rate ($31,585.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,495, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,483.36) for the length of stay and the standard reimbursement.","59613.34","57873.12","79088.97","1 through 10","15421.94","203632.55","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MINOR","614","DRG","","","","","","","","inpatient","","","122488.52","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","45708.4532","","Fee schedule rate ($45,708.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","45708.4532","47884.30","47884.30","1 through 10","15421.94","203632.55","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MINOR","614","DRG","","","","","","","","inpatient","","","122488.52","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","43530.6554","","Fee schedule rate ($43,530.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","43530.6554","43530.64","43530.64","1 through 10","15421.94","203632.55","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MINOR","614","DRG","","","","","","","","inpatient","","","122488.52","","MASSHEALTH [3001]","HB BWH MEDICAID","15421.94","","Case rate ($17,051.61). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,481.61, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18070.27","18070.27","18070.27","1 through 10","15421.94","203632.55","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MINOR","614","DRG","","","","","","","","inpatient","","","122488.52","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","47884.3048","","Fee schedule rate ($47,884.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","47884.3048","46039.31","46039.31","1 through 10","15421.94","203632.55","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MODERATE","614","DRG","","","","","","","","inpatient","","","201602.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","76726.87","","Standard inlier is a Case rate ($76,726.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $64,719, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,890.74) for the length of stay and the standard reimbursement.","76875.81","70096.62","88851.08","1 through 10","15421.94","203632.55","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MODERATE","614","DRG","","","","","","","","inpatient","","","201602.71","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","43530.6554","","Fee schedule rate ($77,159.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","43530.6554","77159.44","77159.44","1 through 10","15421.94","203632.55","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MODERATE","614","DRG","","","","","","","","inpatient","","","201602.71","","MASSHEALTH [3001]","HB BWH MEDICAID","28062.22","","Case rate ($31,027.61). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $73,457.61, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17125.62","14984.92","17125.62","1 through 10","15421.94","203632.55","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MODERATE","614","DRG","","","","","","","","inpatient","","","201602.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","101278.40","","Fee schedule rate ($101,278.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","101278.40","101278.40","101278.40","1 through 10","15421.94","203632.55","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Or Without Other Significant Condition,MODERATE","614","DRG","","","","","","","","inpatient","","","201602.71","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","28062.22","","Case rate ($31,027.61). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $73,457.61, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","32881.19","32881.19","72491.51","1 through 10","15421.94","203632.55","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,EXTREME","612","DRG","","","","","","","","inpatient","","","548916.08","","MASSHEALTH [3001]","HB BWH MEDICAID","76578.50","","Case rate ($84,670.70). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $127,100.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17322.18","17322.18","17322.18","1 through 10","4837","285748.5","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,EXTREME","612","DRG","","","","","","","","inpatient","","","548916.08","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","285748.50","","Fee schedule rate ($285,748.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","285748.50","285748.50","285748.50","1 through 10","4837","285748.5","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,EXTREME","612","DRG","","","","","","","","inpatient","","","548916.08","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","76578.50","","Case rate ($84,670.70). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $127,100.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","146395.32","146395.32","146395.32","1 through 10","4837","285748.5","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","612","DRG","","","","","","","","inpatient","","","324824.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","144428.44","","Standard inlier is a Case rate ($144,428.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $123,960, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,502.49) for the length of stay and the standard reimbursement.","131651.78","131651.78","144428.43","1 through 10","4837","285748.5","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","612","DRG","","","","","","","","inpatient","","","324824.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","162376.49","","Standard inlier is a Case rate ($162,376.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $123,960, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($23,047.99) for the length of stay and the standard reimbursement.","162376.48","148344.94","190721.71","1 through 10","4837","285748.5","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","612","DRG","","","","","","","","inpatient","","","324824.84","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","75244.8247","","Fee schedule rate ($129,985.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","75244.8247","129985.84","129985.84","1 through 10","4837","285748.5","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","612","DRG","","","","","","","","inpatient","","","324824.84","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","142986.15","","Fee schedule rate ($142,986.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","142986.15","142986.15","142986.16","1 through 10","4837","285748.5","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","612","DRG","","","","","","","","inpatient","","","324824.84","","MASSHEALTH [3001]","HB BWH MEDICAID","60891.53","","Case rate ($67,326.06). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $109,756.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,599.46 and the sum of the standard inlier and any outlier amount.","52340.31","33057.04","71348.10","11","4837","285748.5","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","612","DRG","","","","","","","","inpatient","","","324824.84","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5691.00","","Per diem ($5,691). If length of stay < 32.91, first 1 days paid at a per diem of $11,382 instead.","159200.22","159200.22","159200.22","1 through 10","4837","285748.5","per diem","Estimated amount calculated based on 27 day length of stay."
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","612","DRG","","","","","","","","inpatient","","","324824.84","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5976.00","","Per diem ($5,976). If length of stay < 32.91, first 1 days paid at a per diem of $11,952 instead.","190932.53","190932.53","196662.18","1 through 10","4837","285748.5","per diem","Estimated amount calculated based on 27 day length of stay."
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","612","DRG","","","","","","","","inpatient","","","324824.84","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","60891.53","","Case rate ($67,326.06). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $109,756.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,599.46 and the sum of the standard inlier and any outlier amount.","133136.11","71348.11","303448.31","1 through 10","4837","285748.5","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MODERATE","612","DRG","","","","","","","","inpatient","","","374771.93","","MASSHEALTH [3001]","HB BWH MEDICAID","42822.73","","Case rate ($47,347.89). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $89,777.89, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17435.83","17435.83","79929.54","1 through 10","4837","285748.5","case rate",""
"Neonate Birth Weight 1500-1999 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MODERATE","612","DRG","","","","","","","","inpatient","","","374771.93","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","42822.73","","Case rate ($47,347.89). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $89,777.89, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","149987.24","149987.24","149987.24","1 through 10","4837","285748.5","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Congenital Or Perinatal Infection,MAJOR","623","DRG","","","","","","","","inpatient","","","367307.77","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","113148.68","","Standard inlier is a Case rate ($113,148.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $89,912, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,060.52) for the length of stay and the standard reimbursement.","113148.68","113148.68","113148.68","1 through 10","27082.5058","149480.37","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,EXTREME","621","DRG","","","","","","","","inpatient","","","593851.99","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","189421.06","","Standard inlier is a Case rate ($189,421.06). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $142,667, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($26,886.75) for the length of stay and the standard reimbursement.","189421.05","189421.05","189421.05","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,EXTREME","621","DRG","","","","","","","","inpatient","","","593851.99","","MASSHEALTH [3001]","HB BWH MEDICAID","87979.32","","Case rate ($97,276.26). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $139,706.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","275363.21","275363.21","275363.21","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,EXTREME","621","DRG","","","","","","","","inpatient","","","593851.99","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","317746.99","","Fee schedule rate ($317,746.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","308488.75","308488.75","308488.75","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MAJOR","621","DRG","","","","","","","","inpatient","","","245284.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","98898.78","","Standard inlier is a Case rate ($98,898.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $88,556, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,039.28) for the length of stay and the standard reimbursement.","98898.77","98898.77","98898.77","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MAJOR","621","DRG","","","","","","","","inpatient","","","245284.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","111188.88","","Standard inlier is a Case rate ($111,188.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $88,556, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($15,782.34) for the length of stay and the standard reimbursement.","111188.88","111188.88","111188.88","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MAJOR","621","DRG","","","","","","","","inpatient","","","245284.74","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","168905.53","","Fee schedule rate ($168,905.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","168905.53","168905.53","168905.53","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MINOR","621","DRG","","","","","","","","inpatient","","","51223.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","14434.92","","Standard inlier is a Case rate ($14,434.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $21,633, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,048.92) for the length of stay and the standard reimbursement.","14434.92","14434.92","14434.92","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MINOR","621","DRG","","","","","","","","inpatient","","","51223.71","","MASSHEALTH [3001]","HB BWH MEDICAID","8655.71","","Case rate ($9,570.37). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,000.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10142.10","10142.10","10142.10","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MINOR","621","DRG","","","","","","","","inpatient","","","51223.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44471.71","","Fee schedule rate ($44,471.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","43175.93","43175.93","43175.93","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MINOR","621","DRG","","","","","","","","inpatient","","","51223.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46696.02","","Fee schedule rate ($46,696.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17590.18","17590.18","17590.18","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MINOR","621","DRG","","","","","","","","inpatient","","","51223.71","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8655.71","","Case rate ($9,570.37). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,000.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10142.10","10142.10","10142.10","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MODERATE","621","DRG","","","","","","","","inpatient","","","79143.94","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","44307.17","","Standard inlier is a Case rate ($44,307.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,103, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,289.67) for the length of stay and the standard reimbursement.","48201.88","48201.88","48201.88","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MODERATE","621","DRG","","","","","","","","inpatient","","","79143.94","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","49813.20","","Standard inlier is a Case rate ($49,813.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,103, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,070.57) for the length of stay and the standard reimbursement.","46755.32","46755.32","46755.32","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Major Anomaly,MODERATE","621","DRG","","","","","","","","inpatient","","","79143.94","","MASSHEALTH [3001]","HB BWH MEDICAID","20699.67","","Case rate ($22,887.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,317.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","26271.50","26271.50","26271.50","1 through 10","8655.71","333639.56","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MAJOR","625","DRG","","","","","","","","inpatient","","","207244.23","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","87067.74","","Fee schedule rate ($87,067.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","88216.24","88216.24","88216.24","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MINOR","625","DRG","","","","","","","","inpatient","","","157802.57","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","32583.56","","Standard inlier is a Case rate ($32,583.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,987, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,625.43) for the length of stay and the standard reimbursement.","32583.55","7540.13","68256.49","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MINOR","625","DRG","","","","","","","","inpatient","","","157802.57","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","36632.70","","Standard inlier is a Case rate ($36,632.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,987, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,199.71) for the length of stay and the standard reimbursement.","36632.70","33467.13","83166.35","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MINOR","625","DRG","","","","","","","","inpatient","","","157802.57","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","35870.1678","","Fee schedule rate ($35,870.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35870.1678","226851.05","226851.05","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MINOR","625","DRG","","","","","","","","inpatient","","","157802.57","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","34161.1191","","Fee schedule rate ($34,161.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34161.1191","34161.12","34161.12","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MINOR","625","DRG","","","","","","","","inpatient","","","157802.57","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35870.1678","","Fee schedule rate ($35,870.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35870.1678","34486.44","34486.44","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MINOR","625","DRG","","","","","","","","inpatient","","","157802.57","","MASSHEALTH [3001]","HB BWH MEDICAID","17199.46","","Case rate ($19,016.96). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,446.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16408.83","8950.27","20153.03","11","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MINOR","625","DRG","","","","","","","","inpatient","","","157802.57","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57151.49","","Fee schedule rate ($57,151.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","57151.49","55486.41","57151.49","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MINOR","625","DRG","","","","","","","","inpatient","","","157802.57","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","37577.6892","","Fee schedule rate ($37,577.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37577.6892","36129.81","36129.81","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MINOR","625","DRG","","","","","","","","inpatient","","","157802.57","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","17199.46","","Case rate ($19,016.96). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,446.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20153.03","20153.03","71643.03","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MODERATE","625","DRG","","","","","","","","inpatient","","","197591.91","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","44307.17","","Standard inlier is a Case rate ($44,307.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,103, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,289.67) for the length of stay and the standard reimbursement.","46253.60","46253.60","57303.57","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MODERATE","625","DRG","","","","","","","","inpatient","","","197591.91","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","49813.20","","Standard inlier is a Case rate ($49,813.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,103, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,070.57) for the length of stay and the standard reimbursement.","49813.20","49813.20","49813.20","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MODERATE","625","DRG","","","","","","","","inpatient","","","197591.91","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35870.1678","","Fee schedule rate ($35,870.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35870.1678","60337.88","60337.88","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MODERATE","625","DRG","","","","","","","","inpatient","","","197591.91","","MASSHEALTH [3001]","HB BWH MEDICAID","20699.67","","Case rate ($22,887.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,317.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","24254.31","10771.72","24254.31","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MODERATE","625","DRG","","","","","","","","inpatient","","","197591.91","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81240.25","","Fee schedule rate ($81,240.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","81240.25","78873.36","81240.25","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Other Significant Condition,MODERATE","625","DRG","","","","","","","","inpatient","","","197591.91","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","20699.67","","Case rate ($22,887.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,317.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","125113.47","125113.47","125113.47","1 through 10","17199.46","117359.95","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,EXTREME","622","DRG","","","","","","","","inpatient","","","212479.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","45659.0238","","Standard inlier is a Case rate ($132,982.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $115,062, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,877.73) for the length of stay and the standard reimbursement.","45659.0238","132982.95","132982.95","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,EXTREME","622","DRG","","","","","","","","inpatient","","","212479.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","51333.048","","Standard inlier is a Case rate ($149,508.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $115,062, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($21,221.52) for the length of stay and the standard reimbursement.","51333.048","103792.57","103792.57","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,EXTREME","622","DRG","","","","","","","","inpatient","","","212479.36","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","219000.89","","Fee schedule rate ($219,000.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","219000.89","219000.89","219000.89","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","206262.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","45659.0238","","Standard inlier is a Case rate ($77,446.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,872, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,994.07) for the length of stay and the standard reimbursement.","45659.0238","70595.75","137247.23","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","206262.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","51333.048","","Standard inlier is a Case rate ($87,071.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,872, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,359.05) for the length of stay and the standard reimbursement.","51333.048","87071.29","155896.55","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","206262.44","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","34161.1191","","Fee schedule rate ($76,394.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34161.1191","76394.48","76394.48","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","206262.44","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","36127.1784","","Fee schedule rate ($76,394.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","36127.1784","76394.48","76394.48","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","206262.44","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35870.1678","","Fee schedule rate ($80,216.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35870.1678","80216.44","80216.44","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","206262.44","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","37934.5872","","Fee schedule rate ($80,216.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37934.5872","80216.44","80216.44","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","206262.44","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","94250.72","","Fee schedule rate ($94,250.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","95493.96","95493.96","95493.96","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","206262.44","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","84034.96","","Fee schedule rate ($84,034.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","84034.96","84034.96","84034.96","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","206262.44","","MASSHEALTH [3001]","HB BWH MEDICAID","35002.09","","Case rate ($38,700.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $81,130.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","41012.81","30740.40","41012.81","11","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","206262.44","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","117359.95","","Fee schedule rate ($117,359.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","113940.73","113940.73","117359.95","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MAJOR","622","DRG","","","","","","","","inpatient","","","206262.44","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","35002.09","","Case rate ($38,700.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $81,130.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","115737.30","115737.30","178730.10","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MINOR","622","DRG","","","","","","","","inpatient","","","8036.71","","MASSHEALTH [3001]","HB BWH MEDICAID","21530.17","","Case rate ($23,805.31). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,235.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25227.43","25227.43","25227.43","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MODERATE","622","DRG","","","","","","","","inpatient","","","150178.23","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","51333.048","","Standard inlier is a Case rate ($76,777.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $64,753, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,897.97) for the length of stay and the standard reimbursement.","51333.048","70143.12","103190.62","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams With Respiratory Distress Syndrome Or Other Major Respiratory Condition,MODERATE","622","DRG","","","","","","","","inpatient","","","150178.23","","MASSHEALTH [3001]","HB BWH MEDICAID","30286.41","","Case rate ($33,486.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $75,916.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15516.01","15516.01","15516.01","1 through 10","21530.17","219000.89","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","626","DRG","","","","","","","","inpatient","","","18661.54","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","13622.03","","Standard inlier is a Case rate ($13,622.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,241, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,933.73) for the length of stay and the standard reimbursement.","13622.02","12416.97","46073.70","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","626","DRG","","","","","","","","inpatient","","","18661.54","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","15314.83","","Standard inlier is a Case rate ($15,314.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,241, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,173.81) for the length of stay and the standard reimbursement.","13992.52","13991.42","15314.83","15","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","626","DRG","","","","","","","","inpatient","","","18661.54","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4388.4054","","Fee schedule rate ($28,312.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4388.4054","28312.16","28312.16","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","626","DRG","","","","","","","","inpatient","","","18661.54","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","31143.74","","Fee schedule rate ($31,143.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31143.76","31143.76","31143.76","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","626","DRG","","","","","","","","inpatient","","","18661.54","","MASSHEALTH [3001]","HB BWH MEDICAID","8865.90","","Case rate ($9,802.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,232.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10388.40","10388.40","10388.40","24","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","626","DRG","","","","","","","","inpatient","","","18661.54","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34566.60","","Fee schedule rate ($34,566.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34566.60","15016.31","34566.60","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MAJOR","626","DRG","","","","","","","","inpatient","","","18661.54","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8865.90","","Case rate ($9,802.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,232.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","70660.45","10388.40","103698.40","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","9641.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5753.46","","Standard inlier is a Case rate ($5,753.46). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $16,123, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($816.74) for the length of stay and the standard reimbursement.","4495.70","4495.70","4932.00","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","9641.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6468.44","","Standard inlier is a Case rate ($6,468.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $16,123, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($918.14) for the length of stay and the standard reimbursement.","5544.90","5065.74","5544.90","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","9641.58","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","4607.9532","","Fee schedule rate ($4,607.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4607.9532","4641.31","4827.30","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","9641.58","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4388.4054","","Fee schedule rate ($4,388.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4388.4054","4388.40","4388.40","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","9641.58","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4607.9532","","Fee schedule rate ($4,607.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4607.9532","4430.20","4607.96","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","9641.58","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","5414.14","","Fee schedule rate ($5,414.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5485.56","5485.56","5485.56","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","9641.58","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","4827.30","","Fee schedule rate ($4,827.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4641.32","4641.32","4641.32","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","9641.58","","MASSHEALTH [3001]","HB BWH MEDICAID","3504.78","","Case rate ($3,875.14). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,305.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2565.98","2565.98","2565.98","11","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MINOR","626","DRG","","","","","","","","inpatient","","","9641.58","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12348.73","","Fee schedule rate ($12,348.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6717.99","6717.99","6717.99","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","626","DRG","","","","","","","","inpatient","","","9952.63","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5753.46","","Standard inlier is a Case rate ($5,753.46). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $16,123, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($816.74) for the length of stay and the standard reimbursement.","5244.49","5244.49","5753.46","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","626","DRG","","","","","","","","inpatient","","","9952.63","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6468.44","","Standard inlier is a Case rate ($6,468.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $16,123, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($918.14) for the length of stay and the standard reimbursement.","6468.44","5909.48","6468.44","24","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","626","DRG","","","","","","","","inpatient","","","9952.63","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4388.4054","","Fee schedule rate ($9,892.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4388.4054","9892.92","9892.92","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","626","DRG","","","","","","","","inpatient","","","9952.63","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4607.9532","","Fee schedule rate ($10,387.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4607.9532","10387.84","10387.84","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","626","DRG","","","","","","","","inpatient","","","9952.63","","MASSHEALTH [3001]","HB BWH MEDICAID","3504.78","","Case rate ($3,875.14). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,305.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4106.64","4106.64","4106.64","40","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","626","DRG","","","","","","","","inpatient","","","9952.63","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11760.51","","Fee schedule rate ($11,760.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11760.51","11760.51","11760.51","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","626","DRG","","","","","","","","inpatient","","","9952.63","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12348.73","","Fee schedule rate ($12,348.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12348.73","6069.18","12348.73","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 2000-2499 Grams, Normal Newborn Or Neonate With Other Problem,MODERATE","626","DRG","","","","","","","","inpatient","","","9952.63","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","3504.78","","Case rate ($3,875.14). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,305.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","97416.64","97416.64","97416.64","1 through 10","3504.78","46715.61","case rate",""
"Neonate Birth Weight 500-749 Grams Without Major Procedure,EXTREME","591","DRG","","","","","","","","inpatient","","","2080883.27","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","557278.81","","Standard inlier is a Case rate ($557,278.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $397,108, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($77,323.20) for the length of stay and the standard reimbursement.","687543.09","687543.09","687543.09","1 through 10","34418.2024","744012.23","case rate",""
"Neonate Birth Weight 500-749 Grams Without Major Procedure,EXTREME","591","DRG","","","","","","","","inpatient","","","2080883.27","","MASSHEALTH [3001]","HB BWH MEDICAID","189493.39","","Case rate ($209,517.52). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $251,947.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","42426.84","12546.07","58744.85","1 through 10","34418.2024","744012.23","case rate",""
"Neonate Birth Weight 500-749 Grams Without Major Procedure,EXTREME","591","DRG","","","","","","","","inpatient","","","2080883.27","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","189493.39","","Case rate ($209,517.52). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $251,947.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","347990.90","24238.00","1506950.10","1 through 10","34418.2024","744012.23","case rate",""
"Neonate Birth Weight 750-999 Grams Without Major Procedure,EXTREME","593","DRG","","","","","","","","inpatient","","","1186320.68","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","577091.38","","Standard inlier is a Case rate ($577,091.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $410,814, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($81,913.33) for the length of stay and the standard reimbursement.","537571.04","537571.04","537571.04","1 through 10","129948.7","649720.56","case rate",""
"Neonate Birth Weight 750-999 Grams Without Major Procedure,EXTREME","593","DRG","","","","","","","","inpatient","","","1186320.68","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","263569.2864","","Fee schedule rate ($367,283.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","263569.2864","367283.48","367283.48","1 through 10","129948.7","649720.56","case rate",""
"Neonate Birth Weight 750-999 Grams Without Major Procedure,EXTREME","593","DRG","","","","","","","","inpatient","","","1186320.68","","MASSHEALTH [3001]","HB BWH MEDICAID","166823.13","","Case rate ($184,451.65). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $226,881.65, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","40917.92","39534.71","81835.85","1 through 10","129948.7","649720.56","case rate",""
"Neonate Birth Weight 750-999 Grams Without Major Procedure,EXTREME","593","DRG","","","","","","","","inpatient","","","1186320.68","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","166823.13","","Case rate ($184,451.65). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $226,881.65, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","215681.66","215681.66","365689.55","1 through 10","129948.7","649720.56","case rate",""
"Neonate Birth Weight 750-999 Grams Without Major Procedure,MAJOR","593","DRG","","","","","","","","inpatient","","","946471.62","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","330088.42","","Standard inlier is a Case rate ($330,088.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $268,338, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($46,858.04) for the length of stay and the standard reimbursement.","306842.62","306842.62","306842.62","1 through 10","129948.7","649720.56","case rate",""
"Neonate Birth Weight 750-999 Grams Without Major Procedure,MAJOR","593","DRG","","","","","","","","inpatient","","","946471.62","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","371108.34","","Standard inlier is a Case rate ($371,108.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $268,338, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($52,675.75) for the length of stay and the standard reimbursement.","345920.50","345920.50","345920.50","1 through 10","129948.7","649720.56","case rate",""
"Neonate Birth Weight 750-999 Grams Without Major Procedure,MAJOR","593","DRG","","","","","","","","inpatient","","","946471.62","","MASSHEALTH [3001]","HB BWH MEDICAID","129948.70","","Case rate ($143,680.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $186,110.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","36426.82","36426.82","36426.82","1 through 10","129948.7","649720.56","case rate",""
"Neonate Birth Weight 750-999 Grams Without Major Procedure,MAJOR","593","DRG","","","","","","","","inpatient","","","946471.62","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","129948.70","","Case rate ($143,680.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $186,110.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","97897.07","97897.07","97897.07","1 through 10","129948.7","649720.56","case rate",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","","","","inpatient","","","9503.59","7127.69","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13566.30","","Case rate ($13,843.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,587.02, add-ons for qualifying new technology services are included. If operating cost exceeds $62,231.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,627.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $12,275.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,207.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,187.60. The transfer capital threshold is the transfer adjustment factor * $1,187.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18425.40","18425.40","18797.39","1 through 10","13566.3","23118.5","other","Inpatient DRG"
"Neonate, Birth Weight >2499 Grams, Without Significant O.R. Procedures, With Major Problem","790","TRIS-DRG","","","","","","","","inpatient","","","15096.72","","TRICARE [160005]","HB BWH TRICARE","5377.69","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($9,446.23). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $53,173.23 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($4,498.20), capped at $6,798.78. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $53,173.23 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","11333.63","11333.63","11333.63","1 through 10","5377.69","5377.69","other","Inpatient DRGs"
"Neonate, Birth Weight >2499 Grams, Without Significant O.R. Procedures, With Minor Problem","791","TRIS-DRG","","","","","","","","inpatient","","","15759.99","","TRICARE [160005]","HB BWH TRICARE","2054.66","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($3,609.13). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $47,336.13 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($2,887.30), capped at $2,597.62. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $47,336.13 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","3051.11","3051.11","3051.11","1 through 10","2054.66","2054.66","other","Inpatient DRGs"
"Neonate, Birth Weight >2499 Grams, Without Significant O.R. Procedures, With Other Problem","792","TRIS-DRG","","","","","","","","inpatient","","","8593.58","","TRICARE [160005]","HB BWH TRICARE","1567.95","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($2,754.19). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $46,481.19 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($2,503.81), capped at $1,982.29. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $46,481.19 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","3350.50","2384.07","3350.50","1 through 10","1567.95","1567.95","other","Inpatient DRGs"
"Neonate, Birth Weight >2499 Grams, Without Significant O.R. Procedures, With Other Problem","792","TRIS-DRG","","","","","","","","inpatient","","","8593.58","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","1567.95","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($2,754.19). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $46,481.19 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($2,503.81), capped at $1,982.29. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $46,481.19 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","3496.53","3496.53","3496.53","1 through 10","1567.95","1567.95","other","Inpatient DRGs"
"Neonate, Birth Weight 1500-1999 Grams, Without Significant O.R. Procedures, With Major Problem","648","TRIS-DRG","","","","","","","","inpatient","","","89526.94","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","41174.85","","If the length of stay is greater than 5, the reimbursement is as follows: Case rate ($72,325.93). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $116,052.93 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 5, the reimbursement is as follows: Per diem ($5,763.02), capped at $52,055.51. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $116,052.93 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","27959.43","27959.43","27959.43","1 through 10","41174.85","41174.85","other","Inpatient DRGs"
"Neonate, Birth Weight 1500-1999 Grams, Without Significant O.R. Procedures, With Multiple Major Problems","647","TRIS-DRG","","","","","","","","inpatient","","","2377388.03","","TRICARE [160005]","HB BWH TRICARE","50465.49","","If the length of stay is greater than 8, the reimbursement is as follows: Case rate ($88,645.46). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $132,372.46 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 8, the reimbursement is as follows: Per diem ($5,664.25), capped at $63,801.25. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $132,372.46 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","474555.63","474555.63","474555.63","1 through 10","50465.49","50465.49","other","Inpatient DRGs"
"Neonate, Died Within One Day Of Birth","610","TRIS-DRG","","","","","","","","inpatient","","","9199.61","","TRICARE [160005]","HB BWH TRICARE","2693.09","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($4,730.55). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $48,457.56 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($9,461.11), capped at $3,404.75. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $48,457.56 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","5376.17","5376.17","5376.17","1 through 10","2693.09","2693.09","other","Inpatient DRGs"
"Neonate, Transferred < 5 Days Old, Born Here,EXTREME","581","DRG","","","","","","","","inpatient","","","10293.29","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","12651.80","","Standard inlier is a Case rate ($12,651.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $21,487, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,796.00) for the length of stay and the standard reimbursement.","1795.99","1795.99","13019.11","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,EXTREME","581","DRG","","","","","","","","inpatient","","","10293.29","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","14224.03","","Standard inlier is a Case rate ($14,224.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $21,487, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,018.98) for the length of stay and the standard reimbursement.","2018.98","1844.50","4037.96","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,EXTREME","581","DRG","","","","","","","","inpatient","","","10293.29","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3200.7177","","Fee schedule rate ($10,127.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3200.7177","9737.48","9737.48","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,EXTREME","581","DRG","","","","","","","","inpatient","","","10293.29","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3360.8466","","Fee schedule rate ($10,634.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3360.8466","10224.24","10224.24","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,EXTREME","581","DRG","","","","","","","","inpatient","","","10293.29","","MASSHEALTH [3001]","HB BWH MEDICAID","3688.70","","Case rate ($4,078.49). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,508.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3022.48","3022.48","4322.14","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MAJOR","581","DRG","","","","","","","","inpatient","","","4622.29","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","7561.33","","Standard inlier is a Case rate ($7,561.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $17,529, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,073.38) for the length of stay and the standard reimbursement.","1073.37","1073.37","1073.37","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MAJOR","581","DRG","","","","","","","","inpatient","","","4622.29","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","8500.97","","Standard inlier is a Case rate ($8,500.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $17,529, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,206.64) for the length of stay and the standard reimbursement.","1206.64","1102.36","2204.73","12","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MAJOR","581","DRG","","","","","","","","inpatient","","","4622.29","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3200.7177","","Fee schedule rate ($5,385.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3200.7177","5178.40","5178.40","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MAJOR","581","DRG","","","","","","","","inpatient","","","4622.29","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3360.8466","","Fee schedule rate ($5,655.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3360.8466","5655.44","5655.44","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MAJOR","581","DRG","","","","","","","","inpatient","","","4622.29","","MASSHEALTH [3001]","HB BWH MEDICAID","2502.92","","Case rate ($2,767.41). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $45,197.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2050.86","2050.86","2050.86","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MAJOR","581","DRG","","","","","","","","inpatient","","","4622.29","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","2502.92","","Case rate ($2,767.41). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $45,197.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2460.46","2460.46","2460.46","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MAJOR","581","DRG","","","","","","","","inpatient","","","4622.29","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5641.00","","Per diem ($5,641). If length of stay < 1.37, first 1 days paid at a per diem of $11,282 instead.","5640.94","5640.94","5640.94","1 through 10","1928.31","16711.04","per diem","Estimated amount calculated based on 1 day length of stay."
"Neonate, Transferred < 5 Days Old, Born Here,MAJOR","581","DRG","","","","","","","","inpatient","","","4622.29","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5923.00","","Per diem ($5,923). If length of stay < 1.37, first 1 days paid at a per diem of $11,846 instead.","5923.09","5923.09","5923.09","1 through 10","1928.31","16711.04","per diem","Estimated amount calculated based on 1 day length of stay."
"Neonate, Transferred < 5 Days Old, Born Here,MAJOR","581","DRG","","","","","","","","inpatient","","","4622.29","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","2502.92","","Case rate ($2,767.41). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $45,197.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12696.08","12696.08","12696.08","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MINOR","581","DRG","","","","","","","","inpatient","","","9457.39","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3701.45","","Standard inlier is a Case rate ($3,701.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $14,209, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($525.39) for the length of stay and the standard reimbursement.","479.98","479.98","479.98","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MINOR","581","DRG","","","","","","","","inpatient","","","9457.39","","MASSHEALTH [3001]","HB BWH MEDICAID","1928.31","","Case rate ($2,132.08). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $44,562.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1580.04","1580.04","1580.04","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MODERATE","581","DRG","","","","","","","","inpatient","","","4602.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4932.00","","Standard inlier is a Case rate ($4,932.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $15,482, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($700.13) for the length of stay and the standard reimbursement.","700.12","700.12","719.03","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MODERATE","581","DRG","","","","","","","","inpatient","","","4602.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5544.90","","Standard inlier is a Case rate ($5,544.90). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $15,482, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($787.05) for the length of stay and the standard reimbursement.","719.03","719.03","787.05","13","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MODERATE","581","DRG","","","","","","","","inpatient","","","4602.26","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","2171.64","","Case rate ($2,401.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $44,831.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7613.79","7613.79","7613.79","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MODERATE","581","DRG","","","","","","","","inpatient","","","4602.26","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3200.7177","","Fee schedule rate ($3,898.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","3200.7177","3898.56","3898.56","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MODERATE","581","DRG","","","","","","","","inpatient","","","4602.26","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","4288.48","","Fee schedule rate ($4,288.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4288.48","4288.48","4288.48","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MODERATE","581","DRG","","","","","","","","inpatient","","","4602.26","","MASSHEALTH [3001]","HB BWH MEDICAID","2171.64","","Case rate ($2,401.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $44,831.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1779.42","1779.42","2647.66","15","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MODERATE","581","DRG","","","","","","","","inpatient","","","4602.26","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","2171.64","","Case rate ($2,401.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $44,831.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1326.25","1326.25","4018.27","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Born Here,MODERATE","581","DRG","","","","","","","","inpatient","","","4602.26","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3525.00","","Per diem ($3,525). If length of stay < 1.37, first 1 days paid at a per diem of $7,050 instead.","3525.10","3525.10","3525.10","1 through 10","1928.31","16711.04","per diem","Estimated amount calculated based on 1 day length of stay."
"Neonate, Transferred < 5 Days Old, Born Here,MODERATE","581","DRG","","","","","","","","inpatient","","","4602.26","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","2171.64","","Case rate ($2,401.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $44,831.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1779.41","1779.41","1779.41","1 through 10","1928.31","16711.04","case rate",""
"Neonate, Transferred < 5 Days Old, Not Born Here,EXTREME","580","DRG","","","","","","","","inpatient","","","125828.79","","MASSHEALTH [3001]","HB BWH MEDICAID","14283.00","","Case rate ($15,792.31). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,222.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16735.74","16735.74","16735.74","1 through 10","8475.5146","44050.82","case rate",""
"Neonate, Transferred <5 Days Old","611","TRIS-DRG","","","","","","","","inpatient","","","3785.66","","TRICARE [160005]","HB BWH TRICARE","1969.95","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($3,460.32). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $47,187.33 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($5,767.21), capped at $2,490.52. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $47,187.33 is considered a cost outlier and adds an additional payment of 94.4% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","2473.50","2473.50","2473.50","1 through 10","1969.95","1969.95","other","Inpatient DRGs"
"Nephelometry Ea Analyte","PX-30000584","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30000584","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Nephritis And Nephrosis,EXTREME","462","DRG","","","","","","","","inpatient","","","175891.29","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","91012.72","","Standard inlier is a Case rate ($91,012.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $74,601, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,918.50) for the length of stay and the standard reimbursement.","91012.71","91012.71","91012.71","1 through 10","8295.86","98682.44","case rate",""
"Nephritis And Nephrosis,MAJOR","462","DRG","","","","","","","","inpatient","","","96182.03","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10991.1438","","Fee schedule rate ($25,312.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10991.1438","25312.72","25312.72","1 through 10","8295.86","98682.44","case rate",""
"Nephritis And Nephrosis,MAJOR","462","DRG","","","","","","","","inpatient","","","96182.03","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","16213.60","","Case rate ($17,926.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,356.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9548.49","9548.49","9548.49","1 through 10","8295.86","98682.44","case rate",""
"Nerve Conduction Studies 1-2 Stud","PX-92000116","CDM","95907","CPT","0922","RC","","","","both","","","753.00","564.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","182.84","182.84","1 through 10","176.52","598.64","other","OPPS APC"
"Nerve Conduction Studies 1-2 Stud","PX-92000116","CDM","95907","CPT","0922","RC","","","","both","","","753.00","564.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","176.52","598.64","other","OPPS APC"
"Nerve Conduction Studies 1-2 Stud","PX-92000116","CDM","95907","CPT","0922","RC","","","","both","","","753.00","564.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","274.85","36.5","","272.29","272.29","272.29","1 through 10","176.52","598.64","percent of total billed charges",""
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","2079.00","1559.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","253.39","620.04","1 through 10","474.64","1652.81","other","OPPS APC"
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","2079.00","1559.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1652.81","79.5","","1586.59","1586.59","1586.59","1 through 10","474.64","1652.81","percent of total billed charges",""
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","2079.00","1559.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1108.11","53.3","","1586.59","1586.59","1586.59","1 through 10","474.64","1652.81","percent of total billed charges",""
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","2079.00","1559.25","FALLON HEALTH [1008]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1852.56","1852.56","1852.56","1 through 10","474.64","1652.81","other","OPPS APC"
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","2079.00","1559.25","MEDICARE [2001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","630.12","56","474.64","1652.81","other","OPPS APC"
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","2079.00","1559.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","758.84","36.5","","751.97","639.07","751.97","1 through 10","474.64","1652.81","percent of total billed charges",""
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","2079.00","1559.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","796.26","38.3","","788.26","788.26","788.26","1 through 10","474.64","1652.81","percent of total billed charges",""
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","2079.00","1559.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1600.83","77","","2016.00","2016.00","2016.00","1 through 10","474.64","1652.81","percent of total billed charges",""
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","2079.00","1559.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.92","617.52","617.92","1 through 10","474.64","1652.81","other","OPPS APC"
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","both","","","2079.00","1559.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","618.52","573.29","620.04","1 through 10","474.64","1652.81","other","OPPS APC"
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","outpatient","","","2079.00","1559.25","AETNA [1001]","HB AMC AETNA HMO","1451.14","69.8","","1364.83","1364.83","1364.83","1 through 10","1045.95","1784.04","percent of total billed charges",""
"Nerve Conduction Studies 11-12 Stud","PX-92000121","CDM","95912","CPT","0922","RC","","","","outpatient","","","2079.00","1559.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1698.96","81.72","","1611.59","886.44","1611.59","1 through 10","1045.95","1784.04","percent of total billed charges",""
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","5279.00","3959.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","518.25","620.04","1 through 10","474.64","4196.81","other","OPPS APC"
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","5279.00","3959.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4196.81","79.5","","4028.65","4028.65","4028.65","1 through 10","474.64","4196.81","percent of total billed charges",""
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","5279.00","3959.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2813.71","53.3","","2702.83","2585.10","4028.65","1 through 10","474.64","4196.81","percent of total billed charges",""
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","5279.00","3959.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","502.51","620.04","1 through 10","474.64","4196.81","other","OPPS APC"
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","5279.00","3959.25","HUMANA [1012]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","623.82","621.30","623.82","1 through 10","474.64","4196.81","other","OPPS APC"
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","5279.00","3959.25","MEDICARE [2001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","630.12","80","474.64","4196.81","other","OPPS APC"
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","5279.00","3959.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1926.84","36.5","","1909.39","1853.08","1909.39","1 through 10","474.64","4196.81","percent of total billed charges",""
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","5279.00","3959.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2021.86","38.3","","2001.53","2001.53","2001.53","13","474.64","4196.81","percent of total billed charges",""
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","5279.00","3959.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","617.92","617.52","617.92","1 through 10","474.64","4196.81","other","OPPS APC"
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","5279.00","3959.25","TRICARE [160005]","HB BWH TRICARE","598.61","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","630.12","598.61","630.12","1 through 10","474.64","4196.81","other","Tricare OPPS"
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","5279.00","3959.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.72","617.52","617.92","1 through 10","474.64","4196.81","other","OPPS APC"
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","5279.00","3959.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2264.69","42.9","","4092.13","4092.13","4092.13","1 through 10","474.64","4196.81","percent of total billed charges",""
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","both","","","5279.00","3959.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","618.02","574.09","618.52","19","474.64","4196.81","other","OPPS APC"
"Nerve Conduction Studies 13/> Stud","PX-92000122","CDM","95913","CPT","0922","RC","","","","outpatient","","","5279.00","3959.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4314.00","81.72","","4092.13","1270.20","4092.13","1 through 10","1045.95","4314","percent of total billed charges",""
"Nerve Conduction Studies 3-4 Stud","PX-92000117","CDM","95908","CPT","0922","RC","","","","both","","","916.00","687.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","242.06","363.89","1 through 10","283.96","728.22","other","OPPS APC"
"Nerve Conduction Studies 3-4 Stud","PX-92000117","CDM","95908","CPT","0922","RC","","","","both","","","916.00","687.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","728.22","79.5","","698.86","468.86","698.86","1 through 10","283.96","728.22","percent of total billed charges",""
"Nerve Conduction Studies 3-4 Stud","PX-92000117","CDM","95908","CPT","0922","RC","","","","both","","","916.00","687.00","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","369.81","25","283.96","728.22","other","OPPS APC"
"Nerve Conduction Studies 3-4 Stud","PX-92000117","CDM","95908","CPT","0922","RC","","","","both","","","916.00","687.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","350.83","38.3","","347.21","337.44","347.21","1 through 10","283.96","728.22","percent of total billed charges",""
"Nerve Conduction Studies 3-4 Stud","PX-92000117","CDM","95908","CPT","0922","RC","","","","both","","","916.00","687.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.81","362.81","362.81","1 through 10","283.96","728.22","other","OPPS APC"
"Nerve Conduction Studies 3-4 Stud","PX-92000117","CDM","95908","CPT","0922","RC","","","","both","","","916.00","687.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.96","42.9","","709.87","709.87","709.87","1 through 10","283.96","728.22","percent of total billed charges",""
"Nerve Conduction Studies 3-4 Stud","PX-92000117","CDM","95908","CPT","0922","RC","","","","both","","","916.00","687.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.41","336.52","363.89","1 through 10","283.96","728.22","other","OPPS APC"
"Nerve Conduction Studies 3-4 Stud","PX-92000117","CDM","95908","CPT","0922","RC","","","","outpatient","","","916.00","687.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","748.56","81.72","","709.87","351.57","709.87","1 through 10","478.7","966.35","percent of total billed charges",""
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","1100.00","825.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","1 through 10","341","874.5","other","OPPS APC"
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","1100.00","825.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","874.50","79.5","","839.73","804.52","839.73","1 through 10","341","874.5","percent of total billed charges",""
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","1100.00","825.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","586.30","53.3","","563.38","563.38","563.38","1 through 10","341","874.5","percent of total billed charges",""
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","1100.00","825.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","299.06","363.89","1 through 10","341","874.5","other","OPPS APC"
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","1100.00","825.00","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","369.81","83","341","874.5","other","OPPS APC"
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","1100.00","825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","401.50","36.5","","397.99","338.24","397.99","1 through 10","341","874.5","percent of total billed charges",""
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","1100.00","825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","421.30","38.3","","417.20","405.46","417.20","22","341","874.5","percent of total billed charges",""
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","1100.00","825.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.81","362.41","362.81","1 through 10","341","874.5","other","OPPS APC"
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","1100.00","825.00","MOLINA [1014]","HB BWH MOLINA","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","733.70","733.70","733.70","1 through 10","341","874.5","other","OPPS APC"
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","1100.00","825.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1087.23","362.81","1087.23","1 through 10","341","874.5","other","OPPS APC"
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","both","","","1100.00","825.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","336.72","363.90","16","341","874.5","other","OPPS APC"
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","outpatient","","","1100.00","825.00","AETNA [1001]","HB AMC AETNA HMO","767.80","69.8","","722.36","722.36","722.36","1 through 10","574.86","1226.53","percent of total billed charges",""
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","outpatient","","","1100.00","825.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","574.86","52.26","","668.81","668.81","668.81","1 through 10","574.86","1226.53","percent of total billed charges",""
"Nerve Conduction Studies 5-6 Stud","PX-92000118","CDM","95909","CPT","0922","RC","","","","outpatient","","","1100.00","825.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","898.92","81.72","","852.96","852.96","852.96","1 through 10","574.86","1226.53","percent of total billed charges",""
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1475.00","1106.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","337.09","363.89","1 through 10","351.32","1172.63","other","OPPS APC"
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1475.00","1106.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1172.63","79.5","","1125.41","755.04","1125.41","13","351.32","1172.63","percent of total billed charges",""
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1475.00","1106.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","786.18","53.3","","755.04","755.04","755.04","1 through 10","351.32","1172.63","percent of total billed charges",""
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1475.00","1106.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","337.09","363.89","1 through 10","351.32","1172.63","other","OPPS APC"
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1475.00","1106.25","ELDER SERVICES [1037]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","335.72","134.60","335.72","1 through 10","351.32","1172.63","other","OPPS APC"
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1475.00","1106.25","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","91","351.32","1172.63","other","OPPS APC"
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1475.00","1106.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","538.38","36.5","","533.39","453.31","533.39","1 through 10","351.32","1172.63","percent of total billed charges",""
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1475.00","1106.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","564.93","38.3","","559.13","543.40","559.13","23","351.32","1172.63","percent of total billed charges",""
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1475.00","1106.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","362.41","362.81","1 through 10","351.32","1172.63","other","OPPS APC"
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1475.00","1106.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1087.23","336.12","1088.43","1 through 10","351.32","1172.63","other","OPPS APC"
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1475.00","1106.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","632.78","42.9","","628.77","628.77","628.77","1 through 10","351.32","1172.63","percent of total billed charges",""
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","both","","","1475.00","1106.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","362.41","363.89","15","351.32","1172.63","other","OPPS APC"
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","outpatient","","","1475.00","1106.25","AETNA [1001]","HB AMC AETNA HMO","1029.55","69.8","","968.11","968.11","968.11","1 through 10","579.66","1672.53","percent of total billed charges",""
"Nerve Conduction Studies 7-8 Stu","PX-92000119","CDM","95910","CPT","0922","RC","","","","outpatient","","","1475.00","1106.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1205.37","81.72","","1143.14","388.51","1143.14","1 through 10","579.66","1672.53","percent of total billed charges",""
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","1774.00","1330.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","620.04","620.04","1 through 10","474.64","1410.33","other","OPPS APC"
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","1774.00","1330.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1410.33","79.5","","1353.64","1353.64","1353.64","1 through 10","474.64","1410.33","percent of total billed charges",""
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","1774.00","1330.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","945.54","53.3","","908.16","908.16","908.16","1 through 10","474.64","1410.33","percent of total billed charges",""
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","1774.00","1330.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","617.52","575.62","617.52","1 through 10","474.64","1410.33","other","OPPS APC"
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","1774.00","1330.50","MEDICARE [2001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","630.12","78","474.64","1410.33","other","OPPS APC"
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","1774.00","1330.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","647.51","36.5","","641.56","641.56","641.56","1 through 10","474.64","1410.33","percent of total billed charges",""
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","1774.00","1330.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","679.44","38.3","","672.52","653.60","672.52","11","474.64","1410.33","percent of total billed charges",""
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","1774.00","1330.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","617.92","617.92","617.92","1 through 10","474.64","1410.33","other","OPPS APC"
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","1774.00","1330.50","TRICARE [160005]","HB BWH TRICARE","598.61","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","630.12","630.12","630.12","1 through 10","474.64","1410.33","other","Tricare OPPS"
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","1774.00","1330.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1852.56","617.52","1852.56","1 through 10","474.64","1410.33","other","OPPS APC"
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","both","","","1774.00","1330.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","617.45","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","618.52","575.62","620.04","13","474.64","1410.33","other","OPPS APC"
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","outpatient","","","1774.00","1330.50","AETNA [1001]","HB AMC AETNA HMO","1238.25","69.8","","1164.44","1164.44","1164.44","1 through 10","927.09","1784.04","percent of total billed charges",""
"Nerve Conduction Studies 9-10 Stud","PX-92000120","CDM","95911","CPT","0922","RC","","","","outpatient","","","1774.00","1330.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1449.71","81.72","","1374.97","830.17","1374.97","1 through 10","927.09","1784.04","percent of total billed charges",""
"Nervous System Malignancy,EXTREME","041","DRG","","","","","","","","inpatient","","","76610.45","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","48637.63","","Standard inlier is a Case rate ($48,637.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,904.40) for the length of stay and the standard reimbursement.","48637.62","48637.62","48637.62","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,EXTREME","041","DRG","","","","","","","","inpatient","","","76610.45","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","54681.80","","Standard inlier is a Case rate ($54,681.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,761.63) for the length of stay and the standard reimbursement.","54681.80","54681.80","54681.80","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,EXTREME","041","DRG","","","","","","","","inpatient","","","76610.45","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17312.058","","Fee schedule rate ($73,726.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17312.058","73726.12","73726.12","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,EXTREME","041","DRG","","","","","","","","inpatient","","","76610.45","","MASSHEALTH [3001]","HB BWH MEDICAID","19864.60","","Case rate ($21,963.73). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,393.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21958.34","21958.34","21958.34","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,EXTREME","041","DRG","","","","","","","","inpatient","","","76610.45","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","19864.60","","Case rate ($21,963.73). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,393.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21958.34","21958.34","21958.34","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MAJOR","041","DRG","","","","","","","","inpatient","","","59558.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","32874.63","","Standard inlier is a Case rate ($32,874.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,212, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,666.75) for the length of stay and the standard reimbursement.","32874.62","29969.77","32874.62","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MAJOR","041","DRG","","","","","","","","inpatient","","","59558.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","36959.94","","Standard inlier is a Case rate ($36,959.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,212, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,246.16) for the length of stay and the standard reimbursement.","36959.94","33766.09","54674.51","19","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MAJOR","041","DRG","","","","","","","","inpatient","","","59558.85","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17312.058","","Fee schedule rate ($37,833.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17312.058","37833.80","37833.80","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MAJOR","041","DRG","","","","","","","","inpatient","","","59558.85","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","18178.164","","Fee schedule rate ($39,726.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18178.164","39726.56","39726.56","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MAJOR","041","DRG","","","","","","","","inpatient","","","59558.85","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","46676.94","","Fee schedule rate ($46,676.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","47292.65","47292.65","47292.65","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MAJOR","041","DRG","","","","","","","","inpatient","","","59558.85","","MASSHEALTH [3001]","HB BWH MEDICAID","12316.99","","Case rate ($13,618.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,048.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13615.20","13615.20","13615.20","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MAJOR","041","DRG","","","","","","","","inpatient","","","59558.85","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37238.07","","Fee schedule rate ($37,238.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37238.07","37238.07","37238.07","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MAJOR","041","DRG","","","","","","","","inpatient","","","59558.85","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39100.59","","Fee schedule rate ($39,100.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37961.41","37961.41","39100.59","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MAJOR","041","DRG","","","","","","","","inpatient","","","59558.85","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12316.99","","Case rate ($13,618.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,048.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13615.21","13615.21","13615.21","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MINOR","041","DRG","","","","","","","","inpatient","","","31196.92","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7127.22","","Case rate ($7,880.37). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,310.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7878.43","7878.43","7878.43","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MODERATE","041","DRG","","","","","","","","inpatient","","","61084.47","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24886.40","","Standard inlier is a Case rate ($24,886.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,001, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,532.77) for the length of stay and the standard reimbursement.","24886.39","24886.39","24886.39","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MODERATE","041","DRG","","","","","","","","inpatient","","","61084.47","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","27979.02","","Standard inlier is a Case rate ($27,979.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,001, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,971.39) for the length of stay and the standard reimbursement.","27979.02","25561.25","37454.39","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MODERATE","041","DRG","","","","","","","","inpatient","","","61084.47","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28499.74","","Fee schedule rate ($28,499.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24224.78","24224.78","24224.78","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Malignancy,MODERATE","041","DRG","","","","","","","","inpatient","","","61084.47","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8387.25","","Case rate ($9,273.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,703.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9271.27","9271.27","9271.27","1 through 10","7127.22","121649.56","case rate",""
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","60054.51","45040.88","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","14737.63","","Case rate ($14,308.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,147.05, add-ons for qualifying new technology services are included. If operating cost exceeds $62,791.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,668.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,699.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,767.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,228.63. The transfer capital threshold is the transfer adjustment factor * $1,228.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14335.25","14327.34","14410.53","1 through 10","14022.21","22622.9181","other","Inpatient DRG"
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","60054.51","45040.88","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14308.38","","Case rate ($14,308.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,147.05, add-ons for qualifying new technology services are included. If operating cost exceeds $62,791.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,668.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,699.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,767.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,228.63. The transfer capital threshold is the transfer adjustment factor * $1,228.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17689.34","17689.34","17689.34","1 through 10","14022.21","22622.9181","other","Inpatient Replacement Plans DRG"
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","60054.51","45040.88","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","14308.38","","Case rate ($14,308.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,147.05, add-ons for qualifying new technology services are included. If operating cost exceeds $62,791.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,668.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,699.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,767.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,228.63. The transfer capital threshold is the transfer adjustment factor * $1,228.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10336.69","10336.69","10336.69","1 through 10","14022.21","22622.9181","other","Inpatient DRG"
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","60054.51","45040.88","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","13615.21","13615.21","13615.21","1 through 10","14022.21","22622.9181","case rate",""
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","60054.51","45040.88","HUMANA [1012]","HB BWH MEDICARE","14308.38","","Case rate ($14,308.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,147.05, add-ons for qualifying new technology services are included. If operating cost exceeds $62,791.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,668.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,699.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,767.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,228.63. The transfer capital threshold is the transfer adjustment factor * $1,228.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27261.24","27261.24","27261.24","1 through 10","14022.21","22622.9181","other","Inpatient Replacement Plans DRG"
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","60054.51","45040.88","MEDICARE [2001]","HB BWH MEDICARE","14308.38","","Case rate ($14,308.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,147.05, add-ons for qualifying new technology services are included. If operating cost exceeds $62,791.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,668.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,699.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,767.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,228.63. The transfer capital threshold is the transfer adjustment factor * $1,228.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17951.41","126.29","17977.84","64","14022.21","22622.9181","other","Inpatient Replacement Plans DRG"
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","60054.51","45040.88","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","14308.38","","Case rate ($14,308.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,147.05, add-ons for qualifying new technology services are included. If operating cost exceeds $62,791.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,668.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,699.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,767.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,228.63. The transfer capital threshold is the transfer adjustment factor * $1,228.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13653.87","13653.87","13653.87","1 through 10","14022.21","22622.9181","other","Inpatient Replacement Plans DRG"
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","60054.51","45040.88","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14022.21","","Case rate ($14,308.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,147.05, add-ons for qualifying new technology services are included. If operating cost exceeds $62,791.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,668.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,699.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,767.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,228.63. The transfer capital threshold is the transfer adjustment factor * $1,228.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13659.39","13659.39","13688.21","1 through 10","14022.21","22622.9181","other","Inpatient DRG"
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","60054.51","45040.88","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14022.21","","Case rate ($14,308.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,147.05, add-ons for qualifying new technology services are included. If operating cost exceeds $62,791.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,668.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,699.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,767.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,228.63. The transfer capital threshold is the transfer adjustment factor * $1,228.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13997.40","13657.28","19439.37","1 through 10","14022.21","22622.9181","other","Inpatient DRG"
"Nervous System Neoplasms Without McC","055","MS-DRG","","","","","","","","inpatient","","","61084.47","45813.35","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","9971.16","","Case rate ($9,680.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,576.29, add-ons for qualifying new technology services are included. If operating cost exceeds $57,220.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,260.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,480.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,196.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.43. The transfer capital threshold is the transfer adjustment factor * $820.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10494.29","10494.29","10494.29","1 through 10","9487.13","15971.01","other","Inpatient DRG"
"Nervous System Neoplasms Without McC","055","MS-DRG","","","","","","","","inpatient","","","61084.47","45813.35","MEDICARE [2001]","HB BWH MEDICARE","9680.74","","Case rate ($9,680.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,576.29, add-ons for qualifying new technology services are included. If operating cost exceeds $57,220.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,260.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,480.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,196.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.43. The transfer capital threshold is the transfer adjustment factor * $820.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13140.25","0.03","13159.49","1 through 10","9487.13","15971.01","other","Inpatient Replacement Plans DRG"
"NET RETRIEVAL 3X5.5CM RESCUENET FOREIGN BODY BX/5EA","SUP-ITM-10210617","CDM","C1773","HCPCS","0272","RC","","","","both","","","306.43","229.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","111.85","36.5","","114.30","97.14","114.30","1 through 10","94.99","243.61","percent of total billed charges",""
"NET RETRIEVAL 3X5.5CM RESCUENET FOREIGN BODY BX/5EA","SUP-ITM-10210617","CDM","C1773","HCPCS","0272","RC","","","","both","","","306.43","229.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","117.36","38.3","","119.81","116.44","359.43","20","94.99","243.61","percent of total billed charges",""
"NET RETRIEVAL 3X5.5CM RESCUENET FOREIGN BODY BX/5EA","SUP-ITM-10210617","CDM","C1773","HCPCS","0272","RC","","","","both","","","306.43","229.82","WELLPOINT [1015]","HB AMC WELLPOINT","226.08","73.78","","875.53","228.13","875.53","1 through 10","94.99","243.61","percent of total billed charges",""
"NET RETRIEVAL 3X5.5CM RESCUENET FOREIGN BODY BX/5EA","SUP-ITM-10210617","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","306.43","229.82","AETNA [1001]","HB AMC AETNA HMO","213.89","69.8","","207.45","207.45","207.45","1 through 10","160.14","250.41","percent of total billed charges",""
"NET RETRIEVAL 3X5.5CM RESCUENET FOREIGN BODY BX/5EA","SUP-ITM-10210617","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","306.43","229.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","250.41","81.72","","244.96","134.74","244.96","1 through 10","160.14","250.41","percent of total billed charges",""
"Neurodegen With Brain Iron Accum Nextgen Dna Seq Panel (10 Genes)","PX-31000834","CDM","81479","CPT","0310","RC","","","","both","","","1922.00","1441.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1527.99","79.5","","0.65","0.65","0.65","1 through 10","595.82","1825.9","percent of total billed charges",""
"Neurodegen With Brain Iron Accum Nextgen Dna Seq Panel (10 Genes)","PX-31000834","CDM","81479","CPT","0310","RC","","","","both","","","1922.00","1441.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1024.43","53.3","","0.79","0.79","0.79","1 through 10","595.82","1825.9","percent of total billed charges",""
"Neurodegen With Brain Iron Accum Nextgen Dna Seq Panel (10 Genes)","PX-31000834","CDM","81479","CPT","0310","RC","","","","outpatient","","","1922.00","1441.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","961.00","50","","1.00","1.00","1.00","1 through 10","156.55","1585.65","percent of total billed charges",""
"Neurodegen With Brain Iron Accum Nextgen Dna Seq Panel (10 Genes)","PX-31000834","CDM","81479","CPT","0310","RC","","","","outpatient","","","1922.00","1441.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1009.05","52.5","","1.00","0.53","1.00","1 through 10","156.55","1585.65","percent of total billed charges",""
"Neurodevelopment-Expanded","PX-31000799","CDM","81479","CPT","0310","RC","","","","both","","","226.00","169.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","179.67","79.5","","0.65","0.65","0.65","1 through 10","70.06","214.7","percent of total billed charges",""
"Neurodevelopment-Expanded","PX-31000799","CDM","81479","CPT","0310","RC","","","","both","","","226.00","169.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","120.46","53.3","","0.79","0.79","0.79","1 through 10","70.06","214.7","percent of total billed charges",""
"Neurodevelopment-Expanded","PX-31000799","CDM","81479","CPT","0310","RC","","","","outpatient","","","226.00","169.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","113.00","50","","1.00","1.00","1.00","1 through 10","109.38","186.45","percent of total billed charges",""
"Neurodevelopment-Expanded","PX-31000799","CDM","81479","CPT","0310","RC","","","","outpatient","","","226.00","169.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","118.65","52.5","","1.00","0.53","1.00","1 through 10","109.38","186.45","percent of total billed charges",""
"Neurofibromatosis 1 (Nf1)","PX-31000764","CDM","81479","CPT","0310","RC","","","","both","","","1938.00","1453.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1540.71","79.5","","0.65","0.65","0.65","1 through 10","600.78","1841.1","percent of total billed charges",""
"Neurofibromatosis 1 (Nf1)","PX-31000764","CDM","81479","CPT","0310","RC","","","","both","","","1938.00","1453.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1032.95","53.3","","0.79","0.79","0.79","1 through 10","600.78","1841.1","percent of total billed charges",""
"Neurofibromatosis 1 (Nf1)","PX-31000764","CDM","81479","CPT","0310","RC","","","","outpatient","","","1938.00","1453.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","969.00","50","","1.00","1.00","1.00","1 through 10","156.55","1598.85","percent of total billed charges",""
"Neurofibromatosis 1 (Nf1)","PX-31000764","CDM","81479","CPT","0310","RC","","","","outpatient","","","1938.00","1453.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1017.45","52.5","","1.00","0.53","1.00","1 through 10","156.55","1598.85","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","both","","","1813.00","1359.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1441.34","79.5","","1383.55","1383.55","1383.55","1 through 10","113.91","1722.35","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","both","","","1813.00","1359.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","966.33","53.3","","1383.55","928.22","1383.55","1 through 10","113.91","1722.35","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","both","","","1813.00","1359.75","WELLPOINT [1015]","HB AMC WELLPOINT","1337.63","73.78","","1660.00","1308.83","3066.83","1 through 10","113.91","1722.35","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","outpatient","","","1813.00","1359.75","AETNA [1001]","HB AMC AETNA HMO","1265.47","69.8","","840.32","840.32","840.32","1 through 10","725.2","1495.73","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","outpatient","","","1813.00","1359.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1097.77","60.55","","1181.91","1181.91","1181.91","1 through 10","725.2","1495.73","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","outpatient","","","1813.00","1359.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","946.75","52.22","","1215.13","1215.13","1215.13","1 through 10","725.2","1495.73","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","outpatient","","","1813.00","1359.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","906.50","50","","921.19","921.19","1758.00","1 through 10","725.2","1495.73","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","outpatient","","","1813.00","1359.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","997.15","55","","973.93","789.34","1012.61","1 through 10","725.2","1495.73","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","outpatient","","","1813.00","1359.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1481.58","81.72","","1405.35","772.99","1405.35","1 through 10","725.2","1495.73","percent of total billed charges",""
"Neurological Eye Disorders","123","MS-DRG","","","","","","","","inpatient","","","32120.78","24090.58","MEDICARE [2001]","HB BWH MEDICARE","7664.75","","Case rate ($7,664.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,149.44, add-ons for qualifying new technology services are included. If operating cost exceeds $54,793.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,082.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,642.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,769.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.60. The transfer capital threshold is the transfer adjustment factor * $642.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9761.51","9761.51","9761.51","1 through 10","7511.46","12121.0912","other","Inpatient Replacement Plans DRG"
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","both","","","5544.00","4158.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","4407.48","other","OPPS APC"
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","both","","","5544.00","4158.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","4407.48","other","OPPS APC"
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","both","","","5544.00","4158.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2954.95","53.3","","477.31","477.31","477.31","1 through 10","333.03","4407.48","percent of total billed charges",""
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","both","","","5544.00","4158.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","4407.48","other","OPPS APC"
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","both","","","5544.00","4158.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","4407.48","other","OPPS APC"
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","both","","","5544.00","4158.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2023.56","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","4407.48","percent of total billed charges",""
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","both","","","5544.00","4158.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2123.35","38.3","","343.52","323.76","353.46","1 through 10","333.03","4407.48","percent of total billed charges",""
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","both","","","5544.00","4158.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","4407.48","other","Tricare OPPS"
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","both","","","5544.00","4158.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","4407.48","other","OPPS APC"
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","both","","","5544.00","4158.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","4407.48","other","OPPS APC"
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","both","","","5544.00","4158.00","WELLPOINT [1015]","HB AMC WELLPOINT","4090.36","73.78","","673.03","673.03","673.03","1 through 10","333.03","4407.48","percent of total billed charges",""
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","outpatient","","","5544.00","4158.00","AETNA [1001]","HB AMC AETNA HMO","3869.71","69.8","","612.01","612.01","1224.02","1 through 10","700.33","4573.8","percent of total billed charges",""
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","outpatient","","","5544.00","4158.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3356.89","60.55","","579.04","568.57","904.00","30","700.33","4573.8","percent of total billed charges",""
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","outpatient","","","5544.00","4158.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2895.08","52.22","","904.00","656.02","2938.00","26","700.33","4573.8","percent of total billed charges",""
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","outpatient","","","5544.00","4158.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2772.00","50","","1421.10","875.08","2368.50","15","700.33","4573.8","percent of total billed charges",""
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","outpatient","","","5544.00","4158.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2910.60","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","4573.8","percent of total billed charges",""
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","outpatient","","","5544.00","4158.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4530.56","81.72","","722.66","722.66","17449.00","1 through 10","700.33","4573.8","percent of total billed charges",""
"Neuromuscular Junction Test","PX-92000079","CDM","95937","CPT","0922","RC","","","","both","","","489.00","366.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","129.21","129.21","182.84","1 through 10","151.59","388.76","other","OPPS APC"
"Neuromuscular Junction Test","PX-92000079","CDM","95937","CPT","0922","RC","","","","both","","","489.00","366.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","388.76","79.5","","357.40","250.27","373.04","1 through 10","151.59","388.76","percent of total billed charges",""
"Neuromuscular Junction Test","PX-92000079","CDM","95937","CPT","0922","RC","","","","both","","","489.00","366.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","260.64","53.3","","337.04","250.27","373.04","1 through 10","151.59","388.76","percent of total billed charges",""
"Neuromuscular Junction Test","PX-92000079","CDM","95937","CPT","0922","RC","","","","both","","","489.00","366.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","151.59","388.76","other","OPPS APC"
"Neuromuscular Junction Test","PX-92000079","CDM","95937","CPT","0922","RC","","","","both","","","489.00","366.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","178.49","36.5","","176.80","150.26","176.80","1 through 10","151.59","388.76","percent of total billed charges",""
"Neuromuscular Junction Test","PX-92000079","CDM","95937","CPT","0922","RC","","","","both","","","489.00","366.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.29","38.3","","185.33","180.12","185.33","1 through 10","151.59","388.76","percent of total billed charges",""
"Neuromuscular Junction Test","PX-92000079","CDM","95937","CPT","0922","RC","","","","both","","","489.00","366.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","170.48","170.48","170.48","1 through 10","151.59","388.76","other","OPPS APC"
"Neuromuscular Junction Test","PX-92000079","CDM","95937","CPT","0922","RC","","","","both","","","489.00","366.75","WELLPOINT [1015]","HB AMC WELLPOINT","360.78","73.78","","352.89","352.89","826.89","1 through 10","151.59","388.76","percent of total billed charges",""
"Neuromuscular Junction Test","PX-92000079","CDM","95937","CPT","0922","RC","","","","outpatient","","","489.00","366.75","AETNA [1001]","HB AMC AETNA HMO","341.32","69.8","","320.90","320.90","320.90","1 through 10","255.55","545.56","percent of total billed charges",""
"Neuromuscular Junction Test","PX-92000079","CDM","95937","CPT","0922","RC","","","","outpatient","","","489.00","366.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","399.61","81.72","","378.92","208.42","378.92","1 through 10","255.55","545.56","percent of total billed charges",""
"Neuroplasty &/Transpos Median Nrv Carpal Tunne","PX-76002373","CDM","64721","CPT","0761","RC","","","","both","","","4818.00","3613.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2433.76","","APC Price ($2,483.43). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2280.55","2280.55","2280.55","1 through 10","1493.58","3830.31","other","OPPS APC"
"Neuroplasty &/Transpos Median Nrv Carpal Tunne","PX-76002373","CDM","64721","CPT","0761","RC","","","","outpatient","","","4818.00","3613.50","AETNA [1001]","HB AMC AETNA HMO","3362.96","69.8","","5646.18","5646.18","5646.18","1 through 10","1468.33","5545.35","percent of total billed charges",""
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-90000137","CDM","96132","CPT","0918","RC","","","","both","","","781.00","585.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.42","403.33","477.42","45","242.11","620.9","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-90000137","CDM","96132","CPT","0918","RC","","","","both","","","781.00","585.75","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","409.89","485.18","22","242.11","620.9","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-96000032","CDM","96132","CPT","0961","RC","","","","both","","","456.00","342.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.42","403.33","477.42","45","141.36","598.61","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-96000032","CDM","96132","CPT","0961","RC","","","","both","","","456.00","342.00","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","409.89","485.18","22","141.36","598.61","other","OPPS APC"
"Neuroses Except Depressive","882","MS-DRG","","","","","","","","inpatient","","","38735.86","29051.89","MEDICARE [2001]","HB BWH MEDICARE","10175.16","","Case rate ($10,175.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,171.47, add-ons for qualifying new technology services are included. If operating cost exceeds $57,815.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,304.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,931.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,791.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.04. The transfer capital threshold is the transfer adjustment factor * $864.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11619.43","11619.43","11619.43","1 through 10","9971.66","14517.542","other","Inpatient Replacement Plans DRG"
"Neuroses Except Depressive","882","MS-DRG","","","","","","","","inpatient","","","38735.86","29051.89","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9971.66","","Case rate ($10,175.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,171.47, add-ons for qualifying new technology services are included. If operating cost exceeds $57,815.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,304.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,931.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,791.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $864.04. The transfer capital threshold is the transfer adjustment factor * $864.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8890.79","8890.79","8890.79","1 through 10","9971.66","14517.542","other","Inpatient DRG"
"NEUROSTIMULATOR BRAIN CONTROLLER DBS SYSTEM PATIENT","SUP-ITM-10321627","CDM","C1787","HCPCS","0270","RC","","","","both","","","4200.00","3150.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2238.60","53.3","","3163.82","3163.82","3163.82","1 through 10","1302","3339","percent of total billed charges",""
"NEUROSTIMULATOR BRAIN CONTROLLER DBS SYSTEM PATIENT","SUP-ITM-10321627","CDM","C1787","HCPCS","0270","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1639.86","1566.60","1745.64","1 through 10","1302","3339","percent of total billed charges",""
"NEUROSTIMULATOR BRAIN CONTROLLER DBS SYSTEM PATIENT","SUP-ITM-10321627","CDM","C1787","HCPCS","0270","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","1642.20","1642.20","1642.20","1 through 10","1302","3339","percent of total billed charges",""
"NEUROSTIMULATOR BRAIN CONTROLLER DBS SYSTEM PATIENT","SUP-ITM-10321627","CDM","C1787","HCPCS","0270","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2332.15","846.87","3126.90","1 through 10","1302","3339","percent of total billed charges",""
"NEUROSTIMULATOR DEEP BRAIN RECHARGEABLE IMPLANTABLE PERCEPT RC","SUP-ITM-10321513","CDM","C1820","HCPCS","0278","RC","","","","both","","","69887.50","52415.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37250.04","53.3","","54287.50","54287.50","54287.50","1 through 10","21665.13","55560.56","percent of total billed charges",""
"NEUROSTIMULATOR DEEP BRAIN RECHARGEABLE IMPLANTABLE PERCEPT RC","SUP-ITM-10321513","CDM","C1820","HCPCS","0278","RC","","","","both","","","69887.50","52415.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25508.94","36.5","","10467.31","10467.31","10467.31","1 through 10","21665.13","55560.56","percent of total billed charges",""
"NEUROSTIMULATOR DEEP BRAIN RECHARGEABLE IMPLANTABLE PERCEPT RC","SUP-ITM-10321513","CDM","C1820","HCPCS","0278","RC","","","","both","","","69887.50","52415.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26766.91","38.3","","21505.00","21505.00","21505.00","1 through 10","21665.13","55560.56","percent of total billed charges",""
"NEUROSTIMULATOR DEEP BRAIN RECHARGEABLE IMPLANTABLE PERCEPT RC","SUP-ITM-10321513","CDM","C1820","HCPCS","0278","RC","","","","both","","","69887.50","52415.62","WELLPOINT [1015]","HB AMC WELLPOINT","51563.00","73.78","","40016.88","40016.88","40016.88","1 through 10","21665.13","55560.56","percent of total billed charges",""
"NEUROSTIMULATOR DEEP BRAIN STIMULATION PERCEPT PC","SUP-ITM-10274482","CDM","C1767","HCPCS","0278","RC","","","","both","","","49950.00","37462.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","18231.75","36.5","","18081.90","16994.81","18081.90","1 through 10","15484.5","39710.25","percent of total billed charges",""
"NEUROSTIMULATOR DEEP BRAIN STIMULATION PERCEPT PC","SUP-ITM-10274482","CDM","C1767","HCPCS","0278","RC","","","","both","","","49950.00","37462.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","19130.85","38.3","","17814.94","17448.38","17814.94","1 through 10","15484.5","39710.25","percent of total billed charges",""
"NEUROSTIMULATOR DEEP BRAIN STIMULATION PERCEPT PC","SUP-ITM-10274482","CDM","C1767","HCPCS","0278","RC","","","","both","","","49950.00","37462.50","WELLPOINT [1015]","HB AMC WELLPOINT","36853.11","73.78","","33921.28","33921.28","33921.28","1 through 10","15484.5","39710.25","percent of total billed charges",""
"NEUROSTIMULATOR EXTERNAL 43X15X51MM VERIFY ENS POLYCARBONATE ABS BLEND PLASTIC RESIN","SUP-ITM-10152713","CDM","C1787","HCPCS","0270","RC","","","","both","","","1137.50","853.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","606.29","53.3","","3163.82","3163.82","3163.82","1 through 10","352.63","904.31","percent of total billed charges",""
"NEUROSTIMULATOR EXTERNAL 43X15X51MM VERIFY ENS POLYCARBONATE ABS BLEND PLASTIC RESIN","SUP-ITM-10152713","CDM","C1787","HCPCS","0270","RC","","","","both","","","1137.50","853.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","415.19","36.5","","1639.86","1566.60","1745.64","1 through 10","352.63","904.31","percent of total billed charges",""
"NEUROSTIMULATOR EXTERNAL 43X15X51MM VERIFY ENS POLYCARBONATE ABS BLEND PLASTIC RESIN","SUP-ITM-10152713","CDM","C1787","HCPCS","0270","RC","","","","both","","","1137.50","853.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","435.66","38.3","","1642.20","1642.20","1642.20","1 through 10","352.63","904.31","percent of total billed charges",""
"NEUROSTIMULATOR EXTERNAL 43X15X51MM VERIFY ENS POLYCARBONATE ABS BLEND PLASTIC RESIN","SUP-ITM-10152713","CDM","C1787","HCPCS","0270","RC","","","","both","","","1137.50","853.12","WELLPOINT [1015]","HB AMC WELLPOINT","839.25","73.78","","2332.15","846.87","3126.90","1 through 10","352.63","904.31","percent of total billed charges",""
"NEUROSTIMULATOR IMPLANTABLE 65X49 15MM PRIMEADVANCED 16 ELECTRODE","SUP-ITM-10021396","CDM","C1767","HCPCS","0278","RC","","","","both","","","28032.50","21024.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10231.86","36.5","","18081.90","16994.81","18081.90","1 through 10","8690.08","22285.84","percent of total billed charges",""
"NEUROSTIMULATOR IMPLANTABLE 65X49 15MM PRIMEADVANCED 16 ELECTRODE","SUP-ITM-10021396","CDM","C1767","HCPCS","0278","RC","","","","both","","","28032.50","21024.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10736.45","38.3","","17814.94","17448.38","17814.94","1 through 10","8690.08","22285.84","percent of total billed charges",""
"NEUROSTIMULATOR IMPLANTABLE 65X49 15MM PRIMEADVANCED 16 ELECTRODE","SUP-ITM-10021396","CDM","C1767","HCPCS","0278","RC","","","","both","","","28032.50","21024.37","WELLPOINT [1015]","HB AMC WELLPOINT","20682.38","73.78","","33921.28","33921.28","33921.28","1 through 10","8690.08","22285.84","percent of total billed charges",""
"NEUROSTIMULATOR IPG PROCLAIM DRG 4 PORT - DISCONTINUED PER SUPPLIER","SUP-ITM-10209119","CDM","C1820","HCPCS","0278","RC","","","","both","","","43875.00","32906.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23385.38","53.3","","54287.50","54287.50","54287.50","1 through 10","13601.25","34880.63","percent of total billed charges",""
"NEUROSTIMULATOR IPG PROCLAIM DRG 4 PORT - DISCONTINUED PER SUPPLIER","SUP-ITM-10209119","CDM","C1820","HCPCS","0278","RC","","","","both","","","43875.00","32906.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16014.38","36.5","","10467.31","10467.31","10467.31","1 through 10","13601.25","34880.63","percent of total billed charges",""
"NEUROSTIMULATOR IPG PROCLAIM DRG 4 PORT - DISCONTINUED PER SUPPLIER","SUP-ITM-10209119","CDM","C1820","HCPCS","0278","RC","","","","both","","","43875.00","32906.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16804.13","38.3","","21505.00","21505.00","21505.00","1 through 10","13601.25","34880.63","percent of total billed charges",""
"NEUROSTIMULATOR IPG PROCLAIM DRG 4 PORT - DISCONTINUED PER SUPPLIER","SUP-ITM-10209119","CDM","C1820","HCPCS","0278","RC","","","","both","","","43875.00","32906.25","WELLPOINT [1015]","HB AMC WELLPOINT","32370.98","73.78","","40016.88","40016.88","40016.88","1 through 10","13601.25","34880.63","percent of total billed charges",""
"NEUROSTIMULATOR IPG PROCLAIM DRG 4 PORT 16 CHANNEL","SUP-ITM-10211136","CDM","C1820","HCPCS","0278","RC","","","","both","","","46125.00","34593.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","24584.63","53.3","","54287.50","54287.50","54287.50","1 through 10","14298.75","36669.38","percent of total billed charges",""
"NEUROSTIMULATOR IPG PROCLAIM DRG 4 PORT 16 CHANNEL","SUP-ITM-10211136","CDM","C1820","HCPCS","0278","RC","","","","both","","","46125.00","34593.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16835.63","36.5","","10467.31","10467.31","10467.31","1 through 10","14298.75","36669.38","percent of total billed charges",""
"NEUROSTIMULATOR IPG PROCLAIM DRG 4 PORT 16 CHANNEL","SUP-ITM-10211136","CDM","C1820","HCPCS","0278","RC","","","","both","","","46125.00","34593.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17665.88","38.3","","21505.00","21505.00","21505.00","1 through 10","14298.75","36669.38","percent of total billed charges",""
"NEUROSTIMULATOR IPG PROCLAIM DRG 4 PORT 16 CHANNEL","SUP-ITM-10211136","CDM","C1820","HCPCS","0278","RC","","","","both","","","46125.00","34593.75","WELLPOINT [1015]","HB AMC WELLPOINT","34031.03","73.78","","40016.88","40016.88","40016.88","1 through 10","14298.75","36669.38","percent of total billed charges",""
"NEUROSTIMULATOR RECHARGEABLE MRI INTERSTIM MICRO SURESCAN BOWEL BLADDER CONTROL","SUP-ITM-10277210","CDM","C1820","HCPCS","0278","RC","","","","both","","","28062.50","21046.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14957.31","53.3","","54287.50","54287.50","54287.50","1 through 10","8699.38","22309.69","percent of total billed charges",""
"NEUROSTIMULATOR RECHARGEABLE MRI INTERSTIM MICRO SURESCAN BOWEL BLADDER CONTROL","SUP-ITM-10277210","CDM","C1820","HCPCS","0278","RC","","","","both","","","28062.50","21046.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10242.81","36.5","","10467.31","10467.31","10467.31","1 through 10","8699.38","22309.69","percent of total billed charges",""
"NEUROSTIMULATOR RECHARGEABLE MRI INTERSTIM MICRO SURESCAN BOWEL BLADDER CONTROL","SUP-ITM-10277210","CDM","C1820","HCPCS","0278","RC","","","","both","","","28062.50","21046.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10747.94","38.3","","21505.00","21505.00","21505.00","1 through 10","8699.38","22309.69","percent of total billed charges",""
"NEUROSTIMULATOR RECHARGEABLE MRI INTERSTIM MICRO SURESCAN BOWEL BLADDER CONTROL","SUP-ITM-10277210","CDM","C1820","HCPCS","0278","RC","","","","both","","","28062.50","21046.87","WELLPOINT [1015]","HB AMC WELLPOINT","20704.51","73.78","","40016.88","40016.88","40016.88","1 through 10","8699.38","22309.69","percent of total billed charges",""
"NEUROSTIMULATOR RNS","SUP-ITM-10212058","CDM","C1820","HCPCS","0278","RC","","","","both","","","90775.00","68081.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48383.08","53.3","","54287.50","54287.50","54287.50","1 through 10","28140.25","72166.13","percent of total billed charges",""
"NEUROSTIMULATOR RNS","SUP-ITM-10212058","CDM","C1820","HCPCS","0278","RC","","","","both","","","90775.00","68081.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33132.88","36.5","","10467.31","10467.31","10467.31","1 through 10","28140.25","72166.13","percent of total billed charges",""
"NEUROSTIMULATOR RNS","SUP-ITM-10212058","CDM","C1820","HCPCS","0278","RC","","","","both","","","90775.00","68081.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34766.83","38.3","","21505.00","21505.00","21505.00","1 through 10","28140.25","72166.13","percent of total billed charges",""
"NEUROSTIMULATOR RNS","SUP-ITM-10212058","CDM","C1820","HCPCS","0278","RC","","","","both","","","90775.00","68081.25","WELLPOINT [1015]","HB AMC WELLPOINT","66973.80","73.78","","40016.88","40016.88","40016.88","1 through 10","28140.25","72166.13","percent of total billed charges",""
"NEUROSTIMULATOR SPINAL 1.1CM 2 CHANNEL VANTA SCS RECHARGE-FREE BATTERY","SUP-ITM-10286921","CDM","C1767","HCPCS","0278","RC","","","","both","","","40500.00","30375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14782.50","36.5","","18081.90","16994.81","18081.90","1 through 10","12555","32197.5","percent of total billed charges",""
"NEUROSTIMULATOR SPINAL 1.1CM 2 CHANNEL VANTA SCS RECHARGE-FREE BATTERY","SUP-ITM-10286921","CDM","C1767","HCPCS","0278","RC","","","","both","","","40500.00","30375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15511.50","38.3","","17814.94","17448.38","17814.94","1 through 10","12555","32197.5","percent of total billed charges",""
"NEUROSTIMULATOR SPINAL 1.1CM 2 CHANNEL VANTA SCS RECHARGE-FREE BATTERY","SUP-ITM-10286921","CDM","C1767","HCPCS","0278","RC","","","","both","","","40500.00","30375.00","WELLPOINT [1015]","HB AMC WELLPOINT","29880.90","73.78","","33921.28","33921.28","33921.28","1 through 10","12555","32197.5","percent of total billed charges",""
"Neutralization Viral","PX-30000858","CDM","86382","CPT","0302","RC","","","","both","","","216.00","162.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","171.72","79.5","","164.48","164.48","164.48","1 through 10","16.57","205.2","percent of total billed charges",""
"Neutralization Viral","PX-30000858","CDM","86382","CPT","0302","RC","","","","both","","","216.00","162.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","115.13","53.3","","164.48","164.48","164.48","1 through 10","16.57","205.2","percent of total billed charges",""
"Neutralization Viral","PX-30000858","CDM","86382","CPT","0302","RC","","","","both","","","216.00","162.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.84","36.5","","66.25","66.25","66.25","1 through 10","16.57","205.2","percent of total billed charges",""
"Neutralization Viral","PX-30000858","CDM","86382","CPT","0302","RC","","","","both","","","216.00","162.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82.73","38.3","","81.72","81.72","158.84","12","16.57","205.2","percent of total billed charges",""
"Neutralization Viral","PX-30000858","CDM","86382","CPT","0302","RC","","","","outpatient","","","216.00","162.00","AETNA [1001]","HB AMC AETNA HMO","150.77","69.8","","141.49","141.49","141.49","1 through 10","17.44","176.52","percent of total billed charges",""
"Neutralization Viral","PX-30000858","CDM","86382","CPT","0302","RC","","","","outpatient","","","216.00","162.00","AETNA [1001]","HB AMC AETNA PPO","173.66","80.4","","219.03","219.03","219.03","1 through 10","17.44","176.52","percent of total billed charges",""
"Neutralization Viral","PX-30000858","CDM","86382","CPT","0302","RC","","","","outpatient","","","216.00","162.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","176.52","81.72","","167.08","167.08","167.08","1 through 10","17.44","176.52","percent of total billed charges",""
"Neutrophil Antigen Genotyping - Hna-1","PX-31000789","CDM","81479","CPT","0310","RC","","","","both","","","276.00","207.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","219.42","79.5","","0.65","0.65","0.65","1 through 10","85.56","262.2","percent of total billed charges",""
"Neutrophil Antigen Genotyping - Hna-1","PX-31000789","CDM","81479","CPT","0310","RC","","","","both","","","276.00","207.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.11","53.3","","0.79","0.79","0.79","1 through 10","85.56","262.2","percent of total billed charges",""
"Neutrophil Antigen Genotyping - Hna-1","PX-31000789","CDM","81479","CPT","0310","RC","","","","outpatient","","","276.00","207.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","138.00","50","","1.00","1.00","1.00","1 through 10","133.58","227.7","percent of total billed charges",""
"Neutrophil Antigen Genotyping - Hna-1","PX-31000789","CDM","81479","CPT","0310","RC","","","","outpatient","","","276.00","207.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","144.90","52.5","","1.00","0.53","1.00","1 through 10","133.58","227.7","percent of total billed charges",""
"New Patient Psych (99201) – Low Level (< 20 Min)","PX-90000094","CDM","99201","CPT","0914","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","134.84","81.72","","135.10","135.10","258.21","21","120.8","134.84","percent of total billed charges",""
"New Pt - Low Level Visit (99201)","PX-51000075","CDM","99201","CPT","0510","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","134.84","81.72","","135.10","135.10","258.21","21","134.84","134.84","percent of total billed charges",""
"Newborn Metabolic Screening","PX-30003332","CDM","S3620","CPT","0300","RC","","","","outpatient","","","255.00","191.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","154.40","60.55","","166.06","166.06","166.06","1 through 10","102","208.39","percent of total billed charges",""
"Nf1/Spred1 Ngs Testing & Copy Number Analysis","PX-30003386","CDM","81479","CPT","0310","RC","","","","both","","","609.00","456.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","484.16","79.5","","0.65","0.65","0.65","1 through 10","188.79","578.55","percent of total billed charges",""
"Nf1/Spred1 Ngs Testing & Copy Number Analysis","PX-30003386","CDM","81479","CPT","0310","RC","","","","both","","","609.00","456.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","324.60","53.3","","0.79","0.79","0.79","1 through 10","188.79","578.55","percent of total billed charges",""
"Nf1/Spred1 Ngs Testing & Copy Number Analysis","PX-30003386","CDM","81479","CPT","0310","RC","","","","outpatient","","","609.00","456.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","304.50","50","","1.00","1.00","1.00","1 through 10","156.55","502.43","percent of total billed charges",""
"Nf1/Spred1 Ngs Testing & Copy Number Analysis","PX-30003386","CDM","81479","CPT","0310","RC","","","","outpatient","","","609.00","456.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","319.73","52.5","","1.00","0.53","1.00","1 through 10","156.55","502.43","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","both","","","2095.00","1571.25","CHAMPVA [160001]","HB BWH TRICARE","1990.25","95","","154.59","154.59","154.59","1 through 10","125.72","1990.25","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","both","","","2095.00","1571.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1665.53","79.5","","1599.18","1072.90","4797.54","28","125.72","1990.25","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","both","","","2095.00","1571.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1116.64","53.3","","1072.90","1072.90","1599.18","14","125.72","1990.25","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","both","","","2095.00","1571.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","649.45","31","","627.89","627.89","627.89","1 through 10","125.72","1990.25","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","both","","","2095.00","1571.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","764.68","36.5","","757.94","542.34","757.94","19","125.72","1990.25","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","both","","","2095.00","1571.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","802.39","38.3","","794.51","670.56","794.51","83","125.72","1990.25","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","both","","","2095.00","1571.25","TRICARE [160005]","HB BWH TRICARE","1990.25","95","","154.59","146.86","154.59","1 through 10","125.72","1990.25","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","both","","","2095.00","1571.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","898.76","42.9","","1624.38","286.50","1624.38","1 through 10","125.72","1990.25","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","both","","","2095.00","1571.25","WELLPOINT [1015]","HB AMC WELLPOINT","1545.69","73.78","","1512.82","1512.82","1512.82","33","125.72","1990.25","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","outpatient","","","2095.00","1571.25","AETNA [1001]","HB AMC AETNA HMO","1462.31","69.8","","1375.66","971.30","1584.96","28","329.62","1712.03","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","outpatient","","","2095.00","1571.25","AETNA [1001]","HB AMC AETNA PPO","1684.38","80.4","","1584.96","971.30","1584.96","1 through 10","329.62","1712.03","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","outpatient","","","2095.00","1571.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1684.38","80.4","","1584.96","1584.96","1584.96","1 through 10","329.62","1712.03","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","outpatient","","","2095.00","1571.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1712.03","81.72","","893.47","893.47","893.47","1 through 10","329.62","1712.03","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","outpatient","","","2095.00","1571.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1712.03","81.72","","1624.38","893.47","1624.38","32","329.62","1712.03","percent of total billed charges",""
"Nfct Agent Hiv Trgt Viral Next-Gnrj Seq Alys Alg","PX-31001171","CDM","0219U","CPT","0310","RC","","","","outpatient","","","8618.00","6463.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4500.32","52.22","","5776.36","4498.57","5776.36","1 through 10","3128.33","7109.85","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","735.00","551.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","584.33","79.5","","561.13","376.46","1293.04","118","139.78","698.25","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","735.00","551.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","391.76","53.3","","561.13","376.46","1293.04","57","139.78","698.25","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","735.00","551.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","565.95","77","","549.01","549.01","549.01","1 through 10","139.78","698.25","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","735.00","551.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","584.33","79.5","","561.13","561.13","561.13","1 through 10","139.78","698.25","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","735.00","551.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","227.85","31","","507.69","507.69","1015.38","13","139.78","698.25","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","735.00","551.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","268.28","36.5","","265.95","226.02","1329.75","287","139.78","698.25","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","735.00","551.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","281.51","38.3","","624.34","278.78","1873.02","888","139.78","698.25","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","735.00","551.25","MOLINA [1014]","HB BWH MOLINA","257.25","35","","282.98","282.98","282.98","1 through 10","139.78","698.25","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","735.00","551.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","565.95","77","","1281.54","178.29","1281.54","1 through 10","139.78","698.25","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","735.00","551.25","TRICARE [160005]","HB BWH TRICARE","698.25","95","","171.87","163.28","1643.00","1 through 10","139.78","698.25","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","735.00","551.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.32","42.9","","313.51","313.51","1313.41","1 through 10","139.78","698.25","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","735.00","551.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.32","42.9","","722.43","722.43","722.43","1 through 10","139.78","698.25","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","735.00","551.25","WELLPOINT [1015]","HB AMC WELLPOINT","542.28","73.78","","1223.21","530.83","1643.00","105","139.78","698.25","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","AETNA [1001]","HB AMC AETNA HMO","513.03","69.8","","556.14","340.81","1112.31","224","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","AETNA [1001]","HB AMC AETNA PPO","590.94","80.4","","860.93","373.61","1281.54","41","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","410.87","55.9","","373.61","373.61","373.61","1 through 10","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","384.11","52.26","","1016.69","414.95","1016.69","1 through 10","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","52.5","","467.02","406.41","1076.17","26","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","367.50","50","","826.43","373.61","1621.64","550","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","385.88","52.5","","869.15","392.15","2607.45","208","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","459.38","62.5","","467.02","467.02","1313.42","12","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","52.5","","732.78","318.00","903.65","1 through 10","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","404.25","55","","713.00","410.69","1643.00","76","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","590.94","80.4","","1281.54","556.14","1313.42","1 through 10","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","385.88","52.5","","698.28","698.28","698.28","1 through 10","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","600.64","81.72","","722.43","313.51","1621.64","12","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","600.64","81.72","","569.97","313.51","1313.41","182","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","459.38","62.5","","1033.45","1033.45","1033.45","1 through 10","266.81","606.38","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","735.00","551.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","404.25","55","","910.22","910.22","910.22","1 through 10","266.81","606.38","percent of total billed charges",""
"Nfct Ds Chrnc Hcv 6 Biochem Assay Srm Alg Lvr","PX-30003536","CDM","81596","CPT","0300","RC","","","","both","","","602.00","451.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","478.59","79.5","","459.61","308.35","459.61","1 through 10","70.75","571.9","percent of total billed charges",""
"Nfct Ds Chrnc Hcv 6 Biochem Assay Srm Alg Lvr","PX-30003536","CDM","81596","CPT","0300","RC","","","","both","","","602.00","451.50","WELLPOINT [1015]","HB AMC WELLPOINT","444.16","73.78","","434.79","434.79","1018.79","1 through 10","70.75","571.9","percent of total billed charges",""
"Nfct Ds Chrnc Hcv 6 Biochem Assay Srm Alg Lvr","PX-30003536","CDM","81596","CPT","0300","RC","","","","outpatient","","","602.00","451.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","314.61","52.26","","361.38","361.38","361.38","1 through 10","129.94","491.95","percent of total billed charges",""
"Nfct Ds Chrnc Hcv 6 Biochem Assay Srm Alg Lvr","PX-30003536","CDM","81596","CPT","0300","RC","","","","outpatient","","","602.00","451.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","491.95","81.72","","466.85","466.85","466.86","1 through 10","129.94","491.95","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","334.60","70","","478.00","478.00","478.00","1 through 10","103.06","454.1","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","380.01","79.5","","376.19","252.38","376.19","70","103.06","454.1","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","254.77","53.3","","376.19","252.38","482.78","43","103.06","454.1","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","167.30","35","","139.78","139.78","139.78","1 through 10","103.06","454.1","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","368.06","77","","368.06","368.06","368.06","1 through 10","103.06","454.1","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","310.70","65","","621.40","22.96","621.40","1 through 10","103.06","454.1","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","380.01","79.5","","299.28","299.28","299.28","1 through 10","103.06","454.1","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","148.18","31","","147.70","147.70","443.10","14","103.06","454.1","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","174.47","36.5","","178.29","151.53","346.08","73","103.06","454.1","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","183.07","38.3","","186.90","181.64","186.90","166","103.06","454.1","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","TRICARE [160005]","HB BWH TRICARE","454.10","95","","171.87","21.87","300.00","1 through 10","103.06","454.1","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.06","42.9","","382.11","210.18","382.11","1 through 10","103.06","454.1","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","AETNA [1001]","HB AMC AETNA HMO","333.64","69.8","","228.48","228.48","372.84","136","173.51","394.35","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","AETNA [1001]","HB AMC AETNA PPO","384.31","80.4","","372.84","250.47","372.84","1 through 10","173.51","394.35","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","289.43","60.55","","256.73","256.73","256.73","133","173.51","394.35","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","249.80","52.26","","295.79","295.79","295.79","1 through 10","173.51","394.35","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","249.61","52.22","","256.73","256.73","256.73","241","173.51","394.35","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","250.95","52.5","","636.17","478.00","661.85","1 through 10","173.51","394.35","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","239.00","50","","478.00","478.00","1434.00","114","173.51","394.35","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","250.95","52.5","","478.00","478.00","478.00","34","173.51","394.35","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","298.75","62.5","","478.00","478.00","478.00","1 through 10","173.51","394.35","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","250.95","52.5","","556.30","556.30","556.30","1 through 10","173.51","394.35","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","262.90","55","","478.00","478.00","478.00","20","173.51","394.35","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","390.62","81.72","","478.00","478.00","478.00","1 through 10","173.51","394.35","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","390.62","81.72","","382.11","210.18","382.11","21","173.51","394.35","percent of total billed charges",""
"Nicotine (Alkaloids Not Otherwise Specified)","PX-30002960","CDM","80323","CPT","0301","RC","","","","both","","","358.00","268.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","257.04","71.8","","694.00","694.00","694.00","1 through 10","110.34","340.1","percent of total billed charges",""
"Nicotine (Alkaloids Not Otherwise Specified)","PX-30002960","CDM","80323","CPT","0301","RC","","","","both","","","358.00","268.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","234.85","65.6","","234.92","234.92","234.92","1 through 10","110.34","340.1","percent of total billed charges",""
"Nicotine (Alkaloids Not Otherwise Specified)","PX-30002960","CDM","80323","CPT","0301","RC","","","","both","","","358.00","268.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","232.70","65","","225.55","102.70","225.55","1 through 10","110.34","340.1","percent of total billed charges",""
"Nicotine (Alkaloids Not Otherwise Specified)","PX-30002960","CDM","80323","CPT","0301","RC","","","","both","","","358.00","268.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","250.60","70","","336.00","249.84","347.00","1 through 10","110.34","340.1","percent of total billed charges",""
"Nicotine (Alkaloids Not Otherwise Specified)","PX-30002960","CDM","80323","CPT","0301","RC","","","","both","","","358.00","268.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","284.61","79.5","","250.89","250.89","250.89","1 through 10","110.34","340.1","percent of total billed charges",""
"Nicotine (Alkaloids Not Otherwise Specified)","PX-30002960","CDM","80323","CPT","0301","RC","","","","outpatient","","","358.00","268.50","AETNA [1001]","HB AMC AETNA PPO","287.83","80.4","","270.66","270.66","270.66","1 through 10","59.12","438.27","percent of total billed charges",""
"Nicotine (Alkaloids Not Otherwise Specified)","PX-30002960","CDM","80323","CPT","0301","RC","","","","outpatient","","","358.00","268.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","292.56","81.72","","258.75","258.75","258.75","1 through 10","59.12","438.27","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","both","","","158.00","118.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","18.40","10.42","26.49","1 through 10","45.67","150.1","other","OPPS APC"
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","both","","","158.00","118.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.61","79.5","","120.41","120.41","120.41","33","45.67","150.1","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","both","","","158.00","118.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","84.21","53.3","","80.78","80.78","120.41","11","45.67","150.1","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","both","","","158.00","118.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","121.66","77","","117.81","117.81","117.81","1 through 10","45.67","150.1","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","both","","","158.00","118.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","102.70","65","","99.45","99.45","99.45","1 through 10","45.67","150.1","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","both","","","158.00","118.50","MEDICARE [2001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","87.54","43.77","93.22","1 through 10","45.67","150.1","other","OPPS APC"
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","both","","","158.00","118.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.98","31","","47.28","47.28","47.28","1 through 10","45.67","150.1","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","both","","","158.00","118.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.67","36.5","","57.07","48.50","285.35","37","45.67","150.1","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","both","","","158.00","118.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.51","38.3","","59.82","59.82","116.28","78","45.67","150.1","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","both","","","158.00","118.50","WELLPOINT [1015]","HB AMC WELLPOINT","116.57","73.78","","113.91","113.91","266.91","56","45.67","150.1","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","outpatient","","","158.00","118.50","AETNA [1001]","HB AMC AETNA HMO","110.28","69.8","","103.58","73.13","207.16","29","73.79","339.09","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","outpatient","","","158.00","118.50","AETNA [1001]","HB AMC AETNA PPO","127.03","80.4","","119.34","119.34","160.34","1 through 10","73.79","339.09","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","outpatient","","","158.00","118.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","129.12","81.72","","67.27","67.27","67.27","1 through 10","73.79","339.09","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","outpatient","","","158.00","118.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","129.12","81.72","","122.31","122.31","122.31","36","73.79","339.09","percent of total billed charges",""
"Njx Aa&/Strd Plantar Common Digital Nerves","PX-76001517","CDM","64455","CPT","0761","RC","","","","both","","","703.00","527.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","1 through 10","217.93","609.18","other","OPPS APC"
"Njx Aa&/Strd Plantar Common Digital Nerves","PX-76001517","CDM","64455","CPT","0761","RC","","","","both","","","703.00","527.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","269.25","38.3","","266.66","266.66","266.66","1 through 10","217.93","609.18","percent of total billed charges",""
"Njx Aa&/Strd Plantar Common Digital Nerves","PX-76001517","CDM","64455","CPT","0761","RC","","","","outpatient","","","703.00","527.25","AETNA [1001]","HB AMC AETNA HMO","490.69","69.8","","326.00","326.00","326.00","1 through 10","247.48","700.33","percent of total billed charges",""
"Njx Aa&/Strd Plantar Common Digital Nerves","PX-98300448","CDM","64455","CPT","0983","RC","","","","both","","","180.00","135.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","1 through 10","55.8","609.18","other","OPPS APC"
"Njx Aa&/Strd Plantar Common Digital Nerves","PX-98300448","CDM","64455","CPT","0983","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.94","38.3","","266.66","266.66","266.66","1 through 10","55.8","609.18","percent of total billed charges",""
"Njx Aa&/Strd Plantar Common Digital Nerves","PX-98300448","CDM","64455","CPT","0983","RC","","","","outpatient","","","180.00","135.00","AETNA [1001]","HB AMC AETNA HMO","125.64","69.8","","326.00","326.00","326.00","1 through 10","100.62","700.33","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Cervical/Thoracic 1 Level","PX-76001520","CDM","64479","CPT","0761","RC","","","","both","","","2378.00","1783.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1036.13","1036.13","1036.13","1 through 10","737.18","1890.51","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Cervical/Thoracic 1 Level","PX-98300449","CDM","64479","CPT","0983","RC","","","","both","","","1232.00","924.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1036.13","1036.13","1036.13","1 through 10","381.92","1627.62","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","2378.00","1783.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1088.88","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1088.73","1087.93","1088.82","1 through 10","737.18","1890.51","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","2378.00","1783.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1890.51","79.5","","1688.21","1036.12","1688.21","1 through 10","737.18","1890.51","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","2378.00","1783.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1267.47","53.3","","1814.82","1805.08","1814.82","1 through 10","737.18","1890.51","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","2378.00","1783.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1040.35","1040.35","1040.35","1 through 10","737.18","1890.51","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","2378.00","1783.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","910.77","38.3","","853.06","853.06","853.06","1 through 10","737.18","1890.51","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","2378.00","1783.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","974.91","974.91","974.91","1 through 10","737.18","1890.51","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","2378.00","1783.50","TRICARE [160005]","HB BWH TRICARE","1004.41","","APC Price ($1,057.27). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1896.67","1896.67","1896.67","1 through 10","737.18","1890.51","other","Tricare OPPS"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","2378.00","1783.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1044.02","1036.53","1558.61","25","737.18","1890.51","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","AETNA [1001]","HB AMC AETNA HMO","1659.84","69.8","","1561.16","1102.27","1561.16","1 through 10","764.84","2384.07","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1797.37","1797.37","1797.37","1 through 10","764.84","2384.07","other","Multiple Surgery"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-98300451","CDM","64483","CPT","0983","RC","","","","both","","","1118.00","838.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1088.88","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1088.73","1087.93","1088.82","1 through 10","346.58","1627.62","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-98300451","CDM","64483","CPT","0983","RC","","","","both","","","1118.00","838.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","888.81","79.5","","1688.21","1036.12","1688.21","1 through 10","346.58","1627.62","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-98300451","CDM","64483","CPT","0983","RC","","","","both","","","1118.00","838.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","595.89","53.3","","1814.82","1805.08","1814.82","1 through 10","346.58","1627.62","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-98300451","CDM","64483","CPT","0983","RC","","","","both","","","1118.00","838.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1040.35","1040.35","1040.35","1 through 10","346.58","1627.62","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-98300451","CDM","64483","CPT","0983","RC","","","","both","","","1118.00","838.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","428.19","38.3","","853.06","853.06","853.06","1 through 10","346.58","1627.62","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-98300451","CDM","64483","CPT","0983","RC","","","","both","","","1118.00","838.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","974.91","974.91","974.91","1 through 10","346.58","1627.62","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-98300451","CDM","64483","CPT","0983","RC","","","","both","","","1118.00","838.50","TRICARE [160005]","HB BWH TRICARE","1004.41","","APC Price ($1,057.27). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1896.67","1896.67","1896.67","1 through 10","346.58","1627.62","other","Tricare OPPS"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-98300451","CDM","64483","CPT","0983","RC","","","","both","","","1118.00","838.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1044.02","1036.53","1558.61","25","346.58","1627.62","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-98300451","CDM","64483","CPT","0983","RC","","","","outpatient","","","1118.00","838.50","AETNA [1001]","HB AMC AETNA HMO","780.36","69.8","","1561.16","1102.27","1561.16","1 through 10","497.05","2384.07","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-98300451","CDM","64483","CPT","0983","RC","","","","outpatient","","","1118.00","838.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1797.37","1797.37","1797.37","1 through 10","497.05","2384.07","other","Multiple Surgery"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","both","","","2378.00","1783.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1088.88","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1539.18","1535.48","1638.57","1 through 10","1004.41","1321.46","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","both","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1560.54","1560.54","1560.54","1 through 10","1004.41","1321.46","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","both","","","2378.00","1783.50","MEDICARE [2001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1585.91","1492.21","1585.91","1 through 10","1004.41","1321.46","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","both","","","2378.00","1783.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1554.19","1554.19","1554.19","1 through 10","1004.41","1321.46","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","outpatient","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2684.27","2684.27","2684.27","1 through 10","1311.96","4434.37","other","ASC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","outpatient","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3071.30","3071.30","3071.30","1 through 10","1311.96","4434.37","other","ASC "
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-98300451","CDM","64483","CPT","0983","RC","","","50","both","","","1118.00","838.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1088.88","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1539.18","1535.48","1638.57","1 through 10","1004.41","1321.46","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-98300451","CDM","64483","CPT","0983","RC","","","50","both","","","1118.00","838.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1560.54","1560.54","1560.54","1 through 10","1004.41","1321.46","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-98300451","CDM","64483","CPT","0983","RC","","","50","both","","","1118.00","838.50","MEDICARE [2001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1585.91","1492.21","1585.91","1 through 10","1004.41","1321.46","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-98300451","CDM","64483","CPT","0983","RC","","","50","both","","","1118.00","838.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1554.19","1554.19","1554.19","1 through 10","1004.41","1321.46","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl","PX-76001529","CDM","64484","CPT","0761","RC","","","","both","","","455.00","341.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","361.73","79.5","","2071.23","2071.23","2071.23","1 through 10","141.05","1627.62","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl","PX-76001529","CDM","64484","CPT","0761","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","298.56","298.56","298.56","1 through 10","87.19","371.83","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl","PX-98300452","CDM","64484","CPT","0983","RC","","","","both","","","278.00","208.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","221.01","79.5","","2071.23","2071.23","2071.23","1 through 10","86.18","1627.62","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl","PX-98300452","CDM","64484","CPT","0983","RC","","","","outpatient","","","278.00","208.50","AETNA [1001]","HB AMC AETNA HMO","194.04","69.8","","298.56","298.56","298.56","1 through 10","155.4","227.18","percent of total billed charges",""
"Njx Cholangio Prq W/Img Gid Rs&I Existing Access","PX-36000374","CDM","47531","CPT","0361","RC","","","","both","","","585.00","438.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4316.26","","APC Price ($4,190.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1230.62","794.72","1230.62","1 through 10","181.35","5238.18","other","OPPS APC"
"Njx Cholangio Prq W/Img Gid Rs&I Existing Access","PX-36000374","CDM","47531","CPT","0361","RC","","","","both","","","585.00","438.75","MEDICARE [2001]","HB BWH MEDICARE","4190.55","","APC Price ($4,190.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","4190.97","4190.97","1 through 10","181.35","5238.18","other","OPPS APC"
"Njx Cholangio Prq W/Img Gid Rs&I Existing Access","PX-36000374","CDM","47531","CPT","0361","RC","","","","both","","","585.00","438.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","213.53","36.5","","211.49","211.49","211.49","1 through 10","181.35","5238.18","percent of total billed charges",""
"Njx Cholangio Prq W/Img Gid Rs&I Existing Access","PX-36000374","CDM","47531","CPT","0361","RC","","","","both","","","585.00","438.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","4190.55","","APC Price ($4,190.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4107.15","4107.15","4107.15","1 through 10","181.35","5238.18","other","OPPS APC"
"Njx Cholangio Prq W/Img Gid Rs&I Existing Access","PX-36000374","CDM","47531","CPT","0361","RC","","","","both","","","585.00","438.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4106.74","","APC Price ($4,190.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4107.16","4107.16","4115.06","1 through 10","181.35","5238.18","other","OPPS APC"
"Njx Cholangio Prq W/Img Gid Rs&I Existing Access","PX-36000374","CDM","47531","CPT","0361","RC","","","","outpatient","","","585.00","438.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3370.43","","Case rate ($3,370.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6771.19","6771.19","6771.19","1 through 10","305.72","11288.24","other","ASC"
"Njx Drg C-Cathj Nslctv P-Art Angiography","PX-48000143","CDM","93568","CPT","0481","RC","","","","outpatient","","","1185.00","888.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","968.38","81.72","","918.51","918.51","918.51","1 through 10","619.28","968.38","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","2378.00","1783.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","846.26","846.26","847.16","1 through 10","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","742.69","809.25","1 through 10","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","2378.00","1783.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1890.51","79.5","","1814.82","1217.57","1814.82","1 through 10","737.18","1890.51","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","2378.00","1783.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1267.47","53.3","","1814.82","1808.01","1814.82","1 through 10","737.18","1890.51","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","2378.00","1783.50","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","30","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","2378.00","1783.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","867.97","36.5","","834.77","731.00","860.14","1 through 10","737.18","1890.51","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","2378.00","1783.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","910.77","38.3","","901.65","901.65","901.65","11","737.18","1890.51","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","2378.00","1783.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","739.67","739.67","739.67","1 through 10","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","2378.00","1783.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","807.61","739.67","813.47","16","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","AETNA [1001]","HB AMC AETNA HMO","1659.84","69.8","","1102.27","1102.27","1561.16","1 through 10","598.81","2384.07","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","AETNA [1001]","HB AMC AETNA PPO","1911.91","80.4","","1798.68","1798.68","1798.68","1 through 10","598.81","2384.07","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1375.70","1375.70","1401.04","1 through 10","598.81","2384.07","other","ASC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1587.30","1587.30","1603.05","18","598.81","2384.07","other","ASC "
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1473.07","1473.07","1473.07","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1389.24","1389.24","1389.24","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1461.10","1461.10","1461.10","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1736.55","1736.55","1736.55","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1532.95","1532.95","1532.95","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1943.30","81.72","","1843.42","1843.42","1843.42","1 through 10","598.81","2384.07","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","846.26","846.26","847.16","1 through 10","172.98","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","742.69","809.25","1 through 10","172.98","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","443.61","79.5","","1814.82","1217.57","1814.82","1 through 10","172.98","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","297.41","53.3","","1814.82","1808.01","1814.82","1 through 10","172.98","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","30","172.98","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","203.67","36.5","","834.77","731.00","860.14","1 through 10","172.98","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","213.71","38.3","","901.65","901.65","901.65","11","172.98","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","739.67","739.67","739.67","1 through 10","172.98","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","807.61","739.67","813.47","16","172.98","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","AETNA [1001]","HB AMC AETNA HMO","389.48","69.8","","1102.27","1102.27","1561.16","1 through 10","239.38","2384.07","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","AETNA [1001]","HB AMC AETNA PPO","448.63","80.4","","1798.68","1798.68","1798.68","1 through 10","239.38","2384.07","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1473.07","1473.07","1473.07","1 through 10","239.38","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1389.24","1389.24","1389.24","1 through 10","239.38","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1461.10","1461.10","1461.10","1 through 10","239.38","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1736.55","1736.55","1736.55","1 through 10","239.38","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1532.95","1532.95","1532.95","1 through 10","239.38","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","456.00","81.72","","1843.42","1843.42","1843.42","1 through 10","239.38","2384.07","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","847.06","846.26","847.16","19","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","809.25","809.25","48","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1890.51","79.5","","1814.82","1217.57","1814.82","1 through 10","737.18","1890.51","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1267.47","53.3","","1814.82","1217.57","1814.82","1 through 10","737.18","1890.51","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","739.67","809.25","13","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","810.90","810.90","810.90","1 through 10","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","HUMANA [1012]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","810.96","810.90","810.96","1 through 10","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1545.70","65","","1498.90","19.18","1498.90","1 through 10","737.18","1890.51","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","298","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","867.97","36.5","","860.14","731.00","860.14","1 through 10","737.18","1890.51","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","910.77","38.3","","901.65","876.28","901.65","38","737.18","1890.51","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","805.96","739.67","805.96","1 through 10","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","MOLINA [1014]","HB BWH MOLINA","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1631.66","1631.66","1631.66","1 through 10","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1831.06","77","","1798.68","673.17","1814.82","1 through 10","737.18","1890.51","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","TRICARE [160005]","HB BWH TRICARE","781.29","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","781.29","781.29","822.41","1 through 10","737.18","1890.51","other","Tricare OPPS"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.76","807.46","2440.48","17","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","2378.00","1783.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","807.61","747.58","813.87","65","737.18","1890.51","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","AETNA [1001]","HB AMC AETNA HMO","1659.84","69.8","","1561.16","1102.27","3597.36","1 through 10","598.81","2384.07","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","AETNA [1001]","HB AMC AETNA PPO","1911.91","80.4","","1798.68","1208.34","1798.68","1 through 10","598.81","2384.07","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1375.70","1375.70","1401.04","37","598.81","2384.07","other","ASC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1242.74","52.26","","1587.30","1587.30","1587.30","1 through 10","598.81","2384.07","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1587.30","1587.30","1603.05","52","598.81","2384.07","other","ASC "
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1532.95","1532.95","1532.95","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1389.24","1335.35","2670.70","37","598.81","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1461.10","1461.10","2814.40","16","598.81","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1532.95","1532.95","1532.95","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","2378.00","1783.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1943.30","81.72","","1843.42","1843.42","1843.42","18","598.81","2384.07","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","847.06","846.26","847.16","19","159.96","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","809.25","809.25","48","159.96","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","410.22","79.5","","1814.82","1217.57","1814.82","1 through 10","159.96","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","275.03","53.3","","1814.82","1217.57","1814.82","1 through 10","159.96","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","739.67","809.25","13","159.96","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","810.90","810.90","810.90","1 through 10","159.96","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","HUMANA [1012]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","810.96","810.90","810.96","1 through 10","159.96","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","335.40","65","","1498.90","19.18","1498.90","1 through 10","159.96","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","298","159.96","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","188.34","36.5","","860.14","731.00","860.14","1 through 10","159.96","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","197.63","38.3","","901.65","876.28","901.65","38","159.96","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","805.96","739.67","805.96","1 through 10","159.96","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MOLINA [1014]","HB BWH MOLINA","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1631.66","1631.66","1631.66","1 through 10","159.96","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","397.32","77","","1798.68","673.17","1814.82","1 through 10","159.96","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","TRICARE [160005]","HB BWH TRICARE","781.29","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","781.29","781.29","822.41","1 through 10","159.96","1627.62","other","Tricare OPPS"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.76","807.46","2440.48","17","159.96","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","807.61","747.58","813.87","65","159.96","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","AETNA [1001]","HB AMC AETNA HMO","360.17","69.8","","1561.16","1102.27","3597.36","1 through 10","221.36","2384.07","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","AETNA [1001]","HB AMC AETNA PPO","414.86","80.4","","1798.68","1208.34","1798.68","1 through 10","221.36","2384.07","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1532.95","1532.95","1532.95","1 through 10","221.36","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1389.24","1335.35","2670.70","37","221.36","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1461.10","1461.10","2814.40","16","221.36","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1532.95","1532.95","1532.95","1 through 10","221.36","2384.07","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","421.68","81.72","","1843.42","1843.42","1843.42","18","221.36","2384.07","percent of total billed charges",""
"Njx Px Antegrde Nfrosgrm &/Urtrgrm Exstng Acess","PX-76002183","CDM","50431","CPT","0761","RC","","","","both","","","496.00","372.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","776.73","","APC Price ($792.58). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","784.31","776.81","784.71","1 through 10","153.76","990.73","other","OPPS APC"
"Njx W/Plmnt for Cont Med Dlvry Dx/Ther Sbst Cont Inf/Bolus Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002396","CDM","62327","CPT","0761","RC","","","","both","","","2378.00","1783.50","MEDICARE [2001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","994.81","994.81","994.81","1 through 10","737.18","1890.51","other","OPPS APC"
"Njx W/Plmnt for Cont Med Dlvry Dx/Ther Sbst Cont Inf/Bolus Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301331","CDM","62327","CPT","0983","RC","","","","both","","","468.00","351.00","MEDICARE [2001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","994.81","994.81","994.81","1 through 10","145.08","1627.62","other","OPPS APC"
"Nkx2.1 Gene Deletions","PX-31000928","CDM","81479","CPT","0310","RC","","","","both","","","638.00","478.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","507.21","79.5","","0.65","0.65","0.65","1 through 10","197.78","606.1","percent of total billed charges",""
"Nkx2.1 Gene Deletions","PX-31000928","CDM","81479","CPT","0310","RC","","","","both","","","638.00","478.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","340.05","53.3","","0.79","0.79","0.79","1 through 10","197.78","606.1","percent of total billed charges",""
"Nkx2.1 Gene Deletions","PX-31000928","CDM","81479","CPT","0310","RC","","","","outpatient","","","638.00","478.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","319.00","50","","1.00","1.00","1.00","1 through 10","156.55","526.35","percent of total billed charges",""
"Nkx2.1 Gene Deletions","PX-31000928","CDM","81479","CPT","0310","RC","","","","outpatient","","","638.00","478.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","334.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","526.35","percent of total billed charges",""
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2578.00","1933.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","469.56","469.56","1 through 10","453.34","2049.51","other","OPPS APC"
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2578.00","1933.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2049.51","79.5","","1967.50","1967.50","1967.50","1 through 10","453.34","2049.51","percent of total billed charges",""
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2578.00","1933.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1374.07","53.3","","1320.00","1320.00","1320.00","1 through 10","453.34","2049.51","percent of total billed charges",""
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2578.00","1933.50","ELDER SERVICES [1037]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","441.15","441.15","441.15","1 through 10","453.34","2049.51","other","OPPS APC"
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2578.00","1933.50","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","954.40","46","453.34","2049.51","other","OPPS APC"
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2578.00","1933.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","987.37","38.3","","977.50","950.00","977.50","1 through 10","453.34","2049.51","percent of total billed charges",""
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2578.00","1933.50","TRICARE [160005]","HB BWH TRICARE","453.34","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","477.20","477.20","477.20","1 through 10","453.34","2049.51","other","Tricare OPPS"
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2578.00","1933.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","470.66","467.66","472.66","1 through 10","453.34","2049.51","other","OPPS APC"
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","outpatient","","","2578.00","1933.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2106.74","81.72","","1998.50","1007.64","1998.50","1 through 10","727.63","2106.74","percent of total billed charges",""
"NM Bone Marrow Wb","PX-34000010","CDM","78104","CPT","0341","RC","","","","both","","","1922.00","1441.50","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","1 through 10","453.34","1527.99","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1901.00","1425.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","442.95","442.95","469.56","1 through 10","453.34","1511.3","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1901.00","1425.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1511.30","79.5","","1450.44","973.10","1450.44","1 through 10","453.34","1511.3","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1901.00","1425.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1013.23","53.3","","973.10","973.10","973.10","1 through 10","453.34","1511.3","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1901.00","1425.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","469.56","469.56","1 through 10","453.34","1511.3","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1901.00","1425.75","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","41","453.34","1511.3","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1901.00","1425.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","589.31","31","","569.49","569.49","569.49","1 through 10","453.34","1511.3","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1901.00","1425.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","693.87","36.5","","584.23","578.70","667.17","1 through 10","453.34","1511.3","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1901.00","1425.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","728.08","38.3","","720.61","720.61","720.61","1 through 10","453.34","1511.3","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1901.00","1425.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","470.86","470.86","470.86","1 through 10","453.34","1511.3","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1901.00","1425.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","467.66","441.15","472.66","19","453.34","1511.3","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","outpatient","","","1901.00","1425.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1553.50","81.72","","1473.29","1473.29","1473.29","1 through 10","727.63","1587.17","percent of total billed charges",""
"NM Esophageal Motility","PX-34000026","CDM","78258","CPT","0341","RC","","","","both","","","1819.00","1364.25","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","1 through 10","453.34","1446.11","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","442.95","469.56","1 through 10","453.34","1737.87","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1569.55","71.8","","1522.16","1522.16","1522.16","1 through 10","453.34","1737.87","percent of total billed charges",""
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","596.44","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","225.00","225.00","225.00","1 through 10","453.34","1737.87","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1737.87","79.5","","1668.44","1668.44","1668.44","1 through 10","453.34","1737.87","percent of total billed charges",""
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1165.14","53.3","","1119.36","1119.36","1119.36","1 through 10","453.34","1737.87","percent of total billed charges",""
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","469.56","469.56","1 through 10","453.34","1737.87","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","HUMANA [1012]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","471.47","471.47","471.47","1 through 10","453.34","1737.87","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","450.15","477.20","27","453.34","1737.87","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","837.24","38.3","","828.92","805.60","828.92","12","453.34","1737.87","percent of total billed charges",""
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","467.66","444.15","467.66","1 through 10","453.34","1737.87","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.66","469.56","472.66","1 through 10","453.34","1737.87","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","937.79","42.9","","1694.73","1694.73","1694.73","1 through 10","453.34","1737.87","percent of total billed charges",""
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","2186.00","1639.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.66","467.66","472.66","14","453.34","1737.87","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","outpatient","","","2186.00","1639.50","AETNA [1001]","HB AMC AETNA HMO","1525.83","69.8","","1435.24","1435.24","1435.24","1 through 10","727.63","1786.4","percent of total billed charges",""
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","outpatient","","","2186.00","1639.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1142.40","52.26","","727.63","727.63","727.63","1 through 10","727.63","1786.4","percent of total billed charges",""
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","outpatient","","","2186.00","1639.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1786.40","81.72","","2120.00","1056.94","2120.00","1 through 10","727.63","1786.4","percent of total billed charges",""
"NM Hepatobiliary System Imaging","PX-34000022","CDM","78226","CPT","0341","RC","","","","both","","","2060.00","1545.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1637.70","79.5","","1572.43","1572.43","1572.43","1 through 10","453.34","1637.7","percent of total billed charges",""
"NM Hepatobiliary System Imaging","PX-34000022","CDM","78226","CPT","0341","RC","","","","both","","","2060.00","1545.00","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","1 through 10","453.34","1637.7","other","OPPS APC"
"NM Hepatobiliary System Imaging","PX-34000022","CDM","78226","CPT","0341","RC","","","","both","","","2060.00","1545.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","788.98","38.3","","781.22","781.22","781.22","1 through 10","453.34","1637.7","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","3220.00","2415.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.00","629.00","629.00","1 through 10","607.27","2559.9","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","3220.00","2415.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2559.90","79.5","","2457.80","2457.80","2457.80","1 through 10","607.27","2559.9","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","3220.00","2415.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1716.26","53.3","","1648.94","1648.94","1648.94","1 through 10","607.27","2559.9","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","3220.00","2415.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.00","629.00","629.00","1 through 10","607.27","2559.9","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","3220.00","2415.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.00","629.00","629.00","1 through 10","607.27","2559.9","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","3220.00","2415.00","MEDICARE [2001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","589.92","639.23","1 through 10","607.27","2559.9","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","3220.00","2415.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1175.30","36.5","","1164.88","989.99","1164.88","1 through 10","607.27","2559.9","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","3220.00","2415.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1233.26","38.3","","1221.09","1186.74","1221.09","1 through 10","607.27","2559.9","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","outpatient","","","3220.00","2415.00","AETNA [1001]","HB AMC AETNA HMO","2247.56","69.8","","2114.27","2114.27","2114.27","1 through 10","937.64","2631.38","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","outpatient","","","3220.00","2415.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2631.38","81.72","","2496.53","2496.53","2496.53","1 through 10","937.64","2631.38","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1525.53","1525.53","1525.53","20","1472.82","4057.68","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3348.22","65.6","","2170.48","2170.48","2170.48","1 through 10","1472.82","4057.68","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4057.68","79.5","","3895.65","2613.60","13795.65","13","1472.82","4057.68","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2720.43","53.3","","2613.60","2613.60","3895.65","1 through 10","1472.82","4057.68","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1524.98","1519.33","1525.53","1 through 10","1472.82","4057.68","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","FALLON HEALTH [1008]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1525.33","1525.33","1525.33","1 through 10","1472.82","4057.68","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","3930.08","77","","3811.50","3811.50","3811.50","1 through 10","1472.82","4057.68","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","HUMANA [1012]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4950.00","4950.00","4950.00","1 through 10","1472.82","4057.68","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","MEDICARE [2001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1550.34","1549.78","1550.34","216","1472.82","4057.68","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1862.96","36.5","","1846.35","1791.90","1846.35","1 through 10","1472.82","4057.68","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1954.83","38.3","","1935.45","1935.45","5806.35","37","1472.82","4057.68","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1522.53","1522.33","1522.53","11","1472.82","4057.68","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","MOLINA [1014]","HB BWH MOLINA","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3099.56","3075.87","3099.56","1 through 10","1472.82","4057.68","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","1472.82","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1550.34","1550.34","1550.34","1 through 10","1472.82","4057.68","other","Tricare OPPS"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4557.99","1520.83","4572.99","12","1472.82","4057.68","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5104.00","3828.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1522.34","1519.33","1528.07","48","1472.82","4057.68","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","outpatient","","","5104.00","3828.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2667.35","52.26","","5153.92","5153.92","5153.92","1 through 10","2667.35","5519.92","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","outpatient","","","5104.00","3828.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","4170.99","81.72","","3957.03","3957.03","3957.03","1 through 10","2667.35","5519.92","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","outpatient","","","5104.00","3828.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4170.99","81.72","","3957.03","3957.03","3957.03","1 through 10","2667.35","5519.92","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","outpatient","","","5104.00","3828.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4170.99","81.72","","3957.03","3675.85","3957.03","11","2667.35","5519.92","percent of total billed charges",""
"NM Kidney Scan W/Flow & Function","PX-34000104","CDM","78707","CPT","0341","RC","","","","both","","","1771.00","1328.25","MEDICARE [2001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","589.92","1917.69","1 through 10","549.01","1407.95","other","OPPS APC"
"NM Kidney Scan W/Flow & Function","PX-34000104","CDM","78707","CPT","0341","RC","","","","both","","","1771.00","1328.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","678.29","38.3","","671.35","671.35","671.35","1 through 10","549.01","1407.95","percent of total billed charges",""
"NM Kidney Scan W/Flow & Function","PX-34000104","CDM","78707","CPT","0341","RC","","","","both","","","1771.00","1328.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.65","629.65","629.65","1 through 10","549.01","1407.95","other","OPPS APC"
"NM Kidney Scan W/Flow & Function","PX-34000104","CDM","78707","CPT","0341","RC","","","","outpatient","","","1771.00","1328.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1447.26","81.72","","1372.57","1372.57","1372.57","1 through 10","925.52","2045.28","percent of total billed charges",""
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","2200.00","1650.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.00","382.46","629.00","1 through 10","607.27","1749","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","2200.00","1650.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1749.00","79.5","","1678.67","1536.95","1678.67","1 through 10","607.27","1749","percent of total billed charges",""
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","2200.00","1650.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1172.60","53.3","","1126.22","1126.22","1126.22","1 through 10","607.27","1749","percent of total billed charges",""
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","2200.00","1650.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.00","629.00","629.00","1 through 10","607.27","1749","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","2200.00","1650.00","MEDICARE [2001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","589.92","639.23","28","607.27","1749","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","2200.00","1650.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","842.60","38.3","","834.00","810.54","834.00","1 through 10","607.27","1749","percent of total billed charges",""
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","2200.00","1650.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","626.38","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","629.25","579.62","631.45","1 through 10","607.27","1749","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","2200.00","1650.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","626.38","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","629.00","580.48","629.00","1 through 10","607.27","1749","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","outpatient","","","2200.00","1650.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1797.84","81.72","","937.88","937.88","937.88","1 through 10","937.64","2045.28","percent of total billed charges",""
"NM Lymph System","PX-34000013","CDM","78195","CPT","0341","RC","","","","both","","","2687.00","2015.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.00","629.00","629.00","1 through 10","607.27","2136.17","other","OPPS APC"
"NM Lymph System","PX-34000013","CDM","78195","CPT","0341","RC","","","","both","","","2687.00","2015.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2136.17","79.5","","2050.92","2050.92","2050.92","1 through 10","607.27","2136.17","percent of total billed charges",""
"NM Lymph System","PX-34000013","CDM","78195","CPT","0341","RC","","","","both","","","2687.00","2015.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.00","626.44","629.00","1 through 10","607.27","2136.17","other","OPPS APC"
"NM Lymph System","PX-34000013","CDM","78195","CPT","0341","RC","","","","both","","","2687.00","2015.25","FALLON HEALTH [1008]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1879.35","1879.35","1879.35","1 through 10","607.27","2136.17","other","OPPS APC"
"NM Lymph System","PX-34000013","CDM","78195","CPT","0341","RC","","","","both","","","2687.00","2015.25","MEDICARE [2001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","639.23","639.23","24","607.27","2136.17","other","OPPS APC"
"NM Lymph System","PX-34000013","CDM","78195","CPT","0341","RC","","","","both","","","2687.00","2015.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","980.76","36.5","","972.04","972.04","972.04","1 through 10","607.27","2136.17","percent of total billed charges",""
"NM Lymph System","PX-34000013","CDM","78195","CPT","0341","RC","","","","both","","","2687.00","2015.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1029.12","38.3","","3056.85","3056.85","3056.85","1 through 10","607.27","2136.17","percent of total billed charges",""
"NM Lymph System","PX-34000013","CDM","78195","CPT","0341","RC","","","","both","","","2687.00","2015.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","607.27","","APC Price ($639.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1917.69","1917.69","1917.69","1 through 10","607.27","2136.17","other","Tricare OPPS"
"NM Lymph System","PX-34000013","CDM","78195","CPT","0341","RC","","","","both","","","2687.00","2015.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","626.38","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.65","1893.65","1893.65","1 through 10","607.27","2136.17","other","OPPS APC"
"NM Lymph System","PX-34000013","CDM","78195","CPT","0341","RC","","","","both","","","2687.00","2015.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","626.38","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","626.45","583.13","629.00","1 through 10","607.27","2136.17","other","OPPS APC"
"NM Lymph System","PX-34000013","CDM","78195","CPT","0341","RC","","","","outpatient","","","2687.00","2015.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2195.82","81.72","","2083.24","2083.24","2083.24","1 through 10","937.64","2195.82","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1525.53","1131.99","1525.53","17","1472.82","4249.28","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3741.50","70","","1550.34","1550.34","1550.34","1 through 10","1472.82","4249.28","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4249.28","79.5","","4079.02","2736.62","4079.02","1 through 10","1472.82","4249.28","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2848.89","53.3","","2736.62","2736.62","4079.02","1 through 10","1472.82","4249.28","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1525.53","1525.53","1525.53","1 through 10","1472.82","4249.28","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","HUMANA [1012]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1536.90","1528.64","1536.90","1 through 10","1472.82","4249.28","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","MEDICARE [2001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1550.34","1550.34","1550.34","190","1472.82","4249.28","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1950.93","36.5","","5799.78","1933.26","5799.78","1 through 10","1472.82","4249.28","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2047.14","38.3","","2026.55","1969.54","2026.55","18","1472.82","4249.28","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1522.53","1522.53","1522.53","1 through 10","1472.82","4249.28","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1524.33","1519.33","4562.49","1 through 10","1472.82","4249.28","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1192.09","1192.09","1192.09","1 through 10","1472.82","4249.28","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1521.79","1519.33","1524.34","36","1472.82","4249.28","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","5345.00","4008.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2293.01","42.9","","2278.97","2278.97","2278.97","1 through 10","1472.82","4249.28","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","outpatient","","","5345.00","4008.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4367.93","81.72","","2278.97","2278.97","4143.29","1 through 10","2793.3","5519.92","percent of total billed charges",""
"NM Parathyroid W/ Tomographic & Spc","PX-34000131","CDM","78072","CPT","0341","RC","","","","both","","","3363.00","2522.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2185.95","65","","2566.41","2566.41","2566.41","1 through 10","564.66","2673.59","percent of total billed charges",""
"NM Parathyroid W/ Tomographic & Spc","PX-34000131","CDM","78072","CPT","0341","RC","","","","both","","","3363.00","2522.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2673.59","79.5","","2566.41","2566.41","2566.41","1 through 10","564.66","2673.59","percent of total billed charges",""
"NM Parathyroid W/ Tomographic & Spc","PX-34000131","CDM","78072","CPT","0341","RC","","","","both","","","3363.00","2522.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.00","629.00","629.00","1 through 10","564.66","2673.59","other","OPPS APC"
"NM Parathyroid W/ Tomographic & Spc","PX-34000131","CDM","78072","CPT","0341","RC","","","","both","","","3363.00","2522.25","ELDER SERVICES [1037]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","639.23","639.23","1 through 10","564.66","2673.59","other","OPPS APC"
"NM Parathyroid W/ Tomographic & Spc","PX-34000131","CDM","78072","CPT","0341","RC","","","","both","","","3363.00","2522.25","MEDICARE [2001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","589.92","639.23","1 through 10","564.66","2673.59","other","OPPS APC"
"NM Parathyroid W/ Tomographic & Spc","PX-34000131","CDM","78072","CPT","0341","RC","","","","both","","","3363.00","2522.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1227.50","36.5","","1033.74","1033.74","1033.74","1 through 10","564.66","2673.59","percent of total billed charges",""
"NM Parathyroid W/ Tomographic & Spc","PX-34000131","CDM","78072","CPT","0341","RC","","","","both","","","3363.00","2522.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1288.03","38.3","","1239.18","1239.18","1239.18","1 through 10","564.66","2673.59","percent of total billed charges",""
"NM Parathyroid W/ Tomographic & Spc","PX-34000131","CDM","78072","CPT","0341","RC","","","","both","","","3363.00","2522.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","626.38","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","585.12","585.12","585.12","1 through 10","564.66","2673.59","other","OPPS APC"
"NM Parathyroid W/ Tomographic & Spc","PX-34000131","CDM","78072","CPT","0341","RC","","","","both","","","3363.00","2522.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","626.38","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","581.13","580.93","581.13","1 through 10","564.66","2673.59","other","OPPS APC"
"NM Parathyroid W/ Tomographic & Spc","PX-34000131","CDM","78072","CPT","0341","RC","","","","outpatient","","","3363.00","2522.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2748.24","81.72","","3261.00","1433.86","3261.00","1 through 10","782.53","2748.24","percent of total billed charges",""
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","both","","","2201.00","1650.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2134.00","629.00","2134.00","1 through 10","607.27","1749.8","other","OPPS APC"
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","both","","","2201.00","1650.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1443.86","65.6","","1664.52","1664.52","1664.52","1 through 10","607.27","1749.8","percent of total billed charges",""
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","both","","","2201.00","1650.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1540.70","70","","1583.92","1536.48","1583.92","1 through 10","607.27","1749.8","percent of total billed charges",""
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","both","","","2201.00","1650.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","798.95","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","601.23","569.92","1536.63","1 through 10","607.27","1749.8","other","OPPS APC"
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","both","","","2201.00","1650.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1749.80","79.5","","5038.38","1679.46","5038.38","1 through 10","607.27","1749.8","percent of total billed charges",""
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","both","","","2201.00","1650.75","FALLON HEALTH [1008]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","639.23","639.23","1 through 10","607.27","1749.8","other","OPPS APC"
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","both","","","2201.00","1650.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.28","630.28","630.28","1 through 10","607.27","1749.8","other","OPPS APC"
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","both","","","2201.00","1650.75","MEDICARE [2001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","589.92","639.23","25","607.27","1749.8","other","OPPS APC"
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","both","","","2201.00","1650.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","803.37","36.5","","795.98","795.98","795.98","1 through 10","607.27","1749.8","percent of total billed charges",""
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","both","","","2201.00","1650.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","581.02","581.02","581.02","1 through 10","607.27","1749.8","other","OPPS APC"
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","both","","","2201.00","1650.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","626.38","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","631.45","629.25","631.45","1 through 10","607.27","1749.8","other","OPPS APC"
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","both","","","2201.00","1650.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","626.38","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","639.23","626.45","4036.13","11","607.27","1749.8","other","OPPS APC"
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","outpatient","","","2201.00","1650.75","AETNA [1001]","HB AMC AETNA HMO","1536.30","69.8","","1444.72","1444.72","1444.72","1 through 10","937.64","2045.28","percent of total billed charges",""
"NM Pulmonary Perf/Vent Quan Diff","PX-34000089","CDM","78598","CPT","0341","RC","","","","outpatient","","","2201.00","1650.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1798.66","81.72","","1705.92","903.67","1705.92","1 through 10","937.64","2045.28","percent of total billed charges",""
"NM Pulmonary Perfusion Imaging","PX-34000065","CDM","78580","CPT","0341","RC","","","","both","","","1629.00","1221.75","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","1 through 10","453.34","1295.06","other","OPPS APC"
"NM Pulmonary Perfusion Imaging","PX-34000065","CDM","78580","CPT","0341","RC","","","","outpatient","","","1629.00","1221.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1331.22","81.72","","1263.05","1263.05","1263.05","1 through 10","727.63","1587.17","percent of total billed charges",""
"NM Pulmonary Perfusion Quan Diff","PX-34000088","CDM","78597","CPT","0341","RC","","","","both","","","1428.00","1071.00","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","1 through 10","442.68","1135.26","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","2400.00","1800.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.00","629.00","629.00","1 through 10","607.27","1908","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","2400.00","1800.00","MEDICARE [2001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","589.92","639.23","11","607.27","1908","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","919.20","38.3","","909.86","909.86","909.86","1 through 10","607.27","1908","percent of total billed charges",""
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","578.12","578.12","578.12","1 through 10","607.27","1908","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","2400.00","1800.00","MOLINA [1014]","HB BWH MOLINA","626.38","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1179.84","1179.84","1179.84","1 through 10","607.27","1908","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","2400.00","1800.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","626.38","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","629.00","626.45","629.00","1 through 10","607.27","1908","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1961.28","81.72","","1860.20","1860.20","1860.20","1 through 10","937.64","2045.28","percent of total billed charges",""
"NM Radiopaharm Therapy Oral","PX-34000124","CDM","79005","CPT","0342","RC","","","","both","","","1350.00","1012.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","719.55","53.3","","1030.18","1030.18","1030.18","1 through 10","252.86","1073.25","percent of total billed charges",""
"NM Radiopaharm Therapy Oral","PX-34000124","CDM","79005","CPT","0342","RC","","","","both","","","1350.00","1012.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","266.14","","APC Price ($266.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","261.91","261.91","261.91","1 through 10","252.86","1073.25","other","OPPS APC"
"NM Radiopaharm Therapy Oral","PX-34000124","CDM","79005","CPT","0342","RC","","","","both","","","1350.00","1012.50","MEDICARE [2001]","HB BWH MEDICARE","266.14","","APC Price ($266.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","266.17","266.17","266.17","16","252.86","1073.25","other","OPPS APC"
"NM Radiopaharm Therapy Oral","PX-34000124","CDM","79005","CPT","0342","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","492.75","36.5","","488.26","488.26","488.26","1 through 10","252.86","1073.25","percent of total billed charges",""
"NM Radiopaharm Therapy Oral","PX-34000124","CDM","79005","CPT","0342","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","517.05","38.3","","511.82","511.82","511.82","1 through 10","252.86","1073.25","percent of total billed charges",""
"NM Radiopaharm Therapy Oral","PX-34000124","CDM","79005","CPT","0342","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","266.14","","APC Price ($266.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","264.05","260.85","264.05","1 through 10","252.86","1073.25","other","OPPS APC"
"NM Radiopaharm Therapy Oral","PX-34000124","CDM","79005","CPT","0342","RC","","","","both","","","1350.00","1012.50","TRICARE [160005]","HB BWH TRICARE","252.86","","APC Price ($266.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","252.86","252.86","252.86","1 through 10","252.86","1073.25","other","Tricare OPPS"
"NM Radiopaharm Therapy Oral","PX-34000124","CDM","79005","CPT","0342","RC","","","","outpatient","","","1350.00","1012.50","AETNA [1001]","HB AMC AETNA HMO","942.30","69.8","","886.19","886.19","886.19","1 through 10","475.27","1223.41","percent of total billed charges",""
"NM Radiopaharm Therapy Oral","PX-34000124","CDM","79005","CPT","0342","RC","","","","outpatient","","","1350.00","1012.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1103.22","81.72","","1046.41","575.57","1046.41","1 through 10","475.27","1223.41","percent of total billed charges",""
"NM Radiopaharm Thrpy Intra-Artery","PX-34000128","CDM","79445","CPT","0342","RC","","","","both","","","2512.00","1884.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1758.40","70","","2436.00","2436.00","2436.00","1 through 10","252.86","1997.04","percent of total billed charges",""
"NM Radiopaharm Thrpy Intra-Artery","PX-34000128","CDM","79445","CPT","0342","RC","","","","both","","","2512.00","1884.00","MEDICARE [2001]","HB BWH MEDICARE","266.14","","APC Price ($266.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","271.53","271.53","271.53","1 through 10","252.86","1997.04","other","OPPS APC"
"NM Radiopaharm Thrpy Intra-Artery","PX-34000128","CDM","79445","CPT","0342","RC","","","","both","","","2512.00","1884.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","962.10","38.3","","3396.14","3396.14","3396.14","1 through 10","252.86","1997.04","percent of total billed charges",""
"NM RBC Labeled Liver/Spleen","PX-34000011","CDM","78140","CPT","0341","RC","","","","both","","","2110.00","1582.50","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","1 through 10","453.34","1677.45","other","OPPS APC"
"NM Thyroid Carcinoma Mets Uptake","PX-34000004","CDM","78020","CPT","0341","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","497.23","497.23","1 through 10","334.99","523.83","percent of total billed charges",""
"NM Thyroid Carcinoma Mets Wb","PX-34000003","CDM","78018","CPT","0341","RC","","","","both","","","2427.00","1820.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1929.47","79.5","","1242.91","1242.91","1242.91","1 through 10","607.27","1929.47","percent of total billed charges",""
"NM Thyroid Carcinoma Mets Wb","PX-34000003","CDM","78018","CPT","0341","RC","","","","both","","","2427.00","1820.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","529.66","529.66","529.66","1 through 10","607.27","1929.47","other","OPPS APC"
"NM Thyroid Carcinoma Mets Wb","PX-34000003","CDM","78018","CPT","0341","RC","","","","both","","","2427.00","1820.25","MEDICARE [2001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","589.92","639.23","1 through 10","607.27","1929.47","other","OPPS APC"
"NM Thyroid Carcinoma Mets Wb","PX-34000003","CDM","78018","CPT","0341","RC","","","","both","","","2427.00","1820.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","885.86","36.5","","878.04","878.04","878.04","1 through 10","607.27","1929.47","percent of total billed charges",""
"NM Thyroid Carcinoma Mets Wb","PX-34000003","CDM","78018","CPT","0341","RC","","","","both","","","2427.00","1820.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","929.54","38.3","","920.41","920.41","920.41","1 through 10","607.27","1929.47","percent of total billed charges",""
"NM Thyroid Carcinoma Mets Wb","PX-34000003","CDM","78018","CPT","0341","RC","","","","both","","","2427.00","1820.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","639.16","","APC Price ($639.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.65","626.45","629.65","1 through 10","607.27","1929.47","other","OPPS APC"
"NM Thyroid Carcinoma Mets Wb","PX-34000003","CDM","78018","CPT","0341","RC","","","","outpatient","","","2427.00","1820.25","AETNA [1001]","HB AMC AETNA HMO","1694.05","69.8","","1593.66","1593.66","1593.66","1 through 10","937.64","2045.28","percent of total billed charges",""
"NM Thyroid Carcinoma Mets Wb","PX-34000003","CDM","78018","CPT","0341","RC","","","","outpatient","","","2427.00","1820.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1983.34","81.72","","1881.79","1035.05","1881.79","1 through 10","937.64","2045.28","percent of total billed charges",""
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","1781.00","1335.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1415.90","79.5","","911.86","911.86","911.86","1 through 10","453.34","1415.9","percent of total billed charges",""
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","1781.00","1335.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","949.27","53.3","","1359.15","1359.15","1359.15","1 through 10","453.34","1415.9","percent of total billed charges",""
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","1781.00","1335.75","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","13","453.34","1415.9","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","1781.00","1335.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","682.12","38.3","","675.26","675.26","675.26","1 through 10","453.34","1415.9","percent of total billed charges",""
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","1781.00","1335.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","471.76","441.15","471.76","1 through 10","453.34","1415.9","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-98300580","CDM","78014","CPT","0983","RC","","","","both","","","115.00","86.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","91.43","79.5","","911.86","911.86","911.86","1 through 10","35.65","731.17","percent of total billed charges",""
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-98300580","CDM","78014","CPT","0983","RC","","","","both","","","115.00","86.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","61.30","53.3","","1359.15","1359.15","1359.15","1 through 10","35.65","731.17","percent of total billed charges",""
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-98300580","CDM","78014","CPT","0983","RC","","","","both","","","115.00","86.25","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","13","35.65","731.17","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-98300580","CDM","78014","CPT","0983","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44.05","38.3","","675.26","675.26","675.26","1 through 10","35.65","731.17","percent of total billed charges",""
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-98300580","CDM","78014","CPT","0983","RC","","","","both","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","471.76","441.15","471.76","1 through 10","35.65","731.17","other","OPPS APC"
"NM Thyroid Uptake Single/Multiple","PX-34000135","CDM","78012","CPT","0341","RC","","","","both","","","608.00","456.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","221.92","36.5","","220.07","220.07","220.07","1 through 10","188.48","596.44","percent of total billed charges",""
"NM Thyroid Uptake Single/Multiple","PX-98300579","CDM","78012","CPT","0983","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13.87","36.5","","220.07","220.07","220.07","1 through 10","11.78","596.44","percent of total billed charges",""
"NM Tumor Localize Ltd","PX-34000114","CDM","78800","CPT","0341","RC","","","","both","","","1620.00","1215.00","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","1 through 10","467.61","1539","other","OPPS APC"
"NM Tumor Localize Multi","PX-34000115","CDM","78801","CPT","0341","RC","","","","both","","","2236.00","1677.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","469.56","469.56","1 through 10","467.61","2124.2","other","OPPS APC"
"NM Tumor Localize Multi","PX-34000115","CDM","78801","CPT","0341","RC","","","","both","","","2236.00","1677.00","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","450.15","477.20","1 through 10","467.61","2124.2","other","OPPS APC"
"NM Tumor Localize Multi","PX-34000115","CDM","78801","CPT","0341","RC","","","","both","","","2236.00","1677.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","467.61","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.66","472.66","472.66","1 through 10","467.61","2124.2","other","OPPS APC"
"NM Tumor Localize Wb","PX-34000116","CDM","78802","CPT","0341","RC","","","","both","","","2488.00","1866.00","MEDICARE [2001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1549.78","1549.78","1549.78","1 through 10","771.28","1977.96","other","OPPS APC"
"NM Tumor Localize Wb","PX-34000116","CDM","78802","CPT","0341","RC","","","","both","","","2488.00","1866.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4566.39","4566.39","4566.39","1 through 10","771.28","1977.96","other","OPPS APC"
"NM Tumor Localize Whole Body","PX-34000118","CDM","78804","CPT","0341","RC","","","","both","","","4293.00","3219.75","MEDICARE [2001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4651.02","1550.34","4651.02","1 through 10","1330.83","3412.94","other","OPPS APC"
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","both","","","1912.00","1434.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","592.72","1520.04","other","OPPS APC"
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","both","","","1912.00","1434.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","592.72","1520.04","other","OPPS APC"
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","both","","","1912.00","1434.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1520.04","79.5","","2814.50","2346.50","2814.50","1 through 10","592.72","1520.04","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","both","","","1912.00","1434.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","592.72","1520.04","other","OPPS APC"
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","both","","","1912.00","1434.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","592.72","1520.04","other","OPPS APC"
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","both","","","1912.00","1434.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","697.88","36.5","","2677.58","1482.13","2910.89","1 through 10","592.72","1520.04","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","both","","","1912.00","1434.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","732.30","38.3","","2723.31","1555.62","2741.61","12","592.72","1520.04","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","both","","","1912.00","1434.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","592.72","1520.04","other","OPPS APC"
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","both","","","1912.00","1434.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","592.72","1520.04","other","OPPS APC"
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","both","","","1912.00","1434.00","WELLPOINT [1015]","HB AMC WELLPOINT","1410.67","73.78","","2687.65","2687.64","3224.43","1 through 10","592.72","1520.04","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","outpatient","","","1912.00","1434.00","AETNA [1001]","HB AMC AETNA PPO","1537.25","80.4","","1163.76","1163.76","1163.76","1 through 10","956","2384.07","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","outpatient","","","1912.00","1434.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1157.72","60.55","","1781.82","1492.00","4331.00","1 through 10","956","2384.07","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","outpatient","","","1912.00","1434.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","998.45","52.22","","3144.00","1492.00","3610.00","13","956","2384.07","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","outpatient","","","1912.00","1434.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1003.80","52.5","","1182.28","1182.28","1182.28","1 through 10","956","2384.07","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","outpatient","","","1912.00","1434.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","956.00","50","","3610.00","2269.44","3610.00","1 through 10","956","2384.07","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","outpatient","","","1912.00","1434.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1003.80","52.5","","3610.00","2382.05","4331.00","1 through 10","956","2384.07","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","outpatient","","","1912.00","1434.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1051.60","55","","4810.75","3363.17","4810.75","1 through 10","956","2384.07","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","outpatient","","","1912.00","1434.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1562.49","81.72","","8894.69","8894.69","8894.69","1 through 10","956","2384.07","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","outpatient","","","1912.00","1434.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1562.49","81.72","","2885.83","2132.00","3462.21","1 through 10","956","2384.07","percent of total billed charges",""
"Non Esrd Acute Hemodialysis OP","PX-82000035","CDM","90935","CPT","0829","RC","","","","both","","","5261.00","3945.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3451.22","65.6","","3369.43","3369.43","3369.43","1 through 10","789.41","4182.5","percent of total billed charges",""
"Non Esrd Acute Hemodialysis OP","PX-82000035","CDM","90935","CPT","0829","RC","","","","both","","","5261.00","3945.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4182.50","79.5","","1025.44","1025.44","1025.44","1 through 10","789.41","4182.5","percent of total billed charges",""
"Non Esrd Acute Hemodialysis OP","PX-82000035","CDM","90935","CPT","0829","RC","","","","both","","","5261.00","3945.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3419.65","65","","3235.05","884.00","3235.05","30","789.41","4182.5","percent of total billed charges",""
"Non Esrd Acute Hemodialysis OP","PX-82000035","CDM","90935","CPT","0829","RC","","","","both","","","5261.00","3945.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","3419.65","65","","4666.88","2917.65","4666.88","1 through 10","789.41","4182.5","percent of total billed charges",""
"Non Esrd Acute Hemodialysis OP","PX-82000035","CDM","90935","CPT","0829","RC","","","","both","","","5261.00","3945.75","MEDICARE [2001]","HB BWH MEDICARE","830.88","","APC Price ($830.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","830.96","830.96","830.96","1 through 10","789.41","4182.5","other","OPPS APC"
"Non Esrd Acute Hemodialysis OP","PX-82000035","CDM","90935","CPT","0829","RC","","","","both","","","5261.00","3945.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1920.27","36.5","","3603.34","3603.34","3603.34","1 through 10","789.41","4182.5","percent of total billed charges",""
"Non Esrd Acute Hemodialysis OP","PX-82000035","CDM","90935","CPT","0829","RC","","","","outpatient","","","5261.00","3945.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2630.50","50","","2137.92","2137.92","2607.95","1 through 10","1405.4","4340.33","percent of total billed charges",""
"Non Esrd Acute Hemodialysis OP","PX-82000035","CDM","90935","CPT","0829","RC","","","","outpatient","","","5261.00","3945.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4229.84","80.4","","2488.52","2488.50","2488.52","1 through 10","1405.4","4340.33","percent of total billed charges",""
"Non Therapeutic Apheresis Wbc","PX-76001911","CDM","38999","CPT","0761","RC","","","","outpatient","","","3999.00","2999.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2088.28","52.22","","512.50","512.50","512.50","1 through 10","1234.13","3299.18","percent of total billed charges",""
"Non Therapeutic Apheresis Wbc","PX-76001911","CDM","38999","CPT","0761","RC","","","","outpatient","","","3999.00","2999.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1999.50","50","","6776.11","6776.11","6776.11","1 through 10","1234.13","3299.18","percent of total billed charges",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","","","","inpatient","","","83855.69","62891.77","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","21953.57","","Case rate ($21,314.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,580.63, add-ons for qualifying new technology services are included. If operating cost exceeds $71,225.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,286.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,087.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,200.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,846.61. The transfer capital threshold is the transfer adjustment factor * $1,846.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","19572.36","19572.36","19572.36","1 through 10","20887.87","32736.9063","other","Inpatient DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","","","","inpatient","","","83855.69","62891.77","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","21314.15","","Case rate ($21,314.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,580.63, add-ons for qualifying new technology services are included. If operating cost exceeds $71,225.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,286.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,087.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,200.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,846.61. The transfer capital threshold is the transfer adjustment factor * $1,846.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19752.71","19752.71","19752.71","1 through 10","20887.87","32736.9063","other","Inpatient Replacement Plans DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","","","","inpatient","","","83855.69","62891.77","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","21314.15","","Case rate ($21,314.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,580.63, add-ons for qualifying new technology services are included. If operating cost exceeds $71,225.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,286.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,087.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,200.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,846.61. The transfer capital threshold is the transfer adjustment factor * $1,846.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19569.00","19569.00","19569.00","1 through 10","20887.87","32736.9063","other","Inpatient DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","","","","inpatient","","","83855.69","62891.77","MEDICARE [2001]","HB BWH MEDICARE","21314.15","","Case rate ($21,314.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,580.63, add-ons for qualifying new technology services are included. If operating cost exceeds $71,225.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,286.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,087.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,200.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,846.61. The transfer capital threshold is the transfer adjustment factor * $1,846.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25852.50","25852.50","25852.50","1 through 10","20887.87","32736.9063","other","Inpatient Replacement Plans DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","","","","inpatient","","","83855.69","62891.77","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20887.87","","Case rate ($21,314.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,580.63, add-ons for qualifying new technology services are included. If operating cost exceeds $71,225.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,286.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $19,087.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,200.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,846.61. The transfer capital threshold is the transfer adjustment factor * $1,846.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19569.06","19569.06","19569.06","1 through 10","20887.87","32736.9063","other","Inpatient DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC","097","MS-DRG","","","","","","","","inpatient","","","149566.93","112175.20","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","34326.87","","Case rate ($33,327.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,041.80, add-ons for qualifying new technology services are included. If operating cost exceeds $85,686.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,346.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $30,040.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,661.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,906.27. The transfer capital threshold is the transfer adjustment factor * $2,906.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","33862.90","33862.90","33862.90","1 through 10","32660.52","54095.1986","other","Inpatient DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC","097","MS-DRG","","","","","","","","inpatient","","","149566.93","112175.20","MEDICARE [2001]","HB BWH MEDICARE","33327.06","","Case rate ($33,327.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,041.80, add-ons for qualifying new technology services are included. If operating cost exceeds $85,686.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,346.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $30,040.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,661.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,906.27. The transfer capital threshold is the transfer adjustment factor * $2,906.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","42600.89","42600.89","77058.80","1 through 10","32660.52","54095.1986","other","Inpatient Replacement Plans DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC","097","MS-DRG","","","","","","","","inpatient","","","149566.93","112175.20","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","32660.52","","Case rate ($33,327.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,041.80, add-ons for qualifying new technology services are included. If operating cost exceeds $85,686.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,346.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $30,040.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,661.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,906.27. The transfer capital threshold is the transfer adjustment factor * $2,906.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","32329.41","32329.41","32329.41","1 through 10","32660.52","54095.1986","other","Inpatient DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC","097","TRIS-DRG","","","","","","","","inpatient","","","124864.09","","TRICARE [160005]","HB BWH TRICARE","25691.73","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($45,128.97). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $88,855.97 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($9,116.96), capped at $32,480.90. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $88,855.97 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","691.69","691.69","691.69","1 through 10","25691.73","25691.73","other","Inpatient DRGs"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/McC","099","MS-DRG","","","","","","","","inpatient","","","57532.82","43149.61","HUMANA [1012]","HB BWH MEDICARE","12807.78","","Case rate ($12,807.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,340.65, add-ons for qualifying new technology services are included. If operating cost exceeds $60,985.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,536.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,331.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,960.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.27. The transfer capital threshold is the transfer adjustment factor * $1,096.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12721.05","12721.05","12721.05","1 through 10","12551.62","21026.2903","other","Inpatient Replacement Plans DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/McC","099","MS-DRG","","","","","","","","inpatient","","","57532.82","43149.61","MEDICARE [2001]","HB BWH MEDICARE","12807.78","","Case rate ($12,807.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,340.65, add-ons for qualifying new technology services are included. If operating cost exceeds $60,985.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,536.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,331.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,960.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.27. The transfer capital threshold is the transfer adjustment factor * $1,096.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16704.10","16704.10","16728.68","1 through 10","12551.62","21026.2903","other","Inpatient Replacement Plans DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/McC","099","MS-DRG","","","","","","","","inpatient","","","57532.82","43149.61","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12551.62","","Case rate ($12,807.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,340.65, add-ons for qualifying new technology services are included. If operating cost exceeds $60,985.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,536.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,331.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,960.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,096.27. The transfer capital threshold is the transfer adjustment factor * $1,096.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","4.10","4.10","4.10","1 through 10","12551.62","21026.2903","other","Inpatient DRG"
"Non-Bacterial Infections Of Nervous System Except Viral Meningitis,EXTREME","050","DRG","","","","","","","","inpatient","","","149566.93","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","129277.98","","Standard inlier is a Case rate ($129,277.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $101,068, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,349.94) for the length of stay and the standard reimbursement.","129277.98","129277.98","129277.98","1 through 10","8396.39","187622.72","case rate",""
"Non-Bacterial Infections Of Nervous System Except Viral Meningitis,EXTREME","050","DRG","","","","","","","","inpatient","","","149566.93","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","44466.60","","Case rate ($49,165.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $91,595.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","49153.40","49153.40","49153.40","1 through 10","8396.39","187622.72","case rate",""
"Non-Bacterial Infections Of Nervous System Except Viral Meningitis,MAJOR","050","DRG","","","","","","","","inpatient","","","73997.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","63113.69","","Standard inlier is a Case rate ($63,113.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $55,303, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,958.46) for the length of stay and the standard reimbursement.","63113.68","63113.68","63113.68","1 through 10","8396.39","187622.72","case rate",""
"Non-Bacterial Infections Of Nervous System Except Viral Meningitis,MAJOR","050","DRG","","","","","","","","inpatient","","","73997.19","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18385.674","","Fee schedule rate ($48,804.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18385.674","48804.80","48804.80","1 through 10","8396.39","187622.72","case rate",""
"Non-Bacterial Infections Of Nervous System Except Viral Meningitis,MINOR","050","DRG","","","","","","","","inpatient","","","35368.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22899.53","","Standard inlier is a Case rate ($22,899.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,486, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,250.40) for the length of stay and the standard reimbursement.","22899.52","22899.52","22899.52","1 through 10","8396.39","187622.72","case rate",""
"Non-Bacterial Infections Of Nervous System Except Viral Meningitis,MODERATE","050","DRG","","","","","","","","inpatient","","","30445.82","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","39792.38","","Standard inlier is a Case rate ($39,792.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,171, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,648.20) for the length of stay and the standard reimbursement.","39792.38","39792.38","39792.38","1 through 10","8396.39","187622.72","case rate",""
"Non-Bacterial Infections Of Nervous System Except Viral Meningitis,MODERATE","050","DRG","","","","","","","","inpatient","","","30445.82","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18385.674","","Fee schedule rate ($27,108.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18385.674","27108.80","27108.80","1 through 10","8396.39","187622.72","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,EXTREME","323","DRG","","","","","","","","inpatient","","","234558.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","124151.22","","Standard inlier is a Case rate ($124,151.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $97,522, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,622.23) for the length of stay and the standard reimbursement.","124151.22","124151.22","124151.22","1 through 10","17957.99","124151.22","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MAJOR","323","DRG","","","","","","","","inpatient","","","124805.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","89012.92","","Fee schedule rate ($89,012.92). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($10,299.16) multiplied by length of stay and the outlier percent (100%).","81320.98","81320.98","89012.91","1 through 10","17957.99","124151.22","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MAJOR","323","DRG","","","","","","","","inpatient","","","124805.98","","MASSHEALTH [3001]","HB BWH MEDICAID","25124.06","","Case rate ($27,778.96). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,208.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","40770.94","40770.94","258754.75","1 through 10","17957.99","124151.22","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MAJOR","323","DRG","","","","","","","","inpatient","","","124805.98","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","25124.06","","Case rate ($27,778.96). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,208.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","40302.99","40302.99","40302.99","1 through 10","17957.99","124151.22","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MINOR","323","DRG","","","","","","","","inpatient","","","91779.71","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","59561.32","","Standard inlier is a Case rate ($59,561.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,844, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,454.23) for the length of stay and the standard reimbursement.","59561.31","59561.31","59561.31","1 through 10","17957.99","124151.22","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MINOR","323","DRG","","","","","","","","inpatient","","","91779.71","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","17957.99","","Case rate ($19,855.65). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,285.65, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17662.39","17662.39","17662.39","1 through 10","17957.99","124151.22","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MODERATE","323","DRG","","","","","","","","inpatient","","","137848.07","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","59488.04","","Fee schedule rate ($59,488.04). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($6,883.03) multiplied by length of stay and the outlier percent (100%).","54225.51","54225.51","114046.79","1 through 10","17957.99","124151.22","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MODERATE","323","DRG","","","","","","","","inpatient","","","137848.07","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","66880.58","","Fee schedule rate ($66,880.58). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($7,738.36) multiplied by length of stay and the outlier percent (100%).","66880.58","66880.58","66880.58","1 through 10","17957.99","124151.22","case rate",""
"Non-Elective Or Complex Knee Joint Replacement,EXTREME","325","DRG","","","","","","","","inpatient","","","996211.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","158293.26","","Standard inlier is a Case rate ($158,293.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $121,136, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($22,468.41) for the length of stay and the standard reimbursement.","1861.87","1861.87","1861.87","1 through 10","31498.46","158293.26","case rate",""
"Non-Elective Or Complex Knee Joint Replacement,MAJOR","325","DRG","","","","","","","","inpatient","","","201746.05","","MASSHEALTH [3001]","HB BWH MEDICAID","34741.63","","Case rate ($38,412.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,842.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","38403.43","38403.43","38403.43","1 through 10","31498.46","158293.26","case rate",""
"Non-Elective Or Complex Knee Joint Replacement,MINOR","325","DRG","","","","","","","","inpatient","","","89132.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","65826.87","","Standard inlier is a Case rate ($65,826.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $62,838, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,344.52) for the length of stay and the standard reimbursement.","65826.87","65826.87","67611.91","1 through 10","31498.46","158293.26","case rate",""
"Non-Elective Or Complex Knee Joint Replacement,MINOR","325","DRG","","","","","","","","inpatient","","","89132.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","74007.14","","Standard inlier is a Case rate ($74,007.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $62,838, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,504.70) for the length of stay and the standard reimbursement.","67611.91","67611.91","67611.91","1 through 10","31498.46","158293.26","case rate",""
"Non-Elective Or Complex Knee Joint Replacement,MODERATE","325","DRG","","","","","","","","inpatient","","","161908.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","86151.38","","Standard inlier is a Case rate ($86,151.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,237, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,228.47) for the length of stay and the standard reimbursement.","86151.38","86151.38","122033.02","1 through 10","31498.46","158293.26","case rate",""
"Non-Extensive Burns","935","MS-DRG","","","","","","","","inpatient","","","45311.00","33983.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","19746.52","","Case rate ($19,171.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,001.15, add-ons for qualifying new technology services are included. If operating cost exceeds $68,645.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,097.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $17,133.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,621.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.60. The transfer capital threshold is the transfer adjustment factor * $1,657.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","34851.39","34851.39","34851.39","1 through 10","18787.95","32267.84","other","Inpatient DRG"
"Non-Extensive Burns","935","MS-DRG","","","","","","","","inpatient","","","45311.00","33983.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","19171.38","","Case rate ($19,171.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,001.15, add-ons for qualifying new technology services are included. If operating cost exceeds $68,645.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,097.74, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $17,133.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,621.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.60. The transfer capital threshold is the transfer adjustment factor * $1,657.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount.","19996.04","19996.04","19996.04","1 through 10","18787.95","32267.84","other","Inpatient Replacement Plans DRG"
"Non-Extensive Burns","935","MS-DRG","","","","","","","","inpatient","","","45311.00","33983.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","19171.38","","Case rate ($19,171.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,001.15, add-ons for qualifying new technology services are included. If operating cost exceeds $68,645.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,097.74, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $17,133.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,621.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.60. The transfer capital threshold is the transfer adjustment factor * $1,657.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount.","19868.15","19868.15","19868.15","1 through 10","18787.95","32267.84","other","Inpatient DRG"
"Non-Extensive Burns","935","MS-DRG","","","","","","","","inpatient","","","45311.00","33983.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","19171.38","","Case rate ($19,171.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,001.15, add-ons for qualifying new technology services are included. If operating cost exceeds $68,645.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,097.74, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $17,133.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,621.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.60. The transfer capital threshold is the transfer adjustment factor * $1,657.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount.","19876.44","19876.44","19876.44","1 through 10","18787.95","32267.84","other","Inpatient Replacement Plans DRG"
"Non-Extensive Burns","935","MS-DRG","","","","","","","","inpatient","","","45311.00","33983.25","MEDICARE [2001]","HB BWH MEDICARE","19171.38","","Case rate ($19,171.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,001.15, add-ons for qualifying new technology services are included. If operating cost exceeds $68,645.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,097.74, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $17,133.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,621.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.60. The transfer capital threshold is the transfer adjustment factor * $1,657.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount.","26171.97","805.69","56267.49","1 through 10","18787.95","32267.84","other","Inpatient Replacement Plans DRG"
"Non-Extensive Burns","935","MS-DRG","","","","","","","","inpatient","","","45311.00","33983.25","MOLINA [1014]","HB BWH MOLINA","18787.95","","Case rate ($19,171.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,001.15, add-ons for qualifying new technology services are included. If operating cost exceeds $68,645.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,097.74, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $17,133.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,621.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.60. The transfer capital threshold is the transfer adjustment factor * $1,657.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount. Final payment is multiplied by 98%.","40057.91","40057.91","40057.91","1 through 10","18787.95","32267.84","other","Inpatient DRG"
"Non-Extensive Burns","935","MS-DRG","","","","","","","","inpatient","","","45311.00","33983.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","18787.95","","Case rate ($19,171.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,001.15, add-ons for qualifying new technology services are included. If operating cost exceeds $68,645.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,097.74, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $17,133.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,621.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.60. The transfer capital threshold is the transfer adjustment factor * $1,657.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount. Final payment is multiplied by 98%.","5455.49","5455.49","5455.49","1 through 10","18787.95","32267.84","other","Inpatient DRG"
"Non-Extensive Burns","935","MS-DRG","","","","","","","","inpatient","","","45311.00","33983.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","18787.95","","Case rate ($19,171.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,001.15, add-ons for qualifying new technology services are included. If operating cost exceeds $68,645.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 90% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,097.74, the stay qualifies for a capital outlier of 90% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $17,133.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,621.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 90% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,657.60. The transfer capital threshold is the transfer adjustment factor * $1,657.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 90% of the excess amount. Final payment is multiplied by 98%.","19868.23","19868.23","19868.45","1 through 10","18787.95","32267.84","other","Inpatient DRG"
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","952","DRG","","","","","","","","inpatient","","","240230.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","109448.41","","Standard inlier is a Case rate ($109,448.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $96,759, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($15,536.86) for the length of stay and the standard reimbursement.","579359.74","579359.74","579359.74","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","952","DRG","","","","","","","","inpatient","","","240230.36","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","123049.51","","Standard inlier is a Case rate ($123,049.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $96,759, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,465.86) for the length of stay and the standard reimbursement.","123049.51","112416.35","142155.49","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","952","DRG","","","","","","","","inpatient","","","240230.36","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15656.9","","Fee schedule rate ($154,511.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15656.9","151120.40","151120.40","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","952","DRG","","","","","","","","inpatient","","","240230.36","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($154,511.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","151120.40","151120.40","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","952","DRG","","","","","","","","inpatient","","","240230.36","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","45365.64","","Case rate ($50,159.51). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $92,589.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $5,041.16 and the sum of the standard inlier and any outlier amount.","50147.20","50147.20","50147.20","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","952","DRG","","","","","","","","inpatient","","","97581.61","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","43911.97","","Standard inlier is a Case rate ($43,911.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $42,021, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,232.94) for the length of stay and the standard reimbursement.","69956.64","69956.64","69956.64","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","952","DRG","","","","","","","","inpatient","","","97581.61","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","146408.64","146408.64","146408.64","1 through 10","9037.26","254946.65","percent of total billed charges",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","952","DRG","","","","","","","","inpatient","","","97581.61","","MASSHEALTH [3001]","HB BWH MEDICAID","12444.94","","Case rate ($13,760.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,190.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25771.92","25771.92","25771.92","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","952","DRG","","","","","","","","inpatient","","","97581.61","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63222.88","","Fee schedule rate ($63,222.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","53739.45","53739.45","53739.45","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","952","DRG","","","","","","","","inpatient","","","97581.61","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12444.94","","Case rate ($13,760.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,190.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13190.92","13190.92","25771.91","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","952","DRG","","","","","","","","inpatient","","","97581.61","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","12444.94","","Case rate ($13,760.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,190.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12014.75","12014.75","12014.75","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MINOR","952","DRG","","","","","","","","inpatient","","","41600.24","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","31884.08","","Standard inlier is a Case rate ($31,884.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,702, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,525.68) for the length of stay and the standard reimbursement.","31884.08","31884.08","31884.08","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MINOR","952","DRG","","","","","","","","inpatient","","","41600.24","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15656.9","","Fee schedule rate ($17,314.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15656.9","28010.20","28010.20","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MINOR","952","DRG","","","","","","","","inpatient","","","41600.24","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($17,314.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","28010.20","28010.20","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","952","DRG","","","","","","","","inpatient","","","93979.73","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","39058.23","","Standard inlier is a Case rate ($39,058.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $42,021, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,544.55) for the length of stay and the standard reimbursement.","35602.99","35602.99","35602.99","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","952","DRG","","","","","","","","inpatient","","","93979.73","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","43911.97","","Standard inlier is a Case rate ($43,911.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $42,021, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,232.94) for the length of stay and the standard reimbursement.","44891.76","44891.76","44891.76","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","952","DRG","","","","","","","","inpatient","","","93979.73","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15656.9","","Fee schedule rate ($34,404.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15656.9","58266.04","58266.04","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","952","DRG","","","","","","","","inpatient","","","93979.73","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($34,404.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","58266.04","58266.04","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","952","DRG","","","","","","","","inpatient","","","93979.73","","MASSHEALTH [3001]","HB BWH MEDICAID","12444.94","","Case rate ($13,760.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,190.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5422.34","5422.34","5422.34","1 through 10","9037.26","254946.65","case rate",""
"Non-Extensive O.R. Procedures For Other Complications Of Treatment,MODERATE","794","DRG","","","","","","","","inpatient","","","65262.30","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9342.27","","Case rate ($10,329.48). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,759.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10326.95","10326.95","10326.95","1 through 10","9342.27","38832.48","case rate",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","","","","inpatient","","","102562.04","76921.53","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","19838.30","","Case rate ($19,838.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,428.56, add-ons for qualifying new technology services are included. If operating cost exceeds $64,073.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,762.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,135.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,048.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,322.54. The transfer capital threshold is the transfer adjustment factor * $1,322.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15682.37","15682.37","15682.37","1 through 10","15065.48","25745.35","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","","","","inpatient","","","102562.04","76921.53","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","25771.91","25771.91","25771.91","1 through 10","15065.48","25745.35","case rate",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","","","","inpatient","","","102562.04","76921.53","MEDICARE [2001]","HB BWH MEDICARE","19838.30","","Case rate ($19,838.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,428.56, add-ons for qualifying new technology services are included. If operating cost exceeds $64,073.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,762.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,135.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,048.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,322.54. The transfer capital threshold is the transfer adjustment factor * $1,322.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20508.48","20026.98","20538.74","1 through 10","15065.48","25745.35","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","","","","inpatient","","","102562.04","76921.53","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","15065.48","","Case rate ($15,372.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,428.56, add-ons for qualifying new technology services are included. If operating cost exceeds $64,073.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,762.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,670.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,048.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,322.54. The transfer capital threshold is the transfer adjustment factor * $1,322.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15536.94","15536.94","15536.94","1 through 10","15065.48","25745.35","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","","","","inpatient","","","102562.04","76921.53","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15065.48","","Case rate ($15,372.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,428.56, add-ons for qualifying new technology services are included. If operating cost exceeds $64,073.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,762.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,670.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,048.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,322.54. The transfer capital threshold is the transfer adjustment factor * $1,322.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15629.61","15629.61","16082.14","1 through 10","15065.48","25745.35","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","987","MS-DRG","","","","","","","","inpatient","","","206153.88","154615.41","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","40968.42","","Case rate ($40,968.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,027.84, add-ons for qualifying new technology services are included. If operating cost exceeds $83,672.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,198.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,829.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,648.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,758.69. The transfer capital threshold is the transfer adjustment factor * $2,758.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","110250.63","110250.63","110250.63","1 through 10","31021","52859.2457","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","987","MS-DRG","","","","","","","","inpatient","","","206153.88","154615.41","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","31654.08","","Case rate ($31,654.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,027.84, add-ons for qualifying new technology services are included. If operating cost exceeds $83,672.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,198.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,515.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,648.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,758.69. The transfer capital threshold is the transfer adjustment factor * $2,758.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","193494.06","193494.06","193494.06","1 through 10","31021","52859.2457","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","987","MS-DRG","","","","","","","","inpatient","","","206153.88","154615.41","HUMANA [1012]","HB BWH MEDICARE","40968.42","","Case rate ($40,968.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,027.84, add-ons for qualifying new technology services are included. If operating cost exceeds $83,672.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,198.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,829.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,648.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,758.69. The transfer capital threshold is the transfer adjustment factor * $2,758.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","31472.89","31472.89","31472.89","1 through 10","31021","52859.2457","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","987","MS-DRG","","","","","","","","inpatient","","","206153.88","154615.41","MEDICARE [2001]","HB BWH MEDICARE","40968.42","","Case rate ($40,968.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,027.84, add-ons for qualifying new technology services are included. If operating cost exceeds $83,672.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,198.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,829.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,648.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,758.69. The transfer capital threshold is the transfer adjustment factor * $2,758.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","41572.15","0.03","41633.92","20","31021","52859.2457","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","987","MS-DRG","","","","","","","","inpatient","","","206153.88","154615.41","WELLPOINT [1015]","HB AMC WELLPOINT","52859.2457","","Fee schedule rate ($53,702.46).","52859.2457","346726.18","346726.18","1 through 10","31021","52859.2457","case rate",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC","989","MS-DRG","","","","","","","","inpatient","","","60117.35","45088.01","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","11319.05","","Case rate ($11,319.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,548.51, add-ons for qualifying new technology services are included. If operating cost exceeds $59,192.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,405.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,974.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,168.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.95. The transfer capital threshold is the transfer adjustment factor * $964.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10788.86","10788.86","10788.86","1 through 10","11092.67","17437.6505","other","Inpatient Replacement Plans DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC","989","MS-DRG","","","","","","","","inpatient","","","60117.35","45088.01","MEDICARE [2001]","HB BWH MEDICARE","11319.05","","Case rate ($11,319.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,548.51, add-ons for qualifying new technology services are included. If operating cost exceeds $59,192.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,405.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,974.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,168.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $964.95. The transfer capital threshold is the transfer adjustment factor * $964.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6297.49","6297.49","6297.49","1 through 10","11092.67","17437.6505","other","Inpatient Replacement Plans DRG"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.72","71.8","","0.72","0.72","0.72","1 through 10","0.31","0.8","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.66","65.6","","0.78","0.78","0.78","1 through 10","0.31","0.8","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.70","70","","10.00","0.74","10.00","1 through 10","0.31","0.8","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","2.00","2.00","18.87","1 through 10","0.31","0.8","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.31","31","","0.31","0.31","0.31","1 through 10","0.31","0.8","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","0.37","0.32","1.13","37","0.31","0.8","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","0.39","0.38","1.17","124","0.31","0.8","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB AMC WELLPOINT","0.74","73.78","","0.74","0.74","0.75","39","0.31","0.8","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","0.68","0.48","0.78","48","0.18","21.5","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA PPO","0.80","80.4","","0.78","0.78","0.78","1 through 10","0.18","21.5","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","outpatient","","","1.00","0.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","0.52","52.26","","18.87","11.32","18.87","1 through 10","0.18","21.5","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10.30","","APC Price ($10). Final payment is multiplied by 103%.","10.29","6.18","10.29","28","9.5","12.5","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","10.00","","APC Price ($10).","9.81","0.34","9.81","1 through 10","9.5","12.5","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","FALLON HEALTH [1008]","HB BWH MEDICARE","10.00","","APC Price ($10).","29.40","1.00","49.00","11","9.5","12.5","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","10.00","","APC Price ($10).","9.84","9.84","9.84","1 through 10","9.5","12.5","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","10.00","","APC Price ($10).","5.92","5.92","5.92","1 through 10","9.5","12.5","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","MEDICARE [2001]","HB BWH MEDICARE","10.00","","APC Price ($10).","10.00","6.00","10.00","404","9.5","12.5","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","10.00","","APC Price ($10).","0.99","0.98","0.99","12","9.5","12.5","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","MOLINA [1014]","HB BWH MOLINA","9.80","","APC Price ($10). Final payment is multiplied by 98%.","20.00","20.00","20.00","1 through 10","9.5","12.5","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9.80","","APC Price ($10). Final payment is multiplied by 98%.","9.80","5.88","25.48","32","9.5","12.5","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","9.80","","APC Price ($10). Final payment is multiplied by 98%.","0.23","0.23","0.23","1 through 10","9.5","12.5","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9.80","","APC Price ($10). Final payment is multiplied by 98%.","9.80","5.88","10.00","88","9.5","12.5","other","OPPS APC"
"Non-Hypovolemic Sodium Disorders,EXTREME","426","DRG","","","","","","","","inpatient","","","28973.44","","MASSHEALTH [3001]","HB BWH MEDICAID","17938.57","","Case rate ($19,834.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,264.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19829.31","19829.31","19829.31","1 through 10","5993.99","56328.91","case rate",""
"Non-Hypovolemic Sodium Disorders,MAJOR","426","DRG","","","","","","","","inpatient","","","50299.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","28259.57","","Standard inlier is a Case rate ($28,259.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,623, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,011.62) for the length of stay and the standard reimbursement.","28259.56","28259.56","28259.56","1 through 10","5993.99","56328.91","case rate",""
"Non-Hypovolemic Sodium Disorders,MAJOR","426","DRG","","","","","","","","inpatient","","","50299.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","31771.37","","Standard inlier is a Case rate ($31,771.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,623, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,509.68) for the length of stay and the standard reimbursement.","31771.36","31771.36","31771.37","1 through 10","5993.99","56328.91","case rate",""
"Non-Hypovolemic Sodium Disorders,MAJOR","426","DRG","","","","","","","","inpatient","","","50299.53","","MASSHEALTH [3001]","HB BWH MEDICAID","9439.37","","Case rate ($10,436.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,866.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10434.29","10434.29","13278.05","1 through 10","5993.99","56328.91","case rate",""
"Non-Hypovolemic Sodium Disorders,MAJOR","426","DRG","","","","","","","","inpatient","","","50299.53","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28242.30","","Fee schedule rate ($28,242.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28242.30","28242.30","28242.30","1 through 10","5993.99","56328.91","case rate",""
"Non-Hypovolemic Sodium Disorders,MAJOR","426","DRG","","","","","","","","inpatient","","","50299.53","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9439.37","","Case rate ($10,436.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,866.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1988.15","1020.93","10434.29","1 through 10","5993.99","56328.91","case rate",""
"Non-Hypovolemic Sodium Disorders,MODERATE","426","DRG","","","","","","","","inpatient","","","31143.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21736.01","","Standard inlier is a Case rate ($21,736.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,681, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,085.25) for the length of stay and the standard reimbursement.","21736.00","21736.00","21736.00","1 through 10","5993.99","56328.91","case rate",""
"NON-LOCKING SCREW 4.5 X 66MM TI","SUP-ITM-10327227","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","133.56","79.5","","800.18","480.96","1887.97","195","52.08","133.56","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 66MM TI","SUP-ITM-10327227","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","89.54","53.3","","813.12","216.42","1444.50","81","52.08","133.56","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 66MM TI","SUP-ITM-10327227","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","52.08","31","","432.60","432.60","432.60","1 through 10","52.08","133.56","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 66MM TI","SUP-ITM-10327227","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","61.32","36.5","","148.37","54.89","631.39","94","52.08","133.56","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 66MM TI","SUP-ITM-10327227","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64.34","38.3","","279.30","91.72","1116.77","266","52.08","133.56","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 66MM TI","SUP-ITM-10327227","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.07","42.9","","731.00","63.70","731.00","1 through 10","52.08","133.56","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 66MM TI","SUP-ITM-10327227","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.07","42.9","","384.74","384.74","384.74","1 through 10","52.08","133.56","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 66MM TI","SUP-ITM-10327227","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","WELLPOINT [1015]","HB AMC WELLPOINT","123.95","73.78","","286.63","119.22","1107.45","105","52.08","133.56","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 66MM TI","SUP-ITM-10327227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","AETNA [1001]","HB AMC AETNA HMO","117.26","69.8","","675.31","184.75","1721.50","286","87.8","137.29","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 66MM TI","SUP-ITM-10327227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","AETNA [1001]","HB AMC AETNA PPO","135.07","80.4","","1261.44","103.12","1514.10","21","87.8","137.29","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 66MM TI","SUP-ITM-10327227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","135.07","80.4","","1365.00","1365.00","1365.00","1 through 10","87.8","137.29","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 66MM TI","SUP-ITM-10327227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","137.29","81.72","","5157.68","5157.68","5157.68","1 through 10","87.8","137.29","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 66MM TI","SUP-ITM-10327227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","137.29","81.72","","431.26","71.26","1459.57","88","87.8","137.29","percent of total billed charges",""
"Non-Malignant Breast Disorders With Cc/McC","600","MS-DRG","","","","","","","","inpatient","","","31926.88","23945.16","MEDICARE [2001]","HB BWH MEDICARE","9881.42","","Case rate ($9,881.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,817.88, add-ons for qualifying new technology services are included. If operating cost exceeds $57,462.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,278.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,663.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,438.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.13. The transfer capital threshold is the transfer adjustment factor * $838.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11572.66","11572.66","11572.66","1 through 10","9683.79","14436.0506","other","Inpatient Replacement Plans DRG"
"Non-Malignant Breast Disorders Without Cc/McC","601","MS-DRG","","","","","","","","inpatient","","","26945.82","20209.36","MEDICARE [2001]","HB BWH MEDICARE","7542.39","","Case rate ($7,542.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,023.48, add-ons for qualifying new technology services are included. If operating cost exceeds $52,667.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,926.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,675.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,643.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.82. The transfer capital threshold is the transfer adjustment factor * $486.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7356.44","7356.44","7356.44","1 through 10","5780.74","9047.0545","other","Inpatient DRG"
"Non-Malignant Breast Disorders Without Cc/McC","601","MS-DRG","","","","","","","","inpatient","","","26945.82","20209.36","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","5780.74","","Case rate ($5,898.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,023.48, add-ons for qualifying new technology services are included. If operating cost exceeds $52,667.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,926.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,032.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,643.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.82. The transfer capital threshold is the transfer adjustment factor * $486.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8022.14","8022.14","8022.14","1 through 10","5780.74","9047.0545","other","Inpatient DRG"
"Non-Onc Mononuclear Leukocyte Apheresis Clin Trial","PX-76002752","CDM","38999","CPT","0761","RC","","","","outpatient","","","6127.00","4595.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3199.52","52.22","","512.50","512.50","512.50","1 through 10","1234.13","5054.78","percent of total billed charges",""
"Non-Onc Mononuclear Leukocyte Apheresis Clin Trial","PX-76002752","CDM","38999","CPT","0761","RC","","","","outpatient","","","6127.00","4595.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3063.50","50","","6776.11","6776.11","6776.11","1 through 10","1234.13","5054.78","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","462.00","346.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","241.51","","APC Price ($241.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","448.00","43.84","448.00","1 through 10","67.25","367.29","other","OPPS APC"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","462.00","346.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","367.29","79.5","","352.58","264.72","352.58","1 through 10","67.25","367.29","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","462.00","346.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","246.25","53.3","","236.54","236.54","352.58","1 through 10","67.25","367.29","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","462.00","346.50","MEDICARE [2001]","HB BWH MEDICARE","241.51","","APC Price ($241.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","241.54","241.54","241.54","1 through 10","67.25","367.29","other","OPPS APC"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","462.00","346.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","143.22","31","","415.29","415.29","415.29","1 through 10","67.25","367.29","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","462.00","346.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","168.63","36.5","","142.02","142.02","426.06","1 through 10","67.25","367.29","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","462.00","346.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","176.95","38.3","","175.17","175.17","175.17","11","67.25","367.29","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","outpatient","","","462.00","346.50","AETNA [1001]","HB AMC AETNA HMO","322.48","69.8","","349.44","214.14","569.86","1 through 10","237.62","733.83","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","outpatient","","","462.00","346.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","377.55","81.72","","10912.45","10912.45","10912.45","1 through 10","237.62","733.83","percent of total billed charges",""
"Nonpressurized Inhalation Treatment|REPEAT PROCEDURE BY SAME PHYSICIAN","PX-46000001","CDM","94640","CPT","0410","RC","","","76","both","","","462.00","346.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","212.49","","APC Price ($212.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","448.00","448.00","448.00","1 through 10","208.24","265.62","other","OPPS APC"
"Nonslctv Cath Thor Aorta Angio Intr","PX-48000224","CDM","36221","CPT","0361","RC","","","","both","","","9722.00","7291.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5181.83","53.3","","4977.98","4977.98","4977.98","1 through 10","3013.82","7728.99","percent of total billed charges",""
"Nonspecific Cva And Precerebral Occlusion Without Infarction,MAJOR","046","DRG","","","","","","","","inpatient","","","34942.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31474.26","","Standard inlier is a Case rate ($31,474.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,123, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,467.96) for the length of stay and the standard reimbursement.","31474.26","31474.26","31474.26","1 through 10","4871.05","40076.23","case rate",""
"Nonspecific Cva And Precerebral Occlusion Without Infarction,MAJOR","046","DRG","","","","","","","","inpatient","","","34942.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35385.55","","Standard inlier is a Case rate ($35,385.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,123, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,022.69) for the length of stay and the standard reimbursement.","35385.55","35385.55","35385.55","1 through 10","4871.05","40076.23","case rate",""
"Nonspecific Cva And Precerebral Occlusion Without Infarction,MAJOR","046","DRG","","","","","","","","inpatient","","","34942.58","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7321.42","","Case rate ($8,095.09). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,525.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8093.11","8093.11","8093.11","1 through 10","4871.05","40076.23","case rate",""
"Nonspecific Cva And Precerebral Occlusion Without Infarction,MINOR","046","DRG","","","","","","","","inpatient","","","36873.87","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","20875.62","","Fee schedule rate ($20,875.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21150.98","21150.98","21150.98","1 through 10","4871.05","40076.23","case rate",""
"Nonspecific Cva And Precerebral Occlusion Without Infarction,MINOR","046","DRG","","","","","","","","inpatient","","","36873.87","","MASSHEALTH [3001]","HB BWH MEDICAID","4871.05","","Case rate ($5,385.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,815.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5384.46","5384.46","5384.46","1 through 10","4871.05","40076.23","case rate",""
"Nonspecific Cva And Precerebral Occlusion Without Infarction,MODERATE","046","DRG","","","","","","","","inpatient","","","28082.22","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5032.12","","Case rate ($5,563.88). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,993.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5562.51","5562.51","5562.51","1 through 10","4871.05","40076.23","case rate",""
"Nontraumatic Stupor And Coma With McC","080","MS-DRG","","","","","","","","inpatient","","","83367.76","62525.82","MEDICARE [2001]","HB BWH MEDICARE","21808.29","","Case rate ($21,808.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,255.84, add-ons for qualifying new technology services are included. If operating cost exceeds $65,900.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,896.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,972.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,876.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.43. The transfer capital threshold is the transfer adjustment factor * $1,456.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23712.77","23712.77","23747.81","1 through 10","16553.03","28351.84","other","Inpatient DRG"
"Nontraumatic Stupor And Coma With McC","080","MS-DRG","","","","","","","","inpatient","","","83367.76","62525.82","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16553.03","","Case rate ($16,890.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,255.84, add-ons for qualifying new technology services are included. If operating cost exceeds $65,900.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,896.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $15,054.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,876.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.43. The transfer capital threshold is the transfer adjustment factor * $1,456.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17971.72","17971.72","17971.72","1 through 10","16553.03","28351.84","other","Inpatient DRG"
"Nontraumatic Stupor And Coma Without McC","081","MS-DRG","","","","","","","","inpatient","","","38496.69","28872.52","HUMANA [1012]","HB BWH MEDICARE","8549.62","","Case rate ($8,549.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,214.62, add-ons for qualifying new technology services are included. If operating cost exceeds $55,859.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,160.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,449.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,834.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.65. The transfer capital threshold is the transfer adjustment factor * $720.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13679.29","13679.29","13679.29","1 through 10","8378.63","13654.3368","other","Inpatient Replacement Plans DRG"
"Nontraumatic Stupor And Coma Without McC","081","MS-DRG","","","","","","","","inpatient","","","38496.69","28872.52","MEDICARE [2001]","HB BWH MEDICARE","8549.62","","Case rate ($8,549.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,214.62, add-ons for qualifying new technology services are included. If operating cost exceeds $55,859.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,160.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,449.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,834.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.65. The transfer capital threshold is the transfer adjustment factor * $720.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10961.06","10961.06","10961.06","1 through 10","8378.63","13654.3368","other","Inpatient Replacement Plans DRG"
"Normal Newborn","795","MS-DRG","","","","","","","","inpatient","","","8592.71","6444.53","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2158.39","","Case rate ($2,202.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $2,573.89, add-ons for qualifying new technology services are included. If operating cost exceeds $48,218.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,600.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,661.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $2,194.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $160.77. The transfer capital threshold is the transfer adjustment factor * $160.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","3302.97","3302.97","3302.97","1 through 10","2158.39","3129.67","other","Inpatient DRG"
"Normal Newborn","795","TRIS-DRG","","","","","","","","inpatient","","","8721.66","","TRICARE [160005]","HB BWH TRICARE","950.32","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($1,669.29). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $45,396.29 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($1,963.87), capped at $1,201.45. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $45,396.29 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","1908.87","1358.27","7660.96","1 through 10","950.32","950.32","other","Inpatient DRGs"
"Notch 1myd88","PX-31000388","CDM","81479","CPT","0310","RC","","","","both","","","542.00","406.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","430.89","79.5","","0.65","0.65","0.65","1 through 10","168.02","514.9","percent of total billed charges",""
"Notch 1myd88","PX-31000388","CDM","81479","CPT","0310","RC","","","","both","","","542.00","406.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","288.89","53.3","","0.79","0.79","0.79","1 through 10","168.02","514.9","percent of total billed charges",""
"Notch 1myd88","PX-31000388","CDM","81479","CPT","0310","RC","","","","outpatient","","","542.00","406.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","271.00","50","","1.00","1.00","1.00","1 through 10","156.55","447.15","percent of total billed charges",""
"Notch 1myd88","PX-31000388","CDM","81479","CPT","0310","RC","","","","outpatient","","","542.00","406.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","284.55","52.5","","1.00","0.53","1.00","1 through 10","156.55","447.15","percent of total billed charges",""
"Notch1 Del CT","PX-30001700","CDM","81479","CPT","0300","RC","","","","both","","","208.00","156.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","165.36","79.5","","0.65","0.65","0.65","1 through 10","64.48","197.6","percent of total billed charges",""
"Notch1 Del CT","PX-30001700","CDM","81479","CPT","0300","RC","","","","both","","","208.00","156.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","110.86","53.3","","0.79","0.79","0.79","1 through 10","64.48","197.6","percent of total billed charges",""
"Notch1 Del CT","PX-30001700","CDM","81479","CPT","0300","RC","","","","outpatient","","","208.00","156.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","104.00","50","","1.00","1.00","1.00","1 through 10","100.67","171.6","percent of total billed charges",""
"Notch1 Del CT","PX-30001700","CDM","81479","CPT","0300","RC","","","","outpatient","","","208.00","156.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","109.20","52.5","","1.00","0.53","1.00","1 through 10","100.67","171.6","percent of total billed charges",""
"Notch1 Rh Gene Analysis","PX-31000776","CDM","81479","CPT","0310","RC","","","","both","","","6013.00","4509.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4780.34","79.5","","0.65","0.65","0.65","1 through 10","1864.03","5712.35","percent of total billed charges",""
"Notch1 Rh Gene Analysis","PX-31000776","CDM","81479","CPT","0310","RC","","","","both","","","6013.00","4509.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3204.93","53.3","","0.79","0.79","0.79","1 through 10","1864.03","5712.35","percent of total billed charges",""
"Notch1 Rh Gene Analysis","PX-31000776","CDM","81479","CPT","0310","RC","","","","outpatient","","","6013.00","4509.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3640.87","60.55","","1.00","1.00","1.00","1 through 10","2910.29","4960.73","percent of total billed charges",""
"Notch1 Rh Gene Analysis","PX-31000776","CDM","81479","CPT","0310","RC","","","","outpatient","","","6013.00","4509.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3139.99","52.22","","1.00","1.00","1.00","1 through 10","2910.29","4960.73","percent of total billed charges",""
"Notch1 Rh Gene Analysis","PX-31000776","CDM","81479","CPT","0310","RC","","","","outpatient","","","6013.00","4509.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3006.50","50","","1.00","1.00","1.00","1 through 10","2910.29","4960.73","percent of total billed charges",""
"Notch1 Rh Gene Analysis","PX-31000776","CDM","81479","CPT","0310","RC","","","","outpatient","","","6013.00","4509.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3156.83","52.5","","1.00","0.53","1.00","1 through 10","2910.29","4960.73","percent of total billed charges",""
"Ntrk1 & 2 Fusion","PX-31001121","CDM","81479","CPT","0310","RC","","","","both","","","3391.00","2543.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2695.85","79.5","","0.65","0.65","0.65","1 through 10","1051.21","3221.45","percent of total billed charges",""
"Ntrk1 & 2 Fusion","PX-31001121","CDM","81479","CPT","0310","RC","","","","both","","","3391.00","2543.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1807.40","53.3","","0.79","0.79","0.79","1 through 10","1051.21","3221.45","percent of total billed charges",""
"Ntrk1 & 2 Fusion","PX-31001121","CDM","81479","CPT","0310","RC","","","","outpatient","","","3391.00","2543.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1695.50","50","","1.00","1.00","1.00","1 through 10","156.55","2797.58","percent of total billed charges",""
"Ntrk1 & 2 Fusion","PX-31001121","CDM","81479","CPT","0310","RC","","","","outpatient","","","3391.00","2543.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1780.28","52.5","","1.00","0.53","1.00","1 through 10","156.55","2797.58","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","328.00","246.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","229.60","70","","318.00","34.39","318.00","1 through 10","26.86","311.6","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","328.00","246.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","260.76","79.5","","250.27","167.90","250.27","44","26.86","311.6","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","328.00","246.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","174.82","53.3","","250.27","167.90","750.81","30","26.86","311.6","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","328.00","246.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","252.56","77","","244.86","244.86","244.86","1 through 10","26.86","311.6","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","328.00","246.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","213.20","65","","206.70","206.70","206.70","1 through 10","26.86","311.6","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","328.00","246.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","101.68","31","","98.26","98.26","98.26","1 through 10","26.86","311.6","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","328.00","246.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","119.72","36.5","","115.12","100.81","118.61","33","26.86","311.6","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","328.00","246.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","125.62","38.3","","124.34","104.94","373.02","66","26.86","311.6","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","328.00","246.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","252.56","77","","248.04","248.04","248.04","1 through 10","26.86","311.6","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","328.00","246.00","TRICARE [160005]","HB BWH TRICARE","311.60","95","","40.17","40.17","40.17","1 through 10","26.86","311.6","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","328.00","246.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.71","42.9","","254.21","159.08","254.21","1 through 10","26.86","311.6","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","328.00","246.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.71","42.9","","139.82","139.82","139.82","1 through 10","26.86","311.6","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","328.00","246.00","AETNA [1001]","HB AMC AETNA HMO","228.94","69.8","","215.29","152.00","248.04","51","26.86","268.04","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","328.00","246.00","AETNA [1001]","HB AMC AETNA PPO","263.71","80.4","","248.04","166.63","333.26","1 through 10","26.86","268.04","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","328.00","246.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","171.41","52.26","","196.78","196.78","196.78","1 through 10","26.86","268.04","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","328.00","246.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","268.04","81.72","","254.21","254.21","254.21","1 through 10","26.86","268.04","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","328.00","246.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","268.04","81.72","","139.82","139.82","139.82","1 through 10","26.86","268.04","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","328.00","246.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","268.04","81.72","","254.21","139.82","254.21","50","26.86","268.04","percent of total billed charges",""
"Nucleic Acid Amp Borrelia","PX-30001265","CDM","87476","CPT","0306","RC","","","","both","","","445.00","333.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","353.78","79.5","","339.98","339.98","339.98","1 through 10","26.86","422.75","percent of total billed charges",""
"Nucleic Acid Amp Borrelia","PX-30001265","CDM","87476","CPT","0306","RC","","","","both","","","445.00","333.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","237.19","53.3","","339.98","339.98","339.98","1 through 10","26.86","422.75","percent of total billed charges",""
"Nucleic Acid Amp Borrelia","PX-30001265","CDM","87476","CPT","0306","RC","","","","both","","","445.00","333.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","162.43","36.5","","483.42","136.94","483.42","1 through 10","26.86","422.75","percent of total billed charges",""
"Nucleic Acid Amp Borrelia","PX-30001265","CDM","87476","CPT","0306","RC","","","","both","","","445.00","333.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","170.44","38.3","","168.91","168.91","168.91","1 through 10","26.86","422.75","percent of total billed charges",""
"Nucleic Acid Amp Borrelia","PX-30001265","CDM","87476","CPT","0306","RC","","","","both","","","445.00","333.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","190.91","42.9","","345.34","345.34","345.34","1 through 10","26.86","422.75","percent of total billed charges",""
"Nucleic Acid Amp Borrelia","PX-30001265","CDM","87476","CPT","0306","RC","","","","outpatient","","","445.00","333.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","363.65","81.72","","345.34","189.95","345.34","1 through 10","26.86","363.65","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","433.00","324.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","344.24","79.5","","330.54","221.76","420.00","135","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","433.00","324.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","230.79","53.3","","221.76","221.76","991.62","72","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","433.00","324.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","333.41","77","","323.40","323.40","323.40","1 through 10","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","433.00","324.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","344.24","79.5","","330.54","330.54","330.54","1 through 10","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","433.00","324.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","134.23","31","","129.78","129.78","259.56","13","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","433.00","324.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","158.05","36.5","","156.66","133.14","399.42","287","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","433.00","324.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","165.84","38.3","","164.22","159.60","492.66","888","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","433.00","324.75","MOLINA [1014]","HB BWH MOLINA","151.55","35","","69.62","69.62","69.62","1 through 10","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","433.00","324.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","333.41","77","","327.60","43.86","327.60","1 through 10","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","433.00","324.75","TRICARE [160005]","HB BWH TRICARE","411.35","95","","42.28","40.17","42.28","12","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","433.00","324.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","185.76","42.9","","184.67","184.67","335.75","1 through 10","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","433.00","324.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","185.76","42.9","","184.67","184.67","184.67","1 through 10","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","433.00","324.75","AETNA [1001]","HB AMC AETNA HMO","302.23","69.8","","284.34","200.76","327.60","225","26.86","353.85","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","433.00","324.75","AETNA [1001]","HB AMC AETNA PPO","348.13","80.4","","327.60","220.08","327.60","41","26.86","353.85","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","433.00","324.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","242.05","55.9","","220.08","220.08","220.08","1 through 10","26.86","353.85","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","433.00","324.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","226.29","52.26","","259.90","123.73","259.90","1 through 10","26.86","353.85","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","433.00","324.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","348.13","80.4","","327.60","327.60","335.75","1 through 10","26.86","353.85","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","433.00","324.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","353.85","81.72","","278.38","184.67","420.00","12","26.86","353.85","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","433.00","324.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","353.85","81.72","","335.75","184.67","335.75","182","26.86","353.85","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","212.80","70","","212.40","212.40","212.40","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","CHAMPVA [160001]","HB BWH TRICARE","288.80","95","","42.28","42.28","42.28","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","241.68","79.5","","232.17","155.76","696.51","401","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","162.03","53.3","","232.17","155.76","467.28","191","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","234.08","77","","227.15","227.15","227.15","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","197.60","65","","191.75","191.75","191.75","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","241.68","79.5","","232.17","232.17","232.17","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","94.24","31","","182.32","91.16","364.64","34","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","110.96","36.5","","110.04","93.52","330.12","736","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","116.43","38.3","","115.35","115.35","346.05","2420","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","234.08","77","","230.10","31.58","313.39","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","TRICARE [160005]","HB BWH TRICARE","288.80","95","","40.17","40.17","42.28","25","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.42","42.9","","235.82","129.71","530.82","24","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","304.00","228.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.42","42.9","","129.71","129.71","129.71","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","304.00","228.00","AETNA [1001]","HB AMC AETNA HMO","212.19","69.8","","199.72","141.01","230.10","631","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","304.00","228.00","AETNA [1001]","HB AMC AETNA PPO","244.42","80.4","","230.10","154.58","309.16","98","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","304.00","228.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","169.94","55.9","","154.58","154.58","309.16","1 through 10","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","304.00","228.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","158.87","52.26","","123.73","123.73","182.55","1 through 10","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","304.00","228.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","244.42","80.4","","230.10","147.50","235.82","1 through 10","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","304.00","228.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","248.43","81.72","","129.71","129.71","235.82","33","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","304.00","228.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","248.43","81.72","","235.82","129.71","235.82","560","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Nucleic Acid Amp Multi Org","PX-30001347","CDM","87801","CPT","0306","RC","","","","both","","","747.00","560.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","286.10","38.3","","283.08","283.08","283.08","1 through 10","53.71","709.65","percent of total billed charges",""
"Nucleic Acid Amp Multi Org","PX-30001347","CDM","87801","CPT","0306","RC","","","","outpatient","","","747.00","560.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","610.45","81.72","","578.77","578.77","578.77","1 through 10","53.71","610.45","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","212.80","70","","212.40","212.40","212.40","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","CHAMPVA [160001]","HB BWH TRICARE","288.80","95","","42.28","42.28","42.28","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","241.68","79.5","","232.17","155.76","696.51","413","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","162.03","53.3","","232.17","155.76","467.28","189","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","234.08","77","","227.15","227.15","227.15","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","197.60","65","","191.75","191.75","191.75","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","241.68","79.5","","232.17","232.17","232.17","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","94.24","31","","182.32","91.16","364.64","34","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","110.96","36.5","","110.04","93.52","330.12","736","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","116.43","38.3","","115.35","115.35","346.05","2418","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","234.08","77","","230.10","31.58","313.39","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","TRICARE [160005]","HB BWH TRICARE","288.80","95","","40.17","40.17","42.28","25","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.42","42.9","","235.82","129.71","530.82","24","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","304.00","228.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.42","42.9","","129.71","129.71","129.71","1 through 10","26.86","288.8","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","304.00","228.00","AETNA [1001]","HB AMC AETNA HMO","212.19","69.8","","199.72","141.01","230.10","632","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","304.00","228.00","AETNA [1001]","HB AMC AETNA PPO","244.42","80.4","","230.10","154.58","309.16","98","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","304.00","228.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","169.94","55.9","","154.58","154.58","309.16","1 through 10","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","304.00","228.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","158.87","52.26","","123.73","123.73","182.55","1 through 10","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","304.00","228.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","244.42","80.4","","230.10","147.50","235.82","1 through 10","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","304.00","228.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","248.43","81.72","","129.71","129.71","235.82","33","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","304.00","228.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","248.43","81.72","","235.82","129.71","235.82","560","26.86","248.43","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","both","","","410.00","307.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","325.95","79.5","","313.23","313.23","313.23","1 through 10","26.86","389.5","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","both","","","410.00","307.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","218.53","53.3","","313.23","313.23","313.23","1 through 10","26.86","389.5","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","both","","","410.00","307.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","149.65","36.5","","148.45","126.17","148.45","1 through 10","26.86","389.5","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","both","","","410.00","307.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.03","38.3","","155.62","155.62","466.86","23","26.86","389.5","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","both","","","410.00","307.50","TRICARE [160005]","HB BWH TRICARE","389.50","95","","44.91","44.91","44.91","1 through 10","26.86","389.5","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","outpatient","","","410.00","307.50","AETNA [1001]","HB AMC AETNA HMO","286.18","69.8","","269.45","269.45","269.45","1 through 10","26.86","335.05","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","outpatient","","","410.00","307.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","335.05","81.72","","318.16","175.00","318.16","1 through 10","26.86","335.05","percent of total billed charges",""
"Nucleic Acid Amp Probe Cmv","PX-30001280","CDM","87496","CPT","0306","RC","","","","both","","","551.00","413.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","385.70","70","","534.00","534.00","534.00","1 through 10","26.86","523.45","percent of total billed charges",""
"Nucleic Acid Amp Probe Cmv","PX-30001280","CDM","87496","CPT","0306","RC","","","","both","","","551.00","413.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","438.05","79.5","","420.26","420.26","420.26","1 through 10","26.86","523.45","percent of total billed charges",""
"Nucleic Acid Amp Probe Cmv","PX-30001280","CDM","87496","CPT","0306","RC","","","","both","","","551.00","413.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","358.15","65","","694.20","694.20","694.20","1 through 10","26.86","523.45","percent of total billed charges",""
"Nucleic Acid Amp Probe Cmv","PX-30001280","CDM","87496","CPT","0306","RC","","","","both","","","551.00","413.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","211.03","38.3","","208.79","208.79","208.79","1 through 10","26.86","523.45","percent of total billed charges",""
"Nucleic Acid Amp Probe Cmv","PX-30001280","CDM","87496","CPT","0306","RC","","","","both","","","551.00","413.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","236.38","42.9","","426.88","407.38","426.88","1 through 10","26.86","523.45","percent of total billed charges",""
"Nucleic Acid Amp Probe Cmv","PX-30001280","CDM","87496","CPT","0306","RC","","","","outpatient","","","551.00","413.25","AETNA [1001]","HB AMC AETNA HMO","384.60","69.8","","1385.98","1385.98","1385.98","1 through 10","26.86","450.28","percent of total billed charges",""
"Nucleic Acid Amp Probe Cmv","PX-30001280","CDM","87496","CPT","0306","RC","","","","outpatient","","","551.00","413.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","450.28","81.72","","426.88","426.88","426.88","1 through 10","26.86","450.28","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","both","","","339.00","254.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","237.30","70","","329.00","329.00","329.00","1 through 10","26.86","322.05","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","both","","","339.00","254.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","269.51","79.5","","258.93","173.71","517.85","16","26.86","322.05","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","both","","","339.00","254.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","180.69","53.3","","258.93","173.71","676.42","16","26.86","322.05","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","both","","","339.00","254.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","220.35","65","","427.70","427.70","427.70","1 through 10","26.86","322.05","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","both","","","339.00","254.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","105.09","31","","101.66","101.66","101.66","1 through 10","26.86","322.05","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","both","","","339.00","254.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.74","36.5","","122.72","104.30","122.72","47","26.86","322.05","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","both","","","339.00","254.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","129.84","38.3","","128.64","128.64","128.64","162","26.86","322.05","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","both","","","339.00","254.25","TRICARE [160005]","HB BWH TRICARE","322.05","95","","42.28","42.28","42.28","1 through 10","26.86","322.05","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","both","","","339.00","254.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.43","42.9","","263.01","263.00","263.01","1 through 10","26.86","322.05","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","339.00","254.25","AETNA [1001]","HB AMC AETNA HMO","236.62","69.8","","222.74","157.26","256.62","56","26.86","277.03","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","339.00","254.25","AETNA [1001]","HB AMC AETNA PPO","272.56","80.4","","172.40","172.40","256.62","17","26.86","277.03","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","339.00","254.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","272.56","80.4","","263.00","263.00","263.00","1 through 10","26.86","277.03","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","339.00","254.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","277.03","81.72","","144.66","144.66","526.00","1 through 10","26.86","277.03","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","339.00","254.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","277.03","81.72","","263.01","144.66","263.01","45","26.86","277.03","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","both","","","433.00","324.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","344.24","79.5","","330.54","330.54","330.54","1 through 10","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","both","","","433.00","324.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","230.79","53.3","","330.54","330.54","330.54","1 through 10","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","both","","","433.00","324.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","158.05","36.5","","156.66","133.14","156.66","1 through 10","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","both","","","433.00","324.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","165.84","38.3","","164.22","159.60","164.22","21","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","both","","","433.00","324.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","185.76","42.9","","335.75","335.75","335.75","1 through 10","26.86","411.35","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","outpatient","","","433.00","324.75","AETNA [1001]","HB AMC AETNA HMO","302.23","69.8","","284.34","47.37","327.60","1 through 10","26.86","353.85","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","outpatient","","","433.00","324.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","353.85","81.72","","335.75","335.75","335.75","1 through 10","26.86","353.85","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","both","","","431.00","323.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","342.65","79.5","","328.97","220.70","328.97","162","26.86","409.45","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","both","","","431.00","323.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","229.72","53.3","","328.97","220.70","328.97","69","26.86","409.45","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","both","","","431.00","323.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","342.65","79.5","","328.97","183.79","328.97","1 through 10","26.86","409.45","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","both","","","431.00","323.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","133.61","31","","387.48","129.16","387.48","1 through 10","26.86","409.45","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","both","","","431.00","323.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","157.32","36.5","","155.91","132.51","155.91","94","26.86","409.45","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","both","","","431.00","323.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","165.07","38.3","","163.44","158.84","490.32","444","26.86","409.45","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","both","","","431.00","323.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","331.87","77","","314.16","314.16","314.16","1 through 10","26.86","409.45","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","both","","","431.00","323.25","TRICARE [160005]","HB BWH TRICARE","409.45","95","","42.28","40.17","42.28","18","26.86","409.45","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","both","","","431.00","323.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","184.90","42.9","","334.15","183.79","752.15","1 through 10","26.86","409.45","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","outpatient","","","431.00","323.25","AETNA [1001]","HB AMC AETNA HMO","300.84","69.8","","282.99","199.80","326.04","233","26.86","352.21","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","outpatient","","","431.00","323.25","AETNA [1001]","HB AMC AETNA PPO","346.52","80.4","","326.04","219.03","326.04","21","26.86","352.21","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","outpatient","","","431.00","323.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","225.24","52.26","","258.66","258.66","258.66","1 through 10","26.86","352.21","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","outpatient","","","431.00","323.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","352.21","81.72","","334.15","183.79","334.15","1 through 10","26.86","352.21","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","outpatient","","","431.00","323.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","352.21","81.72","","334.15","183.79","334.15","164","26.86","352.21","percent of total billed charges",""
"Nucleic Acid Amp TB","PX-30001320","CDM","87556","CPT","0306","RC","","","","both","","","431.00","323.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","342.65","79.5","","328.97","328.97","328.97","1 through 10","26.86","409.45","percent of total billed charges",""
"Nucleic Acid Amp TB","PX-30001320","CDM","87556","CPT","0306","RC","","","","both","","","431.00","323.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","157.32","36.5","","155.91","155.91","155.91","1 through 10","26.86","409.45","percent of total billed charges",""
"Nucleic Acid Direct Infectious","PX-30001343","CDM","87797","CPT","0306","RC","","","","both","","","349.00","261.75","TRICARE [160005]","HB BWH TRICARE","331.55","95","","34.38","34.38","34.38","1 through 10","20.68","331.55","percent of total billed charges",""
"Nucleic Acid Genotype Hepatitis C","PX-30001361","CDM","87902","CPT","0306","RC","","","","both","","","1561.00","1170.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1241.00","79.5","","1191.52","1191.52","1191.52","1 through 10","84.84","1482.95","percent of total billed charges",""
"Nucleic Acid Genotype Hepatitis C","PX-30001361","CDM","87902","CPT","0306","RC","","","","both","","","1561.00","1170.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","569.77","36.5","","564.72","564.72","564.72","1 through 10","84.84","1482.95","percent of total billed charges",""
"Nucleic Acid Genotype Hiv 1","PX-30001360","CDM","87901","CPT","0306","RC","","","","both","","","1475.00","1106.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","564.93","38.3","","559.13","559.13","559.13","1 through 10","84.84","1401.25","percent of total billed charges",""
"Nucleic Acid Genotype Hiv 1","PX-30001360","CDM","87901","CPT","0306","RC","","","","outpatient","","","1475.00","1106.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1205.37","81.72","","628.77","628.77","628.77","1 through 10","84.84","1753.49","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","453.78","71.8","","440.13","37.78","1320.39","54","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","414.59","65.6","","415.00","415.00","415.00","1 through 10","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","410.80","65","","1195.35","398.45","1618.33","31","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","442.40","70","","436.88","148.51","1324.08","28","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","502.44","79.5","","482.43","398.45","1447.29","14","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","336.86","53.3","","482.43","323.66","511.57","36","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","486.64","77","","1036.42","1036.42","1036.42","1 through 10","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","410.80","65","","398.45","398.45","398.45","1 through 10","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","230.68","36.5","","228.65","221.91","685.95","14","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","242.06","38.3","","239.68","239.68","719.04","31","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","MOLINA [1014]","HB BWH MOLINA","221.20","35","","169.29","127.14","170.67","11","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","486.64","77","","502.66","502.66","502.66","1 through 10","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","TRICARE [160005]","HB BWH TRICARE","600.40","95","","51.62","51.62","51.62","1 through 10","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","632.00","474.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","271.13","42.9","","490.03","269.54","490.04","1 through 10","41.98","600.4","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","632.00","474.00","AETNA [1001]","HB AMC AETNA HMO","441.14","69.8","","415.00","293.01","478.14","54","44.17","516.47","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","632.00","474.00","AETNA [1001]","HB AMC AETNA PPO","508.13","80.4","","478.14","321.21","478.14","1 through 10","44.17","516.47","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","632.00","474.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","508.13","80.4","","306.50","306.50","306.50","1 through 10","44.17","516.47","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","632.00","474.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","516.47","81.72","","269.54","269.54","269.54","1 through 10","44.17","516.47","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","632.00","474.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","516.47","81.72","","490.03","194.21","490.03","52","44.17","516.47","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","both","","","552.00","414.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","396.34","71.8","","1152.39","384.13","1152.39","1 through 10","41.98","524.4","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","both","","","552.00","414.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","362.11","65.6","","362.20","362.20","362.20","1 through 10","41.98","524.4","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","both","","","552.00","414.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","358.80","65","","347.75","282.48","347.75","1 through 10","41.98","524.4","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","both","","","552.00","414.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","386.40","70","","358.93","230.05","535.00","1 through 10","41.98","524.4","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","both","","","552.00","414.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","438.84","79.5","","421.05","282.48","421.05","18","41.98","524.4","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","both","","","552.00","414.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","294.22","53.3","","421.05","282.48","421.05","12","41.98","524.4","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","both","","","552.00","414.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","201.48","36.5","","199.56","193.67","282.08","14","41.98","524.4","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","both","","","552.00","414.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","211.42","38.3","","209.19","209.19","627.57","64","41.98","524.4","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","both","","","552.00","414.00","MOLINA [1014]","HB BWH MOLINA","193.20","35","","41.98","41.98","41.98","1 through 10","41.98","524.4","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","both","","","552.00","414.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","236.81","42.9","","962.68","962.68","962.68","1 through 10","41.98","524.4","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","outpatient","","","552.00","414.00","AETNA [1001]","HB AMC AETNA HMO","385.30","69.8","","362.20","255.73","417.30","27","44.17","451.09","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","outpatient","","","552.00","414.00","AETNA [1001]","HB AMC AETNA PPO","443.81","80.4","","417.30","280.34","417.30","1 through 10","44.17","451.09","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","outpatient","","","552.00","414.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","443.81","80.4","","267.50","267.50","267.50","1 through 10","44.17","451.09","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","outpatient","","","552.00","414.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","451.09","81.72","","235.24","235.24","235.24","1 through 10","44.17","451.09","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","outpatient","","","552.00","414.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","451.09","81.72","","427.68","235.24","427.68","13","44.17","451.09","percent of total billed charges",""
"Nucleic Acid Qn Herpes 6","PX-30001306","CDM","87533","CPT","0306","RC","","","","outpatient","","","759.00","569.25","AETNA [1001]","HB AMC AETNA HMO","529.78","69.8","","498.27","498.27","498.27","1 through 10","43.05","620.25","percent of total billed charges",""
"Nucleic Acid Qn Herpes Smpx","PX-30001302","CDM","87530","CPT","0306","RC","","","","both","","","691.00","518.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","549.35","79.5","","1054.58","1054.58","1054.58","1 through 10","41.98","656.45","percent of total billed charges",""
"Nucleic Acid Qn Herpes Smpx","PX-30001302","CDM","87530","CPT","0306","RC","","","","both","","","691.00","518.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","252.22","36.5","","242.54","212.39","249.91","1 through 10","41.98","656.45","percent of total billed charges",""
"Nucleic Acid Qn Herpes Smpx","PX-30001302","CDM","87530","CPT","0306","RC","","","","both","","","691.00","518.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","264.65","38.3","","261.97","261.97","261.97","1 through 10","41.98","656.45","percent of total billed charges",""
"Nucleic Acid Qn Herpes Smpx","PX-30001302","CDM","87530","CPT","0306","RC","","","","both","","","691.00","518.25","TRICARE [160005]","HB BWH TRICARE","656.45","95","","103.24","103.24","103.24","1 through 10","41.98","656.45","percent of total billed charges",""
"Nucleic Acid Qn Herpes Smpx","PX-30001302","CDM","87530","CPT","0306","RC","","","","both","","","691.00","518.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","296.44","42.9","","535.60","294.60","535.60","1 through 10","41.98","656.45","percent of total billed charges",""
"Nucleic Acid Qn Herpes Smpx","PX-30001302","CDM","87530","CPT","0306","RC","","","","both","","","691.00","518.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","296.44","42.9","","294.60","294.60","294.60","1 through 10","41.98","656.45","percent of total billed charges",""
"Nucleic Acid Qn Herpes Smpx","PX-30001302","CDM","87530","CPT","0306","RC","","","","outpatient","","","691.00","518.25","AETNA [1001]","HB AMC AETNA HMO","482.32","69.8","","640.52","453.59","907.18","1 through 10","44.17","564.69","percent of total billed charges",""
"Nucleic Acid Qn Herpes Smpx","PX-30001302","CDM","87530","CPT","0306","RC","","","","outpatient","","","691.00","518.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","564.69","81.72","","535.60","294.60","535.60","1 through 10","44.17","564.69","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","460.24","71.8","","446.60","37.78","1339.80","71","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","420.50","65.6","","421.09","421.09","421.09","1 through 10","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","416.65","65","","404.30","404.30","1462.23","50","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","448.70","70","","447.84","267.46","1069.84","38","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.60","79.5","","489.51","328.42","489.51","13","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.65","53.3","","489.51","328.42","1072.54","43","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","1062.60","1062.60","1062.60","1 through 10","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","416.65","65","","404.30","404.30","404.30","1 through 10","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.71","31","","192.20","192.20","192.20","1 through 10","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.97","36.5","","225.16","197.17","232.01","35","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.50","38.3","","243.20","243.20","446.60","66","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","493.57","77","","510.04","510.04","510.04","1 through 10","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","TRICARE [160005]","HB BWH TRICARE","608.95","95","","51.62","51.62","51.62","1 through 10","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.99","42.9","","497.23","273.49","497.23","1 through 10","41.98","608.95","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA HMO","447.42","69.8","","421.09","297.32","842.18","79","44.17","523.83","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","AETNA [1001]","HB AMC AETNA PPO","515.36","80.4","","325.93","297.32","485.16","1 through 10","44.17","523.83","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.36","80.4","","622.00","622.00","622.00","1 through 10","44.17","523.83","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.83","81.72","","273.49","273.49","273.49","1 through 10","44.17","523.83","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","641.00","480.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.83","81.72","","497.23","194.21","994.46","62","44.17","523.83","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","592.00","444.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","425.06","71.8","","1236.39","412.13","1236.39","1 through 10","41.98","562.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","592.00","444.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","388.35","65.6","","388.60","388.60","388.60","1 through 10","41.98","562.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","592.00","444.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","384.80","65","","373.10","373.10","373.10","24","41.98","562.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","592.00","444.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","414.40","70","","413.28","246.82","574.00","1 through 10","41.98","562.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","592.00","444.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","470.64","79.5","","451.74","303.07","451.74","12","41.98","562.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","592.00","444.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","315.54","53.3","","373.10","303.07","451.74","1 through 10","41.98","562.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","592.00","444.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","455.84","77","","441.98","441.98","441.98","1 through 10","41.98","562.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","592.00","444.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","384.80","65","","373.10","373.10","373.10","1 through 10","41.98","562.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","592.00","444.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","216.08","36.5","","214.10","214.10","214.10","1 through 10","41.98","562.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","592.00","444.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","226.74","38.3","","224.43","218.12","654.36","59","41.98","562.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","592.00","444.00","MOLINA [1014]","HB BWH MOLINA","207.20","35","","84.99","84.99","84.99","1 through 10","41.98","562.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","592.00","444.00","TRICARE [160005]","HB BWH TRICARE","562.40","95","","51.62","51.62","51.62","1 through 10","41.98","562.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","592.00","444.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","253.97","42.9","","458.86","458.86","458.86","1 through 10","41.98","562.4","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","outpatient","","","592.00","444.00","AETNA [1001]","HB AMC AETNA HMO","413.22","69.8","","388.60","274.37","447.72","18","44.17","483.78","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","outpatient","","","592.00","444.00","AETNA [1001]","HB AMC AETNA PPO","475.97","80.4","","447.72","44.08","447.72","1 through 10","44.17","483.78","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","outpatient","","","592.00","444.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","483.78","81.72","","458.86","458.86","458.86","1 through 10","44.17","483.78","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","outpatient","","","592.00","444.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","483.78","81.72","","458.86","458.86","458.86","1 through 10","44.17","483.78","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","706.00","529.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","506.91","71.8","","1475.49","491.83","1475.49","1 through 10","57.95","670.7","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","706.00","529.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","463.14","65.6","","463.75","463.75","463.75","1 through 10","57.95","670.7","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","706.00","529.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","458.90","65","","445.25","361.68","445.25","1 through 10","57.95","670.7","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","706.00","529.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","494.20","70","","493.20","294.55","685.00","1 through 10","57.95","670.7","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","706.00","529.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","561.27","79.5","","539.10","361.68","1617.30","12","57.95","670.7","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","706.00","529.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","376.30","53.3","","445.25","345.93","539.10","1 through 10","57.95","670.7","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","706.00","529.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","218.86","31","","211.67","211.67","418.06","1 through 10","57.95","670.7","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","706.00","529.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","257.69","36.5","","217.15","217.15","255.51","23","57.95","670.7","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","706.00","529.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","270.40","38.3","","267.84","267.84","803.52","83","57.95","670.7","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","706.00","529.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","543.62","77","","67.97","67.97","67.97","1 through 10","57.95","670.7","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","706.00","529.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","302.87","42.9","","301.19","301.19","301.19","1 through 10","57.95","670.7","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","outpatient","","","706.00","529.50","AETNA [1001]","HB AMC AETNA HMO","492.79","69.8","","463.75","327.43","534.30","17","57.95","579.59","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","outpatient","","","706.00","529.50","AETNA [1001]","HB AMC AETNA PPO","567.62","80.4","","534.30","358.94","534.30","1 through 10","57.95","579.59","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","outpatient","","","706.00","529.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","576.94","81.72","","547.59","547.59","685.00","1 through 10","57.95","579.59","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","outpatient","","","706.00","529.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","576.94","81.72","","547.59","301.19","547.59","11","57.95","579.59","percent of total billed charges",""
"Nucleic Acid Rev Trans/Amp Probe En","PX-30001282","CDM","87498","CPT","0306","RC","","","","both","","","469.00","351.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","372.86","79.5","","240.24","240.24","240.24","1 through 10","26.86","445.55","percent of total billed charges",""
"Nucleic Acid Rev Trans/Amp Probe En","PX-30001282","CDM","87498","CPT","0306","RC","","","","both","","","469.00","351.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","249.98","53.3","","358.09","240.24","358.09","1 through 10","26.86","445.55","percent of total billed charges",""
"Nucleic Acid Rev Trans/Amp Probe En","PX-30001282","CDM","87498","CPT","0306","RC","","","","both","","","469.00","351.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","171.19","36.5","","339.44","339.44","339.44","1 through 10","26.86","445.55","percent of total billed charges",""
"Nucleic Acid Rev Trans/Amp Probe En","PX-30001282","CDM","87498","CPT","0306","RC","","","","both","","","469.00","351.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.63","38.3","","177.91","177.91","177.91","1 through 10","26.86","445.55","percent of total billed charges",""
"Nucleic Acid Rev Trans/Amp Probe En","PX-30001282","CDM","87498","CPT","0306","RC","","","","both","","","469.00","351.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.20","42.9","","200.06","200.06","200.06","1 through 10","26.86","445.55","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","both","","","327.00","245.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","228.90","70","","317.00","317.00","317.00","1 through 10","26.86","310.65","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","both","","","327.00","245.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","259.97","79.5","","249.48","249.48","249.48","1 through 10","26.86","310.65","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","both","","","327.00","245.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","251.79","77","","244.09","244.09","244.09","1 through 10","26.86","310.65","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","both","","","327.00","245.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","212.55","65","","206.05","206.05","206.05","1 through 10","26.86","310.65","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","both","","","327.00","245.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","251.79","77","","247.26","247.26","247.26","1 through 10","26.86","310.65","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","outpatient","","","327.00","245.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","267.22","81.72","","253.41","253.41","253.41","1 through 10","26.86","267.22","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","outpatient","","","327.00","245.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","267.22","81.72","","253.41","201.39","253.41","1 through 10","26.86","267.22","percent of total billed charges",""
"Nucleotidase 5","PX-30000588","CDM","83915","CPT","0301","RC","","","","both","","","184.00","138.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","146.28","79.5","","140.09","140.09","140.09","1 through 10","10.93","174.8","percent of total billed charges",""
"Nucleotidase 5","PX-30000588","CDM","83915","CPT","0301","RC","","","","both","","","184.00","138.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","98.07","53.3","","140.09","140.09","140.09","1 through 10","10.93","174.8","percent of total billed charges",""
"Nucleotidase 5","PX-30000588","CDM","83915","CPT","0301","RC","","","","both","","","184.00","138.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.16","36.5","","66.39","66.39","66.39","1 through 10","10.93","174.8","percent of total billed charges",""
"Nucleotidase 5","PX-30000588","CDM","83915","CPT","0301","RC","","","","both","","","184.00","138.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.47","38.3","","69.60","67.64","202.92","17","10.93","174.8","percent of total billed charges",""
"Nucleotidase 5","PX-30000588","CDM","83915","CPT","0301","RC","","","","both","","","184.00","138.00","TRICARE [160005]","HB BWH TRICARE","174.80","95","","13.44","13.44","13.44","1 through 10","10.93","174.8","percent of total billed charges",""
"Nucleotidase 5","PX-30000588","CDM","83915","CPT","0301","RC","","","","both","","","184.00","138.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.94","42.9","","142.29","142.29","142.29","1 through 10","10.93","174.8","percent of total billed charges",""
"Nucleotidase 5","PX-30000588","CDM","83915","CPT","0301","RC","","","","outpatient","","","184.00","138.00","AETNA [1001]","HB AMC AETNA HMO","128.43","69.8","","120.51","85.08","138.84","1 through 10","11.49","150.36","percent of total billed charges",""
"Nucleotidase 5","PX-30000588","CDM","83915","CPT","0301","RC","","","","outpatient","","","184.00","138.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","150.36","81.72","","142.29","78.27","142.29","1 through 10","11.49","150.36","percent of total billed charges",""
"NUT BONE 4.5MM CORTEX TI SCREW SELF TAPPING","SUP-ITM-10017930","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","65.89","79.5","","800.18","480.96","1887.97","195","25.69","65.89","percent of total billed charges",""
"NUT BONE 4.5MM CORTEX TI SCREW SELF TAPPING","SUP-ITM-10017930","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","44.18","53.3","","813.12","216.42","1444.50","81","25.69","65.89","percent of total billed charges",""
"NUT BONE 4.5MM CORTEX TI SCREW SELF TAPPING","SUP-ITM-10017930","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","25.69","31","","432.60","432.60","432.60","1 through 10","25.69","65.89","percent of total billed charges",""
"NUT BONE 4.5MM CORTEX TI SCREW SELF TAPPING","SUP-ITM-10017930","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30.25","36.5","","148.37","54.89","631.39","94","25.69","65.89","percent of total billed charges",""
"NUT BONE 4.5MM CORTEX TI SCREW SELF TAPPING","SUP-ITM-10017930","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31.74","38.3","","279.30","91.72","1116.77","266","25.69","65.89","percent of total billed charges",""
"NUT BONE 4.5MM CORTEX TI SCREW SELF TAPPING","SUP-ITM-10017930","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.56","42.9","","731.00","63.70","731.00","1 through 10","25.69","65.89","percent of total billed charges",""
"NUT BONE 4.5MM CORTEX TI SCREW SELF TAPPING","SUP-ITM-10017930","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.56","42.9","","384.74","384.74","384.74","1 through 10","25.69","65.89","percent of total billed charges",""
"NUT BONE 4.5MM CORTEX TI SCREW SELF TAPPING","SUP-ITM-10017930","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","WELLPOINT [1015]","HB AMC WELLPOINT","61.15","73.78","","286.63","119.22","1107.45","105","25.69","65.89","percent of total billed charges",""
"NUT BONE 4.5MM CORTEX TI SCREW SELF TAPPING","SUP-ITM-10017930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.88","62.16","AETNA [1001]","HB AMC AETNA HMO","57.85","69.8","","675.31","184.75","1721.50","286","43.31","67.73","percent of total billed charges",""
"NUT BONE 4.5MM CORTEX TI SCREW SELF TAPPING","SUP-ITM-10017930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.88","62.16","AETNA [1001]","HB AMC AETNA PPO","66.64","80.4","","1261.44","103.12","1514.10","21","43.31","67.73","percent of total billed charges",""
"NUT BONE 4.5MM CORTEX TI SCREW SELF TAPPING","SUP-ITM-10017930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.88","62.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","66.64","80.4","","1365.00","1365.00","1365.00","1 through 10","43.31","67.73","percent of total billed charges",""
"NUT BONE 4.5MM CORTEX TI SCREW SELF TAPPING","SUP-ITM-10017930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.88","62.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","67.73","81.72","","5157.68","5157.68","5157.68","1 through 10","43.31","67.73","percent of total billed charges",""
"NUT BONE 4.5MM CORTEX TI SCREW SELF TAPPING","SUP-ITM-10017930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.88","62.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","67.73","81.72","","431.26","71.26","1459.57","88","43.31","67.73","percent of total billed charges",""
"NUT BONE 4.5X11MM SCREW CORTICAL SS","SUP-ITM-10004123","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","60.75","79.5","","800.18","480.96","1887.97","195","23.69","60.75","percent of total billed charges",""
"NUT BONE 4.5X11MM SCREW CORTICAL SS","SUP-ITM-10004123","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","40.73","53.3","","813.12","216.42","1444.50","81","23.69","60.75","percent of total billed charges",""
"NUT BONE 4.5X11MM SCREW CORTICAL SS","SUP-ITM-10004123","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","23.69","31","","432.60","432.60","432.60","1 through 10","23.69","60.75","percent of total billed charges",""
"NUT BONE 4.5X11MM SCREW CORTICAL SS","SUP-ITM-10004123","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.89","36.5","","148.37","54.89","631.39","94","23.69","60.75","percent of total billed charges",""
"NUT BONE 4.5X11MM SCREW CORTICAL SS","SUP-ITM-10004123","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.27","38.3","","279.30","91.72","1116.77","266","23.69","60.75","percent of total billed charges",""
"NUT BONE 4.5X11MM SCREW CORTICAL SS","SUP-ITM-10004123","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.78","42.9","","731.00","63.70","731.00","1 through 10","23.69","60.75","percent of total billed charges",""
"NUT BONE 4.5X11MM SCREW CORTICAL SS","SUP-ITM-10004123","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.78","42.9","","384.74","384.74","384.74","1 through 10","23.69","60.75","percent of total billed charges",""
"NUT BONE 4.5X11MM SCREW CORTICAL SS","SUP-ITM-10004123","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","WELLPOINT [1015]","HB AMC WELLPOINT","56.38","73.78","","286.63","119.22","1107.45","105","23.69","60.75","percent of total billed charges",""
"NUT BONE 4.5X11MM SCREW CORTICAL SS","SUP-ITM-10004123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","76.41","57.31","AETNA [1001]","HB AMC AETNA HMO","53.33","69.8","","675.31","184.75","1721.50","286","39.93","62.44","percent of total billed charges",""
"NUT BONE 4.5X11MM SCREW CORTICAL SS","SUP-ITM-10004123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","76.41","57.31","AETNA [1001]","HB AMC AETNA PPO","61.43","80.4","","1261.44","103.12","1514.10","21","39.93","62.44","percent of total billed charges",""
"NUT BONE 4.5X11MM SCREW CORTICAL SS","SUP-ITM-10004123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","76.41","57.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","61.43","80.4","","1365.00","1365.00","1365.00","1 through 10","39.93","62.44","percent of total billed charges",""
"NUT BONE 4.5X11MM SCREW CORTICAL SS","SUP-ITM-10004123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","76.41","57.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","62.44","81.72","","5157.68","5157.68","5157.68","1 through 10","39.93","62.44","percent of total billed charges",""
"NUT BONE 4.5X11MM SCREW CORTICAL SS","SUP-ITM-10004123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","76.41","57.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","62.44","81.72","","431.26","71.26","1459.57","88","39.93","62.44","percent of total billed charges",""
"NUT BONE 9 TO 14MM UNIVERSAL LOCKING NAIL TIBIAL","SUP-ITM-10025860","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.41","318.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","337.41","79.5","","800.18","480.96","1887.97","195","131.57","337.41","percent of total billed charges",""
"NUT BONE 9 TO 14MM UNIVERSAL LOCKING NAIL TIBIAL","SUP-ITM-10025860","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.41","318.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","226.21","53.3","","813.12","216.42","1444.50","81","131.57","337.41","percent of total billed charges",""
"NUT BONE 9 TO 14MM UNIVERSAL LOCKING NAIL TIBIAL","SUP-ITM-10025860","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.41","318.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","131.57","31","","432.60","432.60","432.60","1 through 10","131.57","337.41","percent of total billed charges",""
"NUT BONE 9 TO 14MM UNIVERSAL LOCKING NAIL TIBIAL","SUP-ITM-10025860","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.41","318.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","154.91","36.5","","148.37","54.89","631.39","94","131.57","337.41","percent of total billed charges",""
"NUT BONE 9 TO 14MM UNIVERSAL LOCKING NAIL TIBIAL","SUP-ITM-10025860","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.41","318.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","162.55","38.3","","279.30","91.72","1116.77","266","131.57","337.41","percent of total billed charges",""
"NUT BONE 9 TO 14MM UNIVERSAL LOCKING NAIL TIBIAL","SUP-ITM-10025860","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.41","318.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","182.07","42.9","","731.00","63.70","731.00","1 through 10","131.57","337.41","percent of total billed charges",""
"NUT BONE 9 TO 14MM UNIVERSAL LOCKING NAIL TIBIAL","SUP-ITM-10025860","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.41","318.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","182.07","42.9","","384.74","384.74","384.74","1 through 10","131.57","337.41","percent of total billed charges",""
"NUT BONE 9 TO 14MM UNIVERSAL LOCKING NAIL TIBIAL","SUP-ITM-10025860","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.41","318.31","WELLPOINT [1015]","HB AMC WELLPOINT","313.13","73.78","","286.63","119.22","1107.45","105","131.57","337.41","percent of total billed charges",""
"NUT BONE 9 TO 14MM UNIVERSAL LOCKING NAIL TIBIAL","SUP-ITM-10025860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.41","318.31","AETNA [1001]","HB AMC AETNA HMO","296.24","69.8","","675.31","184.75","1721.50","286","221.8","346.83","percent of total billed charges",""
"NUT BONE 9 TO 14MM UNIVERSAL LOCKING NAIL TIBIAL","SUP-ITM-10025860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.41","318.31","AETNA [1001]","HB AMC AETNA PPO","341.23","80.4","","1261.44","103.12","1514.10","21","221.8","346.83","percent of total billed charges",""
"NUT BONE 9 TO 14MM UNIVERSAL LOCKING NAIL TIBIAL","SUP-ITM-10025860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.41","318.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","341.23","80.4","","1365.00","1365.00","1365.00","1 through 10","221.8","346.83","percent of total billed charges",""
"NUT BONE 9 TO 14MM UNIVERSAL LOCKING NAIL TIBIAL","SUP-ITM-10025860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.41","318.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","346.83","81.72","","5157.68","5157.68","5157.68","1 through 10","221.8","346.83","percent of total billed charges",""
"NUT BONE 9 TO 14MM UNIVERSAL LOCKING NAIL TIBIAL","SUP-ITM-10025860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.41","318.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","346.83","81.72","","431.26","71.26","1459.57","88","221.8","346.83","percent of total billed charges",""
"NUT BONE BUTTRESS COMPRESSION FOR TROCHANTERIC FIXATION NAIL","SUP-ITM-10019882","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.06","351.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","372.11","79.5","","800.18","480.96","1887.97","195","145.1","372.11","percent of total billed charges",""
"NUT BONE BUTTRESS COMPRESSION FOR TROCHANTERIC FIXATION NAIL","SUP-ITM-10019882","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.06","351.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","249.48","53.3","","813.12","216.42","1444.50","81","145.1","372.11","percent of total billed charges",""
"NUT BONE BUTTRESS COMPRESSION FOR TROCHANTERIC FIXATION NAIL","SUP-ITM-10019882","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.06","351.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","145.10","31","","432.60","432.60","432.60","1 through 10","145.1","372.11","percent of total billed charges",""
"NUT BONE BUTTRESS COMPRESSION FOR TROCHANTERIC FIXATION NAIL","SUP-ITM-10019882","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.06","351.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","170.84","36.5","","148.37","54.89","631.39","94","145.1","372.11","percent of total billed charges",""
"NUT BONE BUTTRESS COMPRESSION FOR TROCHANTERIC FIXATION NAIL","SUP-ITM-10019882","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.06","351.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.27","38.3","","279.30","91.72","1116.77","266","145.1","372.11","percent of total billed charges",""
"NUT BONE BUTTRESS COMPRESSION FOR TROCHANTERIC FIXATION NAIL","SUP-ITM-10019882","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.06","351.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.80","42.9","","731.00","63.70","731.00","1 through 10","145.1","372.11","percent of total billed charges",""
"NUT BONE BUTTRESS COMPRESSION FOR TROCHANTERIC FIXATION NAIL","SUP-ITM-10019882","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.06","351.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.80","42.9","","384.74","384.74","384.74","1 through 10","145.1","372.11","percent of total billed charges",""
"NUT BONE BUTTRESS COMPRESSION FOR TROCHANTERIC FIXATION NAIL","SUP-ITM-10019882","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.06","351.04","WELLPOINT [1015]","HB AMC WELLPOINT","345.33","73.78","","286.63","119.22","1107.45","105","145.1","372.11","percent of total billed charges",""
"NUT BONE BUTTRESS COMPRESSION FOR TROCHANTERIC FIXATION NAIL","SUP-ITM-10019882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.06","351.04","AETNA [1001]","HB AMC AETNA HMO","326.71","69.8","","675.31","184.75","1721.50","286","244.61","382.5","percent of total billed charges",""
"NUT BONE BUTTRESS COMPRESSION FOR TROCHANTERIC FIXATION NAIL","SUP-ITM-10019882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.06","351.04","AETNA [1001]","HB AMC AETNA PPO","376.32","80.4","","1261.44","103.12","1514.10","21","244.61","382.5","percent of total billed charges",""
"NUT BONE BUTTRESS COMPRESSION FOR TROCHANTERIC FIXATION NAIL","SUP-ITM-10019882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.06","351.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","376.32","80.4","","1365.00","1365.00","1365.00","1 through 10","244.61","382.5","percent of total billed charges",""
"NUT BONE BUTTRESS COMPRESSION FOR TROCHANTERIC FIXATION NAIL","SUP-ITM-10019882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.06","351.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","382.50","81.72","","5157.68","5157.68","5157.68","1 through 10","244.61","382.5","percent of total billed charges",""
"NUT BONE BUTTRESS COMPRESSION FOR TROCHANTERIC FIXATION NAIL","SUP-ITM-10019882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.06","351.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","382.50","81.72","","431.26","71.26","1459.57","88","244.61","382.5","percent of total billed charges",""
"NUT COLLAR 11MM BONE ROD SPINAL TI WIDTH ACROSS FLATS","SUP-ITM-10001781","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","1309.77","674.56","6049.93","26","48.83","125.21","percent of total billed charges",""
"NUT COLLAR 11MM BONE ROD SPINAL TI WIDTH ACROSS FLATS","SUP-ITM-10001781","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","1901.83","1901.83","2962.25","1 through 10","48.83","125.21","percent of total billed charges",""
"NUT COLLAR 11MM BONE ROD SPINAL TI WIDTH ACROSS FLATS","SUP-ITM-10001781","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","1620.31","1620.31","19908.88","1 through 10","48.83","125.21","percent of total billed charges",""
"NUT COLLAR 11MM BONE ROD SPINAL TI WIDTH ACROSS FLATS","SUP-ITM-10001781","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","352.91","352.91","2046.30","1 through 10","48.83","125.21","percent of total billed charges",""
"NUT COLLAR 11MM BONE ROD SPINAL TI WIDTH ACROSS FLATS","SUP-ITM-10001781","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","9668.75","9668.75","9668.75","1 through 10","48.83","125.21","percent of total billed charges",""
"NUT COLLAR 11MM BONE ROD SPINAL TI WIDTH ACROSS FLATS","SUP-ITM-10001781","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","699.88","384.10","3443.31","33","48.83","125.21","percent of total billed charges",""
"NUT COLLAR 11MM BONE ROD SPINAL TI WIDTH ACROSS FLATS","SUP-ITM-10001781","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","1421.24","264.50","4933.46","29","82.31","128.71","percent of total billed charges",""
"NUT COLLAR 11MM BONE ROD SPINAL TI WIDTH ACROSS FLATS","SUP-ITM-10001781","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","1022.97","1022.97","3607.50","1 through 10","82.31","128.71","percent of total billed charges",""
"NUT COLLAR 11MM BONE ROD SPINAL TI WIDTH ACROSS FLATS","SUP-ITM-10001781","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","3010.54","693.88","5019.88","35","82.31","128.71","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION HEXAGONAL","SUP-ITM-10038652","CDM","C1889","HCPCS","0278","RC","","","","both","","","402.75","302.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","320.19","79.5","","1309.77","674.56","6049.93","26","124.85","320.19","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION HEXAGONAL","SUP-ITM-10038652","CDM","C1889","HCPCS","0278","RC","","","","both","","","402.75","302.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","214.67","53.3","","1901.83","1901.83","2962.25","1 through 10","124.85","320.19","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION HEXAGONAL","SUP-ITM-10038652","CDM","C1889","HCPCS","0278","RC","","","","both","","","402.75","302.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","147.00","36.5","","1620.31","1620.31","19908.88","1 through 10","124.85","320.19","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION HEXAGONAL","SUP-ITM-10038652","CDM","C1889","HCPCS","0278","RC","","","","both","","","402.75","302.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","154.25","38.3","","352.91","352.91","2046.30","1 through 10","124.85","320.19","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION HEXAGONAL","SUP-ITM-10038652","CDM","C1889","HCPCS","0278","RC","","","","both","","","402.75","302.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.78","42.9","","9668.75","9668.75","9668.75","1 through 10","124.85","320.19","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION HEXAGONAL","SUP-ITM-10038652","CDM","C1889","HCPCS","0278","RC","","","","both","","","402.75","302.06","WELLPOINT [1015]","HB AMC WELLPOINT","297.15","73.78","","699.88","384.10","3443.31","33","124.85","320.19","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION HEXAGONAL","SUP-ITM-10038652","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","402.75","302.06","AETNA [1001]","HB AMC AETNA HMO","281.12","69.8","","1421.24","264.50","4933.46","29","210.48","329.13","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION HEXAGONAL","SUP-ITM-10038652","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","402.75","302.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","323.81","80.4","","1022.97","1022.97","3607.50","1 through 10","210.48","329.13","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION HEXAGONAL","SUP-ITM-10038652","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","402.75","302.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","329.13","81.72","","3010.54","693.88","5019.88","35","210.48","329.13","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION ROUNDED","SUP-ITM-10038650","CDM","C1889","HCPCS","0278","RC","","","","both","","","427.35","320.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","339.74","79.5","","1309.77","674.56","6049.93","26","132.48","339.74","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION ROUNDED","SUP-ITM-10038650","CDM","C1889","HCPCS","0278","RC","","","","both","","","427.35","320.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","227.78","53.3","","1901.83","1901.83","2962.25","1 through 10","132.48","339.74","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION ROUNDED","SUP-ITM-10038650","CDM","C1889","HCPCS","0278","RC","","","","both","","","427.35","320.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","155.98","36.5","","1620.31","1620.31","19908.88","1 through 10","132.48","339.74","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION ROUNDED","SUP-ITM-10038650","CDM","C1889","HCPCS","0278","RC","","","","both","","","427.35","320.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","163.68","38.3","","352.91","352.91","2046.30","1 through 10","132.48","339.74","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION ROUNDED","SUP-ITM-10038650","CDM","C1889","HCPCS","0278","RC","","","","both","","","427.35","320.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","183.33","42.9","","9668.75","9668.75","9668.75","1 through 10","132.48","339.74","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION ROUNDED","SUP-ITM-10038650","CDM","C1889","HCPCS","0278","RC","","","","both","","","427.35","320.51","WELLPOINT [1015]","HB AMC WELLPOINT","315.30","73.78","","699.88","384.10","3443.31","33","132.48","339.74","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION ROUNDED","SUP-ITM-10038650","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","427.35","320.51","AETNA [1001]","HB AMC AETNA HMO","298.29","69.8","","1421.24","264.50","4933.46","29","223.33","349.23","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION ROUNDED","SUP-ITM-10038650","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","427.35","320.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","343.59","80.4","","1022.97","1022.97","3607.50","1 through 10","223.33","349.23","percent of total billed charges",""
"NUT COMPRESSION 6MM SACRAL FIXATION ROUNDED","SUP-ITM-10038650","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","427.35","320.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","349.23","81.72","","3010.54","693.88","5019.88","35","223.33","349.23","percent of total billed charges",""
"NUT COMPRESSION LARGE JUNCTION MODULAR TIVANIUM HIP 16A","SUP-ITM-10006328","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","184.37","52.26","","1113.10","1113.10","1113.10","1 through 10","109.37","280.48","percent of total billed charges",""
"NUT COMPRESSION LARGE JUNCTION MODULAR TIVANIUM HIP 16A","SUP-ITM-10006328","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","280.48","79.5","","1293.60","1148.53","1603.80","1 through 10","109.37","280.48","percent of total billed charges",""
"NUT COMPRESSION LARGE JUNCTION MODULAR TIVANIUM HIP 16A","SUP-ITM-10006328","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","128.77","36.5","","1023.42","771.29","2068.67","33","109.37","280.48","percent of total billed charges",""
"NUT COMPRESSION LARGE JUNCTION MODULAR TIVANIUM HIP 16A","SUP-ITM-10006328","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","135.12","38.3","","850.52","759.78","1211.25","66","109.37","280.48","percent of total billed charges",""
"NUT COMPRESSION LARGE JUNCTION MODULAR TIVANIUM HIP 16A","SUP-ITM-10006328","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.35","42.9","","2548.09","2548.09","2548.09","1 through 10","109.37","280.48","percent of total billed charges",""
"NUT COMPRESSION LARGE JUNCTION MODULAR TIVANIUM HIP 16A","SUP-ITM-10006328","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.35","42.9","","956.46","956.46","956.46","1 through 10","109.37","280.48","percent of total billed charges",""
"NUT COMPRESSION LARGE JUNCTION MODULAR TIVANIUM HIP 16A","SUP-ITM-10006328","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","WELLPOINT [1015]","HB AMC WELLPOINT","260.30","73.78","","2344.73","1619.47","2530.35","16","109.37","280.48","percent of total billed charges",""
"NUT COMPRESSION LARGE JUNCTION MODULAR TIVANIUM HIP 16A","SUP-ITM-10006328","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","352.80","264.60","AETNA [1001]","HB AMC AETNA HMO","246.25","69.8","","1523.63","988.41","4330.26","39","184.37","288.31","percent of total billed charges",""
"NUT COMPRESSION LARGE JUNCTION MODULAR TIVANIUM HIP 16A","SUP-ITM-10006328","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","352.80","264.60","AETNA [1001]","HB AMC AETNA PPO","283.65","80.4","","1670.25","1670.25","1670.25","1 through 10","184.37","288.31","percent of total billed charges",""
"NUT COMPRESSION LARGE JUNCTION MODULAR TIVANIUM HIP 16A","SUP-ITM-10006328","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","352.80","264.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","184.37","52.26","","1113.10","1113.10","1113.10","1 through 10","184.37","288.31","percent of total billed charges",""
"NUT COMPRESSION LARGE JUNCTION MODULAR TIVANIUM HIP 16A","SUP-ITM-10006328","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","352.80","264.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","288.31","81.72","","1738.90","1484.65","2716.94","38","184.37","288.31","percent of total billed charges",""
"NUT EXTERNAL LG FIXATION SS SPRING LOADED RING ROD","SUP-ITM-10004247","CDM","C1889","HCPCS","0278","RC","","","","both","","","133.28","99.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","105.96","79.5","","1309.77","674.56","6049.93","26","41.32","105.96","percent of total billed charges",""
"NUT EXTERNAL LG FIXATION SS SPRING LOADED RING ROD","SUP-ITM-10004247","CDM","C1889","HCPCS","0278","RC","","","","both","","","133.28","99.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","71.04","53.3","","1901.83","1901.83","2962.25","1 through 10","41.32","105.96","percent of total billed charges",""
"NUT EXTERNAL LG FIXATION SS SPRING LOADED RING ROD","SUP-ITM-10004247","CDM","C1889","HCPCS","0278","RC","","","","both","","","133.28","99.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.65","36.5","","1620.31","1620.31","19908.88","1 through 10","41.32","105.96","percent of total billed charges",""
"NUT EXTERNAL LG FIXATION SS SPRING LOADED RING ROD","SUP-ITM-10004247","CDM","C1889","HCPCS","0278","RC","","","","both","","","133.28","99.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","51.05","38.3","","352.91","352.91","2046.30","1 through 10","41.32","105.96","percent of total billed charges",""
"NUT EXTERNAL LG FIXATION SS SPRING LOADED RING ROD","SUP-ITM-10004247","CDM","C1889","HCPCS","0278","RC","","","","both","","","133.28","99.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.18","42.9","","9668.75","9668.75","9668.75","1 through 10","41.32","105.96","percent of total billed charges",""
"NUT EXTERNAL LG FIXATION SS SPRING LOADED RING ROD","SUP-ITM-10004247","CDM","C1889","HCPCS","0278","RC","","","","both","","","133.28","99.96","WELLPOINT [1015]","HB AMC WELLPOINT","98.33","73.78","","699.88","384.10","3443.31","33","41.32","105.96","percent of total billed charges",""
"NUT EXTERNAL LG FIXATION SS SPRING LOADED RING ROD","SUP-ITM-10004247","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","133.28","99.96","AETNA [1001]","HB AMC AETNA HMO","93.03","69.8","","1421.24","264.50","4933.46","29","69.65","108.92","percent of total billed charges",""
"NUT EXTERNAL LG FIXATION SS SPRING LOADED RING ROD","SUP-ITM-10004247","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","133.28","99.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","107.16","80.4","","1022.97","1022.97","3607.50","1 through 10","69.65","108.92","percent of total billed charges",""
"NUT EXTERNAL LG FIXATION SS SPRING LOADED RING ROD","SUP-ITM-10004247","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","133.28","99.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","108.92","81.72","","3010.54","693.88","5019.88","35","69.65","108.92","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.67","84.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","89.57","79.5","","800.18","480.96","1887.97","195","34.93","89.57","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.67","84.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","60.05","53.3","","813.12","216.42","1444.50","81","34.93","89.57","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.67","84.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","34.93","31","","432.60","432.60","432.60","1 through 10","34.93","89.57","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.67","84.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.12","36.5","","148.37","54.89","631.39","94","34.93","89.57","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.67","84.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.15","38.3","","279.30","91.72","1116.77","266","34.93","89.57","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.67","84.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.34","42.9","","731.00","63.70","731.00","1 through 10","34.93","89.57","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.67","84.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.34","42.9","","384.74","384.74","384.74","1 through 10","34.93","89.57","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.67","84.50","WELLPOINT [1015]","HB AMC WELLPOINT","83.13","73.78","","286.63","119.22","1107.45","105","34.93","89.57","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","112.67","84.50","AETNA [1001]","HB AMC AETNA HMO","78.64","69.8","","675.31","184.75","1721.50","286","58.88","92.07","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","112.67","84.50","AETNA [1001]","HB AMC AETNA PPO","90.59","80.4","","1261.44","103.12","1514.10","21","58.88","92.07","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","112.67","84.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","90.59","80.4","","1365.00","1365.00","1365.00","1 through 10","58.88","92.07","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","112.67","84.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","92.07","81.72","","5157.68","5157.68","5157.68","1 through 10","58.88","92.07","percent of total billed charges",""
"NUT EXTERNAL SM FIXATION STAINLESS BONE SPRING LOADED","SUP-ITM-10002421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","112.67","84.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","92.07","81.72","","431.26","71.26","1459.57","88","58.88","92.07","percent of total billed charges",""
"NUT LOCKING 7.5MM SPINE SYNAPSE TI TRANSCONNECTOR","SUP-ITM-10076780","CDM","C1889","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","1309.77","674.56","6049.93","26","54.25","139.13","percent of total billed charges",""
"NUT LOCKING 7.5MM SPINE SYNAPSE TI TRANSCONNECTOR","SUP-ITM-10076780","CDM","C1889","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.28","53.3","","1901.83","1901.83","2962.25","1 through 10","54.25","139.13","percent of total billed charges",""
"NUT LOCKING 7.5MM SPINE SYNAPSE TI TRANSCONNECTOR","SUP-ITM-10076780","CDM","C1889","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","1620.31","1620.31","19908.88","1 through 10","54.25","139.13","percent of total billed charges",""
"NUT LOCKING 7.5MM SPINE SYNAPSE TI TRANSCONNECTOR","SUP-ITM-10076780","CDM","C1889","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","352.91","352.91","2046.30","1 through 10","54.25","139.13","percent of total billed charges",""
"NUT LOCKING 7.5MM SPINE SYNAPSE TI TRANSCONNECTOR","SUP-ITM-10076780","CDM","C1889","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","9668.75","9668.75","9668.75","1 through 10","54.25","139.13","percent of total billed charges",""
"NUT LOCKING 7.5MM SPINE SYNAPSE TI TRANSCONNECTOR","SUP-ITM-10076780","CDM","C1889","HCPCS","0278","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","699.88","384.10","3443.31","33","54.25","139.13","percent of total billed charges",""
"NUT LOCKING 7.5MM SPINE SYNAPSE TI TRANSCONNECTOR","SUP-ITM-10076780","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","1421.24","264.50","4933.46","29","91.46","143.01","percent of total billed charges",""
"NUT LOCKING 7.5MM SPINE SYNAPSE TI TRANSCONNECTOR","SUP-ITM-10076780","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","140.70","80.4","","1022.97","1022.97","3607.50","1 through 10","91.46","143.01","percent of total billed charges",""
"NUT LOCKING 7.5MM SPINE SYNAPSE TI TRANSCONNECTOR","SUP-ITM-10076780","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","3010.54","693.88","5019.88","35","91.46","143.01","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","887.73","79.5","","800.18","480.96","1887.97","195","346.16","887.73","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","595.17","53.3","","813.12","216.42","1444.50","81","346.16","887.73","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","346.16","31","","432.60","432.60","432.60","1 through 10","346.16","887.73","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","407.57","36.5","","148.37","54.89","631.39","94","346.16","887.73","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","427.67","38.3","","279.30","91.72","1116.77","266","346.16","887.73","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","479.04","42.9","","731.00","63.70","731.00","1 through 10","346.16","887.73","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","479.04","42.9","","384.74","384.74","384.74","1 through 10","346.16","887.73","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","WELLPOINT [1015]","HB AMC WELLPOINT","823.86","73.78","","286.63","119.22","1107.45","105","346.16","887.73","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.64","837.48","AETNA [1001]","HB AMC AETNA HMO","779.41","69.8","","675.31","184.75","1721.50","286","583.56","912.52","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.64","837.48","AETNA [1001]","HB AMC AETNA PPO","897.78","80.4","","1261.44","103.12","1514.10","21","583.56","912.52","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.64","837.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","897.78","80.4","","1365.00","1365.00","1365.00","1 through 10","583.56","912.52","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.64","837.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","912.52","81.72","","5157.68","5157.68","5157.68","1 through 10","583.56","912.52","percent of total billed charges",""
"NUT SCREW 5.0X100MM BONE T2 TITANIUM CONDYLAR","SUP-ITM-10033853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.64","837.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","912.52","81.72","","431.26","71.26","1459.57","88","583.56","912.52","percent of total billed charges",""
"NUT SCREW 5MM STAINLESS CANNULATED SERRATED TIP SELF CUTTING BX/2EA","SUP-ITM-10011689","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.63","304.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","323.27","79.5","","800.18","480.96","1887.97","195","126.06","323.27","percent of total billed charges",""
"NUT SCREW 5MM STAINLESS CANNULATED SERRATED TIP SELF CUTTING BX/2EA","SUP-ITM-10011689","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.63","304.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","216.73","53.3","","813.12","216.42","1444.50","81","126.06","323.27","percent of total billed charges",""
"NUT SCREW 5MM STAINLESS CANNULATED SERRATED TIP SELF CUTTING BX/2EA","SUP-ITM-10011689","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.63","304.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","126.06","31","","432.60","432.60","432.60","1 through 10","126.06","323.27","percent of total billed charges",""
"NUT SCREW 5MM STAINLESS CANNULATED SERRATED TIP SELF CUTTING BX/2EA","SUP-ITM-10011689","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.63","304.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","148.42","36.5","","148.37","54.89","631.39","94","126.06","323.27","percent of total billed charges",""
"NUT SCREW 5MM STAINLESS CANNULATED SERRATED TIP SELF CUTTING BX/2EA","SUP-ITM-10011689","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.63","304.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","155.74","38.3","","279.30","91.72","1116.77","266","126.06","323.27","percent of total billed charges",""
"NUT SCREW 5MM STAINLESS CANNULATED SERRATED TIP SELF CUTTING BX/2EA","SUP-ITM-10011689","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.63","304.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.44","42.9","","731.00","63.70","731.00","1 through 10","126.06","323.27","percent of total billed charges",""
"NUT SCREW 5MM STAINLESS CANNULATED SERRATED TIP SELF CUTTING BX/2EA","SUP-ITM-10011689","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.63","304.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.44","42.9","","384.74","384.74","384.74","1 through 10","126.06","323.27","percent of total billed charges",""
"NUT SCREW 5MM STAINLESS CANNULATED SERRATED TIP SELF CUTTING BX/2EA","SUP-ITM-10011689","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.63","304.97","WELLPOINT [1015]","HB AMC WELLPOINT","300.01","73.78","","286.63","119.22","1107.45","105","126.06","323.27","percent of total billed charges",""
"NUT SCREW 5MM STAINLESS CANNULATED SERRATED TIP SELF CUTTING BX/2EA","SUP-ITM-10011689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.63","304.97","AETNA [1001]","HB AMC AETNA HMO","283.83","69.8","","675.31","184.75","1721.50","286","212.5","332.3","percent of total billed charges",""
"NUT SCREW 5MM STAINLESS CANNULATED SERRATED TIP SELF CUTTING BX/2EA","SUP-ITM-10011689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.63","304.97","AETNA [1001]","HB AMC AETNA PPO","326.93","80.4","","1261.44","103.12","1514.10","21","212.5","332.3","percent of total billed charges",""
"NUT SCREW 5MM STAINLESS CANNULATED SERRATED TIP SELF CUTTING BX/2EA","SUP-ITM-10011689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.63","304.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","326.93","80.4","","1365.00","1365.00","1365.00","1 through 10","212.5","332.3","percent of total billed charges",""
"NUT SCREW 5MM STAINLESS CANNULATED SERRATED TIP SELF CUTTING BX/2EA","SUP-ITM-10011689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.63","304.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","332.30","81.72","","5157.68","5157.68","5157.68","1 through 10","212.5","332.3","percent of total billed charges",""
"NUT SCREW 5MM STAINLESS CANNULATED SERRATED TIP SELF CUTTING BX/2EA","SUP-ITM-10011689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.63","304.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","332.30","81.72","","431.26","71.26","1459.57","88","212.5","332.3","percent of total billed charges",""
"NUT TIBIA FIXATION STAINLESS SQUARE MRI CONDITIONAL NONARTICULAR FRAME DISTRACTION EXTERNAL","SUP-ITM-10039207","CDM","C1713","HCPCS","0278","RC","","","","both","","","269.40","202.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","214.17","79.5","","800.18","480.96","1887.97","195","83.51","214.17","percent of total billed charges",""
"NUT TIBIA FIXATION STAINLESS SQUARE MRI CONDITIONAL NONARTICULAR FRAME DISTRACTION EXTERNAL","SUP-ITM-10039207","CDM","C1713","HCPCS","0278","RC","","","","both","","","269.40","202.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","143.59","53.3","","813.12","216.42","1444.50","81","83.51","214.17","percent of total billed charges",""
"NUT TIBIA FIXATION STAINLESS SQUARE MRI CONDITIONAL NONARTICULAR FRAME DISTRACTION EXTERNAL","SUP-ITM-10039207","CDM","C1713","HCPCS","0278","RC","","","","both","","","269.40","202.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","83.51","31","","432.60","432.60","432.60","1 through 10","83.51","214.17","percent of total billed charges",""
"NUT TIBIA FIXATION STAINLESS SQUARE MRI CONDITIONAL NONARTICULAR FRAME DISTRACTION EXTERNAL","SUP-ITM-10039207","CDM","C1713","HCPCS","0278","RC","","","","both","","","269.40","202.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","98.33","36.5","","148.37","54.89","631.39","94","83.51","214.17","percent of total billed charges",""
"NUT TIBIA FIXATION STAINLESS SQUARE MRI CONDITIONAL NONARTICULAR FRAME DISTRACTION EXTERNAL","SUP-ITM-10039207","CDM","C1713","HCPCS","0278","RC","","","","both","","","269.40","202.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","103.18","38.3","","279.30","91.72","1116.77","266","83.51","214.17","percent of total billed charges",""
"NUT TIBIA FIXATION STAINLESS SQUARE MRI CONDITIONAL NONARTICULAR FRAME DISTRACTION EXTERNAL","SUP-ITM-10039207","CDM","C1713","HCPCS","0278","RC","","","","both","","","269.40","202.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","115.57","42.9","","731.00","63.70","731.00","1 through 10","83.51","214.17","percent of total billed charges",""
"NUT TIBIA FIXATION STAINLESS SQUARE MRI CONDITIONAL NONARTICULAR FRAME DISTRACTION EXTERNAL","SUP-ITM-10039207","CDM","C1713","HCPCS","0278","RC","","","","both","","","269.40","202.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","115.57","42.9","","384.74","384.74","384.74","1 through 10","83.51","214.17","percent of total billed charges",""
"NUT TIBIA FIXATION STAINLESS SQUARE MRI CONDITIONAL NONARTICULAR FRAME DISTRACTION EXTERNAL","SUP-ITM-10039207","CDM","C1713","HCPCS","0278","RC","","","","both","","","269.40","202.05","WELLPOINT [1015]","HB AMC WELLPOINT","198.76","73.78","","286.63","119.22","1107.45","105","83.51","214.17","percent of total billed charges",""
"NUT TIBIA FIXATION STAINLESS SQUARE MRI CONDITIONAL NONARTICULAR FRAME DISTRACTION EXTERNAL","SUP-ITM-10039207","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","269.40","202.05","AETNA [1001]","HB AMC AETNA HMO","188.04","69.8","","675.31","184.75","1721.50","286","140.79","220.15","percent of total billed charges",""
"NUT TIBIA FIXATION STAINLESS SQUARE MRI CONDITIONAL NONARTICULAR FRAME DISTRACTION EXTERNAL","SUP-ITM-10039207","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","269.40","202.05","AETNA [1001]","HB AMC AETNA PPO","216.60","80.4","","1261.44","103.12","1514.10","21","140.79","220.15","percent of total billed charges",""
"NUT TIBIA FIXATION STAINLESS SQUARE MRI CONDITIONAL NONARTICULAR FRAME DISTRACTION EXTERNAL","SUP-ITM-10039207","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","269.40","202.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","216.60","80.4","","1365.00","1365.00","1365.00","1 through 10","140.79","220.15","percent of total billed charges",""
"NUT TIBIA FIXATION STAINLESS SQUARE MRI CONDITIONAL NONARTICULAR FRAME DISTRACTION EXTERNAL","SUP-ITM-10039207","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","269.40","202.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","220.15","81.72","","5157.68","5157.68","5157.68","1 through 10","140.79","220.15","percent of total billed charges",""
"NUT TIBIA FIXATION STAINLESS SQUARE MRI CONDITIONAL NONARTICULAR FRAME DISTRACTION EXTERNAL","SUP-ITM-10039207","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","269.40","202.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","220.15","81.72","","431.26","71.26","1459.57","88","140.79","220.15","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","127.00","95.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","100.97","79.5","","96.80","64.94","96.80","20","34.1","120.65","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","127.00","95.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","67.69","53.3","","96.80","96.80","259.78","1 through 10","34.1","120.65","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","127.00","95.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","39.37","31","","38.01","38.01","38.01","1 through 10","34.1","120.65","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","127.00","95.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","46.36","36.5","","45.88","38.99","45.88","117","34.1","120.65","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","127.00","95.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48.64","38.3","","48.09","48.09","48.10","467","34.1","120.65","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","127.00","95.25","WELLPOINT [1015]","HB AMC WELLPOINT","93.70","73.78","","91.57","91.57","91.57","30","34.1","120.65","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","127.00","95.25","AETNA [1001]","HB AMC AETNA HMO","88.65","69.8","","83.27","58.80","333.08","55","54.48","223.58","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","127.00","95.25","AETNA [1001]","HB AMC AETNA PPO","102.11","80.4","","166.54","166.54","166.54","1 through 10","54.48","223.58","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","127.00","95.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","103.78","81.72","","98.33","54.08","196.65","42","54.48","223.58","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","both","","","127.00","95.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","100.97","79.5","","96.80","96.80","193.60","23","28.81","120.65","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","both","","","127.00","95.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","46.36","36.5","","45.88","38.99","45.88","99","28.81","120.65","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","both","","","127.00","95.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48.64","38.3","","48.09","48.09","48.10","399","28.81","120.65","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","both","","","127.00","95.25","WELLPOINT [1015]","HB AMC WELLPOINT","93.70","73.78","","91.57","91.57","91.58","23","28.81","120.65","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","127.00","95.25","AETNA [1001]","HB AMC AETNA HMO","88.65","69.8","","83.27","83.27","191.88","21","66.37","206.21","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","127.00","95.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","103.78","81.72","","98.33","54.09","98.33","11","66.37","206.21","percent of total billed charges",""
"O.R. Procedure For Other Complications Of Treatment,EXTREME","791","DRG","","","","","","","","inpatient","","","195471.76","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18692.1019","","Fee schedule rate ($161,228.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18692.1019","162763.40","162763.40","1 through 10","10445.4642","266029.52","case rate",""
"O.R. Procedure For Other Complications Of Treatment,EXTREME","791","DRG","","","","","","","","inpatient","","","195471.76","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","19627.2502","","Fee schedule rate ($169,294.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19627.2502","169294.12","169294.12","1 through 10","10445.4642","266029.52","case rate",""
"O.R. Procedure For Other Complications Of Treatment,MODERATE","791","DRG","","","","","","","","inpatient","","","91804.91","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18692.1019","","Fee schedule rate ($31,812.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18692.1019","81708.88","81708.88","1 through 10","10445.4642","266029.52","case rate",""
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","","","","inpatient","","","53644.31","40233.23","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","14977.95","","Case rate ($14,977.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,953.09, add-ons for qualifying new technology services are included. If operating cost exceeds $63,597.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,727.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $13,310.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,573.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,287.70. The transfer capital threshold is the transfer adjustment factor * $1,287.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14554.82","14554.82","14554.82","1 through 10","14678.39","24100.327","other","Inpatient DRG"
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","","","","inpatient","","","53644.31","40233.23","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","14977.95","","Case rate ($14,977.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,953.09, add-ons for qualifying new technology services are included. If operating cost exceeds $63,597.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,727.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $13,310.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,573.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,287.70. The transfer capital threshold is the transfer adjustment factor * $1,287.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14581.94","14581.94","14581.94","1 through 10","14678.39","24100.327","other","Inpatient Replacement Plans DRG"
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","","","","inpatient","","","53644.31","40233.23","MEDICARE [2001]","HB BWH MEDICARE","14977.95","","Case rate ($14,977.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,953.09, add-ons for qualifying new technology services are included. If operating cost exceeds $63,597.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,727.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $13,310.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,573.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,287.70. The transfer capital threshold is the transfer adjustment factor * $1,287.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19105.55","0.03","19133.72","1 through 10","14678.39","24100.327","other","Inpatient Replacement Plans DRG"
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","","","","inpatient","","","53644.31","40233.23","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14678.39","","Case rate ($14,977.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,953.09, add-ons for qualifying new technology services are included. If operating cost exceeds $63,597.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,727.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $13,310.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,573.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,287.70. The transfer capital threshold is the transfer adjustment factor * $1,287.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14511.21","14511.21","14511.21","1 through 10","14678.39","24100.327","other","Inpatient DRG"
"O.R. Procedures For Obesity With McC","619","MS-DRG","","","","","","","","inpatient","","","99662.35","74746.76","MEDICARE [2001]","HB BWH MEDICARE","26719.01","","Case rate ($26,719.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,087.01, add-ons for qualifying new technology services are included. If operating cost exceeds $77,731.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,763.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $24,015.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,707.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,323.37. The transfer capital threshold is the transfer adjustment factor * $2,323.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","32469.49","32469.49","32469.49","1 through 10","26184.63","41145.6115","other","Inpatient Replacement Plans DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","61690.34","46267.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","14139.63","","Case rate ($14,139.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,943.91, add-ons for qualifying new technology services are included. If operating cost exceeds $62,588.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,653.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $12,546.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,564.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.75. The transfer capital threshold is the transfer adjustment factor * $1,213.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13309.16","13309.16","13309.16","1 through 10","13856.84","23627.58","other","Inpatient DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","61690.34","46267.75","MEDICARE [2001]","HB BWH MEDICARE","14139.63","","Case rate ($14,139.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,943.91, add-ons for qualifying new technology services are included. If operating cost exceeds $62,588.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,653.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $12,546.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,564.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.75. The transfer capital threshold is the transfer adjustment factor * $1,213.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17537.45","17537.45","17537.45","1 through 10","13856.84","23627.58","other","Inpatient Replacement Plans DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","61690.34","46267.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13856.84","","Case rate ($14,139.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,943.91, add-ons for qualifying new technology services are included. If operating cost exceeds $62,588.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,653.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $12,546.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,564.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.75. The transfer capital threshold is the transfer adjustment factor * $1,213.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13299.82","13299.82","13299.82","1 through 10","13856.84","23627.58","other","Inpatient DRG"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","","","","inpatient","","","89868.55","67401.41","MEDICARE [2001]","HB BWH MEDICARE","21697.28","","Case rate ($21,697.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,041.84, add-ons for qualifying new technology services are included. If operating cost exceeds $71,686.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,320.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $19,437.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,662.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,880.41. The transfer capital threshold is the transfer adjustment factor * $1,880.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25169.92","25169.92","25207.14","1 through 10","21263.33","31863.1374","other","Inpatient Replacement Plans DRG"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","","","","inpatient","","","89868.55","67401.41","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","21263.33","","Case rate ($21,697.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,041.84, add-ons for qualifying new technology services are included. If operating cost exceeds $71,686.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,320.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $19,437.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,662.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,880.41. The transfer capital threshold is the transfer adjustment factor * $1,880.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19057.79","19057.79","19057.79","1 through 10","21263.33","31863.1374","other","Inpatient DRG"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With McC","939","MS-DRG","","","","","","","","inpatient","","","247523.50","185642.62","MEDICARE [2001]","HB BWH MEDICARE","33479.39","","Case rate ($33,479.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,225.18, add-ons for qualifying new technology services are included. If operating cost exceeds $85,869.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,359.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $30,179.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,845.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,919.70. The transfer capital threshold is the transfer adjustment factor * $2,919.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","37697.05","37697.05","37697.05","1 through 10","32809.8","48522.0923","other","Inpatient Replacement Plans DRG"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/McC","941","MS-DRG","","","","","","","","inpatient","","","58332.26","43749.19","MEDICARE [2001]","HB BWH MEDICARE","18876.73","","Case rate ($18,876.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,646.46, add-ons for qualifying new technology services are included. If operating cost exceeds $68,290.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,071.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $16,865.29 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,266.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,631.61. The transfer capital threshold is the transfer adjustment factor * $1,631.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","18499.2","29492.3413","other","Inpatient Replacement Plans DRG"
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","","","","inpatient","","","156423.65","117317.74","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","35635.86","","Case rate ($35,635.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $42,821.15, add-ons for qualifying new technology services are included. If operating cost exceeds $88,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,550.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $32,146.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,441.30 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,109.93. The transfer capital threshold is the transfer adjustment factor * $3,109.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35310.28","35310.28","35310.28","1 through 10","34923.14","59301.5936","other","Inpatient DRG"
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","","","","inpatient","","","156423.65","117317.74","MEDICARE [2001]","HB BWH MEDICARE","35635.86","","Case rate ($35,635.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $42,821.15, add-ons for qualifying new technology services are included. If operating cost exceeds $88,465.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,550.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $32,146.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,441.30 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,109.93. The transfer capital threshold is the transfer adjustment factor * $3,109.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","46604.94","46604.94","46674.25","1 through 10","34923.14","59301.5936","other","Inpatient Replacement Plans DRG"
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","","","","inpatient","","","156423.65","117317.74","WELLPOINT [1015]","HB AMC WELLPOINT","59301.5936","","Fee schedule rate ($60,539.79).","59301.5936","145080.76","145080.76","1 through 10","34923.14","59301.5936","case rate",""
"O2 Uptake Expired Gas Rest","PX-46000040","CDM","94690","CPT","0460","RC","","","","both","","","1344.00","1008.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1068.48","79.5","","1025.46","1025.46","1025.46","1 through 10","67.01","1068.48","percent of total billed charges",""
"O2 Uptake Expired Gas Rest","PX-46000040","CDM","94690","CPT","0460","RC","","","","both","","","1344.00","1008.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","716.35","53.3","","687.98","687.98","687.98","1 through 10","67.01","1068.48","percent of total billed charges",""
"O2 Uptake Expired Gas Rest","PX-46000040","CDM","94690","CPT","0460","RC","","","","both","","","1344.00","1008.00","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","66.76","70.54","1 through 10","67.01","1068.48","other","OPPS APC"
"O2 Uptake Expired Gas Rest","PX-46000040","CDM","94690","CPT","0460","RC","","","","both","","","1344.00","1008.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","514.75","38.3","","1528.41","509.47","1528.41","1 through 10","67.01","1068.48","percent of total billed charges",""
"O2 Uptake Expired Gas Rest","PX-46000040","CDM","94690","CPT","0460","RC","","","","outpatient","","","1344.00","1008.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1098.32","81.72","","1041.62","572.93","1041.62","1 through 10","73.79","1098.32","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","315.03","79.5","","800.18","480.96","1887.97","195","122.84","315.03","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","211.21","53.3","","813.12","216.42","1444.50","81","122.84","315.03","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","122.84","31","","432.60","432.60","432.60","1 through 10","122.84","315.03","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","144.64","36.5","","148.37","54.89","631.39","94","122.84","315.03","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","151.77","38.3","","279.30","91.72","1116.77","266","122.84","315.03","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.00","42.9","","731.00","63.70","731.00","1 through 10","122.84","315.03","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.00","42.9","","384.74","384.74","384.74","1 through 10","122.84","315.03","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","WELLPOINT [1015]","HB AMC WELLPOINT","292.37","73.78","","286.63","119.22","1107.45","105","122.84","315.03","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.27","297.20","AETNA [1001]","HB AMC AETNA HMO","276.60","69.8","","675.31","184.75","1721.50","286","207.09","323.83","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.27","297.20","AETNA [1001]","HB AMC AETNA PPO","318.60","80.4","","1261.44","103.12","1514.10","21","207.09","323.83","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.27","297.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","318.60","80.4","","1365.00","1365.00","1365.00","1 through 10","207.09","323.83","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.27","297.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","323.83","81.72","","5157.68","5157.68","5157.68","1 through 10","207.09","323.83","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.27","297.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","323.83","81.72","","431.26","71.26","1459.57","88","207.09","323.83","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.03","79.5","","4287.55","1443.20","20392.29","31","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.72","53.3","","359.57","119.86","535.95","913","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","180.18","77","","524.37","174.79","524.37","32","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.54","31","","14.03","7.01","56.11","170","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.41","36.5","","71.96","8.43","215.88","2486","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.62","38.3","","88.76","10.14","266.27","5389","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.39","42.9","","181.46","181.46","181.46","14","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","WELLPOINT [1015]","HB AMC WELLPOINT","172.65","73.78","","169.00","169.00","169.00","283","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.95","78.61","","181.46","181.46","181.46","64","129.4","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA HMO","163.33","69.8","","153.68","108.51","262.19","2444","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA PPO","188.14","80.4","","177.06","118.95","227.00","470","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,312).","531.20","252.95","1328.00","481","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.29","52.26","","652.75","652.75","652.75","1 through 10","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,222).","527.40","239.73","1492.00","2365","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","191.22","81.72","","7264.00","7264.00","7264.00","1 through 10","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.22","81.72","","99.81","49.91","227.00","153","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.22","81.72","","99.81","99.81","227.00","839","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.03","79.5","","4287.55","1443.20","20392.29","31","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.72","53.3","","359.57","119.86","535.95","913","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","180.18","77","","524.37","174.79","524.37","32","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.54","31","","14.03","7.01","56.11","170","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.41","36.5","","71.96","8.43","215.88","2486","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.62","38.3","","88.76","10.14","266.27","5389","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.39","42.9","","181.46","181.46","181.46","14","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","WELLPOINT [1015]","HB AMC WELLPOINT","172.65","73.78","","169.00","169.00","169.00","283","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.95","78.61","","181.46","181.46","181.46","64","129.4","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA HMO","163.33","69.8","","153.68","108.51","262.19","2444","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA PPO","188.14","80.4","","177.06","118.95","227.00","470","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,312).","531.20","252.95","1328.00","481","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.29","52.26","","652.75","652.75","652.75","1 through 10","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,222).","527.40","239.73","1492.00","2365","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","191.22","81.72","","7264.00","7264.00","7264.00","1 through 10","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.22","81.72","","99.81","49.91","227.00","153","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.22","81.72","","99.81","99.81","227.00","839","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.03","79.5","","4287.55","1443.20","20392.29","31","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.72","53.3","","359.57","119.86","535.95","913","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","180.18","77","","524.37","174.79","524.37","32","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.54","31","","14.03","7.01","56.11","170","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.41","36.5","","71.96","8.43","215.88","2486","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.62","38.3","","88.76","10.14","266.27","5389","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.39","42.9","","181.46","181.46","181.46","14","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","WELLPOINT [1015]","HB AMC WELLPOINT","172.65","73.78","","169.00","169.00","169.00","283","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.95","78.61","","181.46","181.46","181.46","64","129.4","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA HMO","163.33","69.8","","153.68","108.51","262.19","2444","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA PPO","188.14","80.4","","177.06","118.95","227.00","470","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,312).","531.20","252.95","1328.00","481","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.29","52.26","","652.75","652.75","652.75","1 through 10","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,222).","527.40","239.73","1492.00","2365","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","191.22","81.72","","7264.00","7264.00","7264.00","1 through 10","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.22","81.72","","99.81","49.91","227.00","153","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.22","81.72","","99.81","99.81","227.00","839","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.03","79.5","","4287.55","1443.20","20392.29","31","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.72","53.3","","359.57","119.86","535.95","913","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","180.18","77","","524.37","174.79","524.37","32","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.54","31","","14.03","7.01","56.11","170","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.41","36.5","","71.96","8.43","215.88","2486","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.62","38.3","","88.76","10.14","266.27","5389","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.39","42.9","","181.46","181.46","181.46","14","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","WELLPOINT [1015]","HB AMC WELLPOINT","172.65","73.78","","169.00","169.00","169.00","283","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.95","78.61","","181.46","181.46","181.46","64","129.4","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA HMO","163.33","69.8","","153.68","108.51","262.19","2444","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA PPO","188.14","80.4","","177.06","118.95","227.00","470","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,312).","531.20","252.95","1328.00","481","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.29","52.26","","652.75","652.75","652.75","1 through 10","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,222).","527.40","239.73","1492.00","2365","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","191.22","81.72","","7264.00","7264.00","7264.00","1 through 10","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.22","81.72","","99.81","49.91","227.00","153","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.22","81.72","","99.81","99.81","227.00","839","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.03","79.5","","4287.55","1443.20","20392.29","31","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.72","53.3","","359.57","119.86","535.95","913","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","180.18","77","","524.37","174.79","524.37","32","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.54","31","","14.03","7.01","56.11","170","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.41","36.5","","71.96","8.43","215.88","2486","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.62","38.3","","88.76","10.14","266.27","5389","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.39","42.9","","181.46","181.46","181.46","14","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","WELLPOINT [1015]","HB AMC WELLPOINT","172.65","73.78","","169.00","169.00","169.00","283","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.95","78.61","","181.46","181.46","181.46","64","129.4","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA HMO","163.33","69.8","","153.68","108.51","262.19","2444","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA PPO","188.14","80.4","","177.06","118.95","227.00","470","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,312).","531.20","252.95","1328.00","481","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.29","52.26","","652.75","652.75","652.75","1 through 10","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,222).","527.40","239.73","1492.00","2365","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","191.22","81.72","","7264.00","7264.00","7264.00","1 through 10","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.22","81.72","","99.81","49.91","227.00","153","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.22","81.72","","99.81","99.81","227.00","839","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.03","79.5","","4287.55","1443.20","20392.29","31","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.72","53.3","","359.57","119.86","535.95","913","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","180.18","77","","524.37","174.79","524.37","32","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.54","31","","14.03","7.01","56.11","170","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.41","36.5","","71.96","8.43","215.88","2486","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.62","38.3","","88.76","10.14","266.27","5389","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.39","42.9","","181.46","181.46","181.46","14","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","WELLPOINT [1015]","HB AMC WELLPOINT","172.65","73.78","","169.00","169.00","169.00","283","72.54","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.95","78.61","","181.46","181.46","181.46","64","129.4","186.03","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA HMO","163.33","69.8","","153.68","108.51","262.19","2444","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA PPO","188.14","80.4","","177.06","118.95","227.00","470","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,312).","531.20","252.95","1328.00","481","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.29","52.26","","652.75","652.75","652.75","1 through 10","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,222).","527.40","239.73","1492.00","2365","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","191.22","81.72","","7264.00","7264.00","7264.00","1 through 10","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.22","81.72","","99.81","49.91","227.00","153","122.29","8433","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.22","81.72","","99.81","99.81","227.00","839","122.29","8433","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.03","79.5","","4287.55","1443.20","20392.29","31","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.72","53.3","","359.57","119.86","535.95","913","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","180.18","77","","524.37","174.79","524.37","32","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.54","31","","14.03","7.01","56.11","170","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.41","36.5","","71.96","8.43","215.88","2486","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.62","38.3","","88.76","10.14","266.27","5389","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.39","42.9","","181.46","181.46","181.46","14","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","WELLPOINT [1015]","HB AMC WELLPOINT","172.65","73.78","","169.00","169.00","169.00","283","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.95","78.61","","181.46","181.46","181.46","64","129.4","186.03","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA HMO","163.33","69.8","","153.68","108.51","262.19","2444","122.29","8433","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA PPO","188.14","80.4","","177.06","118.95","227.00","470","122.29","8433","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,312).","531.20","252.95","1328.00","481","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.29","52.26","","652.75","652.75","652.75","1 through 10","122.29","8433","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,222).","527.40","239.73","1492.00","2365","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","191.22","81.72","","7264.00","7264.00","7264.00","1 through 10","122.29","8433","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.22","81.72","","99.81","49.91","227.00","153","122.29","8433","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.22","81.72","","99.81","99.81","227.00","839","122.29","8433","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.03","79.5","","4287.55","1443.20","20392.29","31","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.72","53.3","","359.57","119.86","535.95","913","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","180.18","77","","524.37","174.79","524.37","32","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.54","31","","14.03","7.01","56.11","170","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.41","36.5","","71.96","8.43","215.88","2486","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.62","38.3","","88.76","10.14","266.27","5389","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.39","42.9","","181.46","181.46","181.46","14","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","WELLPOINT [1015]","HB AMC WELLPOINT","172.65","73.78","","169.00","169.00","169.00","283","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.95","78.61","","181.46","181.46","181.46","64","129.4","186.03","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA HMO","163.33","69.8","","153.68","108.51","262.19","2444","122.29","8433","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA PPO","188.14","80.4","","177.06","118.95","227.00","470","122.29","8433","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,312).","531.20","252.95","1328.00","481","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.29","52.26","","652.75","652.75","652.75","1 through 10","122.29","8433","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,222).","527.40","239.73","1492.00","2365","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","191.22","81.72","","7264.00","7264.00","7264.00","1 through 10","122.29","8433","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.22","81.72","","99.81","49.91","227.00","153","122.29","8433","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.22","81.72","","99.81","99.81","227.00","839","122.29","8433","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.03","79.5","","4287.55","1443.20","20392.29","31","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.72","53.3","","359.57","119.86","535.95","913","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","180.18","77","","524.37","174.79","524.37","32","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.54","31","","14.03","7.01","56.11","170","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.41","36.5","","71.96","8.43","215.88","2486","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.62","38.3","","88.76","10.14","266.27","5389","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.39","42.9","","181.46","181.46","181.46","14","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","WELLPOINT [1015]","HB AMC WELLPOINT","172.65","73.78","","169.00","169.00","169.00","283","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.95","78.61","","181.46","181.46","181.46","64","129.4","186.03","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA HMO","163.33","69.8","","153.68","108.51","262.19","2444","122.29","8433","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA PPO","188.14","80.4","","177.06","118.95","227.00","470","122.29","8433","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,312).","531.20","252.95","1328.00","481","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.29","52.26","","652.75","652.75","652.75","1 through 10","122.29","8433","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,222).","527.40","239.73","1492.00","2365","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","191.22","81.72","","7264.00","7264.00","7264.00","1 through 10","122.29","8433","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.22","81.72","","99.81","49.91","227.00","153","122.29","8433","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.22","81.72","","99.81","99.81","227.00","839","122.29","8433","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.03","79.5","","4287.55","1443.20","20392.29","31","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.72","53.3","","359.57","119.86","535.95","913","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","180.18","77","","524.37","174.79","524.37","32","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.54","31","","14.03","7.01","56.11","170","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.41","36.5","","71.96","8.43","215.88","2486","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.62","38.3","","88.76","10.14","266.27","5389","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.39","42.9","","181.46","181.46","181.46","14","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","234.00","175.50","WELLPOINT [1015]","HB AMC WELLPOINT","172.65","73.78","","169.00","169.00","169.00","283","72.54","186.03","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","183.95","78.61","","181.46","181.46","181.46","64","129.4","186.03","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA HMO","163.33","69.8","","153.68","108.51","262.19","2444","122.29","8433","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB AMC AETNA PPO","188.14","80.4","","177.06","118.95","227.00","470","122.29","8433","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,312).","531.20","252.95","1328.00","481","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","122.29","52.26","","652.75","652.75","652.75","1 through 10","122.29","8433","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($5,222).","527.40","239.73","1492.00","2365","122.29","8433","other","Observation Flat Rate <=24 units"
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","191.22","81.72","","7264.00","7264.00","7264.00","1 through 10","122.29","8433","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.22","81.72","","99.81","49.91","227.00","153","122.29","8433","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.22","81.72","","99.81","99.81","227.00","839","122.29","8433","percent of total billed charges",""
"OBTURATOR SLING 12CM INCONTINENCE TVT ABBREVO SYSTEM MID URETHRAL TRANS FEMALE BX/1EA","SUP-ITM-10093910","CDM","C1771","HCPCS","0278","RC","","","","both","","","3921.12","2940.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3117.29","79.5","","1632.15","1632.15","1632.15","1 through 10","1215.55","3117.29","percent of total billed charges",""
"OBTURATOR SLING 12CM INCONTINENCE TVT ABBREVO SYSTEM MID URETHRAL TRANS FEMALE BX/1EA","SUP-ITM-10093910","CDM","C1771","HCPCS","0278","RC","","","","both","","","3921.12","2940.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2089.96","53.3","","9709.13","9709.13","9709.13","1 through 10","1215.55","3117.29","percent of total billed charges",""
"OBTURATOR SLING 12CM INCONTINENCE TVT ABBREVO SYSTEM MID URETHRAL TRANS FEMALE BX/1EA","SUP-ITM-10093910","CDM","C1771","HCPCS","0278","RC","","","","both","","","3921.12","2940.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2548.73","65","","2685.95","2190.09","2685.96","1 through 10","1215.55","3117.29","percent of total billed charges",""
"OBTURATOR SLING 12CM INCONTINENCE TVT ABBREVO SYSTEM MID URETHRAL TRANS FEMALE BX/1EA","SUP-ITM-10093910","CDM","C1771","HCPCS","0278","RC","","","","both","","","3921.12","2940.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1431.21","36.5","","1495.87","1455.73","1541.33","1 through 10","1215.55","3117.29","percent of total billed charges",""
"OBTURATOR SLING 12CM INCONTINENCE TVT ABBREVO SYSTEM MID URETHRAL TRANS FEMALE BX/1EA","SUP-ITM-10093910","CDM","C1771","HCPCS","0278","RC","","","","both","","","3921.12","2940.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1501.79","38.3","","1615.71","1615.71","1615.71","1 through 10","1215.55","3117.29","percent of total billed charges",""
"OBTURATOR SLING 12CM INCONTINENCE TVT ABBREVO SYSTEM MID URETHRAL TRANS FEMALE BX/1EA","SUP-ITM-10093910","CDM","C1771","HCPCS","0278","RC","","","","both","","","3921.12","2940.84","WELLPOINT [1015]","HB AMC WELLPOINT","2893.00","73.78","","3076.44","3076.44","3076.44","1 through 10","1215.55","3117.29","percent of total billed charges",""
"OBTURATOR SLING 12CM INCONTINENCE TVT ABBREVO SYSTEM MID URETHRAL TRANS FEMALE BX/1EA","SUP-ITM-10093910","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3921.12","2940.84","AETNA [1001]","HB AMC AETNA HMO","2736.94","69.8","","4568.79","2411.14","4568.79","1 through 10","2049.18","3204.34","percent of total billed charges",""
"OBTURATOR SLING 12CM INCONTINENCE TVT ABBREVO SYSTEM MID URETHRAL TRANS FEMALE BX/1EA","SUP-ITM-10093910","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3921.12","2940.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3152.58","80.4","","2411.14","1545.60","3223.14","1 through 10","2049.18","3204.34","percent of total billed charges",""
"OBTURATOR SLING 12CM INCONTINENCE TVT ABBREVO SYSTEM MID URETHRAL TRANS FEMALE BX/1EA","SUP-ITM-10093910","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3921.12","2940.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3204.34","81.72","","1816.95","1816.95","1816.95","1 through 10","2049.18","3204.34","percent of total billed charges",""
"OBTURATOR SLING 12CM INCONTINENCE TVT ABBREVO SYSTEM MID URETHRAL TRANS FEMALE BX/1EA","SUP-ITM-10093910","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3921.12","2940.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3204.34","81.72","","3303.30","3303.30","3303.30","1 through 10","2049.18","3204.34","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","both","","","3811.71","2858.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3030.31","79.5","","1632.15","1632.15","1632.15","1 through 10","1181.63","3030.31","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","both","","","3811.71","2858.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2031.64","53.3","","9709.13","9709.13","9709.13","1 through 10","1181.63","3030.31","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","both","","","3811.71","2858.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2477.61","65","","2685.95","2190.09","2685.96","1 through 10","1181.63","3030.31","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","both","","","3811.71","2858.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1391.27","36.5","","1495.87","1455.73","1541.33","1 through 10","1181.63","3030.31","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","both","","","3811.71","2858.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1459.88","38.3","","1615.71","1615.71","1615.71","1 through 10","1181.63","3030.31","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","both","","","3811.71","2858.78","WELLPOINT [1015]","HB AMC WELLPOINT","2812.28","73.78","","3076.44","3076.44","3076.44","1 through 10","1181.63","3030.31","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3811.71","2858.78","AETNA [1001]","HB AMC AETNA HMO","2660.57","69.8","","4568.79","2411.14","4568.79","1 through 10","1992","3114.93","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3811.71","2858.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3064.61","80.4","","2411.14","1545.60","3223.14","1 through 10","1992","3114.93","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3811.71","2858.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3114.93","81.72","","1816.95","1816.95","1816.95","1 through 10","1992","3114.93","percent of total billed charges",""
"OBTURATOR SURGICAL LASER CUT TRANS GYNECARE TVT","SUP-ITM-10042141","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3811.71","2858.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3114.93","81.72","","3303.30","3303.30","3303.30","1 through 10","1992","3114.93","percent of total billed charges",""
"OCCLUDER AMPLATZER 7FR 16MM 4MM 26MM 30MM 45DEG SEPTAL NITINOL POLYESTER SELF EXPANDING MULTI FENESTRATED","SUP-ITM-10007315","CDM","C1817","HCPCS","0278","RC","","","","both","","","19750.00","14812.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15701.25","79.5","","17412.37","11682.00","17412.38","1 through 10","6122.5","15701.25","percent of total billed charges",""
"OCCLUDER AMPLATZER 7FR 16MM 4MM 26MM 30MM 45DEG SEPTAL NITINOL POLYESTER SELF EXPANDING MULTI FENESTRATED","SUP-ITM-10007315","CDM","C1817","HCPCS","0278","RC","","","","both","","","19750.00","14812.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10526.75","53.3","","11682.00","11682.00","11682.00","1 through 10","6122.5","15701.25","percent of total billed charges",""
"OCCLUDER AMPLATZER 7FR 16MM 4MM 26MM 30MM 45DEG SEPTAL NITINOL POLYESTER SELF EXPANDING MULTI FENESTRATED","SUP-ITM-10007315","CDM","C1817","HCPCS","0278","RC","","","","both","","","19750.00","14812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7564.25","38.3","","8650.88","8650.88","9853.20","1 through 10","6122.5","15701.25","percent of total billed charges",""
"OCCLUDER AMPLATZER 7FR 16MM 4MM 26MM 30MM 45DEG SEPTAL NITINOL POLYESTER SELF EXPANDING MULTI FENESTRATED","SUP-ITM-10007315","CDM","C1817","HCPCS","0278","RC","","","","both","","","19750.00","14812.50","WELLPOINT [1015]","HB AMC WELLPOINT","14571.55","73.78","","16472.06","16472.06","16472.06","1 through 10","6122.5","15701.25","percent of total billed charges",""
"OCCLUDER AMPLATZER 7FR 16MM 4MM 26MM 30MM 45DEG SEPTAL NITINOL POLYESTER SELF EXPANDING MULTI FENESTRATED","SUP-ITM-10007315","CDM","C1817","HCPCS","0278","RC","","","","outpatient","","","19750.00","14812.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16139.70","81.72","","17686.73","17686.73","17686.73","1 through 10","10321.35","16139.7","percent of total billed charges",""
"OCCLUDER MUSCULAR AMPLATZER 5FR 180DEG OR 6FR 45DEG 4MM 9MM 7MM VSD SELF EXPANDING","SUP-ITM-10030539","CDM","C1817","HCPCS","0278","RC","","","","both","","","23750.00","17812.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18881.25","79.5","","17412.37","11682.00","17412.38","1 through 10","7362.5","18881.25","percent of total billed charges",""
"OCCLUDER MUSCULAR AMPLATZER 5FR 180DEG OR 6FR 45DEG 4MM 9MM 7MM VSD SELF EXPANDING","SUP-ITM-10030539","CDM","C1817","HCPCS","0278","RC","","","","both","","","23750.00","17812.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12658.75","53.3","","11682.00","11682.00","11682.00","1 through 10","7362.5","18881.25","percent of total billed charges",""
"OCCLUDER MUSCULAR AMPLATZER 5FR 180DEG OR 6FR 45DEG 4MM 9MM 7MM VSD SELF EXPANDING","SUP-ITM-10030539","CDM","C1817","HCPCS","0278","RC","","","","both","","","23750.00","17812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9096.25","38.3","","8650.88","8650.88","9853.20","1 through 10","7362.5","18881.25","percent of total billed charges",""
"OCCLUDER MUSCULAR AMPLATZER 5FR 180DEG OR 6FR 45DEG 4MM 9MM 7MM VSD SELF EXPANDING","SUP-ITM-10030539","CDM","C1817","HCPCS","0278","RC","","","","both","","","23750.00","17812.50","WELLPOINT [1015]","HB AMC WELLPOINT","17522.75","73.78","","16472.06","16472.06","16472.06","1 through 10","7362.5","18881.25","percent of total billed charges",""
"OCCLUDER MUSCULAR AMPLATZER 5FR 180DEG OR 6FR 45DEG 4MM 9MM 7MM VSD SELF EXPANDING","SUP-ITM-10030539","CDM","C1817","HCPCS","0278","RC","","","","outpatient","","","23750.00","17812.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","19408.50","81.72","","17686.73","17686.73","17686.73","1 through 10","12411.75","19408.5","percent of total billed charges",""
"Occlus/Emb Transcath Non-Cns","PX-76001445","CDM","61626","CPT","0361","RC","","","","both","","","31106.00","23329.50","MEDICARE [2001]","HB BWH MEDICARE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38276.44","38276.44","38276.44","1 through 10","9642.86","24729.27","other","OPPS APC"
"Occlus/Emboliz Transcath Cns Perc","PX-76001444","CDM","61624","CPT","0361","RC","","","","both","","","8324.00","6243.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3038.26","36.5","","2558.82","2558.82","2558.82","1 through 10","1168.49","7907.8","percent of total billed charges",""
"Occlus/Emboliz Transcath Cns Perc","PX-76001444","CDM","61624","CPT","0361","RC","","","","outpatient","","","8324.00","6243.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1968.14","","Case rate ($1,968.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2281.08","2281.08","2281.08","1 through 10","1968.14","11593.85","other","ASC "
"Occult Blood Feces Cancer Screen","PX-30000328","CDM","82270","CPT","0301","RC","","","","both","","","55.00","41.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21.07","38.3","","20.72","20.72","20.72","1 through 10","3.36","52.25","percent of total billed charges",""
"Occult Blood Feces Cancer Screen","PX-30000328","CDM","82270","CPT","0301","RC","","","","outpatient","","","55.00","41.25","AETNA [1001]","HB AMC AETNA HMO","38.39","69.8","","35.88","35.88","35.88","1 through 10","3.36","44.95","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","both","","","172.00","129.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","136.74","79.5","","131.43","88.18","131.43","1 through 10","15.29","163.4","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","both","","","172.00","129.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","91.68","53.3","","131.43","88.18","131.43","1 through 10","15.29","163.4","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","both","","","172.00","129.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","62.78","36.5","","62.29","52.94","62.29","16","15.29","163.4","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","both","","","172.00","129.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","65.88","38.3","","65.30","63.46","65.30","52","15.29","163.4","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","both","","","172.00","129.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","73.79","42.9","","133.50","133.50","133.50","1 through 10","15.29","163.4","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","outpatient","","","172.00","129.00","AETNA [1001]","HB AMC AETNA HMO","120.06","69.8","","113.06","79.83","130.26","12","15.29","140.56","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","outpatient","","","172.00","129.00","AETNA [1001]","HB AMC AETNA PPO","138.29","80.4","","167.00","130.26","167.00","1 through 10","15.29","140.56","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","outpatient","","","172.00","129.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","89.89","52.26","","103.34","103.34","103.34","1 through 10","15.29","140.56","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","outpatient","","","172.00","129.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","140.56","81.72","","73.43","73.43","73.43","1 through 10","15.29","140.56","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","outpatient","","","172.00","129.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","140.56","81.72","","133.50","73.43","133.50","1 through 10","15.29","140.56","percent of total billed charges",""
"Occult Blood Feces Ql Other Single","PX-30000330","CDM","82272","CPT","0301","RC","","","","both","","","54.00","40.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","28.78","53.3","","27.46","27.46","27.46","1 through 10","3.36","51.3","percent of total billed charges",""
"Occult Blood Feces Ql Other Single","PX-30000330","CDM","82272","CPT","0301","RC","","","","both","","","54.00","40.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19.71","36.5","","19.40","19.40","19.40","1 through 10","3.36","51.3","percent of total billed charges",""
"Occult Blood Feces Ql Other Single","PX-30000330","CDM","82272","CPT","0301","RC","","","","both","","","54.00","40.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20.68","38.3","","20.33","19.76","20.33","1 through 10","3.36","51.3","percent of total billed charges",""
"Occult Blood Feces Ql Other Single","PX-30000330","CDM","82272","CPT","0301","RC","","","","outpatient","","","54.00","40.50","AETNA [1001]","HB AMC AETNA HMO","37.69","69.8","","24.86","24.86","35.20","1 through 10","3.36","44.13","percent of total billed charges",""
"Occult Blood Feces Ql Other Single","PX-30000330","CDM","82272","CPT","0301","RC","","","","outpatient","","","54.00","40.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","44.13","81.72","","41.57","22.86","41.57","1 through 10","3.36","44.13","percent of total billed charges",""
"Occupational Ther Re-Eval Est Plan Care 30 Mins","PX-43000112","CDM","97168","CPT","0434","RC","","","","both","","","415.00","311.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","158.95","38.3","","157.18","157.18","157.18","1 through 10","76.58","394.25","percent of total billed charges",""
"Occupational Therapy Evaluation, High Complexity","PX-43000110","CDM","97167","CPT","0434","RC","","","","both","","","637.00","477.75","AETNA [1001]","HB AMC AETNA HMO","444.63","69.8","","482.04","418.39","482.04","1 through 10","110.05","605.15","percent of total billed charges",""
"Occupational Therapy Evaluation, High Complexity","PX-43000110","CDM","97167","CPT","0434","RC","","","","both","","","637.00","477.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","339.52","53.3","","326.30","326.30","326.30","1 through 10","110.05","605.15","percent of total billed charges",""
"Occupational Therapy Evaluation, High Complexity","PX-43000110","CDM","97167","CPT","0434","RC","","","","both","","","637.00","477.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","110.05","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($112.30). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($82.68). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","110.06","110.06","110.06","1 through 10","110.05","605.15","fee schedule",""
"Occupational Therapy Evaluation, High Complexity","PX-43000110","CDM","97167","CPT","0434","RC","","","","both","","","637.00","477.75","WELLPOINT [1015]","HB AMC WELLPOINT","469.98","73.78","","460.10","460.10","460.10","1 through 10","110.05","605.15","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","605.00","453.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","480.98","79.5","","461.97","461.97","461.97","1 through 10","110.05","574.75","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","605.00","453.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","322.47","53.3","","309.94","309.94","461.97","11","110.05","574.75","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","605.00","453.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","220.83","36.5","","218.95","186.08","218.95","11","110.05","574.75","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","605.00","453.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","231.72","38.3","","229.52","223.06","229.52","40","110.05","574.75","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","605.00","453.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","465.85","77","","442.60","442.60","442.60","1 through 10","110.05","574.75","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","605.00","453.75","TRICARE [160005]","HB BWH TRICARE","574.75","95","","106.69","106.69","112.78","1 through 10","110.05","574.75","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","605.00","453.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","110.05","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($112.30). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($82.68). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","110.66","110.06","111.33","34","110.05","574.75","fee schedule",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","605.00","453.75","WELLPOINT [1015]","HB AMC WELLPOINT","446.37","73.78","","437.02","406.79","437.02","1 through 10","110.05","574.75","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","outpatient","","","605.00","453.75","AETNA [1001]","HB AMC AETNA HMO","422.29","69.8","","397.40","280.59","457.86","31","228","751.42","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","outpatient","","","605.00","453.75","AETNA [1001]","HB AMC AETNA PPO","486.42","80.4","","457.86","307.59","457.86","1 through 10","228","751.42","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","outpatient","","","605.00","453.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","494.41","81.72","","425.87","425.87","425.87","1 through 10","228","751.42","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","640.00","480.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.12","53.3","","1466.19","1466.19","1466.19","1 through 10","110.05","608","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","640.00","480.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.60","36.5","","231.63","196.86","231.63","1 through 10","110.05","608","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","640.00","480.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.12","38.3","","242.81","242.81","707.94","18","110.05","608","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","640.00","480.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","110.05","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($112.30). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($82.68). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","110.06","110.06","110.96","1 through 10","110.05","608","fee schedule",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","640.00","480.00","WELLPOINT [1015]","HB AMC WELLPOINT","472.19","73.78","","462.33","462.33","462.33","1 through 10","110.05","608","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","outpatient","","","640.00","480.00","AETNA [1001]","HB AMC AETNA HMO","446.72","69.8","","296.84","296.84","484.38","1 through 10","228","751.42","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","outpatient","","","640.00","480.00","AETNA [1001]","HB AMC AETNA PPO","514.56","80.4","","420.42","420.42","484.38","1 through 10","228","751.42","percent of total billed charges",""
"Oct-Vascular Imaging","PX-48000385","CDM","93799","CPT","0480","RC","","","","outpatient","","","7041.00","5280.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","3872.55","55","","13080.03","13080.03","13080.03","1 through 10","3520.5","5808.83","percent of total billed charges",""
"Oct-Vascular Imaging","PX-48000385","CDM","93799","CPT","0481","RC","","","","both","","","7041.00","5280.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","5597.6","other","OPPS APC"
"Oct-Vascular Imaging","PX-48000385","CDM","93799","CPT","0481","RC","","","","outpatient","","","7041.00","5280.75","AETNA [1001]","HB AMC AETNA HMO","4914.62","69.8","","2022.70","2022.70","2022.70","1 through 10","454","5753.91","percent of total billed charges",""
"Oct-Vascular Imaging","PX-48000385","CDM","93799","CPT","0481","RC","","","","outpatient","","","7041.00","5280.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4263.33","60.55","","318.03","318.03","2439.77","1 through 10","454","5753.91","percent of total billed charges",""
"Oct-Vascular Imaging","PX-48000385","CDM","93799","CPT","0481","RC","","","","outpatient","","","7041.00","5280.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3676.81","52.22","","360.38","360.38","4023.00","1 through 10","454","5753.91","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","124.93","71.8","","156.46","121.34","464.50","35","53.94","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","114.14","65.6","","114.41","80.78","114.41","1 through 10","53.94","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","113.10","65","","109.85","89.23","109.85","1 through 10","53.94","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","121.80","70","","121.68","72.67","218.01","96","53.94","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9.33","9.33","9.33","1 through 10","53.94","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","113.10","65","","109.85","106.60","109.85","56","53.94","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","113.10","65","","109.85","106.60","169.00","1 through 10","53.94","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","125.28","72","","121.68","121.68","121.68","1 through 10","53.94","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9.33","9.07","9.33","1 through 10","53.94","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","53.94","31","","52.22","52.22","52.22","120","53.94","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.51","36.5","","63.04","53.57","63.04","3042","53.94","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.64","38.3","","66.08","64.22","66.08","9708","53.94","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8.89","8.89","8.89","1 through 10","53.94","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","133.98","77","","133.00","84.50","169.00","80","53.94","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9.07","9.07","9.07","1 through 10","53.94","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","174.00","130.50","AETNA [1001]","HB AMC AETNA HMO","121.45","69.8","","114.41","80.78","131.82","4138","59.33","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","174.00","130.50","AETNA [1001]","HB AMC AETNA PPO","139.90","80.4","","131.82","88.56","131.82","384","59.33","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","174.00","130.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","97.27","55.9","","88.56","88.56","131.82","15","59.33","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","174.00","130.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59.33","34.1","","133.00","57.63","133.00","271","59.33","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","174.00","130.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","139.90","80.4","","131.82","84.50","131.82","74","59.33","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","174.00","130.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","59.33","34.1","","119.17","108.61","119.17","1 through 10","59.33","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","174.00","130.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","142.19","81.72","","135.10","126.30","135.10","25","59.33","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","142.19","81.72","","135.10","135.10","135.10","1 through 10","59.33","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","212.00","159.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","157.62","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","32.07","32.07","37.72","1 through 10","65.72","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","212.00","159.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.66","30.66","36.41","1 through 10","65.72","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","212.00","159.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.66","30.66","31.47","13","65.72","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","212.00","159.00","FALLON HEALTH [1008]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","31.16","31.16","31.98","18","65.72","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","212.00","159.00","HUMANA [1012]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.54","30.54","36.66","1 through 10","65.72","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","212.00","159.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","31.16","31.16","36.66","93","65.72","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.38","36.5","","55.95","47.55","55.95","12","65.72","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.20","38.3","","58.65","57.00","114.00","18","65.72","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","61.69","36.43","61.69","1 through 10","65.72","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","212.00","159.00","MOLINA [1014]","HB BWH MOLINA","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","61.82","26.11","61.82","30","65.72","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","212.00","159.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","163.24","77","","130.50","130.50","130.50","1 through 10","65.72","191.28","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","212.00","159.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","31.98","30.66","108.21","25","65.72","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","35.93","35.93","36.87","50","65.72","191.28","other","OPPS APC"
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA HMO","147.98","69.8","","117.00","71.70","117.00","1 through 10","72.29","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","outpatient","","","212.00","159.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","72.29","34.1","","75.70","75.70","75.70","1 through 10","72.29","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","outpatient","","","212.00","159.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","72.29","34.1","","75.70","75.70","75.70","1 through 10","72.29","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","outpatient","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","173.25","81.72","","65.96","65.96","65.96","1 through 10","72.29","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","157.62","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","70.78","60.16","70.78","38","103.23","256.41","other","OPPS APC"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","67.68","57.90","97.40","18","103.23","256.41","other","OPPS APC"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","239.09","71.8","","695.73","231.91","695.73","12","103.23","256.41","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","218.45","65.6","","251.94","218.67","251.94","1 through 10","103.23","256.41","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","216.45","65","","209.95","110.14","323.00","1 through 10","103.23","256.41","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","233.10","70","","232.56","176.09","362.25","17","103.23","256.41","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","177.49","53.3","","163.12","151.34","383.30","31","103.23","256.41","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","58.86","57.52","67.68","21","103.23","256.41","other","OPPS APC"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","FALLON HEALTH [1008]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","58.46","58.46","70.38","1 through 10","103.23","256.41","other","OPPS APC"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","58.62","58.62","58.62","1 through 10","103.23","256.41","other","OPPS APC"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","HUMANA [1012]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","67.60","57.29","68.78","1 through 10","103.23","256.41","other","OPPS APC"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","216.45","65","","209.95","171.19","209.95","26","103.23","256.41","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","68.78","58.46","68.78","593","103.23","256.41","other","OPPS APC"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","103.23","31","","99.81","99.81","299.43","52","103.23","256.41","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.55","36.5","","120.48","102.39","361.44","1195","103.23","256.41","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.54","38.3","","126.29","122.74","378.87","4131","103.23","256.41","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","67.40","57.29","115.42","14","103.23","256.41","other","OPPS APC"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","MOLINA [1014]","HB BWH MOLINA","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","118.44","48.56","219.00","70","103.23","256.41","other","OPPS APC"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","256.41","77","","248.71","218.67","251.94","11","103.23","256.41","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","TRICARE [160005]","HB BWH TRICARE","145.39","","APC Price ($153.04). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","65.34","65.34","65.34","1 through 10","103.23","256.41","other","Tricare OPPS"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","68.20","57.52","174.27","41","103.23","256.41","other","OPPS APC"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.06","126.06","126.06","1 through 10","103.23","256.41","other","OPPS APC"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.86","42.9","","224.63","224.63","224.63","1 through 10","103.23","256.41","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","333.00","249.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","67.41","67.40","68.98","290","103.23","256.41","other","OPPS APC"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","333.00","249.75","AETNA [1001]","HB AMC AETNA HMO","232.43","69.8","","218.67","154.39","251.94","1489","105.16","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","333.00","249.75","AETNA [1001]","HB AMC AETNA PPO","267.73","80.4","","251.94","169.25","251.94","199","105.16","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","333.00","249.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","186.15","55.9","","169.25","169.25","169.25","1 through 10","105.16","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","333.00","249.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","113.55","34.1","","254.20","151.34","438.88","185","105.16","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","333.00","249.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","267.73","80.4","","251.94","161.50","251.94","20","105.16","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","333.00","249.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","113.55","34.1","","151.34","151.34","151.34","1 through 10","105.16","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","333.00","249.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","272.13","81.72","","258.21","224.63","258.21","1 through 10","105.16","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","333.00","249.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","272.13","81.72","","224.63","123.56","224.63","1 through 10","105.16","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","333.00","249.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","272.13","81.72","","224.63","218.67","513.76","40","105.16","282.67","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","157.62","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","104.12","88.50","104.12","143","145.39","390.39","other","OPPS APC"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","99.57","84.63","100.51","58","145.39","390.39","other","OPPS APC"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","364.03","71.8","","297.97","154.80","297.97","1 through 10","145.39","390.39","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","191.28","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","138.75","99.17","138.75","1 through 10","145.39","390.39","other","OPPS APC"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","CHAMPVA [160001]","HB BWH TRICARE","145.39","","APC Price ($153.04). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","415.00","86.01","415.00","1 through 10","145.39","390.39","other","Tricare OPPS"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","99.57","84.63","102.17","1 through 10","145.39","390.39","other","OPPS APC"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","101.75","86.49","101.75","1 through 10","145.39","390.39","other","OPPS APC"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","HUMANA [1012]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","100.07","99.17","101.95","24","145.39","390.39","other","OPPS APC"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","101.19","86.01","101.19","1814","145.39","390.39","other","OPPS APC"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","157.17","31","","128.24","128.24","128.24","11","145.39","390.39","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.06","36.5","","154.80","131.56","154.80","363","145.39","390.39","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.18","38.3","","162.27","157.70","162.27","456","145.39","390.39","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","99.17","84.29","203.65","62","145.39","390.39","other","OPPS APC"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","MOLINA [1014]","HB BWH MOLINA","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","200.76","200.36","200.76","1 through 10","145.39","390.39","other","OPPS APC"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","TRICARE [160005]","HB BWH TRICARE","145.39","","APC Price ($153.04). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","96.12","96.12","96.12","1 through 10","145.39","390.39","other","Tricare OPPS"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","99.57","99.17","101.75","37","145.39","390.39","other","OPPS APC"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.50","42.9","","182.48","182.48","182.48","1 through 10","145.39","390.39","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","507.00","380.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","99.17","99.17","101.75","1416","145.39","390.39","other","OPPS APC"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","outpatient","","","507.00","380.25","AETNA [1001]","HB AMC AETNA HMO","353.89","69.8","","280.96","198.37","323.70","114","105.16","414.32","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","outpatient","","","507.00","380.25","AETNA [1001]","HB AMC AETNA PPO","407.63","80.4","","323.70","198.37","323.70","1 through 10","105.16","414.32","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","outpatient","","","507.00","380.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","172.89","34.1","","233.34","233.34","233.34","89","105.16","414.32","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","outpatient","","","507.00","380.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","407.63","80.4","","323.70","323.70","323.70","1 through 10","105.16","414.32","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","outpatient","","","507.00","380.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","414.32","81.72","","331.75","182.48","331.75","1 through 10","105.16","414.32","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","outpatient","","","507.00","380.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","414.32","81.72","","331.75","182.48","331.75","85","105.16","414.32","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","157.62","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","154.36","131.20","154.36","28","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.61","125.47","192.90","1 through 10","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","381.98","71.8","","1111.47","240.86","1111.47","1 through 10","145.39","409.64","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","HUMANA [1012]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.11","125.48","148.31","1 through 10","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","345.80","65","","335.40","166.95","335.40","1 through 10","145.39","409.64","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.91","147.91","147.91","1 through 10","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.01","127.51","150.01","370","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","164.92","31","","190.34","190.34","190.34","1 through 10","145.39","409.64","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.18","36.5","","195.27","163.57","384.94","153","145.39","409.64","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.76","38.3","","240.86","201.76","588.24","304","145.39","409.64","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.96","124.96","147.01","1 through 10","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","TRICARE [160005]","HB BWH TRICARE","145.39","","APC Price ($153.04). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","146.56","142.51","146.56","1 through 10","145.39","409.64","other","Tricare OPPS"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","147.81","125.76","443.73","13","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.23","42.9","","270.86","270.86","270.86","1 through 10","145.39","409.64","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","147.01","147.01","151.18","296","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","AETNA [1001]","HB AMC AETNA HMO","371.34","69.8","","349.33","246.65","480.48","99","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","AETNA [1001]","HB AMC AETNA PPO","427.73","80.4","","402.48","349.33","402.48","15","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","297.39","55.9","","270.38","270.38","270.38","1 through 10","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","181.41","34.1","","328.95","328.95","406.09","18","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","427.73","80.4","","402.48","258.00","402.48","1 through 10","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","434.75","81.72","","492.43","412.49","492.43","1 through 10","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","434.75","81.72","","270.86","270.86","270.86","1 through 10","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","434.75","81.72","","270.86","270.86","492.43","11","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","157.62","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","154.36","131.20","154.36","28","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.61","125.47","192.90","1 through 10","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","381.98","71.8","","1111.47","240.86","1111.47","1 through 10","145.39","409.64","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","HUMANA [1012]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.11","125.48","148.31","1 through 10","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","345.80","65","","335.40","166.95","335.40","1 through 10","145.39","409.64","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.91","147.91","147.91","1 through 10","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.01","127.51","150.01","370","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","164.92","31","","190.34","190.34","190.34","1 through 10","145.39","409.64","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.18","36.5","","195.27","163.57","384.94","153","145.39","409.64","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.76","38.3","","240.86","201.76","588.24","304","145.39","409.64","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.96","124.96","147.01","1 through 10","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","TRICARE [160005]","HB BWH TRICARE","145.39","","APC Price ($153.04). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","146.56","142.51","146.56","1 through 10","145.39","409.64","other","Tricare OPPS"
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","147.81","125.76","443.73","13","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.23","42.9","","270.86","270.86","270.86","1 through 10","145.39","409.64","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","147.01","147.01","151.18","296","145.39","409.64","other","OPPS APC"
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","AETNA [1001]","HB AMC AETNA HMO","371.34","69.8","","349.33","246.65","480.48","99","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","AETNA [1001]","HB AMC AETNA PPO","427.73","80.4","","402.48","349.33","402.48","15","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","297.39","55.9","","270.38","270.38","270.38","1 through 10","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","181.41","34.1","","328.95","328.95","406.09","18","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","427.73","80.4","","402.48","258.00","402.48","1 through 10","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","434.75","81.72","","492.43","412.49","492.43","1 through 10","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","434.75","81.72","","270.86","270.86","270.86","1 through 10","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","outpatient","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","434.75","81.72","","270.86","270.86","492.43","11","105.16","434.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","157.62","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","154.36","131.20","154.36","28","145.39","422.94","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.61","125.47","192.90","1 through 10","145.39","422.94","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","381.98","71.8","","1111.47","240.86","1111.47","1 through 10","145.39","422.94","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","422.94","79.5","","328.95","328.95","406.09","18","145.39","422.94","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","283.56","53.3","","328.95","153.04","382.48","15","145.39","422.94","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","HUMANA [1012]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.11","125.48","148.31","1 through 10","145.39","422.94","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","345.80","65","","335.40","166.95","335.40","1 through 10","145.39","422.94","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.91","147.91","147.91","1 through 10","145.39","422.94","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.01","127.51","150.01","370","145.39","422.94","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","164.92","31","","190.34","190.34","190.34","1 through 10","145.39","422.94","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.18","36.5","","195.27","163.57","384.94","153","145.39","422.94","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.76","38.3","","240.86","201.76","588.24","304","145.39","422.94","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.96","124.96","147.01","1 through 10","145.39","422.94","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","TRICARE [160005]","HB BWH TRICARE","145.39","","APC Price ($153.04). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","146.56","142.51","146.56","1 through 10","145.39","422.94","other","Tricare OPPS"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","147.81","125.76","443.73","13","145.39","422.94","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.23","42.9","","270.86","270.86","270.86","1 through 10","145.39","422.94","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","147.01","147.01","151.18","296","145.39","422.94","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","532.00","399.00","AETNA [1001]","HB AMC AETNA HMO","371.34","69.8","","349.33","246.65","480.48","99","105.16","438.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","532.00","399.00","AETNA [1001]","HB AMC AETNA PPO","427.73","80.4","","402.48","349.33","402.48","15","105.16","438.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","532.00","399.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","297.39","55.9","","270.38","270.38","270.38","1 through 10","105.16","438.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","532.00","399.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","266.00","50","","347.79","332.55","462.12","60","105.16","438.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","532.00","399.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","279.30","52.5","","365.18","325.86","485.23","15","105.16","438.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","532.00","399.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","332.50","62.5","","429.62","429.62","485.23","1 through 10","105.16","438.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","532.00","399.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","292.60","55","","237.77","109.28","429.62","33","105.16","438.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","532.00","399.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","427.73","80.4","","402.48","258.00","402.48","1 through 10","105.16","438.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","532.00","399.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","434.75","81.72","","492.43","412.49","492.43","1 through 10","105.16","438.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","434.75","81.72","","270.86","270.86","270.86","1 through 10","105.16","438.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","434.75","81.72","","270.86","270.86","492.43","11","105.16","438.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","532.00","399.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","292.60","55","","331.73","331.73","331.73","1 through 10","105.16","438.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","27.28","71.8","","156.46","121.34","464.50","35","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","24.93","65.6","","114.41","80.78","114.41","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","24.70","65","","109.85","89.23","109.85","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","26.60","70","","121.68","72.67","218.01","96","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","30.21","79.5","","133.00","57.63","133.00","271","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","20.25","53.3","","133.84","82.82","854.98","33","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","24.70","65","","109.85","106.60","109.85","56","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","30.21","79.5","","119.17","108.61","119.17","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","24.70","65","","109.85","106.60","169.00","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","27.36","72","","121.68","121.68","121.68","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","11.78","31","","52.22","52.22","52.22","120","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13.87","36.5","","63.04","53.57","63.04","3042","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.55","38.3","","66.08","64.22","66.08","9708","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","29.26","77","","133.00","84.50","169.00","80","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","outpatient","","","38.00","28.50","AETNA [1001]","HB AMC AETNA HMO","26.52","69.8","","114.41","80.78","131.82","4138","21.24","120.8","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","outpatient","","","38.00","28.50","AETNA [1001]","HB AMC AETNA PPO","30.55","80.4","","131.82","88.56","131.82","384","21.24","120.8","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","outpatient","","","38.00","28.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","21.24","55.9","","88.56","88.56","131.82","15","21.24","120.8","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","outpatient","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","30.55","80.4","","131.82","84.50","131.82","74","21.24","120.8","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","outpatient","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","31.05","81.72","","135.10","126.30","135.10","25","21.24","120.8","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","outpatient","","","38.00","28.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","31.05","81.72","","135.10","135.10","135.10","1 through 10","21.24","120.8","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100046","CDM","99212","CPT","0961","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","75.70","75.70","75.70","1 through 10","35.93","145.35","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100046","CDM","99212","CPT","0961","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","121.64","79.5","","75.70","75.70","75.70","1 through 10","35.93","145.35","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100046","CDM","99212","CPT","0961","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.85","36.5","","55.95","47.55","55.95","12","35.93","145.35","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100046","CDM","99212","CPT","0961","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","58.65","57.00","114.00","18","35.93","145.35","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100046","CDM","99212","CPT","0961","RC","","","","both","","","153.00","114.75","MOLINA [1014]","HB BWH MOLINA","53.55","35","","61.82","26.11","61.82","30","35.93","145.35","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100046","CDM","99212","CPT","0961","RC","","","","both","","","153.00","114.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","117.81","77","","130.50","130.50","130.50","1 through 10","35.93","145.35","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100046","CDM","99212","CPT","0961","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","117.00","71.70","117.00","1 through 10","85.53","156.87","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100046","CDM","99212","CPT","0961","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","65.96","65.96","65.96","1 through 10","85.53","156.87","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","206.07","71.8","","695.73","231.91","695.73","12","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","188.27","65.6","","251.94","218.67","251.94","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","186.55","65","","209.95","110.14","323.00","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","200.90","70","","232.56","176.09","362.25","17","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","228.17","79.5","","254.20","151.34","438.88","185","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","152.97","53.3","","163.12","151.34","383.30","31","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","186.55","65","","209.95","171.19","209.95","26","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","228.17","79.5","","151.34","151.34","151.34","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","88.97","31","","99.81","99.81","299.43","52","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","104.76","36.5","","120.48","102.39","361.44","1195","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","109.92","38.3","","126.29","122.74","378.87","4131","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","MOLINA [1014]","HB BWH MOLINA","100.45","35","","118.44","48.56","219.00","70","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","220.99","77","","248.71","218.67","251.94","11","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","TRICARE [160005]","HB BWH TRICARE","272.65","95","","65.34","65.34","65.34","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","both","","","287.00","215.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","123.12","42.9","","224.63","224.63","224.63","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","outpatient","","","287.00","215.25","AETNA [1001]","HB AMC AETNA HMO","200.33","69.8","","218.67","154.39","251.94","1489","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","outpatient","","","287.00","215.25","AETNA [1001]","HB AMC AETNA PPO","230.75","80.4","","251.94","169.25","251.94","199","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","outpatient","","","287.00","215.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","160.43","55.9","","169.25","169.25","169.25","1 through 10","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","outpatient","","","287.00","215.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","230.75","80.4","","251.94","161.50","251.94","20","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","outpatient","","","287.00","215.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","234.54","81.72","","258.21","224.63","258.21","1 through 10","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","outpatient","","","287.00","215.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","234.54","81.72","","224.63","123.56","224.63","1 through 10","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","outpatient","","","287.00","215.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","234.54","81.72","","224.63","218.67","513.76","40","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","both","","","422.00","316.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","303.00","71.8","","297.97","154.80","297.97","1 through 10","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","both","","","422.00","316.50","CHAMPVA [160001]","HB BWH TRICARE","400.90","95","","415.00","86.01","415.00","1 through 10","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","both","","","422.00","316.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","335.49","79.5","","233.34","233.34","233.34","89","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","both","","","422.00","316.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","224.93","53.3","","233.34","233.34","233.34","28","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","both","","","422.00","316.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","130.82","31","","128.24","128.24","128.24","11","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","both","","","422.00","316.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","154.03","36.5","","154.80","131.56","154.80","363","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","both","","","422.00","316.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","161.63","38.3","","162.27","157.70","162.27","456","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","both","","","422.00","316.50","MOLINA [1014]","HB BWH MOLINA","147.70","35","","200.76","200.36","200.76","1 through 10","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","both","","","422.00","316.50","TRICARE [160005]","HB BWH TRICARE","400.90","95","","96.12","96.12","96.12","1 through 10","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","both","","","422.00","316.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.04","42.9","","182.48","182.48","182.48","1 through 10","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","outpatient","","","422.00","316.50","AETNA [1001]","HB AMC AETNA HMO","294.56","69.8","","280.96","198.37","323.70","114","105.16","344.86","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","outpatient","","","422.00","316.50","AETNA [1001]","HB AMC AETNA PPO","339.29","80.4","","323.70","198.37","323.70","1 through 10","105.16","344.86","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","outpatient","","","422.00","316.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","339.29","80.4","","323.70","323.70","323.70","1 through 10","105.16","344.86","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","outpatient","","","422.00","316.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","344.86","81.72","","331.75","182.48","331.75","1 through 10","105.16","344.86","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","outpatient","","","422.00","316.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","344.86","81.72","","331.75","182.48","331.75","85","105.16","344.86","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","449.47","71.8","","1111.47","240.86","1111.47","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","497.67","79.5","","328.95","328.95","406.09","18","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","333.66","53.3","","328.95","153.04","382.48","15","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","406.90","65","","335.40","166.95","335.40","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","194.06","31","","190.34","190.34","190.34","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.49","36.5","","195.27","163.57","384.94","153","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.76","38.3","","240.86","201.76","588.24","304","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","TRICARE [160005]","HB BWH TRICARE","594.70","95","","146.56","142.51","146.56","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.55","42.9","","270.86","270.86","270.86","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","outpatient","","","626.00","469.50","AETNA [1001]","HB AMC AETNA HMO","436.95","69.8","","349.33","246.65","480.48","99","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","outpatient","","","626.00","469.50","AETNA [1001]","HB AMC AETNA PPO","503.30","80.4","","402.48","349.33","402.48","15","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","outpatient","","","626.00","469.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","349.93","55.9","","270.38","270.38","270.38","1 through 10","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","outpatient","","","626.00","469.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","503.30","80.4","","402.48","258.00","402.48","1 through 10","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","outpatient","","","626.00","469.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","511.57","81.72","","492.43","412.49","492.43","1 through 10","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","outpatient","","","626.00","469.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","511.57","81.72","","270.86","270.86","270.86","1 through 10","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","outpatient","","","626.00","469.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","511.57","81.72","","270.86","270.86","492.43","11","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","27.28","71.8","","156.46","121.34","464.50","35","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","24.93","65.6","","114.41","80.78","114.41","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","24.70","65","","109.85","89.23","109.85","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","26.60","70","","121.68","72.67","218.01","96","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","30.21","79.5","","133.00","57.63","133.00","271","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","20.25","53.3","","133.84","82.82","854.98","33","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","24.70","65","","109.85","106.60","109.85","56","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","30.21","79.5","","119.17","108.61","119.17","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","24.70","65","","109.85","106.60","169.00","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","27.36","72","","121.68","121.68","121.68","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","11.78","31","","52.22","52.22","52.22","120","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13.87","36.5","","63.04","53.57","63.04","3042","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.55","38.3","","66.08","64.22","66.08","9708","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","both","","","38.00","28.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","29.26","77","","133.00","84.50","169.00","80","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","outpatient","","","38.00","28.50","AETNA [1001]","HB AMC AETNA HMO","26.52","69.8","","114.41","80.78","131.82","4138","21.24","105.16","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","outpatient","","","38.00","28.50","AETNA [1001]","HB AMC AETNA PPO","30.55","80.4","","131.82","88.56","131.82","384","21.24","105.16","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","outpatient","","","38.00","28.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","21.24","55.9","","88.56","88.56","131.82","15","21.24","105.16","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","outpatient","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","30.55","80.4","","131.82","84.50","131.82","74","21.24","105.16","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","outpatient","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","31.05","81.72","","135.10","126.30","135.10","25","21.24","105.16","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300520","CDM","99211","CPT","0983","RC","","","","outpatient","","","38.00","28.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","31.05","81.72","","135.10","135.10","135.10","1 through 10","21.24","105.16","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300521","CDM","99212","CPT","0983","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","75.70","75.70","75.70","1 through 10","35.93","145.35","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300521","CDM","99212","CPT","0983","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","121.64","79.5","","75.70","75.70","75.70","1 through 10","35.93","145.35","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300521","CDM","99212","CPT","0983","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.85","36.5","","55.95","47.55","55.95","12","35.93","145.35","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300521","CDM","99212","CPT","0983","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","58.65","57.00","114.00","18","35.93","145.35","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300521","CDM","99212","CPT","0983","RC","","","","both","","","153.00","114.75","MOLINA [1014]","HB BWH MOLINA","53.55","35","","61.82","26.11","61.82","30","35.93","145.35","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300521","CDM","99212","CPT","0983","RC","","","","both","","","153.00","114.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","117.81","77","","130.50","130.50","130.50","1 through 10","35.93","145.35","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300521","CDM","99212","CPT","0983","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","117.00","71.70","117.00","1 through 10","85.53","134.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300521","CDM","99212","CPT","0983","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","65.96","65.96","65.96","1 through 10","85.53","134.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","206.07","71.8","","695.73","231.91","695.73","12","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","188.27","65.6","","251.94","218.67","251.94","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","186.55","65","","209.95","110.14","323.00","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","200.90","70","","232.56","176.09","362.25","17","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","228.17","79.5","","254.20","151.34","438.88","185","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","152.97","53.3","","163.12","151.34","383.30","31","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","186.55","65","","209.95","171.19","209.95","26","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","228.17","79.5","","151.34","151.34","151.34","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","88.97","31","","99.81","99.81","299.43","52","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","104.76","36.5","","120.48","102.39","361.44","1195","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","109.92","38.3","","126.29","122.74","378.87","4131","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","MOLINA [1014]","HB BWH MOLINA","100.45","35","","118.44","48.56","219.00","70","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","220.99","77","","248.71","218.67","251.94","11","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","TRICARE [160005]","HB BWH TRICARE","272.65","95","","65.34","65.34","65.34","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","both","","","287.00","215.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","123.12","42.9","","224.63","224.63","224.63","1 through 10","67.4","272.65","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","outpatient","","","287.00","215.25","AETNA [1001]","HB AMC AETNA HMO","200.33","69.8","","218.67","154.39","251.94","1489","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","outpatient","","","287.00","215.25","AETNA [1001]","HB AMC AETNA PPO","230.75","80.4","","251.94","169.25","251.94","199","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","outpatient","","","287.00","215.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","160.43","55.9","","169.25","169.25","169.25","1 through 10","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","outpatient","","","287.00","215.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","230.75","80.4","","251.94","161.50","251.94","20","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","outpatient","","","287.00","215.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","234.54","81.72","","258.21","224.63","258.21","1 through 10","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","outpatient","","","287.00","215.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","234.54","81.72","","224.63","123.56","224.63","1 through 10","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300522","CDM","99213","CPT","0983","RC","","","","outpatient","","","287.00","215.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","234.54","81.72","","224.63","218.67","513.76","40","105.16","234.54","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","both","","","422.00","316.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","303.00","71.8","","297.97","154.80","297.97","1 through 10","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","both","","","422.00","316.50","CHAMPVA [160001]","HB BWH TRICARE","400.90","95","","415.00","86.01","415.00","1 through 10","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","both","","","422.00","316.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","335.49","79.5","","233.34","233.34","233.34","89","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","both","","","422.00","316.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","224.93","53.3","","233.34","233.34","233.34","28","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","both","","","422.00","316.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","130.82","31","","128.24","128.24","128.24","11","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","both","","","422.00","316.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","154.03","36.5","","154.80","131.56","154.80","363","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","both","","","422.00","316.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","161.63","38.3","","162.27","157.70","162.27","456","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","both","","","422.00","316.50","MOLINA [1014]","HB BWH MOLINA","147.70","35","","200.76","200.36","200.76","1 through 10","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","both","","","422.00","316.50","TRICARE [160005]","HB BWH TRICARE","400.90","95","","96.12","96.12","96.12","1 through 10","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","both","","","422.00","316.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.04","42.9","","182.48","182.48","182.48","1 through 10","99.17","400.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","outpatient","","","422.00","316.50","AETNA [1001]","HB AMC AETNA HMO","294.56","69.8","","280.96","198.37","323.70","114","105.16","344.86","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","outpatient","","","422.00","316.50","AETNA [1001]","HB AMC AETNA PPO","339.29","80.4","","323.70","198.37","323.70","1 through 10","105.16","344.86","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","outpatient","","","422.00","316.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","339.29","80.4","","323.70","323.70","323.70","1 through 10","105.16","344.86","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","outpatient","","","422.00","316.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","344.86","81.72","","331.75","182.48","331.75","1 through 10","105.16","344.86","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300523","CDM","99214","CPT","0983","RC","","","","outpatient","","","422.00","316.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","344.86","81.72","","331.75","182.48","331.75","85","105.16","344.86","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","449.47","71.8","","1111.47","240.86","1111.47","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","497.67","79.5","","328.95","328.95","406.09","18","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","333.66","53.3","","328.95","153.04","382.48","15","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","406.90","65","","335.40","166.95","335.40","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","194.06","31","","190.34","190.34","190.34","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.49","36.5","","195.27","163.57","384.94","153","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.76","38.3","","240.86","201.76","588.24","304","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","TRICARE [160005]","HB BWH TRICARE","594.70","95","","146.56","142.51","146.56","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.55","42.9","","270.86","270.86","270.86","1 through 10","147.01","594.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","outpatient","","","626.00","469.50","AETNA [1001]","HB AMC AETNA HMO","436.95","69.8","","349.33","246.65","480.48","99","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","outpatient","","","626.00","469.50","AETNA [1001]","HB AMC AETNA PPO","503.30","80.4","","402.48","349.33","402.48","15","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","outpatient","","","626.00","469.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","349.93","55.9","","270.38","270.38","270.38","1 through 10","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","outpatient","","","626.00","469.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","503.30","80.4","","402.48","258.00","402.48","1 through 10","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","outpatient","","","626.00","469.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","511.57","81.72","","492.43","412.49","492.43","1 through 10","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","outpatient","","","626.00","469.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","511.57","81.72","","270.86","270.86","270.86","1 through 10","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","outpatient","","","626.00","469.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","511.57","81.72","","270.86","270.86","492.43","11","105.16","511.57","percent of total billed charges",""
"Office Visit, Established Pat|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-51000080","CDM","99211","CPT","0510","RC","","","25","both","","","174.00","130.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","92.74","53.3","","256.61","85.35","423.98","78","92.74","92.74","percent of total billed charges",""
"Office Visit, Established Pat|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-51000083","CDM","99214","CPT","0510","RC","","","25","both","","","507.00","380.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.07","79.5","","233.34","116.67","466.68","17","270.23","403.07","percent of total billed charges",""
"Office Visit, Established Pat|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-51000083","CDM","99214","CPT","0510","RC","","","25","both","","","507.00","380.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.23","53.3","","233.34","116.67","584.00","1 through 10","270.23","403.07","percent of total billed charges",""
"Office Visit, New Patient","PX-51000076","CDM","99202","CPT","0510","RC","","","","both","","","329.00","246.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","120.09","36.5","","89.52","76.08","89.52","1 through 10","101.99","253.33","percent of total billed charges",""
"Office Visit, New Patient","PX-51000076","CDM","99202","CPT","0510","RC","","","","both","","","329.00","246.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","126.01","38.3","","93.84","93.84","93.84","1 through 10","101.99","253.33","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB AMC AETNA HMO","345.51","69.8","","324.96","229.44","374.40","26","141.78","397.98","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB AMC AETNA PPO","397.98","80.4","","251.52","251.52","251.52","1 through 10","141.78","397.98","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","276.71","55.9","","251.52","251.52","251.52","1 through 10","141.78","397.98","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","both","","","495.00","371.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","168.80","34.1","","225.96","163.68","256.63","1 through 10","141.78","397.98","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","321.75","65","","312.00","312.00","312.00","1 through 10","141.78","397.98","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","321.75","65","","312.00","312.00","312.00","1 through 10","141.78","397.98","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","153.45","31","","148.32","148.32","148.32","1 through 10","141.78","397.98","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","180.68","36.5","","173.76","142.49","456.48","25","141.78","397.98","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","189.59","38.3","","182.40","149.36","547.20","84","141.78","397.98","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","both","","","495.00","371.25","TRICARE [160005]","HB BWH TRICARE","145.39","","APC Price ($153.04). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","480.00","480.00","480.00","1 through 10","141.78","397.98","other","Tricare OPPS"
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.36","42.9","","167.97","167.97","167.97","1 through 10","141.78","397.98","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","outpatient","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","404.51","81.72","","382.00","302.90","382.00","1 through 10","105.16","404.51","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","404.51","81.72","","167.97","167.97","167.97","1 through 10","105.16","404.51","percent of total billed charges",""
"Office Visit, New Patient","PX-51000077","CDM","99203","CPT","0510","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","404.51","81.72","","305.37","167.97","305.37","1 through 10","105.16","404.51","percent of total billed charges",""
"Office Visit, New Patient","PX-51000078","CDM","99204","CPT","0510","RC","","","","both","","","834.00","625.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","583.80","70","","2329.40","269.54","2329.40","1 through 10","145.39","642.18","percent of total billed charges",""
"Office Visit, New Patient","PX-51000078","CDM","99204","CPT","0510","RC","","","","both","","","834.00","625.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","304.41","36.5","","228.65","194.32","228.65","1 through 10","145.39","642.18","percent of total billed charges",""
"Office Visit, New Patient","PX-51000078","CDM","99204","CPT","0510","RC","","","","both","","","834.00","625.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","319.42","38.3","","239.68","239.68","239.68","22","145.39","642.18","percent of total billed charges",""
"Office Visit, New Patient","PX-51000078","CDM","99204","CPT","0510","RC","","","","both","","","834.00","625.50","TRICARE [160005]","HB BWH TRICARE","145.39","","APC Price ($153.04). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","132.15","132.15","132.15","1 through 10","145.39","642.18","other","Tricare OPPS"
"Office Visit, New Patient","PX-51000078","CDM","99204","CPT","0510","RC","","","","outpatient","","","834.00","625.50","AETNA [1001]","HB AMC AETNA HMO","582.13","69.8","","415.00","293.01","478.14","1 through 10","105.16","681.54","percent of total billed charges",""
"Office Visit, New Patient","PX-51000078","CDM","99204","CPT","0510","RC","","","","outpatient","","","834.00","625.50","AETNA [1001]","HB AMC AETNA PPO","670.54","80.4","","478.14","478.14","478.14","1 through 10","105.16","681.54","percent of total billed charges",""
"Office Visit, New Patient","PX-51000078","CDM","99204","CPT","0510","RC","","","","outpatient","","","834.00","625.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","466.21","55.9","","321.21","321.21","321.21","1 through 10","105.16","681.54","percent of total billed charges",""
"Office Visit, New Patient","PX-51000078","CDM","99204","CPT","0510","RC","","","","outpatient","","","834.00","625.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","284.39","34.1","","382.48","382.48","382.48","1 through 10","105.16","681.54","percent of total billed charges",""
"Office Visit, New Patient","PX-51000078","CDM","99204","CPT","0510","RC","","","","outpatient","","","834.00","625.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","670.54","80.4","","478.14","306.50","478.14","1 through 10","105.16","681.54","percent of total billed charges",""
"Office Visit, New Patient","PX-51000078","CDM","99204","CPT","0510","RC","","","","outpatient","","","834.00","625.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","681.54","81.72","","472.07","472.07","472.07","1 through 10","105.16","681.54","percent of total billed charges",""
"Office Visit, New Patient","PX-51000078","CDM","99204","CPT","0510","RC","","","","outpatient","","","834.00","625.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","681.54","81.72","","490.03","269.54","980.06","1 through 10","105.16","681.54","percent of total billed charges",""
"Office Visit, New Patient","PX-51000079","CDM","99205","CPT","0510","RC","","","","both","","","1102.00","826.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","402.23","36.5","","303.62","294.67","753.58","1 through 10","145.39","848.54","percent of total billed charges",""
"Office Visit, New Patient","PX-51000079","CDM","99205","CPT","0510","RC","","","","both","","","1102.00","826.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","422.07","38.3","","406.22","318.27","406.22","11","145.39","848.54","percent of total billed charges",""
"Office Visit, New Patient","PX-51000079","CDM","99205","CPT","0510","RC","","","","outpatient","","","1102.00","826.50","AETNA [1001]","HB AMC AETNA HMO","769.20","69.8","","551.08","422.87","723.71","1 through 10","105.16","900.55","percent of total billed charges",""
"Office Visit, New Patient","PX-51000079","CDM","99205","CPT","0510","RC","","","","outpatient","","","1102.00","826.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","375.78","34.1","","499.20","499.20","499.20","1 through 10","105.16","900.55","percent of total billed charges",""
"Office Visit, New Patient","PX-90000098","CDM","99205","CPT","0914","RC","","","","both","","","1102.00","826.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","876.09","79.5","","499.20","499.20","499.20","1 through 10","145.39","876.09","percent of total billed charges",""
"Office Visit, New Patient","PX-90000098","CDM","99205","CPT","0914","RC","","","","both","","","1102.00","826.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","587.37","53.3","","1426.63","499.20","1426.63","1 through 10","145.39","876.09","percent of total billed charges",""
"Office Visit, New Patient","PX-90000098","CDM","99205","CPT","0914","RC","","","","both","","","1102.00","826.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","402.23","36.5","","303.62","294.67","753.58","1 through 10","145.39","876.09","percent of total billed charges",""
"Office Visit, New Patient","PX-90000098","CDM","99205","CPT","0914","RC","","","","both","","","1102.00","826.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","422.07","38.3","","406.22","318.27","406.22","11","145.39","876.09","percent of total billed charges",""
"Office Visit, New Patient","PX-90000098","CDM","99205","CPT","0914","RC","","","","outpatient","","","1102.00","826.50","AETNA [1001]","HB AMC AETNA HMO","769.20","69.8","","551.08","422.87","723.71","1 through 10","105.16","909.15","percent of total billed charges",""
"Office Visit, New Patient","PX-90000098","CDM","99205","CPT","0914","RC","","","","outpatient","","","1102.00","826.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","551.00","50","","426.54","426.54","814.00","1 through 10","105.16","909.15","percent of total billed charges",""
"Office Visit, New Patient","PX-90000098","CDM","99205","CPT","0914","RC","","","","outpatient","","","1102.00","826.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","578.55","52.5","","679.21","308.28","679.21","1 through 10","105.16","909.15","percent of total billed charges",""
"Office Visit, New Patient","PX-90000098","CDM","99205","CPT","0914","RC","","","","outpatient","","","1102.00","826.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","606.10","55","","241.65","241.65","241.65","1 through 10","105.16","909.15","percent of total billed charges",""
"Office Visit, New Patient","PX-96100041","CDM","99202","CPT","0961","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.60","36.5","","89.52","76.08","89.52","1 through 10","35.93","228","percent of total billed charges",""
"Office Visit, New Patient","PX-96100041","CDM","99202","CPT","0961","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.92","38.3","","93.84","93.84","93.84","1 through 10","35.93","228","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","AETNA [1001]","HB AMC AETNA HMO","286.88","69.8","","324.96","229.44","374.40","26","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","AETNA [1001]","HB AMC AETNA PPO","330.44","80.4","","251.52","251.52","251.52","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","229.75","55.9","","251.52","251.52","251.52","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","326.75","79.5","","225.96","163.68","256.63","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","219.06","53.3","","785.78","225.96","785.78","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","267.15","65","","312.00","312.00","312.00","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","267.15","65","","312.00","312.00","312.00","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","127.41","31","","148.32","148.32","148.32","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","150.02","36.5","","173.76","142.49","456.48","25","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.41","38.3","","182.40","149.36","547.20","84","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","TRICARE [160005]","HB BWH TRICARE","390.45","95","","480.00","480.00","480.00","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","both","","","411.00","308.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.32","42.9","","167.97","167.97","167.97","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","outpatient","","","411.00","308.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","335.87","81.72","","382.00","302.90","382.00","1 through 10","105.16","404.36","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","outpatient","","","411.00","308.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","335.87","81.72","","167.97","167.97","167.97","1 through 10","105.16","404.36","percent of total billed charges",""
"Office Visit, New Patient","PX-96100042","CDM","99203","CPT","0961","RC","","","","outpatient","","","411.00","308.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","335.87","81.72","","305.37","167.97","305.37","1 through 10","105.16","404.36","percent of total billed charges",""
"Office Visit, New Patient","PX-96100043","CDM","99204","CPT","0961","RC","","","","both","","","669.00","501.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","468.30","70","","2329.40","269.54","2329.40","1 through 10","99.17","635.55","percent of total billed charges",""
"Office Visit, New Patient","PX-96100043","CDM","99204","CPT","0961","RC","","","","both","","","669.00","501.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","531.86","79.5","","382.48","382.48","382.48","1 through 10","99.17","635.55","percent of total billed charges",""
"Office Visit, New Patient","PX-96100043","CDM","99204","CPT","0961","RC","","","","both","","","669.00","501.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","356.58","53.3","","382.48","382.48","382.48","1 through 10","99.17","635.55","percent of total billed charges",""
"Office Visit, New Patient","PX-96100043","CDM","99204","CPT","0961","RC","","","","both","","","669.00","501.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","244.19","36.5","","228.65","194.32","228.65","1 through 10","99.17","635.55","percent of total billed charges",""
"Office Visit, New Patient","PX-96100043","CDM","99204","CPT","0961","RC","","","","both","","","669.00","501.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","256.23","38.3","","239.68","239.68","239.68","22","99.17","635.55","percent of total billed charges",""
"Office Visit, New Patient","PX-96100043","CDM","99204","CPT","0961","RC","","","","both","","","669.00","501.75","TRICARE [160005]","HB BWH TRICARE","635.55","95","","132.15","132.15","132.15","1 through 10","99.17","635.55","percent of total billed charges",""
"Office Visit, New Patient","PX-96100043","CDM","99204","CPT","0961","RC","","","","outpatient","","","669.00","501.75","AETNA [1001]","HB AMC AETNA HMO","466.96","69.8","","415.00","293.01","478.14","1 through 10","105.16","605.96","percent of total billed charges",""
"Office Visit, New Patient","PX-96100043","CDM","99204","CPT","0961","RC","","","","outpatient","","","669.00","501.75","AETNA [1001]","HB AMC AETNA PPO","537.88","80.4","","478.14","478.14","478.14","1 through 10","105.16","605.96","percent of total billed charges",""
"Office Visit, New Patient","PX-96100043","CDM","99204","CPT","0961","RC","","","","outpatient","","","669.00","501.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","373.97","55.9","","321.21","321.21","321.21","1 through 10","105.16","605.96","percent of total billed charges",""
"Office Visit, New Patient","PX-96100043","CDM","99204","CPT","0961","RC","","","","outpatient","","","669.00","501.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","537.88","80.4","","478.14","306.50","478.14","1 through 10","105.16","605.96","percent of total billed charges",""
"Office Visit, New Patient","PX-96100043","CDM","99204","CPT","0961","RC","","","","outpatient","","","669.00","501.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","546.71","81.72","","472.07","472.07","472.07","1 through 10","105.16","605.96","percent of total billed charges",""
"Office Visit, New Patient","PX-96100043","CDM","99204","CPT","0961","RC","","","","outpatient","","","669.00","501.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","546.71","81.72","","490.03","269.54","980.06","1 through 10","105.16","605.96","percent of total billed charges",""
"Office Visit, New Patient","PX-96100044","CDM","99205","CPT","0961","RC","","","","both","","","909.00","681.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","722.66","79.5","","499.20","499.20","499.20","1 through 10","147.01","863.55","percent of total billed charges",""
"Office Visit, New Patient","PX-96100044","CDM","99205","CPT","0961","RC","","","","both","","","909.00","681.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","484.50","53.3","","1426.63","499.20","1426.63","1 through 10","147.01","863.55","percent of total billed charges",""
"Office Visit, New Patient","PX-96100044","CDM","99205","CPT","0961","RC","","","","both","","","909.00","681.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","331.79","36.5","","303.62","294.67","753.58","1 through 10","147.01","863.55","percent of total billed charges",""
"Office Visit, New Patient","PX-96100044","CDM","99205","CPT","0961","RC","","","","both","","","909.00","681.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","348.15","38.3","","406.22","318.27","406.22","11","147.01","863.55","percent of total billed charges",""
"Office Visit, New Patient","PX-96100044","CDM","99205","CPT","0961","RC","","","","outpatient","","","909.00","681.75","AETNA [1001]","HB AMC AETNA HMO","634.48","69.8","","551.08","422.87","723.71","1 through 10","105.16","799.07","percent of total billed charges",""
"Office Visit, New Patient","PX-98300516","CDM","99202","CPT","0983","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.60","36.5","","89.52","76.08","89.52","1 through 10","35.93","228","percent of total billed charges",""
"Office Visit, New Patient","PX-98300516","CDM","99202","CPT","0983","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.92","38.3","","93.84","93.84","93.84","1 through 10","35.93","228","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0510","RC","","","","inpatient","","","411.00","308.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","140.15","34.1","","163.68","163.68","163.68","1 through 10","40.19","323.09","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","both","","","411.00","308.25","AETNA [1001]","HB AMC AETNA HMO","286.88","69.8","","324.96","229.44","374.40","26","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","both","","","411.00","308.25","AETNA [1001]","HB AMC AETNA PPO","330.44","80.4","","251.52","251.52","251.52","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","both","","","411.00","308.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","229.75","55.9","","251.52","251.52","251.52","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","both","","","411.00","308.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","267.15","65","","312.00","312.00","312.00","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","both","","","411.00","308.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","267.15","65","","312.00","312.00","312.00","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","127.41","31","","148.32","148.32","148.32","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","150.02","36.5","","173.76","142.49","456.48","25","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.41","38.3","","182.40","149.36","547.20","84","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","both","","","411.00","308.25","TRICARE [160005]","HB BWH TRICARE","390.45","95","","480.00","480.00","480.00","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","both","","","411.00","308.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.32","42.9","","167.97","167.97","167.97","1 through 10","67.4","390.45","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","outpatient","","","411.00","308.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","326.75","79.5","","225.96","163.68","256.63","1 through 10","105.16","404.36","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","outpatient","","","411.00","308.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","219.06","53.3","","785.78","225.96","785.78","1 through 10","105.16","404.36","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","outpatient","","","411.00","308.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","335.87","81.72","","382.00","302.90","382.00","1 through 10","105.16","404.36","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","outpatient","","","411.00","308.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","335.87","81.72","","167.97","167.97","167.97","1 through 10","105.16","404.36","percent of total billed charges",""
"Office Visit, New Patient","PX-98300517","CDM","99203","CPT","0983","RC","","","","outpatient","","","411.00","308.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","335.87","81.72","","305.37","167.97","305.37","1 through 10","105.16","404.36","percent of total billed charges",""
"Office Visit, New Patient","PX-98300518","CDM","99204","CPT","0983","RC","","","","both","","","669.00","501.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","468.30","70","","2329.40","269.54","2329.40","1 through 10","99.17","635.55","percent of total billed charges",""
"Office Visit, New Patient","PX-98300518","CDM","99204","CPT","0983","RC","","","","both","","","669.00","501.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","531.86","79.5","","382.48","382.48","382.48","1 through 10","99.17","635.55","percent of total billed charges",""
"Office Visit, New Patient","PX-98300518","CDM","99204","CPT","0983","RC","","","","both","","","669.00","501.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","356.58","53.3","","382.48","382.48","382.48","1 through 10","99.17","635.55","percent of total billed charges",""
"Office Visit, New Patient","PX-98300518","CDM","99204","CPT","0983","RC","","","","both","","","669.00","501.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","244.19","36.5","","228.65","194.32","228.65","1 through 10","99.17","635.55","percent of total billed charges",""
"Office Visit, New Patient","PX-98300518","CDM","99204","CPT","0983","RC","","","","both","","","669.00","501.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","256.23","38.3","","239.68","239.68","239.68","22","99.17","635.55","percent of total billed charges",""
"Office Visit, New Patient","PX-98300518","CDM","99204","CPT","0983","RC","","","","both","","","669.00","501.75","TRICARE [160005]","HB BWH TRICARE","635.55","95","","132.15","132.15","132.15","1 through 10","99.17","635.55","percent of total billed charges",""
"Office Visit, New Patient","PX-98300518","CDM","99204","CPT","0983","RC","","","","outpatient","","","669.00","501.75","AETNA [1001]","HB AMC AETNA HMO","466.96","69.8","","415.00","293.01","478.14","1 through 10","105.16","605.96","percent of total billed charges",""
"Office Visit, New Patient","PX-98300518","CDM","99204","CPT","0983","RC","","","","outpatient","","","669.00","501.75","AETNA [1001]","HB AMC AETNA PPO","537.88","80.4","","478.14","478.14","478.14","1 through 10","105.16","605.96","percent of total billed charges",""
"Office Visit, New Patient","PX-98300518","CDM","99204","CPT","0983","RC","","","","outpatient","","","669.00","501.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","373.97","55.9","","321.21","321.21","321.21","1 through 10","105.16","605.96","percent of total billed charges",""
"Office Visit, New Patient","PX-98300518","CDM","99204","CPT","0983","RC","","","","outpatient","","","669.00","501.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","537.88","80.4","","478.14","306.50","478.14","1 through 10","105.16","605.96","percent of total billed charges",""
"Office Visit, New Patient","PX-98300518","CDM","99204","CPT","0983","RC","","","","outpatient","","","669.00","501.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","546.71","81.72","","472.07","472.07","472.07","1 through 10","105.16","605.96","percent of total billed charges",""
"Office Visit, New Patient","PX-98300518","CDM","99204","CPT","0983","RC","","","","outpatient","","","669.00","501.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","546.71","81.72","","490.03","269.54","980.06","1 through 10","105.16","605.96","percent of total billed charges",""
"Office Visit, New Patient","PX-98300519","CDM","99205","CPT","0983","RC","","","","both","","","909.00","681.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","722.66","79.5","","499.20","499.20","499.20","1 through 10","147.01","863.55","percent of total billed charges",""
"Office Visit, New Patient","PX-98300519","CDM","99205","CPT","0983","RC","","","","both","","","909.00","681.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","484.50","53.3","","1426.63","499.20","1426.63","1 through 10","147.01","863.55","percent of total billed charges",""
"Office Visit, New Patient","PX-98300519","CDM","99205","CPT","0983","RC","","","","both","","","909.00","681.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","331.79","36.5","","303.62","294.67","753.58","1 through 10","147.01","863.55","percent of total billed charges",""
"Office Visit, New Patient","PX-98300519","CDM","99205","CPT","0983","RC","","","","both","","","909.00","681.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","348.15","38.3","","406.22","318.27","406.22","11","147.01","863.55","percent of total billed charges",""
"Office Visit, New Patient","PX-98300519","CDM","99205","CPT","0983","RC","","","","outpatient","","","909.00","681.75","AETNA [1001]","HB AMC AETNA HMO","634.48","69.8","","551.08","422.87","723.71","1 through 10","105.16","799.07","percent of total billed charges",""
"OLECRANON PLATE 110MM 7 HOLE ELBOW TITANIUM STANDARD LEFT","SUP-ITM-10088528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4338.00","3253.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3448.71","79.5","","800.18","480.96","1887.97","195","1344.78","3448.71","percent of total billed charges",""
"OLECRANON PLATE 110MM 7 HOLE ELBOW TITANIUM STANDARD LEFT","SUP-ITM-10088528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4338.00","3253.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2312.15","53.3","","813.12","216.42","1444.50","81","1344.78","3448.71","percent of total billed charges",""
"OLECRANON PLATE 110MM 7 HOLE ELBOW TITANIUM STANDARD LEFT","SUP-ITM-10088528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4338.00","3253.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1344.78","31","","432.60","432.60","432.60","1 through 10","1344.78","3448.71","percent of total billed charges",""
"OLECRANON PLATE 110MM 7 HOLE ELBOW TITANIUM STANDARD LEFT","SUP-ITM-10088528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4338.00","3253.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1583.37","36.5","","148.37","54.89","631.39","94","1344.78","3448.71","percent of total billed charges",""
"OLECRANON PLATE 110MM 7 HOLE ELBOW TITANIUM STANDARD LEFT","SUP-ITM-10088528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4338.00","3253.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1661.45","38.3","","279.30","91.72","1116.77","266","1344.78","3448.71","percent of total billed charges",""
"OLECRANON PLATE 110MM 7 HOLE ELBOW TITANIUM STANDARD LEFT","SUP-ITM-10088528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4338.00","3253.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1861.00","42.9","","731.00","63.70","731.00","1 through 10","1344.78","3448.71","percent of total billed charges",""
"OLECRANON PLATE 110MM 7 HOLE ELBOW TITANIUM STANDARD LEFT","SUP-ITM-10088528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4338.00","3253.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1861.00","42.9","","384.74","384.74","384.74","1 through 10","1344.78","3448.71","percent of total billed charges",""
"OLECRANON PLATE 110MM 7 HOLE ELBOW TITANIUM STANDARD LEFT","SUP-ITM-10088528","CDM","C1713","HCPCS","0278","RC","","","","both","","","4338.00","3253.50","WELLPOINT [1015]","HB AMC WELLPOINT","3200.58","73.78","","286.63","119.22","1107.45","105","1344.78","3448.71","percent of total billed charges",""
"OLECRANON PLATE 110MM 7 HOLE ELBOW TITANIUM STANDARD LEFT","SUP-ITM-10088528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4338.00","3253.50","AETNA [1001]","HB AMC AETNA HMO","3027.92","69.8","","675.31","184.75","1721.50","286","2267.04","3545.01","percent of total billed charges",""
"OLECRANON PLATE 110MM 7 HOLE ELBOW TITANIUM STANDARD LEFT","SUP-ITM-10088528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4338.00","3253.50","AETNA [1001]","HB AMC AETNA PPO","3487.75","80.4","","1261.44","103.12","1514.10","21","2267.04","3545.01","percent of total billed charges",""
"OLECRANON PLATE 110MM 7 HOLE ELBOW TITANIUM STANDARD LEFT","SUP-ITM-10088528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4338.00","3253.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3487.75","80.4","","1365.00","1365.00","1365.00","1 through 10","2267.04","3545.01","percent of total billed charges",""
"OLECRANON PLATE 110MM 7 HOLE ELBOW TITANIUM STANDARD LEFT","SUP-ITM-10088528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4338.00","3253.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3545.01","81.72","","5157.68","5157.68","5157.68","1 through 10","2267.04","3545.01","percent of total billed charges",""
"OLECRANON PLATE 110MM 7 HOLE ELBOW TITANIUM STANDARD LEFT","SUP-ITM-10088528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4338.00","3253.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3545.01","81.72","","431.26","71.26","1459.57","88","2267.04","3545.01","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.41","2161.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2290.72","79.5","","800.18","480.96","1887.97","195","893.24","2290.72","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.41","2161.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1535.79","53.3","","813.12","216.42","1444.50","81","893.24","2290.72","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.41","2161.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","893.24","31","","432.60","432.60","432.60","1 through 10","893.24","2290.72","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.41","2161.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1051.71","36.5","","148.37","54.89","631.39","94","893.24","2290.72","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.41","2161.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1103.58","38.3","","279.30","91.72","1116.77","266","893.24","2290.72","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.41","2161.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1236.12","42.9","","731.00","63.70","731.00","1 through 10","893.24","2290.72","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.41","2161.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1236.12","42.9","","384.74","384.74","384.74","1 through 10","893.24","2290.72","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2881.41","2161.06","WELLPOINT [1015]","HB AMC WELLPOINT","2125.90","73.78","","286.63","119.22","1107.45","105","893.24","2290.72","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2881.41","2161.06","AETNA [1001]","HB AMC AETNA HMO","2011.22","69.8","","675.31","184.75","1721.50","286","1505.82","2354.69","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2881.41","2161.06","AETNA [1001]","HB AMC AETNA PPO","2316.65","80.4","","1261.44","103.12","1514.10","21","1505.82","2354.69","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2881.41","2161.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2316.65","80.4","","1365.00","1365.00","1365.00","1 through 10","1505.82","2354.69","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2881.41","2161.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2354.69","81.72","","5157.68","5157.68","5157.68","1 through 10","1505.82","2354.69","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2881.41","2161.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2354.69","81.72","","431.26","71.26","1459.57","88","1505.82","2354.69","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2618.45","52.26","","1113.10","1113.10","1113.10","1 through 10","1553.23","3983.28","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3983.28","79.5","","1293.60","1148.53","1603.80","1 through 10","1553.23","3983.28","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1828.80","36.5","","1023.42","771.29","2068.67","33","1553.23","3983.28","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1918.99","38.3","","850.52","759.78","1211.25","66","1553.23","3983.28","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2149.47","42.9","","2548.09","2548.09","2548.09","1 through 10","1553.23","3983.28","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2149.47","42.9","","956.46","956.46","956.46","1 through 10","1553.23","3983.28","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","5010.42","3757.81","WELLPOINT [1015]","HB AMC WELLPOINT","3696.69","73.78","","2344.73","1619.47","2530.35","16","1553.23","3983.28","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5010.42","3757.81","AETNA [1001]","HB AMC AETNA HMO","3497.27","69.8","","1523.63","988.41","4330.26","39","2618.45","4094.52","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5010.42","3757.81","AETNA [1001]","HB AMC AETNA PPO","4028.38","80.4","","1670.25","1670.25","1670.25","1 through 10","2618.45","4094.52","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5010.42","3757.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2618.45","52.26","","1113.10","1113.10","1113.10","1 through 10","2618.45","4094.52","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5010.42","3757.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4094.52","81.72","","1738.90","1484.65","2716.94","38","2618.45","4094.52","percent of total billed charges",""
"OLECRANON PLATE 90MM 5 HOLE BONE ELBOW LOCKING MIDSHAFT SUPERIOR TITANIUM LOW PROFILE LEFT","SUP-ITM-10088527","CDM","C1713","HCPCS","0278","RC","","","","both","","","4459.00","3344.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3544.91","79.5","","800.18","480.96","1887.97","195","1382.29","3544.91","percent of total billed charges",""
"OLECRANON PLATE 90MM 5 HOLE BONE ELBOW LOCKING MIDSHAFT SUPERIOR TITANIUM LOW PROFILE LEFT","SUP-ITM-10088527","CDM","C1713","HCPCS","0278","RC","","","","both","","","4459.00","3344.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2376.65","53.3","","813.12","216.42","1444.50","81","1382.29","3544.91","percent of total billed charges",""
"OLECRANON PLATE 90MM 5 HOLE BONE ELBOW LOCKING MIDSHAFT SUPERIOR TITANIUM LOW PROFILE LEFT","SUP-ITM-10088527","CDM","C1713","HCPCS","0278","RC","","","","both","","","4459.00","3344.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1382.29","31","","432.60","432.60","432.60","1 through 10","1382.29","3544.91","percent of total billed charges",""
"OLECRANON PLATE 90MM 5 HOLE BONE ELBOW LOCKING MIDSHAFT SUPERIOR TITANIUM LOW PROFILE LEFT","SUP-ITM-10088527","CDM","C1713","HCPCS","0278","RC","","","","both","","","4459.00","3344.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1627.54","36.5","","148.37","54.89","631.39","94","1382.29","3544.91","percent of total billed charges",""
"OLECRANON PLATE 90MM 5 HOLE BONE ELBOW LOCKING MIDSHAFT SUPERIOR TITANIUM LOW PROFILE LEFT","SUP-ITM-10088527","CDM","C1713","HCPCS","0278","RC","","","","both","","","4459.00","3344.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1707.80","38.3","","279.30","91.72","1116.77","266","1382.29","3544.91","percent of total billed charges",""
"OLECRANON PLATE 90MM 5 HOLE BONE ELBOW LOCKING MIDSHAFT SUPERIOR TITANIUM LOW PROFILE LEFT","SUP-ITM-10088527","CDM","C1713","HCPCS","0278","RC","","","","both","","","4459.00","3344.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1912.91","42.9","","731.00","63.70","731.00","1 through 10","1382.29","3544.91","percent of total billed charges",""
"OLECRANON PLATE 90MM 5 HOLE BONE ELBOW LOCKING MIDSHAFT SUPERIOR TITANIUM LOW PROFILE LEFT","SUP-ITM-10088527","CDM","C1713","HCPCS","0278","RC","","","","both","","","4459.00","3344.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1912.91","42.9","","384.74","384.74","384.74","1 through 10","1382.29","3544.91","percent of total billed charges",""
"OLECRANON PLATE 90MM 5 HOLE BONE ELBOW LOCKING MIDSHAFT SUPERIOR TITANIUM LOW PROFILE LEFT","SUP-ITM-10088527","CDM","C1713","HCPCS","0278","RC","","","","both","","","4459.00","3344.25","WELLPOINT [1015]","HB AMC WELLPOINT","3289.85","73.78","","286.63","119.22","1107.45","105","1382.29","3544.91","percent of total billed charges",""
"OLECRANON PLATE 90MM 5 HOLE BONE ELBOW LOCKING MIDSHAFT SUPERIOR TITANIUM LOW PROFILE LEFT","SUP-ITM-10088527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4459.00","3344.25","AETNA [1001]","HB AMC AETNA HMO","3112.38","69.8","","675.31","184.75","1721.50","286","2330.27","3643.89","percent of total billed charges",""
"OLECRANON PLATE 90MM 5 HOLE BONE ELBOW LOCKING MIDSHAFT SUPERIOR TITANIUM LOW PROFILE LEFT","SUP-ITM-10088527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4459.00","3344.25","AETNA [1001]","HB AMC AETNA PPO","3585.04","80.4","","1261.44","103.12","1514.10","21","2330.27","3643.89","percent of total billed charges",""
"OLECRANON PLATE 90MM 5 HOLE BONE ELBOW LOCKING MIDSHAFT SUPERIOR TITANIUM LOW PROFILE LEFT","SUP-ITM-10088527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4459.00","3344.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3585.04","80.4","","1365.00","1365.00","1365.00","1 through 10","2330.27","3643.89","percent of total billed charges",""
"OLECRANON PLATE 90MM 5 HOLE BONE ELBOW LOCKING MIDSHAFT SUPERIOR TITANIUM LOW PROFILE LEFT","SUP-ITM-10088527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4459.00","3344.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3643.89","81.72","","5157.68","5157.68","5157.68","1 through 10","2330.27","3643.89","percent of total billed charges",""
"OLECRANON PLATE 90MM 5 HOLE BONE ELBOW LOCKING MIDSHAFT SUPERIOR TITANIUM LOW PROFILE LEFT","SUP-ITM-10088527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4459.00","3344.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3643.89","81.72","","431.26","71.26","1459.57","88","2330.27","3643.89","percent of total billed charges",""
"OLECRANON PLATE MED STANDARD","SUP-ITM-10020092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3361.26","79.5","","800.18","480.96","1887.97","195","1310.68","3361.26","percent of total billed charges",""
"OLECRANON PLATE MED STANDARD","SUP-ITM-10020092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2253.52","53.3","","813.12","216.42","1444.50","81","1310.68","3361.26","percent of total billed charges",""
"OLECRANON PLATE MED STANDARD","SUP-ITM-10020092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1310.68","31","","432.60","432.60","432.60","1 through 10","1310.68","3361.26","percent of total billed charges",""
"OLECRANON PLATE MED STANDARD","SUP-ITM-10020092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1543.22","36.5","","148.37","54.89","631.39","94","1310.68","3361.26","percent of total billed charges",""
"OLECRANON PLATE MED STANDARD","SUP-ITM-10020092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1619.32","38.3","","279.30","91.72","1116.77","266","1310.68","3361.26","percent of total billed charges",""
"OLECRANON PLATE MED STANDARD","SUP-ITM-10020092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.81","42.9","","731.00","63.70","731.00","1 through 10","1310.68","3361.26","percent of total billed charges",""
"OLECRANON PLATE MED STANDARD","SUP-ITM-10020092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.81","42.9","","384.74","384.74","384.74","1 through 10","1310.68","3361.26","percent of total billed charges",""
"OLECRANON PLATE MED STANDARD","SUP-ITM-10020092","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","WELLPOINT [1015]","HB AMC WELLPOINT","3119.42","73.78","","286.63","119.22","1107.45","105","1310.68","3361.26","percent of total billed charges",""
"OLECRANON PLATE MED STANDARD","SUP-ITM-10020092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","AETNA [1001]","HB AMC AETNA HMO","2951.14","69.8","","675.31","184.75","1721.50","286","2209.55","3455.12","percent of total billed charges",""
"OLECRANON PLATE MED STANDARD","SUP-ITM-10020092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","AETNA [1001]","HB AMC AETNA PPO","3399.31","80.4","","1261.44","103.12","1514.10","21","2209.55","3455.12","percent of total billed charges",""
"OLECRANON PLATE MED STANDARD","SUP-ITM-10020092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3399.31","80.4","","1365.00","1365.00","1365.00","1 through 10","2209.55","3455.12","percent of total billed charges",""
"OLECRANON PLATE MED STANDARD","SUP-ITM-10020092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3455.12","81.72","","5157.68","5157.68","5157.68","1 through 10","2209.55","3455.12","percent of total billed charges",""
"OLECRANON PLATE MED STANDARD","SUP-ITM-10020092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3455.12","81.72","","431.26","71.26","1459.57","88","2209.55","3455.12","percent of total billed charges",""
"OLECRANON PLATE XL LOCKING 17 HOLE RIGHT","SUP-ITM-10030623","CDM","C1713","HCPCS","0278","RC","","","","both","","","4110.00","3082.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3267.45","79.5","","800.18","480.96","1887.97","195","1274.1","3267.45","percent of total billed charges",""
"OLECRANON PLATE XL LOCKING 17 HOLE RIGHT","SUP-ITM-10030623","CDM","C1713","HCPCS","0278","RC","","","","both","","","4110.00","3082.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2190.63","53.3","","813.12","216.42","1444.50","81","1274.1","3267.45","percent of total billed charges",""
"OLECRANON PLATE XL LOCKING 17 HOLE RIGHT","SUP-ITM-10030623","CDM","C1713","HCPCS","0278","RC","","","","both","","","4110.00","3082.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1274.10","31","","432.60","432.60","432.60","1 through 10","1274.1","3267.45","percent of total billed charges",""
"OLECRANON PLATE XL LOCKING 17 HOLE RIGHT","SUP-ITM-10030623","CDM","C1713","HCPCS","0278","RC","","","","both","","","4110.00","3082.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1500.15","36.5","","148.37","54.89","631.39","94","1274.1","3267.45","percent of total billed charges",""
"OLECRANON PLATE XL LOCKING 17 HOLE RIGHT","SUP-ITM-10030623","CDM","C1713","HCPCS","0278","RC","","","","both","","","4110.00","3082.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1574.13","38.3","","279.30","91.72","1116.77","266","1274.1","3267.45","percent of total billed charges",""
"OLECRANON PLATE XL LOCKING 17 HOLE RIGHT","SUP-ITM-10030623","CDM","C1713","HCPCS","0278","RC","","","","both","","","4110.00","3082.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1763.19","42.9","","731.00","63.70","731.00","1 through 10","1274.1","3267.45","percent of total billed charges",""
"OLECRANON PLATE XL LOCKING 17 HOLE RIGHT","SUP-ITM-10030623","CDM","C1713","HCPCS","0278","RC","","","","both","","","4110.00","3082.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1763.19","42.9","","384.74","384.74","384.74","1 through 10","1274.1","3267.45","percent of total billed charges",""
"OLECRANON PLATE XL LOCKING 17 HOLE RIGHT","SUP-ITM-10030623","CDM","C1713","HCPCS","0278","RC","","","","both","","","4110.00","3082.50","WELLPOINT [1015]","HB AMC WELLPOINT","3032.36","73.78","","286.63","119.22","1107.45","105","1274.1","3267.45","percent of total billed charges",""
"OLECRANON PLATE XL LOCKING 17 HOLE RIGHT","SUP-ITM-10030623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4110.00","3082.50","AETNA [1001]","HB AMC AETNA HMO","2868.78","69.8","","675.31","184.75","1721.50","286","2147.89","3358.69","percent of total billed charges",""
"OLECRANON PLATE XL LOCKING 17 HOLE RIGHT","SUP-ITM-10030623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4110.00","3082.50","AETNA [1001]","HB AMC AETNA PPO","3304.44","80.4","","1261.44","103.12","1514.10","21","2147.89","3358.69","percent of total billed charges",""
"OLECRANON PLATE XL LOCKING 17 HOLE RIGHT","SUP-ITM-10030623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4110.00","3082.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3304.44","80.4","","1365.00","1365.00","1365.00","1 through 10","2147.89","3358.69","percent of total billed charges",""
"OLECRANON PLATE XL LOCKING 17 HOLE RIGHT","SUP-ITM-10030623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4110.00","3082.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3358.69","81.72","","5157.68","5157.68","5157.68","1 through 10","2147.89","3358.69","percent of total billed charges",""
"OLECRANON PLATE XL LOCKING 17 HOLE RIGHT","SUP-ITM-10030623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4110.00","3082.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3358.69","81.72","","431.26","71.26","1459.57","88","2147.89","3358.69","percent of total billed charges",""
"Oligoclonal Bands","PX-30000589","CDM","83916","CPT","0301","RC","","","","both","","","316.00","237.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","168.43","53.3","","161.57","161.57","161.57","1 through 10","20.73","300.2","percent of total billed charges",""
"Oligoclonal Bands","PX-30000589","CDM","83916","CPT","0301","RC","","","","outpatient","","","316.00","237.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","258.24","81.72","","244.62","244.62","244.62","1 through 10","20.73","258.24","percent of total billed charges",""
"Omalizumab Pwdr Inj 5mg","PX-63600156","CDM","J2357","HCPCS","0636","RC","","","","both","","","148.89","111.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.02","38.3","","74.52","69.62","74.88","31","38.53","114.65","percent of total billed charges",""
"Omalizumab Pwdr Inj 5mg","PX-63600156","CDM","J2357","HCPCS","0636","RC","","","","both","","","148.89","111.67","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.70","","APC Price ($44.60). Final payment is multiplied by 98%.","39.83","39.48","39.91","240","38.53","114.65","other","OPPS APC"
"Omisirge Revenue","PX-81500002","CDM","J3590","HCPCS","0815","RC","","","","outpatient","","","2176000.00","1632000.00","AETNA [1001]","HB AMC AETNA HMO","1518848.00","69.8","","428.01","428.01","428.01","1 through 10","1137177.6","1749504","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.22","9.16","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","8.77","71.8","","2.83","2.83","2.83","50","0.32","9.41","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.22","9.16","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","8.02","65.6","","2.45","1.73","3.07","426","0.32","9.41","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.22","9.16","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","8.55","70","","2.87","1.69","7.83","859","0.32","9.41","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.22","9.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7.94","65","","256.09","192.07","1790.10","1 through 10","0.32","9.41","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.22","9.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3.79","31","","1.12","0.11","3.36","780","0.32","9.41","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.22","9.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4.46","36.5","","1.35","1.15","2.60","22835","0.32","9.41","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.22","9.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4.68","38.3","","1.42","1.38","1.54","53934","0.32","9.41","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.22","9.16","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","9.41","77","","2.83","2.83","2.83","83","0.32","9.41","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","12.22","9.16","AETNA [1001]","HB AMC AETNA HMO","8.53","69.8","","1.88","0.17","2.83","37600","0.32","9.82","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","12.22","9.16","AETNA [1001]","HB AMC AETNA PPO","9.82","80.4","","2.83","0.28","3.80","3073","0.32","9.82","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","12.22","9.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","6.39","52.26","","2.24","2.24","2.24","305","0.32","9.82","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","outpatient","","","12.22","9.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9.82","80.4","","2.83","2.83","2.83","269","0.32","9.82","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","12.22","9.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8.54","69.9","","2.51","1.94","2.78","794","5.73","8.54","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","12.22","9.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5.73","46.9","","1.68","0.01","1.68","269","5.73","8.54","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","6.69","","APC Price ($6.50). Final payment is multiplied by 103%.","6.67","6.59","6.69","1707","6.18","19.67","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","6.50","","APC Price ($6.50).","6.37","6.30","27.46","2449","6.18","19.67","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","17.89","70","","25.74","25.74","25.74","1 through 10","6.18","19.67","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","6.50","","APC Price ($6.50).","6.37","6.30","9.46","910","6.18","19.67","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","ELDER SERVICES [1037]","HB BWH MEDICARE","6.50","","APC Price ($6.50).","129.40","129.40","129.40","1 through 10","6.18","19.67","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","6.50","","APC Price ($6.50).","787.20","787.20","787.20","1 through 10","6.18","19.67","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","MEDICARE [2001]","HB BWH MEDICARE","6.50","","APC Price ($6.50).","6.48","6.41","6.50","39993","6.18","19.67","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","7.92","31","","8.48","8.48","8.48","155","6.18","19.67","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9.33","36.5","","10.24","8.77","10.32","2450","6.18","19.67","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9.79","38.3","","10.73","10.43","10.82","9187","6.18","19.67","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","6.50","","APC Price ($6.50).","6.37","6.34","6.40","800","6.18","19.67","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6.37","","APC Price ($6.50). Final payment is multiplied by 98%.","12.56","6.30","31.39","3073","6.18","19.67","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6.37","","APC Price ($6.50). Final payment is multiplied by 98%.","12.56","6.28","12.74","14995","6.18","19.67","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","outpatient","","","25.55","19.16","AETNA [1001]","HB AMC AETNA HMO","17.83","69.8","","18.59","13.12","21.41","4272","0.01","20.54","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","outpatient","","","25.55","19.16","AETNA [1001]","HB AMC AETNA PPO","20.54","80.4","","14.39","14.39","14.50","790","0.01","20.54","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","outpatient","","","25.55","19.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","17.86","69.9","","19.03","12.74","19.17","5682","0.01","20.54","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","outpatient","","","25.55","19.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11.98","46.9","","12.84","12.74","19.03","1511","0.01","20.54","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","outpatient","","","25.55","19.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","20.54","80.4","","21.58","21.58","21.58","100","0.01","20.54","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0250","RC","","","","inpatient","","","1.38","1.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.74","53.3","","0.21","0.21","0.21","1 through 10","0.59","1.1","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","both","","","1.38","1.03","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.99","71.8","","0.27","0.14","0.32","16","0.22","1.06","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","both","","","1.38","1.03","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.91","65.6","","0.61","0.25","0.61","16","0.22","1.06","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","both","","","1.38","1.03","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.90","65","","1.26","0.24","1.26","24","0.22","1.06","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","both","","","1.38","1.03","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.97","70","","0.37","0.30","0.45","57","0.22","1.06","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","both","","","1.38","1.03","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1.06","77","","0.86","0.29","0.86","52","0.22","1.06","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","both","","","1.38","1.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.43","31","","0.35","0.11","0.35","64","0.22","1.06","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","both","","","1.38","1.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.50","36.5","","0.17","0.13","0.50","1548","0.22","1.06","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","both","","","1.38","1.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.53","38.3","","0.18","0.14","0.53","4304","0.22","1.06","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","both","","","1.38","1.03","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1.06","77","","0.31","0.26","0.31","16","0.22","1.06","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","outpatient","","","1.38","1.03","AETNA [1001]","HB AMC AETNA HMO","0.96","69.8","","0.25","0.18","0.46","1896","0.19","1.11","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","outpatient","","","1.38","1.03","AETNA [1001]","HB AMC AETNA PPO","1.11","80.4","","0.29","0.19","0.39","258","0.19","1.11","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","outpatient","","","1.38","1.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.96","69.9","","0.57","0.22","9.63","2794","0.19","1.11","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","outpatient","","","1.38","1.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.65","46.9","","0.92","0.18","340.18","1818","0.19","1.11","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","outpatient","","","1.38","1.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1.11","80.4","","0.29","0.29","0.35","53","0.19","1.11","percent of total billed charges",""
"Ondansetron Hcl Injection","PX-63601078","CDM","J2405","HCPCS","0636","RC","","","","outpatient","","","1.38","1.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","0.96","69.9","","0.22","0.03","1.16","1 through 10","0.19","1.11","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0250","RC","","","","inpatient","","","13.00","9.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6.93","53.3","","0.21","0.21","0.21","1 through 10","5.58","10.34","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","both","","","13.00","9.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","9.33","71.8","","0.27","0.14","0.32","16","0.22","10.01","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","both","","","13.00","9.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","8.53","65.6","","0.61","0.25","0.61","16","0.22","10.01","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","both","","","13.00","9.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8.45","65","","1.26","0.24","1.26","24","0.22","10.01","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","both","","","13.00","9.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","9.10","70","","0.37","0.30","0.45","57","0.22","10.01","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","both","","","13.00","9.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","10.01","77","","0.86","0.29","0.86","52","0.22","10.01","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","both","","","13.00","9.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4.03","31","","0.35","0.11","0.35","64","0.22","10.01","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","both","","","13.00","9.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4.75","36.5","","0.17","0.13","0.50","1548","0.22","10.01","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","both","","","13.00","9.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4.98","38.3","","0.18","0.14","0.53","4304","0.22","10.01","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","both","","","13.00","9.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","10.01","77","","0.31","0.26","0.31","16","0.22","10.01","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","outpatient","","","13.00","9.75","AETNA [1001]","HB AMC AETNA HMO","9.07","69.8","","0.25","0.18","0.46","1896","0.19","10.45","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","outpatient","","","13.00","9.75","AETNA [1001]","HB AMC AETNA PPO","10.45","80.4","","0.29","0.19","0.39","258","0.19","10.45","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","outpatient","","","13.00","9.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9.09","69.9","","0.57","0.22","9.63","2794","0.19","10.45","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","outpatient","","","13.00","9.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6.10","46.9","","0.92","0.18","340.18","1818","0.19","10.45","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","outpatient","","","13.00","9.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10.45","80.4","","0.29","0.29","0.35","53","0.19","10.45","percent of total billed charges",""
"Ondansetron Inj 1mg","PX-63600157","CDM","J2405","HCPCS","0636","RC","","","","outpatient","","","13.00","9.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","9.09","69.9","","0.22","0.03","1.16","1 through 10","0.19","10.45","percent of total billed charges",""
"Ondansetron Tab 1mg","PX-63600248","CDM","Q0162","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.31","31","","0.06","0.06","0.06","1 through 10","0.04","0.77","percent of total billed charges",""
"Ondansetron Tab 1mg","PX-63600248","CDM","Q0162","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.37","36.5","","0.10","0.10","0.10","1 through 10","0.04","0.77","percent of total billed charges",""
"Ondansetron Tab 1mg","PX-63600248","CDM","Q0162","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","0.11","0.11","0.11","1 through 10","0.04","0.77","percent of total billed charges",""
"Ondansetron Tab 1mg","PX-63600248","CDM","Q0162","HCPCS","0636","RC","","","","both","","","1.00","0.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.77","77","","0.20","0.20","0.20","1 through 10","0.04","0.77","percent of total billed charges",""
"Ondansetron Tab 1mg","PX-63600248","CDM","Q0162","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","0.12","0.12","0.12","1 through 10","0.02","0.8","percent of total billed charges",""
"Ondansetron Tab 1mg","PX-63600248","CDM","Q0162","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.70","69.9","","0.21","0.21","0.21","1 through 10","0.02","0.8","percent of total billed charges",""
"Oocyte ID","PX-30000123","CDM","89254","CPT","0300","RC","","","","both","","","633.00","474.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","415.25","65.6","","415.68","415.68","415.68","1 through 10","196.23","601.35","percent of total billed charges",""
"Oocyte ID","PX-30000123","CDM","89254","CPT","0300","RC","","","","both","","","633.00","474.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","503.24","79.5","","483.22","324.19","483.22","12","196.23","601.35","percent of total billed charges",""
"Oocyte ID","PX-30000123","CDM","89254","CPT","0300","RC","","","","both","","","633.00","474.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","337.39","53.3","","483.22","324.19","483.22","1 through 10","196.23","601.35","percent of total billed charges",""
"Oocyte ID","PX-30000123","CDM","89254","CPT","0300","RC","","","","both","","","633.00","474.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","271.56","42.9","","490.83","490.83","490.83","1 through 10","196.23","601.35","percent of total billed charges",""
"Oocyte ID","PX-30000123","CDM","89254","CPT","0300","RC","","","","both","","","633.00","474.75","WELLPOINT [1015]","HB AMC WELLPOINT","467.03","73.78","","1071.12","457.12","1071.12","15","196.23","601.35","percent of total billed charges",""
"Oocyte ID","PX-30000123","CDM","89254","CPT","0300","RC","","","","outpatient","","","633.00","474.75","AETNA [1001]","HB AMC AETNA HMO","441.83","69.8","","293.49","293.49","293.49","1 through 10","330.55","887.19","percent of total billed charges",""
"Oocyte ID","PX-30000123","CDM","89254","CPT","0300","RC","","","","outpatient","","","633.00","474.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","517.29","81.72","","457.44","269.98","490.83","11","330.55","887.19","percent of total billed charges",""
"Open Craniotomy Except Trauma,EXTREME","021","DRG","","","","","","","","inpatient","","","314971.04","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","117847.37","","Standard inlier is a Case rate ($117,847.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $103,290, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,729.14) for the length of stay and the standard reimbursement.","183865.05","183865.05","467254.98","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,EXTREME","021","DRG","","","","","","","","inpatient","","","314971.04","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","132492.20","","Standard inlier is a Case rate ($132,492.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $103,290, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,806.17) for the length of stay and the standard reimbursement.","188850.97","188850.97","188850.97","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,EXTREME","021","DRG","","","","","","","","inpatient","","","314971.04","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","132492.20","","Standard inlier is a Case rate ($132,492.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $103,290, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,806.17) for the length of stay and the standard reimbursement.","206713.87","188850.97","206713.87","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,EXTREME","021","DRG","","","","","","","","inpatient","","","314971.04","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","306361.04","","Fee schedule rate ($306,361.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","320949.66","320949.66","320949.66","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,EXTREME","021","DRG","","","","","","","","inpatient","","","314971.04","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","291772.42","","Fee schedule rate ($291,772.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","291772.40","280523.76","291772.40","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,EXTREME","021","DRG","","","","","","","","inpatient","","","314971.04","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","306361.04","","Fee schedule rate ($306,361.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","531999.92","531999.92","531999.92","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,EXTREME","021","DRG","","","","","","","","inpatient","","","314971.04","","MASSHEALTH [3001]","HB BWH MEDICAID","37564.42","","Case rate ($41,533.93). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $83,963.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $6,492.13 and the sum of the standard inlier and any outlier amount.","102810.69","32000.55","138307.77","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,EXTREME","021","DRG","","","","","","","","inpatient","","","314971.04","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","37564.42","","Case rate ($41,533.93). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $83,963.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $6,492.13 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,EXTREME","021","DRG","","","","","","","","inpatient","","","314971.04","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","232744.67","","Fee schedule rate ($232,744.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","232744.67","232744.67","232744.67","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,EXTREME","021","DRG","","","","","","","","inpatient","","","314971.04","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","244384.19","","Fee schedule rate ($244,384.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","244384.19","244384.19","244384.19","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,EXTREME","021","DRG","","","","","","","","inpatient","","","314971.04","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","37564.42","","Case rate ($41,533.93). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $83,963.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $6,492.13 and the sum of the standard inlier and any outlier amount.","79148.02","79148.02","108479.65","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","117847.37","","Standard inlier is a Case rate ($117,847.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $103,290, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,729.14) for the length of stay and the standard reimbursement.","117847.36","13635.47","132492.20","21","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","132492.20","","Standard inlier is a Case rate ($132,492.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $103,290, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,806.17) for the length of stay and the standard reimbursement.","121043.07","121043.07","121043.07","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","132492.20","","Standard inlier is a Case rate ($132,492.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $103,290, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,806.17) for the length of stay and the standard reimbursement.","132492.20","121043.07","132492.20","44","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","156465.77","156465.77","156465.77","1 through 10","18723.38","481415.83","percent of total billed charges",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","37564.42","","Case rate ($41,533.93). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $83,963.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19872.78","19872.78","19872.78","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","161195.09","","Fee schedule rate ($161,195.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","161195.08","161195.08","161195.08","14","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","169254.84","","Fee schedule rate ($169,254.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","169254.84","169254.84","325459.20","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","201489.08","","Fee schedule rate ($201,489.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","201489.08","201489.08","201489.08","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","MASSHEALTH [3001]","HB BWH MEDICAID","37564.42","","Case rate ($41,533.93). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $83,963.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","43206.19","41523.73","78230.65","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","37564.42","","Case rate ($41,533.93). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $83,963.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3476.45","3476.45","3476.45","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","232744.67","","Fee schedule rate ($232,744.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","158416.55","158416.55","158416.55","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","244384.19","","Fee schedule rate ($244,384.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","161493.07","161493.07","161493.07","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","37564.42","","Case rate ($41,533.93). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $83,963.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","41523.73","41523.73","77624.41","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MAJOR","021","DRG","","","","","","","","inpatient","","","191768.89","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","37564.42","","Case rate ($41,533.93). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $83,963.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31313.26","31313.26","31313.26","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MINOR","021","DRG","","","","","","","","inpatient","","","117666.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","61881.27","","Standard inlier is a Case rate ($61,881.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,768, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,784.42) for the length of stay and the standard reimbursement.","61881.26","56407.03","61881.26","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MINOR","021","DRG","","","","","","","","inpatient","","","117666.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","69571.22","","Standard inlier is a Case rate ($69,571.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,768, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,875.06) for the length of stay and the standard reimbursement.","69571.22","63559.32","69571.22","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MINOR","021","DRG","","","","","","","","inpatient","","","117666.98","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","70121.58","","Fee schedule rate ($70,121.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","83476.09","83476.09","83476.09","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MINOR","021","DRG","","","","","","","","inpatient","","","117666.98","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","66782.46","","Fee schedule rate ($66,782.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","66782.48","66782.48","66782.48","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MINOR","021","DRG","","","","","","","","inpatient","","","117666.98","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","70121.58","","Fee schedule rate ($70,121.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","70121.60","70121.60","70121.60","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MINOR","021","DRG","","","","","","","","inpatient","","","117666.98","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","70121.58","","Fee schedule rate ($70,121.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","70121.58","70121.58","70121.58","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MINOR","021","DRG","","","","","","","","inpatient","","","117666.98","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","73460.71","","Fee schedule rate ($73,460.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","73460.71","73460.71","73460.71","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MINOR","021","DRG","","","","","","","","inpatient","","","117666.98","","MASSHEALTH [3001]","HB BWH MEDICAID","18723.38","","Case rate ($20,701.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,131.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21535.42","21535.42","21535.42","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MINOR","021","DRG","","","","","","","","inpatient","","","117666.98","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83121.90","","Fee schedule rate ($83,121.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","83121.90","83121.90","83121.90","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MINOR","021","DRG","","","","","","","","inpatient","","","117666.98","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","73460.71","","Fee schedule rate ($73,460.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","70628.59","70628.59","70628.59","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MINOR","021","DRG","","","","","","","","inpatient","","","117666.98","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","18723.38","","Case rate ($20,701.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,131.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20696.83","20696.83","20696.83","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MINOR","021","DRG","","","","","","","","inpatient","","","117666.98","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","18723.38","","Case rate ($20,701.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,131.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13180.92","13180.92","13180.92","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MODERATE","021","DRG","","","","","","","","inpatient","","","143526.78","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","78769.74","","Standard inlier is a Case rate ($78,769.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $72,903, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,181.84) for the length of stay and the standard reimbursement.","78769.73","71801.48","88558.41","29","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MODERATE","021","DRG","","","","","","","","inpatient","","","143526.78","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","88558.42","","Standard inlier is a Case rate ($88,558.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $72,903, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,570.13) for the length of stay and the standard reimbursement.","84189.71","84189.71","84189.71","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MODERATE","021","DRG","","","","","","","","inpatient","","","143526.78","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","88558.42","","Standard inlier is a Case rate ($88,558.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $72,903, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,570.13) for the length of stay and the standard reimbursement.","88558.41","80905.76","88558.41","47","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MODERATE","021","DRG","","","","","","","","inpatient","","","143526.78","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","98053.38","","Fee schedule rate ($98,053.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","102722.58","102722.58","102722.58","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MODERATE","021","DRG","","","","","","","","inpatient","","","143526.78","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","93384.17","","Fee schedule rate ($93,384.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","93384.16","93384.16","93384.16","15","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MODERATE","021","DRG","","","","","","","","inpatient","","","143526.78","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","98053.38","","Fee schedule rate ($98,053.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","98053.36","98053.36","98053.36","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MODERATE","021","DRG","","","","","","","","inpatient","","","143526.78","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","116727.44","","Fee schedule rate ($116,727.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","116727.44","116727.44","116727.44","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MODERATE","021","DRG","","","","","","","","inpatient","","","143526.78","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","102722.58","","Fee schedule rate ($102,722.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","102722.58","102722.58","102722.58","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MODERATE","021","DRG","","","","","","","","inpatient","","","143526.78","","MASSHEALTH [3001]","HB BWH MEDICAID","23678.96","","Case rate ($26,181.16). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $68,611.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,528.46 and the sum of the standard inlier and any outlier amount.","26657.28","26174.73","41523.73","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MODERATE","021","DRG","","","","","","","","inpatient","","","143526.78","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","23678.96","","Case rate ($26,181.16). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $68,611.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,528.46 and the sum of the standard inlier and any outlier amount.","10024.62","10024.62","19043.55","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MODERATE","021","DRG","","","","","","","","inpatient","","","143526.78","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","111391.61","","Fee schedule rate ($111,391.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","108147.70","108147.70","111391.61","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MODERATE","021","DRG","","","","","","","","inpatient","","","143526.78","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","116962.29","","Fee schedule rate ($116,962.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","116962.29","116962.29","131602.29","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy Except Trauma,MODERATE","021","DRG","","","","","","","","inpatient","","","143526.78","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","23678.96","","Case rate ($26,181.16). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $68,611.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,528.46 and the sum of the standard inlier and any outlier amount.","26174.74","2601.22","147798.31","1 through 10","18723.38","481415.83","case rate",""
"Open Craniotomy For Trauma,EXTREME","020","DRG","","","","","","","","inpatient","","","382112.27","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","169628.55","","Standard inlier is a Case rate ($169,628.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $143,558, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($24,079.80) for the length of stay and the standard reimbursement.","174228.41","174228.41","174228.41","1 through 10","18289.28","269203.44","case rate",""
"Open Craniotomy For Trauma,EXTREME","020","DRG","","","","","","","","inpatient","","","382112.27","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","190708.20","","Standard inlier is a Case rate ($190,708.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $143,558, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($27,069.45) for the length of stay and the standard reimbursement.","190708.20","190708.20","190708.20","1 through 10","18289.28","269203.44","case rate",""
"Open Craniotomy For Trauma,EXTREME","020","DRG","","","","","","","","inpatient","","","382112.27","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37650.3711","","Fee schedule rate ($163,151.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37650.3711","156863.92","156863.92","1 through 10","18289.28","269203.44","case rate",""
"Open Craniotomy For Trauma,EXTREME","020","DRG","","","","","","","","inpatient","","","382112.27","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","42322.8374","","Fee schedule rate ($163,151.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42322.8374","156863.92","156863.92","1 through 10","18289.28","269203.44","case rate",""
"Open Craniotomy For Trauma,EXTREME","020","DRG","","","","","","","","inpatient","","","382112.27","","MASSHEALTH [3001]","HB BWH MEDICAID","58034.48","","Case rate ($64,167.09). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $106,597.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $6,012.94 and the sum of the standard inlier and any outlier amount.","73146.81","73146.81","73146.81","1 through 10","18289.28","269203.44","case rate",""
"Open Craniotomy For Trauma,MAJOR","020","DRG","","","","","","","","inpatient","","","223356.08","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37650.3711","","Fee schedule rate ($94,607.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37650.3711","94607.92","94607.92","1 through 10","18289.28","269203.44","case rate",""
"Open Craniotomy For Trauma,MAJOR","020","DRG","","","","","","","","inpatient","","","223356.08","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","42322.8374","","Fee schedule rate ($94,607.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42322.8374","94607.92","94607.92","1 through 10","18289.28","269203.44","case rate",""
"Open Craniotomy For Trauma,MAJOR","020","DRG","","","","","","","","inpatient","","","223356.08","","MASSHEALTH [3001]","HB BWH MEDICAID","33448.48","","Case rate ($36,983.04). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $79,413.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,210.33 and the sum of the standard inlier and any outlier amount.","36973.96","36973.96","36973.96","1 through 10","18289.28","269203.44","case rate",""
"Open Craniotomy For Trauma,MAJOR","020","DRG","","","","","","","","inpatient","","","223356.08","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","33448.48","","Case rate ($36,983.04). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $79,413.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,210.33 and the sum of the standard inlier and any outlier amount.","46159.46","46159.46","46159.46","1 through 10","18289.28","269203.44","case rate",""
"Open Craniotomy For Trauma,MINOR","020","DRG","","","","","","","","inpatient","","","106233.94","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","74214.40","","Standard inlier is a Case rate ($74,214.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $62,980, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,534.12) for the length of stay and the standard reimbursement.","67801.25","67801.25","67801.25","1 through 10","18289.28","269203.44","case rate",""
"Open Craniotomy For Trauma,MODERATE","020","DRG","","","","","","","","inpatient","","","91052.31","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37650.3711","","Fee schedule rate ($94,607.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37650.3711","53951.44","53951.44","1 through 10","18289.28","269203.44","case rate",""
"Open Craniotomy For Trauma,MODERATE","020","DRG","","","","","","","","inpatient","","","91052.31","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","42322.8374","","Fee schedule rate ($94,607.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42322.8374","53951.44","53951.44","1 through 10","18289.28","269203.44","case rate",""
"Open Extracranial Vascular Procedures,EXTREME","024","DRG","","","","","","","","inpatient","","","174520.99","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28801.9859","","Fee schedule rate ($157,626.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28801.9859","157626.96","157626.96","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,EXTREME","024","DRG","","","","","","","","inpatient","","","174520.99","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","30242.9222","","Fee schedule rate ($165,512.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30242.9222","159128.04","159128.04","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,MAJOR","024","DRG","","","","","","","","inpatient","","","142079.78","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","89165.63","","Standard inlier is a Case rate ($89,165.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $73,322, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,656.32) for the length of stay and the standard reimbursement.","81235.51","81235.51","81235.51","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,MAJOR","024","DRG","","","","","","","","inpatient","","","142079.78","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","30242.9222","","Fee schedule rate ($90,165.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30242.9222","173373.76","173373.76","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,MAJOR","024","DRG","","","","","","","","inpatient","","","142079.78","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","94457.22","","Fee schedule rate ($94,457.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","94457.22","94457.22","94457.22","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,MAJOR","024","DRG","","","","","","","","inpatient","","","142079.78","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","107067.65","","Fee schedule rate ($107,067.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","107067.65","107067.65","107067.65","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,MINOR","024","DRG","","","","","","","","inpatient","","","104689.90","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28801.9859","","Fee schedule rate ($28,801.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28801.9859","27692.00","27692.00","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,MINOR","024","DRG","","","","","","","","inpatient","","","104689.90","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","31682.57","","Fee schedule rate ($31,682.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34614.66","34614.66","34614.66","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,MINOR","024","DRG","","","","","","","","inpatient","","","104689.90","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44716.28","","Fee schedule rate ($44,716.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","44716.28","44716.28","44716.28","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,MINOR","024","DRG","","","","","","","","inpatient","","","104689.90","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","20037.10","","Case rate ($22,154.46). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,584.46, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9439.22","9439.22","9439.22","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,MODERATE","024","DRG","","","","","","","","inpatient","","","96163.30","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","79309.83","","Standard inlier is a Case rate ($79,309.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $73,322, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,258.51) for the length of stay and the standard reimbursement.","37690.18","37690.18","37690.18","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,MODERATE","024","DRG","","","","","","","","inpatient","","","96163.30","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","89165.63","","Standard inlier is a Case rate ($89,165.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $73,322, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,656.32) for the length of stay and the standard reimbursement.","42469.21","42469.21","42469.21","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,MODERATE","024","DRG","","","","","","","","inpatient","","","96163.30","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28801.9859","","Fee schedule rate ($40,978.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28801.9859","40978.60","40978.60","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,MODERATE","024","DRG","","","","","","","","inpatient","","","96163.30","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","52382.81","","Fee schedule rate ($52,382.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","52382.81","52382.81","52382.81","1 through 10","20037.1","260087.65","case rate",""
"Open Extracranial Vascular Procedures,MODERATE","024","DRG","","","","","","","","inpatient","","","96163.30","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55001.39","","Fee schedule rate ($55,001.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","55001.39","55001.39","55001.39","1 through 10","20037.1","260087.65","case rate",""
"Open Tx Mandibular Fx W/Interdental Fixation","PX-76000334","CDM","21462","CPT","0761","RC","","","","both","","","12414.00","9310.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4754.56","38.3","","21855.34","21855.34","21855.34","1 through 10","3848.34","9869.13","percent of total billed charges",""
"OPEN-CLOSED REVISION CONNECTOR 11MM 5.0/6.35","SUP-ITM-10245797","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3436.39","79.5","","800.18","480.96","1887.97","195","1339.98","3436.39","percent of total billed charges",""
"OPEN-CLOSED REVISION CONNECTOR 11MM 5.0/6.35","SUP-ITM-10245797","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2303.89","53.3","","813.12","216.42","1444.50","81","1339.98","3436.39","percent of total billed charges",""
"OPEN-CLOSED REVISION CONNECTOR 11MM 5.0/6.35","SUP-ITM-10245797","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1339.98","31","","432.60","432.60","432.60","1 through 10","1339.98","3436.39","percent of total billed charges",""
"OPEN-CLOSED REVISION CONNECTOR 11MM 5.0/6.35","SUP-ITM-10245797","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1577.71","36.5","","148.37","54.89","631.39","94","1339.98","3436.39","percent of total billed charges",""
"OPEN-CLOSED REVISION CONNECTOR 11MM 5.0/6.35","SUP-ITM-10245797","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1655.52","38.3","","279.30","91.72","1116.77","266","1339.98","3436.39","percent of total billed charges",""
"OPEN-CLOSED REVISION CONNECTOR 11MM 5.0/6.35","SUP-ITM-10245797","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1854.35","42.9","","731.00","63.70","731.00","1 through 10","1339.98","3436.39","percent of total billed charges",""
"OPEN-CLOSED REVISION CONNECTOR 11MM 5.0/6.35","SUP-ITM-10245797","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1854.35","42.9","","384.74","384.74","384.74","1 through 10","1339.98","3436.39","percent of total billed charges",""
"OPEN-CLOSED REVISION CONNECTOR 11MM 5.0/6.35","SUP-ITM-10245797","CDM","C1713","HCPCS","0278","RC","","","","both","","","4322.50","3241.87","WELLPOINT [1015]","HB AMC WELLPOINT","3189.14","73.78","","286.63","119.22","1107.45","105","1339.98","3436.39","percent of total billed charges",""
"OPEN-CLOSED REVISION CONNECTOR 11MM 5.0/6.35","SUP-ITM-10245797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","AETNA [1001]","HB AMC AETNA HMO","3017.11","69.8","","675.31","184.75","1721.50","286","2258.94","3532.35","percent of total billed charges",""
"OPEN-CLOSED REVISION CONNECTOR 11MM 5.0/6.35","SUP-ITM-10245797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","AETNA [1001]","HB AMC AETNA PPO","3475.29","80.4","","1261.44","103.12","1514.10","21","2258.94","3532.35","percent of total billed charges",""
"OPEN-CLOSED REVISION CONNECTOR 11MM 5.0/6.35","SUP-ITM-10245797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3475.29","80.4","","1365.00","1365.00","1365.00","1 through 10","2258.94","3532.35","percent of total billed charges",""
"OPEN-CLOSED REVISION CONNECTOR 11MM 5.0/6.35","SUP-ITM-10245797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3532.35","81.72","","5157.68","5157.68","5157.68","1 through 10","2258.94","3532.35","percent of total billed charges",""
"OPEN-CLOSED REVISION CONNECTOR 11MM 5.0/6.35","SUP-ITM-10245797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3532.35","81.72","","431.26","71.26","1459.57","88","2258.94","3532.35","percent of total billed charges",""
"Open/Perq Place Stent Same","PX-76001941","CDM","37238","CPT","0761","RC","","","","both","","","19653.00","14739.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13196.92","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13206.16","13206.16","13206.16","1 through 10","6092.43","16832.81","other","OPPS APC"
"Opioid Abuse And Dependence,EXTREME","773","DRG","","","","","","","","inpatient","","","87384.42","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64456.00","","Fee schedule rate ($64,456.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","64456.00","64456.00","64456.00","1 through 10","954.59","64456","case rate",""
"Opioid Abuse And Dependence,MAJOR","773","DRG","","","","","","","","inpatient","","","62611.85","","MASSHEALTH [3001]","HB BWH MEDICAID","9031.55","","Case rate ($9,985.93). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,415.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9983.48","9983.48","10387.98","1 through 10","954.59","64456","case rate",""
"Opioid Abuse And Dependence,MAJOR","773","DRG","","","","","","","","inpatient","","","62611.85","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","9031.55","","Case rate ($9,985.93). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,415.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1302.56","1302.56","1302.56","1 through 10","954.59","64456","case rate",""
"Opioid Abuse And Dependence,MAJOR","773","DRG","","","","","","","","inpatient","","","62611.85","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22306.19","","Fee schedule rate ($22,306.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18960.26","18960.26","18960.26","1 through 10","954.59","64456","case rate",""
"Opioid Abuse And Dependence,MAJOR","773","DRG","","","","","","","","inpatient","","","62611.85","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23421.86","","Fee schedule rate ($23,421.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23421.86","23421.86","23421.86","1 through 10","954.59","64456","case rate",""
"Opioid Abuse And Dependence,MODERATE","773","DRG","","","","","","","","inpatient","","","54406.33","","MASSHEALTH [3001]","HB BWH MEDICAID","5755.24","","Case rate ($6,363.41). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,793.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2650.00","2650.00","2650.00","1 through 10","954.59","64456","case rate",""
"Opioid Abuse And Dependence,MODERATE","773","DRG","","","","","","","","inpatient","","","54406.33","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","5755.24","","Case rate ($6,363.41). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,793.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","1020.93","1 through 10","954.59","64456","case rate",""
"Opthalmic Scan Optice Nrv Uni/Bi","PX-51000022","CDM","92133","CPT","0510","RC","","","","both","","","261.00","195.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","88.17","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","34.98","34.98","34.98","1 through 10","67.01","200.97","other","OPPS APC"
"Opthalmic Scan Optice Nrv Uni/Bi","PX-51000022","CDM","92133","CPT","0510","RC","","","","both","","","261.00","195.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.27","36.5","","80.20","80.20","94.37","1 through 10","67.01","200.97","percent of total billed charges",""
"Opthalmic Scan Optice Nrv Uni/Bi","PX-51000022","CDM","92133","CPT","0510","RC","","","","both","","","261.00","195.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","99.96","38.3","","98.92","98.92","192.28","33","67.01","200.97","percent of total billed charges",""
"Opthalmic Scan Optice Nrv Uni/Bi","PX-51000022","CDM","92133","CPT","0510","RC","","","","both","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","111.97","42.9","","111.24","111.24","202.25","1 through 10","67.01","200.97","percent of total billed charges",""
"Opthalmic Scan Optice Nrv Uni/Bi","PX-51000022","CDM","92133","CPT","0510","RC","","","","outpatient","","","261.00","195.75","AETNA [1001]","HB AMC AETNA HMO","182.18","69.8","","342.56","171.28","342.56","1 through 10","40.19","326.91","percent of total billed charges",""
"Opthalmic Scan Optice Nrv Uni/Bi","PX-51000022","CDM","92133","CPT","0510","RC","","","","outpatient","","","261.00","195.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","89.00","34.1","","199.11","133.58","199.11","1 through 10","40.19","326.91","percent of total billed charges",""
"Opthalmic Scan Optice Nrv Uni/Bi","PX-51000022","CDM","92133","CPT","0510","RC","","","","outpatient","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","213.29","81.72","","202.25","111.24","202.25","1 through 10","40.19","326.91","percent of total billed charges",""
"Opthalmic Scan Optice Nrv Uni/Bi","PX-51000022","CDM","92133","CPT","0510","RC","","","","outpatient","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","213.29","81.72","","202.25","143.10","202.25","15","40.19","326.91","percent of total billed charges",""
"Oral Dexamethasone","PX-63601226","CDM","J8540","HCPCS","0636","RC","","","","both","","","0.91","0.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.33","36.5","","0.18","0.06","0.21","1102","0.19","0.7","percent of total billed charges",""
"Oral Dexamethasone","PX-63601226","CDM","J8540","HCPCS","0636","RC","","","","both","","","0.91","0.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.35","38.3","","0.07","0.06","0.14","688","0.19","0.7","percent of total billed charges",""
"Oral Dexamethasone","PX-63601226","CDM","J8540","HCPCS","0636","RC","","","","outpatient","","","0.91","0.68","AETNA [1001]","HB AMC AETNA HMO","0.64","69.8","","0.26","0.13","0.26","761","0.04","0.73","percent of total billed charges",""
"Oral Dexamethasone","PX-63601226","CDM","J8540","HCPCS","0636","RC","","","","outpatient","","","0.91","0.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.64","69.9","","0.08","0.08","0.62","132","0.04","0.73","percent of total billed charges",""
"Oral Dexamethasone","PX-63601226","CDM","J8540","HCPCS","0636","RC","","","","outpatient","","","0.91","0.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.43","46.9","","0.18","0.09","0.25","209","0.04","0.73","percent of total billed charges",""
"Orbit And Eye Procedures,MAJOR","073","DRG","","","","","","","","inpatient","","","121181.58","","MASSHEALTH [3001]","HB BWH MEDICAID","26444.63","","Case rate ($29,239.09). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $71,669.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29231.91","29231.91","29231.91","1 through 10","9536.47","150959.78","case rate",""
"Orbit And Eye Procedures,MINOR","073","DRG","","","","","","","","inpatient","","","63468.62","","MASSHEALTH [3001]","HB BWH MEDICAID","9536.47","","Case rate ($10,544.21). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,974.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11174.12","11174.12","11174.12","1 through 10","9536.47","150959.78","case rate",""
"Orbit And Eye Procedures,MODERATE","073","DRG","","","","","","","","inpatient","","","251325.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","40759.56","","Standard inlier is a Case rate ($40,759.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,840, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,785.48) for the length of stay and the standard reimbursement.","61155.53","61155.53","61155.53","1 through 10","9536.47","150959.78","case rate",""
"Orfadin Level","PX-31000766","CDM","80299","CPT","0301","RC","","","","both","","","176.00","132.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.92","79.5","","106.25","71.28","106.25","1 through 10","14.12","167.2","percent of total billed charges",""
"Orfadin Level","PX-31000766","CDM","80299","CPT","0301","RC","","","","both","","","176.00","132.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.81","53.3","","106.25","71.28","106.25","1 through 10","14.12","167.2","percent of total billed charges",""
"Orfadin Level","PX-31000766","CDM","80299","CPT","0301","RC","","","","both","","","176.00","132.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.24","36.5","","50.36","42.80","92.50","13","14.12","167.2","percent of total billed charges",""
"Orfadin Level","PX-31000766","CDM","80299","CPT","0301","RC","","","","both","","","176.00","132.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.41","38.3","","52.79","44.55","158.37","30","14.12","167.2","percent of total billed charges",""
"Orfadin Level","PX-31000766","CDM","80299","CPT","0301","RC","","","","outpatient","","","176.00","132.00","AETNA [1001]","HB AMC AETNA HMO","122.85","69.8","","91.40","64.53","105.30","14","14.12","143.83","percent of total billed charges",""
"Orfadin Level","PX-31000766","CDM","80299","CPT","0301","RC","","","","outpatient","","","176.00","132.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","141.50","80.4","","105.30","105.30","105.30","1 through 10","14.12","143.83","percent of total billed charges",""
"Orfadin Level","PX-31000766","CDM","80299","CPT","0301","RC","","","","outpatient","","","176.00","132.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.83","81.72","","59.36","15.50","59.36","1 through 10","14.12","143.83","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","both","","","202.00","151.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","145.04","71.8","","140.73","140.73","140.73","1 through 10","16.96","191.9","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","both","","","202.00","151.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.59","79.5","","154.25","103.49","154.25","18","16.96","191.9","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","both","","","202.00","151.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","107.67","53.3","","154.25","103.49","310.47","21","16.96","191.9","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","both","","","202.00","151.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","155.54","77","","452.76","150.92","452.76","1 through 10","16.96","191.9","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.73","36.5","","73.11","62.13","73.11","28","16.96","191.9","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.37","38.3","","76.64","76.64","76.64","44","16.96","191.9","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","both","","","202.00","151.50","TRICARE [160005]","HB BWH TRICARE","191.90","95","","24.28","24.28","24.28","1 through 10","16.96","191.9","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","both","","","202.00","151.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","191.90","95","","21.21","21.21","21.21","1 through 10","16.96","191.9","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA HMO","141.00","69.8","","132.69","93.69","132.69","31","16.96","165.07","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA PPO","162.41","80.4","","152.88","152.88","152.88","1 through 10","16.96","165.07","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","outpatient","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.07","81.72","","156.68","86.18","156.68","23","16.96","165.07","percent of total billed charges",""
"Organic Acids Ql","PX-30000591","CDM","83919","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.38","79.5","","247.91","247.91","247.91","1 through 10","16.12","308.75","percent of total billed charges",""
"Organic Acids Ql","PX-30000591","CDM","83919","CPT","0301","RC","","","","both","","","325.00","243.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.23","53.3","","166.32","166.32","166.32","1 through 10","16.12","308.75","percent of total billed charges",""
"Organic Acids Ql","PX-30000591","CDM","83919","CPT","0301","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.48","38.3","","119.70","119.70","119.70","1 through 10","16.12","308.75","percent of total billed charges",""
"Organic Acids Ql","PX-30000591","CDM","83919","CPT","0301","RC","","","","outpatient","","","325.00","243.75","AETNA [1001]","HB AMC AETNA HMO","226.85","69.8","","150.57","150.57","150.57","1 through 10","16.96","265.59","percent of total billed charges",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","65283.69","48962.77","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15508.08","","Case rate ($15,056.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,047.52, add-ons for qualifying new technology services are included. If operating cost exceeds $63,691.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,734.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,381.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,667.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.62. The transfer capital threshold is the transfer adjustment factor * $1,294.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15920.90","15920.90","15920.90","1 through 10","14755.26","25201.81","other","Inpatient DRG"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","65283.69","48962.77","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","19427.48","","Case rate ($19,427.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,047.52, add-ons for qualifying new technology services are included. If operating cost exceeds $63,691.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,734.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $17,753.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,667.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.62. The transfer capital threshold is the transfer adjustment factor * $1,294.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19758.01","19758.01","19758.01","1 through 10","14755.26","25201.81","other","Inpatient DRG"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","65283.69","48962.77","MEDICARE [2001]","HB BWH MEDICARE","19427.48","","Case rate ($19,427.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,047.52, add-ons for qualifying new technology services are included. If operating cost exceeds $63,691.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,734.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $17,753.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,667.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.62. The transfer capital threshold is the transfer adjustment factor * $1,294.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19968.52","0.03","19997.97","26","14755.26","25201.81","other","Inpatient DRG"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","65283.69","48962.77","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","19427.48","","Case rate ($19,427.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,047.52, add-ons for qualifying new technology services are included. If operating cost exceeds $63,691.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,734.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $17,753.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,667.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.62. The transfer capital threshold is the transfer adjustment factor * $1,294.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9778.98","9778.98","9778.98","1 through 10","14755.26","25201.81","other","Inpatient DRG"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","65283.69","48962.77","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14755.26","","Case rate ($15,056.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,047.52, add-ons for qualifying new technology services are included. If operating cost exceeds $63,691.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,734.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,381.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,667.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.62. The transfer capital threshold is the transfer adjustment factor * $1,294.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15221.79","15221.79","15221.79","1 through 10","14755.26","25201.81","other","Inpatient DRG"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","65283.69","48962.77","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14755.26","","Case rate ($15,056.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,047.52, add-ons for qualifying new technology services are included. If operating cost exceeds $63,691.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,734.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,381.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,667.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.62. The transfer capital threshold is the transfer adjustment factor * $1,294.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15196.70","10248.05","22572.45","1 through 10","14755.26","25201.81","other","Inpatient DRG"
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-42000107","CDM","97763","CPT","0421","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","152.82","38.3","","151.32","151.32","151.32","1 through 10","56.36","379.05","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-42000107","CDM","97763","CPT","0421","RC","","","","both","","","399.00","299.25","TRICARE [160005]","HB BWH TRICARE","379.05","95","","57.51","57.51","59.98","1 through 10","56.36","379.05","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-42000107","CDM","97763","CPT","0421","RC","","","","both","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","56.36","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($57.51). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($36.99). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","56.49","46.76","59.19","1 through 10","56.36","379.05","fee schedule",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-42000107","CDM","97763","CPT","0421","RC","","","","both","","","399.00","299.25","WELLPOINT [1015]","HB AMC WELLPOINT","294.38","73.78","","288.12","288.12","288.12","1 through 10","56.36","379.05","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-42000107","CDM","97763","CPT","0421","RC","","","","outpatient","","","399.00","299.25","AETNA [1001]","HB AMC AETNA HMO","278.50","69.8","","301.86","262.00","301.86","1 through 10","208.52","423.68","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-43000114","CDM","97763","CPT","0431","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","152.82","38.3","","151.32","151.32","151.32","1 through 10","56.36","379.05","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-43000114","CDM","97763","CPT","0431","RC","","","","both","","","399.00","299.25","TRICARE [160005]","HB BWH TRICARE","379.05","95","","57.51","57.51","59.98","1 through 10","56.36","379.05","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-43000114","CDM","97763","CPT","0431","RC","","","","both","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","56.36","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($57.51). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($36.99). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","56.49","46.76","59.19","1 through 10","56.36","379.05","fee schedule",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-43000114","CDM","97763","CPT","0431","RC","","","","both","","","399.00","299.25","WELLPOINT [1015]","HB AMC WELLPOINT","294.38","73.78","","288.12","288.12","288.12","1 through 10","56.36","379.05","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-43000114","CDM","97763","CPT","0431","RC","","","","outpatient","","","399.00","299.25","AETNA [1001]","HB AMC AETNA HMO","278.50","69.8","","301.86","262.00","301.86","1 through 10","208.52","423.68","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-98301673","CDM","97763","CPT","0983","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.92","38.3","","151.32","151.32","151.32","1 through 10","56.36","228","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-98301673","CDM","97763","CPT","0983","RC","","","","both","","","240.00","180.00","TRICARE [160005]","HB BWH TRICARE","228.00","95","","57.51","57.51","59.98","1 through 10","56.36","228","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-98301673","CDM","97763","CPT","0983","RC","","","","both","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","56.36","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($57.51). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($36.99). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","56.49","46.76","59.19","1 through 10","56.36","228","fee schedule",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-98301673","CDM","97763","CPT","0983","RC","","","","both","","","240.00","180.00","WELLPOINT [1015]","HB AMC WELLPOINT","177.07","73.78","","288.12","288.12","288.12","1 through 10","56.36","228","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-98301673","CDM","97763","CPT","0983","RC","","","","outpatient","","","240.00","180.00","AETNA [1001]","HB AMC AETNA HMO","167.52","69.8","","301.86","262.00","301.86","1 through 10","120","423.68","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","both","","","112.00","84.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","89.04","79.5","","85.78","57.55","85.78","1 through 10","6.48","106.4","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","both","","","112.00","84.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","59.70","53.3","","57.55","57.55","57.55","1 through 10","6.48","106.4","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","both","","","112.00","84.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","40.88","36.5","","40.66","29.09","40.66","1 through 10","6.48","106.4","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","both","","","112.00","84.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","42.90","38.3","","42.62","42.62","127.86","23","6.48","106.4","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","outpatient","","","112.00","84.00","AETNA [1001]","HB AMC AETNA HMO","78.18","69.8","","73.79","52.10","73.80","1 through 10","6.82","91.53","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","outpatient","","","112.00","84.00","AETNA [1001]","HB AMC AETNA PPO","90.05","80.4","","85.02","85.02","85.02","1 through 10","6.82","91.53","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","91.53","81.72","","87.13","47.93","109.00","1 through 10","6.82","91.53","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","both","","","114.00","85.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","79.80","70","","159.84","159.84","159.84","1 through 10","6.68","108.3","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","both","","","114.00","85.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","90.63","79.5","","87.36","58.61","87.36","1 through 10","6.68","108.3","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","both","","","114.00","85.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","60.76","53.3","","58.61","56.06","58.61","1 through 10","6.68","108.3","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.61","36.5","","41.40","35.19","41.40","1 through 10","6.68","108.3","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.66","38.3","","43.40","43.40","126.54","31","6.68","108.3","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","outpatient","","","114.00","85.50","AETNA [1001]","HB AMC AETNA HMO","79.57","69.8","","75.15","53.06","86.58","15","7.02","93.16","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","outpatient","","","114.00","85.50","AETNA [1001]","HB AMC AETNA PPO","91.66","80.4","","86.58","86.58","86.58","1 through 10","7.02","93.16","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.16","81.72","","88.73","48.81","88.73","11","7.02","93.16","percent of total billed charges",""
"Osmotic Fragility RBC Incubated","PX-30001113","CDM","85557","CPT","0305","RC","","","","both","","","136.00","102.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","108.12","79.5","","103.88","103.88","103.88","1 through 10","8.39","129.2","percent of total billed charges",""
"Osmotic Fragility RBC Incubated","PX-30001113","CDM","85557","CPT","0305","RC","","","","both","","","136.00","102.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.09","38.3","","50.16","50.16","50.16","1 through 10","8.39","129.2","percent of total billed charges",""
"OSSICLE CLIP 3.50MM FLEXIBAL PARTIAL PROSTHESIS","SUP-ITM-10232191","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1878.21","1408.66","AETNA [1001]","HB AMC AETNA HMO","1310.99","69.8","","1013.24","1013.24","1013.24","1 through 10","939.11","1549.52","percent of total billed charges",""
"OSSICLE STAPES .4X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232207","CDM","C1713","HCPCS","0278","RC","","","","both","","","1059.87","794.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","842.60","79.5","","800.18","480.96","1887.97","195","328.56","842.6","percent of total billed charges",""
"OSSICLE STAPES .4X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232207","CDM","C1713","HCPCS","0278","RC","","","","both","","","1059.87","794.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","564.91","53.3","","813.12","216.42","1444.50","81","328.56","842.6","percent of total billed charges",""
"OSSICLE STAPES .4X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232207","CDM","C1713","HCPCS","0278","RC","","","","both","","","1059.87","794.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","328.56","31","","432.60","432.60","432.60","1 through 10","328.56","842.6","percent of total billed charges",""
"OSSICLE STAPES .4X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232207","CDM","C1713","HCPCS","0278","RC","","","","both","","","1059.87","794.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","386.85","36.5","","148.37","54.89","631.39","94","328.56","842.6","percent of total billed charges",""
"OSSICLE STAPES .4X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232207","CDM","C1713","HCPCS","0278","RC","","","","both","","","1059.87","794.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","405.93","38.3","","279.30","91.72","1116.77","266","328.56","842.6","percent of total billed charges",""
"OSSICLE STAPES .4X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232207","CDM","C1713","HCPCS","0278","RC","","","","both","","","1059.87","794.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","454.68","42.9","","731.00","63.70","731.00","1 through 10","328.56","842.6","percent of total billed charges",""
"OSSICLE STAPES .4X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232207","CDM","C1713","HCPCS","0278","RC","","","","both","","","1059.87","794.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","454.68","42.9","","384.74","384.74","384.74","1 through 10","328.56","842.6","percent of total billed charges",""
"OSSICLE STAPES .4X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232207","CDM","C1713","HCPCS","0278","RC","","","","both","","","1059.87","794.90","WELLPOINT [1015]","HB AMC WELLPOINT","781.97","73.78","","286.63","119.22","1107.45","105","328.56","842.6","percent of total billed charges",""
"OSSICLE STAPES .4X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232207","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1059.87","794.90","AETNA [1001]","HB AMC AETNA HMO","739.79","69.8","","675.31","184.75","1721.50","286","553.89","866.13","percent of total billed charges",""
"OSSICLE STAPES .4X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232207","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1059.87","794.90","AETNA [1001]","HB AMC AETNA PPO","852.14","80.4","","1261.44","103.12","1514.10","21","553.89","866.13","percent of total billed charges",""
"OSSICLE STAPES .4X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232207","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1059.87","794.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","852.14","80.4","","1365.00","1365.00","1365.00","1 through 10","553.89","866.13","percent of total billed charges",""
"OSSICLE STAPES .4X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232207","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1059.87","794.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","866.13","81.72","","5157.68","5157.68","5157.68","1 through 10","553.89","866.13","percent of total billed charges",""
"OSSICLE STAPES .4X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232207","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1059.87","794.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","866.13","81.72","","431.26","71.26","1459.57","88","553.89","866.13","percent of total billed charges",""
"OSSICLE STAPES .4X4.75MM NITIBOND PROSTHESIS","SUP-ITM-10232123","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1474.45","1105.84","AETNA [1001]","HB AMC AETNA HMO","1029.17","69.8","","1013.24","1013.24","1013.24","1 through 10","737.23","1216.42","percent of total billed charges",""
"OSSICLE STAPES .6X4.25MM NITIBOND PROSTHESIS","SUP-ITM-10232118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1474.45","1105.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1172.19","79.5","","800.18","480.96","1887.97","195","457.08","1172.19","percent of total billed charges",""
"OSSICLE STAPES .6X4.25MM NITIBOND PROSTHESIS","SUP-ITM-10232118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1474.45","1105.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","785.88","53.3","","813.12","216.42","1444.50","81","457.08","1172.19","percent of total billed charges",""
"OSSICLE STAPES .6X4.25MM NITIBOND PROSTHESIS","SUP-ITM-10232118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1474.45","1105.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","457.08","31","","432.60","432.60","432.60","1 through 10","457.08","1172.19","percent of total billed charges",""
"OSSICLE STAPES .6X4.25MM NITIBOND PROSTHESIS","SUP-ITM-10232118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1474.45","1105.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","538.17","36.5","","148.37","54.89","631.39","94","457.08","1172.19","percent of total billed charges",""
"OSSICLE STAPES .6X4.25MM NITIBOND PROSTHESIS","SUP-ITM-10232118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1474.45","1105.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","564.71","38.3","","279.30","91.72","1116.77","266","457.08","1172.19","percent of total billed charges",""
"OSSICLE STAPES .6X4.25MM NITIBOND PROSTHESIS","SUP-ITM-10232118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1474.45","1105.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","632.54","42.9","","731.00","63.70","731.00","1 through 10","457.08","1172.19","percent of total billed charges",""
"OSSICLE STAPES .6X4.25MM NITIBOND PROSTHESIS","SUP-ITM-10232118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1474.45","1105.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","632.54","42.9","","384.74","384.74","384.74","1 through 10","457.08","1172.19","percent of total billed charges",""
"OSSICLE STAPES .6X4.25MM NITIBOND PROSTHESIS","SUP-ITM-10232118","CDM","C1713","HCPCS","0278","RC","","","","both","","","1474.45","1105.84","WELLPOINT [1015]","HB AMC WELLPOINT","1087.85","73.78","","286.63","119.22","1107.45","105","457.08","1172.19","percent of total billed charges",""
"OSSICLE STAPES .6X4.25MM NITIBOND PROSTHESIS","SUP-ITM-10232118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1474.45","1105.84","AETNA [1001]","HB AMC AETNA HMO","1029.17","69.8","","675.31","184.75","1721.50","286","770.55","1204.92","percent of total billed charges",""
"OSSICLE STAPES .6X4.25MM NITIBOND PROSTHESIS","SUP-ITM-10232118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1474.45","1105.84","AETNA [1001]","HB AMC AETNA PPO","1185.46","80.4","","1261.44","103.12","1514.10","21","770.55","1204.92","percent of total billed charges",""
"OSSICLE STAPES .6X4.25MM NITIBOND PROSTHESIS","SUP-ITM-10232118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1474.45","1105.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1185.46","80.4","","1365.00","1365.00","1365.00","1 through 10","770.55","1204.92","percent of total billed charges",""
"OSSICLE STAPES .6X4.25MM NITIBOND PROSTHESIS","SUP-ITM-10232118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1474.45","1105.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1204.92","81.72","","5157.68","5157.68","5157.68","1 through 10","770.55","1204.92","percent of total billed charges",""
"OSSICLE STAPES .6X4.25MM NITIBOND PROSTHESIS","SUP-ITM-10232118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1474.45","1105.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1204.92","81.72","","431.26","71.26","1459.57","88","770.55","1204.92","percent of total billed charges",""
"OSSICLE STAPES .6X4.50MM NITIBOND PROSTHESIS","SUP-ITM-10232117","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1474.45","1105.84","AETNA [1001]","HB AMC AETNA HMO","1029.17","69.8","","1013.24","1013.24","1013.24","1 through 10","737.23","1216.42","percent of total billed charges",""
"OSSICLE STAPES .6X4.50MM NITIFLEX PROSTHESIS","SUP-ITM-10232105","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1059.87","794.90","AETNA [1001]","HB AMC AETNA HMO","739.79","69.8","","1013.24","1013.24","1013.24","1 through 10","529.94","874.39","percent of total billed charges",""
"Ossicular Implant T1","PX-27000563","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","934.96","701.22","AETNA [1001]","HB AMC AETNA HMO","652.60","69.8","","1013.24","1013.24","1013.24","1 through 10","467.48","771.34","percent of total billed charges",""
"Osteocalcin","PX-30000596","CDM","83937","CPT","0301","RC","","","","both","","","349.00","261.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","250.58","71.8","","242.68","242.68","242.68","1 through 10","29.25","331.55","percent of total billed charges",""
"Osteocalcin","PX-30000596","CDM","83937","CPT","0301","RC","","","","both","","","349.00","261.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.39","36.5","","122.36","122.36","122.36","1 through 10","29.25","331.55","percent of total billed charges",""
"Osteocalcin","PX-30000596","CDM","83937","CPT","0301","RC","","","","both","","","349.00","261.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","133.67","38.3","","132.16","132.16","132.16","1 through 10","29.25","331.55","percent of total billed charges",""
"Osteogenesis Imperfecta Ngs Panel - Dominant & Recessive","PX-31000836","CDM","81479","CPT","0310","RC","","","","both","","","96.00","72.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","76.32","79.5","","0.65","0.65","0.65","1 through 10","29.76","91.2","percent of total billed charges",""
"Osteogenesis Imperfecta Ngs Panel - Dominant & Recessive","PX-31000836","CDM","81479","CPT","0310","RC","","","","both","","","96.00","72.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","51.17","53.3","","0.79","0.79","0.79","1 through 10","29.76","91.2","percent of total billed charges",""
"Osteogenesis Imperfecta Ngs Panel - Dominant & Recessive","PX-31000836","CDM","81479","CPT","0310","RC","","","","outpatient","","","96.00","72.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","48.00","50","","1.00","1.00","1.00","1 through 10","46.46","156.55","percent of total billed charges",""
"Osteogenesis Imperfecta Ngs Panel - Dominant & Recessive","PX-31000836","CDM","81479","CPT","0310","RC","","","","outpatient","","","96.00","72.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","50.40","52.5","","1.00","0.53","1.00","1 through 10","46.46","156.55","percent of total billed charges",""
"Osteomyelitis With Cc","540","MS-DRG","","","","","","","","inpatient","","","54758.27","41068.70","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","12570.97","","Case rate ($12,204.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,614.79, add-ons for qualifying new technology services are included. If operating cost exceeds $60,259.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,483.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,781.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,234.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,043.08. The transfer capital threshold is the transfer adjustment factor * $1,043.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11828.04","11828.04","11828.04","1 through 10","11960.73","19529.2631","other","Inpatient DRG"
"Osteomyelitis With Cc","540","MS-DRG","","","","","","","","inpatient","","","54758.27","41068.70","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","12204.83","","Case rate ($12,204.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,614.79, add-ons for qualifying new technology services are included. If operating cost exceeds $60,259.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,483.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,781.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,234.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,043.08. The transfer capital threshold is the transfer adjustment factor * $1,043.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11783.92","11783.92","11783.92","1 through 10","11960.73","19529.2631","other","Inpatient DRG"
"Osteomyelitis With Cc","540","MS-DRG","","","","","","","","inpatient","","","54758.27","41068.70","MEDICARE [2001]","HB BWH MEDICARE","12204.83","","Case rate ($12,204.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,614.79, add-ons for qualifying new technology services are included. If operating cost exceeds $60,259.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,483.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,781.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,234.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,043.08. The transfer capital threshold is the transfer adjustment factor * $1,043.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15557.44","15557.44","15557.44","1 through 10","11960.73","19529.2631","other","Inpatient Replacement Plans DRG"
"Osteomyelitis With Cc","540","MS-DRG","","","","","","","","inpatient","","","54758.27","41068.70","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","11960.73","","Case rate ($12,204.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,614.79, add-ons for qualifying new technology services are included. If operating cost exceeds $60,259.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,483.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,781.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,234.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,043.08. The transfer capital threshold is the transfer adjustment factor * $1,043.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11917.56","11917.56","11917.56","1 through 10","11960.73","19529.2631","other","Inpatient DRG"
"Osteomyelitis With Cc","540","MS-DRG","","","","","","","","inpatient","","","54758.27","41068.70","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11960.73","","Case rate ($12,204.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,614.79, add-ons for qualifying new technology services are included. If operating cost exceeds $60,259.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,483.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,781.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,234.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,043.08. The transfer capital threshold is the transfer adjustment factor * $1,043.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11274.54","11274.54","11274.54","1 through 10","11960.73","19529.2631","other","Inpatient DRG"
"Osteomyelitis With McC","539","MS-DRG","","","","","","","","inpatient","","","84749.19","63561.89","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","18347.65","","Case rate ($18,347.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,009.55, add-ons for qualifying new technology services are included. If operating cost exceeds $67,653.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,025.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $16,382.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,629.70 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,584.94. The transfer capital threshold is the transfer adjustment factor * $1,584.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18287.17","18287.17","18287.17","1 through 10","17980.7","30520.0384","other","Inpatient DRG"
"Osteomyelitis With McC","539","MS-DRG","","","","","","","","inpatient","","","84749.19","63561.89","MEDICARE [2001]","HB BWH MEDICARE","23698.97","","Case rate ($23,698.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,009.55, add-ons for qualifying new technology services are included. If operating cost exceeds $67,653.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,025.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $21,734.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,629.70 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,584.94. The transfer capital threshold is the transfer adjustment factor * $1,584.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24120.66","0.03","24156.33","11","17980.7","30520.0384","other","Inpatient DRG"
"Osteomyelitis With McC","539","MS-DRG","","","","","","","","inpatient","","","84749.19","63561.89","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17980.70","","Case rate ($18,347.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,009.55, add-ons for qualifying new technology services are included. If operating cost exceeds $67,653.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,025.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $16,382.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,629.70 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,584.94. The transfer capital threshold is the transfer adjustment factor * $1,584.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18295.78","18295.78","18295.78","1 through 10","17980.7","30520.0384","other","Inpatient DRG"
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,EXTREME","344","DRG","","","","","","","","inpatient","","","140468.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","42955.70","","Standard inlier is a Case rate ($42,955.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,360, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,097.21) for the length of stay and the standard reimbursement.","63014.54","63014.54","63014.54","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,EXTREME","344","DRG","","","","","","","","inpatient","","","140468.35","","MASSHEALTH [3001]","HB BWH MEDICAID","12328.41","","Case rate ($13,631.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,061.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,065.33 and the sum of the standard inlier and any outlier amount.","26235.35","26235.35","26235.35","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,EXTREME","344","DRG","","","","","","","","inpatient","","","140468.35","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73349.41","","Fee schedule rate ($73,349.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","73349.41","73349.41","73349.41","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,EXTREME","344","DRG","","","","","","","","inpatient","","","140468.35","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","12328.41","","Case rate ($13,631.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,061.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,065.33 and the sum of the standard inlier and any outlier amount.","14160.04","14160.04","14160.04","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MAJOR","344","DRG","","","","","","","","inpatient","","","76106.81","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","38207.66","","Standard inlier is a Case rate ($38,207.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,360, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,423.81) for the length of stay and the standard reimbursement.","42955.70","42955.70","42955.70","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MAJOR","344","DRG","","","","","","","","inpatient","","","76106.81","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17314.2947","","Fee schedule rate ($87,723.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17314.2947","42177.44","42177.44","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MAJOR","344","DRG","","","","","","","","inpatient","","","76106.81","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","18180.5126","","Fee schedule rate ($92,112.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18180.5126","44287.56","44287.56","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MAJOR","344","DRG","","","","","","","","inpatient","","","76106.81","","MASSHEALTH [3001]","HB BWH MEDICAID","12328.41","","Case rate ($13,631.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,061.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13627.84","13627.84","13627.84","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MAJOR","344","DRG","","","","","","","","inpatient","","","76106.81","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12328.41","","Case rate ($13,631.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,061.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9439.22","9439.22","9439.22","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MINOR","344","DRG","","","","","","","","inpatient","","","40689.11","","MASSHEALTH [3001]","HB BWH MEDICAID","7247.17","","Case rate ($8,012.99). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,442.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6068.96","6068.96","6068.96","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MINOR","344","DRG","","","","","","","","inpatient","","","40689.11","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","7247.17","","Case rate ($8,012.99). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,442.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","37282.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","26636.05","","Standard inlier is a Case rate ($26,636.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,361, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,781.15) for the length of stay and the standard reimbursement.","26636.04","26636.04","26636.04","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","37282.58","","MASSHEALTH [3001]","HB BWH MEDICAID","8535.76","","Case rate ($9,437.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,867.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9435.43","9435.43","9435.43","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","37282.58","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","8535.76","","Case rate ($9,437.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,867.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","37282.58","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28792.82","","Fee schedule rate ($28,792.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28792.82","28792.82","28792.82","1 through 10","7247.17","144745.33","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","37282.58","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8535.76","","Case rate ($9,437.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,867.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1020.93","554.93","9435.43","1 through 10","7247.17","144745.33","case rate",""
"Ot Aquatic Therapy/Exercise 15 Min","PX-43000025","CDM","97113","CPT","0431","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","90.21","31","","87.14","87.14","87.14","1 through 10","40.43","276.45","percent of total billed charges",""
"Ot Aquatic Therapy/Exercise 15 Min","PX-43000025","CDM","97113","CPT","0431","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","111.45","38.3","","107.16","107.16","107.16","1 through 10","40.43","276.45","percent of total billed charges",""
"Ot Debr/Rem Tiss Addl 20 Sq Cm/Part","PX-43000040","CDM","97598","CPT","0431","RC","","","","both","","","272.00","204.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","144.98","53.3","","207.77","207.77","207.77","1 through 10","32.34","216.24","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","both","","","889.00","666.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","706.76","79.5","","678.39","678.39","678.39","1 through 10","47.19","706.76","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","both","","","889.00","666.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","473.84","53.3","","678.39","678.39","678.39","1 through 10","47.19","706.76","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","both","","","889.00","666.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","324.49","36.5","","321.53","312.04","643.06","1 through 10","47.19","706.76","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","both","","","889.00","666.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","340.49","38.3","","1011.12","58.26","1011.12","1 through 10","47.19","706.76","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","outpatient","","","889.00","666.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","1 through 10","176.45","726.49","other","Multiple Surgery"
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","outpatient","","","889.00","666.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","726.49","81.72","","689.08","689.08","689.08","1 through 10","176.45","726.49","percent of total billed charges",""
"Ot E-Stim Attended 15 Min","PX-43000017","CDM","97032","CPT","0431","RC","","","","both","","","136.00","102.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.09","38.3","","51.61","51.61","51.61","1 through 10","15.37","129.2","percent of total billed charges",""
"Ot E-Stim Attended 15 Min","PX-43000017","CDM","97032","CPT","0431","RC","","","","both","","","136.00","102.00","TRICARE [160005]","HB BWH TRICARE","129.20","95","","15.74","15.68","15.74","17","15.37","129.2","percent of total billed charges",""
"Ot E-Stim Attended 15 Min","PX-43000017","CDM","97032","CPT","0431","RC","","","","outpatient","","","136.00","102.00","AETNA [1001]","HB AMC AETNA PPO","109.34","80.4","","55.02","55.02","55.02","1 through 10","71.07","376","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","228.00","171.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","163.70","71.8","","39.87","39.87","158.68","22","31.47","216.6","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","228.00","171.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","159.60","70","","221.00","221.00","221.00","1 through 10","31.47","216.6","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","228.00","171.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","181.26","79.5","","173.93","173.93","173.93","16","31.47","216.6","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","228.00","171.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","121.52","53.3","","116.69","116.69","173.93","668","31.47","216.6","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","70.68","31","","68.29","68.29","68.29","45","31.47","216.6","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.22","36.5","","82.43","70.06","82.44","747","31.47","216.6","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.32","38.3","","86.41","83.98","86.41","3896","31.47","216.6","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","228.00","171.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","175.56","77","","344.76","209.00","344.76","1 through 10","31.47","216.6","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","228.00","171.00","TRICARE [160005]","HB BWH TRICARE","216.60","95","","32.64","30.50","65.28","175","31.47","216.6","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.81","42.9","","250.40","250.40","250.40","1 through 10","31.47","216.6","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","31.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","27.69","24.74","32.07","653","31.47","216.6","fee schedule",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","228.00","171.00","AETNA [1001]","HB AMC AETNA HMO","159.14","69.8","","185.76","105.64","263.53","2075","119.15","376","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","228.00","171.00","AETNA [1001]","HB AMC AETNA PPO","183.31","80.4","","203.63","87.83","303.12","199","119.15","376","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","228.00","171.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","127.45","55.9","","109.52","83.38","109.52","1 through 10","119.15","376","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","183.31","80.4","","172.38","172.38","172.38","1 through 10","119.15","376","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","186.32","81.72","","176.67","160.95","353.33","1 through 10","119.15","376","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","186.32","81.72","","119.60","119.60","221.00","72","119.15","376","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","both","","","197.00","147.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","156.62","79.5","","100.85","100.85","100.85","1 through 10","31.47","187.15","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","both","","","197.00","147.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","105.00","53.3","","150.32","100.85","150.32","1 through 10","31.47","187.15","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","both","","","197.00","147.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.91","36.5","","71.24","60.55","71.25","1 through 10","31.47","187.15","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","both","","","197.00","147.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.45","38.3","","74.68","74.68","74.68","15","31.47","187.15","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","both","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","31.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","23.36","23.31","31.47","1 through 10","31.47","187.15","fee schedule",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","outpatient","","","197.00","147.75","AETNA [1001]","HB AMC AETNA HMO","137.51","69.8","","129.31","98.07","129.31","38","102.95","376","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","outpatient","","","197.00","147.75","AETNA [1001]","HB AMC AETNA PPO","158.39","80.4","","112.99","69.24","112.99","1 through 10","102.95","376","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","245.00","183.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.59","53.3","","187.31","125.67","187.31","1 through 10","35.26","232.75","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.43","36.5","","88.77","88.77","88.77","1 through 10","35.26","232.75","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.84","38.3","","93.06","93.06","93.06","63","35.26","232.75","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","35.26","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.98). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($25.72). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","28.86","27.95","30.30","12","35.26","232.75","fee schedule",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA HMO","171.01","69.8","","197.07","83.58","279.13","37","128.04","376","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA PPO","196.98","80.4","","124.71","113.76","185.64","1 through 10","128.04","376","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","212.00","159.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","168.54","79.5","","168.03","102.92","168.03","1 through 10","29.66","201.4","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","212.00","159.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","113.00","53.3","","108.77","108.77","162.12","277","29.66","201.4","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","65.72","31","","63.65","63.65","63.66","18","29.66","201.4","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.38","36.5","","76.84","65.30","110.65","194","29.66","201.4","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.20","38.3","","80.55","78.28","80.55","1156","29.66","201.4","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","212.00","159.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","163.24","77","","194.00","194.00","194.00","1 through 10","29.66","201.4","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","212.00","159.00","TRICARE [160005]","HB BWH TRICARE","201.40","95","","29.95","28.76","30.27","65","29.66","201.4","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","29.66","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($30.27). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($22.53). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","22.08","22.08","25.93","101","29.66","201.4","fee schedule",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA HMO","147.98","69.8","","98.47","75.02","139.46","510","110.79","376","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA PPO","170.45","80.4","","122.42","82.24","283.10","39","110.79","376","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","118.51","55.9","","78.44","78.44","78.44","1 through 10","110.79","376","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","212.00","159.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","170.45","80.4","","160.68","160.68","160.68","1 through 10","110.79","376","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","212.00","159.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","173.25","81.72","","164.67","149.40","164.68","1 through 10","110.79","376","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","173.25","81.72","","412.00","114.06","412.00","1 through 10","110.79","376","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","233.00","174.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.19","53.3","","119.33","119.33","177.86","52","35.02","221.35","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","233.00","174.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.05","36.5","","84.30","71.64","84.30","104","35.02","221.35","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","233.00","174.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.24","38.3","","88.37","88.37","88.37","503","35.02","221.35","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","233.00","174.75","TRICARE [160005]","HB BWH TRICARE","221.35","95","","36.42","33.94","37.56","12","35.02","221.35","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","233.00","174.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","35.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.73). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($26.43). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","30.76","29.14","35.54","102","35.02","221.35","fee schedule",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","outpatient","","","233.00","174.75","AETNA [1001]","HB AMC AETNA HMO","162.63","69.8","","189.87","108.03","268.91","257","121.77","376","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","outpatient","","","233.00","174.75","AETNA [1001]","HB AMC AETNA PPO","187.33","80.4","","176.28","118.42","208.13","42","121.77","376","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","outpatient","","","233.00","174.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","130.25","55.9","","118.42","111.61","118.42","1 through 10","121.77","376","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","outpatient","","","233.00","174.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","190.41","81.72","","226.00","125.14","226.00","1 through 10","121.77","376","percent of total billed charges",""
"Ot Prosthetic Training Each 15 Min","PX-43000047","CDM","97761","CPT","0431","RC","","","","outpatient","","","227.00","170.25","AETNA [1001]","HB AMC AETNA PPO","182.51","80.4","","171.60","171.60","171.60","1 through 10","118.63","376","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","245.00","183.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","194.78","79.5","","125.66","125.66","125.66","1 through 10","38.35","232.75","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","245.00","183.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.59","53.3","","125.67","125.66","187.31","1 through 10","38.35","232.75","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.43","36.5","","86.16","75.45","226.35","22","38.35","232.75","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.84","38.3","","93.06","90.44","93.06","97","38.35","232.75","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","245.00","183.75","TRICARE [160005]","HB BWH TRICARE","232.75","95","","41.46","41.46","41.46","1 through 10","38.35","232.75","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","38.35","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($39.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($27.12). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","38.50","26.69","237.46","1 through 10","38.35","232.75","fee schedule",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA HMO","171.01","69.8","","185.64","113.76","316.44","69","128.04","376","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA PPO","196.98","80.4","","185.64","185.64","317.50","1 through 10","128.04","376","percent of total billed charges",""
"Ot Traction Mechanical","PX-43000010","CDM","97012","CPT","0431","RC","","","","both","","","113.00","84.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.28","38.3","","43.01","43.01","43.01","1 through 10","15.37","107.35","percent of total billed charges",""
"Ot Ultrasound 15 Min","PX-43000020","CDM","97035","CPT","0431","RC","","","","both","","","87.00","65.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.32","38.3","","32.84","32.84","32.84","1 through 10","15.19","82.65","percent of total billed charges",""
"Other Aftercare And Convalescence,MAJOR","862","DRG","","","","","","","","inpatient","","","44164.40","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24174.90","","Fee schedule rate ($24,174.90). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($2,797.15) multiplied by length of stay and the outlier percent (100%).","22036.30","22036.30","22036.30","1 through 10","6230.46","175953.05","case rate",""
"Other Aftercare And Convalescence,MAJOR","862","DRG","","","","","","","","inpatient","","","44164.40","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12932.5994","","Fee schedule rate ($106,636.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12932.5994","24230.16","24230.16","1 through 10","6230.46","175953.05","case rate",""
"Other Aftercare And Convalescence,MAJOR","862","DRG","","","","","","","","inpatient","","","44164.40","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24661.8542","","Fee schedule rate ($106,636.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24661.8542","24230.16","24230.16","1 through 10","6230.46","175953.05","case rate",""
"Other Aftercare And Convalescence,MAJOR","862","DRG","","","","","","","","inpatient","","","44164.40","","MASSHEALTH [3001]","HB BWH MEDICAID","6962.72","","Case rate ($7,698.48). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,128.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7696.60","7696.60","7696.60","1 through 10","6230.46","175953.05","case rate",""
"Other Aftercare And Convalescence,MODERATE","862","DRG","","","","","","","","inpatient","","","26137.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21636.13","","Fee schedule rate ($21,636.13). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($2,503.40) multiplied by length of stay and the outlier percent (100%).","4563.91","4563.91","4563.91","1 through 10","6230.46","175953.05","case rate",""
"Other Aftercare And Convalescence,MODERATE","862","DRG","","","","","","","","inpatient","","","26137.55","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21773.36","","Fee schedule rate ($21,773.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21773.36","21773.36","21773.36","1 through 10","6230.46","175953.05","case rate",""
"Other Aftercare And Convalescence,MODERATE","862","DRG","","","","","","","","inpatient","","","26137.55","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22862.39","","Fee schedule rate ($22,862.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22196.30","22196.30","22196.30","1 through 10","6230.46","175953.05","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,EXTREME","253","DRG","","","","","","","","inpatient","","","200984.12","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","36839.95","","Standard inlier is a Case rate ($36,839.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,130, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,229.13) for the length of stay and the standard reimbursement.","63459.10","63459.10","63459.10","1 through 10","5185.2","99576.08","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,EXTREME","253","DRG","","","","","","","","inpatient","","","200984.12","","MASSHEALTH [3001]","HB BWH MEDICAID","10227.60","","Case rate ($11,308.37). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,738.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20679.16","20679.16","23228.86","1 through 10","5185.2","99576.08","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MAJOR","253","DRG","","","","","","","","inpatient","","","62393.96","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","32767.90","","Standard inlier is a Case rate ($32,767.90). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,130, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,651.60) for the length of stay and the standard reimbursement.","29869.13","29869.13","29869.13","1 through 10","5185.2","99576.08","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MAJOR","253","DRG","","","","","","","","inpatient","","","62393.96","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","36839.95","","Standard inlier is a Case rate ($36,839.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,130, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,229.13) for the length of stay and the standard reimbursement.","39125.07","39125.07","39125.07","1 through 10","5185.2","99576.08","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MAJOR","253","DRG","","","","","","","","inpatient","","","62393.96","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13048.9078","","Fee schedule rate ($29,578.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13048.9078","29578.12","29578.12","1 through 10","5185.2","99576.08","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MAJOR","253","DRG","","","","","","","","inpatient","","","62393.96","","MASSHEALTH [3001]","HB BWH MEDICAID","10227.60","","Case rate ($11,308.37). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,738.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11305.60","11305.60","11305.60","1 through 10","5185.2","99576.08","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MINOR","253","DRG","","","","","","","","inpatient","","","18900.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","18007.47","","Standard inlier is a Case rate ($18,007.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,650, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,556.27) for the length of stay and the standard reimbursement.","16414.46","16414.46","16414.46","1 through 10","5185.2","99576.08","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MODERATE","253","DRG","","","","","","","","inpatient","","","31193.07","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","26161.02","","Standard inlier is a Case rate ($26,161.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,744, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,713.34) for the length of stay and the standard reimbursement.","26161.02","26161.02","26161.02","1 through 10","5185.2","99576.08","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MODERATE","253","DRG","","","","","","","","inpatient","","","31193.07","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13048.9078","","Fee schedule rate ($18,327.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13048.9078","18327.52","18327.52","1 through 10","5185.2","99576.08","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,EXTREME","663","DRG","","","","","","","","inpatient","","","146506.84","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","","65","","150264.70","150264.70","150264.70","1 through 10","4913.32","254946.65","percent of total billed charges",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,EXTREME","663","DRG","","","","","","","","inpatient","","","146506.84","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11787.6234","","Fee schedule rate ($162,241.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11787.6234","53191.08","53191.08","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,EXTREME","663","DRG","","","","","","","","inpatient","","","146506.84","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22781.42","","Fee schedule rate ($162,241.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22781.42","53191.08","53191.08","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,EXTREME","663","DRG","","","","","","","","inpatient","","","146506.84","","MASSHEALTH [3001]","HB BWH MEDICAID","19039.81","","Case rate ($21,051.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,481.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","39438.42","39438.42","39438.42","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","50051.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","29763.42","","Standard inlier is a Case rate ($29,763.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,792, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,225.10) for the length of stay and the standard reimbursement.","29763.42","29763.42","29763.42","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","50051.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","33462.11","","Standard inlier is a Case rate ($33,462.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,792, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,749.67) for the length of stay and the standard reimbursement.","33462.10","33462.10","35696.81","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","50051.06","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","51714.72","51714.72","51714.72","1 through 10","4913.32","254946.65","percent of total billed charges",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","50051.06","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11225.9973","","Fee schedule rate ($50,656.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11225.9973","24243.60","24243.60","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","50051.06","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($50,656.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","24243.60","24243.60","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","50051.06","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11787.6234","","Fee schedule rate ($53,191.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11787.6234","26668.28","26668.28","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","50051.06","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22781.42","","Fee schedule rate ($53,191.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22781.42","26668.28","26668.28","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","50051.06","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","55723.14","","Fee schedule rate ($55,723.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26668.28","26668.28","26668.28","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","50051.06","","MASSHEALTH [3001]","HB BWH MEDICAID","9152.64","","Case rate ($10,119.81). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,549.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10117.33","10117.33","10117.33","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","50051.06","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9152.64","","Case rate ($10,119.81). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,549.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10117.33","10117.33","10117.33","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","50051.06","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","9152.64","","Case rate ($10,119.81). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,549.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20401.26","20401.26","20401.26","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MINOR","663","DRG","","","","","","","","inpatient","","","17617.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","16940.12","","Standard inlier is a Case rate ($16,940.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,366, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,404.51) for the length of stay and the standard reimbursement.","15476.26","15476.26","15476.26","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MINOR","663","DRG","","","","","","","","inpatient","","","17617.85","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11787.6234","","Fee schedule rate ($11,787.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11787.6234","11787.64","11787.64","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MINOR","663","DRG","","","","","","","","inpatient","","","17617.85","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22781.42","","Fee schedule rate ($11,787.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22781.42","11787.64","11787.64","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MINOR","663","DRG","","","","","","","","inpatient","","","17617.85","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18203.08","","Fee schedule rate ($18,203.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17672.74","17672.74","17672.74","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","35813.45","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21312.72","","Standard inlier is a Case rate ($21,312.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,222, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,025.47) for the length of stay and the standard reimbursement.","21312.71","21312.71","21312.71","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","35813.45","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","23961.24","","Standard inlier is a Case rate ($23,961.24). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,222, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,401.10) for the length of stay and the standard reimbursement.","23961.24","23961.24","23961.24","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","35813.45","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","8814.78","8814.78","8814.78","1 through 10","4913.32","254946.65","percent of total billed charges",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","35813.45","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11225.9973","","Fee schedule rate ($15,433.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11225.9973","15433.24","15433.24","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","35813.45","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($15,433.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","15433.24","15433.24","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","35813.45","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11787.6234","","Fee schedule rate ($16,205.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11787.6234","16205.36","16205.36","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","35813.45","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22781.42","","Fee schedule rate ($16,205.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22781.42","16205.36","16205.36","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","35813.45","","MASSHEALTH [3001]","HB BWH MEDICAID","6465.79","","Case rate ($7,149.04). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,579.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7147.29","7147.29","7147.29","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","35813.45","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","6465.79","","Case rate ($7,149.04). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,579.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","4913.32","254946.65","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","35813.45","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21351.36","","Fee schedule rate ($21,351.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21351.36","21351.36","21351.36","1 through 10","4913.32","254946.65","case rate",""
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","TRIS-DRG","","","","","","","","inpatient","","","18007.18","","TRICARE [160005]","HB BWH TRICARE","10448.12","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($18,352.71). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $62,079.71 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($12,657.04), capped at $13,209.09. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $62,079.71 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","12383.26","12383.26","12383.26","1 through 10","10448.12","10448.12","other","Inpatient DRGs"
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","","","","inpatient","","","24331.24","18248.43","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","6962.35","","Case rate ($6,962.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,303.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,948.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,020.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,001.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,924.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.64. The transfer capital threshold is the transfer adjustment factor * $580.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6961.46","6961.46","6961.46","1 through 10","6823.1","11303.14","other","Inpatient DRG"
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","","","","inpatient","","","24331.24","18248.43","MEDICARE [2001]","HB BWH MEDICARE","6962.35","","Case rate ($6,962.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,303.89, add-ons for qualifying new technology services are included. If operating cost exceeds $53,948.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,020.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,001.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,924.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $580.64. The transfer capital threshold is the transfer adjustment factor * $580.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9102.68","9102.68","9102.68","1 through 10","6823.1","11303.14","other","Inpatient Replacement Plans DRG"
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","TRIS-DRG","","","","","","","","inpatient","","","24090.36","","TRICARE [160005]","HB BWH TRICARE","3416.99","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($6,002.14). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $49,729.14 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($4,287.24), capped at $4,319.95. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $49,729.14 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","6649.43","6649.43","6877.33","1 through 10","3416.99","3416.99","other","Inpatient DRGs"
"Other Antepartum Diagnoses Without O.R. Procedures With McC","831","MS-DRG","","","","","","","","inpatient","","","37127.62","27845.71","MEDICARE [2001]","HB BWH MEDICARE","11349.18","","Case rate ($11,349.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,584.76, add-ons for qualifying new technology services are included. If operating cost exceeds $59,229.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,407.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,001.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,204.91 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $967.60. The transfer capital threshold is the transfer adjustment factor * $967.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13847.60","13847.60","13847.60","1 through 10","11122.2","17369.741","other","Inpatient Replacement Plans DRG"
"Other Antepartum Diagnoses Without O.R. Procedures With McC","831","MS-DRG","","","","","","","","inpatient","","","37127.62","27845.71","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11122.20","","Case rate ($11,349.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,584.76, add-ons for qualifying new technology services are included. If operating cost exceeds $59,229.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,407.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,001.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,204.91 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $967.60. The transfer capital threshold is the transfer adjustment factor * $967.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10439.25","10439.25","10439.25","1 through 10","11122.2","17369.741","other","Inpatient DRG"
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC","833","MS-DRG","","","","","","","","inpatient","","","19549.04","14661.78","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","4112.85","4112.85","4112.85","1 through 10","5046.79","7844.3018","case rate",""
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC","833","MS-DRG","","","","","","","","inpatient","","","19549.04","14661.78","MEDICARE [2001]","HB BWH MEDICARE","5149.79","","Case rate ($5,149.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,121.92, add-ons for qualifying new technology services are included. If operating cost exceeds $51,766.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,860.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,349.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $5,742.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.76. The transfer capital threshold is the transfer adjustment factor * $420.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6406.28","6406.28","6406.28","1 through 10","5046.79","7844.3018","other","Inpatient Replacement Plans DRG"
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC","833","MS-DRG","","","","","","","","inpatient","","","19549.04","14661.78","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","5046.79","","Case rate ($5,149.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,121.92, add-ons for qualifying new technology services are included. If operating cost exceeds $51,766.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,860.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,349.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $5,742.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.76. The transfer capital threshold is the transfer adjustment factor * $420.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","3956.11","3956.11","3956.11","1 through 10","5046.79","7844.3018","other","Inpatient DRG"
"Other Back And Neck Disorders, Fractures And Injuries,EXTREME","347","DRG","","","","","","","","inpatient","","","85578.73","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11680.0474","","Fee schedule rate ($70,066.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11680.0474","70066.88","70066.88","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MAJOR","347","DRG","","","","","","","","inpatient","","","61978.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","32011.12","","Standard inlier is a Case rate ($32,011.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,541, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,544.17) for the length of stay and the standard reimbursement.","29179.30","29179.30","29179.30","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MAJOR","347","DRG","","","","","","","","inpatient","","","61978.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35989.13","","Standard inlier is a Case rate ($35,989.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,541, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,108.36) for the length of stay and the standard reimbursement.","35989.12","35989.12","35989.12","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MAJOR","347","DRG","","","","","","","","inpatient","","","61978.05","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12264.3892","","Fee schedule rate ($27,891.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12264.3892","27891.96","27891.96","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MAJOR","347","DRG","","","","","","","","inpatient","","","61978.05","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","32771.82","","Fee schedule rate ($32,771.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33204.11","33204.11","33204.11","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MAJOR","347","DRG","","","","","","","","inpatient","","","61978.05","","MASSHEALTH [3001]","HB BWH MEDICAID","9152.64","","Case rate ($10,119.81). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,549.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10117.33","10117.33","10281.49","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MAJOR","347","DRG","","","","","","","","inpatient","","","61978.05","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","9152.64","","Case rate ($10,119.81). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,549.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MAJOR","347","DRG","","","","","","","","inpatient","","","61978.05","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31411.10","","Fee schedule rate ($31,411.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26699.43","26699.43","26699.43","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MINOR","347","DRG","","","","","","","","inpatient","","","40497.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","18757.78","","Standard inlier is a Case rate ($18,757.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,234, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,662.78) for the length of stay and the standard reimbursement.","18757.78","18757.78","18757.78","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MINOR","347","DRG","","","","","","","","inpatient","","","40497.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21088.80","","Standard inlier is a Case rate ($21,088.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,234, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,993.38) for the length of stay and the standard reimbursement.","19266.44","19266.44","19266.44","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MINOR","347","DRG","","","","","","","","inpatient","","","40497.22","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25418.07","","Fee schedule rate ($25,418.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22101.50","22101.50","22101.50","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MINOR","347","DRG","","","","","","","","inpatient","","","40497.22","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5019.56","","Case rate ($5,549.98). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,979.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5548.62","5548.62","5548.62","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MODERATE","347","DRG","","","","","","","","inpatient","","","50702.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","23654.21","","Standard inlier is a Case rate ($23,654.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,043, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,357.86) for the length of stay and the standard reimbursement.","23654.20","23654.20","23654.20","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MODERATE","347","DRG","","","","","","","","inpatient","","","50702.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","26593.70","","Standard inlier is a Case rate ($26,593.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,043, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,774.76) for the length of stay and the standard reimbursement.","26593.70","26593.70","26593.70","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MODERATE","347","DRG","","","","","","","","inpatient","","","50702.46","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24207.31","","Fee schedule rate ($24,207.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24207.31","24207.31","24207.31","1 through 10","5019.56","115611.74","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MODERATE","347","DRG","","","","","","","","inpatient","","","50702.46","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6254.45","","Case rate ($6,915.37). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,345.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","6913.68","1 through 10","5019.56","115611.74","case rate",""
"Other Bladder Procedures,MAJOR","445","DRG","","","","","","","","inpatient","","","91694.11","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","53980.36","","Fee schedule rate ($53,980.36). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($6,245.77) multiplied by length of stay and the outlier percent (100%).","5693.30","5693.30","5693.30","1 through 10","8177.06","60688.48","case rate",""
"Other Bladder Procedures,MAJOR","445","DRG","","","","","","","","inpatient","","","91694.11","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","60688.48","","Fee schedule rate ($60,688.48). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($7,021.90) multiplied by length of stay and the outlier percent (100%).","60688.47","60688.47","60688.47","1 through 10","8177.06","60688.48","case rate",""
"Other Bladder Procedures,MODERATE","445","DRG","","","","","","","","inpatient","","","81083.74","","MASSHEALTH [3001]","HB BWH MEDICAID","11893.17","","Case rate ($13,149.95). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,579.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13146.72","13146.72","13146.72","1 through 10","8177.06","60688.48","case rate",""
"Other Bladder Procedures,MODERATE","445","DRG","","","","","","","","inpatient","","","81083.74","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11893.17","","Case rate ($13,149.95). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,579.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13146.72","13146.72","13146.72","1 through 10","8177.06","60688.48","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,EXTREME","167","DRG","","","","","","","","inpatient","","","365951.54","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","170006.93","","Standard inlier is a Case rate ($170,006.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $143,852, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($24,133.51) for the length of stay and the standard reimbursement.","347780.80","347780.80","347780.80","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,EXTREME","167","DRG","","","","","","","","inpatient","","","365951.54","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","191133.61","","Standard inlier is a Case rate ($191,133.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $143,852, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($27,129.83) for the length of stay and the standard reimbursement.","235937.48","235937.48","235937.48","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,EXTREME","167","DRG","","","","","","","","inpatient","","","365951.54","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","154099.68","","Fee schedule rate ($154,099.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","154099.68","154099.68","321375.20","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,EXTREME","167","DRG","","","","","","","","inpatient","","","365951.54","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","161809.15","","Fee schedule rate ($161,809.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","161809.16","161809.16","161809.16","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,EXTREME","167","DRG","","","","","","","","inpatient","","","365951.54","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","169511.72","","Fee schedule rate ($169,511.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","162980.36","162980.36","162980.36","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,EXTREME","167","DRG","","","","","","","","inpatient","","","365951.54","","MASSHEALTH [3001]","HB BWH MEDICAID","46842.72","","Case rate ($51,792.68). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $94,222.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","101665.77","101665.77","101665.77","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,EXTREME","167","DRG","","","","","","","","inpatient","","","365951.54","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","46842.72","","Case rate ($51,792.68). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $94,222.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","142519.32","142519.32","142519.32","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,MAJOR","167","DRG","","","","","","","","inpatient","","","231375.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","143073.35","","Standard inlier is a Case rate ($143,073.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $122,906, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,310.12) for the length of stay and the standard reimbursement.","143073.34","143073.34","143073.34","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,MAJOR","167","DRG","","","","","","","","inpatient","","","231375.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","160853.00","","Standard inlier is a Case rate ($160,853.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $122,906, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($22,831.75) for the length of stay and the standard reimbursement.","146953.11","146953.11","160853.00","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,MAJOR","167","DRG","","","","","","","","inpatient","","","231375.35","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","80286.35","","Fee schedule rate ($80,286.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","80286.36","80286.36","80286.36","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,MAJOR","167","DRG","","","","","","","","inpatient","","","231375.35","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","84303.00","","Fee schedule rate ($84,303.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","84303.00","84303.00","84303.00","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,MAJOR","167","DRG","","","","","","","","inpatient","","","231375.35","","MASSHEALTH [3001]","HB BWH MEDICAID","49470.16","","Case rate ($54,697.77). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $97,127.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","54684.34","54684.34","54684.34","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,MAJOR","167","DRG","","","","","","","","inpatient","","","231375.35","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","49470.16","","Case rate ($54,697.77). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $97,127.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","477356.00","477356.00","477356.00","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,MODERATE","167","DRG","","","","","","","","inpatient","","","102741.61","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","106545.71","","Standard inlier is a Case rate ($106,545.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $85,344, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($15,123.28) for the length of stay and the standard reimbursement.","97338.70","97338.70","97338.70","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic And Thoracic Circulatory Procedures,MODERATE","167","DRG","","","","","","","","inpatient","","","102741.61","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","52300.76","","Fee schedule rate ($52,300.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","60319.32","60319.32","60319.32","1 through 10","29645.54","345820.04","case rate",""
"Other Cardiothoracic Procedures With McC","228","MS-DRG","","","","","","","","inpatient","","","179117.48","134338.11","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","45510.55","","Case rate ($45,510.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,708.31, add-ons for qualifying new technology services are included. If operating cost exceeds $100,352.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,421.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $41,149.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,328.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,980.97. The transfer capital threshold is the transfer adjustment factor * $3,980.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","58141.44","58141.44","58149.82","1 through 10","44600.34","75202.9803","other","Inpatient Replacement Plans DRG"
"Other Cardiothoracic Procedures With McC","228","MS-DRG","","","","","","","","inpatient","","","179117.48","134338.11","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","45510.55","","Case rate ($45,510.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,708.31, add-ons for qualifying new technology services are included. If operating cost exceeds $100,352.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,421.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $41,149.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,328.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,980.97. The transfer capital threshold is the transfer adjustment factor * $3,980.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","44599.93","44599.93","44599.93","1 through 10","44600.34","75202.9803","other","Inpatient DRG"
"Other Cardiothoracic Procedures With McC","228","MS-DRG","","","","","","","","inpatient","","","179117.48","134338.11","MEDICARE [2001]","HB BWH MEDICARE","45510.55","","Case rate ($45,510.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,708.31, add-ons for qualifying new technology services are included. If operating cost exceeds $100,352.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,421.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $41,149.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,328.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,980.97. The transfer capital threshold is the transfer adjustment factor * $3,980.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","59027.19","0.03","59115.06","35","44600.34","75202.9803","other","Inpatient Replacement Plans DRG"
"Other Cardiothoracic Procedures With McC","228","MS-DRG","","","","","","","","inpatient","","","179117.48","134338.11","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","44600.34","","Case rate ($45,510.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,708.31, add-ons for qualifying new technology services are included. If operating cost exceeds $100,352.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,421.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $41,149.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,328.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,980.97. The transfer capital threshold is the transfer adjustment factor * $3,980.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","44747.00","44734.75","82010.51","1 through 10","44600.34","75202.9803","other","Inpatient DRG"
"Other Cardiothoracic Procedures With McC","228","MS-DRG","","","","","","","","inpatient","","","179117.48","134338.11","WELLPOINT [1015]","HB AMC WELLPOINT","75202.9803","","Fee schedule rate ($77,496.07).","75202.9803","75202.98","75202.98","1 through 10","44600.34","75202.9803","case rate",""
"Other Cardiothoracic Procedures Without McC","229","MS-DRG","","","","","","","","inpatient","","","99703.53","74777.65","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","29983.21","","Case rate ($29,109.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,965.17, add-ons for qualifying new technology services are included. If operating cost exceeds $80,609.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,974.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,195.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,585.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,534.27. The transfer capital threshold is the transfer adjustment factor * $2,534.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","29348.97","29298.91","29354.87","1 through 10","28527.71","49333.77","other","Inpatient DRG"
"Other Cardiothoracic Procedures Without McC","229","MS-DRG","","","","","","","","inpatient","","","99703.53","74777.65","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","37666.53","","Case rate ($37,666.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,965.17, add-ons for qualifying new technology services are included. If operating cost exceeds $80,609.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,974.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $34,752.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,585.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,534.27. The transfer capital threshold is the transfer adjustment factor * $2,534.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28507.19","28507.19","28507.19","1 through 10","28527.71","49333.77","other","Inpatient DRG"
"Other Cardiothoracic Procedures Without McC","229","MS-DRG","","","","","","","","inpatient","","","99703.53","74777.65","MEDICARE [2001]","HB BWH MEDICARE","37666.53","","Case rate ($37,666.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,965.17, add-ons for qualifying new technology services are included. If operating cost exceeds $80,609.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,974.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $34,752.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,585.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,534.27. The transfer capital threshold is the transfer adjustment factor * $2,534.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36898.92","0.03","36953.71","37","28527.71","49333.77","other","Inpatient DRG"
"Other Cardiothoracic Procedures Without McC","229","MS-DRG","","","","","","","","inpatient","","","99703.53","74777.65","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28527.71","","Case rate ($29,109.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,965.17, add-ons for qualifying new technology services are included. If operating cost exceeds $80,609.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,974.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,195.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,585.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,534.27. The transfer capital threshold is the transfer adjustment factor * $2,534.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","28031.16","28031.16","28031.16","1 through 10","28527.71","49333.77","other","Inpatient DRG"
"Other Cardiothoracic Procedures Without McC","229","MS-DRG","","","","","","","","inpatient","","","99703.53","74777.65","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28527.71","","Case rate ($29,109.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,965.17, add-ons for qualifying new technology services are included. If operating cost exceeds $80,609.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,974.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,195.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,585.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,534.27. The transfer capital threshold is the transfer adjustment factor * $2,534.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","27913.69","27908.71","28002.73","1 through 10","28527.71","49333.77","other","Inpatient DRG"
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","","","","inpatient","","","65577.25","49182.94","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10031.30","","Case rate ($9,739.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,646.57, add-ons for qualifying new technology services are included. If operating cost exceeds $57,291.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,265.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,533.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,266.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $825.58. The transfer capital threshold is the transfer adjustment factor * $825.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9647.33","9647.33","9647.33","1 through 10","9544.35","15904.4049","other","Inpatient DRG"
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","","","","inpatient","","","65577.25","49182.94","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9739.13","","Case rate ($9,739.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,646.57, add-ons for qualifying new technology services are included. If operating cost exceeds $57,291.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,265.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,533.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,266.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $825.58. The transfer capital threshold is the transfer adjustment factor * $825.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9928.99","9928.99","9928.99","1 through 10","9544.35","15904.4049","other","Inpatient Replacement Plans DRG"
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","","","","inpatient","","","65577.25","49182.94","MEDICARE [2001]","HB BWH MEDICARE","9739.13","","Case rate ($9,739.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,646.57, add-ons for qualifying new technology services are included. If operating cost exceeds $57,291.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,265.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,533.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,266.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $825.58. The transfer capital threshold is the transfer adjustment factor * $825.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12702.87","728.09","12721.46","1 through 10","9544.35","15904.4049","other","Inpatient Replacement Plans DRG"
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","","","","inpatient","","","65577.25","49182.94","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9544.35","","Case rate ($9,739.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,646.57, add-ons for qualifying new technology services are included. If operating cost exceeds $57,291.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,265.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,533.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,266.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $825.58. The transfer capital threshold is the transfer adjustment factor * $825.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9723.06","9723.06","9723.06","1 through 10","9544.35","15904.4049","other","Inpatient DRG"
"Other Cerebrovascular Disorders With McC","070","MS-DRG","","","","","","","","inpatient","","","67633.95","50725.46","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","16033.30","","Case rate ($15,566.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,661.36, add-ons for qualifying new technology services are included. If operating cost exceeds $64,305.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,779.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,846.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,281.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,339.60. The transfer capital threshold is the transfer adjustment factor * $1,339.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","16558.18","16558.18","16598.54","1 through 10","15254.98","26077.43","other","Inpatient DRG"
"Other Cerebrovascular Disorders With McC","070","MS-DRG","","","","","","","","inpatient","","","67633.95","50725.46","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","25881.77","25881.77","25881.77","1 through 10","15254.98","26077.43","case rate",""
"Other Cerebrovascular Disorders With McC","070","MS-DRG","","","","","","","","inpatient","","","67633.95","50725.46","MEDICARE [2001]","HB BWH MEDICARE","20089.27","","Case rate ($20,089.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,661.36, add-ons for qualifying new technology services are included. If operating cost exceeds $64,305.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,779.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $18,369.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,281.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,339.60. The transfer capital threshold is the transfer adjustment factor * $1,339.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20807.91","952.43","54641.82","1 through 10","15254.98","26077.43","other","Inpatient DRG"
"Other Cerebrovascular Disorders With McC","070","MS-DRG","","","","","","","","inpatient","","","67633.95","50725.46","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","15254.98","","Case rate ($15,566.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,661.36, add-ons for qualifying new technology services are included. If operating cost exceeds $64,305.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,779.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,846.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,281.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,339.60. The transfer capital threshold is the transfer adjustment factor * $1,339.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21417.70","21417.70","21417.70","1 through 10","15254.98","26077.43","other","Inpatient DRG"
"Other Chemotherapy,EXTREME","696","DRG","","","","","","","","inpatient","","","119858.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","76958.64","","Standard inlier is a Case rate ($76,958.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,493, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,924.74) for the length of stay and the standard reimbursement.","70150.60","70150.60","70150.60","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,EXTREME","696","DRG","","","","","","","","inpatient","","","119858.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","86522.26","","Standard inlier is a Case rate ($86,522.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,493, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,281.12) for the length of stay and the standard reimbursement.","86522.25","86522.25","211938.39","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,EXTREME","696","DRG","","","","","","","","inpatient","","","119858.72","","MASSHEALTH [3001]","HB BWH MEDICAID","28361.52","","Case rate ($31,358.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $73,788.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31350.84","31350.84","31350.84","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,EXTREME","696","DRG","","","","","","","","inpatient","","","119858.72","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","28361.52","","Case rate ($31,358.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $73,788.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,EXTREME","696","DRG","","","","","","","","inpatient","","","119858.72","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120246.84","","Fee schedule rate ($120,246.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","528423.03","528423.03","528423.03","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,EXTREME","696","DRG","","","","","","","","inpatient","","","119858.72","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","28361.52","","Case rate ($31,358.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $73,788.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31350.84","31350.84","31350.84","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,MAJOR","696","DRG","","","","","","","","inpatient","","","46428.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","38718.65","","Standard inlier is a Case rate ($38,718.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,756, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,496.35) for the length of stay and the standard reimbursement.","38718.64","35298.93","38718.64","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,MAJOR","696","DRG","","","","","","","","inpatient","","","46428.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","43530.19","","Standard inlier is a Case rate ($43,530.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,756, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,178.75) for the length of stay and the standard reimbursement.","43530.19","39768.58","43530.19","14","8305","120246.84","case rate",""
"Other Chemotherapy,MAJOR","696","DRG","","","","","","","","inpatient","","","46428.03","","MASSHEALTH [3001]","HB BWH MEDICAID","14055.67","","Case rate ($15,540.96). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,970.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15537.14","15537.14","16166.68","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,MAJOR","696","DRG","","","","","","","","inpatient","","","46428.03","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","49778.64","","Fee schedule rate ($49,778.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","494428.76","494428.76","494428.76","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,MAJOR","696","DRG","","","","","","","","inpatient","","","46428.03","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14055.67","","Case rate ($15,540.96). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,970.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15537.15","15537.15","15537.15","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,MINOR","696","DRG","","","","","","","","inpatient","","","24142.80","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20423.34","","Standard inlier is a Case rate ($20,423.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,531, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,899.22) for the length of stay and the standard reimbursement.","20423.34","20423.34","20423.34","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,MINOR","696","DRG","","","","","","","","inpatient","","","24142.80","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22961.34","","Standard inlier is a Case rate ($22,961.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,531, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,259.17) for the length of stay and the standard reimbursement.","20977.16","20977.16","20977.16","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,MINOR","696","DRG","","","","","","","","inpatient","","","24142.80","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8305.00","","Case rate ($9,182.61). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,612.61, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9180.35","9180.35","9180.35","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,MODERATE","696","DRG","","","","","","","","inpatient","","","25638.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","26008.63","","Standard inlier is a Case rate ($26,008.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,873, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,692.08) for the length of stay and the standard reimbursement.","26008.63","23707.81","35297.60","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,MODERATE","696","DRG","","","","","","","","inpatient","","","25638.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","29240.71","","Standard inlier is a Case rate ($29,240.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,873, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,150.48) for the length of stay and the standard reimbursement.","29240.71","26713.91","29240.71","33","8305","120246.84","case rate",""
"Other Chemotherapy,MODERATE","696","DRG","","","","","","","","inpatient","","","25638.31","","HEALTH NEW ENGLAND [1034]","HB BWH MEDICAID","9057.82","","Case rate ($10,014.98). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,444.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10012.52","10012.52","10012.52","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,MODERATE","696","DRG","","","","","","","","inpatient","","","25638.31","","MASSHEALTH [3001]","HB BWH MEDICAID","9057.82","","Case rate ($10,014.98). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,444.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10012.52","10012.52","30254.60","1 through 10","8305","120246.84","case rate",""
"Other Chemotherapy,MODERATE","696","DRG","","","","","","","","inpatient","","","25638.31","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9057.82","","Case rate ($10,014.98). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,444.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10012.52","10012.52","10012.52","1 through 10","8305","120246.84","case rate",""
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","49415.50","37061.62","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","9442.19","","Case rate ($9,167.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,958.05, add-ons for qualifying new technology services are included. If operating cost exceeds $56,602.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,215.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,012.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,578.21 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $775.13. The transfer capital threshold is the transfer adjustment factor * $775.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9282.90","9282.90","9282.90","1 through 10","8983.83","15089.13","other","Inpatient DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","49415.50","37061.62","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9167.17","","Case rate ($9,167.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,958.05, add-ons for qualifying new technology services are included. If operating cost exceeds $56,602.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,215.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,012.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,578.21 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $775.13. The transfer capital threshold is the transfer adjustment factor * $775.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8914.63","8914.63","8914.66","1 through 10","8983.83","15089.13","other","Inpatient Replacement Plans DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","49415.50","37061.62","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","11458.96","","Case rate ($9,167.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,958.05, add-ons for qualifying new technology services are included. If operating cost exceeds $56,602.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,215.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,012.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,578.21 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $775.13. The transfer capital threshold is the transfer adjustment factor * $775.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","8867.74","8867.74","8867.74","1 through 10","8983.83","15089.13","other","Inpatient DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","49415.50","37061.62","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9167.17","","Case rate ($9,167.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,958.05, add-ons for qualifying new technology services are included. If operating cost exceeds $56,602.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,215.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,012.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,578.21 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $775.13. The transfer capital threshold is the transfer adjustment factor * $775.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8940.21","8940.21","8940.21","1 through 10","8983.83","15089.13","other","Inpatient DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","49415.50","37061.62","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","8504.77","8504.77","8504.77","1 through 10","8983.83","15089.13","case rate",""
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","49415.50","37061.62","MEDICARE [2001]","HB BWH MEDICARE","9167.17","","Case rate ($9,167.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,958.05, add-ons for qualifying new technology services are included. If operating cost exceeds $56,602.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,215.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,012.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,578.21 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $775.13. The transfer capital threshold is the transfer adjustment factor * $775.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11622.98","0.03","11639.95","74","8983.83","15089.13","other","Inpatient Replacement Plans DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","49415.50","37061.62","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8983.83","","Case rate ($9,167.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,958.05, add-ons for qualifying new technology services are included. If operating cost exceeds $56,602.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,215.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,012.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,578.21 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $775.13. The transfer capital threshold is the transfer adjustment factor * $775.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8879.53","8879.37","8918.31","1 through 10","8983.83","15089.13","other","Inpatient DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","49415.50","37061.62","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8983.83","","Case rate ($9,167.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,958.05, add-ons for qualifying new technology services are included. If operating cost exceeds $56,602.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,215.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,012.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,578.21 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $775.13. The transfer capital threshold is the transfer adjustment factor * $775.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8905.53","8865.41","9012.79","1 through 10","8983.83","15089.13","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","89060.78","66795.58","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","25066.36","","Case rate ($25,066.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,277.87, add-ons for qualifying new technology services are included. If operating cost exceeds $68,922.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,118.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $23,008.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,898.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,677.87. The transfer capital threshold is the transfer adjustment factor * $1,677.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19915.56","19915.56","38283.92","1 through 10","19013.23","32662.57","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","89060.78","66795.58","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","19401.25","","Case rate ($19,401.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,277.87, add-ons for qualifying new technology services are included. If operating cost exceeds $68,922.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,118.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,343.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,898.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,677.87. The transfer capital threshold is the transfer adjustment factor * $1,677.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19566.35","19462.06","19595.16","1 through 10","19013.23","32662.57","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","89060.78","66795.58","ELDER SERVICES [1037]","HB BWH MEDICARE","25066.36","","Case rate ($25,066.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,277.87, add-ons for qualifying new technology services are included. If operating cost exceeds $68,922.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,118.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $23,008.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,898.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,677.87. The transfer capital threshold is the transfer adjustment factor * $1,677.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9809.60","9809.60","9809.60","1 through 10","19013.23","32662.57","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","89060.78","66795.58","MEDICARE [2001]","HB BWH MEDICARE","25066.36","","Case rate ($25,066.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,277.87, add-ons for qualifying new technology services are included. If operating cost exceeds $68,922.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,118.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $23,008.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,898.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,677.87. The transfer capital threshold is the transfer adjustment factor * $1,677.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25666.22","0.03","31437.69","98","19013.23","32662.57","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","89060.78","66795.58","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","25066.36","","Case rate ($25,066.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,277.87, add-ons for qualifying new technology services are included. If operating cost exceeds $68,922.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,118.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $23,008.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,898.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,677.87. The transfer capital threshold is the transfer adjustment factor * $1,677.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19447.09","19447.09","19447.09","1 through 10","19013.23","32662.57","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","89060.78","66795.58","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19013.23","","Case rate ($19,401.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,277.87, add-ons for qualifying new technology services are included. If operating cost exceeds $68,922.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,118.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,343.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,898.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,677.87. The transfer capital threshold is the transfer adjustment factor * $1,677.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19579.58","19579.58","19579.58","1 through 10","19013.23","32662.57","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","89060.78","66795.58","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19013.23","","Case rate ($19,401.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,277.87, add-ons for qualifying new technology services are included. If operating cost exceeds $68,922.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,118.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,343.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,898.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,677.87. The transfer capital threshold is the transfer adjustment factor * $1,677.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19495.14","19462.05","19762.17","12","19013.23","32662.57","other","Inpatient DRG"
"Other Circulatory System Diagnoses Without Cc/McC","316","MS-DRG","","","","","","","","inpatient","","","38458.54","28843.90","MEDICARE [2001]","HB BWH MEDICARE","6602.03","","Case rate ($6,602.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,870.12, add-ons for qualifying new technology services are included. If operating cost exceeds $53,514.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,989.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,673.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,490.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.86. The transfer capital threshold is the transfer adjustment factor * $548.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8326.73","0.03","8338.77","1 through 10","6469.99","10684.41","other","Inpatient Replacement Plans DRG"
"Other Circulatory System Diagnoses Without Cc/McC","316","MS-DRG","","","","","","","","inpatient","","","38458.54","28843.90","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6469.99","","Case rate ($6,602.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,870.12, add-ons for qualifying new technology services are included. If operating cost exceeds $53,514.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,989.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,673.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,490.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $548.86. The transfer capital threshold is the transfer adjustment factor * $548.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8855.96","8855.96","8855.96","1 through 10","6469.99","10684.41","other","Inpatient DRG"
"Other Circulatory System Diagnoses,EXTREME","207","DRG","","","","","","","","inpatient","","","78970.77","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","49277.98","","Standard inlier is a Case rate ($49,277.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,969, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,995.31) for the length of stay and the standard reimbursement.","44918.67","44918.67","44918.67","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,EXTREME","207","DRG","","","","","","","","inpatient","","","78970.77","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","55401.73","","Standard inlier is a Case rate ($55,401.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,969, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,863.82) for the length of stay and the standard reimbursement.","55401.73","55401.73","55401.73","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,EXTREME","207","DRG","","","","","","","","inpatient","","","78970.77","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11208.1037","","Fee schedule rate ($62,739.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11208.1037","62739.44","62739.44","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,EXTREME","207","DRG","","","","","","","","inpatient","","","78970.77","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11768.8346","","Fee schedule rate ($65,878.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11768.8346","65878.24","65878.24","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,EXTREME","207","DRG","","","","","","","","inpatient","","","78970.77","","MASSHEALTH [3001]","HB BWH MEDICAID","17558.17","","Case rate ($19,413.57). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,843.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19408.80","19408.80","19408.80","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,EXTREME","207","DRG","","","","","","","","inpatient","","","78970.77","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","59550.52","","Fee schedule rate ($59,550.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","57815.55","57815.55","57815.55","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,EXTREME","207","DRG","","","","","","","","inpatient","","","78970.77","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","17558.17","","Case rate ($19,413.57). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,843.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19408.81","19408.81","19408.81","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","57580.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","29081.03","","Standard inlier is a Case rate ($29,081.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,261, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,128.23) for the length of stay and the standard reimbursement.","26508.41","26508.41","44922.38","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","57580.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32694.91","","Standard inlier is a Case rate ($32,694.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,261, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,640.77) for the length of stay and the standard reimbursement.","32694.91","29869.62","32694.91","11","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","57580.65","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11208.1037","","Fee schedule rate ($62,739.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11208.1037","26330.44","26330.44","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","57580.65","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11768.8346","","Fee schedule rate ($65,878.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11768.8346","27647.72","27647.72","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","57580.65","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","69014.22","","Fee schedule rate ($69,014.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","53615.50","53615.50","53615.50","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","57580.65","","MASSHEALTH [3001]","HB BWH MEDICAID","9526.19","","Case rate ($10,532.84). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,962.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11907.73","11907.73","11907.73","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","57580.65","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29458.83","","Fee schedule rate ($29,458.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29458.83","29458.83","29458.83","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","57580.65","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30932.25","","Fee schedule rate ($30,932.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30932.25","30932.25","30932.25","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","57580.65","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9526.19","","Case rate ($10,532.84). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,962.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10530.26","10530.26","10530.26","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MINOR","207","DRG","","","","","","","","inpatient","","","39092.81","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","16687.96","","Standard inlier is a Case rate ($16,687.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,624, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,368.96) for the length of stay and the standard reimbursement.","16687.95","16687.95","16687.95","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MINOR","207","DRG","","","","","","","","inpatient","","","39092.81","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18761.76","","Standard inlier is a Case rate ($18,761.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,624, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,663.08) for the length of stay and the standard reimbursement.","17140.48","17140.48","17140.48","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MINOR","207","DRG","","","","","","","","inpatient","","","39092.81","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4606.02","","Case rate ($5,092.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,522.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5091.50","5091.50","5091.50","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MODERATE","207","DRG","","","","","","","","inpatient","","","45715.76","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20908.46","","Standard inlier is a Case rate ($20,908.46). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,906, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,968.08) for the length of stay and the standard reimbursement.","19058.82","19058.82","19058.82","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MODERATE","207","DRG","","","","","","","","inpatient","","","45715.76","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","23506.74","","Standard inlier is a Case rate ($23,506.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,906, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,336.59) for the length of stay and the standard reimbursement.","23506.74","21475.43","23506.74","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MODERATE","207","DRG","","","","","","","","inpatient","","","45715.76","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11208.1037","","Fee schedule rate ($16,437.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11208.1037","16437.52","16437.52","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MODERATE","207","DRG","","","","","","","","inpatient","","","45715.76","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","18081.48","","Fee schedule rate ($18,081.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18081.48","18081.48","18081.48","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MODERATE","207","DRG","","","","","","","","inpatient","","","45715.76","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22532.10","","Fee schedule rate ($22,532.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21875.58","21875.58","21875.58","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System Diagnoses,MODERATE","207","DRG","","","","","","","","inpatient","","","45715.76","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6675.99","","Case rate ($7,381.45). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,811.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7379.64","7379.64","7379.64","1 through 10","4606.02","103521.33","case rate",""
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","","","","inpatient","","","119686.89","89765.17","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","31778.73","","Case rate ($30,853.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $37,063.69, add-ons for qualifying new technology services are included. If operating cost exceeds $82,708.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,128.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $27,785.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,683.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,688.04. The transfer capital threshold is the transfer adjustment factor * $2,688.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","33030.76","33030.76","33030.76","1 through 10","30236.08","52327.16","other","Inpatient DRG"
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","","","","inpatient","","","119686.89","89765.17","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","38566.43","","Case rate ($30,853.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $37,063.69, add-ons for qualifying new technology services are included. If operating cost exceeds $82,708.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,128.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $27,785.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,683.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,688.04. The transfer capital threshold is the transfer adjustment factor * $2,688.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","31436.37","31436.37","31436.37","1 through 10","30236.08","52327.16","other","Inpatient DRG"
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","","","","inpatient","","","119686.89","89765.17","ELDER SERVICES [1037]","HB BWH MEDICARE","30853.14","","Case rate ($30,853.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $37,063.69, add-ons for qualifying new technology services are included. If operating cost exceeds $82,708.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,128.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $27,785.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,683.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,688.04. The transfer capital threshold is the transfer adjustment factor * $2,688.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","113757.45","113757.45","113757.45","1 through 10","30236.08","52327.16","other","Inpatient Replacement Plans DRG"
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","","","","inpatient","","","119686.89","89765.17","MEDICARE [2001]","HB BWH MEDICARE","30853.14","","Case rate ($30,853.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $37,063.69, add-ons for qualifying new technology services are included. If operating cost exceeds $82,708.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,128.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $27,785.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,683.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,688.04. The transfer capital threshold is the transfer adjustment factor * $2,688.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","41482.56","18220.69","42606.27","14","30236.08","52327.16","other","Inpatient Replacement Plans DRG"
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","","","","inpatient","","","119686.89","89765.17","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","30236.08","","Case rate ($30,853.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $37,063.69, add-ons for qualifying new technology services are included. If operating cost exceeds $82,708.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,128.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $27,785.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,683.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,688.04. The transfer capital threshold is the transfer adjustment factor * $2,688.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","65252.43","65252.43","65252.43","1 through 10","30236.08","52327.16","other","Inpatient DRG"
"Other Complications Of Treatment,EXTREME","813","DRG","","","","","","","","inpatient","","","66414.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","55568.31","","Standard inlier is a Case rate ($55,568.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,860, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,888.26) for the length of stay and the standard reimbursement.","50652.53","50652.53","50652.53","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,EXTREME","813","DRG","","","","","","","","inpatient","","","66414.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","62473.75","","Standard inlier is a Case rate ($62,473.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,860, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,867.63) for the length of stay and the standard reimbursement.","62473.75","57075.16","110285.19","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,EXTREME","813","DRG","","","","","","","","inpatient","","","66414.74","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11407.1502","","Fee schedule rate ($71,503.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11407.1502","74906.88","74906.88","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,EXTREME","813","DRG","","","","","","","","inpatient","","","66414.74","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","19627.2502","","Fee schedule rate ($71,503.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19627.2502","74906.88","74906.88","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,EXTREME","813","DRG","","","","","","","","inpatient","","","66414.74","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","20936.14","","Case rate ($23,148.50). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,578.50, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23142.82","23142.82","23142.82","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","58001.52","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31002.08","","Standard inlier is a Case rate ($31,002.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,757, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,400.93) for the length of stay and the standard reimbursement.","28259.52","28259.52","31002.08","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","58001.52","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","34854.70","","Standard inlier is a Case rate ($34,854.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,757, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,947.33) for the length of stay and the standard reimbursement.","34854.69","34854.69","46353.89","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","58001.52","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10863.6519","","Fee schedule rate ($106,636.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10863.6519","26475.80","26475.80","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","58001.52","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18692.1019","","Fee schedule rate ($106,636.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18692.1019","26475.80","26475.80","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","58001.52","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","131561.92","","Fee schedule rate ($131,561.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33095.07","33095.07","33095.07","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","58001.52","","MASSHEALTH [3001]","HB BWH MEDICAID","11496.77","","Case rate ($12,711.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,141.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1431.27","1431.27","12708.54","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","58001.52","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","11496.77","","Case rate ($12,711.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,141.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","58001.52","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33501.36","","Fee schedule rate ($33,501.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34020.56","34020.56","34020.56","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","58001.52","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11496.77","","Case rate ($12,711.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,141.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12708.54","12708.54","12708.54","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MINOR","813","DRG","","","","","","","","inpatient","","","23566.62","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","17354.18","","Standard inlier is a Case rate ($17,354.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,143, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,463.53) for the length of stay and the standard reimbursement.","17354.18","17354.18","17354.18","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MINOR","813","DRG","","","","","","","","inpatient","","","23566.62","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","19510.78","","Standard inlier is a Case rate ($19,510.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,143, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,769.39) for the length of stay and the standard reimbursement.","17826.72","17824.77","19510.77","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MINOR","813","DRG","","","","","","","","inpatient","","","23566.62","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10863.6519","","Fee schedule rate ($15,437.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10863.6519","10863.64","10863.64","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MINOR","813","DRG","","","","","","","","inpatient","","","23566.62","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18692.1019","","Fee schedule rate ($15,437.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18692.1019","10863.64","10863.64","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MINOR","813","DRG","","","","","","","","inpatient","","","23566.62","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11407.1502","","Fee schedule rate ($16,210.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11407.1502","11407.16","11407.16","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MINOR","813","DRG","","","","","","","","inpatient","","","23566.62","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","19627.2502","","Fee schedule rate ($16,210.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19627.2502","11407.16","11407.16","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MINOR","813","DRG","","","","","","","","inpatient","","","23566.62","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","16981.68","","Fee schedule rate ($16,981.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11489.72","11489.72","11489.72","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MODERATE","813","DRG","","","","","","","","inpatient","","","38126.82","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21377.40","","Standard inlier is a Case rate ($21,377.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,271, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,034.65) for the length of stay and the standard reimbursement.","21377.40","21377.40","21377.40","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MODERATE","813","DRG","","","","","","","","inpatient","","","38126.82","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24033.96","","Standard inlier is a Case rate ($24,033.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,271, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,411.42) for the length of stay and the standard reimbursement.","24033.96","24033.96","24033.96","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MODERATE","813","DRG","","","","","","","","inpatient","","","38126.82","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10863.6519","","Fee schedule rate ($24,230.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10863.6519","15437.72","15437.72","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MODERATE","813","DRG","","","","","","","","inpatient","","","38126.82","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18692.1019","","Fee schedule rate ($24,230.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18692.1019","15437.72","15437.72","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MODERATE","813","DRG","","","","","","","","inpatient","","","38126.82","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11407.1502","","Fee schedule rate ($25,442.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11407.1502","15584.72","15584.72","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MODERATE","813","DRG","","","","","","","","inpatient","","","38126.82","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","19627.2502","","Fee schedule rate ($25,442.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19627.2502","15584.72","15584.72","1 through 10","5235.46","175953.05","case rate",""
"Other Complications Of Treatment,MODERATE","813","DRG","","","","","","","","inpatient","","","38126.82","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7353.41","","Case rate ($8,130.46). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,560.46, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8128.46","8128.46","8128.46","1 through 10","5235.46","175953.05","case rate",""
"Other Digestive System And Abdominal Procedures,EXTREME","229","DRG","","","","","","","","inpatient","","","302365.14","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","127866.61","","Standard inlier is a Case rate ($127,866.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $111,081, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,151.44) for the length of stay and the standard reimbursement.","131334.00","131334.00","131334.00","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,EXTREME","229","DRG","","","","","","","","inpatient","","","302365.14","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","143756.53","","Standard inlier is a Case rate ($143,756.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $111,081, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,405.05) for the length of stay and the standard reimbursement.","143756.53","143756.53","143756.53","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,EXTREME","229","DRG","","","","","","","","inpatient","","","302365.14","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","25592.6942","","Fee schedule rate ($140,436.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25592.6942","135019.36","135019.36","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,EXTREME","229","DRG","","","","","","","","inpatient","","","302365.14","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","147122.08","","Fee schedule rate ($147,122.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","147122.08","147122.08","147122.08","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,EXTREME","229","DRG","","","","","","","","inpatient","","","302365.14","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","128461.98","","Fee schedule rate ($128,461.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","128461.98","128461.98","128461.98","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MAJOR","229","DRG","","","","","","","","inpatient","","","176994.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","74099.70","","Standard inlier is a Case rate ($74,099.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $69,271, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,518.90) for the length of stay and the standard reimbursement.","74099.69","74099.69","91739.93","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MAJOR","229","DRG","","","","","","","","inpatient","","","176994.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","83308.03","","Standard inlier is a Case rate ($83,308.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $69,271, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,824.88) for the length of stay and the standard reimbursement.","90406.54","90406.54","90406.54","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MAJOR","229","DRG","","","","","","","","inpatient","","","176994.44","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","25592.6942","","Fee schedule rate ($68,882.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25592.6942","68882.08","68882.08","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MAJOR","229","DRG","","","","","","","","inpatient","","","176994.44","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","80933.38","","Fee schedule rate ($80,933.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","82000.95","82000.95","82000.95","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MAJOR","229","DRG","","","","","","","","inpatient","","","176994.44","","MASSHEALTH [3001]","HB BWH MEDICAID","25665.54","","Case rate ($28,377.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,807.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","28370.70","28370.70","35621.91","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MAJOR","229","DRG","","","","","","","","inpatient","","","176994.44","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","25665.54","","Case rate ($28,377.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,807.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13569.67","13569.67","13569.67","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MAJOR","229","DRG","","","","","","","","inpatient","","","176994.44","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","69128.73","","Fee schedule rate ($69,128.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","69128.73","69128.73","69128.73","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MAJOR","229","DRG","","","","","","","","inpatient","","","176994.44","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","25665.54","","Case rate ($28,377.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,807.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","28370.70","28370.70","28370.70","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MINOR","229","DRG","","","","","","","","inpatient","","","80420.45","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","35594.50","","Standard inlier is a Case rate ($35,594.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,328, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,052.85) for the length of stay and the standard reimbursement.","32445.68","32445.68","32445.68","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MINOR","229","DRG","","","","","","","","inpatient","","","80420.45","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24373.3199","","Fee schedule rate ($24,373.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24373.3199","36601.36","36601.36","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MINOR","229","DRG","","","","","","","","inpatient","","","80420.45","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","25592.6942","","Fee schedule rate ($25,592.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25592.6942","25592.68","25592.68","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MINOR","229","DRG","","","","","","","","inpatient","","","80420.45","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37493.78","","Fee schedule rate ($37,493.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","36401.42","36401.42","36401.42","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MODERATE","229","DRG","","","","","","","","inpatient","","","85712.81","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","49074.23","","Standard inlier is a Case rate ($49,074.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,809, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,966.38) for the length of stay and the standard reimbursement.","44732.95","44732.95","44732.95","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MODERATE","229","DRG","","","","","","","","inpatient","","","85712.81","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","55172.66","","Standard inlier is a Case rate ($55,172.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,809, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,831.30) for the length of stay and the standard reimbursement.","55172.66","55172.66","55172.66","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MODERATE","229","DRG","","","","","","","","inpatient","","","85712.81","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24373.3199","","Fee schedule rate ($65,600.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24373.3199","36601.36","36601.36","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MODERATE","229","DRG","","","","","","","","inpatient","","","85712.81","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65835.86","","Fee schedule rate ($65,835.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","45678.02","45678.02","45678.02","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System And Abdominal Procedures,MODERATE","229","DRG","","","","","","","","inpatient","","","85712.81","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15139.78","","Case rate ($16,739.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,169.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16735.52","16735.52","16735.52","1 through 10","10490.35","220683.12","case rate",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","38587.18","28940.38","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","9182.87","","Case rate ($8,915.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,654.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,299.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,193.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,782.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,275.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.92. The transfer capital threshold is the transfer adjustment factor * $752.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9119.28","9113.88","9127.54","1 through 10","8737.1","14656.8","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","38587.18","28940.38","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8915.41","","Case rate ($8,915.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,654.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,299.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,193.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,782.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,275.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.92. The transfer capital threshold is the transfer adjustment factor * $752.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11218.54","11218.54","11218.54","1 through 10","8737.1","14656.8","other","Inpatient Replacement Plans DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","38587.18","28940.38","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8915.41","","Case rate ($8,915.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,654.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,299.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,193.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,782.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,275.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.92. The transfer capital threshold is the transfer adjustment factor * $752.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8750.35","8750.35","8750.35","1 through 10","8737.1","14656.8","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","38587.18","28940.38","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","13723.81","13019.18","14107.47","1 through 10","8737.1","14656.8","case rate",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","38587.18","28940.38","HUMANA [1012]","HB BWH MEDICARE","8915.41","","Case rate ($8,915.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,654.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,299.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,193.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,782.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,275.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.92. The transfer capital threshold is the transfer adjustment factor * $752.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8675.11","8675.11","8680.20","1 through 10","8737.1","14656.8","other","Inpatient Replacement Plans DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","38587.18","28940.38","MEDICARE [2001]","HB BWH MEDICARE","8915.41","","Case rate ($8,915.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,654.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,299.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,193.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,782.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,275.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.92. The transfer capital threshold is the transfer adjustment factor * $752.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11375.40","0.03","11392.01","102","8737.1","14656.8","other","Inpatient Replacement Plans DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","38587.18","28940.38","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","8915.41","","Case rate ($8,915.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,654.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,299.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,193.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,782.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,275.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.92. The transfer capital threshold is the transfer adjustment factor * $752.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8666.28","8666.28","8666.28","1 through 10","8737.1","14656.8","other","Inpatient Replacement Plans DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","38587.18","28940.38","MOLINA [1014]","HB BWH MOLINA","8737.10","","Case rate ($8,915.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,654.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,299.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,193.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,782.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,275.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.92. The transfer capital threshold is the transfer adjustment factor * $752.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6939.45","6939.45","6939.45","1 through 10","8737.1","14656.8","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","38587.18","28940.38","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8737.10","","Case rate ($8,915.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,654.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,299.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,193.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,782.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,275.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.92. The transfer capital threshold is the transfer adjustment factor * $752.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8645.81","8645.81","8700.57","1 through 10","8737.1","14656.8","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","38587.18","28940.38","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8737.10","","Case rate ($8,915.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,654.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,299.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,193.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,782.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,275.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.92. The transfer capital threshold is the transfer adjustment factor * $752.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8727.43","8710.58","11724.86","1 through 10","8737.1","14656.8","other","Inpatient DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","69975.96","52481.97","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15417.88","","Case rate ($14,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,942.10, add-ons for qualifying new technology services are included. If operating cost exceeds $63,586.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,727.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,302.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,562.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.89. The transfer capital threshold is the transfer adjustment factor * $1,286.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15774.64","15774.61","15862.41","1 through 10","14669.44","24441.3836","other","Inpatient DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","69975.96","52481.97","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14968.82","","Case rate ($14,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,942.10, add-ons for qualifying new technology services are included. If operating cost exceeds $63,586.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,727.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,302.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,562.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.89. The transfer capital threshold is the transfer adjustment factor * $1,286.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15173.44","15143.63","19593.29","1 through 10","14669.44","24441.3836","other","Inpatient Replacement Plans DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","69975.96","52481.97","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","","65.6","","15849.65","15849.65","15849.65","1 through 10","14669.44","24441.3836","percent of total billed charges",""
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","69975.96","52481.97","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","14968.82","","Case rate ($14,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,942.10, add-ons for qualifying new technology services are included. If operating cost exceeds $63,586.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,727.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,302.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,562.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.89. The transfer capital threshold is the transfer adjustment factor * $1,286.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15134.90","15134.90","15134.90","1 through 10","14669.44","24441.3836","other","Inpatient DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","69975.96","52481.97","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","17209.60","17209.60","17209.60","1 through 10","14669.44","24441.3836","case rate",""
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","69975.96","52481.97","FALLON HEALTH [1008]","HB BWH MEDICARE","14968.82","","Case rate ($14,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,942.10, add-ons for qualifying new technology services are included. If operating cost exceeds $63,586.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,727.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,302.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,562.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.89. The transfer capital threshold is the transfer adjustment factor * $1,286.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15309.31","15309.31","15309.31","1 through 10","14669.44","24441.3836","other","Inpatient Replacement Plans DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","69975.96","52481.97","MEDICARE [2001]","HB BWH MEDICARE","14968.82","","Case rate ($14,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,942.10, add-ons for qualifying new technology services are included. If operating cost exceeds $63,586.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,727.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,302.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,562.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.89. The transfer capital threshold is the transfer adjustment factor * $1,286.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19801.11","0.03","19830.31","98","14669.44","24441.3836","other","Inpatient Replacement Plans DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","69975.96","52481.97","MOLINA [1014]","HB BWH MOLINA","14669.44","","Case rate ($14,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,942.10, add-ons for qualifying new technology services are included. If operating cost exceeds $63,586.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,727.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,302.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,562.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.89. The transfer capital threshold is the transfer adjustment factor * $1,286.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","30510.95","30510.95","30510.95","1 through 10","14669.44","24441.3836","other","Inpatient DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","69975.96","52481.97","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14669.44","","Case rate ($14,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,942.10, add-ons for qualifying new technology services are included. If operating cost exceeds $63,586.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,727.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,302.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,562.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.89. The transfer capital threshold is the transfer adjustment factor * $1,286.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15074.13","15074.13","15085.03","1 through 10","14669.44","24441.3836","other","Inpatient DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","69975.96","52481.97","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14669.44","","Case rate ($14,968.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,942.10, add-ons for qualifying new technology services are included. If operating cost exceeds $63,586.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,727.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,302.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,562.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,286.89. The transfer capital threshold is the transfer adjustment factor * $1,286.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","23149.02","15057.82","24636.98","1 through 10","14669.44","24441.3836","other","Inpatient DRG"
"Other Digestive System Diagnoses Without Cc/McC","395","MS-DRG","","","","","","","","inpatient","","","29015.97","21761.98","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","6489.10","","Case rate ($6,300.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,506.66, add-ons for qualifying new technology services are included. If operating cost exceeds $53,151.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,962.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,398.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,126.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $522.22. The transfer capital threshold is the transfer adjustment factor * $522.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6258.29","6258.29","6258.29","1 through 10","6174.1","9603.9124","other","Inpatient DRG"
"Other Digestive System Diagnoses Without Cc/McC","395","MS-DRG","","","","","","","","inpatient","","","29015.97","21761.98","MEDICARE [2001]","HB BWH MEDICARE","6300.10","","Case rate ($6,300.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,506.66, add-ons for qualifying new technology services are included. If operating cost exceeds $53,151.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,962.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,398.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,126.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $522.22. The transfer capital threshold is the transfer adjustment factor * $522.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7780.91","478.20","7792.12","1 through 10","6174.1","9603.9124","other","Inpatient Replacement Plans DRG"
"Other Digestive System Diagnoses Without Cc/McC","395","MS-DRG","","","","","","","","inpatient","","","29015.97","21761.98","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6174.10","","Case rate ($6,300.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,506.66, add-ons for qualifying new technology services are included. If operating cost exceeds $53,151.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,962.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,398.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,126.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $522.22. The transfer capital threshold is the transfer adjustment factor * $522.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5933.62","5933.62","5933.62","1 through 10","6174.1","9603.9124","other","Inpatient DRG"
"Other Digestive System Diagnoses Without Cc/McC","395","MS-DRG","","","","","","","","inpatient","","","29015.97","21761.98","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6174.10","","Case rate ($6,300.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,506.66, add-ons for qualifying new technology services are included. If operating cost exceeds $53,151.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,962.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,398.02 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,126.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $522.22. The transfer capital threshold is the transfer adjustment factor * $522.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5983.66","5983.66","5983.66","1 through 10","6174.1","9603.9124","other","Inpatient DRG"
"Other Digestive System Diagnoses,EXTREME","254","DRG","","","","","","","","inpatient","","","84069.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","54413.73","","Standard inlier is a Case rate ($54,413.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $53,963, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,724.36) for the length of stay and the standard reimbursement.","49600.10","49600.10","49600.10","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,EXTREME","254","DRG","","","","","","","","inpatient","","","84069.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","61175.70","","Standard inlier is a Case rate ($61,175.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $53,963, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,683.38) for the length of stay and the standard reimbursement.","61175.70","55889.28","160289.44","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,EXTREME","254","DRG","","","","","","","","inpatient","","","84069.22","","MASSHEALTH [3001]","HB BWH MEDICAID","21593.00","","Case rate ($23,874.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,304.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","37500.98","37500.98","37500.98","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,EXTREME","254","DRG","","","","","","","","inpatient","","","84069.22","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","21593.00","","Case rate ($23,874.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,304.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23868.92","23868.92","23868.92","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","60664.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","30966.51","","Standard inlier is a Case rate ($30,966.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,730, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,395.88) for the length of stay and the standard reimbursement.","30966.50","28227.10","35866.46","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","60664.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","34814.70","","Standard inlier is a Case rate ($34,814.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,730, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,941.66) for the length of stay and the standard reimbursement.","34814.70","31806.23","34814.70","17","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","60664.35","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","11777.79","","Case rate ($13,022.38). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,452.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15377.62","15377.62","15377.62","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","60664.35","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28245.0476","","Fee schedule rate ($26,292.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28245.0476","26292.40","26292.40","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","60664.35","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","29658.1208","","Fee schedule rate ($27,607.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29658.1208","27607.80","27607.80","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","60664.35","","MASSHEALTH [3001]","HB BWH MEDICAID","11777.79","","Case rate ($13,022.38). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,452.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13019.18","1266.66","13019.18","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","60664.35","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30622.52","","Fee schedule rate ($30,622.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30622.52","30622.52","30622.52","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","60664.35","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32154.15","","Fee schedule rate ($32,154.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32154.15","32154.15","32154.15","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","60664.35","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11777.79","","Case rate ($13,022.38). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,452.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1984.87","473.43","109136.46","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MINOR","254","DRG","","","","","","","","inpatient","","","27269.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","15426.66","","Standard inlier is a Case rate ($15,426.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,644, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,189.91) for the length of stay and the standard reimbursement.","14061.96","14061.96","15426.65","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MINOR","254","DRG","","","","","","","","inpatient","","","27269.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","17343.72","","Standard inlier is a Case rate ($17,343.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,644, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,461.80) for the length of stay and the standard reimbursement.","17343.72","15844.98","17343.72","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MINOR","254","DRG","","","","","","","","inpatient","","","27269.53","","MASSHEALTH [3001]","HB BWH MEDICAID","5274.30","","Case rate ($5,831.65). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,261.65, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6066.45","6066.45","6066.45","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MINOR","254","DRG","","","","","","","","inpatient","","","27269.53","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22817.63","","Fee schedule rate ($22,817.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17621.22","17621.22","17621.22","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","40963.48","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21535.87","","Standard inlier is a Case rate ($21,535.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,395, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,057.15) for the length of stay and the standard reimbursement.","19632.01","19630.73","21535.87","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","40963.48","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24212.12","","Standard inlier is a Case rate ($24,212.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,395, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,436.71) for the length of stay and the standard reimbursement.","24212.12","22119.86","24212.12","12","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","40963.48","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28245.0476","","Fee schedule rate ($16,187.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28245.0476","16187.00","16187.00","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","40963.48","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","29658.1208","","Fee schedule rate ($16,996.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29658.1208","16996.80","16996.80","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","40963.48","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","17805.91","","Fee schedule rate ($17,805.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17119.85","17119.85","17119.85","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","40963.48","","MASSHEALTH [3001]","HB BWH MEDICAID","7034.69","","Case rate ($7,778.06). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,208.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7776.15","7776.15","7776.15","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","40963.48","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","7034.69","","Case rate ($7,778.06). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,208.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","40963.48","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21730.73","","Fee schedule rate ($21,730.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21097.56","21097.56","21097.56","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","40963.48","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22817.63","","Fee schedule rate ($22,817.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22152.85","22152.85","22152.85","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","40963.48","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7034.69","","Case rate ($7,778.06). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,208.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7776.15","7776.15","7776.15","1 through 10","5274.3","106156.42","case rate",""
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","","","","inpatient","","","105948.97","79461.73","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","22241.09","","Case rate ($21,593.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,916.65, add-ons for qualifying new technology services are included. If operating cost exceeds $71,561.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,311.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $19,342.22 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,536.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,871.23. The transfer capital threshold is the transfer adjustment factor * $1,871.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","40135.43","40135.43","40135.43","1 through 10","21161.42","35094.1205","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","","","","inpatient","","","105948.97","79461.73","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","21593.29","","Case rate ($21,593.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,916.65, add-ons for qualifying new technology services are included. If operating cost exceeds $71,561.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,311.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $19,342.22 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,536.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,871.23. The transfer capital threshold is the transfer adjustment factor * $1,871.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20304.62","20304.62","20304.62","1 through 10","21161.42","35094.1205","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","","","","inpatient","","","105948.97","79461.73","MEDICARE [2001]","HB BWH MEDICARE","21593.29","","Case rate ($21,593.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,916.65, add-ons for qualifying new technology services are included. If operating cost exceeds $71,561.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,311.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $19,342.22 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,536.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,871.23. The transfer capital threshold is the transfer adjustment factor * $1,871.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26867.16","0.03","26867.16","1 through 10","21161.42","35094.1205","other","Inpatient Replacement Plans DRG"
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","","","","inpatient","","","105948.97","79461.73","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","21161.42","","Case rate ($21,593.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,916.65, add-ons for qualifying new technology services are included. If operating cost exceeds $71,561.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,311.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $19,342.22 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,536.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,871.23. The transfer capital threshold is the transfer adjustment factor * $1,871.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20395.39","20395.39","20395.39","1 through 10","21161.42","35094.1205","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With McC","356","MS-DRG","","","","","","","","inpatient","","","198710.59","149032.94","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","41664.97","","Case rate ($40,451.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $48,618.13, add-ons for qualifying new technology services are included. If operating cost exceeds $94,262.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,974.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $36,536.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $48,238.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,534.70. The transfer capital threshold is the transfer adjustment factor * $3,534.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","40175.08","40175.08","40182.74","1 through 10","39642.4","64373.6787","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With McC","356","MS-DRG","","","","","","","","inpatient","","","198710.59","149032.94","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","52385.88","","Case rate ($52,385.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $48,618.13, add-ons for qualifying new technology services are included. If operating cost exceeds $94,262.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,974.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $48,471.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $48,238.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,534.70. The transfer capital threshold is the transfer adjustment factor * $3,534.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38577.05","38577.02","38996.69","1 through 10","39642.4","64373.6787","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With McC","356","MS-DRG","","","","","","","","inpatient","","","198710.59","149032.94","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","40451.43","","Case rate ($40,451.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $48,618.13, add-ons for qualifying new technology services are included. If operating cost exceeds $94,262.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,974.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $36,536.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $48,238.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,534.70. The transfer capital threshold is the transfer adjustment factor * $3,534.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38410.99","38410.99","38410.99","1 through 10","39642.4","64373.6787","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With McC","356","MS-DRG","","","","","","","","inpatient","","","198710.59","149032.94","MEDICARE [2001]","HB BWH MEDICARE","52385.88","","Case rate ($52,385.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $48,618.13, add-ons for qualifying new technology services are included. If operating cost exceeds $94,262.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,974.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $48,471.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $48,238.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,534.70. The transfer capital threshold is the transfer adjustment factor * $3,534.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","50567.27","0.03","57158.12","11","39642.4","64373.6787","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With McC","356","MS-DRG","","","","","","","","inpatient","","","198710.59","149032.94","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","39642.40","","Case rate ($40,451.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $48,618.13, add-ons for qualifying new technology services are included. If operating cost exceeds $94,262.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,974.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $36,536.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $48,238.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,534.70. The transfer capital threshold is the transfer adjustment factor * $3,534.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","61326.28","61326.28","61326.28","1 through 10","39642.4","64373.6787","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With McC","356","MS-DRG","","","","","","","","inpatient","","","198710.59","149032.94","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","39642.40","","Case rate ($40,451.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $48,618.13, add-ons for qualifying new technology services are included. If operating cost exceeds $94,262.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,974.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $36,536.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $48,238.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,534.70. The transfer capital threshold is the transfer adjustment factor * $3,534.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","53543.19","38269.27","72392.17","1 through 10","39642.4","64373.6787","other","Inpatient DRG"
"Other Digestive System O.R. Procedures Without Cc/McC","358","MS-DRG","","","","","","","","inpatient","","","72504.55","54378.41","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","13131.64","","Case rate ($13,131.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,730.48, add-ons for qualifying new technology services are included. If operating cost exceeds $61,374.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,564.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,626.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,350.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,124.83. The transfer capital threshold is the transfer adjustment factor * $1,124.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12450.13","12450.13","12450.13","1 through 10","12869.01","21896.71","other","Inpatient Replacement Plans DRG"
"Other Digestive System O.R. Procedures Without Cc/McC","358","MS-DRG","","","","","","","","inpatient","","","72504.55","54378.41","MEDICARE [2001]","HB BWH MEDICARE","13131.64","","Case rate ($13,131.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,730.48, add-ons for qualifying new technology services are included. If operating cost exceeds $61,374.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,564.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,626.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,350.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,124.83. The transfer capital threshold is the transfer adjustment factor * $1,124.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16277.67","16277.67","16277.67","1 through 10","12869.01","21896.71","other","Inpatient Replacement Plans DRG"
"Other Digestive System O.R. Procedures Without Cc/McC","358","MS-DRG","","","","","","","","inpatient","","","72504.55","54378.41","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12869.01","","Case rate ($13,131.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,730.48, add-ons for qualifying new technology services are included. If operating cost exceeds $61,374.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,564.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,626.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,350.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,124.83. The transfer capital threshold is the transfer adjustment factor * $1,124.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12347.55","12347.55","12347.55","1 through 10","12869.01","21896.71","other","Inpatient DRG"
"Other Digestive System O.R. Procedures Without Cc/McC","358","MS-DRG","","","","","","","","inpatient","","","72504.55","54378.41","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12869.01","","Case rate ($13,131.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,730.48, add-ons for qualifying new technology services are included. If operating cost exceeds $61,374.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,564.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $11,626.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,350.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,124.83. The transfer capital threshold is the transfer adjustment factor * $1,124.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16997.75","16997.75","16997.75","1 through 10","12869.01","21896.71","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","57481.49","43111.12","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10003.11","","Case rate ($9,711.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,613.63, add-ons for qualifying new technology services are included. If operating cost exceeds $57,258.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,508.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,233.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.17. The transfer capital threshold is the transfer adjustment factor * $823.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10188.20","10188.20","10188.20","1 through 10","9517.52","16024.27","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","57481.49","43111.12","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9711.76","","Case rate ($9,711.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,613.63, add-ons for qualifying new technology services are included. If operating cost exceeds $57,258.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,508.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,233.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.17. The transfer capital threshold is the transfer adjustment factor * $823.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9901.30","9901.30","9901.30","1 through 10","9517.52","16024.27","other","Inpatient Replacement Plans DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","57481.49","43111.12","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9711.76","","Case rate ($9,711.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,613.63, add-ons for qualifying new technology services are included. If operating cost exceeds $57,258.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,508.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,233.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.17. The transfer capital threshold is the transfer adjustment factor * $823.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10898.00","10898.00","10898.00","1 through 10","9517.52","16024.27","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","57481.49","43111.12","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","5269.55","5269.55","5269.55","1 through 10","9517.52","16024.27","case rate",""
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","57481.49","43111.12","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","9711.76","","Case rate ($9,711.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,613.63, add-ons for qualifying new technology services are included. If operating cost exceeds $57,258.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,508.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,233.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.17. The transfer capital threshold is the transfer adjustment factor * $823.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9846.33","9846.33","9846.33","1 through 10","9517.52","16024.27","other","Inpatient Replacement Plans DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","57481.49","43111.12","HUMANA [1012]","HB BWH MEDICARE","9711.76","","Case rate ($9,711.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,613.63, add-ons for qualifying new technology services are included. If operating cost exceeds $57,258.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,508.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,233.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.17. The transfer capital threshold is the transfer adjustment factor * $823.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9738.65","9738.65","9738.65","1 through 10","9517.52","16024.27","other","Inpatient Replacement Plans DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","57481.49","43111.12","MEDICARE [2001]","HB BWH MEDICARE","9711.76","","Case rate ($9,711.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,613.63, add-ons for qualifying new technology services are included. If operating cost exceeds $57,258.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,508.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,233.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.17. The transfer capital threshold is the transfer adjustment factor * $823.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12774.19","0.03","12778.13","52","9517.52","16024.27","other","Inpatient Replacement Plans DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","57481.49","43111.12","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","9711.76","","Case rate ($9,711.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,613.63, add-ons for qualifying new technology services are included. If operating cost exceeds $57,258.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,508.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,233.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.17. The transfer capital threshold is the transfer adjustment factor * $823.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9703.02","9703.02","9703.02","1 through 10","9517.52","16024.27","other","Inpatient Replacement Plans DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","57481.49","43111.12","MOLINA [1014]","HB BWH MOLINA","9517.52","","Case rate ($9,711.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,613.63, add-ons for qualifying new technology services are included. If operating cost exceeds $57,258.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,508.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,233.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.17. The transfer capital threshold is the transfer adjustment factor * $823.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19732.08","19732.08","19732.08","1 through 10","9517.52","16024.27","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","57481.49","43111.12","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","9517.52","","Case rate ($9,711.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,613.63, add-ons for qualifying new technology services are included. If operating cost exceeds $57,258.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,508.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,233.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.17. The transfer capital threshold is the transfer adjustment factor * $823.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5544.74","5544.74","5544.74","1 through 10","9517.52","16024.27","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","57481.49","43111.12","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9517.52","","Case rate ($9,711.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,613.63, add-ons for qualifying new technology services are included. If operating cost exceeds $57,258.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,508.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,233.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.17. The transfer capital threshold is the transfer adjustment factor * $823.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9749.79","9690.04","16571.10","1 through 10","9517.52","16024.27","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","85768.72","64326.54","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","21171.36","","Case rate ($21,171.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,665.05, add-ons for qualifying new technology services are included. If operating cost exceeds $65,309.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,853.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $19,378.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,285.21 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,413.14. The transfer capital threshold is the transfer adjustment factor * $1,413.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16711.94","16711.94","16711.94","1 through 10","16072.08","27509.12","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","85768.72","64326.54","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","16400.08","","Case rate ($16,400.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,665.05, add-ons for qualifying new technology services are included. If operating cost exceeds $65,309.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,853.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,607.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,285.21 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,413.14. The transfer capital threshold is the transfer adjustment factor * $1,413.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16574.81","16541.29","16621.56","1 through 10","16072.08","27509.12","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","85768.72","64326.54","MEDICARE [2001]","HB BWH MEDICARE","21171.36","","Case rate ($21,171.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,665.05, add-ons for qualifying new technology services are included. If operating cost exceeds $65,309.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,853.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $19,378.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,285.21 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,413.14. The transfer capital threshold is the transfer adjustment factor * $1,413.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21794.10","935.52","21800.87","45","16072.08","27509.12","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","85768.72","64326.54","MOLINA [1014]","HB BWH MOLINA","16072.08","","Case rate ($16,400.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,665.05, add-ons for qualifying new technology services are included. If operating cost exceeds $65,309.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,853.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,607.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,285.21 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,413.14. The transfer capital threshold is the transfer adjustment factor * $1,413.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","33485.46","33485.46","33485.46","1 through 10","16072.08","27509.12","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","85768.72","64326.54","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","16072.08","","Case rate ($16,400.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,665.05, add-ons for qualifying new technology services are included. If operating cost exceeds $65,309.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,853.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,607.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,285.21 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,413.14. The transfer capital threshold is the transfer adjustment factor * $1,413.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13744.98","13744.98","13744.98","1 through 10","16072.08","27509.12","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","85768.72","64326.54","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16072.08","","Case rate ($16,400.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,665.05, add-ons for qualifying new technology services are included. If operating cost exceeds $65,309.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,853.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,607.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,285.21 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,413.14. The transfer capital threshold is the transfer adjustment factor * $1,413.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16567.02","16487.74","16640.83","1 through 10","16072.08","27509.12","other","Inpatient DRG"
"Other Disorders Of Nervous System Without Cc/McC","093","MS-DRG","","","","","","","","inpatient","","","38788.39","29091.29","HUMANA [1012]","HB BWH MEDICARE","9807.17","","Case rate ($9,807.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,124.18, add-ons for qualifying new technology services are included. If operating cost exceeds $54,768.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,080.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,786.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,744.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.75. The transfer capital threshold is the transfer adjustment factor * $640.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7336.57","7336.57","7336.57","1 through 10","7490.89","11911.3263","other","Inpatient DRG"
"Other Disorders Of Nervous System Without Cc/McC","093","MS-DRG","","","","","","","","inpatient","","","38788.39","29091.29","MEDICARE [2001]","HB BWH MEDICARE","9807.17","","Case rate ($9,807.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,124.18, add-ons for qualifying new technology services are included. If operating cost exceeds $54,768.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,080.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,786.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,744.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.75. The transfer capital threshold is the transfer adjustment factor * $640.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9597.37","8750.28","9597.37","1 through 10","7490.89","11911.3263","other","Inpatient DRG"
"Other Disorders Of Nervous System Without Cc/McC","093","MS-DRG","","","","","","","","inpatient","","","38788.39","29091.29","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7490.89","","Case rate ($7,643.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,124.18, add-ons for qualifying new technology services are included. If operating cost exceeds $54,768.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,080.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,623.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,744.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.75. The transfer capital threshold is the transfer adjustment factor * $640.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7311.17","7311.17","7311.17","1 through 10","7490.89","11911.3263","other","Inpatient DRG"
"Other Disorders Of Nervous System,EXTREME","058","DRG","","","","","","","","inpatient","","","103194.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","59704.72","","Standard inlier is a Case rate ($59,704.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $58,076, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,475.45) for the length of stay and the standard reimbursement.","99887.24","99887.24","99887.24","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,EXTREME","058","DRG","","","","","","","","inpatient","","","103194.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","67124.20","","Standard inlier is a Case rate ($67,124.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $58,076, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,527.72) for the length of stay and the standard reimbursement.","67124.19","67124.19","67124.19","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,EXTREME","058","DRG","","","","","","","","inpatient","","","103194.03","","MASSHEALTH [3001]","HB BWH MEDICAID","25039.52","","Case rate ($27,685.49). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,115.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,908.77 and the sum of the standard inlier and any outlier amount.","30126.73","30126.73","30126.73","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","47314.47","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","42906.80","","Standard inlier is a Case rate ($42,906.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,013, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,090.88) for the length of stay and the standard reimbursement.","4964.51","4964.51","4964.51","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","47314.47","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","48238.81","","Standard inlier is a Case rate ($48,238.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,013, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,847.10) for the length of stay and the standard reimbursement.","44070.32","44070.32","44070.32","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","47314.47","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","14110.50","","Case rate ($15,601.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,031.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9740.81","9740.81","9740.81","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","47314.47","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12100.547","","Fee schedule rate ($28,175.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12100.547","28175.72","28175.72","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","47314.47","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($28,175.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","28175.72","28175.72","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","47314.47","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12705.926","","Fee schedule rate ($29,585.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12705.926","35555.05","35555.05","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","47314.47","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22781.42","","Fee schedule rate ($29,585.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22781.42","35555.05","35555.05","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","47314.47","","MASSHEALTH [3001]","HB BWH MEDICAID","14110.50","","Case rate ($15,601.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,031.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15597.76","15597.76","15597.76","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","47314.47","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","14110.50","","Case rate ($15,601.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,031.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","47314.47","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14110.50","","Case rate ($15,601.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,031.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15597.76","2379.40","63903.90","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MINOR","058","DRG","","","","","","","","inpatient","","","35146.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24407.75","","Standard inlier is a Case rate ($24,407.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,627, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,464.83) for the length of stay and the standard reimbursement.","24407.75","24407.75","24407.75","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MINOR","058","DRG","","","","","","","","inpatient","","","35146.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","27440.89","","Standard inlier is a Case rate ($27,440.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,627, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,895.01) for the length of stay and the standard reimbursement.","25069.62","25069.62","25069.62","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MINOR","058","DRG","","","","","","","","inpatient","","","35146.50","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12705.926","","Fee schedule rate ($12,705.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12705.926","12705.92","12705.92","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MINOR","058","DRG","","","","","","","","inpatient","","","35146.50","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22781.42","","Fee schedule rate ($12,705.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22781.42","12705.92","12705.92","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MINOR","058","DRG","","","","","","","","inpatient","","","35146.50","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22813.15","","Fee schedule rate ($22,813.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22813.15","22813.15","22813.15","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MINOR","058","DRG","","","","","","","","inpatient","","","35146.50","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6047.69","","Case rate ($6,686.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,116.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6685.11","6685.11","6685.11","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MODERATE","058","DRG","","","","","","","","inpatient","","","35893.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","32751.73","","Fee schedule rate ($32,751.73). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($3,789.52) multiplied by length of stay and the outlier percent (100%).","3789.52","3789.52","3789.52","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MODERATE","058","DRG","","","","","","","","inpatient","","","35893.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","36821.77","","Fee schedule rate ($36,821.77). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($4,260.43) multiplied by length of stay and the outlier percent (100%).","36821.77","4260.42","36821.77","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MODERATE","058","DRG","","","","","","","","inpatient","","","35893.60","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12100.547","","Fee schedule rate ($28,175.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12100.547","17620.72","17620.72","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MODERATE","058","DRG","","","","","","","","inpatient","","","35893.60","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($28,175.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","17620.72","17620.72","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MODERATE","058","DRG","","","","","","","","inpatient","","","35893.60","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34096.54","","Fee schedule rate ($34,096.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26070.06","26070.06","26070.06","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of Nervous System,MODERATE","058","DRG","","","","","","","","inpatient","","","35893.60","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9662.13","","Case rate ($10,683.15). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,113.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10680.53","10680.53","10680.53","1 through 10","6047.69","67124.2","case rate",""
"Other Disorders Of The Eye With McC Or Thrombolytic Agent","124","MS-DRG","","","","","","","","inpatient","","","45659.30","34244.47","MEDICARE [2001]","HB BWH MEDICARE","16043.92","","Case rate ($16,043.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,909.08, add-ons for qualifying new technology services are included. If operating cost exceeds $60,553.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,504.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $14,599.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,529.25 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,064.64. The transfer capital threshold is the transfer adjustment factor * $1,064.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15673.17","0.03","15673.17","1 through 10","12200.31","19677.1549","other","Inpatient DRG"
"Other Disorders Of The Eye Without McC","125","MS-DRG","","","","","","","","inpatient","","","36032.24","27024.18","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","7383.80","","Case rate ($7,383.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,811.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,455.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,057.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,386.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,431.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $617.82. The transfer capital threshold is the transfer adjustment factor * $617.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9869.15","9869.15","9869.15","1 through 10","7236.12","12026.82","other","Inpatient Replacement Plans DRG"
"Other Disorders Of The Eye Without McC","125","MS-DRG","","","","","","","","inpatient","","","36032.24","27024.18","MEDICARE [2001]","HB BWH MEDICARE","7383.80","","Case rate ($7,383.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,811.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,455.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,057.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,386.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,431.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $617.82. The transfer capital threshold is the transfer adjustment factor * $617.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10024.07","10012.58","10027.14","1 through 10","7236.12","12026.82","other","Inpatient Replacement Plans DRG"
"Other Disorders Of The Eye Without McC","125","MS-DRG","","","","","","","","inpatient","","","36032.24","27024.18","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7236.12","","Case rate ($7,383.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,811.21, add-ons for qualifying new technology services are included. If operating cost exceeds $54,455.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,057.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,386.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,431.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $617.82. The transfer capital threshold is the transfer adjustment factor * $617.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","40559.14","40559.14","40559.14","1 through 10","7236.12","12026.82","other","Inpatient DRG"
"Other Disorders Of The Liver,EXTREME","283","DRG","","","","","","","","inpatient","","","107515.20","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12205.6719","","Fee schedule rate ($67,662.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12205.6719","68362.80","68362.80","1 through 10","5679.84","111644.34","case rate",""
"Other Disorders Of The Liver,EXTREME","283","DRG","","","","","","","","inpatient","","","107515.20","","MASSHEALTH [3001]","HB BWH MEDICAID","10157.92","","Case rate ($11,231.33). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,661.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23895.43","23895.43","46137.46","1 through 10","5679.84","111644.34","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","60106.18","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","29262.14","","Standard inlier is a Case rate ($29,262.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,402, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,153.94) for the length of stay and the standard reimbursement.","29262.13","26673.50","30228.89","1 through 10","5679.84","111644.34","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","60106.18","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32898.53","","Standard inlier is a Case rate ($32,898.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,402, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,669.67) for the length of stay and the standard reimbursement.","32898.52","32898.52","40263.79","1 through 10","5679.84","111644.34","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","60106.18","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12205.6719","","Fee schedule rate ($27,200.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12205.6719","27200.52","27200.52","1 through 10","5679.84","111644.34","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","60106.18","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12816.3102","","Fee schedule rate ($28,561.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12816.3102","28561.32","28561.32","1 through 10","5679.84","111644.34","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","60106.18","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","33558.28","","Fee schedule rate ($33,558.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34000.94","34000.94","34000.94","1 through 10","5679.84","111644.34","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","60106.18","","MASSHEALTH [3001]","HB BWH MEDICAID","10157.92","","Case rate ($11,231.33). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,661.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7605.67","7605.67","11228.57","1 through 10","5679.84","111644.34","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","60106.18","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31351.42","","Fee schedule rate ($31,351.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31351.42","31351.42","31351.42","1 through 10","5679.84","111644.34","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","60106.18","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10157.92","","Case rate ($11,231.33). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,661.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11228.57","11228.57","11228.57","1 through 10","5679.84","111644.34","case rate",""
"Other Disorders Of The Liver,MINOR","283","DRG","","","","","","","","inpatient","","","35326.90","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12205.6719","","Fee schedule rate ($12,205.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12205.6719","12205.68","12205.68","1 through 10","5679.84","111644.34","case rate",""
"Other Disorders Of The Liver,MODERATE","283","DRG","","","","","","","","inpatient","","","40200.59","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20109.63","","Standard inlier is a Case rate ($20,109.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,286, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,854.68) for the length of stay and the standard reimbursement.","18331.89","18331.89","18331.89","1 through 10","5679.84","111644.34","case rate",""
"Other Disorders Of The Liver,MODERATE","283","DRG","","","","","","","","inpatient","","","40200.59","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22608.65","","Standard inlier is a Case rate ($22,608.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,286, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,209.11) for the length of stay and the standard reimbursement.","22608.64","22608.64","33184.78","1 through 10","5679.84","111644.34","case rate",""
"Other Disorders Of The Liver,MODERATE","283","DRG","","","","","","","","inpatient","","","40200.59","","MASSHEALTH [3001]","HB BWH MEDICAID","6880.47","","Case rate ($7,607.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,037.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7605.67","7605.67","7605.67","1 through 10","5679.84","111644.34","case rate",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","","","","inpatient","","","40577.48","30433.11","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8740.25","","Case rate ($8,740.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,444.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,088.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,177.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,622.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,064.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $737.47. The transfer capital threshold is the transfer adjustment factor * $737.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8670.56","8670.56","8670.56","1 through 10","8565.45","14088.9576","other","Inpatient Replacement Plans DRG"
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","","","","inpatient","","","40577.48","30433.11","MEDICARE [2001]","HB BWH MEDICARE","8740.25","","Case rate ($8,740.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,444.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,088.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,177.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,622.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,064.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $737.47. The transfer capital threshold is the transfer adjustment factor * $737.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11297.63","11284.65","11301.10","1 through 10","8565.45","14088.9576","other","Inpatient Replacement Plans DRG"
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","","","","inpatient","","","40577.48","30433.11","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8565.45","","Case rate ($8,740.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,444.13, add-ons for qualifying new technology services are included. If operating cost exceeds $56,088.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,177.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,622.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,064.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $737.47. The transfer capital threshold is the transfer adjustment factor * $737.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8727.57","8727.57","8727.57","1 through 10","8565.45","14088.9576","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat Diagnoses With McC","154","MS-DRG","","","","","","","","inpatient","","","55716.42","41787.31","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","18302.83","","Case rate ($14,642.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,548.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,193.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,698.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,004.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,169.13 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.08. The transfer capital threshold is the transfer adjustment factor * $1,258.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","15039.69","15039.69","15039.69","1 through 10","14349.41","24490.66","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat Diagnoses With McC","154","MS-DRG","","","","","","","","inpatient","","","55716.42","41787.31","MEDICARE [2001]","HB BWH MEDICARE","14642.26","","Case rate ($14,642.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,548.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,193.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,698.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,004.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,169.13 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.08. The transfer capital threshold is the transfer adjustment factor * $1,258.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19479.66","19450.98","59932.08","1 through 10","14349.41","24490.66","other","Inpatient Replacement Plans DRG"
"Other Ear, Nose, Mouth And Throat Diagnoses With McC","154","MS-DRG","","","","","","","","inpatient","","","55716.42","41787.31","MOLINA [1014]","HB BWH MOLINA","14349.41","","Case rate ($14,642.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,548.97, add-ons for qualifying new technology services are included. If operating cost exceeds $63,193.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,698.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,004.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,169.13 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.08. The transfer capital threshold is the transfer adjustment factor * $1,258.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","29946.94","29946.94","29946.94","1 through 10","14349.41","24490.66","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/McC","156","MS-DRG","","","","","","","","inpatient","","","27981.90","20986.42","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","6884.64","","Case rate ($6,684.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,968.95, add-ons for qualifying new technology services are included. If operating cost exceeds $53,613.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,996.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,748.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,589.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.10. The transfer capital threshold is the transfer adjustment factor * $556.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6666.50","6666.50","6666.50","1 through 10","6550.44","10147.1884","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/McC","156","MS-DRG","","","","","","","","inpatient","","","27981.90","20986.42","MEDICARE [2001]","HB BWH MEDICARE","6684.12","","Case rate ($6,684.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,968.95, add-ons for qualifying new technology services are included. If operating cost exceeds $53,613.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,996.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,748.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,589.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.10. The transfer capital threshold is the transfer adjustment factor * $556.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","978.30","978.30","978.30","1 through 10","6550.44","10147.1884","other","Inpatient Replacement Plans DRG"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","","","","inpatient","","","103847.91","77885.93","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","20895.52","","Case rate ($20,895.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,409.20, add-ons for qualifying new technology services are included. If operating cost exceeds $65,053.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,834.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,121.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,029.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,394.39. The transfer capital threshold is the transfer adjustment factor * $1,394.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16223.31","16223.31","16223.31","1 through 10","15863.79","27144.15","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","","","","inpatient","","","103847.91","77885.93","HUMANA [1012]","HB BWH MEDICARE","20895.52","","Case rate ($20,895.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,409.20, add-ons for qualifying new technology services are included. If operating cost exceeds $65,053.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,834.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,121.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,029.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,394.39. The transfer capital threshold is the transfer adjustment factor * $1,394.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16068.30","16068.30","16068.30","1 through 10","15863.79","27144.15","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","","","","inpatient","","","103847.91","77885.93","MEDICARE [2001]","HB BWH MEDICARE","20895.52","","Case rate ($20,895.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,409.20, add-ons for qualifying new technology services are included. If operating cost exceeds $65,053.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,834.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $19,121.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,029.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,394.39. The transfer capital threshold is the transfer adjustment factor * $1,394.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21019.26","20988.29","34578.39","1 through 10","15863.79","27144.15","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","","","","inpatient","","","103847.91","77885.93","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15863.79","","Case rate ($16,187.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,409.20, add-ons for qualifying new technology services are included. If operating cost exceeds $65,053.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,834.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $14,413.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,029.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,394.39. The transfer capital threshold is the transfer adjustment factor * $1,394.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15974.02","15974.02","15974.02","1 through 10","15863.79","27144.15","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With McC","143","MS-DRG","","","","","","","","inpatient","","","135991.15","101993.36","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44735.57","","Case rate ($44,735.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,522.07, add-ons for qualifying new technology services are included. If operating cost exceeds $87,166.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,454.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $41,340.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,142.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,014.73. The transfer capital threshold is the transfer adjustment factor * $3,014.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29890.27","29890.27","29890.27","1 through 10","33865.6","49828.9729","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With McC","143","MS-DRG","","","","","","","","inpatient","","","135991.15","101993.36","MEDICARE [2001]","HB BWH MEDICARE","44735.57","","Case rate ($44,735.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,522.07, add-ons for qualifying new technology services are included. If operating cost exceeds $87,166.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,454.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $41,340.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,142.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,014.73. The transfer capital threshold is the transfer adjustment factor * $3,014.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","39204.89","39204.89","39263.12","1 through 10","33865.6","49828.9729","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With McC","143","MS-DRG","","","","","","","","inpatient","","","135991.15","101993.36","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","33865.60","","Case rate ($34,556.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,522.07, add-ons for qualifying new technology services are included. If operating cost exceeds $87,166.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,454.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $31,162.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,142.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,014.73. The transfer capital threshold is the transfer adjustment factor * $3,014.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","29643.67","29643.67","29643.67","1 through 10","33865.6","49828.9729","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/McC","145","MS-DRG","","","","","","","","inpatient","","","86068.29","64551.22","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","11687.77","","Case rate ($11,347.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,582.55, add-ons for qualifying new technology services are included. If operating cost exceeds $59,226.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,407.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $10,000.07 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,202.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $967.44. The transfer capital threshold is the transfer adjustment factor * $967.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11352.29","11352.29","11352.29","1 through 10","11120.4","17879.8168","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/McC","145","MS-DRG","","","","","","","","inpatient","","","86068.29","64551.22","WELLPOINT [1015]","HB AMC WELLPOINT","17879.8168","","Fee schedule rate ($18,832.83).","17879.8168","17879.81","17879.81","1 through 10","11120.4","17879.8168","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,EXTREME","115","DRG","","","","","","","","inpatient","","","55716.42","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","29873.38","","Standard inlier is a Case rate ($29,873.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,880, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,240.71) for the length of stay and the standard reimbursement.","54643.35","54643.35","54643.35","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,EXTREME","115","DRG","","","","","","","","inpatient","","","55716.42","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","33585.73","","Standard inlier is a Case rate ($33,585.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,880, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,767.22) for the length of stay and the standard reimbursement.","14977.49","14977.49","14977.49","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MAJOR","115","DRG","","","","","","","","inpatient","","","56564.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","29873.38","","Standard inlier is a Case rate ($29,873.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,880, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,240.71) for the length of stay and the standard reimbursement.","29873.38","29873.38","32245.37","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MAJOR","115","DRG","","","","","","","","inpatient","","","56564.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","33585.73","","Standard inlier is a Case rate ($33,585.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,880, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,767.22) for the length of stay and the standard reimbursement.","33585.73","33585.73","33585.73","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MAJOR","115","DRG","","","","","","","","inpatient","","","56564.44","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30993.36","","Fee schedule rate ($30,993.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30993.36","30993.36","30993.36","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MINOR","115","DRG","","","","","","","","inpatient","","","30920.12","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","14285.02","","Standard inlier is a Case rate ($14,285.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,756, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,027.84) for the length of stay and the standard reimbursement.","14285.01","14285.01","14285.01","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MINOR","115","DRG","","","","","","","","inpatient","","","30920.12","","MASSHEALTH [3001]","HB BWH MEDICAID","4760.24","","Case rate ($5,263.26). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,693.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3995.00","3995.00","3995.00","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MINOR","115","DRG","","","","","","","","inpatient","","","30920.12","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4760.24","","Case rate ($5,263.26). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,693.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5261.97","5261.97","5261.97","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MODERATE","115","DRG","","","","","","","","inpatient","","","39028.11","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19740.95","","Standard inlier is a Case rate ($19,740.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,998, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,802.35) for the length of stay and the standard reimbursement.","17994.59","17994.59","17994.59","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MODERATE","115","DRG","","","","","","","","inpatient","","","39028.11","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22194.14","","Standard inlier is a Case rate ($22,194.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,998, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,150.27) for the length of stay and the standard reimbursement.","22194.14","22194.14","22194.14","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MODERATE","115","DRG","","","","","","","","inpatient","","","39028.11","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10827.8647","","Fee schedule rate ($12,901.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10827.8647","12901.28","12901.28","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MODERATE","115","DRG","","","","","","","","inpatient","","","39028.11","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9642.4137","","Fee schedule rate ($12,901.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9642.4137","12901.28","12901.28","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MODERATE","115","DRG","","","","","","","","inpatient","","","39028.11","","MASSHEALTH [3001]","HB BWH MEDICAID","6658.85","","Case rate ($7,362.50). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,792.50, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7360.70","7360.70","7360.70","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MODERATE","115","DRG","","","","","","","","inpatient","","","39028.11","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21692.37","","Fee schedule rate ($21,692.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8867.69","8867.69","8867.69","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MODERATE","115","DRG","","","","","","","","inpatient","","","39028.11","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6658.85","","Case rate ($7,362.50). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,792.50, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7360.70","7360.70","7360.70","1 through 10","4760.24","86950.54","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MAJOR","098","DRG","","","","","","","","inpatient","","","140029.77","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","61244.15","","Standard inlier is a Case rate ($61,244.15). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,273, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,693.98) for the length of stay and the standard reimbursement.","55826.27","55826.27","55826.27","1 through 10","9048.68","215641.76","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MAJOR","098","DRG","","","","","","","","inpatient","","","140029.77","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","24095.93","","Case rate ($26,642.19). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $69,072.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19429.51","19429.51","19429.51","1 through 10","9048.68","215641.76","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MINOR","098","DRG","","","","","","","","inpatient","","","56861.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","26302.94","","Standard inlier is a Case rate ($26,302.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,102, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,733.86) for the length of stay and the standard reimbursement.","26302.93","26302.93","26302.93","1 through 10","9048.68","215641.76","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MINOR","098","DRG","","","","","","","","inpatient","","","56861.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","29571.59","","Standard inlier is a Case rate ($29,571.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,102, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,197.44) for the length of stay and the standard reimbursement.","29571.58","29571.58","30062.87","1 through 10","9048.68","215641.76","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MINOR","098","DRG","","","","","","","","inpatient","","","56861.09","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15656.9","","Fee schedule rate ($15,656.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15656.9","15656.92","15656.92","1 through 10","9048.68","215641.76","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MINOR","098","DRG","","","","","","","","inpatient","","","56861.09","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18323.0464","","Fee schedule rate ($15,656.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18323.0464","15656.92","15656.92","1 through 10","9048.68","215641.76","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MINOR","098","DRG","","","","","","","","inpatient","","","56861.09","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32386.89","","Fee schedule rate ($32,386.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32386.89","32386.89","32386.89","1 through 10","9048.68","215641.76","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MODERATE","098","DRG","","","","","","","","inpatient","","","81760.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","40945.00","","Standard inlier is a Case rate ($40,945.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,968, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,811.80) for the length of stay and the standard reimbursement.","50113.94","50113.94","50113.94","1 through 10","9048.68","215641.76","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MODERATE","098","DRG","","","","","","","","inpatient","","","81760.50","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15656.9","","Fee schedule rate ($21,865.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15656.9","21865.96","21865.96","1 through 10","9048.68","215641.76","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MODERATE","098","DRG","","","","","","","","inpatient","","","81760.50","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18323.0464","","Fee schedule rate ($21,865.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18323.0464","21865.96","21865.96","1 through 10","9048.68","215641.76","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MODERATE","098","DRG","","","","","","","","inpatient","","","81760.50","","MASSHEALTH [3001]","HB BWH MEDICAID","13754.09","","Case rate ($15,207.51). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,637.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1540.29","1540.29","1540.29","1 through 10","9048.68","215641.76","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MODERATE","098","DRG","","","","","","","","inpatient","","","81760.50","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","42381.35","","Fee schedule rate ($42,381.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42381.35","42381.35","42381.35","1 through 10","9048.68","215641.76","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MODERATE","098","DRG","","","","","","","","inpatient","","","81760.50","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","13754.09","","Case rate ($15,207.51). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,637.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5922.40","5922.40","5922.40","1 through 10","9048.68","215641.76","case rate",""
"Other Endocrine Disorders,EXTREME","424","DRG","","","","","","","","inpatient","","","46099.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","62528.29","","Standard inlier is a Case rate ($62,528.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,898, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,875.37) for the length of stay and the standard reimbursement.","62528.29","62528.29","62528.29","1 through 10","5162.35","107444.44","case rate",""
"Other Endocrine Disorders,MAJOR","424","DRG","","","","","","","","inpatient","","","43478.20","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35378.28","","Standard inlier is a Case rate ($35,378.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,118, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,021.65) for the length of stay and the standard reimbursement.","35378.28","35378.28","35378.28","1 through 10","5162.35","107444.44","case rate",""
"Other Endocrine Disorders,MAJOR","424","DRG","","","","","","","","inpatient","","","43478.20","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10890.4923","","Fee schedule rate ($29,247.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10890.4923","29247.08","29247.08","1 through 10","5162.35","107444.44","case rate",""
"Other Endocrine Disorders,MAJOR","424","DRG","","","","","","","","inpatient","","","43478.20","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","32172.19","","Fee schedule rate ($32,172.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32172.20","32172.20","32172.20","1 through 10","5162.35","107444.44","case rate",""
"Other Endocrine Disorders,MAJOR","424","DRG","","","","","","","","inpatient","","","43478.20","","MASSHEALTH [3001]","HB BWH MEDICAID","12781.93","","Case rate ($14,132.62). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,562.62, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17951.56","17951.56","17951.56","1 through 10","5162.35","107444.44","case rate",""
"Other Endocrine Disorders,MINOR","424","DRG","","","","","","","","inpatient","","","9626.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","15378.15","","Standard inlier is a Case rate ($15,378.15). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,606, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,183.02) for the length of stay and the standard reimbursement.","15378.14","15378.14","15378.14","1 through 10","5162.35","107444.44","case rate",""
"Other Endocrine Disorders,MINOR","424","DRG","","","","","","","","inpatient","","","9626.49","","MASSHEALTH [3001]","HB BWH MEDICAID","5162.35","","Case rate ($5,707.87). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,137.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5706.46","5706.46","5706.46","1 through 10","5162.35","107444.44","case rate",""
"Other Endocrine Disorders,MODERATE","424","DRG","","","","","","","","inpatient","","","30727.02","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24059.41","","Standard inlier is a Case rate ($24,059.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,290, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,415.03) for the length of stay and the standard reimbursement.","24059.41","24059.41","24059.41","1 through 10","5162.35","107444.44","case rate",""
"Other Endocrine Disorders,MODERATE","424","DRG","","","","","","","","inpatient","","","30727.02","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10890.4923","","Fee schedule rate ($29,247.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10890.4923","10207.16","10207.16","1 through 10","5162.35","107444.44","case rate",""
"Other Endocrine Disorders,MODERATE","424","DRG","","","","","","","","inpatient","","","30727.02","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11435.3334","","Fee schedule rate ($30,710.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11435.3334","28705.81","28705.81","1 through 10","5162.35","107444.44","case rate",""
"Other Endocrine Disorders,MODERATE","424","DRG","","","","","","","","inpatient","","","30727.02","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","32172.19","","Fee schedule rate ($32,172.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18485.00","18485.00","18485.00","1 through 10","5162.35","107444.44","case rate",""
"Other Endocrine Disorders,MODERATE","424","DRG","","","","","","","","inpatient","","","30727.02","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23499.71","","Fee schedule rate ($23,499.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23499.71","23499.71","23499.71","1 through 10","5162.35","107444.44","case rate",""
"Other Endocrine Disorders,MODERATE","424","DRG","","","","","","","","inpatient","","","30727.02","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7214.04","","Case rate ($7,976.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,406.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7974.41","7974.41","7974.41","1 through 10","5162.35","107444.44","case rate",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","","","","inpatient","","","106378.82","79784.11","MEDICARE [2001]","HB BWH MEDICARE","20255.08","","Case rate ($20,255.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,305.72, add-ons for qualifying new technology services are included. If operating cost exceeds $69,950.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,193.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $18,122.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,925.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,753.19. The transfer capital threshold is the transfer adjustment factor * $1,753.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26793.27","21662.61","26832.93","1 through 10","19849.98","34128.72","other","Inpatient Replacement Plans DRG"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","","","","inpatient","","","106378.82","79784.11","WELLPOINT [1015]","HB AMC WELLPOINT","34128.72","","Fee schedule rate ($34,128.72).","63186.51","63186.51","63186.51","1 through 10","19849.98","34128.72","case rate",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With McC","628","MS-DRG","","","","","","","","inpatient","","","148377.96","111283.47","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","34376.10","","Case rate ($34,376.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,304.63, add-ons for qualifying new technology services are included. If operating cost exceeds $86,949.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,438.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $30,997.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $40,924.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,998.80. The transfer capital threshold is the transfer adjustment factor * $2,998.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35570.53","35570.53","35570.53","1 through 10","33688.58","58376.6","other","Inpatient DRG"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With McC","628","MS-DRG","","","","","","","","inpatient","","","148377.96","111283.47","MEDICARE [2001]","HB BWH MEDICARE","34376.10","","Case rate ($34,376.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,304.63, add-ons for qualifying new technology services are included. If operating cost exceeds $86,949.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,438.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $30,997.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $40,924.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,998.80. The transfer capital threshold is the transfer adjustment factor * $2,998.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","46794.75","27964.88","46864.33","1 through 10","33688.58","58376.6","other","Inpatient Replacement Plans DRG"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With McC","628","MS-DRG","","","","","","","","inpatient","","","148377.96","111283.47","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","33688.58","","Case rate ($34,376.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,304.63, add-ons for qualifying new technology services are included. If operating cost exceeds $86,949.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,438.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $30,997.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $40,924.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,998.80. The transfer capital threshold is the transfer adjustment factor * $2,998.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","36157.64","36157.64","55881.33","1 through 10","33688.58","58376.6","other","Inpatient DRG"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/McC","630","MS-DRG","","","","","","","","inpatient","","","63236.46","47427.34","MEDICARE [2001]","HB BWH MEDICARE","13693.55","","Case rate ($13,693.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,406.93, add-ons for qualifying new technology services are included. If operating cost exceeds $62,051.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,614.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,139.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,027.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,174.40. The transfer capital threshold is the transfer adjustment factor * $1,174.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16798.42","16798.42","16798.42","1 through 10","13419.68","21147.0183","other","Inpatient Replacement Plans DRG"
"Other Endovascular Cardiac Valve Procedures With McC","319","MS-DRG","","","","","","","","inpatient","","","237576.12","178182.09","MEDICARE [2001]","HB BWH MEDICARE","41090.88","","Case rate ($41,090.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,387.91, add-ons for qualifying new technology services are included. If operating cost exceeds $95,032.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,031.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $37,119.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,008.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,591.11. The transfer capital threshold is the transfer adjustment factor * $3,591.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","52126.82","52126.82","52126.82","1 through 10","40269.06","66291.7448","other","Inpatient Replacement Plans DRG"
"Other Endovascular Cardiac Valve Procedures With McC","319","MS-DRG","","","","","","","","inpatient","","","237576.12","178182.09","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","40269.06","","Case rate ($41,090.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,387.91, add-ons for qualifying new technology services are included. If operating cost exceeds $95,032.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,031.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.4. The base transfer operating payment is the transfer adjustment factor * $37,119.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,008.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,591.11. The transfer capital threshold is the transfer adjustment factor * $3,591.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","42508.87","42508.87","42508.87","1 through 10","40269.06","66291.7448","other","Inpatient DRG"
"Other Endovascular Cardiac Valve Procedures Without McC","320","MS-DRG","","","","","","","","inpatient","","","83360.76","62520.57","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","22990.88","","Case rate ($22,321.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,792.96, add-ons for qualifying new technology services are included. If operating cost exceeds $72,437.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,375.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $20,005.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,413.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,935.45. The transfer capital threshold is the transfer adjustment factor * $1,935.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","21906.34","21906.34","21906.34","1 through 10","21874.82","34932.6468","other","Inpatient DRG"
"Other Endovascular Cardiac Valve Procedures Without McC","320","MS-DRG","","","","","","","","inpatient","","","83360.76","62520.57","MEDICARE [2001]","HB BWH MEDICARE","22321.24","","Case rate ($22,321.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,792.96, add-ons for qualifying new technology services are included. If operating cost exceeds $72,437.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,375.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $20,005.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,413.12 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,935.45. The transfer capital threshold is the transfer adjustment factor * $1,935.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","21338.07","0.03","27567.81","1 through 10","21874.82","34932.6468","other","Inpatient Replacement Plans DRG"
"Other Esophageal Disorders,EXTREME","243","DRG","","","","","","","","inpatient","","","50542.52","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9564.1292","","Fee schedule rate ($59,518.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9564.1292","59518.60","59518.60","1 through 10","4898.47","98206.87","case rate",""
"Other Esophageal Disorders,EXTREME","243","DRG","","","","","","","","inpatient","","","50542.52","","MASSHEALTH [3001]","HB BWH MEDICAID","10180.77","","Case rate ($11,256.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,686.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23857.15","23857.15","23857.15","1 through 10","4898.47","98206.87","case rate",""
"Other Esophageal Disorders,EXTREME","243","DRG","","","","","","","","inpatient","","","50542.52","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67575.63","","Fee schedule rate ($67,575.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","67575.63","67575.63","67575.63","1 through 10","4898.47","98206.87","case rate",""
"Other Esophageal Disorders,EXTREME","243","DRG","","","","","","","","inpatient","","","50542.52","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10180.77","","Case rate ($11,256.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,686.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22928.15","22928.15","22928.15","1 through 10","4898.47","98206.87","case rate",""
"Other Esophageal Disorders,MAJOR","243","DRG","","","","","","","","inpatient","","","54202.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","34567.45","","Standard inlier is a Case rate ($34,567.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,558, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,906.56) for the length of stay and the standard reimbursement.","34567.45","34567.45","52927.23","1 through 10","4898.47","98206.87","case rate",""
"Other Esophageal Disorders,MAJOR","243","DRG","","","","","","","","inpatient","","","54202.28","","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","","38.3","","18761.57","18761.57","18761.57","1 through 10","4898.47","98206.87","percent of total billed charges",""
"Other Esophageal Disorders,MAJOR","243","DRG","","","","","","","","inpatient","","","54202.28","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","10180.77","","Case rate ($11,256.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,686.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2040.01","2040.01","2040.01","1 through 10","4898.47","98206.87","case rate",""
"Other Esophageal Disorders,MINOR","243","DRG","","","","","","","","inpatient","","","29539.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18441.79","","Standard inlier is a Case rate ($18,441.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,403, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,617.66) for the length of stay and the standard reimbursement.","18441.79","18441.79","18441.79","1 through 10","4898.47","98206.87","case rate",""
"Other Esophageal Disorders,MINOR","243","DRG","","","","","","","","inpatient","","","29539.86","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4898.47","","Case rate ($5,416.10). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,846.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5414.77","5414.77","5414.77","1 through 10","4898.47","98206.87","case rate",""
"Other Esophageal Disorders,MODERATE","243","DRG","","","","","","","","inpatient","","","44527.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21092.80","","Standard inlier is a Case rate ($21,092.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,051, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,994.25) for the length of stay and the standard reimbursement.","21092.80","21092.80","21092.80","1 through 10","4898.47","98206.87","case rate",""
"Other Esophageal Disorders,MODERATE","243","DRG","","","","","","","","inpatient","","","44527.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","23713.99","","Standard inlier is a Case rate ($23,713.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,051, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,366.00) for the length of stay and the standard reimbursement.","23713.99","23713.99","23713.99","1 through 10","4898.47","98206.87","case rate",""
"Other Esophageal Disorders,MODERATE","243","DRG","","","","","","","","inpatient","","","44527.65","","MASSHEALTH [3001]","HB BWH MEDICAID","6385.83","","Case rate ($7,060.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,490.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7058.89","7058.89","7058.89","1 through 10","4898.47","98206.87","case rate",""
"Other Esophageal Disorders,MODERATE","243","DRG","","","","","","","","inpatient","","","44527.65","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6385.83","","Case rate ($7,060.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,490.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2258.20","2258.20","7058.90","1 through 10","4898.47","98206.87","case rate",""
"Other Factors Influencing Health Status","951","MS-DRG","","","","","","","","inpatient","","","12741.24","9555.93","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","5615.28","","Case rate ($5,451.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,485.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,129.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,887.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,624.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,105.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.39. The transfer capital threshold is the transfer adjustment factor * $447.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","5597.91","5597.91","5597.91","1 through 10","5342.7","8709.18","other","Inpatient DRG"
"Other Factors Influencing Health Status","951","MS-DRG","","","","","","","","inpatient","","","12741.24","9555.93","MEDICARE [2001]","HB BWH MEDICARE","5451.73","","Case rate ($5,451.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,485.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,129.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,887.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,624.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,105.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.39. The transfer capital threshold is the transfer adjustment factor * $447.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6972.72","6972.72","6972.72","1 through 10","5342.7","8709.18","other","Inpatient Replacement Plans DRG"
"Other Factors Influencing Health Status","951","MS-DRG","","","","","","","","inpatient","","","12741.24","9555.93","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","5342.70","","Case rate ($5,451.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,485.40, add-ons for qualifying new technology services are included. If operating cost exceeds $52,129.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,887.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,624.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,105.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.39. The transfer capital threshold is the transfer adjustment factor * $447.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5316.27","5316.27","5316.27","1 through 10","5342.7","8709.18","other","Inpatient DRG"
"Other Female Reproductive System And Related Procedures,MAJOR","518","DRG","","","","","","","","inpatient","","","94905.92","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15889.5168","","Fee schedule rate ($45,167.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15889.5168","45167.92","45167.92","1 through 10","8197.62","142281.21","case rate",""
"Other Female Reproductive System And Related Procedures,MAJOR","518","DRG","","","","","","","","inpatient","","","94905.92","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60452.19","","Fee schedule rate ($60,452.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","51384.36","51384.36","51384.36","1 through 10","8197.62","142281.21","case rate",""
"Other Female Reproductive System And Related Procedures,MINOR","518","DRG","","","","","","","","inpatient","","","69855.01","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","28931.65","","Standard inlier is a Case rate ($28,931.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,660, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,106.61) for the length of stay and the standard reimbursement.","28931.65","26431.56","28931.65","1 through 10","8197.62","142281.21","case rate",""
"Other Female Reproductive System And Related Procedures,MINOR","518","DRG","","","","","","","","inpatient","","","69855.01","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","8197.62","","Case rate ($9,063.88). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,493.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8378.87","8378.87","8378.87","1 through 10","8197.62","142281.21","case rate",""
"Other Female Reproductive System And Related Procedures,MINOR","518","DRG","","","","","","","","inpatient","","","69855.01","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","16684.4544","","Fee schedule rate ($16,684.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16684.4544","16684.44","16684.44","1 through 10","8197.62","142281.21","case rate",""
"Other Female Reproductive System And Related Procedures,MODERATE","518","DRG","","","","","","","","inpatient","","","133619.89","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22713.08","","Standard inlier is a Case rate ($22,713.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,310, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,224.26) for the length of stay and the standard reimbursement.","42234.44","42234.44","42234.44","1 through 10","8197.62","142281.21","case rate",""
"Other Female Reproductive System And Related Procedures,MODERATE","518","DRG","","","","","","","","inpatient","","","133619.89","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25535.63","","Standard inlier is a Case rate ($25,535.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,310, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,624.57) for the length of stay and the standard reimbursement.","54016.55","41992.16","68748.09","1 through 10","8197.62","142281.21","case rate",""
"Other Female Reproductive System And Related Procedures,MODERATE","518","DRG","","","","","","","","inpatient","","","133619.89","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15889.5168","","Fee schedule rate ($23,297.47). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15889.5168","23297.48","23297.48","1 through 10","8197.62","142281.21","case rate",""
"Other Female Reproductive System And Related Procedures,MODERATE","518","DRG","","","","","","","","inpatient","","","133619.89","","MASSHEALTH [3001]","HB BWH MEDICAID","8523.19","","Case rate ($9,423.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,853.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11612.45","11612.45","11612.45","1 through 10","8197.62","142281.21","case rate",""
"Other Female Reproductive System And Related Procedures,MODERATE","518","DRG","","","","","","","","inpatient","","","133619.89","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34186.05","","Fee schedule rate ($34,186.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34885.12","34885.12","34885.12","1 through 10","8197.62","142281.21","case rate",""
"Other Female Reproductive System And Related Procedures,MODERATE","518","DRG","","","","","","","","inpatient","","","133619.89","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8523.19","","Case rate ($9,423.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,853.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11612.45","11612.45","11612.45","1 through 10","8197.62","142281.21","case rate",""
"Other Female Reproductive System O.R. Procedures With Cc/McC","749","MS-DRG","","","","","","","","inpatient","","","163862.72","122897.04","MEDICARE [2001]","HB BWH MEDICARE","23801.76","","Case rate ($23,801.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,575.21, add-ons for qualifying new technology services are included. If operating cost exceeds $74,219.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,506.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $21,355.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,195.37 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,066.04. The transfer capital threshold is the transfer adjustment factor * $2,066.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30841.32","0.03","30841.32","1 through 10","23325.72","39064.5626","other","Inpatient Replacement Plans DRG"
"Other Gastroenteritis, Nausea And Vomiting,EXTREME","249","DRG","","","","","","","","inpatient","","","122214.82","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","46567.81","","Standard inlier is a Case rate ($46,567.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,860, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,610.58) for the length of stay and the standard reimbursement.","42448.25","42448.25","42448.25","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,EXTREME","249","DRG","","","","","","","","inpatient","","","122214.82","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","52354.76","","Standard inlier is a Case rate ($52,354.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,860, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,431.32) for the length of stay and the standard reimbursement.","52354.76","52354.76","60924.81","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,EXTREME","249","DRG","","","","","","","","inpatient","","","122214.82","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","11996.35","11996.35","11996.35","1 through 10","3991.43","77819.99","percent of total billed charges",""
"Other Gastroenteritis, Nausea And Vomiting,EXTREME","249","DRG","","","","","","","","inpatient","","","122214.82","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","9220.6036","","Fee schedule rate ($49,522.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9220.6036","49522.56","49522.56","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,EXTREME","249","DRG","","","","","","","","inpatient","","","122214.82","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","18345.26","","Case rate ($20,283.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,713.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20278.86","20278.86","20278.86","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","42184.83","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","25300.36","","Standard inlier is a Case rate ($25,300.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,322, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,591.54) for the length of stay and the standard reimbursement.","25300.36","23062.20","25300.36","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","42184.83","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","28444.43","","Standard inlier is a Case rate ($28,444.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,322, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,037.45) for the length of stay and the standard reimbursement.","28444.42","25986.44","30398.82","13","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","42184.83","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","66766.14","66766.14","66766.14","1 through 10","3991.43","77819.99","percent of total billed charges",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","42184.83","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","9220.6036","","Fee schedule rate ($18,878.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9220.6036","18878.04","18878.04","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","42184.83","","MASSHEALTH [3001]","HB BWH MEDICAID","8645.43","","Case rate ($9,559). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,989, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9556.66","9556.66","9556.66","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","42184.83","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","8645.43","","Case rate ($9,559). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,989, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","42184.83","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24096.48","","Fee schedule rate ($24,096.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23394.38","23394.38","23394.38","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","42184.83","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25301.70","","Fee schedule rate ($25,301.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25301.70","25301.70","25301.70","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","42184.83","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8645.43","","Case rate ($9,559). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,989, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9556.66","1462.00","9556.66","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MINOR","249","DRG","","","","","","","","inpatient","","","30238.36","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","3991.43","","Case rate ($4,413.21). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,843.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4412.13","4412.13","4412.13","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","34537.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","17493.25","","Standard inlier is a Case rate ($17,493.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,251, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,483.27) for the length of stay and the standard reimbursement.","17493.24","17493.24","17493.24","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","34537.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","19667.12","","Standard inlier is a Case rate ($19,667.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,251, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,791.58) for the length of stay and the standard reimbursement.","19667.12","17968.66","19667.12","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","34537.28","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8781.2842","","Fee schedule rate ($11,548.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8781.2842","11548.08","11548.08","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","34537.28","","MASSHEALTH [3001]","HB BWH MEDICAID","5221.75","","Case rate ($5,773.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,203.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6006.01","6006.01","6006.01","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","34537.28","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17954.07","","Fee schedule rate ($17,954.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17954.07","17954.07","17954.07","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","34537.28","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18852.07","","Fee schedule rate ($18,852.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18302.82","18302.82","18302.82","1 through 10","3991.43","77819.99","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","34537.28","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5221.75","","Case rate ($5,773.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,203.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5772.13","1126.84","27574.16","1 through 10","3991.43","77819.99","case rate",""
"Other Heart Assist System Implant","215","MS-DRG","","","","","","","","inpatient","","","421525.93","316144.45","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","93944.90","","Case rate ($91,208.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $109,719.81, add-ons for qualifying new technology services are included. If operating cost exceeds $155,364.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $10,452.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $82,816.82 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $109,339.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $8,011.99. The transfer capital threshold is the transfer adjustment factor * $8,011.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","99377.80","99333.62","99417.30","1 through 10","89384.47","155966.45","other","Inpatient DRG"
"Other Heart Assist System Implant","215","MS-DRG","","","","","","","","inpatient","","","421525.93","316144.45","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","118260.01","","Case rate ($118,260.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $109,719.81, add-ons for qualifying new technology services are included. If operating cost exceeds $155,364.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $10,452.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $109,868.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $109,339.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $8,011.99. The transfer capital threshold is the transfer adjustment factor * $8,011.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","95408.29","95408.29","96767.34","1 through 10","89384.47","155966.45","other","Inpatient DRG"
"Other Heart Assist System Implant","215","MS-DRG","","","","","","","","inpatient","","","421525.93","316144.45","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","91208.64","","Case rate ($91,208.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $109,719.81, add-ons for qualifying new technology services are included. If operating cost exceeds $155,364.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $10,452.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $82,816.82 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $109,339.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $8,011.99. The transfer capital threshold is the transfer adjustment factor * $8,011.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","94702.41","94702.41","94702.41","1 through 10","89384.47","155966.45","other","Inpatient DRG"
"Other Heart Assist System Implant","215","MS-DRG","","","","","","","","inpatient","","","421525.93","316144.45","MARTIN'S POINT [160007]","HB BWH MEDICARE","118260.01","","Case rate ($118,260.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $109,719.81, add-ons for qualifying new technology services are included. If operating cost exceeds $155,364.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $10,452.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $109,868.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $109,339.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $8,011.99. The transfer capital threshold is the transfer adjustment factor * $8,011.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","94567.47","94567.47","94567.47","1 through 10","89384.47","155966.45","other","Inpatient DRG"
"Other Heart Assist System Implant","215","MS-DRG","","","","","","","","inpatient","","","421525.93","316144.45","MEDICARE [2001]","HB BWH MEDICARE","118260.01","","Case rate ($118,260.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $109,719.81, add-ons for qualifying new technology services are included. If operating cost exceeds $155,364.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $10,452.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $109,868.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $109,339.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $8,011.99. The transfer capital threshold is the transfer adjustment factor * $8,011.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","125329.45","0.03","248875.71","20","89384.47","155966.45","other","Inpatient DRG"
"Other Heart Assist System Implant","215","MS-DRG","","","","","","","","inpatient","","","421525.93","316144.45","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","89384.47","","Case rate ($91,208.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $109,719.81, add-ons for qualifying new technology services are included. If operating cost exceeds $155,364.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $10,452.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $82,816.82 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $109,339.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $8,011.99. The transfer capital threshold is the transfer adjustment factor * $8,011.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","94777.31","94777.31","94777.31","1 through 10","89384.47","155966.45","other","Inpatient DRG"
"Other Heart Assist System Implant","215","MS-DRG","","","","","","","","inpatient","","","421525.93","316144.45","WELLPOINT [1015]","HB AMC WELLPOINT","155966.45","","Fee schedule rate ($155,966.45).","297512.97","297512.97","297512.97","1 through 10","89384.47","155966.45","case rate",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","","","","inpatient","","","71215.91","53411.93","MEDICARE [2001]","HB BWH MEDICARE","20338.08","","Case rate ($20,338.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,405.64, add-ons for qualifying new technology services are included. If operating cost exceeds $70,050.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,200.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $18,197.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,025.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,760.51. The transfer capital threshold is the transfer adjustment factor * $1,760.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27196.44","27196.44","27196.44","1 through 10","19931.32","34271.27","other","Inpatient Replacement Plans DRG"
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","","","","inpatient","","","71215.91","53411.93","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19931.32","","Case rate ($20,338.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,405.64, add-ons for qualifying new technology services are included. If operating cost exceeds $70,050.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,200.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $18,197.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,025.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,760.51. The transfer capital threshold is the transfer adjustment factor * $1,760.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20640.53","20640.53","20640.53","1 through 10","19931.32","34271.27","other","Inpatient DRG"
"Other Hepatobiliary Or Pancreas O.R. Procedures With McC","423","MS-DRG","","","","","","","","inpatient","","","251256.28","188442.21","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","49546.88","","Case rate ($49,546.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $45,984.83, add-ons for qualifying new technology services are included. If operating cost exceeds $91,629.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,781.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $45,825.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,604.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,341.75. The transfer capital threshold is the transfer adjustment factor * $3,341.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","55867.33","55867.33","55867.33","1 through 10","37498.65","61381.1334","other","Inpatient DRG"
"Other Hepatobiliary Or Pancreas O.R. Procedures With McC","423","MS-DRG","","","","","","","","inpatient","","","251256.28","188442.21","MEDICARE [2001]","HB BWH MEDICARE","49546.88","","Case rate ($49,546.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $45,984.83, add-ons for qualifying new technology services are included. If operating cost exceeds $91,629.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,781.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $45,825.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,604.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,341.75. The transfer capital threshold is the transfer adjustment factor * $3,341.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","48301.22","48229.50","161434.67","1 through 10","37498.65","61381.1334","other","Inpatient DRG"
"Other Hepatobiliary Or Pancreas O.R. Procedures With McC","423","MS-DRG","","","","","","","","inpatient","","","251256.28","188442.21","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","37498.65","","Case rate ($38,263.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $45,984.83, add-ons for qualifying new technology services are included. If operating cost exceeds $91,629.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,781.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $34,542.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,604.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,341.75. The transfer capital threshold is the transfer adjustment factor * $3,341.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","36480.39","36480.39","36480.39","1 through 10","37498.65","61381.1334","other","Inpatient DRG"
"Other Hepatobiliary, Pancreas And Abdominal Procedures,EXTREME","264","DRG","","","","","","","","inpatient","","","300246.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","54866.51","","Standard inlier is a Case rate ($54,866.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,315, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,788.63) for the length of stay and the standard reimbursement.","129190.20","129190.20","129190.20","1 through 10","12971.57","296934.6","case rate",""
"Other Hepatobiliary, Pancreas And Abdominal Procedures,EXTREME","264","DRG","","","","","","","","inpatient","","","300246.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","61684.74","","Standard inlier is a Case rate ($61,684.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,315, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,755.64) for the length of stay and the standard reimbursement.","145571.24","145571.24","145571.24","1 through 10","12971.57","296934.6","case rate",""
"Other Hepatobiliary, Pancreas And Abdominal Procedures,EXTREME","264","DRG","","","","","","","","inpatient","","","300246.65","","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","","38.3","","59275.18","59275.18","59275.18","1 through 10","12971.57","296934.6","percent of total billed charges",""
"Other Hepatobiliary, Pancreas And Abdominal Procedures,EXTREME","264","DRG","","","","","","","","inpatient","","","300246.65","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","26849.3468","","Fee schedule rate ($179,958.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26849.3468","179958.16","179958.16","1 through 10","12971.57","296934.6","case rate",""
"Other Hepatobiliary, Pancreas And Abdominal Procedures,EXTREME","264","DRG","","","","","","","","inpatient","","","300246.65","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","21616.99","","Case rate ($23,901.30). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,331.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1945.41","1945.41","461196.66","1 through 10","12971.57","296934.6","case rate",""
"Other Hepatobiliary, Pancreas And Abdominal Procedures,MAJOR","264","DRG","","","","","","","","inpatient","","","66807.87","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","74970.68","","Standard inlier is a Case rate ($74,970.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,503, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,641.47) for the length of stay and the standard reimbursement.","68492.19","68492.19","68492.19","1 through 10","12971.57","296934.6","case rate",""
"Other Hepatobiliary, Pancreas And Abdominal Procedures,MAJOR","264","DRG","","","","","","","","inpatient","","","66807.87","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","26849.3468","","Fee schedule rate ($75,745.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26849.3468","60059.16","60059.16","1 through 10","12971.57","296934.6","case rate",""
"Other Hepatobiliary, Pancreas And Abdominal Procedures,MAJOR","264","DRG","","","","","","","","inpatient","","","66807.87","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78245.94","","Fee schedule rate ($78,245.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","78245.94","78245.94","78245.94","1 through 10","12971.57","296934.6","case rate",""
"Other Hepatobiliary, Pancreas And Abdominal Procedures,MINOR","264","DRG","","","","","","","","inpatient","","","71215.91","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12971.57","","Case rate ($14,342.30). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,772.30, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14338.78","14338.78","14338.78","1 through 10","12971.57","296934.6","case rate",""
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","","","","inpatient","","","65237.05","48927.79","MEDICARE [2001]","HB BWH MEDICARE","9785.64","","Case rate ($9,785.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,702.57, add-ons for qualifying new technology services are included. If operating cost exceeds $57,347.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,269.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,576.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,322.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $829.68. The transfer capital threshold is the transfer adjustment factor * $829.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12658.07","12658.07","12658.07","1 through 10","9589.93","15847.0591","other","Inpatient Replacement Plans DRG"
"Other Infectious And Parasitic Diseases Diagnoses With McC","867","MS-DRG","","","","","","","","inpatient","","","189456.45","142092.34","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","24342.79","","Case rate ($19,474.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,365.72, add-ons for qualifying new technology services are included. If operating cost exceeds $69,010.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,124.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $17,410.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,985.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,684.31. The transfer capital threshold is the transfer adjustment factor * $1,684.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","19792.22","19792.22","19792.22","1 through 10","19084.75","32359.6313","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases Diagnoses With McC","867","MS-DRG","","","","","","","","inpatient","","","189456.45","142092.34","MEDICARE [2001]","HB BWH MEDICARE","19474.23","","Case rate ($19,474.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,365.72, add-ons for qualifying new technology services are included. If operating cost exceeds $69,010.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,124.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $17,410.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,985.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,684.31. The transfer capital threshold is the transfer adjustment factor * $1,684.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25557.76","25557.76","25989.22","1 through 10","19084.75","32359.6313","other","Inpatient Replacement Plans DRG"
"Other Infectious And Parasitic Diseases Diagnoses With McC","867","MS-DRG","","","","","","","","inpatient","","","189456.45","142092.34","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19084.75","","Case rate ($19,474.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,365.72, add-ons for qualifying new technology services are included. If operating cost exceeds $69,010.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,124.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $17,410.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,985.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,684.31. The transfer capital threshold is the transfer adjustment factor * $1,684.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19346.71","19346.71","19346.71","1 through 10","19084.75","32359.6313","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases,EXTREME","724","DRG","","","","","","","","inpatient","","","189456.45","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","206195.69","206195.69","206195.69","1 through 10","6389.25","117940.5","percent of total billed charges",""
"Other Infectious And Parasitic Diseases,EXTREME","724","DRG","","","","","","","","inpatient","","","189456.45","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","19311.70","","Case rate ($21,352.40). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,782.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,572.25 and the sum of the standard inlier and any outlier amount.","6822.66","6822.66","6822.66","1 through 10","6389.25","117940.5","case rate",""
"Other Infectious And Parasitic Diseases,EXTREME","724","DRG","","","","","","","","inpatient","","","189456.45","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14475.9224","","Fee schedule rate ($71,478.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14475.9224","71478.24","71478.24","1 through 10","6389.25","117940.5","case rate",""
"Other Infectious And Parasitic Diseases,MAJOR","724","DRG","","","","","","","","inpatient","","","67094.97","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","19790.748","","Standard inlier is a Case rate ($39,559.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,010, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,615.17) for the length of stay and the standard reimbursement.","19790.748","55972.96","55972.96","1 through 10","6389.25","117940.5","case rate",""
"Other Infectious And Parasitic Diseases,MAJOR","724","DRG","","","","","","","","inpatient","","","67094.97","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","38080.34","38080.34","38080.34","1 through 10","6389.25","117940.5","percent of total billed charges",""
"Other Infectious And Parasitic Diseases,MAJOR","724","DRG","","","","","","","","inpatient","","","67094.97","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14475.9224","","Fee schedule rate ($71,478.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14475.9224","30602.52","30602.52","1 through 10","6389.25","117940.5","case rate",""
"Other Infectious And Parasitic Diseases,MAJOR","724","DRG","","","","","","","","inpatient","","","67094.97","","MASSHEALTH [3001]","HB BWH MEDICAID","9303.43","","Case rate ($10,286.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,716.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16552.63","16552.63","16552.63","1 through 10","6389.25","117940.5","case rate",""
"Other Infectious And Parasitic Diseases,MAJOR","724","DRG","","","","","","","","inpatient","","","67094.97","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9303.43","","Case rate ($10,286.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,716.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10284.02","10284.02","10284.02","1 through 10","6389.25","117940.5","case rate",""
"Other Infectious And Parasitic Diseases,MINOR","724","DRG","","","","","","","","inpatient","","","44939.41","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14475.9224","","Fee schedule rate ($14,475.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14475.9224","14475.92","14475.92","1 through 10","6389.25","117940.5","case rate",""
"Other Infectious And Parasitic Diseases,MINOR","724","DRG","","","","","","","","inpatient","","","44939.41","","MASSHEALTH [3001]","HB BWH MEDICAID","6389.25","","Case rate ($7,064.42). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,494.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7062.68","7062.68","7062.68","1 through 10","6389.25","117940.5","case rate",""
"Other Infectious And Parasitic Diseases,MINOR","724","DRG","","","","","","","","inpatient","","","44939.41","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6389.25","","Case rate ($7,064.42). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,494.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","11498.41","1 through 10","6389.25","117940.5","case rate",""
"Other Infectious And Parasitic Diseases,MODERATE","724","DRG","","","","","","","","inpatient","","","34133.71","","MASSHEALTH [3001]","HB BWH MEDICAID","6389.25","","Case rate ($7,064.42). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,494.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4143.63","4143.63","7263.46","1 through 10","6389.25","117940.5","case rate",""
"Other Infectious And Parasitic Diseases,MODERATE","724","DRG","","","","","","","","inpatient","","","34133.71","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24630.33","","Fee schedule rate ($24,630.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24630.33","24630.33","24630.33","1 through 10","6389.25","117940.5","case rate",""
"Other Infectious And Parasitic Diseases,MODERATE","724","DRG","","","","","","","","inpatient","","","34133.71","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6389.25","","Case rate ($7,064.42). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,494.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7263.46","7263.46","7263.46","1 through 10","6389.25","117940.5","case rate",""
"Other Injury, Poisoning And Toxic Effect Diagnoses With McC","922","MS-DRG","","","","","","","","inpatient","","","179848.07","134886.05","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","16338.04","","Case rate ($16,338.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,590.37, add-ons for qualifying new technology services are included. If operating cost exceeds $65,234.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,847.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $14,550.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,210.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,407.67. The transfer capital threshold is the transfer adjustment factor * $1,407.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15316.85","15316.85","15316.85","1 through 10","16011.28","25494.7354","other","Inpatient DRG"
"Other Injury, Poisoning And Toxic Effect Diagnoses With McC","922","MS-DRG","","","","","","","","inpatient","","","179848.07","134886.05","MARTIN'S POINT [160007]","HB BWH MEDICARE","21090.84","","Case rate ($21,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,590.37, add-ons for qualifying new technology services are included. If operating cost exceeds $65,234.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,847.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $19,303.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,210.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,407.67. The transfer capital threshold is the transfer adjustment factor * $1,407.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15560.77","15560.77","15560.77","1 through 10","16011.28","25494.7354","other","Inpatient DRG"
"Other Injury, Poisoning And Toxic Effect Diagnoses With McC","922","MS-DRG","","","","","","","","inpatient","","","179848.07","134886.05","MEDICARE [2001]","HB BWH MEDICARE","21090.84","","Case rate ($21,090.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,590.37, add-ons for qualifying new technology services are included. If operating cost exceeds $65,234.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,847.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $19,303.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,210.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,407.67. The transfer capital threshold is the transfer adjustment factor * $1,407.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20224.68","20224.68","20224.68","1 through 10","16011.28","25494.7354","other","Inpatient DRG"
"Other Injury, Poisoning And Toxic Effect Diagnoses Without McC","923","MS-DRG","","","","","","","","inpatient","","","34014.02","25510.51","HUMANA [1012]","HB BWH MEDICARE","9663.41","","Case rate ($9,663.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,555.43, add-ons for qualifying new technology services are included. If operating cost exceeds $57,199.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,259.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,464.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,175.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $818.90. The transfer capital threshold is the transfer adjustment factor * $818.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9399.43","9399.43","9399.43","1 through 10","9470.14","15263.0374","other","Inpatient Replacement Plans DRG"
"Other Injury, Poisoning And Toxic Effect Diagnoses,EXTREME","815","DRG","","","","","","","","inpatient","","","193364.81","","MASSHEALTH [3001]","HB BWH MEDICAID","20043.95","","Case rate ($22,162.04). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,592.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22156.60","22156.60","22156.60","1 through 10","4184.49","95979.06","case rate",""
"Other Injury, Poisoning And Toxic Effect Diagnoses,MAJOR","815","DRG","","","","","","","","inpatient","","","37242.70","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","31825.91","","Standard inlier is a Case rate ($31,825.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,661, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,517.42) for the length of stay and the standard reimbursement.","31825.90","31825.90","31825.90","1 through 10","4184.49","95979.06","case rate",""
"Other Injury, Poisoning And Toxic Effect Diagnoses,MAJOR","815","DRG","","","","","","","","inpatient","","","37242.70","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10999.84","","Case rate ($12,162.22). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,592.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1056.77","1056.77","12159.23","1 through 10","4184.49","95979.06","case rate",""
"Other Injury, Poisoning And Toxic Effect Diagnoses,MINOR","815","DRG","","","","","","","","inpatient","","","27725.12","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","13642.27","","Standard inlier is a Case rate ($13,642.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $21,084, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,936.41) for the length of stay and the standard reimbursement.","13642.32","13642.32","13642.32","1 through 10","4184.49","95979.06","case rate",""
"Other Injury, Poisoning And Toxic Effect Diagnoses,MODERATE","815","DRG","","","","","","","","inpatient","","","26981.12","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6417.81","","Case rate ($7,095.99). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,525.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7094.25","7094.25","7094.25","1 through 10","4184.49","95979.06","case rate",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","45472.48","34104.36","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","9927.95","","Case rate ($9,638.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,525.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,170.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,442.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,145.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $816.73. The transfer capital threshold is the transfer adjustment factor * $816.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9848.60","9848.60","9848.60","1 through 10","9446.01","15317.365","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","45472.48","34104.36","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12396.36","","Case rate ($12,396.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,525.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,170.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,199.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,145.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $816.73. The transfer capital threshold is the transfer adjustment factor * $816.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12163.89","12163.89","12163.89","1 through 10","9446.01","15317.365","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","45472.48","34104.36","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","12048.49","","Case rate ($9,638.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,525.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,170.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,442.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,145.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $816.73. The transfer capital threshold is the transfer adjustment factor * $816.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","9535.60","9535.60","9580.20","1 through 10","9446.01","15317.365","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","45472.48","34104.36","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9638.79","","Case rate ($9,638.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,525.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,170.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,442.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,145.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $816.73. The transfer capital threshold is the transfer adjustment factor * $816.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9414.32","9378.43","9461.68","1 through 10","9446.01","15317.365","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","45472.48","34104.36","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","9619.80","9619.80","9619.80","1 through 10","9446.01","15317.365","case rate",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","45472.48","34104.36","FALLON HEALTH [1008]","HB BWH MEDICARE","12396.36","","Case rate ($12,396.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,525.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,170.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,199.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,145.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $816.73. The transfer capital threshold is the transfer adjustment factor * $816.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9548.40","9548.40","9548.40","1 through 10","9446.01","15317.365","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","45472.48","34104.36","HUMANA [1012]","HB BWH MEDICARE","12396.36","","Case rate ($12,396.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,525.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,170.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,199.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,145.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $816.73. The transfer capital threshold is the transfer adjustment factor * $816.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9408.82","9408.82","9408.82","1 through 10","9446.01","15317.365","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","45472.48","34104.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","","65","","59215.03","59215.03","178256.42","1 through 10","9446.01","15317.365","percent of total billed charges",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","45472.48","34104.36","MEDICARE [2001]","HB BWH MEDICARE","12396.36","","Case rate ($12,396.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,525.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,170.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,199.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,145.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $816.73. The transfer capital threshold is the transfer adjustment factor * $816.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12302.04","0.03","12320.02","89","9446.01","15317.365","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","45472.48","34104.36","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","12396.36","","Case rate ($12,396.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,525.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,170.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,199.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,145.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $816.73. The transfer capital threshold is the transfer adjustment factor * $816.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9355.02","9355.02","9357.40","1 through 10","9446.01","15317.365","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","45472.48","34104.36","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9446.01","","Case rate ($9,638.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,525.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,170.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,442.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,145.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $816.73. The transfer capital threshold is the transfer adjustment factor * $816.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9400.39","9386.80","9478.51","1 through 10","9446.01","15317.365","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","45472.48","34104.36","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9446.01","","Case rate ($9,638.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,525.78, add-ons for qualifying new technology services are included. If operating cost exceeds $57,170.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,442.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,145.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $816.73. The transfer capital threshold is the transfer adjustment factor * $816.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9404.18","9363.30","9482.75","13","9446.01","15317.365","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","63518.29","47638.72","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15935.60","","Case rate ($15,471.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,547.17, add-ons for qualifying new technology services are included. If operating cost exceeds $64,191.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,771.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,760.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,167.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.23. The transfer capital threshold is the transfer adjustment factor * $1,331.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","13410.51","13410.51","13410.51","1 through 10","15162.03","25366.4619","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","63518.29","47638.72","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","15471.46","","Case rate ($15,471.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,547.17, add-ons for qualifying new technology services are included. If operating cost exceeds $64,191.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,771.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,760.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,167.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.23. The transfer capital threshold is the transfer adjustment factor * $1,331.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15367.21","15367.21","16547.76","1 through 10","15162.03","25366.4619","other","Inpatient Replacement Plans DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","63518.29","47638.72","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15471.46","","Case rate ($15,471.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,547.17, add-ons for qualifying new technology services are included. If operating cost exceeds $64,191.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,771.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,760.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,167.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.23. The transfer capital threshold is the transfer adjustment factor * $1,331.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15226.48","15226.48","15317.76","1 through 10","15162.03","25366.4619","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","63518.29","47638.72","FALLON HEALTH [1008]","HB BWH MEDICARE","15471.46","","Case rate ($15,471.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,547.17, add-ons for qualifying new technology services are included. If operating cost exceeds $64,191.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,771.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,760.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,167.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.23. The transfer capital threshold is the transfer adjustment factor * $1,331.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15556.38","15556.38","15556.38","1 through 10","15162.03","25366.4619","other","Inpatient Replacement Plans DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","63518.29","47638.72","MEDICARE [2001]","HB BWH MEDICARE","15471.46","","Case rate ($15,471.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,547.17, add-ons for qualifying new technology services are included. If operating cost exceeds $64,191.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,771.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,760.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,167.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.23. The transfer capital threshold is the transfer adjustment factor * $1,331.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20094.68","0.03","20124.32","116","15162.03","25366.4619","other","Inpatient Replacement Plans DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","63518.29","47638.72","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","15471.46","","Case rate ($15,471.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,547.17, add-ons for qualifying new technology services are included. If operating cost exceeds $64,191.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,771.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,760.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,167.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.23. The transfer capital threshold is the transfer adjustment factor * $1,331.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9633.55","9633.55","9633.55","1 through 10","15162.03","25366.4619","other","Inpatient Replacement Plans DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","63518.29","47638.72","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","15162.03","","Case rate ($15,471.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,547.17, add-ons for qualifying new technology services are included. If operating cost exceeds $64,191.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,771.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,760.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,167.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.23. The transfer capital threshold is the transfer adjustment factor * $1,331.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15258.20","9646.16","15391.45","1 through 10","15162.03","25366.4619","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","63518.29","47638.72","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15162.03","","Case rate ($15,471.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,547.17, add-ons for qualifying new technology services are included. If operating cost exceeds $64,191.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,771.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,760.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,167.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.23. The transfer capital threshold is the transfer adjustment factor * $1,331.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15332.64","15264.17","15412.73","1 through 10","15162.03","25366.4619","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses Without Cc/McC","700","MS-DRG","","","","","","","","inpatient","","","25077.19","18807.89","MEDICARE [2001]","HB BWH MEDICARE","8547.52","","Case rate ($8,547.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,955.78, add-ons for qualifying new technology services are included. If operating cost exceeds $53,600.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,995.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,612.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,575.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $555.13. The transfer capital threshold is the transfer adjustment factor * $555.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","3280.22","3280.22","5370.01","1 through 10","6539.73","10476.1722","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,EXTREME","468","DRG","","","","","","","","inpatient","","","61201.71","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","90988.99","","Fee schedule rate ($90,988.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","92189.21","92189.21","92189.21","1 through 10","4687.13","121690.15","case rate",""
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,EXTREME","468","DRG","","","","","","","","inpatient","","","61201.71","","MASSHEALTH [3001]","HB BWH MEDICAID","10427.52","","Case rate ($11,529.41). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,959.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","36579.63","36579.63","36579.63","1 through 10","4687.13","121690.15","case rate",""
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,EXTREME","468","DRG","","","","","","","","inpatient","","","61201.71","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","10427.52","","Case rate ($11,529.41). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,959.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4171.74","4171.74","4171.74","1 through 10","4687.13","121690.15","case rate",""
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,MAJOR","468","DRG","","","","","","","","inpatient","","","48070.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19909.12","","Standard inlier is a Case rate ($19,909.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,129, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,826.22) for the length of stay and the standard reimbursement.","28424.50","28424.50","28424.50","1 through 10","4687.13","121690.15","case rate",""
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,MAJOR","468","DRG","","","","","","","","inpatient","","","48070.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22383.22","","Standard inlier is a Case rate ($22,383.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,129, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,177.11) for the length of stay and the standard reimbursement.","29195.30","29195.30","29195.30","1 through 10","4687.13","121690.15","case rate",""
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,MAJOR","468","DRG","","","","","","","","inpatient","","","48070.98","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","11757.0916","","Fee schedule rate ($27,300.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11757.0916","28599.69","28599.69","1 through 10","4687.13","121690.15","case rate",""
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,MAJOR","468","DRG","","","","","","","","inpatient","","","48070.98","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11196.9202","","Fee schedule rate ($25,999.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11196.9202","25999.40","25999.40","1 through 10","4687.13","121690.15","case rate",""
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,MAJOR","468","DRG","","","","","","","","inpatient","","","48070.98","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","28599.69","","Fee schedule rate ($28,599.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28599.69","28599.69","28599.69","1 through 10","4687.13","121690.15","case rate",""
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,MAJOR","468","DRG","","","","","","","","inpatient","","","48070.98","","MASSHEALTH [3001]","HB BWH MEDICAID","5879.76","","Case rate ($6,501.08). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,931.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11526.59","11526.59","11526.59","1 through 10","4687.13","121690.15","case rate",""
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,MAJOR","468","DRG","","","","","","","","inpatient","","","48070.98","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5879.76","","Case rate ($6,501.08). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,931.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11526.58","11526.58","11526.58","1 through 10","4687.13","121690.15","case rate",""
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,MINOR","468","DRG","","","","","","","","inpatient","","","28971.13","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","16274.74","","Standard inlier is a Case rate ($16,274.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,906, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,310.06) for the length of stay and the standard reimbursement.","16274.73","16274.73","16274.73","1 through 10","4687.13","121690.15","case rate",""
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,MODERATE","468","DRG","","","","","","","","inpatient","","","28470.59","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11196.9202","","Fee schedule rate ($16,629.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11196.9202","16629.88","16629.88","1 through 10","4687.13","121690.15","case rate",""
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","","","","inpatient","","","108043.04","81032.28","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","28066.34","","Case rate ($28,066.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,060.51, add-ons for qualifying new technology services are included. If operating cost exceeds $71,704.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,321.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $25,804.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,680.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,881.77. The transfer capital threshold is the transfer adjustment factor * $1,881.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21001.77","21001.77","21001.77","1 through 10","21278.53","34836.0644","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","","","","inpatient","","","108043.04","81032.28","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","21712.79","","Case rate ($21,712.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,060.51, add-ons for qualifying new technology services are included. If operating cost exceeds $71,704.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,321.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,451.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,680.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,881.77. The transfer capital threshold is the transfer adjustment factor * $1,881.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20976.42","20976.42","20976.42","1 through 10","21278.53","34836.0644","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","","","","inpatient","","","108043.04","81032.28","MEDICARE [2001]","HB BWH MEDICARE","28066.34","","Case rate ($28,066.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,060.51, add-ons for qualifying new technology services are included. If operating cost exceeds $71,704.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,321.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $25,804.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,680.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,881.77. The transfer capital threshold is the transfer adjustment factor * $1,881.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27492.36","27492.36","27533.08","1 through 10","21278.53","34836.0644","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","","","","inpatient","","","108043.04","81032.28","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","21278.53","","Case rate ($21,712.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,060.51, add-ons for qualifying new technology services are included. If operating cost exceeds $71,704.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,321.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,451.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,680.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,881.77. The transfer capital threshold is the transfer adjustment factor * $1,881.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21056.69","21056.69","21056.69","1 through 10","21278.53","34836.0644","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With McC","673","MS-DRG","","","","","","","","inpatient","","","174213.21","130659.91","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","39868.51","","Case rate ($38,707.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,518.52, add-ons for qualifying new technology services are included. If operating cost exceeds $92,162.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,821.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $34,946.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,138.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,380.85. The transfer capital threshold is the transfer adjustment factor * $3,380.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","39514.20","39514.20","39514.20","1 through 10","37933.14","65813.86","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With McC","673","MS-DRG","","","","","","","","inpatient","","","174213.21","130659.91","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","38707.29","","Case rate ($38,707.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,518.52, add-ons for qualifying new technology services are included. If operating cost exceeds $92,162.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,821.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $34,946.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,138.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,380.85. The transfer capital threshold is the transfer adjustment factor * $3,380.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","37843.10","37843.10","37843.10","1 through 10","37933.14","65813.86","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With McC","673","MS-DRG","","","","","","","","inpatient","","","174213.21","130659.91","MEDICARE [2001]","HB BWH MEDICARE","38707.29","","Case rate ($38,707.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,518.52, add-ons for qualifying new technology services are included. If operating cost exceeds $92,162.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,821.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $34,946.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,138.68 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,380.85. The transfer capital threshold is the transfer adjustment factor * $3,380.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","49670.13","49670.13","99747.17","16","37933.14","65813.86","other","Inpatient Replacement Plans DRG"
"Other Kidney, Urinary Tract And Related Non-Percutaneous Procedures,EXTREME","447","DRG","","","","","","","","inpatient","","","421358.20","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","25880.8557","","Fee schedule rate ($186,261.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25880.8557","186261.20","186261.20","1 through 10","15845.76","307334.72","case rate",""
"Other Kidney, Urinary Tract And Related Non-Percutaneous Procedures,EXTREME","447","DRG","","","","","","","","inpatient","","","421358.20","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","27175.6506","","Fee schedule rate ($195,579.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27175.6506","193546.77","193546.77","1 through 10","15845.76","307334.72","case rate",""
"Other Kidney, Urinary Tract And Related Non-Percutaneous Procedures,MAJOR","447","DRG","","","","","","","","inpatient","","","102975.39","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","","65","","79925.14","79925.14","79925.14","1 through 10","15845.76","307334.72","percent of total billed charges",""
"Other Kidney, Urinary Tract And Related Non-Percutaneous Procedures,MAJOR","447","DRG","","","","","","","","inpatient","","","102975.39","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","78994.72","78994.72","78994.72","1 through 10","15845.76","307334.72","percent of total billed charges",""
"Other Kidney, Urinary Tract And Related Non-Percutaneous Procedures,MAJOR","447","DRG","","","","","","","","inpatient","","","102975.39","","MASSHEALTH [3001]","HB BWH MEDICAID","21478.77","","Case rate ($23,748.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,178.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23742.64","23742.64","23742.64","1 through 10","15845.76","307334.72","case rate",""
"Other Kidney, Urinary Tract And Related Non-Percutaneous Procedures,MODERATE","447","DRG","","","","","","","","inpatient","","","25753.37","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","25880.8557","","Fee schedule rate ($31,309.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25880.8557","31309.32","31309.32","1 through 10","15845.76","307334.72","case rate",""
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","","","","inpatient","","","144195.41","108146.56","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","42482.62","","Case rate ($42,482.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,432.34, add-ons for qualifying new technology services are included. If operating cost exceeds $85,076.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,301.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $39,241.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,052.50 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,861.61. The transfer capital threshold is the transfer adjustment factor * $2,861.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","31202.33","31202.33","31202.33","1 through 10","32164.37","51979.4404","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","","","","inpatient","","","144195.41","108146.56","MEDICARE [2001]","HB BWH MEDICARE","42482.62","","Case rate ($42,482.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,432.34, add-ons for qualifying new technology services are included. If operating cost exceeds $85,076.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,301.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $39,241.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,052.50 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,861.61. The transfer capital threshold is the transfer adjustment factor * $2,861.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","40884.87","0.03","40945.60","27","32164.37","51979.4404","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","","","","inpatient","","","144195.41","108146.56","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","42482.62","","Case rate ($42,482.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,432.34, add-ons for qualifying new technology services are included. If operating cost exceeds $85,076.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,301.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $39,241.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,052.50 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,861.61. The transfer capital threshold is the transfer adjustment factor * $2,861.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","30950.05","30950.05","30950.05","1 through 10","32164.37","51979.4404","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","","","","inpatient","","","144195.41","108146.56","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","32164.37","","Case rate ($32,820.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,432.34, add-ons for qualifying new technology services are included. If operating cost exceeds $85,076.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,301.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $29,579.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,052.50 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,861.61. The transfer capital threshold is the transfer adjustment factor * $2,861.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","30955.04","30955.04","30955.04","1 through 10","32164.37","51979.4404","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","","","","inpatient","","","144195.41","108146.56","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","32164.37","","Case rate ($32,820.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,432.34, add-ons for qualifying new technology services are included. If operating cost exceeds $85,076.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,301.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $29,579.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,052.50 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,861.61. The transfer capital threshold is the transfer adjustment factor * $2,861.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","30988.42","30944.71","43608.40","1 through 10","32164.37","51979.4404","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","294982.92","221237.19","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","49966.13","","Case rate ($48,510.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,320.04, add-ons for qualifying new technology services are included. If operating cost exceeds $103,964.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,685.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $43,885.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,940.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,245.62. The transfer capital threshold is the transfer adjustment factor * $4,245.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","49764.53","49764.53","49764.53","1 through 10","47540.59","77462.103","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","294982.92","221237.19","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","62845.57","","Case rate ($62,845.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,320.04, add-ons for qualifying new technology services are included. If operating cost exceeds $103,964.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,685.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $58,220.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,940.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,245.62. The transfer capital threshold is the transfer adjustment factor * $4,245.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","50347.83","50347.83","216238.45","1 through 10","47540.59","77462.103","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","294982.92","221237.19","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","62845.57","","Case rate ($62,845.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,320.04, add-ons for qualifying new technology services are included. If operating cost exceeds $103,964.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,685.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $58,220.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,940.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,245.62. The transfer capital threshold is the transfer adjustment factor * $4,245.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","45973.49","45973.49","45973.49","1 through 10","47540.59","77462.103","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","294982.92","221237.19","MEDICARE [2001]","HB BWH MEDICARE","62845.57","","Case rate ($62,845.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,320.04, add-ons for qualifying new technology services are included. If operating cost exceeds $103,964.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,685.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $58,220.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,940.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,245.62. The transfer capital threshold is the transfer adjustment factor * $4,245.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","60792.01","60792.01","110445.53","27","47540.59","77462.103","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","294982.92","221237.19","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","62845.57","","Case rate ($62,845.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,320.04, add-ons for qualifying new technology services are included. If operating cost exceeds $103,964.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,685.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $58,220.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,940.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,245.62. The transfer capital threshold is the transfer adjustment factor * $4,245.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","100.23","100.23","100.23","1 through 10","47540.59","77462.103","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","294982.92","221237.19","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","47540.59","","Case rate ($48,510.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,320.04, add-ons for qualifying new technology services are included. If operating cost exceeds $103,964.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,685.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $43,885.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,940.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,245.62. The transfer capital threshold is the transfer adjustment factor * $4,245.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","45999.39","45999.39","45999.39","1 through 10","47540.59","77462.103","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","294982.92","221237.19","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","47540.59","","Case rate ($48,510.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,320.04, add-ons for qualifying new technology services are included. If operating cost exceeds $103,964.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,685.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $43,885.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,940.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,245.62. The transfer capital threshold is the transfer adjustment factor * $4,245.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","46115.43","46064.84","63023.95","1 through 10","47540.59","77462.103","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","294982.92","221237.19","WELLPOINT [1015]","HB AMC WELLPOINT","77462.103","","Fee schedule rate ($82,647.96).","77462.103","190478.92","190478.92","1 through 10","47540.59","77462.103","case rate",""
"Other Major Cardiovascular Procedures Without Cc/McC","272","MS-DRG","","","","","","","","inpatient","","","120637.08","90477.81","MEDICARE [2001]","HB BWH MEDICARE","23668.58","","Case rate ($23,668.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,414.88, add-ons for qualifying new technology services are included. If operating cost exceeds $74,059.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,494.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $21,234.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,035.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,054.29. The transfer capital threshold is the transfer adjustment factor * $2,054.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","0.03","0.03","0.03","1 through 10","23195.21","37760.7002","other","Inpatient Replacement Plans DRG"
"Other Major Cardiovascular Procedures Without Cc/McC","272","MS-DRG","","","","","","","","inpatient","","","120637.08","90477.81","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","23195.21","","Case rate ($23,668.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,414.88, add-ons for qualifying new technology services are included. If operating cost exceeds $74,059.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,494.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $21,234.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,035.05 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,054.29. The transfer capital threshold is the transfer adjustment factor * $2,054.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","30275.21","30275.21","30275.21","1 through 10","23195.21","37760.7002","other","Inpatient DRG"
"Other Major Head And Neck Procedures,EXTREME","091","DRG","","","","","","","","inpatient","","","184057.61","","MASSHEALTH [3001]","HB BWH MEDICAID","104135.80","","Case rate ($115,140.03). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $157,570.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","115111.77","115111.77","115111.77","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MAJOR","091","DRG","","","","","","","","inpatient","","","333294.77","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","124199.14","","Standard inlier is a Case rate ($124,199.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $108,231, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,630.82) for the length of stay and the standard reimbursement.","124199.14","124199.14","124199.14","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MAJOR","091","DRG","","","","","","","","inpatient","","","333294.77","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","139633.31","","Standard inlier is a Case rate ($139,633.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $108,231, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($19,819.79) for the length of stay and the standard reimbursement.","127567.08","127567.08","139633.30","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MAJOR","091","DRG","","","","","","","","inpatient","","","333294.77","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","98539.02","","Fee schedule rate ($98,539.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","98539.02","98539.02","98539.02","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MAJOR","091","DRG","","","","","","","","inpatient","","","333294.77","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","106611.89","","Fee schedule rate ($106,611.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","106611.89","106611.89","106611.89","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MAJOR","091","DRG","","","","","","","","inpatient","","","333294.77","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","47409.33","","Case rate ($52,419.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $94,849.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","52406.31","52406.31","52406.31","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MINOR","091","DRG","","","","","","","","inpatient","","","68205.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","69762.77","","Fee schedule rate ($69,762.77). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($8,071.87) multiplied by length of stay and the outlier percent (100%).","42362.76","42362.76","42362.76","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MINOR","091","DRG","","","","","","","","inpatient","","","68205.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","78432.16","","Fee schedule rate ($78,432.16). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($9,074.92) multiplied by length of stay and the outlier percent (100%).","52249.32","52249.32","52249.32","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MINOR","091","DRG","","","","","","","","inpatient","","","68205.74","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18012.1451","","Fee schedule rate ($30,510.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18012.1451","30510.84","30510.84","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MINOR","091","DRG","","","","","","","","inpatient","","","68205.74","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","30510.8247","","Fee schedule rate ($30,510.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30510.8247","30510.84","30510.84","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MINOR","091","DRG","","","","","","","","inpatient","","","68205.74","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","33562.32","","Fee schedule rate ($33,562.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33562.32","33562.32","33562.32","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MODERATE","091","DRG","","","","","","","","inpatient","","","140179.11","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","78432.16","","Standard inlier is a Case rate ($78,432.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $65,898, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,132.79) for the length of stay and the standard reimbursement.","78432.15","78432.15","78432.15","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MODERATE","091","DRG","","","","","","","","inpatient","","","140179.11","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18012.1451","","Fee schedule rate ($75,434.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18012.1451","21865.96","21865.96","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MODERATE","091","DRG","","","","","","","","inpatient","","","140179.11","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","30510.8247","","Fee schedule rate ($75,434.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30510.8247","21865.96","21865.96","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MODERATE","091","DRG","","","","","","","","inpatient","","","140179.11","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","18913.2758","","Fee schedule rate ($79,208.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18913.2758","79208.88","79208.88","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MODERATE","091","DRG","","","","","","","","inpatient","","","140179.11","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","32037.2526","","Fee schedule rate ($79,208.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32037.2526","79208.88","79208.88","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MODERATE","091","DRG","","","","","","","","inpatient","","","140179.11","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","23630.98","","Case rate ($26,128.11). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $68,558.11, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19552.99","19552.99","19552.99","1 through 10","17318.7818","218767.21","case rate",""
"Other Major Head And Neck Procedures,MODERATE","091","DRG","","","","","","","","inpatient","","","140179.11","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67141.48","","Fee schedule rate ($67,141.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","67141.48","67141.48","67141.48","1 through 10","17318.7818","218767.21","case rate",""
"Other Male Reproductive System And Related Procedures,MAJOR","484","DRG","","","","","","","","inpatient","","","87194.82","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","50078.63","","Standard inlier is a Case rate ($50,078.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,287, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,108.25) for the length of stay and the standard reimbursement.","54866.17","54866.17","54866.17","1 through 10","9758.09","71542.28","case rate",""
"Other Male Reproductive System And Related Procedures,MAJOR","484","DRG","","","","","","","","inpatient","","","87194.82","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17014.5769","","Fee schedule rate ($43,358.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17014.5769","43358.44","43358.44","1 through 10","9758.09","71542.28","case rate",""
"Other Male Reproductive System And Related Procedures,MAJOR","484","DRG","","","","","","","","inpatient","","","87194.82","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46449.85","","Fee schedule rate ($46,449.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","53387.34","53387.34","53387.34","1 through 10","9758.09","71542.28","case rate",""
"Other Male Reproductive System And Related Procedures,MODERATE","484","DRG","","","","","","","","inpatient","","","83225.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","44543.26","","Standard inlier is a Case rate ($44,543.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,287, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,323.18) for the length of stay and the standard reimbursement.","40602.80","40602.80","40602.80","1 through 10","9758.09","71542.28","case rate",""
"Other Male Reproductive System And Related Procedures,MODERATE","484","DRG","","","","","","","","inpatient","","","83225.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","50078.63","","Standard inlier is a Case rate ($50,078.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $46,287, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,108.25) for the length of stay and the standard reimbursement.","50078.62","50078.62","50078.62","1 through 10","9758.09","71542.28","case rate",""
"Other Male Reproductive System And Related Procedures,MODERATE","484","DRG","","","","","","","","inpatient","","","83225.66","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","17865.8002","","Fee schedule rate ($30,454.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17865.8002","30454.28","30454.28","1 through 10","9758.09","71542.28","case rate",""
"Other Male Reproductive System Diagnoses With Cc/McC","729","MS-DRG","","","","","","","","inpatient","","","34316.28","25737.21","MEDICARE [2001]","HB BWH MEDICARE","12913.71","","Case rate ($12,913.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,005.65, add-ons for qualifying new technology services are included. If operating cost exceeds $57,650.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,292.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $11,681.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,625.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $851.89. The transfer capital threshold is the transfer adjustment factor * $851.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","9836.66","16583.48","other","Inpatient DRG"
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC","717","MS-DRG","","","","","","","","inpatient","","","75094.71","56321.03","MEDICARE [2001]","HB BWH MEDICARE","22761.32","","Case rate ($22,761.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,139.83, add-ons for qualifying new technology services are included. If operating cost exceeds $66,784.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,961.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $20,860.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,759.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,521.21. The transfer capital threshold is the transfer adjustment factor * $1,521.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22185.77","0.03","22185.77","1 through 10","17272.67","28529.5355","other","Inpatient DRG"
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC","717","MS-DRG","","","","","","","","inpatient","","","75094.71","56321.03","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","17272.67","","Case rate ($17,625.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,139.83, add-ons for qualifying new technology services are included. If operating cost exceeds $66,784.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,961.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $15,724.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,759.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,521.21. The transfer capital threshold is the transfer adjustment factor * $1,521.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16888.57","16888.57","16888.57","1 through 10","17272.67","28529.5355","other","Inpatient DRG"
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/McC","715","MS-DRG","","","","","","","","inpatient","","","84376.83","63282.62","MEDICARE [2001]","HB BWH MEDICARE","20788.73","","Case rate ($20,788.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,948.12, add-ons for qualifying new technology services are included. If operating cost exceeds $70,592.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,240.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $18,608.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,568.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,800.26. The transfer capital threshold is the transfer adjustment factor * $1,800.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26941.55","26941.55","26941.55","1 through 10","20372.96","35045.07","other","Inpatient Replacement Plans DRG"
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","","","","inpatient","","","80816.17","60612.13","MEDICARE [2001]","HB BWH MEDICARE","10148.71","","Case rate ($10,148.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,139.63, add-ons for qualifying new technology services are included. If operating cost exceeds $57,784.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,907.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,759.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.71. The transfer capital threshold is the transfer adjustment factor * $861.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14321.27","14321.27","14321.27","1 through 10","9945.74","16774.58","other","Inpatient Replacement Plans DRG"
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","","","","inpatient","","","80816.17","60612.13","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9945.74","","Case rate ($10,148.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,139.63, add-ons for qualifying new technology services are included. If operating cost exceeds $57,784.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,907.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,759.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.71. The transfer capital threshold is the transfer adjustment factor * $861.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","23068.75","23068.75","23068.75","1 through 10","9945.74","16774.58","other","Inpatient DRG"
"Other Mental Health Conditions And Disorders,MAJOR","760","DRG","","","","","","","","inpatient","","","80816.17","","MASSHEALTH [3001]","HB BWH MEDICAID","15228.88","","Case rate ($16,838.15). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,268.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29348.09","29348.09","29348.09","1 through 10","954.59","46508.04","case rate",""
"Other Mental Health Conditions And Disorders,MAJOR","760","DRG","","","","","","","","inpatient","","","80816.17","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","15228.88","","Case rate ($16,838.15). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,268.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3635.49","3635.49","3635.49","1 through 10","954.59","46508.04","case rate",""
"Other Mental Health Conditions And Disorders,MAJOR","760","DRG","","","","","","","","inpatient","","","80816.17","","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","14253.6534","","Fee schedule rate ($15,031.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14253.6534","34005.83","34005.83","1 through 10","954.59","46508.04","case rate",""
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","","","","inpatient","","","56808.70","42606.52","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14360.38","","Case rate ($14,360.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,209.66, add-ons for qualifying new technology services are included. If operating cost exceeds $62,854.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,673.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,747.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,829.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,233.22. The transfer capital threshold is the transfer adjustment factor * $1,233.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","43897.26","43897.26","43897.26","1 through 10","14073.17","24006.65","other","Inpatient Replacement Plans DRG"
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","","","","inpatient","","","56808.70","42606.52","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","14360.38","","Case rate ($14,360.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,209.66, add-ons for qualifying new technology services are included. If operating cost exceeds $62,854.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,673.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,747.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,829.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,233.22. The transfer capital threshold is the transfer adjustment factor * $1,233.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13754.02","13754.02","13754.02","1 through 10","14073.17","24006.65","other","Inpatient DRG"
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","","","","inpatient","","","56808.70","42606.52","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","15304.80","15304.80","15304.80","1 through 10","14073.17","24006.65","case rate",""
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","","","","inpatient","","","56808.70","42606.52","MEDICARE [2001]","HB BWH MEDICARE","14360.38","","Case rate ($14,360.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,209.66, add-ons for qualifying new technology services are included. If operating cost exceeds $62,854.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,673.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,747.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,829.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,233.22. The transfer capital threshold is the transfer adjustment factor * $1,233.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17989.64","17963.18","17989.64","1 through 10","14073.17","24006.65","other","Inpatient Replacement Plans DRG"
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","","","","inpatient","","","56808.70","42606.52","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14073.17","","Case rate ($14,360.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,209.66, add-ons for qualifying new technology services are included. If operating cost exceeds $62,854.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,673.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,747.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,829.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,233.22. The transfer capital threshold is the transfer adjustment factor * $1,233.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13622.41","13622.41","13622.41","1 through 10","14073.17","24006.65","other","Inpatient DRG"
"Other Multiple Significant Trauma With McC","963","MS-DRG","","","","","","","","inpatient","","","97910.03","73432.52","MEDICARE [2001]","HB BWH MEDICARE","32745.10","","Case rate ($32,745.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,400.29, add-ons for qualifying new technology services are included. If operating cost exceeds $76,044.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,639.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $30,165.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,020.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,199.78. The transfer capital threshold is the transfer adjustment factor * $2,199.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","32353.79","0.03","32353.79","20","24811.5","40997.7197","other","Inpatient DRG"
"Other Multiple Significant Trauma Without Cc/McC","965","MS-DRG","","","","","","","","inpatient","","","28276.01","21207.01","MEDICARE [2001]","HB BWH MEDICARE","8959.17","","Case rate ($8,959.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,707.67, add-ons for qualifying new technology services are included. If operating cost exceeds $56,352.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,196.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $7,822.56 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,327.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.78. The transfer capital threshold is the transfer adjustment factor * $756.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11053.16","11053.16","11053.16","1 through 10","8779.99","13772.0466","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","","","","inpatient","","","54419.45","40814.59","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9268.44","","Case rate ($9,268.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,079.94, add-ons for qualifying new technology services are included. If operating cost exceeds $56,724.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,224.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,104.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,700.10 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $784.06. The transfer capital threshold is the transfer adjustment factor * $784.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9416.64","9416.64","9416.64","1 through 10","9083.07","15263","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","","","","inpatient","","","54419.45","40814.59","MEDICARE [2001]","HB BWH MEDICARE","9268.44","","Case rate ($9,268.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,079.94, add-ons for qualifying new technology services are included. If operating cost exceeds $56,724.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,224.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,104.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,700.10 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $784.06. The transfer capital threshold is the transfer adjustment factor * $784.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12299.69","0.03","12317.67","1 through 10","9083.07","15263","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","","","","inpatient","","","54419.45","40814.59","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9083.07","","Case rate ($9,268.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,079.94, add-ons for qualifying new technology services are included. If operating cost exceeds $56,724.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,224.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,104.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,700.10 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $784.06. The transfer capital threshold is the transfer adjustment factor * $784.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9433.57","9433.57","9433.57","1 through 10","9083.07","15263","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With McC","564","MS-DRG","","","","","","","","inpatient","","","65987.10","49490.32","MEDICARE [2001]","HB BWH MEDICARE","14460.73","","Case rate ($14,460.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,330.45, add-ons for qualifying new technology services are included. If operating cost exceeds $62,974.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,682.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,838.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,950.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,242.07. The transfer capital threshold is the transfer adjustment factor * $1,242.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18777.82","18777.82","18777.82","1 through 10","14171.52","23680.7972","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With McC","564","MS-DRG","","","","","","","","inpatient","","","65987.10","49490.32","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14171.52","","Case rate ($14,460.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,330.45, add-ons for qualifying new technology services are included. If operating cost exceeds $62,974.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,682.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,838.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,950.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,242.07. The transfer capital threshold is the transfer adjustment factor * $1,242.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14419.98","14419.98","14419.98","1 through 10","14171.52","23680.7972","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC","566","MS-DRG","","","","","","","","inpatient","","","26181.60","19636.20","MEDICARE [2001]","HB BWH MEDICARE","7215.03","","Case rate ($7,215.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,608.06, add-ons for qualifying new technology services are included. If operating cost exceeds $54,252.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,043.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,232.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,228.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $602.93. The transfer capital threshold is the transfer adjustment factor * $602.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9110.94","9110.94","9110.94","1 through 10","7070.73","11289.5771","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses,EXTREME","351","DRG","","","","","","","","inpatient","","","61570.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","58183.27","","Standard inlier is a Case rate ($58,183.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $51,891, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,258.63) for the length of stay and the standard reimbursement.","53155.44","53155.44","53155.44","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,EXTREME","351","DRG","","","","","","","","inpatient","","","61570.86","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","7880.05","7880.05","7880.05","1 through 10","4689.41","118870.54","percent of total billed charges",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,EXTREME","351","DRG","","","","","","","","inpatient","","","61570.86","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10707.2674","","Fee schedule rate ($75,646.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10707.2674","69265.44","69265.44","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,EXTREME","351","DRG","","","","","","","","inpatient","","","61570.86","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56377.15","","Fee schedule rate ($56,377.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","54734.48","54734.48","54734.48","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","56782.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","29459.42","","Standard inlier is a Case rate ($29,459.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,557, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,181.94) for the length of stay and the standard reimbursement.","26853.33","26853.33","26853.33","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","56782.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","33120.32","","Standard inlier is a Case rate ($33,120.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,557, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,701.15) for the length of stay and the standard reimbursement.","33120.32","30258.27","33120.32","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","56782.44","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10707.2674","","Fee schedule rate ($25,479.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10707.2674","25479.96","25479.96","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","56782.44","","MASSHEALTH [3001]","HB BWH MEDICAID","9493.06","","Case rate ($10,496.21). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,926.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10493.64","10493.64","10493.64","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","56782.44","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9493.06","","Case rate ($10,496.21). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,926.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","651.28","651.28","10493.64","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MINOR","351","DRG","","","","","","","","inpatient","","","42809.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","16874.68","","Standard inlier is a Case rate ($16,874.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,320, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,395.22) for the length of stay and the standard reimbursement.","15416.47","15416.47","15416.47","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MINOR","351","DRG","","","","","","","","inpatient","","","42809.66","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18252.31","","Fee schedule rate ($18,252.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18252.31","18252.31","18252.31","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MINOR","351","DRG","","","","","","","","inpatient","","","42809.66","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4689.41","","Case rate ($5,184.95). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,614.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5183.68","5183.68","5183.68","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","38126.18","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19029.44","","Standard inlier is a Case rate ($19,029.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,446, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,701.34) for the length of stay and the standard reimbursement.","19029.44","19029.44","19029.44","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","38126.18","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21394.22","","Standard inlier is a Case rate ($21,394.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,446, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,036.73) for the length of stay and the standard reimbursement.","19545.47","19545.47","21394.22","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","38126.18","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","24560.35","24560.35","24560.35","1 through 10","4689.41","118870.54","percent of total billed charges",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","38126.18","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10197.1153","","Fee schedule rate ($13,905.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10197.1153","13905.56","13905.56","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","38126.18","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","15296.31","","Fee schedule rate ($15,296.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15296.32","15296.32","15296.32","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","38126.18","","MASSHEALTH [3001]","HB BWH MEDICAID","5710.69","","Case rate ($6,314.15). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,744.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6312.60","6312.60","6312.60","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","38126.18","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","5710.69","","Case rate ($6,314.15). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,744.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","38126.18","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19676.16","","Fee schedule rate ($19,676.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19676.16","19676.16","19676.16","1 through 10","4689.41","118870.54","case rate",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","","","","inpatient","","","109203.62","81902.71","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","19336.49","","Case rate ($19,336.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,199.90, add-ons for qualifying new technology services are included. If operating cost exceeds $68,844.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,112.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,284.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,820.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.16. The transfer capital threshold is the transfer adjustment factor * $1,672.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18337.60","18337.60","18337.60","1 through 10","18949.76","30358.5647","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","","","","inpatient","","","109203.62","81902.71","MARTIN'S POINT [160007]","HB BWH MEDICARE","19336.49","","Case rate ($19,336.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,199.90, add-ons for qualifying new technology services are included. If operating cost exceeds $68,844.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,112.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,284.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,820.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.16. The transfer capital threshold is the transfer adjustment factor * $1,672.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18219.65","18219.65","18219.65","1 through 10","18949.76","30358.5647","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","","","","inpatient","","","109203.62","81902.71","MEDICARE [2001]","HB BWH MEDICARE","19336.49","","Case rate ($19,336.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,199.90, add-ons for qualifying new technology services are included. If operating cost exceeds $68,844.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,112.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,284.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,820.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.16. The transfer capital threshold is the transfer adjustment factor * $1,672.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24022.52","21257.67","24030.00","22","18949.76","30358.5647","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","","","","inpatient","","","109203.62","81902.71","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","18949.76","","Case rate ($19,336.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,199.90, add-ons for qualifying new technology services are included. If operating cost exceeds $68,844.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,112.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,284.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,820.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.16. The transfer capital threshold is the transfer adjustment factor * $1,672.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18167.11","18167.11","18167.11","1 through 10","18949.76","30358.5647","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","","","","inpatient","","","109203.62","81902.71","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","18949.76","","Case rate ($19,336.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,199.90, add-ons for qualifying new technology services are included. If operating cost exceeds $68,844.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,112.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,284.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,820.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,672.16. The transfer capital threshold is the transfer adjustment factor * $1,672.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25793.09","25793.09","25793.09","1 through 10","18949.76","30358.5647","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC","515","MS-DRG","","","","","","","","inpatient","","","142050.57","106537.93","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29451.07","","Case rate ($29,451.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,375.87, add-ons for qualifying new technology services are included. If operating cost exceeds $81,020.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,004.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,506.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,996.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,564.37. The transfer capital threshold is the transfer adjustment factor * $2,564.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28078.75","28078.75","28078.75","1 through 10","28862.05","49919.6","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC","515","MS-DRG","","","","","","","","inpatient","","","142050.57","106537.93","MEDICARE [2001]","HB BWH MEDICARE","29451.07","","Case rate ($29,451.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,375.87, add-ons for qualifying new technology services are included. If operating cost exceeds $81,020.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,004.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,506.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,996.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,564.37. The transfer capital threshold is the transfer adjustment factor * $2,564.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36735.06","29228.63","62599.56","12","28862.05","49919.6","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC","515","MS-DRG","","","","","","","","inpatient","","","142050.57","106537.93","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28862.05","","Case rate ($29,451.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,375.87, add-ons for qualifying new technology services are included. If operating cost exceeds $81,020.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,004.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,506.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,996.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,564.37. The transfer capital threshold is the transfer adjustment factor * $2,564.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","27813.68","27813.68","27813.68","1 through 10","28862.05","49919.6","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC","517","MS-DRG","","","","","","","","inpatient","","","71775.70","53831.77","HUMANA [1012]","HB BWH MEDICARE","18572.72","","Case rate ($18,572.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,254.67, add-ons for qualifying new technology services are included. If operating cost exceeds $62,899.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,676.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,956.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,874.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,236.52. The transfer capital threshold is the transfer adjustment factor * $1,236.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13591.52","13591.52","13591.52","1 through 10","14109.82","22526.3357","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC","517","MS-DRG","","","","","","","","inpatient","","","71775.70","53831.77","MEDICARE [2001]","HB BWH MEDICARE","18572.72","","Case rate ($18,572.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,254.67, add-ons for qualifying new technology services are included. If operating cost exceeds $62,899.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,676.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,956.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,874.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,236.52. The transfer capital threshold is the transfer adjustment factor * $1,236.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17875.95","16728.58","17902.28","11","14109.82","22526.3357","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC","517","MS-DRG","","","","","","","","inpatient","","","71775.70","53831.77","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","18572.72","","Case rate ($18,572.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,254.67, add-ons for qualifying new technology services are included. If operating cost exceeds $62,899.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,676.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,956.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,874.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,236.52. The transfer capital threshold is the transfer adjustment factor * $1,236.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13570.44","13570.44","13570.44","1 through 10","14109.82","22526.3357","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC","517","MS-DRG","","","","","","","","inpatient","","","71775.70","53831.77","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14109.82","","Case rate ($14,397.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,254.67, add-ons for qualifying new technology services are included. If operating cost exceeds $62,899.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,676.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,781.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,874.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,236.52. The transfer capital threshold is the transfer adjustment factor * $1,236.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13576.68","13576.68","13576.68","1 through 10","14109.82","22526.3357","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC","517","MS-DRG","","","","","","","","inpatient","","","71775.70","53831.77","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14109.82","","Case rate ($14,397.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,254.67, add-ons for qualifying new technology services are included. If operating cost exceeds $62,899.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,676.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,781.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,874.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,236.52. The transfer capital threshold is the transfer adjustment factor * $1,236.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","40277.91","40277.91","40277.91","1 through 10","14109.82","22526.3357","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Procedures,EXTREME","320","DRG","","","","","","","","inpatient","","","173413.95","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","19998.3347","","Fee schedule rate ($141,424.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19998.3347","141424.32","141424.32","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,EXTREME","320","DRG","","","","","","","","inpatient","","","173413.95","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","20998.8326","","Fee schedule rate ($148,499.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20998.8326","142771.08","142771.08","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MAJOR","320","DRG","","","","","","","","inpatient","","","144181.40","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","67427.75","","Standard inlier is a Case rate ($67,427.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $64,082, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,571.78) for the length of stay and the standard reimbursement.","61462.85","61462.85","61462.85","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MAJOR","320","DRG","","","","","","","","inpatient","","","144181.40","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","75806.96","","Standard inlier is a Case rate ($75,806.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $64,082, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,760.17) for the length of stay and the standard reimbursement.","8012.27","8012.27","8012.27","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MAJOR","320","DRG","","","","","","","","inpatient","","","144181.40","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","20998.8326","","Fee schedule rate ($58,402.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20998.8326","58402.64","58402.64","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MAJOR","320","DRG","","","","","","","","inpatient","","","144181.40","","MASSHEALTH [3001]","HB BWH MEDICAID","21072.08","","Case rate ($23,298.81). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,728.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","30326.70","30326.70","30326.70","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MAJOR","320","DRG","","","","","","","","inpatient","","","144181.40","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","21072.08","","Case rate ($23,298.81). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,728.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","24690.68","24690.68","24690.68","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MINOR","320","DRG","","","","","","","","inpatient","","","68442.41","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","33408.25","","Standard inlier is a Case rate ($33,408.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,628, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,742.50) for the length of stay and the standard reimbursement.","33408.25","33408.25","33408.25","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MINOR","320","DRG","","","","","","","","inpatient","","","68442.41","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","37559.88","","Standard inlier is a Case rate ($37,559.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,628, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,331.31) for the length of stay and the standard reimbursement.","37559.88","37559.88","37559.88","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MINOR","320","DRG","","","","","","","","inpatient","","","68442.41","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","20998.8326","","Fee schedule rate ($20,998.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20998.8326","21998.44","21998.44","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MINOR","320","DRG","","","","","","","","inpatient","","","68442.41","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","10368.11","","Case rate ($11,463.73). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,893.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22849.86","22849.86","22849.86","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MINOR","320","DRG","","","","","","","","inpatient","","","68442.41","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","36491.20","","Fee schedule rate ($36,491.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","36491.20","36491.20","36491.20","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MODERATE","320","DRG","","","","","","","","inpatient","","","106746.54","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","52038.43","","Standard inlier is a Case rate ($52,038.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,641, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,386.42) for the length of stay and the standard reimbursement.","52038.43","52038.43","52038.43","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MODERATE","320","DRG","","","","","","","","inpatient","","","106746.54","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","12828.77","","Case rate ($14,184.41). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,614.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20092.40","20092.40","20092.40","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MODERATE","320","DRG","","","","","","","","inpatient","","","106746.54","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44889.44","","Fee schedule rate ($44,889.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38156.02","38156.02","38156.02","1 through 10","10368.11","233352.95","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MODERATE","320","DRG","","","","","","","","inpatient","","","106746.54","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12828.77","","Case rate ($14,184.41). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,614.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14180.93","14180.93","14180.93","1 through 10","10368.11","233352.95","case rate",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","","","","inpatient","","","63777.90","47833.42","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","11829.64","","Case rate ($11,485.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,748.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,392.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,419.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $10,125.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,368.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.59. The transfer capital threshold is the transfer adjustment factor * $979.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11466.85","11466.85","11508.55","1 through 10","11255.39","18036.7632","other","Inpatient DRG"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","","","","inpatient","","","63777.90","47833.42","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","11485.09","","Case rate ($11,485.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,748.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,392.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,419.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $10,125.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,368.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.59. The transfer capital threshold is the transfer adjustment factor * $979.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11030.34","11030.34","11030.34","1 through 10","11255.39","18036.7632","other","Inpatient DRG"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","","","","inpatient","","","63777.90","47833.42","MEDICARE [2001]","HB BWH MEDICARE","14792.55","","Case rate ($14,792.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,748.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,392.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,419.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,433.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,368.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.59. The transfer capital threshold is the transfer adjustment factor * $979.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14368.66","728.09","14389.74","1 through 10","11255.39","18036.7632","other","Inpatient DRG"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","","","","inpatient","","","63777.90","47833.42","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","11255.39","","Case rate ($11,485.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,748.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,392.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,419.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $10,125.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,368.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.59. The transfer capital threshold is the transfer adjustment factor * $979.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10904.20","10904.20","10904.20","1 through 10","11255.39","18036.7632","other","Inpatient DRG"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","","","","inpatient","","","63777.90","47833.42","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11255.39","","Case rate ($11,485.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,748.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,392.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,419.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $10,125.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,368.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.59. The transfer capital threshold is the transfer adjustment factor * $979.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11126.71","11126.71","11126.71","1 through 10","11255.39","18036.7632","other","Inpatient DRG"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC","843","MS-DRG","","","","","","","","inpatient","","","69550.35","52162.76","MEDICARE [2001]","HB BWH MEDICARE","18576.62","","Case rate ($18,576.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,285.17, add-ons for qualifying new technology services are included. If operating cost exceeds $67,929.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,045.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $16,591.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,905.33 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,605.13. The transfer capital threshold is the transfer adjustment factor * $1,605.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22632.07","22598.68","22632.07","17","18205.09","28571.7903","other","Inpatient Replacement Plans DRG"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/McC","845","MS-DRG","","","","","","","","inpatient","","","47455.03","35591.27","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8148.22","","Case rate ($8,148.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,731.44, add-ons for qualifying new technology services are included. If operating cost exceeds $55,375.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,125.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,083.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,351.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $685.25. The transfer capital threshold is the transfer adjustment factor * $685.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7892.10","7892.10","7892.10","1 through 10","7985.26","12628.1488","other","Inpatient Replacement Plans DRG"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/McC","845","MS-DRG","","","","","","","","inpatient","","","47455.03","35591.27","MEDICARE [2001]","HB BWH MEDICARE","8148.22","","Case rate ($8,148.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,731.44, add-ons for qualifying new technology services are included. If operating cost exceeds $55,375.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,125.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,083.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,351.60 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $685.25. The transfer capital threshold is the transfer adjustment factor * $685.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21207.00","21207.00","21207.00","1 through 10","7985.26","12628.1488","other","Inpatient Replacement Plans DRG"
"Other Nervous System And Related Procedures,MAJOR","026","DRG","","","","","","","","inpatient","","","122809.16","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","75713.52","","Standard inlier is a Case rate ($75,713.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $70,525, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,747.99) for the length of stay and the standard reimbursement.","75713.51","75713.51","75713.51","1 through 10","13645.56","283526.65","case rate",""
"Other Nervous System And Related Procedures,MAJOR","026","DRG","","","","","","","","inpatient","","","122809.16","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","85122.40","","Standard inlier is a Case rate ($85,122.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $70,525, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,082.42) for the length of stay and the standard reimbursement.","77766.65","77766.65","77766.65","1 through 10","13645.56","283526.65","case rate",""
"Other Nervous System And Related Procedures,MINOR","026","DRG","","","","","","","","inpatient","","","85976.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","43944.70","","Standard inlier is a Case rate ($43,944.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $42,044, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,237.58) for the length of stay and the standard reimbursement.","43944.69","40147.27","45885.84","1 through 10","13645.56","283526.65","case rate",""
"Other Nervous System And Related Procedures,MINOR","026","DRG","","","","","","","","inpatient","","","85976.86","","MASSHEALTH [3001]","HB BWH MEDICAID","13645.56","","Case rate ($15,087.51). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,517.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15988.85","15988.85","15988.85","1 through 10","13645.56","283526.65","case rate",""
"Other Nervous System And Related Procedures,MODERATE","026","DRG","","","","","","","","inpatient","","","107657.41","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","39087.33","","Standard inlier is a Case rate ($39,087.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $42,044, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,548.68) for the length of stay and the standard reimbursement.","95765.94","95765.94","95765.94","1 through 10","13645.56","283526.65","case rate",""
"Other Nervous System And Related Procedures,MODERATE","026","DRG","","","","","","","","inpatient","","","107657.41","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","43944.70","","Standard inlier is a Case rate ($43,944.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $42,044, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,237.58) for the length of stay and the standard reimbursement.","50863.40","50863.40","77766.65","1 through 10","13645.56","283526.65","case rate",""
"Other Nervous System And Related Procedures,MODERATE","026","DRG","","","","","","","","inpatient","","","107657.41","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24919.0747","","Fee schedule rate ($38,744.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24919.0747","38744.12","38744.12","1 through 10","13645.56","283526.65","case rate",""
"Other Nervous System And Related Procedures,MODERATE","026","DRG","","","","","","","","inpatient","","","107657.41","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","40682.45","","Fee schedule rate ($40,682.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40682.45","40682.45","40682.45","1 through 10","13645.56","283526.65","case rate",""
"Other Nervous System And Related Procedures,MODERATE","026","DRG","","","","","","","","inpatient","","","107657.41","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60208.46","","Fee schedule rate ($60,208.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","60208.46","60208.46","60208.46","1 through 10","13645.56","283526.65","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,EXTREME","425","DRG","","","","","","","","inpatient","","","67652.36","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15685.83","","Case rate ($17,343.38). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,773.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17339.12","17339.12","17339.12","1 through 10","4103.38","51628.35","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MAJOR","425","DRG","","","","","","","","inpatient","","","48634.56","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","16742.94","","Standard inlier is a Case rate ($16,742.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,669, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,376.76) for the length of stay and the standard reimbursement.","22661.33","22661.33","22661.33","1 through 10","4103.38","51628.35","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MAJOR","425","DRG","","","","","","","","inpatient","","","48634.56","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18823.57","","Standard inlier is a Case rate ($18,823.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,669, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,671.85) for the length of stay and the standard reimbursement.","23275.85","23275.85","25477.45","1 through 10","4103.38","51628.35","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MAJOR","425","DRG","","","","","","","","inpatient","","","48634.56","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9579.7861","","Fee schedule rate ($22,673.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9579.7861","22673.44","22673.44","1 through 10","4103.38","51628.35","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MAJOR","425","DRG","","","","","","","","inpatient","","","48634.56","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10059.0538","","Fee schedule rate ($23,807.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10059.0538","63307.63","63307.63","1 through 10","4103.38","51628.35","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MAJOR","425","DRG","","","","","","","","inpatient","","","48634.56","","MASSHEALTH [3001]","HB BWH MEDICAID","5429.67","","Case rate ($6,003.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,433.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10084.46","10084.46","10674.21","1 through 10","4103.38","51628.35","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MAJOR","425","DRG","","","","","","","","inpatient","","","48634.56","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","5429.67","","Case rate ($6,003.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,433.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5562.32","5562.32","5562.32","1 through 10","4103.38","51628.35","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MAJOR","425","DRG","","","","","","","","inpatient","","","48634.56","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26568.35","","Fee schedule rate ($26,568.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25794.29","25794.29","25794.29","1 through 10","4103.38","51628.35","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MAJOR","425","DRG","","","","","","","","inpatient","","","48634.56","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5429.67","","Case rate ($6,003.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,433.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9691.78","9691.78","9691.78","1 through 10","4103.38","51628.35","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MODERATE","425","DRG","","","","","","","","inpatient","","","35967.25","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5429.67","","Case rate ($6,003.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,433.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6001.96","6001.96","6001.96","1 through 10","4103.38","51628.35","case rate",""
"Other O.R. Proc For Obstetric Diagnoses Except Delivery Diagnoses,MINOR","546","DRG","","","","","","","","inpatient","","","16941.23","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11255.07","","Fee schedule rate ($11,255.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11255.08","11255.08","11255.08","1 through 10","10821.8192","62913.66","case rate",""
"Other O.R. Proc For Obstetric Diagnoses Except Delivery Diagnoses,MINOR","546","DRG","","","","","","","","inpatient","","","16941.23","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11818.16","","Fee schedule rate ($11,818.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11818.16","11818.16","11818.16","1 through 10","10821.8192","62913.66","case rate",""
"Other O.R. Proc For Obstetric Diagnoses Except Delivery Diagnoses,MINOR","546","DRG","","","","","","","","inpatient","","","16941.23","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16072.60","","Fee schedule rate ($16,072.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15604.33","15604.33","15604.33","1 through 10","10821.8192","62913.66","case rate",""
"Other O.R. Proc For Obstetric Diagnoses Except Delivery Diagnoses,MODERATE","546","DRG","","","","","","","","inpatient","","","25973.16","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17186.80","","Fee schedule rate ($17,186.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17186.80","17186.80","17186.80","1 through 10","10821.8192","62913.66","case rate",""
"Other O.R. Proc For Obstetric Diagnoses Except Delivery Diagnoses,MODERATE","546","DRG","","","","","","","","inpatient","","","25973.16","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","18046.64","","Fee schedule rate ($18,046.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18046.64","18046.64","18046.64","1 through 10","10821.8192","62913.66","case rate",""
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","","","","inpatient","","","88541.84","66406.38","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","19137.66","","Case rate ($18,580.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,289.56, add-ons for qualifying new technology services are included. If operating cost exceeds $67,934.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,045.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $16,594.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,909.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,605.45. The transfer capital threshold is the transfer adjustment factor * $1,605.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10469.09","10469.09","10469.09","1 through 10","18208.65","30440.0561","other","Inpatient DRG"
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","","","","inpatient","","","88541.84","66406.38","MEDICARE [2001]","HB BWH MEDICARE","24000.85","","Case rate ($24,000.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,289.56, add-ons for qualifying new technology services are included. If operating cost exceeds $67,934.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,045.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $22,015.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,909.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,605.45. The transfer capital threshold is the transfer adjustment factor * $1,605.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24058.20","1924.13","24093.75","25","18208.65","30440.0561","other","Inpatient DRG"
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","","","","inpatient","","","88541.84","66406.38","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","18208.65","","Case rate ($18,580.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,289.56, add-ons for qualifying new technology services are included. If operating cost exceeds $67,934.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,045.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $16,594.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,909.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,605.45. The transfer capital threshold is the transfer adjustment factor * $1,605.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18586.90","18586.90","18586.90","1 through 10","18208.65","30440.0561","other","Inpatient DRG"
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","","","","inpatient","","","88541.84","66406.38","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","18208.65","","Case rate ($18,580.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $22,289.56, add-ons for qualifying new technology services are included. If operating cost exceeds $67,934.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,045.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $16,594.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,909.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,605.45. The transfer capital threshold is the transfer adjustment factor * $1,605.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18281.86","18281.86","18301.12","1 through 10","18208.65","30440.0561","other","Inpatient DRG"
"Other O.R. Procedures For Injuries With McC","907","MS-DRG","","","","","","","","inpatient","","","169139.81","126854.86","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","45833.03","","Case rate ($45,833.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $42,540.03, add-ons for qualifying new technology services are included. If operating cost exceeds $88,184.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,529.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $42,363.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,160.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,089.33. The transfer capital threshold is the transfer adjustment factor * $3,089.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","74105.29","74105.29","74105.29","1 through 10","34694.29","60138.8","other","Inpatient DRG"
"Other O.R. Procedures For Injuries With McC","907","MS-DRG","","","","","","","","inpatient","","","169139.81","126854.86","MEDICARE [2001]","HB BWH MEDICARE","45833.03","","Case rate ($45,833.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $42,540.03, add-ons for qualifying new technology services are included. If operating cost exceeds $88,184.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,529.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $42,363.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,160.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,089.33. The transfer capital threshold is the transfer adjustment factor * $3,089.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","47242.74","180.12","61794.94","24","34694.29","60138.8","other","Inpatient DRG"
"Other O.R. Procedures For Injuries With McC","907","MS-DRG","","","","","","","","inpatient","","","169139.81","126854.86","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","34694.29","","Case rate ($35,402.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $42,540.03, add-ons for qualifying new technology services are included. If operating cost exceeds $88,184.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,529.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $31,933.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,160.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,089.33. The transfer capital threshold is the transfer adjustment factor * $3,089.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","606272.66","606272.66","606272.66","1 through 10","34694.29","60138.8","other","Inpatient DRG"
"Other O.R. Procedures For Injuries With McC","907","TRIS-DRG","","","","","","","","inpatient","","","816056.18","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","27996.68","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($49,177.74). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $8,335.21, and the first day is paid a rate of $16,670.42. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $8,335.21, and the first day is paid a rate of $16,670.42. The transfer payment is capped at $35,394.95. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $92,904.74 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 5.90000009536743). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: , capped at $35,394.95. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $8,335.21, and the first day is paid a rate of $16,670.42. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $8,335.21, and the first day is paid a rate of $16,670.42. The transfer payment is capped at $35,394.95. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $92,904.74 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 5.90000009536743). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","112984.37","112984.37","112984.37","1 through 10","27996.68","27996.68","other","Inpatient DRGs"
"Other O.R. Procedures For Injuries Without Cc/McC","909","MS-DRG","","","","","","","","inpatient","","","61512.20","46134.15","MEDICARE [2001]","HB BWH MEDICARE","12354.44","","Case rate ($12,354.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,794.89, add-ons for qualifying new technology services are included. If operating cost exceeds $60,439.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,496.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $10,918.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,415.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,056.28. The transfer capital threshold is the transfer adjustment factor * $1,056.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15230.46","728.09","15252.82","1 through 10","12107.35","20562.13","other","Inpatient Replacement Plans DRG"
"Other O.R. Procedures For Injuries Without Cc/McC","909","MS-DRG","","","","","","","","inpatient","","","61512.20","46134.15","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12107.35","","Case rate ($12,354.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,794.89, add-ons for qualifying new technology services are included. If operating cost exceeds $60,439.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,496.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $10,918.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,415.04 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,056.28. The transfer capital threshold is the transfer adjustment factor * $1,056.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16346.43","16346.43","16346.43","1 through 10","12107.35","20562.13","other","Inpatient DRG"
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","681","DRG","","","","","","","","inpatient","","","416513.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","61257.09","","Standard inlier is a Case rate ($61,257.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,695.81) for the length of stay and the standard reimbursement.","175498.43","175498.43","175498.43","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","681","DRG","","","","","","","","inpatient","","","416513.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","68869.48","","Standard inlier is a Case rate ($68,869.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,775.45) for the length of stay and the standard reimbursement.","180257.47","180257.47","190811.81","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","681","DRG","","","","","","","","inpatient","","","416513.66","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","21161.03","21161.03","21161.03","1 through 10","10593.16","335589.95","percent of total billed charges",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","681","DRG","","","","","","","","inpatient","","","416513.66","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","22335.6862","","Fee schedule rate ($203,385.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22335.6862","195547.12","203385.36","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","681","DRG","","","","","","","","inpatient","","","416513.66","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","223726.63","","Fee schedule rate ($223,726.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","223726.63","223726.63","223726.63","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","681","DRG","","","","","","","","inpatient","","","416513.66","","MASSHEALTH [3001]","HB BWH MEDICAID","22167.61","","Case rate ($24,510.11). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,940.11, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","222101.91","222101.91","222101.91","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","681","DRG","","","","","","","","inpatient","","","416513.66","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","74741.38","","Fee schedule rate ($74,741.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","217720.82","217720.82","217720.82","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,EXTREME","681","DRG","","","","","","","","inpatient","","","416513.66","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","22167.61","","Case rate ($24,510.11). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,940.11, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","99536.74","99536.74","99536.74","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","681","DRG","","","","","","","","inpatient","","","117707.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","82485.72","","Standard inlier is a Case rate ($82,485.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $75,791, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,709.35) for the length of stay and the standard reimbursement.","82485.72","82485.72","82485.72","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","681","DRG","","","","","","","","inpatient","","","117707.21","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","92736.18","","Standard inlier is a Case rate ($92,736.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $75,791, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,163.13) for the length of stay and the standard reimbursement.","84722.50","84722.50","84722.50","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","681","DRG","","","","","","","","inpatient","","","117707.21","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","49939.54","49939.54","49939.54","1 through 10","10593.16","335589.95","percent of total billed charges",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","681","DRG","","","","","","","","inpatient","","","117707.21","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","22335.6862","","Fee schedule rate ($85,844.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22335.6862","85844.56","85844.56","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","681","DRG","","","","","","","","inpatient","","","117707.21","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","94430.15","","Fee schedule rate ($94,430.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","94430.15","94430.15","94430.15","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MAJOR","681","DRG","","","","","","","","inpatient","","","117707.21","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","27435.06","","Case rate ($30,334.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $72,764.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","75495.79","75495.79","75495.79","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MINOR","681","DRG","","","","","","","","inpatient","","","88855.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","41166.79","","Standard inlier is a Case rate ($41,166.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,121, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,843.28) for the length of stay and the standard reimbursement.","37616.85","37616.85","37616.85","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MINOR","681","DRG","","","","","","","","inpatient","","","88855.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","41166.79","","Standard inlier is a Case rate ($41,166.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,121, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,843.28) for the length of stay and the standard reimbursement.","41166.79","37609.41","41166.79","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MINOR","681","DRG","","","","","","","","inpatient","","","88855.58","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","24349.61","24349.61","24349.61","1 through 10","10593.16","335589.95","percent of total billed charges",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MINOR","681","DRG","","","","","","","","inpatient","","","88855.58","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","22335.6862","","Fee schedule rate ($36,447.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22335.6862","22335.68","22335.68","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MINOR","681","DRG","","","","","","","","inpatient","","","88855.58","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","23453.1196","","Fee schedule rate ($38,270.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23453.1196","23453.12","23453.12","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","681","DRG","","","","","","","","inpatient","","","102723.17","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","48055.49","","Standard inlier is a Case rate ($48,055.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,018, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,821.77) for the length of stay and the standard reimbursement.","48055.49","48055.49","48055.49","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","681","DRG","","","","","","","","inpatient","","","102723.17","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","54027.32","","Standard inlier is a Case rate ($54,027.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,018, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,668.73) for the length of stay and the standard reimbursement.","54027.32","54027.32","54027.32","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","681","DRG","","","","","","","","inpatient","","","102723.17","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","54027.32","","Standard inlier is a Case rate ($54,027.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,018, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,668.73) for the length of stay and the standard reimbursement.","49358.62","54027.32","54027.32","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","681","DRG","","","","","","","","inpatient","","","102723.17","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","62715.48","62715.48","62715.48","1 through 10","10593.16","335589.95","percent of total billed charges",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","681","DRG","","","","","","","","inpatient","","","102723.17","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","94430.15","","Fee schedule rate ($94,430.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40092.20","40092.20","40092.20","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","681","DRG","","","","","","","","inpatient","","","102723.17","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","92523.74","","Fee schedule rate ($92,523.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28501.89","28501.89","28501.89","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Lymphatic, Hematopoietic Or Other Neoplasms,MODERATE","681","DRG","","","","","","","","inpatient","","","102723.17","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14821.06","","Case rate ($16,387.23). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,817.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16383.20","16383.20","16383.20","1 through 10","10593.16","335589.95","case rate",""
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","","","","inpatient","","","221173.13","165879.85","MEDICARE [2001]","HB BWH MEDICARE","38819.50","","Case rate ($38,819.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,653.60, add-ons for qualifying new technology services are included. If operating cost exceeds $92,298.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,830.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $35,048.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,273.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,390.75. The transfer capital threshold is the transfer adjustment factor * $3,390.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","38043.11","61040.0768","other","Inpatient Replacement Plans DRG"
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","","","","inpatient","","","221173.13","165879.85","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","38043.11","","Case rate ($38,819.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,653.60, add-ons for qualifying new technology services are included. If operating cost exceeds $92,298.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,830.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $35,048.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,273.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,390.75. The transfer capital threshold is the transfer adjustment factor * $3,390.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","64589.71","64589.71","64589.71","1 through 10","38043.11","61040.0768","other","Inpatient DRG"
"Other O.R. Procedures For Multiple Significant Trauma With McC","957","MS-DRG","","","","","","","","inpatient","","","253876.30","190407.22","MEDICARE [2001]","HB BWH MEDICARE","90591.27","","Case rate ($90,591.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,055.61, add-ons for qualifying new technology services are included. If operating cost exceeds $129,700.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,571.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $84,080.01 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $83,675.77 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,131.42. The transfer capital threshold is the transfer adjustment factor * $6,131.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","88378.77","88274.89","180763.08","1 through 10","68491.59","112642.2422","other","Inpatient DRG"
"Other O.R. Procedures For Multiple Significant Trauma With McC","957","MS-DRG","","","","","","","","inpatient","","","253876.30","190407.22","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","68491.59","","Case rate ($69,889.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $84,055.61, add-ons for qualifying new technology services are included. If operating cost exceeds $129,700.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,571.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $63,378.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $83,675.77 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,131.42. The transfer capital threshold is the transfer adjustment factor * $6,131.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","66744.41","66744.41","66744.41","1 through 10","68491.59","112642.2422","other","Inpatient DRG"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","","","","inpatient","","","79308.25","59481.19","MEDICARE [2001]","HB BWH MEDICARE","17336.91","","Case rate ($17,336.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,792.82, add-ons for qualifying new technology services are included. If operating cost exceeds $66,437.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,935.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,461.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,412.98 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,495.78. The transfer capital threshold is the transfer adjustment factor * $1,495.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21262.97","21262.97","21262.97","1 through 10","16990.17","28052.6599","other","Inpatient Replacement Plans DRG"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With McC","802","MS-DRG","","","","","","","","inpatient","","","256225.92","192169.44","MEDICARE [2001]","HB BWH MEDICARE","36723.22","","Case rate ($36,723.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $44,130.10, add-ons for qualifying new technology services are included. If operating cost exceeds $89,774.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,645.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $33,137.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $43,750.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,205.84. The transfer capital threshold is the transfer adjustment factor * $3,205.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1537975.07","1537975.07","1537975.07","1 through 10","35988.76","54098.2168","other","Inpatient Replacement Plans DRG"
"Other Open Craniotomy,EXTREME","027","DRG","","","","","","","","inpatient","","","340076.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","182207.23","","Standard inlier is a Case rate ($182,207.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $137,677, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($25,862.80) for the length of stay and the standard reimbursement.","182207.23","182207.23","182207.23","1 through 10","19074.09","182207.23","case rate",""
"Other Open Craniotomy,MAJOR","027","DRG","","","","","","","","inpatient","","","147737.99","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","98294.00","","Standard inlier is a Case rate ($98,294.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $88,085, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,953.43) for the length of stay and the standard reimbursement.","98294.00","98294.00","98294.00","1 through 10","19074.09","182207.23","case rate",""
"Other Open Craniotomy,MINOR","027","DRG","","","","","","","","inpatient","","","127662.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","51968.75","","Standard inlier is a Case rate ($51,968.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,060, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,377.28) for the length of stay and the standard reimbursement.","53378.00","53378.00","53378.00","1 through 10","19074.09","182207.23","case rate",""
"Other Open Craniotomy,MODERATE","027","DRG","","","","","","","","inpatient","","","217418.02","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","68011.38","","Standard inlier is a Case rate ($68,011.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $58,690, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,653.65) for the length of stay and the standard reimbursement.","84112.69","84112.69","84112.69","1 through 10","19074.09","182207.23","case rate",""
"Other Percutaneous Intracranial Procedures,EXTREME","029","DRG","","","","","","","","inpatient","","","194880.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","147719.77","","Standard inlier is a Case rate ($147,719.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $113,822, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,967.59) for the length of stay and the standard reimbursement.","147719.77","147719.77","147719.77","1 through 10","23495.04","147719.77","case rate",""
"Other Percutaneous Intracranial Procedures,EXTREME","029","DRG","","","","","","","","inpatient","","","194880.49","","MASSHEALTH [3001]","HB BWH MEDICAID","55793.16","","Case rate ($61,688.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $104,118.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","61673.79","61673.79","61673.79","1 through 10","23495.04","147719.77","case rate",""
"Other Percutaneous Intracranial Procedures,MINOR","029","DRG","","","","","","","","inpatient","","","123713.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","58880.02","","Standard inlier is a Case rate ($58,880.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,435, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,358.37) for the length of stay and the standard reimbursement.","58880.02","58880.02","58880.02","1 through 10","23495.04","147719.77","case rate",""
"Other Percutaneous Intracranial Procedures,MINOR","029","DRG","","","","","","","","inpatient","","","123713.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","66197.02","","Standard inlier is a Case rate ($66,197.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,435, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,396.12) for the length of stay and the standard reimbursement.","66197.01","66197.01","66197.01","1 through 10","23495.04","147719.77","case rate",""
"Other Percutaneous Intracranial Procedures,MODERATE","029","DRG","","","","","","","","inpatient","","","155107.63","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","61823.06","","Standard inlier is a Case rate ($61,823.06). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,724, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,776.16) for the length of stay and the standard reimbursement.","61823.05","61823.05","61823.05","1 through 10","23495.04","147719.77","case rate",""
"Other Percutaneous Intracranial Procedures,MODERATE","029","DRG","","","","","","","","inpatient","","","155107.63","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","69505.78","","Standard inlier is a Case rate ($69,505.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $59,724, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,865.77) for the length of stay and the standard reimbursement.","69505.77","69505.77","69505.77","1 through 10","23495.04","147719.77","case rate",""
"Other Peripheral Vascular And Circulatory Procedures,EXTREME","180","DRG","","","","","","","","inpatient","","","135660.40","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","131801.36","","Standard inlier is a Case rate ($131,801.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $102,812, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,708.11) for the length of stay and the standard reimbursement.","131801.36","131801.36","131801.36","1 through 10","11288.86","215722.95","case rate",""
"Other Peripheral Vascular And Circulatory Procedures,EXTREME","180","DRG","","","","","","","","inpatient","","","135660.40","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","27752.9736","","Fee schedule rate ($130,739.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27752.9736","130739.60","130739.60","1 through 10","11288.86","215722.95","case rate",""
"Other Peripheral Vascular And Circulatory Procedures,EXTREME","180","DRG","","","","","","","","inpatient","","","135660.40","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","31016.3189","","Fee schedule rate ($130,739.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31016.3189","130739.60","130739.60","1 through 10","11288.86","215722.95","case rate",""
"Other Peripheral Vascular And Circulatory Procedures,EXTREME","180","DRG","","","","","","","","inpatient","","","135660.40","","MASSHEALTH [3001]","HB BWH MEDICAID","45171.44","","Case rate ($49,944.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $92,374.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","57163.42","57163.42","57163.42","1 through 10","11288.86","215722.95","case rate",""
"Other Peripheral Vascular And Circulatory Procedures,MAJOR","180","DRG","","","","","","","","inpatient","","","196454.02","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","63692.37","","Standard inlier is a Case rate ($63,692.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $61,177, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,041.52) for the length of stay and the standard reimbursement.","6717.62","6717.62","6717.62","1 through 10","11288.86","215722.95","case rate",""
"Other Peripheral Vascular And Circulatory Procedures,MAJOR","180","DRG","","","","","","","","inpatient","","","196454.02","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","14543.78","14543.78","14543.78","1 through 10","11288.86","215722.95","percent of total billed charges",""
"Other Peripheral Vascular And Circulatory Procedures,MINOR","180","DRG","","","","","","","","inpatient","","","221792.75","","MASSHEALTH [3001]","HB BWH MEDICAID","11288.86","","Case rate ($12,481.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,911.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18803.10","18803.10","18803.10","1 through 10","11288.86","215722.95","case rate",""
"Other Peripheral Vascular And Circulatory Procedures,MODERATE","180","DRG","","","","","","","","inpatient","","","40803.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","46095.63","","Fee schedule rate ($46,095.63). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($5,333.47) multiplied by length of stay and the outlier percent (100%).","4861.69","4861.69","4861.69","1 through 10","11288.86","215722.95","case rate",""
"Other Peripheral Vascular And Circulatory Procedures,MODERATE","180","DRG","","","","","","","","inpatient","","","40803.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","51823.91","","Fee schedule rate ($51,823.91). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($5,996.24) multiplied by length of stay and the outlier percent (100%).","47345.61","47345.61","47345.61","1 through 10","11288.86","215722.95","case rate",""
"Other Peripheral Vascular And Circulatory Procedures,MODERATE","180","DRG","","","","","","","","inpatient","","","40803.49","","MASSHEALTH [3001]","HB BWH MEDICAID","13082.38","","Case rate ($14,464.82). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,894.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","45776.46","45776.46","45776.46","1 through 10","11288.86","215722.95","case rate",""
"Other Peripheral Vascular And Circulatory Procedures,MODERATE","180","DRG","","","","","","","","inpatient","","","40803.49","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","13082.38","","Case rate ($14,464.82). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,894.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2085.87","2085.87","2085.87","1 through 10","11288.86","215722.95","case rate",""
"Other Peripheral Vascular And Circulatory Procedures,MODERATE","180","DRG","","","","","","","","inpatient","","","40803.49","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","51990.89","","Fee schedule rate ($51,990.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","51990.89","51990.89","51990.89","1 through 10","11288.86","215722.95","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","95749.38","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","41195.97","","Standard inlier is a Case rate ($41,195.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,683, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,848.02) for the length of stay and the standard reimbursement.","41195.96","41195.96","41195.96","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","95749.38","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","46315.37","","Standard inlier is a Case rate ($46,315.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,683, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,574.08) for the length of stay and the standard reimbursement.","42313.08","42313.08","46315.36","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","95749.38","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","48460.34","","Fee schedule rate ($48,460.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","48460.36","48460.36","48460.36","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","95749.38","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","50884.77","","Fee schedule rate ($50,884.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","50884.76","50884.76","50884.76","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","95749.38","","MASSHEALTH [3001]","HB BWH MEDICAID","12895.03","","Case rate ($14,257.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,687.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14254.17","14254.17","14254.17","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","95749.38","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48423.68","","Fee schedule rate ($48,423.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","48423.68","48423.68","48423.68","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","95749.38","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12895.03","","Case rate ($14,257.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,687.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14254.17","14254.17","14254.17","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","49726.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","27389.59","","Standard inlier is a Case rate ($27,389.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,948, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,888.12) for the length of stay and the standard reimbursement.","24966.61","18724.96","24966.61","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","49726.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","30793.28","","Standard inlier is a Case rate ($30,793.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,948, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,370.85) for the length of stay and the standard reimbursement.","28132.32","24634.62","30793.28","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","49726.09","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","5697.48","5697.48","5697.48","1 through 10","3946.87","79960.54","percent of total billed charges",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","49726.09","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","26735.28","","Fee schedule rate ($26,735.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25704.92","25704.92","26735.28","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","49726.09","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","28072.82","","Fee schedule rate ($28,072.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28072.80","28072.80","28072.80","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","49726.09","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","32984.30","","Fee schedule rate ($32,984.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33419.39","33419.39","33419.39","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","49726.09","","MASSHEALTH [3001]","HB BWH MEDICAID","7620.72","","Case rate ($8,426.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,856.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8423.95","1072.77","22832.18","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","49726.09","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","46117.07","","Fee schedule rate ($46,117.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27056.86","27056.86","27056.86","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","49726.09","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48423.68","","Fee schedule rate ($48,423.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29262.78","29262.78","29262.78","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","49726.09","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7620.72","","Case rate ($8,426.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,856.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8423.95","8423.95","8423.95","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MINOR","139","DRG","","","","","","","","inpatient","","","20262.83","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15873.86","","Fee schedule rate ($15,873.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9612.47","9612.47","9612.47","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MINOR","139","DRG","","","","","","","","inpatient","","","20262.83","","MASSHEALTH [3001]","HB BWH MEDICAID","3946.87","","Case rate ($4,363.95). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,793.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4362.87","4362.87","4362.87","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","34668.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19760.35","","Standard inlier is a Case rate ($19,760.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,015, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,805.10) for the length of stay and the standard reimbursement.","19760.35","19760.35","19760.35","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","34668.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22215.96","","Standard inlier is a Case rate ($22,215.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,015, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,153.37) for the length of stay and the standard reimbursement.","22215.96","22215.96","58963.07","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","34668.35","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15873.86","","Fee schedule rate ($15,873.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20696.20","20696.20","20696.20","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","34668.35","","MASSHEALTH [3001]","HB BWH MEDICAID","5101.81","","Case rate ($5,640.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,070.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2203.54","1290.51","5639.54","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","34668.35","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19356.47","","Fee schedule rate ($19,356.47). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16452.95","16452.95","16452.95","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","34668.35","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20324.61","","Fee schedule rate ($20,324.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19732.46","19732.46","19732.46","1 through 10","3946.87","79960.54","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","34668.35","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5101.81","","Case rate ($5,640.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,070.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9320.54","9320.54","9320.54","1 through 10","3946.87","79960.54","case rate",""
"Other Procedures For Endocrine, Nutritional And Metabolic Disorders,EXTREME","405","DRG","","","","","","","","inpatient","","","142272.05","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","211857.66","","Fee schedule rate ($211,857.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","211857.68","211857.68","211857.68","1 through 10","8539.19","317786.49","case rate",""
"Other Procedures For Endocrine, Nutritional And Metabolic Disorders,MAJOR","405","DRG","","","","","","","","inpatient","","","142839.91","","MASSHEALTH [3001]","HB BWH MEDICAID","8539.19","","Case rate ($9,441.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,871.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","35363.93","35363.93","35363.93","1 through 10","8539.19","317786.49","case rate",""
"Other Procedures For Endocrine, Nutritional And Metabolic Disorders,MAJOR","405","DRG","","","","","","","","inpatient","","","142839.91","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8539.19","","Case rate ($9,441.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,871.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","127996.93","127996.93","127996.93","1 through 10","8539.19","317786.49","case rate",""
"Other Procedures For Endocrine, Nutritional And Metabolic Disorders,MINOR","405","DRG","","","","","","","","inpatient","","","62300.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","41250.95","","Standard inlier is a Case rate ($41,250.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,726, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,855.82) for the length of stay and the standard reimbursement.","41250.94","41250.94","41250.94","1 through 10","8539.19","317786.49","case rate",""
"Other Procedures For Endocrine, Nutritional And Metabolic Disorders,MODERATE","405","DRG","","","","","","","","inpatient","","","87633.55","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","25691.3354","","Fee schedule rate ($42,598.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25691.3354","44626.74","44626.74","1 through 10","8539.19","317786.49","case rate",""
"Other Procedures For Endocrine, Nutritional And Metabolic Disorders,MODERATE","405","DRG","","","","","","","","inpatient","","","87633.55","","MASSHEALTH [3001]","HB BWH MEDICAID","16416.94","","Case rate ($18,151.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,581.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15510.51","15510.51","15510.51","1 through 10","8539.19","317786.49","case rate",""
"Other Procedures For Endocrine, Nutritional And Metabolic Disorders,MODERATE","405","DRG","","","","","","","","inpatient","","","87633.55","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","16416.94","","Case rate ($18,151.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,581.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18147.30","18147.30","18147.30","1 through 10","8539.19","317786.49","case rate",""
"Other Procedures Of Blood And Blood-Forming Organs,MINOR","651","DRG","","","","","","","","inpatient","","","53054.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","33401.78","","Standard inlier is a Case rate ($33,401.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,623, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,741.58) for the length of stay and the standard reimbursement.","30446.94","30446.94","30446.94","1 through 10","9662.13","107337.41","case rate",""
"Other Procedures Of Blood And Blood-Forming Organs,MINOR","651","DRG","","","","","","","","inpatient","","","53054.50","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33972.92","","Fee schedule rate ($33,972.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28876.98","28876.98","28876.98","1 through 10","9662.13","107337.41","case rate",""
"Other Procedures Of Blood And Blood-Forming Organs,MINOR","651","DRG","","","","","","","","inpatient","","","53054.50","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9662.13","","Case rate ($10,683.15). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,113.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10680.53","10680.53","10680.53","1 through 10","9662.13","107337.41","case rate",""
"Other Procedures Of Blood And Blood-Forming Organs,MODERATE","651","DRG","","","","","","","","inpatient","","","89454.93","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","54972.68","","Standard inlier is a Case rate ($54,972.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,671, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,802.92) for the length of stay and the standard reimbursement.","54972.68","54972.68","54972.68","1 through 10","9662.13","107337.41","case rate",""
"Other Procedures Of Blood And Blood-Forming Organs,MODERATE","651","DRG","","","","","","","","inpatient","","","89454.93","","MASSHEALTH [3001]","HB BWH MEDICAID","15561.31","","Case rate ($17,205.70). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,635.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27130.35","27130.35","27130.35","1 through 10","9662.13","107337.41","case rate",""
"Other Respiratory And Chest Procedures,EXTREME","121","DRG","","","","","","","","inpatient","","","351121.42","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","155209.93","","Standard inlier is a Case rate ($155,209.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $119,004, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($22,030.76) for the length of stay and the standard reimbursement.","159914.53","159914.53","160955.07","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,EXTREME","121","DRG","","","","","","","","inpatient","","","351121.42","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","177884.46","","Fee schedule rate ($177,884.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","177884.44","177884.44","177884.44","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,EXTREME","121","DRG","","","","","","","","inpatient","","","351121.42","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","46905.55","","Case rate ($51,862.15). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $94,292.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","119835.43","119835.43","119835.43","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MAJOR","121","DRG","","","","","","","","inpatient","","","171643.20","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","83132.54","","Standard inlier is a Case rate ($83,132.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $76,296, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,801.17) for the length of stay and the standard reimbursement.","83132.54","83132.54","83132.54","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MAJOR","121","DRG","","","","","","","","inpatient","","","171643.20","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","93463.38","","Standard inlier is a Case rate ($93,463.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $76,296, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,266.35) for the length of stay and the standard reimbursement.","93463.38","85386.86","136979.13","12","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MAJOR","121","DRG","","","","","","","","inpatient","","","171643.20","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","154898.19","","Fee schedule rate ($154,898.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","72023.96","72023.96","72023.96","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MAJOR","121","DRG","","","","","","","","inpatient","","","171643.20","","MASSHEALTH [3001]","HB BWH MEDICAID","29788.34","","Case rate ($32,936.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $75,366.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","32928.04","32928.04","87719.76","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MAJOR","121","DRG","","","","","","","","inpatient","","","171643.20","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","29788.34","","Case rate ($32,936.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $75,366.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2781.16","2781.16","2781.16","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MAJOR","121","DRG","","","","","","","","inpatient","","","171643.20","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","29788.34","","Case rate ($32,936.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $75,366.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23605.43","23605.43","23605.43","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MAJOR","121","DRG","","","","","","","","inpatient","","","171643.20","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82659.07","","Fee schedule rate ($82,659.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","82659.07","82659.07","82659.07","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MAJOR","121","DRG","","","","","","","","inpatient","","","171643.20","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","29788.34","","Case rate ($32,936.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $75,366.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","46188.79","46188.79","46188.79","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MINOR","121","DRG","","","","","","","","inpatient","","","76115.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","42276.16","","Standard inlier is a Case rate ($42,276.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $44,523, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,001.36) for the length of stay and the standard reimbursement.","42276.15","42276.15","42276.15","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MINOR","121","DRG","","","","","","","","inpatient","","","76115.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","47529.79","","Standard inlier is a Case rate ($47,529.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $44,523, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,746.46) for the length of stay and the standard reimbursement.","43422.56","43422.56","47529.79","19","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MINOR","121","DRG","","","","","","","","inpatient","","","76115.10","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","50934.13","","Fee schedule rate ($50,934.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28236.12","28236.12","28236.12","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MINOR","121","DRG","","","","","","","","inpatient","","","76115.10","","MASSHEALTH [3001]","HB BWH MEDICAID","11623.57","","Case rate ($12,851.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,281.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12848.71","12848.71","12848.71","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MINOR","121","DRG","","","","","","","","inpatient","","","76115.10","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","11623.57","","Case rate ($12,851.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,281.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11645.46","11645.46","11645.46","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MINOR","121","DRG","","","","","","","","inpatient","","","76115.10","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51765.01","","Fee schedule rate ($51,765.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","41417.11","41417.11","41417.11","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MINOR","121","DRG","","","","","","","","inpatient","","","76115.10","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11623.57","","Case rate ($12,851.86). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,281.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12848.71","12848.71","12848.71","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","98875.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","54656.29","","Standard inlier is a Case rate ($54,656.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,151, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,758.79) for the length of stay and the standard reimbursement.","49821.20","5764.59","61448.40","19","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","98875.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","61448.40","","Standard inlier is a Case rate ($61,448.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,151, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,722.09) for the length of stay and the standard reimbursement.","61448.40","6494.67","61448.40","30","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","98875.60","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","39958.65","","Fee schedule rate ($39,958.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","39958.64","39958.64","39958.64","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","98875.60","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","41957.74","","Fee schedule rate ($41,957.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","41957.72","41957.72","41957.72","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","98875.60","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","43955.05","","Fee schedule rate ($43,955.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","43955.05","43955.05","43955.05","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","98875.60","","HEALTH NEW ENGLAND [1034]","HB BWH MEDICAID","15259.73","","Case rate ($16,872.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,302.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","123820.92","123820.92","123820.92","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","98875.60","","MASSHEALTH [3001]","HB BWH MEDICAID","15259.73","","Case rate ($16,872.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,302.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16868.11","16868.11","16868.11","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","98875.60","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51765.01","","Fee schedule rate ($51,765.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","51765.01","51765.01","51765.01","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","98875.60","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54354.12","","Fee schedule rate ($54,354.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","52770.54","52770.54","54354.12","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","98875.60","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15259.73","","Case rate ($16,872.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,302.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16868.11","16868.11","16868.11","1 through 10","11623.57","266826.69","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","143","DRG","","","","","","","","inpatient","","","93632.63","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","49504.37","","Standard inlier is a Case rate ($49,504.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,144, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,027.44) for the length of stay and the standard reimbursement.","45125.03","45125.03","45125.03","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","143","DRG","","","","","","","","inpatient","","","93632.63","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","55656.25","","Standard inlier is a Case rate ($55,656.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,144, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,899.94) for the length of stay and the standard reimbursement.","50846.79","50846.79","61416.07","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","143","DRG","","","","","","","","inpatient","","","93632.63","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11812.0127","","Fee schedule rate ($45,320.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11812.0127","45320.00","45320.00","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","143","DRG","","","","","","","","inpatient","","","93632.63","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","49852.62","","Fee schedule rate ($49,852.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","49852.62","49852.62","49852.62","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","143","DRG","","","","","","","","inpatient","","","93632.63","","MASSHEALTH [3001]","HB BWH MEDICAID","17156.05","","Case rate ($18,968.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,398.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,943.65 and the sum of the standard inlier and any outlier amount.","19732.71","19732.71","19732.71","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","143","DRG","","","","","","","","inpatient","","","93632.63","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","17156.05","","Case rate ($18,968.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,398.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,943.65 and the sum of the standard inlier and any outlier amount.","9847.15","9847.15","9847.15","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","143","DRG","","","","","","","","inpatient","","","93632.63","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53640.56","","Fee schedule rate ($53,640.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","53640.56","53640.56","53640.56","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","143","DRG","","","","","","","","inpatient","","","93632.63","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","17156.05","","Case rate ($18,968.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,398.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,943.65 and the sum of the standard inlier and any outlier amount.","18964.31","18964.31","18964.31","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","143","DRG","","","","","","","","inpatient","","","54907.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","32143.72","","Standard inlier is a Case rate ($32,143.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,643, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,562.99) for the length of stay and the standard reimbursement.","32143.71","32143.71","36138.20","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","143","DRG","","","","","","","","inpatient","","","54907.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","36138.20","","Standard inlier is a Case rate ($36,138.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,643, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,129.52) for the length of stay and the standard reimbursement.","36138.20","33015.37","36138.20","12","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","143","DRG","","","","","","","","inpatient","","","54907.55","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11812.0127","","Fee schedule rate ($72,023.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11812.0127","29591.56","29591.56","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","143","DRG","","","","","","","","inpatient","","","54907.55","","MASSHEALTH [3001]","HB BWH MEDICAID","10971.28","","Case rate ($12,130.64). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,560.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12127.66","5042.69","12127.66","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","143","DRG","","","","","","","","inpatient","","","54907.55","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","10971.28","","Case rate ($12,130.64). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,560.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2850.01","2459.36","10070.09","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","143","DRG","","","","","","","","inpatient","","","54907.55","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82659.07","","Fee schedule rate ($82,659.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34669.55","34669.55","34669.55","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","143","DRG","","","","","","","","inpatient","","","54907.55","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10971.28","","Case rate ($12,130.64). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,560.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","30525.31","30525.31","30525.31","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MINOR","143","DRG","","","","","","","","inpatient","","","15367.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","15853.56","","Standard inlier is a Case rate ($15,853.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,976, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,250.51) for the length of stay and the standard reimbursement.","14701.09","14701.09","14701.09","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","143","DRG","","","","","","","","inpatient","","","40517.93","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22464.06","","Standard inlier is a Case rate ($22,464.06). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,118, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,188.91) for the length of stay and the standard reimbursement.","22464.05","20476.80","29300.17","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","143","DRG","","","","","","","","inpatient","","","40517.93","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25255.66","","Standard inlier is a Case rate ($25,255.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,118, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,584.83) for the length of stay and the standard reimbursement.","25255.65","23073.22","25255.65","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","143","DRG","","","","","","","","inpatient","","","40517.93","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11812.0127","","Fee schedule rate ($29,591.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11812.0127","17513.36","17513.36","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","143","DRG","","","","","","","","inpatient","","","40517.93","","MASSHEALTH [3001]","HB BWH MEDICAID","6590.31","","Case rate ($7,286.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,716.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7284.93","7284.93","7284.93","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","143","DRG","","","","","","","","inpatient","","","40517.93","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","6590.31","","Case rate ($7,286.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,716.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","143","DRG","","","","","","","","inpatient","","","40517.93","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6590.31","","Case rate ($7,286.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,716.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7284.93","7284.93","7284.93","1 through 10","5122.37","118841.01","case rate",""
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","74581.14","55935.85","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","17594.88","","Case rate ($17,082.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,486.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,130.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $15,229.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,106.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.33. The transfer capital threshold is the transfer adjustment factor * $1,473.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17990.05","17990.05","17990.05","1 through 10","16740.76","28680.78","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","74581.14","55935.85","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","22056.91","","Case rate ($22,056.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,486.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,130.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $20,203.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,106.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.33. The transfer capital threshold is the transfer adjustment factor * $1,473.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17225.03","17225.03","17225.03","1 through 10","16740.76","28680.78","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","74581.14","55935.85","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","21353.01","","Case rate ($17,082.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,486.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,130.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $15,229.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,106.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.33. The transfer capital threshold is the transfer adjustment factor * $1,473.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","17564.17","17564.17","17564.17","1 through 10","16740.76","28680.78","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","74581.14","55935.85","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","17082.41","","Case rate ($17,082.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,486.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,130.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $15,229.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,106.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.33. The transfer capital threshold is the transfer adjustment factor * $1,473.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17121.75","17121.75","56805.08","1 through 10","16740.76","28680.78","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","74581.14","55935.85","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","24368.54","24368.54","24368.54","1 through 10","16740.76","28680.78","case rate",""
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","74581.14","55935.85","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","22056.91","","Case rate ($22,056.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,486.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,130.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $20,203.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,106.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.33. The transfer capital threshold is the transfer adjustment factor * $1,473.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17112.45","17112.45","17112.45","1 through 10","16740.76","28680.78","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","74581.14","55935.85","HUMANA [1012]","HB BWH MEDICARE","22056.91","","Case rate ($22,056.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,486.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,130.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $20,203.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,106.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.33. The transfer capital threshold is the transfer adjustment factor * $1,473.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17132.73","17132.73","17132.73","1 through 10","16740.76","28680.78","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","74581.14","55935.85","MEDICARE [2001]","HB BWH MEDICARE","22056.91","","Case rate ($22,056.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,486.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,130.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $20,203.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,106.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.33. The transfer capital threshold is the transfer adjustment factor * $1,473.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22533.84","0.03","22567.14","63","16740.76","28680.78","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","74581.14","55935.85","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","22056.91","","Case rate ($22,056.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,486.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,130.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $20,203.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,106.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.33. The transfer capital threshold is the transfer adjustment factor * $1,473.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17064.97","17064.97","17064.97","1 through 10","16740.76","28680.78","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","74581.14","55935.85","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16740.76","","Case rate ($17,082.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,486.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,130.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $15,229.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,106.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.33. The transfer capital threshold is the transfer adjustment factor * $1,473.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17150.56","17150.56","17150.56","1 through 10","16740.76","28680.78","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","74581.14","55935.85","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16740.76","","Case rate ($17,082.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,486.45, add-ons for qualifying new technology services are included. If operating cost exceeds $66,130.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,913.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $15,229.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,106.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,473.33. The transfer capital threshold is the transfer adjustment factor * $1,473.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17065.03","17065.03","17149.21","1 through 10","16740.76","28680.78","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","41568.19","31176.14","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","11521.45","","Case rate ($11,521.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,714.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,358.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,197.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,384.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,334.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.26. The transfer capital threshold is the transfer adjustment factor * $757.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8407.31","8407.31","8407.31","1 through 10","8785.36","13669.4278","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","41568.19","31176.14","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8964.65","","Case rate ($8,964.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,714.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,358.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,197.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,827.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,334.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.26. The transfer capital threshold is the transfer adjustment factor * $757.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8356.69","8356.69","8356.69","1 through 10","8785.36","13669.4278","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","41568.19","31176.14","FALLON HEALTH [1008]","HB BWH MEDICARE","11521.45","","Case rate ($11,521.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,714.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,358.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,197.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,384.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,334.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.26. The transfer capital threshold is the transfer adjustment factor * $757.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17081.34","17081.34","17081.34","1 through 10","8785.36","13669.4278","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","41568.19","31176.14","MEDICARE [2001]","HB BWH MEDICARE","11521.45","","Case rate ($11,521.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,714.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,358.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,197.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,384.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,334.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.26. The transfer capital threshold is the transfer adjustment factor * $757.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10972.88","0.03","10972.88","26","8785.36","13669.4278","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","41568.19","31176.14","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","11521.45","","Case rate ($11,521.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,714.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,358.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,197.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,384.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,334.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.26. The transfer capital threshold is the transfer adjustment factor * $757.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8351.81","8351.81","8351.81","1 through 10","8785.36","13669.4278","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","41568.19","31176.14","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8785.36","","Case rate ($8,964.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,714.26, add-ons for qualifying new technology services are included. If operating cost exceeds $56,358.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,197.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,827.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,334.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.26. The transfer capital threshold is the transfer adjustment factor * $757.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17148.40","17148.40","17148.40","1 through 10","8785.36","13669.4278","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","","","","inpatient","","","79732.59","59799.44","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","17335.57","","Case rate ($16,830.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,183.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,827.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,891.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $14,999.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,803.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.12. The transfer capital threshold is the transfer adjustment factor * $1,451.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17375.01","17375.01","17375.01","1 through 10","16494.04","28248.46","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","","","","inpatient","","","79732.59","59799.44","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","16830.65","","Case rate ($16,830.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,183.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,827.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,891.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $14,999.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,803.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.12. The transfer capital threshold is the transfer adjustment factor * $1,451.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16589.74","16589.74","16589.74","1 through 10","16494.04","28248.46","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","","","","inpatient","","","79732.59","59799.44","ELDER SERVICES [1037]","HB BWH MEDICARE","16830.65","","Case rate ($16,830.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,183.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,827.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,891.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $14,999.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,803.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.12. The transfer capital threshold is the transfer adjustment factor * $1,451.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","42922.19","42922.19","42922.19","1 through 10","16494.04","28248.46","other","Inpatient Replacement Plans DRG"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","","","","inpatient","","","79732.59","59799.44","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","16830.65","","Case rate ($16,830.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,183.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,827.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,891.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $14,999.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,803.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.12. The transfer capital threshold is the transfer adjustment factor * $1,451.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16646.06","16646.06","16646.06","1 through 10","16494.04","28248.46","other","Inpatient Replacement Plans DRG"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","","","","inpatient","","","79732.59","59799.44","MEDICARE [2001]","HB BWH MEDICARE","16830.65","","Case rate ($16,830.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,183.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,827.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,891.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $14,999.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,803.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.12. The transfer capital threshold is the transfer adjustment factor * $1,451.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19308.61","0.03","21851.64","20","16494.04","28248.46","other","Inpatient Replacement Plans DRG"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","","","","inpatient","","","79732.59","59799.44","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16494.04","","Case rate ($16,830.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,183.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,827.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,891.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $14,999.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,803.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.12. The transfer capital threshold is the transfer adjustment factor * $1,451.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16531.97","16531.97","16531.97","1 through 10","16494.04","28248.46","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","","","","inpatient","","","79732.59","59799.44","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16494.04","","Case rate ($16,830.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,183.36, add-ons for qualifying new technology services are included. If operating cost exceeds $65,827.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,891.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $14,999.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,803.53 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,451.12. The transfer capital threshold is the transfer adjustment factor * $1,451.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16630.58","16630.58","16630.58","1 through 10","16494.04","28248.46","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With McC","166","MS-DRG","","","","","","","","inpatient","","","157468.43","118101.32","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44630.19","","Case rate ($44,630.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,424.33, add-ons for qualifying new technology services are included. If operating cost exceeds $87,068.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,447.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $41,242.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,044.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,007.57. The transfer capital threshold is the transfer adjustment factor * $3,007.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34847.03","34847.03","34847.03","1 through 10","33786.02","58547.33","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With McC","166","MS-DRG","","","","","","","","inpatient","","","157468.43","118101.32","ELDER SERVICES [1037]","HB BWH MEDICARE","44630.19","","Case rate ($44,630.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,424.33, add-ons for qualifying new technology services are included. If operating cost exceeds $87,068.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,447.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $41,242.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,044.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,007.57. The transfer capital threshold is the transfer adjustment factor * $3,007.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","70008.40","70008.40","70008.40","1 through 10","33786.02","58547.33","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With McC","166","MS-DRG","","","","","","","","inpatient","","","157468.43","118101.32","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","44630.19","","Case rate ($44,630.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,424.33, add-ons for qualifying new technology services are included. If operating cost exceeds $87,068.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,447.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $41,242.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,044.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,007.57. The transfer capital threshold is the transfer adjustment factor * $3,007.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34575.43","34575.43","34575.43","1 through 10","33786.02","58547.33","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With McC","166","MS-DRG","","","","","","","","inpatient","","","157468.43","118101.32","MEDICARE [2001]","HB BWH MEDICARE","44630.19","","Case rate ($44,630.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,424.33, add-ons for qualifying new technology services are included. If operating cost exceeds $87,068.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,447.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $41,242.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,044.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,007.57. The transfer capital threshold is the transfer adjustment factor * $3,007.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","40499.93","0.03","45737.96","17","33786.02","58547.33","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With McC","166","MS-DRG","","","","","","","","inpatient","","","157468.43","118101.32","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","33786.02","","Case rate ($34,475.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,424.33, add-ons for qualifying new technology services are included. If operating cost exceeds $87,068.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,447.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $31,088.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,044.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,007.57. The transfer capital threshold is the transfer adjustment factor * $3,007.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","41613.45","41613.45","41613.45","1 through 10","33786.02","58547.33","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With McC","166","MS-DRG","","","","","","","","inpatient","","","157468.43","118101.32","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","33786.02","","Case rate ($34,475.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,424.33, add-ons for qualifying new technology services are included. If operating cost exceeds $87,068.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,447.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $31,088.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,044.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,007.57. The transfer capital threshold is the transfer adjustment factor * $3,007.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13644.48","13644.48","13644.48","1 through 10","33786.02","58547.33","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With McC","166","MS-DRG","","","","","","","","inpatient","","","157468.43","118101.32","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","33786.02","","Case rate ($34,475.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $41,424.33, add-ons for qualifying new technology services are included. If operating cost exceeds $87,068.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,447.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $31,088.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $41,044.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,007.57. The transfer capital threshold is the transfer adjustment factor * $3,007.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","34708.73","30717.31","95404.30","1 through 10","33786.02","58547.33","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With McC","166","MS-DRG","","","","","","","","inpatient","","","157468.43","118101.32","WELLPOINT [1015]","HB AMC WELLPOINT","58547.33","","Fee schedule rate ($58,547.33).","58104.87","58104.87","58104.87","1 through 10","33786.02","58547.33","case rate",""
"Other Respiratory System O.R. Procedures Without Cc/McC","168","MS-DRG","","","","","","","","inpatient","","","64318.75","48239.06","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12844.29","","Case rate ($12,844.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,384.57, add-ons for qualifying new technology services are included. If operating cost exceeds $61,029.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,539.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,364.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,004.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,099.49. The transfer capital threshold is the transfer adjustment factor * $1,099.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12430.98","12430.98","12430.98","1 through 10","12587.4","20431.7049","other","Inpatient Replacement Plans DRG"
"Other Respiratory System O.R. Procedures Without Cc/McC","168","MS-DRG","","","","","","","","inpatient","","","64318.75","48239.06","ELDER SERVICES [1037]","HB BWH MEDICARE","12844.29","","Case rate ($12,844.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,384.57, add-ons for qualifying new technology services are included. If operating cost exceeds $61,029.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,539.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,364.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,004.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,099.49. The transfer capital threshold is the transfer adjustment factor * $1,099.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","63188.35","63188.35","63188.35","1 through 10","12587.4","20431.7049","other","Inpatient Replacement Plans DRG"
"Other Respiratory System O.R. Procedures Without Cc/McC","168","MS-DRG","","","","","","","","inpatient","","","64318.75","48239.06","MEDICARE [2001]","HB BWH MEDICARE","12844.29","","Case rate ($12,844.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,384.57, add-ons for qualifying new technology services are included. If operating cost exceeds $61,029.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,539.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,364.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,004.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,099.49. The transfer capital threshold is the transfer adjustment factor * $1,099.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16239.62","16239.62","16239.62","1 through 10","12587.4","20431.7049","other","Inpatient Replacement Plans DRG"
"Other Significant Hip And Femur Surgery,EXTREME","309","DRG","","","","","","","","inpatient","","","448835.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","146548.98","","Standard inlier is a Case rate ($146,548.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $113,014, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,801.41) for the length of stay and the standard reimbursement.","142318.04","142318.04","142318.04","1 through 10","15274.58","268129.47","case rate",""
"Other Significant Hip And Femur Surgery,MAJOR","309","DRG","","","","","","","","inpatient","","","190102.73","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","91616.29","","Standard inlier is a Case rate ($91,616.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $75,018, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,004.17) for the length of stay and the standard reimbursement.","91616.29","91616.29","91616.29","1 through 10","15274.58","268129.47","case rate",""
"Other Significant Hip And Femur Surgery,MAJOR","309","DRG","","","","","","","","inpatient","","","190102.73","","MASSHEALTH [3001]","HB BWH MEDICAID","26695.95","","Case rate ($29,516.96). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $71,946.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","32470.32","32470.32","32470.32","1 through 10","15274.58","268129.47","case rate",""
"Other Significant Hip And Femur Surgery,MAJOR","309","DRG","","","","","","","","inpatient","","","190102.73","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","26695.95","","Case rate ($29,516.96). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $71,946.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","15274.58","268129.47","case rate",""
"Other Significant Hip And Femur Surgery,MINOR","309","DRG","","","","","","","","inpatient","","","64206.72","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24308.4556","","Fee schedule rate ($26,207.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24308.4556","26207.40","26207.40","1 through 10","15274.58","268129.47","case rate",""
"Other Significant Hip And Femur Surgery,MINOR","309","DRG","","","","","","","","inpatient","","","64206.72","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","26207.4139","","Fee schedule rate ($26,207.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26207.4139","26207.40","26207.40","1 through 10","15274.58","268129.47","case rate",""
"Other Significant Hip And Femur Surgery,MODERATE","309","DRG","","","","","","","","inpatient","","","118983.23","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","64419.01","","Standard inlier is a Case rate ($64,419.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,206, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,143.74) for the length of stay and the standard reimbursement.","64419.01","64419.01","64419.01","1 through 10","15274.58","268129.47","case rate",""
"Other Significant Hip And Femur Surgery,MODERATE","309","DRG","","","","","","","","inpatient","","","118983.23","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24308.4556","","Fee schedule rate ($36,171.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24308.4556","39641.04","39641.04","1 through 10","15274.58","268129.47","case rate",""
"Other Significant Hip And Femur Surgery,MODERATE","309","DRG","","","","","","","","inpatient","","","118983.23","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","26207.4139","","Fee schedule rate ($36,171.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26207.4139","39641.04","39641.04","1 through 10","15274.58","268129.47","case rate",""
"Other Significant Hip And Femur Surgery,MODERATE","309","DRG","","","","","","","","inpatient","","","118983.23","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58593.70","","Fee schedule rate ($58,593.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","58593.70","58593.70","58593.70","1 through 10","15274.58","268129.47","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,EXTREME","385","DRG","","","","","","","","inpatient","","","113341.40","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","55105.83","","Standard inlier is a Case rate ($55,105.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,500, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,822.60) for the length of stay and the standard reimbursement.","55105.82","55105.82","55105.82","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,EXTREME","385","DRG","","","","","","","","inpatient","","","113341.40","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","61953.80","","Standard inlier is a Case rate ($61,953.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,500, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,793.83) for the length of stay and the standard reimbursement.","61953.80","61953.80","61953.80","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,EXTREME","385","DRG","","","","","","","","inpatient","","","113341.40","","MASSHEALTH [3001]","HB BWH MEDICAID","19896.59","","Case rate ($21,999.10). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,429.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","91993.44","91993.44","91993.44","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,EXTREME","385","DRG","","","","","","","","inpatient","","","113341.40","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","19896.59","","Case rate ($21,999.10). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,429.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8343.48","8343.48","8343.48","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MAJOR","385","DRG","","","","","","","","inpatient","","","49619.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","27467.21","","Standard inlier is a Case rate ($27,467.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,006, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,899.14) for the length of stay and the standard reimbursement.","25037.36","25037.36","25037.36","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MAJOR","385","DRG","","","","","","","","inpatient","","","49619.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","30880.55","","Standard inlier is a Case rate ($30,880.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,006, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,383.24) for the length of stay and the standard reimbursement.","28212.04","28212.04","30880.54","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MAJOR","385","DRG","","","","","","","","inpatient","","","49619.74","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10181.4584","","Fee schedule rate ($43,282.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10181.4584","22094.12","22094.12","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MAJOR","385","DRG","","","","","","","","inpatient","","","49619.74","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10690.8272","","Fee schedule rate ($45,447.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10690.8272","21968.68","21968.68","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MAJOR","385","DRG","","","","","","","","inpatient","","","49619.74","","MASSHEALTH [3001]","HB BWH MEDICAID","10266.44","","Case rate ($11,351.32). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,781.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11348.53","11348.53","11348.53","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MAJOR","385","DRG","","","","","","","","inpatient","","","49619.74","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56927.02","","Fee schedule rate ($56,927.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26862.91","26862.91","26862.91","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MAJOR","385","DRG","","","","","","","","inpatient","","","49619.74","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","59774.31","","Fee schedule rate ($59,774.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28206.49","28206.49","28206.49","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MAJOR","385","DRG","","","","","","","","inpatient","","","49619.74","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10266.44","","Case rate ($11,351.32). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,781.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11348.53","11348.53","11348.53","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MINOR","385","DRG","","","","","","","","inpatient","","","24535.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","13411.81","","Standard inlier is a Case rate ($13,411.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,077, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,903.89) for the length of stay and the standard reimbursement.","12225.35","12225.35","12225.35","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MINOR","385","DRG","","","","","","","","inpatient","","","24535.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","15078.49","","Standard inlier is a Case rate ($15,078.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,077, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,140.27) for the length of stay and the standard reimbursement.","13775.50","13775.50","13775.50","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MINOR","385","DRG","","","","","","","","inpatient","","","24535.51","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10690.8272","","Fee schedule rate ($10,690.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10690.8272","10690.84","10690.84","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MINOR","385","DRG","","","","","","","","inpatient","","","24535.51","","MASSHEALTH [3001]","HB BWH MEDICAID","5049.26","","Case rate ($5,582.82). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,012.82, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2816.04","2816.04","2816.04","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MODERATE","385","DRG","","","","","","","","inpatient","","","45953.64","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","17690.53","","Standard inlier is a Case rate ($17,690.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,404, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,511.28) for the length of stay and the standard reimbursement.","17690.52","17690.52","17690.52","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MODERATE","385","DRG","","","","","","","","inpatient","","","45953.64","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","19888.92","","Standard inlier is a Case rate ($19,888.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,404, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,823.07) for the length of stay and the standard reimbursement.","19888.92","18170.24","19888.92","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MODERATE","385","DRG","","","","","","","","inpatient","","","45953.64","","MASSHEALTH [3001]","HB BWH MEDICAID","6029.41","","Case rate ($6,666.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,096.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6664.91","6664.91","6664.91","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MODERATE","385","DRG","","","","","","","","inpatient","","","45953.64","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6029.41","","Case rate ($6,666.55). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,096.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6664.91","6664.91","6664.91","1 through 10","5049.26","71416.8","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","","","","inpatient","","","110858.56","83143.92","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","16627.13","","Case rate ($16,142.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,355.38, add-ons for qualifying new technology services are included. If operating cost exceeds $64,999.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,830.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $14,372.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,975.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,390.45. The transfer capital threshold is the transfer adjustment factor * $1,390.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12114.92","12114.92","12114.92","1 through 10","15819.98","26756.343","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","","","","inpatient","","","110858.56","83143.92","MEDICARE [2001]","HB BWH MEDICARE","16142.84","","Case rate ($16,142.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,355.38, add-ons for qualifying new technology services are included. If operating cost exceeds $64,999.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,830.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $14,372.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,975.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,390.45. The transfer capital threshold is the transfer adjustment factor * $1,390.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20215.28","0.03","21211.72","12","15819.98","26756.343","other","Inpatient Replacement Plans DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","","","","inpatient","","","110858.56","83143.92","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15819.98","","Case rate ($16,142.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,355.38, add-ons for qualifying new technology services are included. If operating cost exceeds $64,999.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,830.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $14,372.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,975.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,390.45. The transfer capital threshold is the transfer adjustment factor * $1,390.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22210.27","22210.27","22210.27","1 through 10","15819.98","26756.343","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","","","","inpatient","","","110858.56","83143.92","WELLPOINT [1015]","HB AMC WELLPOINT","26756.343","","Fee schedule rate ($27,067.39).","26756.343","26756.34","26756.34","1 through 10","15819.98","26756.343","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With McC","579","MS-DRG","","","","","","","","inpatient","","","154417.41","115813.06","MEDICARE [2001]","HB BWH MEDICARE","38720.20","","Case rate ($38,720.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,942.51, add-ons for qualifying new technology services are included. If operating cost exceeds $81,586.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,046.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $35,734.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,562.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,605.89. The transfer capital threshold is the transfer adjustment factor * $2,605.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38703.86","0.03","89087.62","1 through 10","29323.34","49187.6054","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With McC","579","MS-DRG","","","","","","","","inpatient","","","154417.41","115813.06","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","29323.34","","Case rate ($29,921.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,942.51, add-ons for qualifying new technology services are included. If operating cost exceeds $81,586.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,046.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $26,936.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,562.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,605.89. The transfer capital threshold is the transfer adjustment factor * $2,605.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","29313.51","26713.33","29363.90","1 through 10","29323.34","49187.6054","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/McC","581","MS-DRG","","","","","","","","inpatient","","","192238.02","144178.51","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","13543.95","","Case rate ($13,543.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,226.83, add-ons for qualifying new technology services are included. If operating cost exceeds $61,871.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,601.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $12,002.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,846.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.20. The transfer capital threshold is the transfer adjustment factor * $1,161.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13196.89","13196.89","13196.89","1 through 10","13273.07","21718.9672","other","Inpatient Replacement Plans DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/McC","581","MS-DRG","","","","","","","","inpatient","","","192238.02","144178.51","MEDICARE [2001]","HB BWH MEDICARE","13543.95","","Case rate ($13,543.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,226.83, add-ons for qualifying new technology services are included. If operating cost exceeds $61,871.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,601.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $12,002.91 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,846.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.20. The transfer capital threshold is the transfer adjustment factor * $1,161.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17270.61","7025.20","17270.61","1 through 10","13273.07","21718.9672","other","Inpatient Replacement Plans DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/McC","581","MS-DRG","","","","","","","","inpatient","","","192238.02","144178.51","WELLPOINT [1015]","HB AMC WELLPOINT","21718.9672","","Fee schedule rate ($22,604.72).","21718.9672","171743.93","171743.93","1 through 10","13273.07","21718.9672","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,EXTREME","364","DRG","","","","","","","","inpatient","","","71213.42","","MASSHEALTH [3001]","HB BWH MEDICAID","17811.77","","Case rate ($19,693.97). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,123.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31323.06","31323.06","31323.06","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MAJOR","364","DRG","","","","","","","","inpatient","","","138513.79","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","52318.04","","Standard inlier is a Case rate ($52,318.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,331, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,426.86) for the length of stay and the standard reimbursement.","47689.79","47689.79","47689.79","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MAJOR","364","DRG","","","","","","","","inpatient","","","138513.79","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","58819.57","","Standard inlier is a Case rate ($58,819.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,331, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,348.95) for the length of stay and the standard reimbursement.","58819.57","58819.57","58819.57","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MINOR","364","DRG","","","","","","","","inpatient","","","41890.95","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","26659.15","","Standard inlier is a Case rate ($26,659.15). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,087, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,784.05) for the length of stay and the standard reimbursement.","26659.15","26659.15","26659.15","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MINOR","364","DRG","","","","","","","","inpatient","","","41890.95","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","18281.5024","","Fee schedule rate ($18,281.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18281.5024","18281.52","18281.52","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MINOR","364","DRG","","","","","","","","inpatient","","","41890.95","","MASSHEALTH [3001]","HB BWH MEDICAID","7136.36","","Case rate ($7,890.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,320.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4941.22","4941.22","7888.53","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MINOR","364","DRG","","","","","","","","inpatient","","","41890.95","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","7136.36","","Case rate ($7,890.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,320.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2781.16","2781.16","2781.16","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MINOR","364","DRG","","","","","","","","inpatient","","","41890.95","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23482.66","","Fee schedule rate ($23,482.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19960.26","19960.26","19960.26","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MODERATE","364","DRG","","","","","","","","inpatient","","","56167.68","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","32761.43","","Standard inlier is a Case rate ($32,761.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $37,125, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,650.68) for the length of stay and the standard reimbursement.","32761.43","32761.43","32761.43","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MODERATE","364","DRG","","","","","","","","inpatient","","","56167.68","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","17410.4728","","Fee schedule rate ($52,097.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17410.4728","40535.28","40535.28","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MODERATE","364","DRG","","","","","","","","inpatient","","","56167.68","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","18281.5024","","Fee schedule rate ($54,703.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18281.5024","52277.48","52277.48","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MODERATE","364","DRG","","","","","","","","inpatient","","","56167.68","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","57307.64","","Fee schedule rate ($57,307.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29051.92","29051.92","29051.92","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MODERATE","364","DRG","","","","","","","","inpatient","","","56167.68","","MASSHEALTH [3001]","HB BWH MEDICAID","9319.42","","Case rate ($10,304.22). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,734.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10301.70","10301.70","10301.70","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MODERATE","364","DRG","","","","","","","","inpatient","","","56167.68","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","9319.42","","Case rate ($10,304.22). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,734.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","7136.36","183345.32","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MODERATE","364","DRG","","","","","","","","inpatient","","","56167.68","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9319.42","","Case rate ($10,304.22). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,734.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","10301.69","1 through 10","7136.36","183345.32","case rate",""
"Other Small And Large Bowel Procedures,EXTREME","223","DRG","","","","","","","","inpatient","","","153716.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","122954.01","","Standard inlier is a Case rate ($122,954.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $107,262, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,454.06) for the length of stay and the standard reimbursement.","208698.24","208698.24","208698.24","1 through 10","11688.69","223964.06","case rate",""
"Other Small And Large Bowel Procedures,MAJOR","223","DRG","","","","","","","","inpatient","","","67737.90","","MASSHEALTH [3001]","HB BWH MEDICAID","19321.98","","Case rate ($21,363.77). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,793.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21358.52","21358.52","21358.52","1 through 10","11688.69","223964.06","case rate",""
"Other Small And Large Bowel Procedures,MINOR","223","DRG","","","","","","","","inpatient","","","40383.37","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","26460.161","","Fee schedule rate ($26,460.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26460.161","26460.16","26460.16","1 through 10","11688.69","223964.06","case rate",""
"Other Small And Large Bowel Procedures,MINOR","223","DRG","","","","","","","","inpatient","","","40383.37","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","32644.89","","Fee schedule rate ($32,644.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33075.50","33075.50","33075.50","1 through 10","11688.69","223964.06","case rate",""
"Other Small And Large Bowel Procedures,MINOR","223","DRG","","","","","","","","inpatient","","","40383.37","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","26545.30","26545.30","26545.30","1 through 10","11688.69","223964.06","percent of total billed charges",""
"Other Small And Large Bowel Procedures,MINOR","223","DRG","","","","","","","","inpatient","","","40383.37","","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","27783.938","","Fee schedule rate ($27,783.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27783.938","27985.05","27985.05","1 through 10","11688.69","223964.06","case rate",""
"Other Small And Large Bowel Procedures,MODERATE","223","DRG","","","","","","","","inpatient","","","49572.20","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","49572.28","","Standard inlier is a Case rate ($49,572.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,197, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,037.08) for the length of stay and the standard reimbursement.","49572.28","49572.28","49572.28","1 through 10","11688.69","223964.06","case rate",""
"Other Small And Large Bowel Procedures,MODERATE","223","DRG","","","","","","","","inpatient","","","49572.20","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","55732.61","","Standard inlier is a Case rate ($55,732.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,197, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,910.78) for the length of stay and the standard reimbursement.","55732.60","55732.60","55732.60","1 through 10","11688.69","223964.06","case rate",""
"Other Small And Large Bowel Procedures,MODERATE","223","DRG","","","","","","","","inpatient","","","49572.20","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","26460.161","","Fee schedule rate ($35,210.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26460.161","35210.12","35210.12","1 through 10","11688.69","223964.06","case rate",""
"Other Small And Large Bowel Procedures,MODERATE","223","DRG","","","","","","","","inpatient","","","49572.20","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","27783.938","","Fee schedule rate ($36,971.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27783.938","36971.68","36971.68","1 through 10","11688.69","223964.06","case rate",""
"Other Small And Large Bowel Procedures,MODERATE","223","DRG","","","","","","","","inpatient","","","49572.20","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","38731.62","","Fee schedule rate ($38,731.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38731.62","38731.62","38731.62","1 through 10","11688.69","223964.06","case rate",""
"Other Stomach, Esophageal And Duodenal Procedures,EXTREME","222","DRG","","","","","","","","inpatient","","","91125.42","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","19385.4789","","Fee schedule rate ($128,764.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19385.4789","128764.60","128764.60","1 through 10","8576.88","212464.15","case rate",""
"Other Stomach, Esophageal And Duodenal Procedures,EXTREME","222","DRG","","","","","","","","inpatient","","","91125.42","","MASSHEALTH [3001]","HB BWH MEDICAID","19778.92","","Case rate ($21,869). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,299, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","59506.86","59506.86","59506.86","1 through 10","8576.88","212464.15","case rate",""
"Other Stomach, Esophageal And Duodenal Procedures,MAJOR","222","DRG","","","","","","","","inpatient","","","111385.69","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","67462.34","","Standard inlier is a Case rate ($67,462.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $58,310, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,575.72) for the length of stay and the standard reimbursement.","61632.67","61632.67","61632.67","1 through 10","8576.88","212464.15","case rate",""
"Other Stomach, Esophageal And Duodenal Procedures,MAJOR","222","DRG","","","","","","","","inpatient","","","111385.69","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","20355.3162","","Fee schedule rate ($62,223.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20355.3162","62223.80","62223.80","1 through 10","8576.88","212464.15","case rate",""
"Other Stomach, Esophageal And Duodenal Procedures,MINOR","222","DRG","","","","","","","","inpatient","","","26144.86","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24455.77","","Fee schedule rate ($24,455.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24455.77","24455.77","24455.77","1 through 10","8576.88","212464.15","case rate",""
"Other Stomach, Esophageal And Duodenal Procedures,MODERATE","222","DRG","","","","","","","","inpatient","","","22946.70","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","19385.4789","","Fee schedule rate ($45,259.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19385.4789","24046.88","24046.88","1 through 10","8576.88","212464.15","case rate",""
"Other Stomach, Esophageal And Duodenal Procedures,MODERATE","222","DRG","","","","","","","","inpatient","","","22946.70","","MASSHEALTH [3001]","HB BWH MEDICAID","14029.40","","Case rate ($15,511.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,941.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10282.76","10282.76","10282.76","1 through 10","8576.88","212464.15","case rate",""
"Other Stomach, Esophageal And Duodenal Procedures,MODERATE","222","DRG","","","","","","","","inpatient","","","22946.70","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40179.26","","Fee schedule rate ($40,179.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","39008.66","39008.66","39008.66","1 through 10","8576.88","212464.15","case rate",""
"Other Upper Vascular Procedures,EXTREME","182","DRG","","","","","","","","inpatient","","","283063.34","","MASSHEALTH [3001]","HB BWH MEDICAID","49968.23","","Case rate ($55,248.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $97,678.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","55234.91","55234.91","55234.91","1 through 10","19719.52","225441.91","case rate",""
"Other Upper Vascular Procedures,EXTREME","182","DRG","","","","","","","","inpatient","","","283063.34","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","49968.23","","Case rate ($55,248.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $97,678.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","55234.91","55234.91","55234.91","1 through 10","19719.52","225441.91","case rate",""
"Other Upper Vascular Procedures,MAJOR","182","DRG","","","","","","","","inpatient","","","134924.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","77269.12","","Standard inlier is a Case rate ($77,269.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,735, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,968.82) for the length of stay and the standard reimbursement.","77269.11","77269.11","77269.11","1 through 10","19719.52","225441.91","case rate",""
"Other Upper Vascular Procedures,MAJOR","182","DRG","","","","","","","","inpatient","","","134924.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","86871.31","","Standard inlier is a Case rate ($86,871.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $71,735, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,330.66) for the length of stay and the standard reimbursement.","79377.53","79377.53","79377.53","1 through 10","19719.52","225441.91","case rate",""
"Other Upper Vascular Procedures,MAJOR","182","DRG","","","","","","","","inpatient","","","134924.72","","HEALTH NEW ENGLAND [1034]","HB BWH MEDICAID","25279.42","","Case rate ($27,950.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,380.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27943.88","27943.88","27943.88","1 through 10","19719.52","225441.91","case rate",""
"Other Upper Vascular Procedures,MAJOR","182","DRG","","","","","","","","inpatient","","","134924.72","","MASSHEALTH [3001]","HB BWH MEDICAID","25279.42","","Case rate ($27,950.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,380.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27943.89","27943.89","27943.89","1 through 10","19719.52","225441.91","case rate",""
"Other Upper Vascular Procedures,MAJOR","182","DRG","","","","","","","","inpatient","","","134924.72","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","114516.04","","Fee schedule rate ($114,516.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","66385.07","66385.07","66385.07","1 through 10","19719.52","225441.91","case rate",""
"Other Upper Vascular Procedures,MAJOR","182","DRG","","","","","","","","inpatient","","","134924.72","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","25279.42","","Case rate ($27,950.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,380.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27943.88","27943.88","27943.88","1 through 10","19719.52","225441.91","case rate",""
"Other Upper Vascular Procedures,MINOR","182","DRG","","","","","","","","inpatient","","","120517.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","66102.48","","Standard inlier is a Case rate ($66,102.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,371, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,382.70) for the length of stay and the standard reimbursement.","60390.32","60390.32","60390.32","1 through 10","19719.52","225441.91","case rate",""
"Other Upper Vascular Procedures,MODERATE","182","DRG","","","","","","","","inpatient","","","119541.63","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","63847.60","","Standard inlier is a Case rate ($63,847.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $61,297, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,063.55) for the length of stay and the standard reimbursement.","63847.60","63847.60","63847.60","1 through 10","19719.52","225441.91","case rate",""
"Other Upper Vascular Procedures,MODERATE","182","DRG","","","","","","","","inpatient","","","119541.63","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","71781.91","","Standard inlier is a Case rate ($71,781.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $61,297, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,188.85) for the length of stay and the standard reimbursement.","65578.97","65578.97","65578.97","1 through 10","19719.52","225441.91","case rate",""
"Other Upper Vascular Procedures,MODERATE","182","DRG","","","","","","","","inpatient","","","119541.63","","MASSHEALTH [3001]","HB BWH MEDICAID","19719.52","","Case rate ($21,803.32). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,233.32, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21797.97","21797.97","21797.97","1 through 10","19719.52","225441.91","case rate",""
"Other Upper Vascular Procedures,MODERATE","182","DRG","","","","","","","","inpatient","","","119541.63","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","114516.04","","Fee schedule rate ($114,516.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","98188.71","98188.71","101135.01","1 through 10","19719.52","225441.91","case rate",""
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","162958.03","122218.52","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","24778.91","","Case rate ($24,057.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,882.69, add-ons for qualifying new technology services are included. If operating cost exceeds $74,527.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,528.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,588.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,502.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,088.57. The transfer capital threshold is the transfer adjustment factor * $2,088.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","24211.55","24211.55","24211.55","1 through 10","23576.05","38527.323","other","Inpatient DRG"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","162958.03","122218.52","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","31108.97","","Case rate ($31,108.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,882.69, add-ons for qualifying new technology services are included. If operating cost exceeds $74,527.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,528.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $28,640.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,502.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,088.57. The transfer capital threshold is the transfer adjustment factor * $2,088.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23233.59","23139.32","24213.41","1 through 10","23576.05","38527.323","other","Inpatient DRG"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","162958.03","122218.52","HUMANA [1012]","HB BWH MEDICARE","31108.97","","Case rate ($31,108.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,882.69, add-ons for qualifying new technology services are included. If operating cost exceeds $74,527.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,528.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $28,640.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,502.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,088.57. The transfer capital threshold is the transfer adjustment factor * $2,088.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23073.04","23073.04","23073.04","1 through 10","23576.05","38527.323","other","Inpatient DRG"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","162958.03","122218.52","MEDICARE [2001]","HB BWH MEDICARE","31108.97","","Case rate ($31,108.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,882.69, add-ons for qualifying new technology services are included. If operating cost exceeds $74,527.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,528.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $28,640.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,502.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,088.57. The transfer capital threshold is the transfer adjustment factor * $2,088.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30411.52","12093.80","30421.01","44","23576.05","38527.323","other","Inpatient DRG"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","162958.03","122218.52","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","23576.05","","Case rate ($24,057.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,882.69, add-ons for qualifying new technology services are included. If operating cost exceeds $74,527.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,528.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,588.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,502.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,088.57. The transfer capital threshold is the transfer adjustment factor * $2,088.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","23117.11","23117.11","23117.11","1 through 10","23576.05","38527.323","other","Inpatient DRG"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","162958.03","122218.52","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","23576.05","","Case rate ($24,057.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $28,882.69, add-ons for qualifying new technology services are included. If operating cost exceeds $74,527.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,528.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $21,588.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $28,502.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,088.57. The transfer capital threshold is the transfer adjustment factor * $2,088.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","23032.07","23032.07","23032.07","1 through 10","23576.05","38527.323","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","197030.76","147773.07","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","33166.49","","Case rate ($32,200.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,685.61, add-ons for qualifying new technology services are included. If operating cost exceeds $84,330.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,247.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $29,013.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,305.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,806.89. The transfer capital threshold is the transfer adjustment factor * $2,806.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","32417.70","32417.70","32550.78","1 through 10","31556.47","54640.73","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","197030.76","147773.07","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","41677.56","","Case rate ($41,677.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,685.61, add-ons for qualifying new technology services are included. If operating cost exceeds $84,330.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,247.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $38,490.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,305.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,806.89. The transfer capital threshold is the transfer adjustment factor * $2,806.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","65809.68","65809.68","65809.68","1 through 10","31556.47","54640.73","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","197030.76","147773.07","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","32200.48","","Case rate ($32,200.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,685.61, add-ons for qualifying new technology services are included. If operating cost exceeds $84,330.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,247.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $29,013.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,305.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,806.89. The transfer capital threshold is the transfer adjustment factor * $2,806.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","62789.76","30877.99","72989.41","1 through 10","31556.47","54640.73","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","197030.76","147773.07","FALLON HEALTH [1008]","HB BWH MEDICARE","41677.56","","Case rate ($41,677.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,685.61, add-ons for qualifying new technology services are included. If operating cost exceeds $84,330.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,247.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $38,490.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,305.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,806.89. The transfer capital threshold is the transfer adjustment factor * $2,806.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","31414.96","31414.96","31414.96","1 through 10","31556.47","54640.73","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","197030.76","147773.07","HUMANA [1012]","HB BWH MEDICARE","41677.56","","Case rate ($41,677.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,685.61, add-ons for qualifying new technology services are included. If operating cost exceeds $84,330.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,247.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $38,490.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,305.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,806.89. The transfer capital threshold is the transfer adjustment factor * $2,806.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30981.93","30981.93","30981.93","1 through 10","31556.47","54640.73","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","197030.76","147773.07","MEDICARE [2001]","HB BWH MEDICARE","41677.56","","Case rate ($41,677.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,685.61, add-ons for qualifying new technology services are included. If operating cost exceeds $84,330.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,247.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $38,490.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,305.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,806.89. The transfer capital threshold is the transfer adjustment factor * $2,806.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","40767.54","0.03","64391.98","29","31556.47","54640.73","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","197030.76","147773.07","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","41677.56","","Case rate ($41,677.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,685.61, add-ons for qualifying new technology services are included. If operating cost exceeds $84,330.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,247.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $38,490.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,305.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,806.89. The transfer capital threshold is the transfer adjustment factor * $2,806.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","141.73","141.73","141.73","1 through 10","31556.47","54640.73","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","197030.76","147773.07","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","31556.47","","Case rate ($32,200.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,685.61, add-ons for qualifying new technology services are included. If operating cost exceeds $84,330.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,247.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $29,013.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,305.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,806.89. The transfer capital threshold is the transfer adjustment factor * $2,806.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","30786.65","30786.65","30786.65","1 through 10","31556.47","54640.73","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","197030.76","147773.07","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","31556.47","","Case rate ($32,200.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,685.61, add-ons for qualifying new technology services are included. If operating cost exceeds $84,330.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,247.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $29,013.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,305.78 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,806.89. The transfer capital threshold is the transfer adjustment factor * $2,806.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","30819.97","30819.97","30819.97","1 through 10","31556.47","54640.73","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","TRIS-DRG","","","","","","","","inpatient","","","224404.09","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","32058.25","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($56,312.12). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $100,039.12 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($14,439.01), capped at $40,529.81. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $100,039.12 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","35701.72","35701.72","35701.72","1 through 10","32058.25","32058.25","other","Inpatient DRGs"
"Other Vascular Procedures Without Cc/McC","254","MS-DRG","","","","","","","","inpatient","","","102157.55","76618.16","HUMANA [1012]","HB BWH MEDICARE","16632.70","","Case rate ($16,632.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,945.08, add-ons for qualifying new technology services are included. If operating cost exceeds $65,589.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,873.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $14,819.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,565.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,433.66. The transfer capital threshold is the transfer adjustment factor * $1,433.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5134.59","5134.59","5134.59","1 through 10","16300.05","26400.1954","other","Inpatient Replacement Plans DRG"
"Other Vascular Procedures Without Cc/McC","254","MS-DRG","","","","","","","","inpatient","","","102157.55","76618.16","MEDICARE [2001]","HB BWH MEDICARE","16632.70","","Case rate ($16,632.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,945.08, add-ons for qualifying new technology services are included. If operating cost exceeds $65,589.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,873.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $14,819.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,565.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,433.66. The transfer capital threshold is the transfer adjustment factor * $1,433.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20902.23","20902.23","20902.23","1 through 10","16300.05","26400.1954","other","Inpatient Replacement Plans DRG"
"Other Vascular Procedures,EXTREME","173","DRG","","","","","","","","inpatient","","","298937.38","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33702.5956","","Fee schedule rate ($166,441.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33702.5956","166441.80","166441.80","1 through 10","32405.2408","274632.31","case rate",""
"Other Vascular Procedures,MAJOR","173","DRG","","","","","","","","inpatient","","","204114.48","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33702.5956","","Fee schedule rate ($74,960.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33702.5956","74960.76","74960.76","1 through 10","32405.2408","274632.31","case rate",""
"Other Vascular Procedures,MAJOR","173","DRG","","","","","","","","inpatient","","","204114.48","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","82457.85","","Fee schedule rate ($82,457.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","82457.85","82457.85","82457.85","1 through 10","32405.2408","274632.31","case rate",""
"Other Vascular Procedures,MAJOR","173","DRG","","","","","","","","inpatient","","","204114.48","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","116456.21","116456.21","116456.21","1 through 10","32405.2408","274632.31","percent of total billed charges",""
"Other Vascular Procedures,MINOR","173","DRG","","","","","","","","inpatient","","","119848.80","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33702.5956","","Fee schedule rate ($33,702.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33702.5956","35388.72","35388.72","1 through 10","32405.2408","274632.31","case rate",""
"Other Vascular Procedures,MINOR","173","DRG","","","","","","","","inpatient","","","119848.80","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35388.7048","","Fee schedule rate ($35,388.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35388.7048","35388.72","35388.72","1 through 10","32405.2408","274632.31","case rate",""
"Other Vascular Procedures,MODERATE","173","DRG","","","","","","","","inpatient","","","124512.13","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","33702.5956","","Fee schedule rate ($45,617.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33702.5956","45617.48","58813.54","1 through 10","32405.2408","274632.31","case rate",""
"Other Vascular Procedures,MODERATE","173","DRG","","","","","","","","inpatient","","","124512.13","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35388.7048","","Fee schedule rate ($47,899.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35388.7048","47899.68","47899.68","1 through 10","32405.2408","274632.31","case rate",""
"Other Vascular Procedures,MODERATE","173","DRG","","","","","","","","inpatient","","","124512.13","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","75269.79","","Fee schedule rate ($75,269.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","75269.79","75269.79","75269.79","1 through 10","32405.2408","274632.31","case rate",""
"Other Vascular Procedures,MODERATE","173","DRG","","","","","","","","inpatient","","","124512.13","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","56280.00","","Fee schedule rate ($56,280.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","57022.38","57022.38","57022.38","1 through 10","32405.2408","274632.31","case rate",""
"Otitis Media And Uri With McC","152","MS-DRG","","","","","","","","inpatient","","","53568.28","40176.21","MEDICARE [2001]","HB BWH MEDICARE","14375.81","","Case rate ($14,375.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,361.83, add-ons for qualifying new technology services are included. If operating cost exceeds $59,006.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,391.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,044.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,981.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $951.27. The transfer capital threshold is the transfer adjustment factor * $951.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13656.62","13656.62","13672.40","1 through 10","10940.71","17125.2668","other","Inpatient DRG"
"Otitis Media And Uri With McC","152","MS-DRG","","","","","","","","inpatient","","","53568.28","40176.21","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10940.71","","Case rate ($11,163.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,361.83, add-ons for qualifying new technology services are included. If operating cost exceeds $59,006.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,391.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,832.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,981.99 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $951.27. The transfer capital threshold is the transfer adjustment factor * $951.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10400.46","10400.46","10400.46","1 through 10","10940.71","17125.2668","other","Inpatient DRG"
"Otitis Media And Uri Without McC","153","MS-DRG","","","","","","","","inpatient","","","33879.82","25409.86","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","7113.78","","Case rate ($7,113.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,486.18, add-ons for qualifying new technology services are included. If operating cost exceeds $54,130.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,034.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,139.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,106.33 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.00. The transfer capital threshold is the transfer adjustment factor * $594.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6672.40","6672.40","6672.40","1 through 10","6971.5","10740.2647","other","Inpatient Replacement Plans DRG"
"Otitis Media And Uri Without McC","153","MS-DRG","","","","","","","","inpatient","","","33879.82","25409.86","MEDICARE [2001]","HB BWH MEDICARE","7113.78","","Case rate ($7,113.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,486.18, add-ons for qualifying new technology services are included. If operating cost exceeds $54,130.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,034.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,139.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,106.33 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.00. The transfer capital threshold is the transfer adjustment factor * $594.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8668.62","8668.62","8681.17","1 through 10","6971.5","10740.2647","other","Inpatient Replacement Plans DRG"
"Otitis Media And Uri Without McC","153","MS-DRG","","","","","","","","inpatient","","","33879.82","25409.86","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","7113.78","","Case rate ($7,113.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,486.18, add-ons for qualifying new technology services are included. If operating cost exceeds $54,130.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,034.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,139.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,106.33 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.00. The transfer capital threshold is the transfer adjustment factor * $594.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6633.13","6633.13","6633.13","1 through 10","6971.5","10740.2647","other","Inpatient Replacement Plans DRG"
"Otitis Media And Uri Without McC","153","MS-DRG","","","","","","","","inpatient","","","33879.82","25409.86","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6971.50","","Case rate ($7,113.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,486.18, add-ons for qualifying new technology services are included. If operating cost exceeds $54,130.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,034.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,139.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,106.33 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.00. The transfer capital threshold is the transfer adjustment factor * $594.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9784.59","9784.59","9784.59","1 through 10","6971.5","10740.2647","other","Inpatient DRG"
"OVERSTITCH TISSUE HELIX","SUP-ITM-10340597","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.41","566.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","600.55","79.5","","800.18","480.96","1887.97","195","234.18","600.55","percent of total billed charges",""
"OVERSTITCH TISSUE HELIX","SUP-ITM-10340597","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.41","566.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","402.63","53.3","","813.12","216.42","1444.50","81","234.18","600.55","percent of total billed charges",""
"OVERSTITCH TISSUE HELIX","SUP-ITM-10340597","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.41","566.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","234.18","31","","432.60","432.60","432.60","1 through 10","234.18","600.55","percent of total billed charges",""
"OVERSTITCH TISSUE HELIX","SUP-ITM-10340597","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.41","566.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","275.72","36.5","","148.37","54.89","631.39","94","234.18","600.55","percent of total billed charges",""
"OVERSTITCH TISSUE HELIX","SUP-ITM-10340597","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.41","566.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","289.32","38.3","","279.30","91.72","1116.77","266","234.18","600.55","percent of total billed charges",""
"OVERSTITCH TISSUE HELIX","SUP-ITM-10340597","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.41","566.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","324.07","42.9","","731.00","63.70","731.00","1 through 10","234.18","600.55","percent of total billed charges",""
"OVERSTITCH TISSUE HELIX","SUP-ITM-10340597","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.41","566.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","324.07","42.9","","384.74","384.74","384.74","1 through 10","234.18","600.55","percent of total billed charges",""
"OVERSTITCH TISSUE HELIX","SUP-ITM-10340597","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.41","566.56","WELLPOINT [1015]","HB AMC WELLPOINT","557.34","73.78","","286.63","119.22","1107.45","105","234.18","600.55","percent of total billed charges",""
"OVERSTITCH TISSUE HELIX","SUP-ITM-10340597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","755.41","566.56","AETNA [1001]","HB AMC AETNA HMO","527.28","69.8","","675.31","184.75","1721.50","286","394.78","617.32","percent of total billed charges",""
"OVERSTITCH TISSUE HELIX","SUP-ITM-10340597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","755.41","566.56","AETNA [1001]","HB AMC AETNA PPO","607.35","80.4","","1261.44","103.12","1514.10","21","394.78","617.32","percent of total billed charges",""
"OVERSTITCH TISSUE HELIX","SUP-ITM-10340597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","755.41","566.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","607.35","80.4","","1365.00","1365.00","1365.00","1 through 10","394.78","617.32","percent of total billed charges",""
"OVERSTITCH TISSUE HELIX","SUP-ITM-10340597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","755.41","566.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","617.32","81.72","","5157.68","5157.68","5157.68","1 through 10","394.78","617.32","percent of total billed charges",""
"OVERSTITCH TISSUE HELIX","SUP-ITM-10340597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","755.41","566.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","617.32","81.72","","431.26","71.26","1459.57","88","394.78","617.32","percent of total billed charges",""
"Oxalate","PX-30000597","CDM","83945","CPT","0301","RC","","","","outpatient","","","161.00","120.75","AETNA [1001]","HB AMC AETNA HMO","112.38","69.8","","121.68","105.61","121.68","1 through 10","13.27","131.57","percent of total billed charges",""
"Oxycodone Opiate(S), Drug and Metabolites Ec","PX-30002882","CDM","80365","CPT","0301","RC","","","","both","","","64.00","48.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","45.95","71.8","","137.00","137.00","137.00","1 through 10","19.84","143.04","percent of total billed charges",""
"Oxycodone Opiate(S), Drug and Metabolites Ec","PX-30002882","CDM","80365","CPT","0301","RC","","","","both","","","64.00","48.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","44.80","70","","60.24","60.24","60.24","1 through 10","19.84","143.04","percent of total billed charges",""
"Oxycodone Opiate(S), Drug and Metabolites Ec","PX-30002882","CDM","80365","CPT","0301","RC","","","","both","","","64.00","48.00","WELLPOINT [1015]","HB AMC WELLPOINT","47.22","73.78","","102.00","102.00","102.00","1 through 10","19.84","143.04","percent of total billed charges",""
"OZARK VIEW ANTERIOR CERVICAL PLATES CONSTRAINED 3 LEVEL 60 MM","SUP-ITM-10253505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1878.19","79.5","","800.18","480.96","1887.97","195","732.38","1878.19","percent of total billed charges",""
"OZARK VIEW ANTERIOR CERVICAL PLATES CONSTRAINED 3 LEVEL 60 MM","SUP-ITM-10253505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1259.21","53.3","","813.12","216.42","1444.50","81","732.38","1878.19","percent of total billed charges",""
"OZARK VIEW ANTERIOR CERVICAL PLATES CONSTRAINED 3 LEVEL 60 MM","SUP-ITM-10253505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","732.38","31","","432.60","432.60","432.60","1 through 10","732.38","1878.19","percent of total billed charges",""
"OZARK VIEW ANTERIOR CERVICAL PLATES CONSTRAINED 3 LEVEL 60 MM","SUP-ITM-10253505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","862.31","36.5","","148.37","54.89","631.39","94","732.38","1878.19","percent of total billed charges",""
"OZARK VIEW ANTERIOR CERVICAL PLATES CONSTRAINED 3 LEVEL 60 MM","SUP-ITM-10253505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","904.84","38.3","","279.30","91.72","1116.77","266","732.38","1878.19","percent of total billed charges",""
"OZARK VIEW ANTERIOR CERVICAL PLATES CONSTRAINED 3 LEVEL 60 MM","SUP-ITM-10253505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","731.00","63.70","731.00","1 through 10","732.38","1878.19","percent of total billed charges",""
"OZARK VIEW ANTERIOR CERVICAL PLATES CONSTRAINED 3 LEVEL 60 MM","SUP-ITM-10253505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","384.74","384.74","384.74","1 through 10","732.38","1878.19","percent of total billed charges",""
"OZARK VIEW ANTERIOR CERVICAL PLATES CONSTRAINED 3 LEVEL 60 MM","SUP-ITM-10253505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","WELLPOINT [1015]","HB AMC WELLPOINT","1743.05","73.78","","286.63","119.22","1107.45","105","732.38","1878.19","percent of total billed charges",""
"OZARK VIEW ANTERIOR CERVICAL PLATES CONSTRAINED 3 LEVEL 60 MM","SUP-ITM-10253505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA HMO","1649.03","69.8","","675.31","184.75","1721.50","286","1234.64","1930.64","percent of total billed charges",""
"OZARK VIEW ANTERIOR CERVICAL PLATES CONSTRAINED 3 LEVEL 60 MM","SUP-ITM-10253505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA PPO","1899.45","80.4","","1261.44","103.12","1514.10","21","1234.64","1930.64","percent of total billed charges",""
"OZARK VIEW ANTERIOR CERVICAL PLATES CONSTRAINED 3 LEVEL 60 MM","SUP-ITM-10253505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1899.45","80.4","","1365.00","1365.00","1365.00","1 through 10","1234.64","1930.64","percent of total billed charges",""
"OZARK VIEW ANTERIOR CERVICAL PLATES CONSTRAINED 3 LEVEL 60 MM","SUP-ITM-10253505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1930.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1234.64","1930.64","percent of total billed charges",""
"OZARK VIEW ANTERIOR CERVICAL PLATES CONSTRAINED 3 LEVEL 60 MM","SUP-ITM-10253505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1930.64","81.72","","431.26","71.26","1459.57","88","1234.64","1930.64","percent of total billed charges",""
"Pabpn1 Gene Analysis Eval Detc Abnormal Alleles","PX-31000987","CDM","81312","CPT","0310","RC","","","","both","","","1628.00","1221.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","867.72","53.3","","833.71","833.71","833.71","1 through 10","134.26","1546.6","percent of total billed charges",""
"PACEMAKER ACCOLADE 12.2CC 4.45CM 5.02CM .75CM 24.8G DUAL RA IS1-RVIS1 CONNECTOR","SUP-ITM-10140406","CDM","C1785","HCPCS","0275","RC","","","","both","","","6032.50","4524.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2201.86","36.5","","3506.20","3100.26","3506.20","1 through 10","1870.08","4795.84","percent of total billed charges",""
"PACEMAKER ACCOLADE 12.2CC 4.45CM 5.02CM .75CM 24.8G DUAL RA IS1-RVIS1 CONNECTOR","SUP-ITM-10140406","CDM","C1785","HCPCS","0275","RC","","","","both","","","6032.50","4524.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2310.45","38.3","","3675.40","3675.40","3675.40","1 through 10","1870.08","4795.84","percent of total billed charges",""
"PACEMAKER ACCOLADE 12.2CC 4.45CM 5.02CM .75CM 24.8G DUAL RA IS1-RVIS1 CONNECTOR","SUP-ITM-10140406","CDM","C1785","HCPCS","0275","RC","","","","both","","","6032.50","4524.37","WELLPOINT [1015]","HB AMC WELLPOINT","4450.78","73.78","","6998.30","6998.30","6998.30","1 through 10","1870.08","4795.84","percent of total billed charges",""
"PACEMAKER ACCOLADE 12.2CC 4.45CM 5.02CM .75CM 24.8G DUAL RA IS1-RVIS1 CONNECTOR","SUP-ITM-10140406","CDM","C1785","HCPCS","0275","RC","","","","outpatient","","","6032.50","4524.37","AETNA [1001]","HB AMC AETNA HMO","4210.69","69.8","","4493.20","4493.20","4493.20","1 through 10","3152.58","4929.76","percent of total billed charges",""
"PACEMAKER BIVENTRICULAR 56X59X6MM 27G 15CC IS4-LLLL CONNECTOR CRTP ALLURE RF","SUP-ITM-10135917","CDM","C2621","HCPCS","0275","RC","","","","outpatient","","","13200.00","9900.00","AETNA [1001]","HB AMC AETNA HMO","9213.60","69.8","","5258.00","5258.00","5258.00","1 through 10","6898.32","10787.04","percent of total billed charges",""
"PACEMAKER DUAL CHAMBER 47X50X6MM 20G 10.4CC IS-1 CONNECTOR ASSURITY DR RF","SUP-ITM-10132828","CDM","C1785","HCPCS","0275","RC","","","","both","","","9780.00","7335.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3569.70","36.5","","3506.20","3100.26","3506.20","1 through 10","3031.8","7775.1","percent of total billed charges",""
"PACEMAKER DUAL CHAMBER 47X50X6MM 20G 10.4CC IS-1 CONNECTOR ASSURITY DR RF","SUP-ITM-10132828","CDM","C1785","HCPCS","0275","RC","","","","both","","","9780.00","7335.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3745.74","38.3","","3675.40","3675.40","3675.40","1 through 10","3031.8","7775.1","percent of total billed charges",""
"PACEMAKER DUAL CHAMBER 47X50X6MM 20G 10.4CC IS-1 CONNECTOR ASSURITY DR RF","SUP-ITM-10132828","CDM","C1785","HCPCS","0275","RC","","","","both","","","9780.00","7335.00","WELLPOINT [1015]","HB AMC WELLPOINT","7215.68","73.78","","6998.30","6998.30","6998.30","1 through 10","3031.8","7775.1","percent of total billed charges",""
"PACEMAKER DUAL CHAMBER 47X50X6MM 20G 10.4CC IS-1 CONNECTOR ASSURITY DR RF","SUP-ITM-10132828","CDM","C1785","HCPCS","0275","RC","","","","outpatient","","","9780.00","7335.00","AETNA [1001]","HB AMC AETNA HMO","6826.44","69.8","","4493.20","4493.20","4493.20","1 through 10","5111.03","7992.22","percent of total billed charges",""
"Pacemaker Dual Chamber Rate Responsive T3","PX-27000123","CDM","C1785","HCPCS","0275","RC","","","","both","","","8912.40","6684.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3253.03","36.5","","3506.20","3100.26","3506.20","1 through 10","2762.84","7085.36","percent of total billed charges",""
"Pacemaker Dual Chamber Rate Responsive T3","PX-27000123","CDM","C1785","HCPCS","0275","RC","","","","both","","","8912.40","6684.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3413.45","38.3","","3675.40","3675.40","3675.40","1 through 10","2762.84","7085.36","percent of total billed charges",""
"Pacemaker Dual Chamber Rate Responsive T3","PX-27000123","CDM","C1785","HCPCS","0275","RC","","","","both","","","8912.40","6684.30","WELLPOINT [1015]","HB AMC WELLPOINT","6575.57","73.78","","6998.30","6998.30","6998.30","1 through 10","2762.84","7085.36","percent of total billed charges",""
"Pacemaker Dual Chamber Rate Responsive T3","PX-27000123","CDM","C1785","HCPCS","0275","RC","","","","outpatient","","","8912.40","6684.30","AETNA [1001]","HB AMC AETNA HMO","6220.86","69.8","","4493.20","4493.20","4493.20","1 through 10","4657.62","7283.21","percent of total billed charges",""
"PACEMAKER EDORA DUAL CHAMBER DR-T PROMRI W/AUTOMRI CLS AND HM","SUP-ITM-10191542","CDM","C1785","HCPCS","0275","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2336.00","36.5","","3506.20","3100.26","3506.20","1 through 10","1984","5088","percent of total billed charges",""
"PACEMAKER EDORA DUAL CHAMBER DR-T PROMRI W/AUTOMRI CLS AND HM","SUP-ITM-10191542","CDM","C1785","HCPCS","0275","RC","","","","both","","","6400.00","4800.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2451.20","38.3","","3675.40","3675.40","3675.40","1 through 10","1984","5088","percent of total billed charges",""
"PACEMAKER EDORA DUAL CHAMBER DR-T PROMRI W/AUTOMRI CLS AND HM","SUP-ITM-10191542","CDM","C1785","HCPCS","0275","RC","","","","both","","","6400.00","4800.00","WELLPOINT [1015]","HB AMC WELLPOINT","4721.92","73.78","","6998.30","6998.30","6998.30","1 through 10","1984","5088","percent of total billed charges",""
"PACEMAKER EDORA DUAL CHAMBER DR-T PROMRI W/AUTOMRI CLS AND HM","SUP-ITM-10191542","CDM","C1785","HCPCS","0275","RC","","","","outpatient","","","6400.00","4800.00","AETNA [1001]","HB AMC AETNA HMO","4467.20","69.8","","4493.20","4493.20","4493.20","1 through 10","3344.64","5230.08","percent of total billed charges",""
"PACEMAKER ESSENTIO 13.2CC 4.81CM 4.45CM .75CM 23.6G DR RA/RV IS1 CONNECTOR","SUP-ITM-10168292","CDM","C1785","HCPCS","0275","RC","","","","both","","","5037.00","3777.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1838.51","36.5","","3506.20","3100.26","3506.20","1 through 10","1561.47","4004.42","percent of total billed charges",""
"PACEMAKER ESSENTIO 13.2CC 4.81CM 4.45CM .75CM 23.6G DR RA/RV IS1 CONNECTOR","SUP-ITM-10168292","CDM","C1785","HCPCS","0275","RC","","","","both","","","5037.00","3777.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1929.17","38.3","","3675.40","3675.40","3675.40","1 through 10","1561.47","4004.42","percent of total billed charges",""
"PACEMAKER ESSENTIO 13.2CC 4.81CM 4.45CM .75CM 23.6G DR RA/RV IS1 CONNECTOR","SUP-ITM-10168292","CDM","C1785","HCPCS","0275","RC","","","","both","","","5037.00","3777.75","WELLPOINT [1015]","HB AMC WELLPOINT","3716.30","73.78","","6998.30","6998.30","6998.30","1 through 10","1561.47","4004.42","percent of total billed charges",""
"PACEMAKER ESSENTIO 13.2CC 4.81CM 4.45CM .75CM 23.6G DR RA/RV IS1 CONNECTOR","SUP-ITM-10168292","CDM","C1785","HCPCS","0275","RC","","","","outpatient","","","5037.00","3777.75","AETNA [1001]","HB AMC AETNA HMO","3515.83","69.8","","4493.20","4493.20","4493.20","1 through 10","2632.34","4116.24","percent of total billed charges",""
"Pacemaker Non Single/Dual Chamber T3","PX-27000206","CDM","C2621","HCPCS","0275","RC","","","","outpatient","","","17500.00","13125.00","AETNA [1001]","HB AMC AETNA HMO","12215.00","69.8","","5258.00","5258.00","5258.00","1 through 10","9145.5","14301","percent of total billed charges",""
"PACEMAKER SINGLE CHAMBER 47X50X6MM 20G 10.4CC IS-1 CONNECTOR ASSURITY VR PPM RF","SUP-ITM-10132826","CDM","C1786","HCPCS","0275","RC","","","","both","","","5520.00","4140.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2114.16","38.3","","330.52","330.52","330.52","1 through 10","1711.2","4388.4","percent of total billed charges",""
"PACEMAKER SINGLE CHAMBER 47X50X6MM 20G 10.4CC IS-1 CONNECTOR ASSURITY VR PPM RF","SUP-ITM-10132826","CDM","C1786","HCPCS","0275","RC","","","","both","","","5520.00","4140.00","WELLPOINT [1015]","HB AMC WELLPOINT","4072.66","73.78","","22527.75","22527.75","22527.75","1 through 10","1711.2","4388.4","percent of total billed charges",""
"Pacemaker Single Chamber Rate Responsive T3","PX-27000124","CDM","C1786","HCPCS","0275","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2154.38","38.3","","330.52","330.52","330.52","1 through 10","1743.75","4471.88","percent of total billed charges",""
"Pacemaker Single Chamber Rate Responsive T3","PX-27000124","CDM","C1786","HCPCS","0275","RC","","","","both","","","5625.00","4218.75","WELLPOINT [1015]","HB AMC WELLPOINT","4150.13","73.78","","22527.75","22527.75","22527.75","1 through 10","1743.75","4471.88","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","100.00","75.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","70.00","70","","863.10","863.10","863.10","1 through 10","31","79.5","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","100.00","75.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","79.50","79.5","","447.66","447.66","447.66","1 through 10","31","79.5","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","100.00","75.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","65.00","65","","1020.11","1020.11","1020.11","1 through 10","31","79.5","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","100.00","75.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","31.00","31","","208.83","208.83","208.83","1 through 10","31","79.5","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","100.00","75.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36.50","36.5","","312.44","214.23","1086.03","20","31","79.5","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","100.00","75.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38.30","38.3","","264.25","227.63","567.11","31","31","79.5","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","100.00","75.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.90","42.9","","79.94","79.94","79.94","1 through 10","31","79.5","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","100.00","75.00","WELLPOINT [1015]","HB AMC WELLPOINT","73.78","73.78","","174.45","74.45","1168.42","1 through 10","31","79.5","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","100.00","75.00","AETNA [1001]","HB AMC AETNA HMO","69.80","69.8","","655.01","135.40","784.73","1 through 10","52.26","81.72","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","100.00","75.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","81.72","81.72","","540.25","46.28","897.42","36","52.26","81.72","percent of total billed charges",""
"PACK FILLER 2 D VITOSS GRAFT BONE BIOACTIVE SUBSTITUTE FOAM","SUP-ITM-10029651","CDM","C1763","HCPCS","0278","RC","","","","both","","","1627.50","1220.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1057.88","65","","2028.23","1653.70","2028.23","1 through 10","504.53","1293.86","percent of total billed charges",""
"PACK FILLER 2 D VITOSS GRAFT BONE BIOACTIVE SUBSTITUTE FOAM","SUP-ITM-10029651","CDM","C1763","HCPCS","0278","RC","","","","both","","","1627.50","1220.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","594.04","36.5","","1163.89","1163.89","1163.89","1 through 10","504.53","1293.86","percent of total billed charges",""
"PACK FILLER 2 D VITOSS GRAFT BONE BIOACTIVE SUBSTITUTE FOAM","SUP-ITM-10029651","CDM","C1763","HCPCS","0278","RC","","","","both","","","1627.50","1220.62","WELLPOINT [1015]","HB AMC WELLPOINT","1200.77","73.78","","4280.87","4280.87","4280.87","1 through 10","504.53","1293.86","percent of total billed charges",""
"PACK GRAFT 1.2ML BONE VITOSS BIOACTIVE SUBSTITUTE FOAM","SUP-ITM-10029650","CDM","C1763","HCPCS","0278","RC","","","","both","","","948.50","711.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","616.53","65","","2028.23","1653.70","2028.23","1 through 10","294.04","754.06","percent of total billed charges",""
"PACK GRAFT 1.2ML BONE VITOSS BIOACTIVE SUBSTITUTE FOAM","SUP-ITM-10029650","CDM","C1763","HCPCS","0278","RC","","","","both","","","948.50","711.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","346.20","36.5","","1163.89","1163.89","1163.89","1 through 10","294.04","754.06","percent of total billed charges",""
"PACK GRAFT 1.2ML BONE VITOSS BIOACTIVE SUBSTITUTE FOAM","SUP-ITM-10029650","CDM","C1763","HCPCS","0278","RC","","","","both","","","948.50","711.37","WELLPOINT [1015]","HB AMC WELLPOINT","699.80","73.78","","4280.87","4280.87","4280.87","1 through 10","294.04","754.06","percent of total billed charges",""
"PACK GRAFT 10ML BONE SUBSTITUTE VITOSS BIOACTIVE FOAM","SUP-ITM-10029653","CDM","C1763","HCPCS","0278","RC","","","","both","","","5058.00","3793.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3287.70","65","","2028.23","1653.70","2028.23","1 through 10","1567.98","4021.11","percent of total billed charges",""
"PACK GRAFT 10ML BONE SUBSTITUTE VITOSS BIOACTIVE FOAM","SUP-ITM-10029653","CDM","C1763","HCPCS","0278","RC","","","","both","","","5058.00","3793.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1846.17","36.5","","1163.89","1163.89","1163.89","1 through 10","1567.98","4021.11","percent of total billed charges",""
"PACK GRAFT 10ML BONE SUBSTITUTE VITOSS BIOACTIVE FOAM","SUP-ITM-10029653","CDM","C1763","HCPCS","0278","RC","","","","both","","","5058.00","3793.50","WELLPOINT [1015]","HB AMC WELLPOINT","3731.79","73.78","","4280.87","4280.87","4280.87","1 through 10","1567.98","4021.11","percent of total billed charges",""
"PACK GRAFT 5ML IMPLANT SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS","SUP-ITM-10029652","CDM","C1763","HCPCS","0278","RC","","","","both","","","3195.50","2396.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2077.08","65","","2028.23","1653.70","2028.23","1 through 10","990.61","2540.42","percent of total billed charges",""
"PACK GRAFT 5ML IMPLANT SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS","SUP-ITM-10029652","CDM","C1763","HCPCS","0278","RC","","","","both","","","3195.50","2396.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1166.36","36.5","","1163.89","1163.89","1163.89","1 through 10","990.61","2540.42","percent of total billed charges",""
"PACK GRAFT 5ML IMPLANT SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS","SUP-ITM-10029652","CDM","C1763","HCPCS","0278","RC","","","","both","","","3195.50","2396.62","WELLPOINT [1015]","HB AMC WELLPOINT","2357.64","73.78","","4280.87","4280.87","4280.87","1 through 10","990.61","2540.42","percent of total billed charges",""
"PACK NAIL 1.1MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10072409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1010.80","758.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","803.59","79.5","","800.18","480.96","1887.97","195","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.1MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10072409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1010.80","758.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","538.76","53.3","","813.12","216.42","1444.50","81","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.1MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10072409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1010.80","758.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","313.35","31","","432.60","432.60","432.60","1 through 10","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.1MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10072409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1010.80","758.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","368.94","36.5","","148.37","54.89","631.39","94","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.1MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10072409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1010.80","758.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","387.14","38.3","","279.30","91.72","1116.77","266","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.1MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10072409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1010.80","758.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","433.63","42.9","","731.00","63.70","731.00","1 through 10","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.1MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10072409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1010.80","758.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","433.63","42.9","","384.74","384.74","384.74","1 through 10","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.1MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10072409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1010.80","758.10","WELLPOINT [1015]","HB AMC WELLPOINT","745.77","73.78","","286.63","119.22","1107.45","105","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.1MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10072409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1010.80","758.10","AETNA [1001]","HB AMC AETNA HMO","705.54","69.8","","675.31","184.75","1721.50","286","528.24","826.03","percent of total billed charges",""
"PACK NAIL 1.1MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10072409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1010.80","758.10","AETNA [1001]","HB AMC AETNA PPO","812.68","80.4","","1261.44","103.12","1514.10","21","528.24","826.03","percent of total billed charges",""
"PACK NAIL 1.1MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10072409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1010.80","758.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","812.68","80.4","","1365.00","1365.00","1365.00","1 through 10","528.24","826.03","percent of total billed charges",""
"PACK NAIL 1.1MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10072409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1010.80","758.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","826.03","81.72","","5157.68","5157.68","5157.68","1 through 10","528.24","826.03","percent of total billed charges",""
"PACK NAIL 1.1MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10072409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1010.80","758.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","826.03","81.72","","431.26","71.26","1459.57","88","528.24","826.03","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","both","","","1010.80","758.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","803.59","79.5","","1309.77","674.56","6049.93","26","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","both","","","1010.80","758.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","538.76","53.3","","1901.83","1901.83","2962.25","1 through 10","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","both","","","1010.80","758.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","368.94","36.5","","1620.31","1620.31","19908.88","1 through 10","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","both","","","1010.80","758.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","387.14","38.3","","352.91","352.91","2046.30","1 through 10","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","both","","","1010.80","758.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","433.63","42.9","","9668.75","9668.75","9668.75","1 through 10","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","both","","","1010.80","758.10","WELLPOINT [1015]","HB AMC WELLPOINT","745.77","73.78","","699.88","384.10","3443.31","33","313.35","803.59","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1010.80","758.10","AETNA [1001]","HB AMC AETNA HMO","705.54","69.8","","1421.24","264.50","4933.46","29","528.24","826.03","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1010.80","758.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","812.68","80.4","","1022.97","1022.97","3607.50","1 through 10","528.24","826.03","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1010.80","758.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","826.03","81.72","","3010.54","693.88","5019.88","35","528.24","826.03","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","1113.10","1113.10","1113.10","1 through 10","27.13","69.56","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","1293.60","1148.53","1603.80","1 through 10","27.13","69.56","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","1023.42","771.29","2068.67","33","27.13","69.56","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","850.52","759.78","1211.25","66","27.13","69.56","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","2548.09","2548.09","2548.09","1 through 10","27.13","69.56","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","956.46","956.46","956.46","1 through 10","27.13","69.56","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","2344.73","1619.47","2530.35","16","27.13","69.56","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","1523.63","988.41","4330.26","39","45.73","71.51","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","1670.25","1670.25","1670.25","1 through 10","45.73","71.51","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","1113.10","1113.10","1113.10","1 through 10","45.73","71.51","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","1738.90","1484.65","2716.94","38","45.73","71.51","percent of total billed charges",""
"PACK SCREW 2MM 5 CORTEX TI SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10015484","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.07","79.5","","800.18","480.96","1887.97","195","42.92","110.07","percent of total billed charges",""
"PACK SCREW 2MM 5 CORTEX TI SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10015484","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","73.79","53.3","","813.12","216.42","1444.50","81","42.92","110.07","percent of total billed charges",""
"PACK SCREW 2MM 5 CORTEX TI SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10015484","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","42.92","31","","432.60","432.60","432.60","1 through 10","42.92","110.07","percent of total billed charges",""
"PACK SCREW 2MM 5 CORTEX TI SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10015484","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.53","36.5","","148.37","54.89","631.39","94","42.92","110.07","percent of total billed charges",""
"PACK SCREW 2MM 5 CORTEX TI SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10015484","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.03","38.3","","279.30","91.72","1116.77","266","42.92","110.07","percent of total billed charges",""
"PACK SCREW 2MM 5 CORTEX TI SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10015484","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.40","42.9","","731.00","63.70","731.00","1 through 10","42.92","110.07","percent of total billed charges",""
"PACK SCREW 2MM 5 CORTEX TI SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10015484","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.40","42.9","","384.74","384.74","384.74","1 through 10","42.92","110.07","percent of total billed charges",""
"PACK SCREW 2MM 5 CORTEX TI SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10015484","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","WELLPOINT [1015]","HB AMC WELLPOINT","102.15","73.78","","286.63","119.22","1107.45","105","42.92","110.07","percent of total billed charges",""
"PACK SCREW 2MM 5 CORTEX TI SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10015484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.45","103.84","AETNA [1001]","HB AMC AETNA HMO","96.64","69.8","","675.31","184.75","1721.50","286","72.35","113.14","percent of total billed charges",""
"PACK SCREW 2MM 5 CORTEX TI SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10015484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.45","103.84","AETNA [1001]","HB AMC AETNA PPO","111.31","80.4","","1261.44","103.12","1514.10","21","72.35","113.14","percent of total billed charges",""
"PACK SCREW 2MM 5 CORTEX TI SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10015484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.45","103.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.31","80.4","","1365.00","1365.00","1365.00","1 through 10","72.35","113.14","percent of total billed charges",""
"PACK SCREW 2MM 5 CORTEX TI SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10015484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.45","103.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","113.14","81.72","","5157.68","5157.68","5157.68","1 through 10","72.35","113.14","percent of total billed charges",""
"PACK SCREW 2MM 5 CORTEX TI SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10015484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.45","103.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.14","81.72","","431.26","71.26","1459.57","88","72.35","113.14","percent of total billed charges",""
"Pack Superficial Wound Dehiscence","PX-76000120","CDM","12021","CPT","0761","RC","","","","outpatient","","","946.00","709.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","832.56","832.56","832.56","1 through 10","314.08","1234.13","other","ASC "
"Pack Superficial Wound Dehiscence","PX-76000120","CDM","12021","CPT","0761","RC","","","","outpatient","","","946.00","709.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","728.67","728.67","728.67","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pad Rehab per Session","PX-48000022","CDM","93668","CPT","0480","RC","","","","both","","","448.00","336.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","209.25","69.73","209.25","25","67.01","356.16","other","OPPS APC"
"Pamidronate Vl 30mg","PX-63600159","CDM","J2430","HCPCS","0636","RC","","","","both","","","79.65","59.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29.07","36.5","","11.35","11.35","11.35","1 through 10","24.69","61.33","percent of total billed charges",""
"Pancreas Unlstd Proc","PX-76001843","CDM","48999","CPT","0761","RC","","","","outpatient","","","15434.00","11575.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","8059.63","52.22","","1550.84","1550.84","1550.84","1 through 10","1234.13","12733.05","percent of total billed charges",""
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","","","","inpatient","","","165364.60","124023.45","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","27640.85","","Case rate ($26,835.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,227.56, add-ons for qualifying new technology services are included. If operating cost exceeds $77,872.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,773.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $24,122.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,847.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,333.67. The transfer capital threshold is the transfer adjustment factor * $2,333.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","26616.51","26616.51","26616.51","1 through 10","26299.06","42381.5644","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","","","","inpatient","","","165364.60","124023.45","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","34715.10","","Case rate ($34,715.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,227.56, add-ons for qualifying new technology services are included. If operating cost exceeds $77,872.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,773.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $32,001.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,847.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,333.67. The transfer capital threshold is the transfer adjustment factor * $2,333.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25491.42","25490.21","25491.44","1 through 10","26299.06","42381.5644","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","","","","inpatient","","","165364.60","124023.45","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","34174.40","34174.40","34174.40","1 through 10","26299.06","42381.5644","case rate",""
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","","","","inpatient","","","165364.60","124023.45","HUMANA [1012]","HB BWH MEDICARE","34715.10","","Case rate ($34,715.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,227.56, add-ons for qualifying new technology services are included. If operating cost exceeds $77,872.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,773.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $32,001.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,847.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,333.67. The transfer capital threshold is the transfer adjustment factor * $2,333.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25311.38","25311.38","25311.38","1 through 10","26299.06","42381.5644","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","","","","inpatient","","","165364.60","124023.45","MARTIN'S POINT [160007]","HB BWH MEDICARE","34715.10","","Case rate ($34,715.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,227.56, add-ons for qualifying new technology services are included. If operating cost exceeds $77,872.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,773.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $32,001.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,847.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,333.67. The transfer capital threshold is the transfer adjustment factor * $2,333.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25393.38","25393.38","25393.38","1 through 10","26299.06","42381.5644","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","","","","inpatient","","","165364.60","124023.45","MEDICARE [2001]","HB BWH MEDICARE","34715.10","","Case rate ($34,715.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,227.56, add-ons for qualifying new technology services are included. If operating cost exceeds $77,872.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,773.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $32,001.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,847.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,333.67. The transfer capital threshold is the transfer adjustment factor * $2,333.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","33386.94","0.03","33436.47","51","26299.06","42381.5644","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","","","","inpatient","","","165364.60","124023.45","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","26299.06","","Case rate ($26,835.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,227.56, add-ons for qualifying new technology services are included. If operating cost exceeds $77,872.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,773.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $24,122.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,847.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,333.67. The transfer capital threshold is the transfer adjustment factor * $2,333.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25351.60","25327.39","25370.19","1 through 10","26299.06","42381.5644","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","","","","inpatient","","","165364.60","124023.45","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","26299.06","","Case rate ($26,835.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,227.56, add-ons for qualifying new technology services are included. If operating cost exceeds $77,872.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,773.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $24,122.26 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,847.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,333.67. The transfer capital threshold is the transfer adjustment factor * $2,333.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25346.35","25327.94","25380.19","1 through 10","26299.06","42381.5644","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","","","","inpatient","","","165364.60","124023.45","WELLPOINT [1015]","HB AMC WELLPOINT","42381.5644","","Fee schedule rate ($45,428.73).","42381.5644","113636.90","235372.01","1 through 10","26299.06","42381.5644","case rate",""
"Pancreas, Liver And Shunt Procedures With McC","405","MS-DRG","","","","","","","","inpatient","","","266038.33","199528.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","51790.80","","Case rate ($50,282.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,452.59, add-ons for qualifying new technology services are included. If operating cost exceeds $106,097.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,842.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $45,500.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $60,072.74 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,401.89. The transfer capital threshold is the transfer adjustment factor * $4,401.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","104437.33","104437.33","104437.33","1 through 10","49276.68","85689.91","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures With McC","405","MS-DRG","","","","","","","","inpatient","","","266038.33","199528.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","65144.69","","Case rate ($65,144.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,452.59, add-ons for qualifying new technology services are included. If operating cost exceeds $106,097.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,842.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $60,362.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $60,072.74 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,401.89. The transfer capital threshold is the transfer adjustment factor * $4,401.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","49045.07","49045.07","49045.07","1 through 10","49276.68","85689.91","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures With McC","405","MS-DRG","","","","","","","","inpatient","","","266038.33","199528.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","50282.33","","Case rate ($50,282.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,452.59, add-ons for qualifying new technology services are included. If operating cost exceeds $106,097.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,842.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $45,500.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $60,072.74 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,401.89. The transfer capital threshold is the transfer adjustment factor * $4,401.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","150.59","150.59","150.59","1 through 10","49276.68","85689.91","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures With McC","405","MS-DRG","","","","","","","","inpatient","","","266038.33","199528.75","MEDICARE [2001]","HB BWH MEDICARE","65144.69","","Case rate ($65,144.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,452.59, add-ons for qualifying new technology services are included. If operating cost exceeds $106,097.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,842.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $60,362.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $60,072.74 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,401.89. The transfer capital threshold is the transfer adjustment factor * $4,401.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","64278.07","45523.30","64373.81","17","49276.68","85689.91","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures With McC","405","MS-DRG","","","","","","","","inpatient","","","266038.33","199528.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","49276.68","","Case rate ($50,282.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,452.59, add-ons for qualifying new technology services are included. If operating cost exceeds $106,097.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,842.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $45,500.59 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $60,072.74 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,401.89. The transfer capital threshold is the transfer adjustment factor * $4,401.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","28708.37","28708.37","28708.37","1 through 10","49276.68","85689.91","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures With McC","405","MS-DRG","","","","","","","","inpatient","","","266038.33","199528.75","WELLPOINT [1015]","HB AMC WELLPOINT","85689.91","","Fee schedule rate ($85,689.91).","144028.50","144028.50","144028.50","1 through 10","49276.68","85689.91","case rate",""
"Pancreas, Liver And Shunt Procedures Without Cc/McC","407","MS-DRG","","","","","","","","inpatient","","","124422.26","93316.69","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","21246.09","","Case rate ($20,627.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,753.75, add-ons for qualifying new technology services are included. If operating cost exceeds $70,398.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,226.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $18,461.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,373.91 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,786.02. The transfer capital threshold is the transfer adjustment factor * $1,786.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","20278.61","20278.61","20278.61","1 through 10","20214.72","32231.3578","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures Without Cc/McC","407","MS-DRG","","","","","","","","inpatient","","","124422.26","93316.69","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","20627.27","","Case rate ($20,627.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,753.75, add-ons for qualifying new technology services are included. If operating cost exceeds $70,398.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,226.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $18,461.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,373.91 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,786.02. The transfer capital threshold is the transfer adjustment factor * $1,786.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","150.02","150.02","150.02","1 through 10","20214.72","32231.3578","other","Inpatient DRG"
"Pancreas, Liver And Shunt Procedures Without Cc/McC","407","MS-DRG","","","","","","","","inpatient","","","124422.26","93316.69","MEDICARE [2001]","HB BWH MEDICARE","20627.27","","Case rate ($20,627.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,753.75, add-ons for qualifying new technology services are included. If operating cost exceeds $70,398.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,226.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $18,461.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,373.91 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,786.02. The transfer capital threshold is the transfer adjustment factor * $1,786.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25457.55","686.97","25495.22","1 through 10","20214.72","32231.3578","other","Inpatient Replacement Plans DRG"
"Pancreas, Liver And Shunt Procedures Without Cc/McC","407","MS-DRG","","","","","","","","inpatient","","","124422.26","93316.69","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20214.72","","Case rate ($20,627.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,753.75, add-ons for qualifying new technology services are included. If operating cost exceeds $70,398.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,226.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $18,461.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,373.91 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,786.02. The transfer capital threshold is the transfer adjustment factor * $1,786.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19328.44","19328.44","19328.44","1 through 10","20214.72","32231.3578","other","Inpatient DRG"
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Pancreatic Necrosectomy","PX-75000433","CDM","48999","CPT","0750","RC","","","","outpatient","","","17253.00","12939.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","9009.52","52.22","","1550.84","1550.84","1550.84","1 through 10","1234.13","14233.73","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","29.95","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","21.24","19.40","29.92","12","27.63","209.09","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.61","28.61","28.61","19","27.63","209.09","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","36.35","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","29.08","29.08","29.08","1 through 10","27.63","209.09","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","209.09","79.5","","200.69","134.64","436.79","169","27.63","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","140.18","53.3","","200.69","134.64","1251.41","115","27.63","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.50","28.50","28.50","1 through 10","27.63","209.09","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","202.51","77","","196.35","196.35","196.35","1 through 10","27.63","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","HUMANA [1012]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.50","28.50","28.50","1 through 10","27.63","209.09","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","209.09","79.5","","200.69","200.69","200.69","1 through 10","27.63","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","MEDICARE [2001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","87.24","293","27.63","209.09","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16.03","16.03","19.41","23","27.63","209.09","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","81.53","31","","236.40","236.40","236.40","1 through 10","27.63","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","96.00","36.5","","184.62","95.12","276.93","1 through 10","27.63","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.73","38.3","","99.71","99.71","299.13","21","27.63","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.50","28.50","31.85","1 through 10","27.63","209.09","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","MOLINA [1014]","HB BWH MOLINA","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","128.70","128.70","128.70","1 through 10","27.63","209.09","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","202.51","77","","40.72","40.71","40.72","1 through 10","27.63","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","TRICARE [160005]","HB BWH TRICARE","27.63","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","29.08","27.63","30.87","1 through 10","27.63","209.09","other","Tricare OPPS"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","28.50","85.76","1 through 10","27.63","209.09","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.83","42.9","","203.85","112.12","203.85","12","27.63","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","19.03","57.58","81","27.63","209.09","other","OPPS APC"
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","both","","","263.00","197.25","WELLPOINT [1015]","HB AMC WELLPOINT","194.04","73.78","","444.85","189.85","444.85","131","27.63","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","AETNA [1001]","HB AMC AETNA HMO","183.57","69.8","","172.64","121.89","243.78","136","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","AETNA [1001]","HB AMC AETNA PPO","211.45","80.4","","198.90","133.62","267.24","20","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","147.02","55.9","","133.62","133.62","133.62","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","137.44","52.26","","157.79","45.50","157.79","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","138.08","52.5","","21.46","18.89","21.46","38","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","131.50","50","","81.74","81.74","81.74","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","138.08","52.5","","256.61","41.28","266.88","12","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","164.38","62.5","","21.46","21.46","21.46","14","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","138.08","52.5","","18.03","18.03","18.03","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","144.65","55","","18.89","18.89","18.89","66","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","211.45","80.4","","198.90","198.90","198.90","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","138.08","52.5","","21.46","18.89","21.46","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","214.92","81.72","","203.85","112.12","203.85","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.92","81.72","","203.85","112.12","203.85","209","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","164.38","62.5","","21.46","21.46","21.46","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","138.08","52.5","","18.03","18.03","18.03","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-31000144","CDM","Q0091","HCPCS","0770","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","144.65","55","","18.89","18.89","21.46","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","263.00","197.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","29.95","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","21.24","19.40","29.92","12","27.63","36.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","263.00","197.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.61","28.61","28.61","19","27.63","36.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","263.00","197.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","36.35","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","29.08","29.08","29.08","1 through 10","27.63","36.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","263.00","197.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.50","28.50","28.50","1 through 10","27.63","36.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","263.00","197.25","HUMANA [1012]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.50","28.50","28.50","1 through 10","27.63","36.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","263.00","197.25","MEDICARE [2001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","87.24","293","27.63","36.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","263.00","197.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16.03","16.03","19.41","23","27.63","36.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","263.00","197.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.50","28.50","31.85","1 through 10","27.63","36.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","263.00","197.25","MOLINA [1014]","HB BWH MOLINA","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","128.70","128.70","128.70","1 through 10","27.63","36.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","263.00","197.25","TRICARE [160005]","HB BWH TRICARE","27.63","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","29.08","27.63","30.87","1 through 10","27.63","36.35","other","Tricare OPPS"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","263.00","197.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","28.50","85.76","1 through 10","27.63","36.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","19.03","57.58","81","27.63","36.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","263.00","197.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","209.09","79.5","","200.69","134.64","436.79","169","81.53","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","263.00","197.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","140.18","53.3","","200.69","134.64","1251.41","115","81.53","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","263.00","197.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","202.51","77","","196.35","196.35","196.35","1 through 10","81.53","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","263.00","197.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","209.09","79.5","","200.69","200.69","200.69","1 through 10","81.53","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","263.00","197.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","81.53","31","","236.40","236.40","236.40","1 through 10","81.53","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","263.00","197.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","96.00","36.5","","184.62","95.12","276.93","1 through 10","81.53","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","263.00","197.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.73","38.3","","99.71","99.71","299.13","21","81.53","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","263.00","197.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","202.51","77","","40.72","40.71","40.72","1 through 10","81.53","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.83","42.9","","203.85","112.12","203.85","12","81.53","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","263.00","197.25","WELLPOINT [1015]","HB AMC WELLPOINT","194.04","73.78","","444.85","189.85","444.85","131","81.53","209.09","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","AETNA [1001]","HB AMC AETNA HMO","183.57","69.8","","172.64","121.89","243.78","136","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","AETNA [1001]","HB AMC AETNA PPO","211.45","80.4","","198.90","133.62","267.24","20","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","147.02","55.9","","133.62","133.62","133.62","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","137.44","52.26","","157.79","45.50","157.79","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","138.08","52.5","","21.46","18.89","21.46","38","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","131.50","50","","81.74","81.74","81.74","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","138.08","52.5","","256.61","41.28","266.88","12","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","164.38","62.5","","21.46","21.46","21.46","14","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","138.08","52.5","","18.03","18.03","18.03","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","144.65","55","","18.89","18.89","18.89","66","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","211.45","80.4","","198.90","198.90","198.90","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","138.08","52.5","","21.46","18.89","21.46","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","214.92","81.72","","203.85","112.12","203.85","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.92","81.72","","203.85","112.12","203.85","209","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","164.38","62.5","","21.46","21.46","21.46","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","138.08","52.5","","18.03","18.03","18.03","1 through 10","39.44","216.98","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","263.00","197.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","144.65","55","","18.89","18.89","21.46","1 through 10","39.44","216.98","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","366.18","71.8","","747.22","109.20","1066.23","31","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","334.56","65.6","","386.10","386.10","386.10","1 through 10","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","331.50","65","","321.75","261.36","321.75","1 through 10","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","357.00","70","","363.80","143.08","495.00","18","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","405.45","79.5","","389.57","261.36","389.57","122","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","271.83","53.3","","261.36","261.36","1168.71","76","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","392.70","77","","381.15","381.15","381.15","1 through 10","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","331.50","65","","321.75","209.62","430.30","1 through 10","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","158.10","31","","152.96","152.96","152.96","1 through 10","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","186.15","36.5","","184.64","156.92","358.38","150","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","195.33","38.3","","193.55","188.10","580.65","385","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","MOLINA [1014]","HB BWH MOLINA","178.50","35","","81.90","81.90","81.90","1 through 10","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","392.70","77","","499.15","386.10","499.15","1 through 10","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","TRICARE [160005]","HB BWH TRICARE","484.50","95","","49.74","47.25","495.00","1 through 10","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","218.79","42.9","","395.70","217.65","395.71","1 through 10","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","510.00","382.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","218.79","42.9","","395.70","395.70","395.70","1 through 10","40.45","484.5","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","510.00","382.50","AETNA [1001]","HB AMC AETNA HMO","355.98","69.8","","335.12","236.61","386.10","151","42.57","416.77","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","510.00","382.50","AETNA [1001]","HB AMC AETNA PPO","410.04","80.4","","386.10","236.61","518.76","18","42.57","416.77","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","510.00","382.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","266.53","52.26","","306.31","145.39","306.31","1 through 10","42.57","416.77","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","410.04","80.4","","247.50","247.50","247.50","1 through 10","42.57","416.77","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","416.77","81.72","","395.70","395.70","395.70","1 through 10","42.57","416.77","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","510.00","382.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","416.77","81.72","","395.71","217.65","395.71","1 through 10","42.57","416.77","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","510.00","382.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","416.77","81.72","","395.70","217.65","395.70","119","42.57","416.77","percent of total billed charges",""
"Parathyroid Ethanol Injection","PX-76002477","CDM","60699","CPT","0761","RC","","","","both","","","1176.00","882.00","MEDICARE [2001]","HB BWH MEDICARE","6927.95","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6928.65","6928.65","1 through 10","364.56","8659.94","other","OPPS APC"
"Parathyroid Ethanol Injection","PX-76002477","CDM","60699","CPT","0761","RC","","","","both","","","1176.00","882.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","450.41","38.3","","5123.54","4829.42","5123.54","1 through 10","364.56","8659.94","percent of total billed charges",""
"Parathyroid Ethanol Injection","PX-76002477","CDM","60699","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","712.07","60.55","","13483.00","13483.00","13483.00","1 through 10","588","15696.44","percent of total billed charges",""
"Parathyroid Ethanol Injection","PX-76002477","CDM","60699","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","614.11","52.22","","13483.00","12302.64","13483.00","1 through 10","588","15696.44","percent of total billed charges",""
"Parathyroid Ethanol Injection","PX-76002477","CDM","60699","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","588.00","50","","13483.00","13483.00","13483.00","1 through 10","588","15696.44","percent of total billed charges",""
"Parathyroid Ethanol Injection","PX-76002477","CDM","60699","CPT","0761","RC","","","","outpatient","","","1176.00","882.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","617.40","52.5","","13483.00","3582.00","13483.00","1 through 10","588","15696.44","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Parechovirus by Pcr","PX-30003648","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"Paring/Cutting Lesn Benign >4","PX-76000030","CDM","11057","CPT","0761","RC","","","","both","","","423.00","317.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","131.13","336.29","other","OPPS APC"
"Paring/Cutting Lesn Benign >4","PX-76000030","CDM","11057","CPT","0761","RC","","","","both","","","423.00","317.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.26","231.26","231.26","1 through 10","131.13","336.29","other","OPPS APC"
"Paring/Cutting Lesn Benign 1","PX-76000028","CDM","11055","CPT","0761","RC","","","","both","","","296.00","222.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.04","36.5","","287.00","287.00","287.00","1 through 10","91.76","294.93","percent of total billed charges",""
"Paring/Cutting Lesn Benign 1","PX-76000028","CDM","11055","CPT","0761","RC","","","","both","","","296.00","222.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.37","38.3","","287.00","112.22","287.00","1 through 10","91.76","294.93","percent of total billed charges",""
"Paring/Cutting Lesn Benign 1","PX-76000028","CDM","11055","CPT","0761","RC","","","","both","","","296.00","222.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.25","15.76","231.26","1 through 10","91.76","294.93","other","OPPS APC"
"Paring/Cutting Lesn Benign 1","PX-76000028","CDM","11055","CPT","0761","RC","","","","outpatient","","","296.00","222.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","412.84","405.38","450.19","18","154.69","700.33","other","ASC"
"Paring/Cutting Lesn Benign 1","PX-76000028","CDM","11055","CPT","0761","RC","","","","outpatient","","","296.00","222.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","472.37","287.00","515.29","13","154.69","700.33","other","ASC "
"Paring/Cutting Lesn Benign 1","PX-76000028","CDM","11055","CPT","0761","RC","","","","outpatient","","","296.00","222.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","18.84","786.96","1 through 10","154.69","700.33","other","Multiple Surgery"
"Paring/Cutting Lesn Benign 1","PX-76000028","CDM","11055","CPT","0761","RC","","","","outpatient","","","296.00","222.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","414.66","430.54","1 through 10","154.69","700.33","other","Multiple Surgery"
"Paring/Cutting Lesn Benign 2-4","PX-76000029","CDM","11056","CPT","0761","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.41","38.3","","156.01","156.01","156.01","1 through 10","127.41","326.75","percent of total billed charges",""
"Paring/Cutting Lesn Benign 2-4","PX-76000029","CDM","11056","CPT","0761","RC","","","","both","","","411.00","308.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.26","214.13","231.26","14","127.41","326.75","other","OPPS APC"
"Paring/Cutting Lesn Benign 2-4","PX-76000029","CDM","11056","CPT","0761","RC","","","","outpatient","","","411.00","308.25","AETNA [1001]","HB AMC AETNA HMO","286.88","69.8","","270.12","190.72","270.12","1 through 10","176.45","350.18","percent of total billed charges",""
"Paring/Cutting Lesn Benign 2-4","PX-76000029","CDM","11056","CPT","0761","RC","","","","outpatient","","","411.00","308.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","412.84","405.38","412.84","1 through 10","176.45","350.18","other","ASC"
"Paring/Cutting Lesn Benign 2-4","PX-76000029","CDM","11056","CPT","0761","RC","","","","outpatient","","","411.00","308.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","399.00","236.19","472.37","1 through 10","176.45","350.18","other","ASC "
"Paring/Cutting Lesn Benign 2-4","PX-76000029","CDM","11056","CPT","0761","RC","","","","outpatient","","","411.00","308.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","1 through 10","176.45","350.18","other","Multiple Surgery"
"Part Simple Remv Vulva","PX-76002765","CDM","56620","CPT","0761","RC","","","","both","","","5168.00","3876.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3888.77","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3895.81","3895.81","3895.81","1 through 10","1602.08","4719.38","other","OPPS APC"
"Part Simple Remv Vulva","PX-76002765","CDM","56620","CPT","0761","RC","","","","both","","","5168.00","3876.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3715.47","3715.47","3715.47","1 through 10","1602.08","4719.38","other","OPPS APC"
"Part Simple Remv Vulva","PX-76002765","CDM","56620","CPT","0761","RC","","","","both","","","5168.00","3876.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3715.47","3715.47","3715.47","1 through 10","1602.08","4719.38","other","OPPS APC"
"Part Simple Remv Vulva","PX-76002765","CDM","56620","CPT","0761","RC","","","","both","","","5168.00","3876.00","MEDICARE [2001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3412.18","3775.88","1 through 10","1602.08","4719.38","other","OPPS APC"
"Part Simple Remv Vulva","PX-76002765","CDM","56620","CPT","0761","RC","","","","both","","","5168.00","3876.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1979.34","38.3","","11008.61","5879.07","18543.24","1 through 10","1602.08","4719.38","percent of total billed charges",""
"Part Simple Remv Vulva","PX-76002765","CDM","56620","CPT","0761","RC","","","","both","","","5168.00","3876.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7400.72","3708.27","7400.72","1 through 10","1602.08","4719.38","other","OPPS APC"
"Part Simple Remv Vulva","PX-76002765","CDM","56620","CPT","0761","RC","","","","both","","","5168.00","3876.00","WELLPOINT [1015]","HB AMC WELLPOINT","3812.95","73.78","","15060.49","9159.58","15060.49","1 through 10","1602.08","4719.38","percent of total billed charges",""
"Part Simple Remv Vulva","PX-76002765","CDM","56620","CPT","0761","RC","","","","outpatient","","","5168.00","3876.00","AETNA [1001]","HB AMC AETNA HMO","3607.26","69.8","","9669.46","9669.46","9669.46","1 through 10","2125.14","11593.85","percent of total billed charges",""
"Part Simple Remv Vulva","PX-76002765","CDM","56620","CPT","0761","RC","","","","outpatient","","","5168.00","3876.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5424.80","2762.36","5524.71","1 through 10","2125.14","11593.85","other","ASC"
"Part Simple Remv Vulva","PX-76002765","CDM","56620","CPT","0761","RC","","","","outpatient","","","5168.00","3876.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6259.18","3160.65","6321.29","1 through 10","2125.14","11593.85","other","ASC "
"Part Simple Remv Vulva","PX-76002765","CDM","56620","CPT","0761","RC","","","","outpatient","","","5168.00","3876.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4930.32","4930.32","4930.32","1 through 10","2125.14","11593.85","other","Multiple Surgery"
"Part Simple Remv Vulva","PX-76002765","CDM","56620","CPT","0761","RC","","","","outpatient","","","5168.00","3876.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4155.07","80.4","","18627.58","18627.58","18627.58","1 through 10","2125.14","11593.85","percent of total billed charges",""
"Partial Thickness Burns Without Skin Graft,EXTREME","844","DRG","","","","","","","","inpatient","","","147747.34","","MASSHEALTH [3001]","HB BWH MEDICAID","34638.82","","Case rate ($38,299.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,729.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","38289.77","38289.77","38289.77","1 through 10","3286.59","228533.02","case rate",""
"Partial Thickness Burns Without Skin Graft,EXTREME","844","DRG","","","","","","","","inpatient","","","147747.34","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","34638.82","","Case rate ($38,299.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,729.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","3286.59","228533.02","case rate",""
"Partial Thickness Burns Without Skin Graft,EXTREME","844","DRG","","","","","","","","inpatient","","","147747.34","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","34638.82","","Case rate ($38,299.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,729.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","38289.77","38289.77","38289.77","1 through 10","3286.59","228533.02","case rate",""
"Partial Thickness Burns Without Skin Graft,EXTREME","844","DRG","","","","","","","","inpatient","","","147747.34","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","34638.82","","Case rate ($38,299.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $80,729.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15378.31","15378.31","15378.31","1 through 10","3286.59","228533.02","case rate",""
"Partial Thickness Burns Without Skin Graft,MINOR","844","DRG","","","","","","","","inpatient","","","11615.96","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","11451.95","","Standard inlier is a Case rate ($11,451.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $20,554, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,625.67) for the length of stay and the standard reimbursement.","11451.94","11451.94","11451.94","1 through 10","3286.59","228533.02","case rate",""
"Partial Thickness Burns Without Skin Graft,MINOR","844","DRG","","","","","","","","inpatient","","","11615.96","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","12875.08","","Standard inlier is a Case rate ($12,875.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $20,554, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,827.51) for the length of stay and the standard reimbursement.","12875.07","12875.07","12875.07","1 through 10","3286.59","228533.02","case rate",""
"Partial Thickness Burns Without Skin Graft,MINOR","844","DRG","","","","","","","","inpatient","","","11615.96","","MASSHEALTH [3001]","HB BWH MEDICAID","3286.59","","Case rate ($3,633.89). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,063.89, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3632.99","3632.99","3632.99","1 through 10","3286.59","228533.02","case rate",""
"Partial Thickness Burns Without Skin Graft,MINOR","844","DRG","","","","","","","","inpatient","","","11615.96","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","3286.59","","Case rate ($3,633.89). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,063.89, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3633.00","3633.00","3633.00","1 through 10","3286.59","228533.02","case rate",""
"Partial Thickness Burns Without Skin Graft,MODERATE","844","DRG","","","","","","","","inpatient","","","39638.77","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","20863.37","","Standard inlier is a Case rate ($20,863.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,078, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,961.38) for the length of stay and the standard reimbursement.","20990.62","20990.62","20990.62","1 through 10","3286.59","228533.02","case rate",""
"Partial Thickness Burns Without Skin Graft,MODERATE","844","DRG","","","","","","","","inpatient","","","39638.77","","MASSHEALTH [3001]","HB BWH MEDICAID","6552.61","","Case rate ($7,245.04). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,675.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7243.26","5953.36","7243.26","1 through 10","3286.59","228533.02","case rate",""
"Partial Thickness Burns Without Skin Graft,MODERATE","844","DRG","","","","","","","","inpatient","","","39638.77","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6552.61","","Case rate ($7,245.04). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,675.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22506.75","22506.75","22506.75","1 through 10","3286.59","228533.02","case rate",""
"Partial Thickness Burns Without Skin Graft,MODERATE","844","DRG","","","","","","","","inpatient","","","39638.77","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","6552.61","","Case rate ($7,245.04). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,675.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15378.31","15378.31","15378.31","1 through 10","3286.59","228533.02","case rate",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","75.39","71.8","","219.72","73.24","219.72","20","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","68.88","65.6","","69.05","69.05","69.05","1 through 10","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","68.25","65","","66.30","66.30","66.30","1 through 10","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","73.50","70","","102.00","44.85","204.00","15","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","83.48","79.5","","80.27","53.86","240.81","235","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","55.97","53.3","","80.27","53.86","240.83","172","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","80.85","77","","235.62","235.62","235.62","1 through 10","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","68.25","65","","66.30","66.30","193.05","12","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","83.48","79.5","","80.27","80.27","80.27","1 through 10","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","32.55","31","","31.52","31.52","31.52","1 through 10","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.33","36.5","","38.05","32.33","114.15","202","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.22","38.3","","39.88","38.76","119.64","471","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","80.85","77","","80.27","79.56","80.27","1 through 10","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","TRICARE [160005]","HB BWH TRICARE","99.75","95","","6.88","6.88","14.48","1 through 10","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.05","42.9","","81.54","44.85","81.54","1 through 10","5.89","99.75","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","105.00","78.75","AETNA [1001]","HB AMC AETNA HMO","73.29","69.8","","69.05","48.76","79.56","287","6.2","85.81","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","105.00","78.75","AETNA [1001]","HB AMC AETNA PPO","84.42","80.4","","79.56","53.45","155.45","28","6.2","85.81","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","105.00","78.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","58.70","55.9","","53.45","53.45","53.45","1 through 10","6.2","85.81","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","105.00","78.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","54.87","52.26","","63.12","21.65","63.12","1 through 10","6.2","85.81","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","84.42","80.4","","79.56","51.00","102.00","11","6.2","85.81","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","85.81","81.72","","44.85","44.85","81.54","1 through 10","6.2","85.81","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","85.81","81.72","","81.54","44.85","81.54","246","6.2","85.81","percent of total billed charges",""
"Particle Agglutination Screen","PX-30000862","CDM","86403","CPT","0302","RC","","","","both","","","166.00","124.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","116.20","70","","161.00","161.00","161.00","1 through 10","10.51","157.7","percent of total billed charges",""
"Particle Agglutination Screen","PX-30000862","CDM","86403","CPT","0302","RC","","","","both","","","166.00","124.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.58","38.3","","62.95","62.95","62.95","1 through 10","10.51","157.7","percent of total billed charges",""
"Particle Agglutination Screen","PX-30000862","CDM","86403","CPT","0302","RC","","","","outpatient","","","166.00","124.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","135.66","81.72","","128.70","128.70","128.70","1 through 10","10.51","135.66","percent of total billed charges",""
"PARTICLE EMBOLIZATION 100-300UM 2ML SYRINGE MICROSPHERES HYDROPHILIC PORCINE GELATIN NORMAL SALINE YELLOW BX/5EA","SUP-ITM-10021962","CDM","C1889","HCPCS","0278","RC","","","","both","","","868.00","651.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","690.06","79.5","","1309.77","674.56","6049.93","26","269.08","690.06","percent of total billed charges",""
"PARTICLE EMBOLIZATION 100-300UM 2ML SYRINGE MICROSPHERES HYDROPHILIC PORCINE GELATIN NORMAL SALINE YELLOW BX/5EA","SUP-ITM-10021962","CDM","C1889","HCPCS","0278","RC","","","","both","","","868.00","651.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","462.64","53.3","","1901.83","1901.83","2962.25","1 through 10","269.08","690.06","percent of total billed charges",""
"PARTICLE EMBOLIZATION 100-300UM 2ML SYRINGE MICROSPHERES HYDROPHILIC PORCINE GELATIN NORMAL SALINE YELLOW BX/5EA","SUP-ITM-10021962","CDM","C1889","HCPCS","0278","RC","","","","both","","","868.00","651.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","316.82","36.5","","1620.31","1620.31","19908.88","1 through 10","269.08","690.06","percent of total billed charges",""
"PARTICLE EMBOLIZATION 100-300UM 2ML SYRINGE MICROSPHERES HYDROPHILIC PORCINE GELATIN NORMAL SALINE YELLOW BX/5EA","SUP-ITM-10021962","CDM","C1889","HCPCS","0278","RC","","","","both","","","868.00","651.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","332.44","38.3","","352.91","352.91","2046.30","1 through 10","269.08","690.06","percent of total billed charges",""
"PARTICLE EMBOLIZATION 100-300UM 2ML SYRINGE MICROSPHERES HYDROPHILIC PORCINE GELATIN NORMAL SALINE YELLOW BX/5EA","SUP-ITM-10021962","CDM","C1889","HCPCS","0278","RC","","","","both","","","868.00","651.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","372.37","42.9","","9668.75","9668.75","9668.75","1 through 10","269.08","690.06","percent of total billed charges",""
"PARTICLE EMBOLIZATION 100-300UM 2ML SYRINGE MICROSPHERES HYDROPHILIC PORCINE GELATIN NORMAL SALINE YELLOW BX/5EA","SUP-ITM-10021962","CDM","C1889","HCPCS","0278","RC","","","","both","","","868.00","651.00","WELLPOINT [1015]","HB AMC WELLPOINT","640.41","73.78","","699.88","384.10","3443.31","33","269.08","690.06","percent of total billed charges",""
"PARTICLE EMBOLIZATION 100-300UM 2ML SYRINGE MICROSPHERES HYDROPHILIC PORCINE GELATIN NORMAL SALINE YELLOW BX/5EA","SUP-ITM-10021962","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","868.00","651.00","AETNA [1001]","HB AMC AETNA HMO","605.86","69.8","","1421.24","264.50","4933.46","29","453.62","709.33","percent of total billed charges",""
"PARTICLE EMBOLIZATION 100-300UM 2ML SYRINGE MICROSPHERES HYDROPHILIC PORCINE GELATIN NORMAL SALINE YELLOW BX/5EA","SUP-ITM-10021962","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","868.00","651.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","697.87","80.4","","1022.97","1022.97","3607.50","1 through 10","453.62","709.33","percent of total billed charges",""
"PARTICLE EMBOLIZATION 100-300UM 2ML SYRINGE MICROSPHERES HYDROPHILIC PORCINE GELATIN NORMAL SALINE YELLOW BX/5EA","SUP-ITM-10021962","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","868.00","651.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","709.33","81.72","","3010.54","693.88","5019.88","35","453.62","709.33","percent of total billed charges",""
"PARTICLE EMBOLIZATION 250-355UM CONTOUR PVA VIAL PERIPHERAL BX/5EA","SUP-ITM-10000192","CDM","C1889","HCPCS","0278","RC","","","","both","","","422.06","316.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","335.54","79.5","","1309.77","674.56","6049.93","26","130.84","335.54","percent of total billed charges",""
"PARTICLE EMBOLIZATION 250-355UM CONTOUR PVA VIAL PERIPHERAL BX/5EA","SUP-ITM-10000192","CDM","C1889","HCPCS","0278","RC","","","","both","","","422.06","316.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","224.96","53.3","","1901.83","1901.83","2962.25","1 through 10","130.84","335.54","percent of total billed charges",""
"PARTICLE EMBOLIZATION 250-355UM CONTOUR PVA VIAL PERIPHERAL BX/5EA","SUP-ITM-10000192","CDM","C1889","HCPCS","0278","RC","","","","both","","","422.06","316.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","154.05","36.5","","1620.31","1620.31","19908.88","1 through 10","130.84","335.54","percent of total billed charges",""
"PARTICLE EMBOLIZATION 250-355UM CONTOUR PVA VIAL PERIPHERAL BX/5EA","SUP-ITM-10000192","CDM","C1889","HCPCS","0278","RC","","","","both","","","422.06","316.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","161.65","38.3","","352.91","352.91","2046.30","1 through 10","130.84","335.54","percent of total billed charges",""
"PARTICLE EMBOLIZATION 250-355UM CONTOUR PVA VIAL PERIPHERAL BX/5EA","SUP-ITM-10000192","CDM","C1889","HCPCS","0278","RC","","","","both","","","422.06","316.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.06","42.9","","9668.75","9668.75","9668.75","1 through 10","130.84","335.54","percent of total billed charges",""
"PARTICLE EMBOLIZATION 250-355UM CONTOUR PVA VIAL PERIPHERAL BX/5EA","SUP-ITM-10000192","CDM","C1889","HCPCS","0278","RC","","","","both","","","422.06","316.54","WELLPOINT [1015]","HB AMC WELLPOINT","311.40","73.78","","699.88","384.10","3443.31","33","130.84","335.54","percent of total billed charges",""
"PARTICLE EMBOLIZATION 250-355UM CONTOUR PVA VIAL PERIPHERAL BX/5EA","SUP-ITM-10000192","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","422.06","316.54","AETNA [1001]","HB AMC AETNA HMO","294.60","69.8","","1421.24","264.50","4933.46","29","220.57","344.91","percent of total billed charges",""
"PARTICLE EMBOLIZATION 250-355UM CONTOUR PVA VIAL PERIPHERAL BX/5EA","SUP-ITM-10000192","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","422.06","316.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","339.34","80.4","","1022.97","1022.97","3607.50","1 through 10","220.57","344.91","percent of total billed charges",""
"PARTICLE EMBOLIZATION 250-355UM CONTOUR PVA VIAL PERIPHERAL BX/5EA","SUP-ITM-10000192","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","422.06","316.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","344.91","81.72","","3010.54","693.88","5019.88","35","220.57","344.91","percent of total billed charges",""
"PARTICLE EMBOLIZATION 700-900UM 2ML SYRINGE MICROSPHERES GREEN BX/5EA","SUP-ITM-10010410","CDM","C1889","HCPCS","0278","RC","","","","both","","","868.00","651.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","690.06","79.5","","1309.77","674.56","6049.93","26","269.08","690.06","percent of total billed charges",""
"PARTICLE EMBOLIZATION 700-900UM 2ML SYRINGE MICROSPHERES GREEN BX/5EA","SUP-ITM-10010410","CDM","C1889","HCPCS","0278","RC","","","","both","","","868.00","651.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","462.64","53.3","","1901.83","1901.83","2962.25","1 through 10","269.08","690.06","percent of total billed charges",""
"PARTICLE EMBOLIZATION 700-900UM 2ML SYRINGE MICROSPHERES GREEN BX/5EA","SUP-ITM-10010410","CDM","C1889","HCPCS","0278","RC","","","","both","","","868.00","651.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","316.82","36.5","","1620.31","1620.31","19908.88","1 through 10","269.08","690.06","percent of total billed charges",""
"PARTICLE EMBOLIZATION 700-900UM 2ML SYRINGE MICROSPHERES GREEN BX/5EA","SUP-ITM-10010410","CDM","C1889","HCPCS","0278","RC","","","","both","","","868.00","651.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","332.44","38.3","","352.91","352.91","2046.30","1 through 10","269.08","690.06","percent of total billed charges",""
"PARTICLE EMBOLIZATION 700-900UM 2ML SYRINGE MICROSPHERES GREEN BX/5EA","SUP-ITM-10010410","CDM","C1889","HCPCS","0278","RC","","","","both","","","868.00","651.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","372.37","42.9","","9668.75","9668.75","9668.75","1 through 10","269.08","690.06","percent of total billed charges",""
"PARTICLE EMBOLIZATION 700-900UM 2ML SYRINGE MICROSPHERES GREEN BX/5EA","SUP-ITM-10010410","CDM","C1889","HCPCS","0278","RC","","","","both","","","868.00","651.00","WELLPOINT [1015]","HB AMC WELLPOINT","640.41","73.78","","699.88","384.10","3443.31","33","269.08","690.06","percent of total billed charges",""
"PARTICLE EMBOLIZATION 700-900UM 2ML SYRINGE MICROSPHERES GREEN BX/5EA","SUP-ITM-10010410","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","868.00","651.00","AETNA [1001]","HB AMC AETNA HMO","605.86","69.8","","1421.24","264.50","4933.46","29","453.62","709.33","percent of total billed charges",""
"PARTICLE EMBOLIZATION 700-900UM 2ML SYRINGE MICROSPHERES GREEN BX/5EA","SUP-ITM-10010410","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","868.00","651.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","697.87","80.4","","1022.97","1022.97","3607.50","1 through 10","453.62","709.33","percent of total billed charges",""
"PARTICLE EMBOLIZATION 700-900UM 2ML SYRINGE MICROSPHERES GREEN BX/5EA","SUP-ITM-10010410","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","868.00","651.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","709.33","81.72","","3010.54","693.88","5019.88","35","453.62","709.33","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","both","","","130.00","97.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","103.35","79.5","","95.00","66.53","99.16","17","9.6","123.5","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","both","","","130.00","97.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","69.29","53.3","","66.53","66.53","133.06","1 through 10","9.6","123.5","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","both","","","130.00","97.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","47.45","36.5","","47.00","39.57","141.00","17","9.6","123.5","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","both","","","130.00","97.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","49.79","38.3","","49.27","49.27","49.27","62","9.6","123.5","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","both","","","130.00","97.50","TRICARE [160005]","HB BWH TRICARE","123.50","95","","36.22","17.20","36.22","1 through 10","9.6","123.5","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","outpatient","","","130.00","97.50","AETNA [1001]","HB AMC AETNA HMO","90.74","69.8","","60.23","60.23","98.28","26","9.6","106.24","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","outpatient","","","130.00","97.50","AETNA [1001]","HB AMC AETNA PPO","104.52","80.4","","66.03","66.03","66.03","1 through 10","9.6","106.24","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","outpatient","","","130.00","97.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","106.24","81.72","","100.73","100.73","201.45","20","9.6","106.24","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","both","","","777.00","582.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","543.90","70","","134.04","134.04","134.04","1 through 10","240.87","617.72","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","both","","","777.00","582.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","617.72","79.5","","948.87","198.19","1805.30","1 through 10","240.87","617.72","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","both","","","777.00","582.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","414.14","53.3","","462.00","170.45","3253.37","1 through 10","240.87","617.72","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","both","","","777.00","582.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","283.61","36.5","","245.50","107.19","1371.45","1 through 10","240.87","617.72","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","both","","","777.00","582.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","297.59","38.3","","200.79","72.79","355.81","22","240.87","617.72","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","both","","","777.00","582.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","598.29","77","","477.18","477.18","477.18","1 through 10","240.87","617.72","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","both","","","777.00","582.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.33","42.9","","1045.91","1045.91","1045.91","1 through 10","240.87","617.72","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","both","","","777.00","582.75","WELLPOINT [1015]","HB AMC WELLPOINT","573.27","73.78","","1726.50","1726.50","1726.50","1 through 10","240.87","617.72","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","777.00","582.75","AETNA [1001]","HB AMC AETNA HMO","542.35","69.8","","915.80","263.76","2881.00","1 through 10","406.06","634.96","percent of total billed charges",""
"PATCH BIOLOGICAL 9CM 2 W 1MM BOVINE MATRIX VASCULAR THICK XENOSURE","SUP-ITM-10091807","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","777.00","582.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","634.96","81.72","","1531.57","410.52","8841.36","1 through 10","406.06","634.96","percent of total billed charges",""
"PATCH EPTFE 2MMX15 20CM GRAFT TISSUE GORE TEX","SUP-ITM-10001866","CDM","C1781","HCPCS","0278","RC","","","","both","","","5887.50","4415.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4121.25","70","","134.04","134.04","134.04","1 through 10","1825.13","4680.56","percent of total billed charges",""
"PATCH EPTFE 2MMX15 20CM GRAFT TISSUE GORE TEX","SUP-ITM-10001866","CDM","C1781","HCPCS","0278","RC","","","","both","","","5887.50","4415.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4680.56","79.5","","948.87","198.19","1805.30","1 through 10","1825.13","4680.56","percent of total billed charges",""
"PATCH EPTFE 2MMX15 20CM GRAFT TISSUE GORE TEX","SUP-ITM-10001866","CDM","C1781","HCPCS","0278","RC","","","","both","","","5887.50","4415.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3138.04","53.3","","462.00","170.45","3253.37","1 through 10","1825.13","4680.56","percent of total billed charges",""
"PATCH EPTFE 2MMX15 20CM GRAFT TISSUE GORE TEX","SUP-ITM-10001866","CDM","C1781","HCPCS","0278","RC","","","","both","","","5887.50","4415.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2148.94","36.5","","245.50","107.19","1371.45","1 through 10","1825.13","4680.56","percent of total billed charges",""
"PATCH EPTFE 2MMX15 20CM GRAFT TISSUE GORE TEX","SUP-ITM-10001866","CDM","C1781","HCPCS","0278","RC","","","","both","","","5887.50","4415.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2254.91","38.3","","200.79","72.79","355.81","22","1825.13","4680.56","percent of total billed charges",""
"PATCH EPTFE 2MMX15 20CM GRAFT TISSUE GORE TEX","SUP-ITM-10001866","CDM","C1781","HCPCS","0278","RC","","","","both","","","5887.50","4415.62","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4533.38","77","","477.18","477.18","477.18","1 through 10","1825.13","4680.56","percent of total billed charges",""
"PATCH EPTFE 2MMX15 20CM GRAFT TISSUE GORE TEX","SUP-ITM-10001866","CDM","C1781","HCPCS","0278","RC","","","","both","","","5887.50","4415.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2525.74","42.9","","1045.91","1045.91","1045.91","1 through 10","1825.13","4680.56","percent of total billed charges",""
"PATCH EPTFE 2MMX15 20CM GRAFT TISSUE GORE TEX","SUP-ITM-10001866","CDM","C1781","HCPCS","0278","RC","","","","both","","","5887.50","4415.62","WELLPOINT [1015]","HB AMC WELLPOINT","4343.80","73.78","","1726.50","1726.50","1726.50","1 through 10","1825.13","4680.56","percent of total billed charges",""
"PATCH EPTFE 2MMX15 20CM GRAFT TISSUE GORE TEX","SUP-ITM-10001866","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5887.50","4415.62","AETNA [1001]","HB AMC AETNA HMO","4109.48","69.8","","915.80","263.76","2881.00","1 through 10","3076.81","4811.27","percent of total billed charges",""
"PATCH EPTFE 2MMX15 20CM GRAFT TISSUE GORE TEX","SUP-ITM-10001866","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5887.50","4415.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4811.27","81.72","","1531.57","410.52","8841.36","1 through 10","3076.81","4811.27","percent of total billed charges",""
"PATCH HERNIA 6.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148180","CDM","C1781","HCPCS","0278","RC","","","","both","","","1257.45","943.09","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","880.22","70","","134.04","134.04","134.04","1 through 10","389.81","999.67","percent of total billed charges",""
"PATCH HERNIA 6.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148180","CDM","C1781","HCPCS","0278","RC","","","","both","","","1257.45","943.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","999.67","79.5","","948.87","198.19","1805.30","1 through 10","389.81","999.67","percent of total billed charges",""
"PATCH HERNIA 6.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148180","CDM","C1781","HCPCS","0278","RC","","","","both","","","1257.45","943.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","670.22","53.3","","462.00","170.45","3253.37","1 through 10","389.81","999.67","percent of total billed charges",""
"PATCH HERNIA 6.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148180","CDM","C1781","HCPCS","0278","RC","","","","both","","","1257.45","943.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","458.97","36.5","","245.50","107.19","1371.45","1 through 10","389.81","999.67","percent of total billed charges",""
"PATCH HERNIA 6.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148180","CDM","C1781","HCPCS","0278","RC","","","","both","","","1257.45","943.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","481.60","38.3","","200.79","72.79","355.81","22","389.81","999.67","percent of total billed charges",""
"PATCH HERNIA 6.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148180","CDM","C1781","HCPCS","0278","RC","","","","both","","","1257.45","943.09","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","968.24","77","","477.18","477.18","477.18","1 through 10","389.81","999.67","percent of total billed charges",""
"PATCH HERNIA 6.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148180","CDM","C1781","HCPCS","0278","RC","","","","both","","","1257.45","943.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","539.45","42.9","","1045.91","1045.91","1045.91","1 through 10","389.81","999.67","percent of total billed charges",""
"PATCH HERNIA 6.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148180","CDM","C1781","HCPCS","0278","RC","","","","both","","","1257.45","943.09","WELLPOINT [1015]","HB AMC WELLPOINT","927.75","73.78","","1726.50","1726.50","1726.50","1 through 10","389.81","999.67","percent of total billed charges",""
"PATCH HERNIA 6.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148180","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1257.45","943.09","AETNA [1001]","HB AMC AETNA HMO","877.70","69.8","","915.80","263.76","2881.00","1 through 10","657.14","1027.59","percent of total billed charges",""
"PATCH HERNIA 6.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148180","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1257.45","943.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1027.59","81.72","","1531.57","410.52","8841.36","1 through 10","657.14","1027.59","percent of total billed charges",""
"PATCH MEMBRANE 15CMX20 0.1MM GRAFT CARDIOVASCULAR PRECLUDE PERICARDIAL","SUP-ITM-10004835","CDM","C1763","HCPCS","0278","RC","","","","both","","","4935.00","3701.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3207.75","65","","2028.23","1653.70","2028.23","1 through 10","1529.85","3923.33","percent of total billed charges",""
"PATCH MEMBRANE 15CMX20 0.1MM GRAFT CARDIOVASCULAR PRECLUDE PERICARDIAL","SUP-ITM-10004835","CDM","C1763","HCPCS","0278","RC","","","","both","","","4935.00","3701.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1801.28","36.5","","1163.89","1163.89","1163.89","1 through 10","1529.85","3923.33","percent of total billed charges",""
"PATCH MEMBRANE 15CMX20 0.1MM GRAFT CARDIOVASCULAR PRECLUDE PERICARDIAL","SUP-ITM-10004835","CDM","C1763","HCPCS","0278","RC","","","","both","","","4935.00","3701.25","WELLPOINT [1015]","HB AMC WELLPOINT","3641.04","73.78","","4280.87","4280.87","4280.87","1 through 10","1529.85","3923.33","percent of total billed charges",""
"PATCH PERICARDIUM .8CM 8CM DECELLULARIZED BOVINE PHOTOFIX","SUP-ITM-10216272","CDM","C1763","HCPCS","0278","RC","","","","both","","","507.50","380.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","329.88","65","","2028.23","1653.70","2028.23","1 through 10","157.33","403.46","percent of total billed charges",""
"PATCH PERICARDIUM .8CM 8CM DECELLULARIZED BOVINE PHOTOFIX","SUP-ITM-10216272","CDM","C1763","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.24","36.5","","1163.89","1163.89","1163.89","1 through 10","157.33","403.46","percent of total billed charges",""
"PATCH PERICARDIUM .8CM 8CM DECELLULARIZED BOVINE PHOTOFIX","SUP-ITM-10216272","CDM","C1763","HCPCS","0278","RC","","","","both","","","507.50","380.62","WELLPOINT [1015]","HB AMC WELLPOINT","374.43","73.78","","4280.87","4280.87","4280.87","1 through 10","157.33","403.46","percent of total billed charges",""
"PATCH PERICARDIUM 2CM 9CM DECELLULARIZED BOVINE PHOTOFIX","SUP-ITM-10216273","CDM","C1763","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","966.88","65","","2028.23","1653.70","2028.23","1 through 10","461.13","1182.56","percent of total billed charges",""
"PATCH PERICARDIUM 2CM 9CM DECELLULARIZED BOVINE PHOTOFIX","SUP-ITM-10216273","CDM","C1763","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","542.94","36.5","","1163.89","1163.89","1163.89","1 through 10","461.13","1182.56","percent of total billed charges",""
"PATCH PERICARDIUM 2CM 9CM DECELLULARIZED BOVINE PHOTOFIX","SUP-ITM-10216273","CDM","C1763","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","WELLPOINT [1015]","HB AMC WELLPOINT","1097.48","73.78","","4280.87","4280.87","4280.87","1 through 10","461.13","1182.56","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","5437.50","4078.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3806.25","70","","134.04","134.04","134.04","1 through 10","1685.63","4322.81","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","5437.50","4078.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4322.81","79.5","","948.87","198.19","1805.30","1 through 10","1685.63","4322.81","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","5437.50","4078.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2898.19","53.3","","462.00","170.45","3253.37","1 through 10","1685.63","4322.81","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","5437.50","4078.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1984.69","36.5","","245.50","107.19","1371.45","1 through 10","1685.63","4322.81","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","5437.50","4078.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2082.56","38.3","","200.79","72.79","355.81","22","1685.63","4322.81","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","5437.50","4078.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4186.88","77","","477.18","477.18","477.18","1 through 10","1685.63","4322.81","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","5437.50","4078.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2332.69","42.9","","1045.91","1045.91","1045.91","1 through 10","1685.63","4322.81","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","5437.50","4078.12","WELLPOINT [1015]","HB AMC WELLPOINT","4011.79","73.78","","1726.50","1726.50","1726.50","1 through 10","1685.63","4322.81","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5437.50","4078.12","AETNA [1001]","HB AMC AETNA HMO","3795.38","69.8","","915.80","263.76","2881.00","1 through 10","2841.64","4443.53","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5437.50","4078.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4443.53","81.72","","1531.57","410.52","8841.36","1 through 10","2841.64","4443.53","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2070.25","70","","134.04","134.04","134.04","1 through 10","916.83","2351.21","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2351.21","79.5","","948.87","198.19","1805.30","1 through 10","916.83","2351.21","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1576.35","53.3","","462.00","170.45","3253.37","1 through 10","916.83","2351.21","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1079.49","36.5","","245.50","107.19","1371.45","1 through 10","916.83","2351.21","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1132.72","38.3","","200.79","72.79","355.81","22","916.83","2351.21","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2277.28","77","","477.18","477.18","477.18","1 through 10","916.83","2351.21","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1268.77","42.9","","1045.91","1045.91","1045.91","1 through 10","916.83","2351.21","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","WELLPOINT [1015]","HB AMC WELLPOINT","2182.04","73.78","","1726.50","1726.50","1726.50","1 through 10","916.83","2351.21","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2957.50","2218.12","AETNA [1001]","HB AMC AETNA HMO","2064.34","69.8","","915.80","263.76","2881.00","1 through 10","1545.59","2416.87","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2957.50","2218.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2416.87","81.72","","1531.57","410.52","8841.36","1 through 10","1545.59","2416.87","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4890.00","3667.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3423.00","70","","134.04","134.04","134.04","1 through 10","1515.9","3887.55","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4890.00","3667.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3887.55","79.5","","948.87","198.19","1805.30","1 through 10","1515.9","3887.55","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4890.00","3667.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2606.37","53.3","","462.00","170.45","3253.37","1 through 10","1515.9","3887.55","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4890.00","3667.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1784.85","36.5","","245.50","107.19","1371.45","1 through 10","1515.9","3887.55","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4890.00","3667.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1872.87","38.3","","200.79","72.79","355.81","22","1515.9","3887.55","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4890.00","3667.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3765.30","77","","477.18","477.18","477.18","1 through 10","1515.9","3887.55","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4890.00","3667.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2097.81","42.9","","1045.91","1045.91","1045.91","1 through 10","1515.9","3887.55","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4890.00","3667.50","WELLPOINT [1015]","HB AMC WELLPOINT","3607.84","73.78","","1726.50","1726.50","1726.50","1 through 10","1515.9","3887.55","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4890.00","3667.50","AETNA [1001]","HB AMC AETNA HMO","3413.22","69.8","","915.80","263.76","2881.00","1 through 10","2555.51","3996.11","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4890.00","3667.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3996.11","81.72","","1531.57","410.52","8841.36","1 through 10","2555.51","3996.11","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","8100.00","6075.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","5670.00","70","","134.04","134.04","134.04","1 through 10","2511","6439.5","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","8100.00","6075.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6439.50","79.5","","948.87","198.19","1805.30","1 through 10","2511","6439.5","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","8100.00","6075.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4317.30","53.3","","462.00","170.45","3253.37","1 through 10","2511","6439.5","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","8100.00","6075.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2956.50","36.5","","245.50","107.19","1371.45","1 through 10","2511","6439.5","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","8100.00","6075.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3102.30","38.3","","200.79","72.79","355.81","22","2511","6439.5","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","8100.00","6075.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","6237.00","77","","477.18","477.18","477.18","1 through 10","2511","6439.5","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","8100.00","6075.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3474.90","42.9","","1045.91","1045.91","1045.91","1 through 10","2511","6439.5","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","8100.00","6075.00","WELLPOINT [1015]","HB AMC WELLPOINT","5976.18","73.78","","1726.50","1726.50","1726.50","1 through 10","2511","6439.5","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8100.00","6075.00","AETNA [1001]","HB AMC AETNA HMO","5653.80","69.8","","915.80","263.76","2881.00","1 through 10","4233.06","6619.32","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8100.00","6075.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6619.32","81.72","","1531.57","410.52","8841.36","1 through 10","4233.06","6619.32","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.00","388.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","362.60","70","","134.04","134.04","134.04","1 through 10","160.58","411.81","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.00","388.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","411.81","79.5","","948.87","198.19","1805.30","1 through 10","160.58","411.81","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.00","388.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","276.09","53.3","","462.00","170.45","3253.37","1 through 10","160.58","411.81","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","189.07","36.5","","245.50","107.19","1371.45","1 through 10","160.58","411.81","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","198.39","38.3","","200.79","72.79","355.81","22","160.58","411.81","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.00","388.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","398.86","77","","477.18","477.18","477.18","1 through 10","160.58","411.81","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.22","42.9","","1045.91","1045.91","1045.91","1 through 10","160.58","411.81","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.00","388.50","WELLPOINT [1015]","HB AMC WELLPOINT","382.18","73.78","","1726.50","1726.50","1726.50","1 through 10","160.58","411.81","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","AETNA [1001]","HB AMC AETNA HMO","361.56","69.8","","915.80","263.76","2881.00","1 through 10","270.71","423.31","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","423.31","81.72","","1531.57","410.52","8841.36","1 through 10","270.71","423.31","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","823.10","52.26","","1113.10","1113.10","1113.10","1 through 10","488.25","1252.13","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1252.13","79.5","","1293.60","1148.53","1603.80","1 through 10","488.25","1252.13","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","574.88","36.5","","1023.42","771.29","2068.67","33","488.25","1252.13","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","603.23","38.3","","850.52","759.78","1211.25","66","488.25","1252.13","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","2548.09","2548.09","2548.09","1 through 10","488.25","1252.13","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","956.46","956.46","956.46","1 through 10","488.25","1252.13","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB AMC WELLPOINT","1162.04","73.78","","2344.73","1619.47","2530.35","16","488.25","1252.13","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA HMO","1099.35","69.8","","1523.63","988.41","4330.26","39","823.1","1287.09","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA PPO","1266.30","80.4","","1670.25","1670.25","1670.25","1 through 10","823.1","1287.09","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","823.10","52.26","","1113.10","1113.10","1113.10","1 through 10","823.1","1287.09","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1287.09","81.72","","1738.90","1484.65","2716.94","38","823.1","1287.09","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","823.10","52.26","","1113.10","1113.10","1113.10","1 through 10","488.25","1252.13","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1252.13","79.5","","1293.60","1148.53","1603.80","1 through 10","488.25","1252.13","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","574.88","36.5","","1023.42","771.29","2068.67","33","488.25","1252.13","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","603.23","38.3","","850.52","759.78","1211.25","66","488.25","1252.13","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","2548.09","2548.09","2548.09","1 through 10","488.25","1252.13","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","956.46","956.46","956.46","1 through 10","488.25","1252.13","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB AMC WELLPOINT","1162.04","73.78","","2344.73","1619.47","2530.35","16","488.25","1252.13","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA HMO","1099.35","69.8","","1523.63","988.41","4330.26","39","823.1","1287.09","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA PPO","1266.30","80.4","","1670.25","1670.25","1670.25","1 through 10","823.1","1287.09","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","823.10","52.26","","1113.10","1113.10","1113.10","1 through 10","823.1","1287.09","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1287.09","81.72","","1738.90","1484.65","2716.94","38","823.1","1287.09","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","832.24","52.26","","1113.10","1113.10","1113.10","1 through 10","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1266.04","79.5","","1293.60","1148.53","1603.80","1 through 10","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","581.26","36.5","","1023.42","771.29","2068.67","33","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","609.93","38.3","","850.52","759.78","1211.25","66","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","683.18","42.9","","2548.09","2548.09","2548.09","1 through 10","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","683.18","42.9","","956.46","956.46","956.46","1 through 10","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","WELLPOINT [1015]","HB AMC WELLPOINT","1174.95","73.78","","2344.73","1619.47","2530.35","16","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1592.50","1194.37","AETNA [1001]","HB AMC AETNA HMO","1111.57","69.8","","1523.63","988.41","4330.26","39","832.24","1301.39","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1592.50","1194.37","AETNA [1001]","HB AMC AETNA PPO","1280.37","80.4","","1670.25","1670.25","1670.25","1 through 10","832.24","1301.39","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1592.50","1194.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","832.24","52.26","","1113.10","1113.10","1113.10","1 through 10","832.24","1301.39","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1592.50","1194.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1301.39","81.72","","1738.90","1484.65","2716.94","38","832.24","1301.39","percent of total billed charges",""
"PATELLA IMPLANT 35MM POROUS ROUND","SUP-ITM-10289210","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","832.24","52.26","","1113.10","1113.10","1113.10","1 through 10","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 35MM POROUS ROUND","SUP-ITM-10289210","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1266.04","79.5","","1293.60","1148.53","1603.80","1 through 10","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 35MM POROUS ROUND","SUP-ITM-10289210","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","581.26","36.5","","1023.42","771.29","2068.67","33","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 35MM POROUS ROUND","SUP-ITM-10289210","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","609.93","38.3","","850.52","759.78","1211.25","66","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 35MM POROUS ROUND","SUP-ITM-10289210","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","683.18","42.9","","2548.09","2548.09","2548.09","1 through 10","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 35MM POROUS ROUND","SUP-ITM-10289210","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","683.18","42.9","","956.46","956.46","956.46","1 through 10","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 35MM POROUS ROUND","SUP-ITM-10289210","CDM","C1776","HCPCS","0278","RC","","","","both","","","1592.50","1194.37","WELLPOINT [1015]","HB AMC WELLPOINT","1174.95","73.78","","2344.73","1619.47","2530.35","16","493.68","1266.04","percent of total billed charges",""
"PATELLA IMPLANT 35MM POROUS ROUND","SUP-ITM-10289210","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1592.50","1194.37","AETNA [1001]","HB AMC AETNA HMO","1111.57","69.8","","1523.63","988.41","4330.26","39","832.24","1301.39","percent of total billed charges",""
"PATELLA IMPLANT 35MM POROUS ROUND","SUP-ITM-10289210","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1592.50","1194.37","AETNA [1001]","HB AMC AETNA PPO","1280.37","80.4","","1670.25","1670.25","1670.25","1 through 10","832.24","1301.39","percent of total billed charges",""
"PATELLA IMPLANT 35MM POROUS ROUND","SUP-ITM-10289210","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1592.50","1194.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","832.24","52.26","","1113.10","1113.10","1113.10","1 through 10","832.24","1301.39","percent of total billed charges",""
"PATELLA IMPLANT 35MM POROUS ROUND","SUP-ITM-10289210","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1592.50","1194.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1301.39","81.72","","1738.90","1484.65","2716.94","38","832.24","1301.39","percent of total billed charges",""
"PATELLA IMPLANT LG PCA PRIMARY REVISION DURATION ALL POLY LG","SUP-ITM-10014172","CDM","C1776","HCPCS","0278","RC","","","","both","","","4294.50","3220.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2244.31","52.26","","1113.10","1113.10","1113.10","1 through 10","1331.3","3414.13","percent of total billed charges",""
"PATELLA IMPLANT LG PCA PRIMARY REVISION DURATION ALL POLY LG","SUP-ITM-10014172","CDM","C1776","HCPCS","0278","RC","","","","both","","","4294.50","3220.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3414.13","79.5","","1293.60","1148.53","1603.80","1 through 10","1331.3","3414.13","percent of total billed charges",""
"PATELLA IMPLANT LG PCA PRIMARY REVISION DURATION ALL POLY LG","SUP-ITM-10014172","CDM","C1776","HCPCS","0278","RC","","","","both","","","4294.50","3220.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1567.49","36.5","","1023.42","771.29","2068.67","33","1331.3","3414.13","percent of total billed charges",""
"PATELLA IMPLANT LG PCA PRIMARY REVISION DURATION ALL POLY LG","SUP-ITM-10014172","CDM","C1776","HCPCS","0278","RC","","","","both","","","4294.50","3220.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1644.79","38.3","","850.52","759.78","1211.25","66","1331.3","3414.13","percent of total billed charges",""
"PATELLA IMPLANT LG PCA PRIMARY REVISION DURATION ALL POLY LG","SUP-ITM-10014172","CDM","C1776","HCPCS","0278","RC","","","","both","","","4294.50","3220.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1842.34","42.9","","2548.09","2548.09","2548.09","1 through 10","1331.3","3414.13","percent of total billed charges",""
"PATELLA IMPLANT LG PCA PRIMARY REVISION DURATION ALL POLY LG","SUP-ITM-10014172","CDM","C1776","HCPCS","0278","RC","","","","both","","","4294.50","3220.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1842.34","42.9","","956.46","956.46","956.46","1 through 10","1331.3","3414.13","percent of total billed charges",""
"PATELLA IMPLANT LG PCA PRIMARY REVISION DURATION ALL POLY LG","SUP-ITM-10014172","CDM","C1776","HCPCS","0278","RC","","","","both","","","4294.50","3220.87","WELLPOINT [1015]","HB AMC WELLPOINT","3168.48","73.78","","2344.73","1619.47","2530.35","16","1331.3","3414.13","percent of total billed charges",""
"PATELLA IMPLANT LG PCA PRIMARY REVISION DURATION ALL POLY LG","SUP-ITM-10014172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4294.50","3220.87","AETNA [1001]","HB AMC AETNA HMO","2997.56","69.8","","1523.63","988.41","4330.26","39","2244.31","3509.47","percent of total billed charges",""
"PATELLA IMPLANT LG PCA PRIMARY REVISION DURATION ALL POLY LG","SUP-ITM-10014172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4294.50","3220.87","AETNA [1001]","HB AMC AETNA PPO","3452.78","80.4","","1670.25","1670.25","1670.25","1 through 10","2244.31","3509.47","percent of total billed charges",""
"PATELLA IMPLANT LG PCA PRIMARY REVISION DURATION ALL POLY LG","SUP-ITM-10014172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4294.50","3220.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2244.31","52.26","","1113.10","1113.10","1113.10","1 through 10","2244.31","3509.47","percent of total billed charges",""
"PATELLA IMPLANT LG PCA PRIMARY REVISION DURATION ALL POLY LG","SUP-ITM-10014172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4294.50","3220.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3509.47","81.72","","1738.90","1484.65","2716.94","38","2244.31","3509.47","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3885.81","79.5","","800.18","480.96","1887.97","195","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2605.20","53.3","","813.12","216.42","1444.50","81","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1515.22","31","","432.60","432.60","432.60","1 through 10","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1784.05","36.5","","148.37","54.89","631.39","94","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1872.03","38.3","","279.30","91.72","1116.77","266","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.87","42.9","","731.00","63.70","731.00","1 through 10","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.87","42.9","","384.74","384.74","384.74","1 through 10","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","WELLPOINT [1015]","HB AMC WELLPOINT","3606.23","73.78","","286.63","119.22","1107.45","105","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","AETNA [1001]","HB AMC AETNA HMO","3411.69","69.8","","675.31","184.75","1721.50","286","2554.37","3994.32","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","AETNA [1001]","HB AMC AETNA PPO","3929.80","80.4","","1261.44","103.12","1514.10","21","2554.37","3994.32","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3929.80","80.4","","1365.00","1365.00","1365.00","1 through 10","2554.37","3994.32","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3994.32","81.72","","5157.68","5157.68","5157.68","1 through 10","2554.37","3994.32","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3994.32","81.72","","431.26","71.26","1459.57","88","2554.37","3994.32","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3885.81","79.5","","800.18","480.96","1887.97","195","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2605.20","53.3","","813.12","216.42","1444.50","81","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1515.22","31","","432.60","432.60","432.60","1 through 10","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1784.05","36.5","","148.37","54.89","631.39","94","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1872.03","38.3","","279.30","91.72","1116.77","266","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.87","42.9","","731.00","63.70","731.00","1 through 10","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2096.87","42.9","","384.74","384.74","384.74","1 through 10","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4887.81","3665.86","WELLPOINT [1015]","HB AMC WELLPOINT","3606.23","73.78","","286.63","119.22","1107.45","105","1515.22","3885.81","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","AETNA [1001]","HB AMC AETNA HMO","3411.69","69.8","","675.31","184.75","1721.50","286","2554.37","3994.32","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","AETNA [1001]","HB AMC AETNA PPO","3929.80","80.4","","1261.44","103.12","1514.10","21","2554.37","3994.32","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3929.80","80.4","","1365.00","1365.00","1365.00","1 through 10","2554.37","3994.32","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3994.32","81.72","","5157.68","5157.68","5157.68","1 through 10","2554.37","3994.32","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4887.81","3665.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3994.32","81.72","","431.26","71.26","1459.57","88","2554.37","3994.32","percent of total billed charges",""
"Pathfindertg-L34864","PX-31000846","CDM","81479","CPT","0310","RC","","","","both","","","8254.00","6190.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6561.93","79.5","","0.65","0.65","0.65","1 through 10","2558.74","7841.3","percent of total billed charges",""
"Pathfindertg-L34864","PX-31000846","CDM","81479","CPT","0310","RC","","","","both","","","8254.00","6190.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4399.38","53.3","","0.79","0.79","0.79","1 through 10","2558.74","7841.3","percent of total billed charges",""
"Pathfindertg-L34864","PX-31000846","CDM","81479","CPT","0310","RC","","","","outpatient","","","8254.00","6190.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4127.00","50","","1.00","1.00","1.00","1 through 10","156.55","6809.55","percent of total billed charges",""
"Pathfindertg-L34864","PX-31000846","CDM","81479","CPT","0310","RC","","","","outpatient","","","8254.00","6190.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4333.35","52.5","","1.00","0.53","1.00","1 through 10","156.55","6809.55","percent of total billed charges",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","62599.69","46949.77","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10050.09","","Case rate ($9,757.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,668.53, add-ons for qualifying new technology services are included. If operating cost exceeds $57,312.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,267.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,550.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,288.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.19. The transfer capital threshold is the transfer adjustment factor * $827.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10289.39","10289.39","10289.39","1 through 10","9562.22","16102.59","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","62599.69","46949.77","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12550.26","","Case rate ($12,550.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,668.53, add-ons for qualifying new technology services are included. If operating cost exceeds $57,312.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,267.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $11,343.23 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,288.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.19. The transfer capital threshold is the transfer adjustment factor * $827.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12664.67","10838.93","24511.69","1 through 10","9562.22","16102.59","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","62599.69","46949.77","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","","65.6","","62049.05","62049.05","62049.05","1 through 10","9562.22","16102.59","percent of total billed charges",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","62599.69","46949.77","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9757.37","","Case rate ($9,757.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,668.53, add-ons for qualifying new technology services are included. If operating cost exceeds $57,312.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,267.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,550.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,288.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.19. The transfer capital threshold is the transfer adjustment factor * $827.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9743.15","9743.15","9743.15","1 through 10","9562.22","16102.59","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","62599.69","46949.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","","65","","18616.40","18616.40","18616.40","1 through 10","9562.22","16102.59","percent of total billed charges",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","62599.69","46949.77","MEDICARE [2001]","HB BWH MEDICARE","12550.26","","Case rate ($12,550.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,668.53, add-ons for qualifying new technology services are included. If operating cost exceeds $57,312.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,267.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $11,343.23 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,288.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.19. The transfer capital threshold is the transfer adjustment factor * $827.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12785.40","0.03","12804.10","37","9562.22","16102.59","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","62599.69","46949.77","MOLINA [1014]","HB BWH MOLINA","9562.22","","Case rate ($9,757.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,668.53, add-ons for qualifying new technology services are included. If operating cost exceeds $57,312.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,267.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,550.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,288.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.19. The transfer capital threshold is the transfer adjustment factor * $827.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19691.80","19691.80","19691.80","1 through 10","9562.22","16102.59","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","62599.69","46949.77","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9562.22","","Case rate ($9,757.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,668.53, add-ons for qualifying new technology services are included. If operating cost exceeds $57,312.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,267.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,550.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,288.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.19. The transfer capital threshold is the transfer adjustment factor * $827.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9824.97","9824.97","9846.34","1 through 10","9562.22","16102.59","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","62599.69","46949.77","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9562.22","","Case rate ($9,757.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,668.53, add-ons for qualifying new technology services are included. If operating cost exceeds $57,312.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,267.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,550.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,288.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $827.19. The transfer capital threshold is the transfer adjustment factor * $827.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9838.05","9709.64","16465.45","1 through 10","9562.22","16102.59","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","102429.64","76822.23","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","21293.30","","Case rate ($21,293.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,778.16, add-ons for qualifying new technology services are included. If operating cost exceeds $65,422.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,492.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,398.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.43. The transfer capital threshold is the transfer adjustment factor * $1,421.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22027.35","22027.35","22027.35","1 through 10","16164.16","27670.46","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","102429.64","76822.23","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","16494.04","","Case rate ($16,494.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,778.16, add-ons for qualifying new technology services are included. If operating cost exceeds $65,422.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $14,692.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,398.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.43. The transfer capital threshold is the transfer adjustment factor * $1,421.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17014.88","17014.88","17014.88","1 through 10","16164.16","27670.46","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","102429.64","76822.23","MEDICARE [2001]","HB BWH MEDICARE","21293.30","","Case rate ($21,293.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,778.16, add-ons for qualifying new technology services are included. If operating cost exceeds $65,422.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $19,492.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,398.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.43. The transfer capital threshold is the transfer adjustment factor * $1,421.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22266.24","847.81","22299.12","37","16164.16","27670.46","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","102429.64","76822.23","MOLINA [1014]","HB BWH MOLINA","16164.16","","Case rate ($16,494.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,778.16, add-ons for qualifying new technology services are included. If operating cost exceeds $65,422.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $14,692.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,398.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.43. The transfer capital threshold is the transfer adjustment factor * $1,421.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","34089.68","34089.68","34089.68","1 through 10","16164.16","27670.46","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","102429.64","76822.23","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16164.16","","Case rate ($16,494.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,778.16, add-ons for qualifying new technology services are included. If operating cost exceeds $65,422.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $14,692.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,398.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.43. The transfer capital threshold is the transfer adjustment factor * $1,421.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11900.89","11900.89","11900.89","1 through 10","16164.16","27670.46","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","102429.64","76822.23","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","16164.16","","Case rate ($16,494.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,778.16, add-ons for qualifying new technology services are included. If operating cost exceeds $65,422.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $14,692.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,398.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.43. The transfer capital threshold is the transfer adjustment factor * $1,421.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","32337.30","32337.30","32337.30","1 through 10","16164.16","27670.46","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","102429.64","76822.23","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16164.16","","Case rate ($16,494.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,778.16, add-ons for qualifying new technology services are included. If operating cost exceeds $65,422.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $14,692.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,398.32 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.43. The transfer capital threshold is the transfer adjustment factor * $1,421.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16863.09","16309.19","21400.51","1 through 10","16164.16","27670.46","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC","544","MS-DRG","","","","","","","","inpatient","","","39138.27","29353.70","MARTIN'S POINT [160007]","HB BWH MEDICARE","7263.39","","Case rate ($7,263.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,666.26, add-ons for qualifying new technology services are included. If operating cost exceeds $54,310.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,047.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,276.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,286.43 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.20. The transfer capital threshold is the transfer adjustment factor * $607.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6994.81","6994.81","6994.81","1 through 10","7118.12","11820.05","other","Inpatient Replacement Plans DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC","544","MS-DRG","","","","","","","","inpatient","","","39138.27","29353.70","MEDICARE [2001]","HB BWH MEDICARE","7263.39","","Case rate ($7,263.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,666.26, add-ons for qualifying new technology services are included. If operating cost exceeds $54,310.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,047.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,276.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,286.43 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.20. The transfer capital threshold is the transfer adjustment factor * $607.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9200.66","9200.66","9200.66","1 through 10","7118.12","11820.05","other","Inpatient Replacement Plans DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC","544","MS-DRG","","","","","","","","inpatient","","","39138.27","29353.70","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7118.12","","Case rate ($7,263.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,666.26, add-ons for qualifying new technology services are included. If operating cost exceeds $54,310.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,047.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,276.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,286.43 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.20. The transfer capital threshold is the transfer adjustment factor * $607.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7045.04","7045.04","7045.04","1 through 10","7118.12","11820.05","other","Inpatient DRG"
"Patient Programmer Neurostimulator T1","PX-27000125","CDM","C1787","HCPCS","0270","RC","","","","both","","","3974.85","2981.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2118.60","53.3","","3163.82","3163.82","3163.82","1 through 10","1232.2","3160.01","percent of total billed charges",""
"Patient Programmer Neurostimulator T1","PX-27000125","CDM","C1787","HCPCS","0270","RC","","","","both","","","3974.85","2981.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1450.82","36.5","","1639.86","1566.60","1745.64","1 through 10","1232.2","3160.01","percent of total billed charges",""
"Patient Programmer Neurostimulator T1","PX-27000125","CDM","C1787","HCPCS","0270","RC","","","","both","","","3974.85","2981.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1522.37","38.3","","1642.20","1642.20","1642.20","1 through 10","1232.2","3160.01","percent of total billed charges",""
"Patient Programmer Neurostimulator T1","PX-27000125","CDM","C1787","HCPCS","0270","RC","","","","both","","","3974.85","2981.14","WELLPOINT [1015]","HB AMC WELLPOINT","2932.64","73.78","","2332.15","846.87","3126.90","1 through 10","1232.2","3160.01","percent of total billed charges",""
"Pcn G Benz Inj 1.2millu 2ml","PX-63600328","CDM","J0561","HCPCS","0636","RC","","","","both","","","51.95","38.96","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","29.41","","APC Price ($30.01). Final payment is multiplied by 98%.","26.52","26.52","26.52","24","16.1","49.44","other","OPPS APC"
"Pcn G Benz La Inj 100000u","PX-63600069","CDM","J0561","HCPCS","0636","RC","","","","both","","","51.95","38.96","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","29.41","","APC Price ($30.01). Final payment is multiplied by 98%.","26.52","26.52","26.52","24","16.1","49.44","other","OPPS APC"
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","both","","","446.56","334.92","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","156.30","35","","98.47","92.78","98.47","1 through 10","138.43","708.04","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","both","","","446.56","334.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","138.43","31","","413.97","137.99","413.97","1 through 10","138.43","708.04","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","both","","","446.56","334.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","162.99","36.5","","166.57","141.56","484.95","27","138.43","708.04","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","both","","","446.56","334.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","171.03","38.3","","174.60","169.69","339.38","91","138.43","708.04","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","446.56","334.92","AETNA [1001]","HB AMC AETNA HMO","311.70","69.8","","302.32","213.46","348.32","22","209.44","634.87","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","446.56","334.92","AETNA [1001]","HB AMC AETNA PPO","359.03","80.4","","348.32","348.32","348.32","1 through 10","209.44","634.87","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","446.56","334.92","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","233.37","52.26","","276.33","276.33","276.33","1 through 10","209.44","634.87","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","446.56","334.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","312.15","69.9","","309.47","309.47","928.41","13","209.44","634.87","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","446.56","334.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","209.44","46.9","","309.47","207.20","309.47","1 through 10","209.44","634.87","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","446.56","334.92","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","234.44","52.5","","280.89","236.23","280.89","1 through 10","209.44","634.87","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","446.56","334.92","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","223.28","50","","234.00","224.62","702.00","98","209.44","634.87","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","446.56","334.92","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","234.44","52.5","","245.61","236.23","736.83","30","209.44","634.87","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","446.56","334.92","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","279.10","62.5","","292.50","292.50","292.50","1 through 10","209.44","634.87","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","446.56","334.92","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","245.61","55","","247.39","189.09","278.56","12","209.44","634.87","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","446.56","334.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","364.93","81.72","","446.56","446.56","446.56","1 through 10","209.44","634.87","percent of total billed charges",""
"Pcv20 Vaccine for Intramuscular Use","PX-63601352","CDM","90677","CPT","0636","RC","","","","outpatient","","","446.56","334.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","364.93","81.72","","446.56","245.61","640.79","13","209.44","634.87","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","both","","","447.46","335.59","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","321.28","71.8","","963.84","321.28","963.84","1 through 10","138.71","425.09","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","both","","","447.46","335.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","355.73","79.5","","352.15","236.26","401.00","38","138.71","425.09","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","both","","","447.46","335.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","238.50","53.3","","236.26","236.26","472.52","31","138.71","425.09","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","both","","","447.46","335.59","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","156.61","35","","98.67","91.21","98.67","1 through 10","138.71","425.09","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","both","","","447.46","335.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","355.73","79.5","","352.15","352.15","352.15","1 through 10","138.71","425.09","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","both","","","447.46","335.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","163.32","36.5","","166.90","141.84","166.90","115","138.71","425.09","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","both","","","447.46","335.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","171.38","38.3","","174.96","174.96","174.96","354","138.71","425.09","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","both","","","447.46","335.59","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","344.54","77","","349.01","213.89","349.01","1 through 10","138.71","425.09","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","both","","","447.46","335.59","TRICARE [160005]","HB BWH TRICARE","425.09","95","","447.46","305.02","610.04","1 through 10","138.71","425.09","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","both","","","447.46","335.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","191.96","42.9","","704.96","704.96","704.96","1 through 10","138.71","425.09","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","both","","","447.46","335.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","191.96","42.9","","704.96","704.96","704.96","1 through 10","138.71","425.09","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","both","","","447.46","335.59","WELLPOINT [1015]","HB AMC WELLPOINT","330.14","73.78","","333.13","333.13","780.59","63","138.71","425.09","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","outpatient","","","447.46","335.59","AETNA [1001]","HB AMC AETNA HMO","312.33","69.8","","302.93","213.89","302.93","63","178.98","665.29","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","outpatient","","","447.46","335.59","AETNA [1001]","HB AMC AETNA PPO","359.76","80.4","","349.02","234.47","349.02","1 through 10","178.98","665.29","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","outpatient","","","447.46","335.59","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","233.84","52.26","","694.14","276.89","694.14","1 through 10","178.98","665.29","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","outpatient","","","447.46","335.59","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","234.92","52.5","","293.09","257.74","293.09","1 through 10","178.98","665.29","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","outpatient","","","447.46","335.59","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","223.73","50","","234.47","234.47","468.94","271","178.98","665.29","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","outpatient","","","447.46","335.59","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","234.92","52.5","","246.10","246.10","246.10","82","178.98","665.29","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","outpatient","","","447.46","335.59","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","279.66","62.5","","293.09","293.09","293.09","1 through 10","178.98","665.29","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","outpatient","","","447.46","335.59","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","234.92","52.5","","246.10","246.10","246.10","1 through 10","178.98","665.29","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","outpatient","","","447.46","335.59","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","246.10","55","","257.74","184.34","257.74","27","178.98","665.29","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","outpatient","","","447.46","335.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","365.66","81.72","","447.46","447.46","704.96","1 through 10","178.98","665.29","percent of total billed charges",""
"Pcv21 Vaccine for Intramuscular Use","PX-63601445","CDM","90684","CPT","0636","RC","","","","outpatient","","","447.46","335.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","365.66","81.72","","704.96","447.46","704.96","65","178.98","665.29","percent of total billed charges",""
"Pdt Dstr Prmlg Les Skn Illum/Activj by Phys/Qhp","PX-76002482","CDM","96573","CPT","0761","RC","","","","both","","","1559.00","1169.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","224.17","1239.41","other","OPPS APC"
"Pdt Dstr Prmlg Les Skn Illum/Activj by Phys/Qhp","PX-76002482","CDM","96573","CPT","0761","RC","","","","both","","","1559.00","1169.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","231.25","231.25","1 through 10","224.17","1239.41","other","OPPS APC"
"Pdt Dstr Prmlg Les Skn Illum/Activj by Phys/Qhp","PX-76002482","CDM","96573","CPT","0761","RC","","","","both","","","1559.00","1169.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","218.50","235.97","1 through 10","224.17","1239.41","other","OPPS APC"
"PEG AEQUALIS 30MM SM PERFORM GLENOID GED S30 SHOULDER 02 NC","SUP-ITM-10136203","CDM","C1776","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2263.90","52.26","","1113.10","1113.10","1113.10","1 through 10","1342.92","3443.94","percent of total billed charges",""
"PEG AEQUALIS 30MM SM PERFORM GLENOID GED S30 SHOULDER 02 NC","SUP-ITM-10136203","CDM","C1776","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3443.94","79.5","","1293.60","1148.53","1603.80","1 through 10","1342.92","3443.94","percent of total billed charges",""
"PEG AEQUALIS 30MM SM PERFORM GLENOID GED S30 SHOULDER 02 NC","SUP-ITM-10136203","CDM","C1776","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1581.18","36.5","","1023.42","771.29","2068.67","33","1342.92","3443.94","percent of total billed charges",""
"PEG AEQUALIS 30MM SM PERFORM GLENOID GED S30 SHOULDER 02 NC","SUP-ITM-10136203","CDM","C1776","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1659.16","38.3","","850.52","759.78","1211.25","66","1342.92","3443.94","percent of total billed charges",""
"PEG AEQUALIS 30MM SM PERFORM GLENOID GED S30 SHOULDER 02 NC","SUP-ITM-10136203","CDM","C1776","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1858.43","42.9","","2548.09","2548.09","2548.09","1 through 10","1342.92","3443.94","percent of total billed charges",""
"PEG AEQUALIS 30MM SM PERFORM GLENOID GED S30 SHOULDER 02 NC","SUP-ITM-10136203","CDM","C1776","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1858.43","42.9","","956.46","956.46","956.46","1 through 10","1342.92","3443.94","percent of total billed charges",""
"PEG AEQUALIS 30MM SM PERFORM GLENOID GED S30 SHOULDER 02 NC","SUP-ITM-10136203","CDM","C1776","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","WELLPOINT [1015]","HB AMC WELLPOINT","3196.15","73.78","","2344.73","1619.47","2530.35","16","1342.92","3443.94","percent of total billed charges",""
"PEG AEQUALIS 30MM SM PERFORM GLENOID GED S30 SHOULDER 02 NC","SUP-ITM-10136203","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4332.00","3249.00","AETNA [1001]","HB AMC AETNA HMO","3023.74","69.8","","1523.63","988.41","4330.26","39","2263.9","3540.11","percent of total billed charges",""
"PEG AEQUALIS 30MM SM PERFORM GLENOID GED S30 SHOULDER 02 NC","SUP-ITM-10136203","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4332.00","3249.00","AETNA [1001]","HB AMC AETNA PPO","3482.93","80.4","","1670.25","1670.25","1670.25","1 through 10","2263.9","3540.11","percent of total billed charges",""
"PEG AEQUALIS 30MM SM PERFORM GLENOID GED S30 SHOULDER 02 NC","SUP-ITM-10136203","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4332.00","3249.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2263.90","52.26","","1113.10","1113.10","1113.10","1 through 10","2263.9","3540.11","percent of total billed charges",""
"PEG AEQUALIS 30MM SM PERFORM GLENOID GED S30 SHOULDER 02 NC","SUP-ITM-10136203","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4332.00","3249.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3540.11","81.72","","1738.90","1484.65","2716.94","38","2263.9","3540.11","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1384.63","52.26","","1113.10","1113.10","1113.10","1 through 10","821.35","2106.35","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2106.35","79.5","","1293.60","1148.53","1603.80","1 through 10","821.35","2106.35","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","967.07","36.5","","1023.42","771.29","2068.67","33","821.35","2106.35","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1014.76","38.3","","850.52","759.78","1211.25","66","821.35","2106.35","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1136.64","42.9","","2548.09","2548.09","2548.09","1 through 10","821.35","2106.35","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1136.64","42.9","","956.46","956.46","956.46","1 through 10","821.35","2106.35","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","WELLPOINT [1015]","HB AMC WELLPOINT","1954.80","73.78","","2344.73","1619.47","2530.35","16","821.35","2106.35","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2649.50","1987.12","AETNA [1001]","HB AMC AETNA HMO","1849.35","69.8","","1523.63","988.41","4330.26","39","1384.63","2165.17","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2649.50","1987.12","AETNA [1001]","HB AMC AETNA PPO","2130.20","80.4","","1670.25","1670.25","1670.25","1 through 10","1384.63","2165.17","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2649.50","1987.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1384.63","52.26","","1113.10","1113.10","1113.10","1 through 10","1384.63","2165.17","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2649.50","1987.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2165.17","81.72","","1738.90","1484.65","2716.94","38","1384.63","2165.17","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","269.40","79.5","","800.18","480.96","1887.97","195","105.05","269.4","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","180.62","53.3","","813.12","216.42","1444.50","81","105.05","269.4","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","105.05","31","","432.60","432.60","432.60","1 through 10","105.05","269.4","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.69","36.5","","148.37","54.89","631.39","94","105.05","269.4","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","129.79","38.3","","279.30","91.72","1116.77","266","105.05","269.4","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.38","42.9","","731.00","63.70","731.00","1 through 10","105.05","269.4","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.38","42.9","","384.74","384.74","384.74","1 through 10","105.05","269.4","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","WELLPOINT [1015]","HB AMC WELLPOINT","250.02","73.78","","286.63","119.22","1107.45","105","105.05","269.4","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","AETNA [1001]","HB AMC AETNA HMO","236.53","69.8","","675.31","184.75","1721.50","286","177.09","276.92","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","AETNA [1001]","HB AMC AETNA PPO","272.45","80.4","","1261.44","103.12","1514.10","21","177.09","276.92","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","272.45","80.4","","1365.00","1365.00","1365.00","1 through 10","177.09","276.92","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","276.92","81.72","","5157.68","5157.68","5157.68","1 through 10","177.09","276.92","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","276.92","81.72","","431.26","71.26","1459.57","88","177.09","276.92","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","220.10","79.5","","800.18","480.96","1887.97","195","85.82","220.1","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.56","53.3","","813.12","216.42","1444.50","81","85.82","220.1","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.82","31","","432.60","432.60","432.60","1 through 10","85.82","220.1","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","101.05","36.5","","148.37","54.89","631.39","94","85.82","220.1","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","106.03","38.3","","279.30","91.72","1116.77","266","85.82","220.1","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.77","42.9","","731.00","63.70","731.00","1 through 10","85.82","220.1","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.77","42.9","","384.74","384.74","384.74","1 through 10","85.82","220.1","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","WELLPOINT [1015]","HB AMC WELLPOINT","204.26","73.78","","286.63","119.22","1107.45","105","85.82","220.1","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","AETNA [1001]","HB AMC AETNA HMO","193.24","69.8","","675.31","184.75","1721.50","286","144.68","226.24","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","AETNA [1001]","HB AMC AETNA PPO","222.59","80.4","","1261.44","103.12","1514.10","21","144.68","226.24","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","222.59","80.4","","1365.00","1365.00","1365.00","1 through 10","144.68","226.24","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","226.24","81.72","","5157.68","5157.68","5157.68","1 through 10","144.68","226.24","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","226.24","81.72","","431.26","71.26","1459.57","88","144.68","226.24","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","292.16","79.5","","800.18","480.96","1887.97","195","113.93","292.16","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","195.88","53.3","","813.12","216.42","1444.50","81","113.93","292.16","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","113.93","31","","432.60","432.60","432.60","1 through 10","113.93","292.16","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","134.14","36.5","","148.37","54.89","631.39","94","113.93","292.16","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","140.75","38.3","","279.30","91.72","1116.77","266","113.93","292.16","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.66","42.9","","731.00","63.70","731.00","1 through 10","113.93","292.16","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.66","42.9","","384.74","384.74","384.74","1 through 10","113.93","292.16","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","WELLPOINT [1015]","HB AMC WELLPOINT","271.14","73.78","","286.63","119.22","1107.45","105","113.93","292.16","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.50","275.62","AETNA [1001]","HB AMC AETNA HMO","256.52","69.8","","675.31","184.75","1721.50","286","192.06","300.32","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.50","275.62","AETNA [1001]","HB AMC AETNA PPO","295.47","80.4","","1261.44","103.12","1514.10","21","192.06","300.32","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.50","275.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","295.47","80.4","","1365.00","1365.00","1365.00","1 through 10","192.06","300.32","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.50","275.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","300.32","81.72","","5157.68","5157.68","5157.68","1 through 10","192.06","300.32","percent of total billed charges",""
"PEG BONE 16MM VOLAR THREADED","SUP-ITM-10074520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.50","275.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","300.32","81.72","","431.26","71.26","1459.57","88","192.06","300.32","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","269.40","79.5","","800.18","480.96","1887.97","195","105.05","269.4","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","180.62","53.3","","813.12","216.42","1444.50","81","105.05","269.4","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","105.05","31","","432.60","432.60","432.60","1 through 10","105.05","269.4","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.69","36.5","","148.37","54.89","631.39","94","105.05","269.4","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","129.79","38.3","","279.30","91.72","1116.77","266","105.05","269.4","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.38","42.9","","731.00","63.70","731.00","1 through 10","105.05","269.4","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.38","42.9","","384.74","384.74","384.74","1 through 10","105.05","269.4","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","WELLPOINT [1015]","HB AMC WELLPOINT","250.02","73.78","","286.63","119.22","1107.45","105","105.05","269.4","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","AETNA [1001]","HB AMC AETNA HMO","236.53","69.8","","675.31","184.75","1721.50","286","177.09","276.92","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","AETNA [1001]","HB AMC AETNA PPO","272.45","80.4","","1261.44","103.12","1514.10","21","177.09","276.92","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","272.45","80.4","","1365.00","1365.00","1365.00","1 through 10","177.09","276.92","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","276.92","81.72","","5157.68","5157.68","5157.68","1 through 10","177.09","276.92","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","276.92","81.72","","431.26","71.26","1459.57","88","177.09","276.92","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","319.99","79.5","","800.18","480.96","1887.97","195","124.78","319.99","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","214.53","53.3","","813.12","216.42","1444.50","81","124.78","319.99","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","124.78","31","","432.60","432.60","432.60","1 through 10","124.78","319.99","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","146.91","36.5","","148.37","54.89","631.39","94","124.78","319.99","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","154.16","38.3","","279.30","91.72","1116.77","266","124.78","319.99","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.67","42.9","","731.00","63.70","731.00","1 through 10","124.78","319.99","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.67","42.9","","384.74","384.74","384.74","1 through 10","124.78","319.99","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","WELLPOINT [1015]","HB AMC WELLPOINT","296.96","73.78","","286.63","119.22","1107.45","105","124.78","319.99","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","AETNA [1001]","HB AMC AETNA HMO","280.95","69.8","","675.31","184.75","1721.50","286","210.35","328.92","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","AETNA [1001]","HB AMC AETNA PPO","323.61","80.4","","1261.44","103.12","1514.10","21","210.35","328.92","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","323.61","80.4","","1365.00","1365.00","1365.00","1 through 10","210.35","328.92","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","328.92","81.72","","5157.68","5157.68","5157.68","1 through 10","210.35","328.92","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","328.92","81.72","","431.26","71.26","1459.57","88","210.35","328.92","percent of total billed charges",""
"PEG BONE 2.3X12MM TITANIUM THREADED LOCKING","SUP-ITM-10170013","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.50","291.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","308.86","79.5","","800.18","480.96","1887.97","195","120.44","308.86","percent of total billed charges",""
"PEG BONE 2.3X12MM TITANIUM THREADED LOCKING","SUP-ITM-10170013","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.50","291.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","207.07","53.3","","813.12","216.42","1444.50","81","120.44","308.86","percent of total billed charges",""
"PEG BONE 2.3X12MM TITANIUM THREADED LOCKING","SUP-ITM-10170013","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.50","291.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","120.44","31","","432.60","432.60","432.60","1 through 10","120.44","308.86","percent of total billed charges",""
"PEG BONE 2.3X12MM TITANIUM THREADED LOCKING","SUP-ITM-10170013","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.50","291.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","141.80","36.5","","148.37","54.89","631.39","94","120.44","308.86","percent of total billed charges",""
"PEG BONE 2.3X12MM TITANIUM THREADED LOCKING","SUP-ITM-10170013","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.50","291.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","148.80","38.3","","279.30","91.72","1116.77","266","120.44","308.86","percent of total billed charges",""
"PEG BONE 2.3X12MM TITANIUM THREADED LOCKING","SUP-ITM-10170013","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.50","291.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.67","42.9","","731.00","63.70","731.00","1 through 10","120.44","308.86","percent of total billed charges",""
"PEG BONE 2.3X12MM TITANIUM THREADED LOCKING","SUP-ITM-10170013","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.50","291.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.67","42.9","","384.74","384.74","384.74","1 through 10","120.44","308.86","percent of total billed charges",""
"PEG BONE 2.3X12MM TITANIUM THREADED LOCKING","SUP-ITM-10170013","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.50","291.37","WELLPOINT [1015]","HB AMC WELLPOINT","286.64","73.78","","286.63","119.22","1107.45","105","120.44","308.86","percent of total billed charges",""
"PEG BONE 2.3X12MM TITANIUM THREADED LOCKING","SUP-ITM-10170013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","388.50","291.37","AETNA [1001]","HB AMC AETNA HMO","271.17","69.8","","675.31","184.75","1721.50","286","203.03","317.48","percent of total billed charges",""
"PEG BONE 2.3X12MM TITANIUM THREADED LOCKING","SUP-ITM-10170013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","388.50","291.37","AETNA [1001]","HB AMC AETNA PPO","312.35","80.4","","1261.44","103.12","1514.10","21","203.03","317.48","percent of total billed charges",""
"PEG BONE 2.3X12MM TITANIUM THREADED LOCKING","SUP-ITM-10170013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","388.50","291.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","312.35","80.4","","1365.00","1365.00","1365.00","1 through 10","203.03","317.48","percent of total billed charges",""
"PEG BONE 2.3X12MM TITANIUM THREADED LOCKING","SUP-ITM-10170013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","388.50","291.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","317.48","81.72","","5157.68","5157.68","5157.68","1 through 10","203.03","317.48","percent of total billed charges",""
"PEG BONE 2.3X12MM TITANIUM THREADED LOCKING","SUP-ITM-10170013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","388.50","291.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","317.48","81.72","","431.26","71.26","1459.57","88","203.03","317.48","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","389.77","79.5","","800.18","480.96","1887.97","195","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","261.32","53.3","","813.12","216.42","1444.50","81","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","151.99","31","","432.60","432.60","432.60","1 through 10","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","178.95","36.5","","148.37","54.89","631.39","94","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.78","38.3","","279.30","91.72","1116.77","266","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","731.00","63.70","731.00","1 through 10","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","384.74","384.74","384.74","1 through 10","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","WELLPOINT [1015]","HB AMC WELLPOINT","361.73","73.78","","286.63","119.22","1107.45","105","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA HMO","342.22","69.8","","675.31","184.75","1721.50","286","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA PPO","394.19","80.4","","1261.44","103.12","1514.10","21","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","394.19","80.4","","1365.00","1365.00","1365.00","1 through 10","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","400.66","81.72","","5157.68","5157.68","5157.68","1 through 10","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","400.66","81.72","","431.26","71.26","1459.57","88","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","389.77","79.5","","800.18","480.96","1887.97","195","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","261.32","53.3","","813.12","216.42","1444.50","81","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","151.99","31","","432.60","432.60","432.60","1 through 10","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","178.95","36.5","","148.37","54.89","631.39","94","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.78","38.3","","279.30","91.72","1116.77","266","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","731.00","63.70","731.00","1 through 10","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","384.74","384.74","384.74","1 through 10","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","WELLPOINT [1015]","HB AMC WELLPOINT","361.73","73.78","","286.63","119.22","1107.45","105","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA HMO","342.22","69.8","","675.31","184.75","1721.50","286","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA PPO","394.19","80.4","","1261.44","103.12","1514.10","21","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","394.19","80.4","","1365.00","1365.00","1365.00","1 through 10","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","400.66","81.72","","5157.68","5157.68","5157.68","1 through 10","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","400.66","81.72","","431.26","71.26","1459.57","88","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","389.77","79.5","","800.18","480.96","1887.97","195","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","261.32","53.3","","813.12","216.42","1444.50","81","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","151.99","31","","432.60","432.60","432.60","1 through 10","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","178.95","36.5","","148.37","54.89","631.39","94","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.78","38.3","","279.30","91.72","1116.77","266","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","731.00","63.70","731.00","1 through 10","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","384.74","384.74","384.74","1 through 10","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","WELLPOINT [1015]","HB AMC WELLPOINT","361.73","73.78","","286.63","119.22","1107.45","105","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA HMO","342.22","69.8","","675.31","184.75","1721.50","286","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA PPO","394.19","80.4","","1261.44","103.12","1514.10","21","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","394.19","80.4","","1365.00","1365.00","1365.00","1 through 10","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","400.66","81.72","","5157.68","5157.68","5157.68","1 through 10","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","400.66","81.72","","431.26","71.26","1459.57","88","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","389.77","79.5","","800.18","480.96","1887.97","195","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","261.32","53.3","","813.12","216.42","1444.50","81","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","151.99","31","","432.60","432.60","432.60","1 through 10","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","178.95","36.5","","148.37","54.89","631.39","94","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.78","38.3","","279.30","91.72","1116.77","266","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","731.00","63.70","731.00","1 through 10","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","384.74","384.74","384.74","1 through 10","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","WELLPOINT [1015]","HB AMC WELLPOINT","361.73","73.78","","286.63","119.22","1107.45","105","151.99","389.77","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA HMO","342.22","69.8","","675.31","184.75","1721.50","286","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA PPO","394.19","80.4","","1261.44","103.12","1514.10","21","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","394.19","80.4","","1365.00","1365.00","1365.00","1 through 10","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","400.66","81.72","","5157.68","5157.68","5157.68","1 through 10","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","400.66","81.72","","431.26","71.26","1459.57","88","256.22","400.66","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","319.99","79.5","","800.18","480.96","1887.97","195","124.78","319.99","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","214.53","53.3","","813.12","216.42","1444.50","81","124.78","319.99","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","124.78","31","","432.60","432.60","432.60","1 through 10","124.78","319.99","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","146.91","36.5","","148.37","54.89","631.39","94","124.78","319.99","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","154.16","38.3","","279.30","91.72","1116.77","266","124.78","319.99","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.67","42.9","","731.00","63.70","731.00","1 through 10","124.78","319.99","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.67","42.9","","384.74","384.74","384.74","1 through 10","124.78","319.99","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","WELLPOINT [1015]","HB AMC WELLPOINT","296.96","73.78","","286.63","119.22","1107.45","105","124.78","319.99","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","AETNA [1001]","HB AMC AETNA HMO","280.95","69.8","","675.31","184.75","1721.50","286","210.35","328.92","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","AETNA [1001]","HB AMC AETNA PPO","323.61","80.4","","1261.44","103.12","1514.10","21","210.35","328.92","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","323.61","80.4","","1365.00","1365.00","1365.00","1 through 10","210.35","328.92","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","328.92","81.72","","5157.68","5157.68","5157.68","1 through 10","210.35","328.92","percent of total billed charges",""
"PEG BONE 2.7X18MM HIGH COMPRESSION LOCKING","SUP-ITM-10130551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","328.92","81.72","","431.26","71.26","1459.57","88","210.35","328.92","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","500.85","79.5","","800.18","480.96","1887.97","195","195.3","500.85","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","335.79","53.3","","813.12","216.42","1444.50","81","195.3","500.85","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","195.30","31","","432.60","432.60","432.60","1 through 10","195.3","500.85","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","229.95","36.5","","148.37","54.89","631.39","94","195.3","500.85","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","241.29","38.3","","279.30","91.72","1116.77","266","195.3","500.85","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","270.27","42.9","","731.00","63.70","731.00","1 through 10","195.3","500.85","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","270.27","42.9","","384.74","384.74","384.74","1 through 10","195.3","500.85","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","WELLPOINT [1015]","HB AMC WELLPOINT","464.81","73.78","","286.63","119.22","1107.45","105","195.3","500.85","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","AETNA [1001]","HB AMC AETNA HMO","439.74","69.8","","675.31","184.75","1721.50","286","329.24","514.84","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","AETNA [1001]","HB AMC AETNA PPO","506.52","80.4","","1261.44","103.12","1514.10","21","329.24","514.84","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","506.52","80.4","","1365.00","1365.00","1365.00","1 through 10","329.24","514.84","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","514.84","81.72","","5157.68","5157.68","5157.68","1 through 10","329.24","514.84","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","514.84","81.72","","431.26","71.26","1459.57","88","329.24","514.84","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","220.10","79.5","","800.18","480.96","1887.97","195","85.82","220.1","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.56","53.3","","813.12","216.42","1444.50","81","85.82","220.1","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.82","31","","432.60","432.60","432.60","1 through 10","85.82","220.1","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","101.05","36.5","","148.37","54.89","631.39","94","85.82","220.1","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","106.03","38.3","","279.30","91.72","1116.77","266","85.82","220.1","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.77","42.9","","731.00","63.70","731.00","1 through 10","85.82","220.1","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.77","42.9","","384.74","384.74","384.74","1 through 10","85.82","220.1","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","WELLPOINT [1015]","HB AMC WELLPOINT","204.26","73.78","","286.63","119.22","1107.45","105","85.82","220.1","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","AETNA [1001]","HB AMC AETNA HMO","193.24","69.8","","675.31","184.75","1721.50","286","144.68","226.24","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","AETNA [1001]","HB AMC AETNA PPO","222.59","80.4","","1261.44","103.12","1514.10","21","144.68","226.24","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","222.59","80.4","","1365.00","1365.00","1365.00","1 through 10","144.68","226.24","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","226.24","81.72","","5157.68","5157.68","5157.68","1 through 10","144.68","226.24","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","226.24","81.72","","431.26","71.26","1459.57","88","144.68","226.24","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1329.34","79.5","","800.18","480.96","1887.97","195","518.36","1329.34","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","891.25","53.3","","813.12","216.42","1444.50","81","518.36","1329.34","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","518.36","31","","432.60","432.60","432.60","1 through 10","518.36","1329.34","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","610.33","36.5","","148.37","54.89","631.39","94","518.36","1329.34","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","640.43","38.3","","279.30","91.72","1116.77","266","518.36","1329.34","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","717.34","42.9","","731.00","63.70","731.00","1 through 10","518.36","1329.34","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","717.34","42.9","","384.74","384.74","384.74","1 through 10","518.36","1329.34","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1672.13","1254.10","WELLPOINT [1015]","HB AMC WELLPOINT","1233.70","73.78","","286.63","119.22","1107.45","105","518.36","1329.34","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1672.13","1254.10","AETNA [1001]","HB AMC AETNA HMO","1167.15","69.8","","675.31","184.75","1721.50","286","873.86","1366.46","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1672.13","1254.10","AETNA [1001]","HB AMC AETNA PPO","1344.39","80.4","","1261.44","103.12","1514.10","21","873.86","1366.46","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1672.13","1254.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1344.39","80.4","","1365.00","1365.00","1365.00","1 through 10","873.86","1366.46","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1672.13","1254.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1366.46","81.72","","5157.68","5157.68","5157.68","1 through 10","873.86","1366.46","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1672.13","1254.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1366.46","81.72","","431.26","71.26","1459.57","88","873.86","1366.46","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","both","","","2504.31","1878.23","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1642.83","65.6","","0.96","0.96","0.96","1 through 10","776.34","1990.93","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","both","","","2504.31","1878.23","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1753.02","70","","4.45","1.98","14.99","1 through 10","776.34","1990.93","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","both","","","2504.31","1878.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1990.93","79.5","","414.25","7.38","1891.33","1713","776.34","1990.93","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","both","","","2504.31","1878.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1334.80","53.3","","6.50","1.93","26.16","91","776.34","1990.93","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","both","","","2504.31","1878.23","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1928.32","77","","4.84","4.84","4.84","1 through 10","776.34","1990.93","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","both","","","2504.31","1878.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1627.80","65","","11.15","6.10","14.62","1 through 10","776.34","1990.93","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","both","","","2504.31","1878.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1990.93","79.5","","0.59","0.59","1.48","1 through 10","776.34","1990.93","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","both","","","2504.31","1878.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","776.34","31","","0.83","0.83","0.83","1 through 10","776.34","1990.93","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","both","","","2504.31","1878.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","914.07","36.5","","2.33","0.78","11.19","64","776.34","1990.93","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","both","","","2504.31","1878.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","959.15","38.3","","3.61","0.89","16.20","213","776.34","1990.93","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","both","","","2504.31","1878.23","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1928.32","77","","9.22","3.56","12.86","1 through 10","776.34","1990.93","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","both","","","2504.31","1878.23","WELLPOINT [1015]","HB AMC WELLPOINT","1847.68","73.78","","5.23","1.33","24.91","47","776.34","1990.93","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2504.31","1878.23","AETNA [1001]","HB AMC AETNA HMO","1748.01","69.8","","6.04","1.31","22.28","143","1252.16","2066.06","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2504.31","1878.23","AETNA [1001]","HB AMC AETNA PPO","2013.47","80.4","","4.95","1.52","30.51","1 through 10","1252.16","2066.06","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2504.31","1878.23","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1314.76","52.5","","533.60","0.69","533.60","1 through 10","1252.16","2066.06","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2504.31","1878.23","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1252.16","50","","4.92","1.04","22.14","217","1252.16","2066.06","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2504.31","1878.23","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1314.76","52.5","","11.25","1.46","33.02","97","1252.16","2066.06","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2504.31","1878.23","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1565.19","62.5","","4.81","4.81","4.81","1 through 10","1252.16","2066.06","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2504.31","1878.23","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1377.37","55","","9.85","1.05","154.76","17","1252.16","2066.06","percent of total billed charges",""
"Peginterferon Alfa-2a 180mcg/Ml 1ml","PX-63600200","CDM","J3490","HCPCS","0636","RC","","","","outpatient","","","2504.31","1878.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2013.47","80.4","","8.31","5.24","14.69","13","1252.16","2066.06","percent of total billed charges",""
"Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures,MODERATE","510","DRG","","","","","","","","inpatient","","","89713.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","49763.10","","Standard inlier is a Case rate ($49,763.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,345, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,064.17) for the length of stay and the standard reimbursement.","49763.09","49763.09","49763.09","1 through 10","16923.01","60647.63","case rate",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/McC","735","MS-DRG","","","","","","","","inpatient","","","112646.60","84484.95","MEDICARE [2001]","HB BWH MEDICARE","16309.11","","Case rate ($16,309.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,155.06, add-ons for qualifying new technology services are included. If operating cost exceeds $60,799.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,522.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $14,846.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,775.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,082.67. The transfer capital threshold is the transfer adjustment factor * $1,082.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14610.54","14610.54","14610.54","1 through 10","12400.56","18318.9649","other","Inpatient DRG"
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/McC","735","MS-DRG","","","","","","","","inpatient","","","112646.60","84484.95","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12400.56","","Case rate ($12,653.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,155.06, add-ons for qualifying new technology services are included. If operating cost exceeds $60,799.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,522.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $11,191.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,775.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,082.67. The transfer capital threshold is the transfer adjustment factor * $1,082.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11101.07","11101.07","11101.07","1 through 10","12400.56","18318.9649","other","Inpatient DRG"
"PELVIC PLATE 186.5MM 12 HOLE MATTA SS CURVED","SUP-ITM-10142492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.78","2869.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3041.50","79.5","","800.18","480.96","1887.97","195","1185.99","3041.5","percent of total billed charges",""
"PELVIC PLATE 186.5MM 12 HOLE MATTA SS CURVED","SUP-ITM-10142492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.78","2869.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2039.14","53.3","","813.12","216.42","1444.50","81","1185.99","3041.5","percent of total billed charges",""
"PELVIC PLATE 186.5MM 12 HOLE MATTA SS CURVED","SUP-ITM-10142492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.78","2869.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1185.99","31","","432.60","432.60","432.60","1 through 10","1185.99","3041.5","percent of total billed charges",""
"PELVIC PLATE 186.5MM 12 HOLE MATTA SS CURVED","SUP-ITM-10142492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.78","2869.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1396.41","36.5","","148.37","54.89","631.39","94","1185.99","3041.5","percent of total billed charges",""
"PELVIC PLATE 186.5MM 12 HOLE MATTA SS CURVED","SUP-ITM-10142492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.78","2869.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1465.27","38.3","","279.30","91.72","1116.77","266","1185.99","3041.5","percent of total billed charges",""
"PELVIC PLATE 186.5MM 12 HOLE MATTA SS CURVED","SUP-ITM-10142492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.78","2869.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1641.26","42.9","","731.00","63.70","731.00","1 through 10","1185.99","3041.5","percent of total billed charges",""
"PELVIC PLATE 186.5MM 12 HOLE MATTA SS CURVED","SUP-ITM-10142492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.78","2869.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1641.26","42.9","","384.74","384.74","384.74","1 through 10","1185.99","3041.5","percent of total billed charges",""
"PELVIC PLATE 186.5MM 12 HOLE MATTA SS CURVED","SUP-ITM-10142492","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.78","2869.33","WELLPOINT [1015]","HB AMC WELLPOINT","2822.66","73.78","","286.63","119.22","1107.45","105","1185.99","3041.5","percent of total billed charges",""
"PELVIC PLATE 186.5MM 12 HOLE MATTA SS CURVED","SUP-ITM-10142492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3825.78","2869.33","AETNA [1001]","HB AMC AETNA HMO","2670.39","69.8","","675.31","184.75","1721.50","286","1999.35","3126.43","percent of total billed charges",""
"PELVIC PLATE 186.5MM 12 HOLE MATTA SS CURVED","SUP-ITM-10142492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3825.78","2869.33","AETNA [1001]","HB AMC AETNA PPO","3075.93","80.4","","1261.44","103.12","1514.10","21","1999.35","3126.43","percent of total billed charges",""
"PELVIC PLATE 186.5MM 12 HOLE MATTA SS CURVED","SUP-ITM-10142492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3825.78","2869.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3075.93","80.4","","1365.00","1365.00","1365.00","1 through 10","1999.35","3126.43","percent of total billed charges",""
"PELVIC PLATE 186.5MM 12 HOLE MATTA SS CURVED","SUP-ITM-10142492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3825.78","2869.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3126.43","81.72","","5157.68","5157.68","5157.68","1 through 10","1999.35","3126.43","percent of total billed charges",""
"PELVIC PLATE 186.5MM 12 HOLE MATTA SS CURVED","SUP-ITM-10142492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3825.78","2869.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3126.43","81.72","","431.26","71.26","1459.57","88","1999.35","3126.43","percent of total billed charges",""
"PELVIC PLATE 3.5MM 31.5 2 HOLE STAINLESS SPRING","SUP-ITM-10036523","CDM","C1713","HCPCS","0278","RC","","","","both","","","1166.80","875.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","927.61","79.5","","800.18","480.96","1887.97","195","361.71","927.61","percent of total billed charges",""
"PELVIC PLATE 3.5MM 31.5 2 HOLE STAINLESS SPRING","SUP-ITM-10036523","CDM","C1713","HCPCS","0278","RC","","","","both","","","1166.80","875.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","621.90","53.3","","813.12","216.42","1444.50","81","361.71","927.61","percent of total billed charges",""
"PELVIC PLATE 3.5MM 31.5 2 HOLE STAINLESS SPRING","SUP-ITM-10036523","CDM","C1713","HCPCS","0278","RC","","","","both","","","1166.80","875.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","361.71","31","","432.60","432.60","432.60","1 through 10","361.71","927.61","percent of total billed charges",""
"PELVIC PLATE 3.5MM 31.5 2 HOLE STAINLESS SPRING","SUP-ITM-10036523","CDM","C1713","HCPCS","0278","RC","","","","both","","","1166.80","875.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","425.88","36.5","","148.37","54.89","631.39","94","361.71","927.61","percent of total billed charges",""
"PELVIC PLATE 3.5MM 31.5 2 HOLE STAINLESS SPRING","SUP-ITM-10036523","CDM","C1713","HCPCS","0278","RC","","","","both","","","1166.80","875.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","446.88","38.3","","279.30","91.72","1116.77","266","361.71","927.61","percent of total billed charges",""
"PELVIC PLATE 3.5MM 31.5 2 HOLE STAINLESS SPRING","SUP-ITM-10036523","CDM","C1713","HCPCS","0278","RC","","","","both","","","1166.80","875.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.56","42.9","","731.00","63.70","731.00","1 through 10","361.71","927.61","percent of total billed charges",""
"PELVIC PLATE 3.5MM 31.5 2 HOLE STAINLESS SPRING","SUP-ITM-10036523","CDM","C1713","HCPCS","0278","RC","","","","both","","","1166.80","875.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.56","42.9","","384.74","384.74","384.74","1 through 10","361.71","927.61","percent of total billed charges",""
"PELVIC PLATE 3.5MM 31.5 2 HOLE STAINLESS SPRING","SUP-ITM-10036523","CDM","C1713","HCPCS","0278","RC","","","","both","","","1166.80","875.10","WELLPOINT [1015]","HB AMC WELLPOINT","860.87","73.78","","286.63","119.22","1107.45","105","361.71","927.61","percent of total billed charges",""
"PELVIC PLATE 3.5MM 31.5 2 HOLE STAINLESS SPRING","SUP-ITM-10036523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1166.80","875.10","AETNA [1001]","HB AMC AETNA HMO","814.43","69.8","","675.31","184.75","1721.50","286","609.77","953.51","percent of total billed charges",""
"PELVIC PLATE 3.5MM 31.5 2 HOLE STAINLESS SPRING","SUP-ITM-10036523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1166.80","875.10","AETNA [1001]","HB AMC AETNA PPO","938.11","80.4","","1261.44","103.12","1514.10","21","609.77","953.51","percent of total billed charges",""
"PELVIC PLATE 3.5MM 31.5 2 HOLE STAINLESS SPRING","SUP-ITM-10036523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1166.80","875.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","938.11","80.4","","1365.00","1365.00","1365.00","1 through 10","609.77","953.51","percent of total billed charges",""
"PELVIC PLATE 3.5MM 31.5 2 HOLE STAINLESS SPRING","SUP-ITM-10036523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1166.80","875.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","953.51","81.72","","5157.68","5157.68","5157.68","1 through 10","609.77","953.51","percent of total billed charges",""
"PELVIC PLATE 3.5MM 31.5 2 HOLE STAINLESS SPRING","SUP-ITM-10036523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1166.80","875.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","953.51","81.72","","431.26","71.26","1459.57","88","609.77","953.51","percent of total billed charges",""
"PELVIC PLATE 3.5X104MM 8 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1420.62","1065.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1129.39","79.5","","800.18","480.96","1887.97","195","440.39","1129.39","percent of total billed charges",""
"PELVIC PLATE 3.5X104MM 8 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1420.62","1065.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","757.19","53.3","","813.12","216.42","1444.50","81","440.39","1129.39","percent of total billed charges",""
"PELVIC PLATE 3.5X104MM 8 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1420.62","1065.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","440.39","31","","432.60","432.60","432.60","1 through 10","440.39","1129.39","percent of total billed charges",""
"PELVIC PLATE 3.5X104MM 8 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1420.62","1065.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","518.53","36.5","","148.37","54.89","631.39","94","440.39","1129.39","percent of total billed charges",""
"PELVIC PLATE 3.5X104MM 8 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1420.62","1065.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","544.10","38.3","","279.30","91.72","1116.77","266","440.39","1129.39","percent of total billed charges",""
"PELVIC PLATE 3.5X104MM 8 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1420.62","1065.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","609.45","42.9","","731.00","63.70","731.00","1 through 10","440.39","1129.39","percent of total billed charges",""
"PELVIC PLATE 3.5X104MM 8 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1420.62","1065.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","609.45","42.9","","384.74","384.74","384.74","1 through 10","440.39","1129.39","percent of total billed charges",""
"PELVIC PLATE 3.5X104MM 8 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1420.62","1065.46","WELLPOINT [1015]","HB AMC WELLPOINT","1048.13","73.78","","286.63","119.22","1107.45","105","440.39","1129.39","percent of total billed charges",""
"PELVIC PLATE 3.5X104MM 8 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1420.62","1065.46","AETNA [1001]","HB AMC AETNA HMO","991.59","69.8","","675.31","184.75","1721.50","286","742.42","1160.93","percent of total billed charges",""
"PELVIC PLATE 3.5X104MM 8 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1420.62","1065.46","AETNA [1001]","HB AMC AETNA PPO","1142.18","80.4","","1261.44","103.12","1514.10","21","742.42","1160.93","percent of total billed charges",""
"PELVIC PLATE 3.5X104MM 8 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1420.62","1065.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1142.18","80.4","","1365.00","1365.00","1365.00","1 through 10","742.42","1160.93","percent of total billed charges",""
"PELVIC PLATE 3.5X104MM 8 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1420.62","1065.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1160.93","81.72","","5157.68","5157.68","5157.68","1 through 10","742.42","1160.93","percent of total billed charges",""
"PELVIC PLATE 3.5X104MM 8 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1420.62","1065.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1160.93","81.72","","431.26","71.26","1459.57","88","742.42","1160.93","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 14 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2640.51","1980.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2099.21","79.5","","800.18","480.96","1887.97","195","818.56","2099.21","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 14 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2640.51","1980.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1407.39","53.3","","813.12","216.42","1444.50","81","818.56","2099.21","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 14 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2640.51","1980.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","818.56","31","","432.60","432.60","432.60","1 through 10","818.56","2099.21","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 14 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2640.51","1980.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","963.79","36.5","","148.37","54.89","631.39","94","818.56","2099.21","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 14 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2640.51","1980.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1011.32","38.3","","279.30","91.72","1116.77","266","818.56","2099.21","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 14 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2640.51","1980.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1132.78","42.9","","731.00","63.70","731.00","1 through 10","818.56","2099.21","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 14 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2640.51","1980.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1132.78","42.9","","384.74","384.74","384.74","1 through 10","818.56","2099.21","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 14 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2640.51","1980.38","WELLPOINT [1015]","HB AMC WELLPOINT","1948.17","73.78","","286.63","119.22","1107.45","105","818.56","2099.21","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 14 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2640.51","1980.38","AETNA [1001]","HB AMC AETNA HMO","1843.08","69.8","","675.31","184.75","1721.50","286","1379.93","2157.82","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 14 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2640.51","1980.38","AETNA [1001]","HB AMC AETNA PPO","2122.97","80.4","","1261.44","103.12","1514.10","21","1379.93","2157.82","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 14 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2640.51","1980.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2122.97","80.4","","1365.00","1365.00","1365.00","1 through 10","1379.93","2157.82","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 14 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2640.51","1980.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2157.82","81.72","","5157.68","5157.68","5157.68","1 through 10","1379.93","2157.82","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 14 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2640.51","1980.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2157.82","81.72","","431.26","71.26","1459.57","88","1379.93","2157.82","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 8 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038107","CDM","C1713","HCPCS","0278","RC","","","","both","","","2145.82","1609.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1705.93","79.5","","800.18","480.96","1887.97","195","665.2","1705.93","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 8 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038107","CDM","C1713","HCPCS","0278","RC","","","","both","","","2145.82","1609.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1143.72","53.3","","813.12","216.42","1444.50","81","665.2","1705.93","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 8 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038107","CDM","C1713","HCPCS","0278","RC","","","","both","","","2145.82","1609.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","665.20","31","","432.60","432.60","432.60","1 through 10","665.2","1705.93","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 8 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038107","CDM","C1713","HCPCS","0278","RC","","","","both","","","2145.82","1609.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","783.22","36.5","","148.37","54.89","631.39","94","665.2","1705.93","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 8 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038107","CDM","C1713","HCPCS","0278","RC","","","","both","","","2145.82","1609.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","821.85","38.3","","279.30","91.72","1116.77","266","665.2","1705.93","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 8 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038107","CDM","C1713","HCPCS","0278","RC","","","","both","","","2145.82","1609.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","920.56","42.9","","731.00","63.70","731.00","1 through 10","665.2","1705.93","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 8 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038107","CDM","C1713","HCPCS","0278","RC","","","","both","","","2145.82","1609.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","920.56","42.9","","384.74","384.74","384.74","1 through 10","665.2","1705.93","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 8 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038107","CDM","C1713","HCPCS","0278","RC","","","","both","","","2145.82","1609.36","WELLPOINT [1015]","HB AMC WELLPOINT","1583.19","73.78","","286.63","119.22","1107.45","105","665.2","1705.93","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 8 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2145.82","1609.36","AETNA [1001]","HB AMC AETNA HMO","1497.78","69.8","","675.31","184.75","1721.50","286","1121.41","1753.56","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 8 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2145.82","1609.36","AETNA [1001]","HB AMC AETNA PPO","1725.24","80.4","","1261.44","103.12","1514.10","21","1121.41","1753.56","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 8 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2145.82","1609.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1725.24","80.4","","1365.00","1365.00","1365.00","1 through 10","1121.41","1753.56","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 8 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2145.82","1609.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1753.56","81.72","","5157.68","5157.68","5157.68","1 through 10","1121.41","1753.56","percent of total billed charges",""
"PELVIC PLATE 3.5X108MM 8 HOLE SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2145.82","1609.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1753.56","81.72","","431.26","71.26","1459.57","88","1121.41","1753.56","percent of total billed charges",""
"PELVIC PLATE 3.5X117MM 9 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1456.88","1092.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1158.22","79.5","","800.18","480.96","1887.97","195","451.63","1158.22","percent of total billed charges",""
"PELVIC PLATE 3.5X117MM 9 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1456.88","1092.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","776.52","53.3","","813.12","216.42","1444.50","81","451.63","1158.22","percent of total billed charges",""
"PELVIC PLATE 3.5X117MM 9 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1456.88","1092.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","451.63","31","","432.60","432.60","432.60","1 through 10","451.63","1158.22","percent of total billed charges",""
"PELVIC PLATE 3.5X117MM 9 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1456.88","1092.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","531.76","36.5","","148.37","54.89","631.39","94","451.63","1158.22","percent of total billed charges",""
"PELVIC PLATE 3.5X117MM 9 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1456.88","1092.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","557.99","38.3","","279.30","91.72","1116.77","266","451.63","1158.22","percent of total billed charges",""
"PELVIC PLATE 3.5X117MM 9 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1456.88","1092.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","625.00","42.9","","731.00","63.70","731.00","1 through 10","451.63","1158.22","percent of total billed charges",""
"PELVIC PLATE 3.5X117MM 9 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1456.88","1092.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","625.00","42.9","","384.74","384.74","384.74","1 through 10","451.63","1158.22","percent of total billed charges",""
"PELVIC PLATE 3.5X117MM 9 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1456.88","1092.66","WELLPOINT [1015]","HB AMC WELLPOINT","1074.89","73.78","","286.63","119.22","1107.45","105","451.63","1158.22","percent of total billed charges",""
"PELVIC PLATE 3.5X117MM 9 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1456.88","1092.66","AETNA [1001]","HB AMC AETNA HMO","1016.90","69.8","","675.31","184.75","1721.50","286","761.37","1190.56","percent of total billed charges",""
"PELVIC PLATE 3.5X117MM 9 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1456.88","1092.66","AETNA [1001]","HB AMC AETNA PPO","1171.33","80.4","","1261.44","103.12","1514.10","21","761.37","1190.56","percent of total billed charges",""
"PELVIC PLATE 3.5X117MM 9 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1456.88","1092.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1171.33","80.4","","1365.00","1365.00","1365.00","1 through 10","761.37","1190.56","percent of total billed charges",""
"PELVIC PLATE 3.5X117MM 9 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1456.88","1092.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1190.56","81.72","","5157.68","5157.68","5157.68","1 through 10","761.37","1190.56","percent of total billed charges",""
"PELVIC PLATE 3.5X117MM 9 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1456.88","1092.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1190.56","81.72","","431.26","71.26","1459.57","88","761.37","1190.56","percent of total billed charges",""
"PELVIC PLATE 3.5X130MM 10 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1462.06","1096.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1162.34","79.5","","800.18","480.96","1887.97","195","453.24","1162.34","percent of total billed charges",""
"PELVIC PLATE 3.5X130MM 10 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1462.06","1096.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","779.28","53.3","","813.12","216.42","1444.50","81","453.24","1162.34","percent of total billed charges",""
"PELVIC PLATE 3.5X130MM 10 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1462.06","1096.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","453.24","31","","432.60","432.60","432.60","1 through 10","453.24","1162.34","percent of total billed charges",""
"PELVIC PLATE 3.5X130MM 10 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1462.06","1096.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","533.65","36.5","","148.37","54.89","631.39","94","453.24","1162.34","percent of total billed charges",""
"PELVIC PLATE 3.5X130MM 10 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1462.06","1096.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","559.97","38.3","","279.30","91.72","1116.77","266","453.24","1162.34","percent of total billed charges",""
"PELVIC PLATE 3.5X130MM 10 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1462.06","1096.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","627.22","42.9","","731.00","63.70","731.00","1 through 10","453.24","1162.34","percent of total billed charges",""
"PELVIC PLATE 3.5X130MM 10 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1462.06","1096.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","627.22","42.9","","384.74","384.74","384.74","1 through 10","453.24","1162.34","percent of total billed charges",""
"PELVIC PLATE 3.5X130MM 10 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1462.06","1096.54","WELLPOINT [1015]","HB AMC WELLPOINT","1078.71","73.78","","286.63","119.22","1107.45","105","453.24","1162.34","percent of total billed charges",""
"PELVIC PLATE 3.5X130MM 10 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1462.06","1096.54","AETNA [1001]","HB AMC AETNA HMO","1020.52","69.8","","675.31","184.75","1721.50","286","764.07","1194.8","percent of total billed charges",""
"PELVIC PLATE 3.5X130MM 10 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1462.06","1096.54","AETNA [1001]","HB AMC AETNA PPO","1175.50","80.4","","1261.44","103.12","1514.10","21","764.07","1194.8","percent of total billed charges",""
"PELVIC PLATE 3.5X130MM 10 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1462.06","1096.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1175.50","80.4","","1365.00","1365.00","1365.00","1 through 10","764.07","1194.8","percent of total billed charges",""
"PELVIC PLATE 3.5X130MM 10 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1462.06","1096.54","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1194.80","81.72","","5157.68","5157.68","5157.68","1 through 10","764.07","1194.8","percent of total billed charges",""
"PELVIC PLATE 3.5X130MM 10 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1462.06","1096.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1194.80","81.72","","431.26","71.26","1459.57","88","764.07","1194.8","percent of total billed charges",""
"PELVIC PLATE 3.5X143MM 11 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038083","CDM","C1713","HCPCS","0278","RC","","","","both","","","1543.64","1157.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1227.19","79.5","","800.18","480.96","1887.97","195","478.53","1227.19","percent of total billed charges",""
"PELVIC PLATE 3.5X143MM 11 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038083","CDM","C1713","HCPCS","0278","RC","","","","both","","","1543.64","1157.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","822.76","53.3","","813.12","216.42","1444.50","81","478.53","1227.19","percent of total billed charges",""
"PELVIC PLATE 3.5X143MM 11 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038083","CDM","C1713","HCPCS","0278","RC","","","","both","","","1543.64","1157.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","478.53","31","","432.60","432.60","432.60","1 through 10","478.53","1227.19","percent of total billed charges",""
"PELVIC PLATE 3.5X143MM 11 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038083","CDM","C1713","HCPCS","0278","RC","","","","both","","","1543.64","1157.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","563.43","36.5","","148.37","54.89","631.39","94","478.53","1227.19","percent of total billed charges",""
"PELVIC PLATE 3.5X143MM 11 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038083","CDM","C1713","HCPCS","0278","RC","","","","both","","","1543.64","1157.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","591.21","38.3","","279.30","91.72","1116.77","266","478.53","1227.19","percent of total billed charges",""
"PELVIC PLATE 3.5X143MM 11 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038083","CDM","C1713","HCPCS","0278","RC","","","","both","","","1543.64","1157.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","662.22","42.9","","731.00","63.70","731.00","1 through 10","478.53","1227.19","percent of total billed charges",""
"PELVIC PLATE 3.5X143MM 11 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038083","CDM","C1713","HCPCS","0278","RC","","","","both","","","1543.64","1157.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","662.22","42.9","","384.74","384.74","384.74","1 through 10","478.53","1227.19","percent of total billed charges",""
"PELVIC PLATE 3.5X143MM 11 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038083","CDM","C1713","HCPCS","0278","RC","","","","both","","","1543.64","1157.73","WELLPOINT [1015]","HB AMC WELLPOINT","1138.90","73.78","","286.63","119.22","1107.45","105","478.53","1227.19","percent of total billed charges",""
"PELVIC PLATE 3.5X143MM 11 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1543.64","1157.73","AETNA [1001]","HB AMC AETNA HMO","1077.46","69.8","","675.31","184.75","1721.50","286","806.71","1261.46","percent of total billed charges",""
"PELVIC PLATE 3.5X143MM 11 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1543.64","1157.73","AETNA [1001]","HB AMC AETNA PPO","1241.09","80.4","","1261.44","103.12","1514.10","21","806.71","1261.46","percent of total billed charges",""
"PELVIC PLATE 3.5X143MM 11 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1543.64","1157.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1241.09","80.4","","1365.00","1365.00","1365.00","1 through 10","806.71","1261.46","percent of total billed charges",""
"PELVIC PLATE 3.5X143MM 11 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1543.64","1157.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1261.46","81.72","","5157.68","5157.68","5157.68","1 through 10","806.71","1261.46","percent of total billed charges",""
"PELVIC PLATE 3.5X143MM 11 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1543.64","1157.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1261.46","81.72","","431.26","71.26","1459.57","88","806.71","1261.46","percent of total billed charges",""
"PELVIC PLATE 3.5X169MM 13 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038085","CDM","C1713","HCPCS","0278","RC","","","","both","","","1682.21","1261.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1337.36","79.5","","800.18","480.96","1887.97","195","521.49","1337.36","percent of total billed charges",""
"PELVIC PLATE 3.5X169MM 13 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038085","CDM","C1713","HCPCS","0278","RC","","","","both","","","1682.21","1261.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","896.62","53.3","","813.12","216.42","1444.50","81","521.49","1337.36","percent of total billed charges",""
"PELVIC PLATE 3.5X169MM 13 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038085","CDM","C1713","HCPCS","0278","RC","","","","both","","","1682.21","1261.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","521.49","31","","432.60","432.60","432.60","1 through 10","521.49","1337.36","percent of total billed charges",""
"PELVIC PLATE 3.5X169MM 13 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038085","CDM","C1713","HCPCS","0278","RC","","","","both","","","1682.21","1261.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","614.01","36.5","","148.37","54.89","631.39","94","521.49","1337.36","percent of total billed charges",""
"PELVIC PLATE 3.5X169MM 13 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038085","CDM","C1713","HCPCS","0278","RC","","","","both","","","1682.21","1261.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","644.29","38.3","","279.30","91.72","1116.77","266","521.49","1337.36","percent of total billed charges",""
"PELVIC PLATE 3.5X169MM 13 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038085","CDM","C1713","HCPCS","0278","RC","","","","both","","","1682.21","1261.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","721.67","42.9","","731.00","63.70","731.00","1 through 10","521.49","1337.36","percent of total billed charges",""
"PELVIC PLATE 3.5X169MM 13 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038085","CDM","C1713","HCPCS","0278","RC","","","","both","","","1682.21","1261.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","721.67","42.9","","384.74","384.74","384.74","1 through 10","521.49","1337.36","percent of total billed charges",""
"PELVIC PLATE 3.5X169MM 13 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038085","CDM","C1713","HCPCS","0278","RC","","","","both","","","1682.21","1261.66","WELLPOINT [1015]","HB AMC WELLPOINT","1241.13","73.78","","286.63","119.22","1107.45","105","521.49","1337.36","percent of total billed charges",""
"PELVIC PLATE 3.5X169MM 13 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1682.21","1261.66","AETNA [1001]","HB AMC AETNA HMO","1174.18","69.8","","675.31","184.75","1721.50","286","879.12","1374.7","percent of total billed charges",""
"PELVIC PLATE 3.5X169MM 13 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1682.21","1261.66","AETNA [1001]","HB AMC AETNA PPO","1352.50","80.4","","1261.44","103.12","1514.10","21","879.12","1374.7","percent of total billed charges",""
"PELVIC PLATE 3.5X169MM 13 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1682.21","1261.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1352.50","80.4","","1365.00","1365.00","1365.00","1 through 10","879.12","1374.7","percent of total billed charges",""
"PELVIC PLATE 3.5X169MM 13 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1682.21","1261.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1374.70","81.72","","5157.68","5157.68","5157.68","1 through 10","879.12","1374.7","percent of total billed charges",""
"PELVIC PLATE 3.5X169MM 13 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1682.21","1261.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1374.70","81.72","","431.26","71.26","1459.57","88","879.12","1374.7","percent of total billed charges",""
"PELVIC PLATE 3.5X182MM 14 HOLE STAINLESS LOW PROFILE RECONSTRUCTION J SHAPE RIGHT","SUP-ITM-10038120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1959.34","1469.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1557.68","79.5","","800.18","480.96","1887.97","195","607.4","1557.68","percent of total billed charges",""
"PELVIC PLATE 3.5X182MM 14 HOLE STAINLESS LOW PROFILE RECONSTRUCTION J SHAPE RIGHT","SUP-ITM-10038120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1959.34","1469.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1044.33","53.3","","813.12","216.42","1444.50","81","607.4","1557.68","percent of total billed charges",""
"PELVIC PLATE 3.5X182MM 14 HOLE STAINLESS LOW PROFILE RECONSTRUCTION J SHAPE RIGHT","SUP-ITM-10038120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1959.34","1469.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","607.40","31","","432.60","432.60","432.60","1 through 10","607.4","1557.68","percent of total billed charges",""
"PELVIC PLATE 3.5X182MM 14 HOLE STAINLESS LOW PROFILE RECONSTRUCTION J SHAPE RIGHT","SUP-ITM-10038120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1959.34","1469.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","715.16","36.5","","148.37","54.89","631.39","94","607.4","1557.68","percent of total billed charges",""
"PELVIC PLATE 3.5X182MM 14 HOLE STAINLESS LOW PROFILE RECONSTRUCTION J SHAPE RIGHT","SUP-ITM-10038120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1959.34","1469.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","750.43","38.3","","279.30","91.72","1116.77","266","607.4","1557.68","percent of total billed charges",""
"PELVIC PLATE 3.5X182MM 14 HOLE STAINLESS LOW PROFILE RECONSTRUCTION J SHAPE RIGHT","SUP-ITM-10038120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1959.34","1469.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","840.56","42.9","","731.00","63.70","731.00","1 through 10","607.4","1557.68","percent of total billed charges",""
"PELVIC PLATE 3.5X182MM 14 HOLE STAINLESS LOW PROFILE RECONSTRUCTION J SHAPE RIGHT","SUP-ITM-10038120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1959.34","1469.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","840.56","42.9","","384.74","384.74","384.74","1 through 10","607.4","1557.68","percent of total billed charges",""
"PELVIC PLATE 3.5X182MM 14 HOLE STAINLESS LOW PROFILE RECONSTRUCTION J SHAPE RIGHT","SUP-ITM-10038120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1959.34","1469.50","WELLPOINT [1015]","HB AMC WELLPOINT","1445.60","73.78","","286.63","119.22","1107.45","105","607.4","1557.68","percent of total billed charges",""
"PELVIC PLATE 3.5X182MM 14 HOLE STAINLESS LOW PROFILE RECONSTRUCTION J SHAPE RIGHT","SUP-ITM-10038120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1959.34","1469.50","AETNA [1001]","HB AMC AETNA HMO","1367.62","69.8","","675.31","184.75","1721.50","286","1023.95","1601.17","percent of total billed charges",""
"PELVIC PLATE 3.5X182MM 14 HOLE STAINLESS LOW PROFILE RECONSTRUCTION J SHAPE RIGHT","SUP-ITM-10038120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1959.34","1469.50","AETNA [1001]","HB AMC AETNA PPO","1575.31","80.4","","1261.44","103.12","1514.10","21","1023.95","1601.17","percent of total billed charges",""
"PELVIC PLATE 3.5X182MM 14 HOLE STAINLESS LOW PROFILE RECONSTRUCTION J SHAPE RIGHT","SUP-ITM-10038120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1959.34","1469.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1575.31","80.4","","1365.00","1365.00","1365.00","1 through 10","1023.95","1601.17","percent of total billed charges",""
"PELVIC PLATE 3.5X182MM 14 HOLE STAINLESS LOW PROFILE RECONSTRUCTION J SHAPE RIGHT","SUP-ITM-10038120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1959.34","1469.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1601.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1023.95","1601.17","percent of total billed charges",""
"PELVIC PLATE 3.5X182MM 14 HOLE STAINLESS LOW PROFILE RECONSTRUCTION J SHAPE RIGHT","SUP-ITM-10038120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1959.34","1469.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1601.17","81.72","","431.26","71.26","1459.57","88","1023.95","1601.17","percent of total billed charges",""
"PELVIC PLATE 3.5X260MM 20 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2393.16","1794.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1902.56","79.5","","800.18","480.96","1887.97","195","741.88","1902.56","percent of total billed charges",""
"PELVIC PLATE 3.5X260MM 20 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2393.16","1794.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1275.55","53.3","","813.12","216.42","1444.50","81","741.88","1902.56","percent of total billed charges",""
"PELVIC PLATE 3.5X260MM 20 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2393.16","1794.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","741.88","31","","432.60","432.60","432.60","1 through 10","741.88","1902.56","percent of total billed charges",""
"PELVIC PLATE 3.5X260MM 20 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2393.16","1794.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","873.50","36.5","","148.37","54.89","631.39","94","741.88","1902.56","percent of total billed charges",""
"PELVIC PLATE 3.5X260MM 20 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2393.16","1794.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","916.58","38.3","","279.30","91.72","1116.77","266","741.88","1902.56","percent of total billed charges",""
"PELVIC PLATE 3.5X260MM 20 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2393.16","1794.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1026.67","42.9","","731.00","63.70","731.00","1 through 10","741.88","1902.56","percent of total billed charges",""
"PELVIC PLATE 3.5X260MM 20 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2393.16","1794.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1026.67","42.9","","384.74","384.74","384.74","1 through 10","741.88","1902.56","percent of total billed charges",""
"PELVIC PLATE 3.5X260MM 20 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2393.16","1794.87","WELLPOINT [1015]","HB AMC WELLPOINT","1765.67","73.78","","286.63","119.22","1107.45","105","741.88","1902.56","percent of total billed charges",""
"PELVIC PLATE 3.5X260MM 20 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2393.16","1794.87","AETNA [1001]","HB AMC AETNA HMO","1670.43","69.8","","675.31","184.75","1721.50","286","1250.67","1955.69","percent of total billed charges",""
"PELVIC PLATE 3.5X260MM 20 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2393.16","1794.87","AETNA [1001]","HB AMC AETNA PPO","1924.10","80.4","","1261.44","103.12","1514.10","21","1250.67","1955.69","percent of total billed charges",""
"PELVIC PLATE 3.5X260MM 20 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2393.16","1794.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1924.10","80.4","","1365.00","1365.00","1365.00","1 through 10","1250.67","1955.69","percent of total billed charges",""
"PELVIC PLATE 3.5X260MM 20 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2393.16","1794.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1955.69","81.72","","5157.68","5157.68","5157.68","1 through 10","1250.67","1955.69","percent of total billed charges",""
"PELVIC PLATE 3.5X260MM 20 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2393.16","1794.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1955.69","81.72","","431.26","71.26","1459.57","88","1250.67","1955.69","percent of total billed charges",""
"PELVIC PLATE 3.5X78MM 6 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1300.18","975.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1033.64","79.5","","800.18","480.96","1887.97","195","403.06","1033.64","percent of total billed charges",""
"PELVIC PLATE 3.5X78MM 6 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1300.18","975.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","693.00","53.3","","813.12","216.42","1444.50","81","403.06","1033.64","percent of total billed charges",""
"PELVIC PLATE 3.5X78MM 6 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1300.18","975.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","403.06","31","","432.60","432.60","432.60","1 through 10","403.06","1033.64","percent of total billed charges",""
"PELVIC PLATE 3.5X78MM 6 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1300.18","975.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","474.57","36.5","","148.37","54.89","631.39","94","403.06","1033.64","percent of total billed charges",""
"PELVIC PLATE 3.5X78MM 6 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1300.18","975.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","497.97","38.3","","279.30","91.72","1116.77","266","403.06","1033.64","percent of total billed charges",""
"PELVIC PLATE 3.5X78MM 6 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1300.18","975.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","557.78","42.9","","731.00","63.70","731.00","1 through 10","403.06","1033.64","percent of total billed charges",""
"PELVIC PLATE 3.5X78MM 6 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1300.18","975.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","557.78","42.9","","384.74","384.74","384.74","1 through 10","403.06","1033.64","percent of total billed charges",""
"PELVIC PLATE 3.5X78MM 6 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1300.18","975.13","WELLPOINT [1015]","HB AMC WELLPOINT","959.27","73.78","","286.63","119.22","1107.45","105","403.06","1033.64","percent of total billed charges",""
"PELVIC PLATE 3.5X78MM 6 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1300.18","975.13","AETNA [1001]","HB AMC AETNA HMO","907.53","69.8","","675.31","184.75","1721.50","286","679.47","1062.51","percent of total billed charges",""
"PELVIC PLATE 3.5X78MM 6 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1300.18","975.13","AETNA [1001]","HB AMC AETNA PPO","1045.34","80.4","","1261.44","103.12","1514.10","21","679.47","1062.51","percent of total billed charges",""
"PELVIC PLATE 3.5X78MM 6 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1300.18","975.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1045.34","80.4","","1365.00","1365.00","1365.00","1 through 10","679.47","1062.51","percent of total billed charges",""
"PELVIC PLATE 3.5X78MM 6 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1300.18","975.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1062.51","81.72","","5157.68","5157.68","5157.68","1 through 10","679.47","1062.51","percent of total billed charges",""
"PELVIC PLATE 3.5X78MM 6 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1300.18","975.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1062.51","81.72","","431.26","71.26","1459.57","88","679.47","1062.51","percent of total billed charges",""
"PELVIC PLATE 3.5X91MM 7 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1362.34","1021.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1083.06","79.5","","800.18","480.96","1887.97","195","422.33","1083.06","percent of total billed charges",""
"PELVIC PLATE 3.5X91MM 7 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1362.34","1021.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","726.13","53.3","","813.12","216.42","1444.50","81","422.33","1083.06","percent of total billed charges",""
"PELVIC PLATE 3.5X91MM 7 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1362.34","1021.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","422.33","31","","432.60","432.60","432.60","1 through 10","422.33","1083.06","percent of total billed charges",""
"PELVIC PLATE 3.5X91MM 7 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1362.34","1021.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","497.25","36.5","","148.37","54.89","631.39","94","422.33","1083.06","percent of total billed charges",""
"PELVIC PLATE 3.5X91MM 7 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1362.34","1021.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","521.78","38.3","","279.30","91.72","1116.77","266","422.33","1083.06","percent of total billed charges",""
"PELVIC PLATE 3.5X91MM 7 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1362.34","1021.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","584.44","42.9","","731.00","63.70","731.00","1 through 10","422.33","1083.06","percent of total billed charges",""
"PELVIC PLATE 3.5X91MM 7 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1362.34","1021.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","584.44","42.9","","384.74","384.74","384.74","1 through 10","422.33","1083.06","percent of total billed charges",""
"PELVIC PLATE 3.5X91MM 7 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1362.34","1021.75","WELLPOINT [1015]","HB AMC WELLPOINT","1005.13","73.78","","286.63","119.22","1107.45","105","422.33","1083.06","percent of total billed charges",""
"PELVIC PLATE 3.5X91MM 7 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1362.34","1021.75","AETNA [1001]","HB AMC AETNA HMO","950.91","69.8","","675.31","184.75","1721.50","286","711.96","1113.3","percent of total billed charges",""
"PELVIC PLATE 3.5X91MM 7 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1362.34","1021.75","AETNA [1001]","HB AMC AETNA PPO","1095.32","80.4","","1261.44","103.12","1514.10","21","711.96","1113.3","percent of total billed charges",""
"PELVIC PLATE 3.5X91MM 7 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1362.34","1021.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1095.32","80.4","","1365.00","1365.00","1365.00","1 through 10","711.96","1113.3","percent of total billed charges",""
"PELVIC PLATE 3.5X91MM 7 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1362.34","1021.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1113.30","81.72","","5157.68","5157.68","5157.68","1 through 10","711.96","1113.3","percent of total billed charges",""
"PELVIC PLATE 3.5X91MM 7 HOLE SS LOW PROFILE RECONSTRUCTION","SUP-ITM-10038079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1362.34","1021.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1113.30","81.72","","431.26","71.26","1459.57","88","711.96","1113.3","percent of total billed charges",""
"PELVIC PLATE 42.5MM 3 HOLE MATTA SS STRAIGHT","SUP-ITM-10142516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.79","2147.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2275.92","79.5","","800.18","480.96","1887.97","195","887.46","2275.92","percent of total billed charges",""
"PELVIC PLATE 42.5MM 3 HOLE MATTA SS STRAIGHT","SUP-ITM-10142516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.79","2147.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1525.87","53.3","","813.12","216.42","1444.50","81","887.46","2275.92","percent of total billed charges",""
"PELVIC PLATE 42.5MM 3 HOLE MATTA SS STRAIGHT","SUP-ITM-10142516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.79","2147.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","887.46","31","","432.60","432.60","432.60","1 through 10","887.46","2275.92","percent of total billed charges",""
"PELVIC PLATE 42.5MM 3 HOLE MATTA SS STRAIGHT","SUP-ITM-10142516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.79","2147.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1044.92","36.5","","148.37","54.89","631.39","94","887.46","2275.92","percent of total billed charges",""
"PELVIC PLATE 42.5MM 3 HOLE MATTA SS STRAIGHT","SUP-ITM-10142516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.79","2147.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1096.45","38.3","","279.30","91.72","1116.77","266","887.46","2275.92","percent of total billed charges",""
"PELVIC PLATE 42.5MM 3 HOLE MATTA SS STRAIGHT","SUP-ITM-10142516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.79","2147.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1228.14","42.9","","731.00","63.70","731.00","1 through 10","887.46","2275.92","percent of total billed charges",""
"PELVIC PLATE 42.5MM 3 HOLE MATTA SS STRAIGHT","SUP-ITM-10142516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.79","2147.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1228.14","42.9","","384.74","384.74","384.74","1 through 10","887.46","2275.92","percent of total billed charges",""
"PELVIC PLATE 42.5MM 3 HOLE MATTA SS STRAIGHT","SUP-ITM-10142516","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.79","2147.09","WELLPOINT [1015]","HB AMC WELLPOINT","2112.17","73.78","","286.63","119.22","1107.45","105","887.46","2275.92","percent of total billed charges",""
"PELVIC PLATE 42.5MM 3 HOLE MATTA SS STRAIGHT","SUP-ITM-10142516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2862.79","2147.09","AETNA [1001]","HB AMC AETNA HMO","1998.23","69.8","","675.31","184.75","1721.50","286","1496.09","2339.47","percent of total billed charges",""
"PELVIC PLATE 42.5MM 3 HOLE MATTA SS STRAIGHT","SUP-ITM-10142516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2862.79","2147.09","AETNA [1001]","HB AMC AETNA PPO","2301.68","80.4","","1261.44","103.12","1514.10","21","1496.09","2339.47","percent of total billed charges",""
"PELVIC PLATE 42.5MM 3 HOLE MATTA SS STRAIGHT","SUP-ITM-10142516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2862.79","2147.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2301.68","80.4","","1365.00","1365.00","1365.00","1 through 10","1496.09","2339.47","percent of total billed charges",""
"PELVIC PLATE 42.5MM 3 HOLE MATTA SS STRAIGHT","SUP-ITM-10142516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2862.79","2147.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2339.47","81.72","","5157.68","5157.68","5157.68","1 through 10","1496.09","2339.47","percent of total billed charges",""
"PELVIC PLATE 42.5MM 3 HOLE MATTA SS STRAIGHT","SUP-ITM-10142516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2862.79","2147.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2339.47","81.72","","431.26","71.26","1459.57","88","1496.09","2339.47","percent of total billed charges",""
"PELVIS PLATE 108MM 250.5 16 HOLE BONE PELVIC CURVED MATTA RADIUS SS","SUP-ITM-10142496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.75","3147.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3336.42","79.5","","800.18","480.96","1887.97","195","1300.99","3336.42","percent of total billed charges",""
"PELVIS PLATE 108MM 250.5 16 HOLE BONE PELVIC CURVED MATTA RADIUS SS","SUP-ITM-10142496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.75","3147.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2236.87","53.3","","813.12","216.42","1444.50","81","1300.99","3336.42","percent of total billed charges",""
"PELVIS PLATE 108MM 250.5 16 HOLE BONE PELVIC CURVED MATTA RADIUS SS","SUP-ITM-10142496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.75","3147.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1300.99","31","","432.60","432.60","432.60","1 through 10","1300.99","3336.42","percent of total billed charges",""
"PELVIS PLATE 108MM 250.5 16 HOLE BONE PELVIC CURVED MATTA RADIUS SS","SUP-ITM-10142496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.75","3147.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1531.81","36.5","","148.37","54.89","631.39","94","1300.99","3336.42","percent of total billed charges",""
"PELVIS PLATE 108MM 250.5 16 HOLE BONE PELVIC CURVED MATTA RADIUS SS","SUP-ITM-10142496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.75","3147.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1607.36","38.3","","279.30","91.72","1116.77","266","1300.99","3336.42","percent of total billed charges",""
"PELVIS PLATE 108MM 250.5 16 HOLE BONE PELVIC CURVED MATTA RADIUS SS","SUP-ITM-10142496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.75","3147.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1800.41","42.9","","731.00","63.70","731.00","1 through 10","1300.99","3336.42","percent of total billed charges",""
"PELVIS PLATE 108MM 250.5 16 HOLE BONE PELVIC CURVED MATTA RADIUS SS","SUP-ITM-10142496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.75","3147.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1800.41","42.9","","384.74","384.74","384.74","1 through 10","1300.99","3336.42","percent of total billed charges",""
"PELVIS PLATE 108MM 250.5 16 HOLE BONE PELVIC CURVED MATTA RADIUS SS","SUP-ITM-10142496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.75","3147.56","WELLPOINT [1015]","HB AMC WELLPOINT","3096.36","73.78","","286.63","119.22","1107.45","105","1300.99","3336.42","percent of total billed charges",""
"PELVIS PLATE 108MM 250.5 16 HOLE BONE PELVIC CURVED MATTA RADIUS SS","SUP-ITM-10142496","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4196.75","3147.56","AETNA [1001]","HB AMC AETNA HMO","2929.33","69.8","","675.31","184.75","1721.50","286","2193.22","3429.58","percent of total billed charges",""
"PELVIS PLATE 108MM 250.5 16 HOLE BONE PELVIC CURVED MATTA RADIUS SS","SUP-ITM-10142496","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4196.75","3147.56","AETNA [1001]","HB AMC AETNA PPO","3374.19","80.4","","1261.44","103.12","1514.10","21","2193.22","3429.58","percent of total billed charges",""
"PELVIS PLATE 108MM 250.5 16 HOLE BONE PELVIC CURVED MATTA RADIUS SS","SUP-ITM-10142496","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4196.75","3147.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3374.19","80.4","","1365.00","1365.00","1365.00","1 through 10","2193.22","3429.58","percent of total billed charges",""
"PELVIS PLATE 108MM 250.5 16 HOLE BONE PELVIC CURVED MATTA RADIUS SS","SUP-ITM-10142496","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4196.75","3147.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3429.58","81.72","","5157.68","5157.68","5157.68","1 through 10","2193.22","3429.58","percent of total billed charges",""
"PELVIS PLATE 108MM 250.5 16 HOLE BONE PELVIC CURVED MATTA RADIUS SS","SUP-ITM-10142496","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4196.75","3147.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3429.58","81.72","","431.26","71.26","1459.57","88","2193.22","3429.58","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 142.5 12 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142541","CDM","C1713","HCPCS","0278","RC","","","","both","","","4016.88","3012.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3193.42","79.5","","800.18","480.96","1887.97","195","1245.23","3193.42","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 142.5 12 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142541","CDM","C1713","HCPCS","0278","RC","","","","both","","","4016.88","3012.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2141.00","53.3","","813.12","216.42","1444.50","81","1245.23","3193.42","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 142.5 12 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142541","CDM","C1713","HCPCS","0278","RC","","","","both","","","4016.88","3012.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1245.23","31","","432.60","432.60","432.60","1 through 10","1245.23","3193.42","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 142.5 12 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142541","CDM","C1713","HCPCS","0278","RC","","","","both","","","4016.88","3012.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1466.16","36.5","","148.37","54.89","631.39","94","1245.23","3193.42","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 142.5 12 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142541","CDM","C1713","HCPCS","0278","RC","","","","both","","","4016.88","3012.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1538.47","38.3","","279.30","91.72","1116.77","266","1245.23","3193.42","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 142.5 12 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142541","CDM","C1713","HCPCS","0278","RC","","","","both","","","4016.88","3012.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1723.24","42.9","","731.00","63.70","731.00","1 through 10","1245.23","3193.42","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 142.5 12 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142541","CDM","C1713","HCPCS","0278","RC","","","","both","","","4016.88","3012.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1723.24","42.9","","384.74","384.74","384.74","1 through 10","1245.23","3193.42","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 142.5 12 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142541","CDM","C1713","HCPCS","0278","RC","","","","both","","","4016.88","3012.66","WELLPOINT [1015]","HB AMC WELLPOINT","2963.65","73.78","","286.63","119.22","1107.45","105","1245.23","3193.42","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 142.5 12 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4016.88","3012.66","AETNA [1001]","HB AMC AETNA HMO","2803.78","69.8","","675.31","184.75","1721.50","286","2099.22","3282.59","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 142.5 12 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4016.88","3012.66","AETNA [1001]","HB AMC AETNA PPO","3229.57","80.4","","1261.44","103.12","1514.10","21","2099.22","3282.59","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 142.5 12 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4016.88","3012.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3229.57","80.4","","1365.00","1365.00","1365.00","1 through 10","2099.22","3282.59","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 142.5 12 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4016.88","3012.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3282.59","81.72","","5157.68","5157.68","5157.68","1 through 10","2099.22","3282.59","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 142.5 12 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4016.88","3012.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3282.59","81.72","","431.26","71.26","1459.57","88","2099.22","3282.59","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 190.5 16 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142545","CDM","C1713","HCPCS","0278","RC","","","","both","","","4406.61","3304.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3503.25","79.5","","800.18","480.96","1887.97","195","1366.05","3503.25","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 190.5 16 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142545","CDM","C1713","HCPCS","0278","RC","","","","both","","","4406.61","3304.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2348.72","53.3","","813.12","216.42","1444.50","81","1366.05","3503.25","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 190.5 16 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142545","CDM","C1713","HCPCS","0278","RC","","","","both","","","4406.61","3304.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1366.05","31","","432.60","432.60","432.60","1 through 10","1366.05","3503.25","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 190.5 16 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142545","CDM","C1713","HCPCS","0278","RC","","","","both","","","4406.61","3304.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1608.41","36.5","","148.37","54.89","631.39","94","1366.05","3503.25","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 190.5 16 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142545","CDM","C1713","HCPCS","0278","RC","","","","both","","","4406.61","3304.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1687.73","38.3","","279.30","91.72","1116.77","266","1366.05","3503.25","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 190.5 16 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142545","CDM","C1713","HCPCS","0278","RC","","","","both","","","4406.61","3304.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1890.44","42.9","","731.00","63.70","731.00","1 through 10","1366.05","3503.25","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 190.5 16 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142545","CDM","C1713","HCPCS","0278","RC","","","","both","","","4406.61","3304.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1890.44","42.9","","384.74","384.74","384.74","1 through 10","1366.05","3503.25","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 190.5 16 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142545","CDM","C1713","HCPCS","0278","RC","","","","both","","","4406.61","3304.96","WELLPOINT [1015]","HB AMC WELLPOINT","3251.20","73.78","","286.63","119.22","1107.45","105","1366.05","3503.25","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 190.5 16 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4406.61","3304.96","AETNA [1001]","HB AMC AETNA HMO","3075.81","69.8","","675.31","184.75","1721.50","286","2302.89","3601.08","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 190.5 16 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4406.61","3304.96","AETNA [1001]","HB AMC AETNA PPO","3542.91","80.4","","1261.44","103.12","1514.10","21","2302.89","3601.08","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 190.5 16 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4406.61","3304.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3542.91","80.4","","1365.00","1365.00","1365.00","1 through 10","2302.89","3601.08","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 190.5 16 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4406.61","3304.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3601.08","81.72","","5157.68","5157.68","5157.68","1 through 10","2302.89","3601.08","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 190.5 16 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4406.61","3304.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3601.08","81.72","","431.26","71.26","1459.57","88","2302.89","3601.08","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 250.5 16 HOLE BONE MATTA SS STRAIGHT","SUP-ITM-10142529","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.80","2858.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3029.59","79.5","","800.18","480.96","1887.97","195","1181.35","3029.59","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 250.5 16 HOLE BONE MATTA SS STRAIGHT","SUP-ITM-10142529","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.80","2858.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2031.16","53.3","","813.12","216.42","1444.50","81","1181.35","3029.59","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 250.5 16 HOLE BONE MATTA SS STRAIGHT","SUP-ITM-10142529","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.80","2858.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1181.35","31","","432.60","432.60","432.60","1 through 10","1181.35","3029.59","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 250.5 16 HOLE BONE MATTA SS STRAIGHT","SUP-ITM-10142529","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.80","2858.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1390.94","36.5","","148.37","54.89","631.39","94","1181.35","3029.59","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 250.5 16 HOLE BONE MATTA SS STRAIGHT","SUP-ITM-10142529","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.80","2858.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1459.54","38.3","","279.30","91.72","1116.77","266","1181.35","3029.59","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 250.5 16 HOLE BONE MATTA SS STRAIGHT","SUP-ITM-10142529","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.80","2858.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1634.83","42.9","","731.00","63.70","731.00","1 through 10","1181.35","3029.59","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 250.5 16 HOLE BONE MATTA SS STRAIGHT","SUP-ITM-10142529","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.80","2858.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1634.83","42.9","","384.74","384.74","384.74","1 through 10","1181.35","3029.59","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 250.5 16 HOLE BONE MATTA SS STRAIGHT","SUP-ITM-10142529","CDM","C1713","HCPCS","0278","RC","","","","both","","","3810.80","2858.10","WELLPOINT [1015]","HB AMC WELLPOINT","2811.61","73.78","","286.63","119.22","1107.45","105","1181.35","3029.59","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 250.5 16 HOLE BONE MATTA SS STRAIGHT","SUP-ITM-10142529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3810.80","2858.10","AETNA [1001]","HB AMC AETNA HMO","2659.94","69.8","","675.31","184.75","1721.50","286","1991.52","3114.19","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 250.5 16 HOLE BONE MATTA SS STRAIGHT","SUP-ITM-10142529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3810.80","2858.10","AETNA [1001]","HB AMC AETNA PPO","3063.88","80.4","","1261.44","103.12","1514.10","21","1991.52","3114.19","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 250.5 16 HOLE BONE MATTA SS STRAIGHT","SUP-ITM-10142529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3810.80","2858.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3063.88","80.4","","1365.00","1365.00","1365.00","1 through 10","1991.52","3114.19","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 250.5 16 HOLE BONE MATTA SS STRAIGHT","SUP-ITM-10142529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3810.80","2858.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3114.19","81.72","","5157.68","5157.68","5157.68","1 through 10","1991.52","3114.19","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 250.5 16 HOLE BONE MATTA SS STRAIGHT","SUP-ITM-10142529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3810.80","2858.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3114.19","81.72","","431.26","71.26","1459.57","88","1991.52","3114.19","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 46.5 4 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3312.44","2484.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2633.39","79.5","","800.18","480.96","1887.97","195","1026.86","2633.39","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 46.5 4 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3312.44","2484.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1765.53","53.3","","813.12","216.42","1444.50","81","1026.86","2633.39","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 46.5 4 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3312.44","2484.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1026.86","31","","432.60","432.60","432.60","1 through 10","1026.86","2633.39","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 46.5 4 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3312.44","2484.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1209.04","36.5","","148.37","54.89","631.39","94","1026.86","2633.39","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 46.5 4 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3312.44","2484.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1268.66","38.3","","279.30","91.72","1116.77","266","1026.86","2633.39","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 46.5 4 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3312.44","2484.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1421.04","42.9","","731.00","63.70","731.00","1 through 10","1026.86","2633.39","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 46.5 4 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3312.44","2484.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1421.04","42.9","","384.74","384.74","384.74","1 through 10","1026.86","2633.39","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 46.5 4 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3312.44","2484.33","WELLPOINT [1015]","HB AMC WELLPOINT","2443.92","73.78","","286.63","119.22","1107.45","105","1026.86","2633.39","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 46.5 4 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3312.44","2484.33","AETNA [1001]","HB AMC AETNA HMO","2312.08","69.8","","675.31","184.75","1721.50","286","1731.08","2706.93","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 46.5 4 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3312.44","2484.33","AETNA [1001]","HB AMC AETNA PPO","2663.20","80.4","","1261.44","103.12","1514.10","21","1731.08","2706.93","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 46.5 4 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3312.44","2484.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2663.20","80.4","","1365.00","1365.00","1365.00","1 through 10","1731.08","2706.93","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 46.5 4 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3312.44","2484.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2706.93","81.72","","5157.68","5157.68","5157.68","1 through 10","1731.08","2706.93","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 46.5 4 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3312.44","2484.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2706.93","81.72","","431.26","71.26","1459.57","88","1731.08","2706.93","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 58.5 4 HOLE PELVIC BONE MATTA SS CURVED","SUP-ITM-10142484","CDM","C1713","HCPCS","0278","RC","","","","both","","","3155.08","2366.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2508.29","79.5","","800.18","480.96","1887.97","195","978.07","2508.29","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 58.5 4 HOLE PELVIC BONE MATTA SS CURVED","SUP-ITM-10142484","CDM","C1713","HCPCS","0278","RC","","","","both","","","3155.08","2366.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1681.66","53.3","","813.12","216.42","1444.50","81","978.07","2508.29","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 58.5 4 HOLE PELVIC BONE MATTA SS CURVED","SUP-ITM-10142484","CDM","C1713","HCPCS","0278","RC","","","","both","","","3155.08","2366.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","978.07","31","","432.60","432.60","432.60","1 through 10","978.07","2508.29","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 58.5 4 HOLE PELVIC BONE MATTA SS CURVED","SUP-ITM-10142484","CDM","C1713","HCPCS","0278","RC","","","","both","","","3155.08","2366.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1151.60","36.5","","148.37","54.89","631.39","94","978.07","2508.29","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 58.5 4 HOLE PELVIC BONE MATTA SS CURVED","SUP-ITM-10142484","CDM","C1713","HCPCS","0278","RC","","","","both","","","3155.08","2366.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1208.40","38.3","","279.30","91.72","1116.77","266","978.07","2508.29","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 58.5 4 HOLE PELVIC BONE MATTA SS CURVED","SUP-ITM-10142484","CDM","C1713","HCPCS","0278","RC","","","","both","","","3155.08","2366.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1353.53","42.9","","731.00","63.70","731.00","1 through 10","978.07","2508.29","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 58.5 4 HOLE PELVIC BONE MATTA SS CURVED","SUP-ITM-10142484","CDM","C1713","HCPCS","0278","RC","","","","both","","","3155.08","2366.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1353.53","42.9","","384.74","384.74","384.74","1 through 10","978.07","2508.29","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 58.5 4 HOLE PELVIC BONE MATTA SS CURVED","SUP-ITM-10142484","CDM","C1713","HCPCS","0278","RC","","","","both","","","3155.08","2366.31","WELLPOINT [1015]","HB AMC WELLPOINT","2327.82","73.78","","286.63","119.22","1107.45","105","978.07","2508.29","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 58.5 4 HOLE PELVIC BONE MATTA SS CURVED","SUP-ITM-10142484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3155.08","2366.31","AETNA [1001]","HB AMC AETNA HMO","2202.25","69.8","","675.31","184.75","1721.50","286","1648.84","2578.33","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 58.5 4 HOLE PELVIC BONE MATTA SS CURVED","SUP-ITM-10142484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3155.08","2366.31","AETNA [1001]","HB AMC AETNA PPO","2536.68","80.4","","1261.44","103.12","1514.10","21","1648.84","2578.33","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 58.5 4 HOLE PELVIC BONE MATTA SS CURVED","SUP-ITM-10142484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3155.08","2366.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2536.68","80.4","","1365.00","1365.00","1365.00","1 through 10","1648.84","2578.33","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 58.5 4 HOLE PELVIC BONE MATTA SS CURVED","SUP-ITM-10142484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3155.08","2366.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2578.33","81.72","","5157.68","5157.68","5157.68","1 through 10","1648.84","2578.33","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 58.5 4 HOLE PELVIC BONE MATTA SS CURVED","SUP-ITM-10142484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3155.08","2366.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2578.33","81.72","","431.26","71.26","1459.57","88","1648.84","2578.33","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 70.5 6 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3638.43","2728.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2892.55","79.5","","800.18","480.96","1887.97","195","1127.91","2892.55","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 70.5 6 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3638.43","2728.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1939.28","53.3","","813.12","216.42","1444.50","81","1127.91","2892.55","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 70.5 6 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3638.43","2728.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1127.91","31","","432.60","432.60","432.60","1 through 10","1127.91","2892.55","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 70.5 6 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3638.43","2728.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1328.03","36.5","","148.37","54.89","631.39","94","1127.91","2892.55","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 70.5 6 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3638.43","2728.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1393.52","38.3","","279.30","91.72","1116.77","266","1127.91","2892.55","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 70.5 6 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3638.43","2728.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1560.89","42.9","","731.00","63.70","731.00","1 through 10","1127.91","2892.55","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 70.5 6 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3638.43","2728.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1560.89","42.9","","384.74","384.74","384.74","1 through 10","1127.91","2892.55","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 70.5 6 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3638.43","2728.82","WELLPOINT [1015]","HB AMC WELLPOINT","2684.43","73.78","","286.63","119.22","1107.45","105","1127.91","2892.55","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 70.5 6 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3638.43","2728.82","AETNA [1001]","HB AMC AETNA HMO","2539.62","69.8","","675.31","184.75","1721.50","286","1901.44","2973.32","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 70.5 6 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3638.43","2728.82","AETNA [1001]","HB AMC AETNA PPO","2925.30","80.4","","1261.44","103.12","1514.10","21","1901.44","2973.32","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 70.5 6 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3638.43","2728.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2925.30","80.4","","1365.00","1365.00","1365.00","1 through 10","1901.44","2973.32","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 70.5 6 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3638.43","2728.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2973.32","81.72","","5157.68","5157.68","5157.68","1 through 10","1901.44","2973.32","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 70.5 6 HOLE BONE MATTA ANNEALED SS FLEX","SUP-ITM-10142535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3638.43","2728.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2973.32","81.72","","431.26","71.26","1459.57","88","1901.44","2973.32","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 90.5 6 HOLE PELVIC BONE MATTA SS SYMPHYSIS","SUP-ITM-10142551","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.45","3314.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3513.46","79.5","","800.18","480.96","1887.97","195","1370.03","3513.46","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 90.5 6 HOLE PELVIC BONE MATTA SS SYMPHYSIS","SUP-ITM-10142551","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.45","3314.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2355.57","53.3","","813.12","216.42","1444.50","81","1370.03","3513.46","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 90.5 6 HOLE PELVIC BONE MATTA SS SYMPHYSIS","SUP-ITM-10142551","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.45","3314.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1370.03","31","","432.60","432.60","432.60","1 through 10","1370.03","3513.46","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 90.5 6 HOLE PELVIC BONE MATTA SS SYMPHYSIS","SUP-ITM-10142551","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.45","3314.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1613.10","36.5","","148.37","54.89","631.39","94","1370.03","3513.46","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 90.5 6 HOLE PELVIC BONE MATTA SS SYMPHYSIS","SUP-ITM-10142551","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.45","3314.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1692.65","38.3","","279.30","91.72","1116.77","266","1370.03","3513.46","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 90.5 6 HOLE PELVIC BONE MATTA SS SYMPHYSIS","SUP-ITM-10142551","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.45","3314.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1895.94","42.9","","731.00","63.70","731.00","1 through 10","1370.03","3513.46","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 90.5 6 HOLE PELVIC BONE MATTA SS SYMPHYSIS","SUP-ITM-10142551","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.45","3314.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1895.94","42.9","","384.74","384.74","384.74","1 through 10","1370.03","3513.46","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 90.5 6 HOLE PELVIC BONE MATTA SS SYMPHYSIS","SUP-ITM-10142551","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.45","3314.59","WELLPOINT [1015]","HB AMC WELLPOINT","3260.67","73.78","","286.63","119.22","1107.45","105","1370.03","3513.46","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 90.5 6 HOLE PELVIC BONE MATTA SS SYMPHYSIS","SUP-ITM-10142551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4419.45","3314.59","AETNA [1001]","HB AMC AETNA HMO","3084.78","69.8","","675.31","184.75","1721.50","286","2309.6","3611.57","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 90.5 6 HOLE PELVIC BONE MATTA SS SYMPHYSIS","SUP-ITM-10142551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4419.45","3314.59","AETNA [1001]","HB AMC AETNA PPO","3553.24","80.4","","1261.44","103.12","1514.10","21","2309.6","3611.57","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 90.5 6 HOLE PELVIC BONE MATTA SS SYMPHYSIS","SUP-ITM-10142551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4419.45","3314.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3553.24","80.4","","1365.00","1365.00","1365.00","1 through 10","2309.6","3611.57","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 90.5 6 HOLE PELVIC BONE MATTA SS SYMPHYSIS","SUP-ITM-10142551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4419.45","3314.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3611.57","81.72","","5157.68","5157.68","5157.68","1 through 10","2309.6","3611.57","percent of total billed charges",""
"PELVIS PLATE 3.5MM 4.5 90.5 6 HOLE PELVIC BONE MATTA SS SYMPHYSIS","SUP-ITM-10142551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4419.45","3314.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3611.57","81.72","","431.26","71.26","1459.57","88","2309.6","3611.57","percent of total billed charges",""
"PELVIS PLATE 3.5MM 57 4 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030877","CDM","C1713","HCPCS","0278","RC","","","","both","","","2236.47","1677.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1777.99","79.5","","800.18","480.96","1887.97","195","693.31","1777.99","percent of total billed charges",""
"PELVIS PLATE 3.5MM 57 4 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030877","CDM","C1713","HCPCS","0278","RC","","","","both","","","2236.47","1677.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1192.04","53.3","","813.12","216.42","1444.50","81","693.31","1777.99","percent of total billed charges",""
"PELVIS PLATE 3.5MM 57 4 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030877","CDM","C1713","HCPCS","0278","RC","","","","both","","","2236.47","1677.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","693.31","31","","432.60","432.60","432.60","1 through 10","693.31","1777.99","percent of total billed charges",""
"PELVIS PLATE 3.5MM 57 4 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030877","CDM","C1713","HCPCS","0278","RC","","","","both","","","2236.47","1677.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","816.31","36.5","","148.37","54.89","631.39","94","693.31","1777.99","percent of total billed charges",""
"PELVIS PLATE 3.5MM 57 4 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030877","CDM","C1713","HCPCS","0278","RC","","","","both","","","2236.47","1677.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","856.57","38.3","","279.30","91.72","1116.77","266","693.31","1777.99","percent of total billed charges",""
"PELVIS PLATE 3.5MM 57 4 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030877","CDM","C1713","HCPCS","0278","RC","","","","both","","","2236.47","1677.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","959.45","42.9","","731.00","63.70","731.00","1 through 10","693.31","1777.99","percent of total billed charges",""
"PELVIS PLATE 3.5MM 57 4 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030877","CDM","C1713","HCPCS","0278","RC","","","","both","","","2236.47","1677.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","959.45","42.9","","384.74","384.74","384.74","1 through 10","693.31","1777.99","percent of total billed charges",""
"PELVIS PLATE 3.5MM 57 4 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030877","CDM","C1713","HCPCS","0278","RC","","","","both","","","2236.47","1677.35","WELLPOINT [1015]","HB AMC WELLPOINT","1650.07","73.78","","286.63","119.22","1107.45","105","693.31","1777.99","percent of total billed charges",""
"PELVIS PLATE 3.5MM 57 4 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2236.47","1677.35","AETNA [1001]","HB AMC AETNA HMO","1561.06","69.8","","675.31","184.75","1721.50","286","1168.78","1827.64","percent of total billed charges",""
"PELVIS PLATE 3.5MM 57 4 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2236.47","1677.35","AETNA [1001]","HB AMC AETNA PPO","1798.12","80.4","","1261.44","103.12","1514.10","21","1168.78","1827.64","percent of total billed charges",""
"PELVIS PLATE 3.5MM 57 4 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2236.47","1677.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1798.12","80.4","","1365.00","1365.00","1365.00","1 through 10","1168.78","1827.64","percent of total billed charges",""
"PELVIS PLATE 3.5MM 57 4 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2236.47","1677.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1827.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1168.78","1827.64","percent of total billed charges",""
"PELVIS PLATE 3.5MM 57 4 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2236.47","1677.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1827.64","81.72","","431.26","71.26","1459.57","88","1168.78","1827.64","percent of total billed charges",""
"PELVIS PLATE 3.5MM 78 6 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030878","CDM","C1713","HCPCS","0278","RC","","","","both","","","2454.03","1840.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1950.95","79.5","","800.18","480.96","1887.97","195","760.75","1950.95","percent of total billed charges",""
"PELVIS PLATE 3.5MM 78 6 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030878","CDM","C1713","HCPCS","0278","RC","","","","both","","","2454.03","1840.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1308.00","53.3","","813.12","216.42","1444.50","81","760.75","1950.95","percent of total billed charges",""
"PELVIS PLATE 3.5MM 78 6 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030878","CDM","C1713","HCPCS","0278","RC","","","","both","","","2454.03","1840.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","760.75","31","","432.60","432.60","432.60","1 through 10","760.75","1950.95","percent of total billed charges",""
"PELVIS PLATE 3.5MM 78 6 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030878","CDM","C1713","HCPCS","0278","RC","","","","both","","","2454.03","1840.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","895.72","36.5","","148.37","54.89","631.39","94","760.75","1950.95","percent of total billed charges",""
"PELVIS PLATE 3.5MM 78 6 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030878","CDM","C1713","HCPCS","0278","RC","","","","both","","","2454.03","1840.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","939.89","38.3","","279.30","91.72","1116.77","266","760.75","1950.95","percent of total billed charges",""
"PELVIS PLATE 3.5MM 78 6 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030878","CDM","C1713","HCPCS","0278","RC","","","","both","","","2454.03","1840.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1052.78","42.9","","731.00","63.70","731.00","1 through 10","760.75","1950.95","percent of total billed charges",""
"PELVIS PLATE 3.5MM 78 6 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030878","CDM","C1713","HCPCS","0278","RC","","","","both","","","2454.03","1840.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1052.78","42.9","","384.74","384.74","384.74","1 through 10","760.75","1950.95","percent of total billed charges",""
"PELVIS PLATE 3.5MM 78 6 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030878","CDM","C1713","HCPCS","0278","RC","","","","both","","","2454.03","1840.52","WELLPOINT [1015]","HB AMC WELLPOINT","1810.58","73.78","","286.63","119.22","1107.45","105","760.75","1950.95","percent of total billed charges",""
"PELVIS PLATE 3.5MM 78 6 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030878","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2454.03","1840.52","AETNA [1001]","HB AMC AETNA HMO","1712.91","69.8","","675.31","184.75","1721.50","286","1282.48","2005.43","percent of total billed charges",""
"PELVIS PLATE 3.5MM 78 6 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030878","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2454.03","1840.52","AETNA [1001]","HB AMC AETNA PPO","1973.04","80.4","","1261.44","103.12","1514.10","21","1282.48","2005.43","percent of total billed charges",""
"PELVIS PLATE 3.5MM 78 6 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030878","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2454.03","1840.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1973.04","80.4","","1365.00","1365.00","1365.00","1 through 10","1282.48","2005.43","percent of total billed charges",""
"PELVIS PLATE 3.5MM 78 6 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030878","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2454.03","1840.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2005.43","81.72","","5157.68","5157.68","5157.68","1 through 10","1282.48","2005.43","percent of total billed charges",""
"PELVIS PLATE 3.5MM 78 6 HOLE PELVIC SYMPHYSEAL SS COAXIAL COMBIHOLE LOW PROFILE","SUP-ITM-10030878","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2454.03","1840.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2005.43","81.72","","431.26","71.26","1459.57","88","1282.48","2005.43","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 10 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.53","1684.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1785.20","79.5","","800.18","480.96","1887.97","195","696.11","1785.2","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 10 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.53","1684.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1196.87","53.3","","813.12","216.42","1444.50","81","696.11","1785.2","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 10 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.53","1684.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","696.11","31","","432.60","432.60","432.60","1 through 10","696.11","1785.2","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 10 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.53","1684.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","819.62","36.5","","148.37","54.89","631.39","94","696.11","1785.2","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 10 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.53","1684.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","860.04","38.3","","279.30","91.72","1116.77","266","696.11","1785.2","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 10 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.53","1684.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","963.33","42.9","","731.00","63.70","731.00","1 through 10","696.11","1785.2","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 10 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.53","1684.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","963.33","42.9","","384.74","384.74","384.74","1 through 10","696.11","1785.2","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 10 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038108","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.53","1684.15","WELLPOINT [1015]","HB AMC WELLPOINT","1656.75","73.78","","286.63","119.22","1107.45","105","696.11","1785.2","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 10 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.53","1684.15","AETNA [1001]","HB AMC AETNA HMO","1567.38","69.8","","675.31","184.75","1721.50","286","1173.51","1835.05","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 10 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.53","1684.15","AETNA [1001]","HB AMC AETNA PPO","1805.41","80.4","","1261.44","103.12","1514.10","21","1173.51","1835.05","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 10 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.53","1684.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1805.41","80.4","","1365.00","1365.00","1365.00","1 through 10","1173.51","1835.05","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 10 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.53","1684.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1835.05","81.72","","5157.68","5157.68","5157.68","1 through 10","1173.51","1835.05","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 10 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.53","1684.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1835.05","81.72","","431.26","71.26","1459.57","88","1173.51","1835.05","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 6 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1976.17","1482.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1571.06","79.5","","800.18","480.96","1887.97","195","612.61","1571.06","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 6 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1976.17","1482.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1053.30","53.3","","813.12","216.42","1444.50","81","612.61","1571.06","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 6 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1976.17","1482.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","612.61","31","","432.60","432.60","432.60","1 through 10","612.61","1571.06","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 6 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1976.17","1482.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","721.30","36.5","","148.37","54.89","631.39","94","612.61","1571.06","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 6 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1976.17","1482.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","756.87","38.3","","279.30","91.72","1116.77","266","612.61","1571.06","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 6 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1976.17","1482.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","847.78","42.9","","731.00","63.70","731.00","1 through 10","612.61","1571.06","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 6 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1976.17","1482.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","847.78","42.9","","384.74","384.74","384.74","1 through 10","612.61","1571.06","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 6 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038106","CDM","C1713","HCPCS","0278","RC","","","","both","","","1976.17","1482.13","WELLPOINT [1015]","HB AMC WELLPOINT","1458.02","73.78","","286.63","119.22","1107.45","105","612.61","1571.06","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 6 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1976.17","1482.13","AETNA [1001]","HB AMC AETNA HMO","1379.37","69.8","","675.31","184.75","1721.50","286","1032.75","1614.93","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 6 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1976.17","1482.13","AETNA [1001]","HB AMC AETNA PPO","1588.84","80.4","","1261.44","103.12","1514.10","21","1032.75","1614.93","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 6 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1976.17","1482.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1588.84","80.4","","1365.00","1365.00","1365.00","1 through 10","1032.75","1614.93","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 6 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1976.17","1482.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1614.93","81.72","","5157.68","5157.68","5157.68","1 through 10","1032.75","1614.93","percent of total billed charges",""
"PELVIS PLATE 3.5X108MM 6 HOLE PELVIC SS LOW PROFILE RECONSTRUCTION CURVED","SUP-ITM-10038106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1976.17","1482.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1614.93","81.72","","431.26","71.26","1459.57","88","1032.75","1614.93","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","both","","","2125.10","1593.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1689.45","79.5","","800.18","480.96","1887.97","195","658.78","1689.45","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","both","","","2125.10","1593.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1132.68","53.3","","813.12","216.42","1444.50","81","658.78","1689.45","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","both","","","2125.10","1593.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","658.78","31","","432.60","432.60","432.60","1 through 10","658.78","1689.45","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","both","","","2125.10","1593.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","775.66","36.5","","148.37","54.89","631.39","94","658.78","1689.45","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","both","","","2125.10","1593.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","813.91","38.3","","279.30","91.72","1116.77","266","658.78","1689.45","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","both","","","2125.10","1593.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.67","42.9","","731.00","63.70","731.00","1 through 10","658.78","1689.45","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","both","","","2125.10","1593.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.67","42.9","","384.74","384.74","384.74","1 through 10","658.78","1689.45","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","both","","","2125.10","1593.82","WELLPOINT [1015]","HB AMC WELLPOINT","1567.90","73.78","","286.63","119.22","1107.45","105","658.78","1689.45","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2125.10","1593.82","AETNA [1001]","HB AMC AETNA HMO","1483.32","69.8","","675.31","184.75","1721.50","286","1110.58","1736.63","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2125.10","1593.82","AETNA [1001]","HB AMC AETNA PPO","1708.58","80.4","","1261.44","103.12","1514.10","21","1110.58","1736.63","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2125.10","1593.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1708.58","80.4","","1365.00","1365.00","1365.00","1 through 10","1110.58","1736.63","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2125.10","1593.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1736.63","81.72","","5157.68","5157.68","5157.68","1 through 10","1110.58","1736.63","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2125.10","1593.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1736.63","81.72","","431.26","71.26","1459.57","88","1110.58","1736.63","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","both","","","2226.11","1669.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1769.76","79.5","","800.18","480.96","1887.97","195","690.09","1769.76","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","both","","","2226.11","1669.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1186.52","53.3","","813.12","216.42","1444.50","81","690.09","1769.76","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","both","","","2226.11","1669.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","690.09","31","","432.60","432.60","432.60","1 through 10","690.09","1769.76","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","both","","","2226.11","1669.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","812.53","36.5","","148.37","54.89","631.39","94","690.09","1769.76","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","both","","","2226.11","1669.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","852.60","38.3","","279.30","91.72","1116.77","266","690.09","1769.76","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","both","","","2226.11","1669.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","955.00","42.9","","731.00","63.70","731.00","1 through 10","690.09","1769.76","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","both","","","2226.11","1669.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","955.00","42.9","","384.74","384.74","384.74","1 through 10","690.09","1769.76","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","both","","","2226.11","1669.58","WELLPOINT [1015]","HB AMC WELLPOINT","1642.42","73.78","","286.63","119.22","1107.45","105","690.09","1769.76","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2226.11","1669.58","AETNA [1001]","HB AMC AETNA HMO","1553.82","69.8","","675.31","184.75","1721.50","286","1163.37","1819.18","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2226.11","1669.58","AETNA [1001]","HB AMC AETNA PPO","1789.79","80.4","","1261.44","103.12","1514.10","21","1163.37","1819.18","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2226.11","1669.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1789.79","80.4","","1365.00","1365.00","1365.00","1 through 10","1163.37","1819.18","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2226.11","1669.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1819.18","81.72","","5157.68","5157.68","5157.68","1 through 10","1163.37","1819.18","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2226.11","1669.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1819.18","81.72","","431.26","71.26","1459.57","88","1163.37","1819.18","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2123.91","79.5","","800.18","480.96","1887.97","195","828.19","2123.91","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1423.96","53.3","","813.12","216.42","1444.50","81","828.19","2123.91","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","828.19","31","","432.60","432.60","432.60","1 through 10","828.19","2123.91","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","975.13","36.5","","148.37","54.89","631.39","94","828.19","2123.91","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1023.22","38.3","","279.30","91.72","1116.77","266","828.19","2123.91","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1146.11","42.9","","731.00","63.70","731.00","1 through 10","828.19","2123.91","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1146.11","42.9","","384.74","384.74","384.74","1 through 10","828.19","2123.91","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","both","","","2671.59","2003.69","WELLPOINT [1015]","HB AMC WELLPOINT","1971.10","73.78","","286.63","119.22","1107.45","105","828.19","2123.91","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2671.59","2003.69","AETNA [1001]","HB AMC AETNA HMO","1864.77","69.8","","675.31","184.75","1721.50","286","1396.17","2183.22","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2671.59","2003.69","AETNA [1001]","HB AMC AETNA PPO","2147.96","80.4","","1261.44","103.12","1514.10","21","1396.17","2183.22","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2671.59","2003.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2147.96","80.4","","1365.00","1365.00","1365.00","1 through 10","1396.17","2183.22","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2671.59","2003.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2183.22","81.72","","5157.68","5157.68","5157.68","1 through 10","1396.17","2183.22","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2671.59","2003.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2183.22","81.72","","431.26","71.26","1459.57","88","1396.17","2183.22","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.28","1403.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1487.67","79.5","","800.18","480.96","1887.97","195","580.1","1487.67","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.28","1403.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","997.39","53.3","","813.12","216.42","1444.50","81","580.1","1487.67","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.28","1403.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","580.10","31","","432.60","432.60","432.60","1 through 10","580.1","1487.67","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.28","1403.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","683.02","36.5","","148.37","54.89","631.39","94","580.1","1487.67","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.28","1403.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","716.70","38.3","","279.30","91.72","1116.77","266","580.1","1487.67","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.28","1403.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","802.78","42.9","","731.00","63.70","731.00","1 through 10","580.1","1487.67","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.28","1403.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","802.78","42.9","","384.74","384.74","384.74","1 through 10","580.1","1487.67","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.28","1403.46","WELLPOINT [1015]","HB AMC WELLPOINT","1380.63","73.78","","286.63","119.22","1107.45","105","580.1","1487.67","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1871.28","1403.46","AETNA [1001]","HB AMC AETNA HMO","1306.15","69.8","","675.31","184.75","1721.50","286","977.93","1529.21","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1871.28","1403.46","AETNA [1001]","HB AMC AETNA PPO","1504.51","80.4","","1261.44","103.12","1514.10","21","977.93","1529.21","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1871.28","1403.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1504.51","80.4","","1365.00","1365.00","1365.00","1 through 10","977.93","1529.21","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1871.28","1403.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1529.21","81.72","","5157.68","5157.68","5157.68","1 through 10","977.93","1529.21","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1871.28","1403.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1529.21","81.72","","431.26","71.26","1459.57","88","977.93","1529.21","percent of total billed charges",""
"PELVIS PLATE 58.5MM 4 HOLE PELVIC BONE MATTA TITANIUM SYMPHYSIS","SUP-ITM-10142550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4168.92","3126.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3314.29","79.5","","800.18","480.96","1887.97","195","1292.37","3314.29","percent of total billed charges",""
"PELVIS PLATE 58.5MM 4 HOLE PELVIC BONE MATTA TITANIUM SYMPHYSIS","SUP-ITM-10142550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4168.92","3126.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2222.03","53.3","","813.12","216.42","1444.50","81","1292.37","3314.29","percent of total billed charges",""
"PELVIS PLATE 58.5MM 4 HOLE PELVIC BONE MATTA TITANIUM SYMPHYSIS","SUP-ITM-10142550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4168.92","3126.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1292.37","31","","432.60","432.60","432.60","1 through 10","1292.37","3314.29","percent of total billed charges",""
"PELVIS PLATE 58.5MM 4 HOLE PELVIC BONE MATTA TITANIUM SYMPHYSIS","SUP-ITM-10142550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4168.92","3126.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1521.66","36.5","","148.37","54.89","631.39","94","1292.37","3314.29","percent of total billed charges",""
"PELVIS PLATE 58.5MM 4 HOLE PELVIC BONE MATTA TITANIUM SYMPHYSIS","SUP-ITM-10142550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4168.92","3126.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1596.70","38.3","","279.30","91.72","1116.77","266","1292.37","3314.29","percent of total billed charges",""
"PELVIS PLATE 58.5MM 4 HOLE PELVIC BONE MATTA TITANIUM SYMPHYSIS","SUP-ITM-10142550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4168.92","3126.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1788.47","42.9","","731.00","63.70","731.00","1 through 10","1292.37","3314.29","percent of total billed charges",""
"PELVIS PLATE 58.5MM 4 HOLE PELVIC BONE MATTA TITANIUM SYMPHYSIS","SUP-ITM-10142550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4168.92","3126.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1788.47","42.9","","384.74","384.74","384.74","1 through 10","1292.37","3314.29","percent of total billed charges",""
"PELVIS PLATE 58.5MM 4 HOLE PELVIC BONE MATTA TITANIUM SYMPHYSIS","SUP-ITM-10142550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4168.92","3126.69","WELLPOINT [1015]","HB AMC WELLPOINT","3075.83","73.78","","286.63","119.22","1107.45","105","1292.37","3314.29","percent of total billed charges",""
"PELVIS PLATE 58.5MM 4 HOLE PELVIC BONE MATTA TITANIUM SYMPHYSIS","SUP-ITM-10142550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4168.92","3126.69","AETNA [1001]","HB AMC AETNA HMO","2909.91","69.8","","675.31","184.75","1721.50","286","2178.68","3406.84","percent of total billed charges",""
"PELVIS PLATE 58.5MM 4 HOLE PELVIC BONE MATTA TITANIUM SYMPHYSIS","SUP-ITM-10142550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4168.92","3126.69","AETNA [1001]","HB AMC AETNA PPO","3351.81","80.4","","1261.44","103.12","1514.10","21","2178.68","3406.84","percent of total billed charges",""
"PELVIS PLATE 58.5MM 4 HOLE PELVIC BONE MATTA TITANIUM SYMPHYSIS","SUP-ITM-10142550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4168.92","3126.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3351.81","80.4","","1365.00","1365.00","1365.00","1 through 10","2178.68","3406.84","percent of total billed charges",""
"PELVIS PLATE 58.5MM 4 HOLE PELVIC BONE MATTA TITANIUM SYMPHYSIS","SUP-ITM-10142550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4168.92","3126.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3406.84","81.72","","5157.68","5157.68","5157.68","1 through 10","2178.68","3406.84","percent of total billed charges",""
"PELVIS PLATE 58.5MM 4 HOLE PELVIC BONE MATTA TITANIUM SYMPHYSIS","SUP-ITM-10142550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4168.92","3126.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3406.84","81.72","","431.26","71.26","1459.57","88","2178.68","3406.84","percent of total billed charges",""
"Pelvis/Hip Bone Mrgfus","PX-76002346","CDM","27299","CPT","0761","RC","","","","both","","","22719.00","17039.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14973.01","","APC Price ($15,278.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","7042.89","19098.22","other","OPPS APC"
"Pelvis/Hip Joint Unlstd Proc","PX-76001796","CDM","27299","CPT","0761","RC","","","","both","","","6447.00","4835.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","5125.37","other","OPPS APC"
"Pemivibart/ Pemgarda Admin Infusion","PX-33000167","CDM","M0224","HCPCS","0771","RC","","","","both","","","1931.00","1448.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","550.99","","APC Price ($534.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","550.51","550.51","550.51","1 through 10","508.25","1535.15","other","OPPS APC"
"Pemivibart/ Pemgarda Admin Infusion","PX-33000167","CDM","M0224","HCPCS","0771","RC","","","","both","","","1931.00","1448.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","534.94","","APC Price ($534.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1931.00","507.79","1931.00","1 through 10","508.25","1535.15","other","OPPS APC"
"Pemivibart/ Pemgarda Admin Infusion","PX-33000167","CDM","M0224","HCPCS","0771","RC","","","","both","","","1931.00","1448.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1351.70","70","","1390.32","1390.32","1390.32","1 through 10","508.25","1535.15","percent of total billed charges",""
"Pemivibart/ Pemgarda Admin Infusion","PX-33000167","CDM","M0224","HCPCS","0771","RC","","","","both","","","1931.00","1448.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1029.22","53.3","","1519.70","1519.70","1519.70","1 through 10","508.25","1535.15","percent of total billed charges",""
"Pemivibart/ Pemgarda Admin Infusion","PX-33000167","CDM","M0224","HCPCS","0771","RC","","","","both","","","1931.00","1448.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","534.94","","APC Price ($534.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","524.30","505.73","524.30","1 through 10","508.25","1535.15","other","OPPS APC"
"Pemivibart/ Pemgarda Admin Infusion","PX-33000167","CDM","M0224","HCPCS","0771","RC","","","","both","","","1931.00","1448.25","MEDICARE [2001]","HB BWH MEDICARE","534.94","","APC Price ($534.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","535.00","516.05","535.00","46","508.25","1535.15","other","OPPS APC"
"Pemivibart/ Pemgarda Admin Infusion","PX-33000167","CDM","M0224","HCPCS","0771","RC","","","","both","","","1931.00","1448.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","704.82","36.5","","612.13","612.13","612.13","1 through 10","508.25","1535.15","percent of total billed charges",""
"Pemivibart/ Pemgarda Admin Infusion","PX-33000167","CDM","M0224","HCPCS","0771","RC","","","","both","","","1931.00","1448.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","524.24","","APC Price ($534.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","524.30","524.30","524.30","1 through 10","508.25","1535.15","other","OPPS APC"
"Pemivibart/ Pemgarda Admin Infusion","PX-33000167","CDM","M0224","HCPCS","0771","RC","","","","both","","","1931.00","1448.25","WELLPOINT [1015]","HB AMC WELLPOINT","1424.69","73.78","","1437.63","1437.63","1437.63","1 through 10","508.25","1535.15","percent of total billed charges",""
"Pemivibart/ Pemgarda Admin Infusion","PX-33000167","CDM","M0224","HCPCS","0771","RC","","","","outpatient","","","1931.00","1448.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","965.50","50","","1011.84","971.29","1011.84","1 through 10","602.22","1593.08","percent of total billed charges",""
"Pemivibart/ Pemgarda Admin Infusion","PX-33000167","CDM","M0224","HCPCS","0771","RC","","","","outpatient","","","1931.00","1448.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1013.78","52.5","","1062.05","1021.50","1062.05","1 through 10","602.22","1593.08","percent of total billed charges",""
"Penis Procedures With Cc/McC","709","MS-DRG","","","","","","","","inpatient","","","78590.40","58942.80","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","27930.21","","Case rate ($27,930.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,934.23, add-ons for qualifying new technology services are included. If operating cost exceeds $71,578.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,312.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $25,677.84 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,554.39 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,872.52. The transfer capital threshold is the transfer adjustment factor * $1,872.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23.04","23.04","23.04","1 through 10","21175.74","33910.9861","other","Inpatient DRG"
"Penis Procedures With Cc/McC","709","MS-DRG","","","","","","","","inpatient","","","78590.40","58942.80","MEDICARE [2001]","HB BWH MEDICARE","27930.21","","Case rate ($27,930.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,934.23, add-ons for qualifying new technology services are included. If operating cost exceeds $71,578.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,312.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $25,677.84 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,554.39 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,872.52. The transfer capital threshold is the transfer adjustment factor * $1,872.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26769.69","26769.69","26800.97","1 through 10","21175.74","33910.9861","other","Inpatient DRG"
"Penis Procedures Without Cc/McC","710","MS-DRG","","","","","","","","inpatient","","","21481.44","16111.08","MEDICARE [2001]","HB BWH MEDICARE","13161.74","","Case rate ($13,161.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,766.72, add-ons for qualifying new technology services are included. If operating cost exceeds $61,411.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,567.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $11,654.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,386.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,127.49. The transfer capital threshold is the transfer adjustment factor * $1,127.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18005.00","18005.00","18005.00","1 through 10","12898.51","21948.4","other","Inpatient Replacement Plans DRG"
"Penis, Testes And Scrotal Procedures,EXTREME","483","DRG","","","","","","","","inpatient","","","334284.63","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","56702.48","","Case rate ($62,694.34). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $105,124.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","62678.95","62678.95","62678.95","1 through 10","10129.36","130407.35","case rate",""
"Penis, Testes And Scrotal Procedures,MODERATE","483","DRG","","","","","","","","inpatient","","","115023.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","39054.99","","Standard inlier is a Case rate ($39,054.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $42,017, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,544.09) for the length of stay and the standard reimbursement.","39054.99","39054.99","39054.99","1 through 10","10129.36","130407.35","case rate",""
"Penis, Testes And Scrotal Procedures,MODERATE","483","DRG","","","","","","","","inpatient","","","115023.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","43908.34","","Standard inlier is a Case rate ($43,908.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $42,017, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,232.42) for the length of stay and the standard reimbursement.","43908.33","43908.33","43908.33","1 through 10","10129.36","130407.35","case rate",""
"Penis, Testes And Scrotal Procedures,MODERATE","483","DRG","","","","","","","","inpatient","","","115023.32","","MASSHEALTH [3001]","HB BWH MEDICAID","12593.44","","Case rate ($13,924.22). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,354.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14484.84","14484.84","14484.84","1 through 10","10129.36","130407.35","case rate",""
"Peptic Ulcer And Gastritis,EXTREME","241","DRG","","","","","","","","inpatient","","","76212.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","75854.23","","Standard inlier is a Case rate ($75,854.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $64,114, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,766.88) for the length of stay and the standard reimbursement.","69299.39","69299.39","69299.39","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,EXTREME","241","DRG","","","","","","","","inpatient","","","76212.32","","MASSHEALTH [3001]","HB BWH MEDICAID","24616.84","","Case rate ($27,218.15). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $69,648.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11.04","11.04","11.04","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","51530.70","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","34640.45","","Standard inlier is a Case rate ($34,640.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,586, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,917.42) for the length of stay and the standard reimbursement.","34640.44","31578.94","34640.44","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","51530.70","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","38945.20","","Standard inlier is a Case rate ($38,945.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,586, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,527.95) for the length of stay and the standard reimbursement.","38945.19","35579.79","38945.19","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","51530.70","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","70446.41","70446.41","70446.41","1 through 10","5026.41","110825.03","percent of total billed charges",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","51530.70","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11472.0343","","Fee schedule rate ($27,960.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11472.0343","27961.00","27961.00","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","51530.70","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($27,960.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","27961.00","27961.00","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","51530.70","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12045.9694","","Fee schedule rate ($29,359.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12045.9694","29359.84","29359.84","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","51530.70","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","22781.42","","Fee schedule rate ($29,359.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22781.42","29359.84","29359.84","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","51530.70","","MASSHEALTH [3001]","HB BWH MEDICAID","10793.07","","Case rate ($11,933.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,363.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11930.67","11930.67","11930.67","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","51530.70","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","10793.07","","Case rate ($11,933.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,363.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","51530.70","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33972.92","","Fee schedule rate ($33,972.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28035.59","28035.59","28035.59","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","51530.70","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10793.07","","Case rate ($11,933.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,363.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","325.64","325.64","11930.67","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MINOR","241","DRG","","","","","","","","inpatient","","","29624.99","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21463.31","","Standard inlier is a Case rate ($21,463.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,495, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,046.54) for the length of stay and the standard reimbursement.","19608.58","19608.58","19608.58","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MINOR","241","DRG","","","","","","","","inpatient","","","29624.99","","MASSHEALTH [3001]","HB BWH MEDICAID","5026.41","","Case rate ($5,557.56). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,987.56, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1860.25","1860.25","1860.25","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MINOR","241","DRG","","","","","","","","inpatient","","","29624.99","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","5026.41","","Case rate ($5,557.56). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,987.56, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","31746.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","23764.17","","Standard inlier is a Case rate ($23,764.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,128, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,373.47) for the length of stay and the standard reimbursement.","21661.90","21661.90","21661.90","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","31746.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","26717.33","","Standard inlier is a Case rate ($26,717.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,128, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,792.30) for the length of stay and the standard reimbursement.","26717.32","26717.32","26717.32","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","31746.06","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24599.46","","Fee schedule rate ($24,599.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24599.46","24599.46","24599.46","1 through 10","5026.41","110825.03","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","31746.06","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6610.87","","Case rate ($7,309.46). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,739.46, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7307.66","7307.66","7307.66","1 through 10","5026.41","110825.03","case rate",""
"Perc Ablation Sm Bowel Fistula Tract","PX-76002524","CDM","44799","CPT","0761","RC","","","","both","","","2901.00","2175.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","899.31","2306.3","other","OPPS APC"
"Perc Ablation Sm Bowel Fistula Tract","PX-76002524","CDM","44799","CPT","0761","RC","","","","both","","","2901.00","2175.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","899.31","2306.3","other","OPPS APC"
"Perc Ablation Sm Bowel Fistula Tract","PX-76002524","CDM","44799","CPT","0761","RC","","","","both","","","2901.00","2175.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","899.31","2306.3","other","OPPS APC"
"Perc Ablation Sm Bowel Fistula Tract","PX-76002524","CDM","44799","CPT","0761","RC","","","","both","","","2901.00","2175.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","899.31","2306.3","other","OPPS APC"
"Perc Ablation Sm Bowel Fistula Tract","PX-76002524","CDM","44799","CPT","0761","RC","","","","both","","","2901.00","2175.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1244.53","42.9","","1932.92","1932.92","1932.92","1 through 10","899.31","2306.3","percent of total billed charges",""
"Perc Ablation Sm Bowel Fistula Tract","PX-76002524","CDM","44799","CPT","0761","RC","","","","both","","","2901.00","2175.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","899.31","2306.3","other","OPPS APC"
"Perc Ablation Sm Bowel Fistula Tract","PX-76002524","CDM","44799","CPT","0761","RC","","","","both","","","2901.00","2175.75","WELLPOINT [1015]","HB AMC WELLPOINT","2140.36","73.78","","2222.33","2222.33","2222.33","1 through 10","899.31","2306.3","percent of total billed charges",""
"Perc Ablation Sm Bowel Fistula Tract","PX-76002524","CDM","44799","CPT","0761","RC","","","","outpatient","","","2901.00","2175.75","AETNA [1001]","HB AMC AETNA HMO","2024.90","69.8","","2238.60","2238.60","2238.60","1 through 10","1450.5","8899.59","percent of total billed charges",""
"Perc Ablation Sm Bowel Fistula Tract","PX-76002524","CDM","44799","CPT","0761","RC","","","","outpatient","","","2901.00","2175.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1756.56","60.55","","3144.00","2870.00","3286.00","1 through 10","1450.5","8899.59","percent of total billed charges",""
"Perc Ablation Sm Bowel Fistula Tract","PX-76002524","CDM","44799","CPT","0761","RC","","","","outpatient","","","2901.00","2175.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1516.06","52.26","","1775.96","1775.96","1775.96","1 through 10","1450.5","8899.59","percent of total billed charges",""
"Perc Ablation Sm Bowel Fistula Tract","PX-76002524","CDM","44799","CPT","0761","RC","","","","outpatient","","","2901.00","2175.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1514.90","52.22","","3286.00","2018.70","5898.00","1 through 10","1450.5","8899.59","percent of total billed charges",""
"Perc Ablation Sm Bowel Fistula Tract","PX-76002524","CDM","44799","CPT","0761","RC","","","","outpatient","","","2901.00","2175.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1523.03","52.5","","8340.00","8340.00","8340.00","1 through 10","1450.5","8899.59","percent of total billed charges",""
"Perc Ablation Sm Bowel Fistula Tract","PX-76002524","CDM","44799","CPT","0761","RC","","","","outpatient","","","2901.00","2175.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2370.70","81.72","","2294.28","682.69","2294.28","1 through 10","1450.5","8899.59","percent of total billed charges",""
"Perc Close Non-Cong Septal Defect W Implant","PX-48000386","CDM","93799","CPT","0480","RC","","","","outpatient","","","40158.00","30118.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","22086.90","55","","13080.03","13080.03","13080.03","1 through 10","20079","33130.35","percent of total billed charges",""
"Perc Close Non-Cong Septal Defect W Implant","PX-48000386","CDM","93799","CPT","0481","RC","","","","both","","","40158.00","30118.50","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","31925.61","other","OPPS APC"
"Perc Close Non-Cong Septal Defect W Implant","PX-48000386","CDM","93799","CPT","0481","RC","","","","outpatient","","","40158.00","30118.50","AETNA [1001]","HB AMC AETNA HMO","28030.28","69.8","","2022.70","2022.70","2022.70","1 through 10","454","32817.12","percent of total billed charges",""
"Perc Close Non-Cong Septal Defect W Implant","PX-48000386","CDM","93799","CPT","0481","RC","","","","outpatient","","","40158.00","30118.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24315.67","60.55","","318.03","318.03","2439.77","1 through 10","454","32817.12","percent of total billed charges",""
"Perc Close Non-Cong Septal Defect W Implant","PX-48000386","CDM","93799","CPT","0481","RC","","","","outpatient","","","40158.00","30118.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","20970.51","52.22","","360.38","360.38","4023.00","1 through 10","454","32817.12","percent of total billed charges",""
"Perc Cryo Ablation W Guidance; Nerve Plexus/Truncal Nerve","PX-76002750","CDM","0442T","CPT","0761","RC","","","","outpatient","","","3069.00","2301.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6864.10","","Case rate ($6,864.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","15910.98","15910.98","15910.98","1 through 10","1227.6","6864.1","other","ASC "
"Perc Cryoablation Pancreas","PX-76010293","CDM","48999","CPT","0761","RC","","","","outpatient","","","3691.00","2768.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1927.44","52.22","","1550.84","1550.84","1550.84","1 through 10","1234.13","3045.08","percent of total billed charges",""
"Perc Decompression Pneumoperitoneum","PX-76002334","CDM","49999","CPT","0761","RC","","","","both","","","2835.00","2126.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","878.85","2253.83","other","OPPS APC"
"Perc Decompression Pneumoperitoneum","PX-76002334","CDM","49999","CPT","0761","RC","","","","both","","","2835.00","2126.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","878.85","2253.83","other","OPPS APC"
"Perc Decompression Pneumoperitoneum","PX-76002334","CDM","49999","CPT","0761","RC","","","","both","","","2835.00","2126.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","878.85","2253.83","other","OPPS APC"
"Perc Decompression Pneumoperitoneum","PX-76002334","CDM","49999","CPT","0761","RC","","","","outpatient","","","2835.00","2126.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1417.50","50","","14640.00","14640.00","14640.00","1 through 10","1417.5","8899.59","percent of total billed charges",""
"Perc Endo via Exist Access Rf Ablation Biliary Duct Stricture","PX-76002784","CDM","47999","CPT","0761","RC","","","","both","","","22647.00","16985.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","18004.37","other","OPPS APC"
"Perc Endo via Exist Access Rf Ablation Biliary Duct Stricture","PX-76002784","CDM","47999","CPT","0761","RC","","","","both","","","22647.00","16985.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","1057.74","18004.37","other","OPPS APC"
"Perc Endo via Exist Access Rf Ablation Biliary Duct Stricture","PX-76002784","CDM","47999","CPT","0761","RC","","","","outpatient","","","22647.00","16985.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","11826.26","52.22","","3734.00","1019.30","3734.00","1 through 10","9843.6","18683.78","percent of total billed charges",""
"Perc Insert Eluting Drug Microdevice Into Prostate","PX-76002737","CDM","55899","CPT","0761","RC","","","","both","","","3812.00","2859.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1391.38","36.5","","16414.61","16414.61","16414.61","1 through 10","274.39","3030.54","percent of total billed charges",""
"Perc Insert Eluting Drug Microdevice Into Prostate","PX-76002737","CDM","55899","CPT","0761","RC","","","","outpatient","","","3812.00","2859.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2308.17","60.55","","24192.00","270.73","32118.00","1 through 10","700.33","3144.9","percent of total billed charges",""
"Perc Insert Eluting Drug Microdevice Into Prostate","PX-76002737","CDM","55899","CPT","0761","RC","","","","outpatient","","","3812.00","2859.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1990.63","52.22","","24192.00","613.44","32118.00","1 through 10","700.33","3144.9","percent of total billed charges",""
"Perc Insert Eluting Drug Microdevice Into Prostate","PX-76002737","CDM","55899","CPT","0761","RC","","","","outpatient","","","3812.00","2859.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1906.00","50","","18860.73","18860.73","18860.73","1 through 10","700.33","3144.9","percent of total billed charges",""
"Perc Insert Eluting Drug Microdevice Into Prostate","PX-76002737","CDM","55899","CPT","0761","RC","","","","outpatient","","","3812.00","2859.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3115.17","81.72","","28843.15","22507.11","28843.15","1 through 10","700.33","3144.9","percent of total billed charges",""
"Perc Insert Localization Device Pre-OP Abdomen","PX-76002648","CDM","49999","CPT","0761","RC","","","","both","","","826.00","619.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","256.06","1391.62","other","OPPS APC"
"Perc Insert Localization Device Pre-OP Abdomen","PX-76002648","CDM","49999","CPT","0761","RC","","","","both","","","826.00","619.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","256.06","1391.62","other","OPPS APC"
"Perc Insert Localization Device Pre-OP Abdomen","PX-76002648","CDM","49999","CPT","0761","RC","","","","both","","","826.00","619.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","256.06","1391.62","other","OPPS APC"
"Perc Insert Localization Device Pre-OP Abdomen","PX-76002648","CDM","49999","CPT","0761","RC","","","","outpatient","","","826.00","619.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","413.00","50","","14640.00","14640.00","14640.00","1 through 10","413","8899.59","percent of total billed charges",""
"Perc Transcath Closure Interatrial","PX-48000146","CDM","93580","CPT","0481","RC","","","","both","","","49396.00","37047.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","39269.82","79.5","","37698.09","37698.09","37698.09","1 through 10","8223.98","39269.82","percent of total billed charges",""
"Perc Transcath Closure Interatrial","PX-48000146","CDM","93580","CPT","0481","RC","","","","both","","","49396.00","37047.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","26328.07","53.3","","25291.73","25291.73","25291.73","1 through 10","8223.98","39269.82","percent of total billed charges",""
"Perc Transcath Closure Interatrial","PX-48000146","CDM","93580","CPT","0481","RC","","","","both","","","49396.00","37047.00","MEDICARE [2001]","HB BWH MEDICARE","21322.53","","APC Price ($21,322.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38276.44","21324.68","38276.44","1 through 10","8223.98","39269.82","other","OPPS APC"
"Perc Transcath Closure Interatrial","PX-48000146","CDM","93580","CPT","0481","RC","","","","both","","","49396.00","37047.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18918.67","38.3","","18729.29","18729.29","18729.29","1 through 10","8223.98","39269.82","percent of total billed charges",""
"Perc Transcath Closure Interatrial","PX-48000146","CDM","93580","CPT","0481","RC","","","","both","","","49396.00","37047.00","TRICARE [160005]","HB BWH TRICARE","20258.45","","APC Price ($21,324.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","20258.45","20258.45","20258.45","1 through 10","8223.98","39269.82","other","Tricare OPPS"
"Perc Transcath Closure Interatrial","PX-48000146","CDM","93580","CPT","0481","RC","","","","outpatient","","","49396.00","37047.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13819.05","","Case rate ($13,819.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","32060.20","30816.48","32060.20","1 through 10","13819.05","43419","other","Multiple Surgery"
"Perc Transcath Closure Interatrial","PX-48000146","CDM","93580","CPT","0481","RC","","","","outpatient","","","49396.00","37047.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","13819.05","","Case rate ($13,819.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","33718.48","33718.48","33718.48","1 through 10","13819.05","43419","other","Multiple Surgery"
"Perc Transcath Closure Interatrial","PX-48000146","CDM","93580","CPT","0481","RC","","","","outpatient","","","49396.00","37047.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","40366.41","81.72","","38292.06","38292.06","38292.06","1 through 10","13819.05","43419","percent of total billed charges",""
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","both","","","7447.00","5585.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","5920.37","other","OPPS APC"
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","both","","","7447.00","5585.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","5920.37","other","OPPS APC"
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","both","","","7447.00","5585.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5920.37","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","5920.37","percent of total billed charges",""
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","both","","","7447.00","5585.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","5920.37","other","OPPS APC"
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","both","","","7447.00","5585.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","5920.37","other","OPPS APC"
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","both","","","7447.00","5585.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2718.16","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","5920.37","percent of total billed charges",""
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","both","","","7447.00","5585.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2852.20","38.3","","2723.31","1555.62","2741.61","12","1057.74","5920.37","percent of total billed charges",""
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","both","","","7447.00","5585.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","5920.37","other","OPPS APC"
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","both","","","7447.00","5585.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","5920.37","other","OPPS APC"
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","both","","","7447.00","5585.25","WELLPOINT [1015]","HB AMC WELLPOINT","5494.40","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","5920.37","percent of total billed charges",""
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","outpatient","","","7447.00","5585.25","AETNA [1001]","HB AMC AETNA PPO","5987.39","80.4","","1163.76","1163.76","1163.76","1 through 10","2384.07","6143.78","percent of total billed charges",""
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","outpatient","","","7447.00","5585.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4509.16","60.55","","1781.82","1492.00","4331.00","1 through 10","2384.07","6143.78","percent of total billed charges",""
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","outpatient","","","7447.00","5585.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3888.82","52.22","","3144.00","1492.00","3610.00","13","2384.07","6143.78","percent of total billed charges",""
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","outpatient","","","7447.00","5585.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","3909.68","52.5","","1182.28","1182.28","1182.28","1 through 10","2384.07","6143.78","percent of total billed charges",""
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","outpatient","","","7447.00","5585.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3723.50","50","","3610.00","2269.44","3610.00","1 through 10","2384.07","6143.78","percent of total billed charges",""
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","outpatient","","","7447.00","5585.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3909.68","52.5","","3610.00","2382.05","4331.00","1 through 10","2384.07","6143.78","percent of total billed charges",""
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","outpatient","","","7447.00","5585.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","4095.85","55","","4810.75","3363.17","4810.75","1 through 10","2384.07","6143.78","percent of total billed charges",""
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","outpatient","","","7447.00","5585.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6085.69","81.72","","8894.69","8894.69","8894.69","1 through 10","2384.07","6143.78","percent of total billed charges",""
"Perc Transesophageal Gastrostomy Tube Placement via Neck","PX-76002683","CDM","43999","CPT","0761","RC","","","","outpatient","","","7447.00","5585.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6085.69","81.72","","2885.83","2132.00","3462.21","1 through 10","2384.07","6143.78","percent of total billed charges",""
"Perc Visceral Artery Thrombin Inj Pseudoaneurysm","PX-76002698","CDM","37799","CPT","0761","RC","","","","outpatient","","","5765.00","4323.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3010.48","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","4756.13","percent of total billed charges",""
"Perc Visceral Artery Thrombin Inj Pseudoaneurysm","PX-76002698","CDM","37799","CPT","0761","RC","","","","outpatient","","","5765.00","4323.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3026.63","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","4756.13","percent of total billed charges",""
"Percutaneous And Other Intracardiac Procedures With McC","273","MS-DRG","","","","","","","","inpatient","","","171958.18","128968.63","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","39153.48","","Case rate ($38,013.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $45,682.85, add-ons for qualifying new technology services are included. If operating cost exceeds $91,327.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,759.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $34,313.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,303.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,319.62. The transfer capital threshold is the transfer adjustment factor * $3,319.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","36898.35","36898.35","36948.82","1 through 10","37252.83","59010.3373","other","Inpatient DRG"
"Percutaneous And Other Intracardiac Procedures With McC","273","MS-DRG","","","","","","","","inpatient","","","171958.18","128968.63","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","38013.09","","Case rate ($38,013.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $45,682.85, add-ons for qualifying new technology services are included. If operating cost exceeds $91,327.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,759.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $34,313.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,303.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,319.62. The transfer capital threshold is the transfer adjustment factor * $3,319.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35412.84","35412.84","35412.84","1 through 10","37252.83","59010.3373","other","Inpatient Replacement Plans DRG"
"Percutaneous And Other Intracardiac Procedures With McC","273","MS-DRG","","","","","","","","inpatient","","","171958.18","128968.63","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","38013.09","","Case rate ($38,013.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $45,682.85, add-ons for qualifying new technology services are included. If operating cost exceeds $91,327.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,759.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $34,313.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,303.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,319.62. The transfer capital threshold is the transfer adjustment factor * $3,319.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","54752.68","54752.68","54752.68","1 through 10","37252.83","59010.3373","other","Inpatient DRG"
"Percutaneous And Other Intracardiac Procedures With McC","273","MS-DRG","","","","","","","","inpatient","","","171958.18","128968.63","HUMANA [1012]","HB BWH MEDICARE","38013.09","","Case rate ($38,013.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $45,682.85, add-ons for qualifying new technology services are included. If operating cost exceeds $91,327.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,759.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $34,313.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,303.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,319.62. The transfer capital threshold is the transfer adjustment factor * $3,319.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","152505.06","152505.06","152505.06","1 through 10","37252.83","59010.3373","other","Inpatient Replacement Plans DRG"
"Percutaneous And Other Intracardiac Procedures With McC","273","MS-DRG","","","","","","","","inpatient","","","171958.18","128968.63","MEDICARE [2001]","HB BWH MEDICARE","38013.09","","Case rate ($38,013.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $45,682.85, add-ons for qualifying new technology services are included. If operating cost exceeds $91,327.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,759.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $34,313.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,303.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,319.62. The transfer capital threshold is the transfer adjustment factor * $3,319.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","46377.41","0.03","72429.92","27","37252.83","59010.3373","other","Inpatient Replacement Plans DRG"
"Percutaneous And Other Intracardiac Procedures With McC","273","MS-DRG","","","","","","","","inpatient","","","171958.18","128968.63","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","37252.83","","Case rate ($38,013.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $45,682.85, add-ons for qualifying new technology services are included. If operating cost exceeds $91,327.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,759.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $34,313.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,303.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,319.62. The transfer capital threshold is the transfer adjustment factor * $3,319.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","35120.49","35055.40","70360.73","1 through 10","37252.83","59010.3373","other","Inpatient DRG"
"Percutaneous And Other Intracardiac Procedures Without McC","274","MS-DRG","","","","","","","","inpatient","","","99551.56","74663.67","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","31319.30","","Case rate ($30,407.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,526.72, add-ons for qualifying new technology services are included. If operating cost exceeds $82,171.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,088.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $27,378.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,146.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,648.69. The transfer capital threshold is the transfer adjustment factor * $2,648.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","29476.56","29476.56","29476.56","1 through 10","29798.95","47099.011","other","Inpatient DRG"
"Percutaneous And Other Intracardiac Procedures Without McC","274","MS-DRG","","","","","","","","inpatient","","","99551.56","74663.67","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","30407.09","","Case rate ($30,407.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,526.72, add-ons for qualifying new technology services are included. If operating cost exceeds $82,171.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,088.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $27,378.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,146.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,648.69. The transfer capital threshold is the transfer adjustment factor * $2,648.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28298.39","28298.39","28623.59","1 through 10","29798.95","47099.011","other","Inpatient Replacement Plans DRG"
"Percutaneous And Other Intracardiac Procedures Without McC","274","MS-DRG","","","","","","","","inpatient","","","99551.56","74663.67","MEDICARE [2001]","HB BWH MEDICARE","30407.09","","Case rate ($30,407.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,526.72, add-ons for qualifying new technology services are included. If operating cost exceeds $82,171.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,088.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $27,378.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,146.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,648.69. The transfer capital threshold is the transfer adjustment factor * $2,648.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","37072.24","0.03","37127.27","112","29798.95","47099.011","other","Inpatient Replacement Plans DRG"
"Percutaneous And Other Intracardiac Procedures Without McC","274","MS-DRG","","","","","","","","inpatient","","","99551.56","74663.67","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","30407.09","","Case rate ($30,407.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,526.72, add-ons for qualifying new technology services are included. If operating cost exceeds $82,171.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,088.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $27,378.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,146.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,648.69. The transfer capital threshold is the transfer adjustment factor * $2,648.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28082.54","28082.54","28082.54","1 through 10","29798.95","47099.011","other","Inpatient Replacement Plans DRG"
"Percutaneous And Other Intracardiac Procedures Without McC","274","MS-DRG","","","","","","","","inpatient","","","99551.56","74663.67","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","29798.95","","Case rate ($30,407.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,526.72, add-ons for qualifying new technology services are included. If operating cost exceeds $82,171.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,088.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $27,378.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,146.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,648.69. The transfer capital threshold is the transfer adjustment factor * $2,648.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","28086.70","28086.70","28086.70","1 through 10","29798.95","47099.011","other","Inpatient DRG"
"Percutaneous And Other Intracardiac Procedures Without McC","274","MS-DRG","","","","","","","","inpatient","","","99551.56","74663.67","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","29798.95","","Case rate ($30,407.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $36,526.72, add-ons for qualifying new technology services are included. If operating cost exceeds $82,171.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,088.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $27,378.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $36,146.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,648.69. The transfer capital threshold is the transfer adjustment factor * $2,648.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","28087.61","28040.54","34384.93","14","29798.95","47099.011","other","Inpatient DRG"
"Percutaneous Cardiac Intervention With Ami,EXTREME","174","DRG","","","","","","","","inpatient","","","813584.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","117633.92","","Standard inlier is a Case rate ($117,633.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $103,124, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,698.84) for the length of stay and the standard reimbursement.","107227.60","107227.60","107227.60","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,EXTREME","174","DRG","","","","","","","","inpatient","","","813584.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","132252.23","","Standard inlier is a Case rate ($132,252.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $103,124, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,772.11) for the length of stay and the standard reimbursement.","132252.22","132252.22","132252.22","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,EXTREME","174","DRG","","","","","","","","inpatient","","","813584.28","","MASSHEALTH [3001]","HB BWH MEDICAID","30811.90","","Case rate ($34,067.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $76,497.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $23,966.25 and the sum of the standard inlier and any outlier amount.","31691.81","31691.81","31691.81","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MAJOR","174","DRG","","","","","","","","inpatient","","","113217.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","77141.38","","Standard inlier is a Case rate ($77,141.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $65,005, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,949.58) for the length of stay and the standard reimbursement.","86456.48","86456.48","94634.17","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MAJOR","174","DRG","","","","","","","","inpatient","","","113217.25","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","46963.9899","","Fee schedule rate ($62,582.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","46963.9899","62582.88","62582.88","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MAJOR","174","DRG","","","","","","","","inpatient","","","113217.25","","MASSHEALTH [3001]","HB BWH MEDICAID","15512.19","","Case rate ($17,151.39). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,581.39, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","35770.73","35770.73","41485.20","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MAJOR","174","DRG","","","","","","","","inpatient","","","113217.25","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","66509.35","","Fee schedule rate ($66,509.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","70225.06","70225.06","70225.06","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MAJOR","174","DRG","","","","","","","","inpatient","","","113217.25","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","69835.91","","Fee schedule rate ($69,835.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","86749.96","86749.96","86749.96","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MINOR","174","DRG","","","","","","","","inpatient","","","98512.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","63233.12","","Standard inlier is a Case rate ($63,233.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $60,819, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,976.32) for the length of stay and the standard reimbursement.","63233.12","63233.12","63233.12","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MINOR","174","DRG","","","","","","","","inpatient","","","98512.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","71091.07","","Standard inlier is a Case rate ($71,091.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $60,819, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,090.79) for the length of stay and the standard reimbursement.","71091.07","64947.83","71091.07","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MINOR","174","DRG","","","","","","","","inpatient","","","98512.85","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","46963.9899","","Fee schedule rate ($46,963.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","46963.9899","46964.00","46964.00","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MINOR","174","DRG","","","","","","","","inpatient","","","98512.85","","MASSHEALTH [3001]","HB BWH MEDICAID","12690.54","","Case rate ($14,031.58). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,461.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14028.13","6892.91","14028.13","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MINOR","174","DRG","","","","","","","","inpatient","","","98512.85","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","61590.31","","Fee schedule rate ($61,590.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","52351.76","52351.76","52351.76","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MINOR","174","DRG","","","","","","","","inpatient","","","98512.85","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12690.54","","Case rate ($14,031.58). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,461.58, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14028.13","14028.13","14028.13","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MODERATE","174","DRG","","","","","","","","inpatient","","","118204.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","68614.67","","Standard inlier is a Case rate ($68,614.67). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $65,005, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,740.27) for the length of stay and the standard reimbursement.","68614.66","68614.66","68614.66","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MODERATE","174","DRG","","","","","","","","inpatient","","","118204.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","77141.38","","Standard inlier is a Case rate ($77,141.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $65,005, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,949.58) for the length of stay and the standard reimbursement.","77141.37","77141.37","77141.37","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MODERATE","174","DRG","","","","","","","","inpatient","","","118204.09","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","77141.38","","Standard inlier is a Case rate ($77,141.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $65,005, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,949.58) for the length of stay and the standard reimbursement.","77141.37","70475.30","77141.38","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MODERATE","174","DRG","","","","","","","","inpatient","","","118204.09","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","49313.5542","","Fee schedule rate ($53,855.75). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","49313.5542","54245.57","54245.57","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MODERATE","174","DRG","","","","","","","","inpatient","","","118204.09","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","46963.9899","","Fee schedule rate ($51,289.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","46963.9899","51289.76","51289.76","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MODERATE","174","DRG","","","","","","","","inpatient","","","118204.09","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","49313.5542","","Fee schedule rate ($53,855.75). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","49313.5542","53855.76","53855.76","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MODERATE","174","DRG","","","","","","","","inpatient","","","118204.09","","MASSHEALTH [3001]","HB BWH MEDICAID","15512.19","","Case rate ($17,151.39). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,581.39, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17147.18","17147.18","34300.29","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention With Ami,MODERATE","174","DRG","","","","","","","","inpatient","","","118204.09","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15512.19","","Case rate ($17,151.39). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,581.39, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17147.18","17147.18","19766.93","1 through 10","12690.54","150668.75","case rate",""
"Percutaneous Cardiac Intervention Without Ami,EXTREME","175","DRG","","","","","","","","inpatient","","","188104.30","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","146134.48","","Standard inlier is a Case rate ($146,134.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $112,727, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,742.58) for the length of stay and the standard reimbursement.","133506.46","133506.46","146134.47","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,EXTREME","175","DRG","","","","","","","","inpatient","","","188104.30","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","34183.4861","","Fee schedule rate ($89,282.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34183.4861","85841.52","89282.36","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,EXTREME","175","DRG","","","","","","","","inpatient","","","188104.30","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35893.6538","","Fee schedule rate ($93,749.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35893.6538","93749.08","93749.08","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,EXTREME","175","DRG","","","","","","","","inpatient","","","188104.30","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","161377.77","","Fee schedule rate ($161,377.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","161377.77","161377.77","161377.77","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,EXTREME","175","DRG","","","","","","","","inpatient","","","188104.30","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","169449.31","","Fee schedule rate ($169,449.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","169449.31","169449.31","169449.31","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MAJOR","175","DRG","","","","","","","","inpatient","","","156870.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","88824.56","","Fee schedule rate ($88,824.56). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($10,277.40) multiplied by length of stay and the outlier percent (100%).","88824.55","9368.31","88824.55","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MAJOR","175","DRG","","","","","","","","inpatient","","","156870.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","99862.74","","Fee schedule rate ($99,862.74). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($11,554.53) multiplied by length of stay and the outlier percent (100%).","99862.74","11554.52","99862.74","14","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MAJOR","175","DRG","","","","","","","","inpatient","","","156870.50","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","34183.4861","","Fee schedule rate ($52,300.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34183.4861","52300.76","52300.76","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MAJOR","175","DRG","","","","","","","","inpatient","","","156870.50","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35893.6538","","Fee schedule rate ($54,917.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35893.6538","52798.80","52798.80","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MAJOR","175","DRG","","","","","","","","inpatient","","","156870.50","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91471.13","","Fee schedule rate ($91,471.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","91471.13","91471.13","91471.13","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MAJOR","175","DRG","","","","","","","","inpatient","","","156870.50","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96046.19","","Fee schedule rate ($96,046.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","96046.19","96046.19","96046.19","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MAJOR","175","DRG","","","","","","","","inpatient","","","156870.50","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","26782.77","","Case rate ($29,612.96). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $72,042.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29605.69","29605.69","29605.69","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MINOR","175","DRG","","","","","","","","inpatient","","","103331.79","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","63676.19","","Standard inlier is a Case rate ($63,676.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $61,166, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,039.22) for the length of stay and the standard reimbursement.","63676.19","63676.19","63676.19","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MINOR","175","DRG","","","","","","","","inpatient","","","103331.79","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","71589.20","","Standard inlier is a Case rate ($71,589.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $61,166, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,161.49) for the length of stay and the standard reimbursement.","65402.92","65402.92","71589.20","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MINOR","175","DRG","","","","","","","","inpatient","","","103331.79","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","34183.4861","","Fee schedule rate ($37,261.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34183.4861","34183.48","34183.48","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MINOR","175","DRG","","","","","","","","inpatient","","","103331.79","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35893.6538","","Fee schedule rate ($39,125.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35893.6538","35893.64","35893.64","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MODERATE","175","DRG","","","","","","","","inpatient","","","129523.41","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","71971.66","","Standard inlier is a Case rate ($71,971.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $67,615, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,216.81) for the length of stay and the standard reimbursement.","71971.66","65604.79","71971.66","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MODERATE","175","DRG","","","","","","","","inpatient","","","129523.41","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","80915.54","","Standard inlier is a Case rate ($80,915.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $67,615, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,485.29) for the length of stay and the standard reimbursement.","73923.33","73923.33","80915.54","17","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MODERATE","175","DRG","","","","","","","","inpatient","","","129523.41","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","34183.4861","","Fee schedule rate ($37,261.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34183.4861","37261.20","37261.20","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MODERATE","175","DRG","","","","","","","","inpatient","","","129523.41","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","35893.6538","","Fee schedule rate ($39,125.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35893.6538","39125.32","39125.32","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MODERATE","175","DRG","","","","","","","","inpatient","","","129523.41","","MASSHEALTH [3001]","HB BWH MEDICAID","20551.16","","Case rate ($22,722.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,152.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22717.26","22717.26","22717.26","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MODERATE","175","DRG","","","","","","","","inpatient","","","129523.41","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80922.46","","Fee schedule rate ($80,922.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","80922.46","80922.46","80922.46","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiac Intervention Without Ami,MODERATE","175","DRG","","","","","","","","inpatient","","","129523.41","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","20551.16","","Case rate ($22,722.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,152.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22717.27","17963.60","22717.27","1 through 10","16859.04","169449.31","case rate",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","162434.65","121825.99","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","25955.24","","Case rate ($25,199.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,257.53, add-ons for qualifying new technology services are included. If operating cost exceeds $75,901.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,629.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,630.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,877.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,189.32. The transfer capital threshold is the transfer adjustment factor * $2,189.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","26967.31","26967.31","26967.31","1 through 10","24695.27","42618.61","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","162434.65","121825.99","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","32591.18","","Case rate ($32,591.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,257.53, add-ons for qualifying new technology services are included. If operating cost exceeds $75,901.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,629.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $30,022.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,877.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,189.32. The transfer capital threshold is the transfer adjustment factor * $2,189.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","33323.35","25918.37","33382.03","1 through 10","24695.27","42618.61","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","162434.65","121825.99","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","31499.08","","Case rate ($25,199.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,257.53, add-ons for qualifying new technology services are included. If operating cost exceeds $75,901.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,629.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,630.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,877.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,189.32. The transfer capital threshold is the transfer adjustment factor * $2,189.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","26322.08","26322.08","26322.08","1 through 10","24695.27","42618.61","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","162434.65","121825.99","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","25199.26","","Case rate ($25,199.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,257.53, add-ons for qualifying new technology services are included. If operating cost exceeds $75,901.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,629.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,630.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,877.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,189.32. The transfer capital threshold is the transfer adjustment factor * $2,189.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25765.27","25765.27","25765.27","1 through 10","24695.27","42618.61","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","162434.65","121825.99","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","32591.18","","Case rate ($32,591.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,257.53, add-ons for qualifying new technology services are included. If operating cost exceeds $75,901.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,629.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $30,022.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,877.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,189.32. The transfer capital threshold is the transfer adjustment factor * $2,189.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25787.40","25787.40","25787.40","1 through 10","24695.27","42618.61","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","162434.65","121825.99","HUMANA [1012]","HB BWH MEDICARE","32591.18","","Case rate ($32,591.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,257.53, add-ons for qualifying new technology services are included. If operating cost exceeds $75,901.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,629.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $30,022.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,877.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,189.32. The transfer capital threshold is the transfer adjustment factor * $2,189.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25677.87","25677.87","25677.87","1 through 10","24695.27","42618.61","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","162434.65","121825.99","MEDICARE [2001]","HB BWH MEDICARE","32591.18","","Case rate ($32,591.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,257.53, add-ons for qualifying new technology services are included. If operating cost exceeds $75,901.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,629.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $30,022.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,877.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,189.32. The transfer capital threshold is the transfer adjustment factor * $2,189.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","33839.63","0.03","44122.72","72","24695.27","42618.61","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","162434.65","121825.99","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","24695.27","","Case rate ($25,199.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,257.53, add-ons for qualifying new technology services are included. If operating cost exceeds $75,901.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,629.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,630.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,877.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,189.32. The transfer capital threshold is the transfer adjustment factor * $2,189.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25700.59","25700.59","25700.59","1 through 10","24695.27","42618.61","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","162434.65","121825.99","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","24695.27","","Case rate ($25,199.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,257.53, add-ons for qualifying new technology services are included. If operating cost exceeds $75,901.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,629.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $22,630.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,877.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,189.32. The transfer capital threshold is the transfer adjustment factor * $2,189.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25693.73","25619.10","25975.85","14","24695.27","42618.61","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","109105.37","81829.03","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","16955.97","","Case rate ($16,462.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,739.72, add-ons for qualifying new technology services are included. If operating cost exceeds $65,384.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,858.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $14,663.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,359.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.61. The transfer capital threshold is the transfer adjustment factor * $1,418.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","17231.21","17231.21","17284.10","1 through 10","16132.87","27302.6372","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","109105.37","81829.03","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","16462.11","","Case rate ($16,462.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,739.72, add-ons for qualifying new technology services are included. If operating cost exceeds $65,384.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,858.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $14,663.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,359.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.61. The transfer capital threshold is the transfer adjustment factor * $1,418.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16519.24","16519.24","16519.27","1 through 10","16132.87","27302.6372","other","Inpatient Replacement Plans DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","109105.37","81829.03","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","16462.11","","Case rate ($16,462.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,739.72, add-ons for qualifying new technology services are included. If operating cost exceeds $65,384.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,858.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $14,663.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,359.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.61. The transfer capital threshold is the transfer adjustment factor * $1,418.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16451.90","16451.90","16463.30","1 through 10","16132.87","27302.6372","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","109105.37","81829.03","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","16462.11","","Case rate ($16,462.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,739.72, add-ons for qualifying new technology services are included. If operating cost exceeds $65,384.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,858.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $14,663.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,359.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.61. The transfer capital threshold is the transfer adjustment factor * $1,418.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16415.08","16415.08","16415.08","1 through 10","16132.87","27302.6372","other","Inpatient Replacement Plans DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","109105.37","81829.03","MEDICARE [2001]","HB BWH MEDICARE","16462.11","","Case rate ($16,462.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,739.72, add-ons for qualifying new technology services are included. If operating cost exceeds $65,384.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,858.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $14,663.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,359.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.61. The transfer capital threshold is the transfer adjustment factor * $1,418.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21607.22","0.03","21639.12","62","16132.87","27302.6372","other","Inpatient Replacement Plans DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","109105.37","81829.03","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16132.87","","Case rate ($16,462.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,739.72, add-ons for qualifying new technology services are included. If operating cost exceeds $65,384.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,858.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $14,663.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,359.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.61. The transfer capital threshold is the transfer adjustment factor * $1,418.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16414.68","16395.89","16475.00","1 through 10","16132.87","27302.6372","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","109105.37","81829.03","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16132.87","","Case rate ($16,462.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,739.72, add-ons for qualifying new technology services are included. If operating cost exceeds $65,384.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,858.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $14,663.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,359.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.61. The transfer capital threshold is the transfer adjustment factor * $1,418.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16403.68","16388.33","16465.94","1 through 10","16132.87","27302.6372","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","109105.37","81829.03","WELLPOINT [1015]","HB AMC WELLPOINT","27302.6372","","Fee schedule rate ($27,615.63).","27302.6372","170084.97","170084.97","1 through 10","16132.87","27302.6372","case rate",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","109105.37","81829.03","WELLSENSE [1003]","HB BWH MEDICARE","16462.11","","Case rate ($16,462.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,739.72, add-ons for qualifying new technology services are included. If operating cost exceeds $65,384.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,858.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $14,663.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,359.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.61. The transfer capital threshold is the transfer adjustment factor * $1,418.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16945.98","16945.98","16945.98","1 through 10","16132.87","27302.6372","other","Inpatient Replacement Plans DRG"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With McC","250","MS-DRG","","","","","","","","inpatient","","","129449.11","97086.83","MEDICARE [2001]","HB BWH MEDICARE","20288.84","","Case rate ($20,288.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,346.35, add-ons for qualifying new technology services are included. If operating cost exceeds $69,990.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,196.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $18,152.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,966.50 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,756.17. The transfer capital threshold is the transfer adjustment factor * $1,756.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27541.87","27541.87","27582.65","1 through 10","19883.06","34186.68","other","Inpatient Replacement Plans DRG"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With McC","250","MS-DRG","","","","","","","","inpatient","","","129449.11","97086.83","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19883.06","","Case rate ($20,288.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,346.35, add-ons for qualifying new technology services are included. If operating cost exceeds $69,990.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,196.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $18,152.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,966.50 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,756.17. The transfer capital threshold is the transfer adjustment factor * $1,756.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","39144.65","39144.65","39144.65","1 through 10","19883.06","34186.68","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With McC","250","MS-DRG","","","","","","","","inpatient","","","129449.11","97086.83","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19883.06","","Case rate ($20,288.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,346.35, add-ons for qualifying new technology services are included. If operating cost exceeds $69,990.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,196.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $18,152.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,966.50 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,756.17. The transfer capital threshold is the transfer adjustment factor * $1,756.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20934.44","20934.44","20934.44","1 through 10","19883.06","34186.68","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC","251","MS-DRG","","","","","","","","inpatient","","","122630.46","91972.84","MEDICARE [2001]","HB BWH MEDICARE","18073.12","","Case rate ($18,073.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,791.27, add-ons for qualifying new technology services are included. If operating cost exceeds $62,435.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,642.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $16,490.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,411.43 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,202.56. The transfer capital threshold is the transfer adjustment factor * $1,202.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18700.02","18700.02","18700.02","1 through 10","13732.57","23409.85","other","Inpatient DRG"
"Percutaneous Closure Pda","PX-48000387","CDM","93799","CPT","0480","RC","","","","outpatient","","","29406.00","22054.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","16173.30","55","","13080.03","13080.03","13080.03","1 through 10","14703","24259.95","percent of total billed charges",""
"Percutaneous Closure Pda","PX-48000387","CDM","93799","CPT","0481","RC","","","","both","","","29406.00","22054.50","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","23377.77","other","OPPS APC"
"Percutaneous Closure Pda","PX-48000387","CDM","93799","CPT","0481","RC","","","","outpatient","","","29406.00","22054.50","AETNA [1001]","HB AMC AETNA HMO","20525.39","69.8","","2022.70","2022.70","2022.70","1 through 10","454","24030.58","percent of total billed charges",""
"Percutaneous Closure Pda","PX-48000387","CDM","93799","CPT","0481","RC","","","","outpatient","","","29406.00","22054.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","17805.33","60.55","","318.03","318.03","2439.77","1 through 10","454","24030.58","percent of total billed charges",""
"Percutaneous Closure Pda","PX-48000387","CDM","93799","CPT","0481","RC","","","","outpatient","","","29406.00","22054.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","15355.81","52.22","","360.38","360.38","4023.00","1 through 10","454","24030.58","percent of total billed charges",""
"Percutaneous Colon Stent Placement via Stoma","PX-75000526","CDM","45399","CPT","0750","RC","","","","both","","","2076.00","1557.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","757.74","36.5","","2892.24","2892.24","2892.24","1 through 10","643.56","1650.42","percent of total billed charges",""
"Percutaneous Colon Stent Placement via Stoma","PX-75000526","CDM","45399","CPT","0750","RC","","","","both","","","2076.00","1557.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","795.11","38.3","","2777.42","2083.54","2946.52","1 through 10","643.56","1650.42","percent of total billed charges",""
"Percutaneous Colon Stent Placement via Stoma","PX-75000526","CDM","45399","CPT","0750","RC","","","","both","","","2076.00","1557.00","TRICARE [160005]","HB BWH TRICARE","1028.57","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1028.57","1028.57","1028.57","1 through 10","643.56","1650.42","other","Tricare OPPS"
"Percutaneous Colon Stent Placement via Stoma","PX-75000526","CDM","45399","CPT","0750","RC","","","","both","","","2076.00","1557.00","WELLPOINT [1015]","HB AMC WELLPOINT","1531.67","73.78","","5772.85","5772.85","7754.00","1 through 10","643.56","1650.42","percent of total billed charges",""
"Percutaneous Colon Stent Placement via Stoma","PX-75000526","CDM","45399","CPT","0750","RC","","","","outpatient","","","2076.00","1557.00","AETNA [1001]","HB AMC AETNA HMO","1449.05","69.8","","5249.46","3706.41","5249.46","1 through 10","1038","2384.07","percent of total billed charges",""
"Percutaneous Colon Stent Placement via Stoma","PX-75000526","CDM","45399","CPT","0750","RC","","","","outpatient","","","2076.00","1557.00","AETNA [1001]","HB AMC AETNA PPO","1669.10","80.4","","6048.12","6048.12","6048.12","1 through 10","1038","2384.07","percent of total billed charges",""
"Percutaneous Colon Stent Placement via Stoma","PX-75000526","CDM","45399","CPT","0750","RC","","","","outpatient","","","2076.00","1557.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1257.02","60.55","","1533.28","1533.28","7754.00","1 through 10","1038","2384.07","percent of total billed charges",""
"Percutaneous Colon Stent Placement via Stoma","PX-75000526","CDM","45399","CPT","0750","RC","","","","outpatient","","","2076.00","1557.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1084.09","52.22","","1974.52","1533.28","7754.00","21","1038","2384.07","percent of total billed charges",""
"Percutaneous Colon Stent Placement via Stoma","PX-75000526","CDM","45399","CPT","0750","RC","","","","outpatient","","","2076.00","1557.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1089.90","52.5","","4063.09","4063.09","4063.09","1 through 10","1038","2384.07","percent of total billed charges",""
"Percutaneous Colon Stent Placement via Stoma","PX-75000526","CDM","45399","CPT","0750","RC","","","","outpatient","","","2076.00","1557.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1696.51","81.72","","6198.55","6198.55","7754.00","1 through 10","1038","2384.07","percent of total billed charges",""
"Percutaneous Colon Stent Placement via Stoma","PX-75000526","CDM","45399","CPT","0750","RC","","","","outpatient","","","2076.00","1557.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1297.50","62.5","","4691.17","4691.17","4691.17","1 through 10","1038","2384.07","percent of total billed charges",""
"Percutaneous Coronary Lithotripsy With Other Intervention","PX-48000482","CDM","92972","CPT","0481","RC","","","","outpatient","","","8984.00","6738.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7341.72","81.72","","6964.37","6964.37","6964.37","1 through 10","3593.6","7411.8","percent of total billed charges",""
"Percutaneous Cryoablation Peritoneal/Retroperitoneal","PX-76001868","CDM","49999","CPT","0761","RC","","","","both","","","5011.00","3758.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","3983.75","other","OPPS APC"
"Percutaneous Cryoablation Peritoneal/Retroperitoneal","PX-76001868","CDM","49999","CPT","0761","RC","","","","both","","","5011.00","3758.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3983.75","other","OPPS APC"
"Percutaneous Cryoablation Peritoneal/Retroperitoneal","PX-76001868","CDM","49999","CPT","0761","RC","","","","both","","","5011.00","3758.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","1057.74","3983.75","other","OPPS APC"
"Percutaneous Cryoablation Peritoneal/Retroperitoneal","PX-76001868","CDM","49999","CPT","0761","RC","","","","outpatient","","","5011.00","3758.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2505.50","50","","14640.00","14640.00","14640.00","1 through 10","2505.5","8899.59","percent of total billed charges",""
"Percutaneous Endoscopy Non-Biliary via Tube Tract","PX-76002938","CDM","49999","CPT","0761","RC","","","","both","","","2954.00","2215.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","915.74","2348.43","other","OPPS APC"
"Percutaneous Endoscopy Non-Biliary via Tube Tract","PX-76002938","CDM","49999","CPT","0761","RC","","","","both","","","2954.00","2215.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","915.74","2348.43","other","OPPS APC"
"Percutaneous Endoscopy Non-Biliary via Tube Tract","PX-76002938","CDM","49999","CPT","0761","RC","","","","both","","","2954.00","2215.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","915.74","2348.43","other","OPPS APC"
"Percutaneous Endoscopy Non-Biliary via Tube Tract","PX-76002938","CDM","49999","CPT","0761","RC","","","","outpatient","","","2954.00","2215.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1477.00","50","","14640.00","14640.00","14640.00","1 through 10","1477","8899.59","percent of total billed charges",""
"Percutaneous Epicardial Ablation","PX-48000483","CDM","93799","CPT","0481","RC","","","","both","","","53851.00","40388.25","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","42811.55","other","OPPS APC"
"Percutaneous Epicardial Ablation","PX-48000483","CDM","93799","CPT","0481","RC","","","","outpatient","","","53851.00","40388.25","AETNA [1001]","HB AMC AETNA HMO","37588.00","69.8","","2022.70","2022.70","2022.70","1 through 10","454","44427.08","percent of total billed charges",""
"Percutaneous Epicardial Ablation","PX-48000483","CDM","93799","CPT","0481","RC","","","","outpatient","","","53851.00","40388.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","32606.78","60.55","","318.03","318.03","2439.77","1 through 10","454","44427.08","percent of total billed charges",""
"Percutaneous Epicardial Ablation","PX-48000483","CDM","93799","CPT","0481","RC","","","","outpatient","","","53851.00","40388.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","28120.99","52.22","","360.38","360.38","4023.00","1 through 10","454","44427.08","percent of total billed charges",""
"Percutaneous Epicardial Ablation","PX-48000483","CDM","93799","CPT","0481","RC","","","","outpatient","","","53851.00","40388.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","29618.05","55","","13080.03","13080.03","13080.03","1 through 10","454","44427.08","percent of total billed charges",""
"Percutaneous Foreign Body Removal via Biliary Access","PX-76002819","CDM","47999","CPT","0761","RC","","","","both","","","1802.00","1351.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","558.62","1432.59","other","OPPS APC"
"Percutaneous Foreign Body Removal via Biliary Access","PX-76002819","CDM","47999","CPT","0761","RC","","","","both","","","1802.00","1351.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1097.25","973.53","1097.25","1 through 10","558.62","1432.59","other","OPPS APC"
"Percutaneous Foreign Body Removal via Biliary Access","PX-76002819","CDM","47999","CPT","0761","RC","","","","outpatient","","","1802.00","1351.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","941.00","52.22","","3734.00","1019.30","3734.00","1 through 10","901","9843.6","percent of total billed charges",""
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","both","","","980.00","735.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","303.8","1391.62","other","OPPS APC"
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","both","","","980.00","735.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","303.8","1391.62","other","OPPS APC"
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","both","","","980.00","735.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","779.10","79.5","","2814.50","2346.50","2814.50","1 through 10","303.8","1391.62","percent of total billed charges",""
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","both","","","980.00","735.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","303.8","1391.62","other","OPPS APC"
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","both","","","980.00","735.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","303.8","1391.62","other","OPPS APC"
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","357.70","36.5","","2677.58","1482.13","2910.89","1 through 10","303.8","1391.62","percent of total billed charges",""
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","375.34","38.3","","2723.31","1555.62","2741.61","12","303.8","1391.62","percent of total billed charges",""
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","303.8","1391.62","other","OPPS APC"
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","both","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","303.8","1391.62","other","OPPS APC"
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","both","","","980.00","735.00","WELLPOINT [1015]","HB AMC WELLPOINT","723.04","73.78","","2687.65","2687.64","3224.43","1 through 10","303.8","1391.62","percent of total billed charges",""
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","outpatient","","","980.00","735.00","AETNA [1001]","HB AMC AETNA PPO","787.92","80.4","","1163.76","1163.76","1163.76","1 through 10","490","2384.07","percent of total billed charges",""
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","outpatient","","","980.00","735.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","593.39","60.55","","1781.82","1492.00","4331.00","1 through 10","490","2384.07","percent of total billed charges",""
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","outpatient","","","980.00","735.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","511.76","52.22","","3144.00","1492.00","3610.00","13","490","2384.07","percent of total billed charges",""
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","outpatient","","","980.00","735.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","514.50","52.5","","1182.28","1182.28","1182.28","1 through 10","490","2384.07","percent of total billed charges",""
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","outpatient","","","980.00","735.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","490.00","50","","3610.00","2269.44","3610.00","1 through 10","490","2384.07","percent of total billed charges",""
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","outpatient","","","980.00","735.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","514.50","52.5","","3610.00","2382.05","4331.00","1 through 10","490","2384.07","percent of total billed charges",""
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","outpatient","","","980.00","735.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","539.00","55","","4810.75","3363.17","4810.75","1 through 10","490","2384.07","percent of total billed charges",""
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","outpatient","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","800.86","81.72","","8894.69","8894.69","8894.69","1 through 10","490","2384.07","percent of total billed charges",""
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","outpatient","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","800.86","81.72","","2885.83","2132.00","3462.21","1 through 10","490","2384.07","percent of total billed charges",""
"Percutaneous Hepatic Perfusion","PX-76003013","CDM","37799","CPT","0761","RC","","","","outpatient","","","34862.00","26146.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18204.94","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","28761.15","percent of total billed charges",""
"Percutaneous Hepatic Perfusion","PX-76003013","CDM","37799","CPT","0761","RC","","","","outpatient","","","34862.00","26146.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","18302.55","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","28761.15","percent of total billed charges",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,EXTREME","030","DRG","","","","","","","","inpatient","","","156397.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","143458.21","","Standard inlier is a Case rate ($143,458.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $123,205, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,364.76) for the length of stay and the standard reimbursement.","155654.07","155654.07","155654.07","1 through 10","20037.1","161285.69","case rate",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,EXTREME","030","DRG","","","","","","","","inpatient","","","156397.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","161285.69","","Standard inlier is a Case rate ($161,285.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $123,205, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($22,893.16) for the length of stay and the standard reimbursement.","147348.40","147348.40","161285.68","1 through 10","20037.1","161285.69","case rate",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,EXTREME","030","DRG","","","","","","","","inpatient","","","156397.84","","MASSHEALTH [3001]","HB BWH MEDICAID","47971.38","","Case rate ($53,040.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $95,470.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23554.49","23554.49","53027.59","1 through 10","20037.1","161285.69","case rate",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,EXTREME","030","DRG","","","","","","","","inpatient","","","156397.84","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","47971.38","","Case rate ($53,040.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $95,470.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","74422.57","74422.57","74422.57","1 through 10","20037.1","161285.69","case rate",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,MAJOR","030","DRG","","","","","","","","inpatient","","","134997.76","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","122162.33","","Standard inlier is a Case rate ($122,162.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $96,145, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,339.93) for the length of stay and the standard reimbursement.","12911.71","12911.71","12911.71","1 through 10","20037.1","161285.69","case rate",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,MAJOR","030","DRG","","","","","","","","inpatient","","","134997.76","","MASSHEALTH [3001]","HB BWH MEDICAID","36158.17","","Case rate ($39,979.07). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $82,409.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $7,113.71 and the sum of the standard inlier and any outlier amount.","17084.05","17084.05","17084.05","1 through 10","20037.1","161285.69","case rate",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,MAJOR","030","DRG","","","","","","","","inpatient","","","134997.76","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","36158.17","","Case rate ($39,979.07). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $82,409.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $7,113.71 and the sum of the standard inlier and any outlier amount.","39969.26","39969.26","42495.82","1 through 10","20037.1","161285.69","case rate",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,MINOR","030","DRG","","","","","","","","inpatient","","","121768.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","59187.26","","Standard inlier is a Case rate ($59,187.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,675, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,401.99) for the length of stay and the standard reimbursement.","59187.26","59187.26","59187.26","1 through 10","20037.1","161285.69","case rate",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,MINOR","030","DRG","","","","","","","","inpatient","","","121768.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","66542.44","","Standard inlier is a Case rate ($66,542.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,675, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,445.15) for the length of stay and the standard reimbursement.","66640.14","66640.14","66640.14","1 through 10","20037.1","161285.69","case rate",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,MINOR","030","DRG","","","","","","","","inpatient","","","121768.44","","MASSHEALTH [3001]","HB BWH MEDICAID","20037.10","","Case rate ($22,154.46). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,584.46, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22149.02","22149.02","22149.02","1 through 10","20037.1","161285.69","case rate",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,MINOR","030","DRG","","","","","","","","inpatient","","","121768.44","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","20037.10","","Case rate ($22,154.46). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,584.46, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6685.11","6685.11","6685.11","1 through 10","20037.1","161285.69","case rate",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,MODERATE","030","DRG","","","","","","","","inpatient","","","126944.93","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","89165.63","","Standard inlier is a Case rate ($89,165.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $73,322, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($12,656.32) for the length of stay and the standard reimbursement.","90359.04","90359.04","90359.04","1 through 10","20037.1","161285.69","case rate",""
"Percutaneous Intracranial And Extracranial Vascular Procedures,MODERATE","030","DRG","","","","","","","","inpatient","","","126944.93","","MASSHEALTH [3001]","HB BWH MEDICAID","24931.00","","Case rate ($27,565.50). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $69,995.50, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","89715.51","89715.51","89715.51","1 through 10","20037.1","161285.69","case rate",""
"Percutaneous Ligation/Banding Av Fistula","PX-76002681","CDM","37799","CPT","0761","RC","","","","outpatient","","","7582.00","5686.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3959.32","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","6255.15","percent of total billed charges",""
"Percutaneous Ligation/Banding Av Fistula","PX-76002681","CDM","37799","CPT","0761","RC","","","","outpatient","","","7582.00","5686.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3980.55","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","6255.15","percent of total billed charges",""
"Percutaneous Removal of Pancreatic Duct Stent","PX-76002946","CDM","48999","CPT","0761","RC","","","","outpatient","","","6652.00","4989.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3473.67","52.22","","1550.84","1550.84","1550.84","1 through 10","1234.13","5487.9","percent of total billed charges",""
"Percutaneous Rf Ablation Lymph System","PX-76002522","CDM","38999","CPT","0761","RC","","","","outpatient","","","3694.00","2770.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1929.01","52.22","","512.50","512.50","512.50","1 through 10","1234.13","3047.55","percent of total billed charges",""
"Percutaneous Rf Ablation Lymph System","PX-76002522","CDM","38999","CPT","0761","RC","","","","outpatient","","","3694.00","2770.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1847.00","50","","6776.11","6776.11","6776.11","1 through 10","1234.13","3047.55","percent of total billed charges",""
"Percutaneous Spleno-Renal Shunt With Stent","PX-76102093","CDM","37799","CPT","0761","RC","","","","outpatient","","","12027.00","9020.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6280.50","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","9922.28","percent of total billed charges",""
"Percutaneous Spleno-Renal Shunt With Stent","PX-76102093","CDM","37799","CPT","0761","RC","","","","outpatient","","","12027.00","9020.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6314.18","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","9922.28","percent of total billed charges",""
"Percutaneous Structural Cardiac Procedures,EXTREME","183","DRG","","","","","","","","inpatient","","","329825.95","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","243364.75","","Standard inlier is a Case rate ($243,364.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $179,979, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($34,543.61) for the length of stay and the standard reimbursement.","243364.75","243364.75","243364.75","1 through 10","46441.75","243364.75","case rate",""
"Percutaneous Structural Cardiac Procedures,EXTREME","183","DRG","","","","","","","","inpatient","","","329825.95","","MASSHEALTH [3001]","HB BWH MEDICAID","81298.76","","Case rate ($89,889.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $132,319.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","89867.70","89867.70","89867.70","1 through 10","46441.75","243364.75","case rate",""
"Percutaneous Structural Cardiac Procedures,MAJOR","183","DRG","","","","","","","","inpatient","","","175852.64","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","170953.81","","Standard inlier is a Case rate ($170,953.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $129,895, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($24,265.47) for the length of stay and the standard reimbursement.","170953.81","170953.81","170953.81","1 through 10","46441.75","243364.75","case rate",""
"Percutaneous Structural Cardiac Procedures,MAJOR","183","DRG","","","","","","","","inpatient","","","175852.64","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","60188.98","","Case rate ($66,549.26). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $108,979.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","66532.93","66532.93","66532.93","1 through 10","46441.75","243364.75","case rate",""
"Percutaneous Structural Cardiac Procedures,MINOR","183","DRG","","","","","","","","inpatient","","","123692.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","126954.60","","Standard inlier is a Case rate ($126,954.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $110,373, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,021.97) for the length of stay and the standard reimbursement.","142731.18","142731.18","142731.18","1 through 10","46441.75","243364.75","case rate",""
"Percutaneous Structural Cardiac Procedures,MINOR","183","DRG","","","","","","","","inpatient","","","123692.31","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","142731.18","","Standard inlier is a Case rate ($142,731.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $110,373, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,259.51) for the length of stay and the standard reimbursement.","142731.18","142731.18","142731.18","1 through 10","46441.75","243364.75","case rate",""
"Percutaneous Structural Cardiac Procedures,MODERATE","183","DRG","","","","","","","","inpatient","","","141059.75","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","130592.96","","Standard inlier is a Case rate ($130,592.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $113,201, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,538.46) for the length of stay and the standard reimbursement.","119040.24","119040.24","119040.24","1 through 10","46441.75","243364.75","case rate",""
"Percutaneous Structural Cardiac Procedures,MODERATE","183","DRG","","","","","","","","inpatient","","","141059.75","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","146821.68","","Standard inlier is a Case rate ($146,821.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $113,201, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,840.12) for the length of stay and the standard reimbursement.","134134.28","134134.28","146821.68","1 through 10","46441.75","243364.75","case rate",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","both","","","29.00","21.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","19.02","65.6","","310.81","310.81","310.81","1 through 10","8.99","1510.11","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","both","","","29.00","21.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","23.06","79.5","","116.48","78.14","116.48","371","8.99","1510.11","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","both","","","29.00","21.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","15.46","53.3","","116.48","78.14","116.48","138","8.99","1510.11","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","both","","","29.00","21.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1208.09","","APC Price ($1,208.09). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.04","54.04","54.04","23","8.99","1510.11","other","OPPS APC"
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","both","","","29.00","21.75","HUMANA [1012]","HB BWH MEDICARE","1208.09","","APC Price ($1,208.09). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","59.20","59.20","59.20","20","8.99","1510.11","other","OPPS APC"
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","both","","","29.00","21.75","MEDICARE [2001]","HB BWH MEDICARE","1208.09","","APC Price ($1,208.09). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.92","30.21","60.41","244","8.99","1510.11","other","OPPS APC"
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","both","","","29.00","21.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11.11","38.3","","112.48","112.48","115.74","248","8.99","1510.11","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","both","","","29.00","21.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","22.33","77","","2832.72","2832.72","2832.72","1 through 10","8.99","1510.11","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","both","","","29.00","21.75","WELLPOINT [1015]","HB AMC WELLPOINT","21.40","73.78","","110.19","110.19","3070.19","158","8.99","1510.11","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","outpatient","","","29.00","21.75","AETNA [1001]","HB AMC AETNA HMO","20.24","69.8","","100.20","70.74","115.44","144","14.5","197.92","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","outpatient","","","29.00","21.75","AETNA [1001]","HB AMC AETNA PPO","23.32","80.4","","155.10","115.44","155.10","112","14.5","197.92","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","outpatient","","","29.00","21.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","16.21","55.9","","77.55","77.55","77.55","1 through 10","14.5","197.92","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","outpatient","","","29.00","21.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","15.23","52.5","","85.25","85.25","96.94","44","14.5","197.92","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","outpatient","","","29.00","21.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","18.13","62.5","","96.94","93.09","125.26","64","14.5","197.92","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","outpatient","","","29.00","21.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","15.95","55","","85.25","81.99","85.25","120","14.5","197.92","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","outpatient","","","29.00","21.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","23.32","80.4","","115.44","115.44","115.44","22","14.5","197.92","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","outpatient","","","29.00","21.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","15.23","52.5","","93.09","93.09","93.09","28","14.5","197.92","percent of total billed charges",""
"Percutaneous Tests W/Allergenic Extracts","PX-98300830","CDM","95004","CPT","0983","RC","","","","outpatient","","","29.00","21.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","23.70","81.72","","118.31","65.08","118.31","547","14.5","197.92","percent of total billed charges",""
"Perflut Lipid Micro Ty a Optison 1m","PX-25500028","CDM","Q9956","HCPCS","0255","RC","","","","both","","","165.80","124.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","116.06","70","","143.21","143.21","143.21","1 through 10","51.4","127.67","percent of total billed charges",""
"Perflut Lipid Micro Ty a Optison 1m","PX-25500028","CDM","Q9956","HCPCS","0255","RC","","","","both","","","165.80","124.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.52","36.5","","74.19","63.05","74.19","39","51.4","127.67","percent of total billed charges",""
"Perflut Lipid Micro Ty a Optison 1m","PX-25500028","CDM","Q9956","HCPCS","0255","RC","","","","both","","","165.80","124.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.50","38.3","","77.77","77.77","233.31","135","51.4","127.67","percent of total billed charges",""
"Perflut Lipid Micro Ty a Optison 1m","PX-25500028","CDM","Q9956","HCPCS","0255","RC","","","","outpatient","","","165.80","124.35","AETNA [1001]","HB AMC AETNA HMO","115.73","69.8","","134.66","95.07","155.14","51","86.65","133.3","percent of total billed charges",""
"Perflut Lipid Micro Ty a Optison 1m","PX-25500028","CDM","Q9956","HCPCS","0255","RC","","","","outpatient","","","165.80","124.35","AETNA [1001]","HB AMC AETNA PPO","133.30","80.4","","155.14","155.14","155.14","1 through 10","86.65","133.3","percent of total billed charges",""
"Perflut Lipid Micro Ty a Optison 1m","PX-25500028","CDM","Q9956","HCPCS","0255","RC","","","","outpatient","","","165.80","124.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","86.65","52.26","","84.98","84.98","84.98","1 through 10","86.65","133.3","percent of total billed charges",""
"Peri-Proc Device Eval & Prog Pm","PX-48000012","CDM","93286","CPT","0480","RC","","","","both","","","694.00","520.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","551.73","79.5","","355.35","355.35","529.65","1 through 10","215.14","551.73","percent of total billed charges",""
"Peri-Proc Device Eval & Prog Pm","PX-48000012","CDM","93286","CPT","0480","RC","","","","both","","","694.00","520.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","253.31","36.5","","251.03","251.03","251.03","1 through 10","215.14","551.73","percent of total billed charges",""
"Peri-Proc Device Eval & Prog Pm","PX-48000012","CDM","93286","CPT","0480","RC","","","","both","","","694.00","520.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","265.80","38.3","","263.15","263.15","789.44","28","215.14","551.73","percent of total billed charges",""
"Peri-Proc Device Eval & Prog Pm","PX-48000012","CDM","93286","CPT","0480","RC","","","","both","","","694.00","520.50","WELLPOINT [1015]","HB AMC WELLPOINT","512.03","73.78","","501.05","501.05","501.05","1 through 10","215.14","551.73","percent of total billed charges",""
"Peri-Proc Device Eval & Prog Pm","PX-48000012","CDM","93286","CPT","0480","RC","","","","outpatient","","","694.00","520.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","567.14","81.72","","538.00","538.00","538.00","1 through 10","362.68","567.14","percent of total billed charges",""
"Peri-Proc Device Eval & Prog Pm","PX-48000012","CDM","93286","CPT","0480","RC","","","","outpatient","","","694.00","520.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","567.14","81.72","","538.00","295.92","1075.99","1 through 10","362.68","567.14","percent of total billed charges",""
"Peri-Px Dev Eval & Prog Sing/Dual/Multi Lead Dfb","PX-48000013","CDM","93287","CPT","0480","RC","","","","both","","","885.00","663.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","703.58","79.5","","675.25","675.25","675.25","1 through 10","274.35","703.58","percent of total billed charges",""
"Peri-Px Dev Eval & Prog Sing/Dual/Multi Lead Dfb","PX-48000013","CDM","93287","CPT","0480","RC","","","","both","","","885.00","663.75","WELLPOINT [1015]","HB AMC WELLPOINT","652.95","73.78","","638.78","638.78","638.78","1 through 10","274.35","703.58","percent of total billed charges",""
"Peri-Px Dev Eval & Prog Sing/Dual/Multi Lead Dfb","PX-48000013","CDM","93287","CPT","0480","RC","","","","outpatient","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","723.22","81.72","","685.89","685.89","685.89","1 through 10","462.5","723.22","percent of total billed charges",""
"Pericardiocentesis W/Img Guidance When Performed","PX-36000457","CDM","33016","CPT","0361","RC","","","","both","","","6739.00","5054.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1622.97","","APC Price ($1,622.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1715.49","1715.49","1715.49","1 through 10","1590.51","5357.51","other","OPPS APC"
"Peripheral And Other Vascular Disorders,EXTREME","197","DRG","","","","","","","","inpatient","","","55254.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","56834.32","","Standard inlier is a Case rate ($56,834.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,960, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,067.16) for the length of stay and the standard reimbursement.","60927.98","60927.98","60927.98","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,EXTREME","197","DRG","","","","","","","","inpatient","","","55254.50","","MASSHEALTH [3001]","HB BWH MEDICAID","21067.51","","Case rate ($23,293.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,723.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","119650.07","119650.07","119650.07","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,EXTREME","197","DRG","","","","","","","","inpatient","","","55254.50","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","21067.51","","Case rate ($23,293.76). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,723.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,EXTREME","197","DRG","","","","","","","","inpatient","","","55254.50","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61005.15","","Fee schedule rate ($61,005.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61005.15","61005.15","61005.15","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","56855.48","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","27742.11","","Standard inlier is a Case rate ($27,742.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,221, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,938.16) for the length of stay and the standard reimbursement.","27742.10","25291.30","35078.02","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","56855.48","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","31189.61","","Standard inlier is a Case rate ($31,189.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,221, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,427.11) for the length of stay and the standard reimbursement.","31189.60","28494.40","61639.87","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","56855.48","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","9995.83","9995.83","9995.83","1 through 10","5451.37","101008.03","percent of total billed charges",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","56855.48","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13433.6202","","Fee schedule rate ($28,708.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13433.6202","28708.04","28708.04","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","56855.48","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","31579.23","","Fee schedule rate ($31,579.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31579.23","31579.23","31579.23","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","56855.48","","MASSHEALTH [3001]","HB BWH MEDICAID","9097.80","","Case rate ($10,059.19). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,489.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10056.71","169.92","11949.94","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","56855.48","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30767.45","","Fee schedule rate ($30,767.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29870.97","29870.97","29870.97","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","56855.48","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32306.32","","Fee schedule rate ($32,306.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32306.32","32306.32","32306.32","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","56855.48","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9097.80","","Case rate ($10,059.19). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,489.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10056.72","10056.72","21646.59","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MINOR","197","DRG","","","","","","","","inpatient","","","34870.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","16885.58","","Standard inlier is a Case rate ($16,885.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,327, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,396.77) for the length of stay and the standard reimbursement.","15426.43","15426.43","15426.43","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MINOR","197","DRG","","","","","","","","inpatient","","","34870.84","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","14777.16","","Fee schedule rate ($14,777.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14777.16","14777.16","14777.16","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MODERATE","197","DRG","","","","","","","","inpatient","","","39109.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20061.12","","Standard inlier is a Case rate ($20,061.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,248, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,847.80) for the length of stay and the standard reimbursement.","20061.12","20061.12","20061.12","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MODERATE","197","DRG","","","","","","","","inpatient","","","39109.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22554.11","","Standard inlier is a Case rate ($22,554.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,248, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,201.37) for the length of stay and the standard reimbursement.","20605.12","20605.12","20605.12","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MODERATE","197","DRG","","","","","","","","inpatient","","","39109.86","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","14105.6916","","Fee schedule rate ($19,343.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14105.6916","23027.03","23027.03","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MODERATE","197","DRG","","","","","","","","inpatient","","","39109.86","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13433.6202","","Fee schedule rate ($18,421.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13433.6202","18421.48","18421.48","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MODERATE","197","DRG","","","","","","","","inpatient","","","39109.86","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","14105.6916","","Fee schedule rate ($19,343.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14105.6916","19343.08","19343.08","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MODERATE","197","DRG","","","","","","","","inpatient","","","39109.86","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23506.90","","Fee schedule rate ($23,506.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23506.90","23506.90","23506.90","1 through 10","5451.37","101008.03","case rate",""
"Peripheral And Other Vascular Disorders,MODERATE","197","DRG","","","","","","","","inpatient","","","39109.86","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6385.83","","Case rate ($7,060.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,490.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7058.90","7058.90","7058.90","1 through 10","5451.37","101008.03","case rate",""
"Peripheral Nerve Sheath Tumor Ngh Panel","PX-30003383","CDM","81479","CPT","0310","RC","","","","both","","","357.00","267.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","283.82","79.5","","0.65","0.65","0.65","1 through 10","110.67","339.15","percent of total billed charges",""
"Peripheral Nerve Sheath Tumor Ngh Panel","PX-30003383","CDM","81479","CPT","0310","RC","","","","both","","","357.00","267.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","190.28","53.3","","0.79","0.79","0.79","1 through 10","110.67","339.15","percent of total billed charges",""
"Peripheral Nerve Sheath Tumor Ngh Panel","PX-30003383","CDM","81479","CPT","0310","RC","","","","outpatient","","","357.00","267.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","178.50","50","","1.00","1.00","1.00","1 through 10","156.55","294.53","percent of total billed charges",""
"Peripheral Nerve Sheath Tumor Ngh Panel","PX-30003383","CDM","81479","CPT","0310","RC","","","","outpatient","","","357.00","267.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","187.43","52.5","","1.00","0.53","1.00","1 through 10","156.55","294.53","percent of total billed charges",""
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","46018.16","34513.62","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10421.23","","Case rate ($10,117.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,102.30, add-ons for qualifying new technology services are included. If operating cost exceeds $57,746.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,299.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,878.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,722.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.97. The transfer capital threshold is the transfer adjustment factor * $858.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10327.72","10327.72","10339.06","1 through 10","9915.35","16721.32","other","Inpatient DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","46018.16","34513.62","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","10117.70","","Case rate ($10,117.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,102.30, add-ons for qualifying new technology services are included. If operating cost exceeds $57,746.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,299.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,878.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,722.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.97. The transfer capital threshold is the transfer adjustment factor * $858.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9887.11","9887.11","9887.11","1 through 10","9915.35","16721.32","other","Inpatient Replacement Plans DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","46018.16","34513.62","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","10117.70","","Case rate ($10,117.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,102.30, add-ons for qualifying new technology services are included. If operating cost exceeds $57,746.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,299.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,878.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,722.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.97. The transfer capital threshold is the transfer adjustment factor * $858.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","48482.40","48482.40","48482.40","1 through 10","9915.35","16721.32","other","Inpatient DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","46018.16","34513.62","HUMANA [1012]","HB BWH MEDICARE","10117.70","","Case rate ($10,117.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,102.30, add-ons for qualifying new technology services are included. If operating cost exceeds $57,746.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,299.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,878.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,722.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.97. The transfer capital threshold is the transfer adjustment factor * $858.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35940.99","35940.99","35940.99","1 through 10","9915.35","16721.32","other","Inpatient Replacement Plans DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","46018.16","34513.62","MEDICARE [2001]","HB BWH MEDICARE","10117.70","","Case rate ($10,117.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,102.30, add-ons for qualifying new technology services are included. If operating cost exceeds $57,746.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,299.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,878.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,722.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.97. The transfer capital threshold is the transfer adjustment factor * $858.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12899.75","0.03","12918.62","42","9915.35","16721.32","other","Inpatient Replacement Plans DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","46018.16","34513.62","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9915.35","","Case rate ($10,117.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,102.30, add-ons for qualifying new technology services are included. If operating cost exceeds $57,746.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,299.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,878.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,722.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.97. The transfer capital threshold is the transfer adjustment factor * $858.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9884.59","9846.04","9894.73","1 through 10","9915.35","16721.32","other","Inpatient DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","46018.16","34513.62","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9915.35","","Case rate ($10,117.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,102.30, add-ons for qualifying new technology services are included. If operating cost exceeds $57,746.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,299.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,878.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,722.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $858.97. The transfer capital threshold is the transfer adjustment factor * $858.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9828.72","9795.86","9876.30","11","9915.35","16721.32","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","70925.73","53194.30","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15731.72","","Case rate ($15,273.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,308.88, add-ons for qualifying new technology services are included. If operating cost exceeds $63,953.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,753.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,579.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,929.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,313.77. The transfer capital threshold is the transfer adjustment factor * $1,313.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15459.95","15459.95","15459.95","1 through 10","14968.04","25574.61","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","70925.73","53194.30","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15273.51","","Case rate ($15,273.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,308.88, add-ons for qualifying new technology services are included. If operating cost exceeds $63,953.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,753.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,579.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,929.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,313.77. The transfer capital threshold is the transfer adjustment factor * $1,313.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14798.30","14798.30","14798.30","1 through 10","14968.04","25574.61","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","70925.73","53194.30","MARTIN'S POINT [160007]","HB BWH MEDICARE","15273.51","","Case rate ($15,273.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,308.88, add-ons for qualifying new technology services are included. If operating cost exceeds $63,953.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,753.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,579.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,929.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,313.77. The transfer capital threshold is the transfer adjustment factor * $1,313.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","53734.38","53734.38","53734.38","1 through 10","14968.04","25574.61","other","Inpatient Replacement Plans DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","70925.73","53194.30","MEDICARE [2001]","HB BWH MEDICARE","15273.51","","Case rate ($15,273.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,308.88, add-ons for qualifying new technology services are included. If operating cost exceeds $63,953.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,753.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,579.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,929.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,313.77. The transfer capital threshold is the transfer adjustment factor * $1,313.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19348.42","203.50","19376.95","33","14968.04","25574.61","other","Inpatient Replacement Plans DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","70925.73","53194.30","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14968.04","","Case rate ($15,273.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,308.88, add-ons for qualifying new technology services are included. If operating cost exceeds $63,953.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,753.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,579.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,929.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,313.77. The transfer capital threshold is the transfer adjustment factor * $1,313.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14779.36","14728.60","20659.33","1 through 10","14968.04","25574.61","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","70925.73","53194.30","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14968.04","","Case rate ($15,273.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,308.88, add-ons for qualifying new technology services are included. If operating cost exceeds $63,953.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,753.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,579.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,929.03 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,313.77. The transfer capital threshold is the transfer adjustment factor * $1,313.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14731.82","14704.81","14866.97","1 through 10","14968.04","25574.61","other","Inpatient DRG"
"Peripheral Vascular Disorders Without Cc/McC","301","MS-DRG","","","","","","","","inpatient","","","41182.81","30887.11","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7153.38","","Case rate ($6,945.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,283.03, add-ons for qualifying new technology services are included. If operating cost exceeds $53,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,019.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,986.07 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,903.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.11. The transfer capital threshold is the transfer adjustment factor * $579.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6998.14","6998.14","6998.14","1 through 10","6806.13","10765.9194","other","Inpatient DRG"
"Peripheral Vascular Disorders Without Cc/McC","301","MS-DRG","","","","","","","","inpatient","","","41182.81","30887.11","MEDICARE [2001]","HB BWH MEDICARE","8900.33","","Case rate ($8,900.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,283.03, add-ons for qualifying new technology services are included. If operating cost exceeds $53,927.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,019.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,941.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,903.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $579.11. The transfer capital threshold is the transfer adjustment factor * $579.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8688.66","8688.66","8701.24","1 through 10","6806.13","10765.9194","other","Inpatient DRG"
"Peripheral, Cranial And Autonomic Nerve Disorders,EXTREME","048","DRG","","","","","","","","inpatient","","","81094.54","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","62506.48","","Standard inlier is a Case rate ($62,506.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,883, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,872.28) for the length of stay and the standard reimbursement.","62506.47","62506.47","62506.47","1 through 10","4951.01","70274.54","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","68142.92","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","33712.99","","Standard inlier is a Case rate ($33,712.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,967, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,785.28) for the length of stay and the standard reimbursement.","36106.33","36106.33","36106.33","1 through 10","4951.01","70274.54","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","68142.92","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","116875.02","116875.02","116875.02","1 through 10","4951.01","70274.54","percent of total billed charges",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","68142.92","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11773.9888","","Fee schedule rate ($26,122.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11773.9888","26122.40","26122.40","1 through 10","4951.01","70274.54","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","68142.92","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","28735.01","","Fee schedule rate ($28,735.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28735.01","28735.01","28735.01","1 through 10","4951.01","70274.54","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","68142.92","","MASSHEALTH [3001]","HB BWH MEDICAID","10539.47","","Case rate ($11,653.19). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,083.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,618.69 and the sum of the standard inlier and any outlier amount.","11650.33","11650.33","11650.33","1 through 10","4951.01","70274.54","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","68142.92","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10539.47","","Case rate ($11,653.19). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,083.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,618.69 and the sum of the standard inlier and any outlier amount.","11650.33","1494.12","11650.33","1 through 10","4951.01","70274.54","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","68142.92","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","10539.47","","Case rate ($11,653.19). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,083.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,618.69 and the sum of the standard inlier and any outlier amount.","7298.47","7298.47","7298.47","1 through 10","4951.01","70274.54","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MINOR","048","DRG","","","","","","","","inpatient","","","38889.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21572.39","","Standard inlier is a Case rate ($21,572.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,569, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,062.02) for the length of stay and the standard reimbursement.","21572.38","21572.38","21572.38","1 through 10","4951.01","70274.54","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MODERATE","048","DRG","","","","","","","","inpatient","","","60320.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22095.37","","Standard inlier is a Case rate ($22,095.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,829, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,136.57) for the length of stay and the standard reimbursement.","22095.37","22095.37","22095.37","1 through 10","4951.01","70274.54","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MODERATE","048","DRG","","","","","","","","inpatient","","","60320.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24841.15","","Standard inlier is a Case rate ($24,841.15). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,829, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,526.00) for the length of stay and the standard reimbursement.","24841.15","24841.15","24841.15","1 through 10","4951.01","70274.54","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MODERATE","048","DRG","","","","","","","","inpatient","","","60320.51","","MASSHEALTH [3001]","HB BWH MEDICAID","6739.96","","Case rate ($7,452.18). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,882.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","569.67","569.67","569.67","1 through 10","4951.01","70274.54","case rate",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","","","","inpatient","","","101489.54","76117.15","MEDICARE [2001]","HB BWH MEDICARE","26410.09","","Case rate ($26,410.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,524.24, add-ons for qualifying new technology services are included. If operating cost exceeds $70,168.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,209.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,261.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,144.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,769.20. The transfer capital threshold is the transfer adjustment factor * $1,769.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","26900.54","23863.56","26940.38","1 through 10","20027.89","34078.4962","other","Inpatient DRG"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","","","","inpatient","","","101489.54","76117.15","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20027.89","","Case rate ($20,436.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,524.24, add-ons for qualifying new technology services are included. If operating cost exceeds $70,168.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,209.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,287.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,144.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,769.20. The transfer capital threshold is the transfer adjustment factor * $1,769.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","20449.88","20449.88","20449.88","1 through 10","20027.89","34078.4962","other","Inpatient DRG"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With McC","040","MS-DRG","","","","","","","","inpatient","","","169777.78","127333.33","ELDER SERVICES [1037]","HB BWH MEDICARE","35602.12","","Case rate ($35,602.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $42,780.51, add-ons for qualifying new technology services are included. If operating cost exceeds $88,424.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,547.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,115.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,400.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,106.95. The transfer capital threshold is the transfer adjustment factor * $3,106.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","9809.60","9809.60","9809.60","1 through 10","34890.08","60481.84","other","Inpatient Replacement Plans DRG"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With McC","040","MS-DRG","","","","","","","","inpatient","","","169777.78","127333.33","FALLON HEALTH [1008]","HB BWH MEDICARE","35602.12","","Case rate ($35,602.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $42,780.51, add-ons for qualifying new technology services are included. If operating cost exceeds $88,424.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,547.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,115.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,400.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,106.95. The transfer capital threshold is the transfer adjustment factor * $3,106.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","110856.63","110856.63","110856.63","1 through 10","34890.08","60481.84","other","Inpatient Replacement Plans DRG"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With McC","040","MS-DRG","","","","","","","","inpatient","","","169777.78","127333.33","MEDICARE [2001]","HB BWH MEDICARE","35602.12","","Case rate ($35,602.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $42,780.51, add-ons for qualifying new technology services are included. If operating cost exceeds $88,424.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,547.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,115.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,400.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,106.95. The transfer capital threshold is the transfer adjustment factor * $3,106.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","35270.54","0.03","44814.68","11","34890.08","60481.84","other","Inpatient Replacement Plans DRG"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With McC","040","MS-DRG","","","","","","","","inpatient","","","169777.78","127333.33","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","34890.08","","Case rate ($35,602.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $42,780.51, add-ons for qualifying new technology services are included. If operating cost exceeds $88,424.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,547.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,115.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,400.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,106.95. The transfer capital threshold is the transfer adjustment factor * $3,106.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","18075.34","18075.34","18075.34","1 through 10","34890.08","60481.84","other","Inpatient DRG"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With McC","040","MS-DRG","","","","","","","","inpatient","","","169777.78","127333.33","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","34890.08","","Case rate ($35,602.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $42,780.51, add-ons for qualifying new technology services are included. If operating cost exceeds $88,424.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,547.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,115.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $42,400.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,106.95. The transfer capital threshold is the transfer adjustment factor * $3,106.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","34012.81","34012.81","34012.81","1 through 10","34890.08","60481.84","other","Inpatient DRG"
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/McC","042","MS-DRG","","","","","","","","inpatient","","","96843.20","72632.40","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","16624.31","","Case rate ($16,140.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,352.09, add-ons for qualifying new technology services are included. If operating cost exceeds $64,996.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,830.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,370.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,972.25 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,390.21. The transfer capital threshold is the transfer adjustment factor * $1,390.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","16748.61","16748.61","16748.61","1 through 10","15817.31","26523.9416","other","Inpatient DRG"
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/McC","042","MS-DRG","","","","","","","","inpatient","","","96843.20","72632.40","MEDICARE [2001]","HB BWH MEDICARE","16140.11","","Case rate ($16,140.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,352.09, add-ons for qualifying new technology services are included. If operating cost exceeds $64,996.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,830.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,370.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,972.25 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,390.21. The transfer capital threshold is the transfer adjustment factor * $1,390.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","20998.91","20998.91","20998.91","1 through 10","15817.31","26523.9416","other","Inpatient Replacement Plans DRG"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","","","","inpatient","","","118865.89","89149.42","MEDICARE [2001]","HB BWH MEDICARE","25344.58","","Case rate ($25,344.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,535.93, add-ons for qualifying new technology services are included. If operating cost exceeds $69,180.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,136.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $23,267.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,156.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,696.78. The transfer capital threshold is the transfer adjustment factor * $1,696.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25180.51","25180.51","25217.75","12","19223.31","33030.68","other","Inpatient DRG"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","","","","inpatient","","","118865.89","89149.42","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","25344.58","","Case rate ($25,344.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,535.93, add-ons for qualifying new technology services are included. If operating cost exceeds $69,180.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,136.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $23,267.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,156.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,696.78. The transfer capital threshold is the transfer adjustment factor * $1,696.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19105.25","19105.25","19105.25","1 through 10","19223.31","33030.68","other","Inpatient DRG"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","","","","inpatient","","","118865.89","89149.42","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19223.31","","Case rate ($19,615.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,535.93, add-ons for qualifying new technology services are included. If operating cost exceeds $69,180.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,136.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,539.00 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,156.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,696.78. The transfer capital threshold is the transfer adjustment factor * $1,696.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19160.42","19160.42","19160.42","1 through 10","19223.31","33030.68","other","Inpatient DRG"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","","","","inpatient","","","118865.89","89149.42","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19223.31","","Case rate ($19,615.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,535.93, add-ons for qualifying new technology services are included. If operating cost exceeds $69,180.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,136.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,539.00 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,156.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,696.78. The transfer capital threshold is the transfer adjustment factor * $1,696.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19395.69","19395.69","19395.69","1 through 10","19223.31","33030.68","other","Inpatient DRG"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","","","","inpatient","","","118865.89","89149.42","WELLPOINT [1015]","HB AMC WELLPOINT","33030.68","","Fee schedule rate ($33,030.68).","100104.52","100104.52","100104.52","1 through 10","19223.31","33030.68","case rate",""
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","","","","inpatient","","","118865.89","89149.42","WELLSENSE NH [1050]","HB BWH MEDICARE","25344.58","","Case rate ($25,344.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,535.93, add-ons for qualifying new technology services are included. If operating cost exceeds $69,180.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,136.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $23,267.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,156.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,696.78. The transfer capital threshold is the transfer adjustment factor * $1,696.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19109.88","19109.88","19109.88","1 through 10","19223.31","33030.68","other","Inpatient DRG"
"Peritoneal Adhesiolysis With McC","335","MS-DRG","","","","","","","","inpatient","","","154235.15","115676.36","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","33942.60","","Case rate ($32,953.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,592.67, add-ons for qualifying new technology services are included. If operating cost exceeds $85,237.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,313.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $29,700.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,212.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,873.36. The transfer capital threshold is the transfer adjustment factor * $2,873.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","34178.22","34178.22","34178.22","1 through 10","32294.9","54680.7294","other","Inpatient DRG"
"Peritoneal Adhesiolysis With McC","335","MS-DRG","","","","","","","","inpatient","","","154235.15","115676.36","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","32953.98","","Case rate ($32,953.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,592.67, add-ons for qualifying new technology services are included. If operating cost exceeds $85,237.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,313.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $29,700.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,212.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,873.36. The transfer capital threshold is the transfer adjustment factor * $2,873.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","33228.17","33228.17","33228.17","1 through 10","32294.9","54680.7294","other","Inpatient Replacement Plans DRG"
"Peritoneal Adhesiolysis With McC","335","MS-DRG","","","","","","","","inpatient","","","154235.15","115676.36","MEDICARE [2001]","HB BWH MEDICARE","32953.98","","Case rate ($32,953.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,592.67, add-ons for qualifying new technology services are included. If operating cost exceeds $85,237.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,313.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $29,700.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,212.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,873.36. The transfer capital threshold is the transfer adjustment factor * $2,873.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","42995.11","25869.82","43045.52","1 through 10","32294.9","54680.7294","other","Inpatient Replacement Plans DRG"
"Peritoneal Adhesiolysis With McC","335","MS-DRG","","","","","","","","inpatient","","","154235.15","115676.36","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","32294.90","","Case rate ($32,953.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,592.67, add-ons for qualifying new technology services are included. If operating cost exceeds $85,237.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,313.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $29,700.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,212.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,873.36. The transfer capital threshold is the transfer adjustment factor * $2,873.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","48202.97","48202.97","48202.97","1 through 10","32294.9","54680.7294","other","Inpatient DRG"
"Peritoneal Adhesiolysis Without Cc/McC","337","MS-DRG","","","","","","","","inpatient","","","88054.03","66040.52","MEDICARE [2001]","HB BWH MEDICARE","14382.27","","Case rate ($14,382.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,236.01, add-ons for qualifying new technology services are included. If operating cost exceeds $62,880.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,675.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $12,767.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,856.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,235.15. The transfer capital threshold is the transfer adjustment factor * $1,235.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18375.80","18375.80","18397.17","1 through 10","14094.62","24044.24","other","Inpatient Replacement Plans DRG"
"Peritoneal Adhesiolysis Without Cc/McC","337","MS-DRG","","","","","","","","inpatient","","","88054.03","66040.52","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14094.62","","Case rate ($14,382.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,236.01, add-ons for qualifying new technology services are included. If operating cost exceeds $62,880.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,675.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $12,767.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,856.17 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,235.15. The transfer capital threshold is the transfer adjustment factor * $1,235.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14003.44","14003.44","14003.44","1 through 10","14094.62","24044.24","other","Inpatient DRG"
"Peritoneal Adhesiolysis,EXTREME","224","DRG","","","","","","","","inpatient","","","112615.93","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","119409.44","","Standard inlier is a Case rate ($119,409.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $104,504, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,950.89) for the length of stay and the standard reimbursement.","119409.44","119409.44","119409.44","1 through 10","10730.24","186858.77","case rate",""
"Peritoneal Adhesiolysis,MAJOR","224","DRG","","","","","","","","inpatient","","","136482.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","69698.09","","Standard inlier is a Case rate ($69,698.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $65,848, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,894.06) for the length of stay and the standard reimbursement.","63532.34","63532.34","63532.34","1 through 10","10730.24","186858.77","case rate",""
"Peritoneal Adhesiolysis,MAJOR","224","DRG","","","","","","","","inpatient","","","136482.26","","MASSHEALTH [3001]","HB BWH MEDICAID","18548.60","","Case rate ($20,508.66). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,938.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21334.40","21334.40","21334.40","1 through 10","10730.24","186858.77","case rate",""
"Peritoneal Adhesiolysis,MINOR","224","DRG","","","","","","","","inpatient","","","46710.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","44595.54","","Fee schedule rate ($44,595.54). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($5,159.89) multiplied by length of stay and the outlier percent (100%).","6448.48","6448.48","6448.48","1 through 10","10730.24","186858.77","case rate",""
"Peritoneal Adhesiolysis,MINOR","224","DRG","","","","","","","","inpatient","","","46710.49","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","41396.67","","Fee schedule rate ($41,396.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40190.60","40190.60","40190.60","1 through 10","10730.24","186858.77","case rate",""
"Peritoneal Adhesiolysis,MODERATE","224","DRG","","","","","","","","inpatient","","","93273.24","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","49051.59","","Standard inlier is a Case rate ($49,051.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,791, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,963.17) for the length of stay and the standard reimbursement.","55147.21","55147.21","55147.21","1 through 10","10730.24","186858.77","case rate",""
"Peritoneal Adhesiolysis,MODERATE","224","DRG","","","","","","","","inpatient","","","93273.24","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","55147.21","","Standard inlier is a Case rate ($55,147.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,791, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,827.69) for the length of stay and the standard reimbursement.","55147.21","55147.21","55147.21","1 through 10","10730.24","186858.77","case rate",""
"Peritoneal Adhesiolysis,MODERATE","224","DRG","","","","","","","","inpatient","","","93273.24","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52196.78","","Fee schedule rate ($52,196.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","52196.78","52196.78","52196.78","1 through 10","10730.24","186858.77","case rate",""
"Peritoneal Fluid Collection Drain Placement, Transurethral","PX-76002466","CDM","49999","CPT","0761","RC","","","","both","","","1747.00","1310.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","541.57","1391.62","other","OPPS APC"
"Peritoneal Fluid Collection Drain Placement, Transurethral","PX-76002466","CDM","49999","CPT","0761","RC","","","","both","","","1747.00","1310.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","541.57","1391.62","other","OPPS APC"
"Peritoneal Fluid Collection Drain Placement, Transurethral","PX-76002466","CDM","49999","CPT","0761","RC","","","","both","","","1747.00","1310.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","541.57","1391.62","other","OPPS APC"
"Peritoneal Fluid Collection Drain Placement, Transurethral","PX-76002466","CDM","49999","CPT","0761","RC","","","","outpatient","","","1747.00","1310.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","873.50","50","","14640.00","14640.00","14640.00","1 through 10","873.5","8899.59","percent of total billed charges",""
"Peritoneal Kd Cath Manipulation","PX-76002530","CDM","49999","CPT","0761","RC","","","","both","","","1563.00","1172.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","484.53","1391.62","other","OPPS APC"
"Peritoneal Kd Cath Manipulation","PX-76002530","CDM","49999","CPT","0761","RC","","","","both","","","1563.00","1172.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","484.53","1391.62","other","OPPS APC"
"Peritoneal Kd Cath Manipulation","PX-76002530","CDM","49999","CPT","0761","RC","","","","both","","","1563.00","1172.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","484.53","1391.62","other","OPPS APC"
"Peritoneal Kd Cath Manipulation","PX-76002530","CDM","49999","CPT","0761","RC","","","","outpatient","","","1563.00","1172.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","781.50","50","","14640.00","14640.00","14640.00","1 through 10","781.5","8899.59","percent of total billed charges",""
"Permanent Cardiac Pacemaker Implant With Ami, Heart Failure Or Shock,MAJOR","170","DRG","","","","","","","","inpatient","","","154855.71","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","67221.7818","","Fee schedule rate ($91,382.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","67221.7818","91382.60","91382.60","1 through 10","58373.76","207083.56","case rate",""
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","85650.31","64237.73","HUMANA [1012]","HB BWH MEDICARE","19818.13","","Case rate ($19,818.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,779.71, add-ons for qualifying new technology services are included. If operating cost exceeds $69,424.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,154.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $17,723.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,399.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.65. The transfer capital threshold is the transfer adjustment factor * $1,714.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","38118.36","38118.36","38118.36","1 through 10","19421.77","33378.42","other","Inpatient Replacement Plans DRG"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","85650.31","64237.73","MEDICARE [2001]","HB BWH MEDICARE","19818.13","","Case rate ($19,818.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,779.71, add-ons for qualifying new technology services are included. If operating cost exceeds $69,424.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,154.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $17,723.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,399.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.65. The transfer capital threshold is the transfer adjustment factor * $1,714.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","26836.90","0.03","26876.61","32","19421.77","33378.42","other","Inpatient Replacement Plans DRG"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","85650.31","64237.73","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","19818.13","","Case rate ($19,818.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,779.71, add-ons for qualifying new technology services are included. If operating cost exceeds $69,424.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,154.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $17,723.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,399.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.65. The transfer capital threshold is the transfer adjustment factor * $1,714.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","20317.71","20317.71","20317.71","1 through 10","19421.77","33378.42","other","Inpatient Replacement Plans DRG"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","85650.31","64237.73","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19421.77","","Case rate ($19,818.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,779.71, add-ons for qualifying new technology services are included. If operating cost exceeds $69,424.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,154.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $17,723.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,399.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.65. The transfer capital threshold is the transfer adjustment factor * $1,714.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","20379.32","20379.32","20379.32","1 through 10","19421.77","33378.42","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","85650.31","64237.73","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19421.77","","Case rate ($19,818.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,779.71, add-ons for qualifying new technology services are included. If operating cost exceeds $69,424.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,154.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $17,723.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,399.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.65. The transfer capital threshold is the transfer adjustment factor * $1,714.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","20386.20","16325.79","20794.29","1 through 10","19421.77","33378.42","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With McC","242","MS-DRG","","","","","","","","inpatient","","","120475.45","90356.59","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","38179.16","","Case rate ($38,179.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,440.67, add-ons for qualifying new technology services are included. If operating cost exceeds $81,085.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,009.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $35,230.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,060.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,569.11. The transfer capital threshold is the transfer adjustment factor * $2,569.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","31066.51","31066.51","31066.51","1 through 10","28914.8","50012.02","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With McC","242","MS-DRG","","","","","","","","inpatient","","","120475.45","90356.59","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","78990.60","78990.60","78990.60","1 through 10","28914.8","50012.02","case rate",""
"Permanent Cardiac Pacemaker Implant With McC","242","MS-DRG","","","","","","","","inpatient","","","120475.45","90356.59","MEDICARE [2001]","HB BWH MEDICARE","38179.16","","Case rate ($38,179.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,440.67, add-ons for qualifying new technology services are included. If operating cost exceeds $81,085.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,009.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $35,230.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,060.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,569.11. The transfer capital threshold is the transfer adjustment factor * $2,569.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","40326.92","0.03","40326.92","22","28914.8","50012.02","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With McC","242","MS-DRG","","","","","","","","inpatient","","","120475.45","90356.59","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28914.80","","Case rate ($29,504.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,440.67, add-ons for qualifying new technology services are included. If operating cost exceeds $81,085.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,009.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $26,555.94 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,060.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,569.11. The transfer capital threshold is the transfer adjustment factor * $2,569.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","30573.10","30573.10","45367.17","1 through 10","28914.8","50012.02","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,EXTREME","171","DRG","","","","","","","","inpatient","","","355020.01","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","110949.03","","Standard inlier is a Case rate ($110,949.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $97,925, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($15,749.88) for the length of stay and the standard reimbursement.","160695.42","160695.42","160695.42","1 through 10","16469.49","238187.63","case rate",""
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,EXTREME","171","DRG","","","","","","","","inpatient","","","355020.01","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","124736.62","","Standard inlier is a Case rate ($124,736.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $97,925, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($17,705.33) for the length of stay and the standard reimbursement.","124736.61","124736.61","124736.61","1 through 10","16469.49","238187.63","case rate",""
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,MAJOR","171","DRG","","","","","","","","inpatient","","","104571.83","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","74600.98","","Standard inlier is a Case rate ($74,600.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $69,660, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,590.06) for the length of stay and the standard reimbursement.","68001.51","68001.51","68001.51","1 through 10","16469.49","238187.63","case rate",""
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,MAJOR","171","DRG","","","","","","","","inpatient","","","104571.83","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","83871.61","","Standard inlier is a Case rate ($83,871.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $69,660, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,904.88) for the length of stay and the standard reimbursement.","83871.61","83871.61","83871.61","1 through 10","16469.49","238187.63","case rate",""
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,MAJOR","171","DRG","","","","","","","","inpatient","","","104571.83","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70405.36","","Fee schedule rate ($70,405.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","70405.36","70405.36","70405.36","1 through 10","16469.49","238187.63","case rate",""
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,MAJOR","171","DRG","","","","","","","","inpatient","","","104571.83","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73926.79","","Fee schedule rate ($73,926.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","71772.97","71772.97","73926.79","1 through 10","16469.49","238187.63","case rate",""
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,MINOR","171","DRG","","","","","","","","inpatient","","","89168.17","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","58288.18","","Standard inlier is a Case rate ($58,288.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,974, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,274.36) for the length of stay and the standard reimbursement.","50833.58","50833.58","50833.58","1 through 10","16469.49","238187.63","case rate",""
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,MINOR","171","DRG","","","","","","","","inpatient","","","89168.17","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","65531.63","","Standard inlier is a Case rate ($65,531.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,974, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,301.67) for the length of stay and the standard reimbursement.","52212.05","52212.05","52212.05","1 through 10","16469.49","238187.63","case rate",""
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,MODERATE","171","DRG","","","","","","","","inpatient","","","105413.32","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","65531.63","","Standard inlier is a Case rate ($65,531.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,974, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,301.67) for the length of stay and the standard reimbursement.","65531.62","65531.62","65531.62","1 through 10","16469.49","238187.63","case rate",""
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,MODERATE","171","DRG","","","","","","","","inpatient","","","105413.32","","GENERIC COMMERCIAL [1009]","HB BWH MEDICAID","16469.49","","Case rate ($18,209.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,639.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20182.72","20182.72","20182.72","1 through 10","16469.49","238187.63","case rate",""
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,MODERATE","171","DRG","","","","","","","","inpatient","","","105413.32","","MASSHEALTH [3001]","HB BWH MEDICAID","16469.49","","Case rate ($18,209.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,639.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18205.38","18205.38","18205.38","1 through 10","16469.49","238187.63","case rate",""
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,MODERATE","171","DRG","","","","","","","","inpatient","","","105413.32","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","16469.49","","Case rate ($18,209.85). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,639.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","16469.49","238187.63","case rate",""
"Permanent Cardiac Pacemaker Implant Without Ami, Heart Failure Or Shock,MODERATE","171","DRG","","","","","","","","inpatient","","","105413.32","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61860.03","","Fee schedule rate ($61,860.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61860.03","61860.03","61860.03","1 through 10","16469.49","238187.63","case rate",""
"Permanent Cardiac Pacemaker Implant Without Cc/McC","244","MS-DRG","","","","","","","","inpatient","","","69070.96","51803.22","MEDICARE [2001]","HB BWH MEDICARE","21778.69","","Case rate ($21,778.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,228.38, add-ons for qualifying new technology services are included. If operating cost exceeds $65,872.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,894.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $19,944.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,848.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,454.42. The transfer capital threshold is the transfer adjustment factor * $1,454.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","21554.16","1403.90","21585.99","1 through 10","16530.68","27234.7277","other","Inpatient DRG"
"Peroral Endoscopic Myotomy Poem","PX-75000463","CDM","43497","CPT","0750","RC","","","","both","","","7986.00","5989.50","AETNA [1001]","HB AMC AETNA HMO","5574.23","69.8","","16377.98","16377.98","16377.98","1 through 10","2475.66","8835.76","percent of total billed charges",""
"Peroral Endoscopic Myotomy Poem","PX-75000463","CDM","43497","CPT","0750","RC","","","","both","","","7986.00","5989.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7280.66","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","7274.33","7274.33","7274.33","1 through 10","2475.66","8835.76","other","OPPS APC"
"Peroral Endoscopic Myotomy Poem","PX-75000463","CDM","43497","CPT","0750","RC","","","","both","","","7986.00","5989.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1738.36","1738.36","1738.36","1 through 10","2475.66","8835.76","other","OPPS APC"
"Peroral Endoscopic Myotomy Poem","PX-75000463","CDM","43497","CPT","0750","RC","","","","both","","","7986.00","5989.50","MEDICARE [2001]","HB BWH MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7069.32","7069.32","7069.32","1 through 10","2475.66","8835.76","other","OPPS APC"
"Peroral Endoscopic Myotomy Poem","PX-75000463","CDM","43497","CPT","0750","RC","","","","both","","","7986.00","5989.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6927.23","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7069.32","7069.32","7069.32","1 through 10","2475.66","8835.76","other","OPPS APC"
"Peroral Endoscopic Myotomy Poem","PX-75000463","CDM","43497","CPT","0750","RC","","","","both","","","7986.00","5989.50","WELLPOINT [1015]","HB AMC WELLPOINT","5892.07","73.78","","20961.40","5765.41","20961.40","1 through 10","2475.66","8835.76","percent of total billed charges",""
"Peroral Endoscopic Myotomy Poem","PX-75000463","CDM","43497","CPT","0750","RC","","","","outpatient","","","7986.00","5989.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6526.16","81.72","","22507.11","22507.11","22507.11","1 through 10","4170.29","6526.16","percent of total billed charges",""
"Perq Clsr Tcat L Atr Apndge W/Endocardial Implnt","PX-36000404","CDM","33340","CPT","0361","RC","","","","outpatient","","","22623.00","16967.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1345.33","","Case rate ($1,345.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1376.28","1376.28","1376.28","1 through 10","1345.33","18663.98","other","ASC"
"Perq Device Breast 1st Imag","PX-76001936","CDM","19281","CPT","0761","RC","","","","both","","","753.00","564.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1742.02","1740.02","1893.55","1 through 10","233.43","2404.92","other","OPPS APC"
"Perq Device Breast Ea Imag, Mamm Guidance","PX-76001937","CDM","19282","CPT","0761","RC","","","","both","","","365.00","273.75","WELLPOINT [1015]","HB AMC WELLPOINT","269.30","73.78","","263.55","263.55","263.55","1 through 10","113.15","290.18","percent of total billed charges",""
"Perq Device Breast Ea Imag, US Guidance","PX-76001938","CDM","19285","CPT","0761","RC","","","","both","","","646.00","484.50","AETNA [1001]","HB AMC AETNA HMO","450.91","69.8","","423.80","423.80","423.80","1 through 10","200.26","1044.34","percent of total billed charges",""
"Perq Device Breast Ea Imag, US Guidance","PX-76001938","CDM","19285","CPT","0761","RC","","","","both","","","646.00","484.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.75","826.75","826.75","1 through 10","200.26","1044.34","other","OPPS APC"
"Perq Nl/Pl Lithotrp Simple Up to 2 Cm 1 Location","PX-76001221","CDM","50080","CPT","0761","RC","","","","outpatient","","","11506.00","8629.50","AETNA [1001]","HB AMC AETNA HMO","8031.19","69.8","","353.34","353.34","353.34","1 through 10","4602.4","9402.7","percent of total billed charges",""
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-75000480","CDM","43762","CPT","0750","RC","","","","both","","","787.00","590.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","511.55","65","","495.95","495.95","495.95","1 through 10","243.97","625.67","percent of total billed charges",""
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-75000480","CDM","43762","CPT","0750","RC","","","","both","","","787.00","590.25","MEDICARE [2001]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","288.83","288.83","11","243.97","625.67","other","OPPS APC"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-75000480","CDM","43762","CPT","0750","RC","","","","both","","","787.00","590.25","MOLINA [1014]","HB BWH MOLINA","283.02","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","693.18","693.18","693.18","1 through 10","243.97","625.67","other","OPPS APC"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-75000480","CDM","43762","CPT","0750","RC","","","","outpatient","","","787.00","590.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","541.45","531.66","541.45","1 through 10","231.42","2384.07","other","ASC"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-75000480","CDM","43762","CPT","0750","RC","","","","outpatient","","","787.00","590.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","433.25","433.25","433.25","1 through 10","231.42","2384.07","other","ASC "
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-98301825","CDM","43762","CPT","0983","RC","","","","both","","","197.00","147.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","128.05","65","","495.95","495.95","495.95","1 through 10","61.07","361","percent of total billed charges",""
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-98301825","CDM","43762","CPT","0983","RC","","","","both","","","197.00","147.75","MEDICARE [2001]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","288.83","288.83","11","61.07","361","other","OPPS APC"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-98301825","CDM","43762","CPT","0983","RC","","","","both","","","197.00","147.75","MOLINA [1014]","HB BWH MOLINA","283.02","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","693.18","693.18","693.18","1 through 10","61.07","361","other","OPPS APC"
"Perq Sft Tiss Loc Device Plmt 1st Les W/Gdnce","PX-76002177","CDM","10035","CPT","0761","RC","","","","both","","","638.00","478.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","752.55","410.26","752.55","1 through 10","197.78","1044.34","other","OPPS APC"
"Perq Tcat Plmt Ntrac St 1 Les 1+C Segments","PX-48000238","CDM","92928","CPT","0481","RC","","","","both","","","20915.00","15686.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","13594.75","65","","13191.10","13191.10","13191.10","1 through 10","6483.65","16832.81","percent of total billed charges",""
"Perq Tcat Plmt Ntrac St 1 Les 1+C Segments","PX-48000238","CDM","92928","CPT","0481","RC","","","","outpatient","","","20915.00","15686.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","8702.14","","Case rate ($8,702.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","7569.35","7569.35","7569.35","1 through 10","8702.14","33742.46","other","Multiple Surgery"
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","outpatient","","","30108.00","22581.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","22213.71","22213.71","22213.71","1 through 10","8702.14","24604.26","other","ASC"
"Perq Transcath Cls Paravalvr Leak 1 Mitral Valve","PX-48000453","CDM","93590","CPT","0481","RC","","","","both","","","31276.00","23457.00","MEDICARE [2001]","HB BWH MEDICARE","21322.53","","APC Price ($21,322.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38276.44","38276.44","38276.44","1 through 10","9695.56","26653.16","other","OPPS APC"
"Perq Trluml C Angioplasty 1 Maj C Art&/Branches","PX-48000234","CDM","92920","CPT","0481","RC","","","","both","","","12859.00","9644.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6634.81","","APC Price ($6,770.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7783.63","7783.63","7783.63","1 through 10","3986.29","10222.91","other","OPPS APC"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr","PX-76002085","CDM","22514","CPT","0761","RC","","","","both","","","16652.00","12489.00","HUMANA [1012]","HB BWH MEDICARE","8482.75","","APC Price ($8,482.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8313.94","8313.94","8313.94","1 through 10","5162.12","13238.34","other","OPPS APC"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr","PX-76002085","CDM","22514","CPT","0761","RC","","","","both","","","16652.00","12489.00","MEDICARE [2001]","HB BWH MEDICARE","8482.75","","APC Price ($8,482.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8483.61","8483.61","8483.61","1 through 10","5162.12","13238.34","other","OPPS APC"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr","PX-76002085","CDM","22514","CPT","0761","RC","","","","both","","","16652.00","12489.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8313.10","","APC Price ($8,482.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8319.34","8319.34","8319.34","1 through 10","5162.12","13238.34","other","OPPS APC"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr","PX-76002085","CDM","22514","CPT","0761","RC","","","","both","","","16652.00","12489.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8313.10","","APC Price ($8,482.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8313.94","8313.94","8313.94","1 through 10","5162.12","13238.34","other","OPPS APC"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr","PX-76002085","CDM","22514","CPT","0761","RC","","","","outpatient","","","16652.00","12489.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","6517.81","","Case rate ($6,517.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","13335.44","13335.44","13335.44","1 through 10","5129.63","18666.79","other","ASC"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr","PX-76002085","CDM","22514","CPT","0761","RC","","","","outpatient","","","16652.00","12489.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6517.81","","Case rate ($6,517.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","15258.19","15258.19","15258.19","1 through 10","5129.63","18666.79","other","ASC "
"Perq Vertebroplasty Uni/Bi Injection Lumbosacral","PX-76002082","CDM","22511","CPT","0761","RC","","","","both","","","8304.00","6228.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3852.78","","APC Price ($3,852.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3791.52","3791.52","3791.52","1 through 10","2574.24","6601.68","other","OPPS APC"
"Perq Vertebroplasty Uni/Bi Injection Lumbosacral","PX-76002082","CDM","22511","CPT","0761","RC","","","","both","","","8304.00","6228.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3852.78","","APC Price ($3,852.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3791.52","3791.52","3791.52","1 through 10","2574.24","6601.68","other","OPPS APC"
"Perq Vertebroplasty Uni/Bi Injection Lumbosacral","PX-76002082","CDM","22511","CPT","0761","RC","","","","both","","","8304.00","6228.00","MEDICARE [2001]","HB BWH MEDICARE","3852.78","","APC Price ($3,852.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3853.17","3853.17","8483.61","1 through 10","2574.24","6601.68","other","OPPS APC"
"Perq Vertebroplasty Uni/Bi Injection Lumbosacral","PX-76002082","CDM","22511","CPT","0761","RC","","","","outpatient","","","8304.00","6228.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2999.94","","Case rate ($2,999.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3511.43","3511.43","3511.43","1 through 10","2361.01","6786.03","other","ASC "
"Perq Vertebroplasty Uni/Bi Injx Cervicothoracic","PX-76002081","CDM","22510","CPT","0761","RC","","","","both","","","10587.00","7940.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3852.78","","APC Price ($3,852.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3791.52","3791.52","3791.52","1 through 10","3281.97","8416.67","other","OPPS APC"
"Perq Vertebroplasty Uni/Bi Injx Cervicothoracic","PX-76002081","CDM","22510","CPT","0761","RC","","","","both","","","10587.00","7940.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5642.87","53.3","","8080.13","8080.13","8080.13","1 through 10","3281.97","8416.67","percent of total billed charges",""
"Perq Vertebroplasty Uni/Bi Injx Cervicothoracic","PX-76002081","CDM","22510","CPT","0761","RC","","","","both","","","10587.00","7940.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3852.78","","APC Price ($3,852.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8347.87","8347.87","8347.87","1 through 10","3281.97","8416.67","other","OPPS APC"
"Perq Vertebroplasty Uni/Bi Injx Cervicothoracic","PX-76002081","CDM","22510","CPT","0761","RC","","","","both","","","10587.00","7940.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","3852.78","","APC Price ($3,852.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3776.11","3776.11","3776.11","1 through 10","3281.97","8416.67","other","OPPS APC"
"Perq Vertebroplasty Uni/Bi Injx Cervicothoracic","PX-76002081","CDM","22510","CPT","0761","RC","","","","both","","","10587.00","7940.25","MEDICARE [2001]","HB BWH MEDICARE","3852.78","","APC Price ($3,852.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8483.61","3853.17","25450.83","18","3281.97","8416.67","other","OPPS APC"
"Perq Vertebroplasty Uni/Bi Injx Cervicothoracic","PX-76002081","CDM","22510","CPT","0761","RC","","","","outpatient","","","10587.00","7940.25","AETNA [1001]","HB AMC AETNA HMO","7389.73","69.8","","6529.04","6529.04","6529.04","1 through 10","2361.01","8651.7","percent of total billed charges",""
"Perq Vertebroplasty Uni/Bi Injx Cervicothoracic","PX-76002081","CDM","22510","CPT","0761","RC","","","","outpatient","","","10587.00","7940.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2999.94","","Case rate ($2,999.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6137.88","6137.88","6137.88","1 through 10","2361.01","8651.7","other","ASC"
"Perq Vertebroplasty Uni/Bi Injx Cervicothoracic","PX-76002081","CDM","22510","CPT","0761","RC","","","","outpatient","","","10587.00","7940.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2999.94","","Case rate ($2,999.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7022.86","6953.86","7022.86","1 through 10","2361.01","8651.7","other","ASC "
"Perq Vertebroplasty Uni/Bi Injx Cervicothoracic","PX-76002081","CDM","22510","CPT","0761","RC","","","","outpatient","","","10587.00","7940.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2361.01","","Case rate ($2,361.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","5477.54","5477.54","5477.54","1 through 10","2361.01","8651.7","other","Multiple Surgery"
"Pessary Non-Rubber T1","PX-27000005","CDM","A4562","HCPCS","0270","RC","","","","both","","","112.00","84.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","40.88","36.5","","41.78","41.78","41.78","1 through 10","34.72","89.04","percent of total billed charges",""
"Pessary Non-Rubber T1","PX-27000005","CDM","A4562","HCPCS","0270","RC","","","","both","","","112.00","84.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","42.90","38.3","","43.79","43.79","43.79","1 through 10","34.72","89.04","percent of total billed charges",""
"Pessary Non-Rubber T1","PX-27000005","CDM","A4562","HCPCS","0270","RC","","","","both","","","112.00","84.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.05","42.9","","49.25","49.25","49.25","1 through 10","34.72","89.04","percent of total billed charges",""
"Pessary Non-Rubber T1","PX-27000005","CDM","A4562","HCPCS","0270","RC","","","","outpatient","","","112.00","84.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","61.60","55","","63.84","63.84","63.84","1 through 10","56","92.4","percent of total billed charges",""
"Pessary Non-Rubber T1","PX-27000005","CDM","A4562","HCPCS","0270","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","91.53","81.72","","178.11","178.11","178.11","1 through 10","56","92.4","percent of total billed charges",""
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","6373.00","4779.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1704.45","1704.45","1704.45","1 through 10","1645.55","5066.54","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","6373.00","4779.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5066.54","79.5","","4863.66","4863.66","4863.66","1 through 10","1645.55","5066.54","percent of total billed charges",""
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","6373.00","4779.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3396.81","53.3","","3263.04","3263.04","3263.04","1 through 10","1645.55","5066.54","percent of total billed charges",""
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","6373.00","4779.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1704.45","1704.45","1704.45","1 through 10","1645.55","5066.54","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","6373.00","4779.75","MEDICARE [2001]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1755.11","1732.16","1803.68","44","1645.55","5066.54","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","6373.00","4779.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2326.15","36.5","","2237.16","2237.16","2237.16","1 through 10","1645.55","5066.54","percent of total billed charges",""
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","6373.00","4779.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2440.86","38.3","","2416.38","2416.38","2416.38","1 through 10","1645.55","5066.54","percent of total billed charges",""
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","6373.00","4779.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2734.02","42.9","","4940.29","4940.29","4940.29","1 through 10","1645.55","5066.54","percent of total billed charges",""
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","6373.00","4779.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1697.35","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1711.37","1677.54","1711.37","1 through 10","1645.55","5066.54","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","outpatient","","","6373.00","4779.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5123.89","80.4","","4820.40","4820.40","4820.40","1 through 10","3330.53","6176.17","percent of total billed charges",""
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","outpatient","","","6373.00","4779.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5208.02","81.72","","4940.29","4940.29","5373.59","1 through 10","3330.53","6176.17","percent of total billed charges",""
"Pet Myocard Metabolic Eval","PX-40000099","CDM","78459","CPT","0404","RC","","","","both","","","4883.00","3662.25","MEDICARE [2001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1550.34","1549.78","1550.34","1 through 10","1472.82","3881.99","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","6444.00","4833.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1704.45","1704.45","1704.45","1 through 10","1645.55","5122.98","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","6444.00","4833.00","ELDER SERVICES [1037]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1697.52","1697.52","1697.52","1 through 10","1645.55","5122.98","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","6444.00","4833.00","MEDICARE [2001]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1732.16","1732.16","1732.16","1 through 10","1645.55","5122.98","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","6444.00","4833.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2352.06","36.5","","2330.88","2262.14","2330.88","1 through 10","1645.55","5122.98","percent of total billed charges",""
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","6444.00","4833.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2468.05","38.3","","2443.36","2443.36","2443.36","1 through 10","1645.55","5122.98","percent of total billed charges",""
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","6444.00","4833.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1697.35","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1699.02","1697.52","1702.52","1 through 10","1645.55","5122.98","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","outpatient","","","6444.00","4833.00","AETNA [1001]","HB AMC AETNA HMO","4497.91","69.8","","1.41","1.41","1.41","1 through 10","3367.63","6176.17","percent of total billed charges",""
"Pet W/CT Tumor Imaging Whole Body","PX-40000109","CDM","78816","CPT","0404","RC","","","","both","","","6452.00","4839.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","2164.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","1732.16","1732.16","1732.16","1 through 10","1645.55","5129.34","other","OPPS APC"
"Pet W/CT Tumor Imaging Whole Body","PX-40000109","CDM","78816","CPT","0404","RC","","","","both","","","6452.00","4839.00","MEDICARE [2001]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1732.16","1732.16","1732.16","1 through 10","1645.55","5129.34","other","OPPS APC"
"Pet W/CT Tumor Imaging Whole Body","PX-40000109","CDM","78816","CPT","0404","RC","","","","both","","","6452.00","4839.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2354.98","36.5","","2333.86","2333.86","2333.86","1 through 10","1645.55","5129.34","percent of total billed charges",""
"Pet W/CT Tumor Imaging Whole Body","PX-40000109","CDM","78816","CPT","0404","RC","","","","both","","","6452.00","4839.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1697.35","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1700.52","1673.34","1702.52","11","1645.55","5129.34","other","OPPS APC"
"Pet W/CT Tumor Imaging Whole Body","PX-40000109","CDM","78816","CPT","0404","RC","","","","outpatient","","","6452.00","4839.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5272.57","81.72","","5859.96","5859.96","5859.96","1 through 10","3371.82","6176.17","percent of total billed charges",""
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","6378.00","4783.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5070.51","79.5","","4867.60","3265.68","4867.60","11","1645.55","5070.51","percent of total billed charges",""
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","6378.00","4783.50","ELDER SERVICES [1037]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1732.16","1732.16","1732.16","1 through 10","1645.55","5070.51","other","OPPS APC"
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","6378.00","4783.50","HUMANA [1012]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1707.91","1707.91","1707.91","1 through 10","1645.55","5070.51","other","OPPS APC"
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","6378.00","4783.50","MEDICARE [2001]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1732.16","1732.16","1732.16","1 through 10","1645.55","5070.51","other","OPPS APC"
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","6378.00","4783.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2442.77","38.3","","2418.34","2418.34","2418.34","1 through 10","1645.55","5070.51","percent of total billed charges",""
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","6378.00","4783.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1697.35","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1697.72","1678.34","1702.52","107","1645.55","5070.51","other","OPPS APC"
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","outpatient","","","6378.00","4783.50","AETNA [1001]","HB AMC AETNA HMO","4451.84","69.8","","4187.25","2956.43","6185.00","1 through 10","3333.14","6176.17","percent of total billed charges",""
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","outpatient","","","6378.00","4783.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5127.91","80.4","","348.38","348.38","348.38","1 through 10","3333.14","6176.17","percent of total billed charges",""
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","outpatient","","","6378.00","4783.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5212.10","81.72","","5839.52","2719.54","5839.52","1 through 10","3333.14","6176.17","percent of total billed charges",""
"Petmr Fusion","PX-34000191","CDM","78999","CPT","0341","RC","","","","both","","","360.00","270.00","MEDICARE [2001]","HB BWH MEDICARE","477.15","","APC Price ($477.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","1 through 10","111.6","596.44","other","OPPS APC"
"Pf Analys Pump Pain W/O Reprog/Ref","PX-98300425","CDM","62367","CPT","0983","RC","","","","both","","","132.00","99.00","MEDICARE [2001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","356.16","356.16","356.16","1 through 10","40.92","445.16","other","OPPS APC"
"Pf Analysis Neur W/O Prog Smp/Cpx","PX-98300499","CDM","95970","CPT","0983","RC","","","","both","","","96.00","72.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","76.32","79.5","","145.60","145.60","145.60","1 through 10","29.76","191.33","percent of total billed charges",""
"Pf Analysis Neur W/O Prog Smp/Cpx","PX-98300499","CDM","95970","CPT","0983","RC","","","","both","","","96.00","72.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","29.76","191.33","other","OPPS APC"
"Pf Analysis Neur W/O Prog Smp/Cpx","PX-98300499","CDM","95970","CPT","0983","RC","","","","both","","","96.00","72.00","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","29.76","191.33","other","OPPS APC"
"Pf Analysis Neur W/O Prog Smp/Cpx","PX-98300499","CDM","95970","CPT","0983","RC","","","","both","","","96.00","72.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","35.04","36.5","","69.01","58.65","69.01","1 through 10","29.76","191.33","percent of total billed charges",""
"Pf Analysis Neur W/O Prog Smp/Cpx","PX-98300499","CDM","95970","CPT","0983","RC","","","","both","","","96.00","72.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","36.77","38.3","","72.34","72.34","72.34","1 through 10","29.76","191.33","percent of total billed charges",""
"Pf Analysis Neur W/O Prog Smp/Cpx","PX-98300499","CDM","95970","CPT","0983","RC","","","","outpatient","","","96.00","72.00","AETNA [1001]","HB AMC AETNA HMO","67.01","69.8","","125.25","88.43","125.25","1 through 10","49.05","545.56","percent of total billed charges",""
"Pf Analysis Neur W/O Prog Smp/Cpx","PX-98300499","CDM","95970","CPT","0983","RC","","","","outpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","78.45","81.72","","147.89","147.89","147.89","1 through 10","49.05","545.56","percent of total billed charges",""
"Pf Analysis Neurostim Simple W/Prog","PX-98300500","CDM","95971","CPT","0983","RC","","","","both","","","167.00","125.25","MEDICARE [2001]","HB BWH MEDICARE","95.90","","APC Price ($95.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.01","109.01","109.01","1 through 10","51.77","132.77","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","366.81","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","367.39","367.29","367.39","12","75.02","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.46","350.46","350.46","21","75.02","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","192.39","79.5","","732.70","732.70","732.70","1 through 10","75.02","445.16","percent of total billed charges",""
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.46","295.11","350.46","35","75.02","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","HUMANA [1012]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","356.16","351.89","356.16","1 through 10","75.02","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","MEDICARE [2001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","356.16","326.00","356.16","354","75.02","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","75.02","31","","287.68","287.68","287.68","1 through 10","75.02","445.16","percent of total billed charges",""
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","88.33","36.5","","295.13","295.13","347.26","1 through 10","75.02","445.16","percent of total billed charges",""
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","92.69","38.3","","364.02","353.78","364.02","1 through 10","75.02","445.16","percent of total billed charges",""
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","349.04","319.48","349.04","1 through 10","75.02","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","MOLINA [1014]","HB BWH MOLINA","349.00","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","706.62","706.62","706.62","1 through 10","75.02","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","TRICARE [160005]","HB BWH TRICARE","338.35","","APC Price ($356.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","338.35","309.70","338.35","1 through 10","75.02","445.16","other","Tricare OPPS"
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","349.00","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","356.16","350.46","1068.48","29","75.02","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","349.00","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","356.16","319.48","356.16","31","75.02","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","both","","","242.00","181.50","WELLPOINT [1015]","HB AMC WELLPOINT","178.55","73.78","","693.13","693.13","693.13","24","75.02","445.16","percent of total billed charges",""
"Pf Analysis Pump Pain Mgmt W/Rep","PX-98300428","CDM","62370","CPT","0983","RC","","","","outpatient","","","242.00","181.50","AETNA [1001]","HB AMC AETNA PPO","194.57","80.4","","487.84","487.84","487.84","1 through 10","135.28","2547.23","percent of total billed charges",""
"Pf Analysis Pump Pain Mgmt W/Reprog","PX-98300426","CDM","62368","CPT","0983","RC","","","","both","","","204.00","153.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","366.81","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","366.69","366.49","366.69","1 through 10","63.24","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Reprog","PX-98300426","CDM","62368","CPT","0983","RC","","","","both","","","204.00","153.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.46","320.78","350.46","1 through 10","63.24","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Reprog","PX-98300426","CDM","62368","CPT","0983","RC","","","","both","","","204.00","153.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.46","350.46","354.01","1 through 10","63.24","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Reprog","PX-98300426","CDM","62368","CPT","0983","RC","","","","both","","","204.00","153.00","MEDICARE [2001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","356.16","356.16","356.16","68","63.24","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Reprog","PX-98300426","CDM","62368","CPT","0983","RC","","","","both","","","204.00","153.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","349.04","349.04","349.04","1 through 10","63.24","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Reprog","PX-98300426","CDM","62368","CPT","0983","RC","","","","both","","","204.00","153.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","349.00","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.46","350.46","350.46","1 through 10","63.24","445.16","other","OPPS APC"
"Pf Analysis Pump Pain Mgmt W/Reprog","PX-98300426","CDM","62368","CPT","0983","RC","","","","both","","","204.00","153.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","349.00","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","356.16","326.00","712.20","11","63.24","445.16","other","OPPS APC"
"Pf Anes Superior Hypogastric Plexus","PX-98300461","CDM","64517","CPT","0983","RC","","","","both","","","624.00","468.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1088.88","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1088.83","1088.83","1088.83","1 through 10","193.44","1321.46","other","OPPS APC"
"Pf Annual Alcohol Misuse Scrnng","PX-98300593","CDM","G0442","HCPCS","0983","RC","","","","both","","","52.00","39.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","36.44","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","36.41","9.72","36.41","1 through 10","16.12","44.22","other","OPPS APC"
"Pf Annual Alcohol Misuse Scrnng","PX-98300593","CDM","G0442","HCPCS","0983","RC","","","","both","","","52.00","39.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.81","34.81","34.81","21","16.12","44.22","other","OPPS APC"
"Pf Annual Alcohol Misuse Scrnng","PX-98300593","CDM","G0442","HCPCS","0983","RC","","","","both","","","52.00","39.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.82","30.82","30.82","1 through 10","16.12","44.22","other","OPPS APC"
"Pf Annual Alcohol Misuse Scrnng","PX-98300593","CDM","G0442","HCPCS","0983","RC","","","","both","","","52.00","39.00","MEDICARE [2001]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","35.38","35.38","62.64","277","16.12","44.22","other","OPPS APC"
"Pf Annual Alcohol Misuse Scrnng","PX-98300593","CDM","G0442","HCPCS","0983","RC","","","","both","","","52.00","39.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9.45","8.03","9.45","26","16.12","44.22","other","OPPS APC"
"Pf Annual Alcohol Misuse Scrnng","PX-98300593","CDM","G0442","HCPCS","0983","RC","","","","both","","","52.00","39.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.67","30.69","34.67","11","16.12","44.22","other","OPPS APC"
"Pf Annual Alcohol Misuse Scrnng","PX-98300593","CDM","G0442","HCPCS","0983","RC","","","","both","","","52.00","39.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","34.67","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","34.67","34.67","34.67","1 through 10","16.12","44.22","other","OPPS APC"
"Pf Annual Alcohol Misuse Scrnng","PX-98300593","CDM","G0442","HCPCS","0983","RC","","","","both","","","52.00","39.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","34.67","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","34.68","9.54","34.68","73","16.12","44.22","other","OPPS APC"
"Pf Annual Depression Screening 15","PX-98300595","CDM","G0444","HCPCS","0983","RC","","","","both","","","52.00","39.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","36.44","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","36.41","9.72","36.41","1 through 10","16.12","49.4","other","OPPS APC"
"Pf Annual Depression Screening 15","PX-98300595","CDM","G0444","HCPCS","0983","RC","","","","both","","","52.00","39.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.81","34.81","34.81","15","16.12","49.4","other","OPPS APC"
"Pf Annual Depression Screening 15","PX-98300595","CDM","G0444","HCPCS","0983","RC","","","","both","","","52.00","39.00","HUMANA [1012]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.67","34.67","34.67","1 through 10","16.12","49.4","other","OPPS APC"
"Pf Annual Depression Screening 15","PX-98300595","CDM","G0444","HCPCS","0983","RC","","","","both","","","52.00","39.00","MEDICARE [2001]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","35.38","35.38","35.38","204","16.12","49.4","other","OPPS APC"
"Pf Annual Depression Screening 15","PX-98300595","CDM","G0444","HCPCS","0983","RC","","","","both","","","52.00","39.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9.45","8.03","9.45","29","16.12","49.4","other","OPPS APC"
"Pf Annual Depression Screening 15","PX-98300595","CDM","G0444","HCPCS","0983","RC","","","","both","","","52.00","39.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.67","7.87","34.67","1 through 10","16.12","49.4","other","OPPS APC"
"Pf Annual Depression Screening 15","PX-98300595","CDM","G0444","HCPCS","0983","RC","","","","both","","","52.00","39.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","34.67","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","34.67","34.67","34.67","1 through 10","16.12","49.4","other","OPPS APC"
"Pf Annual Depression Screening 15","PX-98300595","CDM","G0444","HCPCS","0983","RC","","","","both","","","52.00","39.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","34.67","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","34.68","9.54","34.68","65","16.12","49.4","other","OPPS APC"
"Pf Anoscopy","PX-98300342","CDM","46600","CPT","0983","RC","","","","both","","","331.00","248.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","176.42","53.3","","267.58","267.58","267.58","1 through 10","102.61","263.15","percent of total billed charges",""
"Pf Anoscopy","PX-98300342","CDM","46600","CPT","0983","RC","","","","both","","","331.00","248.25","WELLPOINT [1015]","HB AMC WELLPOINT","244.21","73.78","","253.13","253.13","253.13","1 through 10","102.61","263.15","percent of total billed charges",""
"Pf Anoscopy","PX-98300342","CDM","46600","CPT","0983","RC","","","","outpatient","","","331.00","248.25","AETNA [1001]","HB AMC AETNA HMO","231.04","69.8","","230.18","230.18","230.18","1 through 10","153.05","700.33","percent of total billed charges",""
"Pf Anoscopy","PX-98300342","CDM","46600","CPT","0983","RC","","","","outpatient","","","331.00","248.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","270.49","81.72","","1947.44","1947.44","1947.44","1 through 10","153.05","700.33","percent of total billed charges",""
"Pf Appl Cast Arm Long","PX-98300269","CDM","29065","CPT","0983","RC","","","","outpatient","","","311.00","233.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","235.58","","Case rate ($235.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","603.08","603.08","603.08","1 through 10","133.42","1409.06","other","Multiple Surgery"
"Pf Appl Cast Arm Short","PX-98300270","CDM","29075","CPT","0983","RC","","","","both","","","289.00","216.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","309.05","","APC Price ($315.36). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","293.11","293.11","293.11","1 through 10","89.59","394.2","other","OPPS APC"
"Pf Appl Cast Arm Short","PX-98300270","CDM","29075","CPT","0983","RC","","","","outpatient","","","289.00","216.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","235.58","","Case rate ($235.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","574.82","574.82","574.82","1 through 10","161.55","1409.06","other","Multiple Surgery"
"Pf Appl Cast Arm Short","PX-98300270","CDM","29075","CPT","0983","RC","","","","outpatient","","","289.00","216.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","235.58","","Case rate ($235.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","374.65","374.65","374.65","1 through 10","161.55","1409.06","other","Multiple Surgery"
"Pf Appl Cast Leg Short|BILATERAL PROCEDURE","PX-98300279","CDM","29405","CPT","0983","RC","","","50","both","","","267.00","200.25","MEDICARE [2001]","HB BWH MEDICARE","315.36","","APC Price ($315.36). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","473.09","473.09","1419.27","1 through 10","299.62","394.2","other","OPPS APC"
"Pf Appl Splint Arm Long","PX-98300272","CDM","29105","CPT","0983","RC","","","","both","","","242.00","181.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","192.39","79.5","","314.80","314.80","314.80","1 through 10","75.02","234.21","percent of total billed charges",""
"Pf Appl Splint Arm Long","PX-98300272","CDM","29105","CPT","0983","RC","","","","outpatient","","","242.00","181.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","134.62","","Case rate ($134.62). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","331.17","331.17","331.17","1 through 10","118.24","701.53","other","Multiple Surgery"
"Pf Appl Splint Finger Static","PX-98300275","CDM","29130","CPT","0983","RC","","","","both","","","127.00","95.25","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","39.37","191.33","other","OPPS APC"
"Pf Appl Splint Leg Short","PX-98300281","CDM","29515","CPT","0983","RC","","","","both","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","183.62","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.39","187.39","187.39","1 through 10","69.75","234.21","other","OPPS APC"
"Pf Apply Cast Finger","PX-98300271","CDM","29086","CPT","0983","RC","","","","both","","","227.00","170.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","169.73","169.73","169.73","1 through 10","70.37","234.21","other","OPPS APC"
"Pf Apply Cast Finger","PX-98300271","CDM","29086","CPT","0983","RC","","","","both","","","227.00","170.25","MEDICARE [2001]","HB BWH MEDICARE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.39","187.39","187.39","19","70.37","234.21","other","OPPS APC"
"Pf Apply Cast Finger","PX-98300271","CDM","29086","CPT","0983","RC","","","","both","","","227.00","170.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","86.94","38.3","","135.29","135.29","135.29","1 through 10","70.37","234.21","percent of total billed charges",""
"Pf Apply Cast Finger","PX-98300271","CDM","29086","CPT","0983","RC","","","","both","","","227.00","170.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.64","168.33","183.64","1 through 10","70.37","234.21","other","OPPS APC"
"Pf Apply Cast Finger","PX-98300271","CDM","29086","CPT","0983","RC","","","","both","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","183.62","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.39","169.22","187.39","1 through 10","70.37","234.21","other","OPPS APC"
"Pf Apply Cast Finger","PX-98300271","CDM","29086","CPT","0983","RC","","","","outpatient","","","227.00","170.25","AETNA [1001]","HB AMC AETNA HMO","158.45","69.8","","269.88","269.88","269.88","1 through 10","126.89","701.53","percent of total billed charges",""
"Pf Apply Cast Finger","PX-98300271","CDM","29086","CPT","0983","RC","","","","outpatient","","","227.00","170.25","AETNA [1001]","HB AMC AETNA PPO","182.51","80.4","","269.88","269.88","269.88","1 through 10","126.89","701.53","percent of total billed charges",""
"Pf Apply Multlay Comprs Bl Knee","PX-98300285","CDM","29581","CPT","0983","RC","","","","both","","","123.00","92.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","192.99","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","192.82","176.96","192.82","13","38.13","234.21","other","OPPS APC"
"Pf Apply Multlay Comprs Bl Knee","PX-98300285","CDM","29581","CPT","0983","RC","","","","both","","","123.00","92.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","184.39","184.39","184.39","1 through 10","38.13","234.21","other","OPPS APC"
"Pf Apply Multlay Comprs Bl Knee","PX-98300285","CDM","29581","CPT","0983","RC","","","","both","","","123.00","92.25","MEDICARE [2001]","HB BWH MEDICARE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.39","171.97","187.39","40","38.13","234.21","other","OPPS APC"
"Pf Apply Multlay Comprs Bl Knee","PX-98300285","CDM","29581","CPT","0983","RC","","","","both","","","123.00","92.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.90","36.5","","129.06","129.06","129.06","13","38.13","234.21","percent of total billed charges",""
"Pf Apply Multlay Comprs Bl Knee","PX-98300285","CDM","29581","CPT","0983","RC","","","","both","","","123.00","92.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","47.11","38.3","","135.29","135.29","135.29","11","38.13","234.21","percent of total billed charges",""
"Pf Apply Multlay Comprs Bl Knee","PX-98300285","CDM","29581","CPT","0983","RC","","","","both","","","123.00","92.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.64","183.64","183.64","1 through 10","38.13","234.21","other","OPPS APC"
"Pf Apply Multlay Comprs Bl Knee","PX-98300285","CDM","29581","CPT","0983","RC","","","","both","","","123.00","92.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","183.62","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.39","168.53","281.09","50","38.13","234.21","other","OPPS APC"
"Pf Apply Multlay Comprs Bl Knee","PX-98300285","CDM","29581","CPT","0983","RC","","","","outpatient","","","123.00","92.25","AETNA [1001]","HB AMC AETNA HMO","85.85","69.8","","165.39","165.39","234.24","1 through 10","68.76","700.33","percent of total billed charges",""
"Pf Apply Multlay Comprs Bl Knee|BILATERAL PROCEDURE","PX-98300285","CDM","29581","CPT","0983","RC","","","50","both","","","123.00","92.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","169.80","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","289.23","289.23","289.23","1 through 10","161.56","206.07","other","OPPS APC"
"Pf Apply Multlay Comprs Bl Knee|BILATERAL PROCEDURE","PX-98300285","CDM","29581","CPT","0983","RC","","","50","both","","","123.00","92.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.90","220.70","276.59","1 through 10","161.56","206.07","other","OPPS APC"
"Pf Apply Multlay Comprs Bl Knee|BILATERAL PROCEDURE","PX-98300285","CDM","29581","CPT","0983","RC","","","50","both","","","123.00","92.25","MEDICARE [2001]","HB BWH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.08","281.08","281.08","37","161.56","206.07","other","OPPS APC"
"Pf Arthrosc Aided Cruciate Lig Ant","PX-98300601","CDM","29888","CPT","0983","RC","","","","outpatient","","","4989.00","3741.75","AETNA [1001]","HB AMC AETNA HMO","3482.32","69.8","","9530.47","9530.47","27109.79","1 through 10","2788.85","8899.59","percent of total billed charges",""
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","both","","","508.00","381.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","335.87","335.87","488.93","1 through 10","157.48","593.02","other","OPPS APC"
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","both","","","508.00","381.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.86","79.5","","1445.72","521.78","1445.72","1 through 10","157.48","593.02","percent of total billed charges",""
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","both","","","508.00","381.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.76","53.3","","1050.18","350.06","1050.18","1 through 10","157.48","593.02","percent of total billed charges",""
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","both","","","508.00","381.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.16","350.16","350.16","1 through 10","157.48","593.02","other","OPPS APC"
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","both","","","508.00","381.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","12","157.48","593.02","other","OPPS APC"
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","both","","","508.00","381.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.42","36.5","","247.30","210.17","247.30","1 through 10","157.48","593.02","percent of total billed charges",""
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","both","","","508.00","381.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.56","38.3","","259.23","251.94","259.23","1 through 10","157.48","593.02","percent of total billed charges",""
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","both","","","508.00","381.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","435.20","435.20","435.20","1 through 10","157.48","593.02","other","OPPS APC"
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","both","","","508.00","381.00","WELLPOINT [1015]","HB AMC WELLPOINT","374.80","73.78","","1156.60","493.60","1156.60","1 through 10","157.48","593.02","percent of total billed charges",""
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","outpatient","","","508.00","381.00","AETNA [1001]","HB AMC AETNA HMO","354.58","69.8","","897.70","448.85","897.70","1 through 10","283.97","700.33","percent of total billed charges",""
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","outpatient","","","508.00","381.00","AETNA [1001]","HB AMC AETNA PPO","408.43","80.4","","517.14","517.14","517.14","1 through 10","283.97","700.33","percent of total billed charges",""
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","outpatient","","","508.00","381.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","728.67","728.67","728.67","1 through 10","283.97","700.33","other","Multiple Surgery"
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","outpatient","","","508.00","381.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","766.36","766.36","766.36","1 through 10","283.97","700.33","other","Multiple Surgery"
"Pf Aspirat Absc/Hema/Bulla/Cyst","PX-98300009","CDM","10160","CPT","0983","RC","","","","outpatient","","","508.00","381.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","415.14","81.72","","530.00","291.52","530.00","1 through 10","283.97","700.33","percent of total billed charges",""
"Pf Aspirat Cyst Breast","PX-98300133","CDM","19000","CPT","0983","RC","","","","both","","","228.00","171.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","755.61","421.42","755.61","1 through 10","70.68","1044.34","other","OPPS APC"
"Pf Aspirat Cyst Breast","PX-98300133","CDM","19000","CPT","0983","RC","","","","both","","","228.00","171.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","181.26","79.5","","1113.61","1113.61","1113.61","1 through 10","70.68","1044.34","percent of total billed charges",""
"Pf Aspirat Cyst Breast","PX-98300133","CDM","19000","CPT","0983","RC","","","","both","","","228.00","171.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","70.68","1044.34","other","OPPS APC"
"Pf Aspirat Cyst Breast","PX-98300133","CDM","19000","CPT","0983","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.22","36.5","","527.80","527.80","527.80","1 through 10","70.68","1044.34","percent of total billed charges",""
"Pf Aspirat Cyst Breast","PX-98300133","CDM","19000","CPT","0983","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.32","38.3","","553.27","537.70","553.27","1 through 10","70.68","1044.34","percent of total billed charges",""
"Pf Aspirat Cyst Breast","PX-98300133","CDM","19000","CPT","0983","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.75","826.35","826.75","1 through 10","70.68","1044.34","other","OPPS APC"
"Pf Aspirat Cyst Breast","PX-98300133","CDM","19000","CPT","0983","RC","","","","both","","","228.00","171.00","WELLPOINT [1015]","HB AMC WELLPOINT","168.22","73.78","","1053.47","1053.47","1053.47","1 through 10","70.68","1044.34","percent of total billed charges",""
"Pf Aspirat Cyst Breast","PX-98300133","CDM","19000","CPT","0983","RC","","","","outpatient","","","228.00","171.00","AETNA [1001]","HB AMC AETNA HMO","159.14","69.8","","957.96","957.96","957.96","1 through 10","119.04","1234.13","percent of total billed charges",""
"Pf Aspirat Cyst Breast","PX-98300133","CDM","19000","CPT","0983","RC","","","","outpatient","","","228.00","171.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1680.09","1680.09","1680.09","1 through 10","119.04","1234.13","other","Multiple Surgery"
"Pf Aspirat Cyst Breast","PX-98300133","CDM","19000","CPT","0983","RC","","","","outpatient","","","228.00","171.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1344.07","1344.07","1344.07","1 through 10","119.04","1234.13","other","Multiple Surgery"
"Pf Aspirat Cyst Breast","PX-98300133","CDM","19000","CPT","0983","RC","","","","outpatient","","","228.00","171.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1413.59","1413.59","1413.59","1 through 10","119.04","1234.13","other","Multiple Surgery"
"Pf Aspirat Cyst Breast","PX-98300133","CDM","19000","CPT","0983","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","186.32","81.72","","1131.15","1131.15","1131.15","1 through 10","119.04","1234.13","percent of total billed charges",""
"Pf Aspirat Fine Needle W/O Imaging","PX-98300001","CDM","10021","CPT","0983","RC","","","","both","","","277.00","207.75","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","85.87","593.02","other","OPPS APC"
"Pf Avulsion Nail Plate Single","PX-98300074","CDM","11730","CPT","0983","RC","","","","both","","","235.00","176.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","243.61","36.94","243.71","1 through 10","72.85","294.93","other","OPPS APC"
"Pf Avulsion Nail Plate Single","PX-98300074","CDM","11730","CPT","0983","RC","","","","both","","","235.00","176.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","72.85","294.93","other","OPPS APC"
"Pf Avulsion Nail Plate Single","PX-98300074","CDM","11730","CPT","0983","RC","","","","both","","","235.00","176.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.78","36.5","","472.65","472.65","472.65","1 through 10","72.85","294.93","percent of total billed charges",""
"Pf Avulsion Nail Plate Single","PX-98300074","CDM","11730","CPT","0983","RC","","","","both","","","235.00","176.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","90.01","38.3","","194.33","89.54","194.33","1 through 10","72.85","294.93","percent of total billed charges",""
"Pf Avulsion Nail Plate Single","PX-98300074","CDM","11730","CPT","0983","RC","","","","both","","","235.00","176.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.19","231.25","235.97","1 through 10","72.85","294.93","other","OPPS APC"
"Pf Avulsion Nail Plate Single","PX-98300074","CDM","11730","CPT","0983","RC","","","","outpatient","","","235.00","176.25","AETNA [1001]","HB AMC AETNA HMO","164.03","69.8","","694.05","694.05","694.05","1 through 10","100.82","700.33","percent of total billed charges",""
"Pf Avulsion Nail Plate Single","PX-98300074","CDM","11730","CPT","0983","RC","","","","outpatient","","","235.00","176.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","451.71","451.71","451.71","1 through 10","100.82","700.33","other","Multiple Surgery"
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","both","","","561.00","420.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1979.93","1820.83","1979.93","1 through 10","173.91","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","both","","","561.00","420.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","870.07","1893.34","1 through 10","173.91","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","both","","","561.00","420.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","446.00","79.5","","7080.64","7080.64","7080.64","1 through 10","173.91","2404.92","percent of total billed charges",""
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","both","","","561.00","420.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","173.91","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","both","","","561.00","420.75","FALLON HEALTH [1008]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1891.15","1891.15","1891.15","1 through 10","173.91","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","both","","","561.00","420.75","HUMANA [1012]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1885.65","1885.65","1885.65","1 through 10","173.91","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","both","","","561.00","420.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","3539.02","36","173.91","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","both","","","561.00","420.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","214.86","38.3","","1553.83","1510.12","1553.83","1 through 10","173.91","2404.92","percent of total billed charges",""
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","both","","","561.00","420.75","MOLINA [1014]","HB BWH MOLINA","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3503.63","3503.63","3503.63","1 through 10","173.91","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","both","","","561.00","420.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5665.95","5665.95","5665.95","1 through 10","173.91","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","both","","","561.00","420.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1892.75","1885.65","1892.75","1 through 10","173.91","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","both","","","561.00","420.75","WELLPOINT [1015]","HB AMC WELLPOINT","413.91","73.78","","2958.64","2958.64","2958.64","1 through 10","173.91","2404.92","percent of total billed charges",""
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","outpatient","","","561.00","420.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","8616.12","8616.12","1 through 10","313.6","5545.35","other","Multiple Surgery"
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","outpatient","","","561.00","420.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3020.60","3020.60","3020.60","1 through 10","313.6","5545.35","other","Multiple Surgery"
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","outpatient","","","561.00","420.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","3590.06","3590.06","3590.06","1 through 10","313.6","5545.35","other","Multiple Surgery"
"Pf Biopsy Bone Trocar/Needle Deep","PX-98300145","CDM","20225","CPT","0983","RC","","","","outpatient","","","561.00","420.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","458.45","81.72","","3176.82","3176.82","3176.82","1 through 10","313.6","5545.35","percent of total billed charges",""
"Pf Biopsy Bone Trocar/Needle Super","PX-98300144","CDM","20220","CPT","0983","RC","","","","both","","","377.00","282.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1988.83","1979.93","1988.83","1 through 10","116.87","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Super","PX-98300144","CDM","20220","CPT","0983","RC","","","","both","","","377.00","282.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","488.67","1893.34","1 through 10","116.87","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Super","PX-98300144","CDM","20220","CPT","0983","RC","","","","both","","","377.00","282.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","263.90","70","","4823.28","4823.28","4823.28","1 through 10","116.87","2404.92","percent of total billed charges",""
"Pf Biopsy Bone Trocar/Needle Super","PX-98300144","CDM","20220","CPT","0983","RC","","","","both","","","377.00","282.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","299.72","79.5","","1179.02","1179.02","1179.02","1 through 10","116.87","2404.92","percent of total billed charges",""
"Pf Biopsy Bone Trocar/Needle Super","PX-98300144","CDM","20220","CPT","0983","RC","","","","both","","","377.00","282.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","200.94","53.3","","4340.30","1757.37","4340.30","1 through 10","116.87","2404.92","percent of total billed charges",""
"Pf Biopsy Bone Trocar/Needle Super","PX-98300144","CDM","20220","CPT","0983","RC","","","","both","","","377.00","282.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1894.65","1894.65","1894.65","1 through 10","116.87","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Super","PX-98300144","CDM","20220","CPT","0983","RC","","","","both","","","377.00","282.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","38","116.87","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Super","PX-98300144","CDM","20220","CPT","0983","RC","","","","both","","","377.00","282.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1885.65","1885.65","1885.65","1 through 10","116.87","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Super","PX-98300144","CDM","20220","CPT","0983","RC","","","","both","","","377.00","282.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.45","1891.05","1893.45","1 through 10","116.87","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Super","PX-98300144","CDM","20220","CPT","0983","RC","","","","both","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1889.50","1742.49","1924.13","1 through 10","116.87","2404.92","other","OPPS APC"
"Pf Biopsy Bone Trocar/Needle Super","PX-98300144","CDM","20220","CPT","0983","RC","","","","outpatient","","","377.00","282.75","AETNA [1001]","HB AMC AETNA HMO","263.15","69.8","","1511.74","1511.74","1511.74","1 through 10","210.74","2384.07","percent of total billed charges",""
"Pf Biopsy Bone Trocar/Needle Super","PX-98300144","CDM","20220","CPT","0983","RC","","","","outpatient","","","377.00","282.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","8616.12","8616.12","1 through 10","210.74","2384.07","other","Multiple Surgery"
"Pf Biopsy Bone Trocar/Needle Super","PX-98300144","CDM","20220","CPT","0983","RC","","","","outpatient","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","308.08","81.72","","1785.06","952.62","1785.06","1 through 10","210.74","2384.07","percent of total billed charges",""
"Pf Biopsy Exc Cervix Local","PX-98300396","CDM","57500","CPT","0983","RC","","","","both","","","511.00","383.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1064.97","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","532.82","532.82","532.82","1 through 10","158.41","1292.44","other","OPPS APC"
"Pf Biopsy Exc Cervix Local","PX-98300396","CDM","57500","CPT","0983","RC","","","","both","","","511.00","383.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","406.25","79.5","","1001.06","1001.06","1001.06","1 through 10","158.41","1292.44","percent of total billed charges",""
"Pf Biopsy Exc Cervix Local","PX-98300396","CDM","57500","CPT","0983","RC","","","","both","","","511.00","383.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","272.36","53.3","","2033.87","671.62","2033.87","1 through 10","158.41","1292.44","percent of total billed charges",""
"Pf Biopsy Exc Cervix Local","PX-98300396","CDM","57500","CPT","0983","RC","","","","both","","","511.00","383.25","MEDICARE [2001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1034.06","1034.06","1034.06","1 through 10","158.41","1292.44","other","OPPS APC"
"Pf Biopsy Exc Cervix Local","PX-98300396","CDM","57500","CPT","0983","RC","","","","both","","","511.00","383.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","195.71","38.3","","497.35","483.36","1492.05","1 through 10","158.41","1292.44","percent of total billed charges",""
"Pf Biopsy Exc Cervix Local","PX-98300396","CDM","57500","CPT","0983","RC","","","","both","","","511.00","383.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","859.86","859.86","859.86","1 through 10","158.41","1292.44","other","OPPS APC"
"Pf Biopsy Exc Cervix Local","PX-98300396","CDM","57500","CPT","0983","RC","","","","both","","","511.00","383.25","WELLPOINT [1015]","HB AMC WELLPOINT","377.02","73.78","","2219.00","2219.00","2219.00","1 through 10","158.41","1292.44","percent of total billed charges",""
"Pf Biopsy Exc Cervix Local","PX-98300396","CDM","57500","CPT","0983","RC","","","","outpatient","","","511.00","383.25","AETNA [1001]","HB AMC AETNA HMO","356.68","69.8","","608.02","608.02","5646.18","1 through 10","236.71","2384.07","percent of total billed charges",""
"Pf Biopsy Exc Cervix Local","PX-98300396","CDM","57500","CPT","0983","RC","","","","outpatient","","","511.00","383.25","AETNA [1001]","HB AMC AETNA PPO","410.84","80.4","","861.14","861.14","861.14","1 through 10","236.71","2384.07","percent of total billed charges",""
"Pf Biopsy Exc Cervix Local","PX-98300396","CDM","57500","CPT","0983","RC","","","","outpatient","","","511.00","383.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1428.58","1272.33","1428.58","1 through 10","236.71","2384.07","other","Multiple Surgery"
"Pf Biopsy Exc Cervix Local","PX-98300396","CDM","57500","CPT","0983","RC","","","","outpatient","","","511.00","383.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1294.65","1294.65","1294.65","1 through 10","236.71","2384.07","other","Multiple Surgery"
"Pf Biopsy Exc Cervix Local","PX-98300396","CDM","57500","CPT","0983","RC","","","","outpatient","","","511.00","383.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","417.59","81.72","","1016.84","1016.84","1016.84","1 through 10","236.71","2384.07","percent of total billed charges",""
"Pf Biopsy Exc Cervix Local","PX-98300396","CDM","57500","CPT","0983","RC","","","","outpatient","","","511.00","383.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","417.59","81.72","","1016.84","1016.84","1016.84","1 through 10","236.71","2384.07","percent of total billed charges",""
"Pf Biopsy Ext Ear","PX-98300482","CDM","69100","CPT","0983","RC","","","","both","","","203.00","152.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","275.75","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.32","262.32","262.32","1 through 10","62.93","344.68","other","OPPS APC"
"Pf Biopsy Ext Ear","PX-98300482","CDM","69100","CPT","0983","RC","","","","both","","","203.00","152.25","MEDICARE [2001]","HB BWH MEDICARE","275.75","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","275.78","275.78","275.78","1 through 10","62.93","344.68","other","OPPS APC"
"Pf Biopsy Ext Ear","PX-98300482","CDM","69100","CPT","0983","RC","","","","both","","","203.00","152.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.10","36.5","","689.31","689.31","689.31","1 through 10","62.93","344.68","percent of total billed charges",""
"Pf Biopsy Ext Ear","PX-98300482","CDM","69100","CPT","0983","RC","","","","both","","","203.00","152.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.75","38.3","","722.58","722.58","722.58","1 through 10","62.93","344.68","percent of total billed charges",""
"Pf Biopsy Ext Ear","PX-98300482","CDM","69100","CPT","0983","RC","","","","both","","","203.00","152.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","275.75","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","135.13","135.13","135.13","1 through 10","62.93","344.68","other","OPPS APC"
"Pf Biopsy Ext Ear","PX-98300482","CDM","69100","CPT","0983","RC","","","","both","","","203.00","152.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","270.23","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","270.26","270.26","270.26","1 through 10","62.93","344.68","other","OPPS APC"
"Pf Biopsy Ext Ear","PX-98300482","CDM","69100","CPT","0983","RC","","","","both","","","203.00","152.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","270.23","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","270.27","270.27","270.27","1 through 10","62.93","344.68","other","OPPS APC"
"Pf Biopsy Ext Ear","PX-98300482","CDM","69100","CPT","0983","RC","","","","outpatient","","","203.00","152.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","206.14","","Case rate ($206.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1508.94","1508.94","1508.94","1 through 10","113.48","1234.13","other","Multiple Surgery"
"Pf Biopsy Eyelid Incis W/Margin","PX-98300481","CDM","67810","CPT","0983","RC","","","","outpatient","","","377.00","282.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","283.52","","Case rate ($283.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","232.39","232.39","232.39","1 through 10","189.3","1234.13","other","Multiple Surgery"
"Pf Biopsy Lip","PX-98300322","CDM","40490","CPT","0983","RC","","","","both","","","340.00","255.00","MEDICARE [2001]","HB BWH MEDICARE","275.75","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","275.78","137.89","275.78","1 through 10","105.4","344.68","other","OPPS APC"
"Pf Biopsy Lip","PX-98300322","CDM","40490","CPT","0983","RC","","","","both","","","340.00","255.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","275.75","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.14","36.57","73.14","1 through 10","105.4","344.68","other","OPPS APC"
"Pf Biopsy Lip","PX-98300322","CDM","40490","CPT","0983","RC","","","","both","","","340.00","255.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","130.22","38.3","","749.55","116.52","749.55","1 through 10","105.4","344.68","percent of total billed charges",""
"Pf Biopsy Lip","PX-98300322","CDM","40490","CPT","0983","RC","","","","both","","","340.00","255.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","270.23","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.97","146.97","146.97","1 through 10","105.4","344.68","other","OPPS APC"
"Pf Biopsy Lip","PX-98300322","CDM","40490","CPT","0983","RC","","","","both","","","340.00","255.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","270.23","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","270.26","270.26","270.26","1 through 10","105.4","344.68","other","OPPS APC"
"Pf Biopsy Lip","PX-98300322","CDM","40490","CPT","0983","RC","","","","both","","","340.00","255.00","WELLPOINT [1015]","HB AMC WELLPOINT","250.85","73.78","","697.60","697.60","697.60","1 through 10","105.4","344.68","percent of total billed charges",""
"Pf Biopsy Lip","PX-98300322","CDM","40490","CPT","0983","RC","","","","outpatient","","","340.00","255.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","206.14","","Case rate ($206.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","597.81","157.64","597.81","1 through 10","183.59","1234.13","other","Multiple Surgery"
"Pf Biopsy Lip","PX-98300322","CDM","40490","CPT","0983","RC","","","","outpatient","","","340.00","255.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","206.14","","Case rate ($206.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","459.69","149.89","478.24","1 through 10","183.59","1234.13","other","Multiple Surgery"
"Pf Biopsy Lip","PX-98300322","CDM","40490","CPT","0983","RC","","","","outpatient","","","340.00","255.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","206.14","","Case rate ($206.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","484.43","157.64","484.43","1 through 10","183.59","1234.13","other","Multiple Surgery"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1985.83","1979.93","6894.20","1 through 10","190.03","2404.92","other","OPPS APC"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","449.83","1893.34","1 through 10","190.03","2404.92","other","OPPS APC"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","398.45","65","","6290.70","6290.70","6290.70","1 through 10","190.03","2404.92","percent of total billed charges",""
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","487.34","79.5","","5263.45","4070.30","5387.01","32","190.03","2404.92","percent of total billed charges",""
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","326.73","53.3","","7802.31","7802.31","7802.31","21","190.03","2404.92","percent of total billed charges",""
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1885.64","1734.12","1885.65","1 through 10","190.03","2404.92","other","OPPS APC"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1897.19","1897.19","1897.19","1 through 10","190.03","2404.92","other","OPPS APC"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","HUMANA [1012]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1901.04","1885.65","1904.89","1 through 10","190.03","2404.92","other","OPPS APC"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","398.45","65","","2035.15","2035.15","2035.15","1 through 10","190.03","2404.92","percent of total billed charges",""
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","101","190.03","2404.92","other","OPPS APC"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.75","36.5","","3067.92","1167.81","3067.92","1 through 10","190.03","2404.92","percent of total billed charges",""
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.78","38.3","","3784.11","1225.88","3784.11","1 through 10","190.03","2404.92","percent of total billed charges",""
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1891.65","1885.65","1891.65","1 through 10","190.03","2404.92","other","OPPS APC"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","1827.93","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1924.13","1924.13","1924.13","1 through 10","190.03","2404.92","other","Tricare OPPS"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5679.15","1887.15","5679.15","12","190.03","2404.92","other","OPPS APC"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1889.50","1734.12","1924.13","16","190.03","2404.92","other","OPPS APC"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","both","","","613.00","459.75","WELLPOINT [1015]","HB AMC WELLPOINT","452.27","73.78","","5627.76","2401.76","5627.76","1 through 10","190.03","2404.92","percent of total billed charges",""
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","outpatient","","","613.00","459.75","AETNA [1001]","HB AMC AETNA HMO","427.87","69.8","","2184.00","1542.03","4368.00","16","216.85","2384.07","percent of total billed charges",""
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","outpatient","","","613.00","459.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1584.58","1584.58","1584.58","1 through 10","216.85","2384.07","other","Multiple Surgery"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","outpatient","","","613.00","459.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","2872.04","14360.20","30","216.85","2384.07","other","Multiple Surgery"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","outpatient","","","613.00","459.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3020.60","3020.60","9061.80","1 through 10","216.85","2384.07","other","Multiple Surgery"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","outpatient","","","613.00","459.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","3590.06","2822.53","3590.06","1 through 10","216.85","2384.07","other","Multiple Surgery"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","outpatient","","","613.00","459.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3045.36","3045.36","3045.36","1 through 10","216.85","2384.07","other","Multiple Surgery"
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","outpatient","","","613.00","459.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","500.94","81.72","","1418.47","1418.47","1418.47","1 through 10","216.85","2384.07","percent of total billed charges",""
"Pf Biopsy Mass Abdominal Perc","PX-98300348","CDM","49180","CPT","0983","RC","","","","outpatient","","","613.00","459.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","500.94","81.72","","2578.86","1418.47","2578.86","1 through 10","216.85","2384.07","percent of total billed charges",""
"Pf Biopsy Mouth Floor","PX-98300326","CDM","41108","CPT","0983","RC","","","","both","","","421.00","315.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","98.92","1885.65","1 through 10","98.92","1885.46","other","OPPS APC"
"Pf Biopsy Mouth Floor","PX-98300326","CDM","41108","CPT","0983","RC","","","","outpatient","","","421.00","315.75","AETNA [1001]","HB AMC AETNA HMO","293.86","69.8","","1231.33","1231.33","1231.33","1 through 10","235.34","1237.95","percent of total billed charges",""
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","both","","","454.00","340.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","622.84","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","622.30","102.04","622.30","1 through 10","140.74","755.88","other","OPPS APC"
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","both","","","454.00","340.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","360.93","79.5","","663.52","454.00","663.52","1 through 10","140.74","755.88","percent of total billed charges",""
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","both","","","454.00","340.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","241.98","53.3","","464.64","454.00","692.56","1 through 10","140.74","755.88","percent of total billed charges",""
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","both","","","454.00","340.50","MEDICARE [2001]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","604.76","453.58","604.76","17","140.74","755.88","other","OPPS APC"
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","both","","","454.00","340.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","99.16","74.37","99.16","17","140.74","755.88","other","OPPS APC"
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","both","","","454.00","340.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","173.88","38.3","","344.08","177.51","1032.24","1 through 10","140.74","755.88","percent of total billed charges",""
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","both","","","454.00","340.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","592.66","97.18","592.66","1 through 10","140.74","755.88","other","OPPS APC"
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","both","","","454.00","340.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","592.61","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","592.66","97.18","592.66","1 through 10","140.74","755.88","other","OPPS APC"
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","both","","","454.00","340.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","194.77","42.9","","1007.30","1007.30","1007.30","1 through 10","140.74","755.88","percent of total billed charges",""
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","both","","","454.00","340.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","592.61","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","442.38","147.68","442.38","1 through 10","140.74","755.88","other","OPPS APC"
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","both","","","454.00","340.50","WELLPOINT [1015]","HB AMC WELLPOINT","334.96","73.78","","993.16","993.16","993.16","1 through 10","140.74","755.88","percent of total billed charges",""
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","both","","","454.00","340.50","WELLSENSE NH [1050]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1790.70","97.18","1790.70","1 through 10","140.74","755.88","other","OPPS APC"
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","outpatient","","","454.00","340.50","AETNA [1001]","HB AMC AETNA HMO","316.89","69.8","","637.65","637.65","637.65","1 through 10","247.63","1234.13","percent of total billed charges",""
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","outpatient","","","454.00","340.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","487.13","","Case rate ($487.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1130.14","356.84","1130.14","1 through 10","247.63","1234.13","other","Multiple Surgery"
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","outpatient","","","454.00","340.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","487.13","","Case rate ($487.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1183.73","249.70","1188.60","1 through 10","247.63","1234.13","other","Multiple Surgery"
"Pf Biopsy Mouth Vestibule","PX-98300323","CDM","40808","CPT","0983","RC","","","","outpatient","","","454.00","340.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.01","81.72","","1066.40","1066.40","1066.40","1 through 10","247.63","1234.13","percent of total billed charges",""
"Pf Biopsy Muscle Deep","PX-98300142","CDM","20205","CPT","0983","RC","","","","both","","","681.00","510.75","MEDICARE [2001]","HB BWH MEDICARE","3398.51","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6202.54","3398.86","9327.21","1 through 10","211.11","4248.14","other","OPPS APC"
"Pf Biopsy Muscle Deep","PX-98300142","CDM","20205","CPT","0983","RC","","","","both","","","681.00","510.75","WELLPOINT [1015]","HB AMC WELLPOINT","502.44","73.78","","2136.72","2136.72","2136.72","1 through 10","211.11","4248.14","percent of total billed charges",""
"Pf Biopsy Muscle Deep","PX-98300142","CDM","20205","CPT","0983","RC","","","","outpatient","","","681.00","510.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4965.87","4965.87","4965.87","1 through 10","302.7","8899.59","other","Multiple Surgery"
"Pf Biopsy Muscle Deep","PX-98300142","CDM","20205","CPT","0983","RC","","","","outpatient","","","681.00","510.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","302.70","44.45","","2294.27","2294.27","2294.27","1 through 10","302.7","8899.59","percent of total billed charges",""
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1979.93","1979.93","1988.83","1 through 10","78.12","2404.92","other","OPPS APC"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1741.20","1893.34","1 through 10","78.12","2404.92","other","OPPS APC"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","163.80","65","","4963.40","4963.40","4963.40","1 through 10","78.12","2404.92","percent of total billed charges",""
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","200.34","79.5","","1913.98","1284.10","6473.06","13","78.12","2404.92","percent of total billed charges",""
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","134.32","53.3","","5741.98","4067.20","5741.98","117","78.12","2404.92","percent of total billed charges",""
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","78.12","2404.92","other","OPPS APC"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1901.04","1901.04","1901.04","1 through 10","78.12","2404.92","other","OPPS APC"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1894.65","1894.65","1894.65","1 through 10","78.12","2404.92","other","OPPS APC"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1769.51","1924.13","100","78.12","2404.92","other","OPPS APC"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91.98","36.5","","770.94","770.94","770.94","1 through 10","78.12","2404.92","percent of total billed charges",""
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.52","38.3","","2852.73","950.91","2852.73","1 through 10","78.12","2404.92","percent of total billed charges",""
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5679.15","1893.34","9435.75","13","78.12","2404.92","other","OPPS APC"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","559.36","559.36","559.36","1 through 10","78.12","2404.92","other","OPPS APC"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.11","42.9","","1106.56","1106.56","1106.56","1 through 10","78.12","2404.92","percent of total billed charges",""
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.15","1885.65","1924.13","1 through 10","78.12","2404.92","other","OPPS APC"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","both","","","252.00","189.00","WELLPOINT [1015]","HB AMC WELLPOINT","185.93","73.78","","4097.75","1810.62","4242.62","13","78.12","2404.92","percent of total billed charges",""
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","outpatient","","","252.00","189.00","AETNA [1001]","HB AMC AETNA HMO","175.90","69.8","","1646.46","1162.50","1646.46","13","140.87","2384.07","percent of total billed charges",""
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","outpatient","","","252.00","189.00","AETNA [1001]","HB AMC AETNA PPO","202.61","80.4","","1896.96","1896.96","1896.96","1 through 10","140.87","2384.07","percent of total billed charges",""
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","outpatient","","","252.00","189.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3169.15","3169.15","3169.15","1 through 10","140.87","2384.07","other","Multiple Surgery"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","outpatient","","","252.00","189.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","2872.04","8616.12","17","140.87","2384.07","other","Multiple Surgery"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","outpatient","","","252.00","189.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3020.60","2909.18","3020.60","1 through 10","140.87","2384.07","other","Multiple Surgery"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","outpatient","","","252.00","189.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1821.68","1821.68","1821.68","1 through 10","140.87","2384.07","other","Multiple Surgery"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","outpatient","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1626.53","1626.53","1626.53","1 through 10","140.87","2384.07","other","Multiple Surgery"
"Pf Biopsy Muscle Needle Perc","PX-98300143","CDM","20206","CPT","0983","RC","","","","outpatient","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","205.93","81.72","","1944.14","1069.35","1944.14","1 through 10","140.87","2384.07","percent of total billed charges",""
"Pf Biopsy Muscle Superficial","PX-98300141","CDM","20200","CPT","0983","RC","","","","outpatient","","","423.00","317.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","256.13","60.55","","3160.08","3160.08","3218.28","1 through 10","169.2","345.68","percent of total billed charges",""
"Pf Biopsy Muscle Superficial","PX-98300141","CDM","20200","CPT","0983","RC","","","","outpatient","","","423.00","317.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","220.89","52.22","","3682.30","3646.12","3682.30","1 through 10","169.2","345.68","percent of total billed charges",""
"Pf Biopsy Nail Unit","PX-98300078","CDM","11755","CPT","0983","RC","","","","both","","","314.00","235.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","818.85","818.85","818.85","1 through 10","97.34","1044.34","other","OPPS APC"
"Pf Biopsy Nail Unit","PX-98300078","CDM","11755","CPT","0983","RC","","","","both","","","314.00","235.50","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","97.34","1044.34","other","OPPS APC"
"Pf Biopsy Nail Unit","PX-98300078","CDM","11755","CPT","0983","RC","","","","both","","","314.00","235.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.26","38.3","","1289.13","1252.86","1289.13","13","97.34","1044.34","percent of total billed charges",""
"Pf Biopsy Nail Unit","PX-98300078","CDM","11755","CPT","0983","RC","","","","outpatient","","","314.00","235.50","AETNA [1001]","HB AMC AETNA HMO","219.17","69.8","","744.02","744.02","744.02","1 through 10","172.45","1234.13","percent of total billed charges",""
"Pf Biopsy Oropharynx","PX-98300330","CDM","42800","CPT","0983","RC","","","","outpatient","","","540.00","405.00","AETNA [1001]","HB AMC AETNA HMO","376.92","69.8","","8329.13","8329.13","8329.13","1 through 10","301.86","2384.07","percent of total billed charges",""
"Pf Biopsy Oropharynx","PX-98300330","CDM","42800","CPT","0983","RC","","","","outpatient","","","540.00","405.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2008.14","","Case rate ($2,008.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2329.44","2329.44","2329.44","1 through 10","301.86","2384.07","other","Multiple Surgery"
"Pf Biopsy Palate/Uvula","PX-98300327","CDM","42100","CPT","0983","RC","","","","both","","","506.00","379.50","MEDICARE [2001]","HB BWH MEDICARE","1758.93","","APC Price ($1,758.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1759.11","1759.11","1759.11","1 through 10","156.86","2198.66","other","OPPS APC"
"Pf Biopsy Palate/Uvula","PX-98300327","CDM","42100","CPT","0983","RC","","","","both","","","506.00","379.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","1758.93","","APC Price ($1,758.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","121.32","121.32","121.32","1 through 10","156.86","2198.66","other","OPPS APC"
"Pf Biopsy Palate/Uvula","PX-98300327","CDM","42100","CPT","0983","RC","","","","both","","","506.00","379.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","184.69","36.5","","13767.06","3033.61","13767.06","1 through 10","156.86","2198.66","percent of total billed charges",""
"Pf Biopsy Penis","PX-98300366","CDM","54100","CPT","0983","RC","","","","both","","","545.00","408.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","168.95","2404.92","other","OPPS APC"
"Pf Biopsy Penis","PX-98300366","CDM","54100","CPT","0983","RC","","","","both","","","545.00","408.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","168.95","2404.92","other","OPPS APC"
"Pf Biopsy Penis","PX-98300366","CDM","54100","CPT","0983","RC","","","","both","","","545.00","408.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","208.74","38.3","","4632.18","4632.18","4632.18","1 through 10","168.95","2404.92","percent of total billed charges",""
"Pf Biopsy Penis","PX-98300366","CDM","54100","CPT","0983","RC","","","","both","","","545.00","408.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1885.65","1885.65","1885.65","1 through 10","168.95","2404.92","other","OPPS APC"
"Pf Biopsy Penis","PX-98300366","CDM","54100","CPT","0983","RC","","","","both","","","545.00","408.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.65","1893.15","1893.65","1 through 10","168.95","2404.92","other","OPPS APC"
"Pf Biopsy Penis","PX-98300366","CDM","54100","CPT","0983","RC","","","","outpatient","","","545.00","408.75","AETNA [1001]","HB AMC AETNA HMO","380.41","69.8","","2673.47","2673.47","2673.47","1 through 10","304.66","2384.07","percent of total billed charges",""
"Pf Biopsy Penis","PX-98300366","CDM","54100","CPT","0983","RC","","","","outpatient","","","545.00","408.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2872.04","2872.04","2872.04","1 through 10","304.66","2384.07","other","Multiple Surgery"
"Pf Biopsy Penis","PX-98300366","CDM","54100","CPT","0983","RC","","","","outpatient","","","545.00","408.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","445.37","81.72","","1736.38","1736.38","1736.38","1 through 10","304.66","2384.07","percent of total billed charges",""
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2505.46","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2510.28","2504.28","2510.28","1 through 10","212.04","3040.6","other","OPPS APC"
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2393.81","2393.81","2393.81","19","212.04","3040.6","other","OPPS APC"
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","543.78","79.5","","9682.46","4805.32","25756.15","14","212.04","3040.6","percent of total billed charges",""
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","364.57","53.3","","8388.62","8388.62","8388.62","1 through 10","212.04","3040.6","percent of total billed charges",""
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2200.80","2200.80","2200.80","1 through 10","212.04","3040.6","other","OPPS APC"
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","526.68","77","","6421.80","6421.80","6421.80","1 through 10","212.04","3040.6","percent of total billed charges",""
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2403.54","2403.54","2403.54","1 through 10","212.04","3040.6","other","OPPS APC"
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","HUMANA [1012]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2398.67","2398.67","2398.67","1 through 10","212.04","3040.6","other","OPPS APC"
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","MEDICARE [2001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2223.03","2432.73","20","212.04","3040.6","other","OPPS APC"
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.97","38.3","","1430.67","1430.67","1430.67","1 through 10","212.04","3040.6","percent of total billed charges",""
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2178.57","2178.57","2178.57","1 through 10","212.04","3040.6","other","OPPS APC"
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2391.48","2186.37","2391.88","1 through 10","212.04","3040.6","other","OPPS APC"
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2388.95","2180.57","2391.98","13","212.04","3040.6","other","OPPS APC"
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","both","","","684.00","513.00","WELLPOINT [1015]","HB AMC WELLPOINT","504.66","73.78","","6209.13","2724.13","7989.97","1 through 10","212.04","3040.6","percent of total billed charges",""
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","outpatient","","","684.00","513.00","AETNA [1001]","HB AMC AETNA HMO","477.43","69.8","","5646.18","2477.14","8329.13","1 through 10","293.44","2384.07","percent of total billed charges",""
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","outpatient","","","684.00","513.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3632.61","3632.61","3632.61","1 through 10","293.44","2384.07","other","Multiple Surgery"
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","outpatient","","","684.00","513.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","11461.50","3820.50","11461.50","1 through 10","293.44","2384.07","other","Multiple Surgery"
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","outpatient","","","684.00","513.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","4008.40","4008.40","4008.40","1 through 10","293.44","2384.07","other","Multiple Surgery"
"Pf Biopsy Prostate Needle/Punch","PX-98300369","CDM","55700","CPT","0983","RC","","","","outpatient","","","684.00","513.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","558.96","81.72","","2925.00","2925.00","2925.00","1 through 10","293.44","2384.07","percent of total billed charges",""
"Pf Biopsy Salivary Gland Needle","PX-98300328","CDM","42400","CPT","0983","RC","","","","both","","","261.00","195.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","867.69","866.49","867.69","1 through 10","80.91","1044.34","other","OPPS APC"
"Pf Biopsy Salivary Gland Needle","PX-98300328","CDM","42400","CPT","0983","RC","","","","both","","","261.00","195.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","207.50","79.5","","1902.18","1902.18","1902.18","1 through 10","80.91","1044.34","percent of total billed charges",""
"Pf Biopsy Salivary Gland Needle","PX-98300328","CDM","42400","CPT","0983","RC","","","","both","","","261.00","195.75","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","80.91","1044.34","other","OPPS APC"
"Pf Biopsy Salivary Gland Needle","PX-98300328","CDM","42400","CPT","0983","RC","","","","both","","","261.00","195.75","MOLINA [1014]","HB BWH MOLINA","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1657.75","1657.75","1657.75","1 through 10","80.91","1044.34","other","OPPS APC"
"Pf Biopsy Salivary Gland Needle","PX-98300328","CDM","42400","CPT","0983","RC","","","","both","","","261.00","195.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","818.85","1 through 10","80.91","1044.34","other","OPPS APC"
"Pf Biopsy Salivary Gland Needle","PX-98300328","CDM","42400","CPT","0983","RC","","","","both","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.75","826.75","826.75","1 through 10","80.91","1044.34","other","OPPS APC"
"Pf Biopsy Salivary Gland Needle","PX-98300328","CDM","42400","CPT","0983","RC","","","","outpatient","","","261.00","195.75","AETNA [1001]","HB AMC AETNA HMO","182.18","69.8","","1636.31","1636.31","1636.31","1 through 10","143.28","2384.07","percent of total billed charges",""
"Pf Biopsy Salivary Gland Needle","PX-98300328","CDM","42400","CPT","0983","RC","","","","outpatient","","","261.00","195.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","4032.21","4032.21","1 through 10","143.28","2384.07","other","Multiple Surgery"
"Pf Biopsy Thyroid Perc","PX-98300411","CDM","60100","CPT","0983","RC","","","","both","","","539.00","404.25","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","167.09","1044.34","other","OPPS APC"
"Pf Biopsy Thyroid Perc","PX-98300411","CDM","60100","CPT","0983","RC","","","","both","","","539.00","404.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","196.74","36.5","","448.56","448.56","448.56","1 through 10","167.09","1044.34","percent of total billed charges",""
"Pf Biopsy Tongue Anterior 2/3","PX-98300324","CDM","41100","CPT","0983","RC","","","","both","","","490.00","367.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","595.08","116.01","595.08","1 through 10","151.9","755.88","other","OPPS APC"
"Pf Biopsy Tongue Anterior 2/3","PX-98300324","CDM","41100","CPT","0983","RC","","","","both","","","490.00","367.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","389.55","79.5","","972.05","476.64","1448.87","1 through 10","151.9","755.88","percent of total billed charges",""
"Pf Biopsy Tongue Anterior 2/3","PX-98300324","CDM","41100","CPT","0983","RC","","","","both","","","490.00","367.50","MEDICARE [2001]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","604.76","604.76","604.76","1 through 10","151.9","755.88","other","OPPS APC"
"Pf Biopsy Tongue Anterior 2/3","PX-98300324","CDM","41100","CPT","0983","RC","","","","both","","","490.00","367.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","604.70","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.34","117.34","117.34","1 through 10","151.9","755.88","other","OPPS APC"
"Pf Biopsy Tongue Anterior 2/3","PX-98300324","CDM","41100","CPT","0983","RC","","","","both","","","490.00","367.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.67","38.3","","719.83","187.29","2159.49","1 through 10","151.9","755.88","percent of total billed charges",""
"Pf Biopsy Tongue Anterior 2/3","PX-98300324","CDM","41100","CPT","0983","RC","","","","both","","","490.00","367.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","592.61","","APC Price ($604.70). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","444.50","86.25","444.50","1 through 10","151.9","755.88","other","OPPS APC"
"Pf Biopsy Tongue Anterior 2/3","PX-98300324","CDM","41100","CPT","0983","RC","","","","outpatient","","","490.00","367.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","487.13","","Case rate ($487.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3390.42","188.25","3390.42","1 through 10","273.91","2384.07","other","Multiple Surgery"
"Pf Biopsy Tongue Anterior 2/3","PX-98300324","CDM","41100","CPT","0983","RC","","","","outpatient","","","490.00","367.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","487.13","","Case rate ($487.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1183.73","1183.73","1183.73","1 through 10","273.91","2384.07","other","Multiple Surgery"
"Pf Biopsy Vaginal Mucosa Simple","PX-98300381","CDM","57100","CPT","0983","RC","","","","both","","","315.00","236.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1017.52","1017.52","1017.52","1 through 10","97.65","1292.44","other","OPPS APC"
"Pf Biopsy Vaginal Mucosa Simple","PX-98300381","CDM","57100","CPT","0983","RC","","","","both","","","315.00","236.25","MEDICARE [2001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3102.18","1034.06","3102.18","1 through 10","97.65","1292.44","other","OPPS APC"
"Pf Biopsy Vaginal Mucosa Simple","PX-98300381","CDM","57100","CPT","0983","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","497.35","497.35","497.35","1 through 10","97.65","1292.44","percent of total billed charges",""
"Pf Biopsy Vaginal Mucosa Simple","PX-98300381","CDM","57100","CPT","0983","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","867.77","867.77","867.77","1 through 10","97.65","1292.44","other","OPPS APC"
"Pf Biopsy Vulva/Perineum Ea","PX-98300376","CDM","56606","CPT","0983","RC","","","","both","","","221.00","165.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.67","36.5","","13458.21","13458.21","13458.21","1 through 10","68.51","175.7","percent of total billed charges",""
"Pf Biopsy Vulva/Perineum Ea","PX-98300376","CDM","56606","CPT","0983","RC","","","","both","","","221.00","165.75","WELLPOINT [1015]","HB AMC WELLPOINT","163.05","73.78","","10731.29","10731.29","10731.29","1 through 10","68.51","175.7","percent of total billed charges",""
"Pf Biopsy Vulva/Perineum Ea","PX-98300376","CDM","56606","CPT","0983","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","180.60","81.72","","85.74","85.74","85.74","1 through 10","89.43","180.6","percent of total billed charges",""
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","both","","","281.00","210.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1064.97","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1064.64","1064.64","1064.64","1 through 10","87.11","1292.44","other","OPPS APC"
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","both","","","281.00","210.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1017.52","1017.52","1017.52","1 through 10","87.11","1292.44","other","OPPS APC"
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","both","","","281.00","210.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","223.40","79.5","","13248.57","671.62","13248.57","1 through 10","87.11","1292.44","percent of total billed charges",""
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","both","","","281.00","210.75","MEDICARE [2001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1034.06","1034.06","1034.06","16","87.11","1292.44","other","OPPS APC"
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","both","","","281.00","210.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","102.57","36.5","","474.46","403.22","13458.21","1 through 10","87.11","1292.44","percent of total billed charges",""
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","both","","","281.00","210.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","107.62","38.3","","966.72","497.35","1492.05","1 through 10","87.11","1292.44","percent of total billed charges",""
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","both","","","281.00","210.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1013.38","1013.38","1013.38","1 through 10","87.11","1292.44","other","OPPS APC"
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","both","","","281.00","210.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1013.38","866.87","1020.88","1 through 10","87.11","1292.44","other","OPPS APC"
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","both","","","281.00","210.75","WELLPOINT [1015]","HB AMC WELLPOINT","207.32","73.78","","2219.00","947.00","10731.29","1 through 10","87.11","1292.44","percent of total billed charges",""
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","outpatient","","","281.00","210.75","AETNA [1001]","HB AMC AETNA HMO","196.14","69.8","","5732.42","608.02","5732.42","1 through 10","157.08","1234.13","percent of total billed charges",""
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","outpatient","","","281.00","210.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3883.95","1294.65","6473.25","13","157.08","1234.13","other","Multiple Surgery"
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","outpatient","","","281.00","210.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1361.62","1361.62","1361.62","1 through 10","157.08","1234.13","other","Multiple Surgery"
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","outpatient","","","281.00","210.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","948.44","948.44","948.44","1 through 10","157.08","1234.13","other","Multiple Surgery"
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","outpatient","","","281.00","210.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","229.63","81.72","","1361.62","1361.62","1361.62","1 through 10","157.08","1234.13","percent of total billed charges",""
"Pf Biopsy Vulva/Perineum One Lesion","PX-98300375","CDM","56605","CPT","0983","RC","","","","outpatient","","","281.00","210.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","229.63","81.72","","559.30","559.30","559.30","1 through 10","157.08","1234.13","percent of total billed charges",""
"Pf Biopsy/Exc Lymph Node Super Ndl","PX-98300318","CDM","38505","CPT","0983","RC","","","","both","","","372.00","279.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.35","1742.02","1893.55","18","115.32","2404.92","other","OPPS APC"
"Pf Biopsy/Exc Lymph Node Super Ndl","PX-98300318","CDM","38505","CPT","0983","RC","","","","outpatient","","","372.00","279.00","AETNA [1001]","HB AMC AETNA HMO","259.66","69.8","","1671.51","1671.51","1671.51","1 through 10","207.95","2384.07","percent of total billed charges",""
"Pf Biopsy/Exc Lymph Node Super Ndl","PX-98300318","CDM","38505","CPT","0983","RC","","","","outpatient","","","372.00","279.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2079.05","1903.82","3045.36","1 through 10","207.95","2384.07","other","Multiple Surgery"
"Pf Biopsy/Rem Lymph Node Axill Opn","PX-98300320","CDM","38525","CPT","0983","RC","","","","outpatient","","","2330.00","1747.50","AETNA [1001]","HB AMC AETNA HMO","1626.34","69.8","","10468.20","10468.20","10468.20","1 through 10","932","1904.08","percent of total billed charges",""
"Pf Biopsy/Rem Lymph Node Cerv Open","PX-98300319","CDM","38510","CPT","0983","RC","","","","both","","","1851.00","1388.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","708.93","38.3","","23485.80","23485.80","23485.80","1 through 10","573.81","1471.55","percent of total billed charges",""
"Pf Bladder Irrigation","PX-98300353","CDM","51700","CPT","0983","RC","","","","both","","","173.00","129.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","265.42","265.42","265.42","1 through 10","53.63","361","other","OPPS APC"
"Pf Bladder Irrigation","PX-98300353","CDM","51700","CPT","0983","RC","","","","both","","","173.00","129.75","FALLON HEALTH [1008]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","269.74","269.74","269.74","1 through 10","53.63","361","other","OPPS APC"
"Pf Bladder Irrigation","PX-98300353","CDM","51700","CPT","0983","RC","","","","both","","","173.00","129.75","MEDICARE [2001]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","288.83","288.83","26","53.63","361","other","OPPS APC"
"Pf Bladder Irrigation","PX-98300353","CDM","51700","CPT","0983","RC","","","","both","","","173.00","129.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.26","38.3","","284.26","284.26","284.26","1 through 10","53.63","361","percent of total billed charges",""
"Pf Bladder Irrigation","PX-98300353","CDM","51700","CPT","0983","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","283.02","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","283.05","283.05","283.06","1 through 10","53.63","361","other","OPPS APC"
"Pf Bladder Irrigation","PX-98300353","CDM","51700","CPT","0983","RC","","","","outpatient","","","173.00","129.75","AETNA [1001]","HB AMC AETNA HMO","120.75","69.8","","567.06","567.06","567.06","1 through 10","96.71","1120.45","percent of total billed charges",""
"Pf Bladder Irrigation","PX-98300353","CDM","51700","CPT","0983","RC","","","","outpatient","","","173.00","129.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","592.44","592.44","592.44","1 through 10","96.71","1120.45","other","Multiple Surgery"
"Pf Bladder Irrigation","PX-98300353","CDM","51700","CPT","0983","RC","","","","outpatient","","","173.00","129.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1548.21","1548.21","1548.21","1 through 10","96.71","1120.45","other","Multiple Surgery"
"Pf Bladder Irrigation","PX-98300353","CDM","51700","CPT","0983","RC","","","","outpatient","","","173.00","129.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","564.66","564.66","564.66","1 through 10","96.71","1120.45","other","Multiple Surgery"
"Pf Bladder Irrigation","PX-98300353","CDM","51700","CPT","0983","RC","","","","outpatient","","","173.00","129.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","592.44","592.44","592.44","1 through 10","96.71","1120.45","other","Multiple Surgery"
"Pf Bladder Irrigation","PX-98300353","CDM","51700","CPT","0983","RC","","","","outpatient","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","139.09","80.4","","363.50","363.50","363.50","1 through 10","96.71","1120.45","percent of total billed charges",""
"Pf Bladder Irrigation","PX-98300353","CDM","51700","CPT","0983","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","141.38","81.72","","319.66","319.66","581.16","1 through 10","96.71","1120.45","percent of total billed charges",""
"Pf Bronch W/Bx Bronc/Endo Sgl/Multi","PX-98300301","CDM","31625","CPT","0983","RC","","","","both","","","812.00","609.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2109.14","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4505.44","4505.44","4505.44","1 through 10","251.72","2559.63","other","OPPS APC"
"Pf Bronch W/Bx Bronc/Endo Sgl/Multi","PX-98300301","CDM","31625","CPT","0983","RC","","","","both","","","812.00","609.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","645.54","79.5","","6346.37","2702.56","6346.37","1 through 10","251.72","2559.63","percent of total billed charges",""
"Pf Bronch W/Bx Bronc/Endo Sgl/Multi","PX-98300301","CDM","31625","CPT","0983","RC","","","","both","","","812.00","609.00","MEDICARE [2001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4378.47","2047.91","4378.47","12","251.72","2559.63","other","OPPS APC"
"Pf Bronch W/Bx Bronc/Endo Sgl/Multi","PX-98300301","CDM","31625","CPT","0983","RC","","","","both","","","812.00","609.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2006.75","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4293.90","4293.90","4293.90","1 through 10","251.72","2559.63","other","OPPS APC"
"Pf Bronch W/Bx Bronc/Endo Sgl/Multi","PX-98300301","CDM","31625","CPT","0983","RC","","","","both","","","812.00","609.00","WELLPOINT [1015]","HB AMC WELLPOINT","599.09","73.78","","5990.61","5990.61","5990.61","1 through 10","251.72","2559.63","percent of total billed charges",""
"Pf Bronch W/Bx Bronc/Endo Sgl/Multi","PX-98300301","CDM","31625","CPT","0983","RC","","","","outpatient","","","812.00","609.00","AETNA [1001]","HB AMC AETNA HMO","566.78","69.8","","2324.82","2324.82","2324.82","1 through 10","453.91","5545.35","percent of total billed charges",""
"Pf Bronch W/Bx Bronc/Endo Sgl/Multi","PX-98300301","CDM","31625","CPT","0983","RC","","","","outpatient","","","812.00","609.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1786.92","1786.92","1786.92","1 through 10","453.91","5545.35","other","Multiple Surgery"
"Pf Bronch W/Bx Bronc/Endo Sgl/Multi","PX-98300301","CDM","31625","CPT","0983","RC","","","","outpatient","","","812.00","609.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4288.62","1429.54","4288.62","1 through 10","453.91","5545.35","other","Multiple Surgery"
"Pf Bronch W/Bx Bronc/Endo Sgl/Multi","PX-98300301","CDM","31625","CPT","0983","RC","","","","outpatient","","","812.00","609.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1503.48","1503.48","1503.48","1 through 10","453.91","5545.35","other","Multiple Surgery"
"Pf Bronch W/Bx Bronc/Endo Sgl/Multi","PX-98300301","CDM","31625","CPT","0983","RC","","","","outpatient","","","812.00","609.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1232.36","","Case rate ($1,232.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1577.42","1577.42","1577.42","1 through 10","453.91","5545.35","other","Multiple Surgery"
"Pf Bronch W/Bx Bronc/Endo Sgl/Multi","PX-98300301","CDM","31625","CPT","0983","RC","","","","outpatient","","","812.00","609.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","663.57","81.72","","2745.14","2223.67","2745.14","1 through 10","453.91","5545.35","percent of total billed charges",""
"Pf Bronchoscopy W&W/O Washings","PX-98300300","CDM","31622","CPT","0983","RC","","","","both","","","684.00","513.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2109.14","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2107.30","2107.30","2107.30","1 through 10","212.04","2559.63","other","OPPS APC"
"Pf Bronchoscopy W&W/O Washings","PX-98300300","CDM","31622","CPT","0983","RC","","","","both","","","684.00","513.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2015.14","2015.14","2015.14","1 through 10","212.04","2559.63","other","OPPS APC"
"Pf Bronchoscopy W&W/O Washings","PX-98300300","CDM","31622","CPT","0983","RC","","","","both","","","684.00","513.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","543.78","79.5","","6563.58","2737.97","6563.58","1 through 10","212.04","2559.63","percent of total billed charges",""
"Pf Bronchoscopy W&W/O Washings","PX-98300300","CDM","31622","CPT","0983","RC","","","","both","","","684.00","513.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1816.48","1816.48","1816.48","1 through 10","212.04","2559.63","other","OPPS APC"
"Pf Bronchoscopy W&W/O Washings","PX-98300300","CDM","31622","CPT","0983","RC","","","","both","","","684.00","513.00","MEDICARE [2001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2047.91","1852.43","2047.91","13","212.04","2559.63","other","OPPS APC"
"Pf Bronchoscopy W&W/O Washings","PX-98300300","CDM","31622","CPT","0983","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","249.66","36.5","","2294.51","2294.51","2294.51","1 through 10","212.04","2559.63","percent of total billed charges",""
"Pf Bronchoscopy W&W/O Washings","PX-98300300","CDM","31622","CPT","0983","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2047.70","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2009.45","2009.45","2009.45","1 through 10","212.04","2559.63","other","OPPS APC"
"Pf Bronchoscopy W&W/O Washings","PX-98300300","CDM","31622","CPT","0983","RC","","","","both","","","684.00","513.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2006.75","","APC Price ($2,047.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2014.46","2006.96","2014.46","1 through 10","212.04","2559.63","other","OPPS APC"
"Pf Bronchoscopy W&W/O Washings","PX-98300300","CDM","31622","CPT","0983","RC","","","","outpatient","","","684.00","513.00","AETNA [1001]","HB AMC AETNA HMO","477.43","69.8","","5646.18","5646.18","5646.18","1 through 10","382.36","2384.07","percent of total billed charges",""
"Pf Bronchoscopy W&W/O Washings","PX-98300300","CDM","31622","CPT","0983","RC","","","","outpatient","","","684.00","513.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","558.96","81.72","","3333.50","3333.50","3333.50","1 through 10","382.36","2384.07","percent of total billed charges",""
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","800.35","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","800.56","799.66","800.56","1 through 10","165.23","971.3","other","OPPS APC"
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","777.04","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","764.69","764.69","777.12","20","165.23","971.3","other","OPPS APC"
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","423.74","79.5","","2571.13","2571.13","2571.13","1 through 10","165.23","971.3","percent of total billed charges",""
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","284.09","53.3","","1724.98","1724.98","1724.98","1 through 10","165.23","971.3","percent of total billed charges",""
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","777.04","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","764.69","764.69","764.69","1 through 10","165.23","971.3","other","OPPS APC"
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","FALLON HEALTH [1008]","HB BWH MEDICARE","777.04","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2197.76","2197.76","2197.76","1 through 10","165.23","971.3","other","OPPS APC"
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","MEDICARE [2001]","HB BWH MEDICARE","777.04","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","777.12","777.12","1554.24","203","165.23","971.3","other","OPPS APC"
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.55","36.5","","1218.59","1218.59","1218.59","1 through 10","165.23","971.3","percent of total billed charges",""
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","204.14","38.3","","1277.40","1277.40","1277.40","1 through 10","165.23","971.3","percent of total billed charges",""
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","777.04","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","761.58","696.51","761.98","1 through 10","165.23","971.3","other","OPPS APC"
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","TRICARE [160005]","HB BWH TRICARE","738.26","","APC Price ($777.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","738.26","738.26","738.26","1 through 10","165.23","971.3","other","Tricare OPPS"
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","761.50","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2284.74","696.11","4790.16","1 through 10","165.23","971.3","other","OPPS APC"
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","761.50","","APC Price ($777.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","767.08","704.02","769.48","18","165.23","971.3","other","OPPS APC"
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","both","","","533.00","399.75","WELLPOINT [1015]","HB AMC WELLPOINT","393.25","73.78","","2432.28","2432.28","3267.00","1 through 10","165.23","971.3","percent of total billed charges",""
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","outpatient","","","533.00","399.75","AETNA [1001]","HB AMC AETNA HMO","372.03","69.8","","2211.76","1561.63","2211.76","1 through 10","297.95","2707.47","percent of total billed charges",""
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","outpatient","","","533.00","399.75","AETNA [1001]","HB AMC AETNA PPO","428.53","80.4","","2548.26","2548.26","2548.26","1 through 10","297.95","2707.47","percent of total billed charges",""
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","outpatient","","","533.00","399.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","435.57","81.72","","2611.64","2611.64","2611.64","1 through 10","297.95","2707.47","percent of total billed charges",""
"Pf Cardioversion Elective External","PX-98300495","CDM","92960","CPT","0983","RC","","","","outpatient","","","533.00","399.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","435.57","81.72","","2611.64","1436.50","2611.64","1 through 10","297.95","2707.47","percent of total billed charges",""
"Pf Catheter Bladder","PX-98300354","CDM","51701","CPT","0983","RC","","","","both","","","268.00","201.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","83.08","213.06","other","OPPS APC"
"Pf Catheter Bladder","PX-98300354","CDM","51701","CPT","0983","RC","","","","both","","","268.00","201.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","213.06","79.5","","267.58","179.52","267.58","1 through 10","83.08","213.06","percent of total billed charges",""
"Pf Catheter Bladder","PX-98300354","CDM","51701","CPT","0983","RC","","","","both","","","268.00","201.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","142.84","53.3","","179.52","179.52","267.58","1 through 10","83.08","213.06","percent of total billed charges",""
"Pf Catheter Bladder","PX-98300354","CDM","51701","CPT","0983","RC","","","","both","","","268.00","201.00","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","83.08","213.06","other","OPPS APC"
"Pf Catheter Bladder","PX-98300354","CDM","51701","CPT","0983","RC","","","","both","","","268.00","201.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.82","36.5","","126.82","107.78","126.82","1 through 10","83.08","213.06","percent of total billed charges",""
"Pf Catheter Bladder","PX-98300354","CDM","51701","CPT","0983","RC","","","","both","","","268.00","201.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","102.64","38.3","","132.94","129.20","132.94","13","83.08","213.06","percent of total billed charges",""
"Pf Catheter Bladder","PX-98300354","CDM","51701","CPT","0983","RC","","","","both","","","268.00","201.00","WELLPOINT [1015]","HB AMC WELLPOINT","197.73","73.78","","253.13","253.13","253.13","1 through 10","83.08","213.06","percent of total billed charges",""
"Pf Catheter Bladder","PX-98300354","CDM","51701","CPT","0983","RC","","","","outpatient","","","268.00","201.00","AETNA [1001]","HB AMC AETNA HMO","187.06","69.8","","230.18","230.18","230.18","1 through 10","90.49","407.82","percent of total billed charges",""
"Pf Catheter Bladder","PX-98300354","CDM","51701","CPT","0983","RC","","","","outpatient","","","268.00","201.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","215.47","80.4","","170.00","170.00","170.00","1 through 10","90.49","407.82","percent of total billed charges",""
"Pf Catheter Bladder","PX-98300354","CDM","51701","CPT","0983","RC","","","","outpatient","","","268.00","201.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","219.01","81.72","","271.80","271.80","271.80","1 through 10","90.49","407.82","percent of total billed charges",""
"Pf Catheter Bladder Complicated","PX-98300356","CDM","51703","CPT","0983","RC","","","","both","","","374.00","280.50","WELLPOINT [1015]","HB AMC WELLPOINT","275.94","73.78","","539.02","539.02","539.02","1 through 10","115.94","297.33","percent of total billed charges",""
"Pf Catheter Bladder Complicated","PX-98300356","CDM","51703","CPT","0983","RC","","","","outpatient","","","374.00","280.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","305.63","81.72","","7477.84","318.34","7477.84","1 through 10","209.07","585.65","percent of total billed charges",""
"Pf Cautery Chemical Tissue Gran","PX-98300120","CDM","17250","CPT","0983","RC","","","","both","","","169.00","126.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","118.30","70","","643.40","643.40","643.40","1 through 10","52.39","294.93","percent of total billed charges",""
"Pf Cautery Chemical Tissue Gran","PX-98300120","CDM","17250","CPT","0983","RC","","","","both","","","169.00","126.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","134.36","79.5","","399.80","399.80","399.80","1 through 10","52.39","294.93","percent of total billed charges",""
"Pf Cautery Chemical Tissue Gran","PX-98300120","CDM","17250","CPT","0983","RC","","","","both","","","169.00","126.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","61.69","36.5","","189.48","61.92","189.48","1 through 10","52.39","294.93","percent of total billed charges",""
"Pf Cautery Chemical Tissue Gran","PX-98300120","CDM","17250","CPT","0983","RC","","","","both","","","169.00","126.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64.73","38.3","","198.63","64.91","198.63","1 through 10","52.39","294.93","percent of total billed charges",""
"Pf Cautery Chemical Tissue Gran","PX-98300120","CDM","17250","CPT","0983","RC","","","","both","","","169.00","126.75","WELLPOINT [1015]","HB AMC WELLPOINT","124.69","73.78","","378.21","378.21","378.21","1 through 10","52.39","294.93","percent of total billed charges",""
"Pf Cautery Chemical Tissue Gran","PX-98300120","CDM","17250","CPT","0983","RC","","","","outpatient","","","169.00","126.75","AETNA [1001]","HB AMC AETNA HMO","117.96","69.8","","456.30","242.82","456.30","1 through 10","94.47","792.78","percent of total billed charges",""
"Pf Cautery Chemical Tissue Gran","PX-98300120","CDM","17250","CPT","0983","RC","","","","outpatient","","","169.00","126.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","393.48","86.98","409.36","1 through 10","94.47","792.78","other","Multiple Surgery"
"Pf Cautery Chemical Tissue Gran","PX-98300120","CDM","17250","CPT","0983","RC","","","","outpatient","","","169.00","126.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","94.47","792.78","other","Multiple Surgery"
"Pf Cautery Chemical Tissue Gran","PX-98300120","CDM","17250","CPT","0983","RC","","","","outpatient","","","169.00","126.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","138.11","81.72","","406.09","406.09","406.10","1 through 10","94.47","792.78","percent of total billed charges",""
"Pf Cervical/Vag Cancer Screening","PX-98300586","CDM","G0101","HCPCS","0983","RC","","","","both","","","149.00","111.75","MEDICARE [2001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","1 through 10","46.19","137.3","other","OPPS APC"
"Pf Cervical/Vag Cancer Screening","PX-98300586","CDM","G0101","HCPCS","0983","RC","","","","both","","","149.00","111.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54.39","36.5","","69.01","55.58","69.01","1 through 10","46.19","137.3","percent of total billed charges",""
"Pf Cervical/Vag Cancer Screening","PX-98300586","CDM","G0101","HCPCS","0983","RC","","","","both","","","149.00","111.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","27.95","27.95","27.95","1 through 10","46.19","137.3","other","OPPS APC"
"Pf Cervical/Vag Cancer Screening","PX-98300586","CDM","G0101","HCPCS","0983","RC","","","","both","","","149.00","111.75","WELLPOINT [1015]","HB AMC WELLPOINT","109.93","73.78","","110.93","110.93","110.93","1 through 10","46.19","137.3","percent of total billed charges",""
"Pf Cervical/Vag Cancer Screening","PX-98300586","CDM","G0101","HCPCS","0983","RC","","","","outpatient","","","149.00","111.75","AETNA [1001]","HB AMC AETNA HMO","104.00","69.8","","100.87","71.22","116.22","1 through 10","69.15","121.76","percent of total billed charges",""
"Pf Cervical/Vag Cancer Screening","PX-98300586","CDM","G0101","HCPCS","0983","RC","","","","outpatient","","","149.00","111.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","121.76","81.72","","65.52","65.52","65.52","1 through 10","69.15","121.76","percent of total billed charges",""
"Pf Cervical/Vag Cancer Screening","PX-98300586","CDM","G0101","HCPCS","0983","RC","","","","outpatient","","","149.00","111.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","121.76","81.72","","65.52","65.52","119.11","1 through 10","69.15","121.76","percent of total billed charges",""
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","both","","","614.00","460.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","361.43","333.65","361.83","1 through 10","190.34","488.13","other","OPPS APC"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","both","","","614.00","460.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","930.00","1 through 10","190.34","488.13","other","OPPS APC"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","both","","","614.00","460.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","488.13","79.5","","731.91","491.04","731.91","43","190.34","488.13","percent of total billed charges",""
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","both","","","614.00","460.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","327.26","53.3","","491.04","491.04","491.04","1 through 10","190.34","488.13","percent of total billed charges",""
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","both","","","614.00","460.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","190.34","488.13","other","OPPS APC"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","both","","","614.00","460.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","223.30","223.30","223.30","1 through 10","190.34","488.13","other","OPPS APC"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","both","","","614.00","460.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","115","190.34","488.13","other","OPPS APC"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","both","","","614.00","460.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","190.34","31","","287.37","287.37","287.37","1 through 10","190.34","488.13","percent of total billed charges",""
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","both","","","614.00","460.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","224.11","36.5","","346.89","229.02","346.89","19","190.34","488.13","percent of total billed charges",""
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","both","","","614.00","460.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","235.16","38.3","","363.63","353.40","688.08","74","190.34","488.13","percent of total billed charges",""
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","both","","","614.00","460.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","343.55","343.55","1 through 10","190.34","488.13","other","OPPS APC"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","both","","","614.00","460.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","175.28","350.56","47","190.34","488.13","other","OPPS APC"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","both","","","614.00","460.50","WELLPOINT [1015]","HB AMC WELLPOINT","453.01","73.78","","692.39","692.39","1149.51","28","190.34","488.13","percent of total billed charges",""
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","outpatient","","","614.00","460.50","AETNA [1001]","HB AMC AETNA HMO","428.57","69.8","","629.61","444.54","725.40","28","247.48","1234.13","percent of total billed charges",""
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","outpatient","","","614.00","460.50","AETNA [1001]","HB AMC AETNA PPO","493.66","80.4","","487.32","487.32","974.64","1 through 10","247.48","1234.13","percent of total billed charges",""
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","outpatient","","","614.00","460.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","633.55","633.55","633.55","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","outpatient","","","614.00","460.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","574.15","574.15","1722.45","88","247.48","1234.13","other","Multiple Surgery"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","outpatient","","","614.00","460.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1163.16","603.85","1811.55","42","247.48","1234.13","other","Multiple Surgery"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","outpatient","","","614.00","460.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 383%, 191.5 procedures at 0%.","744.91","744.91","744.91","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","outpatient","","","614.00","460.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","717.69","717.69","717.69","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","outpatient","","","614.00","460.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","633.55","608.80","633.55","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","outpatient","","","614.00","460.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","263.41","42.9","","743.44","743.44","743.44","1 through 10","247.48","1234.13","percent of total billed charges",""
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","outpatient","","","614.00","460.50","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","608.80","608.80","608.80","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","outpatient","","","614.00","460.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","501.76","81.72","","408.92","408.92","408.92","1 through 10","247.48","1234.13","percent of total billed charges",""
"Pf Chemdnrvtn Mscl Facial Trige Cer","PX-98300576","CDM","64615","CPT","0983","RC","","","","outpatient","","","614.00","460.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","501.76","81.72","","743.44","408.92","930.00","20","247.48","1234.13","percent of total billed charges",""
"Pf Chemo Cns|REDUCED SERVICES","PX-98300581","CDM","96450","CPT","0983","RC","","","52","both","","","367.00","275.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","405.68","","APC Price ($393.86). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","202.65","96.51","202.65","1 through 10","374.21","492.33","other","OPPS APC"
"Pf Chemodnrv/Destr Nrve Nrlytic Fac","PX-98300465","CDM","64612","CPT","0983","RC","","","","both","","","709.00","531.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","360.73","360.73","1 through 10","219.79","563.66","other","OPPS APC"
"Pf Chemodnrv/Destr Nrve Nrlytic Fac","PX-98300465","CDM","64612","CPT","0983","RC","","","","both","","","709.00","531.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","496.30","70","","921.00","921.00","921.00","1 through 10","219.79","563.66","percent of total billed charges",""
"Pf Chemodnrv/Destr Nrve Nrlytic Fac","PX-98300465","CDM","64612","CPT","0983","RC","","","","both","","","709.00","531.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","377.90","53.3","","724.83","486.29","724.83","1 through 10","219.79","563.66","percent of total billed charges",""
"Pf Chemodnrv/Destr Nrve Nrlytic Fac","PX-98300465","CDM","64612","CPT","0983","RC","","","","both","","","709.00","531.75","ELDER SERVICES [1037]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","1 through 10","219.79","563.66","other","OPPS APC"
"Pf Chemodnrv/Destr Nrve Nrlytic Fac","PX-98300465","CDM","64612","CPT","0983","RC","","","","both","","","709.00","531.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","219.79","563.66","other","OPPS APC"
"Pf Chemodnrv/Destr Nrve Nrlytic Fac","PX-98300465","CDM","64612","CPT","0983","RC","","","","both","","","709.00","531.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","258.79","36.5","","343.53","343.53","343.53","1 through 10","219.79","563.66","percent of total billed charges",""
"Pf Chemodnrv/Destr Nrve Nrlytic Fac","PX-98300465","CDM","64612","CPT","0983","RC","","","","both","","","709.00","531.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","271.55","38.3","","360.11","277.22","360.11","1 through 10","219.79","563.66","percent of total billed charges",""
"Pf Chemodnrv/Destr Nrve Nrlytic Fac","PX-98300465","CDM","64612","CPT","0983","RC","","","","both","","","709.00","531.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","345.74","317.45","523.23","1 through 10","219.79","563.66","other","OPPS APC"
"Pf Chemodnrv/Destr Nrve Nrlytic Fac","PX-98300465","CDM","64612","CPT","0983","RC","","","","both","","","709.00","531.75","WELLPOINT [1015]","HB AMC WELLPOINT","523.10","73.78","","685.68","685.68","685.68","1 through 10","219.79","563.66","percent of total billed charges",""
"Pf Chemodnrv/Destr Nrve Nrlytic Fac","PX-98300465","CDM","64612","CPT","0983","RC","","","","outpatient","","","709.00","531.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","861.23","827.82","861.23","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Pf Chemodnrv/Destr Nrve Nrlytic Fac","PX-98300465","CDM","64612","CPT","0983","RC","","","","outpatient","","","709.00","531.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","717.69","717.69","717.69","1 through 10","247.48","1234.13","other","Multiple Surgery"
"Pf Chemodnrv/Destr Nrve Nrlytic Fac","PX-98300465","CDM","64612","CPT","0983","RC","","","","outpatient","","","709.00","531.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","579.39","81.72","","404.96","404.96","404.96","1 through 10","247.48","1234.13","percent of total billed charges",""
"Pf Chemodnrv/Destr Nrve Nrlytic Fac|BILATERAL PROCEDURE","PX-98300465","CDM","64612","CPT","0983","RC","","","50","both","","","709.00","531.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.42","477.13","517.42","1 through 10","333.03","438.15","other","OPPS APC"
"Pf Chemodnrv/Destr Nrve Nrlytic Fac|BILATERAL PROCEDURE","PX-98300465","CDM","64612","CPT","0983","RC","","","50","both","","","709.00","531.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","517.43","344.95","634.38","1 through 10","333.03","438.15","other","OPPS APC"
"Pf Chemodnrv/Destr Nrve Nrlytic Fac|BILATERAL PROCEDURE","PX-98300465","CDM","64612","CPT","0983","RC","","","50","both","","","709.00","531.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","484.89","525.83","19","333.03","438.15","other","OPPS APC"
"Pf Chemodnrv/Destr Nrve Nrlytic Fac|BILATERAL PROCEDURE","PX-98300465","CDM","64612","CPT","0983","RC","","","50","both","","","709.00","531.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","194.22","194.22","199.71","1 through 10","333.03","438.15","other","OPPS APC"
"Pf Chemodnrv/Destr Nrve Nrlytic Fac|BILATERAL PROCEDURE","PX-98300465","CDM","64612","CPT","0983","RC","","","50","both","","","709.00","531.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","475.19","515.32","1 through 10","333.03","438.15","other","OPPS APC"
"Pf Chemodnrv/Destr Nrve Nrlytic Fac|BILATERAL PROCEDURE","PX-98300465","CDM","64612","CPT","0983","RC","","","50","both","","","709.00","531.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","191.11","517.43","1 through 10","333.03","438.15","other","OPPS APC"
"Pf Closure Wound Dehiscence Super","PX-98300098","CDM","12020","CPT","0983","RC","","","","both","","","851.00","638.25","FALLON HEALTH [1008]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","714.40","714.40","714.40","1 through 10","263.81","908.58","other","OPPS APC"
"Pf Closure Wound Dehiscence Super","PX-98300098","CDM","12020","CPT","0983","RC","","","","both","","","851.00","638.25","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","726.94","726.94","1 through 10","263.81","908.58","other","OPPS APC"
"Pf Collect Blood Port/Access Dvc","PX-98300309","CDM","36591","CPT","0983","RC","","","","both","","","134.00","100.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.02","119.28","150.63","1 through 10","41.54","191.33","other","OPPS APC"
"Pf Collect Blood Port/Access Dvc","PX-98300309","CDM","36591","CPT","0983","RC","","","","both","","","134.00","100.50","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","41.54","191.33","other","OPPS APC"
"Pf Collect Blood Port/Access Dvc","PX-98300309","CDM","36591","CPT","0983","RC","","","","outpatient","","","134.00","100.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","244.64","244.64","244.64","1 through 10","74.91","407.82","other","ASC"
"Pf Colposcopy Bx Elect Loop Cervix","PX-98300394","CDM","57460","CPT","0983","RC","","","","both","","","1160.00","870.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","444.28","38.3","","1800.44","1800.44","1800.44","1 through 10","359.6","4719.38","percent of total billed charges",""
"Pf Colposcopy Bx Elect Loop Cervix","PX-98300394","CDM","57460","CPT","0983","RC","","","","both","","","1160.00","870.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3707.87","3707.87","3707.87","1 through 10","359.6","4719.38","other","OPPS APC"
"Pf Colposcopy Bx Elect Loop Cervix","PX-98300394","CDM","57460","CPT","0983","RC","","","","outpatient","","","1160.00","870.00","AETNA [1001]","HB AMC AETNA HMO","809.68","69.8","","11012.08","11012.08","11012.08","1 through 10","494.9","2384.07","percent of total billed charges",""
"Pf Colposcopy Bx Elect Loop Cervix","PX-98300394","CDM","57460","CPT","0983","RC","","","","outpatient","","","1160.00","870.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5185.34","5185.34","5185.34","1 through 10","494.9","2384.07","other","Multiple Surgery"
"Pf Colposcopy Cervix/Vagina","PX-98300390","CDM","57452","CPT","0983","RC","","","","both","","","425.00","318.75","MEDICARE [2001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","238.90","108.74","238.90","1 through 10","131.75","337.88","other","OPPS APC"
"Pf Colposcopy Cervix/Vagina","PX-98300390","CDM","57452","CPT","0983","RC","","","","both","","","425.00","318.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","162.78","38.3","","250.24","250.24","250.24","1 through 10","131.75","337.88","percent of total billed charges",""
"Pf Colposcopy Cervix/Vagina","PX-98300390","CDM","57452","CPT","0983","RC","","","","both","","","425.00","318.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","234.60","94.30","234.60","1 through 10","131.75","337.88","other","OPPS APC"
"Pf Colposcopy Cervix/Vagina","PX-98300390","CDM","57452","CPT","0983","RC","","","","outpatient","","","425.00","318.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","384.96","384.96","384.96","1 through 10","165.93","700.33","other","Multiple Surgery"
"Pf Colposcopy Cervix/Vagina","PX-98300390","CDM","57452","CPT","0983","RC","","","","outpatient","","","425.00","318.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","404.87","404.87","1 through 10","165.93","700.33","other","Multiple Surgery"
"Pf Colposcopy Cervix/Vagina","PX-98300390","CDM","57452","CPT","0983","RC","","","","outpatient","","","425.00","318.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","424.78","424.78","424.78","1 through 10","165.93","700.33","other","Multiple Surgery"
"Pf Colposcopy Conization Cervix","PX-98300395","CDM","57461","CPT","0983","RC","","","","outpatient","","","1283.00","962.25","AETNA [1001]","HB AMC AETNA HMO","895.53","69.8","","3207.63","3207.63","3207.63","1 through 10","562.55","8899.59","percent of total billed charges",""
"Pf Colposcopy Conization Cervix","PX-98300395","CDM","57461","CPT","0983","RC","","","","outpatient","","","1283.00","962.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4930.32","4930.32","4930.32","1 through 10","562.55","8899.59","other","Multiple Surgery"
"Pf Colposcopy Entire Vagina","PX-98300388","CDM","57420","CPT","0983","RC","","","","both","","","393.00","294.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","312.44","79.5","","6346.37","513.12","6346.37","1 through 10","121.83","451.51","percent of total billed charges",""
"Pf Colposcopy Entire Vagina","PX-98300388","CDM","57420","CPT","0983","RC","","","","both","","","393.00","294.75","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","361.24","361.24","1 through 10","121.83","451.51","other","OPPS APC"
"Pf Colposcopy Entire Vagina","PX-98300388","CDM","57420","CPT","0983","RC","","","","both","","","393.00","294.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","143.45","36.5","","243.20","143.61","243.20","1 through 10","121.83","451.51","percent of total billed charges",""
"Pf Colposcopy Entire Vagina","PX-98300388","CDM","57420","CPT","0983","RC","","","","both","","","393.00","294.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","150.52","38.3","","254.93","254.93","254.93","1 through 10","121.83","451.51","percent of total billed charges",""
"Pf Colposcopy Entire Vagina","PX-98300388","CDM","57420","CPT","0983","RC","","","","outpatient","","","393.00","294.75","AETNA [1001]","HB AMC AETNA HMO","274.31","69.8","","441.40","441.40","441.40","1 through 10","219.69","1234.13","percent of total billed charges",""
"Pf Colposcopy Entire Vagina","PX-98300388","CDM","57420","CPT","0983","RC","","","","outpatient","","","393.00","294.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","608.79","608.79","608.79","1 through 10","219.69","1234.13","other","Multiple Surgery"
"Pf Colposcopy Entire Vagina","PX-98300388","CDM","57420","CPT","0983","RC","","","","outpatient","","","393.00","294.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","321.16","81.72","","521.21","286.68","521.21","1 through 10","219.69","1234.13","percent of total billed charges",""
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","both","","","395.00","296.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","246.04","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","246.73","245.83","246.73","1 through 10","122.45","314.03","other","OPPS APC"
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","both","","","395.00","296.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.08","107.00","235.08","1 through 10","122.45","314.03","other","OPPS APC"
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","both","","","395.00","296.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","314.03","79.5","","436.00","436.00","436.00","1 through 10","122.45","314.03","percent of total billed charges",""
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","both","","","395.00","296.25","MEDICARE [2001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","238.90","119.45","238.90","27","122.45","314.03","other","OPPS APC"
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","both","","","395.00","296.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","151.29","38.3","","216.61","182.82","216.61","1 through 10","122.45","314.03","percent of total billed charges",""
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","both","","","395.00","296.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","234.12","234.12","234.12","1 through 10","122.45","314.03","other","OPPS APC"
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","both","","","395.00","296.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","117.54","117.06","235.08","1 through 10","122.45","314.03","other","OPPS APC"
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","both","","","395.00","296.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","169.46","42.9","","442.87","442.87","442.87","1 through 10","122.45","314.03","percent of total billed charges",""
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","both","","","395.00","296.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","238.90","106.57","671.06","1 through 10","122.45","314.03","other","OPPS APC"
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","outpatient","","","395.00","296.25","AETNA [1001]","HB AMC AETNA HMO","275.71","69.8","","375.06","264.81","375.06","1 through 10","165.93","700.33","percent of total billed charges",""
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","outpatient","","","395.00","296.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","555.03","370.02","555.03","1 through 10","165.93","700.33","other","Multiple Surgery"
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","outpatient","","","395.00","296.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","404.87","404.87","1 through 10","165.93","700.33","other","Multiple Surgery"
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","outpatient","","","395.00","296.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","424.78","424.78","424.78","1 through 10","165.93","700.33","other","Multiple Surgery"
"Pf Colposcopy Vulva","PX-98300377","CDM","56820","CPT","0983","RC","","","","outpatient","","","395.00","296.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","322.79","81.72","","442.87","442.87","442.87","1 through 10","165.93","700.33","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","both","","","473.00","354.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","372.04","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","371.71","371.71","371.71","1 through 10","146.63","451.51","other","OPPS APC"
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","both","","","473.00","354.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","355.46","103.16","355.46","1 through 10","146.63","451.51","other","OPPS APC"
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","both","","","473.00","354.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","376.04","79.5","","1001.06","671.62","1001.06","1 through 10","146.63","451.51","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","both","","","473.00","354.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","252.11","53.3","","1001.06","1001.06","1001.06","1 through 10","146.63","451.51","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","both","","","473.00","354.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","355.46","355.46","355.46","1 through 10","146.63","451.51","other","OPPS APC"
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","both","","","473.00","354.75","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","350.13","361.24","22","146.63","451.51","other","OPPS APC"
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","both","","","473.00","354.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","181.16","38.3","","497.35","483.36","497.35","1 through 10","146.63","451.51","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","both","","","473.00","354.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","354.02","354.02","354.02","1 through 10","146.63","451.51","other","OPPS APC"
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","both","","","473.00","354.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","355.46","355.46","355.46","1 through 10","146.63","451.51","other","OPPS APC"
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","both","","","473.00","354.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","361.24","343.13","361.24","1 through 10","146.63","451.51","other","OPPS APC"
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","outpatient","","","473.00","354.75","AETNA [1001]","HB AMC AETNA HMO","330.15","69.8","","861.14","861.14","6847.52","1 through 10","264.41","1234.13","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","outpatient","","","473.00","354.75","AETNA [1001]","HB AMC AETNA PPO","380.29","80.4","","992.16","992.16","992.16","1 through 10","264.41","1234.13","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","outpatient","","","473.00","354.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","633.36","633.36","1900.08","17","264.41","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","outpatient","","","473.00","354.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1924.65","641.55","1924.65","1 through 10","264.41","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","outpatient","","","473.00","354.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","698.88","671.58","698.88","1 through 10","264.41","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Bx Cervix","PX-98300392","CDM","57455","CPT","0983","RC","","","","outpatient","","","473.00","354.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","386.54","81.72","","1016.84","1016.84","1016.84","1 through 10","264.41","1234.13","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","both","","","624.00","468.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","372.04","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","371.71","371.71","371.71","1 through 10","193.44","496.08","other","OPPS APC"
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","both","","","624.00","468.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","436.80","70","","395.60","395.60","395.60","1 through 10","193.44","496.08","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","both","","","624.00","468.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","496.08","79.5","","724.04","485.76","3484.04","17","193.44","496.08","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","both","","","624.00","468.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","332.59","53.3","","724.04","485.76","2172.12","12","193.44","496.08","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","both","","","624.00","468.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","355.46","355.46","355.46","1 through 10","193.44","496.08","other","OPPS APC"
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","both","","","624.00","468.00","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","350.13","361.24","19","193.44","496.08","other","OPPS APC"
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","193.44","31","","852.84","568.56","852.84","1 through 10","193.44","496.08","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","227.76","36.5","","343.16","232.75","343.16","11","193.44","496.08","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","238.99","38.3","","359.72","349.60","1079.16","48","193.44","496.08","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","both","","","624.00","468.00","TRICARE [160005]","HB BWH TRICARE","343.18","","APC Price ($361.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","343.18","343.18","343.18","1 through 10","193.44","496.08","other","Tricare OPPS"
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","both","","","624.00","468.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","354.02","354.02","354.02","1 through 10","193.44","496.08","other","OPPS APC"
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","both","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","355.46","137.35","361.24","1 through 10","193.44","496.08","other","OPPS APC"
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","both","","","624.00","468.00","WELLPOINT [1015]","HB AMC WELLPOINT","460.39","73.78","","1604.94","684.94","1604.94","11","193.44","496.08","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","outpatient","","","624.00","468.00","AETNA [1001]","HB AMC AETNA HMO","435.55","69.8","","1045.29","439.76","1245.68","19","273","1234.13","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","outpatient","","","624.00","468.00","AETNA [1001]","HB AMC AETNA PPO","501.70","80.4","","964.16","717.60","964.16","1 through 10","273","1234.13","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","outpatient","","","624.00","468.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","622.44","622.44","622.44","1 through 10","273","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","outpatient","","","624.00","468.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1217.58","633.36","1900.08","44","273","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","outpatient","","","624.00","468.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","666.12","666.12","1998.36","14","273","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","outpatient","","","624.00","468.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1045.59","1045.59","1045.59","1 through 10","273","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","outpatient","","","624.00","468.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","698.88","671.58","698.88","1 through 10","273","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","outpatient","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","501.70","80.4","","460.00","460.00","460.00","1 through 10","273","1234.13","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","outpatient","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","509.93","81.72","","1028.52","1028.52","1028.52","1 through 10","273","1234.13","percent of total billed charges",""
"Pf Colposcopy W/Bx Cervix & Curett","PX-98300391","CDM","57454","CPT","0983","RC","","","","outpatient","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","509.93","81.72","","735.45","404.52","6667.00","1 through 10","273","1234.13","percent of total billed charges",""
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","both","","","531.00","398.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1017.52","1017.52","1017.52","1 through 10","164.61","1292.44","other","OPPS APC"
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","both","","","531.00","398.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","422.15","79.5","","1001.06","1001.06","1001.06","1 through 10","164.61","1292.44","percent of total billed charges",""
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","both","","","531.00","398.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","283.02","53.3","","3385.66","3385.66","3385.66","1 through 10","164.61","1292.44","percent of total billed charges",""
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","both","","","531.00","398.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","753.70","753.70","753.70","1 through 10","164.61","1292.44","other","OPPS APC"
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","both","","","531.00","398.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","408.87","77","","2938.32","2938.32","2938.32","1 through 10","164.61","1292.44","percent of total billed charges",""
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","both","","","531.00","398.25","MEDICARE [2001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1034.06","877.41","1034.06","26","164.61","1292.44","other","OPPS APC"
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","both","","","531.00","398.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","193.82","36.5","","11776.58","11776.58","11776.58","1 through 10","164.61","1292.44","percent of total billed charges",""
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","both","","","531.00","398.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.37","38.3","","497.35","483.36","497.35","1 through 10","164.61","1292.44","percent of total billed charges",""
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","both","","","531.00","398.25","TRICARE [160005]","HB BWH TRICARE","982.35","","APC Price ($1,034.06). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1034.06","1034.06","1034.06","1 through 10","164.61","1292.44","other","Tricare OPPS"
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","both","","","531.00","398.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1013.38","1013.38","1013.38","1 through 10","164.61","1292.44","other","OPPS APC"
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","both","","","531.00","398.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","865.47","859.86","2285.38","1 through 10","164.61","1292.44","other","OPPS APC"
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","both","","","531.00","398.25","WELLPOINT [1015]","HB AMC WELLPOINT","391.77","73.78","","2219.00","2219.00","2219.00","1 through 10","164.61","1292.44","percent of total billed charges",""
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","outpatient","","","531.00","398.25","AETNA [1001]","HB AMC AETNA HMO","370.64","69.8","","861.14","608.02","861.14","1 through 10","296.83","1234.13","percent of total billed charges",""
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","outpatient","","","531.00","398.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3733.29","1294.65","3883.95","1 through 10","296.83","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","outpatient","","","531.00","398.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1361.62","1244.43","1361.62","1 through 10","296.83","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","outpatient","","","531.00","398.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","426.92","80.4","","864.50","864.50","864.50","1 through 10","296.83","1234.13","percent of total billed charges",""
"Pf Colposcopy W/Bx Vag/Cervix","PX-98300389","CDM","57421","CPT","0983","RC","","","","outpatient","","","531.00","398.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","433.93","81.72","","1016.83","559.30","1016.83","1 through 10","296.83","1234.13","percent of total billed charges",""
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","both","","","527.00","395.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","355.46","355.46","355.46","1 through 10","163.37","451.51","other","OPPS APC"
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","both","","","527.00","395.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","280.89","53.3","","2176.84","2176.84","2176.84","1 through 10","163.37","451.51","percent of total billed charges",""
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","both","","","527.00","395.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","355.46","355.46","355.46","1 through 10","163.37","451.51","other","OPPS APC"
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","both","","","527.00","395.25","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","180.62","361.24","19","163.37","451.51","other","OPPS APC"
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","192.36","36.5","","283.48","283.48","283.48","1 through 10","163.37","451.51","percent of total billed charges",""
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.84","38.3","","16512.90","297.16","16512.90","1 through 10","163.37","451.51","percent of total billed charges",""
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","both","","","527.00","395.25","TRICARE [160005]","HB BWH TRICARE","343.18","","APC Price ($361.24). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","180.62","180.62","180.62","1 through 10","163.37","451.51","other","Tricare OPPS"
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","both","","","527.00","395.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","354.02","354.02","354.02","1 through 10","163.37","451.51","other","OPPS APC"
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","both","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.13","177.73","350.13","1 through 10","163.37","451.51","other","OPPS APC"
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","both","","","527.00","395.25","WELLPOINT [1015]","HB AMC WELLPOINT","388.82","73.78","","2085.82","2085.82","2085.82","1 through 10","163.37","451.51","percent of total billed charges",""
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","outpatient","","","527.00","395.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1900.08","633.36","1900.08","1 through 10","273","700.33","other","Multiple Surgery"
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","outpatient","","","527.00","395.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1998.36","666.12","1998.36","1 through 10","273","700.33","other","Multiple Surgery"
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","outpatient","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","430.66","81.72","","607.54","607.54","607.54","1 through 10","273","700.33","percent of total billed charges",""
"Pf Colposcopy W/Bx Vulva","PX-98300378","CDM","56821","CPT","0983","RC","","","","outpatient","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","430.66","81.72","","607.54","334.17","607.54","1 through 10","273","700.33","percent of total billed charges",""
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","both","","","471.00","353.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","374.45","79.5","","1629.09","543.03","1629.09","1 through 10","146.01","451.51","percent of total billed charges",""
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","both","","","471.00","353.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","251.04","53.3","","543.03","543.03","543.03","1 through 10","146.01","451.51","percent of total billed charges",""
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","both","","","471.00","353.25","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","350.13","361.24","1 through 10","146.01","451.51","other","OPPS APC"
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","both","","","471.00","353.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","171.92","36.5","","218.73","149.31","257.37","1 through 10","146.01","451.51","percent of total billed charges",""
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","both","","","471.00","353.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","180.39","38.3","","269.79","269.79","269.79","1 through 10","146.01","451.51","percent of total billed charges",""
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","both","","","471.00","353.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","353.98","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","354.02","344.53","693.26","1 through 10","146.01","451.51","other","OPPS APC"
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","both","","","471.00","353.25","WELLPOINT [1015]","HB AMC WELLPOINT","347.50","73.78","","1203.71","513.71","1203.71","1 through 10","146.01","451.51","percent of total billed charges",""
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","outpatient","","","471.00","353.25","AETNA [1001]","HB AMC AETNA HMO","328.76","69.8","","467.13","467.13","565.80","1 through 10","263.29","1234.13","percent of total billed charges",""
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","outpatient","","","471.00","353.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","633.36","316.68","1266.72","1 through 10","263.29","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","outpatient","","","471.00","353.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","666.12","666.12","666.12","1 through 10","263.29","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","outpatient","","","471.00","353.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 383%, 191.5 procedures at 0%.","1045.59","1045.59","1045.59","1 through 10","263.29","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","outpatient","","","471.00","353.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","698.88","698.88","698.88","1 through 10","263.29","1234.13","other","Multiple Surgery"
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","outpatient","","","471.00","353.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","378.68","80.4","","538.20","538.20","538.20","1 through 10","263.29","1234.13","percent of total billed charges",""
"Pf Colposcopy W/Curettage","PX-98300393","CDM","57456","CPT","0983","RC","","","","outpatient","","","471.00","353.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","384.90","81.72","","551.59","303.39","928.11","1 through 10","263.29","1234.13","percent of total billed charges",""
"Pf Conization Cervix Loop Elec","PX-98300400","CDM","57522","CPT","0983","RC","","","","both","","","1299.00","974.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1032.71","79.5","","3728.81","3728.81","3728.81","1 through 10","402.69","4719.38","percent of total billed charges",""
"Pf Conization Cervix Loop Elec","PX-98300400","CDM","57522","CPT","0983","RC","","","","both","","","1299.00","974.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","692.37","53.3","","3728.81","3728.81","3728.81","1 through 10","402.69","4719.38","percent of total billed charges",""
"Pf Conization Cervix Loop Elec","PX-98300400","CDM","57522","CPT","0983","RC","","","","both","","","1299.00","974.25","MEDICARE [2001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3412.18","3775.88","1 through 10","402.69","4719.38","other","OPPS APC"
"Pf Conization Cervix Loop Elec","PX-98300400","CDM","57522","CPT","0983","RC","","","","both","","","1299.00","974.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","497.52","38.3","","6360.01","1852.56","14025.42","1 through 10","402.69","4719.38","percent of total billed charges",""
"Pf Conization Cervix Loop Elec","PX-98300400","CDM","57522","CPT","0983","RC","","","","both","","","1299.00","974.25","WELLPOINT [1015]","HB AMC WELLPOINT","958.40","73.78","","8265.44","8265.44","8265.44","1 through 10","402.69","4719.38","percent of total billed charges",""
"Pf Conization Cervix Loop Elec","PX-98300400","CDM","57522","CPT","0983","RC","","","","outpatient","","","1299.00","974.25","AETNA [1001]","HB AMC AETNA HMO","906.70","69.8","","3695.64","2264.76","5880.83","1 through 10","726.14","2384.07","percent of total billed charges",""
"Pf Conization Cervix Loop Elec","PX-98300400","CDM","57522","CPT","0983","RC","","","","outpatient","","","1299.00","974.25","AETNA [1001]","HB AMC AETNA PPO","1044.40","80.4","","3695.64","3695.64","6505.20","1 through 10","726.14","2384.07","percent of total billed charges",""
"Pf Conization Cervix Loop Elec","PX-98300400","CDM","57522","CPT","0983","RC","","","","outpatient","","","1299.00","974.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","14790.96","4930.32","14790.96","1 through 10","726.14","2384.07","other","Multiple Surgery"
"Pf Conization Cervix Loop Elec","PX-98300400","CDM","57522","CPT","0983","RC","","","","outpatient","","","1299.00","974.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4994.08","4994.08","4994.08","1 through 10","726.14","2384.07","other","Multiple Surgery"
"Pf Conization Cervix Loop Elec","PX-98300400","CDM","57522","CPT","0983","RC","","","","outpatient","","","1299.00","974.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","6153.00","5227.84","6153.00","1 through 10","726.14","2384.07","other","Multiple Surgery"
"Pf Cystostomy Tube Change Smp","PX-98300357","CDM","51705","CPT","0983","RC","","","","both","","","275.00","206.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","297.46","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","298.10","298.10","298.10","1 through 10","85.25","361","other","OPPS APC"
"Pf Cystostomy Tube Change Smp","PX-98300357","CDM","51705","CPT","0983","RC","","","","both","","","275.00","206.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.21","284.21","284.21","1 through 10","85.25","361","other","OPPS APC"
"Pf Cystostomy Tube Change Smp","PX-98300357","CDM","51705","CPT","0983","RC","","","","both","","","275.00","206.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","284.21","288.83","1 through 10","85.25","361","other","OPPS APC"
"Pf Cystostomy Tube Change Smp","PX-98300357","CDM","51705","CPT","0983","RC","","","","both","","","275.00","206.25","MEDICARE [2001]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","288.83","288.83","1 through 10","85.25","361","other","OPPS APC"
"Pf Cystostomy Tube Change Smp","PX-98300357","CDM","51705","CPT","0983","RC","","","","both","","","275.00","206.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","264.35","264.35","264.35","1 through 10","85.25","361","other","OPPS APC"
"Pf Cystostomy Tube Change Smp","PX-98300357","CDM","51705","CPT","0983","RC","","","","both","","","275.00","206.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","283.02","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","849.15","849.15","849.15","1 through 10","85.25","361","other","OPPS APC"
"Pf Cystostomy Tube Change Smp","PX-98300357","CDM","51705","CPT","0983","RC","","","","both","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","283.02","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","288.83","288.83","288.83","1 through 10","85.25","361","other","OPPS APC"
"Pf Cystourethro","PX-98300359","CDM","52000","CPT","0983","RC","","","","both","","","493.00","369.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","816.36","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","822.64","822.64","822.64","1 through 10","152.83","990.73","other","OPPS APC"
"Pf Cystourethro","PX-98300359","CDM","52000","CPT","0983","RC","","","","both","","","493.00","369.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","792.58","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","779.98","779.98","779.98","1 through 10","152.83","990.73","other","OPPS APC"
"Pf Cystourethro","PX-98300359","CDM","52000","CPT","0983","RC","","","","both","","","493.00","369.75","MEDICARE [2001]","HB BWH MEDICARE","792.58","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","792.66","792.66","792.66","11","152.83","990.73","other","OPPS APC"
"Pf Cystourethro","PX-98300359","CDM","52000","CPT","0983","RC","","","","both","","","493.00","369.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","188.82","38.3","","725.31","725.31","725.31","1 through 10","152.83","990.73","percent of total billed charges",""
"Pf Cystourethro","PX-98300359","CDM","52000","CPT","0983","RC","","","","both","","","493.00","369.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","776.73","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","776.81","738.55","784.71","1 through 10","152.83","990.73","other","OPPS APC"
"Pf Cystourethro","PX-98300359","CDM","52000","CPT","0983","RC","","","","both","","","493.00","369.75","WELLPOINT [1015]","HB AMC WELLPOINT","363.74","73.78","","6209.13","6209.13","6209.13","1 through 10","152.83","990.73","percent of total billed charges",""
"Pf Cystourethro","PX-98300359","CDM","52000","CPT","0983","RC","","","","outpatient","","","493.00","369.75","AETNA [1001]","HB AMC AETNA HMO","344.11","69.8","","1255.84","1255.84","1255.84","1 through 10","275.59","2384.07","percent of total billed charges",""
"Pf Cystourethro","PX-98300359","CDM","52000","CPT","0983","RC","","","","outpatient","","","493.00","369.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","562.25","","Case rate ($562.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1304.42","1304.42","1304.42","1 through 10","275.59","2384.07","other","Multiple Surgery"
"Pf Cystourethro","PX-98300359","CDM","52000","CPT","0983","RC","","","","outpatient","","","493.00","369.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","562.25","","Case rate ($562.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1630.53","1630.53","1630.53","1 through 10","275.59","2384.07","other","Multiple Surgery"
"Pf Cystourethro","PX-98300359","CDM","52000","CPT","0983","RC","","","","outpatient","","","493.00","369.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","402.88","81.72","","25675.13","25675.13","25675.13","1 through 10","275.59","2384.07","percent of total billed charges",""
"Pf Cystourethro W/Rem FB Smp","PX-98300360","CDM","52310","CPT","0983","RC","","","","both","","","970.00","727.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2505.46","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2504.60","2504.60","2504.60","1 through 10","300.7","3040.6","other","OPPS APC"
"Pf Cystourethro W/Rem FB Smp","PX-98300360","CDM","52310","CPT","0983","RC","","","","both","","","970.00","727.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","630.50","65","","5421.01","5421.00","7996.95","1 through 10","300.7","3040.6","percent of total billed charges",""
"Pf Cystourethro W/Rem FB Smp","PX-98300360","CDM","52310","CPT","0983","RC","","","","both","","","970.00","727.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","679.00","70","","5290.29","5290.29","5290.29","1 through 10","300.7","3040.6","percent of total billed charges",""
"Pf Cystourethro W/Rem FB Smp","PX-98300360","CDM","52310","CPT","0983","RC","","","","both","","","970.00","727.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","3040.60","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","1801.32","1801.32","1801.32","1 through 10","300.7","3040.6","other","OPPS APC"
"Pf Cystourethro W/Rem FB Smp","PX-98300360","CDM","52310","CPT","0983","RC","","","","both","","","970.00","727.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2384.08","2384.08","2384.08","1 through 10","300.7","3040.6","other","OPPS APC"
"Pf Cystourethro W/Rem FB Smp","PX-98300360","CDM","52310","CPT","0983","RC","","","","both","","","970.00","727.50","MEDICARE [2001]","HB BWH MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","1 through 10","300.7","3040.6","other","OPPS APC"
"Pf Cystourethro W/Rem FB Smp","PX-98300360","CDM","52310","CPT","0983","RC","","","","both","","","970.00","727.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","371.51","38.3","","6181.08","3260.94","6181.08","1 through 10","300.7","3040.6","percent of total billed charges",""
"Pf Cystourethro W/Rem FB Smp","PX-98300360","CDM","52310","CPT","0983","RC","","","","both","","","970.00","727.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2393.81","2393.81","2393.81","1 through 10","300.7","3040.6","other","OPPS APC"
"Pf Cystourethro W/Rem FB Smp","PX-98300360","CDM","52310","CPT","0983","RC","","","","both","","","970.00","727.50","WELLPOINT [1015]","HB AMC WELLPOINT","715.67","73.78","","9159.58","9005.47","9159.58","1 through 10","300.7","3040.6","percent of total billed charges",""
"Pf Cystourethro W/Rem FB Smp","PX-98300360","CDM","52310","CPT","0983","RC","","","","outpatient","","","970.00","727.50","AETNA [1001]","HB AMC AETNA HMO","677.06","69.8","","8329.13","6505.20","8329.13","1 through 10","431.17","5545.35","percent of total billed charges",""
"Pf Cystourethro W/Rem FB Smp","PX-98300360","CDM","52310","CPT","0983","RC","","","","outpatient","","","970.00","727.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3632.61","3632.61","7265.22","1 through 10","431.17","5545.35","other","Multiple Surgery"
"Pf D & C Diagnostic/Therapeutic","PX-98300403","CDM","58120","CPT","0983","RC","","","","both","","","1040.00","780.00","MEDICARE [2001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","1 through 10","322.4","4719.38","other","OPPS APC"
"Pf D & C Diagnostic/Therapeutic","PX-98300403","CDM","58120","CPT","0983","RC","","","","both","","","1040.00","780.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.16","42.9","","1897.35","1897.35","1897.35","1 through 10","322.4","4719.38","percent of total billed charges",""
"Pf D & C Diagnostic/Therapeutic","PX-98300403","CDM","58120","CPT","0983","RC","","","","both","","","1040.00","780.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3700.37","3700.37","3700.37","1 through 10","322.4","4719.38","other","OPPS APC"
"Pf D & C Diagnostic/Therapeutic","PX-98300403","CDM","58120","CPT","0983","RC","","","","both","","","1040.00","780.00","WELLPOINT [1015]","HB AMC WELLPOINT","767.31","73.78","","8340.00","7274.57","14906.37","1 through 10","322.4","4719.38","percent of total billed charges",""
"Pf D & C Diagnostic/Therapeutic","PX-98300403","CDM","58120","CPT","0983","RC","","","","outpatient","","","1040.00","780.00","AETNA [1001]","HB AMC AETNA HMO","725.92","69.8","","8325.49","8325.49","8325.49","1 through 10","581.36","2384.07","percent of total billed charges",""
"Pf D & C Diagnostic/Therapeutic","PX-98300403","CDM","58120","CPT","0983","RC","","","","outpatient","","","1040.00","780.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","849.89","81.72","","12837.56","12837.56","12837.56","1 through 10","581.36","2384.07","percent of total billed charges",""
"Pf Debr Nail(S) Up to 5","PX-98300072","CDM","11720","CPT","0983","RC","","","","both","","","62.00","46.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.41","65.69","69.41","1 through 10","19.22","88.17","other","OPPS APC"
"Pf Debr Nail(S) Up to 5","PX-98300072","CDM","11720","CPT","0983","RC","","","","both","","","62.00","46.50","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","70.54","70.54","1 through 10","19.22","88.17","other","OPPS APC"
"Pf Debr Nail(S) Up to 5","PX-98300072","CDM","11720","CPT","0983","RC","","","","both","","","62.00","46.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","14.75","14.75","14.75","12","19.22","88.17","other","OPPS APC"
"Pf Debr Nail(S) Up to 5","PX-98300072","CDM","11720","CPT","0983","RC","","","","both","","","62.00","46.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22.63","36.5","","76.47","22.01","76.47","1 through 10","19.22","88.17","percent of total billed charges",""
"Pf Debr Nail(S) Up to 5","PX-98300072","CDM","11720","CPT","0983","RC","","","","both","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","65.43","14.45","69.13","22","19.22","88.17","other","OPPS APC"
"Pf Debr Nail(S) Up to 5","PX-98300072","CDM","11720","CPT","0983","RC","","","","outpatient","","","62.00","46.50","AETNA [1001]","HB AMC AETNA HMO","43.28","69.8","","97.99","97.99","97.99","1 through 10","34.66","350.18","percent of total billed charges",""
"Pf Debr Nail(S) Up to 5","PX-98300072","CDM","11720","CPT","0983","RC","","","","outpatient","","","62.00","46.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","55.90","","Case rate ($55.90). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","129.69","124.66","129.69","1 through 10","34.66","350.18","other","Multiple Surgery"
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","both","","","268.00","201.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","488.23","447.82","488.23","11","83.08","593.02","other","OPPS APC"
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","both","","","268.00","201.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","466.88","466.88","1 through 10","83.08","593.02","other","OPPS APC"
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","both","","","268.00","201.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","593.02","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","474.47","474.47","474.47","1 through 10","83.08","593.02","other","OPPS APC"
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","both","","","268.00","201.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","142.84","53.3","","500.54","500.54","500.54","1 through 10","83.08","593.02","percent of total billed charges",""
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","both","","","268.00","201.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","428.24","466.88","1 through 10","83.08","593.02","other","OPPS APC"
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","both","","","268.00","201.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","435.20","474.47","141","83.08","593.02","other","OPPS APC"
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","both","","","268.00","201.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.82","36.5","","353.60","353.60","1060.80","1 through 10","83.08","593.02","percent of total billed charges",""
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","both","","","268.00","201.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","102.64","38.3","","370.67","360.24","370.67","1 through 10","83.08","593.02","percent of total billed charges",""
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","both","","","268.00","201.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","464.98","464.98","464.98","1 through 10","83.08","593.02","other","OPPS APC"
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","both","","","268.00","201.00","MOLINA [1014]","HB BWH MOLINA","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","941.35","941.35","941.35","1 through 10","83.08","593.02","other","OPPS APC"
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","both","","","268.00","201.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","464.98","426.50","464.98","1 through 10","83.08","593.02","other","OPPS APC"
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","both","","","268.00","201.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","464.98","426.50","472.89","31","83.08","593.02","other","OPPS APC"
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","both","","","268.00","201.00","WELLPOINT [1015]","HB AMC WELLPOINT","197.73","73.78","","705.79","705.79","1653.79","1 through 10","83.08","593.02","percent of total billed charges",""
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","outpatient","","","268.00","201.00","AETNA [1001]","HB AMC AETNA HMO","187.06","69.8","","641.80","641.80","641.80","1 through 10","149.81","700.33","percent of total billed charges",""
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","outpatient","","","268.00","201.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","728.67","700.40","728.67","1 through 10","149.81","700.33","other","Multiple Surgery"
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","outpatient","","","268.00","201.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","766.36","738.09","766.36","1 through 10","149.81","700.33","other","Multiple Surgery"
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","outpatient","","","268.00","201.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1608.08","1608.08","1608.08","1 through 10","149.81","700.33","other","Multiple Surgery"
"Pf Debr Skin/Subq Tissue","PX-98300012","CDM","11042","CPT","0983","RC","","","","outpatient","","","268.00","201.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","219.01","81.72","","757.83","757.83","757.83","1 through 10","149.81","700.33","percent of total billed charges",""
"Pf Debr Skin/Subq Tissue/Muscle","PX-98300013","CDM","11043","CPT","0983","RC","","","","both","","","846.00","634.50","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","685.47","3634.70","14","262.26","908.58","other","OPPS APC"
"Pf Debr Skin/Subq Tissue/Muscle","PX-98300013","CDM","11043","CPT","0983","RC","","","","both","","","846.00","634.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","308.79","36.5","","601.65","601.65","601.65","1 through 10","262.26","908.58","percent of total billed charges",""
"Pf Debr Skin/Subq Tissue/Muscle","PX-98300013","CDM","11043","CPT","0983","RC","","","","both","","","846.00","634.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","712.33","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","719.91","719.91","719.91","1 through 10","262.26","908.58","other","OPPS APC"
"Pf Debr/Rem Tiss Addl 20 Sq Cm/Part","PX-98300510","CDM","97598","CPT","0983","RC","","","","both","","","190.00","142.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","101.27","53.3","","207.77","207.77","207.77","1 through 10","58.9","208.76","percent of total billed charges",""
"Pf Debride Nail(S) 6 or More","PX-98300073","CDM","11721","CPT","0983","RC","","","","both","","","102.00","76.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","72.65","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","73.49","73.39","73.49","1 through 10","31.62","88.17","other","OPPS APC"
"Pf Debride Nail(S) 6 or More","PX-98300073","CDM","11721","CPT","0983","RC","","","","both","","","102.00","76.50","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","66.76","70.54","22","31.62","88.17","other","OPPS APC"
"Pf Debride Nail(S) 6 or More","PX-98300073","CDM","11721","CPT","0983","RC","","","","both","","","102.00","76.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","24.39","24.39","24.39","1 through 10","31.62","88.17","other","OPPS APC"
"Pf Debride Nail(S) 6 or More","PX-98300073","CDM","11721","CPT","0983","RC","","","","both","","","102.00","76.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.13","24.39","69.13","16","31.62","88.17","other","OPPS APC"
"Pf Debride Skin/Subq Tissue","PX-98300014","CDM","11045","CPT","0983","RC","","","","both","","","106.00","79.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","56.50","53.3","","70.22","70.22","70.22","1 through 10","32.86","84.27","percent of total billed charges",""
"Pf Debride Skin/Subq Tissue","PX-98300014","CDM","11045","CPT","0983","RC","","","","both","","","106.00","79.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.69","36.5","","49.61","49.61","49.61","12","32.86","84.27","percent of total billed charges",""
"Pf Debride Skin/Subq Tissue","PX-98300014","CDM","11045","CPT","0983","RC","","","","both","","","106.00","79.50","WELLPOINT [1015]","HB AMC WELLPOINT","78.21","73.78","","99.02","99.02","99.02","1 through 10","32.86","84.27","percent of total billed charges",""
"Pf Debride Skin/Subq Tissue","PX-98300014","CDM","11045","CPT","0983","RC","","","","outpatient","","","106.00","79.50","AETNA [1001]","HB AMC AETNA HMO","73.99","69.8","","90.04","90.04","90.04","1 through 10","45.47","86.62","percent of total billed charges",""
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","both","","","152.00","114.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","242.81","242.81","242.81","1 through 10","47.12","294.93","other","OPPS APC"
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","both","","","152.00","114.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","47.12","294.93","other","OPPS APC"
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","both","","","152.00","114.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","294.93","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","50.00","50.00","50.00","1 through 10","47.12","294.93","other","OPPS APC"
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","both","","","152.00","114.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","120.84","79.5","","678.39","678.39","678.39","1 through 10","47.12","294.93","percent of total billed charges",""
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","both","","","152.00","114.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.02","53.3","","678.39","678.39","678.39","1 through 10","47.12","294.93","percent of total billed charges",""
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","both","","","152.00","114.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","197.57","197.57","197.57","1 through 10","47.12","294.93","other","OPPS APC"
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","both","","","152.00","114.00","HUMANA [1012]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.14","233.14","233.14","1 through 10","47.12","294.93","other","OPPS APC"
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","both","","","152.00","114.00","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","218.50","235.97","102","47.12","294.93","other","OPPS APC"
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.48","36.5","","321.53","312.04","643.06","1 through 10","47.12","294.93","percent of total billed charges",""
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.22","38.3","","1011.12","58.26","1011.12","1 through 10","47.12","294.93","percent of total billed charges",""
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","both","","","152.00","114.00","MOLINA [1014]","HB BWH MOLINA","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","468.16","468.16","468.16","1 through 10","47.12","294.93","other","OPPS APC"
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","both","","","152.00","114.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.25","231.25","231.25","1 through 10","47.12","294.93","other","OPPS APC"
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","both","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.25","116.24","232.19","27","47.12","294.93","other","OPPS APC"
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","outpatient","","","152.00","114.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","1 through 10","84.97","700.33","other","Multiple Surgery"
"Pf Debride/Rem Dev Tiss <20 Sq Cm","PX-98300509","CDM","97597","CPT","0983","RC","","","","outpatient","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","124.21","81.72","","689.08","689.08","689.08","1 through 10","84.97","700.33","percent of total billed charges",""
"Pf Declot Port Thrombolytic Agent","PX-98300310","CDM","36593","CPT","0983","RC","","","","both","","","167.00","125.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","393.86","","APC Price ($393.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","387.60","387.60","387.60","1 through 10","51.77","492.33","other","OPPS APC"
"Pf Declot Port Thrombolytic Agent","PX-98300310","CDM","36593","CPT","0983","RC","","","","both","","","167.00","125.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","108.55","65","","425.10","425.10","425.10","1 through 10","51.77","492.33","percent of total billed charges",""
"Pf Declot Port Thrombolytic Agent","PX-98300310","CDM","36593","CPT","0983","RC","","","","both","","","167.00","125.25","FALLON HEALTH [1008]","HB BWH MEDICARE","393.86","","APC Price ($393.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1969.50","1969.50","1969.50","1 through 10","51.77","492.33","other","OPPS APC"
"Pf Declot Port Thrombolytic Agent","PX-98300310","CDM","36593","CPT","0983","RC","","","","both","","","167.00","125.25","MEDICARE [2001]","HB BWH MEDICARE","393.86","","APC Price ($393.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","393.90","277.22","1181.70","19","51.77","492.33","other","OPPS APC"
"Pf Declot Port Thrombolytic Agent","PX-98300310","CDM","36593","CPT","0983","RC","","","","outpatient","","","167.00","125.25","AETNA [1001]","HB AMC AETNA HMO","116.57","69.8","","442.76","442.76","442.76","1 through 10","93.35","1278.91","percent of total billed charges",""
"Pf Declot Port Thrombolytic Agent","PX-98300310","CDM","36593","CPT","0983","RC","","","","outpatient","","","167.00","125.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","329.78","","Case rate ($329.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","674.73","662.53","674.73","1 through 10","93.35","1278.91","other","ASC"
"Pf Declot Port Thrombolytic Agent","PX-98300310","CDM","36593","CPT","0983","RC","","","","outpatient","","","167.00","125.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","329.78","","Case rate ($329.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","772.01","764.43","772.01","1 through 10","93.35","1278.91","other","ASC "
"Pf Delivery Vaginal","PX-98300410","CDM","59409","CPT","0983","RC","","","","outpatient","","","3789.00","2841.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","25926.70","25926.70","25926.70","1 through 10","2118.05","10792.81","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","AETNA [1001]","HB AMC AETNA HMO","224.06","69.8","","303.97","214.62","593.58","76","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","AETNA [1001]","HB AMC AETNA PPO","258.08","80.4","","350.22","235.28","350.22","1 through 10","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","243.31","242.81","243.31","1 through 10","99.51","294.93","other","OPPS APC"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","99.51","294.93","other","OPPS APC"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","224.70","70","","449.00","449.00","449.00","1 through 10","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","255.20","79.5","","353.36","237.07","353.36","46","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","171.09","53.3","","353.36","237.07","1516.54","22","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","258.08","80.4","","224.50","224.50","224.50","1 through 10","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","218.50","235.97","47","99.51","294.93","other","OPPS APC"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","78.16","78.16","78.16","1 through 10","99.51","294.93","other","OPPS APC"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","99.51","31","","138.74","138.74","138.74","1 through 10","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","117.17","36.5","","167.48","142.33","167.48","47","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","122.94","38.3","","175.56","170.62","175.56","258","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","137.71","42.9","","358.93","197.43","358.93","1 through 10","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.26","75.29","235.97","16","99.51","294.93","other","OPPS APC"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","WELLPOINT [1015]","HB AMC WELLPOINT","236.83","73.78","","334.28","334.28","783.28","42","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","511.71","226.86","511.71","1 through 10","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","158","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","414.66","430.54","78","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","511.71","402.31","511.71","1 through 10","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","338.78","338.78","338.78","1 through 10","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","434.07","187.79","451.71","39","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","434.07","434.07","434.07","1 through 10","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","262.32","81.72","","197.43","197.43","358.93","1 through 10","176.45","350.18","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","262.32","81.72","","358.93","197.43","358.93","57","176.45","350.18","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","492.30","492.30","492.30","1 through 10","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300118","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","434.07","434.07","434.07","1 through 10","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","AETNA [1001]","HB AMC AETNA HMO","224.06","69.8","","303.97","214.62","593.58","76","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","AETNA [1001]","HB AMC AETNA PPO","258.08","80.4","","350.22","235.28","350.22","1 through 10","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","243.31","242.81","243.31","1 through 10","99.51","294.93","other","OPPS APC"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","99.51","294.93","other","OPPS APC"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","224.70","70","","449.00","449.00","449.00","1 through 10","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","255.20","79.5","","353.36","237.07","353.36","46","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","171.09","53.3","","353.36","237.07","1516.54","22","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","258.08","80.4","","224.50","224.50","224.50","1 through 10","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","218.50","235.97","47","99.51","294.93","other","OPPS APC"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","78.16","78.16","78.16","1 through 10","99.51","294.93","other","OPPS APC"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","99.51","31","","138.74","138.74","138.74","1 through 10","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","117.17","36.5","","167.48","142.33","167.48","47","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","122.94","38.3","","175.56","170.62","175.56","258","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","137.71","42.9","","358.93","197.43","358.93","1 through 10","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.26","75.29","235.97","16","99.51","294.93","other","OPPS APC"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","both","","","321.00","240.75","WELLPOINT [1015]","HB AMC WELLPOINT","236.83","73.78","","334.28","334.28","783.28","42","99.51","294.93","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","511.71","226.86","511.71","1 through 10","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","158","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","414.66","430.54","78","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","511.71","402.31","511.71","1 through 10","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","338.78","338.78","338.78","1 through 10","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","434.07","187.79","451.71","39","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","434.07","434.07","434.07","1 through 10","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","262.32","81.72","","197.43","197.43","358.93","1 through 10","176.45","350.18","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","262.32","81.72","","358.93","197.43","358.93","57","176.45","350.18","percent of total billed charges",""
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","492.30","492.30","492.30","1 through 10","176.45","350.18","other","Multiple Surgery"
"Pf Dest Benign Lesions Up to 14 Les","PX-98300566","CDM","17110","CPT","0983","RC","","","","outpatient","","","321.00","240.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","434.07","434.07","434.07","1 through 10","176.45","350.18","other","Multiple Surgery"
"Pf Dest Lesn Bgn/Premalig 2-14","PX-98300116","CDM","17003","CPT","0983","RC","","","","both","","","41.00","30.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","28.70","70","","216.20","77.00","216.20","1 through 10","12.71","32.6","percent of total billed charges",""
"Pf Dest Lesn Bgn/Premalig 2-14","PX-98300116","CDM","17003","CPT","0983","RC","","","","both","","","41.00","30.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","32.60","79.5","","60.60","40.66","116.12","68","12.71","32.6","percent of total billed charges",""
"Pf Dest Lesn Bgn/Premalig 2-14","PX-98300116","CDM","17003","CPT","0983","RC","","","","both","","","41.00","30.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","21.85","53.3","","60.60","40.66","325.25","41","12.71","32.6","percent of total billed charges",""
"Pf Dest Lesn Bgn/Premalig 2-14","PX-98300116","CDM","17003","CPT","0983","RC","","","","both","","","41.00","30.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","26.65","65","","500.50","500.50","500.50","1 through 10","12.71","32.6","percent of total billed charges",""
"Pf Dest Lesn Bgn/Premalig 2-14","PX-98300116","CDM","17003","CPT","0983","RC","","","","both","","","41.00","30.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14.97","36.5","","28.72","24.41","86.17","94","12.71","32.6","percent of total billed charges",""
"Pf Dest Lesn Bgn/Premalig 2-14","PX-98300116","CDM","17003","CPT","0983","RC","","","","both","","","41.00","30.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15.70","38.3","","30.11","30.11","90.32","355","12.71","32.6","percent of total billed charges",""
"Pf Dest Lesn Bgn/Premalig 2-14","PX-98300116","CDM","17003","CPT","0983","RC","","","","both","","","41.00","30.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17.59","42.9","","33.86","33.86","33.86","1 through 10","12.71","32.6","percent of total billed charges",""
"Pf Dest Lesn Bgn/Premalig 2-14","PX-98300116","CDM","17003","CPT","0983","RC","","","","both","","","41.00","30.75","WELLPOINT [1015]","HB AMC WELLPOINT","30.25","73.78","","57.33","57.33","827.33","96","12.71","32.6","percent of total billed charges",""
"Pf Dest Lesn Bgn/Premalig 2-14","PX-98300116","CDM","17003","CPT","0983","RC","","","","outpatient","","","41.00","30.75","AETNA [1001]","HB AMC AETNA HMO","28.62","69.8","","52.13","36.81","60.06","124","5.86","33.51","percent of total billed charges",""
"Pf Dest Lesn Bgn/Premalig 2-14","PX-98300116","CDM","17003","CPT","0983","RC","","","","outpatient","","","41.00","30.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","33.51","81.72","","61.56","61.56","61.56","1 through 10","5.86","33.51","percent of total billed charges",""
"Pf Dest Lesn Bgn/Premalig 2-14","PX-98300116","CDM","17003","CPT","0983","RC","","","","outpatient","","","41.00","30.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","33.51","81.72","","61.55","33.86","61.56","85","5.86","33.51","percent of total billed charges",""
"Pf Dest Lesn Mal Face/Ear 0.6-1.0cm","PX-98300130","CDM","17281","CPT","0983","RC","","","","both","","","534.00","400.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","231.25","231.25","1 through 10","165.54","424.53","other","OPPS APC"
"Pf Dest Lesn Mal Face/Ear 0.6-1.0cm","PX-98300130","CDM","17281","CPT","0983","RC","","","","both","","","534.00","400.50","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","165.54","424.53","other","OPPS APC"
"Pf Dest Lesn Mal Face/Ear 0.6-1.0cm","PX-98300130","CDM","17281","CPT","0983","RC","","","","both","","","534.00","400.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","433.50","433.50","433.50","1 through 10","165.54","424.53","other","OPPS APC"
"Pf Dest Lesn Mal Face/Ear 1.1-2.0cm","PX-98300131","CDM","17282","CPT","0983","RC","","","","both","","","613.00","459.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.98","117.98","235.97","1 through 10","190.03","487.34","other","OPPS APC"
"Pf Dest Lesn Mal Sclp/Hnd <0.5cm","PX-98300125","CDM","17270","CPT","0983","RC","","","","both","","","437.00","327.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","117.98","648.92","13","135.47","347.42","other","OPPS APC"
"Pf Dest Lesn Mal Sclp/Hnd <0.5cm","PX-98300125","CDM","17270","CPT","0983","RC","","","","both","","","437.00","327.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","167.37","38.3","","266.27","266.27","266.27","1 through 10","135.47","347.42","percent of total billed charges",""
"Pf Dest Lesn Mal Sclp/Hnd <0.5cm","PX-98300125","CDM","17270","CPT","0983","RC","","","","outpatient","","","437.00","327.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","225.86","225.86","225.86","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Dest Lesn Mal Sclp/Hnd 0.6-1.0cm","PX-98300126","CDM","17271","CPT","0983","RC","","","","both","","","477.00","357.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.98","117.98","235.97","1 through 10","147.87","379.22","other","OPPS APC"
"Pf Dest Lesn Mal Sclp/Hnd 0.6-1.0cm","PX-98300126","CDM","17271","CPT","0983","RC","","","","both","","","477.00","357.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","182.69","38.3","","887.97","591.98","887.97","1 through 10","147.87","379.22","percent of total billed charges",""
"Pf Dest Lesn Mal Sclp/Hnd 0.6-1.0cm","PX-98300126","CDM","17271","CPT","0983","RC","","","","outpatient","","","477.00","357.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","818.72","818.72","818.72","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Dest Lesn Mal Sclp/Hnd 2.1-3.0cm","PX-98300128","CDM","17273","CPT","0983","RC","","","","both","","","616.00","462.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","190.96","593.02","other","OPPS APC"
"Pf Dest Lesn Mal Sclp/Hnd 2.1-3.0cm","PX-98300128","CDM","17273","CPT","0983","RC","","","","both","","","616.00","462.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","235.93","38.3","","517.56","517.56","517.56","1 through 10","190.96","593.02","percent of total billed charges",""
"Pf Dest Lesn Mal Sclp/Hnd 2.1-3.0cm","PX-98300128","CDM","17273","CPT","0983","RC","","","","both","","","616.00","462.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","235.66","235.66","235.66","1 through 10","190.96","593.02","other","OPPS APC"
"Pf Dest Lesn Mal Trnk/Arm <0.5cm","PX-98300121","CDM","17260","CPT","0983","RC","","","","both","","","322.00","241.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","243.51","243.51","243.51","1 through 10","99.82","294.93","other","OPPS APC"
"Pf Dest Lesn Mal Trnk/Arm <0.5cm","PX-98300121","CDM","17260","CPT","0983","RC","","","","both","","","322.00","241.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","255.99","79.5","","399.80","399.80","399.80","1 through 10","99.82","294.93","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm <0.5cm","PX-98300121","CDM","17260","CPT","0983","RC","","","","both","","","322.00","241.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","171.63","53.3","","330.20","330.20","330.20","1 through 10","99.82","294.93","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm <0.5cm","PX-98300121","CDM","17260","CPT","0983","RC","","","","both","","","322.00","241.50","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","99.82","294.93","other","OPPS APC"
"Pf Dest Lesn Mal Trnk/Arm <0.5cm","PX-98300121","CDM","17260","CPT","0983","RC","","","","both","","","322.00","241.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","123.33","38.3","","198.63","198.63","198.63","1 through 10","99.82","294.93","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm <0.5cm","PX-98300121","CDM","17260","CPT","0983","RC","","","","outpatient","","","322.00","241.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Dest Lesn Mal Trnk/Arm <0.5cm","PX-98300121","CDM","17260","CPT","0983","RC","","","","outpatient","","","322.00","241.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","338.95","225.86","338.95","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Dest Lesn Mal Trnk/Arm 0.6-1.0cm","PX-98300122","CDM","17261","CPT","0983","RC","","","","both","","","399.00","299.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","123.69","317.21","other","OPPS APC"
"Pf Dest Lesn Mal Trnk/Arm 0.6-1.0cm","PX-98300122","CDM","17261","CPT","0983","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","145.64","36.5","","162.63","157.83","162.63","1 through 10","123.69","317.21","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 0.6-1.0cm","PX-98300122","CDM","17261","CPT","0983","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","152.82","38.3","","170.48","170.48","170.48","1 through 10","123.69","317.21","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 0.6-1.0cm","PX-98300122","CDM","17261","CPT","0983","RC","","","","both","","","399.00","299.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","307.23","77","","388.04","388.04","388.04","1 through 10","123.69","317.21","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 0.6-1.0cm","PX-98300122","CDM","17261","CPT","0983","RC","","","","both","","","399.00","299.25","WELLPOINT [1015]","HB AMC WELLPOINT","294.38","73.78","","324.60","324.60","324.60","1 through 10","123.69","317.21","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 0.6-1.0cm","PX-98300122","CDM","17261","CPT","0983","RC","","","","outpatient","","","399.00","299.25","AETNA [1001]","HB AMC AETNA HMO","278.50","69.8","","295.17","295.17","295.17","1 through 10","176.45","700.33","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 0.6-1.0cm","PX-98300122","CDM","17261","CPT","0983","RC","","","","outpatient","","","399.00","299.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","1228.08","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Dest Lesn Mal Trnk/Arm 0.6-1.0cm","PX-98300122","CDM","17261","CPT","0983","RC","","","","outpatient","","","399.00","299.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","645.81","215.27","645.81","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Dest Lesn Mal Trnk/Arm 0.6-1.0cm","PX-98300122","CDM","17261","CPT","0983","RC","","","","outpatient","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","326.06","81.72","","348.54","348.54","348.54","1 through 10","176.45","700.33","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","both","","","499.00","374.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","243.61","243.61","243.61","1 through 10","154.69","396.71","other","OPPS APC"
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","both","","","499.00","374.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","154.69","396.71","other","OPPS APC"
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","both","","","499.00","374.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","396.71","79.5","","439.15","294.62","439.15","1 through 10","154.69","396.71","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","both","","","499.00","374.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","265.97","53.3","","883.86","883.86","883.86","1 through 10","154.69","396.71","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","both","","","499.00","374.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","15","154.69","396.71","other","OPPS APC"
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","both","","","499.00","374.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","182.14","36.5","","208.13","208.13","208.13","1 through 10","154.69","396.71","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","both","","","499.00","374.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","191.12","38.3","","218.18","212.04","218.18","1 through 10","154.69","396.71","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","both","","","499.00","374.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","233.37","233.37","233.37","1 through 10","154.69","396.71","other","OPPS APC"
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","both","","","499.00","374.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.07","42.9","","446.07","446.07","446.07","1 through 10","154.69","396.71","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","both","","","499.00","374.25","WELLPOINT [1015]","HB AMC WELLPOINT","368.16","73.78","","415.43","415.43","415.43","1 through 10","154.69","396.71","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","outpatient","","","499.00","374.25","AETNA [1001]","HB AMC AETNA HMO","348.30","69.8","","377.77","377.77","377.77","1 through 10","176.45","700.33","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","outpatient","","","499.00","374.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","818.72","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","outpatient","","","499.00","374.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","215.27","215.27","215.27","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Dest Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300123","CDM","17262","CPT","0983","RC","","","","outpatient","","","499.00","374.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","407.78","81.72","","446.07","446.07","446.07","1 through 10","176.45","700.33","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300124","CDM","17263","CPT","0983","RC","","","","both","","","550.00","412.50","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","170.5","437.25","other","OPPS APC"
"Pf Dest Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300124","CDM","17263","CPT","0983","RC","","","","outpatient","","","550.00","412.50","AETNA [1001]","HB AMC AETNA HMO","383.90","69.8","","595.08","595.08","595.08","1 through 10","176.45","700.33","percent of total billed charges",""
"Pf Dest Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300124","CDM","17263","CPT","0983","RC","","","","outpatient","","","550.00","412.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Dest Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300124","CDM","17263","CPT","0983","RC","","","","outpatient","","","550.00","412.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","451.71","451.71","451.71","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","244.81","243.71","246.51","1 through 10","78.43","294.93","other","OPPS APC"
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","53.91","385.00","1 through 10","78.43","294.93","other","OPPS APC"
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","164.45","65","","203.28","203.28","203.28","1 through 10","78.43","294.93","percent of total billed charges",""
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","201.14","79.5","","303.00","203.28","580.58","46","78.43","294.93","percent of total billed charges",""
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","134.85","53.3","","203.28","203.28","1229.31","27","78.43","294.93","percent of total billed charges",""
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","194.81","77","","296.45","296.45","296.45","1 through 10","78.43","294.93","percent of total billed charges",""
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","164.45","65","","250.25","250.25","250.25","1 through 10","78.43","294.93","percent of total billed charges",""
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","42","78.43","294.93","other","OPPS APC"
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","92.35","36.5","","143.61","122.05","143.61","37","78.43","294.93","percent of total billed charges",""
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.90","38.3","","150.54","150.54","150.54","180","78.43","294.93","percent of total billed charges",""
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","231.25","231.25","1 through 10","78.43","294.93","other","OPPS APC"
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.54","42.9","","169.28","169.28","169.28","1 through 10","78.43","294.93","percent of total billed charges",""
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.73","231.26","231.73","1 through 10","78.43","294.93","other","OPPS APC"
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","both","","","253.00","189.75","WELLPOINT [1015]","HB AMC WELLPOINT","186.66","73.78","","286.63","286.63","671.63","46","78.43","294.93","percent of total billed charges",""
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","outpatient","","","253.00","189.75","AETNA [1001]","HB AMC AETNA HMO","176.59","69.8","","260.65","184.03","300.30","68","141.43","350.18","percent of total billed charges",""
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","outpatient","","","253.00","189.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","451.71","451.71","511.71","1 through 10","141.43","350.18","other","Multiple Surgery"
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","outpatient","","","253.00","189.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","1228.08","162","141.43","350.18","other","Multiple Surgery"
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","outpatient","","","253.00","189.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","1291.62","67","141.43","350.18","other","Multiple Surgery"
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","outpatient","","","253.00","189.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","511.71","462.00","511.71","1 through 10","141.43","350.18","other","Multiple Surgery"
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","outpatient","","","253.00","189.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","141.43","350.18","other","Multiple Surgery"
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","outpatient","","","253.00","189.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","313.91","124.13","451.71","38","141.43","350.18","other","Multiple Surgery"
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","outpatient","","","253.00","189.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","203.41","80.4","","192.50","192.50","192.50","1 through 10","141.43","350.18","percent of total billed charges",""
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","outpatient","","","253.00","189.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","206.75","81.72","","307.77","307.77","307.77","1 through 10","141.43","350.18","percent of total billed charges",""
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","outpatient","","","253.00","189.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","206.75","81.72","","307.77","169.28","307.77","48","141.43","350.18","percent of total billed charges",""
"Pf Dest Lesn Premalig 1st Lesion","PX-98300115","CDM","17000","CPT","0983","RC","","","","outpatient","","","253.00","189.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","434.07","434.07","434.07","1 through 10","141.43","350.18","other","Multiple Surgery"
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","both","","","489.00","366.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","488.23","488.23","488.23","1 through 10","151.59","593.02","other","OPPS APC"
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","both","","","489.00","366.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","466.88","466.88","1 through 10","151.59","593.02","other","OPPS APC"
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","both","","","489.00","366.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","388.76","79.5","","601.92","601.92","601.92","1 through 10","151.59","593.02","percent of total billed charges",""
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","both","","","489.00","366.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","260.64","53.3","","601.92","601.92","601.92","1 through 10","151.59","593.02","percent of total billed charges",""
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","both","","","489.00","366.75","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","191","151.59","593.02","other","OPPS APC"
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","both","","","489.00","366.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","178.49","36.5","","425.22","425.22","425.22","1 through 10","151.59","593.02","percent of total billed charges",""
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","both","","","489.00","366.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.29","38.3","","1337.22","433.20","1337.22","1 through 10","151.59","593.02","percent of total billed charges",""
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","both","","","489.00","366.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","464.98","426.50","464.98","1 through 10","151.59","593.02","other","OPPS APC"
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","both","","","489.00","366.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","464.98","464.98","1394.94","1 through 10","151.59","593.02","other","OPPS APC"
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","both","","","489.00","366.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","470.13","434.40","472.89","1 through 10","151.59","593.02","other","OPPS APC"
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","both","","","489.00","366.75","WELLPOINT [1015]","HB AMC WELLPOINT","360.78","73.78","","848.73","848.73","848.73","1 through 10","151.59","593.02","percent of total billed charges",""
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","outpatient","","","489.00","366.75","AETNA [1001]","HB AMC AETNA HMO","341.32","69.8","","889.20","889.20","889.20","1 through 10","273.35","700.33","percent of total billed charges",""
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","outpatient","","","489.00","366.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","910.83","910.83","910.83","1 through 10","273.35","700.33","other","Multiple Surgery"
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","outpatient","","","489.00","366.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2186.01","728.67","2186.01","24","273.35","700.33","other","Multiple Surgery"
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","outpatient","","","489.00","366.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","910.83","910.83","910.83","1 through 10","273.35","700.33","other","Multiple Surgery"
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","outpatient","","","489.00","366.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","804.04","804.04","804.04","1 through 10","273.35","700.33","other","Multiple Surgery"
"Pf Dest Lesn Premalignant 15+ Les","PX-98300117","CDM","17004","CPT","0983","RC","","","","outpatient","","","489.00","366.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","399.61","81.72","","911.32","501.26","911.32","1 through 10","273.35","700.33","percent of total billed charges",""
"Pf Dest Nrv Lumbar/Sacral Sgl","PX-98300472","CDM","64635","CPT","0983","RC","","","","both","","","1161.00","870.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2388.36","","APC Price ($2,318.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2387.18","2387.18","2387.18","1 through 10","359.91","2898.5","other","OPPS APC"
"Pf Dest Nrv Lumbar/Sacral Sgl","PX-98300472","CDM","64635","CPT","0983","RC","","","","both","","","1161.00","870.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2318.80","","APC Price ($2,318.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2281.93","2281.93","2281.93","1 through 10","359.91","2898.5","other","OPPS APC"
"Pf Dest Nrv Lumbar/Sacral Sgl","PX-98300472","CDM","64635","CPT","0983","RC","","","","both","","","1161.00","870.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2272.42","","APC Price ($2,318.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2280.15","2073.06","2280.55","14","359.91","2898.5","other","OPPS APC"
"Pf Destruct Benign Lesions > 15","PX-98300119","CDM","17111","CPT","0983","RC","","","","both","","","388.00","291.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","308.46","79.5","","245.52","245.52","245.52","1 through 10","120.28","308.46","percent of total billed charges",""
"Pf Destruct Benign Lesions > 15","PX-98300119","CDM","17111","CPT","0983","RC","","","","both","","","388.00","291.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","141.62","36.5","","168.33","168.33","168.33","1 through 10","120.28","308.46","percent of total billed charges",""
"Pf Destruct Benign Lesions > 15","PX-98300119","CDM","17111","CPT","0983","RC","","","","outpatient","","","388.00","291.00","AETNA [1001]","HB AMC AETNA HMO","270.82","69.8","","314.81","222.27","314.81","1 through 10","176.45","700.33","percent of total billed charges",""
"Pf Destruct Benign Lesions > 15","PX-98300119","CDM","17111","CPT","0983","RC","","","","outpatient","","","388.00","291.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","818.72","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Destruct Benign Lesions > 15","PX-98300119","CDM","17111","CPT","0983","RC","","","","outpatient","","","388.00","291.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Destruct Benign Lesions > 15","PX-98300119","CDM","17111","CPT","0983","RC","","","","outpatient","","","388.00","291.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","511.71","492.30","511.71","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Destruct Lesion Cryos","PX-98300346","CDM","46916","CPT","0983","RC","","","","outpatient","","","748.00","561.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Destruct Lesion Electro","PX-98300345","CDM","46910","CPT","0983","RC","","","","both","","","730.00","547.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","266.45","36.5","","2643.78","2643.78","2643.78","1 through 10","226.3","580.35","percent of total billed charges",""
"Pf Destruct Lesion Electro","PX-98300345","CDM","46910","CPT","0983","RC","","","","outpatient","","","730.00","547.50","AETNA [1001]","HB AMC AETNA HMO","509.54","69.8","","8329.13","8329.13","8329.13","1 through 10","292","596.56","percent of total billed charges",""
"Pf Destruct Lesion Electro","PX-98300345","CDM","46910","CPT","0983","RC","","","","outpatient","","","730.00","547.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","381.21","52.22","","4146.66","4146.66","4146.66","1 through 10","292","596.56","percent of total billed charges",""
"Pf Destruct Lesn Penis Smp Chem","PX-98300364","CDM","54050","CPT","0983","RC","","","","outpatient","","","495.00","371.25","AETNA [1001]","HB AMC AETNA HMO","345.51","69.8","","9669.46","9669.46","9669.46","1 through 10","276.71","700.33","percent of total billed charges",""
"Pf Destruct Lesn Penis Smp Cryo","PX-98300365","CDM","54056","CPT","0983","RC","","","","both","","","598.00","448.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","475.41","79.5","","293.57","293.57","293.57","1 through 10","185.38","488.69","percent of total billed charges",""
"Pf Destruct Lesn Penis Smp Cryo","PX-98300365","CDM","54056","CPT","0983","RC","","","","both","","","598.00","448.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","318.73","53.3","","293.57","293.57","293.57","1 through 10","185.38","488.69","percent of total billed charges",""
"Pf Destruct Lesn Penis Smp Cryo","PX-98300365","CDM","54056","CPT","0983","RC","","","","both","","","598.00","448.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","229.03","38.3","","217.40","217.40","217.40","1 through 10","185.38","488.69","percent of total billed charges",""
"Pf Destruct Lesn Penis Smp Cryo","PX-98300365","CDM","54056","CPT","0983","RC","","","","both","","","598.00","448.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","488.69","81.72","","444.47","444.47","444.47","1 through 10","185.38","488.69","percent of total billed charges",""
"Pf Destruct Lesn Penis Smp Cryo","PX-98300365","CDM","54056","CPT","0983","RC","","","","both","","","598.00","448.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","218.50","218.50","218.50","1 through 10","185.38","488.69","other","OPPS APC"
"Pf Destruct Lesn Penis Smp Cryo","PX-98300365","CDM","54056","CPT","0983","RC","","","","outpatient","","","598.00","448.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","393.48","204.68","409.36","1 through 10","176.45","480.79","other","Multiple Surgery"
"Pf Destruct Lesn Penis Smp Cryo","PX-98300365","CDM","54056","CPT","0983","RC","","","","outpatient","","","598.00","448.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","176.45","480.79","other","Multiple Surgery"
"Pf Destruct Vagina Lesions Smp","PX-98300380","CDM","57061","CPT","0983","RC","","","","both","","","528.00","396.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3888.77","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3886.28","3886.28","3886.28","1 through 10","163.68","4719.38","other","OPPS APC"
"Pf Destruct Vagina Lesions Smp","PX-98300380","CDM","57061","CPT","0983","RC","","","","both","","","528.00","396.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3715.47","3357.59","3715.47","1 through 10","163.68","4719.38","other","OPPS APC"
"Pf Destruct Vagina Lesions Smp","PX-98300380","CDM","57061","CPT","0983","RC","","","","both","","","528.00","396.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","419.76","79.5","","14373.37","14373.37","14373.37","1 through 10","163.68","4719.38","percent of total billed charges",""
"Pf Destruct Vagina Lesions Smp","PX-98300380","CDM","57061","CPT","0983","RC","","","","both","","","528.00","396.00","MEDICARE [2001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3412.18","3775.88","12","163.68","4719.38","other","OPPS APC"
"Pf Destruct Vagina Lesions Smp","PX-98300380","CDM","57061","CPT","0983","RC","","","","both","","","528.00","396.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","202.22","38.3","","7687.02","1852.56","7687.02","1 through 10","163.68","4719.38","percent of total billed charges",""
"Pf Destruct Vagina Lesions Smp","PX-98300380","CDM","57061","CPT","0983","RC","","","","both","","","528.00","396.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","11123.28","3700.36","11123.28","1 through 10","163.68","4719.38","other","OPPS APC"
"Pf Destruct Vagina Lesions Smp","PX-98300380","CDM","57061","CPT","0983","RC","","","","both","","","528.00","396.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3700.36","3700.36","3700.36","1 through 10","163.68","4719.38","other","OPPS APC"
"Pf Destruct Vagina Lesions Smp","PX-98300380","CDM","57061","CPT","0983","RC","","","","outpatient","","","528.00","396.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4930.32","4930.32","4930.32","1 through 10","295.15","2384.07","other","Multiple Surgery"
"Pf Destruct Vulva Lesions Smp","PX-98300373","CDM","56501","CPT","0983","RC","","","","both","","","610.00","457.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","484.95","79.5","","14373.37","14373.37","14373.37","1 through 10","189.1","2715.13","percent of total billed charges",""
"Pf Destruct Vulva Lesions Smp","PX-98300373","CDM","56501","CPT","0983","RC","","","","both","","","610.00","457.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","233.63","38.3","","1995.66","235.77","1995.66","1 through 10","189.1","2715.13","percent of total billed charges",""
"Pf Destruct Vulva Lesions Smp","PX-98300373","CDM","56501","CPT","0983","RC","","","","outpatient","","","610.00","457.50","AETNA [1001]","HB AMC AETNA HMO","425.78","69.8","","3455.41","3455.41","3455.41","1 through 10","340.99","2384.07","percent of total billed charges",""
"Pf Destruct Vulva Lesions Smp","PX-98300373","CDM","56501","CPT","0983","RC","","","","outpatient","","","610.00","457.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3593.59","3593.59","3593.59","1 through 10","340.99","2384.07","other","Multiple Surgery"
"Pf Dress/Debr Burn <5% Sm","PX-98300112","CDM","16020","CPT","0983","RC","","","","both","","","289.00","216.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","60.60","60.60","60.60","1 through 10","89.59","259.49","other","OPPS APC"
"Pf Dress/Debr Burn <5% Sm","PX-98300112","CDM","16020","CPT","0983","RC","","","","both","","","289.00","216.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","203.44","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","59.39","59.39","59.39","1 through 10","89.59","259.49","other","OPPS APC"
"Pf Endocervical Curettage","PX-98300397","CDM","57505","CPT","0983","RC","","","","both","","","500.00","375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","397.50","79.5","","959.09","959.09","959.09","1 through 10","155","1292.44","percent of total billed charges",""
"Pf Endocervical Curettage","PX-98300397","CDM","57505","CPT","0983","RC","","","","both","","","500.00","375.00","MEDICARE [2001]","HB BWH MEDICARE","1033.95","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1034.06","1034.06","1034.06","1 through 10","155","1292.44","other","OPPS APC"
"Pf Endocervical Curettage","PX-98300397","CDM","57505","CPT","0983","RC","","","","both","","","500.00","375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","191.50","38.3","","497.35","497.35","497.35","1 through 10","155","1292.44","percent of total billed charges",""
"Pf Endocervical Curettage","PX-98300397","CDM","57505","CPT","0983","RC","","","","outpatient","","","500.00","375.00","AETNA [1001]","HB AMC AETNA HMO","349.00","69.8","","1198.29","1198.29","1198.29","1 through 10","279.5","2384.07","percent of total billed charges",""
"Pf Endocervical Curettage","PX-98300397","CDM","57505","CPT","0983","RC","","","","outpatient","","","500.00","375.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1294.65","1294.65","1294.65","1 through 10","279.5","2384.07","other","Multiple Surgery"
"Pf Endocervical Curettage","PX-98300397","CDM","57505","CPT","0983","RC","","","","outpatient","","","500.00","375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","408.60","81.72","","6667.00","1016.84","6667.00","1 through 10","279.5","2384.07","percent of total billed charges",""
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","246.04","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","245.83","67.04","245.83","1 through 10","108.19","298.6","other","OPPS APC"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.08","235.08","235.08","1 through 10","108.19","298.6","other","OPPS APC"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","277.46","79.5","","503.68","337.92","503.68","19","108.19","298.6","percent of total billed charges",""
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","186.02","53.3","","337.92","337.92","503.68","12","108.19","298.6","percent of total billed charges",""
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.08","235.08","235.08","1 through 10","108.19","298.6","other","OPPS APC"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","ELDER SERVICES [1037]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","213.13","213.13","213.13","1 through 10","108.19","298.6","other","OPPS APC"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","214.87","214.87","214.87","1 through 10","108.19","298.6","other","OPPS APC"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","HUMANA [1012]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.56","235.56","235.56","1 through 10","108.19","298.6","other","OPPS APC"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","MEDICARE [2001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","238.90","217.48","238.90","57","108.19","298.6","other","OPPS APC"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","65.15","65.15","65.15","1 through 10","108.19","298.6","other","OPPS APC"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","108.19","31","","593.28","197.76","593.28","1 through 10","108.19","298.6","percent of total billed charges",""
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.39","36.5","","238.72","202.88","716.16","38","108.19","298.6","percent of total billed charges",""
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","133.67","38.3","","250.24","250.24","750.72","66","108.19","298.6","percent of total billed charges",""
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","234.12","234.12","234.12","1 through 10","108.19","298.6","other","OPPS APC"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","235.08","235.08","235.08","1 through 10","108.19","298.6","other","OPPS APC"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","234.12","63.85","238.90","25","108.19","298.6","other","OPPS APC"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","both","","","349.00","261.75","WELLPOINT [1015]","HB AMC WELLPOINT","257.49","73.78","","1116.48","476.48","6209.13","1 through 10","108.19","298.6","percent of total billed charges",""
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","outpatient","","","349.00","261.75","AETNA [1001]","HB AMC AETNA HMO","243.60","69.8","","433.28","305.92","771.42","19","165.93","700.33","percent of total billed charges",""
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","outpatient","","","349.00","261.75","AETNA [1001]","HB AMC AETNA PPO","280.60","80.4","","499.20","433.28","499.20","1 through 10","165.93","700.33","percent of total billed charges",""
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","outpatient","","","349.00","261.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","424.78","424.78","424.78","1 through 10","165.93","700.33","other","Multiple Surgery"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","outpatient","","","349.00","261.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","384.96","384.96","1154.88","50","165.93","700.33","other","Multiple Surgery"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","outpatient","","","349.00","261.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","389.94","1214.61","27","165.93","700.33","other","Multiple Surgery"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","outpatient","","","349.00","261.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","481.20","481.20","481.20","1 through 10","165.93","700.33","other","Multiple Surgery"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","outpatient","","","349.00","261.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","404.87","404.87","1 through 10","165.93","700.33","other","Multiple Surgery"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","outpatient","","","349.00","261.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","424.78","424.78","424.78","1 through 10","165.93","700.33","other","Multiple Surgery"
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","outpatient","","","349.00","261.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","280.60","80.4","","499.20","499.20","499.20","1 through 10","165.93","700.33","percent of total billed charges",""
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","outpatient","","","349.00","261.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","285.20","81.72","","511.62","511.61","511.62","1 through 10","165.93","700.33","percent of total billed charges",""
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","outpatient","","","349.00","261.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","285.20","81.72","","511.62","281.41","511.62","33","165.93","700.33","percent of total billed charges",""
"Pf Endometrial Sampling Biopsy","PX-98300402","CDM","58100","CPT","0983","RC","","","","outpatient","","","349.00","261.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","408.19","408.19","408.19","1 through 10","165.93","700.33","other","Multiple Surgery"
"Pf Epsdt Services Completed","PX-98300592","CDM","S0302","HCPCS","0983","RC","","","","both","","","27.00","20.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21.47","79.5","","15.38","15.38","15.38","14","8.37","25.65","percent of total billed charges",""
"Pf Epsdt Services Completed","PX-98300592","CDM","S0302","HCPCS","0983","RC","","","","both","","","27.00","20.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14.39","53.3","","15.38","15.38","15.38","1 through 10","8.37","25.65","percent of total billed charges",""
"Pf Epsdt Services Completed","PX-98300592","CDM","S0302","HCPCS","0983","RC","","","","both","","","27.00","20.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","8.37","31","","8.34","8.34","8.34","1 through 10","8.37","25.65","percent of total billed charges",""
"Pf Epsdt Services Completed","PX-98300592","CDM","S0302","HCPCS","0983","RC","","","","both","","","27.00","20.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9.86","36.5","","10.07","8.56","10.07","84","8.37","25.65","percent of total billed charges",""
"Pf Epsdt Services Completed","PX-98300592","CDM","S0302","HCPCS","0983","RC","","","","both","","","27.00","20.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10.34","38.3","","10.56","10.56","20.62","222","8.37","25.65","percent of total billed charges",""
"Pf Epsdt Services Completed","PX-98300592","CDM","S0302","HCPCS","0983","RC","","","","both","","","27.00","20.25","TRICARE [160005]","HB BWH TRICARE","25.65","95","","27.00","27.00","27.00","1 through 10","8.37","25.65","percent of total billed charges",""
"Pf Epsdt Services Completed","PX-98300592","CDM","S0302","HCPCS","0983","RC","","","","both","","","27.00","20.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11.58","42.9","","21.58","11.87","21.58","1 through 10","8.37","25.65","percent of total billed charges",""
"Pf Epsdt Services Completed","PX-98300592","CDM","S0302","HCPCS","0983","RC","","","","both","","","27.00","20.25","WELLPOINT [1015]","HB AMC WELLPOINT","19.92","73.78","","27.00","27.00","27.00","1 through 10","8.37","25.65","percent of total billed charges",""
"Pf Epsdt Services Completed","PX-98300592","CDM","S0302","HCPCS","0983","RC","","","","outpatient","","","27.00","20.25","AETNA [1001]","HB AMC AETNA HMO","18.85","69.8","","18.28","12.91","21.06","20","14.1","22.06","percent of total billed charges",""
"Pf Epsdt Services Completed","PX-98300592","CDM","S0302","HCPCS","0983","RC","","","","outpatient","","","27.00","20.25","AETNA [1001]","HB AMC AETNA PPO","21.71","80.4","","42.12","42.12","42.12","1 through 10","14.1","22.06","percent of total billed charges",""
"Pf Epsdt Services Completed","PX-98300592","CDM","S0302","HCPCS","0983","RC","","","","outpatient","","","27.00","20.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","16.35","60.55","","16.85","16.85","18.15","109","14.1","22.06","percent of total billed charges",""
"Pf Epsdt Services Completed","PX-98300592","CDM","S0302","HCPCS","0983","RC","","","","outpatient","","","27.00","20.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","14.10","52.22","","14.54","14.53","18.67","113","14.1","22.06","percent of total billed charges",""
"Pf Epsdt Services Completed","PX-98300592","CDM","S0302","HCPCS","0983","RC","","","","outpatient","","","27.00","20.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22.06","81.72","","21.58","11.87","21.58","13","14.1","22.06","percent of total billed charges",""
"Pf Exam Neurobehavrl by Psych / Hr","PX-96100012","CDM","96116","CPT","0961","RC","","","","both","","","366.00","274.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","86.53","63.48","86.53","1 through 10","113.46","347.7","other","OPPS APC"
"Pf Exam Neurobehavrl by Psych / Hr","PX-96100012","CDM","96116","CPT","0961","RC","","","","both","","","366.00","274.50","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","369.81","485.18","1 through 10","113.46","347.7","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear <0.5cm","PX-98300047","CDM","11440","CPT","0983","RC","","","","both","","","500.00","375.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","1880.00","16","155","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear <0.5cm","PX-98300047","CDM","11440","CPT","0983","RC","","","","both","","","500.00","375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","191.50","38.3","","1683.27","429.71","1683.27","1 through 10","155","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear <0.5cm","PX-98300047","CDM","11440","CPT","0983","RC","","","","both","","","500.00","375.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","755.61","826.75","1 through 10","155","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear <0.5cm","PX-98300047","CDM","11440","CPT","0983","RC","","","","both","","","500.00","375.00","WELLPOINT [1015]","HB AMC WELLPOINT","368.90","73.78","","1068.36","1068.36","1068.36","1 through 10","155","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear <0.5cm","PX-98300047","CDM","11440","CPT","0983","RC","","","","outpatient","","","500.00","375.00","AETNA [1001]","HB AMC AETNA HMO","349.00","69.8","","971.50","525.32","971.50","1 through 10","279.5","1234.13","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear <0.5cm","PX-98300047","CDM","11440","CPT","0983","RC","","","","outpatient","","","500.00","375.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1344.07","1344.07","1344.07","1 through 10","279.5","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Face/Ear <0.5cm","PX-98300047","CDM","11440","CPT","0983","RC","","","","outpatient","","","500.00","375.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1263.27","631.64","1263.27","1 through 10","279.5","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Face/Ear <0.5cm","PX-98300047","CDM","11440","CPT","0983","RC","","","","outpatient","","","500.00","375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","408.60","81.72","","4917.51","4917.51","4917.51","1 through 10","279.5","1234.13","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear >4.0cm","PX-98300052","CDM","11446","CPT","0983","RC","","","","both","","","1431.00","1073.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","762.72","53.3","","19039.11","19039.11","19039.11","1 through 10","335.95","3228.91","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear >4.0cm","PX-98300052","CDM","11446","CPT","0983","RC","","","","both","","","1431.00","1073.25","WELLPOINT [1015]","HB AMC WELLPOINT","1055.79","73.78","","6055.02","5020.16","6055.02","1 through 10","335.95","3228.91","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear >4.0cm","PX-98300052","CDM","11446","CPT","0983","RC","","","","outpatient","","","1431.00","1073.25","AETNA [1001]","HB AMC AETNA HMO","998.84","69.8","","559.65","559.65","559.65","1 through 10","799.93","5545.35","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 0.6-1.0cm","PX-98300048","CDM","11441","CPT","0983","RC","","","","both","","","613.00","459.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","859.79","859.79","866.79","1 through 10","190.03","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear 0.6-1.0cm","PX-98300048","CDM","11441","CPT","0983","RC","","","","both","","","613.00","459.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","190.03","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear 0.6-1.0cm","PX-98300048","CDM","11441","CPT","0983","RC","","","","both","","","613.00","459.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","487.34","79.5","","757.68","378.84","757.68","1 through 10","190.03","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 0.6-1.0cm","PX-98300048","CDM","11441","CPT","0983","RC","","","","both","","","613.00","459.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","326.73","53.3","","1731.84","1731.84","1731.84","1 through 10","190.03","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 0.6-1.0cm","PX-98300048","CDM","11441","CPT","0983","RC","","","","both","","","613.00","459.75","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","2506.68","22","190.03","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear 0.6-1.0cm","PX-98300048","CDM","11441","CPT","0983","RC","","","","both","","","613.00","459.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.75","36.5","","802.89","440.31","1320.93","1 through 10","190.03","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 0.6-1.0cm","PX-98300048","CDM","11441","CPT","0983","RC","","","","both","","","613.00","459.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.78","38.3","","841.62","841.62","1683.27","22","190.03","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 0.6-1.0cm","PX-98300048","CDM","11441","CPT","0983","RC","","","","both","","","613.00","459.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","818.85","1 through 10","190.03","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear 0.6-1.0cm","PX-98300048","CDM","11441","CPT","0983","RC","","","","both","","","613.00","459.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","614.14","614.14","822.19","1 through 10","190.03","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear 0.6-1.0cm","PX-98300048","CDM","11441","CPT","0983","RC","","","","both","","","613.00","459.75","WELLPOINT [1015]","HB AMC WELLPOINT","452.27","73.78","","2423.11","1251.68","2423.11","1 through 10","190.03","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 0.6-1.0cm","PX-98300048","CDM","11441","CPT","0983","RC","","","","outpatient","","","613.00","459.75","AETNA [1001]","HB AMC AETNA HMO","427.87","69.8","","559.65","485.75","559.65","1 through 10","342.67","1234.13","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 0.6-1.0cm","PX-98300048","CDM","11441","CPT","0983","RC","","","","outpatient","","","613.00","459.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","1344.07","4032.21","1 through 10","342.67","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Face/Ear 0.6-1.0cm","PX-98300048","CDM","11441","CPT","0983","RC","","","","outpatient","","","613.00","459.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","500.94","81.72","","1110.37","1110.37","1110.37","1 through 10","342.67","1234.13","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 1.1-2.0cm","PX-98300049","CDM","11442","CPT","0983","RC","","","","both","","","676.00","507.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","860.59","860.59","860.59","1 through 10","209.56","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear 1.1-2.0cm","PX-98300049","CDM","11442","CPT","0983","RC","","","","both","","","676.00","507.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","1 through 10","209.56","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear 1.1-2.0cm","PX-98300049","CDM","11442","CPT","0983","RC","","","","both","","","676.00","507.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","537.42","79.5","","1129.35","1129.35","1129.35","1 through 10","209.56","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 1.1-2.0cm","PX-98300049","CDM","11442","CPT","0983","RC","","","","both","","","676.00","507.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","417.78","835.56","1 through 10","209.56","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear 1.1-2.0cm","PX-98300049","CDM","11442","CPT","0983","RC","","","","both","","","676.00","507.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","246.74","36.5","","2343.27","2343.27","2343.27","1 through 10","209.56","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 1.1-2.0cm","PX-98300049","CDM","11442","CPT","0983","RC","","","","both","","","676.00","507.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","258.91","38.3","","2808.96","272.65","3180.00","1 through 10","209.56","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 1.1-2.0cm","PX-98300049","CDM","11442","CPT","0983","RC","","","","both","","","676.00","507.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","824.85","824.85","824.85","1 through 10","209.56","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear 1.1-2.0cm","PX-98300049","CDM","11442","CPT","0983","RC","","","","both","","","676.00","507.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","409.43","818.85","1 through 10","209.56","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear 1.1-2.0cm","PX-98300049","CDM","11442","CPT","0983","RC","","","","both","","","676.00","507.00","WELLPOINT [1015]","HB AMC WELLPOINT","498.75","73.78","","1251.68","1251.68","1251.68","1 through 10","209.56","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 1.1-2.0cm","PX-98300049","CDM","11442","CPT","0983","RC","","","","outpatient","","","676.00","507.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3875.79","2016.12","4032.21","1 through 10","377.88","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Face/Ear 1.1-2.0cm","PX-98300049","CDM","11442","CPT","0983","RC","","","","outpatient","","","676.00","507.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","552.43","81.72","","1147.14","1147.14","1147.14","1 through 10","377.88","2384.07","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 2.1-3.0cm","PX-98300050","CDM","11443","CPT","0983","RC","","","","both","","","818.00","613.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","650.31","79.5","","1129.35","1129.35","1129.35","1 through 10","253.58","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 2.1-3.0cm","PX-98300050","CDM","11443","CPT","0983","RC","","","","both","","","818.00","613.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","435.99","53.3","","1511.82","1511.82","1511.82","1 through 10","253.58","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 2.1-3.0cm","PX-98300050","CDM","11443","CPT","0983","RC","","","","both","","","818.00","613.50","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","253.58","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear 2.1-3.0cm","PX-98300050","CDM","11443","CPT","0983","RC","","","","both","","","818.00","613.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","313.29","38.3","","936.32","936.32","936.32","1 through 10","253.58","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 2.1-3.0cm","PX-98300050","CDM","11443","CPT","0983","RC","","","","both","","","818.00","613.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","253.58","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Face/Ear 2.1-3.0cm","PX-98300050","CDM","11443","CPT","0983","RC","","","","both","","","818.00","613.50","WELLPOINT [1015]","HB AMC WELLPOINT","603.52","73.78","","5020.16","5020.16","5020.16","1 through 10","253.58","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Face/Ear 3.1-4.0cm","PX-98300051","CDM","11444","CPT","0983","RC","","","","both","","","1027.00","770.25","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","318.37","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd <0.5cm","PX-98300041","CDM","11420","CPT","0983","RC","","","","both","","","379.00","284.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","301.31","79.5","","1167.04","1167.04","1167.04","1 through 10","117.49","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd <0.5cm","PX-98300041","CDM","11420","CPT","0983","RC","","","","both","","","379.00","284.25","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","962.07","1924.13","1 through 10","117.49","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd <0.5cm","PX-98300041","CDM","11420","CPT","0983","RC","","","","both","","","379.00","284.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","138.34","36.5","","2729.37","2470.74","2729.37","1 through 10","117.49","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd <0.5cm","PX-98300041","CDM","11420","CPT","0983","RC","","","","both","","","379.00","284.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","145.16","38.3","","863.33","863.33","2589.99","11","117.49","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd <0.5cm","PX-98300041","CDM","11420","CPT","0983","RC","","","","both","","","379.00","284.25","TRICARE [160005]","HB BWH TRICARE","1827.93","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1924.13","1924.13","1924.13","1 through 10","117.49","2404.92","other","Tricare OPPS"
"Pf Exc Lesn Bgn Sclp/Hnd <0.5cm","PX-98300041","CDM","11420","CPT","0983","RC","","","","both","","","379.00","284.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1741.20","1741.20","1741.20","1 through 10","117.49","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd <0.5cm","PX-98300041","CDM","11420","CPT","0983","RC","","","","both","","","379.00","284.25","WELLPOINT [1015]","HB AMC WELLPOINT","279.63","73.78","","1251.68","1251.68","1251.68","1 through 10","117.49","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd <0.5cm","PX-98300041","CDM","11420","CPT","0983","RC","","","","outpatient","","","379.00","284.25","AETNA [1001]","HB AMC AETNA HMO","264.54","69.8","","1016.26","971.50","1494.82","1 through 10","211.86","2384.07","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd <0.5cm","PX-98300041","CDM","11420","CPT","0983","RC","","","","outpatient","","","379.00","284.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2872.04","2760.63","2872.04","1 through 10","211.86","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd <0.5cm","PX-98300041","CDM","11420","CPT","0983","RC","","","","outpatient","","","379.00","284.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9061.80","9061.80","9061.80","1 through 10","211.86","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd <0.5cm","PX-98300041","CDM","11420","CPT","0983","RC","","","","outpatient","","","379.00","284.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1731.82","1731.82","1731.82","1 through 10","211.86","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd <0.5cm","PX-98300041","CDM","11420","CPT","0983","RC","","","","outpatient","","","379.00","284.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","309.72","81.72","","1765.08","1584.58","1765.08","1 through 10","211.86","2384.07","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd >4.0cm","PX-98300046","CDM","11426","CPT","0983","RC","","","","outpatient","","","1208.00","906.00","AETNA [1001]","HB AMC AETNA HMO","843.18","69.8","","1942.99","1942.99","1942.99","1 through 10","675.27","5545.35","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd >4.0cm","PX-98300046","CDM","11426","CPT","0983","RC","","","","outpatient","","","1208.00","906.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4965.87","4965.87","4965.87","1 through 10","675.27","5545.35","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd >4.0cm","PX-98300046","CDM","11426","CPT","0983","RC","","","","outpatient","","","1208.00","906.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4773.23","4773.23","4773.23","1 through 10","675.27","5545.35","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","both","","","498.00","373.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","395.91","79.5","","564.67","564.67","564.67","1 through 10","154.38","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","both","","","498.00","373.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","265.43","53.3","","1093.15","733.39","1093.15","1 through 10","154.38","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","both","","","498.00","373.50","HUMANA [1012]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","823.86","823.86","823.86","1 through 10","154.38","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","both","","","498.00","373.50","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","1671.12","16","154.38","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","both","","","498.00","373.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","181.77","36.5","","1320.93","1320.93","1320.93","1 through 10","154.38","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","both","","","498.00","373.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","190.73","38.3","","543.10","527.82","1090.60","1 through 10","154.38","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","both","","","498.00","373.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","818.85","1 through 10","154.38","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","both","","","498.00","373.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","824.95","818.85","824.95","1 through 10","154.38","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","both","","","498.00","373.50","WELLPOINT [1015]","HB AMC WELLPOINT","367.42","73.78","","2870.00","2870.00","2870.00","1 through 10","154.38","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","outpatient","","","498.00","373.50","AETNA [1001]","HB AMC AETNA HMO","347.60","69.8","","940.35","940.35","1083.42","1 through 10","278.38","2384.07","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","outpatient","","","498.00","373.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","1344.07","6720.35","11","278.38","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","outpatient","","","498.00","373.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2120.40","680.73","2120.40","1 through 10","278.38","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","outpatient","","","498.00","373.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1483.11","1322.23","2178.89","1 through 10","278.38","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd 0.6-1.0cm","PX-98300042","CDM","11421","CPT","0983","RC","","","","outpatient","","","498.00","373.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","406.97","81.72","","1110.37","573.57","1147.14","1 through 10","278.38","2384.07","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","both","","","627.00","470.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","194.37","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","both","","","627.00","470.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","498.47","79.5","","1093.14","1093.14","1093.14","1 through 10","194.37","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","both","","","627.00","470.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","946.67","946.67","946.67","1 through 10","194.37","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","both","","","627.00","470.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","482.79","77","","1069.53","1069.53","1069.53","1 through 10","194.37","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","both","","","627.00","470.25","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","962.07","1924.13","12","194.37","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","both","","","627.00","470.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.86","36.5","","1320.93","1070.52","1605.78","1 through 10","194.37","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","both","","","627.00","470.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","240.14","38.3","","1629.30","1086.20","5049.78","23","194.37","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","both","","","627.00","470.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1742.02","942.83","1886.65","1 through 10","194.37","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","both","","","627.00","470.25","WELLPOINT [1015]","HB AMC WELLPOINT","462.60","73.78","","2423.11","2423.11","2423.11","1 through 10","194.37","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","outpatient","","","627.00","470.25","AETNA [1001]","HB AMC AETNA HMO","437.65","69.8","","940.35","663.94","971.50","1 through 10","350.49","2384.07","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","outpatient","","","627.00","470.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","8616.12","8616.12","13","350.49","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","outpatient","","","627.00","470.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4530.90","4530.90","9061.80","13","350.49","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","outpatient","","","627.00","470.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3005.00","3005.00","3005.00","1 through 10","350.49","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd 1.1-2.0cm","PX-98300043","CDM","11422","CPT","0983","RC","","","","outpatient","","","627.00","470.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","512.38","81.72","","1110.37","1110.37","1110.37","1 through 10","350.49","2384.07","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 2.1-3.0cm","PX-98300044","CDM","11423","CPT","0983","RC","","","","both","","","723.00","542.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1415.20","1415.20","1415.20","1 through 10","224.13","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 2.1-3.0cm","PX-98300044","CDM","11423","CPT","0983","RC","","","","both","","","723.00","542.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","224.13","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 2.1-3.0cm","PX-98300044","CDM","11423","CPT","0983","RC","","","","both","","","723.00","542.25","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","224.13","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 2.1-3.0cm","PX-98300044","CDM","11423","CPT","0983","RC","","","","both","","","723.00","542.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","263.90","36.5","","1472.98","1472.98","1472.98","1 through 10","224.13","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 2.1-3.0cm","PX-98300044","CDM","11423","CPT","0983","RC","","","","both","","","723.00","542.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","276.91","38.3","","4632.18","561.09","4632.18","1 through 10","224.13","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 2.1-3.0cm","PX-98300044","CDM","11423","CPT","0983","RC","","","","both","","","723.00","542.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","224.13","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 2.1-3.0cm","PX-98300044","CDM","11423","CPT","0983","RC","","","","both","","","723.00","542.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.34","1885.65","1893.34","1 through 10","224.13","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 2.1-3.0cm","PX-98300044","CDM","11423","CPT","0983","RC","","","","outpatient","","","723.00","542.25","AETNA [1001]","HB AMC AETNA HMO","504.65","69.8","","2673.47","2673.47","2673.47","1 through 10","404.16","5545.35","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 2.1-3.0cm","PX-98300044","CDM","11423","CPT","0983","RC","","","","outpatient","","","723.00","542.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8281.89","4308.06","8616.12","12","404.16","5545.35","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd 2.1-3.0cm","PX-98300044","CDM","11423","CPT","0983","RC","","","","outpatient","","","723.00","542.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3169.15","3169.15","3169.15","1 through 10","404.16","5545.35","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd 2.1-3.0cm","PX-98300044","CDM","11423","CPT","0983","RC","","","","outpatient","","","723.00","542.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","590.84","81.72","","1147.14","1147.14","1147.14","1 through 10","404.16","5545.35","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 3.1-4.0cm","PX-98300045","CDM","11424","CPT","0983","RC","","","","both","","","826.00","619.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1986.93","1986.93","1986.93","1 through 10","256.06","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 3.1-4.0cm","PX-98300045","CDM","11424","CPT","0983","RC","","","","both","","","826.00","619.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","256.06","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 3.1-4.0cm","PX-98300045","CDM","11424","CPT","0983","RC","","","","both","","","826.00","619.50","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","256.06","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 3.1-4.0cm","PX-98300045","CDM","11424","CPT","0983","RC","","","","both","","","826.00","619.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","316.36","38.3","","1544.06","1544.06","1544.06","1 through 10","256.06","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Sclp/Hnd 3.1-4.0cm","PX-98300045","CDM","11424","CPT","0983","RC","","","","both","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.15","1893.15","1893.15","1 through 10","256.06","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Sclp/Hnd 3.1-4.0cm","PX-98300045","CDM","11424","CPT","0983","RC","","","","outpatient","","","826.00","619.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","8616.12","8616.12","1 through 10","461.73","5545.35","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd 3.1-4.0cm","PX-98300045","CDM","11424","CPT","0983","RC","","","","outpatient","","","826.00","619.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9061.80","9061.80","9061.80","1 through 10","461.73","5545.35","other","Multiple Surgery"
"Pf Exc Lesn Bgn Sclp/Hnd 3.1-4.0cm","PX-98300045","CDM","11424","CPT","0983","RC","","","","outpatient","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","675.01","81.72","","1147.14","1147.14","1147.14","1 through 10","461.73","5545.35","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","both","","","485.00","363.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","244.11","244.11","244.11","1 through 10","150.35","593.02","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","both","","","485.00","363.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","466.88","466.88","1 through 10","150.35","593.02","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","both","","","485.00","363.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","258.51","53.3","","1093.14","733.39","1093.14","1 through 10","150.35","593.02","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","both","","","485.00","363.75","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","237.23","1423.41","20","150.35","593.02","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","both","","","485.00","363.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","177.03","36.5","","880.62","227.45","1508.46","1 through 10","150.35","593.02","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","both","","","485.00","363.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","185.76","38.3","","1629.30","543.10","1629.30","47","150.35","593.02","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","both","","","485.00","363.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","373.45","77","","1236.21","1236.21","1236.21","1 through 10","150.35","593.02","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","both","","","485.00","363.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.50","232.50","232.50","1 through 10","150.35","593.02","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","both","","","485.00","363.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","208.07","42.9","","573.57","573.57","573.57","1 through 10","150.35","593.02","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","both","","","485.00","363.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.89","466.88","472.89","1 through 10","150.35","593.02","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","both","","","485.00","363.75","WELLPOINT [1015]","HB AMC WELLPOINT","357.83","73.78","","1034.11","1034.11","1034.11","1 through 10","150.35","593.02","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","outpatient","","","485.00","363.75","AETNA [1001]","HB AMC AETNA HMO","338.53","69.8","","940.35","342.97","940.35","1 through 10","271.12","1234.13","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","outpatient","","","485.00","363.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1821.70","1457.34","1821.70","1 through 10","271.12","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","outpatient","","","485.00","363.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2299.08","2299.08","2299.08","1 through 10","271.12","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","outpatient","","","485.00","363.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","772.64","716.82","772.64","1 through 10","271.12","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm .6-1.0cm","PX-98300036","CDM","11401","CPT","0983","RC","","","","outpatient","","","485.00","363.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","396.34","81.72","","1110.37","1110.37","1110.37","1 through 10","271.12","1234.13","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm <0.5cm","PX-98300035","CDM","11400","CPT","0983","RC","","","","both","","","391.00","293.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","859.79","859.79","859.79","1 through 10","121.21","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm <0.5cm","PX-98300035","CDM","11400","CPT","0983","RC","","","","both","","","391.00","293.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","310.85","79.5","","1772.56","1772.56","1772.56","1 through 10","121.21","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm <0.5cm","PX-98300035","CDM","11400","CPT","0983","RC","","","","both","","","391.00","293.25","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","557.04","1671.12","1 through 10","121.21","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm <0.5cm","PX-98300035","CDM","11400","CPT","0983","RC","","","","both","","","391.00","293.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","149.75","38.3","","1289.13","417.62","1683.27","14","121.21","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm <0.5cm","PX-98300035","CDM","11400","CPT","0983","RC","","","","both","","","391.00","293.25","WELLPOINT [1015]","HB AMC WELLPOINT","288.48","73.78","","2503.36","1917.21","2503.36","1 through 10","121.21","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm <0.5cm","PX-98300035","CDM","11400","CPT","0983","RC","","","","outpatient","","","391.00","293.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","645.97","4032.21","1 through 10","218.57","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm <0.5cm","PX-98300035","CDM","11400","CPT","0983","RC","","","","outpatient","","","391.00","293.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1291.93","1291.93","1291.93","1 through 10","218.57","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm <0.5cm","PX-98300035","CDM","11400","CPT","0983","RC","","","","outpatient","","","391.00","293.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1483.11","741.56","1483.11","1 through 10","218.57","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm <0.5cm","PX-98300035","CDM","11400","CPT","0983","RC","","","","outpatient","","","391.00","293.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1344.07","1344.07","1344.07","1 through 10","218.57","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm <0.5cm","PX-98300035","CDM","11400","CPT","0983","RC","","","","outpatient","","","391.00","293.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","319.53","81.72","","5335.20","5335.20","5335.20","1 through 10","218.57","1234.13","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm <0.5cm","PX-98300035","CDM","11400","CPT","0983","RC","","","","outpatient","","","391.00","293.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","712.59","712.59","712.59","1 through 10","218.57","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","both","","","1120.00","840.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1980.83","1980.83","1980.83","1 through 10","347.2","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","both","","","1120.00","840.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","347.2","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","both","","","1120.00","840.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","784.00","70","","5029.39","5029.39","5029.39","1 through 10","347.2","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","both","","","1120.00","840.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","890.40","79.5","","4065.65","378.84","7878.66","1 through 10","347.2","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","both","","","1120.00","840.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","596.96","53.3","","1515.36","1515.36","1515.36","1 through 10","347.2","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","both","","","1120.00","840.00","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","347.2","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","both","","","1120.00","840.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","428.96","38.3","","3119.30","2511.63","4729.54","1 through 10","347.2","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","both","","","1120.00","840.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1886.65","1886.65","1886.65","1 through 10","347.2","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","both","","","1120.00","840.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","480.48","42.9","","9586.80","1147.14","9586.80","1 through 10","347.2","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","both","","","1120.00","840.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.34","1887.39","1893.34","1 through 10","347.2","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","both","","","1120.00","840.00","WELLPOINT [1015]","HB AMC WELLPOINT","826.34","73.78","","1424.47","1424.47","1424.47","1 through 10","347.2","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","outpatient","","","1120.00","840.00","AETNA [1001]","HB AMC AETNA HMO","781.76","69.8","","5781.89","3423.76","7031.73","1 through 10","626.08","5545.35","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","outpatient","","","1120.00","840.00","AETNA [1001]","HB AMC AETNA PPO","900.48","80.4","","5419.21","5419.21","5419.21","1 through 10","626.08","5545.35","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","outpatient","","","1120.00","840.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2872.04","1436.02","4308.06","12","626.08","5545.35","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","outpatient","","","1120.00","840.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1510.30","1510.30","1510.30","1 through 10","626.08","5545.35","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","outpatient","","","1120.00","840.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","915.26","81.72","","5335.20","5335.20","5335.20","1 through 10","626.08","5545.35","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","outpatient","","","1120.00","840.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","915.26","81.72","","9835.02","8002.79","9835.02","1 through 10","626.08","5545.35","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm >4.0cm","PX-98300040","CDM","11406","CPT","0983","RC","","","","outpatient","","","1120.00","840.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1522.68","1522.68","1522.68","1 through 10","626.08","5545.35","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","both","","","529.00","396.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","1 through 10","163.99","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","both","","","529.00","396.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","420.56","79.5","","733.39","733.39","733.39","1 through 10","163.99","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","both","","","529.00","396.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","281.96","53.3","","2568.76","1093.14","2581.35","1 through 10","163.99","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","both","","","529.00","396.75","HUMANA [1012]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","823.86","823.86","823.86","1 through 10","163.99","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","both","","","529.00","396.75","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","767.90","835.56","34","163.99","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","both","","","529.00","396.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","163.99","31","","1287.60","1287.60","1287.60","1 through 10","163.99","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","both","","","529.00","396.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","193.09","36.5","","1320.93","502.82","1508.46","1 through 10","163.99","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","both","","","529.00","396.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","202.61","38.3","","1629.30","543.10","1683.27","47","163.99","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","both","","","529.00","396.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","818.85","818.85","818.85","1 through 10","163.99","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","both","","","529.00","396.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","818.85","1 through 10","163.99","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","both","","","529.00","396.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.94","42.9","","1483.11","1483.11","1483.11","1 through 10","163.99","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","both","","","529.00","396.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","752.55","826.75","1 through 10","163.99","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","both","","","529.00","396.75","WELLPOINT [1015]","HB AMC WELLPOINT","390.30","73.78","","2423.11","1034.11","3765.12","1 through 10","163.99","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","outpatient","","","529.00","396.75","AETNA [1001]","HB AMC AETNA HMO","369.24","69.8","","940.35","663.94","1083.42","1 through 10","295.71","1234.13","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","outpatient","","","529.00","396.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1483.11","1483.11","1483.11","1 through 10","295.71","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","outpatient","","","529.00","396.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","2583.86","4032.21","45","295.71","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","outpatient","","","529.00","396.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4084.35","1413.59","4240.77","19","295.71","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","outpatient","","","529.00","396.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1483.11","1252.77","1786.96","1 through 10","295.71","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm 1.1-2.0cm","PX-98300037","CDM","11402","CPT","0983","RC","","","","outpatient","","","529.00","396.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","432.30","81.72","","610.75","573.57","1110.37","1 through 10","295.71","1234.13","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","both","","","689.00","516.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","860.69","859.79","860.69","1 through 10","213.59","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","both","","","689.00","516.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","755.61","822.19","1 through 10","213.59","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","both","","","689.00","516.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","547.76","79.5","","2568.76","2568.76","5055.37","1 through 10","213.59","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","both","","","689.00","516.75","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","575.93","1671.12","19","213.59","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","both","","","689.00","516.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","251.49","36.5","","1554.30","1554.30","1554.30","1 through 10","213.59","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","both","","","689.00","516.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","263.89","38.3","","1629.30","543.10","1629.30","19","213.59","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","both","","","689.00","516.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.35","759.55","826.75","1 through 10","213.59","1044.34","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","both","","","689.00","516.75","WELLPOINT [1015]","HB AMC WELLPOINT","508.34","73.78","","2423.11","2423.11","3765.12","1 through 10","213.59","1044.34","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","outpatient","","","689.00","516.75","AETNA [1001]","HB AMC AETNA HMO","480.92","69.8","","959.14","663.94","959.14","1 through 10","385.15","2384.07","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","outpatient","","","689.00","516.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2016.12","1344.08","4032.21","1 through 10","385.15","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","outpatient","","","689.00","516.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1361.45","1361.45","1361.45","1 through 10","385.15","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","outpatient","","","689.00","516.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1413.59","1413.59","1413.59","1 through 10","385.15","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","outpatient","","","689.00","516.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1483.11","957.03","1483.11","1 through 10","385.15","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm 2.1-3.0cm","PX-98300038","CDM","11403","CPT","0983","RC","","","","outpatient","","","689.00","516.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","563.05","81.72","","1110.37","1110.37","1110.37","1 through 10","385.15","2384.07","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 3.1-4.0cm","PX-98300039","CDM","11404","CPT","0983","RC","","","","both","","","754.00","565.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1273.40","1273.40","1273.40","1 through 10","233.74","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm 3.1-4.0cm","PX-98300039","CDM","11404","CPT","0983","RC","","","","both","","","754.00","565.50","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3539.02","1924.13","3539.02","1 through 10","233.74","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm 3.1-4.0cm","PX-98300039","CDM","11404","CPT","0983","RC","","","","both","","","754.00","565.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","275.21","36.5","","4418.94","1865.92","4418.94","1 through 10","233.74","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 3.1-4.0cm","PX-98300039","CDM","11404","CPT","0983","RC","","","","both","","","754.00","565.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","288.78","38.3","","4632.18","1544.06","4632.18","1 through 10","233.74","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 3.1-4.0cm","PX-98300039","CDM","11404","CPT","0983","RC","","","","both","","","754.00","565.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.15","1889.50","1893.15","1 through 10","233.74","2404.92","other","OPPS APC"
"Pf Exc Lesn Bgn Trnk/Arm 3.1-4.0cm","PX-98300039","CDM","11404","CPT","0983","RC","","","","both","","","754.00","565.50","WELLPOINT [1015]","HB AMC WELLPOINT","556.30","73.78","","1424.48","1424.48","1424.48","1 through 10","233.74","2404.92","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 3.1-4.0cm","PX-98300039","CDM","11404","CPT","0983","RC","","","","outpatient","","","754.00","565.50","AETNA [1001]","HB AMC AETNA HMO","526.29","69.8","","4639.41","2673.47","4639.41","1 through 10","421.49","2384.07","percent of total billed charges",""
"Pf Exc Lesn Bgn Trnk/Arm 3.1-4.0cm","PX-98300039","CDM","11404","CPT","0983","RC","","","","outpatient","","","754.00","565.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2872.04","1436.02","2872.04","1 through 10","421.49","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Bgn Trnk/Arm 3.1-4.0cm","PX-98300039","CDM","11404","CPT","0983","RC","","","","outpatient","","","754.00","565.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","616.17","81.72","","13003.04","630.97","13003.04","1 through 10","421.49","2384.07","percent of total billed charges",""
"Pf Exc Lesn Mal Face/Ear <0.5cm","PX-98300065","CDM","11640","CPT","0983","RC","","","","both","","","575.00","431.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","457.13","79.5","","998.70","998.70","998.70","1 through 10","178.25","1044.34","percent of total billed charges",""
"Pf Exc Lesn Mal Face/Ear <0.5cm","PX-98300065","CDM","11640","CPT","0983","RC","","","","both","","","575.00","431.25","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","767.90","767.90","767.90","1 through 10","178.25","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Face/Ear >4.0cm","PX-98300070","CDM","11646","CPT","0983","RC","","","","both","","","1714.00","1285.50","MEDICARE [2001]","HB BWH MEDICARE","3398.51","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3101.27","3398.86","1 through 10","531.34","4248.14","other","OPPS APC"
"Pf Exc Lesn Mal Face/Ear 0.6-1.0cm","PX-98300066","CDM","11641","CPT","0983","RC","","","","both","","","703.00","527.25","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","217.93","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Face/Ear 1.1-2.0cm","PX-98300067","CDM","11642","CPT","0983","RC","","","","both","","","817.00","612.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","435.46","53.3","","256.61","256.61","256.61","1 through 10","253.27","1044.34","percent of total billed charges",""
"Pf Exc Lesn Mal Face/Ear 1.1-2.0cm","PX-98300067","CDM","11642","CPT","0983","RC","","","","both","","","817.00","612.75","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","417.78","835.56","1 through 10","253.27","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Face/Ear 2.1-3.0cm","PX-98300068","CDM","11643","CPT","0983","RC","","","","outpatient","","","1017.00","762.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1436.02","1436.02","1436.02","1 through 10","568.5","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Mal Face/Ear 3.1-4.0cm","PX-98300069","CDM","11644","CPT","0983","RC","","","","outpatient","","","1252.00","939.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1023.13","81.72","","10670.39","10670.39","10670.39","1 through 10","699.87","5545.35","percent of total billed charges",""
"Pf Exc Lesn Mal Face/Ear 3.1-4.0cm","PX-98300069","CDM","11644","CPT","0983","RC","","","","outpatient","","","1252.00","939.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1522.68","1522.68","1522.68","1 through 10","699.87","5545.35","other","Multiple Surgery"
"Pf Exc Lesn Mal Sclp/Hnd <0.5cm","PX-98300059","CDM","11620","CPT","0983","RC","","","","both","","","558.00","418.50","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","172.98","2404.92","other","OPPS APC"
"Pf Exc Lesn Mal Sclp/Hnd <0.5cm","PX-98300059","CDM","11620","CPT","0983","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","203.67","36.5","","6067.22","6067.22","6067.22","1 through 10","172.98","2404.92","percent of total billed charges",""
"Pf Exc Lesn Mal Sclp/Hnd <0.5cm","PX-98300059","CDM","11620","CPT","0983","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","213.71","38.3","","374.06","374.06","374.06","1 through 10","172.98","2404.92","percent of total billed charges",""
"Pf Exc Lesn Mal Sclp/Hnd <0.5cm","PX-98300059","CDM","11620","CPT","0983","RC","","","","outpatient","","","558.00","418.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1436.02","1436.02","1436.02","1 through 10","311.92","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Mal Sclp/Hnd >4.0cm","PX-98300064","CDM","11626","CPT","0983","RC","","","","outpatient","","","1286.00","964.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1050.92","81.72","","1529.52","1529.52","1529.52","1 through 10","718.87","5545.35","percent of total billed charges",""
"Pf Exc Lesn Mal Sclp/Hnd 0.6-1.0cm","PX-98300060","CDM","11621","CPT","0983","RC","","","","both","","","676.00","507.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","209.56","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Sclp/Hnd 0.6-1.0cm","PX-98300060","CDM","11621","CPT","0983","RC","","","","both","","","676.00","507.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","246.74","36.5","","1036.20","1036.20","1036.20","1 through 10","209.56","1044.34","percent of total billed charges",""
"Pf Exc Lesn Mal Sclp/Hnd 0.6-1.0cm","PX-98300060","CDM","11621","CPT","0983","RC","","","","outpatient","","","676.00","507.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","2688.14","4032.21","1 through 10","377.88","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Mal Sclp/Hnd 1.1-2.0cm","PX-98300061","CDM","11622","CPT","0983","RC","","","","both","","","762.00","571.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","1 through 10","236.22","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Sclp/Hnd 1.1-2.0cm","PX-98300061","CDM","11622","CPT","0983","RC","","","","both","","","762.00","571.50","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","236.22","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Sclp/Hnd 1.1-2.0cm","PX-98300061","CDM","11622","CPT","0983","RC","","","","both","","","762.00","571.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","278.13","36.5","","1320.93","518.10","1320.93","1 through 10","236.22","1044.34","percent of total billed charges",""
"Pf Exc Lesn Mal Sclp/Hnd 1.1-2.0cm","PX-98300061","CDM","11622","CPT","0983","RC","","","","both","","","762.00","571.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2257.19","2257.19","2257.19","1 through 10","236.22","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Sclp/Hnd 1.1-2.0cm","PX-98300061","CDM","11622","CPT","0983","RC","","","","outpatient","","","762.00","571.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2688.14","2688.14","2688.14","1 through 10","425.96","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Mal Sclp/Hnd 2.1-3.0cm","PX-98300062","CDM","11623","CPT","0983","RC","","","","both","","","937.00","702.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","290.47","2404.92","other","OPPS APC"
"Pf Exc Lesn Mal Sclp/Hnd 2.1-3.0cm","PX-98300062","CDM","11623","CPT","0983","RC","","","","both","","","937.00","702.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","358.87","38.3","","839.04","839.04","839.04","1 through 10","290.47","2404.92","percent of total billed charges",""
"Pf Exc Lesn Mal Sclp/Hnd 2.1-3.0cm","PX-98300062","CDM","11623","CPT","0983","RC","","","","both","","","937.00","702.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","290.47","2404.92","other","OPPS APC"
"Pf Exc Lesn Mal Sclp/Hnd 2.1-3.0cm","PX-98300062","CDM","11623","CPT","0983","RC","","","","both","","","937.00","702.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","290.47","2404.92","other","OPPS APC"
"Pf Exc Lesn Mal Sclp/Hnd 3.1-4.0cm","PX-98300063","CDM","11624","CPT","0983","RC","","","","both","","","1059.00","794.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","688.35","65","","5286.45","5286.45","5286.45","1 through 10","328.29","2404.92","percent of total billed charges",""
"Pf Exc Lesn Mal Sclp/Hnd 3.1-4.0cm","PX-98300063","CDM","11624","CPT","0983","RC","","","","both","","","1059.00","794.25","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5772.39","5772.39","5772.39","1 through 10","328.29","2404.92","other","OPPS APC"
"Pf Exc Lesn Mal Sclp/Hnd 3.1-4.0cm","PX-98300063","CDM","11624","CPT","0983","RC","","","","both","","","1059.00","794.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1887.15","1887.15","1887.15","1 through 10","328.29","2404.92","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm .6-1.0cm","PX-98300054","CDM","11601","CPT","0983","RC","","","","both","","","670.00","502.50","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","626.67","835.56","14","207.7","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm .6-1.0cm","PX-98300054","CDM","11601","CPT","0983","RC","","","","both","","","670.00","502.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","256.61","38.3","","280.54","280.54","280.54","1 through 10","207.7","1044.34","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm .6-1.0cm","PX-98300054","CDM","11601","CPT","0983","RC","","","","outpatient","","","670.00","502.50","AETNA [1001]","HB AMC AETNA HMO","467.66","69.8","","940.35","940.35","940.35","1 through 10","374.53","1234.13","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm <0.5cm","PX-98300053","CDM","11600","CPT","0983","RC","","","","both","","","554.00","415.50","MEDICARE [2001]","HB BWH MEDICARE","894.79","","APC Price ($894.79). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","171.74","1118.49","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm <0.5cm","PX-98300053","CDM","11600","CPT","0983","RC","","","","outpatient","","","554.00","415.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","452.73","81.72","","14338.84","14338.84","14338.84","1 through 10","309.69","2384.07","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm >4.0cm","PX-98300058","CDM","11606","CPT","0983","RC","","","","both","","","1395.00","1046.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1979.93","1979.93","1979.93","1 through 10","432.45","2404.92","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm >4.0cm","PX-98300058","CDM","11606","CPT","0983","RC","","","","both","","","1395.00","1046.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1109.03","79.5","","32008.08","32008.08","32008.08","1 through 10","432.45","2404.92","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm >4.0cm","PX-98300058","CDM","11606","CPT","0983","RC","","","","both","","","1395.00","1046.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","743.54","53.3","","2529.65","2529.65","2529.65","1 through 10","432.45","2404.92","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm >4.0cm","PX-98300058","CDM","11606","CPT","0983","RC","","","","both","","","1395.00","1046.25","ELDER SERVICES [1037]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1885.65","1885.65","1885.65","1 through 10","432.45","2404.92","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm >4.0cm","PX-98300058","CDM","11606","CPT","0983","RC","","","","both","","","1395.00","1046.25","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","17","432.45","2404.92","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm >4.0cm","PX-98300058","CDM","11606","CPT","0983","RC","","","","both","","","1395.00","1046.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","534.29","38.3","","19461.96","19461.96","19461.96","1 through 10","432.45","2404.92","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm >4.0cm","PX-98300058","CDM","11606","CPT","0983","RC","","","","both","","","1395.00","1046.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5673.15","5673.15","5673.15","1 through 10","432.45","2404.92","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm >4.0cm","PX-98300058","CDM","11606","CPT","0983","RC","","","","both","","","1395.00","1046.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1889.48","1889.48","1889.48","1 through 10","432.45","2404.92","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm >4.0cm","PX-98300058","CDM","11606","CPT","0983","RC","","","","outpatient","","","1395.00","1046.25","AETNA [1001]","HB AMC AETNA HMO","973.71","69.8","","5258.84","5258.84","5258.84","1 through 10","779.81","5545.35","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm >4.0cm","PX-98300058","CDM","11606","CPT","0983","RC","","","","outpatient","","","1395.00","1046.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1436.02","1436.02","1436.02","1 through 10","779.81","5545.35","other","Multiple Surgery"
"Pf Exc Lesn Mal Trnk/Arm >4.0cm","PX-98300058","CDM","11606","CPT","0983","RC","","","","outpatient","","","1395.00","1046.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1121.58","80.4","","1678.95","1678.95","1678.95","1 through 10","779.81","5545.35","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","both","","","729.00","546.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","489.22","489.03","495.23","1 through 10","225.99","593.02","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","both","","","729.00","546.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","428.24","1389.00","1 through 10","225.99","593.02","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","both","","","729.00","546.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","579.56","79.5","","55.92","55.92","55.92","1 through 10","225.99","593.02","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","both","","","729.00","546.75","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","355.85","948.93","80","225.99","593.02","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","both","","","729.00","546.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","266.09","36.5","","1554.30","1554.30","1554.30","1 through 10","225.99","593.02","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","both","","","729.00","546.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","279.21","38.3","","1629.30","1055.64","1635.90","42","225.99","593.02","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","both","","","729.00","546.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1394.94","426.50","1394.94","1 through 10","225.99","593.02","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","both","","","729.00","546.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","464.98","464.98","464.98","1 through 10","225.99","593.02","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","both","","","729.00","546.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.74","42.9","","610.74","610.74","610.74","1 through 10","225.99","593.02","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","both","","","729.00","546.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.49","232.50","472.89","1 through 10","225.99","593.02","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","outpatient","","","729.00","546.75","AETNA [1001]","HB AMC AETNA HMO","508.84","69.8","","971.50","883.60","1880.71","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","outpatient","","","729.00","546.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1093.02","728.67","1400.80","13","314.08","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","outpatient","","","729.00","546.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2299.08","2214.27","2299.08","12","314.08","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","outpatient","","","729.00","546.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","766.36","766.36","766.36","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","outpatient","","","729.00","546.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1608.08","772.64","1608.08","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","outpatient","","","729.00","546.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","586.12","80.4","","694.50","694.50","694.50","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm 1.1-2.0cm","PX-98300055","CDM","11602","CPT","0983","RC","","","","outpatient","","","729.00","546.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","595.74","81.72","","1110.37","610.74","1110.37","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","both","","","868.00","651.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","866.50","866.50","866.50","1 through 10","269.08","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","both","","","868.00","651.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","755.61","822.19","1 through 10","269.08","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","both","","","868.00","651.00","ELDER SERVICES [1037]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","752.54","752.54","752.54","1 through 10","269.08","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","both","","","868.00","651.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","626.67","835.56","54","269.08","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","both","","","868.00","651.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","332.44","38.3","","1629.30","543.10","1629.30","1 through 10","269.08","1044.34","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","both","","","868.00","651.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","752.54","409.42","752.54","1 through 10","269.08","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","both","","","868.00","651.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1505.08","818.85","1505.08","1 through 10","269.08","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","both","","","868.00","651.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.35","818.85","827.75","1 through 10","269.08","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","both","","","868.00","651.00","WELLPOINT [1015]","HB AMC WELLPOINT","640.41","73.78","","2423.11","2423.11","2423.11","1 through 10","269.08","1044.34","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","outpatient","","","868.00","651.00","AETNA [1001]","HB AMC AETNA HMO","605.86","69.8","","1457.24","940.35","1457.24","1 through 10","485.21","2384.07","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","outpatient","","","868.00","651.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","2688.14","4032.21","1 through 10","485.21","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","outpatient","","","868.00","651.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4240.77","4240.77","4240.77","1 through 10","485.21","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","outpatient","","","868.00","651.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","867.37","867.37","867.37","1 through 10","485.21","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","outpatient","","","868.00","651.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","709.33","81.72","","1110.37","610.74","1110.37","1 through 10","485.21","2384.07","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","outpatient","","","868.00","651.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1616.36","1616.36","1616.36","1 through 10","485.21","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Mal Trnk/Arm 2.1-3.0cm","PX-98300056","CDM","11603","CPT","0983","RC","","","","outpatient","","","868.00","651.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1425.18","1425.18","1425.18","1 through 10","485.21","2384.07","other","Multiple Surgery"
"Pf Exc Lesn Mal Trnk/Arm 3.1-4.0cm","PX-98300057","CDM","11604","CPT","0983","RC","","","","both","","","952.00","714.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","1 through 10","295.12","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 3.1-4.0cm","PX-98300057","CDM","11604","CPT","0983","RC","","","","both","","","952.00","714.00","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","767.90","835.56","1 through 10","295.12","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 3.1-4.0cm","PX-98300057","CDM","11604","CPT","0983","RC","","","","both","","","952.00","714.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.75","826.75","826.75","1 through 10","295.12","1044.34","other","OPPS APC"
"Pf Exc Lesn Mal Trnk/Arm 3.1-4.0cm","PX-98300057","CDM","11604","CPT","0983","RC","","","","outpatient","","","952.00","714.00","AETNA [1001]","HB AMC AETNA HMO","664.50","69.8","","1927.01","1927.01","1927.01","1 through 10","532.17","5545.35","percent of total billed charges",""
"Pf Exc Lesn Mal Trnk/Arm 3.1-4.0cm","PX-98300057","CDM","11604","CPT","0983","RC","","","","outpatient","","","952.00","714.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4032.21","672.04","4032.21","1 through 10","532.17","5545.35","other","Multiple Surgery"
"Pf Exc Lesn Mal Trnk/Arm 3.1-4.0cm","PX-98300057","CDM","11604","CPT","0983","RC","","","","outpatient","","","952.00","714.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","741.56","741.56","741.56","1 through 10","532.17","5545.35","other","Multiple Surgery"
"Pf Exc Lesn Mal Trnk/Arm 3.1-4.0cm","PX-98300057","CDM","11604","CPT","0983","RC","","","","outpatient","","","952.00","714.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","777.97","81.72","","2422.18","1720.71","2422.18","1 through 10","532.17","5545.35","percent of total billed charges",""
"Pf Exc Nail & Matrix","PX-98300077","CDM","11750","CPT","0983","RC","","","","both","","","674.00","505.50","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","329.73","329.73","474.47","1 through 10","208.94","593.02","other","OPPS APC"
"Pf Exc Tum Face/Scalp Subfasc 2+","PX-98300160","CDM","21014","CPT","0983","RC","","","","both","","","2364.00","1773.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","905.41","38.3","","3366.51","3366.51","3366.51","1 through 10","555.03","3228.91","percent of total billed charges",""
"Pf Exc Tum Soft Tiss Face/Scalp Sub","PX-98300158","CDM","21012","CPT","0983","RC","","","","both","","","1546.00","1159.50","MEDICARE [2001]","HB BWH MEDICARE","2060.54","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","479.26","2575.67","other","OPPS APC"
"Pf Exc Tum Soft Tiss Face/Scalp Sub","PX-98300158","CDM","21012","CPT","0983","RC","","","","outpatient","","","1546.00","1159.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3160.08","3160.08","3160.08","1 through 10","864.21","2384.07","other","ASC"
"Pf Exc Tum Soft Tiss Face/Scalp Sub","PX-98300158","CDM","21012","CPT","0983","RC","","","","outpatient","","","1546.00","1159.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3646.12","3646.12","3682.30","1 through 10","864.21","2384.07","other","ASC "
"Pf Exc Tum Soft Tiss Face/Scalp Sub","PX-98300158","CDM","21012","CPT","0983","RC","","","","outpatient","","","1546.00","1159.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2872.04","2872.04","2872.04","1 through 10","864.21","2384.07","other","Multiple Surgery"
"Pf Exc Tum Soft Tiss Face/Scalp Sub","PX-98300158","CDM","21012","CPT","0983","RC","","","","outpatient","","","1546.00","1159.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","9061.80","9061.80","9061.80","1 through 10","864.21","2384.07","other","Multiple Surgery"
"Pf Exc Tum Soft Tiss Face/Scalp Sub","PX-98300159","CDM","21013","CPT","0983","RC","","","","both","","","1824.00","1368.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","972.19","53.3","","7171.14","7171.14","7171.14","1 through 10","428.31","1827.93","percent of total billed charges",""
"Pf Exc Tum Tiss N/Ant Thx Subq 3+","PX-98300166","CDM","21552","CPT","0983","RC","","","","both","","","2010.00","1507.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3749.00","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3504.42","2821.50","3504.42","1 through 10","623.1","4549.76","other","OPPS APC"
"Pf Exc Tum Tiss N/Ant Thx Subq 3+","PX-98300166","CDM","21552","CPT","0983","RC","","","","both","","","2010.00","1507.50","MEDICARE [2001]","HB BWH MEDICARE","3639.81","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","10196.58","1 through 10","623.1","4549.76","other","OPPS APC"
"Pf Exc Tum Tiss N/Ant Thx Subq 3+","PX-98300166","CDM","21552","CPT","0983","RC","","","","both","","","2010.00","1507.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","733.65","36.5","","909.79","909.79","909.79","1 through 10","623.1","4549.76","percent of total billed charges",""
"Pf Exc Tum Tiss N/Ant Thx Subq 3+","PX-98300166","CDM","21552","CPT","0983","RC","","","","both","","","2010.00","1507.50","WELLPOINT [1015]","HB AMC WELLPOINT","1482.98","73.78","","2136.72","2136.72","2136.72","1 through 10","623.1","4549.76","percent of total billed charges",""
"Pf Exc Tum Tiss N/Ant Thx Subq 3+","PX-98300166","CDM","21552","CPT","0983","RC","","","","outpatient","","","2010.00","1507.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6304.29","3183.42","6366.84","1 through 10","1123.59","9843.6","other","ASC "
"Pf Exc Tum Tiss N/Ant Thx Subq 3+","PX-98300166","CDM","21552","CPT","0983","RC","","","","outpatient","","","2010.00","1507.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1642.57","81.72","","5204.30","5204.30","5204.30","1 through 10","1123.59","9843.6","percent of total billed charges",""
"Pf Exc Tumor Pelvis/Hip Subq 3+","PX-98300219","CDM","27043","CPT","0983","RC","","","","both","","","2106.00","1579.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1674.27","79.5","","22150.98","22150.98","22150.98","1 through 10","652.86","4549.76","percent of total billed charges",""
"Pf Exc Tumor Pelvis/Hip Subq 3+","PX-98300219","CDM","27043","CPT","0983","RC","","","","outpatient","","","2106.00","1579.50","AETNA [1001]","HB AMC AETNA HMO","1469.99","69.8","","7011.78","7011.78","7011.78","1 through 10","1177.25","9843.6","percent of total billed charges",""
"Pf Exc Tumor Tiss Face/Scalp Subq <","PX-98300157","CDM","21011","CPT","0983","RC","","","","both","","","1212.00","909.00","MEDICARE [2001]","HB BWH MEDICARE","2060.54","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","375.72","2575.67","other","OPPS APC"
"Pf Exc Tumor Tiss Face/Scalp Subq <","PX-98300157","CDM","21011","CPT","0983","RC","","","","both","","","1212.00","909.00","WELLPOINT [1015]","HB AMC WELLPOINT","894.21","73.78","","1668.89","1668.89","1668.89","1 through 10","375.72","2575.67","percent of total billed charges",""
"Pf Exc Tumr Back/Flank <3cm","PX-98300170","CDM","21930","CPT","0983","RC","","","","both","","","1657.00","1242.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1412.04","1412.04","1412.04","1 through 10","513.67","2404.92","other","OPPS APC"
"Pf Exc Tumr Back/Flank <3cm","PX-98300170","CDM","21930","CPT","0983","RC","","","","outpatient","","","1657.00","1242.75","AETNA [1001]","HB AMC AETNA HMO","1156.59","69.8","","3986.52","3986.52","3986.52","1 through 10","926.26","5545.35","percent of total billed charges",""
"Pf Exc Tumr Back/Flank <3cm","PX-98300170","CDM","21930","CPT","0983","RC","","","","outpatient","","","1657.00","1242.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8616.12","8616.12","8616.12","1 through 10","926.26","5545.35","other","Multiple Surgery"
"Pf Exc Tumr Back/Flank <3cm","PX-98300170","CDM","21930","CPT","0983","RC","","","","outpatient","","","1657.00","1242.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3020.60","3020.60","3020.60","1 through 10","926.26","5545.35","other","Multiple Surgery"
"Pf Exc Tumr Back/Flank Subq 3cm +","PX-98300171","CDM","21931","CPT","0983","RC","","","","both","","","2111.00","1583.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2060.54","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","654.41","2575.67","other","OPPS APC"
"Pf Exc Tumr Back/Flank Subq 3cm +","PX-98300171","CDM","21931","CPT","0983","RC","","","","both","","","2111.00","1583.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1678.25","79.5","","1515.36","1515.36","1515.36","1 through 10","654.41","2575.67","percent of total billed charges",""
"Pf Exc Tumr Back/Flank Subq 3cm +","PX-98300171","CDM","21931","CPT","0983","RC","","","","both","","","2111.00","1583.25","MEDICARE [2001]","HB BWH MEDICARE","2060.54","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5772.39","1924.13","5772.39","1 through 10","654.41","2575.67","other","OPPS APC"
"Pf Exc Tumr Back/Flank Subq 3cm +","PX-98300171","CDM","21931","CPT","0983","RC","","","","both","","","2111.00","1583.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","808.51","38.3","","18640.14","561.09","18640.14","1 through 10","654.41","2575.67","percent of total billed charges",""
"Pf Exc Tumr Back/Flank Subq 3cm +","PX-98300171","CDM","21931","CPT","0983","RC","","","","outpatient","","","2111.00","1583.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3682.30","3682.30","3682.30","1 through 10","1180.05","9843.6","other","ASC "
"Pf Exc Tumr Back/Flank Subq 3cm +","PX-98300171","CDM","21931","CPT","0983","RC","","","","outpatient","","","2111.00","1583.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2762.51","2762.51","2762.51","1 through 10","1180.05","9843.6","other","Multiple Surgery"
"Pf Exc Tumr Back/Flank Subq 3cm +","PX-98300171","CDM","21931","CPT","0983","RC","","","","outpatient","","","2111.00","1583.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1725.11","81.72","","1147.14","1147.14","1147.14","1 through 10","1180.05","9843.6","percent of total billed charges",""
"Pf Exc Tumr Neck/Chest Sq <3cm","PX-98300167","CDM","21555","CPT","0983","RC","","","","both","","","1406.00","1054.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","435.86","2404.92","other","OPPS APC"
"Pf Exc Tumr Neck/Chest Sq <3cm","PX-98300167","CDM","21555","CPT","0983","RC","","","","both","","","1406.00","1054.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1117.77","79.5","","25870.26","25870.26","25870.26","1 through 10","435.86","2404.92","percent of total billed charges",""
"Pf Exc Tumr Neck/Chest Sq <3cm","PX-98300167","CDM","21555","CPT","0983","RC","","","","both","","","1406.00","1054.50","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","435.86","2404.92","other","OPPS APC"
"Pf Exc Tumr Neck/Chest Sq <3cm","PX-98300167","CDM","21555","CPT","0983","RC","","","","outpatient","","","1406.00","1054.50","AETNA [1001]","HB AMC AETNA HMO","981.39","69.8","","7775.15","7775.15","7775.15","1 through 10","785.95","5545.35","percent of total billed charges",""
"Pf Exc Tumr Neck/Chest Sq <3cm","PX-98300167","CDM","21555","CPT","0983","RC","","","","outpatient","","","1406.00","1054.50","AETNA [1001]","HB AMC AETNA PPO","1130.42","80.4","","7595.90","7595.90","7595.90","1 through 10","785.95","5545.35","percent of total billed charges",""
"Pf Exc Tumr Neck/Chest Sq <3cm","PX-98300167","CDM","21555","CPT","0983","RC","","","","outpatient","","","1406.00","1054.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2872.04","2872.04","2872.04","1 through 10","785.95","5545.35","other","Multiple Surgery"
"Pf Exc Tumr Shoulder Subq 3cm Grter","PX-98300177","CDM","23071","CPT","0983","RC","","","","both","","","1902.00","1426.50","WELLPOINT [1015]","HB AMC WELLPOINT","1403.30","73.78","","17644.75","17644.75","17644.75","1 through 10","589.62","2575.67","percent of total billed charges",""
"Pf Exc Vaginal Cyst/Tumr","PX-98300383","CDM","57135","CPT","0983","RC","","","","both","","","844.00","633.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","670.98","79.5","","15920.22","15920.22","15920.22","1 through 10","261.64","4719.38","percent of total billed charges",""
"Pf Exc Vaginal Cyst/Tumr","PX-98300383","CDM","57135","CPT","0983","RC","","","","both","","","844.00","633.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","323.25","38.3","","1852.56","1852.56","1852.56","1 through 10","261.64","4719.38","percent of total billed charges",""
"Pf Face-to-Face Behavioral Cnsl Obe","PX-98300598","CDM","G0447","HCPCS","0983","RC","","","","both","","","131.00","98.25","MEDICARE [2001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","1 through 10","40.61","137.3","other","OPPS APC"
"Pf Face-to-Face Behavioral Cnsl Obe","PX-98300598","CDM","G0447","HCPCS","0983","RC","","","","both","","","131.00","98.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.65","95.34","107.65","1 through 10","40.61","137.3","other","OPPS APC"
"Pf Face-to-Face Behavioral Cnsl Obe","PX-98300598","CDM","G0447","HCPCS","0983","RC","","","","both","","","131.00","98.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.65","30.82","107.65","1 through 10","40.61","137.3","other","OPPS APC"
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","both","","","215.00","161.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","246.04","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","245.83","223.78","246.63","1 through 10","66.65","298.6","other","OPPS APC"
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","both","","","215.00","161.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.08","214.00","235.08","1 through 10","66.65","298.6","other","OPPS APC"
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","both","","","215.00","161.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.08","235.08","235.08","1 through 10","66.65","298.6","other","OPPS APC"
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","both","","","215.00","161.25","MEDICARE [2001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","238.90","238.90","238.90","39","66.65","298.6","other","OPPS APC"
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","both","","","215.00","161.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","47.50","47.50","47.50","1 through 10","66.65","298.6","other","OPPS APC"
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","both","","","215.00","161.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.48","36.5","","159.27","159.27","159.27","1 through 10","66.65","298.6","percent of total billed charges",""
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","both","","","215.00","161.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82.35","38.3","","166.96","166.96","166.96","1 through 10","66.65","298.6","percent of total billed charges",""
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","both","","","215.00","161.25","MOLINA [1014]","HB BWH MOLINA","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","475.47","473.98","475.47","1 through 10","66.65","298.6","other","OPPS APC"
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","both","","","215.00","161.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","706.66","213.13","706.66","1 through 10","66.65","298.6","other","OPPS APC"
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","both","","","215.00","161.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","234.12","234.12","238.90","16","66.65","298.6","other","OPPS APC"
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","both","","","215.00","161.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.24","42.9","","187.75","187.75","187.75","1 through 10","66.65","298.6","percent of total billed charges",""
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","both","","","215.00","161.25","WELLPOINT [1015]","HB AMC WELLPOINT","158.63","73.78","","317.90","317.90","317.90","1 through 10","66.65","298.6","percent of total billed charges",""
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","outpatient","","","215.00","161.25","AETNA [1001]","HB AMC AETNA HMO","150.07","69.8","","289.08","289.08","289.08","1 through 10","120.19","700.33","percent of total billed charges",""
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","outpatient","","","215.00","161.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1924.80","384.96","1924.80","1 through 10","120.19","700.33","other","Multiple Surgery"
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","outpatient","","","215.00","161.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","404.87","404.87","1 through 10","120.19","700.33","other","Multiple Surgery"
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","outpatient","","","215.00","161.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","212.39","212.39","212.39","1 through 10","120.19","700.33","other","Multiple Surgery"
"Pf Fitting/Insert Pessary","PX-98300385","CDM","57160","CPT","0983","RC","","","","outpatient","","","215.00","161.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","175.70","81.72","","341.34","341.34","341.34","1 through 10","120.19","700.33","percent of total billed charges",""
"Pf Flap Delay/Section Forehd/Hnd/Ft","PX-98300109","CDM","15620","CPT","0983","RC","","","","outpatient","","","1508.00","1131.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","787.48","52.22","","4146.66","4146.66","4146.66","1 through 10","603.2","1232.34","percent of total billed charges",""
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","both","","","873.00","654.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","694.04","79.5","","4781.03","3207.60","4781.03","1 through 10","270.63","4719.38","percent of total billed charges",""
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","both","","","873.00","654.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","465.31","53.3","","3207.60","2978.49","5956.98","1 through 10","270.63","4719.38","percent of total billed charges",""
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","both","","","873.00","654.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","694.04","79.5","","4781.03","4781.03","4781.03","1 through 10","270.63","4719.38","percent of total billed charges",""
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","both","","","873.00","654.75","MEDICARE [2001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3412.18","3775.88","1 through 10","270.63","4719.38","other","OPPS APC"
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","both","","","873.00","654.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","318.65","36.5","","2265.98","1925.78","2265.98","11","270.63","4719.38","percent of total billed charges",""
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","both","","","873.00","654.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","334.36","38.3","","2375.33","2375.33","2375.33","62","270.63","4719.38","percent of total billed charges",""
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","both","","","873.00","654.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","3587.09","","APC Price ($3,775.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3775.88","3775.88","3775.88","1 through 10","270.63","4719.38","other","Tricare OPPS"
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","both","","","873.00","654.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3775.88","3357.59","3775.88","1 through 10","270.63","4719.38","other","OPPS APC"
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","outpatient","","","873.00","654.75","AETNA [1001]","HB AMC AETNA HMO","609.35","69.8","","4112.78","2903.85","4738.50","24","469.65","2384.07","percent of total billed charges",""
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","outpatient","","","873.00","654.75","AETNA [1001]","HB AMC AETNA PPO","701.89","80.4","","4738.50","2903.85","4738.50","1 through 10","469.65","2384.07","percent of total billed charges",""
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","outpatient","","","873.00","654.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6162.91","6162.91","6162.91","1 through 10","469.65","2384.07","other","Multiple Surgery"
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","outpatient","","","873.00","654.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4930.32","4930.32","4930.32","31","469.65","2384.07","other","Multiple Surgery"
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","outpatient","","","873.00","654.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5185.34","5185.34","15556.02","22","469.65","2384.07","other","Multiple Surgery"
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","outpatient","","","873.00","654.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5185.34","5185.34","5185.34","1 through 10","469.65","2384.07","other","Multiple Surgery"
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","outpatient","","","873.00","654.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","5440.36","5165.71","5440.36","1 through 10","469.65","2384.07","other","Multiple Surgery"
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","outpatient","","","873.00","654.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","701.89","80.4","","3037.50","3037.50","3037.50","1 through 10","469.65","2384.07","percent of total billed charges",""
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","outpatient","","","873.00","654.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5227.84","5227.84","5227.84","1 through 10","469.65","2384.07","other","Multiple Surgery"
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","outpatient","","","873.00","654.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","713.42","81.72","","4856.36","2671.18","4937.48","18","469.65","2384.07","percent of total billed charges",""
"Pf Hysteroscopy Diagnostic (S","PX-98300406","CDM","58555","CPT","0983","RC","","","","outpatient","","","873.00","654.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","5929.14","5929.14","5929.14","1 through 10","469.65","2384.07","other","Multiple Surgery"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3888.77","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3517.83","3512.03","3517.83","1 through 10","467.48","4719.38","other","OPPS APC"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","26735.22","26735.22","26735.22","1 through 10","467.48","4719.38","other","OPPS APC"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1198.86","79.5","","8446.00","4459.49","38460.68","18","467.48","4719.38","percent of total billed charges",""
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","803.76","53.3","","8588.45","3227.49","19747.40","17","467.48","4719.38","percent of total billed charges",""
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3715.47","3715.47","3715.47","1 through 10","467.48","4719.38","other","OPPS APC"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3715.47","3715.47","3715.47","1 through 10","467.48","4719.38","other","OPPS APC"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","HUMANA [1012]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3723.02","3723.02","3723.02","1 through 10","467.48","4719.38","other","OPPS APC"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","MEDICARE [2001]","HB BWH MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3412.18","3775.88","25","467.48","4719.38","other","OPPS APC"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","467.48","31","","11404.89","11404.89","11404.89","1 through 10","467.48","4719.38","percent of total billed charges",""
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","550.42","36.5","","7322.90","3057.45","15751.80","18","467.48","4719.38","percent of total billed charges",""
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","577.56","38.3","","6604.78","3302.39","19080.03","82","467.48","4719.38","percent of total billed charges",""
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","TRICARE [160005]","HB BWH TRICARE","3587.09","","APC Price ($3,775.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","7551.76","3587.09","7551.76","1 through 10","467.48","4719.38","other","Tricare OPPS"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","646.93","42.9","","1865.96","1865.96","1865.96","1 through 10","467.48","4719.38","percent of total billed charges",""
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","both","","","1508.00","1131.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3708.67","3351.84","3775.88","1 through 10","467.48","4719.38","other","OPPS APC"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","outpatient","","","1508.00","1131.00","AETNA [1001]","HB AMC AETNA HMO","1052.58","69.8","","6505.20","4037.19","11012.08","18","714.52","5545.35","percent of total billed charges",""
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","outpatient","","","1508.00","1131.00","AETNA [1001]","HB AMC AETNA PPO","1212.43","80.4","","4798.17","4798.16","6587.88","1 through 10","714.52","5545.35","percent of total billed charges",""
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","outpatient","","","1508.00","1131.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6162.91","5440.36","6162.91","1 through 10","714.52","5545.35","other","Multiple Surgery"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","outpatient","","","1508.00","1131.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4930.32","4930.32","14790.96","46","714.52","5545.35","other","Multiple Surgery"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","outpatient","","","1508.00","1131.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5185.34","5185.34","14982.24","32","714.52","5545.35","other","Multiple Surgery"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","outpatient","","","1508.00","1131.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 383%, 191.5 procedures at 0%.","8139.29","8139.29","8139.29","1 through 10","714.52","5545.35","other","Multiple Surgery"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","outpatient","","","1508.00","1131.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","6396.67","6396.67","6396.67","1 through 10","714.52","5545.35","other","Multiple Surgery"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","outpatient","","","1508.00","1131.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4080.27","4080.27","4080.27","1 through 10","714.52","5545.35","other","Multiple Surgery"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","outpatient","","","1508.00","1131.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","10455.68","5440.36","10880.72","1 through 10","714.52","5545.35","other","Multiple Surgery"
"Pf Hysteroscopy W/Biopsy Sample","PX-98300407","CDM","58558","CPT","0983","RC","","","","outpatient","","","1508.00","1131.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1232.34","81.72","","6751.73","3333.50","13003.04","15","714.52","5545.35","percent of total billed charges",""
"Pf I&D Abscess Cplx","PX-98300005","CDM","10061","CPT","0983","RC","","","","both","","","962.00","721.50","FALLON HEALTH [1008]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","464.98","464.98","464.98","1 through 10","298.22","764.79","other","OPPS APC"
"Pf I&D Abscess Cplx","PX-98300005","CDM","10061","CPT","0983","RC","","","","both","","","962.00","721.50","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","298.22","764.79","other","OPPS APC"
"Pf I&D Abscess Cplx","PX-98300005","CDM","10061","CPT","0983","RC","","","","both","","","962.00","721.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","351.13","36.5","","412.54","412.54","412.54","1 through 10","298.22","764.79","percent of total billed charges",""
"Pf I&D Abscess Cplx","PX-98300005","CDM","10061","CPT","0983","RC","","","","both","","","962.00","721.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","368.45","38.3","","432.45","420.28","432.45","1 through 10","298.22","764.79","percent of total billed charges",""
"Pf I&D Abscess Cplx","PX-98300005","CDM","10061","CPT","0983","RC","","","","both","","","962.00","721.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1394.94","1394.94","1394.94","1 through 10","298.22","764.79","other","OPPS APC"
"Pf I&D Abscess Cplx","PX-98300005","CDM","10061","CPT","0983","RC","","","","both","","","962.00","721.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.49","433.50","472.89","1 through 10","298.22","764.79","other","OPPS APC"
"Pf I&D Abscess Cplx","PX-98300005","CDM","10061","CPT","0983","RC","","","","outpatient","","","962.00","721.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","786.15","81.72","","884.14","884.14","884.14","1 through 10","314.08","786.15","percent of total billed charges",""
"Pf I&D Abscess Gland Bartholin's","PX-98300371","CDM","56420","CPT","0983","RC","","","","both","","","497.00","372.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","190.35","38.3","","469.68","187.72","469.68","1 through 10","154.07","395.12","percent of total billed charges",""
"Pf I&D Abscess Gland Bartholin's","PX-98300371","CDM","56420","CPT","0983","RC","","","","outpatient","","","497.00","372.75","AETNA [1001]","HB AMC AETNA HMO","346.91","69.8","","482.04","482.04","482.04","1 through 10","165.93","2384.07","percent of total billed charges",""
"Pf I&D Abscess Gland Bartholin's","PX-98300371","CDM","56420","CPT","0983","RC","","","","outpatient","","","497.00","372.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","384.96","384.96","384.96","1 through 10","165.93","2384.07","other","Multiple Surgery"
"Pf I&D Abscess Gland Bartholin's","PX-98300371","CDM","56420","CPT","0983","RC","","","","outpatient","","","497.00","372.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","268.08","268.08","268.08","1 through 10","165.93","2384.07","other","Multiple Surgery"
"Pf I&D Abscess Gland Bartholin's","PX-98300371","CDM","56420","CPT","0983","RC","","","","outpatient","","","497.00","372.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","406.15","81.72","","494.03","494.03","494.03","1 through 10","165.93","2384.07","percent of total billed charges",""
"Pf I&D Abscess Peritonsillar","PX-98300329","CDM","42700","CPT","0983","RC","","","","both","","","660.00","495.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","524.70","79.5","","726.40","726.40","726.40","1 through 10","146.67","524.7","percent of total billed charges",""
"Pf I&D Abscess Peritonsillar","PX-98300329","CDM","42700","CPT","0983","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","240.90","36.5","","344.28","344.28","344.28","1 through 10","146.67","524.7","percent of total billed charges",""
"Pf I&D Abscess Peritonsillar","PX-98300329","CDM","42700","CPT","0983","RC","","","","outpatient","","","660.00","495.00","AETNA [1001]","HB AMC AETNA PPO","530.64","80.4","","284.59","284.59","284.59","1 through 10","206.14","2384.07","percent of total billed charges",""
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","242.81","242.81","242.81","1 through 10","163.37","418.97","other","OPPS APC"
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","116.09","232.19","1 through 10","163.37","418.97","other","OPPS APC"
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","418.97","79.5","","511.55","511.55","1300.00","1 through 10","163.37","418.97","percent of total billed charges",""
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","280.89","53.3","","511.55","343.20","511.55","1 through 10","163.37","418.97","percent of total billed charges",""
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","163.37","418.97","other","OPPS APC"
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","218.50","437.00","31","163.37","418.97","other","OPPS APC"
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","192.36","36.5","","242.45","206.05","242.45","1 through 10","163.37","418.97","percent of total billed charges",""
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.84","38.3","","254.15","247.00","762.45","20","163.37","418.97","percent of total billed charges",""
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","214.13","231.25","1 through 10","163.37","418.97","other","OPPS APC"
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","TRICARE [160005]","HB BWH TRICARE","224.17","","APC Price ($235.97). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","235.97","235.97","235.97","1 through 10","163.37","418.97","other","Tricare OPPS"
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","214.13","214.13","214.13","1 through 10","163.37","418.97","other","OPPS APC"
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.08","42.9","","519.61","519.61","519.61","1 through 10","163.37","418.97","percent of total billed charges",""
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.25","117.99","235.97","1 through 10","163.37","418.97","other","OPPS APC"
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","both","","","527.00","395.25","WELLPOINT [1015]","HB AMC WELLPOINT","388.82","73.78","","483.93","483.93","483.93","1 through 10","163.37","418.97","percent of total billed charges",""
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","outpatient","","","527.00","395.25","AETNA [1001]","HB AMC AETNA HMO","367.85","69.8","","440.05","310.70","507.00","1 through 10","176.45","700.33","percent of total billed charges",""
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","outpatient","","","527.00","395.25","AETNA [1001]","HB AMC AETNA PPO","423.71","80.4","","507.00","507.00","507.00","1 through 10","176.45","700.33","percent of total billed charges",""
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","outpatient","","","527.00","395.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","outpatient","","","527.00","395.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","outpatient","","","527.00","395.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","451.71","451.71","451.71","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","outpatient","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","430.66","81.72","","285.81","285.81","285.81","1 through 10","176.45","700.33","percent of total billed charges",""
"Pf I&D Abscess Simple","PX-98300004","CDM","10060","CPT","0983","RC","","","","outpatient","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","430.66","81.72","","519.61","519.61","7152.16","1 through 10","176.45","700.33","percent of total billed charges",""
"Pf I&D Abscess Vulva/Perineal","PX-98300370","CDM","56405","CPT","0983","RC","","","","both","","","728.00","546.00","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","180.62","180.62","180.62","1 through 10","225.68","578.76","other","OPPS APC"
"Pf I&D Abscess Vulva/Perineal","PX-98300370","CDM","56405","CPT","0983","RC","","","","both","","","728.00","546.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","278.82","38.3","","6360.01","294.03","6360.01","1 through 10","225.68","578.76","percent of total billed charges",""
"Pf I&D Abscess Vulva/Perineal","PX-98300370","CDM","56405","CPT","0983","RC","","","","outpatient","","","728.00","546.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","633.36","633.36","633.36","1 through 10","273","2384.07","other","Multiple Surgery"
"Pf I&D Cyst Pilonidal Smp","PX-98300006","CDM","10080","CPT","0983","RC","","","","outpatient","","","482.00","361.50","AETNA [1001]","HB AMC AETNA HMO","336.44","69.8","","438.02","438.02","438.02","1 through 10","206.78","2384.07","percent of total billed charges",""
"Pf I&D Hematoma/Seroma/Fluid","PX-98300008","CDM","10140","CPT","0983","RC","","","","both","","","635.00","476.25","AETNA [1001]","HB AMC AETNA HMO","443.23","69.8","","19831.44","19831.44","19831.44","1 through 10","196.85","2404.92","percent of total billed charges",""
"Pf I&D Hematoma/Seroma/Fluid","PX-98300008","CDM","10140","CPT","0983","RC","","","","both","","","635.00","476.25","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","196.85","2404.92","other","OPPS APC"
"Pf I&D Hematoma/Seroma/Fluid","PX-98300008","CDM","10140","CPT","0983","RC","","","","both","","","635.00","476.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","196.85","2404.92","other","OPPS APC"
"Pf I&D Wound Post OP Cplx","PX-98300010","CDM","10180","CPT","0983","RC","","","","both","","","810.00","607.50","MEDICARE [2001]","HB BWH MEDICARE","3398.51","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","3398.86","1 through 10","251.1","4248.14","other","OPPS APC"
"Pf I&D Wound Post OP Cplx","PX-98300010","CDM","10180","CPT","0983","RC","","","","outpatient","","","810.00","607.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6304.29","6304.29","6304.29","1 through 10","452.79","5545.35","other","ASC "
"Pf Implnt Perc Neurostim Elec","PX-98300429","CDM","63650","CPT","0983","RC","","","","both","","","2504.00","1878.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","8026.84","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","10845.19","8026.86","10845.19","1 through 10","776.24","9741.31","other","OPPS APC"
"Pf Implnt Perc Neurostim Elec","PX-98300429","CDM","63650","CPT","0983","RC","","","","both","","","2504.00","1878.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3834.57","3834.57","3834.57","1 through 10","776.24","9741.31","other","OPPS APC"
"Pf Implnt Perc Neurostim Elec","PX-98300429","CDM","63650","CPT","0983","RC","","","","both","","","2504.00","1878.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1334.63","53.3","","18168.65","18168.65","18168.65","1 through 10","776.24","9741.31","percent of total billed charges",""
"Pf Implnt Perc Neurostim Elec","PX-98300429","CDM","63650","CPT","0983","RC","","","","both","","","2504.00","1878.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7669.14","7669.14","7669.14","1 through 10","776.24","9741.31","other","OPPS APC"
"Pf Implnt Perc Neurostim Elec","PX-98300429","CDM","63650","CPT","0983","RC","","","","both","","","2504.00","1878.00","MEDICARE [2001]","HB BWH MEDICARE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3896.92","3896.92","3896.92","16","776.24","9741.31","other","OPPS APC"
"Pf Implnt Perc Neurostim Elec","PX-98300429","CDM","63650","CPT","0983","RC","","","","both","","","2504.00","1878.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7637.19","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7645.76","7645.76","7645.76","1 through 10","776.24","9741.31","other","OPPS APC"
"Pf Implnt Perc Neurostim Elec","PX-98300429","CDM","63650","CPT","0983","RC","","","","both","","","2504.00","1878.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7637.19","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3834.57","3834.57","7645.47","1 through 10","776.24","9741.31","other","OPPS APC"
"Pf Implnt Perc Neurostim Elec","PX-98300429","CDM","63650","CPT","0983","RC","","","","both","","","2504.00","1878.00","WELLPOINT [1015]","HB AMC WELLPOINT","1847.45","73.78","","26862.30","19523.56","26862.30","1 through 10","776.24","9741.31","percent of total billed charges",""
"Pf Implnt Perc Neurostim Elec","PX-98300429","CDM","63650","CPT","0983","RC","","","","outpatient","","","2504.00","1878.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5381.58","","Case rate ($5,381.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6242.64","6000.46","6242.64","1 through 10","1399.74","5545.35","other","Multiple Surgery"
"Pf Incision/Remove FB Subq Smp","PX-98300007","CDM","10120","CPT","0983","RC","","","","both","","","557.00","417.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","488.23","488.23","488.23","1 through 10","172.67","593.02","other","OPPS APC"
"Pf Incision/Remove FB Subq Smp","PX-98300007","CDM","10120","CPT","0983","RC","","","","both","","","557.00","417.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","393.14","466.88","1 through 10","172.67","593.02","other","OPPS APC"
"Pf Incision/Remove FB Subq Smp","PX-98300007","CDM","10120","CPT","0983","RC","","","","both","","","557.00","417.75","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","172.67","593.02","other","OPPS APC"
"Pf Incision/Remove FB Subq Smp","PX-98300007","CDM","10120","CPT","0983","RC","","","","both","","","557.00","417.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","213.33","38.3","","370.67","200.58","370.67","1 through 10","172.67","593.02","percent of total billed charges",""
"Pf Incision/Remove FB Subq Smp","PX-98300007","CDM","10120","CPT","0983","RC","","","","both","","","557.00","417.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","470.98","470.98","470.98","1 through 10","172.67","593.02","other","OPPS APC"
"Pf Inj Anes Ganglion Stellate","PX-98300460","CDM","64510","CPT","0983","RC","","","","outpatient","","","406.00","304.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1866.21","1866.21","1866.21","1 through 10","226.95","2384.07","other","Multiple Surgery"
"Pf Inj Anes Suprascapular Nerve","PX-98300438","CDM","64418","CPT","0983","RC","","","","both","","","359.00","269.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.87","813.87","813.87","1 through 10","111.29","1027.91","other","OPPS APC"
"Pf Inj Lumbar Epidural Blood Patch","PX-98300417","CDM","62273","CPT","0983","RC","","","","both","","","588.00","441.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","606.94","606.94","606.94","1 through 10","182.28","1027.91","other","OPPS APC"
"Pf Inj Lumbar Epidural Blood Patch","PX-98300417","CDM","62273","CPT","0983","RC","","","","both","","","588.00","441.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","313.40","53.3","","1779.41","1779.41","1779.41","1 through 10","182.28","1027.91","percent of total billed charges",""
"Pf Inj Lumbar Epidural Blood Patch","PX-98300417","CDM","62273","CPT","0983","RC","","","","both","","","588.00","441.00","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","616.81","566.08","822.41","13","182.28","1027.91","other","OPPS APC"
"Pf Inj Lumbar Epidural Blood Patch","PX-98300417","CDM","62273","CPT","0983","RC","","","","both","","","588.00","441.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","225.20","38.3","","884.05","884.05","884.05","1 through 10","182.28","1027.91","percent of total billed charges",""
"Pf Inj Lumbar Epidural Blood Patch","PX-98300417","CDM","62273","CPT","0983","RC","","","","both","","","588.00","441.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","822.41","813.97","822.41","1 through 10","182.28","1027.91","other","OPPS APC"
"Pf Inj Lumbar Epidural Blood Patch","PX-98300417","CDM","62273","CPT","0983","RC","","","","both","","","588.00","441.00","WELLPOINT [1015]","HB AMC WELLPOINT","433.83","73.78","","1614.64","1614.64","1614.64","1 through 10","182.28","1027.91","percent of total billed charges",""
"Pf Inj Lumbar Epidural Blood Patch","PX-98300417","CDM","62273","CPT","0983","RC","","","","outpatient","","","588.00","441.00","AETNA [1001]","HB AMC AETNA HMO","410.42","69.8","","1530.70","1437.73","1763.58","1 through 10","328.69","2384.07","percent of total billed charges",""
"Pf Inj Lumbar Epidural Blood Patch","PX-98300417","CDM","62273","CPT","0983","RC","","","","outpatient","","","588.00","441.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1389.24","1335.35","1389.24","1 through 10","328.69","2384.07","other","Multiple Surgery"
"Pf Inj Lumbar Epidural Blood Patch","PX-98300417","CDM","62273","CPT","0983","RC","","","","outpatient","","","588.00","441.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1461.10","1461.10","1461.10","1 through 10","328.69","2384.07","other","Multiple Surgery"
"Pf Inj Lumbar Epidural Blood Patch","PX-98300417","CDM","62273","CPT","0983","RC","","","","outpatient","","","588.00","441.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","480.51","81.72","","994.16","994.16","994.16","1 through 10","328.69","2384.07","percent of total billed charges",""
"Pf Inj Lumbar Epidural Blood Patch","PX-98300417","CDM","62273","CPT","0983","RC","","","","outpatient","","","588.00","441.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","480.51","81.72","","1807.44","1807.44","1807.44","1 through 10","328.69","2384.07","percent of total billed charges",""
"Pf Inj Paravert F Jnt C/T 1 Lev","PX-98300453","CDM","64490","CPT","0983","RC","","","","both","","","531.00","398.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","422.15","79.5","","3629.64","3629.64","3629.64","1 through 10","164.61","1627.62","percent of total billed charges",""
"Pf Inj Paravert F Jnt C/T 1 Lev","PX-98300453","CDM","64490","CPT","0983","RC","","","","both","","","531.00","398.25","FALLON HEALTH [1008]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1036.12","1036.12","1036.12","1 through 10","164.61","1627.62","other","OPPS APC"
"Pf Inj Paravert F Jnt C/T 1 Lev","PX-98300453","CDM","64490","CPT","0983","RC","","","","both","","","531.00","398.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.37","38.3","","3180.00","3180.00","3180.00","1 through 10","164.61","1627.62","percent of total billed charges",""
"Pf Inj Paravert F Jnt C/T 1 Lev","PX-98300453","CDM","64490","CPT","0983","RC","","","","both","","","531.00","398.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1040.35","978.90","1554.20","1 through 10","164.61","1627.62","other","OPPS APC"
"Pf Inj Paravert F Jnt C/T 1 Lev","PX-98300453","CDM","64490","CPT","0983","RC","","","","outpatient","","","531.00","398.25","AETNA [1001]","HB AMC AETNA HMO","370.64","69.8","","1102.27","1102.27","1102.27","1 through 10","296.83","4218.09","percent of total billed charges",""
"Pf Inj Paravert F Jnt C/T 1 Lev|BILATERAL PROCEDURE","PX-98300453","CDM","64490","CPT","0983","RC","","","50","both","","","531.00","398.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1560.54","1560.54","1560.54","1 through 10","1004.41","1321.46","other","OPPS APC"
"Pf Inj Paravert F Jnt C/T 1 Lev|BILATERAL PROCEDURE","PX-98300453","CDM","64490","CPT","0983","RC","","","50","both","","","531.00","398.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1588.37","1588.37","1588.37","1 through 10","1004.41","1321.46","other","OPPS APC"
"Pf Inj Paravert F Jnt C/T 1 Lev|BILATERAL PROCEDURE","PX-98300453","CDM","64490","CPT","0983","RC","","","50","both","","","531.00","398.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1559.59","1559.59","1559.59","1 through 10","1004.41","1321.46","other","OPPS APC"
"Pf Inj Paravert F Jnt C/T 2 Lev","PX-98300454","CDM","64491","CPT","0983","RC","","","","both","","","312.00","234.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","248.04","79.5","","706.73","706.73","706.73","1 through 10","96.72","1627.62","percent of total billed charges",""
"Pf Inj Paravert F Jnt C/T 2 Lev","PX-98300454","CDM","64491","CPT","0983","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.50","38.3","","3180.00","3180.00","3180.00","1 through 10","96.72","1627.62","percent of total billed charges",""
"Pf Inj Paravert F Jnt C/T 2 Lev","PX-98300454","CDM","64491","CPT","0983","RC","","","","outpatient","","","312.00","234.00","AETNA [1001]","HB AMC AETNA HMO","217.78","69.8","","214.62","214.62","214.62","1 through 10","174.41","259.23","percent of total billed charges",""
"Pf Inj Paravert F Jnt L/S 2 Lev","PX-98300457","CDM","64494","CPT","0983","RC","","","","both","","","269.00","201.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","143.38","53.3","","201.70","201.70","201.70","1 through 10","83.39","1627.62","percent of total billed charges",""
"Pf Inj Paravert F Jnt L/S 2 Lev","PX-98300457","CDM","64494","CPT","0983","RC","","","","outpatient","","","269.00","201.75","AETNA [1001]","HB AMC AETNA HMO","187.76","69.8","","182.60","182.60","182.60","1 through 10","115.4","222.43","percent of total billed charges",""
"Pf Inject Anes Celiac Plexus","PX-98300463","CDM","64530","CPT","0983","RC","","","","both","","","493.00","369.75","MEDICARE [2001]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1057.27","1057.27","1057.27","1 through 10","152.83","1627.62","other","OPPS APC"
"Pf Inject Anes Celiac Plexus","PX-98300463","CDM","64530","CPT","0983","RC","","","","both","","","493.00","369.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","188.82","38.3","","9459.07","9459.07","9459.07","1 through 10","152.83","1627.62","percent of total billed charges",""
"Pf Inject Anes Celiac Plexus","PX-98300463","CDM","64530","CPT","0983","RC","","","","both","","","493.00","369.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1044.03","1044.03","1044.03","1 through 10","152.83","1627.62","other","OPPS APC"
"Pf Inject Anes Celiac Plexus","PX-98300463","CDM","64530","CPT","0983","RC","","","","outpatient","","","493.00","369.75","AETNA [1001]","HB AMC AETNA PPO","396.37","80.4","","1798.68","1798.68","1798.68","1 through 10","211.5","2384.07","percent of total billed charges",""
"Pf Inject Anes Intercostal Single","PX-98300439","CDM","64420","CPT","0983","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","128.70","42.9","","1938.91","1938.91","1938.91","1 through 10","93","1027.91","percent of total billed charges",""
"Pf Inject Anes Lumbar/ Thoracic|BILATERAL PROCEDURE","PX-98300462","CDM","64520","CPT","0983","RC","","","50","both","","","443.00","332.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1462.56","1462.56","1462.56","1 through 10","1004.41","1321.46","other","OPPS APC"
"Pf Inject Anes Othperipheral","PX-98300447","CDM","64450","CPT","0983","RC","","","","both","","","275.00","206.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","192.50","70","","1209.84","1209.84","1209.84","1 through 10","85.25","1027.91","percent of total billed charges",""
"Pf Inject Anes Othperipheral","PX-98300447","CDM","64450","CPT","0983","RC","","","","both","","","275.00","206.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","809.25","809.25","1 through 10","85.25","1027.91","other","OPPS APC"
"Pf Inject Anes Othperipheral","PX-98300447","CDM","64450","CPT","0983","RC","","","","both","","","275.00","206.25","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","754.77","822.41","1 through 10","85.25","1027.91","other","OPPS APC"
"Pf Inject Anes Othperipheral","PX-98300447","CDM","64450","CPT","0983","RC","","","","both","","","275.00","206.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.38","36.5","","453.94","153.87","453.94","1 through 10","85.25","1027.91","percent of total billed charges",""
"Pf Inject Anes Othperipheral","PX-98300447","CDM","64450","CPT","0983","RC","","","","both","","","275.00","206.25","TRICARE [160005]","HB BWH TRICARE","781.29","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","822.41","822.41","822.41","1 through 10","85.25","1027.91","other","Tricare OPPS"
"Pf Inject Anes Othperipheral","PX-98300447","CDM","64450","CPT","0983","RC","","","","both","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.87","805.97","813.87","1 through 10","85.25","1027.91","other","OPPS APC"
"Pf Inject Anes Othperipheral","PX-98300447","CDM","64450","CPT","0983","RC","","","","outpatient","","","275.00","206.25","AETNA [1001]","HB AMC AETNA HMO","191.95","69.8","","949.26","823.91","949.26","1 through 10","153.73","1234.13","percent of total billed charges",""
"Pf Inject Anes Othperipheral","PX-98300447","CDM","64450","CPT","0983","RC","","","","outpatient","","","275.00","206.25","AETNA [1001]","HB AMC AETNA PPO","221.10","80.4","","949.26","949.26","949.26","1 through 10","153.73","1234.13","percent of total billed charges",""
"Pf Inject Anes Othperipheral|BILATERAL PROCEDURE","PX-98300447","CDM","64450","CPT","0983","RC","","","50","both","","","275.00","206.25","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1233.61","1233.61","1233.61","1 through 10","781.29","1027.91","other","OPPS APC"
"Pf Inject Anes Othperipheral|BILATERAL PROCEDURE","PX-98300447","CDM","64450","CPT","0983","RC","","","50","both","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1233.61","1233.61","1233.61","1 through 10","781.29","1027.91","other","OPPS APC"
"Pf Inject Arthrogram Sacroiliac Jt","PX-98300571","CDM","27096","CPT","0983","RC","","","","both","","","403.00","302.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","214.80","53.3","","362.02","362.02","362.02","1 through 10","86.15","1004.41","percent of total billed charges",""
"Pf Inject Arthrogram Sacroiliac Jt","PX-98300571","CDM","27096","CPT","0983","RC","","","","outpatient","","","403.00","302.25","AETNA [1001]","HB AMC AETNA HMO","281.29","69.8","","219.88","219.88","219.88","1 through 10","225.28","598.81","percent of total billed charges",""
"Pf Inject Arthrogram Sacroiliac Jt","PX-98300571","CDM","27096","CPT","0983","RC","","","","outpatient","","","403.00","302.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1407.20","1407.20","1407.20","1 through 10","225.28","598.81","other","Multiple Surgery"
"Pf Inject Carpal Tunnel Therapeutic","PX-98300147","CDM","20526","CPT","0983","RC","","","","both","","","250.00","187.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","323.26","323.26","323.26","1 through 10","77.5","438.15","other","OPPS APC"
"Pf Inject Carpal Tunnel Therapeutic","PX-98300147","CDM","20526","CPT","0983","RC","","","","both","","","250.00","187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","95.75","38.3","","267.05","259.54","267.05","1 through 10","77.5","438.15","percent of total billed charges",""
"Pf Inject Carpal Tunnel Therapeutic","PX-98300147","CDM","20526","CPT","0983","RC","","","","outpatient","","","250.00","187.50","AETNA [1001]","HB AMC AETNA HMO","174.50","69.8","","326.47","326.47","326.47","1 through 10","139.75","700.33","percent of total billed charges",""
"Pf Inject Ganglion Cyst","PX-98300154","CDM","20612","CPT","0983","RC","","","","both","","","182.00","136.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","144.69","79.5","","547.75","547.75","547.75","1 through 10","56.42","438.15","percent of total billed charges",""
"Pf Inject Ganglion Cyst","PX-98300154","CDM","20612","CPT","0983","RC","","","","both","","","182.00","136.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","66.43","36.5","","259.61","259.61","259.61","1 through 10","56.42","438.15","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","287.00","287.00","287.00","1 through 10","39.99","294.93","other","OPPS APC"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","39.99","294.93","other","OPPS APC"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","102.56","79.5","","225.87","151.54","225.87","41","39.99","294.93","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","68.76","53.3","","151.54","151.54","225.87","16","39.99","294.93","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.48","30.48","187.70","1 through 10","39.99","294.93","other","OPPS APC"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","99.33","77","","220.99","220.99","220.99","1 through 10","39.99","294.93","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.55","30.55","30.55","1 through 10","39.99","294.93","other","OPPS APC"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","13","39.99","294.93","other","OPPS APC"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.98","30.98","32.17","17","39.99","294.93","other","OPPS APC"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","39.99","31","","197.74","88.68","197.74","1 through 10","39.99","294.93","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","47.09","36.5","","107.05","90.98","107.05","38","39.99","294.93","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","49.41","38.3","","112.22","112.22","112.22","152","39.99","294.93","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","30.36","231.25","1 through 10","39.99","294.93","other","OPPS APC"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","30.36","30.36","231.25","1 through 10","39.99","294.93","other","OPPS APC"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.26","30.37","235.97","1 through 10","39.99","294.93","other","OPPS APC"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.34","42.9","","126.19","126.19","126.19","1 through 10","39.99","294.93","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","both","","","129.00","96.75","WELLPOINT [1015]","HB AMC WELLPOINT","95.18","73.78","","213.67","213.67","500.67","50","39.99","294.93","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","outpatient","","","129.00","96.75","AETNA [1001]","HB AMC AETNA HMO","90.04","69.8","","194.30","137.19","223.86","45","72.11","350.18","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","outpatient","","","129.00","96.75","AETNA [1001]","HB AMC AETNA PPO","103.72","80.4","","223.86","146.20","223.86","1 through 10","72.11","350.18","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","outpatient","","","129.00","96.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","451.71","288.89","456.76","1 through 10","72.11","350.18","other","Multiple Surgery"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","outpatient","","","129.00","96.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","393.48","409.36","102","72.11","350.18","other","Multiple Surgery"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","outpatient","","","129.00","96.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","275.73","430.54","39","72.11","350.18","other","Multiple Surgery"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","outpatient","","","129.00","96.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","492.30","288.42","511.71","1 through 10","72.11","350.18","other","Multiple Surgery"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","outpatient","","","129.00","96.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","317.09","44.33","430.54","1 through 10","72.11","350.18","other","Multiple Surgery"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","outpatient","","","129.00","96.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","288.88","129.88","451.71","19","72.11","350.18","other","Multiple Surgery"
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","outpatient","","","129.00","96.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","105.42","81.72","","230.36","229.43","321.42","1 through 10","72.11","350.18","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","outpatient","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","105.42","81.72","","126.19","126.19","126.19","1 through 10","72.11","350.18","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","outpatient","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","105.42","81.72","","229.43","115.59","332.55","38","72.11","350.18","percent of total billed charges",""
"Pf Inject Intralesional <7 Lesions","PX-98300081","CDM","11900","CPT","0983","RC","","","","outpatient","","","129.00","96.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","434.07","290.79","434.07","1 through 10","72.11","350.18","other","Multiple Surgery"
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","both","","","199.00","149.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","158.21","79.5","","212.26","212.26","316.37","1 through 10","61.69","294.93","percent of total billed charges",""
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","both","","","199.00","149.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.07","53.3","","212.26","212.26","316.37","1 through 10","61.69","294.93","percent of total billed charges",""
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","both","","","199.00","149.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","61.69","294.93","other","OPPS APC"
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","both","","","199.00","149.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","61.69","294.93","other","OPPS APC"
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","both","","","199.00","149.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.64","36.5","","149.95","145.52","412.04","26","61.69","294.93","percent of total billed charges",""
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","both","","","199.00","149.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.22","38.3","","157.18","157.18","157.18","46","61.69","294.93","percent of total billed charges",""
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","both","","","199.00","149.25","WELLPOINT [1015]","HB AMC WELLPOINT","146.82","73.78","","299.29","299.29","701.29","17","61.69","294.93","percent of total billed charges",""
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","outpatient","","","199.00","149.25","AETNA [1001]","HB AMC AETNA HMO","138.90","69.8","","272.15","192.16","313.56","22","111.24","350.18","percent of total billed charges",""
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","outpatient","","","199.00","149.25","AETNA [1001]","HB AMC AETNA PPO","160.00","80.4","","210.65","210.65","210.65","1 through 10","111.24","350.18","percent of total billed charges",""
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","outpatient","","","199.00","149.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","111.24","55.9","","210.65","210.65","210.65","1 through 10","111.24","350.18","percent of total billed charges",""
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","outpatient","","","199.00","149.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","451.71","402.00","451.71","1 through 10","111.24","350.18","other","Multiple Surgery"
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","outpatient","","","199.00","149.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","818.72","29","111.24","350.18","other","Multiple Surgery"
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","outpatient","","","199.00","149.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","1291.62","20","111.24","350.18","other","Multiple Surgery"
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","outpatient","","","199.00","149.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","318.02","318.02","318.02","1 through 10","111.24","350.18","other","Multiple Surgery"
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","outpatient","","","199.00","149.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","162.62","81.72","","321.36","321.36","321.36","1 through 10","111.24","350.18","percent of total billed charges",""
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","outpatient","","","199.00","149.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","162.62","81.72","","321.36","321.36","321.36","1 through 10","111.24","350.18","percent of total billed charges",""
"Pf Inject Intralesional >7 Lesions","PX-98300082","CDM","11901","CPT","0983","RC","","","","outpatient","","","199.00","149.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","162.62","81.72","","176.76","176.76","321.36","1 through 10","111.24","350.18","percent of total billed charges",""
"Pf Inject Single Tend Origin/Insert","PX-98300149","CDM","20551","CPT","0983","RC","","","","both","","","176.00","132.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","39.98","39.98","39.98","1 through 10","54.56","438.15","other","OPPS APC"
"Pf Inject Single Tend Origin/Insert","PX-98300149","CDM","20551","CPT","0983","RC","","","","both","","","176.00","132.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.41","38.3","","272.14","96.18","272.14","1 through 10","54.56","438.15","percent of total billed charges",""
"Pf Inject Single Tend Origin/Insert","PX-98300149","CDM","20551","CPT","0983","RC","","","","both","","","176.00","132.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","261.62","39.59","261.62","1 through 10","54.56","438.15","other","OPPS APC"
"Pf Inject Single Tend Origin/Insert","PX-98300149","CDM","20551","CPT","0983","RC","","","","outpatient","","","176.00","132.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","574.15","47.10","574.15","1 through 10","98.38","700.33","other","Multiple Surgery"
"Pf Inject Single Tendon/Ligament","PX-98300148","CDM","20550","CPT","0983","RC","","","","both","","","183.00","137.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","360.73","360.73","1 through 10","56.73","438.15","other","OPPS APC"
"Pf Inject Single Tendon/Ligament","PX-98300148","CDM","20550","CPT","0983","RC","","","","both","","","183.00","137.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","145.49","79.5","","547.75","367.49","547.75","1 through 10","56.73","438.15","percent of total billed charges",""
"Pf Inject Single Tendon/Ligament","PX-98300148","CDM","20550","CPT","0983","RC","","","","both","","","183.00","137.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","97.54","53.3","","547.75","351.48","547.75","1 through 10","56.73","438.15","percent of total billed charges",""
"Pf Inject Single Tendon/Ligament","PX-98300148","CDM","20550","CPT","0983","RC","","","","both","","","183.00","137.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","32","56.73","438.15","other","OPPS APC"
"Pf Inject Single Tendon/Ligament","PX-98300148","CDM","20550","CPT","0983","RC","","","","both","","","183.00","137.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","66.80","36.5","","259.61","259.61","259.61","1 through 10","56.73","438.15","percent of total billed charges",""
"Pf Inject Single Tendon/Ligament","PX-98300148","CDM","20550","CPT","0983","RC","","","","both","","","183.00","137.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.09","38.3","","272.14","264.48","272.14","1 through 10","56.73","438.15","percent of total billed charges",""
"Pf Inject Single Tendon/Ligament","PX-98300148","CDM","20550","CPT","0983","RC","","","","both","","","183.00","137.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","316.79","343.55","1 through 10","56.73","438.15","other","OPPS APC"
"Pf Inject Single Tendon/Ligament","PX-98300148","CDM","20550","CPT","0983","RC","","","","both","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.95","316.79","350.56","16","56.73","438.15","other","OPPS APC"
"Pf Inject Single Tendon/Ligament","PX-98300148","CDM","20550","CPT","0983","RC","","","","both","","","183.00","137.25","WELLPOINT [1015]","HB AMC WELLPOINT","135.02","73.78","","518.17","518.17","518.17","1 through 10","56.73","438.15","percent of total billed charges",""
"Pf Inject Single Tendon/Ligament","PX-98300148","CDM","20550","CPT","0983","RC","","","","outpatient","","","183.00","137.25","AETNA [1001]","HB AMC AETNA HMO","127.73","69.8","","471.19","332.69","471.19","1 through 10","102.3","700.33","percent of total billed charges",""
"Pf Inject Single Tendon/Ligament","PX-98300148","CDM","20550","CPT","0983","RC","","","","outpatient","","","183.00","137.25","AETNA [1001]","HB AMC AETNA PPO","147.13","80.4","","942.38","942.38","942.38","1 through 10","102.3","700.33","percent of total billed charges",""
"Pf Inject Single Tendon/Ligament","PX-98300148","CDM","20550","CPT","0983","RC","","","","outpatient","","","183.00","137.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","608.80","608.80","608.80","1 through 10","102.3","700.33","other","Multiple Surgery"
"Pf Inject Single Tendon/Ligament","PX-98300148","CDM","20550","CPT","0983","RC","","","","outpatient","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","149.55","81.72","","306.03","306.03","306.03","1 through 10","102.3","700.33","percent of total billed charges",""
"Pf Inject Single Tendon/Ligament|BILATERAL PROCEDURE","PX-98300148","CDM","20550","CPT","0983","RC","","","50","both","","","183.00","137.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","525.83","525.83","1 through 10","333.03","438.15","other","OPPS APC"
"Pf Inject Single Tendon/Ligament|BILATERAL PROCEDURE","PX-98300148","CDM","20550","CPT","0983","RC","","","50","both","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","475.19","475.19","475.19","1 through 10","333.03","438.15","other","OPPS APC"
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","both","","","172.00","129.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","361.53","360.73","361.63","1 through 10","53.32","438.15","other","OPPS APC"
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","both","","","172.00","129.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","696.00","1 through 10","53.32","438.15","other","OPPS APC"
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","both","","","172.00","129.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","136.74","79.5","","547.75","547.75","8425.62","1 through 10","53.32","438.15","percent of total billed charges",""
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","both","","","172.00","129.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","53.32","438.15","other","OPPS APC"
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","both","","","172.00","129.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","696.00","48","53.32","438.15","other","OPPS APC"
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","both","","","172.00","129.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.21","38.21","38.21","1 through 10","53.32","438.15","other","OPPS APC"
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","both","","","172.00","129.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","62.78","36.5","","259.61","259.61","259.61","1 through 10","53.32","438.15","percent of total billed charges",""
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","both","","","172.00","129.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","65.88","38.3","","272.14","64.52","5179.97","1 through 10","53.32","438.15","percent of total billed charges",""
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","both","","","172.00","129.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","343.55","343.55","1 through 10","53.32","438.15","other","OPPS APC"
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","both","","","172.00","129.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","37.45","344.95","1 through 10","53.32","438.15","other","OPPS APC"
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","both","","","172.00","129.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","348.43","343.55","350.56","1 through 10","53.32","438.15","other","OPPS APC"
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","both","","","172.00","129.00","WELLPOINT [1015]","HB AMC WELLPOINT","126.90","73.78","","518.17","518.17","518.17","1 through 10","53.32","438.15","percent of total billed charges",""
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","outpatient","","","172.00","129.00","AETNA [1001]","HB AMC AETNA HMO","120.06","69.8","","671.58","332.69","942.38","1 through 10","96.15","700.33","percent of total billed charges",""
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","outpatient","","","172.00","129.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","574.15","574.15","861.24","1 through 10","96.15","700.33","other","Multiple Surgery"
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","outpatient","","","172.00","129.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","603.85","90.75","603.85","1 through 10","96.15","700.33","other","Multiple Surgery"
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","outpatient","","","172.00","129.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","603.85","603.85","603.85","1 through 10","96.15","700.33","other","Multiple Surgery"
"Pf Inject Trigger Point 1-2 Muscle","PX-98300150","CDM","20552","CPT","0983","RC","","","","outpatient","","","172.00","129.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","140.56","81.72","","556.38","556.38","13838.41","1 through 10","96.15","700.33","percent of total billed charges",""
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","361.53","333.43","361.63","21","59.83","438.15","other","OPPS APC"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","21.39","344.95","37","59.83","438.15","other","OPPS APC"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","153.44","79.5","","547.75","168.19","547.75","31","59.83","438.15","percent of total billed charges",""
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","102.87","53.3","","367.49","168.19","547.75","47","59.83","438.15","percent of total billed charges",""
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","42.77","344.95","14","59.83","438.15","other","OPPS APC"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","HUMANA [1012]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","345.65","42.86","345.65","1 through 10","59.83","438.15","other","OPPS APC"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","696.00","178","59.83","438.15","other","OPPS APC"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.47","43.47","43.47","24","59.83","438.15","other","OPPS APC"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","59.83","31","","215.06","215.06","215.06","1 through 10","59.83","438.15","percent of total billed charges",""
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70.45","36.5","","259.61","67.14","259.61","24","59.83","438.15","percent of total billed charges",""
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.92","38.3","","272.14","70.38","272.14","101","59.83","438.15","percent of total billed charges",""
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","316.79","343.55","1 through 10","59.83","438.15","other","OPPS APC"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","148.61","77","","535.92","535.92","535.92","1 through 10","59.83","438.15","percent of total billed charges",""
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","307.09","273.56","333.03","1 through 10","59.83","438.15","other","Tricare OPPS"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","343.55","343.55","1 through 10","59.83","438.15","other","OPPS APC"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","323.26","350.56","60","59.83","438.15","other","OPPS APC"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","both","","","193.00","144.75","WELLPOINT [1015]","HB AMC WELLPOINT","142.40","73.78","","518.17","518.17","652.18","29","59.83","438.15","percent of total billed charges",""
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","outpatient","","","193.00","144.75","AETNA [1001]","HB AMC AETNA HMO","134.71","69.8","","471.19","332.69","11464.83","16","82.8","700.33","percent of total billed charges",""
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","outpatient","","","193.00","144.75","AETNA [1001]","HB AMC AETNA PPO","155.17","80.4","","683.28","542.88","4370.16","1 through 10","82.8","700.33","percent of total billed charges",""
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","outpatient","","","193.00","144.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","717.69","633.55","721.93","1 through 10","82.8","700.33","other","Multiple Surgery"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","outpatient","","","193.00","144.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","574.15","287.08","574.15","30","82.8","700.33","other","Multiple Surgery"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","outpatient","","","193.00","144.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","603.85","180.00","1811.55","18","82.8","700.33","other","Multiple Surgery"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","outpatient","","","193.00","144.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","581.58","581.58","581.58","1 through 10","82.8","700.33","other","Multiple Surgery"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","outpatient","","","193.00","144.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","633.55","608.80","633.55","20","82.8","700.33","other","Multiple Surgery"
"Pf Inject Trigger Pt 3+ Muscle","PX-98300151","CDM","20553","CPT","0983","RC","","","","outpatient","","","193.00","144.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","157.72","81.72","","556.38","306.03","700.27","41","82.8","700.33","percent of total billed charges",""
"Pf Inject Tx Nerve Celiac Plexus","PX-98300475","CDM","64680","CPT","0983","RC","","","","both","","","939.00","704.25","WELLPOINT [1015]","HB AMC WELLPOINT","692.79","73.78","","12110.04","12110.04","12110.04","1 through 10","291.09","1321.46","percent of total billed charges",""
"Pf Inject Tx Nerve Celiac Plexus","PX-98300475","CDM","64680","CPT","0983","RC","","","","outpatient","","","939.00","704.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1774.43","1774.43","1774.43","1 through 10","524.9","5545.35","other","Multiple Surgery"
"Pf Insert Impl Drug Deliv Non-Biode","PX-98300085","CDM","11981","CPT","0983","RC","","","","both","","","377.00","282.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","299.72","79.5","","833.19","277.73","1275.01","12","116.87","299.72","percent of total billed charges",""
"Pf Insert Impl Drug Deliv Non-Biode","PX-98300085","CDM","11981","CPT","0983","RC","","","","both","","","377.00","282.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","200.94","53.3","","413.96","413.96","413.96","1 through 10","116.87","299.72","percent of total billed charges",""
"Pf Insert Impl Drug Deliv Non-Biode","PX-98300085","CDM","11981","CPT","0983","RC","","","","both","","","377.00","282.75","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","139.42","153.08","1 through 10","116.87","299.72","other","OPPS APC"
"Pf Insert Impl Drug Deliv Non-Biode","PX-98300085","CDM","11981","CPT","0983","RC","","","","both","","","377.00","282.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","137.61","36.5","","333.48","190.41","588.60","1 through 10","116.87","299.72","percent of total billed charges",""
"Pf Insert Impl Drug Deliv Non-Biode","PX-98300085","CDM","11981","CPT","0983","RC","","","","both","","","377.00","282.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","144.39","38.3","","411.34","205.67","617.01","21","116.87","299.72","percent of total billed charges",""
"Pf Insert Impl Drug Deliv Non-Biode","PX-98300085","CDM","11981","CPT","0983","RC","","","","both","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","161.73","42.9","","239.33","239.33","239.33","1 through 10","116.87","299.72","percent of total billed charges",""
"Pf Insert Impl Drug Deliv Non-Biode","PX-98300085","CDM","11981","CPT","0983","RC","","","","both","","","377.00","282.75","WELLPOINT [1015]","HB AMC WELLPOINT","278.15","73.78","","391.61","391.61","391.61","1 through 10","116.87","299.72","percent of total billed charges",""
"Pf Insert Impl Drug Deliv Non-Biode","PX-98300085","CDM","11981","CPT","0983","RC","","","","outpatient","","","377.00","282.75","AETNA [1001]","HB AMC AETNA PPO","303.11","80.4","","410.28","410.28","410.28","1 through 10","178.48","700.33","percent of total billed charges",""
"Pf Insert Impl Drug Deliv Non-Biode","PX-98300085","CDM","11981","CPT","0983","RC","","","","outpatient","","","377.00","282.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","308.08","81.72","","546.57","420.48","546.57","1 through 10","178.48","700.33","percent of total billed charges",""
"Pf Insert Impl Drug Deliv Non-Biode","PX-98300085","CDM","11981","CPT","0983","RC","","","","outpatient","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","308.08","81.72","","420.48","231.28","420.48","1 through 10","178.48","700.33","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","both","","","247.00","185.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","196.37","79.5","","277.03","185.86","831.07","33","76.57","234.65","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","both","","","247.00","185.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","131.65","53.3","","831.07","411.88","7386.00","1 through 10","76.57","234.65","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","both","","","247.00","185.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","190.19","77","","502.04","502.04","502.04","1 through 10","76.57","234.65","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","both","","","247.00","185.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","76.57","31","","217.54","217.54","217.54","1 through 10","76.57","234.65","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","both","","","247.00","185.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","90.16","36.5","","254.85","131.30","393.90","56","76.57","234.65","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","both","","","247.00","185.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","94.60","38.3","","401.28","137.63","412.89","223","76.57","234.65","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","both","","","247.00","185.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.96","42.9","","1865.96","154.77","1897.35","1 through 10","76.57","234.65","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","both","","","247.00","185.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.96","42.9","","154.77","154.77","154.77","1 through 10","76.57","234.65","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","both","","","247.00","185.25","WELLPOINT [1015]","HB AMC WELLPOINT","182.24","73.78","","614.06","262.06","7274.57","1 through 10","76.57","234.65","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","outpatient","","","247.00","185.25","AETNA [1001]","HB AMC AETNA HMO","172.41","69.8","","238.30","168.26","821.37","43","138.07","700.33","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","outpatient","","","247.00","185.25","AETNA [1001]","HB AMC AETNA PPO","198.59","80.4","","274.56","274.56","4798.16","1 through 10","138.07","700.33","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","outpatient","","","247.00","185.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","138.07","55.9","","368.90","368.90","368.90","1 through 10","138.07","700.33","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","outpatient","","","247.00","185.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","198.59","80.4","","274.56","274.56","274.56","1 through 10","138.07","700.33","percent of total billed charges",""
"Pf Insert Intrauterine Device","PX-98300404","CDM","58300","CPT","0983","RC","","","","outpatient","","","247.00","185.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","201.85","81.72","","281.39","154.77","2223.67","22","138.07","700.33","percent of total billed charges",""
"Pf Intubation Endotracheal","PX-98300296","CDM","31500","CPT","0983","RC","","","","outpatient","","","747.00","560.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","452.31","60.55","","473.58","473.58","473.58","1 through 10","298.8","610.45","percent of total billed charges",""
"Pf Irrigation Vagina/Tx Disease","PX-98300384","CDM","57150","CPT","0983","RC","","","","both","","","124.00","93.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","87.13","87.13","87.13","1 through 10","38.44","98.58","other","OPPS APC"
"Pf Irrigation Vagina/Tx Disease","PX-98300384","CDM","57150","CPT","0983","RC","","","","both","","","124.00","93.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","89.03","71.8","","306.59","306.59","306.59","1 through 10","38.44","98.58","percent of total billed charges",""
"Pf Irrigation Vagina/Tx Disease","PX-98300384","CDM","57150","CPT","0983","RC","","","","both","","","124.00","93.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","47.49","38.3","","166.96","166.96","166.96","1 through 10","38.44","98.58","percent of total billed charges",""
"Pf Irrigation Vagina/Tx Disease","PX-98300384","CDM","57150","CPT","0983","RC","","","","outpatient","","","124.00","93.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","106.48","","Case rate ($106.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","272.59","272.59","272.59","1 through 10","69.32","880.53","other","Multiple Surgery"
"Pf Irrigation Vagina/Tx Disease","PX-98300384","CDM","57150","CPT","0983","RC","","","","outpatient","","","124.00","93.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","106.48","","Case rate ($106.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","247.03","247.03","247.03","1 through 10","69.32","880.53","other","Multiple Surgery"
"Pf Laryngosc Fiberoptic","PX-98300297","CDM","31575","CPT","0983","RC","","","","both","","","353.00","264.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","280.64","79.5","","410.61","410.61","410.61","1 through 10","73.25","280.64","percent of total billed charges",""
"Pf Laryngosc Fiberoptic","PX-98300297","CDM","31575","CPT","0983","RC","","","","both","","","353.00","264.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","135.20","38.3","","204.88","204.88","204.88","1 through 10","73.25","280.64","percent of total billed charges",""
"Pf Laryngosc Fiberoptic","PX-98300297","CDM","31575","CPT","0983","RC","","","","outpatient","","","353.00","264.75","AETNA [1001]","HB AMC AETNA HMO","246.39","69.8","","354.75","354.75","354.75","1 through 10","163.97","700.33","percent of total billed charges",""
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","both","","","1050.00","787.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1027.64","1027.64","1027.64","1 through 10","325.5","1353.25","other","OPPS APC"
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","both","","","1050.00","787.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","834.75","79.5","","1282.81","1282.81","1282.81","1 through 10","325.5","1353.25","percent of total billed charges",""
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","both","","","1050.00","787.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","559.65","53.3","","1282.81","1282.81","1282.81","1 through 10","325.5","1353.25","percent of total billed charges",""
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","both","","","1050.00","787.50","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","1082.71","1082.71","22","325.5","1353.25","other","OPPS APC"
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","607.99","516.71","607.99","1 through 10","325.5","1353.25","percent of total billed charges",""
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","637.33","637.33","637.33","14","325.5","1353.25","percent of total billed charges",""
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","984.56","984.56","984.56","1 through 10","325.5","1353.25","other","OPPS APC"
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","outpatient","","","1050.00","787.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2160.18","2160.18","2160.18","1 through 10","450.45","2384.07","other","Multiple Surgery"
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","outpatient","","","1050.00","787.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1728.14","1728.14","1728.14","1 through 10","450.45","2384.07","other","Multiple Surgery"
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","outpatient","","","1050.00","787.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1817.53","1817.53","1817.53","1 through 10","450.45","2384.07","other","Multiple Surgery"
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","outpatient","","","1050.00","787.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1906.92","1906.92","1906.92","1 through 10","450.45","2384.07","other","Multiple Surgery"
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2078.24","2078.24","2078.24","1 through 10","450.45","2384.07","other","Multiple Surgery"
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","858.06","81.72","","1303.02","1303.02","13003.04","1 through 10","450.45","2384.07","percent of total billed charges",""
"Pf Ligate of Hemorrhoid(S)","PX-98300341","CDM","46221","CPT","0983","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1832.43","1832.43","1832.43","1 through 10","450.45","2384.07","other","Multiple Surgery"
"Pf NM Thyroid Ca Ablation","PX-98300492","CDM","79005","CPT","0983","RC","","","","both","","","362.00","271.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","192.95","53.3","","1030.18","1030.18","1030.18","1 through 10","112.22","903.59","percent of total billed charges",""
"Pf NM Thyroid Ca Ablation","PX-98300492","CDM","79005","CPT","0983","RC","","","","both","","","362.00","271.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","266.14","","APC Price ($266.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","261.91","261.91","261.91","1 through 10","112.22","903.59","other","OPPS APC"
"Pf NM Thyroid Ca Ablation","PX-98300492","CDM","79005","CPT","0983","RC","","","","both","","","362.00","271.50","MEDICARE [2001]","HB BWH MEDICARE","266.14","","APC Price ($266.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","266.17","266.17","266.17","16","112.22","903.59","other","OPPS APC"
"Pf NM Thyroid Ca Ablation","PX-98300492","CDM","79005","CPT","0983","RC","","","","both","","","362.00","271.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","132.13","36.5","","488.26","488.26","488.26","1 through 10","112.22","903.59","percent of total billed charges",""
"Pf NM Thyroid Ca Ablation","PX-98300492","CDM","79005","CPT","0983","RC","","","","both","","","362.00","271.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","138.65","38.3","","511.82","511.82","511.82","1 through 10","112.22","903.59","percent of total billed charges",""
"Pf NM Thyroid Ca Ablation","PX-98300492","CDM","79005","CPT","0983","RC","","","","both","","","362.00","271.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","266.14","","APC Price ($266.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","264.05","260.85","264.05","1 through 10","112.22","903.59","other","OPPS APC"
"Pf NM Thyroid Ca Ablation","PX-98300492","CDM","79005","CPT","0983","RC","","","","both","","","362.00","271.50","TRICARE [160005]","HB BWH TRICARE","252.86","","APC Price ($266.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","252.86","252.86","252.86","1 through 10","112.22","903.59","other","Tricare OPPS"
"Pf NM Thyroid Ca Ablation","PX-98300492","CDM","79005","CPT","0983","RC","","","","outpatient","","","362.00","271.50","AETNA [1001]","HB AMC AETNA HMO","252.68","69.8","","886.19","886.19","886.19","1 through 10","202.36","1223.41","percent of total billed charges",""
"Pf NM Thyroid Ca Ablation","PX-98300492","CDM","79005","CPT","0983","RC","","","","outpatient","","","362.00","271.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","295.83","81.72","","1046.41","575.57","1046.41","1 through 10","202.36","1223.41","percent of total billed charges",""
"Pf Pack Superficial Wound Dehis","PX-98300099","CDM","12021","CPT","0983","RC","","","","outpatient","","","635.00","476.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","728.67","728.67","728.67","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","29.95","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","21.24","19.40","29.92","12","24.49","62.81","other","OPPS APC"
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.61","28.61","28.61","19","24.49","62.81","other","OPPS APC"
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","36.35","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","29.08","29.08","29.08","1 through 10","24.49","62.81","other","OPPS APC"
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","62.81","79.5","","200.69","134.64","436.79","169","24.49","62.81","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","42.11","53.3","","200.69","134.64","1251.41","115","24.49","62.81","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.50","28.50","28.50","1 through 10","24.49","62.81","other","OPPS APC"
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","60.83","77","","196.35","196.35","196.35","1 through 10","24.49","62.81","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","HUMANA [1012]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.50","28.50","28.50","1 through 10","24.49","62.81","other","OPPS APC"
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","62.81","79.5","","200.69","200.69","200.69","1 through 10","24.49","62.81","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","MEDICARE [2001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","87.24","293","24.49","62.81","other","OPPS APC"
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16.03","16.03","19.41","23","24.49","62.81","other","OPPS APC"
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","24.49","31","","236.40","236.40","236.40","1 through 10","24.49","62.81","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28.84","36.5","","184.62","95.12","276.93","1 through 10","24.49","62.81","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30.26","38.3","","99.71","99.71","299.13","21","24.49","62.81","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.50","28.50","31.85","1 through 10","24.49","62.81","other","OPPS APC"
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","MOLINA [1014]","HB BWH MOLINA","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","128.70","128.70","128.70","1 through 10","24.49","62.81","other","OPPS APC"
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","60.83","77","","40.72","40.71","40.72","1 through 10","24.49","62.81","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","TRICARE [160005]","HB BWH TRICARE","27.63","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","29.08","27.63","30.87","1 through 10","24.49","62.81","other","Tricare OPPS"
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","28.50","85.76","1 through 10","24.49","62.81","other","OPPS APC"
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.89","42.9","","203.85","112.12","203.85","12","24.49","62.81","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","19.03","57.58","81","24.49","62.81","other","OPPS APC"
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","both","","","79.00","59.25","WELLPOINT [1015]","HB AMC WELLPOINT","58.29","73.78","","444.85","189.85","444.85","131","24.49","62.81","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","AETNA [1001]","HB AMC AETNA HMO","55.14","69.8","","172.64","121.89","243.78","136","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","AETNA [1001]","HB AMC AETNA PPO","63.52","80.4","","198.90","133.62","267.24","20","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","44.16","55.9","","133.62","133.62","133.62","1 through 10","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","41.48","52.5","","21.46","18.89","21.46","38","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","39.50","50","","81.74","81.74","81.74","1 through 10","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","41.48","52.5","","256.61","41.28","266.88","12","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","49.38","62.5","","21.46","21.46","21.46","14","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","41.48","52.5","","18.03","18.03","18.03","1 through 10","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","43.45","55","","18.89","18.89","18.89","66","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","63.52","80.4","","198.90","198.90","198.90","1 through 10","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","41.48","52.5","","21.46","18.89","21.46","1 through 10","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","64.56","81.72","","203.85","112.12","203.85","1 through 10","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","64.56","81.72","","203.85","112.12","203.85","209","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","49.38","62.5","","21.46","21.46","21.46","1 through 10","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","41.48","52.5","","18.03","18.03","18.03","1 through 10","20.98","65.18","percent of total billed charges",""
"Pf Pap Smear Screen","PX-98300591","CDM","Q0091","HCPCS","0983","RC","","","","outpatient","","","79.00","59.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","43.45","55","","18.89","18.89","21.46","1 through 10","20.98","65.18","percent of total billed charges",""
"Pf Paring/Cutting Lesn Benign >4","PX-98300018","CDM","11057","CPT","0983","RC","","","","both","","","140.00","105.00","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","43.4","294.93","other","OPPS APC"
"Pf Paring/Cutting Lesn Benign >4","PX-98300018","CDM","11057","CPT","0983","RC","","","","both","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.26","231.26","231.26","1 through 10","43.4","294.93","other","OPPS APC"
"Pf Paring/Cutting Lesn Benign 1","PX-98300016","CDM","11055","CPT","0983","RC","","","","both","","","77.00","57.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28.11","36.5","","287.00","287.00","287.00","1 through 10","23.87","294.93","percent of total billed charges",""
"Pf Paring/Cutting Lesn Benign 1","PX-98300016","CDM","11055","CPT","0983","RC","","","","both","","","77.00","57.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.49","38.3","","287.00","112.22","287.00","1 through 10","23.87","294.93","percent of total billed charges",""
"Pf Paring/Cutting Lesn Benign 1","PX-98300016","CDM","11055","CPT","0983","RC","","","","both","","","77.00","57.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.25","15.76","231.26","1 through 10","23.87","294.93","other","OPPS APC"
"Pf Paring/Cutting Lesn Benign 1","PX-98300016","CDM","11055","CPT","0983","RC","","","","outpatient","","","77.00","57.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","18.84","786.96","1 through 10","43.04","700.33","other","Multiple Surgery"
"Pf Paring/Cutting Lesn Benign 1","PX-98300016","CDM","11055","CPT","0983","RC","","","","outpatient","","","77.00","57.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","414.66","430.54","1 through 10","43.04","700.33","other","Multiple Surgery"
"Pf Paring/Cutting Lesn Benign 2-4","PX-98300017","CDM","11056","CPT","0983","RC","","","","both","","","104.00","78.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39.83","38.3","","156.01","156.01","156.01","1 through 10","32.24","294.93","percent of total billed charges",""
"Pf Paring/Cutting Lesn Benign 2-4","PX-98300017","CDM","11056","CPT","0983","RC","","","","both","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.26","214.13","231.26","14","32.24","294.93","other","OPPS APC"
"Pf Paring/Cutting Lesn Benign 2-4","PX-98300017","CDM","11056","CPT","0983","RC","","","","outpatient","","","104.00","78.00","AETNA [1001]","HB AMC AETNA HMO","72.59","69.8","","270.12","190.72","270.12","1 through 10","58.14","350.18","percent of total billed charges",""
"Pf Paring/Cutting Lesn Benign 2-4","PX-98300017","CDM","11056","CPT","0983","RC","","","","outpatient","","","104.00","78.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","1 through 10","58.14","350.18","other","Multiple Surgery"
"Pf Preventive Med Estab <1 Yr","PX-98300539","CDM","99391","CPT","0983","RC","","","","both","","","288.00","216.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","228.96","79.5","","162.12","108.77","207.77","11","89.28","273.6","percent of total billed charges",""
"Pf Preventive Med Estab <1 Yr","PX-98300539","CDM","99391","CPT","0983","RC","","","","both","","","288.00","216.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","153.50","53.3","","207.77","162.12","207.77","1 through 10","89.28","273.6","percent of total billed charges",""
"Pf Preventive Med Estab <1 Yr","PX-98300539","CDM","99391","CPT","0983","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","89.28","31","","87.76","87.76","87.76","1 through 10","89.28","273.6","percent of total billed charges",""
"Pf Preventive Med Estab <1 Yr","PX-98300539","CDM","99391","CPT","0983","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.12","36.5","","102.81","74.57","105.93","24","89.28","273.6","percent of total billed charges",""
"Pf Preventive Med Estab <1 Yr","PX-98300539","CDM","99391","CPT","0983","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","110.30","38.3","","111.04","80.55","111.04","49","89.28","273.6","percent of total billed charges",""
"Pf Preventive Med Estab <1 Yr","PX-98300539","CDM","99391","CPT","0983","RC","","","","outpatient","","","288.00","216.00","AETNA [1001]","HB AMC AETNA HMO","201.02","69.8","","331.73","192.27","331.73","23","105.16","243.66","percent of total billed charges",""
"Pf Preventive Med Estab <1 Yr","PX-98300539","CDM","99391","CPT","0983","RC","","","","outpatient","","","288.00","216.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","235.35","81.72","","391.71","391.71","391.71","1 through 10","105.16","243.66","percent of total billed charges",""
"Pf Preventive Med Estab <1 Yr","PX-98300539","CDM","99391","CPT","0983","RC","","","","outpatient","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","235.35","81.72","","391.70","391.70","391.70","1 through 10","105.16","243.66","percent of total billed charges",""
"Pf Preventive Med Estab > 65 Y","PX-98300544","CDM","99397","CPT","0983","RC","","","","both","","","425.00","318.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","337.88","79.5","","262.07","175.82","786.21","15","131.75","403.75","percent of total billed charges",""
"Pf Preventive Med Estab > 65 Y","PX-98300544","CDM","99397","CPT","0983","RC","","","","both","","","425.00","318.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","226.53","53.3","","262.07","175.82","262.07","1 through 10","131.75","403.75","percent of total billed charges",""
"Pf Preventive Med Estab > 65 Y","PX-98300544","CDM","99397","CPT","0983","RC","","","","both","","","425.00","318.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","155.13","36.5","","124.21","105.56","150.59","18","131.75","403.75","percent of total billed charges",""
"Pf Preventive Med Estab > 65 Y","PX-98300544","CDM","99397","CPT","0983","RC","","","","both","","","425.00","318.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","162.78","38.3","","130.20","126.54","162.66","114","131.75","403.75","percent of total billed charges",""
"Pf Preventive Med Estab > 65 Y","PX-98300544","CDM","99397","CPT","0983","RC","","","","both","","","425.00","318.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","327.25","77","","159.17","159.17","159.17","1 through 10","131.75","403.75","percent of total billed charges",""
"Pf Preventive Med Estab > 65 Y","PX-98300544","CDM","99397","CPT","0983","RC","","","","both","","","425.00","318.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","182.33","42.9","","146.42","146.42","146.42","1 through 10","131.75","403.75","percent of total billed charges",""
"Pf Preventive Med Estab > 65 Y","PX-98300544","CDM","99397","CPT","0983","RC","","","","outpatient","","","425.00","318.75","AETNA [1001]","HB AMC AETNA HMO","296.65","69.8","","225.44","159.17","259.74","21","105.16","347.31","percent of total billed charges",""
"Pf Preventive Med Estab > 65 Y","PX-98300544","CDM","99397","CPT","0983","RC","","","","outpatient","","","425.00","318.75","AETNA [1001]","HB AMC AETNA PPO","341.70","80.4","","259.74","259.74","259.74","1 through 10","105.16","347.31","percent of total billed charges",""
"Pf Preventive Med Estab > 65 Y","PX-98300544","CDM","99397","CPT","0983","RC","","","","outpatient","","","425.00","318.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","347.31","81.72","","146.42","146.42","146.42","1 through 10","105.16","347.31","percent of total billed charges",""
"Pf Preventive Med Estab > 65 Y","PX-98300544","CDM","99397","CPT","0983","RC","","","","outpatient","","","425.00","318.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","347.31","81.72","","266.20","266.20","266.20","23","105.16","347.31","percent of total billed charges",""
"Pf Preventive Med Estab 1-4 Yr","PX-98300585","CDM","99392","CPT","0983","RC","","","","both","","","316.00","237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","115.34","36.5","","116.00","86.91","116.00","14","97.96","300.2","percent of total billed charges",""
"Pf Preventive Med Estab 1-4 Yr","PX-98300585","CDM","99392","CPT","0983","RC","","","","both","","","316.00","237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.03","38.3","","121.60","91.10","234.70","70","97.96","300.2","percent of total billed charges",""
"Pf Preventive Med Estab 1-4 Yr","PX-98300585","CDM","99392","CPT","0983","RC","","","","both","","","316.00","237.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.56","42.9","","248.61","248.61","248.61","1 through 10","97.96","300.2","percent of total billed charges",""
"Pf Preventive Med Estab 1-4 Yr","PX-98300585","CDM","99392","CPT","0983","RC","","","","both","","","316.00","237.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","258.24","81.72","","434.87","248.61","434.87","1 through 10","97.96","300.2","percent of total billed charges",""
"Pf Preventive Med Estab 1-4 Yr","PX-98300585","CDM","99392","CPT","0983","RC","","","","outpatient","","","316.00","237.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","251.22","79.5","","183.37","123.02","227.69","1 through 10","105.16","259.41","percent of total billed charges",""
"Pf Preventive Med Estab 1-4 Yr","PX-98300585","CDM","99392","CPT","0983","RC","","","","outpatient","","","316.00","237.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","168.43","53.3","","227.69","123.02","227.69","1 through 10","105.16","259.41","percent of total billed charges",""
"Pf Preventive Med Estab 1-4 Yr","PX-98300585","CDM","99392","CPT","0983","RC","","","","outpatient","","","316.00","237.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","251.22","79.5","","227.69","227.69","227.69","1 through 10","105.16","259.41","percent of total billed charges",""
"Pf Preventive Med Estab 12-17","PX-98300541","CDM","99394","CPT","0983","RC","","","","both","","","359.00","269.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","285.41","79.5","","258.17","139.39","258.17","1 through 10","111.29","341.05","percent of total billed charges",""
"Pf Preventive Med Estab 12-17","PX-98300541","CDM","99394","CPT","0983","RC","","","","both","","","359.00","269.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","191.35","53.3","","258.17","258.17","258.17","1 through 10","111.29","341.05","percent of total billed charges",""
"Pf Preventive Med Estab 12-17","PX-98300541","CDM","99394","CPT","0983","RC","","","","both","","","359.00","269.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","131.04","36.5","","131.67","95.57","131.67","12","111.29","341.05","percent of total billed charges",""
"Pf Preventive Med Estab 12-17","PX-98300541","CDM","99394","CPT","0983","RC","","","","both","","","359.00","269.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","137.50","38.3","","138.02","103.22","265.88","53","111.29","341.05","percent of total billed charges",""
"Pf Preventive Med Estab 12-17","PX-98300541","CDM","99394","CPT","0983","RC","","","","outpatient","","","359.00","269.25","AETNA [1001]","HB AMC AETNA HMO","250.58","69.8","","417.71","168.73","417.71","1 through 10","105.16","293.37","percent of total billed charges",""
"Pf Preventive Med Estab 12-17","PX-98300541","CDM","99394","CPT","0983","RC","","","","outpatient","","","359.00","269.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","293.37","81.72","","353.00","282.19","353.00","1 through 10","105.16","293.37","percent of total billed charges",""
"Pf Preventive Med Estab 18-39","PX-98300542","CDM","99395","CPT","0983","RC","","","","both","","","372.00","279.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","295.74","79.5","","207.77","139.39","265.52","112","115.32","353.4","percent of total billed charges",""
"Pf Preventive Med Estab 18-39","PX-98300542","CDM","99395","CPT","0983","RC","","","","both","","","372.00","279.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.28","53.3","","207.77","139.39","650.44","55","115.32","353.4","percent of total billed charges",""
"Pf Preventive Med Estab 18-39","PX-98300542","CDM","99395","CPT","0983","RC","","","","both","","","372.00","279.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.32","31","","112.48","81.58","112.48","1 through 10","115.32","353.4","percent of total billed charges",""
"Pf Preventive Med Estab 18-39","PX-98300542","CDM","99395","CPT","0983","RC","","","","both","","","372.00","279.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","135.78","36.5","","115.39","83.69","135.77","148","115.32","353.4","percent of total billed charges",""
"Pf Preventive Med Estab 18-39","PX-98300542","CDM","99395","CPT","0983","RC","","","","both","","","372.00","279.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.48","38.3","","103.22","100.32","200.64","491","115.32","353.4","percent of total billed charges",""
"Pf Preventive Med Estab 18-39","PX-98300542","CDM","99395","CPT","0983","RC","","","","both","","","372.00","279.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","286.44","77","","214.25","214.25","214.25","1 through 10","115.32","353.4","percent of total billed charges",""
"Pf Preventive Med Estab 18-39","PX-98300542","CDM","99395","CPT","0983","RC","","","","both","","","372.00","279.00","TRICARE [160005]","HB BWH TRICARE","353.40","95","","84.71","84.71","89.17","1 through 10","115.32","353.4","percent of total billed charges",""
"Pf Preventive Med Estab 18-39","PX-98300542","CDM","99395","CPT","0983","RC","","","","both","","","372.00","279.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.59","42.9","","211.04","116.08","211.04","1 through 10","115.32","353.4","percent of total billed charges",""
"Pf Preventive Med Estab 18-39","PX-98300542","CDM","99395","CPT","0983","RC","","","","outpatient","","","372.00","279.00","AETNA [1001]","HB AMC AETNA HMO","259.66","69.8","","178.73","126.19","398.25","213","105.16","304","percent of total billed charges",""
"Pf Preventive Med Estab 18-39","PX-98300542","CDM","99395","CPT","0983","RC","","","","outpatient","","","372.00","279.00","AETNA [1001]","HB AMC AETNA PPO","299.09","80.4","","205.92","138.34","489.84","24","105.16","304","percent of total billed charges",""
"Pf Preventive Med Estab 18-39","PX-98300542","CDM","99395","CPT","0983","RC","","","","outpatient","","","372.00","279.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","207.95","55.9","","264.00","264.00","264.00","1 through 10","105.16","304","percent of total billed charges",""
"Pf Preventive Med Estab 18-39","PX-98300542","CDM","99395","CPT","0983","RC","","","","outpatient","","","372.00","279.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","304.00","81.72","","211.05","211.04","502.02","1 through 10","105.16","304","percent of total billed charges",""
"Pf Preventive Med Estab 18-39","PX-98300542","CDM","99395","CPT","0983","RC","","","","outpatient","","","372.00","279.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.00","81.72","","211.04","116.08","290.98","181","105.16","304","percent of total billed charges",""
"Pf Preventive Med Estab 40-64","PX-98300543","CDM","99396","CPT","0983","RC","","","","both","","","404.00","303.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","321.18","79.5","","233.74","156.82","287.48","109","125.24","383.8","percent of total billed charges",""
"Pf Preventive Med Estab 40-64","PX-98300543","CDM","99396","CPT","0983","RC","","","","both","","","404.00","303.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","215.33","53.3","","156.82","156.82","287.48","108","125.24","383.8","percent of total billed charges",""
"Pf Preventive Med Estab 40-64","PX-98300543","CDM","99396","CPT","0983","RC","","","","both","","","404.00","303.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","125.24","31","","122.06","91.77","275.31","16","125.24","383.8","percent of total billed charges",""
"Pf Preventive Med Estab 40-64","PX-98300543","CDM","99396","CPT","0983","RC","","","","both","","","404.00","303.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","147.46","36.5","","110.78","94.15","215.02","275","125.24","383.8","percent of total billed charges",""
"Pf Preventive Med Estab 40-64","PX-98300543","CDM","99396","CPT","0983","RC","","","","both","","","404.00","303.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","154.73","38.3","","116.13","112.86","154.45","674","125.24","383.8","percent of total billed charges",""
"Pf Preventive Med Estab 40-64","PX-98300543","CDM","99396","CPT","0983","RC","","","","both","","","404.00","303.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","311.08","77","","383.25","201.07","403.98","1 through 10","125.24","383.8","percent of total billed charges",""
"Pf Preventive Med Estab 40-64","PX-98300543","CDM","99396","CPT","0983","RC","","","","both","","","404.00","303.00","TRICARE [160005]","HB BWH TRICARE","383.80","95","","91.99","91.99","91.99","1 through 10","125.24","383.8","percent of total billed charges",""
"Pf Preventive Med Estab 40-64","PX-98300543","CDM","99396","CPT","0983","RC","","","","both","","","404.00","303.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.32","42.9","","135.14","130.59","237.42","12","125.24","383.8","percent of total billed charges",""
"Pf Preventive Med Estab 40-64","PX-98300543","CDM","99396","CPT","0983","RC","","","","outpatient","","","404.00","303.00","AETNA [1001]","HB AMC AETNA HMO","281.99","69.8","","201.07","141.97","330.78","196","105.16","330.15","percent of total billed charges",""
"Pf Preventive Med Estab 40-64","PX-98300543","CDM","99396","CPT","0983","RC","","","","outpatient","","","404.00","303.00","AETNA [1001]","HB AMC AETNA PPO","324.82","80.4","","231.66","231.66","539.76","16","105.16","330.15","percent of total billed charges",""
"Pf Preventive Med Estab 40-64","PX-98300543","CDM","99396","CPT","0983","RC","","","","outpatient","","","404.00","303.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","324.82","80.4","","231.66","231.66","231.66","1 through 10","105.16","330.15","percent of total billed charges",""
"Pf Preventive Med Estab 40-64","PX-98300543","CDM","99396","CPT","0983","RC","","","","outpatient","","","404.00","303.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","330.15","81.72","","304.27","130.59","304.27","17","105.16","330.15","percent of total billed charges",""
"Pf Preventive Med Estab 40-64","PX-98300543","CDM","99396","CPT","0983","RC","","","","outpatient","","","404.00","303.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","330.15","81.72","","237.42","130.59","237.42","163","105.16","330.15","percent of total billed charges",""
"Pf Preventive Med Estab 5-11 Y","PX-98300540","CDM","99393","CPT","0983","RC","","","","both","","","316.00","237.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","251.22","79.5","","227.69","186.52","227.69","12","97.96","300.2","percent of total billed charges",""
"Pf Preventive Med Estab 5-11 Y","PX-98300540","CDM","99393","CPT","0983","RC","","","","both","","","316.00","237.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","168.43","53.3","","227.69","227.69","227.69","1 through 10","97.96","300.2","percent of total billed charges",""
"Pf Preventive Med Estab 5-11 Y","PX-98300540","CDM","99393","CPT","0983","RC","","","","both","","","316.00","237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","115.34","36.5","","98.59","88.40","116.00","31","97.96","300.2","percent of total billed charges",""
"Pf Preventive Med Estab 5-11 Y","PX-98300540","CDM","99393","CPT","0983","RC","","","","both","","","316.00","237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.03","38.3","","121.60","92.67","234.70","72","97.96","300.2","percent of total billed charges",""
"Pf Preventive Med Estab 5-11 Y","PX-98300540","CDM","99393","CPT","0983","RC","","","","outpatient","","","316.00","237.00","AETNA [1001]","HB AMC AETNA HMO","220.57","69.8","","427.44","371.00","427.44","1 through 10","105.16","258.59","percent of total billed charges",""
"Pf Preventive Med Estab 5-11 Y","PX-98300540","CDM","99393","CPT","0983","RC","","","","outpatient","","","316.00","237.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","258.24","81.72","","438.07","248.61","438.07","1 through 10","105.16","258.59","percent of total billed charges",""
"Pf Preventive Med New <1 Yr","PX-98300532","CDM","99381","CPT","0983","RC","","","","both","","","316.00","237.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","251.22","79.5","","227.69","123.02","227.69","1 through 10","97.96","354.4","percent of total billed charges",""
"Pf Preventive Med New <1 Yr","PX-98300532","CDM","99381","CPT","0983","RC","","","","both","","","316.00","237.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","168.43","53.3","","183.37","117.67","227.69","1 through 10","97.96","354.4","percent of total billed charges",""
"Pf Preventive Med New <1 Yr","PX-98300532","CDM","99381","CPT","0983","RC","","","","both","","","316.00","237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","115.34","36.5","","86.91","73.86","116.00","1 through 10","97.96","354.4","percent of total billed charges",""
"Pf Preventive Med New <1 Yr","PX-98300532","CDM","99381","CPT","0983","RC","","","","both","","","316.00","237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.03","38.3","","91.10","88.54","121.60","1 through 10","97.96","354.4","percent of total billed charges",""
"Pf Preventive Med New <1 Yr","PX-98300532","CDM","99381","CPT","0983","RC","","","","outpatient","","","316.00","237.00","AETNA [1001]","HB AMC AETNA HMO","220.57","69.8","","368.29","260.03","368.29","11","105.16","271.02","percent of total billed charges",""
"Pf Preventive Med New <1 Yr","PX-98300532","CDM","99381","CPT","0983","RC","","","","outpatient","","","316.00","237.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","258.24","81.72","","434.87","434.87","434.87","1 through 10","105.16","271.02","percent of total billed charges",""
"Pf Preventive Med New <1 Yr","PX-98300532","CDM","99381","CPT","0983","RC","","","","outpatient","","","316.00","237.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","258.24","81.72","","239.20","239.20","239.20","1 through 10","105.16","271.02","percent of total billed charges",""
"Pf Preventive Med New > 65 Yrs","PX-98300538","CDM","99387","CPT","0983","RC","","","","both","","","529.00","396.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","420.56","79.5","","946.77","946.77","946.77","1 through 10","163.99","508.63","percent of total billed charges",""
"Pf Preventive Med New > 65 Yrs","PX-98300538","CDM","99387","CPT","0983","RC","","","","both","","","529.00","396.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","193.09","36.5","","127.12","127.12","127.12","1 through 10","163.99","508.63","percent of total billed charges",""
"Pf Preventive Med New > 65 Yrs","PX-98300538","CDM","99387","CPT","0983","RC","","","","both","","","529.00","396.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","202.61","38.3","","156.79","156.79","156.79","1 through 10","163.99","508.63","percent of total billed charges",""
"Pf Preventive Med New > 65 Yrs","PX-98300538","CDM","99387","CPT","0983","RC","","","","outpatient","","","529.00","396.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","432.30","81.72","","320.56","320.56","320.56","1 through 10","105.16","432.3","percent of total billed charges",""
"Pf Preventive Med New 1-4 Yrs","PX-98300533","CDM","99382","CPT","0983","RC","","","","both","","","339.00","254.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.74","36.5","","123.84","123.84","123.84","1 through 10","105.09","379.58","percent of total billed charges",""
"Pf Preventive Med New 18-39 Yr","PX-98300536","CDM","99385","CPT","0983","RC","","","","both","","","407.00","305.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","323.57","79.5","","233.74","156.82","447.88","16","126.17","401.4","percent of total billed charges",""
"Pf Preventive Med New 18-39 Yr","PX-98300536","CDM","99385","CPT","0983","RC","","","","both","","","407.00","305.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","216.93","53.3","","233.74","149.99","289.49","1 through 10","126.17","401.4","percent of total billed charges",""
"Pf Preventive Med New 18-39 Yr","PX-98300536","CDM","99385","CPT","0983","RC","","","","both","","","407.00","305.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","148.56","36.5","","215.02","110.78","432.24","16","126.17","401.4","percent of total billed charges",""
"Pf Preventive Med New 18-39 Yr","PX-98300536","CDM","99385","CPT","0983","RC","","","","both","","","407.00","305.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","155.88","38.3","","116.13","112.86","225.72","76","126.17","401.4","percent of total billed charges",""
"Pf Preventive Med New 18-39 Yr","PX-98300536","CDM","99385","CPT","0983","RC","","","","both","","","407.00","305.25","TRICARE [160005]","HB BWH TRICARE","386.65","95","","99.65","92.63","99.65","1 through 10","126.17","401.4","percent of total billed charges",""
"Pf Preventive Med New 18-39 Yr","PX-98300536","CDM","99385","CPT","0983","RC","","","","both","","","407.00","305.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.60","42.9","","237.42","237.42","237.42","1 through 10","126.17","401.4","percent of total billed charges",""
"Pf Preventive Med New 18-39 Yr","PX-98300536","CDM","99385","CPT","0983","RC","","","","outpatient","","","407.00","305.25","AETNA [1001]","HB AMC AETNA HMO","284.09","69.8","","201.07","141.97","332.21","16","105.16","332.6","percent of total billed charges",""
"Pf Preventive Med New 18-39 Yr","PX-98300536","CDM","99385","CPT","0983","RC","","","","outpatient","","","407.00","305.25","AETNA [1001]","HB AMC AETNA PPO","327.23","80.4","","297.00","297.00","297.00","1 through 10","105.16","332.6","percent of total billed charges",""
"Pf Preventive Med New 18-39 Yr","PX-98300536","CDM","99385","CPT","0983","RC","","","","outpatient","","","407.00","305.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","332.60","81.72","","237.42","130.59","237.42","31","105.16","332.6","percent of total billed charges",""
"Pf Preventive Med New 40-64 Yr","PX-98300537","CDM","99386","CPT","0983","RC","","","","both","","","493.00","369.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","391.94","79.5","","287.26","192.72","287.26","1 through 10","152.83","469.5","percent of total billed charges",""
"Pf Preventive Med New 40-64 Yr","PX-98300537","CDM","99386","CPT","0983","RC","","","","both","","","493.00","369.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","262.77","53.3","","287.26","192.72","287.26","1 through 10","152.83","469.5","percent of total billed charges",""
"Pf Preventive Med New 40-64 Yr","PX-98300537","CDM","99386","CPT","0983","RC","","","","both","","","493.00","369.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","152.83","31","","112.79","112.79","112.79","1 through 10","152.83","469.5","percent of total billed charges",""
"Pf Preventive Med New 40-64 Yr","PX-98300537","CDM","99386","CPT","0983","RC","","","","both","","","493.00","369.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","179.95","36.5","","136.15","115.71","180.16","1 through 10","152.83","469.5","percent of total billed charges",""
"Pf Preventive Med New 40-64 Yr","PX-98300537","CDM","99386","CPT","0983","RC","","","","both","","","493.00","369.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","188.82","38.3","","142.72","138.70","277.40","47","152.83","469.5","percent of total billed charges",""
"Pf Preventive Med New 40-64 Yr","PX-98300537","CDM","99386","CPT","0983","RC","","","","both","","","493.00","369.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","211.50","42.9","","160.49","160.49","160.49","1 through 10","152.83","469.5","percent of total billed charges",""
"Pf Preventive Med New 40-64 Yr","PX-98300537","CDM","99386","CPT","0983","RC","","","","outpatient","","","493.00","369.75","AETNA [1001]","HB AMC AETNA HMO","344.11","69.8","","247.11","174.47","284.70","1 through 10","105.16","402.88","percent of total billed charges",""
"Pf Preventive Med New 40-64 Yr","PX-98300537","CDM","99386","CPT","0983","RC","","","","outpatient","","","493.00","369.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","402.88","81.72","","291.78","291.78","291.78","1 through 10","105.16","402.88","percent of total billed charges",""
"Pf Preventive Med New 40-64 Yr","PX-98300537","CDM","99386","CPT","0983","RC","","","","outpatient","","","493.00","369.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","402.88","81.72","","291.78","160.49","291.78","14","105.16","402.88","percent of total billed charges",""
"Pf Preventive Med New 5-11 Yrs","PX-98300534","CDM","99383","CPT","0983","RC","","","","both","","","359.00","269.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","137.50","38.3","","138.02","134.14","138.02","1 through 10","111.29","371.04","percent of total billed charges",""
"Pf Proctosigmoidos Rigid","PX-98300337","CDM","45300","CPT","0983","RC","","","","outpatient","","","379.00","284.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","229.48","60.55","","855.66","855.66","855.66","1 through 10","151.6","309.72","percent of total billed charges",""
"Pf Prostate Cancer Scr Dre","PX-98300587","CDM","G0102","HCPCS","0983","RC","","","","both","","","82.00","61.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","65.19","79.5","","50.37","33.79","50.37","1 through 10","25.42","65.19","percent of total billed charges",""
"Pf Prostate Cancer Scr Dre","PX-98300587","CDM","G0102","HCPCS","0983","RC","","","","both","","","82.00","61.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","43.71","53.3","","33.79","33.79","33.79","1 through 10","25.42","65.19","percent of total billed charges",""
"Pf Prostate Cancer Scr Dre","PX-98300587","CDM","G0102","HCPCS","0983","RC","","","","both","","","82.00","61.50","WELLPOINT [1015]","HB AMC WELLPOINT","60.50","73.78","","47.65","47.65","47.65","1 through 10","25.42","65.19","percent of total billed charges",""
"Pf Prostate Cancer Scr Dre","PX-98300587","CDM","G0102","HCPCS","0983","RC","","","","outpatient","","","82.00","61.50","AETNA [1001]","HB AMC AETNA HMO","57.24","69.8","","43.33","30.59","43.33","1 through 10","21.77","67.01","percent of total billed charges",""
"Pf Prostate Cancer Scr Dre","PX-98300587","CDM","G0102","HCPCS","0983","RC","","","","outpatient","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","67.01","81.72","","51.16","28.14","51.16","1 through 10","21.77","67.01","percent of total billed charges",""
"Pf Prvnt Phys Exm Init Face-Face 1s","PX-98300589","CDM","G0402","HCPCS","0983","RC","","","","both","","","568.00","426.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.59","150.59","150.59","1 through 10","149.96","539.6","other","OPPS APC"
"Pf Prvnt Phys Exm Init Face-Face 1s","PX-98300589","CDM","G0402","HCPCS","0983","RC","","","","both","","","568.00","426.00","MEDICARE [2001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.04","144.28","153.04","19","149.96","539.6","other","OPPS APC"
"Pf Prvnt Phys Exm Init Face-Face 1s","PX-98300589","CDM","G0402","HCPCS","0983","RC","","","","both","","","568.00","426.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","140.27","140.27","140.27","1 through 10","149.96","539.6","other","OPPS APC"
"Pf Prvnt Phys Exm Init Face-Face 1s","PX-98300589","CDM","G0402","HCPCS","0983","RC","","","","both","","","568.00","426.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","217.54","38.3","","614.00","614.00","614.00","1 through 10","149.96","539.6","percent of total billed charges",""
"Pf Prvnt Phys Exm Init Face-Face 1s","PX-98300589","CDM","G0402","HCPCS","0983","RC","","","","both","","","568.00","426.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","149.98","141.39","149.98","1 through 10","149.96","539.6","other","OPPS APC"
"Pf Psy Thrpy Family W/O Pt","PX-96100001","CDM","90846","CPT","0961","RC","","","","both","","","434.00","325.50","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","174.01","190.81","1 through 10","134.54","412.3","other","OPPS APC"
"Pf Psy Thrpy Family W/O Pt","PX-96100001","CDM","90846","CPT","0961","RC","","","","outpatient","","","434.00","325.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","217.00","50","","165.58","165.58","165.58","1 through 10","180.98","358.05","percent of total billed charges",""
"Pf Psy Thrpy Family W/Pt","PX-96100002","CDM","90847","CPT","0961","RC","","","","both","","","452.00","339.00","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","572.43","27","140.12","429.4","other","OPPS APC"
"Pf Psy Thrpy Family W/Pt","PX-96100002","CDM","90847","CPT","0961","RC","","","","outpatient","","","452.00","339.00","AETNA [1001]","HB AMC AETNA HMO","315.50","69.8","","329.15","3.41","329.15","1 through 10","180.98","372.9","percent of total billed charges",""
"Pf Psy Thrpy Family W/Pt","PX-96100002","CDM","90847","CPT","0961","RC","","","","outpatient","","","452.00","339.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","237.30","52.5","","209.55","209.55","209.55","1 through 10","180.98","372.9","percent of total billed charges",""
"Pf Psy Thrpy Family W/Pt","PX-96100002","CDM","90847","CPT","0961","RC","","","","outpatient","","","452.00","339.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","248.60","55","","194.58","186.20","194.58","1 through 10","180.98","372.9","percent of total billed charges",""
"Pf Psy/Cd Group Therapy","PX-96100003","CDM","90853","CPT","0961","RC","","","","both","","","116.00","87.00","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","1 through 10","35.96","104.36","other","OPPS APC"
"Pf Psy/Cd Group Therapy","PX-96100003","CDM","90853","CPT","0961","RC","","","","outpatient","","","116.00","87.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","60.90","52.5","","75.90","61.55","75.90","1 through 10","58","128.37","percent of total billed charges",""
"Pf Psy/Cd Group Therapy","PX-96100003","CDM","90853","CPT","0961","RC","","","","outpatient","","","116.00","87.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","94.80","81.72","","120.06","120.06","120.06","11","58","128.37","percent of total billed charges",""
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","both","","","724.00","543.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","178.52","178.52","178.52","1 through 10","224.44","687.8","other","OPPS APC"
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","both","","","724.00","543.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","171.23","190.81","14","224.44","687.8","other","OPPS APC"
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","both","","","724.00","543.00","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","190.81","175","224.44","687.8","other","OPPS APC"
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","both","","","724.00","543.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","173.49","173.49","173.49","1 through 10","224.44","687.8","other","OPPS APC"
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","outpatient","","","724.00","543.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","438.38","60.55","","40.92","40.18","40.92","36","156.22","597.3","percent of total billed charges",""
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","outpatient","","","724.00","543.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","378.07","52.22","","46.36","46.36","46.82","92","156.22","597.3","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","630.00","472.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","196.64","186.99","197.14","12","195.3","598.5","other","OPPS APC"
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","630.00","472.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","46.52","187.76","1 through 10","195.3","598.5","other","OPPS APC"
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","630.00","472.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","441.00","70","","190.81","190.81","190.81","1 through 10","195.3","598.5","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","630.00","472.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","171.23","486.95","1 through 10","195.3","598.5","other","OPPS APC"
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","630.00","472.50","HUMANA [1012]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.99","186.99","186.99","1 through 10","195.3","598.5","other","OPPS APC"
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","630.00","472.50","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","190.81","485.18","477","195.3","598.5","other","OPPS APC"
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","630.00","472.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.76","187.76","187.76","1 through 10","195.3","598.5","other","OPPS APC"
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","AETNA [1001]","HB AMC AETNA HMO","439.74","69.8","","331.73","234.22","331.73","1 through 10","156.22","519.75","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","AETNA [1001]","HB AMC AETNA PPO","506.52","80.4","","343.00","343.00","343.00","1 through 10","156.22","519.75","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","381.47","60.55","","40.92","40.18","40.92","80","156.22","519.75","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","328.99","52.22","","46.36","46.36","46.82","185","156.22","519.75","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","315.00","50","","256.76","246.47","256.76","1 through 10","156.22","519.75","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","330.75","52.5","","269.50","218.54","269.50","1 through 10","156.22","519.75","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","514.84","81.72","","426.30","426.30","426.30","1 through 10","156.22","519.75","percent of total billed charges",""
"Pf Pump Maint Includes Elec Anly","PX-98300503","CDM","95990","CPT","0983","RC","","","","both","","","420.00","315.00","MEDICARE [2001]","HB BWH MEDICARE","393.86","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.63","369.63","369.63","1 through 10","130.2","492.33","other","OPPS APC"
"Pf Pump Ref & Main Spin/ Brain Req","PX-98300504","CDM","95991","CPT","0983","RC","","","","both","","","170.00","127.50","MEDICARE [2001]","HB BWH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","52.7","385.5","other","OPPS APC"
"Pf Puncture Arterial","PX-98300311","CDM","36600","CPT","0983","RC","","","","both","","","92.00","69.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","28.52","191.33","other","OPPS APC"
"Pf Puncture Arterial","PX-98300311","CDM","36600","CPT","0983","RC","","","","both","","","92.00","69.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","66.06","71.8","","217.55","217.55","217.55","1 through 10","28.52","191.33","percent of total billed charges",""
"Pf Puncture Arterial","PX-98300311","CDM","36600","CPT","0983","RC","","","","both","","","92.00","69.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","60.35","65.6","","236.34","236.34","236.34","1 through 10","28.52","191.33","percent of total billed charges",""
"Pf Puncture Arterial","PX-98300311","CDM","36600","CPT","0983","RC","","","","both","","","92.00","69.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","64.40","70","","303.00","218.16","303.00","1 through 10","28.52","191.33","percent of total billed charges",""
"Pf Puncture Arterial","PX-98300311","CDM","36600","CPT","0983","RC","","","","both","","","92.00","69.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","191.33","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","36.24","25.33","303.00","1 through 10","28.52","191.33","other","OPPS APC"
"Pf Puncture Arterial","PX-98300311","CDM","36600","CPT","0983","RC","","","","both","","","92.00","69.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","73.14","79.5","","238.46","238.46","238.46","1 through 10","28.52","191.33","percent of total billed charges",""
"Pf Puncture Arterial","PX-98300311","CDM","36600","CPT","0983","RC","","","","both","","","92.00","69.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","49.04","53.3","","159.98","153.02","159.98","1 through 10","28.52","191.33","percent of total billed charges",""
"Pf Puncture Arterial","PX-98300311","CDM","36600","CPT","0983","RC","","","","both","","","92.00","69.00","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","28.52","191.33","other","OPPS APC"
"Pf Puncture Arterial","PX-98300311","CDM","36600","CPT","0983","RC","","","","both","","","92.00","69.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35.24","38.3","","118.47","118.47","118.47","1 through 10","28.52","191.33","percent of total billed charges",""
"Pf Puncture Arterial","PX-98300311","CDM","36600","CPT","0983","RC","","","","both","","","92.00","69.00","WELLPOINT [1015]","HB AMC WELLPOINT","67.88","73.78","","225.58","225.58","225.58","1 through 10","28.52","191.33","percent of total billed charges",""
"Pf Puncture Arterial","PX-98300311","CDM","36600","CPT","0983","RC","","","","outpatient","","","92.00","69.00","AETNA [1001]","HB AMC AETNA HMO","64.22","69.8","","205.13","205.13","205.13","1 through 10","39.63","407.82","percent of total billed charges",""
"Pf Puncture Shunt Tubing/Reser","PX-98300414","CDM","61070","CPT","0983","RC","","","","both","","","1082.00","811.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","809.25","809.25","1 through 10","335.42","1027.91","other","OPPS APC"
"Pf Puncture Shunt Tubing/Reser","PX-98300414","CDM","61070","CPT","0983","RC","","","","both","","","1082.00","811.50","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","335.42","1027.91","other","OPPS APC"
"Pf Puncture Shunt Tubing/Reser","PX-98300414","CDM","61070","CPT","0983","RC","","","","both","","","1082.00","811.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.87","813.87","813.87","1 through 10","335.42","1027.91","other","OPPS APC"
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","both","","","523.00","392.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","635.10","634.70","635.10","1 through 10","162.13","1027.91","other","OPPS APC"
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","both","","","523.00","392.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","606.94","606.94","606.94","1 through 10","162.13","1027.91","other","OPPS APC"
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","both","","","523.00","392.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","415.79","79.5","","4262.39","645.74","4262.39","1 through 10","162.13","1027.91","percent of total billed charges",""
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","both","","","523.00","392.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","278.76","53.3","","645.74","645.74","962.50","1 through 10","162.13","1027.91","percent of total billed charges",""
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","both","","","523.00","392.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","806.96","806.96","806.96","1 through 10","162.13","1027.91","other","OPPS APC"
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","both","","","523.00","392.25","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","616.81","2467.23","22","162.13","1027.91","other","OPPS APC"
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","both","","","523.00","392.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","190.90","36.5","","456.18","387.69","456.18","1 through 10","162.13","1027.91","percent of total billed charges",""
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","both","","","523.00","392.25","TRICARE [160005]","HB BWH TRICARE","781.29","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","585.97","585.97","585.97","1 through 10","162.13","1027.91","other","Tricare OPPS"
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","both","","","523.00","392.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","605.48","605.48","605.48","1 through 10","162.13","1027.91","other","OPPS APC"
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","both","","","523.00","392.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","616.81","608.40","822.41","1 through 10","162.13","1027.91","other","OPPS APC"
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","both","","","523.00","392.25","WELLPOINT [1015]","HB AMC WELLPOINT","385.87","73.78","","2133.52","2133.52","2133.52","1 through 10","162.13","1027.91","percent of total billed charges",""
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","outpatient","","","523.00","392.25","AETNA [1001]","HB AMC AETNA HMO","365.05","69.8","","953.94","953.94","1655.94","1 through 10","274.7","2384.07","percent of total billed charges",""
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","outpatient","","","523.00","392.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1389.24","1389.24","1389.24","1 through 10","274.7","2384.07","other","Multiple Surgery"
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","outpatient","","","523.00","392.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1461.10","1461.10","1461.10","1 through 10","274.7","2384.07","other","Multiple Surgery"
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","outpatient","","","523.00","392.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","766.48","766.48","766.48","1 through 10","274.7","2384.07","other","Multiple Surgery"
"Pf Puncture Spinal Lumbar Diag","PX-98300415","CDM","62270","CPT","0983","RC","","","","outpatient","","","523.00","392.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","427.40","81.72","","1955.33","977.67","1955.33","1 through 10","274.7","2384.07","percent of total billed charges",""
"Pf Puncture Spinal Therapeutic","PX-98300416","CDM","62272","CPT","0983","RC","","","","both","","","531.00","398.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","422.15","79.5","","960.14","960.14","960.14","1 through 10","164.61","1027.91","percent of total billed charges",""
"Pf Puncture Spinal Therapeutic","PX-98300416","CDM","62272","CPT","0983","RC","","","","both","","","531.00","398.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","814.96","814.96","814.96","1 through 10","164.61","1027.91","other","OPPS APC"
"Pf Puncture Spinal Therapeutic","PX-98300416","CDM","62272","CPT","0983","RC","","","","both","","","531.00","398.25","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","616.81","822.41","13","164.61","1027.91","other","OPPS APC"
"Pf Puncture Spinal Therapeutic","PX-98300416","CDM","62272","CPT","0983","RC","","","","both","","","531.00","398.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.87","813.87","813.87","1 through 10","164.61","1027.91","other","OPPS APC"
"Pf Puncture Spinal Therapeutic","PX-98300416","CDM","62272","CPT","0983","RC","","","","outpatient","","","531.00","398.25","AETNA [1001]","HB AMC AETNA HMO","370.64","69.8","","825.94","825.94","825.94","1 through 10","296.83","2384.07","percent of total billed charges",""
"Pf Puncture Ventricular W/O In","PX-98300412","CDM","61020","CPT","0983","RC","","","","both","","","466.00","349.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","178.48","38.3","","901.65","901.65","901.65","1 through 10","144.46","1321.46","percent of total billed charges",""
"Pf Rad Rescj Tum N/Ant Thorax 5cm +","PX-98300169","CDM","21558","CPT","0983","RC","","","","both","","","5898.00","4423.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3143.63","53.3","","10680.91","10680.91","10680.91","1 through 10","1828.38","4688.91","percent of total billed charges",""
"Pf Rad Rescj Tum Tiss Thigh/Knee 5+","PX-98300232","CDM","27364","CPT","0983","RC","","","","outpatient","","","6922.00","5191.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5656.66","81.72","","4126.58","4126.58","4126.58","1 through 10","2768.8","5656.66","percent of total billed charges",""
"Pf Recnst Nipple/Areola","PX-98300140","CDM","19350","CPT","0983","RC","","","","outpatient","","","3593.00","2694.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2936.20","81.72","","22781.76","22781.76","22781.76","1 through 10","1437.2","2936.2","percent of total billed charges",""
"Pf Rem Contraceptive Capsules","PX-98300084","CDM","11976","CPT","0983","RC","","","","both","","","397.00","297.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","152.05","38.3","","294.81","294.81","294.81","1 through 10","123.07","1044.34","percent of total billed charges",""
"Pf Rem Contraceptive Capsules","PX-98300084","CDM","11976","CPT","0983","RC","","","","outpatient","","","397.00","297.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1344.07","1344.07","1344.07","1 through 10","221.92","1234.13","other","Multiple Surgery"
"Pf Rem Implant Superficial","PX-98300156","CDM","20670","CPT","0983","RC","","","","outpatient","","","665.00","498.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1375.50","","Case rate ($1,375.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2640.96","2640.96","2640.96","1 through 10","371.74","2384.07","other","Multiple Surgery"
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","both","","","310.00","232.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","652.00","652.00","652.00","1 through 10","96.1","451.51","other","OPPS APC"
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","both","","","310.00","232.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","246.45","79.5","","513.12","344.26","1381.59","25","96.1","451.51","percent of total billed charges",""
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","both","","","310.00","232.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","165.23","53.3","","513.12","329.26","3227.49","1 through 10","96.1","451.51","percent of total billed charges",""
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","both","","","310.00","232.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","238.70","77","","271.04","271.04","271.04","1 through 10","96.1","451.51","percent of total billed charges",""
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","both","","","310.00","232.50","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","350.13","652.00","1 through 10","96.1","451.51","other","OPPS APC"
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","both","","","310.00","232.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","113.15","36.5","","243.20","206.68","472.04","20","96.1","451.51","percent of total billed charges",""
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","both","","","310.00","232.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","118.73","38.3","","254.93","254.93","764.79","102","96.1","451.51","percent of total billed charges",""
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","both","","","310.00","232.50","TRICARE [160005]","HB BWH TRICARE","343.18","","APC Price ($361.24). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","343.18","343.18","343.18","1 through 10","96.1","451.51","other","Tricare OPPS"
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","both","","","310.00","232.50","WELLPOINT [1015]","HB AMC WELLPOINT","228.72","73.78","","1137.41","716.21","1137.41","15","96.1","451.51","percent of total billed charges",""
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","AETNA [1001]","HB AMC AETNA HMO","216.38","69.8","","441.40","311.66","441.40","20","132.99","700.33","percent of total billed charges",""
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","AETNA [1001]","HB AMC AETNA PPO","249.24","80.4","","341.65","311.66","508.56","1 through 10","132.99","700.33","percent of total billed charges",""
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","173.29","55.9","","477.28","477.28","477.28","1 through 10","132.99","700.33","percent of total billed charges",""
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","462.94","429.76","481.20","1 through 10","132.99","700.33","other","Multiple Surgery"
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","384.96","370.02","740.04","62","132.99","700.33","other","Multiple Surgery"
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","389.94","1169.82","39","132.99","700.33","other","Multiple Surgery"
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","481.20","163.99","481.20","1 through 10","132.99","700.33","other","Multiple Surgery"
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","404.87","404.87","1 through 10","132.99","700.33","other","Multiple Surgery"
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","408.19","212.39","424.78","11","132.99","700.33","other","Multiple Surgery"
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","249.24","80.4","","508.56","508.56","508.56","1 through 10","132.99","700.33","percent of total billed charges",""
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.99","42.9","","1865.96","1865.96","1865.96","1 through 10","132.99","700.33","percent of total billed charges",""
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","253.33","81.72","","596.68","596.68","596.68","1 through 10","132.99","700.33","percent of total billed charges",""
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","253.33","81.72","","521.21","521.20","1803.21","12","132.99","700.33","percent of total billed charges",""
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","389.94","389.94","389.94","1 through 10","132.99","700.33","other","Multiple Surgery"
"Pf Rem Intrauterine Device","PX-98300405","CDM","58301","CPT","0983","RC","","","","outpatient","","","310.00","232.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","408.19","408.19","408.19","1 through 10","132.99","700.33","other","Multiple Surgery"
"Pf Rem Skin Tag <15","PX-98300021","CDM","11200","CPT","0983","RC","","","","both","","","356.00","267.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","189.75","53.3","","482.00","482.00","482.00","1 through 10","110.36","294.93","percent of total billed charges",""
"Pf Rem Skin Tag <15","PX-98300021","CDM","11200","CPT","0983","RC","","","","both","","","356.00","267.00","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","110.36","294.93","other","OPPS APC"
"Pf Rem Skin Tag <15","PX-98300021","CDM","11200","CPT","0983","RC","","","","both","","","356.00","267.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","129.94","36.5","","179.79","174.48","179.79","1 through 10","110.36","294.93","percent of total billed charges",""
"Pf Rem Skin Tag <15","PX-98300021","CDM","11200","CPT","0983","RC","","","","both","","","356.00","267.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","136.35","38.3","","188.46","183.16","561.09","1 through 10","110.36","294.93","percent of total billed charges",""
"Pf Rem Skin Tag <15","PX-98300021","CDM","11200","CPT","0983","RC","","","","outpatient","","","356.00","267.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6151.50","482.00","6151.50","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Rem Skin Tag <15","PX-98300021","CDM","11200","CPT","0983","RC","","","","outpatient","","","356.00","267.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","482.00","482.00","482.00","1 through 10","176.45","700.33","other","Multiple Surgery"
"Pf Rem Skin Tag <15","PX-98300021","CDM","11200","CPT","0983","RC","","","","outpatient","","","356.00","267.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","290.92","81.72","","385.31","385.31","385.31","1 through 10","176.45","700.33","percent of total billed charges",""
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1899.96","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1904.20","1898.30","1907.20","1 through 10","305.66","2305.77","other","OPPS APC"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1815.28","1066.92","1844.80","1 through 10","305.66","2305.77","other","OPPS APC"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","690.20","70","","2385.60","1413.39","2385.60","1 through 10","305.66","2305.77","percent of total billed charges",""
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","783.87","79.5","","2346.83","1574.50","2346.83","12","305.66","2305.77","percent of total billed charges",""
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","525.54","53.3","","2346.83","1574.50","2713.82","1 through 10","305.66","2305.77","percent of total billed charges",""
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1815.28","1815.28","1815.28","1 through 10","305.66","2305.77","other","OPPS APC"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","FALLON HEALTH [1008]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5423.70","1807.90","5423.70","1 through 10","305.66","2305.77","other","OPPS APC"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","HUMANA [1012]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1824.65","1807.90","1824.65","1 through 10","305.66","2305.77","other","OPPS APC"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","MEDICARE [2001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1747.95","1844.80","83","305.66","2305.77","other","OPPS APC"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","359.89","36.5","","1112.29","945.29","1112.29","1 through 10","305.66","2305.77","percent of total billed charges",""
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","377.64","38.3","","1165.96","1165.96","1165.96","1 through 10","305.66","2305.77","percent of total billed charges",""
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1810.40","1807.90","1813.90","1 through 10","305.66","2305.77","other","OPPS APC"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","TRICARE [160005]","HB BWH TRICARE","1752.56","","APC Price ($1,844.80). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1844.80","1752.56","1844.80","1 through 10","305.66","2305.77","other","Tricare OPPS"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1807.72","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1815.30","1712.99","5429.70","1 through 10","305.66","2305.77","other","OPPS APC"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1807.72","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1807.91","1747.95","1844.80","11","305.66","2305.77","other","OPPS APC"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","both","","","986.00","739.50","WELLPOINT [1015]","HB AMC WELLPOINT","727.47","73.78","","2220.10","2220.10","2220.10","1 through 10","305.66","2305.77","percent of total billed charges",""
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","outpatient","","","986.00","739.50","AETNA [1001]","HB AMC AETNA HMO","688.23","69.8","","1425.40","1425.40","2018.81","1 through 10","511.86","2384.07","percent of total billed charges",""
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","outpatient","","","986.00","739.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1587.23","1413.62","1587.23","1 through 10","511.86","2384.07","other","Multiple Surgery"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","outpatient","","","986.00","739.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1438.42","1382.62","1438.42","31","511.86","2384.07","other","Multiple Surgery"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","outpatient","","","986.00","739.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1512.82","1457.02","1512.82","1 through 10","511.86","2384.07","other","Multiple Surgery"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","outpatient","","","986.00","739.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1798.03","1798.03","1798.03","1 through 10","511.86","2384.07","other","Multiple Surgery"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","outpatient","","","986.00","739.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1512.82","756.41","1512.82","1 through 10","511.86","2384.07","other","Multiple Surgery"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","outpatient","","","986.00","739.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1587.23","1525.22","1587.23","1 through 10","511.86","2384.07","other","Multiple Surgery"
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","outpatient","","","986.00","739.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","792.74","80.4","","2325.96","2325.96","2325.96","1 through 10","511.86","2384.07","percent of total billed charges",""
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","outpatient","","","986.00","739.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","805.76","81.72","","2383.81","2383.81","2383.81","1 through 10","511.86","2384.07","percent of total billed charges",""
"Pf Rem Tnl Cv Acc W/Port/Pump","PX-98300308","CDM","36590","CPT","0983","RC","","","","outpatient","","","986.00","739.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","805.76","81.72","","2383.81","1311.19","2383.81","16","511.86","2384.07","percent of total billed charges",""
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","756.17","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","761.41","755.51","762.51","1 through 10","207.7","917.68","other","OPPS APC"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","722.47","722.47","722.47","12","207.7","917.68","other","OPPS APC"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","481.06","71.8","","1222.04","1222.04","1222.04","1 through 10","207.7","917.68","percent of total billed charges",""
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","435.50","65","","1106.30","1106.30","1339.47","1 through 10","207.7","917.68","percent of total billed charges",""
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","469.00","70","","878.06","731.86","2059.42","19","207.7","917.68","percent of total billed charges",""
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","532.65","79.5","","1339.47","898.66","1339.47","1 through 10","207.7","917.68","percent of total billed charges",""
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","357.11","53.3","","1106.30","898.66","1106.30","1 through 10","207.7","917.68","percent of total billed charges",""
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","722.47","722.47","722.47","1 through 10","207.7","917.68","other","OPPS APC"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","FALLON HEALTH [1008]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2202.66","2202.66","2202.66","1 through 10","207.7","917.68","other","OPPS APC"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","719.54","719.54","719.54","1 through 10","207.7","917.68","other","OPPS APC"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","725.54","719.54","725.54","1 through 10","207.7","917.68","other","OPPS APC"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","HUMANA [1012]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","720.12","720.12","720.12","1 through 10","207.7","917.68","other","OPPS APC"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","729.04","729.04","729.04","1 through 10","207.7","917.68","other","OPPS APC"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","MEDICARE [2001]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","734.22","734.22","2202.66","88","207.7","917.68","other","OPPS APC"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","TRICARE [160005]","HB BWH TRICARE","697.51","","APC Price ($734.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","734.22","734.22","734.22","1 through 10","207.7","917.68","other","Tricare OPPS"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","697.51","","APC Price ($734.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2202.66","2202.66","2202.66","1 through 10","207.7","917.68","other","Tricare OPPS"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","719.46","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2180.82","719.54","2180.82","1 through 10","207.7","917.68","other","OPPS APC"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","719.46","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","719.54","671.93","734.22","1 through 10","207.7","917.68","other","OPPS APC"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","WELLPOINT [1015]","HB AMC WELLPOINT","494.33","73.78","","1267.14","1267.14","1267.14","1 through 10","207.7","917.68","percent of total billed charges",""
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","both","","","670.00","502.50","WELLSENSE NH [1050]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.74","726.74","726.74","1 through 10","207.7","917.68","other","OPPS APC"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","outpatient","","","670.00","502.50","AETNA [1001]","HB AMC AETNA HMO","467.66","69.8","","1152.25","813.56","1327.56","1 through 10","367.51","1234.13","percent of total billed charges",""
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","outpatient","","","670.00","502.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1438.42","731.86","1438.42","1 through 10","367.51","1234.13","other","Multiple Surgery"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","outpatient","","","670.00","502.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1512.82","1512.82","1512.82","1 through 10","367.51","1234.13","other","Multiple Surgery"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","outpatient","","","670.00","502.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1798.03","1798.03","1798.03","1 through 10","367.51","1234.13","other","Multiple Surgery"
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","outpatient","","","670.00","502.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","538.68","80.4","","1106.30","1106.30","1106.30","1 through 10","367.51","1234.13","percent of total billed charges",""
"Pf Rem Tnl Cv W/O Port/Pump","PX-98300307","CDM","36589","CPT","0983","RC","","","","outpatient","","","670.00","502.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","547.52","81.72","","1360.58","1360.58","1525.22","1 through 10","367.51","1234.13","percent of total billed charges",""
"Pf Rem Tun Intraperitoneal Cath","PX-98300349","CDM","49422","CPT","0983","RC","","","","both","","","1517.00","1137.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1089.21","71.8","","5349.45","5349.45","5349.45","1 through 10","470.27","4671.83","percent of total billed charges",""
"Pf Rem Tun Intraperitoneal Cath","PX-98300349","CDM","49422","CPT","0983","RC","","","","both","","","1517.00","1137.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","808.56","53.3","","12638.43","12638.43","12638.43","1 through 10","470.27","4671.83","percent of total billed charges",""
"Pf Rem Tun Intraperitoneal Cath","PX-98300349","CDM","49422","CPT","0983","RC","","","","both","","","1517.00","1137.75","MEDICARE [2001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","11213.55","15","470.27","4671.83","other","OPPS APC"
"Pf Rem Tun Intraperitoneal Cath","PX-98300349","CDM","49422","CPT","0983","RC","","","","both","","","1517.00","1137.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3696.73","3696.73","3696.73","1 through 10","470.27","4671.83","other","OPPS APC"
"Pf Rem Tun Intraperitoneal Cath","PX-98300349","CDM","49422","CPT","0983","RC","","","","both","","","1517.00","1137.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3663.10","3663.10","3663.10","1 through 10","470.27","4671.83","other","OPPS APC"
"Pf Rem Tun Intraperitoneal Cath","PX-98300349","CDM","49422","CPT","0983","RC","","","","both","","","1517.00","1137.75","WELLPOINT [1015]","HB AMC WELLPOINT","1119.24","73.78","","9005.47","9005.47","9005.47","1 through 10","470.27","4671.83","percent of total billed charges",""
"Pf Rem Tun Intraperitoneal Cath","PX-98300349","CDM","49422","CPT","0983","RC","","","","outpatient","","","1517.00","1137.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6068.65","6068.65","6068.65","1 through 10","848","3020.73","other","ASC"
"Pf Rem Tun Intraperitoneal Cath","PX-98300349","CDM","49422","CPT","0983","RC","","","","outpatient","","","1517.00","1137.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7002.05","7002.05","7071.53","1 through 10","848","3020.73","other","ASC "
"Pf Rem Tun Intraperitoneal Cath","PX-98300349","CDM","49422","CPT","0983","RC","","","","outpatient","","","1517.00","1137.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2641.52","","Case rate ($2,641.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6762.29","6762.29","6762.29","1 through 10","848","3020.73","other","Multiple Surgery"
"Pf Rem Tun Intraperitoneal Cath","PX-98300349","CDM","49422","CPT","0983","RC","","","","outpatient","","","1517.00","1137.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2641.52","","Case rate ($2,641.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6128.33","6128.33","6128.33","1 through 10","848","3020.73","other","Multiple Surgery"
"Pf Rem Tun Intraperitoneal Cath","PX-98300349","CDM","49422","CPT","0983","RC","","","","outpatient","","","1517.00","1137.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2641.52","","Case rate ($2,641.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6445.31","6445.31","6445.31","1 through 10","848","3020.73","other","Multiple Surgery"
"Pf Remove Cerumen Impacted Unilate","PX-98300485","CDM","69210","CPT","0983","RC","","","","both","","","149.00","111.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.42","28.42","33.43","1 through 10","46.19","118.46","other","OPPS APC"
"Pf Remove Cerumen Impacted Unilate","PX-98300485","CDM","69210","CPT","0983","RC","","","","both","","","149.00","111.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54.39","36.5","","79.08","79.08","79.08","1 through 10","46.19","118.46","percent of total billed charges",""
"Pf Remove Cerumen Impacted Unilate","PX-98300485","CDM","69210","CPT","0983","RC","","","","both","","","149.00","111.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.07","38.3","","82.89","80.56","82.89","1 through 10","46.19","118.46","percent of total billed charges",""
"Pf Remove Cerumen Impacted Unilate","PX-98300485","CDM","69210","CPT","0983","RC","","","","both","","","149.00","111.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","70.54","32.77","139.00","1 through 10","46.19","118.46","other","OPPS APC"
"Pf Remove Cerumen Impacted Unilate","PX-98300485","CDM","69210","CPT","0983","RC","","","","outpatient","","","149.00","111.75","AETNA [1001]","HB AMC AETNA HMO","104.00","69.8","","330.72","330.72","330.72","1 through 10","83.29","350.18","percent of total billed charges",""
"Pf Remove Spine Eltrd Perq Aray","PX-98300431","CDM","63661","CPT","0983","RC","","","","outpatient","","","1635.00","1226.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","853.80","52.22","","2183.79","2162.34","2183.79","1 through 10","654","1482.78","percent of total billed charges",""
"Pf Rev/Rem Elect Neurostim","PX-98300464","CDM","64585","CPT","0983","RC","","","","both","","","1720.00","1290.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4083.62","","APC Price ($4,083.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4018.69","4018.69","4018.69","1 through 10","533.2","5104.52","other","OPPS APC"
"Pf Rev/Rem Elect Neurostim","PX-98300464","CDM","64585","CPT","0983","RC","","","","both","","","1720.00","1290.00","MEDICARE [2001]","HB BWH MEDICARE","4083.62","","APC Price ($4,083.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4084.03","4084.03","4084.03","1 through 10","533.2","5104.52","other","OPPS APC"
"Pf Revise Spine Eltrd Perq Aray","PX-98300432","CDM","63663","CPT","0983","RC","","","","both","","","2346.00","1759.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","856.29","36.5","","16462.76","16462.76","16462.76","1 through 10","727.26","1865.07","percent of total billed charges",""
"Pf Revise Spine Eltrd Perq Aray","PX-98300432","CDM","63663","CPT","0983","RC","","","","both","","","2346.00","1759.50","WELLPOINT [1015]","HB AMC WELLPOINT","1730.88","73.78","","51933.00","51933.00","51933.00","1 through 10","727.26","1865.07","percent of total billed charges",""
"Pf Revise Spine Eltrd Perq Aray","PX-98300432","CDM","63663","CPT","0983","RC","","","","outpatient","","","2346.00","1759.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1420.50","60.55","","13737.40","13737.40","13737.40","1 through 10","938.4","2013.59","percent of total billed charges",""
"Pf Revise/Rem Spinal Neur Gen","PX-98300433","CDM","63688","CPT","0983","RC","","","","outpatient","","","1960.00","1470.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1023.51","52.22","","7709.43","7633.68","7709.43","1 through 10","784","1601.71","percent of total billed charges",""
"Pf Rpr Lac Int Face/Ear <2.5cm","PX-98300106","CDM","12051","CPT","0983","RC","","","","both","","","916.00","687.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","244.11","244.11","244.11","1 through 10","283.96","728.22","other","OPPS APC"
"Pf Rpr Lac Int Face/Ear <2.5cm","PX-98300106","CDM","12051","CPT","0983","RC","","","","both","","","916.00","687.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.43","233.43","237.24","1 through 10","283.96","728.22","other","OPPS APC"
"Pf Rpr Lac Int Face/Ear <2.5cm","PX-98300106","CDM","12051","CPT","0983","RC","","","","both","","","916.00","687.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","728.22","79.5","","1129.35","378.84","1129.35","1 through 10","283.96","728.22","percent of total billed charges",""
"Pf Rpr Lac Int Face/Ear <2.5cm","PX-98300106","CDM","12051","CPT","0983","RC","","","","both","","","916.00","687.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","488.23","53.3","","2692.81","2692.81","2692.81","1 through 10","283.96","728.22","percent of total billed charges",""
"Pf Rpr Lac Int Face/Ear <2.5cm","PX-98300106","CDM","12051","CPT","0983","RC","","","","both","","","916.00","687.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","237.23","35","283.96","728.22","other","OPPS APC"
"Pf Rpr Lac Int Face/Ear <2.5cm","PX-98300106","CDM","12051","CPT","0983","RC","","","","both","","","916.00","687.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.50","232.50","232.50","1 through 10","283.96","728.22","other","OPPS APC"
"Pf Rpr Lac Int Face/Ear <2.5cm","PX-98300106","CDM","12051","CPT","0983","RC","","","","both","","","916.00","687.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","237.24","232.50","237.24","1 through 10","283.96","728.22","other","OPPS APC"
"Pf Rpr Lac Int Face/Ear <2.5cm","PX-98300106","CDM","12051","CPT","0983","RC","","","","both","","","916.00","687.00","WELLPOINT [1015]","HB AMC WELLPOINT","675.82","73.78","","1251.68","1251.68","2157.95","1 through 10","283.96","728.22","percent of total billed charges",""
"Pf Rpr Lac Int Face/Ear <2.5cm","PX-98300106","CDM","12051","CPT","0983","RC","","","","outpatient","","","916.00","687.00","AETNA [1001]","HB AMC AETNA HMO","639.37","69.8","","559.65","485.75","559.65","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Face/Ear <2.5cm","PX-98300106","CDM","12051","CPT","0983","RC","","","","outpatient","","","916.00","687.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1093.02","364.34","1093.02","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Face/Ear <2.5cm","PX-98300106","CDM","12051","CPT","0983","RC","","","","outpatient","","","916.00","687.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","631.64","631.64","631.64","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Face/Ear <2.5cm","PX-98300106","CDM","12051","CPT","0983","RC","","","","outpatient","","","916.00","687.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","748.56","81.72","","1147.14","988.86","1147.14","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Face/Ear 2.6-5.0cm","PX-98300107","CDM","12052","CPT","0983","RC","","","","both","","","1087.00","815.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","864.17","79.5","","757.68","757.68","757.68","1 through 10","336.97","864.17","percent of total billed charges",""
"Pf Rpr Lac Int Face/Ear 2.6-5.0cm","PX-98300107","CDM","12052","CPT","0983","RC","","","","both","","","1087.00","815.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","579.37","53.3","","2003.30","2003.30","2003.30","1 through 10","336.97","864.17","percent of total billed charges",""
"Pf Rpr Lac Int Face/Ear 2.6-5.0cm","PX-98300107","CDM","12052","CPT","0983","RC","","","","both","","","1087.00","815.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.44","233.44","233.44","1 through 10","336.97","864.17","other","OPPS APC"
"Pf Rpr Lac Int Face/Ear 2.6-5.0cm","PX-98300107","CDM","12052","CPT","0983","RC","","","","both","","","1087.00","815.25","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","237.23","15","336.97","864.17","other","OPPS APC"
"Pf Rpr Lac Int Face/Ear 2.6-5.0cm","PX-98300107","CDM","12052","CPT","0983","RC","","","","both","","","1087.00","815.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.49","232.49","232.49","1 through 10","336.97","864.17","other","OPPS APC"
"Pf Rpr Lac Int Face/Ear 2.6-5.0cm","PX-98300107","CDM","12052","CPT","0983","RC","","","","both","","","1087.00","815.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","237.24","237.24","237.24","1 through 10","336.97","864.17","other","OPPS APC"
"Pf Rpr Lac Int Face/Ear 2.6-5.0cm","PX-98300107","CDM","12052","CPT","0983","RC","","","","both","","","1087.00","815.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.97","217.60","237.24","13","336.97","864.17","other","OPPS APC"
"Pf Rpr Lac Int Face/Ear 2.6-5.0cm","PX-98300107","CDM","12052","CPT","0983","RC","","","","outpatient","","","1087.00","815.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1050.60","364.34","1093.02","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Face/Ear 2.6-5.0cm","PX-98300107","CDM","12052","CPT","0983","RC","","","","outpatient","","","1087.00","815.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","888.30","81.72","","838.57","838.57","838.57","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Face/Ear 5.1-7.5cm","PX-98300108","CDM","12053","CPT","0983","RC","","","","both","","","966.00","724.50","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","237.23","1 through 10","299.46","767.97","other","OPPS APC"
"Pf Rpr Lac Int Face/Ear 5.1-7.5cm","PX-98300108","CDM","12053","CPT","0983","RC","","","","both","","","966.00","724.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","299.46","31","","445.89","445.89","445.89","1 through 10","299.46","767.97","percent of total billed charges",""
"Pf Rpr Lac Int Face/Ear 5.1-7.5cm","PX-98300108","CDM","12053","CPT","0983","RC","","","","both","","","966.00","724.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","237.24","232.50","237.24","1 through 10","299.46","767.97","other","OPPS APC"
"Pf Rpr Lac Int Face/Ear 5.1-7.5cm","PX-98300108","CDM","12053","CPT","0983","RC","","","","both","","","966.00","724.50","WELLPOINT [1015]","HB AMC WELLPOINT","712.71","73.78","","6055.02","6055.02","6055.02","1 through 10","299.46","767.97","percent of total billed charges",""
"Pf Rpr Lac Int Face/Ear 5.1-7.5cm","PX-98300108","CDM","12053","CPT","0983","RC","","","","outpatient","","","966.00","724.50","AETNA [1001]","HB AMC AETNA HMO","674.27","69.8","","1125.54","559.65","1125.54","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Face/Ear 5.1-7.5cm","PX-98300108","CDM","12053","CPT","0983","RC","","","","outpatient","","","966.00","724.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","364.34","364.34","364.34","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Face/Ear 5.1-7.5cm","PX-98300108","CDM","12053","CPT","0983","RC","","","","outpatient","","","966.00","724.50","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","402.02","402.02","402.02","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Neck/Hnd <2.5cm","PX-98300104","CDM","12041","CPT","0983","RC","","","","both","","","797.00","597.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","633.62","79.5","","920.00","920.00","920.00","1 through 10","247.07","633.62","percent of total billed charges",""
"Pf Rpr Lac Int Neck/Hnd <2.5cm","PX-98300104","CDM","12041","CPT","0983","RC","","","","both","","","797.00","597.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1435.00","1435.00","1435.00","1 through 10","247.07","633.62","other","OPPS APC"
"Pf Rpr Lac Int Neck/Hnd <2.5cm","PX-98300104","CDM","12041","CPT","0983","RC","","","","outpatient","","","797.00","597.75","AETNA [1001]","HB AMC AETNA HMO","556.31","69.8","","791.41","791.41","911.82","1 through 10","314.08","700.33","percent of total billed charges",""
"Pf Rpr Lac Int Neck/Hnd <2.5cm","PX-98300104","CDM","12041","CPT","0983","RC","","","","outpatient","","","797.00","597.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","386.32","386.32","386.32","1 through 10","314.08","700.33","other","Multiple Surgery"
"Pf Rpr Lac Int Neck/Hnd <2.5cm","PX-98300104","CDM","12041","CPT","0983","RC","","","","outpatient","","","797.00","597.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","651.31","81.72","","573.57","573.57","573.57","1 through 10","314.08","700.33","percent of total billed charges",""
"Pf Rpr Lac Int Neck/Hnd 2.6-7.5cm","PX-98300105","CDM","12042","CPT","0983","RC","","","","both","","","883.00","662.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.43","233.43","233.43","1 through 10","273.73","701.99","other","OPPS APC"
"Pf Rpr Lac Int Neck/Hnd 2.6-7.5cm","PX-98300105","CDM","12042","CPT","0983","RC","","","","both","","","883.00","662.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","573.95","65","","5286.45","5286.45","5286.45","1 through 10","273.73","701.99","percent of total billed charges",""
"Pf Rpr Lac Int Neck/Hnd 2.6-7.5cm","PX-98300105","CDM","12042","CPT","0983","RC","","","","both","","","883.00","662.25","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","237.23","711.69","13","273.73","701.99","other","OPPS APC"
"Pf Rpr Lac Int Neck/Hnd 2.6-7.5cm","PX-98300105","CDM","12042","CPT","0983","RC","","","","both","","","883.00","662.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","237.24","214.75","237.24","1 through 10","273.73","701.99","other","OPPS APC"
"Pf Rpr Lac Int Neck/Hnd 2.6-7.5cm","PX-98300105","CDM","12042","CPT","0983","RC","","","","both","","","883.00","662.25","WELLPOINT [1015]","HB AMC WELLPOINT","651.48","73.78","","1018.48","1018.48","1018.48","1 through 10","273.73","701.99","percent of total billed charges",""
"Pf Rpr Lac Int Neck/Hnd 2.6-7.5cm","PX-98300105","CDM","12042","CPT","0983","RC","","","","outpatient","","","883.00","662.25","AETNA [1001]","HB AMC AETNA HMO","616.33","69.8","","926.14","653.90","926.14","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Neck/Hnd 2.6-7.5cm","PX-98300105","CDM","12042","CPT","0983","RC","","","","outpatient","","","883.00","662.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1050.60","364.34","1093.02","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Neck/Hnd 2.6-7.5cm","PX-98300105","CDM","12042","CPT","0983","RC","","","","outpatient","","","883.00","662.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","369.05","350.20","369.05","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Neck/Hnd 2.6-7.5cm","PX-98300105","CDM","12042","CPT","0983","RC","","","","outpatient","","","883.00","662.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","402.02","402.02","402.02","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Neck/Hnd 2.6-7.5cm","PX-98300105","CDM","12042","CPT","0983","RC","","","","outpatient","","","883.00","662.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","721.59","81.72","","1093.58","1093.58","1093.58","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","both","","","821.00","615.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","244.11","244.11","244.11","1 through 10","254.51","652.7","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","both","","","821.00","615.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.43","214.12","233.43","1 through 10","254.51","652.7","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","both","","","821.00","615.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","652.70","79.5","","3723.30","876.72","3723.30","15","254.51","652.7","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","both","","","821.00","615.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","437.59","53.3","","2497.96","588.19","2497.96","1 through 10","254.51","652.7","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","both","","","821.00","615.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.44","233.44","233.44","1 through 10","254.51","652.7","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","both","","","821.00","615.75","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","711.69","28","254.51","652.7","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","both","","","821.00","615.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.49","213.25","232.49","1 through 10","254.51","652.7","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","both","","","821.00","615.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.50","232.50","232.50","1 through 10","254.51","652.7","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","both","","","821.00","615.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","352.21","42.9","","573.57","402.02","573.57","1 through 10","254.51","652.7","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","both","","","821.00","615.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.50","232.50","237.24","1 through 10","254.51","652.7","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","both","","","821.00","615.75","WELLPOINT [1015]","HB AMC WELLPOINT","605.73","73.78","","1943.37","829.37","1943.37","1 through 10","254.51","652.7","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","outpatient","","","821.00","615.75","AETNA [1001]","HB AMC AETNA HMO","573.06","69.8","","754.18","342.97","868.92","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","outpatient","","","821.00","615.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","804.04","315.65","804.04","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","outpatient","","","821.00","615.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1093.02","728.68","1821.70","37","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","outpatient","","","821.00","615.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1149.54","383.18","1149.54","14","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","outpatient","","","821.00","615.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","296.33","296.33","296.33","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","outpatient","","","821.00","615.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","402.02","386.32","774.17","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Sclp/Ax <2.5cm","PX-98300100","CDM","12031","CPT","0983","RC","","","","outpatient","","","821.00","615.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","670.92","81.72","","890.53","573.57","1147.14","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax 12.6-20.0cm","PX-98300103","CDM","12035","CPT","0983","RC","","","","both","","","1081.00","810.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.43","233.43","233.43","1 through 10","335.11","859.4","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax 12.6-20.0cm","PX-98300103","CDM","12035","CPT","0983","RC","","","","both","","","1081.00","810.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","576.17","53.3","","1515.36","1515.36","1515.36","1 through 10","335.11","859.4","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax 12.6-20.0cm","PX-98300103","CDM","12035","CPT","0983","RC","","","","both","","","1081.00","810.75","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","237.23","1 through 10","335.11","859.4","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax 12.6-20.0cm","PX-98300103","CDM","12035","CPT","0983","RC","","","","outpatient","","","1081.00","810.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1093.02","1093.02","1093.02","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","both","","","1042.00","781.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","244.11","244.11","245.10","1 through 10","323.02","828.39","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","both","","","1042.00","781.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.43","214.12","237.24","21","323.02","828.39","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","both","","","1042.00","781.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","828.39","79.5","","4273.41","1060.09","4517.40","25","323.02","828.39","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","both","","","1042.00","781.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","555.39","53.3","","3213.32","2867.05","4273.41","12","323.02","828.39","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","both","","","1042.00","781.50","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","237.23","174","323.02","828.39","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","both","","","1042.00","781.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","213.25","213.25","213.25","1 through 10","323.02","828.39","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","both","","","1042.00","781.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","430.50","233.50","430.50","1 through 10","323.02","828.39","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","both","","","1042.00","781.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.50","213.69","237.24","32","323.02","828.39","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","both","","","1042.00","781.50","WELLPOINT [1015]","HB AMC WELLPOINT","768.79","73.78","","2349.84","1002.84","2349.84","12","323.02","828.39","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","outpatient","","","1042.00","781.50","AETNA [1001]","HB AMC AETNA HMO","727.32","69.8","","911.92","643.87","1457.24","13","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","outpatient","","","1042.00","781.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","455.42","455.42","455.42","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","outpatient","","","1042.00","781.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1093.02","364.34","1093.02","58","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","outpatient","","","1042.00","781.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1149.54","383.18","1149.54","24","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","outpatient","","","1042.00","781.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","455.42","455.42","455.42","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","outpatient","","","1042.00","781.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","383.18","383.18","383.18","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","outpatient","","","1042.00","781.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","804.04","402.02","1732.93","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","outpatient","","","1042.00","781.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","837.77","80.4","","673.50","673.50","673.50","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","outpatient","","","1042.00","781.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","447.02","42.9","","1147.14","592.28","1147.14","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","outpatient","","","1042.00","781.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","851.52","81.72","","1076.79","592.28","1076.79","13","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax 2.6-7.5cm","PX-98300101","CDM","12032","CPT","0983","RC","","","","outpatient","","","1042.00","781.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","438.14","438.14","438.14","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Int Sclp/Ax 7.6-12.5cm","PX-98300102","CDM","12034","CPT","0983","RC","","","","both","","","986.00","739.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.43","233.43","233.43","1 through 10","305.66","783.87","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax 7.6-12.5cm","PX-98300102","CDM","12034","CPT","0983","RC","","","","both","","","986.00","739.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","783.87","79.5","","5659.32","5659.32","5659.32","1 through 10","305.66","783.87","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax 7.6-12.5cm","PX-98300102","CDM","12034","CPT","0983","RC","","","","both","","","986.00","739.50","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","711.69","28","305.66","783.87","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax 7.6-12.5cm","PX-98300102","CDM","12034","CPT","0983","RC","","","","both","","","986.00","739.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.49","232.49","232.49","1 through 10","305.66","783.87","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax 7.6-12.5cm","PX-98300102","CDM","12034","CPT","0983","RC","","","","both","","","986.00","739.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.50","213.25","237.24","1 through 10","305.66","783.87","other","OPPS APC"
"Pf Rpr Lac Int Sclp/Ax 7.6-12.5cm","PX-98300102","CDM","12034","CPT","0983","RC","","","","outpatient","","","986.00","739.50","AETNA [1001]","HB AMC AETNA HMO","688.23","69.8","","882.29","882.29","882.29","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax 7.6-12.5cm","PX-98300102","CDM","12034","CPT","0983","RC","","","","outpatient","","","986.00","739.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","805.76","81.72","","1108.77","609.86","1108.77","1 through 10","314.08","1234.13","percent of total billed charges",""
"Pf Rpr Lac Int Sclp/Ax 7.6-12.5cm","PX-98300102","CDM","12034","CPT","0983","RC","","","","outpatient","","","986.00","739.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","386.32","386.32","386.32","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Pf Rpr Lac Smp Face/Ear <2.5cm","PX-98300092","CDM","12011","CPT","0983","RC","","","","both","","","371.00","278.25","AETNA [1001]","HB AMC AETNA HMO","258.96","69.8","","334.60","334.60","473.90","1 through 10","115.01","298.28","percent of total billed charges",""
"Pf Rpr Lac Smp Face/Ear <2.5cm","PX-98300092","CDM","12011","CPT","0983","RC","","","","both","","","371.00","278.25","AETNA [1001]","HB AMC AETNA PPO","298.28","80.4","","546.00","546.00","546.00","1 through 10","115.01","298.28","percent of total billed charges",""
"Pf Rpr Lac Smp Face/Ear <2.5cm","PX-98300092","CDM","12011","CPT","0983","RC","","","","both","","","371.00","278.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","197.74","53.3","","1862.47","1862.47","1862.47","1 through 10","115.01","298.28","percent of total billed charges",""
"Pf Rpr Lac Smp Face/Ear <2.5cm","PX-98300092","CDM","12011","CPT","0983","RC","","","","both","","","371.00","278.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.01","31","","216.30","216.30","216.30","1 through 10","115.01","298.28","percent of total billed charges",""
"Pf Rpr Lac Smp Face/Ear <2.5cm","PX-98300092","CDM","12011","CPT","0983","RC","","","","both","","","371.00","278.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.09","38.3","","266.00","266.00","266.00","1 through 10","115.01","298.28","percent of total billed charges",""
"Pf Rpr Lac Smp Sclp/Hnd <2.5cm","PX-98300086","CDM","12001","CPT","0983","RC","","","","both","","","360.00","270.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","286.20","79.5","","532.01","356.93","532.01","1 through 10","111.6","294.93","percent of total billed charges",""
"Pf Rpr Lac Smp Sclp/Hnd <2.5cm","PX-98300086","CDM","12001","CPT","0983","RC","","","","both","","","360.00","270.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","131.40","36.5","","244.71","244.71","244.71","1 through 10","111.6","294.93","percent of total billed charges",""
"Pf Rpr Lac Smp Sclp/Hnd <2.5cm","PX-98300086","CDM","12001","CPT","0983","RC","","","","both","","","360.00","270.00","WELLPOINT [1015]","HB AMC WELLPOINT","265.61","73.78","","503.28","503.28","503.28","1 through 10","111.6","294.93","percent of total billed charges",""
"Pf Rpr Lac Smp Sclp/Hnd <2.5cm","PX-98300086","CDM","12001","CPT","0983","RC","","","","outpatient","","","360.00","270.00","AETNA [1001]","HB AMC AETNA HMO","251.28","69.8","","457.65","311.42","527.28","1 through 10","127.33","700.33","percent of total billed charges",""
"Pf Rpr Lac Smp Sclp/Hnd <2.5cm","PX-98300086","CDM","12001","CPT","0983","RC","","","","outpatient","","","360.00","270.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","393.48","409.36","1 through 10","127.33","700.33","other","Multiple Surgery"
"Pf Rpr Lac Smp Sclp/Hnd 2.6-7.5cm","PX-98300087","CDM","12002","CPT","0983","RC","","","","both","","","399.00","299.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","317.21","79.5","","580.02","580.02","580.02","1 through 10","123.69","317.21","percent of total billed charges",""
"Pf Rpr Lac Smp Sclp/Hnd 2.6-7.5cm","PX-98300087","CDM","12002","CPT","0983","RC","","","","both","","","399.00","299.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","212.67","53.3","","1960.93","1960.93","1960.93","1 through 10","123.69","317.21","percent of total billed charges",""
"Pf Rpr Lac Smp Sclp/Hnd 2.6-7.5cm","PX-98300087","CDM","12002","CPT","0983","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","123.69","31","","227.73","227.73","227.73","1 through 10","123.69","317.21","percent of total billed charges",""
"Pf Rpr Lac Smp Sclp/Hnd 2.6-7.5cm","PX-98300087","CDM","12002","CPT","0983","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","145.64","36.5","","266.79","266.79","266.79","1 through 10","123.69","317.21","percent of total billed charges",""
"Pf Rpr Lac Smp Sclp/Hnd 2.6-7.5cm","PX-98300087","CDM","12002","CPT","0983","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","152.82","38.3","","288.17","288.17","288.17","1 through 10","123.69","317.21","percent of total billed charges",""
"Pf Rpr Lac Smp Sclp/Hnd 7.6-12.5cm","PX-98300088","CDM","12004","CPT","0983","RC","","","","both","","","466.00","349.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","370.47","79.5","","692.40","692.40","692.40","1 through 10","144.46","370.47","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","both","","","24.00","18.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","19.08","79.5","","12.78","12.78","12.78","1 through 10","7.44","22.8","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","both","","","24.00","18.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12.79","53.3","","12.78","12.78","12.78","1 through 10","7.44","22.8","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","both","","","24.00","18.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.76","36.5","","8.95","7.61","26.86","39","7.44","22.8","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","both","","","24.00","18.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9.19","38.3","","10.70","9.38","28.15","125","7.44","22.8","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","both","","","24.00","18.00","TRICARE [160005]","HB BWH TRICARE","22.80","95","","27.58","27.58","27.58","1 through 10","7.44","22.8","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","both","","","24.00","18.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.30","42.9","","42.21","42.21","42.21","1 through 10","7.44","22.8","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","both","","","24.00","18.00","WELLPOINT [1015]","HB AMC WELLPOINT","17.71","73.78","","17.87","17.87","17.87","1 through 10","7.44","22.8","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","outpatient","","","24.00","18.00","AETNA [1001]","HB AMC AETNA HMO","16.75","69.8","","45.89","45.89","74.88","22","10.19","69.52","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","outpatient","","","24.00","18.00","AETNA [1001]","HB AMC AETNA PPO","19.30","80.4","","74.88","74.88","74.88","1 through 10","10.19","69.52","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","outpatient","","","24.00","18.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","12.60","52.5","","72.00","72.00","72.00","1 through 10","10.19","69.52","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","outpatient","","","24.00","18.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","12.00","50","","37.73","37.73","71.07","97","10.19","69.52","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","outpatient","","","24.00","18.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12.60","52.5","","39.60","39.60","39.60","23","10.19","69.52","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","outpatient","","","24.00","18.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","15.00","62.5","","47.16","47.16","47.16","1 through 10","10.19","69.52","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","outpatient","","","24.00","18.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","12.60","52.5","","32.11","32.11","32.11","1 through 10","10.19","69.52","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","outpatient","","","24.00","18.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","13.20","55","","41.47","39.89","44.60","13","10.19","69.52","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","outpatient","","","24.00","18.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","19.61","81.72","","76.75","76.75","96.00","22","10.19","69.52","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","outpatient","","","24.00","18.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","15.00","62.5","","36.79","36.79","36.79","1 through 10","10.19","69.52","percent of total billed charges",""
"Pf Screening Visual Acuity Qn","PX-98300513","CDM","99173","CPT","0983","RC","","","","outpatient","","","24.00","18.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","13.20","55","","41.47","41.47","41.47","1 through 10","10.19","69.52","percent of total billed charges",""
"Pf Shave Lesn Face/Ear <0.5cm","PX-98300031","CDM","11310","CPT","0983","RC","","","","both","","","198.00","148.50","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.25","109.25","109.25","1 through 10","61.38","294.93","other","OPPS APC"
"Pf Shave Lesn Face/Ear <0.5cm","PX-98300031","CDM","11310","CPT","0983","RC","","","","both","","","198.00","148.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.83","38.3","","112.22","112.22","112.22","1 through 10","61.38","294.93","percent of total billed charges",""
"Pf Shave Lesn Face/Ear <0.5cm","PX-98300031","CDM","11310","CPT","0983","RC","","","","both","","","198.00","148.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","235.97","235.97","235.97","1 through 10","61.38","294.93","other","OPPS APC"
"Pf Shave Lesn Face/Ear <0.5cm","PX-98300031","CDM","11310","CPT","0983","RC","","","","outpatient","","","198.00","148.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","161.81","81.72","","229.43","229.43","229.43","1 through 10","110.68","350.18","percent of total billed charges",""
"Pf Shave Lesn Face/Ear 0.6-1.0cm","PX-98300032","CDM","11311","CPT","0983","RC","","","","both","","","275.00","206.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","117.98","235.97","1 through 10","85.25","294.93","other","OPPS APC"
"Pf Shave Lesn Face/Ear 0.6-1.0cm","PX-98300032","CDM","11311","CPT","0983","RC","","","","both","","","275.00","206.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.88","232.88","232.88","1 through 10","85.25","294.93","other","OPPS APC"
"Pf Shave Lesn Face/Ear 1.1-2.0cm","PX-98300033","CDM","11312","CPT","0983","RC","","","","both","","","327.00","245.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","466.88","466.88","1 through 10","101.37","593.02","other","OPPS APC"
"Pf Shave Lesn Face/Ear 1.1-2.0cm","PX-98300033","CDM","11312","CPT","0983","RC","","","","both","","","327.00","245.25","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","101.37","593.02","other","OPPS APC"
"Pf Shave Lesn Sclp/Hnd <0.5cm","PX-98300027","CDM","11305","CPT","0983","RC","","","","both","","","160.00","120.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","225.87","225.87","225.87","1 through 10","49.6","294.93","percent of total billed charges",""
"Pf Shave Lesn Sclp/Hnd <0.5cm","PX-98300027","CDM","11305","CPT","0983","RC","","","","both","","","160.00","120.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.28","38.3","","218.12","218.12","218.12","1 through 10","49.6","294.93","percent of total billed charges",""
"Pf Shave Lesn Sclp/Hnd 0.6-1.0cm","PX-98300028","CDM","11306","CPT","0983","RC","","","","both","","","211.00","158.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.81","38.3","","471.54","471.54","471.54","1 through 10","65.41","294.93","percent of total billed charges",""
"Pf Shave Lesn Sclp/Hnd 0.6-1.0cm","PX-98300028","CDM","11306","CPT","0983","RC","","","","outpatient","","","211.00","158.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1228.08","204.68","1228.08","1 through 10","117.95","350.18","other","Multiple Surgery"
"Pf Shave Lesn Sclp/Hnd 1.1-2.0cm","PX-98300029","CDM","11307","CPT","0983","RC","","","","outpatient","","","267.00","200.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","196.74","196.74","196.74","1 through 10","149.25","350.18","other","Multiple Surgery"
"Pf Shave Lesn Sclp/Hnd 1.1-2.0cm","PX-98300029","CDM","11307","CPT","0983","RC","","","","outpatient","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","218.19","81.72","","327.75","327.75","327.75","1 through 10","149.25","350.18","percent of total billed charges",""
"Pf Shave Lesn Trnk/Arm <0.5cm","PX-98300023","CDM","11300","CPT","0983","RC","","","","both","","","148.00","111.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.68","38.3","","109.06","109.06","109.06","1 through 10","45.88","593.02","percent of total billed charges",""
"Pf Shave Lesn Trnk/Arm >2.0cm","PX-98300026","CDM","11303","CPT","0983","RC","","","","both","","","314.00","235.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.26","38.3","","198.63","198.63","198.63","1 through 10","97.34","593.02","percent of total billed charges",""
"Pf Shave Lesn Trnk/Arm 0.6-1.0cm","PX-98300024","CDM","11301","CPT","0983","RC","","","","both","","","226.00","169.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","86.56","38.3","","468.03","303.24","468.03","12","70.06","294.93","percent of total billed charges",""
"Pf Shave Lesn Trnk/Arm 0.6-1.0cm","PX-98300024","CDM","11301","CPT","0983","RC","","","","both","","","226.00","169.50","WELLPOINT [1015]","HB AMC WELLPOINT","166.74","73.78","","699.63","696.06","699.63","1 through 10","70.06","294.93","percent of total billed charges",""
"Pf Shave Lesn Trnk/Arm 0.6-1.0cm","PX-98300024","CDM","11301","CPT","0983","RC","","","","outpatient","","","226.00","169.50","AETNA [1001]","HB AMC AETNA HMO","157.75","69.8","","270.12","270.12","270.12","1 through 10","126.33","350.18","percent of total billed charges",""
"Pf Shave Lesn Trnk/Arm 0.6-1.0cm","PX-98300024","CDM","11301","CPT","0983","RC","","","","outpatient","","","226.00","169.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1228.08","1228.08","1228.08","1 through 10","126.33","350.18","other","Multiple Surgery"
"Pf Shave Lesn Trnk/Arm 1.1-2.0cm","PX-98300025","CDM","11302","CPT","0983","RC","","","","both","","","262.00","196.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","81.22","294.93","other","OPPS APC"
"Pf Shave Lesn Trnk/Arm 1.1-2.0cm","PX-98300025","CDM","11302","CPT","0983","RC","","","","both","","","262.00","196.50","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","218.50","235.97","1 through 10","81.22","294.93","other","OPPS APC"
"Pf Shave Lesn Trnk/Arm 1.1-2.0cm","PX-98300025","CDM","11302","CPT","0983","RC","","","","both","","","262.00","196.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.35","38.3","","480.93","480.93","480.93","1 through 10","81.22","294.93","percent of total billed charges",""
"Pf Shave Lesn Trnk/Arm 1.1-2.0cm","PX-98300025","CDM","11302","CPT","0983","RC","","","","both","","","262.00","196.50","WELLPOINT [1015]","HB AMC WELLPOINT","193.30","73.78","","715.25","715.25","715.25","1 through 10","81.22","294.93","percent of total billed charges",""
"Pf Shave Lesn Trnk/Arm 1.1-2.0cm","PX-98300025","CDM","11302","CPT","0983","RC","","","","outpatient","","","262.00","196.50","AETNA [1001]","HB AMC AETNA HMO","182.88","69.8","","277.57","277.57","277.57","1 through 10","146.46","350.18","percent of total billed charges",""
"Pf Shave Lesn Trnk/Arm 1.1-2.0cm","PX-98300025","CDM","11302","CPT","0983","RC","","","","outpatient","","","262.00","196.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1228.08","786.96","1228.08","1 through 10","146.46","350.18","other","Multiple Surgery"
"Pf Shave Lesn Trnk/Arm 1.1-2.0cm","PX-98300025","CDM","11302","CPT","0983","RC","","","","outpatient","","","262.00","196.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","451.71","451.71","451.71","1 through 10","146.46","350.18","other","Multiple Surgery"
"Pf Shave Lesn Trnk/Arm 1.1-2.0cm","PX-98300025","CDM","11302","CPT","0983","RC","","","","outpatient","","","262.00","196.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.11","81.72","","327.75","327.75","327.75","1 through 10","146.46","350.18","percent of total billed charges",""
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","both","","","508.00","381.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1114.11","1114.11","1 through 10","157.48","1459.48","other","OPPS APC"
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","both","","","508.00","381.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","532.70","532.70","532.70","1 through 10","157.48","1459.48","other","OPPS APC"
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","both","","","508.00","381.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","355.60","70","","1281.60","1281.60","1281.60","1 through 10","157.48","1459.48","percent of total billed charges",""
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","both","","","508.00","381.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.86","79.5","","1260.77","1260.77","6495.98","1 through 10","157.48","1459.48","percent of total billed charges",""
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","both","","","508.00","381.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.76","53.3","","1260.77","845.86","1260.77","1 through 10","157.48","1459.48","percent of total billed charges",""
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","both","","","508.00","381.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1061.06","1061.06","1061.06","1 through 10","157.48","1459.48","other","OPPS APC"
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","both","","","508.00","381.00","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","1082.71","1082.71","14","157.48","1459.48","other","OPPS APC"
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","both","","","508.00","381.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.42","36.5","","597.55","597.55","597.55","1 through 10","157.48","1459.48","percent of total billed charges",""
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","both","","","508.00","381.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.56","38.3","","626.38","626.38","626.38","1 through 10","157.48","1459.48","percent of total billed charges",""
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","both","","","508.00","381.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","1061.06","1082.71","1 through 10","157.48","1459.48","other","OPPS APC"
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","outpatient","","","508.00","381.00","AETNA [1001]","HB AMC AETNA HMO","354.58","69.8","","1084.55","765.76","1084.55","1 through 10","250.73","2384.07","percent of total billed charges",""
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","outpatient","","","508.00","381.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1728.14","864.07","1728.14","1 through 10","250.73","2384.07","other","Multiple Surgery"
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","outpatient","","","508.00","381.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1817.53","1817.53","1817.53","1 through 10","250.73","2384.07","other","Multiple Surgery"
"Pf Sigmoidoscopy Flex","PX-98300339","CDM","45330","CPT","0983","RC","","","","outpatient","","","508.00","381.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","415.14","81.72","","47009.79","47009.79","47009.79","1 through 10","250.73","2384.07","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","17.51","182.84","36","11.47","232.23","other","OPPS APC"
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","26.57","71.8","","403.52","403.52","403.52","1 through 10","11.47","232.23","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","24.27","65.6","","268.64","268.64","268.64","1 through 10","11.47","232.23","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","24.05","65","","890.22","442.29","890.22","1 through 10","11.47","232.23","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","25.90","70","","438.36","241.66","438.36","1 through 10","11.47","232.23","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","232.23","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","57.61","15.05","369.81","1 through 10","11.47","232.23","other","OPPS APC"
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","29.42","79.5","","442.29","296.74","442.29","70","11.47","232.23","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19.72","53.3","","296.74","296.74","442.29","29","11.47","232.23","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","153.96","182.84","1 through 10","11.47","232.23","other","OPPS APC"
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","ELDER SERVICES [1037]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","11.47","232.23","other","OPPS APC"
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.09","182.09","182.09","1 through 10","11.47","232.23","other","OPPS APC"
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","28.49","77","","432.74","432.74","1298.22","1 through 10","11.47","232.23","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","HUMANA [1012]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.21","183.21","183.21","1 through 10","11.47","232.23","other","OPPS APC"
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","29.42","79.5","","442.29","442.29","442.29","1 through 10","11.47","232.23","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","281","11.47","232.23","other","OPPS APC"
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","11.47","31","","173.66","173.66","173.66","1 through 10","11.47","232.23","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13.51","36.5","","209.63","178.15","628.89","67","11.47","232.23","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.17","38.3","","219.74","213.56","219.74","171","11.47","232.23","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.09","167.47","182.49","14","11.47","232.23","other","OPPS APC"
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","MOLINA [1014]","HB BWH MOLINA","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","368.65","368.65","368.65","1 through 10","11.47","232.23","other","OPPS APC"
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","28.49","77","","313.43","256.70","313.43","1 through 10","11.47","232.23","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","TRICARE [160005]","HB BWH TRICARE","176.52","","APC Price ($185.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","17.01","17.01","17.01","1 through 10","11.47","232.23","other","Tricare OPPS"
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.49","182.09","549.15","20","11.47","232.23","other","OPPS APC"
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.87","42.9","","247.11","247.11","247.11","1 through 10","11.47","232.23","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","both","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.60","182.09","183.10","82","11.47","232.23","other","OPPS APC"
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","outpatient","","","37.00","27.75","AETNA [1001]","HB AMC AETNA HMO","25.83","69.8","","460.84","306.71","760.94","17","20.68","520.69","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","outpatient","","","37.00","27.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","29.75","80.4","","281.00","281.00","281.00","1 through 10","20.68","520.69","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","outpatient","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","30.24","81.72","","247.11","247.11","247.11","1 through 10","20.68","520.69","percent of total billed charges",""
"Pf Spirometry Smp","PX-98300496","CDM","94010","CPT","0983","RC","","","","outpatient","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","30.24","81.72","","449.26","247.11","449.26","96","20.68","520.69","percent of total billed charges",""
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","337.09","363.89","40","17.67","462.21","other","OPPS APC"
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","462.21","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","25.00","25.00","25.00","1 through 10","17.67","462.21","other","OPPS APC"
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","45.32","79.5","","765.75","513.74","765.75","24","17.67","462.21","percent of total billed charges",""
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","30.38","53.3","","765.75","513.74","2099.50","19","17.67","462.21","percent of total billed charges",""
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","294.27","363.89","13","17.67","462.21","other","OPPS APC"
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","ELDER SERVICES [1037]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","335.72","335.72","335.72","1 through 10","17.67","462.21","other","OPPS APC"
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","FALLON HEALTH [1008]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1109.43","1027.71","1109.43","1 through 10","17.67","462.21","other","OPPS APC"
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","43.89","77","","2247.63","2247.63","2247.63","1 through 10","17.67","462.21","percent of total billed charges",""
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","HUMANA [1012]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","362.41","362.41","1 through 10","17.67","462.21","other","OPPS APC"
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","37.05","65","","515.69","515.69","515.69","1 through 10","17.67","462.21","percent of total billed charges",""
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","1109.43","385","17.67","462.21","other","OPPS APC"
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20.81","36.5","","362.93","308.44","1829.28","24","17.67","462.21","percent of total billed charges",""
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21.83","38.3","","380.44","380.44","380.44","59","17.67","462.21","percent of total billed charges",""
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","336.12","362.81","20","17.67","462.21","other","OPPS APC"
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","MOLINA [1014]","HB BWH MOLINA","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","733.70","685.14","733.70","1 through 10","17.67","462.21","other","OPPS APC"
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","TRICARE [160005]","HB BWH TRICARE","351.32","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","369.81","369.81","369.81","1 through 10","17.67","462.21","other","Tricare OPPS"
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","363.01","362.41","1088.43","18","17.67","462.21","other","OPPS APC"
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","both","","","57.00","42.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","362.41","363.89","78","17.67","462.21","other","OPPS APC"
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","outpatient","","","57.00","42.75","AETNA [1001]","HB AMC AETNA HMO","39.79","69.8","","658.72","658.72","658.72","1 through 10","31.86","966.35","percent of total billed charges",""
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","outpatient","","","57.00","42.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","46.58","81.72","","427.83","427.83","427.83","1 through 10","31.86","966.35","percent of total billed charges",""
"Pf Spirometry/Pft Pre & Post B","PX-98300497","CDM","94060","CPT","0983","RC","","","","outpatient","","","57.00","42.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","46.58","81.72","","777.82","427.83","777.82","15","31.86","966.35","percent of total billed charges",""
"Pf Strapping Unna Boot","PX-98300284","CDM","29580","CPT","0983","RC","","","","both","","","144.00","108.00","MEDICARE [2001]","HB BWH MEDICARE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.39","187.39","187.39","1 through 10","44.64","234.21","other","OPPS APC"
"Pf Trimming Nails Dystrophic","PX-98300588","CDM","G0127","HCPCS","0983","RC","","","","both","","","32.00","24.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","72.65","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","54.70","6.80","54.70","1 through 10","9.92","88.17","other","OPPS APC"
"Pf Trimming Nails Dystrophic","PX-98300588","CDM","G0127","HCPCS","0983","RC","","","","both","","","32.00","24.00","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","66.76","66.76","66.76","1 through 10","9.92","88.17","other","OPPS APC"
"Pf Trimming Nails Dystrophic","PX-98300588","CDM","G0127","HCPCS","0983","RC","","","","both","","","32.00","24.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7.57","7.57","7.57","21","9.92","88.17","other","OPPS APC"
"Pf Trimming Nails Dystrophic","PX-98300588","CDM","G0127","HCPCS","0983","RC","","","","both","","","32.00","24.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11.68","36.5","","17.44","9.83","20.52","1 through 10","9.92","88.17","percent of total billed charges",""
"Pf Trimming Nails Dystrophic","PX-98300588","CDM","G0127","HCPCS","0983","RC","","","","both","","","32.00","24.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.13","7.42","69.13","53","9.92","88.17","other","OPPS APC"
"Pf Trimming Nails Dystrophic","PX-98300588","CDM","G0127","HCPCS","0983","RC","","","","outpatient","","","32.00","24.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","55.90","","Case rate ($55.90). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","64.85","4.51","129.69","1 through 10","17.89","247.15","other","Multiple Surgery"
"Pf Trimming Nails Nondystrophi","PX-98300071","CDM","11719","CPT","0983","RC","","","","outpatient","","","32.00","24.00","AETNA [1001]","HB AMC AETNA HMO","22.34","69.8","","141.49","141.49","141.49","1 through 10","17.89","350.18","percent of total billed charges",""
"Pf Trimming Nails Nondystrophi","PX-98300071","CDM","11719","CPT","0983","RC","","","","outpatient","","","32.00","24.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","55.90","","Case rate ($55.90). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","136.40","136.40","136.40","1 through 10","17.89","350.18","other","Multiple Surgery"
"Pf Tx Fx Acetabulum W/O Man Clsd","PX-98300224","CDM","27220","CPT","0983","RC","","","","both","","","2198.00","1648.50","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1747.41","other","OPPS APC"
"Pf Tx Fx Acetabulum W/O Man Clsd","PX-98300224","CDM","27220","CPT","0983","RC","","","","both","","","2198.00","1648.50","TRICARE [160005]","HB BWH TRICARE","270.63","","APC Price ($284.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","284.87","284.87","284.87","1 through 10","270.63","1747.41","other","Tricare OPPS"
"Pf Tx Fx Bimall Ankle W/O Man Clsd","PX-98300248","CDM","27808","CPT","0983","RC","","","","outpatient","","","1475.00","1106.25","AETNA [1001]","HB AMC AETNA HMO","1029.55","69.8","","1344.52","1344.52","1344.52","1 through 10","225.09","2384.07","percent of total billed charges",""
"Pf Tx Fx Calcaneal Clsd","PX-98300255","CDM","28400","CPT","0983","RC","","","","both","","","1102.00","826.50","AETNA [1001]","HB AMC AETNA HMO","769.20","69.8","","1202.76","1202.76","1202.76","1 through 10","270.63","886.01","percent of total billed charges",""
"Pf Tx Fx Calcaneal Clsd","PX-98300255","CDM","28400","CPT","0983","RC","","","","both","","","1102.00","826.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","402.23","36.5","","558.20","558.20","558.20","1 through 10","270.63","886.01","percent of total billed charges",""
"Pf Tx Fx Carpal W/O Man Clsd","PX-98300206","CDM","25630","CPT","0983","RC","","","","both","","","1373.00","1029.75","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","142.44","142.44","142.44","1 through 10","270.63","1091.54","other","OPPS APC"
"Pf Tx Fx Carpal W/O Man Clsd","PX-98300206","CDM","25630","CPT","0983","RC","","","","both","","","1373.00","1029.75","WELLPOINT [1015]","HB AMC WELLPOINT","1013.00","73.78","","964.13","964.13","964.13","1 through 10","270.63","1091.54","percent of total billed charges",""
"Pf Tx Fx Carpal W/O Man Clsd","PX-98300206","CDM","25630","CPT","0983","RC","","","","outpatient","","","1373.00","1029.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1122.02","81.72","","1035.23","1035.23","1035.23","1 through 10","225.09","1122.02","percent of total billed charges",""
"Pf Tx Fx Clavicle W/O Man Clsd","PX-98300181","CDM","23500","CPT","0983","RC","","","","both","","","1114.00","835.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","293.39","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","293.13","293.13","293.13","1 through 10","270.63","885.63","other","OPPS APC"
"Pf Tx Fx Clavicle W/O Man Clsd","PX-98300181","CDM","23500","CPT","0983","RC","","","","both","","","1114.00","835.50","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","885.63","other","OPPS APC"
"Pf Tx Fx Clavicle W/O Man Clsd","PX-98300181","CDM","23500","CPT","0983","RC","","","","outpatient","","","1114.00","835.50","AETNA [1001]","HB AMC AETNA HMO","777.57","69.8","","672.94","475.13","672.94","1 through 10","225.09","2384.07","percent of total billed charges",""
"Pf Tx Fx Clavicle W/O Man Clsd","PX-98300181","CDM","23500","CPT","0983","RC","","","","outpatient","","","1114.00","835.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","910.36","81.72","","794.60","794.60","794.60","1 through 10","225.09","2384.07","percent of total billed charges",""
"Pf Tx Fx Femur Troch W/O Man Clsd","PX-98300226","CDM","27238","CPT","0983","RC","","","","both","","","2177.00","1632.75","MEDICARE [2001]","HB BWH MEDICARE","1900.39","","APC Price ($1,900.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1900.58","1900.58","1900.58","1 through 10","674.87","2375.49","other","OPPS APC"
"Pf Tx Fx Fibula Distal W/O Man Clsd","PX-98300246","CDM","27786","CPT","0983","RC","","","","both","","","1374.00","1030.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","526.24","38.3","","501.26","501.26","501.26","1 through 10","270.63","1092.33","percent of total billed charges",""
"Pf Tx Fx Fibula Distal W/O Man Clsd","PX-98300246","CDM","27786","CPT","0983","RC","","","","both","","","1374.00","1030.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","279.17","279.17","279.17","1 through 10","270.63","1092.33","other","OPPS APC"
"Pf Tx Fx Fibula Prox W/O Man Clsd","PX-98300245","CDM","27780","CPT","0983","RC","","","","both","","","1377.00","1032.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","139.88","139.88","139.88","1 through 10","270.63","1094.72","other","OPPS APC"
"Pf Tx Fx Greater Troch W/O Man Clsd","PX-98300572","CDM","27246","CPT","0983","RC","","","","both","","","1804.00","1353.00","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1474.23","other","OPPS APC"
"Pf Tx Fx Humeral Epicon W/O Man","PX-98300193","CDM","24560","CPT","0983","RC","","","","both","","","1422.00","1066.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","279.38","279.38","279.38","1 through 10","270.63","1130.49","other","OPPS APC"
"Pf Tx Fx Humeral Shaft W/O Man","PX-98300191","CDM","24500","CPT","0983","RC","","","","both","","","1609.00","1206.75","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1279.16","other","OPPS APC"
"Pf Tx Fx Humerus Prox W/O Man","PX-98300184","CDM","23600","CPT","0983","RC","","","","both","","","1535.00","1151.25","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1220.33","other","OPPS APC"
"Pf Tx Fx Humerus Prox W/O Man","PX-98300184","CDM","23600","CPT","0983","RC","","","","both","","","1535.00","1151.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","279.17","279.17","279.17","1 through 10","270.63","1220.33","other","OPPS APC"
"Pf Tx Fx Humerus Tuber W/O Man","PX-98300185","CDM","23620","CPT","0983","RC","","","","both","","","1259.00","944.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","279.17","279.17","279.17","1 through 10","270.63","1000.91","other","OPPS APC"
"Pf Tx Fx Metacarpal W/O Man Clsd","PX-98300211","CDM","26600","CPT","0983","RC","","","","both","","","1404.00","1053.00","WELLPOINT [1015]","HB AMC WELLPOINT","1035.87","73.78","","910.52","910.52","910.52","1 through 10","270.63","1116.18","percent of total billed charges",""
"Pf Tx Fx Metatarsal W/O Man Clsd","PX-98300258","CDM","28470","CPT","0983","RC","","","","both","","","985.00","738.75","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","783.08","other","OPPS APC"
"Pf Tx Fx Metatarsal W/O Man Clsd","PX-98300258","CDM","28470","CPT","0983","RC","","","","both","","","985.00","738.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","377.26","38.3","","343.69","343.69","343.69","1 through 10","270.63","783.08","percent of total billed charges",""
"Pf Tx Fx Navicular W/O Man Clsd","PX-98300205","CDM","25622","CPT","0983","RC","","","","both","","","1379.00","1034.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","735.01","53.3","","938.26","938.26","938.26","1 through 10","270.63","1126.92","percent of total billed charges",""
"Pf Tx Fx Patellar W/O Man Clsd","PX-98300236","CDM","27520","CPT","0983","RC","","","","both","","","1452.00","1089.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","293.39","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","293.13","293.13","293.13","1 through 10","270.63","1186.57","other","OPPS APC"
"Pf Tx Fx Patellar W/O Man Clsd","PX-98300236","CDM","27520","CPT","0983","RC","","","","both","","","1452.00","1089.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.23","252.23","252.23","1 through 10","270.63","1186.57","other","OPPS APC"
"Pf Tx Fx Patellar W/O Man Clsd","PX-98300236","CDM","27520","CPT","0983","RC","","","","both","","","1452.00","1089.00","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1186.57","other","OPPS APC"
"Pf Tx Fx Patellar W/O Man Clsd","PX-98300236","CDM","27520","CPT","0983","RC","","","","both","","","1452.00","1089.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1186.57","81.72","","1044.82","1044.82","1044.82","1 through 10","270.63","1186.57","percent of total billed charges",""
"Pf Tx Fx Patellar W/O Man Clsd","PX-98300236","CDM","27520","CPT","0983","RC","","","","both","","","1452.00","1089.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","279.17","279.17","279.17","1 through 10","270.63","1186.57","other","OPPS APC"
"Pf Tx Fx Patellar W/O Man Clsd","PX-98300236","CDM","27520","CPT","0983","RC","","","","both","","","1452.00","1089.00","WELLPOINT [1015]","HB AMC WELLPOINT","1071.29","73.78","","973.06","973.06","973.06","1 through 10","270.63","1186.57","percent of total billed charges",""
"Pf Tx Fx Radial Dist W/O Man Clsd","PX-98300204","CDM","25600","CPT","0983","RC","","","","both","","","1589.00","1191.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","293.39","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","132.42","132.42","132.42","1 through 10","270.63","1263.26","other","OPPS APC"
"Pf Tx Fx Radial Dist W/O Man Clsd","PX-98300204","CDM","25600","CPT","0983","RC","","","","both","","","1589.00","1191.75","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","142.44","284.87","1 through 10","270.63","1263.26","other","OPPS APC"
"Pf Tx Fx Radial Dist W/O Man Clsd","PX-98300204","CDM","25600","CPT","0983","RC","","","","both","","","1589.00","1191.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","608.59","38.3","","463.73","463.73","463.73","1 through 10","270.63","1263.26","percent of total billed charges",""
"Pf Tx Fx Radial Dist W/O Man Clsd","PX-98300204","CDM","25600","CPT","0983","RC","","","","both","","","1589.00","1191.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","127.66","127.66","127.66","1 through 10","270.63","1263.26","other","OPPS APC"
"Pf Tx Fx Radial Head/Neck W/O Man","PX-98300197","CDM","24650","CPT","0983","RC","","","","both","","","1204.00","903.00","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","957.18","other","OPPS APC"
"Pf Tx Fx Radial Head/Neck W/O Man","PX-98300197","CDM","24650","CPT","0983","RC","","","","both","","","1204.00","903.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","439.46","36.5","","394.63","394.63","394.63","1 through 10","270.63","957.18","percent of total billed charges",""
"Pf Tx Fx Radial Head/Neck W/O Man","PX-98300197","CDM","24650","CPT","0983","RC","","","","both","","","1204.00","903.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","461.13","38.3","","413.68","413.68","413.68","1 through 10","270.63","957.18","percent of total billed charges",""
"Pf Tx Fx Radial Head/Neck W/O Man","PX-98300197","CDM","24650","CPT","0983","RC","","","","outpatient","","","1204.00","903.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","225.09","","Case rate ($225.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","652.76","652.76","652.76","1 through 10","225.09","983.91","other","Multiple Surgery"
"Pf Tx Fx Radial Head/Neck W/O Man","PX-98300197","CDM","24650","CPT","0983","RC","","","","outpatient","","","1204.00","903.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","983.91","81.72","","845.77","845.77","845.77","1 through 10","225.09","983.91","percent of total billed charges",""
"Pf Tx Fx Scapular W/O Man Clsd","PX-98300183","CDM","23570","CPT","0983","RC","","","","both","","","1181.00","885.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","293.39","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","293.13","293.13","293.13","1 through 10","270.63","938.9","other","OPPS APC"
"Pf Tx Fx Scapular W/O Man Clsd","PX-98300183","CDM","23570","CPT","0983","RC","","","","both","","","1181.00","885.75","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","938.9","other","OPPS APC"
"Pf Tx Fx Scapular W/O Man Clsd","PX-98300183","CDM","23570","CPT","0983","RC","","","","both","","","1181.00","885.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","279.17","279.17","279.17","1 through 10","270.63","938.9","other","OPPS APC"
"Pf Tx Fx Scapular W/O Man Clsd","PX-98300183","CDM","23570","CPT","0983","RC","","","","outpatient","","","1181.00","885.75","AETNA [1001]","HB AMC AETNA HMO","824.34","69.8","","747.59","747.59","747.59","1 through 10","225.09","2384.07","percent of total billed charges",""
"Pf Tx Fx Tibial Prox W/O Man Clsd","PX-98300237","CDM","27530","CPT","0983","RC","","","","both","","","1403.00","1052.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","293.39","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","293.13","293.13","293.13","1 through 10","270.63","1146.53","other","OPPS APC"
"Pf Tx Fx Tibial Prox W/O Man Clsd","PX-98300237","CDM","27530","CPT","0983","RC","","","","both","","","1403.00","1052.25","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","257.38","284.87","1 through 10","270.63","1146.53","other","OPPS APC"
"Pf Tx Fx Tibial Prox W/O Man Clsd","PX-98300237","CDM","27530","CPT","0983","RC","","","","both","","","1403.00","1052.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","537.35","38.3","","557.37","557.37","557.37","1 through 10","270.63","1146.53","percent of total billed charges",""
"Pf Tx Fx Tibial Prox W/O Man Clsd","PX-98300237","CDM","27530","CPT","0983","RC","","","","both","","","1403.00","1052.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1146.53","81.72","","742.65","742.65","742.65","1 through 10","270.63","1146.53","percent of total billed charges",""
"Pf Tx Fx Tibial Prox W/O Man Clsd","PX-98300237","CDM","27530","CPT","0983","RC","","","","both","","","1403.00","1052.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","279.75","279.75","279.75","1 through 10","270.63","1146.53","other","OPPS APC"
"Pf Tx Fx Tibial Prox W/O Man Clsd","PX-98300237","CDM","27530","CPT","0983","RC","","","","both","","","1403.00","1052.25","WELLPOINT [1015]","HB AMC WELLPOINT","1035.13","73.78","","2946.46","1723.51","2946.46","1 through 10","270.63","1146.53","percent of total billed charges",""
"Pf Tx Fx Ulnar Styloid Clsd","PX-98300207","CDM","25650","CPT","0983","RC","","","","both","","","1472.00","1104.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","1170.24","other","OPPS APC"
"Pf Tx Fx Ulnar Styloid Clsd","PX-98300207","CDM","25650","CPT","0983","RC","","","","both","","","1472.00","1104.00","WELLPOINT [1015]","HB AMC WELLPOINT","1086.04","73.78","","1454.75","1454.75","1454.75","1 through 10","270.63","1170.24","percent of total billed charges",""
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","both","","","214.00","160.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","170.13","79.5","","546.97","546.97","546.97","1 through 10","66.34","462.21","percent of total billed charges",""
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","both","","","214.00","160.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","114.06","53.3","","366.96","366.96","366.96","1 through 10","66.34","462.21","percent of total billed charges",""
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","both","","","214.00","160.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","139.10","65","","451.75","368.35","451.75","1 through 10","66.34","462.21","percent of total billed charges",""
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","both","","","214.00","160.50","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","342.57","342.57","342.57","1 through 10","66.34","462.21","other","OPPS APC"
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","both","","","214.00","160.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.41","362.41","362.41","1 through 10","66.34","462.21","other","OPPS APC"
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","both","","","214.00","160.50","WELLPOINT [1015]","HB AMC WELLPOINT","157.89","73.78","","517.43","517.43","517.43","1 through 10","66.34","462.21","percent of total billed charges",""
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","outpatient","","","214.00","160.50","AETNA [1001]","HB AMC AETNA HMO","149.37","69.8","","194.33","194.33","194.33","1 through 10","119.63","585.65","percent of total billed charges",""
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","outpatient","","","214.00","160.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","155.47","","Case rate ($155.47). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","156.17","156.17","159.05","13","119.63","585.65","other","ASC"
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","outpatient","","","214.00","160.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","155.47","","Case rate ($155.47). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","180.19","180.19","360.38","27","119.63","585.65","other","ASC "
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","outpatient","","","214.00","160.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","135.95","","Case rate ($135.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","174.02","174.02","174.02","1 through 10","119.63","585.65","other","Multiple Surgery"
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","outpatient","","","214.00","160.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","135.95","","Case rate ($135.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","157.70","151.59","315.40","1 through 10","119.63","585.65","other","Multiple Surgery"
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","outpatient","","","214.00","160.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","135.95","","Case rate ($135.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","165.86","159.74","165.86","1 through 10","119.63","585.65","other","Multiple Surgery"
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","outpatient","","","214.00","160.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","135.95","","Case rate ($135.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","197.13","197.13","197.13","1 through 10","119.63","585.65","other","Multiple Surgery"
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","outpatient","","","214.00","160.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","135.95","","Case rate ($135.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","348.03","174.02","348.03","1 through 10","119.63","585.65","other","Multiple Surgery"
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","outpatient","","","214.00","160.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","172.06","80.4","","347.50","347.50","542.10","1 through 10","119.63","585.65","percent of total billed charges",""
"Pf Uroflowmetry Cplx","PX-98300358","CDM","51741","CPT","0983","RC","","","","outpatient","","","214.00","160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.88","81.72","","555.58","555.58","555.58","1 through 10","119.63","585.65","percent of total billed charges",""
"Pf US Guided Needle Biopsy","PX-98300578","CDM","76942","CPT","0983","RC","","","","both","","","162.00","121.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","106.27","65.6","","663.94","663.94","663.94","1 through 10","50.22","261.88","percent of total billed charges",""
"Pf US Guided Needle Biopsy","PX-98300578","CDM","76942","CPT","0983","RC","","","","both","","","162.00","121.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","105.30","65","","3087.50","902.85","3087.50","1 through 10","50.22","261.88","percent of total billed charges",""
"Pf US Guided Needle Biopsy","PX-98300578","CDM","76942","CPT","0983","RC","","","","both","","","162.00","121.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","113.40","70","","212.20","212.20","212.20","1 through 10","50.22","261.88","percent of total billed charges",""
"Pf US Guided Needle Biopsy","PX-98300578","CDM","76942","CPT","0983","RC","","","","both","","","162.00","121.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","128.79","79.5","","3465.15","1093.14","3588.71","94","50.22","261.88","percent of total billed charges",""
"Pf US Guided Needle Biopsy","PX-98300578","CDM","76942","CPT","0983","RC","","","","both","","","162.00","121.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","86.35","53.3","","1601.37","701.45","1648.33","17","50.22","261.88","percent of total billed charges",""
"Pf US Guided Needle Biopsy","PX-98300578","CDM","76942","CPT","0983","RC","","","","both","","","162.00","121.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","124.74","77","","2139.06","2079.00","2139.06","1 through 10","50.22","261.88","percent of total billed charges",""
"Pf US Guided Needle Biopsy","PX-98300578","CDM","76942","CPT","0983","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","105.30","65","","902.85","92.95","902.85","1 through 10","50.22","261.88","percent of total billed charges",""
"Pf US Guided Needle Biopsy","PX-98300578","CDM","76942","CPT","0983","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","59.13","36.5","","1320.93","440.31","1554.30","37","50.22","261.88","percent of total billed charges",""
"Pf US Guided Needle Biopsy","PX-98300578","CDM","76942","CPT","0983","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","62.05","38.3","","1055.64","543.10","1629.30","72","50.22","261.88","percent of total billed charges",""
"Pf US Guided Needle Biopsy","PX-98300578","CDM","76942","CPT","0983","RC","","","","both","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.50","42.9","","1106.33","632.00","1106.33","1 through 10","50.22","261.88","percent of total billed charges",""
"Pf US Guided Needle Biopsy","PX-98300578","CDM","76942","CPT","0983","RC","","","","outpatient","","","162.00","121.50","AETNA [1001]","HB AMC AETNA HMO","113.08","69.8","","940.35","663.94","940.35","1 through 10","90.56","132.39","percent of total billed charges",""
"Pf US Guided Needle Biopsy","PX-98300578","CDM","76942","CPT","0983","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","132.39","81.72","","610.74","610.74","610.74","1 through 10","90.56","132.39","percent of total billed charges",""
"Pf US Guided Needle Biopsy","PX-98300578","CDM","76942","CPT","0983","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","132.39","81.72","","1110.37","610.74","1110.37","23","90.56","132.39","percent of total billed charges",""
"Pf Venipuncture > Age 3 by MD/Prof","PX-98300303","CDM","36410","CPT","0983","RC","","","","both","","","44.00","33.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16.06","36.5","","24.25","24.25","24.25","1 through 10","13.64","34.98","percent of total billed charges",""
"Pf Venipuncture > Age 3 by MD/Prof","PX-98300303","CDM","36410","CPT","0983","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","35.96","81.72","","28.58","28.58","28.58","1 through 10","15.77","35.96","percent of total billed charges",""
"Pf Xr Fluoro <1 Hr","PX-98300489","CDM","76000","CPT","0983","RC","","","","both","","","65.00","48.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","287.06","1 through 10","20.15","358.78","other","OPPS APC"
"Pf Xr Fluoro <1 Hr","PX-98300489","CDM","76000","CPT","0983","RC","","","","both","","","65.00","48.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","51.68","79.5","","1319.80","1319.80","1319.80","1 through 10","20.15","358.78","percent of total billed charges",""
"Pf Xr Fluoro <1 Hr","PX-98300489","CDM","76000","CPT","0983","RC","","","","both","","","65.00","48.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","34.65","53.3","","885.46","885.46","885.46","1 through 10","20.15","358.78","percent of total billed charges",""
"Pf Xr Fluoro <1 Hr","PX-98300489","CDM","76000","CPT","0983","RC","","","","both","","","65.00","48.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","20.15","358.78","other","OPPS APC"
"Pf Xr Fluoro <1 Hr","PX-98300489","CDM","76000","CPT","0983","RC","","","","both","","","65.00","48.75","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.04","283.04","283.04","1 through 10","20.15","358.78","other","OPPS APC"
"Pf Xr Fluoro <1 Hr","PX-98300489","CDM","76000","CPT","0983","RC","","","","both","","","65.00","48.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","16","20.15","358.78","other","OPPS APC"
"Pf Xr Fluoro <1 Hr","PX-98300489","CDM","76000","CPT","0983","RC","","","","both","","","65.00","48.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.73","36.5","","625.52","625.52","625.52","1 through 10","20.15","358.78","percent of total billed charges",""
"Pf Xr Fluoro <1 Hr","PX-98300489","CDM","76000","CPT","0983","RC","","","","both","","","65.00","48.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.90","38.3","","1967.13","1967.13","1967.13","1 through 10","20.15","358.78","percent of total billed charges",""
"Pf Xr Fluoro <1 Hr","PX-98300489","CDM","76000","CPT","0983","RC","","","","both","","","65.00","48.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","281.32","281.32","1 through 10","20.15","358.78","other","OPPS APC"
"Pf Xr Fluoro <1 Hr","PX-98300489","CDM","76000","CPT","0983","RC","","","","both","","","65.00","48.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.82","281.62","281.82","1 through 10","20.15","358.78","other","OPPS APC"
"Pf Xr Fluoro <1 Hr","PX-98300489","CDM","76000","CPT","0983","RC","","","","outpatient","","","65.00","48.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","53.12","81.72","","1340.59","1253.72","1340.59","1 through 10","36.34","1035.21","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","both","","","115.00","86.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","75.44","65.6","","801.84","801.84","801.84","1 through 10","35.65","91.43","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","both","","","115.00","86.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","91.43","79.5","","809.04","542.78","809.04","32","35.65","91.43","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","both","","","115.00","86.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","61.30","53.3","","542.78","542.78","809.04","23","35.65","91.43","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","both","","","115.00","86.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","74.75","65","","668.20","668.20","668.20","1 through 10","35.65","91.43","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","35.65","31","","317.65","317.65","317.65","1 through 10","35.65","91.43","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.98","36.5","","372.14","325.88","383.44","23","35.65","91.43","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44.05","38.3","","401.95","390.64","401.95","98","35.65","91.43","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","both","","","115.00","86.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","88.55","77","","801.83","801.83","801.83","1 through 10","35.65","91.43","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","both","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.34","42.9","","821.79","452.01","821.79","1 through 10","35.65","91.43","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","both","","","115.00","86.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.34","42.9","","452.01","452.01","452.01","1 through 10","35.65","91.43","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","both","","","115.00","86.25","WELLPOINT [1015]","HB AMC WELLPOINT","84.85","73.78","","765.35","765.35","765.35","31","35.65","91.43","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","outpatient","","","115.00","86.25","AETNA [1001]","HB AMC AETNA HMO","80.27","69.8","","695.96","695.96","695.96","1 through 10","64.29","93.98","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","outpatient","","","115.00","86.25","AETNA [1001]","HB AMC AETNA PPO","92.46","80.4","","801.84","801.84","801.84","1 through 10","64.29","93.98","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","outpatient","","","115.00","86.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","92.46","80.4","","695.96","695.96","695.96","1 through 10","64.29","93.98","percent of total billed charges",""
"Pf Xr Fluoro Biopsy/Aspiration","PX-98300490","CDM","77002","CPT","0983","RC","","","","outpatient","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.98","81.72","","821.78","452.01","821.79","27","64.29","93.98","percent of total billed charges",""
"Pf Xr Fluoro Needle Localizati","PX-98300491","CDM","77003","CPT","0983","RC","","","","both","","","122.00","91.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","96.99","79.5","","805.10","540.14","805.10","1 through 10","37.82","96.99","percent of total billed charges",""
"Pf Xr Fluoro Needle Localizati","PX-98300491","CDM","77003","CPT","0983","RC","","","","both","","","122.00","91.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","65.03","53.3","","540.14","540.14","540.14","1 through 10","37.82","96.99","percent of total billed charges",""
"Pf Xr Fluoro Needle Localizati","PX-98300491","CDM","77003","CPT","0983","RC","","","","both","","","122.00","91.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.53","36.5","","972.87","324.29","972.87","1 through 10","37.82","96.99","percent of total billed charges",""
"Pf Xr Fluoro Needle Localizati","PX-98300491","CDM","77003","CPT","0983","RC","","","","both","","","122.00","91.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.73","38.3","","399.99","399.99","399.99","1 through 10","37.82","96.99","percent of total billed charges",""
"Pg 10137 Nephro Diab Insipidus Panel","PX-30003811","CDM","81479","CPT","0310","RC","","","","both","","","1996.00","1497.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1586.82","79.5","","0.65","0.65","0.65","1 through 10","618.76","1896.2","percent of total billed charges",""
"Pg 10137 Nephro Diab Insipidus Panel","PX-30003811","CDM","81479","CPT","0310","RC","","","","both","","","1996.00","1497.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1063.87","53.3","","0.79","0.79","0.79","1 through 10","618.76","1896.2","percent of total billed charges",""
"Pg 10137 Nephro Diab Insipidus Panel","PX-30003811","CDM","81479","CPT","0310","RC","","","","outpatient","","","1996.00","1497.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","998.00","50","","1.00","1.00","1.00","1 through 10","156.55","1646.7","percent of total billed charges",""
"Pg 10137 Nephro Diab Insipidus Panel","PX-30003811","CDM","81479","CPT","0310","RC","","","","outpatient","","","1996.00","1497.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1047.90","52.5","","1.00","0.53","1.00","1 through 10","156.55","1646.7","percent of total billed charges",""
"Pg Amyotrophic Lateral Sclerosis and Frontotemporal Dementia Sequencing Panel With Cnv Detection","PX-31001056","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Pg Amyotrophic Lateral Sclerosis and Frontotemporal Dementia Sequencing Panel With Cnv Detection","PX-31001056","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Pg Amyotrophic Lateral Sclerosis and Frontotemporal Dementia Sequencing Panel With Cnv Detection","PX-31001056","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Pg Amyotrophic Lateral Sclerosis and Frontotemporal Dementia Sequencing Panel With Cnv Detection","PX-31001056","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Ph Body Fluid","PX-30000601","CDM","83986","CPT","0301","RC","","","","both","","","59.00","44.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46.91","79.5","","44.86","44.86","44.86","1 through 10","3.51","56.05","percent of total billed charges",""
"Ph Body Fluid","PX-30000601","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","AETNA [1001]","HB AMC AETNA PPO","47.44","80.4","","44.46","44.46","44.46","1 through 10","3.68","48.21","percent of total billed charges",""
"Ph Body Fluid","PX-30000601","CDM","83986","CPT","0301","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","48.21","81.72","","45.57","45.57","45.57","1 through 10","3.68","48.21","percent of total billed charges",""
"Phenobarbital","PX-30000186","CDM","80184","CPT","0301","RC","","","","both","","","226.00","169.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","82.49","36.5","","79.28","69.42","79.28","1 through 10","11.81","214.7","percent of total billed charges",""
"Phenobarbital","PX-30000186","CDM","80184","CPT","0301","RC","","","","both","","","226.00","169.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","86.56","38.3","","83.22","83.22","85.63","1 through 10","11.81","214.7","percent of total billed charges",""
"Phenobarbital","PX-30000186","CDM","80184","CPT","0301","RC","","","","outpatient","","","226.00","169.50","AETNA [1001]","HB AMC AETNA HMO","157.75","69.8","","148.26","148.26","148.26","1 through 10","11.81","184.69","percent of total billed charges",""
"Phenytoin (Dilantin) Free","PX-30000031","CDM","80186","CPT","0301","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.43","38.3","","239.28","79.76","239.28","1 through 10","13.48","199.5","percent of total billed charges",""
"Phenytoin (Dilantin) Total","PX-30000187","CDM","80185","CPT","0301","RC","","","","both","","","199.00","149.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.64","36.5","","71.99","71.99","71.99","1 through 10","12.99","189.05","percent of total billed charges",""
"Phenytoin (Dilantin) Total","PX-30000187","CDM","80185","CPT","0301","RC","","","","both","","","199.00","149.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.22","38.3","","75.47","73.34","226.38","1 through 10","12.99","189.05","percent of total billed charges",""
"Phenytoin (Dilantin) Total","PX-30000187","CDM","80185","CPT","0301","RC","","","","outpatient","","","199.00","149.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","162.62","81.72","","154.28","84.86","154.28","1 through 10","13.67","162.62","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","576.00","432.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","157.65","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","158.52","157.84","158.52","12","145.42","457.92","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","576.00","432.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","145.42","457.92","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","576.00","432.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","457.92","79.5","","439.93","439.93","439.93","12","145.42","457.92","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","576.00","432.00","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","139.42","153.08","132","145.42","457.92","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","576.00","432.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","210.24","36.5","","208.51","177.20","208.51","14","145.42","457.92","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","576.00","432.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","220.61","38.3","","218.57","212.42","218.57","42","145.42","457.92","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","576.00","432.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","443.52","77","","183.70","171.34","183.70","1 through 10","145.42","457.92","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","576.00","432.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.63","150.02","451.44","1 through 10","145.42","457.92","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","576.00","432.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.02","150.02","150.02","1 through 10","145.42","457.92","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","576.00","432.00","WELLPOINT [1015]","HB AMC WELLPOINT","424.97","73.78","","416.18","416.18","416.18","1 through 10","145.42","457.92","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","outpatient","","","576.00","432.00","AETNA [1001]","HB AMC AETNA HMO","402.05","69.8","","378.44","267.20","378.44","13","244.64","470.71","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","outpatient","","","576.00","432.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","470.71","81.72","","446.86","446.86","446.86","1 through 10","244.64","470.71","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","both","","","68.00","51.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","48.82","71.8","","142.17","25.81","142.17","19","5.08","64.6","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","both","","","68.00","51.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","47.60","70","","66.00","16.74","66.00","1 through 10","5.08","64.6","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","both","","","68.00","51.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","54.06","79.5","","51.94","34.85","51.94","1 through 10","5.08","64.6","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","both","","","68.00","51.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","36.24","53.3","","51.94","34.85","104.55","1 through 10","5.08","64.6","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","both","","","68.00","51.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","44.20","65","","42.90","42.90","52.65","1 through 10","5.08","64.6","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","both","","","68.00","51.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","21.08","31","","20.39","20.39","20.39","1 through 10","5.08","64.6","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","both","","","68.00","51.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24.82","36.5","","24.62","20.92","24.62","13","5.08","64.6","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","both","","","68.00","51.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26.04","38.3","","25.81","21.78","142.17","30","5.08","64.6","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","both","","","68.00","51.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","52.36","77","","51.94","51.94","51.94","1 through 10","5.08","64.6","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","both","","","68.00","51.00","TRICARE [160005]","HB BWH TRICARE","64.60","95","","5.93","5.93","5.93","1 through 10","5.08","64.6","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","outpatient","","","68.00","51.00","AETNA [1001]","HB AMC AETNA HMO","47.46","69.8","","44.68","31.55","51.48","18","5.34","55.57","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","outpatient","","","68.00","51.00","AETNA [1001]","HB AMC AETNA PPO","54.67","80.4","","51.48","51.48","51.48","1 through 10","5.34","55.57","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","outpatient","","","68.00","51.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","54.67","80.4","","51.48","33.00","51.48","1 through 10","5.34","55.57","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","outpatient","","","68.00","51.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","55.57","81.72","","52.76","52.76","52.76","1 through 10","5.34","55.57","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","outpatient","","","68.00","51.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","55.57","81.72","","52.76","29.02","52.76","19","5.34","55.57","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","both","","","179.00","134.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","128.52","71.8","","124.93","124.93","124.93","1 through 10","14.48","170.05","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","both","","","179.00","134.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","142.31","79.5","","91.87","91.87","136.94","1 through 10","14.48","170.05","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","both","","","179.00","134.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.41","53.3","","136.94","91.87","275.61","1 through 10","14.48","170.05","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.34","36.5","","64.90","55.16","64.90","11","14.48","170.05","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.56","38.3","","68.03","57.42","124.93","36","14.48","170.05","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","both","","","179.00","134.25","MOLINA [1014]","HB BWH MOLINA","62.65","35","","29.56","29.56","29.56","1 through 10","14.48","170.05","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","both","","","179.00","134.25","TRICARE [160005]","HB BWH TRICARE","170.05","95","","17.81","17.81","17.81","1 through 10","14.48","170.05","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","both","","","179.00","134.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.79","42.9","","76.51","76.51","76.51","1 through 10","14.48","170.05","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","outpatient","","","179.00","134.25","AETNA [1001]","HB AMC AETNA HMO","124.94","69.8","","83.17","83.17","117.80","13","15.25","146.28","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","outpatient","","","179.00","134.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","146.28","81.72","","76.51","60.63","139.10","1 through 10","15.25","146.28","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","both","","","136.00","102.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","95.20","70","","132.00","132.00","132.00","1 through 10","4.81","129.2","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","both","","","136.00","102.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","108.12","79.5","","69.70","69.70","103.88","1 through 10","4.81","129.2","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","both","","","136.00","102.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","72.49","53.3","","209.10","69.70","308.36","1 through 10","4.81","129.2","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","both","","","136.00","102.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","88.40","65","","85.80","85.80","85.80","1 through 10","4.81","129.2","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","both","","","136.00","102.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","49.64","36.5","","49.24","41.45","49.24","1 through 10","4.81","129.2","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","both","","","136.00","102.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.09","38.3","","51.61","50.16","154.83","1 through 10","4.81","129.2","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","outpatient","","","136.00","102.00","AETNA [1001]","HB AMC AETNA HMO","94.93","69.8","","83.84","60.67","89.36","1 through 10","4.81","122.42","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","outpatient","","","136.00","102.00","AETNA [1001]","HB AMC AETNA PPO","109.34","80.4","","69.17","69.17","69.17","1 through 10","4.81","122.42","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","outpatient","","","136.00","102.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","109.34","80.4","","66.00","66.00","66.00","1 through 10","4.81","122.42","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","111.14","81.72","","58.04","58.04","58.04","1 through 10","4.81","122.42","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","111.14","81.72","","105.52","81.48","105.52","1 through 10","4.81","122.42","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0300","RC","","","","inpatient","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","61.32","78.61","","32.96","32.96","32.96","1 through 10","43.13","62.01","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","56.00","71.8","","54.57","28.35","120.56","83","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","51.17","65.6","","51.45","51.45","59.28","1 through 10","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","50.70","65","","49.40","40.13","148.20","104","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","54.60","70","","76.00","32.68","98.04","62","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","62.01","79.5","","59.81","40.13","179.43","155","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","41.57","53.3","","59.81","40.13","121.34","99","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","60.06","77","","58.52","58.52","58.52","1 through 10","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","50.70","65","","49.40","49.40","49.40","1 through 10","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","24.18","31","","23.48","23.48","24.09","1 through 10","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28.47","36.5","","28.35","24.09","28.35","150","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.87","38.3","","29.72","28.88","85.05","356","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","MOLINA [1014]","HB BWH MOLINA","27.30","35","","9.40","9.40","9.40","1 through 10","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","60.06","77","","59.28","56.55","62.32","1 through 10","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","TRICARE [160005]","HB BWH TRICARE","74.10","95","","5.71","5.42","76.00","12","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.46","42.9","","33.42","33.42","60.75","1 through 10","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","78.00","58.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.46","42.9","","33.42","33.42","33.42","1 through 10","4.65","74.1","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","78.00","58.50","AETNA [1001]","HB AMC AETNA HMO","54.44","69.8","","51.45","36.33","59.28","299","4.87","63.74","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","78.00","58.50","AETNA [1001]","HB AMC AETNA PPO","62.71","80.4","","59.28","36.33","79.64","22","4.87","63.74","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","78.00","58.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","40.76","52.26","","47.03","12.87","47.03","1 through 10","4.87","63.74","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","62.71","80.4","","59.28","59.28","59.28","1 through 10","4.87","63.74","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","63.74","81.72","","57.76","57.76","57.76","1 through 10","4.87","63.74","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","63.74","81.72","","33.42","33.42","66.84","1 through 10","4.87","63.74","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","63.74","81.72","","60.75","33.42","60.75","172","4.87","63.74","percent of total billed charges",""
"Phosphorus Urine","PX-30000620","CDM","84105","CPT","0301","RC","","","","both","","","73.00","54.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","52.41","71.8","","50.98","50.98","50.98","1 through 10","5.34","69.35","percent of total billed charges",""
"Phosphorus Urine","PX-30000620","CDM","84105","CPT","0301","RC","","","","both","","","73.00","54.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","58.04","79.5","","55.88","55.88","55.88","1 through 10","5.34","69.35","percent of total billed charges",""
"Phosphorus Urine","PX-30000620","CDM","84105","CPT","0301","RC","","","","both","","","73.00","54.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","38.91","53.3","","112.47","112.47","112.47","1 through 10","5.34","69.35","percent of total billed charges",""
"Phosphorus Urine","PX-30000620","CDM","84105","CPT","0301","RC","","","","both","","","73.00","54.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.65","36.5","","26.48","22.51","67.53","11","5.34","69.35","percent of total billed charges",""
"Phosphorus Urine","PX-30000620","CDM","84105","CPT","0301","RC","","","","both","","","73.00","54.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27.96","38.3","","50.98","23.43","53.96","1 through 10","5.34","69.35","percent of total billed charges",""
"Phosphorus Urine","PX-30000620","CDM","84105","CPT","0301","RC","","","","outpatient","","","73.00","54.75","AETNA [1001]","HB AMC AETNA HMO","50.95","69.8","","48.07","33.94","55.38","1 through 10","5.34","59.66","percent of total billed charges",""
"Phosphorus Urine","PX-30000620","CDM","84105","CPT","0301","RC","","","","outpatient","","","73.00","54.75","AETNA [1001]","HB AMC AETNA PPO","58.69","80.4","","55.38","55.38","55.38","1 through 10","5.34","59.66","percent of total billed charges",""
"Photochemotherapy Uva","PX-76001686","CDM","96912","CPT","0761","RC","","","","both","","","636.00","477.00","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","70.54","70.54","21","67.01","505.62","other","OPPS APC"
"Photochemotherapy Uvb","PX-76001685","CDM","96910","CPT","0761","RC","","","","both","","","342.00","256.50","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","66.76","70.54","21","67.01","271.89","other","OPPS APC"
"Photochemotherapy Uvb","PX-76001685","CDM","96910","CPT","0761","RC","","","","both","","","342.00","256.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","130.99","38.3","","129.81","126.16","129.81","47","67.01","271.89","percent of total billed charges",""
"Photopheresis Extracorporeal","PX-76001081","CDM","36522","CPT","0761","RC","","","","both","","","16052.00","12039.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","5730.26","","APC Price ($5,563.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","5726.08","5726.08","5726.08","1 through 10","4976.12","12761.34","other","OPPS APC"
"Photopheresis Extracorporeal","PX-76001081","CDM","36522","CPT","0761","RC","","","","both","","","16052.00","12039.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","5563.36","","APC Price ($5,563.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5474.90","5474.90","5474.90","48","4976.12","12761.34","other","OPPS APC"
"Photopheresis Extracorporeal","PX-76001081","CDM","36522","CPT","0761","RC","","","","both","","","16052.00","12039.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","5563.36","","APC Price ($5,563.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5452.64","4610.21","5474.90","11","4976.12","12761.34","other","OPPS APC"
"Photopheresis Extracorporeal","PX-76001081","CDM","36522","CPT","0761","RC","","","","both","","","16052.00","12039.00","MEDICARE [2001]","HB BWH MEDICARE","5563.36","","APC Price ($5,563.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5563.92","5563.92","5563.92","139","4976.12","12761.34","other","OPPS APC"
"Photopheresis Extracorporeal","PX-76001081","CDM","36522","CPT","0761","RC","","","","both","","","16052.00","12039.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6147.92","38.3","","5915.08","5915.08","5915.08","1 through 10","4976.12","12761.34","percent of total billed charges",""
"Photopheresis Extracorporeal","PX-76001081","CDM","36522","CPT","0761","RC","","","","both","","","16052.00","12039.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","5563.36","","APC Price ($5,563.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4949.88","4949.88","5452.64","1 through 10","4976.12","12761.34","other","OPPS APC"
"Photopheresis Extracorporeal","PX-76001081","CDM","36522","CPT","0761","RC","","","","both","","","16052.00","12039.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","5452.09","","APC Price ($5,563.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3580.18","3580.18","3580.18","1 through 10","4976.12","12761.34","other","OPPS APC"
"Photopheresis Extracorporeal","PX-76001081","CDM","36522","CPT","0761","RC","","","","both","","","16052.00","12039.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","5452.09","","APC Price ($5,563.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5452.65","4949.89","5453.52","22","4976.12","12761.34","other","OPPS APC"
"Photopheresis Extracorporeal","PX-76001081","CDM","36522","CPT","0761","RC","","","","outpatient","","","16052.00","12039.00","AETNA [1001]","HB AMC AETNA HMO","11204.30","69.8","","10538.18","10538.18","10538.18","33","4485.6","15023.18","percent of total billed charges",""
"Photopheresis Extracorporeal","PX-76001081","CDM","36522","CPT","0761","RC","","","","outpatient","","","16052.00","12039.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4485.60","","Case rate ($4,485.60). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","9011.57","9011.57","9177.54","26","4485.6","15023.18","other","ASC"
"Photopheresis Extracorporeal","PX-76001081","CDM","36522","CPT","0761","RC","","","","outpatient","","","16052.00","12039.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4485.60","","Case rate ($4,485.60). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","10397.62","10397.62","10500.79","61","4485.6","15023.18","other","ASC "
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","762.00","571.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.41","69.41","69.41","31","67.01","605.79","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","762.00","571.50","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","70.54","70.54","517","67.01","605.79","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","762.00","571.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","291.85","38.3","","288.95","288.95","288.95","23","67.01","605.79","percent of total billed charges",""
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","762.00","571.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.13","69.13","69.13","17","67.01","605.79","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","762.00","571.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.13","69.13","207.39","60","67.01","605.79","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","762.00","571.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.90","42.9","","324.94","324.94","324.94","21","67.01","605.79","percent of total billed charges",""
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","762.00","571.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.13","65.43","69.13","101","67.01","605.79","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","762.00","571.50","WELLPOINT [1015]","HB AMC WELLPOINT","562.20","73.78","","550.19","550.19","550.19","27","67.01","605.79","percent of total billed charges",""
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","outpatient","","","762.00","571.50","AETNA [1001]","HB AMC AETNA HMO","531.88","69.8","","1000.61","1000.61","1000.61","1 through 10","90.46","622.71","percent of total billed charges",""
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","outpatient","","","762.00","571.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","622.71","81.72","","590.76","590.76","590.76","12","90.46","622.71","percent of total billed charges",""
"Phys/Qhp Svcs OP Pulm Rehab WO Cont Oximtry Mntr","PX-94000056","CDM","94625","CPT","0948","RC","","","","both","","","528.00","396.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.41","69.41","69.41","16","67.01","419.76","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab WO Cont Oximtry Mntr","PX-94000056","CDM","94625","CPT","0948","RC","","","","both","","","528.00","396.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","369.60","70","","225.13","225.13","225.13","1 through 10","67.01","419.76","percent of total billed charges",""
"Phys/Qhp Svcs OP Pulm Rehab WO Cont Oximtry Mntr","PX-94000056","CDM","94625","CPT","0948","RC","","","","both","","","528.00","396.00","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","70.54","70.54","193","67.01","419.76","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab WO Cont Oximtry Mntr","PX-94000056","CDM","94625","CPT","0948","RC","","","","both","","","528.00","396.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","202.22","38.3","","200.19","200.19","200.19","1 through 10","67.01","419.76","percent of total billed charges",""
"Phys/Qhp Svcs OP Pulm Rehab WO Cont Oximtry Mntr","PX-94000056","CDM","94625","CPT","0948","RC","","","","both","","","528.00","396.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.13","69.13","69.13","1 through 10","67.01","419.76","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab WO Cont Oximtry Mntr","PX-94000056","CDM","94625","CPT","0948","RC","","","","both","","","528.00","396.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.23","69.41","208.23","25","67.01","419.76","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab WO Cont Oximtry Mntr","PX-94000056","CDM","94625","CPT","0948","RC","","","","both","","","528.00","396.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.51","42.9","","225.13","225.13","225.13","1 through 10","67.01","419.76","percent of total billed charges",""
"Phys/Qhp Svcs OP Pulm Rehab WO Cont Oximtry Mntr","PX-94000056","CDM","94625","CPT","0948","RC","","","","both","","","528.00","396.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.13","69.13","69.13","35","67.01","419.76","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab WO Cont Oximtry Mntr","PX-94000056","CDM","94625","CPT","0948","RC","","","","both","","","528.00","396.00","WELLPOINT [1015]","HB AMC WELLPOINT","389.56","73.78","","381.18","381.18","381.18","1 through 10","67.01","419.76","percent of total billed charges",""
"Phys/Qhp Svcs OP Pulm Rehab WO Cont Oximtry Mntr","PX-94000056","CDM","94625","CPT","0948","RC","","","","outpatient","","","528.00","396.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","431.48","81.72","","409.30","409.30","409.30","1 through 10","90.46","431.48","percent of total billed charges",""
"Phys/Qhp Telephone Evaluation 11-20 Min","PX-98301966","CDM","99442","CPT","0983","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","86.80","31","","86.52","86.52","86.52","1 through 10","72.1","266","percent of total billed charges",""
"Phys/Qhp Telephone Evaluation 11-20 Min","PX-98301966","CDM","99442","CPT","0983","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","102.20","36.5","","200.38","170.56","200.38","1 through 10","72.1","266","percent of total billed charges",""
"Phys/Qhp Telephone Evaluation 11-20 Min","PX-98301966","CDM","99442","CPT","0983","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","107.24","38.3","","210.32","210.32","210.32","1 through 10","72.1","266","percent of total billed charges",""
"Phys/Qhp Telephone Evaluation 11-20 Min","PX-98301966","CDM","99442","CPT","0983","RC","","","","outpatient","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","228.82","81.72","","276.00","276.00","276.00","1 through 10","45","228.82","percent of total billed charges",""
"Phys/Qhp Telephone Evaluation 21-30 Min","PX-98301967","CDM","99443","CPT","0983","RC","","","","both","","","415.00","311.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","145.25","35","","120.78","120.78","120.78","1 through 10","99.01","394.25","percent of total billed charges",""
"Phys/Qhp Telephone Evaluation 21-30 Min","PX-98301967","CDM","99443","CPT","0983","RC","","","","both","","","415.00","311.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","128.65","31","","128.24","128.24","128.24","1 through 10","99.01","394.25","percent of total billed charges",""
"Phys/Qhp Telephone Evaluation 21-30 Min","PX-98301967","CDM","99443","CPT","0983","RC","","","","both","","","415.00","311.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","151.48","36.5","","250.30","150.23","294.04","54","99.01","394.25","percent of total billed charges",""
"Phys/Qhp Telephone Evaluation 21-30 Min","PX-98301967","CDM","99443","CPT","0983","RC","","","","both","","","415.00","311.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","158.95","38.3","","308.62","157.70","308.62","71","99.01","394.25","percent of total billed charges",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","both","","","635.00","476.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","231.78","36.5","","195.27","195.27","195.27","1 through 10","107.02","603.25","percent of total billed charges",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","both","","","635.00","476.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","243.21","38.3","","234.08","234.08","234.08","1 through 10","107.02","603.25","percent of total billed charges",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","both","","","635.00","476.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($109.20). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($81.13). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","107.62","107.02","110.15","1 through 10","107.02","603.25","fee schedule",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","448.75","71.8","","107.53","107.53","107.53","1 through 10","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","437.50","70","","440.60","440.60","440.60","1 through 10","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","625.00","468.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","496.88","79.5","","476.80","288.36","476.92","1 through 10","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","625.00","468.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","333.13","53.3","","319.97","319.97","476.92","67","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","625.00","468.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","481.25","77","","466.62","439.67","466.62","1 through 10","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","193.75","31","","187.25","187.25","192.10","1 through 10","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.13","36.5","","226.04","192.10","226.04","106","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.38","38.3","","236.95","230.28","236.95","601","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","625.00","468.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","481.25","77","","472.68","472.68","472.68","1 through 10","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","625.00","468.75","TRICARE [160005]","HB BWH TRICARE","593.75","95","","111.59","103.74","717.59","1 through 10","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","625.00","468.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.13","42.9","","250.40","250.40","250.40","1 through 10","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","625.00","468.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($109.20). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($81.13). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","107.62","107.02","109.75","228","107.02","593.75","fee schedule",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","625.00","468.75","WELLPOINT [1015]","HB AMC WELLPOINT","461.13","73.78","","451.17","451.17","451.17","105","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","625.00","468.75","AETNA [1001]","HB AMC AETNA HMO","436.25","69.8","","410.26","289.67","472.68","186","228","673.39","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","625.00","468.75","AETNA [1001]","HB AMC AETNA PPO","502.50","80.4","","472.68","317.54","472.68","18","228","673.39","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","625.00","468.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","349.38","55.9","","317.54","317.54","317.54","1 through 10","228","673.39","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","625.00","468.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","502.50","80.4","","472.68","472.68","472.68","1 through 10","228","673.39","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","625.00","468.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","510.75","81.72","","484.44","484.44","484.44","1 through 10","228","673.39","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","625.00","468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","510.75","81.72","","439.73","29.40","606.00","1 through 10","228","673.39","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","410.00","65.6","","410.26","410.26","410.26","1 through 10","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","625.00","468.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","333.13","53.3","","476.92","319.97","495.12","1 through 10","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","193.75","31","","187.25","187.25","187.25","1 through 10","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.13","36.5","","226.04","192.10","226.04","14","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.38","38.3","","236.95","236.95","236.95","42","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","625.00","468.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($109.20). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($81.13). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","107.62","107.02","109.35","24","107.02","593.75","fee schedule",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","625.00","468.75","WELLPOINT [1015]","HB AMC WELLPOINT","461.13","73.78","","451.17","451.17","1057.17","12","107.02","593.75","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","outpatient","","","625.00","468.75","AETNA [1001]","HB AMC AETNA HMO","436.25","69.8","","289.67","289.67","472.68","15","228","673.39","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","outpatient","","","625.00","468.75","AETNA [1001]","HB AMC AETNA PPO","502.50","80.4","","317.54","317.54","472.68","1 through 10","228","673.39","percent of total billed charges",""
"Physical Therapy Re-Eval Est Plan Care 20 Mins","PX-42000103","CDM","97164","CPT","0424","RC","","","","both","","","428.00","321.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","74.39","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($75.91). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($54.42). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","74.55","74.40","74.55","1 through 10","74.39","406.6","fee schedule",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3070.28","52.26","","1113.10","1113.10","1113.10","1 through 10","1821.25","4670.63","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4670.63","79.5","","1293.60","1148.53","1603.80","1 through 10","1821.25","4670.63","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2144.38","36.5","","1023.42","771.29","2068.67","33","1821.25","4670.63","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2250.13","38.3","","850.52","759.78","1211.25","66","1821.25","4670.63","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2520.38","42.9","","2548.09","2548.09","2548.09","1 through 10","1821.25","4670.63","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2520.38","42.9","","956.46","956.46","956.46","1 through 10","1821.25","4670.63","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","5875.00","4406.25","WELLPOINT [1015]","HB AMC WELLPOINT","4334.58","73.78","","2344.73","1619.47","2530.35","16","1821.25","4670.63","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5875.00","4406.25","AETNA [1001]","HB AMC AETNA HMO","4100.75","69.8","","1523.63","988.41","4330.26","39","3070.28","4801.05","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5875.00","4406.25","AETNA [1001]","HB AMC AETNA PPO","4723.50","80.4","","1670.25","1670.25","1670.25","1 through 10","3070.28","4801.05","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5875.00","4406.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3070.28","52.26","","1113.10","1113.10","1113.10","1 through 10","3070.28","4801.05","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5875.00","4406.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4801.05","81.72","","1738.90","1484.65","2716.94","38","3070.28","4801.05","percent of total billed charges",""
"PIECE PENILE 14CM 3 IMPLANT INFLATABLE INFRAPUBIC APPROACH IZ TREATED AMS 701","SUP-ITM-10027728","CDM","C1813","HCPCS","0278","RC","","","","both","","","27183.00","20387.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10411.09","38.3","","12613.42","12613.42","12613.42","1 through 10","8426.73","21610.49","percent of total billed charges",""
"PIECE PENILE 14CM 3 IMPLANT INFLATABLE INFRAPUBIC APPROACH IZ TREATED AMS 701","SUP-ITM-10027728","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","27183.00","20387.25","AETNA [1001]","HB AMC AETNA HMO","18973.73","69.8","","34275.85","34275.85","50471.26","19","14205.84","22213.95","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3372.39","79.5","","800.18","480.96","1887.97","195","1315.02","3372.39","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2260.99","53.3","","813.12","216.42","1444.50","81","1315.02","3372.39","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1315.02","31","","432.60","432.60","432.60","1 through 10","1315.02","3372.39","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1548.33","36.5","","148.37","54.89","631.39","94","1315.02","3372.39","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1624.69","38.3","","279.30","91.72","1116.77","266","1315.02","3372.39","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1819.82","42.9","","731.00","63.70","731.00","1 through 10","1315.02","3372.39","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1819.82","42.9","","384.74","384.74","384.74","1 through 10","1315.02","3372.39","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","WELLPOINT [1015]","HB AMC WELLPOINT","3129.75","73.78","","286.63","119.22","1107.45","105","1315.02","3372.39","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","AETNA [1001]","HB AMC AETNA HMO","2960.92","69.8","","675.31","184.75","1721.50","286","2216.87","3466.56","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","AETNA [1001]","HB AMC AETNA PPO","3410.57","80.4","","1261.44","103.12","1514.10","21","2216.87","3466.56","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3410.57","80.4","","1365.00","1365.00","1365.00","1 through 10","2216.87","3466.56","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3466.56","81.72","","5157.68","5157.68","5157.68","1 through 10","2216.87","3466.56","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3466.56","81.72","","431.26","71.26","1459.57","88","2216.87","3466.56","percent of total billed charges",""
"PIN AXIS 2.5X50MM","SUP-ITM-10170022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1099.00","824.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","873.71","79.5","","800.18","480.96","1887.97","195","340.69","873.71","percent of total billed charges",""
"PIN AXIS 2.5X50MM","SUP-ITM-10170022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1099.00","824.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","585.77","53.3","","813.12","216.42","1444.50","81","340.69","873.71","percent of total billed charges",""
"PIN AXIS 2.5X50MM","SUP-ITM-10170022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1099.00","824.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","340.69","31","","432.60","432.60","432.60","1 through 10","340.69","873.71","percent of total billed charges",""
"PIN AXIS 2.5X50MM","SUP-ITM-10170022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1099.00","824.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","401.14","36.5","","148.37","54.89","631.39","94","340.69","873.71","percent of total billed charges",""
"PIN AXIS 2.5X50MM","SUP-ITM-10170022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1099.00","824.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","420.92","38.3","","279.30","91.72","1116.77","266","340.69","873.71","percent of total billed charges",""
"PIN AXIS 2.5X50MM","SUP-ITM-10170022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1099.00","824.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","471.47","42.9","","731.00","63.70","731.00","1 through 10","340.69","873.71","percent of total billed charges",""
"PIN AXIS 2.5X50MM","SUP-ITM-10170022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1099.00","824.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","471.47","42.9","","384.74","384.74","384.74","1 through 10","340.69","873.71","percent of total billed charges",""
"PIN AXIS 2.5X50MM","SUP-ITM-10170022","CDM","C1713","HCPCS","0278","RC","","","","both","","","1099.00","824.25","WELLPOINT [1015]","HB AMC WELLPOINT","810.84","73.78","","286.63","119.22","1107.45","105","340.69","873.71","percent of total billed charges",""
"PIN AXIS 2.5X50MM","SUP-ITM-10170022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1099.00","824.25","AETNA [1001]","HB AMC AETNA HMO","767.10","69.8","","675.31","184.75","1721.50","286","574.34","898.1","percent of total billed charges",""
"PIN AXIS 2.5X50MM","SUP-ITM-10170022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1099.00","824.25","AETNA [1001]","HB AMC AETNA PPO","883.60","80.4","","1261.44","103.12","1514.10","21","574.34","898.1","percent of total billed charges",""
"PIN AXIS 2.5X50MM","SUP-ITM-10170022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1099.00","824.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","883.60","80.4","","1365.00","1365.00","1365.00","1 through 10","574.34","898.1","percent of total billed charges",""
"PIN AXIS 2.5X50MM","SUP-ITM-10170022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1099.00","824.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","898.10","81.72","","5157.68","5157.68","5157.68","1 through 10","574.34","898.1","percent of total billed charges",""
"PIN AXIS 2.5X50MM","SUP-ITM-10170022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1099.00","824.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","898.10","81.72","","431.26","71.26","1459.57","88","574.34","898.1","percent of total billed charges",""
"PIN BONE 1.8X14MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006546","CDM","C1889","HCPCS","0278","RC","","","","both","","","159.29","119.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","126.64","79.5","","1309.77","674.56","6049.93","26","49.38","126.64","percent of total billed charges",""
"PIN BONE 1.8X14MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006546","CDM","C1889","HCPCS","0278","RC","","","","both","","","159.29","119.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","84.90","53.3","","1901.83","1901.83","2962.25","1 through 10","49.38","126.64","percent of total billed charges",""
"PIN BONE 1.8X14MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006546","CDM","C1889","HCPCS","0278","RC","","","","both","","","159.29","119.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.14","36.5","","1620.31","1620.31","19908.88","1 through 10","49.38","126.64","percent of total billed charges",""
"PIN BONE 1.8X14MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006546","CDM","C1889","HCPCS","0278","RC","","","","both","","","159.29","119.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.01","38.3","","352.91","352.91","2046.30","1 through 10","49.38","126.64","percent of total billed charges",""
"PIN BONE 1.8X14MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006546","CDM","C1889","HCPCS","0278","RC","","","","both","","","159.29","119.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.34","42.9","","9668.75","9668.75","9668.75","1 through 10","49.38","126.64","percent of total billed charges",""
"PIN BONE 1.8X14MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006546","CDM","C1889","HCPCS","0278","RC","","","","both","","","159.29","119.47","WELLPOINT [1015]","HB AMC WELLPOINT","117.52","73.78","","699.88","384.10","3443.31","33","49.38","126.64","percent of total billed charges",""
"PIN BONE 1.8X14MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006546","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","159.29","119.47","AETNA [1001]","HB AMC AETNA HMO","111.18","69.8","","1421.24","264.50","4933.46","29","83.24","130.17","percent of total billed charges",""
"PIN BONE 1.8X14MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006546","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","159.29","119.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.07","80.4","","1022.97","1022.97","3607.50","1 through 10","83.24","130.17","percent of total billed charges",""
"PIN BONE 1.8X14MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006546","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","159.29","119.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.17","81.72","","3010.54","693.88","5019.88","35","83.24","130.17","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","140.02","79.5","","800.18","480.96","1887.97","195","54.6","140.02","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.87","53.3","","813.12","216.42","1444.50","81","54.6","140.02","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.60","31","","432.60","432.60","432.60","1 through 10","54.6","140.02","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.28","36.5","","148.37","54.89","631.39","94","54.6","140.02","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.45","38.3","","279.30","91.72","1116.77","266","54.6","140.02","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.56","42.9","","731.00","63.70","731.00","1 through 10","54.6","140.02","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.56","42.9","","384.74","384.74","384.74","1 through 10","54.6","140.02","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","WELLPOINT [1015]","HB AMC WELLPOINT","129.94","73.78","","286.63","119.22","1107.45","105","54.6","140.02","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.12","132.09","AETNA [1001]","HB AMC AETNA HMO","122.93","69.8","","675.31","184.75","1721.50","286","92.04","143.93","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.12","132.09","AETNA [1001]","HB AMC AETNA PPO","141.60","80.4","","1261.44","103.12","1514.10","21","92.04","143.93","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.12","132.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","141.60","80.4","","1365.00","1365.00","1365.00","1 through 10","92.04","143.93","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.12","132.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.93","81.72","","5157.68","5157.68","5157.68","1 through 10","92.04","143.93","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS HAND MODULAR TITANIUM","SUP-ITM-10004071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.12","132.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.93","81.72","","431.26","71.26","1459.57","88","92.04","143.93","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","159.29","119.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","126.64","79.5","","1309.77","674.56","6049.93","26","49.38","126.64","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","159.29","119.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","84.90","53.3","","1901.83","1901.83","2962.25","1 through 10","49.38","126.64","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","159.29","119.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.14","36.5","","1620.31","1620.31","19908.88","1 through 10","49.38","126.64","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","159.29","119.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.01","38.3","","352.91","352.91","2046.30","1 through 10","49.38","126.64","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","159.29","119.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.34","42.9","","9668.75","9668.75","9668.75","1 through 10","49.38","126.64","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","159.29","119.47","WELLPOINT [1015]","HB AMC WELLPOINT","117.52","73.78","","699.88","384.10","3443.31","33","49.38","126.64","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","159.29","119.47","AETNA [1001]","HB AMC AETNA HMO","111.18","69.8","","1421.24","264.50","4933.46","29","83.24","130.17","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","159.29","119.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.07","80.4","","1022.97","1022.97","3607.50","1 through 10","83.24","130.17","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","159.29","119.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.17","81.72","","3010.54","693.88","5019.88","35","83.24","130.17","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1182.56","79.5","","800.18","480.96","1887.97","195","461.13","1182.56","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","792.84","53.3","","813.12","216.42","1444.50","81","461.13","1182.56","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","461.13","31","","432.60","432.60","432.60","1 through 10","461.13","1182.56","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","542.94","36.5","","148.37","54.89","631.39","94","461.13","1182.56","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","569.71","38.3","","279.30","91.72","1116.77","266","461.13","1182.56","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","638.14","42.9","","731.00","63.70","731.00","1 through 10","461.13","1182.56","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","638.14","42.9","","384.74","384.74","384.74","1 through 10","461.13","1182.56","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","WELLPOINT [1015]","HB AMC WELLPOINT","1097.48","73.78","","286.63","119.22","1107.45","105","461.13","1182.56","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","AETNA [1001]","HB AMC AETNA HMO","1038.28","69.8","","675.31","184.75","1721.50","286","777.37","1215.59","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","AETNA [1001]","HB AMC AETNA PPO","1195.95","80.4","","1261.44","103.12","1514.10","21","777.37","1215.59","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1195.95","80.4","","1365.00","1365.00","1365.00","1 through 10","777.37","1215.59","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1215.59","81.72","","5157.68","5157.68","5157.68","1 through 10","777.37","1215.59","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1215.59","81.72","","431.26","71.26","1459.57","88","777.37","1215.59","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","414.07","79.5","","800.18","480.96","1887.97","195","161.46","414.07","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","277.61","53.3","","813.12","216.42","1444.50","81","161.46","414.07","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","161.46","31","","432.60","432.60","432.60","1 through 10","161.46","414.07","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","190.11","36.5","","148.37","54.89","631.39","94","161.46","414.07","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","199.48","38.3","","279.30","91.72","1116.77","266","161.46","414.07","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","223.44","42.9","","731.00","63.70","731.00","1 through 10","161.46","414.07","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","223.44","42.9","","384.74","384.74","384.74","1 through 10","161.46","414.07","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.84","390.63","WELLPOINT [1015]","HB AMC WELLPOINT","384.28","73.78","","286.63","119.22","1107.45","105","161.46","414.07","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.84","390.63","AETNA [1001]","HB AMC AETNA HMO","363.55","69.8","","675.31","184.75","1721.50","286","272.19","425.63","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.84","390.63","AETNA [1001]","HB AMC AETNA PPO","418.76","80.4","","1261.44","103.12","1514.10","21","272.19","425.63","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.84","390.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","418.76","80.4","","1365.00","1365.00","1365.00","1 through 10","272.19","425.63","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.84","390.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","425.63","81.72","","5157.68","5157.68","5157.68","1 through 10","272.19","425.63","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.84","390.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","425.63","81.72","","431.26","71.26","1459.57","88","272.19","425.63","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.09","40.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","43.00","79.5","","800.18","480.96","1887.97","195","16.77","43","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.09","40.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","28.83","53.3","","813.12","216.42","1444.50","81","16.77","43","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.09","40.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","16.77","31","","432.60","432.60","432.60","1 through 10","16.77","43","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.09","40.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19.74","36.5","","148.37","54.89","631.39","94","16.77","43","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.09","40.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20.72","38.3","","279.30","91.72","1116.77","266","16.77","43","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.09","40.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23.20","42.9","","731.00","63.70","731.00","1 through 10","16.77","43","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.09","40.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23.20","42.9","","384.74","384.74","384.74","1 through 10","16.77","43","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.09","40.57","WELLPOINT [1015]","HB AMC WELLPOINT","39.91","73.78","","286.63","119.22","1107.45","105","16.77","43","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.09","40.57","AETNA [1001]","HB AMC AETNA HMO","37.75","69.8","","675.31","184.75","1721.50","286","28.27","44.2","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.09","40.57","AETNA [1001]","HB AMC AETNA PPO","43.49","80.4","","1261.44","103.12","1514.10","21","28.27","44.2","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.09","40.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","43.49","80.4","","1365.00","1365.00","1365.00","1 through 10","28.27","44.2","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.09","40.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","44.20","81.72","","5157.68","5157.68","5157.68","1 through 10","28.27","44.2","percent of total billed charges",""
"PIN BONE 2.0X229MM STEINMANN SS FULL THREAD DIAMOND POINT SINGLE STYLE 6 BX/6","SUP-ITM-10028370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.09","40.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","44.20","81.72","","431.26","71.26","1459.57","88","28.27","44.2","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","542.17","79.5","","800.18","480.96","1887.97","195","211.41","542.17","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","363.50","53.3","","813.12","216.42","1444.50","81","211.41","542.17","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","211.41","31","","432.60","432.60","432.60","1 through 10","211.41","542.17","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","248.92","36.5","","148.37","54.89","631.39","94","211.41","542.17","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.20","38.3","","279.30","91.72","1116.77","266","211.41","542.17","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.57","42.9","","731.00","63.70","731.00","1 through 10","211.41","542.17","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.57","42.9","","384.74","384.74","384.74","1 through 10","211.41","542.17","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","WELLPOINT [1015]","HB AMC WELLPOINT","503.16","73.78","","286.63","119.22","1107.45","105","211.41","542.17","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.98","511.48","AETNA [1001]","HB AMC AETNA HMO","476.02","69.8","","675.31","184.75","1721.50","286","356.4","557.31","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.98","511.48","AETNA [1001]","HB AMC AETNA PPO","548.31","80.4","","1261.44","103.12","1514.10","21","356.4","557.31","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.98","511.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","548.31","80.4","","1365.00","1365.00","1365.00","1 through 10","356.4","557.31","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.98","511.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","557.31","81.72","","5157.68","5157.68","5157.68","1 through 10","356.4","557.31","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.98","511.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","557.31","81.72","","431.26","71.26","1459.57","88","356.4","557.31","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.95","79.5","","800.18","480.96","1887.97","195","65.1","166.95","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.93","53.3","","813.12","216.42","1444.50","81","65.1","166.95","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","65.10","31","","432.60","432.60","432.60","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.65","36.5","","148.37","54.89","631.39","94","65.1","166.95","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.43","38.3","","279.30","91.72","1116.77","266","65.1","166.95","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","731.00","63.70","731.00","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","384.74","384.74","384.74","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB AMC WELLPOINT","154.94","73.78","","286.63","119.22","1107.45","105","65.1","166.95","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA HMO","146.58","69.8","","675.31","184.75","1721.50","286","109.75","171.61","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA PPO","168.84","80.4","","1261.44","103.12","1514.10","21","109.75","171.61","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","168.84","80.4","","1365.00","1365.00","1365.00","1 through 10","109.75","171.61","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","171.61","81.72","","5157.68","5157.68","5157.68","1 through 10","109.75","171.61","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.61","81.72","","431.26","71.26","1459.57","88","109.75","171.61","percent of total billed charges",""
"PIN BONE 25MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1085.18","79.5","","800.18","480.96","1887.97","195","423.15","1085.18","percent of total billed charges",""
"PIN BONE 25MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","727.55","53.3","","813.12","216.42","1444.50","81","423.15","1085.18","percent of total billed charges",""
"PIN BONE 25MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","423.15","31","","432.60","432.60","432.60","1 through 10","423.15","1085.18","percent of total billed charges",""
"PIN BONE 25MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","498.23","36.5","","148.37","54.89","631.39","94","423.15","1085.18","percent of total billed charges",""
"PIN BONE 25MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","522.80","38.3","","279.30","91.72","1116.77","266","423.15","1085.18","percent of total billed charges",""
"PIN BONE 25MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","731.00","63.70","731.00","1 through 10","423.15","1085.18","percent of total billed charges",""
"PIN BONE 25MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","384.74","384.74","384.74","1 through 10","423.15","1085.18","percent of total billed charges",""
"PIN BONE 25MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB AMC WELLPOINT","1007.10","73.78","","286.63","119.22","1107.45","105","423.15","1085.18","percent of total billed charges",""
"PIN BONE 25MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA HMO","952.77","69.8","","675.31","184.75","1721.50","286","713.35","1115.48","percent of total billed charges",""
"PIN BONE 25MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA PPO","1097.46","80.4","","1261.44","103.12","1514.10","21","713.35","1115.48","percent of total billed charges",""
"PIN BONE 25MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1097.46","80.4","","1365.00","1365.00","1365.00","1 through 10","713.35","1115.48","percent of total billed charges",""
"PIN BONE 25MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1115.48","81.72","","5157.68","5157.68","5157.68","1 through 10","713.35","1115.48","percent of total billed charges",""
"PIN BONE 25MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1115.48","81.72","","431.26","71.26","1459.57","88","713.35","1115.48","percent of total billed charges",""
"PIN BONE 3.2MM SHORT GUIDE TRIGEN SS THREADED TIP BX/1EA","SUP-ITM-10018375","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.25","460.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","488.33","79.5","","800.18","480.96","1887.97","195","190.42","488.33","percent of total billed charges",""
"PIN BONE 3.2MM SHORT GUIDE TRIGEN SS THREADED TIP BX/1EA","SUP-ITM-10018375","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.25","460.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","327.40","53.3","","813.12","216.42","1444.50","81","190.42","488.33","percent of total billed charges",""
"PIN BONE 3.2MM SHORT GUIDE TRIGEN SS THREADED TIP BX/1EA","SUP-ITM-10018375","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.25","460.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","190.42","31","","432.60","432.60","432.60","1 through 10","190.42","488.33","percent of total billed charges",""
"PIN BONE 3.2MM SHORT GUIDE TRIGEN SS THREADED TIP BX/1EA","SUP-ITM-10018375","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.25","460.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","224.20","36.5","","148.37","54.89","631.39","94","190.42","488.33","percent of total billed charges",""
"PIN BONE 3.2MM SHORT GUIDE TRIGEN SS THREADED TIP BX/1EA","SUP-ITM-10018375","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.25","460.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","235.26","38.3","","279.30","91.72","1116.77","266","190.42","488.33","percent of total billed charges",""
"PIN BONE 3.2MM SHORT GUIDE TRIGEN SS THREADED TIP BX/1EA","SUP-ITM-10018375","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.25","460.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","263.51","42.9","","731.00","63.70","731.00","1 through 10","190.42","488.33","percent of total billed charges",""
"PIN BONE 3.2MM SHORT GUIDE TRIGEN SS THREADED TIP BX/1EA","SUP-ITM-10018375","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.25","460.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","263.51","42.9","","384.74","384.74","384.74","1 through 10","190.42","488.33","percent of total billed charges",""
"PIN BONE 3.2MM SHORT GUIDE TRIGEN SS THREADED TIP BX/1EA","SUP-ITM-10018375","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.25","460.69","WELLPOINT [1015]","HB AMC WELLPOINT","453.19","73.78","","286.63","119.22","1107.45","105","190.42","488.33","percent of total billed charges",""
"PIN BONE 3.2MM SHORT GUIDE TRIGEN SS THREADED TIP BX/1EA","SUP-ITM-10018375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.25","460.69","AETNA [1001]","HB AMC AETNA HMO","428.75","69.8","","675.31","184.75","1721.50","286","321.01","501.97","percent of total billed charges",""
"PIN BONE 3.2MM SHORT GUIDE TRIGEN SS THREADED TIP BX/1EA","SUP-ITM-10018375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.25","460.69","AETNA [1001]","HB AMC AETNA PPO","493.86","80.4","","1261.44","103.12","1514.10","21","321.01","501.97","percent of total billed charges",""
"PIN BONE 3.2MM SHORT GUIDE TRIGEN SS THREADED TIP BX/1EA","SUP-ITM-10018375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.25","460.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","493.86","80.4","","1365.00","1365.00","1365.00","1 through 10","321.01","501.97","percent of total billed charges",""
"PIN BONE 3.2MM SHORT GUIDE TRIGEN SS THREADED TIP BX/1EA","SUP-ITM-10018375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.25","460.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","501.97","81.72","","5157.68","5157.68","5157.68","1 through 10","321.01","501.97","percent of total billed charges",""
"PIN BONE 3.2MM SHORT GUIDE TRIGEN SS THREADED TIP BX/1EA","SUP-ITM-10018375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.25","460.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","501.97","81.72","","431.26","71.26","1459.57","88","321.01","501.97","percent of total billed charges",""
"PIN BONE 3.2X343MM GUIDE TRIGEN INTERTAN COBALT THREADED BRAD POINT TIP","SUP-ITM-10092638","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.75","494.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","524.50","79.5","","800.18","480.96","1887.97","195","204.52","524.5","percent of total billed charges",""
"PIN BONE 3.2X343MM GUIDE TRIGEN INTERTAN COBALT THREADED BRAD POINT TIP","SUP-ITM-10092638","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.75","494.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","351.65","53.3","","813.12","216.42","1444.50","81","204.52","524.5","percent of total billed charges",""
"PIN BONE 3.2X343MM GUIDE TRIGEN INTERTAN COBALT THREADED BRAD POINT TIP","SUP-ITM-10092638","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.75","494.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","204.52","31","","432.60","432.60","432.60","1 through 10","204.52","524.5","percent of total billed charges",""
"PIN BONE 3.2X343MM GUIDE TRIGEN INTERTAN COBALT THREADED BRAD POINT TIP","SUP-ITM-10092638","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.75","494.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","240.81","36.5","","148.37","54.89","631.39","94","204.52","524.5","percent of total billed charges",""
"PIN BONE 3.2X343MM GUIDE TRIGEN INTERTAN COBALT THREADED BRAD POINT TIP","SUP-ITM-10092638","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.75","494.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","252.68","38.3","","279.30","91.72","1116.77","266","204.52","524.5","percent of total billed charges",""
"PIN BONE 3.2X343MM GUIDE TRIGEN INTERTAN COBALT THREADED BRAD POINT TIP","SUP-ITM-10092638","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.75","494.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","283.03","42.9","","731.00","63.70","731.00","1 through 10","204.52","524.5","percent of total billed charges",""
"PIN BONE 3.2X343MM GUIDE TRIGEN INTERTAN COBALT THREADED BRAD POINT TIP","SUP-ITM-10092638","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.75","494.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","283.03","42.9","","384.74","384.74","384.74","1 through 10","204.52","524.5","percent of total billed charges",""
"PIN BONE 3.2X343MM GUIDE TRIGEN INTERTAN COBALT THREADED BRAD POINT TIP","SUP-ITM-10092638","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.75","494.81","WELLPOINT [1015]","HB AMC WELLPOINT","486.76","73.78","","286.63","119.22","1107.45","105","204.52","524.5","percent of total billed charges",""
"PIN BONE 3.2X343MM GUIDE TRIGEN INTERTAN COBALT THREADED BRAD POINT TIP","SUP-ITM-10092638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.75","494.81","AETNA [1001]","HB AMC AETNA HMO","460.51","69.8","","675.31","184.75","1721.50","286","344.79","539.15","percent of total billed charges",""
"PIN BONE 3.2X343MM GUIDE TRIGEN INTERTAN COBALT THREADED BRAD POINT TIP","SUP-ITM-10092638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.75","494.81","AETNA [1001]","HB AMC AETNA PPO","530.44","80.4","","1261.44","103.12","1514.10","21","344.79","539.15","percent of total billed charges",""
"PIN BONE 3.2X343MM GUIDE TRIGEN INTERTAN COBALT THREADED BRAD POINT TIP","SUP-ITM-10092638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.75","494.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","530.44","80.4","","1365.00","1365.00","1365.00","1 through 10","344.79","539.15","percent of total billed charges",""
"PIN BONE 3.2X343MM GUIDE TRIGEN INTERTAN COBALT THREADED BRAD POINT TIP","SUP-ITM-10092638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.75","494.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","539.15","81.72","","5157.68","5157.68","5157.68","1 through 10","344.79","539.15","percent of total billed charges",""
"PIN BONE 3.2X343MM GUIDE TRIGEN INTERTAN COBALT THREADED BRAD POINT TIP","SUP-ITM-10092638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.75","494.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","539.15","81.72","","431.26","71.26","1459.57","88","344.79","539.15","percent of total billed charges",""
"PIN BONE 3.2X37MM HEADED THREADED SQUARE","SUP-ITM-10328778","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","800.18","480.96","1887.97","195","217","556.5","percent of total billed charges",""
"PIN BONE 3.2X37MM HEADED THREADED SQUARE","SUP-ITM-10328778","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","813.12","216.42","1444.50","81","217","556.5","percent of total billed charges",""
"PIN BONE 3.2X37MM HEADED THREADED SQUARE","SUP-ITM-10328778","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","217.00","31","","432.60","432.60","432.60","1 through 10","217","556.5","percent of total billed charges",""
"PIN BONE 3.2X37MM HEADED THREADED SQUARE","SUP-ITM-10328778","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","148.37","54.89","631.39","94","217","556.5","percent of total billed charges",""
"PIN BONE 3.2X37MM HEADED THREADED SQUARE","SUP-ITM-10328778","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","279.30","91.72","1116.77","266","217","556.5","percent of total billed charges",""
"PIN BONE 3.2X37MM HEADED THREADED SQUARE","SUP-ITM-10328778","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","731.00","63.70","731.00","1 through 10","217","556.5","percent of total billed charges",""
"PIN BONE 3.2X37MM HEADED THREADED SQUARE","SUP-ITM-10328778","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","384.74","384.74","384.74","1 through 10","217","556.5","percent of total billed charges",""
"PIN BONE 3.2X37MM HEADED THREADED SQUARE","SUP-ITM-10328778","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","286.63","119.22","1107.45","105","217","556.5","percent of total billed charges",""
"PIN BONE 3.2X37MM HEADED THREADED SQUARE","SUP-ITM-10328778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","675.31","184.75","1721.50","286","365.82","572.04","percent of total billed charges",""
"PIN BONE 3.2X37MM HEADED THREADED SQUARE","SUP-ITM-10328778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA PPO","562.80","80.4","","1261.44","103.12","1514.10","21","365.82","572.04","percent of total billed charges",""
"PIN BONE 3.2X37MM HEADED THREADED SQUARE","SUP-ITM-10328778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","562.80","80.4","","1365.00","1365.00","1365.00","1 through 10","365.82","572.04","percent of total billed charges",""
"PIN BONE 3.2X37MM HEADED THREADED SQUARE","SUP-ITM-10328778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","572.04","81.72","","5157.68","5157.68","5157.68","1 through 10","365.82","572.04","percent of total billed charges",""
"PIN BONE 3.2X37MM HEADED THREADED SQUARE","SUP-ITM-10328778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","431.26","71.26","1459.57","88","365.82","572.04","percent of total billed charges",""
"PIN BONE 3.5X120MM STEINMANN SS EXTERNAL FIXATION","SUP-ITM-10038573","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.68","74.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","79.25","79.5","","800.18","480.96","1887.97","195","30.9","79.25","percent of total billed charges",""
"PIN BONE 3.5X120MM STEINMANN SS EXTERNAL FIXATION","SUP-ITM-10038573","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.68","74.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","53.13","53.3","","813.12","216.42","1444.50","81","30.9","79.25","percent of total billed charges",""
"PIN BONE 3.5X120MM STEINMANN SS EXTERNAL FIXATION","SUP-ITM-10038573","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.68","74.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","30.90","31","","432.60","432.60","432.60","1 through 10","30.9","79.25","percent of total billed charges",""
"PIN BONE 3.5X120MM STEINMANN SS EXTERNAL FIXATION","SUP-ITM-10038573","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.68","74.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36.38","36.5","","148.37","54.89","631.39","94","30.9","79.25","percent of total billed charges",""
"PIN BONE 3.5X120MM STEINMANN SS EXTERNAL FIXATION","SUP-ITM-10038573","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.68","74.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38.18","38.3","","279.30","91.72","1116.77","266","30.9","79.25","percent of total billed charges",""
"PIN BONE 3.5X120MM STEINMANN SS EXTERNAL FIXATION","SUP-ITM-10038573","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.68","74.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.76","42.9","","731.00","63.70","731.00","1 through 10","30.9","79.25","percent of total billed charges",""
"PIN BONE 3.5X120MM STEINMANN SS EXTERNAL FIXATION","SUP-ITM-10038573","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.68","74.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.76","42.9","","384.74","384.74","384.74","1 through 10","30.9","79.25","percent of total billed charges",""
"PIN BONE 3.5X120MM STEINMANN SS EXTERNAL FIXATION","SUP-ITM-10038573","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.68","74.76","WELLPOINT [1015]","HB AMC WELLPOINT","73.54","73.78","","286.63","119.22","1107.45","105","30.9","79.25","percent of total billed charges",""
"PIN BONE 3.5X120MM STEINMANN SS EXTERNAL FIXATION","SUP-ITM-10038573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.68","74.76","AETNA [1001]","HB AMC AETNA HMO","69.58","69.8","","675.31","184.75","1721.50","286","52.09","81.46","percent of total billed charges",""
"PIN BONE 3.5X120MM STEINMANN SS EXTERNAL FIXATION","SUP-ITM-10038573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.68","74.76","AETNA [1001]","HB AMC AETNA PPO","80.14","80.4","","1261.44","103.12","1514.10","21","52.09","81.46","percent of total billed charges",""
"PIN BONE 3.5X120MM STEINMANN SS EXTERNAL FIXATION","SUP-ITM-10038573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.68","74.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","80.14","80.4","","1365.00","1365.00","1365.00","1 through 10","52.09","81.46","percent of total billed charges",""
"PIN BONE 3.5X120MM STEINMANN SS EXTERNAL FIXATION","SUP-ITM-10038573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.68","74.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","81.46","81.72","","5157.68","5157.68","5157.68","1 through 10","52.09","81.46","percent of total billed charges",""
"PIN BONE 3.5X120MM STEINMANN SS EXTERNAL FIXATION","SUP-ITM-10038573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.68","74.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","81.46","81.72","","431.26","71.26","1459.57","88","52.09","81.46","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3372.39","79.5","","800.18","480.96","1887.97","195","1315.02","3372.39","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2260.99","53.3","","813.12","216.42","1444.50","81","1315.02","3372.39","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1315.02","31","","432.60","432.60","432.60","1 through 10","1315.02","3372.39","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1548.33","36.5","","148.37","54.89","631.39","94","1315.02","3372.39","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1624.69","38.3","","279.30","91.72","1116.77","266","1315.02","3372.39","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1819.82","42.9","","731.00","63.70","731.00","1 through 10","1315.02","3372.39","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1819.82","42.9","","384.74","384.74","384.74","1 through 10","1315.02","3372.39","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","WELLPOINT [1015]","HB AMC WELLPOINT","3129.75","73.78","","286.63","119.22","1107.45","105","1315.02","3372.39","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","AETNA [1001]","HB AMC AETNA HMO","2960.92","69.8","","675.31","184.75","1721.50","286","2216.87","3466.56","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","AETNA [1001]","HB AMC AETNA PPO","3410.57","80.4","","1261.44","103.12","1514.10","21","2216.87","3466.56","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3410.57","80.4","","1365.00","1365.00","1365.00","1 through 10","2216.87","3466.56","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3466.56","81.72","","5157.68","5157.68","5157.68","1 through 10","2216.87","3466.56","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3466.56","81.72","","431.26","71.26","1459.57","88","2216.87","3466.56","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10014107","CDM","C1713","HCPCS","0278","RC","","","","both","","","28.02","21.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","22.28","79.5","","800.18","480.96","1887.97","195","8.69","22.28","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10014107","CDM","C1713","HCPCS","0278","RC","","","","both","","","28.02","21.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14.93","53.3","","813.12","216.42","1444.50","81","8.69","22.28","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10014107","CDM","C1713","HCPCS","0278","RC","","","","both","","","28.02","21.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","8.69","31","","432.60","432.60","432.60","1 through 10","8.69","22.28","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10014107","CDM","C1713","HCPCS","0278","RC","","","","both","","","28.02","21.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10.23","36.5","","148.37","54.89","631.39","94","8.69","22.28","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10014107","CDM","C1713","HCPCS","0278","RC","","","","both","","","28.02","21.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10.73","38.3","","279.30","91.72","1116.77","266","8.69","22.28","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10014107","CDM","C1713","HCPCS","0278","RC","","","","both","","","28.02","21.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12.02","42.9","","731.00","63.70","731.00","1 through 10","8.69","22.28","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10014107","CDM","C1713","HCPCS","0278","RC","","","","both","","","28.02","21.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12.02","42.9","","384.74","384.74","384.74","1 through 10","8.69","22.28","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10014107","CDM","C1713","HCPCS","0278","RC","","","","both","","","28.02","21.01","WELLPOINT [1015]","HB AMC WELLPOINT","20.67","73.78","","286.63","119.22","1107.45","105","8.69","22.28","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10014107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","28.02","21.01","AETNA [1001]","HB AMC AETNA HMO","19.56","69.8","","675.31","184.75","1721.50","286","14.64","22.9","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10014107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","28.02","21.01","AETNA [1001]","HB AMC AETNA PPO","22.53","80.4","","1261.44","103.12","1514.10","21","14.64","22.9","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10014107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","28.02","21.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","22.53","80.4","","1365.00","1365.00","1365.00","1 through 10","14.64","22.9","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10014107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","28.02","21.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","22.90","81.72","","5157.68","5157.68","5157.68","1 through 10","14.64","22.9","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10014107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","28.02","21.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22.90","81.72","","431.26","71.26","1459.57","88","14.64","22.9","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN THREADED PLAIN SHANK TROCAR POIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014108","CDM","C1713","HCPCS","0278","RC","","","","both","","","43.03","32.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","34.21","79.5","","800.18","480.96","1887.97","195","13.34","34.21","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN THREADED PLAIN SHANK TROCAR POIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014108","CDM","C1713","HCPCS","0278","RC","","","","both","","","43.03","32.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22.93","53.3","","813.12","216.42","1444.50","81","13.34","34.21","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN THREADED PLAIN SHANK TROCAR POIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014108","CDM","C1713","HCPCS","0278","RC","","","","both","","","43.03","32.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","13.34","31","","432.60","432.60","432.60","1 through 10","13.34","34.21","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN THREADED PLAIN SHANK TROCAR POIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014108","CDM","C1713","HCPCS","0278","RC","","","","both","","","43.03","32.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15.71","36.5","","148.37","54.89","631.39","94","13.34","34.21","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN THREADED PLAIN SHANK TROCAR POIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014108","CDM","C1713","HCPCS","0278","RC","","","","both","","","43.03","32.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.48","38.3","","279.30","91.72","1116.77","266","13.34","34.21","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN THREADED PLAIN SHANK TROCAR POIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014108","CDM","C1713","HCPCS","0278","RC","","","","both","","","43.03","32.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.46","42.9","","731.00","63.70","731.00","1 through 10","13.34","34.21","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN THREADED PLAIN SHANK TROCAR POIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014108","CDM","C1713","HCPCS","0278","RC","","","","both","","","43.03","32.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.46","42.9","","384.74","384.74","384.74","1 through 10","13.34","34.21","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN THREADED PLAIN SHANK TROCAR POIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014108","CDM","C1713","HCPCS","0278","RC","","","","both","","","43.03","32.27","WELLPOINT [1015]","HB AMC WELLPOINT","31.75","73.78","","286.63","119.22","1107.45","105","13.34","34.21","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN THREADED PLAIN SHANK TROCAR POIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","43.03","32.27","AETNA [1001]","HB AMC AETNA HMO","30.03","69.8","","675.31","184.75","1721.50","286","22.49","35.16","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN THREADED PLAIN SHANK TROCAR POIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","43.03","32.27","AETNA [1001]","HB AMC AETNA PPO","34.60","80.4","","1261.44","103.12","1514.10","21","22.49","35.16","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN THREADED PLAIN SHANK TROCAR POIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","43.03","32.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","34.60","80.4","","1365.00","1365.00","1365.00","1 through 10","22.49","35.16","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN THREADED PLAIN SHANK TROCAR POIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","43.03","32.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","35.16","81.72","","5157.68","5157.68","5157.68","1 through 10","22.49","35.16","percent of total billed charges",""
"PIN BONE 3/16X9IN STEINMANN THREADED PLAIN SHANK TROCAR POIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10014108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","43.03","32.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","35.16","81.72","","431.26","71.26","1459.57","88","22.49","35.16","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10013191","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.51","26.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","28.23","79.5","","800.18","480.96","1887.97","195","11.01","28.23","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10013191","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.51","26.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","18.93","53.3","","813.12","216.42","1444.50","81","11.01","28.23","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10013191","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.51","26.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","11.01","31","","432.60","432.60","432.60","1 through 10","11.01","28.23","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10013191","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.51","26.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12.96","36.5","","148.37","54.89","631.39","94","11.01","28.23","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10013191","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.51","26.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","13.60","38.3","","279.30","91.72","1116.77","266","11.01","28.23","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10013191","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.51","26.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.23","42.9","","731.00","63.70","731.00","1 through 10","11.01","28.23","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10013191","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.51","26.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.23","42.9","","384.74","384.74","384.74","1 through 10","11.01","28.23","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10013191","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.51","26.63","WELLPOINT [1015]","HB AMC WELLPOINT","26.20","73.78","","286.63","119.22","1107.45","105","11.01","28.23","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10013191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","35.51","26.63","AETNA [1001]","HB AMC AETNA HMO","24.79","69.8","","675.31","184.75","1721.50","286","18.56","29.02","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10013191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","35.51","26.63","AETNA [1001]","HB AMC AETNA PPO","28.55","80.4","","1261.44","103.12","1514.10","21","18.56","29.02","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10013191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","35.51","26.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","28.55","80.4","","1365.00","1365.00","1365.00","1 through 10","18.56","29.02","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10013191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","35.51","26.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","29.02","81.72","","5157.68","5157.68","5157.68","1 through 10","18.56","29.02","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN NON THREADED PLAIN SHANK TROCAR POINT PK/6EA","SUP-ITM-10013191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","35.51","26.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","29.02","81.72","","431.26","71.26","1459.57","88","18.56","29.02","percent of total billed charges",""
"PIN BONE 4.5X120MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038578","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","146.92","79.5","","800.18","480.96","1887.97","195","57.29","146.92","percent of total billed charges",""
"PIN BONE 4.5X120MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038578","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","98.50","53.3","","813.12","216.42","1444.50","81","57.29","146.92","percent of total billed charges",""
"PIN BONE 4.5X120MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038578","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","57.29","31","","432.60","432.60","432.60","1 through 10","57.29","146.92","percent of total billed charges",""
"PIN BONE 4.5X120MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038578","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.45","36.5","","148.37","54.89","631.39","94","57.29","146.92","percent of total billed charges",""
"PIN BONE 4.5X120MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038578","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.78","38.3","","279.30","91.72","1116.77","266","57.29","146.92","percent of total billed charges",""
"PIN BONE 4.5X120MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038578","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.28","42.9","","731.00","63.70","731.00","1 through 10","57.29","146.92","percent of total billed charges",""
"PIN BONE 4.5X120MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038578","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.28","42.9","","384.74","384.74","384.74","1 through 10","57.29","146.92","percent of total billed charges",""
"PIN BONE 4.5X120MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038578","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","WELLPOINT [1015]","HB AMC WELLPOINT","136.35","73.78","","286.63","119.22","1107.45","105","57.29","146.92","percent of total billed charges",""
"PIN BONE 4.5X120MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.80","138.60","AETNA [1001]","HB AMC AETNA HMO","128.99","69.8","","675.31","184.75","1721.50","286","96.58","151.02","percent of total billed charges",""
"PIN BONE 4.5X120MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.80","138.60","AETNA [1001]","HB AMC AETNA PPO","148.58","80.4","","1261.44","103.12","1514.10","21","96.58","151.02","percent of total billed charges",""
"PIN BONE 4.5X120MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.80","138.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","148.58","80.4","","1365.00","1365.00","1365.00","1 through 10","96.58","151.02","percent of total billed charges",""
"PIN BONE 4.5X120MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.80","138.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","151.02","81.72","","5157.68","5157.68","5157.68","1 through 10","96.58","151.02","percent of total billed charges",""
"PIN BONE 4.5X120MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.80","138.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","151.02","81.72","","431.26","71.26","1459.57","88","96.58","151.02","percent of total billed charges",""
"PIN BONE 4.5X150MM STEINMANN CENTRAL THREAD","SUP-ITM-10038594","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","221.71","79.5","","800.18","480.96","1887.97","195","86.45","221.71","percent of total billed charges",""
"PIN BONE 4.5X150MM STEINMANN CENTRAL THREAD","SUP-ITM-10038594","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","148.64","53.3","","813.12","216.42","1444.50","81","86.45","221.71","percent of total billed charges",""
"PIN BONE 4.5X150MM STEINMANN CENTRAL THREAD","SUP-ITM-10038594","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","86.45","31","","432.60","432.60","432.60","1 through 10","86.45","221.71","percent of total billed charges",""
"PIN BONE 4.5X150MM STEINMANN CENTRAL THREAD","SUP-ITM-10038594","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","101.79","36.5","","148.37","54.89","631.39","94","86.45","221.71","percent of total billed charges",""
"PIN BONE 4.5X150MM STEINMANN CENTRAL THREAD","SUP-ITM-10038594","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","106.81","38.3","","279.30","91.72","1116.77","266","86.45","221.71","percent of total billed charges",""
"PIN BONE 4.5X150MM STEINMANN CENTRAL THREAD","SUP-ITM-10038594","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.64","42.9","","731.00","63.70","731.00","1 through 10","86.45","221.71","percent of total billed charges",""
"PIN BONE 4.5X150MM STEINMANN CENTRAL THREAD","SUP-ITM-10038594","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.64","42.9","","384.74","384.74","384.74","1 through 10","86.45","221.71","percent of total billed charges",""
"PIN BONE 4.5X150MM STEINMANN CENTRAL THREAD","SUP-ITM-10038594","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.88","209.16","WELLPOINT [1015]","HB AMC WELLPOINT","205.76","73.78","","286.63","119.22","1107.45","105","86.45","221.71","percent of total billed charges",""
"PIN BONE 4.5X150MM STEINMANN CENTRAL THREAD","SUP-ITM-10038594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.88","209.16","AETNA [1001]","HB AMC AETNA HMO","194.66","69.8","","675.31","184.75","1721.50","286","145.74","227.9","percent of total billed charges",""
"PIN BONE 4.5X150MM STEINMANN CENTRAL THREAD","SUP-ITM-10038594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.88","209.16","AETNA [1001]","HB AMC AETNA PPO","224.22","80.4","","1261.44","103.12","1514.10","21","145.74","227.9","percent of total billed charges",""
"PIN BONE 4.5X150MM STEINMANN CENTRAL THREAD","SUP-ITM-10038594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.88","209.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","224.22","80.4","","1365.00","1365.00","1365.00","1 through 10","145.74","227.9","percent of total billed charges",""
"PIN BONE 4.5X150MM STEINMANN CENTRAL THREAD","SUP-ITM-10038594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.88","209.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","227.90","81.72","","5157.68","5157.68","5157.68","1 through 10","145.74","227.9","percent of total billed charges",""
"PIN BONE 4.5X150MM STEINMANN CENTRAL THREAD","SUP-ITM-10038594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.88","209.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","227.90","81.72","","431.26","71.26","1459.57","88","145.74","227.9","percent of total billed charges",""
"PIN BONE 4.5X180MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038595","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","247.53","79.5","","800.18","480.96","1887.97","195","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X180MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038595","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","165.95","53.3","","813.12","216.42","1444.50","81","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X180MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038595","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","96.52","31","","432.60","432.60","432.60","1 through 10","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X180MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038595","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","113.65","36.5","","148.37","54.89","631.39","94","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X180MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038595","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.25","38.3","","279.30","91.72","1116.77","266","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X180MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038595","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.57","42.9","","731.00","63.70","731.00","1 through 10","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X180MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038595","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.57","42.9","","384.74","384.74","384.74","1 through 10","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X180MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038595","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","WELLPOINT [1015]","HB AMC WELLPOINT","229.72","73.78","","286.63","119.22","1107.45","105","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X180MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","AETNA [1001]","HB AMC AETNA HMO","217.33","69.8","","675.31","184.75","1721.50","286","162.72","254.44","percent of total billed charges",""
"PIN BONE 4.5X180MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","AETNA [1001]","HB AMC AETNA PPO","250.33","80.4","","1261.44","103.12","1514.10","21","162.72","254.44","percent of total billed charges",""
"PIN BONE 4.5X180MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","250.33","80.4","","1365.00","1365.00","1365.00","1 through 10","162.72","254.44","percent of total billed charges",""
"PIN BONE 4.5X180MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","254.44","81.72","","5157.68","5157.68","5157.68","1 through 10","162.72","254.44","percent of total billed charges",""
"PIN BONE 4.5X180MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","254.44","81.72","","431.26","71.26","1459.57","88","162.72","254.44","percent of total billed charges",""
"PIN BONE 4.5X250MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038601","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","247.53","79.5","","800.18","480.96","1887.97","195","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X250MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038601","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","165.95","53.3","","813.12","216.42","1444.50","81","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X250MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038601","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","96.52","31","","432.60","432.60","432.60","1 through 10","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X250MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038601","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","113.65","36.5","","148.37","54.89","631.39","94","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X250MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038601","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.25","38.3","","279.30","91.72","1116.77","266","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X250MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038601","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.57","42.9","","731.00","63.70","731.00","1 through 10","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X250MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038601","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.57","42.9","","384.74","384.74","384.74","1 through 10","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X250MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038601","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","WELLPOINT [1015]","HB AMC WELLPOINT","229.72","73.78","","286.63","119.22","1107.45","105","96.52","247.53","percent of total billed charges",""
"PIN BONE 4.5X250MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","AETNA [1001]","HB AMC AETNA HMO","217.33","69.8","","675.31","184.75","1721.50","286","162.72","254.44","percent of total billed charges",""
"PIN BONE 4.5X250MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","AETNA [1001]","HB AMC AETNA PPO","250.33","80.4","","1261.44","103.12","1514.10","21","162.72","254.44","percent of total billed charges",""
"PIN BONE 4.5X250MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","250.33","80.4","","1365.00","1365.00","1365.00","1 through 10","162.72","254.44","percent of total billed charges",""
"PIN BONE 4.5X250MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","254.44","81.72","","5157.68","5157.68","5157.68","1 through 10","162.72","254.44","percent of total billed charges",""
"PIN BONE 4.5X250MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","254.44","81.72","","431.26","71.26","1459.57","88","162.72","254.44","percent of total billed charges",""
"PIN BONE 4.7X9IN STEINMAN THREADED POINT TYPE E SS BX/6EA","SUP-ITM-10261532","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","306.08","79.5","","800.18","480.96","1887.97","195","119.35","306.08","percent of total billed charges",""
"PIN BONE 4.7X9IN STEINMAN THREADED POINT TYPE E SS BX/6EA","SUP-ITM-10261532","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","205.21","53.3","","813.12","216.42","1444.50","81","119.35","306.08","percent of total billed charges",""
"PIN BONE 4.7X9IN STEINMAN THREADED POINT TYPE E SS BX/6EA","SUP-ITM-10261532","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","119.35","31","","432.60","432.60","432.60","1 through 10","119.35","306.08","percent of total billed charges",""
"PIN BONE 4.7X9IN STEINMAN THREADED POINT TYPE E SS BX/6EA","SUP-ITM-10261532","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","140.53","36.5","","148.37","54.89","631.39","94","119.35","306.08","percent of total billed charges",""
"PIN BONE 4.7X9IN STEINMAN THREADED POINT TYPE E SS BX/6EA","SUP-ITM-10261532","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","147.46","38.3","","279.30","91.72","1116.77","266","119.35","306.08","percent of total billed charges",""
"PIN BONE 4.7X9IN STEINMAN THREADED POINT TYPE E SS BX/6EA","SUP-ITM-10261532","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","165.17","42.9","","731.00","63.70","731.00","1 through 10","119.35","306.08","percent of total billed charges",""
"PIN BONE 4.7X9IN STEINMAN THREADED POINT TYPE E SS BX/6EA","SUP-ITM-10261532","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","165.17","42.9","","384.74","384.74","384.74","1 through 10","119.35","306.08","percent of total billed charges",""
"PIN BONE 4.7X9IN STEINMAN THREADED POINT TYPE E SS BX/6EA","SUP-ITM-10261532","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","WELLPOINT [1015]","HB AMC WELLPOINT","284.05","73.78","","286.63","119.22","1107.45","105","119.35","306.08","percent of total billed charges",""
"PIN BONE 4.7X9IN STEINMAN THREADED POINT TYPE E SS BX/6EA","SUP-ITM-10261532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","AETNA [1001]","HB AMC AETNA HMO","268.73","69.8","","675.31","184.75","1721.50","286","201.2","314.62","percent of total billed charges",""
"PIN BONE 4.7X9IN STEINMAN THREADED POINT TYPE E SS BX/6EA","SUP-ITM-10261532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","AETNA [1001]","HB AMC AETNA PPO","309.54","80.4","","1261.44","103.12","1514.10","21","201.2","314.62","percent of total billed charges",""
"PIN BONE 4.7X9IN STEINMAN THREADED POINT TYPE E SS BX/6EA","SUP-ITM-10261532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","309.54","80.4","","1365.00","1365.00","1365.00","1 through 10","201.2","314.62","percent of total billed charges",""
"PIN BONE 4.7X9IN STEINMAN THREADED POINT TYPE E SS BX/6EA","SUP-ITM-10261532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","314.62","81.72","","5157.68","5157.68","5157.68","1 through 10","201.2","314.62","percent of total billed charges",""
"PIN BONE 4.7X9IN STEINMAN THREADED POINT TYPE E SS BX/6EA","SUP-ITM-10261532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","314.62","81.72","","431.26","71.26","1459.57","88","201.2","314.62","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","542.17","79.5","","800.18","480.96","1887.97","195","211.41","542.17","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","363.50","53.3","","813.12","216.42","1444.50","81","211.41","542.17","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","211.41","31","","432.60","432.60","432.60","1 through 10","211.41","542.17","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","248.92","36.5","","148.37","54.89","631.39","94","211.41","542.17","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.20","38.3","","279.30","91.72","1116.77","266","211.41","542.17","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.57","42.9","","731.00","63.70","731.00","1 through 10","211.41","542.17","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.57","42.9","","384.74","384.74","384.74","1 through 10","211.41","542.17","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.98","511.48","WELLPOINT [1015]","HB AMC WELLPOINT","503.16","73.78","","286.63","119.22","1107.45","105","211.41","542.17","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.98","511.48","AETNA [1001]","HB AMC AETNA HMO","476.02","69.8","","675.31","184.75","1721.50","286","356.4","557.31","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.98","511.48","AETNA [1001]","HB AMC AETNA PPO","548.31","80.4","","1261.44","103.12","1514.10","21","356.4","557.31","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.98","511.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","548.31","80.4","","1365.00","1365.00","1365.00","1 through 10","356.4","557.31","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.98","511.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","557.31","81.72","","5157.68","5157.68","5157.68","1 through 10","356.4","557.31","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.98","511.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","557.31","81.72","","431.26","71.26","1459.57","88","356.4","557.31","percent of total billed charges",""
"PIN BONE 4X80MM PK/2EA","SUP-ITM-10275042","CDM","C1713","HCPCS","0278","RC","","","","both","","","118.32","88.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","94.06","79.5","","800.18","480.96","1887.97","195","36.68","94.06","percent of total billed charges",""
"PIN BONE 4X80MM PK/2EA","SUP-ITM-10275042","CDM","C1713","HCPCS","0278","RC","","","","both","","","118.32","88.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","63.06","53.3","","813.12","216.42","1444.50","81","36.68","94.06","percent of total billed charges",""
"PIN BONE 4X80MM PK/2EA","SUP-ITM-10275042","CDM","C1713","HCPCS","0278","RC","","","","both","","","118.32","88.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","36.68","31","","432.60","432.60","432.60","1 through 10","36.68","94.06","percent of total billed charges",""
"PIN BONE 4X80MM PK/2EA","SUP-ITM-10275042","CDM","C1713","HCPCS","0278","RC","","","","both","","","118.32","88.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","43.19","36.5","","148.37","54.89","631.39","94","36.68","94.06","percent of total billed charges",""
"PIN BONE 4X80MM PK/2EA","SUP-ITM-10275042","CDM","C1713","HCPCS","0278","RC","","","","both","","","118.32","88.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","45.32","38.3","","279.30","91.72","1116.77","266","36.68","94.06","percent of total billed charges",""
"PIN BONE 4X80MM PK/2EA","SUP-ITM-10275042","CDM","C1713","HCPCS","0278","RC","","","","both","","","118.32","88.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.76","42.9","","731.00","63.70","731.00","1 through 10","36.68","94.06","percent of total billed charges",""
"PIN BONE 4X80MM PK/2EA","SUP-ITM-10275042","CDM","C1713","HCPCS","0278","RC","","","","both","","","118.32","88.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.76","42.9","","384.74","384.74","384.74","1 through 10","36.68","94.06","percent of total billed charges",""
"PIN BONE 4X80MM PK/2EA","SUP-ITM-10275042","CDM","C1713","HCPCS","0278","RC","","","","both","","","118.32","88.74","WELLPOINT [1015]","HB AMC WELLPOINT","87.30","73.78","","286.63","119.22","1107.45","105","36.68","94.06","percent of total billed charges",""
"PIN BONE 4X80MM PK/2EA","SUP-ITM-10275042","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","118.32","88.74","AETNA [1001]","HB AMC AETNA HMO","82.59","69.8","","675.31","184.75","1721.50","286","61.83","96.69","percent of total billed charges",""
"PIN BONE 4X80MM PK/2EA","SUP-ITM-10275042","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","118.32","88.74","AETNA [1001]","HB AMC AETNA PPO","95.13","80.4","","1261.44","103.12","1514.10","21","61.83","96.69","percent of total billed charges",""
"PIN BONE 4X80MM PK/2EA","SUP-ITM-10275042","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","118.32","88.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","95.13","80.4","","1365.00","1365.00","1365.00","1 through 10","61.83","96.69","percent of total billed charges",""
"PIN BONE 4X80MM PK/2EA","SUP-ITM-10275042","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","118.32","88.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","96.69","81.72","","5157.68","5157.68","5157.68","1 through 10","61.83","96.69","percent of total billed charges",""
"PIN BONE 4X80MM PK/2EA","SUP-ITM-10275042","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","118.32","88.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","96.69","81.72","","431.26","71.26","1459.57","88","61.83","96.69","percent of total billed charges",""
"PIN BONE 5/6MM 40X300 APEX TRANSFIXING PLUS","SUP-ITM-10143259","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.91","590.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","625.59","79.5","","800.18","480.96","1887.97","195","243.94","625.59","percent of total billed charges",""
"PIN BONE 5/6MM 40X300 APEX TRANSFIXING PLUS","SUP-ITM-10143259","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.91","590.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","419.42","53.3","","813.12","216.42","1444.50","81","243.94","625.59","percent of total billed charges",""
"PIN BONE 5/6MM 40X300 APEX TRANSFIXING PLUS","SUP-ITM-10143259","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.91","590.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","243.94","31","","432.60","432.60","432.60","1 through 10","243.94","625.59","percent of total billed charges",""
"PIN BONE 5/6MM 40X300 APEX TRANSFIXING PLUS","SUP-ITM-10143259","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.91","590.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","287.22","36.5","","148.37","54.89","631.39","94","243.94","625.59","percent of total billed charges",""
"PIN BONE 5/6MM 40X300 APEX TRANSFIXING PLUS","SUP-ITM-10143259","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.91","590.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","301.39","38.3","","279.30","91.72","1116.77","266","243.94","625.59","percent of total billed charges",""
"PIN BONE 5/6MM 40X300 APEX TRANSFIXING PLUS","SUP-ITM-10143259","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.91","590.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.58","42.9","","731.00","63.70","731.00","1 through 10","243.94","625.59","percent of total billed charges",""
"PIN BONE 5/6MM 40X300 APEX TRANSFIXING PLUS","SUP-ITM-10143259","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.91","590.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.58","42.9","","384.74","384.74","384.74","1 through 10","243.94","625.59","percent of total billed charges",""
"PIN BONE 5/6MM 40X300 APEX TRANSFIXING PLUS","SUP-ITM-10143259","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.91","590.18","WELLPOINT [1015]","HB AMC WELLPOINT","580.58","73.78","","286.63","119.22","1107.45","105","243.94","625.59","percent of total billed charges",""
"PIN BONE 5/6MM 40X300 APEX TRANSFIXING PLUS","SUP-ITM-10143259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.91","590.18","AETNA [1001]","HB AMC AETNA HMO","549.26","69.8","","675.31","184.75","1721.50","286","411.24","643.06","percent of total billed charges",""
"PIN BONE 5/6MM 40X300 APEX TRANSFIXING PLUS","SUP-ITM-10143259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.91","590.18","AETNA [1001]","HB AMC AETNA PPO","632.68","80.4","","1261.44","103.12","1514.10","21","411.24","643.06","percent of total billed charges",""
"PIN BONE 5/6MM 40X300 APEX TRANSFIXING PLUS","SUP-ITM-10143259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.91","590.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","632.68","80.4","","1365.00","1365.00","1365.00","1 through 10","411.24","643.06","percent of total billed charges",""
"PIN BONE 5/6MM 40X300 APEX TRANSFIXING PLUS","SUP-ITM-10143259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.91","590.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","643.06","81.72","","5157.68","5157.68","5157.68","1 through 10","411.24","643.06","percent of total billed charges",""
"PIN BONE 5/6MM 40X300 APEX TRANSFIXING PLUS","SUP-ITM-10143259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.91","590.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","643.06","81.72","","431.26","71.26","1459.57","88","411.24","643.06","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.12","632.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","670.28","79.5","","800.18","480.96","1887.97","195","261.37","670.28","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.12","632.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","449.38","53.3","","813.12","216.42","1444.50","81","261.37","670.28","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.12","632.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","261.37","31","","432.60","432.60","432.60","1 through 10","261.37","670.28","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.12","632.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","307.74","36.5","","148.37","54.89","631.39","94","261.37","670.28","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.12","632.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","322.91","38.3","","279.30","91.72","1116.77","266","261.37","670.28","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.12","632.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","361.70","42.9","","731.00","63.70","731.00","1 through 10","261.37","670.28","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.12","632.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","361.70","42.9","","384.74","384.74","384.74","1 through 10","261.37","670.28","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.12","632.34","WELLPOINT [1015]","HB AMC WELLPOINT","622.05","73.78","","286.63","119.22","1107.45","105","261.37","670.28","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.12","632.34","AETNA [1001]","HB AMC AETNA HMO","588.50","69.8","","675.31","184.75","1721.50","286","440.61","689","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.12","632.34","AETNA [1001]","HB AMC AETNA PPO","677.87","80.4","","1261.44","103.12","1514.10","21","440.61","689","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.12","632.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","677.87","80.4","","1365.00","1365.00","1365.00","1 through 10","440.61","689","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.12","632.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","689.00","81.72","","5157.68","5157.68","5157.68","1 through 10","440.61","689","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.12","632.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","689.00","81.72","","431.26","71.26","1459.57","88","440.61","689","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","150.26","79.5","","1309.77","674.56","6049.93","26","58.59","150.26","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.74","53.3","","1901.83","1901.83","2962.25","1 through 10","58.59","150.26","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.99","36.5","","1620.31","1620.31","19908.88","1 through 10","58.59","150.26","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.39","38.3","","352.91","352.91","2046.30","1 through 10","58.59","150.26","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","9668.75","9668.75","9668.75","1 through 10","58.59","150.26","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","both","","","189.00","141.75","WELLPOINT [1015]","HB AMC WELLPOINT","139.44","73.78","","699.88","384.10","3443.31","33","58.59","150.26","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA HMO","131.92","69.8","","1421.24","264.50","4933.46","29","98.77","154.45","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","151.96","80.4","","1022.97","1022.97","3607.50","1 through 10","98.77","154.45","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","154.45","81.72","","3010.54","693.88","5019.88","35","98.77","154.45","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","146.92","79.5","","800.18","480.96","1887.97","195","57.29","146.92","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","98.50","53.3","","813.12","216.42","1444.50","81","57.29","146.92","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","57.29","31","","432.60","432.60","432.60","1 through 10","57.29","146.92","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.45","36.5","","148.37","54.89","631.39","94","57.29","146.92","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.78","38.3","","279.30","91.72","1116.77","266","57.29","146.92","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.28","42.9","","731.00","63.70","731.00","1 through 10","57.29","146.92","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.28","42.9","","384.74","384.74","384.74","1 through 10","57.29","146.92","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.80","138.60","WELLPOINT [1015]","HB AMC WELLPOINT","136.35","73.78","","286.63","119.22","1107.45","105","57.29","146.92","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.80","138.60","AETNA [1001]","HB AMC AETNA HMO","128.99","69.8","","675.31","184.75","1721.50","286","96.58","151.02","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.80","138.60","AETNA [1001]","HB AMC AETNA PPO","148.58","80.4","","1261.44","103.12","1514.10","21","96.58","151.02","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.80","138.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","148.58","80.4","","1365.00","1365.00","1365.00","1 through 10","96.58","151.02","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.80","138.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","151.02","81.72","","5157.68","5157.68","5157.68","1 through 10","96.58","151.02","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.80","138.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","151.02","81.72","","431.26","71.26","1459.57","88","96.58","151.02","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","247.53","79.5","","800.18","480.96","1887.97","195","96.52","247.53","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","165.95","53.3","","813.12","216.42","1444.50","81","96.52","247.53","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","96.52","31","","432.60","432.60","432.60","1 through 10","96.52","247.53","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","113.65","36.5","","148.37","54.89","631.39","94","96.52","247.53","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.25","38.3","","279.30","91.72","1116.77","266","96.52","247.53","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.57","42.9","","731.00","63.70","731.00","1 through 10","96.52","247.53","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.57","42.9","","384.74","384.74","384.74","1 through 10","96.52","247.53","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.36","233.52","WELLPOINT [1015]","HB AMC WELLPOINT","229.72","73.78","","286.63","119.22","1107.45","105","96.52","247.53","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","AETNA [1001]","HB AMC AETNA HMO","217.33","69.8","","675.31","184.75","1721.50","286","162.72","254.44","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","AETNA [1001]","HB AMC AETNA PPO","250.33","80.4","","1261.44","103.12","1514.10","21","162.72","254.44","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","250.33","80.4","","1365.00","1365.00","1365.00","1 through 10","162.72","254.44","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","254.44","81.72","","5157.68","5157.68","5157.68","1 through 10","162.72","254.44","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.36","233.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","254.44","81.72","","431.26","71.26","1459.57","88","162.72","254.44","percent of total billed charges",""
"PIN BONE FIXATION LONG 48510420","SUP-ITM-10047317","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.95","79.5","","800.18","480.96","1887.97","195","65.1","166.95","percent of total billed charges",""
"PIN BONE FIXATION LONG 48510420","SUP-ITM-10047317","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.93","53.3","","813.12","216.42","1444.50","81","65.1","166.95","percent of total billed charges",""
"PIN BONE FIXATION LONG 48510420","SUP-ITM-10047317","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","65.10","31","","432.60","432.60","432.60","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN BONE FIXATION LONG 48510420","SUP-ITM-10047317","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.65","36.5","","148.37","54.89","631.39","94","65.1","166.95","percent of total billed charges",""
"PIN BONE FIXATION LONG 48510420","SUP-ITM-10047317","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.43","38.3","","279.30","91.72","1116.77","266","65.1","166.95","percent of total billed charges",""
"PIN BONE FIXATION LONG 48510420","SUP-ITM-10047317","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","731.00","63.70","731.00","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN BONE FIXATION LONG 48510420","SUP-ITM-10047317","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","384.74","384.74","384.74","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN BONE FIXATION LONG 48510420","SUP-ITM-10047317","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB AMC WELLPOINT","154.94","73.78","","286.63","119.22","1107.45","105","65.1","166.95","percent of total billed charges",""
"PIN BONE FIXATION LONG 48510420","SUP-ITM-10047317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA HMO","146.58","69.8","","675.31","184.75","1721.50","286","109.75","171.61","percent of total billed charges",""
"PIN BONE FIXATION LONG 48510420","SUP-ITM-10047317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA PPO","168.84","80.4","","1261.44","103.12","1514.10","21","109.75","171.61","percent of total billed charges",""
"PIN BONE FIXATION LONG 48510420","SUP-ITM-10047317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","168.84","80.4","","1365.00","1365.00","1365.00","1 through 10","109.75","171.61","percent of total billed charges",""
"PIN BONE FIXATION LONG 48510420","SUP-ITM-10047317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","171.61","81.72","","5157.68","5157.68","5157.68","1 through 10","109.75","171.61","percent of total billed charges",""
"PIN BONE FIXATION LONG 48510420","SUP-ITM-10047317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.61","81.72","","431.26","71.26","1459.57","88","109.75","171.61","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","260.89","79.5","","800.18","480.96","1887.97","195","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","174.91","53.3","","813.12","216.42","1444.50","81","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","101.73","31","","432.60","432.60","432.60","1 through 10","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","119.78","36.5","","148.37","54.89","631.39","94","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","125.69","38.3","","279.30","91.72","1116.77","266","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.78","42.9","","731.00","63.70","731.00","1 through 10","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.78","42.9","","384.74","384.74","384.74","1 through 10","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","WELLPOINT [1015]","HB AMC WELLPOINT","242.12","73.78","","286.63","119.22","1107.45","105","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","AETNA [1001]","HB AMC AETNA HMO","229.06","69.8","","675.31","184.75","1721.50","286","171.5","268.17","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","AETNA [1001]","HB AMC AETNA PPO","263.84","80.4","","1261.44","103.12","1514.10","21","171.5","268.17","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","263.84","80.4","","1365.00","1365.00","1365.00","1 through 10","171.5","268.17","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","268.17","81.72","","5157.68","5157.68","5157.68","1 through 10","171.5","268.17","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","268.17","81.72","","431.26","71.26","1459.57","88","171.5","268.17","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","260.89","79.5","","800.18","480.96","1887.97","195","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","174.91","53.3","","813.12","216.42","1444.50","81","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","101.73","31","","432.60","432.60","432.60","1 through 10","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","119.78","36.5","","148.37","54.89","631.39","94","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","125.69","38.3","","279.30","91.72","1116.77","266","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.78","42.9","","731.00","63.70","731.00","1 through 10","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.78","42.9","","384.74","384.74","384.74","1 through 10","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","WELLPOINT [1015]","HB AMC WELLPOINT","242.12","73.78","","286.63","119.22","1107.45","105","101.73","260.89","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","AETNA [1001]","HB AMC AETNA HMO","229.06","69.8","","675.31","184.75","1721.50","286","171.5","268.17","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","AETNA [1001]","HB AMC AETNA PPO","263.84","80.4","","1261.44","103.12","1514.10","21","171.5","268.17","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","263.84","80.4","","1365.00","1365.00","1365.00","1 through 10","171.5","268.17","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","268.17","81.72","","5157.68","5157.68","5157.68","1 through 10","171.5","268.17","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","268.17","81.72","","431.26","71.26","1459.57","88","171.5","268.17","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1333.85","1000.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1060.41","79.5","","800.18","480.96","1887.97","195","413.49","1060.41","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1333.85","1000.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","710.94","53.3","","813.12","216.42","1444.50","81","413.49","1060.41","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1333.85","1000.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","413.49","31","","432.60","432.60","432.60","1 through 10","413.49","1060.41","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1333.85","1000.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","486.86","36.5","","148.37","54.89","631.39","94","413.49","1060.41","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1333.85","1000.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","510.86","38.3","","279.30","91.72","1116.77","266","413.49","1060.41","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1333.85","1000.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","572.22","42.9","","731.00","63.70","731.00","1 through 10","413.49","1060.41","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1333.85","1000.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","572.22","42.9","","384.74","384.74","384.74","1 through 10","413.49","1060.41","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1333.85","1000.39","WELLPOINT [1015]","HB AMC WELLPOINT","984.11","73.78","","286.63","119.22","1107.45","105","413.49","1060.41","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1333.85","1000.39","AETNA [1001]","HB AMC AETNA HMO","931.03","69.8","","675.31","184.75","1721.50","286","697.07","1090.02","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1333.85","1000.39","AETNA [1001]","HB AMC AETNA PPO","1072.42","80.4","","1261.44","103.12","1514.10","21","697.07","1090.02","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1333.85","1000.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1072.42","80.4","","1365.00","1365.00","1365.00","1 through 10","697.07","1090.02","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1333.85","1000.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1090.02","81.72","","5157.68","5157.68","5157.68","1 through 10","697.07","1090.02","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1333.85","1000.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1090.02","81.72","","431.26","71.26","1459.57","88","697.07","1090.02","percent of total billed charges",""
"PIN CERCLAGE 4.5MM POSITIONING THRDED TITANIUM","SUP-ITM-10019203","CDM","C1889","HCPCS","0278","RC","","","","both","","","467.50","350.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","371.66","79.5","","1309.77","674.56","6049.93","26","144.93","371.66","percent of total billed charges",""
"PIN CERCLAGE 4.5MM POSITIONING THRDED TITANIUM","SUP-ITM-10019203","CDM","C1889","HCPCS","0278","RC","","","","both","","","467.50","350.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","249.18","53.3","","1901.83","1901.83","2962.25","1 through 10","144.93","371.66","percent of total billed charges",""
"PIN CERCLAGE 4.5MM POSITIONING THRDED TITANIUM","SUP-ITM-10019203","CDM","C1889","HCPCS","0278","RC","","","","both","","","467.50","350.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","170.64","36.5","","1620.31","1620.31","19908.88","1 through 10","144.93","371.66","percent of total billed charges",""
"PIN CERCLAGE 4.5MM POSITIONING THRDED TITANIUM","SUP-ITM-10019203","CDM","C1889","HCPCS","0278","RC","","","","both","","","467.50","350.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.05","38.3","","352.91","352.91","2046.30","1 through 10","144.93","371.66","percent of total billed charges",""
"PIN CERCLAGE 4.5MM POSITIONING THRDED TITANIUM","SUP-ITM-10019203","CDM","C1889","HCPCS","0278","RC","","","","both","","","467.50","350.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.56","42.9","","9668.75","9668.75","9668.75","1 through 10","144.93","371.66","percent of total billed charges",""
"PIN CERCLAGE 4.5MM POSITIONING THRDED TITANIUM","SUP-ITM-10019203","CDM","C1889","HCPCS","0278","RC","","","","both","","","467.50","350.62","WELLPOINT [1015]","HB AMC WELLPOINT","344.92","73.78","","699.88","384.10","3443.31","33","144.93","371.66","percent of total billed charges",""
"PIN CERCLAGE 4.5MM POSITIONING THRDED TITANIUM","SUP-ITM-10019203","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","AETNA [1001]","HB AMC AETNA HMO","326.32","69.8","","1421.24","264.50","4933.46","29","244.32","382.04","percent of total billed charges",""
"PIN CERCLAGE 4.5MM POSITIONING THRDED TITANIUM","SUP-ITM-10019203","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","375.87","80.4","","1022.97","1022.97","3607.50","1 through 10","244.32","382.04","percent of total billed charges",""
"PIN CERCLAGE 4.5MM POSITIONING THRDED TITANIUM","SUP-ITM-10019203","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","467.50","350.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","382.04","81.72","","3010.54","693.88","5019.88","35","244.32","382.04","percent of total billed charges",""
"PIN CERVICAL FIXATION TEMPORARY ACCS TITANIUM COMPRESSION ANTERIOR","SUP-ITM-10031640","CDM","C1889","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.95","79.5","","1309.77","674.56","6049.93","26","65.1","166.95","percent of total billed charges",""
"PIN CERVICAL FIXATION TEMPORARY ACCS TITANIUM COMPRESSION ANTERIOR","SUP-ITM-10031640","CDM","C1889","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.93","53.3","","1901.83","1901.83","2962.25","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN CERVICAL FIXATION TEMPORARY ACCS TITANIUM COMPRESSION ANTERIOR","SUP-ITM-10031640","CDM","C1889","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.65","36.5","","1620.31","1620.31","19908.88","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN CERVICAL FIXATION TEMPORARY ACCS TITANIUM COMPRESSION ANTERIOR","SUP-ITM-10031640","CDM","C1889","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.43","38.3","","352.91","352.91","2046.30","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN CERVICAL FIXATION TEMPORARY ACCS TITANIUM COMPRESSION ANTERIOR","SUP-ITM-10031640","CDM","C1889","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","9668.75","9668.75","9668.75","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN CERVICAL FIXATION TEMPORARY ACCS TITANIUM COMPRESSION ANTERIOR","SUP-ITM-10031640","CDM","C1889","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB AMC WELLPOINT","154.94","73.78","","699.88","384.10","3443.31","33","65.1","166.95","percent of total billed charges",""
"PIN CERVICAL FIXATION TEMPORARY ACCS TITANIUM COMPRESSION ANTERIOR","SUP-ITM-10031640","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA HMO","146.58","69.8","","1421.24","264.50","4933.46","29","109.75","171.61","percent of total billed charges",""
"PIN CERVICAL FIXATION TEMPORARY ACCS TITANIUM COMPRESSION ANTERIOR","SUP-ITM-10031640","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","168.84","80.4","","1022.97","1022.97","3607.50","1 through 10","109.75","171.61","percent of total billed charges",""
"PIN CERVICAL FIXATION TEMPORARY ACCS TITANIUM COMPRESSION ANTERIOR","SUP-ITM-10031640","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.61","81.72","","3010.54","693.88","5019.88","35","109.75","171.61","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3372.39","79.5","","800.18","480.96","1887.97","195","1315.02","3372.39","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2260.99","53.3","","813.12","216.42","1444.50","81","1315.02","3372.39","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1315.02","31","","432.60","432.60","432.60","1 through 10","1315.02","3372.39","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1548.33","36.5","","148.37","54.89","631.39","94","1315.02","3372.39","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1624.69","38.3","","279.30","91.72","1116.77","266","1315.02","3372.39","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1819.82","42.9","","731.00","63.70","731.00","1 through 10","1315.02","3372.39","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1819.82","42.9","","384.74","384.74","384.74","1 through 10","1315.02","3372.39","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","4242.00","3181.50","WELLPOINT [1015]","HB AMC WELLPOINT","3129.75","73.78","","286.63","119.22","1107.45","105","1315.02","3372.39","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","AETNA [1001]","HB AMC AETNA HMO","2960.92","69.8","","675.31","184.75","1721.50","286","2216.87","3466.56","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","AETNA [1001]","HB AMC AETNA PPO","3410.57","80.4","","1261.44","103.12","1514.10","21","2216.87","3466.56","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3410.57","80.4","","1365.00","1365.00","1365.00","1 through 10","2216.87","3466.56","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3466.56","81.72","","5157.68","5157.68","5157.68","1 through 10","2216.87","3466.56","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4242.00","3181.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3466.56","81.72","","431.26","71.26","1459.57","88","2216.87","3466.56","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","619.38","79.5","","800.18","480.96","1887.97","195","241.52","619.38","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","415.26","53.3","","813.12","216.42","1444.50","81","241.52","619.38","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","241.52","31","","432.60","432.60","432.60","1 through 10","241.52","619.38","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","284.37","36.5","","148.37","54.89","631.39","94","241.52","619.38","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","298.40","38.3","","279.30","91.72","1116.77","266","241.52","619.38","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","334.23","42.9","","731.00","63.70","731.00","1 through 10","241.52","619.38","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","334.23","42.9","","384.74","384.74","384.74","1 through 10","241.52","619.38","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","WELLPOINT [1015]","HB AMC WELLPOINT","574.82","73.78","","286.63","119.22","1107.45","105","241.52","619.38","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","AETNA [1001]","HB AMC AETNA HMO","543.81","69.8","","675.31","184.75","1721.50","286","407.16","636.68","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","AETNA [1001]","HB AMC AETNA PPO","626.40","80.4","","1261.44","103.12","1514.10","21","407.16","636.68","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","626.40","80.4","","1365.00","1365.00","1365.00","1 through 10","407.16","636.68","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","636.68","81.72","","5157.68","5157.68","5157.68","1 through 10","407.16","636.68","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","636.68","81.72","","431.26","71.26","1459.57","88","407.16","636.68","percent of total billed charges",""
"PIN DISTRACTOR 12MM TRIMLINE ACDF PK/10EA","SUP-ITM-10215313","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.95","79.5","","800.18","480.96","1887.97","195","65.1","166.95","percent of total billed charges",""
"PIN DISTRACTOR 12MM TRIMLINE ACDF PK/10EA","SUP-ITM-10215313","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.93","53.3","","813.12","216.42","1444.50","81","65.1","166.95","percent of total billed charges",""
"PIN DISTRACTOR 12MM TRIMLINE ACDF PK/10EA","SUP-ITM-10215313","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","65.10","31","","432.60","432.60","432.60","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN DISTRACTOR 12MM TRIMLINE ACDF PK/10EA","SUP-ITM-10215313","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.65","36.5","","148.37","54.89","631.39","94","65.1","166.95","percent of total billed charges",""
"PIN DISTRACTOR 12MM TRIMLINE ACDF PK/10EA","SUP-ITM-10215313","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.43","38.3","","279.30","91.72","1116.77","266","65.1","166.95","percent of total billed charges",""
"PIN DISTRACTOR 12MM TRIMLINE ACDF PK/10EA","SUP-ITM-10215313","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","731.00","63.70","731.00","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN DISTRACTOR 12MM TRIMLINE ACDF PK/10EA","SUP-ITM-10215313","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","384.74","384.74","384.74","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN DISTRACTOR 12MM TRIMLINE ACDF PK/10EA","SUP-ITM-10215313","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB AMC WELLPOINT","154.94","73.78","","286.63","119.22","1107.45","105","65.1","166.95","percent of total billed charges",""
"PIN DISTRACTOR 12MM TRIMLINE ACDF PK/10EA","SUP-ITM-10215313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA HMO","146.58","69.8","","675.31","184.75","1721.50","286","109.75","171.61","percent of total billed charges",""
"PIN DISTRACTOR 12MM TRIMLINE ACDF PK/10EA","SUP-ITM-10215313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA PPO","168.84","80.4","","1261.44","103.12","1514.10","21","109.75","171.61","percent of total billed charges",""
"PIN DISTRACTOR 12MM TRIMLINE ACDF PK/10EA","SUP-ITM-10215313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","168.84","80.4","","1365.00","1365.00","1365.00","1 through 10","109.75","171.61","percent of total billed charges",""
"PIN DISTRACTOR 12MM TRIMLINE ACDF PK/10EA","SUP-ITM-10215313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","171.61","81.72","","5157.68","5157.68","5157.68","1 through 10","109.75","171.61","percent of total billed charges",""
"PIN DISTRACTOR 12MM TRIMLINE ACDF PK/10EA","SUP-ITM-10215313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.61","81.72","","431.26","71.26","1459.57","88","109.75","171.61","percent of total billed charges",""
"PIN DISTRACTOR SURGICAL 16MM TRIMLINE ANTERIOR CERVICAL PK/10EA","SUP-ITM-10215314","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","194.78","79.5","","800.18","480.96","1887.97","195","75.95","194.78","percent of total billed charges",""
"PIN DISTRACTOR SURGICAL 16MM TRIMLINE ANTERIOR CERVICAL PK/10EA","SUP-ITM-10215314","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.59","53.3","","813.12","216.42","1444.50","81","75.95","194.78","percent of total billed charges",""
"PIN DISTRACTOR SURGICAL 16MM TRIMLINE ANTERIOR CERVICAL PK/10EA","SUP-ITM-10215314","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","75.95","31","","432.60","432.60","432.60","1 through 10","75.95","194.78","percent of total billed charges",""
"PIN DISTRACTOR SURGICAL 16MM TRIMLINE ANTERIOR CERVICAL PK/10EA","SUP-ITM-10215314","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.43","36.5","","148.37","54.89","631.39","94","75.95","194.78","percent of total billed charges",""
"PIN DISTRACTOR SURGICAL 16MM TRIMLINE ANTERIOR CERVICAL PK/10EA","SUP-ITM-10215314","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.84","38.3","","279.30","91.72","1116.77","266","75.95","194.78","percent of total billed charges",""
"PIN DISTRACTOR SURGICAL 16MM TRIMLINE ANTERIOR CERVICAL PK/10EA","SUP-ITM-10215314","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.11","42.9","","731.00","63.70","731.00","1 through 10","75.95","194.78","percent of total billed charges",""
"PIN DISTRACTOR SURGICAL 16MM TRIMLINE ANTERIOR CERVICAL PK/10EA","SUP-ITM-10215314","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.11","42.9","","384.74","384.74","384.74","1 through 10","75.95","194.78","percent of total billed charges",""
"PIN DISTRACTOR SURGICAL 16MM TRIMLINE ANTERIOR CERVICAL PK/10EA","SUP-ITM-10215314","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","WELLPOINT [1015]","HB AMC WELLPOINT","180.76","73.78","","286.63","119.22","1107.45","105","75.95","194.78","percent of total billed charges",""
"PIN DISTRACTOR SURGICAL 16MM TRIMLINE ANTERIOR CERVICAL PK/10EA","SUP-ITM-10215314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA HMO","171.01","69.8","","675.31","184.75","1721.50","286","128.04","200.21","percent of total billed charges",""
"PIN DISTRACTOR SURGICAL 16MM TRIMLINE ANTERIOR CERVICAL PK/10EA","SUP-ITM-10215314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA PPO","196.98","80.4","","1261.44","103.12","1514.10","21","128.04","200.21","percent of total billed charges",""
"PIN DISTRACTOR SURGICAL 16MM TRIMLINE ANTERIOR CERVICAL PK/10EA","SUP-ITM-10215314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","196.98","80.4","","1365.00","1365.00","1365.00","1 through 10","128.04","200.21","percent of total billed charges",""
"PIN DISTRACTOR SURGICAL 16MM TRIMLINE ANTERIOR CERVICAL PK/10EA","SUP-ITM-10215314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","200.21","81.72","","5157.68","5157.68","5157.68","1 through 10","128.04","200.21","percent of total billed charges",""
"PIN DISTRACTOR SURGICAL 16MM TRIMLINE ANTERIOR CERVICAL PK/10EA","SUP-ITM-10215314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","200.21","81.72","","431.26","71.26","1459.57","88","128.04","200.21","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","95.58","79.5","","800.18","480.96","1887.97","195","37.27","95.58","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","64.08","53.3","","813.12","216.42","1444.50","81","37.27","95.58","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","37.27","31","","432.60","432.60","432.60","1 through 10","37.27","95.58","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","43.88","36.5","","148.37","54.89","631.39","94","37.27","95.58","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.05","38.3","","279.30","91.72","1116.77","266","37.27","95.58","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","51.58","42.9","","731.00","63.70","731.00","1 through 10","37.27","95.58","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","51.58","42.9","","384.74","384.74","384.74","1 through 10","37.27","95.58","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.23","90.17","WELLPOINT [1015]","HB AMC WELLPOINT","88.71","73.78","","286.63","119.22","1107.45","105","37.27","95.58","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.23","90.17","AETNA [1001]","HB AMC AETNA HMO","83.92","69.8","","675.31","184.75","1721.50","286","62.83","98.25","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.23","90.17","AETNA [1001]","HB AMC AETNA PPO","96.66","80.4","","1261.44","103.12","1514.10","21","62.83","98.25","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.23","90.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","96.66","80.4","","1365.00","1365.00","1365.00","1 through 10","62.83","98.25","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.23","90.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","98.25","81.72","","5157.68","5157.68","5157.68","1 through 10","62.83","98.25","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.23","90.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","98.25","81.72","","431.26","71.26","1459.57","88","62.83","98.25","percent of total billed charges",""
"PIN FIXATION L9IN ODSEC 2.8MM THREADED DOUBLE TROCAR STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072997","CDM","C1713","HCPCS","0278","RC","","","","both","","","40.27","30.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","32.01","79.5","","800.18","480.96","1887.97","195","12.48","32.01","percent of total billed charges",""
"PIN FIXATION L9IN ODSEC 2.8MM THREADED DOUBLE TROCAR STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072997","CDM","C1713","HCPCS","0278","RC","","","","both","","","40.27","30.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","21.46","53.3","","813.12","216.42","1444.50","81","12.48","32.01","percent of total billed charges",""
"PIN FIXATION L9IN ODSEC 2.8MM THREADED DOUBLE TROCAR STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072997","CDM","C1713","HCPCS","0278","RC","","","","both","","","40.27","30.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","12.48","31","","432.60","432.60","432.60","1 through 10","12.48","32.01","percent of total billed charges",""
"PIN FIXATION L9IN ODSEC 2.8MM THREADED DOUBLE TROCAR STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072997","CDM","C1713","HCPCS","0278","RC","","","","both","","","40.27","30.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14.70","36.5","","148.37","54.89","631.39","94","12.48","32.01","percent of total billed charges",""
"PIN FIXATION L9IN ODSEC 2.8MM THREADED DOUBLE TROCAR STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072997","CDM","C1713","HCPCS","0278","RC","","","","both","","","40.27","30.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15.42","38.3","","279.30","91.72","1116.77","266","12.48","32.01","percent of total billed charges",""
"PIN FIXATION L9IN ODSEC 2.8MM THREADED DOUBLE TROCAR STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072997","CDM","C1713","HCPCS","0278","RC","","","","both","","","40.27","30.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17.28","42.9","","731.00","63.70","731.00","1 through 10","12.48","32.01","percent of total billed charges",""
"PIN FIXATION L9IN ODSEC 2.8MM THREADED DOUBLE TROCAR STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072997","CDM","C1713","HCPCS","0278","RC","","","","both","","","40.27","30.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17.28","42.9","","384.74","384.74","384.74","1 through 10","12.48","32.01","percent of total billed charges",""
"PIN FIXATION L9IN ODSEC 2.8MM THREADED DOUBLE TROCAR STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072997","CDM","C1713","HCPCS","0278","RC","","","","both","","","40.27","30.20","WELLPOINT [1015]","HB AMC WELLPOINT","29.71","73.78","","286.63","119.22","1107.45","105","12.48","32.01","percent of total billed charges",""
"PIN FIXATION L9IN ODSEC 2.8MM THREADED DOUBLE TROCAR STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40.27","30.20","AETNA [1001]","HB AMC AETNA HMO","28.11","69.8","","675.31","184.75","1721.50","286","21.05","32.91","percent of total billed charges",""
"PIN FIXATION L9IN ODSEC 2.8MM THREADED DOUBLE TROCAR STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40.27","30.20","AETNA [1001]","HB AMC AETNA PPO","32.38","80.4","","1261.44","103.12","1514.10","21","21.05","32.91","percent of total billed charges",""
"PIN FIXATION L9IN ODSEC 2.8MM THREADED DOUBLE TROCAR STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40.27","30.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","32.38","80.4","","1365.00","1365.00","1365.00","1 through 10","21.05","32.91","percent of total billed charges",""
"PIN FIXATION L9IN ODSEC 2.8MM THREADED DOUBLE TROCAR STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40.27","30.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","32.91","81.72","","5157.68","5157.68","5157.68","1 through 10","21.05","32.91","percent of total billed charges",""
"PIN FIXATION L9IN ODSEC 2.8MM THREADED DOUBLE TROCAR STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40.27","30.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","32.91","81.72","","431.26","71.26","1459.57","88","21.05","32.91","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","800.18","480.96","1887.97","195","48.83","125.21","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","813.12","216.42","1444.50","81","48.83","125.21","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.83","31","","432.60","432.60","432.60","1 through 10","48.83","125.21","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","148.37","54.89","631.39","94","48.83","125.21","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","279.30","91.72","1116.77","266","48.83","125.21","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","731.00","63.70","731.00","1 through 10","48.83","125.21","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","384.74","384.74","384.74","1 through 10","48.83","125.21","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","286.63","119.22","1107.45","105","48.83","125.21","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","675.31","184.75","1721.50","286","82.31","128.71","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA PPO","126.63","80.4","","1261.44","103.12","1514.10","21","82.31","128.71","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","1365.00","1365.00","1365.00","1 through 10","82.31","128.71","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.71","81.72","","5157.68","5157.68","5157.68","1 through 10","82.31","128.71","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","431.26","71.26","1459.57","88","82.31","128.71","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","503.00","52.26","","1113.10","1113.10","1113.10","1 through 10","298.38","765.19","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","765.19","79.5","","1293.60","1148.53","1603.80","1 through 10","298.38","765.19","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","351.31","36.5","","1023.42","771.29","2068.67","33","298.38","765.19","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","368.64","38.3","","850.52","759.78","1211.25","66","298.38","765.19","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","2548.09","2548.09","2548.09","1 through 10","298.38","765.19","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","956.46","956.46","956.46","1 through 10","298.38","765.19","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","962.50","721.87","WELLPOINT [1015]","HB AMC WELLPOINT","710.13","73.78","","2344.73","1619.47","2530.35","16","298.38","765.19","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA HMO","671.83","69.8","","1523.63","988.41","4330.26","39","503","786.56","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA PPO","773.85","80.4","","1670.25","1670.25","1670.25","1 through 10","503","786.56","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","503.00","52.26","","1113.10","1113.10","1113.10","1 through 10","503","786.56","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","786.56","81.72","","1738.90","1484.65","2716.94","38","503","786.56","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","457.84","343.38","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","239.27","52.26","","25.34","25.34","25.34","1 through 10","141.93","363.98","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","457.84","343.38","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","328.73","71.8","","105.81","105.81","366.90","1 through 10","141.93","363.98","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","457.84","343.38","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","320.49","70","","512.90","74.70","612.85","1 through 10","141.93","363.98","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","457.84","343.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","363.98","79.5","","200.27","182.80","200.27","1 through 10","141.93","363.98","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","457.84","343.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","244.03","53.3","","37.73","37.73","169.33","1 through 10","141.93","363.98","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","457.84","343.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","297.60","65","","100.27","8.48","494.52","1 through 10","141.93","363.98","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","457.84","343.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","297.60","65","","160.19","160.19","160.19","1 through 10","141.93","363.98","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","457.84","343.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","141.93","31","","28.12","28.12","28.12","1 through 10","141.93","363.98","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","457.84","343.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","167.11","36.5","","101.66","28.85","502.70","121","141.93","363.98","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","457.84","343.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","175.35","38.3","","61.58","25.32","328.44","138","141.93","363.98","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","457.84","343.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","196.41","42.9","","71.66","71.66","71.66","1 through 10","141.93","363.98","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","457.84","343.38","WELLPOINT [1015]","HB AMC WELLPOINT","337.79","73.78","","74.75","27.97","425.28","93","141.93","363.98","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","457.84","343.38","AETNA [1001]","HB AMC AETNA HMO","319.57","69.8","","52.67","14.36","414.90","1 through 10","239.27","374.15","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","457.84","343.38","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","239.27","52.26","","25.34","25.34","25.34","1 through 10","239.27","374.15","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","457.84","343.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","368.10","80.4","","478.02","107.84","478.02","1 through 10","239.27","374.15","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","457.84","343.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","374.15","81.72","","32.74","12.33","122.05","1 through 10","239.27","374.15","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","457.84","343.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","374.15","81.72","","144.95","32.78","676.91","104","239.27","374.15","percent of total billed charges",""
"PIN HINGE XXS LPS KNEE REPLACEMENT COMPONENT","SUP-ITM-10198100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1271.22","52.26","","1113.10","1113.10","1113.10","1 through 10","754.08","1933.84","percent of total billed charges",""
"PIN HINGE XXS LPS KNEE REPLACEMENT COMPONENT","SUP-ITM-10198100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1933.84","79.5","","1293.60","1148.53","1603.80","1 through 10","754.08","1933.84","percent of total billed charges",""
"PIN HINGE XXS LPS KNEE REPLACEMENT COMPONENT","SUP-ITM-10198100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","887.86","36.5","","1023.42","771.29","2068.67","33","754.08","1933.84","percent of total billed charges",""
"PIN HINGE XXS LPS KNEE REPLACEMENT COMPONENT","SUP-ITM-10198100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","931.65","38.3","","850.52","759.78","1211.25","66","754.08","1933.84","percent of total billed charges",""
"PIN HINGE XXS LPS KNEE REPLACEMENT COMPONENT","SUP-ITM-10198100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1043.54","42.9","","2548.09","2548.09","2548.09","1 through 10","754.08","1933.84","percent of total billed charges",""
"PIN HINGE XXS LPS KNEE REPLACEMENT COMPONENT","SUP-ITM-10198100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1043.54","42.9","","956.46","956.46","956.46","1 through 10","754.08","1933.84","percent of total billed charges",""
"PIN HINGE XXS LPS KNEE REPLACEMENT COMPONENT","SUP-ITM-10198100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","WELLPOINT [1015]","HB AMC WELLPOINT","1794.70","73.78","","2344.73","1619.47","2530.35","16","754.08","1933.84","percent of total billed charges",""
"PIN HINGE XXS LPS KNEE REPLACEMENT COMPONENT","SUP-ITM-10198100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","AETNA [1001]","HB AMC AETNA HMO","1697.89","69.8","","1523.63","988.41","4330.26","39","1271.22","1987.84","percent of total billed charges",""
"PIN HINGE XXS LPS KNEE REPLACEMENT COMPONENT","SUP-ITM-10198100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","AETNA [1001]","HB AMC AETNA PPO","1955.73","80.4","","1670.25","1670.25","1670.25","1 through 10","1271.22","1987.84","percent of total billed charges",""
"PIN HINGE XXS LPS KNEE REPLACEMENT COMPONENT","SUP-ITM-10198100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1271.22","52.26","","1113.10","1113.10","1113.10","1 through 10","1271.22","1987.84","percent of total billed charges",""
"PIN HINGE XXS LPS KNEE REPLACEMENT COMPONENT","SUP-ITM-10198100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1987.84","81.72","","1738.90","1484.65","2716.94","38","1271.22","1987.84","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","800.18","480.96","1887.97","195","27.13","69.56","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.64","53.3","","813.12","216.42","1444.50","81","27.13","69.56","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.13","31","","432.60","432.60","432.60","1 through 10","27.13","69.56","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","148.37","54.89","631.39","94","27.13","69.56","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","279.30","91.72","1116.77","266","27.13","69.56","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","731.00","63.70","731.00","1 through 10","27.13","69.56","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","384.74","384.74","384.74","1 through 10","27.13","69.56","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","286.63","119.22","1107.45","105","27.13","69.56","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","675.31","184.75","1721.50","286","45.73","71.51","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","1261.44","103.12","1514.10","21","45.73","71.51","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","70.35","80.4","","1365.00","1365.00","1365.00","1 through 10","45.73","71.51","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","71.51","81.72","","5157.68","5157.68","5157.68","1 through 10","45.73","71.51","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","431.26","71.26","1459.57","88","45.73","71.51","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","16.43","79.5","","800.18","480.96","1887.97","195","6.41","16.43","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11.02","53.3","","813.12","216.42","1444.50","81","6.41","16.43","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","6.41","31","","432.60","432.60","432.60","1 through 10","6.41","16.43","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7.54","36.5","","148.37","54.89","631.39","94","6.41","16.43","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7.92","38.3","","279.30","91.72","1116.77","266","6.41","16.43","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8.87","42.9","","731.00","63.70","731.00","1 through 10","6.41","16.43","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8.87","42.9","","384.74","384.74","384.74","1 through 10","6.41","16.43","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","20.67","15.50","WELLPOINT [1015]","HB AMC WELLPOINT","15.25","73.78","","286.63","119.22","1107.45","105","6.41","16.43","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.67","15.50","AETNA [1001]","HB AMC AETNA HMO","14.43","69.8","","675.31","184.75","1721.50","286","10.8","16.89","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.67","15.50","AETNA [1001]","HB AMC AETNA PPO","16.62","80.4","","1261.44","103.12","1514.10","21","10.8","16.89","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.67","15.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","16.62","80.4","","1365.00","1365.00","1365.00","1 through 10","10.8","16.89","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.67","15.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","16.89","81.72","","5157.68","5157.68","5157.68","1 through 10","10.8","16.89","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","20.67","15.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16.89","81.72","","431.26","71.26","1459.57","88","10.8","16.89","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.21","16.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","17.66","79.5","","800.18","480.96","1887.97","195","6.89","17.66","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.21","16.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11.84","53.3","","813.12","216.42","1444.50","81","6.89","17.66","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.21","16.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","6.89","31","","432.60","432.60","432.60","1 through 10","6.89","17.66","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.21","16.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.11","36.5","","148.37","54.89","631.39","94","6.89","17.66","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.21","16.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8.51","38.3","","279.30","91.72","1116.77","266","6.89","17.66","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.21","16.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.53","42.9","","731.00","63.70","731.00","1 through 10","6.89","17.66","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.21","16.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.53","42.9","","384.74","384.74","384.74","1 through 10","6.89","17.66","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.21","16.66","WELLPOINT [1015]","HB AMC WELLPOINT","16.39","73.78","","286.63","119.22","1107.45","105","6.89","17.66","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.21","16.66","AETNA [1001]","HB AMC AETNA HMO","15.50","69.8","","675.31","184.75","1721.50","286","11.61","18.15","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.21","16.66","AETNA [1001]","HB AMC AETNA PPO","17.86","80.4","","1261.44","103.12","1514.10","21","11.61","18.15","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.21","16.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","17.86","80.4","","1365.00","1365.00","1365.00","1 through 10","11.61","18.15","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.21","16.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","18.15","81.72","","5157.68","5157.68","5157.68","1 through 10","11.61","18.15","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.21","16.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18.15","81.72","","431.26","71.26","1459.57","88","11.61","18.15","percent of total billed charges",""
"PIN POSITIONING 5.0MM CERCLAGE SS CRIMP","SUP-ITM-10020176","CDM","C1713","HCPCS","0278","RC","","","","both","","","701.89","526.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","558.00","79.5","","800.18","480.96","1887.97","195","217.59","558","percent of total billed charges",""
"PIN POSITIONING 5.0MM CERCLAGE SS CRIMP","SUP-ITM-10020176","CDM","C1713","HCPCS","0278","RC","","","","both","","","701.89","526.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","374.11","53.3","","813.12","216.42","1444.50","81","217.59","558","percent of total billed charges",""
"PIN POSITIONING 5.0MM CERCLAGE SS CRIMP","SUP-ITM-10020176","CDM","C1713","HCPCS","0278","RC","","","","both","","","701.89","526.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","217.59","31","","432.60","432.60","432.60","1 through 10","217.59","558","percent of total billed charges",""
"PIN POSITIONING 5.0MM CERCLAGE SS CRIMP","SUP-ITM-10020176","CDM","C1713","HCPCS","0278","RC","","","","both","","","701.89","526.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","256.19","36.5","","148.37","54.89","631.39","94","217.59","558","percent of total billed charges",""
"PIN POSITIONING 5.0MM CERCLAGE SS CRIMP","SUP-ITM-10020176","CDM","C1713","HCPCS","0278","RC","","","","both","","","701.89","526.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.82","38.3","","279.30","91.72","1116.77","266","217.59","558","percent of total billed charges",""
"PIN POSITIONING 5.0MM CERCLAGE SS CRIMP","SUP-ITM-10020176","CDM","C1713","HCPCS","0278","RC","","","","both","","","701.89","526.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","301.11","42.9","","731.00","63.70","731.00","1 through 10","217.59","558","percent of total billed charges",""
"PIN POSITIONING 5.0MM CERCLAGE SS CRIMP","SUP-ITM-10020176","CDM","C1713","HCPCS","0278","RC","","","","both","","","701.89","526.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","301.11","42.9","","384.74","384.74","384.74","1 through 10","217.59","558","percent of total billed charges",""
"PIN POSITIONING 5.0MM CERCLAGE SS CRIMP","SUP-ITM-10020176","CDM","C1713","HCPCS","0278","RC","","","","both","","","701.89","526.42","WELLPOINT [1015]","HB AMC WELLPOINT","517.85","73.78","","286.63","119.22","1107.45","105","217.59","558","percent of total billed charges",""
"PIN POSITIONING 5.0MM CERCLAGE SS CRIMP","SUP-ITM-10020176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","701.89","526.42","AETNA [1001]","HB AMC AETNA HMO","489.92","69.8","","675.31","184.75","1721.50","286","366.81","573.58","percent of total billed charges",""
"PIN POSITIONING 5.0MM CERCLAGE SS CRIMP","SUP-ITM-10020176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","701.89","526.42","AETNA [1001]","HB AMC AETNA PPO","564.32","80.4","","1261.44","103.12","1514.10","21","366.81","573.58","percent of total billed charges",""
"PIN POSITIONING 5.0MM CERCLAGE SS CRIMP","SUP-ITM-10020176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","701.89","526.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","564.32","80.4","","1365.00","1365.00","1365.00","1 through 10","366.81","573.58","percent of total billed charges",""
"PIN POSITIONING 5.0MM CERCLAGE SS CRIMP","SUP-ITM-10020176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","701.89","526.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","573.58","81.72","","5157.68","5157.68","5157.68","1 through 10","366.81","573.58","percent of total billed charges",""
"PIN POSITIONING 5.0MM CERCLAGE SS CRIMP","SUP-ITM-10020176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","701.89","526.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","573.58","81.72","","431.26","71.26","1459.57","88","366.81","573.58","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.40","427.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","453.47","79.5","","800.18","480.96","1887.97","195","176.82","453.47","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.40","427.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","304.02","53.3","","813.12","216.42","1444.50","81","176.82","453.47","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.40","427.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","176.82","31","","432.60","432.60","432.60","1 through 10","176.82","453.47","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.40","427.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","208.20","36.5","","148.37","54.89","631.39","94","176.82","453.47","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.40","427.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","218.46","38.3","","279.30","91.72","1116.77","266","176.82","453.47","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.40","427.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.70","42.9","","731.00","63.70","731.00","1 through 10","176.82","453.47","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.40","427.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.70","42.9","","384.74","384.74","384.74","1 through 10","176.82","453.47","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.40","427.80","WELLPOINT [1015]","HB AMC WELLPOINT","420.84","73.78","","286.63","119.22","1107.45","105","176.82","453.47","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.40","427.80","AETNA [1001]","HB AMC AETNA HMO","398.14","69.8","","675.31","184.75","1721.50","286","298.09","466.13","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.40","427.80","AETNA [1001]","HB AMC AETNA PPO","458.60","80.4","","1261.44","103.12","1514.10","21","298.09","466.13","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.40","427.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","458.60","80.4","","1365.00","1365.00","1365.00","1 through 10","298.09","466.13","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.40","427.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","466.13","81.72","","5157.68","5157.68","5157.68","1 through 10","298.09","466.13","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.40","427.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","466.13","81.72","","431.26","71.26","1459.57","88","298.09","466.13","percent of total billed charges",""
"PIN PREFIXATION BONE SCREW HEXALOBE TEMPORARY","SUP-ITM-10325110","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.95","79.5","","800.18","480.96","1887.97","195","65.1","166.95","percent of total billed charges",""
"PIN PREFIXATION BONE SCREW HEXALOBE TEMPORARY","SUP-ITM-10325110","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.93","53.3","","813.12","216.42","1444.50","81","65.1","166.95","percent of total billed charges",""
"PIN PREFIXATION BONE SCREW HEXALOBE TEMPORARY","SUP-ITM-10325110","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","65.10","31","","432.60","432.60","432.60","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN PREFIXATION BONE SCREW HEXALOBE TEMPORARY","SUP-ITM-10325110","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.65","36.5","","148.37","54.89","631.39","94","65.1","166.95","percent of total billed charges",""
"PIN PREFIXATION BONE SCREW HEXALOBE TEMPORARY","SUP-ITM-10325110","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.43","38.3","","279.30","91.72","1116.77","266","65.1","166.95","percent of total billed charges",""
"PIN PREFIXATION BONE SCREW HEXALOBE TEMPORARY","SUP-ITM-10325110","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","731.00","63.70","731.00","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN PREFIXATION BONE SCREW HEXALOBE TEMPORARY","SUP-ITM-10325110","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","384.74","384.74","384.74","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN PREFIXATION BONE SCREW HEXALOBE TEMPORARY","SUP-ITM-10325110","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB AMC WELLPOINT","154.94","73.78","","286.63","119.22","1107.45","105","65.1","166.95","percent of total billed charges",""
"PIN PREFIXATION BONE SCREW HEXALOBE TEMPORARY","SUP-ITM-10325110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA HMO","146.58","69.8","","675.31","184.75","1721.50","286","109.75","171.61","percent of total billed charges",""
"PIN PREFIXATION BONE SCREW HEXALOBE TEMPORARY","SUP-ITM-10325110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA PPO","168.84","80.4","","1261.44","103.12","1514.10","21","109.75","171.61","percent of total billed charges",""
"PIN PREFIXATION BONE SCREW HEXALOBE TEMPORARY","SUP-ITM-10325110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","168.84","80.4","","1365.00","1365.00","1365.00","1 through 10","109.75","171.61","percent of total billed charges",""
"PIN PREFIXATION BONE SCREW HEXALOBE TEMPORARY","SUP-ITM-10325110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","171.61","81.72","","5157.68","5157.68","5157.68","1 through 10","109.75","171.61","percent of total billed charges",""
"PIN PREFIXATION BONE SCREW HEXALOBE TEMPORARY","SUP-ITM-10325110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.61","81.72","","431.26","71.26","1459.57","88","109.75","171.61","percent of total billed charges",""
"PIN RETAINER 14MM SPINE CERVICAL","SUP-ITM-10273947","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.95","79.5","","800.18","480.96","1887.97","195","65.1","166.95","percent of total billed charges",""
"PIN RETAINER 14MM SPINE CERVICAL","SUP-ITM-10273947","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.93","53.3","","813.12","216.42","1444.50","81","65.1","166.95","percent of total billed charges",""
"PIN RETAINER 14MM SPINE CERVICAL","SUP-ITM-10273947","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","65.10","31","","432.60","432.60","432.60","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN RETAINER 14MM SPINE CERVICAL","SUP-ITM-10273947","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.65","36.5","","148.37","54.89","631.39","94","65.1","166.95","percent of total billed charges",""
"PIN RETAINER 14MM SPINE CERVICAL","SUP-ITM-10273947","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.43","38.3","","279.30","91.72","1116.77","266","65.1","166.95","percent of total billed charges",""
"PIN RETAINER 14MM SPINE CERVICAL","SUP-ITM-10273947","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","731.00","63.70","731.00","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN RETAINER 14MM SPINE CERVICAL","SUP-ITM-10273947","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","384.74","384.74","384.74","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN RETAINER 14MM SPINE CERVICAL","SUP-ITM-10273947","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB AMC WELLPOINT","154.94","73.78","","286.63","119.22","1107.45","105","65.1","166.95","percent of total billed charges",""
"PIN RETAINER 14MM SPINE CERVICAL","SUP-ITM-10273947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA HMO","146.58","69.8","","675.31","184.75","1721.50","286","109.75","171.61","percent of total billed charges",""
"PIN RETAINER 14MM SPINE CERVICAL","SUP-ITM-10273947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA PPO","168.84","80.4","","1261.44","103.12","1514.10","21","109.75","171.61","percent of total billed charges",""
"PIN RETAINER 14MM SPINE CERVICAL","SUP-ITM-10273947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","168.84","80.4","","1365.00","1365.00","1365.00","1 through 10","109.75","171.61","percent of total billed charges",""
"PIN RETAINER 14MM SPINE CERVICAL","SUP-ITM-10273947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","171.61","81.72","","5157.68","5157.68","5157.68","1 through 10","109.75","171.61","percent of total billed charges",""
"PIN RETAINER 14MM SPINE CERVICAL","SUP-ITM-10273947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.61","81.72","","431.26","71.26","1459.57","88","109.75","171.61","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX30MM STERILE","SUP-ITM-10320398","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","800.18","480.96","1887.97","195","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX30MM STERILE","SUP-ITM-10320398","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.64","53.3","","813.12","216.42","1444.50","81","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX30MM STERILE","SUP-ITM-10320398","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.13","31","","432.60","432.60","432.60","1 through 10","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX30MM STERILE","SUP-ITM-10320398","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","148.37","54.89","631.39","94","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX30MM STERILE","SUP-ITM-10320398","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","279.30","91.72","1116.77","266","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX30MM STERILE","SUP-ITM-10320398","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","731.00","63.70","731.00","1 through 10","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX30MM STERILE","SUP-ITM-10320398","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","384.74","384.74","384.74","1 through 10","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX30MM STERILE","SUP-ITM-10320398","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","286.63","119.22","1107.45","105","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX30MM STERILE","SUP-ITM-10320398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","675.31","184.75","1721.50","286","45.73","71.51","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX30MM STERILE","SUP-ITM-10320398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","1261.44","103.12","1514.10","21","45.73","71.51","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX30MM STERILE","SUP-ITM-10320398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","70.35","80.4","","1365.00","1365.00","1365.00","1 through 10","45.73","71.51","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX30MM STERILE","SUP-ITM-10320398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","71.51","81.72","","5157.68","5157.68","5157.68","1 through 10","45.73","71.51","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX30MM STERILE","SUP-ITM-10320398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","431.26","71.26","1459.57","88","45.73","71.51","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","800.18","480.96","1887.97","195","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.64","53.3","","813.12","216.42","1444.50","81","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.13","31","","432.60","432.60","432.60","1 through 10","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","148.37","54.89","631.39","94","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","279.30","91.72","1116.77","266","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","731.00","63.70","731.00","1 through 10","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","384.74","384.74","384.74","1 through 10","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","286.63","119.22","1107.45","105","27.13","69.56","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","675.31","184.75","1721.50","286","45.73","71.51","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","1261.44","103.12","1514.10","21","45.73","71.51","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","70.35","80.4","","1365.00","1365.00","1365.00","1 through 10","45.73","71.51","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","71.51","81.72","","5157.68","5157.68","5157.68","1 through 10","45.73","71.51","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","431.26","71.26","1459.57","88","45.73","71.51","percent of total billed charges",""
"PIN SE 150MM LONG PERCUTANEOUS NAVIGATION","SUP-ITM-10100606","CDM","C1713","HCPCS","0278","RC","","","","both","","","712.28","534.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","566.26","79.5","","800.18","480.96","1887.97","195","220.81","566.26","percent of total billed charges",""
"PIN SE 150MM LONG PERCUTANEOUS NAVIGATION","SUP-ITM-10100606","CDM","C1713","HCPCS","0278","RC","","","","both","","","712.28","534.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","379.65","53.3","","813.12","216.42","1444.50","81","220.81","566.26","percent of total billed charges",""
"PIN SE 150MM LONG PERCUTANEOUS NAVIGATION","SUP-ITM-10100606","CDM","C1713","HCPCS","0278","RC","","","","both","","","712.28","534.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","220.81","31","","432.60","432.60","432.60","1 through 10","220.81","566.26","percent of total billed charges",""
"PIN SE 150MM LONG PERCUTANEOUS NAVIGATION","SUP-ITM-10100606","CDM","C1713","HCPCS","0278","RC","","","","both","","","712.28","534.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","259.98","36.5","","148.37","54.89","631.39","94","220.81","566.26","percent of total billed charges",""
"PIN SE 150MM LONG PERCUTANEOUS NAVIGATION","SUP-ITM-10100606","CDM","C1713","HCPCS","0278","RC","","","","both","","","712.28","534.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","272.80","38.3","","279.30","91.72","1116.77","266","220.81","566.26","percent of total billed charges",""
"PIN SE 150MM LONG PERCUTANEOUS NAVIGATION","SUP-ITM-10100606","CDM","C1713","HCPCS","0278","RC","","","","both","","","712.28","534.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","305.57","42.9","","731.00","63.70","731.00","1 through 10","220.81","566.26","percent of total billed charges",""
"PIN SE 150MM LONG PERCUTANEOUS NAVIGATION","SUP-ITM-10100606","CDM","C1713","HCPCS","0278","RC","","","","both","","","712.28","534.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","305.57","42.9","","384.74","384.74","384.74","1 through 10","220.81","566.26","percent of total billed charges",""
"PIN SE 150MM LONG PERCUTANEOUS NAVIGATION","SUP-ITM-10100606","CDM","C1713","HCPCS","0278","RC","","","","both","","","712.28","534.21","WELLPOINT [1015]","HB AMC WELLPOINT","525.52","73.78","","286.63","119.22","1107.45","105","220.81","566.26","percent of total billed charges",""
"PIN SE 150MM LONG PERCUTANEOUS NAVIGATION","SUP-ITM-10100606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","712.28","534.21","AETNA [1001]","HB AMC AETNA HMO","497.17","69.8","","675.31","184.75","1721.50","286","372.24","582.08","percent of total billed charges",""
"PIN SE 150MM LONG PERCUTANEOUS NAVIGATION","SUP-ITM-10100606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","712.28","534.21","AETNA [1001]","HB AMC AETNA PPO","572.67","80.4","","1261.44","103.12","1514.10","21","372.24","582.08","percent of total billed charges",""
"PIN SE 150MM LONG PERCUTANEOUS NAVIGATION","SUP-ITM-10100606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","712.28","534.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","572.67","80.4","","1365.00","1365.00","1365.00","1 through 10","372.24","582.08","percent of total billed charges",""
"PIN SE 150MM LONG PERCUTANEOUS NAVIGATION","SUP-ITM-10100606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","712.28","534.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","582.08","81.72","","5157.68","5157.68","5157.68","1 through 10","372.24","582.08","percent of total billed charges",""
"PIN SE 150MM LONG PERCUTANEOUS NAVIGATION","SUP-ITM-10100606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","712.28","534.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","582.08","81.72","","431.26","71.26","1459.57","88","372.24","582.08","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.95","79.5","","800.18","480.96","1887.97","195","65.1","166.95","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.93","53.3","","813.12","216.42","1444.50","81","65.1","166.95","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","65.10","31","","432.60","432.60","432.60","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.65","36.5","","148.37","54.89","631.39","94","65.1","166.95","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.43","38.3","","279.30","91.72","1116.77","266","65.1","166.95","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","731.00","63.70","731.00","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","384.74","384.74","384.74","1 through 10","65.1","166.95","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB AMC WELLPOINT","154.94","73.78","","286.63","119.22","1107.45","105","65.1","166.95","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA HMO","146.58","69.8","","675.31","184.75","1721.50","286","109.75","171.61","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA PPO","168.84","80.4","","1261.44","103.12","1514.10","21","109.75","171.61","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","168.84","80.4","","1365.00","1365.00","1365.00","1 through 10","109.75","171.61","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","171.61","81.72","","5157.68","5157.68","5157.68","1 through 10","109.75","171.61","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.61","81.72","","431.26","71.26","1459.57","88","109.75","171.61","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.33","70.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","74.20","79.5","","800.18","480.96","1887.97","195","28.93","74.2","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.33","70.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","49.74","53.3","","813.12","216.42","1444.50","81","28.93","74.2","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.33","70.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","28.93","31","","432.60","432.60","432.60","1 through 10","28.93","74.2","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.33","70.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34.07","36.5","","148.37","54.89","631.39","94","28.93","74.2","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.33","70.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35.75","38.3","","279.30","91.72","1116.77","266","28.93","74.2","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.33","70.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.04","42.9","","731.00","63.70","731.00","1 through 10","28.93","74.2","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.33","70.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.04","42.9","","384.74","384.74","384.74","1 through 10","28.93","74.2","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.33","70.00","WELLPOINT [1015]","HB AMC WELLPOINT","68.86","73.78","","286.63","119.22","1107.45","105","28.93","74.2","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.33","70.00","AETNA [1001]","HB AMC AETNA HMO","65.14","69.8","","675.31","184.75","1721.50","286","48.77","76.27","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.33","70.00","AETNA [1001]","HB AMC AETNA PPO","75.04","80.4","","1261.44","103.12","1514.10","21","48.77","76.27","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.33","70.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","75.04","80.4","","1365.00","1365.00","1365.00","1 through 10","48.77","76.27","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.33","70.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","76.27","81.72","","5157.68","5157.68","5157.68","1 through 10","48.77","76.27","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.33","70.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","76.27","81.72","","431.26","71.26","1459.57","88","48.77","76.27","percent of total billed charges",""
"PIN STEINMANN 0.125MM 2.5IN SHOULDER THREADED TIP","SUP-ITM-10100163","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.60","418.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","444.09","79.5","","800.18","480.96","1887.97","195","173.17","444.09","percent of total billed charges",""
"PIN STEINMANN 0.125MM 2.5IN SHOULDER THREADED TIP","SUP-ITM-10100163","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.60","418.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","297.73","53.3","","813.12","216.42","1444.50","81","173.17","444.09","percent of total billed charges",""
"PIN STEINMANN 0.125MM 2.5IN SHOULDER THREADED TIP","SUP-ITM-10100163","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.60","418.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","173.17","31","","432.60","432.60","432.60","1 through 10","173.17","444.09","percent of total billed charges",""
"PIN STEINMANN 0.125MM 2.5IN SHOULDER THREADED TIP","SUP-ITM-10100163","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.60","418.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","203.89","36.5","","148.37","54.89","631.39","94","173.17","444.09","percent of total billed charges",""
"PIN STEINMANN 0.125MM 2.5IN SHOULDER THREADED TIP","SUP-ITM-10100163","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.60","418.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","213.94","38.3","","279.30","91.72","1116.77","266","173.17","444.09","percent of total billed charges",""
"PIN STEINMANN 0.125MM 2.5IN SHOULDER THREADED TIP","SUP-ITM-10100163","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.60","418.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.64","42.9","","731.00","63.70","731.00","1 through 10","173.17","444.09","percent of total billed charges",""
"PIN STEINMANN 0.125MM 2.5IN SHOULDER THREADED TIP","SUP-ITM-10100163","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.60","418.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.64","42.9","","384.74","384.74","384.74","1 through 10","173.17","444.09","percent of total billed charges",""
"PIN STEINMANN 0.125MM 2.5IN SHOULDER THREADED TIP","SUP-ITM-10100163","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.60","418.95","WELLPOINT [1015]","HB AMC WELLPOINT","412.14","73.78","","286.63","119.22","1107.45","105","173.17","444.09","percent of total billed charges",""
"PIN STEINMANN 0.125MM 2.5IN SHOULDER THREADED TIP","SUP-ITM-10100163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.60","418.95","AETNA [1001]","HB AMC AETNA HMO","389.90","69.8","","675.31","184.75","1721.50","286","291.92","456.49","percent of total billed charges",""
"PIN STEINMANN 0.125MM 2.5IN SHOULDER THREADED TIP","SUP-ITM-10100163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.60","418.95","AETNA [1001]","HB AMC AETNA PPO","449.11","80.4","","1261.44","103.12","1514.10","21","291.92","456.49","percent of total billed charges",""
"PIN STEINMANN 0.125MM 2.5IN SHOULDER THREADED TIP","SUP-ITM-10100163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.60","418.95","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","449.11","80.4","","1365.00","1365.00","1365.00","1 through 10","291.92","456.49","percent of total billed charges",""
"PIN STEINMANN 0.125MM 2.5IN SHOULDER THREADED TIP","SUP-ITM-10100163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.60","418.95","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","456.49","81.72","","5157.68","5157.68","5157.68","1 through 10","291.92","456.49","percent of total billed charges",""
"PIN STEINMANN 0.125MM 2.5IN SHOULDER THREADED TIP","SUP-ITM-10100163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.60","418.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","456.49","81.72","","431.26","71.26","1459.57","88","291.92","456.49","percent of total billed charges",""
"PIN STERNAL TITANIUM EMERGENCY RELEASE DISPOABLE","SUP-ITM-10026776","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.87","117.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.71","79.5","","800.18","480.96","1887.97","195","48.63","124.71","percent of total billed charges",""
"PIN STERNAL TITANIUM EMERGENCY RELEASE DISPOABLE","SUP-ITM-10026776","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.87","117.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.61","53.3","","813.12","216.42","1444.50","81","48.63","124.71","percent of total billed charges",""
"PIN STERNAL TITANIUM EMERGENCY RELEASE DISPOABLE","SUP-ITM-10026776","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.87","117.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.63","31","","432.60","432.60","432.60","1 through 10","48.63","124.71","percent of total billed charges",""
"PIN STERNAL TITANIUM EMERGENCY RELEASE DISPOABLE","SUP-ITM-10026776","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.87","117.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.26","36.5","","148.37","54.89","631.39","94","48.63","124.71","percent of total billed charges",""
"PIN STERNAL TITANIUM EMERGENCY RELEASE DISPOABLE","SUP-ITM-10026776","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.87","117.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.08","38.3","","279.30","91.72","1116.77","266","48.63","124.71","percent of total billed charges",""
"PIN STERNAL TITANIUM EMERGENCY RELEASE DISPOABLE","SUP-ITM-10026776","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.87","117.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.30","42.9","","731.00","63.70","731.00","1 through 10","48.63","124.71","percent of total billed charges",""
"PIN STERNAL TITANIUM EMERGENCY RELEASE DISPOABLE","SUP-ITM-10026776","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.87","117.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.30","42.9","","384.74","384.74","384.74","1 through 10","48.63","124.71","percent of total billed charges",""
"PIN STERNAL TITANIUM EMERGENCY RELEASE DISPOABLE","SUP-ITM-10026776","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.87","117.65","WELLPOINT [1015]","HB AMC WELLPOINT","115.74","73.78","","286.63","119.22","1107.45","105","48.63","124.71","percent of total billed charges",""
"PIN STERNAL TITANIUM EMERGENCY RELEASE DISPOABLE","SUP-ITM-10026776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.87","117.65","AETNA [1001]","HB AMC AETNA HMO","109.50","69.8","","675.31","184.75","1721.50","286","81.98","128.19","percent of total billed charges",""
"PIN STERNAL TITANIUM EMERGENCY RELEASE DISPOABLE","SUP-ITM-10026776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.87","117.65","AETNA [1001]","HB AMC AETNA PPO","126.12","80.4","","1261.44","103.12","1514.10","21","81.98","128.19","percent of total billed charges",""
"PIN STERNAL TITANIUM EMERGENCY RELEASE DISPOABLE","SUP-ITM-10026776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.87","117.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.12","80.4","","1365.00","1365.00","1365.00","1 through 10","81.98","128.19","percent of total billed charges",""
"PIN STERNAL TITANIUM EMERGENCY RELEASE DISPOABLE","SUP-ITM-10026776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.87","117.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.19","81.72","","5157.68","5157.68","5157.68","1 through 10","81.98","128.19","percent of total billed charges",""
"PIN STERNAL TITANIUM EMERGENCY RELEASE DISPOABLE","SUP-ITM-10026776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.87","117.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.19","81.72","","431.26","71.26","1459.57","88","81.98","128.19","percent of total billed charges",""
"PIN THREADED 3.2MMX330 STERILE","SUP-ITM-10330309","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.00","593.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","628.85","79.5","","800.18","480.96","1887.97","195","245.21","628.85","percent of total billed charges",""
"PIN THREADED 3.2MMX330 STERILE","SUP-ITM-10330309","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.00","593.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","421.60","53.3","","813.12","216.42","1444.50","81","245.21","628.85","percent of total billed charges",""
"PIN THREADED 3.2MMX330 STERILE","SUP-ITM-10330309","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.00","593.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","245.21","31","","432.60","432.60","432.60","1 through 10","245.21","628.85","percent of total billed charges",""
"PIN THREADED 3.2MMX330 STERILE","SUP-ITM-10330309","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.00","593.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","288.72","36.5","","148.37","54.89","631.39","94","245.21","628.85","percent of total billed charges",""
"PIN THREADED 3.2MMX330 STERILE","SUP-ITM-10330309","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.00","593.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","302.95","38.3","","279.30","91.72","1116.77","266","245.21","628.85","percent of total billed charges",""
"PIN THREADED 3.2MMX330 STERILE","SUP-ITM-10330309","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.00","593.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","339.34","42.9","","731.00","63.70","731.00","1 through 10","245.21","628.85","percent of total billed charges",""
"PIN THREADED 3.2MMX330 STERILE","SUP-ITM-10330309","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.00","593.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","339.34","42.9","","384.74","384.74","384.74","1 through 10","245.21","628.85","percent of total billed charges",""
"PIN THREADED 3.2MMX330 STERILE","SUP-ITM-10330309","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.00","593.25","WELLPOINT [1015]","HB AMC WELLPOINT","583.60","73.78","","286.63","119.22","1107.45","105","245.21","628.85","percent of total billed charges",""
"PIN THREADED 3.2MMX330 STERILE","SUP-ITM-10330309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","791.00","593.25","AETNA [1001]","HB AMC AETNA HMO","552.12","69.8","","675.31","184.75","1721.50","286","413.38","646.41","percent of total billed charges",""
"PIN THREADED 3.2MMX330 STERILE","SUP-ITM-10330309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","791.00","593.25","AETNA [1001]","HB AMC AETNA PPO","635.96","80.4","","1261.44","103.12","1514.10","21","413.38","646.41","percent of total billed charges",""
"PIN THREADED 3.2MMX330 STERILE","SUP-ITM-10330309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","791.00","593.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","635.96","80.4","","1365.00","1365.00","1365.00","1 through 10","413.38","646.41","percent of total billed charges",""
"PIN THREADED 3.2MMX330 STERILE","SUP-ITM-10330309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","791.00","593.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","646.41","81.72","","5157.68","5157.68","5157.68","1 through 10","413.38","646.41","percent of total billed charges",""
"PIN THREADED 3.2MMX330 STERILE","SUP-ITM-10330309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","791.00","593.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","646.41","81.72","","431.26","71.26","1459.57","88","413.38","646.41","percent of total billed charges",""
"PIN THREADED ALIGNMENT FOR HINDFOOT ARTHRODESIS NAIL EX","SUP-ITM-10038655","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1133.07","79.5","","800.18","480.96","1887.97","195","441.82","1133.07","percent of total billed charges",""
"PIN THREADED ALIGNMENT FOR HINDFOOT ARTHRODESIS NAIL EX","SUP-ITM-10038655","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","759.65","53.3","","813.12","216.42","1444.50","81","441.82","1133.07","percent of total billed charges",""
"PIN THREADED ALIGNMENT FOR HINDFOOT ARTHRODESIS NAIL EX","SUP-ITM-10038655","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","441.82","31","","432.60","432.60","432.60","1 through 10","441.82","1133.07","percent of total billed charges",""
"PIN THREADED ALIGNMENT FOR HINDFOOT ARTHRODESIS NAIL EX","SUP-ITM-10038655","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","520.21","36.5","","148.37","54.89","631.39","94","441.82","1133.07","percent of total billed charges",""
"PIN THREADED ALIGNMENT FOR HINDFOOT ARTHRODESIS NAIL EX","SUP-ITM-10038655","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","545.87","38.3","","279.30","91.72","1116.77","266","441.82","1133.07","percent of total billed charges",""
"PIN THREADED ALIGNMENT FOR HINDFOOT ARTHRODESIS NAIL EX","SUP-ITM-10038655","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","611.43","42.9","","731.00","63.70","731.00","1 through 10","441.82","1133.07","percent of total billed charges",""
"PIN THREADED ALIGNMENT FOR HINDFOOT ARTHRODESIS NAIL EX","SUP-ITM-10038655","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","611.43","42.9","","384.74","384.74","384.74","1 through 10","441.82","1133.07","percent of total billed charges",""
"PIN THREADED ALIGNMENT FOR HINDFOOT ARTHRODESIS NAIL EX","SUP-ITM-10038655","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","WELLPOINT [1015]","HB AMC WELLPOINT","1051.54","73.78","","286.63","119.22","1107.45","105","441.82","1133.07","percent of total billed charges",""
"PIN THREADED ALIGNMENT FOR HINDFOOT ARTHRODESIS NAIL EX","SUP-ITM-10038655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","AETNA [1001]","HB AMC AETNA HMO","994.82","69.8","","675.31","184.75","1721.50","286","744.83","1164.71","percent of total billed charges",""
"PIN THREADED ALIGNMENT FOR HINDFOOT ARTHRODESIS NAIL EX","SUP-ITM-10038655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","AETNA [1001]","HB AMC AETNA PPO","1145.89","80.4","","1261.44","103.12","1514.10","21","744.83","1164.71","percent of total billed charges",""
"PIN THREADED ALIGNMENT FOR HINDFOOT ARTHRODESIS NAIL EX","SUP-ITM-10038655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1145.89","80.4","","1365.00","1365.00","1365.00","1 through 10","744.83","1164.71","percent of total billed charges",""
"PIN THREADED ALIGNMENT FOR HINDFOOT ARTHRODESIS NAIL EX","SUP-ITM-10038655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1164.71","81.72","","5157.68","5157.68","5157.68","1 through 10","744.83","1164.71","percent of total billed charges",""
"PIN THREADED ALIGNMENT FOR HINDFOOT ARTHRODESIS NAIL EX","SUP-ITM-10038655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1164.71","81.72","","431.26","71.26","1459.57","88","744.83","1164.71","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.48","234.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","248.42","79.5","","800.18","480.96","1887.97","195","96.87","248.42","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.48","234.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","166.55","53.3","","813.12","216.42","1444.50","81","96.87","248.42","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.48","234.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","96.87","31","","432.60","432.60","432.60","1 through 10","96.87","248.42","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.48","234.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.06","36.5","","148.37","54.89","631.39","94","96.87","248.42","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.48","234.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.68","38.3","","279.30","91.72","1116.77","266","96.87","248.42","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.48","234.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.05","42.9","","731.00","63.70","731.00","1 through 10","96.87","248.42","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.48","234.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.05","42.9","","384.74","384.74","384.74","1 through 10","96.87","248.42","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.48","234.36","WELLPOINT [1015]","HB AMC WELLPOINT","230.55","73.78","","286.63","119.22","1107.45","105","96.87","248.42","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.48","234.36","AETNA [1001]","HB AMC AETNA HMO","218.11","69.8","","675.31","184.75","1721.50","286","163.3","255.36","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.48","234.36","AETNA [1001]","HB AMC AETNA PPO","251.23","80.4","","1261.44","103.12","1514.10","21","163.3","255.36","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.48","234.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","251.23","80.4","","1365.00","1365.00","1365.00","1 through 10","163.3","255.36","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.48","234.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","255.36","81.72","","5157.68","5157.68","5157.68","1 through 10","163.3","255.36","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.48","234.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","255.36","81.72","","431.26","71.26","1459.57","88","163.3","255.36","percent of total billed charges",""
"Pinworm Exam Cellophane Tape Prep","PX-30001180","CDM","87172","CPT","0306","RC","","","","both","","","57.00","42.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","45.32","79.5","","43.29","43.29","43.29","1 through 10","4.18","54.15","percent of total billed charges",""
"Pinworm Exam Cellophane Tape Prep","PX-30001180","CDM","87172","CPT","0306","RC","","","","outpatient","","","57.00","42.75","AETNA [1001]","HB AMC AETNA HMO","39.79","69.8","","37.24","37.24","37.24","1 through 10","4.4","46.58","percent of total billed charges",""
"Piperacillin/Tazo Vl 1/0.125gm","PX-63600163","CDM","J2543","HCPCS","0636","RC","","","","outpatient","","","65.00","48.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","45.44","69.9","","2.79","2.79","2.79","1 through 10","2.39","52.26","percent of total billed charges",""
"PISTON EAR .5X3.75 TO 5.25MM SMART STAPEDECTOMY FLUOROPLASTIC NITINOL","SUP-ITM-10019421","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","878.40","658.80","AETNA [1001]","HB AMC AETNA HMO","613.12","69.8","","1013.24","1013.24","1013.24","1 through 10","439.2","724.68","percent of total billed charges",""
"PISTON EAR .5X4MM SMART STAPES OSSICULAR RECONSTRUCTION FLUOROPLASTIC NITINOL","SUP-ITM-10019422","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","888.58","666.43","AETNA [1001]","HB AMC AETNA HMO","620.23","69.8","","1013.24","1013.24","1013.24","1 through 10","444.29","733.08","percent of total billed charges",""
"PISTON PROSTHESIS 0.6X2 4.50MM EAR OSSICULAR LESINSKI FLUROPLASTIC STAPEDOTOMY","SUP-ITM-10005019","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","754.08","565.56","AETNA [1001]","HB AMC AETNA HMO","526.35","69.8","","1013.24","1013.24","1013.24","1 through 10","377.04","622.12","percent of total billed charges",""
"Pl Ndle/Cth Plv/Gntl","PX-76001329","CDM","55920","CPT","0333","RC","","","","both","","","3269.00","2451.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","6037.59","","APC Price ($5,861.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","15045.44","15045.44","15045.44","1 through 10","1013.39","7327.17","other","OPPS APC"
"Pl Ndle/Cth Plv/Gntl","PX-76001329","CDM","55920","CPT","0333","RC","","","","both","","","3269.00","2451.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","5861.74","","APC Price ($5,861.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12598.64","12598.64","12598.64","1 through 10","1013.39","7327.17","other","OPPS APC"
"Pl Ndle/Cth Plv/Gntl","PX-76001329","CDM","55920","CPT","0333","RC","","","","both","","","3269.00","2451.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","5744.50","","APC Price ($5,861.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5748.08","5748.08","5748.08","1 through 10","1013.39","7327.17","other","OPPS APC"
"Pl Ndle/Cth Plv/Gntl","PX-76001329","CDM","55920","CPT","0333","RC","","","","outpatient","","","3269.00","2451.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","9478.70","9478.70","9478.70","1 through 10","1708.38","8899.59","other","ASC"
"Pla2r","PX-30003376","CDM","86021","CPT","0302","RC","","","","both","","","253.00","189.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","177.10","70","","107.73","107.73","107.73","1 through 10","14.75","240.35","percent of total billed charges",""
"Pla2r","PX-30003376","CDM","86021","CPT","0302","RC","","","","both","","","253.00","189.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","201.14","79.5","","129.36","129.36","192.82","1 through 10","14.75","240.35","percent of total billed charges",""
"Pla2r","PX-30003376","CDM","86021","CPT","0302","RC","","","","both","","","253.00","189.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","92.35","36.5","","91.39","91.39","91.39","1 through 10","14.75","240.35","percent of total billed charges",""
"Pla2r","PX-30003376","CDM","86021","CPT","0302","RC","","","","both","","","253.00","189.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.90","38.3","","95.80","95.80","95.80","1 through 10","14.75","240.35","percent of total billed charges",""
"Pla2r","PX-30003376","CDM","86021","CPT","0302","RC","","","","outpatient","","","253.00","189.75","AETNA [1001]","HB AMC AETNA HMO","176.59","69.8","","165.87","117.11","191.10","1 through 10","15.53","206.75","percent of total billed charges",""
"Pla2r","PX-30003376","CDM","86021","CPT","0302","RC","","","","outpatient","","","253.00","189.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","206.75","81.72","","195.85","107.73","195.85","1 through 10","15.53","206.75","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","200.24","200.24","200.24","11","163.37","418.97","other","OPPS APC"
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","342.55","65","","332.15","332.15","332.15","1 through 10","163.37","418.97","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","368.90","70","","224.69","224.69","224.69","1 through 10","163.37","418.97","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","254.35","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","74.48","74.48","74.48","1 through 10","163.37","418.97","other","OPPS APC"
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","418.97","79.5","","402.16","269.81","402.16","14","163.37","418.97","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","280.89","53.3","","402.16","258.06","402.16","1 through 10","163.37","418.97","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","199.43","199.43","1 through 10","163.37","418.97","other","OPPS APC"
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","405.79","77","","763.84","763.84","763.84","1 through 10","163.37","418.97","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","342.55","65","","332.15","332.15","332.15","1 through 10","163.37","418.97","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.53","199.53","199.53","1 through 10","163.37","418.97","other","OPPS APC"
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","MEDICARE [2001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","186.42","610.50","95","163.37","418.97","other","OPPS APC"
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","192.36","36.5","","190.60","161.99","190.60","1 through 10","163.37","418.97","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.84","38.3","","199.80","199.80","199.80","12","163.37","418.97","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","199.43","199.43","1 through 10","163.37","418.97","other","OPPS APC"
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","MOLINA [1014]","HB BWH MOLINA","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1211.22","1211.22","1211.22","1 through 10","163.37","418.97","other","OPPS APC"
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","600.72","182.69","600.72","1 through 10","163.37","418.97","other","OPPS APC"
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.08","42.9","","408.49","381.97","408.49","1 through 10","163.37","418.97","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","182.70","203.50","15","163.37","418.97","other","OPPS APC"
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","both","","","527.00","395.25","WELLPOINT [1015]","HB AMC WELLPOINT","388.82","73.78","","380.44","380.44","891.44","1 through 10","163.37","418.97","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","outpatient","","","527.00","395.25","AETNA [1001]","HB AMC AETNA HMO","367.85","69.8","","691.90","345.95","691.90","1 through 10","265.8","1680.97","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","outpatient","","","527.00","395.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","423.71","80.4","","398.58","398.58","398.58","1 through 10","265.8","1680.97","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","outpatient","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","430.66","81.72","","224.69","224.69","224.69","1 through 10","265.8","1680.97","percent of total billed charges",""
"Pla2r","PX-30003377","CDM","88346","CPT","0312","RC","","","","outpatient","","","527.00","395.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","430.66","81.72","","408.49","224.69","2042.47","1 through 10","265.8","1680.97","percent of total billed charges",""
"Place Cath Abd/Pel/Lwr Ext 1st","PX-76001049","CDM","36245","CPT","0361","RC","","","","inpatient","","","7033.00","5274.75","AETNA [1001]","HB AMC AETNA HMO","4859.80","69.1","","8584.88","6200.19","8584.88","1 through 10","3889.25","5591.24","percent of total billed charges",""
"Place Cath Abd/Pel/Lwr Ext 1st","PX-76001049","CDM","36245","CPT","0361","RC","","","","outpatient","","","7033.00","5274.75","AETNA [1001]","HB AMC AETNA HMO","4909.03","69.8","","4617.14","4617.14","4617.14","1 through 10","400.43","5747.37","percent of total billed charges",""
"Place Cath Abd/Pel/Lwr Ext 3rd","PX-76001051","CDM","36247","CPT","0361","RC","","","","both","","","8483.00","6362.25","WELLPOINT [1015]","HB AMC WELLPOINT","6258.76","73.78","","5928.20","5928.20","5928.20","1 through 10","2629.73","6743.99","percent of total billed charges",""
"Place Cath Abd/Pel/Lwr Ext Add","PX-76001052","CDM","36248","CPT","0361","RC","","","","both","","","1381.00","1035.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1097.90","79.5","","1053.79","1053.79","1053.79","1 through 10","428.11","1097.9","percent of total billed charges",""
"Place Cath Abd/Pel/Lwr Ext Add","PX-76001052","CDM","36248","CPT","0361","RC","","","","both","","","1381.00","1035.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","504.07","36.5","","424.46","424.46","424.46","1 through 10","428.11","1097.9","percent of total billed charges",""
"Place Cath Abd/Pel/Lwr Ext Add","PX-76001052","CDM","36248","CPT","0361","RC","","","","both","","","1381.00","1035.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","528.92","38.3","","1866.80","523.55","1866.80","1 through 10","428.11","1097.9","percent of total billed charges",""
"Place Cath Abd/Pel/Lwr Ext Add","PX-76001052","CDM","36248","CPT","0361","RC","","","","both","","","1381.00","1035.75","WELLPOINT [1015]","HB AMC WELLPOINT","1018.90","73.78","","956.28","956.28","956.28","1 through 10","428.11","1097.9","percent of total billed charges",""
"Place Cath Abd/Pel/Lwr Ext Add","PX-76001052","CDM","36248","CPT","0361","RC","","","","outpatient","","","1381.00","1035.75","AETNA [1001]","HB AMC AETNA HMO","963.94","69.8","","906.51","906.51","906.51","1 through 10","82.43","1128.55","percent of total billed charges",""
"Place Cath Abd/Pel/Lwr Ext Add","PX-76001052","CDM","36248","CPT","0361","RC","","","","outpatient","","","1381.00","1035.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1128.55","81.72","","588.76","588.76","588.76","1 through 10","82.43","1128.55","percent of total billed charges",""
"Place Cath Renal 1st Order Bilat","PX-48000232","CDM","36252","CPT","0361","RC","","","","outpatient","","","8381.00","6285.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7002.05","7002.05","7002.05","1 through 10","3020.73","10117.02","other","ASC "
"Place Cath Thor/Brachio 1st Order","PX-76001045","CDM","36215","CPT","0361","RC","","","","outpatient","","","6805.00","5103.75","AETNA [1001]","HB AMC AETNA PPO","5471.22","80.4","","353.34","353.34","353.34","15","358.53","5561.05","percent of total billed charges",""
"Place Cth Venous 2nd Order Branch","PX-76001033","CDM","36012","CPT","0361","RC","","","","both","","","4723.00","3542.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2517.36","53.3","","2418.24","2418.24","2418.24","1 through 10","1464.13","3754.79","percent of total billed charges",""
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","both","","","10319.00","7739.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","6036.49","","APC Price ($6,036.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7370.26","5557.05","12314.86","1 through 10","3198.89","8203.61","other","OPPS APC"
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","both","","","10319.00","7739.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8203.61","79.5","","5283.70","5283.70","5283.70","1 through 10","3198.89","8203.61","percent of total billed charges",""
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","both","","","10319.00","7739.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5500.03","53.3","","7875.51","7875.51","7875.51","1 through 10","3198.89","8203.61","percent of total billed charges",""
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","both","","","10319.00","7739.25","MEDICARE [2001]","HB BWH MEDICARE","6036.49","","APC Price ($6,036.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16942.23","6037.10","18111.30","62","3198.89","8203.61","other","OPPS APC"
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","both","","","10319.00","7739.25","MOLINA [1014]","HB BWH MOLINA","5915.76","","APC Price ($6,036.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","11977.61","11977.61","11977.61","1 through 10","3198.89","8203.61","other","OPPS APC"
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","both","","","10319.00","7739.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","5915.76","","APC Price ($6,036.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20986.40","7467.94","20986.40","1 through 10","3198.89","8203.61","other","OPPS APC"
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","both","","","10319.00","7739.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4426.85","42.9","","4400.08","4400.08","4400.08","1 through 10","3198.89","8203.61","percent of total billed charges",""
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","both","","","10319.00","7739.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","5915.76","","APC Price ($6,036.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7360.18","5924.06","8642.72","1 through 10","3198.89","8203.61","other","OPPS APC"
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","outpatient","","","10319.00","7739.25","AETNA [1001]","HB AMC AETNA HMO","7202.66","69.8","","6774.74","6774.74","6774.74","1 through 10","3618.49","20332.05","percent of total billed charges",""
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","outpatient","","","10319.00","7739.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4597.72","","Case rate ($4,597.72). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","9406.94","9236.82","9406.94","1 through 10","3618.49","20332.05","other","ASC"
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","outpatient","","","10319.00","7739.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4597.72","","Case rate ($4,597.72). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","10657.51","10657.51","10763.26","13","3618.49","20332.05","other","ASC "
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","outpatient","","","10319.00","7739.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3618.49","","Case rate ($3,618.49). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8394.90","4197.45","8394.90","1 through 10","3618.49","20332.05","other","Multiple Surgery"
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","outpatient","","","10319.00","7739.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3618.49","","Case rate ($3,618.49). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","26487.36","8829.12","26487.36","1 through 10","3618.49","20332.05","other","Multiple Surgery"
"Place Needle Prostate Transperineal","PX-76001327","CDM","55875","CPT","0761","RC","","","","outpatient","","","10319.00","7739.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8432.69","81.72","","4400.08","4400.08","4400.08","1 through 10","3618.49","20332.05","percent of total billed charges",""
"Placement of biodegradeable material, mediastinum/chest, includes imaging","PX-76002958","CDM","32999","CPT","0761","RC","","","","both","","","6317.00","4737.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5022.02","79.5","","0.89","0.89","0.89","1 through 10","697.51","5022.02","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","both","","","3860.00","2895.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3068.70","79.5","","9682.46","6400.67","9682.46","1 through 10","1196.6","3068.7","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","both","","","3860.00","2895.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1478.38","38.3","","4810.47","4810.47","4810.47","1 through 10","1196.6","3068.7","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","both","","","3860.00","2895.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1655.94","42.9","","9835.02","9835.02","9835.02","1 through 10","1196.6","3068.7","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","outpatient","","","3860.00","2895.00","AETNA [1001]","HB AMC AETNA HMO","2694.28","69.8","","17743.49","5880.83","17743.49","1 through 10","1544","3154.39","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","outpatient","","","3860.00","2895.00","AETNA [1001]","HB AMC AETNA PPO","3103.44","80.4","","11030.20","4261.69","11030.20","1 through 10","1544","3154.39","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","outpatient","","","3860.00","2895.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2337.23","60.55","","5363.49","5363.49","5462.27","1 through 10","1544","3154.39","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","outpatient","","","3860.00","2895.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2015.69","52.22","","6188.43","6188.43","6188.43","1 through 10","1544","3154.39","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","outpatient","","","3860.00","2895.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","3154.39","81.72","","13003.04","13003.04","13003.04","1 through 10","1544","3154.39","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1598.89","1488.10","1598.89","14","1543.65","7901.51","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6460.35","65","","7585.11","7585.11","7585.11","1 through 10","1543.65","7901.51","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","6957.30","70","","9638.00","6939.36","9638.00","1 through 10","1543.65","7901.51","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7901.51","79.5","","7585.11","5088.86","19316.92","1 through 10","1543.65","7901.51","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5297.49","53.3","","7585.11","2605.38","7585.11","1 through 10","1543.65","7901.51","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1598.89","1488.10","9605.50","1 through 10","1543.65","7901.51","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","ELDER SERVICES [1037]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5336.97","5336.97","5336.97","1 through 10","1543.65","7901.51","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","FALLON HEALTH [1008]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1624.89","1624.89","1624.89","1 through 10","1543.65","7901.51","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1602.14","1602.14","1602.14","1 through 10","1543.65","7901.51","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","HUMANA [1012]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1592.39","1592.39","1592.39","1 through 10","1543.65","7901.51","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","7156.08","72","","6939.36","6939.36","6939.36","1 through 10","1543.65","7901.51","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","MEDICARE [2001]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1624.89","1624.89","3249.78","161","1543.65","7901.51","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3627.74","36.5","","3594.97","3055.25","3594.97","1 through 10","1543.65","7901.51","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3806.64","38.3","","3768.46","3768.46","3768.46","19","1543.65","7901.51","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","MOLINA [1014]","HB BWH MOLINA","1592.23","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3223.78","3223.78","3223.78","1 through 10","1543.65","7901.51","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1592.23","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1592.39","1482.05","4777.17","17","1543.65","7901.51","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4263.83","42.9","","4237.83","4237.83","4237.83","1 through 10","1543.65","7901.51","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9939.00","7454.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1592.23","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1592.40","1512.30","1598.90","22","1543.65","7901.51","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","outpatient","","","9939.00","7454.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5194.12","52.26","","5963.99","5963.99","5963.99","1 through 10","3242.02","8122.15","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","outpatient","","","9939.00","7454.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8122.15","81.72","","7704.62","4237.83","7704.62","1 through 10","3242.02","8122.15","percent of total billed charges",""
"PLASMA ALLOY 4.5IN SM LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT LEFT 32-8105-073-01","SUP-ITM-10019298","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3871.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY 4.5IN SM LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT LEFT 32-8105-073-01","SUP-ITM-10019298","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5889.16","79.5","","1293.60","1148.53","1603.80","1 through 10","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY 4.5IN SM LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT LEFT 32-8105-073-01","SUP-ITM-10019298","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2703.83","36.5","","1023.42","771.29","2068.67","33","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY 4.5IN SM LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT LEFT 32-8105-073-01","SUP-ITM-10019298","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2837.17","38.3","","850.52","759.78","1211.25","66","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY 4.5IN SM LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT LEFT 32-8105-073-01","SUP-ITM-10019298","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3177.92","42.9","","2548.09","2548.09","2548.09","1 through 10","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY 4.5IN SM LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT LEFT 32-8105-073-01","SUP-ITM-10019298","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3177.92","42.9","","956.46","956.46","956.46","1 through 10","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY 4.5IN SM LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT LEFT 32-8105-073-01","SUP-ITM-10019298","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","WELLPOINT [1015]","HB AMC WELLPOINT","5465.44","73.78","","2344.73","1619.47","2530.35","16","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY 4.5IN SM LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT LEFT 32-8105-073-01","SUP-ITM-10019298","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7407.75","5555.81","AETNA [1001]","HB AMC AETNA HMO","5170.61","69.8","","1523.63","988.41","4330.26","39","3871.29","6053.61","percent of total billed charges",""
"PLASMA ALLOY 4.5IN SM LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT LEFT 32-8105-073-01","SUP-ITM-10019298","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7407.75","5555.81","AETNA [1001]","HB AMC AETNA PPO","5955.83","80.4","","1670.25","1670.25","1670.25","1 through 10","3871.29","6053.61","percent of total billed charges",""
"PLASMA ALLOY 4.5IN SM LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT LEFT 32-8105-073-01","SUP-ITM-10019298","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7407.75","5555.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3871.29","52.26","","1113.10","1113.10","1113.10","1 through 10","3871.29","6053.61","percent of total billed charges",""
"PLASMA ALLOY 4.5IN SM LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT LEFT 32-8105-073-01","SUP-ITM-10019298","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7407.75","5555.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6053.61","81.72","","1738.90","1484.65","2716.94","38","3871.29","6053.61","percent of total billed charges",""
"PLASMA ALLOY LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT RT REGULAR","SUP-ITM-10202631","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3871.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT RT REGULAR","SUP-ITM-10202631","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5889.16","79.5","","1293.60","1148.53","1603.80","1 through 10","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT RT REGULAR","SUP-ITM-10202631","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2703.83","36.5","","1023.42","771.29","2068.67","33","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT RT REGULAR","SUP-ITM-10202631","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2837.17","38.3","","850.52","759.78","1211.25","66","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT RT REGULAR","SUP-ITM-10202631","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3177.92","42.9","","2548.09","2548.09","2548.09","1 through 10","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT RT REGULAR","SUP-ITM-10202631","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3177.92","42.9","","956.46","956.46","956.46","1 through 10","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT RT REGULAR","SUP-ITM-10202631","CDM","C1776","HCPCS","0278","RC","","","","both","","","7407.75","5555.81","WELLPOINT [1015]","HB AMC WELLPOINT","5465.44","73.78","","2344.73","1619.47","2530.35","16","2296.4","5889.16","percent of total billed charges",""
"PLASMA ALLOY LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT RT REGULAR","SUP-ITM-10202631","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7407.75","5555.81","AETNA [1001]","HB AMC AETNA HMO","5170.61","69.8","","1523.63","988.41","4330.26","39","3871.29","6053.61","percent of total billed charges",""
"PLASMA ALLOY LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT RT REGULAR","SUP-ITM-10202631","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7407.75","5555.81","AETNA [1001]","HB AMC AETNA PPO","5955.83","80.4","","1670.25","1670.25","1670.25","1 through 10","3871.29","6053.61","percent of total billed charges",""
"PLASMA ALLOY LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT RT REGULAR","SUP-ITM-10202631","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7407.75","5555.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3871.29","52.26","","1113.10","1113.10","1113.10","1 through 10","3871.29","6053.61","percent of total billed charges",""
"PLASMA ALLOY LONG COMPONENT ULNAR ELBOW COONRAD/MORREY TITANIUM COAT RT REGULAR","SUP-ITM-10202631","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7407.75","5555.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6053.61","81.72","","1738.90","1484.65","2716.94","38","3871.29","6053.61","percent of total billed charges",""
"Plasma Frozen 8 to 24","PX-39000032","CDM","P9059","HCPCS","0390","RC","","","","both","","","766.00","574.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","608.97","79.5","","544.39","544.39","544.39","1 through 10","67.54","608.97","percent of total billed charges",""
"Plasma Frozen 8 to 24","PX-39000032","CDM","P9059","HCPCS","0390","RC","","","","both","","","766.00","574.50","MEDICARE [2001]","HB BWH MEDICARE","71.09","","APC Price ($71.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","71.09","71.09","71.09","1 through 10","67.54","608.97","other","OPPS APC"
"Plasma Frozen 8 to 24","PX-39000032","CDM","P9059","HCPCS","0390","RC","","","","outpatient","","","766.00","574.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","383.00","50","","76.66","76.66","76.66","1 through 10","122.54","631.95","percent of total billed charges",""
"PLATE 12 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.00","1543.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1636.11","79.5","","800.18","480.96","1887.97","195","637.98","1636.11","percent of total billed charges",""
"PLATE 12 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.00","1543.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1096.91","53.3","","813.12","216.42","1444.50","81","637.98","1636.11","percent of total billed charges",""
"PLATE 12 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.00","1543.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","637.98","31","","432.60","432.60","432.60","1 through 10","637.98","1636.11","percent of total billed charges",""
"PLATE 12 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.00","1543.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","751.17","36.5","","148.37","54.89","631.39","94","637.98","1636.11","percent of total billed charges",""
"PLATE 12 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.00","1543.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","788.21","38.3","","279.30","91.72","1116.77","266","637.98","1636.11","percent of total billed charges",""
"PLATE 12 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.00","1543.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","882.88","42.9","","731.00","63.70","731.00","1 through 10","637.98","1636.11","percent of total billed charges",""
"PLATE 12 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.00","1543.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","882.88","42.9","","384.74","384.74","384.74","1 through 10","637.98","1636.11","percent of total billed charges",""
"PLATE 12 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132376","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.00","1543.50","WELLPOINT [1015]","HB AMC WELLPOINT","1518.39","73.78","","286.63","119.22","1107.45","105","637.98","1636.11","percent of total billed charges",""
"PLATE 12 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.00","1543.50","AETNA [1001]","HB AMC AETNA HMO","1436.48","69.8","","675.31","184.75","1721.50","286","1075.51","1681.8","percent of total billed charges",""
"PLATE 12 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.00","1543.50","AETNA [1001]","HB AMC AETNA PPO","1654.63","80.4","","1261.44","103.12","1514.10","21","1075.51","1681.8","percent of total billed charges",""
"PLATE 12 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.00","1543.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1654.63","80.4","","1365.00","1365.00","1365.00","1 through 10","1075.51","1681.8","percent of total billed charges",""
"PLATE 12 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.00","1543.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1681.80","81.72","","5157.68","5157.68","5157.68","1 through 10","1075.51","1681.8","percent of total billed charges",""
"PLATE 12 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.00","1543.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1681.80","81.72","","431.26","71.26","1459.57","88","1075.51","1681.8","percent of total billed charges",""
"PLATE 2.0MM MED TI PSPC MATRIXMANDIBLE DOUBLE RECON PL THICK","SUP-ITM-10168158","CDM","C1713","HCPCS","0278","RC","","","","both","","","13285.05","9963.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10561.61","79.5","","800.18","480.96","1887.97","195","4118.37","10561.61","percent of total billed charges",""
"PLATE 2.0MM MED TI PSPC MATRIXMANDIBLE DOUBLE RECON PL THICK","SUP-ITM-10168158","CDM","C1713","HCPCS","0278","RC","","","","both","","","13285.05","9963.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7080.93","53.3","","813.12","216.42","1444.50","81","4118.37","10561.61","percent of total billed charges",""
"PLATE 2.0MM MED TI PSPC MATRIXMANDIBLE DOUBLE RECON PL THICK","SUP-ITM-10168158","CDM","C1713","HCPCS","0278","RC","","","","both","","","13285.05","9963.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4118.37","31","","432.60","432.60","432.60","1 through 10","4118.37","10561.61","percent of total billed charges",""
"PLATE 2.0MM MED TI PSPC MATRIXMANDIBLE DOUBLE RECON PL THICK","SUP-ITM-10168158","CDM","C1713","HCPCS","0278","RC","","","","both","","","13285.05","9963.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4849.04","36.5","","148.37","54.89","631.39","94","4118.37","10561.61","percent of total billed charges",""
"PLATE 2.0MM MED TI PSPC MATRIXMANDIBLE DOUBLE RECON PL THICK","SUP-ITM-10168158","CDM","C1713","HCPCS","0278","RC","","","","both","","","13285.05","9963.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5088.17","38.3","","279.30","91.72","1116.77","266","4118.37","10561.61","percent of total billed charges",""
"PLATE 2.0MM MED TI PSPC MATRIXMANDIBLE DOUBLE RECON PL THICK","SUP-ITM-10168158","CDM","C1713","HCPCS","0278","RC","","","","both","","","13285.05","9963.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5699.29","42.9","","731.00","63.70","731.00","1 through 10","4118.37","10561.61","percent of total billed charges",""
"PLATE 2.0MM MED TI PSPC MATRIXMANDIBLE DOUBLE RECON PL THICK","SUP-ITM-10168158","CDM","C1713","HCPCS","0278","RC","","","","both","","","13285.05","9963.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5699.29","42.9","","384.74","384.74","384.74","1 through 10","4118.37","10561.61","percent of total billed charges",""
"PLATE 2.0MM MED TI PSPC MATRIXMANDIBLE DOUBLE RECON PL THICK","SUP-ITM-10168158","CDM","C1713","HCPCS","0278","RC","","","","both","","","13285.05","9963.79","WELLPOINT [1015]","HB AMC WELLPOINT","9801.71","73.78","","286.63","119.22","1107.45","105","4118.37","10561.61","percent of total billed charges",""
"PLATE 2.0MM MED TI PSPC MATRIXMANDIBLE DOUBLE RECON PL THICK","SUP-ITM-10168158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13285.05","9963.79","AETNA [1001]","HB AMC AETNA HMO","9272.96","69.8","","675.31","184.75","1721.50","286","6942.77","10856.54","percent of total billed charges",""
"PLATE 2.0MM MED TI PSPC MATRIXMANDIBLE DOUBLE RECON PL THICK","SUP-ITM-10168158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13285.05","9963.79","AETNA [1001]","HB AMC AETNA PPO","10681.18","80.4","","1261.44","103.12","1514.10","21","6942.77","10856.54","percent of total billed charges",""
"PLATE 2.0MM MED TI PSPC MATRIXMANDIBLE DOUBLE RECON PL THICK","SUP-ITM-10168158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13285.05","9963.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10681.18","80.4","","1365.00","1365.00","1365.00","1 through 10","6942.77","10856.54","percent of total billed charges",""
"PLATE 2.0MM MED TI PSPC MATRIXMANDIBLE DOUBLE RECON PL THICK","SUP-ITM-10168158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13285.05","9963.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","10856.54","81.72","","5157.68","5157.68","5157.68","1 through 10","6942.77","10856.54","percent of total billed charges",""
"PLATE 2.0MM MED TI PSPC MATRIXMANDIBLE DOUBLE RECON PL THICK","SUP-ITM-10168158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13285.05","9963.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10856.54","81.72","","431.26","71.26","1459.57","88","6942.77","10856.54","percent of total billed charges",""
"PLATE 2.0MM THICK TITANIUM PATIENT SPECIFIC MANDIBLE NO ANGLE","SUP-ITM-10159068","CDM","C1713","HCPCS","0278","RC","","","","both","","","7922.85","5942.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6298.67","79.5","","800.18","480.96","1887.97","195","2456.08","6298.67","percent of total billed charges",""
"PLATE 2.0MM THICK TITANIUM PATIENT SPECIFIC MANDIBLE NO ANGLE","SUP-ITM-10159068","CDM","C1713","HCPCS","0278","RC","","","","both","","","7922.85","5942.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4222.88","53.3","","813.12","216.42","1444.50","81","2456.08","6298.67","percent of total billed charges",""
"PLATE 2.0MM THICK TITANIUM PATIENT SPECIFIC MANDIBLE NO ANGLE","SUP-ITM-10159068","CDM","C1713","HCPCS","0278","RC","","","","both","","","7922.85","5942.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2456.08","31","","432.60","432.60","432.60","1 through 10","2456.08","6298.67","percent of total billed charges",""
"PLATE 2.0MM THICK TITANIUM PATIENT SPECIFIC MANDIBLE NO ANGLE","SUP-ITM-10159068","CDM","C1713","HCPCS","0278","RC","","","","both","","","7922.85","5942.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2891.84","36.5","","148.37","54.89","631.39","94","2456.08","6298.67","percent of total billed charges",""
"PLATE 2.0MM THICK TITANIUM PATIENT SPECIFIC MANDIBLE NO ANGLE","SUP-ITM-10159068","CDM","C1713","HCPCS","0278","RC","","","","both","","","7922.85","5942.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3034.45","38.3","","279.30","91.72","1116.77","266","2456.08","6298.67","percent of total billed charges",""
"PLATE 2.0MM THICK TITANIUM PATIENT SPECIFIC MANDIBLE NO ANGLE","SUP-ITM-10159068","CDM","C1713","HCPCS","0278","RC","","","","both","","","7922.85","5942.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3398.90","42.9","","731.00","63.70","731.00","1 through 10","2456.08","6298.67","percent of total billed charges",""
"PLATE 2.0MM THICK TITANIUM PATIENT SPECIFIC MANDIBLE NO ANGLE","SUP-ITM-10159068","CDM","C1713","HCPCS","0278","RC","","","","both","","","7922.85","5942.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3398.90","42.9","","384.74","384.74","384.74","1 through 10","2456.08","6298.67","percent of total billed charges",""
"PLATE 2.0MM THICK TITANIUM PATIENT SPECIFIC MANDIBLE NO ANGLE","SUP-ITM-10159068","CDM","C1713","HCPCS","0278","RC","","","","both","","","7922.85","5942.14","WELLPOINT [1015]","HB AMC WELLPOINT","5845.48","73.78","","286.63","119.22","1107.45","105","2456.08","6298.67","percent of total billed charges",""
"PLATE 2.0MM THICK TITANIUM PATIENT SPECIFIC MANDIBLE NO ANGLE","SUP-ITM-10159068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7922.85","5942.14","AETNA [1001]","HB AMC AETNA HMO","5530.15","69.8","","675.31","184.75","1721.50","286","4140.48","6474.55","percent of total billed charges",""
"PLATE 2.0MM THICK TITANIUM PATIENT SPECIFIC MANDIBLE NO ANGLE","SUP-ITM-10159068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7922.85","5942.14","AETNA [1001]","HB AMC AETNA PPO","6369.97","80.4","","1261.44","103.12","1514.10","21","4140.48","6474.55","percent of total billed charges",""
"PLATE 2.0MM THICK TITANIUM PATIENT SPECIFIC MANDIBLE NO ANGLE","SUP-ITM-10159068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7922.85","5942.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6369.97","80.4","","1365.00","1365.00","1365.00","1 through 10","4140.48","6474.55","percent of total billed charges",""
"PLATE 2.0MM THICK TITANIUM PATIENT SPECIFIC MANDIBLE NO ANGLE","SUP-ITM-10159068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7922.85","5942.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6474.55","81.72","","5157.68","5157.68","5157.68","1 through 10","4140.48","6474.55","percent of total billed charges",""
"PLATE 2.0MM THICK TITANIUM PATIENT SPECIFIC MANDIBLE NO ANGLE","SUP-ITM-10159068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7922.85","5942.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6474.55","81.72","","431.26","71.26","1459.57","88","4140.48","6474.55","percent of total billed charges",""
"PLATE 2.7MM 6 HOLE TUBLAR 8240 60 006","SUP-ITM-10028891","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.00","178.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","189.21","79.5","","800.18","480.96","1887.97","195","73.78","189.21","percent of total billed charges",""
"PLATE 2.7MM 6 HOLE TUBLAR 8240 60 006","SUP-ITM-10028891","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.00","178.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","126.85","53.3","","813.12","216.42","1444.50","81","73.78","189.21","percent of total billed charges",""
"PLATE 2.7MM 6 HOLE TUBLAR 8240 60 006","SUP-ITM-10028891","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.00","178.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","73.78","31","","432.60","432.60","432.60","1 through 10","73.78","189.21","percent of total billed charges",""
"PLATE 2.7MM 6 HOLE TUBLAR 8240 60 006","SUP-ITM-10028891","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.00","178.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","86.87","36.5","","148.37","54.89","631.39","94","73.78","189.21","percent of total billed charges",""
"PLATE 2.7MM 6 HOLE TUBLAR 8240 60 006","SUP-ITM-10028891","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.00","178.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.15","38.3","","279.30","91.72","1116.77","266","73.78","189.21","percent of total billed charges",""
"PLATE 2.7MM 6 HOLE TUBLAR 8240 60 006","SUP-ITM-10028891","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.00","178.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.10","42.9","","731.00","63.70","731.00","1 through 10","73.78","189.21","percent of total billed charges",""
"PLATE 2.7MM 6 HOLE TUBLAR 8240 60 006","SUP-ITM-10028891","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.00","178.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.10","42.9","","384.74","384.74","384.74","1 through 10","73.78","189.21","percent of total billed charges",""
"PLATE 2.7MM 6 HOLE TUBLAR 8240 60 006","SUP-ITM-10028891","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.00","178.50","WELLPOINT [1015]","HB AMC WELLPOINT","175.60","73.78","","286.63","119.22","1107.45","105","73.78","189.21","percent of total billed charges",""
"PLATE 2.7MM 6 HOLE TUBLAR 8240 60 006","SUP-ITM-10028891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.00","178.50","AETNA [1001]","HB AMC AETNA HMO","166.12","69.8","","675.31","184.75","1721.50","286","124.38","194.49","percent of total billed charges",""
"PLATE 2.7MM 6 HOLE TUBLAR 8240 60 006","SUP-ITM-10028891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.00","178.50","AETNA [1001]","HB AMC AETNA PPO","191.35","80.4","","1261.44","103.12","1514.10","21","124.38","194.49","percent of total billed charges",""
"PLATE 2.7MM 6 HOLE TUBLAR 8240 60 006","SUP-ITM-10028891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.00","178.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","191.35","80.4","","1365.00","1365.00","1365.00","1 through 10","124.38","194.49","percent of total billed charges",""
"PLATE 2.7MM 6 HOLE TUBLAR 8240 60 006","SUP-ITM-10028891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.00","178.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","194.49","81.72","","5157.68","5157.68","5157.68","1 through 10","124.38","194.49","percent of total billed charges",""
"PLATE 2.7MM 6 HOLE TUBLAR 8240 60 006","SUP-ITM-10028891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.00","178.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","194.49","81.72","","431.26","71.26","1459.57","88","124.38","194.49","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3308.39","79.5","","800.18","480.96","1887.97","195","1290.07","3308.39","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2218.08","53.3","","813.12","216.42","1444.50","81","1290.07","3308.39","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1290.07","31","","432.60","432.60","432.60","1 through 10","1290.07","3308.39","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1518.95","36.5","","148.37","54.89","631.39","94","1290.07","3308.39","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1593.85","38.3","","279.30","91.72","1116.77","266","1290.07","3308.39","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1785.28","42.9","","731.00","63.70","731.00","1 through 10","1290.07","3308.39","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1785.28","42.9","","384.74","384.74","384.74","1 through 10","1290.07","3308.39","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","both","","","4161.50","3121.12","WELLPOINT [1015]","HB AMC WELLPOINT","3070.35","73.78","","286.63","119.22","1107.45","105","1290.07","3308.39","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","AETNA [1001]","HB AMC AETNA HMO","2904.73","69.8","","675.31","184.75","1721.50","286","2174.8","3400.78","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","AETNA [1001]","HB AMC AETNA PPO","3345.85","80.4","","1261.44","103.12","1514.10","21","2174.8","3400.78","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3345.85","80.4","","1365.00","1365.00","1365.00","1 through 10","2174.8","3400.78","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3400.78","81.72","","5157.68","5157.68","5157.68","1 through 10","2174.8","3400.78","percent of total billed charges",""
"PLATE 42MM SM 6 HOLE 5.0DEG FOOT ORTHOLOC 3DI MTP FUSION TITANIUM FIXATION COMPRESSION ANGLE LEFT","SUP-ITM-10129729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4161.50","3121.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3400.78","81.72","","431.26","71.26","1459.57","88","2174.8","3400.78","percent of total billed charges",""
"PLATE 6 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1232.00","924.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","979.44","79.5","","800.18","480.96","1887.97","195","381.92","979.44","percent of total billed charges",""
"PLATE 6 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1232.00","924.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","656.66","53.3","","813.12","216.42","1444.50","81","381.92","979.44","percent of total billed charges",""
"PLATE 6 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1232.00","924.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","381.92","31","","432.60","432.60","432.60","1 through 10","381.92","979.44","percent of total billed charges",""
"PLATE 6 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1232.00","924.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","449.68","36.5","","148.37","54.89","631.39","94","381.92","979.44","percent of total billed charges",""
"PLATE 6 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1232.00","924.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","471.86","38.3","","279.30","91.72","1116.77","266","381.92","979.44","percent of total billed charges",""
"PLATE 6 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1232.00","924.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","528.53","42.9","","731.00","63.70","731.00","1 through 10","381.92","979.44","percent of total billed charges",""
"PLATE 6 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1232.00","924.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","528.53","42.9","","384.74","384.74","384.74","1 through 10","381.92","979.44","percent of total billed charges",""
"PLATE 6 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1232.00","924.00","WELLPOINT [1015]","HB AMC WELLPOINT","908.97","73.78","","286.63","119.22","1107.45","105","381.92","979.44","percent of total billed charges",""
"PLATE 6 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1232.00","924.00","AETNA [1001]","HB AMC AETNA HMO","859.94","69.8","","675.31","184.75","1721.50","286","643.84","1006.79","percent of total billed charges",""
"PLATE 6 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1232.00","924.00","AETNA [1001]","HB AMC AETNA PPO","990.53","80.4","","1261.44","103.12","1514.10","21","643.84","1006.79","percent of total billed charges",""
"PLATE 6 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1232.00","924.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","990.53","80.4","","1365.00","1365.00","1365.00","1 through 10","643.84","1006.79","percent of total billed charges",""
"PLATE 6 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1232.00","924.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1006.79","81.72","","5157.68","5157.68","5157.68","1 through 10","643.84","1006.79","percent of total billed charges",""
"PLATE 6 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1232.00","924.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1006.79","81.72","","431.26","71.26","1459.57","88","643.84","1006.79","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/LEFT/ THICK","SUP-ITM-10168135","CDM","C1713","HCPCS","0278","RC","","","","both","","","14328.20","10746.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11390.92","79.5","","800.18","480.96","1887.97","195","4441.74","11390.92","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/LEFT/ THICK","SUP-ITM-10168135","CDM","C1713","HCPCS","0278","RC","","","","both","","","14328.20","10746.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7636.93","53.3","","813.12","216.42","1444.50","81","4441.74","11390.92","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/LEFT/ THICK","SUP-ITM-10168135","CDM","C1713","HCPCS","0278","RC","","","","both","","","14328.20","10746.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4441.74","31","","432.60","432.60","432.60","1 through 10","4441.74","11390.92","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/LEFT/ THICK","SUP-ITM-10168135","CDM","C1713","HCPCS","0278","RC","","","","both","","","14328.20","10746.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5229.79","36.5","","148.37","54.89","631.39","94","4441.74","11390.92","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/LEFT/ THICK","SUP-ITM-10168135","CDM","C1713","HCPCS","0278","RC","","","","both","","","14328.20","10746.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5487.70","38.3","","279.30","91.72","1116.77","266","4441.74","11390.92","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/LEFT/ THICK","SUP-ITM-10168135","CDM","C1713","HCPCS","0278","RC","","","","both","","","14328.20","10746.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6146.80","42.9","","731.00","63.70","731.00","1 through 10","4441.74","11390.92","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/LEFT/ THICK","SUP-ITM-10168135","CDM","C1713","HCPCS","0278","RC","","","","both","","","14328.20","10746.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6146.80","42.9","","384.74","384.74","384.74","1 through 10","4441.74","11390.92","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/LEFT/ THICK","SUP-ITM-10168135","CDM","C1713","HCPCS","0278","RC","","","","both","","","14328.20","10746.15","WELLPOINT [1015]","HB AMC WELLPOINT","10571.35","73.78","","286.63","119.22","1107.45","105","4441.74","11390.92","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/LEFT/ THICK","SUP-ITM-10168135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14328.20","10746.15","AETNA [1001]","HB AMC AETNA HMO","10001.08","69.8","","675.31","184.75","1721.50","286","7487.92","11709.01","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/LEFT/ THICK","SUP-ITM-10168135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14328.20","10746.15","AETNA [1001]","HB AMC AETNA PPO","11519.87","80.4","","1261.44","103.12","1514.10","21","7487.92","11709.01","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/LEFT/ THICK","SUP-ITM-10168135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14328.20","10746.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11519.87","80.4","","1365.00","1365.00","1365.00","1 through 10","7487.92","11709.01","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/LEFT/ THICK","SUP-ITM-10168135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14328.20","10746.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","11709.01","81.72","","5157.68","5157.68","5157.68","1 through 10","7487.92","11709.01","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/LEFT/ THICK","SUP-ITM-10168135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14328.20","10746.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11709.01","81.72","","431.26","71.26","1459.57","88","7487.92","11709.01","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/RIGHT/ THICK","SUP-ITM-10168132","CDM","C1713","HCPCS","0278","RC","","","","both","","","19590.00","14692.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15574.05","79.5","","800.18","480.96","1887.97","195","6072.9","15574.05","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/RIGHT/ THICK","SUP-ITM-10168132","CDM","C1713","HCPCS","0278","RC","","","","both","","","19590.00","14692.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10441.47","53.3","","813.12","216.42","1444.50","81","6072.9","15574.05","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/RIGHT/ THICK","SUP-ITM-10168132","CDM","C1713","HCPCS","0278","RC","","","","both","","","19590.00","14692.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","6072.90","31","","432.60","432.60","432.60","1 through 10","6072.9","15574.05","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/RIGHT/ THICK","SUP-ITM-10168132","CDM","C1713","HCPCS","0278","RC","","","","both","","","19590.00","14692.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7150.35","36.5","","148.37","54.89","631.39","94","6072.9","15574.05","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/RIGHT/ THICK","SUP-ITM-10168132","CDM","C1713","HCPCS","0278","RC","","","","both","","","19590.00","14692.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7502.97","38.3","","279.30","91.72","1116.77","266","6072.9","15574.05","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/RIGHT/ THICK","SUP-ITM-10168132","CDM","C1713","HCPCS","0278","RC","","","","both","","","19590.00","14692.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8404.11","42.9","","731.00","63.70","731.00","1 through 10","6072.9","15574.05","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/RIGHT/ THICK","SUP-ITM-10168132","CDM","C1713","HCPCS","0278","RC","","","","both","","","19590.00","14692.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8404.11","42.9","","384.74","384.74","384.74","1 through 10","6072.9","15574.05","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/RIGHT/ THICK","SUP-ITM-10168132","CDM","C1713","HCPCS","0278","RC","","","","both","","","19590.00","14692.50","WELLPOINT [1015]","HB AMC WELLPOINT","14453.50","73.78","","286.63","119.22","1107.45","105","6072.9","15574.05","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/RIGHT/ THICK","SUP-ITM-10168132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19590.00","14692.50","AETNA [1001]","HB AMC AETNA HMO","13673.82","69.8","","675.31","184.75","1721.50","286","10237.73","16008.95","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/RIGHT/ THICK","SUP-ITM-10168132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19590.00","14692.50","AETNA [1001]","HB AMC AETNA PPO","15750.36","80.4","","1261.44","103.12","1514.10","21","10237.73","16008.95","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/RIGHT/ THICK","SUP-ITM-10168132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19590.00","14692.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","15750.36","80.4","","1365.00","1365.00","1365.00","1 through 10","10237.73","16008.95","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/RIGHT/ THICK","SUP-ITM-10168132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19590.00","14692.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","16008.95","81.72","","5157.68","5157.68","5157.68","1 through 10","10237.73","16008.95","percent of total billed charges",""
"PLATE 7X2.8MM 23 H TI PSPC MATRIXMANDIBLE ANGLE RECON PL/RIGHT/ THICK","SUP-ITM-10168132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19590.00","14692.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16008.95","81.72","","431.26","71.26","1459.57","88","10237.73","16008.95","percent of total billed charges",""
"PLATE 8 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132374","CDM","C1713","HCPCS","0278","RC","","","","both","","","1648.50","1236.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1310.56","79.5","","800.18","480.96","1887.97","195","511.04","1310.56","percent of total billed charges",""
"PLATE 8 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132374","CDM","C1713","HCPCS","0278","RC","","","","both","","","1648.50","1236.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","878.65","53.3","","813.12","216.42","1444.50","81","511.04","1310.56","percent of total billed charges",""
"PLATE 8 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132374","CDM","C1713","HCPCS","0278","RC","","","","both","","","1648.50","1236.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","511.04","31","","432.60","432.60","432.60","1 through 10","511.04","1310.56","percent of total billed charges",""
"PLATE 8 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132374","CDM","C1713","HCPCS","0278","RC","","","","both","","","1648.50","1236.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","601.70","36.5","","148.37","54.89","631.39","94","511.04","1310.56","percent of total billed charges",""
"PLATE 8 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132374","CDM","C1713","HCPCS","0278","RC","","","","both","","","1648.50","1236.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","631.38","38.3","","279.30","91.72","1116.77","266","511.04","1310.56","percent of total billed charges",""
"PLATE 8 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132374","CDM","C1713","HCPCS","0278","RC","","","","both","","","1648.50","1236.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","707.21","42.9","","731.00","63.70","731.00","1 through 10","511.04","1310.56","percent of total billed charges",""
"PLATE 8 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132374","CDM","C1713","HCPCS","0278","RC","","","","both","","","1648.50","1236.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","707.21","42.9","","384.74","384.74","384.74","1 through 10","511.04","1310.56","percent of total billed charges",""
"PLATE 8 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132374","CDM","C1713","HCPCS","0278","RC","","","","both","","","1648.50","1236.37","WELLPOINT [1015]","HB AMC WELLPOINT","1216.26","73.78","","286.63","119.22","1107.45","105","511.04","1310.56","percent of total billed charges",""
"PLATE 8 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1648.50","1236.37","AETNA [1001]","HB AMC AETNA HMO","1150.65","69.8","","675.31","184.75","1721.50","286","861.51","1347.15","percent of total billed charges",""
"PLATE 8 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1648.50","1236.37","AETNA [1001]","HB AMC AETNA PPO","1325.39","80.4","","1261.44","103.12","1514.10","21","861.51","1347.15","percent of total billed charges",""
"PLATE 8 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1648.50","1236.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1325.39","80.4","","1365.00","1365.00","1365.00","1 through 10","861.51","1347.15","percent of total billed charges",""
"PLATE 8 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1648.50","1236.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1347.15","81.72","","5157.68","5157.68","5157.68","1 through 10","861.51","1347.15","percent of total billed charges",""
"PLATE 8 HOLE TUBULAR STRAIGHT ORTHOLOC 3DI PLATING SYSTEM","SUP-ITM-10132374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1648.50","1236.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1347.15","81.72","","431.26","71.26","1459.57","88","861.51","1347.15","percent of total billed charges",""
"PLATE ANKLE 100MM 6 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3075.20","79.5","","800.18","480.96","1887.97","195","1199.13","3075.2","percent of total billed charges",""
"PLATE ANKLE 100MM 6 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2061.73","53.3","","813.12","216.42","1444.50","81","1199.13","3075.2","percent of total billed charges",""
"PLATE ANKLE 100MM 6 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1199.13","31","","432.60","432.60","432.60","1 through 10","1199.13","3075.2","percent of total billed charges",""
"PLATE ANKLE 100MM 6 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1411.88","36.5","","148.37","54.89","631.39","94","1199.13","3075.2","percent of total billed charges",""
"PLATE ANKLE 100MM 6 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1481.51","38.3","","279.30","91.72","1116.77","266","1199.13","3075.2","percent of total billed charges",""
"PLATE ANKLE 100MM 6 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1659.44","42.9","","731.00","63.70","731.00","1 through 10","1199.13","3075.2","percent of total billed charges",""
"PLATE ANKLE 100MM 6 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1659.44","42.9","","384.74","384.74","384.74","1 through 10","1199.13","3075.2","percent of total billed charges",""
"PLATE ANKLE 100MM 6 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","WELLPOINT [1015]","HB AMC WELLPOINT","2853.94","73.78","","286.63","119.22","1107.45","105","1199.13","3075.2","percent of total billed charges",""
"PLATE ANKLE 100MM 6 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3868.17","2901.13","AETNA [1001]","HB AMC AETNA HMO","2699.98","69.8","","675.31","184.75","1721.50","286","2021.51","3161.07","percent of total billed charges",""
"PLATE ANKLE 100MM 6 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3868.17","2901.13","AETNA [1001]","HB AMC AETNA PPO","3110.01","80.4","","1261.44","103.12","1514.10","21","2021.51","3161.07","percent of total billed charges",""
"PLATE ANKLE 100MM 6 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3868.17","2901.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3110.01","80.4","","1365.00","1365.00","1365.00","1 through 10","2021.51","3161.07","percent of total billed charges",""
"PLATE ANKLE 100MM 6 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3868.17","2901.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3161.07","81.72","","5157.68","5157.68","5157.68","1 through 10","2021.51","3161.07","percent of total billed charges",""
"PLATE ANKLE 100MM 6 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3868.17","2901.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3161.07","81.72","","431.26","71.26","1459.57","88","2021.51","3161.07","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1933.44","1450.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1537.08","79.5","","800.18","480.96","1887.97","195","599.37","1537.08","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1933.44","1450.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1030.52","53.3","","813.12","216.42","1444.50","81","599.37","1537.08","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1933.44","1450.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","599.37","31","","432.60","432.60","432.60","1 through 10","599.37","1537.08","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1933.44","1450.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","705.71","36.5","","148.37","54.89","631.39","94","599.37","1537.08","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1933.44","1450.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","740.51","38.3","","279.30","91.72","1116.77","266","599.37","1537.08","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1933.44","1450.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","829.45","42.9","","731.00","63.70","731.00","1 through 10","599.37","1537.08","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1933.44","1450.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","829.45","42.9","","384.74","384.74","384.74","1 through 10","599.37","1537.08","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1933.44","1450.08","WELLPOINT [1015]","HB AMC WELLPOINT","1426.49","73.78","","286.63","119.22","1107.45","105","599.37","1537.08","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1933.44","1450.08","AETNA [1001]","HB AMC AETNA HMO","1349.54","69.8","","675.31","184.75","1721.50","286","1010.42","1580.01","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1933.44","1450.08","AETNA [1001]","HB AMC AETNA PPO","1554.49","80.4","","1261.44","103.12","1514.10","21","1010.42","1580.01","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1933.44","1450.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1554.49","80.4","","1365.00","1365.00","1365.00","1 through 10","1010.42","1580.01","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1933.44","1450.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1580.01","81.72","","5157.68","5157.68","5157.68","1 through 10","1010.42","1580.01","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1933.44","1450.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1580.01","81.72","","431.26","71.26","1459.57","88","1010.42","1580.01","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.56","3398.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3602.59","79.5","","800.18","480.96","1887.97","195","1404.78","3602.59","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.56","3398.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2415.32","53.3","","813.12","216.42","1444.50","81","1404.78","3602.59","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.56","3398.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1404.78","31","","432.60","432.60","432.60","1 through 10","1404.78","3602.59","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.56","3398.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1654.02","36.5","","148.37","54.89","631.39","94","1404.78","3602.59","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.56","3398.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1735.59","38.3","","279.30","91.72","1116.77","266","1404.78","3602.59","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.56","3398.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.04","42.9","","731.00","63.70","731.00","1 through 10","1404.78","3602.59","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.56","3398.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.04","42.9","","384.74","384.74","384.74","1 through 10","1404.78","3602.59","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4531.56","3398.67","WELLPOINT [1015]","HB AMC WELLPOINT","3343.38","73.78","","286.63","119.22","1107.45","105","1404.78","3602.59","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4531.56","3398.67","AETNA [1001]","HB AMC AETNA HMO","3163.03","69.8","","675.31","184.75","1721.50","286","2368.19","3703.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4531.56","3398.67","AETNA [1001]","HB AMC AETNA PPO","3643.37","80.4","","1261.44","103.12","1514.10","21","2368.19","3703.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4531.56","3398.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3643.37","80.4","","1365.00","1365.00","1365.00","1 through 10","2368.19","3703.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4531.56","3398.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3703.19","81.72","","5157.68","5157.68","5157.68","1 through 10","2368.19","3703.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4531.56","3398.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3703.19","81.72","","431.26","71.26","1459.57","88","2368.19","3703.19","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.38","3036.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3218.46","79.5","","800.18","480.96","1887.97","195","1255","3218.46","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.38","3036.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2157.79","53.3","","813.12","216.42","1444.50","81","1255","3218.46","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.38","3036.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1255.00","31","","432.60","432.60","432.60","1 through 10","1255","3218.46","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.38","3036.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1477.66","36.5","","148.37","54.89","631.39","94","1255","3218.46","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.38","3036.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1550.53","38.3","","279.30","91.72","1116.77","266","1255","3218.46","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.38","3036.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1736.76","42.9","","731.00","63.70","731.00","1 through 10","1255","3218.46","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.38","3036.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1736.76","42.9","","384.74","384.74","384.74","1 through 10","1255","3218.46","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.38","3036.28","WELLPOINT [1015]","HB AMC WELLPOINT","2986.89","73.78","","286.63","119.22","1107.45","105","1255","3218.46","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4048.38","3036.28","AETNA [1001]","HB AMC AETNA HMO","2825.77","69.8","","675.31","184.75","1721.50","286","2115.68","3308.34","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4048.38","3036.28","AETNA [1001]","HB AMC AETNA PPO","3254.90","80.4","","1261.44","103.12","1514.10","21","2115.68","3308.34","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4048.38","3036.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3254.90","80.4","","1365.00","1365.00","1365.00","1 through 10","2115.68","3308.34","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4048.38","3036.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3308.34","81.72","","5157.68","5157.68","5157.68","1 through 10","2115.68","3308.34","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4048.38","3036.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3308.34","81.72","","431.26","71.26","1459.57","88","2115.68","3308.34","percent of total billed charges",""
"PLATE ANKLE 116MM 7 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024511","CDM","C1713","HCPCS","0278","RC","","","","both","","","3973.06","2979.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3158.58","79.5","","800.18","480.96","1887.97","195","1231.65","3158.58","percent of total billed charges",""
"PLATE ANKLE 116MM 7 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024511","CDM","C1713","HCPCS","0278","RC","","","","both","","","3973.06","2979.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2117.64","53.3","","813.12","216.42","1444.50","81","1231.65","3158.58","percent of total billed charges",""
"PLATE ANKLE 116MM 7 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024511","CDM","C1713","HCPCS","0278","RC","","","","both","","","3973.06","2979.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1231.65","31","","432.60","432.60","432.60","1 through 10","1231.65","3158.58","percent of total billed charges",""
"PLATE ANKLE 116MM 7 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024511","CDM","C1713","HCPCS","0278","RC","","","","both","","","3973.06","2979.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1450.17","36.5","","148.37","54.89","631.39","94","1231.65","3158.58","percent of total billed charges",""
"PLATE ANKLE 116MM 7 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024511","CDM","C1713","HCPCS","0278","RC","","","","both","","","3973.06","2979.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1521.68","38.3","","279.30","91.72","1116.77","266","1231.65","3158.58","percent of total billed charges",""
"PLATE ANKLE 116MM 7 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024511","CDM","C1713","HCPCS","0278","RC","","","","both","","","3973.06","2979.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1704.44","42.9","","731.00","63.70","731.00","1 through 10","1231.65","3158.58","percent of total billed charges",""
"PLATE ANKLE 116MM 7 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024511","CDM","C1713","HCPCS","0278","RC","","","","both","","","3973.06","2979.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1704.44","42.9","","384.74","384.74","384.74","1 through 10","1231.65","3158.58","percent of total billed charges",""
"PLATE ANKLE 116MM 7 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024511","CDM","C1713","HCPCS","0278","RC","","","","both","","","3973.06","2979.79","WELLPOINT [1015]","HB AMC WELLPOINT","2931.32","73.78","","286.63","119.22","1107.45","105","1231.65","3158.58","percent of total billed charges",""
"PLATE ANKLE 116MM 7 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3973.06","2979.79","AETNA [1001]","HB AMC AETNA HMO","2773.20","69.8","","675.31","184.75","1721.50","286","2076.32","3246.78","percent of total billed charges",""
"PLATE ANKLE 116MM 7 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3973.06","2979.79","AETNA [1001]","HB AMC AETNA PPO","3194.34","80.4","","1261.44","103.12","1514.10","21","2076.32","3246.78","percent of total billed charges",""
"PLATE ANKLE 116MM 7 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3973.06","2979.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3194.34","80.4","","1365.00","1365.00","1365.00","1 through 10","2076.32","3246.78","percent of total billed charges",""
"PLATE ANKLE 116MM 7 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3973.06","2979.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3246.78","81.72","","5157.68","5157.68","5157.68","1 through 10","2076.32","3246.78","percent of total billed charges",""
"PLATE ANKLE 116MM 7 HOLE ARTHRODESIS LCP LOCKING ANTERIOR","SUP-ITM-10024511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3973.06","2979.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3246.78","81.72","","431.26","71.26","1459.57","88","2076.32","3246.78","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.04","3169.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3359.70","79.5","","800.18","480.96","1887.97","195","1310.07","3359.7","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.04","3169.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2252.48","53.3","","813.12","216.42","1444.50","81","1310.07","3359.7","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.04","3169.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1310.07","31","","432.60","432.60","432.60","1 through 10","1310.07","3359.7","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.04","3169.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1542.50","36.5","","148.37","54.89","631.39","94","1310.07","3359.7","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.04","3169.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1618.57","38.3","","279.30","91.72","1116.77","266","1310.07","3359.7","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.04","3169.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1812.97","42.9","","731.00","63.70","731.00","1 through 10","1310.07","3359.7","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.04","3169.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1812.97","42.9","","384.74","384.74","384.74","1 through 10","1310.07","3359.7","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.04","3169.53","WELLPOINT [1015]","HB AMC WELLPOINT","3117.97","73.78","","286.63","119.22","1107.45","105","1310.07","3359.7","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4226.04","3169.53","AETNA [1001]","HB AMC AETNA HMO","2949.78","69.8","","675.31","184.75","1721.50","286","2208.53","3453.52","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4226.04","3169.53","AETNA [1001]","HB AMC AETNA PPO","3397.74","80.4","","1261.44","103.12","1514.10","21","2208.53","3453.52","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4226.04","3169.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3397.74","80.4","","1365.00","1365.00","1365.00","1 through 10","2208.53","3453.52","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4226.04","3169.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3453.52","81.72","","5157.68","5157.68","5157.68","1 through 10","2208.53","3453.52","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4226.04","3169.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3453.52","81.72","","431.26","71.26","1459.57","88","2208.53","3453.52","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4263.45","3197.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3389.44","79.5","","800.18","480.96","1887.97","195","1321.67","3389.44","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4263.45","3197.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2272.42","53.3","","813.12","216.42","1444.50","81","1321.67","3389.44","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4263.45","3197.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1321.67","31","","432.60","432.60","432.60","1 through 10","1321.67","3389.44","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4263.45","3197.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1556.16","36.5","","148.37","54.89","631.39","94","1321.67","3389.44","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4263.45","3197.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1632.90","38.3","","279.30","91.72","1116.77","266","1321.67","3389.44","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4263.45","3197.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1829.02","42.9","","731.00","63.70","731.00","1 through 10","1321.67","3389.44","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4263.45","3197.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1829.02","42.9","","384.74","384.74","384.74","1 through 10","1321.67","3389.44","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4263.45","3197.59","WELLPOINT [1015]","HB AMC WELLPOINT","3145.57","73.78","","286.63","119.22","1107.45","105","1321.67","3389.44","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4263.45","3197.59","AETNA [1001]","HB AMC AETNA HMO","2975.89","69.8","","675.31","184.75","1721.50","286","2228.08","3484.09","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4263.45","3197.59","AETNA [1001]","HB AMC AETNA PPO","3427.81","80.4","","1261.44","103.12","1514.10","21","2228.08","3484.09","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4263.45","3197.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3427.81","80.4","","1365.00","1365.00","1365.00","1 through 10","2228.08","3484.09","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4263.45","3197.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3484.09","81.72","","5157.68","5157.68","5157.68","1 through 10","2228.08","3484.09","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4263.45","3197.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3484.09","81.72","","431.26","71.26","1459.57","88","2228.08","3484.09","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4006.74","3005.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3185.36","79.5","","800.18","480.96","1887.97","195","1242.09","3185.36","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4006.74","3005.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2135.59","53.3","","813.12","216.42","1444.50","81","1242.09","3185.36","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4006.74","3005.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1242.09","31","","432.60","432.60","432.60","1 through 10","1242.09","3185.36","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4006.74","3005.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1462.46","36.5","","148.37","54.89","631.39","94","1242.09","3185.36","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4006.74","3005.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1534.58","38.3","","279.30","91.72","1116.77","266","1242.09","3185.36","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4006.74","3005.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1718.89","42.9","","731.00","63.70","731.00","1 through 10","1242.09","3185.36","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4006.74","3005.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1718.89","42.9","","384.74","384.74","384.74","1 through 10","1242.09","3185.36","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","4006.74","3005.05","WELLPOINT [1015]","HB AMC WELLPOINT","2956.17","73.78","","286.63","119.22","1107.45","105","1242.09","3185.36","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4006.74","3005.05","AETNA [1001]","HB AMC AETNA HMO","2796.70","69.8","","675.31","184.75","1721.50","286","2093.92","3274.31","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4006.74","3005.05","AETNA [1001]","HB AMC AETNA PPO","3221.42","80.4","","1261.44","103.12","1514.10","21","2093.92","3274.31","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4006.74","3005.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3221.42","80.4","","1365.00","1365.00","1365.00","1 through 10","2093.92","3274.31","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4006.74","3005.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3274.31","81.72","","5157.68","5157.68","5157.68","1 through 10","2093.92","3274.31","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4006.74","3005.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3274.31","81.72","","431.26","71.26","1459.57","88","2093.92","3274.31","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","both","","","5347.05","4010.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4250.90","79.5","","800.18","480.96","1887.97","195","1657.59","4250.9","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","both","","","5347.05","4010.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2849.98","53.3","","813.12","216.42","1444.50","81","1657.59","4250.9","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","both","","","5347.05","4010.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1657.59","31","","432.60","432.60","432.60","1 through 10","1657.59","4250.9","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","both","","","5347.05","4010.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1951.67","36.5","","148.37","54.89","631.39","94","1657.59","4250.9","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","both","","","5347.05","4010.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2047.92","38.3","","279.30","91.72","1116.77","266","1657.59","4250.9","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","both","","","5347.05","4010.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2293.88","42.9","","731.00","63.70","731.00","1 through 10","1657.59","4250.9","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","both","","","5347.05","4010.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2293.88","42.9","","384.74","384.74","384.74","1 through 10","1657.59","4250.9","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","both","","","5347.05","4010.29","WELLPOINT [1015]","HB AMC WELLPOINT","3945.05","73.78","","286.63","119.22","1107.45","105","1657.59","4250.9","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5347.05","4010.29","AETNA [1001]","HB AMC AETNA HMO","3732.24","69.8","","675.31","184.75","1721.50","286","2794.37","4369.61","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5347.05","4010.29","AETNA [1001]","HB AMC AETNA PPO","4299.03","80.4","","1261.44","103.12","1514.10","21","2794.37","4369.61","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5347.05","4010.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4299.03","80.4","","1365.00","1365.00","1365.00","1 through 10","2794.37","4369.61","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5347.05","4010.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4369.61","81.72","","5157.68","5157.68","5157.68","1 through 10","2794.37","4369.61","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5347.05","4010.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4369.61","81.72","","431.26","71.26","1459.57","88","2794.37","4369.61","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","644.91","483.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","512.70","79.5","","800.18","480.96","1887.97","195","199.92","512.7","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","644.91","483.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","343.74","53.3","","813.12","216.42","1444.50","81","199.92","512.7","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","644.91","483.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","199.92","31","","432.60","432.60","432.60","1 through 10","199.92","512.7","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","644.91","483.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","235.39","36.5","","148.37","54.89","631.39","94","199.92","512.7","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","644.91","483.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","247.00","38.3","","279.30","91.72","1116.77","266","199.92","512.7","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","644.91","483.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","276.67","42.9","","731.00","63.70","731.00","1 through 10","199.92","512.7","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","644.91","483.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","276.67","42.9","","384.74","384.74","384.74","1 through 10","199.92","512.7","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","644.91","483.68","WELLPOINT [1015]","HB AMC WELLPOINT","475.81","73.78","","286.63","119.22","1107.45","105","199.92","512.7","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","644.91","483.68","AETNA [1001]","HB AMC AETNA HMO","450.15","69.8","","675.31","184.75","1721.50","286","337.03","527.02","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","644.91","483.68","AETNA [1001]","HB AMC AETNA PPO","518.51","80.4","","1261.44","103.12","1514.10","21","337.03","527.02","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","644.91","483.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","518.51","80.4","","1365.00","1365.00","1365.00","1 through 10","337.03","527.02","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","644.91","483.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","527.02","81.72","","5157.68","5157.68","5157.68","1 through 10","337.03","527.02","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","644.91","483.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","527.02","81.72","","431.26","71.26","1459.57","88","337.03","527.02","percent of total billed charges",""
"PLATE ANKLE 3.5X132MM 8 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092316","CDM","C1713","HCPCS","0278","RC","","","","both","","","3724.42","2793.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2960.91","79.5","","800.18","480.96","1887.97","195","1154.57","2960.91","percent of total billed charges",""
"PLATE ANKLE 3.5X132MM 8 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092316","CDM","C1713","HCPCS","0278","RC","","","","both","","","3724.42","2793.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1985.12","53.3","","813.12","216.42","1444.50","81","1154.57","2960.91","percent of total billed charges",""
"PLATE ANKLE 3.5X132MM 8 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092316","CDM","C1713","HCPCS","0278","RC","","","","both","","","3724.42","2793.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1154.57","31","","432.60","432.60","432.60","1 through 10","1154.57","2960.91","percent of total billed charges",""
"PLATE ANKLE 3.5X132MM 8 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092316","CDM","C1713","HCPCS","0278","RC","","","","both","","","3724.42","2793.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1359.41","36.5","","148.37","54.89","631.39","94","1154.57","2960.91","percent of total billed charges",""
"PLATE ANKLE 3.5X132MM 8 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092316","CDM","C1713","HCPCS","0278","RC","","","","both","","","3724.42","2793.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1426.45","38.3","","279.30","91.72","1116.77","266","1154.57","2960.91","percent of total billed charges",""
"PLATE ANKLE 3.5X132MM 8 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092316","CDM","C1713","HCPCS","0278","RC","","","","both","","","3724.42","2793.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1597.78","42.9","","731.00","63.70","731.00","1 through 10","1154.57","2960.91","percent of total billed charges",""
"PLATE ANKLE 3.5X132MM 8 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092316","CDM","C1713","HCPCS","0278","RC","","","","both","","","3724.42","2793.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1597.78","42.9","","384.74","384.74","384.74","1 through 10","1154.57","2960.91","percent of total billed charges",""
"PLATE ANKLE 3.5X132MM 8 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092316","CDM","C1713","HCPCS","0278","RC","","","","both","","","3724.42","2793.31","WELLPOINT [1015]","HB AMC WELLPOINT","2747.88","73.78","","286.63","119.22","1107.45","105","1154.57","2960.91","percent of total billed charges",""
"PLATE ANKLE 3.5X132MM 8 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3724.42","2793.31","AETNA [1001]","HB AMC AETNA HMO","2599.65","69.8","","675.31","184.75","1721.50","286","1946.38","3043.6","percent of total billed charges",""
"PLATE ANKLE 3.5X132MM 8 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3724.42","2793.31","AETNA [1001]","HB AMC AETNA PPO","2994.43","80.4","","1261.44","103.12","1514.10","21","1946.38","3043.6","percent of total billed charges",""
"PLATE ANKLE 3.5X132MM 8 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3724.42","2793.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2994.43","80.4","","1365.00","1365.00","1365.00","1 through 10","1946.38","3043.6","percent of total billed charges",""
"PLATE ANKLE 3.5X132MM 8 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3724.42","2793.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3043.60","81.72","","5157.68","5157.68","5157.68","1 through 10","1946.38","3043.6","percent of total billed charges",""
"PLATE ANKLE 3.5X132MM 8 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3724.42","2793.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3043.60","81.72","","431.26","71.26","1459.57","88","1946.38","3043.6","percent of total billed charges",""
"PLATE ANKLE 3.5X236MM 16 HOLE LCP DISTAL POSTERIOR TIBIA T SHAPE","SUP-ITM-10092318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4119.40","3089.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3274.92","79.5","","800.18","480.96","1887.97","195","1277.01","3274.92","percent of total billed charges",""
"PLATE ANKLE 3.5X236MM 16 HOLE LCP DISTAL POSTERIOR TIBIA T SHAPE","SUP-ITM-10092318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4119.40","3089.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2195.64","53.3","","813.12","216.42","1444.50","81","1277.01","3274.92","percent of total billed charges",""
"PLATE ANKLE 3.5X236MM 16 HOLE LCP DISTAL POSTERIOR TIBIA T SHAPE","SUP-ITM-10092318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4119.40","3089.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1277.01","31","","432.60","432.60","432.60","1 through 10","1277.01","3274.92","percent of total billed charges",""
"PLATE ANKLE 3.5X236MM 16 HOLE LCP DISTAL POSTERIOR TIBIA T SHAPE","SUP-ITM-10092318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4119.40","3089.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1503.58","36.5","","148.37","54.89","631.39","94","1277.01","3274.92","percent of total billed charges",""
"PLATE ANKLE 3.5X236MM 16 HOLE LCP DISTAL POSTERIOR TIBIA T SHAPE","SUP-ITM-10092318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4119.40","3089.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1577.73","38.3","","279.30","91.72","1116.77","266","1277.01","3274.92","percent of total billed charges",""
"PLATE ANKLE 3.5X236MM 16 HOLE LCP DISTAL POSTERIOR TIBIA T SHAPE","SUP-ITM-10092318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4119.40","3089.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1767.22","42.9","","731.00","63.70","731.00","1 through 10","1277.01","3274.92","percent of total billed charges",""
"PLATE ANKLE 3.5X236MM 16 HOLE LCP DISTAL POSTERIOR TIBIA T SHAPE","SUP-ITM-10092318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4119.40","3089.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1767.22","42.9","","384.74","384.74","384.74","1 through 10","1277.01","3274.92","percent of total billed charges",""
"PLATE ANKLE 3.5X236MM 16 HOLE LCP DISTAL POSTERIOR TIBIA T SHAPE","SUP-ITM-10092318","CDM","C1713","HCPCS","0278","RC","","","","both","","","4119.40","3089.55","WELLPOINT [1015]","HB AMC WELLPOINT","3039.29","73.78","","286.63","119.22","1107.45","105","1277.01","3274.92","percent of total billed charges",""
"PLATE ANKLE 3.5X236MM 16 HOLE LCP DISTAL POSTERIOR TIBIA T SHAPE","SUP-ITM-10092318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4119.40","3089.55","AETNA [1001]","HB AMC AETNA HMO","2875.34","69.8","","675.31","184.75","1721.50","286","2152.8","3366.37","percent of total billed charges",""
"PLATE ANKLE 3.5X236MM 16 HOLE LCP DISTAL POSTERIOR TIBIA T SHAPE","SUP-ITM-10092318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4119.40","3089.55","AETNA [1001]","HB AMC AETNA PPO","3312.00","80.4","","1261.44","103.12","1514.10","21","2152.8","3366.37","percent of total billed charges",""
"PLATE ANKLE 3.5X236MM 16 HOLE LCP DISTAL POSTERIOR TIBIA T SHAPE","SUP-ITM-10092318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4119.40","3089.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3312.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2152.8","3366.37","percent of total billed charges",""
"PLATE ANKLE 3.5X236MM 16 HOLE LCP DISTAL POSTERIOR TIBIA T SHAPE","SUP-ITM-10092318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4119.40","3089.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3366.37","81.72","","5157.68","5157.68","5157.68","1 through 10","2152.8","3366.37","percent of total billed charges",""
"PLATE ANKLE 3.5X236MM 16 HOLE LCP DISTAL POSTERIOR TIBIA T SHAPE","SUP-ITM-10092318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4119.40","3089.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3366.37","81.72","","431.26","71.26","1459.57","88","2152.8","3366.37","percent of total billed charges",""
"PLATE ANKLE 3.5X64MM 3 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092314","CDM","C1713","HCPCS","0278","RC","","","","both","","","1880.34","1410.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1494.87","79.5","","800.18","480.96","1887.97","195","582.91","1494.87","percent of total billed charges",""
"PLATE ANKLE 3.5X64MM 3 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092314","CDM","C1713","HCPCS","0278","RC","","","","both","","","1880.34","1410.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1002.22","53.3","","813.12","216.42","1444.50","81","582.91","1494.87","percent of total billed charges",""
"PLATE ANKLE 3.5X64MM 3 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092314","CDM","C1713","HCPCS","0278","RC","","","","both","","","1880.34","1410.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","582.91","31","","432.60","432.60","432.60","1 through 10","582.91","1494.87","percent of total billed charges",""
"PLATE ANKLE 3.5X64MM 3 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092314","CDM","C1713","HCPCS","0278","RC","","","","both","","","1880.34","1410.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","686.32","36.5","","148.37","54.89","631.39","94","582.91","1494.87","percent of total billed charges",""
"PLATE ANKLE 3.5X64MM 3 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092314","CDM","C1713","HCPCS","0278","RC","","","","both","","","1880.34","1410.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","720.17","38.3","","279.30","91.72","1116.77","266","582.91","1494.87","percent of total billed charges",""
"PLATE ANKLE 3.5X64MM 3 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092314","CDM","C1713","HCPCS","0278","RC","","","","both","","","1880.34","1410.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","806.67","42.9","","731.00","63.70","731.00","1 through 10","582.91","1494.87","percent of total billed charges",""
"PLATE ANKLE 3.5X64MM 3 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092314","CDM","C1713","HCPCS","0278","RC","","","","both","","","1880.34","1410.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","806.67","42.9","","384.74","384.74","384.74","1 through 10","582.91","1494.87","percent of total billed charges",""
"PLATE ANKLE 3.5X64MM 3 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092314","CDM","C1713","HCPCS","0278","RC","","","","both","","","1880.34","1410.25","WELLPOINT [1015]","HB AMC WELLPOINT","1387.31","73.78","","286.63","119.22","1107.45","105","582.91","1494.87","percent of total billed charges",""
"PLATE ANKLE 3.5X64MM 3 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1880.34","1410.25","AETNA [1001]","HB AMC AETNA HMO","1312.48","69.8","","675.31","184.75","1721.50","286","982.67","1536.61","percent of total billed charges",""
"PLATE ANKLE 3.5X64MM 3 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1880.34","1410.25","AETNA [1001]","HB AMC AETNA PPO","1511.79","80.4","","1261.44","103.12","1514.10","21","982.67","1536.61","percent of total billed charges",""
"PLATE ANKLE 3.5X64MM 3 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1880.34","1410.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1511.79","80.4","","1365.00","1365.00","1365.00","1 through 10","982.67","1536.61","percent of total billed charges",""
"PLATE ANKLE 3.5X64MM 3 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1880.34","1410.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1536.61","81.72","","5157.68","5157.68","5157.68","1 through 10","982.67","1536.61","percent of total billed charges",""
"PLATE ANKLE 3.5X64MM 3 HOLE LCP SS T SHAPE DISTAL POSTERIOR TIBIA","SUP-ITM-10092314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1880.34","1410.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1536.61","81.72","","431.26","71.26","1459.57","88","982.67","1536.61","percent of total billed charges",""
"PLATE ANKLE 3.5X90MM 5 HOLE TIBIA LCP SS T SHAPE DISTAL POSTERIOR","SUP-ITM-10092315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1952.86","1464.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1552.52","79.5","","800.18","480.96","1887.97","195","605.39","1552.52","percent of total billed charges",""
"PLATE ANKLE 3.5X90MM 5 HOLE TIBIA LCP SS T SHAPE DISTAL POSTERIOR","SUP-ITM-10092315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1952.86","1464.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1040.87","53.3","","813.12","216.42","1444.50","81","605.39","1552.52","percent of total billed charges",""
"PLATE ANKLE 3.5X90MM 5 HOLE TIBIA LCP SS T SHAPE DISTAL POSTERIOR","SUP-ITM-10092315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1952.86","1464.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","605.39","31","","432.60","432.60","432.60","1 through 10","605.39","1552.52","percent of total billed charges",""
"PLATE ANKLE 3.5X90MM 5 HOLE TIBIA LCP SS T SHAPE DISTAL POSTERIOR","SUP-ITM-10092315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1952.86","1464.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","712.79","36.5","","148.37","54.89","631.39","94","605.39","1552.52","percent of total billed charges",""
"PLATE ANKLE 3.5X90MM 5 HOLE TIBIA LCP SS T SHAPE DISTAL POSTERIOR","SUP-ITM-10092315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1952.86","1464.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","747.95","38.3","","279.30","91.72","1116.77","266","605.39","1552.52","percent of total billed charges",""
"PLATE ANKLE 3.5X90MM 5 HOLE TIBIA LCP SS T SHAPE DISTAL POSTERIOR","SUP-ITM-10092315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1952.86","1464.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","837.78","42.9","","731.00","63.70","731.00","1 through 10","605.39","1552.52","percent of total billed charges",""
"PLATE ANKLE 3.5X90MM 5 HOLE TIBIA LCP SS T SHAPE DISTAL POSTERIOR","SUP-ITM-10092315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1952.86","1464.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","837.78","42.9","","384.74","384.74","384.74","1 through 10","605.39","1552.52","percent of total billed charges",""
"PLATE ANKLE 3.5X90MM 5 HOLE TIBIA LCP SS T SHAPE DISTAL POSTERIOR","SUP-ITM-10092315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1952.86","1464.64","WELLPOINT [1015]","HB AMC WELLPOINT","1440.82","73.78","","286.63","119.22","1107.45","105","605.39","1552.52","percent of total billed charges",""
"PLATE ANKLE 3.5X90MM 5 HOLE TIBIA LCP SS T SHAPE DISTAL POSTERIOR","SUP-ITM-10092315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1952.86","1464.64","AETNA [1001]","HB AMC AETNA HMO","1363.10","69.8","","675.31","184.75","1721.50","286","1020.56","1595.88","percent of total billed charges",""
"PLATE ANKLE 3.5X90MM 5 HOLE TIBIA LCP SS T SHAPE DISTAL POSTERIOR","SUP-ITM-10092315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1952.86","1464.64","AETNA [1001]","HB AMC AETNA PPO","1570.10","80.4","","1261.44","103.12","1514.10","21","1020.56","1595.88","percent of total billed charges",""
"PLATE ANKLE 3.5X90MM 5 HOLE TIBIA LCP SS T SHAPE DISTAL POSTERIOR","SUP-ITM-10092315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1952.86","1464.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1570.10","80.4","","1365.00","1365.00","1365.00","1 through 10","1020.56","1595.88","percent of total billed charges",""
"PLATE ANKLE 3.5X90MM 5 HOLE TIBIA LCP SS T SHAPE DISTAL POSTERIOR","SUP-ITM-10092315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1952.86","1464.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1595.88","81.72","","5157.68","5157.68","5157.68","1 through 10","1020.56","1595.88","percent of total billed charges",""
"PLATE ANKLE 3.5X90MM 5 HOLE TIBIA LCP SS T SHAPE DISTAL POSTERIOR","SUP-ITM-10092315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1952.86","1464.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1595.88","81.72","","431.26","71.26","1459.57","88","1020.56","1595.88","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","both","","","2638.27","1978.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2097.42","79.5","","800.18","480.96","1887.97","195","817.86","2097.42","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","both","","","2638.27","1978.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1406.20","53.3","","813.12","216.42","1444.50","81","817.86","2097.42","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","both","","","2638.27","1978.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","817.86","31","","432.60","432.60","432.60","1 through 10","817.86","2097.42","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","both","","","2638.27","1978.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","962.97","36.5","","148.37","54.89","631.39","94","817.86","2097.42","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","both","","","2638.27","1978.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1010.46","38.3","","279.30","91.72","1116.77","266","817.86","2097.42","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","both","","","2638.27","1978.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1131.82","42.9","","731.00","63.70","731.00","1 through 10","817.86","2097.42","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","both","","","2638.27","1978.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1131.82","42.9","","384.74","384.74","384.74","1 through 10","817.86","2097.42","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","both","","","2638.27","1978.70","WELLPOINT [1015]","HB AMC WELLPOINT","1946.52","73.78","","286.63","119.22","1107.45","105","817.86","2097.42","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2638.27","1978.70","AETNA [1001]","HB AMC AETNA HMO","1841.51","69.8","","675.31","184.75","1721.50","286","1378.76","2155.99","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2638.27","1978.70","AETNA [1001]","HB AMC AETNA PPO","2121.17","80.4","","1261.44","103.12","1514.10","21","1378.76","2155.99","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2638.27","1978.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2121.17","80.4","","1365.00","1365.00","1365.00","1 through 10","1378.76","2155.99","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2638.27","1978.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2155.99","81.72","","5157.68","5157.68","5157.68","1 through 10","1378.76","2155.99","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2638.27","1978.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2155.99","81.72","","431.26","71.26","1459.57","88","1378.76","2155.99","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","both","","","2745.12","2058.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2182.37","79.5","","800.18","480.96","1887.97","195","850.99","2182.37","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","both","","","2745.12","2058.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1463.15","53.3","","813.12","216.42","1444.50","81","850.99","2182.37","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","both","","","2745.12","2058.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","850.99","31","","432.60","432.60","432.60","1 through 10","850.99","2182.37","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","both","","","2745.12","2058.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1001.97","36.5","","148.37","54.89","631.39","94","850.99","2182.37","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","both","","","2745.12","2058.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1051.38","38.3","","279.30","91.72","1116.77","266","850.99","2182.37","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","both","","","2745.12","2058.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1177.66","42.9","","731.00","63.70","731.00","1 through 10","850.99","2182.37","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","both","","","2745.12","2058.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1177.66","42.9","","384.74","384.74","384.74","1 through 10","850.99","2182.37","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","both","","","2745.12","2058.84","WELLPOINT [1015]","HB AMC WELLPOINT","2025.35","73.78","","286.63","119.22","1107.45","105","850.99","2182.37","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2745.12","2058.84","AETNA [1001]","HB AMC AETNA HMO","1916.09","69.8","","675.31","184.75","1721.50","286","1434.6","2243.31","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2745.12","2058.84","AETNA [1001]","HB AMC AETNA PPO","2207.08","80.4","","1261.44","103.12","1514.10","21","1434.6","2243.31","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2745.12","2058.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2207.08","80.4","","1365.00","1365.00","1365.00","1 through 10","1434.6","2243.31","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2745.12","2058.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2243.31","81.72","","5157.68","5157.68","5157.68","1 through 10","1434.6","2243.31","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2745.12","2058.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2243.31","81.72","","431.26","71.26","1459.57","88","1434.6","2243.31","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","13085.00","9813.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10402.58","79.5","","800.18","480.96","1887.97","195","4056.35","10402.58","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","13085.00","9813.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6974.31","53.3","","813.12","216.42","1444.50","81","4056.35","10402.58","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","13085.00","9813.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4056.35","31","","432.60","432.60","432.60","1 through 10","4056.35","10402.58","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","13085.00","9813.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4776.03","36.5","","148.37","54.89","631.39","94","4056.35","10402.58","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","13085.00","9813.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5011.56","38.3","","279.30","91.72","1116.77","266","4056.35","10402.58","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","13085.00","9813.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5613.47","42.9","","731.00","63.70","731.00","1 through 10","4056.35","10402.58","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","13085.00","9813.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5613.47","42.9","","384.74","384.74","384.74","1 through 10","4056.35","10402.58","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","13085.00","9813.75","WELLPOINT [1015]","HB AMC WELLPOINT","9654.11","73.78","","286.63","119.22","1107.45","105","4056.35","10402.58","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13085.00","9813.75","AETNA [1001]","HB AMC AETNA HMO","9133.33","69.8","","675.31","184.75","1721.50","286","6838.22","10693.06","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13085.00","9813.75","AETNA [1001]","HB AMC AETNA PPO","10520.34","80.4","","1261.44","103.12","1514.10","21","6838.22","10693.06","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13085.00","9813.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10520.34","80.4","","1365.00","1365.00","1365.00","1 through 10","6838.22","10693.06","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13085.00","9813.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","10693.06","81.72","","5157.68","5157.68","5157.68","1 through 10","6838.22","10693.06","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13085.00","9813.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10693.06","81.72","","431.26","71.26","1459.57","88","6838.22","10693.06","percent of total billed charges",""
"PLATE BONE 0.6MM 1 HOLE COMPRESSION CONDYLE 5 HOLD PIN RIGHT","SUP-ITM-10019555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.50","1147.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1215.95","79.5","","800.18","480.96","1887.97","195","474.15","1215.95","percent of total billed charges",""
"PLATE BONE 0.6MM 1 HOLE COMPRESSION CONDYLE 5 HOLD PIN RIGHT","SUP-ITM-10019555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.50","1147.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","815.22","53.3","","813.12","216.42","1444.50","81","474.15","1215.95","percent of total billed charges",""
"PLATE BONE 0.6MM 1 HOLE COMPRESSION CONDYLE 5 HOLD PIN RIGHT","SUP-ITM-10019555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.50","1147.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","474.15","31","","432.60","432.60","432.60","1 through 10","474.15","1215.95","percent of total billed charges",""
"PLATE BONE 0.6MM 1 HOLE COMPRESSION CONDYLE 5 HOLD PIN RIGHT","SUP-ITM-10019555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.50","1147.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","558.27","36.5","","148.37","54.89","631.39","94","474.15","1215.95","percent of total billed charges",""
"PLATE BONE 0.6MM 1 HOLE COMPRESSION CONDYLE 5 HOLD PIN RIGHT","SUP-ITM-10019555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.50","1147.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","585.80","38.3","","279.30","91.72","1116.77","266","474.15","1215.95","percent of total billed charges",""
"PLATE BONE 0.6MM 1 HOLE COMPRESSION CONDYLE 5 HOLD PIN RIGHT","SUP-ITM-10019555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.50","1147.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","656.16","42.9","","731.00","63.70","731.00","1 through 10","474.15","1215.95","percent of total billed charges",""
"PLATE BONE 0.6MM 1 HOLE COMPRESSION CONDYLE 5 HOLD PIN RIGHT","SUP-ITM-10019555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.50","1147.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","656.16","42.9","","384.74","384.74","384.74","1 through 10","474.15","1215.95","percent of total billed charges",""
"PLATE BONE 0.6MM 1 HOLE COMPRESSION CONDYLE 5 HOLD PIN RIGHT","SUP-ITM-10019555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.50","1147.12","WELLPOINT [1015]","HB AMC WELLPOINT","1128.47","73.78","","286.63","119.22","1107.45","105","474.15","1215.95","percent of total billed charges",""
"PLATE BONE 0.6MM 1 HOLE COMPRESSION CONDYLE 5 HOLD PIN RIGHT","SUP-ITM-10019555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1529.50","1147.12","AETNA [1001]","HB AMC AETNA HMO","1067.59","69.8","","675.31","184.75","1721.50","286","799.32","1249.91","percent of total billed charges",""
"PLATE BONE 0.6MM 1 HOLE COMPRESSION CONDYLE 5 HOLD PIN RIGHT","SUP-ITM-10019555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1529.50","1147.12","AETNA [1001]","HB AMC AETNA PPO","1229.72","80.4","","1261.44","103.12","1514.10","21","799.32","1249.91","percent of total billed charges",""
"PLATE BONE 0.6MM 1 HOLE COMPRESSION CONDYLE 5 HOLD PIN RIGHT","SUP-ITM-10019555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1529.50","1147.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1229.72","80.4","","1365.00","1365.00","1365.00","1 through 10","799.32","1249.91","percent of total billed charges",""
"PLATE BONE 0.6MM 1 HOLE COMPRESSION CONDYLE 5 HOLD PIN RIGHT","SUP-ITM-10019555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1529.50","1147.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1249.91","81.72","","5157.68","5157.68","5157.68","1 through 10","799.32","1249.91","percent of total billed charges",""
"PLATE BONE 0.6MM 1 HOLE COMPRESSION CONDYLE 5 HOLD PIN RIGHT","SUP-ITM-10019555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1529.50","1147.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1249.91","81.72","","431.26","71.26","1459.57","88","799.32","1249.91","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.00","3057.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3241.22","79.5","","800.18","480.96","1887.97","195","1263.87","3241.22","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.00","3057.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2173.04","53.3","","813.12","216.42","1444.50","81","1263.87","3241.22","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.00","3057.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1263.87","31","","432.60","432.60","432.60","1 through 10","1263.87","3241.22","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.00","3057.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1488.11","36.5","","148.37","54.89","631.39","94","1263.87","3241.22","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.00","3057.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1561.49","38.3","","279.30","91.72","1116.77","266","1263.87","3241.22","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.00","3057.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1749.03","42.9","","731.00","63.70","731.00","1 through 10","1263.87","3241.22","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.00","3057.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1749.03","42.9","","384.74","384.74","384.74","1 through 10","1263.87","3241.22","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.00","3057.75","WELLPOINT [1015]","HB AMC WELLPOINT","3008.01","73.78","","286.63","119.22","1107.45","105","1263.87","3241.22","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.00","3057.75","AETNA [1001]","HB AMC AETNA HMO","2845.75","69.8","","675.31","184.75","1721.50","286","2130.64","3331.72","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.00","3057.75","AETNA [1001]","HB AMC AETNA PPO","3277.91","80.4","","1261.44","103.12","1514.10","21","2130.64","3331.72","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.00","3057.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3277.91","80.4","","1365.00","1365.00","1365.00","1 through 10","2130.64","3331.72","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.00","3057.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3331.72","81.72","","5157.68","5157.68","5157.68","1 through 10","2130.64","3331.72","percent of total billed charges",""
"PLATE BONE 1.3MM 6 HOLE HAND APTUS TITANIUM RT T SHAPE","SUP-ITM-10091774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.00","3057.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3331.72","81.72","","431.26","71.26","1459.57","88","2130.64","3331.72","percent of total billed charges",""
"PLATE BONE 1.5MM LCP TITANIUM 6 HOLE GUIDE 04.114.503","SUP-ITM-10096079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1254.86","941.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","997.61","79.5","","800.18","480.96","1887.97","195","389.01","997.61","percent of total billed charges",""
"PLATE BONE 1.5MM LCP TITANIUM 6 HOLE GUIDE 04.114.503","SUP-ITM-10096079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1254.86","941.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","668.84","53.3","","813.12","216.42","1444.50","81","389.01","997.61","percent of total billed charges",""
"PLATE BONE 1.5MM LCP TITANIUM 6 HOLE GUIDE 04.114.503","SUP-ITM-10096079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1254.86","941.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","389.01","31","","432.60","432.60","432.60","1 through 10","389.01","997.61","percent of total billed charges",""
"PLATE BONE 1.5MM LCP TITANIUM 6 HOLE GUIDE 04.114.503","SUP-ITM-10096079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1254.86","941.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","458.02","36.5","","148.37","54.89","631.39","94","389.01","997.61","percent of total billed charges",""
"PLATE BONE 1.5MM LCP TITANIUM 6 HOLE GUIDE 04.114.503","SUP-ITM-10096079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1254.86","941.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","480.61","38.3","","279.30","91.72","1116.77","266","389.01","997.61","percent of total billed charges",""
"PLATE BONE 1.5MM LCP TITANIUM 6 HOLE GUIDE 04.114.503","SUP-ITM-10096079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1254.86","941.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","538.33","42.9","","731.00","63.70","731.00","1 through 10","389.01","997.61","percent of total billed charges",""
"PLATE BONE 1.5MM LCP TITANIUM 6 HOLE GUIDE 04.114.503","SUP-ITM-10096079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1254.86","941.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","538.33","42.9","","384.74","384.74","384.74","1 through 10","389.01","997.61","percent of total billed charges",""
"PLATE BONE 1.5MM LCP TITANIUM 6 HOLE GUIDE 04.114.503","SUP-ITM-10096079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1254.86","941.14","WELLPOINT [1015]","HB AMC WELLPOINT","925.84","73.78","","286.63","119.22","1107.45","105","389.01","997.61","percent of total billed charges",""
"PLATE BONE 1.5MM LCP TITANIUM 6 HOLE GUIDE 04.114.503","SUP-ITM-10096079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1254.86","941.14","AETNA [1001]","HB AMC AETNA HMO","875.89","69.8","","675.31","184.75","1721.50","286","655.79","1025.47","percent of total billed charges",""
"PLATE BONE 1.5MM LCP TITANIUM 6 HOLE GUIDE 04.114.503","SUP-ITM-10096079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1254.86","941.14","AETNA [1001]","HB AMC AETNA PPO","1008.91","80.4","","1261.44","103.12","1514.10","21","655.79","1025.47","percent of total billed charges",""
"PLATE BONE 1.5MM LCP TITANIUM 6 HOLE GUIDE 04.114.503","SUP-ITM-10096079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1254.86","941.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1008.91","80.4","","1365.00","1365.00","1365.00","1 through 10","655.79","1025.47","percent of total billed charges",""
"PLATE BONE 1.5MM LCP TITANIUM 6 HOLE GUIDE 04.114.503","SUP-ITM-10096079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1254.86","941.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1025.47","81.72","","5157.68","5157.68","5157.68","1 through 10","655.79","1025.47","percent of total billed charges",""
"PLATE BONE 1.5MM LCP TITANIUM 6 HOLE GUIDE 04.114.503","SUP-ITM-10096079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1254.86","941.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1025.47","81.72","","431.26","71.26","1459.57","88","655.79","1025.47","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","1164.21","873.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","925.55","79.5","","800.18","480.96","1887.97","195","360.91","925.55","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","1164.21","873.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","620.52","53.3","","813.12","216.42","1444.50","81","360.91","925.55","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","1164.21","873.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","360.91","31","","432.60","432.60","432.60","1 through 10","360.91","925.55","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","1164.21","873.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","424.94","36.5","","148.37","54.89","631.39","94","360.91","925.55","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","1164.21","873.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","445.89","38.3","","279.30","91.72","1116.77","266","360.91","925.55","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","1164.21","873.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","499.45","42.9","","731.00","63.70","731.00","1 through 10","360.91","925.55","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","1164.21","873.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","499.45","42.9","","384.74","384.74","384.74","1 through 10","360.91","925.55","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","both","","","1164.21","873.16","WELLPOINT [1015]","HB AMC WELLPOINT","858.95","73.78","","286.63","119.22","1107.45","105","360.91","925.55","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1164.21","873.16","AETNA [1001]","HB AMC AETNA HMO","812.62","69.8","","675.31","184.75","1721.50","286","608.42","951.39","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1164.21","873.16","AETNA [1001]","HB AMC AETNA PPO","936.02","80.4","","1261.44","103.12","1514.10","21","608.42","951.39","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1164.21","873.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","936.02","80.4","","1365.00","1365.00","1365.00","1 through 10","608.42","951.39","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1164.21","873.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","951.39","81.72","","5157.68","5157.68","5157.68","1 through 10","608.42","951.39","percent of total billed charges",""
"PLATE BONE 1.5X100MM 20 HOLE TITANIUM STRAIGHT","SUP-ITM-10002425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1164.21","873.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","951.39","81.72","","431.26","71.26","1459.57","88","608.42","951.39","percent of total billed charges",""
"PLATE BONE 1.5X18MM TITANIUM H SHAPE EXTENDED RIGHT","SUP-ITM-10005540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.03","869.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","921.43","79.5","","800.18","480.96","1887.97","195","359.3","921.43","percent of total billed charges",""
"PLATE BONE 1.5X18MM TITANIUM H SHAPE EXTENDED RIGHT","SUP-ITM-10005540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.03","869.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","617.76","53.3","","813.12","216.42","1444.50","81","359.3","921.43","percent of total billed charges",""
"PLATE BONE 1.5X18MM TITANIUM H SHAPE EXTENDED RIGHT","SUP-ITM-10005540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.03","869.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","359.30","31","","432.60","432.60","432.60","1 through 10","359.3","921.43","percent of total billed charges",""
"PLATE BONE 1.5X18MM TITANIUM H SHAPE EXTENDED RIGHT","SUP-ITM-10005540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.03","869.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","423.05","36.5","","148.37","54.89","631.39","94","359.3","921.43","percent of total billed charges",""
"PLATE BONE 1.5X18MM TITANIUM H SHAPE EXTENDED RIGHT","SUP-ITM-10005540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.03","869.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","443.91","38.3","","279.30","91.72","1116.77","266","359.3","921.43","percent of total billed charges",""
"PLATE BONE 1.5X18MM TITANIUM H SHAPE EXTENDED RIGHT","SUP-ITM-10005540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.03","869.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","497.22","42.9","","731.00","63.70","731.00","1 through 10","359.3","921.43","percent of total billed charges",""
"PLATE BONE 1.5X18MM TITANIUM H SHAPE EXTENDED RIGHT","SUP-ITM-10005540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.03","869.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","497.22","42.9","","384.74","384.74","384.74","1 through 10","359.3","921.43","percent of total billed charges",""
"PLATE BONE 1.5X18MM TITANIUM H SHAPE EXTENDED RIGHT","SUP-ITM-10005540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.03","869.27","WELLPOINT [1015]","HB AMC WELLPOINT","855.13","73.78","","286.63","119.22","1107.45","105","359.3","921.43","percent of total billed charges",""
"PLATE BONE 1.5X18MM TITANIUM H SHAPE EXTENDED RIGHT","SUP-ITM-10005540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1159.03","869.27","AETNA [1001]","HB AMC AETNA HMO","809.00","69.8","","675.31","184.75","1721.50","286","605.71","947.16","percent of total billed charges",""
"PLATE BONE 1.5X18MM TITANIUM H SHAPE EXTENDED RIGHT","SUP-ITM-10005540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1159.03","869.27","AETNA [1001]","HB AMC AETNA PPO","931.86","80.4","","1261.44","103.12","1514.10","21","605.71","947.16","percent of total billed charges",""
"PLATE BONE 1.5X18MM TITANIUM H SHAPE EXTENDED RIGHT","SUP-ITM-10005540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1159.03","869.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","931.86","80.4","","1365.00","1365.00","1365.00","1 through 10","605.71","947.16","percent of total billed charges",""
"PLATE BONE 1.5X18MM TITANIUM H SHAPE EXTENDED RIGHT","SUP-ITM-10005540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1159.03","869.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","947.16","81.72","","5157.68","5157.68","5157.68","1 through 10","605.71","947.16","percent of total billed charges",""
"PLATE BONE 1.5X18MM TITANIUM H SHAPE EXTENDED RIGHT","SUP-ITM-10005540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1159.03","869.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","947.16","81.72","","431.26","71.26","1459.57","88","605.71","947.16","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.57","1075.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1139.69","79.5","","800.18","480.96","1887.97","195","444.41","1139.69","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.57","1075.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","764.09","53.3","","813.12","216.42","1444.50","81","444.41","1139.69","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.57","1075.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","444.41","31","","432.60","432.60","432.60","1 through 10","444.41","1139.69","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.57","1075.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","523.25","36.5","","148.37","54.89","631.39","94","444.41","1139.69","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.57","1075.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","549.06","38.3","","279.30","91.72","1116.77","266","444.41","1139.69","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.57","1075.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","615.00","42.9","","731.00","63.70","731.00","1 through 10","444.41","1139.69","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.57","1075.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","615.00","42.9","","384.74","384.74","384.74","1 through 10","444.41","1139.69","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.57","1075.18","WELLPOINT [1015]","HB AMC WELLPOINT","1057.69","73.78","","286.63","119.22","1107.45","105","444.41","1139.69","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1433.57","1075.18","AETNA [1001]","HB AMC AETNA HMO","1000.63","69.8","","675.31","184.75","1721.50","286","749.18","1171.51","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1433.57","1075.18","AETNA [1001]","HB AMC AETNA PPO","1152.59","80.4","","1261.44","103.12","1514.10","21","749.18","1171.51","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1433.57","1075.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1152.59","80.4","","1365.00","1365.00","1365.00","1 through 10","749.18","1171.51","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1433.57","1075.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1171.51","81.72","","5157.68","5157.68","5157.68","1 through 10","749.18","1171.51","percent of total billed charges",""
"PLATE BONE 1.5X36MM 7 HOLE CONDYLAR TITANIUM LEFT","SUP-ITM-10001583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1433.57","1075.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1171.51","81.72","","431.26","71.26","1459.57","88","749.18","1171.51","percent of total billed charges",""
"PLATE BONE 1.5X40MM 4 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10002356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.06","902.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","956.43","79.5","","800.18","480.96","1887.97","195","372.95","956.43","percent of total billed charges",""
"PLATE BONE 1.5X40MM 4 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10002356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.06","902.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","641.23","53.3","","813.12","216.42","1444.50","81","372.95","956.43","percent of total billed charges",""
"PLATE BONE 1.5X40MM 4 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10002356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.06","902.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","372.95","31","","432.60","432.60","432.60","1 through 10","372.95","956.43","percent of total billed charges",""
"PLATE BONE 1.5X40MM 4 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10002356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.06","902.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","439.12","36.5","","148.37","54.89","631.39","94","372.95","956.43","percent of total billed charges",""
"PLATE BONE 1.5X40MM 4 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10002356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.06","902.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","460.77","38.3","","279.30","91.72","1116.77","266","372.95","956.43","percent of total billed charges",""
"PLATE BONE 1.5X40MM 4 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10002356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.06","902.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","516.11","42.9","","731.00","63.70","731.00","1 through 10","372.95","956.43","percent of total billed charges",""
"PLATE BONE 1.5X40MM 4 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10002356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.06","902.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","516.11","42.9","","384.74","384.74","384.74","1 through 10","372.95","956.43","percent of total billed charges",""
"PLATE BONE 1.5X40MM 4 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10002356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1203.06","902.29","WELLPOINT [1015]","HB AMC WELLPOINT","887.62","73.78","","286.63","119.22","1107.45","105","372.95","956.43","percent of total billed charges",""
"PLATE BONE 1.5X40MM 4 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10002356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.06","902.29","AETNA [1001]","HB AMC AETNA HMO","839.74","69.8","","675.31","184.75","1721.50","286","628.72","983.14","percent of total billed charges",""
"PLATE BONE 1.5X40MM 4 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10002356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.06","902.29","AETNA [1001]","HB AMC AETNA PPO","967.26","80.4","","1261.44","103.12","1514.10","21","628.72","983.14","percent of total billed charges",""
"PLATE BONE 1.5X40MM 4 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10002356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.06","902.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","967.26","80.4","","1365.00","1365.00","1365.00","1 through 10","628.72","983.14","percent of total billed charges",""
"PLATE BONE 1.5X40MM 4 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10002356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.06","902.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","983.14","81.72","","5157.68","5157.68","5157.68","1 through 10","628.72","983.14","percent of total billed charges",""
"PLATE BONE 1.5X40MM 4 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10002356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1203.06","902.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","983.14","81.72","","431.26","71.26","1459.57","88","628.72","983.14","percent of total billed charges",""
"PLATE BONE 110X90MM 90DEG POSITIONING","SUP-ITM-10030851","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.29","291.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","308.69","79.5","","800.18","480.96","1887.97","195","120.37","308.69","percent of total billed charges",""
"PLATE BONE 110X90MM 90DEG POSITIONING","SUP-ITM-10030851","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.29","291.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","206.96","53.3","","813.12","216.42","1444.50","81","120.37","308.69","percent of total billed charges",""
"PLATE BONE 110X90MM 90DEG POSITIONING","SUP-ITM-10030851","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.29","291.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","120.37","31","","432.60","432.60","432.60","1 through 10","120.37","308.69","percent of total billed charges",""
"PLATE BONE 110X90MM 90DEG POSITIONING","SUP-ITM-10030851","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.29","291.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","141.73","36.5","","148.37","54.89","631.39","94","120.37","308.69","percent of total billed charges",""
"PLATE BONE 110X90MM 90DEG POSITIONING","SUP-ITM-10030851","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.29","291.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","148.72","38.3","","279.30","91.72","1116.77","266","120.37","308.69","percent of total billed charges",""
"PLATE BONE 110X90MM 90DEG POSITIONING","SUP-ITM-10030851","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.29","291.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.58","42.9","","731.00","63.70","731.00","1 through 10","120.37","308.69","percent of total billed charges",""
"PLATE BONE 110X90MM 90DEG POSITIONING","SUP-ITM-10030851","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.29","291.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.58","42.9","","384.74","384.74","384.74","1 through 10","120.37","308.69","percent of total billed charges",""
"PLATE BONE 110X90MM 90DEG POSITIONING","SUP-ITM-10030851","CDM","C1713","HCPCS","0278","RC","","","","both","","","388.29","291.22","WELLPOINT [1015]","HB AMC WELLPOINT","286.48","73.78","","286.63","119.22","1107.45","105","120.37","308.69","percent of total billed charges",""
"PLATE BONE 110X90MM 90DEG POSITIONING","SUP-ITM-10030851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","388.29","291.22","AETNA [1001]","HB AMC AETNA HMO","271.03","69.8","","675.31","184.75","1721.50","286","202.92","317.31","percent of total billed charges",""
"PLATE BONE 110X90MM 90DEG POSITIONING","SUP-ITM-10030851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","388.29","291.22","AETNA [1001]","HB AMC AETNA PPO","312.19","80.4","","1261.44","103.12","1514.10","21","202.92","317.31","percent of total billed charges",""
"PLATE BONE 110X90MM 90DEG POSITIONING","SUP-ITM-10030851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","388.29","291.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","312.19","80.4","","1365.00","1365.00","1365.00","1 through 10","202.92","317.31","percent of total billed charges",""
"PLATE BONE 110X90MM 90DEG POSITIONING","SUP-ITM-10030851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","388.29","291.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","317.31","81.72","","5157.68","5157.68","5157.68","1 through 10","202.92","317.31","percent of total billed charges",""
"PLATE BONE 110X90MM 90DEG POSITIONING","SUP-ITM-10030851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","388.29","291.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","317.31","81.72","","431.26","71.26","1459.57","88","202.92","317.31","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","856.00","642.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","680.52","79.5","","800.18","480.96","1887.97","195","265.36","680.52","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","856.00","642.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","456.25","53.3","","813.12","216.42","1444.50","81","265.36","680.52","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","856.00","642.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","265.36","31","","432.60","432.60","432.60","1 through 10","265.36","680.52","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","856.00","642.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","312.44","36.5","","148.37","54.89","631.39","94","265.36","680.52","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","856.00","642.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","327.85","38.3","","279.30","91.72","1116.77","266","265.36","680.52","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","856.00","642.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","367.22","42.9","","731.00","63.70","731.00","1 through 10","265.36","680.52","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","856.00","642.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","367.22","42.9","","384.74","384.74","384.74","1 through 10","265.36","680.52","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","856.00","642.00","WELLPOINT [1015]","HB AMC WELLPOINT","631.56","73.78","","286.63","119.22","1107.45","105","265.36","680.52","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","856.00","642.00","AETNA [1001]","HB AMC AETNA HMO","597.49","69.8","","675.31","184.75","1721.50","286","447.35","699.52","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","856.00","642.00","AETNA [1001]","HB AMC AETNA PPO","688.22","80.4","","1261.44","103.12","1514.10","21","447.35","699.52","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","856.00","642.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","688.22","80.4","","1365.00","1365.00","1365.00","1 through 10","447.35","699.52","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","856.00","642.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","699.52","81.72","","5157.68","5157.68","5157.68","1 through 10","447.35","699.52","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","856.00","642.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","699.52","81.72","","431.26","71.26","1459.57","88","447.35","699.52","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1372.70","1029.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1091.30","79.5","","800.18","480.96","1887.97","195","425.54","1091.3","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1372.70","1029.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","731.65","53.3","","813.12","216.42","1444.50","81","425.54","1091.3","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1372.70","1029.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","425.54","31","","432.60","432.60","432.60","1 through 10","425.54","1091.3","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1372.70","1029.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","501.04","36.5","","148.37","54.89","631.39","94","425.54","1091.3","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1372.70","1029.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","525.74","38.3","","279.30","91.72","1116.77","266","425.54","1091.3","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1372.70","1029.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","588.89","42.9","","731.00","63.70","731.00","1 through 10","425.54","1091.3","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1372.70","1029.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","588.89","42.9","","384.74","384.74","384.74","1 through 10","425.54","1091.3","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1372.70","1029.52","WELLPOINT [1015]","HB AMC WELLPOINT","1012.78","73.78","","286.63","119.22","1107.45","105","425.54","1091.3","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1372.70","1029.52","AETNA [1001]","HB AMC AETNA HMO","958.14","69.8","","675.31","184.75","1721.50","286","717.37","1121.77","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1372.70","1029.52","AETNA [1001]","HB AMC AETNA PPO","1103.65","80.4","","1261.44","103.12","1514.10","21","717.37","1121.77","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1372.70","1029.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1103.65","80.4","","1365.00","1365.00","1365.00","1 through 10","717.37","1121.77","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1372.70","1029.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1121.77","81.72","","5157.68","5157.68","5157.68","1 through 10","717.37","1121.77","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1372.70","1029.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1121.77","81.72","","431.26","71.26","1459.57","88","717.37","1121.77","percent of total billed charges",""
"PLATE BONE 116X4.5MM 6 HOLE LCP SS BROAD","SUP-ITM-10010150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1052.84","789.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","837.01","79.5","","800.18","480.96","1887.97","195","326.38","837.01","percent of total billed charges",""
"PLATE BONE 116X4.5MM 6 HOLE LCP SS BROAD","SUP-ITM-10010150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1052.84","789.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","561.16","53.3","","813.12","216.42","1444.50","81","326.38","837.01","percent of total billed charges",""
"PLATE BONE 116X4.5MM 6 HOLE LCP SS BROAD","SUP-ITM-10010150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1052.84","789.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","326.38","31","","432.60","432.60","432.60","1 through 10","326.38","837.01","percent of total billed charges",""
"PLATE BONE 116X4.5MM 6 HOLE LCP SS BROAD","SUP-ITM-10010150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1052.84","789.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","384.29","36.5","","148.37","54.89","631.39","94","326.38","837.01","percent of total billed charges",""
"PLATE BONE 116X4.5MM 6 HOLE LCP SS BROAD","SUP-ITM-10010150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1052.84","789.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","403.24","38.3","","279.30","91.72","1116.77","266","326.38","837.01","percent of total billed charges",""
"PLATE BONE 116X4.5MM 6 HOLE LCP SS BROAD","SUP-ITM-10010150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1052.84","789.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","451.67","42.9","","731.00","63.70","731.00","1 through 10","326.38","837.01","percent of total billed charges",""
"PLATE BONE 116X4.5MM 6 HOLE LCP SS BROAD","SUP-ITM-10010150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1052.84","789.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","451.67","42.9","","384.74","384.74","384.74","1 through 10","326.38","837.01","percent of total billed charges",""
"PLATE BONE 116X4.5MM 6 HOLE LCP SS BROAD","SUP-ITM-10010150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1052.84","789.63","WELLPOINT [1015]","HB AMC WELLPOINT","776.79","73.78","","286.63","119.22","1107.45","105","326.38","837.01","percent of total billed charges",""
"PLATE BONE 116X4.5MM 6 HOLE LCP SS BROAD","SUP-ITM-10010150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1052.84","789.63","AETNA [1001]","HB AMC AETNA HMO","734.88","69.8","","675.31","184.75","1721.50","286","550.21","860.38","percent of total billed charges",""
"PLATE BONE 116X4.5MM 6 HOLE LCP SS BROAD","SUP-ITM-10010150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1052.84","789.63","AETNA [1001]","HB AMC AETNA PPO","846.48","80.4","","1261.44","103.12","1514.10","21","550.21","860.38","percent of total billed charges",""
"PLATE BONE 116X4.5MM 6 HOLE LCP SS BROAD","SUP-ITM-10010150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1052.84","789.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","846.48","80.4","","1365.00","1365.00","1365.00","1 through 10","550.21","860.38","percent of total billed charges",""
"PLATE BONE 116X4.5MM 6 HOLE LCP SS BROAD","SUP-ITM-10010150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1052.84","789.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","860.38","81.72","","5157.68","5157.68","5157.68","1 through 10","550.21","860.38","percent of total billed charges",""
"PLATE BONE 116X4.5MM 6 HOLE LCP SS BROAD","SUP-ITM-10010150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1052.84","789.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","860.38","81.72","","431.26","71.26","1459.57","88","550.21","860.38","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","376.81","79.5","","800.18","480.96","1887.97","195","146.93","376.81","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","252.63","53.3","","813.12","216.42","1444.50","81","146.93","376.81","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","146.93","31","","432.60","432.60","432.60","1 through 10","146.93","376.81","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","173.00","36.5","","148.37","54.89","631.39","94","146.93","376.81","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","181.53","38.3","","279.30","91.72","1116.77","266","146.93","376.81","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","203.33","42.9","","731.00","63.70","731.00","1 through 10","146.93","376.81","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","203.33","42.9","","384.74","384.74","384.74","1 through 10","146.93","376.81","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.97","355.48","WELLPOINT [1015]","HB AMC WELLPOINT","349.70","73.78","","286.63","119.22","1107.45","105","146.93","376.81","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.97","355.48","AETNA [1001]","HB AMC AETNA HMO","330.83","69.8","","675.31","184.75","1721.50","286","247.7","387.33","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.97","355.48","AETNA [1001]","HB AMC AETNA PPO","381.07","80.4","","1261.44","103.12","1514.10","21","247.7","387.33","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.97","355.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","381.07","80.4","","1365.00","1365.00","1365.00","1 through 10","247.7","387.33","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.97","355.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","387.33","81.72","","5157.68","5157.68","5157.68","1 through 10","247.7","387.33","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.97","355.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","387.33","81.72","","431.26","71.26","1459.57","88","247.7","387.33","percent of total billed charges",""
"PLATE BONE 12 HOLE STERNALOCK BLU LADDER","SUP-ITM-10097946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3384.50","2538.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2690.68","79.5","","800.18","480.96","1887.97","195","1049.2","2690.68","percent of total billed charges",""
"PLATE BONE 12 HOLE STERNALOCK BLU LADDER","SUP-ITM-10097946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3384.50","2538.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1803.94","53.3","","813.12","216.42","1444.50","81","1049.2","2690.68","percent of total billed charges",""
"PLATE BONE 12 HOLE STERNALOCK BLU LADDER","SUP-ITM-10097946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3384.50","2538.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1049.20","31","","432.60","432.60","432.60","1 through 10","1049.2","2690.68","percent of total billed charges",""
"PLATE BONE 12 HOLE STERNALOCK BLU LADDER","SUP-ITM-10097946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3384.50","2538.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1235.34","36.5","","148.37","54.89","631.39","94","1049.2","2690.68","percent of total billed charges",""
"PLATE BONE 12 HOLE STERNALOCK BLU LADDER","SUP-ITM-10097946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3384.50","2538.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1296.26","38.3","","279.30","91.72","1116.77","266","1049.2","2690.68","percent of total billed charges",""
"PLATE BONE 12 HOLE STERNALOCK BLU LADDER","SUP-ITM-10097946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3384.50","2538.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1451.95","42.9","","731.00","63.70","731.00","1 through 10","1049.2","2690.68","percent of total billed charges",""
"PLATE BONE 12 HOLE STERNALOCK BLU LADDER","SUP-ITM-10097946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3384.50","2538.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1451.95","42.9","","384.74","384.74","384.74","1 through 10","1049.2","2690.68","percent of total billed charges",""
"PLATE BONE 12 HOLE STERNALOCK BLU LADDER","SUP-ITM-10097946","CDM","C1713","HCPCS","0278","RC","","","","both","","","3384.50","2538.37","WELLPOINT [1015]","HB AMC WELLPOINT","2497.08","73.78","","286.63","119.22","1107.45","105","1049.2","2690.68","percent of total billed charges",""
"PLATE BONE 12 HOLE STERNALOCK BLU LADDER","SUP-ITM-10097946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3384.50","2538.37","AETNA [1001]","HB AMC AETNA HMO","2362.38","69.8","","675.31","184.75","1721.50","286","1768.74","2765.81","percent of total billed charges",""
"PLATE BONE 12 HOLE STERNALOCK BLU LADDER","SUP-ITM-10097946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3384.50","2538.37","AETNA [1001]","HB AMC AETNA PPO","2721.14","80.4","","1261.44","103.12","1514.10","21","1768.74","2765.81","percent of total billed charges",""
"PLATE BONE 12 HOLE STERNALOCK BLU LADDER","SUP-ITM-10097946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3384.50","2538.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2721.14","80.4","","1365.00","1365.00","1365.00","1 through 10","1768.74","2765.81","percent of total billed charges",""
"PLATE BONE 12 HOLE STERNALOCK BLU LADDER","SUP-ITM-10097946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3384.50","2538.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2765.81","81.72","","5157.68","5157.68","5157.68","1 through 10","1768.74","2765.81","percent of total billed charges",""
"PLATE BONE 12 HOLE STERNALOCK BLU LADDER","SUP-ITM-10097946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3384.50","2538.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2765.81","81.72","","431.26","71.26","1459.57","88","1768.74","2765.81","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","415.93","79.5","","800.18","480.96","1887.97","195","162.19","415.93","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","278.85","53.3","","813.12","216.42","1444.50","81","162.19","415.93","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.19","31","","432.60","432.60","432.60","1 through 10","162.19","415.93","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","190.96","36.5","","148.37","54.89","631.39","94","162.19","415.93","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","200.38","38.3","","279.30","91.72","1116.77","266","162.19","415.93","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.44","42.9","","731.00","63.70","731.00","1 through 10","162.19","415.93","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.44","42.9","","384.74","384.74","384.74","1 through 10","162.19","415.93","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","WELLPOINT [1015]","HB AMC WELLPOINT","386.00","73.78","","286.63","119.22","1107.45","105","162.19","415.93","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","523.18","392.38","AETNA [1001]","HB AMC AETNA HMO","365.18","69.8","","675.31","184.75","1721.50","286","273.41","427.54","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","523.18","392.38","AETNA [1001]","HB AMC AETNA PPO","420.64","80.4","","1261.44","103.12","1514.10","21","273.41","427.54","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","523.18","392.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","420.64","80.4","","1365.00","1365.00","1365.00","1 through 10","273.41","427.54","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","523.18","392.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","427.54","81.72","","5157.68","5157.68","5157.68","1 through 10","273.41","427.54","percent of total billed charges",""
"PLATE BONE 121MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR TITANIUM","SUP-ITM-10001687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","523.18","392.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","427.54","81.72","","431.26","71.26","1459.57","88","273.41","427.54","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","378.87","79.5","","800.18","480.96","1887.97","195","147.73","378.87","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","254.01","53.3","","813.12","216.42","1444.50","81","147.73","378.87","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","147.73","31","","432.60","432.60","432.60","1 through 10","147.73","378.87","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","173.94","36.5","","148.37","54.89","631.39","94","147.73","378.87","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","182.52","38.3","","279.30","91.72","1116.77","266","147.73","378.87","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.44","42.9","","731.00","63.70","731.00","1 through 10","147.73","378.87","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.44","42.9","","384.74","384.74","384.74","1 through 10","147.73","378.87","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.56","357.42","WELLPOINT [1015]","HB AMC WELLPOINT","351.61","73.78","","286.63","119.22","1107.45","105","147.73","378.87","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.56","357.42","AETNA [1001]","HB AMC AETNA HMO","332.64","69.8","","675.31","184.75","1721.50","286","249.05","389.44","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.56","357.42","AETNA [1001]","HB AMC AETNA PPO","383.15","80.4","","1261.44","103.12","1514.10","21","249.05","389.44","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.56","357.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","383.15","80.4","","1365.00","1365.00","1365.00","1 through 10","249.05","389.44","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.56","357.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","389.44","81.72","","5157.68","5157.68","5157.68","1 through 10","249.05","389.44","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.56","357.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","389.44","81.72","","431.26","71.26","1459.57","88","249.05","389.44","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","910.39","682.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","723.76","79.5","","800.18","480.96","1887.97","195","282.22","723.76","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","910.39","682.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","485.24","53.3","","813.12","216.42","1444.50","81","282.22","723.76","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","910.39","682.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","282.22","31","","432.60","432.60","432.60","1 through 10","282.22","723.76","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","910.39","682.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","332.29","36.5","","148.37","54.89","631.39","94","282.22","723.76","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","910.39","682.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","348.68","38.3","","279.30","91.72","1116.77","266","282.22","723.76","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","910.39","682.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","390.56","42.9","","731.00","63.70","731.00","1 through 10","282.22","723.76","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","910.39","682.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","390.56","42.9","","384.74","384.74","384.74","1 through 10","282.22","723.76","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","910.39","682.79","WELLPOINT [1015]","HB AMC WELLPOINT","671.69","73.78","","286.63","119.22","1107.45","105","282.22","723.76","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","910.39","682.79","AETNA [1001]","HB AMC AETNA HMO","635.45","69.8","","675.31","184.75","1721.50","286","475.77","743.97","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","910.39","682.79","AETNA [1001]","HB AMC AETNA PPO","731.95","80.4","","1261.44","103.12","1514.10","21","475.77","743.97","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","910.39","682.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","731.95","80.4","","1365.00","1365.00","1365.00","1 through 10","475.77","743.97","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","910.39","682.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","743.97","81.72","","5157.68","5157.68","5157.68","1 through 10","475.77","743.97","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","910.39","682.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","743.97","81.72","","431.26","71.26","1459.57","88","475.77","743.97","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","907.02","79.5","","800.18","480.96","1887.97","195","353.68","907.02","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","608.10","53.3","","813.12","216.42","1444.50","81","353.68","907.02","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","353.68","31","","432.60","432.60","432.60","1 through 10","353.68","907.02","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","416.43","36.5","","148.37","54.89","631.39","94","353.68","907.02","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","436.96","38.3","","279.30","91.72","1116.77","266","353.68","907.02","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","489.45","42.9","","731.00","63.70","731.00","1 through 10","353.68","907.02","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","489.45","42.9","","384.74","384.74","384.74","1 through 10","353.68","907.02","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","WELLPOINT [1015]","HB AMC WELLPOINT","841.76","73.78","","286.63","119.22","1107.45","105","353.68","907.02","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.90","855.67","AETNA [1001]","HB AMC AETNA HMO","796.35","69.8","","675.31","184.75","1721.50","286","596.23","932.34","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.90","855.67","AETNA [1001]","HB AMC AETNA PPO","917.28","80.4","","1261.44","103.12","1514.10","21","596.23","932.34","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.90","855.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","917.28","80.4","","1365.00","1365.00","1365.00","1 through 10","596.23","932.34","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.90","855.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","932.34","81.72","","5157.68","5157.68","5157.68","1 through 10","596.23","932.34","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.90","855.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","932.34","81.72","","431.26","71.26","1459.57","88","596.23","932.34","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.63","364.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","386.08","79.5","","800.18","480.96","1887.97","195","150.55","386.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.63","364.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","258.84","53.3","","813.12","216.42","1444.50","81","150.55","386.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.63","364.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","150.55","31","","432.60","432.60","432.60","1 through 10","150.55","386.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.63","364.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","177.25","36.5","","148.37","54.89","631.39","94","150.55","386.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.63","364.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","186.00","38.3","","279.30","91.72","1116.77","266","150.55","386.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.63","364.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","208.34","42.9","","731.00","63.70","731.00","1 through 10","150.55","386.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.63","364.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","208.34","42.9","","384.74","384.74","384.74","1 through 10","150.55","386.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","485.63","364.22","WELLPOINT [1015]","HB AMC WELLPOINT","358.30","73.78","","286.63","119.22","1107.45","105","150.55","386.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","485.63","364.22","AETNA [1001]","HB AMC AETNA HMO","338.97","69.8","","675.31","184.75","1721.50","286","253.79","396.86","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","485.63","364.22","AETNA [1001]","HB AMC AETNA PPO","390.45","80.4","","1261.44","103.12","1514.10","21","253.79","396.86","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","485.63","364.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","390.45","80.4","","1365.00","1365.00","1365.00","1 through 10","253.79","396.86","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","485.63","364.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","396.86","81.72","","5157.68","5157.68","5157.68","1 through 10","253.79","396.86","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","485.63","364.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","396.86","81.72","","431.26","71.26","1459.57","88","253.79","396.86","percent of total billed charges",""
"PLATE BONE 145MM 12 HOLE LCP TITANIUM COLLAR ONE THIRD TUBULAR","SUP-ITM-10002297","CDM","C1713","HCPCS","0278","RC","","","","both","","","547.79","410.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","435.49","79.5","","800.18","480.96","1887.97","195","169.81","435.49","percent of total billed charges",""
"PLATE BONE 145MM 12 HOLE LCP TITANIUM COLLAR ONE THIRD TUBULAR","SUP-ITM-10002297","CDM","C1713","HCPCS","0278","RC","","","","both","","","547.79","410.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","291.97","53.3","","813.12","216.42","1444.50","81","169.81","435.49","percent of total billed charges",""
"PLATE BONE 145MM 12 HOLE LCP TITANIUM COLLAR ONE THIRD TUBULAR","SUP-ITM-10002297","CDM","C1713","HCPCS","0278","RC","","","","both","","","547.79","410.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","169.81","31","","432.60","432.60","432.60","1 through 10","169.81","435.49","percent of total billed charges",""
"PLATE BONE 145MM 12 HOLE LCP TITANIUM COLLAR ONE THIRD TUBULAR","SUP-ITM-10002297","CDM","C1713","HCPCS","0278","RC","","","","both","","","547.79","410.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","199.94","36.5","","148.37","54.89","631.39","94","169.81","435.49","percent of total billed charges",""
"PLATE BONE 145MM 12 HOLE LCP TITANIUM COLLAR ONE THIRD TUBULAR","SUP-ITM-10002297","CDM","C1713","HCPCS","0278","RC","","","","both","","","547.79","410.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","209.80","38.3","","279.30","91.72","1116.77","266","169.81","435.49","percent of total billed charges",""
"PLATE BONE 145MM 12 HOLE LCP TITANIUM COLLAR ONE THIRD TUBULAR","SUP-ITM-10002297","CDM","C1713","HCPCS","0278","RC","","","","both","","","547.79","410.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","235.00","42.9","","731.00","63.70","731.00","1 through 10","169.81","435.49","percent of total billed charges",""
"PLATE BONE 145MM 12 HOLE LCP TITANIUM COLLAR ONE THIRD TUBULAR","SUP-ITM-10002297","CDM","C1713","HCPCS","0278","RC","","","","both","","","547.79","410.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","235.00","42.9","","384.74","384.74","384.74","1 through 10","169.81","435.49","percent of total billed charges",""
"PLATE BONE 145MM 12 HOLE LCP TITANIUM COLLAR ONE THIRD TUBULAR","SUP-ITM-10002297","CDM","C1713","HCPCS","0278","RC","","","","both","","","547.79","410.84","WELLPOINT [1015]","HB AMC WELLPOINT","404.16","73.78","","286.63","119.22","1107.45","105","169.81","435.49","percent of total billed charges",""
"PLATE BONE 145MM 12 HOLE LCP TITANIUM COLLAR ONE THIRD TUBULAR","SUP-ITM-10002297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","547.79","410.84","AETNA [1001]","HB AMC AETNA HMO","382.36","69.8","","675.31","184.75","1721.50","286","286.28","447.65","percent of total billed charges",""
"PLATE BONE 145MM 12 HOLE LCP TITANIUM COLLAR ONE THIRD TUBULAR","SUP-ITM-10002297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","547.79","410.84","AETNA [1001]","HB AMC AETNA PPO","440.42","80.4","","1261.44","103.12","1514.10","21","286.28","447.65","percent of total billed charges",""
"PLATE BONE 145MM 12 HOLE LCP TITANIUM COLLAR ONE THIRD TUBULAR","SUP-ITM-10002297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","547.79","410.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","440.42","80.4","","1365.00","1365.00","1365.00","1 through 10","286.28","447.65","percent of total billed charges",""
"PLATE BONE 145MM 12 HOLE LCP TITANIUM COLLAR ONE THIRD TUBULAR","SUP-ITM-10002297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","547.79","410.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","447.65","81.72","","5157.68","5157.68","5157.68","1 through 10","286.28","447.65","percent of total billed charges",""
"PLATE BONE 145MM 12 HOLE LCP TITANIUM COLLAR ONE THIRD TUBULAR","SUP-ITM-10002297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","547.79","410.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","447.65","81.72","","431.26","71.26","1459.57","88","286.28","447.65","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.28","372.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","395.34","79.5","","800.18","480.96","1887.97","195","154.16","395.34","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.28","372.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","265.05","53.3","","813.12","216.42","1444.50","81","154.16","395.34","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.28","372.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","154.16","31","","432.60","432.60","432.60","1 through 10","154.16","395.34","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.28","372.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","181.51","36.5","","148.37","54.89","631.39","94","154.16","395.34","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.28","372.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","190.46","38.3","","279.30","91.72","1116.77","266","154.16","395.34","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.28","372.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.33","42.9","","731.00","63.70","731.00","1 through 10","154.16","395.34","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.28","372.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.33","42.9","","384.74","384.74","384.74","1 through 10","154.16","395.34","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.28","372.96","WELLPOINT [1015]","HB AMC WELLPOINT","366.89","73.78","","286.63","119.22","1107.45","105","154.16","395.34","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","497.28","372.96","AETNA [1001]","HB AMC AETNA HMO","347.10","69.8","","675.31","184.75","1721.50","286","259.88","406.38","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","497.28","372.96","AETNA [1001]","HB AMC AETNA PPO","399.81","80.4","","1261.44","103.12","1514.10","21","259.88","406.38","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","497.28","372.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","399.81","80.4","","1365.00","1365.00","1365.00","1 through 10","259.88","406.38","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","497.28","372.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","406.38","81.72","","5157.68","5157.68","5157.68","1 through 10","259.88","406.38","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","497.28","372.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","406.38","81.72","","431.26","71.26","1459.57","88","259.88","406.38","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.65","3244.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3438.89","79.5","","800.18","480.96","1887.97","195","1340.95","3438.89","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.65","3244.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2305.57","53.3","","813.12","216.42","1444.50","81","1340.95","3438.89","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.65","3244.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1340.95","31","","432.60","432.60","432.60","1 through 10","1340.95","3438.89","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.65","3244.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1578.86","36.5","","148.37","54.89","631.39","94","1340.95","3438.89","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.65","3244.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1656.72","38.3","","279.30","91.72","1116.77","266","1340.95","3438.89","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.65","3244.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1855.70","42.9","","731.00","63.70","731.00","1 through 10","1340.95","3438.89","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.65","3244.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1855.70","42.9","","384.74","384.74","384.74","1 through 10","1340.95","3438.89","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.65","3244.24","WELLPOINT [1015]","HB AMC WELLPOINT","3191.46","73.78","","286.63","119.22","1107.45","105","1340.95","3438.89","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.65","3244.24","AETNA [1001]","HB AMC AETNA HMO","3019.30","69.8","","675.31","184.75","1721.50","286","2260.58","3534.92","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.65","3244.24","AETNA [1001]","HB AMC AETNA PPO","3477.82","80.4","","1261.44","103.12","1514.10","21","2260.58","3534.92","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.65","3244.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3477.82","80.4","","1365.00","1365.00","1365.00","1 through 10","2260.58","3534.92","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.65","3244.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3534.92","81.72","","5157.68","5157.68","5157.68","1 through 10","2260.58","3534.92","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.65","3244.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3534.92","81.72","","431.26","71.26","1459.57","88","2260.58","3534.92","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3034.50","2275.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2412.43","79.5","","800.18","480.96","1887.97","195","940.7","2412.43","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3034.50","2275.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1617.39","53.3","","813.12","216.42","1444.50","81","940.7","2412.43","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3034.50","2275.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","940.70","31","","432.60","432.60","432.60","1 through 10","940.7","2412.43","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3034.50","2275.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1107.59","36.5","","148.37","54.89","631.39","94","940.7","2412.43","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3034.50","2275.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1162.21","38.3","","279.30","91.72","1116.77","266","940.7","2412.43","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3034.50","2275.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1301.80","42.9","","731.00","63.70","731.00","1 through 10","940.7","2412.43","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3034.50","2275.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1301.80","42.9","","384.74","384.74","384.74","1 through 10","940.7","2412.43","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","both","","","3034.50","2275.87","WELLPOINT [1015]","HB AMC WELLPOINT","2238.85","73.78","","286.63","119.22","1107.45","105","940.7","2412.43","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3034.50","2275.87","AETNA [1001]","HB AMC AETNA HMO","2118.08","69.8","","675.31","184.75","1721.50","286","1585.83","2479.79","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3034.50","2275.87","AETNA [1001]","HB AMC AETNA PPO","2439.74","80.4","","1261.44","103.12","1514.10","21","1585.83","2479.79","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3034.50","2275.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2439.74","80.4","","1365.00","1365.00","1365.00","1 through 10","1585.83","2479.79","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3034.50","2275.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2479.79","81.72","","5157.68","5157.68","5157.68","1 through 10","1585.83","2479.79","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM","SUP-ITM-10028159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3034.50","2275.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2479.79","81.72","","431.26","71.26","1459.57","88","1585.83","2479.79","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2328.95","79.5","","800.18","480.96","1887.97","195","908.15","2328.95","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1561.42","53.3","","813.12","216.42","1444.50","81","908.15","2328.95","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","908.15","31","","432.60","432.60","432.60","1 through 10","908.15","2328.95","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1069.27","36.5","","148.37","54.89","631.39","94","908.15","2328.95","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1122.00","38.3","","279.30","91.72","1116.77","266","908.15","2328.95","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","731.00","63.70","731.00","1 through 10","908.15","2328.95","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","384.74","384.74","384.74","1 through 10","908.15","2328.95","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","WELLPOINT [1015]","HB AMC WELLPOINT","2161.39","73.78","","286.63","119.22","1107.45","105","908.15","2328.95","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA HMO","2044.79","69.8","","675.31","184.75","1721.50","286","1530.96","2393.99","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA PPO","2355.32","80.4","","1261.44","103.12","1514.10","21","1530.96","2393.99","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2355.32","80.4","","1365.00","1365.00","1365.00","1 through 10","1530.96","2393.99","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2393.99","81.72","","5157.68","5157.68","5157.68","1 through 10","1530.96","2393.99","percent of total billed charges",""
"PLATE BONE 1MM 6 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10021384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2393.99","81.72","","431.26","71.26","1459.57","88","1530.96","2393.99","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2554.34","79.5","","800.18","480.96","1887.97","195","996.03","2554.34","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1712.53","53.3","","813.12","216.42","1444.50","81","996.03","2554.34","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","996.03","31","","432.60","432.60","432.60","1 through 10","996.03","2554.34","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1172.75","36.5","","148.37","54.89","631.39","94","996.03","2554.34","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1230.58","38.3","","279.30","91.72","1116.77","266","996.03","2554.34","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1378.38","42.9","","731.00","63.70","731.00","1 through 10","996.03","2554.34","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1378.38","42.9","","384.74","384.74","384.74","1 through 10","996.03","2554.34","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","WELLPOINT [1015]","HB AMC WELLPOINT","2370.55","73.78","","286.63","119.22","1107.45","105","996.03","2554.34","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3213.00","2409.75","AETNA [1001]","HB AMC AETNA HMO","2242.67","69.8","","675.31","184.75","1721.50","286","1679.11","2625.66","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3213.00","2409.75","AETNA [1001]","HB AMC AETNA PPO","2583.25","80.4","","1261.44","103.12","1514.10","21","1679.11","2625.66","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3213.00","2409.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2583.25","80.4","","1365.00","1365.00","1365.00","1 through 10","1679.11","2625.66","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3213.00","2409.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2625.66","81.72","","5157.68","5157.68","5157.68","1 through 10","1679.11","2625.66","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM","SUP-ITM-10021577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3213.00","2409.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2625.66","81.72","","431.26","71.26","1459.57","88","1679.11","2625.66","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10028160","CDM","C1713","HCPCS","0278","RC","","","","both","","","3143.00","2357.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2498.69","79.5","","800.18","480.96","1887.97","195","974.33","2498.69","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10028160","CDM","C1713","HCPCS","0278","RC","","","","both","","","3143.00","2357.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1675.22","53.3","","813.12","216.42","1444.50","81","974.33","2498.69","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10028160","CDM","C1713","HCPCS","0278","RC","","","","both","","","3143.00","2357.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","974.33","31","","432.60","432.60","432.60","1 through 10","974.33","2498.69","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10028160","CDM","C1713","HCPCS","0278","RC","","","","both","","","3143.00","2357.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1147.20","36.5","","148.37","54.89","631.39","94","974.33","2498.69","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10028160","CDM","C1713","HCPCS","0278","RC","","","","both","","","3143.00","2357.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1203.77","38.3","","279.30","91.72","1116.77","266","974.33","2498.69","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10028160","CDM","C1713","HCPCS","0278","RC","","","","both","","","3143.00","2357.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1348.35","42.9","","731.00","63.70","731.00","1 through 10","974.33","2498.69","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10028160","CDM","C1713","HCPCS","0278","RC","","","","both","","","3143.00","2357.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1348.35","42.9","","384.74","384.74","384.74","1 through 10","974.33","2498.69","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10028160","CDM","C1713","HCPCS","0278","RC","","","","both","","","3143.00","2357.25","WELLPOINT [1015]","HB AMC WELLPOINT","2318.91","73.78","","286.63","119.22","1107.45","105","974.33","2498.69","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10028160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3143.00","2357.25","AETNA [1001]","HB AMC AETNA HMO","2193.81","69.8","","675.31","184.75","1721.50","286","1642.53","2568.46","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10028160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3143.00","2357.25","AETNA [1001]","HB AMC AETNA PPO","2526.97","80.4","","1261.44","103.12","1514.10","21","1642.53","2568.46","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10028160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3143.00","2357.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2526.97","80.4","","1365.00","1365.00","1365.00","1 through 10","1642.53","2568.46","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10028160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3143.00","2357.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2568.46","81.72","","5157.68","5157.68","5157.68","1 through 10","1642.53","2568.46","percent of total billed charges",""
"PLATE BONE 1MM 7 HOLE HAND APTUS TITANIUM LT","SUP-ITM-10028160","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3143.00","2357.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2568.46","81.72","","431.26","71.26","1459.57","88","1642.53","2568.46","percent of total billed charges",""
"PLATE BONE 2.4-2.7MM EXTRA LONG VA LCP TITANIUM LOCKING","SUP-ITM-10096261","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.70","2254.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2389.53","79.5","","800.18","480.96","1887.97","195","931.77","2389.53","percent of total billed charges",""
"PLATE BONE 2.4-2.7MM EXTRA LONG VA LCP TITANIUM LOCKING","SUP-ITM-10096261","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.70","2254.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1602.04","53.3","","813.12","216.42","1444.50","81","931.77","2389.53","percent of total billed charges",""
"PLATE BONE 2.4-2.7MM EXTRA LONG VA LCP TITANIUM LOCKING","SUP-ITM-10096261","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.70","2254.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","931.77","31","","432.60","432.60","432.60","1 through 10","931.77","2389.53","percent of total billed charges",""
"PLATE BONE 2.4-2.7MM EXTRA LONG VA LCP TITANIUM LOCKING","SUP-ITM-10096261","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.70","2254.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1097.08","36.5","","148.37","54.89","631.39","94","931.77","2389.53","percent of total billed charges",""
"PLATE BONE 2.4-2.7MM EXTRA LONG VA LCP TITANIUM LOCKING","SUP-ITM-10096261","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.70","2254.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1151.18","38.3","","279.30","91.72","1116.77","266","931.77","2389.53","percent of total billed charges",""
"PLATE BONE 2.4-2.7MM EXTRA LONG VA LCP TITANIUM LOCKING","SUP-ITM-10096261","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.70","2254.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1289.45","42.9","","731.00","63.70","731.00","1 through 10","931.77","2389.53","percent of total billed charges",""
"PLATE BONE 2.4-2.7MM EXTRA LONG VA LCP TITANIUM LOCKING","SUP-ITM-10096261","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.70","2254.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1289.45","42.9","","384.74","384.74","384.74","1 through 10","931.77","2389.53","percent of total billed charges",""
"PLATE BONE 2.4-2.7MM EXTRA LONG VA LCP TITANIUM LOCKING","SUP-ITM-10096261","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.70","2254.27","WELLPOINT [1015]","HB AMC WELLPOINT","2217.61","73.78","","286.63","119.22","1107.45","105","931.77","2389.53","percent of total billed charges",""
"PLATE BONE 2.4-2.7MM EXTRA LONG VA LCP TITANIUM LOCKING","SUP-ITM-10096261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3005.70","2254.27","AETNA [1001]","HB AMC AETNA HMO","2097.98","69.8","","675.31","184.75","1721.50","286","1570.78","2456.26","percent of total billed charges",""
"PLATE BONE 2.4-2.7MM EXTRA LONG VA LCP TITANIUM LOCKING","SUP-ITM-10096261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3005.70","2254.27","AETNA [1001]","HB AMC AETNA PPO","2416.58","80.4","","1261.44","103.12","1514.10","21","1570.78","2456.26","percent of total billed charges",""
"PLATE BONE 2.4-2.7MM EXTRA LONG VA LCP TITANIUM LOCKING","SUP-ITM-10096261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3005.70","2254.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2416.58","80.4","","1365.00","1365.00","1365.00","1 through 10","1570.78","2456.26","percent of total billed charges",""
"PLATE BONE 2.4-2.7MM EXTRA LONG VA LCP TITANIUM LOCKING","SUP-ITM-10096261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3005.70","2254.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2456.26","81.72","","5157.68","5157.68","5157.68","1 through 10","1570.78","2456.26","percent of total billed charges",""
"PLATE BONE 2.4-2.7MM EXTRA LONG VA LCP TITANIUM LOCKING","SUP-ITM-10096261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3005.70","2254.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2456.26","81.72","","431.26","71.26","1459.57","88","1570.78","2456.26","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.54","1954.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2071.40","79.5","","800.18","480.96","1887.97","195","807.72","2071.4","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.54","1954.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1388.75","53.3","","813.12","216.42","1444.50","81","807.72","2071.4","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.54","1954.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","807.72","31","","432.60","432.60","432.60","1 through 10","807.72","2071.4","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.54","1954.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","951.02","36.5","","148.37","54.89","631.39","94","807.72","2071.4","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.54","1954.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","997.92","38.3","","279.30","91.72","1116.77","266","807.72","2071.4","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.54","1954.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1117.78","42.9","","731.00","63.70","731.00","1 through 10","807.72","2071.4","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.54","1954.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1117.78","42.9","","384.74","384.74","384.74","1 through 10","807.72","2071.4","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.54","1954.15","WELLPOINT [1015]","HB AMC WELLPOINT","1922.37","73.78","","286.63","119.22","1107.45","105","807.72","2071.4","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2605.54","1954.15","AETNA [1001]","HB AMC AETNA HMO","1818.67","69.8","","675.31","184.75","1721.50","286","1361.66","2129.25","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2605.54","1954.15","AETNA [1001]","HB AMC AETNA PPO","2094.85","80.4","","1261.44","103.12","1514.10","21","1361.66","2129.25","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2605.54","1954.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2094.85","80.4","","1365.00","1365.00","1365.00","1 through 10","1361.66","2129.25","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2605.54","1954.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2129.25","81.72","","5157.68","5157.68","5157.68","1 through 10","1361.66","2129.25","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2605.54","1954.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2129.25","81.72","","431.26","71.26","1459.57","88","1361.66","2129.25","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.91","2756.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2922.35","79.5","","800.18","480.96","1887.97","195","1139.53","2922.35","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.91","2756.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1959.26","53.3","","813.12","216.42","1444.50","81","1139.53","2922.35","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.91","2756.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1139.53","31","","432.60","432.60","432.60","1 through 10","1139.53","2922.35","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.91","2756.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1341.71","36.5","","148.37","54.89","631.39","94","1139.53","2922.35","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.91","2756.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1407.87","38.3","","279.30","91.72","1116.77","266","1139.53","2922.35","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.91","2756.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1576.97","42.9","","731.00","63.70","731.00","1 through 10","1139.53","2922.35","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.91","2756.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1576.97","42.9","","384.74","384.74","384.74","1 through 10","1139.53","2922.35","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3675.91","2756.93","WELLPOINT [1015]","HB AMC WELLPOINT","2712.09","73.78","","286.63","119.22","1107.45","105","1139.53","2922.35","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3675.91","2756.93","AETNA [1001]","HB AMC AETNA HMO","2565.79","69.8","","675.31","184.75","1721.50","286","1921.03","3003.95","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3675.91","2756.93","AETNA [1001]","HB AMC AETNA PPO","2955.43","80.4","","1261.44","103.12","1514.10","21","1921.03","3003.95","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3675.91","2756.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2955.43","80.4","","1365.00","1365.00","1365.00","1 through 10","1921.03","3003.95","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3675.91","2756.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3003.95","81.72","","5157.68","5157.68","5157.68","1 through 10","1921.03","3003.95","percent of total billed charges",""
"PLATE BONE 2.4X28MM 4HOLE STRAIGHT LOCKING NARROW","SUP-ITM-10285734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3675.91","2756.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3003.95","81.72","","431.26","71.26","1459.57","88","1921.03","3003.95","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2392.95","79.5","","800.18","480.96","1887.97","195","933.1","2392.95","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1604.33","53.3","","813.12","216.42","1444.50","81","933.1","2392.95","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","933.10","31","","432.60","432.60","432.60","1 through 10","933.1","2392.95","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1098.65","36.5","","148.37","54.89","631.39","94","933.1","2392.95","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1152.83","38.3","","279.30","91.72","1116.77","266","933.1","2392.95","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1291.29","42.9","","731.00","63.70","731.00","1 through 10","933.1","2392.95","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1291.29","42.9","","384.74","384.74","384.74","1 through 10","933.1","2392.95","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","WELLPOINT [1015]","HB AMC WELLPOINT","2220.78","73.78","","286.63","119.22","1107.45","105","933.1","2392.95","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","AETNA [1001]","HB AMC AETNA HMO","2100.98","69.8","","675.31","184.75","1721.50","286","1573.03","2459.77","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","AETNA [1001]","HB AMC AETNA PPO","2420.04","80.4","","1261.44","103.12","1514.10","21","1573.03","2459.77","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2420.04","80.4","","1365.00","1365.00","1365.00","1 through 10","1573.03","2459.77","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2459.77","81.72","","5157.68","5157.68","5157.68","1 through 10","1573.03","2459.77","percent of total billed charges",""
"PLATE BONE 2MM 2X4 HOLE HAND APTUS LOCKING L-SHAPE LT","SUP-ITM-10051631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2459.77","81.72","","431.26","71.26","1459.57","88","1573.03","2459.77","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1813.00","1359.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1441.34","79.5","","800.18","480.96","1887.97","195","562.03","1441.34","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1813.00","1359.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","966.33","53.3","","813.12","216.42","1444.50","81","562.03","1441.34","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1813.00","1359.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","562.03","31","","432.60","432.60","432.60","1 through 10","562.03","1441.34","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1813.00","1359.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","661.75","36.5","","148.37","54.89","631.39","94","562.03","1441.34","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1813.00","1359.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","694.38","38.3","","279.30","91.72","1116.77","266","562.03","1441.34","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1813.00","1359.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","777.78","42.9","","731.00","63.70","731.00","1 through 10","562.03","1441.34","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1813.00","1359.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","777.78","42.9","","384.74","384.74","384.74","1 through 10","562.03","1441.34","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","both","","","1813.00","1359.75","WELLPOINT [1015]","HB AMC WELLPOINT","1337.63","73.78","","286.63","119.22","1107.45","105","562.03","1441.34","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1813.00","1359.75","AETNA [1001]","HB AMC AETNA HMO","1265.47","69.8","","675.31","184.75","1721.50","286","947.47","1481.58","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1813.00","1359.75","AETNA [1001]","HB AMC AETNA PPO","1457.65","80.4","","1261.44","103.12","1514.10","21","947.47","1481.58","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1813.00","1359.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1457.65","80.4","","1365.00","1365.00","1365.00","1 through 10","947.47","1481.58","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1813.00","1359.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1481.58","81.72","","5157.68","5157.68","5157.68","1 through 10","947.47","1481.58","percent of total billed charges",""
"PLATE BONE 2X4 HOLE HAND APTUS LOCKING L SHAPE RT","SUP-ITM-10041980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1813.00","1359.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1481.58","81.72","","431.26","71.26","1459.57","88","947.47","1481.58","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.20","738.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","782.44","79.5","","800.18","480.96","1887.97","195","305.1","782.44","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.20","738.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","524.58","53.3","","813.12","216.42","1444.50","81","305.1","782.44","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.20","738.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","305.10","31","","432.60","432.60","432.60","1 through 10","305.1","782.44","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.20","738.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","359.23","36.5","","148.37","54.89","631.39","94","305.1","782.44","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.20","738.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","376.95","38.3","","279.30","91.72","1116.77","266","305.1","782.44","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.20","738.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","422.22","42.9","","731.00","63.70","731.00","1 through 10","305.1","782.44","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.20","738.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","422.22","42.9","","384.74","384.74","384.74","1 through 10","305.1","782.44","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.20","738.15","WELLPOINT [1015]","HB AMC WELLPOINT","726.14","73.78","","286.63","119.22","1107.45","105","305.1","782.44","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.20","738.15","AETNA [1001]","HB AMC AETNA HMO","686.97","69.8","","675.31","184.75","1721.50","286","514.34","804.29","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.20","738.15","AETNA [1001]","HB AMC AETNA PPO","791.30","80.4","","1261.44","103.12","1514.10","21","514.34","804.29","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.20","738.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","791.30","80.4","","1365.00","1365.00","1365.00","1 through 10","514.34","804.29","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.20","738.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","804.29","81.72","","5157.68","5157.68","5157.68","1 through 10","514.34","804.29","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.20","738.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","804.29","81.72","","431.26","71.26","1459.57","88","514.34","804.29","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","788.66","591.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","626.98","79.5","","800.18","480.96","1887.97","195","244.48","626.98","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","788.66","591.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","420.36","53.3","","813.12","216.42","1444.50","81","244.48","626.98","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","788.66","591.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","244.48","31","","432.60","432.60","432.60","1 through 10","244.48","626.98","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","788.66","591.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","287.86","36.5","","148.37","54.89","631.39","94","244.48","626.98","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","788.66","591.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","302.06","38.3","","279.30","91.72","1116.77","266","244.48","626.98","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","788.66","591.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","338.34","42.9","","731.00","63.70","731.00","1 through 10","244.48","626.98","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","788.66","591.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","338.34","42.9","","384.74","384.74","384.74","1 through 10","244.48","626.98","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","788.66","591.49","WELLPOINT [1015]","HB AMC WELLPOINT","581.87","73.78","","286.63","119.22","1107.45","105","244.48","626.98","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","788.66","591.49","AETNA [1001]","HB AMC AETNA HMO","550.48","69.8","","675.31","184.75","1721.50","286","412.15","644.49","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","788.66","591.49","AETNA [1001]","HB AMC AETNA PPO","634.08","80.4","","1261.44","103.12","1514.10","21","412.15","644.49","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","788.66","591.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","634.08","80.4","","1365.00","1365.00","1365.00","1 through 10","412.15","644.49","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","788.66","591.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","644.49","81.72","","5157.68","5157.68","5157.68","1 through 10","412.15","644.49","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","788.66","591.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","644.49","81.72","","431.26","71.26","1459.57","88","412.15","644.49","percent of total billed charges",""
"PLATE BURR 14MM HOLE TITANIUM MICROPLUS","SUP-ITM-10165222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.87","1147.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1216.25","79.5","","800.18","480.96","1887.97","195","474.26","1216.25","percent of total billed charges",""
"PLATE BURR 14MM HOLE TITANIUM MICROPLUS","SUP-ITM-10165222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.87","1147.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","815.42","53.3","","813.12","216.42","1444.50","81","474.26","1216.25","percent of total billed charges",""
"PLATE BURR 14MM HOLE TITANIUM MICROPLUS","SUP-ITM-10165222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.87","1147.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","474.26","31","","432.60","432.60","432.60","1 through 10","474.26","1216.25","percent of total billed charges",""
"PLATE BURR 14MM HOLE TITANIUM MICROPLUS","SUP-ITM-10165222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.87","1147.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","558.40","36.5","","148.37","54.89","631.39","94","474.26","1216.25","percent of total billed charges",""
"PLATE BURR 14MM HOLE TITANIUM MICROPLUS","SUP-ITM-10165222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.87","1147.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","585.94","38.3","","279.30","91.72","1116.77","266","474.26","1216.25","percent of total billed charges",""
"PLATE BURR 14MM HOLE TITANIUM MICROPLUS","SUP-ITM-10165222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.87","1147.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","656.31","42.9","","731.00","63.70","731.00","1 through 10","474.26","1216.25","percent of total billed charges",""
"PLATE BURR 14MM HOLE TITANIUM MICROPLUS","SUP-ITM-10165222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.87","1147.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","656.31","42.9","","384.74","384.74","384.74","1 through 10","474.26","1216.25","percent of total billed charges",""
"PLATE BURR 14MM HOLE TITANIUM MICROPLUS","SUP-ITM-10165222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1529.87","1147.40","WELLPOINT [1015]","HB AMC WELLPOINT","1128.74","73.78","","286.63","119.22","1107.45","105","474.26","1216.25","percent of total billed charges",""
"PLATE BURR 14MM HOLE TITANIUM MICROPLUS","SUP-ITM-10165222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1529.87","1147.40","AETNA [1001]","HB AMC AETNA HMO","1067.85","69.8","","675.31","184.75","1721.50","286","799.51","1250.21","percent of total billed charges",""
"PLATE BURR 14MM HOLE TITANIUM MICROPLUS","SUP-ITM-10165222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1529.87","1147.40","AETNA [1001]","HB AMC AETNA PPO","1230.02","80.4","","1261.44","103.12","1514.10","21","799.51","1250.21","percent of total billed charges",""
"PLATE BURR 14MM HOLE TITANIUM MICROPLUS","SUP-ITM-10165222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1529.87","1147.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1230.02","80.4","","1365.00","1365.00","1365.00","1 through 10","799.51","1250.21","percent of total billed charges",""
"PLATE BURR 14MM HOLE TITANIUM MICROPLUS","SUP-ITM-10165222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1529.87","1147.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1250.21","81.72","","5157.68","5157.68","5157.68","1 through 10","799.51","1250.21","percent of total billed charges",""
"PLATE BURR 14MM HOLE TITANIUM MICROPLUS","SUP-ITM-10165222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1529.87","1147.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1250.21","81.72","","431.26","71.26","1459.57","88","799.51","1250.21","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2776.48","2082.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2207.30","79.5","","800.18","480.96","1887.97","195","860.71","2207.3","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2776.48","2082.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1479.86","53.3","","813.12","216.42","1444.50","81","860.71","2207.3","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2776.48","2082.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","860.71","31","","432.60","432.60","432.60","1 through 10","860.71","2207.3","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2776.48","2082.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1013.42","36.5","","148.37","54.89","631.39","94","860.71","2207.3","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2776.48","2082.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1063.39","38.3","","279.30","91.72","1116.77","266","860.71","2207.3","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2776.48","2082.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1191.11","42.9","","731.00","63.70","731.00","1 through 10","860.71","2207.3","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2776.48","2082.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1191.11","42.9","","384.74","384.74","384.74","1 through 10","860.71","2207.3","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2776.48","2082.36","WELLPOINT [1015]","HB AMC WELLPOINT","2048.49","73.78","","286.63","119.22","1107.45","105","860.71","2207.3","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2776.48","2082.36","AETNA [1001]","HB AMC AETNA HMO","1937.98","69.8","","675.31","184.75","1721.50","286","1450.99","2268.94","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2776.48","2082.36","AETNA [1001]","HB AMC AETNA PPO","2232.29","80.4","","1261.44","103.12","1514.10","21","1450.99","2268.94","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2776.48","2082.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2232.29","80.4","","1365.00","1365.00","1365.00","1 through 10","1450.99","2268.94","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2776.48","2082.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2268.94","81.72","","5157.68","5157.68","5157.68","1 through 10","1450.99","2268.94","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2776.48","2082.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2268.94","81.72","","431.26","71.26","1459.57","88","1450.99","2268.94","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.53","712.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","755.67","79.5","","800.18","480.96","1887.97","195","294.66","755.67","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.53","712.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","506.63","53.3","","813.12","216.42","1444.50","81","294.66","755.67","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.53","712.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","294.66","31","","432.60","432.60","432.60","1 through 10","294.66","755.67","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.53","712.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","346.94","36.5","","148.37","54.89","631.39","94","294.66","755.67","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.53","712.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","364.05","38.3","","279.30","91.72","1116.77","266","294.66","755.67","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.53","712.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","407.78","42.9","","731.00","63.70","731.00","1 through 10","294.66","755.67","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.53","712.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","407.78","42.9","","384.74","384.74","384.74","1 through 10","294.66","755.67","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.53","712.90","WELLPOINT [1015]","HB AMC WELLPOINT","701.30","73.78","","286.63","119.22","1107.45","105","294.66","755.67","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.53","712.90","AETNA [1001]","HB AMC AETNA HMO","663.47","69.8","","675.31","184.75","1721.50","286","496.75","776.77","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.53","712.90","AETNA [1001]","HB AMC AETNA PPO","764.23","80.4","","1261.44","103.12","1514.10","21","496.75","776.77","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.53","712.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","764.23","80.4","","1365.00","1365.00","1365.00","1 through 10","496.75","776.77","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.53","712.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","776.77","81.72","","5157.68","5157.68","5157.68","1 through 10","496.75","776.77","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM 8 HOLE SS RECONSTRUCTION","SUP-ITM-10038126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.53","712.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","776.77","81.72","","431.26","71.26","1459.57","88","496.75","776.77","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1951.98","79.5","","800.18","480.96","1887.97","195","761.15","1951.98","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1308.69","53.3","","813.12","216.42","1444.50","81","761.15","1951.98","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","761.15","31","","432.60","432.60","432.60","1 through 10","761.15","1951.98","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","896.19","36.5","","148.37","54.89","631.39","94","761.15","1951.98","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","940.39","38.3","","279.30","91.72","1116.77","266","761.15","1951.98","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1053.33","42.9","","731.00","63.70","731.00","1 through 10","761.15","1951.98","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1053.33","42.9","","384.74","384.74","384.74","1 through 10","761.15","1951.98","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","WELLPOINT [1015]","HB AMC WELLPOINT","1811.54","73.78","","286.63","119.22","1107.45","105","761.15","1951.98","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2455.32","1841.49","AETNA [1001]","HB AMC AETNA HMO","1713.81","69.8","","675.31","184.75","1721.50","286","1283.15","2006.49","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2455.32","1841.49","AETNA [1001]","HB AMC AETNA PPO","1974.08","80.4","","1261.44","103.12","1514.10","21","1283.15","2006.49","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2455.32","1841.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1974.08","80.4","","1365.00","1365.00","1365.00","1 through 10","1283.15","2006.49","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2455.32","1841.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2006.49","81.72","","5157.68","5157.68","5157.68","1 through 10","1283.15","2006.49","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2455.32","1841.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2006.49","81.72","","431.26","71.26","1459.57","88","1283.15","2006.49","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.50","739.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","783.47","79.5","","800.18","480.96","1887.97","195","305.51","783.47","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.50","739.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","525.27","53.3","","813.12","216.42","1444.50","81","305.51","783.47","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.50","739.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","305.51","31","","432.60","432.60","432.60","1 through 10","305.51","783.47","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.50","739.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","359.71","36.5","","148.37","54.89","631.39","94","305.51","783.47","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.50","739.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","377.45","38.3","","279.30","91.72","1116.77","266","305.51","783.47","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.50","739.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","422.78","42.9","","731.00","63.70","731.00","1 through 10","305.51","783.47","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.50","739.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","422.78","42.9","","384.74","384.74","384.74","1 through 10","305.51","783.47","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","both","","","985.50","739.12","WELLPOINT [1015]","HB AMC WELLPOINT","727.10","73.78","","286.63","119.22","1107.45","105","305.51","783.47","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","985.50","739.12","AETNA [1001]","HB AMC AETNA HMO","687.88","69.8","","675.31","184.75","1721.50","286","515.02","805.35","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","985.50","739.12","AETNA [1001]","HB AMC AETNA PPO","792.34","80.4","","1261.44","103.12","1514.10","21","515.02","805.35","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","985.50","739.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","792.34","80.4","","1365.00","1365.00","1365.00","1 through 10","515.02","805.35","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","985.50","739.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","805.35","81.72","","5157.68","5157.68","5157.68","1 through 10","515.02","805.35","percent of total billed charges",""
"PLATE CALCANEAL 2.7X72MM 9 HOLE SS RECONSTRUCTION","SUP-ITM-10038127","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","985.50","739.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","805.35","81.72","","431.26","71.26","1459.57","88","515.02","805.35","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2758.35","2068.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2192.89","79.5","","800.18","480.96","1887.97","195","855.09","2192.89","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2758.35","2068.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1470.20","53.3","","813.12","216.42","1444.50","81","855.09","2192.89","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2758.35","2068.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","855.09","31","","432.60","432.60","432.60","1 through 10","855.09","2192.89","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2758.35","2068.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1006.80","36.5","","148.37","54.89","631.39","94","855.09","2192.89","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2758.35","2068.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1056.45","38.3","","279.30","91.72","1116.77","266","855.09","2192.89","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2758.35","2068.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1183.33","42.9","","731.00","63.70","731.00","1 through 10","855.09","2192.89","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2758.35","2068.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1183.33","42.9","","384.74","384.74","384.74","1 through 10","855.09","2192.89","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","2758.35","2068.76","WELLPOINT [1015]","HB AMC WELLPOINT","2035.11","73.78","","286.63","119.22","1107.45","105","855.09","2192.89","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2758.35","2068.76","AETNA [1001]","HB AMC AETNA HMO","1925.33","69.8","","675.31","184.75","1721.50","286","1441.51","2254.12","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2758.35","2068.76","AETNA [1001]","HB AMC AETNA PPO","2217.71","80.4","","1261.44","103.12","1514.10","21","1441.51","2254.12","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2758.35","2068.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2217.71","80.4","","1365.00","1365.00","1365.00","1 through 10","1441.51","2254.12","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2758.35","2068.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2254.12","81.72","","5157.68","5157.68","5157.68","1 through 10","1441.51","2254.12","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2758.35","2068.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2254.12","81.72","","431.26","71.26","1459.57","88","1441.51","2254.12","percent of total billed charges",""
"PLATE CALCANEAL 64MM XS CALCANL LOCKING SS MINI RIGHT","SUP-ITM-10036341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.33","1199.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1271.47","79.5","","800.18","480.96","1887.97","195","495.79","1271.47","percent of total billed charges",""
"PLATE CALCANEAL 64MM XS CALCANL LOCKING SS MINI RIGHT","SUP-ITM-10036341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.33","1199.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","852.44","53.3","","813.12","216.42","1444.50","81","495.79","1271.47","percent of total billed charges",""
"PLATE CALCANEAL 64MM XS CALCANL LOCKING SS MINI RIGHT","SUP-ITM-10036341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.33","1199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","495.79","31","","432.60","432.60","432.60","1 through 10","495.79","1271.47","percent of total billed charges",""
"PLATE CALCANEAL 64MM XS CALCANL LOCKING SS MINI RIGHT","SUP-ITM-10036341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.33","1199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","583.76","36.5","","148.37","54.89","631.39","94","495.79","1271.47","percent of total billed charges",""
"PLATE CALCANEAL 64MM XS CALCANL LOCKING SS MINI RIGHT","SUP-ITM-10036341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.33","1199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","612.54","38.3","","279.30","91.72","1116.77","266","495.79","1271.47","percent of total billed charges",""
"PLATE CALCANEAL 64MM XS CALCANL LOCKING SS MINI RIGHT","SUP-ITM-10036341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.33","1199.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","686.11","42.9","","731.00","63.70","731.00","1 through 10","495.79","1271.47","percent of total billed charges",""
"PLATE CALCANEAL 64MM XS CALCANL LOCKING SS MINI RIGHT","SUP-ITM-10036341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.33","1199.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","686.11","42.9","","384.74","384.74","384.74","1 through 10","495.79","1271.47","percent of total billed charges",""
"PLATE CALCANEAL 64MM XS CALCANL LOCKING SS MINI RIGHT","SUP-ITM-10036341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.33","1199.50","WELLPOINT [1015]","HB AMC WELLPOINT","1179.99","73.78","","286.63","119.22","1107.45","105","495.79","1271.47","percent of total billed charges",""
"PLATE CALCANEAL 64MM XS CALCANL LOCKING SS MINI RIGHT","SUP-ITM-10036341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.33","1199.50","AETNA [1001]","HB AMC AETNA HMO","1116.33","69.8","","675.31","184.75","1721.50","286","835.81","1306.97","percent of total billed charges",""
"PLATE CALCANEAL 64MM XS CALCANL LOCKING SS MINI RIGHT","SUP-ITM-10036341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.33","1199.50","AETNA [1001]","HB AMC AETNA PPO","1285.86","80.4","","1261.44","103.12","1514.10","21","835.81","1306.97","percent of total billed charges",""
"PLATE CALCANEAL 64MM XS CALCANL LOCKING SS MINI RIGHT","SUP-ITM-10036341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.33","1199.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1285.86","80.4","","1365.00","1365.00","1365.00","1 through 10","835.81","1306.97","percent of total billed charges",""
"PLATE CALCANEAL 64MM XS CALCANL LOCKING SS MINI RIGHT","SUP-ITM-10036341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.33","1199.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1306.97","81.72","","5157.68","5157.68","5157.68","1 through 10","835.81","1306.97","percent of total billed charges",""
"PLATE CALCANEAL 64MM XS CALCANL LOCKING SS MINI RIGHT","SUP-ITM-10036341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.33","1199.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1306.97","81.72","","431.26","71.26","1459.57","88","835.81","1306.97","percent of total billed charges",""
"PLATE CALCANEAL 69MM SHORT LCP SS LOCKING RIGHT","SUP-ITM-10036343","CDM","C1713","HCPCS","0278","RC","","","","both","","","1789.69","1342.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1422.80","79.5","","800.18","480.96","1887.97","195","554.8","1422.8","percent of total billed charges",""
"PLATE CALCANEAL 69MM SHORT LCP SS LOCKING RIGHT","SUP-ITM-10036343","CDM","C1713","HCPCS","0278","RC","","","","both","","","1789.69","1342.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","953.90","53.3","","813.12","216.42","1444.50","81","554.8","1422.8","percent of total billed charges",""
"PLATE CALCANEAL 69MM SHORT LCP SS LOCKING RIGHT","SUP-ITM-10036343","CDM","C1713","HCPCS","0278","RC","","","","both","","","1789.69","1342.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","554.80","31","","432.60","432.60","432.60","1 through 10","554.8","1422.8","percent of total billed charges",""
"PLATE CALCANEAL 69MM SHORT LCP SS LOCKING RIGHT","SUP-ITM-10036343","CDM","C1713","HCPCS","0278","RC","","","","both","","","1789.69","1342.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","653.24","36.5","","148.37","54.89","631.39","94","554.8","1422.8","percent of total billed charges",""
"PLATE CALCANEAL 69MM SHORT LCP SS LOCKING RIGHT","SUP-ITM-10036343","CDM","C1713","HCPCS","0278","RC","","","","both","","","1789.69","1342.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","685.45","38.3","","279.30","91.72","1116.77","266","554.8","1422.8","percent of total billed charges",""
"PLATE CALCANEAL 69MM SHORT LCP SS LOCKING RIGHT","SUP-ITM-10036343","CDM","C1713","HCPCS","0278","RC","","","","both","","","1789.69","1342.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","767.78","42.9","","731.00","63.70","731.00","1 through 10","554.8","1422.8","percent of total billed charges",""
"PLATE CALCANEAL 69MM SHORT LCP SS LOCKING RIGHT","SUP-ITM-10036343","CDM","C1713","HCPCS","0278","RC","","","","both","","","1789.69","1342.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","767.78","42.9","","384.74","384.74","384.74","1 through 10","554.8","1422.8","percent of total billed charges",""
"PLATE CALCANEAL 69MM SHORT LCP SS LOCKING RIGHT","SUP-ITM-10036343","CDM","C1713","HCPCS","0278","RC","","","","both","","","1789.69","1342.27","WELLPOINT [1015]","HB AMC WELLPOINT","1320.43","73.78","","286.63","119.22","1107.45","105","554.8","1422.8","percent of total billed charges",""
"PLATE CALCANEAL 69MM SHORT LCP SS LOCKING RIGHT","SUP-ITM-10036343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1789.69","1342.27","AETNA [1001]","HB AMC AETNA HMO","1249.20","69.8","","675.31","184.75","1721.50","286","935.29","1462.53","percent of total billed charges",""
"PLATE CALCANEAL 69MM SHORT LCP SS LOCKING RIGHT","SUP-ITM-10036343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1789.69","1342.27","AETNA [1001]","HB AMC AETNA PPO","1438.91","80.4","","1261.44","103.12","1514.10","21","935.29","1462.53","percent of total billed charges",""
"PLATE CALCANEAL 69MM SHORT LCP SS LOCKING RIGHT","SUP-ITM-10036343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1789.69","1342.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1438.91","80.4","","1365.00","1365.00","1365.00","1 through 10","935.29","1462.53","percent of total billed charges",""
"PLATE CALCANEAL 69MM SHORT LCP SS LOCKING RIGHT","SUP-ITM-10036343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1789.69","1342.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1462.53","81.72","","5157.68","5157.68","5157.68","1 through 10","935.29","1462.53","percent of total billed charges",""
"PLATE CALCANEAL 69MM SHORT LCP SS LOCKING RIGHT","SUP-ITM-10036343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1789.69","1342.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1462.53","81.72","","431.26","71.26","1459.57","88","935.29","1462.53","percent of total billed charges",""
"PLATE CALCANEAL 76MM LONG LCP SS LOCKING RIGHT","SUP-ITM-10036345","CDM","C1713","HCPCS","0278","RC","","","","both","","","1908.83","1431.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1517.52","79.5","","800.18","480.96","1887.97","195","591.74","1517.52","percent of total billed charges",""
"PLATE CALCANEAL 76MM LONG LCP SS LOCKING RIGHT","SUP-ITM-10036345","CDM","C1713","HCPCS","0278","RC","","","","both","","","1908.83","1431.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1017.41","53.3","","813.12","216.42","1444.50","81","591.74","1517.52","percent of total billed charges",""
"PLATE CALCANEAL 76MM LONG LCP SS LOCKING RIGHT","SUP-ITM-10036345","CDM","C1713","HCPCS","0278","RC","","","","both","","","1908.83","1431.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","591.74","31","","432.60","432.60","432.60","1 through 10","591.74","1517.52","percent of total billed charges",""
"PLATE CALCANEAL 76MM LONG LCP SS LOCKING RIGHT","SUP-ITM-10036345","CDM","C1713","HCPCS","0278","RC","","","","both","","","1908.83","1431.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","696.72","36.5","","148.37","54.89","631.39","94","591.74","1517.52","percent of total billed charges",""
"PLATE CALCANEAL 76MM LONG LCP SS LOCKING RIGHT","SUP-ITM-10036345","CDM","C1713","HCPCS","0278","RC","","","","both","","","1908.83","1431.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","731.08","38.3","","279.30","91.72","1116.77","266","591.74","1517.52","percent of total billed charges",""
"PLATE CALCANEAL 76MM LONG LCP SS LOCKING RIGHT","SUP-ITM-10036345","CDM","C1713","HCPCS","0278","RC","","","","both","","","1908.83","1431.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","818.89","42.9","","731.00","63.70","731.00","1 through 10","591.74","1517.52","percent of total billed charges",""
"PLATE CALCANEAL 76MM LONG LCP SS LOCKING RIGHT","SUP-ITM-10036345","CDM","C1713","HCPCS","0278","RC","","","","both","","","1908.83","1431.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","818.89","42.9","","384.74","384.74","384.74","1 through 10","591.74","1517.52","percent of total billed charges",""
"PLATE CALCANEAL 76MM LONG LCP SS LOCKING RIGHT","SUP-ITM-10036345","CDM","C1713","HCPCS","0278","RC","","","","both","","","1908.83","1431.62","WELLPOINT [1015]","HB AMC WELLPOINT","1408.33","73.78","","286.63","119.22","1107.45","105","591.74","1517.52","percent of total billed charges",""
"PLATE CALCANEAL 76MM LONG LCP SS LOCKING RIGHT","SUP-ITM-10036345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1908.83","1431.62","AETNA [1001]","HB AMC AETNA HMO","1332.36","69.8","","675.31","184.75","1721.50","286","997.55","1559.9","percent of total billed charges",""
"PLATE CALCANEAL 76MM LONG LCP SS LOCKING RIGHT","SUP-ITM-10036345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1908.83","1431.62","AETNA [1001]","HB AMC AETNA PPO","1534.70","80.4","","1261.44","103.12","1514.10","21","997.55","1559.9","percent of total billed charges",""
"PLATE CALCANEAL 76MM LONG LCP SS LOCKING RIGHT","SUP-ITM-10036345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1908.83","1431.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1534.70","80.4","","1365.00","1365.00","1365.00","1 through 10","997.55","1559.9","percent of total billed charges",""
"PLATE CALCANEAL 76MM LONG LCP SS LOCKING RIGHT","SUP-ITM-10036345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1908.83","1431.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1559.90","81.72","","5157.68","5157.68","5157.68","1 through 10","997.55","1559.9","percent of total billed charges",""
"PLATE CALCANEAL 76MM LONG LCP SS LOCKING RIGHT","SUP-ITM-10036345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1908.83","1431.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1559.90","81.72","","431.26","71.26","1459.57","88","997.55","1559.9","percent of total billed charges",""
"PLATE CALCANEAL 81MM EXTRA LONG LOCKING SS LEFT","SUP-ITM-10036348","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.88","1481.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1570.03","79.5","","800.18","480.96","1887.97","195","612.21","1570.03","percent of total billed charges",""
"PLATE CALCANEAL 81MM EXTRA LONG LOCKING SS LEFT","SUP-ITM-10036348","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.88","1481.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1052.61","53.3","","813.12","216.42","1444.50","81","612.21","1570.03","percent of total billed charges",""
"PLATE CALCANEAL 81MM EXTRA LONG LOCKING SS LEFT","SUP-ITM-10036348","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.88","1481.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","612.21","31","","432.60","432.60","432.60","1 through 10","612.21","1570.03","percent of total billed charges",""
"PLATE CALCANEAL 81MM EXTRA LONG LOCKING SS LEFT","SUP-ITM-10036348","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.88","1481.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","720.83","36.5","","148.37","54.89","631.39","94","612.21","1570.03","percent of total billed charges",""
"PLATE CALCANEAL 81MM EXTRA LONG LOCKING SS LEFT","SUP-ITM-10036348","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.88","1481.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","756.38","38.3","","279.30","91.72","1116.77","266","612.21","1570.03","percent of total billed charges",""
"PLATE CALCANEAL 81MM EXTRA LONG LOCKING SS LEFT","SUP-ITM-10036348","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.88","1481.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","847.22","42.9","","731.00","63.70","731.00","1 through 10","612.21","1570.03","percent of total billed charges",""
"PLATE CALCANEAL 81MM EXTRA LONG LOCKING SS LEFT","SUP-ITM-10036348","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.88","1481.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","847.22","42.9","","384.74","384.74","384.74","1 through 10","612.21","1570.03","percent of total billed charges",""
"PLATE CALCANEAL 81MM EXTRA LONG LOCKING SS LEFT","SUP-ITM-10036348","CDM","C1713","HCPCS","0278","RC","","","","both","","","1974.88","1481.16","WELLPOINT [1015]","HB AMC WELLPOINT","1457.07","73.78","","286.63","119.22","1107.45","105","612.21","1570.03","percent of total billed charges",""
"PLATE CALCANEAL 81MM EXTRA LONG LOCKING SS LEFT","SUP-ITM-10036348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1974.88","1481.16","AETNA [1001]","HB AMC AETNA HMO","1378.47","69.8","","675.31","184.75","1721.50","286","1032.07","1613.87","percent of total billed charges",""
"PLATE CALCANEAL 81MM EXTRA LONG LOCKING SS LEFT","SUP-ITM-10036348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1974.88","1481.16","AETNA [1001]","HB AMC AETNA PPO","1587.80","80.4","","1261.44","103.12","1514.10","21","1032.07","1613.87","percent of total billed charges",""
"PLATE CALCANEAL 81MM EXTRA LONG LOCKING SS LEFT","SUP-ITM-10036348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1974.88","1481.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1587.80","80.4","","1365.00","1365.00","1365.00","1 through 10","1032.07","1613.87","percent of total billed charges",""
"PLATE CALCANEAL 81MM EXTRA LONG LOCKING SS LEFT","SUP-ITM-10036348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1974.88","1481.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1613.87","81.72","","5157.68","5157.68","5157.68","1 through 10","1032.07","1613.87","percent of total billed charges",""
"PLATE CALCANEAL 81MM EXTRA LONG LOCKING SS LEFT","SUP-ITM-10036348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1974.88","1481.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1613.87","81.72","","431.26","71.26","1459.57","88","1032.07","1613.87","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2798.50","2098.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2224.81","79.5","","800.18","480.96","1887.97","195","867.54","2224.81","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2798.50","2098.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1491.60","53.3","","813.12","216.42","1444.50","81","867.54","2224.81","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2798.50","2098.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","867.54","31","","432.60","432.60","432.60","1 through 10","867.54","2224.81","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2798.50","2098.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1021.45","36.5","","148.37","54.89","631.39","94","867.54","2224.81","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2798.50","2098.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1071.83","38.3","","279.30","91.72","1116.77","266","867.54","2224.81","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2798.50","2098.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.56","42.9","","731.00","63.70","731.00","1 through 10","867.54","2224.81","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2798.50","2098.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.56","42.9","","384.74","384.74","384.74","1 through 10","867.54","2224.81","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2798.50","2098.87","WELLPOINT [1015]","HB AMC WELLPOINT","2064.73","73.78","","286.63","119.22","1107.45","105","867.54","2224.81","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2798.50","2098.87","AETNA [1001]","HB AMC AETNA HMO","1953.35","69.8","","675.31","184.75","1721.50","286","1462.5","2286.93","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2798.50","2098.87","AETNA [1001]","HB AMC AETNA PPO","2249.99","80.4","","1261.44","103.12","1514.10","21","1462.5","2286.93","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2798.50","2098.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2249.99","80.4","","1365.00","1365.00","1365.00","1 through 10","1462.5","2286.93","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2798.50","2098.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2286.93","81.72","","5157.68","5157.68","5157.68","1 through 10","1462.5","2286.93","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2798.50","2098.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2286.93","81.72","","431.26","71.26","1459.57","88","1462.5","2286.93","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","800.18","480.96","1887.97","195","542.5","1391.25","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","813.12","216.42","1444.50","81","542.5","1391.25","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","542.50","31","","432.60","432.60","432.60","1 through 10","542.5","1391.25","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","148.37","54.89","631.39","94","542.5","1391.25","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","279.30","91.72","1116.77","266","542.5","1391.25","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","731.00","63.70","731.00","1 through 10","542.5","1391.25","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","384.74","384.74","384.74","1 through 10","542.5","1391.25","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","286.63","119.22","1107.45","105","542.5","1391.25","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","675.31","184.75","1721.50","286","914.55","1430.1","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1261.44","103.12","1514.10","21","914.55","1430.1","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","1365.00","1365.00","1365.00","1 through 10","914.55","1430.1","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1430.10","81.72","","5157.68","5157.68","5157.68","1 through 10","914.55","1430.1","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","431.26","71.26","1459.57","88","914.55","1430.1","percent of total billed charges",""
"PLATE CLAVICLE 101MM 10 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096874","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2449.24","79.5","","800.18","480.96","1887.97","195","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 101MM 10 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096874","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1642.07","53.3","","813.12","216.42","1444.50","81","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 101MM 10 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096874","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","955.05","31","","432.60","432.60","432.60","1 through 10","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 101MM 10 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096874","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1124.50","36.5","","148.37","54.89","631.39","94","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 101MM 10 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096874","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1179.95","38.3","","279.30","91.72","1116.77","266","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 101MM 10 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096874","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1321.67","42.9","","731.00","63.70","731.00","1 through 10","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 101MM 10 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096874","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1321.67","42.9","","384.74","384.74","384.74","1 through 10","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 101MM 10 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096874","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","WELLPOINT [1015]","HB AMC WELLPOINT","2273.02","73.78","","286.63","119.22","1107.45","105","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 101MM 10 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.81","2310.61","AETNA [1001]","HB AMC AETNA HMO","2150.41","69.8","","675.31","184.75","1721.50","286","1610.03","2517.64","percent of total billed charges",""
"PLATE CLAVICLE 101MM 10 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.81","2310.61","AETNA [1001]","HB AMC AETNA PPO","2476.97","80.4","","1261.44","103.12","1514.10","21","1610.03","2517.64","percent of total billed charges",""
"PLATE CLAVICLE 101MM 10 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.81","2310.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2476.97","80.4","","1365.00","1365.00","1365.00","1 through 10","1610.03","2517.64","percent of total billed charges",""
"PLATE CLAVICLE 101MM 10 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.81","2310.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2517.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1610.03","2517.64","percent of total billed charges",""
"PLATE CLAVICLE 101MM 10 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.81","2310.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2517.64","81.72","","431.26","71.26","1459.57","88","1610.03","2517.64","percent of total billed charges",""
"PLATE CLAVICLE 124MM 12 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096876","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2449.24","79.5","","800.18","480.96","1887.97","195","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 124MM 12 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096876","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1642.07","53.3","","813.12","216.42","1444.50","81","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 124MM 12 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096876","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","955.05","31","","432.60","432.60","432.60","1 through 10","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 124MM 12 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096876","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1124.50","36.5","","148.37","54.89","631.39","94","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 124MM 12 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096876","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1179.95","38.3","","279.30","91.72","1116.77","266","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 124MM 12 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096876","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1321.67","42.9","","731.00","63.70","731.00","1 through 10","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 124MM 12 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096876","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1321.67","42.9","","384.74","384.74","384.74","1 through 10","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 124MM 12 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096876","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.81","2310.61","WELLPOINT [1015]","HB AMC WELLPOINT","2273.02","73.78","","286.63","119.22","1107.45","105","955.05","2449.24","percent of total billed charges",""
"PLATE CLAVICLE 124MM 12 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.81","2310.61","AETNA [1001]","HB AMC AETNA HMO","2150.41","69.8","","675.31","184.75","1721.50","286","1610.03","2517.64","percent of total billed charges",""
"PLATE CLAVICLE 124MM 12 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.81","2310.61","AETNA [1001]","HB AMC AETNA PPO","2476.97","80.4","","1261.44","103.12","1514.10","21","1610.03","2517.64","percent of total billed charges",""
"PLATE CLAVICLE 124MM 12 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.81","2310.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2476.97","80.4","","1365.00","1365.00","1365.00","1 through 10","1610.03","2517.64","percent of total billed charges",""
"PLATE CLAVICLE 124MM 12 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.81","2310.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2517.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1610.03","2517.64","percent of total billed charges",""
"PLATE CLAVICLE 124MM 12 HOLE 2.7/3.5MM VA-LCP SS LATERAL ANTERIOR","SUP-ITM-10096876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.81","2310.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2517.64","81.72","","431.26","71.26","1459.57","88","1610.03","2517.64","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2897.13","2172.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2303.22","79.5","","800.18","480.96","1887.97","195","898.11","2303.22","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2897.13","2172.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1544.17","53.3","","813.12","216.42","1444.50","81","898.11","2303.22","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2897.13","2172.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","898.11","31","","432.60","432.60","432.60","1 through 10","898.11","2303.22","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2897.13","2172.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1057.45","36.5","","148.37","54.89","631.39","94","898.11","2303.22","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2897.13","2172.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1109.60","38.3","","279.30","91.72","1116.77","266","898.11","2303.22","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2897.13","2172.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1242.87","42.9","","731.00","63.70","731.00","1 through 10","898.11","2303.22","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2897.13","2172.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1242.87","42.9","","384.74","384.74","384.74","1 through 10","898.11","2303.22","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2897.13","2172.85","WELLPOINT [1015]","HB AMC WELLPOINT","2137.50","73.78","","286.63","119.22","1107.45","105","898.11","2303.22","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2897.13","2172.85","AETNA [1001]","HB AMC AETNA HMO","2022.20","69.8","","675.31","184.75","1721.50","286","1514.04","2367.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2897.13","2172.85","AETNA [1001]","HB AMC AETNA PPO","2329.29","80.4","","1261.44","103.12","1514.10","21","1514.04","2367.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2897.13","2172.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2329.29","80.4","","1365.00","1365.00","1365.00","1 through 10","1514.04","2367.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2897.13","2172.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2367.53","81.72","","5157.68","5157.68","5157.68","1 through 10","1514.04","2367.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2897.13","2172.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2367.53","81.72","","431.26","71.26","1459.57","88","1514.04","2367.53","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X89MM 9 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095081","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2227.89","79.5","","800.18","480.96","1887.97","195","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X89MM 9 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095081","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1493.67","53.3","","813.12","216.42","1444.50","81","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X89MM 9 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095081","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","868.74","31","","432.60","432.60","432.60","1 through 10","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X89MM 9 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095081","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.87","36.5","","148.37","54.89","631.39","94","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X89MM 9 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095081","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1073.31","38.3","","279.30","91.72","1116.77","266","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X89MM 9 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095081","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1202.22","42.9","","731.00","63.70","731.00","1 through 10","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X89MM 9 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095081","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1202.22","42.9","","384.74","384.74","384.74","1 through 10","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X89MM 9 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095081","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","WELLPOINT [1015]","HB AMC WELLPOINT","2067.60","73.78","","286.63","119.22","1107.45","105","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X89MM 9 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2802.38","2101.78","AETNA [1001]","HB AMC AETNA HMO","1956.06","69.8","","675.31","184.75","1721.50","286","1464.52","2290.1","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X89MM 9 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2802.38","2101.78","AETNA [1001]","HB AMC AETNA PPO","2253.11","80.4","","1261.44","103.12","1514.10","21","1464.52","2290.1","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X89MM 9 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2802.38","2101.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2253.11","80.4","","1365.00","1365.00","1365.00","1 through 10","1464.52","2290.1","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X89MM 9 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2802.38","2101.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2290.10","81.72","","5157.68","5157.68","5157.68","1 through 10","1464.52","2290.1","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X89MM 9 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2802.38","2101.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2290.10","81.72","","431.26","71.26","1459.57","88","1464.52","2290.1","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","3085.25","2313.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2452.77","79.5","","800.18","480.96","1887.97","195","956.43","2452.77","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","3085.25","2313.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1644.44","53.3","","813.12","216.42","1444.50","81","956.43","2452.77","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","3085.25","2313.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","956.43","31","","432.60","432.60","432.60","1 through 10","956.43","2452.77","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","3085.25","2313.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1126.12","36.5","","148.37","54.89","631.39","94","956.43","2452.77","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","3085.25","2313.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1181.65","38.3","","279.30","91.72","1116.77","266","956.43","2452.77","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","3085.25","2313.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1323.57","42.9","","731.00","63.70","731.00","1 through 10","956.43","2452.77","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","3085.25","2313.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1323.57","42.9","","384.74","384.74","384.74","1 through 10","956.43","2452.77","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","3085.25","2313.94","WELLPOINT [1015]","HB AMC WELLPOINT","2276.30","73.78","","286.63","119.22","1107.45","105","956.43","2452.77","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3085.25","2313.94","AETNA [1001]","HB AMC AETNA HMO","2153.50","69.8","","675.31","184.75","1721.50","286","1612.35","2521.27","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3085.25","2313.94","AETNA [1001]","HB AMC AETNA PPO","2480.54","80.4","","1261.44","103.12","1514.10","21","1612.35","2521.27","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3085.25","2313.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2480.54","80.4","","1365.00","1365.00","1365.00","1 through 10","1612.35","2521.27","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3085.25","2313.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2521.27","81.72","","5157.68","5157.68","5157.68","1 through 10","1612.35","2521.27","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3085.25","2313.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2521.27","81.72","","431.26","71.26","1459.57","88","1612.35","2521.27","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","3035.59","2276.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2413.29","79.5","","800.18","480.96","1887.97","195","941.03","2413.29","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","3035.59","2276.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1617.97","53.3","","813.12","216.42","1444.50","81","941.03","2413.29","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","3035.59","2276.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","941.03","31","","432.60","432.60","432.60","1 through 10","941.03","2413.29","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","3035.59","2276.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1107.99","36.5","","148.37","54.89","631.39","94","941.03","2413.29","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","3035.59","2276.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1162.63","38.3","","279.30","91.72","1116.77","266","941.03","2413.29","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","3035.59","2276.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1302.27","42.9","","731.00","63.70","731.00","1 through 10","941.03","2413.29","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","3035.59","2276.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1302.27","42.9","","384.74","384.74","384.74","1 through 10","941.03","2413.29","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","3035.59","2276.69","WELLPOINT [1015]","HB AMC WELLPOINT","2239.66","73.78","","286.63","119.22","1107.45","105","941.03","2413.29","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3035.59","2276.69","AETNA [1001]","HB AMC AETNA HMO","2118.84","69.8","","675.31","184.75","1721.50","286","1586.4","2480.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3035.59","2276.69","AETNA [1001]","HB AMC AETNA PPO","2440.61","80.4","","1261.44","103.12","1514.10","21","1586.4","2480.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3035.59","2276.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2440.61","80.4","","1365.00","1365.00","1365.00","1 through 10","1586.4","2480.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3035.59","2276.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2480.68","81.72","","5157.68","5157.68","5157.68","1 through 10","1586.4","2480.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3035.59","2276.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2480.68","81.72","","431.26","71.26","1459.57","88","1586.4","2480.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.10","2280.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2416.88","79.5","","800.18","480.96","1887.97","195","942.43","2416.88","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.10","2280.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1620.37","53.3","","813.12","216.42","1444.50","81","942.43","2416.88","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.10","2280.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","942.43","31","","432.60","432.60","432.60","1 through 10","942.43","2416.88","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.10","2280.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1109.64","36.5","","148.37","54.89","631.39","94","942.43","2416.88","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.10","2280.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1164.36","38.3","","279.30","91.72","1116.77","266","942.43","2416.88","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.10","2280.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1304.20","42.9","","731.00","63.70","731.00","1 through 10","942.43","2416.88","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.10","2280.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1304.20","42.9","","384.74","384.74","384.74","1 through 10","942.43","2416.88","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.10","2280.07","WELLPOINT [1015]","HB AMC WELLPOINT","2242.99","73.78","","286.63","119.22","1107.45","105","942.43","2416.88","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.10","2280.07","AETNA [1001]","HB AMC AETNA HMO","2121.99","69.8","","675.31","184.75","1721.50","286","1588.76","2484.37","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.10","2280.07","AETNA [1001]","HB AMC AETNA PPO","2444.24","80.4","","1261.44","103.12","1514.10","21","1588.76","2484.37","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.10","2280.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2444.24","80.4","","1365.00","1365.00","1365.00","1 through 10","1588.76","2484.37","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.10","2280.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2484.37","81.72","","5157.68","5157.68","5157.68","1 through 10","1588.76","2484.37","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.10","2280.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2484.37","81.72","","431.26","71.26","1459.57","88","1588.76","2484.37","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.15","2742.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2907.43","79.5","","800.18","480.96","1887.97","195","1133.72","2907.43","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.15","2742.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1949.26","53.3","","813.12","216.42","1444.50","81","1133.72","2907.43","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.15","2742.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1133.72","31","","432.60","432.60","432.60","1 through 10","1133.72","2907.43","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.15","2742.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1334.86","36.5","","148.37","54.89","631.39","94","1133.72","2907.43","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.15","2742.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1400.69","38.3","","279.30","91.72","1116.77","266","1133.72","2907.43","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.15","2742.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1568.92","42.9","","731.00","63.70","731.00","1 through 10","1133.72","2907.43","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.15","2742.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1568.92","42.9","","384.74","384.74","384.74","1 through 10","1133.72","2907.43","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.15","2742.86","WELLPOINT [1015]","HB AMC WELLPOINT","2698.25","73.78","","286.63","119.22","1107.45","105","1133.72","2907.43","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3657.15","2742.86","AETNA [1001]","HB AMC AETNA HMO","2552.69","69.8","","675.31","184.75","1721.50","286","1911.23","2988.62","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3657.15","2742.86","AETNA [1001]","HB AMC AETNA PPO","2940.35","80.4","","1261.44","103.12","1514.10","21","1911.23","2988.62","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3657.15","2742.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2940.35","80.4","","1365.00","1365.00","1365.00","1 through 10","1911.23","2988.62","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3657.15","2742.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2988.62","81.72","","5157.68","5157.68","5157.68","1 through 10","1911.23","2988.62","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3657.15","2742.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2988.62","81.72","","431.26","71.26","1459.57","88","1911.23","2988.62","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.75","2201.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2333.13","79.5","","800.18","480.96","1887.97","195","909.77","2333.13","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.75","2201.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1564.22","53.3","","813.12","216.42","1444.50","81","909.77","2333.13","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.75","2201.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","909.77","31","","432.60","432.60","432.60","1 through 10","909.77","2333.13","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.75","2201.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1071.18","36.5","","148.37","54.89","631.39","94","909.77","2333.13","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.75","2201.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1124.01","38.3","","279.30","91.72","1116.77","266","909.77","2333.13","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.75","2201.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1259.01","42.9","","731.00","63.70","731.00","1 through 10","909.77","2333.13","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.75","2201.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1259.01","42.9","","384.74","384.74","384.74","1 through 10","909.77","2333.13","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.75","2201.06","WELLPOINT [1015]","HB AMC WELLPOINT","2165.26","73.78","","286.63","119.22","1107.45","105","909.77","2333.13","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2934.75","2201.06","AETNA [1001]","HB AMC AETNA HMO","2048.46","69.8","","675.31","184.75","1721.50","286","1533.7","2398.28","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2934.75","2201.06","AETNA [1001]","HB AMC AETNA PPO","2359.54","80.4","","1261.44","103.12","1514.10","21","1533.7","2398.28","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2934.75","2201.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2359.54","80.4","","1365.00","1365.00","1365.00","1 through 10","1533.7","2398.28","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2934.75","2201.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2398.28","81.72","","5157.68","5157.68","5157.68","1 through 10","1533.7","2398.28","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2934.75","2201.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2398.28","81.72","","431.26","71.26","1459.57","88","1533.7","2398.28","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.46","2135.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2263.73","79.5","","800.18","480.96","1887.97","195","882.71","2263.73","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.46","2135.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1517.70","53.3","","813.12","216.42","1444.50","81","882.71","2263.73","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.46","2135.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","882.71","31","","432.60","432.60","432.60","1 through 10","882.71","2263.73","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.46","2135.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1039.32","36.5","","148.37","54.89","631.39","94","882.71","2263.73","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.46","2135.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1090.58","38.3","","279.30","91.72","1116.77","266","882.71","2263.73","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.46","2135.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1221.56","42.9","","731.00","63.70","731.00","1 through 10","882.71","2263.73","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.46","2135.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1221.56","42.9","","384.74","384.74","384.74","1 through 10","882.71","2263.73","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2847.46","2135.59","WELLPOINT [1015]","HB AMC WELLPOINT","2100.86","73.78","","286.63","119.22","1107.45","105","882.71","2263.73","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2847.46","2135.59","AETNA [1001]","HB AMC AETNA HMO","1987.53","69.8","","675.31","184.75","1721.50","286","1488.08","2326.94","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2847.46","2135.59","AETNA [1001]","HB AMC AETNA PPO","2289.36","80.4","","1261.44","103.12","1514.10","21","1488.08","2326.94","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2847.46","2135.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2289.36","80.4","","1365.00","1365.00","1365.00","1 through 10","1488.08","2326.94","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2847.46","2135.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2326.94","81.72","","5157.68","5157.68","5157.68","1 through 10","1488.08","2326.94","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2847.46","2135.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2326.94","81.72","","431.26","71.26","1459.57","88","1488.08","2326.94","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2115.68","79.5","","1309.77","674.56","6049.93","26","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1418.44","53.3","","1901.83","1901.83","2962.25","1 through 10","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","971.35","36.5","","1620.31","1620.31","19908.88","1 through 10","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1019.25","38.3","","352.91","352.91","2046.30","1 through 10","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1141.67","42.9","","9668.75","9668.75","9668.75","1 through 10","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","WELLPOINT [1015]","HB AMC WELLPOINT","1963.46","73.78","","699.88","384.10","3443.31","33","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2661.23","1995.92","AETNA [1001]","HB AMC AETNA HMO","1857.54","69.8","","1421.24","264.50","4933.46","29","1390.76","2174.76","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2661.23","1995.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2139.63","80.4","","1022.97","1022.97","3607.50","1 through 10","1390.76","2174.76","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2661.23","1995.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2174.76","81.72","","3010.54","693.88","5019.88","35","1390.76","2174.76","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2115.68","79.5","","800.18","480.96","1887.97","195","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1418.44","53.3","","813.12","216.42","1444.50","81","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","824.98","31","","432.60","432.60","432.60","1 through 10","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","971.35","36.5","","148.37","54.89","631.39","94","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1019.25","38.3","","279.30","91.72","1116.77","266","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1141.67","42.9","","731.00","63.70","731.00","1 through 10","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1141.67","42.9","","384.74","384.74","384.74","1 through 10","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.23","1995.92","WELLPOINT [1015]","HB AMC WELLPOINT","1963.46","73.78","","286.63","119.22","1107.45","105","824.98","2115.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2661.23","1995.92","AETNA [1001]","HB AMC AETNA HMO","1857.54","69.8","","675.31","184.75","1721.50","286","1390.76","2174.76","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2661.23","1995.92","AETNA [1001]","HB AMC AETNA PPO","2139.63","80.4","","1261.44","103.12","1514.10","21","1390.76","2174.76","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2661.23","1995.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2139.63","80.4","","1365.00","1365.00","1365.00","1 through 10","1390.76","2174.76","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2661.23","1995.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2174.76","81.72","","5157.68","5157.68","5157.68","1 through 10","1390.76","2174.76","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2661.23","1995.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2174.76","81.72","","431.26","71.26","1459.57","88","1390.76","2174.76","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2729.86","2047.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2170.24","79.5","","800.18","480.96","1887.97","195","846.26","2170.24","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2729.86","2047.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1455.02","53.3","","813.12","216.42","1444.50","81","846.26","2170.24","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2729.86","2047.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","846.26","31","","432.60","432.60","432.60","1 through 10","846.26","2170.24","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2729.86","2047.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","996.40","36.5","","148.37","54.89","631.39","94","846.26","2170.24","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2729.86","2047.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1045.54","38.3","","279.30","91.72","1116.77","266","846.26","2170.24","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2729.86","2047.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1171.11","42.9","","731.00","63.70","731.00","1 through 10","846.26","2170.24","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2729.86","2047.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1171.11","42.9","","384.74","384.74","384.74","1 through 10","846.26","2170.24","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2729.86","2047.39","WELLPOINT [1015]","HB AMC WELLPOINT","2014.09","73.78","","286.63","119.22","1107.45","105","846.26","2170.24","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2729.86","2047.39","AETNA [1001]","HB AMC AETNA HMO","1905.44","69.8","","675.31","184.75","1721.50","286","1426.62","2230.84","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2729.86","2047.39","AETNA [1001]","HB AMC AETNA PPO","2194.81","80.4","","1261.44","103.12","1514.10","21","1426.62","2230.84","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2729.86","2047.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2194.81","80.4","","1365.00","1365.00","1365.00","1 through 10","1426.62","2230.84","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2729.86","2047.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2230.84","81.72","","5157.68","5157.68","5157.68","1 through 10","1426.62","2230.84","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2729.86","2047.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2230.84","81.72","","431.26","71.26","1459.57","88","1426.62","2230.84","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2227.89","79.5","","800.18","480.96","1887.97","195","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1493.67","53.3","","813.12","216.42","1444.50","81","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","868.74","31","","432.60","432.60","432.60","1 through 10","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.87","36.5","","148.37","54.89","631.39","94","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1073.31","38.3","","279.30","91.72","1116.77","266","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1202.22","42.9","","731.00","63.70","731.00","1 through 10","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1202.22","42.9","","384.74","384.74","384.74","1 through 10","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2802.38","2101.78","WELLPOINT [1015]","HB AMC WELLPOINT","2067.60","73.78","","286.63","119.22","1107.45","105","868.74","2227.89","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2802.38","2101.78","AETNA [1001]","HB AMC AETNA HMO","1956.06","69.8","","675.31","184.75","1721.50","286","1464.52","2290.1","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2802.38","2101.78","AETNA [1001]","HB AMC AETNA PPO","2253.11","80.4","","1261.44","103.12","1514.10","21","1464.52","2290.1","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2802.38","2101.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2253.11","80.4","","1365.00","1365.00","1365.00","1 through 10","1464.52","2290.1","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2802.38","2101.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2290.10","81.72","","5157.68","5157.68","5157.68","1 through 10","1464.52","2290.1","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2802.38","2101.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2290.10","81.72","","431.26","71.26","1459.57","88","1464.52","2290.1","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2547.27","1910.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2025.08","79.5","","800.18","480.96","1887.97","195","789.65","2025.08","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2547.27","1910.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1357.69","53.3","","813.12","216.42","1444.50","81","789.65","2025.08","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2547.27","1910.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","789.65","31","","432.60","432.60","432.60","1 through 10","789.65","2025.08","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2547.27","1910.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","929.75","36.5","","148.37","54.89","631.39","94","789.65","2025.08","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2547.27","1910.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","975.60","38.3","","279.30","91.72","1116.77","266","789.65","2025.08","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2547.27","1910.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1092.78","42.9","","731.00","63.70","731.00","1 through 10","789.65","2025.08","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2547.27","1910.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1092.78","42.9","","384.74","384.74","384.74","1 through 10","789.65","2025.08","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2547.27","1910.45","WELLPOINT [1015]","HB AMC WELLPOINT","1879.38","73.78","","286.63","119.22","1107.45","105","789.65","2025.08","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2547.27","1910.45","AETNA [1001]","HB AMC AETNA HMO","1777.99","69.8","","675.31","184.75","1721.50","286","1331.2","2081.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2547.27","1910.45","AETNA [1001]","HB AMC AETNA PPO","2048.01","80.4","","1261.44","103.12","1514.10","21","1331.2","2081.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2547.27","1910.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2048.01","80.4","","1365.00","1365.00","1365.00","1 through 10","1331.2","2081.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2547.27","1910.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2081.63","81.72","","5157.68","5157.68","5157.68","1 through 10","1331.2","2081.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2547.27","1910.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2081.63","81.72","","431.26","71.26","1459.57","88","1331.2","2081.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2587.41","1940.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2056.99","79.5","","800.18","480.96","1887.97","195","802.1","2056.99","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2587.41","1940.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1379.09","53.3","","813.12","216.42","1444.50","81","802.1","2056.99","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2587.41","1940.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","802.10","31","","432.60","432.60","432.60","1 through 10","802.1","2056.99","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2587.41","1940.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","944.40","36.5","","148.37","54.89","631.39","94","802.1","2056.99","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2587.41","1940.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","990.98","38.3","","279.30","91.72","1116.77","266","802.1","2056.99","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2587.41","1940.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1110.00","42.9","","731.00","63.70","731.00","1 through 10","802.1","2056.99","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2587.41","1940.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1110.00","42.9","","384.74","384.74","384.74","1 through 10","802.1","2056.99","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2587.41","1940.56","WELLPOINT [1015]","HB AMC WELLPOINT","1908.99","73.78","","286.63","119.22","1107.45","105","802.1","2056.99","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2587.41","1940.56","AETNA [1001]","HB AMC AETNA HMO","1806.01","69.8","","675.31","184.75","1721.50","286","1352.18","2114.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2587.41","1940.56","AETNA [1001]","HB AMC AETNA PPO","2080.28","80.4","","1261.44","103.12","1514.10","21","1352.18","2114.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2587.41","1940.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2080.28","80.4","","1365.00","1365.00","1365.00","1 through 10","1352.18","2114.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2587.41","1940.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2114.43","81.72","","5157.68","5157.68","5157.68","1 through 10","1352.18","2114.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2587.41","1940.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2114.43","81.72","","431.26","71.26","1459.57","88","1352.18","2114.43","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2632.74","1974.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2093.03","79.5","","800.18","480.96","1887.97","195","816.15","2093.03","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2632.74","1974.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1403.25","53.3","","813.12","216.42","1444.50","81","816.15","2093.03","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2632.74","1974.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","816.15","31","","432.60","432.60","432.60","1 through 10","816.15","2093.03","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2632.74","1974.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","960.95","36.5","","148.37","54.89","631.39","94","816.15","2093.03","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2632.74","1974.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1008.34","38.3","","279.30","91.72","1116.77","266","816.15","2093.03","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2632.74","1974.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1129.45","42.9","","731.00","63.70","731.00","1 through 10","816.15","2093.03","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2632.74","1974.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1129.45","42.9","","384.74","384.74","384.74","1 through 10","816.15","2093.03","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2632.74","1974.55","WELLPOINT [1015]","HB AMC WELLPOINT","1942.44","73.78","","286.63","119.22","1107.45","105","816.15","2093.03","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2632.74","1974.55","AETNA [1001]","HB AMC AETNA HMO","1837.65","69.8","","675.31","184.75","1721.50","286","1375.87","2151.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2632.74","1974.55","AETNA [1001]","HB AMC AETNA PPO","2116.72","80.4","","1261.44","103.12","1514.10","21","1375.87","2151.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2632.74","1974.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2116.72","80.4","","1365.00","1365.00","1365.00","1 through 10","1375.87","2151.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2632.74","1974.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2151.48","81.72","","5157.68","5157.68","5157.68","1 through 10","1375.87","2151.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2632.74","1974.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2151.48","81.72","","431.26","71.26","1459.57","88","1375.87","2151.48","percent of total billed charges",""
"PLATE COMPRESSION 1.1X1.5MM 5 HOLE HAND APTUS FIXATION RT PIN","SUP-ITM-10019554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1271.60","79.5","","800.18","480.96","1887.97","195","495.85","1271.6","percent of total billed charges",""
"PLATE COMPRESSION 1.1X1.5MM 5 HOLE HAND APTUS FIXATION RT PIN","SUP-ITM-10019554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","852.53","53.3","","813.12","216.42","1444.50","81","495.85","1271.6","percent of total billed charges",""
"PLATE COMPRESSION 1.1X1.5MM 5 HOLE HAND APTUS FIXATION RT PIN","SUP-ITM-10019554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","495.85","31","","432.60","432.60","432.60","1 through 10","495.85","1271.6","percent of total billed charges",""
"PLATE COMPRESSION 1.1X1.5MM 5 HOLE HAND APTUS FIXATION RT PIN","SUP-ITM-10019554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","583.82","36.5","","148.37","54.89","631.39","94","495.85","1271.6","percent of total billed charges",""
"PLATE COMPRESSION 1.1X1.5MM 5 HOLE HAND APTUS FIXATION RT PIN","SUP-ITM-10019554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","612.61","38.3","","279.30","91.72","1116.77","266","495.85","1271.6","percent of total billed charges",""
"PLATE COMPRESSION 1.1X1.5MM 5 HOLE HAND APTUS FIXATION RT PIN","SUP-ITM-10019554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","686.19","42.9","","731.00","63.70","731.00","1 through 10","495.85","1271.6","percent of total billed charges",""
"PLATE COMPRESSION 1.1X1.5MM 5 HOLE HAND APTUS FIXATION RT PIN","SUP-ITM-10019554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","686.19","42.9","","384.74","384.74","384.74","1 through 10","495.85","1271.6","percent of total billed charges",""
"PLATE COMPRESSION 1.1X1.5MM 5 HOLE HAND APTUS FIXATION RT PIN","SUP-ITM-10019554","CDM","C1713","HCPCS","0278","RC","","","","both","","","1599.50","1199.62","WELLPOINT [1015]","HB AMC WELLPOINT","1180.11","73.78","","286.63","119.22","1107.45","105","495.85","1271.6","percent of total billed charges",""
"PLATE COMPRESSION 1.1X1.5MM 5 HOLE HAND APTUS FIXATION RT PIN","SUP-ITM-10019554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.50","1199.62","AETNA [1001]","HB AMC AETNA HMO","1116.45","69.8","","675.31","184.75","1721.50","286","835.9","1307.11","percent of total billed charges",""
"PLATE COMPRESSION 1.1X1.5MM 5 HOLE HAND APTUS FIXATION RT PIN","SUP-ITM-10019554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.50","1199.62","AETNA [1001]","HB AMC AETNA PPO","1286.00","80.4","","1261.44","103.12","1514.10","21","835.9","1307.11","percent of total billed charges",""
"PLATE COMPRESSION 1.1X1.5MM 5 HOLE HAND APTUS FIXATION RT PIN","SUP-ITM-10019554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.50","1199.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1286.00","80.4","","1365.00","1365.00","1365.00","1 through 10","835.9","1307.11","percent of total billed charges",""
"PLATE COMPRESSION 1.1X1.5MM 5 HOLE HAND APTUS FIXATION RT PIN","SUP-ITM-10019554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.50","1199.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1307.11","81.72","","5157.68","5157.68","5157.68","1 through 10","835.9","1307.11","percent of total billed charges",""
"PLATE COMPRESSION 1.1X1.5MM 5 HOLE HAND APTUS FIXATION RT PIN","SUP-ITM-10019554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1599.50","1199.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1307.11","81.72","","431.26","71.26","1459.57","88","835.9","1307.11","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 103MM 8H STRAIGHT","SUP-ITM-10276218","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.50","700.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","742.93","79.5","","800.18","480.96","1887.97","195","289.7","742.93","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 103MM 8H STRAIGHT","SUP-ITM-10276218","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.50","700.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","498.09","53.3","","813.12","216.42","1444.50","81","289.7","742.93","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 103MM 8H STRAIGHT","SUP-ITM-10276218","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.50","700.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","289.70","31","","432.60","432.60","432.60","1 through 10","289.7","742.93","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 103MM 8H STRAIGHT","SUP-ITM-10276218","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.50","700.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","341.09","36.5","","148.37","54.89","631.39","94","289.7","742.93","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 103MM 8H STRAIGHT","SUP-ITM-10276218","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.50","700.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","357.91","38.3","","279.30","91.72","1116.77","266","289.7","742.93","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 103MM 8H STRAIGHT","SUP-ITM-10276218","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.50","700.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.90","42.9","","731.00","63.70","731.00","1 through 10","289.7","742.93","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 103MM 8H STRAIGHT","SUP-ITM-10276218","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.50","700.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.90","42.9","","384.74","384.74","384.74","1 through 10","289.7","742.93","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 103MM 8H STRAIGHT","SUP-ITM-10276218","CDM","C1713","HCPCS","0278","RC","","","","both","","","934.50","700.87","WELLPOINT [1015]","HB AMC WELLPOINT","689.47","73.78","","286.63","119.22","1107.45","105","289.7","742.93","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 103MM 8H STRAIGHT","SUP-ITM-10276218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","934.50","700.87","AETNA [1001]","HB AMC AETNA HMO","652.28","69.8","","675.31","184.75","1721.50","286","488.37","763.67","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 103MM 8H STRAIGHT","SUP-ITM-10276218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","934.50","700.87","AETNA [1001]","HB AMC AETNA PPO","751.34","80.4","","1261.44","103.12","1514.10","21","488.37","763.67","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 103MM 8H STRAIGHT","SUP-ITM-10276218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","934.50","700.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","751.34","80.4","","1365.00","1365.00","1365.00","1 through 10","488.37","763.67","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 103MM 8H STRAIGHT","SUP-ITM-10276218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","934.50","700.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","763.67","81.72","","5157.68","5157.68","5157.68","1 through 10","488.37","763.67","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 103MM 8H STRAIGHT","SUP-ITM-10276218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","934.50","700.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","763.67","81.72","","431.26","71.26","1459.57","88","488.37","763.67","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 129MM 10H STRAIGHT","SUP-ITM-10276149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.50","769.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","815.27","79.5","","800.18","480.96","1887.97","195","317.91","815.27","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 129MM 10H STRAIGHT","SUP-ITM-10276149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.50","769.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","546.59","53.3","","813.12","216.42","1444.50","81","317.91","815.27","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 129MM 10H STRAIGHT","SUP-ITM-10276149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.50","769.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","317.91","31","","432.60","432.60","432.60","1 through 10","317.91","815.27","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 129MM 10H STRAIGHT","SUP-ITM-10276149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.50","769.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","374.31","36.5","","148.37","54.89","631.39","94","317.91","815.27","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 129MM 10H STRAIGHT","SUP-ITM-10276149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.50","769.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","392.77","38.3","","279.30","91.72","1116.77","266","317.91","815.27","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 129MM 10H STRAIGHT","SUP-ITM-10276149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.50","769.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","439.94","42.9","","731.00","63.70","731.00","1 through 10","317.91","815.27","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 129MM 10H STRAIGHT","SUP-ITM-10276149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.50","769.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","439.94","42.9","","384.74","384.74","384.74","1 through 10","317.91","815.27","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 129MM 10H STRAIGHT","SUP-ITM-10276149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1025.50","769.12","WELLPOINT [1015]","HB AMC WELLPOINT","756.61","73.78","","286.63","119.22","1107.45","105","317.91","815.27","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 129MM 10H STRAIGHT","SUP-ITM-10276149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1025.50","769.12","AETNA [1001]","HB AMC AETNA HMO","715.80","69.8","","675.31","184.75","1721.50","286","535.93","838.04","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 129MM 10H STRAIGHT","SUP-ITM-10276149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1025.50","769.12","AETNA [1001]","HB AMC AETNA PPO","824.50","80.4","","1261.44","103.12","1514.10","21","535.93","838.04","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 129MM 10H STRAIGHT","SUP-ITM-10276149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1025.50","769.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","824.50","80.4","","1365.00","1365.00","1365.00","1 through 10","535.93","838.04","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 129MM 10H STRAIGHT","SUP-ITM-10276149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1025.50","769.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","838.04","81.72","","5157.68","5157.68","5157.68","1 through 10","535.93","838.04","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 129MM 10H STRAIGHT","SUP-ITM-10276149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1025.50","769.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","838.04","81.72","","431.26","71.26","1459.57","88","535.93","838.04","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 64MM 5H STRAIGHT","SUP-ITM-10276229","CDM","C1713","HCPCS","0278","RC","","","","both","","","801.50","601.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","637.19","79.5","","800.18","480.96","1887.97","195","248.47","637.19","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 64MM 5H STRAIGHT","SUP-ITM-10276229","CDM","C1713","HCPCS","0278","RC","","","","both","","","801.50","601.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","427.20","53.3","","813.12","216.42","1444.50","81","248.47","637.19","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 64MM 5H STRAIGHT","SUP-ITM-10276229","CDM","C1713","HCPCS","0278","RC","","","","both","","","801.50","601.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","248.47","31","","432.60","432.60","432.60","1 through 10","248.47","637.19","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 64MM 5H STRAIGHT","SUP-ITM-10276229","CDM","C1713","HCPCS","0278","RC","","","","both","","","801.50","601.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","292.55","36.5","","148.37","54.89","631.39","94","248.47","637.19","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 64MM 5H STRAIGHT","SUP-ITM-10276229","CDM","C1713","HCPCS","0278","RC","","","","both","","","801.50","601.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","306.97","38.3","","279.30","91.72","1116.77","266","248.47","637.19","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 64MM 5H STRAIGHT","SUP-ITM-10276229","CDM","C1713","HCPCS","0278","RC","","","","both","","","801.50","601.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","343.84","42.9","","731.00","63.70","731.00","1 through 10","248.47","637.19","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 64MM 5H STRAIGHT","SUP-ITM-10276229","CDM","C1713","HCPCS","0278","RC","","","","both","","","801.50","601.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","343.84","42.9","","384.74","384.74","384.74","1 through 10","248.47","637.19","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 64MM 5H STRAIGHT","SUP-ITM-10276229","CDM","C1713","HCPCS","0278","RC","","","","both","","","801.50","601.12","WELLPOINT [1015]","HB AMC WELLPOINT","591.35","73.78","","286.63","119.22","1107.45","105","248.47","637.19","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 64MM 5H STRAIGHT","SUP-ITM-10276229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","801.50","601.12","AETNA [1001]","HB AMC AETNA HMO","559.45","69.8","","675.31","184.75","1721.50","286","418.86","654.99","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 64MM 5H STRAIGHT","SUP-ITM-10276229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","801.50","601.12","AETNA [1001]","HB AMC AETNA PPO","644.41","80.4","","1261.44","103.12","1514.10","21","418.86","654.99","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 64MM 5H STRAIGHT","SUP-ITM-10276229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","801.50","601.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","644.41","80.4","","1365.00","1365.00","1365.00","1 through 10","418.86","654.99","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 64MM 5H STRAIGHT","SUP-ITM-10276229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","801.50","601.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","654.99","81.72","","5157.68","5157.68","5157.68","1 through 10","418.86","654.99","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 64MM 5H STRAIGHT","SUP-ITM-10276229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","801.50","601.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","654.99","81.72","","431.26","71.26","1459.57","88","418.86","654.99","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 77MM 6H STRAIGHT","SUP-ITM-10276228","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.50","632.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","670.58","79.5","","800.18","480.96","1887.97","195","261.49","670.58","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 77MM 6H STRAIGHT","SUP-ITM-10276228","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.50","632.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","449.59","53.3","","813.12","216.42","1444.50","81","261.49","670.58","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 77MM 6H STRAIGHT","SUP-ITM-10276228","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.50","632.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","261.49","31","","432.60","432.60","432.60","1 through 10","261.49","670.58","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 77MM 6H STRAIGHT","SUP-ITM-10276228","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.50","632.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","307.88","36.5","","148.37","54.89","631.39","94","261.49","670.58","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 77MM 6H STRAIGHT","SUP-ITM-10276228","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.50","632.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","323.06","38.3","","279.30","91.72","1116.77","266","261.49","670.58","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 77MM 6H STRAIGHT","SUP-ITM-10276228","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.50","632.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","361.86","42.9","","731.00","63.70","731.00","1 through 10","261.49","670.58","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 77MM 6H STRAIGHT","SUP-ITM-10276228","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.50","632.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","361.86","42.9","","384.74","384.74","384.74","1 through 10","261.49","670.58","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 77MM 6H STRAIGHT","SUP-ITM-10276228","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.50","632.62","WELLPOINT [1015]","HB AMC WELLPOINT","622.33","73.78","","286.63","119.22","1107.45","105","261.49","670.58","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 77MM 6H STRAIGHT","SUP-ITM-10276228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.50","632.62","AETNA [1001]","HB AMC AETNA HMO","588.76","69.8","","675.31","184.75","1721.50","286","440.81","689.31","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 77MM 6H STRAIGHT","SUP-ITM-10276228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.50","632.62","AETNA [1001]","HB AMC AETNA PPO","678.17","80.4","","1261.44","103.12","1514.10","21","440.81","689.31","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 77MM 6H STRAIGHT","SUP-ITM-10276228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.50","632.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","678.17","80.4","","1365.00","1365.00","1365.00","1 through 10","440.81","689.31","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 77MM 6H STRAIGHT","SUP-ITM-10276228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.50","632.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","689.31","81.72","","5157.68","5157.68","5157.68","1 through 10","440.81","689.31","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 77MM 6H STRAIGHT","SUP-ITM-10276228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.50","632.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","689.31","81.72","","431.26","71.26","1459.57","88","440.81","689.31","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 90MM 7H STRAIGHT","SUP-ITM-10276227","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.00","666.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","706.76","79.5","","800.18","480.96","1887.97","195","275.59","706.76","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 90MM 7H STRAIGHT","SUP-ITM-10276227","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.00","666.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","473.84","53.3","","813.12","216.42","1444.50","81","275.59","706.76","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 90MM 7H STRAIGHT","SUP-ITM-10276227","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.00","666.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","275.59","31","","432.60","432.60","432.60","1 through 10","275.59","706.76","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 90MM 7H STRAIGHT","SUP-ITM-10276227","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.00","666.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","324.49","36.5","","148.37","54.89","631.39","94","275.59","706.76","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 90MM 7H STRAIGHT","SUP-ITM-10276227","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.00","666.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","340.49","38.3","","279.30","91.72","1116.77","266","275.59","706.76","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 90MM 7H STRAIGHT","SUP-ITM-10276227","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.00","666.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","381.38","42.9","","731.00","63.70","731.00","1 through 10","275.59","706.76","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 90MM 7H STRAIGHT","SUP-ITM-10276227","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.00","666.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","381.38","42.9","","384.74","384.74","384.74","1 through 10","275.59","706.76","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 90MM 7H STRAIGHT","SUP-ITM-10276227","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.00","666.75","WELLPOINT [1015]","HB AMC WELLPOINT","655.90","73.78","","286.63","119.22","1107.45","105","275.59","706.76","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 90MM 7H STRAIGHT","SUP-ITM-10276227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.00","666.75","AETNA [1001]","HB AMC AETNA HMO","620.52","69.8","","675.31","184.75","1721.50","286","464.59","726.49","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 90MM 7H STRAIGHT","SUP-ITM-10276227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.00","666.75","AETNA [1001]","HB AMC AETNA PPO","714.76","80.4","","1261.44","103.12","1514.10","21","464.59","726.49","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 90MM 7H STRAIGHT","SUP-ITM-10276227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.00","666.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","714.76","80.4","","1365.00","1365.00","1365.00","1 through 10","464.59","726.49","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 90MM 7H STRAIGHT","SUP-ITM-10276227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.00","666.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","726.49","81.72","","5157.68","5157.68","5157.68","1 through 10","464.59","726.49","percent of total billed charges",""
"PLATE COMPRESSION 3.5MM 90MM 7H STRAIGHT","SUP-ITM-10276227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.00","666.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","726.49","81.72","","431.26","71.26","1459.57","88","464.59","726.49","percent of total billed charges",""
"PLATE COMPRESSION 3.5X154MM 10 HOLE FEMORAL PEDILOC BOWED LOCKING","SUP-ITM-10167280","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.50","3781.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4008.79","79.5","","800.18","480.96","1887.97","195","1563.18","4008.79","percent of total billed charges",""
"PLATE COMPRESSION 3.5X154MM 10 HOLE FEMORAL PEDILOC BOWED LOCKING","SUP-ITM-10167280","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.50","3781.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2687.65","53.3","","813.12","216.42","1444.50","81","1563.18","4008.79","percent of total billed charges",""
"PLATE COMPRESSION 3.5X154MM 10 HOLE FEMORAL PEDILOC BOWED LOCKING","SUP-ITM-10167280","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.50","3781.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1563.18","31","","432.60","432.60","432.60","1 through 10","1563.18","4008.79","percent of total billed charges",""
"PLATE COMPRESSION 3.5X154MM 10 HOLE FEMORAL PEDILOC BOWED LOCKING","SUP-ITM-10167280","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.50","3781.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1840.51","36.5","","148.37","54.89","631.39","94","1563.18","4008.79","percent of total billed charges",""
"PLATE COMPRESSION 3.5X154MM 10 HOLE FEMORAL PEDILOC BOWED LOCKING","SUP-ITM-10167280","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.50","3781.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1931.28","38.3","","279.30","91.72","1116.77","266","1563.18","4008.79","percent of total billed charges",""
"PLATE COMPRESSION 3.5X154MM 10 HOLE FEMORAL PEDILOC BOWED LOCKING","SUP-ITM-10167280","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.50","3781.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2163.23","42.9","","731.00","63.70","731.00","1 through 10","1563.18","4008.79","percent of total billed charges",""
"PLATE COMPRESSION 3.5X154MM 10 HOLE FEMORAL PEDILOC BOWED LOCKING","SUP-ITM-10167280","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.50","3781.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2163.23","42.9","","384.74","384.74","384.74","1 through 10","1563.18","4008.79","percent of total billed charges",""
"PLATE COMPRESSION 3.5X154MM 10 HOLE FEMORAL PEDILOC BOWED LOCKING","SUP-ITM-10167280","CDM","C1713","HCPCS","0278","RC","","","","both","","","5042.50","3781.87","WELLPOINT [1015]","HB AMC WELLPOINT","3720.36","73.78","","286.63","119.22","1107.45","105","1563.18","4008.79","percent of total billed charges",""
"PLATE COMPRESSION 3.5X154MM 10 HOLE FEMORAL PEDILOC BOWED LOCKING","SUP-ITM-10167280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5042.50","3781.87","AETNA [1001]","HB AMC AETNA HMO","3519.67","69.8","","675.31","184.75","1721.50","286","2635.21","4120.73","percent of total billed charges",""
"PLATE COMPRESSION 3.5X154MM 10 HOLE FEMORAL PEDILOC BOWED LOCKING","SUP-ITM-10167280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5042.50","3781.87","AETNA [1001]","HB AMC AETNA PPO","4054.17","80.4","","1261.44","103.12","1514.10","21","2635.21","4120.73","percent of total billed charges",""
"PLATE COMPRESSION 3.5X154MM 10 HOLE FEMORAL PEDILOC BOWED LOCKING","SUP-ITM-10167280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5042.50","3781.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4054.17","80.4","","1365.00","1365.00","1365.00","1 through 10","2635.21","4120.73","percent of total billed charges",""
"PLATE COMPRESSION 3.5X154MM 10 HOLE FEMORAL PEDILOC BOWED LOCKING","SUP-ITM-10167280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5042.50","3781.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4120.73","81.72","","5157.68","5157.68","5157.68","1 through 10","2635.21","4120.73","percent of total billed charges",""
"PLATE COMPRESSION 3.5X154MM 10 HOLE FEMORAL PEDILOC BOWED LOCKING","SUP-ITM-10167280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5042.50","3781.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4120.73","81.72","","431.26","71.26","1459.57","88","2635.21","4120.73","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 10 HOLES/L127MM","SUP-ITM-10232560","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.04","2866.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3038.52","79.5","","800.18","480.96","1887.97","195","1184.83","3038.52","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 10 HOLES/L127MM","SUP-ITM-10232560","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.04","2866.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2037.15","53.3","","813.12","216.42","1444.50","81","1184.83","3038.52","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 10 HOLES/L127MM","SUP-ITM-10232560","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.04","2866.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1184.83","31","","432.60","432.60","432.60","1 through 10","1184.83","3038.52","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 10 HOLES/L127MM","SUP-ITM-10232560","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.04","2866.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1395.04","36.5","","148.37","54.89","631.39","94","1184.83","3038.52","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 10 HOLES/L127MM","SUP-ITM-10232560","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.04","2866.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1463.84","38.3","","279.30","91.72","1116.77","266","1184.83","3038.52","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 10 HOLES/L127MM","SUP-ITM-10232560","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.04","2866.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1639.66","42.9","","731.00","63.70","731.00","1 through 10","1184.83","3038.52","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 10 HOLES/L127MM","SUP-ITM-10232560","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.04","2866.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1639.66","42.9","","384.74","384.74","384.74","1 through 10","1184.83","3038.52","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 10 HOLES/L127MM","SUP-ITM-10232560","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.04","2866.53","WELLPOINT [1015]","HB AMC WELLPOINT","2819.90","73.78","","286.63","119.22","1107.45","105","1184.83","3038.52","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 10 HOLES/L127MM","SUP-ITM-10232560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.04","2866.53","AETNA [1001]","HB AMC AETNA HMO","2667.78","69.8","","675.31","184.75","1721.50","286","1997.4","3123.37","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 10 HOLES/L127MM","SUP-ITM-10232560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.04","2866.53","AETNA [1001]","HB AMC AETNA PPO","3072.92","80.4","","1261.44","103.12","1514.10","21","1997.4","3123.37","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 10 HOLES/L127MM","SUP-ITM-10232560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.04","2866.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3072.92","80.4","","1365.00","1365.00","1365.00","1 through 10","1997.4","3123.37","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 10 HOLES/L127MM","SUP-ITM-10232560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.04","2866.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3123.37","81.72","","5157.68","5157.68","5157.68","1 through 10","1997.4","3123.37","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 10 HOLES/L127MM","SUP-ITM-10232560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.04","2866.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3123.37","81.72","","431.26","71.26","1459.57","88","1997.4","3123.37","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 14 HOLES/L175MM","SUP-ITM-10232558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4548.99","3411.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3616.45","79.5","","800.18","480.96","1887.97","195","1410.19","3616.45","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 14 HOLES/L175MM","SUP-ITM-10232558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4548.99","3411.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2424.61","53.3","","813.12","216.42","1444.50","81","1410.19","3616.45","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 14 HOLES/L175MM","SUP-ITM-10232558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4548.99","3411.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1410.19","31","","432.60","432.60","432.60","1 through 10","1410.19","3616.45","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 14 HOLES/L175MM","SUP-ITM-10232558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4548.99","3411.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1660.38","36.5","","148.37","54.89","631.39","94","1410.19","3616.45","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 14 HOLES/L175MM","SUP-ITM-10232558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4548.99","3411.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1742.26","38.3","","279.30","91.72","1116.77","266","1410.19","3616.45","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 14 HOLES/L175MM","SUP-ITM-10232558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4548.99","3411.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.52","42.9","","731.00","63.70","731.00","1 through 10","1410.19","3616.45","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 14 HOLES/L175MM","SUP-ITM-10232558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4548.99","3411.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.52","42.9","","384.74","384.74","384.74","1 through 10","1410.19","3616.45","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 14 HOLES/L175MM","SUP-ITM-10232558","CDM","C1713","HCPCS","0278","RC","","","","both","","","4548.99","3411.74","WELLPOINT [1015]","HB AMC WELLPOINT","3356.24","73.78","","286.63","119.22","1107.45","105","1410.19","3616.45","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 14 HOLES/L175MM","SUP-ITM-10232558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4548.99","3411.74","AETNA [1001]","HB AMC AETNA HMO","3175.20","69.8","","675.31","184.75","1721.50","286","2377.3","3717.43","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 14 HOLES/L175MM","SUP-ITM-10232558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4548.99","3411.74","AETNA [1001]","HB AMC AETNA PPO","3657.39","80.4","","1261.44","103.12","1514.10","21","2377.3","3717.43","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 14 HOLES/L175MM","SUP-ITM-10232558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4548.99","3411.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3657.39","80.4","","1365.00","1365.00","1365.00","1 through 10","2377.3","3717.43","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 14 HOLES/L175MM","SUP-ITM-10232558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4548.99","3411.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3717.43","81.72","","5157.68","5157.68","5157.68","1 through 10","2377.3","3717.43","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 14 HOLES/L175MM","SUP-ITM-10232558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4548.99","3411.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3717.43","81.72","","431.26","71.26","1459.57","88","2377.3","3717.43","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 20 HOLES/L247MM","SUP-ITM-10232555","CDM","C1713","HCPCS","0278","RC","","","","both","","","5392.62","4044.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4287.13","79.5","","800.18","480.96","1887.97","195","1671.71","4287.13","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 20 HOLES/L247MM","SUP-ITM-10232555","CDM","C1713","HCPCS","0278","RC","","","","both","","","5392.62","4044.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2874.27","53.3","","813.12","216.42","1444.50","81","1671.71","4287.13","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 20 HOLES/L247MM","SUP-ITM-10232555","CDM","C1713","HCPCS","0278","RC","","","","both","","","5392.62","4044.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1671.71","31","","432.60","432.60","432.60","1 through 10","1671.71","4287.13","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 20 HOLES/L247MM","SUP-ITM-10232555","CDM","C1713","HCPCS","0278","RC","","","","both","","","5392.62","4044.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1968.31","36.5","","148.37","54.89","631.39","94","1671.71","4287.13","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 20 HOLES/L247MM","SUP-ITM-10232555","CDM","C1713","HCPCS","0278","RC","","","","both","","","5392.62","4044.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2065.37","38.3","","279.30","91.72","1116.77","266","1671.71","4287.13","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 20 HOLES/L247MM","SUP-ITM-10232555","CDM","C1713","HCPCS","0278","RC","","","","both","","","5392.62","4044.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2313.43","42.9","","731.00","63.70","731.00","1 through 10","1671.71","4287.13","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 20 HOLES/L247MM","SUP-ITM-10232555","CDM","C1713","HCPCS","0278","RC","","","","both","","","5392.62","4044.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2313.43","42.9","","384.74","384.74","384.74","1 through 10","1671.71","4287.13","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 20 HOLES/L247MM","SUP-ITM-10232555","CDM","C1713","HCPCS","0278","RC","","","","both","","","5392.62","4044.46","WELLPOINT [1015]","HB AMC WELLPOINT","3978.68","73.78","","286.63","119.22","1107.45","105","1671.71","4287.13","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 20 HOLES/L247MM","SUP-ITM-10232555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5392.62","4044.46","AETNA [1001]","HB AMC AETNA HMO","3764.05","69.8","","675.31","184.75","1721.50","286","2818.18","4406.85","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 20 HOLES/L247MM","SUP-ITM-10232555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5392.62","4044.46","AETNA [1001]","HB AMC AETNA PPO","4335.67","80.4","","1261.44","103.12","1514.10","21","2818.18","4406.85","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 20 HOLES/L247MM","SUP-ITM-10232555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5392.62","4044.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4335.67","80.4","","1365.00","1365.00","1365.00","1 through 10","2818.18","4406.85","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 20 HOLES/L247MM","SUP-ITM-10232555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5392.62","4044.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4406.85","81.72","","5157.68","5157.68","5157.68","1 through 10","2818.18","4406.85","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 20 HOLES/L247MM","SUP-ITM-10232555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5392.62","4044.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4406.85","81.72","","431.26","71.26","1459.57","88","2818.18","4406.85","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 22 HOLES/L271MM","SUP-ITM-10232554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4970.25","3727.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3951.35","79.5","","800.18","480.96","1887.97","195","1540.78","3951.35","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 22 HOLES/L271MM","SUP-ITM-10232554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4970.25","3727.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2649.14","53.3","","813.12","216.42","1444.50","81","1540.78","3951.35","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 22 HOLES/L271MM","SUP-ITM-10232554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4970.25","3727.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1540.78","31","","432.60","432.60","432.60","1 through 10","1540.78","3951.35","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 22 HOLES/L271MM","SUP-ITM-10232554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4970.25","3727.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1814.14","36.5","","148.37","54.89","631.39","94","1540.78","3951.35","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 22 HOLES/L271MM","SUP-ITM-10232554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4970.25","3727.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1903.61","38.3","","279.30","91.72","1116.77","266","1540.78","3951.35","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 22 HOLES/L271MM","SUP-ITM-10232554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4970.25","3727.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2132.24","42.9","","731.00","63.70","731.00","1 through 10","1540.78","3951.35","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 22 HOLES/L271MM","SUP-ITM-10232554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4970.25","3727.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2132.24","42.9","","384.74","384.74","384.74","1 through 10","1540.78","3951.35","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 22 HOLES/L271MM","SUP-ITM-10232554","CDM","C1713","HCPCS","0278","RC","","","","both","","","4970.25","3727.69","WELLPOINT [1015]","HB AMC WELLPOINT","3667.05","73.78","","286.63","119.22","1107.45","105","1540.78","3951.35","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 22 HOLES/L271MM","SUP-ITM-10232554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4970.25","3727.69","AETNA [1001]","HB AMC AETNA HMO","3469.23","69.8","","675.31","184.75","1721.50","286","2597.45","4061.69","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 22 HOLES/L271MM","SUP-ITM-10232554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4970.25","3727.69","AETNA [1001]","HB AMC AETNA PPO","3996.08","80.4","","1261.44","103.12","1514.10","21","2597.45","4061.69","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 22 HOLES/L271MM","SUP-ITM-10232554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4970.25","3727.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3996.08","80.4","","1365.00","1365.00","1365.00","1 through 10","2597.45","4061.69","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 22 HOLES/L271MM","SUP-ITM-10232554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4970.25","3727.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4061.69","81.72","","5157.68","5157.68","5157.68","1 through 10","2597.45","4061.69","percent of total billed charges",""
"PLATE COMPRESSION BROAD STRAIGHT 22 HOLES/L271MM","SUP-ITM-10232554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4970.25","3727.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4061.69","81.72","","431.26","71.26","1459.57","88","2597.45","4061.69","percent of total billed charges",""
"PLATE COMPRESSION LOCKING 6 HOLE / L84 MM 4.0MM 627506","SUP-ITM-10232631","CDM","C1713","HCPCS","0278","RC","","","","both","","","4753.48","3565.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3779.02","79.5","","800.18","480.96","1887.97","195","1473.58","3779.02","percent of total billed charges",""
"PLATE COMPRESSION LOCKING 6 HOLE / L84 MM 4.0MM 627506","SUP-ITM-10232631","CDM","C1713","HCPCS","0278","RC","","","","both","","","4753.48","3565.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2533.60","53.3","","813.12","216.42","1444.50","81","1473.58","3779.02","percent of total billed charges",""
"PLATE COMPRESSION LOCKING 6 HOLE / L84 MM 4.0MM 627506","SUP-ITM-10232631","CDM","C1713","HCPCS","0278","RC","","","","both","","","4753.48","3565.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1473.58","31","","432.60","432.60","432.60","1 through 10","1473.58","3779.02","percent of total billed charges",""
"PLATE COMPRESSION LOCKING 6 HOLE / L84 MM 4.0MM 627506","SUP-ITM-10232631","CDM","C1713","HCPCS","0278","RC","","","","both","","","4753.48","3565.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1735.02","36.5","","148.37","54.89","631.39","94","1473.58","3779.02","percent of total billed charges",""
"PLATE COMPRESSION LOCKING 6 HOLE / L84 MM 4.0MM 627506","SUP-ITM-10232631","CDM","C1713","HCPCS","0278","RC","","","","both","","","4753.48","3565.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1820.58","38.3","","279.30","91.72","1116.77","266","1473.58","3779.02","percent of total billed charges",""
"PLATE COMPRESSION LOCKING 6 HOLE / L84 MM 4.0MM 627506","SUP-ITM-10232631","CDM","C1713","HCPCS","0278","RC","","","","both","","","4753.48","3565.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2039.24","42.9","","731.00","63.70","731.00","1 through 10","1473.58","3779.02","percent of total billed charges",""
"PLATE COMPRESSION LOCKING 6 HOLE / L84 MM 4.0MM 627506","SUP-ITM-10232631","CDM","C1713","HCPCS","0278","RC","","","","both","","","4753.48","3565.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2039.24","42.9","","384.74","384.74","384.74","1 through 10","1473.58","3779.02","percent of total billed charges",""
"PLATE COMPRESSION LOCKING 6 HOLE / L84 MM 4.0MM 627506","SUP-ITM-10232631","CDM","C1713","HCPCS","0278","RC","","","","both","","","4753.48","3565.11","WELLPOINT [1015]","HB AMC WELLPOINT","3507.12","73.78","","286.63","119.22","1107.45","105","1473.58","3779.02","percent of total billed charges",""
"PLATE COMPRESSION LOCKING 6 HOLE / L84 MM 4.0MM 627506","SUP-ITM-10232631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4753.48","3565.11","AETNA [1001]","HB AMC AETNA HMO","3317.93","69.8","","675.31","184.75","1721.50","286","2484.17","3884.54","percent of total billed charges",""
"PLATE COMPRESSION LOCKING 6 HOLE / L84 MM 4.0MM 627506","SUP-ITM-10232631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4753.48","3565.11","AETNA [1001]","HB AMC AETNA PPO","3821.80","80.4","","1261.44","103.12","1514.10","21","2484.17","3884.54","percent of total billed charges",""
"PLATE COMPRESSION LOCKING 6 HOLE / L84 MM 4.0MM 627506","SUP-ITM-10232631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4753.48","3565.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3821.80","80.4","","1365.00","1365.00","1365.00","1 through 10","2484.17","3884.54","percent of total billed charges",""
"PLATE COMPRESSION LOCKING 6 HOLE / L84 MM 4.0MM 627506","SUP-ITM-10232631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4753.48","3565.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3884.54","81.72","","5157.68","5157.68","5157.68","1 through 10","2484.17","3884.54","percent of total billed charges",""
"PLATE COMPRESSION LOCKING 6 HOLE / L84 MM 4.0MM 627506","SUP-ITM-10232631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4753.48","3565.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3884.54","81.72","","431.26","71.26","1459.57","88","2484.17","3884.54","percent of total billed charges",""
"PLATE CONDYLAR 70X200MM 12 HOLE 130DEG DCP ANGLED BLADE SS SHAFT","SUP-ITM-10037784","CDM","C1713","HCPCS","0278","RC","","","","both","","","4030.04","3022.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3203.88","79.5","","800.18","480.96","1887.97","195","1249.31","3203.88","percent of total billed charges",""
"PLATE CONDYLAR 70X200MM 12 HOLE 130DEG DCP ANGLED BLADE SS SHAFT","SUP-ITM-10037784","CDM","C1713","HCPCS","0278","RC","","","","both","","","4030.04","3022.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2148.01","53.3","","813.12","216.42","1444.50","81","1249.31","3203.88","percent of total billed charges",""
"PLATE CONDYLAR 70X200MM 12 HOLE 130DEG DCP ANGLED BLADE SS SHAFT","SUP-ITM-10037784","CDM","C1713","HCPCS","0278","RC","","","","both","","","4030.04","3022.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1249.31","31","","432.60","432.60","432.60","1 through 10","1249.31","3203.88","percent of total billed charges",""
"PLATE CONDYLAR 70X200MM 12 HOLE 130DEG DCP ANGLED BLADE SS SHAFT","SUP-ITM-10037784","CDM","C1713","HCPCS","0278","RC","","","","both","","","4030.04","3022.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1470.96","36.5","","148.37","54.89","631.39","94","1249.31","3203.88","percent of total billed charges",""
"PLATE CONDYLAR 70X200MM 12 HOLE 130DEG DCP ANGLED BLADE SS SHAFT","SUP-ITM-10037784","CDM","C1713","HCPCS","0278","RC","","","","both","","","4030.04","3022.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1543.51","38.3","","279.30","91.72","1116.77","266","1249.31","3203.88","percent of total billed charges",""
"PLATE CONDYLAR 70X200MM 12 HOLE 130DEG DCP ANGLED BLADE SS SHAFT","SUP-ITM-10037784","CDM","C1713","HCPCS","0278","RC","","","","both","","","4030.04","3022.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1728.89","42.9","","731.00","63.70","731.00","1 through 10","1249.31","3203.88","percent of total billed charges",""
"PLATE CONDYLAR 70X200MM 12 HOLE 130DEG DCP ANGLED BLADE SS SHAFT","SUP-ITM-10037784","CDM","C1713","HCPCS","0278","RC","","","","both","","","4030.04","3022.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1728.89","42.9","","384.74","384.74","384.74","1 through 10","1249.31","3203.88","percent of total billed charges",""
"PLATE CONDYLAR 70X200MM 12 HOLE 130DEG DCP ANGLED BLADE SS SHAFT","SUP-ITM-10037784","CDM","C1713","HCPCS","0278","RC","","","","both","","","4030.04","3022.53","WELLPOINT [1015]","HB AMC WELLPOINT","2973.36","73.78","","286.63","119.22","1107.45","105","1249.31","3203.88","percent of total billed charges",""
"PLATE CONDYLAR 70X200MM 12 HOLE 130DEG DCP ANGLED BLADE SS SHAFT","SUP-ITM-10037784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4030.04","3022.53","AETNA [1001]","HB AMC AETNA HMO","2812.97","69.8","","675.31","184.75","1721.50","286","2106.1","3293.35","percent of total billed charges",""
"PLATE CONDYLAR 70X200MM 12 HOLE 130DEG DCP ANGLED BLADE SS SHAFT","SUP-ITM-10037784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4030.04","3022.53","AETNA [1001]","HB AMC AETNA PPO","3240.15","80.4","","1261.44","103.12","1514.10","21","2106.1","3293.35","percent of total billed charges",""
"PLATE CONDYLAR 70X200MM 12 HOLE 130DEG DCP ANGLED BLADE SS SHAFT","SUP-ITM-10037784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4030.04","3022.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3240.15","80.4","","1365.00","1365.00","1365.00","1 through 10","2106.1","3293.35","percent of total billed charges",""
"PLATE CONDYLAR 70X200MM 12 HOLE 130DEG DCP ANGLED BLADE SS SHAFT","SUP-ITM-10037784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4030.04","3022.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3293.35","81.72","","5157.68","5157.68","5157.68","1 through 10","2106.1","3293.35","percent of total billed charges",""
"PLATE CONDYLAR 70X200MM 12 HOLE 130DEG DCP ANGLED BLADE SS SHAFT","SUP-ITM-10037784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4030.04","3022.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3293.35","81.72","","431.26","71.26","1459.57","88","2106.1","3293.35","percent of total billed charges",""
"PLATE CRANIAL .5MM LONG 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077314","CDM","C1889","HCPCS","0278","RC","","","","both","","","653.59","490.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","519.60","79.5","","1309.77","674.56","6049.93","26","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM LONG 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077314","CDM","C1889","HCPCS","0278","RC","","","","both","","","653.59","490.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","348.36","53.3","","1901.83","1901.83","2962.25","1 through 10","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM LONG 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077314","CDM","C1889","HCPCS","0278","RC","","","","both","","","653.59","490.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","238.56","36.5","","1620.31","1620.31","19908.88","1 through 10","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM LONG 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077314","CDM","C1889","HCPCS","0278","RC","","","","both","","","653.59","490.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","250.32","38.3","","352.91","352.91","2046.30","1 through 10","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM LONG 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077314","CDM","C1889","HCPCS","0278","RC","","","","both","","","653.59","490.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.39","42.9","","9668.75","9668.75","9668.75","1 through 10","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM LONG 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077314","CDM","C1889","HCPCS","0278","RC","","","","both","","","653.59","490.19","WELLPOINT [1015]","HB AMC WELLPOINT","482.22","73.78","","699.88","384.10","3443.31","33","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM LONG 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077314","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","653.59","490.19","AETNA [1001]","HB AMC AETNA HMO","456.21","69.8","","1421.24","264.50","4933.46","29","341.57","534.11","percent of total billed charges",""
"PLATE CRANIAL .5MM LONG 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077314","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","653.59","490.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","525.49","80.4","","1022.97","1022.97","3607.50","1 through 10","341.57","534.11","percent of total billed charges",""
"PLATE CRANIAL .5MM LONG 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077314","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","653.59","490.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","534.11","81.72","","3010.54","693.88","5019.88","35","341.57","534.11","percent of total billed charges",""
"PLATE CRANIAL .5MM MED 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077313","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","519.60","79.5","","800.18","480.96","1887.97","195","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM MED 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077313","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","348.36","53.3","","813.12","216.42","1444.50","81","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM MED 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077313","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","202.61","31","","432.60","432.60","432.60","1 through 10","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM MED 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077313","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","238.56","36.5","","148.37","54.89","631.39","94","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM MED 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077313","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","250.32","38.3","","279.30","91.72","1116.77","266","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM MED 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077313","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.39","42.9","","731.00","63.70","731.00","1 through 10","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM MED 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077313","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.39","42.9","","384.74","384.74","384.74","1 through 10","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM MED 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077313","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","WELLPOINT [1015]","HB AMC WELLPOINT","482.22","73.78","","286.63","119.22","1107.45","105","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM MED 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.59","490.19","AETNA [1001]","HB AMC AETNA HMO","456.21","69.8","","675.31","184.75","1721.50","286","341.57","534.11","percent of total billed charges",""
"PLATE CRANIAL .5MM MED 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.59","490.19","AETNA [1001]","HB AMC AETNA PPO","525.49","80.4","","1261.44","103.12","1514.10","21","341.57","534.11","percent of total billed charges",""
"PLATE CRANIAL .5MM MED 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.59","490.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","525.49","80.4","","1365.00","1365.00","1365.00","1 through 10","341.57","534.11","percent of total billed charges",""
"PLATE CRANIAL .5MM MED 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.59","490.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","534.11","81.72","","5157.68","5157.68","5157.68","1 through 10","341.57","534.11","percent of total billed charges",""
"PLATE CRANIAL .5MM MED 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.59","490.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","534.11","81.72","","431.26","71.26","1459.57","88","341.57","534.11","percent of total billed charges",""
"PLATE CRANIAL .5MM SHORT 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077312","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","519.60","79.5","","800.18","480.96","1887.97","195","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM SHORT 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077312","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","348.36","53.3","","813.12","216.42","1444.50","81","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM SHORT 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077312","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","202.61","31","","432.60","432.60","432.60","1 through 10","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM SHORT 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077312","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","238.56","36.5","","148.37","54.89","631.39","94","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM SHORT 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077312","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","250.32","38.3","","279.30","91.72","1116.77","266","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM SHORT 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077312","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.39","42.9","","731.00","63.70","731.00","1 through 10","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM SHORT 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077312","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.39","42.9","","384.74","384.74","384.74","1 through 10","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM SHORT 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077312","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.59","490.19","WELLPOINT [1015]","HB AMC WELLPOINT","482.22","73.78","","286.63","119.22","1107.45","105","202.61","519.6","percent of total billed charges",""
"PLATE CRANIAL .5MM SHORT 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.59","490.19","AETNA [1001]","HB AMC AETNA HMO","456.21","69.8","","675.31","184.75","1721.50","286","341.57","534.11","percent of total billed charges",""
"PLATE CRANIAL .5MM SHORT 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.59","490.19","AETNA [1001]","HB AMC AETNA PPO","525.49","80.4","","1261.44","103.12","1514.10","21","341.57","534.11","percent of total billed charges",""
"PLATE CRANIAL .5MM SHORT 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.59","490.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","525.49","80.4","","1365.00","1365.00","1365.00","1 through 10","341.57","534.11","percent of total billed charges",""
"PLATE CRANIAL .5MM SHORT 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.59","490.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","534.11","81.72","","5157.68","5157.68","5157.68","1 through 10","341.57","534.11","percent of total billed charges",""
"PLATE CRANIAL .5MM SHORT 3X3 HOLE MATRIXORTHOGNATHIC TITANIUM L ANATOMIC REVERSIBLE","SUP-ITM-10077312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.59","490.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","534.11","81.72","","431.26","71.26","1459.57","88","341.57","534.11","percent of total billed charges",""
"PLATE CRANIAL .7X4MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077368","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","471.83","79.5","","800.18","480.96","1887.97","195","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X4MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077368","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","316.34","53.3","","813.12","216.42","1444.50","81","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X4MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077368","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","183.99","31","","432.60","432.60","432.60","1 through 10","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X4MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077368","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","216.63","36.5","","148.37","54.89","631.39","94","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X4MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077368","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","227.31","38.3","","279.30","91.72","1116.77","266","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X4MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077368","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","254.61","42.9","","731.00","63.70","731.00","1 through 10","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X4MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077368","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","254.61","42.9","","384.74","384.74","384.74","1 through 10","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X4MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077368","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","WELLPOINT [1015]","HB AMC WELLPOINT","437.88","73.78","","286.63","119.22","1107.45","105","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X4MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077368","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.50","445.12","AETNA [1001]","HB AMC AETNA HMO","414.26","69.8","","675.31","184.75","1721.50","286","310.16","485.01","percent of total billed charges",""
"PLATE CRANIAL .7X4MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077368","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.50","445.12","AETNA [1001]","HB AMC AETNA PPO","477.17","80.4","","1261.44","103.12","1514.10","21","310.16","485.01","percent of total billed charges",""
"PLATE CRANIAL .7X4MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077368","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.50","445.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","477.17","80.4","","1365.00","1365.00","1365.00","1 through 10","310.16","485.01","percent of total billed charges",""
"PLATE CRANIAL .7X4MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077368","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.50","445.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","485.01","81.72","","5157.68","5157.68","5157.68","1 through 10","310.16","485.01","percent of total billed charges",""
"PLATE CRANIAL .7X4MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077368","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.50","445.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","485.01","81.72","","431.26","71.26","1459.57","88","310.16","485.01","percent of total billed charges",""
"PLATE CRANIAL .7X6MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077369","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","471.83","79.5","","800.18","480.96","1887.97","195","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X6MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077369","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","316.34","53.3","","813.12","216.42","1444.50","81","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X6MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077369","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","183.99","31","","432.60","432.60","432.60","1 through 10","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X6MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077369","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","216.63","36.5","","148.37","54.89","631.39","94","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X6MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077369","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","227.31","38.3","","279.30","91.72","1116.77","266","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X6MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077369","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","254.61","42.9","","731.00","63.70","731.00","1 through 10","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X6MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077369","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","254.61","42.9","","384.74","384.74","384.74","1 through 10","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X6MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077369","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.50","445.12","WELLPOINT [1015]","HB AMC WELLPOINT","437.88","73.78","","286.63","119.22","1107.45","105","183.99","471.83","percent of total billed charges",""
"PLATE CRANIAL .7X6MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.50","445.12","AETNA [1001]","HB AMC AETNA HMO","414.26","69.8","","675.31","184.75","1721.50","286","310.16","485.01","percent of total billed charges",""
"PLATE CRANIAL .7X6MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.50","445.12","AETNA [1001]","HB AMC AETNA PPO","477.17","80.4","","1261.44","103.12","1514.10","21","310.16","485.01","percent of total billed charges",""
"PLATE CRANIAL .7X6MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.50","445.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","477.17","80.4","","1365.00","1365.00","1365.00","1 through 10","310.16","485.01","percent of total billed charges",""
"PLATE CRANIAL .7X6MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.50","445.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","485.01","81.72","","5157.68","5157.68","5157.68","1 through 10","310.16","485.01","percent of total billed charges",""
"PLATE CRANIAL .7X6MM 5 HOLE MATRIXORTHOGNATHIC TITANIUM DOUBLE CURVE CHIN","SUP-ITM-10077369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.50","445.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","485.01","81.72","","431.26","71.26","1459.57","88","310.16","485.01","percent of total billed charges",""
"PLATE CRANIAL .8X2MM MATRIXORTHOGNATHIC TITANIUM PREBENT RIGHT MAXILLARY","SUP-ITM-10077325","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","800.22","79.5","","800.18","480.96","1887.97","195","312.04","800.22","percent of total billed charges",""
"PLATE CRANIAL .8X2MM MATRIXORTHOGNATHIC TITANIUM PREBENT RIGHT MAXILLARY","SUP-ITM-10077325","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","536.50","53.3","","813.12","216.42","1444.50","81","312.04","800.22","percent of total billed charges",""
"PLATE CRANIAL .8X2MM MATRIXORTHOGNATHIC TITANIUM PREBENT RIGHT MAXILLARY","SUP-ITM-10077325","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","312.04","31","","432.60","432.60","432.60","1 through 10","312.04","800.22","percent of total billed charges",""
"PLATE CRANIAL .8X2MM MATRIXORTHOGNATHIC TITANIUM PREBENT RIGHT MAXILLARY","SUP-ITM-10077325","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","367.40","36.5","","148.37","54.89","631.39","94","312.04","800.22","percent of total billed charges",""
"PLATE CRANIAL .8X2MM MATRIXORTHOGNATHIC TITANIUM PREBENT RIGHT MAXILLARY","SUP-ITM-10077325","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","385.52","38.3","","279.30","91.72","1116.77","266","312.04","800.22","percent of total billed charges",""
"PLATE CRANIAL .8X2MM MATRIXORTHOGNATHIC TITANIUM PREBENT RIGHT MAXILLARY","SUP-ITM-10077325","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","431.82","42.9","","731.00","63.70","731.00","1 through 10","312.04","800.22","percent of total billed charges",""
"PLATE CRANIAL .8X2MM MATRIXORTHOGNATHIC TITANIUM PREBENT RIGHT MAXILLARY","SUP-ITM-10077325","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","431.82","42.9","","384.74","384.74","384.74","1 through 10","312.04","800.22","percent of total billed charges",""
"PLATE CRANIAL .8X2MM MATRIXORTHOGNATHIC TITANIUM PREBENT RIGHT MAXILLARY","SUP-ITM-10077325","CDM","C1713","HCPCS","0278","RC","","","","both","","","1006.57","754.93","WELLPOINT [1015]","HB AMC WELLPOINT","742.65","73.78","","286.63","119.22","1107.45","105","312.04","800.22","percent of total billed charges",""
"PLATE CRANIAL .8X2MM MATRIXORTHOGNATHIC TITANIUM PREBENT RIGHT MAXILLARY","SUP-ITM-10077325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1006.57","754.93","AETNA [1001]","HB AMC AETNA HMO","702.59","69.8","","675.31","184.75","1721.50","286","526.03","822.57","percent of total billed charges",""
"PLATE CRANIAL .8X2MM MATRIXORTHOGNATHIC TITANIUM PREBENT RIGHT MAXILLARY","SUP-ITM-10077325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1006.57","754.93","AETNA [1001]","HB AMC AETNA PPO","809.28","80.4","","1261.44","103.12","1514.10","21","526.03","822.57","percent of total billed charges",""
"PLATE CRANIAL .8X2MM MATRIXORTHOGNATHIC TITANIUM PREBENT RIGHT MAXILLARY","SUP-ITM-10077325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1006.57","754.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","809.28","80.4","","1365.00","1365.00","1365.00","1 through 10","526.03","822.57","percent of total billed charges",""
"PLATE CRANIAL .8X2MM MATRIXORTHOGNATHIC TITANIUM PREBENT RIGHT MAXILLARY","SUP-ITM-10077325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1006.57","754.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","822.57","81.72","","5157.68","5157.68","5157.68","1 through 10","526.03","822.57","percent of total billed charges",""
"PLATE CRANIAL .8X2MM MATRIXORTHOGNATHIC TITANIUM PREBENT RIGHT MAXILLARY","SUP-ITM-10077325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1006.57","754.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","822.57","81.72","","431.26","71.26","1459.57","88","526.03","822.57","percent of total billed charges",""
"PLATE CRANIAL 2.4X25X25MM 3 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004322","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.62","1520.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1611.96","79.5","","800.18","480.96","1887.97","195","628.56","1611.96","percent of total billed charges",""
"PLATE CRANIAL 2.4X25X25MM 3 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004322","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.62","1520.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1080.72","53.3","","813.12","216.42","1444.50","81","628.56","1611.96","percent of total billed charges",""
"PLATE CRANIAL 2.4X25X25MM 3 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004322","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.62","1520.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","628.56","31","","432.60","432.60","432.60","1 through 10","628.56","1611.96","percent of total billed charges",""
"PLATE CRANIAL 2.4X25X25MM 3 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004322","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.62","1520.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","740.08","36.5","","148.37","54.89","631.39","94","628.56","1611.96","percent of total billed charges",""
"PLATE CRANIAL 2.4X25X25MM 3 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004322","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.62","1520.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","776.58","38.3","","279.30","91.72","1116.77","266","628.56","1611.96","percent of total billed charges",""
"PLATE CRANIAL 2.4X25X25MM 3 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004322","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.62","1520.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","869.85","42.9","","731.00","63.70","731.00","1 through 10","628.56","1611.96","percent of total billed charges",""
"PLATE CRANIAL 2.4X25X25MM 3 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004322","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.62","1520.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","869.85","42.9","","384.74","384.74","384.74","1 through 10","628.56","1611.96","percent of total billed charges",""
"PLATE CRANIAL 2.4X25X25MM 3 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004322","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.62","1520.71","WELLPOINT [1015]","HB AMC WELLPOINT","1495.98","73.78","","286.63","119.22","1107.45","105","628.56","1611.96","percent of total billed charges",""
"PLATE CRANIAL 2.4X25X25MM 3 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.62","1520.71","AETNA [1001]","HB AMC AETNA HMO","1415.28","69.8","","675.31","184.75","1721.50","286","1059.63","1656.97","percent of total billed charges",""
"PLATE CRANIAL 2.4X25X25MM 3 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.62","1520.71","AETNA [1001]","HB AMC AETNA PPO","1630.21","80.4","","1261.44","103.12","1514.10","21","1059.63","1656.97","percent of total billed charges",""
"PLATE CRANIAL 2.4X25X25MM 3 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.62","1520.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1630.21","80.4","","1365.00","1365.00","1365.00","1 through 10","1059.63","1656.97","percent of total billed charges",""
"PLATE CRANIAL 2.4X25X25MM 3 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.62","1520.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1656.97","81.72","","5157.68","5157.68","5157.68","1 through 10","1059.63","1656.97","percent of total billed charges",""
"PLATE CRANIAL 2.4X25X25MM 3 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.62","1520.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1656.97","81.72","","431.26","71.26","1459.57","88","1059.63","1656.97","percent of total billed charges",""
"PLATE CRANIAL 2.4X32MM 4 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.40","1640.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1738.98","79.5","","800.18","480.96","1887.97","195","678.09","1738.98","percent of total billed charges",""
"PLATE CRANIAL 2.4X32MM 4 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.40","1640.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1165.88","53.3","","813.12","216.42","1444.50","81","678.09","1738.98","percent of total billed charges",""
"PLATE CRANIAL 2.4X32MM 4 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.40","1640.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","678.09","31","","432.60","432.60","432.60","1 through 10","678.09","1738.98","percent of total billed charges",""
"PLATE CRANIAL 2.4X32MM 4 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.40","1640.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","798.40","36.5","","148.37","54.89","631.39","94","678.09","1738.98","percent of total billed charges",""
"PLATE CRANIAL 2.4X32MM 4 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.40","1640.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","837.77","38.3","","279.30","91.72","1116.77","266","678.09","1738.98","percent of total billed charges",""
"PLATE CRANIAL 2.4X32MM 4 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.40","1640.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","938.39","42.9","","731.00","63.70","731.00","1 through 10","678.09","1738.98","percent of total billed charges",""
"PLATE CRANIAL 2.4X32MM 4 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.40","1640.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","938.39","42.9","","384.74","384.74","384.74","1 through 10","678.09","1738.98","percent of total billed charges",""
"PLATE CRANIAL 2.4X32MM 4 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004323","CDM","C1713","HCPCS","0278","RC","","","","both","","","2187.40","1640.55","WELLPOINT [1015]","HB AMC WELLPOINT","1613.86","73.78","","286.63","119.22","1107.45","105","678.09","1738.98","percent of total billed charges",""
"PLATE CRANIAL 2.4X32MM 4 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2187.40","1640.55","AETNA [1001]","HB AMC AETNA HMO","1526.81","69.8","","675.31","184.75","1721.50","286","1143.14","1787.54","percent of total billed charges",""
"PLATE CRANIAL 2.4X32MM 4 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2187.40","1640.55","AETNA [1001]","HB AMC AETNA PPO","1758.67","80.4","","1261.44","103.12","1514.10","21","1143.14","1787.54","percent of total billed charges",""
"PLATE CRANIAL 2.4X32MM 4 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2187.40","1640.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1758.67","80.4","","1365.00","1365.00","1365.00","1 through 10","1143.14","1787.54","percent of total billed charges",""
"PLATE CRANIAL 2.4X32MM 4 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2187.40","1640.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1787.54","81.72","","5157.68","5157.68","5157.68","1 through 10","1143.14","1787.54","percent of total billed charges",""
"PLATE CRANIAL 2.4X32MM 4 HOLE UNIVERSAL MANDIBULAR FRACTURE ANGLED","SUP-ITM-10004323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2187.40","1640.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1787.54","81.72","","431.26","71.26","1459.57","88","1143.14","1787.54","percent of total billed charges",""
"PLATE CRANIAL 2.4X80MM 10 HOLE UNIVERSAL TITANIUM FRACTURE STRAIGHT","SUP-ITM-10004321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.50","973.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1032.31","79.5","","800.18","480.96","1887.97","195","402.54","1032.31","percent of total billed charges",""
"PLATE CRANIAL 2.4X80MM 10 HOLE UNIVERSAL TITANIUM FRACTURE STRAIGHT","SUP-ITM-10004321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.50","973.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","692.10","53.3","","813.12","216.42","1444.50","81","402.54","1032.31","percent of total billed charges",""
"PLATE CRANIAL 2.4X80MM 10 HOLE UNIVERSAL TITANIUM FRACTURE STRAIGHT","SUP-ITM-10004321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.50","973.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","402.54","31","","432.60","432.60","432.60","1 through 10","402.54","1032.31","percent of total billed charges",""
"PLATE CRANIAL 2.4X80MM 10 HOLE UNIVERSAL TITANIUM FRACTURE STRAIGHT","SUP-ITM-10004321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.50","973.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","473.95","36.5","","148.37","54.89","631.39","94","402.54","1032.31","percent of total billed charges",""
"PLATE CRANIAL 2.4X80MM 10 HOLE UNIVERSAL TITANIUM FRACTURE STRAIGHT","SUP-ITM-10004321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.50","973.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","497.33","38.3","","279.30","91.72","1116.77","266","402.54","1032.31","percent of total billed charges",""
"PLATE CRANIAL 2.4X80MM 10 HOLE UNIVERSAL TITANIUM FRACTURE STRAIGHT","SUP-ITM-10004321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.50","973.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","557.06","42.9","","731.00","63.70","731.00","1 through 10","402.54","1032.31","percent of total billed charges",""
"PLATE CRANIAL 2.4X80MM 10 HOLE UNIVERSAL TITANIUM FRACTURE STRAIGHT","SUP-ITM-10004321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.50","973.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","557.06","42.9","","384.74","384.74","384.74","1 through 10","402.54","1032.31","percent of total billed charges",""
"PLATE CRANIAL 2.4X80MM 10 HOLE UNIVERSAL TITANIUM FRACTURE STRAIGHT","SUP-ITM-10004321","CDM","C1713","HCPCS","0278","RC","","","","both","","","1298.50","973.87","WELLPOINT [1015]","HB AMC WELLPOINT","958.03","73.78","","286.63","119.22","1107.45","105","402.54","1032.31","percent of total billed charges",""
"PLATE CRANIAL 2.4X80MM 10 HOLE UNIVERSAL TITANIUM FRACTURE STRAIGHT","SUP-ITM-10004321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1298.50","973.87","AETNA [1001]","HB AMC AETNA HMO","906.35","69.8","","675.31","184.75","1721.50","286","678.6","1061.13","percent of total billed charges",""
"PLATE CRANIAL 2.4X80MM 10 HOLE UNIVERSAL TITANIUM FRACTURE STRAIGHT","SUP-ITM-10004321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1298.50","973.87","AETNA [1001]","HB AMC AETNA PPO","1043.99","80.4","","1261.44","103.12","1514.10","21","678.6","1061.13","percent of total billed charges",""
"PLATE CRANIAL 2.4X80MM 10 HOLE UNIVERSAL TITANIUM FRACTURE STRAIGHT","SUP-ITM-10004321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1298.50","973.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1043.99","80.4","","1365.00","1365.00","1365.00","1 through 10","678.6","1061.13","percent of total billed charges",""
"PLATE CRANIAL 2.4X80MM 10 HOLE UNIVERSAL TITANIUM FRACTURE STRAIGHT","SUP-ITM-10004321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1298.50","973.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1061.13","81.72","","5157.68","5157.68","5157.68","1 through 10","678.6","1061.13","percent of total billed charges",""
"PLATE CRANIAL 2.4X80MM 10 HOLE UNIVERSAL TITANIUM FRACTURE STRAIGHT","SUP-ITM-10004321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1298.50","973.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1061.13","81.72","","431.26","71.26","1459.57","88","678.6","1061.13","percent of total billed charges",""
"PLATE CRANIAL 38X45MM TITANIUM LOW PROFILE MESH CONTOURABLE MALLEABLE","SUP-ITM-10014617","CDM","C1713","HCPCS","0278","RC","","","","both","","","3236.07","2427.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2572.68","79.5","","800.18","480.96","1887.97","195","1003.18","2572.68","percent of total billed charges",""
"PLATE CRANIAL 38X45MM TITANIUM LOW PROFILE MESH CONTOURABLE MALLEABLE","SUP-ITM-10014617","CDM","C1713","HCPCS","0278","RC","","","","both","","","3236.07","2427.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1724.83","53.3","","813.12","216.42","1444.50","81","1003.18","2572.68","percent of total billed charges",""
"PLATE CRANIAL 38X45MM TITANIUM LOW PROFILE MESH CONTOURABLE MALLEABLE","SUP-ITM-10014617","CDM","C1713","HCPCS","0278","RC","","","","both","","","3236.07","2427.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1003.18","31","","432.60","432.60","432.60","1 through 10","1003.18","2572.68","percent of total billed charges",""
"PLATE CRANIAL 38X45MM TITANIUM LOW PROFILE MESH CONTOURABLE MALLEABLE","SUP-ITM-10014617","CDM","C1713","HCPCS","0278","RC","","","","both","","","3236.07","2427.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1181.17","36.5","","148.37","54.89","631.39","94","1003.18","2572.68","percent of total billed charges",""
"PLATE CRANIAL 38X45MM TITANIUM LOW PROFILE MESH CONTOURABLE MALLEABLE","SUP-ITM-10014617","CDM","C1713","HCPCS","0278","RC","","","","both","","","3236.07","2427.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1239.41","38.3","","279.30","91.72","1116.77","266","1003.18","2572.68","percent of total billed charges",""
"PLATE CRANIAL 38X45MM TITANIUM LOW PROFILE MESH CONTOURABLE MALLEABLE","SUP-ITM-10014617","CDM","C1713","HCPCS","0278","RC","","","","both","","","3236.07","2427.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1388.27","42.9","","731.00","63.70","731.00","1 through 10","1003.18","2572.68","percent of total billed charges",""
"PLATE CRANIAL 38X45MM TITANIUM LOW PROFILE MESH CONTOURABLE MALLEABLE","SUP-ITM-10014617","CDM","C1713","HCPCS","0278","RC","","","","both","","","3236.07","2427.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1388.27","42.9","","384.74","384.74","384.74","1 through 10","1003.18","2572.68","percent of total billed charges",""
"PLATE CRANIAL 38X45MM TITANIUM LOW PROFILE MESH CONTOURABLE MALLEABLE","SUP-ITM-10014617","CDM","C1713","HCPCS","0278","RC","","","","both","","","3236.07","2427.05","WELLPOINT [1015]","HB AMC WELLPOINT","2387.57","73.78","","286.63","119.22","1107.45","105","1003.18","2572.68","percent of total billed charges",""
"PLATE CRANIAL 38X45MM TITANIUM LOW PROFILE MESH CONTOURABLE MALLEABLE","SUP-ITM-10014617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3236.07","2427.05","AETNA [1001]","HB AMC AETNA HMO","2258.78","69.8","","675.31","184.75","1721.50","286","1691.17","2644.52","percent of total billed charges",""
"PLATE CRANIAL 38X45MM TITANIUM LOW PROFILE MESH CONTOURABLE MALLEABLE","SUP-ITM-10014617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3236.07","2427.05","AETNA [1001]","HB AMC AETNA PPO","2601.80","80.4","","1261.44","103.12","1514.10","21","1691.17","2644.52","percent of total billed charges",""
"PLATE CRANIAL 38X45MM TITANIUM LOW PROFILE MESH CONTOURABLE MALLEABLE","SUP-ITM-10014617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3236.07","2427.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2601.80","80.4","","1365.00","1365.00","1365.00","1 through 10","1691.17","2644.52","percent of total billed charges",""
"PLATE CRANIAL 38X45MM TITANIUM LOW PROFILE MESH CONTOURABLE MALLEABLE","SUP-ITM-10014617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3236.07","2427.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2644.52","81.72","","5157.68","5157.68","5157.68","1 through 10","1691.17","2644.52","percent of total billed charges",""
"PLATE CRANIAL 38X45MM TITANIUM LOW PROFILE MESH CONTOURABLE MALLEABLE","SUP-ITM-10014617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3236.07","2427.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2644.52","81.72","","431.26","71.26","1459.57","88","1691.17","2644.52","percent of total billed charges",""
"PLATE CRANIAL SM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM ARC","SUP-ITM-10014272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1859.13","1394.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1478.01","79.5","","800.18","480.96","1887.97","195","576.33","1478.01","percent of total billed charges",""
"PLATE CRANIAL SM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM ARC","SUP-ITM-10014272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1859.13","1394.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","990.92","53.3","","813.12","216.42","1444.50","81","576.33","1478.01","percent of total billed charges",""
"PLATE CRANIAL SM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM ARC","SUP-ITM-10014272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1859.13","1394.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","576.33","31","","432.60","432.60","432.60","1 through 10","576.33","1478.01","percent of total billed charges",""
"PLATE CRANIAL SM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM ARC","SUP-ITM-10014272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1859.13","1394.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","678.58","36.5","","148.37","54.89","631.39","94","576.33","1478.01","percent of total billed charges",""
"PLATE CRANIAL SM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM ARC","SUP-ITM-10014272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1859.13","1394.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","712.05","38.3","","279.30","91.72","1116.77","266","576.33","1478.01","percent of total billed charges",""
"PLATE CRANIAL SM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM ARC","SUP-ITM-10014272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1859.13","1394.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","797.57","42.9","","731.00","63.70","731.00","1 through 10","576.33","1478.01","percent of total billed charges",""
"PLATE CRANIAL SM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM ARC","SUP-ITM-10014272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1859.13","1394.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","797.57","42.9","","384.74","384.74","384.74","1 through 10","576.33","1478.01","percent of total billed charges",""
"PLATE CRANIAL SM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM ARC","SUP-ITM-10014272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1859.13","1394.35","WELLPOINT [1015]","HB AMC WELLPOINT","1371.67","73.78","","286.63","119.22","1107.45","105","576.33","1478.01","percent of total billed charges",""
"PLATE CRANIAL SM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM ARC","SUP-ITM-10014272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1859.13","1394.35","AETNA [1001]","HB AMC AETNA HMO","1297.67","69.8","","675.31","184.75","1721.50","286","971.58","1519.28","percent of total billed charges",""
"PLATE CRANIAL SM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM ARC","SUP-ITM-10014272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1859.13","1394.35","AETNA [1001]","HB AMC AETNA PPO","1494.74","80.4","","1261.44","103.12","1514.10","21","971.58","1519.28","percent of total billed charges",""
"PLATE CRANIAL SM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM ARC","SUP-ITM-10014272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1859.13","1394.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1494.74","80.4","","1365.00","1365.00","1365.00","1 through 10","971.58","1519.28","percent of total billed charges",""
"PLATE CRANIAL SM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM ARC","SUP-ITM-10014272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1859.13","1394.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1519.28","81.72","","5157.68","5157.68","5157.68","1 through 10","971.58","1519.28","percent of total billed charges",""
"PLATE CRANIAL SM MESH NEUROLOGICAL LOW PROFILE CONTOURABLE RIGID TITANIUM ARC","SUP-ITM-10014272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1859.13","1394.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1519.28","81.72","","431.26","71.26","1459.57","88","971.58","1519.28","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MATRIXMIDFACE TITANIUM MESH ORBITAL FLOOR","SUP-ITM-10100462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.37","2167.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2297.84","79.5","","800.18","480.96","1887.97","195","896.01","2297.84","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MATRIXMIDFACE TITANIUM MESH ORBITAL FLOOR","SUP-ITM-10100462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.37","2167.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1540.57","53.3","","813.12","216.42","1444.50","81","896.01","2297.84","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MATRIXMIDFACE TITANIUM MESH ORBITAL FLOOR","SUP-ITM-10100462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.37","2167.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","896.01","31","","432.60","432.60","432.60","1 through 10","896.01","2297.84","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MATRIXMIDFACE TITANIUM MESH ORBITAL FLOOR","SUP-ITM-10100462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.37","2167.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1054.99","36.5","","148.37","54.89","631.39","94","896.01","2297.84","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MATRIXMIDFACE TITANIUM MESH ORBITAL FLOOR","SUP-ITM-10100462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.37","2167.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1107.01","38.3","","279.30","91.72","1116.77","266","896.01","2297.84","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MATRIXMIDFACE TITANIUM MESH ORBITAL FLOOR","SUP-ITM-10100462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.37","2167.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1239.97","42.9","","731.00","63.70","731.00","1 through 10","896.01","2297.84","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MATRIXMIDFACE TITANIUM MESH ORBITAL FLOOR","SUP-ITM-10100462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.37","2167.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1239.97","42.9","","384.74","384.74","384.74","1 through 10","896.01","2297.84","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MATRIXMIDFACE TITANIUM MESH ORBITAL FLOOR","SUP-ITM-10100462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.37","2167.78","WELLPOINT [1015]","HB AMC WELLPOINT","2132.51","73.78","","286.63","119.22","1107.45","105","896.01","2297.84","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MATRIXMIDFACE TITANIUM MESH ORBITAL FLOOR","SUP-ITM-10100462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2890.37","2167.78","AETNA [1001]","HB AMC AETNA HMO","2017.48","69.8","","675.31","184.75","1721.50","286","1510.51","2362.01","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MATRIXMIDFACE TITANIUM MESH ORBITAL FLOOR","SUP-ITM-10100462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2890.37","2167.78","AETNA [1001]","HB AMC AETNA PPO","2323.86","80.4","","1261.44","103.12","1514.10","21","1510.51","2362.01","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MATRIXMIDFACE TITANIUM MESH ORBITAL FLOOR","SUP-ITM-10100462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2890.37","2167.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2323.86","80.4","","1365.00","1365.00","1365.00","1 through 10","1510.51","2362.01","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MATRIXMIDFACE TITANIUM MESH ORBITAL FLOOR","SUP-ITM-10100462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2890.37","2167.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2362.01","81.72","","5157.68","5157.68","5157.68","1 through 10","1510.51","2362.01","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MATRIXMIDFACE TITANIUM MESH ORBITAL FLOOR","SUP-ITM-10100462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2890.37","2167.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2362.01","81.72","","431.26","71.26","1459.57","88","1510.51","2362.01","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MED MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE TEMPORAL SILVER","SUP-ITM-10076540","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.79","589.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","624.70","79.5","","800.18","480.96","1887.97","195","243.59","624.7","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MED MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE TEMPORAL SILVER","SUP-ITM-10076540","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.79","589.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","418.83","53.3","","813.12","216.42","1444.50","81","243.59","624.7","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MED MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE TEMPORAL SILVER","SUP-ITM-10076540","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.79","589.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","243.59","31","","432.60","432.60","432.60","1 through 10","243.59","624.7","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MED MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE TEMPORAL SILVER","SUP-ITM-10076540","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.79","589.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","286.81","36.5","","148.37","54.89","631.39","94","243.59","624.7","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MED MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE TEMPORAL SILVER","SUP-ITM-10076540","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.79","589.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","300.96","38.3","","279.30","91.72","1116.77","266","243.59","624.7","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MED MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE TEMPORAL SILVER","SUP-ITM-10076540","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.79","589.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.10","42.9","","731.00","63.70","731.00","1 through 10","243.59","624.7","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MED MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE TEMPORAL SILVER","SUP-ITM-10076540","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.79","589.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.10","42.9","","384.74","384.74","384.74","1 through 10","243.59","624.7","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MED MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE TEMPORAL SILVER","SUP-ITM-10076540","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.79","589.34","WELLPOINT [1015]","HB AMC WELLPOINT","579.76","73.78","","286.63","119.22","1107.45","105","243.59","624.7","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MED MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE TEMPORAL SILVER","SUP-ITM-10076540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","785.79","589.34","AETNA [1001]","HB AMC AETNA HMO","548.48","69.8","","675.31","184.75","1721.50","286","410.65","642.15","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MED MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE TEMPORAL SILVER","SUP-ITM-10076540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","785.79","589.34","AETNA [1001]","HB AMC AETNA PPO","631.78","80.4","","1261.44","103.12","1514.10","21","410.65","642.15","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MED MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE TEMPORAL SILVER","SUP-ITM-10076540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","785.79","589.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","631.78","80.4","","1365.00","1365.00","1365.00","1 through 10","410.65","642.15","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MED MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE TEMPORAL SILVER","SUP-ITM-10076540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","785.79","589.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","642.15","81.72","","5157.68","5157.68","5157.68","1 through 10","410.65","642.15","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4MM MED MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE TEMPORAL SILVER","SUP-ITM-10076540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","785.79","589.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","642.15","81.72","","431.26","71.26","1459.57","88","410.65","642.15","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4X100X100MM TITANIUM MESH CONTOURABLE","SUP-ITM-10075895","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.16","3122.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3309.71","79.5","","800.18","480.96","1887.97","195","1290.58","3309.71","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4X100X100MM TITANIUM MESH CONTOURABLE","SUP-ITM-10075895","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.16","3122.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2218.96","53.3","","813.12","216.42","1444.50","81","1290.58","3309.71","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4X100X100MM TITANIUM MESH CONTOURABLE","SUP-ITM-10075895","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.16","3122.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1290.58","31","","432.60","432.60","432.60","1 through 10","1290.58","3309.71","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4X100X100MM TITANIUM MESH CONTOURABLE","SUP-ITM-10075895","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.16","3122.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1519.55","36.5","","148.37","54.89","631.39","94","1290.58","3309.71","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4X100X100MM TITANIUM MESH CONTOURABLE","SUP-ITM-10075895","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.16","3122.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1594.49","38.3","","279.30","91.72","1116.77","266","1290.58","3309.71","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4X100X100MM TITANIUM MESH CONTOURABLE","SUP-ITM-10075895","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.16","3122.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1786.00","42.9","","731.00","63.70","731.00","1 through 10","1290.58","3309.71","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4X100X100MM TITANIUM MESH CONTOURABLE","SUP-ITM-10075895","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.16","3122.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1786.00","42.9","","384.74","384.74","384.74","1 through 10","1290.58","3309.71","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4X100X100MM TITANIUM MESH CONTOURABLE","SUP-ITM-10075895","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.16","3122.37","WELLPOINT [1015]","HB AMC WELLPOINT","3071.58","73.78","","286.63","119.22","1107.45","105","1290.58","3309.71","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4X100X100MM TITANIUM MESH CONTOURABLE","SUP-ITM-10075895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.16","3122.37","AETNA [1001]","HB AMC AETNA HMO","2905.89","69.8","","675.31","184.75","1721.50","286","2175.67","3402.13","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4X100X100MM TITANIUM MESH CONTOURABLE","SUP-ITM-10075895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.16","3122.37","AETNA [1001]","HB AMC AETNA PPO","3347.18","80.4","","1261.44","103.12","1514.10","21","2175.67","3402.13","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4X100X100MM TITANIUM MESH CONTOURABLE","SUP-ITM-10075895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.16","3122.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3347.18","80.4","","1365.00","1365.00","1365.00","1 through 10","2175.67","3402.13","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4X100X100MM TITANIUM MESH CONTOURABLE","SUP-ITM-10075895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.16","3122.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3402.13","81.72","","5157.68","5157.68","5157.68","1 through 10","2175.67","3402.13","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .4X100X100MM TITANIUM MESH CONTOURABLE","SUP-ITM-10075895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.16","3122.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3402.13","81.72","","431.26","71.26","1459.57","88","2175.67","3402.13","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X3 HOLE LONG MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077311","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","498.82","79.5","","800.18","480.96","1887.97","195","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X3 HOLE LONG MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077311","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","334.43","53.3","","813.12","216.42","1444.50","81","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X3 HOLE LONG MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077311","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","194.51","31","","432.60","432.60","432.60","1 through 10","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X3 HOLE LONG MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077311","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","229.02","36.5","","148.37","54.89","631.39","94","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X3 HOLE LONG MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077311","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","240.31","38.3","","279.30","91.72","1116.77","266","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X3 HOLE LONG MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077311","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","269.18","42.9","","731.00","63.70","731.00","1 through 10","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X3 HOLE LONG MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077311","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","269.18","42.9","","384.74","384.74","384.74","1 through 10","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X3 HOLE LONG MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077311","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","WELLPOINT [1015]","HB AMC WELLPOINT","462.93","73.78","","286.63","119.22","1107.45","105","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X3 HOLE LONG MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.45","470.59","AETNA [1001]","HB AMC AETNA HMO","437.96","69.8","","675.31","184.75","1721.50","286","327.91","512.75","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X3 HOLE LONG MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.45","470.59","AETNA [1001]","HB AMC AETNA PPO","504.47","80.4","","1261.44","103.12","1514.10","21","327.91","512.75","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X3 HOLE LONG MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.45","470.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","504.47","80.4","","1365.00","1365.00","1365.00","1 through 10","327.91","512.75","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X3 HOLE LONG MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.45","470.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","512.75","81.72","","5157.68","5157.68","5157.68","1 through 10","327.91","512.75","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X3 HOLE LONG MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.45","470.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","512.75","81.72","","431.26","71.26","1459.57","88","327.91","512.75","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X4 HOLE MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE BLUE LEFT","SUP-ITM-10077425","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","397.23","79.5","","800.18","480.96","1887.97","195","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X4 HOLE MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE BLUE LEFT","SUP-ITM-10077425","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","266.32","53.3","","813.12","216.42","1444.50","81","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X4 HOLE MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE BLUE LEFT","SUP-ITM-10077425","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","154.89","31","","432.60","432.60","432.60","1 through 10","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X4 HOLE MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE BLUE LEFT","SUP-ITM-10077425","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","182.38","36.5","","148.37","54.89","631.39","94","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X4 HOLE MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE BLUE LEFT","SUP-ITM-10077425","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","191.37","38.3","","279.30","91.72","1116.77","266","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X4 HOLE MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE BLUE LEFT","SUP-ITM-10077425","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.35","42.9","","731.00","63.70","731.00","1 through 10","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X4 HOLE MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE BLUE LEFT","SUP-ITM-10077425","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.35","42.9","","384.74","384.74","384.74","1 through 10","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X4 HOLE MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE BLUE LEFT","SUP-ITM-10077425","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","WELLPOINT [1015]","HB AMC WELLPOINT","368.65","73.78","","286.63","119.22","1107.45","105","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X4 HOLE MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE BLUE LEFT","SUP-ITM-10077425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","AETNA [1001]","HB AMC AETNA HMO","348.76","69.8","","675.31","184.75","1721.50","286","261.12","408.32","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X4 HOLE MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE BLUE LEFT","SUP-ITM-10077425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","AETNA [1001]","HB AMC AETNA PPO","401.73","80.4","","1261.44","103.12","1514.10","21","261.12","408.32","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X4 HOLE MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE BLUE LEFT","SUP-ITM-10077425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","401.73","80.4","","1365.00","1365.00","1365.00","1 through 10","261.12","408.32","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X4 HOLE MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE BLUE LEFT","SUP-ITM-10077425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","408.32","81.72","","5157.68","5157.68","5157.68","1 through 10","261.12","408.32","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5MM 3X4 HOLE MATRIXMIDFACE TITANIUM OBLIQUE L SHAPE BLUE LEFT","SUP-ITM-10077425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","408.32","81.72","","431.26","71.26","1459.57","88","261.12","408.32","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X100X100MM RAPIDSORB POLYMER MESH","SUP-ITM-10029169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.14","3182.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3373.30","79.5","","800.18","480.96","1887.97","195","1315.37","3373.3","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X100X100MM RAPIDSORB POLYMER MESH","SUP-ITM-10029169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.14","3182.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2261.59","53.3","","813.12","216.42","1444.50","81","1315.37","3373.3","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X100X100MM RAPIDSORB POLYMER MESH","SUP-ITM-10029169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.14","3182.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1315.37","31","","432.60","432.60","432.60","1 through 10","1315.37","3373.3","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X100X100MM RAPIDSORB POLYMER MESH","SUP-ITM-10029169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.14","3182.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1548.75","36.5","","148.37","54.89","631.39","94","1315.37","3373.3","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X100X100MM RAPIDSORB POLYMER MESH","SUP-ITM-10029169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.14","3182.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1625.12","38.3","","279.30","91.72","1116.77","266","1315.37","3373.3","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X100X100MM RAPIDSORB POLYMER MESH","SUP-ITM-10029169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.14","3182.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1820.31","42.9","","731.00","63.70","731.00","1 through 10","1315.37","3373.3","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X100X100MM RAPIDSORB POLYMER MESH","SUP-ITM-10029169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.14","3182.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1820.31","42.9","","384.74","384.74","384.74","1 through 10","1315.37","3373.3","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X100X100MM RAPIDSORB POLYMER MESH","SUP-ITM-10029169","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.14","3182.35","WELLPOINT [1015]","HB AMC WELLPOINT","3130.59","73.78","","286.63","119.22","1107.45","105","1315.37","3373.3","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X100X100MM RAPIDSORB POLYMER MESH","SUP-ITM-10029169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.14","3182.35","AETNA [1001]","HB AMC AETNA HMO","2961.71","69.8","","675.31","184.75","1721.50","286","2217.46","3467.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X100X100MM RAPIDSORB POLYMER MESH","SUP-ITM-10029169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.14","3182.35","AETNA [1001]","HB AMC AETNA PPO","3411.48","80.4","","1261.44","103.12","1514.10","21","2217.46","3467.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X100X100MM RAPIDSORB POLYMER MESH","SUP-ITM-10029169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.14","3182.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3411.48","80.4","","1365.00","1365.00","1365.00","1 through 10","2217.46","3467.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X100X100MM RAPIDSORB POLYMER MESH","SUP-ITM-10029169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.14","3182.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3467.49","81.72","","5157.68","5157.68","5157.68","1 through 10","2217.46","3467.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X100X100MM RAPIDSORB POLYMER MESH","SUP-ITM-10029169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.14","3182.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3467.49","81.72","","431.26","71.26","1459.57","88","2217.46","3467.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X50X50MM RAPIDSORB POLYMER MESH","SUP-ITM-10029168","CDM","C1713","HCPCS","0278","RC","","","","both","","","2322.71","1742.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1846.55","79.5","","800.18","480.96","1887.97","195","720.04","1846.55","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X50X50MM RAPIDSORB POLYMER MESH","SUP-ITM-10029168","CDM","C1713","HCPCS","0278","RC","","","","both","","","2322.71","1742.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1238.00","53.3","","813.12","216.42","1444.50","81","720.04","1846.55","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X50X50MM RAPIDSORB POLYMER MESH","SUP-ITM-10029168","CDM","C1713","HCPCS","0278","RC","","","","both","","","2322.71","1742.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","720.04","31","","432.60","432.60","432.60","1 through 10","720.04","1846.55","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X50X50MM RAPIDSORB POLYMER MESH","SUP-ITM-10029168","CDM","C1713","HCPCS","0278","RC","","","","both","","","2322.71","1742.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","847.79","36.5","","148.37","54.89","631.39","94","720.04","1846.55","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X50X50MM RAPIDSORB POLYMER MESH","SUP-ITM-10029168","CDM","C1713","HCPCS","0278","RC","","","","both","","","2322.71","1742.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","889.60","38.3","","279.30","91.72","1116.77","266","720.04","1846.55","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X50X50MM RAPIDSORB POLYMER MESH","SUP-ITM-10029168","CDM","C1713","HCPCS","0278","RC","","","","both","","","2322.71","1742.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","996.44","42.9","","731.00","63.70","731.00","1 through 10","720.04","1846.55","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X50X50MM RAPIDSORB POLYMER MESH","SUP-ITM-10029168","CDM","C1713","HCPCS","0278","RC","","","","both","","","2322.71","1742.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","996.44","42.9","","384.74","384.74","384.74","1 through 10","720.04","1846.55","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X50X50MM RAPIDSORB POLYMER MESH","SUP-ITM-10029168","CDM","C1713","HCPCS","0278","RC","","","","both","","","2322.71","1742.03","WELLPOINT [1015]","HB AMC WELLPOINT","1713.70","73.78","","286.63","119.22","1107.45","105","720.04","1846.55","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X50X50MM RAPIDSORB POLYMER MESH","SUP-ITM-10029168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2322.71","1742.03","AETNA [1001]","HB AMC AETNA HMO","1621.25","69.8","","675.31","184.75","1721.50","286","1213.85","1898.12","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X50X50MM RAPIDSORB POLYMER MESH","SUP-ITM-10029168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2322.71","1742.03","AETNA [1001]","HB AMC AETNA PPO","1867.46","80.4","","1261.44","103.12","1514.10","21","1213.85","1898.12","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X50X50MM RAPIDSORB POLYMER MESH","SUP-ITM-10029168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2322.71","1742.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1867.46","80.4","","1365.00","1365.00","1365.00","1 through 10","1213.85","1898.12","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X50X50MM RAPIDSORB POLYMER MESH","SUP-ITM-10029168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2322.71","1742.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1898.12","81.72","","5157.68","5157.68","5157.68","1 through 10","1213.85","1898.12","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .5X50X50MM RAPIDSORB POLYMER MESH","SUP-ITM-10029168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2322.71","1742.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1898.12","81.72","","431.26","71.26","1459.57","88","1213.85","1898.12","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .7X8MM 5 HOLE CHIN DOUBLE CURVE TITANIUM","SUP-ITM-10077370","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","498.82","79.5","","800.18","480.96","1887.97","195","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .7X8MM 5 HOLE CHIN DOUBLE CURVE TITANIUM","SUP-ITM-10077370","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","334.43","53.3","","813.12","216.42","1444.50","81","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .7X8MM 5 HOLE CHIN DOUBLE CURVE TITANIUM","SUP-ITM-10077370","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","194.51","31","","432.60","432.60","432.60","1 through 10","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .7X8MM 5 HOLE CHIN DOUBLE CURVE TITANIUM","SUP-ITM-10077370","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","229.02","36.5","","148.37","54.89","631.39","94","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .7X8MM 5 HOLE CHIN DOUBLE CURVE TITANIUM","SUP-ITM-10077370","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","240.31","38.3","","279.30","91.72","1116.77","266","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .7X8MM 5 HOLE CHIN DOUBLE CURVE TITANIUM","SUP-ITM-10077370","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","269.18","42.9","","731.00","63.70","731.00","1 through 10","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .7X8MM 5 HOLE CHIN DOUBLE CURVE TITANIUM","SUP-ITM-10077370","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","269.18","42.9","","384.74","384.74","384.74","1 through 10","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .7X8MM 5 HOLE CHIN DOUBLE CURVE TITANIUM","SUP-ITM-10077370","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.45","470.59","WELLPOINT [1015]","HB AMC WELLPOINT","462.93","73.78","","286.63","119.22","1107.45","105","194.51","498.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .7X8MM 5 HOLE CHIN DOUBLE CURVE TITANIUM","SUP-ITM-10077370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.45","470.59","AETNA [1001]","HB AMC AETNA HMO","437.96","69.8","","675.31","184.75","1721.50","286","327.91","512.75","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .7X8MM 5 HOLE CHIN DOUBLE CURVE TITANIUM","SUP-ITM-10077370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.45","470.59","AETNA [1001]","HB AMC AETNA PPO","504.47","80.4","","1261.44","103.12","1514.10","21","327.91","512.75","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .7X8MM 5 HOLE CHIN DOUBLE CURVE TITANIUM","SUP-ITM-10077370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.45","470.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","504.47","80.4","","1365.00","1365.00","1365.00","1 through 10","327.91","512.75","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .7X8MM 5 HOLE CHIN DOUBLE CURVE TITANIUM","SUP-ITM-10077370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.45","470.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","512.75","81.72","","5157.68","5157.68","5157.68","1 through 10","327.91","512.75","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL .7X8MM 5 HOLE CHIN DOUBLE CURVE TITANIUM","SUP-ITM-10077370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.45","470.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","512.75","81.72","","431.26","71.26","1459.57","88","327.91","512.75","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH CONTOURABLE RIGID TITANIUM FOR SCREW","SUP-ITM-10005363","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.47","3245.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3440.34","79.5","","800.18","480.96","1887.97","195","1341.52","3440.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH CONTOURABLE RIGID TITANIUM FOR SCREW","SUP-ITM-10005363","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.47","3245.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2306.54","53.3","","813.12","216.42","1444.50","81","1341.52","3440.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH CONTOURABLE RIGID TITANIUM FOR SCREW","SUP-ITM-10005363","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.47","3245.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1341.52","31","","432.60","432.60","432.60","1 through 10","1341.52","3440.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH CONTOURABLE RIGID TITANIUM FOR SCREW","SUP-ITM-10005363","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.47","3245.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1579.53","36.5","","148.37","54.89","631.39","94","1341.52","3440.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH CONTOURABLE RIGID TITANIUM FOR SCREW","SUP-ITM-10005363","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.47","3245.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1657.42","38.3","","279.30","91.72","1116.77","266","1341.52","3440.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH CONTOURABLE RIGID TITANIUM FOR SCREW","SUP-ITM-10005363","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.47","3245.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1856.48","42.9","","731.00","63.70","731.00","1 through 10","1341.52","3440.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH CONTOURABLE RIGID TITANIUM FOR SCREW","SUP-ITM-10005363","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.47","3245.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1856.48","42.9","","384.74","384.74","384.74","1 through 10","1341.52","3440.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH CONTOURABLE RIGID TITANIUM FOR SCREW","SUP-ITM-10005363","CDM","C1713","HCPCS","0278","RC","","","","both","","","4327.47","3245.60","WELLPOINT [1015]","HB AMC WELLPOINT","3192.81","73.78","","286.63","119.22","1107.45","105","1341.52","3440.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH CONTOURABLE RIGID TITANIUM FOR SCREW","SUP-ITM-10005363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4327.47","3245.60","AETNA [1001]","HB AMC AETNA HMO","3020.57","69.8","","675.31","184.75","1721.50","286","2261.54","3536.41","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH CONTOURABLE RIGID TITANIUM FOR SCREW","SUP-ITM-10005363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4327.47","3245.60","AETNA [1001]","HB AMC AETNA PPO","3479.29","80.4","","1261.44","103.12","1514.10","21","2261.54","3536.41","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH CONTOURABLE RIGID TITANIUM FOR SCREW","SUP-ITM-10005363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4327.47","3245.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3479.29","80.4","","1365.00","1365.00","1365.00","1 through 10","2261.54","3536.41","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH CONTOURABLE RIGID TITANIUM FOR SCREW","SUP-ITM-10005363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4327.47","3245.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3536.41","81.72","","5157.68","5157.68","5157.68","1 through 10","2261.54","3536.41","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH CONTOURABLE RIGID TITANIUM FOR SCREW","SUP-ITM-10005363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4327.47","3245.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3536.41","81.72","","431.26","71.26","1459.57","88","2261.54","3536.41","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH INTERNAL FIXATION FOR SCREW","SUP-ITM-10002441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2541.81","1906.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2020.74","79.5","","800.18","480.96","1887.97","195","787.96","2020.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH INTERNAL FIXATION FOR SCREW","SUP-ITM-10002441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2541.81","1906.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1354.78","53.3","","813.12","216.42","1444.50","81","787.96","2020.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH INTERNAL FIXATION FOR SCREW","SUP-ITM-10002441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2541.81","1906.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","787.96","31","","432.60","432.60","432.60","1 through 10","787.96","2020.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH INTERNAL FIXATION FOR SCREW","SUP-ITM-10002441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2541.81","1906.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","927.76","36.5","","148.37","54.89","631.39","94","787.96","2020.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH INTERNAL FIXATION FOR SCREW","SUP-ITM-10002441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2541.81","1906.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","973.51","38.3","","279.30","91.72","1116.77","266","787.96","2020.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH INTERNAL FIXATION FOR SCREW","SUP-ITM-10002441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2541.81","1906.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1090.44","42.9","","731.00","63.70","731.00","1 through 10","787.96","2020.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH INTERNAL FIXATION FOR SCREW","SUP-ITM-10002441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2541.81","1906.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1090.44","42.9","","384.74","384.74","384.74","1 through 10","787.96","2020.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH INTERNAL FIXATION FOR SCREW","SUP-ITM-10002441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2541.81","1906.36","WELLPOINT [1015]","HB AMC WELLPOINT","1875.35","73.78","","286.63","119.22","1107.45","105","787.96","2020.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH INTERNAL FIXATION FOR SCREW","SUP-ITM-10002441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2541.81","1906.36","AETNA [1001]","HB AMC AETNA HMO","1774.18","69.8","","675.31","184.75","1721.50","286","1328.35","2077.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH INTERNAL FIXATION FOR SCREW","SUP-ITM-10002441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2541.81","1906.36","AETNA [1001]","HB AMC AETNA PPO","2043.62","80.4","","1261.44","103.12","1514.10","21","1328.35","2077.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH INTERNAL FIXATION FOR SCREW","SUP-ITM-10002441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2541.81","1906.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2043.62","80.4","","1365.00","1365.00","1365.00","1 through 10","1328.35","2077.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH INTERNAL FIXATION FOR SCREW","SUP-ITM-10002441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2541.81","1906.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2077.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1328.35","2077.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X100X100MM MESH INTERNAL FIXATION FOR SCREW","SUP-ITM-10002441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2541.81","1906.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2077.17","81.72","","431.26","71.26","1459.57","88","1328.35","2077.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X13MM 4 HOLE TITANIUM","SUP-ITM-10007594","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.15","339.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","360.25","79.5","","800.18","480.96","1887.97","195","140.48","360.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X13MM 4 HOLE TITANIUM","SUP-ITM-10007594","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.15","339.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","241.53","53.3","","813.12","216.42","1444.50","81","140.48","360.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X13MM 4 HOLE TITANIUM","SUP-ITM-10007594","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.15","339.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","140.48","31","","432.60","432.60","432.60","1 through 10","140.48","360.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X13MM 4 HOLE TITANIUM","SUP-ITM-10007594","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.15","339.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","165.40","36.5","","148.37","54.89","631.39","94","140.48","360.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X13MM 4 HOLE TITANIUM","SUP-ITM-10007594","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.15","339.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","173.56","38.3","","279.30","91.72","1116.77","266","140.48","360.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X13MM 4 HOLE TITANIUM","SUP-ITM-10007594","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.15","339.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","194.40","42.9","","731.00","63.70","731.00","1 through 10","140.48","360.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X13MM 4 HOLE TITANIUM","SUP-ITM-10007594","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.15","339.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","194.40","42.9","","384.74","384.74","384.74","1 through 10","140.48","360.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X13MM 4 HOLE TITANIUM","SUP-ITM-10007594","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.15","339.86","WELLPOINT [1015]","HB AMC WELLPOINT","334.33","73.78","","286.63","119.22","1107.45","105","140.48","360.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X13MM 4 HOLE TITANIUM","SUP-ITM-10007594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.15","339.86","AETNA [1001]","HB AMC AETNA HMO","316.30","69.8","","675.31","184.75","1721.50","286","236.82","370.31","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X13MM 4 HOLE TITANIUM","SUP-ITM-10007594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.15","339.86","AETNA [1001]","HB AMC AETNA PPO","364.33","80.4","","1261.44","103.12","1514.10","21","236.82","370.31","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X13MM 4 HOLE TITANIUM","SUP-ITM-10007594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.15","339.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","364.33","80.4","","1365.00","1365.00","1365.00","1 through 10","236.82","370.31","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X13MM 4 HOLE TITANIUM","SUP-ITM-10007594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.15","339.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","370.31","81.72","","5157.68","5157.68","5157.68","1 through 10","236.82","370.31","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X13MM 4 HOLE TITANIUM","SUP-ITM-10007594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.15","339.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","370.31","81.72","","431.26","71.26","1459.57","88","236.82","370.31","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","397.23","79.5","","800.18","480.96","1887.97","195","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","266.32","53.3","","813.12","216.42","1444.50","81","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","154.89","31","","432.60","432.60","432.60","1 through 10","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","182.38","36.5","","148.37","54.89","631.39","94","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","191.37","38.3","","279.30","91.72","1116.77","266","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.35","42.9","","731.00","63.70","731.00","1 through 10","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.35","42.9","","384.74","384.74","384.74","1 through 10","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.66","374.74","WELLPOINT [1015]","HB AMC WELLPOINT","368.65","73.78","","286.63","119.22","1107.45","105","154.89","397.23","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","AETNA [1001]","HB AMC AETNA HMO","348.76","69.8","","675.31","184.75","1721.50","286","261.12","408.32","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","AETNA [1001]","HB AMC AETNA PPO","401.73","80.4","","1261.44","103.12","1514.10","21","261.12","408.32","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","401.73","80.4","","1365.00","1365.00","1365.00","1 through 10","261.12","408.32","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","408.32","81.72","","5157.68","5157.68","5157.68","1 through 10","261.12","408.32","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.66","374.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","408.32","81.72","","431.26","71.26","1459.57","88","261.12","408.32","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X50MM UNIVERSAL TITANIUM ORBITAL FLOOR CS/1BX/1EA","SUP-ITM-10025536","CDM","C1713","HCPCS","0278","RC","","","","both","","","6147.50","4610.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4887.26","79.5","","800.18","480.96","1887.97","195","1905.73","4887.26","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X50MM UNIVERSAL TITANIUM ORBITAL FLOOR CS/1BX/1EA","SUP-ITM-10025536","CDM","C1713","HCPCS","0278","RC","","","","both","","","6147.50","4610.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3276.62","53.3","","813.12","216.42","1444.50","81","1905.73","4887.26","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X50MM UNIVERSAL TITANIUM ORBITAL FLOOR CS/1BX/1EA","SUP-ITM-10025536","CDM","C1713","HCPCS","0278","RC","","","","both","","","6147.50","4610.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1905.73","31","","432.60","432.60","432.60","1 through 10","1905.73","4887.26","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X50MM UNIVERSAL TITANIUM ORBITAL FLOOR CS/1BX/1EA","SUP-ITM-10025536","CDM","C1713","HCPCS","0278","RC","","","","both","","","6147.50","4610.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2243.84","36.5","","148.37","54.89","631.39","94","1905.73","4887.26","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X50MM UNIVERSAL TITANIUM ORBITAL FLOOR CS/1BX/1EA","SUP-ITM-10025536","CDM","C1713","HCPCS","0278","RC","","","","both","","","6147.50","4610.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2354.49","38.3","","279.30","91.72","1116.77","266","1905.73","4887.26","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X50MM UNIVERSAL TITANIUM ORBITAL FLOOR CS/1BX/1EA","SUP-ITM-10025536","CDM","C1713","HCPCS","0278","RC","","","","both","","","6147.50","4610.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2637.28","42.9","","731.00","63.70","731.00","1 through 10","1905.73","4887.26","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X50MM UNIVERSAL TITANIUM ORBITAL FLOOR CS/1BX/1EA","SUP-ITM-10025536","CDM","C1713","HCPCS","0278","RC","","","","both","","","6147.50","4610.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2637.28","42.9","","384.74","384.74","384.74","1 through 10","1905.73","4887.26","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X50MM UNIVERSAL TITANIUM ORBITAL FLOOR CS/1BX/1EA","SUP-ITM-10025536","CDM","C1713","HCPCS","0278","RC","","","","both","","","6147.50","4610.62","WELLPOINT [1015]","HB AMC WELLPOINT","4535.63","73.78","","286.63","119.22","1107.45","105","1905.73","4887.26","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X50MM UNIVERSAL TITANIUM ORBITAL FLOOR CS/1BX/1EA","SUP-ITM-10025536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6147.50","4610.62","AETNA [1001]","HB AMC AETNA HMO","4290.96","69.8","","675.31","184.75","1721.50","286","3212.68","5023.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X50MM UNIVERSAL TITANIUM ORBITAL FLOOR CS/1BX/1EA","SUP-ITM-10025536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6147.50","4610.62","AETNA [1001]","HB AMC AETNA PPO","4942.59","80.4","","1261.44","103.12","1514.10","21","3212.68","5023.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X50MM UNIVERSAL TITANIUM ORBITAL FLOOR CS/1BX/1EA","SUP-ITM-10025536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6147.50","4610.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4942.59","80.4","","1365.00","1365.00","1365.00","1 through 10","3212.68","5023.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X50MM UNIVERSAL TITANIUM ORBITAL FLOOR CS/1BX/1EA","SUP-ITM-10025536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6147.50","4610.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5023.74","81.72","","5157.68","5157.68","5157.68","1 through 10","3212.68","5023.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X50MM UNIVERSAL TITANIUM ORBITAL FLOOR CS/1BX/1EA","SUP-ITM-10025536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6147.50","4610.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5023.74","81.72","","431.26","71.26","1459.57","88","3212.68","5023.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5MM 6 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081111","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.08","1326.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1406.42","79.5","","800.18","480.96","1887.97","195","548.41","1406.42","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5MM 6 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081111","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.08","1326.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","942.92","53.3","","813.12","216.42","1444.50","81","548.41","1406.42","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5MM 6 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081111","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.08","1326.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","548.41","31","","432.60","432.60","432.60","1 through 10","548.41","1406.42","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5MM 6 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081111","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.08","1326.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","645.71","36.5","","148.37","54.89","631.39","94","548.41","1406.42","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5MM 6 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081111","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.08","1326.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","677.56","38.3","","279.30","91.72","1116.77","266","548.41","1406.42","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5MM 6 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081111","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.08","1326.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","758.94","42.9","","731.00","63.70","731.00","1 through 10","548.41","1406.42","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5MM 6 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081111","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.08","1326.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","758.94","42.9","","384.74","384.74","384.74","1 through 10","548.41","1406.42","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5MM 6 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081111","CDM","C1713","HCPCS","0278","RC","","","","both","","","1769.08","1326.81","WELLPOINT [1015]","HB AMC WELLPOINT","1305.23","73.78","","286.63","119.22","1107.45","105","548.41","1406.42","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5MM 6 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1769.08","1326.81","AETNA [1001]","HB AMC AETNA HMO","1234.82","69.8","","675.31","184.75","1721.50","286","924.52","1445.69","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5MM 6 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1769.08","1326.81","AETNA [1001]","HB AMC AETNA PPO","1422.34","80.4","","1261.44","103.12","1514.10","21","924.52","1445.69","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5MM 6 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1769.08","1326.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1422.34","80.4","","1365.00","1365.00","1365.00","1 through 10","924.52","1445.69","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5MM 6 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1769.08","1326.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1445.69","81.72","","5157.68","5157.68","5157.68","1 through 10","924.52","1445.69","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5MM 6 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1769.08","1326.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1445.69","81.72","","431.26","71.26","1459.57","88","924.52","1445.69","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100MM MESH CONTOURABLE RIGID TITANIUM","SUP-ITM-10006963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4075.98","3056.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3240.40","79.5","","800.18","480.96","1887.97","195","1263.55","3240.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100MM MESH CONTOURABLE RIGID TITANIUM","SUP-ITM-10006963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4075.98","3056.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2172.50","53.3","","813.12","216.42","1444.50","81","1263.55","3240.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100MM MESH CONTOURABLE RIGID TITANIUM","SUP-ITM-10006963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4075.98","3056.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1263.55","31","","432.60","432.60","432.60","1 through 10","1263.55","3240.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100MM MESH CONTOURABLE RIGID TITANIUM","SUP-ITM-10006963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4075.98","3056.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1487.73","36.5","","148.37","54.89","631.39","94","1263.55","3240.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100MM MESH CONTOURABLE RIGID TITANIUM","SUP-ITM-10006963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4075.98","3056.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1561.10","38.3","","279.30","91.72","1116.77","266","1263.55","3240.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100MM MESH CONTOURABLE RIGID TITANIUM","SUP-ITM-10006963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4075.98","3056.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1748.60","42.9","","731.00","63.70","731.00","1 through 10","1263.55","3240.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100MM MESH CONTOURABLE RIGID TITANIUM","SUP-ITM-10006963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4075.98","3056.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1748.60","42.9","","384.74","384.74","384.74","1 through 10","1263.55","3240.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100MM MESH CONTOURABLE RIGID TITANIUM","SUP-ITM-10006963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4075.98","3056.98","WELLPOINT [1015]","HB AMC WELLPOINT","3007.26","73.78","","286.63","119.22","1107.45","105","1263.55","3240.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100MM MESH CONTOURABLE RIGID TITANIUM","SUP-ITM-10006963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4075.98","3056.98","AETNA [1001]","HB AMC AETNA HMO","2845.03","69.8","","675.31","184.75","1721.50","286","2130.11","3330.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100MM MESH CONTOURABLE RIGID TITANIUM","SUP-ITM-10006963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4075.98","3056.98","AETNA [1001]","HB AMC AETNA PPO","3277.09","80.4","","1261.44","103.12","1514.10","21","2130.11","3330.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100MM MESH CONTOURABLE RIGID TITANIUM","SUP-ITM-10006963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4075.98","3056.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3277.09","80.4","","1365.00","1365.00","1365.00","1 through 10","2130.11","3330.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100MM MESH CONTOURABLE RIGID TITANIUM","SUP-ITM-10006963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4075.98","3056.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3330.89","81.72","","5157.68","5157.68","5157.68","1 through 10","2130.11","3330.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100MM MESH CONTOURABLE RIGID TITANIUM","SUP-ITM-10006963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4075.98","3056.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3330.89","81.72","","431.26","71.26","1459.57","88","2130.11","3330.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH","SUP-ITM-10029171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.18","3550.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3763.67","79.5","","800.18","480.96","1887.97","195","1467.6","3763.67","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH","SUP-ITM-10029171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.18","3550.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2523.32","53.3","","813.12","216.42","1444.50","81","1467.6","3763.67","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH","SUP-ITM-10029171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.18","3550.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1467.60","31","","432.60","432.60","432.60","1 through 10","1467.6","3763.67","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH","SUP-ITM-10029171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.18","3550.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1727.98","36.5","","148.37","54.89","631.39","94","1467.6","3763.67","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH","SUP-ITM-10029171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.18","3550.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1813.19","38.3","","279.30","91.72","1116.77","266","1467.6","3763.67","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH","SUP-ITM-10029171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.18","3550.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2030.96","42.9","","731.00","63.70","731.00","1 through 10","1467.6","3763.67","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH","SUP-ITM-10029171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.18","3550.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2030.96","42.9","","384.74","384.74","384.74","1 through 10","1467.6","3763.67","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH","SUP-ITM-10029171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4734.18","3550.63","WELLPOINT [1015]","HB AMC WELLPOINT","3492.88","73.78","","286.63","119.22","1107.45","105","1467.6","3763.67","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH","SUP-ITM-10029171","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4734.18","3550.63","AETNA [1001]","HB AMC AETNA HMO","3304.46","69.8","","675.31","184.75","1721.50","286","2474.08","3868.77","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH","SUP-ITM-10029171","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4734.18","3550.63","AETNA [1001]","HB AMC AETNA PPO","3806.28","80.4","","1261.44","103.12","1514.10","21","2474.08","3868.77","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH","SUP-ITM-10029171","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4734.18","3550.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3806.28","80.4","","1365.00","1365.00","1365.00","1 through 10","2474.08","3868.77","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH","SUP-ITM-10029171","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4734.18","3550.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3868.77","81.72","","5157.68","5157.68","5157.68","1 through 10","2474.08","3868.77","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH","SUP-ITM-10029171","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4734.18","3550.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3868.77","81.72","","431.26","71.26","1459.57","88","2474.08","3868.77","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029184","CDM","C1713","HCPCS","0278","RC","","","","both","","","4946.04","3709.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3932.10","79.5","","800.18","480.96","1887.97","195","1533.27","3932.1","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029184","CDM","C1713","HCPCS","0278","RC","","","","both","","","4946.04","3709.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2636.24","53.3","","813.12","216.42","1444.50","81","1533.27","3932.1","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029184","CDM","C1713","HCPCS","0278","RC","","","","both","","","4946.04","3709.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1533.27","31","","432.60","432.60","432.60","1 through 10","1533.27","3932.1","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029184","CDM","C1713","HCPCS","0278","RC","","","","both","","","4946.04","3709.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1805.30","36.5","","148.37","54.89","631.39","94","1533.27","3932.1","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029184","CDM","C1713","HCPCS","0278","RC","","","","both","","","4946.04","3709.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1894.33","38.3","","279.30","91.72","1116.77","266","1533.27","3932.1","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029184","CDM","C1713","HCPCS","0278","RC","","","","both","","","4946.04","3709.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2121.85","42.9","","731.00","63.70","731.00","1 through 10","1533.27","3932.1","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029184","CDM","C1713","HCPCS","0278","RC","","","","both","","","4946.04","3709.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2121.85","42.9","","384.74","384.74","384.74","1 through 10","1533.27","3932.1","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029184","CDM","C1713","HCPCS","0278","RC","","","","both","","","4946.04","3709.53","WELLPOINT [1015]","HB AMC WELLPOINT","3649.19","73.78","","286.63","119.22","1107.45","105","1533.27","3932.1","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4946.04","3709.53","AETNA [1001]","HB AMC AETNA HMO","3452.34","69.8","","675.31","184.75","1721.50","286","2584.8","4041.9","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4946.04","3709.53","AETNA [1001]","HB AMC AETNA PPO","3976.62","80.4","","1261.44","103.12","1514.10","21","2584.8","4041.9","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4946.04","3709.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3976.62","80.4","","1365.00","1365.00","1365.00","1 through 10","2584.8","4041.9","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4946.04","3709.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4041.90","81.72","","5157.68","5157.68","5157.68","1 through 10","2584.8","4041.9","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X100X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4946.04","3709.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4041.90","81.72","","431.26","71.26","1459.57","88","2584.8","4041.9","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X150X.8MM RAPIDSORB POLYMER MESH CONTOURABLE STRUT","SUP-ITM-10076749","CDM","C1713","HCPCS","0278","RC","","","","both","","","6705.60","5029.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5330.95","79.5","","800.18","480.96","1887.97","195","2078.74","5330.95","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X150X.8MM RAPIDSORB POLYMER MESH CONTOURABLE STRUT","SUP-ITM-10076749","CDM","C1713","HCPCS","0278","RC","","","","both","","","6705.60","5029.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3574.08","53.3","","813.12","216.42","1444.50","81","2078.74","5330.95","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X150X.8MM RAPIDSORB POLYMER MESH CONTOURABLE STRUT","SUP-ITM-10076749","CDM","C1713","HCPCS","0278","RC","","","","both","","","6705.60","5029.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2078.74","31","","432.60","432.60","432.60","1 through 10","2078.74","5330.95","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X150X.8MM RAPIDSORB POLYMER MESH CONTOURABLE STRUT","SUP-ITM-10076749","CDM","C1713","HCPCS","0278","RC","","","","both","","","6705.60","5029.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2447.54","36.5","","148.37","54.89","631.39","94","2078.74","5330.95","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X150X.8MM RAPIDSORB POLYMER MESH CONTOURABLE STRUT","SUP-ITM-10076749","CDM","C1713","HCPCS","0278","RC","","","","both","","","6705.60","5029.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2568.24","38.3","","279.30","91.72","1116.77","266","2078.74","5330.95","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X150X.8MM RAPIDSORB POLYMER MESH CONTOURABLE STRUT","SUP-ITM-10076749","CDM","C1713","HCPCS","0278","RC","","","","both","","","6705.60","5029.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2876.70","42.9","","731.00","63.70","731.00","1 through 10","2078.74","5330.95","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X150X.8MM RAPIDSORB POLYMER MESH CONTOURABLE STRUT","SUP-ITM-10076749","CDM","C1713","HCPCS","0278","RC","","","","both","","","6705.60","5029.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2876.70","42.9","","384.74","384.74","384.74","1 through 10","2078.74","5330.95","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X150X.8MM RAPIDSORB POLYMER MESH CONTOURABLE STRUT","SUP-ITM-10076749","CDM","C1713","HCPCS","0278","RC","","","","both","","","6705.60","5029.20","WELLPOINT [1015]","HB AMC WELLPOINT","4947.39","73.78","","286.63","119.22","1107.45","105","2078.74","5330.95","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X150X.8MM RAPIDSORB POLYMER MESH CONTOURABLE STRUT","SUP-ITM-10076749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6705.60","5029.20","AETNA [1001]","HB AMC AETNA HMO","4680.51","69.8","","675.31","184.75","1721.50","286","3504.35","5479.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X150X.8MM RAPIDSORB POLYMER MESH CONTOURABLE STRUT","SUP-ITM-10076749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6705.60","5029.20","AETNA [1001]","HB AMC AETNA PPO","5391.30","80.4","","1261.44","103.12","1514.10","21","3504.35","5479.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X150X.8MM RAPIDSORB POLYMER MESH CONTOURABLE STRUT","SUP-ITM-10076749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6705.60","5029.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5391.30","80.4","","1365.00","1365.00","1365.00","1 through 10","3504.35","5479.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X150X.8MM RAPIDSORB POLYMER MESH CONTOURABLE STRUT","SUP-ITM-10076749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6705.60","5029.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5479.82","81.72","","5157.68","5157.68","5157.68","1 through 10","3504.35","5479.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X150X.8MM RAPIDSORB POLYMER MESH CONTOURABLE STRUT","SUP-ITM-10076749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6705.60","5029.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5479.82","81.72","","431.26","71.26","1459.57","88","3504.35","5479.82","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X38X45MM TITANIUM MESH CONTOURABLE RIGID GOLD","SUP-ITM-10029204","CDM","C1713","HCPCS","0278","RC","","","","both","","","3041.43","2281.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2417.94","79.5","","800.18","480.96","1887.97","195","942.84","2417.94","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X38X45MM TITANIUM MESH CONTOURABLE RIGID GOLD","SUP-ITM-10029204","CDM","C1713","HCPCS","0278","RC","","","","both","","","3041.43","2281.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1621.08","53.3","","813.12","216.42","1444.50","81","942.84","2417.94","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X38X45MM TITANIUM MESH CONTOURABLE RIGID GOLD","SUP-ITM-10029204","CDM","C1713","HCPCS","0278","RC","","","","both","","","3041.43","2281.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","942.84","31","","432.60","432.60","432.60","1 through 10","942.84","2417.94","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X38X45MM TITANIUM MESH CONTOURABLE RIGID GOLD","SUP-ITM-10029204","CDM","C1713","HCPCS","0278","RC","","","","both","","","3041.43","2281.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1110.12","36.5","","148.37","54.89","631.39","94","942.84","2417.94","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X38X45MM TITANIUM MESH CONTOURABLE RIGID GOLD","SUP-ITM-10029204","CDM","C1713","HCPCS","0278","RC","","","","both","","","3041.43","2281.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1164.87","38.3","","279.30","91.72","1116.77","266","942.84","2417.94","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X38X45MM TITANIUM MESH CONTOURABLE RIGID GOLD","SUP-ITM-10029204","CDM","C1713","HCPCS","0278","RC","","","","both","","","3041.43","2281.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1304.77","42.9","","731.00","63.70","731.00","1 through 10","942.84","2417.94","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X38X45MM TITANIUM MESH CONTOURABLE RIGID GOLD","SUP-ITM-10029204","CDM","C1713","HCPCS","0278","RC","","","","both","","","3041.43","2281.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1304.77","42.9","","384.74","384.74","384.74","1 through 10","942.84","2417.94","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X38X45MM TITANIUM MESH CONTOURABLE RIGID GOLD","SUP-ITM-10029204","CDM","C1713","HCPCS","0278","RC","","","","both","","","3041.43","2281.07","WELLPOINT [1015]","HB AMC WELLPOINT","2243.97","73.78","","286.63","119.22","1107.45","105","942.84","2417.94","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X38X45MM TITANIUM MESH CONTOURABLE RIGID GOLD","SUP-ITM-10029204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3041.43","2281.07","AETNA [1001]","HB AMC AETNA HMO","2122.92","69.8","","675.31","184.75","1721.50","286","1589.45","2485.46","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X38X45MM TITANIUM MESH CONTOURABLE RIGID GOLD","SUP-ITM-10029204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3041.43","2281.07","AETNA [1001]","HB AMC AETNA PPO","2445.31","80.4","","1261.44","103.12","1514.10","21","1589.45","2485.46","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X38X45MM TITANIUM MESH CONTOURABLE RIGID GOLD","SUP-ITM-10029204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3041.43","2281.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2445.31","80.4","","1365.00","1365.00","1365.00","1 through 10","1589.45","2485.46","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X38X45MM TITANIUM MESH CONTOURABLE RIGID GOLD","SUP-ITM-10029204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3041.43","2281.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2485.46","81.72","","5157.68","5157.68","5157.68","1 through 10","1589.45","2485.46","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X38X45MM TITANIUM MESH CONTOURABLE RIGID GOLD","SUP-ITM-10029204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3041.43","2281.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2485.46","81.72","","431.26","71.26","1459.57","88","1589.45","2485.46","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X50X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029183","CDM","C1713","HCPCS","0278","RC","","","","both","","","2646.11","1984.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2103.66","79.5","","800.18","480.96","1887.97","195","820.29","2103.66","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X50X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029183","CDM","C1713","HCPCS","0278","RC","","","","both","","","2646.11","1984.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1410.38","53.3","","813.12","216.42","1444.50","81","820.29","2103.66","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X50X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029183","CDM","C1713","HCPCS","0278","RC","","","","both","","","2646.11","1984.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","820.29","31","","432.60","432.60","432.60","1 through 10","820.29","2103.66","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X50X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029183","CDM","C1713","HCPCS","0278","RC","","","","both","","","2646.11","1984.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","965.83","36.5","","148.37","54.89","631.39","94","820.29","2103.66","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X50X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029183","CDM","C1713","HCPCS","0278","RC","","","","both","","","2646.11","1984.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1013.46","38.3","","279.30","91.72","1116.77","266","820.29","2103.66","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X50X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029183","CDM","C1713","HCPCS","0278","RC","","","","both","","","2646.11","1984.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1135.18","42.9","","731.00","63.70","731.00","1 through 10","820.29","2103.66","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X50X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029183","CDM","C1713","HCPCS","0278","RC","","","","both","","","2646.11","1984.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1135.18","42.9","","384.74","384.74","384.74","1 through 10","820.29","2103.66","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X50X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029183","CDM","C1713","HCPCS","0278","RC","","","","both","","","2646.11","1984.58","WELLPOINT [1015]","HB AMC WELLPOINT","1952.30","73.78","","286.63","119.22","1107.45","105","820.29","2103.66","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X50X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2646.11","1984.58","AETNA [1001]","HB AMC AETNA HMO","1846.98","69.8","","675.31","184.75","1721.50","286","1382.86","2162.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X50X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2646.11","1984.58","AETNA [1001]","HB AMC AETNA PPO","2127.47","80.4","","1261.44","103.12","1514.10","21","1382.86","2162.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X50X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2646.11","1984.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2127.47","80.4","","1365.00","1365.00","1365.00","1 through 10","1382.86","2162.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X50X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2646.11","1984.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2162.40","81.72","","5157.68","5157.68","5157.68","1 through 10","1382.86","2162.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.5X50X.8MM RAPIDSORB POLYMER MESH CONTOURABLE","SUP-ITM-10029183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2646.11","1984.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2162.40","81.72","","431.26","71.26","1459.57","88","1382.86","2162.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE SILVER","SUP-ITM-10076558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3783.47","2837.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3007.86","79.5","","800.18","480.96","1887.97","195","1172.88","3007.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE SILVER","SUP-ITM-10076558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3783.47","2837.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2016.59","53.3","","813.12","216.42","1444.50","81","1172.88","3007.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE SILVER","SUP-ITM-10076558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3783.47","2837.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1172.88","31","","432.60","432.60","432.60","1 through 10","1172.88","3007.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE SILVER","SUP-ITM-10076558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3783.47","2837.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1380.97","36.5","","148.37","54.89","631.39","94","1172.88","3007.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE SILVER","SUP-ITM-10076558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3783.47","2837.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1449.07","38.3","","279.30","91.72","1116.77","266","1172.88","3007.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE SILVER","SUP-ITM-10076558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3783.47","2837.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1623.11","42.9","","731.00","63.70","731.00","1 through 10","1172.88","3007.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE SILVER","SUP-ITM-10076558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3783.47","2837.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1623.11","42.9","","384.74","384.74","384.74","1 through 10","1172.88","3007.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE SILVER","SUP-ITM-10076558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3783.47","2837.60","WELLPOINT [1015]","HB AMC WELLPOINT","2791.44","73.78","","286.63","119.22","1107.45","105","1172.88","3007.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE SILVER","SUP-ITM-10076558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3783.47","2837.60","AETNA [1001]","HB AMC AETNA HMO","2640.86","69.8","","675.31","184.75","1721.50","286","1977.24","3091.85","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE SILVER","SUP-ITM-10076558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3783.47","2837.60","AETNA [1001]","HB AMC AETNA PPO","3041.91","80.4","","1261.44","103.12","1514.10","21","1977.24","3091.85","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE SILVER","SUP-ITM-10076558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3783.47","2837.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3041.91","80.4","","1365.00","1365.00","1365.00","1 through 10","1977.24","3091.85","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE SILVER","SUP-ITM-10076558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3783.47","2837.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3091.85","81.72","","5157.68","5157.68","5157.68","1 through 10","1977.24","3091.85","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH MALLEABLE SILVER","SUP-ITM-10076558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3783.47","2837.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3091.85","81.72","","431.26","71.26","1459.57","88","1977.24","3091.85","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH RIGID BLUE","SUP-ITM-10076559","CDM","C1713","HCPCS","0278","RC","","","","both","","","4442.87","3332.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3532.08","79.5","","800.18","480.96","1887.97","195","1377.29","3532.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH RIGID BLUE","SUP-ITM-10076559","CDM","C1713","HCPCS","0278","RC","","","","both","","","4442.87","3332.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2368.05","53.3","","813.12","216.42","1444.50","81","1377.29","3532.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH RIGID BLUE","SUP-ITM-10076559","CDM","C1713","HCPCS","0278","RC","","","","both","","","4442.87","3332.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1377.29","31","","432.60","432.60","432.60","1 through 10","1377.29","3532.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH RIGID BLUE","SUP-ITM-10076559","CDM","C1713","HCPCS","0278","RC","","","","both","","","4442.87","3332.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1621.65","36.5","","148.37","54.89","631.39","94","1377.29","3532.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH RIGID BLUE","SUP-ITM-10076559","CDM","C1713","HCPCS","0278","RC","","","","both","","","4442.87","3332.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1701.62","38.3","","279.30","91.72","1116.77","266","1377.29","3532.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH RIGID BLUE","SUP-ITM-10076559","CDM","C1713","HCPCS","0278","RC","","","","both","","","4442.87","3332.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1905.99","42.9","","731.00","63.70","731.00","1 through 10","1377.29","3532.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH RIGID BLUE","SUP-ITM-10076559","CDM","C1713","HCPCS","0278","RC","","","","both","","","4442.87","3332.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1905.99","42.9","","384.74","384.74","384.74","1 through 10","1377.29","3532.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH RIGID BLUE","SUP-ITM-10076559","CDM","C1713","HCPCS","0278","RC","","","","both","","","4442.87","3332.15","WELLPOINT [1015]","HB AMC WELLPOINT","3277.95","73.78","","286.63","119.22","1107.45","105","1377.29","3532.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH RIGID BLUE","SUP-ITM-10076559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4442.87","3332.15","AETNA [1001]","HB AMC AETNA HMO","3101.12","69.8","","675.31","184.75","1721.50","286","2321.84","3630.71","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH RIGID BLUE","SUP-ITM-10076559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4442.87","3332.15","AETNA [1001]","HB AMC AETNA PPO","3572.07","80.4","","1261.44","103.12","1514.10","21","2321.84","3630.71","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH RIGID BLUE","SUP-ITM-10076559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4442.87","3332.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3572.07","80.4","","1365.00","1365.00","1365.00","1 through 10","2321.84","3630.71","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH RIGID BLUE","SUP-ITM-10076559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4442.87","3332.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3630.71","81.72","","5157.68","5157.68","5157.68","1 through 10","2321.84","3630.71","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 100X100MM MATRIXNEURO TITANIUM CONTOURABLE MESH RIGID BLUE","SUP-ITM-10076559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4442.87","3332.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3630.71","81.72","","431.26","71.26","1459.57","88","2321.84","3630.71","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 4 HOLE 5 SHAFT BONE L SHAPE BASE TITANIUM LEFT","SUP-ITM-10003792","CDM","C1713","HCPCS","0278","RC","","","","both","","","517.06","387.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","411.06","79.5","","800.18","480.96","1887.97","195","160.29","411.06","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 4 HOLE 5 SHAFT BONE L SHAPE BASE TITANIUM LEFT","SUP-ITM-10003792","CDM","C1713","HCPCS","0278","RC","","","","both","","","517.06","387.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","275.59","53.3","","813.12","216.42","1444.50","81","160.29","411.06","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 4 HOLE 5 SHAFT BONE L SHAPE BASE TITANIUM LEFT","SUP-ITM-10003792","CDM","C1713","HCPCS","0278","RC","","","","both","","","517.06","387.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","160.29","31","","432.60","432.60","432.60","1 through 10","160.29","411.06","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 4 HOLE 5 SHAFT BONE L SHAPE BASE TITANIUM LEFT","SUP-ITM-10003792","CDM","C1713","HCPCS","0278","RC","","","","both","","","517.06","387.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","188.73","36.5","","148.37","54.89","631.39","94","160.29","411.06","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 4 HOLE 5 SHAFT BONE L SHAPE BASE TITANIUM LEFT","SUP-ITM-10003792","CDM","C1713","HCPCS","0278","RC","","","","both","","","517.06","387.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","198.03","38.3","","279.30","91.72","1116.77","266","160.29","411.06","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 4 HOLE 5 SHAFT BONE L SHAPE BASE TITANIUM LEFT","SUP-ITM-10003792","CDM","C1713","HCPCS","0278","RC","","","","both","","","517.06","387.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","221.82","42.9","","731.00","63.70","731.00","1 through 10","160.29","411.06","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 4 HOLE 5 SHAFT BONE L SHAPE BASE TITANIUM LEFT","SUP-ITM-10003792","CDM","C1713","HCPCS","0278","RC","","","","both","","","517.06","387.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","221.82","42.9","","384.74","384.74","384.74","1 through 10","160.29","411.06","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 4 HOLE 5 SHAFT BONE L SHAPE BASE TITANIUM LEFT","SUP-ITM-10003792","CDM","C1713","HCPCS","0278","RC","","","","both","","","517.06","387.79","WELLPOINT [1015]","HB AMC WELLPOINT","381.49","73.78","","286.63","119.22","1107.45","105","160.29","411.06","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 4 HOLE 5 SHAFT BONE L SHAPE BASE TITANIUM LEFT","SUP-ITM-10003792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","517.06","387.79","AETNA [1001]","HB AMC AETNA HMO","360.91","69.8","","675.31","184.75","1721.50","286","270.22","422.54","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 4 HOLE 5 SHAFT BONE L SHAPE BASE TITANIUM LEFT","SUP-ITM-10003792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","517.06","387.79","AETNA [1001]","HB AMC AETNA PPO","415.72","80.4","","1261.44","103.12","1514.10","21","270.22","422.54","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 4 HOLE 5 SHAFT BONE L SHAPE BASE TITANIUM LEFT","SUP-ITM-10003792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","517.06","387.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","415.72","80.4","","1365.00","1365.00","1365.00","1 through 10","270.22","422.54","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 4 HOLE 5 SHAFT BONE L SHAPE BASE TITANIUM LEFT","SUP-ITM-10003792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","517.06","387.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","422.54","81.72","","5157.68","5157.68","5157.68","1 through 10","270.22","422.54","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 4 HOLE 5 SHAFT BONE L SHAPE BASE TITANIUM LEFT","SUP-ITM-10003792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","517.06","387.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","422.54","81.72","","431.26","71.26","1459.57","88","270.22","422.54","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 5 HOLE TITANIUMXSHAPE","SUP-ITM-10003797","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","369.52","79.5","","800.18","480.96","1887.97","195","144.09","369.52","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 5 HOLE TITANIUMXSHAPE","SUP-ITM-10003797","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","247.74","53.3","","813.12","216.42","1444.50","81","144.09","369.52","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 5 HOLE TITANIUMXSHAPE","SUP-ITM-10003797","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","144.09","31","","432.60","432.60","432.60","1 through 10","144.09","369.52","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 5 HOLE TITANIUMXSHAPE","SUP-ITM-10003797","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","169.65","36.5","","148.37","54.89","631.39","94","144.09","369.52","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 5 HOLE TITANIUMXSHAPE","SUP-ITM-10003797","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","178.02","38.3","","279.30","91.72","1116.77","266","144.09","369.52","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 5 HOLE TITANIUMXSHAPE","SUP-ITM-10003797","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.40","42.9","","731.00","63.70","731.00","1 through 10","144.09","369.52","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 5 HOLE TITANIUMXSHAPE","SUP-ITM-10003797","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.40","42.9","","384.74","384.74","384.74","1 through 10","144.09","369.52","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 5 HOLE TITANIUMXSHAPE","SUP-ITM-10003797","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","WELLPOINT [1015]","HB AMC WELLPOINT","342.93","73.78","","286.63","119.22","1107.45","105","144.09","369.52","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 5 HOLE TITANIUMXSHAPE","SUP-ITM-10003797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","AETNA [1001]","HB AMC AETNA HMO","324.43","69.8","","675.31","184.75","1721.50","286","242.9","379.83","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 5 HOLE TITANIUMXSHAPE","SUP-ITM-10003797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","AETNA [1001]","HB AMC AETNA PPO","373.70","80.4","","1261.44","103.12","1514.10","21","242.9","379.83","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 5 HOLE TITANIUMXSHAPE","SUP-ITM-10003797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","373.70","80.4","","1365.00","1365.00","1365.00","1 through 10","242.9","379.83","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 5 HOLE TITANIUMXSHAPE","SUP-ITM-10003797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","379.83","81.72","","5157.68","5157.68","5157.68","1 through 10","242.9","379.83","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 5 HOLE TITANIUMXSHAPE","SUP-ITM-10003797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","379.83","81.72","","431.26","71.26","1459.57","88","242.9","379.83","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 6 HOLE TITANIUM DOUBLE Y SHAPE","SUP-ITM-10003795","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.05","411.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","436.49","79.5","","800.18","480.96","1887.97","195","170.21","436.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 6 HOLE TITANIUM DOUBLE Y SHAPE","SUP-ITM-10003795","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.05","411.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","292.64","53.3","","813.12","216.42","1444.50","81","170.21","436.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 6 HOLE TITANIUM DOUBLE Y SHAPE","SUP-ITM-10003795","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.05","411.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","170.21","31","","432.60","432.60","432.60","1 through 10","170.21","436.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 6 HOLE TITANIUM DOUBLE Y SHAPE","SUP-ITM-10003795","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.05","411.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","200.40","36.5","","148.37","54.89","631.39","94","170.21","436.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 6 HOLE TITANIUM DOUBLE Y SHAPE","SUP-ITM-10003795","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.05","411.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","210.29","38.3","","279.30","91.72","1116.77","266","170.21","436.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 6 HOLE TITANIUM DOUBLE Y SHAPE","SUP-ITM-10003795","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.05","411.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","235.54","42.9","","731.00","63.70","731.00","1 through 10","170.21","436.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 6 HOLE TITANIUM DOUBLE Y SHAPE","SUP-ITM-10003795","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.05","411.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","235.54","42.9","","384.74","384.74","384.74","1 through 10","170.21","436.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 6 HOLE TITANIUM DOUBLE Y SHAPE","SUP-ITM-10003795","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.05","411.79","WELLPOINT [1015]","HB AMC WELLPOINT","405.09","73.78","","286.63","119.22","1107.45","105","170.21","436.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 6 HOLE TITANIUM DOUBLE Y SHAPE","SUP-ITM-10003795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.05","411.79","AETNA [1001]","HB AMC AETNA HMO","383.24","69.8","","675.31","184.75","1721.50","286","286.93","448.68","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 6 HOLE TITANIUM DOUBLE Y SHAPE","SUP-ITM-10003795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.05","411.79","AETNA [1001]","HB AMC AETNA PPO","441.44","80.4","","1261.44","103.12","1514.10","21","286.93","448.68","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 6 HOLE TITANIUM DOUBLE Y SHAPE","SUP-ITM-10003795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.05","411.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","441.44","80.4","","1365.00","1365.00","1365.00","1 through 10","286.93","448.68","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 6 HOLE TITANIUM DOUBLE Y SHAPE","SUP-ITM-10003795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.05","411.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","448.68","81.72","","5157.68","5157.68","5157.68","1 through 10","286.93","448.68","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1MM 6 HOLE TITANIUM DOUBLE Y SHAPE","SUP-ITM-10003795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.05","411.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","448.68","81.72","","431.26","71.26","1459.57","88","286.93","448.68","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077432","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","519.64","79.5","","800.18","480.96","1887.97","195","202.63","519.64","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077432","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","348.38","53.3","","813.12","216.42","1444.50","81","202.63","519.64","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077432","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","202.63","31","","432.60","432.60","432.60","1 through 10","202.63","519.64","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077432","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","238.57","36.5","","148.37","54.89","631.39","94","202.63","519.64","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077432","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","250.34","38.3","","279.30","91.72","1116.77","266","202.63","519.64","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077432","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.41","42.9","","731.00","63.70","731.00","1 through 10","202.63","519.64","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077432","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.41","42.9","","384.74","384.74","384.74","1 through 10","202.63","519.64","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077432","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","WELLPOINT [1015]","HB AMC WELLPOINT","482.25","73.78","","286.63","119.22","1107.45","105","202.63","519.64","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077432","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.63","490.22","AETNA [1001]","HB AMC AETNA HMO","456.23","69.8","","675.31","184.75","1721.50","286","341.59","534.15","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077432","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.63","490.22","AETNA [1001]","HB AMC AETNA PPO","525.52","80.4","","1261.44","103.12","1514.10","21","341.59","534.15","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077432","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.63","490.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","525.52","80.4","","1365.00","1365.00","1365.00","1 through 10","341.59","534.15","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077432","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.63","490.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","534.15","81.72","","5157.68","5157.68","5157.68","1 through 10","341.59","534.15","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077432","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.63","490.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","534.15","81.72","","431.26","71.26","1459.57","88","341.59","534.15","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077364","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","685.89","79.5","","800.18","480.96","1887.97","195","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077364","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","459.85","53.3","","813.12","216.42","1444.50","81","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077364","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","267.45","31","","432.60","432.60","432.60","1 through 10","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077364","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","314.90","36.5","","148.37","54.89","631.39","94","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077364","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","330.43","38.3","","279.30","91.72","1116.77","266","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077364","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","370.12","42.9","","731.00","63.70","731.00","1 through 10","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077364","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","370.12","42.9","","384.74","384.74","384.74","1 through 10","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077364","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","WELLPOINT [1015]","HB AMC WELLPOINT","636.54","73.78","","286.63","119.22","1107.45","105","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.75","647.06","AETNA [1001]","HB AMC AETNA HMO","602.20","69.8","","675.31","184.75","1721.50","286","450.87","705.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.75","647.06","AETNA [1001]","HB AMC AETNA PPO","693.65","80.4","","1261.44","103.12","1514.10","21","450.87","705.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.75","647.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","693.65","80.4","","1365.00","1365.00","1365.00","1 through 10","450.87","705.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.75","647.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","705.04","81.72","","5157.68","5157.68","5157.68","1 through 10","450.87","705.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.75","647.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","705.04","81.72","","431.26","71.26","1459.57","88","450.87","705.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077360","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.84","656.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","696.29","79.5","","1309.77","674.56","6049.93","26","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077360","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.84","656.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.82","53.3","","1901.83","1901.83","2962.25","1 through 10","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077360","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.84","656.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.68","36.5","","1620.31","1620.31","19908.88","1 through 10","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077360","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.84","656.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.45","38.3","","352.91","352.91","2046.30","1 through 10","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077360","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.84","656.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.74","42.9","","9668.75","9668.75","9668.75","1 through 10","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077360","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.84","656.88","WELLPOINT [1015]","HB AMC WELLPOINT","646.19","73.78","","699.88","384.10","3443.31","33","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077360","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.84","656.88","AETNA [1001]","HB AMC AETNA HMO","611.34","69.8","","1421.24","264.50","4933.46","29","457.71","715.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077360","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.84","656.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","704.18","80.4","","1022.97","1022.97","3607.50","1 through 10","457.71","715.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X10MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077360","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.84","656.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.74","81.72","","3010.54","693.88","5019.88","35","457.71","715.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077365","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.42","521.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","552.86","79.5","","800.18","480.96","1887.97","195","215.58","552.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077365","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.42","521.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","370.66","53.3","","813.12","216.42","1444.50","81","215.58","552.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077365","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.42","521.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","215.58","31","","432.60","432.60","432.60","1 through 10","215.58","552.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077365","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.42","521.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","253.83","36.5","","148.37","54.89","631.39","94","215.58","552.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077365","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.42","521.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","266.35","38.3","","279.30","91.72","1116.77","266","215.58","552.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077365","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.42","521.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.34","42.9","","731.00","63.70","731.00","1 through 10","215.58","552.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077365","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.42","521.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.34","42.9","","384.74","384.74","384.74","1 through 10","215.58","552.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077365","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.42","521.56","WELLPOINT [1015]","HB AMC WELLPOINT","513.08","73.78","","286.63","119.22","1107.45","105","215.58","552.86","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.42","521.56","AETNA [1001]","HB AMC AETNA HMO","485.40","69.8","","675.31","184.75","1721.50","286","363.43","568.3","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.42","521.56","AETNA [1001]","HB AMC AETNA PPO","559.12","80.4","","1261.44","103.12","1514.10","21","363.43","568.3","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.42","521.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","559.12","80.4","","1365.00","1365.00","1365.00","1 through 10","363.43","568.3","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.42","521.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","568.30","81.72","","5157.68","5157.68","5157.68","1 through 10","363.43","568.3","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.42","521.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","568.30","81.72","","431.26","71.26","1459.57","88","363.43","568.3","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077361","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","521.72","79.5","","800.18","480.96","1887.97","195","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077361","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","349.78","53.3","","813.12","216.42","1444.50","81","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077361","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","203.44","31","","432.60","432.60","432.60","1 through 10","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077361","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","239.53","36.5","","148.37","54.89","631.39","94","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077361","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","251.34","38.3","","279.30","91.72","1116.77","266","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077361","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","281.53","42.9","","731.00","63.70","731.00","1 through 10","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077361","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","281.53","42.9","","384.74","384.74","384.74","1 through 10","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077361","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","WELLPOINT [1015]","HB AMC WELLPOINT","484.18","73.78","","286.63","119.22","1107.45","105","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","656.25","492.19","AETNA [1001]","HB AMC AETNA HMO","458.06","69.8","","675.31","184.75","1721.50","286","342.96","536.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","656.25","492.19","AETNA [1001]","HB AMC AETNA PPO","527.63","80.4","","1261.44","103.12","1514.10","21","342.96","536.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","656.25","492.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","527.63","80.4","","1365.00","1365.00","1365.00","1 through 10","342.96","536.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","656.25","492.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","536.29","81.72","","5157.68","5157.68","5157.68","1 through 10","342.96","536.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X12MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","656.25","492.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","536.29","81.72","","431.26","71.26","1459.57","88","342.96","536.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X33MM 11 HOLE BONE TITANIUM ORBITAL RIM","SUP-ITM-10003788","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.06","433.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","459.56","79.5","","800.18","480.96","1887.97","195","179.2","459.56","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X33MM 11 HOLE BONE TITANIUM ORBITAL RIM","SUP-ITM-10003788","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.06","433.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","308.11","53.3","","813.12","216.42","1444.50","81","179.2","459.56","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X33MM 11 HOLE BONE TITANIUM ORBITAL RIM","SUP-ITM-10003788","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.06","433.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","179.20","31","","432.60","432.60","432.60","1 through 10","179.2","459.56","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X33MM 11 HOLE BONE TITANIUM ORBITAL RIM","SUP-ITM-10003788","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.06","433.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","210.99","36.5","","148.37","54.89","631.39","94","179.2","459.56","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X33MM 11 HOLE BONE TITANIUM ORBITAL RIM","SUP-ITM-10003788","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.06","433.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","221.40","38.3","","279.30","91.72","1116.77","266","179.2","459.56","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X33MM 11 HOLE BONE TITANIUM ORBITAL RIM","SUP-ITM-10003788","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.06","433.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.99","42.9","","731.00","63.70","731.00","1 through 10","179.2","459.56","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X33MM 11 HOLE BONE TITANIUM ORBITAL RIM","SUP-ITM-10003788","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.06","433.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.99","42.9","","384.74","384.74","384.74","1 through 10","179.2","459.56","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X33MM 11 HOLE BONE TITANIUM ORBITAL RIM","SUP-ITM-10003788","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.06","433.54","WELLPOINT [1015]","HB AMC WELLPOINT","426.49","73.78","","286.63","119.22","1107.45","105","179.2","459.56","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X33MM 11 HOLE BONE TITANIUM ORBITAL RIM","SUP-ITM-10003788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","578.06","433.54","AETNA [1001]","HB AMC AETNA HMO","403.49","69.8","","675.31","184.75","1721.50","286","302.09","472.39","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X33MM 11 HOLE BONE TITANIUM ORBITAL RIM","SUP-ITM-10003788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","578.06","433.54","AETNA [1001]","HB AMC AETNA PPO","464.76","80.4","","1261.44","103.12","1514.10","21","302.09","472.39","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X33MM 11 HOLE BONE TITANIUM ORBITAL RIM","SUP-ITM-10003788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","578.06","433.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","464.76","80.4","","1365.00","1365.00","1365.00","1 through 10","302.09","472.39","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X33MM 11 HOLE BONE TITANIUM ORBITAL RIM","SUP-ITM-10003788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","578.06","433.54","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","472.39","81.72","","5157.68","5157.68","5157.68","1 through 10","302.09","472.39","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X33MM 11 HOLE BONE TITANIUM ORBITAL RIM","SUP-ITM-10003788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","578.06","433.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","472.39","81.72","","431.26","71.26","1459.57","88","302.09","472.39","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X50X100MM 4 HOLE MESH TITANIUM","SUP-ITM-10002380","CDM","C1713","HCPCS","0278","RC","","","","both","","","3526.57","2644.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2803.62","79.5","","800.18","480.96","1887.97","195","1093.24","2803.62","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X50X100MM 4 HOLE MESH TITANIUM","SUP-ITM-10002380","CDM","C1713","HCPCS","0278","RC","","","","both","","","3526.57","2644.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1879.66","53.3","","813.12","216.42","1444.50","81","1093.24","2803.62","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X50X100MM 4 HOLE MESH TITANIUM","SUP-ITM-10002380","CDM","C1713","HCPCS","0278","RC","","","","both","","","3526.57","2644.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1093.24","31","","432.60","432.60","432.60","1 through 10","1093.24","2803.62","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X50X100MM 4 HOLE MESH TITANIUM","SUP-ITM-10002380","CDM","C1713","HCPCS","0278","RC","","","","both","","","3526.57","2644.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1287.20","36.5","","148.37","54.89","631.39","94","1093.24","2803.62","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X50X100MM 4 HOLE MESH TITANIUM","SUP-ITM-10002380","CDM","C1713","HCPCS","0278","RC","","","","both","","","3526.57","2644.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1350.68","38.3","","279.30","91.72","1116.77","266","1093.24","2803.62","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X50X100MM 4 HOLE MESH TITANIUM","SUP-ITM-10002380","CDM","C1713","HCPCS","0278","RC","","","","both","","","3526.57","2644.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1512.90","42.9","","731.00","63.70","731.00","1 through 10","1093.24","2803.62","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X50X100MM 4 HOLE MESH TITANIUM","SUP-ITM-10002380","CDM","C1713","HCPCS","0278","RC","","","","both","","","3526.57","2644.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1512.90","42.9","","384.74","384.74","384.74","1 through 10","1093.24","2803.62","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X50X100MM 4 HOLE MESH TITANIUM","SUP-ITM-10002380","CDM","C1713","HCPCS","0278","RC","","","","both","","","3526.57","2644.93","WELLPOINT [1015]","HB AMC WELLPOINT","2601.90","73.78","","286.63","119.22","1107.45","105","1093.24","2803.62","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X50X100MM 4 HOLE MESH TITANIUM","SUP-ITM-10002380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3526.57","2644.93","AETNA [1001]","HB AMC AETNA HMO","2461.55","69.8","","675.31","184.75","1721.50","286","1842.99","2881.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X50X100MM 4 HOLE MESH TITANIUM","SUP-ITM-10002380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3526.57","2644.93","AETNA [1001]","HB AMC AETNA PPO","2835.36","80.4","","1261.44","103.12","1514.10","21","1842.99","2881.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X50X100MM 4 HOLE MESH TITANIUM","SUP-ITM-10002380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3526.57","2644.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2835.36","80.4","","1365.00","1365.00","1365.00","1 through 10","1842.99","2881.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X50X100MM 4 HOLE MESH TITANIUM","SUP-ITM-10002380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3526.57","2644.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2881.91","81.72","","5157.68","5157.68","5157.68","1 through 10","1842.99","2881.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X50X100MM 4 HOLE MESH TITANIUM","SUP-ITM-10002380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3526.57","2644.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2881.91","81.72","","431.26","71.26","1459.57","88","1842.99","2881.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X6MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077358","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.84","656.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","696.29","79.5","","800.18","480.96","1887.97","195","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X6MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077358","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.84","656.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.82","53.3","","813.12","216.42","1444.50","81","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X6MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077358","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.84","656.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.51","31","","432.60","432.60","432.60","1 through 10","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X6MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077358","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.84","656.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.68","36.5","","148.37","54.89","631.39","94","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X6MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077358","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.84","656.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.45","38.3","","279.30","91.72","1116.77","266","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X6MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077358","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.84","656.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.74","42.9","","731.00","63.70","731.00","1 through 10","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X6MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077358","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.84","656.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.74","42.9","","384.74","384.74","384.74","1 through 10","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X6MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077358","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.84","656.88","WELLPOINT [1015]","HB AMC WELLPOINT","646.19","73.78","","286.63","119.22","1107.45","105","271.51","696.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X6MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.84","656.88","AETNA [1001]","HB AMC AETNA HMO","611.34","69.8","","675.31","184.75","1721.50","286","457.71","715.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X6MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.84","656.88","AETNA [1001]","HB AMC AETNA PPO","704.18","80.4","","1261.44","103.12","1514.10","21","457.71","715.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X6MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.84","656.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","704.18","80.4","","1365.00","1365.00","1365.00","1 through 10","457.71","715.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X6MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.84","656.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","715.74","81.72","","5157.68","5157.68","5157.68","1 through 10","457.71","715.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X6MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.84","656.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.74","81.72","","431.26","71.26","1459.57","88","457.71","715.74","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077363","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","685.89","79.5","","800.18","480.96","1887.97","195","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077363","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","459.85","53.3","","813.12","216.42","1444.50","81","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077363","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","267.45","31","","432.60","432.60","432.60","1 through 10","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077363","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","314.90","36.5","","148.37","54.89","631.39","94","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077363","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","330.43","38.3","","279.30","91.72","1116.77","266","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077363","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","370.12","42.9","","731.00","63.70","731.00","1 through 10","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077363","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","370.12","42.9","","384.74","384.74","384.74","1 through 10","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077363","CDM","C1713","HCPCS","0278","RC","","","","both","","","862.75","647.06","WELLPOINT [1015]","HB AMC WELLPOINT","636.54","73.78","","286.63","119.22","1107.45","105","267.45","685.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.75","647.06","AETNA [1001]","HB AMC AETNA HMO","602.20","69.8","","675.31","184.75","1721.50","286","450.87","705.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.75","647.06","AETNA [1001]","HB AMC AETNA PPO","693.65","80.4","","1261.44","103.12","1514.10","21","450.87","705.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.75","647.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","693.65","80.4","","1365.00","1365.00","1365.00","1 through 10","450.87","705.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.75","647.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","705.04","81.72","","5157.68","5157.68","5157.68","1 through 10","450.87","705.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 4 HOLE STRAIGHT SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","862.75","647.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","705.04","81.72","","431.26","71.26","1459.57","88","450.87","705.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077359","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","521.72","79.5","","800.18","480.96","1887.97","195","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077359","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","349.78","53.3","","813.12","216.42","1444.50","81","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077359","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","203.44","31","","432.60","432.60","432.60","1 through 10","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077359","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","239.53","36.5","","148.37","54.89","631.39","94","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077359","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","251.34","38.3","","279.30","91.72","1116.77","266","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077359","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","281.53","42.9","","731.00","63.70","731.00","1 through 10","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077359","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","281.53","42.9","","384.74","384.74","384.74","1 through 10","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077359","CDM","C1713","HCPCS","0278","RC","","","","both","","","656.25","492.19","WELLPOINT [1015]","HB AMC WELLPOINT","484.18","73.78","","286.63","119.22","1107.45","105","203.44","521.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","656.25","492.19","AETNA [1001]","HB AMC AETNA HMO","458.06","69.8","","675.31","184.75","1721.50","286","342.96","536.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","656.25","492.19","AETNA [1001]","HB AMC AETNA PPO","527.63","80.4","","1261.44","103.12","1514.10","21","342.96","536.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","656.25","492.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","527.63","80.4","","1365.00","1365.00","1365.00","1 through 10","342.96","536.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","656.25","492.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","536.29","81.72","","5157.68","5157.68","5157.68","1 through 10","342.96","536.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1X8MM 6 HOLE CURVED SAGITTAL SPLIT BAR TITANIUM ORTHOGNATHIC","SUP-ITM-10077359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","656.25","492.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","536.29","81.72","","431.26","71.26","1459.57","88","342.96","536.29","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM LG CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10129706","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4726.04","79.5","","800.18","480.96","1887.97","195","1842.86","4726.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM LG CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10129706","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3168.53","53.3","","813.12","216.42","1444.50","81","1842.86","4726.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM LG CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10129706","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1842.86","31","","432.60","432.60","432.60","1 through 10","1842.86","4726.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM LG CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10129706","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2169.82","36.5","","148.37","54.89","631.39","94","1842.86","4726.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM LG CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10129706","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2276.82","38.3","","279.30","91.72","1116.77","266","1842.86","4726.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM LG CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10129706","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2550.28","42.9","","731.00","63.70","731.00","1 through 10","1842.86","4726.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM LG CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10129706","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2550.28","42.9","","384.74","384.74","384.74","1 through 10","1842.86","4726.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM LG CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10129706","CDM","C1713","HCPCS","0278","RC","","","","both","","","5944.70","4458.52","WELLPOINT [1015]","HB AMC WELLPOINT","4386.00","73.78","","286.63","119.22","1107.45","105","1842.86","4726.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM LG CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10129706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5944.70","4458.52","AETNA [1001]","HB AMC AETNA HMO","4149.40","69.8","","675.31","184.75","1721.50","286","3106.7","4858.01","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM LG CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10129706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5944.70","4458.52","AETNA [1001]","HB AMC AETNA PPO","4779.54","80.4","","1261.44","103.12","1514.10","21","3106.7","4858.01","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM LG CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10129706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5944.70","4458.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4779.54","80.4","","1365.00","1365.00","1365.00","1 through 10","3106.7","4858.01","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM LG CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10129706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5944.70","4458.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4858.01","81.72","","5157.68","5157.68","5157.68","1 through 10","3106.7","4858.01","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM LG CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10129706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5944.70","4458.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4858.01","81.72","","431.26","71.26","1459.57","88","3106.7","4858.01","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MD 5X22X5 HOLE MATRIXMANDIBLE TITANIUM DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076592","CDM","C1713","HCPCS","0278","RC","","","","both","","","4379.76","3284.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3481.91","79.5","","800.18","480.96","1887.97","195","1357.73","3481.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MD 5X22X5 HOLE MATRIXMANDIBLE TITANIUM DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076592","CDM","C1713","HCPCS","0278","RC","","","","both","","","4379.76","3284.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2334.41","53.3","","813.12","216.42","1444.50","81","1357.73","3481.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MD 5X22X5 HOLE MATRIXMANDIBLE TITANIUM DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076592","CDM","C1713","HCPCS","0278","RC","","","","both","","","4379.76","3284.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1357.73","31","","432.60","432.60","432.60","1 through 10","1357.73","3481.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MD 5X22X5 HOLE MATRIXMANDIBLE TITANIUM DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076592","CDM","C1713","HCPCS","0278","RC","","","","both","","","4379.76","3284.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1598.61","36.5","","148.37","54.89","631.39","94","1357.73","3481.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MD 5X22X5 HOLE MATRIXMANDIBLE TITANIUM DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076592","CDM","C1713","HCPCS","0278","RC","","","","both","","","4379.76","3284.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1677.45","38.3","","279.30","91.72","1116.77","266","1357.73","3481.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MD 5X22X5 HOLE MATRIXMANDIBLE TITANIUM DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076592","CDM","C1713","HCPCS","0278","RC","","","","both","","","4379.76","3284.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1878.92","42.9","","731.00","63.70","731.00","1 through 10","1357.73","3481.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MD 5X22X5 HOLE MATRIXMANDIBLE TITANIUM DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076592","CDM","C1713","HCPCS","0278","RC","","","","both","","","4379.76","3284.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1878.92","42.9","","384.74","384.74","384.74","1 through 10","1357.73","3481.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MD 5X22X5 HOLE MATRIXMANDIBLE TITANIUM DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076592","CDM","C1713","HCPCS","0278","RC","","","","both","","","4379.76","3284.82","WELLPOINT [1015]","HB AMC WELLPOINT","3231.39","73.78","","286.63","119.22","1107.45","105","1357.73","3481.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MD 5X22X5 HOLE MATRIXMANDIBLE TITANIUM DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4379.76","3284.82","AETNA [1001]","HB AMC AETNA HMO","3057.07","69.8","","675.31","184.75","1721.50","286","2288.86","3579.14","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MD 5X22X5 HOLE MATRIXMANDIBLE TITANIUM DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4379.76","3284.82","AETNA [1001]","HB AMC AETNA PPO","3521.33","80.4","","1261.44","103.12","1514.10","21","2288.86","3579.14","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MD 5X22X5 HOLE MATRIXMANDIBLE TITANIUM DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4379.76","3284.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3521.33","80.4","","1365.00","1365.00","1365.00","1 through 10","2288.86","3579.14","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MD 5X22X5 HOLE MATRIXMANDIBLE TITANIUM DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4379.76","3284.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3579.14","81.72","","5157.68","5157.68","5157.68","1 through 10","2288.86","3579.14","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MD 5X22X5 HOLE MATRIXMANDIBLE TITANIUM DOUBLE ANGLE RECONSTRUCTION","SUP-ITM-10076592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4379.76","3284.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3579.14","81.72","","431.26","71.26","1459.57","88","2288.86","3579.14","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10115406","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4561.07","79.5","","800.18","480.96","1887.97","195","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10115406","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3057.93","53.3","","813.12","216.42","1444.50","81","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10115406","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1778.53","31","","432.60","432.60","432.60","1 through 10","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10115406","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2094.08","36.5","","148.37","54.89","631.39","94","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10115406","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2197.35","38.3","","279.30","91.72","1116.77","266","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10115406","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2461.26","42.9","","731.00","63.70","731.00","1 through 10","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10115406","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2461.26","42.9","","384.74","384.74","384.74","1 through 10","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10115406","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","WELLPOINT [1015]","HB AMC WELLPOINT","4232.91","73.78","","286.63","119.22","1107.45","105","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10115406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5737.20","4302.90","AETNA [1001]","HB AMC AETNA HMO","4004.57","69.8","","675.31","184.75","1721.50","286","2998.26","4688.44","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10115406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5737.20","4302.90","AETNA [1001]","HB AMC AETNA PPO","4612.71","80.4","","1261.44","103.12","1514.10","21","2998.26","4688.44","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10115406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5737.20","4302.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4612.71","80.4","","1365.00","1365.00","1365.00","1 through 10","2998.26","4688.44","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10115406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5737.20","4302.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4688.44","81.72","","5157.68","5157.68","5157.68","1 through 10","2998.26","4688.44","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION LEFT","SUP-ITM-10115406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5737.20","4302.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4688.44","81.72","","431.26","71.26","1459.57","88","2998.26","4688.44","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131193","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4561.07","79.5","","800.18","480.96","1887.97","195","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131193","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3057.93","53.3","","813.12","216.42","1444.50","81","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131193","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1778.53","31","","432.60","432.60","432.60","1 through 10","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131193","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2094.08","36.5","","148.37","54.89","631.39","94","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131193","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2197.35","38.3","","279.30","91.72","1116.77","266","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131193","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2461.26","42.9","","731.00","63.70","731.00","1 through 10","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131193","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2461.26","42.9","","384.74","384.74","384.74","1 through 10","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131193","CDM","C1713","HCPCS","0278","RC","","","","both","","","5737.20","4302.90","WELLPOINT [1015]","HB AMC WELLPOINT","4232.91","73.78","","286.63","119.22","1107.45","105","1778.53","4561.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5737.20","4302.90","AETNA [1001]","HB AMC AETNA HMO","4004.57","69.8","","675.31","184.75","1721.50","286","2998.26","4688.44","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5737.20","4302.90","AETNA [1001]","HB AMC AETNA PPO","4612.71","80.4","","1261.44","103.12","1514.10","21","2998.26","4688.44","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5737.20","4302.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4612.71","80.4","","1365.00","1365.00","1365.00","1 through 10","2998.26","4688.44","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5737.20","4302.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4688.44","81.72","","5157.68","5157.68","5157.68","1 through 10","2998.26","4688.44","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM MED MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10131193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5737.20","4302.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4688.44","81.72","","431.26","71.26","1459.57","88","2998.26","4688.44","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM SM CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10115405","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4396.11","79.5","","800.18","480.96","1887.97","195","1714.21","4396.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM SM CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10115405","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2947.33","53.3","","813.12","216.42","1444.50","81","1714.21","4396.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM SM CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10115405","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1714.21","31","","432.60","432.60","432.60","1 through 10","1714.21","4396.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM SM CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10115405","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2018.34","36.5","","148.37","54.89","631.39","94","1714.21","4396.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM SM CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10115405","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2117.88","38.3","","279.30","91.72","1116.77","266","1714.21","4396.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM SM CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10115405","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2372.24","42.9","","731.00","63.70","731.00","1 through 10","1714.21","4396.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM SM CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10115405","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2372.24","42.9","","384.74","384.74","384.74","1 through 10","1714.21","4396.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM SM CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10115405","CDM","C1713","HCPCS","0278","RC","","","","both","","","5529.70","4147.27","WELLPOINT [1015]","HB AMC WELLPOINT","4079.81","73.78","","286.63","119.22","1107.45","105","1714.21","4396.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM SM CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10115405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5529.70","4147.27","AETNA [1001]","HB AMC AETNA HMO","3859.73","69.8","","675.31","184.75","1721.50","286","2889.82","4518.87","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM SM CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10115405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5529.70","4147.27","AETNA [1001]","HB AMC AETNA PPO","4445.88","80.4","","1261.44","103.12","1514.10","21","2889.82","4518.87","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM SM CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10115405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5529.70","4147.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4445.88","80.4","","1365.00","1365.00","1365.00","1 through 10","2889.82","4518.87","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM SM CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10115405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5529.70","4147.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4518.87","81.72","","5157.68","5157.68","5157.68","1 through 10","2889.82","4518.87","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2.5MM SM CRANIAL MATRIXMANDIBLE TITANIUM PREFORMED RECONSTRUCTION RIGHT","SUP-ITM-10115405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5529.70","4147.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4518.87","81.72","","431.26","71.26","1459.57","88","2889.82","4518.87","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2MM 12 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.29","1230.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1304.83","79.5","","800.18","480.96","1887.97","195","508.8","1304.83","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2MM 12 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.29","1230.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","874.81","53.3","","813.12","216.42","1444.50","81","508.8","1304.83","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2MM 12 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.29","1230.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","508.80","31","","432.60","432.60","432.60","1 through 10","508.8","1304.83","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2MM 12 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.29","1230.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","599.07","36.5","","148.37","54.89","631.39","94","508.8","1304.83","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2MM 12 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.29","1230.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","628.61","38.3","","279.30","91.72","1116.77","266","508.8","1304.83","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2MM 12 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.29","1230.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","704.11","42.9","","731.00","63.70","731.00","1 through 10","508.8","1304.83","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2MM 12 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.29","1230.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","704.11","42.9","","384.74","384.74","384.74","1 through 10","508.8","1304.83","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2MM 12 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081100","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.29","1230.97","WELLPOINT [1015]","HB AMC WELLPOINT","1210.94","73.78","","286.63","119.22","1107.45","105","508.8","1304.83","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2MM 12 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.29","1230.97","AETNA [1001]","HB AMC AETNA HMO","1145.62","69.8","","675.31","184.75","1721.50","286","857.74","1341.26","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2MM 12 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.29","1230.97","AETNA [1001]","HB AMC AETNA PPO","1319.60","80.4","","1261.44","103.12","1514.10","21","857.74","1341.26","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2MM 12 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.29","1230.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1319.60","80.4","","1365.00","1365.00","1365.00","1 through 10","857.74","1341.26","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2MM 12 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.29","1230.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1341.26","81.72","","5157.68","5157.68","5157.68","1 through 10","857.74","1341.26","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2MM 12 HOLE MATRIXMANDIBLE TITANIUM STRAIGHT","SUP-ITM-10081100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.29","1230.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1341.26","81.72","","431.26","71.26","1459.57","88","857.74","1341.26","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X193MM 30 HOLE ADAPTION DCP BROAD SPACED TITANIUM","SUP-ITM-10001824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.91","803.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","852.17","79.5","","800.18","480.96","1887.97","195","332.29","852.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X193MM 30 HOLE ADAPTION DCP BROAD SPACED TITANIUM","SUP-ITM-10001824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.91","803.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","571.33","53.3","","813.12","216.42","1444.50","81","332.29","852.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X193MM 30 HOLE ADAPTION DCP BROAD SPACED TITANIUM","SUP-ITM-10001824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.91","803.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","332.29","31","","432.60","432.60","432.60","1 through 10","332.29","852.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X193MM 30 HOLE ADAPTION DCP BROAD SPACED TITANIUM","SUP-ITM-10001824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.91","803.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","391.25","36.5","","148.37","54.89","631.39","94","332.29","852.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X193MM 30 HOLE ADAPTION DCP BROAD SPACED TITANIUM","SUP-ITM-10001824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.91","803.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","410.54","38.3","","279.30","91.72","1116.77","266","332.29","852.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X193MM 30 HOLE ADAPTION DCP BROAD SPACED TITANIUM","SUP-ITM-10001824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.91","803.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","459.85","42.9","","731.00","63.70","731.00","1 through 10","332.29","852.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X193MM 30 HOLE ADAPTION DCP BROAD SPACED TITANIUM","SUP-ITM-10001824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.91","803.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","459.85","42.9","","384.74","384.74","384.74","1 through 10","332.29","852.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X193MM 30 HOLE ADAPTION DCP BROAD SPACED TITANIUM","SUP-ITM-10001824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.91","803.93","WELLPOINT [1015]","HB AMC WELLPOINT","790.86","73.78","","286.63","119.22","1107.45","105","332.29","852.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X193MM 30 HOLE ADAPTION DCP BROAD SPACED TITANIUM","SUP-ITM-10001824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.91","803.93","AETNA [1001]","HB AMC AETNA HMO","748.19","69.8","","675.31","184.75","1721.50","286","560.18","875.96","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X193MM 30 HOLE ADAPTION DCP BROAD SPACED TITANIUM","SUP-ITM-10001824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.91","803.93","AETNA [1001]","HB AMC AETNA PPO","861.82","80.4","","1261.44","103.12","1514.10","21","560.18","875.96","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X193MM 30 HOLE ADAPTION DCP BROAD SPACED TITANIUM","SUP-ITM-10001824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.91","803.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","861.82","80.4","","1365.00","1365.00","1365.00","1 through 10","560.18","875.96","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X193MM 30 HOLE ADAPTION DCP BROAD SPACED TITANIUM","SUP-ITM-10001824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.91","803.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","875.96","81.72","","5157.68","5157.68","5157.68","1 through 10","560.18","875.96","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X193MM 30 HOLE ADAPTION DCP BROAD SPACED TITANIUM","SUP-ITM-10001824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.91","803.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","875.96","81.72","","431.26","71.26","1459.57","88","560.18","875.96","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.73","1121.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1189.11","79.5","","800.18","480.96","1887.97","195","463.68","1189.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.73","1121.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","797.22","53.3","","813.12","216.42","1444.50","81","463.68","1189.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.73","1121.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","463.68","31","","432.60","432.60","432.60","1 through 10","463.68","1189.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.73","1121.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","545.94","36.5","","148.37","54.89","631.39","94","463.68","1189.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.73","1121.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","572.86","38.3","","279.30","91.72","1116.77","266","463.68","1189.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.73","1121.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","641.67","42.9","","731.00","63.70","731.00","1 through 10","463.68","1189.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.73","1121.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","641.67","42.9","","384.74","384.74","384.74","1 through 10","463.68","1189.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.73","1121.80","WELLPOINT [1015]","HB AMC WELLPOINT","1103.55","73.78","","286.63","119.22","1107.45","105","463.68","1189.11","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1495.73","1121.80","AETNA [1001]","HB AMC AETNA HMO","1044.02","69.8","","675.31","184.75","1721.50","286","781.67","1222.31","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1495.73","1121.80","AETNA [1001]","HB AMC AETNA PPO","1202.57","80.4","","1261.44","103.12","1514.10","21","781.67","1222.31","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1495.73","1121.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1202.57","80.4","","1365.00","1365.00","1365.00","1 through 10","781.67","1222.31","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1495.73","1121.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1222.31","81.72","","5157.68","5157.68","5157.68","1 through 10","781.67","1222.31","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1495.73","1121.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1222.31","81.72","","431.26","71.26","1459.57","88","781.67","1222.31","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X4MM 5 HOLE CHIN DOUBLE BEND OFFSET TITANIUM","SUP-ITM-10001940","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.44","494.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","524.25","79.5","","800.18","480.96","1887.97","195","204.43","524.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X4MM 5 HOLE CHIN DOUBLE BEND OFFSET TITANIUM","SUP-ITM-10001940","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.44","494.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","351.48","53.3","","813.12","216.42","1444.50","81","204.43","524.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X4MM 5 HOLE CHIN DOUBLE BEND OFFSET TITANIUM","SUP-ITM-10001940","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.44","494.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","204.43","31","","432.60","432.60","432.60","1 through 10","204.43","524.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X4MM 5 HOLE CHIN DOUBLE BEND OFFSET TITANIUM","SUP-ITM-10001940","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.44","494.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","240.70","36.5","","148.37","54.89","631.39","94","204.43","524.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X4MM 5 HOLE CHIN DOUBLE BEND OFFSET TITANIUM","SUP-ITM-10001940","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.44","494.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","252.57","38.3","","279.30","91.72","1116.77","266","204.43","524.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X4MM 5 HOLE CHIN DOUBLE BEND OFFSET TITANIUM","SUP-ITM-10001940","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.44","494.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","282.90","42.9","","731.00","63.70","731.00","1 through 10","204.43","524.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X4MM 5 HOLE CHIN DOUBLE BEND OFFSET TITANIUM","SUP-ITM-10001940","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.44","494.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","282.90","42.9","","384.74","384.74","384.74","1 through 10","204.43","524.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X4MM 5 HOLE CHIN DOUBLE BEND OFFSET TITANIUM","SUP-ITM-10001940","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.44","494.58","WELLPOINT [1015]","HB AMC WELLPOINT","486.53","73.78","","286.63","119.22","1107.45","105","204.43","524.25","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X4MM 5 HOLE CHIN DOUBLE BEND OFFSET TITANIUM","SUP-ITM-10001940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.44","494.58","AETNA [1001]","HB AMC AETNA HMO","460.29","69.8","","675.31","184.75","1721.50","286","344.62","538.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X4MM 5 HOLE CHIN DOUBLE BEND OFFSET TITANIUM","SUP-ITM-10001940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.44","494.58","AETNA [1001]","HB AMC AETNA PPO","530.19","80.4","","1261.44","103.12","1514.10","21","344.62","538.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X4MM 5 HOLE CHIN DOUBLE BEND OFFSET TITANIUM","SUP-ITM-10001940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.44","494.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","530.19","80.4","","1365.00","1365.00","1365.00","1 through 10","344.62","538.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X4MM 5 HOLE CHIN DOUBLE BEND OFFSET TITANIUM","SUP-ITM-10001940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.44","494.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","538.89","81.72","","5157.68","5157.68","5157.68","1 through 10","344.62","538.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X4MM 5 HOLE CHIN DOUBLE BEND OFFSET TITANIUM","SUP-ITM-10001940","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.44","494.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","538.89","81.72","","431.26","71.26","1459.57","88","344.62","538.89","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 3X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1474.73","79.5","","800.18","480.96","1887.97","195","575.05","1474.73","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 3X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","988.72","53.3","","813.12","216.42","1444.50","81","575.05","1474.73","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 3X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","575.05","31","","432.60","432.60","432.60","1 through 10","575.05","1474.73","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 3X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","677.08","36.5","","148.37","54.89","631.39","94","575.05","1474.73","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 3X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","710.47","38.3","","279.30","91.72","1116.77","266","575.05","1474.73","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 3X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","795.80","42.9","","731.00","63.70","731.00","1 through 10","575.05","1474.73","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 3X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","795.80","42.9","","384.74","384.74","384.74","1 through 10","575.05","1474.73","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 3X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","WELLPOINT [1015]","HB AMC WELLPOINT","1368.62","73.78","","286.63","119.22","1107.45","105","575.05","1474.73","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 3X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1855.00","1391.25","AETNA [1001]","HB AMC AETNA HMO","1294.79","69.8","","675.31","184.75","1721.50","286","969.42","1515.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 3X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1855.00","1391.25","AETNA [1001]","HB AMC AETNA PPO","1491.42","80.4","","1261.44","103.12","1514.10","21","969.42","1515.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 3X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1855.00","1391.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1491.42","80.4","","1365.00","1365.00","1365.00","1 through 10","969.42","1515.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 3X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1855.00","1391.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1515.91","81.72","","5157.68","5157.68","5157.68","1 through 10","969.42","1515.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 3X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1855.00","1391.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1515.91","81.72","","431.26","71.26","1459.57","88","969.42","1515.91","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 56MM 4X18 HOLE TITANIUM LOCKING RECONSTRUCTION CONDYLAR HEAD RIGHT","SUP-ITM-10030873","CDM","C1713","HCPCS","0278","RC","","","","both","","","6382.50","4786.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5074.09","79.5","","800.18","480.96","1887.97","195","1978.58","5074.09","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 56MM 4X18 HOLE TITANIUM LOCKING RECONSTRUCTION CONDYLAR HEAD RIGHT","SUP-ITM-10030873","CDM","C1713","HCPCS","0278","RC","","","","both","","","6382.50","4786.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3401.87","53.3","","813.12","216.42","1444.50","81","1978.58","5074.09","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 56MM 4X18 HOLE TITANIUM LOCKING RECONSTRUCTION CONDYLAR HEAD RIGHT","SUP-ITM-10030873","CDM","C1713","HCPCS","0278","RC","","","","both","","","6382.50","4786.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1978.58","31","","432.60","432.60","432.60","1 through 10","1978.58","5074.09","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 56MM 4X18 HOLE TITANIUM LOCKING RECONSTRUCTION CONDYLAR HEAD RIGHT","SUP-ITM-10030873","CDM","C1713","HCPCS","0278","RC","","","","both","","","6382.50","4786.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2329.61","36.5","","148.37","54.89","631.39","94","1978.58","5074.09","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 56MM 4X18 HOLE TITANIUM LOCKING RECONSTRUCTION CONDYLAR HEAD RIGHT","SUP-ITM-10030873","CDM","C1713","HCPCS","0278","RC","","","","both","","","6382.50","4786.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2444.50","38.3","","279.30","91.72","1116.77","266","1978.58","5074.09","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 56MM 4X18 HOLE TITANIUM LOCKING RECONSTRUCTION CONDYLAR HEAD RIGHT","SUP-ITM-10030873","CDM","C1713","HCPCS","0278","RC","","","","both","","","6382.50","4786.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2738.09","42.9","","731.00","63.70","731.00","1 through 10","1978.58","5074.09","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 56MM 4X18 HOLE TITANIUM LOCKING RECONSTRUCTION CONDYLAR HEAD RIGHT","SUP-ITM-10030873","CDM","C1713","HCPCS","0278","RC","","","","both","","","6382.50","4786.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2738.09","42.9","","384.74","384.74","384.74","1 through 10","1978.58","5074.09","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 56MM 4X18 HOLE TITANIUM LOCKING RECONSTRUCTION CONDYLAR HEAD RIGHT","SUP-ITM-10030873","CDM","C1713","HCPCS","0278","RC","","","","both","","","6382.50","4786.87","WELLPOINT [1015]","HB AMC WELLPOINT","4709.01","73.78","","286.63","119.22","1107.45","105","1978.58","5074.09","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 56MM 4X18 HOLE TITANIUM LOCKING RECONSTRUCTION CONDYLAR HEAD RIGHT","SUP-ITM-10030873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6382.50","4786.87","AETNA [1001]","HB AMC AETNA HMO","4454.99","69.8","","675.31","184.75","1721.50","286","3335.49","5215.78","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 56MM 4X18 HOLE TITANIUM LOCKING RECONSTRUCTION CONDYLAR HEAD RIGHT","SUP-ITM-10030873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6382.50","4786.87","AETNA [1001]","HB AMC AETNA PPO","5131.53","80.4","","1261.44","103.12","1514.10","21","3335.49","5215.78","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 56MM 4X18 HOLE TITANIUM LOCKING RECONSTRUCTION CONDYLAR HEAD RIGHT","SUP-ITM-10030873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6382.50","4786.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5131.53","80.4","","1365.00","1365.00","1365.00","1 through 10","3335.49","5215.78","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 56MM 4X18 HOLE TITANIUM LOCKING RECONSTRUCTION CONDYLAR HEAD RIGHT","SUP-ITM-10030873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6382.50","4786.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5215.78","81.72","","5157.68","5157.68","5157.68","1 through 10","3335.49","5215.78","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 56MM 4X18 HOLE TITANIUM LOCKING RECONSTRUCTION CONDYLAR HEAD RIGHT","SUP-ITM-10030873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6382.50","4786.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5215.78","81.72","","431.26","71.26","1459.57","88","3335.49","5215.78","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X10X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077431","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.10","479.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","508.08","79.5","","800.18","480.96","1887.97","195","198.12","508.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X10X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077431","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.10","479.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","340.64","53.3","","813.12","216.42","1444.50","81","198.12","508.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X10X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077431","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.10","479.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.12","31","","432.60","432.60","432.60","1 through 10","198.12","508.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X10X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077431","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.10","479.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.27","36.5","","148.37","54.89","631.39","94","198.12","508.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X10X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077431","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.10","479.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","244.78","38.3","","279.30","91.72","1116.77","266","198.12","508.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X10X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077431","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.10","479.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.17","42.9","","731.00","63.70","731.00","1 through 10","198.12","508.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X10X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077431","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.10","479.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.17","42.9","","384.74","384.74","384.74","1 through 10","198.12","508.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X10X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077431","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.10","479.32","WELLPOINT [1015]","HB AMC WELLPOINT","471.53","73.78","","286.63","119.22","1107.45","105","198.12","508.08","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X10X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.10","479.32","AETNA [1001]","HB AMC AETNA HMO","446.09","69.8","","675.31","184.75","1721.50","286","333.99","522.27","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X10X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.10","479.32","AETNA [1001]","HB AMC AETNA PPO","513.84","80.4","","1261.44","103.12","1514.10","21","333.99","522.27","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X10X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.10","479.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","513.84","80.4","","1365.00","1365.00","1365.00","1 through 10","333.99","522.27","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X10X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.10","479.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","522.27","81.72","","5157.68","5157.68","5157.68","1 through 10","333.99","522.27","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X10X.7MM 4 HOLE MATRIXMIDFACE TITANIUM","SUP-ITM-10077431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.10","479.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","522.27","81.72","","431.26","71.26","1459.57","88","333.99","522.27","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001844","CDM","C1713","HCPCS","0278","RC","","","","both","","","557.73","418.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","443.40","79.5","","800.18","480.96","1887.97","195","172.9","443.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001844","CDM","C1713","HCPCS","0278","RC","","","","both","","","557.73","418.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","297.27","53.3","","813.12","216.42","1444.50","81","172.9","443.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001844","CDM","C1713","HCPCS","0278","RC","","","","both","","","557.73","418.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","172.90","31","","432.60","432.60","432.60","1 through 10","172.9","443.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001844","CDM","C1713","HCPCS","0278","RC","","","","both","","","557.73","418.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","203.57","36.5","","148.37","54.89","631.39","94","172.9","443.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001844","CDM","C1713","HCPCS","0278","RC","","","","both","","","557.73","418.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","213.61","38.3","","279.30","91.72","1116.77","266","172.9","443.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001844","CDM","C1713","HCPCS","0278","RC","","","","both","","","557.73","418.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.27","42.9","","731.00","63.70","731.00","1 through 10","172.9","443.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001844","CDM","C1713","HCPCS","0278","RC","","","","both","","","557.73","418.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.27","42.9","","384.74","384.74","384.74","1 through 10","172.9","443.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001844","CDM","C1713","HCPCS","0278","RC","","","","both","","","557.73","418.30","WELLPOINT [1015]","HB AMC WELLPOINT","411.49","73.78","","286.63","119.22","1107.45","105","172.9","443.4","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","557.73","418.30","AETNA [1001]","HB AMC AETNA HMO","389.30","69.8","","675.31","184.75","1721.50","286","291.47","455.78","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","557.73","418.30","AETNA [1001]","HB AMC AETNA PPO","448.41","80.4","","1261.44","103.12","1514.10","21","291.47","455.78","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","557.73","418.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","448.41","80.4","","1365.00","1365.00","1365.00","1 through 10","291.47","455.78","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","557.73","418.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","455.78","81.72","","5157.68","5157.68","5157.68","1 through 10","291.47","455.78","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 5X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","557.73","418.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","455.78","81.72","","431.26","71.26","1459.57","88","291.47","455.78","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X30MM 16 HOLE BONE STRUT TITANIUM FOR SCREW","SUP-ITM-10027817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1060.29","795.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","842.93","79.5","","800.18","480.96","1887.97","195","328.69","842.93","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X30MM 16 HOLE BONE STRUT TITANIUM FOR SCREW","SUP-ITM-10027817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1060.29","795.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","565.13","53.3","","813.12","216.42","1444.50","81","328.69","842.93","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X30MM 16 HOLE BONE STRUT TITANIUM FOR SCREW","SUP-ITM-10027817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1060.29","795.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","328.69","31","","432.60","432.60","432.60","1 through 10","328.69","842.93","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X30MM 16 HOLE BONE STRUT TITANIUM FOR SCREW","SUP-ITM-10027817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1060.29","795.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","387.01","36.5","","148.37","54.89","631.39","94","328.69","842.93","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X30MM 16 HOLE BONE STRUT TITANIUM FOR SCREW","SUP-ITM-10027817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1060.29","795.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","406.09","38.3","","279.30","91.72","1116.77","266","328.69","842.93","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X30MM 16 HOLE BONE STRUT TITANIUM FOR SCREW","SUP-ITM-10027817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1060.29","795.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","454.86","42.9","","731.00","63.70","731.00","1 through 10","328.69","842.93","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X30MM 16 HOLE BONE STRUT TITANIUM FOR SCREW","SUP-ITM-10027817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1060.29","795.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","454.86","42.9","","384.74","384.74","384.74","1 through 10","328.69","842.93","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X30MM 16 HOLE BONE STRUT TITANIUM FOR SCREW","SUP-ITM-10027817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1060.29","795.22","WELLPOINT [1015]","HB AMC WELLPOINT","782.28","73.78","","286.63","119.22","1107.45","105","328.69","842.93","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X30MM 16 HOLE BONE STRUT TITANIUM FOR SCREW","SUP-ITM-10027817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1060.29","795.22","AETNA [1001]","HB AMC AETNA HMO","740.08","69.8","","675.31","184.75","1721.50","286","554.11","866.47","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X30MM 16 HOLE BONE STRUT TITANIUM FOR SCREW","SUP-ITM-10027817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1060.29","795.22","AETNA [1001]","HB AMC AETNA PPO","852.47","80.4","","1261.44","103.12","1514.10","21","554.11","866.47","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X30MM 16 HOLE BONE STRUT TITANIUM FOR SCREW","SUP-ITM-10027817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1060.29","795.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","852.47","80.4","","1365.00","1365.00","1365.00","1 through 10","554.11","866.47","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X30MM 16 HOLE BONE STRUT TITANIUM FOR SCREW","SUP-ITM-10027817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1060.29","795.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","866.47","81.72","","5157.68","5157.68","5157.68","1 through 10","554.11","866.47","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X30MM 16 HOLE BONE STRUT TITANIUM FOR SCREW","SUP-ITM-10027817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1060.29","795.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","866.47","81.72","","431.26","71.26","1459.57","88","554.11","866.47","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X42MM 22 HOLE STRUT TITANIUM FOR SCREW","SUP-ITM-10028540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.92","895.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","949.17","79.5","","800.18","480.96","1887.97","195","370.12","949.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X42MM 22 HOLE STRUT TITANIUM FOR SCREW","SUP-ITM-10028540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.92","895.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","636.36","53.3","","813.12","216.42","1444.50","81","370.12","949.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X42MM 22 HOLE STRUT TITANIUM FOR SCREW","SUP-ITM-10028540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.92","895.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","370.12","31","","432.60","432.60","432.60","1 through 10","370.12","949.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X42MM 22 HOLE STRUT TITANIUM FOR SCREW","SUP-ITM-10028540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.92","895.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","435.78","36.5","","148.37","54.89","631.39","94","370.12","949.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X42MM 22 HOLE STRUT TITANIUM FOR SCREW","SUP-ITM-10028540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.92","895.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","457.27","38.3","","279.30","91.72","1116.77","266","370.12","949.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X42MM 22 HOLE STRUT TITANIUM FOR SCREW","SUP-ITM-10028540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.92","895.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","512.19","42.9","","731.00","63.70","731.00","1 through 10","370.12","949.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X42MM 22 HOLE STRUT TITANIUM FOR SCREW","SUP-ITM-10028540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.92","895.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","512.19","42.9","","384.74","384.74","384.74","1 through 10","370.12","949.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X42MM 22 HOLE STRUT TITANIUM FOR SCREW","SUP-ITM-10028540","CDM","C1713","HCPCS","0278","RC","","","","both","","","1193.92","895.44","WELLPOINT [1015]","HB AMC WELLPOINT","880.87","73.78","","286.63","119.22","1107.45","105","370.12","949.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X42MM 22 HOLE STRUT TITANIUM FOR SCREW","SUP-ITM-10028540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1193.92","895.44","AETNA [1001]","HB AMC AETNA HMO","833.36","69.8","","675.31","184.75","1721.50","286","623.94","975.67","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X42MM 22 HOLE STRUT TITANIUM FOR SCREW","SUP-ITM-10028540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1193.92","895.44","AETNA [1001]","HB AMC AETNA PPO","959.91","80.4","","1261.44","103.12","1514.10","21","623.94","975.67","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X42MM 22 HOLE STRUT TITANIUM FOR SCREW","SUP-ITM-10028540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1193.92","895.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","959.91","80.4","","1365.00","1365.00","1365.00","1 through 10","623.94","975.67","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X42MM 22 HOLE STRUT TITANIUM FOR SCREW","SUP-ITM-10028540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1193.92","895.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","975.67","81.72","","5157.68","5157.68","5157.68","1 through 10","623.94","975.67","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 6X1X42MM 22 HOLE STRUT TITANIUM FOR SCREW","SUP-ITM-10028540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1193.92","895.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","975.67","81.72","","431.26","71.26","1459.57","88","623.94","975.67","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 8X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001845","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.91","437.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","464.21","79.5","","800.18","480.96","1887.97","195","181.01","464.21","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 8X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001845","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.91","437.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","311.22","53.3","","813.12","216.42","1444.50","81","181.01","464.21","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 8X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001845","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.91","437.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","181.01","31","","432.60","432.60","432.60","1 through 10","181.01","464.21","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 8X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001845","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.91","437.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","213.13","36.5","","148.37","54.89","631.39","94","181.01","464.21","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 8X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001845","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.91","437.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","223.64","38.3","","279.30","91.72","1116.77","266","181.01","464.21","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 8X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001845","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.91","437.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.50","42.9","","731.00","63.70","731.00","1 through 10","181.01","464.21","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 8X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001845","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.91","437.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.50","42.9","","384.74","384.74","384.74","1 through 10","181.01","464.21","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 8X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001845","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.91","437.93","WELLPOINT [1015]","HB AMC WELLPOINT","430.81","73.78","","286.63","119.22","1107.45","105","181.01","464.21","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 8X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","583.91","437.93","AETNA [1001]","HB AMC AETNA HMO","407.57","69.8","","675.31","184.75","1721.50","286","305.15","477.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 8X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","583.91","437.93","AETNA [1001]","HB AMC AETNA PPO","469.46","80.4","","1261.44","103.12","1514.10","21","305.15","477.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 8X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","583.91","437.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","469.46","80.4","","1365.00","1365.00","1365.00","1 through 10","305.15","477.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 8X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","583.91","437.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","477.17","81.72","","5157.68","5157.68","5157.68","1 through 10","305.15","477.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 8X2MM 4 HOLE CHIN STRAIGHT OFFSET TITANIUM CS/1BX/1EA","SUP-ITM-10001845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","583.91","437.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","477.17","81.72","","431.26","71.26","1459.57","88","305.15","477.17","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL LG ORBITAL MATRIXORBITAL INSERT TITANIUM PREFORMED LEFT","SUP-ITM-10077410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.77","2777.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2944.50","79.5","","800.18","480.96","1887.97","195","1148.17","2944.5","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL LG ORBITAL MATRIXORBITAL INSERT TITANIUM PREFORMED LEFT","SUP-ITM-10077410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.77","2777.83","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1974.11","53.3","","813.12","216.42","1444.50","81","1148.17","2944.5","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL LG ORBITAL MATRIXORBITAL INSERT TITANIUM PREFORMED LEFT","SUP-ITM-10077410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.77","2777.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1148.17","31","","432.60","432.60","432.60","1 through 10","1148.17","2944.5","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL LG ORBITAL MATRIXORBITAL INSERT TITANIUM PREFORMED LEFT","SUP-ITM-10077410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.77","2777.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1351.88","36.5","","148.37","54.89","631.39","94","1148.17","2944.5","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL LG ORBITAL MATRIXORBITAL INSERT TITANIUM PREFORMED LEFT","SUP-ITM-10077410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.77","2777.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1418.54","38.3","","279.30","91.72","1116.77","266","1148.17","2944.5","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL LG ORBITAL MATRIXORBITAL INSERT TITANIUM PREFORMED LEFT","SUP-ITM-10077410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.77","2777.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1588.92","42.9","","731.00","63.70","731.00","1 through 10","1148.17","2944.5","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL LG ORBITAL MATRIXORBITAL INSERT TITANIUM PREFORMED LEFT","SUP-ITM-10077410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.77","2777.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1588.92","42.9","","384.74","384.74","384.74","1 through 10","1148.17","2944.5","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL LG ORBITAL MATRIXORBITAL INSERT TITANIUM PREFORMED LEFT","SUP-ITM-10077410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.77","2777.83","WELLPOINT [1015]","HB AMC WELLPOINT","2732.64","73.78","","286.63","119.22","1107.45","105","1148.17","2944.5","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL LG ORBITAL MATRIXORBITAL INSERT TITANIUM PREFORMED LEFT","SUP-ITM-10077410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3703.77","2777.83","AETNA [1001]","HB AMC AETNA HMO","2585.23","69.8","","675.31","184.75","1721.50","286","1935.59","3026.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL LG ORBITAL MATRIXORBITAL INSERT TITANIUM PREFORMED LEFT","SUP-ITM-10077410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3703.77","2777.83","AETNA [1001]","HB AMC AETNA PPO","2977.83","80.4","","1261.44","103.12","1514.10","21","1935.59","3026.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL LG ORBITAL MATRIXORBITAL INSERT TITANIUM PREFORMED LEFT","SUP-ITM-10077410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3703.77","2777.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2977.83","80.4","","1365.00","1365.00","1365.00","1 through 10","1935.59","3026.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL LG ORBITAL MATRIXORBITAL INSERT TITANIUM PREFORMED LEFT","SUP-ITM-10077410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3703.77","2777.83","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3026.72","81.72","","5157.68","5157.68","5157.68","1 through 10","1935.59","3026.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL LG ORBITAL MATRIXORBITAL INSERT TITANIUM PREFORMED LEFT","SUP-ITM-10077410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3703.77","2777.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3026.72","81.72","","431.26","71.26","1459.57","88","1935.59","3026.72","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL MED TITANIUM MESH MALLEABLE LOW PROFILE NEURO TEMPORAL","SUP-ITM-10026021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.00","3789.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4016.34","79.5","","800.18","480.96","1887.97","195","1566.12","4016.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL MED TITANIUM MESH MALLEABLE LOW PROFILE NEURO TEMPORAL","SUP-ITM-10026021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.00","3789.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2692.72","53.3","","813.12","216.42","1444.50","81","1566.12","4016.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL MED TITANIUM MESH MALLEABLE LOW PROFILE NEURO TEMPORAL","SUP-ITM-10026021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.00","3789.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1566.12","31","","432.60","432.60","432.60","1 through 10","1566.12","4016.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL MED TITANIUM MESH MALLEABLE LOW PROFILE NEURO TEMPORAL","SUP-ITM-10026021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.00","3789.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1843.98","36.5","","148.37","54.89","631.39","94","1566.12","4016.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL MED TITANIUM MESH MALLEABLE LOW PROFILE NEURO TEMPORAL","SUP-ITM-10026021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.00","3789.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1934.92","38.3","","279.30","91.72","1116.77","266","1566.12","4016.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL MED TITANIUM MESH MALLEABLE LOW PROFILE NEURO TEMPORAL","SUP-ITM-10026021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.00","3789.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2167.31","42.9","","731.00","63.70","731.00","1 through 10","1566.12","4016.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL MED TITANIUM MESH MALLEABLE LOW PROFILE NEURO TEMPORAL","SUP-ITM-10026021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.00","3789.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2167.31","42.9","","384.74","384.74","384.74","1 through 10","1566.12","4016.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL MED TITANIUM MESH MALLEABLE LOW PROFILE NEURO TEMPORAL","SUP-ITM-10026021","CDM","C1713","HCPCS","0278","RC","","","","both","","","5052.00","3789.00","WELLPOINT [1015]","HB AMC WELLPOINT","3727.37","73.78","","286.63","119.22","1107.45","105","1566.12","4016.34","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL MED TITANIUM MESH MALLEABLE LOW PROFILE NEURO TEMPORAL","SUP-ITM-10026021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5052.00","3789.00","AETNA [1001]","HB AMC AETNA HMO","3526.30","69.8","","675.31","184.75","1721.50","286","2640.18","4128.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL MED TITANIUM MESH MALLEABLE LOW PROFILE NEURO TEMPORAL","SUP-ITM-10026021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5052.00","3789.00","AETNA [1001]","HB AMC AETNA PPO","4061.81","80.4","","1261.44","103.12","1514.10","21","2640.18","4128.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL MED TITANIUM MESH MALLEABLE LOW PROFILE NEURO TEMPORAL","SUP-ITM-10026021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5052.00","3789.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4061.81","80.4","","1365.00","1365.00","1365.00","1 through 10","2640.18","4128.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL MED TITANIUM MESH MALLEABLE LOW PROFILE NEURO TEMPORAL","SUP-ITM-10026021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5052.00","3789.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4128.49","81.72","","5157.68","5157.68","5157.68","1 through 10","2640.18","4128.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL MED TITANIUM MESH MALLEABLE LOW PROFILE NEURO TEMPORAL","SUP-ITM-10026021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5052.00","3789.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4128.49","81.72","","431.26","71.26","1459.57","88","2640.18","4128.49","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL SM MATRIXNEURO TITANIUM MESH CONTOUR MALLEABLE MASTOID SILVER","SUP-ITM-10076571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.59","1246.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1320.96","79.5","","800.18","480.96","1887.97","195","515.09","1320.96","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL SM MATRIXNEURO TITANIUM MESH CONTOUR MALLEABLE MASTOID SILVER","SUP-ITM-10076571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.59","1246.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","885.63","53.3","","813.12","216.42","1444.50","81","515.09","1320.96","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL SM MATRIXNEURO TITANIUM MESH CONTOUR MALLEABLE MASTOID SILVER","SUP-ITM-10076571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.59","1246.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","515.09","31","","432.60","432.60","432.60","1 through 10","515.09","1320.96","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL SM MATRIXNEURO TITANIUM MESH CONTOUR MALLEABLE MASTOID SILVER","SUP-ITM-10076571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.59","1246.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","606.48","36.5","","148.37","54.89","631.39","94","515.09","1320.96","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL SM MATRIXNEURO TITANIUM MESH CONTOUR MALLEABLE MASTOID SILVER","SUP-ITM-10076571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.59","1246.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","636.39","38.3","","279.30","91.72","1116.77","266","515.09","1320.96","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL SM MATRIXNEURO TITANIUM MESH CONTOUR MALLEABLE MASTOID SILVER","SUP-ITM-10076571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.59","1246.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","712.82","42.9","","731.00","63.70","731.00","1 through 10","515.09","1320.96","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL SM MATRIXNEURO TITANIUM MESH CONTOUR MALLEABLE MASTOID SILVER","SUP-ITM-10076571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.59","1246.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","712.82","42.9","","384.74","384.74","384.74","1 through 10","515.09","1320.96","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL SM MATRIXNEURO TITANIUM MESH CONTOUR MALLEABLE MASTOID SILVER","SUP-ITM-10076571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1661.59","1246.19","WELLPOINT [1015]","HB AMC WELLPOINT","1225.92","73.78","","286.63","119.22","1107.45","105","515.09","1320.96","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL SM MATRIXNEURO TITANIUM MESH CONTOUR MALLEABLE MASTOID SILVER","SUP-ITM-10076571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1661.59","1246.19","AETNA [1001]","HB AMC AETNA HMO","1159.79","69.8","","675.31","184.75","1721.50","286","868.35","1357.85","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL SM MATRIXNEURO TITANIUM MESH CONTOUR MALLEABLE MASTOID SILVER","SUP-ITM-10076571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1661.59","1246.19","AETNA [1001]","HB AMC AETNA PPO","1335.92","80.4","","1261.44","103.12","1514.10","21","868.35","1357.85","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL SM MATRIXNEURO TITANIUM MESH CONTOUR MALLEABLE MASTOID SILVER","SUP-ITM-10076571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1661.59","1246.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1335.92","80.4","","1365.00","1365.00","1365.00","1 through 10","868.35","1357.85","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL SM MATRIXNEURO TITANIUM MESH CONTOUR MALLEABLE MASTOID SILVER","SUP-ITM-10076571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1661.59","1246.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1357.85","81.72","","5157.68","5157.68","5157.68","1 through 10","868.35","1357.85","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL SM MATRIXNEURO TITANIUM MESH CONTOUR MALLEABLE MASTOID SILVER","SUP-ITM-10076571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1661.59","1246.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1357.85","81.72","","431.26","71.26","1459.57","88","868.35","1357.85","percent of total billed charges",""
"PLATE CRANIUM .5MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077309","CDM","C1713","HCPCS","0278","RC","","","","both","","","449.68","337.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","357.50","79.5","","800.18","480.96","1887.97","195","139.4","357.5","percent of total billed charges",""
"PLATE CRANIUM .5MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077309","CDM","C1713","HCPCS","0278","RC","","","","both","","","449.68","337.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","239.68","53.3","","813.12","216.42","1444.50","81","139.4","357.5","percent of total billed charges",""
"PLATE CRANIUM .5MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077309","CDM","C1713","HCPCS","0278","RC","","","","both","","","449.68","337.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","139.40","31","","432.60","432.60","432.60","1 through 10","139.4","357.5","percent of total billed charges",""
"PLATE CRANIUM .5MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077309","CDM","C1713","HCPCS","0278","RC","","","","both","","","449.68","337.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","164.13","36.5","","148.37","54.89","631.39","94","139.4","357.5","percent of total billed charges",""
"PLATE CRANIUM .5MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077309","CDM","C1713","HCPCS","0278","RC","","","","both","","","449.68","337.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","172.23","38.3","","279.30","91.72","1116.77","266","139.4","357.5","percent of total billed charges",""
"PLATE CRANIUM .5MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077309","CDM","C1713","HCPCS","0278","RC","","","","both","","","449.68","337.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","192.91","42.9","","731.00","63.70","731.00","1 through 10","139.4","357.5","percent of total billed charges",""
"PLATE CRANIUM .5MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077309","CDM","C1713","HCPCS","0278","RC","","","","both","","","449.68","337.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","192.91","42.9","","384.74","384.74","384.74","1 through 10","139.4","357.5","percent of total billed charges",""
"PLATE CRANIUM .5MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077309","CDM","C1713","HCPCS","0278","RC","","","","both","","","449.68","337.26","WELLPOINT [1015]","HB AMC WELLPOINT","331.77","73.78","","286.63","119.22","1107.45","105","139.4","357.5","percent of total billed charges",""
"PLATE CRANIUM .5MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","449.68","337.26","AETNA [1001]","HB AMC AETNA HMO","313.88","69.8","","675.31","184.75","1721.50","286","235","367.48","percent of total billed charges",""
"PLATE CRANIUM .5MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","449.68","337.26","AETNA [1001]","HB AMC AETNA PPO","361.54","80.4","","1261.44","103.12","1514.10","21","235","367.48","percent of total billed charges",""
"PLATE CRANIUM .5MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","449.68","337.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","361.54","80.4","","1365.00","1365.00","1365.00","1 through 10","235","367.48","percent of total billed charges",""
"PLATE CRANIUM .5MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","449.68","337.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","367.48","81.72","","5157.68","5157.68","5157.68","1 through 10","235","367.48","percent of total billed charges",""
"PLATE CRANIUM .5MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","449.68","337.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","367.48","81.72","","431.26","71.26","1459.57","88","235","367.48","percent of total billed charges",""
"PLATE CRANIUM .8MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077317","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.11","345.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","365.79","79.5","","800.18","480.96","1887.97","195","142.63","365.79","percent of total billed charges",""
"PLATE CRANIUM .8MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077317","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.11","345.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","245.24","53.3","","813.12","216.42","1444.50","81","142.63","365.79","percent of total billed charges",""
"PLATE CRANIUM .8MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077317","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.11","345.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","142.63","31","","432.60","432.60","432.60","1 through 10","142.63","365.79","percent of total billed charges",""
"PLATE CRANIUM .8MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077317","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.11","345.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","167.94","36.5","","148.37","54.89","631.39","94","142.63","365.79","percent of total billed charges",""
"PLATE CRANIUM .8MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077317","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.11","345.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","176.22","38.3","","279.30","91.72","1116.77","266","142.63","365.79","percent of total billed charges",""
"PLATE CRANIUM .8MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077317","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.11","345.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","197.39","42.9","","731.00","63.70","731.00","1 through 10","142.63","365.79","percent of total billed charges",""
"PLATE CRANIUM .8MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077317","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.11","345.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","197.39","42.9","","384.74","384.74","384.74","1 through 10","142.63","365.79","percent of total billed charges",""
"PLATE CRANIUM .8MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077317","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.11","345.08","WELLPOINT [1015]","HB AMC WELLPOINT","339.47","73.78","","286.63","119.22","1107.45","105","142.63","365.79","percent of total billed charges",""
"PLATE CRANIUM .8MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.11","345.08","AETNA [1001]","HB AMC AETNA HMO","321.16","69.8","","675.31","184.75","1721.50","286","240.45","376","percent of total billed charges",""
"PLATE CRANIUM .8MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.11","345.08","AETNA [1001]","HB AMC AETNA PPO","369.93","80.4","","1261.44","103.12","1514.10","21","240.45","376","percent of total billed charges",""
"PLATE CRANIUM .8MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.11","345.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","369.93","80.4","","1365.00","1365.00","1365.00","1 through 10","240.45","376","percent of total billed charges",""
"PLATE CRANIUM .8MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.11","345.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","376.00","81.72","","5157.68","5157.68","5157.68","1 through 10","240.45","376","percent of total billed charges",""
"PLATE CRANIUM .8MM 3X3 HOLE SHORT H MATRIXORTHOGNATHIC TITANIUM L OBLIQUE REVERSIBLE","SUP-ITM-10077317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.11","345.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","376.00","81.72","","431.26","71.26","1459.57","88","240.45","376","percent of total billed charges",""
"PLATE CRANIUM 2MM 8 HOLE Y SHAPE TITANIUM","SUP-ITM-10003764","CDM","C1713","HCPCS","0278","RC","","","","both","","","551.92","413.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","438.78","79.5","","800.18","480.96","1887.97","195","171.1","438.78","percent of total billed charges",""
"PLATE CRANIUM 2MM 8 HOLE Y SHAPE TITANIUM","SUP-ITM-10003764","CDM","C1713","HCPCS","0278","RC","","","","both","","","551.92","413.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","294.17","53.3","","813.12","216.42","1444.50","81","171.1","438.78","percent of total billed charges",""
"PLATE CRANIUM 2MM 8 HOLE Y SHAPE TITANIUM","SUP-ITM-10003764","CDM","C1713","HCPCS","0278","RC","","","","both","","","551.92","413.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","171.10","31","","432.60","432.60","432.60","1 through 10","171.1","438.78","percent of total billed charges",""
"PLATE CRANIUM 2MM 8 HOLE Y SHAPE TITANIUM","SUP-ITM-10003764","CDM","C1713","HCPCS","0278","RC","","","","both","","","551.92","413.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","201.45","36.5","","148.37","54.89","631.39","94","171.1","438.78","percent of total billed charges",""
"PLATE CRANIUM 2MM 8 HOLE Y SHAPE TITANIUM","SUP-ITM-10003764","CDM","C1713","HCPCS","0278","RC","","","","both","","","551.92","413.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","211.39","38.3","","279.30","91.72","1116.77","266","171.1","438.78","percent of total billed charges",""
"PLATE CRANIUM 2MM 8 HOLE Y SHAPE TITANIUM","SUP-ITM-10003764","CDM","C1713","HCPCS","0278","RC","","","","both","","","551.92","413.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","236.77","42.9","","731.00","63.70","731.00","1 through 10","171.1","438.78","percent of total billed charges",""
"PLATE CRANIUM 2MM 8 HOLE Y SHAPE TITANIUM","SUP-ITM-10003764","CDM","C1713","HCPCS","0278","RC","","","","both","","","551.92","413.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","236.77","42.9","","384.74","384.74","384.74","1 through 10","171.1","438.78","percent of total billed charges",""
"PLATE CRANIUM 2MM 8 HOLE Y SHAPE TITANIUM","SUP-ITM-10003764","CDM","C1713","HCPCS","0278","RC","","","","both","","","551.92","413.94","WELLPOINT [1015]","HB AMC WELLPOINT","407.21","73.78","","286.63","119.22","1107.45","105","171.1","438.78","percent of total billed charges",""
"PLATE CRANIUM 2MM 8 HOLE Y SHAPE TITANIUM","SUP-ITM-10003764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","551.92","413.94","AETNA [1001]","HB AMC AETNA HMO","385.24","69.8","","675.31","184.75","1721.50","286","288.43","451.03","percent of total billed charges",""
"PLATE CRANIUM 2MM 8 HOLE Y SHAPE TITANIUM","SUP-ITM-10003764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","551.92","413.94","AETNA [1001]","HB AMC AETNA PPO","443.74","80.4","","1261.44","103.12","1514.10","21","288.43","451.03","percent of total billed charges",""
"PLATE CRANIUM 2MM 8 HOLE Y SHAPE TITANIUM","SUP-ITM-10003764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","551.92","413.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","443.74","80.4","","1365.00","1365.00","1365.00","1 through 10","288.43","451.03","percent of total billed charges",""
"PLATE CRANIUM 2MM 8 HOLE Y SHAPE TITANIUM","SUP-ITM-10003764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","551.92","413.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","451.03","81.72","","5157.68","5157.68","5157.68","1 through 10","288.43","451.03","percent of total billed charges",""
"PLATE CRANIUM 2MM 8 HOLE Y SHAPE TITANIUM","SUP-ITM-10003764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","551.92","413.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","451.03","81.72","","431.26","71.26","1459.57","88","288.43","451.03","percent of total billed charges",""
"PLATE CRANIUM 2MM 9 HOLE H SHAPE TITANIUM","SUP-ITM-10003766","CDM","C1713","HCPCS","0278","RC","","","","both","","","543.20","407.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","431.84","79.5","","800.18","480.96","1887.97","195","168.39","431.84","percent of total billed charges",""
"PLATE CRANIUM 2MM 9 HOLE H SHAPE TITANIUM","SUP-ITM-10003766","CDM","C1713","HCPCS","0278","RC","","","","both","","","543.20","407.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","289.53","53.3","","813.12","216.42","1444.50","81","168.39","431.84","percent of total billed charges",""
"PLATE CRANIUM 2MM 9 HOLE H SHAPE TITANIUM","SUP-ITM-10003766","CDM","C1713","HCPCS","0278","RC","","","","both","","","543.20","407.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","168.39","31","","432.60","432.60","432.60","1 through 10","168.39","431.84","percent of total billed charges",""
"PLATE CRANIUM 2MM 9 HOLE H SHAPE TITANIUM","SUP-ITM-10003766","CDM","C1713","HCPCS","0278","RC","","","","both","","","543.20","407.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","198.27","36.5","","148.37","54.89","631.39","94","168.39","431.84","percent of total billed charges",""
"PLATE CRANIUM 2MM 9 HOLE H SHAPE TITANIUM","SUP-ITM-10003766","CDM","C1713","HCPCS","0278","RC","","","","both","","","543.20","407.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","208.05","38.3","","279.30","91.72","1116.77","266","168.39","431.84","percent of total billed charges",""
"PLATE CRANIUM 2MM 9 HOLE H SHAPE TITANIUM","SUP-ITM-10003766","CDM","C1713","HCPCS","0278","RC","","","","both","","","543.20","407.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","233.03","42.9","","731.00","63.70","731.00","1 through 10","168.39","431.84","percent of total billed charges",""
"PLATE CRANIUM 2MM 9 HOLE H SHAPE TITANIUM","SUP-ITM-10003766","CDM","C1713","HCPCS","0278","RC","","","","both","","","543.20","407.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","233.03","42.9","","384.74","384.74","384.74","1 through 10","168.39","431.84","percent of total billed charges",""
"PLATE CRANIUM 2MM 9 HOLE H SHAPE TITANIUM","SUP-ITM-10003766","CDM","C1713","HCPCS","0278","RC","","","","both","","","543.20","407.40","WELLPOINT [1015]","HB AMC WELLPOINT","400.77","73.78","","286.63","119.22","1107.45","105","168.39","431.84","percent of total billed charges",""
"PLATE CRANIUM 2MM 9 HOLE H SHAPE TITANIUM","SUP-ITM-10003766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","543.20","407.40","AETNA [1001]","HB AMC AETNA HMO","379.15","69.8","","675.31","184.75","1721.50","286","283.88","443.9","percent of total billed charges",""
"PLATE CRANIUM 2MM 9 HOLE H SHAPE TITANIUM","SUP-ITM-10003766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","543.20","407.40","AETNA [1001]","HB AMC AETNA PPO","436.73","80.4","","1261.44","103.12","1514.10","21","283.88","443.9","percent of total billed charges",""
"PLATE CRANIUM 2MM 9 HOLE H SHAPE TITANIUM","SUP-ITM-10003766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","543.20","407.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","436.73","80.4","","1365.00","1365.00","1365.00","1 through 10","283.88","443.9","percent of total billed charges",""
"PLATE CRANIUM 2MM 9 HOLE H SHAPE TITANIUM","SUP-ITM-10003766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","543.20","407.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","443.90","81.72","","5157.68","5157.68","5157.68","1 through 10","283.88","443.9","percent of total billed charges",""
"PLATE CRANIUM 2MM 9 HOLE H SHAPE TITANIUM","SUP-ITM-10003766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","543.20","407.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","443.90","81.72","","431.26","71.26","1459.57","88","283.88","443.9","percent of total billed charges",""
"PLATE CRANIUM 2X100MM 20 HOLE MANDIBULAR TITANIUM LOCKING","SUP-ITM-10003757","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.02","697.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","739.37","79.5","","800.18","480.96","1887.97","195","288.31","739.37","percent of total billed charges",""
"PLATE CRANIUM 2X100MM 20 HOLE MANDIBULAR TITANIUM LOCKING","SUP-ITM-10003757","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.02","697.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","495.70","53.3","","813.12","216.42","1444.50","81","288.31","739.37","percent of total billed charges",""
"PLATE CRANIUM 2X100MM 20 HOLE MANDIBULAR TITANIUM LOCKING","SUP-ITM-10003757","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.02","697.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","288.31","31","","432.60","432.60","432.60","1 through 10","288.31","739.37","percent of total billed charges",""
"PLATE CRANIUM 2X100MM 20 HOLE MANDIBULAR TITANIUM LOCKING","SUP-ITM-10003757","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.02","697.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","339.46","36.5","","148.37","54.89","631.39","94","288.31","739.37","percent of total billed charges",""
"PLATE CRANIUM 2X100MM 20 HOLE MANDIBULAR TITANIUM LOCKING","SUP-ITM-10003757","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.02","697.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","356.20","38.3","","279.30","91.72","1116.77","266","288.31","739.37","percent of total billed charges",""
"PLATE CRANIUM 2X100MM 20 HOLE MANDIBULAR TITANIUM LOCKING","SUP-ITM-10003757","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.02","697.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","398.98","42.9","","731.00","63.70","731.00","1 through 10","288.31","739.37","percent of total billed charges",""
"PLATE CRANIUM 2X100MM 20 HOLE MANDIBULAR TITANIUM LOCKING","SUP-ITM-10003757","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.02","697.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","398.98","42.9","","384.74","384.74","384.74","1 through 10","288.31","739.37","percent of total billed charges",""
"PLATE CRANIUM 2X100MM 20 HOLE MANDIBULAR TITANIUM LOCKING","SUP-ITM-10003757","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.02","697.51","WELLPOINT [1015]","HB AMC WELLPOINT","686.17","73.78","","286.63","119.22","1107.45","105","288.31","739.37","percent of total billed charges",""
"PLATE CRANIUM 2X100MM 20 HOLE MANDIBULAR TITANIUM LOCKING","SUP-ITM-10003757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.02","697.51","AETNA [1001]","HB AMC AETNA HMO","649.15","69.8","","675.31","184.75","1721.50","286","486.03","760.01","percent of total billed charges",""
"PLATE CRANIUM 2X100MM 20 HOLE MANDIBULAR TITANIUM LOCKING","SUP-ITM-10003757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.02","697.51","AETNA [1001]","HB AMC AETNA PPO","747.74","80.4","","1261.44","103.12","1514.10","21","486.03","760.01","percent of total billed charges",""
"PLATE CRANIUM 2X100MM 20 HOLE MANDIBULAR TITANIUM LOCKING","SUP-ITM-10003757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.02","697.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","747.74","80.4","","1365.00","1365.00","1365.00","1 through 10","486.03","760.01","percent of total billed charges",""
"PLATE CRANIUM 2X100MM 20 HOLE MANDIBULAR TITANIUM LOCKING","SUP-ITM-10003757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.02","697.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","760.01","81.72","","5157.68","5157.68","5157.68","1 through 10","486.03","760.01","percent of total billed charges",""
"PLATE CRANIUM 2X100MM 20 HOLE MANDIBULAR TITANIUM LOCKING","SUP-ITM-10003757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.02","697.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","760.01","81.72","","431.26","71.26","1459.57","88","486.03","760.01","percent of total billed charges",""
"PLATE CRANIUM SM MATRIXMANDIBLE TITANIUM ORBITAL PREFORMED LEFT DARK","SUP-ITM-10077409","CDM","C1713","HCPCS","0278","RC","","","","both","","","3558.52","2668.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2829.02","79.5","","800.18","480.96","1887.97","195","1103.14","2829.02","percent of total billed charges",""
"PLATE CRANIUM SM MATRIXMANDIBLE TITANIUM ORBITAL PREFORMED LEFT DARK","SUP-ITM-10077409","CDM","C1713","HCPCS","0278","RC","","","","both","","","3558.52","2668.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1896.69","53.3","","813.12","216.42","1444.50","81","1103.14","2829.02","percent of total billed charges",""
"PLATE CRANIUM SM MATRIXMANDIBLE TITANIUM ORBITAL PREFORMED LEFT DARK","SUP-ITM-10077409","CDM","C1713","HCPCS","0278","RC","","","","both","","","3558.52","2668.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1103.14","31","","432.60","432.60","432.60","1 through 10","1103.14","2829.02","percent of total billed charges",""
"PLATE CRANIUM SM MATRIXMANDIBLE TITANIUM ORBITAL PREFORMED LEFT DARK","SUP-ITM-10077409","CDM","C1713","HCPCS","0278","RC","","","","both","","","3558.52","2668.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1298.86","36.5","","148.37","54.89","631.39","94","1103.14","2829.02","percent of total billed charges",""
"PLATE CRANIUM SM MATRIXMANDIBLE TITANIUM ORBITAL PREFORMED LEFT DARK","SUP-ITM-10077409","CDM","C1713","HCPCS","0278","RC","","","","both","","","3558.52","2668.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1362.91","38.3","","279.30","91.72","1116.77","266","1103.14","2829.02","percent of total billed charges",""
"PLATE CRANIUM SM MATRIXMANDIBLE TITANIUM ORBITAL PREFORMED LEFT DARK","SUP-ITM-10077409","CDM","C1713","HCPCS","0278","RC","","","","both","","","3558.52","2668.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1526.61","42.9","","731.00","63.70","731.00","1 through 10","1103.14","2829.02","percent of total billed charges",""
"PLATE CRANIUM SM MATRIXMANDIBLE TITANIUM ORBITAL PREFORMED LEFT DARK","SUP-ITM-10077409","CDM","C1713","HCPCS","0278","RC","","","","both","","","3558.52","2668.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1526.61","42.9","","384.74","384.74","384.74","1 through 10","1103.14","2829.02","percent of total billed charges",""
"PLATE CRANIUM SM MATRIXMANDIBLE TITANIUM ORBITAL PREFORMED LEFT DARK","SUP-ITM-10077409","CDM","C1713","HCPCS","0278","RC","","","","both","","","3558.52","2668.89","WELLPOINT [1015]","HB AMC WELLPOINT","2625.48","73.78","","286.63","119.22","1107.45","105","1103.14","2829.02","percent of total billed charges",""
"PLATE CRANIUM SM MATRIXMANDIBLE TITANIUM ORBITAL PREFORMED LEFT DARK","SUP-ITM-10077409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3558.52","2668.89","AETNA [1001]","HB AMC AETNA HMO","2483.85","69.8","","675.31","184.75","1721.50","286","1859.68","2908.02","percent of total billed charges",""
"PLATE CRANIUM SM MATRIXMANDIBLE TITANIUM ORBITAL PREFORMED LEFT DARK","SUP-ITM-10077409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3558.52","2668.89","AETNA [1001]","HB AMC AETNA PPO","2861.05","80.4","","1261.44","103.12","1514.10","21","1859.68","2908.02","percent of total billed charges",""
"PLATE CRANIUM SM MATRIXMANDIBLE TITANIUM ORBITAL PREFORMED LEFT DARK","SUP-ITM-10077409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3558.52","2668.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2861.05","80.4","","1365.00","1365.00","1365.00","1 through 10","1859.68","2908.02","percent of total billed charges",""
"PLATE CRANIUM SM MATRIXMANDIBLE TITANIUM ORBITAL PREFORMED LEFT DARK","SUP-ITM-10077409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3558.52","2668.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2908.02","81.72","","5157.68","5157.68","5157.68","1 through 10","1859.68","2908.02","percent of total billed charges",""
"PLATE CRANIUM SM MATRIXMANDIBLE TITANIUM ORBITAL PREFORMED LEFT DARK","SUP-ITM-10077409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3558.52","2668.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2908.02","81.72","","431.26","71.26","1459.57","88","1859.68","2908.02","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2830.87","2123.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2250.54","79.5","","800.18","480.96","1887.97","195","877.57","2250.54","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2830.87","2123.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1508.85","53.3","","813.12","216.42","1444.50","81","877.57","2250.54","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2830.87","2123.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","877.57","31","","432.60","432.60","432.60","1 through 10","877.57","2250.54","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2830.87","2123.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1033.27","36.5","","148.37","54.89","631.39","94","877.57","2250.54","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2830.87","2123.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1084.22","38.3","","279.30","91.72","1116.77","266","877.57","2250.54","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2830.87","2123.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1214.44","42.9","","731.00","63.70","731.00","1 through 10","877.57","2250.54","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2830.87","2123.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1214.44","42.9","","384.74","384.74","384.74","1 through 10","877.57","2250.54","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2830.87","2123.15","WELLPOINT [1015]","HB AMC WELLPOINT","2088.62","73.78","","286.63","119.22","1107.45","105","877.57","2250.54","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2830.87","2123.15","AETNA [1001]","HB AMC AETNA HMO","1975.95","69.8","","675.31","184.75","1721.50","286","1479.41","2313.39","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2830.87","2123.15","AETNA [1001]","HB AMC AETNA PPO","2276.02","80.4","","1261.44","103.12","1514.10","21","1479.41","2313.39","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2830.87","2123.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2276.02","80.4","","1365.00","1365.00","1365.00","1 through 10","1479.41","2313.39","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2830.87","2123.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2313.39","81.72","","5157.68","5157.68","5157.68","1 through 10","1479.41","2313.39","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2830.87","2123.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2313.39","81.72","","431.26","71.26","1459.57","88","1479.41","2313.39","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2409.09","79.5","","800.18","480.96","1887.97","195","939.39","2409.09","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1615.15","53.3","","813.12","216.42","1444.50","81","939.39","2409.09","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","939.39","31","","432.60","432.60","432.60","1 through 10","939.39","2409.09","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1106.06","36.5","","148.37","54.89","631.39","94","939.39","2409.09","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1160.60","38.3","","279.30","91.72","1116.77","266","939.39","2409.09","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1300.00","42.9","","731.00","63.70","731.00","1 through 10","939.39","2409.09","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1300.00","42.9","","384.74","384.74","384.74","1 through 10","939.39","2409.09","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","3030.30","2272.72","WELLPOINT [1015]","HB AMC WELLPOINT","2235.76","73.78","","286.63","119.22","1107.45","105","939.39","2409.09","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","AETNA [1001]","HB AMC AETNA HMO","2115.15","69.8","","675.31","184.75","1721.50","286","1583.63","2476.36","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","AETNA [1001]","HB AMC AETNA PPO","2436.36","80.4","","1261.44","103.12","1514.10","21","1583.63","2476.36","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2436.36","80.4","","1365.00","1365.00","1365.00","1 through 10","1583.63","2476.36","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2476.36","81.72","","5157.68","5157.68","5157.68","1 through 10","1583.63","2476.36","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3030.30","2272.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2476.36","81.72","","431.26","71.26","1459.57","88","1583.63","2476.36","percent of total billed charges",""
"PLATE EXTERNAL 155MM ID FIXATION","SUP-ITM-10062823","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6141.38","79.5","","800.18","480.96","1887.97","195","2394.75","6141.38","percent of total billed charges",""
"PLATE EXTERNAL 155MM ID FIXATION","SUP-ITM-10062823","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4117.43","53.3","","813.12","216.42","1444.50","81","2394.75","6141.38","percent of total billed charges",""
"PLATE EXTERNAL 155MM ID FIXATION","SUP-ITM-10062823","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2394.75","31","","432.60","432.60","432.60","1 through 10","2394.75","6141.38","percent of total billed charges",""
"PLATE EXTERNAL 155MM ID FIXATION","SUP-ITM-10062823","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2819.63","36.5","","148.37","54.89","631.39","94","2394.75","6141.38","percent of total billed charges",""
"PLATE EXTERNAL 155MM ID FIXATION","SUP-ITM-10062823","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2958.68","38.3","","279.30","91.72","1116.77","266","2394.75","6141.38","percent of total billed charges",""
"PLATE EXTERNAL 155MM ID FIXATION","SUP-ITM-10062823","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3314.03","42.9","","731.00","63.70","731.00","1 through 10","2394.75","6141.38","percent of total billed charges",""
"PLATE EXTERNAL 155MM ID FIXATION","SUP-ITM-10062823","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3314.03","42.9","","384.74","384.74","384.74","1 through 10","2394.75","6141.38","percent of total billed charges",""
"PLATE EXTERNAL 155MM ID FIXATION","SUP-ITM-10062823","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","WELLPOINT [1015]","HB AMC WELLPOINT","5699.51","73.78","","286.63","119.22","1107.45","105","2394.75","6141.38","percent of total billed charges",""
"PLATE EXTERNAL 155MM ID FIXATION","SUP-ITM-10062823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","AETNA [1001]","HB AMC AETNA HMO","5392.05","69.8","","675.31","184.75","1721.50","286","4037.09","6312.87","percent of total billed charges",""
"PLATE EXTERNAL 155MM ID FIXATION","SUP-ITM-10062823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","AETNA [1001]","HB AMC AETNA PPO","6210.90","80.4","","1261.44","103.12","1514.10","21","4037.09","6312.87","percent of total billed charges",""
"PLATE EXTERNAL 155MM ID FIXATION","SUP-ITM-10062823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6210.90","80.4","","1365.00","1365.00","1365.00","1 through 10","4037.09","6312.87","percent of total billed charges",""
"PLATE EXTERNAL 155MM ID FIXATION","SUP-ITM-10062823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6312.87","81.72","","5157.68","5157.68","5157.68","1 through 10","4037.09","6312.87","percent of total billed charges",""
"PLATE EXTERNAL 155MM ID FIXATION","SUP-ITM-10062823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6312.87","81.72","","431.26","71.26","1459.57","88","4037.09","6312.87","percent of total billed charges",""
"PLATE FEMORAL 156MM 5 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022886","CDM","C1713","HCPCS","0278","RC","","","","both","","","4334.37","3250.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3445.82","79.5","","800.18","480.96","1887.97","195","1343.65","3445.82","percent of total billed charges",""
"PLATE FEMORAL 156MM 5 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022886","CDM","C1713","HCPCS","0278","RC","","","","both","","","4334.37","3250.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2310.22","53.3","","813.12","216.42","1444.50","81","1343.65","3445.82","percent of total billed charges",""
"PLATE FEMORAL 156MM 5 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022886","CDM","C1713","HCPCS","0278","RC","","","","both","","","4334.37","3250.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1343.65","31","","432.60","432.60","432.60","1 through 10","1343.65","3445.82","percent of total billed charges",""
"PLATE FEMORAL 156MM 5 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022886","CDM","C1713","HCPCS","0278","RC","","","","both","","","4334.37","3250.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1582.05","36.5","","148.37","54.89","631.39","94","1343.65","3445.82","percent of total billed charges",""
"PLATE FEMORAL 156MM 5 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022886","CDM","C1713","HCPCS","0278","RC","","","","both","","","4334.37","3250.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1660.06","38.3","","279.30","91.72","1116.77","266","1343.65","3445.82","percent of total billed charges",""
"PLATE FEMORAL 156MM 5 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022886","CDM","C1713","HCPCS","0278","RC","","","","both","","","4334.37","3250.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1859.44","42.9","","731.00","63.70","731.00","1 through 10","1343.65","3445.82","percent of total billed charges",""
"PLATE FEMORAL 156MM 5 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022886","CDM","C1713","HCPCS","0278","RC","","","","both","","","4334.37","3250.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1859.44","42.9","","384.74","384.74","384.74","1 through 10","1343.65","3445.82","percent of total billed charges",""
"PLATE FEMORAL 156MM 5 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022886","CDM","C1713","HCPCS","0278","RC","","","","both","","","4334.37","3250.78","WELLPOINT [1015]","HB AMC WELLPOINT","3197.90","73.78","","286.63","119.22","1107.45","105","1343.65","3445.82","percent of total billed charges",""
"PLATE FEMORAL 156MM 5 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4334.37","3250.78","AETNA [1001]","HB AMC AETNA HMO","3025.39","69.8","","675.31","184.75","1721.50","286","2265.14","3542.05","percent of total billed charges",""
"PLATE FEMORAL 156MM 5 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4334.37","3250.78","AETNA [1001]","HB AMC AETNA PPO","3484.83","80.4","","1261.44","103.12","1514.10","21","2265.14","3542.05","percent of total billed charges",""
"PLATE FEMORAL 156MM 5 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4334.37","3250.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3484.83","80.4","","1365.00","1365.00","1365.00","1 through 10","2265.14","3542.05","percent of total billed charges",""
"PLATE FEMORAL 156MM 5 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4334.37","3250.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3542.05","81.72","","5157.68","5157.68","5157.68","1 through 10","2265.14","3542.05","percent of total billed charges",""
"PLATE FEMORAL 156MM 5 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4334.37","3250.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3542.05","81.72","","431.26","71.26","1459.57","88","2265.14","3542.05","percent of total billed charges",""
"PLATE FEMORAL 196MM 7 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.84","3314.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3513.77","79.5","","800.18","480.96","1887.97","195","1370.15","3513.77","percent of total billed charges",""
"PLATE FEMORAL 196MM 7 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.84","3314.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2355.77","53.3","","813.12","216.42","1444.50","81","1370.15","3513.77","percent of total billed charges",""
"PLATE FEMORAL 196MM 7 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.84","3314.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1370.15","31","","432.60","432.60","432.60","1 through 10","1370.15","3513.77","percent of total billed charges",""
"PLATE FEMORAL 196MM 7 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.84","3314.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1613.24","36.5","","148.37","54.89","631.39","94","1370.15","3513.77","percent of total billed charges",""
"PLATE FEMORAL 196MM 7 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.84","3314.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1692.80","38.3","","279.30","91.72","1116.77","266","1370.15","3513.77","percent of total billed charges",""
"PLATE FEMORAL 196MM 7 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.84","3314.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1896.11","42.9","","731.00","63.70","731.00","1 through 10","1370.15","3513.77","percent of total billed charges",""
"PLATE FEMORAL 196MM 7 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.84","3314.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1896.11","42.9","","384.74","384.74","384.74","1 through 10","1370.15","3513.77","percent of total billed charges",""
"PLATE FEMORAL 196MM 7 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4419.84","3314.88","WELLPOINT [1015]","HB AMC WELLPOINT","3260.96","73.78","","286.63","119.22","1107.45","105","1370.15","3513.77","percent of total billed charges",""
"PLATE FEMORAL 196MM 7 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022888","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4419.84","3314.88","AETNA [1001]","HB AMC AETNA HMO","3085.05","69.8","","675.31","184.75","1721.50","286","2309.81","3611.89","percent of total billed charges",""
"PLATE FEMORAL 196MM 7 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022888","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4419.84","3314.88","AETNA [1001]","HB AMC AETNA PPO","3553.55","80.4","","1261.44","103.12","1514.10","21","2309.81","3611.89","percent of total billed charges",""
"PLATE FEMORAL 196MM 7 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022888","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4419.84","3314.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3553.55","80.4","","1365.00","1365.00","1365.00","1 through 10","2309.81","3611.89","percent of total billed charges",""
"PLATE FEMORAL 196MM 7 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022888","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4419.84","3314.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3611.89","81.72","","5157.68","5157.68","5157.68","1 through 10","2309.81","3611.89","percent of total billed charges",""
"PLATE FEMORAL 196MM 7 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022888","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4419.84","3314.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3611.89","81.72","","431.26","71.26","1459.57","88","2309.81","3611.89","percent of total billed charges",""
"PLATE FEMORAL 19X73MM PEDIATRIC 100DEG LCP SS","SUP-ITM-10037424","CDM","C1713","HCPCS","0278","RC","","","","both","","","2218.34","1663.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1763.58","79.5","","800.18","480.96","1887.97","195","687.69","1763.58","percent of total billed charges",""
"PLATE FEMORAL 19X73MM PEDIATRIC 100DEG LCP SS","SUP-ITM-10037424","CDM","C1713","HCPCS","0278","RC","","","","both","","","2218.34","1663.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1182.38","53.3","","813.12","216.42","1444.50","81","687.69","1763.58","percent of total billed charges",""
"PLATE FEMORAL 19X73MM PEDIATRIC 100DEG LCP SS","SUP-ITM-10037424","CDM","C1713","HCPCS","0278","RC","","","","both","","","2218.34","1663.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","687.69","31","","432.60","432.60","432.60","1 through 10","687.69","1763.58","percent of total billed charges",""
"PLATE FEMORAL 19X73MM PEDIATRIC 100DEG LCP SS","SUP-ITM-10037424","CDM","C1713","HCPCS","0278","RC","","","","both","","","2218.34","1663.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","809.69","36.5","","148.37","54.89","631.39","94","687.69","1763.58","percent of total billed charges",""
"PLATE FEMORAL 19X73MM PEDIATRIC 100DEG LCP SS","SUP-ITM-10037424","CDM","C1713","HCPCS","0278","RC","","","","both","","","2218.34","1663.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","849.62","38.3","","279.30","91.72","1116.77","266","687.69","1763.58","percent of total billed charges",""
"PLATE FEMORAL 19X73MM PEDIATRIC 100DEG LCP SS","SUP-ITM-10037424","CDM","C1713","HCPCS","0278","RC","","","","both","","","2218.34","1663.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","951.67","42.9","","731.00","63.70","731.00","1 through 10","687.69","1763.58","percent of total billed charges",""
"PLATE FEMORAL 19X73MM PEDIATRIC 100DEG LCP SS","SUP-ITM-10037424","CDM","C1713","HCPCS","0278","RC","","","","both","","","2218.34","1663.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","951.67","42.9","","384.74","384.74","384.74","1 through 10","687.69","1763.58","percent of total billed charges",""
"PLATE FEMORAL 19X73MM PEDIATRIC 100DEG LCP SS","SUP-ITM-10037424","CDM","C1713","HCPCS","0278","RC","","","","both","","","2218.34","1663.75","WELLPOINT [1015]","HB AMC WELLPOINT","1636.69","73.78","","286.63","119.22","1107.45","105","687.69","1763.58","percent of total billed charges",""
"PLATE FEMORAL 19X73MM PEDIATRIC 100DEG LCP SS","SUP-ITM-10037424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2218.34","1663.75","AETNA [1001]","HB AMC AETNA HMO","1548.40","69.8","","675.31","184.75","1721.50","286","1159.3","1812.83","percent of total billed charges",""
"PLATE FEMORAL 19X73MM PEDIATRIC 100DEG LCP SS","SUP-ITM-10037424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2218.34","1663.75","AETNA [1001]","HB AMC AETNA PPO","1783.55","80.4","","1261.44","103.12","1514.10","21","1159.3","1812.83","percent of total billed charges",""
"PLATE FEMORAL 19X73MM PEDIATRIC 100DEG LCP SS","SUP-ITM-10037424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2218.34","1663.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1783.55","80.4","","1365.00","1365.00","1365.00","1 through 10","1159.3","1812.83","percent of total billed charges",""
"PLATE FEMORAL 19X73MM PEDIATRIC 100DEG LCP SS","SUP-ITM-10037424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2218.34","1663.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1812.83","81.72","","5157.68","5157.68","5157.68","1 through 10","1159.3","1812.83","percent of total billed charges",""
"PLATE FEMORAL 19X73MM PEDIATRIC 100DEG LCP SS","SUP-ITM-10037424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2218.34","1663.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1812.83","81.72","","431.26","71.26","1459.57","88","1159.3","1812.83","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2149.14","1611.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1708.57","79.5","","800.18","480.96","1887.97","195","666.23","1708.57","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2149.14","1611.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1145.49","53.3","","813.12","216.42","1444.50","81","666.23","1708.57","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2149.14","1611.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","666.23","31","","432.60","432.60","432.60","1 through 10","666.23","1708.57","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2149.14","1611.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","784.44","36.5","","148.37","54.89","631.39","94","666.23","1708.57","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2149.14","1611.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","823.12","38.3","","279.30","91.72","1116.77","266","666.23","1708.57","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2149.14","1611.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","921.98","42.9","","731.00","63.70","731.00","1 through 10","666.23","1708.57","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2149.14","1611.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","921.98","42.9","","384.74","384.74","384.74","1 through 10","666.23","1708.57","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2149.14","1611.85","WELLPOINT [1015]","HB AMC WELLPOINT","1585.64","73.78","","286.63","119.22","1107.45","105","666.23","1708.57","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2149.14","1611.85","AETNA [1001]","HB AMC AETNA HMO","1500.10","69.8","","675.31","184.75","1721.50","286","1123.14","1756.28","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2149.14","1611.85","AETNA [1001]","HB AMC AETNA PPO","1727.91","80.4","","1261.44","103.12","1514.10","21","1123.14","1756.28","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2149.14","1611.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1727.91","80.4","","1365.00","1365.00","1365.00","1 through 10","1123.14","1756.28","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2149.14","1611.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1756.28","81.72","","5157.68","5157.68","5157.68","1 through 10","1123.14","1756.28","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2149.14","1611.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1756.28","81.72","","431.26","71.26","1459.57","88","1123.14","1756.28","percent of total billed charges",""
"PLATE FEMORAL 276MM 11 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3946.05","2959.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3137.11","79.5","","800.18","480.96","1887.97","195","1223.28","3137.11","percent of total billed charges",""
"PLATE FEMORAL 276MM 11 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3946.05","2959.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2103.24","53.3","","813.12","216.42","1444.50","81","1223.28","3137.11","percent of total billed charges",""
"PLATE FEMORAL 276MM 11 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3946.05","2959.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1223.28","31","","432.60","432.60","432.60","1 through 10","1223.28","3137.11","percent of total billed charges",""
"PLATE FEMORAL 276MM 11 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3946.05","2959.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1440.31","36.5","","148.37","54.89","631.39","94","1223.28","3137.11","percent of total billed charges",""
"PLATE FEMORAL 276MM 11 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3946.05","2959.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1511.34","38.3","","279.30","91.72","1116.77","266","1223.28","3137.11","percent of total billed charges",""
"PLATE FEMORAL 276MM 11 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3946.05","2959.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1692.86","42.9","","731.00","63.70","731.00","1 through 10","1223.28","3137.11","percent of total billed charges",""
"PLATE FEMORAL 276MM 11 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3946.05","2959.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1692.86","42.9","","384.74","384.74","384.74","1 through 10","1223.28","3137.11","percent of total billed charges",""
"PLATE FEMORAL 276MM 11 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3946.05","2959.54","WELLPOINT [1015]","HB AMC WELLPOINT","2911.40","73.78","","286.63","119.22","1107.45","105","1223.28","3137.11","percent of total billed charges",""
"PLATE FEMORAL 276MM 11 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3946.05","2959.54","AETNA [1001]","HB AMC AETNA HMO","2754.34","69.8","","675.31","184.75","1721.50","286","2062.21","3224.71","percent of total billed charges",""
"PLATE FEMORAL 276MM 11 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3946.05","2959.54","AETNA [1001]","HB AMC AETNA PPO","3172.62","80.4","","1261.44","103.12","1514.10","21","2062.21","3224.71","percent of total billed charges",""
"PLATE FEMORAL 276MM 11 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3946.05","2959.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3172.62","80.4","","1365.00","1365.00","1365.00","1 through 10","2062.21","3224.71","percent of total billed charges",""
"PLATE FEMORAL 276MM 11 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3946.05","2959.54","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3224.71","81.72","","5157.68","5157.68","5157.68","1 through 10","2062.21","3224.71","percent of total billed charges",""
"PLATE FEMORAL 276MM 11 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10022892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3946.05","2959.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3224.71","81.72","","431.26","71.26","1459.57","88","2062.21","3224.71","percent of total billed charges",""
"PLATE FEMORAL 316MM 13 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10029916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.53","3016.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3197.12","79.5","","800.18","480.96","1887.97","195","1246.67","3197.12","percent of total billed charges",""
"PLATE FEMORAL 316MM 13 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10029916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.53","3016.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2143.48","53.3","","813.12","216.42","1444.50","81","1246.67","3197.12","percent of total billed charges",""
"PLATE FEMORAL 316MM 13 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10029916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.53","3016.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1246.67","31","","432.60","432.60","432.60","1 through 10","1246.67","3197.12","percent of total billed charges",""
"PLATE FEMORAL 316MM 13 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10029916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.53","3016.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1467.86","36.5","","148.37","54.89","631.39","94","1246.67","3197.12","percent of total billed charges",""
"PLATE FEMORAL 316MM 13 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10029916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.53","3016.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1540.25","38.3","","279.30","91.72","1116.77","266","1246.67","3197.12","percent of total billed charges",""
"PLATE FEMORAL 316MM 13 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10029916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.53","3016.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1725.24","42.9","","731.00","63.70","731.00","1 through 10","1246.67","3197.12","percent of total billed charges",""
"PLATE FEMORAL 316MM 13 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10029916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.53","3016.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1725.24","42.9","","384.74","384.74","384.74","1 through 10","1246.67","3197.12","percent of total billed charges",""
"PLATE FEMORAL 316MM 13 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10029916","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.53","3016.15","WELLPOINT [1015]","HB AMC WELLPOINT","2967.08","73.78","","286.63","119.22","1107.45","105","1246.67","3197.12","percent of total billed charges",""
"PLATE FEMORAL 316MM 13 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10029916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4021.53","3016.15","AETNA [1001]","HB AMC AETNA HMO","2807.03","69.8","","675.31","184.75","1721.50","286","2101.65","3286.39","percent of total billed charges",""
"PLATE FEMORAL 316MM 13 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10029916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4021.53","3016.15","AETNA [1001]","HB AMC AETNA PPO","3233.31","80.4","","1261.44","103.12","1514.10","21","2101.65","3286.39","percent of total billed charges",""
"PLATE FEMORAL 316MM 13 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10029916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4021.53","3016.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3233.31","80.4","","1365.00","1365.00","1365.00","1 through 10","2101.65","3286.39","percent of total billed charges",""
"PLATE FEMORAL 316MM 13 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10029916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4021.53","3016.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3286.39","81.72","","5157.68","5157.68","5157.68","1 through 10","2101.65","3286.39","percent of total billed charges",""
"PLATE FEMORAL 316MM 13 HOLE DISTAL LCP TM RIGHT","SUP-ITM-10029916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4021.53","3016.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3286.39","81.72","","431.26","71.26","1459.57","88","2101.65","3286.39","percent of total billed charges",""
"PLATE FEMORAL 4.5X133MM 2 HOLE PROXIMAL LCP HOOK","SUP-ITM-10030855","CDM","C1713","HCPCS","0278","RC","","","","both","","","4335.66","3251.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3446.85","79.5","","800.18","480.96","1887.97","195","1344.05","3446.85","percent of total billed charges",""
"PLATE FEMORAL 4.5X133MM 2 HOLE PROXIMAL LCP HOOK","SUP-ITM-10030855","CDM","C1713","HCPCS","0278","RC","","","","both","","","4335.66","3251.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2310.91","53.3","","813.12","216.42","1444.50","81","1344.05","3446.85","percent of total billed charges",""
"PLATE FEMORAL 4.5X133MM 2 HOLE PROXIMAL LCP HOOK","SUP-ITM-10030855","CDM","C1713","HCPCS","0278","RC","","","","both","","","4335.66","3251.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1344.05","31","","432.60","432.60","432.60","1 through 10","1344.05","3446.85","percent of total billed charges",""
"PLATE FEMORAL 4.5X133MM 2 HOLE PROXIMAL LCP HOOK","SUP-ITM-10030855","CDM","C1713","HCPCS","0278","RC","","","","both","","","4335.66","3251.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1582.52","36.5","","148.37","54.89","631.39","94","1344.05","3446.85","percent of total billed charges",""
"PLATE FEMORAL 4.5X133MM 2 HOLE PROXIMAL LCP HOOK","SUP-ITM-10030855","CDM","C1713","HCPCS","0278","RC","","","","both","","","4335.66","3251.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1660.56","38.3","","279.30","91.72","1116.77","266","1344.05","3446.85","percent of total billed charges",""
"PLATE FEMORAL 4.5X133MM 2 HOLE PROXIMAL LCP HOOK","SUP-ITM-10030855","CDM","C1713","HCPCS","0278","RC","","","","both","","","4335.66","3251.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1860.00","42.9","","731.00","63.70","731.00","1 through 10","1344.05","3446.85","percent of total billed charges",""
"PLATE FEMORAL 4.5X133MM 2 HOLE PROXIMAL LCP HOOK","SUP-ITM-10030855","CDM","C1713","HCPCS","0278","RC","","","","both","","","4335.66","3251.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1860.00","42.9","","384.74","384.74","384.74","1 through 10","1344.05","3446.85","percent of total billed charges",""
"PLATE FEMORAL 4.5X133MM 2 HOLE PROXIMAL LCP HOOK","SUP-ITM-10030855","CDM","C1713","HCPCS","0278","RC","","","","both","","","4335.66","3251.74","WELLPOINT [1015]","HB AMC WELLPOINT","3198.85","73.78","","286.63","119.22","1107.45","105","1344.05","3446.85","percent of total billed charges",""
"PLATE FEMORAL 4.5X133MM 2 HOLE PROXIMAL LCP HOOK","SUP-ITM-10030855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4335.66","3251.74","AETNA [1001]","HB AMC AETNA HMO","3026.29","69.8","","675.31","184.75","1721.50","286","2265.82","3543.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X133MM 2 HOLE PROXIMAL LCP HOOK","SUP-ITM-10030855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4335.66","3251.74","AETNA [1001]","HB AMC AETNA PPO","3485.87","80.4","","1261.44","103.12","1514.10","21","2265.82","3543.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X133MM 2 HOLE PROXIMAL LCP HOOK","SUP-ITM-10030855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4335.66","3251.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3485.87","80.4","","1365.00","1365.00","1365.00","1 through 10","2265.82","3543.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X133MM 2 HOLE PROXIMAL LCP HOOK","SUP-ITM-10030855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4335.66","3251.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3543.10","81.72","","5157.68","5157.68","5157.68","1 through 10","2265.82","3543.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X133MM 2 HOLE PROXIMAL LCP HOOK","SUP-ITM-10030855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4335.66","3251.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3543.10","81.72","","431.26","71.26","1459.57","88","2265.82","3543.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X139MM 2 HOLE PROXIMAL LCP LEFT","SUP-ITM-10021807","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.55","2806.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2975.33","79.5","","800.18","480.96","1887.97","195","1160.19","2975.33","percent of total billed charges",""
"PLATE FEMORAL 4.5X139MM 2 HOLE PROXIMAL LCP LEFT","SUP-ITM-10021807","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.55","2806.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1994.78","53.3","","813.12","216.42","1444.50","81","1160.19","2975.33","percent of total billed charges",""
"PLATE FEMORAL 4.5X139MM 2 HOLE PROXIMAL LCP LEFT","SUP-ITM-10021807","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.55","2806.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1160.19","31","","432.60","432.60","432.60","1 through 10","1160.19","2975.33","percent of total billed charges",""
"PLATE FEMORAL 4.5X139MM 2 HOLE PROXIMAL LCP LEFT","SUP-ITM-10021807","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.55","2806.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1366.03","36.5","","148.37","54.89","631.39","94","1160.19","2975.33","percent of total billed charges",""
"PLATE FEMORAL 4.5X139MM 2 HOLE PROXIMAL LCP LEFT","SUP-ITM-10021807","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.55","2806.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1433.40","38.3","","279.30","91.72","1116.77","266","1160.19","2975.33","percent of total billed charges",""
"PLATE FEMORAL 4.5X139MM 2 HOLE PROXIMAL LCP LEFT","SUP-ITM-10021807","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.55","2806.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1605.55","42.9","","731.00","63.70","731.00","1 through 10","1160.19","2975.33","percent of total billed charges",""
"PLATE FEMORAL 4.5X139MM 2 HOLE PROXIMAL LCP LEFT","SUP-ITM-10021807","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.55","2806.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1605.55","42.9","","384.74","384.74","384.74","1 through 10","1160.19","2975.33","percent of total billed charges",""
"PLATE FEMORAL 4.5X139MM 2 HOLE PROXIMAL LCP LEFT","SUP-ITM-10021807","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.55","2806.91","WELLPOINT [1015]","HB AMC WELLPOINT","2761.25","73.78","","286.63","119.22","1107.45","105","1160.19","2975.33","percent of total billed charges",""
"PLATE FEMORAL 4.5X139MM 2 HOLE PROXIMAL LCP LEFT","SUP-ITM-10021807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3742.55","2806.91","AETNA [1001]","HB AMC AETNA HMO","2612.30","69.8","","675.31","184.75","1721.50","286","1955.86","3058.41","percent of total billed charges",""
"PLATE FEMORAL 4.5X139MM 2 HOLE PROXIMAL LCP LEFT","SUP-ITM-10021807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3742.55","2806.91","AETNA [1001]","HB AMC AETNA PPO","3009.01","80.4","","1261.44","103.12","1514.10","21","1955.86","3058.41","percent of total billed charges",""
"PLATE FEMORAL 4.5X139MM 2 HOLE PROXIMAL LCP LEFT","SUP-ITM-10021807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3742.55","2806.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3009.01","80.4","","1365.00","1365.00","1365.00","1 through 10","1955.86","3058.41","percent of total billed charges",""
"PLATE FEMORAL 4.5X139MM 2 HOLE PROXIMAL LCP LEFT","SUP-ITM-10021807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3742.55","2806.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3058.41","81.72","","5157.68","5157.68","5157.68","1 through 10","1955.86","3058.41","percent of total billed charges",""
"PLATE FEMORAL 4.5X139MM 2 HOLE PROXIMAL LCP LEFT","SUP-ITM-10021807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3742.55","2806.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3058.41","81.72","","431.26","71.26","1459.57","88","1955.86","3058.41","percent of total billed charges",""
"PLATE FEMORAL 4.5X156MM 5 HOLE LISS TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10007386","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3093.73","79.5","","800.18","480.96","1887.97","195","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X156MM 5 HOLE LISS TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10007386","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2074.16","53.3","","813.12","216.42","1444.50","81","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X156MM 5 HOLE LISS TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10007386","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1206.36","31","","432.60","432.60","432.60","1 through 10","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X156MM 5 HOLE LISS TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10007386","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1420.39","36.5","","148.37","54.89","631.39","94","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X156MM 5 HOLE LISS TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10007386","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1490.44","38.3","","279.30","91.72","1116.77","266","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X156MM 5 HOLE LISS TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10007386","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.44","42.9","","731.00","63.70","731.00","1 through 10","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X156MM 5 HOLE LISS TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10007386","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.44","42.9","","384.74","384.74","384.74","1 through 10","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X156MM 5 HOLE LISS TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10007386","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","WELLPOINT [1015]","HB AMC WELLPOINT","2871.13","73.78","","286.63","119.22","1107.45","105","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X156MM 5 HOLE LISS TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10007386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.48","2918.61","AETNA [1001]","HB AMC AETNA HMO","2716.25","69.8","","675.31","184.75","1721.50","286","2033.69","3180.12","percent of total billed charges",""
"PLATE FEMORAL 4.5X156MM 5 HOLE LISS TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10007386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.48","2918.61","AETNA [1001]","HB AMC AETNA PPO","3128.75","80.4","","1261.44","103.12","1514.10","21","2033.69","3180.12","percent of total billed charges",""
"PLATE FEMORAL 4.5X156MM 5 HOLE LISS TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10007386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.48","2918.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3128.75","80.4","","1365.00","1365.00","1365.00","1 through 10","2033.69","3180.12","percent of total billed charges",""
"PLATE FEMORAL 4.5X156MM 5 HOLE LISS TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10007386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.48","2918.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3180.12","81.72","","5157.68","5157.68","5157.68","1 through 10","2033.69","3180.12","percent of total billed charges",""
"PLATE FEMORAL 4.5X156MM 5 HOLE LISS TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10007386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.48","2918.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3180.12","81.72","","431.26","71.26","1459.57","88","2033.69","3180.12","percent of total billed charges",""
"PLATE FEMORAL 4.5X175MM 4 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10021947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3816.37","2862.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3034.01","79.5","","800.18","480.96","1887.97","195","1183.07","3034.01","percent of total billed charges",""
"PLATE FEMORAL 4.5X175MM 4 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10021947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3816.37","2862.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2034.13","53.3","","813.12","216.42","1444.50","81","1183.07","3034.01","percent of total billed charges",""
"PLATE FEMORAL 4.5X175MM 4 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10021947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3816.37","2862.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1183.07","31","","432.60","432.60","432.60","1 through 10","1183.07","3034.01","percent of total billed charges",""
"PLATE FEMORAL 4.5X175MM 4 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10021947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3816.37","2862.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1392.98","36.5","","148.37","54.89","631.39","94","1183.07","3034.01","percent of total billed charges",""
"PLATE FEMORAL 4.5X175MM 4 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10021947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3816.37","2862.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1461.67","38.3","","279.30","91.72","1116.77","266","1183.07","3034.01","percent of total billed charges",""
"PLATE FEMORAL 4.5X175MM 4 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10021947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3816.37","2862.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1637.22","42.9","","731.00","63.70","731.00","1 through 10","1183.07","3034.01","percent of total billed charges",""
"PLATE FEMORAL 4.5X175MM 4 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10021947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3816.37","2862.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1637.22","42.9","","384.74","384.74","384.74","1 through 10","1183.07","3034.01","percent of total billed charges",""
"PLATE FEMORAL 4.5X175MM 4 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10021947","CDM","C1713","HCPCS","0278","RC","","","","both","","","3816.37","2862.28","WELLPOINT [1015]","HB AMC WELLPOINT","2815.72","73.78","","286.63","119.22","1107.45","105","1183.07","3034.01","percent of total billed charges",""
"PLATE FEMORAL 4.5X175MM 4 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10021947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3816.37","2862.28","AETNA [1001]","HB AMC AETNA HMO","2663.83","69.8","","675.31","184.75","1721.50","286","1994.43","3118.74","percent of total billed charges",""
"PLATE FEMORAL 4.5X175MM 4 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10021947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3816.37","2862.28","AETNA [1001]","HB AMC AETNA PPO","3068.36","80.4","","1261.44","103.12","1514.10","21","1994.43","3118.74","percent of total billed charges",""
"PLATE FEMORAL 4.5X175MM 4 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10021947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3816.37","2862.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3068.36","80.4","","1365.00","1365.00","1365.00","1 through 10","1994.43","3118.74","percent of total billed charges",""
"PLATE FEMORAL 4.5X175MM 4 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10021947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3816.37","2862.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3118.74","81.72","","5157.68","5157.68","5157.68","1 through 10","1994.43","3118.74","percent of total billed charges",""
"PLATE FEMORAL 4.5X175MM 4 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10021947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3816.37","2862.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3118.74","81.72","","431.26","71.26","1459.57","88","1994.43","3118.74","percent of total billed charges",""
"PLATE FEMORAL 4.5X211MM 6 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10019593","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.77","2919.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3094.75","79.5","","800.18","480.96","1887.97","195","1206.76","3094.75","percent of total billed charges",""
"PLATE FEMORAL 4.5X211MM 6 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10019593","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.77","2919.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2074.85","53.3","","813.12","216.42","1444.50","81","1206.76","3094.75","percent of total billed charges",""
"PLATE FEMORAL 4.5X211MM 6 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10019593","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.77","2919.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1206.76","31","","432.60","432.60","432.60","1 through 10","1206.76","3094.75","percent of total billed charges",""
"PLATE FEMORAL 4.5X211MM 6 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10019593","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.77","2919.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1420.86","36.5","","148.37","54.89","631.39","94","1206.76","3094.75","percent of total billed charges",""
"PLATE FEMORAL 4.5X211MM 6 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10019593","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.77","2919.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1490.93","38.3","","279.30","91.72","1116.77","266","1206.76","3094.75","percent of total billed charges",""
"PLATE FEMORAL 4.5X211MM 6 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10019593","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.77","2919.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1670.00","42.9","","731.00","63.70","731.00","1 through 10","1206.76","3094.75","percent of total billed charges",""
"PLATE FEMORAL 4.5X211MM 6 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10019593","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.77","2919.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1670.00","42.9","","384.74","384.74","384.74","1 through 10","1206.76","3094.75","percent of total billed charges",""
"PLATE FEMORAL 4.5X211MM 6 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10019593","CDM","C1713","HCPCS","0278","RC","","","","both","","","3892.77","2919.58","WELLPOINT [1015]","HB AMC WELLPOINT","2872.09","73.78","","286.63","119.22","1107.45","105","1206.76","3094.75","percent of total billed charges",""
"PLATE FEMORAL 4.5X211MM 6 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10019593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.77","2919.58","AETNA [1001]","HB AMC AETNA HMO","2717.15","69.8","","675.31","184.75","1721.50","286","2034.36","3181.17","percent of total billed charges",""
"PLATE FEMORAL 4.5X211MM 6 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10019593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.77","2919.58","AETNA [1001]","HB AMC AETNA PPO","3129.79","80.4","","1261.44","103.12","1514.10","21","2034.36","3181.17","percent of total billed charges",""
"PLATE FEMORAL 4.5X211MM 6 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10019593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.77","2919.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3129.79","80.4","","1365.00","1365.00","1365.00","1 through 10","2034.36","3181.17","percent of total billed charges",""
"PLATE FEMORAL 4.5X211MM 6 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10019593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.77","2919.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3181.17","81.72","","5157.68","5157.68","5157.68","1 through 10","2034.36","3181.17","percent of total billed charges",""
"PLATE FEMORAL 4.5X211MM 6 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10019593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3892.77","2919.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3181.17","81.72","","431.26","71.26","1459.57","88","2034.36","3181.17","percent of total billed charges",""
"PLATE FEMORAL 4.5X236MM 9 HOLE LISS TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10007376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3093.73","79.5","","800.18","480.96","1887.97","195","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X236MM 9 HOLE LISS TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10007376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2074.16","53.3","","813.12","216.42","1444.50","81","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X236MM 9 HOLE LISS TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10007376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1206.36","31","","432.60","432.60","432.60","1 through 10","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X236MM 9 HOLE LISS TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10007376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1420.39","36.5","","148.37","54.89","631.39","94","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X236MM 9 HOLE LISS TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10007376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1490.44","38.3","","279.30","91.72","1116.77","266","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X236MM 9 HOLE LISS TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10007376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.44","42.9","","731.00","63.70","731.00","1 through 10","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X236MM 9 HOLE LISS TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10007376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.44","42.9","","384.74","384.74","384.74","1 through 10","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X236MM 9 HOLE LISS TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10007376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.48","2918.61","WELLPOINT [1015]","HB AMC WELLPOINT","2871.13","73.78","","286.63","119.22","1107.45","105","1206.36","3093.73","percent of total billed charges",""
"PLATE FEMORAL 4.5X236MM 9 HOLE LISS TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10007376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.48","2918.61","AETNA [1001]","HB AMC AETNA HMO","2716.25","69.8","","675.31","184.75","1721.50","286","2033.69","3180.12","percent of total billed charges",""
"PLATE FEMORAL 4.5X236MM 9 HOLE LISS TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10007376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.48","2918.61","AETNA [1001]","HB AMC AETNA PPO","3128.75","80.4","","1261.44","103.12","1514.10","21","2033.69","3180.12","percent of total billed charges",""
"PLATE FEMORAL 4.5X236MM 9 HOLE LISS TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10007376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.48","2918.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3128.75","80.4","","1365.00","1365.00","1365.00","1 through 10","2033.69","3180.12","percent of total billed charges",""
"PLATE FEMORAL 4.5X236MM 9 HOLE LISS TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10007376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.48","2918.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3180.12","81.72","","5157.68","5157.68","5157.68","1 through 10","2033.69","3180.12","percent of total billed charges",""
"PLATE FEMORAL 4.5X236MM 9 HOLE LISS TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10007376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.48","2918.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3180.12","81.72","","431.26","71.26","1459.57","88","2033.69","3180.12","percent of total billed charges",""
"PLATE FEMORAL 4.5X247MM 8 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10024442","CDM","C1713","HCPCS","0278","RC","","","","both","","","4081.84","3061.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3245.06","79.5","","800.18","480.96","1887.97","195","1265.37","3245.06","percent of total billed charges",""
"PLATE FEMORAL 4.5X247MM 8 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10024442","CDM","C1713","HCPCS","0278","RC","","","","both","","","4081.84","3061.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2175.62","53.3","","813.12","216.42","1444.50","81","1265.37","3245.06","percent of total billed charges",""
"PLATE FEMORAL 4.5X247MM 8 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10024442","CDM","C1713","HCPCS","0278","RC","","","","both","","","4081.84","3061.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1265.37","31","","432.60","432.60","432.60","1 through 10","1265.37","3245.06","percent of total billed charges",""
"PLATE FEMORAL 4.5X247MM 8 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10024442","CDM","C1713","HCPCS","0278","RC","","","","both","","","4081.84","3061.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1489.87","36.5","","148.37","54.89","631.39","94","1265.37","3245.06","percent of total billed charges",""
"PLATE FEMORAL 4.5X247MM 8 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10024442","CDM","C1713","HCPCS","0278","RC","","","","both","","","4081.84","3061.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1563.34","38.3","","279.30","91.72","1116.77","266","1265.37","3245.06","percent of total billed charges",""
"PLATE FEMORAL 4.5X247MM 8 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10024442","CDM","C1713","HCPCS","0278","RC","","","","both","","","4081.84","3061.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1751.11","42.9","","731.00","63.70","731.00","1 through 10","1265.37","3245.06","percent of total billed charges",""
"PLATE FEMORAL 4.5X247MM 8 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10024442","CDM","C1713","HCPCS","0278","RC","","","","both","","","4081.84","3061.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1751.11","42.9","","384.74","384.74","384.74","1 through 10","1265.37","3245.06","percent of total billed charges",""
"PLATE FEMORAL 4.5X247MM 8 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10024442","CDM","C1713","HCPCS","0278","RC","","","","both","","","4081.84","3061.38","WELLPOINT [1015]","HB AMC WELLPOINT","3011.58","73.78","","286.63","119.22","1107.45","105","1265.37","3245.06","percent of total billed charges",""
"PLATE FEMORAL 4.5X247MM 8 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10024442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4081.84","3061.38","AETNA [1001]","HB AMC AETNA HMO","2849.12","69.8","","675.31","184.75","1721.50","286","2133.17","3335.68","percent of total billed charges",""
"PLATE FEMORAL 4.5X247MM 8 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10024442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4081.84","3061.38","AETNA [1001]","HB AMC AETNA PPO","3281.80","80.4","","1261.44","103.12","1514.10","21","2133.17","3335.68","percent of total billed charges",""
"PLATE FEMORAL 4.5X247MM 8 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10024442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4081.84","3061.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3281.80","80.4","","1365.00","1365.00","1365.00","1 through 10","2133.17","3335.68","percent of total billed charges",""
"PLATE FEMORAL 4.5X247MM 8 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10024442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4081.84","3061.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3335.68","81.72","","5157.68","5157.68","5157.68","1 through 10","2133.17","3335.68","percent of total billed charges",""
"PLATE FEMORAL 4.5X247MM 8 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10024442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4081.84","3061.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3335.68","81.72","","431.26","71.26","1459.57","88","2133.17","3335.68","percent of total billed charges",""
"PLATE FEMORAL 4.5X283MM 10 HOLE LEG LCP SS PROXIMAL RIGHT","SUP-ITM-10023074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4374.51","3280.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3477.74","79.5","","800.18","480.96","1887.97","195","1356.1","3477.74","percent of total billed charges",""
"PLATE FEMORAL 4.5X283MM 10 HOLE LEG LCP SS PROXIMAL RIGHT","SUP-ITM-10023074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4374.51","3280.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2331.61","53.3","","813.12","216.42","1444.50","81","1356.1","3477.74","percent of total billed charges",""
"PLATE FEMORAL 4.5X283MM 10 HOLE LEG LCP SS PROXIMAL RIGHT","SUP-ITM-10023074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4374.51","3280.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1356.10","31","","432.60","432.60","432.60","1 through 10","1356.1","3477.74","percent of total billed charges",""
"PLATE FEMORAL 4.5X283MM 10 HOLE LEG LCP SS PROXIMAL RIGHT","SUP-ITM-10023074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4374.51","3280.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1596.70","36.5","","148.37","54.89","631.39","94","1356.1","3477.74","percent of total billed charges",""
"PLATE FEMORAL 4.5X283MM 10 HOLE LEG LCP SS PROXIMAL RIGHT","SUP-ITM-10023074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4374.51","3280.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1675.44","38.3","","279.30","91.72","1116.77","266","1356.1","3477.74","percent of total billed charges",""
"PLATE FEMORAL 4.5X283MM 10 HOLE LEG LCP SS PROXIMAL RIGHT","SUP-ITM-10023074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4374.51","3280.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1876.66","42.9","","731.00","63.70","731.00","1 through 10","1356.1","3477.74","percent of total billed charges",""
"PLATE FEMORAL 4.5X283MM 10 HOLE LEG LCP SS PROXIMAL RIGHT","SUP-ITM-10023074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4374.51","3280.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1876.66","42.9","","384.74","384.74","384.74","1 through 10","1356.1","3477.74","percent of total billed charges",""
"PLATE FEMORAL 4.5X283MM 10 HOLE LEG LCP SS PROXIMAL RIGHT","SUP-ITM-10023074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4374.51","3280.88","WELLPOINT [1015]","HB AMC WELLPOINT","3227.51","73.78","","286.63","119.22","1107.45","105","1356.1","3477.74","percent of total billed charges",""
"PLATE FEMORAL 4.5X283MM 10 HOLE LEG LCP SS PROXIMAL RIGHT","SUP-ITM-10023074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4374.51","3280.88","AETNA [1001]","HB AMC AETNA HMO","3053.41","69.8","","675.31","184.75","1721.50","286","2286.12","3574.85","percent of total billed charges",""
"PLATE FEMORAL 4.5X283MM 10 HOLE LEG LCP SS PROXIMAL RIGHT","SUP-ITM-10023074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4374.51","3280.88","AETNA [1001]","HB AMC AETNA PPO","3517.11","80.4","","1261.44","103.12","1514.10","21","2286.12","3574.85","percent of total billed charges",""
"PLATE FEMORAL 4.5X283MM 10 HOLE LEG LCP SS PROXIMAL RIGHT","SUP-ITM-10023074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4374.51","3280.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3517.11","80.4","","1365.00","1365.00","1365.00","1 through 10","2286.12","3574.85","percent of total billed charges",""
"PLATE FEMORAL 4.5X283MM 10 HOLE LEG LCP SS PROXIMAL RIGHT","SUP-ITM-10023074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4374.51","3280.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3574.85","81.72","","5157.68","5157.68","5157.68","1 through 10","2286.12","3574.85","percent of total billed charges",""
"PLATE FEMORAL 4.5X283MM 10 HOLE LEG LCP SS PROXIMAL RIGHT","SUP-ITM-10023074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4374.51","3280.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3574.85","81.72","","431.26","71.26","1459.57","88","2286.12","3574.85","percent of total billed charges",""
"PLATE FEMORAL 4.5X319MM 12 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3970.47","2977.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3156.52","79.5","","800.18","480.96","1887.97","195","1230.85","3156.52","percent of total billed charges",""
"PLATE FEMORAL 4.5X319MM 12 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3970.47","2977.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2116.26","53.3","","813.12","216.42","1444.50","81","1230.85","3156.52","percent of total billed charges",""
"PLATE FEMORAL 4.5X319MM 12 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3970.47","2977.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1230.85","31","","432.60","432.60","432.60","1 through 10","1230.85","3156.52","percent of total billed charges",""
"PLATE FEMORAL 4.5X319MM 12 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3970.47","2977.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1449.22","36.5","","148.37","54.89","631.39","94","1230.85","3156.52","percent of total billed charges",""
"PLATE FEMORAL 4.5X319MM 12 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3970.47","2977.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1520.69","38.3","","279.30","91.72","1116.77","266","1230.85","3156.52","percent of total billed charges",""
"PLATE FEMORAL 4.5X319MM 12 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3970.47","2977.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1703.33","42.9","","731.00","63.70","731.00","1 through 10","1230.85","3156.52","percent of total billed charges",""
"PLATE FEMORAL 4.5X319MM 12 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3970.47","2977.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1703.33","42.9","","384.74","384.74","384.74","1 through 10","1230.85","3156.52","percent of total billed charges",""
"PLATE FEMORAL 4.5X319MM 12 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3970.47","2977.85","WELLPOINT [1015]","HB AMC WELLPOINT","2929.41","73.78","","286.63","119.22","1107.45","105","1230.85","3156.52","percent of total billed charges",""
"PLATE FEMORAL 4.5X319MM 12 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3970.47","2977.85","AETNA [1001]","HB AMC AETNA HMO","2771.39","69.8","","675.31","184.75","1721.50","286","2074.97","3244.67","percent of total billed charges",""
"PLATE FEMORAL 4.5X319MM 12 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3970.47","2977.85","AETNA [1001]","HB AMC AETNA PPO","3192.26","80.4","","1261.44","103.12","1514.10","21","2074.97","3244.67","percent of total billed charges",""
"PLATE FEMORAL 4.5X319MM 12 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3970.47","2977.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3192.26","80.4","","1365.00","1365.00","1365.00","1 through 10","2074.97","3244.67","percent of total billed charges",""
"PLATE FEMORAL 4.5X319MM 12 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3970.47","2977.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3244.67","81.72","","5157.68","5157.68","5157.68","1 through 10","2074.97","3244.67","percent of total billed charges",""
"PLATE FEMORAL 4.5X319MM 12 HOLE PROXIMAL LCP SS RIGHT","SUP-ITM-10023075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3970.47","2977.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3244.67","81.72","","431.26","71.26","1459.57","88","2074.97","3244.67","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","both","","","4357.86","3268.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3464.50","79.5","","800.18","480.96","1887.97","195","1350.94","3464.5","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","both","","","4357.86","3268.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2322.74","53.3","","813.12","216.42","1444.50","81","1350.94","3464.5","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","both","","","4357.86","3268.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1350.94","31","","432.60","432.60","432.60","1 through 10","1350.94","3464.5","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","both","","","4357.86","3268.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1590.62","36.5","","148.37","54.89","631.39","94","1350.94","3464.5","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","both","","","4357.86","3268.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1669.06","38.3","","279.30","91.72","1116.77","266","1350.94","3464.5","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","both","","","4357.86","3268.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1869.52","42.9","","731.00","63.70","731.00","1 through 10","1350.94","3464.5","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","both","","","4357.86","3268.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1869.52","42.9","","384.74","384.74","384.74","1 through 10","1350.94","3464.5","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","both","","","4357.86","3268.39","WELLPOINT [1015]","HB AMC WELLPOINT","3215.23","73.78","","286.63","119.22","1107.45","105","1350.94","3464.5","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4357.86","3268.39","AETNA [1001]","HB AMC AETNA HMO","3041.79","69.8","","675.31","184.75","1721.50","286","2277.42","3561.24","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4357.86","3268.39","AETNA [1001]","HB AMC AETNA PPO","3503.72","80.4","","1261.44","103.12","1514.10","21","2277.42","3561.24","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4357.86","3268.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3503.72","80.4","","1365.00","1365.00","1365.00","1 through 10","2277.42","3561.24","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4357.86","3268.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3561.24","81.72","","5157.68","5157.68","5157.68","1 through 10","2277.42","3561.24","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4357.86","3268.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3561.24","81.72","","431.26","71.26","1459.57","88","2277.42","3561.24","percent of total billed charges",""
"PLATE FEMORAL 4.5X355MM 14 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4287.93","3215.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3408.90","79.5","","800.18","480.96","1887.97","195","1329.26","3408.9","percent of total billed charges",""
"PLATE FEMORAL 4.5X355MM 14 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4287.93","3215.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2285.47","53.3","","813.12","216.42","1444.50","81","1329.26","3408.9","percent of total billed charges",""
"PLATE FEMORAL 4.5X355MM 14 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4287.93","3215.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1329.26","31","","432.60","432.60","432.60","1 through 10","1329.26","3408.9","percent of total billed charges",""
"PLATE FEMORAL 4.5X355MM 14 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4287.93","3215.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1565.09","36.5","","148.37","54.89","631.39","94","1329.26","3408.9","percent of total billed charges",""
"PLATE FEMORAL 4.5X355MM 14 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4287.93","3215.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1642.28","38.3","","279.30","91.72","1116.77","266","1329.26","3408.9","percent of total billed charges",""
"PLATE FEMORAL 4.5X355MM 14 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4287.93","3215.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1839.52","42.9","","731.00","63.70","731.00","1 through 10","1329.26","3408.9","percent of total billed charges",""
"PLATE FEMORAL 4.5X355MM 14 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4287.93","3215.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1839.52","42.9","","384.74","384.74","384.74","1 through 10","1329.26","3408.9","percent of total billed charges",""
"PLATE FEMORAL 4.5X355MM 14 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023072","CDM","C1713","HCPCS","0278","RC","","","","both","","","4287.93","3215.95","WELLPOINT [1015]","HB AMC WELLPOINT","3163.63","73.78","","286.63","119.22","1107.45","105","1329.26","3408.9","percent of total billed charges",""
"PLATE FEMORAL 4.5X355MM 14 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4287.93","3215.95","AETNA [1001]","HB AMC AETNA HMO","2992.98","69.8","","675.31","184.75","1721.50","286","2240.87","3504.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X355MM 14 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4287.93","3215.95","AETNA [1001]","HB AMC AETNA PPO","3447.50","80.4","","1261.44","103.12","1514.10","21","2240.87","3504.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X355MM 14 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4287.93","3215.95","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3447.50","80.4","","1365.00","1365.00","1365.00","1 through 10","2240.87","3504.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X355MM 14 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4287.93","3215.95","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3504.10","81.72","","5157.68","5157.68","5157.68","1 through 10","2240.87","3504.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X355MM 14 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4287.93","3215.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3504.10","81.72","","431.26","71.26","1459.57","88","2240.87","3504.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X385MM 16 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024441","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.27","3377.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3580.10","79.5","","800.18","480.96","1887.97","195","1396.01","3580.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X385MM 16 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024441","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.27","3377.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2400.24","53.3","","813.12","216.42","1444.50","81","1396.01","3580.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X385MM 16 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024441","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.27","3377.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1396.01","31","","432.60","432.60","432.60","1 through 10","1396.01","3580.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X385MM 16 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024441","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.27","3377.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1643.69","36.5","","148.37","54.89","631.39","94","1396.01","3580.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X385MM 16 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024441","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.27","3377.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1724.75","38.3","","279.30","91.72","1116.77","266","1396.01","3580.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X385MM 16 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024441","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.27","3377.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1931.90","42.9","","731.00","63.70","731.00","1 through 10","1396.01","3580.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X385MM 16 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024441","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.27","3377.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1931.90","42.9","","384.74","384.74","384.74","1 through 10","1396.01","3580.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X385MM 16 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024441","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.27","3377.45","WELLPOINT [1015]","HB AMC WELLPOINT","3322.51","73.78","","286.63","119.22","1107.45","105","1396.01","3580.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X385MM 16 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4503.27","3377.45","AETNA [1001]","HB AMC AETNA HMO","3143.28","69.8","","675.31","184.75","1721.50","286","2353.41","3680.07","percent of total billed charges",""
"PLATE FEMORAL 4.5X385MM 16 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4503.27","3377.45","AETNA [1001]","HB AMC AETNA PPO","3620.63","80.4","","1261.44","103.12","1514.10","21","2353.41","3680.07","percent of total billed charges",""
"PLATE FEMORAL 4.5X385MM 16 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4503.27","3377.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3620.63","80.4","","1365.00","1365.00","1365.00","1 through 10","2353.41","3680.07","percent of total billed charges",""
"PLATE FEMORAL 4.5X385MM 16 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4503.27","3377.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3680.07","81.72","","5157.68","5157.68","5157.68","1 through 10","2353.41","3680.07","percent of total billed charges",""
"PLATE FEMORAL 4.5X385MM 16 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4503.27","3377.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3680.07","81.72","","431.26","71.26","1459.57","88","2353.41","3680.07","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.69","3312.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3511.27","79.5","","800.18","480.96","1887.97","195","1369.17","3511.27","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.69","3312.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2354.10","53.3","","813.12","216.42","1444.50","81","1369.17","3511.27","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.69","3312.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1369.17","31","","432.60","432.60","432.60","1 through 10","1369.17","3511.27","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.69","3312.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1612.09","36.5","","148.37","54.89","631.39","94","1369.17","3511.27","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.69","3312.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1691.59","38.3","","279.30","91.72","1116.77","266","1369.17","3511.27","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.69","3312.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1894.76","42.9","","731.00","63.70","731.00","1 through 10","1369.17","3511.27","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.69","3312.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1894.76","42.9","","384.74","384.74","384.74","1 through 10","1369.17","3511.27","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023073","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.69","3312.52","WELLPOINT [1015]","HB AMC WELLPOINT","3258.63","73.78","","286.63","119.22","1107.45","105","1369.17","3511.27","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4416.69","3312.52","AETNA [1001]","HB AMC AETNA HMO","3082.85","69.8","","675.31","184.75","1721.50","286","2308.16","3609.32","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4416.69","3312.52","AETNA [1001]","HB AMC AETNA PPO","3551.02","80.4","","1261.44","103.12","1514.10","21","2308.16","3609.32","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4416.69","3312.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3551.02","80.4","","1365.00","1365.00","1365.00","1 through 10","2308.16","3609.32","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4416.69","3312.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3609.32","81.72","","5157.68","5157.68","5157.68","1 through 10","2308.16","3609.32","percent of total billed charges",""
"PLATE FEMORAL 4.5X391MM 16 HOLE PROXIMAL LCP LEFT","SUP-ITM-10023073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4416.69","3312.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3609.32","81.72","","431.26","71.26","1459.57","88","2308.16","3609.32","percent of total billed charges",""
"PLATE FEMORAL 4.5X405MM 20 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277700","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5200.40","79.5","","800.18","480.96","1887.97","195","2027.83","5200.4","percent of total billed charges",""
"PLATE FEMORAL 4.5X405MM 20 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277700","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3486.56","53.3","","813.12","216.42","1444.50","81","2027.83","5200.4","percent of total billed charges",""
"PLATE FEMORAL 4.5X405MM 20 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277700","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2027.83","31","","432.60","432.60","432.60","1 through 10","2027.83","5200.4","percent of total billed charges",""
"PLATE FEMORAL 4.5X405MM 20 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277700","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2387.60","36.5","","148.37","54.89","631.39","94","2027.83","5200.4","percent of total billed charges",""
"PLATE FEMORAL 4.5X405MM 20 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277700","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2505.35","38.3","","279.30","91.72","1116.77","266","2027.83","5200.4","percent of total billed charges",""
"PLATE FEMORAL 4.5X405MM 20 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277700","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2806.25","42.9","","731.00","63.70","731.00","1 through 10","2027.83","5200.4","percent of total billed charges",""
"PLATE FEMORAL 4.5X405MM 20 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277700","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2806.25","42.9","","384.74","384.74","384.74","1 through 10","2027.83","5200.4","percent of total billed charges",""
"PLATE FEMORAL 4.5X405MM 20 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277700","CDM","C1713","HCPCS","0278","RC","","","","both","","","6541.38","4906.03","WELLPOINT [1015]","HB AMC WELLPOINT","4826.23","73.78","","286.63","119.22","1107.45","105","2027.83","5200.4","percent of total billed charges",""
"PLATE FEMORAL 4.5X405MM 20 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6541.38","4906.03","AETNA [1001]","HB AMC AETNA HMO","4565.88","69.8","","675.31","184.75","1721.50","286","3418.53","5345.62","percent of total billed charges",""
"PLATE FEMORAL 4.5X405MM 20 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6541.38","4906.03","AETNA [1001]","HB AMC AETNA PPO","5259.27","80.4","","1261.44","103.12","1514.10","21","3418.53","5345.62","percent of total billed charges",""
"PLATE FEMORAL 4.5X405MM 20 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6541.38","4906.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5259.27","80.4","","1365.00","1365.00","1365.00","1 through 10","3418.53","5345.62","percent of total billed charges",""
"PLATE FEMORAL 4.5X405MM 20 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6541.38","4906.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5345.62","81.72","","5157.68","5157.68","5157.68","1 through 10","3418.53","5345.62","percent of total billed charges",""
"PLATE FEMORAL 4.5X405MM 20 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6541.38","4906.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5345.62","81.72","","431.26","71.26","1459.57","88","3418.53","5345.62","percent of total billed charges",""
"PLATE FEMORAL 4.5X439MM 22 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277698","CDM","C1713","HCPCS","0278","RC","","","","both","","","7021.90","5266.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5582.41","79.5","","800.18","480.96","1887.97","195","2176.79","5582.41","percent of total billed charges",""
"PLATE FEMORAL 4.5X439MM 22 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277698","CDM","C1713","HCPCS","0278","RC","","","","both","","","7021.90","5266.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3742.67","53.3","","813.12","216.42","1444.50","81","2176.79","5582.41","percent of total billed charges",""
"PLATE FEMORAL 4.5X439MM 22 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277698","CDM","C1713","HCPCS","0278","RC","","","","both","","","7021.90","5266.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2176.79","31","","432.60","432.60","432.60","1 through 10","2176.79","5582.41","percent of total billed charges",""
"PLATE FEMORAL 4.5X439MM 22 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277698","CDM","C1713","HCPCS","0278","RC","","","","both","","","7021.90","5266.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2562.99","36.5","","148.37","54.89","631.39","94","2176.79","5582.41","percent of total billed charges",""
"PLATE FEMORAL 4.5X439MM 22 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277698","CDM","C1713","HCPCS","0278","RC","","","","both","","","7021.90","5266.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2689.39","38.3","","279.30","91.72","1116.77","266","2176.79","5582.41","percent of total billed charges",""
"PLATE FEMORAL 4.5X439MM 22 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277698","CDM","C1713","HCPCS","0278","RC","","","","both","","","7021.90","5266.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3012.40","42.9","","731.00","63.70","731.00","1 through 10","2176.79","5582.41","percent of total billed charges",""
"PLATE FEMORAL 4.5X439MM 22 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277698","CDM","C1713","HCPCS","0278","RC","","","","both","","","7021.90","5266.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3012.40","42.9","","384.74","384.74","384.74","1 through 10","2176.79","5582.41","percent of total billed charges",""
"PLATE FEMORAL 4.5X439MM 22 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277698","CDM","C1713","HCPCS","0278","RC","","","","both","","","7021.90","5266.42","WELLPOINT [1015]","HB AMC WELLPOINT","5180.76","73.78","","286.63","119.22","1107.45","105","2176.79","5582.41","percent of total billed charges",""
"PLATE FEMORAL 4.5X439MM 22 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7021.90","5266.42","AETNA [1001]","HB AMC AETNA HMO","4901.29","69.8","","675.31","184.75","1721.50","286","3669.64","5738.3","percent of total billed charges",""
"PLATE FEMORAL 4.5X439MM 22 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7021.90","5266.42","AETNA [1001]","HB AMC AETNA PPO","5645.61","80.4","","1261.44","103.12","1514.10","21","3669.64","5738.3","percent of total billed charges",""
"PLATE FEMORAL 4.5X439MM 22 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7021.90","5266.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5645.61","80.4","","1365.00","1365.00","1365.00","1 through 10","3669.64","5738.3","percent of total billed charges",""
"PLATE FEMORAL 4.5X439MM 22 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7021.90","5266.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5738.30","81.72","","5157.68","5157.68","5157.68","1 through 10","3669.64","5738.3","percent of total billed charges",""
"PLATE FEMORAL 4.5X439MM 22 HOLE CONDYLAR TI VA-LCP CURVED LEFT","SUP-ITM-10277698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7021.90","5266.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5738.30","81.72","","431.26","71.26","1459.57","88","3669.64","5738.3","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 10 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297796","CDM","C1713","HCPCS","0278","RC","","","","both","","","6895.20","5171.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5481.68","79.5","","800.18","480.96","1887.97","195","2137.51","5481.68","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 10 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297796","CDM","C1713","HCPCS","0278","RC","","","","both","","","6895.20","5171.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3675.14","53.3","","813.12","216.42","1444.50","81","2137.51","5481.68","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 10 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297796","CDM","C1713","HCPCS","0278","RC","","","","both","","","6895.20","5171.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2137.51","31","","432.60","432.60","432.60","1 through 10","2137.51","5481.68","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 10 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297796","CDM","C1713","HCPCS","0278","RC","","","","both","","","6895.20","5171.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2516.75","36.5","","148.37","54.89","631.39","94","2137.51","5481.68","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 10 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297796","CDM","C1713","HCPCS","0278","RC","","","","both","","","6895.20","5171.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2640.86","38.3","","279.30","91.72","1116.77","266","2137.51","5481.68","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 10 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297796","CDM","C1713","HCPCS","0278","RC","","","","both","","","6895.20","5171.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2958.04","42.9","","731.00","63.70","731.00","1 through 10","2137.51","5481.68","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 10 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297796","CDM","C1713","HCPCS","0278","RC","","","","both","","","6895.20","5171.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2958.04","42.9","","384.74","384.74","384.74","1 through 10","2137.51","5481.68","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 10 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297796","CDM","C1713","HCPCS","0278","RC","","","","both","","","6895.20","5171.40","WELLPOINT [1015]","HB AMC WELLPOINT","5087.28","73.78","","286.63","119.22","1107.45","105","2137.51","5481.68","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 10 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6895.20","5171.40","AETNA [1001]","HB AMC AETNA HMO","4812.85","69.8","","675.31","184.75","1721.50","286","3603.43","5634.76","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 10 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6895.20","5171.40","AETNA [1001]","HB AMC AETNA PPO","5543.74","80.4","","1261.44","103.12","1514.10","21","3603.43","5634.76","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 10 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6895.20","5171.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5543.74","80.4","","1365.00","1365.00","1365.00","1 through 10","3603.43","5634.76","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 10 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6895.20","5171.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5634.76","81.72","","5157.68","5157.68","5157.68","1 through 10","3603.43","5634.76","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 10 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6895.20","5171.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5634.76","81.72","","431.26","71.26","1459.57","88","3603.43","5634.76","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297793","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5776.23","79.5","","800.18","480.96","1887.97","195","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297793","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3872.62","53.3","","813.12","216.42","1444.50","81","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297793","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2252.37","31","","432.60","432.60","432.60","1 through 10","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297793","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2651.98","36.5","","148.37","54.89","631.39","94","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297793","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2782.76","38.3","","279.30","91.72","1116.77","266","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297793","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3116.99","42.9","","731.00","63.70","731.00","1 through 10","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297793","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3116.99","42.9","","384.74","384.74","384.74","1 through 10","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297793","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","WELLPOINT [1015]","HB AMC WELLPOINT","5360.63","73.78","","286.63","119.22","1107.45","105","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297793","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7265.70","5449.27","AETNA [1001]","HB AMC AETNA HMO","5071.46","69.8","","675.31","184.75","1721.50","286","3797.05","5937.53","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297793","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7265.70","5449.27","AETNA [1001]","HB AMC AETNA PPO","5841.62","80.4","","1261.44","103.12","1514.10","21","3797.05","5937.53","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297793","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7265.70","5449.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5841.62","80.4","","1365.00","1365.00","1365.00","1 through 10","3797.05","5937.53","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297793","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7265.70","5449.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5937.53","81.72","","5157.68","5157.68","5157.68","1 through 10","3797.05","5937.53","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297793","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7265.70","5449.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5937.53","81.72","","431.26","71.26","1459.57","88","3797.05","5937.53","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297794","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5776.23","79.5","","800.18","480.96","1887.97","195","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297794","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3872.62","53.3","","813.12","216.42","1444.50","81","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297794","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2252.37","31","","432.60","432.60","432.60","1 through 10","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297794","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2651.98","36.5","","148.37","54.89","631.39","94","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297794","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2782.76","38.3","","279.30","91.72","1116.77","266","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297794","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3116.99","42.9","","731.00","63.70","731.00","1 through 10","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297794","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3116.99","42.9","","384.74","384.74","384.74","1 through 10","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297794","CDM","C1713","HCPCS","0278","RC","","","","both","","","7265.70","5449.27","WELLPOINT [1015]","HB AMC WELLPOINT","5360.63","73.78","","286.63","119.22","1107.45","105","2252.37","5776.23","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7265.70","5449.27","AETNA [1001]","HB AMC AETNA HMO","5071.46","69.8","","675.31","184.75","1721.50","286","3797.05","5937.53","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7265.70","5449.27","AETNA [1001]","HB AMC AETNA PPO","5841.62","80.4","","1261.44","103.12","1514.10","21","3797.05","5937.53","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7265.70","5449.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5841.62","80.4","","1365.00","1365.00","1365.00","1 through 10","3797.05","5937.53","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7265.70","5449.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5937.53","81.72","","5157.68","5157.68","5157.68","1 through 10","3797.05","5937.53","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 11 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7265.70","5449.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5937.53","81.72","","431.26","71.26","1459.57","88","3797.05","5937.53","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297791","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6459.38","79.5","","800.18","480.96","1887.97","195","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297791","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4330.63","53.3","","813.12","216.42","1444.50","81","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297791","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2518.75","31","","432.60","432.60","432.60","1 through 10","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297791","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2965.63","36.5","","148.37","54.89","631.39","94","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297791","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3111.88","38.3","","279.30","91.72","1116.77","266","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297791","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3485.63","42.9","","731.00","63.70","731.00","1 through 10","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297791","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3485.63","42.9","","384.74","384.74","384.74","1 through 10","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297791","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","WELLPOINT [1015]","HB AMC WELLPOINT","5994.63","73.78","","286.63","119.22","1107.45","105","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297791","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","AETNA [1001]","HB AMC AETNA HMO","5671.25","69.8","","675.31","184.75","1721.50","286","4246.13","6639.75","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297791","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","AETNA [1001]","HB AMC AETNA PPO","6532.50","80.4","","1261.44","103.12","1514.10","21","4246.13","6639.75","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297791","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6532.50","80.4","","1365.00","1365.00","1365.00","1 through 10","4246.13","6639.75","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297791","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6639.75","81.72","","5157.68","5157.68","5157.68","1 through 10","4246.13","6639.75","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297791","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6639.75","81.72","","431.26","71.26","1459.57","88","4246.13","6639.75","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297792","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6459.38","79.5","","800.18","480.96","1887.97","195","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297792","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4330.63","53.3","","813.12","216.42","1444.50","81","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297792","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2518.75","31","","432.60","432.60","432.60","1 through 10","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297792","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2965.63","36.5","","148.37","54.89","631.39","94","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297792","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3111.88","38.3","","279.30","91.72","1116.77","266","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297792","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3485.63","42.9","","731.00","63.70","731.00","1 through 10","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297792","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3485.63","42.9","","384.74","384.74","384.74","1 through 10","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297792","CDM","C1713","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","WELLPOINT [1015]","HB AMC WELLPOINT","5994.63","73.78","","286.63","119.22","1107.45","105","2518.75","6459.38","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","AETNA [1001]","HB AMC AETNA HMO","5671.25","69.8","","675.31","184.75","1721.50","286","4246.13","6639.75","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","AETNA [1001]","HB AMC AETNA PPO","6532.50","80.4","","1261.44","103.12","1514.10","21","4246.13","6639.75","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6532.50","80.4","","1365.00","1365.00","1365.00","1 through 10","4246.13","6639.75","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6639.75","81.72","","5157.68","5157.68","5157.68","1 through 10","4246.13","6639.75","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5/5MM 12 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL RIGHT","SUP-ITM-10297792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6639.75","81.72","","431.26","71.26","1459.57","88","4246.13","6639.75","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","both","","","5779.80","4334.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4594.94","79.5","","800.18","480.96","1887.97","195","1791.74","4594.94","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","both","","","5779.80","4334.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3080.63","53.3","","813.12","216.42","1444.50","81","1791.74","4594.94","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","both","","","5779.80","4334.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1791.74","31","","432.60","432.60","432.60","1 through 10","1791.74","4594.94","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","both","","","5779.80","4334.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2109.63","36.5","","148.37","54.89","631.39","94","1791.74","4594.94","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","both","","","5779.80","4334.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2213.66","38.3","","279.30","91.72","1116.77","266","1791.74","4594.94","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","both","","","5779.80","4334.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2479.53","42.9","","731.00","63.70","731.00","1 through 10","1791.74","4594.94","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","both","","","5779.80","4334.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2479.53","42.9","","384.74","384.74","384.74","1 through 10","1791.74","4594.94","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","both","","","5779.80","4334.85","WELLPOINT [1015]","HB AMC WELLPOINT","4264.34","73.78","","286.63","119.22","1107.45","105","1791.74","4594.94","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5779.80","4334.85","AETNA [1001]","HB AMC AETNA HMO","4034.30","69.8","","675.31","184.75","1721.50","286","3020.52","4723.25","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5779.80","4334.85","AETNA [1001]","HB AMC AETNA PPO","4646.96","80.4","","1261.44","103.12","1514.10","21","3020.52","4723.25","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5779.80","4334.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4646.96","80.4","","1365.00","1365.00","1365.00","1 through 10","3020.52","4723.25","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5779.80","4334.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4723.25","81.72","","5157.68","5157.68","5157.68","1 through 10","3020.52","4723.25","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5779.80","4334.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4723.25","81.72","","431.26","71.26","1459.57","88","3020.52","4723.25","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 8 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6151.60","4613.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4890.52","79.5","","800.18","480.96","1887.97","195","1907","4890.52","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 8 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6151.60","4613.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3278.80","53.3","","813.12","216.42","1444.50","81","1907","4890.52","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 8 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6151.60","4613.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1907.00","31","","432.60","432.60","432.60","1 through 10","1907","4890.52","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 8 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6151.60","4613.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2245.33","36.5","","148.37","54.89","631.39","94","1907","4890.52","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 8 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6151.60","4613.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2356.06","38.3","","279.30","91.72","1116.77","266","1907","4890.52","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 8 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6151.60","4613.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2639.04","42.9","","731.00","63.70","731.00","1 through 10","1907","4890.52","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 8 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6151.60","4613.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2639.04","42.9","","384.74","384.74","384.74","1 through 10","1907","4890.52","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 8 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297799","CDM","C1713","HCPCS","0278","RC","","","","both","","","6151.60","4613.70","WELLPOINT [1015]","HB AMC WELLPOINT","4538.65","73.78","","286.63","119.22","1107.45","105","1907","4890.52","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 8 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6151.60","4613.70","AETNA [1001]","HB AMC AETNA HMO","4293.82","69.8","","675.31","184.75","1721.50","286","3214.83","5027.09","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 8 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6151.60","4613.70","AETNA [1001]","HB AMC AETNA PPO","4945.89","80.4","","1261.44","103.12","1514.10","21","3214.83","5027.09","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 8 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6151.60","4613.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4945.89","80.4","","1365.00","1365.00","1365.00","1 through 10","3214.83","5027.09","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 8 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6151.60","4613.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5027.09","81.72","","5157.68","5157.68","5157.68","1 through 10","3214.83","5027.09","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 8 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6151.60","4613.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5027.09","81.72","","431.26","71.26","1459.57","88","3214.83","5027.09","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","both","","","6523.40","4892.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5186.10","79.5","","800.18","480.96","1887.97","195","2022.25","5186.1","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","both","","","6523.40","4892.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3476.97","53.3","","813.12","216.42","1444.50","81","2022.25","5186.1","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","both","","","6523.40","4892.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2022.25","31","","432.60","432.60","432.60","1 through 10","2022.25","5186.1","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","both","","","6523.40","4892.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2381.04","36.5","","148.37","54.89","631.39","94","2022.25","5186.1","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","both","","","6523.40","4892.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2498.46","38.3","","279.30","91.72","1116.77","266","2022.25","5186.1","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","both","","","6523.40","4892.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2798.54","42.9","","731.00","63.70","731.00","1 through 10","2022.25","5186.1","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","both","","","6523.40","4892.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2798.54","42.9","","384.74","384.74","384.74","1 through 10","2022.25","5186.1","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","both","","","6523.40","4892.55","WELLPOINT [1015]","HB AMC WELLPOINT","4812.96","73.78","","286.63","119.22","1107.45","105","2022.25","5186.1","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6523.40","4892.55","AETNA [1001]","HB AMC AETNA HMO","4553.33","69.8","","675.31","184.75","1721.50","286","3409.13","5330.92","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6523.40","4892.55","AETNA [1001]","HB AMC AETNA PPO","5244.81","80.4","","1261.44","103.12","1514.10","21","3409.13","5330.92","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6523.40","4892.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5244.81","80.4","","1365.00","1365.00","1365.00","1 through 10","3409.13","5330.92","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6523.40","4892.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5330.92","81.72","","5157.68","5157.68","5157.68","1 through 10","3409.13","5330.92","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6523.40","4892.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5330.92","81.72","","431.26","71.26","1459.57","88","3409.13","5330.92","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","both","","","4533.62","3400.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3604.23","79.5","","800.18","480.96","1887.97","195","1405.42","3604.23","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","both","","","4533.62","3400.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2416.42","53.3","","813.12","216.42","1444.50","81","1405.42","3604.23","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","both","","","4533.62","3400.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1405.42","31","","432.60","432.60","432.60","1 through 10","1405.42","3604.23","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","both","","","4533.62","3400.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1654.77","36.5","","148.37","54.89","631.39","94","1405.42","3604.23","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","both","","","4533.62","3400.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1736.38","38.3","","279.30","91.72","1116.77","266","1405.42","3604.23","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","both","","","4533.62","3400.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.92","42.9","","731.00","63.70","731.00","1 through 10","1405.42","3604.23","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","both","","","4533.62","3400.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.92","42.9","","384.74","384.74","384.74","1 through 10","1405.42","3604.23","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","both","","","4533.62","3400.21","WELLPOINT [1015]","HB AMC WELLPOINT","3344.90","73.78","","286.63","119.22","1107.45","105","1405.42","3604.23","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4533.62","3400.21","AETNA [1001]","HB AMC AETNA HMO","3164.47","69.8","","675.31","184.75","1721.50","286","2369.27","3704.87","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4533.62","3400.21","AETNA [1001]","HB AMC AETNA PPO","3645.03","80.4","","1261.44","103.12","1514.10","21","2369.27","3704.87","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4533.62","3400.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3645.03","80.4","","1365.00","1365.00","1365.00","1 through 10","2369.27","3704.87","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4533.62","3400.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3704.87","81.72","","5157.68","5157.68","5157.68","1 through 10","2369.27","3704.87","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4533.62","3400.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3704.87","81.72","","431.26","71.26","1459.57","88","2369.27","3704.87","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL LEFT","SUP-ITM-10040394","CDM","C1713","HCPCS","0278","RC","","","","both","","","4066.74","3050.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3233.06","79.5","","800.18","480.96","1887.97","195","1260.69","3233.06","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL LEFT","SUP-ITM-10040394","CDM","C1713","HCPCS","0278","RC","","","","both","","","4066.74","3050.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2167.57","53.3","","813.12","216.42","1444.50","81","1260.69","3233.06","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL LEFT","SUP-ITM-10040394","CDM","C1713","HCPCS","0278","RC","","","","both","","","4066.74","3050.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1260.69","31","","432.60","432.60","432.60","1 through 10","1260.69","3233.06","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL LEFT","SUP-ITM-10040394","CDM","C1713","HCPCS","0278","RC","","","","both","","","4066.74","3050.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1484.36","36.5","","148.37","54.89","631.39","94","1260.69","3233.06","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL LEFT","SUP-ITM-10040394","CDM","C1713","HCPCS","0278","RC","","","","both","","","4066.74","3050.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1557.56","38.3","","279.30","91.72","1116.77","266","1260.69","3233.06","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL LEFT","SUP-ITM-10040394","CDM","C1713","HCPCS","0278","RC","","","","both","","","4066.74","3050.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1744.63","42.9","","731.00","63.70","731.00","1 through 10","1260.69","3233.06","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL LEFT","SUP-ITM-10040394","CDM","C1713","HCPCS","0278","RC","","","","both","","","4066.74","3050.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1744.63","42.9","","384.74","384.74","384.74","1 through 10","1260.69","3233.06","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL LEFT","SUP-ITM-10040394","CDM","C1713","HCPCS","0278","RC","","","","both","","","4066.74","3050.05","WELLPOINT [1015]","HB AMC WELLPOINT","3000.44","73.78","","286.63","119.22","1107.45","105","1260.69","3233.06","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL LEFT","SUP-ITM-10040394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4066.74","3050.05","AETNA [1001]","HB AMC AETNA HMO","2838.58","69.8","","675.31","184.75","1721.50","286","2125.28","3323.34","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL LEFT","SUP-ITM-10040394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4066.74","3050.05","AETNA [1001]","HB AMC AETNA PPO","3269.66","80.4","","1261.44","103.12","1514.10","21","2125.28","3323.34","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL LEFT","SUP-ITM-10040394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4066.74","3050.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3269.66","80.4","","1365.00","1365.00","1365.00","1 through 10","2125.28","3323.34","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL LEFT","SUP-ITM-10040394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4066.74","3050.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3323.34","81.72","","5157.68","5157.68","5157.68","1 through 10","2125.28","3323.34","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL LEFT","SUP-ITM-10040394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4066.74","3050.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3323.34","81.72","","431.26","71.26","1459.57","88","2125.28","3323.34","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL RIGHT","SUP-ITM-10040392","CDM","C1713","HCPCS","0278","RC","","","","both","","","4423.35","3317.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3516.56","79.5","","800.18","480.96","1887.97","195","1371.24","3516.56","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL RIGHT","SUP-ITM-10040392","CDM","C1713","HCPCS","0278","RC","","","","both","","","4423.35","3317.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2357.65","53.3","","813.12","216.42","1444.50","81","1371.24","3516.56","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL RIGHT","SUP-ITM-10040392","CDM","C1713","HCPCS","0278","RC","","","","both","","","4423.35","3317.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1371.24","31","","432.60","432.60","432.60","1 through 10","1371.24","3516.56","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL RIGHT","SUP-ITM-10040392","CDM","C1713","HCPCS","0278","RC","","","","both","","","4423.35","3317.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1614.52","36.5","","148.37","54.89","631.39","94","1371.24","3516.56","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL RIGHT","SUP-ITM-10040392","CDM","C1713","HCPCS","0278","RC","","","","both","","","4423.35","3317.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1694.14","38.3","","279.30","91.72","1116.77","266","1371.24","3516.56","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL RIGHT","SUP-ITM-10040392","CDM","C1713","HCPCS","0278","RC","","","","both","","","4423.35","3317.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1897.62","42.9","","731.00","63.70","731.00","1 through 10","1371.24","3516.56","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL RIGHT","SUP-ITM-10040392","CDM","C1713","HCPCS","0278","RC","","","","both","","","4423.35","3317.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1897.62","42.9","","384.74","384.74","384.74","1 through 10","1371.24","3516.56","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL RIGHT","SUP-ITM-10040392","CDM","C1713","HCPCS","0278","RC","","","","both","","","4423.35","3317.51","WELLPOINT [1015]","HB AMC WELLPOINT","3263.55","73.78","","286.63","119.22","1107.45","105","1371.24","3516.56","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL RIGHT","SUP-ITM-10040392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4423.35","3317.51","AETNA [1001]","HB AMC AETNA HMO","3087.50","69.8","","675.31","184.75","1721.50","286","2311.64","3614.76","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL RIGHT","SUP-ITM-10040392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4423.35","3317.51","AETNA [1001]","HB AMC AETNA PPO","3556.37","80.4","","1261.44","103.12","1514.10","21","2311.64","3614.76","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL RIGHT","SUP-ITM-10040392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4423.35","3317.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3556.37","80.4","","1365.00","1365.00","1365.00","1 through 10","2311.64","3614.76","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL RIGHT","SUP-ITM-10040392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4423.35","3317.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3614.76","81.72","","5157.68","5157.68","5157.68","1 through 10","2311.64","3614.76","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE TITANIUM LOCKING COMPRESSION DISTAL RIGHT","SUP-ITM-10040392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4423.35","3317.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3614.76","81.72","","431.26","71.26","1459.57","88","2311.64","3614.76","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE LCP DISTAL RIGHT","SUP-ITM-10096995","CDM","C1713","HCPCS","0278","RC","","","","both","","","4333.44","3250.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3445.08","79.5","","800.18","480.96","1887.97","195","1343.37","3445.08","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE LCP DISTAL RIGHT","SUP-ITM-10096995","CDM","C1713","HCPCS","0278","RC","","","","both","","","4333.44","3250.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2309.72","53.3","","813.12","216.42","1444.50","81","1343.37","3445.08","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE LCP DISTAL RIGHT","SUP-ITM-10096995","CDM","C1713","HCPCS","0278","RC","","","","both","","","4333.44","3250.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1343.37","31","","432.60","432.60","432.60","1 through 10","1343.37","3445.08","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE LCP DISTAL RIGHT","SUP-ITM-10096995","CDM","C1713","HCPCS","0278","RC","","","","both","","","4333.44","3250.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1581.71","36.5","","148.37","54.89","631.39","94","1343.37","3445.08","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE LCP DISTAL RIGHT","SUP-ITM-10096995","CDM","C1713","HCPCS","0278","RC","","","","both","","","4333.44","3250.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1659.71","38.3","","279.30","91.72","1116.77","266","1343.37","3445.08","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE LCP DISTAL RIGHT","SUP-ITM-10096995","CDM","C1713","HCPCS","0278","RC","","","","both","","","4333.44","3250.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1859.05","42.9","","731.00","63.70","731.00","1 through 10","1343.37","3445.08","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE LCP DISTAL RIGHT","SUP-ITM-10096995","CDM","C1713","HCPCS","0278","RC","","","","both","","","4333.44","3250.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1859.05","42.9","","384.74","384.74","384.74","1 through 10","1343.37","3445.08","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE LCP DISTAL RIGHT","SUP-ITM-10096995","CDM","C1713","HCPCS","0278","RC","","","","both","","","4333.44","3250.08","WELLPOINT [1015]","HB AMC WELLPOINT","3197.21","73.78","","286.63","119.22","1107.45","105","1343.37","3445.08","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE LCP DISTAL RIGHT","SUP-ITM-10096995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4333.44","3250.08","AETNA [1001]","HB AMC AETNA HMO","3024.74","69.8","","675.31","184.75","1721.50","286","2264.66","3541.29","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE LCP DISTAL RIGHT","SUP-ITM-10096995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4333.44","3250.08","AETNA [1001]","HB AMC AETNA PPO","3484.09","80.4","","1261.44","103.12","1514.10","21","2264.66","3541.29","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE LCP DISTAL RIGHT","SUP-ITM-10096995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4333.44","3250.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3484.09","80.4","","1365.00","1365.00","1365.00","1 through 10","2264.66","3541.29","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE LCP DISTAL RIGHT","SUP-ITM-10096995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4333.44","3250.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3541.29","81.72","","5157.68","5157.68","5157.68","1 through 10","2264.66","3541.29","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE LCP DISTAL RIGHT","SUP-ITM-10096995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4333.44","3250.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3541.29","81.72","","431.26","71.26","1459.57","88","2264.66","3541.29","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE TI LCP DISTAL LEFT","SUP-ITM-10097614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4765.23","3573.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3788.36","79.5","","800.18","480.96","1887.97","195","1477.22","3788.36","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE TI LCP DISTAL LEFT","SUP-ITM-10097614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4765.23","3573.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2539.87","53.3","","813.12","216.42","1444.50","81","1477.22","3788.36","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE TI LCP DISTAL LEFT","SUP-ITM-10097614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4765.23","3573.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1477.22","31","","432.60","432.60","432.60","1 through 10","1477.22","3788.36","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE TI LCP DISTAL LEFT","SUP-ITM-10097614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4765.23","3573.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1739.31","36.5","","148.37","54.89","631.39","94","1477.22","3788.36","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE TI LCP DISTAL LEFT","SUP-ITM-10097614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4765.23","3573.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1825.08","38.3","","279.30","91.72","1116.77","266","1477.22","3788.36","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE TI LCP DISTAL LEFT","SUP-ITM-10097614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4765.23","3573.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2044.28","42.9","","731.00","63.70","731.00","1 through 10","1477.22","3788.36","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE TI LCP DISTAL LEFT","SUP-ITM-10097614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4765.23","3573.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2044.28","42.9","","384.74","384.74","384.74","1 through 10","1477.22","3788.36","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE TI LCP DISTAL LEFT","SUP-ITM-10097614","CDM","C1713","HCPCS","0278","RC","","","","both","","","4765.23","3573.92","WELLPOINT [1015]","HB AMC WELLPOINT","3515.79","73.78","","286.63","119.22","1107.45","105","1477.22","3788.36","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE TI LCP DISTAL LEFT","SUP-ITM-10097614","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4765.23","3573.92","AETNA [1001]","HB AMC AETNA HMO","3326.13","69.8","","675.31","184.75","1721.50","286","2490.31","3894.15","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE TI LCP DISTAL LEFT","SUP-ITM-10097614","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4765.23","3573.92","AETNA [1001]","HB AMC AETNA PPO","3831.24","80.4","","1261.44","103.12","1514.10","21","2490.31","3894.15","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE TI LCP DISTAL LEFT","SUP-ITM-10097614","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4765.23","3573.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3831.24","80.4","","1365.00","1365.00","1365.00","1 through 10","2490.31","3894.15","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE TI LCP DISTAL LEFT","SUP-ITM-10097614","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4765.23","3573.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3894.15","81.72","","5157.68","5157.68","5157.68","1 through 10","2490.31","3894.15","percent of total billed charges",""
"PLATE FEMUR 356MM 15 HOLE TI LCP DISTAL LEFT","SUP-ITM-10097614","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4765.23","3573.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3894.15","81.72","","431.26","71.26","1459.57","88","2490.31","3894.15","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE LCP DISTAL RIGHT","SUP-ITM-10096997","CDM","C1713","HCPCS","0278","RC","","","","both","","","4411.14","3308.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3506.86","79.5","","800.18","480.96","1887.97","195","1367.45","3506.86","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE LCP DISTAL RIGHT","SUP-ITM-10096997","CDM","C1713","HCPCS","0278","RC","","","","both","","","4411.14","3308.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2351.14","53.3","","813.12","216.42","1444.50","81","1367.45","3506.86","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE LCP DISTAL RIGHT","SUP-ITM-10096997","CDM","C1713","HCPCS","0278","RC","","","","both","","","4411.14","3308.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1367.45","31","","432.60","432.60","432.60","1 through 10","1367.45","3506.86","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE LCP DISTAL RIGHT","SUP-ITM-10096997","CDM","C1713","HCPCS","0278","RC","","","","both","","","4411.14","3308.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1610.07","36.5","","148.37","54.89","631.39","94","1367.45","3506.86","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE LCP DISTAL RIGHT","SUP-ITM-10096997","CDM","C1713","HCPCS","0278","RC","","","","both","","","4411.14","3308.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1689.47","38.3","","279.30","91.72","1116.77","266","1367.45","3506.86","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE LCP DISTAL RIGHT","SUP-ITM-10096997","CDM","C1713","HCPCS","0278","RC","","","","both","","","4411.14","3308.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1892.38","42.9","","731.00","63.70","731.00","1 through 10","1367.45","3506.86","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE LCP DISTAL RIGHT","SUP-ITM-10096997","CDM","C1713","HCPCS","0278","RC","","","","both","","","4411.14","3308.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1892.38","42.9","","384.74","384.74","384.74","1 through 10","1367.45","3506.86","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE LCP DISTAL RIGHT","SUP-ITM-10096997","CDM","C1713","HCPCS","0278","RC","","","","both","","","4411.14","3308.35","WELLPOINT [1015]","HB AMC WELLPOINT","3254.54","73.78","","286.63","119.22","1107.45","105","1367.45","3506.86","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE LCP DISTAL RIGHT","SUP-ITM-10096997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4411.14","3308.35","AETNA [1001]","HB AMC AETNA HMO","3078.98","69.8","","675.31","184.75","1721.50","286","2305.26","3604.78","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE LCP DISTAL RIGHT","SUP-ITM-10096997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4411.14","3308.35","AETNA [1001]","HB AMC AETNA PPO","3546.56","80.4","","1261.44","103.12","1514.10","21","2305.26","3604.78","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE LCP DISTAL RIGHT","SUP-ITM-10096997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4411.14","3308.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3546.56","80.4","","1365.00","1365.00","1365.00","1 through 10","2305.26","3604.78","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE LCP DISTAL RIGHT","SUP-ITM-10096997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4411.14","3308.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3604.78","81.72","","5157.68","5157.68","5157.68","1 through 10","2305.26","3604.78","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE LCP DISTAL RIGHT","SUP-ITM-10096997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4411.14","3308.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3604.78","81.72","","431.26","71.26","1459.57","88","2305.26","3604.78","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE TI LCP DISTAL RIGHT","SUP-ITM-10097615","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.81","3638.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3857.19","79.5","","800.18","480.96","1887.97","195","1504.06","3857.19","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE TI LCP DISTAL RIGHT","SUP-ITM-10097615","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.81","3638.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2586.01","53.3","","813.12","216.42","1444.50","81","1504.06","3857.19","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE TI LCP DISTAL RIGHT","SUP-ITM-10097615","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.81","3638.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1504.06","31","","432.60","432.60","432.60","1 through 10","1504.06","3857.19","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE TI LCP DISTAL RIGHT","SUP-ITM-10097615","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.81","3638.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1770.91","36.5","","148.37","54.89","631.39","94","1504.06","3857.19","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE TI LCP DISTAL RIGHT","SUP-ITM-10097615","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.81","3638.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1858.24","38.3","","279.30","91.72","1116.77","266","1504.06","3857.19","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE TI LCP DISTAL RIGHT","SUP-ITM-10097615","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.81","3638.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2081.43","42.9","","731.00","63.70","731.00","1 through 10","1504.06","3857.19","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE TI LCP DISTAL RIGHT","SUP-ITM-10097615","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.81","3638.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2081.43","42.9","","384.74","384.74","384.74","1 through 10","1504.06","3857.19","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE TI LCP DISTAL RIGHT","SUP-ITM-10097615","CDM","C1713","HCPCS","0278","RC","","","","both","","","4851.81","3638.86","WELLPOINT [1015]","HB AMC WELLPOINT","3579.67","73.78","","286.63","119.22","1107.45","105","1504.06","3857.19","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE TI LCP DISTAL RIGHT","SUP-ITM-10097615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4851.81","3638.86","AETNA [1001]","HB AMC AETNA HMO","3386.56","69.8","","675.31","184.75","1721.50","286","2535.56","3964.9","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE TI LCP DISTAL RIGHT","SUP-ITM-10097615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4851.81","3638.86","AETNA [1001]","HB AMC AETNA PPO","3900.86","80.4","","1261.44","103.12","1514.10","21","2535.56","3964.9","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE TI LCP DISTAL RIGHT","SUP-ITM-10097615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4851.81","3638.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3900.86","80.4","","1365.00","1365.00","1365.00","1 through 10","2535.56","3964.9","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE TI LCP DISTAL RIGHT","SUP-ITM-10097615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4851.81","3638.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3964.90","81.72","","5157.68","5157.68","5157.68","1 through 10","2535.56","3964.9","percent of total billed charges",""
"PLATE FEMUR 396MM 17 HOLE TI LCP DISTAL RIGHT","SUP-ITM-10097615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4851.81","3638.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3964.90","81.72","","431.26","71.26","1459.57","88","2535.56","3964.9","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4395.23","3296.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3494.21","79.5","","800.18","480.96","1887.97","195","1362.52","3494.21","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4395.23","3296.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2342.66","53.3","","813.12","216.42","1444.50","81","1362.52","3494.21","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4395.23","3296.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1362.52","31","","432.60","432.60","432.60","1 through 10","1362.52","3494.21","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4395.23","3296.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1604.26","36.5","","148.37","54.89","631.39","94","1362.52","3494.21","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4395.23","3296.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1683.37","38.3","","279.30","91.72","1116.77","266","1362.52","3494.21","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4395.23","3296.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1885.55","42.9","","731.00","63.70","731.00","1 through 10","1362.52","3494.21","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4395.23","3296.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1885.55","42.9","","384.74","384.74","384.74","1 through 10","1362.52","3494.21","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","both","","","4395.23","3296.42","WELLPOINT [1015]","HB AMC WELLPOINT","3242.80","73.78","","286.63","119.22","1107.45","105","1362.52","3494.21","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4395.23","3296.42","AETNA [1001]","HB AMC AETNA HMO","3067.87","69.8","","675.31","184.75","1721.50","286","2296.95","3591.78","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4395.23","3296.42","AETNA [1001]","HB AMC AETNA PPO","3533.76","80.4","","1261.44","103.12","1514.10","21","2296.95","3591.78","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4395.23","3296.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3533.76","80.4","","1365.00","1365.00","1365.00","1 through 10","2296.95","3591.78","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4395.23","3296.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3591.78","81.72","","5157.68","5157.68","5157.68","1 through 10","2296.95","3591.78","percent of total billed charges",""
"PLATE FEMUR 4.5X169MM 4 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10024288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4395.23","3296.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3591.78","81.72","","431.26","71.26","1459.57","88","2296.95","3591.78","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","4465.16","3348.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3549.80","79.5","","800.18","480.96","1887.97","195","1384.2","3549.8","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","4465.16","3348.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2379.93","53.3","","813.12","216.42","1444.50","81","1384.2","3549.8","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","4465.16","3348.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1384.20","31","","432.60","432.60","432.60","1 through 10","1384.2","3549.8","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","4465.16","3348.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1629.78","36.5","","148.37","54.89","631.39","94","1384.2","3549.8","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","4465.16","3348.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1710.16","38.3","","279.30","91.72","1116.77","266","1384.2","3549.8","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","4465.16","3348.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1915.55","42.9","","731.00","63.70","731.00","1 through 10","1384.2","3549.8","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","4465.16","3348.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1915.55","42.9","","384.74","384.74","384.74","1 through 10","1384.2","3549.8","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","both","","","4465.16","3348.87","WELLPOINT [1015]","HB AMC WELLPOINT","3294.40","73.78","","286.63","119.22","1107.45","105","1384.2","3549.8","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4465.16","3348.87","AETNA [1001]","HB AMC AETNA HMO","3116.68","69.8","","675.31","184.75","1721.50","286","2333.49","3648.93","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4465.16","3348.87","AETNA [1001]","HB AMC AETNA PPO","3589.99","80.4","","1261.44","103.12","1514.10","21","2333.49","3648.93","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4465.16","3348.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3589.99","80.4","","1365.00","1365.00","1365.00","1 through 10","2333.49","3648.93","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4465.16","3348.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3648.93","81.72","","5157.68","5157.68","5157.68","1 through 10","2333.49","3648.93","percent of total billed charges",""
"PLATE FEMUR 4.5X205MM 6 HOLE LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4465.16","3348.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3648.93","81.72","","431.26","71.26","1459.57","88","2333.49","3648.93","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3967.14","2975.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3153.88","79.5","","800.18","480.96","1887.97","195","1229.81","3153.88","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3967.14","2975.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2114.49","53.3","","813.12","216.42","1444.50","81","1229.81","3153.88","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3967.14","2975.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1229.81","31","","432.60","432.60","432.60","1 through 10","1229.81","3153.88","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3967.14","2975.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1448.01","36.5","","148.37","54.89","631.39","94","1229.81","3153.88","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3967.14","2975.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1519.41","38.3","","279.30","91.72","1116.77","266","1229.81","3153.88","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3967.14","2975.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1701.90","42.9","","731.00","63.70","731.00","1 through 10","1229.81","3153.88","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3967.14","2975.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1701.90","42.9","","384.74","384.74","384.74","1 through 10","1229.81","3153.88","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","3967.14","2975.35","WELLPOINT [1015]","HB AMC WELLPOINT","2926.96","73.78","","286.63","119.22","1107.45","105","1229.81","3153.88","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3967.14","2975.35","AETNA [1001]","HB AMC AETNA HMO","2769.06","69.8","","675.31","184.75","1721.50","286","2073.23","3241.95","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3967.14","2975.35","AETNA [1001]","HB AMC AETNA PPO","3189.58","80.4","","1261.44","103.12","1514.10","21","2073.23","3241.95","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3967.14","2975.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3189.58","80.4","","1365.00","1365.00","1365.00","1 through 10","2073.23","3241.95","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3967.14","2975.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3241.95","81.72","","5157.68","5157.68","5157.68","1 through 10","2073.23","3241.95","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3967.14","2975.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3241.95","81.72","","431.26","71.26","1459.57","88","2073.23","3241.95","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","4171.38","3128.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3316.25","79.5","","800.18","480.96","1887.97","195","1293.13","3316.25","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","4171.38","3128.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2223.35","53.3","","813.12","216.42","1444.50","81","1293.13","3316.25","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","4171.38","3128.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1293.13","31","","432.60","432.60","432.60","1 through 10","1293.13","3316.25","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","4171.38","3128.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1522.55","36.5","","148.37","54.89","631.39","94","1293.13","3316.25","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","4171.38","3128.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1597.64","38.3","","279.30","91.72","1116.77","266","1293.13","3316.25","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","4171.38","3128.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1789.52","42.9","","731.00","63.70","731.00","1 through 10","1293.13","3316.25","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","4171.38","3128.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1789.52","42.9","","384.74","384.74","384.74","1 through 10","1293.13","3316.25","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","4171.38","3128.53","WELLPOINT [1015]","HB AMC WELLPOINT","3077.64","73.78","","286.63","119.22","1107.45","105","1293.13","3316.25","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4171.38","3128.53","AETNA [1001]","HB AMC AETNA HMO","2911.62","69.8","","675.31","184.75","1721.50","286","2179.96","3408.85","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4171.38","3128.53","AETNA [1001]","HB AMC AETNA PPO","3353.79","80.4","","1261.44","103.12","1514.10","21","2179.96","3408.85","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4171.38","3128.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3353.79","80.4","","1365.00","1365.00","1365.00","1 through 10","2179.96","3408.85","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4171.38","3128.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3408.85","81.72","","5157.68","5157.68","5157.68","1 through 10","2179.96","3408.85","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4171.38","3128.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3408.85","81.72","","431.26","71.26","1459.57","88","2179.96","3408.85","percent of total billed charges",""
"PLATE FEMUR 4.5X313MM 12 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4306.80","3230.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3423.91","79.5","","800.18","480.96","1887.97","195","1335.11","3423.91","percent of total billed charges",""
"PLATE FEMUR 4.5X313MM 12 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4306.80","3230.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2295.52","53.3","","813.12","216.42","1444.50","81","1335.11","3423.91","percent of total billed charges",""
"PLATE FEMUR 4.5X313MM 12 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4306.80","3230.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1335.11","31","","432.60","432.60","432.60","1 through 10","1335.11","3423.91","percent of total billed charges",""
"PLATE FEMUR 4.5X313MM 12 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4306.80","3230.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1571.98","36.5","","148.37","54.89","631.39","94","1335.11","3423.91","percent of total billed charges",""
"PLATE FEMUR 4.5X313MM 12 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4306.80","3230.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1649.50","38.3","","279.30","91.72","1116.77","266","1335.11","3423.91","percent of total billed charges",""
"PLATE FEMUR 4.5X313MM 12 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4306.80","3230.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1847.62","42.9","","731.00","63.70","731.00","1 through 10","1335.11","3423.91","percent of total billed charges",""
"PLATE FEMUR 4.5X313MM 12 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4306.80","3230.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1847.62","42.9","","384.74","384.74","384.74","1 through 10","1335.11","3423.91","percent of total billed charges",""
"PLATE FEMUR 4.5X313MM 12 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022593","CDM","C1713","HCPCS","0278","RC","","","","both","","","4306.80","3230.10","WELLPOINT [1015]","HB AMC WELLPOINT","3177.56","73.78","","286.63","119.22","1107.45","105","1335.11","3423.91","percent of total billed charges",""
"PLATE FEMUR 4.5X313MM 12 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4306.80","3230.10","AETNA [1001]","HB AMC AETNA HMO","3006.15","69.8","","675.31","184.75","1721.50","286","2250.73","3519.52","percent of total billed charges",""
"PLATE FEMUR 4.5X313MM 12 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4306.80","3230.10","AETNA [1001]","HB AMC AETNA PPO","3462.67","80.4","","1261.44","103.12","1514.10","21","2250.73","3519.52","percent of total billed charges",""
"PLATE FEMUR 4.5X313MM 12 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4306.80","3230.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3462.67","80.4","","1365.00","1365.00","1365.00","1 through 10","2250.73","3519.52","percent of total billed charges",""
"PLATE FEMUR 4.5X313MM 12 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4306.80","3230.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3519.52","81.72","","5157.68","5157.68","5157.68","1 through 10","2250.73","3519.52","percent of total billed charges",""
"PLATE FEMUR 4.5X313MM 12 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4306.80","3230.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3519.52","81.72","","431.26","71.26","1459.57","88","2250.73","3519.52","percent of total billed charges",""
"PLATE FEMUR 50X10MM 90DEG OSTEOTOMY BLADE ADOLESCENT","SUP-ITM-10001684","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.02","1511.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1601.94","79.5","","800.18","480.96","1887.97","195","624.66","1601.94","percent of total billed charges",""
"PLATE FEMUR 50X10MM 90DEG OSTEOTOMY BLADE ADOLESCENT","SUP-ITM-10001684","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.02","1511.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1074.01","53.3","","813.12","216.42","1444.50","81","624.66","1601.94","percent of total billed charges",""
"PLATE FEMUR 50X10MM 90DEG OSTEOTOMY BLADE ADOLESCENT","SUP-ITM-10001684","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.02","1511.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","624.66","31","","432.60","432.60","432.60","1 through 10","624.66","1601.94","percent of total billed charges",""
"PLATE FEMUR 50X10MM 90DEG OSTEOTOMY BLADE ADOLESCENT","SUP-ITM-10001684","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.02","1511.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","735.48","36.5","","148.37","54.89","631.39","94","624.66","1601.94","percent of total billed charges",""
"PLATE FEMUR 50X10MM 90DEG OSTEOTOMY BLADE ADOLESCENT","SUP-ITM-10001684","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.02","1511.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","771.75","38.3","","279.30","91.72","1116.77","266","624.66","1601.94","percent of total billed charges",""
"PLATE FEMUR 50X10MM 90DEG OSTEOTOMY BLADE ADOLESCENT","SUP-ITM-10001684","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.02","1511.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","864.44","42.9","","731.00","63.70","731.00","1 through 10","624.66","1601.94","percent of total billed charges",""
"PLATE FEMUR 50X10MM 90DEG OSTEOTOMY BLADE ADOLESCENT","SUP-ITM-10001684","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.02","1511.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","864.44","42.9","","384.74","384.74","384.74","1 through 10","624.66","1601.94","percent of total billed charges",""
"PLATE FEMUR 50X10MM 90DEG OSTEOTOMY BLADE ADOLESCENT","SUP-ITM-10001684","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.02","1511.26","WELLPOINT [1015]","HB AMC WELLPOINT","1486.68","73.78","","286.63","119.22","1107.45","105","624.66","1601.94","percent of total billed charges",""
"PLATE FEMUR 50X10MM 90DEG OSTEOTOMY BLADE ADOLESCENT","SUP-ITM-10001684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2015.02","1511.26","AETNA [1001]","HB AMC AETNA HMO","1406.48","69.8","","675.31","184.75","1721.50","286","1053.05","1646.67","percent of total billed charges",""
"PLATE FEMUR 50X10MM 90DEG OSTEOTOMY BLADE ADOLESCENT","SUP-ITM-10001684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2015.02","1511.26","AETNA [1001]","HB AMC AETNA PPO","1620.08","80.4","","1261.44","103.12","1514.10","21","1053.05","1646.67","percent of total billed charges",""
"PLATE FEMUR 50X10MM 90DEG OSTEOTOMY BLADE ADOLESCENT","SUP-ITM-10001684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2015.02","1511.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1620.08","80.4","","1365.00","1365.00","1365.00","1 through 10","1053.05","1646.67","percent of total billed charges",""
"PLATE FEMUR 50X10MM 90DEG OSTEOTOMY BLADE ADOLESCENT","SUP-ITM-10001684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2015.02","1511.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1646.67","81.72","","5157.68","5157.68","5157.68","1 through 10","1053.05","1646.67","percent of total billed charges",""
"PLATE FEMUR 50X10MM 90DEG OSTEOTOMY BLADE ADOLESCENT","SUP-ITM-10001684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2015.02","1511.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1646.67","81.72","","431.26","71.26","1459.57","88","1053.05","1646.67","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5MM 4 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10086359","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.60","970.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1028.41","79.5","","800.18","480.96","1887.97","195","401.02","1028.41","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5MM 4 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10086359","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.60","970.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","689.49","53.3","","813.12","216.42","1444.50","81","401.02","1028.41","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5MM 4 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10086359","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.60","970.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","401.02","31","","432.60","432.60","432.60","1 through 10","401.02","1028.41","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5MM 4 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10086359","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.60","970.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","472.16","36.5","","148.37","54.89","631.39","94","401.02","1028.41","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5MM 4 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10086359","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.60","970.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","495.45","38.3","","279.30","91.72","1116.77","266","401.02","1028.41","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5MM 4 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10086359","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.60","970.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","554.95","42.9","","731.00","63.70","731.00","1 through 10","401.02","1028.41","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5MM 4 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10086359","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.60","970.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","554.95","42.9","","384.74","384.74","384.74","1 through 10","401.02","1028.41","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5MM 4 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10086359","CDM","C1713","HCPCS","0278","RC","","","","both","","","1293.60","970.20","WELLPOINT [1015]","HB AMC WELLPOINT","954.42","73.78","","286.63","119.22","1107.45","105","401.02","1028.41","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5MM 4 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10086359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1293.60","970.20","AETNA [1001]","HB AMC AETNA HMO","902.93","69.8","","675.31","184.75","1721.50","286","676.04","1057.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5MM 4 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10086359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1293.60","970.20","AETNA [1001]","HB AMC AETNA PPO","1040.05","80.4","","1261.44","103.12","1514.10","21","676.04","1057.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5MM 4 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10086359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1293.60","970.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1040.05","80.4","","1365.00","1365.00","1365.00","1 through 10","676.04","1057.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5MM 4 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10086359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1293.60","970.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1057.13","81.72","","5157.68","5157.68","5157.68","1 through 10","676.04","1057.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5MM 4 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10086359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1293.60","970.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1057.13","81.72","","431.26","71.26","1459.57","88","676.04","1057.13","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X112MM 6 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1341.76","1006.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1066.70","79.5","","800.18","480.96","1887.97","195","415.95","1066.7","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X112MM 6 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1341.76","1006.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","715.16","53.3","","813.12","216.42","1444.50","81","415.95","1066.7","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X112MM 6 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1341.76","1006.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","415.95","31","","432.60","432.60","432.60","1 through 10","415.95","1066.7","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X112MM 6 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1341.76","1006.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","489.74","36.5","","148.37","54.89","631.39","94","415.95","1066.7","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X112MM 6 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1341.76","1006.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","513.89","38.3","","279.30","91.72","1116.77","266","415.95","1066.7","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X112MM 6 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1341.76","1006.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","575.62","42.9","","731.00","63.70","731.00","1 through 10","415.95","1066.7","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X112MM 6 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1341.76","1006.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","575.62","42.9","","384.74","384.74","384.74","1 through 10","415.95","1066.7","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X112MM 6 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1341.76","1006.32","WELLPOINT [1015]","HB AMC WELLPOINT","989.95","73.78","","286.63","119.22","1107.45","105","415.95","1066.7","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X112MM 6 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1341.76","1006.32","AETNA [1001]","HB AMC AETNA HMO","936.55","69.8","","675.31","184.75","1721.50","286","701.2","1096.49","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X112MM 6 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1341.76","1006.32","AETNA [1001]","HB AMC AETNA PPO","1078.78","80.4","","1261.44","103.12","1514.10","21","701.2","1096.49","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X112MM 6 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1341.76","1006.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1078.78","80.4","","1365.00","1365.00","1365.00","1 through 10","701.2","1096.49","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X112MM 6 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1341.76","1006.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1096.49","81.72","","5157.68","5157.68","5157.68","1 through 10","701.2","1096.49","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X112MM 6 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1341.76","1006.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1096.49","81.72","","431.26","71.26","1459.57","88","701.2","1096.49","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X125MM 7 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.04","1022.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1083.62","79.5","","800.18","480.96","1887.97","195","422.54","1083.62","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X125MM 7 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.04","1022.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","726.50","53.3","","813.12","216.42","1444.50","81","422.54","1083.62","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X125MM 7 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.04","1022.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","422.54","31","","432.60","432.60","432.60","1 through 10","422.54","1083.62","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X125MM 7 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.04","1022.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","497.51","36.5","","148.37","54.89","631.39","94","422.54","1083.62","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X125MM 7 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.04","1022.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","522.04","38.3","","279.30","91.72","1116.77","266","422.54","1083.62","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X125MM 7 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.04","1022.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","584.74","42.9","","731.00","63.70","731.00","1 through 10","422.54","1083.62","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X125MM 7 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.04","1022.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","584.74","42.9","","384.74","384.74","384.74","1 through 10","422.54","1083.62","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X125MM 7 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091762","CDM","C1713","HCPCS","0278","RC","","","","both","","","1363.04","1022.28","WELLPOINT [1015]","HB AMC WELLPOINT","1005.65","73.78","","286.63","119.22","1107.45","105","422.54","1083.62","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X125MM 7 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1363.04","1022.28","AETNA [1001]","HB AMC AETNA HMO","951.40","69.8","","675.31","184.75","1721.50","286","712.32","1113.88","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X125MM 7 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1363.04","1022.28","AETNA [1001]","HB AMC AETNA PPO","1095.88","80.4","","1261.44","103.12","1514.10","21","712.32","1113.88","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X125MM 7 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1363.04","1022.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1095.88","80.4","","1365.00","1365.00","1365.00","1 through 10","712.32","1113.88","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X125MM 7 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1363.04","1022.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1113.88","81.72","","5157.68","5157.68","5157.68","1 through 10","712.32","1113.88","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X125MM 7 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1363.04","1022.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1113.88","81.72","","431.26","71.26","1459.57","88","712.32","1113.88","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X177MM 11 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1460.48","1095.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1161.08","79.5","","800.18","480.96","1887.97","195","452.75","1161.08","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X177MM 11 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1460.48","1095.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","778.44","53.3","","813.12","216.42","1444.50","81","452.75","1161.08","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X177MM 11 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1460.48","1095.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","452.75","31","","432.60","432.60","432.60","1 through 10","452.75","1161.08","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X177MM 11 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1460.48","1095.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","533.08","36.5","","148.37","54.89","631.39","94","452.75","1161.08","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X177MM 11 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1460.48","1095.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","559.36","38.3","","279.30","91.72","1116.77","266","452.75","1161.08","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X177MM 11 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1460.48","1095.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","626.55","42.9","","731.00","63.70","731.00","1 through 10","452.75","1161.08","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X177MM 11 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1460.48","1095.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","626.55","42.9","","384.74","384.74","384.74","1 through 10","452.75","1161.08","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X177MM 11 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1460.48","1095.36","WELLPOINT [1015]","HB AMC WELLPOINT","1077.54","73.78","","286.63","119.22","1107.45","105","452.75","1161.08","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X177MM 11 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1460.48","1095.36","AETNA [1001]","HB AMC AETNA HMO","1019.42","69.8","","675.31","184.75","1721.50","286","763.25","1193.5","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X177MM 11 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1460.48","1095.36","AETNA [1001]","HB AMC AETNA PPO","1174.23","80.4","","1261.44","103.12","1514.10","21","763.25","1193.5","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X177MM 11 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1460.48","1095.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1174.23","80.4","","1365.00","1365.00","1365.00","1 through 10","763.25","1193.5","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X177MM 11 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1460.48","1095.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1193.50","81.72","","5157.68","5157.68","5157.68","1 through 10","763.25","1193.5","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X177MM 11 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1460.48","1095.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1193.50","81.72","","431.26","71.26","1459.57","88","763.25","1193.5","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.52","962.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1020.40","79.5","","800.18","480.96","1887.97","195","397.89","1020.4","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.52","962.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","684.12","53.3","","813.12","216.42","1444.50","81","397.89","1020.4","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.52","962.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","397.89","31","","432.60","432.60","432.60","1 through 10","397.89","1020.4","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.52","962.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","468.48","36.5","","148.37","54.89","631.39","94","397.89","1020.4","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.52","962.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","491.59","38.3","","279.30","91.72","1116.77","266","397.89","1020.4","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.52","962.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","550.63","42.9","","731.00","63.70","731.00","1 through 10","397.89","1020.4","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.52","962.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","550.63","42.9","","384.74","384.74","384.74","1 through 10","397.89","1020.4","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1283.52","962.64","WELLPOINT [1015]","HB AMC WELLPOINT","946.98","73.78","","286.63","119.22","1107.45","105","397.89","1020.4","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1283.52","962.64","AETNA [1001]","HB AMC AETNA HMO","895.90","69.8","","675.31","184.75","1721.50","286","670.77","1048.89","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1283.52","962.64","AETNA [1001]","HB AMC AETNA PPO","1031.95","80.4","","1261.44","103.12","1514.10","21","670.77","1048.89","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1283.52","962.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1031.95","80.4","","1365.00","1365.00","1365.00","1 through 10","670.77","1048.89","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1283.52","962.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1048.89","81.72","","5157.68","5157.68","5157.68","1 through 10","670.77","1048.89","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1283.52","962.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1048.89","81.72","","431.26","71.26","1459.57","88","670.77","1048.89","percent of total billed charges",""
"PLATE FIBULA 4H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1594.37","79.5","","800.18","480.96","1887.97","195","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 4H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1068.93","53.3","","813.12","216.42","1444.50","81","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 4H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","621.71","31","","432.60","432.60","432.60","1 through 10","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 4H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","732.01","36.5","","148.37","54.89","631.39","94","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 4H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","768.11","38.3","","279.30","91.72","1116.77","266","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 4H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","860.36","42.9","","731.00","63.70","731.00","1 through 10","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 4H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","860.36","42.9","","384.74","384.74","384.74","1 through 10","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 4H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268662","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","WELLPOINT [1015]","HB AMC WELLPOINT","1479.66","73.78","","286.63","119.22","1107.45","105","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 4H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.50","1504.12","AETNA [1001]","HB AMC AETNA HMO","1399.84","69.8","","675.31","184.75","1721.50","286","1048.07","1638.89","percent of total billed charges",""
"PLATE FIBULA 4H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.50","1504.12","AETNA [1001]","HB AMC AETNA PPO","1612.42","80.4","","1261.44","103.12","1514.10","21","1048.07","1638.89","percent of total billed charges",""
"PLATE FIBULA 4H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.50","1504.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1612.42","80.4","","1365.00","1365.00","1365.00","1 through 10","1048.07","1638.89","percent of total billed charges",""
"PLATE FIBULA 4H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.50","1504.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1638.89","81.72","","5157.68","5157.68","5157.68","1 through 10","1048.07","1638.89","percent of total billed charges",""
"PLATE FIBULA 4H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.50","1504.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1638.89","81.72","","431.26","71.26","1459.57","88","1048.07","1638.89","percent of total billed charges",""
"PLATE FIBULA 5H RIGHT RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1622.20","79.5","","800.18","480.96","1887.97","195","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 5H RIGHT RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1087.59","53.3","","813.12","216.42","1444.50","81","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 5H RIGHT RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","632.56","31","","432.60","432.60","432.60","1 through 10","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 5H RIGHT RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","744.78","36.5","","148.37","54.89","631.39","94","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 5H RIGHT RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","781.51","38.3","","279.30","91.72","1116.77","266","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 5H RIGHT RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","875.37","42.9","","731.00","63.70","731.00","1 through 10","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 5H RIGHT RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","875.37","42.9","","384.74","384.74","384.74","1 through 10","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 5H RIGHT RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268663","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","WELLPOINT [1015]","HB AMC WELLPOINT","1505.48","73.78","","286.63","119.22","1107.45","105","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 5H RIGHT RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.50","1530.37","AETNA [1001]","HB AMC AETNA HMO","1424.27","69.8","","675.31","184.75","1721.50","286","1066.37","1667.5","percent of total billed charges",""
"PLATE FIBULA 5H RIGHT RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.50","1530.37","AETNA [1001]","HB AMC AETNA PPO","1640.56","80.4","","1261.44","103.12","1514.10","21","1066.37","1667.5","percent of total billed charges",""
"PLATE FIBULA 5H RIGHT RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.50","1530.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1640.56","80.4","","1365.00","1365.00","1365.00","1 through 10","1066.37","1667.5","percent of total billed charges",""
"PLATE FIBULA 5H RIGHT RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.50","1530.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1667.50","81.72","","5157.68","5157.68","5157.68","1 through 10","1066.37","1667.5","percent of total billed charges",""
"PLATE FIBULA 5H RIGHT RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.50","1530.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1667.50","81.72","","431.26","71.26","1459.57","88","1066.37","1667.5","percent of total billed charges",""
"PLATE FIBULA 6H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2089.50","1567.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1661.15","79.5","","800.18","480.96","1887.97","195","647.75","1661.15","percent of total billed charges",""
"PLATE FIBULA 6H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2089.50","1567.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1113.70","53.3","","813.12","216.42","1444.50","81","647.75","1661.15","percent of total billed charges",""
"PLATE FIBULA 6H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2089.50","1567.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","647.75","31","","432.60","432.60","432.60","1 through 10","647.75","1661.15","percent of total billed charges",""
"PLATE FIBULA 6H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2089.50","1567.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","762.67","36.5","","148.37","54.89","631.39","94","647.75","1661.15","percent of total billed charges",""
"PLATE FIBULA 6H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2089.50","1567.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","800.28","38.3","","279.30","91.72","1116.77","266","647.75","1661.15","percent of total billed charges",""
"PLATE FIBULA 6H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2089.50","1567.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","896.40","42.9","","731.00","63.70","731.00","1 through 10","647.75","1661.15","percent of total billed charges",""
"PLATE FIBULA 6H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2089.50","1567.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","896.40","42.9","","384.74","384.74","384.74","1 through 10","647.75","1661.15","percent of total billed charges",""
"PLATE FIBULA 6H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268664","CDM","C1713","HCPCS","0278","RC","","","","both","","","2089.50","1567.12","WELLPOINT [1015]","HB AMC WELLPOINT","1541.63","73.78","","286.63","119.22","1107.45","105","647.75","1661.15","percent of total billed charges",""
"PLATE FIBULA 6H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2089.50","1567.12","AETNA [1001]","HB AMC AETNA HMO","1458.47","69.8","","675.31","184.75","1721.50","286","1091.97","1707.54","percent of total billed charges",""
"PLATE FIBULA 6H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2089.50","1567.12","AETNA [1001]","HB AMC AETNA PPO","1679.96","80.4","","1261.44","103.12","1514.10","21","1091.97","1707.54","percent of total billed charges",""
"PLATE FIBULA 6H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2089.50","1567.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1679.96","80.4","","1365.00","1365.00","1365.00","1 through 10","1091.97","1707.54","percent of total billed charges",""
"PLATE FIBULA 6H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2089.50","1567.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1707.54","81.72","","5157.68","5157.68","5157.68","1 through 10","1091.97","1707.54","percent of total billed charges",""
"PLATE FIBULA 6H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2089.50","1567.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1707.54","81.72","","431.26","71.26","1459.57","88","1091.97","1707.54","percent of total billed charges",""
"PLATE FIBULA 70MM 4H RIGHT LATERAL DISTAL","SUP-ITM-10276047","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1594.37","79.5","","800.18","480.96","1887.97","195","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 70MM 4H RIGHT LATERAL DISTAL","SUP-ITM-10276047","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1068.93","53.3","","813.12","216.42","1444.50","81","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 70MM 4H RIGHT LATERAL DISTAL","SUP-ITM-10276047","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","621.71","31","","432.60","432.60","432.60","1 through 10","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 70MM 4H RIGHT LATERAL DISTAL","SUP-ITM-10276047","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","732.01","36.5","","148.37","54.89","631.39","94","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 70MM 4H RIGHT LATERAL DISTAL","SUP-ITM-10276047","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","768.11","38.3","","279.30","91.72","1116.77","266","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 70MM 4H RIGHT LATERAL DISTAL","SUP-ITM-10276047","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","860.36","42.9","","731.00","63.70","731.00","1 through 10","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 70MM 4H RIGHT LATERAL DISTAL","SUP-ITM-10276047","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","860.36","42.9","","384.74","384.74","384.74","1 through 10","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 70MM 4H RIGHT LATERAL DISTAL","SUP-ITM-10276047","CDM","C1713","HCPCS","0278","RC","","","","both","","","2005.50","1504.12","WELLPOINT [1015]","HB AMC WELLPOINT","1479.66","73.78","","286.63","119.22","1107.45","105","621.71","1594.37","percent of total billed charges",""
"PLATE FIBULA 70MM 4H RIGHT LATERAL DISTAL","SUP-ITM-10276047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.50","1504.12","AETNA [1001]","HB AMC AETNA HMO","1399.84","69.8","","675.31","184.75","1721.50","286","1048.07","1638.89","percent of total billed charges",""
"PLATE FIBULA 70MM 4H RIGHT LATERAL DISTAL","SUP-ITM-10276047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.50","1504.12","AETNA [1001]","HB AMC AETNA PPO","1612.42","80.4","","1261.44","103.12","1514.10","21","1048.07","1638.89","percent of total billed charges",""
"PLATE FIBULA 70MM 4H RIGHT LATERAL DISTAL","SUP-ITM-10276047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.50","1504.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1612.42","80.4","","1365.00","1365.00","1365.00","1 through 10","1048.07","1638.89","percent of total billed charges",""
"PLATE FIBULA 70MM 4H RIGHT LATERAL DISTAL","SUP-ITM-10276047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.50","1504.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1638.89","81.72","","5157.68","5157.68","5157.68","1 through 10","1048.07","1638.89","percent of total billed charges",""
"PLATE FIBULA 70MM 4H RIGHT LATERAL DISTAL","SUP-ITM-10276047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2005.50","1504.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1638.89","81.72","","431.26","71.26","1459.57","88","1048.07","1638.89","percent of total billed charges",""
"PLATE FIBULA 7H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268665","CDM","C1713","HCPCS","0278","RC","","","","both","","","2135.00","1601.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1697.33","79.5","","800.18","480.96","1887.97","195","661.85","1697.33","percent of total billed charges",""
"PLATE FIBULA 7H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268665","CDM","C1713","HCPCS","0278","RC","","","","both","","","2135.00","1601.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1137.96","53.3","","813.12","216.42","1444.50","81","661.85","1697.33","percent of total billed charges",""
"PLATE FIBULA 7H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268665","CDM","C1713","HCPCS","0278","RC","","","","both","","","2135.00","1601.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","661.85","31","","432.60","432.60","432.60","1 through 10","661.85","1697.33","percent of total billed charges",""
"PLATE FIBULA 7H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268665","CDM","C1713","HCPCS","0278","RC","","","","both","","","2135.00","1601.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","779.28","36.5","","148.37","54.89","631.39","94","661.85","1697.33","percent of total billed charges",""
"PLATE FIBULA 7H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268665","CDM","C1713","HCPCS","0278","RC","","","","both","","","2135.00","1601.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","817.71","38.3","","279.30","91.72","1116.77","266","661.85","1697.33","percent of total billed charges",""
"PLATE FIBULA 7H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268665","CDM","C1713","HCPCS","0278","RC","","","","both","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","915.92","42.9","","731.00","63.70","731.00","1 through 10","661.85","1697.33","percent of total billed charges",""
"PLATE FIBULA 7H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268665","CDM","C1713","HCPCS","0278","RC","","","","both","","","2135.00","1601.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","915.92","42.9","","384.74","384.74","384.74","1 through 10","661.85","1697.33","percent of total billed charges",""
"PLATE FIBULA 7H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268665","CDM","C1713","HCPCS","0278","RC","","","","both","","","2135.00","1601.25","WELLPOINT [1015]","HB AMC WELLPOINT","1575.20","73.78","","286.63","119.22","1107.45","105","661.85","1697.33","percent of total billed charges",""
"PLATE FIBULA 7H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268665","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2135.00","1601.25","AETNA [1001]","HB AMC AETNA HMO","1490.23","69.8","","675.31","184.75","1721.50","286","1115.75","1744.72","percent of total billed charges",""
"PLATE FIBULA 7H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268665","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2135.00","1601.25","AETNA [1001]","HB AMC AETNA PPO","1716.54","80.4","","1261.44","103.12","1514.10","21","1115.75","1744.72","percent of total billed charges",""
"PLATE FIBULA 7H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268665","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2135.00","1601.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1716.54","80.4","","1365.00","1365.00","1365.00","1 through 10","1115.75","1744.72","percent of total billed charges",""
"PLATE FIBULA 7H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268665","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1744.72","81.72","","5157.68","5157.68","5157.68","1 through 10","1115.75","1744.72","percent of total billed charges",""
"PLATE FIBULA 7H RIGHT FASTENER LOCKING LATERAL DISTAL","SUP-ITM-10268665","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1744.72","81.72","","431.26","71.26","1459.57","88","1115.75","1744.72","percent of total billed charges",""
"PLATE FIBULA 80MM 5H RIGHT LATERAL DISTAL","SUP-ITM-10276045","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1622.20","79.5","","800.18","480.96","1887.97","195","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 80MM 5H RIGHT LATERAL DISTAL","SUP-ITM-10276045","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1087.59","53.3","","813.12","216.42","1444.50","81","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 80MM 5H RIGHT LATERAL DISTAL","SUP-ITM-10276045","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","632.56","31","","432.60","432.60","432.60","1 through 10","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 80MM 5H RIGHT LATERAL DISTAL","SUP-ITM-10276045","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","744.78","36.5","","148.37","54.89","631.39","94","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 80MM 5H RIGHT LATERAL DISTAL","SUP-ITM-10276045","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","781.51","38.3","","279.30","91.72","1116.77","266","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 80MM 5H RIGHT LATERAL DISTAL","SUP-ITM-10276045","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","875.37","42.9","","731.00","63.70","731.00","1 through 10","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 80MM 5H RIGHT LATERAL DISTAL","SUP-ITM-10276045","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","875.37","42.9","","384.74","384.74","384.74","1 through 10","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 80MM 5H RIGHT LATERAL DISTAL","SUP-ITM-10276045","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.50","1530.37","WELLPOINT [1015]","HB AMC WELLPOINT","1505.48","73.78","","286.63","119.22","1107.45","105","632.56","1622.2","percent of total billed charges",""
"PLATE FIBULA 80MM 5H RIGHT LATERAL DISTAL","SUP-ITM-10276045","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.50","1530.37","AETNA [1001]","HB AMC AETNA HMO","1424.27","69.8","","675.31","184.75","1721.50","286","1066.37","1667.5","percent of total billed charges",""
"PLATE FIBULA 80MM 5H RIGHT LATERAL DISTAL","SUP-ITM-10276045","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.50","1530.37","AETNA [1001]","HB AMC AETNA PPO","1640.56","80.4","","1261.44","103.12","1514.10","21","1066.37","1667.5","percent of total billed charges",""
"PLATE FIBULA 80MM 5H RIGHT LATERAL DISTAL","SUP-ITM-10276045","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.50","1530.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1640.56","80.4","","1365.00","1365.00","1365.00","1 through 10","1066.37","1667.5","percent of total billed charges",""
"PLATE FIBULA 80MM 5H RIGHT LATERAL DISTAL","SUP-ITM-10276045","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.50","1530.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1667.50","81.72","","5157.68","5157.68","5157.68","1 through 10","1066.37","1667.5","percent of total billed charges",""
"PLATE FIBULA 80MM 5H RIGHT LATERAL DISTAL","SUP-ITM-10276045","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.50","1530.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1667.50","81.72","","431.26","71.26","1459.57","88","1066.37","1667.5","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.70","1806.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1914.92","79.5","","800.18","480.96","1887.97","195","746.7","1914.92","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.70","1806.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1283.84","53.3","","813.12","216.42","1444.50","81","746.7","1914.92","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.70","1806.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","746.70","31","","432.60","432.60","432.60","1 through 10","746.7","1914.92","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.70","1806.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","879.18","36.5","","148.37","54.89","631.39","94","746.7","1914.92","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.70","1806.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","922.53","38.3","","279.30","91.72","1116.77","266","746.7","1914.92","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.70","1806.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1033.33","42.9","","731.00","63.70","731.00","1 through 10","746.7","1914.92","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.70","1806.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1033.33","42.9","","384.74","384.74","384.74","1 through 10","746.7","1914.92","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","both","","","2408.70","1806.52","WELLPOINT [1015]","HB AMC WELLPOINT","1777.14","73.78","","286.63","119.22","1107.45","105","746.7","1914.92","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2408.70","1806.52","AETNA [1001]","HB AMC AETNA HMO","1681.27","69.8","","675.31","184.75","1721.50","286","1258.79","1968.39","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2408.70","1806.52","AETNA [1001]","HB AMC AETNA PPO","1936.59","80.4","","1261.44","103.12","1514.10","21","1258.79","1968.39","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2408.70","1806.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1936.59","80.4","","1365.00","1365.00","1365.00","1 through 10","1258.79","1968.39","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2408.70","1806.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1968.39","81.72","","5157.68","5157.68","5157.68","1 through 10","1258.79","1968.39","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2408.70","1806.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1968.39","81.72","","431.26","71.26","1459.57","88","1258.79","1968.39","percent of total billed charges",""
"PLATE HAND 0.6MM 8 HOLE APTUS TITANIUM RIGHT","SUP-ITM-10051623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1168.65","79.5","","800.18","480.96","1887.97","195","455.7","1168.65","percent of total billed charges",""
"PLATE HAND 0.6MM 8 HOLE APTUS TITANIUM RIGHT","SUP-ITM-10051623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","783.51","53.3","","813.12","216.42","1444.50","81","455.7","1168.65","percent of total billed charges",""
"PLATE HAND 0.6MM 8 HOLE APTUS TITANIUM RIGHT","SUP-ITM-10051623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","455.70","31","","432.60","432.60","432.60","1 through 10","455.7","1168.65","percent of total billed charges",""
"PLATE HAND 0.6MM 8 HOLE APTUS TITANIUM RIGHT","SUP-ITM-10051623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","536.55","36.5","","148.37","54.89","631.39","94","455.7","1168.65","percent of total billed charges",""
"PLATE HAND 0.6MM 8 HOLE APTUS TITANIUM RIGHT","SUP-ITM-10051623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","563.01","38.3","","279.30","91.72","1116.77","266","455.7","1168.65","percent of total billed charges",""
"PLATE HAND 0.6MM 8 HOLE APTUS TITANIUM RIGHT","SUP-ITM-10051623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","731.00","63.70","731.00","1 through 10","455.7","1168.65","percent of total billed charges",""
"PLATE HAND 0.6MM 8 HOLE APTUS TITANIUM RIGHT","SUP-ITM-10051623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","384.74","384.74","384.74","1 through 10","455.7","1168.65","percent of total billed charges",""
"PLATE HAND 0.6MM 8 HOLE APTUS TITANIUM RIGHT","SUP-ITM-10051623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB AMC WELLPOINT","1084.57","73.78","","286.63","119.22","1107.45","105","455.7","1168.65","percent of total billed charges",""
"PLATE HAND 0.6MM 8 HOLE APTUS TITANIUM RIGHT","SUP-ITM-10051623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA HMO","1026.06","69.8","","675.31","184.75","1721.50","286","768.22","1201.28","percent of total billed charges",""
"PLATE HAND 0.6MM 8 HOLE APTUS TITANIUM RIGHT","SUP-ITM-10051623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA PPO","1181.88","80.4","","1261.44","103.12","1514.10","21","768.22","1201.28","percent of total billed charges",""
"PLATE HAND 0.6MM 8 HOLE APTUS TITANIUM RIGHT","SUP-ITM-10051623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1181.88","80.4","","1365.00","1365.00","1365.00","1 through 10","768.22","1201.28","percent of total billed charges",""
"PLATE HAND 0.6MM 8 HOLE APTUS TITANIUM RIGHT","SUP-ITM-10051623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1201.28","81.72","","5157.68","5157.68","5157.68","1 through 10","768.22","1201.28","percent of total billed charges",""
"PLATE HAND 0.6MM 8 HOLE APTUS TITANIUM RIGHT","SUP-ITM-10051623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1201.28","81.72","","431.26","71.26","1459.57","88","768.22","1201.28","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 3XHOLE APTUS FIXATION ANGLED RIGHT","SUP-ITM-10029536","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1054.57","79.5","","800.18","480.96","1887.97","195","411.22","1054.57","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 3XHOLE APTUS FIXATION ANGLED RIGHT","SUP-ITM-10029536","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","707.02","53.3","","813.12","216.42","1444.50","81","411.22","1054.57","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 3XHOLE APTUS FIXATION ANGLED RIGHT","SUP-ITM-10029536","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","411.22","31","","432.60","432.60","432.60","1 through 10","411.22","1054.57","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 3XHOLE APTUS FIXATION ANGLED RIGHT","SUP-ITM-10029536","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","484.17","36.5","","148.37","54.89","631.39","94","411.22","1054.57","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 3XHOLE APTUS FIXATION ANGLED RIGHT","SUP-ITM-10029536","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","508.05","38.3","","279.30","91.72","1116.77","266","411.22","1054.57","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 3XHOLE APTUS FIXATION ANGLED RIGHT","SUP-ITM-10029536","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","569.07","42.9","","731.00","63.70","731.00","1 through 10","411.22","1054.57","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 3XHOLE APTUS FIXATION ANGLED RIGHT","SUP-ITM-10029536","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","569.07","42.9","","384.74","384.74","384.74","1 through 10","411.22","1054.57","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 3XHOLE APTUS FIXATION ANGLED RIGHT","SUP-ITM-10029536","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.50","994.87","WELLPOINT [1015]","HB AMC WELLPOINT","978.69","73.78","","286.63","119.22","1107.45","105","411.22","1054.57","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 3XHOLE APTUS FIXATION ANGLED RIGHT","SUP-ITM-10029536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.50","994.87","AETNA [1001]","HB AMC AETNA HMO","925.90","69.8","","675.31","184.75","1721.50","286","693.23","1084.02","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 3XHOLE APTUS FIXATION ANGLED RIGHT","SUP-ITM-10029536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.50","994.87","AETNA [1001]","HB AMC AETNA PPO","1066.51","80.4","","1261.44","103.12","1514.10","21","693.23","1084.02","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 3XHOLE APTUS FIXATION ANGLED RIGHT","SUP-ITM-10029536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.50","994.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1066.51","80.4","","1365.00","1365.00","1365.00","1 through 10","693.23","1084.02","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 3XHOLE APTUS FIXATION ANGLED RIGHT","SUP-ITM-10029536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.50","994.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1084.02","81.72","","5157.68","5157.68","5157.68","1 through 10","693.23","1084.02","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 3XHOLE APTUS FIXATION ANGLED RIGHT","SUP-ITM-10029536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.50","994.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1084.02","81.72","","431.26","71.26","1459.57","88","693.23","1084.02","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10051611","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.50","716.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","759.62","79.5","","800.18","480.96","1887.97","195","296.21","759.62","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10051611","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.50","716.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","509.28","53.3","","813.12","216.42","1444.50","81","296.21","759.62","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10051611","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.50","716.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","296.21","31","","432.60","432.60","432.60","1 through 10","296.21","759.62","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10051611","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.50","716.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","348.76","36.5","","148.37","54.89","631.39","94","296.21","759.62","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10051611","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.50","716.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","365.96","38.3","","279.30","91.72","1116.77","266","296.21","759.62","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10051611","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.50","716.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.91","42.9","","731.00","63.70","731.00","1 through 10","296.21","759.62","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10051611","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.50","716.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.91","42.9","","384.74","384.74","384.74","1 through 10","296.21","759.62","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10051611","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.50","716.62","WELLPOINT [1015]","HB AMC WELLPOINT","704.97","73.78","","286.63","119.22","1107.45","105","296.21","759.62","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10051611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","955.50","716.62","AETNA [1001]","HB AMC AETNA HMO","666.94","69.8","","675.31","184.75","1721.50","286","499.34","780.83","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10051611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","955.50","716.62","AETNA [1001]","HB AMC AETNA PPO","768.22","80.4","","1261.44","103.12","1514.10","21","499.34","780.83","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10051611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","955.50","716.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","768.22","80.4","","1365.00","1365.00","1365.00","1 through 10","499.34","780.83","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10051611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","955.50","716.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","780.83","81.72","","5157.68","5157.68","5157.68","1 through 10","499.34","780.83","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 6 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10051611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","955.50","716.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","780.83","81.72","","431.26","71.26","1459.57","88","499.34","780.83","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 8 HOLE APTUS FIXATION LT TRAPEZOID","SUP-ITM-10029537","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1076.83","79.5","","800.18","480.96","1887.97","195","419.9","1076.83","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 8 HOLE APTUS FIXATION LT TRAPEZOID","SUP-ITM-10029537","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","721.95","53.3","","813.12","216.42","1444.50","81","419.9","1076.83","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 8 HOLE APTUS FIXATION LT TRAPEZOID","SUP-ITM-10029537","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","419.90","31","","432.60","432.60","432.60","1 through 10","419.9","1076.83","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 8 HOLE APTUS FIXATION LT TRAPEZOID","SUP-ITM-10029537","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","494.39","36.5","","148.37","54.89","631.39","94","419.9","1076.83","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 8 HOLE APTUS FIXATION LT TRAPEZOID","SUP-ITM-10029537","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","518.77","38.3","","279.30","91.72","1116.77","266","419.9","1076.83","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 8 HOLE APTUS FIXATION LT TRAPEZOID","SUP-ITM-10029537","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","581.08","42.9","","731.00","63.70","731.00","1 through 10","419.9","1076.83","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 8 HOLE APTUS FIXATION LT TRAPEZOID","SUP-ITM-10029537","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","581.08","42.9","","384.74","384.74","384.74","1 through 10","419.9","1076.83","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 8 HOLE APTUS FIXATION LT TRAPEZOID","SUP-ITM-10029537","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","WELLPOINT [1015]","HB AMC WELLPOINT","999.35","73.78","","286.63","119.22","1107.45","105","419.9","1076.83","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 8 HOLE APTUS FIXATION LT TRAPEZOID","SUP-ITM-10029537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.50","1015.87","AETNA [1001]","HB AMC AETNA HMO","945.44","69.8","","675.31","184.75","1721.50","286","707.86","1106.9","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 8 HOLE APTUS FIXATION LT TRAPEZOID","SUP-ITM-10029537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.50","1015.87","AETNA [1001]","HB AMC AETNA PPO","1089.02","80.4","","1261.44","103.12","1514.10","21","707.86","1106.9","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 8 HOLE APTUS FIXATION LT TRAPEZOID","SUP-ITM-10029537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.50","1015.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1089.02","80.4","","1365.00","1365.00","1365.00","1 through 10","707.86","1106.9","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 8 HOLE APTUS FIXATION LT TRAPEZOID","SUP-ITM-10029537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.50","1015.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1106.90","81.72","","5157.68","5157.68","5157.68","1 through 10","707.86","1106.9","percent of total billed charges",""
"PLATE HAND 1.2 1.5MM 8 HOLE APTUS FIXATION LT TRAPEZOID","SUP-ITM-10029537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.50","1015.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1106.90","81.72","","431.26","71.26","1459.57","88","707.86","1106.9","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED LEFT MODULAR SYSTEM TITANIUM","SUP-ITM-10006270","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.50","874.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","926.57","79.5","","800.18","480.96","1887.97","195","361.31","926.57","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED LEFT MODULAR SYSTEM TITANIUM","SUP-ITM-10006270","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.50","874.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","621.21","53.3","","813.12","216.42","1444.50","81","361.31","926.57","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED LEFT MODULAR SYSTEM TITANIUM","SUP-ITM-10006270","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.50","874.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","361.31","31","","432.60","432.60","432.60","1 through 10","361.31","926.57","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED LEFT MODULAR SYSTEM TITANIUM","SUP-ITM-10006270","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.50","874.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","425.41","36.5","","148.37","54.89","631.39","94","361.31","926.57","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED LEFT MODULAR SYSTEM TITANIUM","SUP-ITM-10006270","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.50","874.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","446.39","38.3","","279.30","91.72","1116.77","266","361.31","926.57","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED LEFT MODULAR SYSTEM TITANIUM","SUP-ITM-10006270","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.50","874.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.00","42.9","","731.00","63.70","731.00","1 through 10","361.31","926.57","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED LEFT MODULAR SYSTEM TITANIUM","SUP-ITM-10006270","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.50","874.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.00","42.9","","384.74","384.74","384.74","1 through 10","361.31","926.57","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED LEFT MODULAR SYSTEM TITANIUM","SUP-ITM-10006270","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.50","874.12","WELLPOINT [1015]","HB AMC WELLPOINT","859.91","73.78","","286.63","119.22","1107.45","105","361.31","926.57","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED LEFT MODULAR SYSTEM TITANIUM","SUP-ITM-10006270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1165.50","874.12","AETNA [1001]","HB AMC AETNA HMO","813.52","69.8","","675.31","184.75","1721.50","286","609.09","952.45","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED LEFT MODULAR SYSTEM TITANIUM","SUP-ITM-10006270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1165.50","874.12","AETNA [1001]","HB AMC AETNA PPO","937.06","80.4","","1261.44","103.12","1514.10","21","609.09","952.45","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED LEFT MODULAR SYSTEM TITANIUM","SUP-ITM-10006270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1165.50","874.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","937.06","80.4","","1365.00","1365.00","1365.00","1 through 10","609.09","952.45","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED LEFT MODULAR SYSTEM TITANIUM","SUP-ITM-10006270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1165.50","874.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","952.45","81.72","","5157.68","5157.68","5157.68","1 through 10","609.09","952.45","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED LEFT MODULAR SYSTEM TITANIUM","SUP-ITM-10006270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1165.50","874.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","952.45","81.72","","431.26","71.26","1459.57","88","609.09","952.45","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED RIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.74","809.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","857.60","79.5","","800.18","480.96","1887.97","195","334.41","857.6","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED RIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.74","809.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","574.97","53.3","","813.12","216.42","1444.50","81","334.41","857.6","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED RIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.74","809.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","334.41","31","","432.60","432.60","432.60","1 through 10","334.41","857.6","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED RIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.74","809.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","393.74","36.5","","148.37","54.89","631.39","94","334.41","857.6","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED RIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.74","809.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","413.16","38.3","","279.30","91.72","1116.77","266","334.41","857.6","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED RIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.74","809.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","462.78","42.9","","731.00","63.70","731.00","1 through 10","334.41","857.6","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED RIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.74","809.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","462.78","42.9","","384.74","384.74","384.74","1 through 10","334.41","857.6","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED RIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.74","809.05","WELLPOINT [1015]","HB AMC WELLPOINT","795.89","73.78","","286.63","119.22","1107.45","105","334.41","857.6","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED RIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.74","809.05","AETNA [1001]","HB AMC AETNA HMO","752.96","69.8","","675.31","184.75","1721.50","286","563.75","881.55","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED RIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.74","809.05","AETNA [1001]","HB AMC AETNA PPO","867.31","80.4","","1261.44","103.12","1514.10","21","563.75","881.55","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED RIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.74","809.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","867.31","80.4","","1365.00","1365.00","1365.00","1 through 10","563.75","881.55","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED RIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.74","809.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","881.55","81.72","","5157.68","5157.68","5157.68","1 through 10","563.75","881.55","percent of total billed charges",""
"PLATE HAND 1.3X15MM H EXTENDED RIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.74","809.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","881.55","81.72","","431.26","71.26","1459.57","88","563.75","881.55","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","446.81","79.5","","800.18","480.96","1887.97","195","174.23","446.81","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","299.56","53.3","","813.12","216.42","1444.50","81","174.23","446.81","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","174.23","31","","432.60","432.60","432.60","1 through 10","174.23","446.81","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","205.14","36.5","","148.37","54.89","631.39","94","174.23","446.81","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","215.26","38.3","","279.30","91.72","1116.77","266","174.23","446.81","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","241.11","42.9","","731.00","63.70","731.00","1 through 10","174.23","446.81","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","241.11","42.9","","384.74","384.74","384.74","1 through 10","174.23","446.81","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.03","421.52","WELLPOINT [1015]","HB AMC WELLPOINT","414.67","73.78","","286.63","119.22","1107.45","105","174.23","446.81","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","AETNA [1001]","HB AMC AETNA HMO","392.30","69.8","","675.31","184.75","1721.50","286","293.72","459.29","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","AETNA [1001]","HB AMC AETNA PPO","451.87","80.4","","1261.44","103.12","1514.10","21","293.72","459.29","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","451.87","80.4","","1365.00","1365.00","1365.00","1 through 10","293.72","459.29","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","459.29","81.72","","5157.68","5157.68","5157.68","1 through 10","293.72","459.29","percent of total billed charges",""
"PLATE HAND 1.5MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10083674","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.03","421.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","459.29","81.72","","431.26","71.26","1459.57","88","293.72","459.29","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.53","772.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","818.48","79.5","","800.18","480.96","1887.97","195","319.15","818.48","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.53","772.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","548.74","53.3","","813.12","216.42","1444.50","81","319.15","818.48","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.53","772.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","319.15","31","","432.60","432.60","432.60","1 through 10","319.15","818.48","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.53","772.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","375.78","36.5","","148.37","54.89","631.39","94","319.15","818.48","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.53","772.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","394.31","38.3","","279.30","91.72","1116.77","266","319.15","818.48","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.53","772.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","441.67","42.9","","731.00","63.70","731.00","1 through 10","319.15","818.48","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.53","772.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","441.67","42.9","","384.74","384.74","384.74","1 through 10","319.15","818.48","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.53","772.15","WELLPOINT [1015]","HB AMC WELLPOINT","759.59","73.78","","286.63","119.22","1107.45","105","319.15","818.48","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.53","772.15","AETNA [1001]","HB AMC AETNA HMO","718.61","69.8","","675.31","184.75","1721.50","286","538.03","841.33","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.53","772.15","AETNA [1001]","HB AMC AETNA PPO","827.74","80.4","","1261.44","103.12","1514.10","21","538.03","841.33","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.53","772.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","827.74","80.4","","1365.00","1365.00","1365.00","1 through 10","538.03","841.33","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.53","772.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","841.33","81.72","","5157.68","5157.68","5157.68","1 through 10","538.03","841.33","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10083675","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.53","772.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","841.33","81.72","","431.26","71.26","1459.57","88","538.03","841.33","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.12","968.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1026.44","79.5","","800.18","480.96","1887.97","195","400.25","1026.44","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.12","968.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","688.17","53.3","","813.12","216.42","1444.50","81","400.25","1026.44","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.12","968.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","400.25","31","","432.60","432.60","432.60","1 through 10","400.25","1026.44","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.12","968.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","471.26","36.5","","148.37","54.89","631.39","94","400.25","1026.44","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.12","968.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","494.50","38.3","","279.30","91.72","1116.77","266","400.25","1026.44","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.12","968.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","553.89","42.9","","731.00","63.70","731.00","1 through 10","400.25","1026.44","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.12","968.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","553.89","42.9","","384.74","384.74","384.74","1 through 10","400.25","1026.44","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.12","968.34","WELLPOINT [1015]","HB AMC WELLPOINT","952.59","73.78","","286.63","119.22","1107.45","105","400.25","1026.44","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1291.12","968.34","AETNA [1001]","HB AMC AETNA HMO","901.20","69.8","","675.31","184.75","1721.50","286","674.74","1055.1","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1291.12","968.34","AETNA [1001]","HB AMC AETNA PPO","1038.06","80.4","","1261.44","103.12","1514.10","21","674.74","1055.1","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1291.12","968.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1038.06","80.4","","1365.00","1365.00","1365.00","1 through 10","674.74","1055.1","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1291.12","968.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1055.10","81.72","","5157.68","5157.68","5157.68","1 through 10","674.74","1055.1","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1291.12","968.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1055.10","81.72","","431.26","71.26","1459.57","88","674.74","1055.1","percent of total billed charges",""
"PLATE HAND 2.0 2.3MM 4 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10024827","CDM","C1713","HCPCS","0278","RC","","","","both","","","969.50","727.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","770.75","79.5","","800.18","480.96","1887.97","195","300.55","770.75","percent of total billed charges",""
"PLATE HAND 2.0 2.3MM 4 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10024827","CDM","C1713","HCPCS","0278","RC","","","","both","","","969.50","727.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","516.74","53.3","","813.12","216.42","1444.50","81","300.55","770.75","percent of total billed charges",""
"PLATE HAND 2.0 2.3MM 4 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10024827","CDM","C1713","HCPCS","0278","RC","","","","both","","","969.50","727.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","300.55","31","","432.60","432.60","432.60","1 through 10","300.55","770.75","percent of total billed charges",""
"PLATE HAND 2.0 2.3MM 4 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10024827","CDM","C1713","HCPCS","0278","RC","","","","both","","","969.50","727.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","353.87","36.5","","148.37","54.89","631.39","94","300.55","770.75","percent of total billed charges",""
"PLATE HAND 2.0 2.3MM 4 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10024827","CDM","C1713","HCPCS","0278","RC","","","","both","","","969.50","727.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","371.32","38.3","","279.30","91.72","1116.77","266","300.55","770.75","percent of total billed charges",""
"PLATE HAND 2.0 2.3MM 4 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10024827","CDM","C1713","HCPCS","0278","RC","","","","both","","","969.50","727.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","415.92","42.9","","731.00","63.70","731.00","1 through 10","300.55","770.75","percent of total billed charges",""
"PLATE HAND 2.0 2.3MM 4 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10024827","CDM","C1713","HCPCS","0278","RC","","","","both","","","969.50","727.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","415.92","42.9","","384.74","384.74","384.74","1 through 10","300.55","770.75","percent of total billed charges",""
"PLATE HAND 2.0 2.3MM 4 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10024827","CDM","C1713","HCPCS","0278","RC","","","","both","","","969.50","727.12","WELLPOINT [1015]","HB AMC WELLPOINT","715.30","73.78","","286.63","119.22","1107.45","105","300.55","770.75","percent of total billed charges",""
"PLATE HAND 2.0 2.3MM 4 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10024827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","969.50","727.12","AETNA [1001]","HB AMC AETNA HMO","676.71","69.8","","675.31","184.75","1721.50","286","506.66","792.28","percent of total billed charges",""
"PLATE HAND 2.0 2.3MM 4 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10024827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","969.50","727.12","AETNA [1001]","HB AMC AETNA PPO","779.48","80.4","","1261.44","103.12","1514.10","21","506.66","792.28","percent of total billed charges",""
"PLATE HAND 2.0 2.3MM 4 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10024827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","969.50","727.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","779.48","80.4","","1365.00","1365.00","1365.00","1 through 10","506.66","792.28","percent of total billed charges",""
"PLATE HAND 2.0 2.3MM 4 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10024827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","969.50","727.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","792.28","81.72","","5157.68","5157.68","5157.68","1 through 10","506.66","792.28","percent of total billed charges",""
"PLATE HAND 2.0 2.3MM 4 HOLE APTUS FIXATION STRAIGHT","SUP-ITM-10024827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","969.50","727.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","792.28","81.72","","431.26","71.26","1459.57","88","506.66","792.28","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.01","717.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","760.82","79.5","","800.18","480.96","1887.97","195","296.67","760.82","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.01","717.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","510.09","53.3","","813.12","216.42","1444.50","81","296.67","760.82","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.01","717.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","296.67","31","","432.60","432.60","432.60","1 through 10","296.67","760.82","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.01","717.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","349.31","36.5","","148.37","54.89","631.39","94","296.67","760.82","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.01","717.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","366.53","38.3","","279.30","91.72","1116.77","266","296.67","760.82","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.01","717.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","410.56","42.9","","731.00","63.70","731.00","1 through 10","296.67","760.82","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.01","717.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","410.56","42.9","","384.74","384.74","384.74","1 through 10","296.67","760.82","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","957.01","717.76","WELLPOINT [1015]","HB AMC WELLPOINT","706.08","73.78","","286.63","119.22","1107.45","105","296.67","760.82","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","957.01","717.76","AETNA [1001]","HB AMC AETNA HMO","667.99","69.8","","675.31","184.75","1721.50","286","500.13","782.07","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","957.01","717.76","AETNA [1001]","HB AMC AETNA PPO","769.44","80.4","","1261.44","103.12","1514.10","21","500.13","782.07","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","957.01","717.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","769.44","80.4","","1365.00","1365.00","1365.00","1 through 10","500.13","782.07","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","957.01","717.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","782.07","81.72","","5157.68","5157.68","5157.68","1 through 10","500.13","782.07","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","957.01","717.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","782.07","81.72","","431.26","71.26","1459.57","88","500.13","782.07","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.71","716.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","759.79","79.5","","800.18","480.96","1887.97","195","296.27","759.79","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.71","716.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","509.39","53.3","","813.12","216.42","1444.50","81","296.27","759.79","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.71","716.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","296.27","31","","432.60","432.60","432.60","1 through 10","296.27","759.79","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.71","716.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","348.83","36.5","","148.37","54.89","631.39","94","296.27","759.79","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.71","716.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","366.04","38.3","","279.30","91.72","1116.77","266","296.27","759.79","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.71","716.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","410.00","42.9","","731.00","63.70","731.00","1 through 10","296.27","759.79","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.71","716.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","410.00","42.9","","384.74","384.74","384.74","1 through 10","296.27","759.79","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","955.71","716.78","WELLPOINT [1015]","HB AMC WELLPOINT","705.12","73.78","","286.63","119.22","1107.45","105","296.27","759.79","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","955.71","716.78","AETNA [1001]","HB AMC AETNA HMO","667.09","69.8","","675.31","184.75","1721.50","286","499.45","781.01","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","955.71","716.78","AETNA [1001]","HB AMC AETNA PPO","768.39","80.4","","1261.44","103.12","1514.10","21","499.45","781.01","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","955.71","716.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","768.39","80.4","","1365.00","1365.00","1365.00","1 through 10","499.45","781.01","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","955.71","716.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","781.01","81.72","","5157.68","5157.68","5157.68","1 through 10","499.45","781.01","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","955.71","716.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","781.01","81.72","","431.26","71.26","1459.57","88","499.45","781.01","percent of total billed charges",""
"PLATE HAND 2XRECTANGULAR 1.2 1.5MM HOLE APTUS FIXATION","SUP-ITM-10028158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","962.75","79.5","","800.18","480.96","1887.97","195","375.41","962.75","percent of total billed charges",""
"PLATE HAND 2XRECTANGULAR 1.2 1.5MM HOLE APTUS FIXATION","SUP-ITM-10028158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","645.46","53.3","","813.12","216.42","1444.50","81","375.41","962.75","percent of total billed charges",""
"PLATE HAND 2XRECTANGULAR 1.2 1.5MM HOLE APTUS FIXATION","SUP-ITM-10028158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","375.41","31","","432.60","432.60","432.60","1 through 10","375.41","962.75","percent of total billed charges",""
"PLATE HAND 2XRECTANGULAR 1.2 1.5MM HOLE APTUS FIXATION","SUP-ITM-10028158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","442.02","36.5","","148.37","54.89","631.39","94","375.41","962.75","percent of total billed charges",""
"PLATE HAND 2XRECTANGULAR 1.2 1.5MM HOLE APTUS FIXATION","SUP-ITM-10028158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","463.81","38.3","","279.30","91.72","1116.77","266","375.41","962.75","percent of total billed charges",""
"PLATE HAND 2XRECTANGULAR 1.2 1.5MM HOLE APTUS FIXATION","SUP-ITM-10028158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","519.52","42.9","","731.00","63.70","731.00","1 through 10","375.41","962.75","percent of total billed charges",""
"PLATE HAND 2XRECTANGULAR 1.2 1.5MM HOLE APTUS FIXATION","SUP-ITM-10028158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","519.52","42.9","","384.74","384.74","384.74","1 through 10","375.41","962.75","percent of total billed charges",""
"PLATE HAND 2XRECTANGULAR 1.2 1.5MM HOLE APTUS FIXATION","SUP-ITM-10028158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.00","908.25","WELLPOINT [1015]","HB AMC WELLPOINT","893.48","73.78","","286.63","119.22","1107.45","105","375.41","962.75","percent of total billed charges",""
"PLATE HAND 2XRECTANGULAR 1.2 1.5MM HOLE APTUS FIXATION","SUP-ITM-10028158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.00","908.25","AETNA [1001]","HB AMC AETNA HMO","845.28","69.8","","675.31","184.75","1721.50","286","632.87","989.63","percent of total billed charges",""
"PLATE HAND 2XRECTANGULAR 1.2 1.5MM HOLE APTUS FIXATION","SUP-ITM-10028158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.00","908.25","AETNA [1001]","HB AMC AETNA PPO","973.64","80.4","","1261.44","103.12","1514.10","21","632.87","989.63","percent of total billed charges",""
"PLATE HAND 2XRECTANGULAR 1.2 1.5MM HOLE APTUS FIXATION","SUP-ITM-10028158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.00","908.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","973.64","80.4","","1365.00","1365.00","1365.00","1 through 10","632.87","989.63","percent of total billed charges",""
"PLATE HAND 2XRECTANGULAR 1.2 1.5MM HOLE APTUS FIXATION","SUP-ITM-10028158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.00","908.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","989.63","81.72","","5157.68","5157.68","5157.68","1 through 10","632.87","989.63","percent of total billed charges",""
"PLATE HAND 2XRECTANGULAR 1.2 1.5MM HOLE APTUS FIXATION","SUP-ITM-10028158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.00","908.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","989.63","81.72","","431.26","71.26","1459.57","88","632.87","989.63","percent of total billed charges",""
"PLATE HAND 3 HOLE APTUS FIXATION APTTUS INLIN","SUP-ITM-10025476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","918.23","79.5","","800.18","480.96","1887.97","195","358.05","918.23","percent of total billed charges",""
"PLATE HAND 3 HOLE APTUS FIXATION APTTUS INLIN","SUP-ITM-10025476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","615.62","53.3","","813.12","216.42","1444.50","81","358.05","918.23","percent of total billed charges",""
"PLATE HAND 3 HOLE APTUS FIXATION APTTUS INLIN","SUP-ITM-10025476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","358.05","31","","432.60","432.60","432.60","1 through 10","358.05","918.23","percent of total billed charges",""
"PLATE HAND 3 HOLE APTUS FIXATION APTTUS INLIN","SUP-ITM-10025476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","421.58","36.5","","148.37","54.89","631.39","94","358.05","918.23","percent of total billed charges",""
"PLATE HAND 3 HOLE APTUS FIXATION APTTUS INLIN","SUP-ITM-10025476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","442.37","38.3","","279.30","91.72","1116.77","266","358.05","918.23","percent of total billed charges",""
"PLATE HAND 3 HOLE APTUS FIXATION APTTUS INLIN","SUP-ITM-10025476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","495.50","42.9","","731.00","63.70","731.00","1 through 10","358.05","918.23","percent of total billed charges",""
"PLATE HAND 3 HOLE APTUS FIXATION APTTUS INLIN","SUP-ITM-10025476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","495.50","42.9","","384.74","384.74","384.74","1 through 10","358.05","918.23","percent of total billed charges",""
"PLATE HAND 3 HOLE APTUS FIXATION APTTUS INLIN","SUP-ITM-10025476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","WELLPOINT [1015]","HB AMC WELLPOINT","852.16","73.78","","286.63","119.22","1107.45","105","358.05","918.23","percent of total billed charges",""
"PLATE HAND 3 HOLE APTUS FIXATION APTTUS INLIN","SUP-ITM-10025476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","AETNA [1001]","HB AMC AETNA HMO","806.19","69.8","","675.31","184.75","1721.50","286","603.6","943.87","percent of total billed charges",""
"PLATE HAND 3 HOLE APTUS FIXATION APTTUS INLIN","SUP-ITM-10025476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","AETNA [1001]","HB AMC AETNA PPO","928.62","80.4","","1261.44","103.12","1514.10","21","603.6","943.87","percent of total billed charges",""
"PLATE HAND 3 HOLE APTUS FIXATION APTTUS INLIN","SUP-ITM-10025476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","928.62","80.4","","1365.00","1365.00","1365.00","1 through 10","603.6","943.87","percent of total billed charges",""
"PLATE HAND 3 HOLE APTUS FIXATION APTTUS INLIN","SUP-ITM-10025476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","943.87","81.72","","5157.68","5157.68","5157.68","1 through 10","603.6","943.87","percent of total billed charges",""
"PLATE HAND 3 HOLE APTUS FIXATION APTTUS INLIN","SUP-ITM-10025476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","943.87","81.72","","431.26","71.26","1459.57","88","603.6","943.87","percent of total billed charges",""
"PLATE HAND 31X2.4MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006278","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1222.05","79.5","","800.18","480.96","1887.97","195","476.52","1222.05","percent of total billed charges",""
"PLATE HAND 31X2.4MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006278","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","819.31","53.3","","813.12","216.42","1444.50","81","476.52","1222.05","percent of total billed charges",""
"PLATE HAND 31X2.4MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006278","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","476.52","31","","432.60","432.60","432.60","1 through 10","476.52","1222.05","percent of total billed charges",""
"PLATE HAND 31X2.4MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006278","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","561.07","36.5","","148.37","54.89","631.39","94","476.52","1222.05","percent of total billed charges",""
"PLATE HAND 31X2.4MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006278","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","588.74","38.3","","279.30","91.72","1116.77","266","476.52","1222.05","percent of total billed charges",""
"PLATE HAND 31X2.4MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006278","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","659.45","42.9","","731.00","63.70","731.00","1 through 10","476.52","1222.05","percent of total billed charges",""
"PLATE HAND 31X2.4MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006278","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","659.45","42.9","","384.74","384.74","384.74","1 through 10","476.52","1222.05","percent of total billed charges",""
"PLATE HAND 31X2.4MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006278","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","WELLPOINT [1015]","HB AMC WELLPOINT","1134.12","73.78","","286.63","119.22","1107.45","105","476.52","1222.05","percent of total billed charges",""
"PLATE HAND 31X2.4MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","AETNA [1001]","HB AMC AETNA HMO","1072.94","69.8","","675.31","184.75","1721.50","286","803.33","1256.18","percent of total billed charges",""
"PLATE HAND 31X2.4MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","AETNA [1001]","HB AMC AETNA PPO","1235.88","80.4","","1261.44","103.12","1514.10","21","803.33","1256.18","percent of total billed charges",""
"PLATE HAND 31X2.4MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1235.88","80.4","","1365.00","1365.00","1365.00","1 through 10","803.33","1256.18","percent of total billed charges",""
"PLATE HAND 31X2.4MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1256.18","81.72","","5157.68","5157.68","5157.68","1 through 10","803.33","1256.18","percent of total billed charges",""
"PLATE HAND 31X2.4MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1256.18","81.72","","431.26","71.26","1459.57","88","803.33","1256.18","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","895.69","79.5","","800.18","480.96","1887.97","195","349.26","895.69","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","600.50","53.3","","813.12","216.42","1444.50","81","349.26","895.69","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","349.26","31","","432.60","432.60","432.60","1 through 10","349.26","895.69","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","411.23","36.5","","148.37","54.89","631.39","94","349.26","895.69","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","431.51","38.3","","279.30","91.72","1116.77","266","349.26","895.69","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","483.33","42.9","","731.00","63.70","731.00","1 through 10","349.26","895.69","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","483.33","42.9","","384.74","384.74","384.74","1 through 10","349.26","895.69","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","WELLPOINT [1015]","HB AMC WELLPOINT","831.24","73.78","","286.63","119.22","1107.45","105","349.26","895.69","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.65","844.99","AETNA [1001]","HB AMC AETNA HMO","786.40","69.8","","675.31","184.75","1721.50","286","588.79","920.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.65","844.99","AETNA [1001]","HB AMC AETNA PPO","905.83","80.4","","1261.44","103.12","1514.10","21","588.79","920.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.65","844.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","905.83","80.4","","1365.00","1365.00","1365.00","1 through 10","588.79","920.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.65","844.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","920.70","81.72","","5157.68","5157.68","5157.68","1 through 10","588.79","920.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.65","844.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","920.70","81.72","","431.26","71.26","1459.57","88","588.79","920.7","percent of total billed charges",""
"PLATE HAND 47X1.3MM 12 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006265","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","839.07","79.5","","800.18","480.96","1887.97","195","327.18","839.07","percent of total billed charges",""
"PLATE HAND 47X1.3MM 12 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006265","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","562.54","53.3","","813.12","216.42","1444.50","81","327.18","839.07","percent of total billed charges",""
"PLATE HAND 47X1.3MM 12 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006265","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","327.18","31","","432.60","432.60","432.60","1 through 10","327.18","839.07","percent of total billed charges",""
"PLATE HAND 47X1.3MM 12 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006265","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","385.23","36.5","","148.37","54.89","631.39","94","327.18","839.07","percent of total billed charges",""
"PLATE HAND 47X1.3MM 12 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006265","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","404.23","38.3","","279.30","91.72","1116.77","266","327.18","839.07","percent of total billed charges",""
"PLATE HAND 47X1.3MM 12 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006265","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","452.78","42.9","","731.00","63.70","731.00","1 through 10","327.18","839.07","percent of total billed charges",""
"PLATE HAND 47X1.3MM 12 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006265","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","452.78","42.9","","384.74","384.74","384.74","1 through 10","327.18","839.07","percent of total billed charges",""
"PLATE HAND 47X1.3MM 12 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006265","CDM","C1713","HCPCS","0278","RC","","","","both","","","1055.43","791.57","WELLPOINT [1015]","HB AMC WELLPOINT","778.70","73.78","","286.63","119.22","1107.45","105","327.18","839.07","percent of total billed charges",""
"PLATE HAND 47X1.3MM 12 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1055.43","791.57","AETNA [1001]","HB AMC AETNA HMO","736.69","69.8","","675.31","184.75","1721.50","286","551.57","862.5","percent of total billed charges",""
"PLATE HAND 47X1.3MM 12 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1055.43","791.57","AETNA [1001]","HB AMC AETNA PPO","848.57","80.4","","1261.44","103.12","1514.10","21","551.57","862.5","percent of total billed charges",""
"PLATE HAND 47X1.3MM 12 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1055.43","791.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","848.57","80.4","","1365.00","1365.00","1365.00","1 through 10","551.57","862.5","percent of total billed charges",""
"PLATE HAND 47X1.3MM 12 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1055.43","791.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","862.50","81.72","","5157.68","5157.68","5157.68","1 through 10","551.57","862.5","percent of total billed charges",""
"PLATE HAND 47X1.3MM 12 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10006265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1055.43","791.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","862.50","81.72","","431.26","71.26","1459.57","88","551.57","862.5","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1734.01","1300.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1378.54","79.5","","800.18","480.96","1887.97","195","537.54","1378.54","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1734.01","1300.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","924.23","53.3","","813.12","216.42","1444.50","81","537.54","1378.54","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1734.01","1300.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","537.54","31","","432.60","432.60","432.60","1 through 10","537.54","1378.54","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1734.01","1300.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","632.91","36.5","","148.37","54.89","631.39","94","537.54","1378.54","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1734.01","1300.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","664.13","38.3","","279.30","91.72","1116.77","266","537.54","1378.54","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1734.01","1300.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","743.89","42.9","","731.00","63.70","731.00","1 through 10","537.54","1378.54","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1734.01","1300.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","743.89","42.9","","384.74","384.74","384.74","1 through 10","537.54","1378.54","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1734.01","1300.51","WELLPOINT [1015]","HB AMC WELLPOINT","1279.35","73.78","","286.63","119.22","1107.45","105","537.54","1378.54","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1734.01","1300.51","AETNA [1001]","HB AMC AETNA HMO","1210.34","69.8","","675.31","184.75","1721.50","286","906.19","1417.03","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1734.01","1300.51","AETNA [1001]","HB AMC AETNA PPO","1394.14","80.4","","1261.44","103.12","1514.10","21","906.19","1417.03","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1734.01","1300.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1394.14","80.4","","1365.00","1365.00","1365.00","1 through 10","906.19","1417.03","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1734.01","1300.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1417.03","81.72","","5157.68","5157.68","5157.68","1 through 10","906.19","1417.03","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1734.01","1300.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1417.03","81.72","","431.26","71.26","1459.57","88","906.19","1417.03","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.58","956.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1014.09","79.5","","800.18","480.96","1887.97","195","395.43","1014.09","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.58","956.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","679.88","53.3","","813.12","216.42","1444.50","81","395.43","1014.09","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.58","956.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","395.43","31","","432.60","432.60","432.60","1 through 10","395.43","1014.09","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.58","956.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","465.59","36.5","","148.37","54.89","631.39","94","395.43","1014.09","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.58","956.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","488.55","38.3","","279.30","91.72","1116.77","266","395.43","1014.09","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.58","956.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","547.22","42.9","","731.00","63.70","731.00","1 through 10","395.43","1014.09","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.58","956.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","547.22","42.9","","384.74","384.74","384.74","1 through 10","395.43","1014.09","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.58","956.68","WELLPOINT [1015]","HB AMC WELLPOINT","941.12","73.78","","286.63","119.22","1107.45","105","395.43","1014.09","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.58","956.68","AETNA [1001]","HB AMC AETNA HMO","890.35","69.8","","675.31","184.75","1721.50","286","666.62","1042.4","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.58","956.68","AETNA [1001]","HB AMC AETNA PPO","1025.57","80.4","","1261.44","103.12","1514.10","21","666.62","1042.4","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.58","956.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1025.57","80.4","","1365.00","1365.00","1365.00","1 through 10","666.62","1042.4","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.58","956.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1042.40","81.72","","5157.68","5157.68","5157.68","1 through 10","666.62","1042.4","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.58","956.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1042.40","81.72","","431.26","71.26","1459.57","88","666.62","1042.4","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1873.87","1405.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1489.73","79.5","","800.18","480.96","1887.97","195","580.9","1489.73","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1873.87","1405.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","998.77","53.3","","813.12","216.42","1444.50","81","580.9","1489.73","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1873.87","1405.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","580.90","31","","432.60","432.60","432.60","1 through 10","580.9","1489.73","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1873.87","1405.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","683.96","36.5","","148.37","54.89","631.39","94","580.9","1489.73","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1873.87","1405.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","717.69","38.3","","279.30","91.72","1116.77","266","580.9","1489.73","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1873.87","1405.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","803.89","42.9","","731.00","63.70","731.00","1 through 10","580.9","1489.73","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1873.87","1405.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","803.89","42.9","","384.74","384.74","384.74","1 through 10","580.9","1489.73","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1873.87","1405.40","WELLPOINT [1015]","HB AMC WELLPOINT","1382.54","73.78","","286.63","119.22","1107.45","105","580.9","1489.73","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1873.87","1405.40","AETNA [1001]","HB AMC AETNA HMO","1307.96","69.8","","675.31","184.75","1721.50","286","979.28","1531.33","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1873.87","1405.40","AETNA [1001]","HB AMC AETNA PPO","1506.59","80.4","","1261.44","103.12","1514.10","21","979.28","1531.33","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1873.87","1405.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1506.59","80.4","","1365.00","1365.00","1365.00","1 through 10","979.28","1531.33","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1873.87","1405.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1531.33","81.72","","5157.68","5157.68","5157.68","1 through 10","979.28","1531.33","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1873.87","1405.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1531.33","81.72","","431.26","71.26","1459.57","88","979.28","1531.33","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.12","774.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","820.54","79.5","","800.18","480.96","1887.97","195","319.96","820.54","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.12","774.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","550.12","53.3","","813.12","216.42","1444.50","81","319.96","820.54","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.12","774.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","319.96","31","","432.60","432.60","432.60","1 through 10","319.96","820.54","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.12","774.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","376.72","36.5","","148.37","54.89","631.39","94","319.96","820.54","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.12","774.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","395.30","38.3","","279.30","91.72","1116.77","266","319.96","820.54","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.12","774.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.78","42.9","","731.00","63.70","731.00","1 through 10","319.96","820.54","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.12","774.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.78","42.9","","384.74","384.74","384.74","1 through 10","319.96","820.54","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.12","774.09","WELLPOINT [1015]","HB AMC WELLPOINT","761.50","73.78","","286.63","119.22","1107.45","105","319.96","820.54","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.12","774.09","AETNA [1001]","HB AMC AETNA HMO","720.42","69.8","","675.31","184.75","1721.50","286","539.39","843.45","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.12","774.09","AETNA [1001]","HB AMC AETNA PPO","829.82","80.4","","1261.44","103.12","1514.10","21","539.39","843.45","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.12","774.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","829.82","80.4","","1365.00","1365.00","1365.00","1 through 10","539.39","843.45","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.12","774.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","843.45","81.72","","5157.68","5157.68","5157.68","1 through 10","539.39","843.45","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.12","774.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","843.45","81.72","","431.26","71.26","1459.57","88","539.39","843.45","percent of total billed charges",""
"PLATE HEX PLUSE","SUP-ITM-10317511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2086.88","79.5","","800.18","480.96","1887.97","195","813.75","2086.88","percent of total billed charges",""
"PLATE HEX PLUSE","SUP-ITM-10317511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1399.13","53.3","","813.12","216.42","1444.50","81","813.75","2086.88","percent of total billed charges",""
"PLATE HEX PLUSE","SUP-ITM-10317511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","813.75","31","","432.60","432.60","432.60","1 through 10","813.75","2086.88","percent of total billed charges",""
"PLATE HEX PLUSE","SUP-ITM-10317511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","958.13","36.5","","148.37","54.89","631.39","94","813.75","2086.88","percent of total billed charges",""
"PLATE HEX PLUSE","SUP-ITM-10317511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1005.38","38.3","","279.30","91.72","1116.77","266","813.75","2086.88","percent of total billed charges",""
"PLATE HEX PLUSE","SUP-ITM-10317511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1126.13","42.9","","731.00","63.70","731.00","1 through 10","813.75","2086.88","percent of total billed charges",""
"PLATE HEX PLUSE","SUP-ITM-10317511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1126.13","42.9","","384.74","384.74","384.74","1 through 10","813.75","2086.88","percent of total billed charges",""
"PLATE HEX PLUSE","SUP-ITM-10317511","CDM","C1713","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","WELLPOINT [1015]","HB AMC WELLPOINT","1936.73","73.78","","286.63","119.22","1107.45","105","813.75","2086.88","percent of total billed charges",""
"PLATE HEX PLUSE","SUP-ITM-10317511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","AETNA [1001]","HB AMC AETNA HMO","1832.25","69.8","","675.31","184.75","1721.50","286","1371.83","2145.15","percent of total billed charges",""
"PLATE HEX PLUSE","SUP-ITM-10317511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","AETNA [1001]","HB AMC AETNA PPO","2110.50","80.4","","1261.44","103.12","1514.10","21","1371.83","2145.15","percent of total billed charges",""
"PLATE HEX PLUSE","SUP-ITM-10317511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2110.50","80.4","","1365.00","1365.00","1365.00","1 through 10","1371.83","2145.15","percent of total billed charges",""
"PLATE HEX PLUSE","SUP-ITM-10317511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2145.15","81.72","","5157.68","5157.68","5157.68","1 through 10","1371.83","2145.15","percent of total billed charges",""
"PLATE HEX PLUSE","SUP-ITM-10317511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2145.15","81.72","","431.26","71.26","1459.57","88","1371.83","2145.15","percent of total billed charges",""
"PLATE HIP 138MM STABILIZATION TROCHANTERIC DHS SS","SUP-ITM-10009071","CDM","C1713","HCPCS","0278","RC","","","","both","","","2123.80","1592.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1688.42","79.5","","800.18","480.96","1887.97","195","658.38","1688.42","percent of total billed charges",""
"PLATE HIP 138MM STABILIZATION TROCHANTERIC DHS SS","SUP-ITM-10009071","CDM","C1713","HCPCS","0278","RC","","","","both","","","2123.80","1592.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1131.99","53.3","","813.12","216.42","1444.50","81","658.38","1688.42","percent of total billed charges",""
"PLATE HIP 138MM STABILIZATION TROCHANTERIC DHS SS","SUP-ITM-10009071","CDM","C1713","HCPCS","0278","RC","","","","both","","","2123.80","1592.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","658.38","31","","432.60","432.60","432.60","1 through 10","658.38","1688.42","percent of total billed charges",""
"PLATE HIP 138MM STABILIZATION TROCHANTERIC DHS SS","SUP-ITM-10009071","CDM","C1713","HCPCS","0278","RC","","","","both","","","2123.80","1592.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","775.19","36.5","","148.37","54.89","631.39","94","658.38","1688.42","percent of total billed charges",""
"PLATE HIP 138MM STABILIZATION TROCHANTERIC DHS SS","SUP-ITM-10009071","CDM","C1713","HCPCS","0278","RC","","","","both","","","2123.80","1592.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","813.42","38.3","","279.30","91.72","1116.77","266","658.38","1688.42","percent of total billed charges",""
"PLATE HIP 138MM STABILIZATION TROCHANTERIC DHS SS","SUP-ITM-10009071","CDM","C1713","HCPCS","0278","RC","","","","both","","","2123.80","1592.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.11","42.9","","731.00","63.70","731.00","1 through 10","658.38","1688.42","percent of total billed charges",""
"PLATE HIP 138MM STABILIZATION TROCHANTERIC DHS SS","SUP-ITM-10009071","CDM","C1713","HCPCS","0278","RC","","","","both","","","2123.80","1592.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.11","42.9","","384.74","384.74","384.74","1 through 10","658.38","1688.42","percent of total billed charges",""
"PLATE HIP 138MM STABILIZATION TROCHANTERIC DHS SS","SUP-ITM-10009071","CDM","C1713","HCPCS","0278","RC","","","","both","","","2123.80","1592.85","WELLPOINT [1015]","HB AMC WELLPOINT","1566.94","73.78","","286.63","119.22","1107.45","105","658.38","1688.42","percent of total billed charges",""
"PLATE HIP 138MM STABILIZATION TROCHANTERIC DHS SS","SUP-ITM-10009071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2123.80","1592.85","AETNA [1001]","HB AMC AETNA HMO","1482.41","69.8","","675.31","184.75","1721.50","286","1109.9","1735.57","percent of total billed charges",""
"PLATE HIP 138MM STABILIZATION TROCHANTERIC DHS SS","SUP-ITM-10009071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2123.80","1592.85","AETNA [1001]","HB AMC AETNA PPO","1707.54","80.4","","1261.44","103.12","1514.10","21","1109.9","1735.57","percent of total billed charges",""
"PLATE HIP 138MM STABILIZATION TROCHANTERIC DHS SS","SUP-ITM-10009071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2123.80","1592.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1707.54","80.4","","1365.00","1365.00","1365.00","1 through 10","1109.9","1735.57","percent of total billed charges",""
"PLATE HIP 138MM STABILIZATION TROCHANTERIC DHS SS","SUP-ITM-10009071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2123.80","1592.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1735.57","81.72","","5157.68","5157.68","5157.68","1 through 10","1109.9","1735.57","percent of total billed charges",""
"PLATE HIP 138MM STABILIZATION TROCHANTERIC DHS SS","SUP-ITM-10009071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2123.80","1592.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1735.57","81.72","","431.26","71.26","1459.57","88","1109.9","1735.57","percent of total billed charges",""
"PLATE HIP 142MM 8 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10004263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1595.76","79.5","","800.18","480.96","1887.97","195","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 142MM 8 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10004263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1069.86","53.3","","813.12","216.42","1444.50","81","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 142MM 8 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10004263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","622.25","31","","432.60","432.60","432.60","1 through 10","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 142MM 8 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10004263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","732.65","36.5","","148.37","54.89","631.39","94","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 142MM 8 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10004263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","768.78","38.3","","279.30","91.72","1116.77","266","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 142MM 8 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10004263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","861.11","42.9","","731.00","63.70","731.00","1 through 10","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 142MM 8 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10004263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","861.11","42.9","","384.74","384.74","384.74","1 through 10","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 142MM 8 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10004263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","WELLPOINT [1015]","HB AMC WELLPOINT","1480.95","73.78","","286.63","119.22","1107.45","105","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 142MM 8 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10004263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","AETNA [1001]","HB AMC AETNA HMO","1401.06","69.8","","675.31","184.75","1721.50","286","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 142MM 8 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10004263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","AETNA [1001]","HB AMC AETNA PPO","1613.83","80.4","","1261.44","103.12","1514.10","21","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 142MM 8 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10004263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1613.83","80.4","","1365.00","1365.00","1365.00","1 through 10","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 142MM 8 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10004263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1640.32","81.72","","5157.68","5157.68","5157.68","1 through 10","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 142MM 8 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10004263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1640.32","81.72","","431.26","71.26","1459.57","88","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10038266","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1755.34","79.5","","800.18","480.96","1887.97","195","684.47","1755.34","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10038266","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1176.85","53.3","","813.12","216.42","1444.50","81","684.47","1755.34","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10038266","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","684.47","31","","432.60","432.60","432.60","1 through 10","684.47","1755.34","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10038266","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","805.91","36.5","","148.37","54.89","631.39","94","684.47","1755.34","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10038266","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","845.66","38.3","","279.30","91.72","1116.77","266","684.47","1755.34","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10038266","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","947.22","42.9","","731.00","63.70","731.00","1 through 10","684.47","1755.34","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10038266","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","947.22","42.9","","384.74","384.74","384.74","1 through 10","684.47","1755.34","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10038266","CDM","C1713","HCPCS","0278","RC","","","","both","","","2207.98","1655.98","WELLPOINT [1015]","HB AMC WELLPOINT","1629.05","73.78","","286.63","119.22","1107.45","105","684.47","1755.34","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10038266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.98","1655.98","AETNA [1001]","HB AMC AETNA HMO","1541.17","69.8","","675.31","184.75","1721.50","286","1153.89","1804.36","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10038266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.98","1655.98","AETNA [1001]","HB AMC AETNA PPO","1775.22","80.4","","1261.44","103.12","1514.10","21","1153.89","1804.36","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10038266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.98","1655.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1775.22","80.4","","1365.00","1365.00","1365.00","1 through 10","1153.89","1804.36","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10038266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.98","1655.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1804.36","81.72","","5157.68","5157.68","5157.68","1 through 10","1153.89","1804.36","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10038266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2207.98","1655.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1804.36","81.72","","431.26","71.26","1459.57","88","1153.89","1804.36","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 150DEG DHS COMPRESSION STANDARD BARREL SS","SUP-ITM-10038311","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1595.76","79.5","","800.18","480.96","1887.97","195","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 150DEG DHS COMPRESSION STANDARD BARREL SS","SUP-ITM-10038311","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1069.86","53.3","","813.12","216.42","1444.50","81","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 150DEG DHS COMPRESSION STANDARD BARREL SS","SUP-ITM-10038311","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","622.25","31","","432.60","432.60","432.60","1 through 10","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 150DEG DHS COMPRESSION STANDARD BARREL SS","SUP-ITM-10038311","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","732.65","36.5","","148.37","54.89","631.39","94","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 150DEG DHS COMPRESSION STANDARD BARREL SS","SUP-ITM-10038311","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","768.78","38.3","","279.30","91.72","1116.77","266","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 150DEG DHS COMPRESSION STANDARD BARREL SS","SUP-ITM-10038311","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","861.11","42.9","","731.00","63.70","731.00","1 through 10","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 150DEG DHS COMPRESSION STANDARD BARREL SS","SUP-ITM-10038311","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","861.11","42.9","","384.74","384.74","384.74","1 through 10","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 150DEG DHS COMPRESSION STANDARD BARREL SS","SUP-ITM-10038311","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","WELLPOINT [1015]","HB AMC WELLPOINT","1480.95","73.78","","286.63","119.22","1107.45","105","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 150DEG DHS COMPRESSION STANDARD BARREL SS","SUP-ITM-10038311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","AETNA [1001]","HB AMC AETNA HMO","1401.06","69.8","","675.31","184.75","1721.50","286","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 150DEG DHS COMPRESSION STANDARD BARREL SS","SUP-ITM-10038311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","AETNA [1001]","HB AMC AETNA PPO","1613.83","80.4","","1261.44","103.12","1514.10","21","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 150DEG DHS COMPRESSION STANDARD BARREL SS","SUP-ITM-10038311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1613.83","80.4","","1365.00","1365.00","1365.00","1 through 10","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 150DEG DHS COMPRESSION STANDARD BARREL SS","SUP-ITM-10038311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1640.32","81.72","","5157.68","5157.68","5157.68","1 through 10","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 174MM 10 HOLE 150DEG DHS COMPRESSION STANDARD BARREL SS","SUP-ITM-10038311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1640.32","81.72","","431.26","71.26","1459.57","88","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 206MM 12 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10001799","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1595.76","79.5","","800.18","480.96","1887.97","195","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 206MM 12 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10001799","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1069.86","53.3","","813.12","216.42","1444.50","81","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 206MM 12 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10001799","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","622.25","31","","432.60","432.60","432.60","1 through 10","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 206MM 12 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10001799","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","732.65","36.5","","148.37","54.89","631.39","94","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 206MM 12 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10001799","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","768.78","38.3","","279.30","91.72","1116.77","266","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 206MM 12 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10001799","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","861.11","42.9","","731.00","63.70","731.00","1 through 10","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 206MM 12 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10001799","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","861.11","42.9","","384.74","384.74","384.74","1 through 10","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 206MM 12 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10001799","CDM","C1713","HCPCS","0278","RC","","","","both","","","2007.25","1505.44","WELLPOINT [1015]","HB AMC WELLPOINT","1480.95","73.78","","286.63","119.22","1107.45","105","622.25","1595.76","percent of total billed charges",""
"PLATE HIP 206MM 12 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10001799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","AETNA [1001]","HB AMC AETNA HMO","1401.06","69.8","","675.31","184.75","1721.50","286","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 206MM 12 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10001799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","AETNA [1001]","HB AMC AETNA PPO","1613.83","80.4","","1261.44","103.12","1514.10","21","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 206MM 12 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10001799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1613.83","80.4","","1365.00","1365.00","1365.00","1 through 10","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 206MM 12 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10001799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1640.32","81.72","","5157.68","5157.68","5157.68","1 through 10","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 206MM 12 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10001799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2007.25","1505.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1640.32","81.72","","431.26","71.26","1459.57","88","1048.99","1640.32","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10006054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2666.41","1999.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2119.80","79.5","","800.18","480.96","1887.97","195","826.59","2119.8","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10006054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2666.41","1999.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1421.20","53.3","","813.12","216.42","1444.50","81","826.59","2119.8","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10006054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2666.41","1999.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","826.59","31","","432.60","432.60","432.60","1 through 10","826.59","2119.8","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10006054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2666.41","1999.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","973.24","36.5","","148.37","54.89","631.39","94","826.59","2119.8","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10006054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2666.41","1999.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1021.24","38.3","","279.30","91.72","1116.77","266","826.59","2119.8","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10006054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2666.41","1999.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1143.89","42.9","","731.00","63.70","731.00","1 through 10","826.59","2119.8","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10006054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2666.41","1999.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1143.89","42.9","","384.74","384.74","384.74","1 through 10","826.59","2119.8","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10006054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2666.41","1999.81","WELLPOINT [1015]","HB AMC WELLPOINT","1967.28","73.78","","286.63","119.22","1107.45","105","826.59","2119.8","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10006054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2666.41","1999.81","AETNA [1001]","HB AMC AETNA HMO","1861.15","69.8","","675.31","184.75","1721.50","286","1393.47","2178.99","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10006054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2666.41","1999.81","AETNA [1001]","HB AMC AETNA PPO","2143.79","80.4","","1261.44","103.12","1514.10","21","1393.47","2178.99","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10006054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2666.41","1999.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2143.79","80.4","","1365.00","1365.00","1365.00","1 through 10","1393.47","2178.99","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10006054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2666.41","1999.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2178.99","81.72","","5157.68","5157.68","5157.68","1 through 10","1393.47","2178.99","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10006054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2666.41","1999.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2178.99","81.72","","431.26","71.26","1459.57","88","1393.47","2178.99","percent of total billed charges",""
"PLATE HIP 3.5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124843","CDM","C1713","HCPCS","0278","RC","","","","both","","","2337.48","1753.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1858.30","79.5","","800.18","480.96","1887.97","195","724.62","1858.3","percent of total billed charges",""
"PLATE HIP 3.5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124843","CDM","C1713","HCPCS","0278","RC","","","","both","","","2337.48","1753.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1245.88","53.3","","813.12","216.42","1444.50","81","724.62","1858.3","percent of total billed charges",""
"PLATE HIP 3.5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124843","CDM","C1713","HCPCS","0278","RC","","","","both","","","2337.48","1753.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","724.62","31","","432.60","432.60","432.60","1 through 10","724.62","1858.3","percent of total billed charges",""
"PLATE HIP 3.5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124843","CDM","C1713","HCPCS","0278","RC","","","","both","","","2337.48","1753.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","853.18","36.5","","148.37","54.89","631.39","94","724.62","1858.3","percent of total billed charges",""
"PLATE HIP 3.5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124843","CDM","C1713","HCPCS","0278","RC","","","","both","","","2337.48","1753.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","895.25","38.3","","279.30","91.72","1116.77","266","724.62","1858.3","percent of total billed charges",""
"PLATE HIP 3.5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124843","CDM","C1713","HCPCS","0278","RC","","","","both","","","2337.48","1753.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1002.78","42.9","","731.00","63.70","731.00","1 through 10","724.62","1858.3","percent of total billed charges",""
"PLATE HIP 3.5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124843","CDM","C1713","HCPCS","0278","RC","","","","both","","","2337.48","1753.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1002.78","42.9","","384.74","384.74","384.74","1 through 10","724.62","1858.3","percent of total billed charges",""
"PLATE HIP 3.5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124843","CDM","C1713","HCPCS","0278","RC","","","","both","","","2337.48","1753.11","WELLPOINT [1015]","HB AMC WELLPOINT","1724.59","73.78","","286.63","119.22","1107.45","105","724.62","1858.3","percent of total billed charges",""
"PLATE HIP 3.5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2337.48","1753.11","AETNA [1001]","HB AMC AETNA HMO","1631.56","69.8","","675.31","184.75","1721.50","286","1221.57","1910.19","percent of total billed charges",""
"PLATE HIP 3.5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2337.48","1753.11","AETNA [1001]","HB AMC AETNA PPO","1879.33","80.4","","1261.44","103.12","1514.10","21","1221.57","1910.19","percent of total billed charges",""
"PLATE HIP 3.5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2337.48","1753.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1879.33","80.4","","1365.00","1365.00","1365.00","1 through 10","1221.57","1910.19","percent of total billed charges",""
"PLATE HIP 3.5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2337.48","1753.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1910.19","81.72","","5157.68","5157.68","5157.68","1 through 10","1221.57","1910.19","percent of total billed charges",""
"PLATE HIP 3.5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2337.48","1753.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1910.19","81.72","","431.26","71.26","1459.57","88","1221.57","1910.19","percent of total billed charges",""
"PLATE HIP 3.5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124844","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1951.98","79.5","","800.18","480.96","1887.97","195","761.15","1951.98","percent of total billed charges",""
"PLATE HIP 3.5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124844","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1308.69","53.3","","813.12","216.42","1444.50","81","761.15","1951.98","percent of total billed charges",""
"PLATE HIP 3.5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124844","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","761.15","31","","432.60","432.60","432.60","1 through 10","761.15","1951.98","percent of total billed charges",""
"PLATE HIP 3.5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124844","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","896.19","36.5","","148.37","54.89","631.39","94","761.15","1951.98","percent of total billed charges",""
"PLATE HIP 3.5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124844","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","940.39","38.3","","279.30","91.72","1116.77","266","761.15","1951.98","percent of total billed charges",""
"PLATE HIP 3.5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124844","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1053.33","42.9","","731.00","63.70","731.00","1 through 10","761.15","1951.98","percent of total billed charges",""
"PLATE HIP 3.5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124844","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1053.33","42.9","","384.74","384.74","384.74","1 through 10","761.15","1951.98","percent of total billed charges",""
"PLATE HIP 3.5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124844","CDM","C1713","HCPCS","0278","RC","","","","both","","","2455.32","1841.49","WELLPOINT [1015]","HB AMC WELLPOINT","1811.54","73.78","","286.63","119.22","1107.45","105","761.15","1951.98","percent of total billed charges",""
"PLATE HIP 3.5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2455.32","1841.49","AETNA [1001]","HB AMC AETNA HMO","1713.81","69.8","","675.31","184.75","1721.50","286","1283.15","2006.49","percent of total billed charges",""
"PLATE HIP 3.5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2455.32","1841.49","AETNA [1001]","HB AMC AETNA PPO","1974.08","80.4","","1261.44","103.12","1514.10","21","1283.15","2006.49","percent of total billed charges",""
"PLATE HIP 3.5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2455.32","1841.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1974.08","80.4","","1365.00","1365.00","1365.00","1 through 10","1283.15","2006.49","percent of total billed charges",""
"PLATE HIP 3.5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2455.32","1841.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2006.49","81.72","","5157.68","5157.68","5157.68","1 through 10","1283.15","2006.49","percent of total billed charges",""
"PLATE HIP 3.5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2455.32","1841.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2006.49","81.72","","431.26","71.26","1459.57","88","1283.15","2006.49","percent of total billed charges",""
"PLATE HIP 3.5MM 9 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124845","CDM","C1713","HCPCS","0278","RC","","","","both","","","2582.23","1936.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2052.87","79.5","","800.18","480.96","1887.97","195","800.49","2052.87","percent of total billed charges",""
"PLATE HIP 3.5MM 9 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124845","CDM","C1713","HCPCS","0278","RC","","","","both","","","2582.23","1936.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1376.33","53.3","","813.12","216.42","1444.50","81","800.49","2052.87","percent of total billed charges",""
"PLATE HIP 3.5MM 9 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124845","CDM","C1713","HCPCS","0278","RC","","","","both","","","2582.23","1936.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","800.49","31","","432.60","432.60","432.60","1 through 10","800.49","2052.87","percent of total billed charges",""
"PLATE HIP 3.5MM 9 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124845","CDM","C1713","HCPCS","0278","RC","","","","both","","","2582.23","1936.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","942.51","36.5","","148.37","54.89","631.39","94","800.49","2052.87","percent of total billed charges",""
"PLATE HIP 3.5MM 9 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124845","CDM","C1713","HCPCS","0278","RC","","","","both","","","2582.23","1936.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","988.99","38.3","","279.30","91.72","1116.77","266","800.49","2052.87","percent of total billed charges",""
"PLATE HIP 3.5MM 9 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124845","CDM","C1713","HCPCS","0278","RC","","","","both","","","2582.23","1936.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1107.78","42.9","","731.00","63.70","731.00","1 through 10","800.49","2052.87","percent of total billed charges",""
"PLATE HIP 3.5MM 9 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124845","CDM","C1713","HCPCS","0278","RC","","","","both","","","2582.23","1936.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1107.78","42.9","","384.74","384.74","384.74","1 through 10","800.49","2052.87","percent of total billed charges",""
"PLATE HIP 3.5MM 9 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124845","CDM","C1713","HCPCS","0278","RC","","","","both","","","2582.23","1936.67","WELLPOINT [1015]","HB AMC WELLPOINT","1905.17","73.78","","286.63","119.22","1107.45","105","800.49","2052.87","percent of total billed charges",""
"PLATE HIP 3.5MM 9 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2582.23","1936.67","AETNA [1001]","HB AMC AETNA HMO","1802.40","69.8","","675.31","184.75","1721.50","286","1349.47","2110.2","percent of total billed charges",""
"PLATE HIP 3.5MM 9 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2582.23","1936.67","AETNA [1001]","HB AMC AETNA PPO","2076.11","80.4","","1261.44","103.12","1514.10","21","1349.47","2110.2","percent of total billed charges",""
"PLATE HIP 3.5MM 9 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2582.23","1936.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2076.11","80.4","","1365.00","1365.00","1365.00","1 through 10","1349.47","2110.2","percent of total billed charges",""
"PLATE HIP 3.5MM 9 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2582.23","1936.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2110.20","81.72","","5157.68","5157.68","5157.68","1 through 10","1349.47","2110.2","percent of total billed charges",""
"PLATE HIP 3.5MM 9 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2582.23","1936.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2110.20","81.72","","431.26","71.26","1459.57","88","1349.47","2110.2","percent of total billed charges",""
"PLATE HIP 3.5X7X25MM INFANT 90DEG DCP SS OSTEOTOMY","SUP-ITM-10037744","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.83","1296.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1374.42","79.5","","800.18","480.96","1887.97","195","535.94","1374.42","percent of total billed charges",""
"PLATE HIP 3.5X7X25MM INFANT 90DEG DCP SS OSTEOTOMY","SUP-ITM-10037744","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.83","1296.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","921.47","53.3","","813.12","216.42","1444.50","81","535.94","1374.42","percent of total billed charges",""
"PLATE HIP 3.5X7X25MM INFANT 90DEG DCP SS OSTEOTOMY","SUP-ITM-10037744","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.83","1296.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","535.94","31","","432.60","432.60","432.60","1 through 10","535.94","1374.42","percent of total billed charges",""
"PLATE HIP 3.5X7X25MM INFANT 90DEG DCP SS OSTEOTOMY","SUP-ITM-10037744","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.83","1296.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","631.02","36.5","","148.37","54.89","631.39","94","535.94","1374.42","percent of total billed charges",""
"PLATE HIP 3.5X7X25MM INFANT 90DEG DCP SS OSTEOTOMY","SUP-ITM-10037744","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.83","1296.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","662.14","38.3","","279.30","91.72","1116.77","266","535.94","1374.42","percent of total billed charges",""
"PLATE HIP 3.5X7X25MM INFANT 90DEG DCP SS OSTEOTOMY","SUP-ITM-10037744","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.83","1296.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","741.67","42.9","","731.00","63.70","731.00","1 through 10","535.94","1374.42","percent of total billed charges",""
"PLATE HIP 3.5X7X25MM INFANT 90DEG DCP SS OSTEOTOMY","SUP-ITM-10037744","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.83","1296.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","741.67","42.9","","384.74","384.74","384.74","1 through 10","535.94","1374.42","percent of total billed charges",""
"PLATE HIP 3.5X7X25MM INFANT 90DEG DCP SS OSTEOTOMY","SUP-ITM-10037744","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.83","1296.62","WELLPOINT [1015]","HB AMC WELLPOINT","1275.53","73.78","","286.63","119.22","1107.45","105","535.94","1374.42","percent of total billed charges",""
"PLATE HIP 3.5X7X25MM INFANT 90DEG DCP SS OSTEOTOMY","SUP-ITM-10037744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.83","1296.62","AETNA [1001]","HB AMC AETNA HMO","1206.72","69.8","","675.31","184.75","1721.50","286","903.49","1412.8","percent of total billed charges",""
"PLATE HIP 3.5X7X25MM INFANT 90DEG DCP SS OSTEOTOMY","SUP-ITM-10037744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.83","1296.62","AETNA [1001]","HB AMC AETNA PPO","1389.98","80.4","","1261.44","103.12","1514.10","21","903.49","1412.8","percent of total billed charges",""
"PLATE HIP 3.5X7X25MM INFANT 90DEG DCP SS OSTEOTOMY","SUP-ITM-10037744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.83","1296.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1389.98","80.4","","1365.00","1365.00","1365.00","1 through 10","903.49","1412.8","percent of total billed charges",""
"PLATE HIP 3.5X7X25MM INFANT 90DEG DCP SS OSTEOTOMY","SUP-ITM-10037744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.83","1296.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1412.80","81.72","","5157.68","5157.68","5157.68","1 through 10","903.49","1412.8","percent of total billed charges",""
"PLATE HIP 3.5X7X25MM INFANT 90DEG DCP SS OSTEOTOMY","SUP-ITM-10037744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.83","1296.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1412.80","81.72","","431.26","71.26","1459.57","88","903.49","1412.8","percent of total billed charges",""
"PLATE HIP 302MM 18 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10002477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.81","2057.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2180.53","79.5","","800.18","480.96","1887.97","195","850.27","2180.53","percent of total billed charges",""
"PLATE HIP 302MM 18 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10002477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.81","2057.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1461.92","53.3","","813.12","216.42","1444.50","81","850.27","2180.53","percent of total billed charges",""
"PLATE HIP 302MM 18 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10002477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.81","2057.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","850.27","31","","432.60","432.60","432.60","1 through 10","850.27","2180.53","percent of total billed charges",""
"PLATE HIP 302MM 18 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10002477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.81","2057.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1001.13","36.5","","148.37","54.89","631.39","94","850.27","2180.53","percent of total billed charges",""
"PLATE HIP 302MM 18 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10002477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.81","2057.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1050.50","38.3","","279.30","91.72","1116.77","266","850.27","2180.53","percent of total billed charges",""
"PLATE HIP 302MM 18 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10002477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.81","2057.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1176.67","42.9","","731.00","63.70","731.00","1 through 10","850.27","2180.53","percent of total billed charges",""
"PLATE HIP 302MM 18 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10002477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.81","2057.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1176.67","42.9","","384.74","384.74","384.74","1 through 10","850.27","2180.53","percent of total billed charges",""
"PLATE HIP 302MM 18 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10002477","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.81","2057.11","WELLPOINT [1015]","HB AMC WELLPOINT","2023.65","73.78","","286.63","119.22","1107.45","105","850.27","2180.53","percent of total billed charges",""
"PLATE HIP 302MM 18 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10002477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2742.81","2057.11","AETNA [1001]","HB AMC AETNA HMO","1914.48","69.8","","675.31","184.75","1721.50","286","1433.39","2241.42","percent of total billed charges",""
"PLATE HIP 302MM 18 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10002477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2742.81","2057.11","AETNA [1001]","HB AMC AETNA PPO","2205.22","80.4","","1261.44","103.12","1514.10","21","1433.39","2241.42","percent of total billed charges",""
"PLATE HIP 302MM 18 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10002477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2742.81","2057.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2205.22","80.4","","1365.00","1365.00","1365.00","1 through 10","1433.39","2241.42","percent of total billed charges",""
"PLATE HIP 302MM 18 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10002477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2742.81","2057.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2241.42","81.72","","5157.68","5157.68","5157.68","1 through 10","1433.39","2241.42","percent of total billed charges",""
"PLATE HIP 302MM 18 HOLE 150DEG COMPRESSION DHS STD BARREL SS","SUP-ITM-10002477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2742.81","2057.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2241.42","81.72","","431.26","71.26","1459.57","88","1433.39","2241.42","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1321.91","79.5","","800.18","480.96","1887.97","195","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","886.26","53.3","","813.12","216.42","1444.50","81","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","515.46","31","","432.60","432.60","432.60","1 through 10","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","606.91","36.5","","148.37","54.89","631.39","94","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","636.84","38.3","","279.30","91.72","1116.77","266","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.33","42.9","","731.00","63.70","731.00","1 through 10","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.33","42.9","","384.74","384.74","384.74","1 through 10","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","WELLPOINT [1015]","HB AMC WELLPOINT","1226.80","73.78","","286.63","119.22","1107.45","105","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.78","1247.08","AETNA [1001]","HB AMC AETNA HMO","1160.62","69.8","","675.31","184.75","1721.50","286","868.97","1358.82","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.78","1247.08","AETNA [1001]","HB AMC AETNA PPO","1336.88","80.4","","1261.44","103.12","1514.10","21","868.97","1358.82","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.78","1247.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1336.88","80.4","","1365.00","1365.00","1365.00","1 through 10","868.97","1358.82","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.78","1247.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1358.82","81.72","","5157.68","5157.68","5157.68","1 through 10","868.97","1358.82","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 130DEG DHS SS COMPRESSION STANDARD BARREL ANGLE","SUP-ITM-10029024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.78","1247.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1358.82","81.72","","431.26","71.26","1459.57","88","868.97","1358.82","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1321.91","79.5","","800.18","480.96","1887.97","195","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","886.26","53.3","","813.12","216.42","1444.50","81","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","515.46","31","","432.60","432.60","432.60","1 through 10","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","606.91","36.5","","148.37","54.89","631.39","94","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","636.84","38.3","","279.30","91.72","1116.77","266","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.33","42.9","","731.00","63.70","731.00","1 through 10","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.33","42.9","","384.74","384.74","384.74","1 through 10","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.78","1247.08","WELLPOINT [1015]","HB AMC WELLPOINT","1226.80","73.78","","286.63","119.22","1107.45","105","515.46","1321.91","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.78","1247.08","AETNA [1001]","HB AMC AETNA HMO","1160.62","69.8","","675.31","184.75","1721.50","286","868.97","1358.82","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.78","1247.08","AETNA [1001]","HB AMC AETNA PPO","1336.88","80.4","","1261.44","103.12","1514.10","21","868.97","1358.82","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.78","1247.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1336.88","80.4","","1365.00","1365.00","1365.00","1 through 10","868.97","1358.82","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.78","1247.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1358.82","81.72","","5157.68","5157.68","5157.68","1 through 10","868.97","1358.82","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.78","1247.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1358.82","81.72","","431.26","71.26","1459.57","88","868.97","1358.82","percent of total billed charges",""
"PLATE HIP 5MM 3 HOLE 100DEG PEDIATRIC LCP PROXIMAL","SUP-ITM-10037428","CDM","C1713","HCPCS","0278","RC","","","","both","","","2306.40","1729.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1833.59","79.5","","800.18","480.96","1887.97","195","714.98","1833.59","percent of total billed charges",""
"PLATE HIP 5MM 3 HOLE 100DEG PEDIATRIC LCP PROXIMAL","SUP-ITM-10037428","CDM","C1713","HCPCS","0278","RC","","","","both","","","2306.40","1729.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1229.31","53.3","","813.12","216.42","1444.50","81","714.98","1833.59","percent of total billed charges",""
"PLATE HIP 5MM 3 HOLE 100DEG PEDIATRIC LCP PROXIMAL","SUP-ITM-10037428","CDM","C1713","HCPCS","0278","RC","","","","both","","","2306.40","1729.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","714.98","31","","432.60","432.60","432.60","1 through 10","714.98","1833.59","percent of total billed charges",""
"PLATE HIP 5MM 3 HOLE 100DEG PEDIATRIC LCP PROXIMAL","SUP-ITM-10037428","CDM","C1713","HCPCS","0278","RC","","","","both","","","2306.40","1729.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","841.84","36.5","","148.37","54.89","631.39","94","714.98","1833.59","percent of total billed charges",""
"PLATE HIP 5MM 3 HOLE 100DEG PEDIATRIC LCP PROXIMAL","SUP-ITM-10037428","CDM","C1713","HCPCS","0278","RC","","","","both","","","2306.40","1729.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","883.35","38.3","","279.30","91.72","1116.77","266","714.98","1833.59","percent of total billed charges",""
"PLATE HIP 5MM 3 HOLE 100DEG PEDIATRIC LCP PROXIMAL","SUP-ITM-10037428","CDM","C1713","HCPCS","0278","RC","","","","both","","","2306.40","1729.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","989.45","42.9","","731.00","63.70","731.00","1 through 10","714.98","1833.59","percent of total billed charges",""
"PLATE HIP 5MM 3 HOLE 100DEG PEDIATRIC LCP PROXIMAL","SUP-ITM-10037428","CDM","C1713","HCPCS","0278","RC","","","","both","","","2306.40","1729.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","989.45","42.9","","384.74","384.74","384.74","1 through 10","714.98","1833.59","percent of total billed charges",""
"PLATE HIP 5MM 3 HOLE 100DEG PEDIATRIC LCP PROXIMAL","SUP-ITM-10037428","CDM","C1713","HCPCS","0278","RC","","","","both","","","2306.40","1729.80","WELLPOINT [1015]","HB AMC WELLPOINT","1701.66","73.78","","286.63","119.22","1107.45","105","714.98","1833.59","percent of total billed charges",""
"PLATE HIP 5MM 3 HOLE 100DEG PEDIATRIC LCP PROXIMAL","SUP-ITM-10037428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2306.40","1729.80","AETNA [1001]","HB AMC AETNA HMO","1609.87","69.8","","675.31","184.75","1721.50","286","1205.32","1884.79","percent of total billed charges",""
"PLATE HIP 5MM 3 HOLE 100DEG PEDIATRIC LCP PROXIMAL","SUP-ITM-10037428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2306.40","1729.80","AETNA [1001]","HB AMC AETNA PPO","1854.35","80.4","","1261.44","103.12","1514.10","21","1205.32","1884.79","percent of total billed charges",""
"PLATE HIP 5MM 3 HOLE 100DEG PEDIATRIC LCP PROXIMAL","SUP-ITM-10037428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2306.40","1729.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1854.35","80.4","","1365.00","1365.00","1365.00","1 through 10","1205.32","1884.79","percent of total billed charges",""
"PLATE HIP 5MM 3 HOLE 100DEG PEDIATRIC LCP PROXIMAL","SUP-ITM-10037428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2306.40","1729.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1884.79","81.72","","5157.68","5157.68","5157.68","1 through 10","1205.32","1884.79","percent of total billed charges",""
"PLATE HIP 5MM 3 HOLE 100DEG PEDIATRIC LCP PROXIMAL","SUP-ITM-10037428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2306.40","1729.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1884.79","81.72","","431.26","71.26","1459.57","88","1205.32","1884.79","percent of total billed charges",""
"PLATE HIP 5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124847","CDM","C1713","HCPCS","0278","RC","","","","both","","","2461.80","1846.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1957.13","79.5","","800.18","480.96","1887.97","195","763.16","1957.13","percent of total billed charges",""
"PLATE HIP 5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124847","CDM","C1713","HCPCS","0278","RC","","","","both","","","2461.80","1846.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1312.14","53.3","","813.12","216.42","1444.50","81","763.16","1957.13","percent of total billed charges",""
"PLATE HIP 5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124847","CDM","C1713","HCPCS","0278","RC","","","","both","","","2461.80","1846.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","763.16","31","","432.60","432.60","432.60","1 through 10","763.16","1957.13","percent of total billed charges",""
"PLATE HIP 5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124847","CDM","C1713","HCPCS","0278","RC","","","","both","","","2461.80","1846.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","898.56","36.5","","148.37","54.89","631.39","94","763.16","1957.13","percent of total billed charges",""
"PLATE HIP 5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124847","CDM","C1713","HCPCS","0278","RC","","","","both","","","2461.80","1846.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","942.87","38.3","","279.30","91.72","1116.77","266","763.16","1957.13","percent of total billed charges",""
"PLATE HIP 5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124847","CDM","C1713","HCPCS","0278","RC","","","","both","","","2461.80","1846.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1056.11","42.9","","731.00","63.70","731.00","1 through 10","763.16","1957.13","percent of total billed charges",""
"PLATE HIP 5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124847","CDM","C1713","HCPCS","0278","RC","","","","both","","","2461.80","1846.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1056.11","42.9","","384.74","384.74","384.74","1 through 10","763.16","1957.13","percent of total billed charges",""
"PLATE HIP 5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124847","CDM","C1713","HCPCS","0278","RC","","","","both","","","2461.80","1846.35","WELLPOINT [1015]","HB AMC WELLPOINT","1816.32","73.78","","286.63","119.22","1107.45","105","763.16","1957.13","percent of total billed charges",""
"PLATE HIP 5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2461.80","1846.35","AETNA [1001]","HB AMC AETNA HMO","1718.34","69.8","","675.31","184.75","1721.50","286","1286.54","2011.78","percent of total billed charges",""
"PLATE HIP 5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2461.80","1846.35","AETNA [1001]","HB AMC AETNA PPO","1979.29","80.4","","1261.44","103.12","1514.10","21","1286.54","2011.78","percent of total billed charges",""
"PLATE HIP 5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2461.80","1846.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1979.29","80.4","","1365.00","1365.00","1365.00","1 through 10","1286.54","2011.78","percent of total billed charges",""
"PLATE HIP 5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2461.80","1846.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2011.78","81.72","","5157.68","5157.68","5157.68","1 through 10","1286.54","2011.78","percent of total billed charges",""
"PLATE HIP 5MM 5 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2461.80","1846.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2011.78","81.72","","431.26","71.26","1459.57","88","1286.54","2011.78","percent of total billed charges",""
"PLATE HIP 5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124848","CDM","C1713","HCPCS","0278","RC","","","","both","","","2628.85","1971.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2089.94","79.5","","800.18","480.96","1887.97","195","814.94","2089.94","percent of total billed charges",""
"PLATE HIP 5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124848","CDM","C1713","HCPCS","0278","RC","","","","both","","","2628.85","1971.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1401.18","53.3","","813.12","216.42","1444.50","81","814.94","2089.94","percent of total billed charges",""
"PLATE HIP 5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124848","CDM","C1713","HCPCS","0278","RC","","","","both","","","2628.85","1971.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","814.94","31","","432.60","432.60","432.60","1 through 10","814.94","2089.94","percent of total billed charges",""
"PLATE HIP 5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124848","CDM","C1713","HCPCS","0278","RC","","","","both","","","2628.85","1971.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","959.53","36.5","","148.37","54.89","631.39","94","814.94","2089.94","percent of total billed charges",""
"PLATE HIP 5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124848","CDM","C1713","HCPCS","0278","RC","","","","both","","","2628.85","1971.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1006.85","38.3","","279.30","91.72","1116.77","266","814.94","2089.94","percent of total billed charges",""
"PLATE HIP 5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124848","CDM","C1713","HCPCS","0278","RC","","","","both","","","2628.85","1971.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1127.78","42.9","","731.00","63.70","731.00","1 through 10","814.94","2089.94","percent of total billed charges",""
"PLATE HIP 5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124848","CDM","C1713","HCPCS","0278","RC","","","","both","","","2628.85","1971.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1127.78","42.9","","384.74","384.74","384.74","1 through 10","814.94","2089.94","percent of total billed charges",""
"PLATE HIP 5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124848","CDM","C1713","HCPCS","0278","RC","","","","both","","","2628.85","1971.64","WELLPOINT [1015]","HB AMC WELLPOINT","1939.57","73.78","","286.63","119.22","1107.45","105","814.94","2089.94","percent of total billed charges",""
"PLATE HIP 5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2628.85","1971.64","AETNA [1001]","HB AMC AETNA HMO","1834.94","69.8","","675.31","184.75","1721.50","286","1373.84","2148.3","percent of total billed charges",""
"PLATE HIP 5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2628.85","1971.64","AETNA [1001]","HB AMC AETNA PPO","2113.60","80.4","","1261.44","103.12","1514.10","21","1373.84","2148.3","percent of total billed charges",""
"PLATE HIP 5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2628.85","1971.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2113.60","80.4","","1365.00","1365.00","1365.00","1 through 10","1373.84","2148.3","percent of total billed charges",""
"PLATE HIP 5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2628.85","1971.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2148.30","81.72","","5157.68","5157.68","5157.68","1 through 10","1373.84","2148.3","percent of total billed charges",""
"PLATE HIP 5MM 7 HOLE 130DEG PEDIATRIC LCP SS","SUP-ITM-10124848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2628.85","1971.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2148.30","81.72","","431.26","71.26","1459.57","88","1373.84","2148.3","percent of total billed charges",""
"PLATE HIP 78MM SHORT 4 HOLE 140DEG COMPRESSION DHS BARREL SS","SUP-ITM-10038342","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1201.46","79.5","","800.18","480.96","1887.97","195","468.49","1201.46","percent of total billed charges",""
"PLATE HIP 78MM SHORT 4 HOLE 140DEG COMPRESSION DHS BARREL SS","SUP-ITM-10038342","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","805.51","53.3","","813.12","216.42","1444.50","81","468.49","1201.46","percent of total billed charges",""
"PLATE HIP 78MM SHORT 4 HOLE 140DEG COMPRESSION DHS BARREL SS","SUP-ITM-10038342","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","468.49","31","","432.60","432.60","432.60","1 through 10","468.49","1201.46","percent of total billed charges",""
"PLATE HIP 78MM SHORT 4 HOLE 140DEG COMPRESSION DHS BARREL SS","SUP-ITM-10038342","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","551.61","36.5","","148.37","54.89","631.39","94","468.49","1201.46","percent of total billed charges",""
"PLATE HIP 78MM SHORT 4 HOLE 140DEG COMPRESSION DHS BARREL SS","SUP-ITM-10038342","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","578.82","38.3","","279.30","91.72","1116.77","266","468.49","1201.46","percent of total billed charges",""
"PLATE HIP 78MM SHORT 4 HOLE 140DEG COMPRESSION DHS BARREL SS","SUP-ITM-10038342","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","648.33","42.9","","731.00","63.70","731.00","1 through 10","468.49","1201.46","percent of total billed charges",""
"PLATE HIP 78MM SHORT 4 HOLE 140DEG COMPRESSION DHS BARREL SS","SUP-ITM-10038342","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","648.33","42.9","","384.74","384.74","384.74","1 through 10","468.49","1201.46","percent of total billed charges",""
"PLATE HIP 78MM SHORT 4 HOLE 140DEG COMPRESSION DHS BARREL SS","SUP-ITM-10038342","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.27","1133.45","WELLPOINT [1015]","HB AMC WELLPOINT","1115.02","73.78","","286.63","119.22","1107.45","105","468.49","1201.46","percent of total billed charges",""
"PLATE HIP 78MM SHORT 4 HOLE 140DEG COMPRESSION DHS BARREL SS","SUP-ITM-10038342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","AETNA [1001]","HB AMC AETNA HMO","1054.87","69.8","","675.31","184.75","1721.50","286","789.79","1235.01","percent of total billed charges",""
"PLATE HIP 78MM SHORT 4 HOLE 140DEG COMPRESSION DHS BARREL SS","SUP-ITM-10038342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","AETNA [1001]","HB AMC AETNA PPO","1215.06","80.4","","1261.44","103.12","1514.10","21","789.79","1235.01","percent of total billed charges",""
"PLATE HIP 78MM SHORT 4 HOLE 140DEG COMPRESSION DHS BARREL SS","SUP-ITM-10038342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1215.06","80.4","","1365.00","1365.00","1365.00","1 through 10","789.79","1235.01","percent of total billed charges",""
"PLATE HIP 78MM SHORT 4 HOLE 140DEG COMPRESSION DHS BARREL SS","SUP-ITM-10038342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1235.01","81.72","","5157.68","5157.68","5157.68","1 through 10","789.79","1235.01","percent of total billed charges",""
"PLATE HIP 78MM SHORT 4 HOLE 140DEG COMPRESSION DHS BARREL SS","SUP-ITM-10038342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.27","1133.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1235.01","81.72","","431.26","71.26","1459.57","88","789.79","1235.01","percent of total billed charges",""
"PLATE HUMERUS 115MM 5H PROXIMAL","SUP-ITM-10276146","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3197.09","79.5","","800.18","480.96","1887.97","195","1246.67","3197.09","percent of total billed charges",""
"PLATE HUMERUS 115MM 5H PROXIMAL","SUP-ITM-10276146","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2143.46","53.3","","813.12","216.42","1444.50","81","1246.67","3197.09","percent of total billed charges",""
"PLATE HUMERUS 115MM 5H PROXIMAL","SUP-ITM-10276146","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1246.67","31","","432.60","432.60","432.60","1 through 10","1246.67","3197.09","percent of total billed charges",""
"PLATE HUMERUS 115MM 5H PROXIMAL","SUP-ITM-10276146","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1467.85","36.5","","148.37","54.89","631.39","94","1246.67","3197.09","percent of total billed charges",""
"PLATE HUMERUS 115MM 5H PROXIMAL","SUP-ITM-10276146","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1540.23","38.3","","279.30","91.72","1116.77","266","1246.67","3197.09","percent of total billed charges",""
"PLATE HUMERUS 115MM 5H PROXIMAL","SUP-ITM-10276146","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1725.22","42.9","","731.00","63.70","731.00","1 through 10","1246.67","3197.09","percent of total billed charges",""
"PLATE HUMERUS 115MM 5H PROXIMAL","SUP-ITM-10276146","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1725.22","42.9","","384.74","384.74","384.74","1 through 10","1246.67","3197.09","percent of total billed charges",""
"PLATE HUMERUS 115MM 5H PROXIMAL","SUP-ITM-10276146","CDM","C1713","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","WELLPOINT [1015]","HB AMC WELLPOINT","2967.06","73.78","","286.63","119.22","1107.45","105","1246.67","3197.09","percent of total billed charges",""
"PLATE HUMERUS 115MM 5H PROXIMAL","SUP-ITM-10276146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4021.50","3016.12","AETNA [1001]","HB AMC AETNA HMO","2807.01","69.8","","675.31","184.75","1721.50","286","2101.64","3286.37","percent of total billed charges",""
"PLATE HUMERUS 115MM 5H PROXIMAL","SUP-ITM-10276146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4021.50","3016.12","AETNA [1001]","HB AMC AETNA PPO","3233.29","80.4","","1261.44","103.12","1514.10","21","2101.64","3286.37","percent of total billed charges",""
"PLATE HUMERUS 115MM 5H PROXIMAL","SUP-ITM-10276146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4021.50","3016.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3233.29","80.4","","1365.00","1365.00","1365.00","1 through 10","2101.64","3286.37","percent of total billed charges",""
"PLATE HUMERUS 115MM 5H PROXIMAL","SUP-ITM-10276146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4021.50","3016.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3286.37","81.72","","5157.68","5157.68","5157.68","1 through 10","2101.64","3286.37","percent of total billed charges",""
"PLATE HUMERUS 115MM 5H PROXIMAL","SUP-ITM-10276146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4021.50","3016.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3286.37","81.72","","431.26","71.26","1459.57","88","2101.64","3286.37","percent of total billed charges",""
"PLATE HUMERUS 140MM 7H PROXIMAL","SUP-ITM-10276145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.50","3147.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3336.22","79.5","","800.18","480.96","1887.97","195","1300.92","3336.22","percent of total billed charges",""
"PLATE HUMERUS 140MM 7H PROXIMAL","SUP-ITM-10276145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.50","3147.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2236.73","53.3","","813.12","216.42","1444.50","81","1300.92","3336.22","percent of total billed charges",""
"PLATE HUMERUS 140MM 7H PROXIMAL","SUP-ITM-10276145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.50","3147.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1300.92","31","","432.60","432.60","432.60","1 through 10","1300.92","3336.22","percent of total billed charges",""
"PLATE HUMERUS 140MM 7H PROXIMAL","SUP-ITM-10276145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.50","3147.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1531.72","36.5","","148.37","54.89","631.39","94","1300.92","3336.22","percent of total billed charges",""
"PLATE HUMERUS 140MM 7H PROXIMAL","SUP-ITM-10276145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.50","3147.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1607.26","38.3","","279.30","91.72","1116.77","266","1300.92","3336.22","percent of total billed charges",""
"PLATE HUMERUS 140MM 7H PROXIMAL","SUP-ITM-10276145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.50","3147.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1800.30","42.9","","731.00","63.70","731.00","1 through 10","1300.92","3336.22","percent of total billed charges",""
"PLATE HUMERUS 140MM 7H PROXIMAL","SUP-ITM-10276145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.50","3147.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1800.30","42.9","","384.74","384.74","384.74","1 through 10","1300.92","3336.22","percent of total billed charges",""
"PLATE HUMERUS 140MM 7H PROXIMAL","SUP-ITM-10276145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4196.50","3147.37","WELLPOINT [1015]","HB AMC WELLPOINT","3096.18","73.78","","286.63","119.22","1107.45","105","1300.92","3336.22","percent of total billed charges",""
"PLATE HUMERUS 140MM 7H PROXIMAL","SUP-ITM-10276145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4196.50","3147.37","AETNA [1001]","HB AMC AETNA HMO","2929.16","69.8","","675.31","184.75","1721.50","286","2193.09","3429.38","percent of total billed charges",""
"PLATE HUMERUS 140MM 7H PROXIMAL","SUP-ITM-10276145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4196.50","3147.37","AETNA [1001]","HB AMC AETNA PPO","3373.99","80.4","","1261.44","103.12","1514.10","21","2193.09","3429.38","percent of total billed charges",""
"PLATE HUMERUS 140MM 7H PROXIMAL","SUP-ITM-10276145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4196.50","3147.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3373.99","80.4","","1365.00","1365.00","1365.00","1 through 10","2193.09","3429.38","percent of total billed charges",""
"PLATE HUMERUS 140MM 7H PROXIMAL","SUP-ITM-10276145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4196.50","3147.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3429.38","81.72","","5157.68","5157.68","5157.68","1 through 10","2193.09","3429.38","percent of total billed charges",""
"PLATE HUMERUS 140MM 7H PROXIMAL","SUP-ITM-10276145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4196.50","3147.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3429.38","81.72","","431.26","71.26","1459.57","88","2193.09","3429.38","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X69MM 1 HOLE SHORT TI VA LCP LAT DSTL PL","SUP-ITM-10125567","CDM","C1713","HCPCS","0278","RC","","","","both","","","3334.63","2500.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2651.03","79.5","","800.18","480.96","1887.97","195","1033.74","2651.03","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X69MM 1 HOLE SHORT TI VA LCP LAT DSTL PL","SUP-ITM-10125567","CDM","C1713","HCPCS","0278","RC","","","","both","","","3334.63","2500.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1777.36","53.3","","813.12","216.42","1444.50","81","1033.74","2651.03","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X69MM 1 HOLE SHORT TI VA LCP LAT DSTL PL","SUP-ITM-10125567","CDM","C1713","HCPCS","0278","RC","","","","both","","","3334.63","2500.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1033.74","31","","432.60","432.60","432.60","1 through 10","1033.74","2651.03","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X69MM 1 HOLE SHORT TI VA LCP LAT DSTL PL","SUP-ITM-10125567","CDM","C1713","HCPCS","0278","RC","","","","both","","","3334.63","2500.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1217.14","36.5","","148.37","54.89","631.39","94","1033.74","2651.03","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X69MM 1 HOLE SHORT TI VA LCP LAT DSTL PL","SUP-ITM-10125567","CDM","C1713","HCPCS","0278","RC","","","","both","","","3334.63","2500.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1277.16","38.3","","279.30","91.72","1116.77","266","1033.74","2651.03","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X69MM 1 HOLE SHORT TI VA LCP LAT DSTL PL","SUP-ITM-10125567","CDM","C1713","HCPCS","0278","RC","","","","both","","","3334.63","2500.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1430.56","42.9","","731.00","63.70","731.00","1 through 10","1033.74","2651.03","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X69MM 1 HOLE SHORT TI VA LCP LAT DSTL PL","SUP-ITM-10125567","CDM","C1713","HCPCS","0278","RC","","","","both","","","3334.63","2500.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1430.56","42.9","","384.74","384.74","384.74","1 through 10","1033.74","2651.03","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X69MM 1 HOLE SHORT TI VA LCP LAT DSTL PL","SUP-ITM-10125567","CDM","C1713","HCPCS","0278","RC","","","","both","","","3334.63","2500.97","WELLPOINT [1015]","HB AMC WELLPOINT","2460.29","73.78","","286.63","119.22","1107.45","105","1033.74","2651.03","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X69MM 1 HOLE SHORT TI VA LCP LAT DSTL PL","SUP-ITM-10125567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3334.63","2500.97","AETNA [1001]","HB AMC AETNA HMO","2327.57","69.8","","675.31","184.75","1721.50","286","1742.68","2725.06","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X69MM 1 HOLE SHORT TI VA LCP LAT DSTL PL","SUP-ITM-10125567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3334.63","2500.97","AETNA [1001]","HB AMC AETNA PPO","2681.04","80.4","","1261.44","103.12","1514.10","21","1742.68","2725.06","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X69MM 1 HOLE SHORT TI VA LCP LAT DSTL PL","SUP-ITM-10125567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3334.63","2500.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2681.04","80.4","","1365.00","1365.00","1365.00","1 through 10","1742.68","2725.06","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X69MM 1 HOLE SHORT TI VA LCP LAT DSTL PL","SUP-ITM-10125567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3334.63","2500.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2725.06","81.72","","5157.68","5157.68","5157.68","1 through 10","1742.68","2725.06","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X69MM 1 HOLE SHORT TI VA LCP LAT DSTL PL","SUP-ITM-10125567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3334.63","2500.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2725.06","81.72","","431.26","71.26","1459.57","88","1742.68","2725.06","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3127.43","2345.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2486.31","79.5","","800.18","480.96","1887.97","195","969.5","2486.31","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3127.43","2345.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1666.92","53.3","","813.12","216.42","1444.50","81","969.5","2486.31","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3127.43","2345.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","969.50","31","","432.60","432.60","432.60","1 through 10","969.5","2486.31","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3127.43","2345.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1141.51","36.5","","148.37","54.89","631.39","94","969.5","2486.31","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3127.43","2345.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1197.81","38.3","","279.30","91.72","1116.77","266","969.5","2486.31","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3127.43","2345.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1341.67","42.9","","731.00","63.70","731.00","1 through 10","969.5","2486.31","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3127.43","2345.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1341.67","42.9","","384.74","384.74","384.74","1 through 10","969.5","2486.31","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3127.43","2345.57","WELLPOINT [1015]","HB AMC WELLPOINT","2307.42","73.78","","286.63","119.22","1107.45","105","969.5","2486.31","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3127.43","2345.57","AETNA [1001]","HB AMC AETNA HMO","2182.95","69.8","","675.31","184.75","1721.50","286","1634.39","2555.74","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3127.43","2345.57","AETNA [1001]","HB AMC AETNA PPO","2514.45","80.4","","1261.44","103.12","1514.10","21","1634.39","2555.74","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3127.43","2345.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2514.45","80.4","","1365.00","1365.00","1365.00","1 through 10","1634.39","2555.74","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3127.43","2345.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2555.74","81.72","","5157.68","5157.68","5157.68","1 through 10","1634.39","2555.74","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3127.43","2345.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2555.74","81.72","","431.26","71.26","1459.57","88","1634.39","2555.74","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.09","3312.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3510.79","79.5","","800.18","480.96","1887.97","195","1368.99","3510.79","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.09","3312.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2353.78","53.3","","813.12","216.42","1444.50","81","1368.99","3510.79","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.09","3312.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1368.99","31","","432.60","432.60","432.60","1 through 10","1368.99","3510.79","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.09","3312.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1611.87","36.5","","148.37","54.89","631.39","94","1368.99","3510.79","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.09","3312.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1691.36","38.3","","279.30","91.72","1116.77","266","1368.99","3510.79","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.09","3312.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1894.50","42.9","","731.00","63.70","731.00","1 through 10","1368.99","3510.79","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.09","3312.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1894.50","42.9","","384.74","384.74","384.74","1 through 10","1368.99","3510.79","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","4416.09","3312.07","WELLPOINT [1015]","HB AMC WELLPOINT","3258.19","73.78","","286.63","119.22","1107.45","105","1368.99","3510.79","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4416.09","3312.07","AETNA [1001]","HB AMC AETNA HMO","3082.43","69.8","","675.31","184.75","1721.50","286","2307.85","3608.83","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4416.09","3312.07","AETNA [1001]","HB AMC AETNA PPO","3550.54","80.4","","1261.44","103.12","1514.10","21","2307.85","3608.83","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4416.09","3312.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3550.54","80.4","","1365.00","1365.00","1365.00","1 through 10","2307.85","3608.83","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4416.09","3312.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3608.83","81.72","","5157.68","5157.68","5157.68","1 through 10","2307.85","3608.83","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4416.09","3312.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3608.83","81.72","","431.26","71.26","1459.57","88","2307.85","3608.83","percent of total billed charges",""
"PLATE HUMERUS 90MM 3H PROXIMAL","SUP-ITM-10276147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3057.97","79.5","","800.18","480.96","1887.97","195","1192.42","3057.97","percent of total billed charges",""
"PLATE HUMERUS 90MM 3H PROXIMAL","SUP-ITM-10276147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2050.18","53.3","","813.12","216.42","1444.50","81","1192.42","3057.97","percent of total billed charges",""
"PLATE HUMERUS 90MM 3H PROXIMAL","SUP-ITM-10276147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1192.42","31","","432.60","432.60","432.60","1 through 10","1192.42","3057.97","percent of total billed charges",""
"PLATE HUMERUS 90MM 3H PROXIMAL","SUP-ITM-10276147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1403.97","36.5","","148.37","54.89","631.39","94","1192.42","3057.97","percent of total billed charges",""
"PLATE HUMERUS 90MM 3H PROXIMAL","SUP-ITM-10276147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1473.21","38.3","","279.30","91.72","1116.77","266","1192.42","3057.97","percent of total billed charges",""
"PLATE HUMERUS 90MM 3H PROXIMAL","SUP-ITM-10276147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1650.15","42.9","","731.00","63.70","731.00","1 through 10","1192.42","3057.97","percent of total billed charges",""
"PLATE HUMERUS 90MM 3H PROXIMAL","SUP-ITM-10276147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1650.15","42.9","","384.74","384.74","384.74","1 through 10","1192.42","3057.97","percent of total billed charges",""
"PLATE HUMERUS 90MM 3H PROXIMAL","SUP-ITM-10276147","CDM","C1713","HCPCS","0278","RC","","","","both","","","3846.50","2884.87","WELLPOINT [1015]","HB AMC WELLPOINT","2837.95","73.78","","286.63","119.22","1107.45","105","1192.42","3057.97","percent of total billed charges",""
"PLATE HUMERUS 90MM 3H PROXIMAL","SUP-ITM-10276147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","AETNA [1001]","HB AMC AETNA HMO","2684.86","69.8","","675.31","184.75","1721.50","286","2010.18","3143.36","percent of total billed charges",""
"PLATE HUMERUS 90MM 3H PROXIMAL","SUP-ITM-10276147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","AETNA [1001]","HB AMC AETNA PPO","3092.59","80.4","","1261.44","103.12","1514.10","21","2010.18","3143.36","percent of total billed charges",""
"PLATE HUMERUS 90MM 3H PROXIMAL","SUP-ITM-10276147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3092.59","80.4","","1365.00","1365.00","1365.00","1 through 10","2010.18","3143.36","percent of total billed charges",""
"PLATE HUMERUS 90MM 3H PROXIMAL","SUP-ITM-10276147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3143.36","81.72","","5157.68","5157.68","5157.68","1 through 10","2010.18","3143.36","percent of total billed charges",""
"PLATE HUMERUS 90MM 3H PROXIMAL","SUP-ITM-10276147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3846.50","2884.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3143.36","81.72","","431.26","71.26","1459.57","88","2010.18","3143.36","percent of total billed charges",""
"PLATE INSERT MATRIXNEURO NEUROSURGERY MODULE ULTRA LOW PROFILE","SUP-ITM-10131718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.13","869.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","921.51","79.5","","800.18","480.96","1887.97","195","359.33","921.51","percent of total billed charges",""
"PLATE INSERT MATRIXNEURO NEUROSURGERY MODULE ULTRA LOW PROFILE","SUP-ITM-10131718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.13","869.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","617.82","53.3","","813.12","216.42","1444.50","81","359.33","921.51","percent of total billed charges",""
"PLATE INSERT MATRIXNEURO NEUROSURGERY MODULE ULTRA LOW PROFILE","SUP-ITM-10131718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.13","869.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","359.33","31","","432.60","432.60","432.60","1 through 10","359.33","921.51","percent of total billed charges",""
"PLATE INSERT MATRIXNEURO NEUROSURGERY MODULE ULTRA LOW PROFILE","SUP-ITM-10131718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.13","869.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","423.08","36.5","","148.37","54.89","631.39","94","359.33","921.51","percent of total billed charges",""
"PLATE INSERT MATRIXNEURO NEUROSURGERY MODULE ULTRA LOW PROFILE","SUP-ITM-10131718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.13","869.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","443.95","38.3","","279.30","91.72","1116.77","266","359.33","921.51","percent of total billed charges",""
"PLATE INSERT MATRIXNEURO NEUROSURGERY MODULE ULTRA LOW PROFILE","SUP-ITM-10131718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.13","869.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","497.27","42.9","","731.00","63.70","731.00","1 through 10","359.33","921.51","percent of total billed charges",""
"PLATE INSERT MATRIXNEURO NEUROSURGERY MODULE ULTRA LOW PROFILE","SUP-ITM-10131718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.13","869.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","497.27","42.9","","384.74","384.74","384.74","1 through 10","359.33","921.51","percent of total billed charges",""
"PLATE INSERT MATRIXNEURO NEUROSURGERY MODULE ULTRA LOW PROFILE","SUP-ITM-10131718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1159.13","869.35","WELLPOINT [1015]","HB AMC WELLPOINT","855.21","73.78","","286.63","119.22","1107.45","105","359.33","921.51","percent of total billed charges",""
"PLATE INSERT MATRIXNEURO NEUROSURGERY MODULE ULTRA LOW PROFILE","SUP-ITM-10131718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1159.13","869.35","AETNA [1001]","HB AMC AETNA HMO","809.07","69.8","","675.31","184.75","1721.50","286","605.76","947.24","percent of total billed charges",""
"PLATE INSERT MATRIXNEURO NEUROSURGERY MODULE ULTRA LOW PROFILE","SUP-ITM-10131718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1159.13","869.35","AETNA [1001]","HB AMC AETNA PPO","931.94","80.4","","1261.44","103.12","1514.10","21","605.76","947.24","percent of total billed charges",""
"PLATE INSERT MATRIXNEURO NEUROSURGERY MODULE ULTRA LOW PROFILE","SUP-ITM-10131718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1159.13","869.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","931.94","80.4","","1365.00","1365.00","1365.00","1 through 10","605.76","947.24","percent of total billed charges",""
"PLATE INSERT MATRIXNEURO NEUROSURGERY MODULE ULTRA LOW PROFILE","SUP-ITM-10131718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1159.13","869.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","947.24","81.72","","5157.68","5157.68","5157.68","1 through 10","605.76","947.24","percent of total billed charges",""
"PLATE INSERT MATRIXNEURO NEUROSURGERY MODULE ULTRA LOW PROFILE","SUP-ITM-10131718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1159.13","869.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","947.24","81.72","","431.26","71.26","1459.57","88","605.76","947.24","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/LONG/RIGHT","SUP-ITM-10096300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.54","2148.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2277.31","79.5","","800.18","480.96","1887.97","195","888.01","2277.31","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/LONG/RIGHT","SUP-ITM-10096300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.54","2148.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1526.80","53.3","","813.12","216.42","1444.50","81","888.01","2277.31","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/LONG/RIGHT","SUP-ITM-10096300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.54","2148.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","888.01","31","","432.60","432.60","432.60","1 through 10","888.01","2277.31","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/LONG/RIGHT","SUP-ITM-10096300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.54","2148.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1045.56","36.5","","148.37","54.89","631.39","94","888.01","2277.31","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/LONG/RIGHT","SUP-ITM-10096300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.54","2148.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1097.12","38.3","","279.30","91.72","1116.77","266","888.01","2277.31","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/LONG/RIGHT","SUP-ITM-10096300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.54","2148.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1228.89","42.9","","731.00","63.70","731.00","1 through 10","888.01","2277.31","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/LONG/RIGHT","SUP-ITM-10096300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.54","2148.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1228.89","42.9","","384.74","384.74","384.74","1 through 10","888.01","2277.31","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/LONG/RIGHT","SUP-ITM-10096300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2864.54","2148.40","WELLPOINT [1015]","HB AMC WELLPOINT","2113.46","73.78","","286.63","119.22","1107.45","105","888.01","2277.31","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/LONG/RIGHT","SUP-ITM-10096300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2864.54","2148.40","AETNA [1001]","HB AMC AETNA HMO","1999.45","69.8","","675.31","184.75","1721.50","286","1497.01","2340.9","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/LONG/RIGHT","SUP-ITM-10096300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2864.54","2148.40","AETNA [1001]","HB AMC AETNA PPO","2303.09","80.4","","1261.44","103.12","1514.10","21","1497.01","2340.9","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/LONG/RIGHT","SUP-ITM-10096300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2864.54","2148.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2303.09","80.4","","1365.00","1365.00","1365.00","1 through 10","1497.01","2340.9","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/LONG/RIGHT","SUP-ITM-10096300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2864.54","2148.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2340.90","81.72","","5157.68","5157.68","5157.68","1 through 10","1497.01","2340.9","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/LONG/RIGHT","SUP-ITM-10096300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2864.54","2148.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2340.90","81.72","","431.26","71.26","1459.57","88","1497.01","2340.9","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/SHORT/RIGHT","SUP-ITM-10096296","CDM","C1713","HCPCS","0278","RC","","","","both","","","2722.09","2041.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2164.06","79.5","","800.18","480.96","1887.97","195","843.85","2164.06","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/SHORT/RIGHT","SUP-ITM-10096296","CDM","C1713","HCPCS","0278","RC","","","","both","","","2722.09","2041.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1450.87","53.3","","813.12","216.42","1444.50","81","843.85","2164.06","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/SHORT/RIGHT","SUP-ITM-10096296","CDM","C1713","HCPCS","0278","RC","","","","both","","","2722.09","2041.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","843.85","31","","432.60","432.60","432.60","1 through 10","843.85","2164.06","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/SHORT/RIGHT","SUP-ITM-10096296","CDM","C1713","HCPCS","0278","RC","","","","both","","","2722.09","2041.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","993.56","36.5","","148.37","54.89","631.39","94","843.85","2164.06","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/SHORT/RIGHT","SUP-ITM-10096296","CDM","C1713","HCPCS","0278","RC","","","","both","","","2722.09","2041.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1042.56","38.3","","279.30","91.72","1116.77","266","843.85","2164.06","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/SHORT/RIGHT","SUP-ITM-10096296","CDM","C1713","HCPCS","0278","RC","","","","both","","","2722.09","2041.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1167.78","42.9","","731.00","63.70","731.00","1 through 10","843.85","2164.06","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/SHORT/RIGHT","SUP-ITM-10096296","CDM","C1713","HCPCS","0278","RC","","","","both","","","2722.09","2041.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1167.78","42.9","","384.74","384.74","384.74","1 through 10","843.85","2164.06","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/SHORT/RIGHT","SUP-ITM-10096296","CDM","C1713","HCPCS","0278","RC","","","","both","","","2722.09","2041.57","WELLPOINT [1015]","HB AMC WELLPOINT","2008.36","73.78","","286.63","119.22","1107.45","105","843.85","2164.06","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/SHORT/RIGHT","SUP-ITM-10096296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2722.09","2041.57","AETNA [1001]","HB AMC AETNA HMO","1900.02","69.8","","675.31","184.75","1721.50","286","1422.56","2224.49","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/SHORT/RIGHT","SUP-ITM-10096296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2722.09","2041.57","AETNA [1001]","HB AMC AETNA PPO","2188.56","80.4","","1261.44","103.12","1514.10","21","1422.56","2224.49","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/SHORT/RIGHT","SUP-ITM-10096296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2722.09","2041.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2188.56","80.4","","1365.00","1365.00","1365.00","1 through 10","1422.56","2224.49","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/SHORT/RIGHT","SUP-ITM-10096296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2722.09","2041.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2224.49","81.72","","5157.68","5157.68","5157.68","1 through 10","1422.56","2224.49","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/SHORT/RIGHT","SUP-ITM-10096296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2722.09","2041.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2224.49","81.72","","431.26","71.26","1459.57","88","1422.56","2224.49","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/STANDARD/RIGHT","SUP-ITM-10096298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2793.32","2094.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2220.69","79.5","","800.18","480.96","1887.97","195","865.93","2220.69","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/STANDARD/RIGHT","SUP-ITM-10096298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2793.32","2094.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1488.84","53.3","","813.12","216.42","1444.50","81","865.93","2220.69","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/STANDARD/RIGHT","SUP-ITM-10096298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2793.32","2094.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","865.93","31","","432.60","432.60","432.60","1 through 10","865.93","2220.69","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/STANDARD/RIGHT","SUP-ITM-10096298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2793.32","2094.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1019.56","36.5","","148.37","54.89","631.39","94","865.93","2220.69","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/STANDARD/RIGHT","SUP-ITM-10096298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2793.32","2094.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1069.84","38.3","","279.30","91.72","1116.77","266","865.93","2220.69","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/STANDARD/RIGHT","SUP-ITM-10096298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2793.32","2094.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1198.33","42.9","","731.00","63.70","731.00","1 through 10","865.93","2220.69","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/STANDARD/RIGHT","SUP-ITM-10096298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2793.32","2094.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1198.33","42.9","","384.74","384.74","384.74","1 through 10","865.93","2220.69","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/STANDARD/RIGHT","SUP-ITM-10096298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2793.32","2094.99","WELLPOINT [1015]","HB AMC WELLPOINT","2060.91","73.78","","286.63","119.22","1107.45","105","865.93","2220.69","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/STANDARD/RIGHT","SUP-ITM-10096298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2793.32","2094.99","AETNA [1001]","HB AMC AETNA HMO","1949.74","69.8","","675.31","184.75","1721.50","286","1459.79","2282.7","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/STANDARD/RIGHT","SUP-ITM-10096298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2793.32","2094.99","AETNA [1001]","HB AMC AETNA PPO","2245.83","80.4","","1261.44","103.12","1514.10","21","1459.79","2282.7","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/STANDARD/RIGHT","SUP-ITM-10096298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2793.32","2094.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2245.83","80.4","","1365.00","1365.00","1365.00","1 through 10","1459.79","2282.7","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/STANDARD/RIGHT","SUP-ITM-10096298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2793.32","2094.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2282.70","81.72","","5157.68","5157.68","5157.68","1 through 10","1459.79","2282.7","percent of total billed charges",""
"PLATE L-FUSION TI VA-LCP 2.4/2.7MM/STANDARD/RIGHT","SUP-ITM-10096298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2793.32","2094.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2282.70","81.72","","431.26","71.26","1459.57","88","1459.79","2282.7","percent of total billed charges",""
"PLATE LABORATORY LARGE DOUBLE ANGLE","SUP-ITM-10212020","CDM","C1713","HCPCS","0278","RC","","","","both","","","9990.00","7492.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7942.05","79.5","","800.18","480.96","1887.97","195","3096.9","7942.05","percent of total billed charges",""
"PLATE LABORATORY LARGE DOUBLE ANGLE","SUP-ITM-10212020","CDM","C1713","HCPCS","0278","RC","","","","both","","","9990.00","7492.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5324.67","53.3","","813.12","216.42","1444.50","81","3096.9","7942.05","percent of total billed charges",""
"PLATE LABORATORY LARGE DOUBLE ANGLE","SUP-ITM-10212020","CDM","C1713","HCPCS","0278","RC","","","","both","","","9990.00","7492.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3096.90","31","","432.60","432.60","432.60","1 through 10","3096.9","7942.05","percent of total billed charges",""
"PLATE LABORATORY LARGE DOUBLE ANGLE","SUP-ITM-10212020","CDM","C1713","HCPCS","0278","RC","","","","both","","","9990.00","7492.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3646.35","36.5","","148.37","54.89","631.39","94","3096.9","7942.05","percent of total billed charges",""
"PLATE LABORATORY LARGE DOUBLE ANGLE","SUP-ITM-10212020","CDM","C1713","HCPCS","0278","RC","","","","both","","","9990.00","7492.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3826.17","38.3","","279.30","91.72","1116.77","266","3096.9","7942.05","percent of total billed charges",""
"PLATE LABORATORY LARGE DOUBLE ANGLE","SUP-ITM-10212020","CDM","C1713","HCPCS","0278","RC","","","","both","","","9990.00","7492.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4285.71","42.9","","731.00","63.70","731.00","1 through 10","3096.9","7942.05","percent of total billed charges",""
"PLATE LABORATORY LARGE DOUBLE ANGLE","SUP-ITM-10212020","CDM","C1713","HCPCS","0278","RC","","","","both","","","9990.00","7492.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4285.71","42.9","","384.74","384.74","384.74","1 through 10","3096.9","7942.05","percent of total billed charges",""
"PLATE LABORATORY LARGE DOUBLE ANGLE","SUP-ITM-10212020","CDM","C1713","HCPCS","0278","RC","","","","both","","","9990.00","7492.50","WELLPOINT [1015]","HB AMC WELLPOINT","7370.62","73.78","","286.63","119.22","1107.45","105","3096.9","7942.05","percent of total billed charges",""
"PLATE LABORATORY LARGE DOUBLE ANGLE","SUP-ITM-10212020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9990.00","7492.50","AETNA [1001]","HB AMC AETNA HMO","6973.02","69.8","","675.31","184.75","1721.50","286","5220.77","8163.83","percent of total billed charges",""
"PLATE LABORATORY LARGE DOUBLE ANGLE","SUP-ITM-10212020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9990.00","7492.50","AETNA [1001]","HB AMC AETNA PPO","8031.96","80.4","","1261.44","103.12","1514.10","21","5220.77","8163.83","percent of total billed charges",""
"PLATE LABORATORY LARGE DOUBLE ANGLE","SUP-ITM-10212020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9990.00","7492.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8031.96","80.4","","1365.00","1365.00","1365.00","1 through 10","5220.77","8163.83","percent of total billed charges",""
"PLATE LABORATORY LARGE DOUBLE ANGLE","SUP-ITM-10212020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9990.00","7492.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8163.83","81.72","","5157.68","5157.68","5157.68","1 through 10","5220.77","8163.83","percent of total billed charges",""
"PLATE LABORATORY LARGE DOUBLE ANGLE","SUP-ITM-10212020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9990.00","7492.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8163.83","81.72","","431.26","71.26","1459.57","88","5220.77","8163.83","percent of total billed charges",""
"PLATE MANDIBLE 1MM 2X2 HOLE PREBENT TENSION BAND TITANIUM MATRIXMANDIBLE LEFT","SUP-ITM-10081081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1066.10","799.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","847.55","79.5","","800.18","480.96","1887.97","195","330.49","847.55","percent of total billed charges",""
"PLATE MANDIBLE 1MM 2X2 HOLE PREBENT TENSION BAND TITANIUM MATRIXMANDIBLE LEFT","SUP-ITM-10081081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1066.10","799.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","568.23","53.3","","813.12","216.42","1444.50","81","330.49","847.55","percent of total billed charges",""
"PLATE MANDIBLE 1MM 2X2 HOLE PREBENT TENSION BAND TITANIUM MATRIXMANDIBLE LEFT","SUP-ITM-10081081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1066.10","799.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","330.49","31","","432.60","432.60","432.60","1 through 10","330.49","847.55","percent of total billed charges",""
"PLATE MANDIBLE 1MM 2X2 HOLE PREBENT TENSION BAND TITANIUM MATRIXMANDIBLE LEFT","SUP-ITM-10081081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1066.10","799.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","389.13","36.5","","148.37","54.89","631.39","94","330.49","847.55","percent of total billed charges",""
"PLATE MANDIBLE 1MM 2X2 HOLE PREBENT TENSION BAND TITANIUM MATRIXMANDIBLE LEFT","SUP-ITM-10081081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1066.10","799.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","408.32","38.3","","279.30","91.72","1116.77","266","330.49","847.55","percent of total billed charges",""
"PLATE MANDIBLE 1MM 2X2 HOLE PREBENT TENSION BAND TITANIUM MATRIXMANDIBLE LEFT","SUP-ITM-10081081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1066.10","799.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","457.36","42.9","","731.00","63.70","731.00","1 through 10","330.49","847.55","percent of total billed charges",""
"PLATE MANDIBLE 1MM 2X2 HOLE PREBENT TENSION BAND TITANIUM MATRIXMANDIBLE LEFT","SUP-ITM-10081081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1066.10","799.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","457.36","42.9","","384.74","384.74","384.74","1 through 10","330.49","847.55","percent of total billed charges",""
"PLATE MANDIBLE 1MM 2X2 HOLE PREBENT TENSION BAND TITANIUM MATRIXMANDIBLE LEFT","SUP-ITM-10081081","CDM","C1713","HCPCS","0278","RC","","","","both","","","1066.10","799.57","WELLPOINT [1015]","HB AMC WELLPOINT","786.57","73.78","","286.63","119.22","1107.45","105","330.49","847.55","percent of total billed charges",""
"PLATE MANDIBLE 1MM 2X2 HOLE PREBENT TENSION BAND TITANIUM MATRIXMANDIBLE LEFT","SUP-ITM-10081081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1066.10","799.57","AETNA [1001]","HB AMC AETNA HMO","744.14","69.8","","675.31","184.75","1721.50","286","557.14","871.22","percent of total billed charges",""
"PLATE MANDIBLE 1MM 2X2 HOLE PREBENT TENSION BAND TITANIUM MATRIXMANDIBLE LEFT","SUP-ITM-10081081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1066.10","799.57","AETNA [1001]","HB AMC AETNA PPO","857.14","80.4","","1261.44","103.12","1514.10","21","557.14","871.22","percent of total billed charges",""
"PLATE MANDIBLE 1MM 2X2 HOLE PREBENT TENSION BAND TITANIUM MATRIXMANDIBLE LEFT","SUP-ITM-10081081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1066.10","799.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","857.14","80.4","","1365.00","1365.00","1365.00","1 through 10","557.14","871.22","percent of total billed charges",""
"PLATE MANDIBLE 1MM 2X2 HOLE PREBENT TENSION BAND TITANIUM MATRIXMANDIBLE LEFT","SUP-ITM-10081081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1066.10","799.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","871.22","81.72","","5157.68","5157.68","5157.68","1 through 10","557.14","871.22","percent of total billed charges",""
"PLATE MANDIBLE 1MM 2X2 HOLE PREBENT TENSION BAND TITANIUM MATRIXMANDIBLE LEFT","SUP-ITM-10081081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1066.10","799.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","871.22","81.72","","431.26","71.26","1459.57","88","557.14","871.22","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081090","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.63","856.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","907.60","79.5","","800.18","480.96","1887.97","195","353.91","907.6","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081090","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.63","856.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","608.49","53.3","","813.12","216.42","1444.50","81","353.91","907.6","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081090","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.63","856.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","353.91","31","","432.60","432.60","432.60","1 through 10","353.91","907.6","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081090","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.63","856.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","416.69","36.5","","148.37","54.89","631.39","94","353.91","907.6","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081090","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.63","856.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","437.24","38.3","","279.30","91.72","1116.77","266","353.91","907.6","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081090","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.63","856.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","489.76","42.9","","731.00","63.70","731.00","1 through 10","353.91","907.6","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081090","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.63","856.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","489.76","42.9","","384.74","384.74","384.74","1 through 10","353.91","907.6","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081090","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.63","856.22","WELLPOINT [1015]","HB AMC WELLPOINT","842.29","73.78","","286.63","119.22","1107.45","105","353.91","907.6","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1141.63","856.22","AETNA [1001]","HB AMC AETNA HMO","796.86","69.8","","675.31","184.75","1721.50","286","596.62","932.94","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1141.63","856.22","AETNA [1001]","HB AMC AETNA PPO","917.87","80.4","","1261.44","103.12","1514.10","21","596.62","932.94","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1141.63","856.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","917.87","80.4","","1365.00","1365.00","1365.00","1 through 10","596.62","932.94","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1141.63","856.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","932.94","81.72","","5157.68","5157.68","5157.68","1 through 10","596.62","932.94","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1141.63","856.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","932.94","81.72","","431.26","71.26","1459.57","88","596.62","932.94","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE NARROW MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081125","CDM","C1713","HCPCS","0278","RC","","","","both","","","912.14","684.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","725.15","79.5","","800.18","480.96","1887.97","195","282.76","725.15","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE NARROW MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081125","CDM","C1713","HCPCS","0278","RC","","","","both","","","912.14","684.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","486.17","53.3","","813.12","216.42","1444.50","81","282.76","725.15","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE NARROW MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081125","CDM","C1713","HCPCS","0278","RC","","","","both","","","912.14","684.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","282.76","31","","432.60","432.60","432.60","1 through 10","282.76","725.15","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE NARROW MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081125","CDM","C1713","HCPCS","0278","RC","","","","both","","","912.14","684.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","332.93","36.5","","148.37","54.89","631.39","94","282.76","725.15","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE NARROW MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081125","CDM","C1713","HCPCS","0278","RC","","","","both","","","912.14","684.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","349.35","38.3","","279.30","91.72","1116.77","266","282.76","725.15","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE NARROW MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081125","CDM","C1713","HCPCS","0278","RC","","","","both","","","912.14","684.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.31","42.9","","731.00","63.70","731.00","1 through 10","282.76","725.15","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE NARROW MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081125","CDM","C1713","HCPCS","0278","RC","","","","both","","","912.14","684.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.31","42.9","","384.74","384.74","384.74","1 through 10","282.76","725.15","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE NARROW MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081125","CDM","C1713","HCPCS","0278","RC","","","","both","","","912.14","684.10","WELLPOINT [1015]","HB AMC WELLPOINT","672.98","73.78","","286.63","119.22","1107.45","105","282.76","725.15","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE NARROW MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","912.14","684.10","AETNA [1001]","HB AMC AETNA HMO","636.67","69.8","","675.31","184.75","1721.50","286","476.68","745.4","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE NARROW MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","912.14","684.10","AETNA [1001]","HB AMC AETNA PPO","733.36","80.4","","1261.44","103.12","1514.10","21","476.68","745.4","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE NARROW MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","912.14","684.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","733.36","80.4","","1365.00","1365.00","1365.00","1 through 10","476.68","745.4","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE NARROW MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","912.14","684.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","745.40","81.72","","5157.68","5157.68","5157.68","1 through 10","476.68","745.4","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X2 HOLE NARROW MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","912.14","684.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","745.40","81.72","","431.26","71.26","1459.57","88","476.68","745.4","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081089","CDM","C1713","HCPCS","0278","RC","","","","both","","","793.03","594.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","630.46","79.5","","800.18","480.96","1887.97","195","245.84","630.46","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081089","CDM","C1713","HCPCS","0278","RC","","","","both","","","793.03","594.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","422.68","53.3","","813.12","216.42","1444.50","81","245.84","630.46","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081089","CDM","C1713","HCPCS","0278","RC","","","","both","","","793.03","594.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","245.84","31","","432.60","432.60","432.60","1 through 10","245.84","630.46","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081089","CDM","C1713","HCPCS","0278","RC","","","","both","","","793.03","594.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","289.46","36.5","","148.37","54.89","631.39","94","245.84","630.46","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081089","CDM","C1713","HCPCS","0278","RC","","","","both","","","793.03","594.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","303.73","38.3","","279.30","91.72","1116.77","266","245.84","630.46","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081089","CDM","C1713","HCPCS","0278","RC","","","","both","","","793.03","594.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.21","42.9","","731.00","63.70","731.00","1 through 10","245.84","630.46","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081089","CDM","C1713","HCPCS","0278","RC","","","","both","","","793.03","594.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.21","42.9","","384.74","384.74","384.74","1 through 10","245.84","630.46","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081089","CDM","C1713","HCPCS","0278","RC","","","","both","","","793.03","594.77","WELLPOINT [1015]","HB AMC WELLPOINT","585.10","73.78","","286.63","119.22","1107.45","105","245.84","630.46","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","793.03","594.77","AETNA [1001]","HB AMC AETNA HMO","553.53","69.8","","675.31","184.75","1721.50","286","414.44","648.06","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","793.03","594.77","AETNA [1001]","HB AMC AETNA PPO","637.60","80.4","","1261.44","103.12","1514.10","21","414.44","648.06","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","793.03","594.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","637.60","80.4","","1365.00","1365.00","1365.00","1 through 10","414.44","648.06","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","793.03","594.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","648.06","81.72","","5157.68","5157.68","5157.68","1 through 10","414.44","648.06","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 2X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","793.03","594.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","648.06","81.72","","431.26","71.26","1459.57","88","414.44","648.06","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081088","CDM","C1713","HCPCS","0278","RC","","","","both","","","851.13","638.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","676.65","79.5","","800.18","480.96","1887.97","195","263.85","676.65","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081088","CDM","C1713","HCPCS","0278","RC","","","","both","","","851.13","638.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","453.65","53.3","","813.12","216.42","1444.50","81","263.85","676.65","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081088","CDM","C1713","HCPCS","0278","RC","","","","both","","","851.13","638.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","263.85","31","","432.60","432.60","432.60","1 through 10","263.85","676.65","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081088","CDM","C1713","HCPCS","0278","RC","","","","both","","","851.13","638.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","310.66","36.5","","148.37","54.89","631.39","94","263.85","676.65","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081088","CDM","C1713","HCPCS","0278","RC","","","","both","","","851.13","638.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","325.98","38.3","","279.30","91.72","1116.77","266","263.85","676.65","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081088","CDM","C1713","HCPCS","0278","RC","","","","both","","","851.13","638.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","365.13","42.9","","731.00","63.70","731.00","1 through 10","263.85","676.65","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081088","CDM","C1713","HCPCS","0278","RC","","","","both","","","851.13","638.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","365.13","42.9","","384.74","384.74","384.74","1 through 10","263.85","676.65","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081088","CDM","C1713","HCPCS","0278","RC","","","","both","","","851.13","638.35","WELLPOINT [1015]","HB AMC WELLPOINT","627.96","73.78","","286.63","119.22","1107.45","105","263.85","676.65","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","851.13","638.35","AETNA [1001]","HB AMC AETNA HMO","594.09","69.8","","675.31","184.75","1721.50","286","444.8","695.54","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","851.13","638.35","AETNA [1001]","HB AMC AETNA PPO","684.31","80.4","","1261.44","103.12","1514.10","21","444.8","695.54","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","851.13","638.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","684.31","80.4","","1365.00","1365.00","1365.00","1 through 10","444.8","695.54","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","851.13","638.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","695.54","81.72","","5157.68","5157.68","5157.68","1 through 10","444.8","695.54","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE BROAD MALLEABLE TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","851.13","638.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","695.54","81.72","","431.26","71.26","1459.57","88","444.8","695.54","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE NARROW TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081122","CDM","C1713","HCPCS","0278","RC","","","","both","","","996.38","747.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","792.12","79.5","","800.18","480.96","1887.97","195","308.88","792.12","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE NARROW TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081122","CDM","C1713","HCPCS","0278","RC","","","","both","","","996.38","747.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","531.07","53.3","","813.12","216.42","1444.50","81","308.88","792.12","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE NARROW TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081122","CDM","C1713","HCPCS","0278","RC","","","","both","","","996.38","747.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","308.88","31","","432.60","432.60","432.60","1 through 10","308.88","792.12","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE NARROW TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081122","CDM","C1713","HCPCS","0278","RC","","","","both","","","996.38","747.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","363.68","36.5","","148.37","54.89","631.39","94","308.88","792.12","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE NARROW TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081122","CDM","C1713","HCPCS","0278","RC","","","","both","","","996.38","747.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","381.61","38.3","","279.30","91.72","1116.77","266","308.88","792.12","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE NARROW TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081122","CDM","C1713","HCPCS","0278","RC","","","","both","","","996.38","747.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.45","42.9","","731.00","63.70","731.00","1 through 10","308.88","792.12","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE NARROW TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081122","CDM","C1713","HCPCS","0278","RC","","","","both","","","996.38","747.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","427.45","42.9","","384.74","384.74","384.74","1 through 10","308.88","792.12","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE NARROW TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081122","CDM","C1713","HCPCS","0278","RC","","","","both","","","996.38","747.28","WELLPOINT [1015]","HB AMC WELLPOINT","735.13","73.78","","286.63","119.22","1107.45","105","308.88","792.12","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE NARROW TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","996.38","747.28","AETNA [1001]","HB AMC AETNA HMO","695.47","69.8","","675.31","184.75","1721.50","286","520.71","814.24","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE NARROW TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","996.38","747.28","AETNA [1001]","HB AMC AETNA PPO","801.09","80.4","","1261.44","103.12","1514.10","21","520.71","814.24","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE NARROW TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","996.38","747.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","801.09","80.4","","1365.00","1365.00","1365.00","1 through 10","520.71","814.24","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE NARROW TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","996.38","747.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","814.24","81.72","","5157.68","5157.68","5157.68","1 through 10","520.71","814.24","percent of total billed charges",""
"PLATE MANDIBLE 1MM MINI 3X3 HOLE NARROW TENSION BAND TITANIUM MATRIXMANDIBLE","SUP-ITM-10081122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","996.38","747.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","814.24","81.72","","431.26","71.26","1459.57","88","520.71","814.24","percent of total billed charges",""
"PLATE MANDIBLE 2.4X35MM 4 HOLE CRANIOMAXILLOFACIAL TITANIUM LC DCP CRESCENT","SUP-ITM-10004318","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.22","910.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","965.30","79.5","","800.18","480.96","1887.97","195","376.41","965.3","percent of total billed charges",""
"PLATE MANDIBLE 2.4X35MM 4 HOLE CRANIOMAXILLOFACIAL TITANIUM LC DCP CRESCENT","SUP-ITM-10004318","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.22","910.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","647.18","53.3","","813.12","216.42","1444.50","81","376.41","965.3","percent of total billed charges",""
"PLATE MANDIBLE 2.4X35MM 4 HOLE CRANIOMAXILLOFACIAL TITANIUM LC DCP CRESCENT","SUP-ITM-10004318","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.22","910.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","376.41","31","","432.60","432.60","432.60","1 through 10","376.41","965.3","percent of total billed charges",""
"PLATE MANDIBLE 2.4X35MM 4 HOLE CRANIOMAXILLOFACIAL TITANIUM LC DCP CRESCENT","SUP-ITM-10004318","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.22","910.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","443.19","36.5","","148.37","54.89","631.39","94","376.41","965.3","percent of total billed charges",""
"PLATE MANDIBLE 2.4X35MM 4 HOLE CRANIOMAXILLOFACIAL TITANIUM LC DCP CRESCENT","SUP-ITM-10004318","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.22","910.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","465.05","38.3","","279.30","91.72","1116.77","266","376.41","965.3","percent of total billed charges",""
"PLATE MANDIBLE 2.4X35MM 4 HOLE CRANIOMAXILLOFACIAL TITANIUM LC DCP CRESCENT","SUP-ITM-10004318","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.22","910.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.90","42.9","","731.00","63.70","731.00","1 through 10","376.41","965.3","percent of total billed charges",""
"PLATE MANDIBLE 2.4X35MM 4 HOLE CRANIOMAXILLOFACIAL TITANIUM LC DCP CRESCENT","SUP-ITM-10004318","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.22","910.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.90","42.9","","384.74","384.74","384.74","1 through 10","376.41","965.3","percent of total billed charges",""
"PLATE MANDIBLE 2.4X35MM 4 HOLE CRANIOMAXILLOFACIAL TITANIUM LC DCP CRESCENT","SUP-ITM-10004318","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.22","910.66","WELLPOINT [1015]","HB AMC WELLPOINT","895.85","73.78","","286.63","119.22","1107.45","105","376.41","965.3","percent of total billed charges",""
"PLATE MANDIBLE 2.4X35MM 4 HOLE CRANIOMAXILLOFACIAL TITANIUM LC DCP CRESCENT","SUP-ITM-10004318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1214.22","910.66","AETNA [1001]","HB AMC AETNA HMO","847.53","69.8","","675.31","184.75","1721.50","286","634.55","992.26","percent of total billed charges",""
"PLATE MANDIBLE 2.4X35MM 4 HOLE CRANIOMAXILLOFACIAL TITANIUM LC DCP CRESCENT","SUP-ITM-10004318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1214.22","910.66","AETNA [1001]","HB AMC AETNA PPO","976.23","80.4","","1261.44","103.12","1514.10","21","634.55","992.26","percent of total billed charges",""
"PLATE MANDIBLE 2.4X35MM 4 HOLE CRANIOMAXILLOFACIAL TITANIUM LC DCP CRESCENT","SUP-ITM-10004318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1214.22","910.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","976.23","80.4","","1365.00","1365.00","1365.00","1 through 10","634.55","992.26","percent of total billed charges",""
"PLATE MANDIBLE 2.4X35MM 4 HOLE CRANIOMAXILLOFACIAL TITANIUM LC DCP CRESCENT","SUP-ITM-10004318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1214.22","910.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","992.26","81.72","","5157.68","5157.68","5157.68","1 through 10","634.55","992.26","percent of total billed charges",""
"PLATE MANDIBLE 2.4X35MM 4 HOLE CRANIOMAXILLOFACIAL TITANIUM LC DCP CRESCENT","SUP-ITM-10004318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1214.22","910.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","992.26","81.72","","431.26","71.26","1459.57","88","634.55","992.26","percent of total billed charges",""
"PLATE MANDIBLE 2MM 20 HOLE MATRIX TITANIUM","SUP-ITM-10168168","CDM","C1713","HCPCS","0278","RC","","","","both","","","8987.50","6740.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7145.06","79.5","","800.18","480.96","1887.97","195","2786.13","7145.06","percent of total billed charges",""
"PLATE MANDIBLE 2MM 20 HOLE MATRIX TITANIUM","SUP-ITM-10168168","CDM","C1713","HCPCS","0278","RC","","","","both","","","8987.50","6740.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4790.34","53.3","","813.12","216.42","1444.50","81","2786.13","7145.06","percent of total billed charges",""
"PLATE MANDIBLE 2MM 20 HOLE MATRIX TITANIUM","SUP-ITM-10168168","CDM","C1713","HCPCS","0278","RC","","","","both","","","8987.50","6740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2786.13","31","","432.60","432.60","432.60","1 through 10","2786.13","7145.06","percent of total billed charges",""
"PLATE MANDIBLE 2MM 20 HOLE MATRIX TITANIUM","SUP-ITM-10168168","CDM","C1713","HCPCS","0278","RC","","","","both","","","8987.50","6740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3280.44","36.5","","148.37","54.89","631.39","94","2786.13","7145.06","percent of total billed charges",""
"PLATE MANDIBLE 2MM 20 HOLE MATRIX TITANIUM","SUP-ITM-10168168","CDM","C1713","HCPCS","0278","RC","","","","both","","","8987.50","6740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3442.21","38.3","","279.30","91.72","1116.77","266","2786.13","7145.06","percent of total billed charges",""
"PLATE MANDIBLE 2MM 20 HOLE MATRIX TITANIUM","SUP-ITM-10168168","CDM","C1713","HCPCS","0278","RC","","","","both","","","8987.50","6740.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3855.64","42.9","","731.00","63.70","731.00","1 through 10","2786.13","7145.06","percent of total billed charges",""
"PLATE MANDIBLE 2MM 20 HOLE MATRIX TITANIUM","SUP-ITM-10168168","CDM","C1713","HCPCS","0278","RC","","","","both","","","8987.50","6740.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3855.64","42.9","","384.74","384.74","384.74","1 through 10","2786.13","7145.06","percent of total billed charges",""
"PLATE MANDIBLE 2MM 20 HOLE MATRIX TITANIUM","SUP-ITM-10168168","CDM","C1713","HCPCS","0278","RC","","","","both","","","8987.50","6740.62","WELLPOINT [1015]","HB AMC WELLPOINT","6630.98","73.78","","286.63","119.22","1107.45","105","2786.13","7145.06","percent of total billed charges",""
"PLATE MANDIBLE 2MM 20 HOLE MATRIX TITANIUM","SUP-ITM-10168168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8987.50","6740.62","AETNA [1001]","HB AMC AETNA HMO","6273.28","69.8","","675.31","184.75","1721.50","286","4696.87","7344.59","percent of total billed charges",""
"PLATE MANDIBLE 2MM 20 HOLE MATRIX TITANIUM","SUP-ITM-10168168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8987.50","6740.62","AETNA [1001]","HB AMC AETNA PPO","7225.95","80.4","","1261.44","103.12","1514.10","21","4696.87","7344.59","percent of total billed charges",""
"PLATE MANDIBLE 2MM 20 HOLE MATRIX TITANIUM","SUP-ITM-10168168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8987.50","6740.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7225.95","80.4","","1365.00","1365.00","1365.00","1 through 10","4696.87","7344.59","percent of total billed charges",""
"PLATE MANDIBLE 2MM 20 HOLE MATRIX TITANIUM","SUP-ITM-10168168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8987.50","6740.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7344.59","81.72","","5157.68","5157.68","5157.68","1 through 10","4696.87","7344.59","percent of total billed charges",""
"PLATE MANDIBLE 2MM 20 HOLE MATRIX TITANIUM","SUP-ITM-10168168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8987.50","6740.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7344.59","81.72","","431.26","71.26","1459.57","88","4696.87","7344.59","percent of total billed charges",""
"PLATE MANDIBLE 2MM 4X4 HOLE CRANIOMAXILLOFACIAL DCP TITANIUM ANGLE","SUP-ITM-10004289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.82","806.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","854.48","79.5","","800.18","480.96","1887.97","195","333.19","854.48","percent of total billed charges",""
"PLATE MANDIBLE 2MM 4X4 HOLE CRANIOMAXILLOFACIAL DCP TITANIUM ANGLE","SUP-ITM-10004289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.82","806.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","572.88","53.3","","813.12","216.42","1444.50","81","333.19","854.48","percent of total billed charges",""
"PLATE MANDIBLE 2MM 4X4 HOLE CRANIOMAXILLOFACIAL DCP TITANIUM ANGLE","SUP-ITM-10004289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.82","806.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","333.19","31","","432.60","432.60","432.60","1 through 10","333.19","854.48","percent of total billed charges",""
"PLATE MANDIBLE 2MM 4X4 HOLE CRANIOMAXILLOFACIAL DCP TITANIUM ANGLE","SUP-ITM-10004289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.82","806.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","392.31","36.5","","148.37","54.89","631.39","94","333.19","854.48","percent of total billed charges",""
"PLATE MANDIBLE 2MM 4X4 HOLE CRANIOMAXILLOFACIAL DCP TITANIUM ANGLE","SUP-ITM-10004289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.82","806.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","411.66","38.3","","279.30","91.72","1116.77","266","333.19","854.48","percent of total billed charges",""
"PLATE MANDIBLE 2MM 4X4 HOLE CRANIOMAXILLOFACIAL DCP TITANIUM ANGLE","SUP-ITM-10004289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.82","806.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","461.10","42.9","","731.00","63.70","731.00","1 through 10","333.19","854.48","percent of total billed charges",""
"PLATE MANDIBLE 2MM 4X4 HOLE CRANIOMAXILLOFACIAL DCP TITANIUM ANGLE","SUP-ITM-10004289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.82","806.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","461.10","42.9","","384.74","384.74","384.74","1 through 10","333.19","854.48","percent of total billed charges",""
"PLATE MANDIBLE 2MM 4X4 HOLE CRANIOMAXILLOFACIAL DCP TITANIUM ANGLE","SUP-ITM-10004289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.82","806.11","WELLPOINT [1015]","HB AMC WELLPOINT","793.00","73.78","","286.63","119.22","1107.45","105","333.19","854.48","percent of total billed charges",""
"PLATE MANDIBLE 2MM 4X4 HOLE CRANIOMAXILLOFACIAL DCP TITANIUM ANGLE","SUP-ITM-10004289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1074.82","806.11","AETNA [1001]","HB AMC AETNA HMO","750.22","69.8","","675.31","184.75","1721.50","286","561.7","878.34","percent of total billed charges",""
"PLATE MANDIBLE 2MM 4X4 HOLE CRANIOMAXILLOFACIAL DCP TITANIUM ANGLE","SUP-ITM-10004289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1074.82","806.11","AETNA [1001]","HB AMC AETNA PPO","864.16","80.4","","1261.44","103.12","1514.10","21","561.7","878.34","percent of total billed charges",""
"PLATE MANDIBLE 2MM 4X4 HOLE CRANIOMAXILLOFACIAL DCP TITANIUM ANGLE","SUP-ITM-10004289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1074.82","806.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","864.16","80.4","","1365.00","1365.00","1365.00","1 through 10","561.7","878.34","percent of total billed charges",""
"PLATE MANDIBLE 2MM 4X4 HOLE CRANIOMAXILLOFACIAL DCP TITANIUM ANGLE","SUP-ITM-10004289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1074.82","806.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","878.34","81.72","","5157.68","5157.68","5157.68","1 through 10","561.7","878.34","percent of total billed charges",""
"PLATE MANDIBLE 2MM 4X4 HOLE CRANIOMAXILLOFACIAL DCP TITANIUM ANGLE","SUP-ITM-10004289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1074.82","806.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","878.34","81.72","","431.26","71.26","1459.57","88","561.7","878.34","percent of total billed charges",""
"PLATE MANDIBLE 2MM RECONSTRUCTION TI PT SPECIFIC ANGLE CUSTOM","SUP-ITM-10159066","CDM","C1713","HCPCS","0278","RC","","","","both","","","10883.35","8162.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8652.26","79.5","","800.18","480.96","1887.97","195","3373.84","8652.26","percent of total billed charges",""
"PLATE MANDIBLE 2MM RECONSTRUCTION TI PT SPECIFIC ANGLE CUSTOM","SUP-ITM-10159066","CDM","C1713","HCPCS","0278","RC","","","","both","","","10883.35","8162.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5800.83","53.3","","813.12","216.42","1444.50","81","3373.84","8652.26","percent of total billed charges",""
"PLATE MANDIBLE 2MM RECONSTRUCTION TI PT SPECIFIC ANGLE CUSTOM","SUP-ITM-10159066","CDM","C1713","HCPCS","0278","RC","","","","both","","","10883.35","8162.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3373.84","31","","432.60","432.60","432.60","1 through 10","3373.84","8652.26","percent of total billed charges",""
"PLATE MANDIBLE 2MM RECONSTRUCTION TI PT SPECIFIC ANGLE CUSTOM","SUP-ITM-10159066","CDM","C1713","HCPCS","0278","RC","","","","both","","","10883.35","8162.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3972.42","36.5","","148.37","54.89","631.39","94","3373.84","8652.26","percent of total billed charges",""
"PLATE MANDIBLE 2MM RECONSTRUCTION TI PT SPECIFIC ANGLE CUSTOM","SUP-ITM-10159066","CDM","C1713","HCPCS","0278","RC","","","","both","","","10883.35","8162.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4168.32","38.3","","279.30","91.72","1116.77","266","3373.84","8652.26","percent of total billed charges",""
"PLATE MANDIBLE 2MM RECONSTRUCTION TI PT SPECIFIC ANGLE CUSTOM","SUP-ITM-10159066","CDM","C1713","HCPCS","0278","RC","","","","both","","","10883.35","8162.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4668.96","42.9","","731.00","63.70","731.00","1 through 10","3373.84","8652.26","percent of total billed charges",""
"PLATE MANDIBLE 2MM RECONSTRUCTION TI PT SPECIFIC ANGLE CUSTOM","SUP-ITM-10159066","CDM","C1713","HCPCS","0278","RC","","","","both","","","10883.35","8162.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4668.96","42.9","","384.74","384.74","384.74","1 through 10","3373.84","8652.26","percent of total billed charges",""
"PLATE MANDIBLE 2MM RECONSTRUCTION TI PT SPECIFIC ANGLE CUSTOM","SUP-ITM-10159066","CDM","C1713","HCPCS","0278","RC","","","","both","","","10883.35","8162.51","WELLPOINT [1015]","HB AMC WELLPOINT","8029.74","73.78","","286.63","119.22","1107.45","105","3373.84","8652.26","percent of total billed charges",""
"PLATE MANDIBLE 2MM RECONSTRUCTION TI PT SPECIFIC ANGLE CUSTOM","SUP-ITM-10159066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10883.35","8162.51","AETNA [1001]","HB AMC AETNA HMO","7596.58","69.8","","675.31","184.75","1721.50","286","5687.64","8893.87","percent of total billed charges",""
"PLATE MANDIBLE 2MM RECONSTRUCTION TI PT SPECIFIC ANGLE CUSTOM","SUP-ITM-10159066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10883.35","8162.51","AETNA [1001]","HB AMC AETNA PPO","8750.21","80.4","","1261.44","103.12","1514.10","21","5687.64","8893.87","percent of total billed charges",""
"PLATE MANDIBLE 2MM RECONSTRUCTION TI PT SPECIFIC ANGLE CUSTOM","SUP-ITM-10159066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10883.35","8162.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8750.21","80.4","","1365.00","1365.00","1365.00","1 through 10","5687.64","8893.87","percent of total billed charges",""
"PLATE MANDIBLE 2MM RECONSTRUCTION TI PT SPECIFIC ANGLE CUSTOM","SUP-ITM-10159066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10883.35","8162.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8893.87","81.72","","5157.68","5157.68","5157.68","1 through 10","5687.64","8893.87","percent of total billed charges",""
"PLATE MANDIBLE 2MM RECONSTRUCTION TI PT SPECIFIC ANGLE CUSTOM","SUP-ITM-10159066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10883.35","8162.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8893.87","81.72","","431.26","71.26","1459.57","88","5687.64","8893.87","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE MANDIBULAR TRAUMA CURVED NARROW TITANIUM","SUP-ITM-10004281","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.97","551.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","584.30","79.5","","800.18","480.96","1887.97","195","227.84","584.3","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE MANDIBULAR TRAUMA CURVED NARROW TITANIUM","SUP-ITM-10004281","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.97","551.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","391.74","53.3","","813.12","216.42","1444.50","81","227.84","584.3","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE MANDIBULAR TRAUMA CURVED NARROW TITANIUM","SUP-ITM-10004281","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.97","551.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","227.84","31","","432.60","432.60","432.60","1 through 10","227.84","584.3","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE MANDIBULAR TRAUMA CURVED NARROW TITANIUM","SUP-ITM-10004281","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.97","551.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","268.26","36.5","","148.37","54.89","631.39","94","227.84","584.3","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE MANDIBULAR TRAUMA CURVED NARROW TITANIUM","SUP-ITM-10004281","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.97","551.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","281.49","38.3","","279.30","91.72","1116.77","266","227.84","584.3","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE MANDIBULAR TRAUMA CURVED NARROW TITANIUM","SUP-ITM-10004281","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.97","551.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.30","42.9","","731.00","63.70","731.00","1 through 10","227.84","584.3","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE MANDIBULAR TRAUMA CURVED NARROW TITANIUM","SUP-ITM-10004281","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.97","551.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.30","42.9","","384.74","384.74","384.74","1 through 10","227.84","584.3","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE MANDIBULAR TRAUMA CURVED NARROW TITANIUM","SUP-ITM-10004281","CDM","C1713","HCPCS","0278","RC","","","","both","","","734.97","551.23","WELLPOINT [1015]","HB AMC WELLPOINT","542.26","73.78","","286.63","119.22","1107.45","105","227.84","584.3","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE MANDIBULAR TRAUMA CURVED NARROW TITANIUM","SUP-ITM-10004281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","734.97","551.23","AETNA [1001]","HB AMC AETNA HMO","513.01","69.8","","675.31","184.75","1721.50","286","384.1","600.62","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE MANDIBULAR TRAUMA CURVED NARROW TITANIUM","SUP-ITM-10004281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","734.97","551.23","AETNA [1001]","HB AMC AETNA PPO","590.92","80.4","","1261.44","103.12","1514.10","21","384.1","600.62","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE MANDIBULAR TRAUMA CURVED NARROW TITANIUM","SUP-ITM-10004281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","734.97","551.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","590.92","80.4","","1365.00","1365.00","1365.00","1 through 10","384.1","600.62","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE MANDIBULAR TRAUMA CURVED NARROW TITANIUM","SUP-ITM-10004281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","734.97","551.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","600.62","81.72","","5157.68","5157.68","5157.68","1 through 10","384.1","600.62","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE MANDIBULAR TRAUMA CURVED NARROW TITANIUM","SUP-ITM-10004281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","734.97","551.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","600.62","81.72","","431.26","71.26","1459.57","88","384.1","600.62","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE TRAUMA STRAIGHT NARROW TITANIUM","SUP-ITM-10004278","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.77","464.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","491.92","79.5","","800.18","480.96","1887.97","195","191.82","491.92","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE TRAUMA STRAIGHT NARROW TITANIUM","SUP-ITM-10004278","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.77","464.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","329.80","53.3","","813.12","216.42","1444.50","81","191.82","491.92","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE TRAUMA STRAIGHT NARROW TITANIUM","SUP-ITM-10004278","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.77","464.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","191.82","31","","432.60","432.60","432.60","1 through 10","191.82","491.92","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE TRAUMA STRAIGHT NARROW TITANIUM","SUP-ITM-10004278","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.77","464.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","225.85","36.5","","148.37","54.89","631.39","94","191.82","491.92","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE TRAUMA STRAIGHT NARROW TITANIUM","SUP-ITM-10004278","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.77","464.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","236.99","38.3","","279.30","91.72","1116.77","266","191.82","491.92","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE TRAUMA STRAIGHT NARROW TITANIUM","SUP-ITM-10004278","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.77","464.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.45","42.9","","731.00","63.70","731.00","1 through 10","191.82","491.92","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE TRAUMA STRAIGHT NARROW TITANIUM","SUP-ITM-10004278","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.77","464.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.45","42.9","","384.74","384.74","384.74","1 through 10","191.82","491.92","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE TRAUMA STRAIGHT NARROW TITANIUM","SUP-ITM-10004278","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.77","464.08","WELLPOINT [1015]","HB AMC WELLPOINT","456.53","73.78","","286.63","119.22","1107.45","105","191.82","491.92","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE TRAUMA STRAIGHT NARROW TITANIUM","SUP-ITM-10004278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.77","464.08","AETNA [1001]","HB AMC AETNA HMO","431.90","69.8","","675.31","184.75","1721.50","286","323.37","505.66","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE TRAUMA STRAIGHT NARROW TITANIUM","SUP-ITM-10004278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.77","464.08","AETNA [1001]","HB AMC AETNA PPO","497.49","80.4","","1261.44","103.12","1514.10","21","323.37","505.66","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE TRAUMA STRAIGHT NARROW TITANIUM","SUP-ITM-10004278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.77","464.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","497.49","80.4","","1365.00","1365.00","1365.00","1 through 10","323.37","505.66","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE TRAUMA STRAIGHT NARROW TITANIUM","SUP-ITM-10004278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.77","464.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","505.66","81.72","","5157.68","5157.68","5157.68","1 through 10","323.37","505.66","percent of total billed charges",""
"PLATE MANDIBLE 2X29MM 4 HOLE TRAUMA STRAIGHT NARROW TITANIUM","SUP-ITM-10004278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.77","464.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","505.66","81.72","","431.26","71.26","1459.57","88","323.37","505.66","percent of total billed charges",""
"PLATE MANDIBLE 2X41MM 6 HOLE MANDIBULAR TRAUMA CURVED BROAD TITANIUM","SUP-ITM-10004288","CDM","C1713","HCPCS","0278","RC","","","","both","","","961.52","721.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","764.41","79.5","","800.18","480.96","1887.97","195","298.07","764.41","percent of total billed charges",""
"PLATE MANDIBLE 2X41MM 6 HOLE MANDIBULAR TRAUMA CURVED BROAD TITANIUM","SUP-ITM-10004288","CDM","C1713","HCPCS","0278","RC","","","","both","","","961.52","721.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","512.49","53.3","","813.12","216.42","1444.50","81","298.07","764.41","percent of total billed charges",""
"PLATE MANDIBLE 2X41MM 6 HOLE MANDIBULAR TRAUMA CURVED BROAD TITANIUM","SUP-ITM-10004288","CDM","C1713","HCPCS","0278","RC","","","","both","","","961.52","721.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","298.07","31","","432.60","432.60","432.60","1 through 10","298.07","764.41","percent of total billed charges",""
"PLATE MANDIBLE 2X41MM 6 HOLE MANDIBULAR TRAUMA CURVED BROAD TITANIUM","SUP-ITM-10004288","CDM","C1713","HCPCS","0278","RC","","","","both","","","961.52","721.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","350.95","36.5","","148.37","54.89","631.39","94","298.07","764.41","percent of total billed charges",""
"PLATE MANDIBLE 2X41MM 6 HOLE MANDIBULAR TRAUMA CURVED BROAD TITANIUM","SUP-ITM-10004288","CDM","C1713","HCPCS","0278","RC","","","","both","","","961.52","721.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","368.26","38.3","","279.30","91.72","1116.77","266","298.07","764.41","percent of total billed charges",""
"PLATE MANDIBLE 2X41MM 6 HOLE MANDIBULAR TRAUMA CURVED BROAD TITANIUM","SUP-ITM-10004288","CDM","C1713","HCPCS","0278","RC","","","","both","","","961.52","721.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.49","42.9","","731.00","63.70","731.00","1 through 10","298.07","764.41","percent of total billed charges",""
"PLATE MANDIBLE 2X41MM 6 HOLE MANDIBULAR TRAUMA CURVED BROAD TITANIUM","SUP-ITM-10004288","CDM","C1713","HCPCS","0278","RC","","","","both","","","961.52","721.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.49","42.9","","384.74","384.74","384.74","1 through 10","298.07","764.41","percent of total billed charges",""
"PLATE MANDIBLE 2X41MM 6 HOLE MANDIBULAR TRAUMA CURVED BROAD TITANIUM","SUP-ITM-10004288","CDM","C1713","HCPCS","0278","RC","","","","both","","","961.52","721.14","WELLPOINT [1015]","HB AMC WELLPOINT","709.41","73.78","","286.63","119.22","1107.45","105","298.07","764.41","percent of total billed charges",""
"PLATE MANDIBLE 2X41MM 6 HOLE MANDIBULAR TRAUMA CURVED BROAD TITANIUM","SUP-ITM-10004288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","961.52","721.14","AETNA [1001]","HB AMC AETNA HMO","671.14","69.8","","675.31","184.75","1721.50","286","502.49","785.75","percent of total billed charges",""
"PLATE MANDIBLE 2X41MM 6 HOLE MANDIBULAR TRAUMA CURVED BROAD TITANIUM","SUP-ITM-10004288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","961.52","721.14","AETNA [1001]","HB AMC AETNA PPO","773.06","80.4","","1261.44","103.12","1514.10","21","502.49","785.75","percent of total billed charges",""
"PLATE MANDIBLE 2X41MM 6 HOLE MANDIBULAR TRAUMA CURVED BROAD TITANIUM","SUP-ITM-10004288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","961.52","721.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","773.06","80.4","","1365.00","1365.00","1365.00","1 through 10","502.49","785.75","percent of total billed charges",""
"PLATE MANDIBLE 2X41MM 6 HOLE MANDIBULAR TRAUMA CURVED BROAD TITANIUM","SUP-ITM-10004288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","961.52","721.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","785.75","81.72","","5157.68","5157.68","5157.68","1 through 10","502.49","785.75","percent of total billed charges",""
"PLATE MANDIBLE 2X41MM 6 HOLE MANDIBULAR TRAUMA CURVED BROAD TITANIUM","SUP-ITM-10004288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","961.52","721.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","785.75","81.72","","431.26","71.26","1459.57","88","502.49","785.75","percent of total billed charges",""
"PLATE MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239692","CDM","C1713","HCPCS","0278","RC","","","","both","","","11642.40","8731.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9255.71","79.5","","800.18","480.96","1887.97","195","3609.14","9255.71","percent of total billed charges",""
"PLATE MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239692","CDM","C1713","HCPCS","0278","RC","","","","both","","","11642.40","8731.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6205.40","53.3","","813.12","216.42","1444.50","81","3609.14","9255.71","percent of total billed charges",""
"PLATE MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239692","CDM","C1713","HCPCS","0278","RC","","","","both","","","11642.40","8731.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3609.14","31","","432.60","432.60","432.60","1 through 10","3609.14","9255.71","percent of total billed charges",""
"PLATE MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239692","CDM","C1713","HCPCS","0278","RC","","","","both","","","11642.40","8731.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4249.48","36.5","","148.37","54.89","631.39","94","3609.14","9255.71","percent of total billed charges",""
"PLATE MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239692","CDM","C1713","HCPCS","0278","RC","","","","both","","","11642.40","8731.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4459.04","38.3","","279.30","91.72","1116.77","266","3609.14","9255.71","percent of total billed charges",""
"PLATE MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239692","CDM","C1713","HCPCS","0278","RC","","","","both","","","11642.40","8731.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4994.59","42.9","","731.00","63.70","731.00","1 through 10","3609.14","9255.71","percent of total billed charges",""
"PLATE MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239692","CDM","C1713","HCPCS","0278","RC","","","","both","","","11642.40","8731.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4994.59","42.9","","384.74","384.74","384.74","1 through 10","3609.14","9255.71","percent of total billed charges",""
"PLATE MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239692","CDM","C1713","HCPCS","0278","RC","","","","both","","","11642.40","8731.80","WELLPOINT [1015]","HB AMC WELLPOINT","8589.76","73.78","","286.63","119.22","1107.45","105","3609.14","9255.71","percent of total billed charges",""
"PLATE MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11642.40","8731.80","AETNA [1001]","HB AMC AETNA HMO","8126.40","69.8","","675.31","184.75","1721.50","286","6084.32","9514.17","percent of total billed charges",""
"PLATE MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11642.40","8731.80","AETNA [1001]","HB AMC AETNA PPO","9360.49","80.4","","1261.44","103.12","1514.10","21","6084.32","9514.17","percent of total billed charges",""
"PLATE MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11642.40","8731.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9360.49","80.4","","1365.00","1365.00","1365.00","1 through 10","6084.32","9514.17","percent of total billed charges",""
"PLATE MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11642.40","8731.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","9514.17","81.72","","5157.68","5157.68","5157.68","1 through 10","6084.32","9514.17","percent of total billed charges",""
"PLATE MANDIBLE LG PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11642.40","8731.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9514.17","81.72","","431.26","71.26","1459.57","88","6084.32","9514.17","percent of total billed charges",""
"PLATE MANDIBLE MINI PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239689","CDM","C1713","HCPCS","0278","RC","","","","both","","","4989.60","3742.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3966.73","79.5","","800.18","480.96","1887.97","195","1546.78","3966.73","percent of total billed charges",""
"PLATE MANDIBLE MINI PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239689","CDM","C1713","HCPCS","0278","RC","","","","both","","","4989.60","3742.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2659.46","53.3","","813.12","216.42","1444.50","81","1546.78","3966.73","percent of total billed charges",""
"PLATE MANDIBLE MINI PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239689","CDM","C1713","HCPCS","0278","RC","","","","both","","","4989.60","3742.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1546.78","31","","432.60","432.60","432.60","1 through 10","1546.78","3966.73","percent of total billed charges",""
"PLATE MANDIBLE MINI PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239689","CDM","C1713","HCPCS","0278","RC","","","","both","","","4989.60","3742.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1821.20","36.5","","148.37","54.89","631.39","94","1546.78","3966.73","percent of total billed charges",""
"PLATE MANDIBLE MINI PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239689","CDM","C1713","HCPCS","0278","RC","","","","both","","","4989.60","3742.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1911.02","38.3","","279.30","91.72","1116.77","266","1546.78","3966.73","percent of total billed charges",""
"PLATE MANDIBLE MINI PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239689","CDM","C1713","HCPCS","0278","RC","","","","both","","","4989.60","3742.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2140.54","42.9","","731.00","63.70","731.00","1 through 10","1546.78","3966.73","percent of total billed charges",""
"PLATE MANDIBLE MINI PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239689","CDM","C1713","HCPCS","0278","RC","","","","both","","","4989.60","3742.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2140.54","42.9","","384.74","384.74","384.74","1 through 10","1546.78","3966.73","percent of total billed charges",""
"PLATE MANDIBLE MINI PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239689","CDM","C1713","HCPCS","0278","RC","","","","both","","","4989.60","3742.20","WELLPOINT [1015]","HB AMC WELLPOINT","3681.33","73.78","","286.63","119.22","1107.45","105","1546.78","3966.73","percent of total billed charges",""
"PLATE MANDIBLE MINI PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4989.60","3742.20","AETNA [1001]","HB AMC AETNA HMO","3482.74","69.8","","675.31","184.75","1721.50","286","2607.56","4077.5","percent of total billed charges",""
"PLATE MANDIBLE MINI PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4989.60","3742.20","AETNA [1001]","HB AMC AETNA PPO","4011.64","80.4","","1261.44","103.12","1514.10","21","2607.56","4077.5","percent of total billed charges",""
"PLATE MANDIBLE MINI PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4989.60","3742.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4011.64","80.4","","1365.00","1365.00","1365.00","1 through 10","2607.56","4077.5","percent of total billed charges",""
"PLATE MANDIBLE MINI PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4989.60","3742.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4077.50","81.72","","5157.68","5157.68","5157.68","1 through 10","2607.56","4077.5","percent of total billed charges",""
"PLATE MANDIBLE MINI PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4989.60","3742.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4077.50","81.72","","431.26","71.26","1459.57","88","2607.56","4077.5","percent of total billed charges",""
"PLATE MANDIBLE PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239687","CDM","C1713","HCPCS","0278","RC","","","","both","","","5378.79","4034.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4276.14","79.5","","800.18","480.96","1887.97","195","1667.42","4276.14","percent of total billed charges",""
"PLATE MANDIBLE PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239687","CDM","C1713","HCPCS","0278","RC","","","","both","","","5378.79","4034.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2866.90","53.3","","813.12","216.42","1444.50","81","1667.42","4276.14","percent of total billed charges",""
"PLATE MANDIBLE PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239687","CDM","C1713","HCPCS","0278","RC","","","","both","","","5378.79","4034.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1667.42","31","","432.60","432.60","432.60","1 through 10","1667.42","4276.14","percent of total billed charges",""
"PLATE MANDIBLE PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239687","CDM","C1713","HCPCS","0278","RC","","","","both","","","5378.79","4034.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1963.26","36.5","","148.37","54.89","631.39","94","1667.42","4276.14","percent of total billed charges",""
"PLATE MANDIBLE PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239687","CDM","C1713","HCPCS","0278","RC","","","","both","","","5378.79","4034.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2060.08","38.3","","279.30","91.72","1116.77","266","1667.42","4276.14","percent of total billed charges",""
"PLATE MANDIBLE PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239687","CDM","C1713","HCPCS","0278","RC","","","","both","","","5378.79","4034.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2307.50","42.9","","731.00","63.70","731.00","1 through 10","1667.42","4276.14","percent of total billed charges",""
"PLATE MANDIBLE PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239687","CDM","C1713","HCPCS","0278","RC","","","","both","","","5378.79","4034.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2307.50","42.9","","384.74","384.74","384.74","1 through 10","1667.42","4276.14","percent of total billed charges",""
"PLATE MANDIBLE PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239687","CDM","C1713","HCPCS","0278","RC","","","","both","","","5378.79","4034.09","WELLPOINT [1015]","HB AMC WELLPOINT","3968.47","73.78","","286.63","119.22","1107.45","105","1667.42","4276.14","percent of total billed charges",""
"PLATE MANDIBLE PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5378.79","4034.09","AETNA [1001]","HB AMC AETNA HMO","3754.40","69.8","","675.31","184.75","1721.50","286","2810.96","4395.55","percent of total billed charges",""
"PLATE MANDIBLE PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5378.79","4034.09","AETNA [1001]","HB AMC AETNA PPO","4324.55","80.4","","1261.44","103.12","1514.10","21","2810.96","4395.55","percent of total billed charges",""
"PLATE MANDIBLE PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5378.79","4034.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4324.55","80.4","","1365.00","1365.00","1365.00","1 through 10","2810.96","4395.55","percent of total billed charges",""
"PLATE MANDIBLE PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5378.79","4034.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4395.55","81.72","","5157.68","5157.68","5157.68","1 through 10","2810.96","4395.55","percent of total billed charges",""
"PLATE MANDIBLE PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5378.79","4034.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4395.55","81.72","","431.26","71.26","1459.57","88","2810.96","4395.55","percent of total billed charges",""
"PLATE MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239691","CDM","C1713","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6611.22","79.5","","800.18","480.96","1887.97","195","2577.96","6611.22","percent of total billed charges",""
"PLATE MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239691","CDM","C1713","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4432.43","53.3","","813.12","216.42","1444.50","81","2577.96","6611.22","percent of total billed charges",""
"PLATE MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239691","CDM","C1713","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2577.96","31","","432.60","432.60","432.60","1 through 10","2577.96","6611.22","percent of total billed charges",""
"PLATE MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239691","CDM","C1713","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3035.34","36.5","","148.37","54.89","631.39","94","2577.96","6611.22","percent of total billed charges",""
"PLATE MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239691","CDM","C1713","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3185.03","38.3","","279.30","91.72","1116.77","266","2577.96","6611.22","percent of total billed charges",""
"PLATE MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239691","CDM","C1713","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3567.56","42.9","","731.00","63.70","731.00","1 through 10","2577.96","6611.22","percent of total billed charges",""
"PLATE MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239691","CDM","C1713","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3567.56","42.9","","384.74","384.74","384.74","1 through 10","2577.96","6611.22","percent of total billed charges",""
"PLATE MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239691","CDM","C1713","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","WELLPOINT [1015]","HB AMC WELLPOINT","6135.54","73.78","","286.63","119.22","1107.45","105","2577.96","6611.22","percent of total billed charges",""
"PLATE MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8316.00","6237.00","AETNA [1001]","HB AMC AETNA HMO","5804.57","69.8","","675.31","184.75","1721.50","286","4345.94","6795.84","percent of total billed charges",""
"PLATE MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8316.00","6237.00","AETNA [1001]","HB AMC AETNA PPO","6686.06","80.4","","1261.44","103.12","1514.10","21","4345.94","6795.84","percent of total billed charges",""
"PLATE MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8316.00","6237.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6686.06","80.4","","1365.00","1365.00","1365.00","1 through 10","4345.94","6795.84","percent of total billed charges",""
"PLATE MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8316.00","6237.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6795.84","81.72","","5157.68","5157.68","5157.68","1 through 10","4345.94","6795.84","percent of total billed charges",""
"PLATE MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE","SUP-ITM-10239691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8316.00","6237.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6795.84","81.72","","431.26","71.26","1459.57","88","4345.94","6795.84","percent of total billed charges",""
"PLATE MANUBRIUM","SUP-ITM-10317509","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","800.18","480.96","1887.97","195","651","1669.5","percent of total billed charges",""
"PLATE MANUBRIUM","SUP-ITM-10317509","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1119.30","53.3","","813.12","216.42","1444.50","81","651","1669.5","percent of total billed charges",""
"PLATE MANUBRIUM","SUP-ITM-10317509","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","651.00","31","","432.60","432.60","432.60","1 through 10","651","1669.5","percent of total billed charges",""
"PLATE MANUBRIUM","SUP-ITM-10317509","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","148.37","54.89","631.39","94","651","1669.5","percent of total billed charges",""
"PLATE MANUBRIUM","SUP-ITM-10317509","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","279.30","91.72","1116.77","266","651","1669.5","percent of total billed charges",""
"PLATE MANUBRIUM","SUP-ITM-10317509","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","731.00","63.70","731.00","1 through 10","651","1669.5","percent of total billed charges",""
"PLATE MANUBRIUM","SUP-ITM-10317509","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","384.74","384.74","384.74","1 through 10","651","1669.5","percent of total billed charges",""
"PLATE MANUBRIUM","SUP-ITM-10317509","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","286.63","119.22","1107.45","105","651","1669.5","percent of total billed charges",""
"PLATE MANUBRIUM","SUP-ITM-10317509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","675.31","184.75","1721.50","286","1097.46","1716.12","percent of total billed charges",""
"PLATE MANUBRIUM","SUP-ITM-10317509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1261.44","103.12","1514.10","21","1097.46","1716.12","percent of total billed charges",""
"PLATE MANUBRIUM","SUP-ITM-10317509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1688.40","80.4","","1365.00","1365.00","1365.00","1 through 10","1097.46","1716.12","percent of total billed charges",""
"PLATE MANUBRIUM","SUP-ITM-10317509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1716.12","81.72","","5157.68","5157.68","5157.68","1 through 10","1097.46","1716.12","percent of total billed charges",""
"PLATE MANUBRIUM","SUP-ITM-10317509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","431.26","71.26","1459.57","88","1097.46","1716.12","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","both","","","1169.63","877.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","929.86","79.5","","800.18","480.96","1887.97","195","362.59","929.86","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","both","","","1169.63","877.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","623.41","53.3","","813.12","216.42","1444.50","81","362.59","929.86","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","both","","","1169.63","877.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","362.59","31","","432.60","432.60","432.60","1 through 10","362.59","929.86","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","both","","","1169.63","877.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","426.91","36.5","","148.37","54.89","631.39","94","362.59","929.86","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","both","","","1169.63","877.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","447.97","38.3","","279.30","91.72","1116.77","266","362.59","929.86","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","both","","","1169.63","877.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","501.77","42.9","","731.00","63.70","731.00","1 through 10","362.59","929.86","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","both","","","1169.63","877.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","501.77","42.9","","384.74","384.74","384.74","1 through 10","362.59","929.86","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","both","","","1169.63","877.22","WELLPOINT [1015]","HB AMC WELLPOINT","862.95","73.78","","286.63","119.22","1107.45","105","362.59","929.86","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1169.63","877.22","AETNA [1001]","HB AMC AETNA HMO","816.40","69.8","","675.31","184.75","1721.50","286","611.25","955.82","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1169.63","877.22","AETNA [1001]","HB AMC AETNA PPO","940.38","80.4","","1261.44","103.12","1514.10","21","611.25","955.82","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1169.63","877.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","940.38","80.4","","1365.00","1365.00","1365.00","1 through 10","611.25","955.82","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1169.63","877.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","955.82","81.72","","5157.68","5157.68","5157.68","1 through 10","611.25","955.82","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1169.63","877.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","955.82","81.72","","431.26","71.26","1459.57","88","611.25","955.82","percent of total billed charges",""
"PLATE MESH 2.4MM 2.7 /5X12 HOLE TI VA LOCKING","SUP-ITM-10096271","CDM","C1713","HCPCS","0278","RC","","","","both","","","4202.46","3151.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3340.96","79.5","","800.18","480.96","1887.97","195","1302.76","3340.96","percent of total billed charges",""
"PLATE MESH 2.4MM 2.7 /5X12 HOLE TI VA LOCKING","SUP-ITM-10096271","CDM","C1713","HCPCS","0278","RC","","","","both","","","4202.46","3151.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2239.91","53.3","","813.12","216.42","1444.50","81","1302.76","3340.96","percent of total billed charges",""
"PLATE MESH 2.4MM 2.7 /5X12 HOLE TI VA LOCKING","SUP-ITM-10096271","CDM","C1713","HCPCS","0278","RC","","","","both","","","4202.46","3151.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1302.76","31","","432.60","432.60","432.60","1 through 10","1302.76","3340.96","percent of total billed charges",""
"PLATE MESH 2.4MM 2.7 /5X12 HOLE TI VA LOCKING","SUP-ITM-10096271","CDM","C1713","HCPCS","0278","RC","","","","both","","","4202.46","3151.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.90","36.5","","148.37","54.89","631.39","94","1302.76","3340.96","percent of total billed charges",""
"PLATE MESH 2.4MM 2.7 /5X12 HOLE TI VA LOCKING","SUP-ITM-10096271","CDM","C1713","HCPCS","0278","RC","","","","both","","","4202.46","3151.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1609.54","38.3","","279.30","91.72","1116.77","266","1302.76","3340.96","percent of total billed charges",""
"PLATE MESH 2.4MM 2.7 /5X12 HOLE TI VA LOCKING","SUP-ITM-10096271","CDM","C1713","HCPCS","0278","RC","","","","both","","","4202.46","3151.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.86","42.9","","731.00","63.70","731.00","1 through 10","1302.76","3340.96","percent of total billed charges",""
"PLATE MESH 2.4MM 2.7 /5X12 HOLE TI VA LOCKING","SUP-ITM-10096271","CDM","C1713","HCPCS","0278","RC","","","","both","","","4202.46","3151.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.86","42.9","","384.74","384.74","384.74","1 through 10","1302.76","3340.96","percent of total billed charges",""
"PLATE MESH 2.4MM 2.7 /5X12 HOLE TI VA LOCKING","SUP-ITM-10096271","CDM","C1713","HCPCS","0278","RC","","","","both","","","4202.46","3151.84","WELLPOINT [1015]","HB AMC WELLPOINT","3100.57","73.78","","286.63","119.22","1107.45","105","1302.76","3340.96","percent of total billed charges",""
"PLATE MESH 2.4MM 2.7 /5X12 HOLE TI VA LOCKING","SUP-ITM-10096271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4202.46","3151.84","AETNA [1001]","HB AMC AETNA HMO","2933.32","69.8","","675.31","184.75","1721.50","286","2196.21","3434.25","percent of total billed charges",""
"PLATE MESH 2.4MM 2.7 /5X12 HOLE TI VA LOCKING","SUP-ITM-10096271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4202.46","3151.84","AETNA [1001]","HB AMC AETNA PPO","3378.78","80.4","","1261.44","103.12","1514.10","21","2196.21","3434.25","percent of total billed charges",""
"PLATE MESH 2.4MM 2.7 /5X12 HOLE TI VA LOCKING","SUP-ITM-10096271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4202.46","3151.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3378.78","80.4","","1365.00","1365.00","1365.00","1 through 10","2196.21","3434.25","percent of total billed charges",""
"PLATE MESH 2.4MM 2.7 /5X12 HOLE TI VA LOCKING","SUP-ITM-10096271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4202.46","3151.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3434.25","81.72","","5157.68","5157.68","5157.68","1 through 10","2196.21","3434.25","percent of total billed charges",""
"PLATE MESH 2.4MM 2.7 /5X12 HOLE TI VA LOCKING","SUP-ITM-10096271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4202.46","3151.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3434.25","81.72","","431.26","71.26","1459.57","88","2196.21","3434.25","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5-4.5X298MM 18 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.72","2600.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2756.04","79.5","","800.18","480.96","1887.97","195","1074.68","2756.04","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5-4.5X298MM 18 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.72","2600.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1847.76","53.3","","813.12","216.42","1444.50","81","1074.68","2756.04","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5-4.5X298MM 18 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.72","2600.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1074.68","31","","432.60","432.60","432.60","1 through 10","1074.68","2756.04","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5-4.5X298MM 18 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.72","2600.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1265.35","36.5","","148.37","54.89","631.39","94","1074.68","2756.04","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5-4.5X298MM 18 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.72","2600.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1327.75","38.3","","279.30","91.72","1116.77","266","1074.68","2756.04","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5-4.5X298MM 18 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.72","2600.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.22","42.9","","731.00","63.70","731.00","1 through 10","1074.68","2756.04","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5-4.5X298MM 18 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.72","2600.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.22","42.9","","384.74","384.74","384.74","1 through 10","1074.68","2756.04","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5-4.5X298MM 18 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.72","2600.04","WELLPOINT [1015]","HB AMC WELLPOINT","2557.75","73.78","","286.63","119.22","1107.45","105","1074.68","2756.04","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5-4.5X298MM 18 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.72","2600.04","AETNA [1001]","HB AMC AETNA HMO","2419.77","69.8","","675.31","184.75","1721.50","286","1811.71","2833","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5-4.5X298MM 18 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.72","2600.04","AETNA [1001]","HB AMC AETNA PPO","2787.24","80.4","","1261.44","103.12","1514.10","21","1811.71","2833","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5-4.5X298MM 18 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.72","2600.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2787.24","80.4","","1365.00","1365.00","1365.00","1 through 10","1811.71","2833","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5-4.5X298MM 18 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.72","2600.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2833.00","81.72","","5157.68","5157.68","5157.68","1 through 10","1811.71","2833","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5-4.5X298MM 18 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.72","2600.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2833.00","81.72","","431.26","71.26","1459.57","88","1811.71","2833","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1871.68","79.5","","800.18","480.96","1887.97","195","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1254.85","53.3","","813.12","216.42","1444.50","81","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","729.84","31","","432.60","432.60","432.60","1 through 10","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","859.32","36.5","","148.37","54.89","631.39","94","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","901.70","38.3","","279.30","91.72","1116.77","266","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1010.00","42.9","","731.00","63.70","731.00","1 through 10","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1010.00","42.9","","384.74","384.74","384.74","1 through 10","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","WELLPOINT [1015]","HB AMC WELLPOINT","1737.01","73.78","","286.63","119.22","1107.45","105","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2354.31","1765.73","AETNA [1001]","HB AMC AETNA HMO","1643.31","69.8","","675.31","184.75","1721.50","286","1230.36","1923.94","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2354.31","1765.73","AETNA [1001]","HB AMC AETNA PPO","1892.87","80.4","","1261.44","103.12","1514.10","21","1230.36","1923.94","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2354.31","1765.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1892.87","80.4","","1365.00","1365.00","1365.00","1 through 10","1230.36","1923.94","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2354.31","1765.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1923.94","81.72","","5157.68","5157.68","5157.68","1 through 10","1230.36","1923.94","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2354.31","1765.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1923.94","81.72","","431.26","71.26","1459.57","88","1230.36","1923.94","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2496.60","79.5","","800.18","480.96","1887.97","195","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1673.82","53.3","","813.12","216.42","1444.50","81","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","973.52","31","","432.60","432.60","432.60","1 through 10","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1146.24","36.5","","148.37","54.89","631.39","94","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1202.77","38.3","","279.30","91.72","1116.77","266","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1347.22","42.9","","731.00","63.70","731.00","1 through 10","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1347.22","42.9","","384.74","384.74","384.74","1 through 10","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","WELLPOINT [1015]","HB AMC WELLPOINT","2316.97","73.78","","286.63","119.22","1107.45","105","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3140.38","2355.28","AETNA [1001]","HB AMC AETNA HMO","2191.99","69.8","","675.31","184.75","1721.50","286","1641.16","2566.32","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3140.38","2355.28","AETNA [1001]","HB AMC AETNA PPO","2524.87","80.4","","1261.44","103.12","1514.10","21","1641.16","2566.32","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3140.38","2355.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2524.87","80.4","","1365.00","1365.00","1365.00","1 through 10","1641.16","2566.32","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3140.38","2355.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2566.32","81.72","","5157.68","5157.68","5157.68","1 through 10","1641.16","2566.32","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3140.38","2355.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2566.32","81.72","","431.26","71.26","1459.57","88","1641.16","2566.32","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X190MM 12 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2496.60","79.5","","800.18","480.96","1887.97","195","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X190MM 12 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1673.82","53.3","","813.12","216.42","1444.50","81","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X190MM 12 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","973.52","31","","432.60","432.60","432.60","1 through 10","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X190MM 12 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1146.24","36.5","","148.37","54.89","631.39","94","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X190MM 12 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1202.77","38.3","","279.30","91.72","1116.77","266","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X190MM 12 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1347.22","42.9","","731.00","63.70","731.00","1 through 10","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X190MM 12 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1347.22","42.9","","384.74","384.74","384.74","1 through 10","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X190MM 12 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3140.38","2355.28","WELLPOINT [1015]","HB AMC WELLPOINT","2316.97","73.78","","286.63","119.22","1107.45","105","973.52","2496.6","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X190MM 12 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3140.38","2355.28","AETNA [1001]","HB AMC AETNA HMO","2191.99","69.8","","675.31","184.75","1721.50","286","1641.16","2566.32","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X190MM 12 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3140.38","2355.28","AETNA [1001]","HB AMC AETNA PPO","2524.87","80.4","","1261.44","103.12","1514.10","21","1641.16","2566.32","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X190MM 12 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3140.38","2355.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2524.87","80.4","","1365.00","1365.00","1365.00","1 through 10","1641.16","2566.32","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X190MM 12 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3140.38","2355.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2566.32","81.72","","5157.68","5157.68","5157.68","1 through 10","1641.16","2566.32","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X190MM 12 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3140.38","2355.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2566.32","81.72","","431.26","71.26","1459.57","88","1641.16","2566.32","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1933.45","79.5","","800.18","480.96","1887.97","195","753.92","1933.45","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1296.26","53.3","","813.12","216.42","1444.50","81","753.92","1933.45","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","753.92","31","","432.60","432.60","432.60","1 through 10","753.92","1933.45","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","887.68","36.5","","148.37","54.89","631.39","94","753.92","1933.45","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","931.46","38.3","","279.30","91.72","1116.77","266","753.92","1933.45","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1043.33","42.9","","731.00","63.70","731.00","1 through 10","753.92","1933.45","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1043.33","42.9","","384.74","384.74","384.74","1 through 10","753.92","1933.45","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.01","1824.01","WELLPOINT [1015]","HB AMC WELLPOINT","1794.34","73.78","","286.63","119.22","1107.45","105","753.92","1933.45","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.01","1824.01","AETNA [1001]","HB AMC AETNA HMO","1697.54","69.8","","675.31","184.75","1721.50","286","1270.97","1987.44","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.01","1824.01","AETNA [1001]","HB AMC AETNA PPO","1955.34","80.4","","1261.44","103.12","1514.10","21","1270.97","1987.44","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.01","1824.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1955.34","80.4","","1365.00","1365.00","1365.00","1 through 10","1270.97","1987.44","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.01","1824.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1987.44","81.72","","5157.68","5157.68","5157.68","1 through 10","1270.97","1987.44","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.01","1824.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1987.44","81.72","","431.26","71.26","1459.57","88","1270.97","1987.44","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 13 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029086","CDM","C1713","HCPCS","0278","RC","","","","both","","","3171.46","2378.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2521.31","79.5","","800.18","480.96","1887.97","195","983.15","2521.31","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 13 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029086","CDM","C1713","HCPCS","0278","RC","","","","both","","","3171.46","2378.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1690.39","53.3","","813.12","216.42","1444.50","81","983.15","2521.31","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 13 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029086","CDM","C1713","HCPCS","0278","RC","","","","both","","","3171.46","2378.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","983.15","31","","432.60","432.60","432.60","1 through 10","983.15","2521.31","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 13 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029086","CDM","C1713","HCPCS","0278","RC","","","","both","","","3171.46","2378.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1157.58","36.5","","148.37","54.89","631.39","94","983.15","2521.31","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 13 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029086","CDM","C1713","HCPCS","0278","RC","","","","both","","","3171.46","2378.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1214.67","38.3","","279.30","91.72","1116.77","266","983.15","2521.31","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 13 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029086","CDM","C1713","HCPCS","0278","RC","","","","both","","","3171.46","2378.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1360.56","42.9","","731.00","63.70","731.00","1 through 10","983.15","2521.31","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 13 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029086","CDM","C1713","HCPCS","0278","RC","","","","both","","","3171.46","2378.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1360.56","42.9","","384.74","384.74","384.74","1 through 10","983.15","2521.31","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 13 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029086","CDM","C1713","HCPCS","0278","RC","","","","both","","","3171.46","2378.59","WELLPOINT [1015]","HB AMC WELLPOINT","2339.90","73.78","","286.63","119.22","1107.45","105","983.15","2521.31","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 13 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3171.46","2378.59","AETNA [1001]","HB AMC AETNA HMO","2213.68","69.8","","675.31","184.75","1721.50","286","1657.4","2591.72","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 13 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3171.46","2378.59","AETNA [1001]","HB AMC AETNA PPO","2549.85","80.4","","1261.44","103.12","1514.10","21","1657.4","2591.72","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 13 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3171.46","2378.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2549.85","80.4","","1365.00","1365.00","1365.00","1 through 10","1657.4","2591.72","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 13 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3171.46","2378.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2591.72","81.72","","5157.68","5157.68","5157.68","1 through 10","1657.4","2591.72","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 13 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3171.46","2378.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2591.72","81.72","","431.26","71.26","1459.57","88","1657.4","2591.72","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2575.87","79.5","","800.18","480.96","1887.97","195","1004.43","2575.87","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1726.97","53.3","","813.12","216.42","1444.50","81","1004.43","2575.87","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1004.43","31","","432.60","432.60","432.60","1 through 10","1004.43","2575.87","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1182.63","36.5","","148.37","54.89","631.39","94","1004.43","2575.87","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1240.95","38.3","","279.30","91.72","1116.77","266","1004.43","2575.87","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1390.00","42.9","","731.00","63.70","731.00","1 through 10","1004.43","2575.87","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1390.00","42.9","","384.74","384.74","384.74","1 through 10","1004.43","2575.87","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.09","2430.07","WELLPOINT [1015]","HB AMC WELLPOINT","2390.54","73.78","","286.63","119.22","1107.45","105","1004.43","2575.87","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","AETNA [1001]","HB AMC AETNA HMO","2261.58","69.8","","675.31","184.75","1721.50","286","1693.27","2647.8","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","AETNA [1001]","HB AMC AETNA PPO","2605.03","80.4","","1261.44","103.12","1514.10","21","1693.27","2647.8","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2605.03","80.4","","1365.00","1365.00","1365.00","1 through 10","1693.27","2647.8","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2647.80","81.72","","5157.68","5157.68","5157.68","1 through 10","1693.27","2647.8","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.09","2430.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2647.80","81.72","","431.26","71.26","1459.57","88","1693.27","2647.8","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X262MM 16 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029087","CDM","C1713","HCPCS","0278","RC","","","","both","","","3403.26","2552.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2705.59","79.5","","800.18","480.96","1887.97","195","1055.01","2705.59","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X262MM 16 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029087","CDM","C1713","HCPCS","0278","RC","","","","both","","","3403.26","2552.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1813.94","53.3","","813.12","216.42","1444.50","81","1055.01","2705.59","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X262MM 16 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029087","CDM","C1713","HCPCS","0278","RC","","","","both","","","3403.26","2552.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1055.01","31","","432.60","432.60","432.60","1 through 10","1055.01","2705.59","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X262MM 16 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029087","CDM","C1713","HCPCS","0278","RC","","","","both","","","3403.26","2552.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1242.19","36.5","","148.37","54.89","631.39","94","1055.01","2705.59","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X262MM 16 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029087","CDM","C1713","HCPCS","0278","RC","","","","both","","","3403.26","2552.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1303.45","38.3","","279.30","91.72","1116.77","266","1055.01","2705.59","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X262MM 16 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029087","CDM","C1713","HCPCS","0278","RC","","","","both","","","3403.26","2552.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1460.00","42.9","","731.00","63.70","731.00","1 through 10","1055.01","2705.59","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X262MM 16 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029087","CDM","C1713","HCPCS","0278","RC","","","","both","","","3403.26","2552.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1460.00","42.9","","384.74","384.74","384.74","1 through 10","1055.01","2705.59","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X262MM 16 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029087","CDM","C1713","HCPCS","0278","RC","","","","both","","","3403.26","2552.44","WELLPOINT [1015]","HB AMC WELLPOINT","2510.93","73.78","","286.63","119.22","1107.45","105","1055.01","2705.59","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X262MM 16 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3403.26","2552.44","AETNA [1001]","HB AMC AETNA HMO","2375.48","69.8","","675.31","184.75","1721.50","286","1778.54","2781.14","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X262MM 16 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3403.26","2552.44","AETNA [1001]","HB AMC AETNA PPO","2736.22","80.4","","1261.44","103.12","1514.10","21","1778.54","2781.14","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X262MM 16 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3403.26","2552.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2736.22","80.4","","1365.00","1365.00","1365.00","1 through 10","1778.54","2781.14","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X262MM 16 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3403.26","2552.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2781.14","81.72","","5157.68","5157.68","5157.68","1 through 10","1778.54","2781.14","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X262MM 16 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10029087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3403.26","2552.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2781.14","81.72","","431.26","71.26","1459.57","88","1778.54","2781.14","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2237.76","1678.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1779.02","79.5","","800.18","480.96","1887.97","195","693.71","1779.02","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2237.76","1678.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1192.73","53.3","","813.12","216.42","1444.50","81","693.71","1779.02","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2237.76","1678.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","693.71","31","","432.60","432.60","432.60","1 through 10","693.71","1779.02","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2237.76","1678.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","816.78","36.5","","148.37","54.89","631.39","94","693.71","1779.02","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2237.76","1678.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","857.06","38.3","","279.30","91.72","1116.77","266","693.71","1779.02","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2237.76","1678.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","960.00","42.9","","731.00","63.70","731.00","1 through 10","693.71","1779.02","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2237.76","1678.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","960.00","42.9","","384.74","384.74","384.74","1 through 10","693.71","1779.02","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2237.76","1678.32","WELLPOINT [1015]","HB AMC WELLPOINT","1651.02","73.78","","286.63","119.22","1107.45","105","693.71","1779.02","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2237.76","1678.32","AETNA [1001]","HB AMC AETNA HMO","1561.96","69.8","","675.31","184.75","1721.50","286","1169.45","1828.7","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2237.76","1678.32","AETNA [1001]","HB AMC AETNA PPO","1799.16","80.4","","1261.44","103.12","1514.10","21","1169.45","1828.7","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2237.76","1678.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1799.16","80.4","","1365.00","1365.00","1365.00","1 through 10","1169.45","1828.7","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2237.76","1678.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1828.70","81.72","","5157.68","5157.68","5157.68","1 through 10","1169.45","1828.7","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2237.76","1678.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1828.70","81.72","","431.26","71.26","1459.57","88","1169.45","1828.7","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5-3.5X136MM 9 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10027398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1871.68","79.5","","800.18","480.96","1887.97","195","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5-3.5X136MM 9 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10027398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1254.85","53.3","","813.12","216.42","1444.50","81","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5-3.5X136MM 9 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10027398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","729.84","31","","432.60","432.60","432.60","1 through 10","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5-3.5X136MM 9 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10027398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","859.32","36.5","","148.37","54.89","631.39","94","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5-3.5X136MM 9 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10027398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","901.70","38.3","","279.30","91.72","1116.77","266","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5-3.5X136MM 9 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10027398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1010.00","42.9","","731.00","63.70","731.00","1 through 10","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5-3.5X136MM 9 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10027398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1010.00","42.9","","384.74","384.74","384.74","1 through 10","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5-3.5X136MM 9 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10027398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2354.31","1765.73","WELLPOINT [1015]","HB AMC WELLPOINT","1737.01","73.78","","286.63","119.22","1107.45","105","729.84","1871.68","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5-3.5X136MM 9 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10027398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2354.31","1765.73","AETNA [1001]","HB AMC AETNA HMO","1643.31","69.8","","675.31","184.75","1721.50","286","1230.36","1923.94","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5-3.5X136MM 9 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10027398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2354.31","1765.73","AETNA [1001]","HB AMC AETNA PPO","1892.87","80.4","","1261.44","103.12","1514.10","21","1230.36","1923.94","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5-3.5X136MM 9 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10027398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2354.31","1765.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1892.87","80.4","","1365.00","1365.00","1365.00","1 through 10","1230.36","1923.94","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5-3.5X136MM 9 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10027398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2354.31","1765.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1923.94","81.72","","5157.68","5157.68","5157.68","1 through 10","1230.36","1923.94","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5-3.5X136MM 9 HOLE COMPRESSION METAPHYSL LCP SS","SUP-ITM-10027398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2354.31","1765.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1923.94","81.72","","431.26","71.26","1459.57","88","1230.36","1923.94","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.35","1530.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1622.08","79.5","","800.18","480.96","1887.97","195","632.51","1622.08","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.35","1530.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1087.51","53.3","","813.12","216.42","1444.50","81","632.51","1622.08","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.35","1530.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","632.51","31","","432.60","432.60","432.60","1 through 10","632.51","1622.08","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.35","1530.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","744.73","36.5","","148.37","54.89","631.39","94","632.51","1622.08","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.35","1530.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","781.45","38.3","","279.30","91.72","1116.77","266","632.51","1622.08","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.35","1530.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","875.31","42.9","","731.00","63.70","731.00","1 through 10","632.51","1622.08","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.35","1530.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","875.31","42.9","","384.74","384.74","384.74","1 through 10","632.51","1622.08","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","both","","","2040.35","1530.26","WELLPOINT [1015]","HB AMC WELLPOINT","1505.37","73.78","","286.63","119.22","1107.45","105","632.51","1622.08","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.35","1530.26","AETNA [1001]","HB AMC AETNA HMO","1424.16","69.8","","675.31","184.75","1721.50","286","1066.29","1667.37","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.35","1530.26","AETNA [1001]","HB AMC AETNA PPO","1640.44","80.4","","1261.44","103.12","1514.10","21","1066.29","1667.37","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.35","1530.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1640.44","80.4","","1365.00","1365.00","1365.00","1 through 10","1066.29","1667.37","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.35","1530.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1667.37","81.72","","5157.68","5157.68","5157.68","1 through 10","1066.29","1667.37","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2040.35","1530.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1667.37","81.72","","431.26","71.26","1459.57","88","1066.29","1667.37","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.75","3458.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3666.34","79.5","","800.18","480.96","1887.97","195","1429.64","3666.34","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.75","3458.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2458.06","53.3","","813.12","216.42","1444.50","81","1429.64","3666.34","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.75","3458.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1429.64","31","","432.60","432.60","432.60","1 through 10","1429.64","3666.34","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.75","3458.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1683.29","36.5","","148.37","54.89","631.39","94","1429.64","3666.34","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.75","3458.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1766.30","38.3","","279.30","91.72","1116.77","266","1429.64","3666.34","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.75","3458.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1978.44","42.9","","731.00","63.70","731.00","1 through 10","1429.64","3666.34","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.75","3458.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1978.44","42.9","","384.74","384.74","384.74","1 through 10","1429.64","3666.34","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","4611.75","3458.81","WELLPOINT [1015]","HB AMC WELLPOINT","3402.55","73.78","","286.63","119.22","1107.45","105","1429.64","3666.34","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4611.75","3458.81","AETNA [1001]","HB AMC AETNA HMO","3219.00","69.8","","675.31","184.75","1721.50","286","2410.1","3768.72","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4611.75","3458.81","AETNA [1001]","HB AMC AETNA PPO","3707.85","80.4","","1261.44","103.12","1514.10","21","2410.1","3768.72","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4611.75","3458.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3707.85","80.4","","1365.00","1365.00","1365.00","1 through 10","2410.1","3768.72","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4611.75","3458.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3768.72","81.72","","5157.68","5157.68","5157.68","1 through 10","2410.1","3768.72","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4611.75","3458.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3768.72","81.72","","431.26","71.26","1459.57","88","2410.1","3768.72","percent of total billed charges",""
"PLATE OLECRANON 2.7- 3.5X73MM VA LCP PROXIMAL TITANIUM LEFT","SUP-ITM-10125493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2125.97","79.5","","800.18","480.96","1887.97","195","829","2125.97","percent of total billed charges",""
"PLATE OLECRANON 2.7- 3.5X73MM VA LCP PROXIMAL TITANIUM LEFT","SUP-ITM-10125493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1425.34","53.3","","813.12","216.42","1444.50","81","829","2125.97","percent of total billed charges",""
"PLATE OLECRANON 2.7- 3.5X73MM VA LCP PROXIMAL TITANIUM LEFT","SUP-ITM-10125493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","829.00","31","","432.60","432.60","432.60","1 through 10","829","2125.97","percent of total billed charges",""
"PLATE OLECRANON 2.7- 3.5X73MM VA LCP PROXIMAL TITANIUM LEFT","SUP-ITM-10125493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","976.08","36.5","","148.37","54.89","631.39","94","829","2125.97","percent of total billed charges",""
"PLATE OLECRANON 2.7- 3.5X73MM VA LCP PROXIMAL TITANIUM LEFT","SUP-ITM-10125493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1024.21","38.3","","279.30","91.72","1116.77","266","829","2125.97","percent of total billed charges",""
"PLATE OLECRANON 2.7- 3.5X73MM VA LCP PROXIMAL TITANIUM LEFT","SUP-ITM-10125493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1147.22","42.9","","731.00","63.70","731.00","1 through 10","829","2125.97","percent of total billed charges",""
"PLATE OLECRANON 2.7- 3.5X73MM VA LCP PROXIMAL TITANIUM LEFT","SUP-ITM-10125493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1147.22","42.9","","384.74","384.74","384.74","1 through 10","829","2125.97","percent of total billed charges",""
"PLATE OLECRANON 2.7- 3.5X73MM VA LCP PROXIMAL TITANIUM LEFT","SUP-ITM-10125493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2674.18","2005.63","WELLPOINT [1015]","HB AMC WELLPOINT","1973.01","73.78","","286.63","119.22","1107.45","105","829","2125.97","percent of total billed charges",""
"PLATE OLECRANON 2.7- 3.5X73MM VA LCP PROXIMAL TITANIUM LEFT","SUP-ITM-10125493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2674.18","2005.63","AETNA [1001]","HB AMC AETNA HMO","1866.58","69.8","","675.31","184.75","1721.50","286","1397.53","2185.34","percent of total billed charges",""
"PLATE OLECRANON 2.7- 3.5X73MM VA LCP PROXIMAL TITANIUM LEFT","SUP-ITM-10125493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2674.18","2005.63","AETNA [1001]","HB AMC AETNA PPO","2150.04","80.4","","1261.44","103.12","1514.10","21","1397.53","2185.34","percent of total billed charges",""
"PLATE OLECRANON 2.7- 3.5X73MM VA LCP PROXIMAL TITANIUM LEFT","SUP-ITM-10125493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2674.18","2005.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2150.04","80.4","","1365.00","1365.00","1365.00","1 through 10","1397.53","2185.34","percent of total billed charges",""
"PLATE OLECRANON 2.7- 3.5X73MM VA LCP PROXIMAL TITANIUM LEFT","SUP-ITM-10125493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2674.18","2005.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2185.34","81.72","","5157.68","5157.68","5157.68","1 through 10","1397.53","2185.34","percent of total billed charges",""
"PLATE OLECRANON 2.7- 3.5X73MM VA LCP PROXIMAL TITANIUM LEFT","SUP-ITM-10125493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2674.18","2005.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2185.34","81.72","","431.26","71.26","1459.57","88","1397.53","2185.34","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2790.73","2093.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2218.63","79.5","","800.18","480.96","1887.97","195","865.13","2218.63","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2790.73","2093.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1487.46","53.3","","813.12","216.42","1444.50","81","865.13","2218.63","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2790.73","2093.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","865.13","31","","432.60","432.60","432.60","1 through 10","865.13","2218.63","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2790.73","2093.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1018.62","36.5","","148.37","54.89","631.39","94","865.13","2218.63","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2790.73","2093.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1068.85","38.3","","279.30","91.72","1116.77","266","865.13","2218.63","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2790.73","2093.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1197.22","42.9","","731.00","63.70","731.00","1 through 10","865.13","2218.63","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2790.73","2093.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1197.22","42.9","","384.74","384.74","384.74","1 through 10","865.13","2218.63","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2790.73","2093.05","WELLPOINT [1015]","HB AMC WELLPOINT","2059.00","73.78","","286.63","119.22","1107.45","105","865.13","2218.63","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2790.73","2093.05","AETNA [1001]","HB AMC AETNA HMO","1947.93","69.8","","675.31","184.75","1721.50","286","1458.44","2280.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2790.73","2093.05","AETNA [1001]","HB AMC AETNA PPO","2243.75","80.4","","1261.44","103.12","1514.10","21","1458.44","2280.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2790.73","2093.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2243.75","80.4","","1365.00","1365.00","1365.00","1 through 10","1458.44","2280.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2790.73","2093.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2280.58","81.72","","5157.68","5157.68","5157.68","1 through 10","1458.44","2280.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2790.73","2093.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2280.58","81.72","","431.26","71.26","1459.57","88","1458.44","2280.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2970.73","2228.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2361.73","79.5","","800.18","480.96","1887.97","195","920.93","2361.73","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2970.73","2228.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1583.40","53.3","","813.12","216.42","1444.50","81","920.93","2361.73","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2970.73","2228.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","920.93","31","","432.60","432.60","432.60","1 through 10","920.93","2361.73","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2970.73","2228.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1084.32","36.5","","148.37","54.89","631.39","94","920.93","2361.73","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2970.73","2228.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1137.79","38.3","","279.30","91.72","1116.77","266","920.93","2361.73","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2970.73","2228.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1274.44","42.9","","731.00","63.70","731.00","1 through 10","920.93","2361.73","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2970.73","2228.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1274.44","42.9","","384.74","384.74","384.74","1 through 10","920.93","2361.73","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","both","","","2970.73","2228.05","WELLPOINT [1015]","HB AMC WELLPOINT","2191.80","73.78","","286.63","119.22","1107.45","105","920.93","2361.73","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2970.73","2228.05","AETNA [1001]","HB AMC AETNA HMO","2073.57","69.8","","675.31","184.75","1721.50","286","1552.5","2427.68","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2970.73","2228.05","AETNA [1001]","HB AMC AETNA PPO","2388.47","80.4","","1261.44","103.12","1514.10","21","1552.5","2427.68","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2970.73","2228.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2388.47","80.4","","1365.00","1365.00","1365.00","1 through 10","1552.5","2427.68","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2970.73","2228.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2427.68","81.72","","5157.68","5157.68","5157.68","1 through 10","1552.5","2427.68","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2970.73","2228.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2427.68","81.72","","431.26","71.26","1459.57","88","1552.5","2427.68","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2718.21","2038.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2160.98","79.5","","800.18","480.96","1887.97","195","842.65","2160.98","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2718.21","2038.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1448.81","53.3","","813.12","216.42","1444.50","81","842.65","2160.98","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2718.21","2038.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","842.65","31","","432.60","432.60","432.60","1 through 10","842.65","2160.98","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2718.21","2038.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","992.15","36.5","","148.37","54.89","631.39","94","842.65","2160.98","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2718.21","2038.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1041.07","38.3","","279.30","91.72","1116.77","266","842.65","2160.98","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2718.21","2038.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1166.11","42.9","","731.00","63.70","731.00","1 through 10","842.65","2160.98","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2718.21","2038.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1166.11","42.9","","384.74","384.74","384.74","1 through 10","842.65","2160.98","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2718.21","2038.66","WELLPOINT [1015]","HB AMC WELLPOINT","2005.50","73.78","","286.63","119.22","1107.45","105","842.65","2160.98","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2718.21","2038.66","AETNA [1001]","HB AMC AETNA HMO","1897.31","69.8","","675.31","184.75","1721.50","286","1420.54","2221.32","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2718.21","2038.66","AETNA [1001]","HB AMC AETNA PPO","2185.44","80.4","","1261.44","103.12","1514.10","21","1420.54","2221.32","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2718.21","2038.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2185.44","80.4","","1365.00","1365.00","1365.00","1 through 10","1420.54","2221.32","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2718.21","2038.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2221.32","81.72","","5157.68","5157.68","5157.68","1 through 10","1420.54","2221.32","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2718.21","2038.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2221.32","81.72","","431.26","71.26","1459.57","88","1420.54","2221.32","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2433.76","1825.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1934.84","79.5","","800.18","480.96","1887.97","195","754.47","1934.84","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2433.76","1825.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1297.19","53.3","","813.12","216.42","1444.50","81","754.47","1934.84","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2433.76","1825.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","754.47","31","","432.60","432.60","432.60","1 through 10","754.47","1934.84","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2433.76","1825.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","888.32","36.5","","148.37","54.89","631.39","94","754.47","1934.84","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2433.76","1825.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","932.13","38.3","","279.30","91.72","1116.77","266","754.47","1934.84","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2433.76","1825.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1044.08","42.9","","731.00","63.70","731.00","1 through 10","754.47","1934.84","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2433.76","1825.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1044.08","42.9","","384.74","384.74","384.74","1 through 10","754.47","1934.84","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2433.76","1825.32","WELLPOINT [1015]","HB AMC WELLPOINT","1795.63","73.78","","286.63","119.22","1107.45","105","754.47","1934.84","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2433.76","1825.32","AETNA [1001]","HB AMC AETNA HMO","1698.76","69.8","","675.31","184.75","1721.50","286","1271.88","1988.87","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2433.76","1825.32","AETNA [1001]","HB AMC AETNA PPO","1956.74","80.4","","1261.44","103.12","1514.10","21","1271.88","1988.87","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2433.76","1825.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1956.74","80.4","","1365.00","1365.00","1365.00","1 through 10","1271.88","1988.87","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2433.76","1825.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1988.87","81.72","","5157.68","5157.68","5157.68","1 through 10","1271.88","1988.87","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2433.76","1825.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1988.87","81.72","","431.26","71.26","1459.57","88","1271.88","1988.87","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2508.80","1881.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1994.50","79.5","","800.18","480.96","1887.97","195","777.73","1994.5","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2508.80","1881.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1337.19","53.3","","813.12","216.42","1444.50","81","777.73","1994.5","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2508.80","1881.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","777.73","31","","432.60","432.60","432.60","1 through 10","777.73","1994.5","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2508.80","1881.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","915.71","36.5","","148.37","54.89","631.39","94","777.73","1994.5","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2508.80","1881.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","960.87","38.3","","279.30","91.72","1116.77","266","777.73","1994.5","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2508.80","1881.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1076.28","42.9","","731.00","63.70","731.00","1 through 10","777.73","1994.5","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2508.80","1881.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1076.28","42.9","","384.74","384.74","384.74","1 through 10","777.73","1994.5","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2508.80","1881.60","WELLPOINT [1015]","HB AMC WELLPOINT","1850.99","73.78","","286.63","119.22","1107.45","105","777.73","1994.5","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2508.80","1881.60","AETNA [1001]","HB AMC AETNA HMO","1751.14","69.8","","675.31","184.75","1721.50","286","1311.1","2050.19","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2508.80","1881.60","AETNA [1001]","HB AMC AETNA PPO","2017.08","80.4","","1261.44","103.12","1514.10","21","1311.1","2050.19","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2508.80","1881.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2017.08","80.4","","1365.00","1365.00","1365.00","1 through 10","1311.1","2050.19","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2508.80","1881.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2050.19","81.72","","5157.68","5157.68","5157.68","1 through 10","1311.1","2050.19","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2508.80","1881.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2050.19","81.72","","431.26","71.26","1459.57","88","1311.1","2050.19","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2586.08","1939.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2055.93","79.5","","800.18","480.96","1887.97","195","801.68","2055.93","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2586.08","1939.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1378.38","53.3","","813.12","216.42","1444.50","81","801.68","2055.93","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2586.08","1939.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","801.68","31","","432.60","432.60","432.60","1 through 10","801.68","2055.93","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2586.08","1939.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","943.92","36.5","","148.37","54.89","631.39","94","801.68","2055.93","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2586.08","1939.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","990.47","38.3","","279.30","91.72","1116.77","266","801.68","2055.93","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2586.08","1939.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1109.43","42.9","","731.00","63.70","731.00","1 through 10","801.68","2055.93","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2586.08","1939.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1109.43","42.9","","384.74","384.74","384.74","1 through 10","801.68","2055.93","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2586.08","1939.56","WELLPOINT [1015]","HB AMC WELLPOINT","1908.01","73.78","","286.63","119.22","1107.45","105","801.68","2055.93","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2586.08","1939.56","AETNA [1001]","HB AMC AETNA HMO","1805.08","69.8","","675.31","184.75","1721.50","286","1351.49","2113.34","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2586.08","1939.56","AETNA [1001]","HB AMC AETNA PPO","2079.21","80.4","","1261.44","103.12","1514.10","21","1351.49","2113.34","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2586.08","1939.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2079.21","80.4","","1365.00","1365.00","1365.00","1 through 10","1351.49","2113.34","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2586.08","1939.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2113.34","81.72","","5157.68","5157.68","5157.68","1 through 10","1351.49","2113.34","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2586.08","1939.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2113.34","81.72","","431.26","71.26","1459.57","88","1351.49","2113.34","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.12","1995.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2115.59","79.5","","800.18","480.96","1887.97","195","824.95","2115.59","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.12","1995.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1418.38","53.3","","813.12","216.42","1444.50","81","824.95","2115.59","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.12","1995.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","824.95","31","","432.60","432.60","432.60","1 through 10","824.95","2115.59","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.12","1995.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","971.31","36.5","","148.37","54.89","631.39","94","824.95","2115.59","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.12","1995.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1019.21","38.3","","279.30","91.72","1116.77","266","824.95","2115.59","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.12","1995.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1141.62","42.9","","731.00","63.70","731.00","1 through 10","824.95","2115.59","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.12","1995.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1141.62","42.9","","384.74","384.74","384.74","1 through 10","824.95","2115.59","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2661.12","1995.84","WELLPOINT [1015]","HB AMC WELLPOINT","1963.37","73.78","","286.63","119.22","1107.45","105","824.95","2115.59","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2661.12","1995.84","AETNA [1001]","HB AMC AETNA HMO","1857.46","69.8","","675.31","184.75","1721.50","286","1390.7","2174.67","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2661.12","1995.84","AETNA [1001]","HB AMC AETNA PPO","2139.54","80.4","","1261.44","103.12","1514.10","21","1390.7","2174.67","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2661.12","1995.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2139.54","80.4","","1365.00","1365.00","1365.00","1 through 10","1390.7","2174.67","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2661.12","1995.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2174.67","81.72","","5157.68","5157.68","5157.68","1 through 10","1390.7","2174.67","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2661.12","1995.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2174.67","81.72","","431.26","71.26","1459.57","88","1390.7","2174.67","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.80","2028.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2150.32","79.5","","800.18","480.96","1887.97","195","838.49","2150.32","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.80","2028.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1441.66","53.3","","813.12","216.42","1444.50","81","838.49","2150.32","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.80","2028.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","838.49","31","","432.60","432.60","432.60","1 through 10","838.49","2150.32","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.80","2028.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","987.25","36.5","","148.37","54.89","631.39","94","838.49","2150.32","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.80","2028.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1035.94","38.3","","279.30","91.72","1116.77","266","838.49","2150.32","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.80","2028.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1160.36","42.9","","731.00","63.70","731.00","1 through 10","838.49","2150.32","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.80","2028.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1160.36","42.9","","384.74","384.74","384.74","1 through 10","838.49","2150.32","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2704.80","2028.60","WELLPOINT [1015]","HB AMC WELLPOINT","1995.60","73.78","","286.63","119.22","1107.45","105","838.49","2150.32","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2704.80","2028.60","AETNA [1001]","HB AMC AETNA HMO","1887.95","69.8","","675.31","184.75","1721.50","286","1413.53","2210.36","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2704.80","2028.60","AETNA [1001]","HB AMC AETNA PPO","2174.66","80.4","","1261.44","103.12","1514.10","21","1413.53","2210.36","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2704.80","2028.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2174.66","80.4","","1365.00","1365.00","1365.00","1 through 10","1413.53","2210.36","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2704.80","2028.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2210.36","81.72","","5157.68","5157.68","5157.68","1 through 10","1413.53","2210.36","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2704.80","2028.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2210.36","81.72","","431.26","71.26","1459.57","88","1413.53","2210.36","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1444.80","1083.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1148.62","79.5","","800.18","480.96","1887.97","195","447.89","1148.62","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1444.80","1083.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","770.08","53.3","","813.12","216.42","1444.50","81","447.89","1148.62","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1444.80","1083.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","447.89","31","","432.60","432.60","432.60","1 through 10","447.89","1148.62","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1444.80","1083.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","527.35","36.5","","148.37","54.89","631.39","94","447.89","1148.62","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1444.80","1083.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","553.36","38.3","","279.30","91.72","1116.77","266","447.89","1148.62","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1444.80","1083.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","619.82","42.9","","731.00","63.70","731.00","1 through 10","447.89","1148.62","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1444.80","1083.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","619.82","42.9","","384.74","384.74","384.74","1 through 10","447.89","1148.62","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1444.80","1083.60","WELLPOINT [1015]","HB AMC WELLPOINT","1065.97","73.78","","286.63","119.22","1107.45","105","447.89","1148.62","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1444.80","1083.60","AETNA [1001]","HB AMC AETNA HMO","1008.47","69.8","","675.31","184.75","1721.50","286","755.05","1180.69","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1444.80","1083.60","AETNA [1001]","HB AMC AETNA PPO","1161.62","80.4","","1261.44","103.12","1514.10","21","755.05","1180.69","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1444.80","1083.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1161.62","80.4","","1365.00","1365.00","1365.00","1 through 10","755.05","1180.69","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1444.80","1083.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1180.69","81.72","","5157.68","5157.68","5157.68","1 through 10","755.05","1180.69","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1444.80","1083.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1180.69","81.72","","431.26","71.26","1459.57","88","755.05","1180.69","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.84","1748.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1853.81","79.5","","800.18","480.96","1887.97","195","722.87","1853.81","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.84","1748.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1242.87","53.3","","813.12","216.42","1444.50","81","722.87","1853.81","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.84","1748.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","722.87","31","","432.60","432.60","432.60","1 through 10","722.87","1853.81","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.84","1748.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","851.12","36.5","","148.37","54.89","631.39","94","722.87","1853.81","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.84","1748.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","893.09","38.3","","279.30","91.72","1116.77","266","722.87","1853.81","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.84","1748.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1000.36","42.9","","731.00","63.70","731.00","1 through 10","722.87","1853.81","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.84","1748.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1000.36","42.9","","384.74","384.74","384.74","1 through 10","722.87","1853.81","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.84","1748.88","WELLPOINT [1015]","HB AMC WELLPOINT","1720.43","73.78","","286.63","119.22","1107.45","105","722.87","1853.81","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2331.84","1748.88","AETNA [1001]","HB AMC AETNA HMO","1627.62","69.8","","675.31","184.75","1721.50","286","1218.62","1905.58","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2331.84","1748.88","AETNA [1001]","HB AMC AETNA PPO","1874.80","80.4","","1261.44","103.12","1514.10","21","1218.62","1905.58","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2331.84","1748.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1874.80","80.4","","1365.00","1365.00","1365.00","1 through 10","1218.62","1905.58","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2331.84","1748.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1905.58","81.72","","5157.68","5157.68","5157.68","1 through 10","1218.62","1905.58","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2331.84","1748.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1905.58","81.72","","431.26","71.26","1459.57","88","1218.62","1905.58","percent of total billed charges",""
"PLATE OSTEOTOMY TRANSLATIONAL CALCANEAL EDGELOCK","SUP-ITM-10082161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.00","3066.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3250.76","79.5","","800.18","480.96","1887.97","195","1267.59","3250.76","percent of total billed charges",""
"PLATE OSTEOTOMY TRANSLATIONAL CALCANEAL EDGELOCK","SUP-ITM-10082161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.00","3066.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2179.44","53.3","","813.12","216.42","1444.50","81","1267.59","3250.76","percent of total billed charges",""
"PLATE OSTEOTOMY TRANSLATIONAL CALCANEAL EDGELOCK","SUP-ITM-10082161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.00","3066.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1267.59","31","","432.60","432.60","432.60","1 through 10","1267.59","3250.76","percent of total billed charges",""
"PLATE OSTEOTOMY TRANSLATIONAL CALCANEAL EDGELOCK","SUP-ITM-10082161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.00","3066.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1492.49","36.5","","148.37","54.89","631.39","94","1267.59","3250.76","percent of total billed charges",""
"PLATE OSTEOTOMY TRANSLATIONAL CALCANEAL EDGELOCK","SUP-ITM-10082161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.00","3066.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1566.09","38.3","","279.30","91.72","1116.77","266","1267.59","3250.76","percent of total billed charges",""
"PLATE OSTEOTOMY TRANSLATIONAL CALCANEAL EDGELOCK","SUP-ITM-10082161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.00","3066.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1754.18","42.9","","731.00","63.70","731.00","1 through 10","1267.59","3250.76","percent of total billed charges",""
"PLATE OSTEOTOMY TRANSLATIONAL CALCANEAL EDGELOCK","SUP-ITM-10082161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.00","3066.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1754.18","42.9","","384.74","384.74","384.74","1 through 10","1267.59","3250.76","percent of total billed charges",""
"PLATE OSTEOTOMY TRANSLATIONAL CALCANEAL EDGELOCK","SUP-ITM-10082161","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.00","3066.75","WELLPOINT [1015]","HB AMC WELLPOINT","3016.86","73.78","","286.63","119.22","1107.45","105","1267.59","3250.76","percent of total billed charges",""
"PLATE OSTEOTOMY TRANSLATIONAL CALCANEAL EDGELOCK","SUP-ITM-10082161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4089.00","3066.75","AETNA [1001]","HB AMC AETNA HMO","2854.12","69.8","","675.31","184.75","1721.50","286","2136.91","3341.53","percent of total billed charges",""
"PLATE OSTEOTOMY TRANSLATIONAL CALCANEAL EDGELOCK","SUP-ITM-10082161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4089.00","3066.75","AETNA [1001]","HB AMC AETNA PPO","3287.56","80.4","","1261.44","103.12","1514.10","21","2136.91","3341.53","percent of total billed charges",""
"PLATE OSTEOTOMY TRANSLATIONAL CALCANEAL EDGELOCK","SUP-ITM-10082161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4089.00","3066.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3287.56","80.4","","1365.00","1365.00","1365.00","1 through 10","2136.91","3341.53","percent of total billed charges",""
"PLATE OSTEOTOMY TRANSLATIONAL CALCANEAL EDGELOCK","SUP-ITM-10082161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4089.00","3066.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3341.53","81.72","","5157.68","5157.68","5157.68","1 through 10","2136.91","3341.53","percent of total billed charges",""
"PLATE OSTEOTOMY TRANSLATIONAL CALCANEAL EDGELOCK","SUP-ITM-10082161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4089.00","3066.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3341.53","81.72","","431.26","71.26","1459.57","88","2136.91","3341.53","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1323.49","992.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1052.17","79.5","","800.18","480.96","1887.97","195","410.28","1052.17","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1323.49","992.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","705.42","53.3","","813.12","216.42","1444.50","81","410.28","1052.17","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1323.49","992.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","410.28","31","","432.60","432.60","432.60","1 through 10","410.28","1052.17","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1323.49","992.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","483.07","36.5","","148.37","54.89","631.39","94","410.28","1052.17","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1323.49","992.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","506.90","38.3","","279.30","91.72","1116.77","266","410.28","1052.17","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1323.49","992.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","567.78","42.9","","731.00","63.70","731.00","1 through 10","410.28","1052.17","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1323.49","992.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","567.78","42.9","","384.74","384.74","384.74","1 through 10","410.28","1052.17","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037397","CDM","C1713","HCPCS","0278","RC","","","","both","","","1323.49","992.62","WELLPOINT [1015]","HB AMC WELLPOINT","976.47","73.78","","286.63","119.22","1107.45","105","410.28","1052.17","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1323.49","992.62","AETNA [1001]","HB AMC AETNA HMO","923.80","69.8","","675.31","184.75","1721.50","286","691.66","1081.56","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1323.49","992.62","AETNA [1001]","HB AMC AETNA PPO","1064.09","80.4","","1261.44","103.12","1514.10","21","691.66","1081.56","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1323.49","992.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1064.09","80.4","","1365.00","1365.00","1365.00","1 through 10","691.66","1081.56","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1323.49","992.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1081.56","81.72","","5157.68","5157.68","5157.68","1 through 10","691.66","1081.56","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1323.49","992.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1081.56","81.72","","431.26","71.26","1459.57","88","691.66","1081.56","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2144.52","1608.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1704.89","79.5","","800.18","480.96","1887.97","195","664.8","1704.89","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2144.52","1608.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1143.03","53.3","","813.12","216.42","1444.50","81","664.8","1704.89","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2144.52","1608.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","664.80","31","","432.60","432.60","432.60","1 through 10","664.8","1704.89","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2144.52","1608.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","782.75","36.5","","148.37","54.89","631.39","94","664.8","1704.89","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2144.52","1608.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","821.35","38.3","","279.30","91.72","1116.77","266","664.8","1704.89","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2144.52","1608.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","920.00","42.9","","731.00","63.70","731.00","1 through 10","664.8","1704.89","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2144.52","1608.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","920.00","42.9","","384.74","384.74","384.74","1 through 10","664.8","1704.89","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2144.52","1608.39","WELLPOINT [1015]","HB AMC WELLPOINT","1582.23","73.78","","286.63","119.22","1107.45","105","664.8","1704.89","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2144.52","1608.39","AETNA [1001]","HB AMC AETNA HMO","1496.87","69.8","","675.31","184.75","1721.50","286","1120.73","1752.5","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2144.52","1608.39","AETNA [1001]","HB AMC AETNA PPO","1724.19","80.4","","1261.44","103.12","1514.10","21","1120.73","1752.5","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2144.52","1608.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1724.19","80.4","","1365.00","1365.00","1365.00","1 through 10","1120.73","1752.5","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2144.52","1608.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1752.50","81.72","","5157.68","5157.68","5157.68","1 through 10","1120.73","1752.5","percent of total billed charges",""
"PLATE PELVIC 3.5X104MM 8 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2144.52","1608.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1752.50","81.72","","431.26","71.26","1459.57","88","1120.73","1752.5","percent of total billed charges",""
"PLATE PELVIC 3.5X117MM 9 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.59","1032.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1094.39","79.5","","800.18","480.96","1887.97","195","426.74","1094.39","percent of total billed charges",""
"PLATE PELVIC 3.5X117MM 9 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.59","1032.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","733.72","53.3","","813.12","216.42","1444.50","81","426.74","1094.39","percent of total billed charges",""
"PLATE PELVIC 3.5X117MM 9 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.59","1032.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","426.74","31","","432.60","432.60","432.60","1 through 10","426.74","1094.39","percent of total billed charges",""
"PLATE PELVIC 3.5X117MM 9 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.59","1032.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","502.46","36.5","","148.37","54.89","631.39","94","426.74","1094.39","percent of total billed charges",""
"PLATE PELVIC 3.5X117MM 9 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.59","1032.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","527.23","38.3","","279.30","91.72","1116.77","266","426.74","1094.39","percent of total billed charges",""
"PLATE PELVIC 3.5X117MM 9 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.59","1032.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","590.56","42.9","","731.00","63.70","731.00","1 through 10","426.74","1094.39","percent of total billed charges",""
"PLATE PELVIC 3.5X117MM 9 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.59","1032.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","590.56","42.9","","384.74","384.74","384.74","1 through 10","426.74","1094.39","percent of total billed charges",""
"PLATE PELVIC 3.5X117MM 9 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037398","CDM","C1713","HCPCS","0278","RC","","","","both","","","1376.59","1032.44","WELLPOINT [1015]","HB AMC WELLPOINT","1015.65","73.78","","286.63","119.22","1107.45","105","426.74","1094.39","percent of total billed charges",""
"PLATE PELVIC 3.5X117MM 9 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1376.59","1032.44","AETNA [1001]","HB AMC AETNA HMO","960.86","69.8","","675.31","184.75","1721.50","286","719.41","1124.95","percent of total billed charges",""
"PLATE PELVIC 3.5X117MM 9 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1376.59","1032.44","AETNA [1001]","HB AMC AETNA PPO","1106.78","80.4","","1261.44","103.12","1514.10","21","719.41","1124.95","percent of total billed charges",""
"PLATE PELVIC 3.5X117MM 9 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1376.59","1032.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1106.78","80.4","","1365.00","1365.00","1365.00","1 through 10","719.41","1124.95","percent of total billed charges",""
"PLATE PELVIC 3.5X117MM 9 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1376.59","1032.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1124.95","81.72","","5157.68","5157.68","5157.68","1 through 10","719.41","1124.95","percent of total billed charges",""
"PLATE PELVIC 3.5X117MM 9 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1376.59","1032.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1124.95","81.72","","431.26","71.26","1459.57","88","719.41","1124.95","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE J RECONSTRUCTION LOCKING LOW PROFILE LEFT","SUP-ITM-10037412","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.34","1798.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1906.68","79.5","","800.18","480.96","1887.97","195","743.49","1906.68","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE J RECONSTRUCTION LOCKING LOW PROFILE LEFT","SUP-ITM-10037412","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.34","1798.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1278.32","53.3","","813.12","216.42","1444.50","81","743.49","1906.68","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE J RECONSTRUCTION LOCKING LOW PROFILE LEFT","SUP-ITM-10037412","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.34","1798.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","743.49","31","","432.60","432.60","432.60","1 through 10","743.49","1906.68","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE J RECONSTRUCTION LOCKING LOW PROFILE LEFT","SUP-ITM-10037412","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.34","1798.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","875.39","36.5","","148.37","54.89","631.39","94","743.49","1906.68","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE J RECONSTRUCTION LOCKING LOW PROFILE LEFT","SUP-ITM-10037412","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.34","1798.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","918.56","38.3","","279.30","91.72","1116.77","266","743.49","1906.68","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE J RECONSTRUCTION LOCKING LOW PROFILE LEFT","SUP-ITM-10037412","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.34","1798.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1028.89","42.9","","731.00","63.70","731.00","1 through 10","743.49","1906.68","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE J RECONSTRUCTION LOCKING LOW PROFILE LEFT","SUP-ITM-10037412","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.34","1798.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1028.89","42.9","","384.74","384.74","384.74","1 through 10","743.49","1906.68","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE J RECONSTRUCTION LOCKING LOW PROFILE LEFT","SUP-ITM-10037412","CDM","C1713","HCPCS","0278","RC","","","","both","","","2398.34","1798.75","WELLPOINT [1015]","HB AMC WELLPOINT","1769.50","73.78","","286.63","119.22","1107.45","105","743.49","1906.68","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE J RECONSTRUCTION LOCKING LOW PROFILE LEFT","SUP-ITM-10037412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2398.34","1798.75","AETNA [1001]","HB AMC AETNA HMO","1674.04","69.8","","675.31","184.75","1721.50","286","1253.37","1959.92","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE J RECONSTRUCTION LOCKING LOW PROFILE LEFT","SUP-ITM-10037412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2398.34","1798.75","AETNA [1001]","HB AMC AETNA PPO","1928.27","80.4","","1261.44","103.12","1514.10","21","1253.37","1959.92","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE J RECONSTRUCTION LOCKING LOW PROFILE LEFT","SUP-ITM-10037412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2398.34","1798.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1928.27","80.4","","1365.00","1365.00","1365.00","1 through 10","1253.37","1959.92","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE J RECONSTRUCTION LOCKING LOW PROFILE LEFT","SUP-ITM-10037412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2398.34","1798.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1959.92","81.72","","5157.68","5157.68","5157.68","1 through 10","1253.37","1959.92","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE J RECONSTRUCTION LOCKING LOW PROFILE LEFT","SUP-ITM-10037412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2398.34","1798.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1959.92","81.72","","431.26","71.26","1459.57","88","1253.37","1959.92","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1432.27","1074.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1138.65","79.5","","800.18","480.96","1887.97","195","444","1138.65","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1432.27","1074.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","763.40","53.3","","813.12","216.42","1444.50","81","444","1138.65","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1432.27","1074.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","444.00","31","","432.60","432.60","432.60","1 through 10","444","1138.65","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1432.27","1074.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.78","36.5","","148.37","54.89","631.39","94","444","1138.65","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1432.27","1074.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.56","38.3","","279.30","91.72","1116.77","266","444","1138.65","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1432.27","1074.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","614.44","42.9","","731.00","63.70","731.00","1 through 10","444","1138.65","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1432.27","1074.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","614.44","42.9","","384.74","384.74","384.74","1 through 10","444","1138.65","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1432.27","1074.20","WELLPOINT [1015]","HB AMC WELLPOINT","1056.73","73.78","","286.63","119.22","1107.45","105","444","1138.65","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1432.27","1074.20","AETNA [1001]","HB AMC AETNA HMO","999.72","69.8","","675.31","184.75","1721.50","286","748.5","1170.45","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1432.27","1074.20","AETNA [1001]","HB AMC AETNA PPO","1151.55","80.4","","1261.44","103.12","1514.10","21","748.5","1170.45","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1432.27","1074.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1151.55","80.4","","1365.00","1365.00","1365.00","1 through 10","748.5","1170.45","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1432.27","1074.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1170.45","81.72","","5157.68","5157.68","5157.68","1 through 10","748.5","1170.45","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1432.27","1074.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1170.45","81.72","","431.26","71.26","1459.57","88","748.5","1170.45","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2303.81","1727.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1831.53","79.5","","800.18","480.96","1887.97","195","714.18","1831.53","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2303.81","1727.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1227.93","53.3","","813.12","216.42","1444.50","81","714.18","1831.53","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2303.81","1727.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","714.18","31","","432.60","432.60","432.60","1 through 10","714.18","1831.53","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2303.81","1727.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","840.89","36.5","","148.37","54.89","631.39","94","714.18","1831.53","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2303.81","1727.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","882.36","38.3","","279.30","91.72","1116.77","266","714.18","1831.53","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2303.81","1727.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","988.33","42.9","","731.00","63.70","731.00","1 through 10","714.18","1831.53","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2303.81","1727.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","988.33","42.9","","384.74","384.74","384.74","1 through 10","714.18","1831.53","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037383","CDM","C1713","HCPCS","0278","RC","","","","both","","","2303.81","1727.86","WELLPOINT [1015]","HB AMC WELLPOINT","1699.75","73.78","","286.63","119.22","1107.45","105","714.18","1831.53","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2303.81","1727.86","AETNA [1001]","HB AMC AETNA HMO","1608.06","69.8","","675.31","184.75","1721.50","286","1203.97","1882.67","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2303.81","1727.86","AETNA [1001]","HB AMC AETNA PPO","1852.26","80.4","","1261.44","103.12","1514.10","21","1203.97","1882.67","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2303.81","1727.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1852.26","80.4","","1365.00","1365.00","1365.00","1 through 10","1203.97","1882.67","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2303.81","1727.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1882.67","81.72","","5157.68","5157.68","5157.68","1 through 10","1203.97","1882.67","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 10 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2303.81","1727.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1882.67","81.72","","431.26","71.26","1459.57","88","1203.97","1882.67","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037413","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.73","1898.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2012.73","79.5","","800.18","480.96","1887.97","195","784.84","2012.73","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037413","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.73","1898.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1349.41","53.3","","813.12","216.42","1444.50","81","784.84","2012.73","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037413","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.73","1898.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","784.84","31","","432.60","432.60","432.60","1 through 10","784.84","2012.73","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037413","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.73","1898.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","924.08","36.5","","148.37","54.89","631.39","94","784.84","2012.73","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037413","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.73","1898.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","969.65","38.3","","279.30","91.72","1116.77","266","784.84","2012.73","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037413","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.73","1898.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.11","42.9","","731.00","63.70","731.00","1 through 10","784.84","2012.73","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037413","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.73","1898.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1086.11","42.9","","384.74","384.74","384.74","1 through 10","784.84","2012.73","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037413","CDM","C1713","HCPCS","0278","RC","","","","both","","","2531.73","1898.80","WELLPOINT [1015]","HB AMC WELLPOINT","1867.91","73.78","","286.63","119.22","1107.45","105","784.84","2012.73","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2531.73","1898.80","AETNA [1001]","HB AMC AETNA HMO","1767.15","69.8","","675.31","184.75","1721.50","286","1323.08","2068.93","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2531.73","1898.80","AETNA [1001]","HB AMC AETNA PPO","2035.51","80.4","","1261.44","103.12","1514.10","21","1323.08","2068.93","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2531.73","1898.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2035.51","80.4","","1365.00","1365.00","1365.00","1 through 10","1323.08","2068.93","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2531.73","1898.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2068.93","81.72","","5157.68","5157.68","5157.68","1 through 10","1323.08","2068.93","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2531.73","1898.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2068.93","81.72","","431.26","71.26","1459.57","88","1323.08","2068.93","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037385","CDM","C1713","HCPCS","0278","RC","","","","both","","","2464.39","1848.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1959.19","79.5","","800.18","480.96","1887.97","195","763.96","1959.19","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037385","CDM","C1713","HCPCS","0278","RC","","","","both","","","2464.39","1848.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1313.52","53.3","","813.12","216.42","1444.50","81","763.96","1959.19","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037385","CDM","C1713","HCPCS","0278","RC","","","","both","","","2464.39","1848.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","763.96","31","","432.60","432.60","432.60","1 through 10","763.96","1959.19","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037385","CDM","C1713","HCPCS","0278","RC","","","","both","","","2464.39","1848.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","899.50","36.5","","148.37","54.89","631.39","94","763.96","1959.19","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037385","CDM","C1713","HCPCS","0278","RC","","","","both","","","2464.39","1848.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","943.86","38.3","","279.30","91.72","1116.77","266","763.96","1959.19","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037385","CDM","C1713","HCPCS","0278","RC","","","","both","","","2464.39","1848.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1057.22","42.9","","731.00","63.70","731.00","1 through 10","763.96","1959.19","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037385","CDM","C1713","HCPCS","0278","RC","","","","both","","","2464.39","1848.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1057.22","42.9","","384.74","384.74","384.74","1 through 10","763.96","1959.19","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037385","CDM","C1713","HCPCS","0278","RC","","","","both","","","2464.39","1848.29","WELLPOINT [1015]","HB AMC WELLPOINT","1818.23","73.78","","286.63","119.22","1107.45","105","763.96","1959.19","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2464.39","1848.29","AETNA [1001]","HB AMC AETNA HMO","1720.14","69.8","","675.31","184.75","1721.50","286","1287.89","2013.9","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2464.39","1848.29","AETNA [1001]","HB AMC AETNA PPO","1981.37","80.4","","1261.44","103.12","1514.10","21","1287.89","2013.9","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2464.39","1848.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1981.37","80.4","","1365.00","1365.00","1365.00","1 through 10","1287.89","2013.9","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2464.39","1848.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2013.90","81.72","","5157.68","5157.68","5157.68","1 through 10","1287.89","2013.9","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 12 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2464.39","1848.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2013.90","81.72","","431.26","71.26","1459.57","88","1287.89","2013.9","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 14 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2669.00","2001.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2121.86","79.5","","800.18","480.96","1887.97","195","827.39","2121.86","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 14 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2669.00","2001.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1422.58","53.3","","813.12","216.42","1444.50","81","827.39","2121.86","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 14 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2669.00","2001.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","827.39","31","","432.60","432.60","432.60","1 through 10","827.39","2121.86","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 14 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2669.00","2001.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","974.19","36.5","","148.37","54.89","631.39","94","827.39","2121.86","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 14 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2669.00","2001.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1022.23","38.3","","279.30","91.72","1116.77","266","827.39","2121.86","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 14 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2669.00","2001.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1145.00","42.9","","731.00","63.70","731.00","1 through 10","827.39","2121.86","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 14 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2669.00","2001.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1145.00","42.9","","384.74","384.74","384.74","1 through 10","827.39","2121.86","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 14 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037415","CDM","C1713","HCPCS","0278","RC","","","","both","","","2669.00","2001.75","WELLPOINT [1015]","HB AMC WELLPOINT","1969.19","73.78","","286.63","119.22","1107.45","105","827.39","2121.86","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 14 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2669.00","2001.75","AETNA [1001]","HB AMC AETNA HMO","1862.96","69.8","","675.31","184.75","1721.50","286","1394.82","2181.11","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 14 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2669.00","2001.75","AETNA [1001]","HB AMC AETNA PPO","2145.88","80.4","","1261.44","103.12","1514.10","21","1394.82","2181.11","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 14 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2669.00","2001.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2145.88","80.4","","1365.00","1365.00","1365.00","1 through 10","1394.82","2181.11","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 14 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2669.00","2001.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2181.11","81.72","","5157.68","5157.68","5157.68","1 through 10","1394.82","2181.11","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 14 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2669.00","2001.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2181.11","81.72","","431.26","71.26","1459.57","88","1394.82","2181.11","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 15 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2823.10","2117.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2244.36","79.5","","800.18","480.96","1887.97","195","875.16","2244.36","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 15 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2823.10","2117.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1504.71","53.3","","813.12","216.42","1444.50","81","875.16","2244.36","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 15 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2823.10","2117.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","875.16","31","","432.60","432.60","432.60","1 through 10","875.16","2244.36","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 15 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2823.10","2117.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1030.43","36.5","","148.37","54.89","631.39","94","875.16","2244.36","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 15 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2823.10","2117.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1081.25","38.3","","279.30","91.72","1116.77","266","875.16","2244.36","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 15 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2823.10","2117.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1211.11","42.9","","731.00","63.70","731.00","1 through 10","875.16","2244.36","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 15 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2823.10","2117.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1211.11","42.9","","384.74","384.74","384.74","1 through 10","875.16","2244.36","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 15 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2823.10","2117.32","WELLPOINT [1015]","HB AMC WELLPOINT","2082.88","73.78","","286.63","119.22","1107.45","105","875.16","2244.36","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 15 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2823.10","2117.32","AETNA [1001]","HB AMC AETNA HMO","1970.52","69.8","","675.31","184.75","1721.50","286","1475.35","2307.04","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 15 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2823.10","2117.32","AETNA [1001]","HB AMC AETNA PPO","2269.77","80.4","","1261.44","103.12","1514.10","21","1475.35","2307.04","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 15 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2823.10","2117.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2269.77","80.4","","1365.00","1365.00","1365.00","1 through 10","1475.35","2307.04","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 15 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2823.10","2117.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2307.04","81.72","","5157.68","5157.68","5157.68","1 through 10","1475.35","2307.04","percent of total billed charges",""
"PLATE PELVIC 3.5X130MM 15 HOLE LOCKING LOW PROFILE J SHAPE RIGHT","SUP-ITM-10037417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2823.10","2117.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2307.04","81.72","","431.26","71.26","1459.57","88","1475.35","2307.04","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037400","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1196.31","79.5","","800.18","480.96","1887.97","195","466.48","1196.31","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037400","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","802.05","53.3","","813.12","216.42","1444.50","81","466.48","1196.31","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037400","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","466.48","31","","432.60","432.60","432.60","1 through 10","466.48","1196.31","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037400","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","549.25","36.5","","148.37","54.89","631.39","94","466.48","1196.31","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037400","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","576.33","38.3","","279.30","91.72","1116.77","266","466.48","1196.31","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037400","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","645.55","42.9","","731.00","63.70","731.00","1 through 10","466.48","1196.31","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037400","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","645.55","42.9","","384.74","384.74","384.74","1 through 10","466.48","1196.31","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037400","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.79","1128.59","WELLPOINT [1015]","HB AMC WELLPOINT","1110.23","73.78","","286.63","119.22","1107.45","105","466.48","1196.31","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1504.79","1128.59","AETNA [1001]","HB AMC AETNA HMO","1050.34","69.8","","675.31","184.75","1721.50","286","786.4","1229.71","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1504.79","1128.59","AETNA [1001]","HB AMC AETNA PPO","1209.85","80.4","","1261.44","103.12","1514.10","21","786.4","1229.71","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1504.79","1128.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1209.85","80.4","","1365.00","1365.00","1365.00","1 through 10","786.4","1229.71","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1504.79","1128.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1229.71","81.72","","5157.68","5157.68","5157.68","1 through 10","786.4","1229.71","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1504.79","1128.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1229.71","81.72","","431.26","71.26","1459.57","88","786.4","1229.71","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2386.69","1790.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1897.42","79.5","","800.18","480.96","1887.97","195","739.87","1897.42","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2386.69","1790.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1272.11","53.3","","813.12","216.42","1444.50","81","739.87","1897.42","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2386.69","1790.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","739.87","31","","432.60","432.60","432.60","1 through 10","739.87","1897.42","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2386.69","1790.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","871.14","36.5","","148.37","54.89","631.39","94","739.87","1897.42","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2386.69","1790.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","914.10","38.3","","279.30","91.72","1116.77","266","739.87","1897.42","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2386.69","1790.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1023.89","42.9","","731.00","63.70","731.00","1 through 10","739.87","1897.42","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2386.69","1790.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1023.89","42.9","","384.74","384.74","384.74","1 through 10","739.87","1897.42","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037384","CDM","C1713","HCPCS","0278","RC","","","","both","","","2386.69","1790.02","WELLPOINT [1015]","HB AMC WELLPOINT","1760.90","73.78","","286.63","119.22","1107.45","105","739.87","1897.42","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2386.69","1790.02","AETNA [1001]","HB AMC AETNA HMO","1665.91","69.8","","675.31","184.75","1721.50","286","1247.28","1950.4","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2386.69","1790.02","AETNA [1001]","HB AMC AETNA PPO","1918.90","80.4","","1261.44","103.12","1514.10","21","1247.28","1950.4","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2386.69","1790.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1918.90","80.4","","1365.00","1365.00","1365.00","1 through 10","1247.28","1950.4","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2386.69","1790.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1950.40","81.72","","5157.68","5157.68","5157.68","1 through 10","1247.28","1950.4","percent of total billed charges",""
"PLATE PELVIC 3.5X143MM 11 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2386.69","1790.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1950.40","81.72","","431.26","71.26","1459.57","88","1247.28","1950.4","percent of total billed charges",""
"PLATE PELVIC 3.5X156MM 12 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.26","1192.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1264.26","79.5","","800.18","480.96","1887.97","195","492.98","1264.26","percent of total billed charges",""
"PLATE PELVIC 3.5X156MM 12 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.26","1192.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","847.61","53.3","","813.12","216.42","1444.50","81","492.98","1264.26","percent of total billed charges",""
"PLATE PELVIC 3.5X156MM 12 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.26","1192.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","492.98","31","","432.60","432.60","432.60","1 through 10","492.98","1264.26","percent of total billed charges",""
"PLATE PELVIC 3.5X156MM 12 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.26","1192.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","580.44","36.5","","148.37","54.89","631.39","94","492.98","1264.26","percent of total billed charges",""
"PLATE PELVIC 3.5X156MM 12 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.26","1192.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","609.07","38.3","","279.30","91.72","1116.77","266","492.98","1264.26","percent of total billed charges",""
"PLATE PELVIC 3.5X156MM 12 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.26","1192.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","682.22","42.9","","731.00","63.70","731.00","1 through 10","492.98","1264.26","percent of total billed charges",""
"PLATE PELVIC 3.5X156MM 12 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.26","1192.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","682.22","42.9","","384.74","384.74","384.74","1 through 10","492.98","1264.26","percent of total billed charges",""
"PLATE PELVIC 3.5X156MM 12 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1590.26","1192.69","WELLPOINT [1015]","HB AMC WELLPOINT","1173.29","73.78","","286.63","119.22","1107.45","105","492.98","1264.26","percent of total billed charges",""
"PLATE PELVIC 3.5X156MM 12 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1590.26","1192.69","AETNA [1001]","HB AMC AETNA HMO","1110.00","69.8","","675.31","184.75","1721.50","286","831.07","1299.56","percent of total billed charges",""
"PLATE PELVIC 3.5X156MM 12 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1590.26","1192.69","AETNA [1001]","HB AMC AETNA PPO","1278.57","80.4","","1261.44","103.12","1514.10","21","831.07","1299.56","percent of total billed charges",""
"PLATE PELVIC 3.5X156MM 12 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1590.26","1192.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1278.57","80.4","","1365.00","1365.00","1365.00","1 through 10","831.07","1299.56","percent of total billed charges",""
"PLATE PELVIC 3.5X156MM 12 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1590.26","1192.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1299.56","81.72","","5157.68","5157.68","5157.68","1 through 10","831.07","1299.56","percent of total billed charges",""
"PLATE PELVIC 3.5X156MM 12 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1590.26","1192.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1299.56","81.72","","431.26","71.26","1459.57","88","831.07","1299.56","percent of total billed charges",""
"PLATE PELVIC 3.5X169MM 13HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1670.55","1252.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1328.09","79.5","","800.18","480.96","1887.97","195","517.87","1328.09","percent of total billed charges",""
"PLATE PELVIC 3.5X169MM 13HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1670.55","1252.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","890.40","53.3","","813.12","216.42","1444.50","81","517.87","1328.09","percent of total billed charges",""
"PLATE PELVIC 3.5X169MM 13HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1670.55","1252.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","517.87","31","","432.60","432.60","432.60","1 through 10","517.87","1328.09","percent of total billed charges",""
"PLATE PELVIC 3.5X169MM 13HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1670.55","1252.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","609.75","36.5","","148.37","54.89","631.39","94","517.87","1328.09","percent of total billed charges",""
"PLATE PELVIC 3.5X169MM 13HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1670.55","1252.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","639.82","38.3","","279.30","91.72","1116.77","266","517.87","1328.09","percent of total billed charges",""
"PLATE PELVIC 3.5X169MM 13HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1670.55","1252.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","716.67","42.9","","731.00","63.70","731.00","1 through 10","517.87","1328.09","percent of total billed charges",""
"PLATE PELVIC 3.5X169MM 13HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1670.55","1252.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","716.67","42.9","","384.74","384.74","384.74","1 through 10","517.87","1328.09","percent of total billed charges",""
"PLATE PELVIC 3.5X169MM 13HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037402","CDM","C1713","HCPCS","0278","RC","","","","both","","","1670.55","1252.91","WELLPOINT [1015]","HB AMC WELLPOINT","1232.53","73.78","","286.63","119.22","1107.45","105","517.87","1328.09","percent of total billed charges",""
"PLATE PELVIC 3.5X169MM 13HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1670.55","1252.91","AETNA [1001]","HB AMC AETNA HMO","1166.04","69.8","","675.31","184.75","1721.50","286","873.03","1365.17","percent of total billed charges",""
"PLATE PELVIC 3.5X169MM 13HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1670.55","1252.91","AETNA [1001]","HB AMC AETNA PPO","1343.12","80.4","","1261.44","103.12","1514.10","21","873.03","1365.17","percent of total billed charges",""
"PLATE PELVIC 3.5X169MM 13HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1670.55","1252.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1343.12","80.4","","1365.00","1365.00","1365.00","1 through 10","873.03","1365.17","percent of total billed charges",""
"PLATE PELVIC 3.5X169MM 13HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1670.55","1252.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1365.17","81.72","","5157.68","5157.68","5157.68","1 through 10","873.03","1365.17","percent of total billed charges",""
"PLATE PELVIC 3.5X169MM 13HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1670.55","1252.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1365.17","81.72","","431.26","71.26","1459.57","88","873.03","1365.17","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037403","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.07","1307.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1385.74","79.5","","800.18","480.96","1887.97","195","540.35","1385.74","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037403","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.07","1307.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","929.06","53.3","","813.12","216.42","1444.50","81","540.35","1385.74","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037403","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.07","1307.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","540.35","31","","432.60","432.60","432.60","1 through 10","540.35","1385.74","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037403","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.07","1307.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","636.22","36.5","","148.37","54.89","631.39","94","540.35","1385.74","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037403","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.07","1307.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","667.60","38.3","","279.30","91.72","1116.77","266","540.35","1385.74","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037403","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.07","1307.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","747.78","42.9","","731.00","63.70","731.00","1 through 10","540.35","1385.74","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037403","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.07","1307.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","747.78","42.9","","384.74","384.74","384.74","1 through 10","540.35","1385.74","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037403","CDM","C1713","HCPCS","0278","RC","","","","both","","","1743.07","1307.30","WELLPOINT [1015]","HB AMC WELLPOINT","1286.04","73.78","","286.63","119.22","1107.45","105","540.35","1385.74","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1743.07","1307.30","AETNA [1001]","HB AMC AETNA HMO","1216.66","69.8","","675.31","184.75","1721.50","286","910.93","1424.44","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1743.07","1307.30","AETNA [1001]","HB AMC AETNA PPO","1401.43","80.4","","1261.44","103.12","1514.10","21","910.93","1424.44","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1743.07","1307.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1401.43","80.4","","1365.00","1365.00","1365.00","1 through 10","910.93","1424.44","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1743.07","1307.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1424.44","81.72","","5157.68","5157.68","5157.68","1 through 10","910.93","1424.44","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1743.07","1307.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1424.44","81.72","","431.26","71.26","1459.57","88","910.93","1424.44","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037387","CDM","C1713","HCPCS","0278","RC","","","","both","","","2627.56","1970.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2088.91","79.5","","800.18","480.96","1887.97","195","814.54","2088.91","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037387","CDM","C1713","HCPCS","0278","RC","","","","both","","","2627.56","1970.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1400.49","53.3","","813.12","216.42","1444.50","81","814.54","2088.91","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037387","CDM","C1713","HCPCS","0278","RC","","","","both","","","2627.56","1970.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","814.54","31","","432.60","432.60","432.60","1 through 10","814.54","2088.91","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037387","CDM","C1713","HCPCS","0278","RC","","","","both","","","2627.56","1970.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","959.06","36.5","","148.37","54.89","631.39","94","814.54","2088.91","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037387","CDM","C1713","HCPCS","0278","RC","","","","both","","","2627.56","1970.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1006.36","38.3","","279.30","91.72","1116.77","266","814.54","2088.91","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037387","CDM","C1713","HCPCS","0278","RC","","","","both","","","2627.56","1970.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1127.22","42.9","","731.00","63.70","731.00","1 through 10","814.54","2088.91","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037387","CDM","C1713","HCPCS","0278","RC","","","","both","","","2627.56","1970.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1127.22","42.9","","384.74","384.74","384.74","1 through 10","814.54","2088.91","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037387","CDM","C1713","HCPCS","0278","RC","","","","both","","","2627.56","1970.67","WELLPOINT [1015]","HB AMC WELLPOINT","1938.61","73.78","","286.63","119.22","1107.45","105","814.54","2088.91","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2627.56","1970.67","AETNA [1001]","HB AMC AETNA HMO","1834.04","69.8","","675.31","184.75","1721.50","286","1373.16","2147.24","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2627.56","1970.67","AETNA [1001]","HB AMC AETNA PPO","2112.56","80.4","","1261.44","103.12","1514.10","21","1373.16","2147.24","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2627.56","1970.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2112.56","80.4","","1365.00","1365.00","1365.00","1 through 10","1373.16","2147.24","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2627.56","1970.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2147.24","81.72","","5157.68","5157.68","5157.68","1 through 10","1373.16","2147.24","percent of total billed charges",""
"PLATE PELVIC 3.5X182MM 14 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2627.56","1970.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2147.24","81.72","","431.26","71.26","1459.57","88","1373.16","2147.24","percent of total billed charges",""
"PLATE PELVIC 3.5X195MM 15 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037404","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.13","1373.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1455.75","79.5","","800.18","480.96","1887.97","195","567.65","1455.75","percent of total billed charges",""
"PLATE PELVIC 3.5X195MM 15 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037404","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.13","1373.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","975.99","53.3","","813.12","216.42","1444.50","81","567.65","1455.75","percent of total billed charges",""
"PLATE PELVIC 3.5X195MM 15 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037404","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.13","1373.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","567.65","31","","432.60","432.60","432.60","1 through 10","567.65","1455.75","percent of total billed charges",""
"PLATE PELVIC 3.5X195MM 15 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037404","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.13","1373.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","668.36","36.5","","148.37","54.89","631.39","94","567.65","1455.75","percent of total billed charges",""
"PLATE PELVIC 3.5X195MM 15 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037404","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.13","1373.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","701.32","38.3","","279.30","91.72","1116.77","266","567.65","1455.75","percent of total billed charges",""
"PLATE PELVIC 3.5X195MM 15 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037404","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.13","1373.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","785.55","42.9","","731.00","63.70","731.00","1 through 10","567.65","1455.75","percent of total billed charges",""
"PLATE PELVIC 3.5X195MM 15 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037404","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.13","1373.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","785.55","42.9","","384.74","384.74","384.74","1 through 10","567.65","1455.75","percent of total billed charges",""
"PLATE PELVIC 3.5X195MM 15 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037404","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.13","1373.35","WELLPOINT [1015]","HB AMC WELLPOINT","1351.01","73.78","","286.63","119.22","1107.45","105","567.65","1455.75","percent of total billed charges",""
"PLATE PELVIC 3.5X195MM 15 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1831.13","1373.35","AETNA [1001]","HB AMC AETNA HMO","1278.13","69.8","","675.31","184.75","1721.50","286","956.95","1496.4","percent of total billed charges",""
"PLATE PELVIC 3.5X195MM 15 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1831.13","1373.35","AETNA [1001]","HB AMC AETNA PPO","1472.23","80.4","","1261.44","103.12","1514.10","21","956.95","1496.4","percent of total billed charges",""
"PLATE PELVIC 3.5X195MM 15 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1831.13","1373.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1472.23","80.4","","1365.00","1365.00","1365.00","1 through 10","956.95","1496.4","percent of total billed charges",""
"PLATE PELVIC 3.5X195MM 15 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1831.13","1373.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1496.40","81.72","","5157.68","5157.68","5157.68","1 through 10","956.95","1496.4","percent of total billed charges",""
"PLATE PELVIC 3.5X195MM 15 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1831.13","1373.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1496.40","81.72","","431.26","71.26","1459.57","88","956.95","1496.4","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037405","CDM","C1713","HCPCS","0278","RC","","","","both","","","1911.42","1433.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1519.58","79.5","","800.18","480.96","1887.97","195","592.54","1519.58","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037405","CDM","C1713","HCPCS","0278","RC","","","","both","","","1911.42","1433.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1018.79","53.3","","813.12","216.42","1444.50","81","592.54","1519.58","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037405","CDM","C1713","HCPCS","0278","RC","","","","both","","","1911.42","1433.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","592.54","31","","432.60","432.60","432.60","1 through 10","592.54","1519.58","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037405","CDM","C1713","HCPCS","0278","RC","","","","both","","","1911.42","1433.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","697.67","36.5","","148.37","54.89","631.39","94","592.54","1519.58","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037405","CDM","C1713","HCPCS","0278","RC","","","","both","","","1911.42","1433.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","732.07","38.3","","279.30","91.72","1116.77","266","592.54","1519.58","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037405","CDM","C1713","HCPCS","0278","RC","","","","both","","","1911.42","1433.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","820.00","42.9","","731.00","63.70","731.00","1 through 10","592.54","1519.58","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037405","CDM","C1713","HCPCS","0278","RC","","","","both","","","1911.42","1433.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","820.00","42.9","","384.74","384.74","384.74","1 through 10","592.54","1519.58","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037405","CDM","C1713","HCPCS","0278","RC","","","","both","","","1911.42","1433.56","WELLPOINT [1015]","HB AMC WELLPOINT","1410.25","73.78","","286.63","119.22","1107.45","105","592.54","1519.58","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1911.42","1433.56","AETNA [1001]","HB AMC AETNA HMO","1334.17","69.8","","675.31","184.75","1721.50","286","998.91","1562.01","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1911.42","1433.56","AETNA [1001]","HB AMC AETNA PPO","1536.78","80.4","","1261.44","103.12","1514.10","21","998.91","1562.01","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1911.42","1433.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1536.78","80.4","","1365.00","1365.00","1365.00","1 through 10","998.91","1562.01","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1911.42","1433.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1562.01","81.72","","5157.68","5157.68","5157.68","1 through 10","998.91","1562.01","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1911.42","1433.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1562.01","81.72","","431.26","71.26","1459.57","88","998.91","1562.01","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037389","CDM","C1713","HCPCS","0278","RC","","","","both","","","2786.84","2090.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2215.54","79.5","","800.18","480.96","1887.97","195","863.92","2215.54","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037389","CDM","C1713","HCPCS","0278","RC","","","","both","","","2786.84","2090.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1485.39","53.3","","813.12","216.42","1444.50","81","863.92","2215.54","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037389","CDM","C1713","HCPCS","0278","RC","","","","both","","","2786.84","2090.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","863.92","31","","432.60","432.60","432.60","1 through 10","863.92","2215.54","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037389","CDM","C1713","HCPCS","0278","RC","","","","both","","","2786.84","2090.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1017.20","36.5","","148.37","54.89","631.39","94","863.92","2215.54","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037389","CDM","C1713","HCPCS","0278","RC","","","","both","","","2786.84","2090.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1067.36","38.3","","279.30","91.72","1116.77","266","863.92","2215.54","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037389","CDM","C1713","HCPCS","0278","RC","","","","both","","","2786.84","2090.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1195.55","42.9","","731.00","63.70","731.00","1 through 10","863.92","2215.54","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037389","CDM","C1713","HCPCS","0278","RC","","","","both","","","2786.84","2090.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1195.55","42.9","","384.74","384.74","384.74","1 through 10","863.92","2215.54","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037389","CDM","C1713","HCPCS","0278","RC","","","","both","","","2786.84","2090.13","WELLPOINT [1015]","HB AMC WELLPOINT","2056.13","73.78","","286.63","119.22","1107.45","105","863.92","2215.54","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2786.84","2090.13","AETNA [1001]","HB AMC AETNA HMO","1945.21","69.8","","675.31","184.75","1721.50","286","1456.4","2277.41","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2786.84","2090.13","AETNA [1001]","HB AMC AETNA PPO","2240.62","80.4","","1261.44","103.12","1514.10","21","1456.4","2277.41","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2786.84","2090.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2240.62","80.4","","1365.00","1365.00","1365.00","1 through 10","1456.4","2277.41","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2786.84","2090.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2277.41","81.72","","5157.68","5157.68","5157.68","1 through 10","1456.4","2277.41","percent of total billed charges",""
"PLATE PELVIC 3.5X208MM 16 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2786.84","2090.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2277.41","81.72","","431.26","71.26","1459.57","88","1456.4","2277.41","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037406","CDM","C1713","HCPCS","0278","RC","","","","both","","","1993.01","1494.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1584.44","79.5","","800.18","480.96","1887.97","195","617.83","1584.44","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037406","CDM","C1713","HCPCS","0278","RC","","","","both","","","1993.01","1494.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1062.27","53.3","","813.12","216.42","1444.50","81","617.83","1584.44","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037406","CDM","C1713","HCPCS","0278","RC","","","","both","","","1993.01","1494.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","617.83","31","","432.60","432.60","432.60","1 through 10","617.83","1584.44","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037406","CDM","C1713","HCPCS","0278","RC","","","","both","","","1993.01","1494.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","727.45","36.5","","148.37","54.89","631.39","94","617.83","1584.44","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037406","CDM","C1713","HCPCS","0278","RC","","","","both","","","1993.01","1494.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","763.32","38.3","","279.30","91.72","1116.77","266","617.83","1584.44","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037406","CDM","C1713","HCPCS","0278","RC","","","","both","","","1993.01","1494.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","855.00","42.9","","731.00","63.70","731.00","1 through 10","617.83","1584.44","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037406","CDM","C1713","HCPCS","0278","RC","","","","both","","","1993.01","1494.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","855.00","42.9","","384.74","384.74","384.74","1 through 10","617.83","1584.44","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037406","CDM","C1713","HCPCS","0278","RC","","","","both","","","1993.01","1494.76","WELLPOINT [1015]","HB AMC WELLPOINT","1470.44","73.78","","286.63","119.22","1107.45","105","617.83","1584.44","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1993.01","1494.76","AETNA [1001]","HB AMC AETNA HMO","1391.12","69.8","","675.31","184.75","1721.50","286","1041.55","1628.69","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1993.01","1494.76","AETNA [1001]","HB AMC AETNA PPO","1602.38","80.4","","1261.44","103.12","1514.10","21","1041.55","1628.69","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1993.01","1494.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1602.38","80.4","","1365.00","1365.00","1365.00","1 through 10","1041.55","1628.69","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1993.01","1494.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1628.69","81.72","","5157.68","5157.68","5157.68","1 through 10","1041.55","1628.69","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1993.01","1494.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1628.69","81.72","","431.26","71.26","1459.57","88","1041.55","1628.69","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037390","CDM","C1713","HCPCS","0278","RC","","","","both","","","2868.43","2151.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2280.40","79.5","","800.18","480.96","1887.97","195","889.21","2280.4","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037390","CDM","C1713","HCPCS","0278","RC","","","","both","","","2868.43","2151.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1528.87","53.3","","813.12","216.42","1444.50","81","889.21","2280.4","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037390","CDM","C1713","HCPCS","0278","RC","","","","both","","","2868.43","2151.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","889.21","31","","432.60","432.60","432.60","1 through 10","889.21","2280.4","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037390","CDM","C1713","HCPCS","0278","RC","","","","both","","","2868.43","2151.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1046.98","36.5","","148.37","54.89","631.39","94","889.21","2280.4","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037390","CDM","C1713","HCPCS","0278","RC","","","","both","","","2868.43","2151.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1098.61","38.3","","279.30","91.72","1116.77","266","889.21","2280.4","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037390","CDM","C1713","HCPCS","0278","RC","","","","both","","","2868.43","2151.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1230.56","42.9","","731.00","63.70","731.00","1 through 10","889.21","2280.4","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037390","CDM","C1713","HCPCS","0278","RC","","","","both","","","2868.43","2151.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1230.56","42.9","","384.74","384.74","384.74","1 through 10","889.21","2280.4","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037390","CDM","C1713","HCPCS","0278","RC","","","","both","","","2868.43","2151.32","WELLPOINT [1015]","HB AMC WELLPOINT","2116.33","73.78","","286.63","119.22","1107.45","105","889.21","2280.4","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2868.43","2151.32","AETNA [1001]","HB AMC AETNA HMO","2002.16","69.8","","675.31","184.75","1721.50","286","1499.04","2344.08","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2868.43","2151.32","AETNA [1001]","HB AMC AETNA PPO","2306.22","80.4","","1261.44","103.12","1514.10","21","1499.04","2344.08","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2868.43","2151.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2306.22","80.4","","1365.00","1365.00","1365.00","1 through 10","1499.04","2344.08","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2868.43","2151.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2344.08","81.72","","5157.68","5157.68","5157.68","1 through 10","1499.04","2344.08","percent of total billed charges",""
"PLATE PELVIC 3.5X234MM 18 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2868.43","2151.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2344.08","81.72","","431.26","71.26","1459.57","88","1499.04","2344.08","percent of total billed charges",""
"PLATE PELVIC 3.5X260MM 20HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE HOLE","SUP-ITM-10037407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.53","1549.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1642.10","79.5","","800.18","480.96","1887.97","195","640.31","1642.1","percent of total billed charges",""
"PLATE PELVIC 3.5X260MM 20HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE HOLE","SUP-ITM-10037407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.53","1549.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1100.93","53.3","","813.12","216.42","1444.50","81","640.31","1642.1","percent of total billed charges",""
"PLATE PELVIC 3.5X260MM 20HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE HOLE","SUP-ITM-10037407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.53","1549.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","640.31","31","","432.60","432.60","432.60","1 through 10","640.31","1642.1","percent of total billed charges",""
"PLATE PELVIC 3.5X260MM 20HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE HOLE","SUP-ITM-10037407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.53","1549.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","753.92","36.5","","148.37","54.89","631.39","94","640.31","1642.1","percent of total billed charges",""
"PLATE PELVIC 3.5X260MM 20HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE HOLE","SUP-ITM-10037407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.53","1549.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","791.10","38.3","","279.30","91.72","1116.77","266","640.31","1642.1","percent of total billed charges",""
"PLATE PELVIC 3.5X260MM 20HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE HOLE","SUP-ITM-10037407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.53","1549.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","886.11","42.9","","731.00","63.70","731.00","1 through 10","640.31","1642.1","percent of total billed charges",""
"PLATE PELVIC 3.5X260MM 20HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE HOLE","SUP-ITM-10037407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.53","1549.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","886.11","42.9","","384.74","384.74","384.74","1 through 10","640.31","1642.1","percent of total billed charges",""
"PLATE PELVIC 3.5X260MM 20HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE HOLE","SUP-ITM-10037407","CDM","C1713","HCPCS","0278","RC","","","","both","","","2065.53","1549.15","WELLPOINT [1015]","HB AMC WELLPOINT","1523.95","73.78","","286.63","119.22","1107.45","105","640.31","1642.1","percent of total billed charges",""
"PLATE PELVIC 3.5X260MM 20HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE HOLE","SUP-ITM-10037407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.53","1549.15","AETNA [1001]","HB AMC AETNA HMO","1441.74","69.8","","675.31","184.75","1721.50","286","1079.45","1687.95","percent of total billed charges",""
"PLATE PELVIC 3.5X260MM 20HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE HOLE","SUP-ITM-10037407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.53","1549.15","AETNA [1001]","HB AMC AETNA PPO","1660.69","80.4","","1261.44","103.12","1514.10","21","1079.45","1687.95","percent of total billed charges",""
"PLATE PELVIC 3.5X260MM 20HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE HOLE","SUP-ITM-10037407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.53","1549.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1660.69","80.4","","1365.00","1365.00","1365.00","1 through 10","1079.45","1687.95","percent of total billed charges",""
"PLATE PELVIC 3.5X260MM 20HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE HOLE","SUP-ITM-10037407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.53","1549.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1687.95","81.72","","5157.68","5157.68","5157.68","1 through 10","1079.45","1687.95","percent of total billed charges",""
"PLATE PELVIC 3.5X260MM 20HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE HOLE","SUP-ITM-10037407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2065.53","1549.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1687.95","81.72","","431.26","71.26","1459.57","88","1079.45","1687.95","percent of total billed charges",""
"PLATE PELVIC 3.5X39MM 3 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1076.15","807.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","855.54","79.5","","800.18","480.96","1887.97","195","333.61","855.54","percent of total billed charges",""
"PLATE PELVIC 3.5X39MM 3 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1076.15","807.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","573.59","53.3","","813.12","216.42","1444.50","81","333.61","855.54","percent of total billed charges",""
"PLATE PELVIC 3.5X39MM 3 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1076.15","807.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","333.61","31","","432.60","432.60","432.60","1 through 10","333.61","855.54","percent of total billed charges",""
"PLATE PELVIC 3.5X39MM 3 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1076.15","807.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","392.79","36.5","","148.37","54.89","631.39","94","333.61","855.54","percent of total billed charges",""
"PLATE PELVIC 3.5X39MM 3 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1076.15","807.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","412.17","38.3","","279.30","91.72","1116.77","266","333.61","855.54","percent of total billed charges",""
"PLATE PELVIC 3.5X39MM 3 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1076.15","807.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","461.67","42.9","","731.00","63.70","731.00","1 through 10","333.61","855.54","percent of total billed charges",""
"PLATE PELVIC 3.5X39MM 3 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1076.15","807.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","461.67","42.9","","384.74","384.74","384.74","1 through 10","333.61","855.54","percent of total billed charges",""
"PLATE PELVIC 3.5X39MM 3 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1076.15","807.11","WELLPOINT [1015]","HB AMC WELLPOINT","793.98","73.78","","286.63","119.22","1107.45","105","333.61","855.54","percent of total billed charges",""
"PLATE PELVIC 3.5X39MM 3 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1076.15","807.11","AETNA [1001]","HB AMC AETNA HMO","751.15","69.8","","675.31","184.75","1721.50","286","562.4","879.43","percent of total billed charges",""
"PLATE PELVIC 3.5X39MM 3 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1076.15","807.11","AETNA [1001]","HB AMC AETNA PPO","865.22","80.4","","1261.44","103.12","1514.10","21","562.4","879.43","percent of total billed charges",""
"PLATE PELVIC 3.5X39MM 3 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1076.15","807.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","865.22","80.4","","1365.00","1365.00","1365.00","1 through 10","562.4","879.43","percent of total billed charges",""
"PLATE PELVIC 3.5X39MM 3 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1076.15","807.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","879.43","81.72","","5157.68","5157.68","5157.68","1 through 10","562.4","879.43","percent of total billed charges",""
"PLATE PELVIC 3.5X39MM 3 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1076.15","807.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","879.43","81.72","","431.26","71.26","1459.57","88","562.4","879.43","percent of total billed charges",""
"PLATE PELVIC 3.5X52MM 4 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.06","843.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","893.63","79.5","","800.18","480.96","1887.97","195","348.46","893.63","percent of total billed charges",""
"PLATE PELVIC 3.5X52MM 4 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.06","843.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","599.12","53.3","","813.12","216.42","1444.50","81","348.46","893.63","percent of total billed charges",""
"PLATE PELVIC 3.5X52MM 4 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.06","843.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","348.46","31","","432.60","432.60","432.60","1 through 10","348.46","893.63","percent of total billed charges",""
"PLATE PELVIC 3.5X52MM 4 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.06","843.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","410.28","36.5","","148.37","54.89","631.39","94","348.46","893.63","percent of total billed charges",""
"PLATE PELVIC 3.5X52MM 4 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.06","843.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","430.51","38.3","","279.30","91.72","1116.77","266","348.46","893.63","percent of total billed charges",""
"PLATE PELVIC 3.5X52MM 4 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.06","843.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","482.22","42.9","","731.00","63.70","731.00","1 through 10","348.46","893.63","percent of total billed charges",""
"PLATE PELVIC 3.5X52MM 4 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.06","843.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","482.22","42.9","","384.74","384.74","384.74","1 through 10","348.46","893.63","percent of total billed charges",""
"PLATE PELVIC 3.5X52MM 4 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037393","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.06","843.04","WELLPOINT [1015]","HB AMC WELLPOINT","829.33","73.78","","286.63","119.22","1107.45","105","348.46","893.63","percent of total billed charges",""
"PLATE PELVIC 3.5X52MM 4 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.06","843.04","AETNA [1001]","HB AMC AETNA HMO","784.59","69.8","","675.31","184.75","1721.50","286","587.43","918.58","percent of total billed charges",""
"PLATE PELVIC 3.5X52MM 4 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.06","843.04","AETNA [1001]","HB AMC AETNA PPO","903.74","80.4","","1261.44","103.12","1514.10","21","587.43","918.58","percent of total billed charges",""
"PLATE PELVIC 3.5X52MM 4 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.06","843.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","903.74","80.4","","1365.00","1365.00","1365.00","1 through 10","587.43","918.58","percent of total billed charges",""
"PLATE PELVIC 3.5X52MM 4 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.06","843.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","918.58","81.72","","5157.68","5157.68","5157.68","1 through 10","587.43","918.58","percent of total billed charges",""
"PLATE PELVIC 3.5X52MM 4 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.06","843.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","918.58","81.72","","431.26","71.26","1459.57","88","587.43","918.58","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 3 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1740.48","1305.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1383.68","79.5","","800.18","480.96","1887.97","195","539.55","1383.68","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 3 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1740.48","1305.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","927.68","53.3","","813.12","216.42","1444.50","81","539.55","1383.68","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 3 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1740.48","1305.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","539.55","31","","432.60","432.60","432.60","1 through 10","539.55","1383.68","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 3 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1740.48","1305.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","635.28","36.5","","148.37","54.89","631.39","94","539.55","1383.68","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 3 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1740.48","1305.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","666.60","38.3","","279.30","91.72","1116.77","266","539.55","1383.68","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 3 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1740.48","1305.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","746.67","42.9","","731.00","63.70","731.00","1 through 10","539.55","1383.68","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 3 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1740.48","1305.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","746.67","42.9","","384.74","384.74","384.74","1 through 10","539.55","1383.68","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 3 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1740.48","1305.36","WELLPOINT [1015]","HB AMC WELLPOINT","1284.13","73.78","","286.63","119.22","1107.45","105","539.55","1383.68","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 3 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1740.48","1305.36","AETNA [1001]","HB AMC AETNA HMO","1214.86","69.8","","675.31","184.75","1721.50","286","909.57","1422.32","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 3 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1740.48","1305.36","AETNA [1001]","HB AMC AETNA PPO","1399.35","80.4","","1261.44","103.12","1514.10","21","909.57","1422.32","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 3 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1740.48","1305.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1399.35","80.4","","1365.00","1365.00","1365.00","1 through 10","909.57","1422.32","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 3 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1740.48","1305.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1422.32","81.72","","5157.68","5157.68","5157.68","1 through 10","909.57","1422.32","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 3 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1740.48","1305.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1422.32","81.72","","431.26","71.26","1459.57","88","909.57","1422.32","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 4 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037377","CDM","C1713","HCPCS","0278","RC","","","","both","","","1828.54","1371.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1453.69","79.5","","800.18","480.96","1887.97","195","566.85","1453.69","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 4 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037377","CDM","C1713","HCPCS","0278","RC","","","","both","","","1828.54","1371.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","974.61","53.3","","813.12","216.42","1444.50","81","566.85","1453.69","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 4 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037377","CDM","C1713","HCPCS","0278","RC","","","","both","","","1828.54","1371.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","566.85","31","","432.60","432.60","432.60","1 through 10","566.85","1453.69","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 4 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037377","CDM","C1713","HCPCS","0278","RC","","","","both","","","1828.54","1371.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","667.42","36.5","","148.37","54.89","631.39","94","566.85","1453.69","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 4 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037377","CDM","C1713","HCPCS","0278","RC","","","","both","","","1828.54","1371.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","700.33","38.3","","279.30","91.72","1116.77","266","566.85","1453.69","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 4 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037377","CDM","C1713","HCPCS","0278","RC","","","","both","","","1828.54","1371.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","784.44","42.9","","731.00","63.70","731.00","1 through 10","566.85","1453.69","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 4 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037377","CDM","C1713","HCPCS","0278","RC","","","","both","","","1828.54","1371.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","784.44","42.9","","384.74","384.74","384.74","1 through 10","566.85","1453.69","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 4 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037377","CDM","C1713","HCPCS","0278","RC","","","","both","","","1828.54","1371.40","WELLPOINT [1015]","HB AMC WELLPOINT","1349.10","73.78","","286.63","119.22","1107.45","105","566.85","1453.69","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 4 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1828.54","1371.40","AETNA [1001]","HB AMC AETNA HMO","1276.32","69.8","","675.31","184.75","1721.50","286","955.6","1494.28","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 4 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1828.54","1371.40","AETNA [1001]","HB AMC AETNA PPO","1470.15","80.4","","1261.44","103.12","1514.10","21","955.6","1494.28","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 4 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1828.54","1371.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1470.15","80.4","","1365.00","1365.00","1365.00","1 through 10","955.6","1494.28","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 4 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1828.54","1371.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1494.28","81.72","","5157.68","5157.68","5157.68","1 through 10","955.6","1494.28","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 4 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1828.54","1371.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1494.28","81.72","","431.26","71.26","1459.57","88","955.6","1494.28","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037394","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.86","881.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","934.81","79.5","","800.18","480.96","1887.97","195","364.52","934.81","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037394","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.86","881.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","626.73","53.3","","813.12","216.42","1444.50","81","364.52","934.81","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037394","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.86","881.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","364.52","31","","432.60","432.60","432.60","1 through 10","364.52","934.81","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037394","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.86","881.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","429.19","36.5","","148.37","54.89","631.39","94","364.52","934.81","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037394","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.86","881.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","450.35","38.3","","279.30","91.72","1116.77","266","364.52","934.81","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037394","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.86","881.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","504.44","42.9","","731.00","63.70","731.00","1 through 10","364.52","934.81","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037394","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.86","881.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","504.44","42.9","","384.74","384.74","384.74","1 through 10","364.52","934.81","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037394","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.86","881.89","WELLPOINT [1015]","HB AMC WELLPOINT","867.55","73.78","","286.63","119.22","1107.45","105","364.52","934.81","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1175.86","881.89","AETNA [1001]","HB AMC AETNA HMO","820.75","69.8","","675.31","184.75","1721.50","286","614.5","960.91","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1175.86","881.89","AETNA [1001]","HB AMC AETNA PPO","945.39","80.4","","1261.44","103.12","1514.10","21","614.5","960.91","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1175.86","881.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","945.39","80.4","","1365.00","1365.00","1365.00","1 through 10","614.5","960.91","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1175.86","881.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","960.91","81.72","","5157.68","5157.68","5157.68","1 through 10","614.5","960.91","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1175.86","881.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","960.91","81.72","","431.26","71.26","1459.57","88","614.5","960.91","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.13","1432.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1518.55","79.5","","800.18","480.96","1887.97","195","592.14","1518.55","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.13","1432.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1018.10","53.3","","813.12","216.42","1444.50","81","592.14","1518.55","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.13","1432.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","592.14","31","","432.60","432.60","432.60","1 through 10","592.14","1518.55","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.13","1432.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","697.20","36.5","","148.37","54.89","631.39","94","592.14","1518.55","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.13","1432.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","731.58","38.3","","279.30","91.72","1116.77","266","592.14","1518.55","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.13","1432.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","819.45","42.9","","731.00","63.70","731.00","1 through 10","592.14","1518.55","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.13","1432.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","819.45","42.9","","384.74","384.74","384.74","1 through 10","592.14","1518.55","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1910.13","1432.60","WELLPOINT [1015]","HB AMC WELLPOINT","1409.29","73.78","","286.63","119.22","1107.45","105","592.14","1518.55","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1910.13","1432.60","AETNA [1001]","HB AMC AETNA HMO","1333.27","69.8","","675.31","184.75","1721.50","286","998.23","1560.96","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1910.13","1432.60","AETNA [1001]","HB AMC AETNA PPO","1535.74","80.4","","1261.44","103.12","1514.10","21","998.23","1560.96","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1910.13","1432.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1535.74","80.4","","1365.00","1365.00","1365.00","1 through 10","998.23","1560.96","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1910.13","1432.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1560.96","81.72","","5157.68","5157.68","5157.68","1 through 10","998.23","1560.96","percent of total billed charges",""
"PLATE PELVIC 3.5X65MM 5 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1910.13","1432.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1560.96","81.72","","431.26","71.26","1459.57","88","998.23","1560.96","percent of total billed charges",""
"PLATE PELVIC 3.5X78MM 6 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1987.83","1490.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1580.32","79.5","","800.18","480.96","1887.97","195","616.23","1580.32","percent of total billed charges",""
"PLATE PELVIC 3.5X78MM 6 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1987.83","1490.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1059.51","53.3","","813.12","216.42","1444.50","81","616.23","1580.32","percent of total billed charges",""
"PLATE PELVIC 3.5X78MM 6 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1987.83","1490.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","616.23","31","","432.60","432.60","432.60","1 through 10","616.23","1580.32","percent of total billed charges",""
"PLATE PELVIC 3.5X78MM 6 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1987.83","1490.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","725.56","36.5","","148.37","54.89","631.39","94","616.23","1580.32","percent of total billed charges",""
"PLATE PELVIC 3.5X78MM 6 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1987.83","1490.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","761.34","38.3","","279.30","91.72","1116.77","266","616.23","1580.32","percent of total billed charges",""
"PLATE PELVIC 3.5X78MM 6 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1987.83","1490.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","852.78","42.9","","731.00","63.70","731.00","1 through 10","616.23","1580.32","percent of total billed charges",""
"PLATE PELVIC 3.5X78MM 6 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1987.83","1490.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","852.78","42.9","","384.74","384.74","384.74","1 through 10","616.23","1580.32","percent of total billed charges",""
"PLATE PELVIC 3.5X78MM 6 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1987.83","1490.87","WELLPOINT [1015]","HB AMC WELLPOINT","1466.62","73.78","","286.63","119.22","1107.45","105","616.23","1580.32","percent of total billed charges",""
"PLATE PELVIC 3.5X78MM 6 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1987.83","1490.87","AETNA [1001]","HB AMC AETNA HMO","1387.51","69.8","","675.31","184.75","1721.50","286","1038.84","1624.45","percent of total billed charges",""
"PLATE PELVIC 3.5X78MM 6 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1987.83","1490.87","AETNA [1001]","HB AMC AETNA PPO","1598.22","80.4","","1261.44","103.12","1514.10","21","1038.84","1624.45","percent of total billed charges",""
"PLATE PELVIC 3.5X78MM 6 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1987.83","1490.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1598.22","80.4","","1365.00","1365.00","1365.00","1 through 10","1038.84","1624.45","percent of total billed charges",""
"PLATE PELVIC 3.5X78MM 6 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1987.83","1490.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1624.45","81.72","","5157.68","5157.68","5157.68","1 through 10","1038.84","1624.45","percent of total billed charges",""
"PLATE PELVIC 3.5X78MM 6 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1987.83","1490.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1624.45","81.72","","431.26","71.26","1459.57","88","1038.84","1624.45","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1278.17","958.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1016.15","79.5","","800.18","480.96","1887.97","195","396.23","1016.15","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1278.17","958.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","681.26","53.3","","813.12","216.42","1444.50","81","396.23","1016.15","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1278.17","958.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","396.23","31","","432.60","432.60","432.60","1 through 10","396.23","1016.15","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1278.17","958.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","466.53","36.5","","148.37","54.89","631.39","94","396.23","1016.15","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1278.17","958.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","489.54","38.3","","279.30","91.72","1116.77","266","396.23","1016.15","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1278.17","958.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","548.33","42.9","","731.00","63.70","731.00","1 through 10","396.23","1016.15","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1278.17","958.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","548.33","42.9","","384.74","384.74","384.74","1 through 10","396.23","1016.15","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037396","CDM","C1713","HCPCS","0278","RC","","","","both","","","1278.17","958.63","WELLPOINT [1015]","HB AMC WELLPOINT","943.03","73.78","","286.63","119.22","1107.45","105","396.23","1016.15","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1278.17","958.63","AETNA [1001]","HB AMC AETNA HMO","892.16","69.8","","675.31","184.75","1721.50","286","667.97","1044.52","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1278.17","958.63","AETNA [1001]","HB AMC AETNA PPO","1027.65","80.4","","1261.44","103.12","1514.10","21","667.97","1044.52","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1278.17","958.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1027.65","80.4","","1365.00","1365.00","1365.00","1 through 10","667.97","1044.52","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1278.17","958.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1044.52","81.72","","5157.68","5157.68","5157.68","1 through 10","667.97","1044.52","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE RECONSTRUCTION WIDE ANGLE LOW PROFILE","SUP-ITM-10037396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1278.17","958.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1044.52","81.72","","431.26","71.26","1459.57","88","667.97","1044.52","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.23","1548.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1641.06","79.5","","800.18","480.96","1887.97","195","639.91","1641.06","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.23","1548.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1100.23","53.3","","813.12","216.42","1444.50","81","639.91","1641.06","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.23","1548.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","639.91","31","","432.60","432.60","432.60","1 through 10","639.91","1641.06","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.23","1548.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","753.44","36.5","","148.37","54.89","631.39","94","639.91","1641.06","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.23","1548.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","790.60","38.3","","279.30","91.72","1116.77","266","639.91","1641.06","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.23","1548.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.55","42.9","","731.00","63.70","731.00","1 through 10","639.91","1641.06","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.23","1548.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.55","42.9","","384.74","384.74","384.74","1 through 10","639.91","1641.06","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037380","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.23","1548.17","WELLPOINT [1015]","HB AMC WELLPOINT","1522.99","73.78","","286.63","119.22","1107.45","105","639.91","1641.06","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2064.23","1548.17","AETNA [1001]","HB AMC AETNA HMO","1440.83","69.8","","675.31","184.75","1721.50","286","1078.77","1686.89","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2064.23","1548.17","AETNA [1001]","HB AMC AETNA PPO","1659.64","80.4","","1261.44","103.12","1514.10","21","1078.77","1686.89","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2064.23","1548.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1659.64","80.4","","1365.00","1365.00","1365.00","1 through 10","1078.77","1686.89","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2064.23","1548.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1686.89","81.72","","5157.68","5157.68","5157.68","1 through 10","1078.77","1686.89","percent of total billed charges",""
"PLATE PELVIC 3.5X91MM 7 HOLE TITANIUM LOCKING LOW PROFILE STRAIGHT","SUP-ITM-10037380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2064.23","1548.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1686.89","81.72","","431.26","71.26","1459.57","88","1078.77","1686.89","percent of total billed charges",""
"PLATE PELVIC 4.5X141MM 9 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004226","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1341.48","79.5","","800.18","480.96","1887.97","195","523.09","1341.48","percent of total billed charges",""
"PLATE PELVIC 4.5X141MM 9 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004226","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","899.38","53.3","","813.12","216.42","1444.50","81","523.09","1341.48","percent of total billed charges",""
"PLATE PELVIC 4.5X141MM 9 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004226","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","523.09","31","","432.60","432.60","432.60","1 through 10","523.09","1341.48","percent of total billed charges",""
"PLATE PELVIC 4.5X141MM 9 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004226","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","615.90","36.5","","148.37","54.89","631.39","94","523.09","1341.48","percent of total billed charges",""
"PLATE PELVIC 4.5X141MM 9 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004226","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","646.27","38.3","","279.30","91.72","1116.77","266","523.09","1341.48","percent of total billed charges",""
"PLATE PELVIC 4.5X141MM 9 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004226","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","723.89","42.9","","731.00","63.70","731.00","1 through 10","523.09","1341.48","percent of total billed charges",""
"PLATE PELVIC 4.5X141MM 9 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004226","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","723.89","42.9","","384.74","384.74","384.74","1 through 10","523.09","1341.48","percent of total billed charges",""
"PLATE PELVIC 4.5X141MM 9 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004226","CDM","C1713","HCPCS","0278","RC","","","","both","","","1687.39","1265.54","WELLPOINT [1015]","HB AMC WELLPOINT","1244.96","73.78","","286.63","119.22","1107.45","105","523.09","1341.48","percent of total billed charges",""
"PLATE PELVIC 4.5X141MM 9 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1687.39","1265.54","AETNA [1001]","HB AMC AETNA HMO","1177.80","69.8","","675.31","184.75","1721.50","286","881.83","1378.94","percent of total billed charges",""
"PLATE PELVIC 4.5X141MM 9 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1687.39","1265.54","AETNA [1001]","HB AMC AETNA PPO","1356.66","80.4","","1261.44","103.12","1514.10","21","881.83","1378.94","percent of total billed charges",""
"PLATE PELVIC 4.5X141MM 9 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1687.39","1265.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1356.66","80.4","","1365.00","1365.00","1365.00","1 through 10","881.83","1378.94","percent of total billed charges",""
"PLATE PELVIC 4.5X141MM 9 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1687.39","1265.54","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1378.94","81.72","","5157.68","5157.68","5157.68","1 through 10","881.83","1378.94","percent of total billed charges",""
"PLATE PELVIC 4.5X141MM 9 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1687.39","1265.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1378.94","81.72","","431.26","71.26","1459.57","88","881.83","1378.94","percent of total billed charges",""
"PLATE PELVIC 4.5X157MM 10 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10041362","CDM","C1713","HCPCS","0278","RC","","","","both","","","1766.38","1324.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1404.27","79.5","","800.18","480.96","1887.97","195","547.58","1404.27","percent of total billed charges",""
"PLATE PELVIC 4.5X157MM 10 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10041362","CDM","C1713","HCPCS","0278","RC","","","","both","","","1766.38","1324.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","941.48","53.3","","813.12","216.42","1444.50","81","547.58","1404.27","percent of total billed charges",""
"PLATE PELVIC 4.5X157MM 10 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10041362","CDM","C1713","HCPCS","0278","RC","","","","both","","","1766.38","1324.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","547.58","31","","432.60","432.60","432.60","1 through 10","547.58","1404.27","percent of total billed charges",""
"PLATE PELVIC 4.5X157MM 10 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10041362","CDM","C1713","HCPCS","0278","RC","","","","both","","","1766.38","1324.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","644.73","36.5","","148.37","54.89","631.39","94","547.58","1404.27","percent of total billed charges",""
"PLATE PELVIC 4.5X157MM 10 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10041362","CDM","C1713","HCPCS","0278","RC","","","","both","","","1766.38","1324.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","676.52","38.3","","279.30","91.72","1116.77","266","547.58","1404.27","percent of total billed charges",""
"PLATE PELVIC 4.5X157MM 10 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10041362","CDM","C1713","HCPCS","0278","RC","","","","both","","","1766.38","1324.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","757.78","42.9","","731.00","63.70","731.00","1 through 10","547.58","1404.27","percent of total billed charges",""
"PLATE PELVIC 4.5X157MM 10 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10041362","CDM","C1713","HCPCS","0278","RC","","","","both","","","1766.38","1324.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","757.78","42.9","","384.74","384.74","384.74","1 through 10","547.58","1404.27","percent of total billed charges",""
"PLATE PELVIC 4.5X157MM 10 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10041362","CDM","C1713","HCPCS","0278","RC","","","","both","","","1766.38","1324.78","WELLPOINT [1015]","HB AMC WELLPOINT","1303.24","73.78","","286.63","119.22","1107.45","105","547.58","1404.27","percent of total billed charges",""
"PLATE PELVIC 4.5X157MM 10 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10041362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1766.38","1324.78","AETNA [1001]","HB AMC AETNA HMO","1232.93","69.8","","675.31","184.75","1721.50","286","923.11","1443.49","percent of total billed charges",""
"PLATE PELVIC 4.5X157MM 10 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10041362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1766.38","1324.78","AETNA [1001]","HB AMC AETNA PPO","1420.17","80.4","","1261.44","103.12","1514.10","21","923.11","1443.49","percent of total billed charges",""
"PLATE PELVIC 4.5X157MM 10 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10041362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1766.38","1324.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1420.17","80.4","","1365.00","1365.00","1365.00","1 through 10","923.11","1443.49","percent of total billed charges",""
"PLATE PELVIC 4.5X157MM 10 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10041362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1766.38","1324.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1443.49","81.72","","5157.68","5157.68","5157.68","1 through 10","923.11","1443.49","percent of total billed charges",""
"PLATE PELVIC 4.5X157MM 10 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10041362","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1766.38","1324.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1443.49","81.72","","431.26","71.26","1459.57","88","923.11","1443.49","percent of total billed charges",""
"PLATE PELVIC 4.5X173MM 11 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004227","CDM","C1713","HCPCS","0278","RC","","","","both","","","1829.84","1372.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1454.72","79.5","","800.18","480.96","1887.97","195","567.25","1454.72","percent of total billed charges",""
"PLATE PELVIC 4.5X173MM 11 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004227","CDM","C1713","HCPCS","0278","RC","","","","both","","","1829.84","1372.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","975.30","53.3","","813.12","216.42","1444.50","81","567.25","1454.72","percent of total billed charges",""
"PLATE PELVIC 4.5X173MM 11 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004227","CDM","C1713","HCPCS","0278","RC","","","","both","","","1829.84","1372.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","567.25","31","","432.60","432.60","432.60","1 through 10","567.25","1454.72","percent of total billed charges",""
"PLATE PELVIC 4.5X173MM 11 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004227","CDM","C1713","HCPCS","0278","RC","","","","both","","","1829.84","1372.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","667.89","36.5","","148.37","54.89","631.39","94","567.25","1454.72","percent of total billed charges",""
"PLATE PELVIC 4.5X173MM 11 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004227","CDM","C1713","HCPCS","0278","RC","","","","both","","","1829.84","1372.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","700.83","38.3","","279.30","91.72","1116.77","266","567.25","1454.72","percent of total billed charges",""
"PLATE PELVIC 4.5X173MM 11 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004227","CDM","C1713","HCPCS","0278","RC","","","","both","","","1829.84","1372.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","785.00","42.9","","731.00","63.70","731.00","1 through 10","567.25","1454.72","percent of total billed charges",""
"PLATE PELVIC 4.5X173MM 11 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004227","CDM","C1713","HCPCS","0278","RC","","","","both","","","1829.84","1372.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","785.00","42.9","","384.74","384.74","384.74","1 through 10","567.25","1454.72","percent of total billed charges",""
"PLATE PELVIC 4.5X173MM 11 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004227","CDM","C1713","HCPCS","0278","RC","","","","both","","","1829.84","1372.38","WELLPOINT [1015]","HB AMC WELLPOINT","1350.06","73.78","","286.63","119.22","1107.45","105","567.25","1454.72","percent of total billed charges",""
"PLATE PELVIC 4.5X173MM 11 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1829.84","1372.38","AETNA [1001]","HB AMC AETNA HMO","1277.23","69.8","","675.31","184.75","1721.50","286","956.27","1495.35","percent of total billed charges",""
"PLATE PELVIC 4.5X173MM 11 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1829.84","1372.38","AETNA [1001]","HB AMC AETNA PPO","1471.19","80.4","","1261.44","103.12","1514.10","21","956.27","1495.35","percent of total billed charges",""
"PLATE PELVIC 4.5X173MM 11 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1829.84","1372.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1471.19","80.4","","1365.00","1365.00","1365.00","1 through 10","956.27","1495.35","percent of total billed charges",""
"PLATE PELVIC 4.5X173MM 11 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1829.84","1372.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1495.35","81.72","","5157.68","5157.68","5157.68","1 through 10","956.27","1495.35","percent of total billed charges",""
"PLATE PELVIC 4.5X173MM 11 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1829.84","1372.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1495.35","81.72","","431.26","71.26","1459.57","88","956.27","1495.35","percent of total billed charges",""
"PLATE PELVIC 4.5X189MM 12 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10027082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1915.31","1436.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1522.67","79.5","","800.18","480.96","1887.97","195","593.75","1522.67","percent of total billed charges",""
"PLATE PELVIC 4.5X189MM 12 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10027082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1915.31","1436.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1020.86","53.3","","813.12","216.42","1444.50","81","593.75","1522.67","percent of total billed charges",""
"PLATE PELVIC 4.5X189MM 12 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10027082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1915.31","1436.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","593.75","31","","432.60","432.60","432.60","1 through 10","593.75","1522.67","percent of total billed charges",""
"PLATE PELVIC 4.5X189MM 12 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10027082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1915.31","1436.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","699.09","36.5","","148.37","54.89","631.39","94","593.75","1522.67","percent of total billed charges",""
"PLATE PELVIC 4.5X189MM 12 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10027082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1915.31","1436.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","733.56","38.3","","279.30","91.72","1116.77","266","593.75","1522.67","percent of total billed charges",""
"PLATE PELVIC 4.5X189MM 12 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10027082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1915.31","1436.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","821.67","42.9","","731.00","63.70","731.00","1 through 10","593.75","1522.67","percent of total billed charges",""
"PLATE PELVIC 4.5X189MM 12 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10027082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1915.31","1436.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","821.67","42.9","","384.74","384.74","384.74","1 through 10","593.75","1522.67","percent of total billed charges",""
"PLATE PELVIC 4.5X189MM 12 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10027082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1915.31","1436.48","WELLPOINT [1015]","HB AMC WELLPOINT","1413.12","73.78","","286.63","119.22","1107.45","105","593.75","1522.67","percent of total billed charges",""
"PLATE PELVIC 4.5X189MM 12 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10027082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1915.31","1436.48","AETNA [1001]","HB AMC AETNA HMO","1336.89","69.8","","675.31","184.75","1721.50","286","1000.94","1565.19","percent of total billed charges",""
"PLATE PELVIC 4.5X189MM 12 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10027082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1915.31","1436.48","AETNA [1001]","HB AMC AETNA PPO","1539.91","80.4","","1261.44","103.12","1514.10","21","1000.94","1565.19","percent of total billed charges",""
"PLATE PELVIC 4.5X189MM 12 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10027082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1915.31","1436.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1539.91","80.4","","1365.00","1365.00","1365.00","1 through 10","1000.94","1565.19","percent of total billed charges",""
"PLATE PELVIC 4.5X189MM 12 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10027082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1915.31","1436.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1565.19","81.72","","5157.68","5157.68","5157.68","1 through 10","1000.94","1565.19","percent of total billed charges",""
"PLATE PELVIC 4.5X189MM 12 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10027082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1915.31","1436.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1565.19","81.72","","431.26","71.26","1459.57","88","1000.94","1565.19","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","2095.31","1571.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1665.77","79.5","","800.18","480.96","1887.97","195","649.55","1665.77","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","2095.31","1571.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1116.80","53.3","","813.12","216.42","1444.50","81","649.55","1665.77","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","2095.31","1571.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","649.55","31","","432.60","432.60","432.60","1 through 10","649.55","1665.77","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","2095.31","1571.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","764.79","36.5","","148.37","54.89","631.39","94","649.55","1665.77","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","2095.31","1571.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","802.50","38.3","","279.30","91.72","1116.77","266","649.55","1665.77","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","2095.31","1571.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","898.89","42.9","","731.00","63.70","731.00","1 through 10","649.55","1665.77","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","2095.31","1571.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","898.89","42.9","","384.74","384.74","384.74","1 through 10","649.55","1665.77","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","2095.31","1571.48","WELLPOINT [1015]","HB AMC WELLPOINT","1545.92","73.78","","286.63","119.22","1107.45","105","649.55","1665.77","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2095.31","1571.48","AETNA [1001]","HB AMC AETNA HMO","1462.53","69.8","","675.31","184.75","1721.50","286","1095.01","1712.29","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2095.31","1571.48","AETNA [1001]","HB AMC AETNA PPO","1684.63","80.4","","1261.44","103.12","1514.10","21","1095.01","1712.29","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2095.31","1571.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1684.63","80.4","","1365.00","1365.00","1365.00","1 through 10","1095.01","1712.29","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2095.31","1571.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1712.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1095.01","1712.29","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2095.31","1571.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1712.29","81.72","","431.26","71.26","1459.57","88","1095.01","1712.29","percent of total billed charges",""
"PLATE PELVIC 4.5X45MM 3 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10001641","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","945.10","79.5","","800.18","480.96","1887.97","195","368.53","945.1","percent of total billed charges",""
"PLATE PELVIC 4.5X45MM 3 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10001641","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","633.64","53.3","","813.12","216.42","1444.50","81","368.53","945.1","percent of total billed charges",""
"PLATE PELVIC 4.5X45MM 3 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10001641","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","368.53","31","","432.60","432.60","432.60","1 through 10","368.53","945.1","percent of total billed charges",""
"PLATE PELVIC 4.5X45MM 3 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10001641","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","433.92","36.5","","148.37","54.89","631.39","94","368.53","945.1","percent of total billed charges",""
"PLATE PELVIC 4.5X45MM 3 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10001641","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","455.31","38.3","","279.30","91.72","1116.77","266","368.53","945.1","percent of total billed charges",""
"PLATE PELVIC 4.5X45MM 3 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10001641","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","510.00","42.9","","731.00","63.70","731.00","1 through 10","368.53","945.1","percent of total billed charges",""
"PLATE PELVIC 4.5X45MM 3 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10001641","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","510.00","42.9","","384.74","384.74","384.74","1 through 10","368.53","945.1","percent of total billed charges",""
"PLATE PELVIC 4.5X45MM 3 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10001641","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","WELLPOINT [1015]","HB AMC WELLPOINT","877.10","73.78","","286.63","119.22","1107.45","105","368.53","945.1","percent of total billed charges",""
"PLATE PELVIC 4.5X45MM 3 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10001641","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.81","891.61","AETNA [1001]","HB AMC AETNA HMO","829.79","69.8","","675.31","184.75","1721.50","286","621.27","971.5","percent of total billed charges",""
"PLATE PELVIC 4.5X45MM 3 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10001641","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.81","891.61","AETNA [1001]","HB AMC AETNA PPO","955.80","80.4","","1261.44","103.12","1514.10","21","621.27","971.5","percent of total billed charges",""
"PLATE PELVIC 4.5X45MM 3 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10001641","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.81","891.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","955.80","80.4","","1365.00","1365.00","1365.00","1 through 10","621.27","971.5","percent of total billed charges",""
"PLATE PELVIC 4.5X45MM 3 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10001641","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.81","891.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","971.50","81.72","","5157.68","5157.68","5157.68","1 through 10","621.27","971.5","percent of total billed charges",""
"PLATE PELVIC 4.5X45MM 3 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10001641","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.81","891.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","971.50","81.72","","431.26","71.26","1459.57","88","621.27","971.5","percent of total billed charges",""
"PLATE PELVIC 4.5X61MM 4 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1236.73","927.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","983.20","79.5","","800.18","480.96","1887.97","195","383.39","983.2","percent of total billed charges",""
"PLATE PELVIC 4.5X61MM 4 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1236.73","927.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","659.18","53.3","","813.12","216.42","1444.50","81","383.39","983.2","percent of total billed charges",""
"PLATE PELVIC 4.5X61MM 4 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1236.73","927.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","383.39","31","","432.60","432.60","432.60","1 through 10","383.39","983.2","percent of total billed charges",""
"PLATE PELVIC 4.5X61MM 4 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1236.73","927.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","451.41","36.5","","148.37","54.89","631.39","94","383.39","983.2","percent of total billed charges",""
"PLATE PELVIC 4.5X61MM 4 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1236.73","927.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","473.67","38.3","","279.30","91.72","1116.77","266","383.39","983.2","percent of total billed charges",""
"PLATE PELVIC 4.5X61MM 4 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1236.73","927.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","530.56","42.9","","731.00","63.70","731.00","1 through 10","383.39","983.2","percent of total billed charges",""
"PLATE PELVIC 4.5X61MM 4 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1236.73","927.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","530.56","42.9","","384.74","384.74","384.74","1 through 10","383.39","983.2","percent of total billed charges",""
"PLATE PELVIC 4.5X61MM 4 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1236.73","927.55","WELLPOINT [1015]","HB AMC WELLPOINT","912.46","73.78","","286.63","119.22","1107.45","105","383.39","983.2","percent of total billed charges",""
"PLATE PELVIC 4.5X61MM 4 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1236.73","927.55","AETNA [1001]","HB AMC AETNA HMO","863.24","69.8","","675.31","184.75","1721.50","286","646.32","1010.66","percent of total billed charges",""
"PLATE PELVIC 4.5X61MM 4 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1236.73","927.55","AETNA [1001]","HB AMC AETNA PPO","994.33","80.4","","1261.44","103.12","1514.10","21","646.32","1010.66","percent of total billed charges",""
"PLATE PELVIC 4.5X61MM 4 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1236.73","927.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","994.33","80.4","","1365.00","1365.00","1365.00","1 through 10","646.32","1010.66","percent of total billed charges",""
"PLATE PELVIC 4.5X61MM 4 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1236.73","927.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1010.66","81.72","","5157.68","5157.68","5157.68","1 through 10","646.32","1010.66","percent of total billed charges",""
"PLATE PELVIC 4.5X61MM 4 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1236.73","927.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1010.66","81.72","","431.26","71.26","1459.57","88","646.32","1010.66","percent of total billed charges",""
"PLATE PELVIC 4.5X77MM 5 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1348.10","1011.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1071.74","79.5","","800.18","480.96","1887.97","195","417.91","1071.74","percent of total billed charges",""
"PLATE PELVIC 4.5X77MM 5 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1348.10","1011.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","718.54","53.3","","813.12","216.42","1444.50","81","417.91","1071.74","percent of total billed charges",""
"PLATE PELVIC 4.5X77MM 5 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1348.10","1011.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","417.91","31","","432.60","432.60","432.60","1 through 10","417.91","1071.74","percent of total billed charges",""
"PLATE PELVIC 4.5X77MM 5 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1348.10","1011.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","492.06","36.5","","148.37","54.89","631.39","94","417.91","1071.74","percent of total billed charges",""
"PLATE PELVIC 4.5X77MM 5 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1348.10","1011.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","516.32","38.3","","279.30","91.72","1116.77","266","417.91","1071.74","percent of total billed charges",""
"PLATE PELVIC 4.5X77MM 5 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1348.10","1011.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","578.33","42.9","","731.00","63.70","731.00","1 through 10","417.91","1071.74","percent of total billed charges",""
"PLATE PELVIC 4.5X77MM 5 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1348.10","1011.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","578.33","42.9","","384.74","384.74","384.74","1 through 10","417.91","1071.74","percent of total billed charges",""
"PLATE PELVIC 4.5X77MM 5 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1348.10","1011.07","WELLPOINT [1015]","HB AMC WELLPOINT","994.63","73.78","","286.63","119.22","1107.45","105","417.91","1071.74","percent of total billed charges",""
"PLATE PELVIC 4.5X77MM 5 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1348.10","1011.07","AETNA [1001]","HB AMC AETNA HMO","940.97","69.8","","675.31","184.75","1721.50","286","704.52","1101.67","percent of total billed charges",""
"PLATE PELVIC 4.5X77MM 5 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1348.10","1011.07","AETNA [1001]","HB AMC AETNA PPO","1083.87","80.4","","1261.44","103.12","1514.10","21","704.52","1101.67","percent of total billed charges",""
"PLATE PELVIC 4.5X77MM 5 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1348.10","1011.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1083.87","80.4","","1365.00","1365.00","1365.00","1 through 10","704.52","1101.67","percent of total billed charges",""
"PLATE PELVIC 4.5X77MM 5 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1348.10","1011.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1101.67","81.72","","5157.68","5157.68","5157.68","1 through 10","704.52","1101.67","percent of total billed charges",""
"PLATE PELVIC 4.5X77MM 5 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1348.10","1011.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1101.67","81.72","","431.26","71.26","1459.57","88","704.52","1101.67","percent of total billed charges",""
"PLATE PELVIC 4.5X93MM 6 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1430.98","1073.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1137.63","79.5","","800.18","480.96","1887.97","195","443.6","1137.63","percent of total billed charges",""
"PLATE PELVIC 4.5X93MM 6 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1430.98","1073.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","762.71","53.3","","813.12","216.42","1444.50","81","443.6","1137.63","percent of total billed charges",""
"PLATE PELVIC 4.5X93MM 6 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1430.98","1073.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","443.60","31","","432.60","432.60","432.60","1 through 10","443.6","1137.63","percent of total billed charges",""
"PLATE PELVIC 4.5X93MM 6 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1430.98","1073.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.31","36.5","","148.37","54.89","631.39","94","443.6","1137.63","percent of total billed charges",""
"PLATE PELVIC 4.5X93MM 6 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1430.98","1073.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.07","38.3","","279.30","91.72","1116.77","266","443.6","1137.63","percent of total billed charges",""
"PLATE PELVIC 4.5X93MM 6 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1430.98","1073.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","613.89","42.9","","731.00","63.70","731.00","1 through 10","443.6","1137.63","percent of total billed charges",""
"PLATE PELVIC 4.5X93MM 6 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1430.98","1073.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","613.89","42.9","","384.74","384.74","384.74","1 through 10","443.6","1137.63","percent of total billed charges",""
"PLATE PELVIC 4.5X93MM 6 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1430.98","1073.23","WELLPOINT [1015]","HB AMC WELLPOINT","1055.78","73.78","","286.63","119.22","1107.45","105","443.6","1137.63","percent of total billed charges",""
"PLATE PELVIC 4.5X93MM 6 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1430.98","1073.23","AETNA [1001]","HB AMC AETNA HMO","998.82","69.8","","675.31","184.75","1721.50","286","747.83","1169.4","percent of total billed charges",""
"PLATE PELVIC 4.5X93MM 6 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1430.98","1073.23","AETNA [1001]","HB AMC AETNA PPO","1150.51","80.4","","1261.44","103.12","1514.10","21","747.83","1169.4","percent of total billed charges",""
"PLATE PELVIC 4.5X93MM 6 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1430.98","1073.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1150.51","80.4","","1365.00","1365.00","1365.00","1 through 10","747.83","1169.4","percent of total billed charges",""
"PLATE PELVIC 4.5X93MM 6 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1430.98","1073.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1169.40","81.72","","5157.68","5157.68","5157.68","1 through 10","747.83","1169.4","percent of total billed charges",""
"PLATE PELVIC 4.5X93MM 6 HOLE LC DCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1430.98","1073.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1169.40","81.72","","431.26","71.26","1459.57","88","747.83","1169.4","percent of total billed charges",""
"PLATE PREBENT 8 HOLE RIBFIX BLU","SUP-ITM-10338530","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.00","3415.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3620.43","79.5","","800.18","480.96","1887.97","195","1411.74","3620.43","percent of total billed charges",""
"PLATE PREBENT 8 HOLE RIBFIX BLU","SUP-ITM-10338530","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.00","3415.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2427.28","53.3","","813.12","216.42","1444.50","81","1411.74","3620.43","percent of total billed charges",""
"PLATE PREBENT 8 HOLE RIBFIX BLU","SUP-ITM-10338530","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.00","3415.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1411.74","31","","432.60","432.60","432.60","1 through 10","1411.74","3620.43","percent of total billed charges",""
"PLATE PREBENT 8 HOLE RIBFIX BLU","SUP-ITM-10338530","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.00","3415.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1662.21","36.5","","148.37","54.89","631.39","94","1411.74","3620.43","percent of total billed charges",""
"PLATE PREBENT 8 HOLE RIBFIX BLU","SUP-ITM-10338530","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.00","3415.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1744.18","38.3","","279.30","91.72","1116.77","266","1411.74","3620.43","percent of total billed charges",""
"PLATE PREBENT 8 HOLE RIBFIX BLU","SUP-ITM-10338530","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.00","3415.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1953.67","42.9","","731.00","63.70","731.00","1 through 10","1411.74","3620.43","percent of total billed charges",""
"PLATE PREBENT 8 HOLE RIBFIX BLU","SUP-ITM-10338530","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.00","3415.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1953.67","42.9","","384.74","384.74","384.74","1 through 10","1411.74","3620.43","percent of total billed charges",""
"PLATE PREBENT 8 HOLE RIBFIX BLU","SUP-ITM-10338530","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.00","3415.50","WELLPOINT [1015]","HB AMC WELLPOINT","3359.94","73.78","","286.63","119.22","1107.45","105","1411.74","3620.43","percent of total billed charges",""
"PLATE PREBENT 8 HOLE RIBFIX BLU","SUP-ITM-10338530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4554.00","3415.50","AETNA [1001]","HB AMC AETNA HMO","3178.69","69.8","","675.31","184.75","1721.50","286","2379.92","3721.53","percent of total billed charges",""
"PLATE PREBENT 8 HOLE RIBFIX BLU","SUP-ITM-10338530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4554.00","3415.50","AETNA [1001]","HB AMC AETNA PPO","3661.42","80.4","","1261.44","103.12","1514.10","21","2379.92","3721.53","percent of total billed charges",""
"PLATE PREBENT 8 HOLE RIBFIX BLU","SUP-ITM-10338530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4554.00","3415.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3661.42","80.4","","1365.00","1365.00","1365.00","1 through 10","2379.92","3721.53","percent of total billed charges",""
"PLATE PREBENT 8 HOLE RIBFIX BLU","SUP-ITM-10338530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4554.00","3415.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3721.53","81.72","","5157.68","5157.68","5157.68","1 through 10","2379.92","3721.53","percent of total billed charges",""
"PLATE PREBENT 8 HOLE RIBFIX BLU","SUP-ITM-10338530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4554.00","3415.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3721.53","81.72","","431.26","71.26","1459.57","88","2379.92","3721.53","percent of total billed charges",""
"PLATE PRINTED 3D MANDIBLE TITANIUM TRUMATCH MANDIBLE MEDIUM","SUP-ITM-10236846","CDM","C1713","HCPCS","0278","RC","","","","both","","","9979.20","7484.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7933.46","79.5","","800.18","480.96","1887.97","195","3093.55","7933.46","percent of total billed charges",""
"PLATE PRINTED 3D MANDIBLE TITANIUM TRUMATCH MANDIBLE MEDIUM","SUP-ITM-10236846","CDM","C1713","HCPCS","0278","RC","","","","both","","","9979.20","7484.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5318.91","53.3","","813.12","216.42","1444.50","81","3093.55","7933.46","percent of total billed charges",""
"PLATE PRINTED 3D MANDIBLE TITANIUM TRUMATCH MANDIBLE MEDIUM","SUP-ITM-10236846","CDM","C1713","HCPCS","0278","RC","","","","both","","","9979.20","7484.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3093.55","31","","432.60","432.60","432.60","1 through 10","3093.55","7933.46","percent of total billed charges",""
"PLATE PRINTED 3D MANDIBLE TITANIUM TRUMATCH MANDIBLE MEDIUM","SUP-ITM-10236846","CDM","C1713","HCPCS","0278","RC","","","","both","","","9979.20","7484.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3642.41","36.5","","148.37","54.89","631.39","94","3093.55","7933.46","percent of total billed charges",""
"PLATE PRINTED 3D MANDIBLE TITANIUM TRUMATCH MANDIBLE MEDIUM","SUP-ITM-10236846","CDM","C1713","HCPCS","0278","RC","","","","both","","","9979.20","7484.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3822.03","38.3","","279.30","91.72","1116.77","266","3093.55","7933.46","percent of total billed charges",""
"PLATE PRINTED 3D MANDIBLE TITANIUM TRUMATCH MANDIBLE MEDIUM","SUP-ITM-10236846","CDM","C1713","HCPCS","0278","RC","","","","both","","","9979.20","7484.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4281.08","42.9","","731.00","63.70","731.00","1 through 10","3093.55","7933.46","percent of total billed charges",""
"PLATE PRINTED 3D MANDIBLE TITANIUM TRUMATCH MANDIBLE MEDIUM","SUP-ITM-10236846","CDM","C1713","HCPCS","0278","RC","","","","both","","","9979.20","7484.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4281.08","42.9","","384.74","384.74","384.74","1 through 10","3093.55","7933.46","percent of total billed charges",""
"PLATE PRINTED 3D MANDIBLE TITANIUM TRUMATCH MANDIBLE MEDIUM","SUP-ITM-10236846","CDM","C1713","HCPCS","0278","RC","","","","both","","","9979.20","7484.40","WELLPOINT [1015]","HB AMC WELLPOINT","7362.65","73.78","","286.63","119.22","1107.45","105","3093.55","7933.46","percent of total billed charges",""
"PLATE PRINTED 3D MANDIBLE TITANIUM TRUMATCH MANDIBLE MEDIUM","SUP-ITM-10236846","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9979.20","7484.40","AETNA [1001]","HB AMC AETNA HMO","6965.48","69.8","","675.31","184.75","1721.50","286","5215.13","8155","percent of total billed charges",""
"PLATE PRINTED 3D MANDIBLE TITANIUM TRUMATCH MANDIBLE MEDIUM","SUP-ITM-10236846","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9979.20","7484.40","AETNA [1001]","HB AMC AETNA PPO","8023.28","80.4","","1261.44","103.12","1514.10","21","5215.13","8155","percent of total billed charges",""
"PLATE PRINTED 3D MANDIBLE TITANIUM TRUMATCH MANDIBLE MEDIUM","SUP-ITM-10236846","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9979.20","7484.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8023.28","80.4","","1365.00","1365.00","1365.00","1 through 10","5215.13","8155","percent of total billed charges",""
"PLATE PRINTED 3D MANDIBLE TITANIUM TRUMATCH MANDIBLE MEDIUM","SUP-ITM-10236846","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9979.20","7484.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8155.00","81.72","","5157.68","5157.68","5157.68","1 through 10","5215.13","8155","percent of total billed charges",""
"PLATE PRINTED 3D MANDIBLE TITANIUM TRUMATCH MANDIBLE MEDIUM","SUP-ITM-10236846","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9979.20","7484.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8155.00","81.72","","431.26","71.26","1459.57","88","5215.13","8155","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","4521.02","3390.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3594.21","79.5","","800.18","480.96","1887.97","195","1401.52","3594.21","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","4521.02","3390.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2409.70","53.3","","813.12","216.42","1444.50","81","1401.52","3594.21","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","4521.02","3390.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1401.52","31","","432.60","432.60","432.60","1 through 10","1401.52","3594.21","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","4521.02","3390.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1650.17","36.5","","148.37","54.89","631.39","94","1401.52","3594.21","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","4521.02","3390.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1731.55","38.3","","279.30","91.72","1116.77","266","1401.52","3594.21","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","4521.02","3390.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1939.52","42.9","","731.00","63.70","731.00","1 through 10","1401.52","3594.21","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","4521.02","3390.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1939.52","42.9","","384.74","384.74","384.74","1 through 10","1401.52","3594.21","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","4521.02","3390.76","WELLPOINT [1015]","HB AMC WELLPOINT","3335.61","73.78","","286.63","119.22","1107.45","105","1401.52","3594.21","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4521.02","3390.76","AETNA [1001]","HB AMC AETNA HMO","3155.67","69.8","","675.31","184.75","1721.50","286","2362.69","3694.58","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4521.02","3390.76","AETNA [1001]","HB AMC AETNA PPO","3634.90","80.4","","1261.44","103.12","1514.10","21","2362.69","3694.58","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4521.02","3390.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3634.90","80.4","","1365.00","1365.00","1365.00","1 through 10","2362.69","3694.58","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4521.02","3390.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3694.58","81.72","","5157.68","5157.68","5157.68","1 through 10","2362.69","3694.58","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4521.02","3390.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3694.58","81.72","","431.26","71.26","1459.57","88","2362.69","3694.58","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10024518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3931.92","2948.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3125.88","79.5","","800.18","480.96","1887.97","195","1218.9","3125.88","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10024518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3931.92","2948.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2095.71","53.3","","813.12","216.42","1444.50","81","1218.9","3125.88","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10024518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3931.92","2948.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1218.90","31","","432.60","432.60","432.60","1 through 10","1218.9","3125.88","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10024518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3931.92","2948.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1435.15","36.5","","148.37","54.89","631.39","94","1218.9","3125.88","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10024518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3931.92","2948.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1505.93","38.3","","279.30","91.72","1116.77","266","1218.9","3125.88","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10024518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3931.92","2948.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1686.79","42.9","","731.00","63.70","731.00","1 through 10","1218.9","3125.88","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10024518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3931.92","2948.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1686.79","42.9","","384.74","384.74","384.74","1 through 10","1218.9","3125.88","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10024518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3931.92","2948.94","WELLPOINT [1015]","HB AMC WELLPOINT","2900.97","73.78","","286.63","119.22","1107.45","105","1218.9","3125.88","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10024518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3931.92","2948.94","AETNA [1001]","HB AMC AETNA HMO","2744.48","69.8","","675.31","184.75","1721.50","286","2054.82","3213.17","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10024518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3931.92","2948.94","AETNA [1001]","HB AMC AETNA PPO","3161.26","80.4","","1261.44","103.12","1514.10","21","2054.82","3213.17","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10024518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3931.92","2948.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3161.26","80.4","","1365.00","1365.00","1365.00","1 through 10","2054.82","3213.17","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10024518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3931.92","2948.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3213.17","81.72","","5157.68","5157.68","5157.68","1 through 10","2054.82","3213.17","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10024518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3931.92","2948.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3213.17","81.72","","431.26","71.26","1459.57","88","2054.82","3213.17","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2234.40","1675.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1776.35","79.5","","800.18","480.96","1887.97","195","692.66","1776.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2234.40","1675.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1190.94","53.3","","813.12","216.42","1444.50","81","692.66","1776.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2234.40","1675.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","692.66","31","","432.60","432.60","432.60","1 through 10","692.66","1776.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2234.40","1675.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","815.56","36.5","","148.37","54.89","631.39","94","692.66","1776.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2234.40","1675.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","855.78","38.3","","279.30","91.72","1116.77","266","692.66","1776.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2234.40","1675.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","958.56","42.9","","731.00","63.70","731.00","1 through 10","692.66","1776.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2234.40","1675.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","958.56","42.9","","384.74","384.74","384.74","1 through 10","692.66","1776.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2234.40","1675.80","WELLPOINT [1015]","HB AMC WELLPOINT","1648.54","73.78","","286.63","119.22","1107.45","105","692.66","1776.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2234.40","1675.80","AETNA [1001]","HB AMC AETNA HMO","1559.61","69.8","","675.31","184.75","1721.50","286","1167.7","1825.95","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2234.40","1675.80","AETNA [1001]","HB AMC AETNA PPO","1796.46","80.4","","1261.44","103.12","1514.10","21","1167.7","1825.95","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2234.40","1675.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1796.46","80.4","","1365.00","1365.00","1365.00","1 through 10","1167.7","1825.95","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2234.40","1675.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1825.95","81.72","","5157.68","5157.68","5157.68","1 through 10","1167.7","1825.95","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2234.40","1675.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1825.95","81.72","","431.26","71.26","1459.57","88","1167.7","1825.95","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2621.82","1966.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2084.35","79.5","","800.18","480.96","1887.97","195","812.76","2084.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2621.82","1966.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1397.43","53.3","","813.12","216.42","1444.50","81","812.76","2084.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2621.82","1966.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","812.76","31","","432.60","432.60","432.60","1 through 10","812.76","2084.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2621.82","1966.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","956.96","36.5","","148.37","54.89","631.39","94","812.76","2084.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2621.82","1966.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1004.16","38.3","","279.30","91.72","1116.77","266","812.76","2084.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2621.82","1966.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1124.76","42.9","","731.00","63.70","731.00","1 through 10","812.76","2084.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2621.82","1966.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1124.76","42.9","","384.74","384.74","384.74","1 through 10","812.76","2084.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2621.82","1966.36","WELLPOINT [1015]","HB AMC WELLPOINT","1934.38","73.78","","286.63","119.22","1107.45","105","812.76","2084.35","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2621.82","1966.36","AETNA [1001]","HB AMC AETNA HMO","1830.03","69.8","","675.31","184.75","1721.50","286","1370.16","2142.55","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2621.82","1966.36","AETNA [1001]","HB AMC AETNA PPO","2107.94","80.4","","1261.44","103.12","1514.10","21","1370.16","2142.55","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2621.82","1966.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2107.94","80.4","","1365.00","1365.00","1365.00","1 through 10","1370.16","2142.55","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2621.82","1966.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2142.55","81.72","","5157.68","5157.68","5157.68","1 through 10","1370.16","2142.55","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2621.82","1966.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2142.55","81.72","","431.26","71.26","1459.57","88","1370.16","2142.55","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2719.82","2039.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2162.26","79.5","","800.18","480.96","1887.97","195","843.14","2162.26","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2719.82","2039.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1449.66","53.3","","813.12","216.42","1444.50","81","843.14","2162.26","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2719.82","2039.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","843.14","31","","432.60","432.60","432.60","1 through 10","843.14","2162.26","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2719.82","2039.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","992.73","36.5","","148.37","54.89","631.39","94","843.14","2162.26","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2719.82","2039.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1041.69","38.3","","279.30","91.72","1116.77","266","843.14","2162.26","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2719.82","2039.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1166.80","42.9","","731.00","63.70","731.00","1 through 10","843.14","2162.26","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2719.82","2039.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1166.80","42.9","","384.74","384.74","384.74","1 through 10","843.14","2162.26","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2719.82","2039.86","WELLPOINT [1015]","HB AMC WELLPOINT","2006.68","73.78","","286.63","119.22","1107.45","105","843.14","2162.26","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2719.82","2039.86","AETNA [1001]","HB AMC AETNA HMO","1898.43","69.8","","675.31","184.75","1721.50","286","1421.38","2222.64","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2719.82","2039.86","AETNA [1001]","HB AMC AETNA PPO","2186.74","80.4","","1261.44","103.12","1514.10","21","1421.38","2222.64","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2719.82","2039.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2186.74","80.4","","1365.00","1365.00","1365.00","1 through 10","1421.38","2222.64","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2719.82","2039.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2222.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1421.38","2222.64","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2719.82","2039.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2222.64","81.72","","431.26","71.26","1459.57","88","1421.38","2222.64","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1761.20","1320.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1400.15","79.5","","800.18","480.96","1887.97","195","545.97","1400.15","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1761.20","1320.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","938.72","53.3","","813.12","216.42","1444.50","81","545.97","1400.15","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1761.20","1320.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","545.97","31","","432.60","432.60","432.60","1 through 10","545.97","1400.15","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1761.20","1320.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","642.84","36.5","","148.37","54.89","631.39","94","545.97","1400.15","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1761.20","1320.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","674.54","38.3","","279.30","91.72","1116.77","266","545.97","1400.15","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1761.20","1320.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","755.55","42.9","","731.00","63.70","731.00","1 through 10","545.97","1400.15","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1761.20","1320.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","755.55","42.9","","384.74","384.74","384.74","1 through 10","545.97","1400.15","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1761.20","1320.90","WELLPOINT [1015]","HB AMC WELLPOINT","1299.41","73.78","","286.63","119.22","1107.45","105","545.97","1400.15","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1761.20","1320.90","AETNA [1001]","HB AMC AETNA HMO","1229.32","69.8","","675.31","184.75","1721.50","286","920.4","1439.25","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1761.20","1320.90","AETNA [1001]","HB AMC AETNA PPO","1416.00","80.4","","1261.44","103.12","1514.10","21","920.4","1439.25","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1761.20","1320.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1416.00","80.4","","1365.00","1365.00","1365.00","1 through 10","920.4","1439.25","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1761.20","1320.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1439.25","81.72","","5157.68","5157.68","5157.68","1 through 10","920.4","1439.25","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1761.20","1320.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1439.25","81.72","","431.26","71.26","1459.57","88","920.4","1439.25","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1914.36","1435.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1521.92","79.5","","800.18","480.96","1887.97","195","593.45","1521.92","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1914.36","1435.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1020.35","53.3","","813.12","216.42","1444.50","81","593.45","1521.92","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1914.36","1435.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","593.45","31","","432.60","432.60","432.60","1 through 10","593.45","1521.92","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1914.36","1435.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","698.74","36.5","","148.37","54.89","631.39","94","593.45","1521.92","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1914.36","1435.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","733.20","38.3","","279.30","91.72","1116.77","266","593.45","1521.92","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1914.36","1435.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","821.26","42.9","","731.00","63.70","731.00","1 through 10","593.45","1521.92","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1914.36","1435.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","821.26","42.9","","384.74","384.74","384.74","1 through 10","593.45","1521.92","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1914.36","1435.77","WELLPOINT [1015]","HB AMC WELLPOINT","1412.41","73.78","","286.63","119.22","1107.45","105","593.45","1521.92","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1914.36","1435.77","AETNA [1001]","HB AMC AETNA HMO","1336.22","69.8","","675.31","184.75","1721.50","286","1000.44","1564.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1914.36","1435.77","AETNA [1001]","HB AMC AETNA PPO","1539.15","80.4","","1261.44","103.12","1514.10","21","1000.44","1564.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1914.36","1435.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1539.15","80.4","","1365.00","1365.00","1365.00","1 through 10","1000.44","1564.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1914.36","1435.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1564.41","81.72","","5157.68","5157.68","5157.68","1 through 10","1000.44","1564.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1914.36","1435.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1564.41","81.72","","431.26","71.26","1459.57","88","1000.44","1564.41","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG LCP TITANIUM SHAPE DISTAL","SUP-ITM-10010129","CDM","C1713","HCPCS","0278","RC","","","","both","","","2107.00","1580.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1675.07","79.5","","800.18","480.96","1887.97","195","653.17","1675.07","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG LCP TITANIUM SHAPE DISTAL","SUP-ITM-10010129","CDM","C1713","HCPCS","0278","RC","","","","both","","","2107.00","1580.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1123.03","53.3","","813.12","216.42","1444.50","81","653.17","1675.07","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG LCP TITANIUM SHAPE DISTAL","SUP-ITM-10010129","CDM","C1713","HCPCS","0278","RC","","","","both","","","2107.00","1580.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","653.17","31","","432.60","432.60","432.60","1 through 10","653.17","1675.07","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG LCP TITANIUM SHAPE DISTAL","SUP-ITM-10010129","CDM","C1713","HCPCS","0278","RC","","","","both","","","2107.00","1580.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","769.06","36.5","","148.37","54.89","631.39","94","653.17","1675.07","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG LCP TITANIUM SHAPE DISTAL","SUP-ITM-10010129","CDM","C1713","HCPCS","0278","RC","","","","both","","","2107.00","1580.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","806.98","38.3","","279.30","91.72","1116.77","266","653.17","1675.07","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG LCP TITANIUM SHAPE DISTAL","SUP-ITM-10010129","CDM","C1713","HCPCS","0278","RC","","","","both","","","2107.00","1580.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","903.90","42.9","","731.00","63.70","731.00","1 through 10","653.17","1675.07","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG LCP TITANIUM SHAPE DISTAL","SUP-ITM-10010129","CDM","C1713","HCPCS","0278","RC","","","","both","","","2107.00","1580.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","903.90","42.9","","384.74","384.74","384.74","1 through 10","653.17","1675.07","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG LCP TITANIUM SHAPE DISTAL","SUP-ITM-10010129","CDM","C1713","HCPCS","0278","RC","","","","both","","","2107.00","1580.25","WELLPOINT [1015]","HB AMC WELLPOINT","1554.54","73.78","","286.63","119.22","1107.45","105","653.17","1675.07","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG LCP TITANIUM SHAPE DISTAL","SUP-ITM-10010129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2107.00","1580.25","AETNA [1001]","HB AMC AETNA HMO","1470.69","69.8","","675.31","184.75","1721.50","286","1101.12","1721.84","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG LCP TITANIUM SHAPE DISTAL","SUP-ITM-10010129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2107.00","1580.25","AETNA [1001]","HB AMC AETNA PPO","1694.03","80.4","","1261.44","103.12","1514.10","21","1101.12","1721.84","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG LCP TITANIUM SHAPE DISTAL","SUP-ITM-10010129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2107.00","1580.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1694.03","80.4","","1365.00","1365.00","1365.00","1 through 10","1101.12","1721.84","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG LCP TITANIUM SHAPE DISTAL","SUP-ITM-10010129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2107.00","1580.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1721.84","81.72","","5157.68","5157.68","5157.68","1 through 10","1101.12","1721.84","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG LCP TITANIUM SHAPE DISTAL","SUP-ITM-10010129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2107.00","1580.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1721.84","81.72","","431.26","71.26","1459.57","88","1101.12","1721.84","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.86","1548.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1641.56","79.5","","800.18","480.96","1887.97","195","640.11","1641.56","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.86","1548.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1100.57","53.3","","813.12","216.42","1444.50","81","640.11","1641.56","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.86","1548.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","640.11","31","","432.60","432.60","432.60","1 through 10","640.11","1641.56","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.86","1548.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","753.67","36.5","","148.37","54.89","631.39","94","640.11","1641.56","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.86","1548.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","790.84","38.3","","279.30","91.72","1116.77","266","640.11","1641.56","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.86","1548.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.82","42.9","","731.00","63.70","731.00","1 through 10","640.11","1641.56","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.86","1548.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.82","42.9","","384.74","384.74","384.74","1 through 10","640.11","1641.56","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","both","","","2064.86","1548.64","WELLPOINT [1015]","HB AMC WELLPOINT","1523.45","73.78","","286.63","119.22","1107.45","105","640.11","1641.56","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2064.86","1548.64","AETNA [1001]","HB AMC AETNA HMO","1441.27","69.8","","675.31","184.75","1721.50","286","1079.1","1687.4","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2064.86","1548.64","AETNA [1001]","HB AMC AETNA PPO","1660.15","80.4","","1261.44","103.12","1514.10","21","1079.1","1687.4","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2064.86","1548.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1660.15","80.4","","1365.00","1365.00","1365.00","1 through 10","1079.1","1687.4","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2064.86","1548.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1687.40","81.72","","5157.68","5157.68","5157.68","1 through 10","1079.1","1687.4","percent of total billed charges",""
"PLATE RADIUS 2.4X48MM SHORT 5 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10012806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2064.86","1548.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1687.40","81.72","","431.26","71.26","1459.57","88","1079.1","1687.4","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2063.36","1547.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1640.37","79.5","","800.18","480.96","1887.97","195","639.64","1640.37","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2063.36","1547.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1099.77","53.3","","813.12","216.42","1444.50","81","639.64","1640.37","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2063.36","1547.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","639.64","31","","432.60","432.60","432.60","1 through 10","639.64","1640.37","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2063.36","1547.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","753.13","36.5","","148.37","54.89","631.39","94","639.64","1640.37","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2063.36","1547.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","790.27","38.3","","279.30","91.72","1116.77","266","639.64","1640.37","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2063.36","1547.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.18","42.9","","731.00","63.70","731.00","1 through 10","639.64","1640.37","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2063.36","1547.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.18","42.9","","384.74","384.74","384.74","1 through 10","639.64","1640.37","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2063.36","1547.52","WELLPOINT [1015]","HB AMC WELLPOINT","1522.35","73.78","","286.63","119.22","1107.45","105","639.64","1640.37","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2063.36","1547.52","AETNA [1001]","HB AMC AETNA HMO","1440.23","69.8","","675.31","184.75","1721.50","286","1078.31","1686.18","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2063.36","1547.52","AETNA [1001]","HB AMC AETNA PPO","1658.94","80.4","","1261.44","103.12","1514.10","21","1078.31","1686.18","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2063.36","1547.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1658.94","80.4","","1365.00","1365.00","1365.00","1 through 10","1078.31","1686.18","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2063.36","1547.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1686.18","81.72","","5157.68","5157.68","5157.68","1 through 10","1078.31","1686.18","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2063.36","1547.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1686.18","81.72","","431.26","71.26","1459.57","88","1078.31","1686.18","percent of total billed charges",""
"PLATE RADIUS 2.4X57MM LONG 6 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10013595","CDM","C1713","HCPCS","0278","RC","","","","both","","","2179.24","1634.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1732.50","79.5","","800.18","480.96","1887.97","195","675.56","1732.5","percent of total billed charges",""
"PLATE RADIUS 2.4X57MM LONG 6 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10013595","CDM","C1713","HCPCS","0278","RC","","","","both","","","2179.24","1634.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1161.53","53.3","","813.12","216.42","1444.50","81","675.56","1732.5","percent of total billed charges",""
"PLATE RADIUS 2.4X57MM LONG 6 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10013595","CDM","C1713","HCPCS","0278","RC","","","","both","","","2179.24","1634.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","675.56","31","","432.60","432.60","432.60","1 through 10","675.56","1732.5","percent of total billed charges",""
"PLATE RADIUS 2.4X57MM LONG 6 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10013595","CDM","C1713","HCPCS","0278","RC","","","","both","","","2179.24","1634.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","795.42","36.5","","148.37","54.89","631.39","94","675.56","1732.5","percent of total billed charges",""
"PLATE RADIUS 2.4X57MM LONG 6 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10013595","CDM","C1713","HCPCS","0278","RC","","","","both","","","2179.24","1634.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","834.65","38.3","","279.30","91.72","1116.77","266","675.56","1732.5","percent of total billed charges",""
"PLATE RADIUS 2.4X57MM LONG 6 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10013595","CDM","C1713","HCPCS","0278","RC","","","","both","","","2179.24","1634.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","934.89","42.9","","731.00","63.70","731.00","1 through 10","675.56","1732.5","percent of total billed charges",""
"PLATE RADIUS 2.4X57MM LONG 6 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10013595","CDM","C1713","HCPCS","0278","RC","","","","both","","","2179.24","1634.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","934.89","42.9","","384.74","384.74","384.74","1 through 10","675.56","1732.5","percent of total billed charges",""
"PLATE RADIUS 2.4X57MM LONG 6 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10013595","CDM","C1713","HCPCS","0278","RC","","","","both","","","2179.24","1634.43","WELLPOINT [1015]","HB AMC WELLPOINT","1607.84","73.78","","286.63","119.22","1107.45","105","675.56","1732.5","percent of total billed charges",""
"PLATE RADIUS 2.4X57MM LONG 6 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10013595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2179.24","1634.43","AETNA [1001]","HB AMC AETNA HMO","1521.11","69.8","","675.31","184.75","1721.50","286","1138.87","1780.87","percent of total billed charges",""
"PLATE RADIUS 2.4X57MM LONG 6 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10013595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2179.24","1634.43","AETNA [1001]","HB AMC AETNA PPO","1752.11","80.4","","1261.44","103.12","1514.10","21","1138.87","1780.87","percent of total billed charges",""
"PLATE RADIUS 2.4X57MM LONG 6 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10013595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2179.24","1634.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1752.11","80.4","","1365.00","1365.00","1365.00","1 through 10","1138.87","1780.87","percent of total billed charges",""
"PLATE RADIUS 2.4X57MM LONG 6 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10013595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2179.24","1634.43","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1780.87","81.72","","5157.68","5157.68","5157.68","1 through 10","1138.87","1780.87","percent of total billed charges",""
"PLATE RADIUS 2.4X57MM LONG 6 HOLE LCP TITANIUM STRAIGHT","SUP-ITM-10013595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2179.24","1634.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1780.87","81.72","","431.26","71.26","1459.57","88","1138.87","1780.87","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2594.62","1945.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2062.72","79.5","","800.18","480.96","1887.97","195","804.33","2062.72","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2594.62","1945.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1382.93","53.3","","813.12","216.42","1444.50","81","804.33","2062.72","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2594.62","1945.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","804.33","31","","432.60","432.60","432.60","1 through 10","804.33","2062.72","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2594.62","1945.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","947.04","36.5","","148.37","54.89","631.39","94","804.33","2062.72","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2594.62","1945.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","993.74","38.3","","279.30","91.72","1116.77","266","804.33","2062.72","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2594.62","1945.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1113.09","42.9","","731.00","63.70","731.00","1 through 10","804.33","2062.72","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2594.62","1945.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1113.09","42.9","","384.74","384.74","384.74","1 through 10","804.33","2062.72","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","both","","","2594.62","1945.96","WELLPOINT [1015]","HB AMC WELLPOINT","1914.31","73.78","","286.63","119.22","1107.45","105","804.33","2062.72","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2594.62","1945.96","AETNA [1001]","HB AMC AETNA HMO","1811.04","69.8","","675.31","184.75","1721.50","286","1355.95","2120.32","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2594.62","1945.96","AETNA [1001]","HB AMC AETNA PPO","2086.07","80.4","","1261.44","103.12","1514.10","21","1355.95","2120.32","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2594.62","1945.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2086.07","80.4","","1365.00","1365.00","1365.00","1 through 10","1355.95","2120.32","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2594.62","1945.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2120.32","81.72","","5157.68","5157.68","5157.68","1 through 10","1355.95","2120.32","percent of total billed charges",""
"PLATE RADIUS 2.4X65MM 4X5 HOLE EXTRA-ARTICULAR DISTAL LCP VOLAR LEFT","SUP-ITM-10017505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2594.62","1945.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2120.32","81.72","","431.26","71.26","1459.57","88","1355.95","2120.32","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4117.12","3087.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3273.11","79.5","","800.18","480.96","1887.97","195","1276.31","3273.11","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4117.12","3087.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2194.42","53.3","","813.12","216.42","1444.50","81","1276.31","3273.11","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4117.12","3087.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1276.31","31","","432.60","432.60","432.60","1 through 10","1276.31","3273.11","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4117.12","3087.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1502.75","36.5","","148.37","54.89","631.39","94","1276.31","3273.11","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4117.12","3087.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1576.86","38.3","","279.30","91.72","1116.77","266","1276.31","3273.11","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4117.12","3087.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1766.24","42.9","","731.00","63.70","731.00","1 through 10","1276.31","3273.11","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4117.12","3087.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1766.24","42.9","","384.74","384.74","384.74","1 through 10","1276.31","3273.11","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4117.12","3087.84","WELLPOINT [1015]","HB AMC WELLPOINT","3037.61","73.78","","286.63","119.22","1107.45","105","1276.31","3273.11","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4117.12","3087.84","AETNA [1001]","HB AMC AETNA HMO","2873.75","69.8","","675.31","184.75","1721.50","286","2151.61","3364.51","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4117.12","3087.84","AETNA [1001]","HB AMC AETNA PPO","3310.16","80.4","","1261.44","103.12","1514.10","21","2151.61","3364.51","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4117.12","3087.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3310.16","80.4","","1365.00","1365.00","1365.00","1 through 10","2151.61","3364.51","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4117.12","3087.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3364.51","81.72","","5157.68","5157.68","5157.68","1 through 10","2151.61","3364.51","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4117.12","3087.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3364.51","81.72","","431.26","71.26","1459.57","88","2151.61","3364.51","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.65","3406.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3611.41","79.5","","800.18","480.96","1887.97","195","1408.22","3611.41","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.65","3406.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2421.23","53.3","","813.12","216.42","1444.50","81","1408.22","3611.41","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.65","3406.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1408.22","31","","432.60","432.60","432.60","1 through 10","1408.22","3611.41","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.65","3406.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1658.07","36.5","","148.37","54.89","631.39","94","1408.22","3611.41","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.65","3406.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1739.83","38.3","","279.30","91.72","1116.77","266","1408.22","3611.41","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.65","3406.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.80","42.9","","731.00","63.70","731.00","1 through 10","1408.22","3611.41","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.65","3406.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1948.80","42.9","","384.74","384.74","384.74","1 through 10","1408.22","3611.41","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212953","CDM","C1713","HCPCS","0278","RC","","","","both","","","4542.65","3406.99","WELLPOINT [1015]","HB AMC WELLPOINT","3351.57","73.78","","286.63","119.22","1107.45","105","1408.22","3611.41","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.65","3406.99","AETNA [1001]","HB AMC AETNA HMO","3170.77","69.8","","675.31","184.75","1721.50","286","2373.99","3712.25","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.65","3406.99","AETNA [1001]","HB AMC AETNA PPO","3652.29","80.4","","1261.44","103.12","1514.10","21","2373.99","3712.25","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.65","3406.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3652.29","80.4","","1365.00","1365.00","1365.00","1 through 10","2373.99","3712.25","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.65","3406.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3712.25","81.72","","5157.68","5157.68","5157.68","1 through 10","2373.99","3712.25","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4542.65","3406.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3712.25","81.72","","431.26","71.26","1459.57","88","2373.99","3712.25","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3432.49","79.5","","800.18","480.96","1887.97","195","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2301.28","53.3","","813.12","216.42","1444.50","81","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1338.46","31","","432.60","432.60","432.60","1 through 10","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1575.92","36.5","","148.37","54.89","631.39","94","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1653.64","38.3","","279.30","91.72","1116.77","266","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1852.25","42.9","","731.00","63.70","731.00","1 through 10","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1852.25","42.9","","384.74","384.74","384.74","1 through 10","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","WELLPOINT [1015]","HB AMC WELLPOINT","3185.53","73.78","","286.63","119.22","1107.45","105","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.60","3238.20","AETNA [1001]","HB AMC AETNA HMO","3013.68","69.8","","675.31","184.75","1721.50","286","2256.38","3528.34","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.60","3238.20","AETNA [1001]","HB AMC AETNA PPO","3471.35","80.4","","1261.44","103.12","1514.10","21","2256.38","3528.34","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.60","3238.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3471.35","80.4","","1365.00","1365.00","1365.00","1 through 10","2256.38","3528.34","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.60","3238.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3528.34","81.72","","5157.68","5157.68","5157.68","1 through 10","2256.38","3528.34","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.60","3238.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3528.34","81.72","","431.26","71.26","1459.57","88","2256.38","3528.34","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3432.49","79.5","","800.18","480.96","1887.97","195","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2301.28","53.3","","813.12","216.42","1444.50","81","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1338.46","31","","432.60","432.60","432.60","1 through 10","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1575.92","36.5","","148.37","54.89","631.39","94","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1653.64","38.3","","279.30","91.72","1116.77","266","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1852.25","42.9","","731.00","63.70","731.00","1 through 10","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1852.25","42.9","","384.74","384.74","384.74","1 through 10","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212956","CDM","C1713","HCPCS","0278","RC","","","","both","","","4317.60","3238.20","WELLPOINT [1015]","HB AMC WELLPOINT","3185.53","73.78","","286.63","119.22","1107.45","105","1338.46","3432.49","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.60","3238.20","AETNA [1001]","HB AMC AETNA HMO","3013.68","69.8","","675.31","184.75","1721.50","286","2256.38","3528.34","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.60","3238.20","AETNA [1001]","HB AMC AETNA PPO","3471.35","80.4","","1261.44","103.12","1514.10","21","2256.38","3528.34","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.60","3238.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3471.35","80.4","","1365.00","1365.00","1365.00","1 through 10","2256.38","3528.34","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.60","3238.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3528.34","81.72","","5157.68","5157.68","5157.68","1 through 10","2256.38","3528.34","percent of total billed charges",""
"PLATE RADIUS 22X145MM DISTAL 6 HEAD HOLE 10 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD RIGHT","SUP-ITM-10212956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4317.60","3238.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3528.34","81.72","","431.26","71.26","1459.57","88","2256.38","3528.34","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.53","3280.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3476.96","79.5","","800.18","480.96","1887.97","195","1355.79","3476.96","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.53","3280.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2331.09","53.3","","813.12","216.42","1444.50","81","1355.79","3476.96","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.53","3280.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1355.79","31","","432.60","432.60","432.60","1 through 10","1355.79","3476.96","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.53","3280.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1596.34","36.5","","148.37","54.89","631.39","94","1355.79","3476.96","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.53","3280.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1675.06","38.3","","279.30","91.72","1116.77","266","1355.79","3476.96","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.53","3280.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1876.24","42.9","","731.00","63.70","731.00","1 through 10","1355.79","3476.96","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.53","3280.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1876.24","42.9","","384.74","384.74","384.74","1 through 10","1355.79","3476.96","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","both","","","4373.53","3280.15","WELLPOINT [1015]","HB AMC WELLPOINT","3226.79","73.78","","286.63","119.22","1107.45","105","1355.79","3476.96","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4373.53","3280.15","AETNA [1001]","HB AMC AETNA HMO","3052.72","69.8","","675.31","184.75","1721.50","286","2285.61","3574.05","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4373.53","3280.15","AETNA [1001]","HB AMC AETNA PPO","3516.32","80.4","","1261.44","103.12","1514.10","21","2285.61","3574.05","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4373.53","3280.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3516.32","80.4","","1365.00","1365.00","1365.00","1 through 10","2285.61","3574.05","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4373.53","3280.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3574.05","81.72","","5157.68","5157.68","5157.68","1 through 10","2285.61","3574.05","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4373.53","3280.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3574.05","81.72","","431.26","71.26","1459.57","88","2285.61","3574.05","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.84","3092.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3277.66","79.5","","800.18","480.96","1887.97","195","1278.08","3277.66","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.84","3092.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2197.47","53.3","","813.12","216.42","1444.50","81","1278.08","3277.66","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.84","3092.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1278.08","31","","432.60","432.60","432.60","1 through 10","1278.08","3277.66","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.84","3092.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1504.84","36.5","","148.37","54.89","631.39","94","1278.08","3277.66","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.84","3092.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1579.05","38.3","","279.30","91.72","1116.77","266","1278.08","3277.66","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.84","3092.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1768.70","42.9","","731.00","63.70","731.00","1 through 10","1278.08","3277.66","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.84","3092.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1768.70","42.9","","384.74","384.74","384.74","1 through 10","1278.08","3277.66","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.84","3092.13","WELLPOINT [1015]","HB AMC WELLPOINT","3041.83","73.78","","286.63","119.22","1107.45","105","1278.08","3277.66","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.84","3092.13","AETNA [1001]","HB AMC AETNA HMO","2877.74","69.8","","675.31","184.75","1721.50","286","2154.6","3369.18","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.84","3092.13","AETNA [1001]","HB AMC AETNA PPO","3314.76","80.4","","1261.44","103.12","1514.10","21","2154.6","3369.18","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.84","3092.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3314.76","80.4","","1365.00","1365.00","1365.00","1 through 10","2154.6","3369.18","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.84","3092.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3369.18","81.72","","5157.68","5157.68","5157.68","1 through 10","2154.6","3369.18","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL STERILE","SUP-ITM-10036550","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.84","3092.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3369.18","81.72","","431.26","71.26","1459.57","88","2154.6","3369.18","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.26","2447.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2594.29","79.5","","800.18","480.96","1887.97","195","1011.61","2594.29","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.26","2447.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1739.32","53.3","","813.12","216.42","1444.50","81","1011.61","2594.29","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.26","2447.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1011.61","31","","432.60","432.60","432.60","1 through 10","1011.61","2594.29","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.26","2447.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1191.09","36.5","","148.37","54.89","631.39","94","1011.61","2594.29","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.26","2447.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1249.83","38.3","","279.30","91.72","1116.77","266","1011.61","2594.29","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.26","2447.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1399.94","42.9","","731.00","63.70","731.00","1 through 10","1011.61","2594.29","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.26","2447.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1399.94","42.9","","384.74","384.74","384.74","1 through 10","1011.61","2594.29","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","3263.26","2447.44","WELLPOINT [1015]","HB AMC WELLPOINT","2407.63","73.78","","286.63","119.22","1107.45","105","1011.61","2594.29","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3263.26","2447.44","AETNA [1001]","HB AMC AETNA HMO","2277.76","69.8","","675.31","184.75","1721.50","286","1705.38","2666.74","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3263.26","2447.44","AETNA [1001]","HB AMC AETNA PPO","2623.66","80.4","","1261.44","103.12","1514.10","21","1705.38","2666.74","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3263.26","2447.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2623.66","80.4","","1365.00","1365.00","1365.00","1 through 10","1705.38","2666.74","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3263.26","2447.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2666.74","81.72","","5157.68","5157.68","5157.68","1 through 10","1705.38","2666.74","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3263.26","2447.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2666.74","81.72","","431.26","71.26","1459.57","88","1705.38","2666.74","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 104MM 8H STRAIGHT","SUP-ITM-10276216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.00","1144.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1213.17","79.5","","800.18","480.96","1887.97","195","473.06","1213.17","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 104MM 8H STRAIGHT","SUP-ITM-10276216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.00","1144.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","813.36","53.3","","813.12","216.42","1444.50","81","473.06","1213.17","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 104MM 8H STRAIGHT","SUP-ITM-10276216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.00","1144.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","473.06","31","","432.60","432.60","432.60","1 through 10","473.06","1213.17","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 104MM 8H STRAIGHT","SUP-ITM-10276216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.00","1144.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","556.99","36.5","","148.37","54.89","631.39","94","473.06","1213.17","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 104MM 8H STRAIGHT","SUP-ITM-10276216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.00","1144.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","584.46","38.3","","279.30","91.72","1116.77","266","473.06","1213.17","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 104MM 8H STRAIGHT","SUP-ITM-10276216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.00","1144.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","654.65","42.9","","731.00","63.70","731.00","1 through 10","473.06","1213.17","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 104MM 8H STRAIGHT","SUP-ITM-10276216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.00","1144.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","654.65","42.9","","384.74","384.74","384.74","1 through 10","473.06","1213.17","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 104MM 8H STRAIGHT","SUP-ITM-10276216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.00","1144.50","WELLPOINT [1015]","HB AMC WELLPOINT","1125.88","73.78","","286.63","119.22","1107.45","105","473.06","1213.17","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 104MM 8H STRAIGHT","SUP-ITM-10276216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1526.00","1144.50","AETNA [1001]","HB AMC AETNA HMO","1065.15","69.8","","675.31","184.75","1721.50","286","797.49","1247.05","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 104MM 8H STRAIGHT","SUP-ITM-10276216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1526.00","1144.50","AETNA [1001]","HB AMC AETNA PPO","1226.90","80.4","","1261.44","103.12","1514.10","21","797.49","1247.05","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 104MM 8H STRAIGHT","SUP-ITM-10276216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1526.00","1144.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1226.90","80.4","","1365.00","1365.00","1365.00","1 through 10","797.49","1247.05","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 104MM 8H STRAIGHT","SUP-ITM-10276216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1526.00","1144.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1247.05","81.72","","5157.68","5157.68","5157.68","1 through 10","797.49","1247.05","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 104MM 8H STRAIGHT","SUP-ITM-10276216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1526.00","1144.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1247.05","81.72","","431.26","71.26","1459.57","88","797.49","1247.05","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 117MM 9H STRAIGHT","SUP-ITM-10276215","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.50","1278.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1355.08","79.5","","800.18","480.96","1887.97","195","528.4","1355.08","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 117MM 9H STRAIGHT","SUP-ITM-10276215","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.50","1278.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","908.50","53.3","","813.12","216.42","1444.50","81","528.4","1355.08","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 117MM 9H STRAIGHT","SUP-ITM-10276215","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.50","1278.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","528.40","31","","432.60","432.60","432.60","1 through 10","528.4","1355.08","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 117MM 9H STRAIGHT","SUP-ITM-10276215","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.50","1278.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","622.14","36.5","","148.37","54.89","631.39","94","528.4","1355.08","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 117MM 9H STRAIGHT","SUP-ITM-10276215","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.50","1278.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","652.82","38.3","","279.30","91.72","1116.77","266","528.4","1355.08","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 117MM 9H STRAIGHT","SUP-ITM-10276215","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.50","1278.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","731.23","42.9","","731.00","63.70","731.00","1 through 10","528.4","1355.08","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 117MM 9H STRAIGHT","SUP-ITM-10276215","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.50","1278.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","731.23","42.9","","384.74","384.74","384.74","1 through 10","528.4","1355.08","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 117MM 9H STRAIGHT","SUP-ITM-10276215","CDM","C1713","HCPCS","0278","RC","","","","both","","","1704.50","1278.37","WELLPOINT [1015]","HB AMC WELLPOINT","1257.58","73.78","","286.63","119.22","1107.45","105","528.4","1355.08","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 117MM 9H STRAIGHT","SUP-ITM-10276215","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.50","1278.37","AETNA [1001]","HB AMC AETNA HMO","1189.74","69.8","","675.31","184.75","1721.50","286","890.77","1392.92","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 117MM 9H STRAIGHT","SUP-ITM-10276215","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.50","1278.37","AETNA [1001]","HB AMC AETNA PPO","1370.42","80.4","","1261.44","103.12","1514.10","21","890.77","1392.92","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 117MM 9H STRAIGHT","SUP-ITM-10276215","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.50","1278.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1370.42","80.4","","1365.00","1365.00","1365.00","1 through 10","890.77","1392.92","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 117MM 9H STRAIGHT","SUP-ITM-10276215","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.50","1278.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1392.92","81.72","","5157.68","5157.68","5157.68","1 through 10","890.77","1392.92","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 117MM 9H STRAIGHT","SUP-ITM-10276215","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1704.50","1278.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1392.92","81.72","","431.26","71.26","1459.57","88","890.77","1392.92","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 65MM 5H STRAIGHT","SUP-ITM-10275981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1309.00","981.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1040.66","79.5","","800.18","480.96","1887.97","195","405.79","1040.66","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 65MM 5H STRAIGHT","SUP-ITM-10275981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1309.00","981.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","697.70","53.3","","813.12","216.42","1444.50","81","405.79","1040.66","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 65MM 5H STRAIGHT","SUP-ITM-10275981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1309.00","981.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","405.79","31","","432.60","432.60","432.60","1 through 10","405.79","1040.66","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 65MM 5H STRAIGHT","SUP-ITM-10275981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1309.00","981.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","477.79","36.5","","148.37","54.89","631.39","94","405.79","1040.66","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 65MM 5H STRAIGHT","SUP-ITM-10275981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1309.00","981.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","501.35","38.3","","279.30","91.72","1116.77","266","405.79","1040.66","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 65MM 5H STRAIGHT","SUP-ITM-10275981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1309.00","981.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","561.56","42.9","","731.00","63.70","731.00","1 through 10","405.79","1040.66","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 65MM 5H STRAIGHT","SUP-ITM-10275981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1309.00","981.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","561.56","42.9","","384.74","384.74","384.74","1 through 10","405.79","1040.66","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 65MM 5H STRAIGHT","SUP-ITM-10275981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1309.00","981.75","WELLPOINT [1015]","HB AMC WELLPOINT","965.78","73.78","","286.63","119.22","1107.45","105","405.79","1040.66","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 65MM 5H STRAIGHT","SUP-ITM-10275981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1309.00","981.75","AETNA [1001]","HB AMC AETNA HMO","913.68","69.8","","675.31","184.75","1721.50","286","684.08","1069.71","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 65MM 5H STRAIGHT","SUP-ITM-10275981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1309.00","981.75","AETNA [1001]","HB AMC AETNA PPO","1052.44","80.4","","1261.44","103.12","1514.10","21","684.08","1069.71","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 65MM 5H STRAIGHT","SUP-ITM-10275981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1309.00","981.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1052.44","80.4","","1365.00","1365.00","1365.00","1 through 10","684.08","1069.71","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 65MM 5H STRAIGHT","SUP-ITM-10275981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1309.00","981.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1069.71","81.72","","5157.68","5157.68","5157.68","1 through 10","684.08","1069.71","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 65MM 5H STRAIGHT","SUP-ITM-10275981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1309.00","981.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1069.71","81.72","","431.26","71.26","1459.57","88","684.08","1069.71","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 78MM 6H STRAIGHT","SUP-ITM-10276222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.00","1034.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1096.31","79.5","","800.18","480.96","1887.97","195","427.49","1096.31","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 78MM 6H STRAIGHT","SUP-ITM-10276222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.00","1034.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","735.01","53.3","","813.12","216.42","1444.50","81","427.49","1096.31","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 78MM 6H STRAIGHT","SUP-ITM-10276222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.00","1034.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","427.49","31","","432.60","432.60","432.60","1 through 10","427.49","1096.31","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 78MM 6H STRAIGHT","SUP-ITM-10276222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.00","1034.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","503.34","36.5","","148.37","54.89","631.39","94","427.49","1096.31","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 78MM 6H STRAIGHT","SUP-ITM-10276222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.00","1034.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","528.16","38.3","","279.30","91.72","1116.77","266","427.49","1096.31","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 78MM 6H STRAIGHT","SUP-ITM-10276222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.00","1034.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","591.59","42.9","","731.00","63.70","731.00","1 through 10","427.49","1096.31","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 78MM 6H STRAIGHT","SUP-ITM-10276222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.00","1034.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","591.59","42.9","","384.74","384.74","384.74","1 through 10","427.49","1096.31","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 78MM 6H STRAIGHT","SUP-ITM-10276222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1379.00","1034.25","WELLPOINT [1015]","HB AMC WELLPOINT","1017.43","73.78","","286.63","119.22","1107.45","105","427.49","1096.31","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 78MM 6H STRAIGHT","SUP-ITM-10276222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1379.00","1034.25","AETNA [1001]","HB AMC AETNA HMO","962.54","69.8","","675.31","184.75","1721.50","286","720.67","1126.92","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 78MM 6H STRAIGHT","SUP-ITM-10276222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1379.00","1034.25","AETNA [1001]","HB AMC AETNA PPO","1108.72","80.4","","1261.44","103.12","1514.10","21","720.67","1126.92","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 78MM 6H STRAIGHT","SUP-ITM-10276222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1379.00","1034.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1108.72","80.4","","1365.00","1365.00","1365.00","1 through 10","720.67","1126.92","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 78MM 6H STRAIGHT","SUP-ITM-10276222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1379.00","1034.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1126.92","81.72","","5157.68","5157.68","5157.68","1 through 10","720.67","1126.92","percent of total billed charges",""
"PLATE RECONSTRUCTION 3.5MM 78MM 6H STRAIGHT","SUP-ITM-10276222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1379.00","1034.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1126.92","81.72","","431.26","71.26","1459.57","88","720.67","1126.92","percent of total billed charges",""
"PLATE RECONSTRUCTION MODULE INSTRUMENT STORAGE IMPLANT MAXILLOFACIAL LOCKING TITANIUM","SUP-ITM-10075379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2332.65","1749.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1854.46","79.5","","800.18","480.96","1887.97","195","723.12","1854.46","percent of total billed charges",""
"PLATE RECONSTRUCTION MODULE INSTRUMENT STORAGE IMPLANT MAXILLOFACIAL LOCKING TITANIUM","SUP-ITM-10075379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2332.65","1749.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1243.30","53.3","","813.12","216.42","1444.50","81","723.12","1854.46","percent of total billed charges",""
"PLATE RECONSTRUCTION MODULE INSTRUMENT STORAGE IMPLANT MAXILLOFACIAL LOCKING TITANIUM","SUP-ITM-10075379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2332.65","1749.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","723.12","31","","432.60","432.60","432.60","1 through 10","723.12","1854.46","percent of total billed charges",""
"PLATE RECONSTRUCTION MODULE INSTRUMENT STORAGE IMPLANT MAXILLOFACIAL LOCKING TITANIUM","SUP-ITM-10075379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2332.65","1749.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","851.42","36.5","","148.37","54.89","631.39","94","723.12","1854.46","percent of total billed charges",""
"PLATE RECONSTRUCTION MODULE INSTRUMENT STORAGE IMPLANT MAXILLOFACIAL LOCKING TITANIUM","SUP-ITM-10075379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2332.65","1749.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","893.40","38.3","","279.30","91.72","1116.77","266","723.12","1854.46","percent of total billed charges",""
"PLATE RECONSTRUCTION MODULE INSTRUMENT STORAGE IMPLANT MAXILLOFACIAL LOCKING TITANIUM","SUP-ITM-10075379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2332.65","1749.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1000.71","42.9","","731.00","63.70","731.00","1 through 10","723.12","1854.46","percent of total billed charges",""
"PLATE RECONSTRUCTION MODULE INSTRUMENT STORAGE IMPLANT MAXILLOFACIAL LOCKING TITANIUM","SUP-ITM-10075379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2332.65","1749.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1000.71","42.9","","384.74","384.74","384.74","1 through 10","723.12","1854.46","percent of total billed charges",""
"PLATE RECONSTRUCTION MODULE INSTRUMENT STORAGE IMPLANT MAXILLOFACIAL LOCKING TITANIUM","SUP-ITM-10075379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2332.65","1749.49","WELLPOINT [1015]","HB AMC WELLPOINT","1721.03","73.78","","286.63","119.22","1107.45","105","723.12","1854.46","percent of total billed charges",""
"PLATE RECONSTRUCTION MODULE INSTRUMENT STORAGE IMPLANT MAXILLOFACIAL LOCKING TITANIUM","SUP-ITM-10075379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2332.65","1749.49","AETNA [1001]","HB AMC AETNA HMO","1628.19","69.8","","675.31","184.75","1721.50","286","1219.04","1906.24","percent of total billed charges",""
"PLATE RECONSTRUCTION MODULE INSTRUMENT STORAGE IMPLANT MAXILLOFACIAL LOCKING TITANIUM","SUP-ITM-10075379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2332.65","1749.49","AETNA [1001]","HB AMC AETNA PPO","1875.45","80.4","","1261.44","103.12","1514.10","21","1219.04","1906.24","percent of total billed charges",""
"PLATE RECONSTRUCTION MODULE INSTRUMENT STORAGE IMPLANT MAXILLOFACIAL LOCKING TITANIUM","SUP-ITM-10075379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2332.65","1749.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1875.45","80.4","","1365.00","1365.00","1365.00","1 through 10","1219.04","1906.24","percent of total billed charges",""
"PLATE RECONSTRUCTION MODULE INSTRUMENT STORAGE IMPLANT MAXILLOFACIAL LOCKING TITANIUM","SUP-ITM-10075379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2332.65","1749.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1906.24","81.72","","5157.68","5157.68","5157.68","1 through 10","1219.04","1906.24","percent of total billed charges",""
"PLATE RECONSTRUCTION MODULE INSTRUMENT STORAGE IMPLANT MAXILLOFACIAL LOCKING TITANIUM","SUP-ITM-10075379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2332.65","1749.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1906.24","81.72","","431.26","71.26","1459.57","88","1219.04","1906.24","percent of total billed charges",""
"PLATE SCREW 3.5X24MM NON LOCKING R3CON","SUP-ITM-10241683","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.80","390.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","414.04","79.5","","800.18","480.96","1887.97","195","161.45","414.04","percent of total billed charges",""
"PLATE SCREW 3.5X24MM NON LOCKING R3CON","SUP-ITM-10241683","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.80","390.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","277.59","53.3","","813.12","216.42","1444.50","81","161.45","414.04","percent of total billed charges",""
"PLATE SCREW 3.5X24MM NON LOCKING R3CON","SUP-ITM-10241683","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.80","390.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","161.45","31","","432.60","432.60","432.60","1 through 10","161.45","414.04","percent of total billed charges",""
"PLATE SCREW 3.5X24MM NON LOCKING R3CON","SUP-ITM-10241683","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.80","390.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","190.09","36.5","","148.37","54.89","631.39","94","161.45","414.04","percent of total billed charges",""
"PLATE SCREW 3.5X24MM NON LOCKING R3CON","SUP-ITM-10241683","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.80","390.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","199.47","38.3","","279.30","91.72","1116.77","266","161.45","414.04","percent of total billed charges",""
"PLATE SCREW 3.5X24MM NON LOCKING R3CON","SUP-ITM-10241683","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.80","390.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","223.42","42.9","","731.00","63.70","731.00","1 through 10","161.45","414.04","percent of total billed charges",""
"PLATE SCREW 3.5X24MM NON LOCKING R3CON","SUP-ITM-10241683","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.80","390.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","223.42","42.9","","384.74","384.74","384.74","1 through 10","161.45","414.04","percent of total billed charges",""
"PLATE SCREW 3.5X24MM NON LOCKING R3CON","SUP-ITM-10241683","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.80","390.60","WELLPOINT [1015]","HB AMC WELLPOINT","384.25","73.78","","286.63","119.22","1107.45","105","161.45","414.04","percent of total billed charges",""
"PLATE SCREW 3.5X24MM NON LOCKING R3CON","SUP-ITM-10241683","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.80","390.60","AETNA [1001]","HB AMC AETNA HMO","363.52","69.8","","675.31","184.75","1721.50","286","272.17","425.6","percent of total billed charges",""
"PLATE SCREW 3.5X24MM NON LOCKING R3CON","SUP-ITM-10241683","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.80","390.60","AETNA [1001]","HB AMC AETNA PPO","418.72","80.4","","1261.44","103.12","1514.10","21","272.17","425.6","percent of total billed charges",""
"PLATE SCREW 3.5X24MM NON LOCKING R3CON","SUP-ITM-10241683","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.80","390.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","418.72","80.4","","1365.00","1365.00","1365.00","1 through 10","272.17","425.6","percent of total billed charges",""
"PLATE SCREW 3.5X24MM NON LOCKING R3CON","SUP-ITM-10241683","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.80","390.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","425.60","81.72","","5157.68","5157.68","5157.68","1 through 10","272.17","425.6","percent of total billed charges",""
"PLATE SCREW 3.5X24MM NON LOCKING R3CON","SUP-ITM-10241683","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.80","390.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","425.60","81.72","","431.26","71.26","1459.57","88","272.17","425.6","percent of total billed charges",""
"PLATE SCREW LOCKING R3CON 3.5X36MM","SUP-ITM-10241735","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.45","511.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","541.75","79.5","","800.18","480.96","1887.97","195","211.25","541.75","percent of total billed charges",""
"PLATE SCREW LOCKING R3CON 3.5X36MM","SUP-ITM-10241735","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.45","511.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","363.21","53.3","","813.12","216.42","1444.50","81","211.25","541.75","percent of total billed charges",""
"PLATE SCREW LOCKING R3CON 3.5X36MM","SUP-ITM-10241735","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.45","511.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","211.25","31","","432.60","432.60","432.60","1 through 10","211.25","541.75","percent of total billed charges",""
"PLATE SCREW LOCKING R3CON 3.5X36MM","SUP-ITM-10241735","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.45","511.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","248.73","36.5","","148.37","54.89","631.39","94","211.25","541.75","percent of total billed charges",""
"PLATE SCREW LOCKING R3CON 3.5X36MM","SUP-ITM-10241735","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.45","511.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.00","38.3","","279.30","91.72","1116.77","266","211.25","541.75","percent of total billed charges",""
"PLATE SCREW LOCKING R3CON 3.5X36MM","SUP-ITM-10241735","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.45","511.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.34","42.9","","731.00","63.70","731.00","1 through 10","211.25","541.75","percent of total billed charges",""
"PLATE SCREW LOCKING R3CON 3.5X36MM","SUP-ITM-10241735","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.45","511.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.34","42.9","","384.74","384.74","384.74","1 through 10","211.25","541.75","percent of total billed charges",""
"PLATE SCREW LOCKING R3CON 3.5X36MM","SUP-ITM-10241735","CDM","C1713","HCPCS","0278","RC","","","","both","","","681.45","511.09","WELLPOINT [1015]","HB AMC WELLPOINT","502.77","73.78","","286.63","119.22","1107.45","105","211.25","541.75","percent of total billed charges",""
"PLATE SCREW LOCKING R3CON 3.5X36MM","SUP-ITM-10241735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.45","511.09","AETNA [1001]","HB AMC AETNA HMO","475.65","69.8","","675.31","184.75","1721.50","286","356.13","556.88","percent of total billed charges",""
"PLATE SCREW LOCKING R3CON 3.5X36MM","SUP-ITM-10241735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.45","511.09","AETNA [1001]","HB AMC AETNA PPO","547.89","80.4","","1261.44","103.12","1514.10","21","356.13","556.88","percent of total billed charges",""
"PLATE SCREW LOCKING R3CON 3.5X36MM","SUP-ITM-10241735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.45","511.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","547.89","80.4","","1365.00","1365.00","1365.00","1 through 10","356.13","556.88","percent of total billed charges",""
"PLATE SCREW LOCKING R3CON 3.5X36MM","SUP-ITM-10241735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.45","511.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","556.88","81.72","","5157.68","5157.68","5157.68","1 through 10","356.13","556.88","percent of total billed charges",""
"PLATE SCREW LOCKING R3CON 3.5X36MM","SUP-ITM-10241735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","681.45","511.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","556.88","81.72","","431.26","71.26","1459.57","88","356.13","556.88","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1085.18","79.5","","800.18","480.96","1887.97","195","423.15","1085.18","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","727.55","53.3","","813.12","216.42","1444.50","81","423.15","1085.18","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","423.15","31","","432.60","432.60","432.60","1 through 10","423.15","1085.18","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","498.23","36.5","","148.37","54.89","631.39","94","423.15","1085.18","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","522.80","38.3","","279.30","91.72","1116.77","266","423.15","1085.18","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","731.00","63.70","731.00","1 through 10","423.15","1085.18","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","384.74","384.74","384.74","1 through 10","423.15","1085.18","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB AMC WELLPOINT","1007.10","73.78","","286.63","119.22","1107.45","105","423.15","1085.18","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA HMO","952.77","69.8","","675.31","184.75","1721.50","286","713.35","1115.48","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA PPO","1097.46","80.4","","1261.44","103.12","1514.10","21","713.35","1115.48","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1097.46","80.4","","1365.00","1365.00","1365.00","1 through 10","713.35","1115.48","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1115.48","81.72","","5157.68","5157.68","5157.68","1 through 10","713.35","1115.48","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1115.48","81.72","","431.26","71.26","1459.57","88","713.35","1115.48","percent of total billed charges",""
"PLATE SHAFT 104X70MM 6 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10037806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3179.23","2384.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2527.49","79.5","","800.18","480.96","1887.97","195","985.56","2527.49","percent of total billed charges",""
"PLATE SHAFT 104X70MM 6 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10037806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3179.23","2384.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1694.53","53.3","","813.12","216.42","1444.50","81","985.56","2527.49","percent of total billed charges",""
"PLATE SHAFT 104X70MM 6 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10037806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3179.23","2384.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","985.56","31","","432.60","432.60","432.60","1 through 10","985.56","2527.49","percent of total billed charges",""
"PLATE SHAFT 104X70MM 6 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10037806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3179.23","2384.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1160.42","36.5","","148.37","54.89","631.39","94","985.56","2527.49","percent of total billed charges",""
"PLATE SHAFT 104X70MM 6 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10037806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3179.23","2384.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1217.65","38.3","","279.30","91.72","1116.77","266","985.56","2527.49","percent of total billed charges",""
"PLATE SHAFT 104X70MM 6 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10037806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3179.23","2384.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1363.89","42.9","","731.00","63.70","731.00","1 through 10","985.56","2527.49","percent of total billed charges",""
"PLATE SHAFT 104X70MM 6 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10037806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3179.23","2384.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1363.89","42.9","","384.74","384.74","384.74","1 through 10","985.56","2527.49","percent of total billed charges",""
"PLATE SHAFT 104X70MM 6 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10037806","CDM","C1713","HCPCS","0278","RC","","","","both","","","3179.23","2384.42","WELLPOINT [1015]","HB AMC WELLPOINT","2345.64","73.78","","286.63","119.22","1107.45","105","985.56","2527.49","percent of total billed charges",""
"PLATE SHAFT 104X70MM 6 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10037806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3179.23","2384.42","AETNA [1001]","HB AMC AETNA HMO","2219.10","69.8","","675.31","184.75","1721.50","286","1661.47","2598.07","percent of total billed charges",""
"PLATE SHAFT 104X70MM 6 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10037806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3179.23","2384.42","AETNA [1001]","HB AMC AETNA PPO","2556.10","80.4","","1261.44","103.12","1514.10","21","1661.47","2598.07","percent of total billed charges",""
"PLATE SHAFT 104X70MM 6 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10037806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3179.23","2384.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2556.10","80.4","","1365.00","1365.00","1365.00","1 through 10","1661.47","2598.07","percent of total billed charges",""
"PLATE SHAFT 104X70MM 6 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10037806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3179.23","2384.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2598.07","81.72","","5157.68","5157.68","5157.68","1 through 10","1661.47","2598.07","percent of total billed charges",""
"PLATE SHAFT 104X70MM 6 HOLE 130DEG CONDYLAR DCP ANGLED BLADE SS","SUP-ITM-10037806","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3179.23","2384.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2598.07","81.72","","431.26","71.26","1459.57","88","1661.47","2598.07","percent of total billed charges",""
"PLATE SMALL 8 HOLE STERNAL TITANIUM LOCKING H SHAPE","SUP-ITM-10026778","CDM","C1713","HCPCS","0278","RC","","","","both","","","1745.87","1309.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1387.97","79.5","","800.18","480.96","1887.97","195","541.22","1387.97","percent of total billed charges",""
"PLATE SMALL 8 HOLE STERNAL TITANIUM LOCKING H SHAPE","SUP-ITM-10026778","CDM","C1713","HCPCS","0278","RC","","","","both","","","1745.87","1309.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","930.55","53.3","","813.12","216.42","1444.50","81","541.22","1387.97","percent of total billed charges",""
"PLATE SMALL 8 HOLE STERNAL TITANIUM LOCKING H SHAPE","SUP-ITM-10026778","CDM","C1713","HCPCS","0278","RC","","","","both","","","1745.87","1309.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","541.22","31","","432.60","432.60","432.60","1 through 10","541.22","1387.97","percent of total billed charges",""
"PLATE SMALL 8 HOLE STERNAL TITANIUM LOCKING H SHAPE","SUP-ITM-10026778","CDM","C1713","HCPCS","0278","RC","","","","both","","","1745.87","1309.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","637.24","36.5","","148.37","54.89","631.39","94","541.22","1387.97","percent of total billed charges",""
"PLATE SMALL 8 HOLE STERNAL TITANIUM LOCKING H SHAPE","SUP-ITM-10026778","CDM","C1713","HCPCS","0278","RC","","","","both","","","1745.87","1309.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","668.67","38.3","","279.30","91.72","1116.77","266","541.22","1387.97","percent of total billed charges",""
"PLATE SMALL 8 HOLE STERNAL TITANIUM LOCKING H SHAPE","SUP-ITM-10026778","CDM","C1713","HCPCS","0278","RC","","","","both","","","1745.87","1309.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","748.98","42.9","","731.00","63.70","731.00","1 through 10","541.22","1387.97","percent of total billed charges",""
"PLATE SMALL 8 HOLE STERNAL TITANIUM LOCKING H SHAPE","SUP-ITM-10026778","CDM","C1713","HCPCS","0278","RC","","","","both","","","1745.87","1309.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","748.98","42.9","","384.74","384.74","384.74","1 through 10","541.22","1387.97","percent of total billed charges",""
"PLATE SMALL 8 HOLE STERNAL TITANIUM LOCKING H SHAPE","SUP-ITM-10026778","CDM","C1713","HCPCS","0278","RC","","","","both","","","1745.87","1309.40","WELLPOINT [1015]","HB AMC WELLPOINT","1288.10","73.78","","286.63","119.22","1107.45","105","541.22","1387.97","percent of total billed charges",""
"PLATE SMALL 8 HOLE STERNAL TITANIUM LOCKING H SHAPE","SUP-ITM-10026778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1745.87","1309.40","AETNA [1001]","HB AMC AETNA HMO","1218.62","69.8","","675.31","184.75","1721.50","286","912.39","1426.72","percent of total billed charges",""
"PLATE SMALL 8 HOLE STERNAL TITANIUM LOCKING H SHAPE","SUP-ITM-10026778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1745.87","1309.40","AETNA [1001]","HB AMC AETNA PPO","1403.68","80.4","","1261.44","103.12","1514.10","21","912.39","1426.72","percent of total billed charges",""
"PLATE SMALL 8 HOLE STERNAL TITANIUM LOCKING H SHAPE","SUP-ITM-10026778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1745.87","1309.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1403.68","80.4","","1365.00","1365.00","1365.00","1 through 10","912.39","1426.72","percent of total billed charges",""
"PLATE SMALL 8 HOLE STERNAL TITANIUM LOCKING H SHAPE","SUP-ITM-10026778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1745.87","1309.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1426.72","81.72","","5157.68","5157.68","5157.68","1 through 10","912.39","1426.72","percent of total billed charges",""
"PLATE SMALL 8 HOLE STERNAL TITANIUM LOCKING H SHAPE","SUP-ITM-10026778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1745.87","1309.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1426.72","81.72","","431.26","71.26","1459.57","88","912.39","1426.72","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","7364.50","5523.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5854.78","79.5","","800.18","480.96","1887.97","195","2283","5854.78","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","7364.50","5523.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3925.28","53.3","","813.12","216.42","1444.50","81","2283","5854.78","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","7364.50","5523.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2283.00","31","","432.60","432.60","432.60","1 through 10","2283","5854.78","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","7364.50","5523.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2688.04","36.5","","148.37","54.89","631.39","94","2283","5854.78","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","7364.50","5523.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2820.60","38.3","","279.30","91.72","1116.77","266","2283","5854.78","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","7364.50","5523.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3159.37","42.9","","731.00","63.70","731.00","1 through 10","2283","5854.78","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","7364.50","5523.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3159.37","42.9","","384.74","384.74","384.74","1 through 10","2283","5854.78","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","7364.50","5523.37","WELLPOINT [1015]","HB AMC WELLPOINT","5433.53","73.78","","286.63","119.22","1107.45","105","2283","5854.78","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7364.50","5523.37","AETNA [1001]","HB AMC AETNA HMO","5140.42","69.8","","675.31","184.75","1721.50","286","3848.69","6018.27","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7364.50","5523.37","AETNA [1001]","HB AMC AETNA PPO","5921.06","80.4","","1261.44","103.12","1514.10","21","3848.69","6018.27","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7364.50","5523.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5921.06","80.4","","1365.00","1365.00","1365.00","1 through 10","3848.69","6018.27","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7364.50","5523.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6018.27","81.72","","5157.68","5157.68","5157.68","1 through 10","3848.69","6018.27","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7364.50","5523.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6018.27","81.72","","431.26","71.26","1459.57","88","3848.69","6018.27","percent of total billed charges",""
"PLATE SPINE 12X33MM HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT ADJUSTABLE SLIDER OBLONG","SUP-ITM-10005601","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.48","745.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","789.82","79.5","","800.18","480.96","1887.97","195","307.98","789.82","percent of total billed charges",""
"PLATE SPINE 12X33MM HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT ADJUSTABLE SLIDER OBLONG","SUP-ITM-10005601","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.48","745.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","529.52","53.3","","813.12","216.42","1444.50","81","307.98","789.82","percent of total billed charges",""
"PLATE SPINE 12X33MM HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT ADJUSTABLE SLIDER OBLONG","SUP-ITM-10005601","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.48","745.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","307.98","31","","432.60","432.60","432.60","1 through 10","307.98","789.82","percent of total billed charges",""
"PLATE SPINE 12X33MM HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT ADJUSTABLE SLIDER OBLONG","SUP-ITM-10005601","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.48","745.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","362.62","36.5","","148.37","54.89","631.39","94","307.98","789.82","percent of total billed charges",""
"PLATE SPINE 12X33MM HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT ADJUSTABLE SLIDER OBLONG","SUP-ITM-10005601","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.48","745.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","380.50","38.3","","279.30","91.72","1116.77","266","307.98","789.82","percent of total billed charges",""
"PLATE SPINE 12X33MM HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT ADJUSTABLE SLIDER OBLONG","SUP-ITM-10005601","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.48","745.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","426.20","42.9","","731.00","63.70","731.00","1 through 10","307.98","789.82","percent of total billed charges",""
"PLATE SPINE 12X33MM HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT ADJUSTABLE SLIDER OBLONG","SUP-ITM-10005601","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.48","745.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","426.20","42.9","","384.74","384.74","384.74","1 through 10","307.98","789.82","percent of total billed charges",""
"PLATE SPINE 12X33MM HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT ADJUSTABLE SLIDER OBLONG","SUP-ITM-10005601","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.48","745.11","WELLPOINT [1015]","HB AMC WELLPOINT","732.99","73.78","","286.63","119.22","1107.45","105","307.98","789.82","percent of total billed charges",""
"PLATE SPINE 12X33MM HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT ADJUSTABLE SLIDER OBLONG","SUP-ITM-10005601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","993.48","745.11","AETNA [1001]","HB AMC AETNA HMO","693.45","69.8","","675.31","184.75","1721.50","286","519.19","811.87","percent of total billed charges",""
"PLATE SPINE 12X33MM HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT ADJUSTABLE SLIDER OBLONG","SUP-ITM-10005601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","993.48","745.11","AETNA [1001]","HB AMC AETNA PPO","798.76","80.4","","1261.44","103.12","1514.10","21","519.19","811.87","percent of total billed charges",""
"PLATE SPINE 12X33MM HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT ADJUSTABLE SLIDER OBLONG","SUP-ITM-10005601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","993.48","745.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","798.76","80.4","","1365.00","1365.00","1365.00","1 through 10","519.19","811.87","percent of total billed charges",""
"PLATE SPINE 12X33MM HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT ADJUSTABLE SLIDER OBLONG","SUP-ITM-10005601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","993.48","745.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","811.87","81.72","","5157.68","5157.68","5157.68","1 through 10","519.19","811.87","percent of total billed charges",""
"PLATE SPINE 12X33MM HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT ADJUSTABLE SLIDER OBLONG","SUP-ITM-10005601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","993.48","745.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","811.87","81.72","","431.26","71.26","1459.57","88","519.19","811.87","percent of total billed charges",""
"PLATE SPINE 2MM 8 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRUT","SUP-ITM-10002210","CDM","C1713","HCPCS","0278","RC","","","","both","","","877.28","657.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","697.44","79.5","","800.18","480.96","1887.97","195","271.96","697.44","percent of total billed charges",""
"PLATE SPINE 2MM 8 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRUT","SUP-ITM-10002210","CDM","C1713","HCPCS","0278","RC","","","","both","","","877.28","657.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","467.59","53.3","","813.12","216.42","1444.50","81","271.96","697.44","percent of total billed charges",""
"PLATE SPINE 2MM 8 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRUT","SUP-ITM-10002210","CDM","C1713","HCPCS","0278","RC","","","","both","","","877.28","657.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.96","31","","432.60","432.60","432.60","1 through 10","271.96","697.44","percent of total billed charges",""
"PLATE SPINE 2MM 8 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRUT","SUP-ITM-10002210","CDM","C1713","HCPCS","0278","RC","","","","both","","","877.28","657.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","320.21","36.5","","148.37","54.89","631.39","94","271.96","697.44","percent of total billed charges",""
"PLATE SPINE 2MM 8 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRUT","SUP-ITM-10002210","CDM","C1713","HCPCS","0278","RC","","","","both","","","877.28","657.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","336.00","38.3","","279.30","91.72","1116.77","266","271.96","697.44","percent of total billed charges",""
"PLATE SPINE 2MM 8 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRUT","SUP-ITM-10002210","CDM","C1713","HCPCS","0278","RC","","","","both","","","877.28","657.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","376.35","42.9","","731.00","63.70","731.00","1 through 10","271.96","697.44","percent of total billed charges",""
"PLATE SPINE 2MM 8 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRUT","SUP-ITM-10002210","CDM","C1713","HCPCS","0278","RC","","","","both","","","877.28","657.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","376.35","42.9","","384.74","384.74","384.74","1 through 10","271.96","697.44","percent of total billed charges",""
"PLATE SPINE 2MM 8 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRUT","SUP-ITM-10002210","CDM","C1713","HCPCS","0278","RC","","","","both","","","877.28","657.96","WELLPOINT [1015]","HB AMC WELLPOINT","647.26","73.78","","286.63","119.22","1107.45","105","271.96","697.44","percent of total billed charges",""
"PLATE SPINE 2MM 8 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRUT","SUP-ITM-10002210","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","877.28","657.96","AETNA [1001]","HB AMC AETNA HMO","612.34","69.8","","675.31","184.75","1721.50","286","458.47","716.91","percent of total billed charges",""
"PLATE SPINE 2MM 8 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRUT","SUP-ITM-10002210","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","877.28","657.96","AETNA [1001]","HB AMC AETNA PPO","705.33","80.4","","1261.44","103.12","1514.10","21","458.47","716.91","percent of total billed charges",""
"PLATE SPINE 2MM 8 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRUT","SUP-ITM-10002210","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","877.28","657.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","705.33","80.4","","1365.00","1365.00","1365.00","1 through 10","458.47","716.91","percent of total billed charges",""
"PLATE SPINE 2MM 8 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRUT","SUP-ITM-10002210","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","877.28","657.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","716.91","81.72","","5157.68","5157.68","5157.68","1 through 10","458.47","716.91","percent of total billed charges",""
"PLATE SPINE 2MM 8 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRUT","SUP-ITM-10002210","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","877.28","657.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","716.91","81.72","","431.26","71.26","1459.57","88","458.47","716.91","percent of total billed charges",""
"PLATE SPINE 2X30MM 4 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRAIGHT","SUP-ITM-10002105","CDM","C1713","HCPCS","0278","RC","","","","both","","","772.70","579.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","614.30","79.5","","800.18","480.96","1887.97","195","239.54","614.3","percent of total billed charges",""
"PLATE SPINE 2X30MM 4 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRAIGHT","SUP-ITM-10002105","CDM","C1713","HCPCS","0278","RC","","","","both","","","772.70","579.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","411.85","53.3","","813.12","216.42","1444.50","81","239.54","614.3","percent of total billed charges",""
"PLATE SPINE 2X30MM 4 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRAIGHT","SUP-ITM-10002105","CDM","C1713","HCPCS","0278","RC","","","","both","","","772.70","579.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","239.54","31","","432.60","432.60","432.60","1 through 10","239.54","614.3","percent of total billed charges",""
"PLATE SPINE 2X30MM 4 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRAIGHT","SUP-ITM-10002105","CDM","C1713","HCPCS","0278","RC","","","","both","","","772.70","579.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","282.04","36.5","","148.37","54.89","631.39","94","239.54","614.3","percent of total billed charges",""
"PLATE SPINE 2X30MM 4 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRAIGHT","SUP-ITM-10002105","CDM","C1713","HCPCS","0278","RC","","","","both","","","772.70","579.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","295.94","38.3","","279.30","91.72","1116.77","266","239.54","614.3","percent of total billed charges",""
"PLATE SPINE 2X30MM 4 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRAIGHT","SUP-ITM-10002105","CDM","C1713","HCPCS","0278","RC","","","","both","","","772.70","579.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","331.49","42.9","","731.00","63.70","731.00","1 through 10","239.54","614.3","percent of total billed charges",""
"PLATE SPINE 2X30MM 4 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRAIGHT","SUP-ITM-10002105","CDM","C1713","HCPCS","0278","RC","","","","both","","","772.70","579.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","331.49","42.9","","384.74","384.74","384.74","1 through 10","239.54","614.3","percent of total billed charges",""
"PLATE SPINE 2X30MM 4 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRAIGHT","SUP-ITM-10002105","CDM","C1713","HCPCS","0278","RC","","","","both","","","772.70","579.52","WELLPOINT [1015]","HB AMC WELLPOINT","570.10","73.78","","286.63","119.22","1107.45","105","239.54","614.3","percent of total billed charges",""
"PLATE SPINE 2X30MM 4 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRAIGHT","SUP-ITM-10002105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","772.70","579.52","AETNA [1001]","HB AMC AETNA HMO","539.34","69.8","","675.31","184.75","1721.50","286","403.81","631.45","percent of total billed charges",""
"PLATE SPINE 2X30MM 4 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRAIGHT","SUP-ITM-10002105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","772.70","579.52","AETNA [1001]","HB AMC AETNA PPO","621.25","80.4","","1261.44","103.12","1514.10","21","403.81","631.45","percent of total billed charges",""
"PLATE SPINE 2X30MM 4 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRAIGHT","SUP-ITM-10002105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","772.70","579.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","621.25","80.4","","1365.00","1365.00","1365.00","1 through 10","403.81","631.45","percent of total billed charges",""
"PLATE SPINE 2X30MM 4 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRAIGHT","SUP-ITM-10002105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","772.70","579.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","631.45","81.72","","5157.68","5157.68","5157.68","1 through 10","403.81","631.45","percent of total billed charges",""
"PLATE SPINE 2X30MM 4 HOLE ORTHOGNATHIC TITANIUM SAGITTAL SPLIT STRAIGHT","SUP-ITM-10002105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","772.70","579.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","631.45","81.72","","431.26","71.26","1459.57","88","403.81","631.45","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE LEFT","SUP-ITM-10273432","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3891.96","79.5","","800.18","480.96","1887.97","195","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE LEFT","SUP-ITM-10273432","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2609.33","53.3","","813.12","216.42","1444.50","81","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE LEFT","SUP-ITM-10273432","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1517.62","31","","432.60","432.60","432.60","1 through 10","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE LEFT","SUP-ITM-10273432","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1786.88","36.5","","148.37","54.89","631.39","94","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE LEFT","SUP-ITM-10273432","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1875.00","38.3","","279.30","91.72","1116.77","266","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE LEFT","SUP-ITM-10273432","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2100.19","42.9","","731.00","63.70","731.00","1 through 10","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE LEFT","SUP-ITM-10273432","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2100.19","42.9","","384.74","384.74","384.74","1 through 10","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE LEFT","SUP-ITM-10273432","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","WELLPOINT [1015]","HB AMC WELLPOINT","3611.94","73.78","","286.63","119.22","1107.45","105","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE LEFT","SUP-ITM-10273432","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4895.55","3671.66","AETNA [1001]","HB AMC AETNA HMO","3417.09","69.8","","675.31","184.75","1721.50","286","2558.41","4000.64","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE LEFT","SUP-ITM-10273432","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4895.55","3671.66","AETNA [1001]","HB AMC AETNA PPO","3936.02","80.4","","1261.44","103.12","1514.10","21","2558.41","4000.64","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE LEFT","SUP-ITM-10273432","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4895.55","3671.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3936.02","80.4","","1365.00","1365.00","1365.00","1 through 10","2558.41","4000.64","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE LEFT","SUP-ITM-10273432","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4895.55","3671.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4000.64","81.72","","5157.68","5157.68","5157.68","1 through 10","2558.41","4000.64","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE LEFT","SUP-ITM-10273432","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4895.55","3671.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4000.64","81.72","","431.26","71.26","1459.57","88","2558.41","4000.64","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE RIGHT","SUP-ITM-10273433","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3891.96","79.5","","800.18","480.96","1887.97","195","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE RIGHT","SUP-ITM-10273433","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2609.33","53.3","","813.12","216.42","1444.50","81","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE RIGHT","SUP-ITM-10273433","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1517.62","31","","432.60","432.60","432.60","1 through 10","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE RIGHT","SUP-ITM-10273433","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1786.88","36.5","","148.37","54.89","631.39","94","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE RIGHT","SUP-ITM-10273433","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1875.00","38.3","","279.30","91.72","1116.77","266","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE RIGHT","SUP-ITM-10273433","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2100.19","42.9","","731.00","63.70","731.00","1 through 10","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE RIGHT","SUP-ITM-10273433","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2100.19","42.9","","384.74","384.74","384.74","1 through 10","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE RIGHT","SUP-ITM-10273433","CDM","C1713","HCPCS","0278","RC","","","","both","","","4895.55","3671.66","WELLPOINT [1015]","HB AMC WELLPOINT","3611.94","73.78","","286.63","119.22","1107.45","105","1517.62","3891.96","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE RIGHT","SUP-ITM-10273433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4895.55","3671.66","AETNA [1001]","HB AMC AETNA HMO","3417.09","69.8","","675.31","184.75","1721.50","286","2558.41","4000.64","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE RIGHT","SUP-ITM-10273433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4895.55","3671.66","AETNA [1001]","HB AMC AETNA PPO","3936.02","80.4","","1261.44","103.12","1514.10","21","2558.41","4000.64","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE RIGHT","SUP-ITM-10273433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4895.55","3671.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3936.02","80.4","","1365.00","1365.00","1365.00","1 through 10","2558.41","4000.64","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE RIGHT","SUP-ITM-10273433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4895.55","3671.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4000.64","81.72","","5157.68","5157.68","5157.68","1 through 10","2558.41","4000.64","percent of total billed charges",""
"PLATE SPINE 4.5X159MM CONDYLAR CURVED TI VA-LCP 6 HOLE RIGHT","SUP-ITM-10273433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4895.55","3671.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4000.64","81.72","","431.26","71.26","1459.57","88","2558.41","4000.64","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE LEFT","SUP-ITM-10273430","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3907.35","79.5","","800.18","480.96","1887.97","195","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE LEFT","SUP-ITM-10273430","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2619.64","53.3","","813.12","216.42","1444.50","81","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE LEFT","SUP-ITM-10273430","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1523.62","31","","432.60","432.60","432.60","1 through 10","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE LEFT","SUP-ITM-10273430","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1793.94","36.5","","148.37","54.89","631.39","94","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE LEFT","SUP-ITM-10273430","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1882.41","38.3","","279.30","91.72","1116.77","266","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE LEFT","SUP-ITM-10273430","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2108.49","42.9","","731.00","63.70","731.00","1 through 10","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE LEFT","SUP-ITM-10273430","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2108.49","42.9","","384.74","384.74","384.74","1 through 10","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE LEFT","SUP-ITM-10273430","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","WELLPOINT [1015]","HB AMC WELLPOINT","3626.21","73.78","","286.63","119.22","1107.45","105","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE LEFT","SUP-ITM-10273430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4914.90","3686.17","AETNA [1001]","HB AMC AETNA HMO","3430.60","69.8","","675.31","184.75","1721.50","286","2568.53","4016.46","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE LEFT","SUP-ITM-10273430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4914.90","3686.17","AETNA [1001]","HB AMC AETNA PPO","3951.58","80.4","","1261.44","103.12","1514.10","21","2568.53","4016.46","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE LEFT","SUP-ITM-10273430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4914.90","3686.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3951.58","80.4","","1365.00","1365.00","1365.00","1 through 10","2568.53","4016.46","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE LEFT","SUP-ITM-10273430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4914.90","3686.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4016.46","81.72","","5157.68","5157.68","5157.68","1 through 10","2568.53","4016.46","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE LEFT","SUP-ITM-10273430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4914.90","3686.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4016.46","81.72","","431.26","71.26","1459.57","88","2568.53","4016.46","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE RIGHT","SUP-ITM-10273431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3907.35","79.5","","800.18","480.96","1887.97","195","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE RIGHT","SUP-ITM-10273431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2619.64","53.3","","813.12","216.42","1444.50","81","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE RIGHT","SUP-ITM-10273431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1523.62","31","","432.60","432.60","432.60","1 through 10","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE RIGHT","SUP-ITM-10273431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1793.94","36.5","","148.37","54.89","631.39","94","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE RIGHT","SUP-ITM-10273431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1882.41","38.3","","279.30","91.72","1116.77","266","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE RIGHT","SUP-ITM-10273431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2108.49","42.9","","731.00","63.70","731.00","1 through 10","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE RIGHT","SUP-ITM-10273431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2108.49","42.9","","384.74","384.74","384.74","1 through 10","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE RIGHT","SUP-ITM-10273431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4914.90","3686.17","WELLPOINT [1015]","HB AMC WELLPOINT","3626.21","73.78","","286.63","119.22","1107.45","105","1523.62","3907.35","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE RIGHT","SUP-ITM-10273431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4914.90","3686.17","AETNA [1001]","HB AMC AETNA HMO","3430.60","69.8","","675.31","184.75","1721.50","286","2568.53","4016.46","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE RIGHT","SUP-ITM-10273431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4914.90","3686.17","AETNA [1001]","HB AMC AETNA PPO","3951.58","80.4","","1261.44","103.12","1514.10","21","2568.53","4016.46","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE RIGHT","SUP-ITM-10273431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4914.90","3686.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3951.58","80.4","","1365.00","1365.00","1365.00","1 through 10","2568.53","4016.46","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE RIGHT","SUP-ITM-10273431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4914.90","3686.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4016.46","81.72","","5157.68","5157.68","5157.68","1 through 10","2568.53","4016.46","percent of total billed charges",""
"PLATE SPINE 4.5X195MM CONDYLAR CURVED TI VA-LCP 8 HOLE RIGHT","SUP-ITM-10273431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4914.90","3686.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4016.46","81.72","","431.26","71.26","1459.57","88","2568.53","4016.46","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE LEFT","SUP-ITM-10273428","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4043.74","79.5","","800.18","480.96","1887.97","195","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE LEFT","SUP-ITM-10273428","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2711.09","53.3","","813.12","216.42","1444.50","81","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE LEFT","SUP-ITM-10273428","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1576.81","31","","432.60","432.60","432.60","1 through 10","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE LEFT","SUP-ITM-10273428","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1856.56","36.5","","148.37","54.89","631.39","94","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE LEFT","SUP-ITM-10273428","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1948.12","38.3","","279.30","91.72","1116.77","266","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE LEFT","SUP-ITM-10273428","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2182.10","42.9","","731.00","63.70","731.00","1 through 10","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE LEFT","SUP-ITM-10273428","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2182.10","42.9","","384.74","384.74","384.74","1 through 10","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE LEFT","SUP-ITM-10273428","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","WELLPOINT [1015]","HB AMC WELLPOINT","3752.80","73.78","","286.63","119.22","1107.45","105","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE LEFT","SUP-ITM-10273428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5086.47","3814.85","AETNA [1001]","HB AMC AETNA HMO","3550.36","69.8","","675.31","184.75","1721.50","286","2658.19","4156.66","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE LEFT","SUP-ITM-10273428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5086.47","3814.85","AETNA [1001]","HB AMC AETNA PPO","4089.52","80.4","","1261.44","103.12","1514.10","21","2658.19","4156.66","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE LEFT","SUP-ITM-10273428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5086.47","3814.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4089.52","80.4","","1365.00","1365.00","1365.00","1 through 10","2658.19","4156.66","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE LEFT","SUP-ITM-10273428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5086.47","3814.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4156.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2658.19","4156.66","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE LEFT","SUP-ITM-10273428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5086.47","3814.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4156.66","81.72","","431.26","71.26","1459.57","88","2658.19","4156.66","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE RIGHT","SUP-ITM-10273429","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4043.74","79.5","","800.18","480.96","1887.97","195","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE RIGHT","SUP-ITM-10273429","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2711.09","53.3","","813.12","216.42","1444.50","81","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE RIGHT","SUP-ITM-10273429","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1576.81","31","","432.60","432.60","432.60","1 through 10","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE RIGHT","SUP-ITM-10273429","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1856.56","36.5","","148.37","54.89","631.39","94","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE RIGHT","SUP-ITM-10273429","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1948.12","38.3","","279.30","91.72","1116.77","266","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE RIGHT","SUP-ITM-10273429","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2182.10","42.9","","731.00","63.70","731.00","1 through 10","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE RIGHT","SUP-ITM-10273429","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2182.10","42.9","","384.74","384.74","384.74","1 through 10","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE RIGHT","SUP-ITM-10273429","CDM","C1713","HCPCS","0278","RC","","","","both","","","5086.47","3814.85","WELLPOINT [1015]","HB AMC WELLPOINT","3752.80","73.78","","286.63","119.22","1107.45","105","1576.81","4043.74","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE RIGHT","SUP-ITM-10273429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5086.47","3814.85","AETNA [1001]","HB AMC AETNA HMO","3550.36","69.8","","675.31","184.75","1721.50","286","2658.19","4156.66","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE RIGHT","SUP-ITM-10273429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5086.47","3814.85","AETNA [1001]","HB AMC AETNA PPO","4089.52","80.4","","1261.44","103.12","1514.10","21","2658.19","4156.66","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE RIGHT","SUP-ITM-10273429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5086.47","3814.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4089.52","80.4","","1365.00","1365.00","1365.00","1 through 10","2658.19","4156.66","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE RIGHT","SUP-ITM-10273429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5086.47","3814.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4156.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2658.19","4156.66","percent of total billed charges",""
"PLATE SPINE 4.5X230MM CONDYLAR CURVED TI VA-LCP 10 HOLE RIGHT","SUP-ITM-10273429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5086.47","3814.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4156.66","81.72","","431.26","71.26","1459.57","88","2658.19","4156.66","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE LEFT","SUP-ITM-10273426","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4110.40","79.5","","800.18","480.96","1887.97","195","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE LEFT","SUP-ITM-10273426","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2755.78","53.3","","813.12","216.42","1444.50","81","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE LEFT","SUP-ITM-10273426","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1602.80","31","","432.60","432.60","432.60","1 through 10","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE LEFT","SUP-ITM-10273426","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1887.17","36.5","","148.37","54.89","631.39","94","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE LEFT","SUP-ITM-10273426","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1980.23","38.3","","279.30","91.72","1116.77","266","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE LEFT","SUP-ITM-10273426","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2218.07","42.9","","731.00","63.70","731.00","1 through 10","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE LEFT","SUP-ITM-10273426","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2218.07","42.9","","384.74","384.74","384.74","1 through 10","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE LEFT","SUP-ITM-10273426","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","WELLPOINT [1015]","HB AMC WELLPOINT","3814.66","73.78","","286.63","119.22","1107.45","105","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE LEFT","SUP-ITM-10273426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.32","3877.74","AETNA [1001]","HB AMC AETNA HMO","3608.88","69.8","","675.31","184.75","1721.50","286","2702.01","4225.19","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE LEFT","SUP-ITM-10273426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.32","3877.74","AETNA [1001]","HB AMC AETNA PPO","4156.94","80.4","","1261.44","103.12","1514.10","21","2702.01","4225.19","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE LEFT","SUP-ITM-10273426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.32","3877.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4156.94","80.4","","1365.00","1365.00","1365.00","1 through 10","2702.01","4225.19","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE LEFT","SUP-ITM-10273426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.32","3877.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4225.19","81.72","","5157.68","5157.68","5157.68","1 through 10","2702.01","4225.19","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE LEFT","SUP-ITM-10273426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.32","3877.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4225.19","81.72","","431.26","71.26","1459.57","88","2702.01","4225.19","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE RIGHT","SUP-ITM-10273427","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4110.40","79.5","","800.18","480.96","1887.97","195","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE RIGHT","SUP-ITM-10273427","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2755.78","53.3","","813.12","216.42","1444.50","81","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE RIGHT","SUP-ITM-10273427","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1602.80","31","","432.60","432.60","432.60","1 through 10","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE RIGHT","SUP-ITM-10273427","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1887.17","36.5","","148.37","54.89","631.39","94","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE RIGHT","SUP-ITM-10273427","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1980.23","38.3","","279.30","91.72","1116.77","266","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE RIGHT","SUP-ITM-10273427","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2218.07","42.9","","731.00","63.70","731.00","1 through 10","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE RIGHT","SUP-ITM-10273427","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2218.07","42.9","","384.74","384.74","384.74","1 through 10","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE RIGHT","SUP-ITM-10273427","CDM","C1713","HCPCS","0278","RC","","","","both","","","5170.32","3877.74","WELLPOINT [1015]","HB AMC WELLPOINT","3814.66","73.78","","286.63","119.22","1107.45","105","1602.8","4110.4","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE RIGHT","SUP-ITM-10273427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.32","3877.74","AETNA [1001]","HB AMC AETNA HMO","3608.88","69.8","","675.31","184.75","1721.50","286","2702.01","4225.19","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE RIGHT","SUP-ITM-10273427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.32","3877.74","AETNA [1001]","HB AMC AETNA PPO","4156.94","80.4","","1261.44","103.12","1514.10","21","2702.01","4225.19","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE RIGHT","SUP-ITM-10273427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.32","3877.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4156.94","80.4","","1365.00","1365.00","1365.00","1 through 10","2702.01","4225.19","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE RIGHT","SUP-ITM-10273427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.32","3877.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4225.19","81.72","","5157.68","5157.68","5157.68","1 through 10","2702.01","4225.19","percent of total billed charges",""
"PLATE SPINE 4.5X266MM CONDYLAR CURVED TI VA-LCP 12 HOLE RIGHT","SUP-ITM-10273427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5170.32","3877.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4225.19","81.72","","431.26","71.26","1459.57","88","2702.01","4225.19","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE LEFT","SUP-ITM-10273424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3686.00","79.5","","800.18","480.96","1887.97","195","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE LEFT","SUP-ITM-10273424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2471.24","53.3","","813.12","216.42","1444.50","81","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE LEFT","SUP-ITM-10273424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1437.31","31","","432.60","432.60","432.60","1 through 10","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE LEFT","SUP-ITM-10273424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1692.32","36.5","","148.37","54.89","631.39","94","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE LEFT","SUP-ITM-10273424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1775.77","38.3","","279.30","91.72","1116.77","266","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE LEFT","SUP-ITM-10273424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1989.05","42.9","","731.00","63.70","731.00","1 through 10","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE LEFT","SUP-ITM-10273424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1989.05","42.9","","384.74","384.74","384.74","1 through 10","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE LEFT","SUP-ITM-10273424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","WELLPOINT [1015]","HB AMC WELLPOINT","3420.79","73.78","","286.63","119.22","1107.45","105","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE LEFT","SUP-ITM-10273424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.48","3477.36","AETNA [1001]","HB AMC AETNA HMO","3236.26","69.8","","675.31","184.75","1721.50","286","2423.02","3788.93","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE LEFT","SUP-ITM-10273424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.48","3477.36","AETNA [1001]","HB AMC AETNA PPO","3727.73","80.4","","1261.44","103.12","1514.10","21","2423.02","3788.93","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE LEFT","SUP-ITM-10273424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.48","3477.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3727.73","80.4","","1365.00","1365.00","1365.00","1 through 10","2423.02","3788.93","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE LEFT","SUP-ITM-10273424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.48","3477.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3788.93","81.72","","5157.68","5157.68","5157.68","1 through 10","2423.02","3788.93","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE LEFT","SUP-ITM-10273424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.48","3477.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3788.93","81.72","","431.26","71.26","1459.57","88","2423.02","3788.93","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE RIGHT","SUP-ITM-10273425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3686.00","79.5","","800.18","480.96","1887.97","195","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE RIGHT","SUP-ITM-10273425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2471.24","53.3","","813.12","216.42","1444.50","81","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE RIGHT","SUP-ITM-10273425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1437.31","31","","432.60","432.60","432.60","1 through 10","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE RIGHT","SUP-ITM-10273425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1692.32","36.5","","148.37","54.89","631.39","94","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE RIGHT","SUP-ITM-10273425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1775.77","38.3","","279.30","91.72","1116.77","266","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE RIGHT","SUP-ITM-10273425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1989.05","42.9","","731.00","63.70","731.00","1 through 10","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE RIGHT","SUP-ITM-10273425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1989.05","42.9","","384.74","384.74","384.74","1 through 10","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE RIGHT","SUP-ITM-10273425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4636.48","3477.36","WELLPOINT [1015]","HB AMC WELLPOINT","3420.79","73.78","","286.63","119.22","1107.45","105","1437.31","3686","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE RIGHT","SUP-ITM-10273425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.48","3477.36","AETNA [1001]","HB AMC AETNA HMO","3236.26","69.8","","675.31","184.75","1721.50","286","2423.02","3788.93","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE RIGHT","SUP-ITM-10273425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.48","3477.36","AETNA [1001]","HB AMC AETNA PPO","3727.73","80.4","","1261.44","103.12","1514.10","21","2423.02","3788.93","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE RIGHT","SUP-ITM-10273425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.48","3477.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3727.73","80.4","","1365.00","1365.00","1365.00","1 through 10","2423.02","3788.93","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE RIGHT","SUP-ITM-10273425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.48","3477.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3788.93","81.72","","5157.68","5157.68","5157.68","1 through 10","2423.02","3788.93","percent of total billed charges",""
"PLATE SPINE 4.5X301MM CONDYLAR CURVED TI VA-LCP 14 HOLE RIGHT","SUP-ITM-10273425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4636.48","3477.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3788.93","81.72","","431.26","71.26","1459.57","88","2423.02","3788.93","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE LEFT","SUP-ITM-10273422","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3823.59","79.5","","800.18","480.96","1887.97","195","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE LEFT","SUP-ITM-10273422","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2563.49","53.3","","813.12","216.42","1444.50","81","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE LEFT","SUP-ITM-10273422","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1490.96","31","","432.60","432.60","432.60","1 through 10","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE LEFT","SUP-ITM-10273422","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1755.49","36.5","","148.37","54.89","631.39","94","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE LEFT","SUP-ITM-10273422","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1842.06","38.3","","279.30","91.72","1116.77","266","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE LEFT","SUP-ITM-10273422","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2063.30","42.9","","731.00","63.70","731.00","1 through 10","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE LEFT","SUP-ITM-10273422","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2063.30","42.9","","384.74","384.74","384.74","1 through 10","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE LEFT","SUP-ITM-10273422","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","WELLPOINT [1015]","HB AMC WELLPOINT","3548.49","73.78","","286.63","119.22","1107.45","105","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE LEFT","SUP-ITM-10273422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4809.55","3607.16","AETNA [1001]","HB AMC AETNA HMO","3357.07","69.8","","675.31","184.75","1721.50","286","2513.47","3930.36","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE LEFT","SUP-ITM-10273422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4809.55","3607.16","AETNA [1001]","HB AMC AETNA PPO","3866.88","80.4","","1261.44","103.12","1514.10","21","2513.47","3930.36","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE LEFT","SUP-ITM-10273422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4809.55","3607.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3866.88","80.4","","1365.00","1365.00","1365.00","1 through 10","2513.47","3930.36","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE LEFT","SUP-ITM-10273422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4809.55","3607.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3930.36","81.72","","5157.68","5157.68","5157.68","1 through 10","2513.47","3930.36","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE LEFT","SUP-ITM-10273422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4809.55","3607.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3930.36","81.72","","431.26","71.26","1459.57","88","2513.47","3930.36","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE RIGHT","SUP-ITM-10273423","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3823.59","79.5","","800.18","480.96","1887.97","195","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE RIGHT","SUP-ITM-10273423","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2563.49","53.3","","813.12","216.42","1444.50","81","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE RIGHT","SUP-ITM-10273423","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1490.96","31","","432.60","432.60","432.60","1 through 10","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE RIGHT","SUP-ITM-10273423","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1755.49","36.5","","148.37","54.89","631.39","94","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE RIGHT","SUP-ITM-10273423","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1842.06","38.3","","279.30","91.72","1116.77","266","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE RIGHT","SUP-ITM-10273423","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2063.30","42.9","","731.00","63.70","731.00","1 through 10","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE RIGHT","SUP-ITM-10273423","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2063.30","42.9","","384.74","384.74","384.74","1 through 10","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE RIGHT","SUP-ITM-10273423","CDM","C1713","HCPCS","0278","RC","","","","both","","","4809.55","3607.16","WELLPOINT [1015]","HB AMC WELLPOINT","3548.49","73.78","","286.63","119.22","1107.45","105","1490.96","3823.59","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE RIGHT","SUP-ITM-10273423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4809.55","3607.16","AETNA [1001]","HB AMC AETNA HMO","3357.07","69.8","","675.31","184.75","1721.50","286","2513.47","3930.36","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE RIGHT","SUP-ITM-10273423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4809.55","3607.16","AETNA [1001]","HB AMC AETNA PPO","3866.88","80.4","","1261.44","103.12","1514.10","21","2513.47","3930.36","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE RIGHT","SUP-ITM-10273423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4809.55","3607.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3866.88","80.4","","1365.00","1365.00","1365.00","1 through 10","2513.47","3930.36","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE RIGHT","SUP-ITM-10273423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4809.55","3607.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3930.36","81.72","","5157.68","5157.68","5157.68","1 through 10","2513.47","3930.36","percent of total billed charges",""
"PLATE SPINE 4.5X336MM CONDYLAR CURVED TI VA-LCP 16 HOLE RIGHT","SUP-ITM-10273423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4809.55","3607.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3930.36","81.72","","431.26","71.26","1459.57","88","2513.47","3930.36","percent of total billed charges",""
"PLATE SPINE 4.5X370MM CONDYLAR CURVED TI VA-LCP 18 HOLE LEFT","SUP-ITM-10273420","CDM","C1713","HCPCS","0278","RC","","","","both","","","5318.03","3988.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4227.83","79.5","","800.18","480.96","1887.97","195","1648.59","4227.83","percent of total billed charges",""
"PLATE SPINE 4.5X370MM CONDYLAR CURVED TI VA-LCP 18 HOLE LEFT","SUP-ITM-10273420","CDM","C1713","HCPCS","0278","RC","","","","both","","","5318.03","3988.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2834.51","53.3","","813.12","216.42","1444.50","81","1648.59","4227.83","percent of total billed charges",""
"PLATE SPINE 4.5X370MM CONDYLAR CURVED TI VA-LCP 18 HOLE LEFT","SUP-ITM-10273420","CDM","C1713","HCPCS","0278","RC","","","","both","","","5318.03","3988.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1648.59","31","","432.60","432.60","432.60","1 through 10","1648.59","4227.83","percent of total billed charges",""
"PLATE SPINE 4.5X370MM CONDYLAR CURVED TI VA-LCP 18 HOLE LEFT","SUP-ITM-10273420","CDM","C1713","HCPCS","0278","RC","","","","both","","","5318.03","3988.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1941.08","36.5","","148.37","54.89","631.39","94","1648.59","4227.83","percent of total billed charges",""
"PLATE SPINE 4.5X370MM CONDYLAR CURVED TI VA-LCP 18 HOLE LEFT","SUP-ITM-10273420","CDM","C1713","HCPCS","0278","RC","","","","both","","","5318.03","3988.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2036.81","38.3","","279.30","91.72","1116.77","266","1648.59","4227.83","percent of total billed charges",""
"PLATE SPINE 4.5X370MM CONDYLAR CURVED TI VA-LCP 18 HOLE LEFT","SUP-ITM-10273420","CDM","C1713","HCPCS","0278","RC","","","","both","","","5318.03","3988.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2281.43","42.9","","731.00","63.70","731.00","1 through 10","1648.59","4227.83","percent of total billed charges",""
"PLATE SPINE 4.5X370MM CONDYLAR CURVED TI VA-LCP 18 HOLE LEFT","SUP-ITM-10273420","CDM","C1713","HCPCS","0278","RC","","","","both","","","5318.03","3988.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2281.43","42.9","","384.74","384.74","384.74","1 through 10","1648.59","4227.83","percent of total billed charges",""
"PLATE SPINE 4.5X370MM CONDYLAR CURVED TI VA-LCP 18 HOLE LEFT","SUP-ITM-10273420","CDM","C1713","HCPCS","0278","RC","","","","both","","","5318.03","3988.52","WELLPOINT [1015]","HB AMC WELLPOINT","3923.64","73.78","","286.63","119.22","1107.45","105","1648.59","4227.83","percent of total billed charges",""
"PLATE SPINE 4.5X370MM CONDYLAR CURVED TI VA-LCP 18 HOLE LEFT","SUP-ITM-10273420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5318.03","3988.52","AETNA [1001]","HB AMC AETNA HMO","3711.98","69.8","","675.31","184.75","1721.50","286","2779.2","4345.89","percent of total billed charges",""
"PLATE SPINE 4.5X370MM CONDYLAR CURVED TI VA-LCP 18 HOLE LEFT","SUP-ITM-10273420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5318.03","3988.52","AETNA [1001]","HB AMC AETNA PPO","4275.70","80.4","","1261.44","103.12","1514.10","21","2779.2","4345.89","percent of total billed charges",""
"PLATE SPINE 4.5X370MM CONDYLAR CURVED TI VA-LCP 18 HOLE LEFT","SUP-ITM-10273420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5318.03","3988.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4275.70","80.4","","1365.00","1365.00","1365.00","1 through 10","2779.2","4345.89","percent of total billed charges",""
"PLATE SPINE 4.5X370MM CONDYLAR CURVED TI VA-LCP 18 HOLE LEFT","SUP-ITM-10273420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5318.03","3988.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4345.89","81.72","","5157.68","5157.68","5157.68","1 through 10","2779.2","4345.89","percent of total billed charges",""
"PLATE SPINE 4.5X370MM CONDYLAR CURVED TI VA-LCP 18 HOLE LEFT","SUP-ITM-10273420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5318.03","3988.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4345.89","81.72","","431.26","71.26","1459.57","88","2779.2","4345.89","percent of total billed charges",""
"PLATE STERNUM 12 HOLE TITANIUM LOCKING STAR SHAPE","SUP-ITM-10026781","CDM","C1713","HCPCS","0278","RC","","","","both","","","1827.21","1370.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1452.63","79.5","","800.18","480.96","1887.97","195","566.44","1452.63","percent of total billed charges",""
"PLATE STERNUM 12 HOLE TITANIUM LOCKING STAR SHAPE","SUP-ITM-10026781","CDM","C1713","HCPCS","0278","RC","","","","both","","","1827.21","1370.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","973.90","53.3","","813.12","216.42","1444.50","81","566.44","1452.63","percent of total billed charges",""
"PLATE STERNUM 12 HOLE TITANIUM LOCKING STAR SHAPE","SUP-ITM-10026781","CDM","C1713","HCPCS","0278","RC","","","","both","","","1827.21","1370.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","566.44","31","","432.60","432.60","432.60","1 through 10","566.44","1452.63","percent of total billed charges",""
"PLATE STERNUM 12 HOLE TITANIUM LOCKING STAR SHAPE","SUP-ITM-10026781","CDM","C1713","HCPCS","0278","RC","","","","both","","","1827.21","1370.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","666.93","36.5","","148.37","54.89","631.39","94","566.44","1452.63","percent of total billed charges",""
"PLATE STERNUM 12 HOLE TITANIUM LOCKING STAR SHAPE","SUP-ITM-10026781","CDM","C1713","HCPCS","0278","RC","","","","both","","","1827.21","1370.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","699.82","38.3","","279.30","91.72","1116.77","266","566.44","1452.63","percent of total billed charges",""
"PLATE STERNUM 12 HOLE TITANIUM LOCKING STAR SHAPE","SUP-ITM-10026781","CDM","C1713","HCPCS","0278","RC","","","","both","","","1827.21","1370.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","783.87","42.9","","731.00","63.70","731.00","1 through 10","566.44","1452.63","percent of total billed charges",""
"PLATE STERNUM 12 HOLE TITANIUM LOCKING STAR SHAPE","SUP-ITM-10026781","CDM","C1713","HCPCS","0278","RC","","","","both","","","1827.21","1370.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","783.87","42.9","","384.74","384.74","384.74","1 through 10","566.44","1452.63","percent of total billed charges",""
"PLATE STERNUM 12 HOLE TITANIUM LOCKING STAR SHAPE","SUP-ITM-10026781","CDM","C1713","HCPCS","0278","RC","","","","both","","","1827.21","1370.41","WELLPOINT [1015]","HB AMC WELLPOINT","1348.12","73.78","","286.63","119.22","1107.45","105","566.44","1452.63","percent of total billed charges",""
"PLATE STERNUM 12 HOLE TITANIUM LOCKING STAR SHAPE","SUP-ITM-10026781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1827.21","1370.41","AETNA [1001]","HB AMC AETNA HMO","1275.39","69.8","","675.31","184.75","1721.50","286","954.9","1493.2","percent of total billed charges",""
"PLATE STERNUM 12 HOLE TITANIUM LOCKING STAR SHAPE","SUP-ITM-10026781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1827.21","1370.41","AETNA [1001]","HB AMC AETNA PPO","1469.08","80.4","","1261.44","103.12","1514.10","21","954.9","1493.2","percent of total billed charges",""
"PLATE STERNUM 12 HOLE TITANIUM LOCKING STAR SHAPE","SUP-ITM-10026781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1827.21","1370.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1469.08","80.4","","1365.00","1365.00","1365.00","1 through 10","954.9","1493.2","percent of total billed charges",""
"PLATE STERNUM 12 HOLE TITANIUM LOCKING STAR SHAPE","SUP-ITM-10026781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1827.21","1370.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1493.20","81.72","","5157.68","5157.68","5157.68","1 through 10","954.9","1493.2","percent of total billed charges",""
"PLATE STERNUM 12 HOLE TITANIUM LOCKING STAR SHAPE","SUP-ITM-10026781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1827.21","1370.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1493.20","81.72","","431.26","71.26","1459.57","88","954.9","1493.2","percent of total billed charges",""
"PLATE STERNUM 20 HOLE BONE LOCKING TITANIUM STRAIGHT","SUP-ITM-10020244","CDM","C1713","HCPCS","0278","RC","","","","both","","","3982.62","2986.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3166.18","79.5","","800.18","480.96","1887.97","195","1234.61","3166.18","percent of total billed charges",""
"PLATE STERNUM 20 HOLE BONE LOCKING TITANIUM STRAIGHT","SUP-ITM-10020244","CDM","C1713","HCPCS","0278","RC","","","","both","","","3982.62","2986.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2122.74","53.3","","813.12","216.42","1444.50","81","1234.61","3166.18","percent of total billed charges",""
"PLATE STERNUM 20 HOLE BONE LOCKING TITANIUM STRAIGHT","SUP-ITM-10020244","CDM","C1713","HCPCS","0278","RC","","","","both","","","3982.62","2986.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1234.61","31","","432.60","432.60","432.60","1 through 10","1234.61","3166.18","percent of total billed charges",""
"PLATE STERNUM 20 HOLE BONE LOCKING TITANIUM STRAIGHT","SUP-ITM-10020244","CDM","C1713","HCPCS","0278","RC","","","","both","","","3982.62","2986.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1453.66","36.5","","148.37","54.89","631.39","94","1234.61","3166.18","percent of total billed charges",""
"PLATE STERNUM 20 HOLE BONE LOCKING TITANIUM STRAIGHT","SUP-ITM-10020244","CDM","C1713","HCPCS","0278","RC","","","","both","","","3982.62","2986.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1525.34","38.3","","279.30","91.72","1116.77","266","1234.61","3166.18","percent of total billed charges",""
"PLATE STERNUM 20 HOLE BONE LOCKING TITANIUM STRAIGHT","SUP-ITM-10020244","CDM","C1713","HCPCS","0278","RC","","","","both","","","3982.62","2986.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1708.54","42.9","","731.00","63.70","731.00","1 through 10","1234.61","3166.18","percent of total billed charges",""
"PLATE STERNUM 20 HOLE BONE LOCKING TITANIUM STRAIGHT","SUP-ITM-10020244","CDM","C1713","HCPCS","0278","RC","","","","both","","","3982.62","2986.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1708.54","42.9","","384.74","384.74","384.74","1 through 10","1234.61","3166.18","percent of total billed charges",""
"PLATE STERNUM 20 HOLE BONE LOCKING TITANIUM STRAIGHT","SUP-ITM-10020244","CDM","C1713","HCPCS","0278","RC","","","","both","","","3982.62","2986.96","WELLPOINT [1015]","HB AMC WELLPOINT","2938.38","73.78","","286.63","119.22","1107.45","105","1234.61","3166.18","percent of total billed charges",""
"PLATE STERNUM 20 HOLE BONE LOCKING TITANIUM STRAIGHT","SUP-ITM-10020244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3982.62","2986.96","AETNA [1001]","HB AMC AETNA HMO","2779.87","69.8","","675.31","184.75","1721.50","286","2081.32","3254.6","percent of total billed charges",""
"PLATE STERNUM 20 HOLE BONE LOCKING TITANIUM STRAIGHT","SUP-ITM-10020244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3982.62","2986.96","AETNA [1001]","HB AMC AETNA PPO","3202.03","80.4","","1261.44","103.12","1514.10","21","2081.32","3254.6","percent of total billed charges",""
"PLATE STERNUM 20 HOLE BONE LOCKING TITANIUM STRAIGHT","SUP-ITM-10020244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3982.62","2986.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3202.03","80.4","","1365.00","1365.00","1365.00","1 through 10","2081.32","3254.6","percent of total billed charges",""
"PLATE STERNUM 20 HOLE BONE LOCKING TITANIUM STRAIGHT","SUP-ITM-10020244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3982.62","2986.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3254.60","81.72","","5157.68","5157.68","5157.68","1 through 10","2081.32","3254.6","percent of total billed charges",""
"PLATE STERNUM 20 HOLE BONE LOCKING TITANIUM STRAIGHT","SUP-ITM-10020244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3982.62","2986.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3254.60","81.72","","431.26","71.26","1459.57","88","2081.32","3254.6","percent of total billed charges",""
"PLATE STERNUM 3MM 12 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10020243","CDM","C1713","HCPCS","0278","RC","","","","both","","","2992.05","2244.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2378.68","79.5","","800.18","480.96","1887.97","195","927.54","2378.68","percent of total billed charges",""
"PLATE STERNUM 3MM 12 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10020243","CDM","C1713","HCPCS","0278","RC","","","","both","","","2992.05","2244.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1594.76","53.3","","813.12","216.42","1444.50","81","927.54","2378.68","percent of total billed charges",""
"PLATE STERNUM 3MM 12 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10020243","CDM","C1713","HCPCS","0278","RC","","","","both","","","2992.05","2244.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","927.54","31","","432.60","432.60","432.60","1 through 10","927.54","2378.68","percent of total billed charges",""
"PLATE STERNUM 3MM 12 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10020243","CDM","C1713","HCPCS","0278","RC","","","","both","","","2992.05","2244.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1092.10","36.5","","148.37","54.89","631.39","94","927.54","2378.68","percent of total billed charges",""
"PLATE STERNUM 3MM 12 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10020243","CDM","C1713","HCPCS","0278","RC","","","","both","","","2992.05","2244.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1145.96","38.3","","279.30","91.72","1116.77","266","927.54","2378.68","percent of total billed charges",""
"PLATE STERNUM 3MM 12 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10020243","CDM","C1713","HCPCS","0278","RC","","","","both","","","2992.05","2244.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1283.59","42.9","","731.00","63.70","731.00","1 through 10","927.54","2378.68","percent of total billed charges",""
"PLATE STERNUM 3MM 12 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10020243","CDM","C1713","HCPCS","0278","RC","","","","both","","","2992.05","2244.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1283.59","42.9","","384.74","384.74","384.74","1 through 10","927.54","2378.68","percent of total billed charges",""
"PLATE STERNUM 3MM 12 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10020243","CDM","C1713","HCPCS","0278","RC","","","","both","","","2992.05","2244.04","WELLPOINT [1015]","HB AMC WELLPOINT","2207.53","73.78","","286.63","119.22","1107.45","105","927.54","2378.68","percent of total billed charges",""
"PLATE STERNUM 3MM 12 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10020243","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2992.05","2244.04","AETNA [1001]","HB AMC AETNA HMO","2088.45","69.8","","675.31","184.75","1721.50","286","1563.65","2445.1","percent of total billed charges",""
"PLATE STERNUM 3MM 12 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10020243","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2992.05","2244.04","AETNA [1001]","HB AMC AETNA PPO","2405.61","80.4","","1261.44","103.12","1514.10","21","1563.65","2445.1","percent of total billed charges",""
"PLATE STERNUM 3MM 12 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10020243","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2992.05","2244.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2405.61","80.4","","1365.00","1365.00","1365.00","1 through 10","1563.65","2445.1","percent of total billed charges",""
"PLATE STERNUM 3MM 12 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10020243","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2992.05","2244.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2445.10","81.72","","5157.68","5157.68","5157.68","1 through 10","1563.65","2445.1","percent of total billed charges",""
"PLATE STERNUM 3MM 12 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10020243","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2992.05","2244.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2445.10","81.72","","431.26","71.26","1459.57","88","1563.65","2445.1","percent of total billed charges",""
"PLATE STERNUM 8 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10045477","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.10","1403.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1487.52","79.5","","800.18","480.96","1887.97","195","580.04","1487.52","percent of total billed charges",""
"PLATE STERNUM 8 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10045477","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.10","1403.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","997.30","53.3","","813.12","216.42","1444.50","81","580.04","1487.52","percent of total billed charges",""
"PLATE STERNUM 8 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10045477","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.10","1403.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","580.04","31","","432.60","432.60","432.60","1 through 10","580.04","1487.52","percent of total billed charges",""
"PLATE STERNUM 8 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10045477","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.10","1403.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","682.95","36.5","","148.37","54.89","631.39","94","580.04","1487.52","percent of total billed charges",""
"PLATE STERNUM 8 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10045477","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.10","1403.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","716.63","38.3","","279.30","91.72","1116.77","266","580.04","1487.52","percent of total billed charges",""
"PLATE STERNUM 8 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10045477","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.10","1403.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","802.70","42.9","","731.00","63.70","731.00","1 through 10","580.04","1487.52","percent of total billed charges",""
"PLATE STERNUM 8 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10045477","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.10","1403.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","802.70","42.9","","384.74","384.74","384.74","1 through 10","580.04","1487.52","percent of total billed charges",""
"PLATE STERNUM 8 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10045477","CDM","C1713","HCPCS","0278","RC","","","","both","","","1871.10","1403.32","WELLPOINT [1015]","HB AMC WELLPOINT","1380.50","73.78","","286.63","119.22","1107.45","105","580.04","1487.52","percent of total billed charges",""
"PLATE STERNUM 8 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10045477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1871.10","1403.32","AETNA [1001]","HB AMC AETNA HMO","1306.03","69.8","","675.31","184.75","1721.50","286","977.84","1529.06","percent of total billed charges",""
"PLATE STERNUM 8 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10045477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1871.10","1403.32","AETNA [1001]","HB AMC AETNA PPO","1504.36","80.4","","1261.44","103.12","1514.10","21","977.84","1529.06","percent of total billed charges",""
"PLATE STERNUM 8 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10045477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1871.10","1403.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1504.36","80.4","","1365.00","1365.00","1365.00","1 through 10","977.84","1529.06","percent of total billed charges",""
"PLATE STERNUM 8 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10045477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1871.10","1403.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1529.06","81.72","","5157.68","5157.68","5157.68","1 through 10","977.84","1529.06","percent of total billed charges",""
"PLATE STERNUM 8 HOLE BONE LOCKING STRAIGHT TITANIUM","SUP-ITM-10045477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1871.10","1403.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1529.06","81.72","","431.26","71.26","1459.57","88","977.84","1529.06","percent of total billed charges",""
"PLATE STRAIGHT 24-HOLE","SUP-ITM-10317519","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2504.25","79.5","","800.18","480.96","1887.97","195","976.5","2504.25","percent of total billed charges",""
"PLATE STRAIGHT 24-HOLE","SUP-ITM-10317519","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1678.95","53.3","","813.12","216.42","1444.50","81","976.5","2504.25","percent of total billed charges",""
"PLATE STRAIGHT 24-HOLE","SUP-ITM-10317519","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","976.50","31","","432.60","432.60","432.60","1 through 10","976.5","2504.25","percent of total billed charges",""
"PLATE STRAIGHT 24-HOLE","SUP-ITM-10317519","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1149.75","36.5","","148.37","54.89","631.39","94","976.5","2504.25","percent of total billed charges",""
"PLATE STRAIGHT 24-HOLE","SUP-ITM-10317519","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1206.45","38.3","","279.30","91.72","1116.77","266","976.5","2504.25","percent of total billed charges",""
"PLATE STRAIGHT 24-HOLE","SUP-ITM-10317519","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","731.00","63.70","731.00","1 through 10","976.5","2504.25","percent of total billed charges",""
"PLATE STRAIGHT 24-HOLE","SUP-ITM-10317519","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","384.74","384.74","384.74","1 through 10","976.5","2504.25","percent of total billed charges",""
"PLATE STRAIGHT 24-HOLE","SUP-ITM-10317519","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","WELLPOINT [1015]","HB AMC WELLPOINT","2324.07","73.78","","286.63","119.22","1107.45","105","976.5","2504.25","percent of total billed charges",""
"PLATE STRAIGHT 24-HOLE","SUP-ITM-10317519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA HMO","2198.70","69.8","","675.31","184.75","1721.50","286","1646.19","2574.18","percent of total billed charges",""
"PLATE STRAIGHT 24-HOLE","SUP-ITM-10317519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA PPO","2532.60","80.4","","1261.44","103.12","1514.10","21","1646.19","2574.18","percent of total billed charges",""
"PLATE STRAIGHT 24-HOLE","SUP-ITM-10317519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2532.60","80.4","","1365.00","1365.00","1365.00","1 through 10","1646.19","2574.18","percent of total billed charges",""
"PLATE STRAIGHT 24-HOLE","SUP-ITM-10317519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2574.18","81.72","","5157.68","5157.68","5157.68","1 through 10","1646.19","2574.18","percent of total billed charges",""
"PLATE STRAIGHT 24-HOLE","SUP-ITM-10317519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2574.18","81.72","","431.26","71.26","1459.57","88","1646.19","2574.18","percent of total billed charges",""
"PLATE STRAIGHT 8-HOLE","SUP-ITM-10317517","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1878.19","79.5","","800.18","480.96","1887.97","195","732.38","1878.19","percent of total billed charges",""
"PLATE STRAIGHT 8-HOLE","SUP-ITM-10317517","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1259.21","53.3","","813.12","216.42","1444.50","81","732.38","1878.19","percent of total billed charges",""
"PLATE STRAIGHT 8-HOLE","SUP-ITM-10317517","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","732.38","31","","432.60","432.60","432.60","1 through 10","732.38","1878.19","percent of total billed charges",""
"PLATE STRAIGHT 8-HOLE","SUP-ITM-10317517","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","862.31","36.5","","148.37","54.89","631.39","94","732.38","1878.19","percent of total billed charges",""
"PLATE STRAIGHT 8-HOLE","SUP-ITM-10317517","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","904.84","38.3","","279.30","91.72","1116.77","266","732.38","1878.19","percent of total billed charges",""
"PLATE STRAIGHT 8-HOLE","SUP-ITM-10317517","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","731.00","63.70","731.00","1 through 10","732.38","1878.19","percent of total billed charges",""
"PLATE STRAIGHT 8-HOLE","SUP-ITM-10317517","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","384.74","384.74","384.74","1 through 10","732.38","1878.19","percent of total billed charges",""
"PLATE STRAIGHT 8-HOLE","SUP-ITM-10317517","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","WELLPOINT [1015]","HB AMC WELLPOINT","1743.05","73.78","","286.63","119.22","1107.45","105","732.38","1878.19","percent of total billed charges",""
"PLATE STRAIGHT 8-HOLE","SUP-ITM-10317517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA HMO","1649.03","69.8","","675.31","184.75","1721.50","286","1234.64","1930.64","percent of total billed charges",""
"PLATE STRAIGHT 8-HOLE","SUP-ITM-10317517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA PPO","1899.45","80.4","","1261.44","103.12","1514.10","21","1234.64","1930.64","percent of total billed charges",""
"PLATE STRAIGHT 8-HOLE","SUP-ITM-10317517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1899.45","80.4","","1365.00","1365.00","1365.00","1 through 10","1234.64","1930.64","percent of total billed charges",""
"PLATE STRAIGHT 8-HOLE","SUP-ITM-10317517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1930.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1234.64","1930.64","percent of total billed charges",""
"PLATE STRAIGHT 8-HOLE","SUP-ITM-10317517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1930.64","81.72","","431.26","71.26","1459.57","88","1234.64","1930.64","percent of total billed charges",""
"PLATE TI 2.4/ 2.7MM 0DEG VA LCP FIRST MTP FUSION /REV//RIGHT","SUP-ITM-10096286","CDM","C1713","HCPCS","0278","RC","","","","both","","","3864.28","2898.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3072.10","79.5","","800.18","480.96","1887.97","195","1197.93","3072.1","percent of total billed charges",""
"PLATE TI 2.4/ 2.7MM 0DEG VA LCP FIRST MTP FUSION /REV//RIGHT","SUP-ITM-10096286","CDM","C1713","HCPCS","0278","RC","","","","both","","","3864.28","2898.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2059.66","53.3","","813.12","216.42","1444.50","81","1197.93","3072.1","percent of total billed charges",""
"PLATE TI 2.4/ 2.7MM 0DEG VA LCP FIRST MTP FUSION /REV//RIGHT","SUP-ITM-10096286","CDM","C1713","HCPCS","0278","RC","","","","both","","","3864.28","2898.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1197.93","31","","432.60","432.60","432.60","1 through 10","1197.93","3072.1","percent of total billed charges",""
"PLATE TI 2.4/ 2.7MM 0DEG VA LCP FIRST MTP FUSION /REV//RIGHT","SUP-ITM-10096286","CDM","C1713","HCPCS","0278","RC","","","","both","","","3864.28","2898.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1410.46","36.5","","148.37","54.89","631.39","94","1197.93","3072.1","percent of total billed charges",""
"PLATE TI 2.4/ 2.7MM 0DEG VA LCP FIRST MTP FUSION /REV//RIGHT","SUP-ITM-10096286","CDM","C1713","HCPCS","0278","RC","","","","both","","","3864.28","2898.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1480.02","38.3","","279.30","91.72","1116.77","266","1197.93","3072.1","percent of total billed charges",""
"PLATE TI 2.4/ 2.7MM 0DEG VA LCP FIRST MTP FUSION /REV//RIGHT","SUP-ITM-10096286","CDM","C1713","HCPCS","0278","RC","","","","both","","","3864.28","2898.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1657.78","42.9","","731.00","63.70","731.00","1 through 10","1197.93","3072.1","percent of total billed charges",""
"PLATE TI 2.4/ 2.7MM 0DEG VA LCP FIRST MTP FUSION /REV//RIGHT","SUP-ITM-10096286","CDM","C1713","HCPCS","0278","RC","","","","both","","","3864.28","2898.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1657.78","42.9","","384.74","384.74","384.74","1 through 10","1197.93","3072.1","percent of total billed charges",""
"PLATE TI 2.4/ 2.7MM 0DEG VA LCP FIRST MTP FUSION /REV//RIGHT","SUP-ITM-10096286","CDM","C1713","HCPCS","0278","RC","","","","both","","","3864.28","2898.21","WELLPOINT [1015]","HB AMC WELLPOINT","2851.07","73.78","","286.63","119.22","1107.45","105","1197.93","3072.1","percent of total billed charges",""
"PLATE TI 2.4/ 2.7MM 0DEG VA LCP FIRST MTP FUSION /REV//RIGHT","SUP-ITM-10096286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3864.28","2898.21","AETNA [1001]","HB AMC AETNA HMO","2697.27","69.8","","675.31","184.75","1721.50","286","2019.47","3157.89","percent of total billed charges",""
"PLATE TI 2.4/ 2.7MM 0DEG VA LCP FIRST MTP FUSION /REV//RIGHT","SUP-ITM-10096286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3864.28","2898.21","AETNA [1001]","HB AMC AETNA PPO","3106.88","80.4","","1261.44","103.12","1514.10","21","2019.47","3157.89","percent of total billed charges",""
"PLATE TI 2.4/ 2.7MM 0DEG VA LCP FIRST MTP FUSION /REV//RIGHT","SUP-ITM-10096286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3864.28","2898.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3106.88","80.4","","1365.00","1365.00","1365.00","1 through 10","2019.47","3157.89","percent of total billed charges",""
"PLATE TI 2.4/ 2.7MM 0DEG VA LCP FIRST MTP FUSION /REV//RIGHT","SUP-ITM-10096286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3864.28","2898.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3157.89","81.72","","5157.68","5157.68","5157.68","1 through 10","2019.47","3157.89","percent of total billed charges",""
"PLATE TI 2.4/ 2.7MM 0DEG VA LCP FIRST MTP FUSION /REV//RIGHT","SUP-ITM-10096286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3864.28","2898.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3157.89","81.72","","431.26","71.26","1459.57","88","2019.47","3157.89","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3969.33","2977.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3155.62","79.5","","800.18","480.96","1887.97","195","1230.49","3155.62","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3969.33","2977.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2115.65","53.3","","813.12","216.42","1444.50","81","1230.49","3155.62","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3969.33","2977.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1230.49","31","","432.60","432.60","432.60","1 through 10","1230.49","3155.62","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3969.33","2977.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1448.81","36.5","","148.37","54.89","631.39","94","1230.49","3155.62","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3969.33","2977.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1520.25","38.3","","279.30","91.72","1116.77","266","1230.49","3155.62","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3969.33","2977.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1702.84","42.9","","731.00","63.70","731.00","1 through 10","1230.49","3155.62","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3969.33","2977.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1702.84","42.9","","384.74","384.74","384.74","1 through 10","1230.49","3155.62","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3969.33","2977.00","WELLPOINT [1015]","HB AMC WELLPOINT","2928.57","73.78","","286.63","119.22","1107.45","105","1230.49","3155.62","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3969.33","2977.00","AETNA [1001]","HB AMC AETNA HMO","2770.59","69.8","","675.31","184.75","1721.50","286","2074.37","3243.74","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3969.33","2977.00","AETNA [1001]","HB AMC AETNA PPO","3191.34","80.4","","1261.44","103.12","1514.10","21","2074.37","3243.74","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3969.33","2977.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3191.34","80.4","","1365.00","1365.00","1365.00","1 through 10","2074.37","3243.74","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3969.33","2977.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3243.74","81.72","","5157.68","5157.68","5157.68","1 through 10","2074.37","3243.74","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3969.33","2977.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3243.74","81.72","","431.26","71.26","1459.57","88","2074.37","3243.74","percent of total billed charges",""
"PLATE TIBIA 2.7MM 6 HOLE VA LCP SS L SHAPE DISTAL LEFT","SUP-ITM-10125018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2400.13","79.5","","800.18","480.96","1887.97","195","935.9","2400.13","percent of total billed charges",""
"PLATE TIBIA 2.7MM 6 HOLE VA LCP SS L SHAPE DISTAL LEFT","SUP-ITM-10125018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1609.14","53.3","","813.12","216.42","1444.50","81","935.9","2400.13","percent of total billed charges",""
"PLATE TIBIA 2.7MM 6 HOLE VA LCP SS L SHAPE DISTAL LEFT","SUP-ITM-10125018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","935.90","31","","432.60","432.60","432.60","1 through 10","935.9","2400.13","percent of total billed charges",""
"PLATE TIBIA 2.7MM 6 HOLE VA LCP SS L SHAPE DISTAL LEFT","SUP-ITM-10125018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1101.95","36.5","","148.37","54.89","631.39","94","935.9","2400.13","percent of total billed charges",""
"PLATE TIBIA 2.7MM 6 HOLE VA LCP SS L SHAPE DISTAL LEFT","SUP-ITM-10125018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1156.29","38.3","","279.30","91.72","1116.77","266","935.9","2400.13","percent of total billed charges",""
"PLATE TIBIA 2.7MM 6 HOLE VA LCP SS L SHAPE DISTAL LEFT","SUP-ITM-10125018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1295.16","42.9","","731.00","63.70","731.00","1 through 10","935.9","2400.13","percent of total billed charges",""
"PLATE TIBIA 2.7MM 6 HOLE VA LCP SS L SHAPE DISTAL LEFT","SUP-ITM-10125018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1295.16","42.9","","384.74","384.74","384.74","1 through 10","935.9","2400.13","percent of total billed charges",""
"PLATE TIBIA 2.7MM 6 HOLE VA LCP SS L SHAPE DISTAL LEFT","SUP-ITM-10125018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3019.03","2264.27","WELLPOINT [1015]","HB AMC WELLPOINT","2227.44","73.78","","286.63","119.22","1107.45","105","935.9","2400.13","percent of total billed charges",""
"PLATE TIBIA 2.7MM 6 HOLE VA LCP SS L SHAPE DISTAL LEFT","SUP-ITM-10125018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3019.03","2264.27","AETNA [1001]","HB AMC AETNA HMO","2107.28","69.8","","675.31","184.75","1721.50","286","1577.75","2467.15","percent of total billed charges",""
"PLATE TIBIA 2.7MM 6 HOLE VA LCP SS L SHAPE DISTAL LEFT","SUP-ITM-10125018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3019.03","2264.27","AETNA [1001]","HB AMC AETNA PPO","2427.30","80.4","","1261.44","103.12","1514.10","21","1577.75","2467.15","percent of total billed charges",""
"PLATE TIBIA 2.7MM 6 HOLE VA LCP SS L SHAPE DISTAL LEFT","SUP-ITM-10125018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3019.03","2264.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2427.30","80.4","","1365.00","1365.00","1365.00","1 through 10","1577.75","2467.15","percent of total billed charges",""
"PLATE TIBIA 2.7MM 6 HOLE VA LCP SS L SHAPE DISTAL LEFT","SUP-ITM-10125018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3019.03","2264.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2467.15","81.72","","5157.68","5157.68","5157.68","1 through 10","1577.75","2467.15","percent of total billed charges",""
"PLATE TIBIA 2.7MM 6 HOLE VA LCP SS L SHAPE DISTAL LEFT","SUP-ITM-10125018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3019.03","2264.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2467.15","81.72","","431.26","71.26","1459.57","88","1577.75","2467.15","percent of total billed charges",""
"PLATE TIBIA 3.5MM 11 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040748","CDM","C1713","HCPCS","0278","RC","","","","both","","","4245.01","3183.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3374.78","79.5","","800.18","480.96","1887.97","195","1315.95","3374.78","percent of total billed charges",""
"PLATE TIBIA 3.5MM 11 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040748","CDM","C1713","HCPCS","0278","RC","","","","both","","","4245.01","3183.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2262.59","53.3","","813.12","216.42","1444.50","81","1315.95","3374.78","percent of total billed charges",""
"PLATE TIBIA 3.5MM 11 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040748","CDM","C1713","HCPCS","0278","RC","","","","both","","","4245.01","3183.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1315.95","31","","432.60","432.60","432.60","1 through 10","1315.95","3374.78","percent of total billed charges",""
"PLATE TIBIA 3.5MM 11 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040748","CDM","C1713","HCPCS","0278","RC","","","","both","","","4245.01","3183.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1549.43","36.5","","148.37","54.89","631.39","94","1315.95","3374.78","percent of total billed charges",""
"PLATE TIBIA 3.5MM 11 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040748","CDM","C1713","HCPCS","0278","RC","","","","both","","","4245.01","3183.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1625.84","38.3","","279.30","91.72","1116.77","266","1315.95","3374.78","percent of total billed charges",""
"PLATE TIBIA 3.5MM 11 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040748","CDM","C1713","HCPCS","0278","RC","","","","both","","","4245.01","3183.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1821.11","42.9","","731.00","63.70","731.00","1 through 10","1315.95","3374.78","percent of total billed charges",""
"PLATE TIBIA 3.5MM 11 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040748","CDM","C1713","HCPCS","0278","RC","","","","both","","","4245.01","3183.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1821.11","42.9","","384.74","384.74","384.74","1 through 10","1315.95","3374.78","percent of total billed charges",""
"PLATE TIBIA 3.5MM 11 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040748","CDM","C1713","HCPCS","0278","RC","","","","both","","","4245.01","3183.76","WELLPOINT [1015]","HB AMC WELLPOINT","3131.97","73.78","","286.63","119.22","1107.45","105","1315.95","3374.78","percent of total billed charges",""
"PLATE TIBIA 3.5MM 11 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4245.01","3183.76","AETNA [1001]","HB AMC AETNA HMO","2963.02","69.8","","675.31","184.75","1721.50","286","2218.44","3469.02","percent of total billed charges",""
"PLATE TIBIA 3.5MM 11 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4245.01","3183.76","AETNA [1001]","HB AMC AETNA PPO","3412.99","80.4","","1261.44","103.12","1514.10","21","2218.44","3469.02","percent of total billed charges",""
"PLATE TIBIA 3.5MM 11 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4245.01","3183.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3412.99","80.4","","1365.00","1365.00","1365.00","1 through 10","2218.44","3469.02","percent of total billed charges",""
"PLATE TIBIA 3.5MM 11 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4245.01","3183.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3469.02","81.72","","5157.68","5157.68","5157.68","1 through 10","2218.44","3469.02","percent of total billed charges",""
"PLATE TIBIA 3.5MM 11 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4245.01","3183.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3469.02","81.72","","431.26","71.26","1459.57","88","2218.44","3469.02","percent of total billed charges",""
"PLATE TIBIA 3.5MM 13 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4291.63","3218.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3411.85","79.5","","800.18","480.96","1887.97","195","1330.41","3411.85","percent of total billed charges",""
"PLATE TIBIA 3.5MM 13 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4291.63","3218.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2287.44","53.3","","813.12","216.42","1444.50","81","1330.41","3411.85","percent of total billed charges",""
"PLATE TIBIA 3.5MM 13 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4291.63","3218.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1330.41","31","","432.60","432.60","432.60","1 through 10","1330.41","3411.85","percent of total billed charges",""
"PLATE TIBIA 3.5MM 13 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4291.63","3218.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1566.44","36.5","","148.37","54.89","631.39","94","1330.41","3411.85","percent of total billed charges",""
"PLATE TIBIA 3.5MM 13 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4291.63","3218.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1643.69","38.3","","279.30","91.72","1116.77","266","1330.41","3411.85","percent of total billed charges",""
"PLATE TIBIA 3.5MM 13 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4291.63","3218.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1841.11","42.9","","731.00","63.70","731.00","1 through 10","1330.41","3411.85","percent of total billed charges",""
"PLATE TIBIA 3.5MM 13 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4291.63","3218.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1841.11","42.9","","384.74","384.74","384.74","1 through 10","1330.41","3411.85","percent of total billed charges",""
"PLATE TIBIA 3.5MM 13 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4291.63","3218.72","WELLPOINT [1015]","HB AMC WELLPOINT","3166.36","73.78","","286.63","119.22","1107.45","105","1330.41","3411.85","percent of total billed charges",""
"PLATE TIBIA 3.5MM 13 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4291.63","3218.72","AETNA [1001]","HB AMC AETNA HMO","2995.56","69.8","","675.31","184.75","1721.50","286","2242.81","3507.12","percent of total billed charges",""
"PLATE TIBIA 3.5MM 13 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4291.63","3218.72","AETNA [1001]","HB AMC AETNA PPO","3450.47","80.4","","1261.44","103.12","1514.10","21","2242.81","3507.12","percent of total billed charges",""
"PLATE TIBIA 3.5MM 13 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4291.63","3218.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3450.47","80.4","","1365.00","1365.00","1365.00","1 through 10","2242.81","3507.12","percent of total billed charges",""
"PLATE TIBIA 3.5MM 13 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4291.63","3218.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3507.12","81.72","","5157.68","5157.68","5157.68","1 through 10","2242.81","3507.12","percent of total billed charges",""
"PLATE TIBIA 3.5MM 13 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4291.63","3218.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3507.12","81.72","","431.26","71.26","1459.57","88","2242.81","3507.12","percent of total billed charges",""
"PLATE TIBIA 3.5MM 15 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040752","CDM","C1713","HCPCS","0278","RC","","","","both","","","4349.91","3262.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3458.18","79.5","","800.18","480.96","1887.97","195","1348.47","3458.18","percent of total billed charges",""
"PLATE TIBIA 3.5MM 15 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040752","CDM","C1713","HCPCS","0278","RC","","","","both","","","4349.91","3262.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2318.50","53.3","","813.12","216.42","1444.50","81","1348.47","3458.18","percent of total billed charges",""
"PLATE TIBIA 3.5MM 15 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040752","CDM","C1713","HCPCS","0278","RC","","","","both","","","4349.91","3262.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1348.47","31","","432.60","432.60","432.60","1 through 10","1348.47","3458.18","percent of total billed charges",""
"PLATE TIBIA 3.5MM 15 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040752","CDM","C1713","HCPCS","0278","RC","","","","both","","","4349.91","3262.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1587.72","36.5","","148.37","54.89","631.39","94","1348.47","3458.18","percent of total billed charges",""
"PLATE TIBIA 3.5MM 15 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040752","CDM","C1713","HCPCS","0278","RC","","","","both","","","4349.91","3262.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1666.02","38.3","","279.30","91.72","1116.77","266","1348.47","3458.18","percent of total billed charges",""
"PLATE TIBIA 3.5MM 15 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040752","CDM","C1713","HCPCS","0278","RC","","","","both","","","4349.91","3262.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.11","42.9","","731.00","63.70","731.00","1 through 10","1348.47","3458.18","percent of total billed charges",""
"PLATE TIBIA 3.5MM 15 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040752","CDM","C1713","HCPCS","0278","RC","","","","both","","","4349.91","3262.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.11","42.9","","384.74","384.74","384.74","1 through 10","1348.47","3458.18","percent of total billed charges",""
"PLATE TIBIA 3.5MM 15 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040752","CDM","C1713","HCPCS","0278","RC","","","","both","","","4349.91","3262.43","WELLPOINT [1015]","HB AMC WELLPOINT","3209.36","73.78","","286.63","119.22","1107.45","105","1348.47","3458.18","percent of total billed charges",""
"PLATE TIBIA 3.5MM 15 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040752","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4349.91","3262.43","AETNA [1001]","HB AMC AETNA HMO","3036.24","69.8","","675.31","184.75","1721.50","286","2273.26","3554.75","percent of total billed charges",""
"PLATE TIBIA 3.5MM 15 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040752","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4349.91","3262.43","AETNA [1001]","HB AMC AETNA PPO","3497.33","80.4","","1261.44","103.12","1514.10","21","2273.26","3554.75","percent of total billed charges",""
"PLATE TIBIA 3.5MM 15 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040752","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4349.91","3262.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3497.33","80.4","","1365.00","1365.00","1365.00","1 through 10","2273.26","3554.75","percent of total billed charges",""
"PLATE TIBIA 3.5MM 15 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040752","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4349.91","3262.43","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3554.75","81.72","","5157.68","5157.68","5157.68","1 through 10","2273.26","3554.75","percent of total billed charges",""
"PLATE TIBIA 3.5MM 15 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040752","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4349.91","3262.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3554.75","81.72","","431.26","71.26","1459.57","88","2273.26","3554.75","percent of total billed charges",""
"PLATE TIBIA 3.5X116MM 4 HOLE L LCP SS RIGHT","SUP-ITM-10011800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.62","2813.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2982.54","79.5","","800.18","480.96","1887.97","195","1163","2982.54","percent of total billed charges",""
"PLATE TIBIA 3.5X116MM 4 HOLE L LCP SS RIGHT","SUP-ITM-10011800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.62","2813.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1999.61","53.3","","813.12","216.42","1444.50","81","1163","2982.54","percent of total billed charges",""
"PLATE TIBIA 3.5X116MM 4 HOLE L LCP SS RIGHT","SUP-ITM-10011800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.62","2813.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1163.00","31","","432.60","432.60","432.60","1 through 10","1163","2982.54","percent of total billed charges",""
"PLATE TIBIA 3.5X116MM 4 HOLE L LCP SS RIGHT","SUP-ITM-10011800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.62","2813.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1369.34","36.5","","148.37","54.89","631.39","94","1163","2982.54","percent of total billed charges",""
"PLATE TIBIA 3.5X116MM 4 HOLE L LCP SS RIGHT","SUP-ITM-10011800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.62","2813.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1436.87","38.3","","279.30","91.72","1116.77","266","1163","2982.54","percent of total billed charges",""
"PLATE TIBIA 3.5X116MM 4 HOLE L LCP SS RIGHT","SUP-ITM-10011800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.62","2813.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1609.44","42.9","","731.00","63.70","731.00","1 through 10","1163","2982.54","percent of total billed charges",""
"PLATE TIBIA 3.5X116MM 4 HOLE L LCP SS RIGHT","SUP-ITM-10011800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.62","2813.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1609.44","42.9","","384.74","384.74","384.74","1 through 10","1163","2982.54","percent of total billed charges",""
"PLATE TIBIA 3.5X116MM 4 HOLE L LCP SS RIGHT","SUP-ITM-10011800","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.62","2813.71","WELLPOINT [1015]","HB AMC WELLPOINT","2767.95","73.78","","286.63","119.22","1107.45","105","1163","2982.54","percent of total billed charges",""
"PLATE TIBIA 3.5X116MM 4 HOLE L LCP SS RIGHT","SUP-ITM-10011800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3751.62","2813.71","AETNA [1001]","HB AMC AETNA HMO","2618.63","69.8","","675.31","184.75","1721.50","286","1960.6","3065.82","percent of total billed charges",""
"PLATE TIBIA 3.5X116MM 4 HOLE L LCP SS RIGHT","SUP-ITM-10011800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3751.62","2813.71","AETNA [1001]","HB AMC AETNA PPO","3016.30","80.4","","1261.44","103.12","1514.10","21","1960.6","3065.82","percent of total billed charges",""
"PLATE TIBIA 3.5X116MM 4 HOLE L LCP SS RIGHT","SUP-ITM-10011800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3751.62","2813.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3016.30","80.4","","1365.00","1365.00","1365.00","1 through 10","1960.6","3065.82","percent of total billed charges",""
"PLATE TIBIA 3.5X116MM 4 HOLE L LCP SS RIGHT","SUP-ITM-10011800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3751.62","2813.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3065.82","81.72","","5157.68","5157.68","5157.68","1 through 10","1960.6","3065.82","percent of total billed charges",""
"PLATE TIBIA 3.5X116MM 4 HOLE L LCP SS RIGHT","SUP-ITM-10011800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3751.62","2813.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3065.82","81.72","","431.26","71.26","1459.57","88","1960.6","3065.82","percent of total billed charges",""
"PLATE TIBIA 3.5X128MM 8 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096141","CDM","C1713","HCPCS","0278","RC","","","","both","","","4144.00","3108.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3294.48","79.5","","800.18","480.96","1887.97","195","1284.64","3294.48","percent of total billed charges",""
"PLATE TIBIA 3.5X128MM 8 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096141","CDM","C1713","HCPCS","0278","RC","","","","both","","","4144.00","3108.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2208.75","53.3","","813.12","216.42","1444.50","81","1284.64","3294.48","percent of total billed charges",""
"PLATE TIBIA 3.5X128MM 8 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096141","CDM","C1713","HCPCS","0278","RC","","","","both","","","4144.00","3108.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1284.64","31","","432.60","432.60","432.60","1 through 10","1284.64","3294.48","percent of total billed charges",""
"PLATE TIBIA 3.5X128MM 8 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096141","CDM","C1713","HCPCS","0278","RC","","","","both","","","4144.00","3108.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1512.56","36.5","","148.37","54.89","631.39","94","1284.64","3294.48","percent of total billed charges",""
"PLATE TIBIA 3.5X128MM 8 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096141","CDM","C1713","HCPCS","0278","RC","","","","both","","","4144.00","3108.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1587.15","38.3","","279.30","91.72","1116.77","266","1284.64","3294.48","percent of total billed charges",""
"PLATE TIBIA 3.5X128MM 8 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096141","CDM","C1713","HCPCS","0278","RC","","","","both","","","4144.00","3108.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1777.78","42.9","","731.00","63.70","731.00","1 through 10","1284.64","3294.48","percent of total billed charges",""
"PLATE TIBIA 3.5X128MM 8 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096141","CDM","C1713","HCPCS","0278","RC","","","","both","","","4144.00","3108.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1777.78","42.9","","384.74","384.74","384.74","1 through 10","1284.64","3294.48","percent of total billed charges",""
"PLATE TIBIA 3.5X128MM 8 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096141","CDM","C1713","HCPCS","0278","RC","","","","both","","","4144.00","3108.00","WELLPOINT [1015]","HB AMC WELLPOINT","3057.44","73.78","","286.63","119.22","1107.45","105","1284.64","3294.48","percent of total billed charges",""
"PLATE TIBIA 3.5X128MM 8 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096141","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4144.00","3108.00","AETNA [1001]","HB AMC AETNA HMO","2892.51","69.8","","675.31","184.75","1721.50","286","2165.65","3386.48","percent of total billed charges",""
"PLATE TIBIA 3.5X128MM 8 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096141","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4144.00","3108.00","AETNA [1001]","HB AMC AETNA PPO","3331.78","80.4","","1261.44","103.12","1514.10","21","2165.65","3386.48","percent of total billed charges",""
"PLATE TIBIA 3.5X128MM 8 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096141","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4144.00","3108.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3331.78","80.4","","1365.00","1365.00","1365.00","1 through 10","2165.65","3386.48","percent of total billed charges",""
"PLATE TIBIA 3.5X128MM 8 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096141","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4144.00","3108.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3386.48","81.72","","5157.68","5157.68","5157.68","1 through 10","2165.65","3386.48","percent of total billed charges",""
"PLATE TIBIA 3.5X128MM 8 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096141","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4144.00","3108.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3386.48","81.72","","431.26","71.26","1459.57","88","2165.65","3386.48","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.51","3060.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3244.01","79.5","","800.18","480.96","1887.97","195","1264.96","3244.01","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.51","3060.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2174.91","53.3","","813.12","216.42","1444.50","81","1264.96","3244.01","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.51","3060.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1264.96","31","","432.60","432.60","432.60","1 through 10","1264.96","3244.01","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.51","3060.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1489.39","36.5","","148.37","54.89","631.39","94","1264.96","3244.01","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.51","3060.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1562.84","38.3","","279.30","91.72","1116.77","266","1264.96","3244.01","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.51","3060.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1750.54","42.9","","731.00","63.70","731.00","1 through 10","1264.96","3244.01","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.51","3060.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1750.54","42.9","","384.74","384.74","384.74","1 through 10","1264.96","3244.01","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.51","3060.38","WELLPOINT [1015]","HB AMC WELLPOINT","3010.60","73.78","","286.63","119.22","1107.45","105","1264.96","3244.01","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4080.51","3060.38","AETNA [1001]","HB AMC AETNA HMO","2848.20","69.8","","675.31","184.75","1721.50","286","2132.47","3334.59","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4080.51","3060.38","AETNA [1001]","HB AMC AETNA PPO","3280.73","80.4","","1261.44","103.12","1514.10","21","2132.47","3334.59","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4080.51","3060.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3280.73","80.4","","1365.00","1365.00","1365.00","1 through 10","2132.47","3334.59","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4080.51","3060.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3334.59","81.72","","5157.68","5157.68","5157.68","1 through 10","2132.47","3334.59","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4080.51","3060.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3334.59","81.72","","431.26","71.26","1459.57","88","2132.47","3334.59","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","4492.26","3369.19","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2347.66","52.26","","1113.10","1113.10","1113.10","1 through 10","1392.6","3571.35","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","4492.26","3369.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3571.35","79.5","","1293.60","1148.53","1603.80","1 through 10","1392.6","3571.35","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","4492.26","3369.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1639.67","36.5","","1023.42","771.29","2068.67","33","1392.6","3571.35","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","4492.26","3369.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1720.54","38.3","","850.52","759.78","1211.25","66","1392.6","3571.35","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","4492.26","3369.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1927.18","42.9","","2548.09","2548.09","2548.09","1 through 10","1392.6","3571.35","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","4492.26","3369.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1927.18","42.9","","956.46","956.46","956.46","1 through 10","1392.6","3571.35","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","4492.26","3369.19","WELLPOINT [1015]","HB AMC WELLPOINT","3314.39","73.78","","2344.73","1619.47","2530.35","16","1392.6","3571.35","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4492.26","3369.19","AETNA [1001]","HB AMC AETNA HMO","3135.60","69.8","","1523.63","988.41","4330.26","39","2347.66","3671.07","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4492.26","3369.19","AETNA [1001]","HB AMC AETNA PPO","3611.78","80.4","","1670.25","1670.25","1670.25","1 through 10","2347.66","3671.07","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4492.26","3369.19","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2347.66","52.26","","1113.10","1113.10","1113.10","1 through 10","2347.66","3671.07","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4492.26","3369.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3671.07","81.72","","1738.90","1484.65","2716.94","38","2347.66","3671.07","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3689.46","2767.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2933.12","79.5","","800.18","480.96","1887.97","195","1143.73","2933.12","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3689.46","2767.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1966.48","53.3","","813.12","216.42","1444.50","81","1143.73","2933.12","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3689.46","2767.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1143.73","31","","432.60","432.60","432.60","1 through 10","1143.73","2933.12","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3689.46","2767.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1346.65","36.5","","148.37","54.89","631.39","94","1143.73","2933.12","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3689.46","2767.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1413.06","38.3","","279.30","91.72","1116.77","266","1143.73","2933.12","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3689.46","2767.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1582.78","42.9","","731.00","63.70","731.00","1 through 10","1143.73","2933.12","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3689.46","2767.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1582.78","42.9","","384.74","384.74","384.74","1 through 10","1143.73","2933.12","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3689.46","2767.09","WELLPOINT [1015]","HB AMC WELLPOINT","2722.08","73.78","","286.63","119.22","1107.45","105","1143.73","2933.12","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3689.46","2767.09","AETNA [1001]","HB AMC AETNA HMO","2575.24","69.8","","675.31","184.75","1721.50","286","1928.11","3015.03","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3689.46","2767.09","AETNA [1001]","HB AMC AETNA PPO","2966.33","80.4","","1261.44","103.12","1514.10","21","1928.11","3015.03","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3689.46","2767.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2966.33","80.4","","1365.00","1365.00","1365.00","1 through 10","1928.11","3015.03","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3689.46","2767.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3015.03","81.72","","5157.68","5157.68","5157.68","1 through 10","1928.11","3015.03","percent of total billed charges",""
"PLATE TIBIA 3.5X194MM 10 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3689.46","2767.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3015.03","81.72","","431.26","71.26","1459.57","88","1928.11","3015.03","percent of total billed charges",""
"PLATE TIBIA 3.5X197MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037870","CDM","C1713","HCPCS","0278","RC","","","","both","","","4139.61","3104.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3290.99","79.5","","800.18","480.96","1887.97","195","1283.28","3290.99","percent of total billed charges",""
"PLATE TIBIA 3.5X197MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037870","CDM","C1713","HCPCS","0278","RC","","","","both","","","4139.61","3104.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2206.41","53.3","","813.12","216.42","1444.50","81","1283.28","3290.99","percent of total billed charges",""
"PLATE TIBIA 3.5X197MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037870","CDM","C1713","HCPCS","0278","RC","","","","both","","","4139.61","3104.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1283.28","31","","432.60","432.60","432.60","1 through 10","1283.28","3290.99","percent of total billed charges",""
"PLATE TIBIA 3.5X197MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037870","CDM","C1713","HCPCS","0278","RC","","","","both","","","4139.61","3104.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1510.96","36.5","","148.37","54.89","631.39","94","1283.28","3290.99","percent of total billed charges",""
"PLATE TIBIA 3.5X197MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037870","CDM","C1713","HCPCS","0278","RC","","","","both","","","4139.61","3104.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1585.47","38.3","","279.30","91.72","1116.77","266","1283.28","3290.99","percent of total billed charges",""
"PLATE TIBIA 3.5X197MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037870","CDM","C1713","HCPCS","0278","RC","","","","both","","","4139.61","3104.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1775.89","42.9","","731.00","63.70","731.00","1 through 10","1283.28","3290.99","percent of total billed charges",""
"PLATE TIBIA 3.5X197MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037870","CDM","C1713","HCPCS","0278","RC","","","","both","","","4139.61","3104.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1775.89","42.9","","384.74","384.74","384.74","1 through 10","1283.28","3290.99","percent of total billed charges",""
"PLATE TIBIA 3.5X197MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037870","CDM","C1713","HCPCS","0278","RC","","","","both","","","4139.61","3104.71","WELLPOINT [1015]","HB AMC WELLPOINT","3054.20","73.78","","286.63","119.22","1107.45","105","1283.28","3290.99","percent of total billed charges",""
"PLATE TIBIA 3.5X197MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4139.61","3104.71","AETNA [1001]","HB AMC AETNA HMO","2889.45","69.8","","675.31","184.75","1721.50","286","2163.36","3382.89","percent of total billed charges",""
"PLATE TIBIA 3.5X197MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4139.61","3104.71","AETNA [1001]","HB AMC AETNA PPO","3328.25","80.4","","1261.44","103.12","1514.10","21","2163.36","3382.89","percent of total billed charges",""
"PLATE TIBIA 3.5X197MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4139.61","3104.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3328.25","80.4","","1365.00","1365.00","1365.00","1 through 10","2163.36","3382.89","percent of total billed charges",""
"PLATE TIBIA 3.5X197MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4139.61","3104.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3382.89","81.72","","5157.68","5157.68","5157.68","1 through 10","2163.36","3382.89","percent of total billed charges",""
"PLATE TIBIA 3.5X197MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4139.61","3104.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3382.89","81.72","","431.26","71.26","1459.57","88","2163.36","3382.89","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LEG LCP SS LOW BEND RIGHT","SUP-ITM-10091737","CDM","C1713","HCPCS","0278","RC","","","","both","","","4392.64","3294.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3492.15","79.5","","800.18","480.96","1887.97","195","1361.72","3492.15","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LEG LCP SS LOW BEND RIGHT","SUP-ITM-10091737","CDM","C1713","HCPCS","0278","RC","","","","both","","","4392.64","3294.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2341.28","53.3","","813.12","216.42","1444.50","81","1361.72","3492.15","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LEG LCP SS LOW BEND RIGHT","SUP-ITM-10091737","CDM","C1713","HCPCS","0278","RC","","","","both","","","4392.64","3294.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1361.72","31","","432.60","432.60","432.60","1 through 10","1361.72","3492.15","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LEG LCP SS LOW BEND RIGHT","SUP-ITM-10091737","CDM","C1713","HCPCS","0278","RC","","","","both","","","4392.64","3294.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1603.31","36.5","","148.37","54.89","631.39","94","1361.72","3492.15","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LEG LCP SS LOW BEND RIGHT","SUP-ITM-10091737","CDM","C1713","HCPCS","0278","RC","","","","both","","","4392.64","3294.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1682.38","38.3","","279.30","91.72","1116.77","266","1361.72","3492.15","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LEG LCP SS LOW BEND RIGHT","SUP-ITM-10091737","CDM","C1713","HCPCS","0278","RC","","","","both","","","4392.64","3294.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1884.44","42.9","","731.00","63.70","731.00","1 through 10","1361.72","3492.15","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LEG LCP SS LOW BEND RIGHT","SUP-ITM-10091737","CDM","C1713","HCPCS","0278","RC","","","","both","","","4392.64","3294.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1884.44","42.9","","384.74","384.74","384.74","1 through 10","1361.72","3492.15","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LEG LCP SS LOW BEND RIGHT","SUP-ITM-10091737","CDM","C1713","HCPCS","0278","RC","","","","both","","","4392.64","3294.48","WELLPOINT [1015]","HB AMC WELLPOINT","3240.89","73.78","","286.63","119.22","1107.45","105","1361.72","3492.15","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LEG LCP SS LOW BEND RIGHT","SUP-ITM-10091737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4392.64","3294.48","AETNA [1001]","HB AMC AETNA HMO","3066.06","69.8","","675.31","184.75","1721.50","286","2295.59","3589.67","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LEG LCP SS LOW BEND RIGHT","SUP-ITM-10091737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4392.64","3294.48","AETNA [1001]","HB AMC AETNA PPO","3531.68","80.4","","1261.44","103.12","1514.10","21","2295.59","3589.67","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LEG LCP SS LOW BEND RIGHT","SUP-ITM-10091737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4392.64","3294.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3531.68","80.4","","1365.00","1365.00","1365.00","1 through 10","2295.59","3589.67","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LEG LCP SS LOW BEND RIGHT","SUP-ITM-10091737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4392.64","3294.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3589.67","81.72","","5157.68","5157.68","5157.68","1 through 10","2295.59","3589.67","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LEG LCP SS LOW BEND RIGHT","SUP-ITM-10091737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4392.64","3294.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3589.67","81.72","","431.26","71.26","1459.57","88","2295.59","3589.67","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4435.38","3326.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3526.13","79.5","","800.18","480.96","1887.97","195","1374.97","3526.13","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4435.38","3326.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2364.06","53.3","","813.12","216.42","1444.50","81","1374.97","3526.13","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4435.38","3326.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1374.97","31","","432.60","432.60","432.60","1 through 10","1374.97","3526.13","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4435.38","3326.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1618.91","36.5","","148.37","54.89","631.39","94","1374.97","3526.13","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4435.38","3326.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1698.75","38.3","","279.30","91.72","1116.77","266","1374.97","3526.13","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4435.38","3326.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1902.78","42.9","","731.00","63.70","731.00","1 through 10","1374.97","3526.13","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4435.38","3326.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1902.78","42.9","","384.74","384.74","384.74","1 through 10","1374.97","3526.13","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096147","CDM","C1713","HCPCS","0278","RC","","","","both","","","4435.38","3326.53","WELLPOINT [1015]","HB AMC WELLPOINT","3272.42","73.78","","286.63","119.22","1107.45","105","1374.97","3526.13","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4435.38","3326.53","AETNA [1001]","HB AMC AETNA HMO","3095.90","69.8","","675.31","184.75","1721.50","286","2317.93","3624.59","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4435.38","3326.53","AETNA [1001]","HB AMC AETNA PPO","3566.05","80.4","","1261.44","103.12","1514.10","21","2317.93","3624.59","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4435.38","3326.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3566.05","80.4","","1365.00","1365.00","1365.00","1 through 10","2317.93","3624.59","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4435.38","3326.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3624.59","81.72","","5157.68","5157.68","5157.68","1 through 10","2317.93","3624.59","percent of total billed charges",""
"PLATE TIBIA 3.5X206MM 14 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4435.38","3326.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3624.59","81.72","","431.26","71.26","1459.57","88","2317.93","3624.59","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4634.33","3475.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2421.90","52.26","","1113.10","1113.10","1113.10","1 through 10","1436.64","3684.29","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4634.33","3475.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3684.29","79.5","","1293.60","1148.53","1603.80","1 through 10","1436.64","3684.29","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4634.33","3475.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1691.53","36.5","","1023.42","771.29","2068.67","33","1436.64","3684.29","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4634.33","3475.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1774.95","38.3","","850.52","759.78","1211.25","66","1436.64","3684.29","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4634.33","3475.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1988.13","42.9","","2548.09","2548.09","2548.09","1 through 10","1436.64","3684.29","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4634.33","3475.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1988.13","42.9","","956.46","956.46","956.46","1 through 10","1436.64","3684.29","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4634.33","3475.75","WELLPOINT [1015]","HB AMC WELLPOINT","3419.21","73.78","","2344.73","1619.47","2530.35","16","1436.64","3684.29","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4634.33","3475.75","AETNA [1001]","HB AMC AETNA HMO","3234.76","69.8","","1523.63","988.41","4330.26","39","2421.9","3787.17","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4634.33","3475.75","AETNA [1001]","HB AMC AETNA PPO","3726.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2421.9","3787.17","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4634.33","3475.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2421.90","52.26","","1113.10","1113.10","1113.10","1 through 10","2421.9","3787.17","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4634.33","3475.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3787.17","81.72","","1738.90","1484.65","2716.94","38","2421.9","3787.17","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3730.90","2798.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2966.07","79.5","","800.18","480.96","1887.97","195","1156.58","2966.07","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3730.90","2798.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1988.57","53.3","","813.12","216.42","1444.50","81","1156.58","2966.07","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3730.90","2798.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1156.58","31","","432.60","432.60","432.60","1 through 10","1156.58","2966.07","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3730.90","2798.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1361.78","36.5","","148.37","54.89","631.39","94","1156.58","2966.07","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3730.90","2798.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1428.93","38.3","","279.30","91.72","1116.77","266","1156.58","2966.07","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3730.90","2798.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.56","42.9","","731.00","63.70","731.00","1 through 10","1156.58","2966.07","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3730.90","2798.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.56","42.9","","384.74","384.74","384.74","1 through 10","1156.58","2966.07","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3730.90","2798.17","WELLPOINT [1015]","HB AMC WELLPOINT","2752.66","73.78","","286.63","119.22","1107.45","105","1156.58","2966.07","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3730.90","2798.17","AETNA [1001]","HB AMC AETNA HMO","2604.17","69.8","","675.31","184.75","1721.50","286","1949.77","3048.89","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3730.90","2798.17","AETNA [1001]","HB AMC AETNA PPO","2999.64","80.4","","1261.44","103.12","1514.10","21","1949.77","3048.89","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3730.90","2798.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2999.64","80.4","","1365.00","1365.00","1365.00","1 through 10","1949.77","3048.89","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3730.90","2798.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3048.89","81.72","","5157.68","5157.68","5157.68","1 through 10","1949.77","3048.89","percent of total billed charges",""
"PLATE TIBIA 3.5X220MM 12 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3730.90","2798.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3048.89","81.72","","431.26","71.26","1459.57","88","1949.77","3048.89","percent of total billed charges",""
"PLATE TIBIA 3.5X223MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4211.85","3158.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3348.42","79.5","","800.18","480.96","1887.97","195","1305.67","3348.42","percent of total billed charges",""
"PLATE TIBIA 3.5X223MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4211.85","3158.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2244.92","53.3","","813.12","216.42","1444.50","81","1305.67","3348.42","percent of total billed charges",""
"PLATE TIBIA 3.5X223MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4211.85","3158.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1305.67","31","","432.60","432.60","432.60","1 through 10","1305.67","3348.42","percent of total billed charges",""
"PLATE TIBIA 3.5X223MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4211.85","3158.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1537.33","36.5","","148.37","54.89","631.39","94","1305.67","3348.42","percent of total billed charges",""
"PLATE TIBIA 3.5X223MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4211.85","3158.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1613.14","38.3","","279.30","91.72","1116.77","266","1305.67","3348.42","percent of total billed charges",""
"PLATE TIBIA 3.5X223MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4211.85","3158.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1806.88","42.9","","731.00","63.70","731.00","1 through 10","1305.67","3348.42","percent of total billed charges",""
"PLATE TIBIA 3.5X223MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4211.85","3158.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1806.88","42.9","","384.74","384.74","384.74","1 through 10","1305.67","3348.42","percent of total billed charges",""
"PLATE TIBIA 3.5X223MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4211.85","3158.89","WELLPOINT [1015]","HB AMC WELLPOINT","3107.50","73.78","","286.63","119.22","1107.45","105","1305.67","3348.42","percent of total billed charges",""
"PLATE TIBIA 3.5X223MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4211.85","3158.89","AETNA [1001]","HB AMC AETNA HMO","2939.87","69.8","","675.31","184.75","1721.50","286","2201.11","3441.92","percent of total billed charges",""
"PLATE TIBIA 3.5X223MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4211.85","3158.89","AETNA [1001]","HB AMC AETNA PPO","3386.33","80.4","","1261.44","103.12","1514.10","21","2201.11","3441.92","percent of total billed charges",""
"PLATE TIBIA 3.5X223MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4211.85","3158.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3386.33","80.4","","1365.00","1365.00","1365.00","1 through 10","2201.11","3441.92","percent of total billed charges",""
"PLATE TIBIA 3.5X223MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4211.85","3158.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3441.92","81.72","","5157.68","5157.68","5157.68","1 through 10","2201.11","3441.92","percent of total billed charges",""
"PLATE TIBIA 3.5X223MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4211.85","3158.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3441.92","81.72","","431.26","71.26","1459.57","88","2201.11","3441.92","percent of total billed charges",""
"PLATE TIBIA 3.5X236MM 17 HOLE L LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10038019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4127.17","3095.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3281.10","79.5","","800.18","480.96","1887.97","195","1279.42","3281.1","percent of total billed charges",""
"PLATE TIBIA 3.5X236MM 17 HOLE L LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10038019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4127.17","3095.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2199.78","53.3","","813.12","216.42","1444.50","81","1279.42","3281.1","percent of total billed charges",""
"PLATE TIBIA 3.5X236MM 17 HOLE L LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10038019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4127.17","3095.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1279.42","31","","432.60","432.60","432.60","1 through 10","1279.42","3281.1","percent of total billed charges",""
"PLATE TIBIA 3.5X236MM 17 HOLE L LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10038019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4127.17","3095.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1506.42","36.5","","148.37","54.89","631.39","94","1279.42","3281.1","percent of total billed charges",""
"PLATE TIBIA 3.5X236MM 17 HOLE L LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10038019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4127.17","3095.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1580.71","38.3","","279.30","91.72","1116.77","266","1279.42","3281.1","percent of total billed charges",""
"PLATE TIBIA 3.5X236MM 17 HOLE L LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10038019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4127.17","3095.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1770.56","42.9","","731.00","63.70","731.00","1 through 10","1279.42","3281.1","percent of total billed charges",""
"PLATE TIBIA 3.5X236MM 17 HOLE L LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10038019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4127.17","3095.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1770.56","42.9","","384.74","384.74","384.74","1 through 10","1279.42","3281.1","percent of total billed charges",""
"PLATE TIBIA 3.5X236MM 17 HOLE L LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10038019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4127.17","3095.38","WELLPOINT [1015]","HB AMC WELLPOINT","3045.03","73.78","","286.63","119.22","1107.45","105","1279.42","3281.1","percent of total billed charges",""
"PLATE TIBIA 3.5X236MM 17 HOLE L LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10038019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4127.17","3095.38","AETNA [1001]","HB AMC AETNA HMO","2880.76","69.8","","675.31","184.75","1721.50","286","2156.86","3372.72","percent of total billed charges",""
"PLATE TIBIA 3.5X236MM 17 HOLE L LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10038019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4127.17","3095.38","AETNA [1001]","HB AMC AETNA PPO","3318.24","80.4","","1261.44","103.12","1514.10","21","2156.86","3372.72","percent of total billed charges",""
"PLATE TIBIA 3.5X236MM 17 HOLE L LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10038019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4127.17","3095.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3318.24","80.4","","1365.00","1365.00","1365.00","1 through 10","2156.86","3372.72","percent of total billed charges",""
"PLATE TIBIA 3.5X236MM 17 HOLE L LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10038019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4127.17","3095.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3372.72","81.72","","5157.68","5157.68","5157.68","1 through 10","2156.86","3372.72","percent of total billed charges",""
"PLATE TIBIA 3.5X236MM 17 HOLE L LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10038019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4127.17","3095.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3372.72","81.72","","431.26","71.26","1459.57","88","2156.86","3372.72","percent of total billed charges",""
"PLATE TIBIA 3.5X239MM 14 HOLE LCP SS LOW BEND MEDIAL DISTAL L RIGHT","SUP-ITM-10095118","CDM","C1713","HCPCS","0278","RC","","","","both","","","3588.45","2691.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2852.82","79.5","","800.18","480.96","1887.97","195","1112.42","2852.82","percent of total billed charges",""
"PLATE TIBIA 3.5X239MM 14 HOLE LCP SS LOW BEND MEDIAL DISTAL L RIGHT","SUP-ITM-10095118","CDM","C1713","HCPCS","0278","RC","","","","both","","","3588.45","2691.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1912.64","53.3","","813.12","216.42","1444.50","81","1112.42","2852.82","percent of total billed charges",""
"PLATE TIBIA 3.5X239MM 14 HOLE LCP SS LOW BEND MEDIAL DISTAL L RIGHT","SUP-ITM-10095118","CDM","C1713","HCPCS","0278","RC","","","","both","","","3588.45","2691.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1112.42","31","","432.60","432.60","432.60","1 through 10","1112.42","2852.82","percent of total billed charges",""
"PLATE TIBIA 3.5X239MM 14 HOLE LCP SS LOW BEND MEDIAL DISTAL L RIGHT","SUP-ITM-10095118","CDM","C1713","HCPCS","0278","RC","","","","both","","","3588.45","2691.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1309.78","36.5","","148.37","54.89","631.39","94","1112.42","2852.82","percent of total billed charges",""
"PLATE TIBIA 3.5X239MM 14 HOLE LCP SS LOW BEND MEDIAL DISTAL L RIGHT","SUP-ITM-10095118","CDM","C1713","HCPCS","0278","RC","","","","both","","","3588.45","2691.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1374.38","38.3","","279.30","91.72","1116.77","266","1112.42","2852.82","percent of total billed charges",""
"PLATE TIBIA 3.5X239MM 14 HOLE LCP SS LOW BEND MEDIAL DISTAL L RIGHT","SUP-ITM-10095118","CDM","C1713","HCPCS","0278","RC","","","","both","","","3588.45","2691.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1539.45","42.9","","731.00","63.70","731.00","1 through 10","1112.42","2852.82","percent of total billed charges",""
"PLATE TIBIA 3.5X239MM 14 HOLE LCP SS LOW BEND MEDIAL DISTAL L RIGHT","SUP-ITM-10095118","CDM","C1713","HCPCS","0278","RC","","","","both","","","3588.45","2691.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1539.45","42.9","","384.74","384.74","384.74","1 through 10","1112.42","2852.82","percent of total billed charges",""
"PLATE TIBIA 3.5X239MM 14 HOLE LCP SS LOW BEND MEDIAL DISTAL L RIGHT","SUP-ITM-10095118","CDM","C1713","HCPCS","0278","RC","","","","both","","","3588.45","2691.34","WELLPOINT [1015]","HB AMC WELLPOINT","2647.56","73.78","","286.63","119.22","1107.45","105","1112.42","2852.82","percent of total billed charges",""
"PLATE TIBIA 3.5X239MM 14 HOLE LCP SS LOW BEND MEDIAL DISTAL L RIGHT","SUP-ITM-10095118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3588.45","2691.34","AETNA [1001]","HB AMC AETNA HMO","2504.74","69.8","","675.31","184.75","1721.50","286","1875.32","2932.48","percent of total billed charges",""
"PLATE TIBIA 3.5X239MM 14 HOLE LCP SS LOW BEND MEDIAL DISTAL L RIGHT","SUP-ITM-10095118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3588.45","2691.34","AETNA [1001]","HB AMC AETNA PPO","2885.11","80.4","","1261.44","103.12","1514.10","21","1875.32","2932.48","percent of total billed charges",""
"PLATE TIBIA 3.5X239MM 14 HOLE LCP SS LOW BEND MEDIAL DISTAL L RIGHT","SUP-ITM-10095118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3588.45","2691.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2885.11","80.4","","1365.00","1365.00","1365.00","1 through 10","1875.32","2932.48","percent of total billed charges",""
"PLATE TIBIA 3.5X239MM 14 HOLE LCP SS LOW BEND MEDIAL DISTAL L RIGHT","SUP-ITM-10095118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3588.45","2691.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2932.48","81.72","","5157.68","5157.68","5157.68","1 through 10","1875.32","2932.48","percent of total billed charges",""
"PLATE TIBIA 3.5X239MM 14 HOLE LCP SS LOW BEND MEDIAL DISTAL L RIGHT","SUP-ITM-10095118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3588.45","2691.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2932.48","81.72","","431.26","71.26","1459.57","88","1875.32","2932.48","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP SS RIGHT","SUP-ITM-10011773","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.11","2970.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3148.29","79.5","","800.18","480.96","1887.97","195","1227.63","3148.29","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP SS RIGHT","SUP-ITM-10011773","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.11","2970.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2110.74","53.3","","813.12","216.42","1444.50","81","1227.63","3148.29","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP SS RIGHT","SUP-ITM-10011773","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.11","2970.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1227.63","31","","432.60","432.60","432.60","1 through 10","1227.63","3148.29","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP SS RIGHT","SUP-ITM-10011773","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.11","2970.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1445.44","36.5","","148.37","54.89","631.39","94","1227.63","3148.29","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP SS RIGHT","SUP-ITM-10011773","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.11","2970.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1516.72","38.3","","279.30","91.72","1116.77","266","1227.63","3148.29","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP SS RIGHT","SUP-ITM-10011773","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.11","2970.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.89","42.9","","731.00","63.70","731.00","1 through 10","1227.63","3148.29","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP SS RIGHT","SUP-ITM-10011773","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.11","2970.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.89","42.9","","384.74","384.74","384.74","1 through 10","1227.63","3148.29","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP SS RIGHT","SUP-ITM-10011773","CDM","C1713","HCPCS","0278","RC","","","","both","","","3960.11","2970.08","WELLPOINT [1015]","HB AMC WELLPOINT","2921.77","73.78","","286.63","119.22","1107.45","105","1227.63","3148.29","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP SS RIGHT","SUP-ITM-10011773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3960.11","2970.08","AETNA [1001]","HB AMC AETNA HMO","2764.16","69.8","","675.31","184.75","1721.50","286","2069.55","3236.2","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP SS RIGHT","SUP-ITM-10011773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3960.11","2970.08","AETNA [1001]","HB AMC AETNA PPO","3183.93","80.4","","1261.44","103.12","1514.10","21","2069.55","3236.2","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP SS RIGHT","SUP-ITM-10011773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3960.11","2970.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3183.93","80.4","","1365.00","1365.00","1365.00","1 through 10","2069.55","3236.2","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP SS RIGHT","SUP-ITM-10011773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3960.11","2970.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3236.20","81.72","","5157.68","5157.68","5157.68","1 through 10","2069.55","3236.2","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP SS RIGHT","SUP-ITM-10011773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3960.11","2970.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3236.20","81.72","","431.26","71.26","1459.57","88","2069.55","3236.2","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3780.11","2835.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3005.19","79.5","","800.18","480.96","1887.97","195","1171.83","3005.19","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3780.11","2835.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2014.80","53.3","","813.12","216.42","1444.50","81","1171.83","3005.19","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3780.11","2835.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1171.83","31","","432.60","432.60","432.60","1 through 10","1171.83","3005.19","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3780.11","2835.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1379.74","36.5","","148.37","54.89","631.39","94","1171.83","3005.19","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3780.11","2835.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1447.78","38.3","","279.30","91.72","1116.77","266","1171.83","3005.19","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3780.11","2835.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1621.67","42.9","","731.00","63.70","731.00","1 through 10","1171.83","3005.19","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3780.11","2835.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1621.67","42.9","","384.74","384.74","384.74","1 through 10","1171.83","3005.19","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3780.11","2835.08","WELLPOINT [1015]","HB AMC WELLPOINT","2788.97","73.78","","286.63","119.22","1107.45","105","1171.83","3005.19","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3780.11","2835.08","AETNA [1001]","HB AMC AETNA HMO","2638.52","69.8","","675.31","184.75","1721.50","286","1975.49","3089.11","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3780.11","2835.08","AETNA [1001]","HB AMC AETNA PPO","3039.21","80.4","","1261.44","103.12","1514.10","21","1975.49","3089.11","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3780.11","2835.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3039.21","80.4","","1365.00","1365.00","1365.00","1 through 10","1975.49","3089.11","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3780.11","2835.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3089.11","81.72","","5157.68","5157.68","5157.68","1 through 10","1975.49","3089.11","percent of total billed charges",""
"PLATE TIBIA 3.5X246MM 14 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3780.11","2835.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3089.11","81.72","","431.26","71.26","1459.57","88","1975.49","3089.11","percent of total billed charges",""
"PLATE TIBIA 3.5X249MM 16 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037878","CDM","C1713","HCPCS","0278","RC","","","","both","","","4517.58","3388.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3591.48","79.5","","800.18","480.96","1887.97","195","1400.45","3591.48","percent of total billed charges",""
"PLATE TIBIA 3.5X249MM 16 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037878","CDM","C1713","HCPCS","0278","RC","","","","both","","","4517.58","3388.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2407.87","53.3","","813.12","216.42","1444.50","81","1400.45","3591.48","percent of total billed charges",""
"PLATE TIBIA 3.5X249MM 16 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037878","CDM","C1713","HCPCS","0278","RC","","","","both","","","4517.58","3388.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1400.45","31","","432.60","432.60","432.60","1 through 10","1400.45","3591.48","percent of total billed charges",""
"PLATE TIBIA 3.5X249MM 16 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037878","CDM","C1713","HCPCS","0278","RC","","","","both","","","4517.58","3388.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1648.92","36.5","","148.37","54.89","631.39","94","1400.45","3591.48","percent of total billed charges",""
"PLATE TIBIA 3.5X249MM 16 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037878","CDM","C1713","HCPCS","0278","RC","","","","both","","","4517.58","3388.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1730.23","38.3","","279.30","91.72","1116.77","266","1400.45","3591.48","percent of total billed charges",""
"PLATE TIBIA 3.5X249MM 16 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037878","CDM","C1713","HCPCS","0278","RC","","","","both","","","4517.58","3388.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1938.04","42.9","","731.00","63.70","731.00","1 through 10","1400.45","3591.48","percent of total billed charges",""
"PLATE TIBIA 3.5X249MM 16 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037878","CDM","C1713","HCPCS","0278","RC","","","","both","","","4517.58","3388.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1938.04","42.9","","384.74","384.74","384.74","1 through 10","1400.45","3591.48","percent of total billed charges",""
"PLATE TIBIA 3.5X249MM 16 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037878","CDM","C1713","HCPCS","0278","RC","","","","both","","","4517.58","3388.18","WELLPOINT [1015]","HB AMC WELLPOINT","3333.07","73.78","","286.63","119.22","1107.45","105","1400.45","3591.48","percent of total billed charges",""
"PLATE TIBIA 3.5X249MM 16 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037878","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4517.58","3388.18","AETNA [1001]","HB AMC AETNA HMO","3153.27","69.8","","675.31","184.75","1721.50","286","2360.89","3691.77","percent of total billed charges",""
"PLATE TIBIA 3.5X249MM 16 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037878","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4517.58","3388.18","AETNA [1001]","HB AMC AETNA PPO","3632.13","80.4","","1261.44","103.12","1514.10","21","2360.89","3691.77","percent of total billed charges",""
"PLATE TIBIA 3.5X249MM 16 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037878","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4517.58","3388.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3632.13","80.4","","1365.00","1365.00","1365.00","1 through 10","2360.89","3691.77","percent of total billed charges",""
"PLATE TIBIA 3.5X249MM 16 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037878","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4517.58","3388.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3691.77","81.72","","5157.68","5157.68","5157.68","1 through 10","2360.89","3691.77","percent of total billed charges",""
"PLATE TIBIA 3.5X249MM 16 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037878","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4517.58","3388.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3691.77","81.72","","431.26","71.26","1459.57","88","2360.89","3691.77","percent of total billed charges",""
"PLATE TIBIA 3.5X262MM 19 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038024","CDM","C1713","HCPCS","0278","RC","","","","both","","","4158.25","3118.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3305.81","79.5","","800.18","480.96","1887.97","195","1289.06","3305.81","percent of total billed charges",""
"PLATE TIBIA 3.5X262MM 19 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038024","CDM","C1713","HCPCS","0278","RC","","","","both","","","4158.25","3118.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2216.35","53.3","","813.12","216.42","1444.50","81","1289.06","3305.81","percent of total billed charges",""
"PLATE TIBIA 3.5X262MM 19 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038024","CDM","C1713","HCPCS","0278","RC","","","","both","","","4158.25","3118.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1289.06","31","","432.60","432.60","432.60","1 through 10","1289.06","3305.81","percent of total billed charges",""
"PLATE TIBIA 3.5X262MM 19 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038024","CDM","C1713","HCPCS","0278","RC","","","","both","","","4158.25","3118.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1517.76","36.5","","148.37","54.89","631.39","94","1289.06","3305.81","percent of total billed charges",""
"PLATE TIBIA 3.5X262MM 19 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038024","CDM","C1713","HCPCS","0278","RC","","","","both","","","4158.25","3118.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1592.61","38.3","","279.30","91.72","1116.77","266","1289.06","3305.81","percent of total billed charges",""
"PLATE TIBIA 3.5X262MM 19 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038024","CDM","C1713","HCPCS","0278","RC","","","","both","","","4158.25","3118.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1783.89","42.9","","731.00","63.70","731.00","1 through 10","1289.06","3305.81","percent of total billed charges",""
"PLATE TIBIA 3.5X262MM 19 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038024","CDM","C1713","HCPCS","0278","RC","","","","both","","","4158.25","3118.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1783.89","42.9","","384.74","384.74","384.74","1 through 10","1289.06","3305.81","percent of total billed charges",""
"PLATE TIBIA 3.5X262MM 19 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038024","CDM","C1713","HCPCS","0278","RC","","","","both","","","4158.25","3118.69","WELLPOINT [1015]","HB AMC WELLPOINT","3067.96","73.78","","286.63","119.22","1107.45","105","1289.06","3305.81","percent of total billed charges",""
"PLATE TIBIA 3.5X262MM 19 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4158.25","3118.69","AETNA [1001]","HB AMC AETNA HMO","2902.46","69.8","","675.31","184.75","1721.50","286","2173.1","3398.12","percent of total billed charges",""
"PLATE TIBIA 3.5X262MM 19 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4158.25","3118.69","AETNA [1001]","HB AMC AETNA PPO","3343.23","80.4","","1261.44","103.12","1514.10","21","2173.1","3398.12","percent of total billed charges",""
"PLATE TIBIA 3.5X262MM 19 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4158.25","3118.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3343.23","80.4","","1365.00","1365.00","1365.00","1 through 10","2173.1","3398.12","percent of total billed charges",""
"PLATE TIBIA 3.5X262MM 19 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4158.25","3118.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3398.12","81.72","","5157.68","5157.68","5157.68","1 through 10","2173.1","3398.12","percent of total billed charges",""
"PLATE TIBIA 3.5X262MM 19 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4158.25","3118.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3398.12","81.72","","431.26","71.26","1459.57","88","2173.1","3398.12","percent of total billed charges",""
"PLATE TIBIA 3.5X275MM 18 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4677.54","3508.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3718.64","79.5","","800.18","480.96","1887.97","195","1450.04","3718.64","percent of total billed charges",""
"PLATE TIBIA 3.5X275MM 18 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4677.54","3508.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2493.13","53.3","","813.12","216.42","1444.50","81","1450.04","3718.64","percent of total billed charges",""
"PLATE TIBIA 3.5X275MM 18 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4677.54","3508.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1450.04","31","","432.60","432.60","432.60","1 through 10","1450.04","3718.64","percent of total billed charges",""
"PLATE TIBIA 3.5X275MM 18 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4677.54","3508.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1707.30","36.5","","148.37","54.89","631.39","94","1450.04","3718.64","percent of total billed charges",""
"PLATE TIBIA 3.5X275MM 18 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4677.54","3508.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1791.50","38.3","","279.30","91.72","1116.77","266","1450.04","3718.64","percent of total billed charges",""
"PLATE TIBIA 3.5X275MM 18 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4677.54","3508.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2006.66","42.9","","731.00","63.70","731.00","1 through 10","1450.04","3718.64","percent of total billed charges",""
"PLATE TIBIA 3.5X275MM 18 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4677.54","3508.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2006.66","42.9","","384.74","384.74","384.74","1 through 10","1450.04","3718.64","percent of total billed charges",""
"PLATE TIBIA 3.5X275MM 18 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037882","CDM","C1713","HCPCS","0278","RC","","","","both","","","4677.54","3508.15","WELLPOINT [1015]","HB AMC WELLPOINT","3451.09","73.78","","286.63","119.22","1107.45","105","1450.04","3718.64","percent of total billed charges",""
"PLATE TIBIA 3.5X275MM 18 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4677.54","3508.15","AETNA [1001]","HB AMC AETNA HMO","3264.92","69.8","","675.31","184.75","1721.50","286","2444.48","3822.49","percent of total billed charges",""
"PLATE TIBIA 3.5X275MM 18 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4677.54","3508.15","AETNA [1001]","HB AMC AETNA PPO","3760.74","80.4","","1261.44","103.12","1514.10","21","2444.48","3822.49","percent of total billed charges",""
"PLATE TIBIA 3.5X275MM 18 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4677.54","3508.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3760.74","80.4","","1365.00","1365.00","1365.00","1 through 10","2444.48","3822.49","percent of total billed charges",""
"PLATE TIBIA 3.5X275MM 18 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4677.54","3508.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3822.49","81.72","","5157.68","5157.68","5157.68","1 through 10","2444.48","3822.49","percent of total billed charges",""
"PLATE TIBIA 3.5X275MM 18 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4677.54","3508.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3822.49","81.72","","431.26","71.26","1459.57","88","2444.48","3822.49","percent of total billed charges",""
"PLATE TIBIA 3.5X288MM 21 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4199.69","3149.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3338.75","79.5","","800.18","480.96","1887.97","195","1301.9","3338.75","percent of total billed charges",""
"PLATE TIBIA 3.5X288MM 21 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4199.69","3149.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2238.43","53.3","","813.12","216.42","1444.50","81","1301.9","3338.75","percent of total billed charges",""
"PLATE TIBIA 3.5X288MM 21 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4199.69","3149.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1301.90","31","","432.60","432.60","432.60","1 through 10","1301.9","3338.75","percent of total billed charges",""
"PLATE TIBIA 3.5X288MM 21 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4199.69","3149.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1532.89","36.5","","148.37","54.89","631.39","94","1301.9","3338.75","percent of total billed charges",""
"PLATE TIBIA 3.5X288MM 21 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4199.69","3149.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.48","38.3","","279.30","91.72","1116.77","266","1301.9","3338.75","percent of total billed charges",""
"PLATE TIBIA 3.5X288MM 21 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4199.69","3149.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.67","42.9","","731.00","63.70","731.00","1 through 10","1301.9","3338.75","percent of total billed charges",""
"PLATE TIBIA 3.5X288MM 21 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4199.69","3149.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.67","42.9","","384.74","384.74","384.74","1 through 10","1301.9","3338.75","percent of total billed charges",""
"PLATE TIBIA 3.5X288MM 21 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4199.69","3149.77","WELLPOINT [1015]","HB AMC WELLPOINT","3098.53","73.78","","286.63","119.22","1107.45","105","1301.9","3338.75","percent of total billed charges",""
"PLATE TIBIA 3.5X288MM 21 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4199.69","3149.77","AETNA [1001]","HB AMC AETNA HMO","2931.38","69.8","","675.31","184.75","1721.50","286","2194.76","3431.99","percent of total billed charges",""
"PLATE TIBIA 3.5X288MM 21 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4199.69","3149.77","AETNA [1001]","HB AMC AETNA PPO","3376.55","80.4","","1261.44","103.12","1514.10","21","2194.76","3431.99","percent of total billed charges",""
"PLATE TIBIA 3.5X288MM 21 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4199.69","3149.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3376.55","80.4","","1365.00","1365.00","1365.00","1 through 10","2194.76","3431.99","percent of total billed charges",""
"PLATE TIBIA 3.5X288MM 21 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4199.69","3149.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3431.99","81.72","","5157.68","5157.68","5157.68","1 through 10","2194.76","3431.99","percent of total billed charges",""
"PLATE TIBIA 3.5X288MM 21 HOLE L LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10038028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4199.69","3149.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3431.99","81.72","","431.26","71.26","1459.57","88","2194.76","3431.99","percent of total billed charges",""
"PLATE TIBIA 3.5X301MM 20 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4834.92","3626.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3843.76","79.5","","800.18","480.96","1887.97","195","1498.83","3843.76","percent of total billed charges",""
"PLATE TIBIA 3.5X301MM 20 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4834.92","3626.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2577.01","53.3","","813.12","216.42","1444.50","81","1498.83","3843.76","percent of total billed charges",""
"PLATE TIBIA 3.5X301MM 20 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4834.92","3626.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1498.83","31","","432.60","432.60","432.60","1 through 10","1498.83","3843.76","percent of total billed charges",""
"PLATE TIBIA 3.5X301MM 20 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4834.92","3626.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1764.75","36.5","","148.37","54.89","631.39","94","1498.83","3843.76","percent of total billed charges",""
"PLATE TIBIA 3.5X301MM 20 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4834.92","3626.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1851.77","38.3","","279.30","91.72","1116.77","266","1498.83","3843.76","percent of total billed charges",""
"PLATE TIBIA 3.5X301MM 20 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4834.92","3626.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2074.18","42.9","","731.00","63.70","731.00","1 through 10","1498.83","3843.76","percent of total billed charges",""
"PLATE TIBIA 3.5X301MM 20 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4834.92","3626.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2074.18","42.9","","384.74","384.74","384.74","1 through 10","1498.83","3843.76","percent of total billed charges",""
"PLATE TIBIA 3.5X301MM 20 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037888","CDM","C1713","HCPCS","0278","RC","","","","both","","","4834.92","3626.19","WELLPOINT [1015]","HB AMC WELLPOINT","3567.20","73.78","","286.63","119.22","1107.45","105","1498.83","3843.76","percent of total billed charges",""
"PLATE TIBIA 3.5X301MM 20 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037888","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4834.92","3626.19","AETNA [1001]","HB AMC AETNA HMO","3374.77","69.8","","675.31","184.75","1721.50","286","2526.73","3951.1","percent of total billed charges",""
"PLATE TIBIA 3.5X301MM 20 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037888","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4834.92","3626.19","AETNA [1001]","HB AMC AETNA PPO","3887.28","80.4","","1261.44","103.12","1514.10","21","2526.73","3951.1","percent of total billed charges",""
"PLATE TIBIA 3.5X301MM 20 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037888","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4834.92","3626.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3887.28","80.4","","1365.00","1365.00","1365.00","1 through 10","2526.73","3951.1","percent of total billed charges",""
"PLATE TIBIA 3.5X301MM 20 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037888","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4834.92","3626.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3951.10","81.72","","5157.68","5157.68","5157.68","1 through 10","2526.73","3951.1","percent of total billed charges",""
"PLATE TIBIA 3.5X301MM 20 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037888","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4834.92","3626.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3951.10","81.72","","431.26","71.26","1459.57","88","2526.73","3951.1","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","both","","","4044.15","3033.11","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2113.47","52.26","","1113.10","1113.10","1113.10","1 through 10","1253.69","3215.1","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","both","","","4044.15","3033.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3215.10","79.5","","1293.60","1148.53","1603.80","1 through 10","1253.69","3215.1","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","both","","","4044.15","3033.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1476.11","36.5","","1023.42","771.29","2068.67","33","1253.69","3215.1","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","both","","","4044.15","3033.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.91","38.3","","850.52","759.78","1211.25","66","1253.69","3215.1","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","both","","","4044.15","3033.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.94","42.9","","2548.09","2548.09","2548.09","1 through 10","1253.69","3215.1","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","both","","","4044.15","3033.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.94","42.9","","956.46","956.46","956.46","1 through 10","1253.69","3215.1","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","both","","","4044.15","3033.11","WELLPOINT [1015]","HB AMC WELLPOINT","2983.77","73.78","","2344.73","1619.47","2530.35","16","1253.69","3215.1","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4044.15","3033.11","AETNA [1001]","HB AMC AETNA HMO","2822.82","69.8","","1523.63","988.41","4330.26","39","2113.47","3304.88","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4044.15","3033.11","AETNA [1001]","HB AMC AETNA PPO","3251.50","80.4","","1670.25","1670.25","1670.25","1 through 10","2113.47","3304.88","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4044.15","3033.11","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2113.47","52.26","","1113.10","1113.10","1113.10","1 through 10","2113.47","3304.88","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4044.15","3033.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3304.88","81.72","","1738.90","1484.65","2716.94","38","2113.47","3304.88","percent of total billed charges",""
"PLATE TIBIA ANTEROLATERAL DISTAL LEFT 11-HOLE","SUP-ITM-10303709","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.75","3644.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3862.71","79.5","","800.18","480.96","1887.97","195","1506.21","3862.71","percent of total billed charges",""
"PLATE TIBIA ANTEROLATERAL DISTAL LEFT 11-HOLE","SUP-ITM-10303709","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.75","3644.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2589.71","53.3","","813.12","216.42","1444.50","81","1506.21","3862.71","percent of total billed charges",""
"PLATE TIBIA ANTEROLATERAL DISTAL LEFT 11-HOLE","SUP-ITM-10303709","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.75","3644.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1506.21","31","","432.60","432.60","432.60","1 through 10","1506.21","3862.71","percent of total billed charges",""
"PLATE TIBIA ANTEROLATERAL DISTAL LEFT 11-HOLE","SUP-ITM-10303709","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.75","3644.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1773.44","36.5","","148.37","54.89","631.39","94","1506.21","3862.71","percent of total billed charges",""
"PLATE TIBIA ANTEROLATERAL DISTAL LEFT 11-HOLE","SUP-ITM-10303709","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.75","3644.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1860.90","38.3","","279.30","91.72","1116.77","266","1506.21","3862.71","percent of total billed charges",""
"PLATE TIBIA ANTEROLATERAL DISTAL LEFT 11-HOLE","SUP-ITM-10303709","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.75","3644.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2084.40","42.9","","731.00","63.70","731.00","1 through 10","1506.21","3862.71","percent of total billed charges",""
"PLATE TIBIA ANTEROLATERAL DISTAL LEFT 11-HOLE","SUP-ITM-10303709","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.75","3644.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2084.40","42.9","","384.74","384.74","384.74","1 through 10","1506.21","3862.71","percent of total billed charges",""
"PLATE TIBIA ANTEROLATERAL DISTAL LEFT 11-HOLE","SUP-ITM-10303709","CDM","C1713","HCPCS","0278","RC","","","","both","","","4858.75","3644.06","WELLPOINT [1015]","HB AMC WELLPOINT","3584.79","73.78","","286.63","119.22","1107.45","105","1506.21","3862.71","percent of total billed charges",""
"PLATE TIBIA ANTEROLATERAL DISTAL LEFT 11-HOLE","SUP-ITM-10303709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4858.75","3644.06","AETNA [1001]","HB AMC AETNA HMO","3391.41","69.8","","675.31","184.75","1721.50","286","2539.18","3970.57","percent of total billed charges",""
"PLATE TIBIA ANTEROLATERAL DISTAL LEFT 11-HOLE","SUP-ITM-10303709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4858.75","3644.06","AETNA [1001]","HB AMC AETNA PPO","3906.44","80.4","","1261.44","103.12","1514.10","21","2539.18","3970.57","percent of total billed charges",""
"PLATE TIBIA ANTEROLATERAL DISTAL LEFT 11-HOLE","SUP-ITM-10303709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4858.75","3644.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3906.44","80.4","","1365.00","1365.00","1365.00","1 through 10","2539.18","3970.57","percent of total billed charges",""
"PLATE TIBIA ANTEROLATERAL DISTAL LEFT 11-HOLE","SUP-ITM-10303709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4858.75","3644.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3970.57","81.72","","5157.68","5157.68","5157.68","1 through 10","2539.18","3970.57","percent of total billed charges",""
"PLATE TIBIA ANTEROLATERAL DISTAL LEFT 11-HOLE","SUP-ITM-10303709","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4858.75","3644.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3970.57","81.72","","431.26","71.26","1459.57","88","2539.18","3970.57","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.86","2630.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2787.95","79.5","","800.18","480.96","1887.97","195","1087.13","2787.95","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.86","2630.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1869.16","53.3","","813.12","216.42","1444.50","81","1087.13","2787.95","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.86","2630.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1087.13","31","","432.60","432.60","432.60","1 through 10","1087.13","2787.95","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.86","2630.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1280.00","36.5","","148.37","54.89","631.39","94","1087.13","2787.95","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.86","2630.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1343.13","38.3","","279.30","91.72","1116.77","266","1087.13","2787.95","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.86","2630.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1504.44","42.9","","731.00","63.70","731.00","1 through 10","1087.13","2787.95","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.86","2630.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1504.44","42.9","","384.74","384.74","384.74","1 through 10","1087.13","2787.95","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3506.86","2630.14","WELLPOINT [1015]","HB AMC WELLPOINT","2587.36","73.78","","286.63","119.22","1107.45","105","1087.13","2787.95","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3506.86","2630.14","AETNA [1001]","HB AMC AETNA HMO","2447.79","69.8","","675.31","184.75","1721.50","286","1832.69","2865.81","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3506.86","2630.14","AETNA [1001]","HB AMC AETNA PPO","2819.52","80.4","","1261.44","103.12","1514.10","21","1832.69","2865.81","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3506.86","2630.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2819.52","80.4","","1365.00","1365.00","1365.00","1 through 10","1832.69","2865.81","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3506.86","2630.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2865.81","81.72","","5157.68","5157.68","5157.68","1 through 10","1832.69","2865.81","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3506.86","2630.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2865.81","81.72","","431.26","71.26","1459.57","88","1832.69","2865.81","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3905.82","2929.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3105.13","79.5","","800.18","480.96","1887.97","195","1210.8","3105.13","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3905.82","2929.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2081.80","53.3","","813.12","216.42","1444.50","81","1210.8","3105.13","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3905.82","2929.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1210.80","31","","432.60","432.60","432.60","1 through 10","1210.8","3105.13","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3905.82","2929.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1425.62","36.5","","148.37","54.89","631.39","94","1210.8","3105.13","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3905.82","2929.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1495.93","38.3","","279.30","91.72","1116.77","266","1210.8","3105.13","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3905.82","2929.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1675.60","42.9","","731.00","63.70","731.00","1 through 10","1210.8","3105.13","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3905.82","2929.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1675.60","42.9","","384.74","384.74","384.74","1 through 10","1210.8","3105.13","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3905.82","2929.36","WELLPOINT [1015]","HB AMC WELLPOINT","2881.71","73.78","","286.63","119.22","1107.45","105","1210.8","3105.13","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3905.82","2929.36","AETNA [1001]","HB AMC AETNA HMO","2726.26","69.8","","675.31","184.75","1721.50","286","2041.18","3191.84","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3905.82","2929.36","AETNA [1001]","HB AMC AETNA PPO","3140.28","80.4","","1261.44","103.12","1514.10","21","2041.18","3191.84","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3905.82","2929.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3140.28","80.4","","1365.00","1365.00","1365.00","1 through 10","2041.18","3191.84","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3905.82","2929.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3191.84","81.72","","5157.68","5157.68","5157.68","1 through 10","2041.18","3191.84","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3905.82","2929.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3191.84","81.72","","431.26","71.26","1459.57","88","2041.18","3191.84","percent of total billed charges",""
"PLATE TIBIAL 300MM 13 HOLE LOCKING COMPRESSION LATERAL RIGHT TITANIUM","SUP-ITM-10040372","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.91","3365.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3567.89","79.5","","800.18","480.96","1887.97","195","1391.25","3567.89","percent of total billed charges",""
"PLATE TIBIAL 300MM 13 HOLE LOCKING COMPRESSION LATERAL RIGHT TITANIUM","SUP-ITM-10040372","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.91","3365.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2392.06","53.3","","813.12","216.42","1444.50","81","1391.25","3567.89","percent of total billed charges",""
"PLATE TIBIAL 300MM 13 HOLE LOCKING COMPRESSION LATERAL RIGHT TITANIUM","SUP-ITM-10040372","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.91","3365.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1391.25","31","","432.60","432.60","432.60","1 through 10","1391.25","3567.89","percent of total billed charges",""
"PLATE TIBIAL 300MM 13 HOLE LOCKING COMPRESSION LATERAL RIGHT TITANIUM","SUP-ITM-10040372","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.91","3365.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1638.09","36.5","","148.37","54.89","631.39","94","1391.25","3567.89","percent of total billed charges",""
"PLATE TIBIAL 300MM 13 HOLE LOCKING COMPRESSION LATERAL RIGHT TITANIUM","SUP-ITM-10040372","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.91","3365.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1718.87","38.3","","279.30","91.72","1116.77","266","1391.25","3567.89","percent of total billed charges",""
"PLATE TIBIAL 300MM 13 HOLE LOCKING COMPRESSION LATERAL RIGHT TITANIUM","SUP-ITM-10040372","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.91","3365.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1925.31","42.9","","731.00","63.70","731.00","1 through 10","1391.25","3567.89","percent of total billed charges",""
"PLATE TIBIAL 300MM 13 HOLE LOCKING COMPRESSION LATERAL RIGHT TITANIUM","SUP-ITM-10040372","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.91","3365.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1925.31","42.9","","384.74","384.74","384.74","1 through 10","1391.25","3567.89","percent of total billed charges",""
"PLATE TIBIAL 300MM 13 HOLE LOCKING COMPRESSION LATERAL RIGHT TITANIUM","SUP-ITM-10040372","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.91","3365.93","WELLPOINT [1015]","HB AMC WELLPOINT","3311.18","73.78","","286.63","119.22","1107.45","105","1391.25","3567.89","percent of total billed charges",""
"PLATE TIBIAL 300MM 13 HOLE LOCKING COMPRESSION LATERAL RIGHT TITANIUM","SUP-ITM-10040372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4487.91","3365.93","AETNA [1001]","HB AMC AETNA HMO","3132.56","69.8","","675.31","184.75","1721.50","286","2345.38","3667.52","percent of total billed charges",""
"PLATE TIBIAL 300MM 13 HOLE LOCKING COMPRESSION LATERAL RIGHT TITANIUM","SUP-ITM-10040372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4487.91","3365.93","AETNA [1001]","HB AMC AETNA PPO","3608.28","80.4","","1261.44","103.12","1514.10","21","2345.38","3667.52","percent of total billed charges",""
"PLATE TIBIAL 300MM 13 HOLE LOCKING COMPRESSION LATERAL RIGHT TITANIUM","SUP-ITM-10040372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4487.91","3365.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3608.28","80.4","","1365.00","1365.00","1365.00","1 through 10","2345.38","3667.52","percent of total billed charges",""
"PLATE TIBIAL 300MM 13 HOLE LOCKING COMPRESSION LATERAL RIGHT TITANIUM","SUP-ITM-10040372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4487.91","3365.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3667.52","81.72","","5157.68","5157.68","5157.68","1 through 10","2345.38","3667.52","percent of total billed charges",""
"PLATE TIBIAL 300MM 13 HOLE LOCKING COMPRESSION LATERAL RIGHT TITANIUM","SUP-ITM-10040372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4487.91","3365.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3667.52","81.72","","431.26","71.26","1459.57","88","2345.38","3667.52","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","4091.22","3068.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3252.52","79.5","","800.18","480.96","1887.97","195","1268.28","3252.52","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","4091.22","3068.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2180.62","53.3","","813.12","216.42","1444.50","81","1268.28","3252.52","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","4091.22","3068.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1268.28","31","","432.60","432.60","432.60","1 through 10","1268.28","3252.52","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","4091.22","3068.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1493.30","36.5","","148.37","54.89","631.39","94","1268.28","3252.52","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","4091.22","3068.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1566.94","38.3","","279.30","91.72","1116.77","266","1268.28","3252.52","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","4091.22","3068.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1755.13","42.9","","731.00","63.70","731.00","1 through 10","1268.28","3252.52","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","4091.22","3068.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1755.13","42.9","","384.74","384.74","384.74","1 through 10","1268.28","3252.52","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","both","","","4091.22","3068.41","WELLPOINT [1015]","HB AMC WELLPOINT","3018.50","73.78","","286.63","119.22","1107.45","105","1268.28","3252.52","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4091.22","3068.41","AETNA [1001]","HB AMC AETNA HMO","2855.67","69.8","","675.31","184.75","1721.50","286","2138.07","3343.34","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4091.22","3068.41","AETNA [1001]","HB AMC AETNA PPO","3289.34","80.4","","1261.44","103.12","1514.10","21","2138.07","3343.34","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4091.22","3068.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3289.34","80.4","","1365.00","1365.00","1365.00","1 through 10","2138.07","3343.34","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4091.22","3068.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3343.34","81.72","","5157.68","5157.68","5157.68","1 through 10","2138.07","3343.34","percent of total billed charges",""
"PLATE TIBIAL 4.5X154MM 8 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4091.22","3068.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3343.34","81.72","","431.26","71.26","1459.57","88","2138.07","3343.34","percent of total billed charges",""
"PLATE TIBIAL 4.5X190MM 10 HOLE PROXIMAL L LOCKING LCP SS LEFT","SUP-ITM-10009188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4251.49","3188.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3379.93","79.5","","800.18","480.96","1887.97","195","1317.96","3379.93","percent of total billed charges",""
"PLATE TIBIAL 4.5X190MM 10 HOLE PROXIMAL L LOCKING LCP SS LEFT","SUP-ITM-10009188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4251.49","3188.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2266.04","53.3","","813.12","216.42","1444.50","81","1317.96","3379.93","percent of total billed charges",""
"PLATE TIBIAL 4.5X190MM 10 HOLE PROXIMAL L LOCKING LCP SS LEFT","SUP-ITM-10009188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4251.49","3188.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1317.96","31","","432.60","432.60","432.60","1 through 10","1317.96","3379.93","percent of total billed charges",""
"PLATE TIBIAL 4.5X190MM 10 HOLE PROXIMAL L LOCKING LCP SS LEFT","SUP-ITM-10009188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4251.49","3188.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1551.79","36.5","","148.37","54.89","631.39","94","1317.96","3379.93","percent of total billed charges",""
"PLATE TIBIAL 4.5X190MM 10 HOLE PROXIMAL L LOCKING LCP SS LEFT","SUP-ITM-10009188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4251.49","3188.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1628.32","38.3","","279.30","91.72","1116.77","266","1317.96","3379.93","percent of total billed charges",""
"PLATE TIBIAL 4.5X190MM 10 HOLE PROXIMAL L LOCKING LCP SS LEFT","SUP-ITM-10009188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4251.49","3188.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1823.89","42.9","","731.00","63.70","731.00","1 through 10","1317.96","3379.93","percent of total billed charges",""
"PLATE TIBIAL 4.5X190MM 10 HOLE PROXIMAL L LOCKING LCP SS LEFT","SUP-ITM-10009188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4251.49","3188.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1823.89","42.9","","384.74","384.74","384.74","1 through 10","1317.96","3379.93","percent of total billed charges",""
"PLATE TIBIAL 4.5X190MM 10 HOLE PROXIMAL L LOCKING LCP SS LEFT","SUP-ITM-10009188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4251.49","3188.62","WELLPOINT [1015]","HB AMC WELLPOINT","3136.75","73.78","","286.63","119.22","1107.45","105","1317.96","3379.93","percent of total billed charges",""
"PLATE TIBIAL 4.5X190MM 10 HOLE PROXIMAL L LOCKING LCP SS LEFT","SUP-ITM-10009188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4251.49","3188.62","AETNA [1001]","HB AMC AETNA HMO","2967.54","69.8","","675.31","184.75","1721.50","286","2221.83","3474.32","percent of total billed charges",""
"PLATE TIBIAL 4.5X190MM 10 HOLE PROXIMAL L LOCKING LCP SS LEFT","SUP-ITM-10009188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4251.49","3188.62","AETNA [1001]","HB AMC AETNA PPO","3418.20","80.4","","1261.44","103.12","1514.10","21","2221.83","3474.32","percent of total billed charges",""
"PLATE TIBIAL 4.5X190MM 10 HOLE PROXIMAL L LOCKING LCP SS LEFT","SUP-ITM-10009188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4251.49","3188.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3418.20","80.4","","1365.00","1365.00","1365.00","1 through 10","2221.83","3474.32","percent of total billed charges",""
"PLATE TIBIAL 4.5X190MM 10 HOLE PROXIMAL L LOCKING LCP SS LEFT","SUP-ITM-10009188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4251.49","3188.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3474.32","81.72","","5157.68","5157.68","5157.68","1 through 10","2221.83","3474.32","percent of total billed charges",""
"PLATE TIBIAL 4.5X190MM 10 HOLE PROXIMAL L LOCKING LCP SS LEFT","SUP-ITM-10009188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4251.49","3188.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3474.32","81.72","","431.26","71.26","1459.57","88","2221.83","3474.32","percent of total billed charges",""
"PLATE TIBIAL 4.5X250MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.44","3324.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3523.79","79.5","","800.18","480.96","1887.97","195","1374.06","3523.79","percent of total billed charges",""
"PLATE TIBIAL 4.5X250MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.44","3324.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2362.49","53.3","","813.12","216.42","1444.50","81","1374.06","3523.79","percent of total billed charges",""
"PLATE TIBIAL 4.5X250MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.44","3324.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1374.06","31","","432.60","432.60","432.60","1 through 10","1374.06","3523.79","percent of total billed charges",""
"PLATE TIBIAL 4.5X250MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.44","3324.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1617.84","36.5","","148.37","54.89","631.39","94","1374.06","3523.79","percent of total billed charges",""
"PLATE TIBIAL 4.5X250MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.44","3324.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1697.62","38.3","","279.30","91.72","1116.77","266","1374.06","3523.79","percent of total billed charges",""
"PLATE TIBIAL 4.5X250MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.44","3324.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1901.52","42.9","","731.00","63.70","731.00","1 through 10","1374.06","3523.79","percent of total billed charges",""
"PLATE TIBIAL 4.5X250MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.44","3324.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1901.52","42.9","","384.74","384.74","384.74","1 through 10","1374.06","3523.79","percent of total billed charges",""
"PLATE TIBIAL 4.5X250MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4432.44","3324.33","WELLPOINT [1015]","HB AMC WELLPOINT","3270.25","73.78","","286.63","119.22","1107.45","105","1374.06","3523.79","percent of total billed charges",""
"PLATE TIBIAL 4.5X250MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4432.44","3324.33","AETNA [1001]","HB AMC AETNA HMO","3093.84","69.8","","675.31","184.75","1721.50","286","2316.39","3622.19","percent of total billed charges",""
"PLATE TIBIAL 4.5X250MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4432.44","3324.33","AETNA [1001]","HB AMC AETNA PPO","3563.68","80.4","","1261.44","103.12","1514.10","21","2316.39","3622.19","percent of total billed charges",""
"PLATE TIBIAL 4.5X250MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4432.44","3324.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3563.68","80.4","","1365.00","1365.00","1365.00","1 through 10","2316.39","3622.19","percent of total billed charges",""
"PLATE TIBIAL 4.5X250MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4432.44","3324.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3622.19","81.72","","5157.68","5157.68","5157.68","1 through 10","2316.39","3622.19","percent of total billed charges",""
"PLATE TIBIAL 4.5X250MM 12 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4432.44","3324.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3622.19","81.72","","431.26","71.26","1459.57","88","2316.39","3622.19","percent of total billed charges",""
"PLATE TIBIAL 4.5X262MM 14 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009191","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.88","3170.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3360.37","79.5","","800.18","480.96","1887.97","195","1310.33","3360.37","percent of total billed charges",""
"PLATE TIBIAL 4.5X262MM 14 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009191","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.88","3170.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2252.93","53.3","","813.12","216.42","1444.50","81","1310.33","3360.37","percent of total billed charges",""
"PLATE TIBIAL 4.5X262MM 14 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009191","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.88","3170.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1310.33","31","","432.60","432.60","432.60","1 through 10","1310.33","3360.37","percent of total billed charges",""
"PLATE TIBIAL 4.5X262MM 14 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009191","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.88","3170.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1542.81","36.5","","148.37","54.89","631.39","94","1310.33","3360.37","percent of total billed charges",""
"PLATE TIBIAL 4.5X262MM 14 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009191","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.88","3170.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1618.90","38.3","","279.30","91.72","1116.77","266","1310.33","3360.37","percent of total billed charges",""
"PLATE TIBIAL 4.5X262MM 14 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009191","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.88","3170.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.33","42.9","","731.00","63.70","731.00","1 through 10","1310.33","3360.37","percent of total billed charges",""
"PLATE TIBIAL 4.5X262MM 14 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009191","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.88","3170.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.33","42.9","","384.74","384.74","384.74","1 through 10","1310.33","3360.37","percent of total billed charges",""
"PLATE TIBIAL 4.5X262MM 14 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009191","CDM","C1713","HCPCS","0278","RC","","","","both","","","4226.88","3170.16","WELLPOINT [1015]","HB AMC WELLPOINT","3118.59","73.78","","286.63","119.22","1107.45","105","1310.33","3360.37","percent of total billed charges",""
"PLATE TIBIAL 4.5X262MM 14 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4226.88","3170.16","AETNA [1001]","HB AMC AETNA HMO","2950.36","69.8","","675.31","184.75","1721.50","286","2208.97","3454.21","percent of total billed charges",""
"PLATE TIBIAL 4.5X262MM 14 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4226.88","3170.16","AETNA [1001]","HB AMC AETNA PPO","3398.41","80.4","","1261.44","103.12","1514.10","21","2208.97","3454.21","percent of total billed charges",""
"PLATE TIBIAL 4.5X262MM 14 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4226.88","3170.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3398.41","80.4","","1365.00","1365.00","1365.00","1 through 10","2208.97","3454.21","percent of total billed charges",""
"PLATE TIBIAL 4.5X262MM 14 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4226.88","3170.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3454.21","81.72","","5157.68","5157.68","5157.68","1 through 10","2208.97","3454.21","percent of total billed charges",""
"PLATE TIBIAL 4.5X262MM 14 HOLE PROXIMAL L LOCKING LCP SS RIGHT","SUP-ITM-10009191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4226.88","3170.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3454.21","81.72","","431.26","71.26","1459.57","88","2208.97","3454.21","percent of total billed charges",""
"PLATE TIBIAL 4.5X286MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.88","3359.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3560.71","79.5","","800.18","480.96","1887.97","195","1388.45","3560.71","percent of total billed charges",""
"PLATE TIBIAL 4.5X286MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.88","3359.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2387.24","53.3","","813.12","216.42","1444.50","81","1388.45","3560.71","percent of total billed charges",""
"PLATE TIBIAL 4.5X286MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.88","3359.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1388.45","31","","432.60","432.60","432.60","1 through 10","1388.45","3560.71","percent of total billed charges",""
"PLATE TIBIAL 4.5X286MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.88","3359.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1634.79","36.5","","148.37","54.89","631.39","94","1388.45","3560.71","percent of total billed charges",""
"PLATE TIBIAL 4.5X286MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.88","3359.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1715.41","38.3","","279.30","91.72","1116.77","266","1388.45","3560.71","percent of total billed charges",""
"PLATE TIBIAL 4.5X286MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.88","3359.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1921.44","42.9","","731.00","63.70","731.00","1 through 10","1388.45","3560.71","percent of total billed charges",""
"PLATE TIBIAL 4.5X286MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.88","3359.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1921.44","42.9","","384.74","384.74","384.74","1 through 10","1388.45","3560.71","percent of total billed charges",""
"PLATE TIBIAL 4.5X286MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037908","CDM","C1713","HCPCS","0278","RC","","","","both","","","4478.88","3359.16","WELLPOINT [1015]","HB AMC WELLPOINT","3304.52","73.78","","286.63","119.22","1107.45","105","1388.45","3560.71","percent of total billed charges",""
"PLATE TIBIAL 4.5X286MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4478.88","3359.16","AETNA [1001]","HB AMC AETNA HMO","3126.26","69.8","","675.31","184.75","1721.50","286","2340.66","3660.14","percent of total billed charges",""
"PLATE TIBIAL 4.5X286MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4478.88","3359.16","AETNA [1001]","HB AMC AETNA PPO","3601.02","80.4","","1261.44","103.12","1514.10","21","2340.66","3660.14","percent of total billed charges",""
"PLATE TIBIAL 4.5X286MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4478.88","3359.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3601.02","80.4","","1365.00","1365.00","1365.00","1 through 10","2340.66","3660.14","percent of total billed charges",""
"PLATE TIBIAL 4.5X286MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4478.88","3359.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3660.14","81.72","","5157.68","5157.68","5157.68","1 through 10","2340.66","3660.14","percent of total billed charges",""
"PLATE TIBIAL 4.5X286MM 14 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4478.88","3359.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3660.14","81.72","","431.26","71.26","1459.57","88","2340.66","3660.14","percent of total billed charges",""
"PLATE TIBIAL 4.5X298MM 14 HOLE LCP SS RIGHT IMAL L","SUP-ITM-10037927","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.89","2996.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3175.94","79.5","","800.18","480.96","1887.97","195","1238.42","3175.94","percent of total billed charges",""
"PLATE TIBIAL 4.5X298MM 14 HOLE LCP SS RIGHT IMAL L","SUP-ITM-10037927","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.89","2996.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2129.28","53.3","","813.12","216.42","1444.50","81","1238.42","3175.94","percent of total billed charges",""
"PLATE TIBIAL 4.5X298MM 14 HOLE LCP SS RIGHT IMAL L","SUP-ITM-10037927","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.89","2996.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1238.42","31","","432.60","432.60","432.60","1 through 10","1238.42","3175.94","percent of total billed charges",""
"PLATE TIBIAL 4.5X298MM 14 HOLE LCP SS RIGHT IMAL L","SUP-ITM-10037927","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.89","2996.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1458.13","36.5","","148.37","54.89","631.39","94","1238.42","3175.94","percent of total billed charges",""
"PLATE TIBIAL 4.5X298MM 14 HOLE LCP SS RIGHT IMAL L","SUP-ITM-10037927","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.89","2996.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1530.04","38.3","","279.30","91.72","1116.77","266","1238.42","3175.94","percent of total billed charges",""
"PLATE TIBIAL 4.5X298MM 14 HOLE LCP SS RIGHT IMAL L","SUP-ITM-10037927","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.89","2996.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1713.81","42.9","","731.00","63.70","731.00","1 through 10","1238.42","3175.94","percent of total billed charges",""
"PLATE TIBIAL 4.5X298MM 14 HOLE LCP SS RIGHT IMAL L","SUP-ITM-10037927","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.89","2996.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1713.81","42.9","","384.74","384.74","384.74","1 through 10","1238.42","3175.94","percent of total billed charges",""
"PLATE TIBIAL 4.5X298MM 14 HOLE LCP SS RIGHT IMAL L","SUP-ITM-10037927","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.89","2996.17","WELLPOINT [1015]","HB AMC WELLPOINT","2947.43","73.78","","286.63","119.22","1107.45","105","1238.42","3175.94","percent of total billed charges",""
"PLATE TIBIAL 4.5X298MM 14 HOLE LCP SS RIGHT IMAL L","SUP-ITM-10037927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3994.89","2996.17","AETNA [1001]","HB AMC AETNA HMO","2788.43","69.8","","675.31","184.75","1721.50","286","2087.73","3264.62","percent of total billed charges",""
"PLATE TIBIAL 4.5X298MM 14 HOLE LCP SS RIGHT IMAL L","SUP-ITM-10037927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3994.89","2996.17","AETNA [1001]","HB AMC AETNA PPO","3211.89","80.4","","1261.44","103.12","1514.10","21","2087.73","3264.62","percent of total billed charges",""
"PLATE TIBIAL 4.5X298MM 14 HOLE LCP SS RIGHT IMAL L","SUP-ITM-10037927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3994.89","2996.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3211.89","80.4","","1365.00","1365.00","1365.00","1 through 10","2087.73","3264.62","percent of total billed charges",""
"PLATE TIBIAL 4.5X298MM 14 HOLE LCP SS RIGHT IMAL L","SUP-ITM-10037927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3994.89","2996.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3264.62","81.72","","5157.68","5157.68","5157.68","1 through 10","2087.73","3264.62","percent of total billed charges",""
"PLATE TIBIAL 4.5X298MM 14 HOLE LCP SS RIGHT IMAL L","SUP-ITM-10037927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3994.89","2996.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3264.62","81.72","","431.26","71.26","1459.57","88","2087.73","3264.62","percent of total billed charges",""
"PLATE TUBULAR 1/3 117MM 10H WITH COLLAR","SUP-ITM-10276148","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","303.29","79.5","","800.18","480.96","1887.97","195","118.27","303.29","percent of total billed charges",""
"PLATE TUBULAR 1/3 117MM 10H WITH COLLAR","SUP-ITM-10276148","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","203.34","53.3","","813.12","216.42","1444.50","81","118.27","303.29","percent of total billed charges",""
"PLATE TUBULAR 1/3 117MM 10H WITH COLLAR","SUP-ITM-10276148","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","118.27","31","","432.60","432.60","432.60","1 through 10","118.27","303.29","percent of total billed charges",""
"PLATE TUBULAR 1/3 117MM 10H WITH COLLAR","SUP-ITM-10276148","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","139.25","36.5","","148.37","54.89","631.39","94","118.27","303.29","percent of total billed charges",""
"PLATE TUBULAR 1/3 117MM 10H WITH COLLAR","SUP-ITM-10276148","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","146.11","38.3","","279.30","91.72","1116.77","266","118.27","303.29","percent of total billed charges",""
"PLATE TUBULAR 1/3 117MM 10H WITH COLLAR","SUP-ITM-10276148","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.66","42.9","","731.00","63.70","731.00","1 through 10","118.27","303.29","percent of total billed charges",""
"PLATE TUBULAR 1/3 117MM 10H WITH COLLAR","SUP-ITM-10276148","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.66","42.9","","384.74","384.74","384.74","1 through 10","118.27","303.29","percent of total billed charges",""
"PLATE TUBULAR 1/3 117MM 10H WITH COLLAR","SUP-ITM-10276148","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","WELLPOINT [1015]","HB AMC WELLPOINT","281.47","73.78","","286.63","119.22","1107.45","105","118.27","303.29","percent of total billed charges",""
"PLATE TUBULAR 1/3 117MM 10H WITH COLLAR","SUP-ITM-10276148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","381.50","286.12","AETNA [1001]","HB AMC AETNA HMO","266.29","69.8","","675.31","184.75","1721.50","286","199.37","311.76","percent of total billed charges",""
"PLATE TUBULAR 1/3 117MM 10H WITH COLLAR","SUP-ITM-10276148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","381.50","286.12","AETNA [1001]","HB AMC AETNA PPO","306.73","80.4","","1261.44","103.12","1514.10","21","199.37","311.76","percent of total billed charges",""
"PLATE TUBULAR 1/3 117MM 10H WITH COLLAR","SUP-ITM-10276148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","381.50","286.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","306.73","80.4","","1365.00","1365.00","1365.00","1 through 10","199.37","311.76","percent of total billed charges",""
"PLATE TUBULAR 1/3 117MM 10H WITH COLLAR","SUP-ITM-10276148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","381.50","286.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","311.76","81.72","","5157.68","5157.68","5157.68","1 through 10","199.37","311.76","percent of total billed charges",""
"PLATE TUBULAR 1/3 117MM 10H WITH COLLAR","SUP-ITM-10276148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","381.50","286.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","311.76","81.72","","431.26","71.26","1459.57","88","199.37","311.76","percent of total billed charges",""
"PLATE TUBULAR 1/3 57MM 5H WITH COLLAR","SUP-ITM-10276226","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","191.99","79.5","","800.18","480.96","1887.97","195","74.87","191.99","percent of total billed charges",""
"PLATE TUBULAR 1/3 57MM 5H WITH COLLAR","SUP-ITM-10276226","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","128.72","53.3","","813.12","216.42","1444.50","81","74.87","191.99","percent of total billed charges",""
"PLATE TUBULAR 1/3 57MM 5H WITH COLLAR","SUP-ITM-10276226","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","74.87","31","","432.60","432.60","432.60","1 through 10","74.87","191.99","percent of total billed charges",""
"PLATE TUBULAR 1/3 57MM 5H WITH COLLAR","SUP-ITM-10276226","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","88.15","36.5","","148.37","54.89","631.39","94","74.87","191.99","percent of total billed charges",""
"PLATE TUBULAR 1/3 57MM 5H WITH COLLAR","SUP-ITM-10276226","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","92.49","38.3","","279.30","91.72","1116.77","266","74.87","191.99","percent of total billed charges",""
"PLATE TUBULAR 1/3 57MM 5H WITH COLLAR","SUP-ITM-10276226","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","103.60","42.9","","731.00","63.70","731.00","1 through 10","74.87","191.99","percent of total billed charges",""
"PLATE TUBULAR 1/3 57MM 5H WITH COLLAR","SUP-ITM-10276226","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","103.60","42.9","","384.74","384.74","384.74","1 through 10","74.87","191.99","percent of total billed charges",""
"PLATE TUBULAR 1/3 57MM 5H WITH COLLAR","SUP-ITM-10276226","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","WELLPOINT [1015]","HB AMC WELLPOINT","178.18","73.78","","286.63","119.22","1107.45","105","74.87","191.99","percent of total billed charges",""
"PLATE TUBULAR 1/3 57MM 5H WITH COLLAR","SUP-ITM-10276226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.50","181.12","AETNA [1001]","HB AMC AETNA HMO","168.57","69.8","","675.31","184.75","1721.50","286","126.21","197.35","percent of total billed charges",""
"PLATE TUBULAR 1/3 57MM 5H WITH COLLAR","SUP-ITM-10276226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.50","181.12","AETNA [1001]","HB AMC AETNA PPO","194.17","80.4","","1261.44","103.12","1514.10","21","126.21","197.35","percent of total billed charges",""
"PLATE TUBULAR 1/3 57MM 5H WITH COLLAR","SUP-ITM-10276226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.50","181.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","194.17","80.4","","1365.00","1365.00","1365.00","1 through 10","126.21","197.35","percent of total billed charges",""
"PLATE TUBULAR 1/3 57MM 5H WITH COLLAR","SUP-ITM-10276226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.50","181.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","197.35","81.72","","5157.68","5157.68","5157.68","1 through 10","126.21","197.35","percent of total billed charges",""
"PLATE TUBULAR 1/3 57MM 5H WITH COLLAR","SUP-ITM-10276226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.50","181.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","197.35","81.72","","431.26","71.26","1459.57","88","126.21","197.35","percent of total billed charges",""
"PLATE TUBULAR 1/3 69MM 6H WITH COLLAR","SUP-ITM-10276225","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","200.34","79.5","","800.18","480.96","1887.97","195","78.12","200.34","percent of total billed charges",""
"PLATE TUBULAR 1/3 69MM 6H WITH COLLAR","SUP-ITM-10276225","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","134.32","53.3","","813.12","216.42","1444.50","81","78.12","200.34","percent of total billed charges",""
"PLATE TUBULAR 1/3 69MM 6H WITH COLLAR","SUP-ITM-10276225","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","78.12","31","","432.60","432.60","432.60","1 through 10","78.12","200.34","percent of total billed charges",""
"PLATE TUBULAR 1/3 69MM 6H WITH COLLAR","SUP-ITM-10276225","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91.98","36.5","","148.37","54.89","631.39","94","78.12","200.34","percent of total billed charges",""
"PLATE TUBULAR 1/3 69MM 6H WITH COLLAR","SUP-ITM-10276225","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.52","38.3","","279.30","91.72","1116.77","266","78.12","200.34","percent of total billed charges",""
"PLATE TUBULAR 1/3 69MM 6H WITH COLLAR","SUP-ITM-10276225","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.11","42.9","","731.00","63.70","731.00","1 through 10","78.12","200.34","percent of total billed charges",""
"PLATE TUBULAR 1/3 69MM 6H WITH COLLAR","SUP-ITM-10276225","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.11","42.9","","384.74","384.74","384.74","1 through 10","78.12","200.34","percent of total billed charges",""
"PLATE TUBULAR 1/3 69MM 6H WITH COLLAR","SUP-ITM-10276225","CDM","C1713","HCPCS","0278","RC","","","","both","","","252.00","189.00","WELLPOINT [1015]","HB AMC WELLPOINT","185.93","73.78","","286.63","119.22","1107.45","105","78.12","200.34","percent of total billed charges",""
"PLATE TUBULAR 1/3 69MM 6H WITH COLLAR","SUP-ITM-10276225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","252.00","189.00","AETNA [1001]","HB AMC AETNA HMO","175.90","69.8","","675.31","184.75","1721.50","286","131.7","205.93","percent of total billed charges",""
"PLATE TUBULAR 1/3 69MM 6H WITH COLLAR","SUP-ITM-10276225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","252.00","189.00","AETNA [1001]","HB AMC AETNA PPO","202.61","80.4","","1261.44","103.12","1514.10","21","131.7","205.93","percent of total billed charges",""
"PLATE TUBULAR 1/3 69MM 6H WITH COLLAR","SUP-ITM-10276225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","252.00","189.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","202.61","80.4","","1365.00","1365.00","1365.00","1 through 10","131.7","205.93","percent of total billed charges",""
"PLATE TUBULAR 1/3 69MM 6H WITH COLLAR","SUP-ITM-10276225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","205.93","81.72","","5157.68","5157.68","5157.68","1 through 10","131.7","205.93","percent of total billed charges",""
"PLATE TUBULAR 1/3 69MM 6H WITH COLLAR","SUP-ITM-10276225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","205.93","81.72","","431.26","71.26","1459.57","88","131.7","205.93","percent of total billed charges",""
"PLATE TUBULAR 1/3 81MM 7H WITH COLLAR","SUP-ITM-10276224","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","239.30","79.5","","800.18","480.96","1887.97","195","93.31","239.3","percent of total billed charges",""
"PLATE TUBULAR 1/3 81MM 7H WITH COLLAR","SUP-ITM-10276224","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","160.43","53.3","","813.12","216.42","1444.50","81","93.31","239.3","percent of total billed charges",""
"PLATE TUBULAR 1/3 81MM 7H WITH COLLAR","SUP-ITM-10276224","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","93.31","31","","432.60","432.60","432.60","1 through 10","93.31","239.3","percent of total billed charges",""
"PLATE TUBULAR 1/3 81MM 7H WITH COLLAR","SUP-ITM-10276224","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","109.87","36.5","","148.37","54.89","631.39","94","93.31","239.3","percent of total billed charges",""
"PLATE TUBULAR 1/3 81MM 7H WITH COLLAR","SUP-ITM-10276224","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","115.28","38.3","","279.30","91.72","1116.77","266","93.31","239.3","percent of total billed charges",""
"PLATE TUBULAR 1/3 81MM 7H WITH COLLAR","SUP-ITM-10276224","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.13","42.9","","731.00","63.70","731.00","1 through 10","93.31","239.3","percent of total billed charges",""
"PLATE TUBULAR 1/3 81MM 7H WITH COLLAR","SUP-ITM-10276224","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.13","42.9","","384.74","384.74","384.74","1 through 10","93.31","239.3","percent of total billed charges",""
"PLATE TUBULAR 1/3 81MM 7H WITH COLLAR","SUP-ITM-10276224","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","WELLPOINT [1015]","HB AMC WELLPOINT","222.08","73.78","","286.63","119.22","1107.45","105","93.31","239.3","percent of total billed charges",""
"PLATE TUBULAR 1/3 81MM 7H WITH COLLAR","SUP-ITM-10276224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.00","225.75","AETNA [1001]","HB AMC AETNA HMO","210.10","69.8","","675.31","184.75","1721.50","286","157.3","245.98","percent of total billed charges",""
"PLATE TUBULAR 1/3 81MM 7H WITH COLLAR","SUP-ITM-10276224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.00","225.75","AETNA [1001]","HB AMC AETNA PPO","242.00","80.4","","1261.44","103.12","1514.10","21","157.3","245.98","percent of total billed charges",""
"PLATE TUBULAR 1/3 81MM 7H WITH COLLAR","SUP-ITM-10276224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.00","225.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","242.00","80.4","","1365.00","1365.00","1365.00","1 through 10","157.3","245.98","percent of total billed charges",""
"PLATE TUBULAR 1/3 81MM 7H WITH COLLAR","SUP-ITM-10276224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","245.98","81.72","","5157.68","5157.68","5157.68","1 through 10","157.3","245.98","percent of total billed charges",""
"PLATE TUBULAR 1/3 81MM 7H WITH COLLAR","SUP-ITM-10276224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","245.98","81.72","","431.26","71.26","1459.57","88","157.3","245.98","percent of total billed charges",""
"PLATE TUBULAR 1/3 WITH COLLAR 93MM 8H","SUP-ITM-10276223","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","267.12","79.5","","800.18","480.96","1887.97","195","104.16","267.12","percent of total billed charges",""
"PLATE TUBULAR 1/3 WITH COLLAR 93MM 8H","SUP-ITM-10276223","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","179.09","53.3","","813.12","216.42","1444.50","81","104.16","267.12","percent of total billed charges",""
"PLATE TUBULAR 1/3 WITH COLLAR 93MM 8H","SUP-ITM-10276223","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","104.16","31","","432.60","432.60","432.60","1 through 10","104.16","267.12","percent of total billed charges",""
"PLATE TUBULAR 1/3 WITH COLLAR 93MM 8H","SUP-ITM-10276223","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","122.64","36.5","","148.37","54.89","631.39","94","104.16","267.12","percent of total billed charges",""
"PLATE TUBULAR 1/3 WITH COLLAR 93MM 8H","SUP-ITM-10276223","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","128.69","38.3","","279.30","91.72","1116.77","266","104.16","267.12","percent of total billed charges",""
"PLATE TUBULAR 1/3 WITH COLLAR 93MM 8H","SUP-ITM-10276223","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","144.14","42.9","","731.00","63.70","731.00","1 through 10","104.16","267.12","percent of total billed charges",""
"PLATE TUBULAR 1/3 WITH COLLAR 93MM 8H","SUP-ITM-10276223","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","144.14","42.9","","384.74","384.74","384.74","1 through 10","104.16","267.12","percent of total billed charges",""
"PLATE TUBULAR 1/3 WITH COLLAR 93MM 8H","SUP-ITM-10276223","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","WELLPOINT [1015]","HB AMC WELLPOINT","247.90","73.78","","286.63","119.22","1107.45","105","104.16","267.12","percent of total billed charges",""
"PLATE TUBULAR 1/3 WITH COLLAR 93MM 8H","SUP-ITM-10276223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","336.00","252.00","AETNA [1001]","HB AMC AETNA HMO","234.53","69.8","","675.31","184.75","1721.50","286","175.59","274.58","percent of total billed charges",""
"PLATE TUBULAR 1/3 WITH COLLAR 93MM 8H","SUP-ITM-10276223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","336.00","252.00","AETNA [1001]","HB AMC AETNA PPO","270.14","80.4","","1261.44","103.12","1514.10","21","175.59","274.58","percent of total billed charges",""
"PLATE TUBULAR 1/3 WITH COLLAR 93MM 8H","SUP-ITM-10276223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","336.00","252.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","270.14","80.4","","1365.00","1365.00","1365.00","1 through 10","175.59","274.58","percent of total billed charges",""
"PLATE TUBULAR 1/3 WITH COLLAR 93MM 8H","SUP-ITM-10276223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","336.00","252.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","274.58","81.72","","5157.68","5157.68","5157.68","1 through 10","175.59","274.58","percent of total billed charges",""
"PLATE TUBULAR 1/3 WITH COLLAR 93MM 8H","SUP-ITM-10276223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","336.00","252.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","274.58","81.72","","431.26","71.26","1459.57","88","175.59","274.58","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X157MM 8 HOLE ARTICLR PROXIMAL VA LCP RIGHT","SUP-ITM-10124811","CDM","C1889","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2734.42","79.5","","1309.77","674.56","6049.93","26","1066.25","2734.42","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X157MM 8 HOLE ARTICLR PROXIMAL VA LCP RIGHT","SUP-ITM-10124811","CDM","C1889","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1833.26","53.3","","1901.83","1901.83","2962.25","1 through 10","1066.25","2734.42","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X157MM 8 HOLE ARTICLR PROXIMAL VA LCP RIGHT","SUP-ITM-10124811","CDM","C1889","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1255.42","36.5","","1620.31","1620.31","19908.88","1 through 10","1066.25","2734.42","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X157MM 8 HOLE ARTICLR PROXIMAL VA LCP RIGHT","SUP-ITM-10124811","CDM","C1889","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1317.34","38.3","","352.91","352.91","2046.30","1 through 10","1066.25","2734.42","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X157MM 8 HOLE ARTICLR PROXIMAL VA LCP RIGHT","SUP-ITM-10124811","CDM","C1889","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1475.55","42.9","","9668.75","9668.75","9668.75","1 through 10","1066.25","2734.42","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X157MM 8 HOLE ARTICLR PROXIMAL VA LCP RIGHT","SUP-ITM-10124811","CDM","C1889","HCPCS","0278","RC","","","","both","","","3439.52","2579.64","WELLPOINT [1015]","HB AMC WELLPOINT","2537.68","73.78","","699.88","384.10","3443.31","33","1066.25","2734.42","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X157MM 8 HOLE ARTICLR PROXIMAL VA LCP RIGHT","SUP-ITM-10124811","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3439.52","2579.64","AETNA [1001]","HB AMC AETNA HMO","2400.78","69.8","","1421.24","264.50","4933.46","29","1797.49","2810.78","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X157MM 8 HOLE ARTICLR PROXIMAL VA LCP RIGHT","SUP-ITM-10124811","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3439.52","2579.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2765.37","80.4","","1022.97","1022.97","3607.50","1 through 10","1797.49","2810.78","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X157MM 8 HOLE ARTICLR PROXIMAL VA LCP RIGHT","SUP-ITM-10124811","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3439.52","2579.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2810.78","81.72","","3010.54","693.88","5019.88","35","1797.49","2810.78","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM /3 OPENING TI VA LOCKING SPACER","SUP-ITM-10096263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2854.18","2140.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2269.07","79.5","","800.18","480.96","1887.97","195","884.8","2269.07","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM /3 OPENING TI VA LOCKING SPACER","SUP-ITM-10096263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2854.18","2140.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1521.28","53.3","","813.12","216.42","1444.50","81","884.8","2269.07","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM /3 OPENING TI VA LOCKING SPACER","SUP-ITM-10096263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2854.18","2140.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","884.80","31","","432.60","432.60","432.60","1 through 10","884.8","2269.07","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM /3 OPENING TI VA LOCKING SPACER","SUP-ITM-10096263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2854.18","2140.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1041.78","36.5","","148.37","54.89","631.39","94","884.8","2269.07","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM /3 OPENING TI VA LOCKING SPACER","SUP-ITM-10096263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2854.18","2140.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1093.15","38.3","","279.30","91.72","1116.77","266","884.8","2269.07","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM /3 OPENING TI VA LOCKING SPACER","SUP-ITM-10096263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2854.18","2140.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1224.44","42.9","","731.00","63.70","731.00","1 through 10","884.8","2269.07","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM /3 OPENING TI VA LOCKING SPACER","SUP-ITM-10096263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2854.18","2140.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1224.44","42.9","","384.74","384.74","384.74","1 through 10","884.8","2269.07","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM /3 OPENING TI VA LOCKING SPACER","SUP-ITM-10096263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2854.18","2140.63","WELLPOINT [1015]","HB AMC WELLPOINT","2105.81","73.78","","286.63","119.22","1107.45","105","884.8","2269.07","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM /3 OPENING TI VA LOCKING SPACER","SUP-ITM-10096263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2854.18","2140.63","AETNA [1001]","HB AMC AETNA HMO","1992.22","69.8","","675.31","184.75","1721.50","286","1491.59","2332.44","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM /3 OPENING TI VA LOCKING SPACER","SUP-ITM-10096263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2854.18","2140.63","AETNA [1001]","HB AMC AETNA PPO","2294.76","80.4","","1261.44","103.12","1514.10","21","1491.59","2332.44","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM /3 OPENING TI VA LOCKING SPACER","SUP-ITM-10096263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2854.18","2140.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2294.76","80.4","","1365.00","1365.00","1365.00","1 through 10","1491.59","2332.44","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM /3 OPENING TI VA LOCKING SPACER","SUP-ITM-10096263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2854.18","2140.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2332.44","81.72","","5157.68","5157.68","5157.68","1 through 10","1491.59","2332.44","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM /3 OPENING TI VA LOCKING SPACER","SUP-ITM-10096263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2854.18","2140.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2332.44","81.72","","431.26","71.26","1459.57","88","1491.59","2332.44","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM OPENING TI VA LOCKING /NO SPACER","SUP-ITM-10096262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.47","2200.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2332.90","79.5","","800.18","480.96","1887.97","195","909.69","2332.9","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM OPENING TI VA LOCKING /NO SPACER","SUP-ITM-10096262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.47","2200.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1564.07","53.3","","813.12","216.42","1444.50","81","909.69","2332.9","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM OPENING TI VA LOCKING /NO SPACER","SUP-ITM-10096262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.47","2200.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","909.69","31","","432.60","432.60","432.60","1 through 10","909.69","2332.9","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM OPENING TI VA LOCKING /NO SPACER","SUP-ITM-10096262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.47","2200.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1071.08","36.5","","148.37","54.89","631.39","94","909.69","2332.9","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM OPENING TI VA LOCKING /NO SPACER","SUP-ITM-10096262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.47","2200.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1123.90","38.3","","279.30","91.72","1116.77","266","909.69","2332.9","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM OPENING TI VA LOCKING /NO SPACER","SUP-ITM-10096262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.47","2200.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1258.89","42.9","","731.00","63.70","731.00","1 through 10","909.69","2332.9","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM OPENING TI VA LOCKING /NO SPACER","SUP-ITM-10096262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.47","2200.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1258.89","42.9","","384.74","384.74","384.74","1 through 10","909.69","2332.9","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM OPENING TI VA LOCKING /NO SPACER","SUP-ITM-10096262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2934.47","2200.85","WELLPOINT [1015]","HB AMC WELLPOINT","2165.05","73.78","","286.63","119.22","1107.45","105","909.69","2332.9","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM OPENING TI VA LOCKING /NO SPACER","SUP-ITM-10096262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2934.47","2200.85","AETNA [1001]","HB AMC AETNA HMO","2048.26","69.8","","675.31","184.75","1721.50","286","1533.55","2398.05","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM OPENING TI VA LOCKING /NO SPACER","SUP-ITM-10096262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2934.47","2200.85","AETNA [1001]","HB AMC AETNA PPO","2359.31","80.4","","1261.44","103.12","1514.10","21","1533.55","2398.05","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM OPENING TI VA LOCKING /NO SPACER","SUP-ITM-10096262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2934.47","2200.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2359.31","80.4","","1365.00","1365.00","1365.00","1 through 10","1533.55","2398.05","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM OPENING TI VA LOCKING /NO SPACER","SUP-ITM-10096262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2934.47","2200.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2398.05","81.72","","5157.68","5157.68","5157.68","1 through 10","1533.55","2398.05","percent of total billed charges",""
"PLATE WEDGE 2.4/ 2.7MM OPENING TI VA LOCKING /NO SPACER","SUP-ITM-10096262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2934.47","2200.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2398.05","81.72","","431.26","71.26","1459.57","88","1533.55","2398.05","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.82","3104.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3290.36","79.5","","800.18","480.96","1887.97","195","1283.03","3290.36","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.82","3104.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2205.99","53.3","","813.12","216.42","1444.50","81","1283.03","3290.36","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.82","3104.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1283.03","31","","432.60","432.60","432.60","1 through 10","1283.03","3290.36","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.82","3104.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1510.67","36.5","","148.37","54.89","631.39","94","1283.03","3290.36","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.82","3104.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1585.17","38.3","","279.30","91.72","1116.77","266","1283.03","3290.36","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.82","3104.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1775.55","42.9","","731.00","63.70","731.00","1 through 10","1283.03","3290.36","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.82","3104.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1775.55","42.9","","384.74","384.74","384.74","1 through 10","1283.03","3290.36","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","4138.82","3104.11","WELLPOINT [1015]","HB AMC WELLPOINT","3053.62","73.78","","286.63","119.22","1107.45","105","1283.03","3290.36","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.82","3104.11","AETNA [1001]","HB AMC AETNA HMO","2888.90","69.8","","675.31","184.75","1721.50","286","2162.95","3382.24","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.82","3104.11","AETNA [1001]","HB AMC AETNA PPO","3327.61","80.4","","1261.44","103.12","1514.10","21","2162.95","3382.24","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.82","3104.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3327.61","80.4","","1365.00","1365.00","1365.00","1 through 10","2162.95","3382.24","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.82","3104.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3382.24","81.72","","5157.68","5157.68","5157.68","1 through 10","2162.95","3382.24","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4138.82","3104.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3382.24","81.72","","431.26","71.26","1459.57","88","2162.95","3382.24","percent of total billed charges",""
"Platelet Aggregation Ea Agent","PX-30001114","CDM","85576","CPT","0305","RC","","","","both","","","362.00","271.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","287.79","79.5","","185.33","185.33","276.24","1 through 10","22.16","343.9","percent of total billed charges",""
"Platelet Aggregation Ea Agent","PX-30001114","CDM","85576","CPT","0305","RC","","","","both","","","362.00","271.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","192.95","53.3","","185.33","185.33","185.33","1 through 10","22.16","343.9","percent of total billed charges",""
"Platelet Aggregation Ea Agent","PX-30001114","CDM","85576","CPT","0305","RC","","","","both","","","362.00","271.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","132.13","36.5","","111.27","111.27","111.27","1 through 10","22.16","343.9","percent of total billed charges",""
"Platelet Aggregation Ea Agent","PX-30001114","CDM","85576","CPT","0305","RC","","","","both","","","362.00","271.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","138.65","38.3","","137.24","137.24","137.24","43","22.16","343.9","percent of total billed charges",""
"Platelet Aggregation Ea Agent","PX-30001114","CDM","85576","CPT","0305","RC","","","","both","","","362.00","271.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.30","42.9","","154.33","154.33","154.33","1 through 10","22.16","343.9","percent of total billed charges",""
"Platelet Aggregation Ea Agent","PX-30001114","CDM","85576","CPT","0305","RC","","","","outpatient","","","362.00","271.50","AETNA [1001]","HB AMC AETNA HMO","252.68","69.8","","167.78","167.78","167.78","15","22.16","295.83","percent of total billed charges",""
"Platelet Aggregation Ea Agent","PX-30001114","CDM","85576","CPT","0305","RC","","","","outpatient","","","362.00","271.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","291.05","80.4","","273.78","273.78","273.78","1 through 10","22.16","295.83","percent of total billed charges",""
"Platelet Aggregation Ea Agent","PX-30001114","CDM","85576","CPT","0305","RC","","","","outpatient","","","362.00","271.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","295.83","81.72","","107.95","107.95","280.59","1 through 10","22.16","295.83","percent of total billed charges",""
"Platelet Antibody ID","PX-30000780","CDM","86022","CPT","0302","RC","","","","outpatient","","","300.00","225.00","AETNA [1001]","HB AMC AETNA HMO","209.40","69.8","","197.01","197.01","197.01","1 through 10","18.94","245.16","percent of total billed charges",""
"Platelet Antibody ID Assoc","PX-30000782","CDM","86023","CPT","0302","RC","","","","outpatient","","","217.00","162.75","AETNA [1001]","HB AMC AETNA HMO","151.47","69.8","","142.17","142.17","142.17","1 through 10","12.85","177.33","percent of total billed charges",""
"Platelets Pheresis L/R Irr Ea","PX-39000017","CDM","P9037","HCPCS","0390","RC","","","","both","","","5593.00","4194.75","MEDICARE [2001]","HB BWH MEDICARE","675.66","","APC Price ($675.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","675.66","675.66","675.66","1 through 10","641.88","4446.44","other","OPPS APC"
"Platelets Pheresis L/R Irr Ea","PX-39000017","CDM","P9037","HCPCS","0390","RC","","","","both","","","5593.00","4194.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","641.88","","APC Price ($675.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","675.66","675.66","675.66","1 through 10","641.88","4446.44","other","Tricare OPPS"
"Platelets, Pheresis, Pathogen-Reduced, Each Unit","PX-39000069","CDM","P9073","HCPCS","0390","RC","","","","both","","","5409.00","4056.75","MEDICARE [2001]","HB BWH MEDICARE","587.28","","APC Price ($587.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","587.28","587.28","587.28","1 through 10","557.92","4300.16","other","OPPS APC"
"Plc Dev/Mkr Rad Therapy Prost 1/1+","PX-76001328","CDM","55876","CPT","0761","RC","","","","both","","","3682.00","2761.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1962.51","53.3","","2810.38","2810.38","2810.38","1 through 10","1141.42","2927.19","percent of total billed charges",""
"Plc Dev/Mkr Rad Therapy Prost 1/1+","PX-76001328","CDM","55876","CPT","0761","RC","","","","both","","","3682.00","2761.50","MEDICARE [2001]","HB BWH MEDICARE","1624.73","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1624.89","1624.89","1624.89","1 through 10","1141.42","2927.19","other","OPPS APC"
"Plc Dev/Mkr Rad Therapy Prost 1/1+","PX-76001328","CDM","55876","CPT","0761","RC","","","","outpatient","","","3682.00","2761.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1363.03","","Case rate ($1,363.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1394.38","1369.17","2788.76","1 through 10","1363.03","5545.35","other","ASC"
"Plc Dev/Mkr Rad Therapy Prost 1/1+","PX-76001328","CDM","55876","CPT","0761","RC","","","","outpatient","","","3682.00","2761.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1363.03","","Case rate ($1,363.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1595.43","1579.75","1595.43","1 through 10","1363.03","5545.35","other","ASC "
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","51.38","363.89","23","197.14","888.02","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","732.75","65.6","","517.67","517.67","517.67","1 through 10","197.14","888.02","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","781.90","70","","879.76","844.74","879.76","1 through 10","197.14","888.02","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","888.02","79.5","","852.32","571.82","852.32","35","197.14","888.02","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","595.36","53.3","","571.82","571.82","1264.90","19","197.14","888.02","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","293.08","363.89","1 through 10","197.14","888.02","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","860.09","77","","2501.73","2501.73","2501.73","1 through 10","197.14","888.02","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","362.41","362.41","1 through 10","197.14","888.02","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","726.05","65","","573.99","573.99","573.99","1 through 10","197.14","888.02","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","254","197.14","888.02","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","407.71","36.5","","403.96","343.31","403.96","28","197.14","888.02","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","427.81","38.3","","423.45","423.45","1270.35","83","197.14","888.02","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","336.12","362.81","1 through 10","197.14","888.02","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","MOLINA [1014]","HB BWH MOLINA","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","736.98","736.98","736.98","1 through 10","197.14","888.02","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","TRICARE [160005]","HB BWH TRICARE","351.32","","APC Price ($369.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","351.32","351.32","369.81","1 through 10","197.14","888.02","other","Tricare OPPS"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1088.03","362.41","1091.67","12","197.14","888.02","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","479.19","42.9","","476.20","476.20","476.20","1 through 10","197.14","888.02","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","1117.00","837.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","362.41","363.42","43","197.14","888.02","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","1117.00","837.75","AETNA [1001]","HB AMC AETNA HMO","779.67","69.8","","733.19","733.19","733.19","1 through 10","304.03","966.35","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","1117.00","837.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","583.74","52.26","","670.16","670.16","670.16","1 through 10","304.03","966.35","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","1117.00","837.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","898.07","80.4","","541.50","541.50","541.50","1 through 10","304.03","966.35","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","1117.00","837.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","912.81","81.72","","476.20","476.20","476.20","1 through 10","304.03","966.35","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","1117.00","837.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","912.81","81.72","","865.75","476.20","865.75","30","304.03","966.35","percent of total billed charges",""
"Pleural Effusion With Cc","187","MS-DRG","","","","","","","","inpatient","","","39416.24","29562.18","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12089.72","","Case rate ($12,089.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,241.36, add-ons for qualifying new technology services are included. If operating cost exceeds $56,885.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,236.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,913.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,861.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $795.89. The transfer capital threshold is the transfer adjustment factor * $795.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6284.28","6284.28","6284.28","1 through 10","9214.46","15151.364","other","Inpatient DRG"
"Pleural Effusion With Cc","187","MS-DRG","","","","","","","","inpatient","","","39416.24","29562.18","MEDICARE [2001]","HB BWH MEDICARE","12089.72","","Case rate ($12,089.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,241.36, add-ons for qualifying new technology services are included. If operating cost exceeds $56,885.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,236.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $10,913.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,861.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $795.89. The transfer capital threshold is the transfer adjustment factor * $795.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12114.60","0.03","12132.30","11","9214.46","15151.364","other","Inpatient DRG"
"Pleural Effusion With McC","186","MS-DRG","","","","","","","","inpatient","","","85012.31","63759.23","MEDICARE [2001]","HB BWH MEDICARE","18830.81","","Case rate ($18,830.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,494.06, add-ons for qualifying new technology services are included. If operating cost exceeds $63,138.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,694.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $17,196.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,114.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,254.06. The transfer capital threshold is the transfer adjustment factor * $1,254.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18905.16","0.03","18933.01","16","14304.72","23843.78","other","Inpatient DRG"
"Pleural Effusion With McC","186","MS-DRG","","","","","","","","inpatient","","","85012.31","63759.23","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14304.72","","Case rate ($14,596.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,494.06, add-ons for qualifying new technology services are included. If operating cost exceeds $63,138.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,694.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $12,962.74 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,114.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,254.06. The transfer capital threshold is the transfer adjustment factor * $1,254.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14328.61","14328.61","14328.61","1 through 10","14304.72","23843.78","other","Inpatient DRG"
"Pleural Effusion Without Cc/McC","188","MS-DRG","","","","","","","","inpatient","","","70111.70","52583.77","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","6922.21","","Case rate ($6,922.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,255.56, add-ons for qualifying new technology services are included. If operating cost exceeds $53,900.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,017.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,965.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,875.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $577.10. The transfer capital threshold is the transfer adjustment factor * $577.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8824.47","8824.47","8824.47","1 through 10","6783.77","11234.22","other","Inpatient Replacement Plans DRG"
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","both","","","560.00","420.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","292.66","52.26","","16.24","16.24","54.15","1 through 10","173.6","445.2","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","both","","","560.00","420.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","402.08","71.8","","86.33","32.67","86.33","1 through 10","173.6","445.2","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","both","","","560.00","420.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","392.00","70","","113.68","63.00","177.34","40","173.6","445.2","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","both","","","560.00","420.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","445.20","79.5","","50.70","21.76","168.00","12","173.6","445.2","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","both","","","560.00","420.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","298.48","53.3","","89.31","89.31","99.75","1 through 10","173.6","445.2","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","both","","","560.00","420.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","364.00","65","","94.41","17.06","2275.00","1 through 10","173.6","445.2","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","both","","","560.00","420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","173.60","31","","35.13","35.13","35.13","1 through 10","173.6","445.2","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","both","","","560.00","420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","204.40","36.5","","40.08","12.40","86.17","108","173.6","445.2","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","both","","","560.00","420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","214.48","38.3","","33.25","10.27","68.43","169","173.6","445.2","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","both","","","560.00","420.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","240.24","42.9","","25.48","14.86","90.88","1 through 10","173.6","445.2","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","both","","","560.00","420.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","240.24","42.9","","90.88","90.88","90.88","1 through 10","173.6","445.2","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","both","","","560.00","420.00","WELLPOINT [1015]","HB AMC WELLPOINT","413.17","73.78","","84.63","19.55","140.02","123","173.6","445.2","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","AETNA [1001]","HB AMC AETNA HMO","390.88","69.8","","76.96","17.77","113.68","14","292.66","457.63","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","AETNA [1001]","HB AMC AETNA PPO","450.24","80.4","","57.31","57.31","57.31","1 through 10","292.66","457.63","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","292.66","52.26","","16.24","16.24","54.15","1 through 10","292.66","457.63","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","450.24","80.4","","68.25","68.25","87.50","1 through 10","292.66","457.63","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","457.63","81.72","","156.19","156.19","156.19","1 through 10","292.66","457.63","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","457.63","81.72","","82.70","12.06","98.97","13","292.66","457.63","percent of total billed charges",""
"PLI KIT SAFESHEATH II 9FR 19.13CM SAFESHEATH PK/5EA","SUP-ITM-10321761","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","560.00","420.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","457.63","81.72","","50.47","25.30","134.30","140","292.66","457.63","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","566.79","425.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","450.60","79.5","","1309.77","674.56","6049.93","26","175.7","450.6","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","566.79","425.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","302.10","53.3","","1901.83","1901.83","2962.25","1 through 10","175.7","450.6","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","566.79","425.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","206.88","36.5","","1620.31","1620.31","19908.88","1 through 10","175.7","450.6","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","566.79","425.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","217.08","38.3","","352.91","352.91","2046.30","1 through 10","175.7","450.6","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","566.79","425.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","243.15","42.9","","9668.75","9668.75","9668.75","1 through 10","175.7","450.6","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","566.79","425.09","WELLPOINT [1015]","HB AMC WELLPOINT","418.18","73.78","","699.88","384.10","3443.31","33","175.7","450.6","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","566.79","425.09","AETNA [1001]","HB AMC AETNA HMO","395.62","69.8","","1421.24","264.50","4933.46","29","296.2","463.18","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","566.79","425.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","455.70","80.4","","1022.97","1022.97","3607.50","1 through 10","296.2","463.18","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","566.79","425.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","463.18","81.72","","3010.54","693.88","5019.88","35","296.2","463.18","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","3195.15","2396.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2540.14","79.5","","1309.77","674.56","6049.93","26","990.5","2540.14","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","3195.15","2396.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1703.01","53.3","","1901.83","1901.83","2962.25","1 through 10","990.5","2540.14","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","3195.15","2396.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1166.23","36.5","","1620.31","1620.31","19908.88","1 through 10","990.5","2540.14","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","3195.15","2396.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1223.74","38.3","","352.91","352.91","2046.30","1 through 10","990.5","2540.14","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","3195.15","2396.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1370.72","42.9","","9668.75","9668.75","9668.75","1 through 10","990.5","2540.14","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","3195.15","2396.36","WELLPOINT [1015]","HB AMC WELLPOINT","2357.38","73.78","","699.88","384.10","3443.31","33","990.5","2540.14","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3195.15","2396.36","AETNA [1001]","HB AMC AETNA HMO","2230.21","69.8","","1421.24","264.50","4933.46","29","1669.79","2611.08","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3195.15","2396.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2568.90","80.4","","1022.97","1022.97","3607.50","1 through 10","1669.79","2611.08","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3195.15","2396.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2611.08","81.72","","3010.54","693.88","5019.88","35","1669.79","2611.08","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","1299.66","974.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1033.23","79.5","","1309.77","674.56","6049.93","26","402.89","1033.23","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","1299.66","974.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","692.72","53.3","","1901.83","1901.83","2962.25","1 through 10","402.89","1033.23","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","1299.66","974.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","474.38","36.5","","1620.31","1620.31","19908.88","1 through 10","402.89","1033.23","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","1299.66","974.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","497.77","38.3","","352.91","352.91","2046.30","1 through 10","402.89","1033.23","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","1299.66","974.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","557.55","42.9","","9668.75","9668.75","9668.75","1 through 10","402.89","1033.23","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","1299.66","974.74","WELLPOINT [1015]","HB AMC WELLPOINT","958.89","73.78","","699.88","384.10","3443.31","33","402.89","1033.23","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1299.66","974.74","AETNA [1001]","HB AMC AETNA HMO","907.16","69.8","","1421.24","264.50","4933.46","29","679.2","1062.08","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1299.66","974.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1044.93","80.4","","1022.97","1022.97","3607.50","1 through 10","679.2","1062.08","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1299.66","974.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1062.08","81.72","","3010.54","693.88","5019.88","35","679.2","1062.08","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","2163.42","1622.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1719.92","79.5","","1309.77","674.56","6049.93","26","670.66","1719.92","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","2163.42","1622.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1153.10","53.3","","1901.83","1901.83","2962.25","1 through 10","670.66","1719.92","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","2163.42","1622.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","789.65","36.5","","1620.31","1620.31","19908.88","1 through 10","670.66","1719.92","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","2163.42","1622.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","828.59","38.3","","352.91","352.91","2046.30","1 through 10","670.66","1719.92","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","2163.42","1622.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","928.11","42.9","","9668.75","9668.75","9668.75","1 through 10","670.66","1719.92","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","2163.42","1622.56","WELLPOINT [1015]","HB AMC WELLPOINT","1596.17","73.78","","699.88","384.10","3443.31","33","670.66","1719.92","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2163.42","1622.56","AETNA [1001]","HB AMC AETNA HMO","1510.07","69.8","","1421.24","264.50","4933.46","29","1130.6","1767.95","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2163.42","1622.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1739.39","80.4","","1022.97","1022.97","3607.50","1 through 10","1130.6","1767.95","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2163.42","1622.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1767.95","81.72","","3010.54","693.88","5019.88","35","1130.6","1767.95","percent of total billed charges",""
"Plmt Bile Duct Stent Prq Existing Access","PX-36000381","CDM","47538","CPT","0361","RC","","","","outpatient","","","2442.00","1831.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5255.62","","Case rate ($5,255.62). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","12303.41","12303.41","12303.41","1 through 10","1276.19","11688.78","other","ASC "
"Plmt Nephrostomy Cath Prq New Access Rs&I","PX-76002184","CDM","50432","CPT","0761","RC","","","","both","","","1613.00","1209.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2384.08","2186.47","2384.08","1 through 10","500.03","3040.6","other","OPPS APC"
"Plmt Nephrostomy Cath Prq New Access Rs&I|BILATERAL PROCEDURE","PX-76002184","CDM","50432","CPT","0761","RC","","","50","both","","","1613.00","1209.75","MEDICARE [2001]","HB BWH MEDICARE","4095.44","","APC Price ($4,095.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4095.86","4095.86","4095.86","1 through 10","3891.07","5119.31","other","OPPS APC"
"PLUG CANCELLOUS 7MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10132442","CDM","C1889","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1331.07","79.5","","1309.77","674.56","6049.93","26","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 7MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10132442","CDM","C1889","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","892.40","53.3","","1901.83","1901.83","2962.25","1 through 10","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 7MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10132442","CDM","C1889","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","611.12","36.5","","1620.31","1620.31","19908.88","1 through 10","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 7MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10132442","CDM","C1889","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","641.26","38.3","","352.91","352.91","2046.30","1 through 10","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 7MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10132442","CDM","C1889","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","718.27","42.9","","9668.75","9668.75","9668.75","1 through 10","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 7MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10132442","CDM","C1889","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","WELLPOINT [1015]","HB AMC WELLPOINT","1235.30","73.78","","699.88","384.10","3443.31","33","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 7MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10132442","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1674.30","1255.72","AETNA [1001]","HB AMC AETNA HMO","1168.66","69.8","","1421.24","264.50","4933.46","29","874.99","1368.24","percent of total billed charges",""
"PLUG CANCELLOUS 7MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10132442","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1674.30","1255.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1346.14","80.4","","1022.97","1022.97","3607.50","1 through 10","874.99","1368.24","percent of total billed charges",""
"PLUG CANCELLOUS 7MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10132442","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1674.30","1255.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1368.24","81.72","","3010.54","693.88","5019.88","35","874.99","1368.24","percent of total billed charges",""
"PLUG CANCELLOUS 9MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10077491","CDM","C1713","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1331.07","79.5","","800.18","480.96","1887.97","195","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 9MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10077491","CDM","C1713","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","892.40","53.3","","813.12","216.42","1444.50","81","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 9MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10077491","CDM","C1713","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","519.03","31","","432.60","432.60","432.60","1 through 10","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 9MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10077491","CDM","C1713","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","611.12","36.5","","148.37","54.89","631.39","94","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 9MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10077491","CDM","C1713","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","641.26","38.3","","279.30","91.72","1116.77","266","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 9MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10077491","CDM","C1713","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","718.27","42.9","","731.00","63.70","731.00","1 through 10","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 9MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10077491","CDM","C1713","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","718.27","42.9","","384.74","384.74","384.74","1 through 10","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 9MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10077491","CDM","C1713","HCPCS","0278","RC","","","","both","","","1674.30","1255.72","WELLPOINT [1015]","HB AMC WELLPOINT","1235.30","73.78","","286.63","119.22","1107.45","105","519.03","1331.07","percent of total billed charges",""
"PLUG CANCELLOUS 9MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10077491","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1674.30","1255.72","AETNA [1001]","HB AMC AETNA HMO","1168.66","69.8","","675.31","184.75","1721.50","286","874.99","1368.24","percent of total billed charges",""
"PLUG CANCELLOUS 9MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10077491","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1674.30","1255.72","AETNA [1001]","HB AMC AETNA PPO","1346.14","80.4","","1261.44","103.12","1514.10","21","874.99","1368.24","percent of total billed charges",""
"PLUG CANCELLOUS 9MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10077491","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1674.30","1255.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1346.14","80.4","","1365.00","1365.00","1365.00","1 through 10","874.99","1368.24","percent of total billed charges",""
"PLUG CANCELLOUS 9MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10077491","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1674.30","1255.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1368.24","81.72","","5157.68","5157.68","5157.68","1 through 10","874.99","1368.24","percent of total billed charges",""
"PLUG CANCELLOUS 9MM GRAFT BONE READIGRAFT ALLOGRAFT CARTILAGE FROZEN","SUP-ITM-10077491","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1674.30","1255.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1368.24","81.72","","431.26","71.26","1459.57","88","874.99","1368.24","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","278.25","79.5","","800.18","480.96","1887.97","195","108.5","278.25","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","186.55","53.3","","813.12","216.42","1444.50","81","108.5","278.25","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","108.50","31","","432.60","432.60","432.60","1 through 10","108.5","278.25","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.75","36.5","","148.37","54.89","631.39","94","108.5","278.25","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","134.05","38.3","","279.30","91.72","1116.77","266","108.5","278.25","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","731.00","63.70","731.00","1 through 10","108.5","278.25","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","384.74","384.74","384.74","1 through 10","108.5","278.25","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","WELLPOINT [1015]","HB AMC WELLPOINT","258.23","73.78","","286.63","119.22","1107.45","105","108.5","278.25","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA HMO","244.30","69.8","","675.31","184.75","1721.50","286","182.91","286.02","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA PPO","281.40","80.4","","1261.44","103.12","1514.10","21","182.91","286.02","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","281.40","80.4","","1365.00","1365.00","1365.00","1 through 10","182.91","286.02","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","286.02","81.72","","5157.68","5157.68","5157.68","1 through 10","182.91","286.02","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","286.02","81.72","","431.26","71.26","1459.57","88","182.91","286.02","percent of total billed charges",""
"PLUG CONNECTOR DBS SENSIGHT","SUP-ITM-10285834","CDM","C1883","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","1073.15","1073.15","1073.15","1 through 10","325.5","834.75","percent of total billed charges",""
"PLUG CONNECTOR DBS SENSIGHT","SUP-ITM-10285834","CDM","C1883","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","1808.38","1642.20","1808.38","1 through 10","325.5","834.75","percent of total billed charges",""
"PLUG CONNECTOR DBS SENSIGHT","SUP-ITM-10285834","CDM","C1883","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB AMC WELLPOINT","774.69","73.78","","625.38","625.38","625.38","1 through 10","325.5","834.75","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","1113.10","1113.10","1113.10","1 through 10","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","1293.60","1148.53","1603.80","1 through 10","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","1023.42","771.29","2068.67","33","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","850.52","759.78","1211.25","66","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","2548.09","2548.09","2548.09","1 through 10","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","956.46","956.46","956.46","1 through 10","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","2344.73","1619.47","2530.35","16","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","1523.63","988.41","4330.26","39","45.73","71.51","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","1670.25","1670.25","1670.25","1 through 10","45.73","71.51","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","1113.10","1113.10","1113.10","1 through 10","45.73","71.51","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","1738.90","1484.65","2716.94","38","45.73","71.51","percent of total billed charges",""
"PLUG FEMORAL 3/8INX24MM SHELL ACETABULAR HOLE THRDED ORTHOPEDIC SAPICAL HIP 16B","SUP-ITM-10026419","CDM","C1776","HCPCS","0278","RC","","","","both","","","462.00","346.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","241.44","52.26","","1113.10","1113.10","1113.10","1 through 10","143.22","367.29","percent of total billed charges",""
"PLUG FEMORAL 3/8INX24MM SHELL ACETABULAR HOLE THRDED ORTHOPEDIC SAPICAL HIP 16B","SUP-ITM-10026419","CDM","C1776","HCPCS","0278","RC","","","","both","","","462.00","346.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","367.29","79.5","","1293.60","1148.53","1603.80","1 through 10","143.22","367.29","percent of total billed charges",""
"PLUG FEMORAL 3/8INX24MM SHELL ACETABULAR HOLE THRDED ORTHOPEDIC SAPICAL HIP 16B","SUP-ITM-10026419","CDM","C1776","HCPCS","0278","RC","","","","both","","","462.00","346.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","168.63","36.5","","1023.42","771.29","2068.67","33","143.22","367.29","percent of total billed charges",""
"PLUG FEMORAL 3/8INX24MM SHELL ACETABULAR HOLE THRDED ORTHOPEDIC SAPICAL HIP 16B","SUP-ITM-10026419","CDM","C1776","HCPCS","0278","RC","","","","both","","","462.00","346.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","176.95","38.3","","850.52","759.78","1211.25","66","143.22","367.29","percent of total billed charges",""
"PLUG FEMORAL 3/8INX24MM SHELL ACETABULAR HOLE THRDED ORTHOPEDIC SAPICAL HIP 16B","SUP-ITM-10026419","CDM","C1776","HCPCS","0278","RC","","","","both","","","462.00","346.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.20","42.9","","2548.09","2548.09","2548.09","1 through 10","143.22","367.29","percent of total billed charges",""
"PLUG FEMORAL 3/8INX24MM SHELL ACETABULAR HOLE THRDED ORTHOPEDIC SAPICAL HIP 16B","SUP-ITM-10026419","CDM","C1776","HCPCS","0278","RC","","","","both","","","462.00","346.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.20","42.9","","956.46","956.46","956.46","1 through 10","143.22","367.29","percent of total billed charges",""
"PLUG FEMORAL 3/8INX24MM SHELL ACETABULAR HOLE THRDED ORTHOPEDIC SAPICAL HIP 16B","SUP-ITM-10026419","CDM","C1776","HCPCS","0278","RC","","","","both","","","462.00","346.50","WELLPOINT [1015]","HB AMC WELLPOINT","340.86","73.78","","2344.73","1619.47","2530.35","16","143.22","367.29","percent of total billed charges",""
"PLUG FEMORAL 3/8INX24MM SHELL ACETABULAR HOLE THRDED ORTHOPEDIC SAPICAL HIP 16B","SUP-ITM-10026419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","462.00","346.50","AETNA [1001]","HB AMC AETNA HMO","322.48","69.8","","1523.63","988.41","4330.26","39","241.44","377.55","percent of total billed charges",""
"PLUG FEMORAL 3/8INX24MM SHELL ACETABULAR HOLE THRDED ORTHOPEDIC SAPICAL HIP 16B","SUP-ITM-10026419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","462.00","346.50","AETNA [1001]","HB AMC AETNA PPO","371.45","80.4","","1670.25","1670.25","1670.25","1 through 10","241.44","377.55","percent of total billed charges",""
"PLUG FEMORAL 3/8INX24MM SHELL ACETABULAR HOLE THRDED ORTHOPEDIC SAPICAL HIP 16B","SUP-ITM-10026419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","462.00","346.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","241.44","52.26","","1113.10","1113.10","1113.10","1 through 10","241.44","377.55","percent of total billed charges",""
"PLUG FEMORAL 3/8INX24MM SHELL ACETABULAR HOLE THRDED ORTHOPEDIC SAPICAL HIP 16B","SUP-ITM-10026419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","462.00","346.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","377.55","81.72","","1738.90","1484.65","2716.94","38","241.44","377.55","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","800.18","480.96","1887.97","195","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.64","53.3","","813.12","216.42","1444.50","81","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.13","31","","432.60","432.60","432.60","1 through 10","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","148.37","54.89","631.39","94","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","279.30","91.72","1116.77","266","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","731.00","63.70","731.00","1 through 10","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","384.74","384.74","384.74","1 through 10","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","286.63","119.22","1107.45","105","27.13","69.56","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","675.31","184.75","1721.50","286","45.73","71.51","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","1261.44","103.12","1514.10","21","45.73","71.51","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","70.35","80.4","","1365.00","1365.00","1365.00","1 through 10","45.73","71.51","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","71.51","81.72","","5157.68","5157.68","5157.68","1 through 10","45.73","71.51","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","431.26","71.26","1459.57","88","45.73","71.51","percent of total billed charges",""
"PLUG FISTULA 0.7X5.1CM BIODESIGN(CONICAL) STERILE LF","SUP-ITM-10118290","CDM","C1763","HCPCS","0278","RC","","","","both","","","4350.50","3262.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2827.83","65","","2028.23","1653.70","2028.23","1 through 10","1348.66","3458.65","percent of total billed charges",""
"PLUG FISTULA 0.7X5.1CM BIODESIGN(CONICAL) STERILE LF","SUP-ITM-10118290","CDM","C1763","HCPCS","0278","RC","","","","both","","","4350.50","3262.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1587.93","36.5","","1163.89","1163.89","1163.89","1 through 10","1348.66","3458.65","percent of total billed charges",""
"PLUG FISTULA 0.7X5.1CM BIODESIGN(CONICAL) STERILE LF","SUP-ITM-10118290","CDM","C1763","HCPCS","0278","RC","","","","both","","","4350.50","3262.87","WELLPOINT [1015]","HB AMC WELLPOINT","3209.80","73.78","","4280.87","4280.87","4280.87","1 through 10","1348.66","3458.65","percent of total billed charges",""
"PLUG FISTULA ANAL BIODESIGN 0.6X9.5CM AREA 5.7 SQCM STERILE LF","SUP-ITM-10104568","CDM","C1763","HCPCS","0278","RC","","","","both","","","4284.00","3213.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2784.60","65","","2028.23","1653.70","2028.23","1 through 10","1328.04","3405.78","percent of total billed charges",""
"PLUG FISTULA ANAL BIODESIGN 0.6X9.5CM AREA 5.7 SQCM STERILE LF","SUP-ITM-10104568","CDM","C1763","HCPCS","0278","RC","","","","both","","","4284.00","3213.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1563.66","36.5","","1163.89","1163.89","1163.89","1 through 10","1328.04","3405.78","percent of total billed charges",""
"PLUG FISTULA ANAL BIODESIGN 0.6X9.5CM AREA 5.7 SQCM STERILE LF","SUP-ITM-10104568","CDM","C1763","HCPCS","0278","RC","","","","both","","","4284.00","3213.00","WELLPOINT [1015]","HB AMC WELLPOINT","3160.74","73.78","","4280.87","4280.87","4280.87","1 through 10","1328.04","3405.78","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","98.77","52.26","","1113.10","1113.10","1113.10","1 through 10","58.59","150.26","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","150.26","79.5","","1293.60","1148.53","1603.80","1 through 10","58.59","150.26","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.99","36.5","","1023.42","771.29","2068.67","33","58.59","150.26","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.39","38.3","","850.52","759.78","1211.25","66","58.59","150.26","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","2548.09","2548.09","2548.09","1 through 10","58.59","150.26","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","956.46","956.46","956.46","1 through 10","58.59","150.26","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","WELLPOINT [1015]","HB AMC WELLPOINT","139.44","73.78","","2344.73","1619.47","2530.35","16","58.59","150.26","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA HMO","131.92","69.8","","1523.63","988.41","4330.26","39","98.77","154.45","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA PPO","151.96","80.4","","1670.25","1670.25","1670.25","1 through 10","98.77","154.45","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","98.77","52.26","","1113.10","1113.10","1113.10","1 through 10","98.77","154.45","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","154.45","81.72","","1738.90","1484.65","2716.94","38","98.77","154.45","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1737.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1030.75","2643.38","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2643.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1030.75","2643.38","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1213.63","36.5","","1023.42","771.29","2068.67","33","1030.75","2643.38","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1273.48","38.3","","850.52","759.78","1211.25","66","1030.75","2643.38","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","2548.09","2548.09","2548.09","1 through 10","1030.75","2643.38","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","956.46","956.46","956.46","1 through 10","1030.75","2643.38","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","WELLPOINT [1015]","HB AMC WELLPOINT","2453.19","73.78","","2344.73","1619.47","2530.35","16","1030.75","2643.38","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA HMO","2320.85","69.8","","1523.63","988.41","4330.26","39","1737.65","2717.19","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA PPO","2673.30","80.4","","1670.25","1670.25","1670.25","1 through 10","1737.65","2717.19","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1737.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1737.65","2717.19","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2717.19","81.72","","1738.90","1484.65","2716.94","38","1737.65","2717.19","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","525.69","394.27","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","367.98","70","","134.04","134.04","134.04","1 through 10","162.96","417.92","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","525.69","394.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.92","79.5","","948.87","198.19","1805.30","1 through 10","162.96","417.92","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","525.69","394.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","280.19","53.3","","462.00","170.45","3253.37","1 through 10","162.96","417.92","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","525.69","394.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.88","36.5","","245.50","107.19","1371.45","1 through 10","162.96","417.92","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","525.69","394.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.34","38.3","","200.79","72.79","355.81","22","162.96","417.92","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","525.69","394.27","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","404.78","77","","477.18","477.18","477.18","1 through 10","162.96","417.92","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","525.69","394.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.52","42.9","","1045.91","1045.91","1045.91","1 through 10","162.96","417.92","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","525.69","394.27","WELLPOINT [1015]","HB AMC WELLPOINT","387.85","73.78","","1726.50","1726.50","1726.50","1 through 10","162.96","417.92","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","525.69","394.27","AETNA [1001]","HB AMC AETNA HMO","366.93","69.8","","915.80","263.76","2881.00","1 through 10","274.73","429.59","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","525.69","394.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.59","81.72","","1531.57","410.52","8841.36","1 through 10","274.73","429.59","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","546.78","410.08","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","382.75","70","","134.04","134.04","134.04","1 through 10","169.5","434.69","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","546.78","410.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","434.69","79.5","","948.87","198.19","1805.30","1 through 10","169.5","434.69","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","546.78","410.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","291.43","53.3","","462.00","170.45","3253.37","1 through 10","169.5","434.69","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","546.78","410.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","199.57","36.5","","245.50","107.19","1371.45","1 through 10","169.5","434.69","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","546.78","410.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","209.42","38.3","","200.79","72.79","355.81","22","169.5","434.69","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","546.78","410.08","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","421.02","77","","477.18","477.18","477.18","1 through 10","169.5","434.69","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","546.78","410.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.57","42.9","","1045.91","1045.91","1045.91","1 through 10","169.5","434.69","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","546.78","410.08","WELLPOINT [1015]","HB AMC WELLPOINT","403.41","73.78","","1726.50","1726.50","1726.50","1 through 10","169.5","434.69","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","546.78","410.08","AETNA [1001]","HB AMC AETNA HMO","381.65","69.8","","915.80","263.76","2881.00","1 through 10","285.75","446.83","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","546.78","410.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","446.83","81.72","","1531.57","410.52","8841.36","1 through 10","285.75","446.83","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","598.43","448.82","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","418.90","70","","134.04","134.04","134.04","1 through 10","185.51","475.75","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","598.43","448.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","475.75","79.5","","948.87","198.19","1805.30","1 through 10","185.51","475.75","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","598.43","448.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","318.96","53.3","","462.00","170.45","3253.37","1 through 10","185.51","475.75","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","598.43","448.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","218.43","36.5","","245.50","107.19","1371.45","1 through 10","185.51","475.75","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","598.43","448.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","229.20","38.3","","200.79","72.79","355.81","22","185.51","475.75","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","598.43","448.82","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","460.79","77","","477.18","477.18","477.18","1 through 10","185.51","475.75","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","598.43","448.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","256.73","42.9","","1045.91","1045.91","1045.91","1 through 10","185.51","475.75","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","598.43","448.82","WELLPOINT [1015]","HB AMC WELLPOINT","441.52","73.78","","1726.50","1726.50","1726.50","1 through 10","185.51","475.75","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","598.43","448.82","AETNA [1001]","HB AMC AETNA HMO","417.70","69.8","","915.80","263.76","2881.00","1 through 10","312.74","489.04","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","598.43","448.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","489.04","81.72","","1531.57","410.52","8841.36","1 through 10","312.74","489.04","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","604.42","453.31","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","423.09","70","","134.04","134.04","134.04","1 through 10","187.37","480.51","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","604.42","453.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","480.51","79.5","","948.87","198.19","1805.30","1 through 10","187.37","480.51","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","604.42","453.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","322.16","53.3","","462.00","170.45","3253.37","1 through 10","187.37","480.51","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","604.42","453.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","220.61","36.5","","245.50","107.19","1371.45","1 through 10","187.37","480.51","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","604.42","453.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","231.49","38.3","","200.79","72.79","355.81","22","187.37","480.51","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","604.42","453.31","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","465.40","77","","477.18","477.18","477.18","1 through 10","187.37","480.51","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","604.42","453.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","259.30","42.9","","1045.91","1045.91","1045.91","1 through 10","187.37","480.51","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","604.42","453.31","WELLPOINT [1015]","HB AMC WELLPOINT","445.94","73.78","","1726.50","1726.50","1726.50","1 through 10","187.37","480.51","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","604.42","453.31","AETNA [1001]","HB AMC AETNA HMO","421.89","69.8","","915.80","263.76","2881.00","1 through 10","315.87","493.93","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","604.42","453.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","493.93","81.72","","1531.57","410.52","8841.36","1 through 10","315.87","493.93","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","610.37","457.78","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","427.26","70","","134.04","134.04","134.04","1 through 10","189.21","485.24","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","610.37","457.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","485.24","79.5","","948.87","198.19","1805.30","1 through 10","189.21","485.24","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","610.37","457.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","325.33","53.3","","462.00","170.45","3253.37","1 through 10","189.21","485.24","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","610.37","457.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","222.79","36.5","","245.50","107.19","1371.45","1 through 10","189.21","485.24","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","610.37","457.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","233.77","38.3","","200.79","72.79","355.81","22","189.21","485.24","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","610.37","457.78","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","469.98","77","","477.18","477.18","477.18","1 through 10","189.21","485.24","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","610.37","457.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","261.85","42.9","","1045.91","1045.91","1045.91","1 through 10","189.21","485.24","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","610.37","457.78","WELLPOINT [1015]","HB AMC WELLPOINT","450.33","73.78","","1726.50","1726.50","1726.50","1 through 10","189.21","485.24","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","610.37","457.78","AETNA [1001]","HB AMC AETNA HMO","426.04","69.8","","915.80","263.76","2881.00","1 through 10","318.98","498.79","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","610.37","457.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","498.79","81.72","","1531.57","410.52","8841.36","1 through 10","318.98","498.79","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","535.90","401.92","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","375.13","70","","134.04","134.04","134.04","1 through 10","166.13","426.04","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","535.90","401.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","426.04","79.5","","948.87","198.19","1805.30","1 through 10","166.13","426.04","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","535.90","401.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","285.63","53.3","","462.00","170.45","3253.37","1 through 10","166.13","426.04","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","535.90","401.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","195.60","36.5","","245.50","107.19","1371.45","1 through 10","166.13","426.04","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","535.90","401.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","205.25","38.3","","200.79","72.79","355.81","22","166.13","426.04","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","535.90","401.92","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","412.64","77","","477.18","477.18","477.18","1 through 10","166.13","426.04","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","535.90","401.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","229.90","42.9","","1045.91","1045.91","1045.91","1 through 10","166.13","426.04","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","535.90","401.92","WELLPOINT [1015]","HB AMC WELLPOINT","395.39","73.78","","1726.50","1726.50","1726.50","1 through 10","166.13","426.04","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","535.90","401.92","AETNA [1001]","HB AMC AETNA HMO","374.06","69.8","","915.80","263.76","2881.00","1 through 10","280.06","437.94","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","535.90","401.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","437.94","81.72","","1531.57","410.52","8841.36","1 through 10","280.06","437.94","percent of total billed charges",""
"PLUG VASCULAR 12MM 180CM 1.5-3MM .027IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10137709","CDM","C1889","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3458.25","79.5","","1309.77","674.56","6049.93","26","1348.5","3458.25","percent of total billed charges",""
"PLUG VASCULAR 12MM 180CM 1.5-3MM .027IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10137709","CDM","C1889","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2318.55","53.3","","1901.83","1901.83","2962.25","1 through 10","1348.5","3458.25","percent of total billed charges",""
"PLUG VASCULAR 12MM 180CM 1.5-3MM .027IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10137709","CDM","C1889","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1587.75","36.5","","1620.31","1620.31","19908.88","1 through 10","1348.5","3458.25","percent of total billed charges",""
"PLUG VASCULAR 12MM 180CM 1.5-3MM .027IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10137709","CDM","C1889","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1666.05","38.3","","352.91","352.91","2046.30","1 through 10","1348.5","3458.25","percent of total billed charges",""
"PLUG VASCULAR 12MM 180CM 1.5-3MM .027IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10137709","CDM","C1889","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.15","42.9","","9668.75","9668.75","9668.75","1 through 10","1348.5","3458.25","percent of total billed charges",""
"PLUG VASCULAR 12MM 180CM 1.5-3MM .027IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10137709","CDM","C1889","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","WELLPOINT [1015]","HB AMC WELLPOINT","3209.43","73.78","","699.88","384.10","3443.31","33","1348.5","3458.25","percent of total billed charges",""
"PLUG VASCULAR 12MM 180CM 1.5-3MM .027IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10137709","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","AETNA [1001]","HB AMC AETNA HMO","3036.30","69.8","","1421.24","264.50","4933.46","29","2273.31","3554.82","percent of total billed charges",""
"PLUG VASCULAR 12MM 180CM 1.5-3MM .027IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10137709","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3497.40","80.4","","1022.97","1022.97","3607.50","1 through 10","2273.31","3554.82","percent of total billed charges",""
"PLUG VASCULAR 12MM 180CM 1.5-3MM .027IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10137709","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3554.82","81.72","","3010.54","693.88","5019.88","35","2273.31","3554.82","percent of total billed charges",""
"PLUG VASCULAR 4FR 16MM 180CM 5-7MM .021IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10158103","CDM","C1889","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","1309.77","674.56","6049.93","26","1534.5","3935.25","percent of total billed charges",""
"PLUG VASCULAR 4FR 16MM 180CM 5-7MM .021IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10158103","CDM","C1889","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2638.35","53.3","","1901.83","1901.83","2962.25","1 through 10","1534.5","3935.25","percent of total billed charges",""
"PLUG VASCULAR 4FR 16MM 180CM 5-7MM .021IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10158103","CDM","C1889","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","1620.31","1620.31","19908.88","1 through 10","1534.5","3935.25","percent of total billed charges",""
"PLUG VASCULAR 4FR 16MM 180CM 5-7MM .021IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10158103","CDM","C1889","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","352.91","352.91","2046.30","1 through 10","1534.5","3935.25","percent of total billed charges",""
"PLUG VASCULAR 4FR 16MM 180CM 5-7MM .021IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10158103","CDM","C1889","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","9668.75","9668.75","9668.75","1 through 10","1534.5","3935.25","percent of total billed charges",""
"PLUG VASCULAR 4FR 16MM 180CM 5-7MM .021IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10158103","CDM","C1889","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","699.88","384.10","3443.31","33","1534.5","3935.25","percent of total billed charges",""
"PLUG VASCULAR 4FR 16MM 180CM 5-7MM .021IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10158103","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","1421.24","264.50","4933.46","29","2586.87","4045.14","percent of total billed charges",""
"PLUG VASCULAR 4FR 16MM 180CM 5-7MM .021IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10158103","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3979.80","80.4","","1022.97","1022.97","3607.50","1 through 10","2586.87","4045.14","percent of total billed charges",""
"PLUG VASCULAR 4FR 16MM 180CM 5-7MM .021IN LF NITINOL MICRO PTFE MECHANICAL","SUP-ITM-10158103","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","3010.54","693.88","5019.88","35","2586.87","4045.14","percent of total billed charges",""
"PLUNGER PACK SHORT 10G","SUP-ITM-10254298","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","806.93","79.5","","800.18","480.96","1887.97","195","314.65","806.93","percent of total billed charges",""
"PLUNGER PACK SHORT 10G","SUP-ITM-10254298","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","541.00","53.3","","813.12","216.42","1444.50","81","314.65","806.93","percent of total billed charges",""
"PLUNGER PACK SHORT 10G","SUP-ITM-10254298","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","314.65","31","","432.60","432.60","432.60","1 through 10","314.65","806.93","percent of total billed charges",""
"PLUNGER PACK SHORT 10G","SUP-ITM-10254298","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","370.48","36.5","","148.37","54.89","631.39","94","314.65","806.93","percent of total billed charges",""
"PLUNGER PACK SHORT 10G","SUP-ITM-10254298","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","388.75","38.3","","279.30","91.72","1116.77","266","314.65","806.93","percent of total billed charges",""
"PLUNGER PACK SHORT 10G","SUP-ITM-10254298","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","435.44","42.9","","731.00","63.70","731.00","1 through 10","314.65","806.93","percent of total billed charges",""
"PLUNGER PACK SHORT 10G","SUP-ITM-10254298","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","435.44","42.9","","384.74","384.74","384.74","1 through 10","314.65","806.93","percent of total billed charges",""
"PLUNGER PACK SHORT 10G","SUP-ITM-10254298","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","WELLPOINT [1015]","HB AMC WELLPOINT","748.87","73.78","","286.63","119.22","1107.45","105","314.65","806.93","percent of total billed charges",""
"PLUNGER PACK SHORT 10G","SUP-ITM-10254298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","AETNA [1001]","HB AMC AETNA HMO","708.47","69.8","","675.31","184.75","1721.50","286","530.44","829.46","percent of total billed charges",""
"PLUNGER PACK SHORT 10G","SUP-ITM-10254298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","AETNA [1001]","HB AMC AETNA PPO","816.06","80.4","","1261.44","103.12","1514.10","21","530.44","829.46","percent of total billed charges",""
"PLUNGER PACK SHORT 10G","SUP-ITM-10254298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","816.06","80.4","","1365.00","1365.00","1365.00","1 through 10","530.44","829.46","percent of total billed charges",""
"PLUNGER PACK SHORT 10G","SUP-ITM-10254298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","829.46","81.72","","5157.68","5157.68","5157.68","1 through 10","530.44","829.46","percent of total billed charges",""
"PLUNGER PACK SHORT 10G","SUP-ITM-10254298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","829.46","81.72","","431.26","71.26","1459.57","88","530.44","829.46","percent of total billed charges",""
"Pneumothorax With Cc","200","MS-DRG","","","","","","","","inpatient","","","38079.06","28559.29","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","10407.78","","Case rate ($10,407.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,451.49, add-ons for qualifying new technology services are included. If operating cost exceeds $58,095.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,324.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,143.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,071.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $884.56. The transfer capital threshold is the transfer adjustment factor * $884.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10218.47","10218.47","10218.47","1 through 10","10199.62","16713.2825","other","Inpatient Replacement Plans DRG"
"Pneumothorax With Cc","200","MS-DRG","","","","","","","","inpatient","","","38079.06","28559.29","MEDICARE [2001]","HB BWH MEDICARE","10407.78","","Case rate ($10,407.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,451.49, add-ons for qualifying new technology services are included. If operating cost exceeds $58,095.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,324.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,143.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,071.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $884.56. The transfer capital threshold is the transfer adjustment factor * $884.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13334.77","3737.85","13354.31","1 through 10","10199.62","16713.2825","other","Inpatient Replacement Plans DRG"
"Pneumothorax With Cc","200","MS-DRG","","","","","","","","inpatient","","","38079.06","28559.29","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","10199.62","","Case rate ($10,407.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,451.49, add-ons for qualifying new technology services are included. If operating cost exceeds $58,095.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,324.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,143.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,071.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $884.56. The transfer capital threshold is the transfer adjustment factor * $884.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10172.65","10172.65","10172.65","1 through 10","10199.62","16713.2825","other","Inpatient DRG"
"Pneumothorax With Cc","200","TRIS-DRG","","","","","","","","inpatient","","","39305.64","","TRICARE [160005]","HB BWH TRICARE","6381.93","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($11,210.21). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $54,937.21 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($7,232.39), capped at $8,068.38. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $54,937.21 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","12186.19","12186.19","12186.19","1 through 10","6381.93","6381.93","other","Inpatient DRGs"
"Pneumothorax With McC","199","MS-DRG","","","","","","","","inpatient","","","70029.80","52522.35","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","21264.87","","Case rate ($21,264.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,751.80, add-ons for qualifying new technology services are included. If operating cost exceeds $65,396.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,859.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,465.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,371.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,419.50. The transfer capital threshold is the transfer adjustment factor * $1,419.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20769.01","20769.01","20769.01","1 through 10","16142.69","26772.9431","other","Inpatient DRG"
"Pneumothorax With McC","199","MS-DRG","","","","","","","","inpatient","","","70029.80","52522.35","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","21264.87","","Case rate ($21,264.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,751.80, add-ons for qualifying new technology services are included. If operating cost exceeds $65,396.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,859.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,465.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,371.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,419.50. The transfer capital threshold is the transfer adjustment factor * $1,419.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16059.40","16059.40","16059.40","1 through 10","16142.69","26772.9431","other","Inpatient DRG"
"Pneumothorax With McC","199","MS-DRG","","","","","","","","inpatient","","","70029.80","52522.35","MEDICARE [2001]","HB BWH MEDICARE","21264.87","","Case rate ($21,264.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,751.80, add-ons for qualifying new technology services are included. If operating cost exceeds $65,396.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,859.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $19,465.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,371.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,419.50. The transfer capital threshold is the transfer adjustment factor * $1,419.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21120.81","21089.68","21120.81","1 through 10","16142.69","26772.9431","other","Inpatient DRG"
"Pneumothorax With McC","199","MS-DRG","","","","","","","","inpatient","","","70029.80","52522.35","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16142.69","","Case rate ($16,472.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,751.80, add-ons for qualifying new technology services are included. If operating cost exceeds $65,396.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,859.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,672.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,371.96 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,419.50. The transfer capital threshold is the transfer adjustment factor * $1,419.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16355.34","16355.34","16355.34","1 through 10","16142.69","26772.9431","other","Inpatient DRG"
"Pneumothorax Without Cc/McC","201","MS-DRG","","","","","","","","inpatient","","","33402.93","25052.20","MEDICARE [2001]","HB BWH MEDICARE","6903.05","","Case rate ($6,903.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,232.51, add-ons for qualifying new technology services are included. If operating cost exceeds $53,876.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,015.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,947.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,852.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.41. The transfer capital threshold is the transfer adjustment factor * $575.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8272.64","8272.64","8272.64","1 through 10","6764.99","10218.1161","other","Inpatient Replacement Plans DRG"
"POD RUBY 8MM X 55CM XL COIL SYSTEM","SUP-ITM-10339817","CDM","C1889","HCPCS","0278","RC","","","","both","","","7575.00","5681.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6022.13","79.5","","1309.77","674.56","6049.93","26","2348.25","6022.13","percent of total billed charges",""
"POD RUBY 8MM X 55CM XL COIL SYSTEM","SUP-ITM-10339817","CDM","C1889","HCPCS","0278","RC","","","","both","","","7575.00","5681.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4037.48","53.3","","1901.83","1901.83","2962.25","1 through 10","2348.25","6022.13","percent of total billed charges",""
"POD RUBY 8MM X 55CM XL COIL SYSTEM","SUP-ITM-10339817","CDM","C1889","HCPCS","0278","RC","","","","both","","","7575.00","5681.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2764.88","36.5","","1620.31","1620.31","19908.88","1 through 10","2348.25","6022.13","percent of total billed charges",""
"POD RUBY 8MM X 55CM XL COIL SYSTEM","SUP-ITM-10339817","CDM","C1889","HCPCS","0278","RC","","","","both","","","7575.00","5681.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2901.23","38.3","","352.91","352.91","2046.30","1 through 10","2348.25","6022.13","percent of total billed charges",""
"POD RUBY 8MM X 55CM XL COIL SYSTEM","SUP-ITM-10339817","CDM","C1889","HCPCS","0278","RC","","","","both","","","7575.00","5681.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3249.68","42.9","","9668.75","9668.75","9668.75","1 through 10","2348.25","6022.13","percent of total billed charges",""
"POD RUBY 8MM X 55CM XL COIL SYSTEM","SUP-ITM-10339817","CDM","C1889","HCPCS","0278","RC","","","","both","","","7575.00","5681.25","WELLPOINT [1015]","HB AMC WELLPOINT","5588.84","73.78","","699.88","384.10","3443.31","33","2348.25","6022.13","percent of total billed charges",""
"POD RUBY 8MM X 55CM XL COIL SYSTEM","SUP-ITM-10339817","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7575.00","5681.25","AETNA [1001]","HB AMC AETNA HMO","5287.35","69.8","","1421.24","264.50","4933.46","29","3958.7","6190.29","percent of total billed charges",""
"POD RUBY 8MM X 55CM XL COIL SYSTEM","SUP-ITM-10339817","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7575.00","5681.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6090.30","80.4","","1022.97","1022.97","3607.50","1 through 10","3958.7","6190.29","percent of total billed charges",""
"POD RUBY 8MM X 55CM XL COIL SYSTEM","SUP-ITM-10339817","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7575.00","5681.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6190.29","81.72","","3010.54","693.88","5019.88","35","3958.7","6190.29","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.04","56.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59.66","79.5","","800.18","480.96","1887.97","195","23.26","59.66","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.04","56.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","40.00","53.3","","813.12","216.42","1444.50","81","23.26","59.66","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.04","56.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","23.26","31","","432.60","432.60","432.60","1 through 10","23.26","59.66","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.04","56.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.39","36.5","","148.37","54.89","631.39","94","23.26","59.66","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.04","56.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.74","38.3","","279.30","91.72","1116.77","266","23.26","59.66","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.04","56.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.19","42.9","","731.00","63.70","731.00","1 through 10","23.26","59.66","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.04","56.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.19","42.9","","384.74","384.74","384.74","1 through 10","23.26","59.66","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.04","56.28","WELLPOINT [1015]","HB AMC WELLPOINT","55.36","73.78","","286.63","119.22","1107.45","105","23.26","59.66","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.04","56.28","AETNA [1001]","HB AMC AETNA HMO","52.38","69.8","","675.31","184.75","1721.50","286","39.22","61.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.04","56.28","AETNA [1001]","HB AMC AETNA PPO","60.33","80.4","","1261.44","103.12","1514.10","21","39.22","61.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.04","56.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","60.33","80.4","","1365.00","1365.00","1365.00","1 through 10","39.22","61.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.04","56.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","61.32","81.72","","5157.68","5157.68","5157.68","1 through 10","39.22","61.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.04","56.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","61.32","81.72","","431.26","71.26","1459.57","88","39.22","61.32","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.48","66.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","70.34","79.5","","800.18","480.96","1887.97","195","27.43","70.34","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.48","66.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","47.16","53.3","","813.12","216.42","1444.50","81","27.43","70.34","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.48","66.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.43","31","","432.60","432.60","432.60","1 through 10","27.43","70.34","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.48","66.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","32.30","36.5","","148.37","54.89","631.39","94","27.43","70.34","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.48","66.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.89","38.3","","279.30","91.72","1116.77","266","27.43","70.34","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.48","66.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.96","42.9","","731.00","63.70","731.00","1 through 10","27.43","70.34","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.48","66.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.96","42.9","","384.74","384.74","384.74","1 through 10","27.43","70.34","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.48","66.36","WELLPOINT [1015]","HB AMC WELLPOINT","65.28","73.78","","286.63","119.22","1107.45","105","27.43","70.34","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.48","66.36","AETNA [1001]","HB AMC AETNA HMO","61.76","69.8","","675.31","184.75","1721.50","286","46.24","72.31","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.48","66.36","AETNA [1001]","HB AMC AETNA PPO","71.14","80.4","","1261.44","103.12","1514.10","21","46.24","72.31","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.48","66.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","71.14","80.4","","1365.00","1365.00","1365.00","1 through 10","46.24","72.31","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.48","66.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","72.31","81.72","","5157.68","5157.68","5157.68","1 through 10","46.24","72.31","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.48","66.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","72.31","81.72","","431.26","71.26","1459.57","88","46.24","72.31","percent of total billed charges",""
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","80104.13","60078.10","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15127.56","","Case rate ($14,686.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,602.78, add-ons for qualifying new technology services are included. If operating cost exceeds $63,247.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,702.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,045.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,222.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,262.03. The transfer capital threshold is the transfer adjustment factor * $1,262.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15653.80","15653.80","15653.80","1 through 10","14393.21","24567.42","other","Inpatient DRG"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","80104.13","60078.10","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","14686.95","","Case rate ($14,686.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,602.78, add-ons for qualifying new technology services are included. If operating cost exceeds $63,247.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,702.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,045.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,222.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,262.03. The transfer capital threshold is the transfer adjustment factor * $1,262.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14935.17","14935.17","109441.07","1 through 10","14393.21","24567.42","other","Inpatient DRG"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","80104.13","60078.10","MEDICARE [2001]","HB BWH MEDICARE","18948.01","","Case rate ($18,948.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,602.78, add-ons for qualifying new technology services are included. If operating cost exceeds $63,247.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,702.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $17,306.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,222.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,262.03. The transfer capital threshold is the transfer adjustment factor * $1,262.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19608.95","15539.85","19637.87","12","14393.21","24567.42","other","Inpatient DRG"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","80104.13","60078.10","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","18948.01","","Case rate ($18,948.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,602.78, add-ons for qualifying new technology services are included. If operating cost exceeds $63,247.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,702.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $17,306.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,222.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,262.03. The transfer capital threshold is the transfer adjustment factor * $1,262.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17059.91","17059.91","17059.91","1 through 10","14393.21","24567.42","other","Inpatient DRG"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","80104.13","60078.10","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14393.21","","Case rate ($14,686.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,602.78, add-ons for qualifying new technology services are included. If operating cost exceeds $63,247.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,702.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,045.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,222.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,262.03. The transfer capital threshold is the transfer adjustment factor * $1,262.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14891.86","14891.86","14891.86","1 through 10","14393.21","24567.42","other","Inpatient DRG"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","80104.13","60078.10","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14393.21","","Case rate ($14,686.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,602.78, add-ons for qualifying new technology services are included. If operating cost exceeds $63,247.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,702.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,045.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,222.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,262.03. The transfer capital threshold is the transfer adjustment factor * $1,262.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14950.21","14950.21","21302.12","1 through 10","14393.21","24567.42","other","Inpatient DRG"
"Poisoning And Toxic Effects Of Drugs Without McC","918","MS-DRG","","","","","","","","inpatient","","","39520.38","29640.28","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8198.40","","Case rate ($8,198.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,791.85, add-ons for qualifying new technology services are included. If operating cost exceeds $55,436.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,129.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,128.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,412.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.67. The transfer capital threshold is the transfer adjustment factor * $689.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8141.38","8141.38","8141.38","1 through 10","8034.43","13425.61","other","Inpatient DRG"
"Poisoning And Toxic Effects Of Drugs Without McC","918","MS-DRG","","","","","","","","inpatient","","","39520.38","29640.28","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","2116.00","2116.00","3424.21","1 through 10","8034.43","13425.61","case rate",""
"Poisoning And Toxic Effects Of Drugs Without McC","918","MS-DRG","","","","","","","","inpatient","","","39520.38","29640.28","MEDICARE [2001]","HB BWH MEDICARE","10526.99","","Case rate ($10,526.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,791.85, add-ons for qualifying new technology services are included. If operating cost exceeds $55,436.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,129.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,457.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,412.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.67. The transfer capital threshold is the transfer adjustment factor * $689.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10722.55","694.33","10722.55","1 through 10","8034.43","13425.61","other","Inpatient DRG"
"Poisoning And Toxic Effects Of Drugs Without McC","918","MS-DRG","","","","","","","","inpatient","","","39520.38","29640.28","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8034.43","","Case rate ($8,198.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,791.85, add-ons for qualifying new technology services are included. If operating cost exceeds $55,436.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,129.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,128.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,412.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.67. The transfer capital threshold is the transfer adjustment factor * $689.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8224.72","8224.72","8224.72","1 through 10","8034.43","13425.61","other","Inpatient DRG"
"Poisoning Of Medicinal Agents,EXTREME","812","DRG","","","","","","","","inpatient","","","41928.59","","MASSHEALTH [3001]","HB BWH MEDICAID","15188.90","","Case rate ($16,793.94). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,223.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16576.16","3984.78","16789.82","1 through 10","5097.24","50455.69","case rate",""
"Poisoning Of Medicinal Agents,EXTREME","812","DRG","","","","","","","","inpatient","","","41928.59","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","15188.90","","Case rate ($16,793.94). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,223.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","5097.24","50455.69","case rate",""
"Poisoning Of Medicinal Agents,EXTREME","812","DRG","","","","","","","","inpatient","","","41928.59","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15188.90","","Case rate ($16,793.94). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,223.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5903.31","5903.31","16789.82","1 through 10","5097.24","50455.69","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","42211.05","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","26230.10","","Standard inlier is a Case rate ($26,230.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,790, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,723.15) for the length of stay and the standard reimbursement.","23963.46","23963.46","23963.46","1 through 10","5097.24","50455.69","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","42211.05","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($21,268.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","21268.80","21268.80","1 through 10","5097.24","50455.69","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","42211.05","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8881.9357","","Fee schedule rate ($21,268.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8881.9357","21268.80","21268.80","1 through 10","5097.24","50455.69","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","42211.05","","MASSHEALTH [3001]","HB BWH MEDICAID","6965.01","","Case rate ($7,701.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,131.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7699.12","7699.12","7699.12","1 through 10","5097.24","50455.69","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","42211.05","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25024.20","","Fee schedule rate ($25,024.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25024.20","25024.20","25024.20","1 through 10","5097.24","50455.69","case rate",""
"Polycystic Kidney Disease Evaluation","PX-31001389","CDM","81406","CPT","0310","RC","","","","both","","","2923.00","2192.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2323.79","79.5","","2231.15","2231.15","2231.15","1 through 10","277.22","2776.85","percent of total billed charges",""
"Pontocerebellar Hypoplasia Panel","PX-31000747","CDM","81479","CPT","0310","RC","","","","both","","","803.00","602.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","638.39","79.5","","0.65","0.65","0.65","1 through 10","248.93","762.85","percent of total billed charges",""
"Pontocerebellar Hypoplasia Panel","PX-31000747","CDM","81479","CPT","0310","RC","","","","both","","","803.00","602.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","428.00","53.3","","0.79","0.79","0.79","1 through 10","248.93","762.85","percent of total billed charges",""
"Pontocerebellar Hypoplasia Panel","PX-31000747","CDM","81479","CPT","0310","RC","","","","outpatient","","","803.00","602.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","401.50","50","","1.00","1.00","1.00","1 through 10","156.55","662.48","percent of total billed charges",""
"Pontocerebellar Hypoplasia Panel","PX-31000747","CDM","81479","CPT","0310","RC","","","","outpatient","","","803.00","602.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","421.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","662.48","percent of total billed charges",""
"Porphobilinogen Qn Urine","PX-30000622","CDM","84110","CPT","0301","RC","","","","outpatient","","","141.00","105.75","AETNA [1001]","HB AMC AETNA HMO","98.42","69.8","","65.49","65.49","65.49","1 through 10","8.7","115.23","percent of total billed charges",""
"Porphobilinogen Qn Urine","PX-30000622","CDM","84110","CPT","0301","RC","","","","outpatient","","","141.00","105.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","115.23","81.72","","219.04","219.04","219.04","1 through 10","8.7","115.23","percent of total billed charges",""
"Porphoryns, Total, Plasma","PX-30003548","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","226.66","453.31","1 through 10","18.62","282.15","percent of total billed charges",""
"Porphoryns, Total, Plasma","PX-30003548","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.07","152.07","226.66","1 through 10","18.62","282.15","percent of total billed charges",""
"Porphoryns, Total, Plasma","PX-30003548","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","104.26","107.42","1 through 10","18.62","282.15","percent of total billed charges",""
"Porphoryns, Total, Plasma","PX-30003548","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","225.22","112.61","337.82","22","18.62","282.15","percent of total billed charges",""
"Porphoryns, Total, Plasma","PX-30003548","CDM","82542","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","131.04","126.64","131.04","1 through 10","18.62","282.15","percent of total billed charges",""
"Porphoryns, Total, Plasma","PX-30003548","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","194.98","224.64","16","18.62","242.71","percent of total billed charges",""
"Porphoryns, Total, Plasma","PX-30003548","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","150.91","150.91","150.91","1 through 10","18.62","242.71","percent of total billed charges",""
"Porphoryns, Total, Plasma","PX-30003548","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.64","126.64","126.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Porphoryns, Total, Plasma","PX-30003548","CDM","82542","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.64","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Porphyrins Qn & Fraction Urine","PX-30000625","CDM","84120","CPT","0301","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.84","38.3","","93.06","93.06","93.06","1 through 10","14.42","232.75","percent of total billed charges",""
"Porphyrins Qn & Fraction Urine","PX-30000625","CDM","84120","CPT","0301","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","200.21","81.72","","380.52","380.52","380.52","1 through 10","15.18","200.21","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","389.55","70","","556.50","556.50","556.50","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","442.42","79.5","","437.97","293.83","444.55","17","172.52","442.42","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","296.61","53.3","","298.25","293.83","444.55","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","361.73","65","","361.73","361.73","361.73","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","172.52","31","","171.96","171.96","171.96","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","203.12","36.5","","207.57","179.06","271.83","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","213.14","38.3","","217.59","211.47","220.86","18","172.52","442.42","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","238.74","42.9","","556.50","451.56","556.50","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","238.74","42.9","","444.87","444.87","444.87","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","WELLPOINT [1015]","HB AMC WELLPOINT","410.59","73.78","","414.31","414.31","420.55","15","172.52","442.42","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","556.50","417.37","AETNA [1001]","HB AMC AETNA HMO","388.44","69.8","","376.75","270.01","580.53","30","290.83","454.77","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","556.50","417.37","AETNA [1001]","HB AMC AETNA PPO","447.43","80.4","","440.60","434.07","440.60","1 through 10","290.83","454.77","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","556.50","417.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","447.43","80.4","","434.07","434.07","440.60","1 through 10","290.83","454.77","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","556.50","417.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","454.77","81.72","","444.87","248.37","444.87","1 through 10","290.83","454.77","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","556.50","417.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","454.77","81.72","","444.87","248.37","451.56","20","290.83","454.77","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","600.25","70","","556.50","556.50","556.50","1 through 10","265.83","681.71","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","681.71","79.5","","437.97","293.83","444.55","17","265.83","681.71","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","457.05","53.3","","298.25","293.83","444.55","1 through 10","265.83","681.71","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","557.38","65","","361.73","361.73","361.73","1 through 10","265.83","681.71","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","265.83","31","","171.96","171.96","171.96","1 through 10","265.83","681.71","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","312.99","36.5","","207.57","179.06","271.83","1 through 10","265.83","681.71","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","328.42","38.3","","217.59","211.47","220.86","18","265.83","681.71","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","367.87","42.9","","556.50","451.56","556.50","1 through 10","265.83","681.71","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","367.87","42.9","","444.87","444.87","444.87","1 through 10","265.83","681.71","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","both","","","857.50","643.12","WELLPOINT [1015]","HB AMC WELLPOINT","632.66","73.78","","414.31","414.31","420.55","15","265.83","681.71","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","AETNA [1001]","HB AMC AETNA HMO","598.54","69.8","","376.75","270.01","580.53","30","448.13","700.75","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","AETNA [1001]","HB AMC AETNA PPO","689.43","80.4","","440.60","434.07","440.60","1 through 10","448.13","700.75","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","689.43","80.4","","434.07","434.07","440.60","1 through 10","448.13","700.75","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","700.75","81.72","","444.87","248.37","444.87","1 through 10","448.13","700.75","percent of total billed charges",""
"PORT DIGNITY 9.5FR INFUSION DUAL PORT SILICONE FILLED SUTURE HOLE","SUP-ITM-10170050","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","700.75","81.72","","444.87","248.37","451.56","20","448.13","700.75","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","both","","","564.87","423.65","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","395.41","70","","556.50","556.50","556.50","1 through 10","175.11","449.07","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","both","","","564.87","423.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","449.07","79.5","","437.97","293.83","444.55","17","175.11","449.07","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","both","","","564.87","423.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","301.08","53.3","","298.25","293.83","444.55","1 through 10","175.11","449.07","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","both","","","564.87","423.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","367.17","65","","361.73","361.73","361.73","1 through 10","175.11","449.07","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","both","","","564.87","423.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","175.11","31","","171.96","171.96","171.96","1 through 10","175.11","449.07","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","both","","","564.87","423.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","206.18","36.5","","207.57","179.06","271.83","1 through 10","175.11","449.07","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","both","","","564.87","423.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","216.35","38.3","","217.59","211.47","220.86","18","175.11","449.07","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","both","","","564.87","423.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","242.33","42.9","","556.50","451.56","556.50","1 through 10","175.11","449.07","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","both","","","564.87","423.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","242.33","42.9","","444.87","444.87","444.87","1 through 10","175.11","449.07","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","both","","","564.87","423.65","WELLPOINT [1015]","HB AMC WELLPOINT","416.76","73.78","","414.31","414.31","420.55","15","175.11","449.07","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","564.87","423.65","AETNA [1001]","HB AMC AETNA HMO","394.28","69.8","","376.75","270.01","580.53","30","295.2","461.61","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","564.87","423.65","AETNA [1001]","HB AMC AETNA PPO","454.16","80.4","","440.60","434.07","440.60","1 through 10","295.2","461.61","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","564.87","423.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","454.16","80.4","","434.07","434.07","440.60","1 through 10","295.2","461.61","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","564.87","423.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","461.61","81.72","","444.87","248.37","444.87","1 through 10","295.2","461.61","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","564.87","423.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","461.61","81.72","","444.87","248.37","451.56","20","295.2","461.61","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","both","","","693.00","519.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","485.10","70","","556.50","556.50","556.50","1 through 10","214.83","550.94","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","both","","","693.00","519.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","550.94","79.5","","437.97","293.83","444.55","17","214.83","550.94","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","both","","","693.00","519.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","369.37","53.3","","298.25","293.83","444.55","1 through 10","214.83","550.94","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","both","","","693.00","519.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","450.45","65","","361.73","361.73","361.73","1 through 10","214.83","550.94","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","both","","","693.00","519.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","214.83","31","","171.96","171.96","171.96","1 through 10","214.83","550.94","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","both","","","693.00","519.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","252.95","36.5","","207.57","179.06","271.83","1 through 10","214.83","550.94","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","both","","","693.00","519.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","265.42","38.3","","217.59","211.47","220.86","18","214.83","550.94","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","both","","","693.00","519.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","297.30","42.9","","556.50","451.56","556.50","1 through 10","214.83","550.94","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","both","","","693.00","519.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","297.30","42.9","","444.87","444.87","444.87","1 through 10","214.83","550.94","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","both","","","693.00","519.75","WELLPOINT [1015]","HB AMC WELLPOINT","511.30","73.78","","414.31","414.31","420.55","15","214.83","550.94","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","693.00","519.75","AETNA [1001]","HB AMC AETNA HMO","483.71","69.8","","376.75","270.01","580.53","30","362.16","566.32","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","693.00","519.75","AETNA [1001]","HB AMC AETNA PPO","557.17","80.4","","440.60","434.07","440.60","1 through 10","362.16","566.32","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","693.00","519.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","557.17","80.4","","434.07","434.07","440.60","1 through 10","362.16","566.32","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","693.00","519.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","566.32","81.72","","444.87","248.37","444.87","1 through 10","362.16","566.32","percent of total billed charges",""
"PORT IMPLANTABLE 6.6FR SINGLE LUMEN INFUSION LOW PROFILE TITANIUM DEVICE OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000067","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","693.00","519.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","566.32","81.72","","444.87","248.37","451.56","20","362.16","566.32","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","477.75","70","","556.50","556.50","556.50","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","542.59","79.5","","437.97","293.83","444.55","17","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","363.77","53.3","","298.25","293.83","444.55","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","443.63","65","","361.73","361.73","361.73","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","211.58","31","","171.96","171.96","171.96","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","249.11","36.5","","207.57","179.06","271.83","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.40","38.3","","217.59","211.47","220.86","18","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.79","42.9","","556.50","451.56","556.50","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.79","42.9","","444.87","444.87","444.87","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","WELLPOINT [1015]","HB AMC WELLPOINT","503.55","73.78","","414.31","414.31","420.55","15","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","AETNA [1001]","HB AMC AETNA HMO","476.39","69.8","","376.75","270.01","580.53","30","356.67","557.74","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","AETNA [1001]","HB AMC AETNA PPO","548.73","80.4","","440.60","434.07","440.60","1 through 10","356.67","557.74","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","548.73","80.4","","434.07","434.07","440.60","1 through 10","356.67","557.74","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","557.74","81.72","","444.87","248.37","444.87","1 through 10","356.67","557.74","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR 76CM INFUSION SINGLE CHAMBER TITANIUM OPEN SUTURE PLUG PREATTACHED SILICONE CATHETER SINGLE LUMEN NON COATED NON CT COMPATIBLE NON MRI SAFE NON POWER INJECTABLE SLIDE LOCK CONNECTOR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000066","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","557.74","81.72","","444.87","248.37","451.56","20","356.67","557.74","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","477.75","70","","556.50","556.50","556.50","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","542.59","79.5","","437.97","293.83","444.55","17","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","363.77","53.3","","298.25","293.83","444.55","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","443.63","65","","361.73","361.73","361.73","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","211.58","31","","171.96","171.96","171.96","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","249.11","36.5","","207.57","179.06","271.83","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.40","38.3","","217.59","211.47","220.86","18","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.79","42.9","","556.50","451.56","556.50","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.79","42.9","","444.87","444.87","444.87","1 through 10","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","both","","","682.50","511.87","WELLPOINT [1015]","HB AMC WELLPOINT","503.55","73.78","","414.31","414.31","420.55","15","211.58","542.59","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","AETNA [1001]","HB AMC AETNA HMO","476.39","69.8","","376.75","270.01","580.53","30","356.67","557.74","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","AETNA [1001]","HB AMC AETNA PPO","548.73","80.4","","440.60","434.07","440.60","1 through 10","356.67","557.74","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","548.73","80.4","","434.07","434.07","440.60","1 through 10","356.67","557.74","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","557.74","81.72","","444.87","248.37","444.87","1 through 10","356.67","557.74","percent of total billed charges",""
"PORT IMPLANTABLE 9.6FR SINGLE LUMEN MRI ATTACHABLE OPEN ENDED SILICONE CATHETER PEEL APART INTRODUCER PLASTIC","SUP-ITM-10001358","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","557.74","81.72","","444.87","248.37","451.56","20","356.67","557.74","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","both","","","1146.40","859.80","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","802.48","70","","556.50","556.50","556.50","1 through 10","355.38","911.39","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","both","","","1146.40","859.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","911.39","79.5","","437.97","293.83","444.55","17","355.38","911.39","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","both","","","1146.40","859.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","611.03","53.3","","298.25","293.83","444.55","1 through 10","355.38","911.39","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","both","","","1146.40","859.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","745.16","65","","361.73","361.73","361.73","1 through 10","355.38","911.39","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","both","","","1146.40","859.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","355.38","31","","171.96","171.96","171.96","1 through 10","355.38","911.39","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","both","","","1146.40","859.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","418.44","36.5","","207.57","179.06","271.83","1 through 10","355.38","911.39","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","both","","","1146.40","859.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","439.07","38.3","","217.59","211.47","220.86","18","355.38","911.39","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","both","","","1146.40","859.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","491.81","42.9","","556.50","451.56","556.50","1 through 10","355.38","911.39","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","both","","","1146.40","859.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","491.81","42.9","","444.87","444.87","444.87","1 through 10","355.38","911.39","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","both","","","1146.40","859.80","WELLPOINT [1015]","HB AMC WELLPOINT","845.81","73.78","","414.31","414.31","420.55","15","355.38","911.39","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1146.40","859.80","AETNA [1001]","HB AMC AETNA HMO","800.19","69.8","","376.75","270.01","580.53","30","599.11","936.84","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1146.40","859.80","AETNA [1001]","HB AMC AETNA PPO","921.71","80.4","","440.60","434.07","440.60","1 through 10","599.11","936.84","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1146.40","859.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","921.71","80.4","","434.07","434.07","440.60","1 through 10","599.11","936.84","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1146.40","859.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","936.84","81.72","","444.87","248.37","444.87","1 through 10","599.11","936.84","percent of total billed charges",""
"Port Indwelling T1","PX-27000126","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1146.40","859.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","936.84","81.72","","444.87","248.37","451.56","20","599.11","936.84","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","both","","","819.00","614.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","573.30","70","","556.50","556.50","556.50","1 through 10","253.89","651.11","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","both","","","819.00","614.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","651.11","79.5","","437.97","293.83","444.55","17","253.89","651.11","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","both","","","819.00","614.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","436.53","53.3","","298.25","293.83","444.55","1 through 10","253.89","651.11","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","both","","","819.00","614.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","532.35","65","","361.73","361.73","361.73","1 through 10","253.89","651.11","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","both","","","819.00","614.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","253.89","31","","171.96","171.96","171.96","1 through 10","253.89","651.11","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","both","","","819.00","614.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","298.94","36.5","","207.57","179.06","271.83","1 through 10","253.89","651.11","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","both","","","819.00","614.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","313.68","38.3","","217.59","211.47","220.86","18","253.89","651.11","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","both","","","819.00","614.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.35","42.9","","556.50","451.56","556.50","1 through 10","253.89","651.11","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","both","","","819.00","614.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.35","42.9","","444.87","444.87","444.87","1 through 10","253.89","651.11","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","both","","","819.00","614.25","WELLPOINT [1015]","HB AMC WELLPOINT","604.26","73.78","","414.31","414.31","420.55","15","253.89","651.11","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","AETNA [1001]","HB AMC AETNA HMO","571.66","69.8","","376.75","270.01","580.53","30","428.01","669.29","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","AETNA [1001]","HB AMC AETNA PPO","658.48","80.4","","440.60","434.07","440.60","1 through 10","428.01","669.29","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","658.48","80.4","","434.07","434.07","440.60","1 through 10","428.01","669.29","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","669.29","81.72","","444.87","248.37","444.87","1 through 10","428.01","669.29","percent of total billed charges",""
"PORT INFUSION 6FR 75CM TITANIUM LOW PROFILE SINGLE LUMEN SINGLE CHAMBER NON CT COMPATIBLE NOT MRI SAFE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10007823","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","669.29","81.72","","444.87","248.37","451.56","20","428.01","669.29","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","389.55","70","","556.50","556.50","556.50","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","442.42","79.5","","437.97","293.83","444.55","17","172.52","442.42","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","296.61","53.3","","298.25","293.83","444.55","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","361.73","65","","361.73","361.73","361.73","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","172.52","31","","171.96","171.96","171.96","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","203.12","36.5","","207.57","179.06","271.83","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","213.14","38.3","","217.59","211.47","220.86","18","172.52","442.42","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","238.74","42.9","","556.50","451.56","556.50","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","238.74","42.9","","444.87","444.87","444.87","1 through 10","172.52","442.42","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","both","","","556.50","417.37","WELLPOINT [1015]","HB AMC WELLPOINT","410.59","73.78","","414.31","414.31","420.55","15","172.52","442.42","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","556.50","417.37","AETNA [1001]","HB AMC AETNA HMO","388.44","69.8","","376.75","270.01","580.53","30","290.83","454.77","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","556.50","417.37","AETNA [1001]","HB AMC AETNA PPO","447.43","80.4","","440.60","434.07","440.60","1 through 10","290.83","454.77","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","556.50","417.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","447.43","80.4","","434.07","434.07","440.60","1 through 10","290.83","454.77","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","556.50","417.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","454.77","81.72","","444.87","248.37","444.87","1 through 10","290.83","454.77","percent of total billed charges",""
"PORT INFUSION 8FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10237536","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","556.50","417.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","454.77","81.72","","444.87","248.37","451.56","20","290.83","454.77","percent of total billed charges",""
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","1981.00","1485.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.77","427.77","1921.00","1 through 10","412.99","1574.9","other","OPPS APC"
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","1981.00","1485.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1386.70","70","","826.03","826.03","826.03","1 through 10","412.99","1574.9","percent of total billed charges",""
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","1981.00","1485.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1574.90","79.5","","1511.83","1511.83","1511.83","1 through 10","412.99","1574.9","percent of total billed charges",""
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","1981.00","1485.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1055.87","53.3","","783.12","783.12","783.12","1 through 10","412.99","1574.9","percent of total billed charges",""
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","1981.00","1485.75","MEDICARE [2001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","434.73","434.73","1304.19","19","412.99","1574.9","other","OPPS APC"
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","1981.00","1485.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","426.04","426.04","426.04","1 through 10","412.99","1574.9","other","OPPS APC"
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","1981.00","1485.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","849.85","42.9","","1535.65","1535.65","1535.65","1 through 10","412.99","1574.9","percent of total billed charges",""
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","1981.00","1485.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","426.91","426.91","427.78","1 through 10","412.99","1574.9","other","OPPS APC"
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","outpatient","","","1981.00","1485.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1618.87","81.72","","1535.65","1535.65","1535.65","1 through 10","875.35","1784.11","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1176.00","70","","556.50","556.50","556.50","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1335.60","79.5","","437.97","293.83","444.55","17","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","895.44","53.3","","298.25","293.83","444.55","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1092.00","65","","361.73","361.73","361.73","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","520.80","31","","171.96","171.96","171.96","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","613.20","36.5","","207.57","179.06","271.83","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","643.44","38.3","","217.59","211.47","220.86","18","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","720.72","42.9","","556.50","451.56","556.50","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","720.72","42.9","","444.87","444.87","444.87","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","WELLPOINT [1015]","HB AMC WELLPOINT","1239.50","73.78","","414.31","414.31","420.55","15","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","AETNA [1001]","HB AMC AETNA HMO","1172.64","69.8","","376.75","270.01","580.53","30","877.97","1372.9","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","AETNA [1001]","HB AMC AETNA PPO","1350.72","80.4","","440.60","434.07","440.60","1 through 10","877.97","1372.9","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1350.72","80.4","","434.07","434.07","440.60","1 through 10","877.97","1372.9","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1372.90","81.72","","444.87","248.37","444.87","1 through 10","877.97","1372.9","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1372.90","81.72","","444.87","248.37","451.56","20","877.97","1372.9","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1176.00","70","","556.50","556.50","556.50","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1335.60","79.5","","437.97","293.83","444.55","17","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","895.44","53.3","","298.25","293.83","444.55","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1092.00","65","","361.73","361.73","361.73","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","520.80","31","","171.96","171.96","171.96","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","613.20","36.5","","207.57","179.06","271.83","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","643.44","38.3","","217.59","211.47","220.86","18","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","720.72","42.9","","556.50","451.56","556.50","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","720.72","42.9","","444.87","444.87","444.87","1 through 10","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","both","","","1680.00","1260.00","WELLPOINT [1015]","HB AMC WELLPOINT","1239.50","73.78","","414.31","414.31","420.55","15","520.8","1335.6","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","AETNA [1001]","HB AMC AETNA HMO","1172.64","69.8","","376.75","270.01","580.53","30","877.97","1372.9","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","AETNA [1001]","HB AMC AETNA PPO","1350.72","80.4","","440.60","434.07","440.60","1 through 10","877.97","1372.9","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1350.72","80.4","","434.07","434.07","440.60","1 through 10","877.97","1372.9","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1372.90","81.72","","444.87","248.37","444.87","1 through 10","877.97","1372.9","percent of total billed charges",""
"PORT POWERPORT 9.5FR INFUSION DUAL LUMEN INTERMEDIATE PROFILE ATTACHABLE AIRGUARD VALVED INTRODUCER DUO MRI POLYURETHANE IMPLANTABLE","SUP-ITM-10050149","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1680.00","1260.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1372.90","81.72","","444.87","248.37","451.56","20","877.97","1372.9","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1029.00","70","","556.50","556.50","556.50","1 through 10","455.7","1168.65","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1168.65","79.5","","437.97","293.83","444.55","17","455.7","1168.65","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","783.51","53.3","","298.25","293.83","444.55","1 through 10","455.7","1168.65","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","955.50","65","","361.73","361.73","361.73","1 through 10","455.7","1168.65","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","455.70","31","","171.96","171.96","171.96","1 through 10","455.7","1168.65","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","536.55","36.5","","207.57","179.06","271.83","1 through 10","455.7","1168.65","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","563.01","38.3","","217.59","211.47","220.86","18","455.7","1168.65","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","556.50","451.56","556.50","1 through 10","455.7","1168.65","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","630.63","42.9","","444.87","444.87","444.87","1 through 10","455.7","1168.65","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB AMC WELLPOINT","1084.57","73.78","","414.31","414.31","420.55","15","455.7","1168.65","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA HMO","1026.06","69.8","","376.75","270.01","580.53","30","768.22","1201.28","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","AETNA [1001]","HB AMC AETNA PPO","1181.88","80.4","","440.60","434.07","440.60","1 through 10","768.22","1201.28","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1181.88","80.4","","434.07","434.07","440.60","1 through 10","768.22","1201.28","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1201.28","81.72","","444.87","248.37","444.87","1 through 10","768.22","1201.28","percent of total billed charges",""
"PORT POWERPORT CLEARVUE ISP 8FR CATHETER POLYURETHANE IMPLANTABLE SINGLE LUMEN INTERMEDIATE VALVED INTRODUCER","SUP-ITM-10137801","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1201.28","81.72","","444.87","248.37","451.56","20","768.22","1201.28","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","both","","","976.96","732.72","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","683.87","70","","556.50","556.50","556.50","1 through 10","302.86","776.68","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","both","","","976.96","732.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","776.68","79.5","","437.97","293.83","444.55","17","302.86","776.68","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","both","","","976.96","732.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","520.72","53.3","","298.25","293.83","444.55","1 through 10","302.86","776.68","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","both","","","976.96","732.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","635.02","65","","361.73","361.73","361.73","1 through 10","302.86","776.68","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","both","","","976.96","732.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","302.86","31","","171.96","171.96","171.96","1 through 10","302.86","776.68","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","both","","","976.96","732.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","356.59","36.5","","207.57","179.06","271.83","1 through 10","302.86","776.68","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","both","","","976.96","732.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","374.18","38.3","","217.59","211.47","220.86","18","302.86","776.68","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","both","","","976.96","732.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","419.12","42.9","","556.50","451.56","556.50","1 through 10","302.86","776.68","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","both","","","976.96","732.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","419.12","42.9","","444.87","444.87","444.87","1 through 10","302.86","776.68","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","both","","","976.96","732.72","WELLPOINT [1015]","HB AMC WELLPOINT","720.80","73.78","","414.31","414.31","420.55","15","302.86","776.68","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","976.96","732.72","AETNA [1001]","HB AMC AETNA HMO","681.92","69.8","","376.75","270.01","580.53","30","510.56","798.37","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","976.96","732.72","AETNA [1001]","HB AMC AETNA PPO","785.48","80.4","","440.60","434.07","440.60","1 through 10","510.56","798.37","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","976.96","732.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","785.48","80.4","","434.07","434.07","440.60","1 through 10","510.56","798.37","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","976.96","732.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","798.37","81.72","","444.87","248.37","444.87","1 through 10","510.56","798.37","percent of total billed charges",""
"PORT POWERPORT ISP 8FR INJECTABLE CLEARVIEW POLYURETHANE CATHETER IMPLANT SOFT SILICONE BODY","SUP-ITM-10147471","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","976.96","732.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","798.37","81.72","","444.87","248.37","451.56","20","510.56","798.37","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","both","","","1218.00","913.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","852.60","70","","556.50","556.50","556.50","1 through 10","377.58","968.31","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","both","","","1218.00","913.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","968.31","79.5","","437.97","293.83","444.55","17","377.58","968.31","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","both","","","1218.00","913.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","649.19","53.3","","298.25","293.83","444.55","1 through 10","377.58","968.31","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","both","","","1218.00","913.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","791.70","65","","361.73","361.73","361.73","1 through 10","377.58","968.31","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","both","","","1218.00","913.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","377.58","31","","171.96","171.96","171.96","1 through 10","377.58","968.31","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","both","","","1218.00","913.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","444.57","36.5","","207.57","179.06","271.83","1 through 10","377.58","968.31","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","both","","","1218.00","913.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","466.49","38.3","","217.59","211.47","220.86","18","377.58","968.31","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","both","","","1218.00","913.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","522.52","42.9","","556.50","451.56","556.50","1 through 10","377.58","968.31","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","both","","","1218.00","913.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","522.52","42.9","","444.87","444.87","444.87","1 through 10","377.58","968.31","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","both","","","1218.00","913.50","WELLPOINT [1015]","HB AMC WELLPOINT","898.64","73.78","","414.31","414.31","420.55","15","377.58","968.31","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1218.00","913.50","AETNA [1001]","HB AMC AETNA HMO","850.16","69.8","","376.75","270.01","580.53","30","636.53","995.35","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1218.00","913.50","AETNA [1001]","HB AMC AETNA PPO","979.27","80.4","","440.60","434.07","440.60","1 through 10","636.53","995.35","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1218.00","913.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","979.27","80.4","","434.07","434.07","440.60","1 through 10","636.53","995.35","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1218.00","913.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","995.35","81.72","","444.87","248.37","444.87","1 through 10","636.53","995.35","percent of total billed charges",""
"PORT POWERPORT MRI 8FR CATHETER IMPLANTABLE INFUSION STD PROFILE SINGLE CHAMBER SILICONE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE POWER INJECTABLE SLIDE LOCK CONNECTOR NON VALVED","SUP-ITM-10021928","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1218.00","913.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","995.35","81.72","","444.87","248.37","451.56","20","636.53","995.35","percent of total billed charges",""
"Port Reposition","PX-76002788","CDM","37799","CPT","0761","RC","","","","outpatient","","","3107.00","2330.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1622.48","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","2563.28","percent of total billed charges",""
"Port Reposition","PX-76002788","CDM","37799","CPT","0761","RC","","","","outpatient","","","3107.00","2330.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1631.18","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","2563.28","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","both","","","647.50","485.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","453.25","70","","556.50","556.50","556.50","1 through 10","200.73","514.76","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","both","","","647.50","485.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","514.76","79.5","","437.97","293.83","444.55","17","200.73","514.76","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","both","","","647.50","485.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","345.12","53.3","","298.25","293.83","444.55","1 through 10","200.73","514.76","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","both","","","647.50","485.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","420.88","65","","361.73","361.73","361.73","1 through 10","200.73","514.76","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","both","","","647.50","485.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","200.73","31","","171.96","171.96","171.96","1 through 10","200.73","514.76","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","both","","","647.50","485.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","236.34","36.5","","207.57","179.06","271.83","1 through 10","200.73","514.76","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","both","","","647.50","485.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","247.99","38.3","","217.59","211.47","220.86","18","200.73","514.76","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","both","","","647.50","485.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.78","42.9","","556.50","451.56","556.50","1 through 10","200.73","514.76","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","both","","","647.50","485.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.78","42.9","","444.87","444.87","444.87","1 through 10","200.73","514.76","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","both","","","647.50","485.62","WELLPOINT [1015]","HB AMC WELLPOINT","477.73","73.78","","414.31","414.31","420.55","15","200.73","514.76","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","AETNA [1001]","HB AMC AETNA HMO","451.96","69.8","","376.75","270.01","580.53","30","338.38","529.14","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","AETNA [1001]","HB AMC AETNA PPO","520.59","80.4","","440.60","434.07","440.60","1 through 10","338.38","529.14","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","520.59","80.4","","434.07","434.07","440.60","1 through 10","338.38","529.14","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","529.14","81.72","","444.87","248.37","444.87","1 through 10","338.38","529.14","percent of total billed charges",""
"PORT VAS-CATH 6FR 60CM INFUSION TITANIUM LOW PROFILE VACCESS CT POWER INJECTABLE POLYURETHANE CATHETER SILICONE FILLED SUTURE PLUG INTERMEDIATE TRAY VACCESS CT","SUP-ITM-10100935","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","529.14","81.72","","444.87","248.37","451.56","20","338.38","529.14","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","both","","","1249.50","937.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","874.65","70","","556.50","556.50","556.50","1 through 10","387.35","993.35","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","both","","","1249.50","937.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","993.35","79.5","","437.97","293.83","444.55","17","387.35","993.35","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","both","","","1249.50","937.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","665.98","53.3","","298.25","293.83","444.55","1 through 10","387.35","993.35","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","both","","","1249.50","937.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","812.18","65","","361.73","361.73","361.73","1 through 10","387.35","993.35","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","both","","","1249.50","937.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","387.35","31","","171.96","171.96","171.96","1 through 10","387.35","993.35","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","both","","","1249.50","937.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","456.07","36.5","","207.57","179.06","271.83","1 through 10","387.35","993.35","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","both","","","1249.50","937.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","478.56","38.3","","217.59","211.47","220.86","18","387.35","993.35","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","both","","","1249.50","937.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","536.04","42.9","","556.50","451.56","556.50","1 through 10","387.35","993.35","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","both","","","1249.50","937.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","536.04","42.9","","444.87","444.87","444.87","1 through 10","387.35","993.35","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","both","","","1249.50","937.12","WELLPOINT [1015]","HB AMC WELLPOINT","921.88","73.78","","414.31","414.31","420.55","15","387.35","993.35","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1249.50","937.12","AETNA [1001]","HB AMC AETNA HMO","872.15","69.8","","376.75","270.01","580.53","30","652.99","1021.09","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1249.50","937.12","AETNA [1001]","HB AMC AETNA PPO","1004.60","80.4","","440.60","434.07","440.60","1 through 10","652.99","1021.09","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1249.50","937.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1004.60","80.4","","434.07","434.07","440.60","1 through 10","652.99","1021.09","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1249.50","937.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1021.09","81.72","","444.87","248.37","444.87","1 through 10","652.99","1021.09","percent of total billed charges",""
"PORT VASCULAR 8FR TI SMARTPORT PLUS STD VORTEX ATTACHED CATHETER BIOFLO VI INTRODUCER H787CT80STBDNFVI0 BX/1EA","SUP-ITM-10275105","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1249.50","937.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1021.09","81.72","","444.87","248.37","451.56","20","652.99","1021.09","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2249.10","70","","556.50","556.50","556.50","1 through 10","996.03","2554.34","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2554.34","79.5","","437.97","293.83","444.55","17","996.03","2554.34","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1712.53","53.3","","298.25","293.83","444.55","1 through 10","996.03","2554.34","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2088.45","65","","361.73","361.73","361.73","1 through 10","996.03","2554.34","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","996.03","31","","171.96","171.96","171.96","1 through 10","996.03","2554.34","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1172.75","36.5","","207.57","179.06","271.83","1 through 10","996.03","2554.34","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1230.58","38.3","","217.59","211.47","220.86","18","996.03","2554.34","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1378.38","42.9","","556.50","451.56","556.50","1 through 10","996.03","2554.34","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1378.38","42.9","","444.87","444.87","444.87","1 through 10","996.03","2554.34","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","both","","","3213.00","2409.75","WELLPOINT [1015]","HB AMC WELLPOINT","2370.55","73.78","","414.31","414.31","420.55","15","996.03","2554.34","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","3213.00","2409.75","AETNA [1001]","HB AMC AETNA HMO","2242.67","69.8","","376.75","270.01","580.53","30","1679.11","2625.66","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","3213.00","2409.75","AETNA [1001]","HB AMC AETNA PPO","2583.25","80.4","","440.60","434.07","440.60","1 through 10","1679.11","2625.66","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","3213.00","2409.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2583.25","80.4","","434.07","434.07","440.60","1 through 10","1679.11","2625.66","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","3213.00","2409.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2625.66","81.72","","444.87","248.37","444.87","1 through 10","1679.11","2625.66","percent of total billed charges",""
"PORT VORTEX 9.6FR 10FR VASCULAR INTRODUCER SINGLE LUMEN TITA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137792","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","3213.00","2409.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2625.66","81.72","","444.87","248.37","451.56","20","1679.11","2625.66","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","both","","","1239.00","929.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","867.30","70","","556.50","556.50","556.50","1 through 10","384.09","985.01","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","both","","","1239.00","929.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","985.01","79.5","","437.97","293.83","444.55","17","384.09","985.01","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","both","","","1239.00","929.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","660.39","53.3","","298.25","293.83","444.55","1 through 10","384.09","985.01","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","both","","","1239.00","929.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","805.35","65","","361.73","361.73","361.73","1 through 10","384.09","985.01","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","both","","","1239.00","929.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","384.09","31","","171.96","171.96","171.96","1 through 10","384.09","985.01","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","both","","","1239.00","929.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","452.24","36.5","","207.57","179.06","271.83","1 through 10","384.09","985.01","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","both","","","1239.00","929.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","474.54","38.3","","217.59","211.47","220.86","18","384.09","985.01","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","both","","","1239.00","929.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","531.53","42.9","","556.50","451.56","556.50","1 through 10","384.09","985.01","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","both","","","1239.00","929.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","531.53","42.9","","444.87","444.87","444.87","1 through 10","384.09","985.01","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","both","","","1239.00","929.25","WELLPOINT [1015]","HB AMC WELLPOINT","914.13","73.78","","414.31","414.31","420.55","15","384.09","985.01","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1239.00","929.25","AETNA [1001]","HB AMC AETNA HMO","864.82","69.8","","376.75","270.01","580.53","30","647.5","1012.51","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1239.00","929.25","AETNA [1001]","HB AMC AETNA PPO","996.16","80.4","","440.60","434.07","440.60","1 through 10","647.5","1012.51","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1239.00","929.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","996.16","80.4","","434.07","434.07","440.60","1 through 10","647.5","1012.51","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1239.00","929.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1012.51","81.72","","444.87","248.37","444.87","1 through 10","647.5","1012.51","percent of total billed charges",""
"PORT XCELA INFUSION 6.6FR 75CM INJECTABLE STANDARD PROFILE SINGLE CHAMBER TITANIUM DEVICE FILLED SUTURE PLUG ATTACHABLE POLYURETHANE CATHETER SINGLE LUMEN NON COATED CT COMPATIBLE MRI SAFE POWER TWIST LOCK CONNECTOR NON VALVED OPEN-ENDED TIP B","SUP-ITM-10048257","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1239.00","929.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1012.51","81.72","","444.87","248.37","451.56","20","647.5","1012.51","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","230.61","79.5","","800.18","480.96","1887.97","195","89.92","230.61","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","154.61","53.3","","813.12","216.42","1444.50","81","89.92","230.61","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","89.92","31","","432.60","432.60","432.60","1 through 10","89.92","230.61","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.88","36.5","","148.37","54.89","631.39","94","89.92","230.61","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","111.10","38.3","","279.30","91.72","1116.77","266","89.92","230.61","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.44","42.9","","731.00","63.70","731.00","1 through 10","89.92","230.61","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.44","42.9","","384.74","384.74","384.74","1 through 10","89.92","230.61","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","WELLPOINT [1015]","HB AMC WELLPOINT","214.02","73.78","","286.63","119.22","1107.45","105","89.92","230.61","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.08","217.56","AETNA [1001]","HB AMC AETNA HMO","202.48","69.8","","675.31","184.75","1721.50","286","151.6","237.05","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.08","217.56","AETNA [1001]","HB AMC AETNA PPO","233.22","80.4","","1261.44","103.12","1514.10","21","151.6","237.05","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.08","217.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","233.22","80.4","","1365.00","1365.00","1365.00","1 through 10","151.6","237.05","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.08","217.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","237.05","81.72","","5157.68","5157.68","5157.68","1 through 10","151.6","237.05","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.08","217.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","237.05","81.72","","431.26","71.26","1459.57","88","151.6","237.05","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.20","239.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","253.76","79.5","","800.18","480.96","1887.97","195","98.95","253.76","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.20","239.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","170.13","53.3","","813.12","216.42","1444.50","81","98.95","253.76","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.20","239.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","98.95","31","","432.60","432.60","432.60","1 through 10","98.95","253.76","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.20","239.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","116.51","36.5","","148.37","54.89","631.39","94","98.95","253.76","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.20","239.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","122.25","38.3","","279.30","91.72","1116.77","266","98.95","253.76","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.20","239.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","136.94","42.9","","731.00","63.70","731.00","1 through 10","98.95","253.76","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.20","239.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","136.94","42.9","","384.74","384.74","384.74","1 through 10","98.95","253.76","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.20","239.40","WELLPOINT [1015]","HB AMC WELLPOINT","235.51","73.78","","286.63","119.22","1107.45","105","98.95","253.76","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","319.20","239.40","AETNA [1001]","HB AMC AETNA HMO","222.80","69.8","","675.31","184.75","1721.50","286","166.81","260.85","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","319.20","239.40","AETNA [1001]","HB AMC AETNA PPO","256.64","80.4","","1261.44","103.12","1514.10","21","166.81","260.85","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","319.20","239.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","256.64","80.4","","1365.00","1365.00","1365.00","1 through 10","166.81","260.85","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","319.20","239.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","260.85","81.72","","5157.68","5157.68","5157.68","1 through 10","166.81","260.85","percent of total billed charges",""
"POST 11MM 90DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10039489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","319.20","239.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","260.85","81.72","","431.26","71.26","1459.57","88","166.81","260.85","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","230.61","79.5","","800.18","480.96","1887.97","195","89.92","230.61","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","154.61","53.3","","813.12","216.42","1444.50","81","89.92","230.61","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","89.92","31","","432.60","432.60","432.60","1 through 10","89.92","230.61","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.88","36.5","","148.37","54.89","631.39","94","89.92","230.61","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","111.10","38.3","","279.30","91.72","1116.77","266","89.92","230.61","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.44","42.9","","731.00","63.70","731.00","1 through 10","89.92","230.61","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.44","42.9","","384.74","384.74","384.74","1 through 10","89.92","230.61","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.08","217.56","WELLPOINT [1015]","HB AMC WELLPOINT","214.02","73.78","","286.63","119.22","1107.45","105","89.92","230.61","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.08","217.56","AETNA [1001]","HB AMC AETNA HMO","202.48","69.8","","675.31","184.75","1721.50","286","151.6","237.05","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.08","217.56","AETNA [1001]","HB AMC AETNA PPO","233.22","80.4","","1261.44","103.12","1514.10","21","151.6","237.05","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.08","217.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","233.22","80.4","","1365.00","1365.00","1365.00","1 through 10","151.6","237.05","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.08","217.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","237.05","81.72","","5157.68","5157.68","5157.68","1 through 10","151.6","237.05","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.08","217.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","237.05","81.72","","431.26","71.26","1459.57","88","151.6","237.05","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","both","","","910.00","682.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","475.57","52.26","","1113.10","1113.10","1113.10","1 through 10","282.1","723.45","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","both","","","910.00","682.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","723.45","79.5","","1293.60","1148.53","1603.80","1 through 10","282.1","723.45","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","both","","","910.00","682.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","332.15","36.5","","1023.42","771.29","2068.67","33","282.1","723.45","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","both","","","910.00","682.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","348.53","38.3","","850.52","759.78","1211.25","66","282.1","723.45","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","both","","","910.00","682.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","390.39","42.9","","2548.09","2548.09","2548.09","1 through 10","282.1","723.45","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","both","","","910.00","682.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","390.39","42.9","","956.46","956.46","956.46","1 through 10","282.1","723.45","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","both","","","910.00","682.50","WELLPOINT [1015]","HB AMC WELLPOINT","671.40","73.78","","2344.73","1619.47","2530.35","16","282.1","723.45","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","910.00","682.50","AETNA [1001]","HB AMC AETNA HMO","635.18","69.8","","1523.63","988.41","4330.26","39","475.57","743.65","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","910.00","682.50","AETNA [1001]","HB AMC AETNA PPO","731.64","80.4","","1670.25","1670.25","1670.25","1 through 10","475.57","743.65","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","910.00","682.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","475.57","52.26","","1113.10","1113.10","1113.10","1 through 10","475.57","743.65","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","910.00","682.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","743.65","81.72","","1738.90","1484.65","2716.94","38","475.57","743.65","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","1141.00","855.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","596.29","52.26","","1113.10","1113.10","1113.10","1 through 10","353.71","907.1","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","1141.00","855.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","907.10","79.5","","1293.60","1148.53","1603.80","1 through 10","353.71","907.1","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","1141.00","855.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","416.47","36.5","","1023.42","771.29","2068.67","33","353.71","907.1","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","1141.00","855.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","437.00","38.3","","850.52","759.78","1211.25","66","353.71","907.1","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","1141.00","855.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","489.49","42.9","","2548.09","2548.09","2548.09","1 through 10","353.71","907.1","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","1141.00","855.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","489.49","42.9","","956.46","956.46","956.46","1 through 10","353.71","907.1","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","1141.00","855.75","WELLPOINT [1015]","HB AMC WELLPOINT","841.83","73.78","","2344.73","1619.47","2530.35","16","353.71","907.1","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1141.00","855.75","AETNA [1001]","HB AMC AETNA HMO","796.42","69.8","","1523.63","988.41","4330.26","39","596.29","932.43","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1141.00","855.75","AETNA [1001]","HB AMC AETNA PPO","917.36","80.4","","1670.25","1670.25","1670.25","1 through 10","596.29","932.43","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1141.00","855.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","596.29","52.26","","1113.10","1113.10","1113.10","1 through 10","596.29","932.43","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1141.00","855.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","932.43","81.72","","1738.90","1484.65","2716.94","38","596.29","932.43","percent of total billed charges",""
"Post Tib Neurostimulation Prq Needle Electrode","PX-98301710","CDM","64566","CPT","0983","RC","","","","both","","","162.00","121.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","17","50.22","438.15","other","OPPS APC"
"Post Tib Neurostimulation Prq Needle Electrode","PX-98301710","CDM","64566","CPT","0983","RC","","","","both","","","162.00","121.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","316.79","345.12","1 through 10","50.22","438.15","other","OPPS APC"
"Post Tib Neurostimulation Prq Needle Electrode","PX-98301710","CDM","64566","CPT","0983","RC","","","","both","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.56","350.56","350.56","1 through 10","50.22","438.15","other","OPPS APC"
"Post-Extraction Dental Bleeding Control, Any Method","PX-76002959","CDM","41899","CPT","0761","RC","","","","outpatient","","","556.00","417.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","336.66","60.55","","481.00","481.00","481.00","1 through 10","278","700.33","percent of total billed charges",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,EXTREME","711","DRG","","","","","","","","inpatient","","","269877.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","133264.32","","Standard inlier is a Case rate ($133,264.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $115,279, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,917.67) for the length of stay and the standard reimbursement.","121475.28","121475.28","121475.28","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,EXTREME","711","DRG","","","","","","","","inpatient","","","269877.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","149825.02","","Standard inlier is a Case rate ($149,825.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $115,279, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($21,266.42) for the length of stay and the standard reimbursement.","136878.09","136878.09","149825.01","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MAJOR","711","DRG","","","","","","","","inpatient","","","142877.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","70965.86","","Standard inlier is a Case rate ($70,965.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $66,833, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,074.03) for the length of stay and the standard reimbursement.","72900.46","72900.46","72900.46","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MAJOR","711","DRG","","","","","","","","inpatient","","","142877.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","79784.75","","Standard inlier is a Case rate ($79,784.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $66,833, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,324.78) for the length of stay and the standard reimbursement.","79784.74","79784.74","104543.08","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MAJOR","711","DRG","","","","","","","","inpatient","","","142877.46","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","28054.027","","Fee schedule rate ($73,971.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28054.027","74506.94","74506.94","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MAJOR","711","DRG","","","","","","","","inpatient","","","142877.46","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","26717.3815","","Fee schedule rate ($70,447.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26717.3815","70447.12","70447.12","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MAJOR","711","DRG","","","","","","","","inpatient","","","142877.46","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","73971.51","","Fee schedule rate ($73,971.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","73971.51","73971.51","73971.51","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MAJOR","711","DRG","","","","","","","","inpatient","","","142877.46","","MASSHEALTH [3001]","HB BWH MEDICAID","25303.41","","Case rate ($27,977.27). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,407.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31202.42","31202.42","31202.42","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MAJOR","711","DRG","","","","","","","","inpatient","","","142877.46","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","25303.41","","Case rate ($27,977.27). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,407.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MAJOR","711","DRG","","","","","","","","inpatient","","","142877.46","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78073.78","","Fee schedule rate ($78,073.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","75798.93","75798.93","75798.93","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MINOR","711","DRG","","","","","","","","inpatient","","","53995.18","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","42945.61","","Standard inlier is a Case rate ($42,945.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,044, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,096.39) for the length of stay and the standard reimbursement.","29936.94","29936.94","29936.94","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MINOR","711","DRG","","","","","","","","inpatient","","","53995.18","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","48282.44","","Standard inlier is a Case rate ($48,282.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,044, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,853.29) for the length of stay and the standard reimbursement.","36923.58","36923.58","36923.58","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MODERATE","711","DRG","","","","","","","","inpatient","","","86863.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","42945.61","","Standard inlier is a Case rate ($42,945.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,044, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,096.39) for the length of stay and the standard reimbursement.","56357.05","56357.05","56357.05","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MODERATE","711","DRG","","","","","","","","inpatient","","","86863.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","48282.44","","Standard inlier is a Case rate ($48,282.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,044, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,853.29) for the length of stay and the standard reimbursement.","44110.18","25931.95","48282.44","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MODERATE","711","DRG","","","","","","","","inpatient","","","86863.72","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","28054.027","","Fee schedule rate ($73,971.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28054.027","40846.84","40846.84","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MODERATE","711","DRG","","","","","","","","inpatient","","","86863.72","","MASSHEALTH [3001]","HB BWH MEDICAID","14404.09","","Case rate ($15,926.20). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,356.20, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15922.29","15922.29","15922.29","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MODERATE","711","DRG","","","","","","","","inpatient","","","86863.72","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78073.78","","Fee schedule rate ($78,073.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","45716.39","45716.39","45716.39","1 through 10","14404.09","256275.26","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,EXTREME","721","DRG","","","","","","","","inpatient","","","143702.92","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","65173.58","","Standard inlier is a Case rate ($65,173.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $62,330, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,251.78) for the length of stay and the standard reimbursement.","73272.67","59408.09","126569.95","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,EXTREME","721","DRG","","","","","","","","inpatient","","","143702.92","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","73272.67","","Standard inlier is a Case rate ($73,272.67). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $62,330, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,400.45) for the length of stay and the standard reimbursement.","73272.67","66940.91","75215.30","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,EXTREME","721","DRG","","","","","","","","inpatient","","","143702.92","","MASSHEALTH [3001]","HB BWH MEDICAID","25710.09","","Case rate ($28,426.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,856.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,393.65 and the sum of the standard inlier and any outlier amount.","97338.93","97338.93","97338.93","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,EXTREME","721","DRG","","","","","","","","inpatient","","","143702.92","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","25710.09","","Case rate ($28,426.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $70,856.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,393.65 and the sum of the standard inlier and any outlier amount.","28419.95","28419.95","28419.95","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","59135.14","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","36373.92","","Standard inlier is a Case rate ($36,373.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,933, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,163.50) for the length of stay and the standard reimbursement.","36373.92","36373.92","36373.92","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","59135.14","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","40894.09","","Standard inlier is a Case rate ($40,894.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,933, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,804.58) for the length of stay and the standard reimbursement.","37360.28","4731.61","40894.09","11","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","59135.14","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","52328.25","52328.25","52328.25","1 through 10","5974.57","116239.14","percent of total billed charges",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","59135.14","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14695.119","","Fee schedule rate ($70,447.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14695.119","32544.00","32544.00","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","59135.14","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","26717.3815","","Fee schedule rate ($70,447.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26717.3815","32544.00","32544.00","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","59135.14","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","15430.302","","Fee schedule rate ($73,971.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15430.302","32853.92","32853.92","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","59135.14","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","28054.027","","Fee schedule rate ($73,971.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28054.027","32853.92","32853.92","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","59135.14","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","39672.02","","Fee schedule rate ($39,672.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","39672.02","39672.02","39672.02","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","59135.14","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12956.72","","Case rate ($14,325.88). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,755.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14322.36","14322.36","14322.36","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MINOR","721","DRG","","","","","","","","inpatient","","","29910.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","17499.72","","Standard inlier is a Case rate ($17,499.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,257, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,484.19) for the length of stay and the standard reimbursement.","17499.71","17499.71","17499.71","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MINOR","721","DRG","","","","","","","","inpatient","","","29910.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","19674.40","","Standard inlier is a Case rate ($19,674.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,257, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,792.62) for the length of stay and the standard reimbursement.","19674.39","17974.25","19674.39","11","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MINOR","721","DRG","","","","","","","","inpatient","","","29910.53","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","15430.302","","Fee schedule rate ($15,430.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15430.302","16164.83","16164.83","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MINOR","721","DRG","","","","","","","","inpatient","","","29910.53","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","28054.027","","Fee schedule rate ($15,430.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28054.027","16164.83","16164.83","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MINOR","721","DRG","","","","","","","","inpatient","","","29910.53","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","15430.302","","Fee schedule rate ($15,430.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15430.302","14835.08","14835.08","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MINOR","721","DRG","","","","","","","","inpatient","","","29910.53","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","28054.027","","Fee schedule rate ($15,430.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28054.027","14835.08","14835.08","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MINOR","721","DRG","","","","","","","","inpatient","","","29910.53","","MASSHEALTH [3001]","HB BWH MEDICAID","5974.57","","Case rate ($6,605.92). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,035.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","942.32","942.32","942.32","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","36532.02","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","23065.60","","Standard inlier is a Case rate ($23,065.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,583, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,274.30) for the length of stay and the standard reimbursement.","23065.60","21025.13","23065.60","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","36532.02","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25931.95","","Standard inlier is a Case rate ($25,931.95). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,583, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,680.83) for the length of stay and the standard reimbursement.","23691.07","3000.43","25931.95","14","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","36532.02","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","43281.83","43281.83","43281.83","1 through 10","5974.57","116239.14","percent of total billed charges",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","36532.02","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14695.119","","Fee schedule rate ($32,543.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14695.119","20450.16","20450.16","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","36532.02","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","26717.3815","","Fee schedule rate ($32,543.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26717.3815","20450.16","20450.16","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","36532.02","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","15430.302","","Fee schedule rate ($34,172.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15430.302","21473.25","21473.25","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","36532.02","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","28054.027","","Fee schedule rate ($34,172.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28054.027","21473.25","21473.25","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","36532.02","","MASSHEALTH [3001]","HB BWH MEDICAID","7452.80","","Case rate ($8,240.35). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,670.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8238.32","8238.32","8238.32","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","36532.02","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","41656.27","","Fee schedule rate ($41,656.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25856.70","25856.70","25856.70","1 through 10","5974.57","116239.14","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","36532.02","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7452.80","","Case rate ($8,240.35). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,670.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8238.32","8238.32","8238.32","1 through 10","5974.57","116239.14","case rate",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3284.12","2463.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2610.88","79.5","","800.18","480.96","1887.97","195","1018.08","2610.88","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3284.12","2463.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1750.44","53.3","","813.12","216.42","1444.50","81","1018.08","2610.88","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3284.12","2463.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1018.08","31","","432.60","432.60","432.60","1 through 10","1018.08","2610.88","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3284.12","2463.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1198.70","36.5","","148.37","54.89","631.39","94","1018.08","2610.88","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3284.12","2463.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1257.82","38.3","","279.30","91.72","1116.77","266","1018.08","2610.88","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3284.12","2463.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1408.89","42.9","","731.00","63.70","731.00","1 through 10","1018.08","2610.88","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3284.12","2463.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1408.89","42.9","","384.74","384.74","384.74","1 through 10","1018.08","2610.88","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3284.12","2463.09","WELLPOINT [1015]","HB AMC WELLPOINT","2423.02","73.78","","286.63","119.22","1107.45","105","1018.08","2610.88","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3284.12","2463.09","AETNA [1001]","HB AMC AETNA HMO","2292.32","69.8","","675.31","184.75","1721.50","286","1716.28","2683.78","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3284.12","2463.09","AETNA [1001]","HB AMC AETNA PPO","2640.43","80.4","","1261.44","103.12","1514.10","21","1716.28","2683.78","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3284.12","2463.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2640.43","80.4","","1365.00","1365.00","1365.00","1 through 10","1716.28","2683.78","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3284.12","2463.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2683.78","81.72","","5157.68","5157.68","5157.68","1 through 10","1716.28","2683.78","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3284.12","2463.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2683.78","81.72","","431.26","71.26","1459.57","88","1716.28","2683.78","percent of total billed charges",""
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","59135.14","44351.35","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","17526.29","","Case rate ($17,015.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,406.28, add-ons for qualifying new technology services are included. If operating cost exceeds $66,050.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,907.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,168.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,026.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,467.46. The transfer capital threshold is the transfer adjustment factor * $1,467.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10421.43","10421.43","10421.43","1 through 10","16675.5","27747.8217","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","59135.14","44351.35","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","17015.82","","Case rate ($17,015.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,406.28, add-ons for qualifying new technology services are included. If operating cost exceeds $66,050.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,907.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,168.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,026.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,467.46. The transfer capital threshold is the transfer adjustment factor * $1,467.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16862.00","16862.00","16862.00","1 through 10","16675.5","27747.8217","other","Inpatient Replacement Plans DRG"
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","59135.14","44351.35","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","17015.82","","Case rate ($17,015.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,406.28, add-ons for qualifying new technology services are included. If operating cost exceeds $66,050.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,907.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,168.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,026.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,467.46. The transfer capital threshold is the transfer adjustment factor * $1,467.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16628.23","16628.23","16661.93","1 through 10","16675.5","27747.8217","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","59135.14","44351.35","HUMANA [1012]","HB BWH MEDICARE","17015.82","","Case rate ($17,015.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,406.28, add-ons for qualifying new technology services are included. If operating cost exceeds $66,050.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,907.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,168.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,026.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,467.46. The transfer capital threshold is the transfer adjustment factor * $1,467.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16706.87","16706.87","16706.87","1 through 10","16675.5","27747.8217","other","Inpatient Replacement Plans DRG"
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","59135.14","44351.35","MEDICARE [2001]","HB BWH MEDICARE","17015.82","","Case rate ($17,015.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,406.28, add-ons for qualifying new technology services are included. If operating cost exceeds $66,050.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,907.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,168.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,026.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,467.46. The transfer capital threshold is the transfer adjustment factor * $1,467.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21955.00","0.03","21987.43","23","16675.5","27747.8217","other","Inpatient Replacement Plans DRG"
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","59135.14","44351.35","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","17015.82","","Case rate ($17,015.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,406.28, add-ons for qualifying new technology services are included. If operating cost exceeds $66,050.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,907.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,168.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,026.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,467.46. The transfer capital threshold is the transfer adjustment factor * $1,467.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13139.07","13139.07","13139.07","1 through 10","16675.5","27747.8217","other","Inpatient Replacement Plans DRG"
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","59135.14","44351.35","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16675.50","","Case rate ($17,015.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,406.28, add-ons for qualifying new technology services are included. If operating cost exceeds $66,050.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,907.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,168.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,026.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,467.46. The transfer capital threshold is the transfer adjustment factor * $1,467.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13463.32","13463.32","16913.06","1 through 10","16675.5","27747.8217","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","59135.14","44351.35","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16675.50","","Case rate ($17,015.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,406.28, add-ons for qualifying new technology services are included. If operating cost exceeds $66,050.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,907.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,168.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,026.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,467.46. The transfer capital threshold is the transfer adjustment factor * $1,467.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16689.83","16628.31","16767.74","1 through 10","16675.5","27747.8217","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","35844.87","26883.65","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9482.79","","Case rate ($9,482.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,337.99, add-ons for qualifying new technology services are included. If operating cost exceeds $56,982.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,243.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,299.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,958.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $802.97. The transfer capital threshold is the transfer adjustment factor * $802.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9252.26","9252.26","9252.26","1 through 10","9293.13","15631.11","other","Inpatient Replacement Plans DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","35844.87","26883.65","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9482.79","","Case rate ($9,482.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,337.99, add-ons for qualifying new technology services are included. If operating cost exceeds $56,982.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,243.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,299.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,958.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $802.97. The transfer capital threshold is the transfer adjustment factor * $802.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9255.65","9255.65","9255.65","1 through 10","9293.13","15631.11","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","35844.87","26883.65","HUMANA [1012]","HB BWH MEDICARE","9482.79","","Case rate ($9,482.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,337.99, add-ons for qualifying new technology services are included. If operating cost exceeds $56,982.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,243.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,299.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,958.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $802.97. The transfer capital threshold is the transfer adjustment factor * $802.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9194.65","9194.65","9194.65","1 through 10","9293.13","15631.11","other","Inpatient Replacement Plans DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","35844.87","26883.65","MARTIN'S POINT [160007]","HB BWH MEDICARE","9482.79","","Case rate ($9,482.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,337.99, add-ons for qualifying new technology services are included. If operating cost exceeds $56,982.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,243.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,299.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,958.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $802.97. The transfer capital threshold is the transfer adjustment factor * $802.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9187.70","9187.70","9187.70","1 through 10","9293.13","15631.11","other","Inpatient Replacement Plans DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","35844.87","26883.65","MEDICARE [2001]","HB BWH MEDICARE","9482.79","","Case rate ($9,482.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,337.99, add-ons for qualifying new technology services are included. If operating cost exceeds $56,982.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,243.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,299.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,958.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $802.97. The transfer capital threshold is the transfer adjustment factor * $802.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12066.24","0.03","12083.89","29","9293.13","15631.11","other","Inpatient Replacement Plans DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","35844.87","26883.65","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","9482.79","","Case rate ($9,482.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,337.99, add-ons for qualifying new technology services are included. If operating cost exceeds $56,982.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,243.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,299.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,958.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $802.97. The transfer capital threshold is the transfer adjustment factor * $802.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","143.19","143.19","143.19","1 through 10","9293.13","15631.11","other","Inpatient Replacement Plans DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","35844.87","26883.65","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9293.13","","Case rate ($9,482.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,337.99, add-ons for qualifying new technology services are included. If operating cost exceeds $56,982.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,243.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,299.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,958.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $802.97. The transfer capital threshold is the transfer adjustment factor * $802.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9206.79","0.03","9225.77","1 through 10","9293.13","15631.11","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","","","","inpatient","","","101368.48","76026.36","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","25732.90","","Case rate ($25,732.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,896.11, add-ons for qualifying new technology services are included. If operating cost exceeds $69,540.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,163.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $23,629.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,516.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,723.18. The transfer capital threshold is the transfer adjustment factor * $1,723.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19838.94","19838.94","19838.94","1 through 10","19516.53","32881.7799","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","","","","inpatient","","","101368.48","76026.36","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","19914.83","","Case rate ($19,914.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,896.11, add-ons for qualifying new technology services are included. If operating cost exceeds $69,540.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,163.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $17,811.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,516.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,723.18. The transfer capital threshold is the transfer adjustment factor * $1,723.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19681.18","19681.18","19681.18","1 through 10","19516.53","32881.7799","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","","","","inpatient","","","101368.48","76026.36","MEDICARE [2001]","HB BWH MEDICARE","25732.90","","Case rate ($25,732.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,896.11, add-ons for qualifying new technology services are included. If operating cost exceeds $69,540.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,163.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $23,629.88 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,516.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,723.18. The transfer capital threshold is the transfer adjustment factor * $1,723.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25965.67","0.03","26004.09","16","19516.53","32881.7799","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","","","","inpatient","","","101368.48","76026.36","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19516.53","","Case rate ($19,914.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,896.11, add-ons for qualifying new technology services are included. If operating cost exceeds $69,540.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,163.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $17,811.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,516.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,723.18. The transfer capital threshold is the transfer adjustment factor * $1,723.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19825.22","19720.14","28823.85","1 through 10","19516.53","32881.7799","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","","","","inpatient","","","101368.48","76026.36","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19516.53","","Case rate ($19,914.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,896.11, add-ons for qualifying new technology services are included. If operating cost exceeds $69,540.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,163.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $17,811.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,516.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,723.18. The transfer capital threshold is the transfer adjustment factor * $1,723.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","30996.84","28197.61","50349.63","1 through 10","19516.53","32881.7799","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC","856","MS-DRG","","","","","","","","inpatient","","","199674.88","149756.16","MEDICARE [2001]","HB BWH MEDICARE","41873.56","","Case rate ($41,873.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,330.10, add-ons for qualifying new technology services are included. If operating cost exceeds $95,974.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,100.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $37,833.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,950.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,660.15. The transfer capital threshold is the transfer adjustment factor * $3,660.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","46599.71","0.03","53545.79","14","41036.09","68644.4317","other","Inpatient Replacement Plans DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC","856","MS-DRG","","","","","","","","inpatient","","","199674.88","149756.16","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","41036.09","","Case rate ($41,873.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,330.10, add-ons for qualifying new technology services are included. If operating cost exceeds $95,974.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,100.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $37,833.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,950.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,660.15. The transfer capital threshold is the transfer adjustment factor * $3,660.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","288254.45","288254.45","288254.45","1 through 10","41036.09","68644.4317","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC","856","MS-DRG","","","","","","","","inpatient","","","199674.88","149756.16","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","41036.09","","Case rate ($41,873.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $50,330.10, add-ons for qualifying new technology services are included. If operating cost exceeds $95,974.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,100.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $37,833.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,950.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,660.15. The transfer capital threshold is the transfer adjustment factor * $3,660.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","44903.08","44903.08","114655.82","1 through 10","41036.09","68644.4317","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/McC","858","MS-DRG","","","","","","","","inpatient","","","68701.01","51525.76","MEDICARE [2001]","HB BWH MEDICARE","13086.03","","Case rate ($13,086.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,675.58, add-ons for qualifying new technology services are included. If operating cost exceeds $61,320.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,560.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,585.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,295.74 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,120.81. The transfer capital threshold is the transfer adjustment factor * $1,120.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15490.15","15490.15","15490.15","1 through 10","12824.31","19367.7894","other","Inpatient Replacement Plans DRG"
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","","","","inpatient","","","17082.23","12811.67","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","208.36","208.36","208.36","1 through 10","6225.04","10255.22","case rate",""
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","","","","inpatient","","","17082.23","12811.67","MEDICARE [2001]","HB BWH MEDICARE","6352.08","","Case rate ($6,352.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,569.24, add-ons for qualifying new technology services are included. If operating cost exceeds $53,213.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,966.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,445.43 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,189.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $526.81. The transfer capital threshold is the transfer adjustment factor * $526.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8702.43","8702.43","8702.43","1 through 10","6225.04","10255.22","other","Inpatient Replacement Plans DRG"
"Postpartum And Post Abortion Diagnoses Without Procedure,EXTREME","561","DRG","","","","","","","","inpatient","","","109679.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20032.02","","Standard inlier is a Case rate ($20,032.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,224, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,843.67) for the length of stay and the standard reimbursement.","30043.50","30043.50","30043.50","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,EXTREME","561","DRG","","","","","","","","inpatient","","","109679.03","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6222.47","","Case rate ($6,880.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,310.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15687.42","15687.42","15687.42","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MAJOR","561","DRG","","","","","","","","inpatient","","","31856.12","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20032.02","","Standard inlier is a Case rate ($20,032.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,224, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,843.67) for the length of stay and the standard reimbursement.","18260.67","18260.67","20032.01","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MAJOR","561","DRG","","","","","","","","inpatient","","","31856.12","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22521.38","","Standard inlier is a Case rate ($22,521.38). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,224, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,196.72) for the length of stay and the standard reimbursement.","22521.38","22521.38","22521.38","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MAJOR","561","DRG","","","","","","","","inpatient","","","31856.12","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8966.9303","","Fee schedule rate ($17,685.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8966.9303","17685.60","17685.60","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MAJOR","561","DRG","","","","","","","","inpatient","","","31856.12","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18511.91","","Fee schedule rate ($18,511.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18511.91","18511.91","18511.91","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MAJOR","561","DRG","","","","","","","","inpatient","","","31856.12","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6222.47","","Case rate ($6,880.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,310.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,730.16 and the sum of the standard inlier and any outlier amount.","6878.32","196.65","6878.32","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","14851.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","8434.53","","Standard inlier is a Case rate ($8,434.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $18,206, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,197.33) for the length of stay and the standard reimbursement.","8434.53","8434.53","24987.71","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","14851.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","9482.69","","Standard inlier is a Case rate ($9,482.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $18,206, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,345.99) for the length of stay and the standard reimbursement.","9482.68","8663.25","9482.69","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","14851.10","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","9415.5374","","Fee schedule rate ($9,415.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9415.5374","9863.74","9863.74","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","14851.10","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8966.9303","","Fee schedule rate ($8,966.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8966.9303","8966.92","8966.92","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","14851.10","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","9415.5374","","Fee schedule rate ($9,415.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9415.5374","9415.52","9415.52","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","14851.10","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","9863.74","","Fee schedule rate ($9,863.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9863.76","9863.76","9863.76","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","14851.10","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7936.96","","Fee schedule rate ($7,936.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7936.96","7936.96","7936.96","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","14851.10","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8333.94","","Fee schedule rate ($8,333.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8333.94","8333.94","8333.94","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MINOR","561","DRG","","","","","","","","inpatient","","","14851.10","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","3635.01","","Case rate ($4,019.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,449.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4018.14","1.43","4018.14","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","17903.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","12807.04","","Standard inlier is a Case rate ($12,807.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $21,606, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,818.04) for the length of stay and the standard reimbursement.","12807.03","12807.03","14398.56","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","17903.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","14398.56","","Standard inlier is a Case rate ($14,398.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $21,606, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,043.76) for the length of stay and the standard reimbursement.","14398.56","13154.32","14398.56","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","17903.46","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","9415.5374","","Fee schedule rate ($10,956.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9415.5374","11477.77","11477.77","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","17903.46","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8966.9303","","Fee schedule rate ($10,434.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8966.9303","10434.20","10434.20","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","17903.46","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","9415.5374","","Fee schedule rate ($10,956.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9415.5374","10956.20","10956.20","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","17903.46","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","12873.07","","Fee schedule rate ($12,873.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13042.87","13042.87","13042.87","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","17903.46","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","11477.77","","Fee schedule rate ($11,477.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11477.77","11477.77","11477.77","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","17903.46","","MASSHEALTH [3001]","HB BWH MEDICAID","4783.09","","Case rate ($5,288.52). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,718.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5287.23","5284.65","5287.23","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","17903.46","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11410.98","","Fee schedule rate ($11,410.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11410.98","11410.98","11410.98","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","17903.46","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11981.72","","Fee schedule rate ($11,981.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11981.72","11632.64","11981.72","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","17903.46","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4783.09","","Case rate ($5,288.52). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,718.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5287.23","5284.65","5287.23","1 through 10","3635.01","61644.09","case rate",""
"Postpartum And Post Abortion Diagnosis With O.R. Procedure,MAJOR","548","DRG","","","","","","","","inpatient","","","48738.87","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","54692.71","","Standard inlier is a Case rate ($54,692.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,477, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,763.18) for the length of stay and the standard reimbursement.","54692.71","54692.71","54692.71","1 through 10","5193.2","54692.71","case rate",""
"Postpartum And Post Abortion Diagnosis With O.R. Procedure,MAJOR","548","DRG","","","","","","","","inpatient","","","48738.87","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","15922.30","","Case rate ($17,604.84). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,034.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17600.52","17600.52","17600.52","1 through 10","5193.2","54692.71","case rate",""
"Postpartum And Post Abortion Diagnosis With O.R. Procedure,MINOR","548","DRG","","","","","","","","inpatient","","","19444.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","14042.46","","Standard inlier is a Case rate ($14,042.46). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,568, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,993.41) for the length of stay and the standard reimbursement.","14042.46","14042.46","14042.46","1 through 10","5193.2","54692.71","case rate",""
"Postpartum And Post Abortion Diagnosis With O.R. Procedure,MINOR","548","DRG","","","","","","","","inpatient","","","19444.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","15787.51","","Standard inlier is a Case rate ($15,787.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,568, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,240.91) for the length of stay and the standard reimbursement.","15787.51","15787.51","15787.51","1 through 10","5193.2","54692.71","case rate",""
"Postpartum And Post Abortion Diagnosis With O.R. Procedure,MODERATE","548","DRG","","","","","","","","inpatient","","","38958.60","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32738.54","","Standard inlier is a Case rate ($32,738.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,292, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,646.96) for the length of stay and the standard reimbursement.","32738.54","29909.48","32738.54","1 through 10","5193.2","54692.71","case rate",""
"Postpartum And Post Abortion Diagnosis With O.R. Procedure,MODERATE","548","DRG","","","","","","","","inpatient","","","38958.60","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9648.42","","Case rate ($10,667.99). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,097.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10665.37","10665.37","10665.37","1 through 10","5193.2","54692.71","case rate",""
"Pot Chl Inj 2meq","PX-63600197","CDM","J3480","HCPCS","0636","RC","","","","both","","","1.00","0.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","0.70","70","","0.63","0.63","0.63","1 through 10","0.27","0.77","percent of total billed charges",""
"Pot Chl Inj 2meq","PX-63600197","CDM","J3480","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","2.30","0.77","2.30","140","0.27","0.77","percent of total billed charges",""
"Pot Chl Inj 2meq","PX-63600197","CDM","J3480","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","AETNA [1001]","HB AMC AETNA HMO","0.70","69.8","","2.07","2.07","2.07","1 through 10","0.37","0.8","percent of total billed charges",""
"Pot Chl Inj 2meq","PX-63600197","CDM","J3480","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.70","69.9","","2.31","1.42","2.31","50","0.37","0.8","percent of total billed charges",""
"Pot Chl Inj 2meq","PX-63600197","CDM","J3480","HCPCS","0636","RC","","","","outpatient","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.47","46.9","","2.16","2.16","2.16","1 through 10","0.37","0.8","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","both","","","79.00","59.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","51.82","65.6","","60.06","60.06","60.06","1 through 10","4.66","75.05","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","both","","","79.00","59.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","55.30","70","","77.00","68.54","77.00","1 through 10","4.66","75.05","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","both","","","79.00","59.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","62.81","79.5","","60.60","56.55","88.16","70","4.66","75.05","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","both","","","79.00","59.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","42.11","53.3","","40.66","40.66","60.60","12","4.66","75.05","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","both","","","79.00","59.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","24.49","31","","23.79","23.79","23.79","1 through 10","4.66","75.05","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","both","","","79.00","59.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28.84","36.5","","28.72","24.41","28.72","13","4.66","75.05","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","both","","","79.00","59.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30.26","38.3","","30.11","30.11","30.11","123","4.66","75.05","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","both","","","79.00","59.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","60.83","77","","60.60","60.60","60.60","1 through 10","4.66","75.05","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","both","","","79.00","59.25","TRICARE [160005]","HB BWH TRICARE","75.05","95","","5.45","5.45","5.45","1 through 10","4.66","75.05","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","both","","","79.00","59.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.89","42.9","","61.55","61.55","61.55","1 through 10","4.66","75.05","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","79.00","59.25","AETNA [1001]","HB AMC AETNA HMO","55.14","69.8","","52.13","36.81","61.55","36","4.73","64.56","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","79.00","59.25","AETNA [1001]","HB AMC AETNA PPO","63.52","80.4","","60.06","60.06","60.06","1 through 10","4.73","64.56","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","79.00","59.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","41.29","52.26","","47.65","47.65","47.65","1 through 10","4.73","64.56","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","79.00","59.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","63.52","80.4","","60.06","60.06","60.06","1 through 10","4.73","64.56","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","79.00","59.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","64.56","81.72","","812.91","812.91","812.91","1 through 10","4.73","64.56","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","79.00","59.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","64.56","81.72","","61.55","33.86","61.55","24","4.73","64.56","percent of total billed charges",""
"Potassium Urine","PX-30000629","CDM","84133","CPT","0301","RC","","","","both","","","75.00","56.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59.63","79.5","","38.54","36.50","57.45","1 through 10","4.43","71.25","percent of total billed charges",""
"Potassium Urine","PX-30000629","CDM","84133","CPT","0301","RC","","","","both","","","75.00","56.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39.98","53.3","","38.54","38.54","38.54","1 through 10","4.43","71.25","percent of total billed charges",""
"Potassium Urine","PX-30000629","CDM","84133","CPT","0301","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.38","36.5","","69.42","23.14","69.42","1 through 10","4.43","71.25","percent of total billed charges",""
"Potassium Urine","PX-30000629","CDM","84133","CPT","0301","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.73","38.3","","28.54","27.74","55.48","16","4.43","71.25","percent of total billed charges",""
"Potassium Urine","PX-30000629","CDM","84133","CPT","0301","RC","","","","outpatient","","","75.00","56.25","AETNA [1001]","HB AMC AETNA HMO","52.35","69.8","","47.16","34.89","56.94","1 through 10","4.43","61.29","percent of total billed charges",""
"Potassium Urine","PX-30000629","CDM","84133","CPT","0301","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","61.29","81.72","","58.36","58.36","58.36","1 through 10","4.43","61.29","percent of total billed charges",""
"Pouchoscopy W/ Stricture Dilation of Rectum","PX-75000541","CDM","45999","CPT","0750","RC","","","","outpatient","","","3559.00","2669.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1858.51","52.22","","1324.00","1324.00","1324.00","1 through 10","1234.13","2936.18","percent of total billed charges",""
"Pouchoscopy W/ Stricture Dilation of Rectum","PX-75000541","CDM","45999","CPT","0750","RC","","","","outpatient","","","3559.00","2669.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1779.50","50","","1324.00","1324.00","1324.00","1 through 10","1234.13","2936.18","percent of total billed charges",""
"Pouchoscopy W/ Stricture Dilation of Rectum","PX-75000541","CDM","45999","CPT","0750","RC","","","","outpatient","","","3559.00","2669.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1868.48","52.5","","728.20","728.20","728.20","1 through 10","1234.13","2936.18","percent of total billed charges",""
"Pouchoscopy With Polypectomy","PX-75000459","CDM","45999","CPT","0750","RC","","","","outpatient","","","1365.00","1023.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","712.80","52.22","","1324.00","1324.00","1324.00","1 through 10","682.5","1234.13","percent of total billed charges",""
"Pouchoscopy With Polypectomy","PX-75000459","CDM","45999","CPT","0750","RC","","","","outpatient","","","1365.00","1023.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","682.50","50","","1324.00","1324.00","1324.00","1 through 10","682.5","1234.13","percent of total billed charges",""
"Pouchoscopy With Polypectomy","PX-75000459","CDM","45999","CPT","0750","RC","","","","outpatient","","","1365.00","1023.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","716.63","52.5","","728.20","728.20","728.20","1 through 10","682.5","1234.13","percent of total billed charges",""
"Pouchoscopy With Stricture Dilation","PX-75000466","CDM","45999","CPT","0750","RC","","","","outpatient","","","3494.00","2620.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1824.57","52.22","","1324.00","1324.00","1324.00","1 through 10","1234.13","2882.55","percent of total billed charges",""
"Pouchoscopy With Stricture Dilation","PX-75000466","CDM","45999","CPT","0750","RC","","","","outpatient","","","3494.00","2620.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1747.00","50","","1324.00","1324.00","1324.00","1 through 10","1234.13","2882.55","percent of total billed charges",""
"Pouchoscopy With Stricture Dilation","PX-75000466","CDM","45999","CPT","0750","RC","","","","outpatient","","","3494.00","2620.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1834.35","52.5","","728.20","728.20","728.20","1 through 10","1234.13","2882.55","percent of total billed charges",""
"Power Module Patient Cable2225","PX-27000874","CDM","Q0508","HCPCS","0274","RC","","","","both","","","3325.00","2493.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2161.25","65","","1092.00","1092.00","1092.00","1 through 10","1030.75","3158.75","percent of total billed charges",""
"Power Module Patient Cable2225","PX-27000874","CDM","Q0508","HCPCS","0274","RC","","","","both","","","3325.00","2493.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2327.50","70","","51.84","51.84","51.84","21","1030.75","3158.75","percent of total billed charges",""
"Power Module Patient Cable2225","PX-27000874","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2013.29","60.55","","48.41","48.41","48.41","1 through 10","1330","2743.13","percent of total billed charges",""
"Power Module Patient Cable2225","PX-27000874","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1736.32","52.22","","43.55","43.55","43.55","24","1330","2743.13","percent of total billed charges",""
"Power Module Patient Cable2225","PX-27000874","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","3325.00","2493.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1662.50","50","","37.73","37.73","188.64","1 through 10","1330","2743.13","percent of total billed charges",""
"Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use","PX-63601006","CDM","90732","CPT","0636","RC","","","","both","","","218.87","164.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","83.83","38.3","","85.58","83.17","85.58","1 through 10","67.85","327.38","percent of total billed charges",""
"Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use","PX-63601006","CDM","90732","CPT","0636","RC","","","","both","","","218.87","164.15","TRICARE [160005]","HB BWH TRICARE","207.93","95","","437.74","437.74","437.74","1 through 10","67.85","327.38","percent of total billed charges",""
"Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use","PX-63601006","CDM","90732","CPT","0636","RC","","","","outpatient","","","218.87","164.15","AETNA [1001]","HB AMC AETNA HMO","152.77","69.8","","148.17","148.17","148.17","1 through 10","102.65","274.62","percent of total billed charges",""
"Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use","PX-63601006","CDM","90732","CPT","0636","RC","","","","outpatient","","","218.87","164.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","152.99","69.9","","151.68","151.68","151.68","1 through 10","102.65","274.62","percent of total billed charges",""
"Ppsv23 Vaccine 2 Yrs or Older for Subq/Im Use","PX-63601006","CDM","90732","CPT","0636","RC","","","","outpatient","","","218.87","164.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","178.86","81.72","","286.96","218.87","286.96","1 through 10","102.65","274.62","percent of total billed charges",""
"Pre-OP Placement Marker, Gland","PX-76002836","CDM","60699","CPT","0761","RC","","","","both","","","646.00","484.50","MEDICARE [2001]","HB BWH MEDICARE","6927.95","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6928.65","6928.65","1 through 10","200.26","8659.94","other","OPPS APC"
"Pre-OP Placement Marker, Gland","PX-76002836","CDM","60699","CPT","0761","RC","","","","both","","","646.00","484.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","247.42","38.3","","5123.54","4829.42","5123.54","1 through 10","200.26","8659.94","percent of total billed charges",""
"Pre-OP Placement Marker, Gland","PX-76002836","CDM","60699","CPT","0761","RC","","","","outpatient","","","646.00","484.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","391.15","60.55","","13483.00","13483.00","13483.00","1 through 10","323","15696.44","percent of total billed charges",""
"Pre-OP Placement Marker, Gland","PX-76002836","CDM","60699","CPT","0761","RC","","","","outpatient","","","646.00","484.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","337.34","52.22","","13483.00","12302.64","13483.00","1 through 10","323","15696.44","percent of total billed charges",""
"Pre-OP Placement Marker, Gland","PX-76002836","CDM","60699","CPT","0761","RC","","","","outpatient","","","646.00","484.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","323.00","50","","13483.00","13483.00","13483.00","1 through 10","323","15696.44","percent of total billed charges",""
"Pre-OP Placement Marker, Gland","PX-76002836","CDM","60699","CPT","0761","RC","","","","outpatient","","","646.00","484.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","339.15","52.5","","13483.00","3582.00","13483.00","1 through 10","323","15696.44","percent of total billed charges",""
"Pre-OP Placement Wire/Coil/Tattoo, Abdomen","PX-76002945","CDM","49999","CPT","0761","RC","","","","both","","","3793.00","2844.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","3015.44","other","OPPS APC"
"Pre-OP Placement Wire/Coil/Tattoo, Abdomen","PX-76002945","CDM","49999","CPT","0761","RC","","","","both","","","3793.00","2844.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3015.44","other","OPPS APC"
"Pre-OP Placement Wire/Coil/Tattoo, Abdomen","PX-76002945","CDM","49999","CPT","0761","RC","","","","both","","","3793.00","2844.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","1057.74","3015.44","other","OPPS APC"
"Pre-OP Placement Wire/Coil/Tattoo, Abdomen","PX-76002945","CDM","49999","CPT","0761","RC","","","","outpatient","","","3793.00","2844.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1896.50","50","","14640.00","14640.00","14640.00","1 through 10","1896.5","8899.59","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","143.00","65","","502.45","138.45","562.30","15","14.3","209","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","154.00","70","","153.36","78.16","460.08","1 through 10","14.3","209","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","138.45","112.46","167.63","22","14.3","209","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","276.90","112.46","337.38","1 through 10","14.3","209","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","both","","","220.00","165.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","143.00","65","","148.20","148.20","148.20","1 through 10","14.3","209","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","77.11","79.45","1 through 10","14.3","209","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","83.28","249.84","46","14.3","209","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","17.58","17.58","17.58","1 through 10","14.3","209","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","14.3","209","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","144.20","17","15.04","179.78","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","223.22","166.14","223.22","1 through 10","15.04","179.78","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","51.55","51.55","51.55","1 through 10","15.04","179.78","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","93.66","93.66","170.27","17","15.04","179.78","percent of total billed charges",""
"Precerebral Occlusion Without Infarction With McC","067","MS-DRG","","","","","","","","inpatient","","","49638.72","37229.04","MEDICARE [2001]","HB BWH MEDICARE","13777.47","","Case rate ($13,777.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,507.94, add-ons for qualifying new technology services are included. If operating cost exceeds $62,152.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,621.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $12,215.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,128.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.80. The transfer capital threshold is the transfer adjustment factor * $1,181.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17455.98","0.03","17455.98","1 through 10","13501.92","21955.8959","other","Inpatient Replacement Plans DRG"
"Precerebral Occlusion Without Infarction Without McC","068","MS-DRG","","","","","","","","inpatient","","","36873.87","27655.40","MEDICARE [2001]","HB BWH MEDICARE","8264.98","","Case rate ($8,264.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,872.01, add-ons for qualifying new technology services are included. If operating cost exceeds $55,516.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,135.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,189.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,492.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10670.42","1104.24","10685.96","1 through 10","8099.68","13302.7165","other","Inpatient Replacement Plans DRG"
"Precerebral Occlusion Without Infarction Without McC","068","MS-DRG","","","","","","","","inpatient","","","36873.87","27655.40","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8099.68","","Case rate ($8,264.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,872.01, add-ons for qualifying new technology services are included. If operating cost exceeds $55,516.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,135.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,189.60 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,492.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $695.55. The transfer capital threshold is the transfer adjustment factor * $695.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8197.22","8197.22","8197.22","1 through 10","8099.68","13302.7165","other","Inpatient DRG"
"Precerebral Occlusion Without Infarction Without McC","068","TRIS-DRG","","","","","","","","inpatient","","","18898.96","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","6257.17","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($10,991.06). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $54,718.06 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($10,467.68), capped at $7,910.65. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $54,718.06 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","15718.96","15718.96","15718.96","1 through 10","6257.17","6257.17","other","Inpatient DRGs"
"Prednisone Oral IR or Dr per 1 Mg","PX-63601210","CDM","J7512","HCPCS","0636","RC","","","","both","","","0.47","0.35","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","0.34","71.8","","0.09","0.09","0.09","1 through 10","0.02","0.36","percent of total billed charges",""
"Prednisone Oral IR or Dr per 1 Mg","PX-63601210","CDM","J7512","HCPCS","0636","RC","","","","both","","","0.47","0.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","0.31","65.6","","0.03","0.03","0.03","1 through 10","0.02","0.36","percent of total billed charges",""
"Prednisone Oral IR or Dr per 1 Mg","PX-63601210","CDM","J7512","HCPCS","0636","RC","","","","both","","","0.47","0.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","0.31","65","","0.07","0.07","0.07","15","0.02","0.36","percent of total billed charges",""
"Prednisone Oral IR or Dr per 1 Mg","PX-63601210","CDM","J7512","HCPCS","0636","RC","","","","both","","","0.47","0.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","0.15","31","","0.02","0.02","0.02","60","0.02","0.36","percent of total billed charges",""
"Prednisone Oral IR or Dr per 1 Mg","PX-63601210","CDM","J7512","HCPCS","0636","RC","","","","both","","","0.47","0.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.17","36.5","","0.02","0.01","0.03","435","0.02","0.36","percent of total billed charges",""
"Prednisone Oral IR or Dr per 1 Mg","PX-63601210","CDM","J7512","HCPCS","0636","RC","","","","both","","","0.47","0.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.18","38.3","","0.02","0.01","0.04","610","0.02","0.36","percent of total billed charges",""
"Prednisone Oral IR or Dr per 1 Mg","PX-63601210","CDM","J7512","HCPCS","0636","RC","","","","outpatient","","","0.47","0.35","AETNA [1001]","HB AMC AETNA HMO","0.33","69.8","","0.02","0.01","0.04","612","0.22","3.03","percent of total billed charges",""
"Prednisone Oral IR or Dr per 1 Mg","PX-63601210","CDM","J7512","HCPCS","0636","RC","","","","outpatient","","","0.47","0.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.33","69.9","","0.02","0.01","0.08","245","0.22","3.03","percent of total billed charges",""
"Prednisone Oral IR or Dr per 1 Mg","PX-63601210","CDM","J7512","HCPCS","0636","RC","","","","outpatient","","","0.47","0.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.22","46.9","","0.03","0.01","0.04","487","0.22","3.03","percent of total billed charges",""
"Pregnenolone","PX-30000633","CDM","84140","CPT","0301","RC","","","","both","","","343.00","257.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","272.69","79.5","","262.07","262.07","262.07","1 through 10","20.26","325.85","percent of total billed charges",""
"Pregnenolone","PX-30000633","CDM","84140","CPT","0301","RC","","","","outpatient","","","343.00","257.25","AETNA [1001]","HB AMC AETNA HMO","239.41","69.8","","159.17","159.17","159.17","1 through 10","21.31","280.3","percent of total billed charges",""
"Pregnenolone","PX-30000633","CDM","84140","CPT","0301","RC","","","","outpatient","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","280.30","81.72","","146.42","146.42","146.42","1 through 10","21.31","280.3","percent of total billed charges",""
"Pregnenolone 17-Hydroxy","PX-30000634","CDM","84143","CPT","0301","RC","","","","both","","","258.00","193.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","205.11","79.5","","196.75","196.75","196.75","1 through 10","22.33","245.1","percent of total billed charges",""
"Pregnenolone 17-Hydroxy","PX-30000634","CDM","84143","CPT","0301","RC","","","","both","","","258.00","193.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","137.51","53.3","","132.00","132.00","132.00","1 through 10","22.33","245.1","percent of total billed charges",""
"Pregnenolone 17-Hydroxy","PX-30000634","CDM","84143","CPT","0301","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","94.17","36.5","","93.25","93.25","93.25","1 through 10","22.33","245.1","percent of total billed charges",""
"Pregnenolone 17-Hydroxy","PX-30000634","CDM","84143","CPT","0301","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","98.81","38.3","","97.75","97.75","97.75","1 through 10","22.33","245.1","percent of total billed charges",""
"Pregnenolone 17-Hydroxy","PX-30000634","CDM","84143","CPT","0301","RC","","","","both","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.68","42.9","","109.93","109.93","109.93","1 through 10","22.33","245.1","percent of total billed charges",""
"Pregnenolone 17-Hydroxy","PX-30000634","CDM","84143","CPT","0301","RC","","","","outpatient","","","258.00","193.50","AETNA [1001]","HB AMC AETNA HMO","180.08","69.8","","169.25","169.25","169.25","1 through 10","22.33","210.84","percent of total billed charges",""
"Pregnenolone 17-Hydroxy","PX-30000634","CDM","84143","CPT","0301","RC","","","","outpatient","","","258.00","193.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","144.22","55.9","","131.00","131.00","131.00","1 through 10","22.33","210.84","percent of total billed charges",""
"Pregnenolone 17-Hydroxy","PX-30000634","CDM","84143","CPT","0301","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","210.84","81.72","","199.85","103.39","199.85","1 through 10","22.33","210.84","percent of total billed charges",""
"Prematurity With Major Problems","791","MS-DRG","","","","","","","","inpatient","","","129799.27","97349.45","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","111746.62","111746.62","111746.62","1 through 10","36658.34","63580.18","case rate",""
"Prematurity With Major Problems","791","MS-DRG","","","","","","","","inpatient","","","129799.27","97349.45","WELLPOINT [1015]","HB AMC WELLPOINT","63580.18","","Fee schedule rate ($63,580.18).","753661.63","753661.63","753661.63","1 through 10","36658.34","63580.18","case rate",""
"Prematurity Without Major Problems","792","MS-DRG","","","","","","","","inpatient","","","16814.58","12610.93","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","22267.27","","Case rate ($22,721.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,275.03, add-ons for qualifying new technology services are included. If operating cost exceeds $72,919.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,410.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $20,371.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,895.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,970.77. The transfer capital threshold is the transfer adjustment factor * $1,970.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","31018.11","31018.11","31018.11","1 through 10","22267.27","36968.4227","other","Inpatient DRG"
"Prenatal Known Familial Mutation (Includes Mcc)","PX-31000821","CDM","81479","CPT","0310","RC","","","","both","","","1664.00","1248.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1322.88","79.5","","0.65","0.65","0.65","1 through 10","515.84","1580.8","percent of total billed charges",""
"Prenatal Known Familial Mutation (Includes Mcc)","PX-31000821","CDM","81479","CPT","0310","RC","","","","both","","","1664.00","1248.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","886.91","53.3","","0.79","0.79","0.79","1 through 10","515.84","1580.8","percent of total billed charges",""
"Prenatal Known Familial Mutation (Includes Mcc)","PX-31000821","CDM","81479","CPT","0310","RC","","","","outpatient","","","1664.00","1248.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","832.00","50","","1.00","1.00","1.00","1 through 10","156.55","1372.8","percent of total billed charges",""
"Prenatal Known Familial Mutation (Includes Mcc)","PX-31000821","CDM","81479","CPT","0310","RC","","","","outpatient","","","1664.00","1248.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","873.60","52.5","","1.00","0.53","1.00","1 through 10","156.55","1372.8","percent of total billed charges",""
"Preop Place Wire/Coil/Tattoo Lung/Pleura","PX-76001898","CDM","32999","CPT","0761","RC","","","","both","","","2422.00","1816.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1925.49","79.5","","0.89","0.89","0.89","1 through 10","697.51","1925.49","percent of total billed charges",""
"Preop Plcmnt Ndl Locwire Eaadd","PX-76001998","CDM","17999","CPT","0761","RC","","","","both","","","1365.00","1023.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4490.63","3878.56","4490.63","1 through 10","224.17","1085.18","other","OPPS APC"
"Preop Plcmnt Ndl Locwire Eaadd","PX-76001998","CDM","17999","CPT","0761","RC","","","","outpatient","","","1365.00","1023.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","712.80","52.22","","467.73","465.00","467.73","1 through 10","682.5","1126.13","percent of total billed charges",""
"Prep With Instillation of Feca Microbiota by Any Method","PX-98301651","CDM","G0455","HCPCS","0983","RC","","","","both","","","305.00","228.75","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","1 through 10","94.55","1353.25","other","OPPS APC"
"Prep Wound F/Nhf/G 1st 100cm Child","PX-76000165","CDM","15004","CPT","0761","RC","","","","both","","","1888.00","1416.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1500.96","79.5","","7878.66","5539.50","7878.66","1 through 10","267.79","1500.96","percent of total billed charges",""
"Prep Wound F/Nhf/G 1st 100cm Child","PX-76000165","CDM","15004","CPT","0761","RC","","","","both","","","1888.00","1416.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1006.30","53.3","","7098.94","7098.94","7098.94","1 through 10","267.79","1500.96","percent of total billed charges",""
"Prep Wound F/Nhf/G 1st 100cm Child","PX-76000165","CDM","15004","CPT","0761","RC","","","","both","","","1888.00","1416.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","723.10","38.3","","8318.13","8318.13","8318.13","1 through 10","267.79","1500.96","percent of total billed charges",""
"Prep Wound F/Nhf/G 1st 100cm Child","PX-76000165","CDM","15004","CPT","0761","RC","","","","outpatient","","","1888.00","1416.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1129.82","1129.82","1129.82","1 through 10","482.89","1542.87","other","ASC"
"Prep Wound Trk/Arm/Leg 1st 100cm","PX-76000164","CDM","15002","CPT","0761","RC","","","","both","","","1526.00","1144.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1213.17","79.5","","1694.02","1694.02","1694.02","1 through 10","473.06","1213.17","percent of total billed charges",""
"Prep Wound Trk/Arm/Leg 1st 100cm","PX-76000164","CDM","15002","CPT","0761","RC","","","","both","","","1526.00","1144.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","584.46","38.3","","4702.56","4702.56","4702.56","1 through 10","473.06","1213.17","percent of total billed charges",""
"Prep Wound Trk/Arm/Leg 1st 100cm","PX-76000164","CDM","15002","CPT","0761","RC","","","","outpatient","","","1526.00","1144.50","AETNA [1001]","HB AMC AETNA HMO","1065.15","69.8","","4834.73","4834.73","4834.73","1 through 10","610.4","1247.05","percent of total billed charges",""
"Prep Wound Trk/Arm/Leg 1st 100cm","PX-76000164","CDM","15002","CPT","0761","RC","","","","outpatient","","","1526.00","1144.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","923.99","60.55","","4146.66","4146.66","4146.66","1 through 10","610.4","1247.05","percent of total billed charges",""
"Prep Wound Trk/Arm/Leg 1st 100cm","PX-76000164","CDM","15002","CPT","0761","RC","","","","outpatient","","","1526.00","1144.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","796.88","52.22","","4105.92","4105.92","4105.92","1 through 10","610.4","1247.05","percent of total billed charges",""
"PRESSURIZER BONE CEMENT LG PROXIMAL FEMORAL CANAL WITHOUT HUB RED LG PK/6EA","SUP-ITM-10148254","CDM","C1713","HCPCS","0278","RC","","","","both","","","50.88","38.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","40.45","79.5","","800.18","480.96","1887.97","195","15.77","40.45","percent of total billed charges",""
"PRESSURIZER BONE CEMENT LG PROXIMAL FEMORAL CANAL WITHOUT HUB RED LG PK/6EA","SUP-ITM-10148254","CDM","C1713","HCPCS","0278","RC","","","","both","","","50.88","38.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","27.12","53.3","","813.12","216.42","1444.50","81","15.77","40.45","percent of total billed charges",""
"PRESSURIZER BONE CEMENT LG PROXIMAL FEMORAL CANAL WITHOUT HUB RED LG PK/6EA","SUP-ITM-10148254","CDM","C1713","HCPCS","0278","RC","","","","both","","","50.88","38.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","15.77","31","","432.60","432.60","432.60","1 through 10","15.77","40.45","percent of total billed charges",""
"PRESSURIZER BONE CEMENT LG PROXIMAL FEMORAL CANAL WITHOUT HUB RED LG PK/6EA","SUP-ITM-10148254","CDM","C1713","HCPCS","0278","RC","","","","both","","","50.88","38.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","18.57","36.5","","148.37","54.89","631.39","94","15.77","40.45","percent of total billed charges",""
"PRESSURIZER BONE CEMENT LG PROXIMAL FEMORAL CANAL WITHOUT HUB RED LG PK/6EA","SUP-ITM-10148254","CDM","C1713","HCPCS","0278","RC","","","","both","","","50.88","38.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","19.49","38.3","","279.30","91.72","1116.77","266","15.77","40.45","percent of total billed charges",""
"PRESSURIZER BONE CEMENT LG PROXIMAL FEMORAL CANAL WITHOUT HUB RED LG PK/6EA","SUP-ITM-10148254","CDM","C1713","HCPCS","0278","RC","","","","both","","","50.88","38.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21.83","42.9","","731.00","63.70","731.00","1 through 10","15.77","40.45","percent of total billed charges",""
"PRESSURIZER BONE CEMENT LG PROXIMAL FEMORAL CANAL WITHOUT HUB RED LG PK/6EA","SUP-ITM-10148254","CDM","C1713","HCPCS","0278","RC","","","","both","","","50.88","38.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21.83","42.9","","384.74","384.74","384.74","1 through 10","15.77","40.45","percent of total billed charges",""
"PRESSURIZER BONE CEMENT LG PROXIMAL FEMORAL CANAL WITHOUT HUB RED LG PK/6EA","SUP-ITM-10148254","CDM","C1713","HCPCS","0278","RC","","","","both","","","50.88","38.16","WELLPOINT [1015]","HB AMC WELLPOINT","37.54","73.78","","286.63","119.22","1107.45","105","15.77","40.45","percent of total billed charges",""
"PRESSURIZER BONE CEMENT LG PROXIMAL FEMORAL CANAL WITHOUT HUB RED LG PK/6EA","SUP-ITM-10148254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","50.88","38.16","AETNA [1001]","HB AMC AETNA HMO","35.51","69.8","","675.31","184.75","1721.50","286","26.59","41.58","percent of total billed charges",""
"PRESSURIZER BONE CEMENT LG PROXIMAL FEMORAL CANAL WITHOUT HUB RED LG PK/6EA","SUP-ITM-10148254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","50.88","38.16","AETNA [1001]","HB AMC AETNA PPO","40.91","80.4","","1261.44","103.12","1514.10","21","26.59","41.58","percent of total billed charges",""
"PRESSURIZER BONE CEMENT LG PROXIMAL FEMORAL CANAL WITHOUT HUB RED LG PK/6EA","SUP-ITM-10148254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","50.88","38.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","40.91","80.4","","1365.00","1365.00","1365.00","1 through 10","26.59","41.58","percent of total billed charges",""
"PRESSURIZER BONE CEMENT LG PROXIMAL FEMORAL CANAL WITHOUT HUB RED LG PK/6EA","SUP-ITM-10148254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","50.88","38.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","41.58","81.72","","5157.68","5157.68","5157.68","1 through 10","26.59","41.58","percent of total billed charges",""
"PRESSURIZER BONE CEMENT LG PROXIMAL FEMORAL CANAL WITHOUT HUB RED LG PK/6EA","SUP-ITM-10148254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","50.88","38.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","41.58","81.72","","431.26","71.26","1459.57","88","26.59","41.58","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","AETNA [1001]","HB AMC AETNA HMO","436.25","69.8","","410.26","289.67","472.68","45","60.9","593.75","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","448.75","71.8","","1305.33","435.11","1305.33","1 through 10","60.9","593.75","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","410.00","65.6","","410.26","410.26","410.26","1 through 10","60.9","593.75","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","406.25","65","","1181.70","393.90","1181.70","1 through 10","60.9","593.75","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","437.50","70","","436.32","260.58","436.32","1 through 10","60.9","593.75","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","496.88","79.5","","476.92","319.97","1430.76","27","60.9","593.75","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","333.13","53.3","","319.97","306.03","1430.76","23","60.9","593.75","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","193.75","31","","187.25","187.25","187.25","1 through 10","60.9","593.75","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.13","36.5","","226.04","190.28","226.04","42","60.9","593.75","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.38","38.3","","236.95","230.28","710.85","80","60.9","593.75","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","625.00","468.75","AETNA [1001]","HB AMC AETNA PPO","502.50","80.4","","472.68","317.54","923.54","1 through 10","205.18","594.32","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","625.00","468.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","326.63","52.26","","205.18","205.18","205.18","1 through 10","205.18","594.32","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","625.00","468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","510.75","81.72","","484.44","266.46","484.44","1 through 10","205.18","594.32","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","625.00","468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","510.75","81.72","","484.44","266.46","484.44","33","205.18","594.32","percent of total billed charges",""
"Preterm Labor,MINOR","563","DRG","","","","","","","","inpatient","","","17126.42","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","7264.8016","","Fee schedule rate ($7,264.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7264.8016","7264.80","7264.80","1 through 10","6985.1488","21818.83","case rate",""
"Preterm Labor,MINOR","563","DRG","","","","","","","","inpatient","","","17126.42","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","8962.86","","Fee schedule rate ($8,962.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9081.08","9081.08","9081.08","1 through 10","6985.1488","21818.83","case rate",""
"Preterm Labor,MODERATE","563","DRG","","","","","","","","inpatient","","","17112.93","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","7628.2528","","Fee schedule rate ($9,420.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7628.2528","9420.24","9420.24","1 through 10","6985.1488","21818.83","case rate",""
"Preterm Labor,MODERATE","563","DRG","","","","","","","","inpatient","","","17112.93","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","9868.66","","Fee schedule rate ($9,868.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9868.68","9868.68","9868.68","1 through 10","6985.1488","21818.83","case rate",""
"Preterm Labor,MODERATE","563","DRG","","","","","","","","inpatient","","","17112.93","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11587.85","","Fee schedule rate ($11,587.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11587.85","11587.85","11587.85","1 through 10","6985.1488","21818.83","case rate",""
"Prev Gen Strc Gene Sequence","PX-30003752","CDM","81479","CPT","0300","RC","","","","both","","","3858.00","2893.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3067.11","79.5","","0.65","0.65","0.65","1 through 10","1195.98","3665.1","percent of total billed charges",""
"Prev Gen Strc Gene Sequence","PX-30003752","CDM","81479","CPT","0300","RC","","","","both","","","3858.00","2893.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2056.31","53.3","","0.79","0.79","0.79","1 through 10","1195.98","3665.1","percent of total billed charges",""
"Prev Gen Strc Gene Sequence","PX-30003752","CDM","81479","CPT","0300","RC","","","","outpatient","","","3858.00","2893.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1929.00","50","","1.00","1.00","1.00","1 through 10","156.55","3182.85","percent of total billed charges",""
"Prev Gen Strc Gene Sequence","PX-30003752","CDM","81479","CPT","0300","RC","","","","outpatient","","","3858.00","2893.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2025.45","52.5","","1.00","0.53","1.00","1 through 10","156.55","3182.85","percent of total billed charges",""
"Prevention Genetics, 2000 Genome Wide Chrom Microarray Include Peric","PX-31001279","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2946.27","79.5","","2828.48","1814.97","2828.48","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Prevention Genetics, 2000 Genome Wide Chrom Microarray Include Peric","PX-31001279","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1975.30","53.3","","1814.97","1761.95","1814.97","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Prevention Genetics, 2000 Genome Wide Chrom Microarray Include Peric","PX-31001279","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1352.69","36.5","","1340.56","1340.56","1340.56","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Prevention Genetics, 2000 Genome Wide Chrom Microarray Include Peric","PX-31001279","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1419.40","38.3","","1405.25","1405.25","1405.25","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Prevention Genetics, 2000 Genome Wide Chrom Microarray Include Peric","PX-31001279","CDM","81229","CPT","0310","RC","","","","both","","","3706.00","2779.50","WELLPOINT [1015]","HB AMC WELLPOINT","2734.29","73.78","","6269.73","2675.73","7188.00","1 through 10","1136.8","3520.7","percent of total billed charges",""
"Prevention Genetics, 2000 Genome Wide Chrom Microarray Include Peric","PX-31001279","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","AETNA [1001]","HB AMC AETNA HMO","2586.79","69.8","","2433.14","2433.14","2433.14","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Prevention Genetics, 2000 Genome Wide Chrom Microarray Include Peric","PX-31001279","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2979.62","80.4","","2803.32","2803.32","2803.32","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Prevention Genetics, 2000 Genome Wide Chrom Microarray Include Peric","PX-31001279","CDM","81229","CPT","0310","RC","","","","outpatient","","","3706.00","2779.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3028.54","81.72","","2873.04","1533.07","3526.61","1 through 10","1793.7","7110.8","percent of total billed charges",""
"Prevention Genetics, 2000 Genome Wide Chrom Microarray Include Peric","PX-31001311","CDM","81403","CPT","0310","RC","","","","outpatient","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","864.60","81.72","","820.18","820.18","820.18","1 through 10","512.07","1135.28","percent of total billed charges",""
"Prevention Genetics, Neurohypophyseal Nephrogenic Diabetes Insipidus Pan","PX-31001202","CDM","81479","CPT","0310","RC","","","","both","","","997.00","747.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","792.62","79.5","","0.65","0.65","0.65","1 through 10","309.07","947.15","percent of total billed charges",""
"Prevention Genetics, Neurohypophyseal Nephrogenic Diabetes Insipidus Pan","PX-31001202","CDM","81479","CPT","0310","RC","","","","both","","","997.00","747.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","531.40","53.3","","0.79","0.79","0.79","1 through 10","309.07","947.15","percent of total billed charges",""
"Prevention Genetics, Neurohypophyseal Nephrogenic Diabetes Insipidus Pan","PX-31001202","CDM","81479","CPT","0310","RC","","","","outpatient","","","997.00","747.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","498.50","50","","1.00","1.00","1.00","1 through 10","156.55","822.53","percent of total billed charges",""
"Prevention Genetics, Neurohypophyseal Nephrogenic Diabetes Insipidus Pan","PX-31001202","CDM","81479","CPT","0310","RC","","","","outpatient","","","997.00","747.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","523.43","52.5","","1.00","0.53","1.00","1 through 10","156.55","822.53","percent of total billed charges",""
"Prevention Genetics, Septo-Optic Dysplasia Spectrum Panel","PX-31001215","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Prevention Genetics, Septo-Optic Dysplasia Spectrum Panel","PX-31001215","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Prevention Genetics, Septo-Optic Dysplasia Spectrum Panel","PX-31001215","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Prevention Genetics, Septo-Optic Dysplasia Spectrum Panel","PX-31001215","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Preventive Med Estab <1 Yr","PX-77000008","CDM","99391","CPT","0510","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA HMO","147.98","69.8","","331.73","192.27","331.73","23","118.51","170.45","percent of total billed charges",""
"Preventive Med Estab <1 Yr","PX-77000008","CDM","99391","CPT","0770","RC","","","","both","","","212.00","159.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","168.54","79.5","","162.12","108.77","207.77","11","65.72","265.71","percent of total billed charges",""
"Preventive Med Estab <1 Yr","PX-77000008","CDM","99391","CPT","0770","RC","","","","both","","","212.00","159.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","113.00","53.3","","207.77","162.12","207.77","1 through 10","65.72","265.71","percent of total billed charges",""
"Preventive Med Estab <1 Yr","PX-77000008","CDM","99391","CPT","0770","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","65.72","31","","87.76","87.76","87.76","1 through 10","65.72","265.71","percent of total billed charges",""
"Preventive Med Estab <1 Yr","PX-77000008","CDM","99391","CPT","0770","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.38","36.5","","102.81","74.57","105.93","24","65.72","265.71","percent of total billed charges",""
"Preventive Med Estab <1 Yr","PX-77000008","CDM","99391","CPT","0770","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.20","38.3","","111.04","80.55","111.04","49","65.72","265.71","percent of total billed charges",""
"Preventive Med Estab <1 Yr","PX-77000008","CDM","99391","CPT","0770","RC","","","","outpatient","","","212.00","159.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","173.25","81.72","","391.71","391.71","391.71","1 through 10","105.16","173.25","percent of total billed charges",""
"Preventive Med Estab <1 Yr","PX-77000008","CDM","99391","CPT","0770","RC","","","","outpatient","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","173.25","81.72","","391.70","391.70","391.70","1 through 10","105.16","173.25","percent of total billed charges",""
"Preventive Med Estab > 65 Yrs","PX-77000014","CDM","99397","CPT","0510","RC","","","","outpatient","","","343.00","257.25","AETNA [1001]","HB AMC AETNA HMO","239.41","69.8","","225.44","159.17","259.74","21","191.74","275.77","percent of total billed charges",""
"Preventive Med Estab > 65 Yrs","PX-77000014","CDM","99397","CPT","0510","RC","","","","outpatient","","","343.00","257.25","AETNA [1001]","HB AMC AETNA PPO","275.77","80.4","","259.74","259.74","259.74","1 through 10","191.74","275.77","percent of total billed charges",""
"Preventive Med Estab > 65 Yrs","PX-77000014","CDM","99397","CPT","0770","RC","","","","both","","","343.00","257.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","272.69","79.5","","262.07","175.82","786.21","15","106.33","395","percent of total billed charges",""
"Preventive Med Estab > 65 Yrs","PX-77000014","CDM","99397","CPT","0770","RC","","","","both","","","343.00","257.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","182.82","53.3","","262.07","175.82","262.07","1 through 10","106.33","395","percent of total billed charges",""
"Preventive Med Estab > 65 Yrs","PX-77000014","CDM","99397","CPT","0770","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","125.20","36.5","","124.21","105.56","150.59","18","106.33","395","percent of total billed charges",""
"Preventive Med Estab > 65 Yrs","PX-77000014","CDM","99397","CPT","0770","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","131.37","38.3","","130.20","126.54","162.66","114","106.33","395","percent of total billed charges",""
"Preventive Med Estab > 65 Yrs","PX-77000014","CDM","99397","CPT","0770","RC","","","","both","","","343.00","257.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","264.11","77","","159.17","159.17","159.17","1 through 10","106.33","395","percent of total billed charges",""
"Preventive Med Estab > 65 Yrs","PX-77000014","CDM","99397","CPT","0770","RC","","","","both","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.15","42.9","","146.42","146.42","146.42","1 through 10","106.33","395","percent of total billed charges",""
"Preventive Med Estab > 65 Yrs","PX-77000014","CDM","99397","CPT","0770","RC","","","","outpatient","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","280.30","81.72","","146.42","146.42","146.42","1 through 10","105.16","280.3","percent of total billed charges",""
"Preventive Med Estab > 65 Yrs","PX-77000014","CDM","99397","CPT","0770","RC","","","","outpatient","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","280.30","81.72","","266.20","266.20","266.20","23","105.16","280.3","percent of total billed charges",""
"Preventive Med Estab 1-4 Yrs","PX-77000009","CDM","99392","CPT","0770","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.60","36.5","","116.00","86.91","116.00","14","74.4","296.08","percent of total billed charges",""
"Preventive Med Estab 1-4 Yrs","PX-77000009","CDM","99392","CPT","0770","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.92","38.3","","121.60","91.10","234.70","70","74.4","296.08","percent of total billed charges",""
"Preventive Med Estab 1-4 Yrs","PX-77000009","CDM","99392","CPT","0770","RC","","","","both","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.96","42.9","","248.61","248.61","248.61","1 through 10","74.4","296.08","percent of total billed charges",""
"Preventive Med Estab 1-4 Yrs","PX-77000009","CDM","99392","CPT","0770","RC","","","","both","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","196.13","81.72","","434.87","248.61","434.87","1 through 10","74.4","296.08","percent of total billed charges",""
"Preventive Med Estab 1-4 Yrs","PX-77000009","CDM","99392","CPT","0770","RC","","","","outpatient","","","240.00","180.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","190.80","79.5","","183.37","123.02","227.69","1 through 10","105.16","190.8","percent of total billed charges",""
"Preventive Med Estab 1-4 Yrs","PX-77000009","CDM","99392","CPT","0770","RC","","","","outpatient","","","240.00","180.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","127.92","53.3","","227.69","123.02","227.69","1 through 10","105.16","190.8","percent of total billed charges",""
"Preventive Med Estab 1-4 Yrs","PX-77000009","CDM","99392","CPT","0770","RC","","","","outpatient","","","240.00","180.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","126.00","52.5","","259.41","259.41","259.41","1 through 10","105.16","190.8","percent of total billed charges",""
"Preventive Med Estab 1-4 Yrs","PX-77000009","CDM","99392","CPT","0770","RC","","","","outpatient","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","190.80","79.5","","227.69","227.69","227.69","1 through 10","105.16","190.8","percent of total billed charges",""
"Preventive Med Estab 12-17 Yrs","PX-77000011","CDM","99394","CPT","0510","RC","","","","outpatient","","","272.00","204.00","AETNA [1001]","HB AMC AETNA HMO","189.86","69.8","","417.71","168.73","417.71","1 through 10","152.05","218.69","percent of total billed charges",""
"Preventive Med Estab 12-17 Yrs","PX-77000011","CDM","99394","CPT","0770","RC","","","","both","","","272.00","204.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","216.24","79.5","","258.17","139.39","258.17","1 through 10","84.32","321.27","percent of total billed charges",""
"Preventive Med Estab 12-17 Yrs","PX-77000011","CDM","99394","CPT","0770","RC","","","","both","","","272.00","204.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","144.98","53.3","","258.17","258.17","258.17","1 through 10","84.32","321.27","percent of total billed charges",""
"Preventive Med Estab 12-17 Yrs","PX-77000011","CDM","99394","CPT","0770","RC","","","","both","","","272.00","204.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","99.28","36.5","","131.67","95.57","131.67","12","84.32","321.27","percent of total billed charges",""
"Preventive Med Estab 12-17 Yrs","PX-77000011","CDM","99394","CPT","0770","RC","","","","both","","","272.00","204.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","104.18","38.3","","138.02","103.22","265.88","53","84.32","321.27","percent of total billed charges",""
"Preventive Med Estab 12-17 Yrs","PX-77000011","CDM","99394","CPT","0770","RC","","","","outpatient","","","272.00","204.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","222.28","81.72","","353.00","282.19","353.00","1 through 10","105.16","222.28","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0510","RC","","","","outpatient","","","272.00","204.00","AETNA [1001]","HB AMC AETNA HMO","189.86","69.8","","178.73","126.19","398.25","213","152.05","218.69","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0510","RC","","","","outpatient","","","272.00","204.00","AETNA [1001]","HB AMC AETNA PPO","218.69","80.4","","205.92","138.34","489.84","24","152.05","218.69","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0510","RC","","","","outpatient","","","272.00","204.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","152.05","55.9","","264.00","264.00","264.00","1 through 10","152.05","218.69","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","both","","","272.00","204.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","216.24","79.5","","207.77","139.39","265.52","112","84.32","325.54","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","both","","","272.00","204.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","144.98","53.3","","207.77","139.39","650.44","55","84.32","325.54","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","both","","","272.00","204.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","84.32","31","","112.48","81.58","112.48","1 through 10","84.32","325.54","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","both","","","272.00","204.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","99.28","36.5","","115.39","83.69","135.77","148","84.32","325.54","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","both","","","272.00","204.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","104.18","38.3","","103.22","100.32","200.64","491","84.32","325.54","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","both","","","272.00","204.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","209.44","77","","214.25","214.25","214.25","1 through 10","84.32","325.54","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","both","","","272.00","204.00","TRICARE [160005]","HB BWH TRICARE","258.40","95","","84.71","84.71","89.17","1 through 10","84.32","325.54","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","both","","","272.00","204.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","116.69","42.9","","211.04","116.08","211.04","1 through 10","84.32","325.54","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","outpatient","","","272.00","204.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","142.80","52.5","","289.26","289.26","289.26","1 through 10","105.16","222.28","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","outpatient","","","272.00","204.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","142.80","52.5","","211.04","211.04","211.04","1 through 10","105.16","222.28","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","outpatient","","","272.00","204.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","222.28","81.72","","211.05","211.04","502.02","1 through 10","105.16","222.28","percent of total billed charges",""
"Preventive Med Estab 18-39 Yrs","PX-77000012","CDM","99395","CPT","0770","RC","","","","outpatient","","","272.00","204.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","222.28","81.72","","211.04","116.08","290.98","181","105.16","222.28","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0510","RC","","","","outpatient","","","306.00","229.50","AETNA [1001]","HB AMC AETNA HMO","213.59","69.8","","201.07","141.97","330.78","196","171.05","246.02","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0510","RC","","","","outpatient","","","306.00","229.50","AETNA [1001]","HB AMC AETNA PPO","246.02","80.4","","231.66","231.66","539.76","16","171.05","246.02","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0510","RC","","","","outpatient","","","306.00","229.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","246.02","80.4","","231.66","231.66","231.66","1 through 10","171.05","246.02","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","both","","","306.00","229.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","243.27","79.5","","233.74","156.82","287.48","109","94.86","358.78","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","both","","","306.00","229.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","163.10","53.3","","156.82","156.82","287.48","108","94.86","358.78","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","both","","","306.00","229.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","94.86","31","","122.06","91.77","275.31","16","94.86","358.78","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","both","","","306.00","229.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","111.69","36.5","","110.78","94.15","215.02","275","94.86","358.78","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","both","","","306.00","229.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","117.20","38.3","","116.13","112.86","154.45","674","94.86","358.78","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","both","","","306.00","229.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","235.62","77","","383.25","201.07","403.98","1 through 10","94.86","358.78","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","both","","","306.00","229.50","TRICARE [160005]","HB BWH TRICARE","290.70","95","","91.99","91.99","91.99","1 through 10","94.86","358.78","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","both","","","306.00","229.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","131.27","42.9","","135.14","130.59","237.42","12","94.86","358.78","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","outpatient","","","306.00","229.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","160.65","52.5","","307.48","307.48","307.48","1 through 10","105.16","250.06","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","outpatient","","","306.00","229.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","160.65","52.5","","307.48","307.48","307.48","1 through 10","105.16","250.06","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","outpatient","","","306.00","229.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","250.06","81.72","","304.27","130.59","304.27","17","105.16","250.06","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","outpatient","","","306.00","229.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","250.06","81.72","","237.42","130.59","237.42","163","105.16","250.06","percent of total billed charges",""
"Preventive Med Estab 40-64 Yrs","PX-77000013","CDM","99396","CPT","0770","RC","","","","outpatient","","","306.00","229.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","160.65","52.5","","307.48","307.48","307.48","1 through 10","105.16","250.06","percent of total billed charges",""
"Preventive Med Estab 5-11 Yrs","PX-77000010","CDM","99393","CPT","0510","RC","","","","outpatient","","","244.00","183.00","AETNA [1001]","HB AMC AETNA HMO","170.31","69.8","","427.44","371.00","427.44","1 through 10","136.4","196.18","percent of total billed charges",""
"Preventive Med Estab 5-11 Yrs","PX-77000010","CDM","99393","CPT","0770","RC","","","","both","","","244.00","183.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","193.98","79.5","","227.69","186.52","227.69","12","75.64","291.8","percent of total billed charges",""
"Preventive Med Estab 5-11 Yrs","PX-77000010","CDM","99393","CPT","0770","RC","","","","both","","","244.00","183.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.05","53.3","","227.69","227.69","227.69","1 through 10","75.64","291.8","percent of total billed charges",""
"Preventive Med Estab 5-11 Yrs","PX-77000010","CDM","99393","CPT","0770","RC","","","","both","","","244.00","183.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.06","36.5","","98.59","88.40","116.00","31","75.64","291.8","percent of total billed charges",""
"Preventive Med Estab 5-11 Yrs","PX-77000010","CDM","99393","CPT","0770","RC","","","","both","","","244.00","183.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.45","38.3","","121.60","92.67","234.70","72","75.64","291.8","percent of total billed charges",""
"Preventive Med Estab 5-11 Yrs","PX-77000010","CDM","99393","CPT","0770","RC","","","","outpatient","","","244.00","183.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","199.40","81.72","","438.07","248.61","438.07","1 through 10","105.16","199.4","percent of total billed charges",""
"Preventive Med New <1 Yr","PX-77000001","CDM","99381","CPT","0510","RC","","","","outpatient","","","240.00","180.00","AETNA [1001]","HB AMC AETNA HMO","167.52","69.8","","368.29","260.03","368.29","11","134.16","192.96","percent of total billed charges",""
"Preventive Med New <1 Yr","PX-77000001","CDM","99381","CPT","0770","RC","","","","both","","","240.00","180.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","190.80","79.5","","227.69","123.02","227.69","1 through 10","74.4","354.4","percent of total billed charges",""
"Preventive Med New <1 Yr","PX-77000001","CDM","99381","CPT","0770","RC","","","","both","","","240.00","180.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","127.92","53.3","","183.37","117.67","227.69","1 through 10","74.4","354.4","percent of total billed charges",""
"Preventive Med New <1 Yr","PX-77000001","CDM","99381","CPT","0770","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.60","36.5","","86.91","73.86","116.00","1 through 10","74.4","354.4","percent of total billed charges",""
"Preventive Med New <1 Yr","PX-77000001","CDM","99381","CPT","0770","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.92","38.3","","91.10","88.54","121.60","1 through 10","74.4","354.4","percent of total billed charges",""
"Preventive Med New <1 Yr","PX-77000001","CDM","99381","CPT","0770","RC","","","","outpatient","","","240.00","180.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","126.00","52.5","","271.03","271.03","271.03","1 through 10","105.16","196.13","percent of total billed charges",""
"Preventive Med New <1 Yr","PX-77000001","CDM","99381","CPT","0770","RC","","","","outpatient","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","196.13","81.72","","434.87","434.87","434.87","1 through 10","105.16","196.13","percent of total billed charges",""
"Preventive Med New <1 Yr","PX-77000001","CDM","99381","CPT","0770","RC","","","","outpatient","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","196.13","81.72","","239.20","239.20","239.20","1 through 10","105.16","196.13","percent of total billed charges",""
"Preventive Med New > 65 Yrs","PX-77000007","CDM","99387","CPT","0770","RC","","","","both","","","414.00","310.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","329.13","79.5","","946.77","946.77","946.77","1 through 10","128.34","508.63","percent of total billed charges",""
"Preventive Med New > 65 Yrs","PX-77000007","CDM","99387","CPT","0770","RC","","","","both","","","414.00","310.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","151.11","36.5","","127.12","127.12","127.12","1 through 10","128.34","508.63","percent of total billed charges",""
"Preventive Med New > 65 Yrs","PX-77000007","CDM","99387","CPT","0770","RC","","","","both","","","414.00","310.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","158.56","38.3","","156.79","156.79","156.79","1 through 10","128.34","508.63","percent of total billed charges",""
"Preventive Med New > 65 Yrs","PX-77000007","CDM","99387","CPT","0770","RC","","","","outpatient","","","414.00","310.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","338.32","81.72","","320.56","320.56","320.56","1 through 10","105.16","338.32","percent of total billed charges",""
"Preventive Med New 1-4 Yrs","PX-77000002","CDM","99382","CPT","0770","RC","","","","both","","","272.00","204.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","99.28","36.5","","123.84","123.84","123.84","1 through 10","84.32","379.58","percent of total billed charges",""
"Preventive Med New 18-39 Yrs","PX-77000005","CDM","99385","CPT","0510","RC","","","","outpatient","","","306.00","229.50","AETNA [1001]","HB AMC AETNA HMO","213.59","69.8","","201.07","141.97","332.21","16","171.05","246.02","percent of total billed charges",""
"Preventive Med New 18-39 Yrs","PX-77000005","CDM","99385","CPT","0510","RC","","","","outpatient","","","306.00","229.50","AETNA [1001]","HB AMC AETNA PPO","246.02","80.4","","297.00","297.00","297.00","1 through 10","171.05","246.02","percent of total billed charges",""
"Preventive Med New 18-39 Yrs","PX-77000005","CDM","99385","CPT","0770","RC","","","","both","","","306.00","229.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","243.27","79.5","","233.74","156.82","447.88","16","94.86","401.4","percent of total billed charges",""
"Preventive Med New 18-39 Yrs","PX-77000005","CDM","99385","CPT","0770","RC","","","","both","","","306.00","229.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","163.10","53.3","","233.74","149.99","289.49","1 through 10","94.86","401.4","percent of total billed charges",""
"Preventive Med New 18-39 Yrs","PX-77000005","CDM","99385","CPT","0770","RC","","","","both","","","306.00","229.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","111.69","36.5","","215.02","110.78","432.24","16","94.86","401.4","percent of total billed charges",""
"Preventive Med New 18-39 Yrs","PX-77000005","CDM","99385","CPT","0770","RC","","","","both","","","306.00","229.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","117.20","38.3","","116.13","112.86","225.72","76","94.86","401.4","percent of total billed charges",""
"Preventive Med New 18-39 Yrs","PX-77000005","CDM","99385","CPT","0770","RC","","","","both","","","306.00","229.50","TRICARE [160005]","HB BWH TRICARE","290.70","95","","99.65","92.63","99.65","1 through 10","94.86","401.4","percent of total billed charges",""
"Preventive Med New 18-39 Yrs","PX-77000005","CDM","99385","CPT","0770","RC","","","","both","","","306.00","229.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","131.27","42.9","","237.42","237.42","237.42","1 through 10","94.86","401.4","percent of total billed charges",""
"Preventive Med New 18-39 Yrs","PX-77000005","CDM","99385","CPT","0770","RC","","","","outpatient","","","306.00","229.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","250.06","81.72","","237.42","130.59","237.42","31","105.16","250.06","percent of total billed charges",""
"Preventive Med New 40-64 Yrs","PX-77000006","CDM","99386","CPT","0510","RC","","","","outpatient","","","376.00","282.00","AETNA [1001]","HB AMC AETNA HMO","262.45","69.8","","247.11","174.47","284.70","1 through 10","210.18","302.3","percent of total billed charges",""
"Preventive Med New 40-64 Yrs","PX-77000006","CDM","99386","CPT","0770","RC","","","","both","","","376.00","282.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","298.92","79.5","","287.26","192.72","287.26","1 through 10","116.56","469.5","percent of total billed charges",""
"Preventive Med New 40-64 Yrs","PX-77000006","CDM","99386","CPT","0770","RC","","","","both","","","376.00","282.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","200.41","53.3","","287.26","192.72","287.26","1 through 10","116.56","469.5","percent of total billed charges",""
"Preventive Med New 40-64 Yrs","PX-77000006","CDM","99386","CPT","0770","RC","","","","both","","","376.00","282.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","116.56","31","","112.79","112.79","112.79","1 through 10","116.56","469.5","percent of total billed charges",""
"Preventive Med New 40-64 Yrs","PX-77000006","CDM","99386","CPT","0770","RC","","","","both","","","376.00","282.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","137.24","36.5","","136.15","115.71","180.16","1 through 10","116.56","469.5","percent of total billed charges",""
"Preventive Med New 40-64 Yrs","PX-77000006","CDM","99386","CPT","0770","RC","","","","both","","","376.00","282.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","144.01","38.3","","142.72","138.70","277.40","47","116.56","469.5","percent of total billed charges",""
"Preventive Med New 40-64 Yrs","PX-77000006","CDM","99386","CPT","0770","RC","","","","both","","","376.00","282.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","161.30","42.9","","160.49","160.49","160.49","1 through 10","116.56","469.5","percent of total billed charges",""
"Preventive Med New 40-64 Yrs","PX-77000006","CDM","99386","CPT","0770","RC","","","","outpatient","","","376.00","282.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","307.27","81.72","","291.78","291.78","291.78","1 through 10","105.16","307.27","percent of total billed charges",""
"Preventive Med New 40-64 Yrs","PX-77000006","CDM","99386","CPT","0770","RC","","","","outpatient","","","376.00","282.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","307.27","81.72","","291.78","160.49","291.78","14","105.16","307.27","percent of total billed charges",""
"Preventive Med New 5-11 Yrs","PX-77000003","CDM","99383","CPT","0770","RC","","","","both","","","278.00","208.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","106.47","38.3","","138.02","134.14","138.02","1 through 10","86.18","371.04","percent of total billed charges",""
"Prevg 10405 Heterotaxy, Situs Inversus, and Kartageners","PX-31001214","CDM","81479","CPT","0310","RC","","","","both","","","1947.00","1460.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1547.87","79.5","","0.65","0.65","0.65","1 through 10","603.57","1849.65","percent of total billed charges",""
"Prevg 10405 Heterotaxy, Situs Inversus, and Kartageners","PX-31001214","CDM","81479","CPT","0310","RC","","","","both","","","1947.00","1460.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1037.75","53.3","","0.79","0.79","0.79","1 through 10","603.57","1849.65","percent of total billed charges",""
"Prevg 10405 Heterotaxy, Situs Inversus, and Kartageners","PX-31001214","CDM","81479","CPT","0310","RC","","","","outpatient","","","1947.00","1460.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","973.50","50","","1.00","1.00","1.00","1 through 10","156.55","1606.28","percent of total billed charges",""
"Prevg 10405 Heterotaxy, Situs Inversus, and Kartageners","PX-31001214","CDM","81479","CPT","0310","RC","","","","outpatient","","","1947.00","1460.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1022.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","1606.28","percent of total billed charges",""
"Prevg Disorders of Sex Development (Dsd) Sequencing Panel With Cnv Detection","PX-31001059","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Prevg Disorders of Sex Development (Dsd) Sequencing Panel With Cnv Detection","PX-31001059","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Prevg Disorders of Sex Development (Dsd) Sequencing Panel With Cnv Detection","PX-31001059","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Prevg Disorders of Sex Development (Dsd) Sequencing Panel With Cnv Detection","PX-31001059","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Prevg P10657 Cleft Lip/Palate 163 Gene Panel by Ngs","PX-31001185","CDM","81479","CPT","0310","RC","","","","both","","","1390.00","1042.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1105.05","79.5","","0.65","0.65","0.65","1 through 10","430.9","1320.5","percent of total billed charges",""
"Prevg P10657 Cleft Lip/Palate 163 Gene Panel by Ngs","PX-31001185","CDM","81479","CPT","0310","RC","","","","both","","","1390.00","1042.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","740.87","53.3","","0.79","0.79","0.79","1 through 10","430.9","1320.5","percent of total billed charges",""
"Prevg P10657 Cleft Lip/Palate 163 Gene Panel by Ngs","PX-31001185","CDM","81479","CPT","0310","RC","","","","outpatient","","","1390.00","1042.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","695.00","50","","1.00","1.00","1.00","1 through 10","156.55","1146.75","percent of total billed charges",""
"Prevg P10657 Cleft Lip/Palate 163 Gene Panel by Ngs","PX-31001185","CDM","81479","CPT","0310","RC","","","","outpatient","","","1390.00","1042.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","729.75","52.5","","1.00","0.53","1.00","1 through 10","156.55","1146.75","percent of total billed charges",""
"Prgrmg Dev Eval Implantable Subq Lead Dfb System","PX-48000421","CDM","93260","CPT","0480","RC","","","","both","","","535.00","401.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","425.33","79.5","","408.45","408.45","408.45","1 through 10","42.07","425.33","percent of total billed charges",""
"Prgrmg Dev Eval Implantable Subq Lead Dfb System","PX-48000421","CDM","93260","CPT","0480","RC","","","","both","","","535.00","401.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","1 through 10","42.07","425.33","other","OPPS APC"
"Prgrmg Dev Eval Implantable Subq Lead Dfb System","PX-48000421","CDM","93260","CPT","0480","RC","","","","both","","","535.00","401.25","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","41.16","88.56","1 through 10","42.07","425.33","other","OPPS APC"
"Prgrmg Dev Eval Implantable Subq Lead Dfb System","PX-48000421","CDM","93260","CPT","0480","RC","","","","both","","","535.00","401.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","195.28","36.5","","329.04","164.52","329.04","1 through 10","42.07","425.33","percent of total billed charges",""
"Prgrmg Dev Eval Implantable Subq Lead Dfb System","PX-48000421","CDM","93260","CPT","0480","RC","","","","both","","","535.00","401.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","204.91","38.3","","608.79","608.79","608.79","1 through 10","42.07","425.33","percent of total billed charges",""
"Prgrmg Dev Eval Implantable Subq Lead Dfb System","PX-48000421","CDM","93260","CPT","0480","RC","","","","outpatient","","","535.00","401.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","437.20","81.72","","414.89","414.89","414.89","1 through 10","82.5","437.2","percent of total billed charges",""
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","2563.00","1922.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","2485.00","1 through 10","42.07","2037.59","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","2563.00","1922.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2037.59","79.5","","1955.70","1955.70","1955.70","1 through 10","42.07","2037.59","percent of total billed charges",""
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","2563.00","1922.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1366.08","53.3","","3936.24","1312.08","3936.24","1 through 10","42.07","2037.59","percent of total billed charges",""
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","2563.00","1922.25","FALLON HEALTH [1008]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","130.17","40.34","130.17","1 through 10","42.07","2037.59","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","2563.00","1922.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.05","114.05","114.05","1 through 10","42.07","2037.59","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","2563.00","1922.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1973.51","77","","1913.45","1913.45","1913.45","1 through 10","42.07","2037.59","percent of total billed charges",""
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","2563.00","1922.25","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","41.16","88.56","46","42.07","2037.59","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","2563.00","1922.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","935.50","36.5","","1799.14","926.91","1799.14","1 through 10","42.07","2037.59","percent of total billed charges",""
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","2563.00","1922.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","981.63","38.3","","2914.92","971.64","2914.92","1 through 10","42.07","2037.59","percent of total billed charges",""
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","2563.00","1922.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","86.78","43.79","86.78","1 through 10","42.07","2037.59","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","2563.00","1922.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","44.28","43.90","44.28","1 through 10","42.07","2037.59","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","outpatient","","","2563.00","1922.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2094.48","81.72","","1986.51","1092.65","1986.51","1 through 10","85.36","2094.48","percent of total billed charges",""
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","1769.00","1326.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","106.90","44.28","106.90","1 through 10","42.07","1406.36","other","OPPS APC"
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","1769.00","1326.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","55.35","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","44.28","44.28","44.28","1 through 10","42.07","1406.36","other","OPPS APC"
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","1769.00","1326.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1406.36","79.5","","1349.71","905.52","1349.71","1 through 10","42.07","1406.36","percent of total billed charges",""
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","1769.00","1326.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","942.88","53.3","","905.52","905.52","905.52","1 through 10","42.07","1406.36","percent of total billed charges",""
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","1769.00","1326.75","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","41.16","88.56","27","42.07","1406.36","other","OPPS APC"
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","1769.00","1326.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","645.69","36.5","","1919.10","620.83","1919.10","1 through 10","42.07","1406.36","percent of total billed charges",""
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","1769.00","1326.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","677.53","38.3","","670.57","670.57","670.57","1 through 10","42.07","1406.36","percent of total billed charges",""
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","1769.00","1326.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","87.58","87.58","87.58","1 through 10","42.07","1406.36","other","OPPS APC"
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","1769.00","1326.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","44.28","43.39","44.28","1 through 10","42.07","1406.36","other","OPPS APC"
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","outpatient","","","1769.00","1326.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1445.63","81.72","","754.09","754.09","754.09","1 through 10","85.36","1445.63","percent of total billed charges",""
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","outpatient","","","1769.00","1326.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1445.63","81.72","","1370.97","95.13","1370.97","1 through 10","85.36","1445.63","percent of total billed charges",""
"Primary Ab Def Panel, Seq (35 Genes) and Del/Dup (26 Genes)","PX-31000838","CDM","81479","CPT","0310","RC","","","","both","","","812.00","609.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","645.54","79.5","","0.65","0.65","0.65","1 through 10","251.72","771.4","percent of total billed charges",""
"Primary Ab Def Panel, Seq (35 Genes) and Del/Dup (26 Genes)","PX-31000838","CDM","81479","CPT","0310","RC","","","","both","","","812.00","609.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","432.80","53.3","","0.79","0.79","0.79","1 through 10","251.72","771.4","percent of total billed charges",""
"Primary Ab Def Panel, Seq (35 Genes) and Del/Dup (26 Genes)","PX-31000838","CDM","81479","CPT","0310","RC","","","","outpatient","","","812.00","609.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","406.00","50","","1.00","1.00","1.00","1 through 10","156.55","669.9","percent of total billed charges",""
"Primary Ab Def Panel, Seq (35 Genes) and Del/Dup (26 Genes)","PX-31000838","CDM","81479","CPT","0310","RC","","","","outpatient","","","812.00","609.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","426.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","669.9","percent of total billed charges",""
"Primary Antibody Deficiency Panel, Sequencing (35 Genes) and Deletion/Duplication (26 Genes)","PX-31000795","CDM","81479","CPT","0310","RC","","","","both","","","812.00","609.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","645.54","79.5","","0.65","0.65","0.65","1 through 10","251.72","771.4","percent of total billed charges",""
"Primary Antibody Deficiency Panel, Sequencing (35 Genes) and Deletion/Duplication (26 Genes)","PX-31000795","CDM","81479","CPT","0310","RC","","","","both","","","812.00","609.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","432.80","53.3","","0.79","0.79","0.79","1 through 10","251.72","771.4","percent of total billed charges",""
"Primary Antibody Deficiency Panel, Sequencing (35 Genes) and Deletion/Duplication (26 Genes)","PX-31000795","CDM","81479","CPT","0310","RC","","","","outpatient","","","812.00","609.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","406.00","50","","1.00","1.00","1.00","1 through 10","156.55","669.9","percent of total billed charges",""
"Primary Antibody Deficiency Panel, Sequencing (35 Genes) and Deletion/Duplication (26 Genes)","PX-31000795","CDM","81479","CPT","0310","RC","","","","outpatient","","","812.00","609.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","426.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","669.9","percent of total billed charges",""
"Primidone","PX-30000032","CDM","80188","CPT","0301","RC","","","","both","","","213.00","159.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.58","38.3","","80.94","80.94","80.94","1 through 10","16.26","202.35","percent of total billed charges",""
"PROBE ABLATION 10CM CRYOICE MALLEABLE BX/3EA","SUP-ITM-10072469","CDM","C2618","HCPCS","0272","RC","","","","both","","","5750.00","4312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2202.25","38.3","","1876.80","640.73","1876.80","1 through 10","1782.5","4571.25","percent of total billed charges",""
"PROBE ABLATION 10CM CRYOICE MALLEABLE BX/3EA","SUP-ITM-10072469","CDM","C2618","HCPCS","0272","RC","","","","both","","","5750.00","4312.50","WELLPOINT [1015]","HB AMC WELLPOINT","4242.35","73.78","","2802.54","1220.01","4020.30","1 through 10","1782.5","4571.25","percent of total billed charges",""
"PROBE ABLATION 10CM CRYOICE MALLEABLE BX/3EA","SUP-ITM-10072469","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","5750.00","4312.50","AETNA [1001]","HB AMC AETNA HMO","4013.50","69.8","","2175.20","2175.20","2175.20","1 through 10","3004.95","4698.9","percent of total billed charges",""
"PROBE ABLATION 10CM CRYOICE MALLEABLE BX/3EA","SUP-ITM-10072469","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","5750.00","4312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4698.90","81.72","","4750.00","720.54","7250.00","11","3004.95","4698.9","percent of total billed charges",""
"PROBE ABLATION 14GA 15CM LG MICROWAVE ANTENNA AVECURE","SUP-ITM-10273913","CDM","C1889","HCPCS","0272","RC","","","","both","","","7000.00","5250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5565.00","79.5","","1309.77","674.56","6049.93","26","2170","5565","percent of total billed charges",""
"PROBE ABLATION 14GA 15CM LG MICROWAVE ANTENNA AVECURE","SUP-ITM-10273913","CDM","C1889","HCPCS","0272","RC","","","","both","","","7000.00","5250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3731.00","53.3","","1901.83","1901.83","2962.25","1 through 10","2170","5565","percent of total billed charges",""
"PROBE ABLATION 14GA 15CM LG MICROWAVE ANTENNA AVECURE","SUP-ITM-10273913","CDM","C1889","HCPCS","0272","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2555.00","36.5","","1620.31","1620.31","19908.88","1 through 10","2170","5565","percent of total billed charges",""
"PROBE ABLATION 14GA 15CM LG MICROWAVE ANTENNA AVECURE","SUP-ITM-10273913","CDM","C1889","HCPCS","0272","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2681.00","38.3","","352.91","352.91","2046.30","1 through 10","2170","5565","percent of total billed charges",""
"PROBE ABLATION 14GA 15CM LG MICROWAVE ANTENNA AVECURE","SUP-ITM-10273913","CDM","C1889","HCPCS","0272","RC","","","","both","","","7000.00","5250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3003.00","42.9","","9668.75","9668.75","9668.75","1 through 10","2170","5565","percent of total billed charges",""
"PROBE ABLATION 14GA 15CM LG MICROWAVE ANTENNA AVECURE","SUP-ITM-10273913","CDM","C1889","HCPCS","0272","RC","","","","both","","","7000.00","5250.00","WELLPOINT [1015]","HB AMC WELLPOINT","5164.60","73.78","","699.88","384.10","3443.31","33","2170","5565","percent of total billed charges",""
"PROBE ABLATION 14GA 15CM LG MICROWAVE ANTENNA AVECURE","SUP-ITM-10273913","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","7000.00","5250.00","AETNA [1001]","HB AMC AETNA HMO","4886.00","69.8","","1421.24","264.50","4933.46","29","3658.2","5720.4","percent of total billed charges",""
"PROBE ABLATION 14GA 15CM LG MICROWAVE ANTENNA AVECURE","SUP-ITM-10273913","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","7000.00","5250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5628.00","80.4","","1022.97","1022.97","3607.50","1 through 10","3658.2","5720.4","percent of total billed charges",""
"PROBE ABLATION 14GA 15CM LG MICROWAVE ANTENNA AVECURE","SUP-ITM-10273913","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","7000.00","5250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5720.40","81.72","","3010.54","693.88","5019.88","35","3658.2","5720.4","percent of total billed charges",""
"PROBE ABLATION 14GAX150MM VERSION 5 AMICA","SUP-ITM-10124366","CDM","C1889","HCPCS","0272","RC","","","","both","","","5875.00","4406.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4670.63","79.5","","1309.77","674.56","6049.93","26","1821.25","4670.63","percent of total billed charges",""
"PROBE ABLATION 14GAX150MM VERSION 5 AMICA","SUP-ITM-10124366","CDM","C1889","HCPCS","0272","RC","","","","both","","","5875.00","4406.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3131.38","53.3","","1901.83","1901.83","2962.25","1 through 10","1821.25","4670.63","percent of total billed charges",""
"PROBE ABLATION 14GAX150MM VERSION 5 AMICA","SUP-ITM-10124366","CDM","C1889","HCPCS","0272","RC","","","","both","","","5875.00","4406.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2144.38","36.5","","1620.31","1620.31","19908.88","1 through 10","1821.25","4670.63","percent of total billed charges",""
"PROBE ABLATION 14GAX150MM VERSION 5 AMICA","SUP-ITM-10124366","CDM","C1889","HCPCS","0272","RC","","","","both","","","5875.00","4406.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2250.13","38.3","","352.91","352.91","2046.30","1 through 10","1821.25","4670.63","percent of total billed charges",""
"PROBE ABLATION 14GAX150MM VERSION 5 AMICA","SUP-ITM-10124366","CDM","C1889","HCPCS","0272","RC","","","","both","","","5875.00","4406.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2520.38","42.9","","9668.75","9668.75","9668.75","1 through 10","1821.25","4670.63","percent of total billed charges",""
"PROBE ABLATION 14GAX150MM VERSION 5 AMICA","SUP-ITM-10124366","CDM","C1889","HCPCS","0272","RC","","","","both","","","5875.00","4406.25","WELLPOINT [1015]","HB AMC WELLPOINT","4334.58","73.78","","699.88","384.10","3443.31","33","1821.25","4670.63","percent of total billed charges",""
"PROBE ABLATION 14GAX150MM VERSION 5 AMICA","SUP-ITM-10124366","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5875.00","4406.25","AETNA [1001]","HB AMC AETNA HMO","4100.75","69.8","","1421.24","264.50","4933.46","29","3070.28","4801.05","percent of total billed charges",""
"PROBE ABLATION 14GAX150MM VERSION 5 AMICA","SUP-ITM-10124366","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5875.00","4406.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4723.50","80.4","","1022.97","1022.97","3607.50","1 through 10","3070.28","4801.05","percent of total billed charges",""
"PROBE ABLATION 14GAX150MM VERSION 5 AMICA","SUP-ITM-10124366","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5875.00","4406.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4801.05","81.72","","3010.54","693.88","5019.88","35","3070.28","4801.05","percent of total billed charges",""
"PROBE ABLATION 15GA 20CM LK XT CERTUS MICORWAVE NEUWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10239794","CDM","C1886","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3665.39","71.8","","4399.55","4399.55","4399.55","1 through 10","1582.55","4058.48","percent of total billed charges",""
"PROBE ABLATION 15GA 20CM LK XT CERTUS MICORWAVE NEUWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10239794","CDM","C1886","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1863.33","36.5","","1413.19","621.27","1413.19","1 through 10","1582.55","4058.48","percent of total billed charges",""
"PROBE ABLATION 15GA 20CM LK XT CERTUS MICORWAVE NEUWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10239794","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","5105.00","3828.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4171.81","81.72","","8168.27","2209.17","8168.27","1 through 10","2667.87","4171.81","percent of total billed charges",""
"PROBE ABLATION 17GA 15CM LIVER KIDNEY CERTUS MICROWAVE NEUWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10239787","CDM","C1889","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4058.48","79.5","","1309.77","674.56","6049.93","26","1582.55","4058.48","percent of total billed charges",""
"PROBE ABLATION 17GA 15CM LIVER KIDNEY CERTUS MICROWAVE NEUWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10239787","CDM","C1889","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2720.97","53.3","","1901.83","1901.83","2962.25","1 through 10","1582.55","4058.48","percent of total billed charges",""
"PROBE ABLATION 17GA 15CM LIVER KIDNEY CERTUS MICROWAVE NEUWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10239787","CDM","C1889","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1863.33","36.5","","1620.31","1620.31","19908.88","1 through 10","1582.55","4058.48","percent of total billed charges",""
"PROBE ABLATION 17GA 15CM LIVER KIDNEY CERTUS MICROWAVE NEUWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10239787","CDM","C1889","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1955.22","38.3","","352.91","352.91","2046.30","1 through 10","1582.55","4058.48","percent of total billed charges",""
"PROBE ABLATION 17GA 15CM LIVER KIDNEY CERTUS MICROWAVE NEUWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10239787","CDM","C1889","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2190.05","42.9","","9668.75","9668.75","9668.75","1 through 10","1582.55","4058.48","percent of total billed charges",""
"PROBE ABLATION 17GA 15CM LIVER KIDNEY CERTUS MICROWAVE NEUWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10239787","CDM","C1889","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","WELLPOINT [1015]","HB AMC WELLPOINT","3766.47","73.78","","699.88","384.10","3443.31","33","1582.55","4058.48","percent of total billed charges",""
"PROBE ABLATION 17GA 15CM LIVER KIDNEY CERTUS MICROWAVE NEUWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10239787","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5105.00","3828.75","AETNA [1001]","HB AMC AETNA HMO","3563.29","69.8","","1421.24","264.50","4933.46","29","2667.87","4171.81","percent of total billed charges",""
"PROBE ABLATION 17GA 15CM LIVER KIDNEY CERTUS MICROWAVE NEUWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10239787","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5105.00","3828.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4104.42","80.4","","1022.97","1022.97","3607.50","1 through 10","2667.87","4171.81","percent of total billed charges",""
"PROBE ABLATION 17GA 15CM LIVER KIDNEY CERTUS MICROWAVE NEUWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10239787","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5105.00","3828.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4171.81","81.72","","3010.54","693.88","5019.88","35","2667.87","4171.81","percent of total billed charges",""
"PROBE COLON 190CM 2.3MM OD ARGON PLASMA COAGULATION HYBRID BX/5EA","SUP-ITM-10211055","CDM","C1886","HCPCS","0272","RC","","","","both","","","1851.50","1388.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1329.38","71.8","","4399.55","4399.55","4399.55","1 through 10","573.97","1471.94","percent of total billed charges",""
"PROBE COLON 190CM 2.3MM OD ARGON PLASMA COAGULATION HYBRID BX/5EA","SUP-ITM-10211055","CDM","C1886","HCPCS","0272","RC","","","","both","","","1851.50","1388.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","675.80","36.5","","1413.19","621.27","1413.19","1 through 10","573.97","1471.94","percent of total billed charges",""
"PROBE COLON 190CM 2.3MM OD ARGON PLASMA COAGULATION HYBRID BX/5EA","SUP-ITM-10211055","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","1851.50","1388.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1513.05","81.72","","8168.27","2209.17","8168.27","1 through 10","967.59","1513.05","percent of total billed charges",""
"PROBE CRYOSURGICAL 70MM SURGIFROST FREEZING SEGMENT","SUP-ITM-10017945","CDM","C2618","HCPCS","0272","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","1876.80","640.73","1876.80","1 through 10","1627.5","4173.75","percent of total billed charges",""
"PROBE CRYOSURGICAL 70MM SURGIFROST FREEZING SEGMENT","SUP-ITM-10017945","CDM","C2618","HCPCS","0272","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","2802.54","1220.01","4020.30","1 through 10","1627.5","4173.75","percent of total billed charges",""
"PROBE CRYOSURGICAL 70MM SURGIFROST FREEZING SEGMENT","SUP-ITM-10017945","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","2175.20","2175.20","2175.20","1 through 10","2743.65","4290.3","percent of total billed charges",""
"PROBE CRYOSURGICAL 70MM SURGIFROST FREEZING SEGMENT","SUP-ITM-10017945","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","4750.00","720.54","7250.00","11","2743.65","4290.3","percent of total billed charges",""
"PROBE ELECTRODE 15CM NANOKNIFE SINGLE ACTIVATION","SUP-ITM-10281922","CDM","C1886","HCPCS","0272","RC","","","","both","","","7500.00","5625.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","5385.00","71.8","","4399.55","4399.55","4399.55","1 through 10","2325","5962.5","percent of total billed charges",""
"PROBE ELECTRODE 15CM NANOKNIFE SINGLE ACTIVATION","SUP-ITM-10281922","CDM","C1886","HCPCS","0272","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2737.50","36.5","","1413.19","621.27","1413.19","1 through 10","2325","5962.5","percent of total billed charges",""
"PROBE ELECTRODE 15CM NANOKNIFE SINGLE ACTIVATION","SUP-ITM-10281922","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6129.00","81.72","","8168.27","2209.17","8168.27","1 through 10","3919.5","6129","percent of total billed charges",""
"PROBE LASER SIZE #00 NEUROBLATE SYSTEM FULLFIRE DIFFUSING TIP","SUP-ITM-10188845","CDM","C1886","HCPCS","0272","RC","","","","both","","","24202.50","18151.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","17377.40","71.8","","4399.55","4399.55","4399.55","1 through 10","7502.78","19240.99","percent of total billed charges",""
"PROBE LASER SIZE #00 NEUROBLATE SYSTEM FULLFIRE DIFFUSING TIP","SUP-ITM-10188845","CDM","C1886","HCPCS","0272","RC","","","","both","","","24202.50","18151.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8833.91","36.5","","1413.19","621.27","1413.19","1 through 10","7502.78","19240.99","percent of total billed charges",""
"PROBE LASER SIZE #00 NEUROBLATE SYSTEM FULLFIRE DIFFUSING TIP","SUP-ITM-10188845","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","24202.50","18151.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","19778.28","81.72","","8168.27","2209.17","8168.27","1 through 10","12648.23","19778.28","percent of total billed charges",""
"PROBE LASER SIZE #000 NEUROBLATE SYSTEM FULLFIRE DIFFUSING TIP","SUP-ITM-10188844","CDM","C1886","HCPCS","0272","RC","","","","both","","","26430.00","19822.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","18976.74","71.8","","4399.55","4399.55","4399.55","1 through 10","8193.3","21011.85","percent of total billed charges",""
"PROBE LASER SIZE #000 NEUROBLATE SYSTEM FULLFIRE DIFFUSING TIP","SUP-ITM-10188844","CDM","C1886","HCPCS","0272","RC","","","","both","","","26430.00","19822.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9646.95","36.5","","1413.19","621.27","1413.19","1 through 10","8193.3","21011.85","percent of total billed charges",""
"PROBE LASER SIZE #000 NEUROBLATE SYSTEM FULLFIRE DIFFUSING TIP","SUP-ITM-10188844","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","26430.00","19822.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21598.60","81.72","","8168.27","2209.17","8168.27","1 through 10","13812.32","21598.6","percent of total billed charges",""
"PROBE LUNG 17G 20CM ABLATION CERTUS MICROWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10165847","CDM","C1889","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4058.48","79.5","","1309.77","674.56","6049.93","26","1582.55","4058.48","percent of total billed charges",""
"PROBE LUNG 17G 20CM ABLATION CERTUS MICROWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10165847","CDM","C1889","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2720.97","53.3","","1901.83","1901.83","2962.25","1 through 10","1582.55","4058.48","percent of total billed charges",""
"PROBE LUNG 17G 20CM ABLATION CERTUS MICROWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10165847","CDM","C1889","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1863.33","36.5","","1620.31","1620.31","19908.88","1 through 10","1582.55","4058.48","percent of total billed charges",""
"PROBE LUNG 17G 20CM ABLATION CERTUS MICROWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10165847","CDM","C1889","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1955.22","38.3","","352.91","352.91","2046.30","1 through 10","1582.55","4058.48","percent of total billed charges",""
"PROBE LUNG 17G 20CM ABLATION CERTUS MICROWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10165847","CDM","C1889","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2190.05","42.9","","9668.75","9668.75","9668.75","1 through 10","1582.55","4058.48","percent of total billed charges",""
"PROBE LUNG 17G 20CM ABLATION CERTUS MICROWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10165847","CDM","C1889","HCPCS","0272","RC","","","","both","","","5105.00","3828.75","WELLPOINT [1015]","HB AMC WELLPOINT","3766.47","73.78","","699.88","384.10","3443.31","33","1582.55","4058.48","percent of total billed charges",""
"PROBE LUNG 17G 20CM ABLATION CERTUS MICROWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10165847","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5105.00","3828.75","AETNA [1001]","HB AMC AETNA HMO","3563.29","69.8","","1421.24","264.50","4933.46","29","2667.87","4171.81","percent of total billed charges",""
"PROBE LUNG 17G 20CM ABLATION CERTUS MICROWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10165847","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5105.00","3828.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4104.42","80.4","","1022.97","1022.97","3607.50","1 through 10","2667.87","4171.81","percent of total billed charges",""
"PROBE LUNG 17G 20CM ABLATION CERTUS MICROWAVE - DISCONTINUED PER SUPPLIER","SUP-ITM-10165847","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5105.00","3828.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4171.81","81.72","","3010.54","693.88","5019.88","35","2667.87","4171.81","percent of total billed charges",""
"PROBE NANOKNIFE 15CM ELECTRODE SINGLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10118248","CDM","C1886","HCPCS","0272","RC","","","","both","","","6037.50","4528.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","4334.93","71.8","","4399.55","4399.55","4399.55","1 through 10","1871.63","4799.81","percent of total billed charges",""
"PROBE NANOKNIFE 15CM ELECTRODE SINGLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10118248","CDM","C1886","HCPCS","0272","RC","","","","both","","","6037.50","4528.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2203.69","36.5","","1413.19","621.27","1413.19","1 through 10","1871.63","4799.81","percent of total billed charges",""
"PROBE NANOKNIFE 15CM ELECTRODE SINGLE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10118248","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","6037.50","4528.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4933.85","81.72","","8168.27","2209.17","8168.27","1 through 10","3155.2","4933.85","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","11050.00","8287.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8784.75","79.5","","1309.77","674.56","6049.93","26","3425.5","8784.75","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","11050.00","8287.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5889.65","53.3","","1901.83","1901.83","2962.25","1 through 10","3425.5","8784.75","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","11050.00","8287.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4033.25","36.5","","1620.31","1620.31","19908.88","1 through 10","3425.5","8784.75","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","11050.00","8287.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4232.15","38.3","","352.91","352.91","2046.30","1 through 10","3425.5","8784.75","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","11050.00","8287.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4740.45","42.9","","9668.75","9668.75","9668.75","1 through 10","3425.5","8784.75","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","11050.00","8287.50","WELLPOINT [1015]","HB AMC WELLPOINT","8152.69","73.78","","699.88","384.10","3443.31","33","3425.5","8784.75","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","11050.00","8287.50","AETNA [1001]","HB AMC AETNA HMO","7712.90","69.8","","1421.24","264.50","4933.46","29","5774.73","9030.06","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","11050.00","8287.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8884.20","80.4","","1022.97","1022.97","3607.50","1 through 10","5774.73","9030.06","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","11050.00","8287.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9030.06","81.72","","3010.54","693.88","5019.88","35","5774.73","9030.06","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","both","","","2576.00","1932.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2047.92","79.5","","1309.77","674.56","6049.93","26","798.56","2047.92","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","both","","","2576.00","1932.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1373.01","53.3","","1901.83","1901.83","2962.25","1 through 10","798.56","2047.92","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","both","","","2576.00","1932.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","940.24","36.5","","1620.31","1620.31","19908.88","1 through 10","798.56","2047.92","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","both","","","2576.00","1932.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","986.61","38.3","","352.91","352.91","2046.30","1 through 10","798.56","2047.92","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","both","","","2576.00","1932.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1105.10","42.9","","9668.75","9668.75","9668.75","1 through 10","798.56","2047.92","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","both","","","2576.00","1932.00","WELLPOINT [1015]","HB AMC WELLPOINT","1900.57","73.78","","699.88","384.10","3443.31","33","798.56","2047.92","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2576.00","1932.00","AETNA [1001]","HB AMC AETNA HMO","1798.05","69.8","","1421.24","264.50","4933.46","29","1346.22","2105.11","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2576.00","1932.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2071.10","80.4","","1022.97","1022.97","3607.50","1 through 10","1346.22","2105.11","percent of total billed charges",""
"PROBE STIMULATING 200MM MONOPOLAR","SUP-ITM-10125912","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2576.00","1932.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2105.11","81.72","","3010.54","693.88","5019.88","35","1346.22","2105.11","percent of total billed charges",""
"Procainamide Challenge Test","PX-48000490","CDM","93799","CPT","0481","RC","","","","both","","","3668.00","2751.00","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","2916.06","other","OPPS APC"
"Procainamide Challenge Test","PX-48000490","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","AETNA [1001]","HB AMC AETNA HMO","2560.26","69.8","","2022.70","2022.70","2022.70","1 through 10","454","3026.1","percent of total billed charges",""
"Procainamide Challenge Test","PX-48000490","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2220.97","60.55","","318.03","318.03","2439.77","1 through 10","454","3026.1","percent of total billed charges",""
"Procainamide Challenge Test","PX-48000490","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1915.43","52.22","","360.38","360.38","4023.00","1 through 10","454","3026.1","percent of total billed charges",""
"Procainamide Challenge Test","PX-48000490","CDM","93799","CPT","0481","RC","","","","outpatient","","","3668.00","2751.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2017.40","55","","13080.03","13080.03","13080.03","1 through 10","454","3026.1","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","both","","","329.00","246.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","236.22","71.8","","319.00","319.00","319.00","1 through 10","26.68","312.55","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","both","","","329.00","246.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","230.30","70","","957.00","957.00","957.00","1 through 10","26.68","312.55","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","both","","","329.00","246.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","261.56","79.5","","251.05","188.49","251.05","1 through 10","26.68","312.55","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","both","","","329.00","246.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","175.36","53.3","","598.49","168.43","598.49","1 through 10","26.68","312.55","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","both","","","329.00","246.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","253.33","77","","245.63","245.63","245.63","1 through 10","26.68","312.55","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","both","","","329.00","246.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","120.09","36.5","","118.99","101.12","118.99","1 through 10","26.68","312.55","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","both","","","329.00","246.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","126.01","38.3","","124.73","124.73","124.73","1 through 10","26.68","312.55","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","outpatient","","","329.00","246.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","268.86","81.72","","255.01","255.01","255.01","1 through 10","27.61","268.86","percent of total billed charges",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MAJOR","850","DRG","","","","","","","","inpatient","","","120816.02","","MASSHEALTH [3001]","HB BWH MEDICAID","17667.83","","Case rate ($19,534.83). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,964.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","33695.81","33695.81","33695.81","1 through 10","14991.27","380168.71","case rate",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MINOR","850","DRG","","","","","","","","inpatient","","","100845.11","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","59484.96","","Standard inlier is a Case rate ($59,484.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,443.40) for the length of stay and the standard reimbursement.","59484.96","59484.96","59484.96","1 through 10","14991.27","380168.71","case rate",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MINOR","850","DRG","","","","","","","","inpatient","","","100845.11","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","25895.6636","","Fee schedule rate ($25,895.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25895.6636","25895.68","25895.68","1 through 10","14991.27","380168.71","case rate",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MINOR","850","DRG","","","","","","","","inpatient","","","100845.11","","MASSHEALTH [3001]","HB BWH MEDICAID","14991.27","","Case rate ($16,575.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,005.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16571.36","16571.36","16571.36","1 through 10","14991.27","380168.71","case rate",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MINOR","850","DRG","","","","","","","","inpatient","","","100845.11","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14991.27","","Case rate ($16,575.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,005.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16571.36","16571.36","16571.36","1 through 10","14991.27","380168.71","case rate",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MODERATE","850","DRG","","","","","","","","inpatient","","","83272.10","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","59484.96","","Standard inlier is a Case rate ($59,484.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $52,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,443.40) for the length of stay and the standard reimbursement.","80679.20","73707.42","80679.20","1 through 10","14991.27","380168.71","case rate",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MODERATE","850","DRG","","","","","","","","inpatient","","","83272.10","","MASSHEALTH [3001]","HB BWH MEDICAID","14991.27","","Case rate ($16,575.43). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,005.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","33265.91","33265.91","33265.91","1 through 10","14991.27","380168.71","case rate",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MODERATE","850","DRG","","","","","","","","inpatient","","","83272.10","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","69498.78","","Fee schedule rate ($69,498.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","69498.78","69498.78","69498.78","1 through 10","14991.27","380168.71","case rate",""
"Procedures For Obesity,MAJOR","403","DRG","","","","","","","","inpatient","","","137980.89","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","27741.7901","","Fee schedule rate ($55,875.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27741.7901","55875.00","55875.00","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MAJOR","403","DRG","","","","","","","","inpatient","","","137980.89","","MASSHEALTH [3001]","HB BWH MEDICAID","20205.03","","Case rate ($22,340.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,770.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22334.64","22334.64","22334.64","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MAJOR","403","DRG","","","","","","","","inpatient","","","137980.89","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44521.20","","Fee schedule rate ($44,521.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","44521.20","44521.20","44521.20","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","58696.52","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","35778.85","","Standard inlier is a Case rate ($35,778.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,079.02) for the length of stay and the standard reimbursement.","32613.72","32613.72","35778.84","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","58696.52","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","40225.07","","Standard inlier is a Case rate ($40,225.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,709.61) for the length of stay and the standard reimbursement.","40225.06","36749.07","40225.06","17","8712.83","254024.85","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","58696.52","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","27741.7901","","Fee schedule rate ($30,989.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27741.7901","27741.80","27741.80","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","58696.52","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","29129.6858","","Fee schedule rate ($32,539.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29129.6858","29129.68","29129.68","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","58696.52","","MASSHEALTH [3001]","HB BWH MEDICAID","8712.83","","Case rate ($9,633.53). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,063.53, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9631.16","9631.16","10209.03","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","58696.52","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","24260.89","","Fee schedule rate ($24,260.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19704.77","19704.77","19704.77","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","58696.52","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28542.54","","Fee schedule rate ($28,542.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23877.53","23877.53","23877.53","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","58696.52","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29969.76","","Fee schedule rate ($29,969.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25071.49","24341.42","25071.49","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","58696.52","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8712.83","","Case rate ($9,633.53). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,063.53, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9631.16","9631.16","9631.16","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","79257.87","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","41538.78","","Standard inlier is a Case rate ($41,538.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,949, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,896.68) for the length of stay and the standard reimbursement.","37864.11","37864.11","41538.78","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","79257.87","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","46700.78","","Standard inlier is a Case rate ($46,700.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,949, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,628.79) for the length of stay and the standard reimbursement.","46700.78","46700.78","46700.78","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","79257.87","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","27741.7901","","Fee schedule rate ($30,989.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27741.7901","30989.48","30989.48","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","79257.87","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","29129.6858","","Fee schedule rate ($32,539.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29129.6858","32539.84","32539.84","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","79257.87","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28542.54","","Fee schedule rate ($28,542.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28542.54","28542.54","28542.54","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","79257.87","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29969.76","","Fee schedule rate ($29,969.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29969.76","29969.76","29969.76","1 through 10","8712.83","254024.85","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","79257.87","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9539.90","","Case rate ($10,548). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,978, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10545.41","10545.41","10545.41","1 through 10","8712.83","254024.85","case rate",""
"Prochlorper Vl 5mg/Ml 2ml","PX-63600085","CDM","J0780","HCPCS","0636","RC","","","","both","","","10.24","7.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3.74","36.5","","1.21","1.04","3.92","17","3.17","7.88","percent of total billed charges",""
"Prochlorper Vl 5mg/Ml 2ml","PX-63600085","CDM","J0780","HCPCS","0636","RC","","","","both","","","10.24","7.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3.92","38.3","","2.57","1.27","4.92","19","3.17","7.88","percent of total billed charges",""
"Prochlorper Vl 5mg/Ml 2ml","PX-63600085","CDM","J0780","HCPCS","0636","RC","","","","outpatient","","","10.24","7.68","AETNA [1001]","HB AMC AETNA HMO","7.15","69.8","","8.48","2.57","8.48","1 through 10","0.01","8.23","percent of total billed charges",""
"Prochlorper Vl 5mg/Ml 2ml","PX-63600085","CDM","J0780","HCPCS","0636","RC","","","","outpatient","","","10.24","7.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7.16","69.9","","6.87","2.50","6.87","1 through 10","0.01","8.23","percent of total billed charges",""
"Prochlorper Vl 5mg/Ml 2ml","PX-63600085","CDM","J0780","HCPCS","0636","RC","","","","outpatient","","","10.24","7.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4.80","46.9","","27422.16","1.14","27422.16","1 through 10","0.01","8.23","percent of total billed charges",""
"Proctosigmoidoscopy Flexible With Eus","PX-75000500","CDM","45999","CPT","0750","RC","","","","outpatient","","","2866.00","2149.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1496.63","52.22","","1324.00","1324.00","1324.00","1 through 10","1234.13","2364.45","percent of total billed charges",""
"Proctosigmoidoscopy Flexible With Eus","PX-75000500","CDM","45999","CPT","0750","RC","","","","outpatient","","","2866.00","2149.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1433.00","50","","1324.00","1324.00","1324.00","1 through 10","1234.13","2364.45","percent of total billed charges",""
"Proctosigmoidoscopy Flexible With Eus","PX-75000500","CDM","45999","CPT","0750","RC","","","","outpatient","","","2866.00","2149.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1504.65","52.5","","728.20","728.20","728.20","1 through 10","1234.13","2364.45","percent of total billed charges",""
"Proctosigmoidoscopy Rigid","PX-75000173","CDM","45300","CPT","0750","RC","","","","outpatient","","","1638.00","1228.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","991.81","60.55","","855.66","855.66","855.66","1 through 10","655.2","1338.57","percent of total billed charges",""
"Proctosigmoidoscopy With Eus and Fna Biopsy","PX-75000494","CDM","45999","CPT","0750","RC","","","","outpatient","","","1495.00","1121.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","780.69","52.22","","1324.00","1324.00","1324.00","1 through 10","747.5","1234.13","percent of total billed charges",""
"Proctosigmoidoscopy With Eus and Fna Biopsy","PX-75000494","CDM","45999","CPT","0750","RC","","","","outpatient","","","1495.00","1121.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","747.50","50","","1324.00","1324.00","1324.00","1 through 10","747.5","1234.13","percent of total billed charges",""
"Proctosigmoidoscopy With Eus and Fna Biopsy","PX-75000494","CDM","45999","CPT","0750","RC","","","","outpatient","","","1495.00","1121.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","784.88","52.5","","728.20","728.20","728.20","1 through 10","747.5","1234.13","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs 1 Njx","PX-98302599","CDM","95115","CPT","0983","RC","","","","both","","","51.00","38.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.61","1 through 10","15.81","68.49","other","OPPS APC"
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs 1 Njx","PX-98302599","CDM","95115","CPT","0983","RC","","","","both","","","51.00","38.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","1 through 10","15.81","68.49","other","OPPS APC"
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs 1 Njx","PX-98302599","CDM","95115","CPT","0983","RC","","","","both","","","51.00","38.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","40.55","79.5","","39.07","39.07","58.24","23","15.81","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs 1 Njx","PX-98302599","CDM","95115","CPT","0983","RC","","","","both","","","51.00","38.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","27.18","53.3","","58.24","39.07","58.24","40","15.81","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs 1 Njx","PX-98302599","CDM","95115","CPT","0983","RC","","","","both","","","51.00","38.25","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","54.79","54.79","54","15.81","68.49","other","OPPS APC"
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs 1 Njx","PX-98302599","CDM","95115","CPT","0983","RC","","","","both","","","51.00","38.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","19.53","38.3","","28.93","28.12","28.93","93","15.81","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs 1 Njx","PX-98302599","CDM","95115","CPT","0983","RC","","","","both","","","51.00","38.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","53.69","53.69","1 through 10","15.81","68.49","other","OPPS APC"
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs 1 Njx","PX-98302599","CDM","95115","CPT","0983","RC","","","","both","","","51.00","38.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21.88","42.9","","32.54","32.54","59.16","1 through 10","15.81","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs 1 Njx","PX-98302599","CDM","95115","CPT","0983","RC","","","","both","","","51.00","38.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","50.82","53.69","1 through 10","15.81","68.49","other","OPPS APC"
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs 1 Njx","PX-98302599","CDM","95115","CPT","0983","RC","","","","both","","","51.00","38.25","WELLPOINT [1015]","HB AMC WELLPOINT","37.63","73.78","","55.09","55.09","55.09","1 through 10","15.81","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs 1 Njx","PX-98302599","CDM","95115","CPT","0983","RC","","","","outpatient","","","51.00","38.25","AETNA [1001]","HB AMC AETNA HMO","35.60","69.8","","50.10","35.37","50.10","13","28.51","204.32","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs 1 Njx","PX-98302599","CDM","95115","CPT","0983","RC","","","","outpatient","","","51.00","38.25","AETNA [1001]","HB AMC AETNA PPO","41.00","80.4","","38.78","38.78","38.78","1 through 10","28.51","204.32","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs 1 Njx","PX-98302599","CDM","95115","CPT","0983","RC","","","","outpatient","","","51.00","38.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","41.68","81.72","","59.16","59.16","59.16","72","28.51","204.32","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","AETNA [1001]","HB AMC AETNA HMO","44.67","69.8","","86.66","61.18","99.84","442","19.84","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","AETNA [1001]","HB AMC AETNA PPO","51.46","80.4","","99.84","67.07","199.68","55","19.84","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.61","16","19.84","68.49","other","OPPS APC"
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","39","19.84","68.49","other","OPPS APC"
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","50.88","79.5","","100.74","67.58","100.74","260","19.84","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","34.11","53.3","","100.74","67.58","100.74","67","19.84","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","ELDER SERVICES [1037]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.85","51.85","54.79","1 through 10","19.84","68.49","other","OPPS APC"
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","54.79","54.79","469","19.84","68.49","other","OPPS APC"
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","19.84","31","","39.55","39.55","39.55","1 through 10","19.84","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.36","36.5","","47.74","40.58","47.74","169","19.84","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.51","38.3","","50.05","50.05","50.05","1485","19.84","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.81","53.69","24","19.84","68.49","other","OPPS APC"
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","49.28","77","","21.72","21.72","21.72","1 through 10","19.84","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","TRICARE [160005]","HB BWH TRICARE","52.05","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","54.79","52.05","54.79","13","19.84","68.49","other","Tricare OPPS"
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","53.69","161.07","30","19.84","68.49","other","OPPS APC"
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.46","42.9","","56.28","56.28","102.32","36","19.84","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","50.82","54.79","99","19.84","68.49","other","OPPS APC"
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","both","","","64.00","48.00","WELLPOINT [1015]","HB AMC WELLPOINT","47.22","73.78","","95.30","95.30","95.30","93","19.84","68.49","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","outpatient","","","64.00","48.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","52.30","81.72","","56.28","56.28","56.28","14","52.3","204.32","percent of total billed charges",""
"Prof Svcs Allg Immntx X W/Prv Allgic Xtrcs Njxs","PX-98301197","CDM","95117","CPT","0983","RC","","","","outpatient","","","64.00","48.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","52.30","81.72","","102.32","92.43","102.32","331","52.3","204.32","percent of total billed charges",""
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","both","","","14.00","10.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","17.01","17.01","53.91","11","4.34","68.49","other","OPPS APC"
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","both","","","14.00","10.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11.13","79.5","","85.00","57.02","85.00","185","4.34","68.49","percent of total billed charges",""
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","both","","","14.00","10.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7.46","53.3","","85.00","57.02","171.07","68","4.34","68.49","percent of total billed charges",""
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","both","","","14.00","10.50","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1.83","1.73","3.04","108","4.34","68.49","other","OPPS APC"
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","both","","","14.00","10.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4.34","31","","33.37","33.37","33.37","1 through 10","4.34","68.49","percent of total billed charges",""
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","both","","","14.00","10.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5.11","36.5","","40.28","34.24","40.29","484","4.34","68.49","percent of total billed charges",""
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","both","","","14.00","10.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5.36","38.3","","42.23","42.23","42.23","4853","4.34","68.49","percent of total billed charges",""
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","both","","","14.00","10.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","4.34","68.49","other","OPPS APC"
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","both","","","14.00","10.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","10.78","77","","54.99","54.99","54.99","1 through 10","4.34","68.49","percent of total billed charges",""
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","both","","","14.00","10.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.01","42.9","","47.49","47.49","86.34","89","4.34","68.49","percent of total billed charges",""
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","both","","","14.00","10.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1.79","1.79","2.69","51","4.34","68.49","other","OPPS APC"
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","both","","","14.00","10.50","WELLPOINT [1015]","HB AMC WELLPOINT","10.33","73.78","","80.41","80.41","80.41","225","4.34","68.49","percent of total billed charges",""
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","outpatient","","","14.00","10.50","AETNA [1001]","HB AMC AETNA HMO","9.77","69.8","","73.12","51.62","84.24","1011","7.83","204.32","percent of total billed charges",""
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","outpatient","","","14.00","10.50","AETNA [1001]","HB AMC AETNA PPO","11.26","80.4","","84.24","56.59","84.24","138","7.83","204.32","percent of total billed charges",""
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","outpatient","","","14.00","10.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","11.44","81.72","","47.49","47.49","47.49","54","7.83","204.32","percent of total billed charges",""
"Profes Svc,Immunother,Single/Mult Ags","PX-98301279","CDM","95165","CPT","0983","RC","","","","outpatient","","","14.00","10.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11.44","81.72","","86.34","47.49","89.02","1002","7.83","204.32","percent of total billed charges",""
"Prog Dec Eval Implt Loop Recorder","PX-48000011","CDM","93285","CPT","0480","RC","","","","both","","","1204.00","903.00","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","88.56","1 through 10","42.07","957.18","other","OPPS APC"
"Prog Dec Eval Implt Loop Recorder","PX-48000011","CDM","93285","CPT","0480","RC","","","","both","","","1204.00","903.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","439.46","36.5","","370.26","370.26","370.26","1 through 10","42.07","957.18","percent of total billed charges",""
"Prog Dec Eval Implt Loop Recorder","PX-48000011","CDM","93285","CPT","0480","RC","","","","both","","","1204.00","903.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","461.13","38.3","","1370.07","456.69","1370.07","1 through 10","42.07","957.18","percent of total billed charges",""
"Prog Dec Eval Implt Loop Recorder","PX-48000011","CDM","93285","CPT","0480","RC","","","","both","","","1204.00","903.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.79","43.79","43.79","1 through 10","42.07","957.18","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","1677.00","1257.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.43","43.57","1626.00","1 through 10","42.07","1333.22","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","1677.00","1257.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1333.22","79.5","","1279.66","858.53","1534.65","1 through 10","42.07","1333.22","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","1677.00","1257.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","893.84","53.3","","858.53","858.53","858.53","1 through 10","42.07","1333.22","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","1677.00","1257.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1 through 10","42.07","1333.22","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","1677.00","1257.75","HUMANA [1012]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.75","43.75","43.75","1 through 10","42.07","1333.22","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","1677.00","1257.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","1 through 10","42.07","1333.22","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","1677.00","1257.75","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","88.56","147","42.07","1333.22","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","1677.00","1257.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","612.11","36.5","","606.50","606.50","606.50","1 through 10","42.07","1333.22","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","1677.00","1257.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","642.29","38.3","","635.77","617.88","635.77","20","42.07","1333.22","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","1677.00","1257.75","MOLINA [1014]","HB BWH MOLINA","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","87.85","87.85","87.85","1 through 10","42.07","1333.22","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","1677.00","1257.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.79","40.34","43.79","1 through 10","42.07","1333.22","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","1677.00","1257.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.39","40.34","43.90","22","42.07","1333.22","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","outpatient","","","1677.00","1257.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1348.31","80.4","","813.00","813.00","813.00","1 through 10","85.36","1370.44","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","outpatient","","","1677.00","1257.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1370.44","81.72","","1299.83","1299.83","1299.83","1 through 10","85.36","1370.44","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","outpatient","","","1677.00","1257.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1370.44","81.72","","1299.82","1299.82","1299.82","1 through 10","85.36","1370.44","percent of total billed charges",""
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","1959.00","1469.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","1 through 10","42.07","1557.41","other","OPPS APC"
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","1959.00","1469.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1557.41","79.5","","1495.30","1495.30","1495.30","1 through 10","42.07","1557.41","percent of total billed charges",""
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","1959.00","1469.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1508.43","77","","4389.00","4389.00","4389.00","1 through 10","42.07","1557.41","percent of total billed charges",""
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","1959.00","1469.25","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","88.56","28","42.07","1557.41","other","OPPS APC"
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","1959.00","1469.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","715.04","36.5","","669.74","669.74","669.74","1 through 10","42.07","1557.41","percent of total billed charges",""
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","1959.00","1469.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","750.30","38.3","","742.90","742.90","742.90","1 through 10","42.07","1557.41","percent of total billed charges",""
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","1959.00","1469.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.39","43.39","43.39","1 through 10","42.07","1557.41","other","OPPS APC"
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","1959.00","1469.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","86.78","43.79","86.78","1 through 10","42.07","1557.41","other","OPPS APC"
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","1959.00","1469.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.40","43.39","43.40","1 through 10","42.07","1557.41","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","1444.00","1083.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","41.77","43.57","1 through 10","42.07","1147.98","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","1444.00","1083.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","55.35","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","143.44","143.44","143.44","1 through 10","42.07","1147.98","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","1444.00","1083.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","769.65","53.3","","1101.80","1101.80","1101.80","1 through 10","42.07","1147.98","percent of total billed charges",""
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","1444.00","1083.00","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","41.16","88.56","48","42.07","1147.98","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","1444.00","1083.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.80","40.34","44.28","1 through 10","42.07","1147.98","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","outpatient","","","1444.00","1083.00","AETNA [1001]","HB AMC AETNA HMO","1007.91","69.8","","669.20","669.20","669.20","1 through 10","85.36","1180.04","percent of total billed charges",""
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","outpatient","","","1444.00","1083.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1180.04","81.72","","1119.16","1119.16","1119.16","1 through 10","85.36","1180.04","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","244.00","183.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","160.06","65.6","","160.45","160.45","160.45","1 through 10","20.44","231.8","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","244.00","183.00","CHAMPVA [160001]","HB BWH TRICARE","231.80","95","","25.14","25.14","25.14","1 through 10","20.44","231.8","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","244.00","183.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","193.98","79.5","","186.52","125.14","186.52","315","20.44","231.8","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","244.00","183.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.05","53.3","","125.14","125.14","186.52","140","20.44","231.8","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","244.00","183.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","193.98","79.5","","186.52","186.52","186.52","1 through 10","20.44","231.8","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","244.00","183.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","75.64","31","","73.23","73.23","73.23","1 through 10","20.44","231.8","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","244.00","183.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.06","36.5","","88.40","75.13","88.40","65","20.44","231.8","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","244.00","183.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.45","38.3","","92.67","90.06","92.67","365","20.44","231.8","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","244.00","183.00","TRICARE [160005]","HB BWH TRICARE","231.80","95","","23.88","23.88","25.14","1 through 10","20.44","231.8","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","244.00","183.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.68","42.9","","189.46","189.46","189.46","14","20.44","231.8","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","244.00","183.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.68","42.9","","189.46","189.46","189.46","1 through 10","20.44","231.8","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","244.00","183.00","AETNA [1001]","HB AMC AETNA HMO","170.31","69.8","","160.45","113.29","184.86","329","21.52","199.4","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","244.00","183.00","AETNA [1001]","HB AMC AETNA PPO","196.18","80.4","","184.86","113.29","184.86","44","21.52","199.4","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","244.00","183.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","199.40","81.72","","104.21","104.21","189.46","1 through 10","21.52","199.4","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","244.00","183.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","199.40","81.72","","189.46","104.21","189.46","230","21.52","199.4","percent of total billed charges",""
"PROGRAMMER ACTIVA PATINET","SUP-ITM-10267683","CDM","C1787","HCPCS","0270","RC","","","","both","","","4530.00","3397.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2414.49","53.3","","3163.82","3163.82","3163.82","1 through 10","1404.3","3601.35","percent of total billed charges",""
"PROGRAMMER ACTIVA PATINET","SUP-ITM-10267683","CDM","C1787","HCPCS","0270","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1653.45","36.5","","1639.86","1566.60","1745.64","1 through 10","1404.3","3601.35","percent of total billed charges",""
"PROGRAMMER ACTIVA PATINET","SUP-ITM-10267683","CDM","C1787","HCPCS","0270","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1734.99","38.3","","1642.20","1642.20","1642.20","1 through 10","1404.3","3601.35","percent of total billed charges",""
"PROGRAMMER ACTIVA PATINET","SUP-ITM-10267683","CDM","C1787","HCPCS","0270","RC","","","","both","","","4530.00","3397.50","WELLPOINT [1015]","HB AMC WELLPOINT","3342.23","73.78","","2332.15","846.87","3126.90","1 through 10","1404.3","3601.35","percent of total billed charges",""
"PROGRAMMER DEVICE PATIENT SMART INTERSTIM II MODULATION","SUP-ITM-10295477","CDM","C1787","HCPCS","0270","RC","","","","both","","","4680.00","3510.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2494.44","53.3","","3163.82","3163.82","3163.82","1 through 10","1450.8","3720.6","percent of total billed charges",""
"PROGRAMMER DEVICE PATIENT SMART INTERSTIM II MODULATION","SUP-ITM-10295477","CDM","C1787","HCPCS","0270","RC","","","","both","","","4680.00","3510.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1708.20","36.5","","1639.86","1566.60","1745.64","1 through 10","1450.8","3720.6","percent of total billed charges",""
"PROGRAMMER DEVICE PATIENT SMART INTERSTIM II MODULATION","SUP-ITM-10295477","CDM","C1787","HCPCS","0270","RC","","","","both","","","4680.00","3510.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1792.44","38.3","","1642.20","1642.20","1642.20","1 through 10","1450.8","3720.6","percent of total billed charges",""
"PROGRAMMER DEVICE PATIENT SMART INTERSTIM II MODULATION","SUP-ITM-10295477","CDM","C1787","HCPCS","0270","RC","","","","both","","","4680.00","3510.00","WELLPOINT [1015]","HB AMC WELLPOINT","3452.90","73.78","","2332.15","846.87","3126.90","1 through 10","1450.8","3720.6","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR 2.2IN H .1.1 111 G DEEP BRAIN STIMULATION","SUP-ITM-10079669","CDM","C1787","HCPCS","0270","RC","","","","both","","","3699.50","2774.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1971.83","53.3","","3163.82","3163.82","3163.82","1 through 10","1146.85","2941.1","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR 2.2IN H .1.1 111 G DEEP BRAIN STIMULATION","SUP-ITM-10079669","CDM","C1787","HCPCS","0270","RC","","","","both","","","3699.50","2774.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1350.32","36.5","","1639.86","1566.60","1745.64","1 through 10","1146.85","2941.1","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR 2.2IN H .1.1 111 G DEEP BRAIN STIMULATION","SUP-ITM-10079669","CDM","C1787","HCPCS","0270","RC","","","","both","","","3699.50","2774.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1416.91","38.3","","1642.20","1642.20","1642.20","1 through 10","1146.85","2941.1","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR 2.2IN H .1.1 111 G DEEP BRAIN STIMULATION","SUP-ITM-10079669","CDM","C1787","HCPCS","0270","RC","","","","both","","","3699.50","2774.62","WELLPOINT [1015]","HB AMC WELLPOINT","2729.49","73.78","","2332.15","846.87","3126.90","1 through 10","1146.85","2941.1","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR 2.8X5.6 9.4CM MYSTIM PATIENT HAND HELD","SUP-ITM-10104824","CDM","C1787","HCPCS","0270","RC","","","","both","","","3132.50","2349.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1669.62","53.3","","3163.82","3163.82","3163.82","1 through 10","971.08","2490.34","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR 2.8X5.6 9.4CM MYSTIM PATIENT HAND HELD","SUP-ITM-10104824","CDM","C1787","HCPCS","0270","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1143.36","36.5","","1639.86","1566.60","1745.64","1 through 10","971.08","2490.34","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR 2.8X5.6 9.4CM MYSTIM PATIENT HAND HELD","SUP-ITM-10104824","CDM","C1787","HCPCS","0270","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1199.75","38.3","","1642.20","1642.20","1642.20","1 through 10","971.08","2490.34","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR 2.8X5.6 9.4CM MYSTIM PATIENT HAND HELD","SUP-ITM-10104824","CDM","C1787","HCPCS","0270","RC","","","","both","","","3132.50","2349.37","WELLPOINT [1015]","HB AMC WELLPOINT","2311.16","73.78","","2332.15","846.87","3126.90","1 through 10","971.08","2490.34","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR DEEP BRAIN STIMULATION PATIENT PERCEPT PC TH91DBS","SUP-ITM-10321515","CDM","C1787","HCPCS","0270","RC","","","","both","","","4530.00","3397.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2414.49","53.3","","3163.82","3163.82","3163.82","1 through 10","1404.3","3601.35","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR DEEP BRAIN STIMULATION PATIENT PERCEPT PC TH91DBS","SUP-ITM-10321515","CDM","C1787","HCPCS","0270","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1653.45","36.5","","1639.86","1566.60","1745.64","1 through 10","1404.3","3601.35","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR DEEP BRAIN STIMULATION PATIENT PERCEPT PC TH91DBS","SUP-ITM-10321515","CDM","C1787","HCPCS","0270","RC","","","","both","","","4530.00","3397.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1734.99","38.3","","1642.20","1642.20","1642.20","1 through 10","1404.3","3601.35","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR DEEP BRAIN STIMULATION PATIENT PERCEPT PC TH91DBS","SUP-ITM-10321515","CDM","C1787","HCPCS","0270","RC","","","","both","","","4530.00","3397.50","WELLPOINT [1015]","HB AMC WELLPOINT","3342.23","73.78","","2332.15","846.87","3126.90","1 through 10","1404.3","3601.35","percent of total billed charges",""
"PROGRAMMER PATIENT MYSTIM PC SMART/SMART HANDSET","SUP-ITM-10286922","CDM","C1787","HCPCS","0270","RC","","","","both","","","3132.50","2349.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1669.62","53.3","","3163.82","3163.82","3163.82","1 through 10","971.08","2490.34","percent of total billed charges",""
"PROGRAMMER PATIENT MYSTIM PC SMART/SMART HANDSET","SUP-ITM-10286922","CDM","C1787","HCPCS","0270","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1143.36","36.5","","1639.86","1566.60","1745.64","1 through 10","971.08","2490.34","percent of total billed charges",""
"PROGRAMMER PATIENT MYSTIM PC SMART/SMART HANDSET","SUP-ITM-10286922","CDM","C1787","HCPCS","0270","RC","","","","both","","","3132.50","2349.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1199.75","38.3","","1642.20","1642.20","1642.20","1 through 10","971.08","2490.34","percent of total billed charges",""
"PROGRAMMER PATIENT MYSTIM PC SMART/SMART HANDSET","SUP-ITM-10286922","CDM","C1787","HCPCS","0270","RC","","","","both","","","3132.50","2349.37","WELLPOINT [1015]","HB AMC WELLPOINT","2311.16","73.78","","2332.15","846.87","3126.90","1 through 10","971.08","2490.34","percent of total billed charges",""
"PROGRAMMER PATIENT PROCLAIM DRG - DISCONTINUED PER SUPPLIER","SUP-ITM-10211137","CDM","C1787","HCPCS","0270","RC","","","","both","","","4750.00","3562.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2531.75","53.3","","3163.82","3163.82","3163.82","1 through 10","1472.5","3776.25","percent of total billed charges",""
"PROGRAMMER PATIENT PROCLAIM DRG - DISCONTINUED PER SUPPLIER","SUP-ITM-10211137","CDM","C1787","HCPCS","0270","RC","","","","both","","","4750.00","3562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1733.75","36.5","","1639.86","1566.60","1745.64","1 through 10","1472.5","3776.25","percent of total billed charges",""
"PROGRAMMER PATIENT PROCLAIM DRG - DISCONTINUED PER SUPPLIER","SUP-ITM-10211137","CDM","C1787","HCPCS","0270","RC","","","","both","","","4750.00","3562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1819.25","38.3","","1642.20","1642.20","1642.20","1 through 10","1472.5","3776.25","percent of total billed charges",""
"PROGRAMMER PATIENT PROCLAIM DRG - DISCONTINUED PER SUPPLIER","SUP-ITM-10211137","CDM","C1787","HCPCS","0270","RC","","","","both","","","4750.00","3562.50","WELLPOINT [1015]","HB AMC WELLPOINT","3504.55","73.78","","2332.15","846.87","3126.90","1 through 10","1472.5","3776.25","percent of total billed charges",""
"Proinsulin","PX-30000658","CDM","84206","CPT","0301","RC","","","","both","","","242.00","181.50","AETNA [1001]","HB AMC AETNA HMO","168.92","69.8","","183.30","112.33","183.30","1 through 10","18.37","229.9","percent of total billed charges",""
"Proinsulin","PX-30000658","CDM","84206","CPT","0301","RC","","","","both","","","242.00","181.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","192.39","79.5","","124.08","124.08","124.08","1 through 10","18.37","229.9","percent of total billed charges",""
"Proinsulin","PX-30000658","CDM","84206","CPT","0301","RC","","","","both","","","242.00","181.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","128.99","53.3","","124.08","124.08","124.08","1 through 10","18.37","229.9","percent of total billed charges",""
"Proinsulin","PX-30000658","CDM","84206","CPT","0301","RC","","","","both","","","242.00","181.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","92.69","38.3","","91.89","91.89","91.89","1 through 10","18.37","229.9","percent of total billed charges",""
"Proinsulin","PX-30000658","CDM","84206","CPT","0301","RC","","","","outpatient","","","242.00","181.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","197.76","81.72","","187.86","187.86","187.86","1 through 10","18.37","197.76","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","228.00","171.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","159.60","70","","221.00","221.00","221.00","1 through 10","18.99","216.6","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","228.00","171.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","181.26","79.5","","173.93","116.69","521.79","147","18.99","216.6","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","228.00","171.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","121.52","53.3","","173.93","116.69","350.07","71","18.99","216.6","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","181.26","79.5","","173.93","173.93","173.93","1 through 10","18.99","216.6","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","70.68","31","","68.29","68.29","136.58","1 through 10","18.99","216.6","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.22","36.5","","82.43","70.06","247.29","137","18.99","216.6","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.32","38.3","","86.41","83.98","259.23","473","18.99","216.6","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","228.00","171.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","175.56","77","","173.93","173.93","173.93","1 through 10","18.99","216.6","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","228.00","171.00","TRICARE [160005]","HB BWH TRICARE","216.60","95","","22.18","22.18","23.35","1 through 10","18.99","216.6","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.81","42.9","","97.17","97.17","176.67","13","18.99","216.6","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","228.00","171.00","AETNA [1001]","HB AMC AETNA HMO","159.14","69.8","","149.62","105.64","172.38","190","19.98","186.32","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","228.00","171.00","AETNA [1001]","HB AMC AETNA PPO","183.31","80.4","","172.38","105.64","172.38","19","19.98","186.32","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","228.00","171.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","127.45","55.9","","115.80","115.80","115.80","1 through 10","19.98","186.32","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","228.00","171.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","119.15","52.26","","68.06","58.61","136.75","1 through 10","19.98","186.32","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","183.31","80.4","","172.38","172.38","172.38","1 through 10","19.98","186.32","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","186.32","81.72","","176.67","97.17","176.67","1 through 10","19.98","186.32","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","186.32","81.72","","176.67","97.17","176.67","167","19.98","186.32","percent of total billed charges",""
"Prolonged Outpatient E/M Service Each 15 Minutes","PX-98301999","CDM","99417","CPT","0983","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","47.09","36.5","","47.74","40.58","47.74","1 through 10","39.99","102.56","percent of total billed charges",""
"Prolonged Outpatient E/M Service Each 15 Minutes","PX-98301999","CDM","99417","CPT","0983","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","49.41","38.3","","50.05","50.05","50.05","1 through 10","39.99","102.56","percent of total billed charges",""
"Prolonged Outpatient E/M Service Each 15 Minutes","PX-98301999","CDM","99417","CPT","0983","RC","","","","outpatient","","","129.00","96.75","AETNA [1001]","HB AMC AETNA HMO","90.04","69.8","","89.60","86.66","89.60","1 through 10","72.11","105.42","percent of total billed charges",""
"Promethazine Inj 50mg","PX-63600164","CDM","J2550","HCPCS","0636","RC","","","","both","","","6.24","4.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2.39","38.3","","7.44","7.44","7.44","1 through 10","1.93","8.53","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","both","","","625.00","468.75","AETNA [1001]","HB AMC AETNA HMO","436.25","69.8","","410.26","289.67","472.68","45","60.9","593.75","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","448.75","71.8","","1305.33","435.11","1305.33","1 through 10","60.9","593.75","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","410.00","65.6","","410.26","410.26","410.26","1 through 10","60.9","593.75","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","406.25","65","","1181.70","393.90","1181.70","1 through 10","60.9","593.75","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","both","","","625.00","468.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","437.50","70","","436.32","260.58","436.32","1 through 10","60.9","593.75","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","both","","","625.00","468.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","496.88","79.5","","476.92","319.97","1430.76","27","60.9","593.75","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","both","","","625.00","468.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","333.13","53.3","","319.97","306.03","1430.76","23","60.9","593.75","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","193.75","31","","187.25","187.25","187.25","1 through 10","60.9","593.75","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.13","36.5","","226.04","190.28","226.04","42","60.9","593.75","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","both","","","625.00","468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.38","38.3","","236.95","230.28","710.85","80","60.9","593.75","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","outpatient","","","625.00","468.75","AETNA [1001]","HB AMC AETNA PPO","502.50","80.4","","472.68","317.54","923.54","1 through 10","205.18","594.32","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","outpatient","","","625.00","468.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","326.63","52.26","","205.18","205.18","205.18","1 through 10","205.18","594.32","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","outpatient","","","625.00","468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","510.75","81.72","","484.44","266.46","484.44","1 through 10","205.18","594.32","percent of total billed charges",""
"Propoxyphene Presumptive Screen","PX-30003656","CDM","80307","CPT","0300","RC","","","","outpatient","","","625.00","468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","510.75","81.72","","484.44","266.46","484.44","33","205.18","594.32","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","both","","","295.00","221.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","234.53","79.5","","225.08","151.01","225.08","1 through 10","25.74","280.25","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","both","","","295.00","221.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","157.24","53.3","","151.01","151.01","151.01","1 through 10","25.74","280.25","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","both","","","295.00","221.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","107.68","36.5","","106.68","106.68","106.68","1 through 10","25.74","280.25","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","both","","","295.00","221.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","112.99","38.3","","223.66","111.83","335.48","14","25.74","280.25","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","both","","","295.00","221.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.56","42.9","","125.75","111.83","125.75","1 through 10","25.74","280.25","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","outpatient","","","295.00","221.25","AETNA [1001]","HB AMC AETNA HMO","205.91","69.8","","193.62","193.62","223.08","1 through 10","25.74","256.05","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","outpatient","","","295.00","221.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","241.07","81.72","","125.75","125.75","125.75","1 through 10","25.74","256.05","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","outpatient","","","295.00","221.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","241.07","81.72","","228.63","228.63","228.63","1 through 10","25.74","256.05","percent of total billed charges",""
"Prostate Cancer Screen Dre","PX-77000027","CDM","G0102","HCPCS","0510","RC","","","","outpatient","","","66.00","49.50","AETNA [1001]","HB AMC AETNA HMO","46.07","69.8","","43.33","30.59","43.33","1 through 10","36.89","53.06","percent of total billed charges",""
"Prostate Cancer Screen Dre","PX-77000027","CDM","G0102","HCPCS","0770","RC","","","","both","","","66.00","49.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","52.47","79.5","","50.37","33.79","50.37","1 through 10","20.46","52.47","percent of total billed charges",""
"Prostate Cancer Screen Dre","PX-77000027","CDM","G0102","HCPCS","0770","RC","","","","both","","","66.00","49.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","35.18","53.3","","33.79","33.79","33.79","1 through 10","20.46","52.47","percent of total billed charges",""
"Prostate Cancer Screen Dre","PX-77000027","CDM","G0102","HCPCS","0770","RC","","","","both","","","66.00","49.50","WELLPOINT [1015]","HB AMC WELLPOINT","48.69","73.78","","47.65","47.65","47.65","1 through 10","20.46","52.47","percent of total billed charges",""
"Prostate Cancer Screen Dre","PX-77000027","CDM","G0102","HCPCS","0770","RC","","","","outpatient","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","53.94","81.72","","51.16","28.14","51.16","1 through 10","34.49","53.94","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","213.00","159.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","152.93","71.8","","445.89","148.63","445.89","1 through 10","18.92","202.35","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","213.00","159.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","139.73","65.6","","161.46","161.46","161.46","1 through 10","18.92","202.35","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","213.00","159.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","149.10","70","","207.00","46.60","207.00","1 through 10","18.92","202.35","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","213.00","159.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","169.34","79.5","","162.91","109.30","162.91","204","18.92","202.35","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","213.00","159.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","113.53","53.3","","109.30","109.30","327.90","136","18.92","202.35","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","213.00","159.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","164.01","77","","159.39","159.39","159.39","1 through 10","18.92","202.35","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","213.00","159.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","138.45","65","","185.90","134.55","185.90","1 through 10","18.92","202.35","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","213.00","159.75","MOLINA [1014]","HB BWH MOLINA","74.55","35","","38.23","38.23","38.23","1 through 10","18.92","202.35","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","213.00","159.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","164.01","77","","161.46","161.46","161.46","1 through 10","18.92","202.35","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.38","42.9","","165.48","91.02","165.48","1 through 10","18.92","202.35","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","213.00","159.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.38","42.9","","91.02","91.02","165.48","1 through 10","18.92","202.35","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","213.00","159.75","AETNA [1001]","HB AMC AETNA HMO","148.67","69.8","","140.14","98.95","161.46","277","18.96","187.26","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","213.00","159.75","AETNA [1001]","HB AMC AETNA PPO","171.25","80.4","","161.46","98.95","161.46","18","18.96","187.26","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","213.00","159.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","111.31","52.26","","64.96","64.96","128.10","1 through 10","18.96","187.26","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","213.00","159.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","171.25","80.4","","161.46","161.46","161.46","1 through 10","18.96","187.26","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","174.06","81.72","","165.48","91.02","165.48","1 through 10","18.96","187.26","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.06","81.72","","165.48","91.02","165.48","156","18.96","187.26","percent of total billed charges",""
"Prostatectomy With Cc","666","MS-DRG","","","","","","","","inpatient","","","81306.84","60980.13","MEDICARE [2001]","HB BWH MEDICARE","21089.67","","Case rate ($21,089.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,589.28, add-ons for qualifying new technology services are included. If operating cost exceeds $65,233.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,847.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $19,302.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,209.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,407.59. The transfer capital threshold is the transfer adjustment factor * $1,407.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","16010.4","24859.4043","other","Inpatient DRG"
"Prostatectomy With McC","665","MS-DRG","","","","","","","","inpatient","","","183096.71","137322.53","MEDICARE [2001]","HB BWH MEDICARE","37331.49","","Case rate ($37,331.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,654.41, add-ons for qualifying new technology services are included. If operating cost exceeds $80,298.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,951.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $34,440.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,274.57 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,511.50. The transfer capital threshold is the transfer adjustment factor * $2,511.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","40757.53","40757.53","40757.53","1 through 10","28274.72","48890.48","other","Inpatient DRG"
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","both","","","214.00","160.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","170.13","79.5","","163.70","109.82","163.70","27","18.02","203.3","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","both","","","214.00","160.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","114.06","53.3","","163.70","109.82","163.70","15","18.02","203.3","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","both","","","214.00","160.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","139.10","65","","135.20","135.20","135.20","1 through 10","18.02","203.3","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","both","","","214.00","160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.11","36.5","","77.58","65.94","77.58","18","18.02","203.3","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","both","","","214.00","160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.96","38.3","","81.33","79.04","81.33","63","18.02","203.3","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","both","","","214.00","160.50","MOLINA [1014]","HB BWH MOLINA","74.90","35","","18.39","18.39","18.39","1 through 10","18.02","203.3","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","both","","","214.00","160.50","TRICARE [160005]","HB BWH TRICARE","203.30","95","","21.05","21.05","22.16","1 through 10","18.02","203.3","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","both","","","214.00","160.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.81","42.9","","91.46","91.46","91.46","1 through 10","18.02","203.3","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","214.00","160.50","AETNA [1001]","HB AMC AETNA HMO","149.37","69.8","","140.82","99.42","162.24","33","18.96","174.88","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","214.00","160.50","AETNA [1001]","HB AMC AETNA PPO","172.06","80.4","","162.24","162.24","162.24","1 through 10","18.96","174.88","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","214.00","160.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","172.06","80.4","","104.00","104.00","162.24","1 through 10","18.96","174.88","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","214.00","160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.88","81.72","","166.28","91.46","166.28","24","18.96","174.88","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","213.00","159.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","152.93","71.8","","297.26","297.26","297.26","1 through 10","18.02","202.35","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","213.00","159.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","149.10","70","","162.40","162.40","162.40","1 through 10","18.02","202.35","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","213.00","159.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","169.34","79.5","","162.91","109.30","162.91","128","18.02","202.35","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","213.00","159.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","113.53","53.3","","109.30","109.30","162.91","65","18.02","202.35","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","213.00","159.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","164.01","77","","478.17","159.39","478.17","1 through 10","18.02","202.35","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","213.00","159.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","138.45","65","","134.55","134.55","134.55","1 through 10","18.02","202.35","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","213.00","159.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","66.03","31","","191.88","63.96","191.88","11","18.02","202.35","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","213.00","159.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.75","36.5","","77.21","65.62","231.63","292","18.02","202.35","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","213.00","159.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.58","38.3","","80.94","80.94","242.82","931","18.02","202.35","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","213.00","159.75","MOLINA [1014]","HB BWH MOLINA","74.55","35","","36.49","36.04","36.49","15","18.02","202.35","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","213.00","159.75","TRICARE [160005]","HB BWH TRICARE","202.35","95","","21.05","21.05","22.16","18","18.02","202.35","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","213.00","159.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","202.35","95","","18.39","18.39","18.39","1 through 10","18.02","202.35","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.38","42.9","","165.48","91.02","165.49","1 through 10","18.02","202.35","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","213.00","159.75","AETNA [1001]","HB AMC AETNA HMO","148.67","69.8","","140.14","98.95","140.14","176","18.96","174.06","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","213.00","159.75","AETNA [1001]","HB AMC AETNA PPO","171.25","80.4","","161.46","19.00","161.46","1 through 10","18.96","174.06","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","213.00","159.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","111.31","52.26","","128.09","64.96","128.10","1 through 10","18.96","174.06","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","213.00","159.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","171.25","80.4","","161.46","103.50","161.46","1 through 10","18.96","174.06","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","174.06","81.72","","91.02","91.02","165.48","1 through 10","18.96","174.06","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.06","81.72","","165.48","91.02","165.48","90","18.96","174.06","percent of total billed charges",""
"Prosth Voice Indwelling T1","PX-27000558","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","712.25","534.19","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","356.13","50","","492.94","492.94","492.94","1 through 10","213.03","587.61","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","3038.00","2278.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1587.66","52.26","","1113.10","1113.10","1113.10","1 through 10","941.78","2415.21","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","3038.00","2278.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2415.21","79.5","","1293.60","1148.53","1603.80","1 through 10","941.78","2415.21","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","3038.00","2278.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1108.87","36.5","","1023.42","771.29","2068.67","33","941.78","2415.21","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","3038.00","2278.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1163.55","38.3","","850.52","759.78","1211.25","66","941.78","2415.21","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","3038.00","2278.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1303.30","42.9","","2548.09","2548.09","2548.09","1 through 10","941.78","2415.21","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","3038.00","2278.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1303.30","42.9","","956.46","956.46","956.46","1 through 10","941.78","2415.21","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","3038.00","2278.50","WELLPOINT [1015]","HB AMC WELLPOINT","2241.44","73.78","","2344.73","1619.47","2530.35","16","941.78","2415.21","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3038.00","2278.50","AETNA [1001]","HB AMC AETNA HMO","2120.52","69.8","","1523.63","988.41","4330.26","39","1587.66","2482.65","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3038.00","2278.50","AETNA [1001]","HB AMC AETNA PPO","2442.55","80.4","","1670.25","1670.25","1670.25","1 through 10","1587.66","2482.65","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3038.00","2278.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1587.66","52.26","","1113.10","1113.10","1113.10","1 through 10","1587.66","2482.65","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3038.00","2278.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2482.65","81.72","","1738.90","1484.65","2716.94","38","1587.66","2482.65","percent of total billed charges",""
"PROSTHESIS PENILE 18CM LGX PRE CONNECT PSI IZ","SUP-ITM-10329080","CDM","C1813","HCPCS","0278","RC","","","","both","","","33627.75","25220.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12879.43","38.3","","12613.42","12613.42","12613.42","1 through 10","10424.6","26734.06","percent of total billed charges",""
"PROSTHESIS PENILE 18CM LGX PRE CONNECT PSI IZ","SUP-ITM-10329080","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","33627.75","25220.81","AETNA [1001]","HB AMC AETNA HMO","23472.17","69.8","","34275.85","34275.85","50471.26","19","17573.86","27480.6","percent of total billed charges",""
"Prosthesis Penile Inflatable T1","PX-27000131","CDM","C1813","HCPCS","0278","RC","","","","both","","","2169.58","1627.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","830.95","38.3","","12613.42","12613.42","12613.42","1 through 10","672.57","1724.82","percent of total billed charges",""
"Prosthesis Penile Inflatable T1","PX-27000131","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","2169.58","1627.18","AETNA [1001]","HB AMC AETNA HMO","1514.37","69.8","","34275.85","34275.85","50471.26","19","1133.82","1772.98","percent of total billed charges",""
"Prosthesis Penile Inflatable T2","PX-27000132","CDM","C1813","HCPCS","0278","RC","","","","both","","","4139.34","3104.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1585.37","38.3","","12613.42","12613.42","12613.42","1 through 10","1283.2","3290.78","percent of total billed charges",""
"Prosthesis Penile Inflatable T2","PX-27000132","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","4139.34","3104.50","AETNA [1001]","HB AMC AETNA HMO","2889.26","69.8","","34275.85","34275.85","50471.26","19","2163.22","3382.67","percent of total billed charges",""
"Prosthesis Penile Inflatable T3","PX-27000133","CDM","C1813","HCPCS","0278","RC","","","","both","","","17447.80","13085.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6682.51","38.3","","12613.42","12613.42","12613.42","1 through 10","5408.82","13871","percent of total billed charges",""
"Prosthesis Penile Inflatable T3","PX-27000133","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","17447.80","13085.85","AETNA [1001]","HB AMC AETNA HMO","12178.56","69.8","","34275.85","34275.85","50471.26","19","9118.22","14258.34","percent of total billed charges",""
"Prosthesis Urinary Sphincter T2","PX-27000135","CDM","C1815","HCPCS","0278","RC","","","","both","","","5105.19","3828.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4058.63","79.5","","18938.70","18113.72","18938.70","1 through 10","1582.61","4058.63","percent of total billed charges",""
"Prosthesis Urinary Sphincter T2","PX-27000135","CDM","C1815","HCPCS","0278","RC","","","","both","","","5105.19","3828.89","WELLPOINT [1015]","HB AMC WELLPOINT","3766.61","73.78","","27772.46","27772.46","27772.46","1 through 10","1582.61","4058.63","percent of total billed charges",""
"Prosthesis Urinary Sphincter T3","PX-27000136","CDM","C1815","HCPCS","0278","RC","","","","both","","","8207.98","6155.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6525.34","79.5","","18938.70","18113.72","18938.70","1 through 10","2544.47","6525.34","percent of total billed charges",""
"Prosthesis Urinary Sphincter T3","PX-27000136","CDM","C1815","HCPCS","0278","RC","","","","both","","","8207.98","6155.98","WELLPOINT [1015]","HB AMC WELLPOINT","6055.85","73.78","","27772.46","27772.46","27772.46","1 through 10","2544.47","6525.34","percent of total billed charges",""
"PROSTHESIS VOICE 16FRX10MM INDWELLING BLOM SINGER CLASSIC SILICONE","SUP-ITM-10154496","CDM","L8509","HCPCS","0274","RC","","","","both","","","1015.00","761.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","507.50","50","","492.94","492.94","492.94","1 through 10","126.1","964.25","percent of total billed charges",""
"PROSTHESIS VOICE 16FRX10MM INDWELLING BLOM SINGER CLASSIC SILICONE","SUP-ITM-10154496","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","1015.00","761.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","507.50","50","","492.94","492.94","492.94","1 through 10","213.03","837.38","percent of total billed charges",""
"PROSTHESIS VOICE 16FRX6MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215952","CDM","L8509","HCPCS","0274","RC","","","","both","","","1015.00","761.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","507.50","50","","492.94","492.94","492.94","1 through 10","126.1","964.25","percent of total billed charges",""
"PROSTHESIS VOICE 16FRX6MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215952","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","1015.00","761.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","507.50","50","","492.94","492.94","492.94","1 through 10","213.03","837.38","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215951","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","806.93","79.5","","800.18","480.96","1887.97","195","314.65","806.93","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215951","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","541.00","53.3","","813.12","216.42","1444.50","81","314.65","806.93","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215951","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","314.65","31","","432.60","432.60","432.60","1 through 10","314.65","806.93","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215951","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","370.48","36.5","","148.37","54.89","631.39","94","314.65","806.93","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215951","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","388.75","38.3","","279.30","91.72","1116.77","266","314.65","806.93","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215951","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","435.44","42.9","","731.00","63.70","731.00","1 through 10","314.65","806.93","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215951","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","435.44","42.9","","384.74","384.74","384.74","1 through 10","314.65","806.93","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215951","CDM","C1713","HCPCS","0278","RC","","","","both","","","1015.00","761.25","WELLPOINT [1015]","HB AMC WELLPOINT","748.87","73.78","","286.63","119.22","1107.45","105","314.65","806.93","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","AETNA [1001]","HB AMC AETNA HMO","708.47","69.8","","675.31","184.75","1721.50","286","530.44","829.46","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","AETNA [1001]","HB AMC AETNA PPO","816.06","80.4","","1261.44","103.12","1514.10","21","530.44","829.46","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","816.06","80.4","","1365.00","1365.00","1365.00","1 through 10","530.44","829.46","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","829.46","81.72","","5157.68","5157.68","5157.68","1 through 10","530.44","829.46","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING CLASSIC BLOM-SINGER","SUP-ITM-10215951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1015.00","761.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","829.46","81.72","","431.26","71.26","1459.57","88","530.44","829.46","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING FLANGE LG ESOPHAGEAL","SUP-ITM-10215947","CDM","L8509","HCPCS","0274","RC","","","","both","","","1225.00","918.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","612.50","50","","492.94","492.94","492.94","1 through 10","126.1","1163.75","percent of total billed charges",""
"PROSTHESIS VOICE 20FRX10MM INDWELLING FLANGE LG ESOPHAGEAL","SUP-ITM-10215947","CDM","L8509","HCPCS","0274","RC","","","","outpatient","","","1225.00","918.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","612.50","50","","492.94","492.94","492.94","1 through 10","213.03","1010.63","percent of total billed charges",""
"Prosthetics Training Initial Enctr Ea 15 Mins","PX-42000109","CDM","97761","CPT","0421","RC","","","","outpatient","","","227.00","170.25","AETNA [1001]","HB AMC AETNA PPO","182.51","80.4","","171.60","171.60","171.60","1 through 10","118.63","376","percent of total billed charges",""
"Prosthetics Training Initial Enctr Ea 15 Mins","PX-43000116","CDM","97761","CPT","0431","RC","","","","outpatient","","","227.00","170.25","AETNA [1001]","HB AMC AETNA PPO","182.51","80.4","","171.60","171.60","171.60","1 through 10","118.63","376","percent of total billed charges",""
"PROTECTOR GRAFT 20X2.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124163","CDM","C1763","HCPCS","0278","RC","","","","both","","","5097.50","3823.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3313.38","65","","2028.23","1653.70","2028.23","1 through 10","1580.23","4052.51","percent of total billed charges",""
"PROTECTOR GRAFT 20X2.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124163","CDM","C1763","HCPCS","0278","RC","","","","both","","","5097.50","3823.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1860.59","36.5","","1163.89","1163.89","1163.89","1 through 10","1580.23","4052.51","percent of total billed charges",""
"PROTECTOR GRAFT 20X2.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124163","CDM","C1763","HCPCS","0278","RC","","","","both","","","5097.50","3823.12","WELLPOINT [1015]","HB AMC WELLPOINT","3760.94","73.78","","4280.87","4280.87","4280.87","1 through 10","1580.23","4052.51","percent of total billed charges",""
"PROTECTOR GRAFT 40X5.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124168","CDM","C1763","HCPCS","0278","RC","","","","both","","","6672.50","5004.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4337.13","65","","2028.23","1653.70","2028.23","1 through 10","2068.48","5304.64","percent of total billed charges",""
"PROTECTOR GRAFT 40X5.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124168","CDM","C1763","HCPCS","0278","RC","","","","both","","","6672.50","5004.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2435.46","36.5","","1163.89","1163.89","1163.89","1 through 10","2068.48","5304.64","percent of total billed charges",""
"PROTECTOR GRAFT 40X5.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124168","CDM","C1763","HCPCS","0278","RC","","","","both","","","6672.50","5004.37","WELLPOINT [1015]","HB AMC WELLPOINT","4922.97","73.78","","4280.87","4280.87","4280.87","1 through 10","2068.48","5304.64","percent of total billed charges",""
"PROTECTOR GRAFT 40X7.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124169","CDM","C1763","HCPCS","0278","RC","","","","both","","","6845.00","5133.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4449.25","65","","2028.23","1653.70","2028.23","1 through 10","2121.95","5441.78","percent of total billed charges",""
"PROTECTOR GRAFT 40X7.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124169","CDM","C1763","HCPCS","0278","RC","","","","both","","","6845.00","5133.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2498.43","36.5","","1163.89","1163.89","1163.89","1 through 10","2121.95","5441.78","percent of total billed charges",""
"PROTECTOR GRAFT 40X7.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124169","CDM","C1763","HCPCS","0278","RC","","","","both","","","6845.00","5133.75","WELLPOINT [1015]","HB AMC WELLPOINT","5050.24","73.78","","4280.87","4280.87","4280.87","1 through 10","2121.95","5441.78","percent of total billed charges",""
"PROTECTOR GRAFT DIA 7.0MM LENGTH 20 NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124165","CDM","C1763","HCPCS","0278","RC","","","","both","","","5240.00","3930.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3406.00","65","","2028.23","1653.70","2028.23","1 through 10","1624.4","4165.8","percent of total billed charges",""
"PROTECTOR GRAFT DIA 7.0MM LENGTH 20 NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124165","CDM","C1763","HCPCS","0278","RC","","","","both","","","5240.00","3930.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1912.60","36.5","","1163.89","1163.89","1163.89","1 through 10","1624.4","4165.8","percent of total billed charges",""
"PROTECTOR GRAFT DIA 7.0MM LENGTH 20 NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124165","CDM","C1763","HCPCS","0278","RC","","","","both","","","5240.00","3930.00","WELLPOINT [1015]","HB AMC WELLPOINT","3866.07","73.78","","4280.87","4280.87","4280.87","1 through 10","1624.4","4165.8","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","both","","","214.00","160.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","149.80","70","","208.00","91.46","208.00","1 through 10","13.15","203.3","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","both","","","214.00","160.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","170.13","79.5","","163.70","109.83","491.10","15","13.15","203.3","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","both","","","214.00","160.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","114.06","53.3","","329.48","109.82","474.57","15","13.15","203.3","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","both","","","214.00","160.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","139.10","65","","135.20","130.65","270.40","1 through 10","13.15","203.3","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","both","","","214.00","160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.11","36.5","","232.75","77.58","543.06","28","13.15","203.3","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","both","","","214.00","160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.96","38.3","","81.33","81.33","395.20","53","13.15","203.3","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","both","","","214.00","160.50","TRICARE [160005]","HB BWH TRICARE","203.30","95","","15.85","15.85","15.85","1 through 10","13.15","203.3","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","outpatient","","","214.00","160.50","AETNA [1001]","HB AMC AETNA HMO","149.37","69.8","","140.82","99.43","162.24","23","13.15","174.88","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","outpatient","","","214.00","160.50","AETNA [1001]","HB AMC AETNA PPO","172.06","80.4","","140.82","140.82","140.82","1 through 10","13.15","174.88","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","outpatient","","","214.00","160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.88","81.72","","166.28","91.46","166.28","17","13.15","174.88","percent of total billed charges",""
"Protein C Antigen","PX-30001073","CDM","85302","CPT","0305","RC","","","","both","","","202.00","151.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.59","79.5","","103.49","103.49","103.49","1 through 10","11.77","191.9","percent of total billed charges",""
"Protein C Antigen","PX-30001073","CDM","85302","CPT","0305","RC","","","","both","","","202.00","151.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.37","38.3","","76.64","76.64","76.64","1 through 10","11.77","191.9","percent of total billed charges",""
"Protein C Antigen","PX-30001073","CDM","85302","CPT","0305","RC","","","","outpatient","","","202.00","151.50","AETNA [1001]","HB AMC AETNA PPO","162.41","80.4","","132.69","132.69","132.69","1 through 10","12.4","165.07","percent of total billed charges",""
"Protein C Antigen","PX-30001073","CDM","85302","CPT","0305","RC","","","","outpatient","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.07","81.72","","86.18","86.18","86.18","1 through 10","12.4","165.07","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","129.96","71.8","","126.37","9.47","379.11","26","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","118.74","65.6","","11.05","11.05","11.05","1 through 10","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","117.65","65","","114.40","114.40","114.40","1 through 10","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","126.70","70","","176.00","77.39","176.00","1 through 10","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","CHAMPVA [160001]","HB BWH TRICARE","171.95","95","","12.94","12.94","12.94","1 through 10","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","143.90","79.5","","138.51","92.93","138.51","77","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","96.47","53.3","","92.93","92.93","415.53","41","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","139.37","77","","406.56","135.52","406.56","1 through 10","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","117.65","65","","114.40","114.40","114.40","1 through 10","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","56.11","31","","54.38","54.38","54.38","1 through 10","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","66.07","36.5","","65.65","55.79","65.65","70","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","69.32","38.3","","68.82","66.88","206.46","212","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","MOLINA [1014]","HB BWH MOLINA","63.35","35","","21.31","21.31","21.31","1 through 10","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","139.37","77","","137.28","128.93","137.28","1 through 10","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","TRICARE [160005]","HB BWH TRICARE","171.95","95","","12.29","12.29","12.29","1 through 10","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.65","42.9","","77.39","77.39","140.69","1 through 10","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","181.00","135.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.65","42.9","","77.39","77.39","77.39","1 through 10","10.53","171.95","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","181.00","135.75","AETNA [1001]","HB AMC AETNA HMO","126.34","69.8","","119.15","84.13","137.28","94","11.07","147.91","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","181.00","135.75","AETNA [1001]","HB AMC AETNA PPO","145.52","80.4","","137.28","92.22","274.56","13","11.07","147.91","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","181.00","135.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","94.59","52.26","","108.91","54.68","108.91","1 through 10","11.07","147.91","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","181.00","135.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","145.52","80.4","","88.00","88.00","137.28","1 through 10","11.07","147.91","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","181.00","135.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","147.91","81.72","","140.69","140.69","140.69","1 through 10","11.07","147.91","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","147.91","81.72","","140.69","77.39","140.69","1 through 10","11.07","147.91","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","147.91","81.72","","140.69","77.39","140.69","84","11.07","147.91","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","both","","","239.00","179.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","167.30","70","","102.01","102.01","102.01","1 through 10","17.47","227.05","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","both","","","239.00","179.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","190.01","79.5","","182.58","122.50","182.58","1 through 10","17.47","227.05","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","both","","","239.00","179.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","127.39","53.3","","122.50","122.50","182.58","1 through 10","17.47","227.05","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","both","","","239.00","179.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","155.35","65","","150.80","150.80","150.80","1 through 10","17.47","227.05","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","both","","","239.00","179.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","74.09","31","","215.07","215.07","215.07","1 through 10","17.47","227.05","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","both","","","239.00","179.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.24","36.5","","86.54","86.54","86.54","1 through 10","17.47","227.05","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","both","","","239.00","179.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.54","38.3","","264.48","90.71","272.13","30","17.47","227.05","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","both","","","239.00","179.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.53","42.9","","102.01","102.01","102.01","1 through 10","17.47","227.05","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","outpatient","","","239.00","179.25","AETNA [1001]","HB AMC AETNA HMO","166.82","69.8","","157.06","110.90","180.96","1 through 10","18.4","195.31","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","outpatient","","","239.00","179.25","AETNA [1001]","HB AMC AETNA PPO","192.16","80.4","","180.96","180.96","180.96","1 through 10","18.4","195.31","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","outpatient","","","239.00","179.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","195.31","81.72","","185.46","185.46","185.46","1 through 10","18.4","195.31","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","outpatient","","","239.00","179.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","195.31","81.72","","185.46","80.82","185.46","1 through 10","18.4","195.31","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","both","","","239.00","179.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","190.01","79.5","","122.50","122.50","122.50","1 through 10","14.72","227.05","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","both","","","239.00","179.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","127.39","53.3","","367.50","367.50","367.50","1 through 10","14.72","227.05","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","both","","","239.00","179.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","155.35","65","","150.80","145.60","150.80","1 through 10","14.72","227.05","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","both","","","239.00","179.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.24","36.5","","220.62","86.54","259.62","1 through 10","14.72","227.05","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","both","","","239.00","179.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.54","38.3","","264.48","88.16","272.13","12","14.72","227.05","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","outpatient","","","239.00","179.25","AETNA [1001]","HB AMC AETNA HMO","166.82","69.8","","180.96","110.90","221.80","1 through 10","14.72","195.31","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","outpatient","","","239.00","179.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","195.31","81.72","","185.46","59.92","185.46","1 through 10","14.72","195.31","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","both","","","189.00","141.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","132.30","70","","80.47","80.47","80.47","1 through 10","11.38","179.55","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","both","","","189.00","141.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","150.26","79.5","","432.06","96.62","432.06","1 through 10","11.38","179.55","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","both","","","189.00","141.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.74","53.3","","432.06","96.62","451.74","12","11.38","179.55","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","both","","","189.00","141.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","122.85","65","","118.95","115.70","118.95","1 through 10","11.38","179.55","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.99","36.5","","477.82","68.26","477.82","14","11.38","179.55","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.39","38.3","","71.55","69.54","214.65","23","11.38","179.55","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","both","","","189.00","141.75","TRICARE [160005]","HB BWH TRICARE","179.55","95","","13.29","13.29","13.29","1 through 10","11.38","179.55","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA HMO","131.92","69.8","","123.89","87.47","174.94","13","11.97","154.45","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA PPO","151.96","80.4","","142.74","142.74","142.74","1 through 10","11.97","154.45","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","154.45","81.72","","146.29","80.47","146.29","11","11.97","154.45","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","both","","","67.00","50.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","53.27","79.5","","153.48","34.32","153.48","1 through 10","3.77","63.65","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","both","","","67.00","50.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","35.71","53.3","","34.32","34.32","51.16","1 through 10","3.77","63.65","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","both","","","67.00","50.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24.46","36.5","","24.25","20.61","24.25","1 through 10","3.77","63.65","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","both","","","67.00","50.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25.66","38.3","","25.42","25.42","25.42","1 through 10","3.77","63.65","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","outpatient","","","67.00","50.25","AETNA [1001]","HB AMC AETNA HMO","46.77","69.8","","50.70","31.07","88.02","1 through 10","3.77","54.75","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","outpatient","","","67.00","50.25","AETNA [1001]","HB AMC AETNA PPO","53.87","80.4","","34.06","34.06","34.06","1 through 10","3.77","54.75","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","outpatient","","","67.00","50.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","54.75","81.72","","51.96","28.58","51.96","1 through 10","3.77","54.75","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","45.23","71.8","","43.80","9.72","131.40","63","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","41.33","65.6","","41.30","41.30","41.30","1 through 10","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","40.95","65","","39.65","32.21","48.01","56","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","44.10","70","","48.76","26.23","78.69","37","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","50.09","79.5","","48.01","32.21","48.01","177","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33.58","53.3","","32.21","32.21","48.01","93","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","48.51","77","","140.91","46.97","140.91","1 through 10","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","40.95","65","","39.65","39.00","39.65","1 through 10","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","50.09","79.5","","48.01","48.01","48.01","1 through 10","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","19.53","31","","18.85","18.85","18.85","1 through 10","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.00","36.5","","22.75","19.34","22.75","173","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.13","38.3","","23.85","23.85","71.55","560","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","MOLINA [1014]","HB BWH MOLINA","22.05","35","","7.28","7.28","7.28","1 through 10","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","48.51","77","","47.58","47.58","47.58","1 through 10","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","TRICARE [160005]","HB BWH TRICARE","59.85","95","","4.42","4.20","4.42","11","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.03","42.9","","48.76","26.82","48.76","1 through 10","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.03","42.9","","26.82","26.82","26.82","1 through 10","3.6","59.85","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","63.00","47.25","AETNA [1001]","HB AMC AETNA HMO","43.97","69.8","","41.30","29.16","47.58","338","3.77","51.48","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","63.00","47.25","AETNA [1001]","HB AMC AETNA PPO","50.65","80.4","","47.58","29.16","47.58","45","3.77","51.48","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","50.65","80.4","","47.58","30.50","47.58","1 through 10","3.77","51.48","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","51.48","81.72","","48.76","48.76","48.76","1 through 10","3.77","51.48","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","51.48","81.72","","29.06","26.82","48.76","1 through 10","3.77","51.48","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","51.48","81.72","","48.76","26.82","48.76","243","3.77","51.48","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","both","","","65.00","48.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","46.67","71.8","","135.69","45.23","135.69","17","3.6","61.75","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","both","","","65.00","48.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","45.50","70","","63.00","63.00","63.00","1 through 10","3.6","61.75","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","both","","","65.00","48.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","51.68","79.5","","49.58","49.58","49.58","1 through 10","3.6","61.75","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","both","","","65.00","48.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","42.25","65","","40.95","39.65","40.95","1 through 10","3.6","61.75","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","both","","","65.00","48.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.73","36.5","","23.50","19.97","45.23","1 through 10","3.6","61.75","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","both","","","65.00","48.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.90","38.3","","24.63","20.79","135.69","15","3.6","61.75","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","both","","","65.00","48.75","TRICARE [160005]","HB BWH TRICARE","61.75","95","","4.20","4.20","4.20","1 through 10","3.6","61.75","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","outpatient","","","65.00","48.75","AETNA [1001]","HB AMC AETNA HMO","45.37","69.8","","42.65","30.11","49.14","11","3.77","53.12","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","outpatient","","","65.00","48.75","AETNA [1001]","HB AMC AETNA PPO","52.26","80.4","","49.14","49.14","49.14","1 through 10","3.77","53.12","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","outpatient","","","65.00","48.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","52.26","80.4","","31.50","31.50","31.50","1 through 10","3.77","53.12","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","outpatient","","","65.00","48.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","53.12","81.72","","50.36","50.36","50.36","1 through 10","3.77","53.12","percent of total billed charges",""
"Protein Western Blot Band ID","PX-30000654","CDM","84182","CPT","0301","RC","","","","both","","","231.00","173.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","183.65","79.5","","176.29","176.29","176.29","1 through 10","18.56","219.45","percent of total billed charges",""
"Protein Western Blot Band ID","PX-30000654","CDM","84182","CPT","0301","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","84.32","36.5","","83.55","71.01","83.55","1 through 10","18.56","219.45","percent of total billed charges",""
"Protein Western Blot Band ID","PX-30000654","CDM","84182","CPT","0301","RC","","","","both","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.10","42.9","","358.13","179.07","358.13","1 through 10","18.56","219.45","percent of total billed charges",""
"Protein Western Blot Band ID","PX-30000654","CDM","84182","CPT","0301","RC","","","","outpatient","","","231.00","173.25","AETNA [1001]","HB AMC AETNA HMO","161.24","69.8","","174.72","107.07","174.72","1 through 10","18.56","188.77","percent of total billed charges",""
"Protein Western Blot Band ID","PX-30000654","CDM","84182","CPT","0301","RC","","","","outpatient","","","231.00","173.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","120.72","52.26","","47.09","47.09","47.09","1 through 10","18.56","188.77","percent of total billed charges",""
"Protein Western Blot Band ID","PX-30000654","CDM","84182","CPT","0301","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","188.77","81.72","","98.50","98.50","179.07","1 through 10","18.56","188.77","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","50.26","71.8","","146.46","48.82","146.46","24","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","45.92","65.6","","46.04","46.04","46.04","1 through 10","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","45.50","65","","44.20","35.90","179.50","42","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","49.00","70","","68.00","43.64","146.88","34","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","55.65","79.5","","53.52","44.20","160.56","433","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37.31","53.3","","35.91","35.90","127.57","205","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","53.90","77","","157.08","52.36","157.08","11","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","45.50","65","","44.20","42.90","88.40","18","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","55.65","79.5","","53.52","53.52","53.52","1 through 10","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","21.70","31","","41.50","21.01","63.03","1 through 10","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","25.55","36.5","","25.36","21.56","76.08","350","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","26.81","38.3","","26.59","26.59","79.77","908","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","MOLINA [1014]","HB BWH MOLINA","24.50","35","","8.51","8.51","8.51","1 through 10","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","53.90","77","","53.04","6.75","53.52","1 through 10","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","TRICARE [160005]","HB BWH TRICARE","66.50","95","","4.91","4.91","5.17","1 through 10","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.03","42.9","","54.36","29.90","54.36","15","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","70.00","52.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.03","42.9","","29.90","29.90","29.90","1 through 10","4.06","66.5","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA HMO","48.86","69.8","","46.04","32.50","65.00","485","4.06","57.2","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","70.00","52.50","AETNA [1001]","HB AMC AETNA PPO","56.28","80.4","","53.04","35.63","103.63","37","4.06","57.2","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","70.00","52.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","36.58","52.26","","42.08","13.41","42.08","1 through 10","4.06","57.2","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","70.00","52.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","56.28","80.4","","53.04","34.00","53.04","13","4.06","57.2","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","57.20","81.72","","29.90","29.90","54.36","15","4.06","57.2","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","70.00","52.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","57.20","81.72","","54.36","29.90","54.36","370","4.06","57.2","percent of total billed charges",""
"Prothrombin Time Substitution","PX-30001119","CDM","85611","CPT","0305","RC","","","","outpatient","","","68.00","51.00","AETNA [1001]","HB AMC AETNA HMO","47.46","69.8","","44.68","44.68","44.68","1 through 10","4.07","55.57","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","108.58","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.55","53.3","","78.14","78.14","116.48","1 through 10","9.6","145.35","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.85","36.5","","165.60","55.20","165.60","1 through 10","9.6","145.35","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","57.87","57.87","57.87","14","9.6","145.35","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","both","","","153.00","114.75","TRICARE [160005]","HB BWH TRICARE","145.35","95","","14.93","14.18","14.93","1 through 10","9.6","145.35","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","141.48","70.74","200.40","1 through 10","9.6","125.03","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","118.31","65.08","118.31","13","9.6","125.03","percent of total billed charges",""
"Provenge Collection - Dendreon Contract","PX-76001995","CDM","36511","CPT","0761","RC","","","","both","","","4772.00","3579.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1674.59","1674.59","1674.59","1 through 10","1479.32","3793.74","other","OPPS APC"
"Provenge Collection - Dendreon Contract","PX-76001995","CDM","36511","CPT","0761","RC","","","","both","","","4772.00","3579.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3340.40","70","","2112.22","2112.22","2112.22","1 through 10","1479.32","3793.74","percent of total billed charges",""
"Provenge Collection - Dendreon Contract","PX-76001995","CDM","36511","CPT","0761","RC","","","","both","","","4772.00","3579.00","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1641.10","1641.10","1641.10","1 through 10","1479.32","3793.74","other","OPPS APC"
"Provenge Collection - Dendreon Contract","PX-76001995","CDM","36511","CPT","0761","RC","","","","both","","","4772.00","3579.00","MEDICARE [2001]","HB BWH MEDICARE","1946.55","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1946.74","1674.59","1946.74","1 through 10","1479.32","3793.74","other","OPPS APC"
"Provenge Collection - Dendreon Contract","PX-76001995","CDM","36511","CPT","0761","RC","","","","both","","","4772.00","3579.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1827.68","38.3","","1809.55","1809.55","1809.55","1 through 10","1479.32","3793.74","percent of total billed charges",""
"Provenge Collection - Dendreon Contract","PX-76001995","CDM","36511","CPT","0761","RC","","","","both","","","4772.00","3579.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1907.62","","APC Price ($1,946.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1641.10","1641.10","1641.10","1 through 10","1479.32","3793.74","other","OPPS APC"
"Provenge Collection - Dendreon Contract","PX-76001995","CDM","36511","CPT","0761","RC","","","","outpatient","","","4772.00","3579.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1426.02","","Case rate ($1,426.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2917.64","2864.87","2917.64","1 through 10","1426.02","7081.86","other","ASC"
"Provenge Collection - Dendreon Contract","PX-76001995","CDM","36511","CPT","0761","RC","","","","outpatient","","","4772.00","3579.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1426.02","","Case rate ($1,426.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3338.31","3338.31","4628.00","1 through 10","1426.02","7081.86","other","ASC "
"Provenge Collection - Dendreon Contract","PX-76001995","CDM","36511","CPT","0761","RC","","","","outpatient","","","4772.00","3579.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3899.68","81.72","","3699.63","3699.62","3699.63","1 through 10","1426.02","7081.86","percent of total billed charges",""
"Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging","PX-98301709","CDM","64561","CPT","0983","RC","","","","both","","","1827.00","1370.25","MEDICARE [2001]","HB BWH MEDICARE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7793.84","7793.84","7793.84","1 through 10","566.37","9741.31","other","OPPS APC"
"Prq Impltj Neurostimulator Eltrd Peripheral Nrv","PX-98301708","CDM","64555","CPT","0983","RC","","","","both","","","1782.00","1336.50","MEDICARE [2001]","HB BWH MEDICARE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7793.84","7793.84","7793.84","1 through 10","552.42","9741.31","other","OPPS APC"
"Prq Impltj Neurostimulator Eltrd Peripheral Nrv","PX-98301708","CDM","64555","CPT","0983","RC","","","","both","","","1782.00","1336.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7637.19","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7639.96","7639.96","7639.96","1 through 10","552.42","9741.31","other","OPPS APC"
"Prq Impltj Neurostimulator Eltrd Peripheral Nrv","PX-98301708","CDM","64555","CPT","0983","RC","","","","outpatient","","","1782.00","1336.50","AETNA [1001]","HB AMC AETNA HMO","1243.84","69.8","","10578.13","10578.13","10578.13","1 through 10","996.14","5381.58","percent of total billed charges",""
"Prq Plmt Biliary Drg Cath W/Img Gid Rs&I Int-Ext","PX-36000377","CDM","47534","CPT","0361","RC","","","","both","","","3293.00","2469.75","MEDICARE [2001]","HB BWH MEDICARE","4190.55","","APC Price ($4,190.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","4190.97","4190.97","1 through 10","1020.83","5238.18","other","OPPS APC"
"Prq Plmt Biliary Drg Cath W/Img Gid Rs&I Int-Ext","PX-36000377","CDM","47534","CPT","0361","RC","","","","both","","","3293.00","2469.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1201.95","36.5","","1190.99","1190.99","1190.99","1 through 10","1020.83","5238.18","percent of total billed charges",""
"Prq Plmt Biliary Drg Cath W/Img Gid Rs&I Int-Ext","PX-36000377","CDM","47534","CPT","0361","RC","","","","outpatient","","","3293.00","2469.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3370.43","","Case rate ($3,370.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7890.18","7890.18","7890.18","1 through 10","1720.92","11688.78","other","ASC "
"Prq Trluml Coronary Byp Grft Revasc Des One Vessel","PX-48000408","CDM","C9604","HCPCS","0481","RC","","","","both","","","18822.00","14116.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13196.92","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13206.16","13206.16","13206.16","1 through 10","5834.82","16832.81","other","OPPS APC"
"Prq Trluml Coronary Des W/Angio One Art/Brnch","PX-48000404","CDM","C9600","HCPCS","0481","RC","","","","both","","","20927.00","15695.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13196.92","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13205.80","13198.26","18283.02","1 through 10","6487.37","16832.81","other","OPPS APC"
"Prq Trluml Coronary Des W/Angio One Art/Brnch","PX-48000404","CDM","C9600","HCPCS","0481","RC","","","","outpatient","","","20927.00","15695.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","17101.54","81.72","","16223.02","16223.02","16223.02","1 through 10","8702.14","33742.46","percent of total billed charges",""
"Prq Trluml Coronry Chronic Occlus Revasc Des One Vsl","PX-48000411","CDM","C9607","HCPCS","0481","RC","","","","both","","","18720.00","14040.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20896.08","","APC Price ($21,322.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20905.69","20905.69","20905.69","1 through 10","5803.2","26653.16","other","OPPS APC"
"Prq Trluml Coronry Des/Ath/Angio One Art/Brnch","PX-48000406","CDM","C9602","HCPCS","0481","RC","","","","both","","","18651.00","13988.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20896.08","","APC Price ($21,322.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20905.69","18755.46","20906.09","1 through 10","5781.81","26653.16","other","OPPS APC"
"Prvnt Phys Exam Init Face-Face 1st","PX-51000144","CDM","G0402","HCPCS","0510","RC","","","","both","","","633.00","474.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.59","150.59","150.59","1 through 10","149.96","601.35","other","OPPS APC"
"Prvnt Phys Exam Init Face-Face 1st","PX-51000144","CDM","G0402","HCPCS","0510","RC","","","","both","","","633.00","474.75","MEDICARE [2001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.04","144.28","153.04","19","149.96","601.35","other","OPPS APC"
"Prvnt Phys Exam Init Face-Face 1st","PX-51000144","CDM","G0402","HCPCS","0510","RC","","","","both","","","633.00","474.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","140.27","140.27","140.27","1 through 10","149.96","601.35","other","OPPS APC"
"Prvnt Phys Exam Init Face-Face 1st","PX-51000144","CDM","G0402","HCPCS","0510","RC","","","","both","","","633.00","474.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","242.44","38.3","","614.00","614.00","614.00","1 through 10","149.96","601.35","percent of total billed charges",""
"Prvnt Phys Exam Init Face-Face 1st","PX-51000144","CDM","G0402","HCPCS","0510","RC","","","","both","","","633.00","474.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","149.98","141.39","149.98","1 through 10","149.96","601.35","other","OPPS APC"
"Pst Tibl Neurostimulation 1 Tx","PX-76001557","CDM","64566","CPT","0761","RC","","","","both","","","704.00","528.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","17","218.24","559.68","other","OPPS APC"
"Pst Tibl Neurostimulation 1 Tx","PX-76001557","CDM","64566","CPT","0761","RC","","","","both","","","704.00","528.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","316.79","345.12","1 through 10","218.24","559.68","other","OPPS APC"
"Pst Tibl Neurostimulation 1 Tx","PX-76001557","CDM","64566","CPT","0761","RC","","","","both","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.56","350.56","350.56","1 through 10","218.24","559.68","other","OPPS APC"
"Pst Tibl Neurostimulation 1 Tx","PX-76001557","CDM","64566","CPT","0761","RC","","","","outpatient","","","704.00","528.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","656.02","656.02","656.02","1 through 10","247.48","700.33","other","ASC "
"Psych - Prolonged Outpatient E/M Service Each 15 Minutes","PX-96000059","CDM","99417","CPT","0961","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","47.09","36.5","","47.74","40.58","47.74","1 through 10","39.99","102.56","percent of total billed charges",""
"Psych - Prolonged Outpatient E/M Service Each 15 Minutes","PX-96000059","CDM","99417","CPT","0961","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","49.41","38.3","","50.05","50.05","50.05","1 through 10","39.99","102.56","percent of total billed charges",""
"Psych - Prolonged Outpatient E/M Service Each 15 Minutes","PX-96000059","CDM","99417","CPT","0961","RC","","","","outpatient","","","129.00","96.75","AETNA [1001]","HB AMC AETNA HMO","90.04","69.8","","89.60","86.66","89.60","1 through 10","72.11","105.42","percent of total billed charges",""
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0510","RC","","","","outpatient","","","509.00","381.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","266.00","52.26","","305.69","305.69","305.69","1 through 10","40.19","266","percent of total billed charges",""
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0914","RC","","","","both","","","509.00","381.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","178.52","178.52","178.52","1 through 10","157.79","483.55","other","OPPS APC"
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0914","RC","","","","both","","","509.00","381.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","171.23","190.81","14","157.79","483.55","other","OPPS APC"
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0914","RC","","","","both","","","509.00","381.75","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","190.81","175","157.79","483.55","other","OPPS APC"
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0914","RC","","","","both","","","509.00","381.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","173.49","173.49","173.49","1 through 10","157.79","483.55","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","157.62","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","70.78","60.16","70.78","38","103.23","264.74","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","67.68","57.90","97.40","18","103.23","264.74","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","239.09","71.8","","695.73","231.91","695.73","12","103.23","264.74","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","218.45","65.6","","251.94","218.67","251.94","1 through 10","103.23","264.74","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","216.45","65","","209.95","110.14","323.00","1 through 10","103.23","264.74","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","233.10","70","","232.56","176.09","362.25","17","103.23","264.74","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","264.74","79.5","","254.20","151.34","438.88","185","103.23","264.74","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","177.49","53.3","","163.12","151.34","383.30","31","103.23","264.74","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","58.86","57.52","67.68","21","103.23","264.74","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","FALLON HEALTH [1008]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","58.46","58.46","70.38","1 through 10","103.23","264.74","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","58.62","58.62","58.62","1 through 10","103.23","264.74","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","HUMANA [1012]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","67.60","57.29","68.78","1 through 10","103.23","264.74","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","216.45","65","","209.95","171.19","209.95","26","103.23","264.74","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","264.74","79.5","","151.34","151.34","151.34","1 through 10","103.23","264.74","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","68.78","58.46","68.78","593","103.23","264.74","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","103.23","31","","99.81","99.81","299.43","52","103.23","264.74","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.55","36.5","","120.48","102.39","361.44","1195","103.23","264.74","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.54","38.3","","126.29","122.74","378.87","4131","103.23","264.74","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","67.40","57.29","115.42","14","103.23","264.74","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","MOLINA [1014]","HB BWH MOLINA","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","118.44","48.56","219.00","70","103.23","264.74","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","256.41","77","","248.71","218.67","251.94","11","103.23","264.74","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","TRICARE [160005]","HB BWH TRICARE","145.39","","APC Price ($153.04). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","65.34","65.34","65.34","1 through 10","103.23","264.74","other","Tricare OPPS"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","68.20","57.52","174.27","41","103.23","264.74","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.06","126.06","126.06","1 through 10","103.23","264.74","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.86","42.9","","224.63","224.63","224.63","1 through 10","103.23","264.74","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","333.00","249.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","67.41","67.40","68.98","290","103.23","264.74","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","333.00","249.75","AETNA [1001]","HB AMC AETNA HMO","232.43","69.8","","218.67","154.39","251.94","1489","105.16","282.67","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","333.00","249.75","AETNA [1001]","HB AMC AETNA PPO","267.73","80.4","","251.94","169.25","251.94","199","105.16","282.67","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","333.00","249.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","186.15","55.9","","169.25","169.25","169.25","1 through 10","105.16","282.67","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","166.50","50","","206.09","103.05","618.27","205","105.16","282.67","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","174.83","52.5","","183.94","108.19","315.00","95","105.16","282.67","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","208.13","62.5","","216.39","216.39","323.00","1 through 10","105.16","282.67","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","183.15","55","","139.43","69.34","226.02","96","105.16","282.67","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","333.00","249.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","267.73","80.4","","251.94","161.50","251.94","20","105.16","282.67","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","333.00","249.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","272.13","81.72","","258.21","224.63","258.21","1 through 10","105.16","282.67","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","333.00","249.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","272.13","81.72","","224.63","123.56","224.63","1 through 10","105.16","282.67","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","333.00","249.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","272.13","81.72","","224.63","218.67","513.76","40","105.16","282.67","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","124.93","71.8","","156.46","121.34","464.50","35","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","114.14","65.6","","114.41","80.78","114.41","1 through 10","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","113.10","65","","109.85","89.23","109.85","1 through 10","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","121.80","70","","121.68","72.67","218.01","96","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","138.33","79.5","","133.00","57.63","133.00","271","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","92.74","53.3","","133.84","82.82","854.98","33","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9.33","9.33","9.33","1 through 10","53.94","191.28","other","OPPS APC"
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","113.10","65","","109.85","106.60","109.85","56","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","138.33","79.5","","119.17","108.61","119.17","1 through 10","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","113.10","65","","109.85","106.60","169.00","1 through 10","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","125.28","72","","121.68","121.68","121.68","1 through 10","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9.33","9.07","9.33","1 through 10","53.94","191.28","other","OPPS APC"
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","53.94","31","","52.22","52.22","52.22","120","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.51","36.5","","63.04","53.57","63.04","3042","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.64","38.3","","66.08","64.22","66.08","9708","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8.89","8.89","8.89","1 through 10","53.94","191.28","other","OPPS APC"
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","133.98","77","","133.00","84.50","169.00","80","53.94","191.28","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9.07","9.07","9.07","1 through 10","53.94","191.28","other","OPPS APC"
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","174.00","130.50","AETNA [1001]","HB AMC AETNA HMO","121.45","69.8","","114.41","80.78","131.82","4138","87","282.67","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","174.00","130.50","AETNA [1001]","HB AMC AETNA PPO","139.90","80.4","","131.82","88.56","131.82","384","87","282.67","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","174.00","130.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","97.27","55.9","","88.56","88.56","131.82","15","87","282.67","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","174.00","130.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","87.00","50","","88.56","70.84","88.56","25","87","282.67","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","174.00","130.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","91.35","52.5","","67.46","29.88","135.10","64","87","282.67","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","174.00","130.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","108.75","62.5","","169.00","24.96","169.00","1 through 10","87","282.67","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","174.00","130.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","95.70","55","","71.42","31.28","137.80","240","87","282.67","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","174.00","130.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","139.90","80.4","","131.82","84.50","131.82","74","87","282.67","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","174.00","130.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","142.19","81.72","","135.10","126.30","135.10","25","87","282.67","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","142.19","81.72","","135.10","135.10","135.10","1 through 10","87","282.67","percent of total billed charges",""
"Psych Grp Therapy 15 Min","PX-90000022","CDM","90853","CPT","0915","RC","","","","both","","","138.00","103.50","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","1 through 10","42.78","109.71","other","OPPS APC"
"Psych Grp Therapy 15 Min","PX-90000022","CDM","90853","CPT","0915","RC","","","","outpatient","","","138.00","103.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","72.45","52.5","","75.90","61.55","75.90","1 through 10","69","128.37","percent of total billed charges",""
"Psych Grp Therapy 15 Min","PX-90000022","CDM","90853","CPT","0915","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","112.77","81.72","","120.06","120.06","120.06","11","69","128.37","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB AMC AETNA HMO","345.51","69.8","","324.96","229.44","374.40","26","141.78","397.98","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB AMC AETNA PPO","397.98","80.4","","251.52","251.52","251.52","1 through 10","141.78","397.98","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","276.71","55.9","","251.52","251.52","251.52","1 through 10","141.78","397.98","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","495.00","371.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","393.53","79.5","","225.96","163.68","256.63","1 through 10","141.78","397.98","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","495.00","371.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","263.84","53.3","","785.78","225.96","785.78","1 through 10","141.78","397.98","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","321.75","65","","312.00","312.00","312.00","1 through 10","141.78","397.98","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","321.75","65","","312.00","312.00","312.00","1 through 10","141.78","397.98","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","153.45","31","","148.32","148.32","148.32","1 through 10","141.78","397.98","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","180.68","36.5","","173.76","142.49","456.48","25","141.78","397.98","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","189.59","38.3","","182.40","149.36","547.20","84","141.78","397.98","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","495.00","371.25","TRICARE [160005]","HB BWH TRICARE","145.39","","APC Price ($153.04). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","480.00","480.00","480.00","1 through 10","141.78","397.98","other","Tricare OPPS"
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.36","42.9","","167.97","167.97","167.97","1 through 10","141.78","397.98","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","outpatient","","","495.00","371.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.50","50","","200.17","138.22","382.00","1 through 10","105.16","408.38","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","outpatient","","","495.00","371.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","259.88","52.5","","382.00","170.37","396.14","1 through 10","105.16","408.38","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","outpatient","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","404.51","81.72","","382.00","302.90","382.00","1 through 10","105.16","408.38","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","404.51","81.72","","167.97","167.97","167.97","1 through 10","105.16","408.38","percent of total billed charges",""
"Psych New Patient (99203) - Medium Level (16-45 Min)","PX-90000096","CDM","99203","CPT","0914","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","404.51","81.72","","305.37","167.97","305.37","1 through 10","105.16","408.38","percent of total billed charges",""
"Psych Phys/Qhp Telephone Evaluation 11-20 Min","PX-96000064","CDM","99442","CPT","0961","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","86.80","31","","86.52","86.52","86.52","1 through 10","72.1","266","percent of total billed charges",""
"Psych Phys/Qhp Telephone Evaluation 11-20 Min","PX-96000064","CDM","99442","CPT","0961","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","102.20","36.5","","200.38","170.56","200.38","1 through 10","72.1","266","percent of total billed charges",""
"Psych Phys/Qhp Telephone Evaluation 11-20 Min","PX-96000064","CDM","99442","CPT","0961","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","107.24","38.3","","210.32","210.32","210.32","1 through 10","72.1","266","percent of total billed charges",""
"Psych Phys/Qhp Telephone Evaluation 11-20 Min","PX-96000064","CDM","99442","CPT","0961","RC","","","","outpatient","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","228.82","81.72","","276.00","276.00","276.00","1 through 10","45","228.82","percent of total billed charges",""
"Psych Phys/Qhp Telephone Evaluation 21-30 Min","PX-96000063","CDM","99443","CPT","0961","RC","","","","both","","","415.00","311.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","145.25","35","","120.78","120.78","120.78","1 through 10","99.01","394.25","percent of total billed charges",""
"Psych Phys/Qhp Telephone Evaluation 21-30 Min","PX-96000063","CDM","99443","CPT","0961","RC","","","","both","","","415.00","311.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","128.65","31","","128.24","128.24","128.24","1 through 10","99.01","394.25","percent of total billed charges",""
"Psych Phys/Qhp Telephone Evaluation 21-30 Min","PX-96000063","CDM","99443","CPT","0961","RC","","","","both","","","415.00","311.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","151.48","36.5","","250.30","150.23","294.04","54","99.01","394.25","percent of total billed charges",""
"Psych Phys/Qhp Telephone Evaluation 21-30 Min","PX-96000063","CDM","99443","CPT","0961","RC","","","","both","","","415.00","311.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","158.95","38.3","","308.62","157.70","308.62","71","99.01","394.25","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-90000186","CDM","98015","CPT","0914","RC","","","","both","","","532.00","399.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","422.94","79.5","","438.56","438.56","438.56","1 through 10","164.92","505.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-90000186","CDM","98015","CPT","0914","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.18","36.5","","202.17","202.17","202.17","1 through 10","164.92","505.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-90000186","CDM","98015","CPT","0914","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.76","38.3","","211.92","211.92","211.92","1 through 10","164.92","505.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-90000186","CDM","98015","CPT","0914","RC","","","","outpatient","","","532.00","399.00","AETNA [1001]","HB AMC AETNA HMO","371.34","69.8","","422.76","366.93","422.76","1 through 10","212.8","438.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-90000186","CDM","98015","CPT","0914","RC","","","","outpatient","","","532.00","399.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","266.00","50","","284.01","165.48","284.01","1 through 10","212.8","438.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-96000081","CDM","98015","CPT","0961","RC","","","","both","","","550.00","412.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","437.25","79.5","","438.56","438.56","438.56","1 through 10","170.5","522.5","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-96000081","CDM","98015","CPT","0961","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","200.75","36.5","","202.17","202.17","202.17","1 through 10","170.5","522.5","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-96000081","CDM","98015","CPT","0961","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","210.65","38.3","","211.92","211.92","211.92","1 through 10","170.5","522.5","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-96000081","CDM","98015","CPT","0961","RC","","","","outpatient","","","550.00","412.50","AETNA [1001]","HB AMC AETNA HMO","383.90","69.8","","422.76","366.93","422.76","1 through 10","220","453.75","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-96000081","CDM","98015","CPT","0961","RC","","","","outpatient","","","550.00","412.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","275.00","50","","284.01","165.48","284.01","1 through 10","220","453.75","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-90000184","CDM","98013","CPT","0914","RC","","","","both","","","333.00","249.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","239.09","71.8","","178.06","178.06","178.06","1 through 10","103.23","316.35","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-90000184","CDM","98013","CPT","0914","RC","","","","both","","","333.00","249.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","264.74","79.5","","211.42","211.42","211.42","15","103.23","316.35","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-90000184","CDM","98013","CPT","0914","RC","","","","both","","","333.00","249.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","177.49","53.3","","211.42","211.42","211.42","1 through 10","103.23","316.35","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-90000184","CDM","98013","CPT","0914","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.55","36.5","","92.50","78.62","92.50","21","103.23","316.35","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-90000184","CDM","98013","CPT","0914","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.54","38.3","","96.97","96.97","96.97","43","103.23","316.35","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-90000184","CDM","98013","CPT","0914","RC","","","","both","","","333.00","249.75","WELLPOINT [1015]","HB AMC WELLPOINT","245.69","73.78","","184.64","184.64","184.64","1 through 10","103.23","316.35","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-90000184","CDM","98013","CPT","0914","RC","","","","outpatient","","","333.00","249.75","AETNA [1001]","HB AMC AETNA HMO","232.43","69.8","","167.90","118.54","193.44","12","133.2","274.73","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-90000184","CDM","98013","CPT","0914","RC","","","","outpatient","","","333.00","249.75","AETNA [1001]","HB AMC AETNA PPO","267.73","80.4","","193.44","129.95","193.44","1 through 10","133.2","274.73","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-90000184","CDM","98013","CPT","0914","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","166.50","50","","129.95","124.00","218.51","69","133.2","274.73","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-90000184","CDM","98013","CPT","0914","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","174.83","52.5","","136.40","136.40","229.35","13","133.2","274.73","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-90000184","CDM","98013","CPT","0914","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","183.15","55","","131.19","131.19","131.19","1 through 10","133.2","274.73","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-96000079","CDM","98013","CPT","0961","RC","","","","both","","","252.00","189.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","180.94","71.8","","178.06","178.06","178.06","1 through 10","78.12","239.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-96000079","CDM","98013","CPT","0961","RC","","","","both","","","252.00","189.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","200.34","79.5","","211.42","211.42","211.42","15","78.12","239.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-96000079","CDM","98013","CPT","0961","RC","","","","both","","","252.00","189.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","134.32","53.3","","211.42","211.42","211.42","1 through 10","78.12","239.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-96000079","CDM","98013","CPT","0961","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91.98","36.5","","92.50","78.62","92.50","21","78.12","239.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-96000079","CDM","98013","CPT","0961","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.52","38.3","","96.97","96.97","96.97","43","78.12","239.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-96000079","CDM","98013","CPT","0961","RC","","","","both","","","252.00","189.00","WELLPOINT [1015]","HB AMC WELLPOINT","185.93","73.78","","184.64","184.64","184.64","1 through 10","78.12","239.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-96000079","CDM","98013","CPT","0961","RC","","","","outpatient","","","252.00","189.00","AETNA [1001]","HB AMC AETNA HMO","175.90","69.8","","167.90","118.54","193.44","12","100.8","207.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-96000079","CDM","98013","CPT","0961","RC","","","","outpatient","","","252.00","189.00","AETNA [1001]","HB AMC AETNA PPO","202.61","80.4","","193.44","129.95","193.44","1 through 10","100.8","207.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-96000079","CDM","98013","CPT","0961","RC","","","","outpatient","","","252.00","189.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","126.00","50","","129.95","124.00","218.51","69","100.8","207.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-96000079","CDM","98013","CPT","0961","RC","","","","outpatient","","","252.00","189.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","132.30","52.5","","136.40","136.40","229.35","13","100.8","207.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-96000079","CDM","98013","CPT","0961","RC","","","","outpatient","","","252.00","189.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","138.60","55","","131.19","131.19","131.19","1 through 10","100.8","207.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-90000185","CDM","98014","CPT","0914","RC","","","","both","","","507.00","380.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.07","79.5","","271.75","271.75","349.83","20","157.17","481.65","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-90000185","CDM","98014","CPT","0914","RC","","","","both","","","507.00","380.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.23","53.3","","271.75","271.75","271.75","1 through 10","157.17","481.65","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-90000185","CDM","98014","CPT","0914","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.06","36.5","","136.89","116.34","136.89","56","157.17","481.65","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-90000185","CDM","98014","CPT","0914","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.18","38.3","","143.50","143.50","143.50","77","157.17","481.65","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-90000185","CDM","98014","CPT","0914","RC","","","","both","","","507.00","380.25","WELLPOINT [1015]","HB AMC WELLPOINT","374.06","73.78","","273.23","273.23","273.23","1 through 10","157.17","481.65","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-90000185","CDM","98014","CPT","0914","RC","","","","outpatient","","","507.00","380.25","AETNA [1001]","HB AMC AETNA HMO","353.89","69.8","","286.26","248.46","286.26","1 through 10","202.8","418.28","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-90000185","CDM","98014","CPT","0914","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","253.50","50","","192.31","192.31","192.31","66","202.8","418.28","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-90000185","CDM","98014","CPT","0914","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","266.18","52.5","","201.85","201.85","201.85","1 through 10","202.8","418.28","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-90000185","CDM","98014","CPT","0914","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","316.88","62.5","","194.14","194.14","194.14","1 through 10","202.8","418.28","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-90000185","CDM","98014","CPT","0914","RC","","","","outpatient","","","507.00","380.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","414.32","81.72","","293.38","293.38","293.38","1 through 10","202.8","418.28","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-96000080","CDM","98014","CPT","0961","RC","","","","both","","","372.00","279.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","295.74","79.5","","271.75","271.75","349.83","20","115.32","353.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-96000080","CDM","98014","CPT","0961","RC","","","","both","","","372.00","279.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.28","53.3","","271.75","271.75","271.75","1 through 10","115.32","353.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-96000080","CDM","98014","CPT","0961","RC","","","","both","","","372.00","279.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","135.78","36.5","","136.89","116.34","136.89","56","115.32","353.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-96000080","CDM","98014","CPT","0961","RC","","","","both","","","372.00","279.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.48","38.3","","143.50","143.50","143.50","77","115.32","353.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-96000080","CDM","98014","CPT","0961","RC","","","","both","","","372.00","279.00","WELLPOINT [1015]","HB AMC WELLPOINT","274.46","73.78","","273.23","273.23","273.23","1 through 10","115.32","353.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-96000080","CDM","98014","CPT","0961","RC","","","","outpatient","","","372.00","279.00","AETNA [1001]","HB AMC AETNA HMO","259.66","69.8","","286.26","248.46","286.26","1 through 10","148.8","306.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-96000080","CDM","98014","CPT","0961","RC","","","","outpatient","","","372.00","279.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","186.00","50","","192.31","192.31","192.31","66","148.8","306.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-96000080","CDM","98014","CPT","0961","RC","","","","outpatient","","","372.00","279.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","195.30","52.5","","201.85","201.85","201.85","1 through 10","148.8","306.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-96000080","CDM","98014","CPT","0961","RC","","","","outpatient","","","372.00","279.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","232.50","62.5","","194.14","194.14","194.14","1 through 10","148.8","306.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-96000080","CDM","98014","CPT","0961","RC","","","","outpatient","","","372.00","279.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","304.00","81.72","","293.38","293.38","293.38","1 through 10","148.8","306.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-90000183","CDM","98012","CPT","0914","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.38","36.5","","50.73","50.73","50.73","1 through 10","65.72","201.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-90000183","CDM","98012","CPT","0914","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.20","38.3","","53.18","53.18","53.18","1 through 10","65.72","201.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-90000183","CDM","98012","CPT","0914","RC","","","","both","","","212.00","159.00","WELLPOINT [1015]","HB AMC WELLPOINT","156.41","73.78","","101.25","101.25","101.25","1 through 10","65.72","201.4","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-90000183","CDM","98012","CPT","0914","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA HMO","147.98","69.8","","65.01","65.01","65.01","1 through 10","84.8","174.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-90000183","CDM","98012","CPT","0914","RC","","","","outpatient","","","212.00","159.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","106.00","50","","71.26","71.26","71.26","14","84.8","174.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-90000183","CDM","98012","CPT","0914","RC","","","","outpatient","","","212.00","159.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","111.30","52.5","","74.80","74.80","74.80","1 through 10","84.8","174.9","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-96000078","CDM","98012","CPT","0961","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.37","36.5","","50.73","50.73","50.73","1 through 10","42.78","131.1","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-96000078","CDM","98012","CPT","0961","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.85","38.3","","53.18","53.18","53.18","1 through 10","42.78","131.1","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-96000078","CDM","98012","CPT","0961","RC","","","","both","","","138.00","103.50","WELLPOINT [1015]","HB AMC WELLPOINT","101.82","73.78","","101.25","101.25","101.25","1 through 10","42.78","131.1","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-96000078","CDM","98012","CPT","0961","RC","","","","outpatient","","","138.00","103.50","AETNA [1001]","HB AMC AETNA HMO","96.32","69.8","","65.01","65.01","65.01","1 through 10","55.2","113.85","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-96000078","CDM","98012","CPT","0961","RC","","","","outpatient","","","138.00","103.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","69.00","50","","71.26","71.26","71.26","14","55.2","113.85","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-96000078","CDM","98012","CPT","0961","RC","","","","outpatient","","","138.00","103.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","72.45","52.5","","74.80","74.80","74.80","1 through 10","55.2","113.85","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit New Mod Mdm 45 Min","PX-90000181","CDM","98010","CPT","0914","RC","","","","both","","","834.00","625.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","304.41","36.5","","188.74","188.74","188.74","1 through 10","258.54","792.3","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit New Mod Mdm 45 Min","PX-90000181","CDM","98010","CPT","0914","RC","","","","outpatient","","","834.00","625.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","437.85","52.5","","278.30","278.30","278.30","1 through 10","333.6","688.05","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit New Mod Mdm 45 Min","PX-96000076","CDM","98010","CPT","0961","RC","","","","both","","","513.00","384.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","187.25","36.5","","188.74","188.74","188.74","1 through 10","159.03","487.35","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit New Mod Mdm 45 Min","PX-96000076","CDM","98010","CPT","0961","RC","","","","outpatient","","","513.00","384.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","269.33","52.5","","278.30","278.30","278.30","1 through 10","205.2","423.23","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-90000176","CDM","98005","CPT","0914","RC","","","","both","","","333.00","249.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","177.49","53.3","","136.89","136.89","136.89","1 through 10","103.23","316.35","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-90000176","CDM","98005","CPT","0914","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.55","36.5","","100.71","85.59","100.71","14","103.23","316.35","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-90000176","CDM","98005","CPT","0914","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.54","38.3","","105.57","105.57","105.57","13","103.23","316.35","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-90000176","CDM","98005","CPT","0914","RC","","","","both","","","333.00","249.75","WELLPOINT [1015]","HB AMC WELLPOINT","245.69","73.78","","201.02","201.02","201.02","1 through 10","103.23","316.35","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-90000176","CDM","98005","CPT","0914","RC","","","","outpatient","","","333.00","249.75","AETNA [1001]","HB AMC AETNA HMO","232.43","69.8","","182.79","182.79","182.79","1 through 10","133.2","274.73","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-90000176","CDM","98005","CPT","0914","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","166.50","50","","141.48","135.00","141.48","29","133.2","274.73","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-90000176","CDM","98005","CPT","0914","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","174.83","52.5","","148.50","135.00","148.50","1 through 10","133.2","274.73","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-90000176","CDM","98005","CPT","0914","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","183.15","55","","142.83","142.83","142.83","1 through 10","133.2","274.73","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-96000071","CDM","98005","CPT","0961","RC","","","","both","","","274.00","205.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","146.04","53.3","","136.89","136.89","136.89","1 through 10","84.94","260.3","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-96000071","CDM","98005","CPT","0961","RC","","","","both","","","274.00","205.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.01","36.5","","100.71","85.59","100.71","14","84.94","260.3","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-96000071","CDM","98005","CPT","0961","RC","","","","both","","","274.00","205.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","104.94","38.3","","105.57","105.57","105.57","13","84.94","260.3","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-96000071","CDM","98005","CPT","0961","RC","","","","both","","","274.00","205.50","WELLPOINT [1015]","HB AMC WELLPOINT","202.16","73.78","","201.02","201.02","201.02","1 through 10","84.94","260.3","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-96000071","CDM","98005","CPT","0961","RC","","","","outpatient","","","274.00","205.50","AETNA [1001]","HB AMC AETNA HMO","191.25","69.8","","182.79","182.79","182.79","1 through 10","109.6","226.05","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-96000071","CDM","98005","CPT","0961","RC","","","","outpatient","","","274.00","205.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","137.00","50","","141.48","135.00","141.48","29","109.6","226.05","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-96000071","CDM","98005","CPT","0961","RC","","","","outpatient","","","274.00","205.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","143.85","52.5","","148.50","135.00","148.50","1 through 10","109.6","226.05","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-96000071","CDM","98005","CPT","0961","RC","","","","outpatient","","","274.00","205.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","150.70","55","","142.83","142.83","142.83","1 through 10","109.6","226.05","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-90000177","CDM","98006","CPT","0914","RC","","","","both","","","507.00","380.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.07","79.5","","288.99","288.99","367.07","1 through 10","157.17","481.65","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-90000177","CDM","98006","CPT","0914","RC","","","","both","","","507.00","380.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.23","53.3","","858.99","858.99","858.99","1 through 10","157.17","481.65","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-90000177","CDM","98006","CPT","0914","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.06","36.5","","149.57","127.12","149.57","28","157.17","481.65","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-90000177","CDM","98006","CPT","0914","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.18","38.3","","156.79","156.79","156.79","48","157.17","481.65","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-90000177","CDM","98006","CPT","0914","RC","","","","both","","","507.00","380.25","WELLPOINT [1015]","HB AMC WELLPOINT","374.06","73.78","","298.54","298.54","298.54","1 through 10","157.17","481.65","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-90000177","CDM","98006","CPT","0914","RC","","","","outpatient","","","507.00","380.25","AETNA [1001]","HB AMC AETNA HMO","353.89","69.8","","312.78","191.68","312.78","15","202.8","418.28","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-90000177","CDM","98006","CPT","0914","RC","","","","outpatient","","","507.00","380.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","283.41","55.9","","210.12","210.12","210.12","1 through 10","202.8","418.28","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-90000177","CDM","98006","CPT","0914","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","253.50","50","","210.12","210.12","210.12","63","202.8","418.28","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-90000177","CDM","98006","CPT","0914","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","266.18","52.5","","220.55","220.55","220.55","19","202.8","418.28","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-90000177","CDM","98006","CPT","0914","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","266.18","52.5","","212.13","212.13","212.13","1 through 10","202.8","418.28","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-90000177","CDM","98006","CPT","0914","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","278.85","55","","212.13","212.13","212.13","1 through 10","202.8","418.28","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-96000072","CDM","98006","CPT","0961","RC","","","","both","","","407.00","305.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","323.57","79.5","","288.99","288.99","367.07","1 through 10","126.17","386.65","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-96000072","CDM","98006","CPT","0961","RC","","","","both","","","407.00","305.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","216.93","53.3","","858.99","858.99","858.99","1 through 10","126.17","386.65","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-96000072","CDM","98006","CPT","0961","RC","","","","both","","","407.00","305.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","148.56","36.5","","149.57","127.12","149.57","28","126.17","386.65","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-96000072","CDM","98006","CPT","0961","RC","","","","both","","","407.00","305.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","155.88","38.3","","156.79","156.79","156.79","48","126.17","386.65","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-96000072","CDM","98006","CPT","0961","RC","","","","both","","","407.00","305.25","WELLPOINT [1015]","HB AMC WELLPOINT","300.28","73.78","","298.54","298.54","298.54","1 through 10","126.17","386.65","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-96000072","CDM","98006","CPT","0961","RC","","","","outpatient","","","407.00","305.25","AETNA [1001]","HB AMC AETNA HMO","284.09","69.8","","312.78","191.68","312.78","15","162.8","335.78","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-96000072","CDM","98006","CPT","0961","RC","","","","outpatient","","","407.00","305.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","227.51","55.9","","210.12","210.12","210.12","1 through 10","162.8","335.78","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-96000072","CDM","98006","CPT","0961","RC","","","","outpatient","","","407.00","305.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","203.50","50","","210.12","210.12","210.12","63","162.8","335.78","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-96000072","CDM","98006","CPT","0961","RC","","","","outpatient","","","407.00","305.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","213.68","52.5","","220.55","220.55","220.55","19","162.8","335.78","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-96000072","CDM","98006","CPT","0961","RC","","","","outpatient","","","407.00","305.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","213.68","52.5","","212.13","212.13","212.13","1 through 10","162.8","335.78","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-96000072","CDM","98006","CPT","0961","RC","","","","outpatient","","","407.00","305.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","223.85","55","","212.13","212.13","212.13","1 through 10","162.8","335.78","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Sf Mdm 10 Min","PX-90000175","CDM","98004","CPT","0914","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.20","38.3","","56.70","56.70","56.70","1 through 10","65.72","201.4","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Sf Mdm 10 Min","PX-90000175","CDM","98004","CPT","0914","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA HMO","147.98","69.8","","113.10","113.10","113.10","1 through 10","84.8","174.9","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Sf Mdm 10 Min","PX-90000175","CDM","98004","CPT","0914","RC","","","","outpatient","","","212.00","159.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","106.00","50","","75.98","75.98","75.98","1 through 10","84.8","174.9","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Sf Mdm 10 Min","PX-96000070","CDM","98004","CPT","0961","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.30","38.3","","56.70","56.70","56.70","1 through 10","45.57","139.65","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Sf Mdm 10 Min","PX-96000070","CDM","98004","CPT","0961","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA HMO","102.61","69.8","","113.10","113.10","113.10","1 through 10","58.8","121.28","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Sf Mdm 10 Min","PX-96000070","CDM","98004","CPT","0961","RC","","","","outpatient","","","147.00","110.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","73.50","50","","75.98","75.98","75.98","1 through 10","58.8","121.28","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-90000173","CDM","98002","CPT","0914","RC","","","","both","","","834.00","625.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","319.42","38.3","","211.92","211.92","211.92","1 through 10","258.54","792.3","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-90000173","CDM","98002","CPT","0914","RC","","","","outpatient","","","834.00","625.50","AETNA [1001]","HB AMC AETNA HMO","582.13","69.8","","366.93","366.93","366.93","1 through 10","333.6","688.05","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-90000173","CDM","98002","CPT","0914","RC","","","","outpatient","","","834.00","625.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","417.00","50","","284.01","284.01","284.01","1 through 10","333.6","688.05","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-96000068","CDM","98002","CPT","0961","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","210.65","38.3","","211.92","211.92","211.92","1 through 10","170.5","522.5","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-96000068","CDM","98002","CPT","0961","RC","","","","outpatient","","","550.00","412.50","AETNA [1001]","HB AMC AETNA HMO","383.90","69.8","","366.93","366.93","366.93","1 through 10","220","453.75","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-96000068","CDM","98002","CPT","0961","RC","","","","outpatient","","","550.00","412.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","275.00","50","","284.01","284.01","284.01","1 through 10","220","453.75","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-90000178","CDM","98007","CPT","0914","RC","","","","both","","","532.00","399.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","422.94","79.5","","360.48","360.48","360.48","1 through 10","164.92","505.4","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-90000178","CDM","98007","CPT","0914","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.18","36.5","","171.81","171.81","171.81","1 through 10","164.92","505.4","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-90000178","CDM","98007","CPT","0914","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.76","38.3","","211.92","211.92","211.92","1 through 10","164.92","505.4","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-90000178","CDM","98007","CPT","0914","RC","","","","both","","","532.00","399.00","WELLPOINT [1015]","HB AMC WELLPOINT","392.51","73.78","","403.52","403.52","403.52","1 through 10","164.92","505.4","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-90000178","CDM","98007","CPT","0914","RC","","","","outpatient","","","532.00","399.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","266.00","50","","284.01","284.01","284.01","1 through 10","212.8","438.9","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-90000178","CDM","98007","CPT","0914","RC","","","","outpatient","","","532.00","399.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","279.30","52.5","","298.10","298.10","298.10","1 through 10","212.8","438.9","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-96000073","CDM","98007","CPT","0961","RC","","","","both","","","550.00","412.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","437.25","79.5","","360.48","360.48","360.48","1 through 10","170.5","522.5","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-96000073","CDM","98007","CPT","0961","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","200.75","36.5","","171.81","171.81","171.81","1 through 10","170.5","522.5","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-96000073","CDM","98007","CPT","0961","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","210.65","38.3","","211.92","211.92","211.92","1 through 10","170.5","522.5","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-96000073","CDM","98007","CPT","0961","RC","","","","both","","","550.00","412.50","WELLPOINT [1015]","HB AMC WELLPOINT","405.79","73.78","","403.52","403.52","403.52","1 through 10","170.5","522.5","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-96000073","CDM","98007","CPT","0961","RC","","","","outpatient","","","550.00","412.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","275.00","50","","284.01","284.01","284.01","1 through 10","220","453.75","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-96000073","CDM","98007","CPT","0961","RC","","","","outpatient","","","550.00","412.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","288.75","52.5","","298.10","298.10","298.10","1 through 10","220","453.75","percent of total billed charges",""
"Psych Therapy Family W/O Pt","PX-90000024","CDM","90846","CPT","0916","RC","","","","both","","","326.00","244.50","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","174.01","190.81","1 through 10","101.06","309.7","other","OPPS APC"
"Psych Therapy Family W/O Pt","PX-90000024","CDM","90846","CPT","0916","RC","","","","outpatient","","","326.00","244.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","163.00","50","","165.58","165.58","165.58","1 through 10","163","270.73","percent of total billed charges",""
"Psych Therapy Family W/Pt","PX-90000025","CDM","90847","CPT","0916","RC","","","","both","","","393.00","294.75","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","572.43","27","121.83","373.35","other","OPPS APC"
"Psych Therapy Family W/Pt","PX-90000025","CDM","90847","CPT","0916","RC","","","","outpatient","","","393.00","294.75","AETNA [1001]","HB AMC AETNA HMO","274.31","69.8","","329.15","3.41","329.15","1 through 10","180.98","324.23","percent of total billed charges",""
"Psych Therapy Family W/Pt","PX-90000025","CDM","90847","CPT","0916","RC","","","","outpatient","","","393.00","294.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","206.33","52.5","","209.55","209.55","209.55","1 through 10","180.98","324.23","percent of total billed charges",""
"Psych Therapy Family W/Pt","PX-90000025","CDM","90847","CPT","0916","RC","","","","outpatient","","","393.00","294.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","216.15","55","","194.58","186.20","194.58","1 through 10","180.98","324.23","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","505.00","378.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","196.64","186.99","197.14","12","156.55","479.75","other","OPPS APC"
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","505.00","378.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","46.52","187.76","1 through 10","156.55","479.75","other","OPPS APC"
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","505.00","378.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","353.50","70","","190.81","190.81","190.81","1 through 10","156.55","479.75","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","505.00","378.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","171.23","486.95","1 through 10","156.55","479.75","other","OPPS APC"
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","505.00","378.75","HUMANA [1012]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.99","186.99","186.99","1 through 10","156.55","479.75","other","OPPS APC"
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","505.00","378.75","MEDICARE [2001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","190.81","485.18","477","156.55","479.75","other","OPPS APC"
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","505.00","378.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.76","187.76","187.76","1 through 10","156.55","479.75","other","OPPS APC"
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","outpatient","","","505.00","378.75","AETNA [1001]","HB AMC AETNA HMO","352.49","69.8","","331.73","234.22","331.73","1 through 10","156.22","416.63","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","outpatient","","","505.00","378.75","AETNA [1001]","HB AMC AETNA PPO","406.02","80.4","","343.00","343.00","343.00","1 through 10","156.22","416.63","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","outpatient","","","505.00","378.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","252.50","50","","256.76","246.47","256.76","1 through 10","156.22","416.63","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","outpatient","","","505.00","378.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","265.13","52.5","","269.50","218.54","269.50","1 through 10","156.22","416.63","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","outpatient","","","505.00","378.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","412.69","81.72","","426.30","426.30","426.30","1 through 10","156.22","416.63","percent of total billed charges",""
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","95493.29","71619.97","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","13121.59","","Case rate ($13,121.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,718.40, add-ons for qualifying new technology services are included. If operating cost exceeds $61,362.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,564.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $11,617.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,338.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,123.95. The transfer capital threshold is the transfer adjustment factor * $1,123.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12844.83","12844.83","12844.83","1 through 10","12859.16","21879.48","other","Inpatient DRG"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","95493.29","71619.97","MEDICARE [2001]","HB BWH MEDICARE","13121.59","","Case rate ($13,121.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,718.40, add-ons for qualifying new technology services are included. If operating cost exceeds $61,362.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,564.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $11,617.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,338.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,123.95. The transfer capital threshold is the transfer adjustment factor * $1,123.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16896.29","0.03","16921.14","1 through 10","12859.16","21879.48","other","Inpatient Replacement Plans DRG"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","95493.29","71619.97","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12859.16","","Case rate ($13,121.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,718.40, add-ons for qualifying new technology services are included. If operating cost exceeds $61,362.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,564.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $11,617.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,338.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,123.95. The transfer capital threshold is the transfer adjustment factor * $1,123.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12867.65","12867.65","12867.65","1 through 10","12859.16","21879.48","other","Inpatient DRG"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","95493.29","71619.97","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12859.16","","Case rate ($13,121.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,718.40, add-ons for qualifying new technology services are included. If operating cost exceeds $61,362.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,564.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $11,617.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,338.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,123.95. The transfer capital threshold is the transfer adjustment factor * $1,123.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18384.25","18384.25","18384.25","1 through 10","12859.16","21879.48","other","Inpatient DRG"
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-90000139","CDM","96136","CPT","0918","RC","","","","both","","","184.00","138.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20.93","15.35","20.93","1 through 10","57.04","146.28","other","OPPS APC"
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-96000034","CDM","96136","CPT","0961","RC","","","","both","","","106.00","79.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20.93","15.35","20.93","1 through 10","32.86","145.42","other","OPPS APC"
"Pt Aquatic Therapy/Exercise 15 Min","PX-42000025","CDM","97113","CPT","0421","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","90.21","31","","87.14","87.14","87.14","1 through 10","40.43","276.45","percent of total billed charges",""
"Pt Aquatic Therapy/Exercise 15 Min","PX-42000025","CDM","97113","CPT","0421","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","111.45","38.3","","107.16","107.16","107.16","1 through 10","40.43","276.45","percent of total billed charges",""
"Pt Canalith Repositioning per Day","PX-42000007","CDM","95992","CPT","0421","RC","","","","both","","","287.00","215.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","152.97","53.3","","218.79","218.79","218.79","1 through 10","36.25","272.65","percent of total billed charges",""
"Pt Canalith Repositioning per Day","PX-42000007","CDM","95992","CPT","0421","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","109.92","38.3","","108.70","105.64","108.70","21","36.25","272.65","percent of total billed charges",""
"Pt Canalith Repositioning per Day","PX-42000007","CDM","95992","CPT","0421","RC","","","","both","","","287.00","215.25","TRICARE [160005]","HB BWH TRICARE","272.65","95","","35.14","35.14","35.14","1 through 10","36.25","272.65","percent of total billed charges",""
"Pt Canalith Repositioning per Day","PX-42000007","CDM","95992","CPT","0421","RC","","","","outpatient","","","287.00","215.25","AETNA [1001]","HB AMC AETNA HMO","200.33","69.8","","132.88","132.88","188.21","1 through 10","149.99","376","percent of total billed charges",""
"Pt Debr/Rem Tiss Addl 20 Sq Cm/Part","PX-42000040","CDM","97598","CPT","0421","RC","","","","both","","","272.00","204.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","144.98","53.3","","207.77","207.77","207.77","1 through 10","32.34","216.24","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","both","","","889.00","666.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","706.76","79.5","","678.39","678.39","678.39","1 through 10","47.19","706.76","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","both","","","889.00","666.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","473.84","53.3","","678.39","678.39","678.39","1 through 10","47.19","706.76","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","both","","","889.00","666.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","324.49","36.5","","321.53","312.04","643.06","1 through 10","47.19","706.76","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","both","","","889.00","666.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","340.49","38.3","","1011.12","58.26","1011.12","1 through 10","47.19","706.76","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","outpatient","","","889.00","666.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","409.36","409.36","1 through 10","176.45","726.49","other","Multiple Surgery"
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","outpatient","","","889.00","666.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","726.49","81.72","","689.08","689.08","689.08","1 through 10","176.45","726.49","percent of total billed charges",""
"Pt E-Stim Attended 15 Min","PX-42000017","CDM","97032","CPT","0421","RC","","","","both","","","136.00","102.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.09","38.3","","51.61","51.61","51.61","1 through 10","15.37","129.2","percent of total billed charges",""
"Pt E-Stim Attended 15 Min","PX-42000017","CDM","97032","CPT","0421","RC","","","","both","","","136.00","102.00","TRICARE [160005]","HB BWH TRICARE","129.20","95","","15.74","15.68","15.74","17","15.37","129.2","percent of total billed charges",""
"Pt E-Stim Attended 15 Min","PX-42000017","CDM","97032","CPT","0421","RC","","","","outpatient","","","136.00","102.00","AETNA [1001]","HB AMC AETNA PPO","109.34","80.4","","55.02","55.02","55.02","1 through 10","71.07","376","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","228.00","171.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","163.70","71.8","","39.87","39.87","158.68","22","31.47","216.6","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","228.00","171.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","159.60","70","","221.00","221.00","221.00","1 through 10","31.47","216.6","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","228.00","171.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","181.26","79.5","","173.93","173.93","173.93","16","31.47","216.6","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","228.00","171.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","121.52","53.3","","116.69","116.69","173.93","668","31.47","216.6","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","70.68","31","","68.29","68.29","68.29","45","31.47","216.6","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.22","36.5","","82.43","70.06","82.44","747","31.47","216.6","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.32","38.3","","86.41","83.98","86.41","3896","31.47","216.6","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","228.00","171.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","175.56","77","","344.76","209.00","344.76","1 through 10","31.47","216.6","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","228.00","171.00","TRICARE [160005]","HB BWH TRICARE","216.60","95","","32.64","30.50","65.28","175","31.47","216.6","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.81","42.9","","250.40","250.40","250.40","1 through 10","31.47","216.6","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","31.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","27.69","24.74","32.07","653","31.47","216.6","fee schedule",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","228.00","171.00","AETNA [1001]","HB AMC AETNA HMO","159.14","69.8","","185.76","105.64","263.53","2075","119.15","376","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","228.00","171.00","AETNA [1001]","HB AMC AETNA PPO","183.31","80.4","","203.63","87.83","303.12","199","119.15","376","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","228.00","171.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","127.45","55.9","","109.52","83.38","109.52","1 through 10","119.15","376","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","183.31","80.4","","172.38","172.38","172.38","1 through 10","119.15","376","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","186.32","81.72","","176.67","160.95","353.33","1 through 10","119.15","376","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","186.32","81.72","","119.60","119.60","221.00","72","119.15","376","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","197.00","147.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","156.62","79.5","","100.85","100.85","100.85","1 through 10","31.47","187.15","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","197.00","147.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","105.00","53.3","","150.32","100.85","150.32","1 through 10","31.47","187.15","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","197.00","147.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.91","36.5","","71.24","60.55","71.25","1 through 10","31.47","187.15","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","197.00","147.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.45","38.3","","74.68","74.68","74.68","15","31.47","187.15","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","31.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","23.36","23.31","31.47","1 through 10","31.47","187.15","fee schedule",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","outpatient","","","197.00","147.75","AETNA [1001]","HB AMC AETNA HMO","137.51","69.8","","129.31","98.07","129.31","38","102.95","376","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","outpatient","","","197.00","147.75","AETNA [1001]","HB AMC AETNA PPO","158.39","80.4","","112.99","69.24","112.99","1 through 10","102.95","376","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","245.00","183.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.59","53.3","","187.31","125.67","187.31","1 through 10","35.26","232.75","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.43","36.5","","88.77","88.77","88.77","1 through 10","35.26","232.75","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.84","38.3","","93.06","93.06","93.06","63","35.26","232.75","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","35.26","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.98). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($25.72). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","28.86","27.95","30.30","12","35.26","232.75","fee schedule",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA HMO","171.01","69.8","","197.07","83.58","279.13","37","128.04","376","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA PPO","196.98","80.4","","124.71","113.76","185.64","1 through 10","128.04","376","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","212.00","159.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","168.54","79.5","","168.03","102.92","168.03","1 through 10","29.66","201.4","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","212.00","159.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","113.00","53.3","","108.77","108.77","162.12","277","29.66","201.4","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","65.72","31","","63.65","63.65","63.66","18","29.66","201.4","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.38","36.5","","76.84","65.30","110.65","194","29.66","201.4","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.20","38.3","","80.55","78.28","80.55","1156","29.66","201.4","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","212.00","159.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","163.24","77","","194.00","194.00","194.00","1 through 10","29.66","201.4","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","212.00","159.00","TRICARE [160005]","HB BWH TRICARE","201.40","95","","29.95","28.76","30.27","65","29.66","201.4","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","29.66","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($30.27). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($22.53). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","22.08","22.08","25.93","101","29.66","201.4","fee schedule",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA HMO","147.98","69.8","","98.47","75.02","139.46","510","110.79","376","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA PPO","170.45","80.4","","122.42","82.24","283.10","39","110.79","376","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","118.51","55.9","","78.44","78.44","78.44","1 through 10","110.79","376","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","212.00","159.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","170.45","80.4","","160.68","160.68","160.68","1 through 10","110.79","376","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","212.00","159.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","173.25","81.72","","164.67","149.40","164.68","1 through 10","110.79","376","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","173.25","81.72","","412.00","114.06","412.00","1 through 10","110.79","376","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","233.00","174.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.19","53.3","","119.33","119.33","177.86","52","35.02","221.35","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","233.00","174.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.05","36.5","","84.30","71.64","84.30","104","35.02","221.35","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","233.00","174.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.24","38.3","","88.37","88.37","88.37","503","35.02","221.35","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","233.00","174.75","TRICARE [160005]","HB BWH TRICARE","221.35","95","","36.42","33.94","37.56","12","35.02","221.35","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","233.00","174.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","35.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.73). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($26.43). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","30.76","29.14","35.54","102","35.02","221.35","fee schedule",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","outpatient","","","233.00","174.75","AETNA [1001]","HB AMC AETNA HMO","162.63","69.8","","189.87","108.03","268.91","257","121.77","376","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","outpatient","","","233.00","174.75","AETNA [1001]","HB AMC AETNA PPO","187.33","80.4","","176.28","118.42","208.13","42","121.77","376","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","outpatient","","","233.00","174.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","130.25","55.9","","118.42","111.61","118.42","1 through 10","121.77","376","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","outpatient","","","233.00","174.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","190.41","81.72","","226.00","125.14","226.00","1 through 10","121.77","376","percent of total billed charges",""
"Pt Prosthetic Training Each 15 Min","PX-42000047","CDM","97761","CPT","0421","RC","","","","outpatient","","","227.00","170.25","AETNA [1001]","HB AMC AETNA PPO","182.51","80.4","","171.60","171.60","171.60","1 through 10","118.63","376","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","245.00","183.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","194.78","79.5","","125.66","125.66","125.66","1 through 10","38.35","232.75","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","245.00","183.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.59","53.3","","125.67","125.66","187.31","1 through 10","38.35","232.75","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.43","36.5","","86.16","75.45","226.35","22","38.35","232.75","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.84","38.3","","93.06","90.44","93.06","97","38.35","232.75","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","245.00","183.75","TRICARE [160005]","HB BWH TRICARE","232.75","95","","41.46","41.46","41.46","1 through 10","38.35","232.75","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","38.35","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($39.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($27.12). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","38.50","26.69","237.46","1 through 10","38.35","232.75","fee schedule",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA HMO","171.01","69.8","","185.64","113.76","316.44","69","128.04","376","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA PPO","196.98","80.4","","185.64","185.64","317.50","1 through 10","128.04","376","percent of total billed charges",""
"Pt Traction Mechanical","PX-42000009","CDM","97012","CPT","0421","RC","","","","both","","","113.00","84.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.28","38.3","","43.01","43.01","43.01","1 through 10","15.37","107.35","percent of total billed charges",""
"Pt Ultrasound 15 Min","PX-42000020","CDM","97035","CPT","0421","RC","","","","both","","","87.00","65.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.32","38.3","","32.84","32.84","32.84","1 through 10","15.19","82.65","percent of total billed charges",""
"Ptt Substitution","PX-30001130","CDM","85732","CPT","0305","RC","","","","outpatient","","","117.00","87.75","AETNA [1001]","HB AMC AETNA HMO","81.67","69.8","","88.14","88.14","88.14","1 through 10","6.67","95.61","percent of total billed charges",""
"PUBIC PLATE 2X3.5 78MM 6 HOLE SYMPHYSIS DCP","SUP-ITM-10037371","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.60","2020.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2141.41","79.5","","800.18","480.96","1887.97","195","835.02","2141.41","percent of total billed charges",""
"PUBIC PLATE 2X3.5 78MM 6 HOLE SYMPHYSIS DCP","SUP-ITM-10037371","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.60","2020.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1435.69","53.3","","813.12","216.42","1444.50","81","835.02","2141.41","percent of total billed charges",""
"PUBIC PLATE 2X3.5 78MM 6 HOLE SYMPHYSIS DCP","SUP-ITM-10037371","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.60","2020.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","835.02","31","","432.60","432.60","432.60","1 through 10","835.02","2141.41","percent of total billed charges",""
"PUBIC PLATE 2X3.5 78MM 6 HOLE SYMPHYSIS DCP","SUP-ITM-10037371","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.60","2020.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","983.16","36.5","","148.37","54.89","631.39","94","835.02","2141.41","percent of total billed charges",""
"PUBIC PLATE 2X3.5 78MM 6 HOLE SYMPHYSIS DCP","SUP-ITM-10037371","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.60","2020.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1031.65","38.3","","279.30","91.72","1116.77","266","835.02","2141.41","percent of total billed charges",""
"PUBIC PLATE 2X3.5 78MM 6 HOLE SYMPHYSIS DCP","SUP-ITM-10037371","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.60","2020.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1155.55","42.9","","731.00","63.70","731.00","1 through 10","835.02","2141.41","percent of total billed charges",""
"PUBIC PLATE 2X3.5 78MM 6 HOLE SYMPHYSIS DCP","SUP-ITM-10037371","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.60","2020.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1155.55","42.9","","384.74","384.74","384.74","1 through 10","835.02","2141.41","percent of total billed charges",""
"PUBIC PLATE 2X3.5 78MM 6 HOLE SYMPHYSIS DCP","SUP-ITM-10037371","CDM","C1713","HCPCS","0278","RC","","","","both","","","2693.60","2020.20","WELLPOINT [1015]","HB AMC WELLPOINT","1987.34","73.78","","286.63","119.22","1107.45","105","835.02","2141.41","percent of total billed charges",""
"PUBIC PLATE 2X3.5 78MM 6 HOLE SYMPHYSIS DCP","SUP-ITM-10037371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2693.60","2020.20","AETNA [1001]","HB AMC AETNA HMO","1880.13","69.8","","675.31","184.75","1721.50","286","1407.68","2201.21","percent of total billed charges",""
"PUBIC PLATE 2X3.5 78MM 6 HOLE SYMPHYSIS DCP","SUP-ITM-10037371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2693.60","2020.20","AETNA [1001]","HB AMC AETNA PPO","2165.65","80.4","","1261.44","103.12","1514.10","21","1407.68","2201.21","percent of total billed charges",""
"PUBIC PLATE 2X3.5 78MM 6 HOLE SYMPHYSIS DCP","SUP-ITM-10037371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2693.60","2020.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2165.65","80.4","","1365.00","1365.00","1365.00","1 through 10","1407.68","2201.21","percent of total billed charges",""
"PUBIC PLATE 2X3.5 78MM 6 HOLE SYMPHYSIS DCP","SUP-ITM-10037371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2693.60","2020.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2201.21","81.72","","5157.68","5157.68","5157.68","1 through 10","1407.68","2201.21","percent of total billed charges",""
"PUBIC PLATE 2X3.5 78MM 6 HOLE SYMPHYSIS DCP","SUP-ITM-10037371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2693.60","2020.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2201.21","81.72","","431.26","71.26","1459.57","88","1407.68","2201.21","percent of total billed charges",""
"Pulmonary Artery Aspirate Thrombectomy","PX-48000263","CDM","37799","CPT","0481","RC","","","","outpatient","","","14287.00","10715.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","7460.67","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","11786.78","percent of total billed charges",""
"Pulmonary Artery Aspirate Thrombectomy","PX-48000263","CDM","37799","CPT","0481","RC","","","","outpatient","","","14287.00","10715.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","7500.68","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","11786.78","percent of total billed charges",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","81715.77","61286.83","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","11998.77","","Case rate ($11,649.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,946.04, add-ons for qualifying new technology services are included. If operating cost exceeds $59,590.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,434.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,275.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,566.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $994.08. The transfer capital threshold is the transfer adjustment factor * $994.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11859.52","11859.52","11859.52","1 through 10","11416.3","19351.31","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","81715.77","61286.83","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","15005.65","","Case rate ($15,005.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,946.04, add-ons for qualifying new technology services are included. If operating cost exceeds $59,590.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,434.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,631.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,566.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $994.08. The transfer capital threshold is the transfer adjustment factor * $994.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11384.88","11384.88","11384.88","1 through 10","11416.3","19351.31","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","81715.77","61286.83","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","11649.29","","Case rate ($11,649.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,946.04, add-ons for qualifying new technology services are included. If operating cost exceeds $59,590.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,434.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,275.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,566.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $994.08. The transfer capital threshold is the transfer adjustment factor * $994.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11323.83","11318.19","11367.29","1 through 10","11416.3","19351.31","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","81715.77","61286.83","HUMANA [1012]","HB BWH MEDICARE","15005.65","","Case rate ($15,005.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,946.04, add-ons for qualifying new technology services are included. If operating cost exceeds $59,590.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,434.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,631.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,566.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $994.08. The transfer capital threshold is the transfer adjustment factor * $994.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11327.31","11327.31","11327.31","1 through 10","11416.3","19351.31","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","81715.77","61286.83","MARTIN'S POINT [160007]","HB BWH MEDICARE","15005.65","","Case rate ($15,005.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,946.04, add-ons for qualifying new technology services are included. If operating cost exceeds $59,590.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,434.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,631.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,566.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $994.08. The transfer capital threshold is the transfer adjustment factor * $994.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11344.84","11344.84","11344.84","1 through 10","11416.3","19351.31","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","81715.77","61286.83","MEDICARE [2001]","HB BWH MEDICARE","15005.65","","Case rate ($15,005.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,946.04, add-ons for qualifying new technology services are included. If operating cost exceeds $59,590.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,434.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $13,631.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,566.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $994.08. The transfer capital threshold is the transfer adjustment factor * $994.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14866.18","4512.55","14888.00","21","11416.3","19351.31","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","81715.77","61286.83","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","11416.30","","Case rate ($11,649.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,946.04, add-ons for qualifying new technology services are included. If operating cost exceeds $59,590.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,434.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,275.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,566.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $994.08. The transfer capital threshold is the transfer adjustment factor * $994.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11316.91","11316.91","11316.91","1 through 10","11416.3","19351.31","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","81715.77","61286.83","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11416.30","","Case rate ($11,649.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,946.04, add-ons for qualifying new technology services are included. If operating cost exceeds $59,590.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,434.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,275.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,566.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $994.08. The transfer capital threshold is the transfer adjustment factor * $994.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11352.31","11308.71","29744.95","1 through 10","11416.3","19351.31","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","69312.42","51984.31","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12909.98","","Case rate ($12,909.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,463.64, add-ons for qualifying new technology services are included. If operating cost exceeds $61,108.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,545.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,424.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,083.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,105.28. The transfer capital threshold is the transfer adjustment factor * $1,105.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16636.90","16636.90","16636.90","1 through 10","12651.78","21516.07","other","Inpatient Replacement Plans DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","69312.42","51984.31","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","16137.48","","Case rate ($12,909.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,463.64, add-ons for qualifying new technology services are included. If operating cost exceeds $61,108.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,545.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,424.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,083.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,105.28. The transfer capital threshold is the transfer adjustment factor * $1,105.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","13068.31","13068.31","13068.31","1 through 10","12651.78","21516.07","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","69312.42","51984.31","HUMANA [1012]","HB BWH MEDICARE","12909.98","","Case rate ($12,909.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,463.64, add-ons for qualifying new technology services are included. If operating cost exceeds $61,108.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,545.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,424.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,083.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,105.28. The transfer capital threshold is the transfer adjustment factor * $1,105.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12846.22","12846.22","12846.22","1 through 10","12651.78","21516.07","other","Inpatient Replacement Plans DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","69312.42","51984.31","MEDICARE [2001]","HB BWH MEDICARE","12909.98","","Case rate ($12,909.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,463.64, add-ons for qualifying new technology services are included. If operating cost exceeds $61,108.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,545.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,424.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,083.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,105.28. The transfer capital threshold is the transfer adjustment factor * $1,105.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16890.38","0.03","16915.23","34","12651.78","21516.07","other","Inpatient Replacement Plans DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","69312.42","51984.31","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","12909.98","","Case rate ($12,909.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,463.64, add-ons for qualifying new technology services are included. If operating cost exceeds $61,108.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,545.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,424.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,083.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,105.28. The transfer capital threshold is the transfer adjustment factor * $1,105.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12824.20","12824.20","12824.20","1 through 10","12651.78","21516.07","other","Inpatient Replacement Plans DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","69312.42","51984.31","MOLINA [1014]","HB BWH MOLINA","12651.78","","Case rate ($12,909.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,463.64, add-ons for qualifying new technology services are included. If operating cost exceeds $61,108.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,545.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,424.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,083.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,105.28. The transfer capital threshold is the transfer adjustment factor * $1,105.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25957.38","25957.38","25957.38","1 through 10","12651.78","21516.07","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","69312.42","51984.31","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12651.78","","Case rate ($12,909.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,463.64, add-ons for qualifying new technology services are included. If operating cost exceeds $61,108.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,545.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,424.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,083.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,105.28. The transfer capital threshold is the transfer adjustment factor * $1,105.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12873.32","12873.32","12873.32","1 through 10","12651.78","21516.07","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","69312.42","51984.31","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","12651.78","","Case rate ($12,909.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,463.64, add-ons for qualifying new technology services are included. If operating cost exceeds $61,108.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,545.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,424.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,083.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,105.28. The transfer capital threshold is the transfer adjustment factor * $1,105.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6805.59","6805.59","6805.59","1 through 10","12651.78","21516.07","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","69312.42","51984.31","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12651.78","","Case rate ($12,909.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,463.64, add-ons for qualifying new technology services are included. If operating cost exceeds $61,108.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,545.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,424.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,083.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,105.28. The transfer capital threshold is the transfer adjustment factor * $1,105.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12855.39","10197.73","12957.06","1 through 10","12651.78","21516.07","other","Inpatient DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","44168.18","33126.13","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7954.83","","Case rate ($7,723.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,219.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,087.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,695.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,839.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $647.75. The transfer capital threshold is the transfer adjustment factor * $647.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7912.83","7912.83","7912.83","1 through 10","7568.68","12291.6195","other","Inpatient DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","44168.18","33126.13","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","9910.18","","Case rate ($9,910.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,219.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,087.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $8,882.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,839.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $647.75. The transfer capital threshold is the transfer adjustment factor * $647.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","78314.68","78314.68","78314.68","1 through 10","7568.68","12291.6195","other","Inpatient DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","44168.18","33126.13","HUMANA [1012]","HB BWH MEDICARE","9910.18","","Case rate ($9,910.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,219.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,087.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $8,882.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,839.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $647.75. The transfer capital threshold is the transfer adjustment factor * $647.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7551.19","7551.19","7551.19","1 through 10","7568.68","12291.6195","other","Inpatient DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","44168.18","33126.13","MEDICARE [2001]","HB BWH MEDICARE","9910.18","","Case rate ($9,910.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,219.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,087.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $8,882.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,839.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $647.75. The transfer capital threshold is the transfer adjustment factor * $647.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9880.54","1254.17","9894.90","29","7568.68","12291.6195","other","Inpatient DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","44168.18","33126.13","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","9910.18","","Case rate ($9,910.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,219.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,087.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $8,882.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,839.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $647.75. The transfer capital threshold is the transfer adjustment factor * $647.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7545.87","7533.81","7562.81","1 through 10","7568.68","12291.6195","other","Inpatient DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","44168.18","33126.13","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7568.68","","Case rate ($7,723.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,219.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,087.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,695.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,839.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $647.75. The transfer capital threshold is the transfer adjustment factor * $647.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7535.63","7535.63","7535.63","1 through 10","7568.68","12291.6195","other","Inpatient DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","44168.18","33126.13","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7568.68","","Case rate ($7,723.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,219.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,087.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,695.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,839.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $647.75. The transfer capital threshold is the transfer adjustment factor * $647.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7543.42","7543.42","7543.42","1 through 10","7568.68","12291.6195","other","Inpatient DRG"
"Pulmonary Embolism,EXTREME","134","DRG","","","","","","","","inpatient","","","111906.73","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","51807.05","","Standard inlier is a Case rate ($51,807.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $51,934, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,354.32) for the length of stay and the standard reimbursement.","51807.04","47224.01","53211.91","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,EXTREME","134","DRG","","","","","","","","inpatient","","","111906.73","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","58245.08","","Standard inlier is a Case rate ($58,245.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $51,934, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,267.41) for the length of stay and the standard reimbursement.","53211.91","53211.91","58245.08","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,EXTREME","134","DRG","","","","","","","","inpatient","","","111906.73","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","19081.2877","","Fee schedule rate ($154,898.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19081.2877","65761.20","65761.20","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,EXTREME","134","DRG","","","","","","","","inpatient","","","111906.73","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","38169.2855","","Fee schedule rate ($154,898.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38169.2855","65761.20","65761.20","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,EXTREME","134","DRG","","","","","","","","inpatient","","","111906.73","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","20035.9066","","Fee schedule rate ($162,647.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20035.9066","69051.20","69051.20","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,EXTREME","134","DRG","","","","","","","","inpatient","","","111906.73","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","40078.859","","Fee schedule rate ($162,647.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40078.859","69051.20","69051.20","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,EXTREME","134","DRG","","","","","","","","inpatient","","","111906.73","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17905.82","","Fee schedule rate ($17,905.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38158.12","38158.12","38158.12","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,EXTREME","134","DRG","","","","","","","","inpatient","","","111906.73","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","16320.98","","Case rate ($18,045.65). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $60,475.65, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18041.22","18041.22","18041.22","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","58889.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","34035.67","","Standard inlier is a Case rate ($34,035.67). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,116, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,831.57) for the length of stay and the standard reimbursement.","33181.53","31024.75","38265.26","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","58889.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","38265.26","","Standard inlier is a Case rate ($38,265.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,116, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,431.44) for the length of stay and the standard reimbursement.","38265.26","34958.62","45375.32","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","58889.43","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","20035.9066","","Fee schedule rate ($38,989.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20035.9066","38989.12","38989.12","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","58889.43","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","40078.859","","Fee schedule rate ($38,989.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40078.859","38989.12","38989.12","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","58889.43","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","40845.10","","Fee schedule rate ($40,845.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40845.12","40845.12","40845.12","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","58889.43","","MASSHEALTH [3001]","HB BWH MEDICAID","9467.93","","Case rate ($10,468.42). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,898.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4856.55","95.46","10513.51","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","58889.43","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","9467.93","","Case rate ($10,468.42). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,898.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3476.45","3476.45","3476.45","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","58889.43","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25886.24","","Fee schedule rate ($25,886.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25886.24","25886.24","25886.24","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","58889.43","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9467.93","","Case rate ($10,468.42). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,898.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10465.85","695.29","10465.85","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","42557.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","23592.76","","Standard inlier is a Case rate ($23,592.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,993, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,349.13) for the length of stay and the standard reimbursement.","23592.75","23592.75","23592.75","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","42557.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","26524.62","","Standard inlier is a Case rate ($26,524.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,993, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,764.95) for the length of stay and the standard reimbursement.","24232.53","24232.53","24232.53","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","42557.06","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","19081.2877","","Fee schedule rate ($24,042.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19081.2877","24042.28","24042.28","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","42557.06","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","38169.2855","","Fee schedule rate ($24,042.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38169.2855","24042.28","24042.28","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","42557.06","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","26446.84","","Fee schedule rate ($26,446.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26446.84","26446.84","26446.84","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","42557.06","","MASSHEALTH [3001]","HB BWH MEDICAID","6134.51","","Case rate ($6,782.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,212.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6781.08","6781.08","6781.08","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","42557.06","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","6134.51","","Case rate ($6,782.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,212.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","42557.06","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18801.17","","Fee schedule rate ($18,801.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18801.17","18801.17","18801.17","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","42557.06","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6134.51","","Case rate ($6,782.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,212.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1337.60","1332.37","6781.09","1 through 10","4207.33","255585.12","case rate",""
"Pulmonary Rehab Consult","PX-41000022","CDM","94799","CPT","0410","RC","","","","both","","","366.00","274.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","754.00","71.74","754.00","1 through 10","113.46","290.97","other","OPPS APC"
"Pulmonary Rehab Consult","PX-41000022","CDM","94799","CPT","0410","RC","","","","both","","","366.00","274.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","290.97","79.5","","398.11","398.11","398.11","1 through 10","113.46","290.97","percent of total billed charges",""
"Pulmonary Rehab Consult","PX-41000022","CDM","94799","CPT","0410","RC","","","","both","","","366.00","274.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","237.90","65","","399.62","399.62","399.62","1 through 10","113.46","290.97","percent of total billed charges",""
"Pulmonary Rehab Consult","PX-41000022","CDM","94799","CPT","0410","RC","","","","both","","","366.00","274.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","140.18","38.3","","294.81","294.81","294.81","1 through 10","113.46","290.97","percent of total billed charges",""
"Pulmonary Rehab Consult","PX-41000022","CDM","94799","CPT","0410","RC","","","","outpatient","","","366.00","274.50","AETNA [1001]","HB AMC AETNA HMO","255.47","69.8","","510.46","510.46","510.46","1 through 10","183","304.03","percent of total billed charges",""
"Pulmonary Rehab Consult","PX-41000022","CDM","94799","CPT","0410","RC","","","","outpatient","","","366.00","274.50","AETNA [1001]","HB AMC AETNA PPO","294.26","80.4","","588.12","588.12","588.12","1 through 10","183","304.03","percent of total billed charges",""
"Pulmonary Rehab Consult","PX-41000022","CDM","94799","CPT","0410","RC","","","","outpatient","","","366.00","274.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","221.61","60.55","","363.93","312.34","754.00","1 through 10","183","304.03","percent of total billed charges",""
"Pulmonary Rehab Consult","PX-41000022","CDM","94799","CPT","0410","RC","","","","outpatient","","","366.00","274.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","191.13","52.22","","363.93","360.37","754.00","1 through 10","183","304.03","percent of total billed charges",""
"Pulmonary Rehab Consult","PX-41000022","CDM","94799","CPT","0410","RC","","","","outpatient","","","366.00","274.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","183.00","50","","754.00","754.00","754.00","1 through 10","183","304.03","percent of total billed charges",""
"Pulmonary Rehab Consult","PX-41000022","CDM","94799","CPT","0410","RC","","","","outpatient","","","366.00","274.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","192.15","52.5","","754.00","414.70","754.00","1 through 10","183","304.03","percent of total billed charges",""
"Pulmonary Rehab Consult","PX-41000022","CDM","94799","CPT","0410","RC","","","","outpatient","","","366.00","274.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","201.30","55","","434.30","434.30","434.30","1 through 10","183","304.03","percent of total billed charges",""
"Pulmonary Rehab Consult","PX-41000022","CDM","94799","CPT","0410","RC","","","","outpatient","","","366.00","274.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","299.10","81.72","","602.75","602.75","602.75","1 through 10","183","304.03","percent of total billed charges",""
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","5110.00","28","351.32","4188.86","other","OPPS APC"
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3688.30","70","","7358.40","7358.40","7358.40","1 through 10","351.32","4188.86","percent of total billed charges",""
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4188.86","79.5","","4021.57","2698.08","8950.88","12","351.32","4188.86","percent of total billed charges",""
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2808.38","53.3","","2698.08","2505.81","4021.57","1 through 10","351.32","4188.86","percent of total billed charges",""
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","1 through 10","351.32","4188.86","other","OPPS APC"
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","FALLON HEALTH [1008]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","724.82","724.82","724.82","1 through 10","351.32","4188.86","other","OPPS APC"
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","4057.13","77","","3934.70","3934.70","3934.70","1 through 10","351.32","4188.86","percent of total billed charges",""
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.52","363.52","363.52","1 through 10","351.32","4188.86","other","OPPS APC"
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","685.14","212","351.32","4188.86","other","OPPS APC"
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1923.19","36.5","","1849.82","1619.87","3118.63","1 through 10","351.32","4188.86","percent of total billed charges",""
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2018.03","38.3","","1998.01","1998.01","1998.01","16","351.32","4188.86","percent of total billed charges",""
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.81","362.81","362.81","1 through 10","351.32","4188.86","other","OPPS APC"
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","TRICARE [160005]","HB BWH TRICARE","351.32","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","351.32","351.32","351.32","1 through 10","351.32","4188.86","other","Tricare OPPS"
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","351.32","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","369.81","369.81","369.81","1 through 10","351.32","4188.86","other","Tricare OPPS"
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","363.01","362.41","1087.23","16","351.32","4188.86","other","OPPS APC"
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","5269.00","3951.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","362.41","363.90","16","351.32","4188.86","other","OPPS APC"
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","outpatient","","","5269.00","3951.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4236.28","80.4","","2555.00","2555.00","2555.00","1 through 10","579.66","4305.83","percent of total billed charges",""
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","outpatient","","","5269.00","3951.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","4305.83","81.72","","3841.58","3841.58","3841.58","1 through 10","579.66","4305.83","percent of total billed charges",""
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","outpatient","","","5269.00","3951.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4305.83","81.72","","4084.93","2246.87","4084.93","1 through 10","579.66","4305.83","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","7.91","333.00","1 through 10","106.33","272.69","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","246.27","71.8","","239.09","239.09","239.09","1 through 10","106.33","272.69","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","225.01","65.6","","259.74","259.74","259.74","1 through 10","106.33","272.69","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","240.10","70","","239.76","50.00","247.16","1 through 10","106.33","272.69","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","191.33","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","50.00","27.84","239.79","1 through 10","106.33","272.69","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","272.69","79.5","","262.07","175.82","786.21","1 through 10","106.33","272.69","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","182.82","53.3","","175.82","168.17","262.07","1 through 10","106.33","272.69","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.02","150.02","150.02","1 through 10","106.33","272.69","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","264.11","77","","769.23","769.23","769.23","1 through 10","106.33","272.69","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","HUMANA [1012]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","151.02","151.02","151.02","1 through 10","106.33","272.69","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","20","106.33","272.69","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","125.20","36.5","","124.21","105.56","124.21","1 through 10","106.33","272.69","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","131.37","38.3","","130.20","126.54","130.20","12","106.33","272.69","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.02","150.02","150.02","1 through 10","106.33","272.69","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.42","150.02","150.62","1 through 10","106.33","272.69","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.15","42.9","","146.42","146.42","146.42","1 through 10","106.33","272.69","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.52","150.02","333.00","1 through 10","106.33","272.69","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","343.00","257.25","WELLPOINT [1015]","HB AMC WELLPOINT","253.07","73.78","","247.92","247.92","580.92","12","106.33","272.69","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","outpatient","","","343.00","257.25","AETNA [1001]","HB AMC AETNA HMO","239.41","69.8","","225.44","225.44","225.44","1 through 10","179.25","425.62","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","outpatient","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","280.30","81.72","","266.20","146.42","266.20","1 through 10","179.25","425.62","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","both","","","1155.00","866.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","754.00","71.74","754.00","1 through 10","176.52","918.23","other","OPPS APC"
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","both","","","1155.00","866.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","918.23","79.5","","398.11","398.11","398.11","1 through 10","176.52","918.23","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","both","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","750.75","65","","399.62","399.62","399.62","1 through 10","176.52","918.23","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","442.37","38.3","","294.81","294.81","294.81","1 through 10","176.52","918.23","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","outpatient","","","1155.00","866.25","AETNA [1001]","HB AMC AETNA HMO","806.19","69.8","","510.46","510.46","510.46","1 through 10","304.03","952.88","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","outpatient","","","1155.00","866.25","AETNA [1001]","HB AMC AETNA PPO","928.62","80.4","","588.12","588.12","588.12","1 through 10","304.03","952.88","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","outpatient","","","1155.00","866.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","699.35","60.55","","363.93","312.34","754.00","1 through 10","304.03","952.88","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","outpatient","","","1155.00","866.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","603.14","52.22","","363.93","360.37","754.00","1 through 10","304.03","952.88","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","outpatient","","","1155.00","866.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","577.50","50","","754.00","754.00","754.00","1 through 10","304.03","952.88","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","outpatient","","","1155.00","866.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","606.38","52.5","","754.00","414.70","754.00","1 through 10","304.03","952.88","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","outpatient","","","1155.00","866.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","635.25","55","","434.30","434.30","434.30","1 through 10","304.03","952.88","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","outpatient","","","1155.00","866.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","943.87","81.72","","602.75","602.75","602.75","1 through 10","304.03","952.88","percent of total billed charges",""
"Pulse Ox Multi Determinations","PX-46000049","CDM","94761","CPT","0460","RC","","","","both","","","177.00","132.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","123.90","70","","123.84","0.02","123.84","1 through 10","54.87","140.72","percent of total billed charges",""
"Pulse Ox Multi Determinations","PX-46000049","CDM","94761","CPT","0460","RC","","","","both","","","177.00","132.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","136.29","77","","397.32","397.32","397.32","1 through 10","54.87","140.72","percent of total billed charges",""
"Pulse Ox Multi Determinations","PX-46000049","CDM","94761","CPT","0460","RC","","","","both","","","177.00","132.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","115.05","65","","111.80","111.80","111.80","1 through 10","54.87","140.72","percent of total billed charges",""
"Pulse Ox Multi Determinations","PX-46000049","CDM","94761","CPT","0460","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.61","36.5","","54.52","54.52","54.52","1 through 10","54.87","140.72","percent of total billed charges",""
"Pulse Ox Multi Determinations","PX-46000049","CDM","94761","CPT","0460","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.79","38.3","","67.25","67.25","67.25","1 through 10","54.87","140.72","percent of total billed charges",""
"Pulse Ox Multi Determinations","PX-46000049","CDM","94761","CPT","0460","RC","","","","both","","","177.00","132.75","WELLPOINT [1015]","HB AMC WELLPOINT","130.59","73.78","","128.05","128.05","300.05","13","54.87","140.72","percent of total billed charges",""
"Pulse Ox Multi Determinations","PX-46000049","CDM","94761","CPT","0460","RC","","","","outpatient","","","177.00","132.75","AETNA [1001]","HB AMC AETNA HMO","123.55","69.8","","116.44","116.44","116.44","1 through 10","92.5","144.64","percent of total billed charges",""
"Pulse Ox Multi Determinations","PX-46000049","CDM","94761","CPT","0460","RC","","","","outpatient","","","177.00","132.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","142.31","80.4","","86.00","86.00","86.00","1 through 10","92.5","144.64","percent of total billed charges",""
"Pulse Ox Multi Determinations","PX-46000049","CDM","94761","CPT","0460","RC","","","","outpatient","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","144.64","81.72","","137.50","137.50","137.50","1 through 10","92.5","144.64","percent of total billed charges",""
"Pulse Ox Single Determination","PX-46000048","CDM","94760","CPT","0460","RC","","","","both","","","85.00","63.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","67.58","79.5","","82.00","82.00","82.00","1 through 10","26.35","67.58","percent of total billed charges",""
"Pulse Ox Single Determination","PX-46000048","CDM","94760","CPT","0460","RC","","","","both","","","85.00","63.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.56","38.3","","32.06","32.06","32.06","1 through 10","26.35","67.58","percent of total billed charges",""
"Pulse Ox Single Determination","PX-46000048","CDM","94760","CPT","0460","RC","","","","both","","","85.00","63.75","WELLPOINT [1015]","HB AMC WELLPOINT","62.71","73.78","","61.05","61.05","61.05","1 through 10","26.35","67.58","percent of total billed charges",""
"Pulse Ox Single Determination","PX-46000048","CDM","94760","CPT","0460","RC","","","","outpatient","","","85.00","63.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","69.46","81.72","","65.55","65.55","65.55","1 through 10","47.52","69.46","percent of total billed charges",""
"Pulsed Electric Field Ablation of Lymph Node","PX-76002892","CDM","38999","CPT","0761","RC","","","","outpatient","","","13564.00","10173.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","7083.12","52.22","","512.50","512.50","512.50","1 through 10","1234.13","11190.3","percent of total billed charges",""
"Pulsed Electric Field Ablation of Lymph Node","PX-76002892","CDM","38999","CPT","0761","RC","","","","outpatient","","","13564.00","10173.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6782.00","50","","6776.11","6776.11","6776.11","1 through 10","1234.13","11190.3","percent of total billed charges",""
"Pulsed Electric Field Ablation of Peritoneal Tumor","PX-76002900","CDM","49999","CPT","0761","RC","","","","both","","","13564.00","10173.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","10783.38","other","OPPS APC"
"Pulsed Electric Field Ablation of Peritoneal Tumor","PX-76002900","CDM","49999","CPT","0761","RC","","","","both","","","13564.00","10173.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","10783.38","other","OPPS APC"
"Pulsed Electric Field Ablation of Peritoneal Tumor","PX-76002900","CDM","49999","CPT","0761","RC","","","","both","","","13564.00","10173.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","1057.74","10783.38","other","OPPS APC"
"Pulsed Electric Field Ablation of Peritoneal Tumor","PX-76002900","CDM","49999","CPT","0761","RC","","","","outpatient","","","13564.00","10173.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6782.00","50","","14640.00","14640.00","14640.00","1 through 10","6782","11190.3","percent of total billed charges",""
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1014.42","other","OPPS APC"
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1014.42","other","OPPS APC"
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","680.11","53.3","","477.31","477.31","477.31","1 through 10","333.03","1014.42","percent of total billed charges",""
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1014.42","other","OPPS APC"
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1014.42","other","OPPS APC"
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","465.74","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1014.42","percent of total billed charges",""
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","488.71","38.3","","343.52","323.76","353.46","1 through 10","333.03","1014.42","percent of total billed charges",""
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1014.42","other","Tricare OPPS"
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1014.42","other","OPPS APC"
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1014.42","other","OPPS APC"
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","WELLPOINT [1015]","HB AMC WELLPOINT","941.43","73.78","","673.03","673.03","673.03","1 through 10","333.03","1014.42","percent of total billed charges",""
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","AETNA [1001]","HB AMC AETNA HMO","890.65","69.8","","612.01","612.01","1224.02","1 through 10","638","1052.7","percent of total billed charges",""
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","772.62","60.55","","579.04","568.57","904.00","30","638","1052.7","percent of total billed charges",""
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","666.33","52.22","","904.00","656.02","2938.00","26","638","1052.7","percent of total billed charges",""
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","638.00","50","","1421.10","875.08","2368.50","15","638","1052.7","percent of total billed charges",""
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","669.90","52.5","","2985.00","904.00","2985.00","1 through 10","638","1052.7","percent of total billed charges",""
"Pulsed Radiofrequency Ablation, Nerve","PX-76002552","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1042.75","81.72","","722.66","722.66","17449.00","1 through 10","638","1052.7","percent of total billed charges",""
"PUMP IMPLANT 15CMX12MM PENILE INFLATABLE MINOCYCLINE RIFAMPIN INHIBIZONE PARYLENE","SUP-ITM-10027721","CDM","C1813","HCPCS","0278","RC","","","","both","","","26861.25","20145.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10287.86","38.3","","12613.42","12613.42","12613.42","1 through 10","8326.99","21354.69","percent of total billed charges",""
"PUMP IMPLANT 15CMX12MM PENILE INFLATABLE MINOCYCLINE RIFAMPIN INHIBIZONE PARYLENE","SUP-ITM-10027721","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","26861.25","20145.94","AETNA [1001]","HB AMC AETNA HMO","18749.15","69.8","","34275.85","34275.85","50471.26","19","14037.69","21951.01","percent of total billed charges",""
"Pump Implant Maint Includes Elec","PX-94000001","CDM","95990","CPT","0940","RC","","","","both","","","639.00","479.25","MEDICARE [2001]","HB BWH MEDICARE","393.86","","APC Price ($393.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.63","369.63","369.63","1 through 10","198.09","508.01","other","OPPS APC"
"PUMP INFUSION 20ML PAIN SYNCHROMED III PROGRAMMABLE","SUP-ITM-10320796","CDM","C1772","HCPCS","0278","RC","","","","both","","","28000.00","21000.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","22260.00","79.5","","22036.00","22036.00","22036.00","1 through 10","8680","22260","percent of total billed charges",""
"PUMP INFUSION 20ML PAIN SYNCHROMED III PROGRAMMABLE","SUP-ITM-10320796","CDM","C1772","HCPCS","0278","RC","","","","both","","","28000.00","21000.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14924.00","53.3","","14140.00","14140.00","14140.00","1 through 10","8680","22260","percent of total billed charges",""
"PUMP INFUSION 20ML PAIN SYNCHROMED III PROGRAMMABLE","SUP-ITM-10320796","CDM","C1772","HCPCS","0278","RC","","","","outpatient","","","28000.00","21000.00","AETNA [1001]","HB AMC AETNA HMO","19544.00","69.8","","13384.00","13272.00","13384.00","1 through 10","14632.8","22881.6","percent of total billed charges",""
"PUMP INFUSION 20ML PAIN SYNCHROMED III PROGRAMMABLE","SUP-ITM-10320796","CDM","C1772","HCPCS","0278","RC","","","","outpatient","","","28000.00","21000.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","22881.60","81.72","","22383.20","22383.20","22383.20","1 through 10","14632.8","22881.6","percent of total billed charges",""
"PUMP MS 100ML PROSTHESIS PENILE INFLATABLE INHIBIZONE A 700","SUP-ITM-10100383","CDM","C1813","HCPCS","0278","RC","","","","both","","","6688.50","5016.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2561.70","38.3","","12613.42","12613.42","12613.42","1 through 10","2073.44","5317.36","percent of total billed charges",""
"PUMP MS 100ML PROSTHESIS PENILE INFLATABLE INHIBIZONE A 700","SUP-ITM-10100383","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","6688.50","5016.37","AETNA [1001]","HB AMC AETNA HMO","4668.57","69.8","","34275.85","34275.85","50471.26","19","3495.41","5465.84","percent of total billed charges",""
"PUMP PENILE 65ML MALLEABLE MINOCYCLINE RIFAMPIN INHIBIZONE PARYLENE","SUP-ITM-10020255","CDM","C1813","HCPCS","0278","RC","","","","both","","","6688.50","5016.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2561.70","38.3","","12613.42","12613.42","12613.42","1 through 10","2073.44","5317.36","percent of total billed charges",""
"PUMP PENILE 65ML MALLEABLE MINOCYCLINE RIFAMPIN INHIBIZONE PARYLENE","SUP-ITM-10020255","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","6688.50","5016.37","AETNA [1001]","HB AMC AETNA HMO","4668.57","69.8","","34275.85","34275.85","50471.26","19","3495.41","5465.84","percent of total billed charges",""
"PUMP PROSTHESIS UROLOGICAL CONTROL ACTICON NEOSPHINCTER FLUID FILLED DEVICE INHIBIZONE AMS 800","SUP-ITM-10027740","CDM","C1815","HCPCS","0278","RC","","","","both","","","14839.50","11129.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11797.40","79.5","","18938.70","18113.72","18938.70","1 through 10","4600.25","11797.4","percent of total billed charges",""
"PUMP PROSTHESIS UROLOGICAL CONTROL ACTICON NEOSPHINCTER FLUID FILLED DEVICE INHIBIZONE AMS 800","SUP-ITM-10027740","CDM","C1815","HCPCS","0278","RC","","","","both","","","14839.50","11129.62","WELLPOINT [1015]","HB AMC WELLPOINT","10948.58","73.78","","27772.46","27772.46","27772.46","1 through 10","4600.25","11797.4","percent of total billed charges",""
"Pump Refill & Main Spin/ Brain Req","PX-94000002","CDM","95991","CPT","0940","RC","","","","both","","","526.00","394.50","MEDICARE [2001]","HB BWH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","163.06","418.17","other","OPPS APC"
"PUMP TOUCH PROSTHESIS PENILE TITAN OTR INFLATABLE ASSEMBLY","SUP-ITM-10191312","CDM","C1813","HCPCS","0278","RC","","","","both","","","14097.50","10573.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5399.34","38.3","","12613.42","12613.42","12613.42","1 through 10","4370.23","11207.51","percent of total billed charges",""
"PUMP TOUCH PROSTHESIS PENILE TITAN OTR INFLATABLE ASSEMBLY","SUP-ITM-10191312","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","14097.50","10573.12","AETNA [1001]","HB AMC AETNA HMO","9840.06","69.8","","34275.85","34275.85","50471.26","19","7367.35","11520.48","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","both","","","211.00","158.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","167.75","79.5","","866.49","161.34","866.49","1 through 10","65.41","167.75","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","both","","","211.00","158.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","112.46","53.3","","481.01","481.01","481.01","1 through 10","65.41","167.75","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","both","","","211.00","158.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.02","36.5","","194.97","76.47","194.97","1 through 10","65.41","167.75","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","both","","","211.00","158.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.81","38.3","","240.48","233.70","240.48","34","65.41","167.75","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","both","","","211.00","158.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.52","42.9","","163.88","163.88","163.88","1 through 10","65.41","167.75","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","both","","","211.00","158.25","WELLPOINT [1015]","HB AMC WELLPOINT","155.68","73.78","","152.63","152.62","357.62","1 through 10","65.41","167.75","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","outpatient","","","211.00","158.25","AETNA [1001]","HB AMC AETNA HMO","147.28","69.8","","138.79","138.79","2591.72","1 through 10","46.11","172.43","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","outpatient","","","211.00","158.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","110.27","52.26","","126.86","126.86","126.86","1 through 10","46.11","172.43","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","outpatient","","","211.00","158.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","172.43","81.72","","163.88","90.14","163.88","1 through 10","46.11","172.43","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","both","","","111.00","83.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","88.25","79.5","","866.49","161.34","866.49","1 through 10","34.41","88.25","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","both","","","111.00","83.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","59.16","53.3","","481.01","481.01","481.01","1 through 10","34.41","88.25","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","40.52","36.5","","194.97","76.47","194.97","1 through 10","34.41","88.25","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","42.51","38.3","","240.48","233.70","240.48","34","34.41","88.25","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","both","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.62","42.9","","163.88","163.88","163.88","1 through 10","34.41","88.25","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","both","","","111.00","83.25","WELLPOINT [1015]","HB AMC WELLPOINT","81.90","73.78","","152.63","152.62","357.62","1 through 10","34.41","88.25","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","outpatient","","","111.00","83.25","AETNA [1001]","HB AMC AETNA HMO","77.48","69.8","","138.79","138.79","2591.72","1 through 10","62.05","90.71","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","90.71","81.72","","163.88","90.14","163.88","1 through 10","62.05","90.71","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","488.23","465.58","488.73","1 through 10","185.38","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","428.24","466.88","28","185.38","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","475.41","79.5","","1602.33","306.24","1897.46","37","185.38","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","318.73","53.3","","918.72","456.46","1602.33","17","185.38","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","373.84","466.88","13","185.38","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","FALLON HEALTH [1008]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2372.35","1423.41","2372.35","1 through 10","185.38","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","49.06","49.06","49.06","1 through 10","185.38","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","HUMANA [1012]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","471.98","468.85","471.98","1 through 10","185.38","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","948.94","339","185.38","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","185.38","31","","537.66","537.66","537.66","1 through 10","185.38","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","218.27","36.5","","551.58","209.96","649.02","25","185.38","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","229.03","38.3","","680.34","440.80","680.34","196","185.38","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","464.98","426.50","464.98","1 through 10","185.38","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","TRICARE [160005]","HB BWH TRICARE","450.74","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","474.47","450.75","474.47","1 through 10","185.38","593.02","other","Tricare OPPS"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1403.48","426.50","1403.48","11","185.38","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","256.54","42.9","","463.65","463.65","463.65","1 through 10","185.38","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","465.93","426.50","472.69","37","185.38","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","598.00","448.50","WELLPOINT [1015]","HB AMC WELLPOINT","441.20","73.78","","1011.81","431.81","1011.81","24","185.38","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","AETNA [1001]","HB AMC AETNA HMO","417.40","69.8","","392.66","277.24","452.40","36","176.45","700.33","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","AETNA [1001]","HB AMC AETNA PPO","480.79","80.4","","607.84","303.92","607.84","1 through 10","176.45","700.33","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","405.38","412.84","66","176.45","700.33","other","ASC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","312.51","52.26","","467.73","358.91","467.73","1 through 10","176.45","700.33","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","472.37","162","176.45","700.33","other","ASC "
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","511.71","451.71","511.71","1 through 10","176.45","700.33","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1228.08","409.36","1228.08","148","176.45","700.33","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1291.62","430.54","1291.62","45","176.45","700.33","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","511.71","511.71","511.71","1 through 10","176.45","700.33","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","451.71","290.00","801.50","13","176.45","700.33","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","480.79","80.4","","452.40","452.40","452.40","1 through 10","176.45","700.33","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","488.69","81.72","","463.65","463.65","463.65","1 through 10","176.45","700.33","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","488.69","81.72","","255.03","255.03","255.03","1 through 10","176.45","700.33","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","488.69","81.72","","463.65","255.03","463.65","26","176.45","700.33","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","598.00","448.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","492.30","492.30","492.30","1 through 10","176.45","700.33","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","488.23","465.58","488.73","1 through 10","63.55","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","428.24","466.88","28","63.55","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","162.98","79.5","","1602.33","306.24","1897.46","37","63.55","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.27","53.3","","918.72","456.46","1602.33","17","63.55","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","373.84","466.88","13","63.55","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","FALLON HEALTH [1008]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2372.35","1423.41","2372.35","1 through 10","63.55","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","49.06","49.06","49.06","1 through 10","63.55","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","HUMANA [1012]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","471.98","468.85","471.98","1 through 10","63.55","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","948.94","339","63.55","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","63.55","31","","537.66","537.66","537.66","1 through 10","63.55","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.83","36.5","","551.58","209.96","649.02","25","63.55","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.52","38.3","","680.34","440.80","680.34","196","63.55","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","464.98","426.50","464.98","1 through 10","63.55","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","TRICARE [160005]","HB BWH TRICARE","450.74","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","474.47","450.75","474.47","1 through 10","63.55","593.02","other","Tricare OPPS"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1403.48","426.50","1403.48","11","63.55","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.95","42.9","","463.65","463.65","463.65","1 through 10","63.55","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","465.93","426.50","472.69","37","63.55","593.02","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","WELLPOINT [1015]","HB AMC WELLPOINT","151.25","73.78","","1011.81","431.81","1011.81","24","63.55","593.02","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","AETNA [1001]","HB AMC AETNA HMO","143.09","69.8","","392.66","277.24","452.40","36","114.6","700.33","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","AETNA [1001]","HB AMC AETNA PPO","164.82","80.4","","607.84","303.92","607.84","1 through 10","114.6","700.33","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","511.71","451.71","511.71","1 through 10","114.6","700.33","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1228.08","409.36","1228.08","148","114.6","700.33","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1291.62","430.54","1291.62","45","114.6","700.33","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","511.71","511.71","511.71","1 through 10","114.6","700.33","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","451.71","290.00","801.50","13","114.6","700.33","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","164.82","80.4","","452.40","452.40","452.40","1 through 10","114.6","700.33","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","167.53","81.72","","463.65","463.65","463.65","1 through 10","114.6","700.33","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","167.53","81.72","","255.03","255.03","255.03","1 through 10","114.6","700.33","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","167.53","81.72","","463.65","255.03","463.65","26","114.6","700.33","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","492.30","492.30","492.30","1 through 10","114.6","700.33","other","Multiple Surgery"
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","312.00","234.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","96.72","248.04","other","OPPS APC"
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","312.00","234.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","224.02","71.8","","217.55","217.55","217.55","1 through 10","96.72","248.04","percent of total billed charges",""
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","312.00","234.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","204.67","65.6","","236.34","236.34","236.34","1 through 10","96.72","248.04","percent of total billed charges",""
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","312.00","234.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","218.40","70","","303.00","218.16","303.00","1 through 10","96.72","248.04","percent of total billed charges",""
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","312.00","234.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","191.33","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","36.24","25.33","303.00","1 through 10","96.72","248.04","other","OPPS APC"
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","312.00","234.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","248.04","79.5","","238.46","238.46","238.46","1 through 10","96.72","248.04","percent of total billed charges",""
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","312.00","234.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","166.30","53.3","","159.98","153.02","159.98","1 through 10","96.72","248.04","percent of total billed charges",""
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","312.00","234.00","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","96.72","248.04","other","OPPS APC"
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.50","38.3","","118.47","118.47","118.47","1 through 10","96.72","248.04","percent of total billed charges",""
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","312.00","234.00","WELLPOINT [1015]","HB AMC WELLPOINT","230.19","73.78","","225.58","225.58","225.58","1 through 10","96.72","248.04","percent of total billed charges",""
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","outpatient","","","312.00","234.00","AETNA [1001]","HB AMC AETNA HMO","217.78","69.8","","205.13","205.13","205.13","1 through 10","121.77","407.82","percent of total billed charges",""
"Punct Asp/Inj Shunt Tubing/Reserv","PX-76001419","CDM","61070","CPT","0761","RC","","","","both","","","1656.00","1242.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","809.25","809.25","1 through 10","513.36","1316.52","other","OPPS APC"
"Punct Asp/Inj Shunt Tubing/Reserv","PX-76001419","CDM","61070","CPT","0761","RC","","","","both","","","1656.00","1242.00","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","513.36","1316.52","other","OPPS APC"
"Punct Asp/Inj Shunt Tubing/Reserv","PX-76001419","CDM","61070","CPT","0761","RC","","","","both","","","1656.00","1242.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.87","813.87","813.87","1 through 10","513.36","1316.52","other","OPPS APC"
"Punct Follicle Retrieval Oocyte","PX-76001408","CDM","58970","CPT","0761","RC","","","","both","","","1394.00","1045.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","914.46","65.6","","915.30","915.30","915.30","1 through 10","432.14","1324.3","percent of total billed charges",""
"Punct Follicle Retrieval Oocyte","PX-76001408","CDM","58970","CPT","0761","RC","","","","both","","","1394.00","1045.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1108.23","79.5","","3192.33","3058.53","3192.33","198","432.14","1324.3","percent of total billed charges",""
"Punct Follicle Retrieval Oocyte","PX-76001408","CDM","58970","CPT","0761","RC","","","","both","","","1394.00","1045.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","743.00","53.3","","2141.76","2141.76","4282.09","84","432.14","1324.3","percent of total billed charges",""
"Punct Follicle Retrieval Oocyte","PX-76001408","CDM","58970","CPT","0761","RC","","","","both","","","1394.00","1045.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","598.03","42.9","","1080.79","1080.79","1080.79","1 through 10","432.14","1324.3","percent of total billed charges",""
"Punct Follicle Retrieval Oocyte","PX-76001408","CDM","58970","CPT","0761","RC","","","","both","","","1394.00","1045.50","WELLPOINT [1015]","HB AMC WELLPOINT","1028.49","73.78","","2358.56","1006.56","2358.56","15","432.14","1324.3","percent of total billed charges",""
"Punct Follicle Retrieval Oocyte","PX-76001408","CDM","58970","CPT","0761","RC","","","","outpatient","","","1394.00","1045.50","AETNA [1001]","HB AMC AETNA HMO","973.01","69.8","","915.30","646.26","2109.12","19","558.04","1139.18","percent of total billed charges",""
"Punct Follicle Retrieval Oocyte","PX-76001408","CDM","58970","CPT","0761","RC","","","","outpatient","","","1394.00","1045.50","AETNA [1001]","HB AMC AETNA PPO","1120.78","80.4","","1054.56","1054.56","1054.56","1 through 10","558.04","1139.18","percent of total billed charges",""
"Punct Follicle Retrieval Oocyte","PX-76001408","CDM","58970","CPT","0761","RC","","","","outpatient","","","1394.00","1045.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1556.93","1428.58","1556.93","1 through 10","558.04","1139.18","other","Multiple Surgery"
"Punct Follicle Retrieval Oocyte","PX-76001408","CDM","58970","CPT","0761","RC","","","","outpatient","","","1394.00","1045.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1361.62","1361.62","1361.62","1 through 10","558.04","1139.18","other","Multiple Surgery"
"Punct Follicle Retrieval Oocyte","PX-76001408","CDM","58970","CPT","0761","RC","","","","outpatient","","","1394.00","1045.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 383%, 191.5 procedures at 0%.","2137.29","2137.29","2137.29","1 through 10","558.04","1139.18","other","Multiple Surgery"
"Punct Follicle Retrieval Oocyte","PX-76001408","CDM","58970","CPT","0761","RC","","","","outpatient","","","1394.00","1045.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2132.04","2132.04","2132.04","1 through 10","558.04","1139.18","other","Multiple Surgery"
"Punct Follicle Retrieval Oocyte","PX-76001408","CDM","58970","CPT","0761","RC","","","","outpatient","","","1394.00","1045.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1139.18","81.72","","1080.79","594.47","1080.80","1 through 10","558.04","1139.18","percent of total billed charges",""
"Punct Ventricular","PX-76001415","CDM","61020","CPT","0761","RC","","","","both","","","2378.00","1783.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","910.77","38.3","","901.65","901.65","901.65","1 through 10","737.18","1890.51","percent of total billed charges",""
"Pure Tone Hearing Test, Air","PX-98301345","CDM","92551","CPT","0983","RC","","","","both","","","61.00","45.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","48.50","79.5","","43.54","43.54","62.96","23","18.91","57.95","percent of total billed charges",""
"Pure Tone Hearing Test, Air","PX-98301345","CDM","92551","CPT","0983","RC","","","","both","","","61.00","45.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","32.51","53.3","","43.54","42.24","43.54","1 through 10","18.91","57.95","percent of total billed charges",""
"Pure Tone Hearing Test, Air","PX-98301345","CDM","92551","CPT","0983","RC","","","","both","","","61.00","45.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","48.50","79.5","","62.96","43.54","62.96","1 through 10","18.91","57.95","percent of total billed charges",""
"Pure Tone Hearing Test, Air","PX-98301345","CDM","92551","CPT","0983","RC","","","","both","","","61.00","45.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22.27","36.5","","22.38","19.02","29.84","89","18.91","57.95","percent of total billed charges",""
"Pure Tone Hearing Test, Air","PX-98301345","CDM","92551","CPT","0983","RC","","","","both","","","61.00","45.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23.36","38.3","","31.28","23.46","42.68","225","18.91","57.95","percent of total billed charges",""
"Pure Tone Hearing Test, Air","PX-98301345","CDM","92551","CPT","0983","RC","","","","both","","","61.00","45.75","TRICARE [160005]","HB BWH TRICARE","57.95","95","","13.88","13.88","13.88","1 through 10","18.91","57.95","percent of total billed charges",""
"Pure Tone Hearing Test, Air","PX-98301345","CDM","92551","CPT","0983","RC","","","","both","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.17","42.9","","61.56","61.56","61.56","1 through 10","18.91","57.95","percent of total billed charges",""
"Pure Tone Hearing Test, Air","PX-98301345","CDM","92551","CPT","0983","RC","","","","both","","","61.00","45.75","WELLPOINT [1015]","HB AMC WELLPOINT","45.01","73.78","","104.23","104.23","104.23","24","18.91","57.95","percent of total billed charges",""
"Pure Tone Hearing Test, Air","PX-98301345","CDM","92551","CPT","0983","RC","","","","outpatient","","","61.00","45.75","AETNA [1001]","HB AMC AETNA HMO","42.58","69.8","","71.98","66.92","109.20","36","27.58","52.06","percent of total billed charges",""
"Pure Tone Hearing Test, Air","PX-98301345","CDM","92551","CPT","0983","RC","","","","outpatient","","","61.00","45.75","AETNA [1001]","HB AMC AETNA PPO","49.04","80.4","","171.60","171.60","171.60","1 through 10","27.58","52.06","percent of total billed charges",""
"Pure Tone Hearing Test, Air","PX-98301345","CDM","92551","CPT","0983","RC","","","","outpatient","","","61.00","45.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","49.85","81.72","","111.91","111.91","111.91","1 through 10","27.58","52.06","percent of total billed charges",""
"Pure Tone Hearing Test, Air","PX-98301345","CDM","92551","CPT","0983","RC","","","","outpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","49.85","81.72","","111.91","111.91","140.00","20","27.58","52.06","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3680.56","79.5","","800.18","480.96","1887.97","195","1435.19","3680.56","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2467.59","53.3","","813.12","216.42","1444.50","81","1435.19","3680.56","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1435.19","31","","432.60","432.60","432.60","1 through 10","1435.19","3680.56","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1689.81","36.5","","148.37","54.89","631.39","94","1435.19","3680.56","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1773.15","38.3","","279.30","91.72","1116.77","266","1435.19","3680.56","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.11","42.9","","731.00","63.70","731.00","1 through 10","1435.19","3680.56","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.11","42.9","","384.74","384.74","384.74","1 through 10","1435.19","3680.56","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","4629.63","3472.22","WELLPOINT [1015]","HB AMC WELLPOINT","3415.74","73.78","","286.63","119.22","1107.45","105","1435.19","3680.56","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4629.63","3472.22","AETNA [1001]","HB AMC AETNA HMO","3231.48","69.8","","675.31","184.75","1721.50","286","2419.44","3783.33","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4629.63","3472.22","AETNA [1001]","HB AMC AETNA PPO","3722.22","80.4","","1261.44","103.12","1514.10","21","2419.44","3783.33","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4629.63","3472.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3722.22","80.4","","1365.00","1365.00","1365.00","1 through 10","2419.44","3783.33","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4629.63","3472.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3783.33","81.72","","5157.68","5157.68","5157.68","1 through 10","2419.44","3783.33","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4629.63","3472.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3783.33","81.72","","431.26","71.26","1459.57","88","2419.44","3783.33","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","514.08","385.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","408.69","79.5","","1309.77","674.56","6049.93","26","159.36","408.69","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","514.08","385.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","274.00","53.3","","1901.83","1901.83","2962.25","1 through 10","159.36","408.69","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","514.08","385.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","187.64","36.5","","1620.31","1620.31","19908.88","1 through 10","159.36","408.69","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","514.08","385.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","196.89","38.3","","352.91","352.91","2046.30","1 through 10","159.36","408.69","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","514.08","385.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.54","42.9","","9668.75","9668.75","9668.75","1 through 10","159.36","408.69","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","514.08","385.56","WELLPOINT [1015]","HB AMC WELLPOINT","379.29","73.78","","699.88","384.10","3443.31","33","159.36","408.69","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","514.08","385.56","AETNA [1001]","HB AMC AETNA HMO","358.83","69.8","","1421.24","264.50","4933.46","29","268.66","420.11","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","514.08","385.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","413.32","80.4","","1022.97","1022.97","3607.50","1 through 10","268.66","420.11","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","514.08","385.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","420.11","81.72","","3010.54","693.88","5019.88","35","268.66","420.11","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","2044.00","1533.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1624.98","79.5","","800.18","480.96","1887.97","195","633.64","1624.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","2044.00","1533.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1089.45","53.3","","813.12","216.42","1444.50","81","633.64","1624.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","2044.00","1533.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","633.64","31","","432.60","432.60","432.60","1 through 10","633.64","1624.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","2044.00","1533.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","746.06","36.5","","148.37","54.89","631.39","94","633.64","1624.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","2044.00","1533.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","782.85","38.3","","279.30","91.72","1116.77","266","633.64","1624.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","2044.00","1533.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","876.88","42.9","","731.00","63.70","731.00","1 through 10","633.64","1624.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","2044.00","1533.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","876.88","42.9","","384.74","384.74","384.74","1 through 10","633.64","1624.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","2044.00","1533.00","WELLPOINT [1015]","HB AMC WELLPOINT","1508.06","73.78","","286.63","119.22","1107.45","105","633.64","1624.98","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2044.00","1533.00","AETNA [1001]","HB AMC AETNA HMO","1426.71","69.8","","675.31","184.75","1721.50","286","1068.19","1670.36","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2044.00","1533.00","AETNA [1001]","HB AMC AETNA PPO","1643.38","80.4","","1261.44","103.12","1514.10","21","1068.19","1670.36","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2044.00","1533.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1643.38","80.4","","1365.00","1365.00","1365.00","1 through 10","1068.19","1670.36","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2044.00","1533.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1670.36","81.72","","5157.68","5157.68","5157.68","1 through 10","1068.19","1670.36","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2044.00","1533.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1670.36","81.72","","431.26","71.26","1459.57","88","1068.19","1670.36","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6910.24","79.5","","800.18","480.96","1887.97","195","2694.56","6910.24","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4632.91","53.3","","813.12","216.42","1444.50","81","2694.56","6910.24","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2694.56","31","","432.60","432.60","432.60","1 through 10","2694.56","6910.24","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3172.63","36.5","","148.37","54.89","631.39","94","2694.56","6910.24","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3329.09","38.3","","279.30","91.72","1116.77","266","2694.56","6910.24","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3728.92","42.9","","731.00","63.70","731.00","1 through 10","2694.56","6910.24","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3728.92","42.9","","384.74","384.74","384.74","1 through 10","2694.56","6910.24","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","8692.13","6519.10","WELLPOINT [1015]","HB AMC WELLPOINT","6413.05","73.78","","286.63","119.22","1107.45","105","2694.56","6910.24","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8692.13","6519.10","AETNA [1001]","HB AMC AETNA HMO","6067.11","69.8","","675.31","184.75","1721.50","286","4542.51","7103.21","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8692.13","6519.10","AETNA [1001]","HB AMC AETNA PPO","6988.47","80.4","","1261.44","103.12","1514.10","21","4542.51","7103.21","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8692.13","6519.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6988.47","80.4","","1365.00","1365.00","1365.00","1 through 10","4542.51","7103.21","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8692.13","6519.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","7103.21","81.72","","5157.68","5157.68","5157.68","1 through 10","4542.51","7103.21","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8692.13","6519.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7103.21","81.72","","431.26","71.26","1459.57","88","4542.51","7103.21","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.88","849.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","900.64","79.5","","800.18","480.96","1887.97","195","351.19","900.64","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.88","849.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","603.83","53.3","","813.12","216.42","1444.50","81","351.19","900.64","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.88","849.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","351.19","31","","432.60","432.60","432.60","1 through 10","351.19","900.64","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.88","849.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","413.50","36.5","","148.37","54.89","631.39","94","351.19","900.64","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.88","849.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","433.89","38.3","","279.30","91.72","1116.77","266","351.19","900.64","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.88","849.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","486.01","42.9","","731.00","63.70","731.00","1 through 10","351.19","900.64","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.88","849.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","486.01","42.9","","384.74","384.74","384.74","1 through 10","351.19","900.64","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.88","849.66","WELLPOINT [1015]","HB AMC WELLPOINT","835.84","73.78","","286.63","119.22","1107.45","105","351.19","900.64","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.88","849.66","AETNA [1001]","HB AMC AETNA HMO","790.75","69.8","","675.31","184.75","1721.50","286","592.04","925.79","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.88","849.66","AETNA [1001]","HB AMC AETNA PPO","910.84","80.4","","1261.44","103.12","1514.10","21","592.04","925.79","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.88","849.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","910.84","80.4","","1365.00","1365.00","1365.00","1 through 10","592.04","925.79","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.88","849.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","925.79","81.72","","5157.68","5157.68","5157.68","1 through 10","592.04","925.79","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.88","849.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","925.79","81.72","","431.26","71.26","1459.57","88","592.04","925.79","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","2058.70","1544.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1636.67","79.5","","1309.77","674.56","6049.93","26","638.2","1636.67","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","2058.70","1544.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1097.29","53.3","","1901.83","1901.83","2962.25","1 through 10","638.2","1636.67","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","2058.70","1544.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","751.43","36.5","","1620.31","1620.31","19908.88","1 through 10","638.2","1636.67","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","2058.70","1544.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","788.48","38.3","","352.91","352.91","2046.30","1 through 10","638.2","1636.67","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","2058.70","1544.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","883.18","42.9","","9668.75","9668.75","9668.75","1 through 10","638.2","1636.67","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","2058.70","1544.02","WELLPOINT [1015]","HB AMC WELLPOINT","1518.91","73.78","","699.88","384.10","3443.31","33","638.2","1636.67","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2058.70","1544.02","AETNA [1001]","HB AMC AETNA HMO","1436.97","69.8","","1421.24","264.50","4933.46","29","1075.88","1682.37","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2058.70","1544.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1655.19","80.4","","1022.97","1022.97","3607.50","1 through 10","1075.88","1682.37","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2058.70","1544.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1682.37","81.72","","3010.54","693.88","5019.88","35","1075.88","1682.37","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2351.21","79.5","","1309.77","674.56","6049.93","26","916.83","2351.21","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1576.35","53.3","","1901.83","1901.83","2962.25","1 through 10","916.83","2351.21","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1079.49","36.5","","1620.31","1620.31","19908.88","1 through 10","916.83","2351.21","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1132.72","38.3","","352.91","352.91","2046.30","1 through 10","916.83","2351.21","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1268.77","42.9","","9668.75","9668.75","9668.75","1 through 10","916.83","2351.21","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","both","","","2957.50","2218.12","WELLPOINT [1015]","HB AMC WELLPOINT","2182.04","73.78","","699.88","384.10","3443.31","33","916.83","2351.21","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2957.50","2218.12","AETNA [1001]","HB AMC AETNA HMO","2064.34","69.8","","1421.24","264.50","4933.46","29","1545.59","2416.87","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2957.50","2218.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2377.83","80.4","","1022.97","1022.97","3607.50","1 through 10","1545.59","2416.87","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2957.50","2218.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2416.87","81.72","","3010.54","693.88","5019.88","35","1545.59","2416.87","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2086.88","79.5","","1309.77","674.56","6049.93","26","813.75","2086.88","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1399.13","53.3","","1901.83","1901.83","2962.25","1 through 10","813.75","2086.88","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","958.13","36.5","","1620.31","1620.31","19908.88","1 through 10","813.75","2086.88","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1005.38","38.3","","352.91","352.91","2046.30","1 through 10","813.75","2086.88","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1126.13","42.9","","9668.75","9668.75","9668.75","1 through 10","813.75","2086.88","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","WELLPOINT [1015]","HB AMC WELLPOINT","1936.73","73.78","","699.88","384.10","3443.31","33","813.75","2086.88","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","AETNA [1001]","HB AMC AETNA HMO","1832.25","69.8","","1421.24","264.50","4933.46","29","1371.83","2145.15","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2110.50","80.4","","1022.97","1022.97","3607.50","1 through 10","1371.83","2145.15","percent of total billed charges",""
"PUTTY BONE GRAFT 1CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232281","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2145.15","81.72","","3010.54","693.88","5019.88","35","1371.83","2145.15","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3816.00","79.5","","1309.77","674.56","6049.93","26","1488","3816","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2558.40","53.3","","1901.83","1901.83","2962.25","1 through 10","1488","3816","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1752.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1488","3816","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1838.40","38.3","","352.91","352.91","2046.30","1 through 10","1488","3816","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","9668.75","9668.75","9668.75","1 through 10","1488","3816","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","WELLPOINT [1015]","HB AMC WELLPOINT","3541.44","73.78","","699.88","384.10","3443.31","33","1488","3816","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA HMO","3350.40","69.8","","1421.24","264.50","4933.46","29","2508.48","3922.56","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3859.20","80.4","","1022.97","1022.97","3607.50","1 through 10","2508.48","3922.56","percent of total billed charges",""
"PUTTY BONE GRAFT 2.5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232280","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3922.56","81.72","","3010.54","693.88","5019.88","35","2508.48","3922.56","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5962.50","79.5","","1309.77","674.56","6049.93","26","2325","5962.5","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3997.50","53.3","","1901.83","1901.83","2962.25","1 through 10","2325","5962.5","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2737.50","36.5","","1620.31","1620.31","19908.88","1 through 10","2325","5962.5","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2872.50","38.3","","352.91","352.91","2046.30","1 through 10","2325","5962.5","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3217.50","42.9","","9668.75","9668.75","9668.75","1 through 10","2325","5962.5","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","WELLPOINT [1015]","HB AMC WELLPOINT","5533.50","73.78","","699.88","384.10","3443.31","33","2325","5962.5","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","AETNA [1001]","HB AMC AETNA HMO","5235.00","69.8","","1421.24","264.50","4933.46","29","3919.5","6129","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6030.00","80.4","","1022.97","1022.97","3607.50","1 through 10","3919.5","6129","percent of total billed charges",""
"PUTTY BONE GRAFT 5CC I-FACTOR PEPTIDE ENHANCED","SUP-ITM-10232279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6129.00","81.72","","3010.54","693.88","5019.88","35","3919.5","6129","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.96","2395.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2539.20","79.5","","800.18","480.96","1887.97","195","990.13","2539.2","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.96","2395.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1702.38","53.3","","813.12","216.42","1444.50","81","990.13","2539.2","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.96","2395.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","990.13","31","","432.60","432.60","432.60","1 through 10","990.13","2539.2","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.96","2395.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1165.80","36.5","","148.37","54.89","631.39","94","990.13","2539.2","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.96","2395.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1223.29","38.3","","279.30","91.72","1116.77","266","990.13","2539.2","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.96","2395.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1370.21","42.9","","731.00","63.70","731.00","1 through 10","990.13","2539.2","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.96","2395.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1370.21","42.9","","384.74","384.74","384.74","1 through 10","990.13","2539.2","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.96","2395.47","WELLPOINT [1015]","HB AMC WELLPOINT","2356.50","73.78","","286.63","119.22","1107.45","105","990.13","2539.2","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.96","2395.47","AETNA [1001]","HB AMC AETNA HMO","2229.38","69.8","","675.31","184.75","1721.50","286","1669.16","2610.1","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.96","2395.47","AETNA [1001]","HB AMC AETNA PPO","2567.94","80.4","","1261.44","103.12","1514.10","21","1669.16","2610.1","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.96","2395.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2567.94","80.4","","1365.00","1365.00","1365.00","1 through 10","1669.16","2610.1","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.96","2395.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2610.10","81.72","","5157.68","5157.68","5157.68","1 through 10","1669.16","2610.1","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.96","2395.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2610.10","81.72","","431.26","71.26","1459.57","88","1669.16","2610.1","percent of total billed charges",""
"Pvb Thoracic Single Injection Site W/Img Gid","PX-76002194","CDM","64461","CPT","0761","RC","","","","both","","","639.00","479.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1218.82","812.87","1218.82","1 through 10","198.09","1027.91","other","OPPS APC"
"Pvb Thoracic Single Injection Site W/Img Gid","PX-98301704","CDM","64461","CPT","0983","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1218.82","812.87","1218.82","1 through 10","130.2","1027.91","other","OPPS APC"
"Quantitative Coronary Angiography 3d","PX-48000546","CDM","93799","CPT","0481","RC","","","","both","","","29588.00","22191.00","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","23522.46","other","OPPS APC"
"Quantitative Coronary Angiography 3d","PX-48000546","CDM","93799","CPT","0481","RC","","","","outpatient","","","29588.00","22191.00","AETNA [1001]","HB AMC AETNA HMO","20652.42","69.8","","2022.70","2022.70","2022.70","1 through 10","454","24410.1","percent of total billed charges",""
"Quantitative Coronary Angiography 3d","PX-48000546","CDM","93799","CPT","0481","RC","","","","outpatient","","","29588.00","22191.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","17915.53","60.55","","318.03","318.03","2439.77","1 through 10","454","24410.1","percent of total billed charges",""
"Quantitative Coronary Angiography 3d","PX-48000546","CDM","93799","CPT","0481","RC","","","","outpatient","","","29588.00","22191.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","15450.85","52.22","","360.38","360.38","4023.00","1 through 10","454","24410.1","percent of total billed charges",""
"Quantitative Coronary Angiography 3d","PX-48000546","CDM","93799","CPT","0481","RC","","","","outpatient","","","29588.00","22191.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","16273.40","55","","13080.03","13080.03","13080.03","1 through 10","454","24410.1","percent of total billed charges",""
"R Hrt Cath Chd W/Img Cath Trgt Zon Abnl Nt Connj","PX-48000476","CDM","93594","CPT","0481","RC","","","","both","","","33621.00","25215.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","26728.70","79.5","","25659.35","25659.35","25659.35","1 through 10","3628.7","26728.7","percent of total billed charges",""
"R Hrt Cath Chd W/Img Cath Trgt Zon Abnl Nt Connj","PX-48000476","CDM","93594","CPT","0481","RC","","","","both","","","33621.00","25215.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","25888.17","77","","26372.74","26372.74","26372.74","1 through 10","3628.7","26728.7","percent of total billed charges",""
"R Hrt Cath Chd W/Img Cath Trgt Zon Abnl Nt Connj","PX-48000476","CDM","93594","CPT","0481","RC","","","","outpatient","","","33621.00","25215.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3332.73","","Case rate ($3,332.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6818.77","6818.77","6818.77","1 through 10","2529.37","27475.08","other","ASC"
"R Hrt Cath Chd W/Img Cath Trgt Zon Abnl Nt Connj","PX-48000476","CDM","93594","CPT","0481","RC","","","","outpatient","","","33621.00","25215.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3332.73","","Case rate ($3,332.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7725.27","7725.27","7801.92","1 through 10","2529.37","27475.08","other","ASC "
"R Hrt Cath Chd W/Img Cath Trgt Zon Abnl Nt Connj","PX-48000476","CDM","93594","CPT","0481","RC","","","","outpatient","","","33621.00","25215.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","5868.14","5868.14","5868.14","1 through 10","2529.37","27475.08","other","Multiple Surgery"
"R Hrt Cath Chd W/Img Cath Trgt Zon Abnl Nt Connj","PX-48000476","CDM","93594","CPT","0481","RC","","","","outpatient","","","33621.00","25215.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","26063.64","26063.64","26063.64","1 through 10","2529.37","27475.08","other","Multiple Surgery"
"R Hrt Cath Chd W/Img Cath Trgt Zone Nml Nt Connj","PX-48000475","CDM","93593","CPT","0481","RC","","","","both","","","28018.00","21013.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14933.59","53.3","","21382.79","21382.79","21382.79","1 through 10","3628.7","22274.31","percent of total billed charges",""
"R Hrt Cath Chd W/Img Cath Trgt Zone Nml Nt Connj","PX-48000475","CDM","93593","CPT","0481","RC","","","","both","","","28018.00","21013.50","MEDICARE [2001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3819.68","3819.68","3819.68","1 through 10","3628.7","22274.31","other","OPPS APC"
"R Hrt Cath Chd W/Img Cath Trgt Zone Nml Nt Connj","PX-48000475","CDM","93593","CPT","0481","RC","","","","both","","","28018.00","21013.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10730.89","38.3","","10623.47","10623.47","10623.47","1 through 10","3628.7","22274.31","percent of total billed charges",""
"R Hrt Cath Chd W/Img Cath Trgt Zone Nml Nt Connj","PX-48000475","CDM","93593","CPT","0481","RC","","","","outpatient","","","28018.00","21013.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3332.73","","Case rate ($3,332.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6695.45","6695.45","6695.45","1 through 10","2529.37","22896.31","other","ASC"
"R Hrt Cath Chd W/Img Cath Trgt Zone Nml Nt Connj","PX-48000475","CDM","93593","CPT","0481","RC","","","","outpatient","","","28018.00","21013.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3332.73","","Case rate ($3,332.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7725.27","7725.27","7801.92","1 through 10","2529.37","22896.31","other","ASC "
"R&L Hrt Cath Chd Img Cath Trgt Zon Abnl Nt Connj","PX-48000478","CDM","93597","CPT","0481","RC","","","","outpatient","","","47820.00","35865.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3332.73","","Case rate ($3,332.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7801.92","7801.92","7801.92","1 through 10","2529.37","39078.5","other","ASC "
"R&L Hrt Cath Chd Img Cath Trgt Zone Nml Nt Connj","PX-48000477","CDM","93596","CPT","0481","RC","","","","both","","","39850.00","29887.50","MEDICARE [2001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3819.68","3819.68","3819.68","1 through 10","3628.7","31680.75","other","OPPS APC"
"Rabies Imm Glob Human Vl Im/Sq","PX-63600003","CDM","90375","CPT","0636","RC","","","","outpatient","","","280.56","210.42","AETNA [1001]","HB AMC AETNA HMO","195.83","69.8","","620.55","620.54","620.55","26","131.58","635.11","percent of total billed charges",""
"Rabies Imm Glob Human Vl Im/Sq","PX-63600003","CDM","90375","CPT","0636","RC","","","","outpatient","","","280.56","210.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","196.11","69.9","","445.88","445.88","445.88","1 through 10","131.58","635.11","percent of total billed charges",""
"Rabies Imm Glob Human Vl Im/Sq","PX-63600003","CDM","90375","CPT","0636","RC","","","","outpatient","","","280.56","210.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","131.58","46.9","","629.62","629.62","629.62","11","131.58","635.11","percent of total billed charges",""
"Rabies Immune Globulin Rig Human Im/Subq","PX-63601055","CDM","90375","CPT","0636","RC","","","","outpatient","","","605.82","454.36","AETNA [1001]","HB AMC AETNA HMO","422.86","69.8","","620.55","620.54","620.55","26","284.13","635.11","percent of total billed charges",""
"Rabies Immune Globulin Rig Human Im/Subq","PX-63601055","CDM","90375","CPT","0636","RC","","","","outpatient","","","605.82","454.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","423.47","69.9","","445.88","445.88","445.88","1 through 10","284.13","635.11","percent of total billed charges",""
"Rabies Immune Globulin Rig Human Im/Subq","PX-63601055","CDM","90375","CPT","0636","RC","","","","outpatient","","","605.82","454.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","284.13","46.9","","629.62","629.62","629.62","11","284.13","635.11","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","605.82","454.36","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","323.09","","APC Price ($313.68). Final payment is multiplied by 103%.","338.66","338.66","338.66","1 through 10","187.8","805.87","other","OPPS APC"
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","605.82","454.36","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","313.68","","APC Price ($313.68).","307.04","307.04","322.54","1 through 10","187.8","805.87","other","OPPS APC"
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","605.82","454.36","HUMANA [1012]","HB BWH MEDICARE","313.68","","APC Price ($313.68).","322.54","322.54","327.69","1 through 10","187.8","805.87","other","OPPS APC"
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","605.82","454.36","MEDICARE [2001]","HB BWH MEDICARE","313.68","","APC Price ($313.68).","312.03","312.03","327.78","1 through 10","187.8","805.87","other","OPPS APC"
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","605.82","454.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","221.12","36.5","","225.97","192.83","225.97","1 through 10","187.8","805.87","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","605.82","454.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","232.03","38.3","","236.88","214.08","236.88","21","187.8","805.87","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","605.82","454.36","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","307.41","","APC Price ($313.68). Final payment is multiplied by 98%.","917.37","305.79","917.37","16","187.8","805.87","other","OPPS APC"
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","outpatient","","","605.82","454.36","AETNA [1001]","HB AMC AETNA HMO","422.86","69.8","","247.12","246.44","410.14","23","259.9","636.46","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","outpatient","","","605.82","454.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","423.47","69.9","","358.27","358.27","419.83","15","259.9","636.46","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","outpatient","","","605.82","454.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","284.13","46.9","","357.28","281.10","520.82","1 through 10","259.9","636.46","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","outpatient","","","605.82","454.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","495.08","81.72","","605.82","605.82","605.82","1 through 10","259.9","636.46","percent of total billed charges",""
"Rad Resect Tumor Soft Tiss Neck/Ant Thorax 5cm/>","PX-76000346","CDM","21558","CPT","0761","RC","","","","both","","","10050.00","7537.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5356.65","53.3","","10680.91","10680.91","10680.91","1 through 10","3115.5","7989.75","percent of total billed charges",""
"Rad Resection Tumor Soft Tis Thigh/Knee 5 Cm/>","PX-76000567","CDM","27364","CPT","0761","RC","","","","outpatient","","","11409.00","8556.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9323.43","81.72","","4126.58","4126.58","4126.58","1 through 10","4563.6","9323.43","percent of total billed charges",""
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","321.64","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","321.36","321.36","321.56","23","296.69","2001.02","other","OPPS APC"
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","307.30","307.30","626.68","21","296.69","2001.02","other","OPPS APC"
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1636.05","65","","1921.07","1586.65","1921.07","1 through 10","296.69","2001.02","percent of total billed charges",""
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1761.90","70","","1611.06","1049.63","1757.52","23","296.69","2001.02","percent of total billed charges",""
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2001.02","79.5","","1921.07","1840.51","1921.07","18","296.69","2001.02","percent of total billed charges",""
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1341.56","53.3","","1921.07","1288.85","2465.42","16","296.69","2001.02","percent of total billed charges",""
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","307.30","306.05","307.30","25","296.69","2001.02","other","OPPS APC"
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","FALLON HEALTH [1008]","HB BWH MEDICARE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.45","287.45","312.30","1 through 10","296.69","2001.02","other","OPPS APC"
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","307.93","307.93","307.93","1 through 10","296.69","2001.02","other","OPPS APC"
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1938.09","77","","3649.80","3649.80","3649.80","1 through 10","296.69","2001.02","percent of total billed charges",""
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","307.93","307.93","307.93","1 through 10","296.69","2001.02","other","OPPS APC"
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","MEDICARE [2001]","HB BWH MEDICARE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","312.30","312.30","312.30","488","296.69","2001.02","other","OPPS APC"
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","918.71","36.5","","883.64","773.80","910.49","1 through 10","296.69","2001.02","percent of total billed charges",""
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","964.01","38.3","","954.43","954.43","954.43","1 through 10","296.69","2001.02","percent of total billed charges",""
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","MOLINA [1014]","HB BWH MOLINA","306.03","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","619.60","619.60","619.60","1 through 10","296.69","2001.02","other","OPPS APC"
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","306.03","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","306.05","288.65","307.30","33","296.69","2001.02","other","OPPS APC"
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","306.03","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","561.43","561.43","561.43","1 through 10","296.69","2001.02","other","OPPS APC"
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1079.79","42.9","","1073.31","1073.31","1951.34","1 through 10","296.69","2001.02","percent of total billed charges",""
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","306.03","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","306.05","287.46","307.31","249","296.69","2001.02","other","OPPS APC"
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","outpatient","","","2517.00","1887.75","AETNA [1001]","HB AMC AETNA HMO","1756.87","69.8","","1652.56","1166.80","1903.98","42","610.53","2056.89","percent of total billed charges",""
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","outpatient","","","2517.00","1887.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1315.38","52.26","","1510.49","1510.49","1510.49","1 through 10","610.53","2056.89","percent of total billed charges",""
"Rad Therapy Cplx 1-5 Mev","PX-33000041","CDM","77412","CPT","0333","RC","","","","outpatient","","","2517.00","1887.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2056.89","81.72","","1951.33","1073.31","1951.34","21","610.53","2056.89","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","675.98","675.98","5954.00","54","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","4408.52","71.8","","4274.97","4274.97","4274.97","1 through 10","652.62","4881.3","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4027.84","65.6","","4030.86","2846.01","4030.86","1 through 10","652.62","4881.3","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4298.00","70","","4291.11","4286.88","5954.00","1 through 10","652.62","4881.3","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4881.30","79.5","","4685.80","3143.71","11490.99","14","652.62","4881.3","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3272.62","53.3","","3006.77","2332.09","4685.80","1 through 10","652.62","4881.3","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","675.98","673.23","675.98","13","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","FALLON HEALTH [1008]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","673.23","673.23","686.97","1 through 10","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1443.12","1443.12","1443.12","1 through 10","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","4727.80","77","","4584.58","4584.58","4584.58","1 through 10","652.62","4881.3","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","675.98","673.23","675.98","1 through 10","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","HUMANA [1012]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","673.23","632.20","675.98","1 through 10","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","673.23","629.63","677.35","1 through 10","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","MEDICARE [2001]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","686.97","686.97","686.97","599","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1903.40","31","","1839.79","1839.79","1839.79","1 through 10","652.62","4881.3","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2241.10","36.5","","2220.84","2155.35","3352.66","13","652.62","4881.3","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2351.62","38.3","","2328.01","2262.52","6984.03","21","652.62","4881.3","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","673.23","629.63","673.23","1 through 10","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","MOLINA [1014]","HB BWH MOLINA","673.16","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1362.95","686.97","1362.95","1 through 10","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","4727.80","77","","654.94","654.94","654.94","1 through 10","652.62","4881.3","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","TRICARE [160005]","HB BWH TRICARE","652.62","","APC Price ($686.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","652.62","652.62","652.62","1 through 10","652.62","4881.3","other","Tricare OPPS"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","652.62","","APC Price ($686.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","686.97","686.97","686.97","1 through 10","652.62","4881.3","other","Tricare OPPS"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","673.16","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","673.23","629.63","1346.46","38","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","673.16","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1369.42","1369.42","1369.42","1 through 10","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","673.16","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","673.24","673.23","686.97","40","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","6140.00","4605.00","WELLSENSE [1003]","HB BWH MEDICARE","686.90","","APC Price ($686.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","693.84","693.84","693.84","1 through 10","652.62","4881.3","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","outpatient","","","6140.00","4605.00","AETNA [1001]","HB AMC AETNA HMO","4285.72","69.8","","4030.86","2846.01","5954.00","1 through 10","1413.99","5017.61","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","outpatient","","","6140.00","4605.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3208.76","52.26","","3684.34","3684.34","3684.34","1 through 10","1413.99","5017.61","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","outpatient","","","6140.00","4605.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","5017.61","81.72","","4759.63","4759.63","4759.63","1 through 10","1413.99","5017.61","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","outpatient","","","6140.00","4605.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5017.61","81.72","","4759.63","4759.63","4759.63","1 through 10","1413.99","5017.61","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","outpatient","","","6140.00","4605.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5017.61","81.72","","4759.63","2617.97","4759.63","29","1413.99","5017.61","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw","PX-32000418","CDM","72081","CPT","0320","RC","","","","both","","","387.00","290.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","206.27","53.3","","295.13","295.13","295.13","1 through 10","99.34","307.67","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw","PX-32000418","CDM","72081","CPT","0320","RC","","","","both","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.02","42.9","","122.36","122.36","122.36","1 through 10","99.34","307.67","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","688.00","516.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","90.19","124.27","1 through 10","119.97","546.96","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","688.00","516.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","546.96","79.5","","524.93","352.18","524.93","1 through 10","119.97","546.96","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","688.00","516.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","366.70","53.3","","352.18","336.84","352.18","1 through 10","119.97","546.96","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","688.00","516.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","546.96","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","688.00","516.00","FALLON HEALTH [1008]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","378.87","378.87","378.87","1 through 10","119.97","546.96","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","688.00","516.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","24","119.97","546.96","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","688.00","516.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","251.12","36.5","","211.44","211.44","211.44","1 through 10","119.97","546.96","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","688.00","516.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","263.50","38.3","","782.40","260.80","782.40","1 through 10","119.97","546.96","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","688.00","516.00","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","546.96","other","Tricare OPPS"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","688.00","516.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","546.96","other","Tricare OPPS"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","688.00","516.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.07","124.27","1 through 10","119.97","546.96","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","outpatient","","","688.00","516.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","562.23","81.72","","533.20","533.20","533.20","1 through 10","231.59","562.23","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","both","","","754.00","565.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","599.43","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","both","","","754.00","565.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","599.43","79.5","","575.30","385.97","575.30","1 through 10","119.97","599.43","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","both","","","754.00","565.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","599.43","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","both","","","754.00","565.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","288.78","38.3","","285.82","285.82","285.82","1 through 10","119.97","599.43","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","both","","","754.00","565.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","119.97","599.43","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 6/> Vw","PX-32000421","CDM","72084","CPT","0320","RC","","","","both","","","897.00","672.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","713.12","79.5","","459.36","459.36","459.36","1 through 10","119.97","713.12","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 6/> Vw","PX-32000421","CDM","72084","CPT","0320","RC","","","","both","","","897.00","672.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","713.12","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 6/> Vw","PX-32000421","CDM","72084","CPT","0320","RC","","","","both","","","897.00","672.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","327.41","36.5","","973.53","314.94","973.53","1 through 10","119.97","713.12","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 6/> Vw","PX-32000421","CDM","72084","CPT","0320","RC","","","","both","","","897.00","672.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","343.55","38.3","","330.60","330.60","330.60","1 through 10","119.97","713.12","percent of total billed charges",""
"Radex Hip Unilateral With Pelvis 1 View","PX-32000422","CDM","73501","CPT","0320","RC","","","","both","","","305.00","228.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.97","102.97","102.97","1 through 10","94.55","242.48","other","OPPS APC"
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","456.00","342.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","362.52","79.5","","347.85","347.85","695.71","1 through 10","99.34","362.52","percent of total billed charges",""
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","456.00","342.00","ELDER SERVICES [1037]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","362.52","other","OPPS APC"
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","456.00","342.00","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","442.00","442.00","442.00","1 through 10","99.34","362.52","other","OPPS APC"
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","456.00","342.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.67","102.97","61","99.34","362.52","other","OPPS APC"
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","456.00","342.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.62","42.9","","194.35","194.35","194.35","1 through 10","99.34","362.52","percent of total billed charges",""
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","outpatient","","","456.00","342.00","AETNA [1001]","HB AMC AETNA HMO","318.29","69.8","","299.23","211.28","299.23","1 through 10","128.23","372.64","percent of total billed charges",""
"Radex Hip Unilateral With Pelvis Minimum 4 Views","PX-32000424","CDM","73503","CPT","0320","RC","","","","both","","","564.00","423.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","448.38","79.5","","430.49","430.49","430.49","1 through 10","119.97","448.38","percent of total billed charges",""
"Radex Hip Unilateral With Pelvis Minimum 4 Views","PX-32000424","CDM","73503","CPT","0320","RC","","","","both","","","564.00","423.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","117.90","124.27","15","119.97","448.38","other","OPPS APC"
"Radex Hip Unilateral With Pelvis Minimum 4 Views","PX-32000424","CDM","73503","CPT","0320","RC","","","","outpatient","","","564.00","423.00","AETNA [1001]","HB AMC AETNA HMO","393.67","69.8","","370.32","370.32","370.32","1 through 10","231.59","505.17","percent of total billed charges",""
"Radex Hip Unilateral With Pelvis Minimum 4 Views","PX-32000424","CDM","73503","CPT","0320","RC","","","","outpatient","","","564.00","423.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","460.90","81.72","","257.99","257.99","257.99","1 through 10","231.59","505.17","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis 2 Views","PX-32000425","CDM","73521","CPT","0320","RC","","","","both","","","429.00","321.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","341.06","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 2 Views","PX-32000425","CDM","73521","CPT","0320","RC","","","","both","","","429.00","321.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","341.06","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 2 Views","PX-32000425","CDM","73521","CPT","0320","RC","","","","both","","","429.00","321.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","119.97","341.06","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 2 Views","PX-32000425","CDM","73521","CPT","0320","RC","","","","outpatient","","","429.00","321.75","AETNA [1001]","HB AMC AETNA HMO","299.44","69.8","","281.63","281.63","281.63","1 through 10","224.2","505.17","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","both","","","510.00","382.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","405.45","79.5","","389.57","389.57","389.57","1 through 10","119.97","405.45","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","both","","","510.00","382.50","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.87","123.87","123.87","1 through 10","119.97","405.45","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","both","","","510.00","382.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","405.45","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","both","","","510.00","382.50","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","119.97","405.45","other","Tricare OPPS"
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","both","","","510.00","382.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","119.97","405.45","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","617.00","462.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","42","119.97","490.52","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","617.00","462.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","490.52","79.5","","470.63","470.63","470.63","1 through 10","119.97","490.52","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","617.00","462.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","328.86","53.3","","315.74","315.74","470.63","1 through 10","119.97","490.52","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","617.00","462.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","118.07","103.07","125.97","1 through 10","119.97","490.52","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","617.00","462.75","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.77","124.77","124.77","1 through 10","119.97","490.52","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","617.00","462.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","378.87","393","119.97","490.52","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","617.00","462.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","225.21","36.5","","223.05","216.48","669.15","15","119.97","490.52","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","617.00","462.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","236.31","38.3","","233.82","227.24","701.46","27","119.97","490.52","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","617.00","462.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.06","117.59","359.84","1 through 10","119.97","490.52","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","617.00","462.75","MOLINA [1014]","HB BWH MOLINA","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","239.98","239.98","239.98","1 through 10","119.97","490.52","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","617.00","462.75","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","126.29","1 through 10","119.97","490.52","other","Tricare OPPS"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","617.00","462.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","372.81","124.27","621.35","12","119.97","490.52","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","617.00","462.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","117.90","124.27","42","119.97","490.52","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","outpatient","","","617.00","462.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","504.21","81.72","","478.04","478.04","478.04","1 through 10","231.59","505.17","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","outpatient","","","617.00","462.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","504.21","81.72","","478.04","262.94","478.04","11","231.59","505.17","percent of total billed charges",""
"Radex Spine Thoracolumbar Junction Min 2 Views","PX-32000063","CDM","72080","CPT","0320","RC","","","","both","","","414.00","310.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","329.13","79.5","","218.82","218.82","218.82","1 through 10","99.34","329.13","percent of total billed charges",""
"Radex Spine Thoracolumbar Junction Min 2 Views","PX-32000063","CDM","72080","CPT","0320","RC","","","","both","","","414.00","310.50","MEDICARE [2001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","209.12","104.56","209.12","1 through 10","99.34","329.13","other","OPPS APC"
"Radex Spine Thoracolumbar Junction Min 2 Views","PX-32000063","CDM","72080","CPT","0320","RC","","","","both","","","414.00","310.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","158.56","38.3","","470.37","156.79","470.37","1 through 10","99.34","329.13","percent of total billed charges",""
"Radex Spine Thoracolumbar Junction Min 2 Views","PX-32000063","CDM","72080","CPT","0320","RC","","","","both","","","414.00","310.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.77","102.77","102.77","1 through 10","99.34","329.13","other","OPPS APC"
"Radex Spine Thoracolumbar Junction Min 2 Views","PX-32000063","CDM","72080","CPT","0320","RC","","","","both","","","414.00","310.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","102.47","1 through 10","99.34","329.13","other","OPPS APC"
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.00","3377.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3579.89","79.5","","800.18","480.96","1887.97","195","1395.93","3579.89","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.00","3377.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2400.10","53.3","","813.12","216.42","1444.50","81","1395.93","3579.89","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.00","3377.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1395.93","31","","432.60","432.60","432.60","1 through 10","1395.93","3579.89","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.00","3377.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1643.60","36.5","","148.37","54.89","631.39","94","1395.93","3579.89","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.00","3377.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1724.65","38.3","","279.30","91.72","1116.77","266","1395.93","3579.89","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.00","3377.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1931.79","42.9","","731.00","63.70","731.00","1 through 10","1395.93","3579.89","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.00","3377.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1931.79","42.9","","384.74","384.74","384.74","1 through 10","1395.93","3579.89","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","both","","","4503.00","3377.25","WELLPOINT [1015]","HB AMC WELLPOINT","3322.31","73.78","","286.63","119.22","1107.45","105","1395.93","3579.89","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4503.00","3377.25","AETNA [1001]","HB AMC AETNA HMO","3143.09","69.8","","675.31","184.75","1721.50","286","2353.27","3679.85","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4503.00","3377.25","AETNA [1001]","HB AMC AETNA PPO","3620.41","80.4","","1261.44","103.12","1514.10","21","2353.27","3679.85","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4503.00","3377.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3620.41","80.4","","1365.00","1365.00","1365.00","1 through 10","2353.27","3679.85","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4503.00","3377.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3679.85","81.72","","5157.68","5157.68","5157.68","1 through 10","2353.27","3679.85","percent of total billed charges",""
"RADIAL PLATE 20MM HEAD EVOLVE TRIAD","SUP-ITM-10116800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4503.00","3377.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3679.85","81.72","","431.26","71.26","1459.57","88","2353.27","3679.85","percent of total billed charges",""
"RADIAL PLATE 21MM HEAD EVOLVE TRIAD","SUP-ITM-10116804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3434.40","79.5","","800.18","480.96","1887.97","195","1339.2","3434.4","percent of total billed charges",""
"RADIAL PLATE 21MM HEAD EVOLVE TRIAD","SUP-ITM-10116804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2302.56","53.3","","813.12","216.42","1444.50","81","1339.2","3434.4","percent of total billed charges",""
"RADIAL PLATE 21MM HEAD EVOLVE TRIAD","SUP-ITM-10116804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1339.20","31","","432.60","432.60","432.60","1 through 10","1339.2","3434.4","percent of total billed charges",""
"RADIAL PLATE 21MM HEAD EVOLVE TRIAD","SUP-ITM-10116804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1576.80","36.5","","148.37","54.89","631.39","94","1339.2","3434.4","percent of total billed charges",""
"RADIAL PLATE 21MM HEAD EVOLVE TRIAD","SUP-ITM-10116804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1654.56","38.3","","279.30","91.72","1116.77","266","1339.2","3434.4","percent of total billed charges",""
"RADIAL PLATE 21MM HEAD EVOLVE TRIAD","SUP-ITM-10116804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1853.28","42.9","","731.00","63.70","731.00","1 through 10","1339.2","3434.4","percent of total billed charges",""
"RADIAL PLATE 21MM HEAD EVOLVE TRIAD","SUP-ITM-10116804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1853.28","42.9","","384.74","384.74","384.74","1 through 10","1339.2","3434.4","percent of total billed charges",""
"RADIAL PLATE 21MM HEAD EVOLVE TRIAD","SUP-ITM-10116804","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","WELLPOINT [1015]","HB AMC WELLPOINT","3187.30","73.78","","286.63","119.22","1107.45","105","1339.2","3434.4","percent of total billed charges",""
"RADIAL PLATE 21MM HEAD EVOLVE TRIAD","SUP-ITM-10116804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4320.00","3240.00","AETNA [1001]","HB AMC AETNA HMO","3015.36","69.8","","675.31","184.75","1721.50","286","2257.63","3530.3","percent of total billed charges",""
"RADIAL PLATE 21MM HEAD EVOLVE TRIAD","SUP-ITM-10116804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4320.00","3240.00","AETNA [1001]","HB AMC AETNA PPO","3473.28","80.4","","1261.44","103.12","1514.10","21","2257.63","3530.3","percent of total billed charges",""
"RADIAL PLATE 21MM HEAD EVOLVE TRIAD","SUP-ITM-10116804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4320.00","3240.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3473.28","80.4","","1365.00","1365.00","1365.00","1 through 10","2257.63","3530.3","percent of total billed charges",""
"RADIAL PLATE 21MM HEAD EVOLVE TRIAD","SUP-ITM-10116804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4320.00","3240.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3530.30","81.72","","5157.68","5157.68","5157.68","1 through 10","2257.63","3530.3","percent of total billed charges",""
"RADIAL PLATE 21MM HEAD EVOLVE TRIAD","SUP-ITM-10116804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4320.00","3240.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3530.30","81.72","","431.26","71.26","1459.57","88","2257.63","3530.3","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","321.64","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","321.36","321.36","321.56","23","296.69","2001.02","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","307.30","307.30","626.68","21","296.69","2001.02","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1636.05","65","","1921.07","1586.65","1921.07","1 through 10","296.69","2001.02","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1761.90","70","","1611.06","1049.63","1757.52","23","296.69","2001.02","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2001.02","79.5","","1921.07","1840.51","1921.07","18","296.69","2001.02","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1341.56","53.3","","1921.07","1288.85","2465.42","16","296.69","2001.02","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","307.30","306.05","307.30","25","296.69","2001.02","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","FALLON HEALTH [1008]","HB BWH MEDICARE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.45","287.45","312.30","1 through 10","296.69","2001.02","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","307.93","307.93","307.93","1 through 10","296.69","2001.02","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1938.09","77","","3649.80","3649.80","3649.80","1 through 10","296.69","2001.02","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","307.93","307.93","307.93","1 through 10","296.69","2001.02","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","MEDICARE [2001]","HB BWH MEDICARE","312.27","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","312.30","312.30","312.30","488","296.69","2001.02","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","918.71","36.5","","883.64","773.80","910.49","1 through 10","296.69","2001.02","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","964.01","38.3","","954.43","954.43","954.43","1 through 10","296.69","2001.02","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","MOLINA [1014]","HB BWH MOLINA","306.03","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","619.60","619.60","619.60","1 through 10","296.69","2001.02","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","306.03","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","306.05","288.65","307.30","33","296.69","2001.02","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","306.03","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","561.43","561.43","561.43","1 through 10","296.69","2001.02","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1079.79","42.9","","1073.31","1073.31","1951.34","1 through 10","296.69","2001.02","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2517.00","1887.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","306.03","","APC Price ($312.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","306.05","287.46","307.31","249","296.69","2001.02","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","outpatient","","","2517.00","1887.75","AETNA [1001]","HB AMC AETNA HMO","1756.87","69.8","","1652.56","1166.80","1903.98","42","610.53","2056.89","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","outpatient","","","2517.00","1887.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1315.38","52.26","","1510.49","1510.49","1510.49","1 through 10","610.53","2056.89","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","outpatient","","","2517.00","1887.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2056.89","81.72","","1951.33","1073.31","1951.34","21","610.53","2056.89","percent of total billed charges",""
"Radiofreq Ablat Peritonl Mass","PX-76001922","CDM","49999","CPT","0761","RC","","","","both","","","11641.00","8730.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","9254.6","other","OPPS APC"
"Radiofreq Ablat Peritonl Mass","PX-76001922","CDM","49999","CPT","0761","RC","","","","both","","","11641.00","8730.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","9254.6","other","OPPS APC"
"Radiofreq Ablat Peritonl Mass","PX-76001922","CDM","49999","CPT","0761","RC","","","","both","","","11641.00","8730.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","1057.74","9254.6","other","OPPS APC"
"Radiofreq Ablat Peritonl Mass","PX-76001922","CDM","49999","CPT","0761","RC","","","","outpatient","","","11641.00","8730.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5820.50","50","","14640.00","14640.00","14640.00","1 through 10","5820.5","9603.83","percent of total billed charges",""
"Radiofreq Ablation Adrenal Tmr","PX-76001987","CDM","60699","CPT","0761","RC","","","","both","","","11641.00","8730.75","MEDICARE [2001]","HB BWH MEDICARE","6927.95","","APC Price ($6,927.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6928.65","6928.65","1 through 10","3608.71","9254.6","other","OPPS APC"
"Radiofreq Ablation Adrenal Tmr","PX-76001987","CDM","60699","CPT","0761","RC","","","","both","","","11641.00","8730.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4458.50","38.3","","5123.54","4829.42","5123.54","1 through 10","3608.71","9254.6","percent of total billed charges",""
"Radiofreq Ablation Adrenal Tmr","PX-76001987","CDM","60699","CPT","0761","RC","","","","outpatient","","","11641.00","8730.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","7048.63","60.55","","13483.00","13483.00","13483.00","1 through 10","5820.5","15696.44","percent of total billed charges",""
"Radiofreq Ablation Adrenal Tmr","PX-76001987","CDM","60699","CPT","0761","RC","","","","outpatient","","","11641.00","8730.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6078.93","52.22","","13483.00","12302.64","13483.00","1 through 10","5820.5","15696.44","percent of total billed charges",""
"Radiofreq Ablation Adrenal Tmr","PX-76001987","CDM","60699","CPT","0761","RC","","","","outpatient","","","11641.00","8730.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5820.50","50","","13483.00","13483.00","13483.00","1 through 10","5820.5","15696.44","percent of total billed charges",""
"Radiofreq Ablation Adrenal Tmr","PX-76001987","CDM","60699","CPT","0761","RC","","","","outpatient","","","11641.00","8730.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6111.53","52.5","","13483.00","3582.00","13483.00","1 through 10","5820.5","15696.44","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","96.73","104.56","14","99.34","307.67","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","130.69","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","38.42","38.42","38.42","1 through 10","99.34","307.67","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","307.67","79.5","","295.13","198.00","295.13","20","99.34","307.67","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","206.27","53.3","","198.00","189.38","295.13","1 through 10","99.34","307.67","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","97.59","102.89","1 through 10","99.34","307.67","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","ELDER SERVICES [1037]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","307.67","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","HUMANA [1012]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.47","102.47","102.47","1 through 10","99.34","307.67","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","251.55","65","","243.75","243.75","243.75","1 through 10","99.34","307.67","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","MEDICARE [2001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","99.18","104.56","84","99.34","307.67","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","141.26","36.5","","139.88","139.88","271.50","13","99.34","307.67","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","148.22","38.3","","146.63","142.50","439.89","28","99.34","307.67","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","297.99","77","","295.13","295.13","295.13","1 through 10","99.34","307.67","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","TRICARE [160005]","HB BWH TRICARE","99.34","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","104.56","104.56","104.56","1 through 10","99.34","307.67","other","Tricare OPPS"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","99.34","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","104.56","104.56","104.56","1 through 10","99.34","307.67","other","Tricare OPPS"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","308.67","102.47","308.67","1 through 10","99.34","307.67","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","86.25","86.25","86.25","1 through 10","99.34","307.67","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.02","42.9","","299.78","164.89","299.78","1 through 10","99.34","307.67","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.50","102.97","21","99.34","307.67","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","387.00","290.25","WELLPOINT [1015]","HB AMC WELLPOINT","285.53","73.78","","279.19","279.19","654.19","16","99.34","307.67","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","387.00","290.25","AETNA [1001]","HB AMC AETNA HMO","270.13","69.8","","253.88","179.25","253.88","1 through 10","128.23","316.26","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","387.00","290.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","202.25","52.26","","128.23","128.23","128.23","1 through 10","128.23","316.26","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","316.26","81.72","","299.78","164.89","299.78","11","128.23","316.26","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","546.00","409.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.97","63.97","63.97","1 through 10","119.97","434.07","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","546.00","409.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","434.07","79.5","","416.32","416.32","416.32","1 through 10","119.97","434.07","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","546.00","409.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","291.02","53.3","","279.31","279.31","279.31","1 through 10","119.97","434.07","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","546.00","409.50","ELDER SERVICES [1037]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","434.07","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","546.00","409.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","11","119.97","434.07","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","546.00","409.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","199.29","36.5","","167.69","167.69","167.69","1 through 10","119.97","434.07","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","546.00","409.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","209.12","38.3","","206.84","206.84","206.84","1 through 10","119.97","434.07","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","546.00","409.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.17","124.17","124.17","1 through 10","119.97","434.07","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","546.00","409.50","WELLPOINT [1015]","HB AMC WELLPOINT","402.84","73.78","","393.84","393.84","393.84","1 through 10","119.97","434.07","percent of total billed charges",""
"Radiologic Exam Abdomen 3+ Views","PX-32000438","CDM","74021","CPT","0320","RC","","","","both","","","596.00","447.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","473.82","other","OPPS APC"
"Radiologic Exam Abdomen 3+ Views","PX-32000438","CDM","74021","CPT","0320","RC","","","","both","","","596.00","447.00","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","473.82","other","Tricare OPPS"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","97.59","102.89","385","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","338.90","71.8","","986.52","77.53","986.52","17","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","309.63","65.6","","107.59","107.59","357.24","1 through 10","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","306.80","65","","725.46","297.70","1209.10","26","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","330.40","70","","201.38","132.89","366.40","19","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICAID REPLACEMENT","130.69","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","102.77","102.77","102.77","1 through 10","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","130.69","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","46.95","10.00","104.56","22","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","CHAMPVA [160001]","HB BWH TRICARE","99.34","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","104.56","104.56","104.56","1 through 10","99.34","375.24","other","Tricare OPPS"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","375.24","79.5","","360.45","0.24","360.45","366","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","251.58","53.3","","241.82","241.82","360.45","146","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","86.64","102.89","85","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","ELDER SERVICES [1037]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","97.20","104.56","14","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","FALLON HEALTH [1008]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","307.41","97.20","512.35","37","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","458.00","99.16","458.00","1 through 10","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","198.36","97.89","206.14","1 through 10","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","363.44","77","","1057.98","352.66","1057.98","12","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","HUMANA [1012]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.10","102.47","104.56","26","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","306.80","65","","297.70","242.74","9150.38","1 through 10","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","375.24","79.5","","294.35","286.76","360.45","1 through 10","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.78","102.47","102.78","13","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","MEDICARE [2001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","313.68","3309","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","146.32","31","","141.52","141.52","424.56","16","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","172.28","36.5","","170.83","145.19","497.40","163","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","180.78","38.3","","179.08","174.04","358.16","397","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.47","97.20","102.77","124","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","MOLINA [1014]","HB BWH MOLINA","102.46","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.45","198.36","208.37","22","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","363.44","77","","442.00","139.49","458.00","1 through 10","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","TRICARE [160005]","HB BWH TRICARE","99.34","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","104.56","99.33","104.56","20","99.34","375.24","other","Tricare OPPS"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","99.34","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","104.56","104.56","104.56","1 through 10","99.34","375.24","other","Tricare OPPS"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","103.07","102.47","308.61","283","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","105.34","105.34","210.68","18","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.49","42.9","","208.39","201.38","366.13","13","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","677","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.49","42.9","","201.38","201.38","366.13","1 through 10","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","WELLPOINT [1015]","HB AMC WELLPOINT","348.24","73.78","","340.98","340.98","798.98","205","99.34","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","WELLSENSE [1003]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","105.61","105.61","105.61","1 through 10","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","472.00","354.00","WELLSENSE NH [1050]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.07","104.56","1 through 10","99.34","375.24","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","inpatient","","","472.00","354.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.04","78.61","","366.13","366.13","366.13","1 through 10","261.02","375.24","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","472.00","354.00","AETNA [1001]","HB AMC AETNA HMO","329.46","69.8","","310.07","218.92","310.07","24","128.23","385.72","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","472.00","354.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","246.67","52.26","","283.42","283.41","283.42","1 through 10","128.23","385.72","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","472.00","354.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","379.49","80.4","","229.00","229.00","357.24","1 through 10","128.23","385.72","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","472.00","354.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","385.72","81.72","","366.13","340.38","366.13","1 through 10","128.23","385.72","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","472.00","354.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","385.72","81.72","","201.38","102.97","201.38","13","128.23","385.72","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","472.00","354.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","385.72","81.72","","366.13","201.38","366.13","179","128.23","385.72","percent of total billed charges",""
"Radiologic Exam Chest 3 Views","PX-32000441","CDM","71047","CPT","0324","RC","","","","both","","","567.00","425.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","450.77","79.5","","432.85","432.85","432.85","1 through 10","99.34","450.77","percent of total billed charges",""
"Radiologic Exam Chest 3 Views","PX-32000441","CDM","71047","CPT","0324","RC","","","","both","","","567.00","425.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","217.16","38.3","","215.05","215.05","215.05","1 through 10","99.34","450.77","percent of total billed charges",""
"Radiologic Exam Chest 4+ Views","PX-32000442","CDM","71048","CPT","0324","RC","","","","both","","","684.00","513.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","364.57","53.3","","350.06","350.06","350.06","1 through 10","119.97","543.78","percent of total billed charges",""
"Radiologic Exam Chest 4+ Views","PX-32000442","CDM","71048","CPT","0324","RC","","","","both","","","684.00","513.00","ELDER SERVICES [1037]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","119.97","543.78","other","OPPS APC"
"Radiologic Exam Chest 4+ Views","PX-32000442","CDM","71048","CPT","0324","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.97","38.3","","259.23","259.23","259.23","1 through 10","119.97","543.78","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","66.10","174.11","19","99.34","297.33","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","243.10","65","","707.85","707.85","707.85","1 through 10","99.34","297.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.80","70","","239.58","239.58","239.58","1 through 10","99.34","297.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","130.69","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","66.18","66.18","66.18","1 through 10","99.34","297.33","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","297.33","79.5","","343.01","257.11","953.84","43","99.34","297.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","199.34","53.3","","191.66","191.66","653.13","15","99.34","297.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","97.20","86.64","102.89","1 through 10","99.34","297.33","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","ELDER SERVICES [1037]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.00","363.00","363.00","1 through 10","99.34","297.33","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","FALLON HEALTH [1008]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","522.80","522.80","522.80","1 through 10","99.34","297.33","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","287.98","77","","279.51","279.51","279.51","1 through 10","99.34","297.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","HUMANA [1012]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.47","102.47","102.47","1 through 10","99.34","297.33","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","243.10","65","","235.95","235.95","235.95","1 through 10","99.34","297.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.47","102.47","102.47","1 through 10","99.34","297.33","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","MEDICARE [2001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","99.18","104.56","124","99.34","297.33","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.94","31","","112.17","112.17","112.17","1 through 10","99.34","297.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.51","36.5","","135.40","115.07","406.20","20","99.34","297.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","143.24","38.3","","141.93","137.94","413.82","28","99.34","297.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","97.20","97.20","97.20","1 through 10","99.34","297.33","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","205.14","102.47","307.41","20","99.34","297.33","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","83.49","83.49","250.47","13","99.34","297.33","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.45","42.9","","290.18","290.18","290.18","15","99.34","297.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.20","102.97","25","99.34","297.33","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","374.00","280.50","WELLPOINT [1015]","HB AMC WELLPOINT","275.94","73.78","","270.25","270.25","633.25","24","99.34","297.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","374.00","280.50","AETNA [1001]","HB AMC AETNA HMO","261.05","69.8","","245.75","161.63","491.50","1 through 10","128.23","305.63","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","374.00","280.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","305.63","81.72","","290.18","290.18","290.18","1 through 10","128.23","305.63","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","374.00","280.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","305.63","81.72","","159.61","159.61","363.00","1 through 10","128.23","305.63","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","374.00","280.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","305.63","81.72","","290.18","159.61","290.18","37","128.23","305.63","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","217.73","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","217.74","217.54","217.74","12","200.84","752.07","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","197.32","208.03","13","200.84","752.07","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","614.90","65","","1788.15","596.05","1788.15","1 through 10","200.84","752.07","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","264.24","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","29.50","29.50","29.50","1 through 10","200.84","752.07","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","752.07","79.5","","721.68","484.18","721.68","1 through 10","200.84","752.07","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","CIGNA [1006]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","209.43","209.43","209.43","1 through 10","200.84","752.07","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","504.22","53.3","","484.18","484.18","721.68","1 through 10","200.84","752.07","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","752.07","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","ELDER SERVICES [1037]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","752.07","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","728.42","77","","706.09","706.09","706.09","1 through 10","200.84","752.07","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","HUMANA [1012]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.45","207.18","209.34","1 through 10","200.84","752.07","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","614.90","65","","486.01","486.01","486.01","1 through 10","200.84","752.07","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.82","207.82","207.82","1 through 10","200.84","752.07","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","200","200.84","752.07","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","345.29","36.5","","342.04","290.69","342.04","13","200.84","752.07","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","362.32","38.3","","358.55","358.55","1075.65","28","200.84","752.07","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.48","196.82","207.48","1 through 10","200.84","752.07","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","TRICARE [160005]","HB BWH TRICARE","200.84","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","200.84","200.84","200.84","1 through 10","200.84","752.07","other","Tricare OPPS"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","207.18","625.34","16","200.84","752.07","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.69","196.82","207.69","24","200.84","752.07","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","946.00","709.50","WELLPOINT [1015]","HB AMC WELLPOINT","697.96","73.78","","682.71","682.71","682.71","1 through 10","200.84","752.07","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","946.00","709.50","AETNA [1001]","HB AMC AETNA HMO","660.31","69.8","","620.81","438.33","715.26","1 through 10","359.46","905.81","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","946.00","709.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","773.07","81.72","","733.05","403.20","733.05","16","359.46","905.81","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study|REDUCED SERVICES","PX-32000447","CDM","74221","CPT","0320","RC","","","52","both","","","946.00","709.50","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","105.70","105.70","105.70","1 through 10","200.84","264.24","other","OPPS APC"
"Radiologic Examination Femur Minimum 2 Views","PX-32000429","CDM","73552","CPT","0320","RC","","","","both","","","348.00","261.00","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","337.00","337.00","337.00","1 through 10","99.34","276.66","other","OPPS APC"
"Radiologic Examination Femur Minimum 2 Views","PX-32000429","CDM","73552","CPT","0320","RC","","","","both","","","348.00","261.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","102.77","1 through 10","99.34","276.66","other","OPPS APC"
"Radiologic Examination Femur Minimum 2 Views","PX-32000429","CDM","73552","CPT","0320","RC","","","","outpatient","","","348.00","261.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","284.39","81.72","","118.26","118.26","167.49","1 through 10","128.23","284.39","percent of total billed charges",""
"Radiologic Small Intestine Follow-Through Study","PX-32000448","CDM","74248","CPT","0320","RC","","","","both","","","772.00","579.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","411.48","53.3","","395.47","378.25","395.47","1 through 10","239.32","613.74","percent of total billed charges",""
"Radiologic Small Intestine Follow-Through Study","PX-32000448","CDM","74248","CPT","0320","RC","","","","both","","","772.00","579.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","281.78","36.5","","813.42","279.38","813.42","1 through 10","239.32","613.74","percent of total billed charges",""
"Radiologic Small Intestine Follow-Through Study","PX-32000448","CDM","74248","CPT","0320","RC","","","","both","","","772.00","579.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","295.68","38.3","","284.62","284.62","284.62","1 through 10","239.32","613.74","percent of total billed charges",""
"Radiologic Small Intestine Follow-Through Study","PX-32000448","CDM","74248","CPT","0320","RC","","","","both","","","772.00","579.00","WELLPOINT [1015]","HB AMC WELLPOINT","569.58","73.78","","557.63","557.63","557.63","1 through 10","239.32","613.74","percent of total billed charges",""
"Radiotherapy","849","MS-DRG","","","","","","","","inpatient","","","105783.61","79337.71","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","32457.42","","Case rate ($32,457.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,133.45, add-ons for qualifying new technology services are included. If operating cost exceeds $75,777.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,620.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $29,897.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,753.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,180.22. The transfer capital threshold is the transfer adjustment factor * $2,180.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24612.22","24612.22","24612.22","1 through 10","24594.28","40309.5701","other","Inpatient DRG"
"Radiotherapy,EXTREME","692","DRG","","","","","","","","inpatient","","","212676.96","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","104830.12","","Standard inlier is a Case rate ($104,830.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $93,169, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,881.27) for the length of stay and the standard reimbursement.","95556.47","95556.47","95556.47","1 through 10","11656.7","254946.65","case rate",""
"Radiotherapy,EXTREME","692","DRG","","","","","","","","inpatient","","","212676.96","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","117857.30","","Standard inlier is a Case rate ($117,857.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $93,169, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,728.87) for the length of stay and the standard reimbursement.","49639.45","49639.45","71653.62","1 through 10","11656.7","254946.65","case rate",""
"Radiotherapy,MINOR","692","DRG","","","","","","","","inpatient","","","99739.70","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11656.70","","Case rate ($12,888.49). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,318.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12885.33","12885.33","12885.33","1 through 10","11656.7","254946.65","case rate",""
"RADIUS IMPLANT SZ 1 RT","SUP-ITM-10139573","CDM","C1776","HCPCS","0278","RC","","","","both","","","19513.98","14635.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","10198.01","52.26","","1113.10","1113.10","1113.10","1 through 10","6049.33","15513.61","percent of total billed charges",""
"RADIUS IMPLANT SZ 1 RT","SUP-ITM-10139573","CDM","C1776","HCPCS","0278","RC","","","","both","","","19513.98","14635.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15513.61","79.5","","1293.60","1148.53","1603.80","1 through 10","6049.33","15513.61","percent of total billed charges",""
"RADIUS IMPLANT SZ 1 RT","SUP-ITM-10139573","CDM","C1776","HCPCS","0278","RC","","","","both","","","19513.98","14635.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7122.60","36.5","","1023.42","771.29","2068.67","33","6049.33","15513.61","percent of total billed charges",""
"RADIUS IMPLANT SZ 1 RT","SUP-ITM-10139573","CDM","C1776","HCPCS","0278","RC","","","","both","","","19513.98","14635.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7473.85","38.3","","850.52","759.78","1211.25","66","6049.33","15513.61","percent of total billed charges",""
"RADIUS IMPLANT SZ 1 RT","SUP-ITM-10139573","CDM","C1776","HCPCS","0278","RC","","","","both","","","19513.98","14635.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8371.50","42.9","","2548.09","2548.09","2548.09","1 through 10","6049.33","15513.61","percent of total billed charges",""
"RADIUS IMPLANT SZ 1 RT","SUP-ITM-10139573","CDM","C1776","HCPCS","0278","RC","","","","both","","","19513.98","14635.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8371.50","42.9","","956.46","956.46","956.46","1 through 10","6049.33","15513.61","percent of total billed charges",""
"RADIUS IMPLANT SZ 1 RT","SUP-ITM-10139573","CDM","C1776","HCPCS","0278","RC","","","","both","","","19513.98","14635.48","WELLPOINT [1015]","HB AMC WELLPOINT","14397.41","73.78","","2344.73","1619.47","2530.35","16","6049.33","15513.61","percent of total billed charges",""
"RADIUS IMPLANT SZ 1 RT","SUP-ITM-10139573","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","19513.98","14635.48","AETNA [1001]","HB AMC AETNA HMO","13620.76","69.8","","1523.63","988.41","4330.26","39","10198.01","15946.82","percent of total billed charges",""
"RADIUS IMPLANT SZ 1 RT","SUP-ITM-10139573","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","19513.98","14635.48","AETNA [1001]","HB AMC AETNA PPO","15689.24","80.4","","1670.25","1670.25","1670.25","1 through 10","10198.01","15946.82","percent of total billed charges",""
"RADIUS IMPLANT SZ 1 RT","SUP-ITM-10139573","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","19513.98","14635.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","10198.01","52.26","","1113.10","1113.10","1113.10","1 through 10","10198.01","15946.82","percent of total billed charges",""
"RADIUS IMPLANT SZ 1 RT","SUP-ITM-10139573","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","19513.98","14635.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15946.82","81.72","","1738.90","1484.65","2716.94","38","10198.01","15946.82","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.65","1822.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1932.37","79.5","","800.18","480.96","1887.97","195","753.5","1932.37","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.65","1822.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1295.54","53.3","","813.12","216.42","1444.50","81","753.5","1932.37","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.65","1822.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","753.50","31","","432.60","432.60","432.60","1 through 10","753.5","1932.37","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.65","1822.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","887.19","36.5","","148.37","54.89","631.39","94","753.5","1932.37","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.65","1822.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","930.94","38.3","","279.30","91.72","1116.77","266","753.5","1932.37","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.65","1822.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1042.75","42.9","","731.00","63.70","731.00","1 through 10","753.5","1932.37","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.65","1822.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1042.75","42.9","","384.74","384.74","384.74","1 through 10","753.5","1932.37","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.65","1822.99","WELLPOINT [1015]","HB AMC WELLPOINT","1793.33","73.78","","286.63","119.22","1107.45","105","753.5","1932.37","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.65","1822.99","AETNA [1001]","HB AMC AETNA HMO","1696.59","69.8","","675.31","184.75","1721.50","286","1270.26","1986.33","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.65","1822.99","AETNA [1001]","HB AMC AETNA PPO","1954.24","80.4","","1261.44","103.12","1514.10","21","1270.26","1986.33","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.65","1822.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1954.24","80.4","","1365.00","1365.00","1365.00","1 through 10","1270.26","1986.33","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.65","1822.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1986.33","81.72","","5157.68","5157.68","5157.68","1 through 10","1270.26","1986.33","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.65","1822.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1986.33","81.72","","431.26","71.26","1459.57","88","1270.26","1986.33","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1878.24","1408.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1493.20","79.5","","800.18","480.96","1887.97","195","582.25","1493.2","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1878.24","1408.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1001.10","53.3","","813.12","216.42","1444.50","81","582.25","1493.2","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1878.24","1408.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","582.25","31","","432.60","432.60","432.60","1 through 10","582.25","1493.2","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1878.24","1408.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","685.56","36.5","","148.37","54.89","631.39","94","582.25","1493.2","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1878.24","1408.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","719.37","38.3","","279.30","91.72","1116.77","266","582.25","1493.2","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1878.24","1408.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","805.76","42.9","","731.00","63.70","731.00","1 through 10","582.25","1493.2","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1878.24","1408.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","805.76","42.9","","384.74","384.74","384.74","1 through 10","582.25","1493.2","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1878.24","1408.68","WELLPOINT [1015]","HB AMC WELLPOINT","1385.77","73.78","","286.63","119.22","1107.45","105","582.25","1493.2","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1878.24","1408.68","AETNA [1001]","HB AMC AETNA HMO","1311.01","69.8","","675.31","184.75","1721.50","286","981.57","1534.9","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1878.24","1408.68","AETNA [1001]","HB AMC AETNA PPO","1510.10","80.4","","1261.44","103.12","1514.10","21","981.57","1534.9","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1878.24","1408.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1510.10","80.4","","1365.00","1365.00","1365.00","1 through 10","981.57","1534.9","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1878.24","1408.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1534.90","81.72","","5157.68","5157.68","5157.68","1 through 10","981.57","1534.9","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1878.24","1408.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1534.90","81.72","","431.26","71.26","1459.57","88","981.57","1534.9","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1846.67","1385.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1468.10","79.5","","800.18","480.96","1887.97","195","572.47","1468.1","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1846.67","1385.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","984.28","53.3","","813.12","216.42","1444.50","81","572.47","1468.1","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1846.67","1385.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","572.47","31","","432.60","432.60","432.60","1 through 10","572.47","1468.1","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1846.67","1385.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","674.03","36.5","","148.37","54.89","631.39","94","572.47","1468.1","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1846.67","1385.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","707.27","38.3","","279.30","91.72","1116.77","266","572.47","1468.1","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1846.67","1385.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","792.22","42.9","","731.00","63.70","731.00","1 through 10","572.47","1468.1","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1846.67","1385.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","792.22","42.9","","384.74","384.74","384.74","1 through 10","572.47","1468.1","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1846.67","1385.00","WELLPOINT [1015]","HB AMC WELLPOINT","1362.47","73.78","","286.63","119.22","1107.45","105","572.47","1468.1","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1846.67","1385.00","AETNA [1001]","HB AMC AETNA HMO","1288.98","69.8","","675.31","184.75","1721.50","286","965.07","1509.1","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1846.67","1385.00","AETNA [1001]","HB AMC AETNA PPO","1484.72","80.4","","1261.44","103.12","1514.10","21","965.07","1509.1","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1846.67","1385.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1484.72","80.4","","1365.00","1365.00","1365.00","1 through 10","965.07","1509.1","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1846.67","1385.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1509.10","81.72","","5157.68","5157.68","5157.68","1 through 10","965.07","1509.1","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1846.67","1385.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1509.10","81.72","","431.26","71.26","1459.57","88","965.07","1509.1","percent of total billed charges",""
"RADIUS PLATE 2.4X52MM 3 HOLE HD 4 SHAFT 20DEG LCP TI DISTAL PLUS L SHAPE","SUP-ITM-10013597","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.33","1654.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1754.03","79.5","","800.18","480.96","1887.97","195","683.96","1754.03","percent of total billed charges",""
"RADIUS PLATE 2.4X52MM 3 HOLE HD 4 SHAFT 20DEG LCP TI DISTAL PLUS L SHAPE","SUP-ITM-10013597","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.33","1654.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1175.97","53.3","","813.12","216.42","1444.50","81","683.96","1754.03","percent of total billed charges",""
"RADIUS PLATE 2.4X52MM 3 HOLE HD 4 SHAFT 20DEG LCP TI DISTAL PLUS L SHAPE","SUP-ITM-10013597","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.33","1654.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","683.96","31","","432.60","432.60","432.60","1 through 10","683.96","1754.03","percent of total billed charges",""
"RADIUS PLATE 2.4X52MM 3 HOLE HD 4 SHAFT 20DEG LCP TI DISTAL PLUS L SHAPE","SUP-ITM-10013597","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.33","1654.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","805.31","36.5","","148.37","54.89","631.39","94","683.96","1754.03","percent of total billed charges",""
"RADIUS PLATE 2.4X52MM 3 HOLE HD 4 SHAFT 20DEG LCP TI DISTAL PLUS L SHAPE","SUP-ITM-10013597","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.33","1654.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","845.02","38.3","","279.30","91.72","1116.77","266","683.96","1754.03","percent of total billed charges",""
"RADIUS PLATE 2.4X52MM 3 HOLE HD 4 SHAFT 20DEG LCP TI DISTAL PLUS L SHAPE","SUP-ITM-10013597","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.33","1654.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","946.52","42.9","","731.00","63.70","731.00","1 through 10","683.96","1754.03","percent of total billed charges",""
"RADIUS PLATE 2.4X52MM 3 HOLE HD 4 SHAFT 20DEG LCP TI DISTAL PLUS L SHAPE","SUP-ITM-10013597","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.33","1654.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","946.52","42.9","","384.74","384.74","384.74","1 through 10","683.96","1754.03","percent of total billed charges",""
"RADIUS PLATE 2.4X52MM 3 HOLE HD 4 SHAFT 20DEG LCP TI DISTAL PLUS L SHAPE","SUP-ITM-10013597","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.33","1654.75","WELLPOINT [1015]","HB AMC WELLPOINT","1627.83","73.78","","286.63","119.22","1107.45","105","683.96","1754.03","percent of total billed charges",""
"RADIUS PLATE 2.4X52MM 3 HOLE HD 4 SHAFT 20DEG LCP TI DISTAL PLUS L SHAPE","SUP-ITM-10013597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2206.33","1654.75","AETNA [1001]","HB AMC AETNA HMO","1540.02","69.8","","675.31","184.75","1721.50","286","1153.03","1803.01","percent of total billed charges",""
"RADIUS PLATE 2.4X52MM 3 HOLE HD 4 SHAFT 20DEG LCP TI DISTAL PLUS L SHAPE","SUP-ITM-10013597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2206.33","1654.75","AETNA [1001]","HB AMC AETNA PPO","1773.89","80.4","","1261.44","103.12","1514.10","21","1153.03","1803.01","percent of total billed charges",""
"RADIUS PLATE 2.4X52MM 3 HOLE HD 4 SHAFT 20DEG LCP TI DISTAL PLUS L SHAPE","SUP-ITM-10013597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2206.33","1654.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1773.89","80.4","","1365.00","1365.00","1365.00","1 through 10","1153.03","1803.01","percent of total billed charges",""
"RADIUS PLATE 2.4X52MM 3 HOLE HD 4 SHAFT 20DEG LCP TI DISTAL PLUS L SHAPE","SUP-ITM-10013597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2206.33","1654.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1803.01","81.72","","5157.68","5157.68","5157.68","1 through 10","1153.03","1803.01","percent of total billed charges",""
"RADIUS PLATE 2.4X52MM 3 HOLE HD 4 SHAFT 20DEG LCP TI DISTAL PLUS L SHAPE","SUP-ITM-10013597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2206.33","1654.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1803.01","81.72","","431.26","71.26","1459.57","88","1153.03","1803.01","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2527.04","1895.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2009.00","79.5","","800.18","480.96","1887.97","195","783.38","2009","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2527.04","1895.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1346.91","53.3","","813.12","216.42","1444.50","81","783.38","2009","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2527.04","1895.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","783.38","31","","432.60","432.60","432.60","1 through 10","783.38","2009","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2527.04","1895.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","922.37","36.5","","148.37","54.89","631.39","94","783.38","2009","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2527.04","1895.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","967.86","38.3","","279.30","91.72","1116.77","266","783.38","2009","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2527.04","1895.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1084.10","42.9","","731.00","63.70","731.00","1 through 10","783.38","2009","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2527.04","1895.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1084.10","42.9","","384.74","384.74","384.74","1 through 10","783.38","2009","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2527.04","1895.28","WELLPOINT [1015]","HB AMC WELLPOINT","1864.45","73.78","","286.63","119.22","1107.45","105","783.38","2009","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2527.04","1895.28","AETNA [1001]","HB AMC AETNA HMO","1763.87","69.8","","675.31","184.75","1721.50","286","1320.63","2065.1","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2527.04","1895.28","AETNA [1001]","HB AMC AETNA PPO","2031.74","80.4","","1261.44","103.12","1514.10","21","1320.63","2065.1","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2527.04","1895.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2031.74","80.4","","1365.00","1365.00","1365.00","1 through 10","1320.63","2065.1","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2527.04","1895.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2065.10","81.72","","5157.68","5157.68","5157.68","1 through 10","1320.63","2065.1","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2527.04","1895.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2065.10","81.72","","431.26","71.26","1459.57","88","1320.63","2065.1","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1845.38","1384.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1467.08","79.5","","800.18","480.96","1887.97","195","572.07","1467.08","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1845.38","1384.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","983.59","53.3","","813.12","216.42","1444.50","81","572.07","1467.08","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1845.38","1384.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","572.07","31","","432.60","432.60","432.60","1 through 10","572.07","1467.08","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1845.38","1384.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","673.56","36.5","","148.37","54.89","631.39","94","572.07","1467.08","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1845.38","1384.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","706.78","38.3","","279.30","91.72","1116.77","266","572.07","1467.08","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1845.38","1384.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","791.67","42.9","","731.00","63.70","731.00","1 through 10","572.07","1467.08","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1845.38","1384.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","791.67","42.9","","384.74","384.74","384.74","1 through 10","572.07","1467.08","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1845.38","1384.03","WELLPOINT [1015]","HB AMC WELLPOINT","1361.52","73.78","","286.63","119.22","1107.45","105","572.07","1467.08","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1845.38","1384.03","AETNA [1001]","HB AMC AETNA HMO","1288.08","69.8","","675.31","184.75","1721.50","286","964.4","1508.04","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1845.38","1384.03","AETNA [1001]","HB AMC AETNA PPO","1483.69","80.4","","1261.44","103.12","1514.10","21","964.4","1508.04","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1845.38","1384.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1483.69","80.4","","1365.00","1365.00","1365.00","1 through 10","964.4","1508.04","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1845.38","1384.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1508.04","81.72","","5157.68","5157.68","5157.68","1 through 10","964.4","1508.04","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1845.38","1384.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1508.04","81.72","","431.26","71.26","1459.57","88","964.4","1508.04","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.09","1486.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1575.76","79.5","","800.18","480.96","1887.97","195","614.45","1575.76","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.09","1486.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1056.45","53.3","","813.12","216.42","1444.50","81","614.45","1575.76","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.09","1486.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","614.45","31","","432.60","432.60","432.60","1 through 10","614.45","1575.76","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.09","1486.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","723.46","36.5","","148.37","54.89","631.39","94","614.45","1575.76","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.09","1486.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","759.14","38.3","","279.30","91.72","1116.77","266","614.45","1575.76","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.09","1486.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","850.32","42.9","","731.00","63.70","731.00","1 through 10","614.45","1575.76","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.09","1486.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","850.32","42.9","","384.74","384.74","384.74","1 through 10","614.45","1575.76","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1982.09","1486.57","WELLPOINT [1015]","HB AMC WELLPOINT","1462.39","73.78","","286.63","119.22","1107.45","105","614.45","1575.76","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1982.09","1486.57","AETNA [1001]","HB AMC AETNA HMO","1383.50","69.8","","675.31","184.75","1721.50","286","1035.84","1619.76","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1982.09","1486.57","AETNA [1001]","HB AMC AETNA PPO","1593.60","80.4","","1261.44","103.12","1514.10","21","1035.84","1619.76","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1982.09","1486.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1593.60","80.4","","1365.00","1365.00","1365.00","1 through 10","1035.84","1619.76","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1982.09","1486.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1619.76","81.72","","5157.68","5157.68","5157.68","1 through 10","1035.84","1619.76","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1982.09","1486.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1619.76","81.72","","431.26","71.26","1459.57","88","1035.84","1619.76","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","2108.96","1581.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1676.62","79.5","","800.18","480.96","1887.97","195","653.78","1676.62","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","2108.96","1581.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1124.08","53.3","","813.12","216.42","1444.50","81","653.78","1676.62","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","2108.96","1581.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","653.78","31","","432.60","432.60","432.60","1 through 10","653.78","1676.62","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","2108.96","1581.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","769.77","36.5","","148.37","54.89","631.39","94","653.78","1676.62","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","2108.96","1581.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","807.73","38.3","","279.30","91.72","1116.77","266","653.78","1676.62","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","2108.96","1581.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","904.74","42.9","","731.00","63.70","731.00","1 through 10","653.78","1676.62","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","2108.96","1581.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","904.74","42.9","","384.74","384.74","384.74","1 through 10","653.78","1676.62","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","2108.96","1581.72","WELLPOINT [1015]","HB AMC WELLPOINT","1555.99","73.78","","286.63","119.22","1107.45","105","653.78","1676.62","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2108.96","1581.72","AETNA [1001]","HB AMC AETNA HMO","1472.05","69.8","","675.31","184.75","1721.50","286","1102.14","1723.44","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2108.96","1581.72","AETNA [1001]","HB AMC AETNA PPO","1695.60","80.4","","1261.44","103.12","1514.10","21","1102.14","1723.44","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2108.96","1581.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1695.60","80.4","","1365.00","1365.00","1365.00","1 through 10","1102.14","1723.44","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2108.96","1581.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1723.44","81.72","","5157.68","5157.68","5157.68","1 through 10","1102.14","1723.44","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2108.96","1581.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1723.44","81.72","","431.26","71.26","1459.57","88","1102.14","1723.44","percent of total billed charges",""
"RADIUS PLATE 212MM 13 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10030097","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.67","3311.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3510.46","79.5","","800.18","480.96","1887.97","195","1368.86","3510.46","percent of total billed charges",""
"RADIUS PLATE 212MM 13 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10030097","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.67","3311.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2353.55","53.3","","813.12","216.42","1444.50","81","1368.86","3510.46","percent of total billed charges",""
"RADIUS PLATE 212MM 13 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10030097","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.67","3311.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1368.86","31","","432.60","432.60","432.60","1 through 10","1368.86","3510.46","percent of total billed charges",""
"RADIUS PLATE 212MM 13 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10030097","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.67","3311.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1611.72","36.5","","148.37","54.89","631.39","94","1368.86","3510.46","percent of total billed charges",""
"RADIUS PLATE 212MM 13 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10030097","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.67","3311.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1691.20","38.3","","279.30","91.72","1116.77","266","1368.86","3510.46","percent of total billed charges",""
"RADIUS PLATE 212MM 13 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10030097","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.67","3311.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1894.32","42.9","","731.00","63.70","731.00","1 through 10","1368.86","3510.46","percent of total billed charges",""
"RADIUS PLATE 212MM 13 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10030097","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.67","3311.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1894.32","42.9","","384.74","384.74","384.74","1 through 10","1368.86","3510.46","percent of total billed charges",""
"RADIUS PLATE 212MM 13 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10030097","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.67","3311.75","WELLPOINT [1015]","HB AMC WELLPOINT","3257.88","73.78","","286.63","119.22","1107.45","105","1368.86","3510.46","percent of total billed charges",""
"RADIUS PLATE 212MM 13 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10030097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.67","3311.75","AETNA [1001]","HB AMC AETNA HMO","3082.14","69.8","","675.31","184.75","1721.50","286","2307.63","3608.49","percent of total billed charges",""
"RADIUS PLATE 212MM 13 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10030097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.67","3311.75","AETNA [1001]","HB AMC AETNA PPO","3550.20","80.4","","1261.44","103.12","1514.10","21","2307.63","3608.49","percent of total billed charges",""
"RADIUS PLATE 212MM 13 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10030097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.67","3311.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3550.20","80.4","","1365.00","1365.00","1365.00","1 through 10","2307.63","3608.49","percent of total billed charges",""
"RADIUS PLATE 212MM 13 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10030097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.67","3311.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3608.49","81.72","","5157.68","5157.68","5157.68","1 through 10","2307.63","3608.49","percent of total billed charges",""
"RADIUS PLATE 212MM 13 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10030097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.67","3311.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3608.49","81.72","","431.26","71.26","1459.57","88","2307.63","3608.49","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1776.06","52.26","","1113.10","1113.10","1113.10","1 through 10","1053.54","2701.81","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2701.81","79.5","","1293.60","1148.53","1603.80","1 through 10","1053.54","2701.81","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1240.45","36.5","","1023.42","771.29","2068.67","33","1053.54","2701.81","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1301.63","38.3","","850.52","759.78","1211.25","66","1053.54","2701.81","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1457.96","42.9","","2548.09","2548.09","2548.09","1 through 10","1053.54","2701.81","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1457.96","42.9","","956.46","956.46","956.46","1 through 10","1053.54","2701.81","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3398.50","2548.87","WELLPOINT [1015]","HB AMC WELLPOINT","2507.41","73.78","","2344.73","1619.47","2530.35","16","1053.54","2701.81","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3398.50","2548.87","AETNA [1001]","HB AMC AETNA HMO","2372.15","69.8","","1523.63","988.41","4330.26","39","1776.06","2777.25","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3398.50","2548.87","AETNA [1001]","HB AMC AETNA PPO","2732.39","80.4","","1670.25","1670.25","1670.25","1 through 10","1776.06","2777.25","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3398.50","2548.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1776.06","52.26","","1113.10","1113.10","1113.10","1 through 10","1776.06","2777.25","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3398.50","2548.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2777.25","81.72","","1738.90","1484.65","2716.94","38","1776.06","2777.25","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3444.00","2583.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2737.98","79.5","","800.18","480.96","1887.97","195","1067.64","2737.98","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3444.00","2583.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1835.65","53.3","","813.12","216.42","1444.50","81","1067.64","2737.98","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3444.00","2583.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1067.64","31","","432.60","432.60","432.60","1 through 10","1067.64","2737.98","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3444.00","2583.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1257.06","36.5","","148.37","54.89","631.39","94","1067.64","2737.98","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3444.00","2583.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1319.05","38.3","","279.30","91.72","1116.77","266","1067.64","2737.98","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3444.00","2583.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1477.48","42.9","","731.00","63.70","731.00","1 through 10","1067.64","2737.98","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3444.00","2583.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1477.48","42.9","","384.74","384.74","384.74","1 through 10","1067.64","2737.98","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","3444.00","2583.00","WELLPOINT [1015]","HB AMC WELLPOINT","2540.98","73.78","","286.63","119.22","1107.45","105","1067.64","2737.98","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3444.00","2583.00","AETNA [1001]","HB AMC AETNA HMO","2403.91","69.8","","675.31","184.75","1721.50","286","1799.83","2814.44","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3444.00","2583.00","AETNA [1001]","HB AMC AETNA PPO","2768.98","80.4","","1261.44","103.12","1514.10","21","1799.83","2814.44","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3444.00","2583.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2768.98","80.4","","1365.00","1365.00","1365.00","1 through 10","1799.83","2814.44","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3444.00","2583.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2814.44","81.72","","5157.68","5157.68","5157.68","1 through 10","1799.83","2814.44","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3444.00","2583.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2814.44","81.72","","431.26","71.26","1459.57","88","1799.83","2814.44","percent of total billed charges",""
"RADIUS PLATE 7 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT STANDARD","SUP-ITM-10130528","CDM","C1776","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1995.55","52.26","","1113.10","1113.10","1113.10","1 through 10","1183.74","3035.71","percent of total billed charges",""
"RADIUS PLATE 7 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT STANDARD","SUP-ITM-10130528","CDM","C1776","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3035.71","79.5","","1293.60","1148.53","1603.80","1 through 10","1183.74","3035.71","percent of total billed charges",""
"RADIUS PLATE 7 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT STANDARD","SUP-ITM-10130528","CDM","C1776","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1393.75","36.5","","1023.42","771.29","2068.67","33","1183.74","3035.71","percent of total billed charges",""
"RADIUS PLATE 7 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT STANDARD","SUP-ITM-10130528","CDM","C1776","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1462.49","38.3","","850.52","759.78","1211.25","66","1183.74","3035.71","percent of total billed charges",""
"RADIUS PLATE 7 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT STANDARD","SUP-ITM-10130528","CDM","C1776","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1638.14","42.9","","2548.09","2548.09","2548.09","1 through 10","1183.74","3035.71","percent of total billed charges",""
"RADIUS PLATE 7 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT STANDARD","SUP-ITM-10130528","CDM","C1776","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1638.14","42.9","","956.46","956.46","956.46","1 through 10","1183.74","3035.71","percent of total billed charges",""
"RADIUS PLATE 7 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT STANDARD","SUP-ITM-10130528","CDM","C1776","HCPCS","0278","RC","","","","both","","","3818.50","2863.87","WELLPOINT [1015]","HB AMC WELLPOINT","2817.29","73.78","","2344.73","1619.47","2530.35","16","1183.74","3035.71","percent of total billed charges",""
"RADIUS PLATE 7 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT STANDARD","SUP-ITM-10130528","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3818.50","2863.87","AETNA [1001]","HB AMC AETNA HMO","2665.31","69.8","","1523.63","988.41","4330.26","39","1995.55","3120.48","percent of total billed charges",""
"RADIUS PLATE 7 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT STANDARD","SUP-ITM-10130528","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3818.50","2863.87","AETNA [1001]","HB AMC AETNA PPO","3070.07","80.4","","1670.25","1670.25","1670.25","1 through 10","1995.55","3120.48","percent of total billed charges",""
"RADIUS PLATE 7 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT STANDARD","SUP-ITM-10130528","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3818.50","2863.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1995.55","52.26","","1113.10","1113.10","1113.10","1 through 10","1995.55","3120.48","percent of total billed charges",""
"RADIUS PLATE 7 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT STANDARD","SUP-ITM-10130528","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3818.50","2863.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3120.48","81.72","","1738.90","1484.65","2716.94","38","1995.55","3120.48","percent of total billed charges",""
"RADIUS PLATE 80MM 6 HOLE BONE VOLAR TITANIUM MIDSHAFT","SUP-ITM-10044462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2723.00","2042.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2164.79","79.5","","800.18","480.96","1887.97","195","844.13","2164.79","percent of total billed charges",""
"RADIUS PLATE 80MM 6 HOLE BONE VOLAR TITANIUM MIDSHAFT","SUP-ITM-10044462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2723.00","2042.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1451.36","53.3","","813.12","216.42","1444.50","81","844.13","2164.79","percent of total billed charges",""
"RADIUS PLATE 80MM 6 HOLE BONE VOLAR TITANIUM MIDSHAFT","SUP-ITM-10044462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2723.00","2042.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","844.13","31","","432.60","432.60","432.60","1 through 10","844.13","2164.79","percent of total billed charges",""
"RADIUS PLATE 80MM 6 HOLE BONE VOLAR TITANIUM MIDSHAFT","SUP-ITM-10044462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2723.00","2042.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","993.90","36.5","","148.37","54.89","631.39","94","844.13","2164.79","percent of total billed charges",""
"RADIUS PLATE 80MM 6 HOLE BONE VOLAR TITANIUM MIDSHAFT","SUP-ITM-10044462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2723.00","2042.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1042.91","38.3","","279.30","91.72","1116.77","266","844.13","2164.79","percent of total billed charges",""
"RADIUS PLATE 80MM 6 HOLE BONE VOLAR TITANIUM MIDSHAFT","SUP-ITM-10044462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2723.00","2042.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1168.17","42.9","","731.00","63.70","731.00","1 through 10","844.13","2164.79","percent of total billed charges",""
"RADIUS PLATE 80MM 6 HOLE BONE VOLAR TITANIUM MIDSHAFT","SUP-ITM-10044462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2723.00","2042.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1168.17","42.9","","384.74","384.74","384.74","1 through 10","844.13","2164.79","percent of total billed charges",""
"RADIUS PLATE 80MM 6 HOLE BONE VOLAR TITANIUM MIDSHAFT","SUP-ITM-10044462","CDM","C1713","HCPCS","0278","RC","","","","both","","","2723.00","2042.25","WELLPOINT [1015]","HB AMC WELLPOINT","2009.03","73.78","","286.63","119.22","1107.45","105","844.13","2164.79","percent of total billed charges",""
"RADIUS PLATE 80MM 6 HOLE BONE VOLAR TITANIUM MIDSHAFT","SUP-ITM-10044462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2723.00","2042.25","AETNA [1001]","HB AMC AETNA HMO","1900.65","69.8","","675.31","184.75","1721.50","286","1423.04","2225.24","percent of total billed charges",""
"RADIUS PLATE 80MM 6 HOLE BONE VOLAR TITANIUM MIDSHAFT","SUP-ITM-10044462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2723.00","2042.25","AETNA [1001]","HB AMC AETNA PPO","2189.29","80.4","","1261.44","103.12","1514.10","21","1423.04","2225.24","percent of total billed charges",""
"RADIUS PLATE 80MM 6 HOLE BONE VOLAR TITANIUM MIDSHAFT","SUP-ITM-10044462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2723.00","2042.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2189.29","80.4","","1365.00","1365.00","1365.00","1 through 10","1423.04","2225.24","percent of total billed charges",""
"RADIUS PLATE 80MM 6 HOLE BONE VOLAR TITANIUM MIDSHAFT","SUP-ITM-10044462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2723.00","2042.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2225.24","81.72","","5157.68","5157.68","5157.68","1 through 10","1423.04","2225.24","percent of total billed charges",""
"RADIUS PLATE 80MM 6 HOLE BONE VOLAR TITANIUM MIDSHAFT","SUP-ITM-10044462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2723.00","2042.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2225.24","81.72","","431.26","71.26","1459.57","88","1423.04","2225.24","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","4271.61","3203.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3395.93","79.5","","800.18","480.96","1887.97","195","1324.2","3395.93","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","4271.61","3203.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2276.77","53.3","","813.12","216.42","1444.50","81","1324.2","3395.93","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","4271.61","3203.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1324.20","31","","432.60","432.60","432.60","1 through 10","1324.2","3395.93","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","4271.61","3203.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1559.14","36.5","","148.37","54.89","631.39","94","1324.2","3395.93","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","4271.61","3203.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1636.03","38.3","","279.30","91.72","1116.77","266","1324.2","3395.93","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","4271.61","3203.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1832.52","42.9","","731.00","63.70","731.00","1 through 10","1324.2","3395.93","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","4271.61","3203.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1832.52","42.9","","384.74","384.74","384.74","1 through 10","1324.2","3395.93","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","4271.61","3203.71","WELLPOINT [1015]","HB AMC WELLPOINT","3151.59","73.78","","286.63","119.22","1107.45","105","1324.2","3395.93","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4271.61","3203.71","AETNA [1001]","HB AMC AETNA HMO","2981.58","69.8","","675.31","184.75","1721.50","286","2232.34","3490.76","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4271.61","3203.71","AETNA [1001]","HB AMC AETNA PPO","3434.37","80.4","","1261.44","103.12","1514.10","21","2232.34","3490.76","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4271.61","3203.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3434.37","80.4","","1365.00","1365.00","1365.00","1 through 10","2232.34","3490.76","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4271.61","3203.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3490.76","81.72","","5157.68","5157.68","5157.68","1 through 10","2232.34","3490.76","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4271.61","3203.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3490.76","81.72","","431.26","71.26","1459.57","88","2232.34","3490.76","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.14","1837.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.86","79.5","","800.18","480.96","1887.97","195","759.54","1947.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.14","1837.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.92","53.3","","813.12","216.42","1444.50","81","759.54","1947.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.14","1837.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","759.54","31","","432.60","432.60","432.60","1 through 10","759.54","1947.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.14","1837.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.30","36.5","","148.37","54.89","631.39","94","759.54","1947.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.14","1837.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.40","38.3","","279.30","91.72","1116.77","266","759.54","1947.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.14","1837.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.11","42.9","","731.00","63.70","731.00","1 through 10","759.54","1947.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.14","1837.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.11","42.9","","384.74","384.74","384.74","1 through 10","759.54","1947.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.14","1837.60","WELLPOINT [1015]","HB AMC WELLPOINT","1807.71","73.78","","286.63","119.22","1107.45","105","759.54","1947.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.14","1837.60","AETNA [1001]","HB AMC AETNA HMO","1710.20","69.8","","675.31","184.75","1721.50","286","1280.44","2002.25","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.14","1837.60","AETNA [1001]","HB AMC AETNA PPO","1969.91","80.4","","1261.44","103.12","1514.10","21","1280.44","2002.25","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.14","1837.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.91","80.4","","1365.00","1365.00","1365.00","1 through 10","1280.44","2002.25","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.14","1837.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2002.25","81.72","","5157.68","5157.68","5157.68","1 through 10","1280.44","2002.25","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.14","1837.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.25","81.72","","431.26","71.26","1459.57","88","1280.44","2002.25","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2569.63","1927.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2042.86","79.5","","800.18","480.96","1887.97","195","796.59","2042.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2569.63","1927.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1369.61","53.3","","813.12","216.42","1444.50","81","796.59","2042.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2569.63","1927.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","796.59","31","","432.60","432.60","432.60","1 through 10","796.59","2042.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2569.63","1927.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","937.91","36.5","","148.37","54.89","631.39","94","796.59","2042.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2569.63","1927.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","984.17","38.3","","279.30","91.72","1116.77","266","796.59","2042.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2569.63","1927.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1102.37","42.9","","731.00","63.70","731.00","1 through 10","796.59","2042.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2569.63","1927.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1102.37","42.9","","384.74","384.74","384.74","1 through 10","796.59","2042.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2569.63","1927.22","WELLPOINT [1015]","HB AMC WELLPOINT","1895.87","73.78","","286.63","119.22","1107.45","105","796.59","2042.86","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2569.63","1927.22","AETNA [1001]","HB AMC AETNA HMO","1793.60","69.8","","675.31","184.75","1721.50","286","1342.89","2099.9","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2569.63","1927.22","AETNA [1001]","HB AMC AETNA PPO","2065.98","80.4","","1261.44","103.12","1514.10","21","1342.89","2099.9","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2569.63","1927.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2065.98","80.4","","1365.00","1365.00","1365.00","1 through 10","1342.89","2099.9","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2569.63","1927.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2099.90","81.72","","5157.68","5157.68","5157.68","1 through 10","1342.89","2099.9","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2569.63","1927.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2099.90","81.72","","431.26","71.26","1459.57","88","1342.89","2099.9","percent of total billed charges",""
"Rapid Malaria Binaxnow","PX-30001668","CDM","87899","CPT","0306","RC","","","","both","","","405.00","303.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","290.79","71.8","","14.17","14.17","14.17","1 through 10","11.81","384.75","percent of total billed charges",""
"Rapid Malaria Binaxnow","PX-30001668","CDM","87899","CPT","0306","RC","","","","both","","","405.00","303.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","283.50","70","","393.00","393.00","393.00","1 through 10","11.81","384.75","percent of total billed charges",""
"Rapid Malaria Binaxnow","PX-30001668","CDM","87899","CPT","0306","RC","","","","both","","","405.00","303.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","215.87","53.3","","166.91","166.91","166.91","1 through 10","11.81","384.75","percent of total billed charges",""
"Rapid Malaria Binaxnow","PX-30001668","CDM","87899","CPT","0306","RC","","","","both","","","405.00","303.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","155.12","38.3","","153.66","78.20","153.66","1 through 10","11.81","384.75","percent of total billed charges",""
"Rapid Malaria Binaxnow","PX-30001668","CDM","87899","CPT","0306","RC","","","","outpatient","","","405.00","303.75","AETNA [1001]","HB AMC AETNA HMO","282.69","69.8","","187.85","95.60","306.54","1 through 10","11.81","330.97","percent of total billed charges",""
"Rapid Malaria Binaxnow","PX-30001668","CDM","87899","CPT","0306","RC","","","","outpatient","","","405.00","303.75","AETNA [1001]","HB AMC AETNA PPO","325.62","80.4","","306.54","306.54","306.54","1 through 10","11.81","330.97","percent of total billed charges",""
"Rapid Malaria Binaxnow","PX-30001668","CDM","87899","CPT","0306","RC","","","","outpatient","","","405.00","303.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","330.97","81.72","","314.16","314.16","314.16","1 through 10","11.81","330.97","percent of total billed charges",""
"Rasa1-Related Disorders (Rasa1) Deletion/Duplication","PX-31000671","CDM","81479","CPT","0310","RC","","","","both","","","921.00","690.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","732.20","79.5","","0.65","0.65","0.65","1 through 10","285.51","874.95","percent of total billed charges",""
"Rasa1-Related Disorders (Rasa1) Deletion/Duplication","PX-31000671","CDM","81479","CPT","0310","RC","","","","both","","","921.00","690.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","490.89","53.3","","0.79","0.79","0.79","1 through 10","285.51","874.95","percent of total billed charges",""
"Rasa1-Related Disorders (Rasa1) Deletion/Duplication","PX-31000671","CDM","81479","CPT","0310","RC","","","","outpatient","","","921.00","690.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","460.50","50","","1.00","1.00","1.00","1 through 10","156.55","759.83","percent of total billed charges",""
"Rasa1-Related Disorders (Rasa1) Deletion/Duplication","PX-31000671","CDM","81479","CPT","0310","RC","","","","outpatient","","","921.00","690.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","483.53","52.5","","1.00","0.53","1.00","1 through 10","156.55","759.83","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","55.90","65","","161.85","161.85","161.85","57","5.12","81.7","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","60.20","70","","83.00","83.00","83.00","1 through 10","5.12","81.7","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","68.37","79.5","","65.32","43.82","65.32","1177","5.12","81.7","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.84","53.3","","43.82","43.82","131.47","524","5.12","81.7","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","66.22","77","","63.91","63.91","63.91","17","5.12","81.7","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","55.90","65","","53.95","53.95","53.95","17","5.12","81.7","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.66","31","","25.65","25.65","25.65","20","5.12","81.7","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.39","36.5","","30.96","26.31","30.96","1595","5.12","81.7","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.94","38.3","","32.45","31.54","32.45","4903","5.12","81.7","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","TRICARE [160005]","HB BWH TRICARE","81.70","95","","83.00","5.98","83.00","28","5.12","81.7","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","66.35","36.50","97.36","84","5.12","81.7","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.89","42.9","","36.50","36.50","36.50","42","5.12","81.7","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA HMO","60.03","69.8","","56.19","39.67","64.74","1585","5.39","70.28","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","AETNA [1001]","HB AMC AETNA PPO","69.14","80.4","","64.74","43.49","86.98","136","5.39","70.28","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","44.94","52.26","","18.56","18.56","18.56","24","5.39","70.28","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","70.28","81.72","","36.50","36.50","66.35","79","5.39","70.28","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","70.28","81.72","","66.35","23.34","66.35","1627","5.39","70.28","percent of total billed charges",""
"Rast Allergen Multi Ql","PX-30000777","CDM","86005","CPT","0302","RC","","","","both","","","135.00","101.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","94.50","70","","104.80","104.80","104.80","1 through 10","7.81","128.25","percent of total billed charges",""
"RBC Antibody Elution","PX-30000068","CDM","86860","CPT","0302","RC","","","","both","","","340.00","255.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","270.30","79.5","","259.71","259.71","259.71","1 through 10","105.4","270.3","percent of total billed charges",""
"RBC Antibody Elution","PX-30000068","CDM","86860","CPT","0302","RC","","","","both","","","340.00","255.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","181.22","53.3","","871.20","871.20","871.20","1 through 10","105.4","270.3","percent of total billed charges",""
"RBC Antibody Elution","PX-30000068","CDM","86860","CPT","0302","RC","","","","both","","","340.00","255.00","MEDICARE [2001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","203.50","203.50","1 through 10","105.4","270.3","other","OPPS APC"
"RBC Antibody Elution","PX-30000068","CDM","86860","CPT","0302","RC","","","","both","","","340.00","255.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","124.10","36.5","","369.27","369.27","369.27","1 through 10","105.4","270.3","percent of total billed charges",""
"RBC Antibody Elution","PX-30000068","CDM","86860","CPT","0302","RC","","","","both","","","340.00","255.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","130.22","38.3","","129.03","129.03","129.03","1 through 10","105.4","270.3","percent of total billed charges",""
"RBC Antibody Elution","PX-30000068","CDM","86860","CPT","0302","RC","","","","outpatient","","","340.00","255.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","277.85","81.72","","263.80","263.80","263.80","1 through 10","172.31","887.19","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","439.96","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","439.58","439.58","439.58","1 through 10","105.4","533.93","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","330.00","89.33","420.35","1 through 10","105.4","533.93","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","533.93","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","213.60","213.60","213.60","1 through 10","105.4","533.93","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","270.30","79.5","","174.24","174.24","259.71","16","105.4","533.93","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","181.22","53.3","","174.24","174.24","174.24","1 through 10","105.4","533.93","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","HUMANA [1012]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.46","211.46","211.46","1 through 10","105.4","533.93","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","221.00","65","","214.50","214.50","214.50","1 through 10","105.4","533.93","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","209.38","209.38","209.38","1 through 10","105.4","533.93","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","MEDICARE [2001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.19","213.60","640.79","28","105.4","533.93","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","105.40","31","","101.97","101.97","101.97","1 through 10","105.4","533.93","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","124.10","36.5","","123.09","104.61","369.27","16","105.4","533.93","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","130.22","38.3","","129.03","125.40","387.09","45","105.4","533.93","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","418.65","418.65","1 through 10","105.4","533.93","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","418.65","418.65","1 through 10","105.4","533.93","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.86","42.9","","145.10","145.10","145.10","1 through 10","105.4","533.93","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","384.47","128.16","418.65","1 through 10","105.4","533.93","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","340.00","255.00","WELLPOINT [1015]","HB AMC WELLPOINT","250.85","73.78","","575.69","575.69","575.69","1 through 10","105.4","533.93","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","outpatient","","","340.00","255.00","AETNA [1001]","HB AMC AETNA HMO","237.32","69.8","","223.41","157.74","315.48","17","177.68","1680.97","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","outpatient","","","340.00","255.00","AETNA [1001]","HB AMC AETNA PPO","273.36","80.4","","257.40","241.28","514.80","1 through 10","177.68","1680.97","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","outpatient","","","340.00","255.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","177.68","52.26","","564.46","564.46","564.46","1 through 10","177.68","1680.97","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","outpatient","","","340.00","255.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","273.36","80.4","","241.28","241.28","241.28","1 through 10","177.68","1680.97","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","outpatient","","","340.00","255.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","277.85","81.72","","263.80","145.10","263.80","15","177.68","1680.97","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0300","RC","","","","inpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","129.91","69.1","","87.00","87.00","87.00","1 through 10","103.96","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","139.42","24.35","182.00","56","58.28","149.46","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","134.98","71.8","","392.04","130.68","392.04","20","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","123.33","65.6","","123.21","123.21","141.96","1 through 10","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","122.20","65","","118.30","96.10","118.30","1 through 10","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","131.60","70","","182.00","131.04","393.12","27","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","79.31","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","24.84","4.40","182.00","1 through 10","58.28","149.46","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","149.46","79.5","","143.23","96.10","429.69","502","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.20","53.3","","143.23","96.10","341.47","236","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.43","62.43","62.43","1 through 10","58.28","149.46","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","144.76","77","","420.42","140.14","420.42","17","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","122.20","65","","118.30","118.30","131.30","18","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","149.46","79.5","","143.23","137.23","143.23","1 through 10","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","MEDICARE [2001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.00","63.45","182.00","1 through 10","58.28","149.46","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","58.28","31","","56.24","56.24","168.72","1 through 10","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.62","36.5","","67.89","57.69","203.67","358","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","71.16","69.16","213.48","1082","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","144.76","77","","141.96","141.96","141.96","1 through 10","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","TRICARE [160005]","HB BWH TRICARE","60.28","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","63.45","60.28","182.00","1 through 10","58.28","149.46","other","Tricare OPPS"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","41.86","41.86","41.86","1 through 10","58.28","149.46","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.65","42.9","","145.49","80.03","182.00","23","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9.57","9.57","9.57","1 through 10","58.28","149.46","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.65","42.9","","80.03","80.03","80.03","1 through 10","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","188.00","141.00","WELLPOINT [1015]","HB AMC WELLPOINT","138.71","73.78","","135.50","135.50","317.50","207","58.28","149.46","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","123.21","87.00","141.96","630","98.25","312.51","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA PPO","151.15","80.4","","141.96","95.37","141.96","69","98.25","312.51","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","188.00","141.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","98.25","52.26","","104.94","104.94","112.62","1 through 10","98.25","312.51","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","188.00","141.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","151.15","80.4","","141.96","91.00","152.31","18","98.25","312.51","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","188.00","141.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","153.63","81.72","","145.49","145.49","145.49","1 through 10","98.25","312.51","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","153.63","81.72","","80.03","80.03","145.49","21","98.25","312.51","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","153.63","81.72","","145.49","80.03","145.49","540","98.25","312.51","percent of total billed charges",""
"RBC Pretreatment Absorption","PX-30000104","CDM","86978","CPT","0302","RC","","","","both","","","332.00","249.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.16","38.3","","106.26","106.26","106.26","1 through 10","18.5","263.94","percent of total billed charges",""
"RBC Pretreatment Chemical","PX-30000098","CDM","86970","CPT","0300","RC","","","","both","","","241.00","180.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","173.04","71.8","","168.01","168.01","168.01","1 through 10","18.5","191.6","percent of total billed charges",""
"RBC Pretreatment Chemical","PX-30000098","CDM","86970","CPT","0300","RC","","","","outpatient","","","241.00","180.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","196.95","81.72","","748.24","748.24","748.24","1 through 10","18.5","196.95","percent of total billed charges",""
"RBC Pretreatment Enzyme","PX-30000099","CDM","86971","CPT","0302","RC","","","","outpatient","","","213.00","159.75","AETNA [1001]","HB AMC AETNA HMO","148.67","69.8","","98.95","98.95","98.95","1 through 10","18.5","1680.97","percent of total billed charges",""
"RBC Pretreatment Serum Incubation","PX-30000101","CDM","86975","CPT","0302","RC","","","","both","","","332.00","249.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.16","38.3","","122.36","122.36","122.36","1 through 10","18.5","592.3","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Real-Time Powassan Virus (Powv) Pcr","PX-30003698","CDM","87798","CPT","0300","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","222.60","79.5","","800.18","480.96","1887.97","195","86.8","222.6","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","149.24","53.3","","813.12","216.42","1444.50","81","86.8","222.6","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","86.80","31","","432.60","432.60","432.60","1 through 10","86.8","222.6","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","102.20","36.5","","148.37","54.89","631.39","94","86.8","222.6","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","107.24","38.3","","279.30","91.72","1116.77","266","86.8","222.6","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.12","42.9","","731.00","63.70","731.00","1 through 10","86.8","222.6","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.12","42.9","","384.74","384.74","384.74","1 through 10","86.8","222.6","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","WELLPOINT [1015]","HB AMC WELLPOINT","206.58","73.78","","286.63","119.22","1107.45","105","86.8","222.6","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","AETNA [1001]","HB AMC AETNA HMO","195.44","69.8","","675.31","184.75","1721.50","286","146.33","228.82","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","AETNA [1001]","HB AMC AETNA PPO","225.12","80.4","","1261.44","103.12","1514.10","21","146.33","228.82","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","225.12","80.4","","1365.00","1365.00","1365.00","1 through 10","146.33","228.82","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","228.82","81.72","","5157.68","5157.68","5157.68","1 through 10","146.33","228.82","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","228.82","81.72","","431.26","71.26","1459.57","88","146.33","228.82","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","both","","","1344.00","1008.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1068.48","79.5","","1309.77","674.56","6049.93","26","416.64","1068.48","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","both","","","1344.00","1008.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","716.35","53.3","","1901.83","1901.83","2962.25","1 through 10","416.64","1068.48","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","both","","","1344.00","1008.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","490.56","36.5","","1620.31","1620.31","19908.88","1 through 10","416.64","1068.48","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","both","","","1344.00","1008.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","514.75","38.3","","352.91","352.91","2046.30","1 through 10","416.64","1068.48","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","both","","","1344.00","1008.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","576.58","42.9","","9668.75","9668.75","9668.75","1 through 10","416.64","1068.48","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","both","","","1344.00","1008.00","WELLPOINT [1015]","HB AMC WELLPOINT","991.60","73.78","","699.88","384.10","3443.31","33","416.64","1068.48","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1344.00","1008.00","AETNA [1001]","HB AMC AETNA HMO","938.11","69.8","","1421.24","264.50","4933.46","29","702.37","1098.32","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1344.00","1008.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1080.58","80.4","","1022.97","1022.97","3607.50","1 through 10","702.37","1098.32","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1344.00","1008.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1098.32","81.72","","3010.54","693.88","5019.88","35","702.37","1098.32","percent of total billed charges",""
"Receptor Assay Non Endocrine","PX-30000666","CDM","84238","CPT","0301","RC","","","","both","","","454.00","340.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","360.93","79.5","","346.28","346.28","346.28","1 through 10","35.84","431.3","percent of total billed charges",""
"Receptor Assay Non Endocrine","PX-30000666","CDM","84238","CPT","0301","RC","","","","both","","","454.00","340.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","165.71","36.5","","138.16","138.16","138.16","1 through 10","35.84","431.3","percent of total billed charges",""
"Receptor Assay Non Endocrine","PX-30000666","CDM","84238","CPT","0301","RC","","","","both","","","454.00","340.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","173.88","38.3","","172.04","172.04","172.04","1 through 10","35.84","431.3","percent of total billed charges",""
"Reconstr Nipple Areola","PX-76000266","CDM","19350","CPT","0761","RC","","","","outpatient","","","6875.00","5156.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5618.25","81.72","","22781.76","22781.76","22781.76","1 through 10","2750","5618.25","percent of total billed charges",""
"Recorder Event Cardiac T3","PX-27000079","CDM","C1764","HCPCS","0278","RC","","","","both","","","8913.45","6685.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7086.19","79.5","","8853.75","7870.00","8853.75","1 through 10","2763.17","7086.19","percent of total billed charges",""
"Recorder Event Cardiac T3","PX-27000079","CDM","C1764","HCPCS","0278","RC","","","","both","","","8913.45","6685.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4750.87","53.3","","6996.00","5280.00","6996.00","1 through 10","2763.17","7086.19","percent of total billed charges",""
"Recorder Event Cardiac T3","PX-27000079","CDM","C1764","HCPCS","0278","RC","","","","both","","","8913.45","6685.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3253.41","36.5","","4200.25","4200.25","4200.25","1 through 10","2763.17","7086.19","percent of total billed charges",""
"Recorder Event Cardiac T3","PX-27000079","CDM","C1764","HCPCS","0278","RC","","","","both","","","8913.45","6685.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3413.85","38.3","","3910.00","3800.00","4398.75","11","2763.17","7086.19","percent of total billed charges",""
"Recorder Event Cardiac T3","PX-27000079","CDM","C1764","HCPCS","0278","RC","","","","both","","","8913.45","6685.09","WELLPOINT [1015]","HB AMC WELLPOINT","6576.34","73.78","","8375.63","7445.00","8375.63","1 through 10","2763.17","7086.19","percent of total billed charges",""
"Recorder Event Cardiac T3","PX-27000079","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","8913.45","6685.09","AETNA [1001]","HB AMC AETNA HMO","6221.59","69.8","","7616.25","5377.50","11250.00","1 through 10","4658.17","7284.07","percent of total billed charges",""
"Recorder Event Cardiac T3","PX-27000079","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","8913.45","6685.09","AETNA [1001]","HB AMC AETNA PPO","7166.41","80.4","","7800.00","7800.00","7800.00","1 through 10","4658.17","7284.07","percent of total billed charges",""
"Recorder Event Cardiac T3","PX-27000079","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","8913.45","6685.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7166.41","80.4","","7540.00","7540.00","7540.00","1 through 10","4658.17","7284.07","percent of total billed charges",""
"Recorder Event Cardiac T3","PX-27000079","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","8913.45","6685.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7284.07","81.72","","8993.25","8993.25","8993.25","1 through 10","4658.17","7284.07","percent of total billed charges",""
"RECORDER LOOP CARDIAC REVEAL LINQ II","SUP-ITM-10276443","CDM","C1764","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8943.75","79.5","","8853.75","7870.00","8853.75","1 through 10","3487.5","8943.75","percent of total billed charges",""
"RECORDER LOOP CARDIAC REVEAL LINQ II","SUP-ITM-10276443","CDM","C1764","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5996.25","53.3","","6996.00","5280.00","6996.00","1 through 10","3487.5","8943.75","percent of total billed charges",""
"RECORDER LOOP CARDIAC REVEAL LINQ II","SUP-ITM-10276443","CDM","C1764","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4106.25","36.5","","4200.25","4200.25","4200.25","1 through 10","3487.5","8943.75","percent of total billed charges",""
"RECORDER LOOP CARDIAC REVEAL LINQ II","SUP-ITM-10276443","CDM","C1764","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4308.75","38.3","","3910.00","3800.00","4398.75","11","3487.5","8943.75","percent of total billed charges",""
"RECORDER LOOP CARDIAC REVEAL LINQ II","SUP-ITM-10276443","CDM","C1764","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","WELLPOINT [1015]","HB AMC WELLPOINT","8300.25","73.78","","8375.63","7445.00","8375.63","1 through 10","3487.5","8943.75","percent of total billed charges",""
"RECORDER LOOP CARDIAC REVEAL LINQ II","SUP-ITM-10276443","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","11250.00","8437.50","AETNA [1001]","HB AMC AETNA HMO","7852.50","69.8","","7616.25","5377.50","11250.00","1 through 10","5879.25","9193.5","percent of total billed charges",""
"RECORDER LOOP CARDIAC REVEAL LINQ II","SUP-ITM-10276443","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","11250.00","8437.50","AETNA [1001]","HB AMC AETNA PPO","9045.00","80.4","","7800.00","7800.00","7800.00","1 through 10","5879.25","9193.5","percent of total billed charges",""
"RECORDER LOOP CARDIAC REVEAL LINQ II","SUP-ITM-10276443","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","11250.00","8437.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9045.00","80.4","","7540.00","7540.00","7540.00","1 through 10","5879.25","9193.5","percent of total billed charges",""
"RECORDER LOOP CARDIAC REVEAL LINQ II","SUP-ITM-10276443","CDM","C1764","HCPCS","0278","RC","","","","outpatient","","","11250.00","8437.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9193.50","81.72","","8993.25","8993.25","8993.25","1 through 10","5879.25","9193.5","percent of total billed charges",""
"Rectal Resection With Cc","333","MS-DRG","","","","","","","","inpatient","","","111641.12","83730.84","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","22398.00","","Case rate ($21,745.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,100.05, add-ons for qualifying new technology services are included. If operating cost exceeds $71,744.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,324.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $19,481.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,720.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,884.67. The transfer capital threshold is the transfer adjustment factor * $1,884.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","20173.93","20173.93","20173.93","1 through 10","21310.72","32072.9023","other","Inpatient DRG"
"Rectal Resection With Cc","333","MS-DRG","","","","","","","","inpatient","","","111641.12","83730.84","MEDICARE [2001]","HB BWH MEDICARE","28108.97","","Case rate ($28,108.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $26,100.05, add-ons for qualifying new technology services are included. If operating cost exceeds $71,744.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,324.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $25,844.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,720.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,884.67. The transfer capital threshold is the transfer adjustment factor * $1,884.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25363.35","25363.35","25363.35","1 through 10","21310.72","32072.9023","other","Inpatient DRG"
"Rectal Resection With Cc","333","TRIS-DRG","","","","","","","","inpatient","","","115878.20","","TRICARE [160005]","HB BWH TRICARE","23640.15","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($41,525.25). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $10,128.11, and the first day is paid a rate of $20,256.22. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $10,128.11, and the first day is paid a rate of $20,256.22. The transfer payment is capped at $29,887.18. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $85,252.25 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 4.09999990463257). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: , capped at $29,887.18. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $10,128.11, and the first day is paid a rate of $20,256.22. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $10,128.11, and the first day is paid a rate of $20,256.22. The transfer payment is capped at $29,887.18. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $85,252.25 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 4.09999990463257). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","50464.11","50464.11","50464.11","1 through 10","23640.15","23640.15","other","Inpatient DRGs"
"Rectal Resection With McC","332","MS-DRG","","","","","","","","inpatient","","","154130.64","115597.98","MEDICARE [2001]","HB BWH MEDICARE","33408.24","","Case rate ($33,408.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,139.53, add-ons for qualifying new technology services are included. If operating cost exceeds $85,783.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,353.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $30,114.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,759.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,913.43. The transfer capital threshold is the transfer adjustment factor * $2,913.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","41232.49","41232.49","41232.49","1 through 10","32740.08","52346.1517","other","Inpatient Replacement Plans DRG"
"Rectal Resection With McC","332","MS-DRG","","","","","","","","inpatient","","","154130.64","115597.98","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","32740.08","","Case rate ($33,408.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,139.53, add-ons for qualifying new technology services are included. If operating cost exceeds $85,783.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,353.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.4. The base transfer operating payment is the transfer adjustment factor * $30,114.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,759.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,913.43. The transfer capital threshold is the transfer adjustment factor * $2,913.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13409.31","13409.31","13409.31","1 through 10","32740.08","52346.1517","other","Inpatient DRG"
"Rectal Resection Without Cc/McC","334","MS-DRG","","","","","","","","inpatient","","","75763.54","56822.65","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15780.57","","Case rate ($15,320.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,365.97, add-ons for qualifying new technology services are included. If operating cost exceeds $64,010.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,758.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $13,623.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,986.13 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,317.95. The transfer capital threshold is the transfer adjustment factor * $1,317.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15798.97","15798.97","15798.97","1 through 10","15014.52","25029.9326","other","Inpatient DRG"
"Rectal Resection Without Cc/McC","334","MS-DRG","","","","","","","","inpatient","","","75763.54","56822.65","MEDICARE [2001]","HB BWH MEDICARE","15320.94","","Case rate ($15,320.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,365.97, add-ons for qualifying new technology services are included. If operating cost exceeds $64,010.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,758.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $13,623.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,986.13 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,317.95. The transfer capital threshold is the transfer adjustment factor * $1,317.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19831.78","19831.78","19831.78","1 through 10","15014.52","25029.9326","other","Inpatient Replacement Plans DRG"
"Rectal Resection Without Cc/McC","334","MS-DRG","","","","","","","","inpatient","","","75763.54","56822.65","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15014.52","","Case rate ($15,320.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,365.97, add-ons for qualifying new technology services are included. If operating cost exceeds $64,010.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,758.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $13,623.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,986.13 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,317.95. The transfer capital threshold is the transfer adjustment factor * $1,317.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21341.29","21341.29","21341.29","1 through 10","15014.52","25029.9326","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","78937.53","59203.15","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","13585.71","","Case rate ($13,190.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,800.76, add-ons for qualifying new technology services are included. If operating cost exceeds $61,445.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,570.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,680.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,420.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,129.98. The transfer capital threshold is the transfer adjustment factor * $1,129.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","13494.36","13494.36","13561.72","1 through 10","12926.21","21996.96","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","78937.53","59203.15","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","13190.01","","Case rate ($13,190.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,800.76, add-ons for qualifying new technology services are included. If operating cost exceeds $61,445.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,570.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,680.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,420.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,129.98. The transfer capital threshold is the transfer adjustment factor * $1,129.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12820.85","12820.85","12869.31","1 through 10","12926.21","21996.96","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","78937.53","59203.15","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","19321.30","19321.30","19321.30","1 through 10","12926.21","21996.96","case rate",""
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","78937.53","59203.15","MEDICARE [2001]","HB BWH MEDICARE","17005.24","","Case rate ($17,005.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,800.76, add-ons for qualifying new technology services are included. If operating cost exceeds $61,445.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,570.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $15,495.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,420.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,129.98. The transfer capital threshold is the transfer adjustment factor * $1,129.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1975.33","0.03","16889.24","38","12926.21","21996.96","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","78937.53","59203.15","MOLINA [1014]","HB BWH MOLINA","12926.21","","Case rate ($13,190.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,800.76, add-ons for qualifying new technology services are included. If operating cost exceeds $61,445.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,570.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,680.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,420.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,129.98. The transfer capital threshold is the transfer adjustment factor * $1,129.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26138.81","26138.81","26138.81","1 through 10","12926.21","21996.96","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","78937.53","59203.15","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12926.21","","Case rate ($13,190.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,800.76, add-ons for qualifying new technology services are included. If operating cost exceeds $61,445.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,570.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,680.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,420.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,129.98. The transfer capital threshold is the transfer adjustment factor * $1,129.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","88089.41","88089.41","88089.41","1 through 10","12926.21","21996.96","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","78937.53","59203.15","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","12926.21","","Case rate ($13,190.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,800.76, add-ons for qualifying new technology services are included. If operating cost exceeds $61,445.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,570.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,680.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,420.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,129.98. The transfer capital threshold is the transfer adjustment factor * $1,129.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","33319.50","33319.50","33319.50","1 through 10","12926.21","21996.96","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","78937.53","59203.15","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12926.21","","Case rate ($13,190.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,800.76, add-ons for qualifying new technology services are included. If operating cost exceeds $61,445.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,570.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,680.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,420.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,129.98. The transfer capital threshold is the transfer adjustment factor * $1,129.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12882.53","12882.53","19794.63","1 through 10","12926.21","21996.96","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","45890.80","34418.10","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","11250.34","","Case rate ($11,250.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,462.79, add-ons for qualifying new technology services are included. If operating cost exceeds $56,107.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,178.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,131.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,082.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $738.84. The transfer capital threshold is the transfer adjustment factor * $738.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8566.21","8560.84","8599.75","1 through 10","8580.64","14382.68","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","45890.80","34418.10","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8755.76","","Case rate ($8,755.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,462.79, add-ons for qualifying new technology services are included. If operating cost exceeds $56,107.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,178.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,637.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,082.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $738.84. The transfer capital threshold is the transfer adjustment factor * $738.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8550.30","8550.30","8582.16","1 through 10","8580.64","14382.68","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","45890.80","34418.10","FALLON HEALTH [1008]","HB BWH MEDICARE","11250.34","","Case rate ($11,250.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,462.79, add-ons for qualifying new technology services are included. If operating cost exceeds $56,107.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,178.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,131.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,082.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $738.84. The transfer capital threshold is the transfer adjustment factor * $738.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8490.03","8490.03","8532.38","1 through 10","8580.64","14382.68","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","45890.80","34418.10","MEDICARE [2001]","HB BWH MEDICARE","11250.34","","Case rate ($11,250.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,462.79, add-ons for qualifying new technology services are included. If operating cost exceeds $56,107.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,178.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,131.66 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,082.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $738.84. The transfer capital threshold is the transfer adjustment factor * $738.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","2223.03","186.02","11174.76","60","8580.64","14382.68","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","45890.80","34418.10","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8580.64","","Case rate ($8,755.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,462.79, add-ons for qualifying new technology services are included. If operating cost exceeds $56,107.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,178.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,637.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,082.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $738.84. The transfer capital threshold is the transfer adjustment factor * $738.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8522.78","8522.78","8522.78","1 through 10","8580.64","14382.68","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","45890.80","34418.10","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8580.64","","Case rate ($8,755.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,462.79, add-ons for qualifying new technology services are included. If operating cost exceeds $56,107.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,178.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,637.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,082.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $738.84. The transfer capital threshold is the transfer adjustment factor * $738.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8536.78","8508.99","8690.54","1 through 10","8580.64","14382.68","other","Inpatient DRG"
"Red Cell Genotyping","PX-30003362","CDM","81479","CPT","0300","RC","","","","both","","","732.00","549.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","581.94","79.5","","0.65","0.65","0.65","1 through 10","226.92","695.4","percent of total billed charges",""
"Red Cell Genotyping","PX-30003362","CDM","81479","CPT","0300","RC","","","","both","","","732.00","549.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","390.16","53.3","","0.79","0.79","0.79","1 through 10","226.92","695.4","percent of total billed charges",""
"Red Cell Genotyping","PX-30003362","CDM","81479","CPT","0300","RC","","","","outpatient","","","732.00","549.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","366.00","50","","1.00","1.00","1.00","1 through 10","156.55","603.9","percent of total billed charges",""
"Red Cell Genotyping","PX-30003362","CDM","81479","CPT","0300","RC","","","","outpatient","","","732.00","549.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","384.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","603.9","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","255.80","","APC Price ($255.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","251.71","251.71","251.71","1 through 10","243.01","1676.66","other","OPPS APC"
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1514.26","71.8","","1468.31","1468.31","1468.31","1 through 10","243.01","1676.66","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","319.75","","APC Price ($255.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","247.43","247.43","255.80","24","243.01","1676.66","other","OPPS APC"
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1676.66","79.5","","1609.42","1496.69","4101.06","12","243.01","1676.66","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1124.10","53.3","","5653.53","5653.53","5653.53","1 through 10","243.01","1676.66","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","255.80","","APC Price ($255.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1945.30","1945.30","1945.30","1 through 10","243.01","1676.66","other","OPPS APC"
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","HUMANA [1012]","HB BWH MEDICARE","255.80","","APC Price ($255.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6627.98","6627.98","6627.98","1 through 10","243.01","1676.66","other","OPPS APC"
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","MEDICARE [2001]","HB BWH MEDICARE","255.80","","APC Price ($255.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","259.12","252.48","767.40","448","243.01","1676.66","other","OPPS APC"
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","769.79","36.5","","648.27","648.27","648.27","1 through 10","243.01","1676.66","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","807.75","38.3","","799.60","799.60","799.60","1 through 10","243.01","1676.66","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","255.80","","APC Price ($255.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","251.64","251.64","251.64","1 through 10","243.01","1676.66","other","OPPS APC"
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","904.76","42.9","","1634.77","1634.77","1634.77","1 through 10","243.01","1676.66","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","250.68","","APC Price ($255.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","250.69","250.69","250.69","1 through 10","243.01","1676.66","other","OPPS APC"
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","2109.00","1581.75","WELLPOINT [1015]","HB AMC WELLPOINT","1556.02","73.78","","1522.51","1522.51","1522.51","1 through 10","243.01","1676.66","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","outpatient","","","2109.00","1581.75","AETNA [1001]","HB AMC AETNA HMO","1472.08","69.8","","1384.47","1384.47","1384.47","1 through 10","448.84","1739.93","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","outpatient","","","2109.00","1581.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1054.50","50","","255.58","255.58","766.74","1 through 10","448.84","1739.93","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","outpatient","","","2109.00","1581.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1107.23","52.5","","536.72","536.72","536.72","1 through 10","448.84","1739.93","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","outpatient","","","2109.00","1581.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1107.23","52.5","","268.36","268.36","268.36","32","448.84","1739.93","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","outpatient","","","2109.00","1581.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1159.95","55","","281.14","281.14","281.14","1 through 10","448.84","1739.93","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","outpatient","","","2109.00","1581.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1723.47","81.72","","1634.77","1634.77","1634.77","1 through 10","448.84","1739.93","percent of total billed charges",""
"Reduce Pregnancy Multi-Fetal","PX-72000036","CDM","59866","CPT","0361","RC","","","","both","","","4025.00","3018.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3199.88","79.5","","3071.66","3071.66","3071.66","1 through 10","343.18","3199.88","percent of total billed charges",""
"Reduce Pregnancy Multi-Fetal","PX-72000036","CDM","59866","CPT","0361","RC","","","","both","","","4025.00","3018.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1541.58","38.3","","2966.28","2966.28","2966.28","1 through 10","343.18","3199.88","percent of total billed charges",""
"Reduce Pregnancy Multi-Fetal","PX-72000036","CDM","59866","CPT","0361","RC","","","","outpatient","","","4025.00","3018.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","638.74","627.19","638.74","1 through 10","273","5545.35","other","ASC"
"Reduce Pregnancy Multi-Fetal","PX-72000036","CDM","59866","CPT","0361","RC","","","","outpatient","","","4025.00","3018.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","730.84","723.66","730.84","1 through 10","273","5545.35","other","ASC "
"Reduce Pregnancy Multi-Fetal","PX-72000036","CDM","59866","CPT","0361","RC","","","","outpatient","","","4025.00","3018.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","633.36","633.36","633.36","1 through 10","273","5545.35","other","Multiple Surgery"
"Reduce Pregnancy Multi-Fetal","PX-72000036","CDM","59866","CPT","0361","RC","","","","outpatient","","","4025.00","3018.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","666.12","666.12","666.12","1 through 10","273","5545.35","other","Multiple Surgery"
"Regadenoson Inj 0.1mg","PX-63600169","CDM","J2785","HCPCS","0636","RC","","","","both","","","196.75","147.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","127.89","65","","10.96","10.96","44.15","1 through 10","60.99","151.5","percent of total billed charges",""
"Regadenoson Inj 0.1mg","PX-63600169","CDM","J2785","HCPCS","0636","RC","","","","both","","","196.75","147.56","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","151.50","77","","38.55","38.55","38.55","1 through 10","60.99","151.5","percent of total billed charges",""
"Regadenoson Inj 0.1mg","PX-63600169","CDM","J2785","HCPCS","0636","RC","","","","outpatient","","","196.75","147.56","AETNA [1001]","HB AMC AETNA HMO","137.33","69.8","","34.62","34.62","34.62","1 through 10","6.21","158.19","percent of total billed charges",""
"Regadenoson Inj 0.1mg","PX-63600170","CDM","J2785","HCPCS","0636","RC","","","","both","","","196.78","147.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","127.91","65","","10.96","10.96","44.15","1 through 10","61","151.52","percent of total billed charges",""
"Regadenoson Inj 0.1mg","PX-63600170","CDM","J2785","HCPCS","0636","RC","","","","both","","","196.78","147.58","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","151.52","77","","38.55","38.55","38.55","1 through 10","61","151.52","percent of total billed charges",""
"Regadenoson Inj 0.1mg","PX-63600170","CDM","J2785","HCPCS","0636","RC","","","","outpatient","","","196.78","147.58","AETNA [1001]","HB AMC AETNA HMO","137.35","69.8","","34.62","34.62","34.62","1 through 10","6.21","158.21","percent of total billed charges",""
"Rehabilitation With Cc/McC","945","MS-DRG","","","","","","","","inpatient","","","18207.69","13655.77","MEDICARE [2001]","HB BWH MEDICARE","18713.62","","Case rate ($18,713.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,385.36, add-ons for qualifying new technology services are included. If operating cost exceeds $63,029.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,686.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $17,087.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,005.51 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,246.09. The transfer capital threshold is the transfer adjustment factor * $1,246.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7346.92","7346.92","7346.92","1 through 10","14216.22","23036.4115","other","Inpatient DRG"
"Relocate Pocket Skin for Pacemaker","PX-48000057","CDM","33222","CPT","0361","RC","","","","both","","","9712.00","7284.00","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","1 through 10","2063.7","7721.04","other","OPPS APC"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","6049.00","4536.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3749.00","","APC Price ($3,639.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","6194.00","6194.00","6194.00","1 through 10","1875.19","4808.96","other","OPPS APC"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","6049.00","4536.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4808.96","79.5","","19039.10","10680.91","34633.51","1 through 10","1875.19","4808.96","percent of total billed charges",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","6049.00","4536.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3224.12","53.3","","8588.45","4403.52","8588.45","1 through 10","1875.19","4808.96","percent of total billed charges",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","6049.00","4536.75","MEDICARE [2001]","HB BWH MEDICARE","3639.81","","APC Price ($3,639.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3101.27","10196.58","16","1875.19","4808.96","other","OPPS APC"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","6049.00","4536.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2207.89","36.5","","3110.82","3110.82","3110.82","1 through 10","1875.19","4808.96","percent of total billed charges",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","6049.00","4536.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2316.77","38.3","","12558.14","7909.54","21855.34","1 through 10","1875.19","4808.96","percent of total billed charges",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","6049.00","4536.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","3639.81","","APC Price ($3,639.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3336.88","3336.88","3336.88","1 through 10","1875.19","4808.96","other","OPPS APC"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","6049.00","4536.75","TRICARE [160005]","HB BWH TRICARE","3228.91","","APC Price ($3,398.86). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3228.92","3228.92","3228.92","1 through 10","1875.19","4808.96","other","Tricare OPPS"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","6049.00","4536.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3567.01","","APC Price ($3,639.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3338.79","3336.99","7042.93","1 through 10","1875.19","4808.96","other","OPPS APC"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","6049.00","4536.75","WELLPOINT [1015]","HB AMC WELLPOINT","4462.95","73.78","","20961.40","20961.40","20961.40","1 through 10","1875.19","4808.96","percent of total billed charges",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","AETNA [1001]","HB AMC AETNA HMO","4222.20","69.8","","8118.92","1966.35","27109.79","1 through 10","2378.29","5545.35","percent of total billed charges",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","AETNA [1001]","HB AMC AETNA PPO","4863.40","80.4","","9434.88","9434.88","9434.88","1 through 10","2378.29","5545.35","percent of total billed charges",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5463.90","2782.27","19874.62","1 through 10","2378.29","5545.35","other","ASC"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6304.29","3152.15","6366.84","12","2378.29","5545.35","other","ASC "
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2378.29","","Case rate ($2,378.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","16552.89","5517.63","16552.89","1 through 10","2378.29","5545.35","other","Multiple Surgery"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2378.29","","Case rate ($2,378.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5803.03","5803.03","5803.03","1 through 10","2378.29","5545.35","other","Multiple Surgery"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2378.29","","Case rate ($2,378.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","6088.42","6088.42","6088.42","1 through 10","2378.29","5545.35","other","Multiple Surgery"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","6049.00","4536.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4943.24","81.72","","19339.08","12703.27","41515.24","1 through 10","2378.29","5545.35","percent of total billed charges",""
"Rem Interrog Icpms <30 D Phys/Qhp","PX-48000523","CDM","93297","CPT","0480","RC","","","","both","","","626.00","469.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","1 through 10","42.07","503.3","other","OPPS APC"
"Rem Interrog Icpms <30 D Phys/Qhp","PX-48000523","CDM","93297","CPT","0480","RC","","","","both","","","626.00","469.50","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1 through 10","42.07","503.3","other","OPPS APC"
"Rem Interrog Icpms <30 D Phys/Qhp","PX-48000523","CDM","93297","CPT","0480","RC","","","","both","","","626.00","469.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.79","43.79","43.79","1 through 10","42.07","503.3","other","OPPS APC"
"Rem Interrog Icpms <30 D Phys/Qhp","PX-48000523","CDM","93297","CPT","0480","RC","","","","outpatient","","","626.00","469.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","511.57","81.72","","485.24","485.24","485.24","1 through 10","86.21","511.57","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","45.61","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","45.60","42.36","46.46","248","42.07","589.89","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","44.28","143","42.07","589.89","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","482.30","65","","380.16","380.16","380.16","1 through 10","42.07","589.89","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","55.35","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","43.39","43.39","43.39","1 through 10","42.07","589.89","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","589.89","79.5","","566.64","380.16","566.64","70","42.07","589.89","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","395.49","53.3","","566.64","380.16","566.64","28","42.07","589.89","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","35.36","43.57","27","42.07","589.89","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","ELDER SERVICES [1037]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1 through 10","42.07","589.89","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","1 through 10","42.07","589.89","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.57","43.57","43.57","1 through 10","42.07","589.89","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","HUMANA [1012]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.66","43.39","44.28","26","42.07","589.89","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","MEDICARE [2001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.28","44.28","44.28","2288","42.07","589.89","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","230.02","31","","222.48","222.48","222.48","1 through 10","42.07","589.89","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","270.83","36.5","","268.56","228.24","287.58","49","42.07","589.89","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","284.19","38.3","","281.52","273.60","281.52","248","42.07","589.89","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","44.28","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.39","40.74","43.79","34","42.07","589.89","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","571.34","77","","57.62","57.62","57.62","1 through 10","42.07","589.89","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","TRICARE [160005]","HB BWH TRICARE","42.07","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","44.28","42.07","44.28","16","42.07","589.89","other","Tricare OPPS"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.79","43.39","131.37","57","42.07","589.89","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","318.32","42.9","","327.60","327.60","327.60","1 through 10","42.07","589.89","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","43.39","","APC Price ($44.28). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.60","41.14","44.28","235","42.07","589.89","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","318.32","42.9","","316.58","316.58","316.58","1 through 10","42.07","589.89","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","742.00","556.50","WELLPOINT [1015]","HB AMC WELLPOINT","547.45","73.78","","536.04","536.04","536.04","56","42.07","589.89","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","742.00","556.50","AETNA [1001]","HB AMC AETNA HMO","517.92","69.8","","487.44","344.16","487.44","99","86.21","606.36","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","742.00","556.50","AETNA [1001]","HB AMC AETNA PPO","596.57","80.4","","377.28","355.80","561.60","1 through 10","86.21","606.36","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","742.00","556.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","387.77","52.26","","102.58","102.58","102.58","1 through 10","86.21","606.36","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","742.00","556.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","596.57","80.4","","561.60","561.60","561.60","1 through 10","86.21","606.36","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","742.00","556.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","606.36","81.72","","575.57","575.57","575.57","1 through 10","86.21","606.36","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","742.00","556.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","606.36","81.72","","575.57","316.58","575.57","109","86.21","606.36","percent of total billed charges",""
"Rem Lead Transvenous Dual","PX-48000069","CDM","33235","CPT","0361","RC","","","","both","","","18287.00","13715.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4321.45","","APC Price ($4,321.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4039.95","4039.95","4039.95","1 through 10","4105.79","14538.17","other","OPPS APC"
"Rem Lead Transvenous Dual","PX-48000069","CDM","33235","CPT","0361","RC","","","","both","","","18287.00","13715.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9746.97","53.3","","10968.67","10968.67","10968.67","1 through 10","4105.79","14538.17","percent of total billed charges",""
"Rem Lead Transvenous Dual","PX-48000069","CDM","33235","CPT","0361","RC","","","","outpatient","","","18287.00","13715.25","AETNA [1001]","HB AMC AETNA HMO","12764.33","69.8","","12694.72","12694.72","12694.72","1 through 10","3130.53","14944.14","percent of total billed charges",""
"Rem Lead Transvenous Dual","PX-48000069","CDM","33235","CPT","0361","RC","","","","outpatient","","","18287.00","13715.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3579.94","","Case rate ($3,579.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3662.28","3596.05","3662.28","1 through 10","3130.53","14944.14","other","ASC"
"Rem Lead Transvenous Dual","PX-48000069","CDM","33235","CPT","0361","RC","","","","outpatient","","","18287.00","13715.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3579.94","","Case rate ($3,579.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3596.05","3596.05","3596.05","1 through 10","3130.53","14944.14","other","ASC "
"Rem Lead Transvenous Dual","PX-48000069","CDM","33235","CPT","0361","RC","","","","outpatient","","","18287.00","13715.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3130.53","","Case rate ($3,130.53). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","17734.00","17734.00","17734.00","1 through 10","3130.53","14944.14","other","Multiple Surgery"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1899.96","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1904.20","1898.30","1907.20","1 through 10","953.25","2444.63","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1815.28","1066.92","1844.80","1 through 10","953.25","2444.63","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2152.50","70","","2385.60","1413.39","2385.60","1 through 10","953.25","2444.63","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2444.63","79.5","","2346.83","1574.50","2346.83","12","953.25","2444.63","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1638.98","53.3","","2346.83","1574.50","2713.82","1 through 10","953.25","2444.63","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1815.28","1815.28","1815.28","1 through 10","953.25","2444.63","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","FALLON HEALTH [1008]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5423.70","1807.90","5423.70","1 through 10","953.25","2444.63","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","HUMANA [1012]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1824.65","1807.90","1824.65","1 through 10","953.25","2444.63","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","MEDICARE [2001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1747.95","1844.80","83","953.25","2444.63","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1122.38","36.5","","1112.29","945.29","1112.29","1 through 10","953.25","2444.63","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1177.73","38.3","","1165.96","1165.96","1165.96","1 through 10","953.25","2444.63","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1810.40","1807.90","1813.90","1 through 10","953.25","2444.63","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","TRICARE [160005]","HB BWH TRICARE","1752.56","","APC Price ($1,844.80). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1844.80","1752.56","1844.80","1 through 10","953.25","2444.63","other","Tricare OPPS"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1807.72","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1815.30","1712.99","5429.70","1 through 10","953.25","2444.63","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1807.72","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1807.91","1747.95","1844.80","11","953.25","2444.63","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","3075.00","2306.25","WELLPOINT [1015]","HB AMC WELLPOINT","2268.74","73.78","","2220.10","2220.10","2220.10","1 through 10","953.25","2444.63","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","3075.00","2306.25","AETNA [1001]","HB AMC AETNA HMO","2146.35","69.8","","1425.40","1425.40","2018.81","1 through 10","620.01","2512.89","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","3075.00","2306.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","709.02","","Case rate ($709.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1424.42","1424.42","1450.65","39","620.01","2512.89","other","ASC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","3075.00","2306.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","709.02","","Case rate ($709.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1643.51","1643.51","1659.82","78","620.01","2512.89","other","ASC "
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","3075.00","2306.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1587.23","1413.62","1587.23","1 through 10","620.01","2512.89","other","Multiple Surgery"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","3075.00","2306.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1438.42","1382.62","1438.42","31","620.01","2512.89","other","Multiple Surgery"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","3075.00","2306.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1512.82","1457.02","1512.82","1 through 10","620.01","2512.89","other","Multiple Surgery"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","3075.00","2306.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1798.03","1798.03","1798.03","1 through 10","620.01","2512.89","other","Multiple Surgery"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","3075.00","2306.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1512.82","756.41","1512.82","1 through 10","620.01","2512.89","other","Multiple Surgery"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","3075.00","2306.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1587.23","1525.22","1587.23","1 through 10","620.01","2512.89","other","Multiple Surgery"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","3075.00","2306.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2472.30","80.4","","2325.96","2325.96","2325.96","1 through 10","620.01","2512.89","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","3075.00","2306.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2512.89","81.72","","2383.81","2383.81","2383.81","1 through 10","620.01","2512.89","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","3075.00","2306.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2512.89","81.72","","2383.81","1311.19","2383.81","16","620.01","2512.89","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","756.17","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","761.41","755.51","762.51","1 through 10","544.05","1395.23","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","722.47","722.47","722.47","12","544.05","1395.23","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1260.09","71.8","","1222.04","1222.04","1222.04","1 through 10","544.05","1395.23","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1140.75","65","","1106.30","1106.30","1339.47","1 through 10","544.05","1395.23","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1228.50","70","","878.06","731.86","2059.42","19","544.05","1395.23","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1395.23","79.5","","1339.47","898.66","1339.47","1 through 10","544.05","1395.23","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","935.42","53.3","","1106.30","898.66","1106.30","1 through 10","544.05","1395.23","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","722.47","722.47","722.47","1 through 10","544.05","1395.23","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","FALLON HEALTH [1008]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2202.66","2202.66","2202.66","1 through 10","544.05","1395.23","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","719.54","719.54","719.54","1 through 10","544.05","1395.23","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","725.54","719.54","725.54","1 through 10","544.05","1395.23","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","HUMANA [1012]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","720.12","720.12","720.12","1 through 10","544.05","1395.23","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","729.04","729.04","729.04","1 through 10","544.05","1395.23","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","MEDICARE [2001]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","734.22","734.22","2202.66","88","544.05","1395.23","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","TRICARE [160005]","HB BWH TRICARE","697.51","","APC Price ($734.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","734.22","734.22","734.22","1 through 10","544.05","1395.23","other","Tricare OPPS"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","697.51","","APC Price ($734.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2202.66","2202.66","2202.66","1 through 10","544.05","1395.23","other","Tricare OPPS"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","719.46","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2180.82","719.54","2180.82","1 through 10","544.05","1395.23","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","719.46","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","719.54","671.93","734.22","1 through 10","544.05","1395.23","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","WELLPOINT [1015]","HB AMC WELLPOINT","1294.84","73.78","","1267.14","1267.14","1267.14","1 through 10","544.05","1395.23","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1755.00","1316.25","WELLSENSE NH [1050]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.74","726.74","726.74","1 through 10","544.05","1395.23","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1755.00","1316.25","AETNA [1001]","HB AMC AETNA HMO","1224.99","69.8","","1152.25","813.56","1327.56","1 through 10","620.01","1434.19","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1755.00","1316.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","709.02","","Case rate ($709.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1424.42","1053.20","1450.65","16","620.01","1434.19","other","ASC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1755.00","1316.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","709.02","","Case rate ($709.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1643.51","1643.51","1659.82","39","620.01","1434.19","other","ASC "
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1755.00","1316.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1438.42","731.86","1438.42","1 through 10","620.01","1434.19","other","Multiple Surgery"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1755.00","1316.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1512.82","1512.82","1512.82","1 through 10","620.01","1434.19","other","Multiple Surgery"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1755.00","1316.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1798.03","1798.03","1798.03","1 through 10","620.01","1434.19","other","Multiple Surgery"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1755.00","1316.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1411.02","80.4","","1106.30","1106.30","1106.30","1 through 10","620.01","1434.19","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1755.00","1316.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1434.19","81.72","","1360.58","1360.58","1525.22","1 through 10","620.01","1434.19","percent of total billed charges",""
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","both","","","6104.00","4578.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","4382.67","71.8","","5349.45","5349.45","5349.45","1 through 10","1892.24","4852.68","percent of total billed charges",""
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","both","","","6104.00","4578.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3253.43","53.3","","12638.43","12638.43","12638.43","1 through 10","1892.24","4852.68","percent of total billed charges",""
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","both","","","6104.00","4578.00","MEDICARE [2001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","11213.55","15","1892.24","4852.68","other","OPPS APC"
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","both","","","6104.00","4578.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3696.73","3696.73","3696.73","1 through 10","1892.24","4852.68","other","OPPS APC"
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","both","","","6104.00","4578.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3663.10","3663.10","3663.10","1 through 10","1892.24","4852.68","other","OPPS APC"
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","both","","","6104.00","4578.00","WELLPOINT [1015]","HB AMC WELLPOINT","4503.53","73.78","","9005.47","9005.47","9005.47","1 through 10","1892.24","4852.68","percent of total billed charges",""
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","outpatient","","","6104.00","4578.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6068.65","6068.65","6068.65","1 through 10","2384.07","4988.19","other","ASC"
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","outpatient","","","6104.00","4578.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7002.05","7002.05","7071.53","1 through 10","2384.07","4988.19","other","ASC "
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","outpatient","","","6104.00","4578.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2641.52","","Case rate ($2,641.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6762.29","6762.29","6762.29","1 through 10","2384.07","4988.19","other","Multiple Surgery"
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","outpatient","","","6104.00","4578.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2641.52","","Case rate ($2,641.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6128.33","6128.33","6128.33","1 through 10","2384.07","4988.19","other","Multiple Surgery"
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","outpatient","","","6104.00","4578.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2641.52","","Case rate ($2,641.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6445.31","6445.31","6445.31","1 through 10","2384.07","4988.19","other","Multiple Surgery"
"Rem/Reinsert Impl Drug Delivery","PX-76000105","CDM","11983","CPT","0761","RC","","","","both","","","1201.00","900.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.05","","APC Price ($473.84). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","488.42","488.42","488.42","1 through 10","372.31","954.8","other","OPPS APC"
"Rem/Reinsert Impl Drug Delivery","PX-76000105","CDM","11983","CPT","0761","RC","","","","both","","","1201.00","900.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","954.80","79.5","","916.86","916.86","916.86","1 through 10","372.31","954.8","percent of total billed charges",""
"Rem/Reinsert Impl Drug Delivery","PX-76000105","CDM","11983","CPT","0761","RC","","","","both","","","1201.00","900.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","924.77","77","","897.05","897.05","897.05","1 through 10","372.31","954.8","percent of total billed charges",""
"Rem/Reinsert Impl Drug Delivery","PX-76000105","CDM","11983","CPT","0761","RC","","","","both","","","1201.00","900.75","MEDICARE [2001]","HB BWH MEDICARE","473.84","","APC Price ($473.84). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","473.88","473.88","473.88","1 through 10","372.31","954.8","other","OPPS APC"
"Rem/Reinsert Impl Drug Delivery","PX-76000105","CDM","11983","CPT","0761","RC","","","","both","","","1201.00","900.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","459.98","38.3","","455.52","455.52","885.40","1 through 10","372.31","954.8","percent of total billed charges",""
"Rem/Reinsert Impl Drug Delivery","PX-76000105","CDM","11983","CPT","0761","RC","","","","both","","","1201.00","900.75","WELLPOINT [1015]","HB AMC WELLPOINT","886.10","73.78","","2032.34","2032.34","2032.34","1 through 10","372.31","954.8","percent of total billed charges",""
"Rem/Reinsert Impl Drug Delivery","PX-76000105","CDM","11983","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","AETNA [1001]","HB AMC AETNA HMO","838.30","69.8","","556.87","556.87","556.87","1 through 10","398.14","1333.45","percent of total billed charges",""
"Rem/Reinsert Impl Drug Delivery","PX-76000105","CDM","11983","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","398.14","","Case rate ($398.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","814.59","799.86","814.59","1 through 10","398.14","1333.45","other","ASC"
"Rem/Reinsert Impl Drug Delivery","PX-76000105","CDM","11983","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","398.14","","Case rate ($398.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","932.05","922.89","932.05","11","398.14","1333.45","other","ASC "
"REMOTE SLEEP BLUETOOTH PATIENT HANDHELD INSPIRE IPG COMPATIBLE","SUP-ITM-10306192","CDM","C1787","HCPCS","0270","RC","","","","both","","","4200.00","3150.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2238.60","53.3","","3163.82","3163.82","3163.82","1 through 10","1302","3339","percent of total billed charges",""
"REMOTE SLEEP BLUETOOTH PATIENT HANDHELD INSPIRE IPG COMPATIBLE","SUP-ITM-10306192","CDM","C1787","HCPCS","0270","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1639.86","1566.60","1745.64","1 through 10","1302","3339","percent of total billed charges",""
"REMOTE SLEEP BLUETOOTH PATIENT HANDHELD INSPIRE IPG COMPATIBLE","SUP-ITM-10306192","CDM","C1787","HCPCS","0270","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","1642.20","1642.20","1642.20","1 through 10","1302","3339","percent of total billed charges",""
"REMOTE SLEEP BLUETOOTH PATIENT HANDHELD INSPIRE IPG COMPATIBLE","SUP-ITM-10306192","CDM","C1787","HCPCS","0270","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2332.15","846.87","3126.90","1 through 10","1302","3339","percent of total billed charges",""
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","both","","","748.00","561.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1145.70","1031.00","1145.70","1 through 10","231.88","1391.62","other","OPPS APC"
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","both","","","748.00","561.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1094.04","1094.04","1094.04","1 through 10","231.88","1391.62","other","OPPS APC"
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","both","","","748.00","561.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","989.36","1113.41","1 through 10","231.88","1391.62","other","OPPS APC"
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","both","","","748.00","561.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","231.88","1391.62","other","OPPS APC"
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","outpatient","","","748.00","561.00","AETNA [1001]","HB AMC AETNA HMO","522.10","69.8","","565.50","565.50","565.50","1 through 10","390.9","2384.07","percent of total billed charges",""
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","outpatient","","","748.00","561.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1749.60","1749.60","1749.60","1 through 10","390.9","2384.07","other","ASC"
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","outpatient","","","748.00","561.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2038.73","2018.70","2038.73","1 through 10","390.9","2384.07","other","ASC "
"Removal Biliary Drg Catheter Req Fluor Gid Rs&I","PX-36000380","CDM","47537","CPT","0361","RC","","","","outpatient","","","748.00","561.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","611.27","81.72","","579.57","579.57","579.57","1 through 10","390.9","2384.07","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-76002197","CDM","69209","CPT","0761","RC","","","","both","","","103.00","77.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","81.89","79.5","","78.70","78.70","78.70","1 through 10","31.93","88.17","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-76002197","CDM","69209","CPT","0761","RC","","","","both","","","103.00","77.25","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","70.54","70.54","1 through 10","31.93","88.17","other","OPPS APC"
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-76002197","CDM","69209","CPT","0761","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37.60","36.5","","31.70","31.70","31.70","1 through 10","31.93","88.17","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-76002197","CDM","69209","CPT","0761","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39.45","38.3","","39.10","29.72","39.10","11","31.93","88.17","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-76002197","CDM","69209","CPT","0761","RC","","","","outpatient","","","103.00","77.25","AETNA [1001]","HB AMC AETNA HMO","71.89","69.8","","67.70","47.80","67.70","1 through 10","53.83","350.18","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-76002197","CDM","69209","CPT","0761","RC","","","","outpatient","","","103.00","77.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","63.92","","Case rate ($63.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","149.64","149.64","149.64","1 through 10","53.83","350.18","other","ASC "
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-98301336","CDM","69209","CPT","0983","RC","","","","both","","","76.00","57.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","60.42","79.5","","78.70","78.70","78.70","1 through 10","23.56","88.17","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-98301336","CDM","69209","CPT","0983","RC","","","","both","","","76.00","57.00","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","70.54","70.54","1 through 10","23.56","88.17","other","OPPS APC"
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-98301336","CDM","69209","CPT","0983","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.74","36.5","","31.70","31.70","31.70","1 through 10","23.56","88.17","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-98301336","CDM","69209","CPT","0983","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.11","38.3","","39.10","29.72","39.10","11","23.56","88.17","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-98301336","CDM","69209","CPT","0983","RC","","","","outpatient","","","76.00","57.00","AETNA [1001]","HB AMC AETNA HMO","53.05","69.8","","67.70","47.80","67.70","1 through 10","42.48","350.18","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-98301336","CDM","69209","CPT","0983","RC","","","","outpatient","","","76.00","57.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","63.92","","Case rate ($63.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","149.64","149.64","149.64","1 through 10","42.48","350.18","other","ASC "
"Removal Impacted Cerumen Irrigation/Lvg Unilat|BILATERAL PROCEDURE","PX-76002197","CDM","69209","CPT","0761","RC","","","50","outpatient","","","103.00","77.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","95.88","","Case rate ($95.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","196.17","192.62","271.68","1 through 10","95.88","651.34","other","ASC"
"Removal Impacted Cerumen Irrigation/Lvg Unilat|BILATERAL PROCEDURE","PX-76002197","CDM","69209","CPT","0761","RC","","","50","outpatient","","","103.00","77.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","95.88","","Case rate ($95.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","224.46","222.25","224.46","1 through 10","95.88","651.34","other","ASC "
"Removal Impacted Cerumen Irrigation/Lvg Unilat|BILATERAL PROCEDURE","PX-98301336","CDM","69209","CPT","0983","RC","","","50","outpatient","","","76.00","57.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","95.88","","Case rate ($95.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","196.17","192.62","271.68","1 through 10","95.88","651.34","other","ASC"
"Removal Impacted Cerumen Irrigation/Lvg Unilat|BILATERAL PROCEDURE","PX-98301336","CDM","69209","CPT","0983","RC","","","50","outpatient","","","76.00","57.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","95.88","","Case rate ($95.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","224.46","222.25","224.46","1 through 10","95.88","651.34","other","ASC "
"Removal Non-Biodegradable Drug Delivery Implant","PX-76001576","CDM","11982","CPT","0761","RC","","","","both","","","673.00","504.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","535.04","79.5","","513.91","344.78","5340.46","1 through 10","208.63","592.3","percent of total billed charges",""
"Removal Non-Biodegradable Drug Delivery Implant","PX-76001576","CDM","11982","CPT","0761","RC","","","","both","","","673.00","504.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","245.65","36.5","","243.57","207.00","243.57","1 through 10","208.63","592.3","percent of total billed charges",""
"Removal Non-Biodegradable Drug Delivery Implant","PX-76001576","CDM","11982","CPT","0761","RC","","","","both","","","673.00","504.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","257.76","38.3","","255.32","255.32","4729.54","1 through 10","208.63","592.3","percent of total billed charges",""
"Removal Non-Biodegradable Drug Delivery Implant","PX-76001576","CDM","11982","CPT","0761","RC","","","","outpatient","","","673.00","504.75","AETNA [1001]","HB AMC AETNA HMO","469.75","69.8","","312.13","312.13","312.13","1 through 10","351.71","1333.45","percent of total billed charges",""
"Removal Non-Biodegradable Drug Delivery Implant","PX-76001576","CDM","11982","CPT","0761","RC","","","","outpatient","","","673.00","504.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","398.14","","Case rate ($398.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","932.05","799.86","932.05","1 through 10","351.71","1333.45","other","ASC"
"Removal Non-Biodegradable Drug Delivery Implant","PX-76001576","CDM","11982","CPT","0761","RC","","","","outpatient","","","673.00","504.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","398.14","","Case rate ($398.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","922.89","922.89","932.05","22","351.71","1333.45","other","ASC "
"Removal Non-Biodegradable Drug Delivery Implant","PX-76001576","CDM","11982","CPT","0761","RC","","","","outpatient","","","673.00","504.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","549.98","81.72","","522.01","287.12","8085.53","1 through 10","351.71","1333.45","percent of total billed charges",""
"Removal of Sperm Duct(S)","PX-98301382","CDM","55250","CPT","0983","RC","","","","both","","","2064.00","1548.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","790.51","38.3","","7909.54","7909.54","7909.54","1 through 10","639.84","3040.6","percent of total billed charges",""
"Removal of Sperm Duct(S)","PX-98301382","CDM","55250","CPT","0983","RC","","","","both","","","2064.00","1548.00","WELLPOINT [1015]","HB AMC WELLPOINT","1522.82","73.78","","6209.13","6209.13","6209.13","1 through 10","639.84","3040.6","percent of total billed charges",""
"Removal of Sperm Duct(S)","PX-98301382","CDM","55250","CPT","0983","RC","","","","outpatient","","","2064.00","1548.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3820.50","3820.50","3820.50","1 through 10","736.64","2384.07","other","Multiple Surgery"
"Removal of Sperm Duct(S)","PX-98301382","CDM","55250","CPT","0983","RC","","","","outpatient","","","2064.00","1548.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1686.70","81.72","","4008.40","4008.40","4008.40","1 through 10","736.64","2384.07","percent of total billed charges",""
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","both","","","2395.00","1796.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","860.54","","APC Price ($835.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","868.69","868.69","868.69","1 through 10","742.45","1904.03","other","OPPS APC"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","both","","","2395.00","1796.25","HUMANA [1012]","HB BWH MEDICARE","835.47","","APC Price ($835.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","823.86","823.86","823.86","1 through 10","742.45","1904.03","other","OPPS APC"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","both","","","2395.00","1796.25","MEDICARE [2001]","HB BWH MEDICARE","835.47","","APC Price ($835.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","767.90","835.56","13","742.45","1904.03","other","OPPS APC"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","both","","","2395.00","1796.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","874.18","36.5","","736.39","736.39","736.39","1 through 10","742.45","1904.03","percent of total billed charges",""
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","both","","","2395.00","1796.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","917.29","38.3","","1718.32","908.29","1718.32","1 through 10","742.45","1904.03","percent of total billed charges",""
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","both","","","2395.00","1796.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","818.85","818.85","1 through 10","742.45","1904.03","other","OPPS APC"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2395.00","1796.25","AETNA [1001]","HB AMC AETNA HMO","1671.71","69.8","","1811.94","1572.67","1811.94","1 through 10","579.34","2384.07","percent of total billed charges",""
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2395.00","1796.25","AETNA [1001]","HB AMC AETNA PPO","1925.58","80.4","","1217.25","1217.25","1217.25","1 through 10","579.34","2384.07","percent of total billed charges",""
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2395.00","1796.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1330.98","1330.98","1330.98","1 through 10","579.34","2384.07","other","ASC"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2395.00","1796.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1535.70","767.85","1550.94","1 through 10","579.34","2384.07","other","ASC "
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2395.00","1796.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1680.09","1680.09","1680.09","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2395.00","1796.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1344.07","1344.07","1344.07","1 through 10","579.34","2384.07","other","Multiple Surgery"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2395.00","1796.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1957.19","81.72","","1857.01","1857.01","1857.01","1 through 10","579.34","2384.07","percent of total billed charges",""
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2395.00","1796.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1957.19","81.72","","1857.01","1857.01","1857.01","1 through 10","579.34","2384.07","percent of total billed charges",""
"Removal Sutures/Staples Not Requiring Anesthesia","PX-76002803","CDM","15853","CPT","0761","RC","","","","both","","","101.00","75.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38.68","38.3","","38.32","38.32","38.32","1 through 10","31.31","80.3","percent of total billed charges",""
"Removal Sutures/Staples Not Requiring Anesthesia","PX-98302402","CDM","15853","CPT","0983","RC","","","","both","","","55.00","41.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21.07","38.3","","38.32","38.32","38.32","1 through 10","17.05","43.73","percent of total billed charges",""
"Remove Cerumen Impacted Unilate","PX-76001668","CDM","69210","CPT","0761","RC","","","","both","","","219.00","164.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.42","28.42","33.43","1 through 10","67.01","174.11","other","OPPS APC"
"Remove Cerumen Impacted Unilate","PX-76001668","CDM","69210","CPT","0761","RC","","","","both","","","219.00","164.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","79.94","36.5","","79.08","79.08","79.08","1 through 10","67.01","174.11","percent of total billed charges",""
"Remove Cerumen Impacted Unilate","PX-76001668","CDM","69210","CPT","0761","RC","","","","both","","","219.00","164.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","83.88","38.3","","82.89","80.56","82.89","1 through 10","67.01","174.11","percent of total billed charges",""
"Remove Cerumen Impacted Unilate","PX-76001668","CDM","69210","CPT","0761","RC","","","","both","","","219.00","164.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","70.54","32.77","139.00","1 through 10","67.01","174.11","other","OPPS APC"
"Remove Cerumen Impacted Unilate","PX-76001668","CDM","69210","CPT","0761","RC","","","","outpatient","","","219.00","164.25","AETNA [1001]","HB AMC AETNA HMO","152.86","69.8","","330.72","330.72","330.72","1 through 10","63.92","350.18","percent of total billed charges",""
"Remove Cerumen Impacted Unilate|BILATERAL PROCEDURE","PX-76001668","CDM","69210","CPT","0761","RC","","","50","outpatient","","","219.00","164.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","95.88","","Case rate ($95.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","128.42","95.84","222.57","1 through 10","95.88","651.34","other","ASC"
"Remove Cerumen Impacted Unilate|BILATERAL PROCEDURE","PX-76001668","CDM","69210","CPT","0761","RC","","","50","outpatient","","","219.00","164.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","95.88","","Case rate ($95.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","148.17","148.17","149.64","1 through 10","95.88","651.34","other","ASC "
"Remove Contraceptive Capsule","PX-76000102","CDM","11976","CPT","0761","RC","","","","both","","","778.00","583.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","297.97","38.3","","294.81","294.81","294.81","1 through 10","241.18","1044.34","percent of total billed charges",""
"Remove Contraceptive Capsule","PX-76000102","CDM","11976","CPT","0761","RC","","","","outpatient","","","778.00","583.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1344.07","1344.07","1344.07","1 through 10","406.58","1234.13","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","672.00","504.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","652.00","652.00","652.00","1 through 10","208.32","534.24","other","OPPS APC"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","672.00","504.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","534.24","79.5","","513.12","344.26","1381.59","25","208.32","534.24","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","672.00","504.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","358.18","53.3","","513.12","329.26","3227.49","1 through 10","208.32","534.24","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","672.00","504.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","517.44","77","","271.04","271.04","271.04","1 through 10","208.32","534.24","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","672.00","504.00","MEDICARE [2001]","HB BWH MEDICARE","361.21","","APC Price ($361.21). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.24","350.13","652.00","1 through 10","208.32","534.24","other","OPPS APC"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","245.28","36.5","","243.20","206.68","472.04","20","208.32","534.24","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","257.38","38.3","","254.93","254.93","764.79","102","208.32","534.24","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","672.00","504.00","TRICARE [160005]","HB BWH TRICARE","343.18","","APC Price ($361.24). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","343.18","343.18","343.18","1 through 10","208.32","534.24","other","Tricare OPPS"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","672.00","504.00","WELLPOINT [1015]","HB AMC WELLPOINT","495.80","73.78","","1137.41","716.21","1137.41","15","208.32","534.24","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","AETNA [1001]","HB AMC AETNA HMO","469.06","69.8","","441.40","311.66","441.40","20","165.93","700.33","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","AETNA [1001]","HB AMC AETNA PPO","540.29","80.4","","341.65","311.66","508.56","1 through 10","165.93","700.33","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","375.65","55.9","","477.28","477.28","477.28","1 through 10","165.93","700.33","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","381.21","381.21","388.23","69","165.93","700.33","other","ASC"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","439.84","439.84","444.20","154","165.93","700.33","other","ASC "
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","462.94","429.76","481.20","1 through 10","165.93","700.33","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","384.96","370.02","740.04","62","165.93","700.33","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","389.94","1169.82","39","165.93","700.33","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","481.20","163.99","481.20","1 through 10","165.93","700.33","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","404.87","404.87","1 through 10","165.93","700.33","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","408.19","212.39","424.78","11","165.93","700.33","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","540.29","80.4","","508.56","508.56","508.56","1 through 10","165.93","700.33","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","288.29","42.9","","1865.96","1865.96","1865.96","1 through 10","165.93","700.33","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","549.16","81.72","","596.68","596.68","596.68","1 through 10","165.93","700.33","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","549.16","81.72","","521.21","521.20","1803.21","12","165.93","700.33","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","389.94","389.94","389.94","1 through 10","165.93","700.33","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","672.00","504.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","408.19","408.19","408.19","1 through 10","165.93","700.33","other","Multiple Surgery"
"Remove Drug Implant Device","PX-98300625","CDM","11982","CPT","0983","RC","","","","both","","","522.00","391.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","414.99","79.5","","513.91","344.78","5340.46","1 through 10","161.82","592.3","percent of total billed charges",""
"Remove Drug Implant Device","PX-98300625","CDM","11982","CPT","0983","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","190.53","36.5","","243.57","207.00","243.57","1 through 10","161.82","592.3","percent of total billed charges",""
"Remove Drug Implant Device","PX-98300625","CDM","11982","CPT","0983","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","199.93","38.3","","255.32","255.32","4729.54","1 through 10","161.82","592.3","percent of total billed charges",""
"Remove Drug Implant Device","PX-98300625","CDM","11982","CPT","0983","RC","","","","outpatient","","","522.00","391.50","AETNA [1001]","HB AMC AETNA HMO","364.36","69.8","","312.13","312.13","312.13","1 through 10","208.04","1333.45","percent of total billed charges",""
"Remove Drug Implant Device","PX-98300625","CDM","11982","CPT","0983","RC","","","","outpatient","","","522.00","391.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","426.58","81.72","","522.01","287.12","8085.53","1 through 10","208.04","1333.45","percent of total billed charges",""
"Remove FB Muscle/Tendon Smp","PX-76000283","CDM","20520","CPT","0761","RC","","","","outpatient","","","2233.00","1674.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1166.07","52.22","","3646.12","3646.12","3646.12","1 through 10","893.2","1824.81","percent of total billed charges",""
"Remove Impl Wire Superfic","PX-76000303","CDM","20670","CPT","0761","RC","","","","outpatient","","","3993.00","2994.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1375.50","","Case rate ($1,375.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2640.96","2640.96","2640.96","1 through 10","1375.5","3263.08","other","Multiple Surgery"
"Remove Pacemaker Pulse Gen Only","PX-48000067","CDM","33233","CPT","0361","RC","","","","both","","","8746.00","6559.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9827.23","","APC Price ($9,827.23). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4039.95","4039.95","4039.95","1 through 10","2711.26","12284.04","other","OPPS APC"
"Remove Pacemaker Pulse Gen Only","PX-48000067","CDM","33233","CPT","0361","RC","","","","both","","","8746.00","6559.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4661.62","53.3","","10968.67","10968.67","10968.67","1 through 10","2711.26","12284.04","percent of total billed charges",""
"Remove Pacemaker Pulse Gen Only","PX-48000067","CDM","33233","CPT","0361","RC","","","","outpatient","","","8746.00","6559.50","AETNA [1001]","HB AMC AETNA HMO","6104.71","69.8","","12694.72","12694.72","12694.72","1 through 10","2384.07","8467.02","percent of total billed charges",""
"Remove Pacemaker Pulse Gen Only","PX-48000067","CDM","33233","CPT","0361","RC","","","","outpatient","","","8746.00","6559.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","8467.02","","Case rate ($8,467.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","8661.76","8505.12","8661.76","1 through 10","2384.07","8467.02","other","ASC"
"Remove Pacemaker Pulse Gen Only","PX-48000067","CDM","33233","CPT","0361","RC","","","","outpatient","","","8746.00","6559.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","8467.02","","Case rate ($8,467.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","8505.12","8505.12","8505.12","1 through 10","2384.07","8467.02","other","ASC "
"Remove Pacemaker Pulse Gen Only","PX-48000067","CDM","33233","CPT","0361","RC","","","","outpatient","","","8746.00","6559.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4812.67","","Case rate ($4,812.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","8481.00","8481.00","8481.00","1 through 10","2384.07","8467.02","other","Multiple Surgery"
"Remove Renal Tube Fluoro","PX-76001227","CDM","50389","CPT","0761","RC","","","","both","","","1913.00","1434.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","776.73","","APC Price ($792.58). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","776.81","776.81","776.81","1 through 10","593.03","1520.84","other","OPPS APC"
"Remove Renal Tube Fluoro","PX-76001227","CDM","50389","CPT","0761","RC","","","","outpatient","","","1913.00","1434.75","AETNA [1001]","HB AMC AETNA HMO","1335.27","69.8","","886.69","886.69","886.69","1 through 10","562.25","2384.07","percent of total billed charges",""
"Remove Spine Eltrd Perq Aray","PX-76001491","CDM","63661","CPT","0761","RC","","","","outpatient","","","5957.00","4467.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3110.75","52.22","","2183.79","2162.34","2183.79","1 through 10","2382.8","4868.06","percent of total billed charges",""
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","both","","","497.00","372.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","264.90","53.3","","482.00","482.00","482.00","1 through 10","154.07","395.12","percent of total billed charges",""
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","both","","","497.00","372.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","154.07","395.12","other","OPPS APC"
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","both","","","497.00","372.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","181.41","36.5","","179.79","174.48","179.79","1 through 10","154.07","395.12","percent of total billed charges",""
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","both","","","497.00","372.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","190.35","38.3","","188.46","183.16","561.09","1 through 10","154.07","395.12","percent of total billed charges",""
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","outpatient","","","497.00","372.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","405.38","412.84","1 through 10","176.45","700.33","other","ASC"
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","outpatient","","","497.00","372.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","472.37","467.73","482.00","14","176.45","700.33","other","ASC "
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","outpatient","","","497.00","372.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6151.50","482.00","6151.50","1 through 10","176.45","700.33","other","Multiple Surgery"
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","outpatient","","","497.00","372.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","482.00","482.00","482.00","1 through 10","176.45","700.33","other","Multiple Surgery"
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","outpatient","","","497.00","372.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","406.15","81.72","","385.31","385.31","385.31","1 through 10","176.45","700.33","percent of total billed charges",""
"Remove/Insert Drug Implant","PX-98300626","CDM","11983","CPT","0983","RC","","","","both","","","726.00","544.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.05","","APC Price ($473.84). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","488.42","488.42","488.42","1 through 10","225.06","592.3","other","OPPS APC"
"Remove/Insert Drug Implant","PX-98300626","CDM","11983","CPT","0983","RC","","","","both","","","726.00","544.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","577.17","79.5","","916.86","916.86","916.86","1 through 10","225.06","592.3","percent of total billed charges",""
"Remove/Insert Drug Implant","PX-98300626","CDM","11983","CPT","0983","RC","","","","both","","","726.00","544.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","559.02","77","","897.05","897.05","897.05","1 through 10","225.06","592.3","percent of total billed charges",""
"Remove/Insert Drug Implant","PX-98300626","CDM","11983","CPT","0983","RC","","","","both","","","726.00","544.50","MEDICARE [2001]","HB BWH MEDICARE","473.84","","APC Price ($473.84). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","473.88","473.88","473.88","1 through 10","225.06","592.3","other","OPPS APC"
"Remove/Insert Drug Implant","PX-98300626","CDM","11983","CPT","0983","RC","","","","both","","","726.00","544.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","278.06","38.3","","455.52","455.52","885.40","1 through 10","225.06","592.3","percent of total billed charges",""
"Remove/Insert Drug Implant","PX-98300626","CDM","11983","CPT","0983","RC","","","","both","","","726.00","544.50","WELLPOINT [1015]","HB AMC WELLPOINT","535.64","73.78","","2032.34","2032.34","2032.34","1 through 10","225.06","592.3","percent of total billed charges",""
"Remove/Insert Drug Implant","PX-98300626","CDM","11983","CPT","0983","RC","","","","outpatient","","","726.00","544.50","AETNA [1001]","HB AMC AETNA HMO","506.75","69.8","","556.87","556.87","556.87","1 through 10","293.67","1333.45","percent of total billed charges",""
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","9433.00","7074.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","12799.76","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","12799.07","12788.63","12803.23","1 through 10","2924.23","15533.69","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","9433.00","7074.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12426.95","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12229.36","12229.36","12229.36","1 through 10","2924.23","15533.69","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","9433.00","7074.75","HUMANA [1012]","HB BWH MEDICARE","12426.95","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9019.93","8972.36","9019.93","1 through 10","2924.23","15533.69","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","9433.00","7074.75","MEDICARE [2001]","HB BWH MEDICARE","12426.95","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12428.21","12428.21","37284.63","67","2924.23","15533.69","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","9433.00","7074.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3443.05","36.5","","2899.92","2899.92","2899.92","1 through 10","2924.23","15533.69","percent of total billed charges",""
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","9433.00","7074.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3612.84","38.3","","3576.87","3576.87","3576.87","1 through 10","2924.23","15533.69","percent of total billed charges",""
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","9433.00","7074.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","12426.95","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12179.65","12179.65","12179.65","1 through 10","2924.23","15533.69","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","9433.00","7074.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12178.41","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","12181.65","12181.65","12181.65","1 through 10","2924.23","15533.69","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","9433.00","7074.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12178.41","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","12186.65","12179.65","12198.89","1 through 10","2924.23","15533.69","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","outpatient","","","9433.00","7074.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","11297.59","","Case rate ($11,297.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","23114.87","23114.87","23114.87","1 through 10","4929.69","43419","other","ASC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","outpatient","","","9433.00","7074.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","11297.59","","Case rate ($11,297.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","26187.81","26187.81","26447.66","1 through 10","4929.69","43419","other","ASC "
"Remove/Rplc Perm Pm Gen Mlt Sys","PX-48000064","CDM","33229","CPT","0361","RC","","","","both","","","9814.00","7360.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","22645.86","","APC Price ($22,645.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","22285.78","22285.78","22285.78","1 through 10","3042.34","28307.32","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Mlt Sys","PX-48000064","CDM","33229","CPT","0361","RC","","","","both","","","9814.00","7360.50","MEDICARE [2001]","HB BWH MEDICARE","22645.86","","APC Price ($22,645.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","22648.15","22648.15","67944.45","17","3042.34","28307.32","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Mlt Sys","PX-48000064","CDM","33229","CPT","0361","RC","","","","both","","","9814.00","7360.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","22192.94","","APC Price ($22,645.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","66601.77","22197.19","66601.77","1 through 10","3042.34","28307.32","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Mlt Sys","PX-48000064","CDM","33229","CPT","0361","RC","","","","outpatient","","","9814.00","7360.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20216.96","","Case rate ($20,216.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","40615.87","40615.87","40615.87","1 through 10","5128.8","43419","other","ASC"
"Remove/Rplc Perm Pm Gen Mlt Sys","PX-48000064","CDM","33229","CPT","0361","RC","","","","outpatient","","","9814.00","7360.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","20216.96","","Case rate ($20,216.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","47327.90","47327.90","47327.90","1 through 10","5128.8","43419","other","ASC "
"Remove/Rplc Perm Pm Gen Sgl Sys","PX-48000062","CDM","33227","CPT","0361","RC","","","","both","","","26119.00","19589.25","MEDICARE [2001]","HB BWH MEDICARE","9827.23","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9828.22","9272.38","9828.22","1 through 10","8096.89","20764.61","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Sgl Sys","PX-48000062","CDM","33227","CPT","0361","RC","","","","both","","","26119.00","19589.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9630.69","","APC Price ($9,827.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9631.66","9631.66","9631.66","1 through 10","8096.89","20764.61","other","OPPS APC"
"Remvoe Vena Cava Filter Endovasc","PX-76001136","CDM","37193","CPT","0361","RC","","","","both","","","10052.00","7539.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","3849.59","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3847.25","3847.25","3847.25","1 through 10","3116.12","7991.34","other","OPPS APC"
"Remvoe Vena Cava Filter Endovasc","PX-76001136","CDM","37193","CPT","0361","RC","","","","both","","","10052.00","7539.00","MEDICARE [2001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","3737.85","1 through 10","3116.12","7991.34","other","OPPS APC"
"Remvoe Vena Cava Filter Endovasc","PX-76001136","CDM","37193","CPT","0361","RC","","","","both","","","10052.00","7539.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3849.92","38.3","","3811.47","3811.47","3811.47","1 through 10","3116.12","7991.34","percent of total billed charges",""
"Remvoe Vena Cava Filter Endovasc","PX-76001136","CDM","37193","CPT","0361","RC","","","","both","","","10052.00","7539.00","WELLPOINT [1015]","HB AMC WELLPOINT","7416.37","73.78","","7257.39","7257.39","7257.39","1 through 10","3116.12","7991.34","percent of total billed charges",""
"Remvoe Vena Cava Filter Endovasc","PX-76001136","CDM","37193","CPT","0361","RC","","","","outpatient","","","10052.00","7539.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6068.65","6068.65","6068.65","1 through 10","2377.37","9843.6","other","ASC"
"Remvoe Vena Cava Filter Endovasc","PX-76001136","CDM","37193","CPT","0361","RC","","","","outpatient","","","10052.00","7539.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7071.53","7002.05","7071.53","1 through 10","2377.37","9843.6","other","ASC "
"Renal Dialysis Access Procedures,MAJOR","444","DRG","","","","","","","","inpatient","","","66150.57","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","71825.54","","Standard inlier is a Case rate ($71,825.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $61,328, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,195.04) for the length of stay and the standard reimbursement.","71825.54","71825.54","71825.54","1 through 10","15845.76","119697.23","case rate",""
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","41242.95","30932.21","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","8620.05","","Case rate ($8,368.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,997.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,641.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,144.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,284.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,617.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.72. The transfer capital threshold is the transfer adjustment factor * $704.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8681.03","8681.03","8681.03","1 through 10","8201.6","13718.53","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","41242.95","30932.21","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","10748.37","","Case rate ($10,748.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,997.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,641.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,144.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,663.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,617.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.72. The transfer capital threshold is the transfer adjustment factor * $704.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8255.58","8255.58","8381.57","1 through 10","8201.6","13718.53","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","41242.95","30932.21","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8368.98","","Case rate ($8,368.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,997.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,641.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,144.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,284.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,617.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.72. The transfer capital threshold is the transfer adjustment factor * $704.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","39906.58","10898.00","55059.10","1 through 10","8201.6","13718.53","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","41242.95","30932.21","HUMANA [1012]","HB BWH MEDICARE","10748.37","","Case rate ($10,748.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,997.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,641.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,144.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,663.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,617.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.72. The transfer capital threshold is the transfer adjustment factor * $704.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8254.76","8254.76","8254.76","1 through 10","8201.6","13718.53","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","41242.95","30932.21","MEDICARE [2001]","HB BWH MEDICARE","10748.37","","Case rate ($10,748.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,997.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,641.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,144.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,663.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,617.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.72. The transfer capital threshold is the transfer adjustment factor * $704.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10757.67","267.44","10773.34","77","8201.6","13718.53","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","41242.95","30932.21","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","10748.37","","Case rate ($10,748.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,997.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,641.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,144.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,663.81 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,617.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.72. The transfer capital threshold is the transfer adjustment factor * $704.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8190.33","8190.33","8190.33","1 through 10","8201.6","13718.53","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","41242.95","30932.21","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8201.60","","Case rate ($8,368.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,997.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,641.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,144.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,284.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,617.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.72. The transfer capital threshold is the transfer adjustment factor * $704.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8179.65","8179.65","8179.65","1 through 10","8201.6","13718.53","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","41242.95","30932.21","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8201.60","","Case rate ($8,368.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,997.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,641.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,144.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,284.42 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,617.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.72. The transfer capital threshold is the transfer adjustment factor * $704.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8221.73","1203.19","8285.53","11","8201.6","13718.53","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","74781.02","56085.76","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","14306.37","","Case rate ($13,889.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,643.02, add-ons for qualifying new technology services are included. If operating cost exceeds $62,287.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,631.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,318.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,263.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,191.70. The transfer capital threshold is the transfer adjustment factor * $1,191.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14451.13","14372.85","23030.09","1 through 10","13611.89","23198.38","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","74781.02","56085.76","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","17913.29","","Case rate ($17,913.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,643.02, add-ons for qualifying new technology services are included. If operating cost exceeds $62,287.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,631.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,341.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,263.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,191.70. The transfer capital threshold is the transfer adjustment factor * $1,191.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13759.92","13759.92","13759.92","1 through 10","13611.89","23198.38","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","74781.02","56085.76","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","13889.68","","Case rate ($13,889.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,643.02, add-ons for qualifying new technology services are included. If operating cost exceeds $62,287.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,631.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,318.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,263.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,191.70. The transfer capital threshold is the transfer adjustment factor * $1,191.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13689.80","13689.80","106901.04","1 through 10","13611.89","23198.38","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","74781.02","56085.76","HUMANA [1012]","HB BWH MEDICARE","17913.29","","Case rate ($17,913.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,643.02, add-ons for qualifying new technology services are included. If operating cost exceeds $62,287.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,631.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,341.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,263.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,191.70. The transfer capital threshold is the transfer adjustment factor * $1,191.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13672.45","13672.45","13672.45","1 through 10","13611.89","23198.38","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","74781.02","56085.76","MEDICARE [2001]","HB BWH MEDICARE","17913.29","","Case rate ($17,913.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,643.02, add-ons for qualifying new technology services are included. If operating cost exceeds $62,287.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,631.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,341.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,263.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,191.70. The transfer capital threshold is the transfer adjustment factor * $1,191.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17984.43","0.03","18010.90","60","13611.89","23198.38","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","74781.02","56085.76","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","17913.29","","Case rate ($17,913.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,643.02, add-ons for qualifying new technology services are included. If operating cost exceeds $62,287.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,631.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,341.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,263.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,191.70. The transfer capital threshold is the transfer adjustment factor * $1,191.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","103.83","103.83","103.83","1 through 10","13611.89","23198.38","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","74781.02","56085.76","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","13611.89","","Case rate ($13,889.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,643.02, add-ons for qualifying new technology services are included. If operating cost exceeds $62,287.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,631.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,318.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,263.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,191.70. The transfer capital threshold is the transfer adjustment factor * $1,191.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13697.59","13697.59","13697.59","1 through 10","13611.89","23198.38","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","74781.02","56085.76","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","13611.89","","Case rate ($13,889.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,643.02, add-ons for qualifying new technology services are included. If operating cost exceeds $62,287.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,631.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,318.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,263.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,191.70. The transfer capital threshold is the transfer adjustment factor * $1,191.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","64660.94","64660.94","64660.94","1 through 10","13611.89","23198.38","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","74781.02","56085.76","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13611.89","","Case rate ($13,889.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,643.02, add-ons for qualifying new technology services are included. If operating cost exceeds $62,287.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,631.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,318.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,263.18 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,191.70. The transfer capital threshold is the transfer adjustment factor * $1,191.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13713.17","13650.73","20008.00","1 through 10","13611.89","23198.38","other","Inpatient DRG"
"Renal Failure Without Cc/McC","684","MS-DRG","","","","","","","","inpatient","","","29029.54","21772.15","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","5855.84","","Case rate ($5,855.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,971.87, add-ons for qualifying new technology services are included. If operating cost exceeds $52,616.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,923.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,992.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,592.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.04. The transfer capital threshold is the transfer adjustment factor * $483.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5727.88","5727.88","5727.88","1 through 10","5738.72","9166.2734","other","Inpatient Replacement Plans DRG"
"Renal Failure Without Cc/McC","684","MS-DRG","","","","","","","","inpatient","","","29029.54","21772.15","MEDICARE [2001]","HB BWH MEDICARE","5855.84","","Case rate ($5,855.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $6,971.87, add-ons for qualifying new technology services are included. If operating cost exceeds $52,616.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,923.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,992.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,592.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.04. The transfer capital threshold is the transfer adjustment factor * $483.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","126.29","126.29","126.29","1 through 10","5738.72","9166.2734","other","Inpatient Replacement Plans DRG"
"Renal Failure,EXTREME","460","DRG","","","","","","","","inpatient","","","212594.85","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","","65","","173463.80","173463.80","173463.80","1 through 10","13682.1172","120575.59","percent of total billed charges",""
"Renal Failure,EXTREME","460","DRG","","","","","","","","inpatient","","","212594.85","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","257274.81","257274.81","257274.81","1 through 10","13682.1172","120575.59","percent of total billed charges",""
"Renal Failure,EXTREME","460","DRG","","","","","","","","inpatient","","","212594.85","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14229.8854","","Fee schedule rate ($73,075.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14229.8854","47560.82","47560.82","1 through 10","13682.1172","120575.59","case rate",""
"Renal Failure,MAJOR","460","DRG","","","","","","","","inpatient","","","38589.45","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14229.8854","","Fee schedule rate ($24,648.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14229.8854","24648.44","24648.44","1 through 10","13682.1172","120575.59","case rate",""
"Renal Failure,MAJOR","460","DRG","","","","","","","","inpatient","","","38589.45","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","14941.7932","","Fee schedule rate ($25,881.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14941.7932","25881.56","25881.56","1 through 10","13682.1172","120575.59","case rate",""
"Renal Failure,MAJOR","460","DRG","","","","","","","","inpatient","","","38589.45","","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","","65","","28514.99","28514.99","28514.99","1 through 10","13682.1172","120575.59","percent of total billed charges",""
"Renal Failure,MODERATE","460","DRG","","","","","","","","inpatient","","","47034.28","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","14941.7932","","Fee schedule rate ($18,006.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14941.7932","25881.56","25881.56","1 through 10","13682.1172","120575.59","case rate",""
"Renal Failure,MODERATE","460","DRG","","","","","","","","inpatient","","","47034.28","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","18863.89","","Fee schedule rate ($18,863.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18863.89","18863.89","18863.89","1 through 10","13682.1172","120575.59","case rate",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","120.62","71.8","","351.09","63.73","351.09","21","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","110.21","65.6","","110.35","77.91","110.35","1 through 10","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","109.20","65","","128.28","105.95","128.28","1 through 10","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","117.60","70","","163.00","28.09","163.00","1 through 10","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","133.56","79.5","","128.28","86.06","128.28","30","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","89.54","53.3","","86.06","86.06","384.84","22","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","129.36","77","","125.51","125.51","125.51","1 through 10","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","109.20","65","","105.95","102.70","105.95","23","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","52.08","31","","50.37","50.37","50.37","1 through 10","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","61.32","36.5","","60.80","51.67","60.80","44","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64.34","38.3","","63.73","61.94","191.19","108","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","MOLINA [1014]","HB BWH MOLINA","58.80","35","","17.22","17.22","17.22","1 through 10","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","129.36","77","","127.14","127.14","127.14","1 through 10","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","168.00","126.00","TRICARE [160005]","HB BWH TRICARE","159.60","95","","9.94","9.94","163.00","1 through 10","8.51","159.6","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","168.00","126.00","AETNA [1001]","HB AMC AETNA HMO","117.26","69.8","","110.35","77.91","127.14","73","8.96","137.29","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","168.00","126.00","AETNA [1001]","HB AMC AETNA PPO","135.07","80.4","","127.14","127.14","127.14","1 through 10","8.96","137.29","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","135.07","80.4","","81.50","81.50","81.50","1 through 10","8.96","137.29","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","137.29","81.72","","130.31","130.31","130.31","1 through 10","8.96","137.29","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","137.29","81.72","","130.30","130.30","130.30","1 through 10","8.96","137.29","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","137.29","81.72","","130.30","71.67","130.31","43","8.96","137.29","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","both","","","267.00","200.25","CHAMPVA [160001]","HB BWH TRICARE","253.65","95","","26.50","26.50","26.50","1 through 10","21.55","253.65","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","both","","","267.00","200.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","212.27","79.5","","203.83","136.75","203.83","16","21.55","253.65","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","both","","","267.00","200.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","142.31","53.3","","136.75","136.75","136.75","11","21.55","253.65","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","both","","","267.00","200.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.46","36.5","","96.61","82.10","246.30","30","21.55","253.65","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","both","","","267.00","200.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","102.26","38.3","","101.27","98.42","289.83","85","21.55","253.65","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","both","","","267.00","200.25","TRICARE [160005]","HB BWH TRICARE","253.65","95","","259.00","153.04","259.00","1 through 10","21.55","253.65","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","both","","","267.00","200.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.54","42.9","","113.88","113.88","113.88","1 through 10","21.55","253.65","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","outpatient","","","267.00","200.25","AETNA [1001]","HB AMC AETNA HMO","186.37","69.8","","175.34","123.80","202.02","26","22.69","218.19","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","outpatient","","","267.00","200.25","AETNA [1001]","HB AMC AETNA PPO","214.67","80.4","","202.02","202.02","202.02","1 through 10","22.69","218.19","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","outpatient","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","218.19","81.72","","207.04","99.72","207.05","40","22.69","218.19","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","800.18","480.96","1887.97","195","922.25","2365.13","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1585.68","53.3","","813.12","216.42","1444.50","81","922.25","2365.13","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","922.25","31","","432.60","432.60","432.60","1 through 10","922.25","2365.13","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","148.37","54.89","631.39","94","922.25","2365.13","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","279.30","91.72","1116.77","266","922.25","2365.13","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","731.00","63.70","731.00","1 through 10","922.25","2365.13","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","384.74","384.74","384.74","1 through 10","922.25","2365.13","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","WELLPOINT [1015]","HB AMC WELLPOINT","2194.96","73.78","","286.63","119.22","1107.45","105","922.25","2365.13","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","675.31","184.75","1721.50","286","1554.74","2431.17","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA PPO","2391.90","80.4","","1261.44","103.12","1514.10","21","1554.74","2431.17","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2391.90","80.4","","1365.00","1365.00","1365.00","1 through 10","1554.74","2431.17","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2431.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1554.74","2431.17","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","431.26","71.26","1459.57","88","1554.74","2431.17","percent of total billed charges",""
"Repair Complex 1.1-2.5 Cm - 13131","PX-76000146","CDM","13131","CPT","0761","RC","","","","both","","","1898.00","1423.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","244.11","244.11","244.11","1 through 10","450.74","1508.91","other","OPPS APC"
"Repair Complex 1.1-2.5 Cm - 13131","PX-76000146","CDM","13131","CPT","0761","RC","","","","both","","","1898.00","1423.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.43","233.43","233.43","1 through 10","450.74","1508.91","other","OPPS APC"
"Repair Complex 1.1-2.5 Cm - 13131","PX-76000146","CDM","13131","CPT","0761","RC","","","","both","","","1898.00","1423.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1508.91","79.5","","1129.35","1129.35","1129.35","1 through 10","450.74","1508.91","percent of total billed charges",""
"Repair Complex 1.1-2.5 Cm - 13131","PX-76000146","CDM","13131","CPT","0761","RC","","","","both","","","1898.00","1423.50","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","237.23","1 through 10","450.74","1508.91","other","OPPS APC"
"Repair Complex 1.1-2.5 Cm - 13131","PX-76000146","CDM","13131","CPT","0761","RC","","","","both","","","1898.00","1423.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","692.77","36.5","","686.69","686.69","686.69","1 through 10","450.74","1508.91","percent of total billed charges",""
"Repair Complex 1.1-2.5 Cm - 13131","PX-76000146","CDM","13131","CPT","0761","RC","","","","both","","","1898.00","1423.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","726.93","38.3","","719.83","719.83","719.83","1 through 10","450.74","1508.91","percent of total billed charges",""
"Repair Complex 1.1-2.5 Cm - 13131","PX-76000146","CDM","13131","CPT","0761","RC","","","","outpatient","","","1898.00","1423.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","416.28","416.28","416.28","1 through 10","314.08","1551.05","other","ASC "
"Repair Complex 1.1-2.5 Cm - 13131","PX-76000146","CDM","13131","CPT","0761","RC","","","","outpatient","","","1898.00","1423.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","455.42","455.42","455.42","1 through 10","314.08","1551.05","other","Multiple Surgery"
"Repair Complex 2.6-7.5 Cm - 13132","PX-76000147","CDM","13132","CPT","0761","RC","","","","both","","","3225.00","2418.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1718.93","53.3","","19039.11","19039.11","19039.11","1 through 10","690.59","2563.88","percent of total billed charges",""
"Repair Complex 2.6-7.5 Cm - 13132","PX-76000147","CDM","13132","CPT","0761","RC","","","","both","","","3225.00","2418.75","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","726.94","726.94","1 through 10","690.59","2563.88","other","OPPS APC"
"Repair Complex 2.6-7.5 Cm - 13132","PX-76000147","CDM","13132","CPT","0761","RC","","","","both","","","3225.00","2418.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1177.13","36.5","","1102.07","1102.07","1102.07","1 through 10","690.59","2563.88","percent of total billed charges",""
"Repair Complex 2.6-7.5 Cm - 13132","PX-76000147","CDM","13132","CPT","0761","RC","","","","both","","","3225.00","2418.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1235.18","38.3","","1222.66","1222.66","1222.66","1 through 10","690.59","2563.88","percent of total billed charges",""
"Repair Complex 2.6-7.5 Cm - 13132","PX-76000147","CDM","13132","CPT","0761","RC","","","","both","","","3225.00","2418.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","712.33","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","712.41","712.41","719.91","1 through 10","690.59","2563.88","other","OPPS APC"
"Repair Complex 2.6-7.5 Cm - 13132","PX-76000147","CDM","13132","CPT","0761","RC","","","","outpatient","","","3225.00","2418.75","AETNA [1001]","HB AMC AETNA HMO","2251.05","69.8","","971.50","971.50","971.50","1 through 10","482.89","2635.47","percent of total billed charges",""
"Repair Complex 2.6-7.5 Cm - 13132","PX-76000147","CDM","13132","CPT","0761","RC","","","","outpatient","","","3225.00","2418.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","560.15","560.15","560.15","1 through 10","482.89","2635.47","other","Multiple Surgery"
"Repair Complex 2.6-7.5 Cm - 13132","PX-76000147","CDM","13132","CPT","0761","RC","","","","outpatient","","","3225.00","2418.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1178.25","1178.25","1178.25","1 through 10","482.89","2635.47","other","Multiple Surgery"
"Repair Complex 2.6-7.5 Cm - 13132","PX-76000147","CDM","13132","CPT","0761","RC","","","","outpatient","","","3225.00","2418.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2635.47","81.72","","1529.52","1147.14","1529.52","1 through 10","482.89","2635.47","percent of total billed charges",""
"Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm","PX-98300873","CDM","13151","CPT","0983","RC","","","","both","","","1236.00","927.00","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","363.47","726.94","1 through 10","383.16","982.62","other","OPPS APC"
"Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm","PX-98300873","CDM","13151","CPT","0983","RC","","","","both","","","1236.00","927.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","451.14","36.5","","788.15","788.15","788.15","1 through 10","383.16","982.62","percent of total billed charges",""
"Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm","PX-98300873","CDM","13151","CPT","0983","RC","","","","both","","","1236.00","927.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","473.39","38.3","","2478.54","802.94","2478.54","1 through 10","383.16","982.62","percent of total billed charges",""
"Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm","PX-98300873","CDM","13151","CPT","0983","RC","","","","outpatient","","","1236.00","927.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1076.84","1076.84","1076.84","1 through 10","482.89","1234.13","other","Multiple Surgery"
"Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm","PX-98300873","CDM","13151","CPT","0983","RC","","","","outpatient","","","1236.00","927.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1236.20","1236.20","1236.20","1 through 10","482.89","1234.13","other","Multiple Surgery"
"Repair Complex Scalp/Arm/Leg 2.6-7.5 Cm","PX-98300868","CDM","13121","CPT","0983","RC","","","","both","","","1418.00","1063.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","755.79","53.3","","4546.08","4546.08","4546.08","1 through 10","439.58","1127.31","percent of total billed charges",""
"Repair Complex Scalp/Arm/Leg 2.6-7.5 Cm","PX-98300868","CDM","13121","CPT","0983","RC","","","","both","","","1418.00","1063.50","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.47","363.47","726.94","1 through 10","439.58","1127.31","other","OPPS APC"
"Repair Complex Scalp/Arm/Leg 2.6-7.5 Cm","PX-98300868","CDM","13121","CPT","0983","RC","","","","both","","","1418.00","1063.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","712.33","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","715.31","715.31","715.31","1 through 10","439.58","1127.31","other","OPPS APC"
"Repair Complex Scalp/Arm/Leg 2.6-7.5 Cm","PX-98300868","CDM","13121","CPT","0983","RC","","","","outpatient","","","1418.00","1063.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1236.20","1236.20","1236.20","1 through 10","482.89","1234.13","other","Multiple Surgery"
"Repair Complex Trunk 2.6-7.5 Cm","PX-98300865","CDM","13101","CPT","0983","RC","","","","both","","","1352.00","1014.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","337.25","337.25","337.25","1 through 10","419.12","1074.84","other","OPPS APC"
"Repair Complex Trunk 2.6-7.5 Cm","PX-98300865","CDM","13101","CPT","0983","RC","","","","both","","","1352.00","1014.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","712.33","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","712.40","712.40","712.40","1 through 10","419.12","1074.84","other","OPPS APC"
"Repair Complex Trunk 2.6-7.5 Cm","PX-98300865","CDM","13101","CPT","0983","RC","","","","outpatient","","","1352.00","1014.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1087.01","80.4","","1678.95","1678.95","1678.95","1 through 10","482.89","1234.13","percent of total billed charges",""
"Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm","PX-98300862","CDM","12044","CPT","0983","RC","","","","both","","","962.00","721.50","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","726.94","726.94","1 through 10","298.22","908.58","other","OPPS APC"
"Repair Intermediate S/a/T/E 20.1-30.0 Cm","PX-98300617","CDM","12036","CPT","0983","RC","","","","both","","","1256.00","942.00","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.47","363.47","363.47","1 through 10","389.36","998.52","other","OPPS APC"
"Repair Intermediate S/a/T/E 20.1-30.0 Cm","PX-98300617","CDM","12036","CPT","0983","RC","","","","both","","","1256.00","942.00","WELLPOINT [1015]","HB AMC WELLPOINT","926.68","73.78","","1424.47","1424.47","1424.47","1 through 10","389.36","998.52","percent of total billed charges",""
"Repair Nail Bed","PX-76000095","CDM","11760","CPT","0761","RC","","","","outpatient","","","906.00","679.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1280.02","1280.02","1280.02","1 through 10","473.48","740.38","other","ASC "
"Repair Vagina/Perineum","PX-45000029","CDM","57210","CPT","0450","RC","","","","both","","","8960.00","6720.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3270.40","36.5","","8757.50","8757.50","8757.50","1 through 10","2777.6","7123.2","percent of total billed charges",""
"Repair Vagina/Perineum","PX-45000029","CDM","57210","CPT","0450","RC","","","","outpatient","","","8960.00","6720.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($864).","14790.96","14790.96","14790.96","1 through 10","3584","7322.11","other","Emergency Room"
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","6911.00","5183.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3678.04","3678.04","3678.04","1 through 10","2142.41","5494.25","other","OPPS APC"
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","6911.00","5183.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","4671.83","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","3703.84","3703.84","3703.84","1 through 10","2142.41","5494.25","other","OPPS APC"
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","6911.00","5183.25","MEDICARE [2001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3478.89","3737.85","1 through 10","2142.41","5494.25","other","OPPS APC"
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","outpatient","","","6911.00","5183.25","AETNA [1001]","HB AMC AETNA HMO","4823.88","69.8","","4275.84","4275.84","4275.84","1 through 10","2377.37","5647.67","percent of total billed charges",""
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","outpatient","","","6911.00","5183.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6068.65","6068.65","6068.65","1 through 10","2377.37","5647.67","other","ASC"
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","outpatient","","","6911.00","5183.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2377.37","","Case rate ($2,377.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","11173.64","5800.78","11173.64","1 through 10","2377.37","5647.67","other","Multiple Surgery"
"Repl Device Cv Tnl W/Port","PX-76001100","CDM","36582","CPT","0361","RC","","","","both","","","8335.00","6251.25","MEDICARE [2001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","3737.85","1 through 10","2583.85","6626.33","other","OPPS APC"
"Repl Device Cv Tnl W/Port","PX-76001100","CDM","36582","CPT","0361","RC","","","","outpatient","","","8335.00","6251.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","6068.65","6068.65","6068.65","1 through 10","2377.37","6811.36","other","ASC"
"Repl Device Cv Tnl W/Port","PX-76001100","CDM","36582","CPT","0361","RC","","","","outpatient","","","8335.00","6251.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7002.05","7002.05","7002.05","1 through 10","2377.37","6811.36","other","ASC "
"Repl Device Cv Tnl W/Pump","PX-76001101","CDM","36583","CPT","0361","RC","","","","outpatient","","","8172.00","6129.00","AETNA [1001]","HB AMC AETNA HMO","5704.06","69.8","","6181.50","6181.50","6181.50","1 through 10","3938.87","6678.16","percent of total billed charges",""
"Repl Picc W/O Port/Pump","PX-76001102","CDM","36584","CPT","0761","RC","","","","outpatient","","","3175.00","2381.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2898.96","2512.52","2898.96","1 through 10","1093.63","5545.35","other","ASC"
"Replace Picc W/O Imaging","PX-76002574","CDM","37799","CPT","0761","RC","","","","outpatient","","","563.00","422.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","294.00","52.22","","28155.00","28155.00","28155.00","1 through 10","281.5","700.33","percent of total billed charges",""
"Replace Picc W/O Imaging","PX-76002574","CDM","37799","CPT","0761","RC","","","","outpatient","","","563.00","422.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","295.58","52.5","","2271.00","2271.00","2271.00","1 through 10","281.5","700.33","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5761.67","52.26","","1113.10","1113.10","1113.10","1 through 10","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8764.88","79.5","","1293.60","1148.53","1603.80","1 through 10","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4024.13","36.5","","1023.42","771.29","2068.67","33","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4222.58","38.3","","850.52","759.78","1211.25","66","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4729.73","42.9","","2548.09","2548.09","2548.09","1 through 10","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4729.73","42.9","","956.46","956.46","956.46","1 through 10","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","WELLPOINT [1015]","HB AMC WELLPOINT","8134.25","73.78","","2344.73","1619.47","2530.35","16","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11025.00","8268.75","AETNA [1001]","HB AMC AETNA HMO","7695.45","69.8","","1523.63","988.41","4330.26","39","5761.67","9009.63","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11025.00","8268.75","AETNA [1001]","HB AMC AETNA PPO","8864.10","80.4","","1670.25","1670.25","1670.25","1 through 10","5761.67","9009.63","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11025.00","8268.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5761.67","52.26","","1113.10","1113.10","1113.10","1 through 10","5761.67","9009.63","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11025.00","8268.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9009.63","81.72","","1738.90","1484.65","2716.94","38","5761.67","9009.63","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5761.67","52.26","","1113.10","1113.10","1113.10","1 through 10","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8764.88","79.5","","1293.60","1148.53","1603.80","1 through 10","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4024.13","36.5","","1023.42","771.29","2068.67","33","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4222.58","38.3","","850.52","759.78","1211.25","66","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4729.73","42.9","","2548.09","2548.09","2548.09","1 through 10","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4729.73","42.9","","956.46","956.46","956.46","1 through 10","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","11025.00","8268.75","WELLPOINT [1015]","HB AMC WELLPOINT","8134.25","73.78","","2344.73","1619.47","2530.35","16","3417.75","8764.88","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11025.00","8268.75","AETNA [1001]","HB AMC AETNA HMO","7695.45","69.8","","1523.63","988.41","4330.26","39","5761.67","9009.63","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11025.00","8268.75","AETNA [1001]","HB AMC AETNA PPO","8864.10","80.4","","1670.25","1670.25","1670.25","1 through 10","5761.67","9009.63","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11025.00","8268.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5761.67","52.26","","1113.10","1113.10","1113.10","1 through 10","5761.67","9009.63","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11025.00","8268.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9009.63","81.72","","1738.90","1484.65","2716.94","38","5761.67","9009.63","percent of total billed charges",""
"REPLACEMENT RING SIZE 22 FEMORAL REGENEREX PLUS LIMITED HOLE ONE APICAL PLUG ACETABULAR SYSTEM","SUP-ITM-10121924","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","215.10","52.26","","1113.10","1113.10","1113.10","1 through 10","127.6","327.22","percent of total billed charges",""
"REPLACEMENT RING SIZE 22 FEMORAL REGENEREX PLUS LIMITED HOLE ONE APICAL PLUG ACETABULAR SYSTEM","SUP-ITM-10121924","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","327.22","79.5","","1293.60","1148.53","1603.80","1 through 10","127.6","327.22","percent of total billed charges",""
"REPLACEMENT RING SIZE 22 FEMORAL REGENEREX PLUS LIMITED HOLE ONE APICAL PLUG ACETABULAR SYSTEM","SUP-ITM-10121924","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","150.23","36.5","","1023.42","771.29","2068.67","33","127.6","327.22","percent of total billed charges",""
"REPLACEMENT RING SIZE 22 FEMORAL REGENEREX PLUS LIMITED HOLE ONE APICAL PLUG ACETABULAR SYSTEM","SUP-ITM-10121924","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.64","38.3","","850.52","759.78","1211.25","66","127.6","327.22","percent of total billed charges",""
"REPLACEMENT RING SIZE 22 FEMORAL REGENEREX PLUS LIMITED HOLE ONE APICAL PLUG ACETABULAR SYSTEM","SUP-ITM-10121924","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.58","42.9","","2548.09","2548.09","2548.09","1 through 10","127.6","327.22","percent of total billed charges",""
"REPLACEMENT RING SIZE 22 FEMORAL REGENEREX PLUS LIMITED HOLE ONE APICAL PLUG ACETABULAR SYSTEM","SUP-ITM-10121924","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.58","42.9","","956.46","956.46","956.46","1 through 10","127.6","327.22","percent of total billed charges",""
"REPLACEMENT RING SIZE 22 FEMORAL REGENEREX PLUS LIMITED HOLE ONE APICAL PLUG ACETABULAR SYSTEM","SUP-ITM-10121924","CDM","C1776","HCPCS","0278","RC","","","","both","","","411.60","308.70","WELLPOINT [1015]","HB AMC WELLPOINT","303.68","73.78","","2344.73","1619.47","2530.35","16","127.6","327.22","percent of total billed charges",""
"REPLACEMENT RING SIZE 22 FEMORAL REGENEREX PLUS LIMITED HOLE ONE APICAL PLUG ACETABULAR SYSTEM","SUP-ITM-10121924","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","411.60","308.70","AETNA [1001]","HB AMC AETNA HMO","287.30","69.8","","1523.63","988.41","4330.26","39","215.1","336.36","percent of total billed charges",""
"REPLACEMENT RING SIZE 22 FEMORAL REGENEREX PLUS LIMITED HOLE ONE APICAL PLUG ACETABULAR SYSTEM","SUP-ITM-10121924","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","411.60","308.70","AETNA [1001]","HB AMC AETNA PPO","330.93","80.4","","1670.25","1670.25","1670.25","1 through 10","215.1","336.36","percent of total billed charges",""
"REPLACEMENT RING SIZE 22 FEMORAL REGENEREX PLUS LIMITED HOLE ONE APICAL PLUG ACETABULAR SYSTEM","SUP-ITM-10121924","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","411.60","308.70","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","215.10","52.26","","1113.10","1113.10","1113.10","1 through 10","215.1","336.36","percent of total billed charges",""
"REPLACEMENT RING SIZE 22 FEMORAL REGENEREX PLUS LIMITED HOLE ONE APICAL PLUG ACETABULAR SYSTEM","SUP-ITM-10121924","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","411.60","308.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","336.36","81.72","","1738.90","1484.65","2716.94","38","215.1","336.36","percent of total billed charges",""
"REPLACEMENT RING SIZE 23 FEMORAL REGENEREX PLUS ONE APICAL PLUG ACETABULAR","SUP-ITM-10121925","CDM","C1776","HCPCS","0278","RC","","","","both","","","532.88","399.66","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","278.48","52.26","","1113.10","1113.10","1113.10","1 through 10","165.19","423.64","percent of total billed charges",""
"REPLACEMENT RING SIZE 23 FEMORAL REGENEREX PLUS ONE APICAL PLUG ACETABULAR","SUP-ITM-10121925","CDM","C1776","HCPCS","0278","RC","","","","both","","","532.88","399.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","423.64","79.5","","1293.60","1148.53","1603.80","1 through 10","165.19","423.64","percent of total billed charges",""
"REPLACEMENT RING SIZE 23 FEMORAL REGENEREX PLUS ONE APICAL PLUG ACETABULAR","SUP-ITM-10121925","CDM","C1776","HCPCS","0278","RC","","","","both","","","532.88","399.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.50","36.5","","1023.42","771.29","2068.67","33","165.19","423.64","percent of total billed charges",""
"REPLACEMENT RING SIZE 23 FEMORAL REGENEREX PLUS ONE APICAL PLUG ACETABULAR","SUP-ITM-10121925","CDM","C1776","HCPCS","0278","RC","","","","both","","","532.88","399.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","204.09","38.3","","850.52","759.78","1211.25","66","165.19","423.64","percent of total billed charges",""
"REPLACEMENT RING SIZE 23 FEMORAL REGENEREX PLUS ONE APICAL PLUG ACETABULAR","SUP-ITM-10121925","CDM","C1776","HCPCS","0278","RC","","","","both","","","532.88","399.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.61","42.9","","2548.09","2548.09","2548.09","1 through 10","165.19","423.64","percent of total billed charges",""
"REPLACEMENT RING SIZE 23 FEMORAL REGENEREX PLUS ONE APICAL PLUG ACETABULAR","SUP-ITM-10121925","CDM","C1776","HCPCS","0278","RC","","","","both","","","532.88","399.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.61","42.9","","956.46","956.46","956.46","1 through 10","165.19","423.64","percent of total billed charges",""
"REPLACEMENT RING SIZE 23 FEMORAL REGENEREX PLUS ONE APICAL PLUG ACETABULAR","SUP-ITM-10121925","CDM","C1776","HCPCS","0278","RC","","","","both","","","532.88","399.66","WELLPOINT [1015]","HB AMC WELLPOINT","393.16","73.78","","2344.73","1619.47","2530.35","16","165.19","423.64","percent of total billed charges",""
"REPLACEMENT RING SIZE 23 FEMORAL REGENEREX PLUS ONE APICAL PLUG ACETABULAR","SUP-ITM-10121925","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","532.88","399.66","AETNA [1001]","HB AMC AETNA HMO","371.95","69.8","","1523.63","988.41","4330.26","39","278.48","435.47","percent of total billed charges",""
"REPLACEMENT RING SIZE 23 FEMORAL REGENEREX PLUS ONE APICAL PLUG ACETABULAR","SUP-ITM-10121925","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","532.88","399.66","AETNA [1001]","HB AMC AETNA PPO","428.44","80.4","","1670.25","1670.25","1670.25","1 through 10","278.48","435.47","percent of total billed charges",""
"REPLACEMENT RING SIZE 23 FEMORAL REGENEREX PLUS ONE APICAL PLUG ACETABULAR","SUP-ITM-10121925","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","532.88","399.66","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","278.48","52.26","","1113.10","1113.10","1113.10","1 through 10","278.48","435.47","percent of total billed charges",""
"REPLACEMENT RING SIZE 23 FEMORAL REGENEREX PLUS ONE APICAL PLUG ACETABULAR","SUP-ITM-10121925","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","532.88","399.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","435.47","81.72","","1738.90","1484.65","2716.94","38","278.48","435.47","percent of total billed charges",""
"Reposition Cv Cath W/Fluoro","PX-76001113","CDM","36597","CPT","0361","RC","","","","both","","","2981.00","2235.75","MEDICARE [2001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1844.80","1844.80","1 through 10","924.11","2369.9","other","OPPS APC"
"Reposition of Peritoneal Dialysis Catheter","PX-76002871","CDM","49999","CPT","0761","RC","","","","both","","","3065.00","2298.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","950.15","2436.68","other","OPPS APC"
"Reposition of Peritoneal Dialysis Catheter","PX-76002871","CDM","49999","CPT","0761","RC","","","","both","","","3065.00","2298.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","950.15","2436.68","other","OPPS APC"
"Reposition of Peritoneal Dialysis Catheter","PX-76002871","CDM","49999","CPT","0761","RC","","","","both","","","3065.00","2298.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","950.15","2436.68","other","OPPS APC"
"Reposition of Peritoneal Dialysis Catheter","PX-76002871","CDM","49999","CPT","0761","RC","","","","outpatient","","","3065.00","2298.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1532.50","50","","14640.00","14640.00","14640.00","1 through 10","1532.5","8899.59","percent of total billed charges",""
"Repositioning Esophageal Stent","PX-75000513","CDM","43499","CPT","0750","RC","","","","both","","","8718.00","6538.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4646.69","53.3","","0.07","0.07","0.07","30","1057.74","6930.81","percent of total billed charges",""
"Repositioning Esophageal Stent","PX-75000513","CDM","43499","CPT","0750","RC","","","","both","","","8718.00","6538.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","6930.81","other","OPPS APC"
"Repositioning Esophageal Stent","PX-75000513","CDM","43499","CPT","0750","RC","","","","both","","","8718.00","6538.50","WELLPOINT [1015]","HB AMC WELLPOINT","6432.14","73.78","","2340.71","2340.71","2340.71","1 through 10","1057.74","6930.81","percent of total billed charges",""
"Repositioning Esophageal Stent","PX-75000513","CDM","43499","CPT","0750","RC","","","","outpatient","","","8718.00","6538.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4552.54","52.22","","6151.50","2038.73","10659.00","1 through 10","2384.07","7192.35","percent of total billed charges",""
"Repositioning Esophageal Stent","PX-75000513","CDM","43499","CPT","0750","RC","","","","outpatient","","","8718.00","6538.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4359.00","50","","3144.00","3144.00","3144.00","1 through 10","2384.07","7192.35","percent of total billed charges",""
"Repositioning Esophageal Stent","PX-75000513","CDM","43499","CPT","0750","RC","","","","outpatient","","","8718.00","6538.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7124.35","81.72","","1810.95","1810.95","1810.95","1 through 10","2384.07","7192.35","percent of total billed charges",""
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","both","","","688.00","516.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.46","86.45","350.46","19","213.28","553.15","other","OPPS APC"
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","both","","","688.00","516.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","546.96","79.5","","352.18","352.18","352.18","1 through 10","213.28","553.15","percent of total billed charges",""
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","both","","","688.00","516.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.46","280.04","350.46","1 through 10","213.28","553.15","other","OPPS APC"
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","both","","","688.00","516.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","349.04","349.04","349.04","1 through 10","213.28","553.15","other","OPPS APC"
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","both","","","688.00","516.00","MEDICARE [2001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","356.16","356.16","1068.48","142","213.28","553.15","other","OPPS APC"
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","both","","","688.00","516.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","251.12","36.5","","211.44","211.44","211.44","1 through 10","213.28","553.15","percent of total billed charges",""
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","both","","","688.00","516.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","263.50","38.3","","260.80","260.80","260.80","1 through 10","213.28","553.15","percent of total billed charges",""
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","both","","","688.00","516.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","356.13","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","349.04","319.48","349.04","1 through 10","213.28","553.15","other","OPPS APC"
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","both","","","688.00","516.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","349.00","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","349.04","319.48","349.04","1 through 10","213.28","553.15","other","OPPS APC"
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","both","","","688.00","516.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","349.00","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","153.41","153.41","153.41","1 through 10","213.28","553.15","other","OPPS APC"
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","both","","","688.00","516.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","349.00","","APC Price ($356.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","351.04","320.79","356.16","20","213.28","553.15","other","OPPS APC"
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","both","","","688.00","516.00","WELLPOINT [1015]","HB AMC WELLPOINT","507.61","73.78","","496.58","496.58","496.58","1 through 10","213.28","553.15","percent of total billed charges",""
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","outpatient","","","688.00","516.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","320.66","","Case rate ($320.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","644.21","371.65","743.29","17","320.66","1073.97","other","ASC"
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","outpatient","","","688.00","516.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","320.66","","Case rate ($320.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","743.29","371.65","750.67","29","320.66","1073.97","other","ASC "
"Reprogram Programmable Shunt CSF","PX-76001456","CDM","62252","CPT","0761","RC","","","","outpatient","","","688.00","516.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","562.23","81.72","","533.20","533.20","533.20","1 through 10","320.66","1073.97","percent of total billed charges",""
"Reptilase Test","PX-30001122","CDM","85635","CPT","0305","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","129.20","129.20","129.20","1 through 10","9.65","166.25","percent of total billed charges",""
"Reptilase Test","PX-30001122","CDM","85635","CPT","0305","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","115.09","115.09","115.09","1 through 10","10.15","143.01","percent of total billed charges",""
"Research Phlebotomy","PX-94000058","CDM","99199","CPT","0940","RC","","","","both","","","848.00","636.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","674.16","79.5","","2475.01","315.17","2475.01","1 through 10","262.88","805.6","percent of total billed charges",""
"Research Phlebotomy","PX-94000058","CDM","99199","CPT","0940","RC","","","","inpatient","","","848.00","636.00","AETNA [1001]","HB AMC AETNA PPO","674.16","79.5","","12252.89","4048.72","34960.93","4483","468.94","674.16","percent of total billed charges",""
"Research Phlebotomy","PX-94000058","CDM","99199","CPT","0940","RC","","","","inpatient","","","848.00","636.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","468.94","55.3","","23008.10","23008.10","23008.10","248","468.94","674.16","percent of total billed charges",""
"Research Phlebotomy","PX-94000058","CDM","99199","CPT","0940","RC","","","","inpatient","","","848.00","636.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","674.16","79.5","","50807.79","50807.79","50807.79","284","468.94","674.16","percent of total billed charges",""
"Research Phlebotomy","PX-94000058","CDM","99199","CPT","0940","RC","","","","outpatient","","","848.00","636.00","AETNA [1001]","HB AMC AETNA HMO","591.90","69.8","","1482.39","1482.39","1482.39","27","339.2","699.6","percent of total billed charges",""
"Research Phlebotomy","PX-94000058","CDM","99199","CPT","0940","RC","","","","outpatient","","","848.00","636.00","AETNA [1001]","HB AMC AETNA PPO","681.79","80.4","","601.53","0.18","1277.78","350","339.2","699.6","percent of total billed charges",""
"Research Phlebotomy","PX-94000058","CDM","99199","CPT","0940","RC","","","","outpatient","","","848.00","636.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","474.03","55.9","","0.18","0.03","6.03","1 through 10","339.2","699.6","percent of total billed charges",""
"Research Phlebotomy- Add On","PX-94000059","CDM","99199","CPT","0940","RC","","","","both","","","635.00","476.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","504.83","79.5","","2475.01","315.17","2475.01","1 through 10","196.85","603.25","percent of total billed charges",""
"Research Phlebotomy- Add On","PX-94000059","CDM","99199","CPT","0940","RC","","","","inpatient","","","635.00","476.25","AETNA [1001]","HB AMC AETNA PPO","504.83","79.5","","12252.89","4048.72","34960.93","4483","351.16","504.83","percent of total billed charges",""
"Research Phlebotomy- Add On","PX-94000059","CDM","99199","CPT","0940","RC","","","","inpatient","","","635.00","476.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","351.16","55.3","","23008.10","23008.10","23008.10","248","351.16","504.83","percent of total billed charges",""
"Research Phlebotomy- Add On","PX-94000059","CDM","99199","CPT","0940","RC","","","","inpatient","","","635.00","476.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","504.83","79.5","","50807.79","50807.79","50807.79","284","351.16","504.83","percent of total billed charges",""
"Research Phlebotomy- Add On","PX-94000059","CDM","99199","CPT","0940","RC","","","","outpatient","","","635.00","476.25","AETNA [1001]","HB AMC AETNA HMO","443.23","69.8","","1482.39","1482.39","1482.39","27","254","523.88","percent of total billed charges",""
"Research Phlebotomy- Add On","PX-94000059","CDM","99199","CPT","0940","RC","","","","outpatient","","","635.00","476.25","AETNA [1001]","HB AMC AETNA PPO","510.54","80.4","","601.53","0.18","1277.78","350","254","523.88","percent of total billed charges",""
"Research Phlebotomy- Add On","PX-94000059","CDM","99199","CPT","0940","RC","","","","outpatient","","","635.00","476.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","354.97","55.9","","0.18","0.03","6.03","1 through 10","254","523.88","percent of total billed charges",""
"RESERVOIR DRAINAGE 1.5CM OMMAYA SILICONE ELASTOMER SINGLE FLUSHING BURR HOLE STANDARD CSF","SUP-ITM-10014342","CDM","C1889","HCPCS","0278","RC","","","","both","","","1497.90","1123.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1190.83","79.5","","1309.77","674.56","6049.93","26","464.35","1190.83","percent of total billed charges",""
"RESERVOIR DRAINAGE 1.5CM OMMAYA SILICONE ELASTOMER SINGLE FLUSHING BURR HOLE STANDARD CSF","SUP-ITM-10014342","CDM","C1889","HCPCS","0278","RC","","","","both","","","1497.90","1123.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","798.38","53.3","","1901.83","1901.83","2962.25","1 through 10","464.35","1190.83","percent of total billed charges",""
"RESERVOIR DRAINAGE 1.5CM OMMAYA SILICONE ELASTOMER SINGLE FLUSHING BURR HOLE STANDARD CSF","SUP-ITM-10014342","CDM","C1889","HCPCS","0278","RC","","","","both","","","1497.90","1123.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","546.73","36.5","","1620.31","1620.31","19908.88","1 through 10","464.35","1190.83","percent of total billed charges",""
"RESERVOIR DRAINAGE 1.5CM OMMAYA SILICONE ELASTOMER SINGLE FLUSHING BURR HOLE STANDARD CSF","SUP-ITM-10014342","CDM","C1889","HCPCS","0278","RC","","","","both","","","1497.90","1123.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","573.70","38.3","","352.91","352.91","2046.30","1 through 10","464.35","1190.83","percent of total billed charges",""
"RESERVOIR DRAINAGE 1.5CM OMMAYA SILICONE ELASTOMER SINGLE FLUSHING BURR HOLE STANDARD CSF","SUP-ITM-10014342","CDM","C1889","HCPCS","0278","RC","","","","both","","","1497.90","1123.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","642.60","42.9","","9668.75","9668.75","9668.75","1 through 10","464.35","1190.83","percent of total billed charges",""
"RESERVOIR DRAINAGE 1.5CM OMMAYA SILICONE ELASTOMER SINGLE FLUSHING BURR HOLE STANDARD CSF","SUP-ITM-10014342","CDM","C1889","HCPCS","0278","RC","","","","both","","","1497.90","1123.42","WELLPOINT [1015]","HB AMC WELLPOINT","1105.15","73.78","","699.88","384.10","3443.31","33","464.35","1190.83","percent of total billed charges",""
"RESERVOIR DRAINAGE 1.5CM OMMAYA SILICONE ELASTOMER SINGLE FLUSHING BURR HOLE STANDARD CSF","SUP-ITM-10014342","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1497.90","1123.42","AETNA [1001]","HB AMC AETNA HMO","1045.53","69.8","","1421.24","264.50","4933.46","29","782.8","1224.08","percent of total billed charges",""
"RESERVOIR DRAINAGE 1.5CM OMMAYA SILICONE ELASTOMER SINGLE FLUSHING BURR HOLE STANDARD CSF","SUP-ITM-10014342","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1497.90","1123.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1204.31","80.4","","1022.97","1022.97","3607.50","1 through 10","782.8","1224.08","percent of total billed charges",""
"RESERVOIR DRAINAGE 1.5CM OMMAYA SILICONE ELASTOMER SINGLE FLUSHING BURR HOLE STANDARD CSF","SUP-ITM-10014342","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1497.90","1123.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1224.08","81.72","","3010.54","693.88","5019.88","35","782.8","1224.08","percent of total billed charges",""
"RESERVOIR HOLTER 9.5M RICKMAN","SUP-ITM-10027266","CDM","C1889","HCPCS","0278","RC","","","","both","","","789.01","591.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","627.26","79.5","","1309.77","674.56","6049.93","26","244.59","627.26","percent of total billed charges",""
"RESERVOIR HOLTER 9.5M RICKMAN","SUP-ITM-10027266","CDM","C1889","HCPCS","0278","RC","","","","both","","","789.01","591.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","420.54","53.3","","1901.83","1901.83","2962.25","1 through 10","244.59","627.26","percent of total billed charges",""
"RESERVOIR HOLTER 9.5M RICKMAN","SUP-ITM-10027266","CDM","C1889","HCPCS","0278","RC","","","","both","","","789.01","591.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","287.99","36.5","","1620.31","1620.31","19908.88","1 through 10","244.59","627.26","percent of total billed charges",""
"RESERVOIR HOLTER 9.5M RICKMAN","SUP-ITM-10027266","CDM","C1889","HCPCS","0278","RC","","","","both","","","789.01","591.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","302.19","38.3","","352.91","352.91","2046.30","1 through 10","244.59","627.26","percent of total billed charges",""
"RESERVOIR HOLTER 9.5M RICKMAN","SUP-ITM-10027266","CDM","C1889","HCPCS","0278","RC","","","","both","","","789.01","591.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","338.49","42.9","","9668.75","9668.75","9668.75","1 through 10","244.59","627.26","percent of total billed charges",""
"RESERVOIR HOLTER 9.5M RICKMAN","SUP-ITM-10027266","CDM","C1889","HCPCS","0278","RC","","","","both","","","789.01","591.76","WELLPOINT [1015]","HB AMC WELLPOINT","582.13","73.78","","699.88","384.10","3443.31","33","244.59","627.26","percent of total billed charges",""
"RESERVOIR HOLTER 9.5M RICKMAN","SUP-ITM-10027266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","789.01","591.76","AETNA [1001]","HB AMC AETNA HMO","550.73","69.8","","1421.24","264.50","4933.46","29","412.34","644.78","percent of total billed charges",""
"RESERVOIR HOLTER 9.5M RICKMAN","SUP-ITM-10027266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","789.01","591.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","634.36","80.4","","1022.97","1022.97","3607.50","1 through 10","412.34","644.78","percent of total billed charges",""
"RESERVOIR HOLTER 9.5M RICKMAN","SUP-ITM-10027266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","789.01","591.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","644.78","81.72","","3010.54","693.88","5019.88","35","412.34","644.78","percent of total billed charges",""
"RESERVOIR PROSTHESIS T 75ML PENILE TITAN CLOVERLEAF LOCKOUT","SUP-ITM-10115077","CDM","C1813","HCPCS","0278","RC","","","","both","","","6192.50","4644.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2371.73","38.3","","12613.42","12613.42","12613.42","1 through 10","1919.68","4923.04","percent of total billed charges",""
"RESERVOIR PROSTHESIS T 75ML PENILE TITAN CLOVERLEAF LOCKOUT","SUP-ITM-10115077","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","6192.50","4644.37","AETNA [1001]","HB AMC AETNA HMO","4322.37","69.8","","34275.85","34275.85","50471.26","19","3236.2","5060.51","percent of total billed charges",""
"RESERVOIR SHUNT CSF ON/OFF PROXIMAL OCCLUDER REINFORCED FLAT BOTTOM WITHOUT ANTI SIPHON DEVICE","SUP-ITM-10021494","CDM","C1889","HCPCS","0278","RC","","","","both","","","3527.97","2645.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2804.74","79.5","","1309.77","674.56","6049.93","26","1093.67","2804.74","percent of total billed charges",""
"RESERVOIR SHUNT CSF ON/OFF PROXIMAL OCCLUDER REINFORCED FLAT BOTTOM WITHOUT ANTI SIPHON DEVICE","SUP-ITM-10021494","CDM","C1889","HCPCS","0278","RC","","","","both","","","3527.97","2645.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1880.41","53.3","","1901.83","1901.83","2962.25","1 through 10","1093.67","2804.74","percent of total billed charges",""
"RESERVOIR SHUNT CSF ON/OFF PROXIMAL OCCLUDER REINFORCED FLAT BOTTOM WITHOUT ANTI SIPHON DEVICE","SUP-ITM-10021494","CDM","C1889","HCPCS","0278","RC","","","","both","","","3527.97","2645.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1287.71","36.5","","1620.31","1620.31","19908.88","1 through 10","1093.67","2804.74","percent of total billed charges",""
"RESERVOIR SHUNT CSF ON/OFF PROXIMAL OCCLUDER REINFORCED FLAT BOTTOM WITHOUT ANTI SIPHON DEVICE","SUP-ITM-10021494","CDM","C1889","HCPCS","0278","RC","","","","both","","","3527.97","2645.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1351.21","38.3","","352.91","352.91","2046.30","1 through 10","1093.67","2804.74","percent of total billed charges",""
"RESERVOIR SHUNT CSF ON/OFF PROXIMAL OCCLUDER REINFORCED FLAT BOTTOM WITHOUT ANTI SIPHON DEVICE","SUP-ITM-10021494","CDM","C1889","HCPCS","0278","RC","","","","both","","","3527.97","2645.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1513.50","42.9","","9668.75","9668.75","9668.75","1 through 10","1093.67","2804.74","percent of total billed charges",""
"RESERVOIR SHUNT CSF ON/OFF PROXIMAL OCCLUDER REINFORCED FLAT BOTTOM WITHOUT ANTI SIPHON DEVICE","SUP-ITM-10021494","CDM","C1889","HCPCS","0278","RC","","","","both","","","3527.97","2645.98","WELLPOINT [1015]","HB AMC WELLPOINT","2602.94","73.78","","699.88","384.10","3443.31","33","1093.67","2804.74","percent of total billed charges",""
"RESERVOIR SHUNT CSF ON/OFF PROXIMAL OCCLUDER REINFORCED FLAT BOTTOM WITHOUT ANTI SIPHON DEVICE","SUP-ITM-10021494","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3527.97","2645.98","AETNA [1001]","HB AMC AETNA HMO","2462.52","69.8","","1421.24","264.50","4933.46","29","1843.72","2883.06","percent of total billed charges",""
"RESERVOIR SHUNT CSF ON/OFF PROXIMAL OCCLUDER REINFORCED FLAT BOTTOM WITHOUT ANTI SIPHON DEVICE","SUP-ITM-10021494","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3527.97","2645.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2836.49","80.4","","1022.97","1022.97","3607.50","1 through 10","1843.72","2883.06","percent of total billed charges",""
"RESERVOIR SHUNT CSF ON/OFF PROXIMAL OCCLUDER REINFORCED FLAT BOTTOM WITHOUT ANTI SIPHON DEVICE","SUP-ITM-10021494","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3527.97","2645.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2883.06","81.72","","3010.54","693.88","5019.88","35","1843.72","2883.06","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","both","","","1800.75","1350.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1431.60","79.5","","1309.77","674.56","6049.93","26","558.23","1431.6","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","both","","","1800.75","1350.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","959.80","53.3","","1901.83","1901.83","2962.25","1 through 10","558.23","1431.6","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","both","","","1800.75","1350.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","657.27","36.5","","1620.31","1620.31","19908.88","1 through 10","558.23","1431.6","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","both","","","1800.75","1350.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","689.69","38.3","","352.91","352.91","2046.30","1 through 10","558.23","1431.6","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","both","","","1800.75","1350.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","772.52","42.9","","9668.75","9668.75","9668.75","1 through 10","558.23","1431.6","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","both","","","1800.75","1350.56","WELLPOINT [1015]","HB AMC WELLPOINT","1328.59","73.78","","699.88","384.10","3443.31","33","558.23","1431.6","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1800.75","1350.56","AETNA [1001]","HB AMC AETNA HMO","1256.92","69.8","","1421.24","264.50","4933.46","29","941.07","1471.57","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1800.75","1350.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1447.80","80.4","","1022.97","1022.97","3607.50","1 through 10","941.07","1471.57","percent of total billed charges",""
"RESERVOIR VENTRICULAR 20X180MM DRAINAGE CATHETER FLAT STD","SUP-ITM-10014085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1800.75","1350.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1471.57","81.72","","3010.54","693.88","5019.88","35","941.07","1471.57","percent of total billed charges",""
"RESERVOIR VENTRICULOSTOMY 1.4CM RICKHAM S S BASE V-CATH STYLET STANDARD","SUP-ITM-10000368","CDM","C1889","HCPCS","0278","RC","","","","both","","","708.16","531.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","562.99","79.5","","1309.77","674.56","6049.93","26","219.53","562.99","percent of total billed charges",""
"RESERVOIR VENTRICULOSTOMY 1.4CM RICKHAM S S BASE V-CATH STYLET STANDARD","SUP-ITM-10000368","CDM","C1889","HCPCS","0278","RC","","","","both","","","708.16","531.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","377.45","53.3","","1901.83","1901.83","2962.25","1 through 10","219.53","562.99","percent of total billed charges",""
"RESERVOIR VENTRICULOSTOMY 1.4CM RICKHAM S S BASE V-CATH STYLET STANDARD","SUP-ITM-10000368","CDM","C1889","HCPCS","0278","RC","","","","both","","","708.16","531.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","258.48","36.5","","1620.31","1620.31","19908.88","1 through 10","219.53","562.99","percent of total billed charges",""
"RESERVOIR VENTRICULOSTOMY 1.4CM RICKHAM S S BASE V-CATH STYLET STANDARD","SUP-ITM-10000368","CDM","C1889","HCPCS","0278","RC","","","","both","","","708.16","531.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","271.23","38.3","","352.91","352.91","2046.30","1 through 10","219.53","562.99","percent of total billed charges",""
"RESERVOIR VENTRICULOSTOMY 1.4CM RICKHAM S S BASE V-CATH STYLET STANDARD","SUP-ITM-10000368","CDM","C1889","HCPCS","0278","RC","","","","both","","","708.16","531.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","303.80","42.9","","9668.75","9668.75","9668.75","1 through 10","219.53","562.99","percent of total billed charges",""
"RESERVOIR VENTRICULOSTOMY 1.4CM RICKHAM S S BASE V-CATH STYLET STANDARD","SUP-ITM-10000368","CDM","C1889","HCPCS","0278","RC","","","","both","","","708.16","531.12","WELLPOINT [1015]","HB AMC WELLPOINT","522.48","73.78","","699.88","384.10","3443.31","33","219.53","562.99","percent of total billed charges",""
"RESERVOIR VENTRICULOSTOMY 1.4CM RICKHAM S S BASE V-CATH STYLET STANDARD","SUP-ITM-10000368","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","708.16","531.12","AETNA [1001]","HB AMC AETNA HMO","494.30","69.8","","1421.24","264.50","4933.46","29","370.08","578.71","percent of total billed charges",""
"RESERVOIR VENTRICULOSTOMY 1.4CM RICKHAM S S BASE V-CATH STYLET STANDARD","SUP-ITM-10000368","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","708.16","531.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","569.36","80.4","","1022.97","1022.97","3607.50","1 through 10","370.08","578.71","percent of total billed charges",""
"RESERVOIR VENTRICULOSTOMY 1.4CM RICKHAM S S BASE V-CATH STYLET STANDARD","SUP-ITM-10000368","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","708.16","531.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","578.71","81.72","","3010.54","693.88","5019.88","35","370.08","578.71","percent of total billed charges",""
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","360.00","270.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.87","45.86","45.87","57","38.07","286.2","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","360.00","270.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","252.00","70","","153.46","153.46","153.46","1 through 10","38.07","286.2","percent of total billed charges",""
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","360.00","270.00","MEDICARE [2001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.61","46.61","93.22","839","38.07","286.2","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","360.00","270.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","137.88","38.3","","136.46","136.46","136.46","27","38.07","286.2","percent of total billed charges",""
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","360.00","270.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","46.61","","APC Price ($46.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.68","45.68","45.68","22","38.07","286.2","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","360.00","270.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","45.83","45.68","137.58","113","38.07","286.2","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","360.00","270.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","154.44","42.9","","153.46","153.46","153.46","27","38.07","286.2","percent of total billed charges",""
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","360.00","270.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","45.67","","APC Price ($46.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","45.68","43.05","45.83","136","38.07","286.2","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","outpatient","","","360.00","270.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","294.19","81.72","","278.99","278.99","278.99","18","73.79","304.57","percent of total billed charges",""
"Respiratory Failure,EXTREME","133","DRG","","","","","","","","inpatient","","","123678.90","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","56988.08","","Standard inlier is a Case rate ($56,988.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $55,963, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,089.80) for the length of stay and the standard reimbursement.","64069.95","64069.95","64069.95","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Failure,EXTREME","133","DRG","","","","","","","","inpatient","","","123678.90","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","64069.96","","Standard inlier is a Case rate ($64,069.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $55,963, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,094.20) for the length of stay and the standard reimbursement.","58533.43","58533.43","58533.43","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Failure,EXTREME","133","DRG","","","","","","","","inpatient","","","123678.90","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13650.5801","","Fee schedule rate ($154,511.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13650.5801","47297.29","47297.29","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Failure,EXTREME","133","DRG","","","","","","","","inpatient","","","123678.90","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($154,511.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","47297.29","47297.29","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Failure,EXTREME","133","DRG","","","","","","","","inpatient","","","123678.90","","MASSHEALTH [3001]","HB BWH MEDICAID","18564.59","","Case rate ($20,526.35). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,956.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20521.31","2995.82","20521.31","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Failure,EXTREME","133","DRG","","","","","","","","inpatient","","","123678.90","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","18564.59","","Case rate ($20,526.35). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,956.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Failure,EXTREME","133","DRG","","","","","","","","inpatient","","","123678.90","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","18564.59","","Case rate ($20,526.35). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,956.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20521.31","20521.31","20521.31","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","82207.90","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","34527.25","","Standard inlier is a Case rate ($34,527.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,498, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,901.35) for the length of stay and the standard reimbursement.","34527.25","34527.25","34527.25","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","82207.90","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","38817.94","","Standard inlier is a Case rate ($38,817.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,498, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,509.88) for the length of stay and the standard reimbursement.","35463.53","35463.53","38817.93","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","82207.90","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13650.5801","","Fee schedule rate ($32,926.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13650.5801","32926.48","32926.48","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","82207.90","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","21695.99","","Fee schedule rate ($32,926.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21695.99","32926.48","32926.48","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","82207.90","","MASSHEALTH [3001]","HB BWH MEDICAID","11343.69","","Case rate ($12,542.40). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,972.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13047.40","12539.32","13047.40","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","82207.90","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11343.69","","Case rate ($12,542.40). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,972.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12539.33","12539.33","12539.33","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Failure,MODERATE","133","DRG","","","","","","","","inpatient","","","15484.19","","MASSHEALTH [3001]","HB BWH MEDICAID","6533.19","","Case rate ($7,223.57). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,653.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12539.32","12539.32","12539.32","1 through 10","6533.19","254946.65","case rate",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","52150.35","39112.76","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","9561.50","","Case rate ($9,283.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,097.51, add-ons for qualifying new technology services are included. If operating cost exceeds $56,741.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,225.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,117.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,717.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $785.35. The transfer capital threshold is the transfer adjustment factor * $785.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9594.98","9594.98","9594.98","1 through 10","9097.35","15288.06","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","52150.35","39112.76","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","11934.63","","Case rate ($11,934.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,097.51, add-ons for qualifying new technology services are included. If operating cost exceeds $56,741.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,225.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,769.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,717.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $785.35. The transfer capital threshold is the transfer adjustment factor * $785.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9182.22","9182.22","9182.22","1 through 10","9097.35","15288.06","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","52150.35","39112.76","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","9225.81","9225.81","9225.81","1 through 10","9097.35","15288.06","case rate",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","52150.35","39112.76","MEDICARE [2001]","HB BWH MEDICARE","11934.63","","Case rate ($11,934.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,097.51, add-ons for qualifying new technology services are included. If operating cost exceeds $56,741.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,225.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,769.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,717.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $785.35. The transfer capital threshold is the transfer adjustment factor * $785.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11974.32","0.03","11991.80","41","9097.35","15288.06","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","52150.35","39112.76","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9097.35","","Case rate ($9,283.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,097.51, add-ons for qualifying new technology services are included. If operating cost exceeds $56,741.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,225.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,117.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,717.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $785.35. The transfer capital threshold is the transfer adjustment factor * $785.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9097.72","9097.72","19133.13","1 through 10","9097.35","15288.06","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","52150.35","39112.76","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9097.35","","Case rate ($9,283.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,097.51, add-ons for qualifying new technology services are included. If operating cost exceeds $56,741.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,225.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,117.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,717.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $785.35. The transfer capital threshold is the transfer adjustment factor * $785.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9181.42","9097.65","9196.85","1 through 10","9097.35","15288.06","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","74178.76","55634.07","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15074.01","","Case rate ($14,634.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,540.18, add-ons for qualifying new technology services are included. If operating cost exceeds $63,184.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,697.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,997.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,160.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,257.44. The transfer capital threshold is the transfer adjustment factor * $1,257.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15500.97","15444.80","15542.10","1 through 10","14342.26","24478.13","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","74178.76","55634.07","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14634.96","","Case rate ($14,634.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,540.18, add-ons for qualifying new technology services are included. If operating cost exceeds $63,184.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,697.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,997.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,160.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,257.44. The transfer capital threshold is the transfer adjustment factor * $1,257.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19068.01","14950.77","19076.39","1 through 10","14342.26","24478.13","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","74178.76","55634.07","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","14634.96","","Case rate ($14,634.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,540.18, add-ons for qualifying new technology services are included. If operating cost exceeds $63,184.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,697.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,997.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,160.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,257.44. The transfer capital threshold is the transfer adjustment factor * $1,257.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14736.32","12817.38","88571.21","1 through 10","14342.26","24478.13","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","74178.76","55634.07","FALLON HEALTH [1008]","HB BWH MEDICARE","14634.96","","Case rate ($14,634.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,540.18, add-ons for qualifying new technology services are included. If operating cost exceeds $63,184.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,697.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,997.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,160.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,257.44. The transfer capital threshold is the transfer adjustment factor * $1,257.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14971.04","14971.04","14971.04","1 through 10","14342.26","24478.13","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","74178.76","55634.07","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","14634.96","","Case rate ($14,634.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,540.18, add-ons for qualifying new technology services are included. If operating cost exceeds $63,184.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,697.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,997.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,160.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,257.44. The transfer capital threshold is the transfer adjustment factor * $1,257.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14364.22","14364.22","14364.22","1 through 10","14342.26","24478.13","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","74178.76","55634.07","HUMANA [1012]","HB BWH MEDICARE","14634.96","","Case rate ($14,634.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,540.18, add-ons for qualifying new technology services are included. If operating cost exceeds $63,184.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,697.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,997.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,160.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,257.44. The transfer capital threshold is the transfer adjustment factor * $1,257.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14793.66","14793.66","14971.06","1 through 10","14342.26","24478.13","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","74178.76","55634.07","MARTIN'S POINT [160007]","HB BWH MEDICARE","14634.96","","Case rate ($14,634.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,540.18, add-ons for qualifying new technology services are included. If operating cost exceeds $63,184.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,697.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,997.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,160.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,257.44. The transfer capital threshold is the transfer adjustment factor * $1,257.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14810.64","14810.64","14810.64","1 through 10","14342.26","24478.13","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","74178.76","55634.07","MEDICARE [2001]","HB BWH MEDICARE","14634.96","","Case rate ($14,634.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,540.18, add-ons for qualifying new technology services are included. If operating cost exceeds $63,184.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,697.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,997.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,160.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,257.44. The transfer capital threshold is the transfer adjustment factor * $1,257.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19335.46","0.03","19363.97","175","14342.26","24478.13","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","74178.76","55634.07","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","14634.96","","Case rate ($14,634.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,540.18, add-ons for qualifying new technology services are included. If operating cost exceeds $63,184.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,697.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,997.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,160.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,257.44. The transfer capital threshold is the transfer adjustment factor * $1,257.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12793.98","12793.98","12793.98","1 through 10","14342.26","24478.13","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","74178.76","55634.07","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14342.26","","Case rate ($14,634.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,540.18, add-ons for qualifying new technology services are included. If operating cost exceeds $63,184.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,697.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,997.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,160.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,257.44. The transfer capital threshold is the transfer adjustment factor * $1,257.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14691.77","14691.77","14740.48","1 through 10","14342.26","24478.13","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","74178.76","55634.07","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","14342.26","","Case rate ($14,634.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,540.18, add-ons for qualifying new technology services are included. If operating cost exceeds $63,184.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,697.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,997.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,160.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,257.44. The transfer capital threshold is the transfer adjustment factor * $1,257.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","41854.18","41854.18","41854.18","1 through 10","14342.26","24478.13","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","74178.76","55634.07","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14342.26","","Case rate ($14,634.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,540.18, add-ons for qualifying new technology services are included. If operating cost exceeds $63,184.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,697.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,997.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,160.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,257.44. The transfer capital threshold is the transfer adjustment factor * $1,257.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14751.02","14659.79","20695.37","21","14342.26","24478.13","other","Inpatient DRG"
"Respiratory Infections And Inflammations Without Cc/McC","179","MS-DRG","","","","","","","","inpatient","","","37396.86","28047.64","MEDICARE [2001]","HB BWH MEDICARE","7267.02","","Case rate ($7,267.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,670.66, add-ons for qualifying new technology services are included. If operating cost exceeds $54,315.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,047.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,279.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,290.82 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.52. The transfer capital threshold is the transfer adjustment factor * $607.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9365.97","9365.97","9365.97","1 through 10","7121.68","11615.5427","other","Inpatient Replacement Plans DRG"
"Respiratory Malignancy,EXTREME","136","DRG","","","","","","","","inpatient","","","109876.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","53178.31","","Standard inlier is a Case rate ($53,178.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $53,002, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,548.98) for the length of stay and the standard reimbursement.","48473.96","48473.96","66548.49","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Malignancy,EXTREME","136","DRG","","","","","","","","inpatient","","","109876.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","59786.75","","Standard inlier is a Case rate ($59,786.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $53,002, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,486.23) for the length of stay and the standard reimbursement.","59786.74","55030.11","113130.04","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Malignancy,EXTREME","136","DRG","","","","","","","","inpatient","","","109876.74","","MASSHEALTH [3001]","HB BWH MEDICAID","19388.24","","Case rate ($21,437.03). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,867.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","56740.88","56740.88","56740.88","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Malignancy,EXTREME","136","DRG","","","","","","","","inpatient","","","109876.74","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58069.40","","Fee schedule rate ($58,069.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","58069.40","58069.40","58069.40","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Malignancy,EXTREME","136","DRG","","","","","","","","inpatient","","","109876.74","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","19388.24","","Case rate ($21,437.03). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,867.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21431.77","21431.77","21431.77","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Malignancy,MAJOR","136","DRG","","","","","","","","inpatient","","","78969.69","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","37512.33","","Standard inlier is a Case rate ($37,512.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,818, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,325.10) for the length of stay and the standard reimbursement.","37512.32","37512.32","42173.96","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Malignancy,MAJOR","136","DRG","","","","","","","","inpatient","","","78969.69","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","42173.96","","Standard inlier is a Case rate ($42,173.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $40,818, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,986.24) for the length of stay and the standard reimbursement.","42173.96","38529.55","52821.23","20","5757.52","106691.56","case rate",""
"Respiratory Malignancy,MAJOR","136","DRG","","","","","","","","inpatient","","","78969.69","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","17450.098","","Fee schedule rate ($39,263.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17450.098","39263.88","67909.56","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Malignancy,MAJOR","136","DRG","","","","","","","","inpatient","","","78969.69","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38819.50","","Fee schedule rate ($38,819.50). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38819.50","38819.50","38819.50","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Malignancy,MAJOR","136","DRG","","","","","","","","inpatient","","","78969.69","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40761.11","","Fee schedule rate ($40,761.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37767.42","37767.42","37767.42","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Malignancy,MAJOR","136","DRG","","","","","","","","inpatient","","","78969.69","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11865.76","","Case rate ($13,119.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,549.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13116.41","13116.41","13116.41","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Malignancy,MINOR","136","DRG","","","","","","","","inpatient","","","19418.37","","MASSHEALTH [3001]","HB BWH MEDICAID","5757.52","","Case rate ($6,365.93). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,795.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6364.37","6364.37","6364.37","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Malignancy,MODERATE","136","DRG","","","","","","","","inpatient","","","37706.61","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","29666.12","","Standard inlier is a Case rate ($29,666.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,167, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,210.86) for the length of stay and the standard reimbursement.","27102.56","27102.56","29666.12","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Malignancy,MODERATE","136","DRG","","","","","","","","inpatient","","","37706.61","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","16618.681","","Fee schedule rate ($37,393.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16618.681","20114.64","20114.64","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Malignancy,MODERATE","136","DRG","","","","","","","","inpatient","","","37706.61","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7521.34","","Case rate ($8,316.13). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,746.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8314.09","748.59","8314.09","1 through 10","5757.52","106691.56","case rate",""
"Respiratory Motion Management Simulation","PX-33000097","CDM","77293","CPT","0333","RC","","","","both","","","2741.00","2055.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1918.70","70","","2658.00","2658.00","2658.00","1 through 10","849.71","2179.1","percent of total billed charges",""
"Respiratory Motion Management Simulation","PX-33000097","CDM","77293","CPT","0333","RC","","","","both","","","2741.00","2055.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1460.95","53.3","","1403.42","1403.42","1403.42","1 through 10","849.71","2179.1","percent of total billed charges",""
"Respiratory Motion Management Simulation","PX-33000097","CDM","77293","CPT","0333","RC","","","","both","","","2741.00","2055.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","849.71","31","","821.32","821.32","821.32","1 through 10","849.71","2179.1","percent of total billed charges",""
"Respiratory Motion Management Simulation","PX-33000097","CDM","77293","CPT","0333","RC","","","","both","","","2741.00","2055.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1000.47","36.5","","991.43","962.20","991.43","1 through 10","849.71","2179.1","percent of total billed charges",""
"Respiratory Motion Management Simulation","PX-33000097","CDM","77293","CPT","0333","RC","","","","both","","","2741.00","2055.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1049.80","38.3","","1039.28","1039.28","1039.28","1 through 10","849.71","2179.1","percent of total billed charges",""
"Respiratory Motion Management Simulation","PX-33000097","CDM","77293","CPT","0333","RC","","","","both","","","2741.00","2055.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2110.57","77","","292.38","292.38","292.38","1 through 10","849.71","2179.1","percent of total billed charges",""
"Respiratory Motion Management Simulation","PX-33000097","CDM","77293","CPT","0333","RC","","","","both","","","2741.00","2055.75","WELLPOINT [1015]","HB AMC WELLPOINT","2022.31","73.78","","1978.88","1978.88","1978.88","1 through 10","849.71","2179.1","percent of total billed charges",""
"Respiratory Motion Management Simulation","PX-33000097","CDM","77293","CPT","0333","RC","","","","outpatient","","","2741.00","2055.75","AETNA [1001]","HB AMC AETNA HMO","1913.22","69.8","","1270.52","1270.52","1270.52","1 through 10","1432.45","2239.95","percent of total billed charges",""
"Respiratory Motion Management Simulation","PX-33000097","CDM","77293","CPT","0333","RC","","","","outpatient","","","2741.00","2055.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2239.95","81.72","","12180.24","2124.81","12180.24","1 through 10","1432.45","2239.95","percent of total billed charges",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","51470.20","38602.65","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","10149.62","","Case rate ($10,149.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,140.72, add-ons for qualifying new technology services are included. If operating cost exceeds $57,785.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,907.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,760.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.79. The transfer capital threshold is the transfer adjustment factor * $861.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10243.60","10243.60","10243.60","1 through 10","9946.63","16776.14","other","Inpatient Replacement Plans DRG"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","51470.20","38602.65","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","13116.41","13116.41","13116.41","1 through 10","9946.63","16776.14","case rate",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","51470.20","38602.65","MEDICARE [2001]","HB BWH MEDICARE","10149.62","","Case rate ($10,149.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,140.72, add-ons for qualifying new technology services are included. If operating cost exceeds $57,785.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,907.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,760.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.79. The transfer capital threshold is the transfer adjustment factor * $861.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13367.77","728.09","13387.35","29","9946.63","16776.14","other","Inpatient Replacement Plans DRG"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","51470.20","38602.65","MOLINA [1014]","HB BWH MOLINA","9946.63","","Case rate ($10,149.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,140.72, add-ons for qualifying new technology services are included. If operating cost exceeds $57,785.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,907.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,760.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.79. The transfer capital threshold is the transfer adjustment factor * $861.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20595.70","20595.70","20595.70","1 through 10","9946.63","16776.14","other","Inpatient DRG"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","51470.20","38602.65","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9946.63","","Case rate ($10,149.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,140.72, add-ons for qualifying new technology services are included. If operating cost exceeds $57,785.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,907.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,760.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.79. The transfer capital threshold is the transfer adjustment factor * $861.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10178.25","10178.25","10178.25","1 through 10","9946.63","16776.14","other","Inpatient DRG"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","51470.20","38602.65","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9946.63","","Case rate ($10,149.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,140.72, add-ons for qualifying new technology services are included. If operating cost exceeds $57,785.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,301.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,907.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,760.88 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $861.79. The transfer capital threshold is the transfer adjustment factor * $861.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10162.67","10162.67","10162.67","1 through 10","9946.63","16776.14","other","Inpatient DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","91988.23","68991.17","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","16984.15","","Case rate ($16,489.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,772.66, add-ons for qualifying new technology services are included. If operating cost exceeds $65,417.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,688.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,392.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.03. The transfer capital threshold is the transfer adjustment factor * $1,421.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","16680.65","16633.25","16680.65","1 through 10","16159.68","26376.0498","other","Inpatient DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","91988.23","68991.17","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","16489.47","","Case rate ($16,489.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,772.66, add-ons for qualifying new technology services are included. If operating cost exceeds $65,417.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,688.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,392.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.03. The transfer capital threshold is the transfer adjustment factor * $1,421.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15967.95","15967.92","20633.08","1 through 10","16159.68","26376.0498","other","Inpatient Replacement Plans DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","91988.23","68991.17","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","21431.77","21431.77","21431.77","1 through 10","16159.68","26376.0498","case rate",""
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","91988.23","68991.17","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","16489.47","","Case rate ($16,489.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,772.66, add-ons for qualifying new technology services are included. If operating cost exceeds $65,417.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,688.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,392.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.03. The transfer capital threshold is the transfer adjustment factor * $1,421.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15958.00","15958.00","15958.00","1 through 10","16159.68","26376.0498","other","Inpatient Replacement Plans DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","91988.23","68991.17","HUMANA [1012]","HB BWH MEDICARE","16489.47","","Case rate ($16,489.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,772.66, add-ons for qualifying new technology services are included. If operating cost exceeds $65,417.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,688.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,392.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.03. The transfer capital threshold is the transfer adjustment factor * $1,421.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15923.60","15923.60","646728.12","1 through 10","16159.68","26376.0498","other","Inpatient Replacement Plans DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","91988.23","68991.17","MEDICARE [2001]","HB BWH MEDICARE","16489.47","","Case rate ($16,489.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,772.66, add-ons for qualifying new technology services are included. If operating cost exceeds $65,417.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,688.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,392.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.03. The transfer capital threshold is the transfer adjustment factor * $1,421.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20883.38","0.03","20914.20","70","16159.68","26376.0498","other","Inpatient Replacement Plans DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","91988.23","68991.17","MOLINA [1014]","HB BWH MOLINA","16159.68","","Case rate ($16,489.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,772.66, add-ons for qualifying new technology services are included. If operating cost exceeds $65,417.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,688.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,392.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.03. The transfer capital threshold is the transfer adjustment factor * $1,421.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","32299.14","32299.14","32299.14","1 through 10","16159.68","26376.0498","other","Inpatient DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","91988.23","68991.17","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16159.68","","Case rate ($16,489.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,772.66, add-ons for qualifying new technology services are included. If operating cost exceeds $65,417.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,688.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,392.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.03. The transfer capital threshold is the transfer adjustment factor * $1,421.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15938.52","15888.57","18304.54","1 through 10","16159.68","26376.0498","other","Inpatient DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","91988.23","68991.17","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16159.68","","Case rate ($16,489.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,772.66, add-ons for qualifying new technology services are included. If operating cost exceeds $65,417.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,861.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,688.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,392.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.03. The transfer capital threshold is the transfer adjustment factor * $1,421.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15919.79","15919.79","15919.79","1 through 10","16159.68","26376.0498","other","Inpatient DRG"
"Respiratory Neoplasms With McC","180","TRIS-DRG","","","","","","","","inpatient","","","197556.95","","TRICARE [160005]","HB BWH TRICARE","11081.15","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($19,464.67). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $63,191.67 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($7,209.14), capped at $14,009.40. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $63,191.67 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","1085.55","1085.55","1085.55","1 through 10","11081.15","11081.15","other","Inpatient DRGs"
"Respiratory Neoplasms Without Cc/McC","182","MS-DRG","","","","","","","","inpatient","","","35255.57","26441.68","MEDICARE [2001]","HB BWH MEDICARE","7256.07","","Case rate ($7,256.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,657.48, add-ons for qualifying new technology services are included. If operating cost exceeds $54,301.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,046.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,269.69 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,277.64 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $606.55. The transfer capital threshold is the transfer adjustment factor * $606.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1033.09","262.72","10163.35","1 through 10","7110.95","11807.52","other","Inpatient Replacement Plans DRG"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","","","","inpatient","","","39588.41","29691.31","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7977.38","","Case rate ($7,745.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,246.07, add-ons for qualifying new technology services are included. If operating cost exceeds $54,890.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,089.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,715.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,866.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.68. The transfer capital threshold is the transfer adjustment factor * $649.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7871.75","7871.75","7871.75","1 through 10","7590.13","12238.801","other","Inpatient DRG"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","","","","inpatient","","","39588.41","29691.31","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7745.03","","Case rate ($7,745.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,246.07, add-ons for qualifying new technology services are included. If operating cost exceeds $54,890.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,089.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,715.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,866.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.68. The transfer capital threshold is the transfer adjustment factor * $649.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7537.98","7537.98","7537.98","1 through 10","7590.13","12238.801","other","Inpatient DRG"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","","","","inpatient","","","39588.41","29691.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","","65","","78539.02","78539.02","78539.02","1 through 10","7590.13","12238.801","percent of total billed charges",""
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","","","","inpatient","","","39588.41","29691.31","MEDICARE [2001]","HB BWH MEDICARE","7745.03","","Case rate ($7,745.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,246.07, add-ons for qualifying new technology services are included. If operating cost exceeds $54,890.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,089.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,715.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,866.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.68. The transfer capital threshold is the transfer adjustment factor * $649.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9839.30","251.12","9853.58","1 through 10","7590.13","12238.801","other","Inpatient Replacement Plans DRG"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","","","","inpatient","","","39588.41","29691.31","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7590.13","","Case rate ($7,745.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,246.07, add-ons for qualifying new technology services are included. If operating cost exceeds $54,890.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,089.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,715.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,866.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.68. The transfer capital threshold is the transfer adjustment factor * $649.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7538.09","7538.09","7538.09","1 through 10","7590.13","12238.801","other","Inpatient DRG"
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","144","DRG","","","","","","","","inpatient","","","106563.37","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","56085.30","","Standard inlier is a Case rate ($56,085.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,441, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,960.84) for the length of stay and the standard reimbursement.","56085.30","56085.30","59992.80","1 through 10","4826.5","266826.69","case rate",""
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","144","DRG","","","","","","","","inpatient","","","106563.37","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10143.6034","","Fee schedule rate ($169,801.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10143.6034","53744.62","53744.62","1 through 10","4826.5","266826.69","case rate",""
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","144","DRG","","","","","","","","inpatient","","","106563.37","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","13810.06","","Case rate ($15,269.40). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $57,699.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15265.65","15265.65","15265.65","1 through 10","4826.5","266826.69","case rate",""
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","144","DRG","","","","","","","","inpatient","","","61858.03","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32160.42","","Standard inlier is a Case rate ($32,160.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,893, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,564.90) for the length of stay and the standard reimbursement.","32160.42","32160.42","32160.42","1 through 10","4826.5","266826.69","case rate",""
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","144","DRG","","","","","","","","inpatient","","","61858.03","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10143.6034","","Fee schedule rate ($19,873.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10143.6034","19873.84","19873.84","1 through 10","4826.5","266826.69","case rate",""
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","144","DRG","","","","","","","","inpatient","","","61858.03","","MASSHEALTH [3001]","HB BWH MEDICAID","9573.03","","Case rate ($10,584.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,014.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3333.11","3333.11","3333.11","1 through 10","4826.5","266826.69","case rate",""
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","144","DRG","","","","","","","","inpatient","","","61858.03","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","9573.03","","Case rate ($10,584.63). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,014.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6342.05","6342.05","6342.05","1 through 10","4826.5","266826.69","case rate",""
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,MINOR","144","DRG","","","","","","","","inpatient","","","52107.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","17296.45","","Standard inlier is a Case rate ($17,296.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,612, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,455.09) for the length of stay and the standard reimbursement.","17296.45","17296.45","17296.45","1 through 10","4826.5","266826.69","case rate",""
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","144","DRG","","","","","","","","inpatient","","","35957.04","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20248.70","","Standard inlier is a Case rate ($20,248.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,395, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,874.43) for the length of stay and the standard reimbursement.","18457.42","18457.42","18457.42","1 through 10","4826.5","266826.69","case rate",""
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","144","DRG","","","","","","","","inpatient","","","35957.04","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22765.00","","Standard inlier is a Case rate ($22,765.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,395, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,231.30) for the length of stay and the standard reimbursement.","22764.99","22764.99","22764.99","1 through 10","4826.5","266826.69","case rate",""
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","137853.65","103390.24","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","25453.76","","Case rate ($25,453.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,563.90, add-ons for qualifying new technology services are included. If operating cost exceeds $76,208.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,651.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $22,862.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,184.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,211.77. The transfer capital threshold is the transfer adjustment factor * $2,211.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","44284.65","44284.65","44284.65","1 through 10","24944.68","40501.2258","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","137853.65","103390.24","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","20141.21","20141.21","20141.21","1 through 10","24944.68","40501.2258","case rate",""
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","137853.65","103390.24","MEDICARE [2001]","HB BWH MEDICARE","32921.48","","Case rate ($32,921.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,563.90, add-ons for qualifying new technology services are included. If operating cost exceeds $76,208.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,651.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $30,329.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,184.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,211.77. The transfer capital threshold is the transfer adjustment factor * $2,211.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","31965.35","0.03","31965.35","32","24944.68","40501.2258","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","137853.65","103390.24","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","24944.68","","Case rate ($25,453.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,563.90, add-ons for qualifying new technology services are included. If operating cost exceeds $76,208.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,651.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $22,862.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,184.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,211.77. The transfer capital threshold is the transfer adjustment factor * $2,211.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","24379.13","24379.13","24379.13","1 through 10","24944.68","40501.2258","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","137853.65","103390.24","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","24944.68","","Case rate ($25,453.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,563.90, add-ons for qualifying new technology services are included. If operating cost exceeds $76,208.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,651.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $22,862.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,184.07 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,211.77. The transfer capital threshold is the transfer adjustment factor * $2,211.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","32963.90","24312.38","35637.92","1 through 10","24944.68","40501.2258","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","137853.65","103390.24","WELLPOINT [1015]","HB AMC WELLPOINT","40501.2258","","Fee schedule rate ($43,055.64).","40501.2258","102066.92","102066.92","1 through 10","24944.68","40501.2258","case rate",""
"Respiratory System Diagnosis With Ventilator Support > 96 Hours,EXTREME","130","DRG","","","","","","","","inpatient","","","422270.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","160233.48","","Standard inlier is a Case rate ($160,233.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $136,251, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($22,746.11) for the length of stay and the standard reimbursement.","251985.07","251985.07","251985.07","1 through 10","27149.1744","266826.69","case rate",""
"Respiratory System Diagnosis With Ventilator Support > 96 Hours,EXTREME","130","DRG","","","","","","","","inpatient","","","422270.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","180145.62","","Standard inlier is a Case rate ($180,145.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $136,251, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($25,570.17) for the length of stay and the standard reimbursement.","164578.58","164578.58","180145.62","1 through 10","27149.1744","266826.69","case rate",""
"Respiratory System Diagnosis With Ventilator Support > 96 Hours,EXTREME","130","DRG","","","","","","","","inpatient","","","422270.84","","MASSHEALTH [3001]","HB BWH MEDICAID","59449.87","","Case rate ($65,732.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $108,162.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","161286.02","161286.02","161286.02","1 through 10","27149.1744","266826.69","case rate",""
"Respiratory System Diagnosis With Ventilator Support > 96 Hours,EXTREME","130","DRG","","","","","","","","inpatient","","","422270.84","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","59449.87","","Case rate ($65,732.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $108,162.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","27149.1744","266826.69","case rate",""
"Respiratory System Diagnosis With Ventilator Support > 96 Hours,EXTREME","130","DRG","","","","","","","","inpatient","","","422270.84","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","59449.87","","Case rate ($65,732.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $108,162.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","42025.63","42025.63","42025.63","1 through 10","27149.1744","266826.69","case rate",""
"Respiratory System Diagnosis With Ventilator Support > 96 Hours,EXTREME","130","DRG","","","","","","","","inpatient","","","422270.84","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157513.57","","Fee schedule rate ($157,513.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","204092.65","204092.65","204092.65","1 through 10","27149.1744","266826.69","case rate",""
"Respiratory System Diagnosis With Ventilator Support > 96 Hours,EXTREME","130","DRG","","","","","","","","inpatient","","","422270.84","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","59449.87","","Case rate ($65,732.05). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $108,162.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","72856.07","2607.48","111047.95","1 through 10","27149.1744","266826.69","case rate",""
"Respiratory System Diagnosis With Ventilator Support > 96 Hours,MAJOR","130","DRG","","","","","","","","inpatient","","","160247.85","","MASSHEALTH [3001]","HB BWH MEDICAID","46555.98","","Case rate ($51,475.64). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $93,905.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","51463.01","51463.01","51463.01","1 through 10","27149.1744","266826.69","case rate",""
"Respiratory System Diagnosis With Ventilator Support > 96 Hours,MAJOR","130","DRG","","","","","","","","inpatient","","","160247.85","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","46555.98","","Case rate ($51,475.64). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $93,905.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","51463.01","51463.01","51463.01","1 through 10","27149.1744","266826.69","case rate",""
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","","","","inpatient","","","332911.27","249683.45","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","60850.19","","Case rate ($59,077.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $71,040.68, add-ons for qualifying new technology services are included. If operating cost exceeds $116,685.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,617.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $53,520.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $70,660.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,177.74. The transfer capital threshold is the transfer adjustment factor * $5,177.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","64248.35","64248.35","64248.35","1 through 10","57896.29","97596.5152","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","","","","inpatient","","","332911.27","249683.45","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","76559.77","","Case rate ($76,559.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $71,040.68, add-ons for qualifying new technology services are included. If operating cost exceeds $116,685.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,617.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $71,002.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $70,660.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,177.74. The transfer capital threshold is the transfer adjustment factor * $5,177.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","201928.67","201928.67","201928.67","1 through 10","57896.29","97596.5152","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","","","","inpatient","","","332911.27","249683.45","MEDICARE [2001]","HB BWH MEDICARE","76559.77","","Case rate ($76,559.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $71,040.68, add-ons for qualifying new technology services are included. If operating cost exceeds $116,685.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,617.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $71,002.20 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $70,660.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,177.74. The transfer capital threshold is the transfer adjustment factor * $5,177.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","76521.11","76521.11","76635.17","13","57896.29","97596.5152","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","","","","inpatient","","","332911.27","249683.45","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","57896.29","","Case rate ($59,077.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $71,040.68, add-ons for qualifying new technology services are included. If operating cost exceeds $116,685.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,617.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $53,520.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $70,660.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,177.74. The transfer capital threshold is the transfer adjustment factor * $5,177.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","58132.22","58132.22","58132.22","1 through 10","57896.29","97596.5152","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","","","","inpatient","","","332911.27","249683.45","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","57896.29","","Case rate ($59,077.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $71,040.68, add-ons for qualifying new technology services are included. If operating cost exceeds $116,685.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,617.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $53,520.28 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $70,660.83 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,177.74. The transfer capital threshold is the transfer adjustment factor * $5,177.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","58050.49","58050.49","58050.49","1 through 10","57896.29","97596.5152","other","Inpatient DRG"
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","both","","","778.00","583.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","754.00","71.74","754.00","1 through 10","176.52","618.51","other","OPPS APC"
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","both","","","778.00","583.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","618.51","79.5","","398.11","398.11","398.11","1 through 10","176.52","618.51","percent of total billed charges",""
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","both","","","778.00","583.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","505.70","65","","399.62","399.62","399.62","1 through 10","176.52","618.51","percent of total billed charges",""
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","both","","","778.00","583.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","297.97","38.3","","294.81","294.81","294.81","1 through 10","176.52","618.51","percent of total billed charges",""
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","outpatient","","","778.00","583.50","AETNA [1001]","HB AMC AETNA HMO","543.04","69.8","","510.46","510.46","510.46","1 through 10","304.03","641.85","percent of total billed charges",""
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","outpatient","","","778.00","583.50","AETNA [1001]","HB AMC AETNA PPO","625.51","80.4","","588.12","588.12","588.12","1 through 10","304.03","641.85","percent of total billed charges",""
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","outpatient","","","778.00","583.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471.08","60.55","","363.93","312.34","754.00","1 through 10","304.03","641.85","percent of total billed charges",""
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","outpatient","","","778.00","583.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","406.27","52.22","","363.93","360.37","754.00","1 through 10","304.03","641.85","percent of total billed charges",""
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","outpatient","","","778.00","583.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","389.00","50","","754.00","754.00","754.00","1 through 10","304.03","641.85","percent of total billed charges",""
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","outpatient","","","778.00","583.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","408.45","52.5","","754.00","414.70","754.00","1 through 10","304.03","641.85","percent of total billed charges",""
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","outpatient","","","778.00","583.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","427.90","55","","434.30","434.30","434.30","1 through 10","304.03","641.85","percent of total billed charges",""
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","outpatient","","","778.00","583.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","635.78","81.72","","602.75","602.75","602.75","1 through 10","304.03","641.85","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","91.46","52.26","","1113.10","1113.10","1113.10","1 through 10","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","1293.60","1148.53","1603.80","1 through 10","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","1023.42","771.29","2068.67","33","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","850.52","759.78","1211.25","66","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","2548.09","2548.09","2548.09","1 through 10","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","956.46","956.46","956.46","1 through 10","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","2344.73","1619.47","2530.35","16","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","1523.63","988.41","4330.26","39","91.46","143.01","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA PPO","140.70","80.4","","1670.25","1670.25","1670.25","1 through 10","91.46","143.01","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","91.46","52.26","","1113.10","1113.10","1113.10","1 through 10","91.46","143.01","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","1738.90","1484.65","2716.94","38","91.46","143.01","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","91.46","52.26","","1113.10","1113.10","1113.10","1 through 10","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","1293.60","1148.53","1603.80","1 through 10","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","1023.42","771.29","2068.67","33","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","850.52","759.78","1211.25","66","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","2548.09","2548.09","2548.09","1 through 10","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","956.46","956.46","956.46","1 through 10","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","2344.73","1619.47","2530.35","16","54.25","139.13","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","1523.63","988.41","4330.26","39","91.46","143.01","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA PPO","140.70","80.4","","1670.25","1670.25","1670.25","1 through 10","91.46","143.01","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","91.46","52.26","","1113.10","1113.10","1113.10","1 through 10","91.46","143.01","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","1738.90","1484.65","2716.94","38","91.46","143.01","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","297.50","223.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","155.47","52.26","","1113.10","1113.10","1113.10","1 through 10","92.23","236.51","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","297.50","223.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.51","79.5","","1293.60","1148.53","1603.80","1 through 10","92.23","236.51","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.59","36.5","","1023.42","771.29","2068.67","33","92.23","236.51","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.94","38.3","","850.52","759.78","1211.25","66","92.23","236.51","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.63","42.9","","2548.09","2548.09","2548.09","1 through 10","92.23","236.51","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","297.50","223.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.63","42.9","","956.46","956.46","956.46","1 through 10","92.23","236.51","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","297.50","223.12","WELLPOINT [1015]","HB AMC WELLPOINT","219.50","73.78","","2344.73","1619.47","2530.35","16","92.23","236.51","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","AETNA [1001]","HB AMC AETNA HMO","207.66","69.8","","1523.63","988.41","4330.26","39","155.47","243.12","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","AETNA [1001]","HB AMC AETNA PPO","239.19","80.4","","1670.25","1670.25","1670.25","1 through 10","155.47","243.12","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","155.47","52.26","","1113.10","1113.10","1113.10","1 through 10","155.47","243.12","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","243.12","81.72","","1738.90","1484.65","2716.94","38","155.47","243.12","percent of total billed charges",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","","","","inpatient","","","45298.58","33973.93","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9629.66","","Case rate ($9,629.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,514.80, add-ons for qualifying new technology services are included. If operating cost exceeds $57,159.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,433.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,134.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.92. The transfer capital threshold is the transfer adjustment factor * $815.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9418.70","9418.70","9427.08","1 through 10","9437.07","15883.3","other","Inpatient Replacement Plans DRG"
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","","","","inpatient","","","45298.58","33973.93","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","12037.08","","Case rate ($9,629.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,514.80, add-ons for qualifying new technology services are included. If operating cost exceeds $57,159.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,433.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,134.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.92. The transfer capital threshold is the transfer adjustment factor * $815.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","9513.86","9513.86","9513.86","1 through 10","9437.07","15883.3","other","Inpatient DRG"
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","","","","inpatient","","","45298.58","33973.93","HUMANA [1012]","HB BWH MEDICARE","9629.66","","Case rate ($9,629.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,514.80, add-ons for qualifying new technology services are included. If operating cost exceeds $57,159.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,433.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,134.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.92. The transfer capital threshold is the transfer adjustment factor * $815.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9513.86","9513.86","9513.86","1 through 10","9437.07","15883.3","other","Inpatient Replacement Plans DRG"
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","","","","inpatient","","","45298.58","33973.93","MEDICARE [2001]","HB BWH MEDICARE","9629.66","","Case rate ($9,629.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,514.80, add-ons for qualifying new technology services are included. If operating cost exceeds $57,159.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,433.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,134.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.92. The transfer capital threshold is the transfer adjustment factor * $815.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12257.24","0.03","12275.15","17","9437.07","15883.3","other","Inpatient Replacement Plans DRG"
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","","","","inpatient","","","45298.58","33973.93","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","9629.66","","Case rate ($9,629.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,514.80, add-ons for qualifying new technology services are included. If operating cost exceeds $57,159.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,433.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,134.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.92. The transfer capital threshold is the transfer adjustment factor * $815.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9332.09","9332.09","9332.09","1 through 10","9437.07","15883.3","other","Inpatient Replacement Plans DRG"
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","","","","inpatient","","","45298.58","33973.93","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9437.07","","Case rate ($9,629.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,514.80, add-ons for qualifying new technology services are included. If operating cost exceeds $57,159.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,256.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,433.89 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,134.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.92. The transfer capital threshold is the transfer adjustment factor * $815.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9362.54","9362.54","9362.54","1 through 10","9437.07","15883.3","other","Inpatient DRG"
"Reticuloendothelial And Immunity Disorders With McC","814","MS-DRG","","","","","","","","inpatient","","","75727.73","56795.80","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","25557.69","","Case rate ($25,557.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,733.59, add-ons for qualifying new technology services are included. If operating cost exceeds $69,378.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,151.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,466.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,353.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,711.27. The transfer capital threshold is the transfer adjustment factor * $1,711.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19253.09","19253.09","19253.09","1 through 10","19384.23","31547.7355","other","Inpatient DRG"
"Reticuloendothelial And Immunity Disorders With McC","814","MS-DRG","","","","","","","","inpatient","","","75727.73","56795.80","MEDICARE [2001]","HB BWH MEDICARE","25557.69","","Case rate ($25,557.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,733.59, add-ons for qualifying new technology services are included. If operating cost exceeds $69,378.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,151.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $23,466.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,353.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,711.27. The transfer capital threshold is the transfer adjustment factor * $1,711.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24923.51","0.03","24960.37","19","19384.23","31547.7355","other","Inpatient DRG"
"Reticuloendothelial And Immunity Disorders With McC","814","MS-DRG","","","","","","","","inpatient","","","75727.73","56795.80","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19384.23","","Case rate ($19,779.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,733.59, add-ons for qualifying new technology services are included. If operating cost exceeds $69,378.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,151.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $17,688.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,353.75 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,711.27. The transfer capital threshold is the transfer adjustment factor * $1,711.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19253.12","19253.12","19253.12","1 through 10","19384.23","31547.7355","other","Inpatient DRG"
"Reticuloendothelial And Immunity Disorders With McC","814","TRIS-DRG","","","","","","","","inpatient","","","193630.93","","TRICARE [160005]","HB BWH TRICARE","14550.51","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($25,558.79). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $69,285.79 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($9,128.14), capped at $18,395.56. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $69,285.79 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","20265.65","20265.65","76894.16","1 through 10","14550.51","14550.51","other","Inpatient DRGs"
"Reticuloendothelial And Immunity Disorders With McC","814","TRIS-DRG","","","","","","","","inpatient","","","193630.93","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","14550.51","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($25,558.79). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $69,285.79 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($9,128.14), capped at $18,395.56. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $69,285.79 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","29722.06","29722.06","29722.06","1 through 10","14550.51","14550.51","other","Inpatient DRGs"
"Reticuloendothelial And Immunity Disorders Without Cc/McC","816","MS-DRG","","","","","","","","inpatient","","","37996.79","28497.59","MEDICARE [2001]","HB BWH MEDICARE","6145.02","","Case rate ($6,145.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,319.97, add-ons for qualifying new technology services are included. If operating cost exceeds $52,964.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,948.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,256.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,940.13 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.54. The transfer capital threshold is the transfer adjustment factor * $508.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8061.22","8061.22","8063.67","1 through 10","6022.12","9899.65","other","Inpatient Replacement Plans DRG"
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","301.00","225.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","157.30","52.26","","16.24","16.24","54.15","1 through 10","93.31","239.3","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","301.00","225.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","216.12","71.8","","86.33","32.67","86.33","1 through 10","93.31","239.3","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","301.00","225.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","210.70","70","","113.68","63.00","177.34","40","93.31","239.3","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","301.00","225.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","239.30","79.5","","50.70","21.76","168.00","12","93.31","239.3","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","301.00","225.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","160.43","53.3","","89.31","89.31","99.75","1 through 10","93.31","239.3","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","301.00","225.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","195.65","65","","94.41","17.06","2275.00","1 through 10","93.31","239.3","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","301.00","225.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","93.31","31","","35.13","35.13","35.13","1 through 10","93.31","239.3","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","301.00","225.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","109.87","36.5","","40.08","12.40","86.17","108","93.31","239.3","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","301.00","225.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","115.28","38.3","","33.25","10.27","68.43","169","93.31","239.3","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.13","42.9","","25.48","14.86","90.88","1 through 10","93.31","239.3","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","301.00","225.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.13","42.9","","90.88","90.88","90.88","1 through 10","93.31","239.3","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","301.00","225.75","WELLPOINT [1015]","HB AMC WELLPOINT","222.08","73.78","","84.63","19.55","140.02","123","93.31","239.3","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","301.00","225.75","AETNA [1001]","HB AMC AETNA HMO","210.10","69.8","","76.96","17.77","113.68","14","157.3","245.98","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","301.00","225.75","AETNA [1001]","HB AMC AETNA PPO","242.00","80.4","","57.31","57.31","57.31","1 through 10","157.3","245.98","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","301.00","225.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","157.30","52.26","","16.24","16.24","54.15","1 through 10","157.3","245.98","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","301.00","225.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","242.00","80.4","","68.25","68.25","87.50","1 through 10","157.3","245.98","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","301.00","225.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","245.98","81.72","","156.19","156.19","156.19","1 through 10","157.3","245.98","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","245.98","81.72","","82.70","12.06","98.97","13","157.3","245.98","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","245.98","81.72","","50.47","25.30","134.30","140","157.3","245.98","percent of total billed charges",""
"Retrieval Device Fractured Med Device T1","PX-27000092","CDM","C1773","HCPCS","0272","RC","","","","both","","","1446.41","1084.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","527.94","36.5","","114.30","97.14","114.30","1 through 10","448.39","1149.9","percent of total billed charges",""
"Retrieval Device Fractured Med Device T1","PX-27000092","CDM","C1773","HCPCS","0272","RC","","","","both","","","1446.41","1084.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","553.98","38.3","","119.81","116.44","359.43","20","448.39","1149.9","percent of total billed charges",""
"Retrieval Device Fractured Med Device T1","PX-27000092","CDM","C1773","HCPCS","0272","RC","","","","both","","","1446.41","1084.81","WELLPOINT [1015]","HB AMC WELLPOINT","1067.16","73.78","","875.53","228.13","875.53","1 through 10","448.39","1149.9","percent of total billed charges",""
"Retrieval Device Fractured Med Device T1","PX-27000092","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1446.41","1084.81","AETNA [1001]","HB AMC AETNA HMO","1009.59","69.8","","207.45","207.45","207.45","1 through 10","755.89","1182.01","percent of total billed charges",""
"Retrieval Device Fractured Med Device T1","PX-27000092","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1446.41","1084.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1182.01","81.72","","244.96","134.74","244.96","1 through 10","755.89","1182.01","percent of total billed charges",""
"Retrieval Device Fractured Med Device T2","PX-27000093","CDM","C1773","HCPCS","0272","RC","","","","both","","","4312.50","3234.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1574.06","36.5","","114.30","97.14","114.30","1 through 10","1336.88","3428.44","percent of total billed charges",""
"Retrieval Device Fractured Med Device T2","PX-27000093","CDM","C1773","HCPCS","0272","RC","","","","both","","","4312.50","3234.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1651.69","38.3","","119.81","116.44","359.43","20","1336.88","3428.44","percent of total billed charges",""
"Retrieval Device Fractured Med Device T2","PX-27000093","CDM","C1773","HCPCS","0272","RC","","","","both","","","4312.50","3234.37","WELLPOINT [1015]","HB AMC WELLPOINT","3181.76","73.78","","875.53","228.13","875.53","1 through 10","1336.88","3428.44","percent of total billed charges",""
"Retrieval Device Fractured Med Device T2","PX-27000093","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","4312.50","3234.37","AETNA [1001]","HB AMC AETNA HMO","3010.13","69.8","","207.45","207.45","207.45","1 through 10","2253.71","3524.18","percent of total billed charges",""
"Retrieval Device Fractured Med Device T2","PX-27000093","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","4312.50","3234.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3524.18","81.72","","244.96","134.74","244.96","1 through 10","2253.71","3524.18","percent of total billed charges",""
"Retrieval Device Fractured Med Device T3","PX-27000094","CDM","C1773","HCPCS","0272","RC","","","","both","","","7754.55","5815.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2830.41","36.5","","114.30","97.14","114.30","1 through 10","2403.91","6164.87","percent of total billed charges",""
"Retrieval Device Fractured Med Device T3","PX-27000094","CDM","C1773","HCPCS","0272","RC","","","","both","","","7754.55","5815.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2969.99","38.3","","119.81","116.44","359.43","20","2403.91","6164.87","percent of total billed charges",""
"Retrieval Device Fractured Med Device T3","PX-27000094","CDM","C1773","HCPCS","0272","RC","","","","both","","","7754.55","5815.91","WELLPOINT [1015]","HB AMC WELLPOINT","5721.31","73.78","","875.53","228.13","875.53","1 through 10","2403.91","6164.87","percent of total billed charges",""
"Retrieval Device Fractured Med Device T3","PX-27000094","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","7754.55","5815.91","AETNA [1001]","HB AMC AETNA HMO","5412.68","69.8","","207.45","207.45","207.45","1 through 10","4052.53","6337.02","percent of total billed charges",""
"Retrieval Device Fractured Med Device T3","PX-27000094","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","7754.55","5815.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6337.02","81.72","","244.96","134.74","244.96","1 through 10","4052.53","6337.02","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","both","","","2524.00","1893.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","782.44","2006.58","other","OPPS APC"
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","both","","","2524.00","1893.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","782.44","2006.58","other","OPPS APC"
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","both","","","2524.00","1893.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2006.58","79.5","","2814.50","2346.50","2814.50","1 through 10","782.44","2006.58","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","both","","","2524.00","1893.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","782.44","2006.58","other","OPPS APC"
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","both","","","2524.00","1893.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","782.44","2006.58","other","OPPS APC"
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","both","","","2524.00","1893.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","921.26","36.5","","2677.58","1482.13","2910.89","1 through 10","782.44","2006.58","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","both","","","2524.00","1893.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","966.69","38.3","","2723.31","1555.62","2741.61","12","782.44","2006.58","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","both","","","2524.00","1893.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","782.44","2006.58","other","OPPS APC"
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","both","","","2524.00","1893.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","782.44","2006.58","other","OPPS APC"
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","both","","","2524.00","1893.00","WELLPOINT [1015]","HB AMC WELLPOINT","1862.21","73.78","","2687.65","2687.64","3224.43","1 through 10","782.44","2006.58","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","outpatient","","","2524.00","1893.00","AETNA [1001]","HB AMC AETNA PPO","2029.30","80.4","","1163.76","1163.76","1163.76","1 through 10","1262","2384.07","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","outpatient","","","2524.00","1893.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1528.28","60.55","","1781.82","1492.00","4331.00","1 through 10","1262","2384.07","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","outpatient","","","2524.00","1893.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1318.03","52.22","","3144.00","1492.00","3610.00","13","1262","2384.07","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","outpatient","","","2524.00","1893.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1325.10","52.5","","1182.28","1182.28","1182.28","1 through 10","1262","2384.07","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","outpatient","","","2524.00","1893.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1262.00","50","","3610.00","2269.44","3610.00","1 through 10","1262","2384.07","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","outpatient","","","2524.00","1893.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1325.10","52.5","","3610.00","2382.05","4331.00","1 through 10","1262","2384.07","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","outpatient","","","2524.00","1893.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1388.20","55","","4810.75","3363.17","4810.75","1 through 10","1262","2384.07","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","outpatient","","","2524.00","1893.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2062.61","81.72","","8894.69","8894.69","8894.69","1 through 10","1262","2384.07","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","outpatient","","","2524.00","1893.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2062.61","81.72","","2885.83","2132.00","3462.21","1 through 10","1262","2384.07","percent of total billed charges",""
"Retrograde Enteroscopy With Control of Bleeding","PX-75000475","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1057.74","3603.74","other","OPPS APC"
"Retrograde Enteroscopy With Control of Bleeding","PX-75000475","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","3603.74","other","OPPS APC"
"Retrograde Enteroscopy With Control of Bleeding","PX-75000475","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3603.74","other","OPPS APC"
"Retrograde Enteroscopy With Control of Bleeding","PX-75000475","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1057.74","3603.74","other","OPPS APC"
"Retrograde Enteroscopy With Control of Bleeding","PX-75000475","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.66","42.9","","1932.92","1932.92","1932.92","1 through 10","1057.74","3603.74","percent of total billed charges",""
"Retrograde Enteroscopy With Control of Bleeding","PX-75000475","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1057.74","3603.74","other","OPPS APC"
"Retrograde Enteroscopy With Control of Bleeding","PX-75000475","CDM","44799","CPT","0750","RC","","","","both","","","4533.00","3399.75","WELLPOINT [1015]","HB AMC WELLPOINT","3344.45","73.78","","2222.33","2222.33","2222.33","1 through 10","1057.74","3603.74","percent of total billed charges",""
"Retrograde Enteroscopy With Control of Bleeding","PX-75000475","CDM","44799","CPT","0750","RC","","","","outpatient","","","4533.00","3399.75","AETNA [1001]","HB AMC AETNA HMO","3164.03","69.8","","2238.60","2238.60","2238.60","1 through 10","2266.5","8899.59","percent of total billed charges",""
"Retrograde Enteroscopy With Control of Bleeding","PX-75000475","CDM","44799","CPT","0750","RC","","","","outpatient","","","4533.00","3399.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2744.73","60.55","","3144.00","2870.00","3286.00","1 through 10","2266.5","8899.59","percent of total billed charges",""
"Retrograde Enteroscopy With Control of Bleeding","PX-75000475","CDM","44799","CPT","0750","RC","","","","outpatient","","","4533.00","3399.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2368.95","52.26","","1775.96","1775.96","1775.96","1 through 10","2266.5","8899.59","percent of total billed charges",""
"Retrograde Enteroscopy With Control of Bleeding","PX-75000475","CDM","44799","CPT","0750","RC","","","","outpatient","","","4533.00","3399.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2367.13","52.22","","3286.00","2018.70","5898.00","1 through 10","2266.5","8899.59","percent of total billed charges",""
"Retrograde Enteroscopy With Control of Bleeding","PX-75000475","CDM","44799","CPT","0750","RC","","","","outpatient","","","4533.00","3399.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2379.83","52.5","","8340.00","8340.00","8340.00","1 through 10","2266.5","8899.59","percent of total billed charges",""
"Retrograde Enteroscopy With Control of Bleeding","PX-75000475","CDM","44799","CPT","0750","RC","","","","outpatient","","","4533.00","3399.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3704.37","81.72","","2294.28","682.69","2294.28","1 through 10","2266.5","8899.59","percent of total billed charges",""
"Rev/Rem Elect Neurostim Peripherial","PX-76001564","CDM","64585","CPT","0761","RC","","","","both","","","5957.00","4467.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4083.62","","APC Price ($4,083.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4018.69","4018.69","4018.69","1 through 10","1846.67","5104.52","other","OPPS APC"
"Rev/Rem Elect Neurostim Peripherial","PX-76001564","CDM","64585","CPT","0761","RC","","","","both","","","5957.00","4467.75","MEDICARE [2001]","HB BWH MEDICARE","4083.62","","APC Price ($4,083.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4084.03","4084.03","4084.03","1 through 10","1846.67","5104.52","other","OPPS APC"
"Revasc Fem/Pop Artery Unilateral","PX-76001152","CDM","37224","CPT","0361","RC","","","","both","","","15840.00","11880.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6634.81","","APC Price ($6,770.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6635.49","6635.49","6643.39","1 through 10","4910.4","12592.8","other","OPPS APC"
"Revise Spine Eltrd Perq Aray","PX-76001493","CDM","63663","CPT","0761","RC","","","","both","","","16113.00","12084.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5881.25","36.5","","16462.76","16462.76","16462.76","1 through 10","4995.03","12809.84","percent of total billed charges",""
"Revise Spine Eltrd Perq Aray","PX-76001493","CDM","63663","CPT","0761","RC","","","","both","","","16113.00","12084.75","WELLPOINT [1015]","HB AMC WELLPOINT","11888.17","73.78","","51933.00","51933.00","51933.00","1 through 10","4995.03","12809.84","percent of total billed charges",""
"Revise Spine Eltrd Perq Aray","PX-76001493","CDM","63663","CPT","0761","RC","","","","outpatient","","","16113.00","12084.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","9756.42","60.55","","13737.40","13737.40","13737.40","1 through 10","6445.2","13167.54","percent of total billed charges",""
"Revise Tips","PX-76001128","CDM","37183","CPT","0361","RC","","","","both","","","34875.00","26156.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","22668.75","65","","17856.96","17856.96","17856.96","1 through 10","6432.35","27725.63","percent of total billed charges",""
"Revise/Rem Generator/Receiver Neuro","PX-76001496","CDM","63688","CPT","0761","RC","","","","outpatient","","","7739.00","5804.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4041.31","52.22","","7709.43","7633.68","7709.43","1 through 10","3095.6","6324.31","percent of total billed charges",""
"Revision CSF Shunt","PX-36000445","CDM","62230","CPT","0361","RC","","","","both","","","10319.00","7739.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3952.18","38.3","","12558.14","12558.14","12558.14","1 through 10","3198.89","8203.61","percent of total billed charges",""
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","131346.01","98509.51","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","33526.36","","Case rate ($32,549.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,106.20, add-ons for qualifying new technology services are included. If operating cost exceeds $84,750.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,277.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $29,332.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,726.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,837.71. The transfer capital threshold is the transfer adjustment factor * $2,837.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","32321.69","32321.69","32321.69","1 through 10","31898.86","51689.6932","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","131346.01","98509.51","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","32549.86","","Case rate ($32,549.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,106.20, add-ons for qualifying new technology services are included. If operating cost exceeds $84,750.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,277.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $29,332.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,726.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,837.71. The transfer capital threshold is the transfer adjustment factor * $2,837.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","31012.66","20778.91","31029.91","1 through 10","31898.86","51689.6932","other","Inpatient Replacement Plans DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","131346.01","98509.51","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","32549.86","","Case rate ($32,549.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,106.20, add-ons for qualifying new technology services are included. If operating cost exceeds $84,750.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,277.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $29,332.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,726.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,837.71. The transfer capital threshold is the transfer adjustment factor * $2,837.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","126212.57","126212.57","126212.57","1 through 10","31898.86","51689.6932","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","131346.01","98509.51","FALLON HEALTH [1008]","HB BWH MEDICARE","32549.86","","Case rate ($32,549.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,106.20, add-ons for qualifying new technology services are included. If operating cost exceeds $84,750.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,277.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $29,332.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,726.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,837.71. The transfer capital threshold is the transfer adjustment factor * $2,837.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","31410.75","31410.75","31410.75","1 through 10","31898.86","51689.6932","other","Inpatient Replacement Plans DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","131346.01","98509.51","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","32549.86","","Case rate ($32,549.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,106.20, add-ons for qualifying new technology services are included. If operating cost exceeds $84,750.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,277.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $29,332.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,726.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,837.71. The transfer capital threshold is the transfer adjustment factor * $2,837.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","30740.54","30740.54","30740.54","1 through 10","31898.86","51689.6932","other","Inpatient Replacement Plans DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","131346.01","98509.51","HUMANA [1012]","HB BWH MEDICARE","32549.86","","Case rate ($32,549.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,106.20, add-ons for qualifying new technology services are included. If operating cost exceeds $84,750.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,277.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $29,332.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,726.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,837.71. The transfer capital threshold is the transfer adjustment factor * $2,837.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","30782.56","30782.56","30782.56","1 through 10","31898.86","51689.6932","other","Inpatient Replacement Plans DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","131346.01","98509.51","MARTIN'S POINT [160007]","HB BWH MEDICARE","32549.86","","Case rate ($32,549.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,106.20, add-ons for qualifying new technology services are included. If operating cost exceeds $84,750.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,277.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $29,332.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,726.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,837.71. The transfer capital threshold is the transfer adjustment factor * $2,837.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","30861.44","30861.44","30861.44","1 through 10","31898.86","51689.6932","other","Inpatient Replacement Plans DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","131346.01","98509.51","MEDICARE [2001]","HB BWH MEDICARE","32549.86","","Case rate ($32,549.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,106.20, add-ons for qualifying new technology services are included. If operating cost exceeds $84,750.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,277.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $29,332.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,726.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,837.71. The transfer capital threshold is the transfer adjustment factor * $2,837.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","40658.49","0.03","40718.89","65","31898.86","51689.6932","other","Inpatient Replacement Plans DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","131346.01","98509.51","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","32549.86","","Case rate ($32,549.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,106.20, add-ons for qualifying new technology services are included. If operating cost exceeds $84,750.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,277.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $29,332.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,726.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,837.71. The transfer capital threshold is the transfer adjustment factor * $2,837.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","30795.93","30795.93","30795.93","1 through 10","31898.86","51689.6932","other","Inpatient Replacement Plans DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","131346.01","98509.51","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","31898.86","","Case rate ($32,549.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,106.20, add-ons for qualifying new technology services are included. If operating cost exceeds $84,750.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,277.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $29,332.31 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,726.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,837.71. The transfer capital threshold is the transfer adjustment factor * $2,837.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","30824.62","30821.52","30828.44","1 through 10","31898.86","51689.6932","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement With McC","466","MS-DRG","","","","","","","","inpatient","","","226007.02","169505.26","MARTIN'S POINT [160007]","HB BWH MEDICARE","62006.18","","Case rate ($62,006.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $57,541.46, add-ons for qualifying new technology services are included. If operating cost exceeds $103,185.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,628.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $57,437.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,161.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,188.57. The transfer capital threshold is the transfer adjustment factor * $4,188.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","30897.39","30897.39","30897.39","1 through 10","46906.77","81537.39","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement With McC","466","MS-DRG","","","","","","","","inpatient","","","226007.02","169505.26","MEDICARE [2001]","HB BWH MEDICARE","62006.18","","Case rate ($62,006.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $57,541.46, add-ons for qualifying new technology services are included. If operating cost exceeds $103,185.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,628.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $57,437.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,161.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,188.57. The transfer capital threshold is the transfer adjustment factor * $4,188.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","60339.32","0.03","60429.16","11","46906.77","81537.39","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement With McC","466","MS-DRG","","","","","","","","inpatient","","","226007.02","169505.26","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","46906.77","","Case rate ($47,864.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $57,541.46, add-ons for qualifying new technology services are included. If operating cost exceeds $103,185.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,628.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $43,295.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $57,161.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,188.57. The transfer capital threshold is the transfer adjustment factor * $4,188.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","45624.93","45624.93","45624.93","1 through 10","46906.77","81537.39","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement Without Cc/McC","468","MS-DRG","","","","","","","","inpatient","","","100848.28","75636.21","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","25447.39","","Case rate ($25,447.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,556.23, add-ons for qualifying new technology services are included. If operating cost exceeds $76,200.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,651.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $22,856.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,176.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,211.20. The transfer capital threshold is the transfer adjustment factor * $2,211.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","36772.99","36772.99","36772.99","1 through 10","24938.44","39588.2203","other","Inpatient Replacement Plans DRG"
"Revision Of Hip Or Knee Replacement Without Cc/McC","468","MS-DRG","","","","","","","","inpatient","","","100848.28","75636.21","MARTIN'S POINT [160007]","HB BWH MEDICARE","25447.39","","Case rate ($25,447.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,556.23, add-ons for qualifying new technology services are included. If operating cost exceeds $76,200.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,651.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $22,856.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,176.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,211.20. The transfer capital threshold is the transfer adjustment factor * $2,211.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","23648.75","23648.75","23648.75","1 through 10","24938.44","39588.2203","other","Inpatient Replacement Plans DRG"
"Revision Of Hip Or Knee Replacement Without Cc/McC","468","MS-DRG","","","","","","","","inpatient","","","100848.28","75636.21","MEDICARE [2001]","HB BWH MEDICARE","25447.39","","Case rate ($25,447.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,556.23, add-ons for qualifying new technology services are included. If operating cost exceeds $76,200.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,651.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $22,856.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,176.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,211.20. The transfer capital threshold is the transfer adjustment factor * $2,211.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","31204.77","31204.77","31241.26","14","24938.44","39588.2203","other","Inpatient Replacement Plans DRG"
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","both","","","1629.00","1221.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1295.06","other","OPPS APC"
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","both","","","1629.00","1221.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1295.06","other","OPPS APC"
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","both","","","1629.00","1221.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","868.26","53.3","","477.31","477.31","477.31","1 through 10","333.03","1295.06","percent of total billed charges",""
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","both","","","1629.00","1221.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1295.06","other","OPPS APC"
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","both","","","1629.00","1221.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1295.06","other","OPPS APC"
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","both","","","1629.00","1221.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","594.59","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1295.06","percent of total billed charges",""
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","both","","","1629.00","1221.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","623.91","38.3","","343.52","323.76","353.46","1 through 10","333.03","1295.06","percent of total billed charges",""
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","both","","","1629.00","1221.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1295.06","other","Tricare OPPS"
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","both","","","1629.00","1221.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1295.06","other","OPPS APC"
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","both","","","1629.00","1221.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1295.06","other","OPPS APC"
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","both","","","1629.00","1221.75","WELLPOINT [1015]","HB AMC WELLPOINT","1201.88","73.78","","673.03","673.03","673.03","1 through 10","333.03","1295.06","percent of total billed charges",""
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","outpatient","","","1629.00","1221.75","AETNA [1001]","HB AMC AETNA HMO","1137.04","69.8","","612.01","612.01","1224.02","1 through 10","700.33","1343.93","percent of total billed charges",""
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","outpatient","","","1629.00","1221.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","986.36","60.55","","579.04","568.57","904.00","30","700.33","1343.93","percent of total billed charges",""
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","outpatient","","","1629.00","1221.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","850.66","52.22","","904.00","656.02","2938.00","26","700.33","1343.93","percent of total billed charges",""
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","outpatient","","","1629.00","1221.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","814.50","50","","1421.10","875.08","2368.50","15","700.33","1343.93","percent of total billed charges",""
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","outpatient","","","1629.00","1221.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","855.23","52.5","","2985.00","904.00","2985.00","1 through 10","700.33","1343.93","percent of total billed charges",""
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","outpatient","","","1629.00","1221.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1331.22","81.72","","722.66","722.66","17449.00","1 through 10","700.33","1343.93","percent of total billed charges",""
"Revision Tracheostomy Scar","PX-76000809","CDM","31830","CPT","0761","RC","","","","outpatient","","","6634.00","4975.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2008.14","","Case rate ($2,008.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4658.88","4658.88","4658.88","1 through 10","2008.14","5545.35","other","Multiple Surgery"
"Revsc Fem/Pop Artery W/Stent","PX-76001154","CDM","37226","CPT","0361","RC","","","","both","","","14236.00","10677.00","MEDICARE [2001]","HB BWH MEDICARE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13467.61","13467.61","13467.61","1 through 10","4413.16","16832.81","other","OPPS APC"
"Revsc Fem/Pop Artery W/Stent","PX-76001154","CDM","37226","CPT","0361","RC","","","","outpatient","","","14236.00","10677.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","8702.14","","Case rate ($8,702.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","10616.61","10616.61","10616.61","1 through 10","7439.73","42063.88","other","Multiple Surgery"
"Revsc Iliac Artery Uni W/Stent","PX-76001149","CDM","37221","CPT","0361","RC","","","","outpatient","","","13304.00","9978.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","8702.14","","Case rate ($8,702.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","21233.22","21233.22","21233.22","1 through 10","6952.67","33742.46","other","Multiple Surgery"
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1014.42","other","OPPS APC"
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1014.42","other","OPPS APC"
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","680.11","53.3","","477.31","477.31","477.31","1 through 10","333.03","1014.42","percent of total billed charges",""
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1014.42","other","OPPS APC"
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1014.42","other","OPPS APC"
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","465.74","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1014.42","percent of total billed charges",""
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","488.71","38.3","","343.52","323.76","353.46","1 through 10","333.03","1014.42","percent of total billed charges",""
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1014.42","other","Tricare OPPS"
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1014.42","other","OPPS APC"
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1014.42","other","OPPS APC"
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","WELLPOINT [1015]","HB AMC WELLPOINT","941.43","73.78","","673.03","673.03","673.03","1 through 10","333.03","1014.42","percent of total billed charges",""
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","AETNA [1001]","HB AMC AETNA HMO","890.65","69.8","","612.01","612.01","1224.02","1 through 10","638","1052.7","percent of total billed charges",""
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","772.62","60.55","","579.04","568.57","904.00","30","638","1052.7","percent of total billed charges",""
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","666.33","52.22","","904.00","656.02","2938.00","26","638","1052.7","percent of total billed charges",""
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","638.00","50","","1421.10","875.08","2368.50","15","638","1052.7","percent of total billed charges",""
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","669.90","52.5","","2985.00","904.00","2985.00","1 through 10","638","1052.7","percent of total billed charges",""
"Rf Ablation of Knee/Hip/Shoulder/Other Pn","PX-76010297","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1042.75","81.72","","722.66","722.66","17449.00","1 through 10","638","1052.7","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","1014.42","other","OPPS APC"
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","1014.42","other","OPPS APC"
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","680.11","53.3","","477.31","477.31","477.31","1 through 10","333.03","1014.42","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","1014.42","other","OPPS APC"
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1014.42","other","OPPS APC"
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","465.74","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","1014.42","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","488.71","38.3","","343.52","323.76","353.46","1 through 10","333.03","1014.42","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","1014.42","other","Tricare OPPS"
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","1014.42","other","OPPS APC"
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","1014.42","other","OPPS APC"
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","both","","","1276.00","957.00","WELLPOINT [1015]","HB AMC WELLPOINT","941.43","73.78","","673.03","673.03","673.03","1 through 10","333.03","1014.42","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","AETNA [1001]","HB AMC AETNA HMO","890.65","69.8","","612.01","612.01","1224.02","1 through 10","638","1052.7","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","772.62","60.55","","579.04","568.57","904.00","30","638","1052.7","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","666.33","52.22","","904.00","656.02","2938.00","26","638","1052.7","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","638.00","50","","1421.10","875.08","2368.50","15","638","1052.7","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","669.90","52.5","","2985.00","904.00","2985.00","1 through 10","638","1052.7","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-76010294","CDM","64999","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1042.75","81.72","","722.66","722.66","17449.00","1 through 10","638","1052.7","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","both","","","762.00","571.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","236.22","605.79","other","OPPS APC"
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","both","","","762.00","571.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","236.22","605.79","other","OPPS APC"
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","both","","","762.00","571.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","406.15","53.3","","477.31","477.31","477.31","1 through 10","236.22","605.79","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","both","","","762.00","571.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","236.22","605.79","other","OPPS APC"
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","both","","","762.00","571.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","236.22","605.79","other","OPPS APC"
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","both","","","762.00","571.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","278.13","36.5","","1095.87","337.19","1095.87","1 through 10","236.22","605.79","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","both","","","762.00","571.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","291.85","38.3","","343.52","323.76","353.46","1 through 10","236.22","605.79","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","both","","","762.00","571.50","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","236.22","605.79","other","Tricare OPPS"
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","both","","","762.00","571.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","236.22","605.79","other","OPPS APC"
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","both","","","762.00","571.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","236.22","605.79","other","OPPS APC"
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","both","","","762.00","571.50","WELLPOINT [1015]","HB AMC WELLPOINT","562.20","73.78","","673.03","673.03","673.03","1 through 10","236.22","605.79","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","outpatient","","","762.00","571.50","AETNA [1001]","HB AMC AETNA HMO","531.88","69.8","","612.01","612.01","1224.02","1 through 10","381","700.33","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","outpatient","","","762.00","571.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","461.39","60.55","","579.04","568.57","904.00","30","381","700.33","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","outpatient","","","762.00","571.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","397.92","52.22","","904.00","656.02","2938.00","26","381","700.33","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","outpatient","","","762.00","571.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","381.00","50","","1421.10","875.08","2368.50","15","381","700.33","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","outpatient","","","762.00","571.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","400.05","52.5","","2985.00","904.00","2985.00","1 through 10","381","700.33","percent of total billed charges",""
"Rf Ablation of Si Joint/Nerves","PX-98301928","CDM","64999","CPT","0983","RC","","","","outpatient","","","762.00","571.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","622.71","81.72","","722.66","722.66","17449.00","1 through 10","381","700.33","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","both","","","1165.00","873.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","333.03","926.18","other","OPPS APC"
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","both","","","1165.00","873.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","333.03","926.18","other","OPPS APC"
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","both","","","1165.00","873.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","620.95","53.3","","477.31","477.31","477.31","1 through 10","333.03","926.18","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","both","","","1165.00","873.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","333.03","926.18","other","OPPS APC"
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","both","","","1165.00","873.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","926.18","other","OPPS APC"
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","both","","","1165.00","873.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","425.23","36.5","","1095.87","337.19","1095.87","1 through 10","333.03","926.18","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","both","","","1165.00","873.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","446.20","38.3","","343.52","323.76","353.46","1 through 10","333.03","926.18","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","both","","","1165.00","873.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","333.03","926.18","other","Tricare OPPS"
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","both","","","1165.00","873.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","333.03","926.18","other","OPPS APC"
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","both","","","1165.00","873.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","333.03","926.18","other","OPPS APC"
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","both","","","1165.00","873.75","WELLPOINT [1015]","HB AMC WELLPOINT","859.54","73.78","","673.03","673.03","673.03","1 through 10","333.03","926.18","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","outpatient","","","1165.00","873.75","AETNA [1001]","HB AMC AETNA HMO","813.17","69.8","","612.01","612.01","1224.02","1 through 10","582.5","961.13","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","outpatient","","","1165.00","873.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","705.41","60.55","","579.04","568.57","904.00","30","582.5","961.13","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","outpatient","","","1165.00","873.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","608.36","52.22","","904.00","656.02","2938.00","26","582.5","961.13","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","outpatient","","","1165.00","873.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","582.50","50","","1421.10","875.08","2368.50","15","582.5","961.13","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","outpatient","","","1165.00","873.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","611.63","52.5","","2985.00","904.00","2985.00","1 through 10","582.5","961.13","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-76010296","CDM","64999","CPT","0761","RC","","","","outpatient","","","1165.00","873.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","952.04","81.72","","722.66","722.66","17449.00","1 through 10","582.5","961.13","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","both","","","839.00","629.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","260.09","667.01","other","OPPS APC"
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","both","","","839.00","629.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","260.09","667.01","other","OPPS APC"
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","both","","","839.00","629.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.19","53.3","","477.31","477.31","477.31","1 through 10","260.09","667.01","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","both","","","839.00","629.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","260.09","667.01","other","OPPS APC"
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","both","","","839.00","629.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","260.09","667.01","other","OPPS APC"
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","both","","","839.00","629.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.24","36.5","","1095.87","337.19","1095.87","1 through 10","260.09","667.01","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","both","","","839.00","629.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.34","38.3","","343.52","323.76","353.46","1 through 10","260.09","667.01","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","both","","","839.00","629.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","260.09","667.01","other","Tricare OPPS"
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","both","","","839.00","629.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","260.09","667.01","other","OPPS APC"
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","both","","","839.00","629.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","260.09","667.01","other","OPPS APC"
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","both","","","839.00","629.25","WELLPOINT [1015]","HB AMC WELLPOINT","619.01","73.78","","673.03","673.03","673.03","1 through 10","260.09","667.01","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","outpatient","","","839.00","629.25","AETNA [1001]","HB AMC AETNA HMO","585.62","69.8","","612.01","612.01","1224.02","1 through 10","419.5","700.33","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","outpatient","","","839.00","629.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","508.01","60.55","","579.04","568.57","904.00","30","419.5","700.33","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","outpatient","","","839.00","629.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","438.13","52.22","","904.00","656.02","2938.00","26","419.5","700.33","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","outpatient","","","839.00","629.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","419.50","50","","1421.10","875.08","2368.50","15","419.5","700.33","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","outpatient","","","839.00","629.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","440.48","52.5","","2985.00","904.00","2985.00","1 through 10","419.5","700.33","percent of total billed charges",""
"Rf Denervation of Spine/Back","PX-98301931","CDM","64999","CPT","0983","RC","","","","outpatient","","","839.00","629.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","685.63","81.72","","722.66","722.66","17449.00","1 through 10","419.5","700.33","percent of total billed charges",""
"Rh E/E Antigen Genotyping","PX-31000738","CDM","81479","CPT","0310","RC","","","","both","","","132.00","99.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","104.94","79.5","","0.65","0.65","0.65","1 through 10","40.92","125.4","percent of total billed charges",""
"Rh E/E Antigen Genotyping","PX-31000738","CDM","81479","CPT","0310","RC","","","","both","","","132.00","99.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","70.36","53.3","","0.79","0.79","0.79","1 through 10","40.92","125.4","percent of total billed charges",""
"Rh E/E Antigen Genotyping","PX-31000738","CDM","81479","CPT","0310","RC","","","","outpatient","","","132.00","99.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","66.00","50","","1.00","1.00","1.00","1 through 10","63.89","156.55","percent of total billed charges",""
"Rh E/E Antigen Genotyping","PX-31000738","CDM","81479","CPT","0310","RC","","","","outpatient","","","132.00","99.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","69.30","52.5","","1.00","0.53","1.00","1 through 10","63.89","156.55","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","98.00","73.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","70.36","71.8","","15.00","15.00","15.00","1 through 10","5.56","93.1","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","98.00","73.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","68.60","70","","95.00","95.00","95.00","1 through 10","5.56","93.1","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","98.00","73.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","77.91","79.5","","74.77","50.16","224.31","81","5.56","93.1","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","98.00","73.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","52.23","53.3","","74.77","50.16","224.31","57","5.56","93.1","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","98.00","73.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","75.46","77","","219.45","73.15","219.45","1 through 10","5.56","93.1","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","63.70","65","","50.35","50.35","50.35","1 through 10","5.56","93.1","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","77.91","79.5","","74.77","74.77","74.77","1 through 10","5.56","93.1","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","98.00","73.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","30.38","31","","29.36","29.36","29.36","1 through 10","5.56","93.1","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","98.00","73.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","35.77","36.5","","35.44","30.12","70.56","69","5.56","93.1","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","98.00","73.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37.53","38.3","","37.15","37.15","111.45","242","5.56","93.1","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","98.00","73.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","75.46","77","","95.00","95.00","95.00","1 through 10","5.56","93.1","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","98.00","73.50","TRICARE [160005]","HB BWH TRICARE","93.10","95","","6.83","6.49","6.83","1 through 10","5.56","93.1","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.04","42.9","","75.94","41.77","75.94","1 through 10","5.56","93.1","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","98.00","73.50","AETNA [1001]","HB AMC AETNA HMO","68.40","69.8","","64.32","45.41","74.10","106","5.85","80.09","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","98.00","73.50","AETNA [1001]","HB AMC AETNA PPO","78.79","80.4","","74.10","49.78","99.56","12","5.85","80.09","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","98.00","73.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","51.21","52.26","","58.79","58.79","58.79","1 through 10","5.85","80.09","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","78.79","80.4","","47.50","47.50","74.10","1 through 10","5.85","80.09","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","80.09","81.72","","75.94","41.77","75.94","1 through 10","5.85","80.09","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","80.09","81.72","","75.94","41.77","75.94","76","5.85","80.09","percent of total billed charges",""
"Rho D Imm Glob 300 Mcg / 1500 Iu","PX-63600171","CDM","J2790","HCPCS","0636","RC","","","","both","","","501.50","376.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","192.07","38.3","","135.86","135.86","135.86","1 through 10","155.47","386.16","percent of total billed charges",""
"Rho D Imm Glob 300 Mcg / 1500 Iu","PX-63600171","CDM","J2790","HCPCS","0636","RC","","","","outpatient","","","501.50","376.12","AETNA [1001]","HB AMC AETNA HMO","350.05","69.8","","235.24","166.10","235.24","1 through 10","177.2","403.21","percent of total billed charges",""
"Rho D Immune Globulin Inj","PX-63601027","CDM","J2790","HCPCS","0636","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","135.86","135.86","135.86","1 through 10","68.2","189.59","percent of total billed charges",""
"Rho D Immune Globulin Inj","PX-63601027","CDM","J2790","HCPCS","0636","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","235.24","166.10","235.24","1 through 10","103.18","177.2","percent of total billed charges",""
"Rho D Immune Globulin Inj","PX-63601058","CDM","J2790","HCPCS","0636","RC","","","","both","","","501.50","376.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","192.07","38.3","","135.86","135.86","135.86","1 through 10","155.47","386.16","percent of total billed charges",""
"Rho D Immune Globulin Inj","PX-63601058","CDM","J2790","HCPCS","0636","RC","","","","outpatient","","","501.50","376.12","AETNA [1001]","HB AMC AETNA HMO","350.05","69.8","","235.24","166.10","235.24","1 through 10","177.2","403.21","percent of total billed charges",""
"Rhophylac Injection 1500 Iu","PX-63601472","CDM","J2791","HCPCS","0636","RC","","","","both","","","316.35","237.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.16","38.3","","24.11","8.04","24.11","270","11.91","243.59","percent of total billed charges",""
"Rhophylac Injection 1500 Iu","PX-63601472","CDM","J2791","HCPCS","0636","RC","","","","outpatient","","","316.35","237.26","AETNA [1001]","HB AMC AETNA HMO","220.81","69.8","","15.70","15.70","15.70","15","10.69","254.35","percent of total billed charges",""
"Rhophylac Injection 1500 Iu","PX-63601472","CDM","J2791","HCPCS","0636","RC","","","","outpatient","","","316.35","237.26","AETNA [1001]","HB AMC AETNA PPO","254.35","80.4","","16.03","16.03","16.03","15","10.69","254.35","percent of total billed charges",""
"Rhophylac Injection 1500 Iu","PX-63601472","CDM","J2791","HCPCS","0636","RC","","","","outpatient","","","316.35","237.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","221.13","69.9","","9.54","9.54","14.24","45","10.69","254.35","percent of total billed charges",""
"Rhophylac Injection 1500 Iu","PX-63601472","CDM","J2791","HCPCS","0636","RC","","","","outpatient","","","316.35","237.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","148.37","46.9","","14.24","14.24","14.24","15","10.69","254.35","percent of total billed charges",""
"Rhophylac Injection 1500 Iu","PX-63601472","CDM","J2791","HCPCS","0636","RC","","","","outpatient","","","316.35","237.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","254.35","80.4","","16.17","16.17","16.17","15","10.69","254.35","percent of total billed charges",""
"Rhophylac Injection per 100 Iu","PX-63601028","CDM","J2791","HCPCS","0636","RC","","","","both","","","20.55","15.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7.87","38.3","","24.11","8.04","24.11","270","6.37","15.82","percent of total billed charges",""
"Rhophylac Injection per 100 Iu","PX-63601028","CDM","J2791","HCPCS","0636","RC","","","","outpatient","","","20.55","15.41","AETNA [1001]","HB AMC AETNA HMO","14.34","69.8","","15.70","15.70","15.70","15","9.64","16.52","percent of total billed charges",""
"Rhophylac Injection per 100 Iu","PX-63601028","CDM","J2791","HCPCS","0636","RC","","","","outpatient","","","20.55","15.41","AETNA [1001]","HB AMC AETNA PPO","16.52","80.4","","16.03","16.03","16.03","15","9.64","16.52","percent of total billed charges",""
"Rhophylac Injection per 100 Iu","PX-63601028","CDM","J2791","HCPCS","0636","RC","","","","outpatient","","","20.55","15.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","14.36","69.9","","9.54","9.54","14.24","45","9.64","16.52","percent of total billed charges",""
"Rhophylac Injection per 100 Iu","PX-63601028","CDM","J2791","HCPCS","0636","RC","","","","outpatient","","","20.55","15.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9.64","46.9","","14.24","14.24","14.24","15","9.64","16.52","percent of total billed charges",""
"Rhophylac Injection per 100 Iu","PX-63601028","CDM","J2791","HCPCS","0636","RC","","","","outpatient","","","20.55","15.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","16.52","80.4","","16.17","16.17","16.17","15","9.64","16.52","percent of total billed charges",""
"RIB PLATE NUMBER 8-9 18 HOLE MATRIX TI PRECONTOURED LEFT","SUP-ITM-10041783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2592.66","1944.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2061.16","79.5","","800.18","480.96","1887.97","195","803.72","2061.16","percent of total billed charges",""
"RIB PLATE NUMBER 8-9 18 HOLE MATRIX TI PRECONTOURED LEFT","SUP-ITM-10041783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2592.66","1944.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1381.89","53.3","","813.12","216.42","1444.50","81","803.72","2061.16","percent of total billed charges",""
"RIB PLATE NUMBER 8-9 18 HOLE MATRIX TI PRECONTOURED LEFT","SUP-ITM-10041783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2592.66","1944.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","803.72","31","","432.60","432.60","432.60","1 through 10","803.72","2061.16","percent of total billed charges",""
"RIB PLATE NUMBER 8-9 18 HOLE MATRIX TI PRECONTOURED LEFT","SUP-ITM-10041783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2592.66","1944.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","946.32","36.5","","148.37","54.89","631.39","94","803.72","2061.16","percent of total billed charges",""
"RIB PLATE NUMBER 8-9 18 HOLE MATRIX TI PRECONTOURED LEFT","SUP-ITM-10041783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2592.66","1944.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","992.99","38.3","","279.30","91.72","1116.77","266","803.72","2061.16","percent of total billed charges",""
"RIB PLATE NUMBER 8-9 18 HOLE MATRIX TI PRECONTOURED LEFT","SUP-ITM-10041783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2592.66","1944.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1112.25","42.9","","731.00","63.70","731.00","1 through 10","803.72","2061.16","percent of total billed charges",""
"RIB PLATE NUMBER 8-9 18 HOLE MATRIX TI PRECONTOURED LEFT","SUP-ITM-10041783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2592.66","1944.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1112.25","42.9","","384.74","384.74","384.74","1 through 10","803.72","2061.16","percent of total billed charges",""
"RIB PLATE NUMBER 8-9 18 HOLE MATRIX TI PRECONTOURED LEFT","SUP-ITM-10041783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2592.66","1944.49","WELLPOINT [1015]","HB AMC WELLPOINT","1912.86","73.78","","286.63","119.22","1107.45","105","803.72","2061.16","percent of total billed charges",""
"RIB PLATE NUMBER 8-9 18 HOLE MATRIX TI PRECONTOURED LEFT","SUP-ITM-10041783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2592.66","1944.49","AETNA [1001]","HB AMC AETNA HMO","1809.68","69.8","","675.31","184.75","1721.50","286","1354.92","2118.72","percent of total billed charges",""
"RIB PLATE NUMBER 8-9 18 HOLE MATRIX TI PRECONTOURED LEFT","SUP-ITM-10041783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2592.66","1944.49","AETNA [1001]","HB AMC AETNA PPO","2084.50","80.4","","1261.44","103.12","1514.10","21","1354.92","2118.72","percent of total billed charges",""
"RIB PLATE NUMBER 8-9 18 HOLE MATRIX TI PRECONTOURED LEFT","SUP-ITM-10041783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2592.66","1944.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2084.50","80.4","","1365.00","1365.00","1365.00","1 through 10","1354.92","2118.72","percent of total billed charges",""
"RIB PLATE NUMBER 8-9 18 HOLE MATRIX TI PRECONTOURED LEFT","SUP-ITM-10041783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2592.66","1944.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2118.72","81.72","","5157.68","5157.68","5157.68","1 through 10","1354.92","2118.72","percent of total billed charges",""
"RIB PLATE NUMBER 8-9 18 HOLE MATRIX TI PRECONTOURED LEFT","SUP-ITM-10041783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2592.66","1944.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2118.72","81.72","","431.26","71.26","1459.57","88","1354.92","2118.72","percent of total billed charges",""
"RIB PLATE UNIVERSAL 8-9 HOLE BONE MATRIX TI PRECONTOURED","SUP-ITM-10046659","CDM","C1713","HCPCS","0278","RC","","","","both","","","1677.59","1258.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1333.68","79.5","","800.18","480.96","1887.97","195","520.05","1333.68","percent of total billed charges",""
"RIB PLATE UNIVERSAL 8-9 HOLE BONE MATRIX TI PRECONTOURED","SUP-ITM-10046659","CDM","C1713","HCPCS","0278","RC","","","","both","","","1677.59","1258.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","894.16","53.3","","813.12","216.42","1444.50","81","520.05","1333.68","percent of total billed charges",""
"RIB PLATE UNIVERSAL 8-9 HOLE BONE MATRIX TI PRECONTOURED","SUP-ITM-10046659","CDM","C1713","HCPCS","0278","RC","","","","both","","","1677.59","1258.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","520.05","31","","432.60","432.60","432.60","1 through 10","520.05","1333.68","percent of total billed charges",""
"RIB PLATE UNIVERSAL 8-9 HOLE BONE MATRIX TI PRECONTOURED","SUP-ITM-10046659","CDM","C1713","HCPCS","0278","RC","","","","both","","","1677.59","1258.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","612.32","36.5","","148.37","54.89","631.39","94","520.05","1333.68","percent of total billed charges",""
"RIB PLATE UNIVERSAL 8-9 HOLE BONE MATRIX TI PRECONTOURED","SUP-ITM-10046659","CDM","C1713","HCPCS","0278","RC","","","","both","","","1677.59","1258.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","642.52","38.3","","279.30","91.72","1116.77","266","520.05","1333.68","percent of total billed charges",""
"RIB PLATE UNIVERSAL 8-9 HOLE BONE MATRIX TI PRECONTOURED","SUP-ITM-10046659","CDM","C1713","HCPCS","0278","RC","","","","both","","","1677.59","1258.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","719.69","42.9","","731.00","63.70","731.00","1 through 10","520.05","1333.68","percent of total billed charges",""
"RIB PLATE UNIVERSAL 8-9 HOLE BONE MATRIX TI PRECONTOURED","SUP-ITM-10046659","CDM","C1713","HCPCS","0278","RC","","","","both","","","1677.59","1258.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","719.69","42.9","","384.74","384.74","384.74","1 through 10","520.05","1333.68","percent of total billed charges",""
"RIB PLATE UNIVERSAL 8-9 HOLE BONE MATRIX TI PRECONTOURED","SUP-ITM-10046659","CDM","C1713","HCPCS","0278","RC","","","","both","","","1677.59","1258.19","WELLPOINT [1015]","HB AMC WELLPOINT","1237.73","73.78","","286.63","119.22","1107.45","105","520.05","1333.68","percent of total billed charges",""
"RIB PLATE UNIVERSAL 8-9 HOLE BONE MATRIX TI PRECONTOURED","SUP-ITM-10046659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1677.59","1258.19","AETNA [1001]","HB AMC AETNA HMO","1170.96","69.8","","675.31","184.75","1721.50","286","876.71","1370.93","percent of total billed charges",""
"RIB PLATE UNIVERSAL 8-9 HOLE BONE MATRIX TI PRECONTOURED","SUP-ITM-10046659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1677.59","1258.19","AETNA [1001]","HB AMC AETNA PPO","1348.78","80.4","","1261.44","103.12","1514.10","21","876.71","1370.93","percent of total billed charges",""
"RIB PLATE UNIVERSAL 8-9 HOLE BONE MATRIX TI PRECONTOURED","SUP-ITM-10046659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1677.59","1258.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1348.78","80.4","","1365.00","1365.00","1365.00","1 through 10","876.71","1370.93","percent of total billed charges",""
"RIB PLATE UNIVERSAL 8-9 HOLE BONE MATRIX TI PRECONTOURED","SUP-ITM-10046659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1677.59","1258.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1370.93","81.72","","5157.68","5157.68","5157.68","1 through 10","876.71","1370.93","percent of total billed charges",""
"RIB PLATE UNIVERSAL 8-9 HOLE BONE MATRIX TI PRECONTOURED","SUP-ITM-10046659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1677.59","1258.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1370.93","81.72","","431.26","71.26","1459.57","88","876.71","1370.93","percent of total billed charges",""
"Rickettsia Antibody","PX-30000988","CDM","86757","CPT","0302","RC","","","","both","","","262.00","196.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","208.29","79.5","","199.90","199.90","399.80","1 through 10","18.96","248.9","percent of total billed charges",""
"Rickettsia Antibody","PX-30000988","CDM","86757","CPT","0302","RC","","","","both","","","262.00","196.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.63","36.5","","94.74","94.74","94.74","1 through 10","18.96","248.9","percent of total billed charges",""
"Rickettsia Antibody","PX-30000988","CDM","86757","CPT","0302","RC","","","","both","","","262.00","196.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.35","38.3","","99.32","99.32","99.32","1 through 10","18.96","248.9","percent of total billed charges",""
"Rickettsia Antibody","PX-30000988","CDM","86757","CPT","0302","RC","","","","outpatient","","","262.00","196.50","AETNA [1001]","HB AMC AETNA HMO","182.88","69.8","","242.82","171.96","242.82","1 through 10","19.95","214.11","percent of total billed charges",""
"Rickettsia Antibody","PX-30000988","CDM","86757","CPT","0302","RC","","","","outpatient","","","262.00","196.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.11","81.72","","406.10","203.05","406.10","1 through 10","19.95","214.11","percent of total billed charges",""
"Right Heart Artery/Graft Angio","PX-48000122","CDM","93457","CPT","0481","RC","","","","both","","","36580.00","27435.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19497.14","53.3","","27917.25","27917.25","27917.25","1 through 10","3628.7","29081.1","percent of total billed charges",""
"Right Heart Artery/Graft Angio","PX-48000122","CDM","93457","CPT","0481","RC","","","","both","","","36580.00","27435.00","MEDICARE [2001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3819.68","3819.68","3819.68","1 through 10","3628.7","29081.1","other","OPPS APC"
"Right Heart Artery/Graft Angio","PX-48000122","CDM","93457","CPT","0481","RC","","","","outpatient","","","36580.00","27435.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6171.66","6171.66","6171.66","1 through 10","2529.37","29893.18","other","Multiple Surgery"
"RIM HELICAL 37X62MM MEDPOR RIGHT","SUP-ITM-10020940","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","2647.84","1985.88","AETNA [1001]","HB AMC AETNA HMO","1848.19","69.8","","1013.24","1013.24","1013.24","1 through 10","1323.92","2184.47","percent of total billed charges",""
"RIM ORBITAL 0.5MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077416","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","635.11","79.5","","800.18","480.96","1887.97","195","247.65","635.11","percent of total billed charges",""
"RIM ORBITAL 0.5MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077416","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","425.80","53.3","","813.12","216.42","1444.50","81","247.65","635.11","percent of total billed charges",""
"RIM ORBITAL 0.5MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077416","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","247.65","31","","432.60","432.60","432.60","1 through 10","247.65","635.11","percent of total billed charges",""
"RIM ORBITAL 0.5MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077416","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","291.59","36.5","","148.37","54.89","631.39","94","247.65","635.11","percent of total billed charges",""
"RIM ORBITAL 0.5MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077416","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","305.97","38.3","","279.30","91.72","1116.77","266","247.65","635.11","percent of total billed charges",""
"RIM ORBITAL 0.5MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077416","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.72","42.9","","731.00","63.70","731.00","1 through 10","247.65","635.11","percent of total billed charges",""
"RIM ORBITAL 0.5MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077416","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.72","42.9","","384.74","384.74","384.74","1 through 10","247.65","635.11","percent of total billed charges",""
"RIM ORBITAL 0.5MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077416","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","WELLPOINT [1015]","HB AMC WELLPOINT","589.41","73.78","","286.63","119.22","1107.45","105","247.65","635.11","percent of total billed charges",""
"RIM ORBITAL 0.5MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.88","599.16","AETNA [1001]","HB AMC AETNA HMO","557.62","69.8","","675.31","184.75","1721.50","286","417.49","652.84","percent of total billed charges",""
"RIM ORBITAL 0.5MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.88","599.16","AETNA [1001]","HB AMC AETNA PPO","642.30","80.4","","1261.44","103.12","1514.10","21","417.49","652.84","percent of total billed charges",""
"RIM ORBITAL 0.5MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.88","599.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","642.30","80.4","","1365.00","1365.00","1365.00","1 through 10","417.49","652.84","percent of total billed charges",""
"RIM ORBITAL 0.5MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.88","599.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","652.84","81.72","","5157.68","5157.68","5157.68","1 through 10","417.49","652.84","percent of total billed charges",""
"RIM ORBITAL 0.5MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.88","599.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","652.84","81.72","","431.26","71.26","1459.57","88","417.49","652.84","percent of total billed charges",""
"RIM ORBITAL 0.7MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077428","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.96","505.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","535.80","79.5","","800.18","480.96","1887.97","195","208.93","535.8","percent of total billed charges",""
"RIM ORBITAL 0.7MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077428","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.96","505.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","359.22","53.3","","813.12","216.42","1444.50","81","208.93","535.8","percent of total billed charges",""
"RIM ORBITAL 0.7MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077428","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.96","505.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","208.93","31","","432.60","432.60","432.60","1 through 10","208.93","535.8","percent of total billed charges",""
"RIM ORBITAL 0.7MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077428","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.96","505.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","246.00","36.5","","148.37","54.89","631.39","94","208.93","535.8","percent of total billed charges",""
"RIM ORBITAL 0.7MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077428","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.96","505.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","258.13","38.3","","279.30","91.72","1116.77","266","208.93","535.8","percent of total billed charges",""
"RIM ORBITAL 0.7MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077428","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.96","505.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.13","42.9","","731.00","63.70","731.00","1 through 10","208.93","535.8","percent of total billed charges",""
"RIM ORBITAL 0.7MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077428","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.96","505.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.13","42.9","","384.74","384.74","384.74","1 through 10","208.93","535.8","percent of total billed charges",""
"RIM ORBITAL 0.7MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077428","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.96","505.47","WELLPOINT [1015]","HB AMC WELLPOINT","497.25","73.78","","286.63","119.22","1107.45","105","208.93","535.8","percent of total billed charges",""
"RIM ORBITAL 0.7MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.96","505.47","AETNA [1001]","HB AMC AETNA HMO","470.42","69.8","","675.31","184.75","1721.50","286","352.21","550.76","percent of total billed charges",""
"RIM ORBITAL 0.7MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.96","505.47","AETNA [1001]","HB AMC AETNA PPO","541.86","80.4","","1261.44","103.12","1514.10","21","352.21","550.76","percent of total billed charges",""
"RIM ORBITAL 0.7MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.96","505.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","541.86","80.4","","1365.00","1365.00","1365.00","1 through 10","352.21","550.76","percent of total billed charges",""
"RIM ORBITAL 0.7MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.96","505.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","550.76","81.72","","5157.68","5157.68","5157.68","1 through 10","352.21","550.76","percent of total billed charges",""
"RIM ORBITAL 0.7MM 12 HOLE PLATE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM","SUP-ITM-10077428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.96","505.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","550.76","81.72","","431.26","71.26","1459.57","88","352.21","550.76","percent of total billed charges",""
"RIM ORBITAL 0.8MM 12 HOLE PLATE CRANIAL MATRIXMIDFACE TITANIUM","SUP-ITM-10100465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.34","781.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","828.66","79.5","","800.18","480.96","1887.97","195","323.13","828.66","percent of total billed charges",""
"RIM ORBITAL 0.8MM 12 HOLE PLATE CRANIAL MATRIXMIDFACE TITANIUM","SUP-ITM-10100465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.34","781.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","555.57","53.3","","813.12","216.42","1444.50","81","323.13","828.66","percent of total billed charges",""
"RIM ORBITAL 0.8MM 12 HOLE PLATE CRANIAL MATRIXMIDFACE TITANIUM","SUP-ITM-10100465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.34","781.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","323.13","31","","432.60","432.60","432.60","1 through 10","323.13","828.66","percent of total billed charges",""
"RIM ORBITAL 0.8MM 12 HOLE PLATE CRANIAL MATRIXMIDFACE TITANIUM","SUP-ITM-10100465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.34","781.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","380.45","36.5","","148.37","54.89","631.39","94","323.13","828.66","percent of total billed charges",""
"RIM ORBITAL 0.8MM 12 HOLE PLATE CRANIAL MATRIXMIDFACE TITANIUM","SUP-ITM-10100465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.34","781.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","399.22","38.3","","279.30","91.72","1116.77","266","323.13","828.66","percent of total billed charges",""
"RIM ORBITAL 0.8MM 12 HOLE PLATE CRANIAL MATRIXMIDFACE TITANIUM","SUP-ITM-10100465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.34","781.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","447.16","42.9","","731.00","63.70","731.00","1 through 10","323.13","828.66","percent of total billed charges",""
"RIM ORBITAL 0.8MM 12 HOLE PLATE CRANIAL MATRIXMIDFACE TITANIUM","SUP-ITM-10100465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.34","781.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","447.16","42.9","","384.74","384.74","384.74","1 through 10","323.13","828.66","percent of total billed charges",""
"RIM ORBITAL 0.8MM 12 HOLE PLATE CRANIAL MATRIXMIDFACE TITANIUM","SUP-ITM-10100465","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.34","781.75","WELLPOINT [1015]","HB AMC WELLPOINT","769.04","73.78","","286.63","119.22","1107.45","105","323.13","828.66","percent of total billed charges",""
"RIM ORBITAL 0.8MM 12 HOLE PLATE CRANIAL MATRIXMIDFACE TITANIUM","SUP-ITM-10100465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.34","781.75","AETNA [1001]","HB AMC AETNA HMO","727.55","69.8","","675.31","184.75","1721.50","286","544.73","851.8","percent of total billed charges",""
"RIM ORBITAL 0.8MM 12 HOLE PLATE CRANIAL MATRIXMIDFACE TITANIUM","SUP-ITM-10100465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.34","781.75","AETNA [1001]","HB AMC AETNA PPO","838.04","80.4","","1261.44","103.12","1514.10","21","544.73","851.8","percent of total billed charges",""
"RIM ORBITAL 0.8MM 12 HOLE PLATE CRANIAL MATRIXMIDFACE TITANIUM","SUP-ITM-10100465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.34","781.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","838.04","80.4","","1365.00","1365.00","1365.00","1 through 10","544.73","851.8","percent of total billed charges",""
"RIM ORBITAL 0.8MM 12 HOLE PLATE CRANIAL MATRIXMIDFACE TITANIUM","SUP-ITM-10100465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.34","781.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","851.80","81.72","","5157.68","5157.68","5157.68","1 through 10","544.73","851.8","percent of total billed charges",""
"RIM ORBITAL 0.8MM 12 HOLE PLATE CRANIAL MATRIXMIDFACE TITANIUM","SUP-ITM-10100465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.34","781.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","851.80","81.72","","431.26","71.26","1459.57","88","544.73","851.8","percent of total billed charges",""
"RIM ORBITAL 47X40MM LT SIDE AUGMENTATION CRANIOFACIAL MEDPOR POROUS POLYETHYLENE EXTENDED INFERIOR","SUP-ITM-10020066","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.44","1714.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1817.72","79.5","","800.18","480.96","1887.97","195","708.8","1817.72","percent of total billed charges",""
"RIM ORBITAL 47X40MM LT SIDE AUGMENTATION CRANIOFACIAL MEDPOR POROUS POLYETHYLENE EXTENDED INFERIOR","SUP-ITM-10020066","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.44","1714.83","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1218.67","53.3","","813.12","216.42","1444.50","81","708.8","1817.72","percent of total billed charges",""
"RIM ORBITAL 47X40MM LT SIDE AUGMENTATION CRANIOFACIAL MEDPOR POROUS POLYETHYLENE EXTENDED INFERIOR","SUP-ITM-10020066","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.44","1714.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","708.80","31","","432.60","432.60","432.60","1 through 10","708.8","1817.72","percent of total billed charges",""
"RIM ORBITAL 47X40MM LT SIDE AUGMENTATION CRANIOFACIAL MEDPOR POROUS POLYETHYLENE EXTENDED INFERIOR","SUP-ITM-10020066","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.44","1714.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","834.55","36.5","","148.37","54.89","631.39","94","708.8","1817.72","percent of total billed charges",""
"RIM ORBITAL 47X40MM LT SIDE AUGMENTATION CRANIOFACIAL MEDPOR POROUS POLYETHYLENE EXTENDED INFERIOR","SUP-ITM-10020066","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.44","1714.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","875.71","38.3","","279.30","91.72","1116.77","266","708.8","1817.72","percent of total billed charges",""
"RIM ORBITAL 47X40MM LT SIDE AUGMENTATION CRANIOFACIAL MEDPOR POROUS POLYETHYLENE EXTENDED INFERIOR","SUP-ITM-10020066","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.44","1714.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","980.88","42.9","","731.00","63.70","731.00","1 through 10","708.8","1817.72","percent of total billed charges",""
"RIM ORBITAL 47X40MM LT SIDE AUGMENTATION CRANIOFACIAL MEDPOR POROUS POLYETHYLENE EXTENDED INFERIOR","SUP-ITM-10020066","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.44","1714.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","980.88","42.9","","384.74","384.74","384.74","1 through 10","708.8","1817.72","percent of total billed charges",""
"RIM ORBITAL 47X40MM LT SIDE AUGMENTATION CRANIOFACIAL MEDPOR POROUS POLYETHYLENE EXTENDED INFERIOR","SUP-ITM-10020066","CDM","C1713","HCPCS","0278","RC","","","","both","","","2286.44","1714.83","WELLPOINT [1015]","HB AMC WELLPOINT","1686.94","73.78","","286.63","119.22","1107.45","105","708.8","1817.72","percent of total billed charges",""
"RIM ORBITAL 47X40MM LT SIDE AUGMENTATION CRANIOFACIAL MEDPOR POROUS POLYETHYLENE EXTENDED INFERIOR","SUP-ITM-10020066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2286.44","1714.83","AETNA [1001]","HB AMC AETNA HMO","1595.94","69.8","","675.31","184.75","1721.50","286","1194.89","1868.48","percent of total billed charges",""
"RIM ORBITAL 47X40MM LT SIDE AUGMENTATION CRANIOFACIAL MEDPOR POROUS POLYETHYLENE EXTENDED INFERIOR","SUP-ITM-10020066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2286.44","1714.83","AETNA [1001]","HB AMC AETNA PPO","1838.30","80.4","","1261.44","103.12","1514.10","21","1194.89","1868.48","percent of total billed charges",""
"RIM ORBITAL 47X40MM LT SIDE AUGMENTATION CRANIOFACIAL MEDPOR POROUS POLYETHYLENE EXTENDED INFERIOR","SUP-ITM-10020066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2286.44","1714.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1838.30","80.4","","1365.00","1365.00","1365.00","1 through 10","1194.89","1868.48","percent of total billed charges",""
"RIM ORBITAL 47X40MM LT SIDE AUGMENTATION CRANIOFACIAL MEDPOR POROUS POLYETHYLENE EXTENDED INFERIOR","SUP-ITM-10020066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2286.44","1714.83","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1868.48","81.72","","5157.68","5157.68","5157.68","1 through 10","1194.89","1868.48","percent of total billed charges",""
"RIM ORBITAL 47X40MM LT SIDE AUGMENTATION CRANIOFACIAL MEDPOR POROUS POLYETHYLENE EXTENDED INFERIOR","SUP-ITM-10020066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2286.44","1714.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1868.48","81.72","","431.26","71.26","1459.57","88","1194.89","1868.48","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1870.65","79.5","","800.18","480.96","1887.97","195","729.44","1870.65","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1254.16","53.3","","813.12","216.42","1444.50","81","729.44","1870.65","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","729.44","31","","432.60","432.60","432.60","1 through 10","729.44","1870.65","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","858.85","36.5","","148.37","54.89","631.39","94","729.44","1870.65","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","901.21","38.3","","279.30","91.72","1116.77","266","729.44","1870.65","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1009.45","42.9","","731.00","63.70","731.00","1 through 10","729.44","1870.65","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1009.45","42.9","","384.74","384.74","384.74","1 through 10","729.44","1870.65","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2353.02","1764.76","WELLPOINT [1015]","HB AMC WELLPOINT","1736.06","73.78","","286.63","119.22","1107.45","105","729.44","1870.65","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2353.02","1764.76","AETNA [1001]","HB AMC AETNA HMO","1642.41","69.8","","675.31","184.75","1721.50","286","1229.69","1922.89","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2353.02","1764.76","AETNA [1001]","HB AMC AETNA PPO","1891.83","80.4","","1261.44","103.12","1514.10","21","1229.69","1922.89","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2353.02","1764.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1891.83","80.4","","1365.00","1365.00","1365.00","1 through 10","1229.69","1922.89","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2353.02","1764.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1922.89","81.72","","5157.68","5157.68","5157.68","1 through 10","1229.69","1922.89","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2353.02","1764.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1922.89","81.72","","431.26","71.26","1459.57","88","1229.69","1922.89","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.35","2548.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2700.89","79.5","","800.18","480.96","1887.97","195","1053.18","2700.89","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.35","2548.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1810.79","53.3","","813.12","216.42","1444.50","81","1053.18","2700.89","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.35","2548.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1053.18","31","","432.60","432.60","432.60","1 through 10","1053.18","2700.89","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.35","2548.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1240.03","36.5","","148.37","54.89","631.39","94","1053.18","2700.89","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.35","2548.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1301.19","38.3","","279.30","91.72","1116.77","266","1053.18","2700.89","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.35","2548.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1457.46","42.9","","731.00","63.70","731.00","1 through 10","1053.18","2700.89","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.35","2548.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1457.46","42.9","","384.74","384.74","384.74","1 through 10","1053.18","2700.89","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","3397.35","2548.01","WELLPOINT [1015]","HB AMC WELLPOINT","2506.56","73.78","","286.63","119.22","1107.45","105","1053.18","2700.89","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3397.35","2548.01","AETNA [1001]","HB AMC AETNA HMO","2371.35","69.8","","675.31","184.75","1721.50","286","1775.46","2776.31","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3397.35","2548.01","AETNA [1001]","HB AMC AETNA PPO","2731.47","80.4","","1261.44","103.12","1514.10","21","1775.46","2776.31","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3397.35","2548.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2731.47","80.4","","1365.00","1365.00","1365.00","1 through 10","1775.46","2776.31","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3397.35","2548.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2776.31","81.72","","5157.68","5157.68","5157.68","1 through 10","1775.46","2776.31","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3397.35","2548.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2776.31","81.72","","431.26","71.26","1459.57","88","1775.46","2776.31","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","98.77","52.26","","1113.10","1113.10","1113.10","1 through 10","58.59","150.26","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","150.26","79.5","","1293.60","1148.53","1603.80","1 through 10","58.59","150.26","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.99","36.5","","1023.42","771.29","2068.67","33","58.59","150.26","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.39","38.3","","850.52","759.78","1211.25","66","58.59","150.26","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","2548.09","2548.09","2548.09","1 through 10","58.59","150.26","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","956.46","956.46","956.46","1 through 10","58.59","150.26","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","189.00","141.75","WELLPOINT [1015]","HB AMC WELLPOINT","139.44","73.78","","2344.73","1619.47","2530.35","16","58.59","150.26","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA HMO","131.92","69.8","","1523.63","988.41","4330.26","39","98.77","154.45","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA PPO","151.96","80.4","","1670.25","1670.25","1670.25","1 through 10","98.77","154.45","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","98.77","52.26","","1113.10","1113.10","1113.10","1 through 10","98.77","154.45","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","154.45","81.72","","1738.90","1484.65","2716.94","38","98.77","154.45","percent of total billed charges",""
"RING ACETABULAR 62MM CUP HIP TRILOGY MODULAR LOCKING REPLACEMENT","SUP-ITM-10021387","CDM","C1776","HCPCS","0278","RC","","","","both","","","176.40","132.30","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","92.19","52.26","","1113.10","1113.10","1113.10","1 through 10","54.68","140.24","percent of total billed charges",""
"RING ACETABULAR 62MM CUP HIP TRILOGY MODULAR LOCKING REPLACEMENT","SUP-ITM-10021387","CDM","C1776","HCPCS","0278","RC","","","","both","","","176.40","132.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","140.24","79.5","","1293.60","1148.53","1603.80","1 through 10","54.68","140.24","percent of total billed charges",""
"RING ACETABULAR 62MM CUP HIP TRILOGY MODULAR LOCKING REPLACEMENT","SUP-ITM-10021387","CDM","C1776","HCPCS","0278","RC","","","","both","","","176.40","132.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.39","36.5","","1023.42","771.29","2068.67","33","54.68","140.24","percent of total billed charges",""
"RING ACETABULAR 62MM CUP HIP TRILOGY MODULAR LOCKING REPLACEMENT","SUP-ITM-10021387","CDM","C1776","HCPCS","0278","RC","","","","both","","","176.40","132.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.56","38.3","","850.52","759.78","1211.25","66","54.68","140.24","percent of total billed charges",""
"RING ACETABULAR 62MM CUP HIP TRILOGY MODULAR LOCKING REPLACEMENT","SUP-ITM-10021387","CDM","C1776","HCPCS","0278","RC","","","","both","","","176.40","132.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.68","42.9","","2548.09","2548.09","2548.09","1 through 10","54.68","140.24","percent of total billed charges",""
"RING ACETABULAR 62MM CUP HIP TRILOGY MODULAR LOCKING REPLACEMENT","SUP-ITM-10021387","CDM","C1776","HCPCS","0278","RC","","","","both","","","176.40","132.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.68","42.9","","956.46","956.46","956.46","1 through 10","54.68","140.24","percent of total billed charges",""
"RING ACETABULAR 62MM CUP HIP TRILOGY MODULAR LOCKING REPLACEMENT","SUP-ITM-10021387","CDM","C1776","HCPCS","0278","RC","","","","both","","","176.40","132.30","WELLPOINT [1015]","HB AMC WELLPOINT","130.15","73.78","","2344.73","1619.47","2530.35","16","54.68","140.24","percent of total billed charges",""
"RING ACETABULAR 62MM CUP HIP TRILOGY MODULAR LOCKING REPLACEMENT","SUP-ITM-10021387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","176.40","132.30","AETNA [1001]","HB AMC AETNA HMO","123.13","69.8","","1523.63","988.41","4330.26","39","92.19","144.15","percent of total billed charges",""
"RING ACETABULAR 62MM CUP HIP TRILOGY MODULAR LOCKING REPLACEMENT","SUP-ITM-10021387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","176.40","132.30","AETNA [1001]","HB AMC AETNA PPO","141.83","80.4","","1670.25","1670.25","1670.25","1 through 10","92.19","144.15","percent of total billed charges",""
"RING ACETABULAR 62MM CUP HIP TRILOGY MODULAR LOCKING REPLACEMENT","SUP-ITM-10021387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","176.40","132.30","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","92.19","52.26","","1113.10","1113.10","1113.10","1 through 10","92.19","144.15","percent of total billed charges",""
"RING ACETABULAR 62MM CUP HIP TRILOGY MODULAR LOCKING REPLACEMENT","SUP-ITM-10021387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","176.40","132.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","144.15","81.72","","1738.90","1484.65","2716.94","38","92.19","144.15","percent of total billed charges",""
"RING ANNULOPLASTY 26MM MITRAL FLEX PHYSIO","SUP-ITM-10272823","CDM","C1889","HCPCS","0278","RC","","","","both","","","4567.20","3425.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3630.92","79.5","","1309.77","674.56","6049.93","26","1415.83","3630.92","percent of total billed charges",""
"RING ANNULOPLASTY 26MM MITRAL FLEX PHYSIO","SUP-ITM-10272823","CDM","C1889","HCPCS","0278","RC","","","","both","","","4567.20","3425.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2434.32","53.3","","1901.83","1901.83","2962.25","1 through 10","1415.83","3630.92","percent of total billed charges",""
"RING ANNULOPLASTY 26MM MITRAL FLEX PHYSIO","SUP-ITM-10272823","CDM","C1889","HCPCS","0278","RC","","","","both","","","4567.20","3425.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1667.03","36.5","","1620.31","1620.31","19908.88","1 through 10","1415.83","3630.92","percent of total billed charges",""
"RING ANNULOPLASTY 26MM MITRAL FLEX PHYSIO","SUP-ITM-10272823","CDM","C1889","HCPCS","0278","RC","","","","both","","","4567.20","3425.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1749.24","38.3","","352.91","352.91","2046.30","1 through 10","1415.83","3630.92","percent of total billed charges",""
"RING ANNULOPLASTY 26MM MITRAL FLEX PHYSIO","SUP-ITM-10272823","CDM","C1889","HCPCS","0278","RC","","","","both","","","4567.20","3425.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1959.33","42.9","","9668.75","9668.75","9668.75","1 through 10","1415.83","3630.92","percent of total billed charges",""
"RING ANNULOPLASTY 26MM MITRAL FLEX PHYSIO","SUP-ITM-10272823","CDM","C1889","HCPCS","0278","RC","","","","both","","","4567.20","3425.40","WELLPOINT [1015]","HB AMC WELLPOINT","3369.68","73.78","","699.88","384.10","3443.31","33","1415.83","3630.92","percent of total billed charges",""
"RING ANNULOPLASTY 26MM MITRAL FLEX PHYSIO","SUP-ITM-10272823","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4567.20","3425.40","AETNA [1001]","HB AMC AETNA HMO","3187.91","69.8","","1421.24","264.50","4933.46","29","2386.82","3732.32","percent of total billed charges",""
"RING ANNULOPLASTY 26MM MITRAL FLEX PHYSIO","SUP-ITM-10272823","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4567.20","3425.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3672.03","80.4","","1022.97","1022.97","3607.50","1 through 10","2386.82","3732.32","percent of total billed charges",""
"RING ANNULOPLASTY 26MM MITRAL FLEX PHYSIO","SUP-ITM-10272823","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4567.20","3425.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3732.32","81.72","","3010.54","693.88","5019.88","35","2386.82","3732.32","percent of total billed charges",""
"RING ANNULOPLASTY 38MM MITRAL FLEX PHYSIO","SUP-ITM-10272829","CDM","C1889","HCPCS","0278","RC","","","","both","","","4567.20","3425.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3630.92","79.5","","1309.77","674.56","6049.93","26","1415.83","3630.92","percent of total billed charges",""
"RING ANNULOPLASTY 38MM MITRAL FLEX PHYSIO","SUP-ITM-10272829","CDM","C1889","HCPCS","0278","RC","","","","both","","","4567.20","3425.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2434.32","53.3","","1901.83","1901.83","2962.25","1 through 10","1415.83","3630.92","percent of total billed charges",""
"RING ANNULOPLASTY 38MM MITRAL FLEX PHYSIO","SUP-ITM-10272829","CDM","C1889","HCPCS","0278","RC","","","","both","","","4567.20","3425.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1667.03","36.5","","1620.31","1620.31","19908.88","1 through 10","1415.83","3630.92","percent of total billed charges",""
"RING ANNULOPLASTY 38MM MITRAL FLEX PHYSIO","SUP-ITM-10272829","CDM","C1889","HCPCS","0278","RC","","","","both","","","4567.20","3425.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1749.24","38.3","","352.91","352.91","2046.30","1 through 10","1415.83","3630.92","percent of total billed charges",""
"RING ANNULOPLASTY 38MM MITRAL FLEX PHYSIO","SUP-ITM-10272829","CDM","C1889","HCPCS","0278","RC","","","","both","","","4567.20","3425.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1959.33","42.9","","9668.75","9668.75","9668.75","1 through 10","1415.83","3630.92","percent of total billed charges",""
"RING ANNULOPLASTY 38MM MITRAL FLEX PHYSIO","SUP-ITM-10272829","CDM","C1889","HCPCS","0278","RC","","","","both","","","4567.20","3425.40","WELLPOINT [1015]","HB AMC WELLPOINT","3369.68","73.78","","699.88","384.10","3443.31","33","1415.83","3630.92","percent of total billed charges",""
"RING ANNULOPLASTY 38MM MITRAL FLEX PHYSIO","SUP-ITM-10272829","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4567.20","3425.40","AETNA [1001]","HB AMC AETNA HMO","3187.91","69.8","","1421.24","264.50","4933.46","29","2386.82","3732.32","percent of total billed charges",""
"RING ANNULOPLASTY 38MM MITRAL FLEX PHYSIO","SUP-ITM-10272829","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4567.20","3425.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3672.03","80.4","","1022.97","1022.97","3607.50","1 through 10","2386.82","3732.32","percent of total billed charges",""
"RING ANNULOPLASTY 38MM MITRAL FLEX PHYSIO","SUP-ITM-10272829","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4567.20","3425.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3732.32","81.72","","3010.54","693.88","5019.88","35","2386.82","3732.32","percent of total billed charges",""
"RING EXTERNAL 205MM FIXATION TAYLOR SPATIAL FRAME ALUMINUM HALF","SUP-ITM-10062760","CDM","C1889","HCPCS","0278","RC","","","","both","","","5812.50","4359.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4620.94","79.5","","1309.77","674.56","6049.93","26","1801.88","4620.94","percent of total billed charges",""
"RING EXTERNAL 205MM FIXATION TAYLOR SPATIAL FRAME ALUMINUM HALF","SUP-ITM-10062760","CDM","C1889","HCPCS","0278","RC","","","","both","","","5812.50","4359.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3098.06","53.3","","1901.83","1901.83","2962.25","1 through 10","1801.88","4620.94","percent of total billed charges",""
"RING EXTERNAL 205MM FIXATION TAYLOR SPATIAL FRAME ALUMINUM HALF","SUP-ITM-10062760","CDM","C1889","HCPCS","0278","RC","","","","both","","","5812.50","4359.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2121.56","36.5","","1620.31","1620.31","19908.88","1 through 10","1801.88","4620.94","percent of total billed charges",""
"RING EXTERNAL 205MM FIXATION TAYLOR SPATIAL FRAME ALUMINUM HALF","SUP-ITM-10062760","CDM","C1889","HCPCS","0278","RC","","","","both","","","5812.50","4359.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2226.19","38.3","","352.91","352.91","2046.30","1 through 10","1801.88","4620.94","percent of total billed charges",""
"RING EXTERNAL 205MM FIXATION TAYLOR SPATIAL FRAME ALUMINUM HALF","SUP-ITM-10062760","CDM","C1889","HCPCS","0278","RC","","","","both","","","5812.50","4359.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2493.56","42.9","","9668.75","9668.75","9668.75","1 through 10","1801.88","4620.94","percent of total billed charges",""
"RING EXTERNAL 205MM FIXATION TAYLOR SPATIAL FRAME ALUMINUM HALF","SUP-ITM-10062760","CDM","C1889","HCPCS","0278","RC","","","","both","","","5812.50","4359.37","WELLPOINT [1015]","HB AMC WELLPOINT","4288.46","73.78","","699.88","384.10","3443.31","33","1801.88","4620.94","percent of total billed charges",""
"RING EXTERNAL 205MM FIXATION TAYLOR SPATIAL FRAME ALUMINUM HALF","SUP-ITM-10062760","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5812.50","4359.37","AETNA [1001]","HB AMC AETNA HMO","4057.13","69.8","","1421.24","264.50","4933.46","29","3037.61","4749.98","percent of total billed charges",""
"RING EXTERNAL 205MM FIXATION TAYLOR SPATIAL FRAME ALUMINUM HALF","SUP-ITM-10062760","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5812.50","4359.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4673.25","80.4","","1022.97","1022.97","3607.50","1 through 10","3037.61","4749.98","percent of total billed charges",""
"RING EXTERNAL 205MM FIXATION TAYLOR SPATIAL FRAME ALUMINUM HALF","SUP-ITM-10062760","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5812.50","4359.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4749.98","81.72","","3010.54","693.88","5019.88","35","3037.61","4749.98","percent of total billed charges",""
"RING HEART 39MM SIMULUS FR FULLY FLEXIBLE","SUP-ITM-10273784","CDM","C1889","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2768.59","79.5","","1309.77","674.56","6049.93","26","1079.58","2768.59","percent of total billed charges",""
"RING HEART 39MM SIMULUS FR FULLY FLEXIBLE","SUP-ITM-10273784","CDM","C1889","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1856.17","53.3","","1901.83","1901.83","2962.25","1 through 10","1079.58","2768.59","percent of total billed charges",""
"RING HEART 39MM SIMULUS FR FULLY FLEXIBLE","SUP-ITM-10273784","CDM","C1889","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1271.11","36.5","","1620.31","1620.31","19908.88","1 through 10","1079.58","2768.59","percent of total billed charges",""
"RING HEART 39MM SIMULUS FR FULLY FLEXIBLE","SUP-ITM-10273784","CDM","C1889","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1333.80","38.3","","352.91","352.91","2046.30","1 through 10","1079.58","2768.59","percent of total billed charges",""
"RING HEART 39MM SIMULUS FR FULLY FLEXIBLE","SUP-ITM-10273784","CDM","C1889","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1493.99","42.9","","9668.75","9668.75","9668.75","1 through 10","1079.58","2768.59","percent of total billed charges",""
"RING HEART 39MM SIMULUS FR FULLY FLEXIBLE","SUP-ITM-10273784","CDM","C1889","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","WELLPOINT [1015]","HB AMC WELLPOINT","2569.39","73.78","","699.88","384.10","3443.31","33","1079.58","2768.59","percent of total billed charges",""
"RING HEART 39MM SIMULUS FR FULLY FLEXIBLE","SUP-ITM-10273784","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3482.50","2611.87","AETNA [1001]","HB AMC AETNA HMO","2430.79","69.8","","1421.24","264.50","4933.46","29","1819.95","2845.9","percent of total billed charges",""
"RING HEART 39MM SIMULUS FR FULLY FLEXIBLE","SUP-ITM-10273784","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3482.50","2611.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2799.93","80.4","","1022.97","1022.97","3607.50","1 through 10","1819.95","2845.9","percent of total billed charges",""
"RING HEART 39MM SIMULUS FR FULLY FLEXIBLE","SUP-ITM-10273784","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3482.50","2611.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2845.90","81.72","","3010.54","693.88","5019.88","35","1819.95","2845.9","percent of total billed charges",""
"RING LINER 32X55 8.6MM 10DEG FEMORAL HIP LOC ACETABULAR CONSTRAINED ANGLED NECK","SUP-ITM-10011093","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","670.28","52.26","","1113.10","1113.10","1113.10","1 through 10","397.6","1019.65","percent of total billed charges",""
"RING LINER 32X55 8.6MM 10DEG FEMORAL HIP LOC ACETABULAR CONSTRAINED ANGLED NECK","SUP-ITM-10011093","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1019.65","79.5","","1293.60","1148.53","1603.80","1 through 10","397.6","1019.65","percent of total billed charges",""
"RING LINER 32X55 8.6MM 10DEG FEMORAL HIP LOC ACETABULAR CONSTRAINED ANGLED NECK","SUP-ITM-10011093","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","468.14","36.5","","1023.42","771.29","2068.67","33","397.6","1019.65","percent of total billed charges",""
"RING LINER 32X55 8.6MM 10DEG FEMORAL HIP LOC ACETABULAR CONSTRAINED ANGLED NECK","SUP-ITM-10011093","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","491.23","38.3","","850.52","759.78","1211.25","66","397.6","1019.65","percent of total billed charges",""
"RING LINER 32X55 8.6MM 10DEG FEMORAL HIP LOC ACETABULAR CONSTRAINED ANGLED NECK","SUP-ITM-10011093","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","550.23","42.9","","2548.09","2548.09","2548.09","1 through 10","397.6","1019.65","percent of total billed charges",""
"RING LINER 32X55 8.6MM 10DEG FEMORAL HIP LOC ACETABULAR CONSTRAINED ANGLED NECK","SUP-ITM-10011093","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","550.23","42.9","","956.46","956.46","956.46","1 through 10","397.6","1019.65","percent of total billed charges",""
"RING LINER 32X55 8.6MM 10DEG FEMORAL HIP LOC ACETABULAR CONSTRAINED ANGLED NECK","SUP-ITM-10011093","CDM","C1776","HCPCS","0278","RC","","","","both","","","1282.58","961.93","WELLPOINT [1015]","HB AMC WELLPOINT","946.29","73.78","","2344.73","1619.47","2530.35","16","397.6","1019.65","percent of total billed charges",""
"RING LINER 32X55 8.6MM 10DEG FEMORAL HIP LOC ACETABULAR CONSTRAINED ANGLED NECK","SUP-ITM-10011093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1282.58","961.93","AETNA [1001]","HB AMC AETNA HMO","895.24","69.8","","1523.63","988.41","4330.26","39","670.28","1048.12","percent of total billed charges",""
"RING LINER 32X55 8.6MM 10DEG FEMORAL HIP LOC ACETABULAR CONSTRAINED ANGLED NECK","SUP-ITM-10011093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1282.58","961.93","AETNA [1001]","HB AMC AETNA PPO","1031.19","80.4","","1670.25","1670.25","1670.25","1 through 10","670.28","1048.12","percent of total billed charges",""
"RING LINER 32X55 8.6MM 10DEG FEMORAL HIP LOC ACETABULAR CONSTRAINED ANGLED NECK","SUP-ITM-10011093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1282.58","961.93","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","670.28","52.26","","1113.10","1113.10","1113.10","1 through 10","670.28","1048.12","percent of total billed charges",""
"RING LINER 32X55 8.6MM 10DEG FEMORAL HIP LOC ACETABULAR CONSTRAINED ANGLED NECK","SUP-ITM-10011093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1282.58","961.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1048.12","81.72","","1738.90","1484.65","2716.94","38","670.28","1048.12","percent of total billed charges",""
"RING REPLACEMENT SIZE 26 LOC PLUS FEMORAL ACETABULAR","SUP-ITM-10115618","CDM","C1776","HCPCS","0278","RC","","","","both","","","714.42","535.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","373.36","52.26","","1113.10","1113.10","1113.10","1 through 10","221.47","567.96","percent of total billed charges",""
"RING REPLACEMENT SIZE 26 LOC PLUS FEMORAL ACETABULAR","SUP-ITM-10115618","CDM","C1776","HCPCS","0278","RC","","","","both","","","714.42","535.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","567.96","79.5","","1293.60","1148.53","1603.80","1 through 10","221.47","567.96","percent of total billed charges",""
"RING REPLACEMENT SIZE 26 LOC PLUS FEMORAL ACETABULAR","SUP-ITM-10115618","CDM","C1776","HCPCS","0278","RC","","","","both","","","714.42","535.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","260.76","36.5","","1023.42","771.29","2068.67","33","221.47","567.96","percent of total billed charges",""
"RING REPLACEMENT SIZE 26 LOC PLUS FEMORAL ACETABULAR","SUP-ITM-10115618","CDM","C1776","HCPCS","0278","RC","","","","both","","","714.42","535.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","273.62","38.3","","850.52","759.78","1211.25","66","221.47","567.96","percent of total billed charges",""
"RING REPLACEMENT SIZE 26 LOC PLUS FEMORAL ACETABULAR","SUP-ITM-10115618","CDM","C1776","HCPCS","0278","RC","","","","both","","","714.42","535.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","306.49","42.9","","2548.09","2548.09","2548.09","1 through 10","221.47","567.96","percent of total billed charges",""
"RING REPLACEMENT SIZE 26 LOC PLUS FEMORAL ACETABULAR","SUP-ITM-10115618","CDM","C1776","HCPCS","0278","RC","","","","both","","","714.42","535.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","306.49","42.9","","956.46","956.46","956.46","1 through 10","221.47","567.96","percent of total billed charges",""
"RING REPLACEMENT SIZE 26 LOC PLUS FEMORAL ACETABULAR","SUP-ITM-10115618","CDM","C1776","HCPCS","0278","RC","","","","both","","","714.42","535.81","WELLPOINT [1015]","HB AMC WELLPOINT","527.10","73.78","","2344.73","1619.47","2530.35","16","221.47","567.96","percent of total billed charges",""
"RING REPLACEMENT SIZE 26 LOC PLUS FEMORAL ACETABULAR","SUP-ITM-10115618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","714.42","535.81","AETNA [1001]","HB AMC AETNA HMO","498.67","69.8","","1523.63","988.41","4330.26","39","373.36","583.82","percent of total billed charges",""
"RING REPLACEMENT SIZE 26 LOC PLUS FEMORAL ACETABULAR","SUP-ITM-10115618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","714.42","535.81","AETNA [1001]","HB AMC AETNA PPO","574.39","80.4","","1670.25","1670.25","1670.25","1 through 10","373.36","583.82","percent of total billed charges",""
"RING REPLACEMENT SIZE 26 LOC PLUS FEMORAL ACETABULAR","SUP-ITM-10115618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","714.42","535.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","373.36","52.26","","1113.10","1113.10","1113.10","1 through 10","373.36","583.82","percent of total billed charges",""
"RING REPLACEMENT SIZE 26 LOC PLUS FEMORAL ACETABULAR","SUP-ITM-10115618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","714.42","535.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","583.82","81.72","","1738.90","1484.65","2716.94","38","373.36","583.82","percent of total billed charges",""
"RING SPINE ES2 ROD ALIGNMENT","SUP-ITM-10124782","CDM","C1889","HCPCS","0278","RC","","","","both","","","528.50","396.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","420.16","79.5","","1309.77","674.56","6049.93","26","163.84","420.16","percent of total billed charges",""
"RING SPINE ES2 ROD ALIGNMENT","SUP-ITM-10124782","CDM","C1889","HCPCS","0278","RC","","","","both","","","528.50","396.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","281.69","53.3","","1901.83","1901.83","2962.25","1 through 10","163.84","420.16","percent of total billed charges",""
"RING SPINE ES2 ROD ALIGNMENT","SUP-ITM-10124782","CDM","C1889","HCPCS","0278","RC","","","","both","","","528.50","396.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","192.90","36.5","","1620.31","1620.31","19908.88","1 through 10","163.84","420.16","percent of total billed charges",""
"RING SPINE ES2 ROD ALIGNMENT","SUP-ITM-10124782","CDM","C1889","HCPCS","0278","RC","","","","both","","","528.50","396.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","202.42","38.3","","352.91","352.91","2046.30","1 through 10","163.84","420.16","percent of total billed charges",""
"RING SPINE ES2 ROD ALIGNMENT","SUP-ITM-10124782","CDM","C1889","HCPCS","0278","RC","","","","both","","","528.50","396.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.73","42.9","","9668.75","9668.75","9668.75","1 through 10","163.84","420.16","percent of total billed charges",""
"RING SPINE ES2 ROD ALIGNMENT","SUP-ITM-10124782","CDM","C1889","HCPCS","0278","RC","","","","both","","","528.50","396.37","WELLPOINT [1015]","HB AMC WELLPOINT","389.93","73.78","","699.88","384.10","3443.31","33","163.84","420.16","percent of total billed charges",""
"RING SPINE ES2 ROD ALIGNMENT","SUP-ITM-10124782","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","528.50","396.37","AETNA [1001]","HB AMC AETNA HMO","368.89","69.8","","1421.24","264.50","4933.46","29","276.19","431.89","percent of total billed charges",""
"RING SPINE ES2 ROD ALIGNMENT","SUP-ITM-10124782","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","528.50","396.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","424.91","80.4","","1022.97","1022.97","3607.50","1 through 10","276.19","431.89","percent of total billed charges",""
"RING SPINE ES2 ROD ALIGNMENT","SUP-ITM-10124782","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","528.50","396.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","431.89","81.72","","3010.54","693.88","5019.88","35","276.19","431.89","percent of total billed charges",""
"Riv3 Vaccine Preservative Free for Im Use","PX-63601167","CDM","90673","CPT","0636","RC","","","","both","","","126.64","94.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48.50","38.3","","48.12","48.12","48.12","1 through 10","39.26","120.31","percent of total billed charges",""
"Rmvl & Rplcmt Xtrnl Accessible Nephrourtrl Cath","PX-76002202","CDM","50387","CPT","0761","RC","","","","both","","","4590.00","3442.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2391.58","2391.58","2391.58","1 through 10","1422.9","3649.05","other","OPPS APC"
"Rmvl Impltbl Dfb Plse Gen W/Repl Plse Gen 1 Lead","PX-48000075","CDM","33262","CPT","0361","RC","","","","both","","","26837.00","20127.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","27453.11","","APC Price ($26,653.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","27463.79","27429.23","27463.79","1 through 10","8319.47","33316.88","other","OPPS APC"
"Rmvl Impltbl Dfb Plse Gen W/Repl Plse Gen 1 Lead","PX-48000075","CDM","33262","CPT","0361","RC","","","","both","","","26837.00","20127.75","MEDICARE [2001]","HB BWH MEDICARE","26653.50","","APC Price ($26,653.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","26656.20","25726.38","51452.76","1 through 10","8319.47","33316.88","other","OPPS APC"
"Rmvl Impltbl Dfb Plse Gen W/Repl Plse Gen 1 Lead","PX-48000075","CDM","33262","CPT","0361","RC","","","","both","","","26837.00","20127.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9795.51","36.5","","7142.03","7142.03","7142.03","1 through 10","8319.47","33316.88","percent of total billed charges",""
"Rmvl Impltbl Dfb Plse Gen W/Repl Plse Gen 1 Lead","PX-48000075","CDM","33262","CPT","0361","RC","","","","both","","","26837.00","20127.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","26120.43","","APC Price ($26,653.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","25219.76","25219.76","25219.76","1 through 10","8319.47","33316.88","other","OPPS APC"
"Rmvl Impltbl Dfb Plse Gen W/Repl Plse Gen 1 Lead","PX-48000075","CDM","33262","CPT","0361","RC","","","","both","","","26837.00","20127.75","WELLPOINT [1015]","HB AMC WELLPOINT","19800.34","73.78","","14472.93","14472.93","14472.93","1 through 10","8319.47","33316.88","percent of total billed charges",""
"Rmvl Impltbl Dfb Plse Gen W/Repl Plse Gen 1 Lead","PX-48000075","CDM","33262","CPT","0361","RC","","","","outpatient","","","26837.00","20127.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25154.21","","Case rate ($25,154.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","58886.01","58307.46","58886.01","1 through 10","14025.02","45709.74","other","ASC "
"Rmvl Impltbl Dfb Plse Gen W/Rplcmt Plse Gen 2 Ld","PX-48000076","CDM","33263","CPT","0361","RC","","","","both","","","21131.00","15848.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","27453.11","","APC Price ($26,653.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","27436.23","27436.23","27436.23","1 through 10","6550.61","33316.88","other","OPPS APC"
"Rmvl Impltbl Dfb Plse Gen W/Rplcmt Plse Gen 2 Ld","PX-48000076","CDM","33263","CPT","0361","RC","","","","both","","","21131.00","15848.25","MEDICARE [2001]","HB BWH MEDICARE","26653.50","","APC Price ($26,653.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","26656.20","26656.20","51452.76","14","6550.61","33316.88","other","OPPS APC"
"Rmvl Impltbl Dfb Plse Gen W/Rplcmt Plse Gen 2 Ld","PX-48000076","CDM","33263","CPT","0361","RC","","","","both","","","21131.00","15848.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8093.17","38.3","","7786.96","7786.96","7786.96","1 through 10","6550.61","33316.88","percent of total billed charges",""
"Rmvl Impltbl Dfb Plse Gen W/Rplcmt Plse Gen 2 Ld","PX-48000076","CDM","33263","CPT","0361","RC","","","","both","","","21131.00","15848.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","26120.43","","APC Price ($26,653.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","78391.44","78391.44","78391.44","1 through 10","6550.61","33316.88","other","OPPS APC"
"Rmvl Impltbl Dfb Plse Gen W/Rplcmt Plse Gen 2 Ld","PX-48000076","CDM","33263","CPT","0361","RC","","","","outpatient","","","21131.00","15848.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","25154.21","","Case rate ($25,154.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","51465.51","51465.51","51465.51","1 through 10","9065.2","45709.74","other","ASC"
"Rmvl Impltbl Dfb Plse Gen W/Rplcmt Plse Gen 2 Ld","PX-48000076","CDM","33263","CPT","0361","RC","","","","outpatient","","","21131.00","15848.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25154.21","","Case rate ($25,154.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","58307.46","58307.46","58886.01","1 through 10","9065.2","45709.74","other","ASC "
"Rmvl Impltbl Dfb Plse Gen W/Rplcmt Plse Gen 2 Ld","PX-48000076","CDM","33263","CPT","0361","RC","","","","outpatient","","","21131.00","15848.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14297.70","","Case rate ($14,297.70). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","63767.74","63767.74","63767.74","1 through 10","9065.2","45709.74","other","Multiple Surgery"
"Rmvl Ndwellg Tun Pleural Cath W/Cuf","PX-76000828","CDM","32552","CPT","0761","RC","","","","both","","","1724.00","1293.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","722.47","722.47","722.47","1 through 10","534.44","1370.58","other","OPPS APC"
"Rmvl Ndwellg Tun Pleural Cath W/Cuf","PX-76000828","CDM","32552","CPT","0761","RC","","","","both","","","1724.00","1293.00","MEDICARE [2001]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","734.22","734.22","734.22","1 through 10","534.44","1370.58","other","OPPS APC"
"Rmvl Ndwellg Tun Pleural Cath W/Cuf","PX-76000828","CDM","32552","CPT","0761","RC","","","","both","","","1724.00","1293.00","MOLINA [1014]","HB BWH MOLINA","719.46","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1453.76","1453.76","1453.76","1 through 10","534.44","1370.58","other","OPPS APC"
"Rmvl Ndwellg Tun Pleural Cath W/Cuf","PX-76000828","CDM","32552","CPT","0761","RC","","","","both","","","1724.00","1293.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","719.46","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","719.54","719.54","719.54","1 through 10","534.44","1370.58","other","OPPS APC"
"Rmvl Ndwellg Tun Pleural Cath W/Cuf","PX-76000828","CDM","32552","CPT","0761","RC","","","","both","","","1724.00","1293.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","719.46","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","727.24","719.54","727.44","1 through 10","534.44","1370.58","other","OPPS APC"
"Rmvl Ndwellg Tun Pleural Cath W/Cuf","PX-76000828","CDM","32552","CPT","0761","RC","","","","outpatient","","","1724.00","1293.00","AETNA [1001]","HB AMC AETNA HMO","1203.35","69.8","","685.93","685.93","685.93","1 through 10","620.01","2384.07","percent of total billed charges",""
"Rmvl Ndwellg Tun Pleural Cath W/Cuf","PX-76000828","CDM","32552","CPT","0761","RC","","","","outpatient","","","1724.00","1293.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","709.02","","Case rate ($709.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1643.51","1643.51","1643.51","1 through 10","620.01","2384.07","other","ASC "
"Rmvl Ndwellg Tun Pleural Cath W/Cuf","PX-76000828","CDM","32552","CPT","0761","RC","","","","outpatient","","","1724.00","1293.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1438.42","1438.42","1438.42","1 through 10","620.01","2384.07","other","Multiple Surgery"
"Rmvl Ndwellg Tun Pleural Cath W/Cuf","PX-76000828","CDM","32552","CPT","0761","RC","","","","outpatient","","","1724.00","1293.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1512.82","1512.82","1512.82","1 through 10","620.01","2384.07","other","Multiple Surgery"
"Rmvl Ndwellg Tun Pleural Cath W/Cuf","PX-76000828","CDM","32552","CPT","0761","RC","","","","outpatient","","","1724.00","1293.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1408.85","81.72","","1147.14","1147.14","1147.14","1 through 10","620.01","2384.07","percent of total billed charges",""
"Rmvl Ndwellg Tunneled Pleural Catheter W/Cuff","PX-98301025","CDM","32552","CPT","0983","RC","","","","both","","","821.00","615.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","722.47","722.47","722.47","1 through 10","254.51","917.68","other","OPPS APC"
"Rmvl Ndwellg Tunneled Pleural Catheter W/Cuff","PX-98301025","CDM","32552","CPT","0983","RC","","","","both","","","821.00","615.75","MEDICARE [2001]","HB BWH MEDICARE","734.15","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","734.22","734.22","734.22","1 through 10","254.51","917.68","other","OPPS APC"
"Rmvl Ndwellg Tunneled Pleural Catheter W/Cuff","PX-98301025","CDM","32552","CPT","0983","RC","","","","both","","","821.00","615.75","MOLINA [1014]","HB BWH MOLINA","719.46","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1453.76","1453.76","1453.76","1 through 10","254.51","917.68","other","OPPS APC"
"Rmvl Ndwellg Tunneled Pleural Catheter W/Cuff","PX-98301025","CDM","32552","CPT","0983","RC","","","","both","","","821.00","615.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","719.46","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","719.54","719.54","719.54","1 through 10","254.51","917.68","other","OPPS APC"
"Rmvl Ndwellg Tunneled Pleural Catheter W/Cuff","PX-98301025","CDM","32552","CPT","0983","RC","","","","both","","","821.00","615.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","719.46","","APC Price ($734.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","727.24","719.54","727.44","1 through 10","254.51","917.68","other","OPPS APC"
"Rmvl Ndwellg Tunneled Pleural Catheter W/Cuff","PX-98301025","CDM","32552","CPT","0983","RC","","","","outpatient","","","821.00","615.75","AETNA [1001]","HB AMC AETNA HMO","573.06","69.8","","685.93","685.93","685.93","1 through 10","458.94","2384.07","percent of total billed charges",""
"Rmvl Ndwellg Tunneled Pleural Catheter W/Cuff","PX-98301025","CDM","32552","CPT","0983","RC","","","","outpatient","","","821.00","615.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1438.42","1438.42","1438.42","1 through 10","458.94","2384.07","other","Multiple Surgery"
"Rmvl Ndwellg Tunneled Pleural Catheter W/Cuff","PX-98301025","CDM","32552","CPT","0983","RC","","","","outpatient","","","821.00","615.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1512.82","1512.82","1512.82","1 through 10","458.94","2384.07","other","Multiple Surgery"
"Rmvl Ndwellg Tunneled Pleural Catheter W/Cuff","PX-98301025","CDM","32552","CPT","0983","RC","","","","outpatient","","","821.00","615.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","670.92","81.72","","1147.14","1147.14","1147.14","1 through 10","458.94","2384.07","percent of total billed charges",""
"Rmvl of Subq Implantable Defibrillator Electrode","PX-36000311","CDM","33272","CPT","0480","RC","","","","outpatient","","","10464.00","7848.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3130.53","","Case rate ($3,130.53). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3490.54","3490.54","3490.54","1 through 10","3130.53","8551.18","other","Multiple Surgery"
"Rmvl Peritoneal-Venous Shunt","PX-75000297","CDM","49429","CPT","0750","RC","","","","outpatient","","","5592.00","4194.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","7071.53","7071.53","7071.53","1 through 10","2384.07","4569.78","other","ASC "
"Rmvl Substernal Implantable Defibrillator Eltrd","PX-48000534","CDM","0573T","CPT","0480","RC","","","","outpatient","","","13512.00","10134.00","AETNA [1001]","HB AMC AETNA HMO","9431.38","69.8","","9537.53","9537.53","9537.53","1 through 10","5404.8","11042.01","percent of total billed charges",""
"Rmvl Substernal Impltbl Dfb Pulse Generator Only","PX-36000502","CDM","0580T","CPT","0361","RC","","","","outpatient","","","6853.00","5139.75","AETNA [1001]","HB AMC AETNA HMO","4783.39","69.8","","9537.53","9537.53","9537.53","1 through 10","2741.2","5600.27","percent of total billed charges",""
"ROD 130MM EXTERNAL FIXATOR S/S PARTIAL THREADED BX/5EA","SUP-ITM-10064940","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.73","271.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","287.58","79.5","","1309.77","674.56","6049.93","26","112.14","287.58","percent of total billed charges",""
"ROD 130MM EXTERNAL FIXATOR S/S PARTIAL THREADED BX/5EA","SUP-ITM-10064940","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.73","271.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","192.80","53.3","","1901.83","1901.83","2962.25","1 through 10","112.14","287.58","percent of total billed charges",""
"ROD 130MM EXTERNAL FIXATOR S/S PARTIAL THREADED BX/5EA","SUP-ITM-10064940","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.73","271.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","132.03","36.5","","1620.31","1620.31","19908.88","1 through 10","112.14","287.58","percent of total billed charges",""
"ROD 130MM EXTERNAL FIXATOR S/S PARTIAL THREADED BX/5EA","SUP-ITM-10064940","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.73","271.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","138.54","38.3","","352.91","352.91","2046.30","1 through 10","112.14","287.58","percent of total billed charges",""
"ROD 130MM EXTERNAL FIXATOR S/S PARTIAL THREADED BX/5EA","SUP-ITM-10064940","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.73","271.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.18","42.9","","9668.75","9668.75","9668.75","1 through 10","112.14","287.58","percent of total billed charges",""
"ROD 130MM EXTERNAL FIXATOR S/S PARTIAL THREADED BX/5EA","SUP-ITM-10064940","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.73","271.30","WELLPOINT [1015]","HB AMC WELLPOINT","266.88","73.78","","699.88","384.10","3443.31","33","112.14","287.58","percent of total billed charges",""
"ROD 130MM EXTERNAL FIXATOR S/S PARTIAL THREADED BX/5EA","SUP-ITM-10064940","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","361.73","271.30","AETNA [1001]","HB AMC AETNA HMO","252.49","69.8","","1421.24","264.50","4933.46","29","189.04","295.61","percent of total billed charges",""
"ROD 130MM EXTERNAL FIXATOR S/S PARTIAL THREADED BX/5EA","SUP-ITM-10064940","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","361.73","271.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","290.83","80.4","","1022.97","1022.97","3607.50","1 through 10","189.04","295.61","percent of total billed charges",""
"ROD 130MM EXTERNAL FIXATOR S/S PARTIAL THREADED BX/5EA","SUP-ITM-10064940","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","361.73","271.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","295.61","81.72","","3010.54","693.88","5019.88","35","189.04","295.61","percent of total billed charges",""
"ROD 40MM EXTERNAL FIXATION DEVICE ILIZAROV SS THREADED SLOTTED BX/5EA","SUP-ITM-10062138","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.50","259.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","275.47","79.5","","800.18","480.96","1887.97","195","107.42","275.47","percent of total billed charges",""
"ROD 40MM EXTERNAL FIXATION DEVICE ILIZAROV SS THREADED SLOTTED BX/5EA","SUP-ITM-10062138","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.50","259.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","184.68","53.3","","813.12","216.42","1444.50","81","107.42","275.47","percent of total billed charges",""
"ROD 40MM EXTERNAL FIXATION DEVICE ILIZAROV SS THREADED SLOTTED BX/5EA","SUP-ITM-10062138","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.50","259.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","107.42","31","","432.60","432.60","432.60","1 through 10","107.42","275.47","percent of total billed charges",""
"ROD 40MM EXTERNAL FIXATION DEVICE ILIZAROV SS THREADED SLOTTED BX/5EA","SUP-ITM-10062138","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.50","259.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","126.47","36.5","","148.37","54.89","631.39","94","107.42","275.47","percent of total billed charges",""
"ROD 40MM EXTERNAL FIXATION DEVICE ILIZAROV SS THREADED SLOTTED BX/5EA","SUP-ITM-10062138","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.50","259.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","132.71","38.3","","279.30","91.72","1116.77","266","107.42","275.47","percent of total billed charges",""
"ROD 40MM EXTERNAL FIXATION DEVICE ILIZAROV SS THREADED SLOTTED BX/5EA","SUP-ITM-10062138","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.50","259.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.65","42.9","","731.00","63.70","731.00","1 through 10","107.42","275.47","percent of total billed charges",""
"ROD 40MM EXTERNAL FIXATION DEVICE ILIZAROV SS THREADED SLOTTED BX/5EA","SUP-ITM-10062138","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.50","259.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.65","42.9","","384.74","384.74","384.74","1 through 10","107.42","275.47","percent of total billed charges",""
"ROD 40MM EXTERNAL FIXATION DEVICE ILIZAROV SS THREADED SLOTTED BX/5EA","SUP-ITM-10062138","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.50","259.87","WELLPOINT [1015]","HB AMC WELLPOINT","255.65","73.78","","286.63","119.22","1107.45","105","107.42","275.47","percent of total billed charges",""
"ROD 40MM EXTERNAL FIXATION DEVICE ILIZAROV SS THREADED SLOTTED BX/5EA","SUP-ITM-10062138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.50","259.87","AETNA [1001]","HB AMC AETNA HMO","241.86","69.8","","675.31","184.75","1721.50","286","181.08","283.16","percent of total billed charges",""
"ROD 40MM EXTERNAL FIXATION DEVICE ILIZAROV SS THREADED SLOTTED BX/5EA","SUP-ITM-10062138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.50","259.87","AETNA [1001]","HB AMC AETNA PPO","278.59","80.4","","1261.44","103.12","1514.10","21","181.08","283.16","percent of total billed charges",""
"ROD 40MM EXTERNAL FIXATION DEVICE ILIZAROV SS THREADED SLOTTED BX/5EA","SUP-ITM-10062138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.50","259.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","278.59","80.4","","1365.00","1365.00","1365.00","1 through 10","181.08","283.16","percent of total billed charges",""
"ROD 40MM EXTERNAL FIXATION DEVICE ILIZAROV SS THREADED SLOTTED BX/5EA","SUP-ITM-10062138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.50","259.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","283.16","81.72","","5157.68","5157.68","5157.68","1 through 10","181.08","283.16","percent of total billed charges",""
"ROD 40MM EXTERNAL FIXATION DEVICE ILIZAROV SS THREADED SLOTTED BX/5EA","SUP-ITM-10062138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.50","259.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","283.16","81.72","","431.26","71.26","1459.57","88","181.08","283.16","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","800.18","480.96","1887.97","195","217","556.5","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","813.12","216.42","1444.50","81","217","556.5","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","217.00","31","","432.60","432.60","432.60","1 through 10","217","556.5","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","148.37","54.89","631.39","94","217","556.5","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","279.30","91.72","1116.77","266","217","556.5","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","731.00","63.70","731.00","1 through 10","217","556.5","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","384.74","384.74","384.74","1 through 10","217","556.5","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","286.63","119.22","1107.45","105","217","556.5","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","675.31","184.75","1721.50","286","365.82","572.04","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA PPO","562.80","80.4","","1261.44","103.12","1514.10","21","365.82","572.04","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","562.80","80.4","","1365.00","1365.00","1365.00","1 through 10","365.82","572.04","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","572.04","81.72","","5157.68","5157.68","5157.68","1 through 10","365.82","572.04","percent of total billed charges",""
"ROD 5.4 L550MM STRAIGHT TITANIUM DIAM HEXAGONAL TIP","SUP-ITM-10184797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","431.26","71.26","1459.57","88","365.82","572.04","percent of total billed charges",""
"ROD 5.5X100MM SPINAL CD HORIZON SOLERA COBALT CURVE","SUP-ITM-10111323","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","1309.77","674.56","6049.93","26","162.75","417.38","percent of total billed charges",""
"ROD 5.5X100MM SPINAL CD HORIZON SOLERA COBALT CURVE","SUP-ITM-10111323","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","1901.83","1901.83","2962.25","1 through 10","162.75","417.38","percent of total billed charges",""
"ROD 5.5X100MM SPINAL CD HORIZON SOLERA COBALT CURVE","SUP-ITM-10111323","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","1620.31","1620.31","19908.88","1 through 10","162.75","417.38","percent of total billed charges",""
"ROD 5.5X100MM SPINAL CD HORIZON SOLERA COBALT CURVE","SUP-ITM-10111323","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","352.91","352.91","2046.30","1 through 10","162.75","417.38","percent of total billed charges",""
"ROD 5.5X100MM SPINAL CD HORIZON SOLERA COBALT CURVE","SUP-ITM-10111323","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","9668.75","9668.75","9668.75","1 through 10","162.75","417.38","percent of total billed charges",""
"ROD 5.5X100MM SPINAL CD HORIZON SOLERA COBALT CURVE","SUP-ITM-10111323","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","699.88","384.10","3443.31","33","162.75","417.38","percent of total billed charges",""
"ROD 5.5X100MM SPINAL CD HORIZON SOLERA COBALT CURVE","SUP-ITM-10111323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","1421.24","264.50","4933.46","29","274.37","429.03","percent of total billed charges",""
"ROD 5.5X100MM SPINAL CD HORIZON SOLERA COBALT CURVE","SUP-ITM-10111323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1022.97","1022.97","3607.50","1 through 10","274.37","429.03","percent of total billed charges",""
"ROD 5.5X100MM SPINAL CD HORIZON SOLERA COBALT CURVE","SUP-ITM-10111323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","3010.54","693.88","5019.88","35","274.37","429.03","percent of total billed charges",""
"ROD 80MM EXTERNAL FIXATOR CIRCULAR S/S THREADED TELESCOPE BX/5EA","SUP-ITM-10062139","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","314.42","79.5","","800.18","480.96","1887.97","195","122.61","314.42","percent of total billed charges",""
"ROD 80MM EXTERNAL FIXATOR CIRCULAR S/S THREADED TELESCOPE BX/5EA","SUP-ITM-10062139","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","210.80","53.3","","813.12","216.42","1444.50","81","122.61","314.42","percent of total billed charges",""
"ROD 80MM EXTERNAL FIXATOR CIRCULAR S/S THREADED TELESCOPE BX/5EA","SUP-ITM-10062139","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","122.61","31","","432.60","432.60","432.60","1 through 10","122.61","314.42","percent of total billed charges",""
"ROD 80MM EXTERNAL FIXATOR CIRCULAR S/S THREADED TELESCOPE BX/5EA","SUP-ITM-10062139","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","144.36","36.5","","148.37","54.89","631.39","94","122.61","314.42","percent of total billed charges",""
"ROD 80MM EXTERNAL FIXATOR CIRCULAR S/S THREADED TELESCOPE BX/5EA","SUP-ITM-10062139","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","151.48","38.3","","279.30","91.72","1116.77","266","122.61","314.42","percent of total billed charges",""
"ROD 80MM EXTERNAL FIXATOR CIRCULAR S/S THREADED TELESCOPE BX/5EA","SUP-ITM-10062139","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","169.67","42.9","","731.00","63.70","731.00","1 through 10","122.61","314.42","percent of total billed charges",""
"ROD 80MM EXTERNAL FIXATOR CIRCULAR S/S THREADED TELESCOPE BX/5EA","SUP-ITM-10062139","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","169.67","42.9","","384.74","384.74","384.74","1 through 10","122.61","314.42","percent of total billed charges",""
"ROD 80MM EXTERNAL FIXATOR CIRCULAR S/S THREADED TELESCOPE BX/5EA","SUP-ITM-10062139","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","WELLPOINT [1015]","HB AMC WELLPOINT","291.80","73.78","","286.63","119.22","1107.45","105","122.61","314.42","percent of total billed charges",""
"ROD 80MM EXTERNAL FIXATOR CIRCULAR S/S THREADED TELESCOPE BX/5EA","SUP-ITM-10062139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.50","296.62","AETNA [1001]","HB AMC AETNA HMO","276.06","69.8","","675.31","184.75","1721.50","286","206.69","323.2","percent of total billed charges",""
"ROD 80MM EXTERNAL FIXATOR CIRCULAR S/S THREADED TELESCOPE BX/5EA","SUP-ITM-10062139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.50","296.62","AETNA [1001]","HB AMC AETNA PPO","317.98","80.4","","1261.44","103.12","1514.10","21","206.69","323.2","percent of total billed charges",""
"ROD 80MM EXTERNAL FIXATOR CIRCULAR S/S THREADED TELESCOPE BX/5EA","SUP-ITM-10062139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.50","296.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","317.98","80.4","","1365.00","1365.00","1365.00","1 through 10","206.69","323.2","percent of total billed charges",""
"ROD 80MM EXTERNAL FIXATOR CIRCULAR S/S THREADED TELESCOPE BX/5EA","SUP-ITM-10062139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.50","296.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","323.20","81.72","","5157.68","5157.68","5157.68","1 through 10","206.69","323.2","percent of total billed charges",""
"ROD 80MM EXTERNAL FIXATOR CIRCULAR S/S THREADED TELESCOPE BX/5EA","SUP-ITM-10062139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.50","296.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","323.20","81.72","","431.26","71.26","1459.57","88","206.69","323.2","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","567.84","425.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","451.43","79.5","","1309.77","674.56","6049.93","26","176.03","451.43","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","567.84","425.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","302.66","53.3","","1901.83","1901.83","2962.25","1 through 10","176.03","451.43","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","567.84","425.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","207.26","36.5","","1620.31","1620.31","19908.88","1 through 10","176.03","451.43","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","567.84","425.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","217.48","38.3","","352.91","352.91","2046.30","1 through 10","176.03","451.43","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","567.84","425.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","243.60","42.9","","9668.75","9668.75","9668.75","1 through 10","176.03","451.43","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","567.84","425.88","WELLPOINT [1015]","HB AMC WELLPOINT","418.95","73.78","","699.88","384.10","3443.31","33","176.03","451.43","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","567.84","425.88","AETNA [1001]","HB AMC AETNA HMO","396.35","69.8","","1421.24","264.50","4933.46","29","296.75","464.04","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","567.84","425.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","456.54","80.4","","1022.97","1022.97","3607.50","1 through 10","296.75","464.04","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","567.84","425.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","464.04","81.72","","3010.54","693.88","5019.88","35","296.75","464.04","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","622.72","467.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","495.06","79.5","","1309.77","674.56","6049.93","26","193.04","495.06","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","622.72","467.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","331.91","53.3","","1901.83","1901.83","2962.25","1 through 10","193.04","495.06","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","622.72","467.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","227.29","36.5","","1620.31","1620.31","19908.88","1 through 10","193.04","495.06","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","622.72","467.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","238.50","38.3","","352.91","352.91","2046.30","1 through 10","193.04","495.06","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","622.72","467.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","267.15","42.9","","9668.75","9668.75","9668.75","1 through 10","193.04","495.06","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","622.72","467.04","WELLPOINT [1015]","HB AMC WELLPOINT","459.44","73.78","","699.88","384.10","3443.31","33","193.04","495.06","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","622.72","467.04","AETNA [1001]","HB AMC AETNA HMO","434.66","69.8","","1421.24","264.50","4933.46","29","325.43","508.89","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","622.72","467.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","500.67","80.4","","1022.97","1022.97","3607.50","1 through 10","325.43","508.89","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","622.72","467.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","508.89","81.72","","3010.54","693.88","5019.88","35","325.43","508.89","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","both","","","622.72","467.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","495.06","79.5","","1309.77","674.56","6049.93","26","193.04","495.06","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","both","","","622.72","467.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","331.91","53.3","","1901.83","1901.83","2962.25","1 through 10","193.04","495.06","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","both","","","622.72","467.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","227.29","36.5","","1620.31","1620.31","19908.88","1 through 10","193.04","495.06","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","both","","","622.72","467.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","238.50","38.3","","352.91","352.91","2046.30","1 through 10","193.04","495.06","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","both","","","622.72","467.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","267.15","42.9","","9668.75","9668.75","9668.75","1 through 10","193.04","495.06","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","both","","","622.72","467.04","WELLPOINT [1015]","HB AMC WELLPOINT","459.44","73.78","","699.88","384.10","3443.31","33","193.04","495.06","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","622.72","467.04","AETNA [1001]","HB AMC AETNA HMO","434.66","69.8","","1421.24","264.50","4933.46","29","325.43","508.89","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","622.72","467.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","500.67","80.4","","1022.97","1022.97","3607.50","1 through 10","325.43","508.89","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","622.72","467.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","508.89","81.72","","3010.54","693.88","5019.88","35","325.43","508.89","percent of total billed charges",""
"ROD BONE 11X600MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10022041","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.12","504.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","535.13","79.5","","800.18","480.96","1887.97","195","208.67","535.13","percent of total billed charges",""
"ROD BONE 11X600MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10022041","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.12","504.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","358.77","53.3","","813.12","216.42","1444.50","81","208.67","535.13","percent of total billed charges",""
"ROD BONE 11X600MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10022041","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.12","504.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","208.67","31","","432.60","432.60","432.60","1 through 10","208.67","535.13","percent of total billed charges",""
"ROD BONE 11X600MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10022041","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.12","504.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","245.69","36.5","","148.37","54.89","631.39","94","208.67","535.13","percent of total billed charges",""
"ROD BONE 11X600MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10022041","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.12","504.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","257.80","38.3","","279.30","91.72","1116.77","266","208.67","535.13","percent of total billed charges",""
"ROD BONE 11X600MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10022041","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.12","504.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","288.77","42.9","","731.00","63.70","731.00","1 through 10","208.67","535.13","percent of total billed charges",""
"ROD BONE 11X600MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10022041","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.12","504.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","288.77","42.9","","384.74","384.74","384.74","1 through 10","208.67","535.13","percent of total billed charges",""
"ROD BONE 11X600MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10022041","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.12","504.84","WELLPOINT [1015]","HB AMC WELLPOINT","496.63","73.78","","286.63","119.22","1107.45","105","208.67","535.13","percent of total billed charges",""
"ROD BONE 11X600MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10022041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.12","504.84","AETNA [1001]","HB AMC AETNA HMO","469.84","69.8","","675.31","184.75","1721.50","286","351.77","550.07","percent of total billed charges",""
"ROD BONE 11X600MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10022041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.12","504.84","AETNA [1001]","HB AMC AETNA PPO","541.19","80.4","","1261.44","103.12","1514.10","21","351.77","550.07","percent of total billed charges",""
"ROD BONE 11X600MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10022041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.12","504.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","541.19","80.4","","1365.00","1365.00","1365.00","1 through 10","351.77","550.07","percent of total billed charges",""
"ROD BONE 11X600MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10022041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.12","504.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","550.07","81.72","","5157.68","5157.68","5157.68","1 through 10","351.77","550.07","percent of total billed charges",""
"ROD BONE 11X600MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10022041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.12","504.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","550.07","81.72","","431.26","71.26","1459.57","88","351.77","550.07","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X65MM LORDOSED TRIALTIS","SUP-ITM-10331012","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","1309.77","674.56","6049.93","26","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X65MM LORDOSED TRIALTIS","SUP-ITM-10331012","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","1901.83","1901.83","2962.25","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X65MM LORDOSED TRIALTIS","SUP-ITM-10331012","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","1620.31","1620.31","19908.88","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X65MM LORDOSED TRIALTIS","SUP-ITM-10331012","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","352.91","352.91","2046.30","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X65MM LORDOSED TRIALTIS","SUP-ITM-10331012","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","9668.75","9668.75","9668.75","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X65MM LORDOSED TRIALTIS","SUP-ITM-10331012","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","699.88","384.10","3443.31","33","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X65MM LORDOSED TRIALTIS","SUP-ITM-10331012","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","1421.24","264.50","4933.46","29","438.98","686.45","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X65MM LORDOSED TRIALTIS","SUP-ITM-10331012","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1022.97","1022.97","3607.50","1 through 10","438.98","686.45","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X65MM LORDOSED TRIALTIS","SUP-ITM-10331012","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","3010.54","693.88","5019.88","35","438.98","686.45","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X75MM LORDOSED TRIALTIS","SUP-ITM-10331018","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","800.18","480.96","1887.97","195","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X75MM LORDOSED TRIALTIS","SUP-ITM-10331018","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","813.12","216.42","1444.50","81","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X75MM LORDOSED TRIALTIS","SUP-ITM-10331018","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","260.40","31","","432.60","432.60","432.60","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X75MM LORDOSED TRIALTIS","SUP-ITM-10331018","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","148.37","54.89","631.39","94","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X75MM LORDOSED TRIALTIS","SUP-ITM-10331018","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","279.30","91.72","1116.77","266","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X75MM LORDOSED TRIALTIS","SUP-ITM-10331018","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","731.00","63.70","731.00","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X75MM LORDOSED TRIALTIS","SUP-ITM-10331018","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","384.74","384.74","384.74","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X75MM LORDOSED TRIALTIS","SUP-ITM-10331018","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","286.63","119.22","1107.45","105","260.4","667.8","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X75MM LORDOSED TRIALTIS","SUP-ITM-10331018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","675.31","184.75","1721.50","286","438.98","686.45","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X75MM LORDOSED TRIALTIS","SUP-ITM-10331018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA PPO","675.36","80.4","","1261.44","103.12","1514.10","21","438.98","686.45","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X75MM LORDOSED TRIALTIS","SUP-ITM-10331018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1365.00","1365.00","1365.00","1 through 10","438.98","686.45","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X75MM LORDOSED TRIALTIS","SUP-ITM-10331018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","686.45","81.72","","5157.68","5157.68","5157.68","1 through 10","438.98","686.45","percent of total billed charges",""
"ROD COBALT CHROMIUM 5.5X75MM LORDOSED TRIALTIS","SUP-ITM-10331018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","431.26","71.26","1459.57","88","438.98","686.45","percent of total billed charges",""
"ROD COCR 4X240 STR","SUP-ITM-10243745","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","459.11","79.5","","800.18","480.96","1887.97","195","179.03","459.11","percent of total billed charges",""
"ROD COCR 4X240 STR","SUP-ITM-10243745","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","307.81","53.3","","813.12","216.42","1444.50","81","179.03","459.11","percent of total billed charges",""
"ROD COCR 4X240 STR","SUP-ITM-10243745","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","179.03","31","","432.60","432.60","432.60","1 through 10","179.03","459.11","percent of total billed charges",""
"ROD COCR 4X240 STR","SUP-ITM-10243745","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","210.79","36.5","","148.37","54.89","631.39","94","179.03","459.11","percent of total billed charges",""
"ROD COCR 4X240 STR","SUP-ITM-10243745","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","221.18","38.3","","279.30","91.72","1116.77","266","179.03","459.11","percent of total billed charges",""
"ROD COCR 4X240 STR","SUP-ITM-10243745","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.75","42.9","","731.00","63.70","731.00","1 through 10","179.03","459.11","percent of total billed charges",""
"ROD COCR 4X240 STR","SUP-ITM-10243745","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.75","42.9","","384.74","384.74","384.74","1 through 10","179.03","459.11","percent of total billed charges",""
"ROD COCR 4X240 STR","SUP-ITM-10243745","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","WELLPOINT [1015]","HB AMC WELLPOINT","426.08","73.78","","286.63","119.22","1107.45","105","179.03","459.11","percent of total billed charges",""
"ROD COCR 4X240 STR","SUP-ITM-10243745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","AETNA [1001]","HB AMC AETNA HMO","403.10","69.8","","675.31","184.75","1721.50","286","301.8","471.93","percent of total billed charges",""
"ROD COCR 4X240 STR","SUP-ITM-10243745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","AETNA [1001]","HB AMC AETNA PPO","464.31","80.4","","1261.44","103.12","1514.10","21","301.8","471.93","percent of total billed charges",""
"ROD COCR 4X240 STR","SUP-ITM-10243745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","464.31","80.4","","1365.00","1365.00","1365.00","1 through 10","301.8","471.93","percent of total billed charges",""
"ROD COCR 4X240 STR","SUP-ITM-10243745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","471.93","81.72","","5157.68","5157.68","5157.68","1 through 10","301.8","471.93","percent of total billed charges",""
"ROD COCR 4X240 STR","SUP-ITM-10243745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","471.93","81.72","","431.26","71.26","1459.57","88","301.8","471.93","percent of total billed charges",""
"ROD PERCUTANEOUS 100MM PALISADE FIXED","SUP-ITM-10170181","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","800.18","480.96","1887.97","195","260.4","667.8","percent of total billed charges",""
"ROD PERCUTANEOUS 100MM PALISADE FIXED","SUP-ITM-10170181","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","813.12","216.42","1444.50","81","260.4","667.8","percent of total billed charges",""
"ROD PERCUTANEOUS 100MM PALISADE FIXED","SUP-ITM-10170181","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","260.40","31","","432.60","432.60","432.60","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD PERCUTANEOUS 100MM PALISADE FIXED","SUP-ITM-10170181","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","148.37","54.89","631.39","94","260.4","667.8","percent of total billed charges",""
"ROD PERCUTANEOUS 100MM PALISADE FIXED","SUP-ITM-10170181","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","279.30","91.72","1116.77","266","260.4","667.8","percent of total billed charges",""
"ROD PERCUTANEOUS 100MM PALISADE FIXED","SUP-ITM-10170181","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","731.00","63.70","731.00","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD PERCUTANEOUS 100MM PALISADE FIXED","SUP-ITM-10170181","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","384.74","384.74","384.74","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD PERCUTANEOUS 100MM PALISADE FIXED","SUP-ITM-10170181","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","286.63","119.22","1107.45","105","260.4","667.8","percent of total billed charges",""
"ROD PERCUTANEOUS 100MM PALISADE FIXED","SUP-ITM-10170181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","675.31","184.75","1721.50","286","438.98","686.45","percent of total billed charges",""
"ROD PERCUTANEOUS 100MM PALISADE FIXED","SUP-ITM-10170181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA PPO","675.36","80.4","","1261.44","103.12","1514.10","21","438.98","686.45","percent of total billed charges",""
"ROD PERCUTANEOUS 100MM PALISADE FIXED","SUP-ITM-10170181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1365.00","1365.00","1365.00","1 through 10","438.98","686.45","percent of total billed charges",""
"ROD PERCUTANEOUS 100MM PALISADE FIXED","SUP-ITM-10170181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","686.45","81.72","","5157.68","5157.68","5157.68","1 through 10","438.98","686.45","percent of total billed charges",""
"ROD PERCUTANEOUS 100MM PALISADE FIXED","SUP-ITM-10170181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","431.26","71.26","1459.57","88","438.98","686.45","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1321.69","79.5","","800.18","480.96","1887.97","195","515.38","1321.69","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","886.11","53.3","","813.12","216.42","1444.50","81","515.38","1321.69","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","515.38","31","","432.60","432.60","432.60","1 through 10","515.38","1321.69","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","606.81","36.5","","148.37","54.89","631.39","94","515.38","1321.69","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","636.74","38.3","","279.30","91.72","1116.77","266","515.38","1321.69","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.21","42.9","","731.00","63.70","731.00","1 through 10","515.38","1321.69","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.21","42.9","","384.74","384.74","384.74","1 through 10","515.38","1321.69","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","WELLPOINT [1015]","HB AMC WELLPOINT","1226.59","73.78","","286.63","119.22","1107.45","105","515.38","1321.69","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","AETNA [1001]","HB AMC AETNA HMO","1160.43","69.8","","675.31","184.75","1721.50","286","868.82","1358.6","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","AETNA [1001]","HB AMC AETNA PPO","1336.65","80.4","","1261.44","103.12","1514.10","21","868.82","1358.6","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1336.65","80.4","","1365.00","1365.00","1365.00","1 through 10","868.82","1358.6","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1358.60","81.72","","5157.68","5157.68","5157.68","1 through 10","868.82","1358.6","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1358.60","81.72","","431.26","71.26","1459.57","88","868.82","1358.6","percent of total billed charges",""
"ROD SACRAL 6X260MM EXTERNAL FIXATION","SUP-ITM-10038654","CDM","C1889","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1802.70","79.5","","1309.77","674.56","6049.93","26","702.94","1802.7","percent of total billed charges",""
"ROD SACRAL 6X260MM EXTERNAL FIXATION","SUP-ITM-10038654","CDM","C1889","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1208.60","53.3","","1901.83","1901.83","2962.25","1 through 10","702.94","1802.7","percent of total billed charges",""
"ROD SACRAL 6X260MM EXTERNAL FIXATION","SUP-ITM-10038654","CDM","C1889","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","827.66","36.5","","1620.31","1620.31","19908.88","1 through 10","702.94","1802.7","percent of total billed charges",""
"ROD SACRAL 6X260MM EXTERNAL FIXATION","SUP-ITM-10038654","CDM","C1889","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","868.47","38.3","","352.91","352.91","2046.30","1 through 10","702.94","1802.7","percent of total billed charges",""
"ROD SACRAL 6X260MM EXTERNAL FIXATION","SUP-ITM-10038654","CDM","C1889","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","972.78","42.9","","9668.75","9668.75","9668.75","1 through 10","702.94","1802.7","percent of total billed charges",""
"ROD SACRAL 6X260MM EXTERNAL FIXATION","SUP-ITM-10038654","CDM","C1889","HCPCS","0278","RC","","","","both","","","2267.55","1700.66","WELLPOINT [1015]","HB AMC WELLPOINT","1673.00","73.78","","699.88","384.10","3443.31","33","702.94","1802.7","percent of total billed charges",""
"ROD SACRAL 6X260MM EXTERNAL FIXATION","SUP-ITM-10038654","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2267.55","1700.66","AETNA [1001]","HB AMC AETNA HMO","1582.75","69.8","","1421.24","264.50","4933.46","29","1185.02","1853.04","percent of total billed charges",""
"ROD SACRAL 6X260MM EXTERNAL FIXATION","SUP-ITM-10038654","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2267.55","1700.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1823.11","80.4","","1022.97","1022.97","3607.50","1 through 10","1185.02","1853.04","percent of total billed charges",""
"ROD SACRAL 6X260MM EXTERNAL FIXATION","SUP-ITM-10038654","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2267.55","1700.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1853.04","81.72","","3010.54","693.88","5019.88","35","1185.02","1853.04","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI MED","SUP-ITM-10286244","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1321.69","79.5","","1309.77","674.56","6049.93","26","515.38","1321.69","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI MED","SUP-ITM-10286244","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","886.11","53.3","","1901.83","1901.83","2962.25","1 through 10","515.38","1321.69","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI MED","SUP-ITM-10286244","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","606.81","36.5","","1620.31","1620.31","19908.88","1 through 10","515.38","1321.69","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI MED","SUP-ITM-10286244","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","636.74","38.3","","352.91","352.91","2046.30","1 through 10","515.38","1321.69","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI MED","SUP-ITM-10286244","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.21","42.9","","9668.75","9668.75","9668.75","1 through 10","515.38","1321.69","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI MED","SUP-ITM-10286244","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.50","1246.87","WELLPOINT [1015]","HB AMC WELLPOINT","1226.59","73.78","","699.88","384.10","3443.31","33","515.38","1321.69","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI MED","SUP-ITM-10286244","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","AETNA [1001]","HB AMC AETNA HMO","1160.43","69.8","","1421.24","264.50","4933.46","29","868.82","1358.6","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI MED","SUP-ITM-10286244","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1336.65","80.4","","1022.97","1022.97","3607.50","1 through 10","868.82","1358.6","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI MED","SUP-ITM-10286244","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1662.50","1246.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1358.60","81.72","","3010.54","693.88","5019.88","35","868.82","1358.6","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI SHORT","SUP-ITM-10285749","CDM","C1889","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1252.13","79.5","","1309.77","674.56","6049.93","26","488.25","1252.13","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI SHORT","SUP-ITM-10285749","CDM","C1889","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","839.48","53.3","","1901.83","1901.83","2962.25","1 through 10","488.25","1252.13","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI SHORT","SUP-ITM-10285749","CDM","C1889","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","574.88","36.5","","1620.31","1620.31","19908.88","1 through 10","488.25","1252.13","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI SHORT","SUP-ITM-10285749","CDM","C1889","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","603.23","38.3","","352.91","352.91","2046.30","1 through 10","488.25","1252.13","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI SHORT","SUP-ITM-10285749","CDM","C1889","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","9668.75","9668.75","9668.75","1 through 10","488.25","1252.13","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI SHORT","SUP-ITM-10285749","CDM","C1889","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB AMC WELLPOINT","1162.04","73.78","","699.88","384.10","3443.31","33","488.25","1252.13","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI SHORT","SUP-ITM-10285749","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA HMO","1099.35","69.8","","1421.24","264.50","4933.46","29","823.1","1287.09","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI SHORT","SUP-ITM-10285749","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1266.30","80.4","","1022.97","1022.97","3607.50","1 through 10","823.1","1287.09","percent of total billed charges",""
"ROD SPINAL 5.5MM EXPEDIUM PRECONTOURED TI SHORT","SUP-ITM-10285749","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1287.09","81.72","","3010.54","693.88","5019.88","35","823.1","1287.09","percent of total billed charges",""
"ROD SPINE 5.5X150MM EXPEDIUM COCR PRE-LORD","SUP-ITM-10249692","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","1309.77","674.56","6049.93","26","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X150MM EXPEDIUM COCR PRE-LORD","SUP-ITM-10249692","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","1901.83","1901.83","2962.25","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X150MM EXPEDIUM COCR PRE-LORD","SUP-ITM-10249692","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","1620.31","1620.31","19908.88","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X150MM EXPEDIUM COCR PRE-LORD","SUP-ITM-10249692","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","352.91","352.91","2046.30","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X150MM EXPEDIUM COCR PRE-LORD","SUP-ITM-10249692","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","9668.75","9668.75","9668.75","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X150MM EXPEDIUM COCR PRE-LORD","SUP-ITM-10249692","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","699.88","384.10","3443.31","33","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X150MM EXPEDIUM COCR PRE-LORD","SUP-ITM-10249692","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","1421.24","264.50","4933.46","29","438.98","686.45","percent of total billed charges",""
"ROD SPINE 5.5X150MM EXPEDIUM COCR PRE-LORD","SUP-ITM-10249692","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1022.97","1022.97","3607.50","1 through 10","438.98","686.45","percent of total billed charges",""
"ROD SPINE 5.5X150MM EXPEDIUM COCR PRE-LORD","SUP-ITM-10249692","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","3010.54","693.88","5019.88","35","438.98","686.45","percent of total billed charges",""
"ROD SPINE 5.5X40MM CD HORIZON SOLERA PERCUTANEOUS COBALT CHROME","SUP-ITM-10212623","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","800.18","480.96","1887.97","195","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X40MM CD HORIZON SOLERA PERCUTANEOUS COBALT CHROME","SUP-ITM-10212623","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","813.12","216.42","1444.50","81","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X40MM CD HORIZON SOLERA PERCUTANEOUS COBALT CHROME","SUP-ITM-10212623","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","260.40","31","","432.60","432.60","432.60","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X40MM CD HORIZON SOLERA PERCUTANEOUS COBALT CHROME","SUP-ITM-10212623","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","148.37","54.89","631.39","94","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X40MM CD HORIZON SOLERA PERCUTANEOUS COBALT CHROME","SUP-ITM-10212623","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","279.30","91.72","1116.77","266","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X40MM CD HORIZON SOLERA PERCUTANEOUS COBALT CHROME","SUP-ITM-10212623","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","731.00","63.70","731.00","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X40MM CD HORIZON SOLERA PERCUTANEOUS COBALT CHROME","SUP-ITM-10212623","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","384.74","384.74","384.74","1 through 10","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X40MM CD HORIZON SOLERA PERCUTANEOUS COBALT CHROME","SUP-ITM-10212623","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","286.63","119.22","1107.45","105","260.4","667.8","percent of total billed charges",""
"ROD SPINE 5.5X40MM CD HORIZON SOLERA PERCUTANEOUS COBALT CHROME","SUP-ITM-10212623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","675.31","184.75","1721.50","286","438.98","686.45","percent of total billed charges",""
"ROD SPINE 5.5X40MM CD HORIZON SOLERA PERCUTANEOUS COBALT CHROME","SUP-ITM-10212623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA PPO","675.36","80.4","","1261.44","103.12","1514.10","21","438.98","686.45","percent of total billed charges",""
"ROD SPINE 5.5X40MM CD HORIZON SOLERA PERCUTANEOUS COBALT CHROME","SUP-ITM-10212623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1365.00","1365.00","1365.00","1 through 10","438.98","686.45","percent of total billed charges",""
"ROD SPINE 5.5X40MM CD HORIZON SOLERA PERCUTANEOUS COBALT CHROME","SUP-ITM-10212623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","686.45","81.72","","5157.68","5157.68","5157.68","1 through 10","438.98","686.45","percent of total billed charges",""
"ROD SPINE 5.5X40MM CD HORIZON SOLERA PERCUTANEOUS COBALT CHROME","SUP-ITM-10212623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","431.26","71.26","1459.57","88","438.98","686.45","percent of total billed charges",""
"ROD TI 3.5-4X220 ADJ","SUP-ITM-10243838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","800.18","480.96","1887.97","195","759.5","1947.75","percent of total billed charges",""
"ROD TI 3.5-4X220 ADJ","SUP-ITM-10243838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.85","53.3","","813.12","216.42","1444.50","81","759.5","1947.75","percent of total billed charges",""
"ROD TI 3.5-4X220 ADJ","SUP-ITM-10243838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","759.50","31","","432.60","432.60","432.60","1 through 10","759.5","1947.75","percent of total billed charges",""
"ROD TI 3.5-4X220 ADJ","SUP-ITM-10243838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","148.37","54.89","631.39","94","759.5","1947.75","percent of total billed charges",""
"ROD TI 3.5-4X220 ADJ","SUP-ITM-10243838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","279.30","91.72","1116.77","266","759.5","1947.75","percent of total billed charges",""
"ROD TI 3.5-4X220 ADJ","SUP-ITM-10243838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","731.00","63.70","731.00","1 through 10","759.5","1947.75","percent of total billed charges",""
"ROD TI 3.5-4X220 ADJ","SUP-ITM-10243838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","384.74","384.74","384.74","1 through 10","759.5","1947.75","percent of total billed charges",""
"ROD TI 3.5-4X220 ADJ","SUP-ITM-10243838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","286.63","119.22","1107.45","105","759.5","1947.75","percent of total billed charges",""
"ROD TI 3.5-4X220 ADJ","SUP-ITM-10243838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","675.31","184.75","1721.50","286","1280.37","2002.14","percent of total billed charges",""
"ROD TI 3.5-4X220 ADJ","SUP-ITM-10243838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA PPO","1969.80","80.4","","1261.44","103.12","1514.10","21","1280.37","2002.14","percent of total billed charges",""
"ROD TI 3.5-4X220 ADJ","SUP-ITM-10243838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.80","80.4","","1365.00","1365.00","1365.00","1 through 10","1280.37","2002.14","percent of total billed charges",""
"ROD TI 3.5-4X220 ADJ","SUP-ITM-10243838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2002.14","81.72","","5157.68","5157.68","5157.68","1 through 10","1280.37","2002.14","percent of total billed charges",""
"ROD TI 3.5-4X220 ADJ","SUP-ITM-10243838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","431.26","71.26","1459.57","88","1280.37","2002.14","percent of total billed charges",""
"ROD TI 4.0-5.5X420 DD","SUP-ITM-10243841","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","639.98","79.5","","800.18","480.96","1887.97","195","249.55","639.98","percent of total billed charges",""
"ROD TI 4.0-5.5X420 DD","SUP-ITM-10243841","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","429.07","53.3","","813.12","216.42","1444.50","81","249.55","639.98","percent of total billed charges",""
"ROD TI 4.0-5.5X420 DD","SUP-ITM-10243841","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","249.55","31","","432.60","432.60","432.60","1 through 10","249.55","639.98","percent of total billed charges",""
"ROD TI 4.0-5.5X420 DD","SUP-ITM-10243841","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","293.83","36.5","","148.37","54.89","631.39","94","249.55","639.98","percent of total billed charges",""
"ROD TI 4.0-5.5X420 DD","SUP-ITM-10243841","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","308.32","38.3","","279.30","91.72","1116.77","266","249.55","639.98","percent of total billed charges",""
"ROD TI 4.0-5.5X420 DD","SUP-ITM-10243841","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","345.35","42.9","","731.00","63.70","731.00","1 through 10","249.55","639.98","percent of total billed charges",""
"ROD TI 4.0-5.5X420 DD","SUP-ITM-10243841","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","345.35","42.9","","384.74","384.74","384.74","1 through 10","249.55","639.98","percent of total billed charges",""
"ROD TI 4.0-5.5X420 DD","SUP-ITM-10243841","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","WELLPOINT [1015]","HB AMC WELLPOINT","593.93","73.78","","286.63","119.22","1107.45","105","249.55","639.98","percent of total billed charges",""
"ROD TI 4.0-5.5X420 DD","SUP-ITM-10243841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","805.00","603.75","AETNA [1001]","HB AMC AETNA HMO","561.89","69.8","","675.31","184.75","1721.50","286","420.69","657.85","percent of total billed charges",""
"ROD TI 4.0-5.5X420 DD","SUP-ITM-10243841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","805.00","603.75","AETNA [1001]","HB AMC AETNA PPO","647.22","80.4","","1261.44","103.12","1514.10","21","420.69","657.85","percent of total billed charges",""
"ROD TI 4.0-5.5X420 DD","SUP-ITM-10243841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","805.00","603.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","647.22","80.4","","1365.00","1365.00","1365.00","1 through 10","420.69","657.85","percent of total billed charges",""
"ROD TI 4.0-5.5X420 DD","SUP-ITM-10243841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","805.00","603.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","657.85","81.72","","5157.68","5157.68","5157.68","1 through 10","420.69","657.85","percent of total billed charges",""
"ROD TI 4.0-5.5X420 DD","SUP-ITM-10243841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","805.00","603.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","657.85","81.72","","431.26","71.26","1459.57","88","420.69","657.85","percent of total billed charges",""
"ROD TI 5.5MM PRCTRD M","SUP-ITM-10278949","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1252.13","79.5","","800.18","480.96","1887.97","195","488.25","1252.13","percent of total billed charges",""
"ROD TI 5.5MM PRCTRD M","SUP-ITM-10278949","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","839.48","53.3","","813.12","216.42","1444.50","81","488.25","1252.13","percent of total billed charges",""
"ROD TI 5.5MM PRCTRD M","SUP-ITM-10278949","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","488.25","31","","432.60","432.60","432.60","1 through 10","488.25","1252.13","percent of total billed charges",""
"ROD TI 5.5MM PRCTRD M","SUP-ITM-10278949","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","574.88","36.5","","148.37","54.89","631.39","94","488.25","1252.13","percent of total billed charges",""
"ROD TI 5.5MM PRCTRD M","SUP-ITM-10278949","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","603.23","38.3","","279.30","91.72","1116.77","266","488.25","1252.13","percent of total billed charges",""
"ROD TI 5.5MM PRCTRD M","SUP-ITM-10278949","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","731.00","63.70","731.00","1 through 10","488.25","1252.13","percent of total billed charges",""
"ROD TI 5.5MM PRCTRD M","SUP-ITM-10278949","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","384.74","384.74","384.74","1 through 10","488.25","1252.13","percent of total billed charges",""
"ROD TI 5.5MM PRCTRD M","SUP-ITM-10278949","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB AMC WELLPOINT","1162.04","73.78","","286.63","119.22","1107.45","105","488.25","1252.13","percent of total billed charges",""
"ROD TI 5.5MM PRCTRD M","SUP-ITM-10278949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA HMO","1099.35","69.8","","675.31","184.75","1721.50","286","823.1","1287.09","percent of total billed charges",""
"ROD TI 5.5MM PRCTRD M","SUP-ITM-10278949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA PPO","1266.30","80.4","","1261.44","103.12","1514.10","21","823.1","1287.09","percent of total billed charges",""
"ROD TI 5.5MM PRCTRD M","SUP-ITM-10278949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1266.30","80.4","","1365.00","1365.00","1365.00","1 through 10","823.1","1287.09","percent of total billed charges",""
"ROD TI 5.5MM PRCTRD M","SUP-ITM-10278949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1287.09","81.72","","5157.68","5157.68","5157.68","1 through 10","823.1","1287.09","percent of total billed charges",""
"ROD TI 5.5MM PRCTRD M","SUP-ITM-10278949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1287.09","81.72","","431.26","71.26","1459.57","88","823.1","1287.09","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","both","","","3573.00","2679.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","2840.54","other","OPPS APC"
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","both","","","3573.00","2679.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","2840.54","other","OPPS APC"
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","both","","","3573.00","2679.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2840.54","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","2840.54","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","both","","","3573.00","2679.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","2840.54","other","OPPS APC"
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","both","","","3573.00","2679.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","2840.54","other","OPPS APC"
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","both","","","3573.00","2679.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1304.15","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","2840.54","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","both","","","3573.00","2679.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1368.46","38.3","","2723.31","1555.62","2741.61","12","1057.74","2840.54","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","both","","","3573.00","2679.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","2840.54","other","OPPS APC"
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","both","","","3573.00","2679.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","2840.54","other","OPPS APC"
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","both","","","3573.00","2679.75","WELLPOINT [1015]","HB AMC WELLPOINT","2636.16","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","2840.54","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","outpatient","","","3573.00","2679.75","AETNA [1001]","HB AMC AETNA PPO","2872.69","80.4","","1163.76","1163.76","1163.76","1 through 10","1786.5","2947.73","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","outpatient","","","3573.00","2679.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2163.45","60.55","","1781.82","1492.00","4331.00","1 through 10","1786.5","2947.73","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","outpatient","","","3573.00","2679.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1865.82","52.22","","3144.00","1492.00","3610.00","13","1786.5","2947.73","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","outpatient","","","3573.00","2679.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","1875.83","52.5","","1182.28","1182.28","1182.28","1 through 10","1786.5","2947.73","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","outpatient","","","3573.00","2679.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1786.50","50","","3610.00","2269.44","3610.00","1 through 10","1786.5","2947.73","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","outpatient","","","3573.00","2679.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1875.83","52.5","","3610.00","2382.05","4331.00","1 through 10","1786.5","2947.73","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","outpatient","","","3573.00","2679.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1965.15","55","","4810.75","3363.17","4810.75","1 through 10","1786.5","2947.73","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","outpatient","","","3573.00","2679.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2919.86","81.72","","8894.69","8894.69","8894.69","1 through 10","1786.5","2947.73","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","outpatient","","","3573.00","2679.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2919.86","81.72","","2885.83","2132.00","3462.21","1 through 10","1786.5","2947.73","percent of total billed charges",""
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","4191.00","3143.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1525.53","1525.53","1525.53","1 through 10","1002.61","3331.85","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","4191.00","3143.25","MEDICARE [2001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3100.68","1550.34","3100.68","49","1002.61","3331.85","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","4191.00","3143.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1605.15","38.3","","3178.04","1589.02","3178.04","1 through 10","1002.61","3331.85","percent of total billed charges",""
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","4191.00","3143.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3048.66","1522.13","3048.66","1 through 10","1002.61","3331.85","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","4191.00","3143.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1522.34","1519.54","1522.34","1 through 10","1002.61","3331.85","other","OPPS APC"
"Rp Loclzj Tum Spect CT 2area/Sep Acquisj Img","PX-34000188","CDM","78832","CPT","0341","RC","","","","both","","","6293.00","4719.75","MEDICARE [2001]","HB BWH MEDICARE","1731.99","","APC Price ($1,731.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1732.16","1707.48","1732.16","1 through 10","1645.55","5002.94","other","OPPS APC"
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1596.68","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1598.30","1595.30","1601.81","17","1472.82","4011.57","other","OPPS APC"
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1525.53","1524.98","1550.34","21","1472.82","4011.57","other","OPPS APC"
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3532.20","70","","270.36","270.36","270.36","1 through 10","1472.82","4011.57","percent of total billed charges",""
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4011.57","79.5","","3850.79","2583.50","11552.37","13","1472.82","4011.57","percent of total billed charges",""
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2689.52","53.3","","3815.19","3815.19","3815.19","1 through 10","1472.82","4011.57","percent of total billed charges",""
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1518.78","1284.59","1519.33","1 through 10","1472.82","4011.57","other","OPPS APC"
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","ELDER SERVICES [1037]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1519.33","1519.33","1519.33","1 through 10","1472.82","4011.57","other","OPPS APC"
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","FALLON HEALTH [1008]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1550.34","1550.34","1550.34","1 through 10","1472.82","4011.57","other","OPPS APC"
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4103.69","4103.69","4103.69","1 through 10","1472.82","4011.57","other","OPPS APC"
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","HUMANA [1012]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1531.74","1531.74","1531.74","1 through 10","1472.82","4011.57","other","OPPS APC"
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","MEDICARE [2001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1550.34","1550.34","1550.34","298","1472.82","4011.57","other","OPPS APC"
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1841.79","36.5","","1825.09","1536.40","1825.09","1 through 10","1472.82","4011.57","percent of total billed charges",""
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1932.62","38.3","","1913.16","1913.16","1913.16","15","1472.82","4011.57","percent of total billed charges",""
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1522.53","1519.33","1522.53","1 through 10","1472.82","4011.57","other","OPPS APC"
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","MOLINA [1014]","HB BWH MOLINA","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3077.54","3068.56","3077.54","1 through 10","1472.82","4011.57","other","OPPS APC"
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1519.33","1518.78","4557.99","28","1472.82","4011.57","other","OPPS APC"
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1519.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1522.34","1518.78","1550.34","28","1472.82","4011.57","other","OPPS APC"
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","both","","","5046.00","3784.50","WELLPOINT [1015]","HB AMC WELLPOINT","3722.94","73.78","","3642.84","3642.84","3642.84","1 through 10","1472.82","4011.57","percent of total billed charges",""
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","outpatient","","","5046.00","3784.50","AETNA [1001]","HB AMC AETNA HMO","3522.11","69.8","","3312.56","2338.85","3816.54","1 through 10","2637.04","5519.92","percent of total billed charges",""
"Rp Loclzj Tum Spect W/CT 1 Area/Acquisj 1day Img","PX-34000186","CDM","78830","CPT","0341","RC","","","","outpatient","","","5046.00","3784.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4123.59","81.72","","3911.46","3779.65","3911.46","11","2637.04","5519.92","percent of total billed charges",""
"Rplc Duoden/Jejunos TB Perc Fluoro","PX-75000303","CDM","49451","CPT","0361","RC","","","","both","","","1757.00","1317.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","989.36","989.36","1113.41","1 through 10","544.67","1396.82","other","OPPS APC"
"Rplc Duoden/Jejunos TB Perc Fluoro","PX-75000303","CDM","49451","CPT","0361","RC","","","","both","","","1757.00","1317.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.15","1091.15","1091.15","1 through 10","544.67","1396.82","other","OPPS APC"
"Rplc Duoden/Jejunos TB Perc Fluoro","PX-75000303","CDM","49451","CPT","0361","RC","","","","outpatient","","","1757.00","1317.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2038.73","2038.73","2038.73","1 through 10","761.55","1435.82","other","ASC "
"Rplc Gastro-Jejun TB Undr Fluoro","PX-75000304","CDM","49452","CPT","0361","RC","","","","both","","","1700.00","1275.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","1152.70","1 through 10","527","1391.62","other","OPPS APC"
"Rplc Gastro-Jejun TB Undr Fluoro","PX-75000304","CDM","49452","CPT","0361","RC","","","","both","","","1700.00","1275.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1351.50","79.5","","1297.76","1297.76","1297.76","1 through 10","527","1391.62","percent of total billed charges",""
"Rplc Gastro-Jejun TB Undr Fluoro","PX-75000304","CDM","49452","CPT","0361","RC","","","","both","","","1700.00","1275.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","11","527","1391.62","other","OPPS APC"
"Rplc Gastro-Jejun TB Undr Fluoro","PX-75000304","CDM","49452","CPT","0361","RC","","","","both","","","1700.00","1275.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.15","1091.15","1091.15","1 through 10","527","1391.62","other","OPPS APC"
"Rplc Gastro-Jejun TB Undr Fluoro","PX-75000304","CDM","49452","CPT","0361","RC","","","","outpatient","","","1700.00","1275.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2038.73","2038.73","2038.73","1 through 10","761.55","1389.24","other","ASC "
"Rplc Gastro-Jejun TB Undr Fluoro","PX-75000304","CDM","49452","CPT","0361","RC","","","","outpatient","","","1700.00","1275.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1766.80","1766.80","1766.80","1 through 10","761.55","1389.24","other","Multiple Surgery"
"Rplce G/Cec/Oth Clnc TB Undr Fluoro","PX-75000302","CDM","49450","CPT","0361","RC","","","","both","","","1775.00","1331.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1095.60","1113.41","1 through 10","550.25","1411.13","other","OPPS APC"
"Rplce G/Cec/Oth Clnc TB Undr Fluoro","PX-75000302","CDM","49450","CPT","0361","RC","","","","both","","","1775.00","1331.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","969.57","969.57","969.57","1 through 10","550.25","1411.13","other","OPPS APC"
"Rplce G/Cec/Oth Clnc TB Undr Fluoro","PX-75000302","CDM","49450","CPT","0361","RC","","","","both","","","1775.00","1331.25","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","989.36","1113.41","22","550.25","1411.13","other","OPPS APC"
"Rplce G/Cec/Oth Clnc TB Undr Fluoro","PX-75000302","CDM","49450","CPT","0361","RC","","","","both","","","1775.00","1331.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","977.64","1099.05","1 through 10","550.25","1411.13","other","OPPS APC"
"Rplce G/Cec/Oth Clnc TB Undr Fluoro","PX-75000302","CDM","49450","CPT","0361","RC","","","","outpatient","","","1775.00","1331.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1766.80","1766.80","1766.80","1 through 10","761.55","1450.53","other","Multiple Surgery"
"Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible","PX-98301106","CDM","49505","CPT","0983","RC","","","","both","","","2770.00","2077.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1060.91","38.3","","6578.18","6578.18","6578.18","1 through 10","858.7","5610.09","percent of total billed charges",""
"Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible","PX-98301106","CDM","49505","CPT","0983","RC","","","","both","","","2770.00","2077.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2132.90","77","","13695.03","13695.03","13695.03","1 through 10","858.7","5610.09","percent of total billed charges",""
"Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible","PX-98301106","CDM","49505","CPT","0983","RC","","","","both","","","2770.00","2077.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4398.31","","APC Price ($4,488.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4114.66","3707.45","6103.78","1 through 10","858.7","5610.09","other","OPPS APC"
"Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|BILATERAL PROCEDURE","PX-98301106","CDM","49505","CPT","0983","RC","","","50","both","","","2770.00","2077.50","MEDICARE [2001]","HB BWH MEDICARE","7570.48","","APC Price ($7,570.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7069.32","7069.32","7069.32","1 through 10","6715.85","9463.09","other","OPPS APC"
"Rpr 1st Ingun Hrna Age 5 Yrs/> Reducible|BILATERAL PROCEDURE","PX-98301106","CDM","49505","CPT","0983","RC","","","50","outpatient","","","2770.00","2077.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5055.65","","Case rate ($5,055.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","11719.00","11719.00","11835.28","1 through 10","5055.65","18309.09","other","ASC "
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","both","","","2245.00","1683.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7419.84","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6790.08","6790.08","6790.08","1 through 10","695.95","9274.8","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","both","","","2245.00","1683.75","FALLON HEALTH [1008]","HB BWH MEDICARE","7419.84","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6795.58","6795.58","6795.58","1 through 10","695.95","9274.8","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","both","","","2245.00","1683.75","MEDICARE [2001]","HB BWH MEDICARE","7419.84","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6297.49","6928.65","1 through 10","695.95","9274.8","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","both","","","2245.00","1683.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","859.84","38.3","","11008.61","6360.01","11008.61","1 through 10","695.95","9274.8","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","outpatient","","","2245.00","1683.75","AETNA [1001]","HB AMC AETNA HMO","1567.01","69.8","","7775.15","7775.15","7775.15","1 through 10","1254.96","15696.44","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","outpatient","","","2245.00","1683.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5790.38","","Case rate ($5,790.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","11632.87","11632.87","11632.87","1 through 10","1254.96","15696.44","other","ASC"
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","outpatient","","","2245.00","1683.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5790.38","","Case rate ($5,790.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","13555.28","13422.10","13555.28","1 through 10","1254.96","15696.44","other","ASC "
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","outpatient","","","2245.00","1683.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1834.61","81.72","","14421.57","14421.57","14421.57","1 through 10","1254.96","15696.44","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4622.72","","APC Price ($4,488.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4321.41","4312.51","4321.41","1 through 10","501.58","5610.09","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4488.08","","APC Price ($4,488.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4123.91","4123.91","4123.91","1 through 10","501.58","5610.09","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1286.31","79.5","","20901.15","9682.46","20901.15","1 through 10","501.58","5610.09","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","862.39","53.3","","10680.91","6495.98","10680.91","1 through 10","501.58","5610.09","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","MEDICARE [2001]","HB BWH MEDICARE","4488.08","","APC Price ($4,488.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","4190.97","4190.97","11","501.58","5610.09","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","619.69","38.3","","21240.48","7909.54","21240.48","1 through 10","501.58","5610.09","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4398.31","","APC Price ($4,488.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4123.91","4123.91","4123.91","1 through 10","501.58","5610.09","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","694.12","42.9","","19339.08","19339.08","19339.08","1 through 10","501.58","5610.09","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","outpatient","","","1618.00","1213.50","AETNA [1001]","HB AMC AETNA HMO","1129.36","69.8","","12411.99","7775.15","20443.02","1 through 10","904.46","10159.42","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","outpatient","","","1618.00","1213.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3934.87","","Case rate ($3,934.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","7905.15","4025.37","8050.74","1 through 10","904.46","10159.42","other","ASC"
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","outpatient","","","1618.00","1213.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3934.87","","Case rate ($3,934.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","9121.03","4560.52","9211.53","18","904.46","10159.42","other","ASC "
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","outpatient","","","1618.00","1213.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1322.23","81.72","","16171.06","6446.36","16171.06","1 through 10","904.46","10159.42","percent of total billed charges",""
"Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated","PX-98302394","CDM","49596","CPT","0983","RC","","","","outpatient","","","4411.00","3308.25","AETNA [1001]","HB AMC AETNA HMO","3078.88","69.8","","10251.27","10251.27","10251.27","1 through 10","1764.4","3604.67","percent of total billed charges",""
"Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated","PX-98302394","CDM","49596","CPT","0983","RC","","","","outpatient","","","4411.00","3308.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2670.86","60.55","","11683.22","11683.22","11683.22","1 through 10","1764.4","3604.67","percent of total billed charges",""
"Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated","PX-98302394","CDM","49596","CPT","0983","RC","","","","outpatient","","","4411.00","3308.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2303.42","52.22","","13613.95","13613.95","13613.95","1 through 10","1764.4","3604.67","percent of total billed charges",""
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","both","","","3515.00","2636.25","MEDICARE [2001]","HB BWH MEDICARE","7419.84","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6928.65","6928.65","1 through 10","1089.65","9274.8","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","both","","","3515.00","2636.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1282.98","36.5","","12693.95","10181.41","12693.95","1 through 10","1089.65","9274.8","percent of total billed charges",""
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","both","","","3515.00","2636.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1346.25","38.3","","18756.27","18756.27","18756.27","1 through 10","1089.65","9274.8","percent of total billed charges",""
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","both","","","3515.00","2636.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7271.44","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6797.58","6797.58","6797.58","1 through 10","1089.65","9274.8","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","outpatient","","","3515.00","2636.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","5790.38","","Case rate ($5,790.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","11632.87","11632.87","11632.87","1 through 10","1964.89","15696.44","other","ASC"
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","outpatient","","","3515.00","2636.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5790.38","","Case rate ($5,790.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","13422.10","13422.10","13422.10","1 through 10","1964.89","15696.44","other","ASC "
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","outpatient","","","3515.00","2636.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2872.46","81.72","","16171.06","16171.06","16171.06","1 through 10","1964.89","15696.44","percent of total billed charges",""
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","both","","","2704.00","2028.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","8173.45","","APC Price ($7,935.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","7624.97","7624.97","7624.97","1 through 10","838.24","9919.24","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","both","","","2704.00","2028.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2149.68","79.5","","15920.22","15920.22","15920.22","1 through 10","838.24","9919.24","percent of total billed charges",""
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","both","","","2704.00","2028.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7935.39","","APC Price ($7,935.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7291.52","7291.52","7291.52","1 through 10","838.24","9919.24","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","both","","","2704.00","2028.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","7935.39","","APC Price ($7,935.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7270.88","7270.88","7270.88","1 through 10","838.24","9919.24","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","both","","","2704.00","2028.00","MEDICARE [2001]","HB BWH MEDICARE","7935.39","","APC Price ($7,935.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7410.08","7410.08","7410.08","1 through 10","838.24","9919.24","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","both","","","2704.00","2028.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","986.96","36.5","","11579.06","11579.06","11579.06","1 through 10","838.24","9919.24","percent of total billed charges",""
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","both","","","2704.00","2028.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7776.68","","APC Price ($7,935.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7264.88","7264.88","7264.88","1 through 10","838.24","9919.24","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","both","","","2704.00","2028.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7776.68","","APC Price ($7,935.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3707.45","3707.45","3707.45","1 through 10","838.24","9919.24","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","outpatient","","","2704.00","2028.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3934.87","","Case rate ($3,934.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","7905.15","7905.15","7905.15","1 through 10","1511.54","10159.42","other","ASC"
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","outpatient","","","2704.00","2028.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3934.87","","Case rate ($3,934.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","9211.53","9121.03","9211.53","1 through 10","1511.54","10159.42","other","ASC "
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","outpatient","","","2704.00","2028.00","CIGNA ALTERNATE [1018]","HB AMC TUFTS CIGNA CARELINK HYBRID","9843.60","","Case rate ($9,843.60). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 121%, 60.5 procedures at 0%.","11507.97","11507.97","11507.97","1 through 10","1511.54","10159.42","other","Surgical CPT"
"Rpr Aa Hernia Recr < 3 Cm Reducible","PX-98302395","CDM","49613","CPT","0983","RC","","","","outpatient","","","1820.00","1365.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1102.01","60.55","","8050.74","8050.74","8050.74","1 through 10","728","1487.3","percent of total billed charges",""
"Rpr Aa Hernia Recr < 3 Cm Reducible","PX-98302395","CDM","49613","CPT","0983","RC","","","","outpatient","","","1820.00","1365.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","950.40","52.22","","9121.03","9121.03","9121.03","1 through 10","728","1487.3","percent of total billed charges",""
"Rpr Aa Hernia Recr > 10 Cm Ncrc8/Strangulated","PX-98302400","CDM","49618","CPT","0983","RC","","","","outpatient","","","5345.00","4008.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4367.93","81.72","","31096.26","31096.26","31096.26","1 through 10","2138","4367.93","percent of total billed charges",""
"Rpr Aa Hernia Recr > 10 Cm Reducible","PX-98302399","CDM","49617","CPT","0983","RC","","","","outpatient","","","3823.00","2867.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1996.37","52.22","","13480.19","13480.19","13480.19","1 through 10","1529.2","3124.16","percent of total billed charges",""
"Rpr Cath Cv W/Port/Pump","PX-76001096","CDM","36576","CPT","0361","RC","","","","outpatient","","","3140.00","2355.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2566.01","81.72","","1338.89","1338.89","1338.89","1 through 10","1093.63","2566.01","percent of total billed charges",""
"Rpr Fist Trachoesophageal W/Prosth","PX-76000779","CDM","31611","CPT","0761","RC","","","","outpatient","","","6345.00","4758.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2551.58","","Case rate ($2,551.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","5973.25","5973.25","5973.25","1 through 10","2008.14","8899.59","other","ASC "
"Rpr Fist Trachoesophageal W/Prosth","PX-76000779","CDM","31611","CPT","0761","RC","","","","outpatient","","","6345.00","4758.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2008.14","","Case rate ($2,008.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4478.15","4478.15","4478.15","1 through 10","2008.14","8899.59","other","Multiple Surgery"
"Rpr Lac Cplx Eye/Ear/Lip 1.1-2.5cm","PX-76000150","CDM","13151","CPT","0761","RC","","","","both","","","2179.00","1634.25","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","363.47","726.94","1 through 10","675.49","1732.31","other","OPPS APC"
"Rpr Lac Cplx Eye/Ear/Lip 1.1-2.5cm","PX-76000150","CDM","13151","CPT","0761","RC","","","","both","","","2179.00","1634.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","795.34","36.5","","788.15","788.15","788.15","1 through 10","675.49","1732.31","percent of total billed charges",""
"Rpr Lac Cplx Eye/Ear/Lip 1.1-2.5cm","PX-76000150","CDM","13151","CPT","0761","RC","","","","both","","","2179.00","1634.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","834.56","38.3","","2478.54","802.94","2478.54","1 through 10","675.49","1732.31","percent of total billed charges",""
"Rpr Lac Cplx Eye/Ear/Lip 1.1-2.5cm","PX-76000150","CDM","13151","CPT","0761","RC","","","","outpatient","","","2179.00","1634.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1109.39","1109.39","1109.39","1 through 10","482.89","1780.68","other","ASC"
"Rpr Lac Cplx Eye/Ear/Lip 1.1-2.5cm","PX-76000150","CDM","13151","CPT","0761","RC","","","","outpatient","","","2179.00","1634.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1280.02","1279.47","1280.02","1 through 10","482.89","1780.68","other","ASC "
"Rpr Lac Cplx Eye/Ear/Lip 1.1-2.5cm","PX-76000150","CDM","13151","CPT","0761","RC","","","","outpatient","","","2179.00","1634.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1076.84","1076.84","1076.84","1 through 10","482.89","1780.68","other","Multiple Surgery"
"Rpr Lac Cplx Eye/Ear/Lip 1.1-2.5cm","PX-76000150","CDM","13151","CPT","0761","RC","","","","outpatient","","","2179.00","1634.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1236.20","1236.20","1236.20","1 through 10","482.89","1780.68","other","Multiple Surgery"
"Rpr Lac Cplx Eye/Ear/Lip 2.6-7.5cm","PX-76000151","CDM","13152","CPT","0761","RC","","","","both","","","2014.00","1510.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","771.36","38.3","","763.62","763.62","763.62","1 through 10","348.19","1601.13","percent of total billed charges",""
"Rpr Lac Cplx Eye/Ear/Lip 2.6-7.5cm","PX-76000151","CDM","13152","CPT","0761","RC","","","","outpatient","","","2014.00","1510.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","640.01","640.01","640.01","1 through 10","482.89","1645.84","other","ASC "
"Rpr Lac Cplx Eye/Ear/Lip 2.6-7.5cm|MULTIPLE PROCEDURES","PX-76000151","CDM","13152","CPT","0761","RC","","","51","both","","","2014.00","1510.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","715.31","715.31","715.31","1 through 10","712.33","908.58","other","OPPS APC"
"Rpr Lac Cplx Eye/Ear/Lip 2.6-7.5cm|MULTIPLE PROCEDURES","PX-76000151","CDM","13152","CPT","0761","RC","","","51","both","","","2014.00","1510.50","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","685.47","726.94","20","712.33","908.58","other","OPPS APC"
"Rpr Lac Cplx Forehd/Hnd/Ft Add 5cm","PX-76000148","CDM","13133","CPT","0761","RC","","","","both","","","905.00","678.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","482.37","53.3","","19039.11","19039.11","19039.11","1 through 10","280.55","719.48","percent of total billed charges",""
"Rpr Lac Cplx Forehd/Hnd/Ft Add 5cm","PX-76000148","CDM","13133","CPT","0761","RC","","","","outpatient","","","905.00","678.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","739.57","81.72","","1529.52","1529.52","1529.52","1 through 10","222.44","739.57","percent of total billed charges",""
"Rpr Lac Cplx Scalp/Arm/Leg 1.1-2.5","PX-76000143","CDM","13120","CPT","0761","RC","","","","outpatient","","","1680.00","1260.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","640.01","640.01","640.01","1 through 10","482.89","1372.9","other","ASC "
"Rpr Lac Cplx Scalp/Arm/Leg 2-7.5cm","PX-76000144","CDM","13121","CPT","0761","RC","","","","both","","","2320.00","1740.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1236.56","53.3","","4546.08","4546.08","4546.08","1 through 10","690.59","1844.4","percent of total billed charges",""
"Rpr Lac Cplx Scalp/Arm/Leg 2-7.5cm","PX-76000144","CDM","13121","CPT","0761","RC","","","","both","","","2320.00","1740.00","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.47","363.47","726.94","1 through 10","690.59","1844.4","other","OPPS APC"
"Rpr Lac Cplx Scalp/Arm/Leg 2-7.5cm","PX-76000144","CDM","13121","CPT","0761","RC","","","","both","","","2320.00","1740.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","712.33","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","715.31","715.31","715.31","1 through 10","690.59","1844.4","other","OPPS APC"
"Rpr Lac Cplx Scalp/Arm/Leg 2-7.5cm","PX-76000144","CDM","13121","CPT","0761","RC","","","","outpatient","","","2320.00","1740.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","554.70","554.70","554.70","1 through 10","482.89","1895.9","other","ASC"
"Rpr Lac Cplx Scalp/Arm/Leg 2-7.5cm","PX-76000144","CDM","13121","CPT","0761","RC","","","","outpatient","","","2320.00","1740.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","640.01","640.01","646.36","1 through 10","482.89","1895.9","other","ASC "
"Rpr Lac Cplx Scalp/Arm/Leg 2-7.5cm","PX-76000144","CDM","13121","CPT","0761","RC","","","","outpatient","","","2320.00","1740.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1236.20","1236.20","1236.20","1 through 10","482.89","1895.9","other","Multiple Surgery"
"Rpr Lac Cplx Trunk 2.6-7.5cm","PX-76000141","CDM","13101","CPT","0761","RC","","","","both","","","2002.00","1501.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","337.25","337.25","337.25","1 through 10","620.62","1591.59","other","OPPS APC"
"Rpr Lac Cplx Trunk 2.6-7.5cm","PX-76000141","CDM","13101","CPT","0761","RC","","","","both","","","2002.00","1501.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","712.33","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","712.40","712.40","712.40","1 through 10","620.62","1591.59","other","OPPS APC"
"Rpr Lac Cplx Trunk 2.6-7.5cm","PX-76000141","CDM","13101","CPT","0761","RC","","","","outpatient","","","2002.00","1501.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","640.01","640.01","1280.02","1 through 10","482.89","1636.03","other","ASC "
"Rpr Lac Cplx Trunk 2.6-7.5cm","PX-76000141","CDM","13101","CPT","0761","RC","","","","outpatient","","","2002.00","1501.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1609.61","80.4","","1678.95","1678.95","1678.95","1 through 10","482.89","1636.03","percent of total billed charges",""
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","both","","","1276.00","957.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","244.11","244.11","244.11","1 through 10","395.56","1014.42","other","OPPS APC"
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","both","","","1276.00","957.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.43","233.43","237.24","1 through 10","395.56","1014.42","other","OPPS APC"
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","both","","","1276.00","957.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1014.42","79.5","","1129.35","378.84","1129.35","1 through 10","395.56","1014.42","percent of total billed charges",""
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","both","","","1276.00","957.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","680.11","53.3","","2692.81","2692.81","2692.81","1 through 10","395.56","1014.42","percent of total billed charges",""
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","both","","","1276.00","957.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","237.23","35","395.56","1014.42","other","OPPS APC"
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","both","","","1276.00","957.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.50","232.50","232.50","1 through 10","395.56","1014.42","other","OPPS APC"
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","both","","","1276.00","957.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","237.24","232.50","237.24","1 through 10","395.56","1014.42","other","OPPS APC"
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","both","","","1276.00","957.00","WELLPOINT [1015]","HB AMC WELLPOINT","941.43","73.78","","1251.68","1251.68","2157.95","1 through 10","395.56","1014.42","percent of total billed charges",""
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","AETNA [1001]","HB AMC AETNA HMO","890.65","69.8","","559.65","485.75","559.65","1 through 10","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","367.43","360.79","734.86","1 through 10","314.08","1234.13","other","ASC"
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","416.28","416.28","832.56","23","314.08","1234.13","other","ASC "
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1093.02","364.34","1093.02","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","631.64","631.64","631.64","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Face/Ear/Lip <2.5cm","PX-76000133","CDM","12051","CPT","0761","RC","","","","outpatient","","","1276.00","957.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1042.75","81.72","","1147.14","988.86","1147.14","1 through 10","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Face/Ear/Lip12.6-20","PX-76000137","CDM","12055","CPT","0761","RC","","","","both","","","1942.00","1456.50","WELLPOINT [1015]","HB AMC WELLPOINT","1432.81","73.78","","5020.16","5020.16","5020.16","1 through 10","450.74","1543.89","percent of total billed charges",""
"Rpr Lac Intermd Face/Ear/Lip2.6-5.0","PX-76000134","CDM","12052","CPT","0761","RC","","","","both","","","1082.00","811.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","860.19","79.5","","757.68","757.68","757.68","1 through 10","335.42","860.19","percent of total billed charges",""
"Rpr Lac Intermd Face/Ear/Lip2.6-5.0","PX-76000134","CDM","12052","CPT","0761","RC","","","","both","","","1082.00","811.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","576.71","53.3","","2003.30","2003.30","2003.30","1 through 10","335.42","860.19","percent of total billed charges",""
"Rpr Lac Intermd Face/Ear/Lip2.6-5.0","PX-76000134","CDM","12052","CPT","0761","RC","","","","both","","","1082.00","811.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.44","233.44","233.44","1 through 10","335.42","860.19","other","OPPS APC"
"Rpr Lac Intermd Face/Ear/Lip2.6-5.0","PX-76000134","CDM","12052","CPT","0761","RC","","","","both","","","1082.00","811.50","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","237.23","15","335.42","860.19","other","OPPS APC"
"Rpr Lac Intermd Face/Ear/Lip2.6-5.0","PX-76000134","CDM","12052","CPT","0761","RC","","","","both","","","1082.00","811.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.49","232.49","232.49","1 through 10","335.42","860.19","other","OPPS APC"
"Rpr Lac Intermd Face/Ear/Lip2.6-5.0","PX-76000134","CDM","12052","CPT","0761","RC","","","","both","","","1082.00","811.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","237.24","237.24","237.24","1 through 10","335.42","860.19","other","OPPS APC"
"Rpr Lac Intermd Face/Ear/Lip2.6-5.0","PX-76000134","CDM","12052","CPT","0761","RC","","","","both","","","1082.00","811.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.97","217.60","237.24","13","335.42","860.19","other","OPPS APC"
"Rpr Lac Intermd Face/Ear/Lip2.6-5.0","PX-76000134","CDM","12052","CPT","0761","RC","","","","outpatient","","","1082.00","811.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","360.79","324.56","721.57","1 through 10","314.08","1234.13","other","ASC"
"Rpr Lac Intermd Face/Ear/Lip2.6-5.0","PX-76000134","CDM","12052","CPT","0761","RC","","","","outpatient","","","1082.00","811.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","416.28","416.28","416.28","1 through 10","314.08","1234.13","other","ASC "
"Rpr Lac Intermd Face/Ear/Lip2.6-5.0","PX-76000134","CDM","12052","CPT","0761","RC","","","","outpatient","","","1082.00","811.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1050.60","364.34","1093.02","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Face/Ear/Lip2.6-5.0","PX-76000134","CDM","12052","CPT","0761","RC","","","","outpatient","","","1082.00","811.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","884.21","81.72","","838.57","838.57","838.57","1 through 10","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Face/Ear/Lip5.1-7.5","PX-76000135","CDM","12053","CPT","0761","RC","","","","both","","","1488.00","1116.00","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","237.23","1 through 10","450.74","1182.96","other","OPPS APC"
"Rpr Lac Intermd Face/Ear/Lip5.1-7.5","PX-76000135","CDM","12053","CPT","0761","RC","","","","both","","","1488.00","1116.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","461.28","31","","445.89","445.89","445.89","1 through 10","450.74","1182.96","percent of total billed charges",""
"Rpr Lac Intermd Face/Ear/Lip5.1-7.5","PX-76000135","CDM","12053","CPT","0761","RC","","","","both","","","1488.00","1116.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","237.24","232.50","237.24","1 through 10","450.74","1182.96","other","OPPS APC"
"Rpr Lac Intermd Face/Ear/Lip5.1-7.5","PX-76000135","CDM","12053","CPT","0761","RC","","","","both","","","1488.00","1116.00","WELLPOINT [1015]","HB AMC WELLPOINT","1097.85","73.78","","6055.02","6055.02","6055.02","1 through 10","450.74","1182.96","percent of total billed charges",""
"Rpr Lac Intermd Face/Ear/Lip5.1-7.5","PX-76000135","CDM","12053","CPT","0761","RC","","","","outpatient","","","1488.00","1116.00","AETNA [1001]","HB AMC AETNA HMO","1038.62","69.8","","1125.54","559.65","1125.54","1 through 10","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Face/Ear/Lip5.1-7.5","PX-76000135","CDM","12053","CPT","0761","RC","","","","outpatient","","","1488.00","1116.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","364.34","364.34","364.34","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Face/Ear/Lip5.1-7.5","PX-76000135","CDM","12053","CPT","0761","RC","","","","outpatient","","","1488.00","1116.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","402.02","402.02","402.02","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Hnd/Ft/Gen <2.5cm","PX-76000127","CDM","12041","CPT","0761","RC","","","","both","","","1205.00","903.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","957.98","79.5","","920.00","920.00","920.00","1 through 10","373.55","957.98","percent of total billed charges",""
"Rpr Lac Intermd Hnd/Ft/Gen <2.5cm","PX-76000127","CDM","12041","CPT","0761","RC","","","","both","","","1205.00","903.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1435.00","1435.00","1435.00","1 through 10","373.55","957.98","other","OPPS APC"
"Rpr Lac Intermd Hnd/Ft/Gen <2.5cm","PX-76000127","CDM","12041","CPT","0761","RC","","","","outpatient","","","1205.00","903.75","AETNA [1001]","HB AMC AETNA HMO","841.09","69.8","","791.41","791.41","911.82","1 through 10","314.08","984.73","percent of total billed charges",""
"Rpr Lac Intermd Hnd/Ft/Gen <2.5cm","PX-76000127","CDM","12041","CPT","0761","RC","","","","outpatient","","","1205.00","903.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","360.79","360.79","721.57","1 through 10","314.08","984.73","other","ASC"
"Rpr Lac Intermd Hnd/Ft/Gen <2.5cm","PX-76000127","CDM","12041","CPT","0761","RC","","","","outpatient","","","1205.00","903.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","416.28","416.28","420.41","1 through 10","314.08","984.73","other","ASC "
"Rpr Lac Intermd Hnd/Ft/Gen <2.5cm","PX-76000127","CDM","12041","CPT","0761","RC","","","","outpatient","","","1205.00","903.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","386.32","386.32","386.32","1 through 10","314.08","984.73","other","Multiple Surgery"
"Rpr Lac Intermd Hnd/Ft/Gen <2.5cm","PX-76000127","CDM","12041","CPT","0761","RC","","","","outpatient","","","1205.00","903.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","984.73","81.72","","573.57","573.57","573.57","1 through 10","314.08","984.73","percent of total billed charges",""
"Rpr Lac Intermd Hnd/Ft/Gen 12.6-20.","PX-76000130","CDM","12045","CPT","0761","RC","","","","outpatient","","","1658.00","1243.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1109.39","1109.39","1109.39","1 through 10","482.89","1354.92","other","ASC"
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","both","","","1411.00","1058.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.43","233.43","233.43","1 through 10","437.41","1121.75","other","OPPS APC"
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","both","","","1411.00","1058.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","917.15","65","","5286.45","5286.45","5286.45","1 through 10","437.41","1121.75","percent of total billed charges",""
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","both","","","1411.00","1058.25","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","237.23","711.69","13","437.41","1121.75","other","OPPS APC"
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","both","","","1411.00","1058.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","237.24","214.75","237.24","1 through 10","437.41","1121.75","other","OPPS APC"
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","both","","","1411.00","1058.25","WELLPOINT [1015]","HB AMC WELLPOINT","1041.04","73.78","","1018.48","1018.48","1018.48","1 through 10","437.41","1121.75","percent of total billed charges",""
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","outpatient","","","1411.00","1058.25","AETNA [1001]","HB AMC AETNA HMO","984.88","69.8","","926.14","653.90","926.14","1 through 10","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","outpatient","","","1411.00","1058.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","360.79","360.79","367.43","1 through 10","314.08","1234.13","other","ASC"
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","outpatient","","","1411.00","1058.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","416.28","416.28","420.41","1 through 10","314.08","1234.13","other","ASC "
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","outpatient","","","1411.00","1058.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1050.60","364.34","1093.02","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","outpatient","","","1411.00","1058.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","369.05","350.20","369.05","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","outpatient","","","1411.00","1058.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","402.02","402.02","402.02","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","outpatient","","","1411.00","1058.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1153.07","81.72","","1093.58","1093.58","1093.58","1 through 10","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Hnd/Ft/Gen 7.6-12.5","PX-76000129","CDM","12044","CPT","0761","RC","","","","both","","","1477.00","1107.75","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","726.94","726.94","1 through 10","457.87","1174.22","other","OPPS APC"
"Rpr Lac Intermd Hnd/Ft/Gen 7.6-12.5","PX-76000129","CDM","12044","CPT","0761","RC","","","","outpatient","","","1477.00","1107.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","646.36","646.36","646.36","1 through 10","482.89","1234.13","other","ASC "
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1149.00","861.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","244.11","244.11","244.11","1 through 10","356.19","913.46","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1149.00","861.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.43","214.12","233.43","1 through 10","356.19","913.46","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1149.00","861.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","913.46","79.5","","3723.30","876.72","3723.30","15","356.19","913.46","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1149.00","861.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","612.42","53.3","","2497.96","588.19","2497.96","1 through 10","356.19","913.46","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1149.00","861.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.44","233.44","233.44","1 through 10","356.19","913.46","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1149.00","861.75","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","711.69","28","356.19","913.46","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1149.00","861.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.49","213.25","232.49","1 through 10","356.19","913.46","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1149.00","861.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.50","232.50","232.50","1 through 10","356.19","913.46","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1149.00","861.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","492.92","42.9","","573.57","402.02","573.57","1 through 10","356.19","913.46","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1149.00","861.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.50","232.50","237.24","1 through 10","356.19","913.46","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1149.00","861.75","WELLPOINT [1015]","HB AMC WELLPOINT","847.73","73.78","","1943.37","829.37","1943.37","1 through 10","356.19","913.46","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","outpatient","","","1149.00","861.75","AETNA [1001]","HB AMC AETNA HMO","802.00","69.8","","754.18","342.97","868.92","1 through 10","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","outpatient","","","1149.00","861.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","367.43","360.79","367.43","12","314.08","1234.13","other","ASC"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","outpatient","","","1149.00","861.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","416.28","416.28","420.41","43","314.08","1234.13","other","ASC "
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","outpatient","","","1149.00","861.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","804.04","315.65","804.04","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","outpatient","","","1149.00","861.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1093.02","728.68","1821.70","37","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","outpatient","","","1149.00","861.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1149.54","383.18","1149.54","14","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","outpatient","","","1149.00","861.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","296.33","296.33","296.33","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","outpatient","","","1149.00","861.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","402.02","386.32","774.17","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","outpatient","","","1149.00","861.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","938.96","81.72","","890.53","573.57","1147.14","1 through 10","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 12.6-20.","PX-76000124","CDM","12035","CPT","0761","RC","","","","both","","","1622.00","1216.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.43","233.43","233.43","1 through 10","450.74","1289.49","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 12.6-20.","PX-76000124","CDM","12035","CPT","0761","RC","","","","both","","","1622.00","1216.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","864.53","53.3","","1515.36","1515.36","1515.36","1 through 10","450.74","1289.49","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 12.6-20.","PX-76000124","CDM","12035","CPT","0761","RC","","","","both","","","1622.00","1216.50","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","237.23","1 through 10","450.74","1289.49","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 12.6-20.","PX-76000124","CDM","12035","CPT","0761","RC","","","","outpatient","","","1622.00","1216.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","367.43","367.43","367.43","1 through 10","314.08","1325.5","other","ASC"
"Rpr Lac Intermd Scalp/Axil 12.6-20.","PX-76000124","CDM","12035","CPT","0761","RC","","","","outpatient","","","1622.00","1216.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","420.41","420.41","420.41","1 through 10","314.08","1325.5","other","ASC "
"Rpr Lac Intermd Scalp/Axil 12.6-20.","PX-76000124","CDM","12035","CPT","0761","RC","","","","outpatient","","","1622.00","1216.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1093.02","1093.02","1093.02","1 through 10","314.08","1325.5","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","both","","","1389.00","1041.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","488.65","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","244.11","244.11","245.10","1 through 10","430.59","1104.26","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","both","","","1389.00","1041.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.43","214.12","237.24","21","430.59","1104.26","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","both","","","1389.00","1041.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1104.26","79.5","","4273.41","1060.09","4517.40","25","430.59","1104.26","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","both","","","1389.00","1041.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","740.34","53.3","","3213.32","2867.05","4273.41","12","430.59","1104.26","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","both","","","1389.00","1041.75","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","237.23","174","430.59","1104.26","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","both","","","1389.00","1041.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","213.25","213.25","213.25","1 through 10","430.59","1104.26","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","both","","","1389.00","1041.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","430.50","233.50","430.50","1 through 10","430.59","1104.26","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","both","","","1389.00","1041.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.50","213.69","237.24","32","430.59","1104.26","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","both","","","1389.00","1041.75","WELLPOINT [1015]","HB AMC WELLPOINT","1024.80","73.78","","2349.84","1002.84","2349.84","12","430.59","1104.26","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","1389.00","1041.75","AETNA [1001]","HB AMC AETNA HMO","969.52","69.8","","911.92","643.87","1457.24","13","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","1389.00","1041.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","360.79","360.79","367.43","28","314.08","1234.13","other","ASC"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","1389.00","1041.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","420.41","416.28","420.41","88","314.08","1234.13","other","ASC "
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","1389.00","1041.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","455.42","455.42","455.42","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","1389.00","1041.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1093.02","364.34","1093.02","58","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","1389.00","1041.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1149.54","383.18","1149.54","24","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","1389.00","1041.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","455.42","455.42","455.42","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","1389.00","1041.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","383.18","383.18","383.18","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","1389.00","1041.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","804.04","402.02","1732.93","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","1389.00","1041.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1116.76","80.4","","673.50","673.50","673.50","1 through 10","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","1389.00","1041.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","595.88","42.9","","1147.14","592.28","1147.14","1 through 10","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","1389.00","1041.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1135.09","81.72","","1076.79","592.28","1076.79","13","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","1389.00","1041.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","438.14","438.14","438.14","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil 20.1-30.","PX-76000125","CDM","12036","CPT","0761","RC","","","","both","","","1889.00","1416.75","MEDICARE [2001]","HB BWH MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.47","363.47","363.47","1 through 10","585.59","1501.76","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 20.1-30.","PX-76000125","CDM","12036","CPT","0761","RC","","","","both","","","1889.00","1416.75","WELLPOINT [1015]","HB AMC WELLPOINT","1393.70","73.78","","1424.47","1424.47","1424.47","1 through 10","585.59","1501.76","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 7.6-12.5","PX-76000123","CDM","12034","CPT","0761","RC","","","","both","","","1430.00","1072.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.43","233.43","233.43","1 through 10","443.3","1136.85","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 7.6-12.5","PX-76000123","CDM","12034","CPT","0761","RC","","","","both","","","1430.00","1072.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1136.85","79.5","","5659.32","5659.32","5659.32","1 through 10","443.3","1136.85","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 7.6-12.5","PX-76000123","CDM","12034","CPT","0761","RC","","","","both","","","1430.00","1072.50","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","237.23","237.23","711.69","28","443.3","1136.85","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 7.6-12.5","PX-76000123","CDM","12034","CPT","0761","RC","","","","both","","","1430.00","1072.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.49","232.49","232.49","1 through 10","443.3","1136.85","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 7.6-12.5","PX-76000123","CDM","12034","CPT","0761","RC","","","","both","","","1430.00","1072.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.50","213.25","237.24","1 through 10","443.3","1136.85","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 7.6-12.5","PX-76000123","CDM","12034","CPT","0761","RC","","","","outpatient","","","1430.00","1072.50","AETNA [1001]","HB AMC AETNA HMO","998.14","69.8","","882.29","882.29","882.29","1 through 10","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 7.6-12.5","PX-76000123","CDM","12034","CPT","0761","RC","","","","outpatient","","","1430.00","1072.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","360.79","360.79","367.43","1 through 10","314.08","1234.13","other","ASC"
"Rpr Lac Intermd Scalp/Axil 7.6-12.5","PX-76000123","CDM","12034","CPT","0761","RC","","","","outpatient","","","1430.00","1072.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","420.41","416.28","420.41","1 through 10","314.08","1234.13","other","ASC "
"Rpr Lac Intermd Scalp/Axil 7.6-12.5","PX-76000123","CDM","12034","CPT","0761","RC","","","","outpatient","","","1430.00","1072.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1168.60","81.72","","1108.77","609.86","1108.77","1 through 10","314.08","1234.13","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 7.6-12.5","PX-76000123","CDM","12034","CPT","0761","RC","","","","outpatient","","","1430.00","1072.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","386.32","386.32","386.32","1 through 10","314.08","1234.13","other","Multiple Surgery"
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","both","","","722.00","541.50","AETNA [1001]","HB AMC AETNA HMO","503.96","69.8","","334.60","334.60","473.90","1 through 10","203.44","580.49","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","both","","","722.00","541.50","AETNA [1001]","HB AMC AETNA PPO","580.49","80.4","","546.00","546.00","546.00","1 through 10","203.44","580.49","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","both","","","722.00","541.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","384.83","53.3","","1862.47","1862.47","1862.47","1 through 10","203.44","580.49","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","both","","","722.00","541.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","223.82","31","","216.30","216.30","216.30","1 through 10","203.44","580.49","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","both","","","722.00","541.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","276.53","38.3","","266.00","266.00","266.00","1 through 10","203.44","580.49","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","outpatient","","","722.00","541.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","233.87","233.87","233.87","1 through 10","176.45","2384.07","other","ASC "
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","both","","","697.00","522.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","554.12","79.5","","532.01","356.93","532.01","1 through 10","216.07","554.12","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","both","","","697.00","522.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","254.41","36.5","","244.71","244.71","244.71","1 through 10","216.07","554.12","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","both","","","697.00","522.75","WELLPOINT [1015]","HB AMC WELLPOINT","514.25","73.78","","503.28","503.28","503.28","1 through 10","216.07","554.12","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","outpatient","","","697.00","522.75","AETNA [1001]","HB AMC AETNA HMO","486.51","69.8","","457.65","311.42","527.28","1 through 10","176.45","700.33","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","outpatient","","","697.00","522.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","467.73","1 through 10","176.45","700.33","other","ASC "
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","outpatient","","","697.00","522.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","409.36","393.48","409.36","1 through 10","176.45","700.33","other","Multiple Surgery"
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","both","","","760.00","570.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","604.20","79.5","","580.02","580.02","580.02","1 through 10","203.44","604.2","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","both","","","760.00","570.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","405.08","53.3","","1960.93","1960.93","1960.93","1 through 10","203.44","604.2","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","both","","","760.00","570.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","235.60","31","","227.73","227.73","227.73","1 through 10","203.44","604.2","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","both","","","760.00","570.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","277.40","36.5","","266.79","266.79","266.79","1 through 10","203.44","604.2","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","both","","","760.00","570.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","291.08","38.3","","288.17","288.17","288.17","1 through 10","203.44","604.2","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","outpatient","","","760.00","570.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","472.37","467.73","472.37","1 through 10","176.45","700.33","other","ASC "
"Rpr Lac Smp Sclp/Hnd/Gen 7.6-12.5cm","PX-76000108","CDM","12004","CPT","0761","RC","","","","both","","","908.00","681.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","721.86","79.5","","692.40","692.40","692.40","1 through 10","203.44","721.86","percent of total billed charges",""
"Rpsg Prev Implted Pm/Dfb R Atr/R Ventr Electrode","PX-48000051","CDM","33215","CPT","0361","RC","","","","both","","","8774.00","6580.50","MEDICARE [2001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","3737.85","1 through 10","2719.94","6975.33","other","OPPS APC"
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","both","","","548.83","411.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","394.06","71.8","","1182.18","1182.18","1182.18","1 through 10","170.14","521.39","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","both","","","548.83","411.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","384.18","70","","236.00","236.00","236.00","1 through 10","170.14","521.39","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","both","","","548.83","411.62","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","422.60","77","","422.60","422.60","422.60","1 through 10","170.14","521.39","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","both","","","548.83","411.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","170.14","31","","169.59","169.59","169.59","1 through 10","170.14","521.39","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","both","","","548.83","411.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","200.32","36.5","","198.68","173.98","204.71","16","170.14","521.39","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","both","","","548.83","411.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","210.20","38.3","","214.59","208.56","625.68","54","170.14","521.39","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","both","","","548.83","411.62","TRICARE [160005]","HB BWH TRICARE","521.39","95","","297.07","297.07","297.07","1 through 10","170.14","521.39","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","both","","","548.83","411.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","235.45","42.9","","761.10","761.10","761.10","1 through 10","170.14","521.39","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","both","","","548.83","411.62","WELLPOINT [1015]","HB AMC WELLPOINT","404.93","73.78","","957.43","408.60","957.43","1 through 10","170.14","521.39","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","outpatient","","","548.83","411.62","AETNA [1001]","HB AMC AETNA HMO","383.08","69.8","","371.56","262.34","428.09","25","257.4","747","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","outpatient","","","548.83","411.62","AETNA [1001]","HB AMC AETNA PPO","441.26","80.4","","428.09","428.09","428.09","1 through 10","257.4","747","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","outpatient","","","548.83","411.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","286.82","52.26","","339.62","339.62","339.62","1 through 10","257.4","747","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","outpatient","","","548.83","411.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","383.63","69.9","","380.34","254.66","380.34","18","257.4","747","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","outpatient","","","548.83","411.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","257.40","46.9","","277.16","254.66","380.34","1 through 10","257.4","747","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","outpatient","","","548.83","411.62","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","274.42","50","","287.59","287.59","541.69","52","257.4","747","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","outpatient","","","548.83","411.62","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","288.14","52.5","","301.86","290.33","569.14","33","257.4","747","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","outpatient","","","548.83","411.62","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","343.02","62.5","","359.48","345.21","359.48","1 through 10","257.4","747","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","outpatient","","","548.83","411.62","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","288.14","52.5","","290.33","290.33","301.86","1 through 10","257.4","747","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","outpatient","","","548.83","411.62","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","301.86","55","","281.73","232.66","316.13","1 through 10","257.4","747","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","outpatient","","","548.83","411.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","448.50","81.72","","761.10","548.83","761.10","1 through 10","257.4","747","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","outpatient","","","548.83","411.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","448.50","81.72","","761.10","548.83","761.10","21","257.4","747","percent of total billed charges",""
"Rsv Vaccine Pref Subunit Bivalent for Im Use","PX-63601422","CDM","90678","CPT","0636","RC","","","","outpatient","","","548.83","411.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","301.86","55","","304.05","304.05","304.05","1 through 10","257.4","747","percent of total billed charges",""
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","32117.00","24087.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3758.57","2332.23","8097.88","1 through 10","3628.7","25533.02","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","32117.00","24087.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","21068.75","65.6","","25704.75","25704.75","25704.75","1 through 10","3628.7","25533.02","percent of total billed charges",""
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","32117.00","24087.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","22481.90","70","","30595.45","30595.45","30595.45","1 through 10","3628.7","25533.02","percent of total billed charges",""
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","32117.00","24087.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","4774.12","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","3725.23","280.00","3725.23","1 through 10","3628.7","25533.02","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","32117.00","24087.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6944.90","6944.90","6944.90","1 through 10","3628.7","25533.02","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","32117.00","24087.75","MEDICARE [2001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3819.68","3819.68","10669.41","33","3628.7","25533.02","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","32117.00","24087.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12300.81","38.3","","12177.70","12177.70","12177.70","1 through 10","3628.7","25533.02","percent of total billed charges",""
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","32117.00","24087.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8040.90","3743.69","8040.90","1 through 10","3628.7","25533.02","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","32117.00","24087.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","17651.82","11229.87","17651.82","1 through 10","3628.7","25533.02","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","32117.00","24087.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3743.29","3493.25","6635.49","1 through 10","3628.7","25533.02","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","outpatient","","","32117.00","24087.75","AETNA [1001]","HB AMC AETNA HMO","22417.67","69.8","","21085.17","21085.17","21085.17","1 through 10","2529.37","26246.01","percent of total billed charges",""
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","outpatient","","","32117.00","24087.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","5868.14","5640.50","11736.28","1 through 10","2529.37","26246.01","other","Multiple Surgery"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","31970.00","23977.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3758.57","3710.18","7407.99","1 through 10","3628.7","25416.15","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","31970.00","23977.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","4774.12","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","395.00","395.00","395.00","1 through 10","3628.7","25416.15","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","31970.00","23977.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","25416.15","79.5","","24399.36","24399.36","24399.36","1 through 10","3628.7","25416.15","percent of total billed charges",""
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","31970.00","23977.50","MEDICARE [2001]","HB BWH MEDICARE","3819.29","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3819.68","3819.68","3819.68","16","3628.7","25416.15","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","31970.00","23977.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12244.51","38.3","","12122.17","12122.17","12122.17","1 through 10","3628.7","25416.15","percent of total billed charges",""
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","31970.00","23977.50","MOLINA [1014]","HB BWH MOLINA","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7578.25","7578.25","7578.25","1 through 10","3628.7","25416.15","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","31970.00","23977.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","11231.07","3758.57","11231.07","1 through 10","3628.7","25416.15","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","31970.00","23977.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3742.91","","APC Price ($3,819.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9025.65","6204.08","9025.65","1 through 10","3628.7","25416.15","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","outpatient","","","31970.00","23977.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","5868.14","5868.14","5868.14","1 through 10","2529.37","26125.88","other","Multiple Surgery"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","outpatient","","","31970.00","23977.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 383%, 191.5 procedures at 0%.","7613.40","7613.40","7613.40","1 through 10","2529.37","26125.88","other","Multiple Surgery"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","outpatient","","","31970.00","23977.50","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2529.37","","Case rate ($2,529.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6222.25","6222.25","6222.25","1 through 10","2529.37","26125.88","other","Multiple Surgery"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","outpatient","","","31970.00","23977.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","26125.88","81.72","","24783.80","24783.80","24783.80","1 through 10","2529.37","26125.88","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","121.34","71.8","","353.25","117.75","353.25","15","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","109.85","65","","106.60","106.60","106.60","1 through 10","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","118.30","70","","164.00","118.08","164.00","1 through 10","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","134.36","79.5","","129.07","86.59","129.07","224","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","90.08","53.3","","86.59","86.59","129.07","83","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","130.13","77","","126.28","126.28","126.28","1 through 10","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","109.85","65","","106.60","106.60","106.60","1 through 10","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","134.36","79.5","","129.07","129.07","129.07","1 through 10","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","52.39","31","","50.68","50.68","50.68","1 through 10","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","61.69","36.5","","61.17","51.99","183.51","172","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64.73","38.3","","64.12","62.32","192.36","729","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","TRICARE [160005]","HB BWH TRICARE","160.55","95","","17.34","17.34","17.34","1 through 10","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.50","42.9","","131.10","72.11","295.10","12","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","169.00","126.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.50","42.9","","72.11","72.11","72.11","1 through 10","14.1","160.55","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","169.00","126.75","AETNA [1001]","HB AMC AETNA HMO","117.96","69.8","","111.03","78.39","127.92","343","14.84","138.11","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","169.00","126.75","AETNA [1001]","HB AMC AETNA PPO","135.88","80.4","","127.92","85.94","127.92","34","14.84","138.11","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","169.00","126.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","88.32","52.26","","50.53","50.53","50.53","1 through 10","14.84","138.11","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","169.00","126.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","135.88","80.4","","82.00","82.00","82.00","1 through 10","14.84","138.11","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","169.00","126.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","138.11","81.72","","72.11","72.11","131.11","1 through 10","14.84","138.11","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","169.00","126.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","138.11","81.72","","131.10","72.11","131.10","245","14.84","138.11","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","109.14","71.8","","316.65","105.55","316.65","15","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","98.80","65","","115.69","95.55","115.69","1 through 10","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","106.40","70","","147.00","19.88","147.00","1 through 10","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","120.84","79.5","","115.69","77.62","147.00","100","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.02","53.3","","77.62","77.62","148.48","36","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","117.04","77","","113.19","113.19","113.19","1 through 10","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","98.80","65","","95.55","95.55","95.55","1 through 10","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","120.84","79.5","","115.69","115.69","115.69","1 through 10","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","47.12","31","","45.42","45.42","45.42","1 through 10","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.48","36.5","","54.83","46.60","164.49","105","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.22","38.3","","57.48","55.86","172.44","312","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","TRICARE [160005]","HB BWH TRICARE","144.40","95","","15.52","15.52","15.52","1 through 10","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.21","42.9","","117.51","64.64","117.51","1 through 10","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","152.00","114.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.21","42.9","","64.64","64.64","64.64","1 through 10","12.62","144.4","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","152.00","114.00","AETNA [1001]","HB AMC AETNA HMO","106.10","69.8","","99.52","70.27","114.66","119","13.29","124.21","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","152.00","114.00","AETNA [1001]","HB AMC AETNA PPO","122.21","80.4","","114.66","77.03","154.06","20","13.29","124.21","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","152.00","114.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","79.44","52.26","","45.36","45.36","45.36","1 through 10","13.29","124.21","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","152.00","114.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","122.21","80.4","","73.50","73.50","73.50","1 through 10","13.29","124.21","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","124.21","81.72","","64.64","64.64","64.64","1 through 10","13.29","124.21","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","124.21","81.72","","117.51","64.64","117.51","82","13.29","124.21","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","both","","","101.00","75.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","70.70","70","","98.00","43.09","98.00","1 through 10","6.19","95.95","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","both","","","101.00","75.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","80.30","79.5","","77.13","51.74","231.39","32","6.19","95.95","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","both","","","101.00","75.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","53.83","53.3","","155.22","51.74","613.51","41","6.19","95.95","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","both","","","101.00","75.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","77.77","77","","75.46","75.46","75.46","1 through 10","6.19","95.95","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","both","","","101.00","75.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","65.65","65","","63.70","61.75","63.70","1 through 10","6.19","95.95","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","both","","","101.00","75.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36.87","36.5","","36.55","31.07","255.85","49","6.19","95.95","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","both","","","101.00","75.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38.68","38.3","","38.32","38.32","114.96","109","6.19","95.95","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","both","","","101.00","75.75","TRICARE [160005]","HB BWH TRICARE","95.95","95","","11.54","11.54","11.54","1 through 10","6.19","95.95","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","both","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.33","42.9","","78.34","78.34","78.34","1 through 10","6.19","95.95","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","101.00","75.75","AETNA [1001]","HB AMC AETNA HMO","70.50","69.8","","66.35","46.84","93.68","40","6.19","82.54","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","101.00","75.75","AETNA [1001]","HB AMC AETNA PPO","81.20","80.4","","102.70","51.35","102.70","1 through 10","6.19","82.54","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","101.00","75.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","81.20","80.4","","147.00","49.00","147.00","1 through 10","6.19","82.54","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","82.54","81.72","","43.09","43.09","43.09","1 through 10","6.19","82.54","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","82.54","81.72","","78.34","43.09","78.34","41","6.19","82.54","percent of total billed charges",""
"Rv5 Vaccine 3 Dose Schedule Live for Oral Use","PX-63600313","CDM","90680","CPT","0636","RC","","","","outpatient","","","174.33","130.75","AETNA [1001]","HB AMC AETNA HMO","121.68","69.8","","0.01","0.01","0.01","1 through 10","0.01","140.16","percent of total billed charges",""
"Rvot-Aorta Device Closure Procedure","PX-36000472","CDM","93799","CPT","0361","RC","","","","both","","","40158.00","30118.50","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","31925.61","other","OPPS APC"
"Rvot-Aorta Device Closure Procedure","PX-36000472","CDM","93799","CPT","0361","RC","","","","outpatient","","","40158.00","30118.50","AETNA [1001]","HB AMC AETNA HMO","28030.28","69.8","","2022.70","2022.70","2022.70","1 through 10","454","33130.35","percent of total billed charges",""
"Rvot-Aorta Device Closure Procedure","PX-36000472","CDM","93799","CPT","0361","RC","","","","outpatient","","","40158.00","30118.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24315.67","60.55","","318.03","318.03","2439.77","1 through 10","454","33130.35","percent of total billed charges",""
"Rvot-Aorta Device Closure Procedure","PX-36000472","CDM","93799","CPT","0361","RC","","","","outpatient","","","40158.00","30118.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","20970.51","52.22","","360.38","360.38","4023.00","1 through 10","454","33130.35","percent of total billed charges",""
"Rvot-Aorta Device Closure Procedure","PX-36000472","CDM","93799","CPT","0361","RC","","","","outpatient","","","40158.00","30118.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","22086.90","55","","13080.03","13080.03","13080.03","1 through 10","454","33130.35","percent of total billed charges",""
"S.Pneumoniae Ag Urine (Infec Agent)","PX-30002771","CDM","87899","CPT","0306","RC","","","","both","","","206.00","154.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","147.91","71.8","","14.17","14.17","14.17","1 through 10","11.81","195.7","percent of total billed charges",""
"S.Pneumoniae Ag Urine (Infec Agent)","PX-30002771","CDM","87899","CPT","0306","RC","","","","both","","","206.00","154.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","144.20","70","","393.00","393.00","393.00","1 through 10","11.81","195.7","percent of total billed charges",""
"S.Pneumoniae Ag Urine (Infec Agent)","PX-30002771","CDM","87899","CPT","0306","RC","","","","both","","","206.00","154.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.80","53.3","","166.91","166.91","166.91","1 through 10","11.81","195.7","percent of total billed charges",""
"S.Pneumoniae Ag Urine (Infec Agent)","PX-30002771","CDM","87899","CPT","0306","RC","","","","both","","","206.00","154.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.90","38.3","","153.66","78.20","153.66","1 through 10","11.81","195.7","percent of total billed charges",""
"S.Pneumoniae Ag Urine (Infec Agent)","PX-30002771","CDM","87899","CPT","0306","RC","","","","outpatient","","","206.00","154.50","AETNA [1001]","HB AMC AETNA HMO","143.79","69.8","","187.85","95.60","306.54","1 through 10","11.81","168.34","percent of total billed charges",""
"S.Pneumoniae Ag Urine (Infec Agent)","PX-30002771","CDM","87899","CPT","0306","RC","","","","outpatient","","","206.00","154.50","AETNA [1001]","HB AMC AETNA PPO","165.62","80.4","","306.54","306.54","306.54","1 through 10","11.81","168.34","percent of total billed charges",""
"S.Pneumoniae Ag Urine (Infec Agent)","PX-30002771","CDM","87899","CPT","0306","RC","","","","outpatient","","","206.00","154.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","168.34","81.72","","314.16","314.16","314.16","1 through 10","11.81","168.34","percent of total billed charges",""
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","153.45","438.15","other","OPPS APC"
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","both","","","495.00","371.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","153.45","438.15","other","OPPS APC"
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","both","","","495.00","371.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","263.84","53.3","","477.31","477.31","477.31","1 through 10","153.45","438.15","percent of total billed charges",""
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","both","","","495.00","371.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","153.45","438.15","other","OPPS APC"
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","both","","","495.00","371.25","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","153.45","438.15","other","OPPS APC"
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","180.68","36.5","","1095.87","337.19","1095.87","1 through 10","153.45","438.15","percent of total billed charges",""
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","189.59","38.3","","343.52","323.76","353.46","1 through 10","153.45","438.15","percent of total billed charges",""
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","both","","","495.00","371.25","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","153.45","438.15","other","Tricare OPPS"
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","both","","","495.00","371.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","153.45","438.15","other","OPPS APC"
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","153.45","438.15","other","OPPS APC"
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","both","","","495.00","371.25","WELLPOINT [1015]","HB AMC WELLPOINT","365.21","73.78","","673.03","673.03","673.03","1 through 10","153.45","438.15","percent of total billed charges",""
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","outpatient","","","495.00","371.25","AETNA [1001]","HB AMC AETNA HMO","345.51","69.8","","612.01","612.01","1224.02","1 through 10","247.5","700.33","percent of total billed charges",""
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","outpatient","","","495.00","371.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","299.72","60.55","","579.04","568.57","904.00","30","247.5","700.33","percent of total billed charges",""
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","outpatient","","","495.00","371.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","258.49","52.22","","904.00","656.02","2938.00","26","247.5","700.33","percent of total billed charges",""
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","outpatient","","","495.00","371.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","247.50","50","","1421.10","875.08","2368.50","15","247.5","700.33","percent of total billed charges",""
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","outpatient","","","495.00","371.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","259.88","52.5","","2985.00","904.00","2985.00","1 through 10","247.5","700.33","percent of total billed charges",""
"Sacroiliac Injection","PX-76010298","CDM","64999","CPT","0761","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","404.51","81.72","","722.66","722.66","17449.00","1 through 10","247.5","700.33","percent of total billed charges",""
"SADDLE 4.75X5.5MM OPEN","SUP-ITM-10247209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1349.51","79.5","","800.18","480.96","1887.97","195","526.23","1349.51","percent of total billed charges",""
"SADDLE 4.75X5.5MM OPEN","SUP-ITM-10247209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","904.77","53.3","","813.12","216.42","1444.50","81","526.23","1349.51","percent of total billed charges",""
"SADDLE 4.75X5.5MM OPEN","SUP-ITM-10247209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","526.23","31","","432.60","432.60","432.60","1 through 10","526.23","1349.51","percent of total billed charges",""
"SADDLE 4.75X5.5MM OPEN","SUP-ITM-10247209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","619.59","36.5","","148.37","54.89","631.39","94","526.23","1349.51","percent of total billed charges",""
"SADDLE 4.75X5.5MM OPEN","SUP-ITM-10247209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","650.14","38.3","","279.30","91.72","1116.77","266","526.23","1349.51","percent of total billed charges",""
"SADDLE 4.75X5.5MM OPEN","SUP-ITM-10247209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.23","42.9","","731.00","63.70","731.00","1 through 10","526.23","1349.51","percent of total billed charges",""
"SADDLE 4.75X5.5MM OPEN","SUP-ITM-10247209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.23","42.9","","384.74","384.74","384.74","1 through 10","526.23","1349.51","percent of total billed charges",""
"SADDLE 4.75X5.5MM OPEN","SUP-ITM-10247209","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","WELLPOINT [1015]","HB AMC WELLPOINT","1252.42","73.78","","286.63","119.22","1107.45","105","526.23","1349.51","percent of total billed charges",""
"SADDLE 4.75X5.5MM OPEN","SUP-ITM-10247209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","AETNA [1001]","HB AMC AETNA HMO","1184.86","69.8","","675.31","184.75","1721.50","286","887.11","1387.2","percent of total billed charges",""
"SADDLE 4.75X5.5MM OPEN","SUP-ITM-10247209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","AETNA [1001]","HB AMC AETNA PPO","1364.79","80.4","","1261.44","103.12","1514.10","21","887.11","1387.2","percent of total billed charges",""
"SADDLE 4.75X5.5MM OPEN","SUP-ITM-10247209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1364.79","80.4","","1365.00","1365.00","1365.00","1 through 10","887.11","1387.2","percent of total billed charges",""
"SADDLE 4.75X5.5MM OPEN","SUP-ITM-10247209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1387.20","81.72","","5157.68","5157.68","5157.68","1 through 10","887.11","1387.2","percent of total billed charges",""
"SADDLE 4.75X5.5MM OPEN","SUP-ITM-10247209","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1387.20","81.72","","431.26","71.26","1459.57","88","887.11","1387.2","percent of total billed charges",""
"SAGITTAL PLATE 2X12MM 6 HOLE ORTHOGNATHIC TITANIUM SPLIT CURVED","SUP-ITM-10014115","CDM","C1713","HCPCS","0278","RC","","","","both","","","729.16","546.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","579.68","79.5","","800.18","480.96","1887.97","195","226.04","579.68","percent of total billed charges",""
"SAGITTAL PLATE 2X12MM 6 HOLE ORTHOGNATHIC TITANIUM SPLIT CURVED","SUP-ITM-10014115","CDM","C1713","HCPCS","0278","RC","","","","both","","","729.16","546.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","388.64","53.3","","813.12","216.42","1444.50","81","226.04","579.68","percent of total billed charges",""
"SAGITTAL PLATE 2X12MM 6 HOLE ORTHOGNATHIC TITANIUM SPLIT CURVED","SUP-ITM-10014115","CDM","C1713","HCPCS","0278","RC","","","","both","","","729.16","546.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","226.04","31","","432.60","432.60","432.60","1 through 10","226.04","579.68","percent of total billed charges",""
"SAGITTAL PLATE 2X12MM 6 HOLE ORTHOGNATHIC TITANIUM SPLIT CURVED","SUP-ITM-10014115","CDM","C1713","HCPCS","0278","RC","","","","both","","","729.16","546.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","266.14","36.5","","148.37","54.89","631.39","94","226.04","579.68","percent of total billed charges",""
"SAGITTAL PLATE 2X12MM 6 HOLE ORTHOGNATHIC TITANIUM SPLIT CURVED","SUP-ITM-10014115","CDM","C1713","HCPCS","0278","RC","","","","both","","","729.16","546.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","279.27","38.3","","279.30","91.72","1116.77","266","226.04","579.68","percent of total billed charges",""
"SAGITTAL PLATE 2X12MM 6 HOLE ORTHOGNATHIC TITANIUM SPLIT CURVED","SUP-ITM-10014115","CDM","C1713","HCPCS","0278","RC","","","","both","","","729.16","546.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.81","42.9","","731.00","63.70","731.00","1 through 10","226.04","579.68","percent of total billed charges",""
"SAGITTAL PLATE 2X12MM 6 HOLE ORTHOGNATHIC TITANIUM SPLIT CURVED","SUP-ITM-10014115","CDM","C1713","HCPCS","0278","RC","","","","both","","","729.16","546.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.81","42.9","","384.74","384.74","384.74","1 through 10","226.04","579.68","percent of total billed charges",""
"SAGITTAL PLATE 2X12MM 6 HOLE ORTHOGNATHIC TITANIUM SPLIT CURVED","SUP-ITM-10014115","CDM","C1713","HCPCS","0278","RC","","","","both","","","729.16","546.87","WELLPOINT [1015]","HB AMC WELLPOINT","537.97","73.78","","286.63","119.22","1107.45","105","226.04","579.68","percent of total billed charges",""
"SAGITTAL PLATE 2X12MM 6 HOLE ORTHOGNATHIC TITANIUM SPLIT CURVED","SUP-ITM-10014115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","729.16","546.87","AETNA [1001]","HB AMC AETNA HMO","508.95","69.8","","675.31","184.75","1721.50","286","381.06","595.87","percent of total billed charges",""
"SAGITTAL PLATE 2X12MM 6 HOLE ORTHOGNATHIC TITANIUM SPLIT CURVED","SUP-ITM-10014115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","729.16","546.87","AETNA [1001]","HB AMC AETNA PPO","586.24","80.4","","1261.44","103.12","1514.10","21","381.06","595.87","percent of total billed charges",""
"SAGITTAL PLATE 2X12MM 6 HOLE ORTHOGNATHIC TITANIUM SPLIT CURVED","SUP-ITM-10014115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","729.16","546.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","586.24","80.4","","1365.00","1365.00","1365.00","1 through 10","381.06","595.87","percent of total billed charges",""
"SAGITTAL PLATE 2X12MM 6 HOLE ORTHOGNATHIC TITANIUM SPLIT CURVED","SUP-ITM-10014115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","729.16","546.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","595.87","81.72","","5157.68","5157.68","5157.68","1 through 10","381.06","595.87","percent of total billed charges",""
"SAGITTAL PLATE 2X12MM 6 HOLE ORTHOGNATHIC TITANIUM SPLIT CURVED","SUP-ITM-10014115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","729.16","546.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","595.87","81.72","","431.26","71.26","1459.57","88","381.06","595.87","percent of total billed charges",""
"Saline Injection Into Drainage Catheter","PX-76002956","CDM","17999","CPT","0761","RC","","","","both","","","153.00","114.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4490.63","3878.56","4490.63","1 through 10","47.43","294.93","other","OPPS APC"
"Saline Injection Into Drainage Catheter","PX-76002956","CDM","17999","CPT","0761","RC","","","","outpatient","","","153.00","114.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","79.90","52.22","","467.73","465.00","467.73","1 through 10","76.5","700.33","percent of total billed charges",""
"Salivary Gland Procedures","139","MS-DRG","","","","","","","","inpatient","","","61032.20","45774.15","MEDICARE [2001]","HB BWH MEDICARE","11652.03","","Case rate ($11,652.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,949.33, add-ons for qualifying new technology services are included. If operating cost exceeds $59,593.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,434.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,277.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,569.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $994.32. The transfer capital threshold is the transfer adjustment factor * $994.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16488.99","16488.99","16488.99","1 through 10","11418.99","19356","other","Inpatient Replacement Plans DRG"
"Salivary Gland Procedures","139","MS-DRG","","","","","","","","inpatient","","","61032.20","45774.15","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11418.99","","Case rate ($11,652.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,949.33, add-ons for qualifying new technology services are included. If operating cost exceeds $59,593.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,434.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,277.87 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,569.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $994.32. The transfer capital threshold is the transfer adjustment factor * $994.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12509.45","12509.45","12509.45","1 through 10","11418.99","19356","other","Inpatient DRG"
"Salivary Gland Procedures","139","TRIS-DRG","","","","","","","","inpatient","","","55519.73","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","10749.23","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($18,881.63). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $62,608.63 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($12,181.70), capped at $13,589.77. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $62,608.63 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","9782.82","9782.82","9782.82","1 through 10","10749.23","10749.23","other","Inpatient DRGs"
"Salmonella Antibody","PX-30000995","CDM","86768","CPT","0302","RC","","","","outpatient","","","156.00","117.00","AETNA [1001]","HB AMC AETNA HMO","108.89","69.8","","72.18","72.18","72.18","1 through 10","9.6","127.48","percent of total billed charges",""
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","both","","","1532.00","1149.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1217.94","79.5","","10016.92","2883.29","10016.92","16","474.92","1292.44","percent of total billed charges",""
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","both","","","1532.00","1149.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","816.56","53.3","","2503.29","2353.83","2503.29","11","474.92","1292.44","percent of total billed charges",""
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","both","","","1532.00","1149.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","559.18","36.5","","1662.84","554.28","1662.84","12","474.92","1292.44","percent of total billed charges",""
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","both","","","1532.00","1149.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","586.76","38.3","","1743.09","581.03","1743.09","32","474.92","1292.44","percent of total billed charges",""
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1532.00","1149.00","AETNA [1001]","HB AMC AETNA HMO","1069.34","69.8","","1006.02","710.31","1159.08","1 through 10","558.04","1251.95","percent of total billed charges",""
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1532.00","1149.00","AETNA [1001]","HB AMC AETNA PPO","1231.73","80.4","","778.66","778.66","778.66","1 through 10","558.04","1251.95","percent of total billed charges",""
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1532.00","1149.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1282.04","1282.04","1479.23","1 through 10","558.04","1251.95","other","ASC"
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1532.00","1149.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1493.91","1479.23","1493.91","31","558.04","1251.95","other","ASC "
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1532.00","1149.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3883.95","1294.65","3883.95","13","558.04","1251.95","other","Multiple Surgery"
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1532.00","1149.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4084.86","4084.86","4084.86","1 through 10","558.04","1251.95","other","Multiple Surgery"
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1532.00","1149.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1361.62","1361.62","1361.62","1 through 10","558.04","1251.95","other","Multiple Surgery"
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1532.00","1149.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","558.04","","Case rate ($558.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","2857.16","1428.58","2857.16","1 through 10","558.04","1251.95","other","Multiple Surgery"
"Sample Chorionic Villus","PX-72000005","CDM","59015","CPT","0761","RC","","","","outpatient","","","1532.00","1149.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1251.95","81.72","","1187.91","1187.91","1596.39","1 through 10","558.04","1251.95","percent of total billed charges",""
"Sandostatin (Octreotide), Serum/Plasma","PX-30003487","CDM","80299","CPT","0301","RC","","","","both","","","455.00","341.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","361.73","79.5","","106.25","71.28","106.25","1 through 10","14.12","432.25","percent of total billed charges",""
"Sandostatin (Octreotide), Serum/Plasma","PX-30003487","CDM","80299","CPT","0301","RC","","","","both","","","455.00","341.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.52","53.3","","106.25","71.28","106.25","1 through 10","14.12","432.25","percent of total billed charges",""
"Sandostatin (Octreotide), Serum/Plasma","PX-30003487","CDM","80299","CPT","0301","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.08","36.5","","50.36","42.80","92.50","13","14.12","432.25","percent of total billed charges",""
"Sandostatin (Octreotide), Serum/Plasma","PX-30003487","CDM","80299","CPT","0301","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.27","38.3","","52.79","44.55","158.37","30","14.12","432.25","percent of total billed charges",""
"Sandostatin (Octreotide), Serum/Plasma","PX-30003487","CDM","80299","CPT","0301","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","91.40","64.53","105.30","14","14.12","371.83","percent of total billed charges",""
"Sandostatin (Octreotide), Serum/Plasma","PX-30003487","CDM","80299","CPT","0301","RC","","","","outpatient","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","365.82","80.4","","105.30","105.30","105.30","1 through 10","14.12","371.83","percent of total billed charges",""
"Sandostatin (Octreotide), Serum/Plasma","PX-30003487","CDM","80299","CPT","0301","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.83","81.72","","59.36","15.50","59.36","1 through 10","14.12","371.83","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","both","","","227.70","170.77","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","163.49","71.8","","163.49","163.49","163.49","1 through 10","70.59","216.32","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","both","","","227.70","170.77","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","79.70","35","","50.21","47.30","50.21","1 through 10","70.59","216.32","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","both","","","227.70","170.77","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","175.33","77","","175.33","175.33","175.33","1 through 10","70.59","216.32","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","both","","","227.70","170.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","70.59","31","","70.36","70.36","211.08","1 through 10","70.59","216.32","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","both","","","227.70","170.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.11","36.5","","84.93","72.18","164.86","74","70.59","216.32","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","both","","","227.70","170.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.21","38.3","","89.03","86.53","259.59","254","70.59","216.32","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","both","","","227.70","170.77","MOLINA [1014]","HB BWH MOLINA","79.70","35","","102.46","101.44","102.46","1 through 10","70.59","216.32","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","both","","","227.70","170.77","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","175.33","77","","132.17","108.84","132.17","1 through 10","70.59","216.32","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","both","","","227.70","170.77","TRICARE [160005]","HB BWH TRICARE","216.32","95","","155.90","155.90","493.70","1 through 10","70.59","216.32","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","both","","","227.70","170.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.68","42.9","","335.19","335.19","335.19","1 through 10","70.59","216.32","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","both","","","227.70","170.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.68","42.9","","281.87","281.87","281.87","1 through 10","70.59","216.32","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","both","","","227.70","170.77","WELLPOINT [1015]","HB AMC WELLPOINT","168.00","73.78","","169.52","169.52","397.22","30","70.59","216.32","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","AETNA [1001]","HB AMC AETNA HMO","158.93","69.8","","154.15","108.84","177.61","48","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","AETNA [1001]","HB AMC AETNA PPO","183.07","80.4","","177.61","119.31","177.61","1 through 10","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","127.28","55.9","","119.31","119.31","119.31","1 through 10","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","137.87","60.55","","131.11","131.11","131.11","207","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","119.00","52.26","","140.90","140.90","140.90","1 through 10","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","118.90","52.22","","131.11","131.11","131.11","358","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.16","69.9","","157.80","105.65","218.11","31","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.79","46.9","","132.41","105.65","229.98","17","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","119.54","52.5","","149.14","131.16","149.14","1 through 10","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","113.85","50","","224.74","119.31","224.74","257","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","119.54","52.5","","236.12","125.24","236.12","90","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","142.31","62.5","","149.14","143.22","149.14","1 through 10","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","119.54","52.5","","125.24","120.45","125.24","1 through 10","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","125.24","55","","126.15","96.22","131.16","17","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","119.54","52.5","","143.22","143.22","143.22","1 through 10","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","186.08","81.72","","281.87","227.70","335.19","1 through 10","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","186.08","81.72","","281.87","227.70","335.19","48","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","142.31","62.5","","143.22","143.22","143.22","1 through 10","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","119.54","52.5","","125.24","125.24","125.24","1 through 10","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vacc 30mcg/0.3ml Tris-Sucrose Im Use","PX-63601408","CDM","91320","CPT","0636","RC","","","","outpatient","","","227.70","170.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","125.24","55","","126.15","126.15","126.15","1 through 10","106.79","187.85","percent of total billed charges",""
"Sarscov2 Vaccine 25 Mcg/0.25 Ml for Im Use|STATE SUPPLIED VACCINE","PX-63601409","CDM","91321","CPT","0636","RC","","","SL","outpatient","","","254.50","190.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","177.90","69.9","","147.38","147.38","147.38","1 through 10","119.36","177.9","percent of total billed charges",""
"Sarscov2 Vaccine 50 Mcg/0.5 Ml for Im Use","PX-63601410","CDM","91322","CPT","0636","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","93.44","36.5","","92.67","81.15","92.67","1 through 10","79.36","243.2","percent of total billed charges",""
"Sarscov2 Vaccine 50 Mcg/0.5 Ml for Im Use","PX-63601410","CDM","91322","CPT","0636","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","98.05","38.3","","100.10","97.28","100.10","1 through 10","79.36","243.2","percent of total billed charges",""
"Sarscov2 Vaccine 50 Mcg/0.5 Ml for Im Use","PX-63601410","CDM","91322","CPT","0636","RC","","","","both","","","256.00","192.00","WELLPOINT [1015]","HB AMC WELLPOINT","188.88","73.78","","446.59","446.59","446.59","1 through 10","79.36","243.2","percent of total billed charges",""
"Sarscov2 Vaccine 50 Mcg/0.5 Ml for Im Use","PX-63601410","CDM","91322","CPT","0636","RC","","","","outpatient","","","256.00","192.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","155.01","60.55","","145.93","145.93","145.93","1 through 10","120.06","211.2","percent of total billed charges",""
"Sarscov2 Vaccine 50 Mcg/0.5 Ml for Im Use","PX-63601410","CDM","91322","CPT","0636","RC","","","","outpatient","","","256.00","192.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","133.68","52.22","","145.93","145.93","145.93","1 through 10","120.06","211.2","percent of total billed charges",""
"Sarscov2 Vaccine 50 Mcg/0.5 Ml for Im Use","PX-63601410","CDM","91322","CPT","0636","RC","","","","outpatient","","","256.00","192.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","120.06","46.9","","118.78","118.78","118.78","1 through 10","120.06","211.2","percent of total billed charges",""
"Sarscov2 Vaccine 50 Mcg/0.5 Ml for Im Use","PX-63601410","CDM","91322","CPT","0636","RC","","","","outpatient","","","256.00","192.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","128.00","50","","252.67","128.77","257.54","14","120.06","211.2","percent of total billed charges",""
"Sarscov2 Vaccine 50 Mcg/0.5 Ml for Im Use","PX-63601410","CDM","91322","CPT","0636","RC","","","","outpatient","","","256.00","192.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","134.40","52.5","","265.47","140.80","265.47","1 through 10","120.06","211.2","percent of total billed charges",""
"Sarscov2 Vaccine 50 Mcg/0.5 Ml for Im Use","PX-63601410","CDM","91322","CPT","0636","RC","","","","outpatient","","","256.00","192.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","140.80","55","","141.82","141.82","141.82","1 through 10","120.06","211.2","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","113.13","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","113.83","109.83","113.83","1 through 10","104.36","371.14","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.09","108.09","108.09","1 through 10","104.36","371.14","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","MEDICARE [2001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","174.01","101","104.36","371.14","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","106.73","90.72","109.54","29","104.36","371.14","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","149.42","31","","144.30","135.34","144.30","1 through 10","104.36","371.14","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","175.93","36.5","","163.37","148.04","174.19","90","104.36","371.14","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","184.61","38.3","","182.60","171.26","182.60","137","104.36","371.14","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.65","107.65","107.65","1 through 10","104.36","371.14","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","371.14","77","","406.29","406.29","406.29","1 through 10","104.36","371.14","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","TRICARE [160005]","HB BWH TRICARE","104.36","","APC Price ($109.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","104.36","104.36","109.85","1 through 10","104.36","371.14","other","Tricare OPPS"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.65","104.60","107.65","1 through 10","104.36","371.14","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.66","107.65","170.53","86","104.36","371.14","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.78","42.9","","205.34","205.34","205.34","1 through 10","104.36","371.14","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","both","","","482.00","361.50","WELLPOINT [1015]","HB AMC WELLPOINT","355.62","73.78","","326.09","326.09","1231.09","16","104.36","371.14","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","outpatient","","","482.00","361.50","AETNA [1001]","HB AMC AETNA HMO","336.44","69.8","","223.23","223.23","432.59","21","164.36","575.66","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","outpatient","","","482.00","361.50","AETNA [1001]","HB AMC AETNA PPO","387.53","80.4","","705.90","364.26","705.90","12","164.36","575.66","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","outpatient","","","482.00","361.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","164.36","34.1","","367.53","233.50","367.53","1 through 10","164.36","575.66","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","outpatient","","","482.00","361.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","393.89","81.72","","205.34","205.34","205.34","1 through 10","164.36","575.66","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-51000643","CDM","99493","CPT","0510","RC","","","","outpatient","","","482.00","361.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","393.89","81.72","","373.32","205.34","723.46","26","164.36","575.66","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","113.13","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","113.83","109.83","113.83","1 through 10","104.36","353.78","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.09","108.09","108.09","1 through 10","104.36","353.78","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","353.78","79.5","","367.53","233.50","367.53","1 through 10","104.36","353.78","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","237.19","53.3","","238.69","233.50","246.58","1 through 10","104.36","353.78","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","MEDICARE [2001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","174.01","101","104.36","353.78","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","106.73","90.72","109.54","29","104.36","353.78","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","137.95","31","","144.30","135.34","144.30","1 through 10","104.36","353.78","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","162.43","36.5","","163.37","148.04","174.19","90","104.36","353.78","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","170.44","38.3","","182.60","171.26","182.60","137","104.36","353.78","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","109.84","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.65","107.65","107.65","1 through 10","104.36","353.78","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","342.65","77","","406.29","406.29","406.29","1 through 10","104.36","353.78","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","TRICARE [160005]","HB BWH TRICARE","104.36","","APC Price ($109.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","104.36","104.36","109.85","1 through 10","104.36","353.78","other","Tricare OPPS"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.65","104.60","107.65","1 through 10","104.36","353.78","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","107.64","","APC Price ($109.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.66","107.65","170.53","86","104.36","353.78","other","OPPS APC"
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","190.91","42.9","","205.34","205.34","205.34","1 through 10","104.36","353.78","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","both","","","445.00","333.75","WELLPOINT [1015]","HB AMC WELLPOINT","328.32","73.78","","326.09","326.09","1231.09","16","104.36","353.78","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","outpatient","","","445.00","333.75","AETNA [1001]","HB AMC AETNA HMO","310.61","69.8","","223.23","223.23","432.59","21","248.76","575.66","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","outpatient","","","445.00","333.75","AETNA [1001]","HB AMC AETNA PPO","357.78","80.4","","705.90","364.26","705.90","12","248.76","575.66","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","outpatient","","","445.00","333.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","363.65","81.72","","205.34","205.34","205.34","1 through 10","248.76","575.66","percent of total billed charges",""
"Sbsq Psychiatric Collab Care Mgmt 1st 60 Mins","PX-98301771","CDM","99493","CPT","0983","RC","","","","outpatient","","","445.00","333.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","363.65","81.72","","373.32","205.34","723.46","26","248.76","575.66","percent of total billed charges",""
"Sc Infus Thpy/Proph/Dx Intl Up to 1","PX-26000007","CDM","96369","CPT","0260","RC","","","","both","","","2218.00","1663.50","CHAMPVA [160001]","HB BWH TRICARE","237.70","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","250.21","250.21","250.21","1 through 10","237.7","1763.31","other","Tricare OPPS"
"Sc Infus Thpy/Proph/Dx Intl Up to 1","PX-26000007","CDM","96369","CPT","0260","RC","","","","both","","","2218.00","1663.50","MEDICARE [2001]","HB BWH MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.93","233.93","233.93","1 through 10","237.7","1763.31","other","OPPS APC"
"Sclerotherapy Fluid Collection Prq W/Img Gid","PX-36000388","CDM","49185","CPT","0361","RC","","","","both","","","917.00","687.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1981.66","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","984.27","871.25","1820.83","1 through 10","284.27","2404.92","other","OPPS APC"
"Sclerotherapy Fluid Collection Prq W/Img Gid","PX-36000388","CDM","49185","CPT","0361","RC","","","","both","","","917.00","687.75","MEDICARE [2001]","HB BWH MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","284.27","2404.92","other","OPPS APC"
"Sclerotherapy Fluid Collection Prq W/Img Gid","PX-36000388","CDM","49185","CPT","0361","RC","","","","both","","","917.00","687.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1891.05","1889.63","1891.05","1 through 10","284.27","2404.92","other","OPPS APC"
"Sclerotherapy Fluid Collection Prq W/Img Gid","PX-36000388","CDM","49185","CPT","0361","RC","","","","outpatient","","","917.00","687.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1355.50","1355.50","1355.50","1 through 10","479.22","2384.07","other","ASC"
"Sclerotherapy Inject Lymphnode","PX-76001907","CDM","38999","CPT","0761","RC","","","","outpatient","","","1307.00","980.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","682.52","52.22","","512.50","512.50","512.50","1 through 10","653.5","1234.13","percent of total billed charges",""
"Sclerotherapy Inject Lymphnode","PX-76001907","CDM","38999","CPT","0761","RC","","","","outpatient","","","1307.00","980.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","653.50","50","","6776.11","6776.11","6776.11","1 through 10","653.5","1234.13","percent of total billed charges",""
"Scn9a Gene Sequencing","PX-31000759","CDM","81479","CPT","0310","RC","","","","both","","","5826.00","4369.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4631.67","79.5","","0.65","0.65","0.65","1 through 10","1806.06","5534.7","percent of total billed charges",""
"Scn9a Gene Sequencing","PX-31000759","CDM","81479","CPT","0310","RC","","","","both","","","5826.00","4369.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3105.26","53.3","","0.79","0.79","0.79","1 through 10","1806.06","5534.7","percent of total billed charges",""
"Scn9a Gene Sequencing","PX-31000759","CDM","81479","CPT","0310","RC","","","","outpatient","","","5826.00","4369.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2913.00","50","","1.00","1.00","1.00","1 through 10","156.55","4806.45","percent of total billed charges",""
"Scn9a Gene Sequencing","PX-31000759","CDM","81479","CPT","0310","RC","","","","outpatient","","","5826.00","4369.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3058.65","52.5","","1.00","0.53","1.00","1 through 10","156.55","4806.45","percent of total billed charges",""
"SCREEN MESH 1.0MM 100XPLATE CRANIOFACIAL TITANIUM","SUP-ITM-10075883","CDM","C1713","HCPCS","0278","RC","","","","both","","","6202.50","4651.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4930.99","79.5","","800.18","480.96","1887.97","195","1922.78","4930.99","percent of total billed charges",""
"SCREEN MESH 1.0MM 100XPLATE CRANIOFACIAL TITANIUM","SUP-ITM-10075883","CDM","C1713","HCPCS","0278","RC","","","","both","","","6202.50","4651.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3305.93","53.3","","813.12","216.42","1444.50","81","1922.78","4930.99","percent of total billed charges",""
"SCREEN MESH 1.0MM 100XPLATE CRANIOFACIAL TITANIUM","SUP-ITM-10075883","CDM","C1713","HCPCS","0278","RC","","","","both","","","6202.50","4651.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1922.78","31","","432.60","432.60","432.60","1 through 10","1922.78","4930.99","percent of total billed charges",""
"SCREEN MESH 1.0MM 100XPLATE CRANIOFACIAL TITANIUM","SUP-ITM-10075883","CDM","C1713","HCPCS","0278","RC","","","","both","","","6202.50","4651.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2263.91","36.5","","148.37","54.89","631.39","94","1922.78","4930.99","percent of total billed charges",""
"SCREEN MESH 1.0MM 100XPLATE CRANIOFACIAL TITANIUM","SUP-ITM-10075883","CDM","C1713","HCPCS","0278","RC","","","","both","","","6202.50","4651.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2375.56","38.3","","279.30","91.72","1116.77","266","1922.78","4930.99","percent of total billed charges",""
"SCREEN MESH 1.0MM 100XPLATE CRANIOFACIAL TITANIUM","SUP-ITM-10075883","CDM","C1713","HCPCS","0278","RC","","","","both","","","6202.50","4651.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2660.87","42.9","","731.00","63.70","731.00","1 through 10","1922.78","4930.99","percent of total billed charges",""
"SCREEN MESH 1.0MM 100XPLATE CRANIOFACIAL TITANIUM","SUP-ITM-10075883","CDM","C1713","HCPCS","0278","RC","","","","both","","","6202.50","4651.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2660.87","42.9","","384.74","384.74","384.74","1 through 10","1922.78","4930.99","percent of total billed charges",""
"SCREEN MESH 1.0MM 100XPLATE CRANIOFACIAL TITANIUM","SUP-ITM-10075883","CDM","C1713","HCPCS","0278","RC","","","","both","","","6202.50","4651.87","WELLPOINT [1015]","HB AMC WELLPOINT","4576.20","73.78","","286.63","119.22","1107.45","105","1922.78","4930.99","percent of total billed charges",""
"SCREEN MESH 1.0MM 100XPLATE CRANIOFACIAL TITANIUM","SUP-ITM-10075883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6202.50","4651.87","AETNA [1001]","HB AMC AETNA HMO","4329.35","69.8","","675.31","184.75","1721.50","286","3241.43","5068.68","percent of total billed charges",""
"SCREEN MESH 1.0MM 100XPLATE CRANIOFACIAL TITANIUM","SUP-ITM-10075883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6202.50","4651.87","AETNA [1001]","HB AMC AETNA PPO","4986.81","80.4","","1261.44","103.12","1514.10","21","3241.43","5068.68","percent of total billed charges",""
"SCREEN MESH 1.0MM 100XPLATE CRANIOFACIAL TITANIUM","SUP-ITM-10075883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6202.50","4651.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4986.81","80.4","","1365.00","1365.00","1365.00","1 through 10","3241.43","5068.68","percent of total billed charges",""
"SCREEN MESH 1.0MM 100XPLATE CRANIOFACIAL TITANIUM","SUP-ITM-10075883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6202.50","4651.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","5068.68","81.72","","5157.68","5157.68","5157.68","1 through 10","3241.43","5068.68","percent of total billed charges",""
"SCREEN MESH 1.0MM 100XPLATE CRANIOFACIAL TITANIUM","SUP-ITM-10075883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6202.50","4651.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5068.68","81.72","","431.26","71.26","1459.57","88","3241.43","5068.68","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","both","","","74.00","55.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.01","36.5","","8.95","7.61","26.86","39","22.94","70.3","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","both","","","74.00","55.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.34","38.3","","10.70","9.38","28.15","125","22.94","70.3","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","both","","","74.00","55.50","TRICARE [160005]","HB BWH TRICARE","70.30","95","","27.58","27.58","27.58","1 through 10","22.94","70.3","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","both","","","74.00","55.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.75","42.9","","42.21","42.21","42.21","1 through 10","22.94","70.3","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","both","","","74.00","55.50","WELLPOINT [1015]","HB AMC WELLPOINT","54.60","73.78","","17.87","17.87","17.87","1 through 10","22.94","70.3","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","outpatient","","","74.00","55.50","AETNA [1001]","HB AMC AETNA HMO","51.65","69.8","","45.89","45.89","74.88","22","25.23","69.52","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","outpatient","","","74.00","55.50","AETNA [1001]","HB AMC AETNA PPO","59.50","80.4","","74.88","74.88","74.88","1 through 10","25.23","69.52","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","outpatient","","","74.00","55.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","38.67","52.26","","57.09","57.09","57.09","1 through 10","25.23","69.52","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","outpatient","","","74.00","55.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","25.23","34.1","","12.78","12.78","12.78","1 through 10","25.23","69.52","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","outpatient","","","74.00","55.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","38.85","52.5","","72.00","72.00","72.00","1 through 10","25.23","69.52","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","outpatient","","","74.00","55.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37.00","50","","37.73","37.73","71.07","97","25.23","69.52","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","outpatient","","","74.00","55.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","38.85","52.5","","39.60","39.60","39.60","23","25.23","69.52","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","outpatient","","","74.00","55.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","46.25","62.5","","47.16","47.16","47.16","1 through 10","25.23","69.52","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","outpatient","","","74.00","55.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","38.85","52.5","","32.11","32.11","32.11","1 through 10","25.23","69.52","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","outpatient","","","74.00","55.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","40.70","55","","41.47","39.89","44.60","13","25.23","69.52","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","outpatient","","","74.00","55.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","60.47","81.72","","76.75","76.75","96.00","22","25.23","69.52","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","outpatient","","","74.00","55.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","46.25","62.5","","36.79","36.79","36.79","1 through 10","25.23","69.52","percent of total billed charges",""
"Screen Visual Acuity Qn Bilat","PX-51000073","CDM","99173","CPT","0510","RC","","","","outpatient","","","74.00","55.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","40.70","55","","41.47","41.47","41.47","1 through 10","25.23","69.52","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","155.81","71.8","","69.30","69.30","69.30","1 through 10","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","151.90","70","","210.00","27.33","210.00","1 through 10","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","CHAMPVA [160001]","HB BWH TRICARE","206.15","95","","28.69","27.88","28.69","1 through 10","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","172.52","79.5","","165.27","110.88","165.27","431","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","115.66","53.3","","110.88","110.88","165.27","221","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","141.05","65","","136.50","136.50","136.50","1 through 10","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","172.52","79.5","","165.27","165.27","165.27","1 through 10","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","67.27","31","","64.89","64.89","64.89","14","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","79.21","36.5","","78.33","66.57","78.33","286","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","83.11","38.3","","82.11","79.80","82.11","1144","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","167.09","77","","142.17","62.62","224.07","1 through 10","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","TRICARE [160005]","HB BWH TRICARE","206.15","95","","27.88","26.49","28.69","27","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.09","42.9","","167.87","92.34","167.87","22","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","217.00","162.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.09","42.9","","92.34","92.34","92.34","1 through 10","27.32","206.15","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","217.00","162.75","AETNA [1001]","HB AMC AETNA HMO","151.47","69.8","","142.17","100.38","142.17","49","80.89","183.12","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","217.00","162.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","80.89","","Case rate ($80.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","40.45","40.45","40.45","1073","80.89","183.12","other","Multiple Imaging"
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","217.00","162.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","113.40","52.26","","40.45","40.45","64.98","15","80.89","183.12","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","217.00","162.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","80.89","","Case rate ($80.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","40.45","40.45","40.45","2332","80.89","183.12","other","Multiple Imaging"
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","217.00","162.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","177.33","81.72","","167.87","167.87","167.87","1 through 10","80.89","183.12","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","217.00","162.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","177.33","81.72","","92.34","92.34","167.87","11","80.89","183.12","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","217.00","162.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","177.33","81.72","","167.87","92.34","167.87","271","80.89","183.12","percent of total billed charges",""
"SCREW 4.5MM TITANIUM CANNULATED + LT - 48MM","SUP-ITM-10337611","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.56","898.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","952.06","79.5","","800.18","480.96","1887.97","195","371.24","952.06","percent of total billed charges",""
"SCREW 4.5MM TITANIUM CANNULATED + LT - 48MM","SUP-ITM-10337611","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.56","898.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","638.30","53.3","","813.12","216.42","1444.50","81","371.24","952.06","percent of total billed charges",""
"SCREW 4.5MM TITANIUM CANNULATED + LT - 48MM","SUP-ITM-10337611","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.56","898.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","371.24","31","","432.60","432.60","432.60","1 through 10","371.24","952.06","percent of total billed charges",""
"SCREW 4.5MM TITANIUM CANNULATED + LT - 48MM","SUP-ITM-10337611","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.56","898.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","437.11","36.5","","148.37","54.89","631.39","94","371.24","952.06","percent of total billed charges",""
"SCREW 4.5MM TITANIUM CANNULATED + LT - 48MM","SUP-ITM-10337611","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.56","898.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","458.67","38.3","","279.30","91.72","1116.77","266","371.24","952.06","percent of total billed charges",""
"SCREW 4.5MM TITANIUM CANNULATED + LT - 48MM","SUP-ITM-10337611","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.56","898.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","513.75","42.9","","731.00","63.70","731.00","1 through 10","371.24","952.06","percent of total billed charges",""
"SCREW 4.5MM TITANIUM CANNULATED + LT - 48MM","SUP-ITM-10337611","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.56","898.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","513.75","42.9","","384.74","384.74","384.74","1 through 10","371.24","952.06","percent of total billed charges",""
"SCREW 4.5MM TITANIUM CANNULATED + LT - 48MM","SUP-ITM-10337611","CDM","C1713","HCPCS","0278","RC","","","","both","","","1197.56","898.17","WELLPOINT [1015]","HB AMC WELLPOINT","883.56","73.78","","286.63","119.22","1107.45","105","371.24","952.06","percent of total billed charges",""
"SCREW 4.5MM TITANIUM CANNULATED + LT - 48MM","SUP-ITM-10337611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1197.56","898.17","AETNA [1001]","HB AMC AETNA HMO","835.90","69.8","","675.31","184.75","1721.50","286","625.84","978.65","percent of total billed charges",""
"SCREW 4.5MM TITANIUM CANNULATED + LT - 48MM","SUP-ITM-10337611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1197.56","898.17","AETNA [1001]","HB AMC AETNA PPO","962.84","80.4","","1261.44","103.12","1514.10","21","625.84","978.65","percent of total billed charges",""
"SCREW 4.5MM TITANIUM CANNULATED + LT - 48MM","SUP-ITM-10337611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1197.56","898.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","962.84","80.4","","1365.00","1365.00","1365.00","1 through 10","625.84","978.65","percent of total billed charges",""
"SCREW 4.5MM TITANIUM CANNULATED + LT - 48MM","SUP-ITM-10337611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1197.56","898.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","978.65","81.72","","5157.68","5157.68","5157.68","1 through 10","625.84","978.65","percent of total billed charges",""
"SCREW 4.5MM TITANIUM CANNULATED + LT - 48MM","SUP-ITM-10337611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1197.56","898.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","978.65","81.72","","431.26","71.26","1459.57","88","625.84","978.65","percent of total billed charges",""
"SCREW BONE 1.2X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075768","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.00","598.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","634.41","79.5","","800.18","480.96","1887.97","195","247.38","634.41","percent of total billed charges",""
"SCREW BONE 1.2X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075768","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.00","598.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","425.33","53.3","","813.12","216.42","1444.50","81","247.38","634.41","percent of total billed charges",""
"SCREW BONE 1.2X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075768","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.00","598.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","247.38","31","","432.60","432.60","432.60","1 through 10","247.38","634.41","percent of total billed charges",""
"SCREW BONE 1.2X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075768","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.00","598.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","291.27","36.5","","148.37","54.89","631.39","94","247.38","634.41","percent of total billed charges",""
"SCREW BONE 1.2X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075768","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.00","598.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","305.63","38.3","","279.30","91.72","1116.77","266","247.38","634.41","percent of total billed charges",""
"SCREW BONE 1.2X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075768","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.00","598.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.34","42.9","","731.00","63.70","731.00","1 through 10","247.38","634.41","percent of total billed charges",""
"SCREW BONE 1.2X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075768","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.00","598.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.34","42.9","","384.74","384.74","384.74","1 through 10","247.38","634.41","percent of total billed charges",""
"SCREW BONE 1.2X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075768","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.00","598.50","WELLPOINT [1015]","HB AMC WELLPOINT","588.76","73.78","","286.63","119.22","1107.45","105","247.38","634.41","percent of total billed charges",""
"SCREW BONE 1.2X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.00","598.50","AETNA [1001]","HB AMC AETNA HMO","557.00","69.8","","675.31","184.75","1721.50","286","417.03","652.13","percent of total billed charges",""
"SCREW BONE 1.2X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.00","598.50","AETNA [1001]","HB AMC AETNA PPO","641.59","80.4","","1261.44","103.12","1514.10","21","417.03","652.13","percent of total billed charges",""
"SCREW BONE 1.2X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.00","598.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","641.59","80.4","","1365.00","1365.00","1365.00","1 through 10","417.03","652.13","percent of total billed charges",""
"SCREW BONE 1.2X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.00","598.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","652.13","81.72","","5157.68","5157.68","5157.68","1 through 10","417.03","652.13","percent of total billed charges",""
"SCREW BONE 1.2X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.00","598.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","652.13","81.72","","431.26","71.26","1459.57","88","417.03","652.13","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075764","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.53","148.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","157.04","79.5","","800.18","480.96","1887.97","195","61.23","157.04","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075764","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.53","148.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","105.28","53.3","","813.12","216.42","1444.50","81","61.23","157.04","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075764","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.53","148.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","61.23","31","","432.60","432.60","432.60","1 through 10","61.23","157.04","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075764","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.53","148.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.10","36.5","","148.37","54.89","631.39","94","61.23","157.04","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075764","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.53","148.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.65","38.3","","279.30","91.72","1116.77","266","61.23","157.04","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075764","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.53","148.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.74","42.9","","731.00","63.70","731.00","1 through 10","61.23","157.04","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075764","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.53","148.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.74","42.9","","384.74","384.74","384.74","1 through 10","61.23","157.04","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075764","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.53","148.15","WELLPOINT [1015]","HB AMC WELLPOINT","145.74","73.78","","286.63","119.22","1107.45","105","61.23","157.04","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","197.53","148.15","AETNA [1001]","HB AMC AETNA HMO","137.88","69.8","","675.31","184.75","1721.50","286","103.23","161.42","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","197.53","148.15","AETNA [1001]","HB AMC AETNA PPO","158.81","80.4","","1261.44","103.12","1514.10","21","103.23","161.42","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","197.53","148.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","158.81","80.4","","1365.00","1365.00","1365.00","1 through 10","103.23","161.42","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","197.53","148.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","161.42","81.72","","5157.68","5157.68","5157.68","1 through 10","103.23","161.42","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","197.53","148.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","161.42","81.72","","431.26","71.26","1459.57","88","103.23","161.42","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTICAL SELF TAPPING EMERGENCY TI PK/5EA","SUP-ITM-10002325","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","154.73","79.5","","800.18","480.96","1887.97","195","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTICAL SELF TAPPING EMERGENCY TI PK/5EA","SUP-ITM-10002325","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","103.74","53.3","","813.12","216.42","1444.50","81","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTICAL SELF TAPPING EMERGENCY TI PK/5EA","SUP-ITM-10002325","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","60.34","31","","432.60","432.60","432.60","1 through 10","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTICAL SELF TAPPING EMERGENCY TI PK/5EA","SUP-ITM-10002325","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.04","36.5","","148.37","54.89","631.39","94","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTICAL SELF TAPPING EMERGENCY TI PK/5EA","SUP-ITM-10002325","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","74.54","38.3","","279.30","91.72","1116.77","266","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTICAL SELF TAPPING EMERGENCY TI PK/5EA","SUP-ITM-10002325","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.50","42.9","","731.00","63.70","731.00","1 through 10","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTICAL SELF TAPPING EMERGENCY TI PK/5EA","SUP-ITM-10002325","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.50","42.9","","384.74","384.74","384.74","1 through 10","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTICAL SELF TAPPING EMERGENCY TI PK/5EA","SUP-ITM-10002325","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","WELLPOINT [1015]","HB AMC WELLPOINT","143.60","73.78","","286.63","119.22","1107.45","105","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTICAL SELF TAPPING EMERGENCY TI PK/5EA","SUP-ITM-10002325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.63","145.97","AETNA [1001]","HB AMC AETNA HMO","135.85","69.8","","675.31","184.75","1721.50","286","101.71","159.05","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTICAL SELF TAPPING EMERGENCY TI PK/5EA","SUP-ITM-10002325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.63","145.97","AETNA [1001]","HB AMC AETNA PPO","156.48","80.4","","1261.44","103.12","1514.10","21","101.71","159.05","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTICAL SELF TAPPING EMERGENCY TI PK/5EA","SUP-ITM-10002325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.63","145.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","156.48","80.4","","1365.00","1365.00","1365.00","1 through 10","101.71","159.05","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTICAL SELF TAPPING EMERGENCY TI PK/5EA","SUP-ITM-10002325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.63","145.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","159.05","81.72","","5157.68","5157.68","5157.68","1 through 10","101.71","159.05","percent of total billed charges",""
"SCREW BONE 1.2X4MM CORTICAL SELF TAPPING EMERGENCY TI PK/5EA","SUP-ITM-10002325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.63","145.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","159.05","81.72","","431.26","71.26","1459.57","88","101.71","159.05","percent of total billed charges",""
"SCREW BONE 1.2X7MM CRANIAL TI SELF TAP EMERG TEAL PK/5EA","SUP-ITM-10003786","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","154.73","79.5","","800.18","480.96","1887.97","195","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X7MM CRANIAL TI SELF TAP EMERG TEAL PK/5EA","SUP-ITM-10003786","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","103.74","53.3","","813.12","216.42","1444.50","81","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X7MM CRANIAL TI SELF TAP EMERG TEAL PK/5EA","SUP-ITM-10003786","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","60.34","31","","432.60","432.60","432.60","1 through 10","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X7MM CRANIAL TI SELF TAP EMERG TEAL PK/5EA","SUP-ITM-10003786","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.04","36.5","","148.37","54.89","631.39","94","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X7MM CRANIAL TI SELF TAP EMERG TEAL PK/5EA","SUP-ITM-10003786","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","74.54","38.3","","279.30","91.72","1116.77","266","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X7MM CRANIAL TI SELF TAP EMERG TEAL PK/5EA","SUP-ITM-10003786","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.50","42.9","","731.00","63.70","731.00","1 through 10","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X7MM CRANIAL TI SELF TAP EMERG TEAL PK/5EA","SUP-ITM-10003786","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.50","42.9","","384.74","384.74","384.74","1 through 10","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X7MM CRANIAL TI SELF TAP EMERG TEAL PK/5EA","SUP-ITM-10003786","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.63","145.97","WELLPOINT [1015]","HB AMC WELLPOINT","143.60","73.78","","286.63","119.22","1107.45","105","60.34","154.73","percent of total billed charges",""
"SCREW BONE 1.2X7MM CRANIAL TI SELF TAP EMERG TEAL PK/5EA","SUP-ITM-10003786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.63","145.97","AETNA [1001]","HB AMC AETNA HMO","135.85","69.8","","675.31","184.75","1721.50","286","101.71","159.05","percent of total billed charges",""
"SCREW BONE 1.2X7MM CRANIAL TI SELF TAP EMERG TEAL PK/5EA","SUP-ITM-10003786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.63","145.97","AETNA [1001]","HB AMC AETNA PPO","156.48","80.4","","1261.44","103.12","1514.10","21","101.71","159.05","percent of total billed charges",""
"SCREW BONE 1.2X7MM CRANIAL TI SELF TAP EMERG TEAL PK/5EA","SUP-ITM-10003786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.63","145.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","156.48","80.4","","1365.00","1365.00","1365.00","1 through 10","101.71","159.05","percent of total billed charges",""
"SCREW BONE 1.2X7MM CRANIAL TI SELF TAP EMERG TEAL PK/5EA","SUP-ITM-10003786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.63","145.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","159.05","81.72","","5157.68","5157.68","5157.68","1 through 10","101.71","159.05","percent of total billed charges",""
"SCREW BONE 1.2X7MM CRANIAL TI SELF TAP EMERG TEAL PK/5EA","SUP-ITM-10003786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.63","145.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","159.05","81.72","","431.26","71.26","1459.57","88","101.71","159.05","percent of total billed charges",""
"SCREW BONE 1.3MM 11 TI LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164376","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.33","228.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","241.94","79.5","","800.18","480.96","1887.97","195","94.34","241.94","percent of total billed charges",""
"SCREW BONE 1.3MM 11 TI LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164376","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.33","228.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","162.21","53.3","","813.12","216.42","1444.50","81","94.34","241.94","percent of total billed charges",""
"SCREW BONE 1.3MM 11 TI LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164376","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.33","228.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","94.34","31","","432.60","432.60","432.60","1 through 10","94.34","241.94","percent of total billed charges",""
"SCREW BONE 1.3MM 11 TI LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164376","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.33","228.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","111.08","36.5","","148.37","54.89","631.39","94","94.34","241.94","percent of total billed charges",""
"SCREW BONE 1.3MM 11 TI LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164376","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.33","228.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","116.56","38.3","","279.30","91.72","1116.77","266","94.34","241.94","percent of total billed charges",""
"SCREW BONE 1.3MM 11 TI LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164376","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.33","228.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.56","42.9","","731.00","63.70","731.00","1 through 10","94.34","241.94","percent of total billed charges",""
"SCREW BONE 1.3MM 11 TI LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164376","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.33","228.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.56","42.9","","384.74","384.74","384.74","1 through 10","94.34","241.94","percent of total billed charges",""
"SCREW BONE 1.3MM 11 TI LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164376","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.33","228.25","WELLPOINT [1015]","HB AMC WELLPOINT","224.53","73.78","","286.63","119.22","1107.45","105","94.34","241.94","percent of total billed charges",""
"SCREW BONE 1.3MM 11 TI LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.33","228.25","AETNA [1001]","HB AMC AETNA HMO","212.42","69.8","","675.31","184.75","1721.50","286","159.04","248.7","percent of total billed charges",""
"SCREW BONE 1.3MM 11 TI LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.33","228.25","AETNA [1001]","HB AMC AETNA PPO","244.68","80.4","","1261.44","103.12","1514.10","21","159.04","248.7","percent of total billed charges",""
"SCREW BONE 1.3MM 11 TI LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.33","228.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","244.68","80.4","","1365.00","1365.00","1365.00","1 through 10","159.04","248.7","percent of total billed charges",""
"SCREW BONE 1.3MM 11 TI LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.33","228.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","248.70","81.72","","5157.68","5157.68","5157.68","1 through 10","159.04","248.7","percent of total billed charges",""
"SCREW BONE 1.3MM 11 TI LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.33","228.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","248.70","81.72","","431.26","71.26","1459.57","88","159.04","248.7","percent of total billed charges",""
"SCREW BONE 1.3X15MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164657","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.13","207.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","220.32","79.5","","800.18","480.96","1887.97","195","85.91","220.32","percent of total billed charges",""
"SCREW BONE 1.3X15MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164657","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.13","207.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.71","53.3","","813.12","216.42","1444.50","81","85.91","220.32","percent of total billed charges",""
"SCREW BONE 1.3X15MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164657","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.13","207.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.91","31","","432.60","432.60","432.60","1 through 10","85.91","220.32","percent of total billed charges",""
"SCREW BONE 1.3X15MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164657","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.13","207.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","101.15","36.5","","148.37","54.89","631.39","94","85.91","220.32","percent of total billed charges",""
"SCREW BONE 1.3X15MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164657","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.13","207.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","106.14","38.3","","279.30","91.72","1116.77","266","85.91","220.32","percent of total billed charges",""
"SCREW BONE 1.3X15MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164657","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.13","207.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.89","42.9","","731.00","63.70","731.00","1 through 10","85.91","220.32","percent of total billed charges",""
"SCREW BONE 1.3X15MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164657","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.13","207.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.89","42.9","","384.74","384.74","384.74","1 through 10","85.91","220.32","percent of total billed charges",""
"SCREW BONE 1.3X15MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164657","CDM","C1713","HCPCS","0278","RC","","","","both","","","277.13","207.85","WELLPOINT [1015]","HB AMC WELLPOINT","204.47","73.78","","286.63","119.22","1107.45","105","85.91","220.32","percent of total billed charges",""
"SCREW BONE 1.3X15MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","277.13","207.85","AETNA [1001]","HB AMC AETNA HMO","193.44","69.8","","675.31","184.75","1721.50","286","144.83","226.47","percent of total billed charges",""
"SCREW BONE 1.3X15MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","277.13","207.85","AETNA [1001]","HB AMC AETNA PPO","222.81","80.4","","1261.44","103.12","1514.10","21","144.83","226.47","percent of total billed charges",""
"SCREW BONE 1.3X15MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","277.13","207.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","222.81","80.4","","1365.00","1365.00","1365.00","1 through 10","144.83","226.47","percent of total billed charges",""
"SCREW BONE 1.3X15MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","277.13","207.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","226.47","81.72","","5157.68","5157.68","5157.68","1 through 10","144.83","226.47","percent of total billed charges",""
"SCREW BONE 1.3X15MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","277.13","207.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","226.47","81.72","","431.26","71.26","1459.57","88","144.83","226.47","percent of total billed charges",""
"SCREW BONE 1.3X3MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075761","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","147.81","79.5","","800.18","480.96","1887.97","195","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.3X3MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075761","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","99.10","53.3","","813.12","216.42","1444.50","81","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.3X3MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075761","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","57.64","31","","432.60","432.60","432.60","1 through 10","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.3X3MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075761","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.86","36.5","","148.37","54.89","631.39","94","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.3X3MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075761","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71.21","38.3","","279.30","91.72","1116.77","266","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.3X3MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075761","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.76","42.9","","731.00","63.70","731.00","1 through 10","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.3X3MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075761","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.76","42.9","","384.74","384.74","384.74","1 through 10","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.3X3MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075761","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","WELLPOINT [1015]","HB AMC WELLPOINT","137.17","73.78","","286.63","119.22","1107.45","105","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.3X3MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075761","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.92","139.44","AETNA [1001]","HB AMC AETNA HMO","129.77","69.8","","675.31","184.75","1721.50","286","97.16","151.93","percent of total billed charges",""
"SCREW BONE 1.3X3MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075761","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.92","139.44","AETNA [1001]","HB AMC AETNA PPO","149.48","80.4","","1261.44","103.12","1514.10","21","97.16","151.93","percent of total billed charges",""
"SCREW BONE 1.3X3MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075761","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.92","139.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","149.48","80.4","","1365.00","1365.00","1365.00","1 through 10","97.16","151.93","percent of total billed charges",""
"SCREW BONE 1.3X3MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075761","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.92","139.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","151.93","81.72","","5157.68","5157.68","5157.68","1 through 10","97.16","151.93","percent of total billed charges",""
"SCREW BONE 1.3X3MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075761","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.92","139.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","151.93","81.72","","431.26","71.26","1459.57","88","97.16","151.93","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.10","135.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","143.18","79.5","","800.18","480.96","1887.97","195","55.83","143.18","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.10","135.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.99","53.3","","813.12","216.42","1444.50","81","55.83","143.18","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.10","135.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","55.83","31","","432.60","432.60","432.60","1 through 10","55.83","143.18","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.10","135.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.74","36.5","","148.37","54.89","631.39","94","55.83","143.18","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.10","135.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.98","38.3","","279.30","91.72","1116.77","266","55.83","143.18","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.10","135.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.26","42.9","","731.00","63.70","731.00","1 through 10","55.83","143.18","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.10","135.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.26","42.9","","384.74","384.74","384.74","1 through 10","55.83","143.18","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.10","135.07","WELLPOINT [1015]","HB AMC WELLPOINT","132.88","73.78","","286.63","119.22","1107.45","105","55.83","143.18","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.10","135.07","AETNA [1001]","HB AMC AETNA HMO","125.71","69.8","","675.31","184.75","1721.50","286","94.12","147.18","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.10","135.07","AETNA [1001]","HB AMC AETNA PPO","144.80","80.4","","1261.44","103.12","1514.10","21","94.12","147.18","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.10","135.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","144.80","80.4","","1365.00","1365.00","1365.00","1 through 10","94.12","147.18","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.10","135.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","147.18","81.72","","5157.68","5157.68","5157.68","1 through 10","94.12","147.18","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.10","135.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","147.18","81.72","","431.26","71.26","1459.57","88","94.12","147.18","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.20","132.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","140.87","79.5","","800.18","480.96","1887.97","195","54.93","140.87","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.20","132.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","94.45","53.3","","813.12","216.42","1444.50","81","54.93","140.87","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.20","132.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.93","31","","432.60","432.60","432.60","1 through 10","54.93","140.87","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.20","132.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.68","36.5","","148.37","54.89","631.39","94","54.93","140.87","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.20","132.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.87","38.3","","279.30","91.72","1116.77","266","54.93","140.87","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.20","132.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.02","42.9","","731.00","63.70","731.00","1 through 10","54.93","140.87","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.20","132.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.02","42.9","","384.74","384.74","384.74","1 through 10","54.93","140.87","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.20","132.90","WELLPOINT [1015]","HB AMC WELLPOINT","130.74","73.78","","286.63","119.22","1107.45","105","54.93","140.87","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.20","132.90","AETNA [1001]","HB AMC AETNA HMO","123.69","69.8","","675.31","184.75","1721.50","286","92.6","144.81","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.20","132.90","AETNA [1001]","HB AMC AETNA PPO","142.47","80.4","","1261.44","103.12","1514.10","21","92.6","144.81","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.20","132.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","142.47","80.4","","1365.00","1365.00","1365.00","1 through 10","92.6","144.81","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.20","132.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","144.81","81.72","","5157.68","5157.68","5157.68","1 through 10","92.6","144.81","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.20","132.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","144.81","81.72","","431.26","71.26","1459.57","88","92.6","144.81","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","257.71","193.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","204.88","79.5","","800.18","480.96","1887.97","195","79.89","204.88","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","257.71","193.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","137.36","53.3","","813.12","216.42","1444.50","81","79.89","204.88","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","257.71","193.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","79.89","31","","432.60","432.60","432.60","1 through 10","79.89","204.88","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","257.71","193.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","94.06","36.5","","148.37","54.89","631.39","94","79.89","204.88","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","257.71","193.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","98.70","38.3","","279.30","91.72","1116.77","266","79.89","204.88","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","257.71","193.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.56","42.9","","731.00","63.70","731.00","1 through 10","79.89","204.88","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","257.71","193.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.56","42.9","","384.74","384.74","384.74","1 through 10","79.89","204.88","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","257.71","193.28","WELLPOINT [1015]","HB AMC WELLPOINT","190.14","73.78","","286.63","119.22","1107.45","105","79.89","204.88","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","257.71","193.28","AETNA [1001]","HB AMC AETNA HMO","179.88","69.8","","675.31","184.75","1721.50","286","134.68","210.6","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","257.71","193.28","AETNA [1001]","HB AMC AETNA PPO","207.20","80.4","","1261.44","103.12","1514.10","21","134.68","210.6","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","257.71","193.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","207.20","80.4","","1365.00","1365.00","1365.00","1 through 10","134.68","210.6","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","257.71","193.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","210.60","81.72","","5157.68","5157.68","5157.68","1 through 10","134.68","210.6","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","257.71","193.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","210.60","81.72","","431.26","71.26","1459.57","88","134.68","210.6","percent of total billed charges",""
"SCREW BONE 1.5MM 8X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049369","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","278.25","79.5","","800.18","480.96","1887.97","195","108.5","278.25","percent of total billed charges",""
"SCREW BONE 1.5MM 8X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049369","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","186.55","53.3","","813.12","216.42","1444.50","81","108.5","278.25","percent of total billed charges",""
"SCREW BONE 1.5MM 8X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049369","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","108.50","31","","432.60","432.60","432.60","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 1.5MM 8X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049369","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.75","36.5","","148.37","54.89","631.39","94","108.5","278.25","percent of total billed charges",""
"SCREW BONE 1.5MM 8X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049369","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","134.05","38.3","","279.30","91.72","1116.77","266","108.5","278.25","percent of total billed charges",""
"SCREW BONE 1.5MM 8X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049369","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","731.00","63.70","731.00","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 1.5MM 8X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049369","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","384.74","384.74","384.74","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 1.5MM 8X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049369","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","WELLPOINT [1015]","HB AMC WELLPOINT","258.23","73.78","","286.63","119.22","1107.45","105","108.5","278.25","percent of total billed charges",""
"SCREW BONE 1.5MM 8X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA HMO","244.30","69.8","","675.31","184.75","1721.50","286","182.91","286.02","percent of total billed charges",""
"SCREW BONE 1.5MM 8X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA PPO","281.40","80.4","","1261.44","103.12","1514.10","21","182.91","286.02","percent of total billed charges",""
"SCREW BONE 1.5MM 8X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","281.40","80.4","","1365.00","1365.00","1365.00","1 through 10","182.91","286.02","percent of total billed charges",""
"SCREW BONE 1.5MM 8X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","286.02","81.72","","5157.68","5157.68","5157.68","1 through 10","182.91","286.02","percent of total billed charges",""
"SCREW BONE 1.5MM 8X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","286.02","81.72","","431.26","71.26","1459.57","88","182.91","286.02","percent of total billed charges",""
"SCREW BONE 1.5X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116854","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","294.95","79.5","","800.18","480.96","1887.97","195","115.01","294.95","percent of total billed charges",""
"SCREW BONE 1.5X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116854","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","197.74","53.3","","813.12","216.42","1444.50","81","115.01","294.95","percent of total billed charges",""
"SCREW BONE 1.5X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116854","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.01","31","","432.60","432.60","432.60","1 through 10","115.01","294.95","percent of total billed charges",""
"SCREW BONE 1.5X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116854","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","135.42","36.5","","148.37","54.89","631.39","94","115.01","294.95","percent of total billed charges",""
"SCREW BONE 1.5X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116854","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.09","38.3","","279.30","91.72","1116.77","266","115.01","294.95","percent of total billed charges",""
"SCREW BONE 1.5X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116854","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.16","42.9","","731.00","63.70","731.00","1 through 10","115.01","294.95","percent of total billed charges",""
"SCREW BONE 1.5X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116854","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.16","42.9","","384.74","384.74","384.74","1 through 10","115.01","294.95","percent of total billed charges",""
"SCREW BONE 1.5X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116854","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","WELLPOINT [1015]","HB AMC WELLPOINT","273.72","73.78","","286.63","119.22","1107.45","105","115.01","294.95","percent of total billed charges",""
"SCREW BONE 1.5X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.00","278.25","AETNA [1001]","HB AMC AETNA HMO","258.96","69.8","","675.31","184.75","1721.50","286","193.88","303.18","percent of total billed charges",""
"SCREW BONE 1.5X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.00","278.25","AETNA [1001]","HB AMC AETNA PPO","298.28","80.4","","1261.44","103.12","1514.10","21","193.88","303.18","percent of total billed charges",""
"SCREW BONE 1.5X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.00","278.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","298.28","80.4","","1365.00","1365.00","1365.00","1 through 10","193.88","303.18","percent of total billed charges",""
"SCREW BONE 1.5X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.00","278.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","303.18","81.72","","5157.68","5157.68","5157.68","1 through 10","193.88","303.18","percent of total billed charges",""
"SCREW BONE 1.5X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.00","278.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","303.18","81.72","","431.26","71.26","1459.57","88","193.88","303.18","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE","SUP-ITM-10131086","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.73","143.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","152.43","79.5","","800.18","480.96","1887.97","195","59.44","152.43","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE","SUP-ITM-10131086","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.73","143.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","102.19","53.3","","813.12","216.42","1444.50","81","59.44","152.43","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE","SUP-ITM-10131086","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.73","143.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","59.44","31","","432.60","432.60","432.60","1 through 10","59.44","152.43","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE","SUP-ITM-10131086","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.73","143.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","69.98","36.5","","148.37","54.89","631.39","94","59.44","152.43","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE","SUP-ITM-10131086","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.73","143.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.43","38.3","","279.30","91.72","1116.77","266","59.44","152.43","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE","SUP-ITM-10131086","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.73","143.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.25","42.9","","731.00","63.70","731.00","1 through 10","59.44","152.43","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE","SUP-ITM-10131086","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.73","143.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.25","42.9","","384.74","384.74","384.74","1 through 10","59.44","152.43","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE","SUP-ITM-10131086","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.73","143.80","WELLPOINT [1015]","HB AMC WELLPOINT","141.46","73.78","","286.63","119.22","1107.45","105","59.44","152.43","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE","SUP-ITM-10131086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.73","143.80","AETNA [1001]","HB AMC AETNA HMO","133.83","69.8","","675.31","184.75","1721.50","286","100.2","156.68","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE","SUP-ITM-10131086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.73","143.80","AETNA [1001]","HB AMC AETNA PPO","154.15","80.4","","1261.44","103.12","1514.10","21","100.2","156.68","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE","SUP-ITM-10131086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.73","143.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","154.15","80.4","","1365.00","1365.00","1365.00","1 through 10","100.2","156.68","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE","SUP-ITM-10131086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.73","143.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","156.68","81.72","","5157.68","5157.68","5157.68","1 through 10","100.2","156.68","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE","SUP-ITM-10131086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.73","143.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","156.68","81.72","","431.26","71.26","1459.57","88","100.2","156.68","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077399","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.24","79.5","","800.18","480.96","1887.97","195","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077399","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.93","53.3","","813.12","216.42","1444.50","81","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077399","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.33","31","","432.60","432.60","432.60","1 through 10","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077399","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.37","36.5","","148.37","54.89","631.39","94","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077399","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.00","38.3","","279.30","91.72","1116.77","266","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077399","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.72","42.9","","731.00","63.70","731.00","1 through 10","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077399","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.72","42.9","","384.74","384.74","384.74","1 through 10","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077399","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","WELLPOINT [1015]","HB AMC WELLPOINT","107.87","73.78","","286.63","119.22","1107.45","105","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","146.21","109.66","AETNA [1001]","HB AMC AETNA HMO","102.05","69.8","","675.31","184.75","1721.50","286","76.41","119.48","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","146.21","109.66","AETNA [1001]","HB AMC AETNA PPO","117.55","80.4","","1261.44","103.12","1514.10","21","76.41","119.48","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","146.21","109.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","117.55","80.4","","1365.00","1365.00","1365.00","1 through 10","76.41","119.48","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","146.21","109.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","119.48","81.72","","5157.68","5157.68","5157.68","1 through 10","76.41","119.48","percent of total billed charges",""
"SCREW BONE 1.5X10MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","146.21","109.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","119.48","81.72","","431.26","71.26","1459.57","88","76.41","119.48","percent of total billed charges",""
"SCREW BONE 1.5X10MM TI VA LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164353","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.49","274.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","291.36","79.5","","800.18","480.96","1887.97","195","113.61","291.36","percent of total billed charges",""
"SCREW BONE 1.5X10MM TI VA LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164353","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.49","274.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","195.34","53.3","","813.12","216.42","1444.50","81","113.61","291.36","percent of total billed charges",""
"SCREW BONE 1.5X10MM TI VA LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164353","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.49","274.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","113.61","31","","432.60","432.60","432.60","1 through 10","113.61","291.36","percent of total billed charges",""
"SCREW BONE 1.5X10MM TI VA LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164353","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.49","274.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","133.77","36.5","","148.37","54.89","631.39","94","113.61","291.36","percent of total billed charges",""
"SCREW BONE 1.5X10MM TI VA LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164353","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.49","274.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","140.37","38.3","","279.30","91.72","1116.77","266","113.61","291.36","percent of total billed charges",""
"SCREW BONE 1.5X10MM TI VA LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164353","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.49","274.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.22","42.9","","731.00","63.70","731.00","1 through 10","113.61","291.36","percent of total billed charges",""
"SCREW BONE 1.5X10MM TI VA LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164353","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.49","274.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.22","42.9","","384.74","384.74","384.74","1 through 10","113.61","291.36","percent of total billed charges",""
"SCREW BONE 1.5X10MM TI VA LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164353","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.49","274.87","WELLPOINT [1015]","HB AMC WELLPOINT","270.40","73.78","","286.63","119.22","1107.45","105","113.61","291.36","percent of total billed charges",""
"SCREW BONE 1.5X10MM TI VA LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","366.49","274.87","AETNA [1001]","HB AMC AETNA HMO","255.81","69.8","","675.31","184.75","1721.50","286","191.53","299.5","percent of total billed charges",""
"SCREW BONE 1.5X10MM TI VA LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","366.49","274.87","AETNA [1001]","HB AMC AETNA PPO","294.66","80.4","","1261.44","103.12","1514.10","21","191.53","299.5","percent of total billed charges",""
"SCREW BONE 1.5X10MM TI VA LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","366.49","274.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","294.66","80.4","","1365.00","1365.00","1365.00","1 through 10","191.53","299.5","percent of total billed charges",""
"SCREW BONE 1.5X10MM TI VA LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","366.49","274.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","299.50","81.72","","5157.68","5157.68","5157.68","1 through 10","191.53","299.5","percent of total billed charges",""
"SCREW BONE 1.5X10MM TI VA LOCKING SELF TAPPING T4 STARDRIVE RECESS","SUP-ITM-10164353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","366.49","274.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","299.50","81.72","","431.26","71.26","1459.57","88","191.53","299.5","percent of total billed charges",""
"SCREW BONE 1.5X12MM COMPRESSION HEADLESS TITANIUM STERILE","SUP-ITM-10097855","CDM","C1713","HCPCS","0278","RC","","","","both","","","641.76","481.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","510.20","79.5","","800.18","480.96","1887.97","195","198.95","510.2","percent of total billed charges",""
"SCREW BONE 1.5X12MM COMPRESSION HEADLESS TITANIUM STERILE","SUP-ITM-10097855","CDM","C1713","HCPCS","0278","RC","","","","both","","","641.76","481.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","342.06","53.3","","813.12","216.42","1444.50","81","198.95","510.2","percent of total billed charges",""
"SCREW BONE 1.5X12MM COMPRESSION HEADLESS TITANIUM STERILE","SUP-ITM-10097855","CDM","C1713","HCPCS","0278","RC","","","","both","","","641.76","481.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.95","31","","432.60","432.60","432.60","1 through 10","198.95","510.2","percent of total billed charges",""
"SCREW BONE 1.5X12MM COMPRESSION HEADLESS TITANIUM STERILE","SUP-ITM-10097855","CDM","C1713","HCPCS","0278","RC","","","","both","","","641.76","481.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","234.24","36.5","","148.37","54.89","631.39","94","198.95","510.2","percent of total billed charges",""
"SCREW BONE 1.5X12MM COMPRESSION HEADLESS TITANIUM STERILE","SUP-ITM-10097855","CDM","C1713","HCPCS","0278","RC","","","","both","","","641.76","481.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.79","38.3","","279.30","91.72","1116.77","266","198.95","510.2","percent of total billed charges",""
"SCREW BONE 1.5X12MM COMPRESSION HEADLESS TITANIUM STERILE","SUP-ITM-10097855","CDM","C1713","HCPCS","0278","RC","","","","both","","","641.76","481.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","275.32","42.9","","731.00","63.70","731.00","1 through 10","198.95","510.2","percent of total billed charges",""
"SCREW BONE 1.5X12MM COMPRESSION HEADLESS TITANIUM STERILE","SUP-ITM-10097855","CDM","C1713","HCPCS","0278","RC","","","","both","","","641.76","481.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","275.32","42.9","","384.74","384.74","384.74","1 through 10","198.95","510.2","percent of total billed charges",""
"SCREW BONE 1.5X12MM COMPRESSION HEADLESS TITANIUM STERILE","SUP-ITM-10097855","CDM","C1713","HCPCS","0278","RC","","","","both","","","641.76","481.32","WELLPOINT [1015]","HB AMC WELLPOINT","473.49","73.78","","286.63","119.22","1107.45","105","198.95","510.2","percent of total billed charges",""
"SCREW BONE 1.5X12MM COMPRESSION HEADLESS TITANIUM STERILE","SUP-ITM-10097855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","641.76","481.32","AETNA [1001]","HB AMC AETNA HMO","447.95","69.8","","675.31","184.75","1721.50","286","335.38","524.45","percent of total billed charges",""
"SCREW BONE 1.5X12MM COMPRESSION HEADLESS TITANIUM STERILE","SUP-ITM-10097855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","641.76","481.32","AETNA [1001]","HB AMC AETNA PPO","515.98","80.4","","1261.44","103.12","1514.10","21","335.38","524.45","percent of total billed charges",""
"SCREW BONE 1.5X12MM COMPRESSION HEADLESS TITANIUM STERILE","SUP-ITM-10097855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","641.76","481.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.98","80.4","","1365.00","1365.00","1365.00","1 through 10","335.38","524.45","percent of total billed charges",""
"SCREW BONE 1.5X12MM COMPRESSION HEADLESS TITANIUM STERILE","SUP-ITM-10097855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","641.76","481.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","524.45","81.72","","5157.68","5157.68","5157.68","1 through 10","335.38","524.45","percent of total billed charges",""
"SCREW BONE 1.5X12MM COMPRESSION HEADLESS TITANIUM STERILE","SUP-ITM-10097855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","641.76","481.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","524.45","81.72","","431.26","71.26","1459.57","88","335.38","524.45","percent of total billed charges",""
"SCREW BONE 1.5X12MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077400","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.24","79.5","","800.18","480.96","1887.97","195","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X12MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077400","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.93","53.3","","813.12","216.42","1444.50","81","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X12MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077400","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.33","31","","432.60","432.60","432.60","1 through 10","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X12MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077400","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.37","36.5","","148.37","54.89","631.39","94","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X12MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077400","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.00","38.3","","279.30","91.72","1116.77","266","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X12MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077400","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.72","42.9","","731.00","63.70","731.00","1 through 10","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X12MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077400","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.72","42.9","","384.74","384.74","384.74","1 through 10","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X12MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077400","CDM","C1713","HCPCS","0278","RC","","","","both","","","146.21","109.66","WELLPOINT [1015]","HB AMC WELLPOINT","107.87","73.78","","286.63","119.22","1107.45","105","45.33","116.24","percent of total billed charges",""
"SCREW BONE 1.5X12MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","146.21","109.66","AETNA [1001]","HB AMC AETNA HMO","102.05","69.8","","675.31","184.75","1721.50","286","76.41","119.48","percent of total billed charges",""
"SCREW BONE 1.5X12MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","146.21","109.66","AETNA [1001]","HB AMC AETNA PPO","117.55","80.4","","1261.44","103.12","1514.10","21","76.41","119.48","percent of total billed charges",""
"SCREW BONE 1.5X12MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","146.21","109.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","117.55","80.4","","1365.00","1365.00","1365.00","1 through 10","76.41","119.48","percent of total billed charges",""
"SCREW BONE 1.5X12MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","146.21","109.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","119.48","81.72","","5157.68","5157.68","5157.68","1 through 10","76.41","119.48","percent of total billed charges",""
"SCREW BONE 1.5X12MM MATRIXMIDFACE TI SELF TAPPING BRONZE PK/5EA","SUP-ITM-10077400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","146.21","109.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","119.48","81.72","","431.26","71.26","1459.57","88","76.41","119.48","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.11","115.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","122.52","79.5","","800.18","480.96","1887.97","195","47.77","122.52","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.11","115.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","82.14","53.3","","813.12","216.42","1444.50","81","47.77","122.52","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.11","115.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","47.77","31","","432.60","432.60","432.60","1 through 10","47.77","122.52","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.11","115.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56.25","36.5","","148.37","54.89","631.39","94","47.77","122.52","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.11","115.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","59.02","38.3","","279.30","91.72","1116.77","266","47.77","122.52","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.11","115.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.11","42.9","","731.00","63.70","731.00","1 through 10","47.77","122.52","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.11","115.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.11","42.9","","384.74","384.74","384.74","1 through 10","47.77","122.52","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.11","115.58","WELLPOINT [1015]","HB AMC WELLPOINT","113.70","73.78","","286.63","119.22","1107.45","105","47.77","122.52","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","154.11","115.58","AETNA [1001]","HB AMC AETNA HMO","107.57","69.8","","675.31","184.75","1721.50","286","80.54","125.94","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","154.11","115.58","AETNA [1001]","HB AMC AETNA PPO","123.90","80.4","","1261.44","103.12","1514.10","21","80.54","125.94","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","154.11","115.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","123.90","80.4","","1365.00","1365.00","1365.00","1 through 10","80.54","125.94","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","154.11","115.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","125.94","81.72","","5157.68","5157.68","5157.68","1 through 10","80.54","125.94","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","154.11","115.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.94","81.72","","431.26","71.26","1459.57","88","80.54","125.94","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.68","101.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","107.07","79.5","","800.18","480.96","1887.97","195","41.75","107.07","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.68","101.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","71.78","53.3","","813.12","216.42","1444.50","81","41.75","107.07","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.68","101.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","41.75","31","","432.60","432.60","432.60","1 through 10","41.75","107.07","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.68","101.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","49.16","36.5","","148.37","54.89","631.39","94","41.75","107.07","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.68","101.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","51.58","38.3","","279.30","91.72","1116.77","266","41.75","107.07","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.68","101.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.78","42.9","","731.00","63.70","731.00","1 through 10","41.75","107.07","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.68","101.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.78","42.9","","384.74","384.74","384.74","1 through 10","41.75","107.07","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.68","101.01","WELLPOINT [1015]","HB AMC WELLPOINT","99.37","73.78","","286.63","119.22","1107.45","105","41.75","107.07","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.68","101.01","AETNA [1001]","HB AMC AETNA HMO","94.01","69.8","","675.31","184.75","1721.50","286","70.38","110.06","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.68","101.01","AETNA [1001]","HB AMC AETNA PPO","108.28","80.4","","1261.44","103.12","1514.10","21","70.38","110.06","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.68","101.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","108.28","80.4","","1365.00","1365.00","1365.00","1 through 10","70.38","110.06","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.68","101.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","110.06","81.72","","5157.68","5157.68","5157.68","1 through 10","70.38","110.06","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.68","101.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","110.06","81.72","","431.26","71.26","1459.57","88","70.38","110.06","percent of total billed charges",""
"SCREW BONE 1.5X18MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071989","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.87","79.5","","800.18","480.96","1887.97","195","45.57","116.87","percent of total billed charges",""
"SCREW BONE 1.5X18MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071989","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.35","53.3","","813.12","216.42","1444.50","81","45.57","116.87","percent of total billed charges",""
"SCREW BONE 1.5X18MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071989","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.57","31","","432.60","432.60","432.60","1 through 10","45.57","116.87","percent of total billed charges",""
"SCREW BONE 1.5X18MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071989","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.66","36.5","","148.37","54.89","631.39","94","45.57","116.87","percent of total billed charges",""
"SCREW BONE 1.5X18MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071989","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.30","38.3","","279.30","91.72","1116.77","266","45.57","116.87","percent of total billed charges",""
"SCREW BONE 1.5X18MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071989","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.06","42.9","","731.00","63.70","731.00","1 through 10","45.57","116.87","percent of total billed charges",""
"SCREW BONE 1.5X18MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071989","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.06","42.9","","384.74","384.74","384.74","1 through 10","45.57","116.87","percent of total billed charges",""
"SCREW BONE 1.5X18MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071989","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.00","110.25","WELLPOINT [1015]","HB AMC WELLPOINT","108.46","73.78","","286.63","119.22","1107.45","105","45.57","116.87","percent of total billed charges",""
"SCREW BONE 1.5X18MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA HMO","102.61","69.8","","675.31","184.75","1721.50","286","76.82","120.13","percent of total billed charges",""
"SCREW BONE 1.5X18MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA PPO","118.19","80.4","","1261.44","103.12","1514.10","21","76.82","120.13","percent of total billed charges",""
"SCREW BONE 1.5X18MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","118.19","80.4","","1365.00","1365.00","1365.00","1 through 10","76.82","120.13","percent of total billed charges",""
"SCREW BONE 1.5X18MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","120.13","81.72","","5157.68","5157.68","5157.68","1 through 10","76.82","120.13","percent of total billed charges",""
"SCREW BONE 1.5X18MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","120.13","81.72","","431.26","71.26","1459.57","88","76.82","120.13","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10131091","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.36","79.5","","800.18","480.96","1887.97","195","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10131091","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.84","53.3","","813.12","216.42","1444.50","81","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10131091","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","62.14","31","","432.60","432.60","432.60","1 through 10","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10131091","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.16","36.5","","148.37","54.89","631.39","94","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10131091","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.77","38.3","","279.30","91.72","1116.77","266","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10131091","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.99","42.9","","731.00","63.70","731.00","1 through 10","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10131091","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.99","42.9","","384.74","384.74","384.74","1 through 10","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10131091","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","WELLPOINT [1015]","HB AMC WELLPOINT","147.89","73.78","","286.63","119.22","1107.45","105","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10131091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.45","150.34","AETNA [1001]","HB AMC AETNA HMO","139.91","69.8","","675.31","184.75","1721.50","286","104.76","163.81","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10131091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.45","150.34","AETNA [1001]","HB AMC AETNA PPO","161.16","80.4","","1261.44","103.12","1514.10","21","104.76","163.81","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10131091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.45","150.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","161.16","80.4","","1365.00","1365.00","1365.00","1 through 10","104.76","163.81","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10131091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.45","150.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","163.81","81.72","","5157.68","5157.68","5157.68","1 through 10","104.76","163.81","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10131091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.45","150.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.81","81.72","","431.26","71.26","1459.57","88","104.76","163.81","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING","SUP-ITM-10076574","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","58.46","79.5","","800.18","480.96","1887.97","195","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING","SUP-ITM-10076574","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39.20","53.3","","813.12","216.42","1444.50","81","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING","SUP-ITM-10076574","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","22.80","31","","432.60","432.60","432.60","1 through 10","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING","SUP-ITM-10076574","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.84","36.5","","148.37","54.89","631.39","94","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING","SUP-ITM-10076574","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.17","38.3","","279.30","91.72","1116.77","266","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING","SUP-ITM-10076574","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.55","42.9","","731.00","63.70","731.00","1 through 10","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING","SUP-ITM-10076574","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.55","42.9","","384.74","384.74","384.74","1 through 10","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING","SUP-ITM-10076574","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","WELLPOINT [1015]","HB AMC WELLPOINT","54.26","73.78","","286.63","119.22","1107.45","105","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING","SUP-ITM-10076574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","AETNA [1001]","HB AMC AETNA HMO","51.33","69.8","","675.31","184.75","1721.50","286","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING","SUP-ITM-10076574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","AETNA [1001]","HB AMC AETNA PPO","59.13","80.4","","1261.44","103.12","1514.10","21","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING","SUP-ITM-10076574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","59.13","80.4","","1365.00","1365.00","1365.00","1 through 10","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING","SUP-ITM-10076574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","60.10","81.72","","5157.68","5157.68","5157.68","1 through 10","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING","SUP-ITM-10076574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","60.10","81.72","","431.26","71.26","1459.57","88","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING PK/5EA","SUP-ITM-10076575","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","58.46","79.5","","800.18","480.96","1887.97","195","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING PK/5EA","SUP-ITM-10076575","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39.20","53.3","","813.12","216.42","1444.50","81","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING PK/5EA","SUP-ITM-10076575","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","22.80","31","","432.60","432.60","432.60","1 through 10","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING PK/5EA","SUP-ITM-10076575","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.84","36.5","","148.37","54.89","631.39","94","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING PK/5EA","SUP-ITM-10076575","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.17","38.3","","279.30","91.72","1116.77","266","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING PK/5EA","SUP-ITM-10076575","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.55","42.9","","731.00","63.70","731.00","1 through 10","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING PK/5EA","SUP-ITM-10076575","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.55","42.9","","384.74","384.74","384.74","1 through 10","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING PK/5EA","SUP-ITM-10076575","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","WELLPOINT [1015]","HB AMC WELLPOINT","54.26","73.78","","286.63","119.22","1107.45","105","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING PK/5EA","SUP-ITM-10076575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","AETNA [1001]","HB AMC AETNA HMO","51.33","69.8","","675.31","184.75","1721.50","286","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING PK/5EA","SUP-ITM-10076575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","AETNA [1001]","HB AMC AETNA PPO","59.13","80.4","","1261.44","103.12","1514.10","21","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING PK/5EA","SUP-ITM-10076575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","59.13","80.4","","1365.00","1365.00","1365.00","1 through 10","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING PK/5EA","SUP-ITM-10076575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","60.10","81.72","","5157.68","5157.68","5157.68","1 through 10","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X3MM MATRIXNEURO TI SELF DRILLING PK/5EA","SUP-ITM-10076575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","60.10","81.72","","431.26","71.26","1459.57","88","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077394","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.78","119.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.03","79.5","","800.18","480.96","1887.97","195","49.53","127.03","percent of total billed charges",""
"SCREW BONE 1.5X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077394","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.78","119.83","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.16","53.3","","813.12","216.42","1444.50","81","49.53","127.03","percent of total billed charges",""
"SCREW BONE 1.5X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077394","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.78","119.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.53","31","","432.60","432.60","432.60","1 through 10","49.53","127.03","percent of total billed charges",""
"SCREW BONE 1.5X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077394","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.78","119.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.32","36.5","","148.37","54.89","631.39","94","49.53","127.03","percent of total billed charges",""
"SCREW BONE 1.5X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077394","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.78","119.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.20","38.3","","279.30","91.72","1116.77","266","49.53","127.03","percent of total billed charges",""
"SCREW BONE 1.5X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077394","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.78","119.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.55","42.9","","731.00","63.70","731.00","1 through 10","49.53","127.03","percent of total billed charges",""
"SCREW BONE 1.5X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077394","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.78","119.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.55","42.9","","384.74","384.74","384.74","1 through 10","49.53","127.03","percent of total billed charges",""
"SCREW BONE 1.5X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077394","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.78","119.83","WELLPOINT [1015]","HB AMC WELLPOINT","117.89","73.78","","286.63","119.22","1107.45","105","49.53","127.03","percent of total billed charges",""
"SCREW BONE 1.5X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.78","119.83","AETNA [1001]","HB AMC AETNA HMO","111.53","69.8","","675.31","184.75","1721.50","286","83.5","130.57","percent of total billed charges",""
"SCREW BONE 1.5X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.78","119.83","AETNA [1001]","HB AMC AETNA PPO","128.46","80.4","","1261.44","103.12","1514.10","21","83.5","130.57","percent of total billed charges",""
"SCREW BONE 1.5X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.78","119.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","128.46","80.4","","1365.00","1365.00","1365.00","1 through 10","83.5","130.57","percent of total billed charges",""
"SCREW BONE 1.5X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.78","119.83","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","130.57","81.72","","5157.68","5157.68","5157.68","1 through 10","83.5","130.57","percent of total billed charges",""
"SCREW BONE 1.5X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.78","119.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.57","81.72","","431.26","71.26","1459.57","88","83.5","130.57","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","127.82","95.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","101.62","79.5","","800.18","480.96","1887.97","195","39.62","101.62","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","127.82","95.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","68.13","53.3","","813.12","216.42","1444.50","81","39.62","101.62","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","127.82","95.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","39.62","31","","432.60","432.60","432.60","1 through 10","39.62","101.62","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","127.82","95.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","46.65","36.5","","148.37","54.89","631.39","94","39.62","101.62","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","127.82","95.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48.96","38.3","","279.30","91.72","1116.77","266","39.62","101.62","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","127.82","95.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.83","42.9","","731.00","63.70","731.00","1 through 10","39.62","101.62","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","127.82","95.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.83","42.9","","384.74","384.74","384.74","1 through 10","39.62","101.62","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","127.82","95.86","WELLPOINT [1015]","HB AMC WELLPOINT","94.31","73.78","","286.63","119.22","1107.45","105","39.62","101.62","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","127.82","95.86","AETNA [1001]","HB AMC AETNA HMO","89.22","69.8","","675.31","184.75","1721.50","286","66.8","104.45","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","127.82","95.86","AETNA [1001]","HB AMC AETNA PPO","102.77","80.4","","1261.44","103.12","1514.10","21","66.8","104.45","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","127.82","95.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","102.77","80.4","","1365.00","1365.00","1365.00","1 through 10","66.8","104.45","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","127.82","95.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","104.45","81.72","","5157.68","5157.68","5157.68","1 through 10","66.8","104.45","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","127.82","95.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","104.45","81.72","","431.26","71.26","1459.57","88","66.8","104.45","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.37","112.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","119.54","79.5","","800.18","480.96","1887.97","195","46.61","119.54","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.37","112.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","80.15","53.3","","813.12","216.42","1444.50","81","46.61","119.54","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.37","112.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","46.61","31","","432.60","432.60","432.60","1 through 10","46.61","119.54","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.37","112.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54.89","36.5","","148.37","54.89","631.39","94","46.61","119.54","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.37","112.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.59","38.3","","279.30","91.72","1116.77","266","46.61","119.54","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.37","112.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.51","42.9","","731.00","63.70","731.00","1 through 10","46.61","119.54","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.37","112.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.51","42.9","","384.74","384.74","384.74","1 through 10","46.61","119.54","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.37","112.78","WELLPOINT [1015]","HB AMC WELLPOINT","110.94","73.78","","286.63","119.22","1107.45","105","46.61","119.54","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.37","112.78","AETNA [1001]","HB AMC AETNA HMO","104.96","69.8","","675.31","184.75","1721.50","286","78.58","122.88","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.37","112.78","AETNA [1001]","HB AMC AETNA PPO","120.90","80.4","","1261.44","103.12","1514.10","21","78.58","122.88","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.37","112.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","120.90","80.4","","1365.00","1365.00","1365.00","1 through 10","78.58","122.88","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.37","112.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","122.88","81.72","","5157.68","5157.68","5157.68","1 through 10","78.58","122.88","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.37","112.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","122.88","81.72","","431.26","71.26","1459.57","88","78.58","122.88","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI SELF DRILLING MATRIXNEURO","SUP-ITM-10076577","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","58.46","79.5","","800.18","480.96","1887.97","195","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI SELF DRILLING MATRIXNEURO","SUP-ITM-10076577","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39.20","53.3","","813.12","216.42","1444.50","81","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI SELF DRILLING MATRIXNEURO","SUP-ITM-10076577","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","22.80","31","","432.60","432.60","432.60","1 through 10","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI SELF DRILLING MATRIXNEURO","SUP-ITM-10076577","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.84","36.5","","148.37","54.89","631.39","94","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI SELF DRILLING MATRIXNEURO","SUP-ITM-10076577","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.17","38.3","","279.30","91.72","1116.77","266","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI SELF DRILLING MATRIXNEURO","SUP-ITM-10076577","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.55","42.9","","731.00","63.70","731.00","1 through 10","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI SELF DRILLING MATRIXNEURO","SUP-ITM-10076577","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.55","42.9","","384.74","384.74","384.74","1 through 10","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI SELF DRILLING MATRIXNEURO","SUP-ITM-10076577","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.54","55.15","WELLPOINT [1015]","HB AMC WELLPOINT","54.26","73.78","","286.63","119.22","1107.45","105","22.8","58.46","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI SELF DRILLING MATRIXNEURO","SUP-ITM-10076577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","AETNA [1001]","HB AMC AETNA HMO","51.33","69.8","","675.31","184.75","1721.50","286","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI SELF DRILLING MATRIXNEURO","SUP-ITM-10076577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","AETNA [1001]","HB AMC AETNA PPO","59.13","80.4","","1261.44","103.12","1514.10","21","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI SELF DRILLING MATRIXNEURO","SUP-ITM-10076577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","59.13","80.4","","1365.00","1365.00","1365.00","1 through 10","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI SELF DRILLING MATRIXNEURO","SUP-ITM-10076577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","60.10","81.72","","5157.68","5157.68","5157.68","1 through 10","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI SELF DRILLING MATRIXNEURO","SUP-ITM-10076577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.54","55.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","60.10","81.72","","431.26","71.26","1459.57","88","38.43","60.1","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.36","79.5","","800.18","480.96","1887.97","195","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.84","53.3","","813.12","216.42","1444.50","81","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","62.14","31","","432.60","432.60","432.60","1 through 10","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.16","36.5","","148.37","54.89","631.39","94","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.77","38.3","","279.30","91.72","1116.77","266","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.99","42.9","","731.00","63.70","731.00","1 through 10","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.99","42.9","","384.74","384.74","384.74","1 through 10","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.45","150.34","WELLPOINT [1015]","HB AMC WELLPOINT","147.89","73.78","","286.63","119.22","1107.45","105","62.14","159.36","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.45","150.34","AETNA [1001]","HB AMC AETNA HMO","139.91","69.8","","675.31","184.75","1721.50","286","104.76","163.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.45","150.34","AETNA [1001]","HB AMC AETNA PPO","161.16","80.4","","1261.44","103.12","1514.10","21","104.76","163.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.45","150.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","161.16","80.4","","1365.00","1365.00","1365.00","1 through 10","104.76","163.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.45","150.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","163.81","81.72","","5157.68","5157.68","5157.68","1 through 10","104.76","163.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.45","150.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.81","81.72","","431.26","71.26","1459.57","88","104.76","163.81","percent of total billed charges",""
"SCREW BONE 1.5X6MM CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM RECESS PK/5EA","SUP-ITM-10004054","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.92","93.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","99.31","79.5","","800.18","480.96","1887.97","195","38.73","99.31","percent of total billed charges",""
"SCREW BONE 1.5X6MM CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM RECESS PK/5EA","SUP-ITM-10004054","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.92","93.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","66.58","53.3","","813.12","216.42","1444.50","81","38.73","99.31","percent of total billed charges",""
"SCREW BONE 1.5X6MM CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM RECESS PK/5EA","SUP-ITM-10004054","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.92","93.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","38.73","31","","432.60","432.60","432.60","1 through 10","38.73","99.31","percent of total billed charges",""
"SCREW BONE 1.5X6MM CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM RECESS PK/5EA","SUP-ITM-10004054","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.92","93.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","45.60","36.5","","148.37","54.89","631.39","94","38.73","99.31","percent of total billed charges",""
"SCREW BONE 1.5X6MM CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM RECESS PK/5EA","SUP-ITM-10004054","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.92","93.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","47.84","38.3","","279.30","91.72","1116.77","266","38.73","99.31","percent of total billed charges",""
"SCREW BONE 1.5X6MM CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM RECESS PK/5EA","SUP-ITM-10004054","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.92","93.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.59","42.9","","731.00","63.70","731.00","1 through 10","38.73","99.31","percent of total billed charges",""
"SCREW BONE 1.5X6MM CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM RECESS PK/5EA","SUP-ITM-10004054","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.92","93.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.59","42.9","","384.74","384.74","384.74","1 through 10","38.73","99.31","percent of total billed charges",""
"SCREW BONE 1.5X6MM CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM RECESS PK/5EA","SUP-ITM-10004054","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.92","93.69","WELLPOINT [1015]","HB AMC WELLPOINT","92.17","73.78","","286.63","119.22","1107.45","105","38.73","99.31","percent of total billed charges",""
"SCREW BONE 1.5X6MM CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM RECESS PK/5EA","SUP-ITM-10004054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.92","93.69","AETNA [1001]","HB AMC AETNA HMO","87.19","69.8","","675.31","184.75","1721.50","286","65.28","102.08","percent of total billed charges",""
"SCREW BONE 1.5X6MM CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM RECESS PK/5EA","SUP-ITM-10004054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.92","93.69","AETNA [1001]","HB AMC AETNA PPO","100.44","80.4","","1261.44","103.12","1514.10","21","65.28","102.08","percent of total billed charges",""
"SCREW BONE 1.5X6MM CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM RECESS PK/5EA","SUP-ITM-10004054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.92","93.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","100.44","80.4","","1365.00","1365.00","1365.00","1 through 10","65.28","102.08","percent of total billed charges",""
"SCREW BONE 1.5X6MM CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM RECESS PK/5EA","SUP-ITM-10004054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.92","93.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","102.08","81.72","","5157.68","5157.68","5157.68","1 through 10","65.28","102.08","percent of total billed charges",""
"SCREW BONE 1.5X6MM CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM RECESS PK/5EA","SUP-ITM-10004054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.92","93.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","102.08","81.72","","431.26","71.26","1459.57","88","65.28","102.08","percent of total billed charges",""
"SCREW BONE 1.5X7MM STARDRIVE TITANIUM CORTEX SELF TAPPING T4 RECESS","SUP-ITM-10096325","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.35","126.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","133.84","79.5","","800.18","480.96","1887.97","195","52.19","133.84","percent of total billed charges",""
"SCREW BONE 1.5X7MM STARDRIVE TITANIUM CORTEX SELF TAPPING T4 RECESS","SUP-ITM-10096325","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.35","126.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","89.73","53.3","","813.12","216.42","1444.50","81","52.19","133.84","percent of total billed charges",""
"SCREW BONE 1.5X7MM STARDRIVE TITANIUM CORTEX SELF TAPPING T4 RECESS","SUP-ITM-10096325","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.35","126.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","52.19","31","","432.60","432.60","432.60","1 through 10","52.19","133.84","percent of total billed charges",""
"SCREW BONE 1.5X7MM STARDRIVE TITANIUM CORTEX SELF TAPPING T4 RECESS","SUP-ITM-10096325","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.35","126.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","61.45","36.5","","148.37","54.89","631.39","94","52.19","133.84","percent of total billed charges",""
"SCREW BONE 1.5X7MM STARDRIVE TITANIUM CORTEX SELF TAPPING T4 RECESS","SUP-ITM-10096325","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.35","126.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64.48","38.3","","279.30","91.72","1116.77","266","52.19","133.84","percent of total billed charges",""
"SCREW BONE 1.5X7MM STARDRIVE TITANIUM CORTEX SELF TAPPING T4 RECESS","SUP-ITM-10096325","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.35","126.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.22","42.9","","731.00","63.70","731.00","1 through 10","52.19","133.84","percent of total billed charges",""
"SCREW BONE 1.5X7MM STARDRIVE TITANIUM CORTEX SELF TAPPING T4 RECESS","SUP-ITM-10096325","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.35","126.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.22","42.9","","384.74","384.74","384.74","1 through 10","52.19","133.84","percent of total billed charges",""
"SCREW BONE 1.5X7MM STARDRIVE TITANIUM CORTEX SELF TAPPING T4 RECESS","SUP-ITM-10096325","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.35","126.26","WELLPOINT [1015]","HB AMC WELLPOINT","124.21","73.78","","286.63","119.22","1107.45","105","52.19","133.84","percent of total billed charges",""
"SCREW BONE 1.5X7MM STARDRIVE TITANIUM CORTEX SELF TAPPING T4 RECESS","SUP-ITM-10096325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.35","126.26","AETNA [1001]","HB AMC AETNA HMO","117.51","69.8","","675.31","184.75","1721.50","286","87.98","137.58","percent of total billed charges",""
"SCREW BONE 1.5X7MM STARDRIVE TITANIUM CORTEX SELF TAPPING T4 RECESS","SUP-ITM-10096325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.35","126.26","AETNA [1001]","HB AMC AETNA PPO","135.35","80.4","","1261.44","103.12","1514.10","21","87.98","137.58","percent of total billed charges",""
"SCREW BONE 1.5X7MM STARDRIVE TITANIUM CORTEX SELF TAPPING T4 RECESS","SUP-ITM-10096325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.35","126.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","135.35","80.4","","1365.00","1365.00","1365.00","1 through 10","87.98","137.58","percent of total billed charges",""
"SCREW BONE 1.5X7MM STARDRIVE TITANIUM CORTEX SELF TAPPING T4 RECESS","SUP-ITM-10096325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.35","126.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","137.58","81.72","","5157.68","5157.68","5157.68","1 through 10","87.98","137.58","percent of total billed charges",""
"SCREW BONE 1.5X7MM STARDRIVE TITANIUM CORTEX SELF TAPPING T4 RECESS","SUP-ITM-10096325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.35","126.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","137.58","81.72","","431.26","71.26","1459.57","88","87.98","137.58","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX SS RAPIDSORB RAPID RESORBABLE PK/4EA","SUP-ITM-10275642","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.10","119.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","126.48","79.5","","800.18","480.96","1887.97","195","49.32","126.48","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX SS RAPIDSORB RAPID RESORBABLE PK/4EA","SUP-ITM-10275642","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.10","119.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","84.80","53.3","","813.12","216.42","1444.50","81","49.32","126.48","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX SS RAPIDSORB RAPID RESORBABLE PK/4EA","SUP-ITM-10275642","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.10","119.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.32","31","","432.60","432.60","432.60","1 through 10","49.32","126.48","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX SS RAPIDSORB RAPID RESORBABLE PK/4EA","SUP-ITM-10275642","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.10","119.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.07","36.5","","148.37","54.89","631.39","94","49.32","126.48","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX SS RAPIDSORB RAPID RESORBABLE PK/4EA","SUP-ITM-10275642","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.10","119.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.94","38.3","","279.30","91.72","1116.77","266","49.32","126.48","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX SS RAPIDSORB RAPID RESORBABLE PK/4EA","SUP-ITM-10275642","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.10","119.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.25","42.9","","731.00","63.70","731.00","1 through 10","49.32","126.48","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX SS RAPIDSORB RAPID RESORBABLE PK/4EA","SUP-ITM-10275642","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.10","119.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.25","42.9","","384.74","384.74","384.74","1 through 10","49.32","126.48","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX SS RAPIDSORB RAPID RESORBABLE PK/4EA","SUP-ITM-10275642","CDM","C1713","HCPCS","0278","RC","","","","both","","","159.10","119.32","WELLPOINT [1015]","HB AMC WELLPOINT","117.38","73.78","","286.63","119.22","1107.45","105","49.32","126.48","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX SS RAPIDSORB RAPID RESORBABLE PK/4EA","SUP-ITM-10275642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.10","119.32","AETNA [1001]","HB AMC AETNA HMO","111.05","69.8","","675.31","184.75","1721.50","286","83.15","130.02","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX SS RAPIDSORB RAPID RESORBABLE PK/4EA","SUP-ITM-10275642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.10","119.32","AETNA [1001]","HB AMC AETNA PPO","127.92","80.4","","1261.44","103.12","1514.10","21","83.15","130.02","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX SS RAPIDSORB RAPID RESORBABLE PK/4EA","SUP-ITM-10275642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.10","119.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","127.92","80.4","","1365.00","1365.00","1365.00","1 through 10","83.15","130.02","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX SS RAPIDSORB RAPID RESORBABLE PK/4EA","SUP-ITM-10275642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.10","119.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","130.02","81.72","","5157.68","5157.68","5157.68","1 through 10","83.15","130.02","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX SS RAPIDSORB RAPID RESORBABLE PK/4EA","SUP-ITM-10275642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","159.10","119.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.02","81.72","","431.26","71.26","1459.57","88","83.15","130.02","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10019110","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","117.37","79.5","","800.18","480.96","1887.97","195","45.77","117.37","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10019110","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.69","53.3","","813.12","216.42","1444.50","81","45.77","117.37","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10019110","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.77","31","","432.60","432.60","432.60","1 through 10","45.77","117.37","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10019110","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.88","36.5","","148.37","54.89","631.39","94","45.77","117.37","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10019110","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.54","38.3","","279.30","91.72","1116.77","266","45.77","117.37","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10019110","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.33","42.9","","731.00","63.70","731.00","1 through 10","45.77","117.37","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10019110","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.33","42.9","","384.74","384.74","384.74","1 through 10","45.77","117.37","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10019110","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","WELLPOINT [1015]","HB AMC WELLPOINT","108.92","73.78","","286.63","119.22","1107.45","105","45.77","117.37","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10019110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","AETNA [1001]","HB AMC AETNA HMO","103.05","69.8","","675.31","184.75","1721.50","286","77.15","120.64","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10019110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","AETNA [1001]","HB AMC AETNA PPO","118.69","80.4","","1261.44","103.12","1514.10","21","77.15","120.64","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10019110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","118.69","80.4","","1365.00","1365.00","1365.00","1 through 10","77.15","120.64","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10019110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","120.64","81.72","","5157.68","5157.68","5157.68","1 through 10","77.15","120.64","percent of total billed charges",""
"SCREW BONE 1.5X8MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10019110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","120.64","81.72","","431.26","71.26","1459.57","88","77.15","120.64","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.14","89.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","94.72","79.5","","800.18","480.96","1887.97","195","36.93","94.72","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.14","89.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","63.50","53.3","","813.12","216.42","1444.50","81","36.93","94.72","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.14","89.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","36.93","31","","432.60","432.60","432.60","1 through 10","36.93","94.72","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.14","89.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","43.49","36.5","","148.37","54.89","631.39","94","36.93","94.72","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.14","89.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","45.63","38.3","","279.30","91.72","1116.77","266","36.93","94.72","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.14","89.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","51.11","42.9","","731.00","63.70","731.00","1 through 10","36.93","94.72","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.14","89.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","51.11","42.9","","384.74","384.74","384.74","1 through 10","36.93","94.72","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.14","89.35","WELLPOINT [1015]","HB AMC WELLPOINT","87.90","73.78","","286.63","119.22","1107.45","105","36.93","94.72","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.14","89.35","AETNA [1001]","HB AMC AETNA HMO","83.16","69.8","","675.31","184.75","1721.50","286","62.26","97.36","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.14","89.35","AETNA [1001]","HB AMC AETNA PPO","95.79","80.4","","1261.44","103.12","1514.10","21","62.26","97.36","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.14","89.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","95.79","80.4","","1365.00","1365.00","1365.00","1 through 10","62.26","97.36","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.14","89.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","97.36","81.72","","5157.68","5157.68","5157.68","1 through 10","62.26","97.36","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.14","89.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","97.36","81.72","","431.26","71.26","1459.57","88","62.26","97.36","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.50","548.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","581.54","79.5","","800.18","480.96","1887.97","195","226.77","581.54","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.50","548.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","389.89","53.3","","813.12","216.42","1444.50","81","226.77","581.54","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.50","548.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","226.77","31","","432.60","432.60","432.60","1 through 10","226.77","581.54","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.50","548.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","267.00","36.5","","148.37","54.89","631.39","94","226.77","581.54","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.50","548.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","280.16","38.3","","279.30","91.72","1116.77","266","226.77","581.54","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.50","548.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","313.81","42.9","","731.00","63.70","731.00","1 through 10","226.77","581.54","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.50","548.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","313.81","42.9","","384.74","384.74","384.74","1 through 10","226.77","581.54","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.50","548.62","WELLPOINT [1015]","HB AMC WELLPOINT","539.70","73.78","","286.63","119.22","1107.45","105","226.77","581.54","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","731.50","548.62","AETNA [1001]","HB AMC AETNA HMO","510.59","69.8","","675.31","184.75","1721.50","286","382.28","597.78","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","731.50","548.62","AETNA [1001]","HB AMC AETNA PPO","588.13","80.4","","1261.44","103.12","1514.10","21","382.28","597.78","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","731.50","548.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","588.13","80.4","","1365.00","1365.00","1365.00","1 through 10","382.28","597.78","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","731.50","548.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","597.78","81.72","","5157.68","5157.68","5157.68","1 through 10","382.28","597.78","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","731.50","548.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","597.78","81.72","","431.26","71.26","1459.57","88","382.28","597.78","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX TITANIUM SELF TAPPING CROSS FIT LEIBINGER","SUP-ITM-10006105","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.91","74.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","78.63","79.5","","800.18","480.96","1887.97","195","30.66","78.63","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX TITANIUM SELF TAPPING CROSS FIT LEIBINGER","SUP-ITM-10006105","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.91","74.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","52.72","53.3","","813.12","216.42","1444.50","81","30.66","78.63","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX TITANIUM SELF TAPPING CROSS FIT LEIBINGER","SUP-ITM-10006105","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.91","74.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","30.66","31","","432.60","432.60","432.60","1 through 10","30.66","78.63","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX TITANIUM SELF TAPPING CROSS FIT LEIBINGER","SUP-ITM-10006105","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.91","74.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36.10","36.5","","148.37","54.89","631.39","94","30.66","78.63","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX TITANIUM SELF TAPPING CROSS FIT LEIBINGER","SUP-ITM-10006105","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.91","74.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37.88","38.3","","279.30","91.72","1116.77","266","30.66","78.63","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX TITANIUM SELF TAPPING CROSS FIT LEIBINGER","SUP-ITM-10006105","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.91","74.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.43","42.9","","731.00","63.70","731.00","1 through 10","30.66","78.63","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX TITANIUM SELF TAPPING CROSS FIT LEIBINGER","SUP-ITM-10006105","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.91","74.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.43","42.9","","384.74","384.74","384.74","1 through 10","30.66","78.63","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX TITANIUM SELF TAPPING CROSS FIT LEIBINGER","SUP-ITM-10006105","CDM","C1713","HCPCS","0278","RC","","","","both","","","98.91","74.18","WELLPOINT [1015]","HB AMC WELLPOINT","72.98","73.78","","286.63","119.22","1107.45","105","30.66","78.63","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX TITANIUM SELF TAPPING CROSS FIT LEIBINGER","SUP-ITM-10006105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.91","74.18","AETNA [1001]","HB AMC AETNA HMO","69.04","69.8","","675.31","184.75","1721.50","286","51.69","80.83","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX TITANIUM SELF TAPPING CROSS FIT LEIBINGER","SUP-ITM-10006105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.91","74.18","AETNA [1001]","HB AMC AETNA PPO","79.52","80.4","","1261.44","103.12","1514.10","21","51.69","80.83","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX TITANIUM SELF TAPPING CROSS FIT LEIBINGER","SUP-ITM-10006105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.91","74.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","79.52","80.4","","1365.00","1365.00","1365.00","1 through 10","51.69","80.83","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX TITANIUM SELF TAPPING CROSS FIT LEIBINGER","SUP-ITM-10006105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.91","74.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","80.83","81.72","","5157.68","5157.68","5157.68","1 through 10","51.69","80.83","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX TITANIUM SELF TAPPING CROSS FIT LEIBINGER","SUP-ITM-10006105","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","98.91","74.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","80.83","81.72","","431.26","71.26","1459.57","88","51.69","80.83","percent of total billed charges",""
"SCREW BONE 1.7X3MM SELF TAPPING PARTIAL THREAD","SUP-ITM-10165221","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.76","221.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","234.33","79.5","","800.18","480.96","1887.97","195","91.38","234.33","percent of total billed charges",""
"SCREW BONE 1.7X3MM SELF TAPPING PARTIAL THREAD","SUP-ITM-10165221","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.76","221.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","157.11","53.3","","813.12","216.42","1444.50","81","91.38","234.33","percent of total billed charges",""
"SCREW BONE 1.7X3MM SELF TAPPING PARTIAL THREAD","SUP-ITM-10165221","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.76","221.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","91.38","31","","432.60","432.60","432.60","1 through 10","91.38","234.33","percent of total billed charges",""
"SCREW BONE 1.7X3MM SELF TAPPING PARTIAL THREAD","SUP-ITM-10165221","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.76","221.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","107.59","36.5","","148.37","54.89","631.39","94","91.38","234.33","percent of total billed charges",""
"SCREW BONE 1.7X3MM SELF TAPPING PARTIAL THREAD","SUP-ITM-10165221","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.76","221.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","112.89","38.3","","279.30","91.72","1116.77","266","91.38","234.33","percent of total billed charges",""
"SCREW BONE 1.7X3MM SELF TAPPING PARTIAL THREAD","SUP-ITM-10165221","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.76","221.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.45","42.9","","731.00","63.70","731.00","1 through 10","91.38","234.33","percent of total billed charges",""
"SCREW BONE 1.7X3MM SELF TAPPING PARTIAL THREAD","SUP-ITM-10165221","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.76","221.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.45","42.9","","384.74","384.74","384.74","1 through 10","91.38","234.33","percent of total billed charges",""
"SCREW BONE 1.7X3MM SELF TAPPING PARTIAL THREAD","SUP-ITM-10165221","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.76","221.07","WELLPOINT [1015]","HB AMC WELLPOINT","217.47","73.78","","286.63","119.22","1107.45","105","91.38","234.33","percent of total billed charges",""
"SCREW BONE 1.7X3MM SELF TAPPING PARTIAL THREAD","SUP-ITM-10165221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.76","221.07","AETNA [1001]","HB AMC AETNA HMO","205.74","69.8","","675.31","184.75","1721.50","286","154.04","240.88","percent of total billed charges",""
"SCREW BONE 1.7X3MM SELF TAPPING PARTIAL THREAD","SUP-ITM-10165221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.76","221.07","AETNA [1001]","HB AMC AETNA PPO","236.99","80.4","","1261.44","103.12","1514.10","21","154.04","240.88","percent of total billed charges",""
"SCREW BONE 1.7X3MM SELF TAPPING PARTIAL THREAD","SUP-ITM-10165221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.76","221.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","236.99","80.4","","1365.00","1365.00","1365.00","1 through 10","154.04","240.88","percent of total billed charges",""
"SCREW BONE 1.7X3MM SELF TAPPING PARTIAL THREAD","SUP-ITM-10165221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.76","221.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","240.88","81.72","","5157.68","5157.68","5157.68","1 through 10","154.04","240.88","percent of total billed charges",""
"SCREW BONE 1.7X3MM SELF TAPPING PARTIAL THREAD","SUP-ITM-10165221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.76","221.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","240.88","81.72","","431.26","71.26","1459.57","88","154.04","240.88","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTICAL EMERGENCY CRUCIFORM RECESS TI PK/5EA","SUP-ITM-10002459","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","147.81","79.5","","800.18","480.96","1887.97","195","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTICAL EMERGENCY CRUCIFORM RECESS TI PK/5EA","SUP-ITM-10002459","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","99.10","53.3","","813.12","216.42","1444.50","81","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTICAL EMERGENCY CRUCIFORM RECESS TI PK/5EA","SUP-ITM-10002459","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","57.64","31","","432.60","432.60","432.60","1 through 10","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTICAL EMERGENCY CRUCIFORM RECESS TI PK/5EA","SUP-ITM-10002459","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.86","36.5","","148.37","54.89","631.39","94","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTICAL EMERGENCY CRUCIFORM RECESS TI PK/5EA","SUP-ITM-10002459","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71.21","38.3","","279.30","91.72","1116.77","266","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTICAL EMERGENCY CRUCIFORM RECESS TI PK/5EA","SUP-ITM-10002459","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.76","42.9","","731.00","63.70","731.00","1 through 10","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTICAL EMERGENCY CRUCIFORM RECESS TI PK/5EA","SUP-ITM-10002459","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.76","42.9","","384.74","384.74","384.74","1 through 10","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTICAL EMERGENCY CRUCIFORM RECESS TI PK/5EA","SUP-ITM-10002459","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.92","139.44","WELLPOINT [1015]","HB AMC WELLPOINT","137.17","73.78","","286.63","119.22","1107.45","105","57.64","147.81","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTICAL EMERGENCY CRUCIFORM RECESS TI PK/5EA","SUP-ITM-10002459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.92","139.44","AETNA [1001]","HB AMC AETNA HMO","129.77","69.8","","675.31","184.75","1721.50","286","97.16","151.93","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTICAL EMERGENCY CRUCIFORM RECESS TI PK/5EA","SUP-ITM-10002459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.92","139.44","AETNA [1001]","HB AMC AETNA PPO","149.48","80.4","","1261.44","103.12","1514.10","21","97.16","151.93","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTICAL EMERGENCY CRUCIFORM RECESS TI PK/5EA","SUP-ITM-10002459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.92","139.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","149.48","80.4","","1365.00","1365.00","1365.00","1 through 10","97.16","151.93","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTICAL EMERGENCY CRUCIFORM RECESS TI PK/5EA","SUP-ITM-10002459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.92","139.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","151.93","81.72","","5157.68","5157.68","5157.68","1 through 10","97.16","151.93","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTICAL EMERGENCY CRUCIFORM RECESS TI PK/5EA","SUP-ITM-10002459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.92","139.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","151.93","81.72","","431.26","71.26","1459.57","88","97.16","151.93","percent of total billed charges",""
"SCREW BONE 1.7X5MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042221","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.83","133.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","141.37","79.5","","800.18","480.96","1887.97","195","55.13","141.37","percent of total billed charges",""
"SCREW BONE 1.7X5MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042221","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.83","133.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","94.78","53.3","","813.12","216.42","1444.50","81","55.13","141.37","percent of total billed charges",""
"SCREW BONE 1.7X5MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042221","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.83","133.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","55.13","31","","432.60","432.60","432.60","1 through 10","55.13","141.37","percent of total billed charges",""
"SCREW BONE 1.7X5MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042221","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.83","133.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.91","36.5","","148.37","54.89","631.39","94","55.13","141.37","percent of total billed charges",""
"SCREW BONE 1.7X5MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042221","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.83","133.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.11","38.3","","279.30","91.72","1116.77","266","55.13","141.37","percent of total billed charges",""
"SCREW BONE 1.7X5MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042221","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.83","133.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.29","42.9","","731.00","63.70","731.00","1 through 10","55.13","141.37","percent of total billed charges",""
"SCREW BONE 1.7X5MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042221","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.83","133.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.29","42.9","","384.74","384.74","384.74","1 through 10","55.13","141.37","percent of total billed charges",""
"SCREW BONE 1.7X5MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042221","CDM","C1713","HCPCS","0278","RC","","","","both","","","177.83","133.37","WELLPOINT [1015]","HB AMC WELLPOINT","131.20","73.78","","286.63","119.22","1107.45","105","55.13","141.37","percent of total billed charges",""
"SCREW BONE 1.7X5MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.83","133.37","AETNA [1001]","HB AMC AETNA HMO","124.13","69.8","","675.31","184.75","1721.50","286","92.93","145.32","percent of total billed charges",""
"SCREW BONE 1.7X5MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.83","133.37","AETNA [1001]","HB AMC AETNA PPO","142.98","80.4","","1261.44","103.12","1514.10","21","92.93","145.32","percent of total billed charges",""
"SCREW BONE 1.7X5MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.83","133.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","142.98","80.4","","1365.00","1365.00","1365.00","1 through 10","92.93","145.32","percent of total billed charges",""
"SCREW BONE 1.7X5MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.83","133.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","145.32","81.72","","5157.68","5157.68","5157.68","1 through 10","92.93","145.32","percent of total billed charges",""
"SCREW BONE 1.7X5MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","177.83","133.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","145.32","81.72","","431.26","71.26","1459.57","88","92.93","145.32","percent of total billed charges",""
"SCREW BONE 1.85X16MM MATRIXORTHOGNATHIC TITANIUM COARSE PITCH SELF-TAPPING PK/5EA","SUP-ITM-10077347","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","108.54","79.5","","800.18","480.96","1887.97","195","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X16MM MATRIXORTHOGNATHIC TITANIUM COARSE PITCH SELF-TAPPING PK/5EA","SUP-ITM-10077347","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","72.77","53.3","","813.12","216.42","1444.50","81","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X16MM MATRIXORTHOGNATHIC TITANIUM COARSE PITCH SELF-TAPPING PK/5EA","SUP-ITM-10077347","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","42.32","31","","432.60","432.60","432.60","1 through 10","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X16MM MATRIXORTHOGNATHIC TITANIUM COARSE PITCH SELF-TAPPING PK/5EA","SUP-ITM-10077347","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","49.83","36.5","","148.37","54.89","631.39","94","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X16MM MATRIXORTHOGNATHIC TITANIUM COARSE PITCH SELF-TAPPING PK/5EA","SUP-ITM-10077347","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.29","38.3","","279.30","91.72","1116.77","266","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X16MM MATRIXORTHOGNATHIC TITANIUM COARSE PITCH SELF-TAPPING PK/5EA","SUP-ITM-10077347","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.57","42.9","","731.00","63.70","731.00","1 through 10","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X16MM MATRIXORTHOGNATHIC TITANIUM COARSE PITCH SELF-TAPPING PK/5EA","SUP-ITM-10077347","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.57","42.9","","384.74","384.74","384.74","1 through 10","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X16MM MATRIXORTHOGNATHIC TITANIUM COARSE PITCH SELF-TAPPING PK/5EA","SUP-ITM-10077347","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","WELLPOINT [1015]","HB AMC WELLPOINT","100.73","73.78","","286.63","119.22","1107.45","105","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X16MM MATRIXORTHOGNATHIC TITANIUM COARSE PITCH SELF-TAPPING PK/5EA","SUP-ITM-10077347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","AETNA [1001]","HB AMC AETNA HMO","95.30","69.8","","675.31","184.75","1721.50","286","71.35","111.57","percent of total billed charges",""
"SCREW BONE 1.85X16MM MATRIXORTHOGNATHIC TITANIUM COARSE PITCH SELF-TAPPING PK/5EA","SUP-ITM-10077347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","AETNA [1001]","HB AMC AETNA PPO","109.77","80.4","","1261.44","103.12","1514.10","21","71.35","111.57","percent of total billed charges",""
"SCREW BONE 1.85X16MM MATRIXORTHOGNATHIC TITANIUM COARSE PITCH SELF-TAPPING PK/5EA","SUP-ITM-10077347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","109.77","80.4","","1365.00","1365.00","1365.00","1 through 10","71.35","111.57","percent of total billed charges",""
"SCREW BONE 1.85X16MM MATRIXORTHOGNATHIC TITANIUM COARSE PITCH SELF-TAPPING PK/5EA","SUP-ITM-10077347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","111.57","81.72","","5157.68","5157.68","5157.68","1 through 10","71.35","111.57","percent of total billed charges",""
"SCREW BONE 1.85X16MM MATRIXORTHOGNATHIC TITANIUM COARSE PITCH SELF-TAPPING PK/5EA","SUP-ITM-10077347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","111.57","81.72","","431.26","71.26","1459.57","88","71.35","111.57","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF DRILLING PK/5EA","SUP-ITM-10077307","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","120.09","79.5","","800.18","480.96","1887.97","195","46.83","120.09","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF DRILLING PK/5EA","SUP-ITM-10077307","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","80.51","53.3","","813.12","216.42","1444.50","81","46.83","120.09","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF DRILLING PK/5EA","SUP-ITM-10077307","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","46.83","31","","432.60","432.60","432.60","1 through 10","46.83","120.09","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF DRILLING PK/5EA","SUP-ITM-10077307","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.14","36.5","","148.37","54.89","631.39","94","46.83","120.09","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF DRILLING PK/5EA","SUP-ITM-10077307","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.86","38.3","","279.30","91.72","1116.77","266","46.83","120.09","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF DRILLING PK/5EA","SUP-ITM-10077307","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.80","42.9","","731.00","63.70","731.00","1 through 10","46.83","120.09","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF DRILLING PK/5EA","SUP-ITM-10077307","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.80","42.9","","384.74","384.74","384.74","1 through 10","46.83","120.09","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF DRILLING PK/5EA","SUP-ITM-10077307","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.06","113.29","WELLPOINT [1015]","HB AMC WELLPOINT","111.45","73.78","","286.63","119.22","1107.45","105","46.83","120.09","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF DRILLING PK/5EA","SUP-ITM-10077307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.06","113.29","AETNA [1001]","HB AMC AETNA HMO","105.44","69.8","","675.31","184.75","1721.50","286","78.94","123.45","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF DRILLING PK/5EA","SUP-ITM-10077307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.06","113.29","AETNA [1001]","HB AMC AETNA PPO","121.45","80.4","","1261.44","103.12","1514.10","21","78.94","123.45","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF DRILLING PK/5EA","SUP-ITM-10077307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.06","113.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","121.45","80.4","","1365.00","1365.00","1365.00","1 through 10","78.94","123.45","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF DRILLING PK/5EA","SUP-ITM-10077307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.06","113.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","123.45","81.72","","5157.68","5157.68","5157.68","1 through 10","78.94","123.45","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF DRILLING PK/5EA","SUP-ITM-10077307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.06","113.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","123.45","81.72","","431.26","71.26","1459.57","88","78.94","123.45","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF TAPPING SINGLE","SUP-ITM-10131197","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.54","102.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","108.55","79.5","","800.18","480.96","1887.97","195","42.33","108.55","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF TAPPING SINGLE","SUP-ITM-10131197","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.54","102.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","72.78","53.3","","813.12","216.42","1444.50","81","42.33","108.55","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF TAPPING SINGLE","SUP-ITM-10131197","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.54","102.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","42.33","31","","432.60","432.60","432.60","1 through 10","42.33","108.55","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF TAPPING SINGLE","SUP-ITM-10131197","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.54","102.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","49.84","36.5","","148.37","54.89","631.39","94","42.33","108.55","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF TAPPING SINGLE","SUP-ITM-10131197","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.54","102.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.29","38.3","","279.30","91.72","1116.77","266","42.33","108.55","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF TAPPING SINGLE","SUP-ITM-10131197","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.54","102.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.58","42.9","","731.00","63.70","731.00","1 through 10","42.33","108.55","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF TAPPING SINGLE","SUP-ITM-10131197","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.54","102.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.58","42.9","","384.74","384.74","384.74","1 through 10","42.33","108.55","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF TAPPING SINGLE","SUP-ITM-10131197","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.54","102.40","WELLPOINT [1015]","HB AMC WELLPOINT","100.74","73.78","","286.63","119.22","1107.45","105","42.33","108.55","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF TAPPING SINGLE","SUP-ITM-10131197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.54","102.40","AETNA [1001]","HB AMC AETNA HMO","95.30","69.8","","675.31","184.75","1721.50","286","71.36","111.58","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF TAPPING SINGLE","SUP-ITM-10131197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.54","102.40","AETNA [1001]","HB AMC AETNA PPO","109.78","80.4","","1261.44","103.12","1514.10","21","71.36","111.58","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF TAPPING SINGLE","SUP-ITM-10131197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.54","102.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","109.78","80.4","","1365.00","1365.00","1365.00","1 through 10","71.36","111.58","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF TAPPING SINGLE","SUP-ITM-10131197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.54","102.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","111.58","81.72","","5157.68","5157.68","5157.68","1 through 10","71.36","111.58","percent of total billed charges",""
"SCREW BONE 1.85X6MM MATRIX TITANIUM SELF TAPPING SINGLE","SUP-ITM-10131197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.54","102.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","111.58","81.72","","431.26","71.26","1459.57","88","71.36","111.58","percent of total billed charges",""
"SCREW BONE 1.85X6MM TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10077342","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","108.54","79.5","","800.18","480.96","1887.97","195","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X6MM TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10077342","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","72.77","53.3","","813.12","216.42","1444.50","81","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X6MM TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10077342","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","42.32","31","","432.60","432.60","432.60","1 through 10","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X6MM TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10077342","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","49.83","36.5","","148.37","54.89","631.39","94","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X6MM TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10077342","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.29","38.3","","279.30","91.72","1116.77","266","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X6MM TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10077342","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.57","42.9","","731.00","63.70","731.00","1 through 10","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X6MM TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10077342","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.57","42.9","","384.74","384.74","384.74","1 through 10","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X6MM TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10077342","CDM","C1713","HCPCS","0278","RC","","","","both","","","136.53","102.40","WELLPOINT [1015]","HB AMC WELLPOINT","100.73","73.78","","286.63","119.22","1107.45","105","42.32","108.54","percent of total billed charges",""
"SCREW BONE 1.85X6MM TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10077342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","AETNA [1001]","HB AMC AETNA HMO","95.30","69.8","","675.31","184.75","1721.50","286","71.35","111.57","percent of total billed charges",""
"SCREW BONE 1.85X6MM TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10077342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","AETNA [1001]","HB AMC AETNA PPO","109.77","80.4","","1261.44","103.12","1514.10","21","71.35","111.57","percent of total billed charges",""
"SCREW BONE 1.85X6MM TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10077342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","109.77","80.4","","1365.00","1365.00","1365.00","1 through 10","71.35","111.57","percent of total billed charges",""
"SCREW BONE 1.85X6MM TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10077342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","111.57","81.72","","5157.68","5157.68","5157.68","1 through 10","71.35","111.57","percent of total billed charges",""
"SCREW BONE 1.85X6MM TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10077342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","111.57","81.72","","431.26","71.26","1459.57","88","71.35","111.57","percent of total billed charges",""
"SCREW BONE 1.8X12MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131101","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.51","148.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","157.02","79.5","","800.18","480.96","1887.97","195","61.23","157.02","percent of total billed charges",""
"SCREW BONE 1.8X12MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131101","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.51","148.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","105.27","53.3","","813.12","216.42","1444.50","81","61.23","157.02","percent of total billed charges",""
"SCREW BONE 1.8X12MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131101","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.51","148.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","61.23","31","","432.60","432.60","432.60","1 through 10","61.23","157.02","percent of total billed charges",""
"SCREW BONE 1.8X12MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131101","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.51","148.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.09","36.5","","148.37","54.89","631.39","94","61.23","157.02","percent of total billed charges",""
"SCREW BONE 1.8X12MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131101","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.51","148.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.65","38.3","","279.30","91.72","1116.77","266","61.23","157.02","percent of total billed charges",""
"SCREW BONE 1.8X12MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131101","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.51","148.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.73","42.9","","731.00","63.70","731.00","1 through 10","61.23","157.02","percent of total billed charges",""
"SCREW BONE 1.8X12MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131101","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.51","148.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.73","42.9","","384.74","384.74","384.74","1 through 10","61.23","157.02","percent of total billed charges",""
"SCREW BONE 1.8X12MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131101","CDM","C1713","HCPCS","0278","RC","","","","both","","","197.51","148.13","WELLPOINT [1015]","HB AMC WELLPOINT","145.72","73.78","","286.63","119.22","1107.45","105","61.23","157.02","percent of total billed charges",""
"SCREW BONE 1.8X12MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","197.51","148.13","AETNA [1001]","HB AMC AETNA HMO","137.86","69.8","","675.31","184.75","1721.50","286","103.22","161.41","percent of total billed charges",""
"SCREW BONE 1.8X12MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","197.51","148.13","AETNA [1001]","HB AMC AETNA PPO","158.80","80.4","","1261.44","103.12","1514.10","21","103.22","161.41","percent of total billed charges",""
"SCREW BONE 1.8X12MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","197.51","148.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","158.80","80.4","","1365.00","1365.00","1365.00","1 through 10","103.22","161.41","percent of total billed charges",""
"SCREW BONE 1.8X12MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","197.51","148.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","161.41","81.72","","5157.68","5157.68","5157.68","1 through 10","103.22","161.41","percent of total billed charges",""
"SCREW BONE 1.8X12MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","197.51","148.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","161.41","81.72","","431.26","71.26","1459.57","88","103.22","161.41","percent of total billed charges",""
"SCREW BONE 1.8X12MM MATRIXMIDFACE TITANIUM EMERGENCY SELF TAPPING PK/5EA","SUP-ITM-10077407","CDM","C1889","HCPCS","0278","RC","","","","both","","","154.92","116.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","123.16","79.5","","1309.77","674.56","6049.93","26","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X12MM MATRIXMIDFACE TITANIUM EMERGENCY SELF TAPPING PK/5EA","SUP-ITM-10077407","CDM","C1889","HCPCS","0278","RC","","","","both","","","154.92","116.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","82.57","53.3","","1901.83","1901.83","2962.25","1 through 10","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X12MM MATRIXMIDFACE TITANIUM EMERGENCY SELF TAPPING PK/5EA","SUP-ITM-10077407","CDM","C1889","HCPCS","0278","RC","","","","both","","","154.92","116.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56.55","36.5","","1620.31","1620.31","19908.88","1 through 10","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X12MM MATRIXMIDFACE TITANIUM EMERGENCY SELF TAPPING PK/5EA","SUP-ITM-10077407","CDM","C1889","HCPCS","0278","RC","","","","both","","","154.92","116.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","59.33","38.3","","352.91","352.91","2046.30","1 through 10","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X12MM MATRIXMIDFACE TITANIUM EMERGENCY SELF TAPPING PK/5EA","SUP-ITM-10077407","CDM","C1889","HCPCS","0278","RC","","","","both","","","154.92","116.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.46","42.9","","9668.75","9668.75","9668.75","1 through 10","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X12MM MATRIXMIDFACE TITANIUM EMERGENCY SELF TAPPING PK/5EA","SUP-ITM-10077407","CDM","C1889","HCPCS","0278","RC","","","","both","","","154.92","116.19","WELLPOINT [1015]","HB AMC WELLPOINT","114.30","73.78","","699.88","384.10","3443.31","33","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X12MM MATRIXMIDFACE TITANIUM EMERGENCY SELF TAPPING PK/5EA","SUP-ITM-10077407","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","154.92","116.19","AETNA [1001]","HB AMC AETNA HMO","108.13","69.8","","1421.24","264.50","4933.46","29","80.96","126.6","percent of total billed charges",""
"SCREW BONE 1.8X12MM MATRIXMIDFACE TITANIUM EMERGENCY SELF TAPPING PK/5EA","SUP-ITM-10077407","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","154.92","116.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","124.56","80.4","","1022.97","1022.97","3607.50","1 through 10","80.96","126.6","percent of total billed charges",""
"SCREW BONE 1.8X12MM MATRIXMIDFACE TITANIUM EMERGENCY SELF TAPPING PK/5EA","SUP-ITM-10077407","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","154.92","116.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","126.60","81.72","","3010.54","693.88","5019.88","35","80.96","126.6","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","260.89","79.5","","800.18","480.96","1887.97","195","101.73","260.89","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","174.91","53.3","","813.12","216.42","1444.50","81","101.73","260.89","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","101.73","31","","432.60","432.60","432.60","1 through 10","101.73","260.89","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","119.78","36.5","","148.37","54.89","631.39","94","101.73","260.89","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","125.69","38.3","","279.30","91.72","1116.77","266","101.73","260.89","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.78","42.9","","731.00","63.70","731.00","1 through 10","101.73","260.89","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.78","42.9","","384.74","384.74","384.74","1 through 10","101.73","260.89","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","328.16","246.12","WELLPOINT [1015]","HB AMC WELLPOINT","242.12","73.78","","286.63","119.22","1107.45","105","101.73","260.89","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","AETNA [1001]","HB AMC AETNA HMO","229.06","69.8","","675.31","184.75","1721.50","286","171.5","268.17","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","AETNA [1001]","HB AMC AETNA PPO","263.84","80.4","","1261.44","103.12","1514.10","21","171.5","268.17","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","263.84","80.4","","1365.00","1365.00","1365.00","1 through 10","171.5","268.17","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","268.17","81.72","","5157.68","5157.68","5157.68","1 through 10","171.5","268.17","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","328.16","246.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","268.17","81.72","","431.26","71.26","1459.57","88","171.5","268.17","percent of total billed charges",""
"SCREW BONE 1.8X3MM MATRIXNEURO EMERGENCY TI SELF TAP PK/5EA","SUP-ITM-10076584","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","150.12","79.5","","800.18","480.96","1887.97","195","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1.8X3MM MATRIXNEURO EMERGENCY TI SELF TAP PK/5EA","SUP-ITM-10076584","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.65","53.3","","813.12","216.42","1444.50","81","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1.8X3MM MATRIXNEURO EMERGENCY TI SELF TAP PK/5EA","SUP-ITM-10076584","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","58.54","31","","432.60","432.60","432.60","1 through 10","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1.8X3MM MATRIXNEURO EMERGENCY TI SELF TAP PK/5EA","SUP-ITM-10076584","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.92","36.5","","148.37","54.89","631.39","94","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1.8X3MM MATRIXNEURO EMERGENCY TI SELF TAP PK/5EA","SUP-ITM-10076584","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.32","38.3","","279.30","91.72","1116.77","266","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1.8X3MM MATRIXNEURO EMERGENCY TI SELF TAP PK/5EA","SUP-ITM-10076584","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.01","42.9","","731.00","63.70","731.00","1 through 10","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1.8X3MM MATRIXNEURO EMERGENCY TI SELF TAP PK/5EA","SUP-ITM-10076584","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.01","42.9","","384.74","384.74","384.74","1 through 10","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1.8X3MM MATRIXNEURO EMERGENCY TI SELF TAP PK/5EA","SUP-ITM-10076584","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","WELLPOINT [1015]","HB AMC WELLPOINT","139.32","73.78","","286.63","119.22","1107.45","105","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1.8X3MM MATRIXNEURO EMERGENCY TI SELF TAP PK/5EA","SUP-ITM-10076584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","188.83","141.62","AETNA [1001]","HB AMC AETNA HMO","131.80","69.8","","675.31","184.75","1721.50","286","98.68","154.31","percent of total billed charges",""
"SCREW BONE 1.8X3MM MATRIXNEURO EMERGENCY TI SELF TAP PK/5EA","SUP-ITM-10076584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","188.83","141.62","AETNA [1001]","HB AMC AETNA PPO","151.82","80.4","","1261.44","103.12","1514.10","21","98.68","154.31","percent of total billed charges",""
"SCREW BONE 1.8X3MM MATRIXNEURO EMERGENCY TI SELF TAP PK/5EA","SUP-ITM-10076584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","188.83","141.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","151.82","80.4","","1365.00","1365.00","1365.00","1 through 10","98.68","154.31","percent of total billed charges",""
"SCREW BONE 1.8X3MM MATRIXNEURO EMERGENCY TI SELF TAP PK/5EA","SUP-ITM-10076584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","188.83","141.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","154.31","81.72","","5157.68","5157.68","5157.68","1 through 10","98.68","154.31","percent of total billed charges",""
"SCREW BONE 1.8X3MM MATRIXNEURO EMERGENCY TI SELF TAP PK/5EA","SUP-ITM-10076584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","188.83","141.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","154.31","81.72","","431.26","71.26","1459.57","88","98.68","154.31","percent of total billed charges",""
"SCREW BONE 1.8X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077401","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.92","116.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","123.16","79.5","","800.18","480.96","1887.97","195","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077401","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.92","116.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","82.57","53.3","","813.12","216.42","1444.50","81","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077401","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.92","116.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.03","31","","432.60","432.60","432.60","1 through 10","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077401","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.92","116.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56.55","36.5","","148.37","54.89","631.39","94","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077401","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.92","116.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","59.33","38.3","","279.30","91.72","1116.77","266","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077401","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.92","116.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.46","42.9","","731.00","63.70","731.00","1 through 10","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077401","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.92","116.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.46","42.9","","384.74","384.74","384.74","1 through 10","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077401","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.92","116.19","WELLPOINT [1015]","HB AMC WELLPOINT","114.30","73.78","","286.63","119.22","1107.45","105","48.03","123.16","percent of total billed charges",""
"SCREW BONE 1.8X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","154.92","116.19","AETNA [1001]","HB AMC AETNA HMO","108.13","69.8","","675.31","184.75","1721.50","286","80.96","126.6","percent of total billed charges",""
"SCREW BONE 1.8X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","154.92","116.19","AETNA [1001]","HB AMC AETNA PPO","124.56","80.4","","1261.44","103.12","1514.10","21","80.96","126.6","percent of total billed charges",""
"SCREW BONE 1.8X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","154.92","116.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","124.56","80.4","","1365.00","1365.00","1365.00","1 through 10","80.96","126.6","percent of total billed charges",""
"SCREW BONE 1.8X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","154.92","116.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","126.60","81.72","","5157.68","5157.68","5157.68","1 through 10","80.96","126.6","percent of total billed charges",""
"SCREW BONE 1.8X3MM TI MATRIX MIDFACE SELF DRILL SILVER PK/5EA","SUP-ITM-10077401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","154.92","116.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","126.60","81.72","","431.26","71.26","1459.57","88","80.96","126.6","percent of total billed charges",""
"SCREW BONE 10.5X130MM LAG GAMMA3 TITANIUM PARTIAL THREADED","SUP-ITM-10033979","CDM","C1889","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2380.18","79.5","","1309.77","674.56","6049.93","26","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X130MM LAG GAMMA3 TITANIUM PARTIAL THREADED","SUP-ITM-10033979","CDM","C1889","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1595.77","53.3","","1901.83","1901.83","2962.25","1 through 10","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X130MM LAG GAMMA3 TITANIUM PARTIAL THREADED","SUP-ITM-10033979","CDM","C1889","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1092.79","36.5","","1620.31","1620.31","19908.88","1 through 10","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X130MM LAG GAMMA3 TITANIUM PARTIAL THREADED","SUP-ITM-10033979","CDM","C1889","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1146.68","38.3","","352.91","352.91","2046.30","1 through 10","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X130MM LAG GAMMA3 TITANIUM PARTIAL THREADED","SUP-ITM-10033979","CDM","C1889","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1284.40","42.9","","9668.75","9668.75","9668.75","1 through 10","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X130MM LAG GAMMA3 TITANIUM PARTIAL THREADED","SUP-ITM-10033979","CDM","C1889","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","WELLPOINT [1015]","HB AMC WELLPOINT","2208.93","73.78","","699.88","384.10","3443.31","33","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X130MM LAG GAMMA3 TITANIUM PARTIAL THREADED","SUP-ITM-10033979","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2993.94","2245.45","AETNA [1001]","HB AMC AETNA HMO","2089.77","69.8","","1421.24","264.50","4933.46","29","1564.63","2446.65","percent of total billed charges",""
"SCREW BONE 10.5X130MM LAG GAMMA3 TITANIUM PARTIAL THREADED","SUP-ITM-10033979","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2993.94","2245.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2407.13","80.4","","1022.97","1022.97","3607.50","1 through 10","1564.63","2446.65","percent of total billed charges",""
"SCREW BONE 10.5X130MM LAG GAMMA3 TITANIUM PARTIAL THREADED","SUP-ITM-10033979","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2993.94","2245.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2446.65","81.72","","3010.54","693.88","5019.88","35","1564.63","2446.65","percent of total billed charges",""
"SCREW BONE 10.5X85MM TITANIUM TFNA FENESTRATED AQANIFE","SUP-ITM-10236249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1343.53","79.5","","800.18","480.96","1887.97","195","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X85MM TITANIUM TFNA FENESTRATED AQANIFE","SUP-ITM-10236249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","900.76","53.3","","813.12","216.42","1444.50","81","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X85MM TITANIUM TFNA FENESTRATED AQANIFE","SUP-ITM-10236249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","523.89","31","","432.60","432.60","432.60","1 through 10","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X85MM TITANIUM TFNA FENESTRATED AQANIFE","SUP-ITM-10236249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","616.84","36.5","","148.37","54.89","631.39","94","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X85MM TITANIUM TFNA FENESTRATED AQANIFE","SUP-ITM-10236249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","647.26","38.3","","279.30","91.72","1116.77","266","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X85MM TITANIUM TFNA FENESTRATED AQANIFE","SUP-ITM-10236249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.00","42.9","","731.00","63.70","731.00","1 through 10","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X85MM TITANIUM TFNA FENESTRATED AQANIFE","SUP-ITM-10236249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.00","42.9","","384.74","384.74","384.74","1 through 10","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X85MM TITANIUM TFNA FENESTRATED AQANIFE","SUP-ITM-10236249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","WELLPOINT [1015]","HB AMC WELLPOINT","1246.87","73.78","","286.63","119.22","1107.45","105","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X85MM TITANIUM TFNA FENESTRATED AQANIFE","SUP-ITM-10236249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","AETNA [1001]","HB AMC AETNA HMO","1179.61","69.8","","675.31","184.75","1721.50","286","883.18","1381.05","percent of total billed charges",""
"SCREW BONE 10.5X85MM TITANIUM TFNA FENESTRATED AQANIFE","SUP-ITM-10236249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","AETNA [1001]","HB AMC AETNA PPO","1358.74","80.4","","1261.44","103.12","1514.10","21","883.18","1381.05","percent of total billed charges",""
"SCREW BONE 10.5X85MM TITANIUM TFNA FENESTRATED AQANIFE","SUP-ITM-10236249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1358.74","80.4","","1365.00","1365.00","1365.00","1 through 10","883.18","1381.05","percent of total billed charges",""
"SCREW BONE 10.5X85MM TITANIUM TFNA FENESTRATED AQANIFE","SUP-ITM-10236249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1381.05","81.72","","5157.68","5157.68","5157.68","1 through 10","883.18","1381.05","percent of total billed charges",""
"SCREW BONE 10.5X85MM TITANIUM TFNA FENESTRATED AQANIFE","SUP-ITM-10236249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1381.05","81.72","","431.26","71.26","1459.57","88","883.18","1381.05","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2380.18","79.5","","800.18","480.96","1887.97","195","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1595.77","53.3","","813.12","216.42","1444.50","81","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","928.12","31","","432.60","432.60","432.60","1 through 10","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1092.79","36.5","","148.37","54.89","631.39","94","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1146.68","38.3","","279.30","91.72","1116.77","266","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1284.40","42.9","","731.00","63.70","731.00","1 through 10","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1284.40","42.9","","384.74","384.74","384.74","1 through 10","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","WELLPOINT [1015]","HB AMC WELLPOINT","2208.93","73.78","","286.63","119.22","1107.45","105","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2993.94","2245.45","AETNA [1001]","HB AMC AETNA HMO","2089.77","69.8","","675.31","184.75","1721.50","286","1564.63","2446.65","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2993.94","2245.45","AETNA [1001]","HB AMC AETNA PPO","2407.13","80.4","","1261.44","103.12","1514.10","21","1564.63","2446.65","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2993.94","2245.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2407.13","80.4","","1365.00","1365.00","1365.00","1 through 10","1564.63","2446.65","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2993.94","2245.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2446.65","81.72","","5157.68","5157.68","5157.68","1 through 10","1564.63","2446.65","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2993.94","2245.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2446.65","81.72","","431.26","71.26","1459.57","88","1564.63","2446.65","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1343.53","79.5","","800.18","480.96","1887.97","195","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","900.76","53.3","","813.12","216.42","1444.50","81","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","523.89","31","","432.60","432.60","432.60","1 through 10","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","616.84","36.5","","148.37","54.89","631.39","94","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","647.26","38.3","","279.30","91.72","1116.77","266","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.00","42.9","","731.00","63.70","731.00","1 through 10","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.00","42.9","","384.74","384.74","384.74","1 through 10","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1267.48","WELLPOINT [1015]","HB AMC WELLPOINT","1246.87","73.78","","286.63","119.22","1107.45","105","523.89","1343.53","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","AETNA [1001]","HB AMC AETNA HMO","1179.61","69.8","","675.31","184.75","1721.50","286","883.18","1381.05","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","AETNA [1001]","HB AMC AETNA PPO","1358.74","80.4","","1261.44","103.12","1514.10","21","883.18","1381.05","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1358.74","80.4","","1365.00","1365.00","1365.00","1 through 10","883.18","1381.05","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1381.05","81.72","","5157.68","5157.68","5157.68","1 through 10","883.18","1381.05","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1267.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1381.05","81.72","","431.26","71.26","1459.57","88","883.18","1381.05","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2380.18","79.5","","800.18","480.96","1887.97","195","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1595.77","53.3","","813.12","216.42","1444.50","81","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","928.12","31","","432.60","432.60","432.60","1 through 10","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1092.79","36.5","","148.37","54.89","631.39","94","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1146.68","38.3","","279.30","91.72","1116.77","266","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1284.40","42.9","","731.00","63.70","731.00","1 through 10","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1284.40","42.9","","384.74","384.74","384.74","1 through 10","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2993.94","2245.45","WELLPOINT [1015]","HB AMC WELLPOINT","2208.93","73.78","","286.63","119.22","1107.45","105","928.12","2380.18","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2993.94","2245.45","AETNA [1001]","HB AMC AETNA HMO","2089.77","69.8","","675.31","184.75","1721.50","286","1564.63","2446.65","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2993.94","2245.45","AETNA [1001]","HB AMC AETNA PPO","2407.13","80.4","","1261.44","103.12","1514.10","21","1564.63","2446.65","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2993.94","2245.45","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2407.13","80.4","","1365.00","1365.00","1365.00","1 through 10","1564.63","2446.65","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2993.94","2245.45","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2446.65","81.72","","5157.68","5157.68","5157.68","1 through 10","1564.63","2446.65","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2993.94","2245.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2446.65","81.72","","431.26","71.26","1459.57","88","1564.63","2446.65","percent of total billed charges",""
"SCREW BONE 10MM CREO MIS FENESTRATED TULIP REDUCTION","SUP-ITM-10315789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1252.13","79.5","","800.18","480.96","1887.97","195","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 10MM CREO MIS FENESTRATED TULIP REDUCTION","SUP-ITM-10315789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","839.48","53.3","","813.12","216.42","1444.50","81","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 10MM CREO MIS FENESTRATED TULIP REDUCTION","SUP-ITM-10315789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","488.25","31","","432.60","432.60","432.60","1 through 10","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 10MM CREO MIS FENESTRATED TULIP REDUCTION","SUP-ITM-10315789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","574.88","36.5","","148.37","54.89","631.39","94","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 10MM CREO MIS FENESTRATED TULIP REDUCTION","SUP-ITM-10315789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","603.23","38.3","","279.30","91.72","1116.77","266","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 10MM CREO MIS FENESTRATED TULIP REDUCTION","SUP-ITM-10315789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","731.00","63.70","731.00","1 through 10","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 10MM CREO MIS FENESTRATED TULIP REDUCTION","SUP-ITM-10315789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","384.74","384.74","384.74","1 through 10","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 10MM CREO MIS FENESTRATED TULIP REDUCTION","SUP-ITM-10315789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB AMC WELLPOINT","1162.04","73.78","","286.63","119.22","1107.45","105","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 10MM CREO MIS FENESTRATED TULIP REDUCTION","SUP-ITM-10315789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA HMO","1099.35","69.8","","675.31","184.75","1721.50","286","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 10MM CREO MIS FENESTRATED TULIP REDUCTION","SUP-ITM-10315789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA PPO","1266.30","80.4","","1261.44","103.12","1514.10","21","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 10MM CREO MIS FENESTRATED TULIP REDUCTION","SUP-ITM-10315789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1266.30","80.4","","1365.00","1365.00","1365.00","1 through 10","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 10MM CREO MIS FENESTRATED TULIP REDUCTION","SUP-ITM-10315789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1287.09","81.72","","5157.68","5157.68","5157.68","1 through 10","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 10MM CREO MIS FENESTRATED TULIP REDUCTION","SUP-ITM-10315789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1287.09","81.72","","431.26","71.26","1459.57","88","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 10MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10021332","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","97.44","79.5","","800.18","480.96","1887.97","195","38","97.44","percent of total billed charges",""
"SCREW BONE 10MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10021332","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","65.33","53.3","","813.12","216.42","1444.50","81","38","97.44","percent of total billed charges",""
"SCREW BONE 10MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10021332","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","38.00","31","","432.60","432.60","432.60","1 through 10","38","97.44","percent of total billed charges",""
"SCREW BONE 10MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10021332","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.74","36.5","","148.37","54.89","631.39","94","38","97.44","percent of total billed charges",""
"SCREW BONE 10MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10021332","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.94","38.3","","279.30","91.72","1116.77","266","38","97.44","percent of total billed charges",""
"SCREW BONE 10MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10021332","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.58","42.9","","731.00","63.70","731.00","1 through 10","38","97.44","percent of total billed charges",""
"SCREW BONE 10MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10021332","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.58","42.9","","384.74","384.74","384.74","1 through 10","38","97.44","percent of total billed charges",""
"SCREW BONE 10MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10021332","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","WELLPOINT [1015]","HB AMC WELLPOINT","90.43","73.78","","286.63","119.22","1107.45","105","38","97.44","percent of total billed charges",""
"SCREW BONE 10MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10021332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.57","91.93","AETNA [1001]","HB AMC AETNA HMO","85.55","69.8","","675.31","184.75","1721.50","286","64.06","100.16","percent of total billed charges",""
"SCREW BONE 10MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10021332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.57","91.93","AETNA [1001]","HB AMC AETNA PPO","98.55","80.4","","1261.44","103.12","1514.10","21","64.06","100.16","percent of total billed charges",""
"SCREW BONE 10MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10021332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.57","91.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","98.55","80.4","","1365.00","1365.00","1365.00","1 through 10","64.06","100.16","percent of total billed charges",""
"SCREW BONE 10MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10021332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.57","91.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","100.16","81.72","","5157.68","5157.68","5157.68","1 through 10","64.06","100.16","percent of total billed charges",""
"SCREW BONE 10MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10021332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.57","91.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","100.16","81.72","","431.26","71.26","1459.57","88","64.06","100.16","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","294.95","79.5","","800.18","480.96","1887.97","195","115.01","294.95","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","197.74","53.3","","813.12","216.42","1444.50","81","115.01","294.95","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.01","31","","432.60","432.60","432.60","1 through 10","115.01","294.95","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","135.42","36.5","","148.37","54.89","631.39","94","115.01","294.95","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.09","38.3","","279.30","91.72","1116.77","266","115.01","294.95","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.16","42.9","","731.00","63.70","731.00","1 through 10","115.01","294.95","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.16","42.9","","384.74","384.74","384.74","1 through 10","115.01","294.95","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.00","278.25","WELLPOINT [1015]","HB AMC WELLPOINT","273.72","73.78","","286.63","119.22","1107.45","105","115.01","294.95","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.00","278.25","AETNA [1001]","HB AMC AETNA HMO","258.96","69.8","","675.31","184.75","1721.50","286","193.88","303.18","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.00","278.25","AETNA [1001]","HB AMC AETNA PPO","298.28","80.4","","1261.44","103.12","1514.10","21","193.88","303.18","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.00","278.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","298.28","80.4","","1365.00","1365.00","1365.00","1 through 10","193.88","303.18","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.00","278.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","303.18","81.72","","5157.68","5157.68","5157.68","1 through 10","193.88","303.18","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.00","278.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","303.18","81.72","","431.26","71.26","1459.57","88","193.88","303.18","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","319.99","79.5","","800.18","480.96","1887.97","195","124.78","319.99","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","214.53","53.3","","813.12","216.42","1444.50","81","124.78","319.99","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","124.78","31","","432.60","432.60","432.60","1 through 10","124.78","319.99","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","146.91","36.5","","148.37","54.89","631.39","94","124.78","319.99","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","154.16","38.3","","279.30","91.72","1116.77","266","124.78","319.99","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.67","42.9","","731.00","63.70","731.00","1 through 10","124.78","319.99","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.67","42.9","","384.74","384.74","384.74","1 through 10","124.78","319.99","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","WELLPOINT [1015]","HB AMC WELLPOINT","296.96","73.78","","286.63","119.22","1107.45","105","124.78","319.99","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","AETNA [1001]","HB AMC AETNA HMO","280.95","69.8","","675.31","184.75","1721.50","286","210.35","328.92","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","AETNA [1001]","HB AMC AETNA PPO","323.61","80.4","","1261.44","103.12","1514.10","21","210.35","328.92","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","323.61","80.4","","1365.00","1365.00","1365.00","1 through 10","210.35","328.92","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","328.92","81.72","","5157.68","5157.68","5157.68","1 through 10","210.35","328.92","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","328.92","81.72","","431.26","71.26","1459.57","88","210.35","328.92","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","220.10","79.5","","800.18","480.96","1887.97","195","85.82","220.1","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.56","53.3","","813.12","216.42","1444.50","81","85.82","220.1","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.82","31","","432.60","432.60","432.60","1 through 10","85.82","220.1","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","101.05","36.5","","148.37","54.89","631.39","94","85.82","220.1","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","106.03","38.3","","279.30","91.72","1116.77","266","85.82","220.1","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.77","42.9","","731.00","63.70","731.00","1 through 10","85.82","220.1","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.77","42.9","","384.74","384.74","384.74","1 through 10","85.82","220.1","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","WELLPOINT [1015]","HB AMC WELLPOINT","204.26","73.78","","286.63","119.22","1107.45","105","85.82","220.1","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","AETNA [1001]","HB AMC AETNA HMO","193.24","69.8","","675.31","184.75","1721.50","286","144.68","226.24","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","AETNA [1001]","HB AMC AETNA PPO","222.59","80.4","","1261.44","103.12","1514.10","21","144.68","226.24","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","222.59","80.4","","1365.00","1365.00","1365.00","1 through 10","144.68","226.24","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","226.24","81.72","","5157.68","5157.68","5157.68","1 through 10","144.68","226.24","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","226.24","81.72","","431.26","71.26","1459.57","88","144.68","226.24","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","289.38","79.5","","800.18","480.96","1887.97","195","112.84","289.38","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","194.01","53.3","","813.12","216.42","1444.50","81","112.84","289.38","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","112.84","31","","432.60","432.60","432.60","1 through 10","112.84","289.38","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","132.86","36.5","","148.37","54.89","631.39","94","112.84","289.38","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","139.41","38.3","","279.30","91.72","1116.77","266","112.84","289.38","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.16","42.9","","731.00","63.70","731.00","1 through 10","112.84","289.38","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.16","42.9","","384.74","384.74","384.74","1 through 10","112.84","289.38","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","WELLPOINT [1015]","HB AMC WELLPOINT","268.56","73.78","","286.63","119.22","1107.45","105","112.84","289.38","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.00","273.00","AETNA [1001]","HB AMC AETNA HMO","254.07","69.8","","675.31","184.75","1721.50","286","190.23","297.46","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.00","273.00","AETNA [1001]","HB AMC AETNA PPO","292.66","80.4","","1261.44","103.12","1514.10","21","190.23","297.46","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.00","273.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","292.66","80.4","","1365.00","1365.00","1365.00","1 through 10","190.23","297.46","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","297.46","81.72","","5157.68","5157.68","5157.68","1 through 10","190.23","297.46","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","297.46","81.72","","431.26","71.26","1459.57","88","190.23","297.46","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","876.49","79.5","","800.18","480.96","1887.97","195","341.78","876.49","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","587.63","53.3","","813.12","216.42","1444.50","81","341.78","876.49","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","341.78","31","","432.60","432.60","432.60","1 through 10","341.78","876.49","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","402.41","36.5","","148.37","54.89","631.39","94","341.78","876.49","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","422.26","38.3","","279.30","91.72","1116.77","266","341.78","876.49","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","472.97","42.9","","731.00","63.70","731.00","1 through 10","341.78","876.49","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","472.97","42.9","","384.74","384.74","384.74","1 through 10","341.78","876.49","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.50","826.87","WELLPOINT [1015]","HB AMC WELLPOINT","813.42","73.78","","286.63","119.22","1107.45","105","341.78","876.49","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","AETNA [1001]","HB AMC AETNA HMO","769.55","69.8","","675.31","184.75","1721.50","286","576.17","900.96","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","AETNA [1001]","HB AMC AETNA PPO","886.41","80.4","","1261.44","103.12","1514.10","21","576.17","900.96","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","886.41","80.4","","1365.00","1365.00","1365.00","1 through 10","576.17","900.96","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","900.96","81.72","","5157.68","5157.68","5157.68","1 through 10","576.17","900.96","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.50","826.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","900.96","81.72","","431.26","71.26","1459.57","88","576.17","900.96","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","800.18","480.96","1887.97","195","434","1113","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","813.12","216.42","1444.50","81","434","1113","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","434.00","31","","432.60","432.60","432.60","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","148.37","54.89","631.39","94","434","1113","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","279.30","91.72","1116.77","266","434","1113","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","731.00","63.70","731.00","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","384.74","384.74","384.74","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","286.63","119.22","1107.45","105","434","1113","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","675.31","184.75","1721.50","286","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA PPO","1125.60","80.4","","1261.44","103.12","1514.10","21","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1365.00","1365.00","1365.00","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1144.08","81.72","","5157.68","5157.68","5157.68","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","431.26","71.26","1459.57","88","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 115MM CANCELLOUS","SUP-ITM-10071438","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.13","827.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","876.99","79.5","","800.18","480.96","1887.97","195","341.97","876.99","percent of total billed charges",""
"SCREW BONE 115MM CANCELLOUS","SUP-ITM-10071438","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.13","827.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","587.97","53.3","","813.12","216.42","1444.50","81","341.97","876.99","percent of total billed charges",""
"SCREW BONE 115MM CANCELLOUS","SUP-ITM-10071438","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.13","827.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","341.97","31","","432.60","432.60","432.60","1 through 10","341.97","876.99","percent of total billed charges",""
"SCREW BONE 115MM CANCELLOUS","SUP-ITM-10071438","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.13","827.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","402.64","36.5","","148.37","54.89","631.39","94","341.97","876.99","percent of total billed charges",""
"SCREW BONE 115MM CANCELLOUS","SUP-ITM-10071438","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.13","827.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","422.50","38.3","","279.30","91.72","1116.77","266","341.97","876.99","percent of total billed charges",""
"SCREW BONE 115MM CANCELLOUS","SUP-ITM-10071438","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.13","827.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","473.24","42.9","","731.00","63.70","731.00","1 through 10","341.97","876.99","percent of total billed charges",""
"SCREW BONE 115MM CANCELLOUS","SUP-ITM-10071438","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.13","827.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","473.24","42.9","","384.74","384.74","384.74","1 through 10","341.97","876.99","percent of total billed charges",""
"SCREW BONE 115MM CANCELLOUS","SUP-ITM-10071438","CDM","C1713","HCPCS","0278","RC","","","","both","","","1103.13","827.35","WELLPOINT [1015]","HB AMC WELLPOINT","813.89","73.78","","286.63","119.22","1107.45","105","341.97","876.99","percent of total billed charges",""
"SCREW BONE 115MM CANCELLOUS","SUP-ITM-10071438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1103.13","827.35","AETNA [1001]","HB AMC AETNA HMO","769.98","69.8","","675.31","184.75","1721.50","286","576.5","901.48","percent of total billed charges",""
"SCREW BONE 115MM CANCELLOUS","SUP-ITM-10071438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1103.13","827.35","AETNA [1001]","HB AMC AETNA PPO","886.92","80.4","","1261.44","103.12","1514.10","21","576.5","901.48","percent of total billed charges",""
"SCREW BONE 115MM CANCELLOUS","SUP-ITM-10071438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1103.13","827.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","886.92","80.4","","1365.00","1365.00","1365.00","1 through 10","576.5","901.48","percent of total billed charges",""
"SCREW BONE 115MM CANCELLOUS","SUP-ITM-10071438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1103.13","827.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","901.48","81.72","","5157.68","5157.68","5157.68","1 through 10","576.5","901.48","percent of total billed charges",""
"SCREW BONE 115MM CANCELLOUS","SUP-ITM-10071438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1103.13","827.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","901.48","81.72","","431.26","71.26","1459.57","88","576.5","901.48","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","800.18","480.96","1887.97","195","260.4","667.8","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","813.12","216.42","1444.50","81","260.4","667.8","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","260.40","31","","432.60","432.60","432.60","1 through 10","260.4","667.8","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","148.37","54.89","631.39","94","260.4","667.8","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","279.30","91.72","1116.77","266","260.4","667.8","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","731.00","63.70","731.00","1 through 10","260.4","667.8","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","384.74","384.74","384.74","1 through 10","260.4","667.8","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","286.63","119.22","1107.45","105","260.4","667.8","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","675.31","184.75","1721.50","286","438.98","686.45","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA PPO","675.36","80.4","","1261.44","103.12","1514.10","21","438.98","686.45","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1365.00","1365.00","1365.00","1 through 10","438.98","686.45","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","686.45","81.72","","5157.68","5157.68","5157.68","1 through 10","438.98","686.45","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","431.26","71.26","1459.57","88","438.98","686.45","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","626.06","79.5","","800.18","480.96","1887.97","195","244.13","626.06","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","419.74","53.3","","813.12","216.42","1444.50","81","244.13","626.06","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","244.13","31","","432.60","432.60","432.60","1 through 10","244.13","626.06","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","287.44","36.5","","148.37","54.89","631.39","94","244.13","626.06","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","301.61","38.3","","279.30","91.72","1116.77","266","244.13","626.06","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.84","42.9","","731.00","63.70","731.00","1 through 10","244.13","626.06","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.84","42.9","","384.74","384.74","384.74","1 through 10","244.13","626.06","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","both","","","787.50","590.62","WELLPOINT [1015]","HB AMC WELLPOINT","581.02","73.78","","286.63","119.22","1107.45","105","244.13","626.06","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","AETNA [1001]","HB AMC AETNA HMO","549.68","69.8","","675.31","184.75","1721.50","286","411.55","643.55","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","AETNA [1001]","HB AMC AETNA PPO","633.15","80.4","","1261.44","103.12","1514.10","21","411.55","643.55","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","633.15","80.4","","1365.00","1365.00","1365.00","1 through 10","411.55","643.55","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","643.55","81.72","","5157.68","5157.68","5157.68","1 through 10","411.55","643.55","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","643.55","81.72","","431.26","71.26","1459.57","88","411.55","643.55","percent of total billed charges",""
"SCREW BONE 11X2MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028200","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","484.16","79.5","","800.18","480.96","1887.97","195","188.79","484.16","percent of total billed charges",""
"SCREW BONE 11X2MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028200","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","324.60","53.3","","813.12","216.42","1444.50","81","188.79","484.16","percent of total billed charges",""
"SCREW BONE 11X2MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028200","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","188.79","31","","432.60","432.60","432.60","1 through 10","188.79","484.16","percent of total billed charges",""
"SCREW BONE 11X2MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028200","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","222.29","36.5","","148.37","54.89","631.39","94","188.79","484.16","percent of total billed charges",""
"SCREW BONE 11X2MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028200","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","233.25","38.3","","279.30","91.72","1116.77","266","188.79","484.16","percent of total billed charges",""
"SCREW BONE 11X2MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028200","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","261.26","42.9","","731.00","63.70","731.00","1 through 10","188.79","484.16","percent of total billed charges",""
"SCREW BONE 11X2MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028200","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","261.26","42.9","","384.74","384.74","384.74","1 through 10","188.79","484.16","percent of total billed charges",""
"SCREW BONE 11X2MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028200","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","WELLPOINT [1015]","HB AMC WELLPOINT","449.32","73.78","","286.63","119.22","1107.45","105","188.79","484.16","percent of total billed charges",""
"SCREW BONE 11X2MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.00","456.75","AETNA [1001]","HB AMC AETNA HMO","425.08","69.8","","675.31","184.75","1721.50","286","318.26","497.67","percent of total billed charges",""
"SCREW BONE 11X2MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.00","456.75","AETNA [1001]","HB AMC AETNA PPO","489.64","80.4","","1261.44","103.12","1514.10","21","318.26","497.67","percent of total billed charges",""
"SCREW BONE 11X2MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.00","456.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","489.64","80.4","","1365.00","1365.00","1365.00","1 through 10","318.26","497.67","percent of total billed charges",""
"SCREW BONE 11X2MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.00","456.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","497.67","81.72","","5157.68","5157.68","5157.68","1 through 10","318.26","497.67","percent of total billed charges",""
"SCREW BONE 11X2MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.00","456.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","497.67","81.72","","431.26","71.26","1459.57","88","318.26","497.67","percent of total billed charges",""
"SCREW BONE 11X80MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097454","CDM","C1713","HCPCS","0278","RC","","","","both","","","1964.03","1473.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1561.40","79.5","","800.18","480.96","1887.97","195","608.85","1561.4","percent of total billed charges",""
"SCREW BONE 11X80MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097454","CDM","C1713","HCPCS","0278","RC","","","","both","","","1964.03","1473.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1046.83","53.3","","813.12","216.42","1444.50","81","608.85","1561.4","percent of total billed charges",""
"SCREW BONE 11X80MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097454","CDM","C1713","HCPCS","0278","RC","","","","both","","","1964.03","1473.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","608.85","31","","432.60","432.60","432.60","1 through 10","608.85","1561.4","percent of total billed charges",""
"SCREW BONE 11X80MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097454","CDM","C1713","HCPCS","0278","RC","","","","both","","","1964.03","1473.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","716.87","36.5","","148.37","54.89","631.39","94","608.85","1561.4","percent of total billed charges",""
"SCREW BONE 11X80MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097454","CDM","C1713","HCPCS","0278","RC","","","","both","","","1964.03","1473.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","752.22","38.3","","279.30","91.72","1116.77","266","608.85","1561.4","percent of total billed charges",""
"SCREW BONE 11X80MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097454","CDM","C1713","HCPCS","0278","RC","","","","both","","","1964.03","1473.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","842.57","42.9","","731.00","63.70","731.00","1 through 10","608.85","1561.4","percent of total billed charges",""
"SCREW BONE 11X80MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097454","CDM","C1713","HCPCS","0278","RC","","","","both","","","1964.03","1473.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","842.57","42.9","","384.74","384.74","384.74","1 through 10","608.85","1561.4","percent of total billed charges",""
"SCREW BONE 11X80MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097454","CDM","C1713","HCPCS","0278","RC","","","","both","","","1964.03","1473.02","WELLPOINT [1015]","HB AMC WELLPOINT","1449.06","73.78","","286.63","119.22","1107.45","105","608.85","1561.4","percent of total billed charges",""
"SCREW BONE 11X80MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097454","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1964.03","1473.02","AETNA [1001]","HB AMC AETNA HMO","1370.89","69.8","","675.31","184.75","1721.50","286","1026.4","1605.01","percent of total billed charges",""
"SCREW BONE 11X80MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097454","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1964.03","1473.02","AETNA [1001]","HB AMC AETNA PPO","1579.08","80.4","","1261.44","103.12","1514.10","21","1026.4","1605.01","percent of total billed charges",""
"SCREW BONE 11X80MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097454","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1964.03","1473.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1579.08","80.4","","1365.00","1365.00","1365.00","1 through 10","1026.4","1605.01","percent of total billed charges",""
"SCREW BONE 11X80MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097454","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1964.03","1473.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1605.01","81.72","","5157.68","5157.68","5157.68","1 through 10","1026.4","1605.01","percent of total billed charges",""
"SCREW BONE 11X80MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097454","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1964.03","1473.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1605.01","81.72","","431.26","71.26","1459.57","88","1026.4","1605.01","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1594.01","1195.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1267.24","79.5","","800.18","480.96","1887.97","195","494.14","1267.24","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1594.01","1195.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","849.61","53.3","","813.12","216.42","1444.50","81","494.14","1267.24","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1594.01","1195.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","494.14","31","","432.60","432.60","432.60","1 through 10","494.14","1267.24","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1594.01","1195.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","581.81","36.5","","148.37","54.89","631.39","94","494.14","1267.24","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1594.01","1195.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","610.51","38.3","","279.30","91.72","1116.77","266","494.14","1267.24","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1594.01","1195.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","683.83","42.9","","731.00","63.70","731.00","1 through 10","494.14","1267.24","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1594.01","1195.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","683.83","42.9","","384.74","384.74","384.74","1 through 10","494.14","1267.24","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1594.01","1195.51","WELLPOINT [1015]","HB AMC WELLPOINT","1176.06","73.78","","286.63","119.22","1107.45","105","494.14","1267.24","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1594.01","1195.51","AETNA [1001]","HB AMC AETNA HMO","1112.62","69.8","","675.31","184.75","1721.50","286","833.03","1302.62","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1594.01","1195.51","AETNA [1001]","HB AMC AETNA PPO","1281.58","80.4","","1261.44","103.12","1514.10","21","833.03","1302.62","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1594.01","1195.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1281.58","80.4","","1365.00","1365.00","1365.00","1 through 10","833.03","1302.62","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1594.01","1195.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1302.62","81.72","","5157.68","5157.68","5157.68","1 through 10","833.03","1302.62","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1594.01","1195.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1302.62","81.72","","431.26","71.26","1459.57","88","833.03","1302.62","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1182.56","79.5","","800.18","480.96","1887.97","195","461.13","1182.56","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","792.84","53.3","","813.12","216.42","1444.50","81","461.13","1182.56","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","461.13","31","","432.60","432.60","432.60","1 through 10","461.13","1182.56","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","542.94","36.5","","148.37","54.89","631.39","94","461.13","1182.56","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","569.71","38.3","","279.30","91.72","1116.77","266","461.13","1182.56","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","638.14","42.9","","731.00","63.70","731.00","1 through 10","461.13","1182.56","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","638.14","42.9","","384.74","384.74","384.74","1 through 10","461.13","1182.56","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","WELLPOINT [1015]","HB AMC WELLPOINT","1097.48","73.78","","286.63","119.22","1107.45","105","461.13","1182.56","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","AETNA [1001]","HB AMC AETNA HMO","1038.28","69.8","","675.31","184.75","1721.50","286","777.37","1215.59","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","AETNA [1001]","HB AMC AETNA PPO","1195.95","80.4","","1261.44","103.12","1514.10","21","777.37","1215.59","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1195.95","80.4","","1365.00","1365.00","1365.00","1 through 10","777.37","1215.59","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1215.59","81.72","","5157.68","5157.68","5157.68","1 through 10","777.37","1215.59","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1215.59","81.72","","431.26","71.26","1459.57","88","777.37","1215.59","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","92.66","79.5","","800.18","480.96","1887.97","195","36.13","92.66","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","62.12","53.3","","813.12","216.42","1444.50","81","36.13","92.66","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","36.13","31","","432.60","432.60","432.60","1 through 10","36.13","92.66","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","42.54","36.5","","148.37","54.89","631.39","94","36.13","92.66","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44.64","38.3","","279.30","91.72","1116.77","266","36.13","92.66","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.00","42.9","","731.00","63.70","731.00","1 through 10","36.13","92.66","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.00","42.9","","384.74","384.74","384.74","1 through 10","36.13","92.66","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","WELLPOINT [1015]","HB AMC WELLPOINT","85.99","73.78","","286.63","119.22","1107.45","105","36.13","92.66","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","116.55","87.41","AETNA [1001]","HB AMC AETNA HMO","81.35","69.8","","675.31","184.75","1721.50","286","60.91","95.24","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","116.55","87.41","AETNA [1001]","HB AMC AETNA PPO","93.71","80.4","","1261.44","103.12","1514.10","21","60.91","95.24","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","116.55","87.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","93.71","80.4","","1365.00","1365.00","1365.00","1 through 10","60.91","95.24","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","116.55","87.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","95.24","81.72","","5157.68","5157.68","5157.68","1 through 10","60.91","95.24","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","116.55","87.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","95.24","81.72","","431.26","71.26","1459.57","88","60.91","95.24","percent of total billed charges",""
"SCREW BONE 12.7X50MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009526","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","714.49","79.5","","800.18","480.96","1887.97","195","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X50MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009526","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","479.02","53.3","","813.12","216.42","1444.50","81","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X50MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009526","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","278.61","31","","432.60","432.60","432.60","1 through 10","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X50MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009526","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","328.04","36.5","","148.37","54.89","631.39","94","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X50MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009526","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","344.21","38.3","","279.30","91.72","1116.77","266","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X50MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009526","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.56","42.9","","731.00","63.70","731.00","1 through 10","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X50MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009526","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.56","42.9","","384.74","384.74","384.74","1 through 10","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X50MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009526","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","WELLPOINT [1015]","HB AMC WELLPOINT","663.08","73.78","","286.63","119.22","1107.45","105","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X50MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","AETNA [1001]","HB AMC AETNA HMO","627.31","69.8","","675.31","184.75","1721.50","286","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X50MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","AETNA [1001]","HB AMC AETNA PPO","722.58","80.4","","1261.44","103.12","1514.10","21","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X50MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","722.58","80.4","","1365.00","1365.00","1365.00","1 through 10","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X50MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","734.44","81.72","","5157.68","5157.68","5157.68","1 through 10","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X50MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","734.44","81.72","","431.26","71.26","1459.57","88","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X55MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10011825","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","714.49","79.5","","800.18","480.96","1887.97","195","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X55MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10011825","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","479.02","53.3","","813.12","216.42","1444.50","81","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X55MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10011825","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","278.61","31","","432.60","432.60","432.60","1 through 10","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X55MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10011825","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","328.04","36.5","","148.37","54.89","631.39","94","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X55MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10011825","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","344.21","38.3","","279.30","91.72","1116.77","266","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X55MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10011825","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.56","42.9","","731.00","63.70","731.00","1 through 10","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X55MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10011825","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.56","42.9","","384.74","384.74","384.74","1 through 10","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X55MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10011825","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","WELLPOINT [1015]","HB AMC WELLPOINT","663.08","73.78","","286.63","119.22","1107.45","105","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X55MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10011825","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","AETNA [1001]","HB AMC AETNA HMO","627.31","69.8","","675.31","184.75","1721.50","286","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X55MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10011825","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","AETNA [1001]","HB AMC AETNA PPO","722.58","80.4","","1261.44","103.12","1514.10","21","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X55MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10011825","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","722.58","80.4","","1365.00","1365.00","1365.00","1 through 10","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X55MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10011825","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","734.44","81.72","","5157.68","5157.68","5157.68","1 through 10","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X55MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10011825","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","734.44","81.72","","431.26","71.26","1459.57","88","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","714.49","79.5","","800.18","480.96","1887.97","195","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","479.02","53.3","","813.12","216.42","1444.50","81","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","278.61","31","","432.60","432.60","432.60","1 through 10","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","328.04","36.5","","148.37","54.89","631.39","94","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","344.21","38.3","","279.30","91.72","1116.77","266","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.56","42.9","","731.00","63.70","731.00","1 through 10","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.56","42.9","","384.74","384.74","384.74","1 through 10","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","both","","","898.73","674.05","WELLPOINT [1015]","HB AMC WELLPOINT","663.08","73.78","","286.63","119.22","1107.45","105","278.61","714.49","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","AETNA [1001]","HB AMC AETNA HMO","627.31","69.8","","675.31","184.75","1721.50","286","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","AETNA [1001]","HB AMC AETNA PPO","722.58","80.4","","1261.44","103.12","1514.10","21","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","722.58","80.4","","1365.00","1365.00","1365.00","1 through 10","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","734.44","81.72","","5157.68","5157.68","5157.68","1 through 10","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","898.73","674.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","734.44","81.72","","431.26","71.26","1459.57","88","469.68","734.44","percent of total billed charges",""
"SCREW BONE 12X2.7MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10088504","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.00","367.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","389.55","79.5","","800.18","480.96","1887.97","195","151.9","389.55","percent of total billed charges",""
"SCREW BONE 12X2.7MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10088504","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.00","367.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","261.17","53.3","","813.12","216.42","1444.50","81","151.9","389.55","percent of total billed charges",""
"SCREW BONE 12X2.7MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10088504","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.00","367.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","151.90","31","","432.60","432.60","432.60","1 through 10","151.9","389.55","percent of total billed charges",""
"SCREW BONE 12X2.7MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10088504","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.00","367.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","178.85","36.5","","148.37","54.89","631.39","94","151.9","389.55","percent of total billed charges",""
"SCREW BONE 12X2.7MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10088504","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.00","367.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.67","38.3","","279.30","91.72","1116.77","266","151.9","389.55","percent of total billed charges",""
"SCREW BONE 12X2.7MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10088504","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.00","367.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.21","42.9","","731.00","63.70","731.00","1 through 10","151.9","389.55","percent of total billed charges",""
"SCREW BONE 12X2.7MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10088504","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.00","367.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.21","42.9","","384.74","384.74","384.74","1 through 10","151.9","389.55","percent of total billed charges",""
"SCREW BONE 12X2.7MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10088504","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.00","367.50","WELLPOINT [1015]","HB AMC WELLPOINT","361.52","73.78","","286.63","119.22","1107.45","105","151.9","389.55","percent of total billed charges",""
"SCREW BONE 12X2.7MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10088504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.00","367.50","AETNA [1001]","HB AMC AETNA HMO","342.02","69.8","","675.31","184.75","1721.50","286","256.07","400.43","percent of total billed charges",""
"SCREW BONE 12X2.7MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10088504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.00","367.50","AETNA [1001]","HB AMC AETNA PPO","393.96","80.4","","1261.44","103.12","1514.10","21","256.07","400.43","percent of total billed charges",""
"SCREW BONE 12X2.7MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10088504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.00","367.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","393.96","80.4","","1365.00","1365.00","1365.00","1 through 10","256.07","400.43","percent of total billed charges",""
"SCREW BONE 12X2.7MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10088504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.00","367.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","400.43","81.72","","5157.68","5157.68","5157.68","1 through 10","256.07","400.43","percent of total billed charges",""
"SCREW BONE 12X2.7MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10088504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.00","367.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","400.43","81.72","","431.26","71.26","1459.57","88","256.07","400.43","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.50","538.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.41","79.5","","800.18","480.96","1887.97","195","222.43","570.41","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.50","538.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","382.43","53.3","","813.12","216.42","1444.50","81","222.43","570.41","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.50","538.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","222.43","31","","432.60","432.60","432.60","1 through 10","222.43","570.41","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.50","538.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","261.89","36.5","","148.37","54.89","631.39","94","222.43","570.41","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.50","538.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.80","38.3","","279.30","91.72","1116.77","266","222.43","570.41","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.50","538.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.81","42.9","","731.00","63.70","731.00","1 through 10","222.43","570.41","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.50","538.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.81","42.9","","384.74","384.74","384.74","1 through 10","222.43","570.41","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","717.50","538.12","WELLPOINT [1015]","HB AMC WELLPOINT","529.37","73.78","","286.63","119.22","1107.45","105","222.43","570.41","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","717.50","538.12","AETNA [1001]","HB AMC AETNA HMO","500.82","69.8","","675.31","184.75","1721.50","286","374.97","586.34","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","717.50","538.12","AETNA [1001]","HB AMC AETNA PPO","576.87","80.4","","1261.44","103.12","1514.10","21","374.97","586.34","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","717.50","538.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","576.87","80.4","","1365.00","1365.00","1365.00","1 through 10","374.97","586.34","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","717.50","538.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","586.34","81.72","","5157.68","5157.68","5157.68","1 through 10","374.97","586.34","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","717.50","538.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","586.34","81.72","","431.26","71.26","1459.57","88","374.97","586.34","percent of total billed charges",""
"SCREW BONE 12X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130599","CDM","C1713","HCPCS","0278","RC","","","","both","","","374.50","280.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","297.73","79.5","","800.18","480.96","1887.97","195","116.1","297.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130599","CDM","C1713","HCPCS","0278","RC","","","","both","","","374.50","280.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","199.61","53.3","","813.12","216.42","1444.50","81","116.1","297.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130599","CDM","C1713","HCPCS","0278","RC","","","","both","","","374.50","280.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","116.10","31","","432.60","432.60","432.60","1 through 10","116.1","297.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130599","CDM","C1713","HCPCS","0278","RC","","","","both","","","374.50","280.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.69","36.5","","148.37","54.89","631.39","94","116.1","297.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130599","CDM","C1713","HCPCS","0278","RC","","","","both","","","374.50","280.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","143.43","38.3","","279.30","91.72","1116.77","266","116.1","297.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130599","CDM","C1713","HCPCS","0278","RC","","","","both","","","374.50","280.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.66","42.9","","731.00","63.70","731.00","1 through 10","116.1","297.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130599","CDM","C1713","HCPCS","0278","RC","","","","both","","","374.50","280.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.66","42.9","","384.74","384.74","384.74","1 through 10","116.1","297.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130599","CDM","C1713","HCPCS","0278","RC","","","","both","","","374.50","280.87","WELLPOINT [1015]","HB AMC WELLPOINT","276.31","73.78","","286.63","119.22","1107.45","105","116.1","297.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","374.50","280.87","AETNA [1001]","HB AMC AETNA HMO","261.40","69.8","","675.31","184.75","1721.50","286","195.71","306.04","percent of total billed charges",""
"SCREW BONE 12X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","374.50","280.87","AETNA [1001]","HB AMC AETNA PPO","301.10","80.4","","1261.44","103.12","1514.10","21","195.71","306.04","percent of total billed charges",""
"SCREW BONE 12X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","374.50","280.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","301.10","80.4","","1365.00","1365.00","1365.00","1 through 10","195.71","306.04","percent of total billed charges",""
"SCREW BONE 12X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","374.50","280.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","306.04","81.72","","5157.68","5157.68","5157.68","1 through 10","195.71","306.04","percent of total billed charges",""
"SCREW BONE 12X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","374.50","280.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","306.04","81.72","","431.26","71.26","1459.57","88","195.71","306.04","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","289.38","79.5","","800.18","480.96","1887.97","195","112.84","289.38","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","194.01","53.3","","813.12","216.42","1444.50","81","112.84","289.38","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","112.84","31","","432.60","432.60","432.60","1 through 10","112.84","289.38","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","132.86","36.5","","148.37","54.89","631.39","94","112.84","289.38","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","139.41","38.3","","279.30","91.72","1116.77","266","112.84","289.38","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.16","42.9","","731.00","63.70","731.00","1 through 10","112.84","289.38","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.16","42.9","","384.74","384.74","384.74","1 through 10","112.84","289.38","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.00","273.00","WELLPOINT [1015]","HB AMC WELLPOINT","268.56","73.78","","286.63","119.22","1107.45","105","112.84","289.38","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.00","273.00","AETNA [1001]","HB AMC AETNA HMO","254.07","69.8","","675.31","184.75","1721.50","286","190.23","297.46","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.00","273.00","AETNA [1001]","HB AMC AETNA PPO","292.66","80.4","","1261.44","103.12","1514.10","21","190.23","297.46","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.00","273.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","292.66","80.4","","1365.00","1365.00","1365.00","1 through 10","190.23","297.46","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","297.46","81.72","","5157.68","5157.68","5157.68","1 through 10","190.23","297.46","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","297.46","81.72","","431.26","71.26","1459.57","88","190.23","297.46","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.50","186.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","197.56","79.5","","800.18","480.96","1887.97","195","77.04","197.56","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.50","186.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","132.45","53.3","","813.12","216.42","1444.50","81","77.04","197.56","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.50","186.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","77.04","31","","432.60","432.60","432.60","1 through 10","77.04","197.56","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.50","186.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","90.70","36.5","","148.37","54.89","631.39","94","77.04","197.56","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.50","186.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","95.18","38.3","","279.30","91.72","1116.77","266","77.04","197.56","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.50","186.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.61","42.9","","731.00","63.70","731.00","1 through 10","77.04","197.56","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.50","186.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.61","42.9","","384.74","384.74","384.74","1 through 10","77.04","197.56","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.50","186.37","WELLPOINT [1015]","HB AMC WELLPOINT","183.34","73.78","","286.63","119.22","1107.45","105","77.04","197.56","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.50","186.37","AETNA [1001]","HB AMC AETNA HMO","173.45","69.8","","675.31","184.75","1721.50","286","129.87","203.07","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.50","186.37","AETNA [1001]","HB AMC AETNA PPO","199.79","80.4","","1261.44","103.12","1514.10","21","129.87","203.07","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.50","186.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","199.79","80.4","","1365.00","1365.00","1365.00","1 through 10","129.87","203.07","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.50","186.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","203.07","81.72","","5157.68","5157.68","5157.68","1 through 10","129.87","203.07","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.50","186.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","203.07","81.72","","431.26","71.26","1459.57","88","129.87","203.07","percent of total billed charges",""
"SCREW BONE 12X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","800.18","480.96","1887.97","195","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 12X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","813.12","216.42","1444.50","81","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 12X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","542.50","31","","432.60","432.60","432.60","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 12X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","148.37","54.89","631.39","94","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 12X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","279.30","91.72","1116.77","266","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 12X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","731.00","63.70","731.00","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 12X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","384.74","384.74","384.74","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 12X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","286.63","119.22","1107.45","105","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 12X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","675.31","184.75","1721.50","286","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 12X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1261.44","103.12","1514.10","21","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 12X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","1365.00","1365.00","1365.00","1 through 10","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 12X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1430.10","81.72","","5157.68","5157.68","5157.68","1 through 10","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 12X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","431.26","71.26","1459.57","88","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","97.39","79.5","","800.18","480.96","1887.97","195","37.98","97.39","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","65.29","53.3","","813.12","216.42","1444.50","81","37.98","97.39","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","37.98","31","","432.60","432.60","432.60","1 through 10","37.98","97.39","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.71","36.5","","148.37","54.89","631.39","94","37.98","97.39","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.92","38.3","","279.30","91.72","1116.77","266","37.98","97.39","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.55","42.9","","731.00","63.70","731.00","1 through 10","37.98","97.39","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.55","42.9","","384.74","384.74","384.74","1 through 10","37.98","97.39","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","WELLPOINT [1015]","HB AMC WELLPOINT","90.38","73.78","","286.63","119.22","1107.45","105","37.98","97.39","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","AETNA [1001]","HB AMC AETNA HMO","85.51","69.8","","675.31","184.75","1721.50","286","64.02","100.11","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","AETNA [1001]","HB AMC AETNA PPO","98.49","80.4","","1261.44","103.12","1514.10","21","64.02","100.11","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","98.49","80.4","","1365.00","1365.00","1365.00","1 through 10","64.02","100.11","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","100.11","81.72","","5157.68","5157.68","5157.68","1 through 10","64.02","100.11","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","100.11","81.72","","431.26","71.26","1459.57","88","64.02","100.11","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","219.82","79.5","","800.18","480.96","1887.97","195","85.72","219.82","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.37","53.3","","813.12","216.42","1444.50","81","85.72","219.82","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.72","31","","432.60","432.60","432.60","1 through 10","85.72","219.82","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.92","36.5","","148.37","54.89","631.39","94","85.72","219.82","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.90","38.3","","279.30","91.72","1116.77","266","85.72","219.82","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.62","42.9","","731.00","63.70","731.00","1 through 10","85.72","219.82","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.62","42.9","","384.74","384.74","384.74","1 through 10","85.72","219.82","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","WELLPOINT [1015]","HB AMC WELLPOINT","204.00","73.78","","286.63","119.22","1107.45","105","85.72","219.82","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","AETNA [1001]","HB AMC AETNA HMO","193.00","69.8","","675.31","184.75","1721.50","286","144.5","225.96","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","AETNA [1001]","HB AMC AETNA PPO","222.31","80.4","","1261.44","103.12","1514.10","21","144.5","225.96","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","222.31","80.4","","1365.00","1365.00","1365.00","1 through 10","144.5","225.96","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","225.96","81.72","","5157.68","5157.68","5157.68","1 through 10","144.5","225.96","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","225.96","81.72","","431.26","71.26","1459.57","88","144.5","225.96","percent of total billed charges",""
"SCREW BONE 14X125MM LAG DHS DCS ONE STEP THREAD","SUP-ITM-10038242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","907.02","79.5","","800.18","480.96","1887.97","195","353.68","907.02","percent of total billed charges",""
"SCREW BONE 14X125MM LAG DHS DCS ONE STEP THREAD","SUP-ITM-10038242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","608.10","53.3","","813.12","216.42","1444.50","81","353.68","907.02","percent of total billed charges",""
"SCREW BONE 14X125MM LAG DHS DCS ONE STEP THREAD","SUP-ITM-10038242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","353.68","31","","432.60","432.60","432.60","1 through 10","353.68","907.02","percent of total billed charges",""
"SCREW BONE 14X125MM LAG DHS DCS ONE STEP THREAD","SUP-ITM-10038242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","416.43","36.5","","148.37","54.89","631.39","94","353.68","907.02","percent of total billed charges",""
"SCREW BONE 14X125MM LAG DHS DCS ONE STEP THREAD","SUP-ITM-10038242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","436.96","38.3","","279.30","91.72","1116.77","266","353.68","907.02","percent of total billed charges",""
"SCREW BONE 14X125MM LAG DHS DCS ONE STEP THREAD","SUP-ITM-10038242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","489.45","42.9","","731.00","63.70","731.00","1 through 10","353.68","907.02","percent of total billed charges",""
"SCREW BONE 14X125MM LAG DHS DCS ONE STEP THREAD","SUP-ITM-10038242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","489.45","42.9","","384.74","384.74","384.74","1 through 10","353.68","907.02","percent of total billed charges",""
"SCREW BONE 14X125MM LAG DHS DCS ONE STEP THREAD","SUP-ITM-10038242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.90","855.67","WELLPOINT [1015]","HB AMC WELLPOINT","841.76","73.78","","286.63","119.22","1107.45","105","353.68","907.02","percent of total billed charges",""
"SCREW BONE 14X125MM LAG DHS DCS ONE STEP THREAD","SUP-ITM-10038242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.90","855.67","AETNA [1001]","HB AMC AETNA HMO","796.35","69.8","","675.31","184.75","1721.50","286","596.23","932.34","percent of total billed charges",""
"SCREW BONE 14X125MM LAG DHS DCS ONE STEP THREAD","SUP-ITM-10038242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.90","855.67","AETNA [1001]","HB AMC AETNA PPO","917.28","80.4","","1261.44","103.12","1514.10","21","596.23","932.34","percent of total billed charges",""
"SCREW BONE 14X125MM LAG DHS DCS ONE STEP THREAD","SUP-ITM-10038242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.90","855.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","917.28","80.4","","1365.00","1365.00","1365.00","1 through 10","596.23","932.34","percent of total billed charges",""
"SCREW BONE 14X125MM LAG DHS DCS ONE STEP THREAD","SUP-ITM-10038242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.90","855.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","932.34","81.72","","5157.68","5157.68","5157.68","1 through 10","596.23","932.34","percent of total billed charges",""
"SCREW BONE 14X125MM LAG DHS DCS ONE STEP THREAD","SUP-ITM-10038242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.90","855.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","932.34","81.72","","431.26","71.26","1459.57","88","596.23","932.34","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","134.70","79.5","","800.18","480.96","1887.97","195","52.53","134.7","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","90.31","53.3","","813.12","216.42","1444.50","81","52.53","134.7","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","52.53","31","","432.60","432.60","432.60","1 through 10","52.53","134.7","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","61.85","36.5","","148.37","54.89","631.39","94","52.53","134.7","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64.90","38.3","","279.30","91.72","1116.77","266","52.53","134.7","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.69","42.9","","731.00","63.70","731.00","1 through 10","52.53","134.7","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.69","42.9","","384.74","384.74","384.74","1 through 10","52.53","134.7","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","WELLPOINT [1015]","HB AMC WELLPOINT","125.01","73.78","","286.63","119.22","1107.45","105","52.53","134.7","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.44","127.08","AETNA [1001]","HB AMC AETNA HMO","118.27","69.8","","675.31","184.75","1721.50","286","88.55","138.47","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.44","127.08","AETNA [1001]","HB AMC AETNA PPO","136.23","80.4","","1261.44","103.12","1514.10","21","88.55","138.47","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.44","127.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","136.23","80.4","","1365.00","1365.00","1365.00","1 through 10","88.55","138.47","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.44","127.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","138.47","81.72","","5157.68","5157.68","5157.68","1 through 10","88.55","138.47","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.44","127.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","138.47","81.72","","431.26","71.26","1459.57","88","88.55","138.47","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","651.11","79.5","","800.18","480.96","1887.97","195","253.89","651.11","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","436.53","53.3","","813.12","216.42","1444.50","81","253.89","651.11","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","253.89","31","","432.60","432.60","432.60","1 through 10","253.89","651.11","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","298.94","36.5","","148.37","54.89","631.39","94","253.89","651.11","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","313.68","38.3","","279.30","91.72","1116.77","266","253.89","651.11","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.35","42.9","","731.00","63.70","731.00","1 through 10","253.89","651.11","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.35","42.9","","384.74","384.74","384.74","1 through 10","253.89","651.11","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","819.00","614.25","WELLPOINT [1015]","HB AMC WELLPOINT","604.26","73.78","","286.63","119.22","1107.45","105","253.89","651.11","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","AETNA [1001]","HB AMC AETNA HMO","571.66","69.8","","675.31","184.75","1721.50","286","428.01","669.29","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","AETNA [1001]","HB AMC AETNA PPO","658.48","80.4","","1261.44","103.12","1514.10","21","428.01","669.29","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","658.48","80.4","","1365.00","1365.00","1365.00","1 through 10","428.01","669.29","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","669.29","81.72","","5157.68","5157.68","5157.68","1 through 10","428.01","669.29","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","819.00","614.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","669.29","81.72","","431.26","71.26","1459.57","88","428.01","669.29","percent of total billed charges",""
"SCREW BONE 14X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019552","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","800.18","480.96","1887.97","195","217","556.5","percent of total billed charges",""
"SCREW BONE 14X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019552","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","813.12","216.42","1444.50","81","217","556.5","percent of total billed charges",""
"SCREW BONE 14X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019552","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","217.00","31","","432.60","432.60","432.60","1 through 10","217","556.5","percent of total billed charges",""
"SCREW BONE 14X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019552","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","148.37","54.89","631.39","94","217","556.5","percent of total billed charges",""
"SCREW BONE 14X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019552","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","279.30","91.72","1116.77","266","217","556.5","percent of total billed charges",""
"SCREW BONE 14X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019552","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","731.00","63.70","731.00","1 through 10","217","556.5","percent of total billed charges",""
"SCREW BONE 14X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019552","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","384.74","384.74","384.74","1 through 10","217","556.5","percent of total billed charges",""
"SCREW BONE 14X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019552","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","286.63","119.22","1107.45","105","217","556.5","percent of total billed charges",""
"SCREW BONE 14X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","675.31","184.75","1721.50","286","365.82","572.04","percent of total billed charges",""
"SCREW BONE 14X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA PPO","562.80","80.4","","1261.44","103.12","1514.10","21","365.82","572.04","percent of total billed charges",""
"SCREW BONE 14X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","562.80","80.4","","1365.00","1365.00","1365.00","1 through 10","365.82","572.04","percent of total billed charges",""
"SCREW BONE 14X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","572.04","81.72","","5157.68","5157.68","5157.68","1 through 10","365.82","572.04","percent of total billed charges",""
"SCREW BONE 14X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","431.26","71.26","1459.57","88","365.82","572.04","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","169.73","79.5","","800.18","480.96","1887.97","195","66.19","169.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","113.80","53.3","","813.12","216.42","1444.50","81","66.19","169.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","66.19","31","","432.60","432.60","432.60","1 through 10","66.19","169.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.93","36.5","","148.37","54.89","631.39","94","66.19","169.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.77","38.3","","279.30","91.72","1116.77","266","66.19","169.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.59","42.9","","731.00","63.70","731.00","1 through 10","66.19","169.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.59","42.9","","384.74","384.74","384.74","1 through 10","66.19","169.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","WELLPOINT [1015]","HB AMC WELLPOINT","157.52","73.78","","286.63","119.22","1107.45","105","66.19","169.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.50","160.12","AETNA [1001]","HB AMC AETNA HMO","149.02","69.8","","675.31","184.75","1721.50","286","111.58","174.47","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.50","160.12","AETNA [1001]","HB AMC AETNA PPO","171.65","80.4","","1261.44","103.12","1514.10","21","111.58","174.47","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.50","160.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","171.65","80.4","","1365.00","1365.00","1365.00","1 through 10","111.58","174.47","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.50","160.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","174.47","81.72","","5157.68","5157.68","5157.68","1 through 10","111.58","174.47","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.50","160.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.47","81.72","","431.26","71.26","1459.57","88","111.58","174.47","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.00","341.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","361.73","79.5","","800.18","480.96","1887.97","195","141.05","361.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.00","341.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.52","53.3","","813.12","216.42","1444.50","81","141.05","361.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","141.05","31","","432.60","432.60","432.60","1 through 10","141.05","361.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.08","36.5","","148.37","54.89","631.39","94","141.05","361.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.27","38.3","","279.30","91.72","1116.77","266","141.05","361.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.20","42.9","","731.00","63.70","731.00","1 through 10","141.05","361.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.00","341.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.20","42.9","","384.74","384.74","384.74","1 through 10","141.05","361.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.00","341.25","WELLPOINT [1015]","HB AMC WELLPOINT","335.70","73.78","","286.63","119.22","1107.45","105","141.05","361.73","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","675.31","184.75","1721.50","286","237.78","371.83","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA PPO","365.82","80.4","","1261.44","103.12","1514.10","21","237.78","371.83","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","365.82","80.4","","1365.00","1365.00","1365.00","1 through 10","237.78","371.83","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","371.83","81.72","","5157.68","5157.68","5157.68","1 through 10","237.78","371.83","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.83","81.72","","431.26","71.26","1459.57","88","237.78","371.83","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","385.00","288.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","306.08","79.5","","1309.77","674.56","6049.93","26","119.35","306.08","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","385.00","288.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","205.21","53.3","","1901.83","1901.83","2962.25","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","140.53","36.5","","1620.31","1620.31","19908.88","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","147.46","38.3","","352.91","352.91","2046.30","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","165.17","42.9","","9668.75","9668.75","9668.75","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","385.00","288.75","WELLPOINT [1015]","HB AMC WELLPOINT","284.05","73.78","","699.88","384.10","3443.31","33","119.35","306.08","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","AETNA [1001]","HB AMC AETNA HMO","268.73","69.8","","1421.24","264.50","4933.46","29","201.2","314.62","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","309.54","80.4","","1022.97","1022.97","3607.50","1 through 10","201.2","314.62","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","314.62","81.72","","3010.54","693.88","5019.88","35","201.2","314.62","percent of total billed charges",""
"SCREW BONE 14X4.6MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM SELF DRILLING GOLD","SUP-ITM-10017577","CDM","C1889","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","1309.77","674.56","6049.93","26","97.65","250.43","percent of total billed charges",""
"SCREW BONE 14X4.6MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM SELF DRILLING GOLD","SUP-ITM-10017577","CDM","C1889","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","1901.83","1901.83","2962.25","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 14X4.6MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM SELF DRILLING GOLD","SUP-ITM-10017577","CDM","C1889","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","1620.31","1620.31","19908.88","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 14X4.6MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM SELF DRILLING GOLD","SUP-ITM-10017577","CDM","C1889","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","352.91","352.91","2046.30","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 14X4.6MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM SELF DRILLING GOLD","SUP-ITM-10017577","CDM","C1889","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","9668.75","9668.75","9668.75","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 14X4.6MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM SELF DRILLING GOLD","SUP-ITM-10017577","CDM","C1889","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB AMC WELLPOINT","232.41","73.78","","699.88","384.10","3443.31","33","97.65","250.43","percent of total billed charges",""
"SCREW BONE 14X4.6MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM SELF DRILLING GOLD","SUP-ITM-10017577","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","1421.24","264.50","4933.46","29","164.62","257.42","percent of total billed charges",""
"SCREW BONE 14X4.6MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM SELF DRILLING GOLD","SUP-ITM-10017577","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","1022.97","1022.97","3607.50","1 through 10","164.62","257.42","percent of total billed charges",""
"SCREW BONE 14X4.6MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM SELF DRILLING GOLD","SUP-ITM-10017577","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","3010.54","693.88","5019.88","35","164.62","257.42","percent of total billed charges",""
"SCREW BONE 14X60MM LAG DHS DCS ONE STEP THREAD SS","SUP-ITM-10009419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.69","759.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","805.09","79.5","","800.18","480.96","1887.97","195","313.93","805.09","percent of total billed charges",""
"SCREW BONE 14X60MM LAG DHS DCS ONE STEP THREAD SS","SUP-ITM-10009419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.69","759.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","539.76","53.3","","813.12","216.42","1444.50","81","313.93","805.09","percent of total billed charges",""
"SCREW BONE 14X60MM LAG DHS DCS ONE STEP THREAD SS","SUP-ITM-10009419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.69","759.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","313.93","31","","432.60","432.60","432.60","1 through 10","313.93","805.09","percent of total billed charges",""
"SCREW BONE 14X60MM LAG DHS DCS ONE STEP THREAD SS","SUP-ITM-10009419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.69","759.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","369.63","36.5","","148.37","54.89","631.39","94","313.93","805.09","percent of total billed charges",""
"SCREW BONE 14X60MM LAG DHS DCS ONE STEP THREAD SS","SUP-ITM-10009419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.69","759.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","387.86","38.3","","279.30","91.72","1116.77","266","313.93","805.09","percent of total billed charges",""
"SCREW BONE 14X60MM LAG DHS DCS ONE STEP THREAD SS","SUP-ITM-10009419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.69","759.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.44","42.9","","731.00","63.70","731.00","1 through 10","313.93","805.09","percent of total billed charges",""
"SCREW BONE 14X60MM LAG DHS DCS ONE STEP THREAD SS","SUP-ITM-10009419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.69","759.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.44","42.9","","384.74","384.74","384.74","1 through 10","313.93","805.09","percent of total billed charges",""
"SCREW BONE 14X60MM LAG DHS DCS ONE STEP THREAD SS","SUP-ITM-10009419","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.69","759.52","WELLPOINT [1015]","HB AMC WELLPOINT","747.16","73.78","","286.63","119.22","1107.45","105","313.93","805.09","percent of total billed charges",""
"SCREW BONE 14X60MM LAG DHS DCS ONE STEP THREAD SS","SUP-ITM-10009419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.69","759.52","AETNA [1001]","HB AMC AETNA HMO","706.86","69.8","","675.31","184.75","1721.50","286","529.23","827.57","percent of total billed charges",""
"SCREW BONE 14X60MM LAG DHS DCS ONE STEP THREAD SS","SUP-ITM-10009419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.69","759.52","AETNA [1001]","HB AMC AETNA PPO","814.20","80.4","","1261.44","103.12","1514.10","21","529.23","827.57","percent of total billed charges",""
"SCREW BONE 14X60MM LAG DHS DCS ONE STEP THREAD SS","SUP-ITM-10009419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.69","759.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","814.20","80.4","","1365.00","1365.00","1365.00","1 through 10","529.23","827.57","percent of total billed charges",""
"SCREW BONE 14X60MM LAG DHS DCS ONE STEP THREAD SS","SUP-ITM-10009419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.69","759.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","827.57","81.72","","5157.68","5157.68","5157.68","1 through 10","529.23","827.57","percent of total billed charges",""
"SCREW BONE 14X60MM LAG DHS DCS ONE STEP THREAD SS","SUP-ITM-10009419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.69","759.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","827.57","81.72","","431.26","71.26","1459.57","88","529.23","827.57","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","151.90","79.5","","800.18","480.96","1887.97","195","59.23","151.9","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","101.84","53.3","","813.12","216.42","1444.50","81","59.23","151.9","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","59.23","31","","432.60","432.60","432.60","1 through 10","59.23","151.9","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","69.74","36.5","","148.37","54.89","631.39","94","59.23","151.9","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.18","38.3","","279.30","91.72","1116.77","266","59.23","151.9","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.97","42.9","","731.00","63.70","731.00","1 through 10","59.23","151.9","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.97","42.9","","384.74","384.74","384.74","1 through 10","59.23","151.9","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","WELLPOINT [1015]","HB AMC WELLPOINT","140.97","73.78","","286.63","119.22","1107.45","105","59.23","151.9","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.07","143.30","AETNA [1001]","HB AMC AETNA HMO","133.37","69.8","","675.31","184.75","1721.50","286","99.85","156.14","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.07","143.30","AETNA [1001]","HB AMC AETNA PPO","153.62","80.4","","1261.44","103.12","1514.10","21","99.85","156.14","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.07","143.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","153.62","80.4","","1365.00","1365.00","1365.00","1 through 10","99.85","156.14","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.07","143.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","156.14","81.72","","5157.68","5157.68","5157.68","1 through 10","99.85","156.14","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.07","143.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","156.14","81.72","","431.26","71.26","1459.57","88","99.85","156.14","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1207.50","905.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","959.96","79.5","","800.18","480.96","1887.97","195","374.33","959.96","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1207.50","905.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","643.60","53.3","","813.12","216.42","1444.50","81","374.33","959.96","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1207.50","905.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","374.33","31","","432.60","432.60","432.60","1 through 10","374.33","959.96","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1207.50","905.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","440.74","36.5","","148.37","54.89","631.39","94","374.33","959.96","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1207.50","905.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","462.47","38.3","","279.30","91.72","1116.77","266","374.33","959.96","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1207.50","905.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","518.02","42.9","","731.00","63.70","731.00","1 through 10","374.33","959.96","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1207.50","905.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","518.02","42.9","","384.74","384.74","384.74","1 through 10","374.33","959.96","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1207.50","905.62","WELLPOINT [1015]","HB AMC WELLPOINT","890.89","73.78","","286.63","119.22","1107.45","105","374.33","959.96","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1207.50","905.62","AETNA [1001]","HB AMC AETNA HMO","842.84","69.8","","675.31","184.75","1721.50","286","631.04","986.77","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1207.50","905.62","AETNA [1001]","HB AMC AETNA PPO","970.83","80.4","","1261.44","103.12","1514.10","21","631.04","986.77","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1207.50","905.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","970.83","80.4","","1365.00","1365.00","1365.00","1 through 10","631.04","986.77","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1207.50","905.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","986.77","81.72","","5157.68","5157.68","5157.68","1 through 10","631.04","986.77","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1207.50","905.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","986.77","81.72","","431.26","71.26","1459.57","88","631.04","986.77","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","220.10","79.5","","800.18","480.96","1887.97","195","85.82","220.1","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.56","53.3","","813.12","216.42","1444.50","81","85.82","220.1","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.82","31","","432.60","432.60","432.60","1 through 10","85.82","220.1","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","101.05","36.5","","148.37","54.89","631.39","94","85.82","220.1","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","106.03","38.3","","279.30","91.72","1116.77","266","85.82","220.1","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.77","42.9","","731.00","63.70","731.00","1 through 10","85.82","220.1","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.77","42.9","","384.74","384.74","384.74","1 through 10","85.82","220.1","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.85","207.64","WELLPOINT [1015]","HB AMC WELLPOINT","204.26","73.78","","286.63","119.22","1107.45","105","85.82","220.1","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","AETNA [1001]","HB AMC AETNA HMO","193.24","69.8","","675.31","184.75","1721.50","286","144.68","226.24","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","AETNA [1001]","HB AMC AETNA PPO","222.59","80.4","","1261.44","103.12","1514.10","21","144.68","226.24","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","222.59","80.4","","1365.00","1365.00","1365.00","1 through 10","144.68","226.24","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","226.24","81.72","","5157.68","5157.68","5157.68","1 through 10","144.68","226.24","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.85","207.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","226.24","81.72","","431.26","71.26","1459.57","88","144.68","226.24","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","both","","","577.50","433.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","459.11","79.5","","1309.77","674.56","6049.93","26","179.03","459.11","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","both","","","577.50","433.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","307.81","53.3","","1901.83","1901.83","2962.25","1 through 10","179.03","459.11","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","210.79","36.5","","1620.31","1620.31","19908.88","1 through 10","179.03","459.11","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","221.18","38.3","","352.91","352.91","2046.30","1 through 10","179.03","459.11","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.75","42.9","","9668.75","9668.75","9668.75","1 through 10","179.03","459.11","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","both","","","577.50","433.12","WELLPOINT [1015]","HB AMC WELLPOINT","426.08","73.78","","699.88","384.10","3443.31","33","179.03","459.11","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","AETNA [1001]","HB AMC AETNA HMO","403.10","69.8","","1421.24","264.50","4933.46","29","301.8","471.93","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","464.31","80.4","","1022.97","1022.97","3607.50","1 through 10","301.8","471.93","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","471.93","81.72","","3010.54","693.88","5019.88","35","301.8","471.93","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","239.30","79.5","","800.18","480.96","1887.97","195","93.31","239.3","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","160.43","53.3","","813.12","216.42","1444.50","81","93.31","239.3","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","93.31","31","","432.60","432.60","432.60","1 through 10","93.31","239.3","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","109.87","36.5","","148.37","54.89","631.39","94","93.31","239.3","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","115.28","38.3","","279.30","91.72","1116.77","266","93.31","239.3","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.13","42.9","","731.00","63.70","731.00","1 through 10","93.31","239.3","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.13","42.9","","384.74","384.74","384.74","1 through 10","93.31","239.3","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.00","225.75","WELLPOINT [1015]","HB AMC WELLPOINT","222.08","73.78","","286.63","119.22","1107.45","105","93.31","239.3","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.00","225.75","AETNA [1001]","HB AMC AETNA HMO","210.10","69.8","","675.31","184.75","1721.50","286","157.3","245.98","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.00","225.75","AETNA [1001]","HB AMC AETNA PPO","242.00","80.4","","1261.44","103.12","1514.10","21","157.3","245.98","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.00","225.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","242.00","80.4","","1365.00","1365.00","1365.00","1 through 10","157.3","245.98","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","245.98","81.72","","5157.68","5157.68","5157.68","1 through 10","157.3","245.98","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","245.98","81.72","","431.26","71.26","1459.57","88","157.3","245.98","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","269.40","79.5","","800.18","480.96","1887.97","195","105.05","269.4","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","180.62","53.3","","813.12","216.42","1444.50","81","105.05","269.4","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","105.05","31","","432.60","432.60","432.60","1 through 10","105.05","269.4","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.69","36.5","","148.37","54.89","631.39","94","105.05","269.4","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","129.79","38.3","","279.30","91.72","1116.77","266","105.05","269.4","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.38","42.9","","731.00","63.70","731.00","1 through 10","105.05","269.4","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.38","42.9","","384.74","384.74","384.74","1 through 10","105.05","269.4","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","WELLPOINT [1015]","HB AMC WELLPOINT","250.02","73.78","","286.63","119.22","1107.45","105","105.05","269.4","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","AETNA [1001]","HB AMC AETNA HMO","236.53","69.8","","675.31","184.75","1721.50","286","177.09","276.92","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","AETNA [1001]","HB AMC AETNA PPO","272.45","80.4","","1261.44","103.12","1514.10","21","177.09","276.92","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","272.45","80.4","","1365.00","1365.00","1365.00","1 through 10","177.09","276.92","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","276.92","81.72","","5157.68","5157.68","5157.68","1 through 10","177.09","276.92","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","276.92","81.72","","431.26","71.26","1459.57","88","177.09","276.92","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","800.18","480.96","1887.97","195","97.65","250.43","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","813.12","216.42","1444.50","81","97.65","250.43","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","97.65","31","","432.60","432.60","432.60","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","148.37","54.89","631.39","94","97.65","250.43","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","279.30","91.72","1116.77","266","97.65","250.43","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","731.00","63.70","731.00","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","384.74","384.74","384.74","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB AMC WELLPOINT","232.41","73.78","","286.63","119.22","1107.45","105","97.65","250.43","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","675.31","184.75","1721.50","286","164.62","257.42","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA PPO","253.26","80.4","","1261.44","103.12","1514.10","21","164.62","257.42","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","1365.00","1365.00","1365.00","1 through 10","164.62","257.42","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","257.42","81.72","","5157.68","5157.68","5157.68","1 through 10","164.62","257.42","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","431.26","71.26","1459.57","88","164.62","257.42","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","264.34","79.5","","800.18","480.96","1887.97","195","103.08","264.34","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","177.22","53.3","","813.12","216.42","1444.50","81","103.08","264.34","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","103.08","31","","432.60","432.60","432.60","1 through 10","103.08","264.34","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.36","36.5","","148.37","54.89","631.39","94","103.08","264.34","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.35","38.3","","279.30","91.72","1116.77","266","103.08","264.34","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.64","42.9","","731.00","63.70","731.00","1 through 10","103.08","264.34","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.64","42.9","","384.74","384.74","384.74","1 through 10","103.08","264.34","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","WELLPOINT [1015]","HB AMC WELLPOINT","245.32","73.78","","286.63","119.22","1107.45","105","103.08","264.34","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.50","249.37","AETNA [1001]","HB AMC AETNA HMO","232.09","69.8","","675.31","184.75","1721.50","286","173.76","271.72","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.50","249.37","AETNA [1001]","HB AMC AETNA PPO","267.33","80.4","","1261.44","103.12","1514.10","21","173.76","271.72","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.50","249.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","267.33","80.4","","1365.00","1365.00","1365.00","1 through 10","173.76","271.72","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.50","249.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","271.72","81.72","","5157.68","5157.68","5157.68","1 through 10","173.76","271.72","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.50","249.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","271.72","81.72","","431.26","71.26","1459.57","88","173.76","271.72","percent of total billed charges",""
"SCREW BONE 18MM 6.7X70 CANNULATED TITANIUM LOW PROFILE THREAD","SUP-ITM-10046552","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","800.18","480.96","1887.97","195","271.25","695.63","percent of total billed charges",""
"SCREW BONE 18MM 6.7X70 CANNULATED TITANIUM LOW PROFILE THREAD","SUP-ITM-10046552","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","813.12","216.42","1444.50","81","271.25","695.63","percent of total billed charges",""
"SCREW BONE 18MM 6.7X70 CANNULATED TITANIUM LOW PROFILE THREAD","SUP-ITM-10046552","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.25","31","","432.60","432.60","432.60","1 through 10","271.25","695.63","percent of total billed charges",""
"SCREW BONE 18MM 6.7X70 CANNULATED TITANIUM LOW PROFILE THREAD","SUP-ITM-10046552","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","148.37","54.89","631.39","94","271.25","695.63","percent of total billed charges",""
"SCREW BONE 18MM 6.7X70 CANNULATED TITANIUM LOW PROFILE THREAD","SUP-ITM-10046552","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","279.30","91.72","1116.77","266","271.25","695.63","percent of total billed charges",""
"SCREW BONE 18MM 6.7X70 CANNULATED TITANIUM LOW PROFILE THREAD","SUP-ITM-10046552","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","731.00","63.70","731.00","1 through 10","271.25","695.63","percent of total billed charges",""
"SCREW BONE 18MM 6.7X70 CANNULATED TITANIUM LOW PROFILE THREAD","SUP-ITM-10046552","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","384.74","384.74","384.74","1 through 10","271.25","695.63","percent of total billed charges",""
"SCREW BONE 18MM 6.7X70 CANNULATED TITANIUM LOW PROFILE THREAD","SUP-ITM-10046552","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","286.63","119.22","1107.45","105","271.25","695.63","percent of total billed charges",""
"SCREW BONE 18MM 6.7X70 CANNULATED TITANIUM LOW PROFILE THREAD","SUP-ITM-10046552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","675.31","184.75","1721.50","286","457.28","715.05","percent of total billed charges",""
"SCREW BONE 18MM 6.7X70 CANNULATED TITANIUM LOW PROFILE THREAD","SUP-ITM-10046552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA PPO","703.50","80.4","","1261.44","103.12","1514.10","21","457.28","715.05","percent of total billed charges",""
"SCREW BONE 18MM 6.7X70 CANNULATED TITANIUM LOW PROFILE THREAD","SUP-ITM-10046552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1365.00","1365.00","1365.00","1 through 10","457.28","715.05","percent of total billed charges",""
"SCREW BONE 18MM 6.7X70 CANNULATED TITANIUM LOW PROFILE THREAD","SUP-ITM-10046552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","715.05","81.72","","5157.68","5157.68","5157.68","1 through 10","457.28","715.05","percent of total billed charges",""
"SCREW BONE 18MM 6.7X70 CANNULATED TITANIUM LOW PROFILE THREAD","SUP-ITM-10046552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","431.26","71.26","1459.57","88","457.28","715.05","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","347.81","79.5","","800.18","480.96","1887.97","195","135.63","347.81","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","233.19","53.3","","813.12","216.42","1444.50","81","135.63","347.81","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","135.63","31","","432.60","432.60","432.60","1 through 10","135.63","347.81","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","159.69","36.5","","148.37","54.89","631.39","94","135.63","347.81","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","167.56","38.3","","279.30","91.72","1116.77","266","135.63","347.81","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.69","42.9","","731.00","63.70","731.00","1 through 10","135.63","347.81","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.69","42.9","","384.74","384.74","384.74","1 through 10","135.63","347.81","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","WELLPOINT [1015]","HB AMC WELLPOINT","322.79","73.78","","286.63","119.22","1107.45","105","135.63","347.81","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","AETNA [1001]","HB AMC AETNA HMO","305.38","69.8","","675.31","184.75","1721.50","286","228.64","357.53","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","AETNA [1001]","HB AMC AETNA PPO","351.75","80.4","","1261.44","103.12","1514.10","21","228.64","357.53","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","351.75","80.4","","1365.00","1365.00","1365.00","1 through 10","228.64","357.53","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","357.53","81.72","","5157.68","5157.68","5157.68","1 through 10","228.64","357.53","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","357.53","81.72","","431.26","71.26","1459.57","88","228.64","357.53","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","517.55","79.5","","800.18","480.96","1887.97","195","201.81","517.55","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","346.98","53.3","","813.12","216.42","1444.50","81","201.81","517.55","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","201.81","31","","432.60","432.60","432.60","1 through 10","201.81","517.55","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","237.62","36.5","","148.37","54.89","631.39","94","201.81","517.55","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","249.33","38.3","","279.30","91.72","1116.77","266","201.81","517.55","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","279.28","42.9","","731.00","63.70","731.00","1 through 10","201.81","517.55","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","279.28","42.9","","384.74","384.74","384.74","1 through 10","201.81","517.55","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","WELLPOINT [1015]","HB AMC WELLPOINT","480.31","73.78","","286.63","119.22","1107.45","105","201.81","517.55","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.00","488.25","AETNA [1001]","HB AMC AETNA HMO","454.40","69.8","","675.31","184.75","1721.50","286","340.21","532","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.00","488.25","AETNA [1001]","HB AMC AETNA PPO","523.40","80.4","","1261.44","103.12","1514.10","21","340.21","532","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.00","488.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","523.40","80.4","","1365.00","1365.00","1365.00","1 through 10","340.21","532","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.00","488.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","532.00","81.72","","5157.68","5157.68","5157.68","1 through 10","340.21","532","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.00","488.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","532.00","81.72","","431.26","71.26","1459.57","88","340.21","532","percent of total billed charges",""
"SCREW BONE 1X7MM CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10003783","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","150.12","79.5","","800.18","480.96","1887.97","195","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1X7MM CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10003783","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.65","53.3","","813.12","216.42","1444.50","81","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1X7MM CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10003783","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","58.54","31","","432.60","432.60","432.60","1 through 10","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1X7MM CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10003783","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.92","36.5","","148.37","54.89","631.39","94","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1X7MM CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10003783","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.32","38.3","","279.30","91.72","1116.77","266","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1X7MM CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10003783","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.01","42.9","","731.00","63.70","731.00","1 through 10","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1X7MM CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10003783","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.01","42.9","","384.74","384.74","384.74","1 through 10","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1X7MM CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10003783","CDM","C1713","HCPCS","0278","RC","","","","both","","","188.83","141.62","WELLPOINT [1015]","HB AMC WELLPOINT","139.32","73.78","","286.63","119.22","1107.45","105","58.54","150.12","percent of total billed charges",""
"SCREW BONE 1X7MM CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10003783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","188.83","141.62","AETNA [1001]","HB AMC AETNA HMO","131.80","69.8","","675.31","184.75","1721.50","286","98.68","154.31","percent of total billed charges",""
"SCREW BONE 1X7MM CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10003783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","188.83","141.62","AETNA [1001]","HB AMC AETNA PPO","151.82","80.4","","1261.44","103.12","1514.10","21","98.68","154.31","percent of total billed charges",""
"SCREW BONE 1X7MM CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10003783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","188.83","141.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","151.82","80.4","","1365.00","1365.00","1365.00","1 through 10","98.68","154.31","percent of total billed charges",""
"SCREW BONE 1X7MM CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10003783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","188.83","141.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","154.31","81.72","","5157.68","5157.68","5157.68","1 through 10","98.68","154.31","percent of total billed charges",""
"SCREW BONE 1X7MM CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10003783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","188.83","141.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","154.31","81.72","","431.26","71.26","1459.57","88","98.68","154.31","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","164.72","79.5","","800.18","480.96","1887.97","195","64.23","164.72","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","110.44","53.3","","813.12","216.42","1444.50","81","64.23","164.72","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","64.23","31","","432.60","432.60","432.60","1 through 10","64.23","164.72","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","75.63","36.5","","148.37","54.89","631.39","94","64.23","164.72","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","79.36","38.3","","279.30","91.72","1116.77","266","64.23","164.72","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.89","42.9","","731.00","63.70","731.00","1 through 10","64.23","164.72","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.89","42.9","","384.74","384.74","384.74","1 through 10","64.23","164.72","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","WELLPOINT [1015]","HB AMC WELLPOINT","152.87","73.78","","286.63","119.22","1107.45","105","64.23","164.72","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","AETNA [1001]","HB AMC AETNA HMO","144.63","69.8","","675.31","184.75","1721.50","286","108.28","169.32","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","AETNA [1001]","HB AMC AETNA PPO","166.59","80.4","","1261.44","103.12","1514.10","21","108.28","169.32","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","166.59","80.4","","1365.00","1365.00","1365.00","1 through 10","108.28","169.32","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","169.32","81.72","","5157.68","5157.68","5157.68","1 through 10","108.28","169.32","percent of total billed charges",""
"SCREW BONE 1X8MM HAND CORTICAL SELF TAPPING TI MODULAR SYSTEM","SUP-ITM-10002184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","169.32","81.72","","431.26","71.26","1459.57","88","108.28","169.32","percent of total billed charges",""
"SCREW BONE 2.0X7.0MM LORENZ TITANIUM SELF DRILLING CROSS DRIVE HIGH TORQUE BLUE","SUP-ITM-10042843","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","222.60","79.5","","800.18","480.96","1887.97","195","86.8","222.6","percent of total billed charges",""
"SCREW BONE 2.0X7.0MM LORENZ TITANIUM SELF DRILLING CROSS DRIVE HIGH TORQUE BLUE","SUP-ITM-10042843","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","149.24","53.3","","813.12","216.42","1444.50","81","86.8","222.6","percent of total billed charges",""
"SCREW BONE 2.0X7.0MM LORENZ TITANIUM SELF DRILLING CROSS DRIVE HIGH TORQUE BLUE","SUP-ITM-10042843","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","86.80","31","","432.60","432.60","432.60","1 through 10","86.8","222.6","percent of total billed charges",""
"SCREW BONE 2.0X7.0MM LORENZ TITANIUM SELF DRILLING CROSS DRIVE HIGH TORQUE BLUE","SUP-ITM-10042843","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","102.20","36.5","","148.37","54.89","631.39","94","86.8","222.6","percent of total billed charges",""
"SCREW BONE 2.0X7.0MM LORENZ TITANIUM SELF DRILLING CROSS DRIVE HIGH TORQUE BLUE","SUP-ITM-10042843","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","107.24","38.3","","279.30","91.72","1116.77","266","86.8","222.6","percent of total billed charges",""
"SCREW BONE 2.0X7.0MM LORENZ TITANIUM SELF DRILLING CROSS DRIVE HIGH TORQUE BLUE","SUP-ITM-10042843","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.12","42.9","","731.00","63.70","731.00","1 through 10","86.8","222.6","percent of total billed charges",""
"SCREW BONE 2.0X7.0MM LORENZ TITANIUM SELF DRILLING CROSS DRIVE HIGH TORQUE BLUE","SUP-ITM-10042843","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.12","42.9","","384.74","384.74","384.74","1 through 10","86.8","222.6","percent of total billed charges",""
"SCREW BONE 2.0X7.0MM LORENZ TITANIUM SELF DRILLING CROSS DRIVE HIGH TORQUE BLUE","SUP-ITM-10042843","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.00","210.00","WELLPOINT [1015]","HB AMC WELLPOINT","206.58","73.78","","286.63","119.22","1107.45","105","86.8","222.6","percent of total billed charges",""
"SCREW BONE 2.0X7.0MM LORENZ TITANIUM SELF DRILLING CROSS DRIVE HIGH TORQUE BLUE","SUP-ITM-10042843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","AETNA [1001]","HB AMC AETNA HMO","195.44","69.8","","675.31","184.75","1721.50","286","146.33","228.82","percent of total billed charges",""
"SCREW BONE 2.0X7.0MM LORENZ TITANIUM SELF DRILLING CROSS DRIVE HIGH TORQUE BLUE","SUP-ITM-10042843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","AETNA [1001]","HB AMC AETNA PPO","225.12","80.4","","1261.44","103.12","1514.10","21","146.33","228.82","percent of total billed charges",""
"SCREW BONE 2.0X7.0MM LORENZ TITANIUM SELF DRILLING CROSS DRIVE HIGH TORQUE BLUE","SUP-ITM-10042843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","225.12","80.4","","1365.00","1365.00","1365.00","1 through 10","146.33","228.82","percent of total billed charges",""
"SCREW BONE 2.0X7.0MM LORENZ TITANIUM SELF DRILLING CROSS DRIVE HIGH TORQUE BLUE","SUP-ITM-10042843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","228.82","81.72","","5157.68","5157.68","5157.68","1 through 10","146.33","228.82","percent of total billed charges",""
"SCREW BONE 2.0X7.0MM LORENZ TITANIUM SELF DRILLING CROSS DRIVE HIGH TORQUE BLUE","SUP-ITM-10042843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.00","210.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","228.82","81.72","","431.26","71.26","1459.57","88","146.33","228.82","percent of total billed charges",""
"SCREW BONE 2.0X7MM FIXATION TITANIUM FOSSA CROSS DRIVE","SUP-ITM-10126231","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.50","312.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","331.12","79.5","","800.18","480.96","1887.97","195","129.12","331.12","percent of total billed charges",""
"SCREW BONE 2.0X7MM FIXATION TITANIUM FOSSA CROSS DRIVE","SUP-ITM-10126231","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.50","312.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","221.99","53.3","","813.12","216.42","1444.50","81","129.12","331.12","percent of total billed charges",""
"SCREW BONE 2.0X7MM FIXATION TITANIUM FOSSA CROSS DRIVE","SUP-ITM-10126231","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.50","312.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","129.12","31","","432.60","432.60","432.60","1 through 10","129.12","331.12","percent of total billed charges",""
"SCREW BONE 2.0X7MM FIXATION TITANIUM FOSSA CROSS DRIVE","SUP-ITM-10126231","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.50","312.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","152.02","36.5","","148.37","54.89","631.39","94","129.12","331.12","percent of total billed charges",""
"SCREW BONE 2.0X7MM FIXATION TITANIUM FOSSA CROSS DRIVE","SUP-ITM-10126231","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.50","312.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","159.52","38.3","","279.30","91.72","1116.77","266","129.12","331.12","percent of total billed charges",""
"SCREW BONE 2.0X7MM FIXATION TITANIUM FOSSA CROSS DRIVE","SUP-ITM-10126231","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.50","312.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.68","42.9","","731.00","63.70","731.00","1 through 10","129.12","331.12","percent of total billed charges",""
"SCREW BONE 2.0X7MM FIXATION TITANIUM FOSSA CROSS DRIVE","SUP-ITM-10126231","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.50","312.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.68","42.9","","384.74","384.74","384.74","1 through 10","129.12","331.12","percent of total billed charges",""
"SCREW BONE 2.0X7MM FIXATION TITANIUM FOSSA CROSS DRIVE","SUP-ITM-10126231","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.50","312.37","WELLPOINT [1015]","HB AMC WELLPOINT","307.29","73.78","","286.63","119.22","1107.45","105","129.12","331.12","percent of total billed charges",""
"SCREW BONE 2.0X7MM FIXATION TITANIUM FOSSA CROSS DRIVE","SUP-ITM-10126231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.50","312.37","AETNA [1001]","HB AMC AETNA HMO","290.72","69.8","","675.31","184.75","1721.50","286","217.66","340.36","percent of total billed charges",""
"SCREW BONE 2.0X7MM FIXATION TITANIUM FOSSA CROSS DRIVE","SUP-ITM-10126231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.50","312.37","AETNA [1001]","HB AMC AETNA PPO","334.87","80.4","","1261.44","103.12","1514.10","21","217.66","340.36","percent of total billed charges",""
"SCREW BONE 2.0X7MM FIXATION TITANIUM FOSSA CROSS DRIVE","SUP-ITM-10126231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.50","312.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","334.87","80.4","","1365.00","1365.00","1365.00","1 through 10","217.66","340.36","percent of total billed charges",""
"SCREW BONE 2.0X7MM FIXATION TITANIUM FOSSA CROSS DRIVE","SUP-ITM-10126231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.50","312.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","340.36","81.72","","5157.68","5157.68","5157.68","1 through 10","217.66","340.36","percent of total billed charges",""
"SCREW BONE 2.0X7MM FIXATION TITANIUM FOSSA CROSS DRIVE","SUP-ITM-10126231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.50","312.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","340.36","81.72","","431.26","71.26","1459.57","88","217.66","340.36","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.51","494.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","524.31","79.5","","800.18","480.96","1887.97","195","204.45","524.31","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.51","494.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","351.52","53.3","","813.12","216.42","1444.50","81","204.45","524.31","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.51","494.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","204.45","31","","432.60","432.60","432.60","1 through 10","204.45","524.31","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.51","494.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","240.72","36.5","","148.37","54.89","631.39","94","204.45","524.31","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.51","494.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","252.59","38.3","","279.30","91.72","1116.77","266","204.45","524.31","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.51","494.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","282.93","42.9","","731.00","63.70","731.00","1 through 10","204.45","524.31","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.51","494.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","282.93","42.9","","384.74","384.74","384.74","1 through 10","204.45","524.31","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","659.51","494.63","WELLPOINT [1015]","HB AMC WELLPOINT","486.59","73.78","","286.63","119.22","1107.45","105","204.45","524.31","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.51","494.63","AETNA [1001]","HB AMC AETNA HMO","460.34","69.8","","675.31","184.75","1721.50","286","344.66","538.95","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.51","494.63","AETNA [1001]","HB AMC AETNA PPO","530.25","80.4","","1261.44","103.12","1514.10","21","344.66","538.95","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.51","494.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","530.25","80.4","","1365.00","1365.00","1365.00","1 through 10","344.66","538.95","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.51","494.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","538.95","81.72","","5157.68","5157.68","5157.68","1 through 10","344.66","538.95","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","659.51","494.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","538.95","81.72","","431.26","71.26","1459.57","88","344.66","538.95","percent of total billed charges",""
"SCREW BONE 2.3X8MM LOCKING SD","SUP-ITM-10317488","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.75","374.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","396.51","79.5","","800.18","480.96","1887.97","195","154.61","396.51","percent of total billed charges",""
"SCREW BONE 2.3X8MM LOCKING SD","SUP-ITM-10317488","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.75","374.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","265.83","53.3","","813.12","216.42","1444.50","81","154.61","396.51","percent of total billed charges",""
"SCREW BONE 2.3X8MM LOCKING SD","SUP-ITM-10317488","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.75","374.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","154.61","31","","432.60","432.60","432.60","1 through 10","154.61","396.51","percent of total billed charges",""
"SCREW BONE 2.3X8MM LOCKING SD","SUP-ITM-10317488","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.75","374.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","182.04","36.5","","148.37","54.89","631.39","94","154.61","396.51","percent of total billed charges",""
"SCREW BONE 2.3X8MM LOCKING SD","SUP-ITM-10317488","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.75","374.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","191.02","38.3","","279.30","91.72","1116.77","266","154.61","396.51","percent of total billed charges",""
"SCREW BONE 2.3X8MM LOCKING SD","SUP-ITM-10317488","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.75","374.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.96","42.9","","731.00","63.70","731.00","1 through 10","154.61","396.51","percent of total billed charges",""
"SCREW BONE 2.3X8MM LOCKING SD","SUP-ITM-10317488","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.75","374.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.96","42.9","","384.74","384.74","384.74","1 through 10","154.61","396.51","percent of total billed charges",""
"SCREW BONE 2.3X8MM LOCKING SD","SUP-ITM-10317488","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.75","374.06","WELLPOINT [1015]","HB AMC WELLPOINT","367.98","73.78","","286.63","119.22","1107.45","105","154.61","396.51","percent of total billed charges",""
"SCREW BONE 2.3X8MM LOCKING SD","SUP-ITM-10317488","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.75","374.06","AETNA [1001]","HB AMC AETNA HMO","348.13","69.8","","675.31","184.75","1721.50","286","260.65","407.58","percent of total billed charges",""
"SCREW BONE 2.3X8MM LOCKING SD","SUP-ITM-10317488","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.75","374.06","AETNA [1001]","HB AMC AETNA PPO","401.00","80.4","","1261.44","103.12","1514.10","21","260.65","407.58","percent of total billed charges",""
"SCREW BONE 2.3X8MM LOCKING SD","SUP-ITM-10317488","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.75","374.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","401.00","80.4","","1365.00","1365.00","1365.00","1 through 10","260.65","407.58","percent of total billed charges",""
"SCREW BONE 2.3X8MM LOCKING SD","SUP-ITM-10317488","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.75","374.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","407.58","81.72","","5157.68","5157.68","5157.68","1 through 10","260.65","407.58","percent of total billed charges",""
"SCREW BONE 2.3X8MM LOCKING SD","SUP-ITM-10317488","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.75","374.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","407.58","81.72","","431.26","71.26","1459.57","88","260.65","407.58","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.88","335.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","355.27","79.5","","800.18","480.96","1887.97","195","138.53","355.27","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.88","335.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","238.19","53.3","","813.12","216.42","1444.50","81","138.53","355.27","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.88","335.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","138.53","31","","432.60","432.60","432.60","1 through 10","138.53","355.27","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.88","335.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","163.11","36.5","","148.37","54.89","631.39","94","138.53","355.27","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.88","335.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","171.16","38.3","","279.30","91.72","1116.77","266","138.53","355.27","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.88","335.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","191.71","42.9","","731.00","63.70","731.00","1 through 10","138.53","355.27","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.88","335.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","191.71","42.9","","384.74","384.74","384.74","1 through 10","138.53","355.27","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.88","335.16","WELLPOINT [1015]","HB AMC WELLPOINT","329.71","73.78","","286.63","119.22","1107.45","105","138.53","355.27","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.88","335.16","AETNA [1001]","HB AMC AETNA HMO","311.92","69.8","","675.31","184.75","1721.50","286","233.54","365.19","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.88","335.16","AETNA [1001]","HB AMC AETNA PPO","359.29","80.4","","1261.44","103.12","1514.10","21","233.54","365.19","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.88","335.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","359.29","80.4","","1365.00","1365.00","1365.00","1 through 10","233.54","365.19","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.88","335.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","365.19","81.72","","5157.68","5157.68","5157.68","1 through 10","233.54","365.19","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.88","335.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","365.19","81.72","","431.26","71.26","1459.57","88","233.54","365.19","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.58","79.5","","800.18","480.96","1887.97","195","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.52","53.3","","813.12","216.42","1444.50","81","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.58","31","","432.60","432.60","432.60","1 through 10","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.20","36.5","","148.37","54.89","631.39","94","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.02","38.3","","279.30","91.72","1116.77","266","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.22","42.9","","731.00","63.70","731.00","1 through 10","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.22","42.9","","384.74","384.74","384.74","1 through 10","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","WELLPOINT [1015]","HB AMC WELLPOINT","115.61","73.78","","286.63","119.22","1107.45","105","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.70","117.52","AETNA [1001]","HB AMC AETNA HMO","109.38","69.8","","675.31","184.75","1721.50","286","81.89","128.06","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.70","117.52","AETNA [1001]","HB AMC AETNA PPO","125.99","80.4","","1261.44","103.12","1514.10","21","81.89","128.06","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.70","117.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","125.99","80.4","","1365.00","1365.00","1365.00","1 through 10","81.89","128.06","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.70","117.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.06","81.72","","5157.68","5157.68","5157.68","1 through 10","81.89","128.06","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.70","117.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.06","81.72","","431.26","71.26","1459.57","88","81.89","128.06","percent of total billed charges",""
"SCREW BONE 2.4X10MM ESCALATE TITANIUM SELF TAPPING","SUP-ITM-10107144","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","194.78","79.5","","800.18","480.96","1887.97","195","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.4X10MM ESCALATE TITANIUM SELF TAPPING","SUP-ITM-10107144","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.59","53.3","","813.12","216.42","1444.50","81","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.4X10MM ESCALATE TITANIUM SELF TAPPING","SUP-ITM-10107144","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","75.95","31","","432.60","432.60","432.60","1 through 10","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.4X10MM ESCALATE TITANIUM SELF TAPPING","SUP-ITM-10107144","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.43","36.5","","148.37","54.89","631.39","94","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.4X10MM ESCALATE TITANIUM SELF TAPPING","SUP-ITM-10107144","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.84","38.3","","279.30","91.72","1116.77","266","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.4X10MM ESCALATE TITANIUM SELF TAPPING","SUP-ITM-10107144","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.11","42.9","","731.00","63.70","731.00","1 through 10","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.4X10MM ESCALATE TITANIUM SELF TAPPING","SUP-ITM-10107144","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.11","42.9","","384.74","384.74","384.74","1 through 10","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.4X10MM ESCALATE TITANIUM SELF TAPPING","SUP-ITM-10107144","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","WELLPOINT [1015]","HB AMC WELLPOINT","180.76","73.78","","286.63","119.22","1107.45","105","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.4X10MM ESCALATE TITANIUM SELF TAPPING","SUP-ITM-10107144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA HMO","171.01","69.8","","675.31","184.75","1721.50","286","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2.4X10MM ESCALATE TITANIUM SELF TAPPING","SUP-ITM-10107144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA PPO","196.98","80.4","","1261.44","103.12","1514.10","21","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2.4X10MM ESCALATE TITANIUM SELF TAPPING","SUP-ITM-10107144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","196.98","80.4","","1365.00","1365.00","1365.00","1 through 10","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2.4X10MM ESCALATE TITANIUM SELF TAPPING","SUP-ITM-10107144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","200.21","81.72","","5157.68","5157.68","5157.68","1 through 10","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2.4X10MM ESCALATE TITANIUM SELF TAPPING","SUP-ITM-10107144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","200.21","81.72","","431.26","71.26","1459.57","88","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2.4X10MM MANDIBLE LOCKING SELF TAPPING CRUCIFORM RECESS NON TI PK/5EA","SUP-ITM-10006047","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.50","968.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1026.74","79.5","","800.18","480.96","1887.97","195","400.37","1026.74","percent of total billed charges",""
"SCREW BONE 2.4X10MM MANDIBLE LOCKING SELF TAPPING CRUCIFORM RECESS NON TI PK/5EA","SUP-ITM-10006047","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.50","968.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","688.37","53.3","","813.12","216.42","1444.50","81","400.37","1026.74","percent of total billed charges",""
"SCREW BONE 2.4X10MM MANDIBLE LOCKING SELF TAPPING CRUCIFORM RECESS NON TI PK/5EA","SUP-ITM-10006047","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.50","968.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","400.37","31","","432.60","432.60","432.60","1 through 10","400.37","1026.74","percent of total billed charges",""
"SCREW BONE 2.4X10MM MANDIBLE LOCKING SELF TAPPING CRUCIFORM RECESS NON TI PK/5EA","SUP-ITM-10006047","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.50","968.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","471.40","36.5","","148.37","54.89","631.39","94","400.37","1026.74","percent of total billed charges",""
"SCREW BONE 2.4X10MM MANDIBLE LOCKING SELF TAPPING CRUCIFORM RECESS NON TI PK/5EA","SUP-ITM-10006047","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.50","968.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","494.64","38.3","","279.30","91.72","1116.77","266","400.37","1026.74","percent of total billed charges",""
"SCREW BONE 2.4X10MM MANDIBLE LOCKING SELF TAPPING CRUCIFORM RECESS NON TI PK/5EA","SUP-ITM-10006047","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.50","968.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","554.05","42.9","","731.00","63.70","731.00","1 through 10","400.37","1026.74","percent of total billed charges",""
"SCREW BONE 2.4X10MM MANDIBLE LOCKING SELF TAPPING CRUCIFORM RECESS NON TI PK/5EA","SUP-ITM-10006047","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.50","968.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","554.05","42.9","","384.74","384.74","384.74","1 through 10","400.37","1026.74","percent of total billed charges",""
"SCREW BONE 2.4X10MM MANDIBLE LOCKING SELF TAPPING CRUCIFORM RECESS NON TI PK/5EA","SUP-ITM-10006047","CDM","C1713","HCPCS","0278","RC","","","","both","","","1291.50","968.62","WELLPOINT [1015]","HB AMC WELLPOINT","952.87","73.78","","286.63","119.22","1107.45","105","400.37","1026.74","percent of total billed charges",""
"SCREW BONE 2.4X10MM MANDIBLE LOCKING SELF TAPPING CRUCIFORM RECESS NON TI PK/5EA","SUP-ITM-10006047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1291.50","968.62","AETNA [1001]","HB AMC AETNA HMO","901.47","69.8","","675.31","184.75","1721.50","286","674.94","1055.41","percent of total billed charges",""
"SCREW BONE 2.4X10MM MANDIBLE LOCKING SELF TAPPING CRUCIFORM RECESS NON TI PK/5EA","SUP-ITM-10006047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1291.50","968.62","AETNA [1001]","HB AMC AETNA PPO","1038.37","80.4","","1261.44","103.12","1514.10","21","674.94","1055.41","percent of total billed charges",""
"SCREW BONE 2.4X10MM MANDIBLE LOCKING SELF TAPPING CRUCIFORM RECESS NON TI PK/5EA","SUP-ITM-10006047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1291.50","968.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1038.37","80.4","","1365.00","1365.00","1365.00","1 through 10","674.94","1055.41","percent of total billed charges",""
"SCREW BONE 2.4X10MM MANDIBLE LOCKING SELF TAPPING CRUCIFORM RECESS NON TI PK/5EA","SUP-ITM-10006047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1291.50","968.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1055.41","81.72","","5157.68","5157.68","5157.68","1 through 10","674.94","1055.41","percent of total billed charges",""
"SCREW BONE 2.4X10MM MANDIBLE LOCKING SELF TAPPING CRUCIFORM RECESS NON TI PK/5EA","SUP-ITM-10006047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1291.50","968.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1055.41","81.72","","431.26","71.26","1459.57","88","674.94","1055.41","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","302.68","79.5","","800.18","480.96","1887.97","195","118.03","302.68","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","202.93","53.3","","813.12","216.42","1444.50","81","118.03","302.68","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","118.03","31","","432.60","432.60","432.60","1 through 10","118.03","302.68","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","138.97","36.5","","148.37","54.89","631.39","94","118.03","302.68","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","145.82","38.3","","279.30","91.72","1116.77","266","118.03","302.68","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.33","42.9","","731.00","63.70","731.00","1 through 10","118.03","302.68","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.33","42.9","","384.74","384.74","384.74","1 through 10","118.03","302.68","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","380.73","285.55","WELLPOINT [1015]","HB AMC WELLPOINT","280.90","73.78","","286.63","119.22","1107.45","105","118.03","302.68","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","380.73","285.55","AETNA [1001]","HB AMC AETNA HMO","265.75","69.8","","675.31","184.75","1721.50","286","198.97","311.13","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","380.73","285.55","AETNA [1001]","HB AMC AETNA PPO","306.11","80.4","","1261.44","103.12","1514.10","21","198.97","311.13","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","380.73","285.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","306.11","80.4","","1365.00","1365.00","1365.00","1 through 10","198.97","311.13","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","380.73","285.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","311.13","81.72","","5157.68","5157.68","5157.68","1 through 10","198.97","311.13","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","380.73","285.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","311.13","81.72","","431.26","71.26","1459.57","88","198.97","311.13","percent of total billed charges",""
"SCREW BONE 2.4X10MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10175029","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","732.83","79.5","","800.18","480.96","1887.97","195","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X10MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10175029","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","491.32","53.3","","813.12","216.42","1444.50","81","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X10MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10175029","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","285.76","31","","432.60","432.60","432.60","1 through 10","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X10MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10175029","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","336.46","36.5","","148.37","54.89","631.39","94","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X10MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10175029","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","353.05","38.3","","279.30","91.72","1116.77","266","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X10MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10175029","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","395.45","42.9","","731.00","63.70","731.00","1 through 10","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X10MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10175029","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","395.45","42.9","","384.74","384.74","384.74","1 through 10","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X10MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10175029","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","WELLPOINT [1015]","HB AMC WELLPOINT","680.10","73.78","","286.63","119.22","1107.45","105","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X10MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10175029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","AETNA [1001]","HB AMC AETNA HMO","643.42","69.8","","675.31","184.75","1721.50","286","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.4X10MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10175029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","AETNA [1001]","HB AMC AETNA PPO","741.13","80.4","","1261.44","103.12","1514.10","21","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.4X10MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10175029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","741.13","80.4","","1365.00","1365.00","1365.00","1 through 10","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.4X10MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10175029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","753.29","81.72","","5157.68","5157.68","5157.68","1 through 10","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.4X10MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10175029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","753.29","81.72","","431.26","71.26","1459.57","88","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.44","150.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.35","79.5","","800.18","480.96","1887.97","195","62.14","159.35","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.44","150.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.83","53.3","","813.12","216.42","1444.50","81","62.14","159.35","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.44","150.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","62.14","31","","432.60","432.60","432.60","1 through 10","62.14","159.35","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.44","150.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.16","36.5","","148.37","54.89","631.39","94","62.14","159.35","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.44","150.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.77","38.3","","279.30","91.72","1116.77","266","62.14","159.35","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.44","150.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.99","42.9","","731.00","63.70","731.00","1 through 10","62.14","159.35","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.44","150.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.99","42.9","","384.74","384.74","384.74","1 through 10","62.14","159.35","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.44","150.33","WELLPOINT [1015]","HB AMC WELLPOINT","147.88","73.78","","286.63","119.22","1107.45","105","62.14","159.35","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.44","150.33","AETNA [1001]","HB AMC AETNA HMO","139.91","69.8","","675.31","184.75","1721.50","286","104.75","163.8","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.44","150.33","AETNA [1001]","HB AMC AETNA PPO","161.15","80.4","","1261.44","103.12","1514.10","21","104.75","163.8","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.44","150.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","161.15","80.4","","1365.00","1365.00","1365.00","1 through 10","104.75","163.8","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.44","150.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","163.80","81.72","","5157.68","5157.68","5157.68","1 through 10","104.75","163.8","percent of total billed charges",""
"SCREW BONE 2.4X12MM CRANIAL CORTEX TI SELF TAPPING CRUCIFORM RECESS GOLD PK/5EA","SUP-ITM-10004297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.44","150.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.80","81.72","","431.26","71.26","1459.57","88","104.75","163.8","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.69","176.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","187.37","79.5","","800.18","480.96","1887.97","195","73.06","187.37","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.69","176.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","125.62","53.3","","813.12","216.42","1444.50","81","73.06","187.37","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.69","176.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","73.06","31","","432.60","432.60","432.60","1 through 10","73.06","187.37","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.69","176.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","86.03","36.5","","148.37","54.89","631.39","94","73.06","187.37","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.69","176.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","90.27","38.3","","279.30","91.72","1116.77","266","73.06","187.37","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.69","176.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.11","42.9","","731.00","63.70","731.00","1 through 10","73.06","187.37","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.69","176.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.11","42.9","","384.74","384.74","384.74","1 through 10","73.06","187.37","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.69","176.77","WELLPOINT [1015]","HB AMC WELLPOINT","173.89","73.78","","286.63","119.22","1107.45","105","73.06","187.37","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.69","176.77","AETNA [1001]","HB AMC AETNA HMO","164.51","69.8","","675.31","184.75","1721.50","286","123.17","192.61","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.69","176.77","AETNA [1001]","HB AMC AETNA PPO","189.49","80.4","","1261.44","103.12","1514.10","21","123.17","192.61","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.69","176.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","189.49","80.4","","1365.00","1365.00","1365.00","1 through 10","123.17","192.61","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.69","176.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","192.61","81.72","","5157.68","5157.68","5157.68","1 through 10","123.17","192.61","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.69","176.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","192.61","81.72","","431.26","71.26","1459.57","88","123.17","192.61","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.65","262.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","277.97","79.5","","800.18","480.96","1887.97","195","108.39","277.97","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.65","262.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","186.36","53.3","","813.12","216.42","1444.50","81","108.39","277.97","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.65","262.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","108.39","31","","432.60","432.60","432.60","1 through 10","108.39","277.97","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.65","262.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.62","36.5","","148.37","54.89","631.39","94","108.39","277.97","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.65","262.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","133.92","38.3","","279.30","91.72","1116.77","266","108.39","277.97","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.65","262.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.00","42.9","","731.00","63.70","731.00","1 through 10","108.39","277.97","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.65","262.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.00","42.9","","384.74","384.74","384.74","1 through 10","108.39","277.97","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.65","262.24","WELLPOINT [1015]","HB AMC WELLPOINT","257.97","73.78","","286.63","119.22","1107.45","105","108.39","277.97","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.65","262.24","AETNA [1001]","HB AMC AETNA HMO","244.06","69.8","","675.31","184.75","1721.50","286","182.73","285.73","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.65","262.24","AETNA [1001]","HB AMC AETNA PPO","281.12","80.4","","1261.44","103.12","1514.10","21","182.73","285.73","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.65","262.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","281.12","80.4","","1365.00","1365.00","1365.00","1 through 10","182.73","285.73","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.65","262.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","285.73","81.72","","5157.68","5157.68","5157.68","1 through 10","182.73","285.73","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.65","262.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","285.73","81.72","","431.26","71.26","1459.57","88","182.73","285.73","percent of total billed charges",""
"SCREW BONE 2.4X12MM MANDIBLE MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING","SUP-ITM-10131162","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.89","300.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","318.71","79.5","","800.18","480.96","1887.97","195","124.28","318.71","percent of total billed charges",""
"SCREW BONE 2.4X12MM MANDIBLE MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING","SUP-ITM-10131162","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.89","300.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","213.67","53.3","","813.12","216.42","1444.50","81","124.28","318.71","percent of total billed charges",""
"SCREW BONE 2.4X12MM MANDIBLE MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING","SUP-ITM-10131162","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.89","300.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","124.28","31","","432.60","432.60","432.60","1 through 10","124.28","318.71","percent of total billed charges",""
"SCREW BONE 2.4X12MM MANDIBLE MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING","SUP-ITM-10131162","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.89","300.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","146.32","36.5","","148.37","54.89","631.39","94","124.28","318.71","percent of total billed charges",""
"SCREW BONE 2.4X12MM MANDIBLE MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING","SUP-ITM-10131162","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.89","300.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","153.54","38.3","","279.30","91.72","1116.77","266","124.28","318.71","percent of total billed charges",""
"SCREW BONE 2.4X12MM MANDIBLE MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING","SUP-ITM-10131162","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.89","300.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","171.98","42.9","","731.00","63.70","731.00","1 through 10","124.28","318.71","percent of total billed charges",""
"SCREW BONE 2.4X12MM MANDIBLE MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING","SUP-ITM-10131162","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.89","300.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","171.98","42.9","","384.74","384.74","384.74","1 through 10","124.28","318.71","percent of total billed charges",""
"SCREW BONE 2.4X12MM MANDIBLE MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING","SUP-ITM-10131162","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.89","300.67","WELLPOINT [1015]","HB AMC WELLPOINT","295.78","73.78","","286.63","119.22","1107.45","105","124.28","318.71","percent of total billed charges",""
"SCREW BONE 2.4X12MM MANDIBLE MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING","SUP-ITM-10131162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.89","300.67","AETNA [1001]","HB AMC AETNA HMO","279.82","69.8","","675.31","184.75","1721.50","286","209.51","327.61","percent of total billed charges",""
"SCREW BONE 2.4X12MM MANDIBLE MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING","SUP-ITM-10131162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.89","300.67","AETNA [1001]","HB AMC AETNA PPO","322.32","80.4","","1261.44","103.12","1514.10","21","209.51","327.61","percent of total billed charges",""
"SCREW BONE 2.4X12MM MANDIBLE MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING","SUP-ITM-10131162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.89","300.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","322.32","80.4","","1365.00","1365.00","1365.00","1 through 10","209.51","327.61","percent of total billed charges",""
"SCREW BONE 2.4X12MM MANDIBLE MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING","SUP-ITM-10131162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.89","300.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","327.61","81.72","","5157.68","5157.68","5157.68","1 through 10","209.51","327.61","percent of total billed charges",""
"SCREW BONE 2.4X12MM MANDIBLE MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING","SUP-ITM-10131162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.89","300.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","327.61","81.72","","431.26","71.26","1459.57","88","209.51","327.61","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","428.98","79.5","","800.18","480.96","1887.97","195","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","287.61","53.3","","813.12","216.42","1444.50","81","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","167.28","31","","432.60","432.60","432.60","1 through 10","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","196.95","36.5","","148.37","54.89","631.39","94","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","206.67","38.3","","279.30","91.72","1116.77","266","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.49","42.9","","731.00","63.70","731.00","1 through 10","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.49","42.9","","384.74","384.74","384.74","1 through 10","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","WELLPOINT [1015]","HB AMC WELLPOINT","398.12","73.78","","286.63","119.22","1107.45","105","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.60","404.70","AETNA [1001]","HB AMC AETNA HMO","376.64","69.8","","675.31","184.75","1721.50","286","281.99","440.96","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.60","404.70","AETNA [1001]","HB AMC AETNA PPO","433.84","80.4","","1261.44","103.12","1514.10","21","281.99","440.96","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.60","404.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","433.84","80.4","","1365.00","1365.00","1365.00","1 through 10","281.99","440.96","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.60","404.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","440.96","81.72","","5157.68","5157.68","5157.68","1 through 10","281.99","440.96","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.60","404.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","440.96","81.72","","431.26","71.26","1459.57","88","281.99","440.96","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.24","129.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","136.93","79.5","","800.18","480.96","1887.97","195","53.39","136.93","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.24","129.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","91.80","53.3","","813.12","216.42","1444.50","81","53.39","136.93","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.24","129.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","53.39","31","","432.60","432.60","432.60","1 through 10","53.39","136.93","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.24","129.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","62.87","36.5","","148.37","54.89","631.39","94","53.39","136.93","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.24","129.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","65.97","38.3","","279.30","91.72","1116.77","266","53.39","136.93","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.24","129.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","73.89","42.9","","731.00","63.70","731.00","1 through 10","53.39","136.93","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.24","129.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","73.89","42.9","","384.74","384.74","384.74","1 through 10","53.39","136.93","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.24","129.18","WELLPOINT [1015]","HB AMC WELLPOINT","127.08","73.78","","286.63","119.22","1107.45","105","53.39","136.93","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.24","129.18","AETNA [1001]","HB AMC AETNA HMO","120.22","69.8","","675.31","184.75","1721.50","286","90.01","140.75","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.24","129.18","AETNA [1001]","HB AMC AETNA PPO","138.48","80.4","","1261.44","103.12","1514.10","21","90.01","140.75","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.24","129.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","138.48","80.4","","1365.00","1365.00","1365.00","1 through 10","90.01","140.75","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.24","129.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","140.75","81.72","","5157.68","5157.68","5157.68","1 through 10","90.01","140.75","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.24","129.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","140.75","81.72","","431.26","71.26","1459.57","88","90.01","140.75","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","252.24","79.5","","800.18","480.96","1887.97","195","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","169.11","53.3","","813.12","216.42","1444.50","81","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","98.36","31","","432.60","432.60","432.60","1 through 10","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","115.81","36.5","","148.37","54.89","631.39","94","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.52","38.3","","279.30","91.72","1116.77","266","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","136.11","42.9","","731.00","63.70","731.00","1 through 10","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","136.11","42.9","","384.74","384.74","384.74","1 through 10","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","WELLPOINT [1015]","HB AMC WELLPOINT","234.09","73.78","","286.63","119.22","1107.45","105","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.28","237.96","AETNA [1001]","HB AMC AETNA HMO","221.46","69.8","","675.31","184.75","1721.50","286","165.81","259.28","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.28","237.96","AETNA [1001]","HB AMC AETNA PPO","255.09","80.4","","1261.44","103.12","1514.10","21","165.81","259.28","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.28","237.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","255.09","80.4","","1365.00","1365.00","1365.00","1 through 10","165.81","259.28","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.28","237.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","259.28","81.72","","5157.68","5157.68","5157.68","1 through 10","165.81","259.28","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.28","237.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","259.28","81.72","","431.26","71.26","1459.57","88","165.81","259.28","percent of total billed charges",""
"SCREW BONE 2.4X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081043","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.54","239.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","254.03","79.5","","800.18","480.96","1887.97","195","99.06","254.03","percent of total billed charges",""
"SCREW BONE 2.4X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081043","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.54","239.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","170.31","53.3","","813.12","216.42","1444.50","81","99.06","254.03","percent of total billed charges",""
"SCREW BONE 2.4X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081043","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.54","239.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","99.06","31","","432.60","432.60","432.60","1 through 10","99.06","254.03","percent of total billed charges",""
"SCREW BONE 2.4X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081043","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.54","239.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","116.63","36.5","","148.37","54.89","631.39","94","99.06","254.03","percent of total billed charges",""
"SCREW BONE 2.4X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081043","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.54","239.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","122.38","38.3","","279.30","91.72","1116.77","266","99.06","254.03","percent of total billed charges",""
"SCREW BONE 2.4X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081043","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.54","239.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","137.08","42.9","","731.00","63.70","731.00","1 through 10","99.06","254.03","percent of total billed charges",""
"SCREW BONE 2.4X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081043","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.54","239.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","137.08","42.9","","384.74","384.74","384.74","1 through 10","99.06","254.03","percent of total billed charges",""
"SCREW BONE 2.4X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081043","CDM","C1713","HCPCS","0278","RC","","","","both","","","319.54","239.65","WELLPOINT [1015]","HB AMC WELLPOINT","235.76","73.78","","286.63","119.22","1107.45","105","99.06","254.03","percent of total billed charges",""
"SCREW BONE 2.4X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","319.54","239.65","AETNA [1001]","HB AMC AETNA HMO","223.04","69.8","","675.31","184.75","1721.50","286","166.99","261.13","percent of total billed charges",""
"SCREW BONE 2.4X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","319.54","239.65","AETNA [1001]","HB AMC AETNA PPO","256.91","80.4","","1261.44","103.12","1514.10","21","166.99","261.13","percent of total billed charges",""
"SCREW BONE 2.4X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","319.54","239.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","256.91","80.4","","1365.00","1365.00","1365.00","1 through 10","166.99","261.13","percent of total billed charges",""
"SCREW BONE 2.4X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","319.54","239.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","261.13","81.72","","5157.68","5157.68","5157.68","1 through 10","166.99","261.13","percent of total billed charges",""
"SCREW BONE 2.4X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","319.54","239.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","261.13","81.72","","431.26","71.26","1459.57","88","166.99","261.13","percent of total billed charges",""
"SCREW BONE 2.4X18MM NON LOCKING TITANIUM ORTHOLOC PLATING SYSTEM","SUP-ITM-10132030","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","233.73","79.5","","800.18","480.96","1887.97","195","91.14","233.73","percent of total billed charges",""
"SCREW BONE 2.4X18MM NON LOCKING TITANIUM ORTHOLOC PLATING SYSTEM","SUP-ITM-10132030","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","156.70","53.3","","813.12","216.42","1444.50","81","91.14","233.73","percent of total billed charges",""
"SCREW BONE 2.4X18MM NON LOCKING TITANIUM ORTHOLOC PLATING SYSTEM","SUP-ITM-10132030","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","91.14","31","","432.60","432.60","432.60","1 through 10","91.14","233.73","percent of total billed charges",""
"SCREW BONE 2.4X18MM NON LOCKING TITANIUM ORTHOLOC PLATING SYSTEM","SUP-ITM-10132030","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","107.31","36.5","","148.37","54.89","631.39","94","91.14","233.73","percent of total billed charges",""
"SCREW BONE 2.4X18MM NON LOCKING TITANIUM ORTHOLOC PLATING SYSTEM","SUP-ITM-10132030","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","112.60","38.3","","279.30","91.72","1116.77","266","91.14","233.73","percent of total billed charges",""
"SCREW BONE 2.4X18MM NON LOCKING TITANIUM ORTHOLOC PLATING SYSTEM","SUP-ITM-10132030","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.13","42.9","","731.00","63.70","731.00","1 through 10","91.14","233.73","percent of total billed charges",""
"SCREW BONE 2.4X18MM NON LOCKING TITANIUM ORTHOLOC PLATING SYSTEM","SUP-ITM-10132030","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.13","42.9","","384.74","384.74","384.74","1 through 10","91.14","233.73","percent of total billed charges",""
"SCREW BONE 2.4X18MM NON LOCKING TITANIUM ORTHOLOC PLATING SYSTEM","SUP-ITM-10132030","CDM","C1713","HCPCS","0278","RC","","","","both","","","294.00","220.50","WELLPOINT [1015]","HB AMC WELLPOINT","216.91","73.78","","286.63","119.22","1107.45","105","91.14","233.73","percent of total billed charges",""
"SCREW BONE 2.4X18MM NON LOCKING TITANIUM ORTHOLOC PLATING SYSTEM","SUP-ITM-10132030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","AETNA [1001]","HB AMC AETNA HMO","205.21","69.8","","675.31","184.75","1721.50","286","153.64","240.26","percent of total billed charges",""
"SCREW BONE 2.4X18MM NON LOCKING TITANIUM ORTHOLOC PLATING SYSTEM","SUP-ITM-10132030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","AETNA [1001]","HB AMC AETNA PPO","236.38","80.4","","1261.44","103.12","1514.10","21","153.64","240.26","percent of total billed charges",""
"SCREW BONE 2.4X18MM NON LOCKING TITANIUM ORTHOLOC PLATING SYSTEM","SUP-ITM-10132030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","236.38","80.4","","1365.00","1365.00","1365.00","1 through 10","153.64","240.26","percent of total billed charges",""
"SCREW BONE 2.4X18MM NON LOCKING TITANIUM ORTHOLOC PLATING SYSTEM","SUP-ITM-10132030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","240.26","81.72","","5157.68","5157.68","5157.68","1 through 10","153.64","240.26","percent of total billed charges",""
"SCREW BONE 2.4X18MM NON LOCKING TITANIUM ORTHOLOC PLATING SYSTEM","SUP-ITM-10132030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","294.00","220.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","240.26","81.72","","431.26","71.26","1459.57","88","153.64","240.26","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.36","548.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","581.43","79.5","","800.18","480.96","1887.97","195","226.72","581.43","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.36","548.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","389.81","53.3","","813.12","216.42","1444.50","81","226.72","581.43","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.36","548.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","226.72","31","","432.60","432.60","432.60","1 through 10","226.72","581.43","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.36","548.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","266.95","36.5","","148.37","54.89","631.39","94","226.72","581.43","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.36","548.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","280.11","38.3","","279.30","91.72","1116.77","266","226.72","581.43","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.36","548.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","313.75","42.9","","731.00","63.70","731.00","1 through 10","226.72","581.43","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.36","548.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","313.75","42.9","","384.74","384.74","384.74","1 through 10","226.72","581.43","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","731.36","548.52","WELLPOINT [1015]","HB AMC WELLPOINT","539.60","73.78","","286.63","119.22","1107.45","105","226.72","581.43","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","731.36","548.52","AETNA [1001]","HB AMC AETNA HMO","510.49","69.8","","675.31","184.75","1721.50","286","382.21","597.67","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","731.36","548.52","AETNA [1001]","HB AMC AETNA PPO","588.01","80.4","","1261.44","103.12","1514.10","21","382.21","597.67","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","731.36","548.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","588.01","80.4","","1365.00","1365.00","1365.00","1 through 10","382.21","597.67","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","731.36","548.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","597.67","81.72","","5157.68","5157.68","5157.68","1 through 10","382.21","597.67","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","731.36","548.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","597.67","81.72","","431.26","71.26","1459.57","88","382.21","597.67","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","732.83","79.5","","800.18","480.96","1887.97","195","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","491.32","53.3","","813.12","216.42","1444.50","81","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","285.76","31","","432.60","432.60","432.60","1 through 10","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","336.46","36.5","","148.37","54.89","631.39","94","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","353.05","38.3","","279.30","91.72","1116.77","266","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","395.45","42.9","","731.00","63.70","731.00","1 through 10","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","395.45","42.9","","384.74","384.74","384.74","1 through 10","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","WELLPOINT [1015]","HB AMC WELLPOINT","680.10","73.78","","286.63","119.22","1107.45","105","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","AETNA [1001]","HB AMC AETNA HMO","643.42","69.8","","675.31","184.75","1721.50","286","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","AETNA [1001]","HB AMC AETNA PPO","741.13","80.4","","1261.44","103.12","1514.10","21","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","741.13","80.4","","1365.00","1365.00","1365.00","1 through 10","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","753.29","81.72","","5157.68","5157.68","5157.68","1 through 10","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","753.29","81.72","","431.26","71.26","1459.57","88","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.50","380.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.46","79.5","","800.18","480.96","1887.97","195","157.33","403.46","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.50","380.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.50","53.3","","813.12","216.42","1444.50","81","157.33","403.46","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","157.33","31","","432.60","432.60","432.60","1 through 10","157.33","403.46","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.24","36.5","","148.37","54.89","631.39","94","157.33","403.46","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.37","38.3","","279.30","91.72","1116.77","266","157.33","403.46","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.72","42.9","","731.00","63.70","731.00","1 through 10","157.33","403.46","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.50","380.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.72","42.9","","384.74","384.74","384.74","1 through 10","157.33","403.46","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.50","380.62","WELLPOINT [1015]","HB AMC WELLPOINT","374.43","73.78","","286.63","119.22","1107.45","105","157.33","403.46","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","AETNA [1001]","HB AMC AETNA HMO","354.24","69.8","","675.31","184.75","1721.50","286","265.22","414.73","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","AETNA [1001]","HB AMC AETNA PPO","408.03","80.4","","1261.44","103.12","1514.10","21","265.22","414.73","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","408.03","80.4","","1365.00","1365.00","1365.00","1 through 10","265.22","414.73","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","414.73","81.72","","5157.68","5157.68","5157.68","1 through 10","265.22","414.73","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","414.73","81.72","","431.26","71.26","1459.57","88","265.22","414.73","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","252.24","79.5","","800.18","480.96","1887.97","195","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","169.11","53.3","","813.12","216.42","1444.50","81","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","98.36","31","","432.60","432.60","432.60","1 through 10","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","115.81","36.5","","148.37","54.89","631.39","94","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.52","38.3","","279.30","91.72","1116.77","266","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","136.11","42.9","","731.00","63.70","731.00","1 through 10","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","136.11","42.9","","384.74","384.74","384.74","1 through 10","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.28","237.96","WELLPOINT [1015]","HB AMC WELLPOINT","234.09","73.78","","286.63","119.22","1107.45","105","98.36","252.24","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.28","237.96","AETNA [1001]","HB AMC AETNA HMO","221.46","69.8","","675.31","184.75","1721.50","286","165.81","259.28","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.28","237.96","AETNA [1001]","HB AMC AETNA PPO","255.09","80.4","","1261.44","103.12","1514.10","21","165.81","259.28","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.28","237.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","255.09","80.4","","1365.00","1365.00","1365.00","1 through 10","165.81","259.28","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.28","237.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","259.28","81.72","","5157.68","5157.68","5157.68","1 through 10","165.81","259.28","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.28","237.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","259.28","81.72","","431.26","71.26","1459.57","88","165.81","259.28","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.58","79.5","","800.18","480.96","1887.97","195","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.52","53.3","","813.12","216.42","1444.50","81","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.58","31","","432.60","432.60","432.60","1 through 10","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.20","36.5","","148.37","54.89","631.39","94","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.02","38.3","","279.30","91.72","1116.77","266","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.22","42.9","","731.00","63.70","731.00","1 through 10","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.22","42.9","","384.74","384.74","384.74","1 through 10","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.70","117.52","WELLPOINT [1015]","HB AMC WELLPOINT","115.61","73.78","","286.63","119.22","1107.45","105","48.58","124.58","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.70","117.52","AETNA [1001]","HB AMC AETNA HMO","109.38","69.8","","675.31","184.75","1721.50","286","81.89","128.06","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.70","117.52","AETNA [1001]","HB AMC AETNA PPO","125.99","80.4","","1261.44","103.12","1514.10","21","81.89","128.06","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.70","117.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","125.99","80.4","","1365.00","1365.00","1365.00","1 through 10","81.89","128.06","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.70","117.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.06","81.72","","5157.68","5157.68","5157.68","1 through 10","81.89","128.06","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.70","117.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.06","81.72","","431.26","71.26","1459.57","88","81.89","128.06","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTICAL SELF TAPPING EMERGENCY WITH FLUTED TIP TI PK/5EA","SUP-ITM-10003933","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.24","108.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","115.47","79.5","","800.18","480.96","1887.97","195","45.02","115.47","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTICAL SELF TAPPING EMERGENCY WITH FLUTED TIP TI PK/5EA","SUP-ITM-10003933","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.24","108.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.41","53.3","","813.12","216.42","1444.50","81","45.02","115.47","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTICAL SELF TAPPING EMERGENCY WITH FLUTED TIP TI PK/5EA","SUP-ITM-10003933","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.24","108.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.02","31","","432.60","432.60","432.60","1 through 10","45.02","115.47","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTICAL SELF TAPPING EMERGENCY WITH FLUTED TIP TI PK/5EA","SUP-ITM-10003933","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.24","108.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.01","36.5","","148.37","54.89","631.39","94","45.02","115.47","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTICAL SELF TAPPING EMERGENCY WITH FLUTED TIP TI PK/5EA","SUP-ITM-10003933","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.24","108.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.63","38.3","","279.30","91.72","1116.77","266","45.02","115.47","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTICAL SELF TAPPING EMERGENCY WITH FLUTED TIP TI PK/5EA","SUP-ITM-10003933","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.24","108.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.31","42.9","","731.00","63.70","731.00","1 through 10","45.02","115.47","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTICAL SELF TAPPING EMERGENCY WITH FLUTED TIP TI PK/5EA","SUP-ITM-10003933","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.24","108.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.31","42.9","","384.74","384.74","384.74","1 through 10","45.02","115.47","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTICAL SELF TAPPING EMERGENCY WITH FLUTED TIP TI PK/5EA","SUP-ITM-10003933","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.24","108.93","WELLPOINT [1015]","HB AMC WELLPOINT","107.16","73.78","","286.63","119.22","1107.45","105","45.02","115.47","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTICAL SELF TAPPING EMERGENCY WITH FLUTED TIP TI PK/5EA","SUP-ITM-10003933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.24","108.93","AETNA [1001]","HB AMC AETNA HMO","101.38","69.8","","675.31","184.75","1721.50","286","75.9","118.69","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTICAL SELF TAPPING EMERGENCY WITH FLUTED TIP TI PK/5EA","SUP-ITM-10003933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.24","108.93","AETNA [1001]","HB AMC AETNA PPO","116.77","80.4","","1261.44","103.12","1514.10","21","75.9","118.69","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTICAL SELF TAPPING EMERGENCY WITH FLUTED TIP TI PK/5EA","SUP-ITM-10003933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.24","108.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","116.77","80.4","","1365.00","1365.00","1365.00","1 through 10","75.9","118.69","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTICAL SELF TAPPING EMERGENCY WITH FLUTED TIP TI PK/5EA","SUP-ITM-10003933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.24","108.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","118.69","81.72","","5157.68","5157.68","5157.68","1 through 10","75.9","118.69","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTICAL SELF TAPPING EMERGENCY WITH FLUTED TIP TI PK/5EA","SUP-ITM-10003933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.24","108.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","118.69","81.72","","431.26","71.26","1459.57","88","75.9","118.69","percent of total billed charges",""
"SCREW BONE 2.4X6MM MANDIBLE MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131129","CDM","C1713","HCPCS","0278","RC","","","","both","","","249.83","187.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","198.61","79.5","","800.18","480.96","1887.97","195","77.45","198.61","percent of total billed charges",""
"SCREW BONE 2.4X6MM MANDIBLE MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131129","CDM","C1713","HCPCS","0278","RC","","","","both","","","249.83","187.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","133.16","53.3","","813.12","216.42","1444.50","81","77.45","198.61","percent of total billed charges",""
"SCREW BONE 2.4X6MM MANDIBLE MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131129","CDM","C1713","HCPCS","0278","RC","","","","both","","","249.83","187.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","77.45","31","","432.60","432.60","432.60","1 through 10","77.45","198.61","percent of total billed charges",""
"SCREW BONE 2.4X6MM MANDIBLE MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131129","CDM","C1713","HCPCS","0278","RC","","","","both","","","249.83","187.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91.19","36.5","","148.37","54.89","631.39","94","77.45","198.61","percent of total billed charges",""
"SCREW BONE 2.4X6MM MANDIBLE MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131129","CDM","C1713","HCPCS","0278","RC","","","","both","","","249.83","187.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","95.68","38.3","","279.30","91.72","1116.77","266","77.45","198.61","percent of total billed charges",""
"SCREW BONE 2.4X6MM MANDIBLE MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131129","CDM","C1713","HCPCS","0278","RC","","","","both","","","249.83","187.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","107.18","42.9","","731.00","63.70","731.00","1 through 10","77.45","198.61","percent of total billed charges",""
"SCREW BONE 2.4X6MM MANDIBLE MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131129","CDM","C1713","HCPCS","0278","RC","","","","both","","","249.83","187.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","107.18","42.9","","384.74","384.74","384.74","1 through 10","77.45","198.61","percent of total billed charges",""
"SCREW BONE 2.4X6MM MANDIBLE MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131129","CDM","C1713","HCPCS","0278","RC","","","","both","","","249.83","187.37","WELLPOINT [1015]","HB AMC WELLPOINT","184.32","73.78","","286.63","119.22","1107.45","105","77.45","198.61","percent of total billed charges",""
"SCREW BONE 2.4X6MM MANDIBLE MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","249.83","187.37","AETNA [1001]","HB AMC AETNA HMO","174.38","69.8","","675.31","184.75","1721.50","286","130.56","204.16","percent of total billed charges",""
"SCREW BONE 2.4X6MM MANDIBLE MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","249.83","187.37","AETNA [1001]","HB AMC AETNA PPO","200.86","80.4","","1261.44","103.12","1514.10","21","130.56","204.16","percent of total billed charges",""
"SCREW BONE 2.4X6MM MANDIBLE MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","249.83","187.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","200.86","80.4","","1365.00","1365.00","1365.00","1 through 10","130.56","204.16","percent of total billed charges",""
"SCREW BONE 2.4X6MM MANDIBLE MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","249.83","187.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","204.16","81.72","","5157.68","5157.68","5157.68","1 through 10","130.56","204.16","percent of total billed charges",""
"SCREW BONE 2.4X6MM MANDIBLE MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","249.83","187.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","204.16","81.72","","431.26","71.26","1459.57","88","130.56","204.16","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.27","102.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","109.13","79.5","","800.18","480.96","1887.97","195","42.55","109.13","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.27","102.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","73.16","53.3","","813.12","216.42","1444.50","81","42.55","109.13","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.27","102.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","42.55","31","","432.60","432.60","432.60","1 through 10","42.55","109.13","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.27","102.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.10","36.5","","148.37","54.89","631.39","94","42.55","109.13","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.27","102.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.57","38.3","","279.30","91.72","1116.77","266","42.55","109.13","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.27","102.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.89","42.9","","731.00","63.70","731.00","1 through 10","42.55","109.13","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.27","102.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.89","42.9","","384.74","384.74","384.74","1 through 10","42.55","109.13","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.27","102.95","WELLPOINT [1015]","HB AMC WELLPOINT","101.28","73.78","","286.63","119.22","1107.45","105","42.55","109.13","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","137.27","102.95","AETNA [1001]","HB AMC AETNA HMO","95.81","69.8","","675.31","184.75","1721.50","286","71.74","112.18","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","137.27","102.95","AETNA [1001]","HB AMC AETNA PPO","110.37","80.4","","1261.44","103.12","1514.10","21","71.74","112.18","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","137.27","102.95","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","110.37","80.4","","1365.00","1365.00","1365.00","1 through 10","71.74","112.18","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","137.27","102.95","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","112.18","81.72","","5157.68","5157.68","5157.68","1 through 10","71.74","112.18","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","137.27","102.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","112.18","81.72","","431.26","71.26","1459.57","88","71.74","112.18","percent of total billed charges",""
"SCREW BONE 2.4X8MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075857","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.15","111.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","117.78","79.5","","800.18","480.96","1887.97","195","45.93","117.78","percent of total billed charges",""
"SCREW BONE 2.4X8MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075857","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.15","111.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.96","53.3","","813.12","216.42","1444.50","81","45.93","117.78","percent of total billed charges",""
"SCREW BONE 2.4X8MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075857","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.15","111.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.93","31","","432.60","432.60","432.60","1 through 10","45.93","117.78","percent of total billed charges",""
"SCREW BONE 2.4X8MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075857","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.15","111.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54.07","36.5","","148.37","54.89","631.39","94","45.93","117.78","percent of total billed charges",""
"SCREW BONE 2.4X8MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075857","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.15","111.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.74","38.3","","279.30","91.72","1116.77","266","45.93","117.78","percent of total billed charges",""
"SCREW BONE 2.4X8MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075857","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.15","111.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.56","42.9","","731.00","63.70","731.00","1 through 10","45.93","117.78","percent of total billed charges",""
"SCREW BONE 2.4X8MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075857","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.15","111.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.56","42.9","","384.74","384.74","384.74","1 through 10","45.93","117.78","percent of total billed charges",""
"SCREW BONE 2.4X8MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075857","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.15","111.11","WELLPOINT [1015]","HB AMC WELLPOINT","109.31","73.78","","286.63","119.22","1107.45","105","45.93","117.78","percent of total billed charges",""
"SCREW BONE 2.4X8MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.15","111.11","AETNA [1001]","HB AMC AETNA HMO","103.41","69.8","","675.31","184.75","1721.50","286","77.42","121.07","percent of total billed charges",""
"SCREW BONE 2.4X8MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.15","111.11","AETNA [1001]","HB AMC AETNA PPO","119.11","80.4","","1261.44","103.12","1514.10","21","77.42","121.07","percent of total billed charges",""
"SCREW BONE 2.4X8MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.15","111.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","119.11","80.4","","1365.00","1365.00","1365.00","1 through 10","77.42","121.07","percent of total billed charges",""
"SCREW BONE 2.4X8MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.15","111.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","121.07","81.72","","5157.68","5157.68","5157.68","1 through 10","77.42","121.07","percent of total billed charges",""
"SCREW BONE 2.4X8MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.15","111.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","121.07","81.72","","431.26","71.26","1459.57","88","77.42","121.07","percent of total billed charges",""
"SCREW BONE 2.4X9MM CANNULATED COMPRESSION HEADLESS SHORT THREAD TITANIUM","SUP-ITM-10096339","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.52","605.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","641.98","79.5","","800.18","480.96","1887.97","195","250.33","641.98","percent of total billed charges",""
"SCREW BONE 2.4X9MM CANNULATED COMPRESSION HEADLESS SHORT THREAD TITANIUM","SUP-ITM-10096339","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.52","605.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","430.41","53.3","","813.12","216.42","1444.50","81","250.33","641.98","percent of total billed charges",""
"SCREW BONE 2.4X9MM CANNULATED COMPRESSION HEADLESS SHORT THREAD TITANIUM","SUP-ITM-10096339","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.52","605.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","250.33","31","","432.60","432.60","432.60","1 through 10","250.33","641.98","percent of total billed charges",""
"SCREW BONE 2.4X9MM CANNULATED COMPRESSION HEADLESS SHORT THREAD TITANIUM","SUP-ITM-10096339","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.52","605.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","294.74","36.5","","148.37","54.89","631.39","94","250.33","641.98","percent of total billed charges",""
"SCREW BONE 2.4X9MM CANNULATED COMPRESSION HEADLESS SHORT THREAD TITANIUM","SUP-ITM-10096339","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.52","605.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","309.28","38.3","","279.30","91.72","1116.77","266","250.33","641.98","percent of total billed charges",""
"SCREW BONE 2.4X9MM CANNULATED COMPRESSION HEADLESS SHORT THREAD TITANIUM","SUP-ITM-10096339","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.52","605.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.43","42.9","","731.00","63.70","731.00","1 through 10","250.33","641.98","percent of total billed charges",""
"SCREW BONE 2.4X9MM CANNULATED COMPRESSION HEADLESS SHORT THREAD TITANIUM","SUP-ITM-10096339","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.52","605.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.43","42.9","","384.74","384.74","384.74","1 through 10","250.33","641.98","percent of total billed charges",""
"SCREW BONE 2.4X9MM CANNULATED COMPRESSION HEADLESS SHORT THREAD TITANIUM","SUP-ITM-10096339","CDM","C1713","HCPCS","0278","RC","","","","both","","","807.52","605.64","WELLPOINT [1015]","HB AMC WELLPOINT","595.79","73.78","","286.63","119.22","1107.45","105","250.33","641.98","percent of total billed charges",""
"SCREW BONE 2.4X9MM CANNULATED COMPRESSION HEADLESS SHORT THREAD TITANIUM","SUP-ITM-10096339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","807.52","605.64","AETNA [1001]","HB AMC AETNA HMO","563.65","69.8","","675.31","184.75","1721.50","286","422.01","659.91","percent of total billed charges",""
"SCREW BONE 2.4X9MM CANNULATED COMPRESSION HEADLESS SHORT THREAD TITANIUM","SUP-ITM-10096339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","807.52","605.64","AETNA [1001]","HB AMC AETNA PPO","649.25","80.4","","1261.44","103.12","1514.10","21","422.01","659.91","percent of total billed charges",""
"SCREW BONE 2.4X9MM CANNULATED COMPRESSION HEADLESS SHORT THREAD TITANIUM","SUP-ITM-10096339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","807.52","605.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","649.25","80.4","","1365.00","1365.00","1365.00","1 through 10","422.01","659.91","percent of total billed charges",""
"SCREW BONE 2.4X9MM CANNULATED COMPRESSION HEADLESS SHORT THREAD TITANIUM","SUP-ITM-10096339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","807.52","605.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","659.91","81.72","","5157.68","5157.68","5157.68","1 through 10","422.01","659.91","percent of total billed charges",""
"SCREW BONE 2.4X9MM CANNULATED COMPRESSION HEADLESS SHORT THREAD TITANIUM","SUP-ITM-10096339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","807.52","605.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","659.91","81.72","","431.26","71.26","1459.57","88","422.01","659.91","percent of total billed charges",""
"SCREW BONE 2.5-4X50MM SCHANZ TITANIUM MANDIBULAR FIXATION EXTERNAL SELF TAPPING BLUNT TIP","SUP-ITM-10076516","CDM","C1889","HCPCS","0278","RC","","","","both","","","618.77","464.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","491.92","79.5","","1309.77","674.56","6049.93","26","191.82","491.92","percent of total billed charges",""
"SCREW BONE 2.5-4X50MM SCHANZ TITANIUM MANDIBULAR FIXATION EXTERNAL SELF TAPPING BLUNT TIP","SUP-ITM-10076516","CDM","C1889","HCPCS","0278","RC","","","","both","","","618.77","464.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","329.80","53.3","","1901.83","1901.83","2962.25","1 through 10","191.82","491.92","percent of total billed charges",""
"SCREW BONE 2.5-4X50MM SCHANZ TITANIUM MANDIBULAR FIXATION EXTERNAL SELF TAPPING BLUNT TIP","SUP-ITM-10076516","CDM","C1889","HCPCS","0278","RC","","","","both","","","618.77","464.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","225.85","36.5","","1620.31","1620.31","19908.88","1 through 10","191.82","491.92","percent of total billed charges",""
"SCREW BONE 2.5-4X50MM SCHANZ TITANIUM MANDIBULAR FIXATION EXTERNAL SELF TAPPING BLUNT TIP","SUP-ITM-10076516","CDM","C1889","HCPCS","0278","RC","","","","both","","","618.77","464.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","236.99","38.3","","352.91","352.91","2046.30","1 through 10","191.82","491.92","percent of total billed charges",""
"SCREW BONE 2.5-4X50MM SCHANZ TITANIUM MANDIBULAR FIXATION EXTERNAL SELF TAPPING BLUNT TIP","SUP-ITM-10076516","CDM","C1889","HCPCS","0278","RC","","","","both","","","618.77","464.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.45","42.9","","9668.75","9668.75","9668.75","1 through 10","191.82","491.92","percent of total billed charges",""
"SCREW BONE 2.5-4X50MM SCHANZ TITANIUM MANDIBULAR FIXATION EXTERNAL SELF TAPPING BLUNT TIP","SUP-ITM-10076516","CDM","C1889","HCPCS","0278","RC","","","","both","","","618.77","464.08","WELLPOINT [1015]","HB AMC WELLPOINT","456.53","73.78","","699.88","384.10","3443.31","33","191.82","491.92","percent of total billed charges",""
"SCREW BONE 2.5-4X50MM SCHANZ TITANIUM MANDIBULAR FIXATION EXTERNAL SELF TAPPING BLUNT TIP","SUP-ITM-10076516","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","618.77","464.08","AETNA [1001]","HB AMC AETNA HMO","431.90","69.8","","1421.24","264.50","4933.46","29","323.37","505.66","percent of total billed charges",""
"SCREW BONE 2.5-4X50MM SCHANZ TITANIUM MANDIBULAR FIXATION EXTERNAL SELF TAPPING BLUNT TIP","SUP-ITM-10076516","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","618.77","464.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","497.49","80.4","","1022.97","1022.97","3607.50","1 through 10","323.37","505.66","percent of total billed charges",""
"SCREW BONE 2.5-4X50MM SCHANZ TITANIUM MANDIBULAR FIXATION EXTERNAL SELF TAPPING BLUNT TIP","SUP-ITM-10076516","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","618.77","464.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","505.66","81.72","","3010.54","693.88","5019.88","35","323.37","505.66","percent of total billed charges",""
"SCREW BONE 2.5-4X60MM EXTERNAL FIXATION SCHANZ TI SELF DRILLING","SUP-ITM-10024334","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.22","544.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","577.34","79.5","","800.18","480.96","1887.97","195","225.13","577.34","percent of total billed charges",""
"SCREW BONE 2.5-4X60MM EXTERNAL FIXATION SCHANZ TI SELF DRILLING","SUP-ITM-10024334","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.22","544.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","387.08","53.3","","813.12","216.42","1444.50","81","225.13","577.34","percent of total billed charges",""
"SCREW BONE 2.5-4X60MM EXTERNAL FIXATION SCHANZ TI SELF DRILLING","SUP-ITM-10024334","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.22","544.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","225.13","31","","432.60","432.60","432.60","1 through 10","225.13","577.34","percent of total billed charges",""
"SCREW BONE 2.5-4X60MM EXTERNAL FIXATION SCHANZ TI SELF DRILLING","SUP-ITM-10024334","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.22","544.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","265.07","36.5","","148.37","54.89","631.39","94","225.13","577.34","percent of total billed charges",""
"SCREW BONE 2.5-4X60MM EXTERNAL FIXATION SCHANZ TI SELF DRILLING","SUP-ITM-10024334","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.22","544.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","278.14","38.3","","279.30","91.72","1116.77","266","225.13","577.34","percent of total billed charges",""
"SCREW BONE 2.5-4X60MM EXTERNAL FIXATION SCHANZ TI SELF DRILLING","SUP-ITM-10024334","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.22","544.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","311.55","42.9","","731.00","63.70","731.00","1 through 10","225.13","577.34","percent of total billed charges",""
"SCREW BONE 2.5-4X60MM EXTERNAL FIXATION SCHANZ TI SELF DRILLING","SUP-ITM-10024334","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.22","544.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","311.55","42.9","","384.74","384.74","384.74","1 through 10","225.13","577.34","percent of total billed charges",""
"SCREW BONE 2.5-4X60MM EXTERNAL FIXATION SCHANZ TI SELF DRILLING","SUP-ITM-10024334","CDM","C1713","HCPCS","0278","RC","","","","both","","","726.22","544.66","WELLPOINT [1015]","HB AMC WELLPOINT","535.81","73.78","","286.63","119.22","1107.45","105","225.13","577.34","percent of total billed charges",""
"SCREW BONE 2.5-4X60MM EXTERNAL FIXATION SCHANZ TI SELF DRILLING","SUP-ITM-10024334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","726.22","544.66","AETNA [1001]","HB AMC AETNA HMO","506.90","69.8","","675.31","184.75","1721.50","286","379.52","593.47","percent of total billed charges",""
"SCREW BONE 2.5-4X60MM EXTERNAL FIXATION SCHANZ TI SELF DRILLING","SUP-ITM-10024334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","726.22","544.66","AETNA [1001]","HB AMC AETNA PPO","583.88","80.4","","1261.44","103.12","1514.10","21","379.52","593.47","percent of total billed charges",""
"SCREW BONE 2.5-4X60MM EXTERNAL FIXATION SCHANZ TI SELF DRILLING","SUP-ITM-10024334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","726.22","544.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","583.88","80.4","","1365.00","1365.00","1365.00","1 through 10","379.52","593.47","percent of total billed charges",""
"SCREW BONE 2.5-4X60MM EXTERNAL FIXATION SCHANZ TI SELF DRILLING","SUP-ITM-10024334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","726.22","544.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","593.47","81.72","","5157.68","5157.68","5157.68","1 through 10","379.52","593.47","percent of total billed charges",""
"SCREW BONE 2.5-4X60MM EXTERNAL FIXATION SCHANZ TI SELF DRILLING","SUP-ITM-10024334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","726.22","544.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","593.47","81.72","","431.26","71.26","1459.57","88","379.52","593.47","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","584.33","79.5","","800.18","480.96","1887.97","195","227.85","584.33","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","391.76","53.3","","813.12","216.42","1444.50","81","227.85","584.33","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","227.85","31","","432.60","432.60","432.60","1 through 10","227.85","584.33","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","268.28","36.5","","148.37","54.89","631.39","94","227.85","584.33","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","281.51","38.3","","279.30","91.72","1116.77","266","227.85","584.33","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.32","42.9","","731.00","63.70","731.00","1 through 10","227.85","584.33","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.32","42.9","","384.74","384.74","384.74","1 through 10","227.85","584.33","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.00","551.25","WELLPOINT [1015]","HB AMC WELLPOINT","542.28","73.78","","286.63","119.22","1107.45","105","227.85","584.33","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.00","551.25","AETNA [1001]","HB AMC AETNA HMO","513.03","69.8","","675.31","184.75","1721.50","286","384.11","600.64","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.00","551.25","AETNA [1001]","HB AMC AETNA PPO","590.94","80.4","","1261.44","103.12","1514.10","21","384.11","600.64","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.00","551.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","590.94","80.4","","1365.00","1365.00","1365.00","1 through 10","384.11","600.64","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.00","551.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","600.64","81.72","","5157.68","5157.68","5157.68","1 through 10","384.11","600.64","percent of total billed charges",""
"SCREW BONE 2.5X10MM COMPRESSION DART FIRE CANNULATED TITANIUM SELF DRILLING TAPPING HEADLESS GRAY","SUP-ITM-10133789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.00","551.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","600.64","81.72","","431.26","71.26","1459.57","88","384.11","600.64","percent of total billed charges",""
"SCREW BONE 2.5X10MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116833","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","542.59","79.5","","800.18","480.96","1887.97","195","211.58","542.59","percent of total billed charges",""
"SCREW BONE 2.5X10MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116833","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","363.77","53.3","","813.12","216.42","1444.50","81","211.58","542.59","percent of total billed charges",""
"SCREW BONE 2.5X10MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116833","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","211.58","31","","432.60","432.60","432.60","1 through 10","211.58","542.59","percent of total billed charges",""
"SCREW BONE 2.5X10MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116833","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","249.11","36.5","","148.37","54.89","631.39","94","211.58","542.59","percent of total billed charges",""
"SCREW BONE 2.5X10MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116833","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.40","38.3","","279.30","91.72","1116.77","266","211.58","542.59","percent of total billed charges",""
"SCREW BONE 2.5X10MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116833","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.79","42.9","","731.00","63.70","731.00","1 through 10","211.58","542.59","percent of total billed charges",""
"SCREW BONE 2.5X10MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116833","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.79","42.9","","384.74","384.74","384.74","1 through 10","211.58","542.59","percent of total billed charges",""
"SCREW BONE 2.5X10MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116833","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","WELLPOINT [1015]","HB AMC WELLPOINT","503.55","73.78","","286.63","119.22","1107.45","105","211.58","542.59","percent of total billed charges",""
"SCREW BONE 2.5X10MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","AETNA [1001]","HB AMC AETNA HMO","476.39","69.8","","675.31","184.75","1721.50","286","356.67","557.74","percent of total billed charges",""
"SCREW BONE 2.5X10MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","AETNA [1001]","HB AMC AETNA PPO","548.73","80.4","","1261.44","103.12","1514.10","21","356.67","557.74","percent of total billed charges",""
"SCREW BONE 2.5X10MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","548.73","80.4","","1365.00","1365.00","1365.00","1 through 10","356.67","557.74","percent of total billed charges",""
"SCREW BONE 2.5X10MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","557.74","81.72","","5157.68","5157.68","5157.68","1 through 10","356.67","557.74","percent of total billed charges",""
"SCREW BONE 2.5X10MM EVOLVE TRIAD CANNULATED FULLY THREADED","SUP-ITM-10116833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","557.74","81.72","","431.26","71.26","1459.57","88","356.67","557.74","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277805","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","155.82","79.5","","800.18","480.96","1887.97","195","60.76","155.82","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277805","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","104.47","53.3","","813.12","216.42","1444.50","81","60.76","155.82","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277805","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","60.76","31","","432.60","432.60","432.60","1 through 10","60.76","155.82","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277805","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.54","36.5","","148.37","54.89","631.39","94","60.76","155.82","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277805","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.07","38.3","","279.30","91.72","1116.77","266","60.76","155.82","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277805","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.08","42.9","","731.00","63.70","731.00","1 through 10","60.76","155.82","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277805","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.08","42.9","","384.74","384.74","384.74","1 through 10","60.76","155.82","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277805","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","WELLPOINT [1015]","HB AMC WELLPOINT","144.61","73.78","","286.63","119.22","1107.45","105","60.76","155.82","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","AETNA [1001]","HB AMC AETNA HMO","136.81","69.8","","675.31","184.75","1721.50","286","102.43","160.17","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","AETNA [1001]","HB AMC AETNA PPO","157.58","80.4","","1261.44","103.12","1514.10","21","102.43","160.17","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","157.58","80.4","","1365.00","1365.00","1365.00","1 through 10","102.43","160.17","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","160.17","81.72","","5157.68","5157.68","5157.68","1 through 10","102.43","160.17","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","160.17","81.72","","431.26","71.26","1459.57","88","102.43","160.17","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM SS NONLOCKING","SUP-ITM-10278193","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","133.56","79.5","","800.18","480.96","1887.97","195","52.08","133.56","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM SS NONLOCKING","SUP-ITM-10278193","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","89.54","53.3","","813.12","216.42","1444.50","81","52.08","133.56","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM SS NONLOCKING","SUP-ITM-10278193","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","52.08","31","","432.60","432.60","432.60","1 through 10","52.08","133.56","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM SS NONLOCKING","SUP-ITM-10278193","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","61.32","36.5","","148.37","54.89","631.39","94","52.08","133.56","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM SS NONLOCKING","SUP-ITM-10278193","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64.34","38.3","","279.30","91.72","1116.77","266","52.08","133.56","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM SS NONLOCKING","SUP-ITM-10278193","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.07","42.9","","731.00","63.70","731.00","1 through 10","52.08","133.56","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM SS NONLOCKING","SUP-ITM-10278193","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.07","42.9","","384.74","384.74","384.74","1 through 10","52.08","133.56","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM SS NONLOCKING","SUP-ITM-10278193","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","WELLPOINT [1015]","HB AMC WELLPOINT","123.95","73.78","","286.63","119.22","1107.45","105","52.08","133.56","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM SS NONLOCKING","SUP-ITM-10278193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","AETNA [1001]","HB AMC AETNA HMO","117.26","69.8","","675.31","184.75","1721.50","286","87.8","137.29","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM SS NONLOCKING","SUP-ITM-10278193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","AETNA [1001]","HB AMC AETNA PPO","135.07","80.4","","1261.44","103.12","1514.10","21","87.8","137.29","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM SS NONLOCKING","SUP-ITM-10278193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","135.07","80.4","","1365.00","1365.00","1365.00","1 through 10","87.8","137.29","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM SS NONLOCKING","SUP-ITM-10278193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","137.29","81.72","","5157.68","5157.68","5157.68","1 through 10","87.8","137.29","percent of total billed charges",""
"SCREW BONE 2.5X14MM ANTHEM SS NONLOCKING","SUP-ITM-10278193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","137.29","81.72","","431.26","71.26","1459.57","88","87.8","137.29","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","873.43","79.5","","800.18","480.96","1887.97","195","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","585.58","53.3","","813.12","216.42","1444.50","81","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","340.58","31","","432.60","432.60","432.60","1 through 10","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","401.01","36.5","","148.37","54.89","631.39","94","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","420.78","38.3","","279.30","91.72","1116.77","266","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","471.32","42.9","","731.00","63.70","731.00","1 through 10","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","471.32","42.9","","384.74","384.74","384.74","1 through 10","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","WELLPOINT [1015]","HB AMC WELLPOINT","810.58","73.78","","286.63","119.22","1107.45","105","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","AETNA [1001]","HB AMC AETNA HMO","766.86","69.8","","675.31","184.75","1721.50","286","574.15","897.82","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","AETNA [1001]","HB AMC AETNA PPO","883.31","80.4","","1261.44","103.12","1514.10","21","574.15","897.82","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","883.31","80.4","","1365.00","1365.00","1365.00","1 through 10","574.15","897.82","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","897.82","81.72","","5157.68","5157.68","5157.68","1 through 10","574.15","897.82","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","897.82","81.72","","431.26","71.26","1459.57","88","574.15","897.82","percent of total billed charges",""
"SCREW BONE 2.5X19MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277831","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","587.11","79.5","","800.18","480.96","1887.97","195","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X19MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277831","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","393.62","53.3","","813.12","216.42","1444.50","81","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X19MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277831","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","228.94","31","","432.60","432.60","432.60","1 through 10","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X19MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277831","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","269.55","36.5","","148.37","54.89","631.39","94","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X19MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277831","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","282.85","38.3","","279.30","91.72","1116.77","266","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X19MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277831","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.82","42.9","","731.00","63.70","731.00","1 through 10","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X19MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277831","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.82","42.9","","384.74","384.74","384.74","1 through 10","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X19MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277831","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","WELLPOINT [1015]","HB AMC WELLPOINT","544.87","73.78","","286.63","119.22","1107.45","105","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X19MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","738.50","553.87","AETNA [1001]","HB AMC AETNA HMO","515.47","69.8","","675.31","184.75","1721.50","286","385.94","603.5","percent of total billed charges",""
"SCREW BONE 2.5X19MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","738.50","553.87","AETNA [1001]","HB AMC AETNA PPO","593.75","80.4","","1261.44","103.12","1514.10","21","385.94","603.5","percent of total billed charges",""
"SCREW BONE 2.5X19MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","738.50","553.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","593.75","80.4","","1365.00","1365.00","1365.00","1 through 10","385.94","603.5","percent of total billed charges",""
"SCREW BONE 2.5X19MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","738.50","553.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","603.50","81.72","","5157.68","5157.68","5157.68","1 through 10","385.94","603.5","percent of total billed charges",""
"SCREW BONE 2.5X19MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","738.50","553.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","603.50","81.72","","431.26","71.26","1459.57","88","385.94","603.5","percent of total billed charges",""
"SCREW BONE 2.5X24MM MINI HEADLESS CANNULATED","SUP-ITM-10232430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1303.66","79.5","","800.18","480.96","1887.97","195","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X24MM MINI HEADLESS CANNULATED","SUP-ITM-10232430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","874.02","53.3","","813.12","216.42","1444.50","81","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X24MM MINI HEADLESS CANNULATED","SUP-ITM-10232430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","508.34","31","","432.60","432.60","432.60","1 through 10","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X24MM MINI HEADLESS CANNULATED","SUP-ITM-10232430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","598.53","36.5","","148.37","54.89","631.39","94","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X24MM MINI HEADLESS CANNULATED","SUP-ITM-10232430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","628.05","38.3","","279.30","91.72","1116.77","266","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X24MM MINI HEADLESS CANNULATED","SUP-ITM-10232430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","703.48","42.9","","731.00","63.70","731.00","1 through 10","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X24MM MINI HEADLESS CANNULATED","SUP-ITM-10232430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","703.48","42.9","","384.74","384.74","384.74","1 through 10","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X24MM MINI HEADLESS CANNULATED","SUP-ITM-10232430","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","WELLPOINT [1015]","HB AMC WELLPOINT","1209.86","73.78","","286.63","119.22","1107.45","105","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X24MM MINI HEADLESS CANNULATED","SUP-ITM-10232430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.82","1229.86","AETNA [1001]","HB AMC AETNA HMO","1144.59","69.8","","675.31","184.75","1721.50","286","856.97","1340.06","percent of total billed charges",""
"SCREW BONE 2.5X24MM MINI HEADLESS CANNULATED","SUP-ITM-10232430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.82","1229.86","AETNA [1001]","HB AMC AETNA PPO","1318.42","80.4","","1261.44","103.12","1514.10","21","856.97","1340.06","percent of total billed charges",""
"SCREW BONE 2.5X24MM MINI HEADLESS CANNULATED","SUP-ITM-10232430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.82","1229.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1318.42","80.4","","1365.00","1365.00","1365.00","1 through 10","856.97","1340.06","percent of total billed charges",""
"SCREW BONE 2.5X24MM MINI HEADLESS CANNULATED","SUP-ITM-10232430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.82","1229.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1340.06","81.72","","5157.68","5157.68","5157.68","1 through 10","856.97","1340.06","percent of total billed charges",""
"SCREW BONE 2.5X24MM MINI HEADLESS CANNULATED","SUP-ITM-10232430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.82","1229.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1340.06","81.72","","431.26","71.26","1459.57","88","856.97","1340.06","percent of total billed charges",""
"SCREW BONE 2.5X24MM MONOAX SS LOCKING","SUP-ITM-10278198","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.50","401.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","425.72","79.5","","800.18","480.96","1887.97","195","166.01","425.72","percent of total billed charges",""
"SCREW BONE 2.5X24MM MONOAX SS LOCKING","SUP-ITM-10278198","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.50","401.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","285.42","53.3","","813.12","216.42","1444.50","81","166.01","425.72","percent of total billed charges",""
"SCREW BONE 2.5X24MM MONOAX SS LOCKING","SUP-ITM-10278198","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.50","401.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","166.01","31","","432.60","432.60","432.60","1 through 10","166.01","425.72","percent of total billed charges",""
"SCREW BONE 2.5X24MM MONOAX SS LOCKING","SUP-ITM-10278198","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.50","401.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","195.46","36.5","","148.37","54.89","631.39","94","166.01","425.72","percent of total billed charges",""
"SCREW BONE 2.5X24MM MONOAX SS LOCKING","SUP-ITM-10278198","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.50","401.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","205.10","38.3","","279.30","91.72","1116.77","266","166.01","425.72","percent of total billed charges",""
"SCREW BONE 2.5X24MM MONOAX SS LOCKING","SUP-ITM-10278198","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.50","401.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","229.73","42.9","","731.00","63.70","731.00","1 through 10","166.01","425.72","percent of total billed charges",""
"SCREW BONE 2.5X24MM MONOAX SS LOCKING","SUP-ITM-10278198","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.50","401.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","229.73","42.9","","384.74","384.74","384.74","1 through 10","166.01","425.72","percent of total billed charges",""
"SCREW BONE 2.5X24MM MONOAX SS LOCKING","SUP-ITM-10278198","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.50","401.62","WELLPOINT [1015]","HB AMC WELLPOINT","395.09","73.78","","286.63","119.22","1107.45","105","166.01","425.72","percent of total billed charges",""
"SCREW BONE 2.5X24MM MONOAX SS LOCKING","SUP-ITM-10278198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.50","401.62","AETNA [1001]","HB AMC AETNA HMO","373.78","69.8","","675.31","184.75","1721.50","286","279.85","437.61","percent of total billed charges",""
"SCREW BONE 2.5X24MM MONOAX SS LOCKING","SUP-ITM-10278198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.50","401.62","AETNA [1001]","HB AMC AETNA PPO","430.54","80.4","","1261.44","103.12","1514.10","21","279.85","437.61","percent of total billed charges",""
"SCREW BONE 2.5X24MM MONOAX SS LOCKING","SUP-ITM-10278198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.50","401.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","430.54","80.4","","1365.00","1365.00","1365.00","1 through 10","279.85","437.61","percent of total billed charges",""
"SCREW BONE 2.5X24MM MONOAX SS LOCKING","SUP-ITM-10278198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.50","401.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","437.61","81.72","","5157.68","5157.68","5157.68","1 through 10","279.85","437.61","percent of total billed charges",""
"SCREW BONE 2.5X24MM MONOAX SS LOCKING","SUP-ITM-10278198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.50","401.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","437.61","81.72","","431.26","71.26","1459.57","88","279.85","437.61","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1303.66","79.5","","800.18","480.96","1887.97","195","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","874.02","53.3","","813.12","216.42","1444.50","81","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","508.34","31","","432.60","432.60","432.60","1 through 10","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","598.53","36.5","","148.37","54.89","631.39","94","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","628.05","38.3","","279.30","91.72","1116.77","266","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","703.48","42.9","","731.00","63.70","731.00","1 through 10","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","703.48","42.9","","384.74","384.74","384.74","1 through 10","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1639.82","1229.86","WELLPOINT [1015]","HB AMC WELLPOINT","1209.86","73.78","","286.63","119.22","1107.45","105","508.34","1303.66","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.82","1229.86","AETNA [1001]","HB AMC AETNA HMO","1144.59","69.8","","675.31","184.75","1721.50","286","856.97","1340.06","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.82","1229.86","AETNA [1001]","HB AMC AETNA PPO","1318.42","80.4","","1261.44","103.12","1514.10","21","856.97","1340.06","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.82","1229.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1318.42","80.4","","1365.00","1365.00","1365.00","1 through 10","856.97","1340.06","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.82","1229.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1340.06","81.72","","5157.68","5157.68","5157.68","1 through 10","856.97","1340.06","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1639.82","1229.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1340.06","81.72","","431.26","71.26","1459.57","88","856.97","1340.06","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","389.77","79.5","","800.18","480.96","1887.97","195","151.99","389.77","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","261.32","53.3","","813.12","216.42","1444.50","81","151.99","389.77","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","151.99","31","","432.60","432.60","432.60","1 through 10","151.99","389.77","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","178.95","36.5","","148.37","54.89","631.39","94","151.99","389.77","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.78","38.3","","279.30","91.72","1116.77","266","151.99","389.77","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","731.00","63.70","731.00","1 through 10","151.99","389.77","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","384.74","384.74","384.74","1 through 10","151.99","389.77","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","WELLPOINT [1015]","HB AMC WELLPOINT","361.73","73.78","","286.63","119.22","1107.45","105","151.99","389.77","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA HMO","342.22","69.8","","675.31","184.75","1721.50","286","256.22","400.66","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA PPO","394.19","80.4","","1261.44","103.12","1514.10","21","256.22","400.66","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","394.19","80.4","","1365.00","1365.00","1365.00","1 through 10","256.22","400.66","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","400.66","81.72","","5157.68","5157.68","5157.68","1 through 10","256.22","400.66","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","400.66","81.72","","431.26","71.26","1459.57","88","256.22","400.66","percent of total billed charges",""
"SCREW BONE 2.5X4X10MM SCHANZ TI SELF DRILLING TIP THREADED RAMUS","SUP-ITM-10076520","CDM","C1713","HCPCS","0278","RC","","","","both","","","671.02","503.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","533.46","79.5","","800.18","480.96","1887.97","195","208.02","533.46","percent of total billed charges",""
"SCREW BONE 2.5X4X10MM SCHANZ TI SELF DRILLING TIP THREADED RAMUS","SUP-ITM-10076520","CDM","C1713","HCPCS","0278","RC","","","","both","","","671.02","503.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","357.65","53.3","","813.12","216.42","1444.50","81","208.02","533.46","percent of total billed charges",""
"SCREW BONE 2.5X4X10MM SCHANZ TI SELF DRILLING TIP THREADED RAMUS","SUP-ITM-10076520","CDM","C1713","HCPCS","0278","RC","","","","both","","","671.02","503.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","208.02","31","","432.60","432.60","432.60","1 through 10","208.02","533.46","percent of total billed charges",""
"SCREW BONE 2.5X4X10MM SCHANZ TI SELF DRILLING TIP THREADED RAMUS","SUP-ITM-10076520","CDM","C1713","HCPCS","0278","RC","","","","both","","","671.02","503.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","244.92","36.5","","148.37","54.89","631.39","94","208.02","533.46","percent of total billed charges",""
"SCREW BONE 2.5X4X10MM SCHANZ TI SELF DRILLING TIP THREADED RAMUS","SUP-ITM-10076520","CDM","C1713","HCPCS","0278","RC","","","","both","","","671.02","503.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","257.00","38.3","","279.30","91.72","1116.77","266","208.02","533.46","percent of total billed charges",""
"SCREW BONE 2.5X4X10MM SCHANZ TI SELF DRILLING TIP THREADED RAMUS","SUP-ITM-10076520","CDM","C1713","HCPCS","0278","RC","","","","both","","","671.02","503.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","287.87","42.9","","731.00","63.70","731.00","1 through 10","208.02","533.46","percent of total billed charges",""
"SCREW BONE 2.5X4X10MM SCHANZ TI SELF DRILLING TIP THREADED RAMUS","SUP-ITM-10076520","CDM","C1713","HCPCS","0278","RC","","","","both","","","671.02","503.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","287.87","42.9","","384.74","384.74","384.74","1 through 10","208.02","533.46","percent of total billed charges",""
"SCREW BONE 2.5X4X10MM SCHANZ TI SELF DRILLING TIP THREADED RAMUS","SUP-ITM-10076520","CDM","C1713","HCPCS","0278","RC","","","","both","","","671.02","503.26","WELLPOINT [1015]","HB AMC WELLPOINT","495.08","73.78","","286.63","119.22","1107.45","105","208.02","533.46","percent of total billed charges",""
"SCREW BONE 2.5X4X10MM SCHANZ TI SELF DRILLING TIP THREADED RAMUS","SUP-ITM-10076520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","671.02","503.26","AETNA [1001]","HB AMC AETNA HMO","468.37","69.8","","675.31","184.75","1721.50","286","350.68","548.36","percent of total billed charges",""
"SCREW BONE 2.5X4X10MM SCHANZ TI SELF DRILLING TIP THREADED RAMUS","SUP-ITM-10076520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","671.02","503.26","AETNA [1001]","HB AMC AETNA PPO","539.50","80.4","","1261.44","103.12","1514.10","21","350.68","548.36","percent of total billed charges",""
"SCREW BONE 2.5X4X10MM SCHANZ TI SELF DRILLING TIP THREADED RAMUS","SUP-ITM-10076520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","671.02","503.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","539.50","80.4","","1365.00","1365.00","1365.00","1 through 10","350.68","548.36","percent of total billed charges",""
"SCREW BONE 2.5X4X10MM SCHANZ TI SELF DRILLING TIP THREADED RAMUS","SUP-ITM-10076520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","671.02","503.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","548.36","81.72","","5157.68","5157.68","5157.68","1 through 10","350.68","548.36","percent of total billed charges",""
"SCREW BONE 2.5X4X10MM SCHANZ TI SELF DRILLING TIP THREADED RAMUS","SUP-ITM-10076520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","671.02","503.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","548.36","81.72","","431.26","71.26","1459.57","88","350.68","548.36","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","298.56","79.5","","800.18","480.96","1887.97","195","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","200.17","53.3","","813.12","216.42","1444.50","81","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","116.42","31","","432.60","432.60","432.60","1 through 10","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","137.08","36.5","","148.37","54.89","631.39","94","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","143.84","38.3","","279.30","91.72","1116.77","266","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","161.11","42.9","","731.00","63.70","731.00","1 through 10","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","161.11","42.9","","384.74","384.74","384.74","1 through 10","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","WELLPOINT [1015]","HB AMC WELLPOINT","277.08","73.78","","286.63","119.22","1107.45","105","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.55","281.66","AETNA [1001]","HB AMC AETNA HMO","262.13","69.8","","675.31","184.75","1721.50","286","196.26","306.9","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.55","281.66","AETNA [1001]","HB AMC AETNA PPO","301.94","80.4","","1261.44","103.12","1514.10","21","196.26","306.9","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.55","281.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","301.94","80.4","","1365.00","1365.00","1365.00","1 through 10","196.26","306.9","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.55","281.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","306.90","81.72","","5157.68","5157.68","5157.68","1 through 10","196.26","306.9","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.55","281.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","306.90","81.72","","431.26","71.26","1459.57","88","196.26","306.9","percent of total billed charges",""
"SCREW BONE 2.5X75MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277811","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","587.11","79.5","","800.18","480.96","1887.97","195","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X75MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277811","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","393.62","53.3","","813.12","216.42","1444.50","81","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X75MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277811","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","228.94","31","","432.60","432.60","432.60","1 through 10","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X75MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277811","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","269.55","36.5","","148.37","54.89","631.39","94","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X75MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277811","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","282.85","38.3","","279.30","91.72","1116.77","266","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X75MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277811","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.82","42.9","","731.00","63.70","731.00","1 through 10","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X75MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277811","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.82","42.9","","384.74","384.74","384.74","1 through 10","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X75MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277811","CDM","C1713","HCPCS","0278","RC","","","","both","","","738.50","553.87","WELLPOINT [1015]","HB AMC WELLPOINT","544.87","73.78","","286.63","119.22","1107.45","105","228.94","587.11","percent of total billed charges",""
"SCREW BONE 2.5X75MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","738.50","553.87","AETNA [1001]","HB AMC AETNA HMO","515.47","69.8","","675.31","184.75","1721.50","286","385.94","603.5","percent of total billed charges",""
"SCREW BONE 2.5X75MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","738.50","553.87","AETNA [1001]","HB AMC AETNA PPO","593.75","80.4","","1261.44","103.12","1514.10","21","385.94","603.5","percent of total billed charges",""
"SCREW BONE 2.5X75MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","738.50","553.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","593.75","80.4","","1365.00","1365.00","1365.00","1 through 10","385.94","603.5","percent of total billed charges",""
"SCREW BONE 2.5X75MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","738.50","553.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","603.50","81.72","","5157.68","5157.68","5157.68","1 through 10","385.94","603.5","percent of total billed charges",""
"SCREW BONE 2.5X75MM ANTHEM COBALT CHROME LOCKING","SUP-ITM-10277811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","738.50","553.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","603.50","81.72","","431.26","71.26","1459.57","88","385.94","603.5","percent of total billed charges",""
"SCREW BONE 2.5X80MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 20MM THREAD","SUP-ITM-10038628","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","298.56","79.5","","800.18","480.96","1887.97","195","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X80MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 20MM THREAD","SUP-ITM-10038628","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","200.17","53.3","","813.12","216.42","1444.50","81","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X80MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 20MM THREAD","SUP-ITM-10038628","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","116.42","31","","432.60","432.60","432.60","1 through 10","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X80MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 20MM THREAD","SUP-ITM-10038628","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","137.08","36.5","","148.37","54.89","631.39","94","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X80MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 20MM THREAD","SUP-ITM-10038628","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","143.84","38.3","","279.30","91.72","1116.77","266","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X80MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 20MM THREAD","SUP-ITM-10038628","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","161.11","42.9","","731.00","63.70","731.00","1 through 10","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X80MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 20MM THREAD","SUP-ITM-10038628","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","161.11","42.9","","384.74","384.74","384.74","1 through 10","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X80MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 20MM THREAD","SUP-ITM-10038628","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.55","281.66","WELLPOINT [1015]","HB AMC WELLPOINT","277.08","73.78","","286.63","119.22","1107.45","105","116.42","298.56","percent of total billed charges",""
"SCREW BONE 2.5X80MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 20MM THREAD","SUP-ITM-10038628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.55","281.66","AETNA [1001]","HB AMC AETNA HMO","262.13","69.8","","675.31","184.75","1721.50","286","196.26","306.9","percent of total billed charges",""
"SCREW BONE 2.5X80MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 20MM THREAD","SUP-ITM-10038628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.55","281.66","AETNA [1001]","HB AMC AETNA PPO","301.94","80.4","","1261.44","103.12","1514.10","21","196.26","306.9","percent of total billed charges",""
"SCREW BONE 2.5X80MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 20MM THREAD","SUP-ITM-10038628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.55","281.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","301.94","80.4","","1365.00","1365.00","1365.00","1 through 10","196.26","306.9","percent of total billed charges",""
"SCREW BONE 2.5X80MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 20MM THREAD","SUP-ITM-10038628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.55","281.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","306.90","81.72","","5157.68","5157.68","5157.68","1 through 10","196.26","306.9","percent of total billed charges",""
"SCREW BONE 2.5X80MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 20MM THREAD","SUP-ITM-10038628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.55","281.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","306.90","81.72","","431.26","71.26","1459.57","88","196.26","306.9","percent of total billed charges",""
"SCREW BONE 2.6X4MM SPINE CERVICAL LAMI SELF TAPPING RELIEVE","SUP-ITM-10048975","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","194.78","79.5","","800.18","480.96","1887.97","195","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.6X4MM SPINE CERVICAL LAMI SELF TAPPING RELIEVE","SUP-ITM-10048975","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.59","53.3","","813.12","216.42","1444.50","81","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.6X4MM SPINE CERVICAL LAMI SELF TAPPING RELIEVE","SUP-ITM-10048975","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","75.95","31","","432.60","432.60","432.60","1 through 10","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.6X4MM SPINE CERVICAL LAMI SELF TAPPING RELIEVE","SUP-ITM-10048975","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.43","36.5","","148.37","54.89","631.39","94","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.6X4MM SPINE CERVICAL LAMI SELF TAPPING RELIEVE","SUP-ITM-10048975","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.84","38.3","","279.30","91.72","1116.77","266","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.6X4MM SPINE CERVICAL LAMI SELF TAPPING RELIEVE","SUP-ITM-10048975","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.11","42.9","","731.00","63.70","731.00","1 through 10","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.6X4MM SPINE CERVICAL LAMI SELF TAPPING RELIEVE","SUP-ITM-10048975","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.11","42.9","","384.74","384.74","384.74","1 through 10","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.6X4MM SPINE CERVICAL LAMI SELF TAPPING RELIEVE","SUP-ITM-10048975","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","WELLPOINT [1015]","HB AMC WELLPOINT","180.76","73.78","","286.63","119.22","1107.45","105","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2.6X4MM SPINE CERVICAL LAMI SELF TAPPING RELIEVE","SUP-ITM-10048975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA HMO","171.01","69.8","","675.31","184.75","1721.50","286","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2.6X4MM SPINE CERVICAL LAMI SELF TAPPING RELIEVE","SUP-ITM-10048975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA PPO","196.98","80.4","","1261.44","103.12","1514.10","21","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2.6X4MM SPINE CERVICAL LAMI SELF TAPPING RELIEVE","SUP-ITM-10048975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","196.98","80.4","","1365.00","1365.00","1365.00","1 through 10","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2.6X4MM SPINE CERVICAL LAMI SELF TAPPING RELIEVE","SUP-ITM-10048975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","200.21","81.72","","5157.68","5157.68","5157.68","1 through 10","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2.6X4MM SPINE CERVICAL LAMI SELF TAPPING RELIEVE","SUP-ITM-10048975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","200.21","81.72","","431.26","71.26","1459.57","88","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.66","570.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","604.72","79.5","","800.18","480.96","1887.97","195","235.8","604.72","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.66","570.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","405.43","53.3","","813.12","216.42","1444.50","81","235.8","604.72","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.66","570.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","235.80","31","","432.60","432.60","432.60","1 through 10","235.8","604.72","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.66","570.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","277.64","36.5","","148.37","54.89","631.39","94","235.8","604.72","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.66","570.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","291.33","38.3","","279.30","91.72","1116.77","266","235.8","604.72","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.66","570.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.32","42.9","","731.00","63.70","731.00","1 through 10","235.8","604.72","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.66","570.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.32","42.9","","384.74","384.74","384.74","1 through 10","235.8","604.72","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.66","570.49","WELLPOINT [1015]","HB AMC WELLPOINT","561.21","73.78","","286.63","119.22","1107.45","105","235.8","604.72","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.66","570.49","AETNA [1001]","HB AMC AETNA HMO","530.94","69.8","","675.31","184.75","1721.50","286","397.52","621.61","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.66","570.49","AETNA [1001]","HB AMC AETNA PPO","611.57","80.4","","1261.44","103.12","1514.10","21","397.52","621.61","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.66","570.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","611.57","80.4","","1365.00","1365.00","1365.00","1 through 10","397.52","621.61","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.66","570.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","621.61","81.72","","5157.68","5157.68","5157.68","1 through 10","397.52","621.61","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.66","570.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","621.61","81.72","","431.26","71.26","1459.57","88","397.52","621.61","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.50","1036.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1099.09","79.5","","800.18","480.96","1887.97","195","428.58","1099.09","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.50","1036.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","736.87","53.3","","813.12","216.42","1444.50","81","428.58","1099.09","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.50","1036.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","428.58","31","","432.60","432.60","432.60","1 through 10","428.58","1099.09","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.50","1036.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","504.61","36.5","","148.37","54.89","631.39","94","428.58","1099.09","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.50","1036.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","529.50","38.3","","279.30","91.72","1116.77","266","428.58","1099.09","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.50","1036.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","593.09","42.9","","731.00","63.70","731.00","1 through 10","428.58","1099.09","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.50","1036.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","593.09","42.9","","384.74","384.74","384.74","1 through 10","428.58","1099.09","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.50","1036.87","WELLPOINT [1015]","HB AMC WELLPOINT","1020.01","73.78","","286.63","119.22","1107.45","105","428.58","1099.09","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.50","1036.87","AETNA [1001]","HB AMC AETNA HMO","964.99","69.8","","675.31","184.75","1721.50","286","722.49","1129.78","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.50","1036.87","AETNA [1001]","HB AMC AETNA PPO","1111.53","80.4","","1261.44","103.12","1514.10","21","722.49","1129.78","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.50","1036.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1111.53","80.4","","1365.00","1365.00","1365.00","1 through 10","722.49","1129.78","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.50","1036.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1129.78","81.72","","5157.68","5157.68","5157.68","1 through 10","722.49","1129.78","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.50","1036.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1129.78","81.72","","431.26","71.26","1459.57","88","722.49","1129.78","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","320.99","79.5","","800.18","480.96","1887.97","195","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","215.20","53.3","","813.12","216.42","1444.50","81","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","125.17","31","","432.60","432.60","432.60","1 through 10","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","147.37","36.5","","148.37","54.89","631.39","94","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","154.64","38.3","","279.30","91.72","1116.77","266","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.21","42.9","","731.00","63.70","731.00","1 through 10","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.21","42.9","","384.74","384.74","384.74","1 through 10","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","WELLPOINT [1015]","HB AMC WELLPOINT","297.89","73.78","","286.63","119.22","1107.45","105","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","403.76","302.82","AETNA [1001]","HB AMC AETNA HMO","281.82","69.8","","675.31","184.75","1721.50","286","211","329.95","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","403.76","302.82","AETNA [1001]","HB AMC AETNA PPO","324.62","80.4","","1261.44","103.12","1514.10","21","211","329.95","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","403.76","302.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","324.62","80.4","","1365.00","1365.00","1365.00","1 through 10","211","329.95","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","403.76","302.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","329.95","81.72","","5157.68","5157.68","5157.68","1 through 10","211","329.95","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","403.76","302.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","329.95","81.72","","431.26","71.26","1459.57","88","211","329.95","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004309","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","729.02","79.5","","800.18","480.96","1887.97","195","284.27","729.02","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004309","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","488.76","53.3","","813.12","216.42","1444.50","81","284.27","729.02","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004309","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","284.27","31","","432.60","432.60","432.60","1 through 10","284.27","729.02","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004309","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","334.71","36.5","","148.37","54.89","631.39","94","284.27","729.02","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004309","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","351.21","38.3","","279.30","91.72","1116.77","266","284.27","729.02","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004309","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.39","42.9","","731.00","63.70","731.00","1 through 10","284.27","729.02","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004309","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.39","42.9","","384.74","384.74","384.74","1 through 10","284.27","729.02","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004309","CDM","C1713","HCPCS","0278","RC","","","","both","","","917.00","687.75","WELLPOINT [1015]","HB AMC WELLPOINT","676.56","73.78","","286.63","119.22","1107.45","105","284.27","729.02","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","917.00","687.75","AETNA [1001]","HB AMC AETNA HMO","640.07","69.8","","675.31","184.75","1721.50","286","479.22","749.37","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","917.00","687.75","AETNA [1001]","HB AMC AETNA PPO","737.27","80.4","","1261.44","103.12","1514.10","21","479.22","749.37","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","917.00","687.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","737.27","80.4","","1365.00","1365.00","1365.00","1 through 10","479.22","749.37","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","917.00","687.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","749.37","81.72","","5157.68","5157.68","5157.68","1 through 10","479.22","749.37","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","917.00","687.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","749.37","81.72","","431.26","71.26","1459.57","88","479.22","749.37","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10024327","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.43","79.5","","800.18","480.96","1887.97","195","72.7","186.43","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10024327","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.99","53.3","","813.12","216.42","1444.50","81","72.7","186.43","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10024327","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.70","31","","432.60","432.60","432.60","1 through 10","72.7","186.43","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10024327","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.59","36.5","","148.37","54.89","631.39","94","72.7","186.43","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10024327","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.81","38.3","","279.30","91.72","1116.77","266","72.7","186.43","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10024327","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.60","42.9","","731.00","63.70","731.00","1 through 10","72.7","186.43","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10024327","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.60","42.9","","384.74","384.74","384.74","1 through 10","72.7","186.43","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10024327","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","WELLPOINT [1015]","HB AMC WELLPOINT","173.01","73.78","","286.63","119.22","1107.45","105","72.7","186.43","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10024327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","234.50","175.87","AETNA [1001]","HB AMC AETNA HMO","163.68","69.8","","675.31","184.75","1721.50","286","122.55","191.63","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10024327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","234.50","175.87","AETNA [1001]","HB AMC AETNA PPO","188.54","80.4","","1261.44","103.12","1514.10","21","122.55","191.63","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10024327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","234.50","175.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","188.54","80.4","","1365.00","1365.00","1365.00","1 through 10","122.55","191.63","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10024327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","234.50","175.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.63","81.72","","5157.68","5157.68","5157.68","1 through 10","122.55","191.63","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10024327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","234.50","175.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.63","81.72","","431.26","71.26","1459.57","88","122.55","191.63","percent of total billed charges",""
"SCREW BONE 2.7X10MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072004","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","120.37","79.5","","800.18","480.96","1887.97","195","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X10MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072004","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","80.70","53.3","","813.12","216.42","1444.50","81","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X10MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072004","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","46.94","31","","432.60","432.60","432.60","1 through 10","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X10MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072004","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.26","36.5","","148.37","54.89","631.39","94","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X10MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072004","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.99","38.3","","279.30","91.72","1116.77","266","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X10MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072004","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.95","42.9","","731.00","63.70","731.00","1 through 10","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X10MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072004","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.95","42.9","","384.74","384.74","384.74","1 through 10","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X10MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072004","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","WELLPOINT [1015]","HB AMC WELLPOINT","111.71","73.78","","286.63","119.22","1107.45","105","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X10MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.41","113.56","AETNA [1001]","HB AMC AETNA HMO","105.68","69.8","","675.31","184.75","1721.50","286","79.13","123.73","percent of total billed charges",""
"SCREW BONE 2.7X10MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.41","113.56","AETNA [1001]","HB AMC AETNA PPO","121.73","80.4","","1261.44","103.12","1514.10","21","79.13","123.73","percent of total billed charges",""
"SCREW BONE 2.7X10MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.41","113.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","121.73","80.4","","1365.00","1365.00","1365.00","1 through 10","79.13","123.73","percent of total billed charges",""
"SCREW BONE 2.7X10MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.41","113.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","123.73","81.72","","5157.68","5157.68","5157.68","1 through 10","79.13","123.73","percent of total billed charges",""
"SCREW BONE 2.7X10MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.41","113.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","123.73","81.72","","431.26","71.26","1459.57","88","79.13","123.73","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","134.70","79.5","","800.18","480.96","1887.97","195","52.53","134.7","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","90.31","53.3","","813.12","216.42","1444.50","81","52.53","134.7","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","52.53","31","","432.60","432.60","432.60","1 through 10","52.53","134.7","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","61.85","36.5","","148.37","54.89","631.39","94","52.53","134.7","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64.90","38.3","","279.30","91.72","1116.77","266","52.53","134.7","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.69","42.9","","731.00","63.70","731.00","1 through 10","52.53","134.7","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.69","42.9","","384.74","384.74","384.74","1 through 10","52.53","134.7","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.44","127.08","WELLPOINT [1015]","HB AMC WELLPOINT","125.01","73.78","","286.63","119.22","1107.45","105","52.53","134.7","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.44","127.08","AETNA [1001]","HB AMC AETNA HMO","118.27","69.8","","675.31","184.75","1721.50","286","88.55","138.47","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.44","127.08","AETNA [1001]","HB AMC AETNA PPO","136.23","80.4","","1261.44","103.12","1514.10","21","88.55","138.47","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.44","127.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","136.23","80.4","","1365.00","1365.00","1365.00","1 through 10","88.55","138.47","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.44","127.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","138.47","81.72","","5157.68","5157.68","5157.68","1 through 10","88.55","138.47","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.44","127.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","138.47","81.72","","431.26","71.26","1459.57","88","88.55","138.47","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","282.09","79.5","","800.18","480.96","1887.97","195","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","189.12","53.3","","813.12","216.42","1444.50","81","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","110.00","31","","432.60","432.60","432.60","1 through 10","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","129.51","36.5","","148.37","54.89","631.39","94","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","135.90","38.3","","279.30","91.72","1116.77","266","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","152.22","42.9","","731.00","63.70","731.00","1 through 10","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","152.22","42.9","","384.74","384.74","384.74","1 through 10","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","WELLPOINT [1015]","HB AMC WELLPOINT","261.79","73.78","","286.63","119.22","1107.45","105","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.83","266.12","AETNA [1001]","HB AMC AETNA HMO","247.67","69.8","","675.31","184.75","1721.50","286","185.43","289.97","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.83","266.12","AETNA [1001]","HB AMC AETNA PPO","285.28","80.4","","1261.44","103.12","1514.10","21","185.43","289.97","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.83","266.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","285.28","80.4","","1365.00","1365.00","1365.00","1 through 10","185.43","289.97","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.83","266.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","289.97","81.72","","5157.68","5157.68","5157.68","1 through 10","185.43","289.97","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.83","266.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","289.97","81.72","","431.26","71.26","1459.57","88","185.43","289.97","percent of total billed charges",""
"SCREW BONE 2.7X12MM CHARLOTTE MTP FUSION SS FIXATION NONLOCKING","SUP-ITM-10025096","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.50","228.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","242.08","79.5","","800.18","480.96","1887.97","195","94.4","242.08","percent of total billed charges",""
"SCREW BONE 2.7X12MM CHARLOTTE MTP FUSION SS FIXATION NONLOCKING","SUP-ITM-10025096","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.50","228.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","162.30","53.3","","813.12","216.42","1444.50","81","94.4","242.08","percent of total billed charges",""
"SCREW BONE 2.7X12MM CHARLOTTE MTP FUSION SS FIXATION NONLOCKING","SUP-ITM-10025096","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.50","228.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","94.40","31","","432.60","432.60","432.60","1 through 10","94.4","242.08","percent of total billed charges",""
"SCREW BONE 2.7X12MM CHARLOTTE MTP FUSION SS FIXATION NONLOCKING","SUP-ITM-10025096","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.50","228.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","111.14","36.5","","148.37","54.89","631.39","94","94.4","242.08","percent of total billed charges",""
"SCREW BONE 2.7X12MM CHARLOTTE MTP FUSION SS FIXATION NONLOCKING","SUP-ITM-10025096","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.50","228.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","116.62","38.3","","279.30","91.72","1116.77","266","94.4","242.08","percent of total billed charges",""
"SCREW BONE 2.7X12MM CHARLOTTE MTP FUSION SS FIXATION NONLOCKING","SUP-ITM-10025096","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.50","228.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.63","42.9","","731.00","63.70","731.00","1 through 10","94.4","242.08","percent of total billed charges",""
"SCREW BONE 2.7X12MM CHARLOTTE MTP FUSION SS FIXATION NONLOCKING","SUP-ITM-10025096","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.50","228.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.63","42.9","","384.74","384.74","384.74","1 through 10","94.4","242.08","percent of total billed charges",""
"SCREW BONE 2.7X12MM CHARLOTTE MTP FUSION SS FIXATION NONLOCKING","SUP-ITM-10025096","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.50","228.37","WELLPOINT [1015]","HB AMC WELLPOINT","224.66","73.78","","286.63","119.22","1107.45","105","94.4","242.08","percent of total billed charges",""
"SCREW BONE 2.7X12MM CHARLOTTE MTP FUSION SS FIXATION NONLOCKING","SUP-ITM-10025096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.50","228.37","AETNA [1001]","HB AMC AETNA HMO","212.54","69.8","","675.31","184.75","1721.50","286","159.13","248.84","percent of total billed charges",""
"SCREW BONE 2.7X12MM CHARLOTTE MTP FUSION SS FIXATION NONLOCKING","SUP-ITM-10025096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.50","228.37","AETNA [1001]","HB AMC AETNA PPO","244.82","80.4","","1261.44","103.12","1514.10","21","159.13","248.84","percent of total billed charges",""
"SCREW BONE 2.7X12MM CHARLOTTE MTP FUSION SS FIXATION NONLOCKING","SUP-ITM-10025096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.50","228.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","244.82","80.4","","1365.00","1365.00","1365.00","1 through 10","159.13","248.84","percent of total billed charges",""
"SCREW BONE 2.7X12MM CHARLOTTE MTP FUSION SS FIXATION NONLOCKING","SUP-ITM-10025096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.50","228.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","248.84","81.72","","5157.68","5157.68","5157.68","1 through 10","159.13","248.84","percent of total billed charges",""
"SCREW BONE 2.7X12MM CHARLOTTE MTP FUSION SS FIXATION NONLOCKING","SUP-ITM-10025096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.50","228.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","248.84","81.72","","431.26","71.26","1459.57","88","159.13","248.84","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTEX TI SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004077","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.39","100.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","106.05","79.5","","800.18","480.96","1887.97","195","41.35","106.05","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTEX TI SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004077","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.39","100.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","71.10","53.3","","813.12","216.42","1444.50","81","41.35","106.05","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTEX TI SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004077","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.39","100.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","41.35","31","","432.60","432.60","432.60","1 through 10","41.35","106.05","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTEX TI SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004077","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.39","100.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.69","36.5","","148.37","54.89","631.39","94","41.35","106.05","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTEX TI SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004077","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.39","100.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","51.09","38.3","","279.30","91.72","1116.77","266","41.35","106.05","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTEX TI SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004077","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.39","100.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.22","42.9","","731.00","63.70","731.00","1 through 10","41.35","106.05","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTEX TI SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004077","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.39","100.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.22","42.9","","384.74","384.74","384.74","1 through 10","41.35","106.05","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTEX TI SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004077","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.39","100.04","WELLPOINT [1015]","HB AMC WELLPOINT","98.42","73.78","","286.63","119.22","1107.45","105","41.35","106.05","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTEX TI SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.39","100.04","AETNA [1001]","HB AMC AETNA HMO","93.11","69.8","","675.31","184.75","1721.50","286","69.71","109.01","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTEX TI SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.39","100.04","AETNA [1001]","HB AMC AETNA PPO","107.25","80.4","","1261.44","103.12","1514.10","21","69.71","109.01","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTEX TI SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.39","100.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","107.25","80.4","","1365.00","1365.00","1365.00","1 through 10","69.71","109.01","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTEX TI SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.39","100.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","109.01","81.72","","5157.68","5157.68","5157.68","1 through 10","69.71","109.01","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTEX TI SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10004077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.39","100.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","109.01","81.72","","431.26","71.26","1459.57","88","69.71","109.01","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL ACU LOK FIXED ANGLE TITANIUM LOCKING FULL THREAD PROXIMALIMAL HEAD LOW PROFILE","SUP-ITM-10021715","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.00","309.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","328.34","79.5","","800.18","480.96","1887.97","195","128.03","328.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL ACU LOK FIXED ANGLE TITANIUM LOCKING FULL THREAD PROXIMALIMAL HEAD LOW PROFILE","SUP-ITM-10021715","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.00","309.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","220.13","53.3","","813.12","216.42","1444.50","81","128.03","328.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL ACU LOK FIXED ANGLE TITANIUM LOCKING FULL THREAD PROXIMALIMAL HEAD LOW PROFILE","SUP-ITM-10021715","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.00","309.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","128.03","31","","432.60","432.60","432.60","1 through 10","128.03","328.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL ACU LOK FIXED ANGLE TITANIUM LOCKING FULL THREAD PROXIMALIMAL HEAD LOW PROFILE","SUP-ITM-10021715","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.00","309.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","150.75","36.5","","148.37","54.89","631.39","94","128.03","328.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL ACU LOK FIXED ANGLE TITANIUM LOCKING FULL THREAD PROXIMALIMAL HEAD LOW PROFILE","SUP-ITM-10021715","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.00","309.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","158.18","38.3","","279.30","91.72","1116.77","266","128.03","328.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL ACU LOK FIXED ANGLE TITANIUM LOCKING FULL THREAD PROXIMALIMAL HEAD LOW PROFILE","SUP-ITM-10021715","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.00","309.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","177.18","42.9","","731.00","63.70","731.00","1 through 10","128.03","328.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL ACU LOK FIXED ANGLE TITANIUM LOCKING FULL THREAD PROXIMALIMAL HEAD LOW PROFILE","SUP-ITM-10021715","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.00","309.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","177.18","42.9","","384.74","384.74","384.74","1 through 10","128.03","328.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL ACU LOK FIXED ANGLE TITANIUM LOCKING FULL THREAD PROXIMALIMAL HEAD LOW PROFILE","SUP-ITM-10021715","CDM","C1713","HCPCS","0278","RC","","","","both","","","413.00","309.75","WELLPOINT [1015]","HB AMC WELLPOINT","304.71","73.78","","286.63","119.22","1107.45","105","128.03","328.34","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL ACU LOK FIXED ANGLE TITANIUM LOCKING FULL THREAD PROXIMALIMAL HEAD LOW PROFILE","SUP-ITM-10021715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.00","309.75","AETNA [1001]","HB AMC AETNA HMO","288.27","69.8","","675.31","184.75","1721.50","286","215.83","337.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL ACU LOK FIXED ANGLE TITANIUM LOCKING FULL THREAD PROXIMALIMAL HEAD LOW PROFILE","SUP-ITM-10021715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.00","309.75","AETNA [1001]","HB AMC AETNA PPO","332.05","80.4","","1261.44","103.12","1514.10","21","215.83","337.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL ACU LOK FIXED ANGLE TITANIUM LOCKING FULL THREAD PROXIMALIMAL HEAD LOW PROFILE","SUP-ITM-10021715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.00","309.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","332.05","80.4","","1365.00","1365.00","1365.00","1 through 10","215.83","337.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL ACU LOK FIXED ANGLE TITANIUM LOCKING FULL THREAD PROXIMALIMAL HEAD LOW PROFILE","SUP-ITM-10021715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.00","309.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","337.50","81.72","","5157.68","5157.68","5157.68","1 through 10","215.83","337.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL ACU LOK FIXED ANGLE TITANIUM LOCKING FULL THREAD PROXIMALIMAL HEAD LOW PROFILE","SUP-ITM-10021715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","413.00","309.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","337.50","81.72","","431.26","71.26","1459.57","88","215.83","337.5","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","97.81","79.5","","800.18","480.96","1887.97","195","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","65.57","53.3","","813.12","216.42","1444.50","81","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","38.14","31","","432.60","432.60","432.60","1 through 10","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.91","36.5","","148.37","54.89","631.39","94","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","47.12","38.3","","279.30","91.72","1116.77","266","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.78","42.9","","731.00","63.70","731.00","1 through 10","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.78","42.9","","384.74","384.74","384.74","1 through 10","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","WELLPOINT [1015]","HB AMC WELLPOINT","90.77","73.78","","286.63","119.22","1107.45","105","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.03","92.27","AETNA [1001]","HB AMC AETNA HMO","85.87","69.8","","675.31","184.75","1721.50","286","64.3","100.54","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.03","92.27","AETNA [1001]","HB AMC AETNA PPO","98.92","80.4","","1261.44","103.12","1514.10","21","64.3","100.54","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.03","92.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","98.92","80.4","","1365.00","1365.00","1365.00","1 through 10","64.3","100.54","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.03","92.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","100.54","81.72","","5157.68","5157.68","5157.68","1 through 10","64.3","100.54","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.03","92.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","100.54","81.72","","431.26","71.26","1459.57","88","64.3","100.54","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.59","427.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","452.82","79.5","","800.18","480.96","1887.97","195","176.57","452.82","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.59","427.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","303.59","53.3","","813.12","216.42","1444.50","81","176.57","452.82","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.59","427.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","176.57","31","","432.60","432.60","432.60","1 through 10","176.57","452.82","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.59","427.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","207.90","36.5","","148.37","54.89","631.39","94","176.57","452.82","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.59","427.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","218.15","38.3","","279.30","91.72","1116.77","266","176.57","452.82","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.59","427.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.35","42.9","","731.00","63.70","731.00","1 through 10","176.57","452.82","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.59","427.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.35","42.9","","384.74","384.74","384.74","1 through 10","176.57","452.82","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.59","427.19","WELLPOINT [1015]","HB AMC WELLPOINT","420.24","73.78","","286.63","119.22","1107.45","105","176.57","452.82","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.59","427.19","AETNA [1001]","HB AMC AETNA HMO","397.57","69.8","","675.31","184.75","1721.50","286","297.67","465.47","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.59","427.19","AETNA [1001]","HB AMC AETNA PPO","457.95","80.4","","1261.44","103.12","1514.10","21","297.67","465.47","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.59","427.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","457.95","80.4","","1365.00","1365.00","1365.00","1 through 10","297.67","465.47","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.59","427.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","465.47","81.72","","5157.68","5157.68","5157.68","1 through 10","297.67","465.47","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.59","427.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","465.47","81.72","","431.26","71.26","1459.57","88","297.67","465.47","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","120.37","79.5","","800.18","480.96","1887.97","195","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","80.70","53.3","","813.12","216.42","1444.50","81","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","46.94","31","","432.60","432.60","432.60","1 through 10","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.26","36.5","","148.37","54.89","631.39","94","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.99","38.3","","279.30","91.72","1116.77","266","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.95","42.9","","731.00","63.70","731.00","1 through 10","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.95","42.9","","384.74","384.74","384.74","1 through 10","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.41","113.56","WELLPOINT [1015]","HB AMC WELLPOINT","111.71","73.78","","286.63","119.22","1107.45","105","46.94","120.37","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.41","113.56","AETNA [1001]","HB AMC AETNA HMO","105.68","69.8","","675.31","184.75","1721.50","286","79.13","123.73","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.41","113.56","AETNA [1001]","HB AMC AETNA PPO","121.73","80.4","","1261.44","103.12","1514.10","21","79.13","123.73","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.41","113.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","121.73","80.4","","1365.00","1365.00","1365.00","1 through 10","79.13","123.73","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.41","113.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","123.73","81.72","","5157.68","5157.68","5157.68","1 through 10","79.13","123.73","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.41","113.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","123.73","81.72","","431.26","71.26","1459.57","88","79.13","123.73","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.96","85.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","90.60","79.5","","800.18","480.96","1887.97","195","35.33","90.6","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.96","85.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","60.74","53.3","","813.12","216.42","1444.50","81","35.33","90.6","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.96","85.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","35.33","31","","432.60","432.60","432.60","1 through 10","35.33","90.6","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.96","85.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.60","36.5","","148.37","54.89","631.39","94","35.33","90.6","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.96","85.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.65","38.3","","279.30","91.72","1116.77","266","35.33","90.6","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.96","85.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.89","42.9","","731.00","63.70","731.00","1 through 10","35.33","90.6","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.96","85.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.89","42.9","","384.74","384.74","384.74","1 through 10","35.33","90.6","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.96","85.47","WELLPOINT [1015]","HB AMC WELLPOINT","84.08","73.78","","286.63","119.22","1107.45","105","35.33","90.6","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.96","85.47","AETNA [1001]","HB AMC AETNA HMO","79.54","69.8","","675.31","184.75","1721.50","286","59.56","93.13","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.96","85.47","AETNA [1001]","HB AMC AETNA PPO","91.62","80.4","","1261.44","103.12","1514.10","21","59.56","93.13","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.96","85.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","91.62","80.4","","1365.00","1365.00","1365.00","1 through 10","59.56","93.13","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.96","85.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","93.13","81.72","","5157.68","5157.68","5157.68","1 through 10","59.56","93.13","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.96","85.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.13","81.72","","431.26","71.26","1459.57","88","59.56","93.13","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004311","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.88","163.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","173.21","79.5","","800.18","480.96","1887.97","195","67.54","173.21","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004311","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.88","163.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","116.13","53.3","","813.12","216.42","1444.50","81","67.54","173.21","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004311","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.88","163.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","67.54","31","","432.60","432.60","432.60","1 through 10","67.54","173.21","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004311","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.88","163.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","79.53","36.5","","148.37","54.89","631.39","94","67.54","173.21","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004311","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.88","163.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","83.45","38.3","","279.30","91.72","1116.77","266","67.54","173.21","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004311","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.88","163.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.47","42.9","","731.00","63.70","731.00","1 through 10","67.54","173.21","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004311","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.88","163.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.47","42.9","","384.74","384.74","384.74","1 through 10","67.54","173.21","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004311","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.88","163.41","WELLPOINT [1015]","HB AMC WELLPOINT","160.75","73.78","","286.63","119.22","1107.45","105","67.54","173.21","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.88","163.41","AETNA [1001]","HB AMC AETNA HMO","152.08","69.8","","675.31","184.75","1721.50","286","113.86","178.05","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.88","163.41","AETNA [1001]","HB AMC AETNA PPO","175.18","80.4","","1261.44","103.12","1514.10","21","113.86","178.05","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.88","163.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","175.18","80.4","","1365.00","1365.00","1365.00","1 through 10","113.86","178.05","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.88","163.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","178.05","81.72","","5157.68","5157.68","5157.68","1 through 10","113.86","178.05","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL SELF TAPPING EMERGENCY CRUCIFORM HEAD TI PK/5EA","SUP-ITM-10004311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.88","163.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","178.05","81.72","","431.26","71.26","1459.57","88","113.86","178.05","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","370.07","79.5","","800.18","480.96","1887.97","195","144.31","370.07","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","248.11","53.3","","813.12","216.42","1444.50","81","144.31","370.07","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","144.31","31","","432.60","432.60","432.60","1 through 10","144.31","370.07","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","169.91","36.5","","148.37","54.89","631.39","94","144.31","370.07","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","178.29","38.3","","279.30","91.72","1116.77","266","144.31","370.07","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.70","42.9","","731.00","63.70","731.00","1 through 10","144.31","370.07","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.70","42.9","","384.74","384.74","384.74","1 through 10","144.31","370.07","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","WELLPOINT [1015]","HB AMC WELLPOINT","343.45","73.78","","286.63","119.22","1107.45","105","144.31","370.07","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.50","349.12","AETNA [1001]","HB AMC AETNA HMO","324.92","69.8","","675.31","184.75","1721.50","286","243.27","380.41","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.50","349.12","AETNA [1001]","HB AMC AETNA PPO","374.26","80.4","","1261.44","103.12","1514.10","21","243.27","380.41","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.50","349.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","374.26","80.4","","1365.00","1365.00","1365.00","1 through 10","243.27","380.41","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.50","349.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","380.41","81.72","","5157.68","5157.68","5157.68","1 through 10","243.27","380.41","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.50","349.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","380.41","81.72","","431.26","71.26","1459.57","88","243.27","380.41","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.62","94.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","99.87","79.5","","800.18","480.96","1887.97","195","38.94","99.87","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.62","94.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","66.96","53.3","","813.12","216.42","1444.50","81","38.94","99.87","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.62","94.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","38.94","31","","432.60","432.60","432.60","1 through 10","38.94","99.87","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.62","94.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","45.85","36.5","","148.37","54.89","631.39","94","38.94","99.87","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.62","94.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48.11","38.3","","279.30","91.72","1116.77","266","38.94","99.87","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.62","94.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.89","42.9","","731.00","63.70","731.00","1 through 10","38.94","99.87","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.62","94.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.89","42.9","","384.74","384.74","384.74","1 through 10","38.94","99.87","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.62","94.21","WELLPOINT [1015]","HB AMC WELLPOINT","92.68","73.78","","286.63","119.22","1107.45","105","38.94","99.87","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.62","94.21","AETNA [1001]","HB AMC AETNA HMO","87.68","69.8","","675.31","184.75","1721.50","286","65.65","102.66","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.62","94.21","AETNA [1001]","HB AMC AETNA PPO","101.00","80.4","","1261.44","103.12","1514.10","21","65.65","102.66","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.62","94.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","101.00","80.4","","1365.00","1365.00","1365.00","1 through 10","65.65","102.66","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.62","94.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","102.66","81.72","","5157.68","5157.68","5157.68","1 through 10","65.65","102.66","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.62","94.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","102.66","81.72","","431.26","71.26","1459.57","88","65.65","102.66","percent of total billed charges",""
"SCREW BONE 2.7X16MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125579","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","181.20","79.5","","800.18","480.96","1887.97","195","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X16MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125579","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","121.48","53.3","","813.12","216.42","1444.50","81","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X16MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125579","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","70.66","31","","432.60","432.60","432.60","1 through 10","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X16MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125579","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.19","36.5","","148.37","54.89","631.39","94","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X16MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125579","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.29","38.3","","279.30","91.72","1116.77","266","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X16MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125579","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.78","42.9","","731.00","63.70","731.00","1 through 10","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X16MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125579","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.78","42.9","","384.74","384.74","384.74","1 through 10","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X16MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125579","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","WELLPOINT [1015]","HB AMC WELLPOINT","168.16","73.78","","286.63","119.22","1107.45","105","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X16MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.92","170.94","AETNA [1001]","HB AMC AETNA HMO","159.09","69.8","","675.31","184.75","1721.50","286","119.11","186.26","percent of total billed charges",""
"SCREW BONE 2.7X16MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.92","170.94","AETNA [1001]","HB AMC AETNA PPO","183.25","80.4","","1261.44","103.12","1514.10","21","119.11","186.26","percent of total billed charges",""
"SCREW BONE 2.7X16MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.92","170.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","183.25","80.4","","1365.00","1365.00","1365.00","1 through 10","119.11","186.26","percent of total billed charges",""
"SCREW BONE 2.7X16MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.92","170.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","186.26","81.72","","5157.68","5157.68","5157.68","1 through 10","119.11","186.26","percent of total billed charges",""
"SCREW BONE 2.7X16MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.92","170.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","186.26","81.72","","431.26","71.26","1459.57","88","119.11","186.26","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","282.09","79.5","","800.18","480.96","1887.97","195","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","189.12","53.3","","813.12","216.42","1444.50","81","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","110.00","31","","432.60","432.60","432.60","1 through 10","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","129.51","36.5","","148.37","54.89","631.39","94","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","135.90","38.3","","279.30","91.72","1116.77","266","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","152.22","42.9","","731.00","63.70","731.00","1 through 10","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","152.22","42.9","","384.74","384.74","384.74","1 through 10","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.83","266.12","WELLPOINT [1015]","HB AMC WELLPOINT","261.79","73.78","","286.63","119.22","1107.45","105","110","282.09","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.83","266.12","AETNA [1001]","HB AMC AETNA HMO","247.67","69.8","","675.31","184.75","1721.50","286","185.43","289.97","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.83","266.12","AETNA [1001]","HB AMC AETNA PPO","285.28","80.4","","1261.44","103.12","1514.10","21","185.43","289.97","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.83","266.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","285.28","80.4","","1365.00","1365.00","1365.00","1 through 10","185.43","289.97","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.83","266.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","289.97","81.72","","5157.68","5157.68","5157.68","1 through 10","185.43","289.97","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.83","266.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","289.97","81.72","","431.26","71.26","1459.57","88","185.43","289.97","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","443.86","79.5","","800.18","480.96","1887.97","195","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","297.58","53.3","","813.12","216.42","1444.50","81","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","173.08","31","","432.60","432.60","432.60","1 through 10","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","203.79","36.5","","148.37","54.89","631.39","94","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","213.84","38.3","","279.30","91.72","1116.77","266","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.52","42.9","","731.00","63.70","731.00","1 through 10","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.52","42.9","","384.74","384.74","384.74","1 through 10","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","WELLPOINT [1015]","HB AMC WELLPOINT","411.93","73.78","","286.63","119.22","1107.45","105","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","AETNA [1001]","HB AMC AETNA HMO","389.71","69.8","","675.31","184.75","1721.50","286","291.78","456.26","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","AETNA [1001]","HB AMC AETNA PPO","448.89","80.4","","1261.44","103.12","1514.10","21","291.78","456.26","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","448.89","80.4","","1365.00","1365.00","1365.00","1 through 10","291.78","456.26","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","456.26","81.72","","5157.68","5157.68","5157.68","1 through 10","291.78","456.26","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","456.26","81.72","","431.26","71.26","1459.57","88","291.78","456.26","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","428.98","79.5","","800.18","480.96","1887.97","195","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","287.61","53.3","","813.12","216.42","1444.50","81","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","167.28","31","","432.60","432.60","432.60","1 through 10","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","196.95","36.5","","148.37","54.89","631.39","94","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","206.67","38.3","","279.30","91.72","1116.77","266","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.49","42.9","","731.00","63.70","731.00","1 through 10","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.49","42.9","","384.74","384.74","384.74","1 through 10","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.60","404.70","WELLPOINT [1015]","HB AMC WELLPOINT","398.12","73.78","","286.63","119.22","1107.45","105","167.28","428.98","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.60","404.70","AETNA [1001]","HB AMC AETNA HMO","376.64","69.8","","675.31","184.75","1721.50","286","281.99","440.96","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.60","404.70","AETNA [1001]","HB AMC AETNA PPO","433.84","80.4","","1261.44","103.12","1514.10","21","281.99","440.96","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.60","404.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","433.84","80.4","","1365.00","1365.00","1365.00","1 through 10","281.99","440.96","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.60","404.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","440.96","81.72","","5157.68","5157.68","5157.68","1 through 10","281.99","440.96","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.60","404.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","440.96","81.72","","431.26","71.26","1459.57","88","281.99","440.96","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","732.83","79.5","","800.18","480.96","1887.97","195","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","491.32","53.3","","813.12","216.42","1444.50","81","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","285.76","31","","432.60","432.60","432.60","1 through 10","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","336.46","36.5","","148.37","54.89","631.39","94","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","353.05","38.3","","279.30","91.72","1116.77","266","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","395.45","42.9","","731.00","63.70","731.00","1 through 10","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","395.45","42.9","","384.74","384.74","384.74","1 through 10","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.80","691.35","WELLPOINT [1015]","HB AMC WELLPOINT","680.10","73.78","","286.63","119.22","1107.45","105","285.76","732.83","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","AETNA [1001]","HB AMC AETNA HMO","643.42","69.8","","675.31","184.75","1721.50","286","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","AETNA [1001]","HB AMC AETNA PPO","741.13","80.4","","1261.44","103.12","1514.10","21","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","741.13","80.4","","1365.00","1365.00","1365.00","1 through 10","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","753.29","81.72","","5157.68","5157.68","5157.68","1 through 10","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.80","691.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","753.29","81.72","","431.26","71.26","1459.57","88","481.73","753.29","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","320.99","79.5","","800.18","480.96","1887.97","195","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","215.20","53.3","","813.12","216.42","1444.50","81","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","125.17","31","","432.60","432.60","432.60","1 through 10","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","147.37","36.5","","148.37","54.89","631.39","94","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","154.64","38.3","","279.30","91.72","1116.77","266","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.21","42.9","","731.00","63.70","731.00","1 through 10","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.21","42.9","","384.74","384.74","384.74","1 through 10","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.76","302.82","WELLPOINT [1015]","HB AMC WELLPOINT","297.89","73.78","","286.63","119.22","1107.45","105","125.17","320.99","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","403.76","302.82","AETNA [1001]","HB AMC AETNA HMO","281.82","69.8","","675.31","184.75","1721.50","286","211","329.95","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","403.76","302.82","AETNA [1001]","HB AMC AETNA PPO","324.62","80.4","","1261.44","103.12","1514.10","21","211","329.95","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","403.76","302.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","324.62","80.4","","1365.00","1365.00","1365.00","1 through 10","211","329.95","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","403.76","302.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","329.95","81.72","","5157.68","5157.68","5157.68","1 through 10","211","329.95","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","403.76","302.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","329.95","81.72","","431.26","71.26","1459.57","88","211","329.95","percent of total billed charges",""
"SCREW BONE 2.7X20MM TITANIUM LCP LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10027408","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","259.44","79.5","","800.18","480.96","1887.97","195","101.17","259.44","percent of total billed charges",""
"SCREW BONE 2.7X20MM TITANIUM LCP LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10027408","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.94","53.3","","813.12","216.42","1444.50","81","101.17","259.44","percent of total billed charges",""
"SCREW BONE 2.7X20MM TITANIUM LCP LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10027408","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","101.17","31","","432.60","432.60","432.60","1 through 10","101.17","259.44","percent of total billed charges",""
"SCREW BONE 2.7X20MM TITANIUM LCP LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10027408","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","119.11","36.5","","148.37","54.89","631.39","94","101.17","259.44","percent of total billed charges",""
"SCREW BONE 2.7X20MM TITANIUM LCP LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10027408","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.99","38.3","","279.30","91.72","1116.77","266","101.17","259.44","percent of total billed charges",""
"SCREW BONE 2.7X20MM TITANIUM LCP LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10027408","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.00","42.9","","731.00","63.70","731.00","1 through 10","101.17","259.44","percent of total billed charges",""
"SCREW BONE 2.7X20MM TITANIUM LCP LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10027408","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.00","42.9","","384.74","384.74","384.74","1 through 10","101.17","259.44","percent of total billed charges",""
"SCREW BONE 2.7X20MM TITANIUM LCP LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10027408","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","WELLPOINT [1015]","HB AMC WELLPOINT","240.77","73.78","","286.63","119.22","1107.45","105","101.17","259.44","percent of total billed charges",""
"SCREW BONE 2.7X20MM TITANIUM LCP LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10027408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","AETNA [1001]","HB AMC AETNA HMO","227.79","69.8","","675.31","184.75","1721.50","286","170.55","266.69","percent of total billed charges",""
"SCREW BONE 2.7X20MM TITANIUM LCP LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10027408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","AETNA [1001]","HB AMC AETNA PPO","262.38","80.4","","1261.44","103.12","1514.10","21","170.55","266.69","percent of total billed charges",""
"SCREW BONE 2.7X20MM TITANIUM LCP LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10027408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","262.38","80.4","","1365.00","1365.00","1365.00","1 through 10","170.55","266.69","percent of total billed charges",""
"SCREW BONE 2.7X20MM TITANIUM LCP LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10027408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","266.69","81.72","","5157.68","5157.68","5157.68","1 through 10","170.55","266.69","percent of total billed charges",""
"SCREW BONE 2.7X20MM TITANIUM LCP LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10027408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","266.69","81.72","","431.26","71.26","1459.57","88","170.55","266.69","percent of total billed charges",""
"SCREW BONE 2.7X22MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019596","CDM","C1713","HCPCS","0278","RC","","","","both","","","591.50","443.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","470.24","79.5","","800.18","480.96","1887.97","195","183.37","470.24","percent of total billed charges",""
"SCREW BONE 2.7X22MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019596","CDM","C1713","HCPCS","0278","RC","","","","both","","","591.50","443.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","315.27","53.3","","813.12","216.42","1444.50","81","183.37","470.24","percent of total billed charges",""
"SCREW BONE 2.7X22MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019596","CDM","C1713","HCPCS","0278","RC","","","","both","","","591.50","443.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","183.37","31","","432.60","432.60","432.60","1 through 10","183.37","470.24","percent of total billed charges",""
"SCREW BONE 2.7X22MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019596","CDM","C1713","HCPCS","0278","RC","","","","both","","","591.50","443.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","215.90","36.5","","148.37","54.89","631.39","94","183.37","470.24","percent of total billed charges",""
"SCREW BONE 2.7X22MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019596","CDM","C1713","HCPCS","0278","RC","","","","both","","","591.50","443.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","226.54","38.3","","279.30","91.72","1116.77","266","183.37","470.24","percent of total billed charges",""
"SCREW BONE 2.7X22MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019596","CDM","C1713","HCPCS","0278","RC","","","","both","","","591.50","443.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","253.75","42.9","","731.00","63.70","731.00","1 through 10","183.37","470.24","percent of total billed charges",""
"SCREW BONE 2.7X22MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019596","CDM","C1713","HCPCS","0278","RC","","","","both","","","591.50","443.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","253.75","42.9","","384.74","384.74","384.74","1 through 10","183.37","470.24","percent of total billed charges",""
"SCREW BONE 2.7X22MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019596","CDM","C1713","HCPCS","0278","RC","","","","both","","","591.50","443.62","WELLPOINT [1015]","HB AMC WELLPOINT","436.41","73.78","","286.63","119.22","1107.45","105","183.37","470.24","percent of total billed charges",""
"SCREW BONE 2.7X22MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","591.50","443.62","AETNA [1001]","HB AMC AETNA HMO","412.87","69.8","","675.31","184.75","1721.50","286","309.12","483.37","percent of total billed charges",""
"SCREW BONE 2.7X22MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","591.50","443.62","AETNA [1001]","HB AMC AETNA PPO","475.57","80.4","","1261.44","103.12","1514.10","21","309.12","483.37","percent of total billed charges",""
"SCREW BONE 2.7X22MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","591.50","443.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","475.57","80.4","","1365.00","1365.00","1365.00","1 through 10","309.12","483.37","percent of total billed charges",""
"SCREW BONE 2.7X22MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","591.50","443.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","483.37","81.72","","5157.68","5157.68","5157.68","1 through 10","309.12","483.37","percent of total billed charges",""
"SCREW BONE 2.7X22MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","591.50","443.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","483.37","81.72","","431.26","71.26","1459.57","88","309.12","483.37","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","234.73","79.5","","800.18","480.96","1887.97","195","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","157.37","53.3","","813.12","216.42","1444.50","81","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","91.53","31","","432.60","432.60","432.60","1 through 10","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","107.77","36.5","","148.37","54.89","631.39","94","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.08","38.3","","279.30","91.72","1116.77","266","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.67","42.9","","731.00","63.70","731.00","1 through 10","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.67","42.9","","384.74","384.74","384.74","1 through 10","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","WELLPOINT [1015]","HB AMC WELLPOINT","217.84","73.78","","286.63","119.22","1107.45","105","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","295.26","221.44","AETNA [1001]","HB AMC AETNA HMO","206.09","69.8","","675.31","184.75","1721.50","286","154.3","241.29","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","295.26","221.44","AETNA [1001]","HB AMC AETNA PPO","237.39","80.4","","1261.44","103.12","1514.10","21","154.3","241.29","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","295.26","221.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","237.39","80.4","","1365.00","1365.00","1365.00","1 through 10","154.3","241.29","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","295.26","221.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","241.29","81.72","","5157.68","5157.68","5157.68","1 through 10","154.3","241.29","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","295.26","221.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","241.29","81.72","","431.26","71.26","1459.57","88","154.3","241.29","percent of total billed charges",""
"SCREW BONE 2.7X24MM VARIAX 2 T8 LOCKING FULLY THREADED MINI STERILE","SUP-ITM-10185895","CDM","C1713","HCPCS","0278","RC","","","","both","","","966.74","725.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","768.56","79.5","","800.18","480.96","1887.97","195","299.69","768.56","percent of total billed charges",""
"SCREW BONE 2.7X24MM VARIAX 2 T8 LOCKING FULLY THREADED MINI STERILE","SUP-ITM-10185895","CDM","C1713","HCPCS","0278","RC","","","","both","","","966.74","725.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","515.27","53.3","","813.12","216.42","1444.50","81","299.69","768.56","percent of total billed charges",""
"SCREW BONE 2.7X24MM VARIAX 2 T8 LOCKING FULLY THREADED MINI STERILE","SUP-ITM-10185895","CDM","C1713","HCPCS","0278","RC","","","","both","","","966.74","725.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","299.69","31","","432.60","432.60","432.60","1 through 10","299.69","768.56","percent of total billed charges",""
"SCREW BONE 2.7X24MM VARIAX 2 T8 LOCKING FULLY THREADED MINI STERILE","SUP-ITM-10185895","CDM","C1713","HCPCS","0278","RC","","","","both","","","966.74","725.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","352.86","36.5","","148.37","54.89","631.39","94","299.69","768.56","percent of total billed charges",""
"SCREW BONE 2.7X24MM VARIAX 2 T8 LOCKING FULLY THREADED MINI STERILE","SUP-ITM-10185895","CDM","C1713","HCPCS","0278","RC","","","","both","","","966.74","725.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","370.26","38.3","","279.30","91.72","1116.77","266","299.69","768.56","percent of total billed charges",""
"SCREW BONE 2.7X24MM VARIAX 2 T8 LOCKING FULLY THREADED MINI STERILE","SUP-ITM-10185895","CDM","C1713","HCPCS","0278","RC","","","","both","","","966.74","725.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","414.73","42.9","","731.00","63.70","731.00","1 through 10","299.69","768.56","percent of total billed charges",""
"SCREW BONE 2.7X24MM VARIAX 2 T8 LOCKING FULLY THREADED MINI STERILE","SUP-ITM-10185895","CDM","C1713","HCPCS","0278","RC","","","","both","","","966.74","725.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","414.73","42.9","","384.74","384.74","384.74","1 through 10","299.69","768.56","percent of total billed charges",""
"SCREW BONE 2.7X24MM VARIAX 2 T8 LOCKING FULLY THREADED MINI STERILE","SUP-ITM-10185895","CDM","C1713","HCPCS","0278","RC","","","","both","","","966.74","725.05","WELLPOINT [1015]","HB AMC WELLPOINT","713.26","73.78","","286.63","119.22","1107.45","105","299.69","768.56","percent of total billed charges",""
"SCREW BONE 2.7X24MM VARIAX 2 T8 LOCKING FULLY THREADED MINI STERILE","SUP-ITM-10185895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","966.74","725.05","AETNA [1001]","HB AMC AETNA HMO","674.78","69.8","","675.31","184.75","1721.50","286","505.22","790.02","percent of total billed charges",""
"SCREW BONE 2.7X24MM VARIAX 2 T8 LOCKING FULLY THREADED MINI STERILE","SUP-ITM-10185895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","966.74","725.05","AETNA [1001]","HB AMC AETNA PPO","777.26","80.4","","1261.44","103.12","1514.10","21","505.22","790.02","percent of total billed charges",""
"SCREW BONE 2.7X24MM VARIAX 2 T8 LOCKING FULLY THREADED MINI STERILE","SUP-ITM-10185895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","966.74","725.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","777.26","80.4","","1365.00","1365.00","1365.00","1 through 10","505.22","790.02","percent of total billed charges",""
"SCREW BONE 2.7X24MM VARIAX 2 T8 LOCKING FULLY THREADED MINI STERILE","SUP-ITM-10185895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","966.74","725.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","790.02","81.72","","5157.68","5157.68","5157.68","1 through 10","505.22","790.02","percent of total billed charges",""
"SCREW BONE 2.7X24MM VARIAX 2 T8 LOCKING FULLY THREADED MINI STERILE","SUP-ITM-10185895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","966.74","725.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","790.02","81.72","","431.26","71.26","1459.57","88","505.22","790.02","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","234.73","79.5","","800.18","480.96","1887.97","195","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","157.37","53.3","","813.12","216.42","1444.50","81","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","91.53","31","","432.60","432.60","432.60","1 through 10","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","107.77","36.5","","148.37","54.89","631.39","94","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.08","38.3","","279.30","91.72","1116.77","266","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.67","42.9","","731.00","63.70","731.00","1 through 10","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.67","42.9","","384.74","384.74","384.74","1 through 10","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","WELLPOINT [1015]","HB AMC WELLPOINT","217.84","73.78","","286.63","119.22","1107.45","105","91.53","234.73","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","295.26","221.44","AETNA [1001]","HB AMC AETNA HMO","206.09","69.8","","675.31","184.75","1721.50","286","154.3","241.29","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","295.26","221.44","AETNA [1001]","HB AMC AETNA PPO","237.39","80.4","","1261.44","103.12","1514.10","21","154.3","241.29","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","295.26","221.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","237.39","80.4","","1365.00","1365.00","1365.00","1 through 10","154.3","241.29","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","295.26","221.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","241.29","81.72","","5157.68","5157.68","5157.68","1 through 10","154.3","241.29","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","295.26","221.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","241.29","81.72","","431.26","71.26","1459.57","88","154.3","241.29","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.91","154.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","163.70","79.5","","800.18","480.96","1887.97","195","63.83","163.7","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.91","154.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.75","53.3","","813.12","216.42","1444.50","81","63.83","163.7","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.91","154.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","63.83","31","","432.60","432.60","432.60","1 through 10","63.83","163.7","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.91","154.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","75.16","36.5","","148.37","54.89","631.39","94","63.83","163.7","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.91","154.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.86","38.3","","279.30","91.72","1116.77","266","63.83","163.7","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.91","154.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.34","42.9","","731.00","63.70","731.00","1 through 10","63.83","163.7","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.91","154.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.34","42.9","","384.74","384.74","384.74","1 through 10","63.83","163.7","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.91","154.43","WELLPOINT [1015]","HB AMC WELLPOINT","151.92","73.78","","286.63","119.22","1107.45","105","63.83","163.7","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.91","154.43","AETNA [1001]","HB AMC AETNA HMO","143.73","69.8","","675.31","184.75","1721.50","286","107.61","168.27","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.91","154.43","AETNA [1001]","HB AMC AETNA PPO","165.55","80.4","","1261.44","103.12","1514.10","21","107.61","168.27","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.91","154.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","165.55","80.4","","1365.00","1365.00","1365.00","1 through 10","107.61","168.27","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.91","154.43","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","168.27","81.72","","5157.68","5157.68","5157.68","1 through 10","107.61","168.27","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.91","154.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","168.27","81.72","","431.26","71.26","1459.57","88","107.61","168.27","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125582","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","181.20","79.5","","800.18","480.96","1887.97","195","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125582","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","121.48","53.3","","813.12","216.42","1444.50","81","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125582","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","70.66","31","","432.60","432.60","432.60","1 through 10","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125582","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.19","36.5","","148.37","54.89","631.39","94","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125582","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.29","38.3","","279.30","91.72","1116.77","266","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125582","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.78","42.9","","731.00","63.70","731.00","1 through 10","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125582","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.78","42.9","","384.74","384.74","384.74","1 through 10","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125582","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.92","170.94","WELLPOINT [1015]","HB AMC WELLPOINT","168.16","73.78","","286.63","119.22","1107.45","105","70.66","181.2","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125582","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.92","170.94","AETNA [1001]","HB AMC AETNA HMO","159.09","69.8","","675.31","184.75","1721.50","286","119.11","186.26","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125582","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.92","170.94","AETNA [1001]","HB AMC AETNA PPO","183.25","80.4","","1261.44","103.12","1514.10","21","119.11","186.26","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125582","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.92","170.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","183.25","80.4","","1365.00","1365.00","1365.00","1 through 10","119.11","186.26","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125582","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.92","170.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","186.26","81.72","","5157.68","5157.68","5157.68","1 through 10","119.11","186.26","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125582","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.92","170.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","186.26","81.72","","431.26","71.26","1459.57","88","119.11","186.26","percent of total billed charges",""
"SCREW BONE 2.7X40MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171216","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","443.86","79.5","","800.18","480.96","1887.97","195","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X40MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171216","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","297.58","53.3","","813.12","216.42","1444.50","81","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X40MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171216","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","173.08","31","","432.60","432.60","432.60","1 through 10","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X40MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171216","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","203.79","36.5","","148.37","54.89","631.39","94","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X40MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171216","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","213.84","38.3","","279.30","91.72","1116.77","266","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X40MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171216","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.52","42.9","","731.00","63.70","731.00","1 through 10","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X40MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171216","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.52","42.9","","384.74","384.74","384.74","1 through 10","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X40MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171216","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","WELLPOINT [1015]","HB AMC WELLPOINT","411.93","73.78","","286.63","119.22","1107.45","105","173.08","443.86","percent of total billed charges",""
"SCREW BONE 2.7X40MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","AETNA [1001]","HB AMC AETNA HMO","389.71","69.8","","675.31","184.75","1721.50","286","291.78","456.26","percent of total billed charges",""
"SCREW BONE 2.7X40MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","AETNA [1001]","HB AMC AETNA PPO","448.89","80.4","","1261.44","103.12","1514.10","21","291.78","456.26","percent of total billed charges",""
"SCREW BONE 2.7X40MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","448.89","80.4","","1365.00","1365.00","1365.00","1 through 10","291.78","456.26","percent of total billed charges",""
"SCREW BONE 2.7X40MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","456.26","81.72","","5157.68","5157.68","5157.68","1 through 10","291.78","456.26","percent of total billed charges",""
"SCREW BONE 2.7X40MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","456.26","81.72","","431.26","71.26","1459.57","88","291.78","456.26","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","819.22","79.5","","800.18","480.96","1887.97","195","319.45","819.22","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","549.24","53.3","","813.12","216.42","1444.50","81","319.45","819.22","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","319.45","31","","432.60","432.60","432.60","1 through 10","319.45","819.22","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","376.12","36.5","","148.37","54.89","631.39","94","319.45","819.22","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","394.67","38.3","","279.30","91.72","1116.77","266","319.45","819.22","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.07","42.9","","731.00","63.70","731.00","1 through 10","319.45","819.22","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.07","42.9","","384.74","384.74","384.74","1 through 10","319.45","819.22","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","WELLPOINT [1015]","HB AMC WELLPOINT","760.28","73.78","","286.63","119.22","1107.45","105","319.45","819.22","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","AETNA [1001]","HB AMC AETNA HMO","719.27","69.8","","675.31","184.75","1721.50","286","538.52","842.1","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","AETNA [1001]","HB AMC AETNA PPO","828.50","80.4","","1261.44","103.12","1514.10","21","538.52","842.1","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","828.50","80.4","","1365.00","1365.00","1365.00","1 through 10","538.52","842.1","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","842.10","81.72","","5157.68","5157.68","5157.68","1 through 10","538.52","842.1","percent of total billed charges",""
"SCREW BONE 2.7X42MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186812","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","842.10","81.72","","431.26","71.26","1459.57","88","538.52","842.1","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","97.81","79.5","","800.18","480.96","1887.97","195","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","65.57","53.3","","813.12","216.42","1444.50","81","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","38.14","31","","432.60","432.60","432.60","1 through 10","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.91","36.5","","148.37","54.89","631.39","94","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","47.12","38.3","","279.30","91.72","1116.77","266","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.78","42.9","","731.00","63.70","731.00","1 through 10","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.78","42.9","","384.74","384.74","384.74","1 through 10","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.03","92.27","WELLPOINT [1015]","HB AMC WELLPOINT","90.77","73.78","","286.63","119.22","1107.45","105","38.14","97.81","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.03","92.27","AETNA [1001]","HB AMC AETNA HMO","85.87","69.8","","675.31","184.75","1721.50","286","64.3","100.54","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.03","92.27","AETNA [1001]","HB AMC AETNA PPO","98.92","80.4","","1261.44","103.12","1514.10","21","64.3","100.54","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.03","92.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","98.92","80.4","","1365.00","1365.00","1365.00","1 through 10","64.3","100.54","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.03","92.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","100.54","81.72","","5157.68","5157.68","5157.68","1 through 10","64.3","100.54","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.03","92.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","100.54","81.72","","431.26","71.26","1459.57","88","64.3","100.54","percent of total billed charges",""
"SCREW BONE 2.7X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10021379","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.50","233.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","247.64","79.5","","800.18","480.96","1887.97","195","96.57","247.64","percent of total billed charges",""
"SCREW BONE 2.7X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10021379","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.50","233.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","166.03","53.3","","813.12","216.42","1444.50","81","96.57","247.64","percent of total billed charges",""
"SCREW BONE 2.7X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10021379","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.50","233.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","96.57","31","","432.60","432.60","432.60","1 through 10","96.57","247.64","percent of total billed charges",""
"SCREW BONE 2.7X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10021379","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.50","233.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","113.70","36.5","","148.37","54.89","631.39","94","96.57","247.64","percent of total billed charges",""
"SCREW BONE 2.7X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10021379","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.50","233.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.30","38.3","","279.30","91.72","1116.77","266","96.57","247.64","percent of total billed charges",""
"SCREW BONE 2.7X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10021379","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.50","233.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.63","42.9","","731.00","63.70","731.00","1 through 10","96.57","247.64","percent of total billed charges",""
"SCREW BONE 2.7X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10021379","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.50","233.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.63","42.9","","384.74","384.74","384.74","1 through 10","96.57","247.64","percent of total billed charges",""
"SCREW BONE 2.7X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10021379","CDM","C1713","HCPCS","0278","RC","","","","both","","","311.50","233.62","WELLPOINT [1015]","HB AMC WELLPOINT","229.82","73.78","","286.63","119.22","1107.45","105","96.57","247.64","percent of total billed charges",""
"SCREW BONE 2.7X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10021379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.50","233.62","AETNA [1001]","HB AMC AETNA HMO","217.43","69.8","","675.31","184.75","1721.50","286","162.79","254.56","percent of total billed charges",""
"SCREW BONE 2.7X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10021379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.50","233.62","AETNA [1001]","HB AMC AETNA PPO","250.45","80.4","","1261.44","103.12","1514.10","21","162.79","254.56","percent of total billed charges",""
"SCREW BONE 2.7X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10021379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.50","233.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","250.45","80.4","","1365.00","1365.00","1365.00","1 through 10","162.79","254.56","percent of total billed charges",""
"SCREW BONE 2.7X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10021379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.50","233.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","254.56","81.72","","5157.68","5157.68","5157.68","1 through 10","162.79","254.56","percent of total billed charges",""
"SCREW BONE 2.7X50MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10021379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","311.50","233.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","254.56","81.72","","431.26","71.26","1459.57","88","162.79","254.56","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","142.45","106.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","113.25","79.5","","800.18","480.96","1887.97","195","44.16","113.25","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","142.45","106.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","75.93","53.3","","813.12","216.42","1444.50","81","44.16","113.25","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","142.45","106.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","44.16","31","","432.60","432.60","432.60","1 through 10","44.16","113.25","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","142.45","106.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.99","36.5","","148.37","54.89","631.39","94","44.16","113.25","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","142.45","106.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.56","38.3","","279.30","91.72","1116.77","266","44.16","113.25","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","142.45","106.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.11","42.9","","731.00","63.70","731.00","1 through 10","44.16","113.25","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","142.45","106.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.11","42.9","","384.74","384.74","384.74","1 through 10","44.16","113.25","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","142.45","106.84","WELLPOINT [1015]","HB AMC WELLPOINT","105.10","73.78","","286.63","119.22","1107.45","105","44.16","113.25","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","142.45","106.84","AETNA [1001]","HB AMC AETNA HMO","99.43","69.8","","675.31","184.75","1721.50","286","74.44","116.41","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","142.45","106.84","AETNA [1001]","HB AMC AETNA PPO","114.53","80.4","","1261.44","103.12","1514.10","21","74.44","116.41","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","142.45","106.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","114.53","80.4","","1365.00","1365.00","1365.00","1 through 10","74.44","116.41","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","142.45","106.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","116.41","81.72","","5157.68","5157.68","5157.68","1 through 10","74.44","116.41","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","142.45","106.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","116.41","81.72","","431.26","71.26","1459.57","88","74.44","116.41","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10039818","CDM","C1713","HCPCS","0278","RC","","","","both","","","155.40","116.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","123.54","79.5","","800.18","480.96","1887.97","195","48.17","123.54","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10039818","CDM","C1713","HCPCS","0278","RC","","","","both","","","155.40","116.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","82.83","53.3","","813.12","216.42","1444.50","81","48.17","123.54","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10039818","CDM","C1713","HCPCS","0278","RC","","","","both","","","155.40","116.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.17","31","","432.60","432.60","432.60","1 through 10","48.17","123.54","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10039818","CDM","C1713","HCPCS","0278","RC","","","","both","","","155.40","116.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56.72","36.5","","148.37","54.89","631.39","94","48.17","123.54","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10039818","CDM","C1713","HCPCS","0278","RC","","","","both","","","155.40","116.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","59.52","38.3","","279.30","91.72","1116.77","266","48.17","123.54","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10039818","CDM","C1713","HCPCS","0278","RC","","","","both","","","155.40","116.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.67","42.9","","731.00","63.70","731.00","1 through 10","48.17","123.54","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10039818","CDM","C1713","HCPCS","0278","RC","","","","both","","","155.40","116.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.67","42.9","","384.74","384.74","384.74","1 through 10","48.17","123.54","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10039818","CDM","C1713","HCPCS","0278","RC","","","","both","","","155.40","116.55","WELLPOINT [1015]","HB AMC WELLPOINT","114.65","73.78","","286.63","119.22","1107.45","105","48.17","123.54","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10039818","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","155.40","116.55","AETNA [1001]","HB AMC AETNA HMO","108.47","69.8","","675.31","184.75","1721.50","286","81.21","126.99","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10039818","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","155.40","116.55","AETNA [1001]","HB AMC AETNA PPO","124.94","80.4","","1261.44","103.12","1514.10","21","81.21","126.99","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10039818","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","155.40","116.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","124.94","80.4","","1365.00","1365.00","1365.00","1 through 10","81.21","126.99","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10039818","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","155.40","116.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","126.99","81.72","","5157.68","5157.68","5157.68","1 through 10","81.21","126.99","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX TITANIUM SELF TAPPING FULL THREAD SPHERICAL HEAD SM HEXAGONAL SOCKET","SUP-ITM-10039818","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","155.40","116.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","126.99","81.72","","431.26","71.26","1459.57","88","81.21","126.99","percent of total billed charges",""
"SCREW BONE 2.7X65MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295499","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","102.95","79.5","","800.18","480.96","1887.97","195","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X65MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295499","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","69.02","53.3","","813.12","216.42","1444.50","81","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X65MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295499","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","40.15","31","","432.60","432.60","432.60","1 through 10","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X65MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295499","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","47.27","36.5","","148.37","54.89","631.39","94","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X65MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295499","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","49.60","38.3","","279.30","91.72","1116.77","266","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X65MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295499","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.56","42.9","","731.00","63.70","731.00","1 through 10","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X65MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295499","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.56","42.9","","384.74","384.74","384.74","1 through 10","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X65MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295499","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","WELLPOINT [1015]","HB AMC WELLPOINT","95.55","73.78","","286.63","119.22","1107.45","105","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X65MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","AETNA [1001]","HB AMC AETNA HMO","90.39","69.8","","675.31","184.75","1721.50","286","67.68","105.83","percent of total billed charges",""
"SCREW BONE 2.7X65MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","AETNA [1001]","HB AMC AETNA PPO","104.12","80.4","","1261.44","103.12","1514.10","21","67.68","105.83","percent of total billed charges",""
"SCREW BONE 2.7X65MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","104.12","80.4","","1365.00","1365.00","1365.00","1 through 10","67.68","105.83","percent of total billed charges",""
"SCREW BONE 2.7X65MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","105.83","81.72","","5157.68","5157.68","5157.68","1 through 10","67.68","105.83","percent of total billed charges",""
"SCREW BONE 2.7X65MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","105.83","81.72","","431.26","71.26","1459.57","88","67.68","105.83","percent of total billed charges",""
"SCREW BONE 2.7X75MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295501","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","102.95","79.5","","800.18","480.96","1887.97","195","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295501","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","69.02","53.3","","813.12","216.42","1444.50","81","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295501","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","40.15","31","","432.60","432.60","432.60","1 through 10","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295501","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","47.27","36.5","","148.37","54.89","631.39","94","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295501","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","49.60","38.3","","279.30","91.72","1116.77","266","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295501","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.56","42.9","","731.00","63.70","731.00","1 through 10","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295501","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.56","42.9","","384.74","384.74","384.74","1 through 10","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295501","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.50","97.12","WELLPOINT [1015]","HB AMC WELLPOINT","95.55","73.78","","286.63","119.22","1107.45","105","40.15","102.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","AETNA [1001]","HB AMC AETNA HMO","90.39","69.8","","675.31","184.75","1721.50","286","67.68","105.83","percent of total billed charges",""
"SCREW BONE 2.7X75MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","AETNA [1001]","HB AMC AETNA PPO","104.12","80.4","","1261.44","103.12","1514.10","21","67.68","105.83","percent of total billed charges",""
"SCREW BONE 2.7X75MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","104.12","80.4","","1365.00","1365.00","1365.00","1 through 10","67.68","105.83","percent of total billed charges",""
"SCREW BONE 2.7X75MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","105.83","81.72","","5157.68","5157.68","5157.68","1 through 10","67.68","105.83","percent of total billed charges",""
"SCREW BONE 2.7X75MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.50","97.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","105.83","81.72","","431.26","71.26","1459.57","88","67.68","105.83","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","343.86","79.5","","800.18","480.96","1887.97","195","134.08","343.86","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","230.54","53.3","","813.12","216.42","1444.50","81","134.08","343.86","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","134.08","31","","432.60","432.60","432.60","1 through 10","134.08","343.86","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","157.87","36.5","","148.37","54.89","631.39","94","134.08","343.86","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","165.66","38.3","","279.30","91.72","1116.77","266","134.08","343.86","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","185.56","42.9","","731.00","63.70","731.00","1 through 10","134.08","343.86","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","185.56","42.9","","384.74","384.74","384.74","1 through 10","134.08","343.86","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.53","324.40","WELLPOINT [1015]","HB AMC WELLPOINT","319.12","73.78","","286.63","119.22","1107.45","105","134.08","343.86","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.53","324.40","AETNA [1001]","HB AMC AETNA HMO","301.91","69.8","","675.31","184.75","1721.50","286","226.04","353.46","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.53","324.40","AETNA [1001]","HB AMC AETNA PPO","347.75","80.4","","1261.44","103.12","1514.10","21","226.04","353.46","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.53","324.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","347.75","80.4","","1365.00","1365.00","1365.00","1 through 10","226.04","353.46","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.53","324.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","353.46","81.72","","5157.68","5157.68","5157.68","1 through 10","226.04","353.46","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.53","324.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","353.46","81.72","","431.26","71.26","1459.57","88","226.04","353.46","percent of total billed charges",""
"SCREW BONE 2.7X80MM VARIAX T8","SUP-ITM-10306455","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.07","421.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","446.85","79.5","","800.18","480.96","1887.97","195","174.24","446.85","percent of total billed charges",""
"SCREW BONE 2.7X80MM VARIAX T8","SUP-ITM-10306455","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.07","421.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","299.58","53.3","","813.12","216.42","1444.50","81","174.24","446.85","percent of total billed charges",""
"SCREW BONE 2.7X80MM VARIAX T8","SUP-ITM-10306455","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.07","421.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","174.24","31","","432.60","432.60","432.60","1 through 10","174.24","446.85","percent of total billed charges",""
"SCREW BONE 2.7X80MM VARIAX T8","SUP-ITM-10306455","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.07","421.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","205.16","36.5","","148.37","54.89","631.39","94","174.24","446.85","percent of total billed charges",""
"SCREW BONE 2.7X80MM VARIAX T8","SUP-ITM-10306455","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.07","421.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","215.27","38.3","","279.30","91.72","1116.77","266","174.24","446.85","percent of total billed charges",""
"SCREW BONE 2.7X80MM VARIAX T8","SUP-ITM-10306455","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.07","421.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","241.13","42.9","","731.00","63.70","731.00","1 through 10","174.24","446.85","percent of total billed charges",""
"SCREW BONE 2.7X80MM VARIAX T8","SUP-ITM-10306455","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.07","421.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","241.13","42.9","","384.74","384.74","384.74","1 through 10","174.24","446.85","percent of total billed charges",""
"SCREW BONE 2.7X80MM VARIAX T8","SUP-ITM-10306455","CDM","C1713","HCPCS","0278","RC","","","","both","","","562.07","421.55","WELLPOINT [1015]","HB AMC WELLPOINT","414.70","73.78","","286.63","119.22","1107.45","105","174.24","446.85","percent of total billed charges",""
"SCREW BONE 2.7X80MM VARIAX T8","SUP-ITM-10306455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.07","421.55","AETNA [1001]","HB AMC AETNA HMO","392.32","69.8","","675.31","184.75","1721.50","286","293.74","459.32","percent of total billed charges",""
"SCREW BONE 2.7X80MM VARIAX T8","SUP-ITM-10306455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.07","421.55","AETNA [1001]","HB AMC AETNA PPO","451.90","80.4","","1261.44","103.12","1514.10","21","293.74","459.32","percent of total billed charges",""
"SCREW BONE 2.7X80MM VARIAX T8","SUP-ITM-10306455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.07","421.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","451.90","80.4","","1365.00","1365.00","1365.00","1 through 10","293.74","459.32","percent of total billed charges",""
"SCREW BONE 2.7X80MM VARIAX T8","SUP-ITM-10306455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.07","421.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","459.32","81.72","","5157.68","5157.68","5157.68","1 through 10","293.74","459.32","percent of total billed charges",""
"SCREW BONE 2.7X80MM VARIAX T8","SUP-ITM-10306455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","562.07","421.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","459.32","81.72","","431.26","71.26","1459.57","88","293.74","459.32","percent of total billed charges",""
"SCREW BONE 2.7X8MM COMPONENT MAXLOCK EXTREME","SUP-ITM-10082162","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.50","375.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","397.90","79.5","","800.18","480.96","1887.97","195","155.16","397.9","percent of total billed charges",""
"SCREW BONE 2.7X8MM COMPONENT MAXLOCK EXTREME","SUP-ITM-10082162","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.50","375.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","266.77","53.3","","813.12","216.42","1444.50","81","155.16","397.9","percent of total billed charges",""
"SCREW BONE 2.7X8MM COMPONENT MAXLOCK EXTREME","SUP-ITM-10082162","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.50","375.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","155.16","31","","432.60","432.60","432.60","1 through 10","155.16","397.9","percent of total billed charges",""
"SCREW BONE 2.7X8MM COMPONENT MAXLOCK EXTREME","SUP-ITM-10082162","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.50","375.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","182.68","36.5","","148.37","54.89","631.39","94","155.16","397.9","percent of total billed charges",""
"SCREW BONE 2.7X8MM COMPONENT MAXLOCK EXTREME","SUP-ITM-10082162","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.50","375.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","191.69","38.3","","279.30","91.72","1116.77","266","155.16","397.9","percent of total billed charges",""
"SCREW BONE 2.7X8MM COMPONENT MAXLOCK EXTREME","SUP-ITM-10082162","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.50","375.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.71","42.9","","731.00","63.70","731.00","1 through 10","155.16","397.9","percent of total billed charges",""
"SCREW BONE 2.7X8MM COMPONENT MAXLOCK EXTREME","SUP-ITM-10082162","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.50","375.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.71","42.9","","384.74","384.74","384.74","1 through 10","155.16","397.9","percent of total billed charges",""
"SCREW BONE 2.7X8MM COMPONENT MAXLOCK EXTREME","SUP-ITM-10082162","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.50","375.37","WELLPOINT [1015]","HB AMC WELLPOINT","369.27","73.78","","286.63","119.22","1107.45","105","155.16","397.9","percent of total billed charges",""
"SCREW BONE 2.7X8MM COMPONENT MAXLOCK EXTREME","SUP-ITM-10082162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","500.50","375.37","AETNA [1001]","HB AMC AETNA HMO","349.35","69.8","","675.31","184.75","1721.50","286","261.56","409.01","percent of total billed charges",""
"SCREW BONE 2.7X8MM COMPONENT MAXLOCK EXTREME","SUP-ITM-10082162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","500.50","375.37","AETNA [1001]","HB AMC AETNA PPO","402.40","80.4","","1261.44","103.12","1514.10","21","261.56","409.01","percent of total billed charges",""
"SCREW BONE 2.7X8MM COMPONENT MAXLOCK EXTREME","SUP-ITM-10082162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","500.50","375.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","402.40","80.4","","1365.00","1365.00","1365.00","1 through 10","261.56","409.01","percent of total billed charges",""
"SCREW BONE 2.7X8MM COMPONENT MAXLOCK EXTREME","SUP-ITM-10082162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","500.50","375.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","409.01","81.72","","5157.68","5157.68","5157.68","1 through 10","261.56","409.01","percent of total billed charges",""
"SCREW BONE 2.7X8MM COMPONENT MAXLOCK EXTREME","SUP-ITM-10082162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","500.50","375.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","409.01","81.72","","431.26","71.26","1459.57","88","261.56","409.01","percent of total billed charges",""
"SCREW BONE 2.7X8MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125577","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.25","145.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","154.43","79.5","","800.18","480.96","1887.97","195","60.22","154.43","percent of total billed charges",""
"SCREW BONE 2.7X8MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125577","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.25","145.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","103.54","53.3","","813.12","216.42","1444.50","81","60.22","154.43","percent of total billed charges",""
"SCREW BONE 2.7X8MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125577","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.25","145.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","60.22","31","","432.60","432.60","432.60","1 through 10","60.22","154.43","percent of total billed charges",""
"SCREW BONE 2.7X8MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125577","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.25","145.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70.90","36.5","","148.37","54.89","631.39","94","60.22","154.43","percent of total billed charges",""
"SCREW BONE 2.7X8MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125577","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.25","145.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","74.40","38.3","","279.30","91.72","1116.77","266","60.22","154.43","percent of total billed charges",""
"SCREW BONE 2.7X8MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125577","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.25","145.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.33","42.9","","731.00","63.70","731.00","1 through 10","60.22","154.43","percent of total billed charges",""
"SCREW BONE 2.7X8MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125577","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.25","145.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.33","42.9","","384.74","384.74","384.74","1 through 10","60.22","154.43","percent of total billed charges",""
"SCREW BONE 2.7X8MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125577","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.25","145.69","WELLPOINT [1015]","HB AMC WELLPOINT","143.32","73.78","","286.63","119.22","1107.45","105","60.22","154.43","percent of total billed charges",""
"SCREW BONE 2.7X8MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.25","145.69","AETNA [1001]","HB AMC AETNA HMO","135.59","69.8","","675.31","184.75","1721.50","286","101.52","158.74","percent of total billed charges",""
"SCREW BONE 2.7X8MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.25","145.69","AETNA [1001]","HB AMC AETNA PPO","156.18","80.4","","1261.44","103.12","1514.10","21","101.52","158.74","percent of total billed charges",""
"SCREW BONE 2.7X8MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.25","145.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","156.18","80.4","","1365.00","1365.00","1365.00","1 through 10","101.52","158.74","percent of total billed charges",""
"SCREW BONE 2.7X8MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.25","145.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","158.74","81.72","","5157.68","5157.68","5157.68","1 through 10","101.52","158.74","percent of total billed charges",""
"SCREW BONE 2.7X8MM METAPHYSEAL SELF TAPPING TITANIUM WITH T8 STARDRIVE RECESS","SUP-ITM-10125577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.25","145.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","158.74","81.72","","431.26","71.26","1459.57","88","101.52","158.74","percent of total billed charges",""
"SCREW BONE 2.7X8MMXDRIVE TITANIUM HIGH TORQUE","SUP-ITM-10126236","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","314.42","79.5","","800.18","480.96","1887.97","195","122.61","314.42","percent of total billed charges",""
"SCREW BONE 2.7X8MMXDRIVE TITANIUM HIGH TORQUE","SUP-ITM-10126236","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","210.80","53.3","","813.12","216.42","1444.50","81","122.61","314.42","percent of total billed charges",""
"SCREW BONE 2.7X8MMXDRIVE TITANIUM HIGH TORQUE","SUP-ITM-10126236","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","122.61","31","","432.60","432.60","432.60","1 through 10","122.61","314.42","percent of total billed charges",""
"SCREW BONE 2.7X8MMXDRIVE TITANIUM HIGH TORQUE","SUP-ITM-10126236","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","144.36","36.5","","148.37","54.89","631.39","94","122.61","314.42","percent of total billed charges",""
"SCREW BONE 2.7X8MMXDRIVE TITANIUM HIGH TORQUE","SUP-ITM-10126236","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","151.48","38.3","","279.30","91.72","1116.77","266","122.61","314.42","percent of total billed charges",""
"SCREW BONE 2.7X8MMXDRIVE TITANIUM HIGH TORQUE","SUP-ITM-10126236","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","169.67","42.9","","731.00","63.70","731.00","1 through 10","122.61","314.42","percent of total billed charges",""
"SCREW BONE 2.7X8MMXDRIVE TITANIUM HIGH TORQUE","SUP-ITM-10126236","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","169.67","42.9","","384.74","384.74","384.74","1 through 10","122.61","314.42","percent of total billed charges",""
"SCREW BONE 2.7X8MMXDRIVE TITANIUM HIGH TORQUE","SUP-ITM-10126236","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.50","296.62","WELLPOINT [1015]","HB AMC WELLPOINT","291.80","73.78","","286.63","119.22","1107.45","105","122.61","314.42","percent of total billed charges",""
"SCREW BONE 2.7X8MMXDRIVE TITANIUM HIGH TORQUE","SUP-ITM-10126236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.50","296.62","AETNA [1001]","HB AMC AETNA HMO","276.06","69.8","","675.31","184.75","1721.50","286","206.69","323.2","percent of total billed charges",""
"SCREW BONE 2.7X8MMXDRIVE TITANIUM HIGH TORQUE","SUP-ITM-10126236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.50","296.62","AETNA [1001]","HB AMC AETNA PPO","317.98","80.4","","1261.44","103.12","1514.10","21","206.69","323.2","percent of total billed charges",""
"SCREW BONE 2.7X8MMXDRIVE TITANIUM HIGH TORQUE","SUP-ITM-10126236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.50","296.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","317.98","80.4","","1365.00","1365.00","1365.00","1 through 10","206.69","323.2","percent of total billed charges",""
"SCREW BONE 2.7X8MMXDRIVE TITANIUM HIGH TORQUE","SUP-ITM-10126236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.50","296.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","323.20","81.72","","5157.68","5157.68","5157.68","1 through 10","206.69","323.2","percent of total billed charges",""
"SCREW BONE 2.7X8MMXDRIVE TITANIUM HIGH TORQUE","SUP-ITM-10126236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.50","296.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","323.20","81.72","","431.26","71.26","1459.57","88","206.69","323.2","percent of total billed charges",""
"SCREW BONE 2.7X90MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295504","CDM","C1713","HCPCS","0278","RC","","","","both","","","141.16","105.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","112.22","79.5","","800.18","480.96","1887.97","195","43.76","112.22","percent of total billed charges",""
"SCREW BONE 2.7X90MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295504","CDM","C1713","HCPCS","0278","RC","","","","both","","","141.16","105.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","75.24","53.3","","813.12","216.42","1444.50","81","43.76","112.22","percent of total billed charges",""
"SCREW BONE 2.7X90MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295504","CDM","C1713","HCPCS","0278","RC","","","","both","","","141.16","105.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","43.76","31","","432.60","432.60","432.60","1 through 10","43.76","112.22","percent of total billed charges",""
"SCREW BONE 2.7X90MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295504","CDM","C1713","HCPCS","0278","RC","","","","both","","","141.16","105.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.52","36.5","","148.37","54.89","631.39","94","43.76","112.22","percent of total billed charges",""
"SCREW BONE 2.7X90MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295504","CDM","C1713","HCPCS","0278","RC","","","","both","","","141.16","105.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.06","38.3","","279.30","91.72","1116.77","266","43.76","112.22","percent of total billed charges",""
"SCREW BONE 2.7X90MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295504","CDM","C1713","HCPCS","0278","RC","","","","both","","","141.16","105.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.56","42.9","","731.00","63.70","731.00","1 through 10","43.76","112.22","percent of total billed charges",""
"SCREW BONE 2.7X90MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295504","CDM","C1713","HCPCS","0278","RC","","","","both","","","141.16","105.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.56","42.9","","384.74","384.74","384.74","1 through 10","43.76","112.22","percent of total billed charges",""
"SCREW BONE 2.7X90MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295504","CDM","C1713","HCPCS","0278","RC","","","","both","","","141.16","105.87","WELLPOINT [1015]","HB AMC WELLPOINT","104.15","73.78","","286.63","119.22","1107.45","105","43.76","112.22","percent of total billed charges",""
"SCREW BONE 2.7X90MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","141.16","105.87","AETNA [1001]","HB AMC AETNA HMO","98.53","69.8","","675.31","184.75","1721.50","286","73.77","115.36","percent of total billed charges",""
"SCREW BONE 2.7X90MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","141.16","105.87","AETNA [1001]","HB AMC AETNA PPO","113.49","80.4","","1261.44","103.12","1514.10","21","73.77","115.36","percent of total billed charges",""
"SCREW BONE 2.7X90MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","141.16","105.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","113.49","80.4","","1365.00","1365.00","1365.00","1 through 10","73.77","115.36","percent of total billed charges",""
"SCREW BONE 2.7X90MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","141.16","105.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","115.36","81.72","","5157.68","5157.68","5157.68","1 through 10","73.77","115.36","percent of total billed charges",""
"SCREW BONE 2.7X90MM CORTEX SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10295504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","141.16","105.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","115.36","81.72","","431.26","71.26","1459.57","88","73.77","115.36","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","269.40","79.5","","800.18","480.96","1887.97","195","105.05","269.4","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","180.62","53.3","","813.12","216.42","1444.50","81","105.05","269.4","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","105.05","31","","432.60","432.60","432.60","1 through 10","105.05","269.4","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.69","36.5","","148.37","54.89","631.39","94","105.05","269.4","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","129.79","38.3","","279.30","91.72","1116.77","266","105.05","269.4","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.38","42.9","","731.00","63.70","731.00","1 through 10","105.05","269.4","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.38","42.9","","384.74","384.74","384.74","1 through 10","105.05","269.4","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","338.87","254.15","WELLPOINT [1015]","HB AMC WELLPOINT","250.02","73.78","","286.63","119.22","1107.45","105","105.05","269.4","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","AETNA [1001]","HB AMC AETNA HMO","236.53","69.8","","675.31","184.75","1721.50","286","177.09","276.92","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","AETNA [1001]","HB AMC AETNA PPO","272.45","80.4","","1261.44","103.12","1514.10","21","177.09","276.92","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","272.45","80.4","","1365.00","1365.00","1365.00","1 through 10","177.09","276.92","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","276.92","81.72","","5157.68","5157.68","5157.68","1 through 10","177.09","276.92","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","338.87","254.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","276.92","81.72","","431.26","71.26","1459.57","88","177.09","276.92","percent of total billed charges",""
"SCREW BONE 2.9X10MM LOCKING MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131167","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","369.52","79.5","","800.18","480.96","1887.97","195","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM LOCKING MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131167","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","247.74","53.3","","813.12","216.42","1444.50","81","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM LOCKING MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131167","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","144.09","31","","432.60","432.60","432.60","1 through 10","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM LOCKING MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131167","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","169.65","36.5","","148.37","54.89","631.39","94","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM LOCKING MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131167","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","178.02","38.3","","279.30","91.72","1116.77","266","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM LOCKING MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131167","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.40","42.9","","731.00","63.70","731.00","1 through 10","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM LOCKING MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131167","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.40","42.9","","384.74","384.74","384.74","1 through 10","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM LOCKING MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131167","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","WELLPOINT [1015]","HB AMC WELLPOINT","342.93","73.78","","286.63","119.22","1107.45","105","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM LOCKING MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","AETNA [1001]","HB AMC AETNA HMO","324.43","69.8","","675.31","184.75","1721.50","286","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM LOCKING MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","AETNA [1001]","HB AMC AETNA PPO","373.70","80.4","","1261.44","103.12","1514.10","21","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM LOCKING MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","373.70","80.4","","1365.00","1365.00","1365.00","1 through 10","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM LOCKING MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","379.83","81.72","","5157.68","5157.68","5157.68","1 through 10","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM LOCKING MATRIXMANDIBLE TITANIUM SELF TAPPING","SUP-ITM-10131167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","379.83","81.72","","431.26","71.26","1459.57","88","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TI NONLOCKING SELF TAPPING PK/5EA","SUP-ITM-10275638","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.97","239.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","253.58","79.5","","800.18","480.96","1887.97","195","98.88","253.58","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TI NONLOCKING SELF TAPPING PK/5EA","SUP-ITM-10275638","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.97","239.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","170.01","53.3","","813.12","216.42","1444.50","81","98.88","253.58","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TI NONLOCKING SELF TAPPING PK/5EA","SUP-ITM-10275638","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.97","239.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","98.88","31","","432.60","432.60","432.60","1 through 10","98.88","253.58","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TI NONLOCKING SELF TAPPING PK/5EA","SUP-ITM-10275638","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.97","239.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","116.42","36.5","","148.37","54.89","631.39","94","98.88","253.58","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TI NONLOCKING SELF TAPPING PK/5EA","SUP-ITM-10275638","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.97","239.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","122.17","38.3","","279.30","91.72","1116.77","266","98.88","253.58","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TI NONLOCKING SELF TAPPING PK/5EA","SUP-ITM-10275638","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.97","239.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","136.84","42.9","","731.00","63.70","731.00","1 through 10","98.88","253.58","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TI NONLOCKING SELF TAPPING PK/5EA","SUP-ITM-10275638","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.97","239.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","136.84","42.9","","384.74","384.74","384.74","1 through 10","98.88","253.58","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TI NONLOCKING SELF TAPPING PK/5EA","SUP-ITM-10275638","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.97","239.23","WELLPOINT [1015]","HB AMC WELLPOINT","235.34","73.78","","286.63","119.22","1107.45","105","98.88","253.58","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TI NONLOCKING SELF TAPPING PK/5EA","SUP-ITM-10275638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.97","239.23","AETNA [1001]","HB AMC AETNA HMO","222.64","69.8","","675.31","184.75","1721.50","286","166.69","260.66","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TI NONLOCKING SELF TAPPING PK/5EA","SUP-ITM-10275638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.97","239.23","AETNA [1001]","HB AMC AETNA PPO","256.45","80.4","","1261.44","103.12","1514.10","21","166.69","260.66","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TI NONLOCKING SELF TAPPING PK/5EA","SUP-ITM-10275638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.97","239.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","256.45","80.4","","1365.00","1365.00","1365.00","1 through 10","166.69","260.66","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TI NONLOCKING SELF TAPPING PK/5EA","SUP-ITM-10275638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.97","239.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","260.66","81.72","","5157.68","5157.68","5157.68","1 through 10","166.69","260.66","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TI NONLOCKING SELF TAPPING PK/5EA","SUP-ITM-10275638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.97","239.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","260.66","81.72","","431.26","71.26","1459.57","88","166.69","260.66","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING","SUP-ITM-10046569","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","369.52","79.5","","800.18","480.96","1887.97","195","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING","SUP-ITM-10046569","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","247.74","53.3","","813.12","216.42","1444.50","81","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING","SUP-ITM-10046569","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","144.09","31","","432.60","432.60","432.60","1 through 10","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING","SUP-ITM-10046569","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","169.65","36.5","","148.37","54.89","631.39","94","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING","SUP-ITM-10046569","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","178.02","38.3","","279.30","91.72","1116.77","266","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING","SUP-ITM-10046569","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.40","42.9","","731.00","63.70","731.00","1 through 10","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING","SUP-ITM-10046569","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.40","42.9","","384.74","384.74","384.74","1 through 10","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING","SUP-ITM-10046569","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.80","348.60","WELLPOINT [1015]","HB AMC WELLPOINT","342.93","73.78","","286.63","119.22","1107.45","105","144.09","369.52","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING","SUP-ITM-10046569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","AETNA [1001]","HB AMC AETNA HMO","324.43","69.8","","675.31","184.75","1721.50","286","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING","SUP-ITM-10046569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","AETNA [1001]","HB AMC AETNA PPO","373.70","80.4","","1261.44","103.12","1514.10","21","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING","SUP-ITM-10046569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","373.70","80.4","","1365.00","1365.00","1365.00","1 through 10","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING","SUP-ITM-10046569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","379.83","81.72","","5157.68","5157.68","5157.68","1 through 10","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING","SUP-ITM-10046569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.80","348.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","379.83","81.72","","431.26","71.26","1459.57","88","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10041781","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.79","348.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","369.51","79.5","","800.18","480.96","1887.97","195","144.08","369.51","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10041781","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.79","348.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","247.73","53.3","","813.12","216.42","1444.50","81","144.08","369.51","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10041781","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.79","348.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","144.08","31","","432.60","432.60","432.60","1 through 10","144.08","369.51","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10041781","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.79","348.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","169.65","36.5","","148.37","54.89","631.39","94","144.08","369.51","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10041781","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.79","348.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","178.01","38.3","","279.30","91.72","1116.77","266","144.08","369.51","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10041781","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.79","348.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.39","42.9","","731.00","63.70","731.00","1 through 10","144.08","369.51","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10041781","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.79","348.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.39","42.9","","384.74","384.74","384.74","1 through 10","144.08","369.51","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10041781","CDM","C1713","HCPCS","0278","RC","","","","both","","","464.79","348.59","WELLPOINT [1015]","HB AMC WELLPOINT","342.92","73.78","","286.63","119.22","1107.45","105","144.08","369.51","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10041781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.79","348.59","AETNA [1001]","HB AMC AETNA HMO","324.42","69.8","","675.31","184.75","1721.50","286","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10041781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.79","348.59","AETNA [1001]","HB AMC AETNA PPO","373.69","80.4","","1261.44","103.12","1514.10","21","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10041781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.79","348.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","373.69","80.4","","1365.00","1365.00","1365.00","1 through 10","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10041781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.79","348.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","379.83","81.72","","5157.68","5157.68","5157.68","1 through 10","242.9","379.83","percent of total billed charges",""
"SCREW BONE 2.9X10MM MATRIXRIB TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10041781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","464.79","348.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","379.83","81.72","","431.26","71.26","1459.57","88","242.9","379.83","percent of total billed charges",""
"SCREW BONE 20.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018065","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","264.34","79.5","","800.18","480.96","1887.97","195","103.08","264.34","percent of total billed charges",""
"SCREW BONE 20.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018065","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","177.22","53.3","","813.12","216.42","1444.50","81","103.08","264.34","percent of total billed charges",""
"SCREW BONE 20.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018065","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","103.08","31","","432.60","432.60","432.60","1 through 10","103.08","264.34","percent of total billed charges",""
"SCREW BONE 20.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018065","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.36","36.5","","148.37","54.89","631.39","94","103.08","264.34","percent of total billed charges",""
"SCREW BONE 20.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018065","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.35","38.3","","279.30","91.72","1116.77","266","103.08","264.34","percent of total billed charges",""
"SCREW BONE 20.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018065","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.64","42.9","","731.00","63.70","731.00","1 through 10","103.08","264.34","percent of total billed charges",""
"SCREW BONE 20.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018065","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.64","42.9","","384.74","384.74","384.74","1 through 10","103.08","264.34","percent of total billed charges",""
"SCREW BONE 20.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018065","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.50","249.37","WELLPOINT [1015]","HB AMC WELLPOINT","245.32","73.78","","286.63","119.22","1107.45","105","103.08","264.34","percent of total billed charges",""
"SCREW BONE 20.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.50","249.37","AETNA [1001]","HB AMC AETNA HMO","232.09","69.8","","675.31","184.75","1721.50","286","173.76","271.72","percent of total billed charges",""
"SCREW BONE 20.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.50","249.37","AETNA [1001]","HB AMC AETNA PPO","267.33","80.4","","1261.44","103.12","1514.10","21","173.76","271.72","percent of total billed charges",""
"SCREW BONE 20.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.50","249.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","267.33","80.4","","1365.00","1365.00","1365.00","1 through 10","173.76","271.72","percent of total billed charges",""
"SCREW BONE 20.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.50","249.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","271.72","81.72","","5157.68","5157.68","5157.68","1 through 10","173.76","271.72","percent of total billed charges",""
"SCREW BONE 20.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.50","249.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","271.72","81.72","","431.26","71.26","1459.57","88","173.76","271.72","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 ASNIS III TITANIUM CANNULATED THREAD","SUP-ITM-10144146","CDM","C1713","HCPCS","0278","RC","","","","both","","","1596.28","1197.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1269.04","79.5","","800.18","480.96","1887.97","195","494.85","1269.04","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 ASNIS III TITANIUM CANNULATED THREAD","SUP-ITM-10144146","CDM","C1713","HCPCS","0278","RC","","","","both","","","1596.28","1197.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","850.82","53.3","","813.12","216.42","1444.50","81","494.85","1269.04","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 ASNIS III TITANIUM CANNULATED THREAD","SUP-ITM-10144146","CDM","C1713","HCPCS","0278","RC","","","","both","","","1596.28","1197.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","494.85","31","","432.60","432.60","432.60","1 through 10","494.85","1269.04","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 ASNIS III TITANIUM CANNULATED THREAD","SUP-ITM-10144146","CDM","C1713","HCPCS","0278","RC","","","","both","","","1596.28","1197.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","582.64","36.5","","148.37","54.89","631.39","94","494.85","1269.04","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 ASNIS III TITANIUM CANNULATED THREAD","SUP-ITM-10144146","CDM","C1713","HCPCS","0278","RC","","","","both","","","1596.28","1197.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","611.38","38.3","","279.30","91.72","1116.77","266","494.85","1269.04","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 ASNIS III TITANIUM CANNULATED THREAD","SUP-ITM-10144146","CDM","C1713","HCPCS","0278","RC","","","","both","","","1596.28","1197.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","684.80","42.9","","731.00","63.70","731.00","1 through 10","494.85","1269.04","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 ASNIS III TITANIUM CANNULATED THREAD","SUP-ITM-10144146","CDM","C1713","HCPCS","0278","RC","","","","both","","","1596.28","1197.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","684.80","42.9","","384.74","384.74","384.74","1 through 10","494.85","1269.04","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 ASNIS III TITANIUM CANNULATED THREAD","SUP-ITM-10144146","CDM","C1713","HCPCS","0278","RC","","","","both","","","1596.28","1197.21","WELLPOINT [1015]","HB AMC WELLPOINT","1177.74","73.78","","286.63","119.22","1107.45","105","494.85","1269.04","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 ASNIS III TITANIUM CANNULATED THREAD","SUP-ITM-10144146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1596.28","1197.21","AETNA [1001]","HB AMC AETNA HMO","1114.20","69.8","","675.31","184.75","1721.50","286","834.22","1304.48","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 ASNIS III TITANIUM CANNULATED THREAD","SUP-ITM-10144146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1596.28","1197.21","AETNA [1001]","HB AMC AETNA PPO","1283.41","80.4","","1261.44","103.12","1514.10","21","834.22","1304.48","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 ASNIS III TITANIUM CANNULATED THREAD","SUP-ITM-10144146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1596.28","1197.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1283.41","80.4","","1365.00","1365.00","1365.00","1 through 10","834.22","1304.48","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 ASNIS III TITANIUM CANNULATED THREAD","SUP-ITM-10144146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1596.28","1197.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1304.48","81.72","","5157.68","5157.68","5157.68","1 through 10","834.22","1304.48","percent of total billed charges",""
"SCREW BONE 20MM 6.5X90 ASNIS III TITANIUM CANNULATED THREAD","SUP-ITM-10144146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1596.28","1197.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1304.48","81.72","","431.26","71.26","1459.57","88","834.22","1304.48","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","484.16","79.5","","800.18","480.96","1887.97","195","188.79","484.16","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","324.60","53.3","","813.12","216.42","1444.50","81","188.79","484.16","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","188.79","31","","432.60","432.60","432.60","1 through 10","188.79","484.16","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","222.29","36.5","","148.37","54.89","631.39","94","188.79","484.16","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","233.25","38.3","","279.30","91.72","1116.77","266","188.79","484.16","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","261.26","42.9","","731.00","63.70","731.00","1 through 10","188.79","484.16","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","261.26","42.9","","384.74","384.74","384.74","1 through 10","188.79","484.16","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.00","456.75","WELLPOINT [1015]","HB AMC WELLPOINT","449.32","73.78","","286.63","119.22","1107.45","105","188.79","484.16","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.00","456.75","AETNA [1001]","HB AMC AETNA HMO","425.08","69.8","","675.31","184.75","1721.50","286","318.26","497.67","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.00","456.75","AETNA [1001]","HB AMC AETNA PPO","489.64","80.4","","1261.44","103.12","1514.10","21","318.26","497.67","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.00","456.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","489.64","80.4","","1365.00","1365.00","1365.00","1 through 10","318.26","497.67","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.00","456.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","497.67","81.72","","5157.68","5157.68","5157.68","1 through 10","318.26","497.67","percent of total billed charges",""
"SCREW BONE 20X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.00","456.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","497.67","81.72","","431.26","71.26","1459.57","88","318.26","497.67","percent of total billed charges",""
"SCREW BONE 20X4.0MM CORTICAL NCB TITANIUM LOCKING","SUP-ITM-10030396","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.23","340.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","361.11","79.5","","800.18","480.96","1887.97","195","140.81","361.11","percent of total billed charges",""
"SCREW BONE 20X4.0MM CORTICAL NCB TITANIUM LOCKING","SUP-ITM-10030396","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.23","340.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.10","53.3","","813.12","216.42","1444.50","81","140.81","361.11","percent of total billed charges",""
"SCREW BONE 20X4.0MM CORTICAL NCB TITANIUM LOCKING","SUP-ITM-10030396","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.23","340.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","140.81","31","","432.60","432.60","432.60","1 through 10","140.81","361.11","percent of total billed charges",""
"SCREW BONE 20X4.0MM CORTICAL NCB TITANIUM LOCKING","SUP-ITM-10030396","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.23","340.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","165.79","36.5","","148.37","54.89","631.39","94","140.81","361.11","percent of total billed charges",""
"SCREW BONE 20X4.0MM CORTICAL NCB TITANIUM LOCKING","SUP-ITM-10030396","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.23","340.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","173.97","38.3","","279.30","91.72","1116.77","266","140.81","361.11","percent of total billed charges",""
"SCREW BONE 20X4.0MM CORTICAL NCB TITANIUM LOCKING","SUP-ITM-10030396","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.23","340.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","194.86","42.9","","731.00","63.70","731.00","1 through 10","140.81","361.11","percent of total billed charges",""
"SCREW BONE 20X4.0MM CORTICAL NCB TITANIUM LOCKING","SUP-ITM-10030396","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.23","340.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","194.86","42.9","","384.74","384.74","384.74","1 through 10","140.81","361.11","percent of total billed charges",""
"SCREW BONE 20X4.0MM CORTICAL NCB TITANIUM LOCKING","SUP-ITM-10030396","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.23","340.67","WELLPOINT [1015]","HB AMC WELLPOINT","335.13","73.78","","286.63","119.22","1107.45","105","140.81","361.11","percent of total billed charges",""
"SCREW BONE 20X4.0MM CORTICAL NCB TITANIUM LOCKING","SUP-ITM-10030396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.23","340.67","AETNA [1001]","HB AMC AETNA HMO","317.05","69.8","","675.31","184.75","1721.50","286","237.38","371.2","percent of total billed charges",""
"SCREW BONE 20X4.0MM CORTICAL NCB TITANIUM LOCKING","SUP-ITM-10030396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.23","340.67","AETNA [1001]","HB AMC AETNA PPO","365.20","80.4","","1261.44","103.12","1514.10","21","237.38","371.2","percent of total billed charges",""
"SCREW BONE 20X4.0MM CORTICAL NCB TITANIUM LOCKING","SUP-ITM-10030396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.23","340.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","365.20","80.4","","1365.00","1365.00","1365.00","1 through 10","237.38","371.2","percent of total billed charges",""
"SCREW BONE 20X4.0MM CORTICAL NCB TITANIUM LOCKING","SUP-ITM-10030396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.23","340.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","371.20","81.72","","5157.68","5157.68","5157.68","1 through 10","237.38","371.2","percent of total billed charges",""
"SCREW BONE 20X4.0MM CORTICAL NCB TITANIUM LOCKING","SUP-ITM-10030396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.23","340.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.20","81.72","","431.26","71.26","1459.57","88","237.38","371.2","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","598.24","79.5","","800.18","480.96","1887.97","195","233.28","598.24","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","401.08","53.3","","813.12","216.42","1444.50","81","233.28","598.24","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","233.28","31","","432.60","432.60","432.60","1 through 10","233.28","598.24","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","274.66","36.5","","148.37","54.89","631.39","94","233.28","598.24","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","288.21","38.3","","279.30","91.72","1116.77","266","233.28","598.24","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","322.82","42.9","","731.00","63.70","731.00","1 through 10","233.28","598.24","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","322.82","42.9","","384.74","384.74","384.74","1 through 10","233.28","598.24","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","WELLPOINT [1015]","HB AMC WELLPOINT","555.19","73.78","","286.63","119.22","1107.45","105","233.28","598.24","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","752.50","564.37","AETNA [1001]","HB AMC AETNA HMO","525.25","69.8","","675.31","184.75","1721.50","286","393.26","614.94","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","752.50","564.37","AETNA [1001]","HB AMC AETNA PPO","605.01","80.4","","1261.44","103.12","1514.10","21","393.26","614.94","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","752.50","564.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","605.01","80.4","","1365.00","1365.00","1365.00","1 through 10","393.26","614.94","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","752.50","564.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","614.94","81.72","","5157.68","5157.68","5157.68","1 through 10","393.26","614.94","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","752.50","564.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","614.94","81.72","","431.26","71.26","1459.57","88","393.26","614.94","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","292.16","79.5","","800.18","480.96","1887.97","195","113.93","292.16","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","195.88","53.3","","813.12","216.42","1444.50","81","113.93","292.16","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","113.93","31","","432.60","432.60","432.60","1 through 10","113.93","292.16","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","134.14","36.5","","148.37","54.89","631.39","94","113.93","292.16","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","140.75","38.3","","279.30","91.72","1116.77","266","113.93","292.16","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.66","42.9","","731.00","63.70","731.00","1 through 10","113.93","292.16","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.66","42.9","","384.74","384.74","384.74","1 through 10","113.93","292.16","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","367.50","275.62","WELLPOINT [1015]","HB AMC WELLPOINT","271.14","73.78","","286.63","119.22","1107.45","105","113.93","292.16","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.50","275.62","AETNA [1001]","HB AMC AETNA HMO","256.52","69.8","","675.31","184.75","1721.50","286","192.06","300.32","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.50","275.62","AETNA [1001]","HB AMC AETNA PPO","295.47","80.4","","1261.44","103.12","1514.10","21","192.06","300.32","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.50","275.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","295.47","80.4","","1365.00","1365.00","1365.00","1 through 10","192.06","300.32","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.50","275.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","300.32","81.72","","5157.68","5157.68","5157.68","1 through 10","192.06","300.32","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","367.50","275.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","300.32","81.72","","431.26","71.26","1459.57","88","192.06","300.32","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","623.28","79.5","","800.18","480.96","1887.97","195","243.04","623.28","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","417.87","53.3","","813.12","216.42","1444.50","81","243.04","623.28","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","243.04","31","","432.60","432.60","432.60","1 through 10","243.04","623.28","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","286.16","36.5","","148.37","54.89","631.39","94","243.04","623.28","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","300.27","38.3","","279.30","91.72","1116.77","266","243.04","623.28","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","336.34","42.9","","731.00","63.70","731.00","1 through 10","243.04","623.28","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","336.34","42.9","","384.74","384.74","384.74","1 through 10","243.04","623.28","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.00","588.00","WELLPOINT [1015]","HB AMC WELLPOINT","578.44","73.78","","286.63","119.22","1107.45","105","243.04","623.28","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.00","588.00","AETNA [1001]","HB AMC AETNA HMO","547.23","69.8","","675.31","184.75","1721.50","286","409.72","640.68","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.00","588.00","AETNA [1001]","HB AMC AETNA PPO","630.34","80.4","","1261.44","103.12","1514.10","21","409.72","640.68","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.00","588.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","630.34","80.4","","1365.00","1365.00","1365.00","1 through 10","409.72","640.68","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.00","588.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","640.68","81.72","","5157.68","5157.68","5157.68","1 through 10","409.72","640.68","percent of total billed charges",""
"SCREW BONE 23X7.0MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10117460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.00","588.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","640.68","81.72","","431.26","71.26","1459.57","88","409.72","640.68","percent of total billed charges",""
"SCREW BONE 24MM MONOBLOCK BASEPLATE","SUP-ITM-10233539","CDM","C1776","HCPCS","0278","RC","","","","both","","","4485.46","3364.09","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2344.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1390.49","3565.94","percent of total billed charges",""
"SCREW BONE 24MM MONOBLOCK BASEPLATE","SUP-ITM-10233539","CDM","C1776","HCPCS","0278","RC","","","","both","","","4485.46","3364.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3565.94","79.5","","1293.60","1148.53","1603.80","1 through 10","1390.49","3565.94","percent of total billed charges",""
"SCREW BONE 24MM MONOBLOCK BASEPLATE","SUP-ITM-10233539","CDM","C1776","HCPCS","0278","RC","","","","both","","","4485.46","3364.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1637.19","36.5","","1023.42","771.29","2068.67","33","1390.49","3565.94","percent of total billed charges",""
"SCREW BONE 24MM MONOBLOCK BASEPLATE","SUP-ITM-10233539","CDM","C1776","HCPCS","0278","RC","","","","both","","","4485.46","3364.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1717.93","38.3","","850.52","759.78","1211.25","66","1390.49","3565.94","percent of total billed charges",""
"SCREW BONE 24MM MONOBLOCK BASEPLATE","SUP-ITM-10233539","CDM","C1776","HCPCS","0278","RC","","","","both","","","4485.46","3364.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1924.26","42.9","","2548.09","2548.09","2548.09","1 through 10","1390.49","3565.94","percent of total billed charges",""
"SCREW BONE 24MM MONOBLOCK BASEPLATE","SUP-ITM-10233539","CDM","C1776","HCPCS","0278","RC","","","","both","","","4485.46","3364.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1924.26","42.9","","956.46","956.46","956.46","1 through 10","1390.49","3565.94","percent of total billed charges",""
"SCREW BONE 24MM MONOBLOCK BASEPLATE","SUP-ITM-10233539","CDM","C1776","HCPCS","0278","RC","","","","both","","","4485.46","3364.09","WELLPOINT [1015]","HB AMC WELLPOINT","3309.37","73.78","","2344.73","1619.47","2530.35","16","1390.49","3565.94","percent of total billed charges",""
"SCREW BONE 24MM MONOBLOCK BASEPLATE","SUP-ITM-10233539","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4485.46","3364.09","AETNA [1001]","HB AMC AETNA HMO","3130.85","69.8","","1523.63","988.41","4330.26","39","2344.1","3665.52","percent of total billed charges",""
"SCREW BONE 24MM MONOBLOCK BASEPLATE","SUP-ITM-10233539","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4485.46","3364.09","AETNA [1001]","HB AMC AETNA PPO","3606.31","80.4","","1670.25","1670.25","1670.25","1 through 10","2344.1","3665.52","percent of total billed charges",""
"SCREW BONE 24MM MONOBLOCK BASEPLATE","SUP-ITM-10233539","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4485.46","3364.09","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2344.10","52.26","","1113.10","1113.10","1113.10","1 through 10","2344.1","3665.52","percent of total billed charges",""
"SCREW BONE 24MM MONOBLOCK BASEPLATE","SUP-ITM-10233539","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4485.46","3364.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3665.52","81.72","","1738.90","1484.65","2716.94","38","2344.1","3665.52","percent of total billed charges",""
"SCREW BONE 24MM SPINE LINK REVERSE LEFT","SUP-ITM-10024317","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","800.18","480.96","1887.97","195","162.75","417.38","percent of total billed charges",""
"SCREW BONE 24MM SPINE LINK REVERSE LEFT","SUP-ITM-10024317","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","813.12","216.42","1444.50","81","162.75","417.38","percent of total billed charges",""
"SCREW BONE 24MM SPINE LINK REVERSE LEFT","SUP-ITM-10024317","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.75","31","","432.60","432.60","432.60","1 through 10","162.75","417.38","percent of total billed charges",""
"SCREW BONE 24MM SPINE LINK REVERSE LEFT","SUP-ITM-10024317","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","148.37","54.89","631.39","94","162.75","417.38","percent of total billed charges",""
"SCREW BONE 24MM SPINE LINK REVERSE LEFT","SUP-ITM-10024317","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","279.30","91.72","1116.77","266","162.75","417.38","percent of total billed charges",""
"SCREW BONE 24MM SPINE LINK REVERSE LEFT","SUP-ITM-10024317","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","731.00","63.70","731.00","1 through 10","162.75","417.38","percent of total billed charges",""
"SCREW BONE 24MM SPINE LINK REVERSE LEFT","SUP-ITM-10024317","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","384.74","384.74","384.74","1 through 10","162.75","417.38","percent of total billed charges",""
"SCREW BONE 24MM SPINE LINK REVERSE LEFT","SUP-ITM-10024317","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","286.63","119.22","1107.45","105","162.75","417.38","percent of total billed charges",""
"SCREW BONE 24MM SPINE LINK REVERSE LEFT","SUP-ITM-10024317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","675.31","184.75","1721.50","286","274.37","429.03","percent of total billed charges",""
"SCREW BONE 24MM SPINE LINK REVERSE LEFT","SUP-ITM-10024317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA PPO","422.10","80.4","","1261.44","103.12","1514.10","21","274.37","429.03","percent of total billed charges",""
"SCREW BONE 24MM SPINE LINK REVERSE LEFT","SUP-ITM-10024317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1365.00","1365.00","1365.00","1 through 10","274.37","429.03","percent of total billed charges",""
"SCREW BONE 24MM SPINE LINK REVERSE LEFT","SUP-ITM-10024317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","429.03","81.72","","5157.68","5157.68","5157.68","1 through 10","274.37","429.03","percent of total billed charges",""
"SCREW BONE 24MM SPINE LINK REVERSE LEFT","SUP-ITM-10024317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","431.26","71.26","1459.57","88","274.37","429.03","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","800.18","480.96","1887.97","195","651","1669.5","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1119.30","53.3","","813.12","216.42","1444.50","81","651","1669.5","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","651.00","31","","432.60","432.60","432.60","1 through 10","651","1669.5","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","148.37","54.89","631.39","94","651","1669.5","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","279.30","91.72","1116.77","266","651","1669.5","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","731.00","63.70","731.00","1 through 10","651","1669.5","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","384.74","384.74","384.74","1 through 10","651","1669.5","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","286.63","119.22","1107.45","105","651","1669.5","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","675.31","184.75","1721.50","286","1097.46","1716.12","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1261.44","103.12","1514.10","21","1097.46","1716.12","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1688.40","80.4","","1365.00","1365.00","1365.00","1 through 10","1097.46","1716.12","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1716.12","81.72","","5157.68","5157.68","5157.68","1 through 10","1097.46","1716.12","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","431.26","71.26","1459.57","88","1097.46","1716.12","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","659.45","79.5","","800.18","480.96","1887.97","195","257.15","659.45","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","442.12","53.3","","813.12","216.42","1444.50","81","257.15","659.45","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","257.15","31","","432.60","432.60","432.60","1 through 10","257.15","659.45","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","302.77","36.5","","148.37","54.89","631.39","94","257.15","659.45","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","317.70","38.3","","279.30","91.72","1116.77","266","257.15","659.45","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","355.86","42.9","","731.00","63.70","731.00","1 through 10","257.15","659.45","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","355.86","42.9","","384.74","384.74","384.74","1 through 10","257.15","659.45","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","WELLPOINT [1015]","HB AMC WELLPOINT","612.01","73.78","","286.63","119.22","1107.45","105","257.15","659.45","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","829.50","622.12","AETNA [1001]","HB AMC AETNA HMO","578.99","69.8","","675.31","184.75","1721.50","286","433.5","677.87","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","829.50","622.12","AETNA [1001]","HB AMC AETNA PPO","666.92","80.4","","1261.44","103.12","1514.10","21","433.5","677.87","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","829.50","622.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","666.92","80.4","","1365.00","1365.00","1365.00","1 through 10","433.5","677.87","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","829.50","622.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","677.87","81.72","","5157.68","5157.68","5157.68","1 through 10","433.5","677.87","percent of total billed charges",""
"SCREW BONE 25X4.5MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","829.50","622.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","677.87","81.72","","431.26","71.26","1459.57","88","433.5","677.87","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","150.26","79.5","","800.18","480.96","1887.97","195","58.59","150.26","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.74","53.3","","813.12","216.42","1444.50","81","58.59","150.26","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","58.59","31","","432.60","432.60","432.60","1 through 10","58.59","150.26","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.99","36.5","","148.37","54.89","631.39","94","58.59","150.26","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.39","38.3","","279.30","91.72","1116.77","266","58.59","150.26","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","731.00","63.70","731.00","1 through 10","58.59","150.26","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","384.74","384.74","384.74","1 through 10","58.59","150.26","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","WELLPOINT [1015]","HB AMC WELLPOINT","139.44","73.78","","286.63","119.22","1107.45","105","58.59","150.26","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA HMO","131.92","69.8","","675.31","184.75","1721.50","286","98.77","154.45","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA PPO","151.96","80.4","","1261.44","103.12","1514.10","21","98.77","154.45","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","151.96","80.4","","1365.00","1365.00","1365.00","1 through 10","98.77","154.45","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","154.45","81.72","","5157.68","5157.68","5157.68","1 through 10","98.77","154.45","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","154.45","81.72","","431.26","71.26","1459.57","88","98.77","154.45","percent of total billed charges",""
"SCREW BONE 26X2.7MM DARCO FIXATION TITANIUM LOCKING LOW PROFILE ANATOMICALLY SHAPE","SUP-ITM-10025666","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","383.99","79.5","","800.18","480.96","1887.97","195","149.73","383.99","percent of total billed charges",""
"SCREW BONE 26X2.7MM DARCO FIXATION TITANIUM LOCKING LOW PROFILE ANATOMICALLY SHAPE","SUP-ITM-10025666","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","257.44","53.3","","813.12","216.42","1444.50","81","149.73","383.99","percent of total billed charges",""
"SCREW BONE 26X2.7MM DARCO FIXATION TITANIUM LOCKING LOW PROFILE ANATOMICALLY SHAPE","SUP-ITM-10025666","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","149.73","31","","432.60","432.60","432.60","1 through 10","149.73","383.99","percent of total billed charges",""
"SCREW BONE 26X2.7MM DARCO FIXATION TITANIUM LOCKING LOW PROFILE ANATOMICALLY SHAPE","SUP-ITM-10025666","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","176.30","36.5","","148.37","54.89","631.39","94","149.73","383.99","percent of total billed charges",""
"SCREW BONE 26X2.7MM DARCO FIXATION TITANIUM LOCKING LOW PROFILE ANATOMICALLY SHAPE","SUP-ITM-10025666","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","184.99","38.3","","279.30","91.72","1116.77","266","149.73","383.99","percent of total billed charges",""
"SCREW BONE 26X2.7MM DARCO FIXATION TITANIUM LOCKING LOW PROFILE ANATOMICALLY SHAPE","SUP-ITM-10025666","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","207.21","42.9","","731.00","63.70","731.00","1 through 10","149.73","383.99","percent of total billed charges",""
"SCREW BONE 26X2.7MM DARCO FIXATION TITANIUM LOCKING LOW PROFILE ANATOMICALLY SHAPE","SUP-ITM-10025666","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","207.21","42.9","","384.74","384.74","384.74","1 through 10","149.73","383.99","percent of total billed charges",""
"SCREW BONE 26X2.7MM DARCO FIXATION TITANIUM LOCKING LOW PROFILE ANATOMICALLY SHAPE","SUP-ITM-10025666","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","WELLPOINT [1015]","HB AMC WELLPOINT","356.36","73.78","","286.63","119.22","1107.45","105","149.73","383.99","percent of total billed charges",""
"SCREW BONE 26X2.7MM DARCO FIXATION TITANIUM LOCKING LOW PROFILE ANATOMICALLY SHAPE","SUP-ITM-10025666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.00","362.25","AETNA [1001]","HB AMC AETNA HMO","337.13","69.8","","675.31","184.75","1721.50","286","252.42","394.71","percent of total billed charges",""
"SCREW BONE 26X2.7MM DARCO FIXATION TITANIUM LOCKING LOW PROFILE ANATOMICALLY SHAPE","SUP-ITM-10025666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.00","362.25","AETNA [1001]","HB AMC AETNA PPO","388.33","80.4","","1261.44","103.12","1514.10","21","252.42","394.71","percent of total billed charges",""
"SCREW BONE 26X2.7MM DARCO FIXATION TITANIUM LOCKING LOW PROFILE ANATOMICALLY SHAPE","SUP-ITM-10025666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.00","362.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","388.33","80.4","","1365.00","1365.00","1365.00","1 through 10","252.42","394.71","percent of total billed charges",""
"SCREW BONE 26X2.7MM DARCO FIXATION TITANIUM LOCKING LOW PROFILE ANATOMICALLY SHAPE","SUP-ITM-10025666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.00","362.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","394.71","81.72","","5157.68","5157.68","5157.68","1 through 10","252.42","394.71","percent of total billed charges",""
"SCREW BONE 26X2.7MM DARCO FIXATION TITANIUM LOCKING LOW PROFILE ANATOMICALLY SHAPE","SUP-ITM-10025666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.00","362.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","394.71","81.72","","431.26","71.26","1459.57","88","252.42","394.71","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.14","283.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","300.62","79.5","","800.18","480.96","1887.97","195","117.22","300.62","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.14","283.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","201.55","53.3","","813.12","216.42","1444.50","81","117.22","300.62","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.14","283.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","117.22","31","","432.60","432.60","432.60","1 through 10","117.22","300.62","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.14","283.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","138.02","36.5","","148.37","54.89","631.39","94","117.22","300.62","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.14","283.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","144.83","38.3","","279.30","91.72","1116.77","266","117.22","300.62","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.14","283.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","162.22","42.9","","731.00","63.70","731.00","1 through 10","117.22","300.62","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.14","283.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","162.22","42.9","","384.74","384.74","384.74","1 through 10","117.22","300.62","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.14","283.60","WELLPOINT [1015]","HB AMC WELLPOINT","278.99","73.78","","286.63","119.22","1107.45","105","117.22","300.62","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.14","283.60","AETNA [1001]","HB AMC AETNA HMO","263.94","69.8","","675.31","184.75","1721.50","286","197.62","309.02","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.14","283.60","AETNA [1001]","HB AMC AETNA PPO","304.02","80.4","","1261.44","103.12","1514.10","21","197.62","309.02","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.14","283.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","304.02","80.4","","1365.00","1365.00","1365.00","1 through 10","197.62","309.02","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.14","283.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","309.02","81.72","","5157.68","5157.68","5157.68","1 through 10","197.62","309.02","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.14","283.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","309.02","81.72","","431.26","71.26","1459.57","88","197.62","309.02","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","72.35","79.5","","800.18","480.96","1887.97","195","28.21","72.35","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.50","53.3","","813.12","216.42","1444.50","81","28.21","72.35","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","28.21","31","","432.60","432.60","432.60","1 through 10","28.21","72.35","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.22","36.5","","148.37","54.89","631.39","94","28.21","72.35","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.85","38.3","","279.30","91.72","1116.77","266","28.21","72.35","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.04","42.9","","731.00","63.70","731.00","1 through 10","28.21","72.35","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.04","42.9","","384.74","384.74","384.74","1 through 10","28.21","72.35","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","WELLPOINT [1015]","HB AMC WELLPOINT","67.14","73.78","","286.63","119.22","1107.45","105","28.21","72.35","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA HMO","63.52","69.8","","675.31","184.75","1721.50","286","47.56","74.37","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA PPO","73.16","80.4","","1261.44","103.12","1514.10","21","47.56","74.37","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","73.16","80.4","","1365.00","1365.00","1365.00","1 through 10","47.56","74.37","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","74.37","81.72","","5157.68","5157.68","5157.68","1 through 10","47.56","74.37","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","74.37","81.72","","431.26","71.26","1459.57","88","47.56","74.37","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.95","79.5","","800.18","480.96","1887.97","195","65.1","166.95","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.93","53.3","","813.12","216.42","1444.50","81","65.1","166.95","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","65.10","31","","432.60","432.60","432.60","1 through 10","65.1","166.95","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.65","36.5","","148.37","54.89","631.39","94","65.1","166.95","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.43","38.3","","279.30","91.72","1116.77","266","65.1","166.95","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","731.00","63.70","731.00","1 through 10","65.1","166.95","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","384.74","384.74","384.74","1 through 10","65.1","166.95","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB AMC WELLPOINT","154.94","73.78","","286.63","119.22","1107.45","105","65.1","166.95","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA HMO","146.58","69.8","","675.31","184.75","1721.50","286","109.75","171.61","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA PPO","168.84","80.4","","1261.44","103.12","1514.10","21","109.75","171.61","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","168.84","80.4","","1365.00","1365.00","1365.00","1 through 10","109.75","171.61","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","171.61","81.72","","5157.68","5157.68","5157.68","1 through 10","109.75","171.61","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.61","81.72","","431.26","71.26","1459.57","88","109.75","171.61","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","140.02","79.5","","800.18","480.96","1887.97","195","54.6","140.02","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.87","53.3","","813.12","216.42","1444.50","81","54.6","140.02","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.60","31","","432.60","432.60","432.60","1 through 10","54.6","140.02","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.28","36.5","","148.37","54.89","631.39","94","54.6","140.02","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.45","38.3","","279.30","91.72","1116.77","266","54.6","140.02","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.56","42.9","","731.00","63.70","731.00","1 through 10","54.6","140.02","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.56","42.9","","384.74","384.74","384.74","1 through 10","54.6","140.02","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.12","132.09","WELLPOINT [1015]","HB AMC WELLPOINT","129.94","73.78","","286.63","119.22","1107.45","105","54.6","140.02","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.12","132.09","AETNA [1001]","HB AMC AETNA HMO","122.93","69.8","","675.31","184.75","1721.50","286","92.04","143.93","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.12","132.09","AETNA [1001]","HB AMC AETNA PPO","141.60","80.4","","1261.44","103.12","1514.10","21","92.04","143.93","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.12","132.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","141.60","80.4","","1365.00","1365.00","1365.00","1 through 10","92.04","143.93","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.12","132.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.93","81.72","","5157.68","5157.68","5157.68","1 through 10","92.04","143.93","percent of total billed charges",""
"SCREW BONE 28X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10028314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.12","132.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.93","81.72","","431.26","71.26","1459.57","88","92.04","143.93","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","105.01","79.5","","800.18","480.96","1887.97","195","40.95","105.01","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","70.40","53.3","","813.12","216.42","1444.50","81","40.95","105.01","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","40.95","31","","432.60","432.60","432.60","1 through 10","40.95","105.01","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.21","36.5","","148.37","54.89","631.39","94","40.95","105.01","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","50.59","38.3","","279.30","91.72","1116.77","266","40.95","105.01","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.67","42.9","","731.00","63.70","731.00","1 through 10","40.95","105.01","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.67","42.9","","384.74","384.74","384.74","1 through 10","40.95","105.01","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","WELLPOINT [1015]","HB AMC WELLPOINT","97.46","73.78","","286.63","119.22","1107.45","105","40.95","105.01","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.09","99.07","AETNA [1001]","HB AMC AETNA HMO","92.20","69.8","","675.31","184.75","1721.50","286","69.03","107.94","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.09","99.07","AETNA [1001]","HB AMC AETNA PPO","106.20","80.4","","1261.44","103.12","1514.10","21","69.03","107.94","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.09","99.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","106.20","80.4","","1365.00","1365.00","1365.00","1 through 10","69.03","107.94","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.09","99.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","107.94","81.72","","5157.68","5157.68","5157.68","1 through 10","69.03","107.94","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.09","99.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","107.94","81.72","","431.26","71.26","1459.57","88","69.03","107.94","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.52","113.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","120.46","79.5","","800.18","480.96","1887.97","195","46.97","120.46","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.52","113.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","80.76","53.3","","813.12","216.42","1444.50","81","46.97","120.46","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.52","113.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","46.97","31","","432.60","432.60","432.60","1 through 10","46.97","120.46","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.52","113.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.30","36.5","","148.37","54.89","631.39","94","46.97","120.46","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.52","113.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.03","38.3","","279.30","91.72","1116.77","266","46.97","120.46","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.52","113.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.00","42.9","","731.00","63.70","731.00","1 through 10","46.97","120.46","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.52","113.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.00","42.9","","384.74","384.74","384.74","1 through 10","46.97","120.46","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","151.52","113.64","WELLPOINT [1015]","HB AMC WELLPOINT","111.79","73.78","","286.63","119.22","1107.45","105","46.97","120.46","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.52","113.64","AETNA [1001]","HB AMC AETNA HMO","105.76","69.8","","675.31","184.75","1721.50","286","79.18","123.82","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.52","113.64","AETNA [1001]","HB AMC AETNA PPO","121.82","80.4","","1261.44","103.12","1514.10","21","79.18","123.82","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.52","113.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","121.82","80.4","","1365.00","1365.00","1365.00","1 through 10","79.18","123.82","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.52","113.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","123.82","81.72","","5157.68","5157.68","5157.68","1 through 10","79.18","123.82","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","151.52","113.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","123.82","81.72","","431.26","71.26","1459.57","88","79.18","123.82","percent of total billed charges",""
"SCREW BONE 2X10MM CRANIAL EMERGENCY TITANIUM TEAL PK/5EA","SUP-ITM-10075813","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.00","399.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","422.94","79.5","","800.18","480.96","1887.97","195","164.92","422.94","percent of total billed charges",""
"SCREW BONE 2X10MM CRANIAL EMERGENCY TITANIUM TEAL PK/5EA","SUP-ITM-10075813","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.00","399.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","283.56","53.3","","813.12","216.42","1444.50","81","164.92","422.94","percent of total billed charges",""
"SCREW BONE 2X10MM CRANIAL EMERGENCY TITANIUM TEAL PK/5EA","SUP-ITM-10075813","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","164.92","31","","432.60","432.60","432.60","1 through 10","164.92","422.94","percent of total billed charges",""
"SCREW BONE 2X10MM CRANIAL EMERGENCY TITANIUM TEAL PK/5EA","SUP-ITM-10075813","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.18","36.5","","148.37","54.89","631.39","94","164.92","422.94","percent of total billed charges",""
"SCREW BONE 2X10MM CRANIAL EMERGENCY TITANIUM TEAL PK/5EA","SUP-ITM-10075813","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.76","38.3","","279.30","91.72","1116.77","266","164.92","422.94","percent of total billed charges",""
"SCREW BONE 2X10MM CRANIAL EMERGENCY TITANIUM TEAL PK/5EA","SUP-ITM-10075813","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.23","42.9","","731.00","63.70","731.00","1 through 10","164.92","422.94","percent of total billed charges",""
"SCREW BONE 2X10MM CRANIAL EMERGENCY TITANIUM TEAL PK/5EA","SUP-ITM-10075813","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.00","399.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.23","42.9","","384.74","384.74","384.74","1 through 10","164.92","422.94","percent of total billed charges",""
"SCREW BONE 2X10MM CRANIAL EMERGENCY TITANIUM TEAL PK/5EA","SUP-ITM-10075813","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.00","399.00","WELLPOINT [1015]","HB AMC WELLPOINT","392.51","73.78","","286.63","119.22","1107.45","105","164.92","422.94","percent of total billed charges",""
"SCREW BONE 2X10MM CRANIAL EMERGENCY TITANIUM TEAL PK/5EA","SUP-ITM-10075813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","532.00","399.00","AETNA [1001]","HB AMC AETNA HMO","371.34","69.8","","675.31","184.75","1721.50","286","278.02","434.75","percent of total billed charges",""
"SCREW BONE 2X10MM CRANIAL EMERGENCY TITANIUM TEAL PK/5EA","SUP-ITM-10075813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","532.00","399.00","AETNA [1001]","HB AMC AETNA PPO","427.73","80.4","","1261.44","103.12","1514.10","21","278.02","434.75","percent of total billed charges",""
"SCREW BONE 2X10MM CRANIAL EMERGENCY TITANIUM TEAL PK/5EA","SUP-ITM-10075813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","532.00","399.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","427.73","80.4","","1365.00","1365.00","1365.00","1 through 10","278.02","434.75","percent of total billed charges",""
"SCREW BONE 2X10MM CRANIAL EMERGENCY TITANIUM TEAL PK/5EA","SUP-ITM-10075813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","434.75","81.72","","5157.68","5157.68","5157.68","1 through 10","278.02","434.75","percent of total billed charges",""
"SCREW BONE 2X10MM CRANIAL EMERGENCY TITANIUM TEAL PK/5EA","SUP-ITM-10075813","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","434.75","81.72","","431.26","71.26","1459.57","88","278.02","434.75","percent of total billed charges",""
"SCREW BONE 2X10MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071995","CDM","C1713","HCPCS","0278","RC","","","","both","","","260.40","195.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","207.02","79.5","","800.18","480.96","1887.97","195","80.72","207.02","percent of total billed charges",""
"SCREW BONE 2X10MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071995","CDM","C1713","HCPCS","0278","RC","","","","both","","","260.40","195.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","138.79","53.3","","813.12","216.42","1444.50","81","80.72","207.02","percent of total billed charges",""
"SCREW BONE 2X10MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071995","CDM","C1713","HCPCS","0278","RC","","","","both","","","260.40","195.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","80.72","31","","432.60","432.60","432.60","1 through 10","80.72","207.02","percent of total billed charges",""
"SCREW BONE 2X10MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071995","CDM","C1713","HCPCS","0278","RC","","","","both","","","260.40","195.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.05","36.5","","148.37","54.89","631.39","94","80.72","207.02","percent of total billed charges",""
"SCREW BONE 2X10MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071995","CDM","C1713","HCPCS","0278","RC","","","","both","","","260.40","195.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","99.73","38.3","","279.30","91.72","1116.77","266","80.72","207.02","percent of total billed charges",""
"SCREW BONE 2X10MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071995","CDM","C1713","HCPCS","0278","RC","","","","both","","","260.40","195.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","111.71","42.9","","731.00","63.70","731.00","1 through 10","80.72","207.02","percent of total billed charges",""
"SCREW BONE 2X10MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071995","CDM","C1713","HCPCS","0278","RC","","","","both","","","260.40","195.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","111.71","42.9","","384.74","384.74","384.74","1 through 10","80.72","207.02","percent of total billed charges",""
"SCREW BONE 2X10MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071995","CDM","C1713","HCPCS","0278","RC","","","","both","","","260.40","195.30","WELLPOINT [1015]","HB AMC WELLPOINT","192.12","73.78","","286.63","119.22","1107.45","105","80.72","207.02","percent of total billed charges",""
"SCREW BONE 2X10MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","260.40","195.30","AETNA [1001]","HB AMC AETNA HMO","181.76","69.8","","675.31","184.75","1721.50","286","136.09","212.8","percent of total billed charges",""
"SCREW BONE 2X10MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","260.40","195.30","AETNA [1001]","HB AMC AETNA PPO","209.36","80.4","","1261.44","103.12","1514.10","21","136.09","212.8","percent of total billed charges",""
"SCREW BONE 2X10MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","260.40","195.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","209.36","80.4","","1365.00","1365.00","1365.00","1 through 10","136.09","212.8","percent of total billed charges",""
"SCREW BONE 2X10MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","260.40","195.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","212.80","81.72","","5157.68","5157.68","5157.68","1 through 10","136.09","212.8","percent of total billed charges",""
"SCREW BONE 2X10MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","260.40","195.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","212.80","81.72","","431.26","71.26","1459.57","88","136.09","212.8","percent of total billed charges",""
"SCREW BONE 2X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116820","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","272.69","79.5","","800.18","480.96","1887.97","195","106.33","272.69","percent of total billed charges",""
"SCREW BONE 2X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116820","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","182.82","53.3","","813.12","216.42","1444.50","81","106.33","272.69","percent of total billed charges",""
"SCREW BONE 2X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116820","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","106.33","31","","432.60","432.60","432.60","1 through 10","106.33","272.69","percent of total billed charges",""
"SCREW BONE 2X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116820","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","125.20","36.5","","148.37","54.89","631.39","94","106.33","272.69","percent of total billed charges",""
"SCREW BONE 2X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116820","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","131.37","38.3","","279.30","91.72","1116.77","266","106.33","272.69","percent of total billed charges",""
"SCREW BONE 2X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116820","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.15","42.9","","731.00","63.70","731.00","1 through 10","106.33","272.69","percent of total billed charges",""
"SCREW BONE 2X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116820","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.15","42.9","","384.74","384.74","384.74","1 through 10","106.33","272.69","percent of total billed charges",""
"SCREW BONE 2X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116820","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","WELLPOINT [1015]","HB AMC WELLPOINT","253.07","73.78","","286.63","119.22","1107.45","105","106.33","272.69","percent of total billed charges",""
"SCREW BONE 2X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","AETNA [1001]","HB AMC AETNA HMO","239.41","69.8","","675.31","184.75","1721.50","286","179.25","280.3","percent of total billed charges",""
"SCREW BONE 2X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","AETNA [1001]","HB AMC AETNA PPO","275.77","80.4","","1261.44","103.12","1514.10","21","179.25","280.3","percent of total billed charges",""
"SCREW BONE 2X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","275.77","80.4","","1365.00","1365.00","1365.00","1 through 10","179.25","280.3","percent of total billed charges",""
"SCREW BONE 2X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","280.30","81.72","","5157.68","5157.68","5157.68","1 through 10","179.25","280.3","percent of total billed charges",""
"SCREW BONE 2X10MM EVOLVE TRIAD NONLOCKING","SUP-ITM-10116820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","280.30","81.72","","431.26","71.26","1459.57","88","179.25","280.3","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.56","181.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","192.84","79.5","","800.18","480.96","1887.97","195","75.19","192.84","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.56","181.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","129.28","53.3","","813.12","216.42","1444.50","81","75.19","192.84","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.56","181.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","75.19","31","","432.60","432.60","432.60","1 through 10","75.19","192.84","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.56","181.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","88.53","36.5","","148.37","54.89","631.39","94","75.19","192.84","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.56","181.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","92.90","38.3","","279.30","91.72","1116.77","266","75.19","192.84","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.56","181.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.06","42.9","","731.00","63.70","731.00","1 through 10","75.19","192.84","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.56","181.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.06","42.9","","384.74","384.74","384.74","1 through 10","75.19","192.84","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.56","181.92","WELLPOINT [1015]","HB AMC WELLPOINT","178.96","73.78","","286.63","119.22","1107.45","105","75.19","192.84","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.56","181.92","AETNA [1001]","HB AMC AETNA HMO","169.31","69.8","","675.31","184.75","1721.50","286","126.76","198.22","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.56","181.92","AETNA [1001]","HB AMC AETNA PPO","195.02","80.4","","1261.44","103.12","1514.10","21","126.76","198.22","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.56","181.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","195.02","80.4","","1365.00","1365.00","1365.00","1 through 10","126.76","198.22","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.56","181.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","198.22","81.72","","5157.68","5157.68","5157.68","1 through 10","126.76","198.22","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.56","181.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","198.22","81.72","","431.26","71.26","1459.57","88","126.76","198.22","percent of total billed charges",""
"SCREW BONE 2X12MM LOCKING TITANIUM VA SELF TAP T6 STARDRIVE RECESS","SUP-ITM-10164317","CDM","C1713","HCPCS","0278","RC","","","","both","","","365.19","273.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","290.33","79.5","","800.18","480.96","1887.97","195","113.21","290.33","percent of total billed charges",""
"SCREW BONE 2X12MM LOCKING TITANIUM VA SELF TAP T6 STARDRIVE RECESS","SUP-ITM-10164317","CDM","C1713","HCPCS","0278","RC","","","","both","","","365.19","273.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","194.65","53.3","","813.12","216.42","1444.50","81","113.21","290.33","percent of total billed charges",""
"SCREW BONE 2X12MM LOCKING TITANIUM VA SELF TAP T6 STARDRIVE RECESS","SUP-ITM-10164317","CDM","C1713","HCPCS","0278","RC","","","","both","","","365.19","273.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","113.21","31","","432.60","432.60","432.60","1 through 10","113.21","290.33","percent of total billed charges",""
"SCREW BONE 2X12MM LOCKING TITANIUM VA SELF TAP T6 STARDRIVE RECESS","SUP-ITM-10164317","CDM","C1713","HCPCS","0278","RC","","","","both","","","365.19","273.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","133.29","36.5","","148.37","54.89","631.39","94","113.21","290.33","percent of total billed charges",""
"SCREW BONE 2X12MM LOCKING TITANIUM VA SELF TAP T6 STARDRIVE RECESS","SUP-ITM-10164317","CDM","C1713","HCPCS","0278","RC","","","","both","","","365.19","273.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","139.87","38.3","","279.30","91.72","1116.77","266","113.21","290.33","percent of total billed charges",""
"SCREW BONE 2X12MM LOCKING TITANIUM VA SELF TAP T6 STARDRIVE RECESS","SUP-ITM-10164317","CDM","C1713","HCPCS","0278","RC","","","","both","","","365.19","273.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.67","42.9","","731.00","63.70","731.00","1 through 10","113.21","290.33","percent of total billed charges",""
"SCREW BONE 2X12MM LOCKING TITANIUM VA SELF TAP T6 STARDRIVE RECESS","SUP-ITM-10164317","CDM","C1713","HCPCS","0278","RC","","","","both","","","365.19","273.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.67","42.9","","384.74","384.74","384.74","1 through 10","113.21","290.33","percent of total billed charges",""
"SCREW BONE 2X12MM LOCKING TITANIUM VA SELF TAP T6 STARDRIVE RECESS","SUP-ITM-10164317","CDM","C1713","HCPCS","0278","RC","","","","both","","","365.19","273.89","WELLPOINT [1015]","HB AMC WELLPOINT","269.44","73.78","","286.63","119.22","1107.45","105","113.21","290.33","percent of total billed charges",""
"SCREW BONE 2X12MM LOCKING TITANIUM VA SELF TAP T6 STARDRIVE RECESS","SUP-ITM-10164317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","365.19","273.89","AETNA [1001]","HB AMC AETNA HMO","254.90","69.8","","675.31","184.75","1721.50","286","190.85","298.43","percent of total billed charges",""
"SCREW BONE 2X12MM LOCKING TITANIUM VA SELF TAP T6 STARDRIVE RECESS","SUP-ITM-10164317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","365.19","273.89","AETNA [1001]","HB AMC AETNA PPO","293.61","80.4","","1261.44","103.12","1514.10","21","190.85","298.43","percent of total billed charges",""
"SCREW BONE 2X12MM LOCKING TITANIUM VA SELF TAP T6 STARDRIVE RECESS","SUP-ITM-10164317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","365.19","273.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","293.61","80.4","","1365.00","1365.00","1365.00","1 through 10","190.85","298.43","percent of total billed charges",""
"SCREW BONE 2X12MM LOCKING TITANIUM VA SELF TAP T6 STARDRIVE RECESS","SUP-ITM-10164317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","365.19","273.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","298.43","81.72","","5157.68","5157.68","5157.68","1 through 10","190.85","298.43","percent of total billed charges",""
"SCREW BONE 2X12MM LOCKING TITANIUM VA SELF TAP T6 STARDRIVE RECESS","SUP-ITM-10164317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","365.19","273.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","298.43","81.72","","431.26","71.26","1459.57","88","190.85","298.43","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","873.43","79.5","","800.18","480.96","1887.97","195","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","585.58","53.3","","813.12","216.42","1444.50","81","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","340.58","31","","432.60","432.60","432.60","1 through 10","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","401.01","36.5","","148.37","54.89","631.39","94","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","420.78","38.3","","279.30","91.72","1116.77","266","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","471.32","42.9","","731.00","63.70","731.00","1 through 10","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","471.32","42.9","","384.74","384.74","384.74","1 through 10","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","WELLPOINT [1015]","HB AMC WELLPOINT","810.58","73.78","","286.63","119.22","1107.45","105","340.58","873.43","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","AETNA [1001]","HB AMC AETNA HMO","766.86","69.8","","675.31","184.75","1721.50","286","574.15","897.82","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","AETNA [1001]","HB AMC AETNA PPO","883.31","80.4","","1261.44","103.12","1514.10","21","574.15","897.82","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","883.31","80.4","","1365.00","1365.00","1365.00","1 through 10","574.15","897.82","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","897.82","81.72","","5157.68","5157.68","5157.68","1 through 10","574.15","897.82","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","897.82","81.72","","431.26","71.26","1459.57","88","574.15","897.82","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.82","249.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","264.59","79.5","","800.18","480.96","1887.97","195","103.17","264.59","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.82","249.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","177.39","53.3","","813.12","216.42","1444.50","81","103.17","264.59","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.82","249.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","103.17","31","","432.60","432.60","432.60","1 through 10","103.17","264.59","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.82","249.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.48","36.5","","148.37","54.89","631.39","94","103.17","264.59","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.82","249.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.47","38.3","","279.30","91.72","1116.77","266","103.17","264.59","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.82","249.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.78","42.9","","731.00","63.70","731.00","1 through 10","103.17","264.59","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.82","249.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.78","42.9","","384.74","384.74","384.74","1 through 10","103.17","264.59","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","332.82","249.61","WELLPOINT [1015]","HB AMC WELLPOINT","245.55","73.78","","286.63","119.22","1107.45","105","103.17","264.59","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.82","249.61","AETNA [1001]","HB AMC AETNA HMO","232.31","69.8","","675.31","184.75","1721.50","286","173.93","271.98","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.82","249.61","AETNA [1001]","HB AMC AETNA PPO","267.59","80.4","","1261.44","103.12","1514.10","21","173.93","271.98","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.82","249.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","267.59","80.4","","1365.00","1365.00","1365.00","1 through 10","173.93","271.98","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.82","249.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","271.98","81.72","","5157.68","5157.68","5157.68","1 through 10","173.93","271.98","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","332.82","249.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","271.98","81.72","","431.26","71.26","1459.57","88","173.93","271.98","percent of total billed charges",""
"SCREW BONE 2X15MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10129726","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.65","151.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","161.11","79.5","","800.18","480.96","1887.97","195","62.82","161.11","percent of total billed charges",""
"SCREW BONE 2X15MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10129726","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.65","151.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","108.01","53.3","","813.12","216.42","1444.50","81","62.82","161.11","percent of total billed charges",""
"SCREW BONE 2X15MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10129726","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.65","151.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","62.82","31","","432.60","432.60","432.60","1 through 10","62.82","161.11","percent of total billed charges",""
"SCREW BONE 2X15MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10129726","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.65","151.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.97","36.5","","148.37","54.89","631.39","94","62.82","161.11","percent of total billed charges",""
"SCREW BONE 2X15MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10129726","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.65","151.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.61","38.3","","279.30","91.72","1116.77","266","62.82","161.11","percent of total billed charges",""
"SCREW BONE 2X15MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10129726","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.65","151.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.94","42.9","","731.00","63.70","731.00","1 through 10","62.82","161.11","percent of total billed charges",""
"SCREW BONE 2X15MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10129726","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.65","151.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.94","42.9","","384.74","384.74","384.74","1 through 10","62.82","161.11","percent of total billed charges",""
"SCREW BONE 2X15MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10129726","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.65","151.99","WELLPOINT [1015]","HB AMC WELLPOINT","149.52","73.78","","286.63","119.22","1107.45","105","62.82","161.11","percent of total billed charges",""
"SCREW BONE 2X15MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10129726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.65","151.99","AETNA [1001]","HB AMC AETNA HMO","141.45","69.8","","675.31","184.75","1721.50","286","105.9","165.61","percent of total billed charges",""
"SCREW BONE 2X15MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10129726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.65","151.99","AETNA [1001]","HB AMC AETNA PPO","162.93","80.4","","1261.44","103.12","1514.10","21","105.9","165.61","percent of total billed charges",""
"SCREW BONE 2X15MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10129726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.65","151.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","162.93","80.4","","1365.00","1365.00","1365.00","1 through 10","105.9","165.61","percent of total billed charges",""
"SCREW BONE 2X15MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10129726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.65","151.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","165.61","81.72","","5157.68","5157.68","5157.68","1 through 10","105.9","165.61","percent of total billed charges",""
"SCREW BONE 2X15MM MAXDRIVE TITANIUM FIXATION","SUP-ITM-10129726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.65","151.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.61","81.72","","431.26","71.26","1459.57","88","105.9","165.61","percent of total billed charges",""
"SCREW BONE 2X16MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10015782","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","115.31","79.5","","800.18","480.96","1887.97","195","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X16MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10015782","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.31","53.3","","813.12","216.42","1444.50","81","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X16MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10015782","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","44.96","31","","432.60","432.60","432.60","1 through 10","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X16MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10015782","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","52.94","36.5","","148.37","54.89","631.39","94","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X16MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10015782","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.55","38.3","","279.30","91.72","1116.77","266","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X16MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10015782","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.22","42.9","","731.00","63.70","731.00","1 through 10","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X16MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10015782","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.22","42.9","","384.74","384.74","384.74","1 through 10","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X16MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10015782","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","WELLPOINT [1015]","HB AMC WELLPOINT","107.01","73.78","","286.63","119.22","1107.45","105","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X16MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10015782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.04","108.78","AETNA [1001]","HB AMC AETNA HMO","101.24","69.8","","675.31","184.75","1721.50","286","75.8","118.53","percent of total billed charges",""
"SCREW BONE 2X16MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10015782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.04","108.78","AETNA [1001]","HB AMC AETNA PPO","116.61","80.4","","1261.44","103.12","1514.10","21","75.8","118.53","percent of total billed charges",""
"SCREW BONE 2X16MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10015782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.04","108.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","116.61","80.4","","1365.00","1365.00","1365.00","1 through 10","75.8","118.53","percent of total billed charges",""
"SCREW BONE 2X16MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10015782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.04","108.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","118.53","81.72","","5157.68","5157.68","5157.68","1 through 10","75.8","118.53","percent of total billed charges",""
"SCREW BONE 2X16MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10015782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.04","108.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","118.53","81.72","","431.26","71.26","1459.57","88","75.8","118.53","percent of total billed charges",""
"SCREW BONE 2X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081049","CDM","C1713","HCPCS","0278","RC","","","","both","","","259.99","194.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","206.69","79.5","","800.18","480.96","1887.97","195","80.6","206.69","percent of total billed charges",""
"SCREW BONE 2X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081049","CDM","C1713","HCPCS","0278","RC","","","","both","","","259.99","194.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","138.57","53.3","","813.12","216.42","1444.50","81","80.6","206.69","percent of total billed charges",""
"SCREW BONE 2X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081049","CDM","C1713","HCPCS","0278","RC","","","","both","","","259.99","194.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","80.60","31","","432.60","432.60","432.60","1 through 10","80.6","206.69","percent of total billed charges",""
"SCREW BONE 2X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081049","CDM","C1713","HCPCS","0278","RC","","","","both","","","259.99","194.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","94.90","36.5","","148.37","54.89","631.39","94","80.6","206.69","percent of total billed charges",""
"SCREW BONE 2X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081049","CDM","C1713","HCPCS","0278","RC","","","","both","","","259.99","194.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","99.58","38.3","","279.30","91.72","1116.77","266","80.6","206.69","percent of total billed charges",""
"SCREW BONE 2X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081049","CDM","C1713","HCPCS","0278","RC","","","","both","","","259.99","194.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","111.54","42.9","","731.00","63.70","731.00","1 through 10","80.6","206.69","percent of total billed charges",""
"SCREW BONE 2X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081049","CDM","C1713","HCPCS","0278","RC","","","","both","","","259.99","194.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","111.54","42.9","","384.74","384.74","384.74","1 through 10","80.6","206.69","percent of total billed charges",""
"SCREW BONE 2X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081049","CDM","C1713","HCPCS","0278","RC","","","","both","","","259.99","194.99","WELLPOINT [1015]","HB AMC WELLPOINT","191.82","73.78","","286.63","119.22","1107.45","105","80.6","206.69","percent of total billed charges",""
"SCREW BONE 2X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081049","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","259.99","194.99","AETNA [1001]","HB AMC AETNA HMO","181.47","69.8","","675.31","184.75","1721.50","286","135.87","212.46","percent of total billed charges",""
"SCREW BONE 2X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081049","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","259.99","194.99","AETNA [1001]","HB AMC AETNA PPO","209.03","80.4","","1261.44","103.12","1514.10","21","135.87","212.46","percent of total billed charges",""
"SCREW BONE 2X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081049","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","259.99","194.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","209.03","80.4","","1365.00","1365.00","1365.00","1 through 10","135.87","212.46","percent of total billed charges",""
"SCREW BONE 2X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081049","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","259.99","194.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","212.46","81.72","","5157.68","5157.68","5157.68","1 through 10","135.87","212.46","percent of total billed charges",""
"SCREW BONE 2X18MM MATRIXMANDIBLE TITANIUM LOCKING SELF TAPPING PK/5EA","SUP-ITM-10081049","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","259.99","194.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","212.46","81.72","","431.26","71.26","1459.57","88","135.87","212.46","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075830","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.43","104.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.85","79.5","","800.18","480.96","1887.97","195","43.22","110.85","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075830","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.43","104.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.32","53.3","","813.12","216.42","1444.50","81","43.22","110.85","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075830","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.43","104.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","43.22","31","","432.60","432.60","432.60","1 through 10","43.22","110.85","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075830","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.43","104.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.89","36.5","","148.37","54.89","631.39","94","43.22","110.85","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075830","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.43","104.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.40","38.3","","279.30","91.72","1116.77","266","43.22","110.85","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075830","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.43","104.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.82","42.9","","731.00","63.70","731.00","1 through 10","43.22","110.85","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075830","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.43","104.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.82","42.9","","384.74","384.74","384.74","1 through 10","43.22","110.85","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075830","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.43","104.57","WELLPOINT [1015]","HB AMC WELLPOINT","102.87","73.78","","286.63","119.22","1107.45","105","43.22","110.85","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075830","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.43","104.57","AETNA [1001]","HB AMC AETNA HMO","97.32","69.8","","675.31","184.75","1721.50","286","72.87","113.94","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075830","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.43","104.57","AETNA [1001]","HB AMC AETNA PPO","112.10","80.4","","1261.44","103.12","1514.10","21","72.87","113.94","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075830","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.43","104.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.10","80.4","","1365.00","1365.00","1365.00","1 through 10","72.87","113.94","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075830","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.43","104.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","113.94","81.72","","5157.68","5157.68","5157.68","1 through 10","72.87","113.94","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075830","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.43","104.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.94","81.72","","431.26","71.26","1459.57","88","72.87","113.94","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015483","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.07","79.5","","800.18","480.96","1887.97","195","42.92","110.07","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015483","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","73.79","53.3","","813.12","216.42","1444.50","81","42.92","110.07","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015483","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","42.92","31","","432.60","432.60","432.60","1 through 10","42.92","110.07","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015483","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.53","36.5","","148.37","54.89","631.39","94","42.92","110.07","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015483","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.03","38.3","","279.30","91.72","1116.77","266","42.92","110.07","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015483","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.40","42.9","","731.00","63.70","731.00","1 through 10","42.92","110.07","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015483","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.40","42.9","","384.74","384.74","384.74","1 through 10","42.92","110.07","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015483","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.45","103.84","WELLPOINT [1015]","HB AMC WELLPOINT","102.15","73.78","","286.63","119.22","1107.45","105","42.92","110.07","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.45","103.84","AETNA [1001]","HB AMC AETNA HMO","96.64","69.8","","675.31","184.75","1721.50","286","72.35","113.14","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.45","103.84","AETNA [1001]","HB AMC AETNA PPO","111.31","80.4","","1261.44","103.12","1514.10","21","72.35","113.14","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.45","103.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.31","80.4","","1365.00","1365.00","1365.00","1 through 10","72.35","113.14","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.45","103.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","113.14","81.72","","5157.68","5157.68","5157.68","1 through 10","72.35","113.14","percent of total billed charges",""
"SCREW BONE 2X4MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.45","103.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.14","81.72","","431.26","71.26","1459.57","88","72.35","113.14","percent of total billed charges",""
"SCREW BONE 2X4MM EMERGENCY TITANIUM CRUCIFORM RECESS TEAL PK/5EA","SUP-ITM-10075808","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.62","100.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","106.23","79.5","","800.18","480.96","1887.97","195","41.42","106.23","percent of total billed charges",""
"SCREW BONE 2X4MM EMERGENCY TITANIUM CRUCIFORM RECESS TEAL PK/5EA","SUP-ITM-10075808","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.62","100.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","71.22","53.3","","813.12","216.42","1444.50","81","41.42","106.23","percent of total billed charges",""
"SCREW BONE 2X4MM EMERGENCY TITANIUM CRUCIFORM RECESS TEAL PK/5EA","SUP-ITM-10075808","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.62","100.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","41.42","31","","432.60","432.60","432.60","1 through 10","41.42","106.23","percent of total billed charges",""
"SCREW BONE 2X4MM EMERGENCY TITANIUM CRUCIFORM RECESS TEAL PK/5EA","SUP-ITM-10075808","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.62","100.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.77","36.5","","148.37","54.89","631.39","94","41.42","106.23","percent of total billed charges",""
"SCREW BONE 2X4MM EMERGENCY TITANIUM CRUCIFORM RECESS TEAL PK/5EA","SUP-ITM-10075808","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.62","100.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","51.18","38.3","","279.30","91.72","1116.77","266","41.42","106.23","percent of total billed charges",""
"SCREW BONE 2X4MM EMERGENCY TITANIUM CRUCIFORM RECESS TEAL PK/5EA","SUP-ITM-10075808","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.62","100.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.32","42.9","","731.00","63.70","731.00","1 through 10","41.42","106.23","percent of total billed charges",""
"SCREW BONE 2X4MM EMERGENCY TITANIUM CRUCIFORM RECESS TEAL PK/5EA","SUP-ITM-10075808","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.62","100.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.32","42.9","","384.74","384.74","384.74","1 through 10","41.42","106.23","percent of total billed charges",""
"SCREW BONE 2X4MM EMERGENCY TITANIUM CRUCIFORM RECESS TEAL PK/5EA","SUP-ITM-10075808","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.62","100.21","WELLPOINT [1015]","HB AMC WELLPOINT","98.58","73.78","","286.63","119.22","1107.45","105","41.42","106.23","percent of total billed charges",""
"SCREW BONE 2X4MM EMERGENCY TITANIUM CRUCIFORM RECESS TEAL PK/5EA","SUP-ITM-10075808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.62","100.21","AETNA [1001]","HB AMC AETNA HMO","93.27","69.8","","675.31","184.75","1721.50","286","69.83","109.19","percent of total billed charges",""
"SCREW BONE 2X4MM EMERGENCY TITANIUM CRUCIFORM RECESS TEAL PK/5EA","SUP-ITM-10075808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.62","100.21","AETNA [1001]","HB AMC AETNA PPO","107.43","80.4","","1261.44","103.12","1514.10","21","69.83","109.19","percent of total billed charges",""
"SCREW BONE 2X4MM EMERGENCY TITANIUM CRUCIFORM RECESS TEAL PK/5EA","SUP-ITM-10075808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.62","100.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","107.43","80.4","","1365.00","1365.00","1365.00","1 through 10","69.83","109.19","percent of total billed charges",""
"SCREW BONE 2X4MM EMERGENCY TITANIUM CRUCIFORM RECESS TEAL PK/5EA","SUP-ITM-10075808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.62","100.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","109.19","81.72","","5157.68","5157.68","5157.68","1 through 10","69.83","109.19","percent of total billed charges",""
"SCREW BONE 2X4MM EMERGENCY TITANIUM CRUCIFORM RECESS TEAL PK/5EA","SUP-ITM-10075808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.62","100.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","109.19","81.72","","431.26","71.26","1459.57","88","69.83","109.19","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","194.78","79.5","","800.18","480.96","1887.97","195","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","130.59","53.3","","813.12","216.42","1444.50","81","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","75.95","31","","432.60","432.60","432.60","1 through 10","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","89.43","36.5","","148.37","54.89","631.39","94","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.84","38.3","","279.30","91.72","1116.77","266","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.11","42.9","","731.00","63.70","731.00","1 through 10","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.11","42.9","","384.74","384.74","384.74","1 through 10","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.00","183.75","WELLPOINT [1015]","HB AMC WELLPOINT","180.76","73.78","","286.63","119.22","1107.45","105","75.95","194.78","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA HMO","171.01","69.8","","675.31","184.75","1721.50","286","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","AETNA [1001]","HB AMC AETNA PPO","196.98","80.4","","1261.44","103.12","1514.10","21","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","196.98","80.4","","1365.00","1365.00","1365.00","1 through 10","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","200.21","81.72","","5157.68","5157.68","5157.68","1 through 10","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2X4MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","200.21","81.72","","431.26","71.26","1459.57","88","128.04","200.21","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015485","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.27","99.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","105.95","79.5","","800.18","480.96","1887.97","195","41.31","105.95","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015485","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.27","99.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","71.03","53.3","","813.12","216.42","1444.50","81","41.31","105.95","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015485","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.27","99.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","41.31","31","","432.60","432.60","432.60","1 through 10","41.31","105.95","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015485","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.27","99.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.64","36.5","","148.37","54.89","631.39","94","41.31","105.95","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015485","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.27","99.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","51.04","38.3","","279.30","91.72","1116.77","266","41.31","105.95","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015485","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.27","99.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.17","42.9","","731.00","63.70","731.00","1 through 10","41.31","105.95","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015485","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.27","99.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.17","42.9","","384.74","384.74","384.74","1 through 10","41.31","105.95","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015485","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.27","99.95","WELLPOINT [1015]","HB AMC WELLPOINT","98.33","73.78","","286.63","119.22","1107.45","105","41.31","105.95","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.27","99.95","AETNA [1001]","HB AMC AETNA HMO","93.02","69.8","","675.31","184.75","1721.50","286","69.65","108.91","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.27","99.95","AETNA [1001]","HB AMC AETNA PPO","107.15","80.4","","1261.44","103.12","1514.10","21","69.65","108.91","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.27","99.95","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","107.15","80.4","","1365.00","1365.00","1365.00","1 through 10","69.65","108.91","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.27","99.95","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","108.91","81.72","","5157.68","5157.68","5157.68","1 through 10","69.65","108.91","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX SELF DRILLING WITH PLUSDRIVE RECESS TITANIUM PK/5EA","SUP-ITM-10015485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.27","99.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","108.91","81.72","","431.26","71.26","1459.57","88","69.65","108.91","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019126","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","115.31","79.5","","800.18","480.96","1887.97","195","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019126","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.31","53.3","","813.12","216.42","1444.50","81","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019126","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","44.96","31","","432.60","432.60","432.60","1 through 10","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019126","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","52.94","36.5","","148.37","54.89","631.39","94","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019126","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.55","38.3","","279.30","91.72","1116.77","266","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019126","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.22","42.9","","731.00","63.70","731.00","1 through 10","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019126","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.22","42.9","","384.74","384.74","384.74","1 through 10","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019126","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.04","108.78","WELLPOINT [1015]","HB AMC WELLPOINT","107.01","73.78","","286.63","119.22","1107.45","105","44.96","115.31","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.04","108.78","AETNA [1001]","HB AMC AETNA HMO","101.24","69.8","","675.31","184.75","1721.50","286","75.8","118.53","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.04","108.78","AETNA [1001]","HB AMC AETNA PPO","116.61","80.4","","1261.44","103.12","1514.10","21","75.8","118.53","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.04","108.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","116.61","80.4","","1365.00","1365.00","1365.00","1 through 10","75.8","118.53","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.04","108.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","118.53","81.72","","5157.68","5157.68","5157.68","1 through 10","75.8","118.53","percent of total billed charges",""
"SCREW BONE 2X6MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.04","108.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","118.53","81.72","","431.26","71.26","1459.57","88","75.8","118.53","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI LOCKING SELF DRILLING PK/5EA","SUP-ITM-10275568","CDM","C1713","HCPCS","0278","RC","","","","both","","","348.59","261.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","277.13","79.5","","800.18","480.96","1887.97","195","108.06","277.13","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI LOCKING SELF DRILLING PK/5EA","SUP-ITM-10275568","CDM","C1713","HCPCS","0278","RC","","","","both","","","348.59","261.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","185.80","53.3","","813.12","216.42","1444.50","81","108.06","277.13","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI LOCKING SELF DRILLING PK/5EA","SUP-ITM-10275568","CDM","C1713","HCPCS","0278","RC","","","","both","","","348.59","261.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","108.06","31","","432.60","432.60","432.60","1 through 10","108.06","277.13","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI LOCKING SELF DRILLING PK/5EA","SUP-ITM-10275568","CDM","C1713","HCPCS","0278","RC","","","","both","","","348.59","261.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.24","36.5","","148.37","54.89","631.39","94","108.06","277.13","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI LOCKING SELF DRILLING PK/5EA","SUP-ITM-10275568","CDM","C1713","HCPCS","0278","RC","","","","both","","","348.59","261.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","133.51","38.3","","279.30","91.72","1116.77","266","108.06","277.13","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI LOCKING SELF DRILLING PK/5EA","SUP-ITM-10275568","CDM","C1713","HCPCS","0278","RC","","","","both","","","348.59","261.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","149.55","42.9","","731.00","63.70","731.00","1 through 10","108.06","277.13","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI LOCKING SELF DRILLING PK/5EA","SUP-ITM-10275568","CDM","C1713","HCPCS","0278","RC","","","","both","","","348.59","261.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","149.55","42.9","","384.74","384.74","384.74","1 through 10","108.06","277.13","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI LOCKING SELF DRILLING PK/5EA","SUP-ITM-10275568","CDM","C1713","HCPCS","0278","RC","","","","both","","","348.59","261.44","WELLPOINT [1015]","HB AMC WELLPOINT","257.19","73.78","","286.63","119.22","1107.45","105","108.06","277.13","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI LOCKING SELF DRILLING PK/5EA","SUP-ITM-10275568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","348.59","261.44","AETNA [1001]","HB AMC AETNA HMO","243.32","69.8","","675.31","184.75","1721.50","286","182.17","284.87","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI LOCKING SELF DRILLING PK/5EA","SUP-ITM-10275568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","348.59","261.44","AETNA [1001]","HB AMC AETNA PPO","280.27","80.4","","1261.44","103.12","1514.10","21","182.17","284.87","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI LOCKING SELF DRILLING PK/5EA","SUP-ITM-10275568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","348.59","261.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","280.27","80.4","","1365.00","1365.00","1365.00","1 through 10","182.17","284.87","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI LOCKING SELF DRILLING PK/5EA","SUP-ITM-10275568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","348.59","261.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","284.87","81.72","","5157.68","5157.68","5157.68","1 through 10","182.17","284.87","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI LOCKING SELF DRILLING PK/5EA","SUP-ITM-10275568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","348.59","261.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","284.87","81.72","","431.26","71.26","1459.57","88","182.17","284.87","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI SELF DRILLING PK/5EA","SUP-ITM-10275570","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.34","152.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","161.66","79.5","","800.18","480.96","1887.97","195","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI SELF DRILLING PK/5EA","SUP-ITM-10275570","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.34","152.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","108.38","53.3","","813.12","216.42","1444.50","81","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI SELF DRILLING PK/5EA","SUP-ITM-10275570","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.34","152.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","63.04","31","","432.60","432.60","432.60","1 through 10","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI SELF DRILLING PK/5EA","SUP-ITM-10275570","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.34","152.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.22","36.5","","148.37","54.89","631.39","94","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI SELF DRILLING PK/5EA","SUP-ITM-10275570","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.34","152.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.88","38.3","","279.30","91.72","1116.77","266","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI SELF DRILLING PK/5EA","SUP-ITM-10275570","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.34","152.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.23","42.9","","731.00","63.70","731.00","1 through 10","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI SELF DRILLING PK/5EA","SUP-ITM-10275570","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.34","152.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.23","42.9","","384.74","384.74","384.74","1 through 10","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI SELF DRILLING PK/5EA","SUP-ITM-10275570","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.34","152.50","WELLPOINT [1015]","HB AMC WELLPOINT","150.02","73.78","","286.63","119.22","1107.45","105","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI SELF DRILLING PK/5EA","SUP-ITM-10275570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.34","152.50","AETNA [1001]","HB AMC AETNA HMO","141.93","69.8","","675.31","184.75","1721.50","286","106.27","166.17","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI SELF DRILLING PK/5EA","SUP-ITM-10275570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.34","152.50","AETNA [1001]","HB AMC AETNA PPO","163.49","80.4","","1261.44","103.12","1514.10","21","106.27","166.17","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI SELF DRILLING PK/5EA","SUP-ITM-10275570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.34","152.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","163.49","80.4","","1365.00","1365.00","1365.00","1 through 10","106.27","166.17","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI SELF DRILLING PK/5EA","SUP-ITM-10275570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.34","152.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","166.17","81.72","","5157.68","5157.68","5157.68","1 through 10","106.27","166.17","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TI SELF DRILLING PK/5EA","SUP-ITM-10275570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.34","152.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","166.17","81.72","","431.26","71.26","1459.57","88","106.27","166.17","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TITANIUM SELF DRILLING","SUP-ITM-10131144","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.35","152.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","161.66","79.5","","800.18","480.96","1887.97","195","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TITANIUM SELF DRILLING","SUP-ITM-10131144","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.35","152.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","108.39","53.3","","813.12","216.42","1444.50","81","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TITANIUM SELF DRILLING","SUP-ITM-10131144","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.35","152.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","63.04","31","","432.60","432.60","432.60","1 through 10","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TITANIUM SELF DRILLING","SUP-ITM-10131144","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.35","152.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.22","36.5","","148.37","54.89","631.39","94","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TITANIUM SELF DRILLING","SUP-ITM-10131144","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.35","152.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.88","38.3","","279.30","91.72","1116.77","266","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TITANIUM SELF DRILLING","SUP-ITM-10131144","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.35","152.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.24","42.9","","731.00","63.70","731.00","1 through 10","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TITANIUM SELF DRILLING","SUP-ITM-10131144","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.35","152.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.24","42.9","","384.74","384.74","384.74","1 through 10","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TITANIUM SELF DRILLING","SUP-ITM-10131144","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.35","152.51","WELLPOINT [1015]","HB AMC WELLPOINT","150.03","73.78","","286.63","119.22","1107.45","105","63.04","161.66","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TITANIUM SELF DRILLING","SUP-ITM-10131144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.35","152.51","AETNA [1001]","HB AMC AETNA HMO","141.94","69.8","","675.31","184.75","1721.50","286","106.27","166.18","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TITANIUM SELF DRILLING","SUP-ITM-10131144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.35","152.51","AETNA [1001]","HB AMC AETNA PPO","163.49","80.4","","1261.44","103.12","1514.10","21","106.27","166.18","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TITANIUM SELF DRILLING","SUP-ITM-10131144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.35","152.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","163.49","80.4","","1365.00","1365.00","1365.00","1 through 10","106.27","166.18","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TITANIUM SELF DRILLING","SUP-ITM-10131144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.35","152.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","166.18","81.72","","5157.68","5157.68","5157.68","1 through 10","106.27","166.18","percent of total billed charges",""
"SCREW BONE 2X6MM MATRIXMANDIBLE TITANIUM SELF DRILLING","SUP-ITM-10131144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.35","152.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","166.18","81.72","","431.26","71.26","1459.57","88","106.27","166.18","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.90","383.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","406.17","79.5","","800.18","480.96","1887.97","195","158.38","406.17","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.90","383.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","272.31","53.3","","813.12","216.42","1444.50","81","158.38","406.17","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.90","383.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","158.38","31","","432.60","432.60","432.60","1 through 10","158.38","406.17","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.90","383.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","186.48","36.5","","148.37","54.89","631.39","94","158.38","406.17","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.90","383.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","195.67","38.3","","279.30","91.72","1116.77","266","158.38","406.17","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.90","383.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","219.18","42.9","","731.00","63.70","731.00","1 through 10","158.38","406.17","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.90","383.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","219.18","42.9","","384.74","384.74","384.74","1 through 10","158.38","406.17","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.90","383.17","WELLPOINT [1015]","HB AMC WELLPOINT","376.94","73.78","","286.63","119.22","1107.45","105","158.38","406.17","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.90","383.17","AETNA [1001]","HB AMC AETNA HMO","356.61","69.8","","675.31","184.75","1721.50","286","267","417.51","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.90","383.17","AETNA [1001]","HB AMC AETNA PPO","410.76","80.4","","1261.44","103.12","1514.10","21","267","417.51","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.90","383.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","410.76","80.4","","1365.00","1365.00","1365.00","1 through 10","267","417.51","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.90","383.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","417.51","81.72","","5157.68","5157.68","5157.68","1 through 10","267","417.51","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.90","383.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","417.51","81.72","","431.26","71.26","1459.57","88","267","417.51","percent of total billed charges",""
"SCREW BONE 2X7MM CORTEX TITANIUM SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10075841","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.51","107.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","114.09","79.5","","800.18","480.96","1887.97","195","44.49","114.09","percent of total billed charges",""
"SCREW BONE 2X7MM CORTEX TITANIUM SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10075841","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.51","107.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","76.49","53.3","","813.12","216.42","1444.50","81","44.49","114.09","percent of total billed charges",""
"SCREW BONE 2X7MM CORTEX TITANIUM SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10075841","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.51","107.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","44.49","31","","432.60","432.60","432.60","1 through 10","44.49","114.09","percent of total billed charges",""
"SCREW BONE 2X7MM CORTEX TITANIUM SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10075841","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.51","107.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","52.38","36.5","","148.37","54.89","631.39","94","44.49","114.09","percent of total billed charges",""
"SCREW BONE 2X7MM CORTEX TITANIUM SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10075841","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.51","107.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.96","38.3","","279.30","91.72","1116.77","266","44.49","114.09","percent of total billed charges",""
"SCREW BONE 2X7MM CORTEX TITANIUM SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10075841","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.51","107.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.57","42.9","","731.00","63.70","731.00","1 through 10","44.49","114.09","percent of total billed charges",""
"SCREW BONE 2X7MM CORTEX TITANIUM SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10075841","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.51","107.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.57","42.9","","384.74","384.74","384.74","1 through 10","44.49","114.09","percent of total billed charges",""
"SCREW BONE 2X7MM CORTEX TITANIUM SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10075841","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.51","107.63","WELLPOINT [1015]","HB AMC WELLPOINT","105.88","73.78","","286.63","119.22","1107.45","105","44.49","114.09","percent of total billed charges",""
"SCREW BONE 2X7MM CORTEX TITANIUM SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10075841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.51","107.63","AETNA [1001]","HB AMC AETNA HMO","100.17","69.8","","675.31","184.75","1721.50","286","75","117.28","percent of total billed charges",""
"SCREW BONE 2X7MM CORTEX TITANIUM SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10075841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.51","107.63","AETNA [1001]","HB AMC AETNA PPO","115.38","80.4","","1261.44","103.12","1514.10","21","75","117.28","percent of total billed charges",""
"SCREW BONE 2X7MM CORTEX TITANIUM SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10075841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.51","107.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","115.38","80.4","","1365.00","1365.00","1365.00","1 through 10","75","117.28","percent of total billed charges",""
"SCREW BONE 2X7MM CORTEX TITANIUM SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10075841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.51","107.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","117.28","81.72","","5157.68","5157.68","5157.68","1 through 10","75","117.28","percent of total billed charges",""
"SCREW BONE 2X7MM CORTEX TITANIUM SELF DRILLING PLUSDRIVE RECESS PK/5EA","SUP-ITM-10075841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.51","107.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","117.28","81.72","","431.26","71.26","1459.57","88","75","117.28","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.43","208.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","221.35","79.5","","800.18","480.96","1887.97","195","86.31","221.35","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.43","208.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","148.40","53.3","","813.12","216.42","1444.50","81","86.31","221.35","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.43","208.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","86.31","31","","432.60","432.60","432.60","1 through 10","86.31","221.35","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.43","208.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","101.63","36.5","","148.37","54.89","631.39","94","86.31","221.35","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.43","208.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","106.64","38.3","","279.30","91.72","1116.77","266","86.31","221.35","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.43","208.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.45","42.9","","731.00","63.70","731.00","1 through 10","86.31","221.35","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.43","208.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.45","42.9","","384.74","384.74","384.74","1 through 10","86.31","221.35","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","278.43","208.82","WELLPOINT [1015]","HB AMC WELLPOINT","205.43","73.78","","286.63","119.22","1107.45","105","86.31","221.35","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.43","208.82","AETNA [1001]","HB AMC AETNA HMO","194.34","69.8","","675.31","184.75","1721.50","286","145.51","227.53","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.43","208.82","AETNA [1001]","HB AMC AETNA PPO","223.86","80.4","","1261.44","103.12","1514.10","21","145.51","227.53","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.43","208.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","223.86","80.4","","1365.00","1365.00","1365.00","1 through 10","145.51","227.53","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.43","208.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","227.53","81.72","","5157.68","5157.68","5157.68","1 through 10","145.51","227.53","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","278.43","208.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","227.53","81.72","","431.26","71.26","1459.57","88","145.51","227.53","percent of total billed charges",""
"SCREW BONE 2X8MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071994","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","141.91","79.5","","800.18","480.96","1887.97","195","55.34","141.91","percent of total billed charges",""
"SCREW BONE 2X8MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071994","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.14","53.3","","813.12","216.42","1444.50","81","55.34","141.91","percent of total billed charges",""
"SCREW BONE 2X8MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071994","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","55.34","31","","432.60","432.60","432.60","1 through 10","55.34","141.91","percent of total billed charges",""
"SCREW BONE 2X8MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071994","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.15","36.5","","148.37","54.89","631.39","94","55.34","141.91","percent of total billed charges",""
"SCREW BONE 2X8MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071994","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.37","38.3","","279.30","91.72","1116.77","266","55.34","141.91","percent of total billed charges",""
"SCREW BONE 2X8MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071994","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.58","42.9","","731.00","63.70","731.00","1 through 10","55.34","141.91","percent of total billed charges",""
"SCREW BONE 2X8MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071994","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.58","42.9","","384.74","384.74","384.74","1 through 10","55.34","141.91","percent of total billed charges",""
"SCREW BONE 2X8MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071994","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","WELLPOINT [1015]","HB AMC WELLPOINT","131.70","73.78","","286.63","119.22","1107.45","105","55.34","141.91","percent of total billed charges",""
"SCREW BONE 2X8MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","AETNA [1001]","HB AMC AETNA HMO","124.59","69.8","","675.31","184.75","1721.50","286","93.28","145.87","percent of total billed charges",""
"SCREW BONE 2X8MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","AETNA [1001]","HB AMC AETNA PPO","143.51","80.4","","1261.44","103.12","1514.10","21","93.28","145.87","percent of total billed charges",""
"SCREW BONE 2X8MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","143.51","80.4","","1365.00","1365.00","1365.00","1 through 10","93.28","145.87","percent of total billed charges",""
"SCREW BONE 2X8MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","145.87","81.72","","5157.68","5157.68","5157.68","1 through 10","93.28","145.87","percent of total billed charges",""
"SCREW BONE 2X8MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","145.87","81.72","","431.26","71.26","1459.57","88","93.28","145.87","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","92.66","79.5","","800.18","480.96","1887.97","195","36.13","92.66","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","62.12","53.3","","813.12","216.42","1444.50","81","36.13","92.66","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","36.13","31","","432.60","432.60","432.60","1 through 10","36.13","92.66","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","42.54","36.5","","148.37","54.89","631.39","94","36.13","92.66","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44.64","38.3","","279.30","91.72","1116.77","266","36.13","92.66","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.00","42.9","","731.00","63.70","731.00","1 through 10","36.13","92.66","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.00","42.9","","384.74","384.74","384.74","1 through 10","36.13","92.66","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.55","87.41","WELLPOINT [1015]","HB AMC WELLPOINT","85.99","73.78","","286.63","119.22","1107.45","105","36.13","92.66","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","116.55","87.41","AETNA [1001]","HB AMC AETNA HMO","81.35","69.8","","675.31","184.75","1721.50","286","60.91","95.24","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","116.55","87.41","AETNA [1001]","HB AMC AETNA PPO","93.71","80.4","","1261.44","103.12","1514.10","21","60.91","95.24","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","116.55","87.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","93.71","80.4","","1365.00","1365.00","1365.00","1 through 10","60.91","95.24","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","116.55","87.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","95.24","81.72","","5157.68","5157.68","5157.68","1 through 10","60.91","95.24","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","116.55","87.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","95.24","81.72","","431.26","71.26","1459.57","88","60.91","95.24","percent of total billed charges",""
"SCREW BONE 2X8MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10118296","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.92","284.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","301.24","79.5","","800.18","480.96","1887.97","195","117.47","301.24","percent of total billed charges",""
"SCREW BONE 2X8MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10118296","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.92","284.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","201.96","53.3","","813.12","216.42","1444.50","81","117.47","301.24","percent of total billed charges",""
"SCREW BONE 2X8MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10118296","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.92","284.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","117.47","31","","432.60","432.60","432.60","1 through 10","117.47","301.24","percent of total billed charges",""
"SCREW BONE 2X8MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10118296","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.92","284.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","138.31","36.5","","148.37","54.89","631.39","94","117.47","301.24","percent of total billed charges",""
"SCREW BONE 2X8MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10118296","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.92","284.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","145.13","38.3","","279.30","91.72","1116.77","266","117.47","301.24","percent of total billed charges",""
"SCREW BONE 2X8MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10118296","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.92","284.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","162.56","42.9","","731.00","63.70","731.00","1 through 10","117.47","301.24","percent of total billed charges",""
"SCREW BONE 2X8MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10118296","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.92","284.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","162.56","42.9","","384.74","384.74","384.74","1 through 10","117.47","301.24","percent of total billed charges",""
"SCREW BONE 2X8MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10118296","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.92","284.19","WELLPOINT [1015]","HB AMC WELLPOINT","279.57","73.78","","286.63","119.22","1107.45","105","117.47","301.24","percent of total billed charges",""
"SCREW BONE 2X8MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10118296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.92","284.19","AETNA [1001]","HB AMC AETNA HMO","264.49","69.8","","675.31","184.75","1721.50","286","198.02","309.65","percent of total billed charges",""
"SCREW BONE 2X8MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10118296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.92","284.19","AETNA [1001]","HB AMC AETNA PPO","304.65","80.4","","1261.44","103.12","1514.10","21","198.02","309.65","percent of total billed charges",""
"SCREW BONE 2X8MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10118296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.92","284.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","304.65","80.4","","1365.00","1365.00","1365.00","1 through 10","198.02","309.65","percent of total billed charges",""
"SCREW BONE 2X8MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10118296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.92","284.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","309.65","81.72","","5157.68","5157.68","5157.68","1 through 10","198.02","309.65","percent of total billed charges",""
"SCREW BONE 2X8MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10118296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.92","284.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","309.65","81.72","","431.26","71.26","1459.57","88","198.02","309.65","percent of total billed charges",""
"SCREW BONE 2X8MM MANDIBLE CORTEX TITANIUM SELF TAPPING COARSE PITCH PK/5EA","SUP-ITM-10075867","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.27","103.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","109.92","79.5","","800.18","480.96","1887.97","195","42.86","109.92","percent of total billed charges",""
"SCREW BONE 2X8MM MANDIBLE CORTEX TITANIUM SELF TAPPING COARSE PITCH PK/5EA","SUP-ITM-10075867","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.27","103.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","73.70","53.3","","813.12","216.42","1444.50","81","42.86","109.92","percent of total billed charges",""
"SCREW BONE 2X8MM MANDIBLE CORTEX TITANIUM SELF TAPPING COARSE PITCH PK/5EA","SUP-ITM-10075867","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.27","103.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","42.86","31","","432.60","432.60","432.60","1 through 10","42.86","109.92","percent of total billed charges",""
"SCREW BONE 2X8MM MANDIBLE CORTEX TITANIUM SELF TAPPING COARSE PITCH PK/5EA","SUP-ITM-10075867","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.27","103.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.47","36.5","","148.37","54.89","631.39","94","42.86","109.92","percent of total billed charges",""
"SCREW BONE 2X8MM MANDIBLE CORTEX TITANIUM SELF TAPPING COARSE PITCH PK/5EA","SUP-ITM-10075867","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.27","103.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.96","38.3","","279.30","91.72","1116.77","266","42.86","109.92","percent of total billed charges",""
"SCREW BONE 2X8MM MANDIBLE CORTEX TITANIUM SELF TAPPING COARSE PITCH PK/5EA","SUP-ITM-10075867","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.27","103.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.32","42.9","","731.00","63.70","731.00","1 through 10","42.86","109.92","percent of total billed charges",""
"SCREW BONE 2X8MM MANDIBLE CORTEX TITANIUM SELF TAPPING COARSE PITCH PK/5EA","SUP-ITM-10075867","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.27","103.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.32","42.9","","384.74","384.74","384.74","1 through 10","42.86","109.92","percent of total billed charges",""
"SCREW BONE 2X8MM MANDIBLE CORTEX TITANIUM SELF TAPPING COARSE PITCH PK/5EA","SUP-ITM-10075867","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.27","103.70","WELLPOINT [1015]","HB AMC WELLPOINT","102.02","73.78","","286.63","119.22","1107.45","105","42.86","109.92","percent of total billed charges",""
"SCREW BONE 2X8MM MANDIBLE CORTEX TITANIUM SELF TAPPING COARSE PITCH PK/5EA","SUP-ITM-10075867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.27","103.70","AETNA [1001]","HB AMC AETNA HMO","96.51","69.8","","675.31","184.75","1721.50","286","72.26","112.99","percent of total billed charges",""
"SCREW BONE 2X8MM MANDIBLE CORTEX TITANIUM SELF TAPPING COARSE PITCH PK/5EA","SUP-ITM-10075867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.27","103.70","AETNA [1001]","HB AMC AETNA PPO","111.17","80.4","","1261.44","103.12","1514.10","21","72.26","112.99","percent of total billed charges",""
"SCREW BONE 2X8MM MANDIBLE CORTEX TITANIUM SELF TAPPING COARSE PITCH PK/5EA","SUP-ITM-10075867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.27","103.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.17","80.4","","1365.00","1365.00","1365.00","1 through 10","72.26","112.99","percent of total billed charges",""
"SCREW BONE 2X8MM MANDIBLE CORTEX TITANIUM SELF TAPPING COARSE PITCH PK/5EA","SUP-ITM-10075867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.27","103.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","112.99","81.72","","5157.68","5157.68","5157.68","1 through 10","72.26","112.99","percent of total billed charges",""
"SCREW BONE 2X8MM MANDIBLE CORTEX TITANIUM SELF TAPPING COARSE PITCH PK/5EA","SUP-ITM-10075867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.27","103.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","112.99","81.72","","431.26","71.26","1459.57","88","72.26","112.99","percent of total billed charges",""
"SCREW BONE 3.030MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198156","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","779.10","79.5","","800.18","480.96","1887.97","195","303.8","779.1","percent of total billed charges",""
"SCREW BONE 3.030MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198156","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","522.34","53.3","","813.12","216.42","1444.50","81","303.8","779.1","percent of total billed charges",""
"SCREW BONE 3.030MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198156","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","303.80","31","","432.60","432.60","432.60","1 through 10","303.8","779.1","percent of total billed charges",""
"SCREW BONE 3.030MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198156","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","357.70","36.5","","148.37","54.89","631.39","94","303.8","779.1","percent of total billed charges",""
"SCREW BONE 3.030MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198156","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","375.34","38.3","","279.30","91.72","1116.77","266","303.8","779.1","percent of total billed charges",""
"SCREW BONE 3.030MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198156","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.42","42.9","","731.00","63.70","731.00","1 through 10","303.8","779.1","percent of total billed charges",""
"SCREW BONE 3.030MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198156","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.42","42.9","","384.74","384.74","384.74","1 through 10","303.8","779.1","percent of total billed charges",""
"SCREW BONE 3.030MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198156","CDM","C1713","HCPCS","0278","RC","","","","both","","","980.00","735.00","WELLPOINT [1015]","HB AMC WELLPOINT","723.04","73.78","","286.63","119.22","1107.45","105","303.8","779.1","percent of total billed charges",""
"SCREW BONE 3.030MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","AETNA [1001]","HB AMC AETNA HMO","684.04","69.8","","675.31","184.75","1721.50","286","512.15","800.86","percent of total billed charges",""
"SCREW BONE 3.030MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","AETNA [1001]","HB AMC AETNA PPO","787.92","80.4","","1261.44","103.12","1514.10","21","512.15","800.86","percent of total billed charges",""
"SCREW BONE 3.030MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","787.92","80.4","","1365.00","1365.00","1365.00","1 through 10","512.15","800.86","percent of total billed charges",""
"SCREW BONE 3.030MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","800.86","81.72","","5157.68","5157.68","5157.68","1 through 10","512.15","800.86","percent of total billed charges",""
"SCREW BONE 3.030MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","980.00","735.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","800.86","81.72","","431.26","71.26","1459.57","88","512.15","800.86","percent of total billed charges",""
"SCREW BONE 3.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057148","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.50","412.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","436.85","79.5","","800.18","480.96","1887.97","195","170.35","436.85","percent of total billed charges",""
"SCREW BONE 3.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057148","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.50","412.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","292.88","53.3","","813.12","216.42","1444.50","81","170.35","436.85","percent of total billed charges",""
"SCREW BONE 3.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057148","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.50","412.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","170.35","31","","432.60","432.60","432.60","1 through 10","170.35","436.85","percent of total billed charges",""
"SCREW BONE 3.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057148","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.50","412.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","200.57","36.5","","148.37","54.89","631.39","94","170.35","436.85","percent of total billed charges",""
"SCREW BONE 3.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057148","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.50","412.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","210.46","38.3","","279.30","91.72","1116.77","266","170.35","436.85","percent of total billed charges",""
"SCREW BONE 3.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057148","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.50","412.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","235.74","42.9","","731.00","63.70","731.00","1 through 10","170.35","436.85","percent of total billed charges",""
"SCREW BONE 3.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057148","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.50","412.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","235.74","42.9","","384.74","384.74","384.74","1 through 10","170.35","436.85","percent of total billed charges",""
"SCREW BONE 3.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057148","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.50","412.12","WELLPOINT [1015]","HB AMC WELLPOINT","405.42","73.78","","286.63","119.22","1107.45","105","170.35","436.85","percent of total billed charges",""
"SCREW BONE 3.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.50","412.12","AETNA [1001]","HB AMC AETNA HMO","383.55","69.8","","675.31","184.75","1721.50","286","287.17","449.05","percent of total billed charges",""
"SCREW BONE 3.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.50","412.12","AETNA [1001]","HB AMC AETNA PPO","441.80","80.4","","1261.44","103.12","1514.10","21","287.17","449.05","percent of total billed charges",""
"SCREW BONE 3.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.50","412.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","441.80","80.4","","1365.00","1365.00","1365.00","1 through 10","287.17","449.05","percent of total billed charges",""
"SCREW BONE 3.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.50","412.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","449.05","81.72","","5157.68","5157.68","5157.68","1 through 10","287.17","449.05","percent of total billed charges",""
"SCREW BONE 3.0X10MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.50","412.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","449.05","81.72","","431.26","71.26","1459.57","88","287.17","449.05","percent of total billed charges",""
"SCREW BONE 3.0X28MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017400","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","520.33","79.5","","800.18","480.96","1887.97","195","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.0X28MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017400","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","348.85","53.3","","813.12","216.42","1444.50","81","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.0X28MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017400","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","202.90","31","","432.60","432.60","432.60","1 through 10","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.0X28MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017400","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","238.89","36.5","","148.37","54.89","631.39","94","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.0X28MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017400","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","250.67","38.3","","279.30","91.72","1116.77","266","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.0X28MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017400","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.78","42.9","","731.00","63.70","731.00","1 through 10","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.0X28MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017400","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.78","42.9","","384.74","384.74","384.74","1 through 10","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.0X28MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017400","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","WELLPOINT [1015]","HB AMC WELLPOINT","482.89","73.78","","286.63","119.22","1107.45","105","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.0X28MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","AETNA [1001]","HB AMC AETNA HMO","456.84","69.8","","675.31","184.75","1721.50","286","342.04","534.86","percent of total billed charges",""
"SCREW BONE 3.0X28MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","AETNA [1001]","HB AMC AETNA PPO","526.22","80.4","","1261.44","103.12","1514.10","21","342.04","534.86","percent of total billed charges",""
"SCREW BONE 3.0X28MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","526.22","80.4","","1365.00","1365.00","1365.00","1 through 10","342.04","534.86","percent of total billed charges",""
"SCREW BONE 3.0X28MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","534.86","81.72","","5157.68","5157.68","5157.68","1 through 10","342.04","534.86","percent of total billed charges",""
"SCREW BONE 3.0X28MM COMPRESSION CHARLOTTE SS CANNULATED SELF DRILLING TAPPING HEADLESS SHORT","SUP-ITM-10017400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","534.86","81.72","","431.26","71.26","1459.57","88","342.04","534.86","percent of total billed charges",""
"SCREW BONE 3.2X3.5X33MM HEADED SS CORTICAL HEX HEAD","SUP-ITM-10106883","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.60","308.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","327.22","79.5","","800.18","480.96","1887.97","195","127.6","327.22","percent of total billed charges",""
"SCREW BONE 3.2X3.5X33MM HEADED SS CORTICAL HEX HEAD","SUP-ITM-10106883","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.60","308.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","219.38","53.3","","813.12","216.42","1444.50","81","127.6","327.22","percent of total billed charges",""
"SCREW BONE 3.2X3.5X33MM HEADED SS CORTICAL HEX HEAD","SUP-ITM-10106883","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.60","308.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","127.60","31","","432.60","432.60","432.60","1 through 10","127.6","327.22","percent of total billed charges",""
"SCREW BONE 3.2X3.5X33MM HEADED SS CORTICAL HEX HEAD","SUP-ITM-10106883","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.60","308.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","150.23","36.5","","148.37","54.89","631.39","94","127.6","327.22","percent of total billed charges",""
"SCREW BONE 3.2X3.5X33MM HEADED SS CORTICAL HEX HEAD","SUP-ITM-10106883","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.60","308.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.64","38.3","","279.30","91.72","1116.77","266","127.6","327.22","percent of total billed charges",""
"SCREW BONE 3.2X3.5X33MM HEADED SS CORTICAL HEX HEAD","SUP-ITM-10106883","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.60","308.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.58","42.9","","731.00","63.70","731.00","1 through 10","127.6","327.22","percent of total billed charges",""
"SCREW BONE 3.2X3.5X33MM HEADED SS CORTICAL HEX HEAD","SUP-ITM-10106883","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.60","308.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.58","42.9","","384.74","384.74","384.74","1 through 10","127.6","327.22","percent of total billed charges",""
"SCREW BONE 3.2X3.5X33MM HEADED SS CORTICAL HEX HEAD","SUP-ITM-10106883","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.60","308.70","WELLPOINT [1015]","HB AMC WELLPOINT","303.68","73.78","","286.63","119.22","1107.45","105","127.6","327.22","percent of total billed charges",""
"SCREW BONE 3.2X3.5X33MM HEADED SS CORTICAL HEX HEAD","SUP-ITM-10106883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.60","308.70","AETNA [1001]","HB AMC AETNA HMO","287.30","69.8","","675.31","184.75","1721.50","286","215.1","336.36","percent of total billed charges",""
"SCREW BONE 3.2X3.5X33MM HEADED SS CORTICAL HEX HEAD","SUP-ITM-10106883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.60","308.70","AETNA [1001]","HB AMC AETNA PPO","330.93","80.4","","1261.44","103.12","1514.10","21","215.1","336.36","percent of total billed charges",""
"SCREW BONE 3.2X3.5X33MM HEADED SS CORTICAL HEX HEAD","SUP-ITM-10106883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.60","308.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","330.93","80.4","","1365.00","1365.00","1365.00","1 through 10","215.1","336.36","percent of total billed charges",""
"SCREW BONE 3.2X3.5X33MM HEADED SS CORTICAL HEX HEAD","SUP-ITM-10106883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.60","308.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","336.36","81.72","","5157.68","5157.68","5157.68","1 through 10","215.1","336.36","percent of total billed charges",""
"SCREW BONE 3.2X3.5X33MM HEADED SS CORTICAL HEX HEAD","SUP-ITM-10106883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.60","308.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","336.36","81.72","","431.26","71.26","1459.57","88","215.1","336.36","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.44","405.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","429.65","79.5","","800.18","480.96","1887.97","195","167.54","429.65","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.44","405.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","288.05","53.3","","813.12","216.42","1444.50","81","167.54","429.65","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.44","405.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","167.54","31","","432.60","432.60","432.60","1 through 10","167.54","429.65","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.44","405.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","197.26","36.5","","148.37","54.89","631.39","94","167.54","429.65","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.44","405.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","206.99","38.3","","279.30","91.72","1116.77","266","167.54","429.65","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.44","405.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.85","42.9","","731.00","63.70","731.00","1 through 10","167.54","429.65","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.44","405.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.85","42.9","","384.74","384.74","384.74","1 through 10","167.54","429.65","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.44","405.33","WELLPOINT [1015]","HB AMC WELLPOINT","398.74","73.78","","286.63","119.22","1107.45","105","167.54","429.65","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.44","405.33","AETNA [1001]","HB AMC AETNA HMO","377.23","69.8","","675.31","184.75","1721.50","286","282.43","441.65","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.44","405.33","AETNA [1001]","HB AMC AETNA PPO","434.51","80.4","","1261.44","103.12","1514.10","21","282.43","441.65","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.44","405.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","434.51","80.4","","1365.00","1365.00","1365.00","1 through 10","282.43","441.65","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.44","405.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","441.65","81.72","","5157.68","5157.68","5157.68","1 through 10","282.43","441.65","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.44","405.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","441.65","81.72","","431.26","71.26","1459.57","88","282.43","441.65","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS LOCKING T15 HEXALOBE","SUP-ITM-10136879","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","631.63","79.5","","800.18","480.96","1887.97","195","246.3","631.63","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS LOCKING T15 HEXALOBE","SUP-ITM-10136879","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","423.47","53.3","","813.12","216.42","1444.50","81","246.3","631.63","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS LOCKING T15 HEXALOBE","SUP-ITM-10136879","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","246.30","31","","432.60","432.60","432.60","1 through 10","246.3","631.63","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS LOCKING T15 HEXALOBE","SUP-ITM-10136879","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","289.99","36.5","","148.37","54.89","631.39","94","246.3","631.63","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS LOCKING T15 HEXALOBE","SUP-ITM-10136879","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","304.29","38.3","","279.30","91.72","1116.77","266","246.3","631.63","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS LOCKING T15 HEXALOBE","SUP-ITM-10136879","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.84","42.9","","731.00","63.70","731.00","1 through 10","246.3","631.63","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS LOCKING T15 HEXALOBE","SUP-ITM-10136879","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.84","42.9","","384.74","384.74","384.74","1 through 10","246.3","631.63","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS LOCKING T15 HEXALOBE","SUP-ITM-10136879","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","WELLPOINT [1015]","HB AMC WELLPOINT","586.18","73.78","","286.63","119.22","1107.45","105","246.3","631.63","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS LOCKING T15 HEXALOBE","SUP-ITM-10136879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.50","595.87","AETNA [1001]","HB AMC AETNA HMO","554.56","69.8","","675.31","184.75","1721.50","286","415.21","649.27","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS LOCKING T15 HEXALOBE","SUP-ITM-10136879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.50","595.87","AETNA [1001]","HB AMC AETNA PPO","638.78","80.4","","1261.44","103.12","1514.10","21","415.21","649.27","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS LOCKING T15 HEXALOBE","SUP-ITM-10136879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.50","595.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","638.78","80.4","","1365.00","1365.00","1365.00","1 through 10","415.21","649.27","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS LOCKING T15 HEXALOBE","SUP-ITM-10136879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.50","595.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","649.27","81.72","","5157.68","5157.68","5157.68","1 through 10","415.21","649.27","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS LOCKING T15 HEXALOBE","SUP-ITM-10136879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.50","595.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","649.27","81.72","","431.26","71.26","1459.57","88","415.21","649.27","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS SELF TAPPING T15 HEXALOBE","SUP-ITM-10136868","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","169.73","79.5","","800.18","480.96","1887.97","195","66.19","169.73","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS SELF TAPPING T15 HEXALOBE","SUP-ITM-10136868","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","113.80","53.3","","813.12","216.42","1444.50","81","66.19","169.73","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS SELF TAPPING T15 HEXALOBE","SUP-ITM-10136868","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","66.19","31","","432.60","432.60","432.60","1 through 10","66.19","169.73","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS SELF TAPPING T15 HEXALOBE","SUP-ITM-10136868","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.93","36.5","","148.37","54.89","631.39","94","66.19","169.73","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS SELF TAPPING T15 HEXALOBE","SUP-ITM-10136868","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.77","38.3","","279.30","91.72","1116.77","266","66.19","169.73","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS SELF TAPPING T15 HEXALOBE","SUP-ITM-10136868","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.59","42.9","","731.00","63.70","731.00","1 through 10","66.19","169.73","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS SELF TAPPING T15 HEXALOBE","SUP-ITM-10136868","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.59","42.9","","384.74","384.74","384.74","1 through 10","66.19","169.73","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS SELF TAPPING T15 HEXALOBE","SUP-ITM-10136868","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.50","160.12","WELLPOINT [1015]","HB AMC WELLPOINT","157.52","73.78","","286.63","119.22","1107.45","105","66.19","169.73","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS SELF TAPPING T15 HEXALOBE","SUP-ITM-10136868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.50","160.12","AETNA [1001]","HB AMC AETNA HMO","149.02","69.8","","675.31","184.75","1721.50","286","111.58","174.47","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS SELF TAPPING T15 HEXALOBE","SUP-ITM-10136868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.50","160.12","AETNA [1001]","HB AMC AETNA PPO","171.65","80.4","","1261.44","103.12","1514.10","21","111.58","174.47","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS SELF TAPPING T15 HEXALOBE","SUP-ITM-10136868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.50","160.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","171.65","80.4","","1365.00","1365.00","1365.00","1 through 10","111.58","174.47","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS SELF TAPPING T15 HEXALOBE","SUP-ITM-10136868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.50","160.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","174.47","81.72","","5157.68","5157.68","5157.68","1 through 10","111.58","174.47","percent of total billed charges",""
"SCREW BONE 3.5MMX20MM CORTICAL PEDILOC SS SELF TAPPING T15 HEXALOBE","SUP-ITM-10136868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.50","160.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.47","81.72","","431.26","71.26","1459.57","88","111.58","174.47","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","333.01","79.5","","800.18","480.96","1887.97","195","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","223.26","53.3","","813.12","216.42","1444.50","81","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","129.85","31","","432.60","432.60","432.60","1 through 10","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","152.89","36.5","","148.37","54.89","631.39","94","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","160.43","38.3","","279.30","91.72","1116.77","266","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","179.70","42.9","","731.00","63.70","731.00","1 through 10","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","179.70","42.9","","384.74","384.74","384.74","1 through 10","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","WELLPOINT [1015]","HB AMC WELLPOINT","309.05","73.78","","286.63","119.22","1107.45","105","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","418.88","314.16","AETNA [1001]","HB AMC AETNA HMO","292.38","69.8","","675.31","184.75","1721.50","286","218.91","342.31","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","418.88","314.16","AETNA [1001]","HB AMC AETNA PPO","336.78","80.4","","1261.44","103.12","1514.10","21","218.91","342.31","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","418.88","314.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","336.78","80.4","","1365.00","1365.00","1365.00","1 through 10","218.91","342.31","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","418.88","314.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","342.31","81.72","","5157.68","5157.68","5157.68","1 through 10","218.91","342.31","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","418.88","314.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","342.31","81.72","","431.26","71.26","1459.57","88","218.91","342.31","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","65.89","79.5","","800.18","480.96","1887.97","195","25.69","65.89","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","44.18","53.3","","813.12","216.42","1444.50","81","25.69","65.89","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","25.69","31","","432.60","432.60","432.60","1 through 10","25.69","65.89","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30.25","36.5","","148.37","54.89","631.39","94","25.69","65.89","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31.74","38.3","","279.30","91.72","1116.77","266","25.69","65.89","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.56","42.9","","731.00","63.70","731.00","1 through 10","25.69","65.89","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.56","42.9","","384.74","384.74","384.74","1 through 10","25.69","65.89","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.88","62.16","WELLPOINT [1015]","HB AMC WELLPOINT","61.15","73.78","","286.63","119.22","1107.45","105","25.69","65.89","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.88","62.16","AETNA [1001]","HB AMC AETNA HMO","57.85","69.8","","675.31","184.75","1721.50","286","43.31","67.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.88","62.16","AETNA [1001]","HB AMC AETNA PPO","66.64","80.4","","1261.44","103.12","1514.10","21","43.31","67.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.88","62.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","66.64","80.4","","1365.00","1365.00","1365.00","1 through 10","43.31","67.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.88","62.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","67.73","81.72","","5157.68","5157.68","5157.68","1 through 10","43.31","67.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.88","62.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","67.73","81.72","","431.26","71.26","1459.57","88","43.31","67.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","404.32","303.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","321.43","79.5","","800.18","480.96","1887.97","195","125.34","321.43","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","404.32","303.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","215.50","53.3","","813.12","216.42","1444.50","81","125.34","321.43","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","404.32","303.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","125.34","31","","432.60","432.60","432.60","1 through 10","125.34","321.43","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","404.32","303.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","147.58","36.5","","148.37","54.89","631.39","94","125.34","321.43","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","404.32","303.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","154.85","38.3","","279.30","91.72","1116.77","266","125.34","321.43","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","404.32","303.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.45","42.9","","731.00","63.70","731.00","1 through 10","125.34","321.43","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","404.32","303.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.45","42.9","","384.74","384.74","384.74","1 through 10","125.34","321.43","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","404.32","303.24","WELLPOINT [1015]","HB AMC WELLPOINT","298.31","73.78","","286.63","119.22","1107.45","105","125.34","321.43","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","404.32","303.24","AETNA [1001]","HB AMC AETNA HMO","282.22","69.8","","675.31","184.75","1721.50","286","211.3","330.41","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","404.32","303.24","AETNA [1001]","HB AMC AETNA PPO","325.07","80.4","","1261.44","103.12","1514.10","21","211.3","330.41","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","404.32","303.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","325.07","80.4","","1365.00","1365.00","1365.00","1 through 10","211.3","330.41","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","404.32","303.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","330.41","81.72","","5157.68","5157.68","5157.68","1 through 10","211.3","330.41","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","404.32","303.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","330.41","81.72","","431.26","71.26","1459.57","88","211.3","330.41","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","74.52","79.5","","800.18","480.96","1887.97","195","29.06","74.52","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","49.96","53.3","","813.12","216.42","1444.50","81","29.06","74.52","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","29.06","31","","432.60","432.60","432.60","1 through 10","29.06","74.52","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34.21","36.5","","148.37","54.89","631.39","94","29.06","74.52","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35.90","38.3","","279.30","91.72","1116.77","266","29.06","74.52","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.21","42.9","","731.00","63.70","731.00","1 through 10","29.06","74.52","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.21","42.9","","384.74","384.74","384.74","1 through 10","29.06","74.52","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","WELLPOINT [1015]","HB AMC WELLPOINT","69.15","73.78","","286.63","119.22","1107.45","105","29.06","74.52","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","AETNA [1001]","HB AMC AETNA HMO","65.42","69.8","","675.31","184.75","1721.50","286","48.98","76.6","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","AETNA [1001]","HB AMC AETNA PPO","75.36","80.4","","1261.44","103.12","1514.10","21","48.98","76.6","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","75.36","80.4","","1365.00","1365.00","1365.00","1 through 10","48.98","76.6","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","76.60","81.72","","5157.68","5157.68","5157.68","1 through 10","48.98","76.6","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","76.60","81.72","","431.26","71.26","1459.57","88","48.98","76.6","percent of total billed charges",""
"SCREW BONE 3.5X10MM EPS EVOLVE CORTICAL NONLOCKING","SUP-ITM-10047678","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","183.65","79.5","","800.18","480.96","1887.97","195","71.61","183.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM EPS EVOLVE CORTICAL NONLOCKING","SUP-ITM-10047678","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","123.12","53.3","","813.12","216.42","1444.50","81","71.61","183.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM EPS EVOLVE CORTICAL NONLOCKING","SUP-ITM-10047678","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","71.61","31","","432.60","432.60","432.60","1 through 10","71.61","183.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM EPS EVOLVE CORTICAL NONLOCKING","SUP-ITM-10047678","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","84.32","36.5","","148.37","54.89","631.39","94","71.61","183.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM EPS EVOLVE CORTICAL NONLOCKING","SUP-ITM-10047678","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","88.47","38.3","","279.30","91.72","1116.77","266","71.61","183.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM EPS EVOLVE CORTICAL NONLOCKING","SUP-ITM-10047678","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.10","42.9","","731.00","63.70","731.00","1 through 10","71.61","183.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM EPS EVOLVE CORTICAL NONLOCKING","SUP-ITM-10047678","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.10","42.9","","384.74","384.74","384.74","1 through 10","71.61","183.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM EPS EVOLVE CORTICAL NONLOCKING","SUP-ITM-10047678","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","WELLPOINT [1015]","HB AMC WELLPOINT","170.43","73.78","","286.63","119.22","1107.45","105","71.61","183.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM EPS EVOLVE CORTICAL NONLOCKING","SUP-ITM-10047678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.00","173.25","AETNA [1001]","HB AMC AETNA HMO","161.24","69.8","","675.31","184.75","1721.50","286","120.72","188.77","percent of total billed charges",""
"SCREW BONE 3.5X10MM EPS EVOLVE CORTICAL NONLOCKING","SUP-ITM-10047678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.00","173.25","AETNA [1001]","HB AMC AETNA PPO","185.72","80.4","","1261.44","103.12","1514.10","21","120.72","188.77","percent of total billed charges",""
"SCREW BONE 3.5X10MM EPS EVOLVE CORTICAL NONLOCKING","SUP-ITM-10047678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.00","173.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","185.72","80.4","","1365.00","1365.00","1365.00","1 through 10","120.72","188.77","percent of total billed charges",""
"SCREW BONE 3.5X10MM EPS EVOLVE CORTICAL NONLOCKING","SUP-ITM-10047678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","188.77","81.72","","5157.68","5157.68","5157.68","1 through 10","120.72","188.77","percent of total billed charges",""
"SCREW BONE 3.5X10MM EPS EVOLVE CORTICAL NONLOCKING","SUP-ITM-10047678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","188.77","81.72","","431.26","71.26","1459.57","88","120.72","188.77","percent of total billed charges",""
"SCREW BONE 3.5X12MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057165","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.50","427.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","453.55","79.5","","800.18","480.96","1887.97","195","176.86","453.55","percent of total billed charges",""
"SCREW BONE 3.5X12MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057165","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.50","427.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","304.08","53.3","","813.12","216.42","1444.50","81","176.86","453.55","percent of total billed charges",""
"SCREW BONE 3.5X12MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057165","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.50","427.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","176.86","31","","432.60","432.60","432.60","1 through 10","176.86","453.55","percent of total billed charges",""
"SCREW BONE 3.5X12MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057165","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.50","427.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","208.23","36.5","","148.37","54.89","631.39","94","176.86","453.55","percent of total billed charges",""
"SCREW BONE 3.5X12MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057165","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.50","427.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","218.50","38.3","","279.30","91.72","1116.77","266","176.86","453.55","percent of total billed charges",""
"SCREW BONE 3.5X12MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057165","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.50","427.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.74","42.9","","731.00","63.70","731.00","1 through 10","176.86","453.55","percent of total billed charges",""
"SCREW BONE 3.5X12MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057165","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.50","427.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.74","42.9","","384.74","384.74","384.74","1 through 10","176.86","453.55","percent of total billed charges",""
"SCREW BONE 3.5X12MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057165","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.50","427.87","WELLPOINT [1015]","HB AMC WELLPOINT","420.91","73.78","","286.63","119.22","1107.45","105","176.86","453.55","percent of total billed charges",""
"SCREW BONE 3.5X12MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.50","427.87","AETNA [1001]","HB AMC AETNA HMO","398.21","69.8","","675.31","184.75","1721.50","286","298.14","466.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.50","427.87","AETNA [1001]","HB AMC AETNA PPO","458.68","80.4","","1261.44","103.12","1514.10","21","298.14","466.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.50","427.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","458.68","80.4","","1365.00","1365.00","1365.00","1 through 10","298.14","466.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.50","427.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","466.21","81.72","","5157.68","5157.68","5157.68","1 through 10","298.14","466.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GREEN","SUP-ITM-10057165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.50","427.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","466.21","81.72","","431.26","71.26","1459.57","88","298.14","466.21","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.24","45.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","47.89","79.5","","800.18","480.96","1887.97","195","18.67","47.89","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.24","45.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","32.11","53.3","","813.12","216.42","1444.50","81","18.67","47.89","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.24","45.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","18.67","31","","432.60","432.60","432.60","1 through 10","18.67","47.89","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.24","45.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21.99","36.5","","148.37","54.89","631.39","94","18.67","47.89","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.24","45.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23.07","38.3","","279.30","91.72","1116.77","266","18.67","47.89","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.24","45.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.84","42.9","","731.00","63.70","731.00","1 through 10","18.67","47.89","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.24","45.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.84","42.9","","384.74","384.74","384.74","1 through 10","18.67","47.89","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.24","45.18","WELLPOINT [1015]","HB AMC WELLPOINT","44.45","73.78","","286.63","119.22","1107.45","105","18.67","47.89","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.24","45.18","AETNA [1001]","HB AMC AETNA HMO","42.05","69.8","","675.31","184.75","1721.50","286","31.48","49.23","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.24","45.18","AETNA [1001]","HB AMC AETNA PPO","48.43","80.4","","1261.44","103.12","1514.10","21","31.48","49.23","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.24","45.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","48.43","80.4","","1365.00","1365.00","1365.00","1 through 10","31.48","49.23","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.24","45.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","49.23","81.72","","5157.68","5157.68","5157.68","1 through 10","31.48","49.23","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.24","45.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","49.23","81.72","","431.26","71.26","1459.57","88","31.48","49.23","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.18","63.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","66.92","79.5","","800.18","480.96","1887.97","195","26.1","66.92","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.18","63.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","44.87","53.3","","813.12","216.42","1444.50","81","26.1","66.92","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.18","63.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.10","31","","432.60","432.60","432.60","1 through 10","26.1","66.92","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.18","63.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30.73","36.5","","148.37","54.89","631.39","94","26.1","66.92","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.18","63.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.24","38.3","","279.30","91.72","1116.77","266","26.1","66.92","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.18","63.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.11","42.9","","731.00","63.70","731.00","1 through 10","26.1","66.92","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.18","63.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.11","42.9","","384.74","384.74","384.74","1 through 10","26.1","66.92","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.18","63.13","WELLPOINT [1015]","HB AMC WELLPOINT","62.11","73.78","","286.63","119.22","1107.45","105","26.1","66.92","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.18","63.13","AETNA [1001]","HB AMC AETNA HMO","58.76","69.8","","675.31","184.75","1721.50","286","43.99","68.79","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.18","63.13","AETNA [1001]","HB AMC AETNA PPO","67.68","80.4","","1261.44","103.12","1514.10","21","43.99","68.79","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.18","63.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","67.68","80.4","","1365.00","1365.00","1365.00","1 through 10","43.99","68.79","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.18","63.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","68.79","81.72","","5157.68","5157.68","5157.68","1 through 10","43.99","68.79","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.18","63.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","68.79","81.72","","431.26","71.26","1459.57","88","43.99","68.79","percent of total billed charges",""
"SCREW BONE 3.5X12MM LOCKING","SUP-ITM-10100221","CDM","C1713","HCPCS","0278","RC","","","","both","","","479.50","359.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","381.20","79.5","","800.18","480.96","1887.97","195","148.65","381.2","percent of total billed charges",""
"SCREW BONE 3.5X12MM LOCKING","SUP-ITM-10100221","CDM","C1713","HCPCS","0278","RC","","","","both","","","479.50","359.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","255.57","53.3","","813.12","216.42","1444.50","81","148.65","381.2","percent of total billed charges",""
"SCREW BONE 3.5X12MM LOCKING","SUP-ITM-10100221","CDM","C1713","HCPCS","0278","RC","","","","both","","","479.50","359.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","148.65","31","","432.60","432.60","432.60","1 through 10","148.65","381.2","percent of total billed charges",""
"SCREW BONE 3.5X12MM LOCKING","SUP-ITM-10100221","CDM","C1713","HCPCS","0278","RC","","","","both","","","479.50","359.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","175.02","36.5","","148.37","54.89","631.39","94","148.65","381.2","percent of total billed charges",""
"SCREW BONE 3.5X12MM LOCKING","SUP-ITM-10100221","CDM","C1713","HCPCS","0278","RC","","","","both","","","479.50","359.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","183.65","38.3","","279.30","91.72","1116.77","266","148.65","381.2","percent of total billed charges",""
"SCREW BONE 3.5X12MM LOCKING","SUP-ITM-10100221","CDM","C1713","HCPCS","0278","RC","","","","both","","","479.50","359.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.71","42.9","","731.00","63.70","731.00","1 through 10","148.65","381.2","percent of total billed charges",""
"SCREW BONE 3.5X12MM LOCKING","SUP-ITM-10100221","CDM","C1713","HCPCS","0278","RC","","","","both","","","479.50","359.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.71","42.9","","384.74","384.74","384.74","1 through 10","148.65","381.2","percent of total billed charges",""
"SCREW BONE 3.5X12MM LOCKING","SUP-ITM-10100221","CDM","C1713","HCPCS","0278","RC","","","","both","","","479.50","359.62","WELLPOINT [1015]","HB AMC WELLPOINT","353.78","73.78","","286.63","119.22","1107.45","105","148.65","381.2","percent of total billed charges",""
"SCREW BONE 3.5X12MM LOCKING","SUP-ITM-10100221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","479.50","359.62","AETNA [1001]","HB AMC AETNA HMO","334.69","69.8","","675.31","184.75","1721.50","286","250.59","391.85","percent of total billed charges",""
"SCREW BONE 3.5X12MM LOCKING","SUP-ITM-10100221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","479.50","359.62","AETNA [1001]","HB AMC AETNA PPO","385.52","80.4","","1261.44","103.12","1514.10","21","250.59","391.85","percent of total billed charges",""
"SCREW BONE 3.5X12MM LOCKING","SUP-ITM-10100221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","479.50","359.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","385.52","80.4","","1365.00","1365.00","1365.00","1 through 10","250.59","391.85","percent of total billed charges",""
"SCREW BONE 3.5X12MM LOCKING","SUP-ITM-10100221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","479.50","359.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","391.85","81.72","","5157.68","5157.68","5157.68","1 through 10","250.59","391.85","percent of total billed charges",""
"SCREW BONE 3.5X12MM LOCKING","SUP-ITM-10100221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","479.50","359.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","391.85","81.72","","431.26","71.26","1459.57","88","250.59","391.85","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.75","216.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","229.56","79.5","","800.18","480.96","1887.97","195","89.51","229.56","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.75","216.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","153.90","53.3","","813.12","216.42","1444.50","81","89.51","229.56","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.75","216.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","89.51","31","","432.60","432.60","432.60","1 through 10","89.51","229.56","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.75","216.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.39","36.5","","148.37","54.89","631.39","94","89.51","229.56","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.75","216.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","110.59","38.3","","279.30","91.72","1116.77","266","89.51","229.56","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.75","216.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","123.87","42.9","","731.00","63.70","731.00","1 through 10","89.51","229.56","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.75","216.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","123.87","42.9","","384.74","384.74","384.74","1 through 10","89.51","229.56","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.75","216.56","WELLPOINT [1015]","HB AMC WELLPOINT","213.04","73.78","","286.63","119.22","1107.45","105","89.51","229.56","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","288.75","216.56","AETNA [1001]","HB AMC AETNA HMO","201.55","69.8","","675.31","184.75","1721.50","286","150.9","235.97","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","288.75","216.56","AETNA [1001]","HB AMC AETNA PPO","232.16","80.4","","1261.44","103.12","1514.10","21","150.9","235.97","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","288.75","216.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","232.16","80.4","","1365.00","1365.00","1365.00","1 through 10","150.9","235.97","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","288.75","216.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","235.97","81.72","","5157.68","5157.68","5157.68","1 through 10","150.9","235.97","percent of total billed charges",""
"SCREW BONE 3.5X13MM SPINE CERVICAL DIVERGENCE SELF DRILLING ANTERIOR PK/2EA","SUP-ITM-10239394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","288.75","216.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","235.97","81.72","","431.26","71.26","1459.57","88","150.9","235.97","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","191.99","79.5","","800.18","480.96","1887.97","195","74.87","191.99","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","128.72","53.3","","813.12","216.42","1444.50","81","74.87","191.99","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","74.87","31","","432.60","432.60","432.60","1 through 10","74.87","191.99","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","88.15","36.5","","148.37","54.89","631.39","94","74.87","191.99","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","92.49","38.3","","279.30","91.72","1116.77","266","74.87","191.99","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","103.60","42.9","","731.00","63.70","731.00","1 through 10","74.87","191.99","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","103.60","42.9","","384.74","384.74","384.74","1 through 10","74.87","191.99","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.50","181.12","WELLPOINT [1015]","HB AMC WELLPOINT","178.18","73.78","","286.63","119.22","1107.45","105","74.87","191.99","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.50","181.12","AETNA [1001]","HB AMC AETNA HMO","168.57","69.8","","675.31","184.75","1721.50","286","126.21","197.35","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.50","181.12","AETNA [1001]","HB AMC AETNA PPO","194.17","80.4","","1261.44","103.12","1514.10","21","126.21","197.35","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.50","181.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","194.17","80.4","","1365.00","1365.00","1365.00","1 through 10","126.21","197.35","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.50","181.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","197.35","81.72","","5157.68","5157.68","5157.68","1 through 10","126.21","197.35","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.50","181.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","197.35","81.72","","431.26","71.26","1459.57","88","126.21","197.35","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","246.06","79.5","","800.18","480.96","1887.97","195","95.95","246.06","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","164.97","53.3","","813.12","216.42","1444.50","81","95.95","246.06","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","95.95","31","","432.60","432.60","432.60","1 through 10","95.95","246.06","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","112.97","36.5","","148.37","54.89","631.39","94","95.95","246.06","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","118.54","38.3","","279.30","91.72","1116.77","266","95.95","246.06","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.78","42.9","","731.00","63.70","731.00","1 through 10","95.95","246.06","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.78","42.9","","384.74","384.74","384.74","1 through 10","95.95","246.06","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","WELLPOINT [1015]","HB AMC WELLPOINT","228.36","73.78","","286.63","119.22","1107.45","105","95.95","246.06","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","AETNA [1001]","HB AMC AETNA HMO","216.04","69.8","","675.31","184.75","1721.50","286","161.75","252.93","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","AETNA [1001]","HB AMC AETNA PPO","248.85","80.4","","1261.44","103.12","1514.10","21","161.75","252.93","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","248.85","80.4","","1365.00","1365.00","1365.00","1 through 10","161.75","252.93","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","252.93","81.72","","5157.68","5157.68","5157.68","1 through 10","161.75","252.93","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","252.93","81.72","","431.26","71.26","1459.57","88","161.75","252.93","percent of total billed charges",""
"SCREW BONE 3.5X16MM ANTHEM SS NONLOCKING","SUP-ITM-10278089","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","91.82","79.5","","800.18","480.96","1887.97","195","35.81","91.82","percent of total billed charges",""
"SCREW BONE 3.5X16MM ANTHEM SS NONLOCKING","SUP-ITM-10278089","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","61.56","53.3","","813.12","216.42","1444.50","81","35.81","91.82","percent of total billed charges",""
"SCREW BONE 3.5X16MM ANTHEM SS NONLOCKING","SUP-ITM-10278089","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","35.81","31","","432.60","432.60","432.60","1 through 10","35.81","91.82","percent of total billed charges",""
"SCREW BONE 3.5X16MM ANTHEM SS NONLOCKING","SUP-ITM-10278089","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","42.16","36.5","","148.37","54.89","631.39","94","35.81","91.82","percent of total billed charges",""
"SCREW BONE 3.5X16MM ANTHEM SS NONLOCKING","SUP-ITM-10278089","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44.24","38.3","","279.30","91.72","1116.77","266","35.81","91.82","percent of total billed charges",""
"SCREW BONE 3.5X16MM ANTHEM SS NONLOCKING","SUP-ITM-10278089","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.55","42.9","","731.00","63.70","731.00","1 through 10","35.81","91.82","percent of total billed charges",""
"SCREW BONE 3.5X16MM ANTHEM SS NONLOCKING","SUP-ITM-10278089","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.55","42.9","","384.74","384.74","384.74","1 through 10","35.81","91.82","percent of total billed charges",""
"SCREW BONE 3.5X16MM ANTHEM SS NONLOCKING","SUP-ITM-10278089","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.50","86.62","WELLPOINT [1015]","HB AMC WELLPOINT","85.22","73.78","","286.63","119.22","1107.45","105","35.81","91.82","percent of total billed charges",""
"SCREW BONE 3.5X16MM ANTHEM SS NONLOCKING","SUP-ITM-10278089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.50","86.62","AETNA [1001]","HB AMC AETNA HMO","80.62","69.8","","675.31","184.75","1721.50","286","60.36","94.39","percent of total billed charges",""
"SCREW BONE 3.5X16MM ANTHEM SS NONLOCKING","SUP-ITM-10278089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.50","86.62","AETNA [1001]","HB AMC AETNA PPO","92.86","80.4","","1261.44","103.12","1514.10","21","60.36","94.39","percent of total billed charges",""
"SCREW BONE 3.5X16MM ANTHEM SS NONLOCKING","SUP-ITM-10278089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.50","86.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","92.86","80.4","","1365.00","1365.00","1365.00","1 through 10","60.36","94.39","percent of total billed charges",""
"SCREW BONE 3.5X16MM ANTHEM SS NONLOCKING","SUP-ITM-10278089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.50","86.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","94.39","81.72","","5157.68","5157.68","5157.68","1 through 10","60.36","94.39","percent of total billed charges",""
"SCREW BONE 3.5X16MM ANTHEM SS NONLOCKING","SUP-ITM-10278089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.50","86.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","94.39","81.72","","431.26","71.26","1459.57","88","60.36","94.39","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","464.29","79.5","","800.18","480.96","1887.97","195","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","311.28","53.3","","813.12","216.42","1444.50","81","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","181.04","31","","432.60","432.60","432.60","1 through 10","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","213.16","36.5","","148.37","54.89","631.39","94","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","223.68","38.3","","279.30","91.72","1116.77","266","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.54","42.9","","731.00","63.70","731.00","1 through 10","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.54","42.9","","384.74","384.74","384.74","1 through 10","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","WELLPOINT [1015]","HB AMC WELLPOINT","430.88","73.78","","286.63","119.22","1107.45","105","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.01","438.01","AETNA [1001]","HB AMC AETNA HMO","407.64","69.8","","675.31","184.75","1721.50","286","305.2","477.25","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.01","438.01","AETNA [1001]","HB AMC AETNA PPO","469.54","80.4","","1261.44","103.12","1514.10","21","305.2","477.25","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.01","438.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","469.54","80.4","","1365.00","1365.00","1365.00","1 through 10","305.2","477.25","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.01","438.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","477.25","81.72","","5157.68","5157.68","5157.68","1 through 10","305.2","477.25","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.01","438.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","477.25","81.72","","431.26","71.26","1459.57","88","305.2","477.25","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.34","50.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","53.54","79.5","","800.18","480.96","1887.97","195","20.88","53.54","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.34","50.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","35.89","53.3","","813.12","216.42","1444.50","81","20.88","53.54","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.34","50.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","20.88","31","","432.60","432.60","432.60","1 through 10","20.88","53.54","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.34","50.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24.58","36.5","","148.37","54.89","631.39","94","20.88","53.54","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.34","50.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25.79","38.3","","279.30","91.72","1116.77","266","20.88","53.54","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.34","50.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.89","42.9","","731.00","63.70","731.00","1 through 10","20.88","53.54","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.34","50.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.89","42.9","","384.74","384.74","384.74","1 through 10","20.88","53.54","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","both","","","67.34","50.50","WELLPOINT [1015]","HB AMC WELLPOINT","49.68","73.78","","286.63","119.22","1107.45","105","20.88","53.54","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","67.34","50.50","AETNA [1001]","HB AMC AETNA HMO","47.00","69.8","","675.31","184.75","1721.50","286","35.19","55.03","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","67.34","50.50","AETNA [1001]","HB AMC AETNA PPO","54.14","80.4","","1261.44","103.12","1514.10","21","35.19","55.03","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","67.34","50.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","54.14","80.4","","1365.00","1365.00","1365.00","1 through 10","35.19","55.03","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","67.34","50.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","55.03","81.72","","5157.68","5157.68","5157.68","1 through 10","35.19","55.03","percent of total billed charges",""
"SCREW BONE 3.5X16MM TITANIUM LCP SHAFT PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","67.34","50.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","55.03","81.72","","431.26","71.26","1459.57","88","35.19","55.03","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","151.90","79.5","","800.18","480.96","1887.97","195","59.23","151.9","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","101.84","53.3","","813.12","216.42","1444.50","81","59.23","151.9","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","59.23","31","","432.60","432.60","432.60","1 through 10","59.23","151.9","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","69.74","36.5","","148.37","54.89","631.39","94","59.23","151.9","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.18","38.3","","279.30","91.72","1116.77","266","59.23","151.9","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.97","42.9","","731.00","63.70","731.00","1 through 10","59.23","151.9","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.97","42.9","","384.74","384.74","384.74","1 through 10","59.23","151.9","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.07","143.30","WELLPOINT [1015]","HB AMC WELLPOINT","140.97","73.78","","286.63","119.22","1107.45","105","59.23","151.9","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.07","143.30","AETNA [1001]","HB AMC AETNA HMO","133.37","69.8","","675.31","184.75","1721.50","286","99.85","156.14","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.07","143.30","AETNA [1001]","HB AMC AETNA PPO","153.62","80.4","","1261.44","103.12","1514.10","21","99.85","156.14","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.07","143.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","153.62","80.4","","1365.00","1365.00","1365.00","1 through 10","99.85","156.14","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.07","143.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","156.14","81.72","","5157.68","5157.68","5157.68","1 through 10","99.85","156.14","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.07","143.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","156.14","81.72","","431.26","71.26","1459.57","88","99.85","156.14","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.99","722.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","765.58","79.5","","800.18","480.96","1887.97","195","298.53","765.58","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.99","722.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","513.27","53.3","","813.12","216.42","1444.50","81","298.53","765.58","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.99","722.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","298.53","31","","432.60","432.60","432.60","1 through 10","298.53","765.58","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.99","722.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","351.49","36.5","","148.37","54.89","631.39","94","298.53","765.58","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.99","722.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","368.83","38.3","","279.30","91.72","1116.77","266","298.53","765.58","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.99","722.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","413.12","42.9","","731.00","63.70","731.00","1 through 10","298.53","765.58","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.99","722.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","413.12","42.9","","384.74","384.74","384.74","1 through 10","298.53","765.58","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.99","722.24","WELLPOINT [1015]","HB AMC WELLPOINT","710.49","73.78","","286.63","119.22","1107.45","105","298.53","765.58","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.99","722.24","AETNA [1001]","HB AMC AETNA HMO","672.17","69.8","","675.31","184.75","1721.50","286","503.26","786.96","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.99","722.24","AETNA [1001]","HB AMC AETNA PPO","774.24","80.4","","1261.44","103.12","1514.10","21","503.26","786.96","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.99","722.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","774.24","80.4","","1365.00","1365.00","1365.00","1 through 10","503.26","786.96","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.99","722.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","786.96","81.72","","5157.68","5157.68","5157.68","1 through 10","503.26","786.96","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.99","722.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","786.96","81.72","","431.26","71.26","1459.57","88","503.26","786.96","percent of total billed charges",""
"SCREW BONE 3.5X20MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL GOLD","SUP-ITM-10041742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","800.18","480.96","1887.97","195","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 3.5X20MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL GOLD","SUP-ITM-10041742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","813.12","216.42","1444.50","81","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 3.5X20MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL GOLD","SUP-ITM-10041742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","542.50","31","","432.60","432.60","432.60","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 3.5X20MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL GOLD","SUP-ITM-10041742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","148.37","54.89","631.39","94","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 3.5X20MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL GOLD","SUP-ITM-10041742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","279.30","91.72","1116.77","266","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 3.5X20MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL GOLD","SUP-ITM-10041742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","731.00","63.70","731.00","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 3.5X20MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL GOLD","SUP-ITM-10041742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","384.74","384.74","384.74","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 3.5X20MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL GOLD","SUP-ITM-10041742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","286.63","119.22","1107.45","105","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 3.5X20MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL GOLD","SUP-ITM-10041742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","675.31","184.75","1721.50","286","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 3.5X20MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL GOLD","SUP-ITM-10041742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1261.44","103.12","1514.10","21","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 3.5X20MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL GOLD","SUP-ITM-10041742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","1365.00","1365.00","1365.00","1 through 10","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 3.5X20MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL GOLD","SUP-ITM-10041742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1430.10","81.72","","5157.68","5157.68","5157.68","1 through 10","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 3.5X20MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL GOLD","SUP-ITM-10041742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","431.26","71.26","1459.57","88","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","819.22","79.5","","800.18","480.96","1887.97","195","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","549.24","53.3","","813.12","216.42","1444.50","81","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","319.45","31","","432.60","432.60","432.60","1 through 10","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","376.12","36.5","","148.37","54.89","631.39","94","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","394.67","38.3","","279.30","91.72","1116.77","266","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.07","42.9","","731.00","63.70","731.00","1 through 10","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.07","42.9","","384.74","384.74","384.74","1 through 10","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","WELLPOINT [1015]","HB AMC WELLPOINT","760.28","73.78","","286.63","119.22","1107.45","105","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","AETNA [1001]","HB AMC AETNA HMO","719.27","69.8","","675.31","184.75","1721.50","286","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","AETNA [1001]","HB AMC AETNA PPO","828.50","80.4","","1261.44","103.12","1514.10","21","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","828.50","80.4","","1365.00","1365.00","1365.00","1 through 10","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","842.10","81.72","","5157.68","5157.68","5157.68","1 through 10","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","842.10","81.72","","431.26","71.26","1459.57","88","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","443.86","79.5","","800.18","480.96","1887.97","195","173.08","443.86","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","297.58","53.3","","813.12","216.42","1444.50","81","173.08","443.86","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","173.08","31","","432.60","432.60","432.60","1 through 10","173.08","443.86","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","203.79","36.5","","148.37","54.89","631.39","94","173.08","443.86","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","213.84","38.3","","279.30","91.72","1116.77","266","173.08","443.86","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.52","42.9","","731.00","63.70","731.00","1 through 10","173.08","443.86","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.52","42.9","","384.74","384.74","384.74","1 through 10","173.08","443.86","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.32","418.74","WELLPOINT [1015]","HB AMC WELLPOINT","411.93","73.78","","286.63","119.22","1107.45","105","173.08","443.86","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","AETNA [1001]","HB AMC AETNA HMO","389.71","69.8","","675.31","184.75","1721.50","286","291.78","456.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","AETNA [1001]","HB AMC AETNA PPO","448.89","80.4","","1261.44","103.12","1514.10","21","291.78","456.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","448.89","80.4","","1365.00","1365.00","1365.00","1 through 10","291.78","456.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","456.26","81.72","","5157.68","5157.68","5157.68","1 through 10","291.78","456.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.32","418.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","456.26","81.72","","431.26","71.26","1459.57","88","291.78","456.26","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","873.43","79.5","","800.18","480.96","1887.97","195","340.58","873.43","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","585.58","53.3","","813.12","216.42","1444.50","81","340.58","873.43","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","340.58","31","","432.60","432.60","432.60","1 through 10","340.58","873.43","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","401.01","36.5","","148.37","54.89","631.39","94","340.58","873.43","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","420.78","38.3","","279.30","91.72","1116.77","266","340.58","873.43","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","471.32","42.9","","731.00","63.70","731.00","1 through 10","340.58","873.43","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","471.32","42.9","","384.74","384.74","384.74","1 through 10","340.58","873.43","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1098.65","823.99","WELLPOINT [1015]","HB AMC WELLPOINT","810.58","73.78","","286.63","119.22","1107.45","105","340.58","873.43","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","AETNA [1001]","HB AMC AETNA HMO","766.86","69.8","","675.31","184.75","1721.50","286","574.15","897.82","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","AETNA [1001]","HB AMC AETNA PPO","883.31","80.4","","1261.44","103.12","1514.10","21","574.15","897.82","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","883.31","80.4","","1365.00","1365.00","1365.00","1 through 10","574.15","897.82","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","897.82","81.72","","5157.68","5157.68","5157.68","1 through 10","574.15","897.82","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1098.65","823.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","897.82","81.72","","431.26","71.26","1459.57","88","574.15","897.82","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","270.77","79.5","","800.18","480.96","1887.97","195","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","181.53","53.3","","813.12","216.42","1444.50","81","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","105.58","31","","432.60","432.60","432.60","1 through 10","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","124.32","36.5","","148.37","54.89","631.39","94","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","130.45","38.3","","279.30","91.72","1116.77","266","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.11","42.9","","731.00","63.70","731.00","1 through 10","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.11","42.9","","384.74","384.74","384.74","1 through 10","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","WELLPOINT [1015]","HB AMC WELLPOINT","251.29","73.78","","286.63","119.22","1107.45","105","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.59","255.44","AETNA [1001]","HB AMC AETNA HMO","237.73","69.8","","675.31","184.75","1721.50","286","177.99","278.33","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.59","255.44","AETNA [1001]","HB AMC AETNA PPO","273.83","80.4","","1261.44","103.12","1514.10","21","177.99","278.33","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.59","255.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","273.83","80.4","","1365.00","1365.00","1365.00","1 through 10","177.99","278.33","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.59","255.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","278.33","81.72","","5157.68","5157.68","5157.68","1 through 10","177.99","278.33","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.59","255.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","278.33","81.72","","431.26","71.26","1459.57","88","177.99","278.33","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.36","910.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","965.42","79.5","","800.18","480.96","1887.97","195","376.45","965.42","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.36","910.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","647.25","53.3","","813.12","216.42","1444.50","81","376.45","965.42","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.36","910.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","376.45","31","","432.60","432.60","432.60","1 through 10","376.45","965.42","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.36","910.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","443.24","36.5","","148.37","54.89","631.39","94","376.45","965.42","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.36","910.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","465.10","38.3","","279.30","91.72","1116.77","266","376.45","965.42","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.36","910.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.96","42.9","","731.00","63.70","731.00","1 through 10","376.45","965.42","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.36","910.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.96","42.9","","384.74","384.74","384.74","1 through 10","376.45","965.42","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1214.36","910.77","WELLPOINT [1015]","HB AMC WELLPOINT","895.95","73.78","","286.63","119.22","1107.45","105","376.45","965.42","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1214.36","910.77","AETNA [1001]","HB AMC AETNA HMO","847.62","69.8","","675.31","184.75","1721.50","286","634.62","992.37","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1214.36","910.77","AETNA [1001]","HB AMC AETNA PPO","976.35","80.4","","1261.44","103.12","1514.10","21","634.62","992.37","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1214.36","910.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","976.35","80.4","","1365.00","1365.00","1365.00","1 through 10","634.62","992.37","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1214.36","910.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","992.37","81.72","","5157.68","5157.68","5157.68","1 through 10","634.62","992.37","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1214.36","910.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","992.37","81.72","","431.26","71.26","1459.57","88","634.62","992.37","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.65","67.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","72.07","79.5","","800.18","480.96","1887.97","195","28.1","72.07","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.65","67.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.32","53.3","","813.12","216.42","1444.50","81","28.1","72.07","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.65","67.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","28.10","31","","432.60","432.60","432.60","1 through 10","28.1","72.07","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.65","67.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.09","36.5","","148.37","54.89","631.39","94","28.1","72.07","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.65","67.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.72","38.3","","279.30","91.72","1116.77","266","28.1","72.07","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.65","67.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","38.89","42.9","","731.00","63.70","731.00","1 through 10","28.1","72.07","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.65","67.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","38.89","42.9","","384.74","384.74","384.74","1 through 10","28.1","72.07","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.65","67.99","WELLPOINT [1015]","HB AMC WELLPOINT","66.88","73.78","","286.63","119.22","1107.45","105","28.1","72.07","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","90.65","67.99","AETNA [1001]","HB AMC AETNA HMO","63.27","69.8","","675.31","184.75","1721.50","286","47.37","74.08","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","90.65","67.99","AETNA [1001]","HB AMC AETNA PPO","72.88","80.4","","1261.44","103.12","1514.10","21","47.37","74.08","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","90.65","67.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","72.88","80.4","","1365.00","1365.00","1365.00","1 through 10","47.37","74.08","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","90.65","67.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","74.08","81.72","","5157.68","5157.68","5157.68","1 through 10","47.37","74.08","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","90.65","67.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","74.08","81.72","","431.26","71.26","1459.57","88","47.37","74.08","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.50","79.5","","800.18","480.96","1887.97","195","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.63","53.3","","813.12","216.42","1444.50","81","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","64.93","31","","432.60","432.60","432.60","1 through 10","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.45","36.5","","148.37","54.89","631.39","94","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.22","38.3","","279.30","91.72","1116.77","266","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.85","42.9","","731.00","63.70","731.00","1 through 10","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.85","42.9","","384.74","384.74","384.74","1 through 10","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","WELLPOINT [1015]","HB AMC WELLPOINT","154.52","73.78","","286.63","119.22","1107.45","105","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","AETNA [1001]","HB AMC AETNA HMO","146.19","69.8","","675.31","184.75","1721.50","286","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","AETNA [1001]","HB AMC AETNA PPO","168.39","80.4","","1261.44","103.12","1514.10","21","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","168.39","80.4","","1365.00","1365.00","1365.00","1 through 10","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","171.15","81.72","","5157.68","5157.68","5157.68","1 through 10","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.15","81.72","","431.26","71.26","1459.57","88","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X26MM TI CORTICAL LOCKING","SUP-ITM-10295776","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.50","475.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","503.63","79.5","","800.18","480.96","1887.97","195","196.39","503.63","percent of total billed charges",""
"SCREW BONE 3.5X26MM TI CORTICAL LOCKING","SUP-ITM-10295776","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.50","475.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","337.66","53.3","","813.12","216.42","1444.50","81","196.39","503.63","percent of total billed charges",""
"SCREW BONE 3.5X26MM TI CORTICAL LOCKING","SUP-ITM-10295776","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.50","475.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","196.39","31","","432.60","432.60","432.60","1 through 10","196.39","503.63","percent of total billed charges",""
"SCREW BONE 3.5X26MM TI CORTICAL LOCKING","SUP-ITM-10295776","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.50","475.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","231.23","36.5","","148.37","54.89","631.39","94","196.39","503.63","percent of total billed charges",""
"SCREW BONE 3.5X26MM TI CORTICAL LOCKING","SUP-ITM-10295776","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.50","475.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","242.63","38.3","","279.30","91.72","1116.77","266","196.39","503.63","percent of total billed charges",""
"SCREW BONE 3.5X26MM TI CORTICAL LOCKING","SUP-ITM-10295776","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.50","475.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","271.77","42.9","","731.00","63.70","731.00","1 through 10","196.39","503.63","percent of total billed charges",""
"SCREW BONE 3.5X26MM TI CORTICAL LOCKING","SUP-ITM-10295776","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.50","475.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","271.77","42.9","","384.74","384.74","384.74","1 through 10","196.39","503.63","percent of total billed charges",""
"SCREW BONE 3.5X26MM TI CORTICAL LOCKING","SUP-ITM-10295776","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.50","475.12","WELLPOINT [1015]","HB AMC WELLPOINT","467.40","73.78","","286.63","119.22","1107.45","105","196.39","503.63","percent of total billed charges",""
"SCREW BONE 3.5X26MM TI CORTICAL LOCKING","SUP-ITM-10295776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","633.50","475.12","AETNA [1001]","HB AMC AETNA HMO","442.18","69.8","","675.31","184.75","1721.50","286","331.07","517.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM TI CORTICAL LOCKING","SUP-ITM-10295776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","633.50","475.12","AETNA [1001]","HB AMC AETNA PPO","509.33","80.4","","1261.44","103.12","1514.10","21","331.07","517.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM TI CORTICAL LOCKING","SUP-ITM-10295776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","633.50","475.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","509.33","80.4","","1365.00","1365.00","1365.00","1 through 10","331.07","517.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM TI CORTICAL LOCKING","SUP-ITM-10295776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","633.50","475.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","517.70","81.72","","5157.68","5157.68","5157.68","1 through 10","331.07","517.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM TI CORTICAL LOCKING","SUP-ITM-10295776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","633.50","475.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","517.70","81.72","","431.26","71.26","1459.57","88","331.07","517.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","819.22","79.5","","800.18","480.96","1887.97","195","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","549.24","53.3","","813.12","216.42","1444.50","81","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","319.45","31","","432.60","432.60","432.60","1 through 10","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","376.12","36.5","","148.37","54.89","631.39","94","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","394.67","38.3","","279.30","91.72","1116.77","266","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.07","42.9","","731.00","63.70","731.00","1 through 10","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.07","42.9","","384.74","384.74","384.74","1 through 10","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","WELLPOINT [1015]","HB AMC WELLPOINT","760.28","73.78","","286.63","119.22","1107.45","105","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","AETNA [1001]","HB AMC AETNA HMO","719.27","69.8","","675.31","184.75","1721.50","286","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","AETNA [1001]","HB AMC AETNA PPO","828.50","80.4","","1261.44","103.12","1514.10","21","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","828.50","80.4","","1365.00","1365.00","1365.00","1 through 10","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","842.10","81.72","","5157.68","5157.68","5157.68","1 through 10","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","842.10","81.72","","431.26","71.26","1459.57","88","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","612.15","79.5","","800.18","480.96","1887.97","195","238.7","612.15","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","410.41","53.3","","813.12","216.42","1444.50","81","238.7","612.15","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","238.70","31","","432.60","432.60","432.60","1 through 10","238.7","612.15","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","281.05","36.5","","148.37","54.89","631.39","94","238.7","612.15","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","294.91","38.3","","279.30","91.72","1116.77","266","238.7","612.15","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","330.33","42.9","","731.00","63.70","731.00","1 through 10","238.7","612.15","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","330.33","42.9","","384.74","384.74","384.74","1 through 10","238.7","612.15","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","WELLPOINT [1015]","HB AMC WELLPOINT","568.11","73.78","","286.63","119.22","1107.45","105","238.7","612.15","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","AETNA [1001]","HB AMC AETNA HMO","537.46","69.8","","675.31","184.75","1721.50","286","402.4","629.24","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","AETNA [1001]","HB AMC AETNA PPO","619.08","80.4","","1261.44","103.12","1514.10","21","402.4","629.24","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","619.08","80.4","","1365.00","1365.00","1365.00","1 through 10","402.4","629.24","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","629.24","81.72","","5157.68","5157.68","5157.68","1 through 10","402.4","629.24","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","629.24","81.72","","431.26","71.26","1459.57","88","402.4","629.24","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.16","46.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","49.42","79.5","","800.18","480.96","1887.97","195","19.27","49.42","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.16","46.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33.13","53.3","","813.12","216.42","1444.50","81","19.27","49.42","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.16","46.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","19.27","31","","432.60","432.60","432.60","1 through 10","19.27","49.42","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.16","46.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22.69","36.5","","148.37","54.89","631.39","94","19.27","49.42","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.16","46.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23.81","38.3","","279.30","91.72","1116.77","266","19.27","49.42","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.16","46.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.67","42.9","","731.00","63.70","731.00","1 through 10","19.27","49.42","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.16","46.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.67","42.9","","384.74","384.74","384.74","1 through 10","19.27","49.42","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","62.16","46.62","WELLPOINT [1015]","HB AMC WELLPOINT","45.86","73.78","","286.63","119.22","1107.45","105","19.27","49.42","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.16","46.62","AETNA [1001]","HB AMC AETNA HMO","43.39","69.8","","675.31","184.75","1721.50","286","32.48","50.8","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.16","46.62","AETNA [1001]","HB AMC AETNA PPO","49.98","80.4","","1261.44","103.12","1514.10","21","32.48","50.8","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.16","46.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","49.98","80.4","","1365.00","1365.00","1365.00","1 through 10","32.48","50.8","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.16","46.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","50.80","81.72","","5157.68","5157.68","5157.68","1 through 10","32.48","50.8","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","62.16","46.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","50.80","81.72","","431.26","71.26","1459.57","88","32.48","50.8","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.50","79.5","","800.18","480.96","1887.97","195","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.63","53.3","","813.12","216.42","1444.50","81","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","64.93","31","","432.60","432.60","432.60","1 through 10","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.45","36.5","","148.37","54.89","631.39","94","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.22","38.3","","279.30","91.72","1116.77","266","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.85","42.9","","731.00","63.70","731.00","1 through 10","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.85","42.9","","384.74","384.74","384.74","1 through 10","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","WELLPOINT [1015]","HB AMC WELLPOINT","154.52","73.78","","286.63","119.22","1107.45","105","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","AETNA [1001]","HB AMC AETNA HMO","146.19","69.8","","675.31","184.75","1721.50","286","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","AETNA [1001]","HB AMC AETNA PPO","168.39","80.4","","1261.44","103.12","1514.10","21","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","168.39","80.4","","1365.00","1365.00","1365.00","1 through 10","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","171.15","81.72","","5157.68","5157.68","5157.68","1 through 10","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.15","81.72","","431.26","71.26","1459.57","88","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X34MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198129","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.00","409.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","434.07","79.5","","800.18","480.96","1887.97","195","169.26","434.07","percent of total billed charges",""
"SCREW BONE 3.5X34MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198129","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.00","409.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","291.02","53.3","","813.12","216.42","1444.50","81","169.26","434.07","percent of total billed charges",""
"SCREW BONE 3.5X34MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198129","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.00","409.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","169.26","31","","432.60","432.60","432.60","1 through 10","169.26","434.07","percent of total billed charges",""
"SCREW BONE 3.5X34MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198129","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.00","409.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","199.29","36.5","","148.37","54.89","631.39","94","169.26","434.07","percent of total billed charges",""
"SCREW BONE 3.5X34MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198129","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.00","409.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","209.12","38.3","","279.30","91.72","1116.77","266","169.26","434.07","percent of total billed charges",""
"SCREW BONE 3.5X34MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198129","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.00","409.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.23","42.9","","731.00","63.70","731.00","1 through 10","169.26","434.07","percent of total billed charges",""
"SCREW BONE 3.5X34MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198129","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.00","409.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.23","42.9","","384.74","384.74","384.74","1 through 10","169.26","434.07","percent of total billed charges",""
"SCREW BONE 3.5X34MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198129","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.00","409.50","WELLPOINT [1015]","HB AMC WELLPOINT","402.84","73.78","","286.63","119.22","1107.45","105","169.26","434.07","percent of total billed charges",""
"SCREW BONE 3.5X34MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.00","409.50","AETNA [1001]","HB AMC AETNA HMO","381.11","69.8","","675.31","184.75","1721.50","286","285.34","446.19","percent of total billed charges",""
"SCREW BONE 3.5X34MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.00","409.50","AETNA [1001]","HB AMC AETNA PPO","438.98","80.4","","1261.44","103.12","1514.10","21","285.34","446.19","percent of total billed charges",""
"SCREW BONE 3.5X34MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.00","409.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","438.98","80.4","","1365.00","1365.00","1365.00","1 through 10","285.34","446.19","percent of total billed charges",""
"SCREW BONE 3.5X34MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.00","409.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","446.19","81.72","","5157.68","5157.68","5157.68","1 through 10","285.34","446.19","percent of total billed charges",""
"SCREW BONE 3.5X34MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198129","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.00","409.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","446.19","81.72","","431.26","71.26","1459.57","88","285.34","446.19","percent of total billed charges",""
"SCREW BONE 3.5X34MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198192","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","520.33","79.5","","800.18","480.96","1887.97","195","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.5X34MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198192","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","348.85","53.3","","813.12","216.42","1444.50","81","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.5X34MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198192","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","202.90","31","","432.60","432.60","432.60","1 through 10","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.5X34MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198192","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","238.89","36.5","","148.37","54.89","631.39","94","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.5X34MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198192","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","250.67","38.3","","279.30","91.72","1116.77","266","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.5X34MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198192","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.78","42.9","","731.00","63.70","731.00","1 through 10","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.5X34MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198192","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.78","42.9","","384.74","384.74","384.74","1 through 10","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.5X34MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198192","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.50","490.87","WELLPOINT [1015]","HB AMC WELLPOINT","482.89","73.78","","286.63","119.22","1107.45","105","202.9","520.33","percent of total billed charges",""
"SCREW BONE 3.5X34MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","AETNA [1001]","HB AMC AETNA HMO","456.84","69.8","","675.31","184.75","1721.50","286","342.04","534.86","percent of total billed charges",""
"SCREW BONE 3.5X34MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","AETNA [1001]","HB AMC AETNA PPO","526.22","80.4","","1261.44","103.12","1514.10","21","342.04","534.86","percent of total billed charges",""
"SCREW BONE 3.5X34MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","526.22","80.4","","1365.00","1365.00","1365.00","1 through 10","342.04","534.86","percent of total billed charges",""
"SCREW BONE 3.5X34MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","534.86","81.72","","5157.68","5157.68","5157.68","1 through 10","342.04","534.86","percent of total billed charges",""
"SCREW BONE 3.5X34MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.50","490.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","534.86","81.72","","431.26","71.26","1459.57","88","342.04","534.86","percent of total billed charges",""
"SCREW BONE 3.5X36MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277767","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","141.91","79.5","","800.18","480.96","1887.97","195","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X36MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277767","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.14","53.3","","813.12","216.42","1444.50","81","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X36MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277767","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","55.34","31","","432.60","432.60","432.60","1 through 10","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X36MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277767","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.15","36.5","","148.37","54.89","631.39","94","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X36MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277767","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.37","38.3","","279.30","91.72","1116.77","266","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X36MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277767","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.58","42.9","","731.00","63.70","731.00","1 through 10","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X36MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277767","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.58","42.9","","384.74","384.74","384.74","1 through 10","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X36MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277767","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","WELLPOINT [1015]","HB AMC WELLPOINT","131.70","73.78","","286.63","119.22","1107.45","105","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X36MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","AETNA [1001]","HB AMC AETNA HMO","124.59","69.8","","675.31","184.75","1721.50","286","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X36MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","AETNA [1001]","HB AMC AETNA PPO","143.51","80.4","","1261.44","103.12","1514.10","21","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X36MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","143.51","80.4","","1365.00","1365.00","1365.00","1 through 10","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X36MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","145.87","81.72","","5157.68","5157.68","5157.68","1 through 10","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X36MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","145.87","81.72","","431.26","71.26","1459.57","88","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","148.95","79.5","","800.18","480.96","1887.97","195","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","99.86","53.3","","813.12","216.42","1444.50","81","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","58.08","31","","432.60","432.60","432.60","1 through 10","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.39","36.5","","148.37","54.89","631.39","94","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71.76","38.3","","279.30","91.72","1116.77","266","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.38","42.9","","731.00","63.70","731.00","1 through 10","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.38","42.9","","384.74","384.74","384.74","1 through 10","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","WELLPOINT [1015]","HB AMC WELLPOINT","138.23","73.78","","286.63","119.22","1107.45","105","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","187.36","140.52","AETNA [1001]","HB AMC AETNA HMO","130.78","69.8","","675.31","184.75","1721.50","286","97.91","153.11","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","187.36","140.52","AETNA [1001]","HB AMC AETNA PPO","150.64","80.4","","1261.44","103.12","1514.10","21","97.91","153.11","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","187.36","140.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","150.64","80.4","","1365.00","1365.00","1365.00","1 through 10","97.91","153.11","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","187.36","140.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","153.11","81.72","","5157.68","5157.68","5157.68","1 through 10","97.91","153.11","percent of total billed charges",""
"SCREW BONE 3.5X36MM AXSOS CORTEX TITANIUM","SUP-ITM-10144962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","187.36","140.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","153.11","81.72","","431.26","71.26","1459.57","88","97.91","153.11","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","333.01","79.5","","800.18","480.96","1887.97","195","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","223.26","53.3","","813.12","216.42","1444.50","81","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","129.85","31","","432.60","432.60","432.60","1 through 10","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","152.89","36.5","","148.37","54.89","631.39","94","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","160.43","38.3","","279.30","91.72","1116.77","266","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","179.70","42.9","","731.00","63.70","731.00","1 through 10","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","179.70","42.9","","384.74","384.74","384.74","1 through 10","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","418.88","314.16","WELLPOINT [1015]","HB AMC WELLPOINT","309.05","73.78","","286.63","119.22","1107.45","105","129.85","333.01","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","418.88","314.16","AETNA [1001]","HB AMC AETNA HMO","292.38","69.8","","675.31","184.75","1721.50","286","218.91","342.31","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","418.88","314.16","AETNA [1001]","HB AMC AETNA PPO","336.78","80.4","","1261.44","103.12","1514.10","21","218.91","342.31","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","418.88","314.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","336.78","80.4","","1365.00","1365.00","1365.00","1 through 10","218.91","342.31","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","418.88","314.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","342.31","81.72","","5157.68","5157.68","5157.68","1 through 10","218.91","342.31","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","418.88","314.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","342.31","81.72","","431.26","71.26","1459.57","88","218.91","342.31","percent of total billed charges",""
"SCREW BONE 3.5X36MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072348","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","464.29","79.5","","800.18","480.96","1887.97","195","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X36MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072348","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","311.28","53.3","","813.12","216.42","1444.50","81","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X36MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072348","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","181.04","31","","432.60","432.60","432.60","1 through 10","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X36MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072348","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","213.16","36.5","","148.37","54.89","631.39","94","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X36MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072348","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","223.68","38.3","","279.30","91.72","1116.77","266","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X36MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072348","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.54","42.9","","731.00","63.70","731.00","1 through 10","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X36MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072348","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.54","42.9","","384.74","384.74","384.74","1 through 10","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X36MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072348","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.01","438.01","WELLPOINT [1015]","HB AMC WELLPOINT","430.88","73.78","","286.63","119.22","1107.45","105","181.04","464.29","percent of total billed charges",""
"SCREW BONE 3.5X36MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.01","438.01","AETNA [1001]","HB AMC AETNA HMO","407.64","69.8","","675.31","184.75","1721.50","286","305.2","477.25","percent of total billed charges",""
"SCREW BONE 3.5X36MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.01","438.01","AETNA [1001]","HB AMC AETNA PPO","469.54","80.4","","1261.44","103.12","1514.10","21","305.2","477.25","percent of total billed charges",""
"SCREW BONE 3.5X36MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.01","438.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","469.54","80.4","","1365.00","1365.00","1365.00","1 through 10","305.2","477.25","percent of total billed charges",""
"SCREW BONE 3.5X36MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.01","438.01","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","477.25","81.72","","5157.68","5157.68","5157.68","1 through 10","305.2","477.25","percent of total billed charges",""
"SCREW BONE 3.5X36MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.01","438.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","477.25","81.72","","431.26","71.26","1459.57","88","305.2","477.25","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","819.22","79.5","","800.18","480.96","1887.97","195","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","549.24","53.3","","813.12","216.42","1444.50","81","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","319.45","31","","432.60","432.60","432.60","1 through 10","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","376.12","36.5","","148.37","54.89","631.39","94","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","394.67","38.3","","279.30","91.72","1116.77","266","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.07","42.9","","731.00","63.70","731.00","1 through 10","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.07","42.9","","384.74","384.74","384.74","1 through 10","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1030.47","772.85","WELLPOINT [1015]","HB AMC WELLPOINT","760.28","73.78","","286.63","119.22","1107.45","105","319.45","819.22","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","AETNA [1001]","HB AMC AETNA HMO","719.27","69.8","","675.31","184.75","1721.50","286","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","AETNA [1001]","HB AMC AETNA PPO","828.50","80.4","","1261.44","103.12","1514.10","21","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","828.50","80.4","","1365.00","1365.00","1365.00","1 through 10","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","842.10","81.72","","5157.68","5157.68","5157.68","1 through 10","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1030.47","772.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","842.10","81.72","","431.26","71.26","1459.57","88","538.52","842.1","percent of total billed charges",""
"SCREW BONE 3.5X38MM A.L.P.S. TI CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030163","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","315.26","79.5","","800.18","480.96","1887.97","195","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X38MM A.L.P.S. TI CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030163","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","211.36","53.3","","813.12","216.42","1444.50","81","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X38MM A.L.P.S. TI CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030163","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","122.93","31","","432.60","432.60","432.60","1 through 10","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X38MM A.L.P.S. TI CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030163","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","144.74","36.5","","148.37","54.89","631.39","94","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X38MM A.L.P.S. TI CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030163","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","151.88","38.3","","279.30","91.72","1116.77","266","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X38MM A.L.P.S. TI CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030163","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.12","42.9","","731.00","63.70","731.00","1 through 10","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X38MM A.L.P.S. TI CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030163","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.12","42.9","","384.74","384.74","384.74","1 through 10","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X38MM A.L.P.S. TI CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030163","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","WELLPOINT [1015]","HB AMC WELLPOINT","292.57","73.78","","286.63","119.22","1107.45","105","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X38MM A.L.P.S. TI CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.55","297.41","AETNA [1001]","HB AMC AETNA HMO","276.79","69.8","","675.31","184.75","1721.50","286","207.24","324.06","percent of total billed charges",""
"SCREW BONE 3.5X38MM A.L.P.S. TI CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.55","297.41","AETNA [1001]","HB AMC AETNA PPO","318.83","80.4","","1261.44","103.12","1514.10","21","207.24","324.06","percent of total billed charges",""
"SCREW BONE 3.5X38MM A.L.P.S. TI CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.55","297.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","318.83","80.4","","1365.00","1365.00","1365.00","1 through 10","207.24","324.06","percent of total billed charges",""
"SCREW BONE 3.5X38MM A.L.P.S. TI CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.55","297.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","324.06","81.72","","5157.68","5157.68","5157.68","1 through 10","207.24","324.06","percent of total billed charges",""
"SCREW BONE 3.5X38MM A.L.P.S. TI CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.55","297.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","324.06","81.72","","431.26","71.26","1459.57","88","207.24","324.06","percent of total billed charges",""
"SCREW BONE 3.5X38MM NON-LOCKING CORTICAL ORTHOLOC SPS","SUP-ITM-10306424","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.75","501.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","531.66","79.5","","800.18","480.96","1887.97","195","207.31","531.66","percent of total billed charges",""
"SCREW BONE 3.5X38MM NON-LOCKING CORTICAL ORTHOLOC SPS","SUP-ITM-10306424","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.75","501.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","356.44","53.3","","813.12","216.42","1444.50","81","207.31","531.66","percent of total billed charges",""
"SCREW BONE 3.5X38MM NON-LOCKING CORTICAL ORTHOLOC SPS","SUP-ITM-10306424","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.75","501.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","207.31","31","","432.60","432.60","432.60","1 through 10","207.31","531.66","percent of total billed charges",""
"SCREW BONE 3.5X38MM NON-LOCKING CORTICAL ORTHOLOC SPS","SUP-ITM-10306424","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.75","501.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","244.09","36.5","","148.37","54.89","631.39","94","207.31","531.66","percent of total billed charges",""
"SCREW BONE 3.5X38MM NON-LOCKING CORTICAL ORTHOLOC SPS","SUP-ITM-10306424","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.75","501.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","256.13","38.3","","279.30","91.72","1116.77","266","207.31","531.66","percent of total billed charges",""
"SCREW BONE 3.5X38MM NON-LOCKING CORTICAL ORTHOLOC SPS","SUP-ITM-10306424","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.75","501.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","286.89","42.9","","731.00","63.70","731.00","1 through 10","207.31","531.66","percent of total billed charges",""
"SCREW BONE 3.5X38MM NON-LOCKING CORTICAL ORTHOLOC SPS","SUP-ITM-10306424","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.75","501.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","286.89","42.9","","384.74","384.74","384.74","1 through 10","207.31","531.66","percent of total billed charges",""
"SCREW BONE 3.5X38MM NON-LOCKING CORTICAL ORTHOLOC SPS","SUP-ITM-10306424","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.75","501.56","WELLPOINT [1015]","HB AMC WELLPOINT","493.40","73.78","","286.63","119.22","1107.45","105","207.31","531.66","percent of total billed charges",""
"SCREW BONE 3.5X38MM NON-LOCKING CORTICAL ORTHOLOC SPS","SUP-ITM-10306424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.75","501.56","AETNA [1001]","HB AMC AETNA HMO","466.79","69.8","","675.31","184.75","1721.50","286","349.49","546.5","percent of total billed charges",""
"SCREW BONE 3.5X38MM NON-LOCKING CORTICAL ORTHOLOC SPS","SUP-ITM-10306424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.75","501.56","AETNA [1001]","HB AMC AETNA PPO","537.68","80.4","","1261.44","103.12","1514.10","21","349.49","546.5","percent of total billed charges",""
"SCREW BONE 3.5X38MM NON-LOCKING CORTICAL ORTHOLOC SPS","SUP-ITM-10306424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.75","501.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","537.68","80.4","","1365.00","1365.00","1365.00","1 through 10","349.49","546.5","percent of total billed charges",""
"SCREW BONE 3.5X38MM NON-LOCKING CORTICAL ORTHOLOC SPS","SUP-ITM-10306424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.75","501.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","546.50","81.72","","5157.68","5157.68","5157.68","1 through 10","349.49","546.5","percent of total billed charges",""
"SCREW BONE 3.5X38MM NON-LOCKING CORTICAL ORTHOLOC SPS","SUP-ITM-10306424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.75","501.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","546.50","81.72","","431.26","71.26","1459.57","88","349.49","546.5","percent of total billed charges",""
"SCREW BONE 3.5X38MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080938","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.55","94.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","99.81","79.5","","800.18","480.96","1887.97","195","38.92","99.81","percent of total billed charges",""
"SCREW BONE 3.5X38MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080938","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.55","94.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","66.92","53.3","","813.12","216.42","1444.50","81","38.92","99.81","percent of total billed charges",""
"SCREW BONE 3.5X38MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080938","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.55","94.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","38.92","31","","432.60","432.60","432.60","1 through 10","38.92","99.81","percent of total billed charges",""
"SCREW BONE 3.5X38MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080938","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.55","94.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","45.83","36.5","","148.37","54.89","631.39","94","38.92","99.81","percent of total billed charges",""
"SCREW BONE 3.5X38MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080938","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.55","94.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48.09","38.3","","279.30","91.72","1116.77","266","38.92","99.81","percent of total billed charges",""
"SCREW BONE 3.5X38MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080938","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.55","94.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.86","42.9","","731.00","63.70","731.00","1 through 10","38.92","99.81","percent of total billed charges",""
"SCREW BONE 3.5X38MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080938","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.55","94.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.86","42.9","","384.74","384.74","384.74","1 through 10","38.92","99.81","percent of total billed charges",""
"SCREW BONE 3.5X38MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080938","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.55","94.16","WELLPOINT [1015]","HB AMC WELLPOINT","92.63","73.78","","286.63","119.22","1107.45","105","38.92","99.81","percent of total billed charges",""
"SCREW BONE 3.5X38MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.55","94.16","AETNA [1001]","HB AMC AETNA HMO","87.63","69.8","","675.31","184.75","1721.50","286","65.61","102.6","percent of total billed charges",""
"SCREW BONE 3.5X38MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.55","94.16","AETNA [1001]","HB AMC AETNA PPO","100.94","80.4","","1261.44","103.12","1514.10","21","65.61","102.6","percent of total billed charges",""
"SCREW BONE 3.5X38MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.55","94.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","100.94","80.4","","1365.00","1365.00","1365.00","1 through 10","65.61","102.6","percent of total billed charges",""
"SCREW BONE 3.5X38MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.55","94.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","102.60","81.72","","5157.68","5157.68","5157.68","1 through 10","65.61","102.6","percent of total billed charges",""
"SCREW BONE 3.5X38MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.55","94.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","102.60","81.72","","431.26","71.26","1459.57","88","65.61","102.6","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","315.26","79.5","","800.18","480.96","1887.97","195","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","211.36","53.3","","813.12","216.42","1444.50","81","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","122.93","31","","432.60","432.60","432.60","1 through 10","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","144.74","36.5","","148.37","54.89","631.39","94","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","151.88","38.3","","279.30","91.72","1116.77","266","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.12","42.9","","731.00","63.70","731.00","1 through 10","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.12","42.9","","384.74","384.74","384.74","1 through 10","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.55","297.41","WELLPOINT [1015]","HB AMC WELLPOINT","292.57","73.78","","286.63","119.22","1107.45","105","122.93","315.26","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.55","297.41","AETNA [1001]","HB AMC AETNA HMO","276.79","69.8","","675.31","184.75","1721.50","286","207.24","324.06","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.55","297.41","AETNA [1001]","HB AMC AETNA PPO","318.83","80.4","","1261.44","103.12","1514.10","21","207.24","324.06","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.55","297.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","318.83","80.4","","1365.00","1365.00","1365.00","1 through 10","207.24","324.06","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.55","297.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","324.06","81.72","","5157.68","5157.68","5157.68","1 through 10","207.24","324.06","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.55","297.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","324.06","81.72","","431.26","71.26","1459.57","88","207.24","324.06","percent of total billed charges",""
"SCREW BONE 3.5X40MM AXSOS CORTEX TITANIUM","SUP-ITM-10144964","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","148.95","79.5","","800.18","480.96","1887.97","195","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X40MM AXSOS CORTEX TITANIUM","SUP-ITM-10144964","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","99.86","53.3","","813.12","216.42","1444.50","81","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X40MM AXSOS CORTEX TITANIUM","SUP-ITM-10144964","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","58.08","31","","432.60","432.60","432.60","1 through 10","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X40MM AXSOS CORTEX TITANIUM","SUP-ITM-10144964","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.39","36.5","","148.37","54.89","631.39","94","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X40MM AXSOS CORTEX TITANIUM","SUP-ITM-10144964","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71.76","38.3","","279.30","91.72","1116.77","266","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X40MM AXSOS CORTEX TITANIUM","SUP-ITM-10144964","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.38","42.9","","731.00","63.70","731.00","1 through 10","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X40MM AXSOS CORTEX TITANIUM","SUP-ITM-10144964","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.38","42.9","","384.74","384.74","384.74","1 through 10","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X40MM AXSOS CORTEX TITANIUM","SUP-ITM-10144964","CDM","C1713","HCPCS","0278","RC","","","","both","","","187.36","140.52","WELLPOINT [1015]","HB AMC WELLPOINT","138.23","73.78","","286.63","119.22","1107.45","105","58.08","148.95","percent of total billed charges",""
"SCREW BONE 3.5X40MM AXSOS CORTEX TITANIUM","SUP-ITM-10144964","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","187.36","140.52","AETNA [1001]","HB AMC AETNA HMO","130.78","69.8","","675.31","184.75","1721.50","286","97.91","153.11","percent of total billed charges",""
"SCREW BONE 3.5X40MM AXSOS CORTEX TITANIUM","SUP-ITM-10144964","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","187.36","140.52","AETNA [1001]","HB AMC AETNA PPO","150.64","80.4","","1261.44","103.12","1514.10","21","97.91","153.11","percent of total billed charges",""
"SCREW BONE 3.5X40MM AXSOS CORTEX TITANIUM","SUP-ITM-10144964","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","187.36","140.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","150.64","80.4","","1365.00","1365.00","1365.00","1 through 10","97.91","153.11","percent of total billed charges",""
"SCREW BONE 3.5X40MM AXSOS CORTEX TITANIUM","SUP-ITM-10144964","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","187.36","140.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","153.11","81.72","","5157.68","5157.68","5157.68","1 through 10","97.91","153.11","percent of total billed charges",""
"SCREW BONE 3.5X40MM AXSOS CORTEX TITANIUM","SUP-ITM-10144964","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","187.36","140.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","153.11","81.72","","431.26","71.26","1459.57","88","97.91","153.11","percent of total billed charges",""
"SCREW BONE 3.5X44MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277764","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","141.91","79.5","","800.18","480.96","1887.97","195","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X44MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277764","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.14","53.3","","813.12","216.42","1444.50","81","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X44MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277764","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","55.34","31","","432.60","432.60","432.60","1 through 10","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X44MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277764","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.15","36.5","","148.37","54.89","631.39","94","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X44MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277764","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.37","38.3","","279.30","91.72","1116.77","266","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X44MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277764","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.58","42.9","","731.00","63.70","731.00","1 through 10","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X44MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277764","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.58","42.9","","384.74","384.74","384.74","1 through 10","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X44MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277764","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","WELLPOINT [1015]","HB AMC WELLPOINT","131.70","73.78","","286.63","119.22","1107.45","105","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X44MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","AETNA [1001]","HB AMC AETNA HMO","124.59","69.8","","675.31","184.75","1721.50","286","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X44MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","AETNA [1001]","HB AMC AETNA PPO","143.51","80.4","","1261.44","103.12","1514.10","21","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X44MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","143.51","80.4","","1365.00","1365.00","1365.00","1 through 10","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X44MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","145.87","81.72","","5157.68","5157.68","5157.68","1 through 10","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X44MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277764","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","145.87","81.72","","431.26","71.26","1459.57","88","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X44MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10126569","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.11","376.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","399.18","79.5","","800.18","480.96","1887.97","195","155.65","399.18","percent of total billed charges",""
"SCREW BONE 3.5X44MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10126569","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.11","376.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","267.62","53.3","","813.12","216.42","1444.50","81","155.65","399.18","percent of total billed charges",""
"SCREW BONE 3.5X44MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10126569","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.11","376.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","155.65","31","","432.60","432.60","432.60","1 through 10","155.65","399.18","percent of total billed charges",""
"SCREW BONE 3.5X44MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10126569","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.11","376.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","183.27","36.5","","148.37","54.89","631.39","94","155.65","399.18","percent of total billed charges",""
"SCREW BONE 3.5X44MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10126569","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.11","376.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","192.31","38.3","","279.30","91.72","1116.77","266","155.65","399.18","percent of total billed charges",""
"SCREW BONE 3.5X44MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10126569","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.11","376.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","215.41","42.9","","731.00","63.70","731.00","1 through 10","155.65","399.18","percent of total billed charges",""
"SCREW BONE 3.5X44MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10126569","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.11","376.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","215.41","42.9","","384.74","384.74","384.74","1 through 10","155.65","399.18","percent of total billed charges",""
"SCREW BONE 3.5X44MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10126569","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.11","376.58","WELLPOINT [1015]","HB AMC WELLPOINT","370.46","73.78","","286.63","119.22","1107.45","105","155.65","399.18","percent of total billed charges",""
"SCREW BONE 3.5X44MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10126569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.11","376.58","AETNA [1001]","HB AMC AETNA HMO","350.47","69.8","","675.31","184.75","1721.50","286","262.4","410.32","percent of total billed charges",""
"SCREW BONE 3.5X44MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10126569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.11","376.58","AETNA [1001]","HB AMC AETNA PPO","403.70","80.4","","1261.44","103.12","1514.10","21","262.4","410.32","percent of total billed charges",""
"SCREW BONE 3.5X44MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10126569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.11","376.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","403.70","80.4","","1365.00","1365.00","1365.00","1 through 10","262.4","410.32","percent of total billed charges",""
"SCREW BONE 3.5X44MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10126569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.11","376.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","410.32","81.72","","5157.68","5157.68","5157.68","1 through 10","262.4","410.32","percent of total billed charges",""
"SCREW BONE 3.5X44MM VARIAX POLYAXIAL TITANIUM NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10126569","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.11","376.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","410.32","81.72","","431.26","71.26","1459.57","88","262.4","410.32","percent of total billed charges",""
"SCREW BONE 3.5X46MM SS CORTEX LOW PROFILE SELF TAPPING HEXDRIVE STERILE","SUP-ITM-10125176","CDM","C1713","HCPCS","0278","RC","","","","both","","","287.49","215.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","228.55","79.5","","800.18","480.96","1887.97","195","89.12","228.55","percent of total billed charges",""
"SCREW BONE 3.5X46MM SS CORTEX LOW PROFILE SELF TAPPING HEXDRIVE STERILE","SUP-ITM-10125176","CDM","C1713","HCPCS","0278","RC","","","","both","","","287.49","215.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","153.23","53.3","","813.12","216.42","1444.50","81","89.12","228.55","percent of total billed charges",""
"SCREW BONE 3.5X46MM SS CORTEX LOW PROFILE SELF TAPPING HEXDRIVE STERILE","SUP-ITM-10125176","CDM","C1713","HCPCS","0278","RC","","","","both","","","287.49","215.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","89.12","31","","432.60","432.60","432.60","1 through 10","89.12","228.55","percent of total billed charges",""
"SCREW BONE 3.5X46MM SS CORTEX LOW PROFILE SELF TAPPING HEXDRIVE STERILE","SUP-ITM-10125176","CDM","C1713","HCPCS","0278","RC","","","","both","","","287.49","215.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","104.93","36.5","","148.37","54.89","631.39","94","89.12","228.55","percent of total billed charges",""
"SCREW BONE 3.5X46MM SS CORTEX LOW PROFILE SELF TAPPING HEXDRIVE STERILE","SUP-ITM-10125176","CDM","C1713","HCPCS","0278","RC","","","","both","","","287.49","215.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","110.11","38.3","","279.30","91.72","1116.77","266","89.12","228.55","percent of total billed charges",""
"SCREW BONE 3.5X46MM SS CORTEX LOW PROFILE SELF TAPPING HEXDRIVE STERILE","SUP-ITM-10125176","CDM","C1713","HCPCS","0278","RC","","","","both","","","287.49","215.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","123.33","42.9","","731.00","63.70","731.00","1 through 10","89.12","228.55","percent of total billed charges",""
"SCREW BONE 3.5X46MM SS CORTEX LOW PROFILE SELF TAPPING HEXDRIVE STERILE","SUP-ITM-10125176","CDM","C1713","HCPCS","0278","RC","","","","both","","","287.49","215.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","123.33","42.9","","384.74","384.74","384.74","1 through 10","89.12","228.55","percent of total billed charges",""
"SCREW BONE 3.5X46MM SS CORTEX LOW PROFILE SELF TAPPING HEXDRIVE STERILE","SUP-ITM-10125176","CDM","C1713","HCPCS","0278","RC","","","","both","","","287.49","215.62","WELLPOINT [1015]","HB AMC WELLPOINT","212.11","73.78","","286.63","119.22","1107.45","105","89.12","228.55","percent of total billed charges",""
"SCREW BONE 3.5X46MM SS CORTEX LOW PROFILE SELF TAPPING HEXDRIVE STERILE","SUP-ITM-10125176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","287.49","215.62","AETNA [1001]","HB AMC AETNA HMO","200.67","69.8","","675.31","184.75","1721.50","286","150.24","234.94","percent of total billed charges",""
"SCREW BONE 3.5X46MM SS CORTEX LOW PROFILE SELF TAPPING HEXDRIVE STERILE","SUP-ITM-10125176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","287.49","215.62","AETNA [1001]","HB AMC AETNA PPO","231.14","80.4","","1261.44","103.12","1514.10","21","150.24","234.94","percent of total billed charges",""
"SCREW BONE 3.5X46MM SS CORTEX LOW PROFILE SELF TAPPING HEXDRIVE STERILE","SUP-ITM-10125176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","287.49","215.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","231.14","80.4","","1365.00","1365.00","1365.00","1 through 10","150.24","234.94","percent of total billed charges",""
"SCREW BONE 3.5X46MM SS CORTEX LOW PROFILE SELF TAPPING HEXDRIVE STERILE","SUP-ITM-10125176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","287.49","215.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","234.94","81.72","","5157.68","5157.68","5157.68","1 through 10","150.24","234.94","percent of total billed charges",""
"SCREW BONE 3.5X46MM SS CORTEX LOW PROFILE SELF TAPPING HEXDRIVE STERILE","SUP-ITM-10125176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","287.49","215.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","234.94","81.72","","431.26","71.26","1459.57","88","150.24","234.94","percent of total billed charges",""
"SCREW BONE 3.5X48MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277762","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","141.91","79.5","","800.18","480.96","1887.97","195","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X48MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277762","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.14","53.3","","813.12","216.42","1444.50","81","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X48MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277762","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","55.34","31","","432.60","432.60","432.60","1 through 10","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X48MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277762","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.15","36.5","","148.37","54.89","631.39","94","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X48MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277762","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.37","38.3","","279.30","91.72","1116.77","266","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X48MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277762","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.58","42.9","","731.00","63.70","731.00","1 through 10","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X48MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277762","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.58","42.9","","384.74","384.74","384.74","1 through 10","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X48MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277762","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","WELLPOINT [1015]","HB AMC WELLPOINT","131.70","73.78","","286.63","119.22","1107.45","105","55.34","141.91","percent of total billed charges",""
"SCREW BONE 3.5X48MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","AETNA [1001]","HB AMC AETNA HMO","124.59","69.8","","675.31","184.75","1721.50","286","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X48MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","AETNA [1001]","HB AMC AETNA PPO","143.51","80.4","","1261.44","103.12","1514.10","21","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X48MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","143.51","80.4","","1365.00","1365.00","1365.00","1 through 10","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X48MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","145.87","81.72","","5157.68","5157.68","5157.68","1 through 10","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X48MM ANTHEM COBALT CHROME NONLOCKING","SUP-ITM-10277762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","145.87","81.72","","431.26","71.26","1459.57","88","93.28","145.87","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","727.65","545.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","578.48","79.5","","800.18","480.96","1887.97","195","225.57","578.48","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","727.65","545.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","387.84","53.3","","813.12","216.42","1444.50","81","225.57","578.48","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","727.65","545.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","225.57","31","","432.60","432.60","432.60","1 through 10","225.57","578.48","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","727.65","545.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","265.59","36.5","","148.37","54.89","631.39","94","225.57","578.48","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","727.65","545.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","278.69","38.3","","279.30","91.72","1116.77","266","225.57","578.48","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","727.65","545.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.16","42.9","","731.00","63.70","731.00","1 through 10","225.57","578.48","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","727.65","545.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.16","42.9","","384.74","384.74","384.74","1 through 10","225.57","578.48","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","727.65","545.74","WELLPOINT [1015]","HB AMC WELLPOINT","536.86","73.78","","286.63","119.22","1107.45","105","225.57","578.48","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","727.65","545.74","AETNA [1001]","HB AMC AETNA HMO","507.90","69.8","","675.31","184.75","1721.50","286","380.27","594.64","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","727.65","545.74","AETNA [1001]","HB AMC AETNA PPO","585.03","80.4","","1261.44","103.12","1514.10","21","380.27","594.64","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","727.65","545.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","585.03","80.4","","1365.00","1365.00","1365.00","1 through 10","380.27","594.64","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","727.65","545.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","594.64","81.72","","5157.68","5157.68","5157.68","1 through 10","380.27","594.64","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","727.65","545.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","594.64","81.72","","431.26","71.26","1459.57","88","380.27","594.64","percent of total billed charges",""
"SCREW BONE 3.5X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080135","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","473.03","79.5","","800.18","480.96","1887.97","195","184.45","473.03","percent of total billed charges",""
"SCREW BONE 3.5X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080135","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","317.14","53.3","","813.12","216.42","1444.50","81","184.45","473.03","percent of total billed charges",""
"SCREW BONE 3.5X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080135","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","184.45","31","","432.60","432.60","432.60","1 through 10","184.45","473.03","percent of total billed charges",""
"SCREW BONE 3.5X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080135","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","217.18","36.5","","148.37","54.89","631.39","94","184.45","473.03","percent of total billed charges",""
"SCREW BONE 3.5X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080135","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","227.89","38.3","","279.30","91.72","1116.77","266","184.45","473.03","percent of total billed charges",""
"SCREW BONE 3.5X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080135","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.26","42.9","","731.00","63.70","731.00","1 through 10","184.45","473.03","percent of total billed charges",""
"SCREW BONE 3.5X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080135","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.26","42.9","","384.74","384.74","384.74","1 through 10","184.45","473.03","percent of total billed charges",""
"SCREW BONE 3.5X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080135","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.00","446.25","WELLPOINT [1015]","HB AMC WELLPOINT","438.99","73.78","","286.63","119.22","1107.45","105","184.45","473.03","percent of total billed charges",""
"SCREW BONE 3.5X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","AETNA [1001]","HB AMC AETNA HMO","415.31","69.8","","675.31","184.75","1721.50","286","310.95","486.23","percent of total billed charges",""
"SCREW BONE 3.5X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","AETNA [1001]","HB AMC AETNA PPO","478.38","80.4","","1261.44","103.12","1514.10","21","310.95","486.23","percent of total billed charges",""
"SCREW BONE 3.5X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","478.38","80.4","","1365.00","1365.00","1365.00","1 through 10","310.95","486.23","percent of total billed charges",""
"SCREW BONE 3.5X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","486.23","81.72","","5157.68","5157.68","5157.68","1 through 10","310.95","486.23","percent of total billed charges",""
"SCREW BONE 3.5X50MM TAP LOC HEXALOBE TITANIUM VARIABLE ANGLE LOCKING FULL THREAD DISTAL","SUP-ITM-10080135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","486.23","81.72","","431.26","71.26","1459.57","88","310.95","486.23","percent of total billed charges",""
"SCREW BONE 3.5X54MM LOCKING BLUNT TIPPED ORTHOLOC SPS","SUP-ITM-10306399","CDM","C1713","HCPCS","0278","RC","","","","both","","","664.90","498.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","528.60","79.5","","800.18","480.96","1887.97","195","206.12","528.6","percent of total billed charges",""
"SCREW BONE 3.5X54MM LOCKING BLUNT TIPPED ORTHOLOC SPS","SUP-ITM-10306399","CDM","C1713","HCPCS","0278","RC","","","","both","","","664.90","498.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","354.39","53.3","","813.12","216.42","1444.50","81","206.12","528.6","percent of total billed charges",""
"SCREW BONE 3.5X54MM LOCKING BLUNT TIPPED ORTHOLOC SPS","SUP-ITM-10306399","CDM","C1713","HCPCS","0278","RC","","","","both","","","664.90","498.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","206.12","31","","432.60","432.60","432.60","1 through 10","206.12","528.6","percent of total billed charges",""
"SCREW BONE 3.5X54MM LOCKING BLUNT TIPPED ORTHOLOC SPS","SUP-ITM-10306399","CDM","C1713","HCPCS","0278","RC","","","","both","","","664.90","498.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","242.69","36.5","","148.37","54.89","631.39","94","206.12","528.6","percent of total billed charges",""
"SCREW BONE 3.5X54MM LOCKING BLUNT TIPPED ORTHOLOC SPS","SUP-ITM-10306399","CDM","C1713","HCPCS","0278","RC","","","","both","","","664.90","498.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","254.66","38.3","","279.30","91.72","1116.77","266","206.12","528.6","percent of total billed charges",""
"SCREW BONE 3.5X54MM LOCKING BLUNT TIPPED ORTHOLOC SPS","SUP-ITM-10306399","CDM","C1713","HCPCS","0278","RC","","","","both","","","664.90","498.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","285.24","42.9","","731.00","63.70","731.00","1 through 10","206.12","528.6","percent of total billed charges",""
"SCREW BONE 3.5X54MM LOCKING BLUNT TIPPED ORTHOLOC SPS","SUP-ITM-10306399","CDM","C1713","HCPCS","0278","RC","","","","both","","","664.90","498.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","285.24","42.9","","384.74","384.74","384.74","1 through 10","206.12","528.6","percent of total billed charges",""
"SCREW BONE 3.5X54MM LOCKING BLUNT TIPPED ORTHOLOC SPS","SUP-ITM-10306399","CDM","C1713","HCPCS","0278","RC","","","","both","","","664.90","498.67","WELLPOINT [1015]","HB AMC WELLPOINT","490.56","73.78","","286.63","119.22","1107.45","105","206.12","528.6","percent of total billed charges",""
"SCREW BONE 3.5X54MM LOCKING BLUNT TIPPED ORTHOLOC SPS","SUP-ITM-10306399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","664.90","498.67","AETNA [1001]","HB AMC AETNA HMO","464.10","69.8","","675.31","184.75","1721.50","286","347.48","543.36","percent of total billed charges",""
"SCREW BONE 3.5X54MM LOCKING BLUNT TIPPED ORTHOLOC SPS","SUP-ITM-10306399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","664.90","498.67","AETNA [1001]","HB AMC AETNA PPO","534.58","80.4","","1261.44","103.12","1514.10","21","347.48","543.36","percent of total billed charges",""
"SCREW BONE 3.5X54MM LOCKING BLUNT TIPPED ORTHOLOC SPS","SUP-ITM-10306399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","664.90","498.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","534.58","80.4","","1365.00","1365.00","1365.00","1 through 10","347.48","543.36","percent of total billed charges",""
"SCREW BONE 3.5X54MM LOCKING BLUNT TIPPED ORTHOLOC SPS","SUP-ITM-10306399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","664.90","498.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","543.36","81.72","","5157.68","5157.68","5157.68","1 through 10","347.48","543.36","percent of total billed charges",""
"SCREW BONE 3.5X54MM LOCKING BLUNT TIPPED ORTHOLOC SPS","SUP-ITM-10306399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","664.90","498.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","543.36","81.72","","431.26","71.26","1459.57","88","347.48","543.36","percent of total billed charges",""
"SCREW BONE 3.5X55MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10019412","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","225.38","79.5","","800.18","480.96","1887.97","195","87.89","225.38","percent of total billed charges",""
"SCREW BONE 3.5X55MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10019412","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","151.11","53.3","","813.12","216.42","1444.50","81","87.89","225.38","percent of total billed charges",""
"SCREW BONE 3.5X55MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10019412","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","87.89","31","","432.60","432.60","432.60","1 through 10","87.89","225.38","percent of total billed charges",""
"SCREW BONE 3.5X55MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10019412","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","103.48","36.5","","148.37","54.89","631.39","94","87.89","225.38","percent of total billed charges",""
"SCREW BONE 3.5X55MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10019412","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","108.58","38.3","","279.30","91.72","1116.77","266","87.89","225.38","percent of total billed charges",""
"SCREW BONE 3.5X55MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10019412","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","121.62","42.9","","731.00","63.70","731.00","1 through 10","87.89","225.38","percent of total billed charges",""
"SCREW BONE 3.5X55MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10019412","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","121.62","42.9","","384.74","384.74","384.74","1 through 10","87.89","225.38","percent of total billed charges",""
"SCREW BONE 3.5X55MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10019412","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","WELLPOINT [1015]","HB AMC WELLPOINT","209.17","73.78","","286.63","119.22","1107.45","105","87.89","225.38","percent of total billed charges",""
"SCREW BONE 3.5X55MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10019412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","283.50","212.62","AETNA [1001]","HB AMC AETNA HMO","197.88","69.8","","675.31","184.75","1721.50","286","148.16","231.68","percent of total billed charges",""
"SCREW BONE 3.5X55MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10019412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","283.50","212.62","AETNA [1001]","HB AMC AETNA PPO","227.93","80.4","","1261.44","103.12","1514.10","21","148.16","231.68","percent of total billed charges",""
"SCREW BONE 3.5X55MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10019412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","283.50","212.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","227.93","80.4","","1365.00","1365.00","1365.00","1 through 10","148.16","231.68","percent of total billed charges",""
"SCREW BONE 3.5X55MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10019412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","283.50","212.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","231.68","81.72","","5157.68","5157.68","5157.68","1 through 10","148.16","231.68","percent of total billed charges",""
"SCREW BONE 3.5X55MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD","SUP-ITM-10019412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","283.50","212.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","231.68","81.72","","431.26","71.26","1459.57","88","148.16","231.68","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.52","343.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","363.73","79.5","","800.18","480.96","1887.97","195","141.83","363.73","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.52","343.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","243.86","53.3","","813.12","216.42","1444.50","81","141.83","363.73","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.52","343.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","141.83","31","","432.60","432.60","432.60","1 through 10","141.83","363.73","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.52","343.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.99","36.5","","148.37","54.89","631.39","94","141.83","363.73","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.52","343.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","175.23","38.3","","279.30","91.72","1116.77","266","141.83","363.73","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.52","343.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","196.28","42.9","","731.00","63.70","731.00","1 through 10","141.83","363.73","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.52","343.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","196.28","42.9","","384.74","384.74","384.74","1 through 10","141.83","363.73","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.52","343.14","WELLPOINT [1015]","HB AMC WELLPOINT","337.56","73.78","","286.63","119.22","1107.45","105","141.83","363.73","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.52","343.14","AETNA [1001]","HB AMC AETNA HMO","319.35","69.8","","675.31","184.75","1721.50","286","239.1","373.89","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.52","343.14","AETNA [1001]","HB AMC AETNA PPO","367.85","80.4","","1261.44","103.12","1514.10","21","239.1","373.89","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.52","343.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","367.85","80.4","","1365.00","1365.00","1365.00","1 through 10","239.1","373.89","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.52","343.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","373.89","81.72","","5157.68","5157.68","5157.68","1 through 10","239.1","373.89","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.52","343.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","373.89","81.72","","431.26","71.26","1459.57","88","239.1","373.89","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.01","75.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","80.30","79.5","","800.18","480.96","1887.97","195","31.31","80.3","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.01","75.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","53.84","53.3","","813.12","216.42","1444.50","81","31.31","80.3","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.01","75.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","31.31","31","","432.60","432.60","432.60","1 through 10","31.31","80.3","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.01","75.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36.87","36.5","","148.37","54.89","631.39","94","31.31","80.3","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.01","75.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38.69","38.3","","279.30","91.72","1116.77","266","31.31","80.3","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.01","75.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.33","42.9","","731.00","63.70","731.00","1 through 10","31.31","80.3","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.01","75.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.33","42.9","","384.74","384.74","384.74","1 through 10","31.31","80.3","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","both","","","101.01","75.76","WELLPOINT [1015]","HB AMC WELLPOINT","74.53","73.78","","286.63","119.22","1107.45","105","31.31","80.3","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","101.01","75.76","AETNA [1001]","HB AMC AETNA HMO","70.50","69.8","","675.31","184.75","1721.50","286","52.79","82.55","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","101.01","75.76","AETNA [1001]","HB AMC AETNA PPO","81.21","80.4","","1261.44","103.12","1514.10","21","52.79","82.55","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","101.01","75.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","81.21","80.4","","1365.00","1365.00","1365.00","1 through 10","52.79","82.55","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","101.01","75.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","82.55","81.72","","5157.68","5157.68","5157.68","1 through 10","52.79","82.55","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","101.01","75.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","82.55","81.72","","431.26","71.26","1459.57","88","52.79","82.55","percent of total billed charges",""
"SCREW BONE 3.5X65MM ANTHEM SS NONLOCKING","SUP-ITM-10278071","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.50","107.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","114.08","79.5","","800.18","480.96","1887.97","195","44.49","114.08","percent of total billed charges",""
"SCREW BONE 3.5X65MM ANTHEM SS NONLOCKING","SUP-ITM-10278071","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.50","107.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","76.49","53.3","","813.12","216.42","1444.50","81","44.49","114.08","percent of total billed charges",""
"SCREW BONE 3.5X65MM ANTHEM SS NONLOCKING","SUP-ITM-10278071","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.50","107.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","44.49","31","","432.60","432.60","432.60","1 through 10","44.49","114.08","percent of total billed charges",""
"SCREW BONE 3.5X65MM ANTHEM SS NONLOCKING","SUP-ITM-10278071","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.50","107.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","52.38","36.5","","148.37","54.89","631.39","94","44.49","114.08","percent of total billed charges",""
"SCREW BONE 3.5X65MM ANTHEM SS NONLOCKING","SUP-ITM-10278071","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.50","107.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.96","38.3","","279.30","91.72","1116.77","266","44.49","114.08","percent of total billed charges",""
"SCREW BONE 3.5X65MM ANTHEM SS NONLOCKING","SUP-ITM-10278071","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.50","107.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.56","42.9","","731.00","63.70","731.00","1 through 10","44.49","114.08","percent of total billed charges",""
"SCREW BONE 3.5X65MM ANTHEM SS NONLOCKING","SUP-ITM-10278071","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.50","107.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.56","42.9","","384.74","384.74","384.74","1 through 10","44.49","114.08","percent of total billed charges",""
"SCREW BONE 3.5X65MM ANTHEM SS NONLOCKING","SUP-ITM-10278071","CDM","C1713","HCPCS","0278","RC","","","","both","","","143.50","107.62","WELLPOINT [1015]","HB AMC WELLPOINT","105.87","73.78","","286.63","119.22","1107.45","105","44.49","114.08","percent of total billed charges",""
"SCREW BONE 3.5X65MM ANTHEM SS NONLOCKING","SUP-ITM-10278071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.50","107.62","AETNA [1001]","HB AMC AETNA HMO","100.16","69.8","","675.31","184.75","1721.50","286","74.99","117.27","percent of total billed charges",""
"SCREW BONE 3.5X65MM ANTHEM SS NONLOCKING","SUP-ITM-10278071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.50","107.62","AETNA [1001]","HB AMC AETNA PPO","115.37","80.4","","1261.44","103.12","1514.10","21","74.99","117.27","percent of total billed charges",""
"SCREW BONE 3.5X65MM ANTHEM SS NONLOCKING","SUP-ITM-10278071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.50","107.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","115.37","80.4","","1365.00","1365.00","1365.00","1 through 10","74.99","117.27","percent of total billed charges",""
"SCREW BONE 3.5X65MM ANTHEM SS NONLOCKING","SUP-ITM-10278071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.50","107.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","117.27","81.72","","5157.68","5157.68","5157.68","1 through 10","74.99","117.27","percent of total billed charges",""
"SCREW BONE 3.5X65MM ANTHEM SS NONLOCKING","SUP-ITM-10278071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","143.50","107.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","117.27","81.72","","431.26","71.26","1459.57","88","74.99","117.27","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.51","340.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","361.34","79.5","","800.18","480.96","1887.97","195","140.9","361.34","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.51","340.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.25","53.3","","813.12","216.42","1444.50","81","140.9","361.34","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.51","340.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","140.90","31","","432.60","432.60","432.60","1 through 10","140.9","361.34","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.51","340.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","165.90","36.5","","148.37","54.89","631.39","94","140.9","361.34","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.51","340.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.08","38.3","","279.30","91.72","1116.77","266","140.9","361.34","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.51","340.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","194.98","42.9","","731.00","63.70","731.00","1 through 10","140.9","361.34","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.51","340.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","194.98","42.9","","384.74","384.74","384.74","1 through 10","140.9","361.34","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.51","340.88","WELLPOINT [1015]","HB AMC WELLPOINT","335.34","73.78","","286.63","119.22","1107.45","105","140.9","361.34","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.51","340.88","AETNA [1001]","HB AMC AETNA HMO","317.25","69.8","","675.31","184.75","1721.50","286","237.53","371.43","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.51","340.88","AETNA [1001]","HB AMC AETNA PPO","365.43","80.4","","1261.44","103.12","1514.10","21","237.53","371.43","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.51","340.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","365.43","80.4","","1365.00","1365.00","1365.00","1 through 10","237.53","371.43","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.51","340.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","371.43","81.72","","5157.68","5157.68","5157.68","1 through 10","237.53","371.43","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.51","340.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.43","81.72","","431.26","71.26","1459.57","88","237.53","371.43","percent of total billed charges",""
"SCREW BONE 3.5X70MM CORTICAL","SUP-ITM-10175214","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.50","79.5","","800.18","480.96","1887.97","195","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X70MM CORTICAL","SUP-ITM-10175214","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.63","53.3","","813.12","216.42","1444.50","81","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X70MM CORTICAL","SUP-ITM-10175214","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","64.93","31","","432.60","432.60","432.60","1 through 10","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X70MM CORTICAL","SUP-ITM-10175214","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.45","36.5","","148.37","54.89","631.39","94","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X70MM CORTICAL","SUP-ITM-10175214","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.22","38.3","","279.30","91.72","1116.77","266","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X70MM CORTICAL","SUP-ITM-10175214","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.85","42.9","","731.00","63.70","731.00","1 through 10","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X70MM CORTICAL","SUP-ITM-10175214","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.85","42.9","","384.74","384.74","384.74","1 through 10","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X70MM CORTICAL","SUP-ITM-10175214","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.44","157.08","WELLPOINT [1015]","HB AMC WELLPOINT","154.52","73.78","","286.63","119.22","1107.45","105","64.93","166.5","percent of total billed charges",""
"SCREW BONE 3.5X70MM CORTICAL","SUP-ITM-10175214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","AETNA [1001]","HB AMC AETNA HMO","146.19","69.8","","675.31","184.75","1721.50","286","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X70MM CORTICAL","SUP-ITM-10175214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","AETNA [1001]","HB AMC AETNA PPO","168.39","80.4","","1261.44","103.12","1514.10","21","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X70MM CORTICAL","SUP-ITM-10175214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","168.39","80.4","","1365.00","1365.00","1365.00","1 through 10","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X70MM CORTICAL","SUP-ITM-10175214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","171.15","81.72","","5157.68","5157.68","5157.68","1 through 10","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X70MM CORTICAL","SUP-ITM-10175214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.44","157.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.15","81.72","","431.26","71.26","1459.57","88","109.45","171.15","percent of total billed charges",""
"SCREW BONE 3.5X70MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10092335","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.37","373.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","396.20","79.5","","800.18","480.96","1887.97","195","154.49","396.2","percent of total billed charges",""
"SCREW BONE 3.5X70MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10092335","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.37","373.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","265.63","53.3","","813.12","216.42","1444.50","81","154.49","396.2","percent of total billed charges",""
"SCREW BONE 3.5X70MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10092335","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.37","373.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","154.49","31","","432.60","432.60","432.60","1 through 10","154.49","396.2","percent of total billed charges",""
"SCREW BONE 3.5X70MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10092335","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.37","373.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","181.91","36.5","","148.37","54.89","631.39","94","154.49","396.2","percent of total billed charges",""
"SCREW BONE 3.5X70MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10092335","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.37","373.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","190.88","38.3","","279.30","91.72","1116.77","266","154.49","396.2","percent of total billed charges",""
"SCREW BONE 3.5X70MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10092335","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.37","373.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.80","42.9","","731.00","63.70","731.00","1 through 10","154.49","396.2","percent of total billed charges",""
"SCREW BONE 3.5X70MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10092335","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.37","373.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.80","42.9","","384.74","384.74","384.74","1 through 10","154.49","396.2","percent of total billed charges",""
"SCREW BONE 3.5X70MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10092335","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.37","373.78","WELLPOINT [1015]","HB AMC WELLPOINT","367.70","73.78","","286.63","119.22","1107.45","105","154.49","396.2","percent of total billed charges",""
"SCREW BONE 3.5X70MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10092335","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.37","373.78","AETNA [1001]","HB AMC AETNA HMO","347.86","69.8","","675.31","184.75","1721.50","286","260.45","407.27","percent of total billed charges",""
"SCREW BONE 3.5X70MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10092335","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.37","373.78","AETNA [1001]","HB AMC AETNA PPO","400.69","80.4","","1261.44","103.12","1514.10","21","260.45","407.27","percent of total billed charges",""
"SCREW BONE 3.5X70MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10092335","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.37","373.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","400.69","80.4","","1365.00","1365.00","1365.00","1 through 10","260.45","407.27","percent of total billed charges",""
"SCREW BONE 3.5X70MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10092335","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.37","373.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","407.27","81.72","","5157.68","5157.68","5157.68","1 through 10","260.45","407.27","percent of total billed charges",""
"SCREW BONE 3.5X70MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10092335","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.37","373.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","407.27","81.72","","431.26","71.26","1459.57","88","260.45","407.27","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","460.84","79.5","","800.18","480.96","1887.97","195","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","308.96","53.3","","813.12","216.42","1444.50","81","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","179.70","31","","432.60","432.60","432.60","1 through 10","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","211.58","36.5","","148.37","54.89","631.39","94","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","222.01","38.3","","279.30","91.72","1116.77","266","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","248.68","42.9","","731.00","63.70","731.00","1 through 10","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","248.68","42.9","","384.74","384.74","384.74","1 through 10","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","WELLPOINT [1015]","HB AMC WELLPOINT","427.68","73.78","","286.63","119.22","1107.45","105","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","579.67","434.75","AETNA [1001]","HB AMC AETNA HMO","404.61","69.8","","675.31","184.75","1721.50","286","302.94","473.71","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","579.67","434.75","AETNA [1001]","HB AMC AETNA PPO","466.05","80.4","","1261.44","103.12","1514.10","21","302.94","473.71","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","579.67","434.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","466.05","80.4","","1365.00","1365.00","1365.00","1 through 10","302.94","473.71","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","579.67","434.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","473.71","81.72","","5157.68","5157.68","5157.68","1 through 10","302.94","473.71","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","579.67","434.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","473.71","81.72","","431.26","71.26","1459.57","88","302.94","473.71","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","270.77","79.5","","800.18","480.96","1887.97","195","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","181.53","53.3","","813.12","216.42","1444.50","81","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","105.58","31","","432.60","432.60","432.60","1 through 10","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","124.32","36.5","","148.37","54.89","631.39","94","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","130.45","38.3","","279.30","91.72","1116.77","266","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.11","42.9","","731.00","63.70","731.00","1 through 10","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.11","42.9","","384.74","384.74","384.74","1 through 10","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.59","255.44","WELLPOINT [1015]","HB AMC WELLPOINT","251.29","73.78","","286.63","119.22","1107.45","105","105.58","270.77","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.59","255.44","AETNA [1001]","HB AMC AETNA HMO","237.73","69.8","","675.31","184.75","1721.50","286","177.99","278.33","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.59","255.44","AETNA [1001]","HB AMC AETNA PPO","273.83","80.4","","1261.44","103.12","1514.10","21","177.99","278.33","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.59","255.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","273.83","80.4","","1365.00","1365.00","1365.00","1 through 10","177.99","278.33","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.59","255.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","278.33","81.72","","5157.68","5157.68","5157.68","1 through 10","177.99","278.33","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.59","255.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","278.33","81.72","","431.26","71.26","1459.57","88","177.99","278.33","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","79.28","79.5","","800.18","480.96","1887.97","195","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","53.15","53.3","","813.12","216.42","1444.50","81","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","30.91","31","","432.60","432.60","432.60","1 through 10","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36.40","36.5","","148.37","54.89","631.39","94","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38.19","38.3","","279.30","91.72","1116.77","266","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.78","42.9","","731.00","63.70","731.00","1 through 10","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.78","42.9","","384.74","384.74","384.74","1 through 10","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","WELLPOINT [1015]","HB AMC WELLPOINT","73.57","73.78","","286.63","119.22","1107.45","105","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.72","74.79","AETNA [1001]","HB AMC AETNA HMO","69.60","69.8","","675.31","184.75","1721.50","286","52.11","81.49","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.72","74.79","AETNA [1001]","HB AMC AETNA PPO","80.17","80.4","","1261.44","103.12","1514.10","21","52.11","81.49","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.72","74.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","80.17","80.4","","1365.00","1365.00","1365.00","1 through 10","52.11","81.49","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.72","74.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","81.49","81.72","","5157.68","5157.68","5157.68","1 through 10","52.11","81.49","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.72","74.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","81.49","81.72","","431.26","71.26","1459.57","88","52.11","81.49","percent of total billed charges",""
"SCREW BONE 3.5X85MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075962","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","460.84","79.5","","800.18","480.96","1887.97","195","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X85MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075962","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","308.96","53.3","","813.12","216.42","1444.50","81","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X85MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075962","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","179.70","31","","432.60","432.60","432.60","1 through 10","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X85MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075962","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","211.58","36.5","","148.37","54.89","631.39","94","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X85MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075962","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","222.01","38.3","","279.30","91.72","1116.77","266","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X85MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075962","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","248.68","42.9","","731.00","63.70","731.00","1 through 10","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X85MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075962","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","248.68","42.9","","384.74","384.74","384.74","1 through 10","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X85MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075962","CDM","C1713","HCPCS","0278","RC","","","","both","","","579.67","434.75","WELLPOINT [1015]","HB AMC WELLPOINT","427.68","73.78","","286.63","119.22","1107.45","105","179.7","460.84","percent of total billed charges",""
"SCREW BONE 3.5X85MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","579.67","434.75","AETNA [1001]","HB AMC AETNA HMO","404.61","69.8","","675.31","184.75","1721.50","286","302.94","473.71","percent of total billed charges",""
"SCREW BONE 3.5X85MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","579.67","434.75","AETNA [1001]","HB AMC AETNA PPO","466.05","80.4","","1261.44","103.12","1514.10","21","302.94","473.71","percent of total billed charges",""
"SCREW BONE 3.5X85MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","579.67","434.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","466.05","80.4","","1365.00","1365.00","1365.00","1 through 10","302.94","473.71","percent of total billed charges",""
"SCREW BONE 3.5X85MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","579.67","434.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","473.71","81.72","","5157.68","5157.68","5157.68","1 through 10","302.94","473.71","percent of total billed charges",""
"SCREW BONE 3.5X85MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","579.67","434.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","473.71","81.72","","431.26","71.26","1459.57","88","302.94","473.71","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.99","354.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","376.03","79.5","","800.18","480.96","1887.97","195","146.63","376.03","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.99","354.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","252.10","53.3","","813.12","216.42","1444.50","81","146.63","376.03","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.99","354.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","146.63","31","","432.60","432.60","432.60","1 through 10","146.63","376.03","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.99","354.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","172.64","36.5","","148.37","54.89","631.39","94","146.63","376.03","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.99","354.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","181.16","38.3","","279.30","91.72","1116.77","266","146.63","376.03","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.99","354.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.91","42.9","","731.00","63.70","731.00","1 through 10","146.63","376.03","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.99","354.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.91","42.9","","384.74","384.74","384.74","1 through 10","146.63","376.03","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.99","354.74","WELLPOINT [1015]","HB AMC WELLPOINT","348.97","73.78","","286.63","119.22","1107.45","105","146.63","376.03","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.99","354.74","AETNA [1001]","HB AMC AETNA HMO","330.15","69.8","","675.31","184.75","1721.50","286","247.18","386.53","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.99","354.74","AETNA [1001]","HB AMC AETNA PPO","380.28","80.4","","1261.44","103.12","1514.10","21","247.18","386.53","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.99","354.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","380.28","80.4","","1365.00","1365.00","1365.00","1 through 10","247.18","386.53","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.99","354.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","386.53","81.72","","5157.68","5157.68","5157.68","1 through 10","247.18","386.53","percent of total billed charges",""
"SCREW BONE 3.5X8MM CORTICAL UCS.","SUP-ITM-10014646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.99","354.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","386.53","81.72","","431.26","71.26","1459.57","88","247.18","386.53","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","79.28","79.5","","800.18","480.96","1887.97","195","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","53.15","53.3","","813.12","216.42","1444.50","81","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","30.91","31","","432.60","432.60","432.60","1 through 10","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36.40","36.5","","148.37","54.89","631.39","94","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38.19","38.3","","279.30","91.72","1116.77","266","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.78","42.9","","731.00","63.70","731.00","1 through 10","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.78","42.9","","384.74","384.74","384.74","1 through 10","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.72","74.79","WELLPOINT [1015]","HB AMC WELLPOINT","73.57","73.78","","286.63","119.22","1107.45","105","30.91","79.28","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.72","74.79","AETNA [1001]","HB AMC AETNA HMO","69.60","69.8","","675.31","184.75","1721.50","286","52.11","81.49","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.72","74.79","AETNA [1001]","HB AMC AETNA PPO","80.17","80.4","","1261.44","103.12","1514.10","21","52.11","81.49","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.72","74.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","80.17","80.4","","1365.00","1365.00","1365.00","1 through 10","52.11","81.49","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.72","74.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","81.49","81.72","","5157.68","5157.68","5157.68","1 through 10","52.11","81.49","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.72","74.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","81.49","81.72","","431.26","71.26","1459.57","88","52.11","81.49","percent of total billed charges",""
"SCREW BONE 3.7X16MM SPINE CERVICAL TITANIUM ZERO P SELF DRILL VA","SUP-ITM-10189004","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","459.11","79.5","","800.18","480.96","1887.97","195","179.03","459.11","percent of total billed charges",""
"SCREW BONE 3.7X16MM SPINE CERVICAL TITANIUM ZERO P SELF DRILL VA","SUP-ITM-10189004","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","307.81","53.3","","813.12","216.42","1444.50","81","179.03","459.11","percent of total billed charges",""
"SCREW BONE 3.7X16MM SPINE CERVICAL TITANIUM ZERO P SELF DRILL VA","SUP-ITM-10189004","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","179.03","31","","432.60","432.60","432.60","1 through 10","179.03","459.11","percent of total billed charges",""
"SCREW BONE 3.7X16MM SPINE CERVICAL TITANIUM ZERO P SELF DRILL VA","SUP-ITM-10189004","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","210.79","36.5","","148.37","54.89","631.39","94","179.03","459.11","percent of total billed charges",""
"SCREW BONE 3.7X16MM SPINE CERVICAL TITANIUM ZERO P SELF DRILL VA","SUP-ITM-10189004","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","221.18","38.3","","279.30","91.72","1116.77","266","179.03","459.11","percent of total billed charges",""
"SCREW BONE 3.7X16MM SPINE CERVICAL TITANIUM ZERO P SELF DRILL VA","SUP-ITM-10189004","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.75","42.9","","731.00","63.70","731.00","1 through 10","179.03","459.11","percent of total billed charges",""
"SCREW BONE 3.7X16MM SPINE CERVICAL TITANIUM ZERO P SELF DRILL VA","SUP-ITM-10189004","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.75","42.9","","384.74","384.74","384.74","1 through 10","179.03","459.11","percent of total billed charges",""
"SCREW BONE 3.7X16MM SPINE CERVICAL TITANIUM ZERO P SELF DRILL VA","SUP-ITM-10189004","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","WELLPOINT [1015]","HB AMC WELLPOINT","426.08","73.78","","286.63","119.22","1107.45","105","179.03","459.11","percent of total billed charges",""
"SCREW BONE 3.7X16MM SPINE CERVICAL TITANIUM ZERO P SELF DRILL VA","SUP-ITM-10189004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","AETNA [1001]","HB AMC AETNA HMO","403.10","69.8","","675.31","184.75","1721.50","286","301.8","471.93","percent of total billed charges",""
"SCREW BONE 3.7X16MM SPINE CERVICAL TITANIUM ZERO P SELF DRILL VA","SUP-ITM-10189004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","AETNA [1001]","HB AMC AETNA PPO","464.31","80.4","","1261.44","103.12","1514.10","21","301.8","471.93","percent of total billed charges",""
"SCREW BONE 3.7X16MM SPINE CERVICAL TITANIUM ZERO P SELF DRILL VA","SUP-ITM-10189004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","464.31","80.4","","1365.00","1365.00","1365.00","1 through 10","301.8","471.93","percent of total billed charges",""
"SCREW BONE 3.7X16MM SPINE CERVICAL TITANIUM ZERO P SELF DRILL VA","SUP-ITM-10189004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","471.93","81.72","","5157.68","5157.68","5157.68","1 through 10","301.8","471.93","percent of total billed charges",""
"SCREW BONE 3.7X16MM SPINE CERVICAL TITANIUM ZERO P SELF DRILL VA","SUP-ITM-10189004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","471.93","81.72","","431.26","71.26","1459.57","88","301.8","471.93","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","598.24","79.5","","800.18","480.96","1887.97","195","233.28","598.24","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","401.08","53.3","","813.12","216.42","1444.50","81","233.28","598.24","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","233.28","31","","432.60","432.60","432.60","1 through 10","233.28","598.24","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","274.66","36.5","","148.37","54.89","631.39","94","233.28","598.24","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","288.21","38.3","","279.30","91.72","1116.77","266","233.28","598.24","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","322.82","42.9","","731.00","63.70","731.00","1 through 10","233.28","598.24","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","322.82","42.9","","384.74","384.74","384.74","1 through 10","233.28","598.24","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","752.50","564.37","WELLPOINT [1015]","HB AMC WELLPOINT","555.19","73.78","","286.63","119.22","1107.45","105","233.28","598.24","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","752.50","564.37","AETNA [1001]","HB AMC AETNA HMO","525.25","69.8","","675.31","184.75","1721.50","286","393.26","614.94","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","752.50","564.37","AETNA [1001]","HB AMC AETNA PPO","605.01","80.4","","1261.44","103.12","1514.10","21","393.26","614.94","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","752.50","564.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","605.01","80.4","","1365.00","1365.00","1365.00","1 through 10","393.26","614.94","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","752.50","564.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","614.94","81.72","","5157.68","5157.68","5157.68","1 through 10","393.26","614.94","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","752.50","564.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","614.94","81.72","","431.26","71.26","1459.57","88","393.26","614.94","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","459.11","79.5","","800.18","480.96","1887.97","195","179.03","459.11","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","307.81","53.3","","813.12","216.42","1444.50","81","179.03","459.11","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","179.03","31","","432.60","432.60","432.60","1 through 10","179.03","459.11","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","210.79","36.5","","148.37","54.89","631.39","94","179.03","459.11","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","221.18","38.3","","279.30","91.72","1116.77","266","179.03","459.11","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.75","42.9","","731.00","63.70","731.00","1 through 10","179.03","459.11","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.75","42.9","","384.74","384.74","384.74","1 through 10","179.03","459.11","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","WELLPOINT [1015]","HB AMC WELLPOINT","426.08","73.78","","286.63","119.22","1107.45","105","179.03","459.11","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","AETNA [1001]","HB AMC AETNA HMO","403.10","69.8","","675.31","184.75","1721.50","286","301.8","471.93","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","AETNA [1001]","HB AMC AETNA PPO","464.31","80.4","","1261.44","103.12","1514.10","21","301.8","471.93","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","464.31","80.4","","1365.00","1365.00","1365.00","1 through 10","301.8","471.93","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","471.93","81.72","","5157.68","5157.68","5157.68","1 through 10","301.8","471.93","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","471.93","81.72","","431.26","71.26","1459.57","88","301.8","471.93","percent of total billed charges",""
"SCREW BONE 32MM 3.5 6.5X65 CANCELLOUS AXSOS SS THREAD HEXAGONAL DRIVE","SUP-ITM-10016884","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","181.73","79.5","","800.18","480.96","1887.97","195","70.86","181.73","percent of total billed charges",""
"SCREW BONE 32MM 3.5 6.5X65 CANCELLOUS AXSOS SS THREAD HEXAGONAL DRIVE","SUP-ITM-10016884","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","121.84","53.3","","813.12","216.42","1444.50","81","70.86","181.73","percent of total billed charges",""
"SCREW BONE 32MM 3.5 6.5X65 CANCELLOUS AXSOS SS THREAD HEXAGONAL DRIVE","SUP-ITM-10016884","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","70.86","31","","432.60","432.60","432.60","1 through 10","70.86","181.73","percent of total billed charges",""
"SCREW BONE 32MM 3.5 6.5X65 CANCELLOUS AXSOS SS THREAD HEXAGONAL DRIVE","SUP-ITM-10016884","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.44","36.5","","148.37","54.89","631.39","94","70.86","181.73","percent of total billed charges",""
"SCREW BONE 32MM 3.5 6.5X65 CANCELLOUS AXSOS SS THREAD HEXAGONAL DRIVE","SUP-ITM-10016884","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.55","38.3","","279.30","91.72","1116.77","266","70.86","181.73","percent of total billed charges",""
"SCREW BONE 32MM 3.5 6.5X65 CANCELLOUS AXSOS SS THREAD HEXAGONAL DRIVE","SUP-ITM-10016884","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.07","42.9","","731.00","63.70","731.00","1 through 10","70.86","181.73","percent of total billed charges",""
"SCREW BONE 32MM 3.5 6.5X65 CANCELLOUS AXSOS SS THREAD HEXAGONAL DRIVE","SUP-ITM-10016884","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.07","42.9","","384.74","384.74","384.74","1 through 10","70.86","181.73","percent of total billed charges",""
"SCREW BONE 32MM 3.5 6.5X65 CANCELLOUS AXSOS SS THREAD HEXAGONAL DRIVE","SUP-ITM-10016884","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","WELLPOINT [1015]","HB AMC WELLPOINT","168.65","73.78","","286.63","119.22","1107.45","105","70.86","181.73","percent of total billed charges",""
"SCREW BONE 32MM 3.5 6.5X65 CANCELLOUS AXSOS SS THREAD HEXAGONAL DRIVE","SUP-ITM-10016884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.59","171.44","AETNA [1001]","HB AMC AETNA HMO","159.56","69.8","","675.31","184.75","1721.50","286","119.46","186.8","percent of total billed charges",""
"SCREW BONE 32MM 3.5 6.5X65 CANCELLOUS AXSOS SS THREAD HEXAGONAL DRIVE","SUP-ITM-10016884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.59","171.44","AETNA [1001]","HB AMC AETNA PPO","183.79","80.4","","1261.44","103.12","1514.10","21","119.46","186.8","percent of total billed charges",""
"SCREW BONE 32MM 3.5 6.5X65 CANCELLOUS AXSOS SS THREAD HEXAGONAL DRIVE","SUP-ITM-10016884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.59","171.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","183.79","80.4","","1365.00","1365.00","1365.00","1 through 10","119.46","186.8","percent of total billed charges",""
"SCREW BONE 32MM 3.5 6.5X65 CANCELLOUS AXSOS SS THREAD HEXAGONAL DRIVE","SUP-ITM-10016884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.59","171.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","186.80","81.72","","5157.68","5157.68","5157.68","1 through 10","119.46","186.8","percent of total billed charges",""
"SCREW BONE 32MM 3.5 6.5X65 CANCELLOUS AXSOS SS THREAD HEXAGONAL DRIVE","SUP-ITM-10016884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.59","171.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","186.80","81.72","","431.26","71.26","1459.57","88","119.46","186.8","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.95","79.5","","800.18","480.96","1887.97","195","65.1","166.95","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","111.93","53.3","","813.12","216.42","1444.50","81","65.1","166.95","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","65.10","31","","432.60","432.60","432.60","1 through 10","65.1","166.95","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.65","36.5","","148.37","54.89","631.39","94","65.1","166.95","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.43","38.3","","279.30","91.72","1116.77","266","65.1","166.95","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","731.00","63.70","731.00","1 through 10","65.1","166.95","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","384.74","384.74","384.74","1 through 10","65.1","166.95","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB AMC WELLPOINT","154.94","73.78","","286.63","119.22","1107.45","105","65.1","166.95","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA HMO","146.58","69.8","","675.31","184.75","1721.50","286","109.75","171.61","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA PPO","168.84","80.4","","1261.44","103.12","1514.10","21","109.75","171.61","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","168.84","80.4","","1365.00","1365.00","1365.00","1 through 10","109.75","171.61","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","171.61","81.72","","5157.68","5157.68","5157.68","1 through 10","109.75","171.61","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.61","81.72","","431.26","71.26","1459.57","88","109.75","171.61","percent of total billed charges",""
"SCREW BONE 38X3.5MM IASSIST HEX HEAD","SUP-ITM-10134876","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.80","154.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","163.61","79.5","","800.18","480.96","1887.97","195","63.8","163.61","percent of total billed charges",""
"SCREW BONE 38X3.5MM IASSIST HEX HEAD","SUP-ITM-10134876","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.80","154.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.69","53.3","","813.12","216.42","1444.50","81","63.8","163.61","percent of total billed charges",""
"SCREW BONE 38X3.5MM IASSIST HEX HEAD","SUP-ITM-10134876","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.80","154.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","63.80","31","","432.60","432.60","432.60","1 through 10","63.8","163.61","percent of total billed charges",""
"SCREW BONE 38X3.5MM IASSIST HEX HEAD","SUP-ITM-10134876","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.80","154.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","75.12","36.5","","148.37","54.89","631.39","94","63.8","163.61","percent of total billed charges",""
"SCREW BONE 38X3.5MM IASSIST HEX HEAD","SUP-ITM-10134876","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.80","154.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.82","38.3","","279.30","91.72","1116.77","266","63.8","163.61","percent of total billed charges",""
"SCREW BONE 38X3.5MM IASSIST HEX HEAD","SUP-ITM-10134876","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.80","154.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.29","42.9","","731.00","63.70","731.00","1 through 10","63.8","163.61","percent of total billed charges",""
"SCREW BONE 38X3.5MM IASSIST HEX HEAD","SUP-ITM-10134876","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.80","154.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.29","42.9","","384.74","384.74","384.74","1 through 10","63.8","163.61","percent of total billed charges",""
"SCREW BONE 38X3.5MM IASSIST HEX HEAD","SUP-ITM-10134876","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.80","154.35","WELLPOINT [1015]","HB AMC WELLPOINT","151.84","73.78","","286.63","119.22","1107.45","105","63.8","163.61","percent of total billed charges",""
"SCREW BONE 38X3.5MM IASSIST HEX HEAD","SUP-ITM-10134876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.80","154.35","AETNA [1001]","HB AMC AETNA HMO","143.65","69.8","","675.31","184.75","1721.50","286","107.55","168.18","percent of total billed charges",""
"SCREW BONE 38X3.5MM IASSIST HEX HEAD","SUP-ITM-10134876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.80","154.35","AETNA [1001]","HB AMC AETNA PPO","165.46","80.4","","1261.44","103.12","1514.10","21","107.55","168.18","percent of total billed charges",""
"SCREW BONE 38X3.5MM IASSIST HEX HEAD","SUP-ITM-10134876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.80","154.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","165.46","80.4","","1365.00","1365.00","1365.00","1 through 10","107.55","168.18","percent of total billed charges",""
"SCREW BONE 38X3.5MM IASSIST HEX HEAD","SUP-ITM-10134876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.80","154.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","168.18","81.72","","5157.68","5157.68","5157.68","1 through 10","107.55","168.18","percent of total billed charges",""
"SCREW BONE 38X3.5MM IASSIST HEX HEAD","SUP-ITM-10134876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.80","154.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","168.18","81.72","","431.26","71.26","1459.57","88","107.55","168.18","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1407.95","79.5","","800.18","480.96","1887.97","195","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","943.94","53.3","","813.12","216.42","1444.50","81","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","549.01","31","","432.60","432.60","432.60","1 through 10","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","646.42","36.5","","148.37","54.89","631.39","94","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","678.29","38.3","","279.30","91.72","1116.77","266","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","759.76","42.9","","731.00","63.70","731.00","1 through 10","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","759.76","42.9","","384.74","384.74","384.74","1 through 10","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","WELLPOINT [1015]","HB AMC WELLPOINT","1306.64","73.78","","286.63","119.22","1107.45","105","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1771.00","1328.25","AETNA [1001]","HB AMC AETNA HMO","1236.16","69.8","","675.31","184.75","1721.50","286","925.52","1447.26","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1771.00","1328.25","AETNA [1001]","HB AMC AETNA PPO","1423.88","80.4","","1261.44","103.12","1514.10","21","925.52","1447.26","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1771.00","1328.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1423.88","80.4","","1365.00","1365.00","1365.00","1 through 10","925.52","1447.26","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1771.00","1328.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1447.26","81.72","","5157.68","5157.68","5157.68","1 through 10","925.52","1447.26","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1771.00","1328.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1447.26","81.72","","431.26","71.26","1459.57","88","925.52","1447.26","percent of total billed charges",""
"SCREW BONE 3X14MM LOCKING FOR STERNAL PLATE TITANIUM PK/5EA","SUP-ITM-10022176","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","295.60","79.5","","800.18","480.96","1887.97","195","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X14MM LOCKING FOR STERNAL PLATE TITANIUM PK/5EA","SUP-ITM-10022176","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.19","53.3","","813.12","216.42","1444.50","81","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X14MM LOCKING FOR STERNAL PLATE TITANIUM PK/5EA","SUP-ITM-10022176","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.27","31","","432.60","432.60","432.60","1 through 10","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X14MM LOCKING FOR STERNAL PLATE TITANIUM PK/5EA","SUP-ITM-10022176","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","135.72","36.5","","148.37","54.89","631.39","94","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X14MM LOCKING FOR STERNAL PLATE TITANIUM PK/5EA","SUP-ITM-10022176","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.41","38.3","","279.30","91.72","1116.77","266","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X14MM LOCKING FOR STERNAL PLATE TITANIUM PK/5EA","SUP-ITM-10022176","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.52","42.9","","731.00","63.70","731.00","1 through 10","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X14MM LOCKING FOR STERNAL PLATE TITANIUM PK/5EA","SUP-ITM-10022176","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.52","42.9","","384.74","384.74","384.74","1 through 10","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X14MM LOCKING FOR STERNAL PLATE TITANIUM PK/5EA","SUP-ITM-10022176","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","WELLPOINT [1015]","HB AMC WELLPOINT","274.34","73.78","","286.63","119.22","1107.45","105","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X14MM LOCKING FOR STERNAL PLATE TITANIUM PK/5EA","SUP-ITM-10022176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.83","278.87","AETNA [1001]","HB AMC AETNA HMO","259.54","69.8","","675.31","184.75","1721.50","286","194.32","303.86","percent of total billed charges",""
"SCREW BONE 3X14MM LOCKING FOR STERNAL PLATE TITANIUM PK/5EA","SUP-ITM-10022176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.83","278.87","AETNA [1001]","HB AMC AETNA PPO","298.95","80.4","","1261.44","103.12","1514.10","21","194.32","303.86","percent of total billed charges",""
"SCREW BONE 3X14MM LOCKING FOR STERNAL PLATE TITANIUM PK/5EA","SUP-ITM-10022176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.83","278.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","298.95","80.4","","1365.00","1365.00","1365.00","1 through 10","194.32","303.86","percent of total billed charges",""
"SCREW BONE 3X14MM LOCKING FOR STERNAL PLATE TITANIUM PK/5EA","SUP-ITM-10022176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.83","278.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","303.86","81.72","","5157.68","5157.68","5157.68","1 through 10","194.32","303.86","percent of total billed charges",""
"SCREW BONE 3X14MM LOCKING FOR STERNAL PLATE TITANIUM PK/5EA","SUP-ITM-10022176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.83","278.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","303.86","81.72","","431.26","71.26","1459.57","88","194.32","303.86","percent of total billed charges",""
"SCREW BONE 3X14MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042695","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","295.59","79.5","","800.18","480.96","1887.97","195","115.26","295.59","percent of total billed charges",""
"SCREW BONE 3X14MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042695","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.17","53.3","","813.12","216.42","1444.50","81","115.26","295.59","percent of total billed charges",""
"SCREW BONE 3X14MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042695","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.26","31","","432.60","432.60","432.60","1 through 10","115.26","295.59","percent of total billed charges",""
"SCREW BONE 3X14MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042695","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","135.71","36.5","","148.37","54.89","631.39","94","115.26","295.59","percent of total billed charges",""
"SCREW BONE 3X14MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042695","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.40","38.3","","279.30","91.72","1116.77","266","115.26","295.59","percent of total billed charges",""
"SCREW BONE 3X14MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042695","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.51","42.9","","731.00","63.70","731.00","1 through 10","115.26","295.59","percent of total billed charges",""
"SCREW BONE 3X14MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042695","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.51","42.9","","384.74","384.74","384.74","1 through 10","115.26","295.59","percent of total billed charges",""
"SCREW BONE 3X14MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042695","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.81","278.86","WELLPOINT [1015]","HB AMC WELLPOINT","274.32","73.78","","286.63","119.22","1107.45","105","115.26","295.59","percent of total billed charges",""
"SCREW BONE 3X14MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.81","278.86","AETNA [1001]","HB AMC AETNA HMO","259.52","69.8","","675.31","184.75","1721.50","286","194.31","303.84","percent of total billed charges",""
"SCREW BONE 3X14MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.81","278.86","AETNA [1001]","HB AMC AETNA PPO","298.94","80.4","","1261.44","103.12","1514.10","21","194.31","303.84","percent of total billed charges",""
"SCREW BONE 3X14MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.81","278.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","298.94","80.4","","1365.00","1365.00","1365.00","1 through 10","194.31","303.84","percent of total billed charges",""
"SCREW BONE 3X14MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.81","278.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","303.84","81.72","","5157.68","5157.68","5157.68","1 through 10","194.31","303.84","percent of total billed charges",""
"SCREW BONE 3X14MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.81","278.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","303.84","81.72","","431.26","71.26","1459.57","88","194.31","303.84","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.72","341.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","361.50","79.5","","800.18","480.96","1887.97","195","140.96","361.5","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.72","341.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.37","53.3","","813.12","216.42","1444.50","81","140.96","361.5","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.72","341.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","140.96","31","","432.60","432.60","432.60","1 through 10","140.96","361.5","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.72","341.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","165.97","36.5","","148.37","54.89","631.39","94","140.96","361.5","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.72","341.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.16","38.3","","279.30","91.72","1116.77","266","140.96","361.5","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.72","341.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.07","42.9","","731.00","63.70","731.00","1 through 10","140.96","361.5","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.72","341.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.07","42.9","","384.74","384.74","384.74","1 through 10","140.96","361.5","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","454.72","341.04","WELLPOINT [1015]","HB AMC WELLPOINT","335.49","73.78","","286.63","119.22","1107.45","105","140.96","361.5","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.72","341.04","AETNA [1001]","HB AMC AETNA HMO","317.39","69.8","","675.31","184.75","1721.50","286","237.64","371.6","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.72","341.04","AETNA [1001]","HB AMC AETNA PPO","365.59","80.4","","1261.44","103.12","1514.10","21","237.64","371.6","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.72","341.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","365.59","80.4","","1365.00","1365.00","1365.00","1 through 10","237.64","371.6","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.72","341.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","371.60","81.72","","5157.68","5157.68","5157.68","1 through 10","237.64","371.6","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","454.72","341.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.60","81.72","","431.26","71.26","1459.57","88","237.64","371.6","percent of total billed charges",""
"SCREW BONE 3X18MM MANDIBLE TI LOCKING SELF TAPPING CRUCIFORM RECESS FOR RECONSTRUCTION PLATE PK/5EA","SUP-ITM-10275508","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","295.60","79.5","","800.18","480.96","1887.97","195","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X18MM MANDIBLE TI LOCKING SELF TAPPING CRUCIFORM RECESS FOR RECONSTRUCTION PLATE PK/5EA","SUP-ITM-10275508","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.19","53.3","","813.12","216.42","1444.50","81","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X18MM MANDIBLE TI LOCKING SELF TAPPING CRUCIFORM RECESS FOR RECONSTRUCTION PLATE PK/5EA","SUP-ITM-10275508","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.27","31","","432.60","432.60","432.60","1 through 10","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X18MM MANDIBLE TI LOCKING SELF TAPPING CRUCIFORM RECESS FOR RECONSTRUCTION PLATE PK/5EA","SUP-ITM-10275508","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","135.72","36.5","","148.37","54.89","631.39","94","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X18MM MANDIBLE TI LOCKING SELF TAPPING CRUCIFORM RECESS FOR RECONSTRUCTION PLATE PK/5EA","SUP-ITM-10275508","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.41","38.3","","279.30","91.72","1116.77","266","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X18MM MANDIBLE TI LOCKING SELF TAPPING CRUCIFORM RECESS FOR RECONSTRUCTION PLATE PK/5EA","SUP-ITM-10275508","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.52","42.9","","731.00","63.70","731.00","1 through 10","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X18MM MANDIBLE TI LOCKING SELF TAPPING CRUCIFORM RECESS FOR RECONSTRUCTION PLATE PK/5EA","SUP-ITM-10275508","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.52","42.9","","384.74","384.74","384.74","1 through 10","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X18MM MANDIBLE TI LOCKING SELF TAPPING CRUCIFORM RECESS FOR RECONSTRUCTION PLATE PK/5EA","SUP-ITM-10275508","CDM","C1713","HCPCS","0278","RC","","","","both","","","371.83","278.87","WELLPOINT [1015]","HB AMC WELLPOINT","274.34","73.78","","286.63","119.22","1107.45","105","115.27","295.6","percent of total billed charges",""
"SCREW BONE 3X18MM MANDIBLE TI LOCKING SELF TAPPING CRUCIFORM RECESS FOR RECONSTRUCTION PLATE PK/5EA","SUP-ITM-10275508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.83","278.87","AETNA [1001]","HB AMC AETNA HMO","259.54","69.8","","675.31","184.75","1721.50","286","194.32","303.86","percent of total billed charges",""
"SCREW BONE 3X18MM MANDIBLE TI LOCKING SELF TAPPING CRUCIFORM RECESS FOR RECONSTRUCTION PLATE PK/5EA","SUP-ITM-10275508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.83","278.87","AETNA [1001]","HB AMC AETNA PPO","298.95","80.4","","1261.44","103.12","1514.10","21","194.32","303.86","percent of total billed charges",""
"SCREW BONE 3X18MM MANDIBLE TI LOCKING SELF TAPPING CRUCIFORM RECESS FOR RECONSTRUCTION PLATE PK/5EA","SUP-ITM-10275508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.83","278.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","298.95","80.4","","1365.00","1365.00","1365.00","1 through 10","194.32","303.86","percent of total billed charges",""
"SCREW BONE 3X18MM MANDIBLE TI LOCKING SELF TAPPING CRUCIFORM RECESS FOR RECONSTRUCTION PLATE PK/5EA","SUP-ITM-10275508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.83","278.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","303.86","81.72","","5157.68","5157.68","5157.68","1 through 10","194.32","303.86","percent of total billed charges",""
"SCREW BONE 3X18MM MANDIBLE TI LOCKING SELF TAPPING CRUCIFORM RECESS FOR RECONSTRUCTION PLATE PK/5EA","SUP-ITM-10275508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","371.83","278.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","303.86","81.72","","431.26","71.26","1459.57","88","194.32","303.86","percent of total billed charges",""
"SCREW BONE 3X18MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042697","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.77","259.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","274.89","79.5","","800.18","480.96","1887.97","195","107.19","274.89","percent of total billed charges",""
"SCREW BONE 3X18MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042697","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.77","259.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","184.30","53.3","","813.12","216.42","1444.50","81","107.19","274.89","percent of total billed charges",""
"SCREW BONE 3X18MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042697","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.77","259.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","107.19","31","","432.60","432.60","432.60","1 through 10","107.19","274.89","percent of total billed charges",""
"SCREW BONE 3X18MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042697","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.77","259.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","126.21","36.5","","148.37","54.89","631.39","94","107.19","274.89","percent of total billed charges",""
"SCREW BONE 3X18MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042697","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.77","259.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","132.43","38.3","","279.30","91.72","1116.77","266","107.19","274.89","percent of total billed charges",""
"SCREW BONE 3X18MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042697","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.77","259.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.34","42.9","","731.00","63.70","731.00","1 through 10","107.19","274.89","percent of total billed charges",""
"SCREW BONE 3X18MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042697","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.77","259.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.34","42.9","","384.74","384.74","384.74","1 through 10","107.19","274.89","percent of total billed charges",""
"SCREW BONE 3X18MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042697","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.77","259.33","WELLPOINT [1015]","HB AMC WELLPOINT","255.11","73.78","","286.63","119.22","1107.45","105","107.19","274.89","percent of total billed charges",""
"SCREW BONE 3X18MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.77","259.33","AETNA [1001]","HB AMC AETNA HMO","241.35","69.8","","675.31","184.75","1721.50","286","180.7","282.56","percent of total billed charges",""
"SCREW BONE 3X18MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.77","259.33","AETNA [1001]","HB AMC AETNA PPO","278.00","80.4","","1261.44","103.12","1514.10","21","180.7","282.56","percent of total billed charges",""
"SCREW BONE 3X18MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.77","259.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","278.00","80.4","","1365.00","1365.00","1365.00","1 through 10","180.7","282.56","percent of total billed charges",""
"SCREW BONE 3X18MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.77","259.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","282.56","81.72","","5157.68","5157.68","5157.68","1 through 10","180.7","282.56","percent of total billed charges",""
"SCREW BONE 3X18MM STERNAL TITANIUM LOCKING SELF DRILLING","SUP-ITM-10042697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.77","259.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","282.56","81.72","","431.26","71.26","1459.57","88","180.7","282.56","percent of total billed charges",""
"SCREW BONE 3X24MM TITANIUM FIXATION LOCKING SELF TAPPING STERNAL PK/5EA","SUP-ITM-10083635","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.55","331.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","351.03","79.5","","800.18","480.96","1887.97","195","136.88","351.03","percent of total billed charges",""
"SCREW BONE 3X24MM TITANIUM FIXATION LOCKING SELF TAPPING STERNAL PK/5EA","SUP-ITM-10083635","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.55","331.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","235.35","53.3","","813.12","216.42","1444.50","81","136.88","351.03","percent of total billed charges",""
"SCREW BONE 3X24MM TITANIUM FIXATION LOCKING SELF TAPPING STERNAL PK/5EA","SUP-ITM-10083635","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.55","331.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","136.88","31","","432.60","432.60","432.60","1 through 10","136.88","351.03","percent of total billed charges",""
"SCREW BONE 3X24MM TITANIUM FIXATION LOCKING SELF TAPPING STERNAL PK/5EA","SUP-ITM-10083635","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.55","331.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","161.17","36.5","","148.37","54.89","631.39","94","136.88","351.03","percent of total billed charges",""
"SCREW BONE 3X24MM TITANIUM FIXATION LOCKING SELF TAPPING STERNAL PK/5EA","SUP-ITM-10083635","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.55","331.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","169.11","38.3","","279.30","91.72","1116.77","266","136.88","351.03","percent of total billed charges",""
"SCREW BONE 3X24MM TITANIUM FIXATION LOCKING SELF TAPPING STERNAL PK/5EA","SUP-ITM-10083635","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.55","331.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.42","42.9","","731.00","63.70","731.00","1 through 10","136.88","351.03","percent of total billed charges",""
"SCREW BONE 3X24MM TITANIUM FIXATION LOCKING SELF TAPPING STERNAL PK/5EA","SUP-ITM-10083635","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.55","331.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.42","42.9","","384.74","384.74","384.74","1 through 10","136.88","351.03","percent of total billed charges",""
"SCREW BONE 3X24MM TITANIUM FIXATION LOCKING SELF TAPPING STERNAL PK/5EA","SUP-ITM-10083635","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.55","331.16","WELLPOINT [1015]","HB AMC WELLPOINT","325.78","73.78","","286.63","119.22","1107.45","105","136.88","351.03","percent of total billed charges",""
"SCREW BONE 3X24MM TITANIUM FIXATION LOCKING SELF TAPPING STERNAL PK/5EA","SUP-ITM-10083635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","441.55","331.16","AETNA [1001]","HB AMC AETNA HMO","308.20","69.8","","675.31","184.75","1721.50","286","230.75","360.83","percent of total billed charges",""
"SCREW BONE 3X24MM TITANIUM FIXATION LOCKING SELF TAPPING STERNAL PK/5EA","SUP-ITM-10083635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","441.55","331.16","AETNA [1001]","HB AMC AETNA PPO","355.01","80.4","","1261.44","103.12","1514.10","21","230.75","360.83","percent of total billed charges",""
"SCREW BONE 3X24MM TITANIUM FIXATION LOCKING SELF TAPPING STERNAL PK/5EA","SUP-ITM-10083635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","441.55","331.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","355.01","80.4","","1365.00","1365.00","1365.00","1 through 10","230.75","360.83","percent of total billed charges",""
"SCREW BONE 3X24MM TITANIUM FIXATION LOCKING SELF TAPPING STERNAL PK/5EA","SUP-ITM-10083635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","441.55","331.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","360.83","81.72","","5157.68","5157.68","5157.68","1 through 10","230.75","360.83","percent of total billed charges",""
"SCREW BONE 3X24MM TITANIUM FIXATION LOCKING SELF TAPPING STERNAL PK/5EA","SUP-ITM-10083635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","441.55","331.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","360.83","81.72","","431.26","71.26","1459.57","88","230.75","360.83","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","730.24","547.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","580.54","79.5","","800.18","480.96","1887.97","195","226.37","580.54","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","730.24","547.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","389.22","53.3","","813.12","216.42","1444.50","81","226.37","580.54","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","730.24","547.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","226.37","31","","432.60","432.60","432.60","1 through 10","226.37","580.54","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","730.24","547.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","266.54","36.5","","148.37","54.89","631.39","94","226.37","580.54","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","730.24","547.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","279.68","38.3","","279.30","91.72","1116.77","266","226.37","580.54","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","730.24","547.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","313.27","42.9","","731.00","63.70","731.00","1 through 10","226.37","580.54","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","730.24","547.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","313.27","42.9","","384.74","384.74","384.74","1 through 10","226.37","580.54","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","730.24","547.68","WELLPOINT [1015]","HB AMC WELLPOINT","538.77","73.78","","286.63","119.22","1107.45","105","226.37","580.54","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","730.24","547.68","AETNA [1001]","HB AMC AETNA HMO","509.71","69.8","","675.31","184.75","1721.50","286","381.62","596.75","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","730.24","547.68","AETNA [1001]","HB AMC AETNA PPO","587.11","80.4","","1261.44","103.12","1514.10","21","381.62","596.75","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","730.24","547.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","587.11","80.4","","1365.00","1365.00","1365.00","1 through 10","381.62","596.75","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","730.24","547.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","596.75","81.72","","5157.68","5157.68","5157.68","1 through 10","381.62","596.75","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","730.24","547.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","596.75","81.72","","431.26","71.26","1459.57","88","381.62","596.75","percent of total billed charges",""
"SCREW BONE 3X30MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040437","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.40","604.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","641.09","79.5","","800.18","480.96","1887.97","195","249.98","641.09","percent of total billed charges",""
"SCREW BONE 3X30MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040437","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.40","604.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","429.81","53.3","","813.12","216.42","1444.50","81","249.98","641.09","percent of total billed charges",""
"SCREW BONE 3X30MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040437","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.40","604.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","249.98","31","","432.60","432.60","432.60","1 through 10","249.98","641.09","percent of total billed charges",""
"SCREW BONE 3X30MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040437","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.40","604.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","294.34","36.5","","148.37","54.89","631.39","94","249.98","641.09","percent of total billed charges",""
"SCREW BONE 3X30MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040437","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.40","604.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","308.85","38.3","","279.30","91.72","1116.77","266","249.98","641.09","percent of total billed charges",""
"SCREW BONE 3X30MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040437","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.40","604.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","345.95","42.9","","731.00","63.70","731.00","1 through 10","249.98","641.09","percent of total billed charges",""
"SCREW BONE 3X30MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040437","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.40","604.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","345.95","42.9","","384.74","384.74","384.74","1 through 10","249.98","641.09","percent of total billed charges",""
"SCREW BONE 3X30MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040437","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.40","604.80","WELLPOINT [1015]","HB AMC WELLPOINT","594.96","73.78","","286.63","119.22","1107.45","105","249.98","641.09","percent of total billed charges",""
"SCREW BONE 3X30MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","806.40","604.80","AETNA [1001]","HB AMC AETNA HMO","562.87","69.8","","675.31","184.75","1721.50","286","421.42","658.99","percent of total billed charges",""
"SCREW BONE 3X30MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","806.40","604.80","AETNA [1001]","HB AMC AETNA PPO","648.35","80.4","","1261.44","103.12","1514.10","21","421.42","658.99","percent of total billed charges",""
"SCREW BONE 3X30MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","806.40","604.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","648.35","80.4","","1365.00","1365.00","1365.00","1 through 10","421.42","658.99","percent of total billed charges",""
"SCREW BONE 3X30MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","806.40","604.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","658.99","81.72","","5157.68","5157.68","5157.68","1 through 10","421.42","658.99","percent of total billed charges",""
"SCREW BONE 3X30MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","806.40","604.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","658.99","81.72","","431.26","71.26","1459.57","88","421.42","658.99","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3589.43","79.5","","800.18","480.96","1887.97","195","1399.65","3589.43","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2406.50","53.3","","813.12","216.42","1444.50","81","1399.65","3589.43","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1399.65","31","","432.60","432.60","432.60","1 through 10","1399.65","3589.43","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1647.98","36.5","","148.37","54.89","631.39","94","1399.65","3589.43","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1729.25","38.3","","279.30","91.72","1116.77","266","1399.65","3589.43","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1936.94","42.9","","731.00","63.70","731.00","1 through 10","1399.65","3589.43","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1936.94","42.9","","384.74","384.74","384.74","1 through 10","1399.65","3589.43","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","4515.00","3386.25","WELLPOINT [1015]","HB AMC WELLPOINT","3331.17","73.78","","286.63","119.22","1107.45","105","1399.65","3589.43","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4515.00","3386.25","AETNA [1001]","HB AMC AETNA HMO","3151.47","69.8","","675.31","184.75","1721.50","286","2359.54","3689.66","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4515.00","3386.25","AETNA [1001]","HB AMC AETNA PPO","3630.06","80.4","","1261.44","103.12","1514.10","21","2359.54","3689.66","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4515.00","3386.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3630.06","80.4","","1365.00","1365.00","1365.00","1 through 10","2359.54","3689.66","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4515.00","3386.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3689.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2359.54","3689.66","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4515.00","3386.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3689.66","81.72","","431.26","71.26","1459.57","88","2359.54","3689.66","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ TITANIUM SELF DRILLING","SUP-ITM-10027387","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","374.75","79.5","","800.18","480.96","1887.97","195","146.13","374.75","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ TITANIUM SELF DRILLING","SUP-ITM-10027387","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","251.25","53.3","","813.12","216.42","1444.50","81","146.13","374.75","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ TITANIUM SELF DRILLING","SUP-ITM-10027387","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","146.13","31","","432.60","432.60","432.60","1 through 10","146.13","374.75","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ TITANIUM SELF DRILLING","SUP-ITM-10027387","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","172.05","36.5","","148.37","54.89","631.39","94","146.13","374.75","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ TITANIUM SELF DRILLING","SUP-ITM-10027387","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","180.54","38.3","","279.30","91.72","1116.77","266","146.13","374.75","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ TITANIUM SELF DRILLING","SUP-ITM-10027387","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.22","42.9","","731.00","63.70","731.00","1 through 10","146.13","374.75","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ TITANIUM SELF DRILLING","SUP-ITM-10027387","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.22","42.9","","384.74","384.74","384.74","1 through 10","146.13","374.75","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ TITANIUM SELF DRILLING","SUP-ITM-10027387","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.38","353.53","WELLPOINT [1015]","HB AMC WELLPOINT","347.78","73.78","","286.63","119.22","1107.45","105","146.13","374.75","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ TITANIUM SELF DRILLING","SUP-ITM-10027387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.38","353.53","AETNA [1001]","HB AMC AETNA HMO","329.02","69.8","","675.31","184.75","1721.50","286","246.34","385.21","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ TITANIUM SELF DRILLING","SUP-ITM-10027387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.38","353.53","AETNA [1001]","HB AMC AETNA PPO","378.99","80.4","","1261.44","103.12","1514.10","21","246.34","385.21","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ TITANIUM SELF DRILLING","SUP-ITM-10027387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.38","353.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","378.99","80.4","","1365.00","1365.00","1365.00","1 through 10","246.34","385.21","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ TITANIUM SELF DRILLING","SUP-ITM-10027387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.38","353.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","385.21","81.72","","5157.68","5157.68","5157.68","1 through 10","246.34","385.21","percent of total billed charges",""
"SCREW BONE 3X80MM SCHANZ TITANIUM SELF DRILLING","SUP-ITM-10027387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.38","353.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","385.21","81.72","","431.26","71.26","1459.57","88","246.34","385.21","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","both","","","385.00","288.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","306.08","79.5","","1309.77","674.56","6049.93","26","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","both","","","385.00","288.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","205.21","53.3","","1901.83","1901.83","2962.25","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","140.53","36.5","","1620.31","1620.31","19908.88","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","147.46","38.3","","352.91","352.91","2046.30","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","both","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","165.17","42.9","","9668.75","9668.75","9668.75","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","both","","","385.00","288.75","WELLPOINT [1015]","HB AMC WELLPOINT","284.05","73.78","","699.88","384.10","3443.31","33","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","AETNA [1001]","HB AMC AETNA HMO","268.73","69.8","","1421.24","264.50","4933.46","29","201.2","314.62","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","309.54","80.4","","1022.97","1022.97","3607.50","1 through 10","201.2","314.62","percent of total billed charges",""
"SCREW BONE 4.0X12MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING BLUE","SUP-ITM-10021487","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","314.62","81.72","","3010.54","693.88","5019.88","35","201.2","314.62","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","306.08","79.5","","800.18","480.96","1887.97","195","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","205.21","53.3","","813.12","216.42","1444.50","81","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","119.35","31","","432.60","432.60","432.60","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","140.53","36.5","","148.37","54.89","631.39","94","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","147.46","38.3","","279.30","91.72","1116.77","266","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","165.17","42.9","","731.00","63.70","731.00","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","165.17","42.9","","384.74","384.74","384.74","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","WELLPOINT [1015]","HB AMC WELLPOINT","284.05","73.78","","286.63","119.22","1107.45","105","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","AETNA [1001]","HB AMC AETNA HMO","268.73","69.8","","675.31","184.75","1721.50","286","201.2","314.62","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","AETNA [1001]","HB AMC AETNA PPO","309.54","80.4","","1261.44","103.12","1514.10","21","201.2","314.62","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","309.54","80.4","","1365.00","1365.00","1365.00","1 through 10","201.2","314.62","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","314.62","81.72","","5157.68","5157.68","5157.68","1 through 10","201.2","314.62","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","314.62","81.72","","431.26","71.26","1459.57","88","201.2","314.62","percent of total billed charges",""
"SCREW BONE 4.0X22MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033868","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","828.16","79.5","","800.18","480.96","1887.97","195","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X22MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033868","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","555.23","53.3","","813.12","216.42","1444.50","81","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X22MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033868","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","322.93","31","","432.60","432.60","432.60","1 through 10","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X22MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033868","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","380.22","36.5","","148.37","54.89","631.39","94","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X22MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033868","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","398.97","38.3","","279.30","91.72","1116.77","266","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X22MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033868","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.89","42.9","","731.00","63.70","731.00","1 through 10","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X22MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033868","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.89","42.9","","384.74","384.74","384.74","1 through 10","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X22MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033868","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","WELLPOINT [1015]","HB AMC WELLPOINT","768.57","73.78","","286.63","119.22","1107.45","105","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X22MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.71","781.28","AETNA [1001]","HB AMC AETNA HMO","727.11","69.8","","675.31","184.75","1721.50","286","544.4","851.29","percent of total billed charges",""
"SCREW BONE 4.0X22MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.71","781.28","AETNA [1001]","HB AMC AETNA PPO","837.53","80.4","","1261.44","103.12","1514.10","21","544.4","851.29","percent of total billed charges",""
"SCREW BONE 4.0X22MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.71","781.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","837.53","80.4","","1365.00","1365.00","1365.00","1 through 10","544.4","851.29","percent of total billed charges",""
"SCREW BONE 4.0X22MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.71","781.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","851.29","81.72","","5157.68","5157.68","5157.68","1 through 10","544.4","851.29","percent of total billed charges",""
"SCREW BONE 4.0X22MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.71","781.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","851.29","81.72","","431.26","71.26","1459.57","88","544.4","851.29","percent of total billed charges",""
"SCREW BONE 4.0X24.0MM SPINE PEDICLE OASYS POLYAXIAL TITANIUM BIASED","SUP-ITM-10030806","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","1309.77","674.56","6049.93","26","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 4.0X24.0MM SPINE PEDICLE OASYS POLYAXIAL TITANIUM BIASED","SUP-ITM-10030806","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","1901.83","1901.83","2962.25","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 4.0X24.0MM SPINE PEDICLE OASYS POLYAXIAL TITANIUM BIASED","SUP-ITM-10030806","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","1620.31","1620.31","19908.88","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 4.0X24.0MM SPINE PEDICLE OASYS POLYAXIAL TITANIUM BIASED","SUP-ITM-10030806","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","352.91","352.91","2046.30","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 4.0X24.0MM SPINE PEDICLE OASYS POLYAXIAL TITANIUM BIASED","SUP-ITM-10030806","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","9668.75","9668.75","9668.75","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 4.0X24.0MM SPINE PEDICLE OASYS POLYAXIAL TITANIUM BIASED","SUP-ITM-10030806","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","699.88","384.10","3443.31","33","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 4.0X24.0MM SPINE PEDICLE OASYS POLYAXIAL TITANIUM BIASED","SUP-ITM-10030806","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","1421.24","264.50","4933.46","29","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 4.0X24.0MM SPINE PEDICLE OASYS POLYAXIAL TITANIUM BIASED","SUP-ITM-10030806","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","1022.97","1022.97","3607.50","1 through 10","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 4.0X24.0MM SPINE PEDICLE OASYS POLYAXIAL TITANIUM BIASED","SUP-ITM-10030806","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","3010.54","693.88","5019.88","35","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","828.16","79.5","","800.18","480.96","1887.97","195","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","555.23","53.3","","813.12","216.42","1444.50","81","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","322.93","31","","432.60","432.60","432.60","1 through 10","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","380.22","36.5","","148.37","54.89","631.39","94","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","398.97","38.3","","279.30","91.72","1116.77","266","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.89","42.9","","731.00","63.70","731.00","1 through 10","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.89","42.9","","384.74","384.74","384.74","1 through 10","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","both","","","1041.71","781.28","WELLPOINT [1015]","HB AMC WELLPOINT","768.57","73.78","","286.63","119.22","1107.45","105","322.93","828.16","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.71","781.28","AETNA [1001]","HB AMC AETNA HMO","727.11","69.8","","675.31","184.75","1721.50","286","544.4","851.29","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.71","781.28","AETNA [1001]","HB AMC AETNA PPO","837.53","80.4","","1261.44","103.12","1514.10","21","544.4","851.29","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.71","781.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","837.53","80.4","","1365.00","1365.00","1365.00","1 through 10","544.4","851.29","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.71","781.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","851.29","81.72","","5157.68","5157.68","5157.68","1 through 10","544.4","851.29","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1041.71","781.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","851.29","81.72","","431.26","71.26","1459.57","88","544.4","851.29","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","97.39","79.5","","800.18","480.96","1887.97","195","37.98","97.39","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","65.29","53.3","","813.12","216.42","1444.50","81","37.98","97.39","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","37.98","31","","432.60","432.60","432.60","1 through 10","37.98","97.39","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.71","36.5","","148.37","54.89","631.39","94","37.98","97.39","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.92","38.3","","279.30","91.72","1116.77","266","37.98","97.39","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.55","42.9","","731.00","63.70","731.00","1 through 10","37.98","97.39","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.55","42.9","","384.74","384.74","384.74","1 through 10","37.98","97.39","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","WELLPOINT [1015]","HB AMC WELLPOINT","90.38","73.78","","286.63","119.22","1107.45","105","37.98","97.39","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","AETNA [1001]","HB AMC AETNA HMO","85.51","69.8","","675.31","184.75","1721.50","286","64.02","100.11","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","AETNA [1001]","HB AMC AETNA PPO","98.49","80.4","","1261.44","103.12","1514.10","21","64.02","100.11","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","98.49","80.4","","1365.00","1365.00","1365.00","1 through 10","64.02","100.11","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","100.11","81.72","","5157.68","5157.68","5157.68","1 through 10","64.02","100.11","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","100.11","81.72","","431.26","71.26","1459.57","88","64.02","100.11","percent of total billed charges",""
"SCREW BONE 4.0X60MM CANCELLOUS CONGRUENT TITANIUM","SUP-ITM-10017014","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","269.90","79.5","","800.18","480.96","1887.97","195","105.25","269.9","percent of total billed charges",""
"SCREW BONE 4.0X60MM CANCELLOUS CONGRUENT TITANIUM","SUP-ITM-10017014","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","180.95","53.3","","813.12","216.42","1444.50","81","105.25","269.9","percent of total billed charges",""
"SCREW BONE 4.0X60MM CANCELLOUS CONGRUENT TITANIUM","SUP-ITM-10017014","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","105.25","31","","432.60","432.60","432.60","1 through 10","105.25","269.9","percent of total billed charges",""
"SCREW BONE 4.0X60MM CANCELLOUS CONGRUENT TITANIUM","SUP-ITM-10017014","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.92","36.5","","148.37","54.89","631.39","94","105.25","269.9","percent of total billed charges",""
"SCREW BONE 4.0X60MM CANCELLOUS CONGRUENT TITANIUM","SUP-ITM-10017014","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","130.03","38.3","","279.30","91.72","1116.77","266","105.25","269.9","percent of total billed charges",""
"SCREW BONE 4.0X60MM CANCELLOUS CONGRUENT TITANIUM","SUP-ITM-10017014","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.65","42.9","","731.00","63.70","731.00","1 through 10","105.25","269.9","percent of total billed charges",""
"SCREW BONE 4.0X60MM CANCELLOUS CONGRUENT TITANIUM","SUP-ITM-10017014","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.65","42.9","","384.74","384.74","384.74","1 through 10","105.25","269.9","percent of total billed charges",""
"SCREW BONE 4.0X60MM CANCELLOUS CONGRUENT TITANIUM","SUP-ITM-10017014","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.50","254.62","WELLPOINT [1015]","HB AMC WELLPOINT","250.48","73.78","","286.63","119.22","1107.45","105","105.25","269.9","percent of total billed charges",""
"SCREW BONE 4.0X60MM CANCELLOUS CONGRUENT TITANIUM","SUP-ITM-10017014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.50","254.62","AETNA [1001]","HB AMC AETNA HMO","236.97","69.8","","675.31","184.75","1721.50","286","177.42","277.44","percent of total billed charges",""
"SCREW BONE 4.0X60MM CANCELLOUS CONGRUENT TITANIUM","SUP-ITM-10017014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.50","254.62","AETNA [1001]","HB AMC AETNA PPO","272.96","80.4","","1261.44","103.12","1514.10","21","177.42","277.44","percent of total billed charges",""
"SCREW BONE 4.0X60MM CANCELLOUS CONGRUENT TITANIUM","SUP-ITM-10017014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.50","254.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","272.96","80.4","","1365.00","1365.00","1365.00","1 through 10","177.42","277.44","percent of total billed charges",""
"SCREW BONE 4.0X60MM CANCELLOUS CONGRUENT TITANIUM","SUP-ITM-10017014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.50","254.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","277.44","81.72","","5157.68","5157.68","5157.68","1 through 10","177.42","277.44","percent of total billed charges",""
"SCREW BONE 4.0X60MM CANCELLOUS CONGRUENT TITANIUM","SUP-ITM-10017014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.50","254.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","277.44","81.72","","431.26","71.26","1459.57","88","177.42","277.44","percent of total billed charges",""
"SCREW BONE 4.0X85MM AXSOS SS LOCKING SELF TAPPING T15 DRIVE","SUP-ITM-10118235","CDM","C1713","HCPCS","0278","RC","","","","both","","","783.16","587.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","622.61","79.5","","800.18","480.96","1887.97","195","242.78","622.61","percent of total billed charges",""
"SCREW BONE 4.0X85MM AXSOS SS LOCKING SELF TAPPING T15 DRIVE","SUP-ITM-10118235","CDM","C1713","HCPCS","0278","RC","","","","both","","","783.16","587.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","417.42","53.3","","813.12","216.42","1444.50","81","242.78","622.61","percent of total billed charges",""
"SCREW BONE 4.0X85MM AXSOS SS LOCKING SELF TAPPING T15 DRIVE","SUP-ITM-10118235","CDM","C1713","HCPCS","0278","RC","","","","both","","","783.16","587.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","242.78","31","","432.60","432.60","432.60","1 through 10","242.78","622.61","percent of total billed charges",""
"SCREW BONE 4.0X85MM AXSOS SS LOCKING SELF TAPPING T15 DRIVE","SUP-ITM-10118235","CDM","C1713","HCPCS","0278","RC","","","","both","","","783.16","587.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","285.85","36.5","","148.37","54.89","631.39","94","242.78","622.61","percent of total billed charges",""
"SCREW BONE 4.0X85MM AXSOS SS LOCKING SELF TAPPING T15 DRIVE","SUP-ITM-10118235","CDM","C1713","HCPCS","0278","RC","","","","both","","","783.16","587.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","299.95","38.3","","279.30","91.72","1116.77","266","242.78","622.61","percent of total billed charges",""
"SCREW BONE 4.0X85MM AXSOS SS LOCKING SELF TAPPING T15 DRIVE","SUP-ITM-10118235","CDM","C1713","HCPCS","0278","RC","","","","both","","","783.16","587.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","335.98","42.9","","731.00","63.70","731.00","1 through 10","242.78","622.61","percent of total billed charges",""
"SCREW BONE 4.0X85MM AXSOS SS LOCKING SELF TAPPING T15 DRIVE","SUP-ITM-10118235","CDM","C1713","HCPCS","0278","RC","","","","both","","","783.16","587.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","335.98","42.9","","384.74","384.74","384.74","1 through 10","242.78","622.61","percent of total billed charges",""
"SCREW BONE 4.0X85MM AXSOS SS LOCKING SELF TAPPING T15 DRIVE","SUP-ITM-10118235","CDM","C1713","HCPCS","0278","RC","","","","both","","","783.16","587.37","WELLPOINT [1015]","HB AMC WELLPOINT","577.82","73.78","","286.63","119.22","1107.45","105","242.78","622.61","percent of total billed charges",""
"SCREW BONE 4.0X85MM AXSOS SS LOCKING SELF TAPPING T15 DRIVE","SUP-ITM-10118235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","783.16","587.37","AETNA [1001]","HB AMC AETNA HMO","546.65","69.8","","675.31","184.75","1721.50","286","409.28","640","percent of total billed charges",""
"SCREW BONE 4.0X85MM AXSOS SS LOCKING SELF TAPPING T15 DRIVE","SUP-ITM-10118235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","783.16","587.37","AETNA [1001]","HB AMC AETNA PPO","629.66","80.4","","1261.44","103.12","1514.10","21","409.28","640","percent of total billed charges",""
"SCREW BONE 4.0X85MM AXSOS SS LOCKING SELF TAPPING T15 DRIVE","SUP-ITM-10118235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","783.16","587.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","629.66","80.4","","1365.00","1365.00","1365.00","1 through 10","409.28","640","percent of total billed charges",""
"SCREW BONE 4.0X85MM AXSOS SS LOCKING SELF TAPPING T15 DRIVE","SUP-ITM-10118235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","783.16","587.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","640.00","81.72","","5157.68","5157.68","5157.68","1 through 10","409.28","640","percent of total billed charges",""
"SCREW BONE 4.0X85MM AXSOS SS LOCKING SELF TAPPING T15 DRIVE","SUP-ITM-10118235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","783.16","587.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","640.00","81.72","","431.26","71.26","1459.57","88","409.28","640","percent of total billed charges",""
"SCREW BONE 4.35X16MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD PURPLE","SUP-ITM-10032819","CDM","C1889","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","1309.77","674.56","6049.93","26","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.35X16MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD PURPLE","SUP-ITM-10032819","CDM","C1889","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","1901.83","1901.83","2962.25","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.35X16MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD PURPLE","SUP-ITM-10032819","CDM","C1889","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","1620.31","1620.31","19908.88","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.35X16MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD PURPLE","SUP-ITM-10032819","CDM","C1889","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","352.91","352.91","2046.30","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.35X16MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD PURPLE","SUP-ITM-10032819","CDM","C1889","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","9668.75","9668.75","9668.75","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.35X16MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD PURPLE","SUP-ITM-10032819","CDM","C1889","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB AMC WELLPOINT","232.41","73.78","","699.88","384.10","3443.31","33","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.35X16MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD PURPLE","SUP-ITM-10032819","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","1421.24","264.50","4933.46","29","164.62","257.42","percent of total billed charges",""
"SCREW BONE 4.35X16MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD PURPLE","SUP-ITM-10032819","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","1022.97","1022.97","3607.50","1 through 10","164.62","257.42","percent of total billed charges",""
"SCREW BONE 4.35X16MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD PURPLE","SUP-ITM-10032819","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","3010.54","693.88","5019.88","35","164.62","257.42","percent of total billed charges",""
"SCREW BONE 4.35X25MM SPINE PEDICLE POLYAXIAL EXPEDIUM 4.5 TITANIUM","SUP-ITM-10046079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","800.18","480.96","1887.97","195","434","1113","percent of total billed charges",""
"SCREW BONE 4.35X25MM SPINE PEDICLE POLYAXIAL EXPEDIUM 4.5 TITANIUM","SUP-ITM-10046079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","813.12","216.42","1444.50","81","434","1113","percent of total billed charges",""
"SCREW BONE 4.35X25MM SPINE PEDICLE POLYAXIAL EXPEDIUM 4.5 TITANIUM","SUP-ITM-10046079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","434.00","31","","432.60","432.60","432.60","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 4.35X25MM SPINE PEDICLE POLYAXIAL EXPEDIUM 4.5 TITANIUM","SUP-ITM-10046079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","148.37","54.89","631.39","94","434","1113","percent of total billed charges",""
"SCREW BONE 4.35X25MM SPINE PEDICLE POLYAXIAL EXPEDIUM 4.5 TITANIUM","SUP-ITM-10046079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","279.30","91.72","1116.77","266","434","1113","percent of total billed charges",""
"SCREW BONE 4.35X25MM SPINE PEDICLE POLYAXIAL EXPEDIUM 4.5 TITANIUM","SUP-ITM-10046079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","731.00","63.70","731.00","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 4.35X25MM SPINE PEDICLE POLYAXIAL EXPEDIUM 4.5 TITANIUM","SUP-ITM-10046079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","384.74","384.74","384.74","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 4.35X25MM SPINE PEDICLE POLYAXIAL EXPEDIUM 4.5 TITANIUM","SUP-ITM-10046079","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","286.63","119.22","1107.45","105","434","1113","percent of total billed charges",""
"SCREW BONE 4.35X25MM SPINE PEDICLE POLYAXIAL EXPEDIUM 4.5 TITANIUM","SUP-ITM-10046079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","675.31","184.75","1721.50","286","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 4.35X25MM SPINE PEDICLE POLYAXIAL EXPEDIUM 4.5 TITANIUM","SUP-ITM-10046079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA PPO","1125.60","80.4","","1261.44","103.12","1514.10","21","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 4.35X25MM SPINE PEDICLE POLYAXIAL EXPEDIUM 4.5 TITANIUM","SUP-ITM-10046079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1365.00","1365.00","1365.00","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 4.35X25MM SPINE PEDICLE POLYAXIAL EXPEDIUM 4.5 TITANIUM","SUP-ITM-10046079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1144.08","81.72","","5157.68","5157.68","5157.68","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 4.35X25MM SPINE PEDICLE POLYAXIAL EXPEDIUM 4.5 TITANIUM","SUP-ITM-10046079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","431.26","71.26","1459.57","88","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 4.35X40MM SPINE PEDICLE CORTICAL POLYAXIAL TITANIUM FIXATION THREAD EXPEDIUM","SUP-ITM-10132536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2253.83","79.5","","800.18","480.96","1887.97","195","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.35X40MM SPINE PEDICLE CORTICAL POLYAXIAL TITANIUM FIXATION THREAD EXPEDIUM","SUP-ITM-10132536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1511.06","53.3","","813.12","216.42","1444.50","81","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.35X40MM SPINE PEDICLE CORTICAL POLYAXIAL TITANIUM FIXATION THREAD EXPEDIUM","SUP-ITM-10132536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","878.85","31","","432.60","432.60","432.60","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.35X40MM SPINE PEDICLE CORTICAL POLYAXIAL TITANIUM FIXATION THREAD EXPEDIUM","SUP-ITM-10132536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1034.78","36.5","","148.37","54.89","631.39","94","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.35X40MM SPINE PEDICLE CORTICAL POLYAXIAL TITANIUM FIXATION THREAD EXPEDIUM","SUP-ITM-10132536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1085.81","38.3","","279.30","91.72","1116.77","266","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.35X40MM SPINE PEDICLE CORTICAL POLYAXIAL TITANIUM FIXATION THREAD EXPEDIUM","SUP-ITM-10132536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","731.00","63.70","731.00","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.35X40MM SPINE PEDICLE CORTICAL POLYAXIAL TITANIUM FIXATION THREAD EXPEDIUM","SUP-ITM-10132536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","384.74","384.74","384.74","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.35X40MM SPINE PEDICLE CORTICAL POLYAXIAL TITANIUM FIXATION THREAD EXPEDIUM","SUP-ITM-10132536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB AMC WELLPOINT","2091.66","73.78","","286.63","119.22","1107.45","105","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.35X40MM SPINE PEDICLE CORTICAL POLYAXIAL TITANIUM FIXATION THREAD EXPEDIUM","SUP-ITM-10132536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA HMO","1978.83","69.8","","675.31","184.75","1721.50","286","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 4.35X40MM SPINE PEDICLE CORTICAL POLYAXIAL TITANIUM FIXATION THREAD EXPEDIUM","SUP-ITM-10132536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA PPO","2279.34","80.4","","1261.44","103.12","1514.10","21","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 4.35X40MM SPINE PEDICLE CORTICAL POLYAXIAL TITANIUM FIXATION THREAD EXPEDIUM","SUP-ITM-10132536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2279.34","80.4","","1365.00","1365.00","1365.00","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 4.35X40MM SPINE PEDICLE CORTICAL POLYAXIAL TITANIUM FIXATION THREAD EXPEDIUM","SUP-ITM-10132536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2316.76","81.72","","5157.68","5157.68","5157.68","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 4.35X40MM SPINE PEDICLE CORTICAL POLYAXIAL TITANIUM FIXATION THREAD EXPEDIUM","SUP-ITM-10132536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2316.76","81.72","","431.26","71.26","1459.57","88","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1453.76","1090.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1155.74","79.5","","800.18","480.96","1887.97","195","450.67","1155.74","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1453.76","1090.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","774.85","53.3","","813.12","216.42","1444.50","81","450.67","1155.74","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1453.76","1090.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","450.67","31","","432.60","432.60","432.60","1 through 10","450.67","1155.74","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1453.76","1090.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","530.62","36.5","","148.37","54.89","631.39","94","450.67","1155.74","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1453.76","1090.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","556.79","38.3","","279.30","91.72","1116.77","266","450.67","1155.74","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1453.76","1090.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","623.66","42.9","","731.00","63.70","731.00","1 through 10","450.67","1155.74","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1453.76","1090.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","623.66","42.9","","384.74","384.74","384.74","1 through 10","450.67","1155.74","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1453.76","1090.32","WELLPOINT [1015]","HB AMC WELLPOINT","1072.58","73.78","","286.63","119.22","1107.45","105","450.67","1155.74","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1453.76","1090.32","AETNA [1001]","HB AMC AETNA HMO","1014.72","69.8","","675.31","184.75","1721.50","286","759.73","1188.01","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1453.76","1090.32","AETNA [1001]","HB AMC AETNA PPO","1168.82","80.4","","1261.44","103.12","1514.10","21","759.73","1188.01","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1453.76","1090.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1168.82","80.4","","1365.00","1365.00","1365.00","1 through 10","759.73","1188.01","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1453.76","1090.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1188.01","81.72","","5157.68","5157.68","5157.68","1 through 10","759.73","1188.01","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1453.76","1090.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1188.01","81.72","","431.26","71.26","1459.57","88","759.73","1188.01","percent of total billed charges",""
"SCREW BONE 4.5MM AXSOS TITANIUM CORTICAL 661732","SUP-ITM-10139265","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","169.79","79.5","","800.18","480.96","1887.97","195","66.21","169.79","percent of total billed charges",""
"SCREW BONE 4.5MM AXSOS TITANIUM CORTICAL 661732","SUP-ITM-10139265","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","113.83","53.3","","813.12","216.42","1444.50","81","66.21","169.79","percent of total billed charges",""
"SCREW BONE 4.5MM AXSOS TITANIUM CORTICAL 661732","SUP-ITM-10139265","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","66.21","31","","432.60","432.60","432.60","1 through 10","66.21","169.79","percent of total billed charges",""
"SCREW BONE 4.5MM AXSOS TITANIUM CORTICAL 661732","SUP-ITM-10139265","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.95","36.5","","148.37","54.89","631.39","94","66.21","169.79","percent of total billed charges",""
"SCREW BONE 4.5MM AXSOS TITANIUM CORTICAL 661732","SUP-ITM-10139265","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.80","38.3","","279.30","91.72","1116.77","266","66.21","169.79","percent of total billed charges",""
"SCREW BONE 4.5MM AXSOS TITANIUM CORTICAL 661732","SUP-ITM-10139265","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.62","42.9","","731.00","63.70","731.00","1 through 10","66.21","169.79","percent of total billed charges",""
"SCREW BONE 4.5MM AXSOS TITANIUM CORTICAL 661732","SUP-ITM-10139265","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.62","42.9","","384.74","384.74","384.74","1 through 10","66.21","169.79","percent of total billed charges",""
"SCREW BONE 4.5MM AXSOS TITANIUM CORTICAL 661732","SUP-ITM-10139265","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","WELLPOINT [1015]","HB AMC WELLPOINT","157.57","73.78","","286.63","119.22","1107.45","105","66.21","169.79","percent of total billed charges",""
"SCREW BONE 4.5MM AXSOS TITANIUM CORTICAL 661732","SUP-ITM-10139265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","AETNA [1001]","HB AMC AETNA HMO","149.07","69.8","","675.31","184.75","1721.50","286","111.61","174.53","percent of total billed charges",""
"SCREW BONE 4.5MM AXSOS TITANIUM CORTICAL 661732","SUP-ITM-10139265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","AETNA [1001]","HB AMC AETNA PPO","171.71","80.4","","1261.44","103.12","1514.10","21","111.61","174.53","percent of total billed charges",""
"SCREW BONE 4.5MM AXSOS TITANIUM CORTICAL 661732","SUP-ITM-10139265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","171.71","80.4","","1365.00","1365.00","1365.00","1 through 10","111.61","174.53","percent of total billed charges",""
"SCREW BONE 4.5MM AXSOS TITANIUM CORTICAL 661732","SUP-ITM-10139265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","174.53","81.72","","5157.68","5157.68","5157.68","1 through 10","111.61","174.53","percent of total billed charges",""
"SCREW BONE 4.5MM AXSOS TITANIUM CORTICAL 661732","SUP-ITM-10139265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.53","81.72","","431.26","71.26","1459.57","88","111.61","174.53","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","497.73","79.5","","800.18","480.96","1887.97","195","194.08","497.73","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","333.70","53.3","","813.12","216.42","1444.50","81","194.08","497.73","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","194.08","31","","432.60","432.60","432.60","1 through 10","194.08","497.73","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.52","36.5","","148.37","54.89","631.39","94","194.08","497.73","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.79","38.3","","279.30","91.72","1116.77","266","194.08","497.73","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.59","42.9","","731.00","63.70","731.00","1 through 10","194.08","497.73","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.59","42.9","","384.74","384.74","384.74","1 through 10","194.08","497.73","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","WELLPOINT [1015]","HB AMC WELLPOINT","461.92","73.78","","286.63","119.22","1107.45","105","194.08","497.73","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.08","469.56","AETNA [1001]","HB AMC AETNA HMO","437.00","69.8","","675.31","184.75","1721.50","286","327.19","511.63","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.08","469.56","AETNA [1001]","HB AMC AETNA PPO","503.37","80.4","","1261.44","103.12","1514.10","21","327.19","511.63","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.08","469.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","503.37","80.4","","1365.00","1365.00","1365.00","1 through 10","327.19","511.63","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.08","469.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","511.63","81.72","","5157.68","5157.68","5157.68","1 through 10","327.19","511.63","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.08","469.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","511.63","81.72","","431.26","71.26","1459.57","88","327.19","511.63","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1407.95","79.5","","800.18","480.96","1887.97","195","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","943.94","53.3","","813.12","216.42","1444.50","81","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","549.01","31","","432.60","432.60","432.60","1 through 10","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","646.42","36.5","","148.37","54.89","631.39","94","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","678.29","38.3","","279.30","91.72","1116.77","266","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","759.76","42.9","","731.00","63.70","731.00","1 through 10","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","759.76","42.9","","384.74","384.74","384.74","1 through 10","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1771.00","1328.25","WELLPOINT [1015]","HB AMC WELLPOINT","1306.64","73.78","","286.63","119.22","1107.45","105","549.01","1407.95","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1771.00","1328.25","AETNA [1001]","HB AMC AETNA HMO","1236.16","69.8","","675.31","184.75","1721.50","286","925.52","1447.26","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1771.00","1328.25","AETNA [1001]","HB AMC AETNA PPO","1423.88","80.4","","1261.44","103.12","1514.10","21","925.52","1447.26","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1771.00","1328.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1423.88","80.4","","1365.00","1365.00","1365.00","1 through 10","925.52","1447.26","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1771.00","1328.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1447.26","81.72","","5157.68","5157.68","5157.68","1 through 10","925.52","1447.26","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1771.00","1328.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1447.26","81.72","","431.26","71.26","1459.57","88","925.52","1447.26","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.50","459.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","486.94","79.5","","800.18","480.96","1887.97","195","189.88","486.94","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.50","459.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","326.46","53.3","","813.12","216.42","1444.50","81","189.88","486.94","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","189.88","31","","432.60","432.60","432.60","1 through 10","189.88","486.94","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.56","36.5","","148.37","54.89","631.39","94","189.88","486.94","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.59","38.3","","279.30","91.72","1116.77","266","189.88","486.94","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","262.76","42.9","","731.00","63.70","731.00","1 through 10","189.88","486.94","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.50","459.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","262.76","42.9","","384.74","384.74","384.74","1 through 10","189.88","486.94","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.50","459.37","WELLPOINT [1015]","HB AMC WELLPOINT","451.90","73.78","","286.63","119.22","1107.45","105","189.88","486.94","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","AETNA [1001]","HB AMC AETNA HMO","427.53","69.8","","675.31","184.75","1721.50","286","320.09","500.54","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","AETNA [1001]","HB AMC AETNA PPO","492.45","80.4","","1261.44","103.12","1514.10","21","320.09","500.54","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","492.45","80.4","","1365.00","1365.00","1365.00","1 through 10","320.09","500.54","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","500.54","81.72","","5157.68","5157.68","5157.68","1 through 10","320.09","500.54","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","500.54","81.72","","431.26","71.26","1459.57","88","320.09","500.54","percent of total billed charges",""
"SCREW BONE 4.5X100MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10041365","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","246.06","79.5","","800.18","480.96","1887.97","195","95.95","246.06","percent of total billed charges",""
"SCREW BONE 4.5X100MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10041365","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","164.97","53.3","","813.12","216.42","1444.50","81","95.95","246.06","percent of total billed charges",""
"SCREW BONE 4.5X100MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10041365","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","95.95","31","","432.60","432.60","432.60","1 through 10","95.95","246.06","percent of total billed charges",""
"SCREW BONE 4.5X100MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10041365","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","112.97","36.5","","148.37","54.89","631.39","94","95.95","246.06","percent of total billed charges",""
"SCREW BONE 4.5X100MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10041365","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","118.54","38.3","","279.30","91.72","1116.77","266","95.95","246.06","percent of total billed charges",""
"SCREW BONE 4.5X100MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10041365","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.78","42.9","","731.00","63.70","731.00","1 through 10","95.95","246.06","percent of total billed charges",""
"SCREW BONE 4.5X100MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10041365","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.78","42.9","","384.74","384.74","384.74","1 through 10","95.95","246.06","percent of total billed charges",""
"SCREW BONE 4.5X100MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10041365","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","WELLPOINT [1015]","HB AMC WELLPOINT","228.36","73.78","","286.63","119.22","1107.45","105","95.95","246.06","percent of total billed charges",""
"SCREW BONE 4.5X100MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10041365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","AETNA [1001]","HB AMC AETNA HMO","216.04","69.8","","675.31","184.75","1721.50","286","161.75","252.93","percent of total billed charges",""
"SCREW BONE 4.5X100MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10041365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","AETNA [1001]","HB AMC AETNA PPO","248.85","80.4","","1261.44","103.12","1514.10","21","161.75","252.93","percent of total billed charges",""
"SCREW BONE 4.5X100MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10041365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","248.85","80.4","","1365.00","1365.00","1365.00","1 through 10","161.75","252.93","percent of total billed charges",""
"SCREW BONE 4.5X100MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10041365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","252.93","81.72","","5157.68","5157.68","5157.68","1 through 10","161.75","252.93","percent of total billed charges",""
"SCREW BONE 4.5X100MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10041365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","252.93","81.72","","431.26","71.26","1459.57","88","161.75","252.93","percent of total billed charges",""
"SCREW BONE 4.5X125MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10001631","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","146.03","79.5","","800.18","480.96","1887.97","195","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X125MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10001631","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","97.90","53.3","","813.12","216.42","1444.50","81","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X125MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10001631","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","56.94","31","","432.60","432.60","432.60","1 through 10","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X125MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10001631","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.04","36.5","","148.37","54.89","631.39","94","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X125MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10001631","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.35","38.3","","279.30","91.72","1116.77","266","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X125MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10001631","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.80","42.9","","731.00","63.70","731.00","1 through 10","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X125MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10001631","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.80","42.9","","384.74","384.74","384.74","1 through 10","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X125MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10001631","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","WELLPOINT [1015]","HB AMC WELLPOINT","135.52","73.78","","286.63","119.22","1107.45","105","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X125MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10001631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.68","137.76","AETNA [1001]","HB AMC AETNA HMO","128.21","69.8","","675.31","184.75","1721.50","286","95.99","150.1","percent of total billed charges",""
"SCREW BONE 4.5X125MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10001631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.68","137.76","AETNA [1001]","HB AMC AETNA PPO","147.68","80.4","","1261.44","103.12","1514.10","21","95.99","150.1","percent of total billed charges",""
"SCREW BONE 4.5X125MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10001631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.68","137.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","147.68","80.4","","1365.00","1365.00","1365.00","1 through 10","95.99","150.1","percent of total billed charges",""
"SCREW BONE 4.5X125MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10001631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.68","137.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","150.10","81.72","","5157.68","5157.68","5157.68","1 through 10","95.99","150.1","percent of total billed charges",""
"SCREW BONE 4.5X125MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10001631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.68","137.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","150.10","81.72","","431.26","71.26","1459.57","88","95.99","150.1","percent of total billed charges",""
"SCREW BONE 4.5X145MM SS CORTEX SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037500","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","132.81","79.5","","800.18","480.96","1887.97","195","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X145MM SS CORTEX SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037500","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","89.04","53.3","","813.12","216.42","1444.50","81","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X145MM SS CORTEX SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037500","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","51.79","31","","432.60","432.60","432.60","1 through 10","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X145MM SS CORTEX SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037500","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.98","36.5","","148.37","54.89","631.39","94","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X145MM SS CORTEX SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037500","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.98","38.3","","279.30","91.72","1116.77","266","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X145MM SS CORTEX SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037500","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.67","42.9","","731.00","63.70","731.00","1 through 10","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X145MM SS CORTEX SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037500","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.67","42.9","","384.74","384.74","384.74","1 through 10","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X145MM SS CORTEX SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037500","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","WELLPOINT [1015]","HB AMC WELLPOINT","123.26","73.78","","286.63","119.22","1107.45","105","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X145MM SS CORTEX SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037500","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.06","125.29","AETNA [1001]","HB AMC AETNA HMO","116.61","69.8","","675.31","184.75","1721.50","286","87.31","136.52","percent of total billed charges",""
"SCREW BONE 4.5X145MM SS CORTEX SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037500","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.06","125.29","AETNA [1001]","HB AMC AETNA PPO","134.32","80.4","","1261.44","103.12","1514.10","21","87.31","136.52","percent of total billed charges",""
"SCREW BONE 4.5X145MM SS CORTEX SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037500","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.06","125.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","134.32","80.4","","1365.00","1365.00","1365.00","1 through 10","87.31","136.52","percent of total billed charges",""
"SCREW BONE 4.5X145MM SS CORTEX SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037500","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.06","125.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","136.52","81.72","","5157.68","5157.68","5157.68","1 through 10","87.31","136.52","percent of total billed charges",""
"SCREW BONE 4.5X145MM SS CORTEX SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037500","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.06","125.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","136.52","81.72","","431.26","71.26","1459.57","88","87.31","136.52","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","146.03","79.5","","800.18","480.96","1887.97","195","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","97.90","53.3","","813.12","216.42","1444.50","81","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","56.94","31","","432.60","432.60","432.60","1 through 10","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.04","36.5","","148.37","54.89","631.39","94","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.35","38.3","","279.30","91.72","1116.77","266","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.80","42.9","","731.00","63.70","731.00","1 through 10","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.80","42.9","","384.74","384.74","384.74","1 through 10","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.68","137.76","WELLPOINT [1015]","HB AMC WELLPOINT","135.52","73.78","","286.63","119.22","1107.45","105","56.94","146.03","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.68","137.76","AETNA [1001]","HB AMC AETNA HMO","128.21","69.8","","675.31","184.75","1721.50","286","95.99","150.1","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.68","137.76","AETNA [1001]","HB AMC AETNA PPO","147.68","80.4","","1261.44","103.12","1514.10","21","95.99","150.1","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.68","137.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","147.68","80.4","","1365.00","1365.00","1365.00","1 through 10","95.99","150.1","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.68","137.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","150.10","81.72","","5157.68","5157.68","5157.68","1 through 10","95.99","150.1","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.68","137.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","150.10","81.72","","431.26","71.26","1459.57","88","95.99","150.1","percent of total billed charges",""
"SCREW BONE 4.5X16MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040230","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.60","77.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","82.36","79.5","","800.18","480.96","1887.97","195","32.12","82.36","percent of total billed charges",""
"SCREW BONE 4.5X16MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040230","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.60","77.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","55.22","53.3","","813.12","216.42","1444.50","81","32.12","82.36","percent of total billed charges",""
"SCREW BONE 4.5X16MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040230","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.60","77.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","32.12","31","","432.60","432.60","432.60","1 through 10","32.12","82.36","percent of total billed charges",""
"SCREW BONE 4.5X16MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040230","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.60","77.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37.81","36.5","","148.37","54.89","631.39","94","32.12","82.36","percent of total billed charges",""
"SCREW BONE 4.5X16MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040230","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.60","77.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39.68","38.3","","279.30","91.72","1116.77","266","32.12","82.36","percent of total billed charges",""
"SCREW BONE 4.5X16MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040230","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.60","77.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.44","42.9","","731.00","63.70","731.00","1 through 10","32.12","82.36","percent of total billed charges",""
"SCREW BONE 4.5X16MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040230","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.60","77.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.44","42.9","","384.74","384.74","384.74","1 through 10","32.12","82.36","percent of total billed charges",""
"SCREW BONE 4.5X16MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040230","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.60","77.70","WELLPOINT [1015]","HB AMC WELLPOINT","76.44","73.78","","286.63","119.22","1107.45","105","32.12","82.36","percent of total billed charges",""
"SCREW BONE 4.5X16MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.60","77.70","AETNA [1001]","HB AMC AETNA HMO","72.31","69.8","","675.31","184.75","1721.50","286","54.14","84.66","percent of total billed charges",""
"SCREW BONE 4.5X16MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.60","77.70","AETNA [1001]","HB AMC AETNA PPO","83.29","80.4","","1261.44","103.12","1514.10","21","54.14","84.66","percent of total billed charges",""
"SCREW BONE 4.5X16MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.60","77.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","83.29","80.4","","1365.00","1365.00","1365.00","1 through 10","54.14","84.66","percent of total billed charges",""
"SCREW BONE 4.5X16MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.60","77.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","84.66","81.72","","5157.68","5157.68","5157.68","1 through 10","54.14","84.66","percent of total billed charges",""
"SCREW BONE 4.5X16MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.60","77.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","84.66","81.72","","431.26","71.26","1459.57","88","54.14","84.66","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.50","170.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","180.86","79.5","","800.18","480.96","1887.97","195","70.53","180.86","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.50","170.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","121.26","53.3","","813.12","216.42","1444.50","81","70.53","180.86","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.50","170.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","70.53","31","","432.60","432.60","432.60","1 through 10","70.53","180.86","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.50","170.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.04","36.5","","148.37","54.89","631.39","94","70.53","180.86","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.50","170.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.13","38.3","","279.30","91.72","1116.77","266","70.53","180.86","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.50","170.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.60","42.9","","731.00","63.70","731.00","1 through 10","70.53","180.86","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.50","170.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.60","42.9","","384.74","384.74","384.74","1 through 10","70.53","180.86","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","227.50","170.62","WELLPOINT [1015]","HB AMC WELLPOINT","167.85","73.78","","286.63","119.22","1107.45","105","70.53","180.86","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.50","170.62","AETNA [1001]","HB AMC AETNA HMO","158.80","69.8","","675.31","184.75","1721.50","286","118.89","185.91","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.50","170.62","AETNA [1001]","HB AMC AETNA PPO","182.91","80.4","","1261.44","103.12","1514.10","21","118.89","185.91","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.50","170.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","182.91","80.4","","1365.00","1365.00","1365.00","1 through 10","118.89","185.91","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.50","170.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","185.91","81.72","","5157.68","5157.68","5157.68","1 through 10","118.89","185.91","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","227.50","170.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","185.91","81.72","","431.26","71.26","1459.57","88","118.89","185.91","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","171.85","79.5","","800.18","480.96","1887.97","195","67.01","171.85","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","115.21","53.3","","813.12","216.42","1444.50","81","67.01","171.85","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","67.01","31","","432.60","432.60","432.60","1 through 10","67.01","171.85","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.90","36.5","","148.37","54.89","631.39","94","67.01","171.85","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82.79","38.3","","279.30","91.72","1116.77","266","67.01","171.85","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.73","42.9","","731.00","63.70","731.00","1 through 10","67.01","171.85","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.73","42.9","","384.74","384.74","384.74","1 through 10","67.01","171.85","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","WELLPOINT [1015]","HB AMC WELLPOINT","159.48","73.78","","286.63","119.22","1107.45","105","67.01","171.85","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","216.16","162.12","AETNA [1001]","HB AMC AETNA HMO","150.88","69.8","","675.31","184.75","1721.50","286","112.97","176.65","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","216.16","162.12","AETNA [1001]","HB AMC AETNA PPO","173.79","80.4","","1261.44","103.12","1514.10","21","112.97","176.65","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","216.16","162.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","173.79","80.4","","1365.00","1365.00","1365.00","1 through 10","112.97","176.65","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","216.16","162.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","176.65","81.72","","5157.68","5157.68","5157.68","1 through 10","112.97","176.65","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","216.16","162.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","176.65","81.72","","431.26","71.26","1459.57","88","112.97","176.65","percent of total billed charges",""
"SCREW BONE 4.5X20.0MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082756","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","659.45","79.5","","800.18","480.96","1887.97","195","257.15","659.45","percent of total billed charges",""
"SCREW BONE 4.5X20.0MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082756","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","442.12","53.3","","813.12","216.42","1444.50","81","257.15","659.45","percent of total billed charges",""
"SCREW BONE 4.5X20.0MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082756","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","257.15","31","","432.60","432.60","432.60","1 through 10","257.15","659.45","percent of total billed charges",""
"SCREW BONE 4.5X20.0MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082756","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","302.77","36.5","","148.37","54.89","631.39","94","257.15","659.45","percent of total billed charges",""
"SCREW BONE 4.5X20.0MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082756","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","317.70","38.3","","279.30","91.72","1116.77","266","257.15","659.45","percent of total billed charges",""
"SCREW BONE 4.5X20.0MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082756","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","355.86","42.9","","731.00","63.70","731.00","1 through 10","257.15","659.45","percent of total billed charges",""
"SCREW BONE 4.5X20.0MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082756","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","355.86","42.9","","384.74","384.74","384.74","1 through 10","257.15","659.45","percent of total billed charges",""
"SCREW BONE 4.5X20.0MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082756","CDM","C1713","HCPCS","0278","RC","","","","both","","","829.50","622.12","WELLPOINT [1015]","HB AMC WELLPOINT","612.01","73.78","","286.63","119.22","1107.45","105","257.15","659.45","percent of total billed charges",""
"SCREW BONE 4.5X20.0MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","829.50","622.12","AETNA [1001]","HB AMC AETNA HMO","578.99","69.8","","675.31","184.75","1721.50","286","433.5","677.87","percent of total billed charges",""
"SCREW BONE 4.5X20.0MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","829.50","622.12","AETNA [1001]","HB AMC AETNA PPO","666.92","80.4","","1261.44","103.12","1514.10","21","433.5","677.87","percent of total billed charges",""
"SCREW BONE 4.5X20.0MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","829.50","622.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","666.92","80.4","","1365.00","1365.00","1365.00","1 through 10","433.5","677.87","percent of total billed charges",""
"SCREW BONE 4.5X20.0MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","829.50","622.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","677.87","81.72","","5157.68","5157.68","5157.68","1 through 10","433.5","677.87","percent of total billed charges",""
"SCREW BONE 4.5X20.0MM SPINE LUMBAR BRIGADE ANTERIOR","SUP-ITM-10082756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","829.50","622.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","677.87","81.72","","431.26","71.26","1459.57","88","433.5","677.87","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","357.94","79.5","","800.18","480.96","1887.97","195","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","239.98","53.3","","813.12","216.42","1444.50","81","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","139.57","31","","432.60","432.60","432.60","1 through 10","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","164.34","36.5","","148.37","54.89","631.39","94","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","172.44","38.3","","279.30","91.72","1116.77","266","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.15","42.9","","731.00","63.70","731.00","1 through 10","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.15","42.9","","384.74","384.74","384.74","1 through 10","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","WELLPOINT [1015]","HB AMC WELLPOINT","332.19","73.78","","286.63","119.22","1107.45","105","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.24","337.68","AETNA [1001]","HB AMC AETNA HMO","314.27","69.8","","675.31","184.75","1721.50","286","235.3","367.94","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.24","337.68","AETNA [1001]","HB AMC AETNA PPO","361.99","80.4","","1261.44","103.12","1514.10","21","235.3","367.94","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.24","337.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","361.99","80.4","","1365.00","1365.00","1365.00","1 through 10","235.3","367.94","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.24","337.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","367.94","81.72","","5157.68","5157.68","5157.68","1 through 10","235.3","367.94","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.24","337.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","367.94","81.72","","431.26","71.26","1459.57","88","235.3","367.94","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040179","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","396.23","79.5","","800.18","480.96","1887.97","195","154.5","396.23","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040179","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","265.65","53.3","","813.12","216.42","1444.50","81","154.5","396.23","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040179","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","154.50","31","","432.60","432.60","432.60","1 through 10","154.5","396.23","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040179","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","181.92","36.5","","148.37","54.89","631.39","94","154.5","396.23","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040179","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","190.89","38.3","","279.30","91.72","1116.77","266","154.5","396.23","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040179","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.81","42.9","","731.00","63.70","731.00","1 through 10","154.5","396.23","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040179","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.81","42.9","","384.74","384.74","384.74","1 through 10","154.5","396.23","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040179","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","WELLPOINT [1015]","HB AMC WELLPOINT","367.72","73.78","","286.63","119.22","1107.45","105","154.5","396.23","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.40","373.80","AETNA [1001]","HB AMC AETNA HMO","347.88","69.8","","675.31","184.75","1721.50","286","260.46","407.29","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.40","373.80","AETNA [1001]","HB AMC AETNA PPO","400.71","80.4","","1261.44","103.12","1514.10","21","260.46","407.29","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.40","373.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","400.71","80.4","","1365.00","1365.00","1365.00","1 through 10","260.46","407.29","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.40","373.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","407.29","81.72","","5157.68","5157.68","5157.68","1 through 10","260.46","407.29","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.40","373.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","407.29","81.72","","431.26","71.26","1459.57","88","260.46","407.29","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","627.73","79.5","","800.18","480.96","1887.97","195","244.78","627.73","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","420.86","53.3","","813.12","216.42","1444.50","81","244.78","627.73","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","244.78","31","","432.60","432.60","432.60","1 through 10","244.78","627.73","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","288.20","36.5","","148.37","54.89","631.39","94","244.78","627.73","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","302.42","38.3","","279.30","91.72","1116.77","266","244.78","627.73","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","338.74","42.9","","731.00","63.70","731.00","1 through 10","244.78","627.73","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","338.74","42.9","","384.74","384.74","384.74","1 through 10","244.78","627.73","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","both","","","789.60","592.20","WELLPOINT [1015]","HB AMC WELLPOINT","582.57","73.78","","286.63","119.22","1107.45","105","244.78","627.73","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","789.60","592.20","AETNA [1001]","HB AMC AETNA HMO","551.14","69.8","","675.31","184.75","1721.50","286","412.64","645.26","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","789.60","592.20","AETNA [1001]","HB AMC AETNA PPO","634.84","80.4","","1261.44","103.12","1514.10","21","412.64","645.26","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","789.60","592.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","634.84","80.4","","1365.00","1365.00","1365.00","1 through 10","412.64","645.26","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","789.60","592.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","645.26","81.72","","5157.68","5157.68","5157.68","1 through 10","412.64","645.26","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","789.60","592.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","645.26","81.72","","431.26","71.26","1459.57","88","412.64","645.26","percent of total billed charges",""
"SCREW BONE 4.5X20MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131920","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","592.67","79.5","","800.18","480.96","1887.97","195","231.11","592.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131920","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","397.35","53.3","","813.12","216.42","1444.50","81","231.11","592.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131920","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","231.11","31","","432.60","432.60","432.60","1 through 10","231.11","592.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131920","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","272.11","36.5","","148.37","54.89","631.39","94","231.11","592.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131920","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","285.53","38.3","","279.30","91.72","1116.77","266","231.11","592.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131920","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","319.82","42.9","","731.00","63.70","731.00","1 through 10","231.11","592.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131920","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","319.82","42.9","","384.74","384.74","384.74","1 through 10","231.11","592.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131920","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","WELLPOINT [1015]","HB AMC WELLPOINT","550.03","73.78","","286.63","119.22","1107.45","105","231.11","592.67","percent of total billed charges",""
"SCREW BONE 4.5X20MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.50","559.12","AETNA [1001]","HB AMC AETNA HMO","520.36","69.8","","675.31","184.75","1721.50","286","389.6","609.22","percent of total billed charges",""
"SCREW BONE 4.5X20MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.50","559.12","AETNA [1001]","HB AMC AETNA PPO","599.38","80.4","","1261.44","103.12","1514.10","21","389.6","609.22","percent of total billed charges",""
"SCREW BONE 4.5X20MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.50","559.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","599.38","80.4","","1365.00","1365.00","1365.00","1 through 10","389.6","609.22","percent of total billed charges",""
"SCREW BONE 4.5X20MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.50","559.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","609.22","81.72","","5157.68","5157.68","5157.68","1 through 10","389.6","609.22","percent of total billed charges",""
"SCREW BONE 4.5X20MM ORTHOLOC 3DI PLATING SYSTEM LOCKING","SUP-ITM-10131920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.50","559.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","609.22","81.72","","431.26","71.26","1459.57","88","389.6","609.22","percent of total billed charges",""
"SCREW BONE 4.5X20MM WRIST UNIVERSAL2 UNIVERSAL","SUP-ITM-10018492","CDM","C1713","HCPCS","0278","RC","","","","both","","","640.78","480.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","509.42","79.5","","800.18","480.96","1887.97","195","198.64","509.42","percent of total billed charges",""
"SCREW BONE 4.5X20MM WRIST UNIVERSAL2 UNIVERSAL","SUP-ITM-10018492","CDM","C1713","HCPCS","0278","RC","","","","both","","","640.78","480.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","341.54","53.3","","813.12","216.42","1444.50","81","198.64","509.42","percent of total billed charges",""
"SCREW BONE 4.5X20MM WRIST UNIVERSAL2 UNIVERSAL","SUP-ITM-10018492","CDM","C1713","HCPCS","0278","RC","","","","both","","","640.78","480.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.64","31","","432.60","432.60","432.60","1 through 10","198.64","509.42","percent of total billed charges",""
"SCREW BONE 4.5X20MM WRIST UNIVERSAL2 UNIVERSAL","SUP-ITM-10018492","CDM","C1713","HCPCS","0278","RC","","","","both","","","640.78","480.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.88","36.5","","148.37","54.89","631.39","94","198.64","509.42","percent of total billed charges",""
"SCREW BONE 4.5X20MM WRIST UNIVERSAL2 UNIVERSAL","SUP-ITM-10018492","CDM","C1713","HCPCS","0278","RC","","","","both","","","640.78","480.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","245.42","38.3","","279.30","91.72","1116.77","266","198.64","509.42","percent of total billed charges",""
"SCREW BONE 4.5X20MM WRIST UNIVERSAL2 UNIVERSAL","SUP-ITM-10018492","CDM","C1713","HCPCS","0278","RC","","","","both","","","640.78","480.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.89","42.9","","731.00","63.70","731.00","1 through 10","198.64","509.42","percent of total billed charges",""
"SCREW BONE 4.5X20MM WRIST UNIVERSAL2 UNIVERSAL","SUP-ITM-10018492","CDM","C1713","HCPCS","0278","RC","","","","both","","","640.78","480.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.89","42.9","","384.74","384.74","384.74","1 through 10","198.64","509.42","percent of total billed charges",""
"SCREW BONE 4.5X20MM WRIST UNIVERSAL2 UNIVERSAL","SUP-ITM-10018492","CDM","C1713","HCPCS","0278","RC","","","","both","","","640.78","480.58","WELLPOINT [1015]","HB AMC WELLPOINT","472.77","73.78","","286.63","119.22","1107.45","105","198.64","509.42","percent of total billed charges",""
"SCREW BONE 4.5X20MM WRIST UNIVERSAL2 UNIVERSAL","SUP-ITM-10018492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","640.78","480.58","AETNA [1001]","HB AMC AETNA HMO","447.26","69.8","","675.31","184.75","1721.50","286","334.87","523.65","percent of total billed charges",""
"SCREW BONE 4.5X20MM WRIST UNIVERSAL2 UNIVERSAL","SUP-ITM-10018492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","640.78","480.58","AETNA [1001]","HB AMC AETNA PPO","515.19","80.4","","1261.44","103.12","1514.10","21","334.87","523.65","percent of total billed charges",""
"SCREW BONE 4.5X20MM WRIST UNIVERSAL2 UNIVERSAL","SUP-ITM-10018492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","640.78","480.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","515.19","80.4","","1365.00","1365.00","1365.00","1 through 10","334.87","523.65","percent of total billed charges",""
"SCREW BONE 4.5X20MM WRIST UNIVERSAL2 UNIVERSAL","SUP-ITM-10018492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","640.78","480.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","523.65","81.72","","5157.68","5157.68","5157.68","1 through 10","334.87","523.65","percent of total billed charges",""
"SCREW BONE 4.5X20MM WRIST UNIVERSAL2 UNIVERSAL","SUP-ITM-10018492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","640.78","480.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","523.65","81.72","","431.26","71.26","1459.57","88","334.87","523.65","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","1075.41","806.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","854.95","79.5","","800.18","480.96","1887.97","195","333.38","854.95","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","1075.41","806.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","573.19","53.3","","813.12","216.42","1444.50","81","333.38","854.95","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","1075.41","806.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","333.38","31","","432.60","432.60","432.60","1 through 10","333.38","854.95","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","1075.41","806.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","392.52","36.5","","148.37","54.89","631.39","94","333.38","854.95","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","1075.41","806.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","411.88","38.3","","279.30","91.72","1116.77","266","333.38","854.95","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","1075.41","806.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","461.35","42.9","","731.00","63.70","731.00","1 through 10","333.38","854.95","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","1075.41","806.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","461.35","42.9","","384.74","384.74","384.74","1 through 10","333.38","854.95","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","1075.41","806.56","WELLPOINT [1015]","HB AMC WELLPOINT","793.44","73.78","","286.63","119.22","1107.45","105","333.38","854.95","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1075.41","806.56","AETNA [1001]","HB AMC AETNA HMO","750.64","69.8","","675.31","184.75","1721.50","286","562.01","878.83","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1075.41","806.56","AETNA [1001]","HB AMC AETNA PPO","864.63","80.4","","1261.44","103.12","1514.10","21","562.01","878.83","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1075.41","806.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","864.63","80.4","","1365.00","1365.00","1365.00","1 through 10","562.01","878.83","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1075.41","806.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","878.83","81.72","","5157.68","5157.68","5157.68","1 through 10","562.01","878.83","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1075.41","806.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","878.83","81.72","","431.26","71.26","1459.57","88","562.01","878.83","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","211.47","79.5","","800.18","480.96","1887.97","195","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","141.78","53.3","","813.12","216.42","1444.50","81","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","82.46","31","","432.60","432.60","432.60","1 through 10","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.09","36.5","","148.37","54.89","631.39","94","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","101.88","38.3","","279.30","91.72","1116.77","266","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.11","42.9","","731.00","63.70","731.00","1 through 10","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.11","42.9","","384.74","384.74","384.74","1 through 10","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","WELLPOINT [1015]","HB AMC WELLPOINT","196.25","73.78","","286.63","119.22","1107.45","105","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","AETNA [1001]","HB AMC AETNA HMO","185.67","69.8","","675.31","184.75","1721.50","286","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","AETNA [1001]","HB AMC AETNA PPO","213.86","80.4","","1261.44","103.12","1514.10","21","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","213.86","80.4","","1365.00","1365.00","1365.00","1 through 10","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","217.38","81.72","","5157.68","5157.68","5157.68","1 through 10","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","217.38","81.72","","431.26","71.26","1459.57","88","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004458","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.83","131.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","138.99","79.5","","800.18","480.96","1887.97","195","54.2","138.99","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004458","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.83","131.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.18","53.3","","813.12","216.42","1444.50","81","54.2","138.99","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004458","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.83","131.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.20","31","","432.60","432.60","432.60","1 through 10","54.2","138.99","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004458","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.83","131.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.81","36.5","","148.37","54.89","631.39","94","54.2","138.99","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004458","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.83","131.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.96","38.3","","279.30","91.72","1116.77","266","54.2","138.99","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004458","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.83","131.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.00","42.9","","731.00","63.70","731.00","1 through 10","54.2","138.99","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004458","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.83","131.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.00","42.9","","384.74","384.74","384.74","1 through 10","54.2","138.99","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004458","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.83","131.12","WELLPOINT [1015]","HB AMC WELLPOINT","128.99","73.78","","286.63","119.22","1107.45","105","54.2","138.99","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.83","131.12","AETNA [1001]","HB AMC AETNA HMO","122.03","69.8","","675.31","184.75","1721.50","286","91.37","142.87","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.83","131.12","AETNA [1001]","HB AMC AETNA PPO","140.56","80.4","","1261.44","103.12","1514.10","21","91.37","142.87","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.83","131.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","140.56","80.4","","1365.00","1365.00","1365.00","1 through 10","91.37","142.87","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.83","131.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","142.87","81.72","","5157.68","5157.68","5157.68","1 through 10","91.37","142.87","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.83","131.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","142.87","81.72","","431.26","71.26","1459.57","88","91.37","142.87","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017855","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","72.35","79.5","","800.18","480.96","1887.97","195","28.21","72.35","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017855","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.50","53.3","","813.12","216.42","1444.50","81","28.21","72.35","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017855","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","28.21","31","","432.60","432.60","432.60","1 through 10","28.21","72.35","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017855","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.22","36.5","","148.37","54.89","631.39","94","28.21","72.35","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017855","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.85","38.3","","279.30","91.72","1116.77","266","28.21","72.35","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017855","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.04","42.9","","731.00","63.70","731.00","1 through 10","28.21","72.35","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017855","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.04","42.9","","384.74","384.74","384.74","1 through 10","28.21","72.35","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017855","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.00","68.25","WELLPOINT [1015]","HB AMC WELLPOINT","67.14","73.78","","286.63","119.22","1107.45","105","28.21","72.35","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA HMO","63.52","69.8","","675.31","184.75","1721.50","286","47.56","74.37","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA PPO","73.16","80.4","","1261.44","103.12","1514.10","21","47.56","74.37","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","73.16","80.4","","1365.00","1365.00","1365.00","1 through 10","47.56","74.37","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","74.37","81.72","","5157.68","5157.68","5157.68","1 through 10","47.56","74.37","percent of total billed charges",""
"SCREW BONE 4.5X24MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","74.37","81.72","","431.26","71.26","1459.57","88","47.56","74.37","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","248.34","79.5","","800.18","480.96","1887.97","195","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","166.50","53.3","","813.12","216.42","1444.50","81","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","96.84","31","","432.60","432.60","432.60","1 through 10","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.02","36.5","","148.37","54.89","631.39","94","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.64","38.3","","279.30","91.72","1116.77","266","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.01","42.9","","731.00","63.70","731.00","1 through 10","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.01","42.9","","384.74","384.74","384.74","1 through 10","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","WELLPOINT [1015]","HB AMC WELLPOINT","230.47","73.78","","286.63","119.22","1107.45","105","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.38","234.28","AETNA [1001]","HB AMC AETNA HMO","218.04","69.8","","675.31","184.75","1721.50","286","163.25","255.28","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.38","234.28","AETNA [1001]","HB AMC AETNA PPO","251.15","80.4","","1261.44","103.12","1514.10","21","163.25","255.28","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.38","234.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","251.15","80.4","","1365.00","1365.00","1365.00","1 through 10","163.25","255.28","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.38","234.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","255.28","81.72","","5157.68","5157.68","5157.68","1 through 10","163.25","255.28","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.38","234.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","255.28","81.72","","431.26","71.26","1459.57","88","163.25","255.28","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","211.47","79.5","","800.18","480.96","1887.97","195","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","141.78","53.3","","813.12","216.42","1444.50","81","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","82.46","31","","432.60","432.60","432.60","1 through 10","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.09","36.5","","148.37","54.89","631.39","94","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","101.88","38.3","","279.30","91.72","1116.77","266","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.11","42.9","","731.00","63.70","731.00","1 through 10","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.11","42.9","","384.74","384.74","384.74","1 through 10","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","WELLPOINT [1015]","HB AMC WELLPOINT","196.25","73.78","","286.63","119.22","1107.45","105","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","AETNA [1001]","HB AMC AETNA HMO","185.67","69.8","","675.31","184.75","1721.50","286","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","AETNA [1001]","HB AMC AETNA PPO","213.86","80.4","","1261.44","103.12","1514.10","21","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","213.86","80.4","","1365.00","1365.00","1365.00","1 through 10","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","217.38","81.72","","5157.68","5157.68","5157.68","1 through 10","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","217.38","81.72","","431.26","71.26","1459.57","88","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","542.59","79.5","","800.18","480.96","1887.97","195","211.58","542.59","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","363.77","53.3","","813.12","216.42","1444.50","81","211.58","542.59","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","211.58","31","","432.60","432.60","432.60","1 through 10","211.58","542.59","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","249.11","36.5","","148.37","54.89","631.39","94","211.58","542.59","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.40","38.3","","279.30","91.72","1116.77","266","211.58","542.59","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.79","42.9","","731.00","63.70","731.00","1 through 10","211.58","542.59","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.79","42.9","","384.74","384.74","384.74","1 through 10","211.58","542.59","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","both","","","682.50","511.87","WELLPOINT [1015]","HB AMC WELLPOINT","503.55","73.78","","286.63","119.22","1107.45","105","211.58","542.59","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","AETNA [1001]","HB AMC AETNA HMO","476.39","69.8","","675.31","184.75","1721.50","286","356.67","557.74","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","AETNA [1001]","HB AMC AETNA PPO","548.73","80.4","","1261.44","103.12","1514.10","21","356.67","557.74","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","548.73","80.4","","1365.00","1365.00","1365.00","1 through 10","356.67","557.74","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","557.74","81.72","","5157.68","5157.68","5157.68","1 through 10","356.67","557.74","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","682.50","511.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","557.74","81.72","","431.26","71.26","1459.57","88","356.67","557.74","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","218.85","79.5","","800.18","480.96","1887.97","195","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","146.72","53.3","","813.12","216.42","1444.50","81","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.34","31","","432.60","432.60","432.60","1 through 10","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.48","36.5","","148.37","54.89","631.39","94","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.43","38.3","","279.30","91.72","1116.77","266","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.10","42.9","","731.00","63.70","731.00","1 through 10","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.10","42.9","","384.74","384.74","384.74","1 through 10","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","WELLPOINT [1015]","HB AMC WELLPOINT","203.10","73.78","","286.63","119.22","1107.45","105","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","AETNA [1001]","HB AMC AETNA HMO","192.15","69.8","","675.31","184.75","1721.50","286","143.86","224.96","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","AETNA [1001]","HB AMC AETNA PPO","221.33","80.4","","1261.44","103.12","1514.10","21","143.86","224.96","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","221.33","80.4","","1365.00","1365.00","1365.00","1 through 10","143.86","224.96","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","224.96","81.72","","5157.68","5157.68","5157.68","1 through 10","143.86","224.96","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","224.96","81.72","","431.26","71.26","1459.57","88","143.86","224.96","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","218.85","79.5","","800.18","480.96","1887.97","195","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","146.72","53.3","","813.12","216.42","1444.50","81","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.34","31","","432.60","432.60","432.60","1 through 10","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.48","36.5","","148.37","54.89","631.39","94","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.43","38.3","","279.30","91.72","1116.77","266","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.10","42.9","","731.00","63.70","731.00","1 through 10","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.10","42.9","","384.74","384.74","384.74","1 through 10","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","WELLPOINT [1015]","HB AMC WELLPOINT","203.10","73.78","","286.63","119.22","1107.45","105","85.34","218.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","AETNA [1001]","HB AMC AETNA HMO","192.15","69.8","","675.31","184.75","1721.50","286","143.86","224.96","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","AETNA [1001]","HB AMC AETNA PPO","221.33","80.4","","1261.44","103.12","1514.10","21","143.86","224.96","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","221.33","80.4","","1365.00","1365.00","1365.00","1 through 10","143.86","224.96","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","224.96","81.72","","5157.68","5157.68","5157.68","1 through 10","143.86","224.96","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","224.96","81.72","","431.26","71.26","1459.57","88","143.86","224.96","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTICAL FIXATION PROXIMALIMAL ANGLE TITANIUM SELF TAPPING FULL THREAD DISTAL HEXAGONAL HEAD","SUP-ITM-10002090","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","105.74","79.5","","800.18","480.96","1887.97","195","41.23","105.74","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTICAL FIXATION PROXIMALIMAL ANGLE TITANIUM SELF TAPPING FULL THREAD DISTAL HEXAGONAL HEAD","SUP-ITM-10002090","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","70.89","53.3","","813.12","216.42","1444.50","81","41.23","105.74","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTICAL FIXATION PROXIMALIMAL ANGLE TITANIUM SELF TAPPING FULL THREAD DISTAL HEXAGONAL HEAD","SUP-ITM-10002090","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","41.23","31","","432.60","432.60","432.60","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTICAL FIXATION PROXIMALIMAL ANGLE TITANIUM SELF TAPPING FULL THREAD DISTAL HEXAGONAL HEAD","SUP-ITM-10002090","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.55","36.5","","148.37","54.89","631.39","94","41.23","105.74","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTICAL FIXATION PROXIMALIMAL ANGLE TITANIUM SELF TAPPING FULL THREAD DISTAL HEXAGONAL HEAD","SUP-ITM-10002090","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","50.94","38.3","","279.30","91.72","1116.77","266","41.23","105.74","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTICAL FIXATION PROXIMALIMAL ANGLE TITANIUM SELF TAPPING FULL THREAD DISTAL HEXAGONAL HEAD","SUP-ITM-10002090","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.06","42.9","","731.00","63.70","731.00","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTICAL FIXATION PROXIMALIMAL ANGLE TITANIUM SELF TAPPING FULL THREAD DISTAL HEXAGONAL HEAD","SUP-ITM-10002090","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.06","42.9","","384.74","384.74","384.74","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTICAL FIXATION PROXIMALIMAL ANGLE TITANIUM SELF TAPPING FULL THREAD DISTAL HEXAGONAL HEAD","SUP-ITM-10002090","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","WELLPOINT [1015]","HB AMC WELLPOINT","98.13","73.78","","286.63","119.22","1107.45","105","41.23","105.74","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTICAL FIXATION PROXIMALIMAL ANGLE TITANIUM SELF TAPPING FULL THREAD DISTAL HEXAGONAL HEAD","SUP-ITM-10002090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","AETNA [1001]","HB AMC AETNA HMO","92.83","69.8","","675.31","184.75","1721.50","286","69.51","108.69","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTICAL FIXATION PROXIMALIMAL ANGLE TITANIUM SELF TAPPING FULL THREAD DISTAL HEXAGONAL HEAD","SUP-ITM-10002090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","AETNA [1001]","HB AMC AETNA PPO","106.93","80.4","","1261.44","103.12","1514.10","21","69.51","108.69","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTICAL FIXATION PROXIMALIMAL ANGLE TITANIUM SELF TAPPING FULL THREAD DISTAL HEXAGONAL HEAD","SUP-ITM-10002090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","106.93","80.4","","1365.00","1365.00","1365.00","1 through 10","69.51","108.69","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTICAL FIXATION PROXIMALIMAL ANGLE TITANIUM SELF TAPPING FULL THREAD DISTAL HEXAGONAL HEAD","SUP-ITM-10002090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","108.69","81.72","","5157.68","5157.68","5157.68","1 through 10","69.51","108.69","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTICAL FIXATION PROXIMALIMAL ANGLE TITANIUM SELF TAPPING FULL THREAD DISTAL HEXAGONAL HEAD","SUP-ITM-10002090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","108.69","81.72","","431.26","71.26","1459.57","88","69.51","108.69","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","211.47","79.5","","800.18","480.96","1887.97","195","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","141.78","53.3","","813.12","216.42","1444.50","81","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","82.46","31","","432.60","432.60","432.60","1 through 10","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.09","36.5","","148.37","54.89","631.39","94","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","101.88","38.3","","279.30","91.72","1116.77","266","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.11","42.9","","731.00","63.70","731.00","1 through 10","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.11","42.9","","384.74","384.74","384.74","1 through 10","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","WELLPOINT [1015]","HB AMC WELLPOINT","196.25","73.78","","286.63","119.22","1107.45","105","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","AETNA [1001]","HB AMC AETNA HMO","185.67","69.8","","675.31","184.75","1721.50","286","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","AETNA [1001]","HB AMC AETNA PPO","213.86","80.4","","1261.44","103.12","1514.10","21","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","213.86","80.4","","1365.00","1365.00","1365.00","1 through 10","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","217.38","81.72","","5157.68","5157.68","5157.68","1 through 10","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","217.38","81.72","","431.26","71.26","1459.57","88","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","211.47","79.5","","800.18","480.96","1887.97","195","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","141.78","53.3","","813.12","216.42","1444.50","81","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","82.46","31","","432.60","432.60","432.60","1 through 10","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.09","36.5","","148.37","54.89","631.39","94","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","101.88","38.3","","279.30","91.72","1116.77","266","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.11","42.9","","731.00","63.70","731.00","1 through 10","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.11","42.9","","384.74","384.74","384.74","1 through 10","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","266.00","199.50","WELLPOINT [1015]","HB AMC WELLPOINT","196.25","73.78","","286.63","119.22","1107.45","105","82.46","211.47","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","AETNA [1001]","HB AMC AETNA HMO","185.67","69.8","","675.31","184.75","1721.50","286","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","AETNA [1001]","HB AMC AETNA PPO","213.86","80.4","","1261.44","103.12","1514.10","21","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","213.86","80.4","","1365.00","1365.00","1365.00","1 through 10","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","217.38","81.72","","5157.68","5157.68","5157.68","1 through 10","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","217.38","81.72","","431.26","71.26","1459.57","88","139.01","217.38","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","357.94","79.5","","800.18","480.96","1887.97","195","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","239.98","53.3","","813.12","216.42","1444.50","81","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","139.57","31","","432.60","432.60","432.60","1 through 10","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","164.34","36.5","","148.37","54.89","631.39","94","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","172.44","38.3","","279.30","91.72","1116.77","266","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.15","42.9","","731.00","63.70","731.00","1 through 10","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.15","42.9","","384.74","384.74","384.74","1 through 10","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.24","337.68","WELLPOINT [1015]","HB AMC WELLPOINT","332.19","73.78","","286.63","119.22","1107.45","105","139.57","357.94","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.24","337.68","AETNA [1001]","HB AMC AETNA HMO","314.27","69.8","","675.31","184.75","1721.50","286","235.3","367.94","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.24","337.68","AETNA [1001]","HB AMC AETNA PPO","361.99","80.4","","1261.44","103.12","1514.10","21","235.3","367.94","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.24","337.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","361.99","80.4","","1365.00","1365.00","1365.00","1 through 10","235.3","367.94","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.24","337.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","367.94","81.72","","5157.68","5157.68","5157.68","1 through 10","235.3","367.94","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.24","337.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","367.94","81.72","","431.26","71.26","1459.57","88","235.3","367.94","percent of total billed charges",""
"SCREW BONE 4.5X32MM SPINE ROD CONNECTOR SFX EXPEDIUM TITANIUM LATERAL P14","SUP-ITM-10046452","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","800.18","480.96","1887.97","195","482.83","1238.21","percent of total billed charges",""
"SCREW BONE 4.5X32MM SPINE ROD CONNECTOR SFX EXPEDIUM TITANIUM LATERAL P14","SUP-ITM-10046452","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","813.12","216.42","1444.50","81","482.83","1238.21","percent of total billed charges",""
"SCREW BONE 4.5X32MM SPINE ROD CONNECTOR SFX EXPEDIUM TITANIUM LATERAL P14","SUP-ITM-10046452","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","482.83","31","","432.60","432.60","432.60","1 through 10","482.83","1238.21","percent of total billed charges",""
"SCREW BONE 4.5X32MM SPINE ROD CONNECTOR SFX EXPEDIUM TITANIUM LATERAL P14","SUP-ITM-10046452","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","148.37","54.89","631.39","94","482.83","1238.21","percent of total billed charges",""
"SCREW BONE 4.5X32MM SPINE ROD CONNECTOR SFX EXPEDIUM TITANIUM LATERAL P14","SUP-ITM-10046452","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","279.30","91.72","1116.77","266","482.83","1238.21","percent of total billed charges",""
"SCREW BONE 4.5X32MM SPINE ROD CONNECTOR SFX EXPEDIUM TITANIUM LATERAL P14","SUP-ITM-10046452","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","731.00","63.70","731.00","1 through 10","482.83","1238.21","percent of total billed charges",""
"SCREW BONE 4.5X32MM SPINE ROD CONNECTOR SFX EXPEDIUM TITANIUM LATERAL P14","SUP-ITM-10046452","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","384.74","384.74","384.74","1 through 10","482.83","1238.21","percent of total billed charges",""
"SCREW BONE 4.5X32MM SPINE ROD CONNECTOR SFX EXPEDIUM TITANIUM LATERAL P14","SUP-ITM-10046452","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","286.63","119.22","1107.45","105","482.83","1238.21","percent of total billed charges",""
"SCREW BONE 4.5X32MM SPINE ROD CONNECTOR SFX EXPEDIUM TITANIUM LATERAL P14","SUP-ITM-10046452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","675.31","184.75","1721.50","286","813.95","1272.79","percent of total billed charges",""
"SCREW BONE 4.5X32MM SPINE ROD CONNECTOR SFX EXPEDIUM TITANIUM LATERAL P14","SUP-ITM-10046452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA PPO","1252.23","80.4","","1261.44","103.12","1514.10","21","813.95","1272.79","percent of total billed charges",""
"SCREW BONE 4.5X32MM SPINE ROD CONNECTOR SFX EXPEDIUM TITANIUM LATERAL P14","SUP-ITM-10046452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.23","80.4","","1365.00","1365.00","1365.00","1 through 10","813.95","1272.79","percent of total billed charges",""
"SCREW BONE 4.5X32MM SPINE ROD CONNECTOR SFX EXPEDIUM TITANIUM LATERAL P14","SUP-ITM-10046452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1272.79","81.72","","5157.68","5157.68","5157.68","1 through 10","813.95","1272.79","percent of total billed charges",""
"SCREW BONE 4.5X32MM SPINE ROD CONNECTOR SFX EXPEDIUM TITANIUM LATERAL P14","SUP-ITM-10046452","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","431.26","71.26","1459.57","88","813.95","1272.79","percent of total billed charges",""
"SCREW BONE 4.5X34MM CANNULATED TITANIUM FULLY THREADED","SUP-ITM-10040211","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.72","383.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","406.02","79.5","","800.18","480.96","1887.97","195","158.32","406.02","percent of total billed charges",""
"SCREW BONE 4.5X34MM CANNULATED TITANIUM FULLY THREADED","SUP-ITM-10040211","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.72","383.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","272.21","53.3","","813.12","216.42","1444.50","81","158.32","406.02","percent of total billed charges",""
"SCREW BONE 4.5X34MM CANNULATED TITANIUM FULLY THREADED","SUP-ITM-10040211","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.72","383.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","158.32","31","","432.60","432.60","432.60","1 through 10","158.32","406.02","percent of total billed charges",""
"SCREW BONE 4.5X34MM CANNULATED TITANIUM FULLY THREADED","SUP-ITM-10040211","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.72","383.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","186.41","36.5","","148.37","54.89","631.39","94","158.32","406.02","percent of total billed charges",""
"SCREW BONE 4.5X34MM CANNULATED TITANIUM FULLY THREADED","SUP-ITM-10040211","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.72","383.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","195.61","38.3","","279.30","91.72","1116.77","266","158.32","406.02","percent of total billed charges",""
"SCREW BONE 4.5X34MM CANNULATED TITANIUM FULLY THREADED","SUP-ITM-10040211","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.72","383.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","219.10","42.9","","731.00","63.70","731.00","1 through 10","158.32","406.02","percent of total billed charges",""
"SCREW BONE 4.5X34MM CANNULATED TITANIUM FULLY THREADED","SUP-ITM-10040211","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.72","383.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","219.10","42.9","","384.74","384.74","384.74","1 through 10","158.32","406.02","percent of total billed charges",""
"SCREW BONE 4.5X34MM CANNULATED TITANIUM FULLY THREADED","SUP-ITM-10040211","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.72","383.04","WELLPOINT [1015]","HB AMC WELLPOINT","376.81","73.78","","286.63","119.22","1107.45","105","158.32","406.02","percent of total billed charges",""
"SCREW BONE 4.5X34MM CANNULATED TITANIUM FULLY THREADED","SUP-ITM-10040211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.72","383.04","AETNA [1001]","HB AMC AETNA HMO","356.48","69.8","","675.31","184.75","1721.50","286","266.9","417.36","percent of total billed charges",""
"SCREW BONE 4.5X34MM CANNULATED TITANIUM FULLY THREADED","SUP-ITM-10040211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.72","383.04","AETNA [1001]","HB AMC AETNA PPO","410.62","80.4","","1261.44","103.12","1514.10","21","266.9","417.36","percent of total billed charges",""
"SCREW BONE 4.5X34MM CANNULATED TITANIUM FULLY THREADED","SUP-ITM-10040211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.72","383.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","410.62","80.4","","1365.00","1365.00","1365.00","1 through 10","266.9","417.36","percent of total billed charges",""
"SCREW BONE 4.5X34MM CANNULATED TITANIUM FULLY THREADED","SUP-ITM-10040211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.72","383.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","417.36","81.72","","5157.68","5157.68","5157.68","1 through 10","266.9","417.36","percent of total billed charges",""
"SCREW BONE 4.5X34MM CANNULATED TITANIUM FULLY THREADED","SUP-ITM-10040211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.72","383.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","417.36","81.72","","431.26","71.26","1459.57","88","266.9","417.36","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE POLYAXIAL LOW PROFILE TITANIUM XIA II","SUP-ITM-10018080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","800.18","480.96","1887.97","195","434","1113","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE POLYAXIAL LOW PROFILE TITANIUM XIA II","SUP-ITM-10018080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","813.12","216.42","1444.50","81","434","1113","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE POLYAXIAL LOW PROFILE TITANIUM XIA II","SUP-ITM-10018080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","434.00","31","","432.60","432.60","432.60","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE POLYAXIAL LOW PROFILE TITANIUM XIA II","SUP-ITM-10018080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","148.37","54.89","631.39","94","434","1113","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE POLYAXIAL LOW PROFILE TITANIUM XIA II","SUP-ITM-10018080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","279.30","91.72","1116.77","266","434","1113","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE POLYAXIAL LOW PROFILE TITANIUM XIA II","SUP-ITM-10018080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","731.00","63.70","731.00","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE POLYAXIAL LOW PROFILE TITANIUM XIA II","SUP-ITM-10018080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","384.74","384.74","384.74","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE POLYAXIAL LOW PROFILE TITANIUM XIA II","SUP-ITM-10018080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","286.63","119.22","1107.45","105","434","1113","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE POLYAXIAL LOW PROFILE TITANIUM XIA II","SUP-ITM-10018080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","675.31","184.75","1721.50","286","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE POLYAXIAL LOW PROFILE TITANIUM XIA II","SUP-ITM-10018080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA PPO","1125.60","80.4","","1261.44","103.12","1514.10","21","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE POLYAXIAL LOW PROFILE TITANIUM XIA II","SUP-ITM-10018080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1365.00","1365.00","1365.00","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE POLYAXIAL LOW PROFILE TITANIUM XIA II","SUP-ITM-10018080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1144.08","81.72","","5157.68","5157.68","5157.68","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE POLYAXIAL LOW PROFILE TITANIUM XIA II","SUP-ITM-10018080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","431.26","71.26","1459.57","88","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.56","346.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","367.74","79.5","","800.18","480.96","1887.97","195","143.39","367.74","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.56","346.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","246.54","53.3","","813.12","216.42","1444.50","81","143.39","367.74","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.56","346.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","143.39","31","","432.60","432.60","432.60","1 through 10","143.39","367.74","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.56","346.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","168.83","36.5","","148.37","54.89","631.39","94","143.39","367.74","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.56","346.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","177.16","38.3","","279.30","91.72","1116.77","266","143.39","367.74","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.56","346.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.44","42.9","","731.00","63.70","731.00","1 through 10","143.39","367.74","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.56","346.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.44","42.9","","384.74","384.74","384.74","1 through 10","143.39","367.74","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.56","346.92","WELLPOINT [1015]","HB AMC WELLPOINT","341.28","73.78","","286.63","119.22","1107.45","105","143.39","367.74","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.56","346.92","AETNA [1001]","HB AMC AETNA HMO","322.87","69.8","","675.31","184.75","1721.50","286","241.73","378","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.56","346.92","AETNA [1001]","HB AMC AETNA PPO","371.90","80.4","","1261.44","103.12","1514.10","21","241.73","378","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.56","346.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","371.90","80.4","","1365.00","1365.00","1365.00","1 through 10","241.73","378","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.56","346.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","378.00","81.72","","5157.68","5157.68","5157.68","1 through 10","241.73","378","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.56","346.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","378.00","81.72","","431.26","71.26","1459.57","88","241.73","378","percent of total billed charges",""
"SCREW BONE 4.5X42MM FOOT CHARLOTTE LISFRANC CANNULATED","SUP-ITM-10056899","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2573.81","79.5","","800.18","480.96","1887.97","195","1003.63","2573.81","percent of total billed charges",""
"SCREW BONE 4.5X42MM FOOT CHARLOTTE LISFRANC CANNULATED","SUP-ITM-10056899","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1725.59","53.3","","813.12","216.42","1444.50","81","1003.63","2573.81","percent of total billed charges",""
"SCREW BONE 4.5X42MM FOOT CHARLOTTE LISFRANC CANNULATED","SUP-ITM-10056899","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1003.63","31","","432.60","432.60","432.60","1 through 10","1003.63","2573.81","percent of total billed charges",""
"SCREW BONE 4.5X42MM FOOT CHARLOTTE LISFRANC CANNULATED","SUP-ITM-10056899","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1181.69","36.5","","148.37","54.89","631.39","94","1003.63","2573.81","percent of total billed charges",""
"SCREW BONE 4.5X42MM FOOT CHARLOTTE LISFRANC CANNULATED","SUP-ITM-10056899","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1239.96","38.3","","279.30","91.72","1116.77","266","1003.63","2573.81","percent of total billed charges",""
"SCREW BONE 4.5X42MM FOOT CHARLOTTE LISFRANC CANNULATED","SUP-ITM-10056899","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1388.89","42.9","","731.00","63.70","731.00","1 through 10","1003.63","2573.81","percent of total billed charges",""
"SCREW BONE 4.5X42MM FOOT CHARLOTTE LISFRANC CANNULATED","SUP-ITM-10056899","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1388.89","42.9","","384.74","384.74","384.74","1 through 10","1003.63","2573.81","percent of total billed charges",""
"SCREW BONE 4.5X42MM FOOT CHARLOTTE LISFRANC CANNULATED","SUP-ITM-10056899","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","WELLPOINT [1015]","HB AMC WELLPOINT","2388.63","73.78","","286.63","119.22","1107.45","105","1003.63","2573.81","percent of total billed charges",""
"SCREW BONE 4.5X42MM FOOT CHARLOTTE LISFRANC CANNULATED","SUP-ITM-10056899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","AETNA [1001]","HB AMC AETNA HMO","2259.78","69.8","","675.31","184.75","1721.50","286","1691.92","2645.69","percent of total billed charges",""
"SCREW BONE 4.5X42MM FOOT CHARLOTTE LISFRANC CANNULATED","SUP-ITM-10056899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","AETNA [1001]","HB AMC AETNA PPO","2602.95","80.4","","1261.44","103.12","1514.10","21","1691.92","2645.69","percent of total billed charges",""
"SCREW BONE 4.5X42MM FOOT CHARLOTTE LISFRANC CANNULATED","SUP-ITM-10056899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2602.95","80.4","","1365.00","1365.00","1365.00","1 through 10","1691.92","2645.69","percent of total billed charges",""
"SCREW BONE 4.5X42MM FOOT CHARLOTTE LISFRANC CANNULATED","SUP-ITM-10056899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2645.69","81.72","","5157.68","5157.68","5157.68","1 through 10","1691.92","2645.69","percent of total billed charges",""
"SCREW BONE 4.5X42MM FOOT CHARLOTTE LISFRANC CANNULATED","SUP-ITM-10056899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2645.69","81.72","","431.26","71.26","1459.57","88","1691.92","2645.69","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","248.34","79.5","","800.18","480.96","1887.97","195","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","166.50","53.3","","813.12","216.42","1444.50","81","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","96.84","31","","432.60","432.60","432.60","1 through 10","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.02","36.5","","148.37","54.89","631.39","94","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.64","38.3","","279.30","91.72","1116.77","266","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.01","42.9","","731.00","63.70","731.00","1 through 10","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.01","42.9","","384.74","384.74","384.74","1 through 10","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.38","234.28","WELLPOINT [1015]","HB AMC WELLPOINT","230.47","73.78","","286.63","119.22","1107.45","105","96.84","248.34","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.38","234.28","AETNA [1001]","HB AMC AETNA HMO","218.04","69.8","","675.31","184.75","1721.50","286","163.25","255.28","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.38","234.28","AETNA [1001]","HB AMC AETNA PPO","251.15","80.4","","1261.44","103.12","1514.10","21","163.25","255.28","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.38","234.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","251.15","80.4","","1365.00","1365.00","1365.00","1 through 10","163.25","255.28","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.38","234.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","255.28","81.72","","5157.68","5157.68","5157.68","1 through 10","163.25","255.28","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.38","234.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","255.28","81.72","","431.26","71.26","1459.57","88","163.25","255.28","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.54","70.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","75.16","79.5","","800.18","480.96","1887.97","195","29.31","75.16","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.54","70.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","50.39","53.3","","813.12","216.42","1444.50","81","29.31","75.16","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.54","70.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","29.31","31","","432.60","432.60","432.60","1 through 10","29.31","75.16","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.54","70.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34.51","36.5","","148.37","54.89","631.39","94","29.31","75.16","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.54","70.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","36.21","38.3","","279.30","91.72","1116.77","266","29.31","75.16","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.54","70.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.56","42.9","","731.00","63.70","731.00","1 through 10","29.31","75.16","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.54","70.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.56","42.9","","384.74","384.74","384.74","1 through 10","29.31","75.16","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.54","70.90","WELLPOINT [1015]","HB AMC WELLPOINT","69.75","73.78","","286.63","119.22","1107.45","105","29.31","75.16","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","94.54","70.90","AETNA [1001]","HB AMC AETNA HMO","65.99","69.8","","675.31","184.75","1721.50","286","49.41","77.26","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","94.54","70.90","AETNA [1001]","HB AMC AETNA PPO","76.01","80.4","","1261.44","103.12","1514.10","21","49.41","77.26","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","94.54","70.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","76.01","80.4","","1365.00","1365.00","1365.00","1 through 10","49.41","77.26","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","94.54","70.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","77.26","81.72","","5157.68","5157.68","5157.68","1 through 10","49.41","77.26","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","94.54","70.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","77.26","81.72","","431.26","71.26","1459.57","88","49.41","77.26","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","both","","","647.50","485.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","338.38","52.26","","1113.10","1113.10","1113.10","1 through 10","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","both","","","647.50","485.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","514.76","79.5","","1293.60","1148.53","1603.80","1 through 10","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","both","","","647.50","485.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","236.34","36.5","","1023.42","771.29","2068.67","33","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","both","","","647.50","485.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","247.99","38.3","","850.52","759.78","1211.25","66","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","both","","","647.50","485.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.78","42.9","","2548.09","2548.09","2548.09","1 through 10","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","both","","","647.50","485.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.78","42.9","","956.46","956.46","956.46","1 through 10","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","both","","","647.50","485.62","WELLPOINT [1015]","HB AMC WELLPOINT","477.73","73.78","","2344.73","1619.47","2530.35","16","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","AETNA [1001]","HB AMC AETNA HMO","451.96","69.8","","1523.63","988.41","4330.26","39","338.38","529.14","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","AETNA [1001]","HB AMC AETNA PPO","520.59","80.4","","1670.25","1670.25","1670.25","1 through 10","338.38","529.14","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","338.38","52.26","","1113.10","1113.10","1113.10","1 through 10","338.38","529.14","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","529.14","81.72","","1738.90","1484.65","2716.94","38","338.38","529.14","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.85","146.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","154.91","79.5","","800.18","480.96","1887.97","195","60.4","154.91","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.85","146.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","103.86","53.3","","813.12","216.42","1444.50","81","60.4","154.91","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.85","146.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","60.40","31","","432.60","432.60","432.60","1 through 10","60.4","154.91","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.85","146.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.12","36.5","","148.37","54.89","631.39","94","60.4","154.91","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.85","146.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","74.63","38.3","","279.30","91.72","1116.77","266","60.4","154.91","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.85","146.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.59","42.9","","731.00","63.70","731.00","1 through 10","60.4","154.91","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.85","146.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.59","42.9","","384.74","384.74","384.74","1 through 10","60.4","154.91","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","both","","","194.85","146.14","WELLPOINT [1015]","HB AMC WELLPOINT","143.76","73.78","","286.63","119.22","1107.45","105","60.4","154.91","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.85","146.14","AETNA [1001]","HB AMC AETNA HMO","136.01","69.8","","675.31","184.75","1721.50","286","101.83","159.23","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.85","146.14","AETNA [1001]","HB AMC AETNA PPO","156.66","80.4","","1261.44","103.12","1514.10","21","101.83","159.23","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.85","146.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","156.66","80.4","","1365.00","1365.00","1365.00","1 through 10","101.83","159.23","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.85","146.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","159.23","81.72","","5157.68","5157.68","5157.68","1 through 10","101.83","159.23","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10016886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","194.85","146.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","159.23","81.72","","431.26","71.26","1459.57","88","101.83","159.23","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","74.52","79.5","","800.18","480.96","1887.97","195","29.06","74.52","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","49.96","53.3","","813.12","216.42","1444.50","81","29.06","74.52","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","29.06","31","","432.60","432.60","432.60","1 through 10","29.06","74.52","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34.21","36.5","","148.37","54.89","631.39","94","29.06","74.52","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35.90","38.3","","279.30","91.72","1116.77","266","29.06","74.52","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.21","42.9","","731.00","63.70","731.00","1 through 10","29.06","74.52","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.21","42.9","","384.74","384.74","384.74","1 through 10","29.06","74.52","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.73","70.30","WELLPOINT [1015]","HB AMC WELLPOINT","69.15","73.78","","286.63","119.22","1107.45","105","29.06","74.52","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","AETNA [1001]","HB AMC AETNA HMO","65.42","69.8","","675.31","184.75","1721.50","286","48.98","76.6","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","AETNA [1001]","HB AMC AETNA PPO","75.36","80.4","","1261.44","103.12","1514.10","21","48.98","76.6","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","75.36","80.4","","1365.00","1365.00","1365.00","1 through 10","48.98","76.6","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","76.60","81.72","","5157.68","5157.68","5157.68","1 through 10","48.98","76.6","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.73","70.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","76.60","81.72","","431.26","71.26","1459.57","88","48.98","76.6","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.50","485.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","514.76","79.5","","800.18","480.96","1887.97","195","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.50","485.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","345.12","53.3","","813.12","216.42","1444.50","81","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.50","485.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","200.73","31","","432.60","432.60","432.60","1 through 10","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.50","485.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","236.34","36.5","","148.37","54.89","631.39","94","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.50","485.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","247.99","38.3","","279.30","91.72","1116.77","266","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.50","485.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.78","42.9","","731.00","63.70","731.00","1 through 10","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.50","485.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.78","42.9","","384.74","384.74","384.74","1 through 10","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.50","485.62","WELLPOINT [1015]","HB AMC WELLPOINT","477.73","73.78","","286.63","119.22","1107.45","105","200.73","514.76","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","AETNA [1001]","HB AMC AETNA HMO","451.96","69.8","","675.31","184.75","1721.50","286","338.38","529.14","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","AETNA [1001]","HB AMC AETNA PPO","520.59","80.4","","1261.44","103.12","1514.10","21","338.38","529.14","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","520.59","80.4","","1365.00","1365.00","1365.00","1 through 10","338.38","529.14","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","529.14","81.72","","5157.68","5157.68","5157.68","1 through 10","338.38","529.14","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.50","485.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","529.14","81.72","","431.26","71.26","1459.57","88","338.38","529.14","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","208.69","79.5","","800.18","480.96","1887.97","195","81.38","208.69","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.91","53.3","","813.12","216.42","1444.50","81","81.38","208.69","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","81.38","31","","432.60","432.60","432.60","1 through 10","81.38","208.69","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.81","36.5","","148.37","54.89","631.39","94","81.38","208.69","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.54","38.3","","279.30","91.72","1116.77","266","81.38","208.69","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.61","42.9","","731.00","63.70","731.00","1 through 10","81.38","208.69","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.61","42.9","","384.74","384.74","384.74","1 through 10","81.38","208.69","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","WELLPOINT [1015]","HB AMC WELLPOINT","193.67","73.78","","286.63","119.22","1107.45","105","81.38","208.69","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","AETNA [1001]","HB AMC AETNA HMO","183.23","69.8","","675.31","184.75","1721.50","286","137.18","214.52","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","AETNA [1001]","HB AMC AETNA PPO","211.05","80.4","","1261.44","103.12","1514.10","21","137.18","214.52","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","211.05","80.4","","1365.00","1365.00","1365.00","1 through 10","137.18","214.52","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","214.52","81.72","","5157.68","5157.68","5157.68","1 through 10","137.18","214.52","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.52","81.72","","431.26","71.26","1459.57","88","137.18","214.52","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX FULL THREAD TITANIUM LG HEXAGONAL SOCKET","SUP-ITM-10001650","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","148.25","79.5","","800.18","480.96","1887.97","195","57.81","148.25","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX FULL THREAD TITANIUM LG HEXAGONAL SOCKET","SUP-ITM-10001650","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","99.39","53.3","","813.12","216.42","1444.50","81","57.81","148.25","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX FULL THREAD TITANIUM LG HEXAGONAL SOCKET","SUP-ITM-10001650","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","57.81","31","","432.60","432.60","432.60","1 through 10","57.81","148.25","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX FULL THREAD TITANIUM LG HEXAGONAL SOCKET","SUP-ITM-10001650","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.07","36.5","","148.37","54.89","631.39","94","57.81","148.25","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX FULL THREAD TITANIUM LG HEXAGONAL SOCKET","SUP-ITM-10001650","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71.42","38.3","","279.30","91.72","1116.77","266","57.81","148.25","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX FULL THREAD TITANIUM LG HEXAGONAL SOCKET","SUP-ITM-10001650","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.00","42.9","","731.00","63.70","731.00","1 through 10","57.81","148.25","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX FULL THREAD TITANIUM LG HEXAGONAL SOCKET","SUP-ITM-10001650","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.00","42.9","","384.74","384.74","384.74","1 through 10","57.81","148.25","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX FULL THREAD TITANIUM LG HEXAGONAL SOCKET","SUP-ITM-10001650","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.48","139.86","WELLPOINT [1015]","HB AMC WELLPOINT","137.58","73.78","","286.63","119.22","1107.45","105","57.81","148.25","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX FULL THREAD TITANIUM LG HEXAGONAL SOCKET","SUP-ITM-10001650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.48","139.86","AETNA [1001]","HB AMC AETNA HMO","130.16","69.8","","675.31","184.75","1721.50","286","97.45","152.39","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX FULL THREAD TITANIUM LG HEXAGONAL SOCKET","SUP-ITM-10001650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.48","139.86","AETNA [1001]","HB AMC AETNA PPO","149.93","80.4","","1261.44","103.12","1514.10","21","97.45","152.39","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX FULL THREAD TITANIUM LG HEXAGONAL SOCKET","SUP-ITM-10001650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.48","139.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","149.93","80.4","","1365.00","1365.00","1365.00","1 through 10","97.45","152.39","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX FULL THREAD TITANIUM LG HEXAGONAL SOCKET","SUP-ITM-10001650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.48","139.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","152.39","81.72","","5157.68","5157.68","5157.68","1 through 10","97.45","152.39","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX FULL THREAD TITANIUM LG HEXAGONAL SOCKET","SUP-ITM-10001650","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.48","139.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","152.39","81.72","","431.26","71.26","1459.57","88","97.45","152.39","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2253.83","79.5","","800.18","480.96","1887.97","195","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1511.06","53.3","","813.12","216.42","1444.50","81","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","878.85","31","","432.60","432.60","432.60","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1034.78","36.5","","148.37","54.89","631.39","94","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1085.81","38.3","","279.30","91.72","1116.77","266","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","731.00","63.70","731.00","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","384.74","384.74","384.74","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB AMC WELLPOINT","2091.66","73.78","","286.63","119.22","1107.45","105","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA HMO","1978.83","69.8","","675.31","184.75","1721.50","286","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA PPO","2279.34","80.4","","1261.44","103.12","1514.10","21","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2279.34","80.4","","1365.00","1365.00","1365.00","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2316.76","81.72","","5157.68","5157.68","5157.68","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2316.76","81.72","","431.26","71.26","1459.57","88","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","132.81","79.5","","800.18","480.96","1887.97","195","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","89.04","53.3","","813.12","216.42","1444.50","81","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","51.79","31","","432.60","432.60","432.60","1 through 10","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.98","36.5","","148.37","54.89","631.39","94","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.98","38.3","","279.30","91.72","1116.77","266","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.67","42.9","","731.00","63.70","731.00","1 through 10","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.67","42.9","","384.74","384.74","384.74","1 through 10","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.06","125.29","WELLPOINT [1015]","HB AMC WELLPOINT","123.26","73.78","","286.63","119.22","1107.45","105","51.79","132.81","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.06","125.29","AETNA [1001]","HB AMC AETNA HMO","116.61","69.8","","675.31","184.75","1721.50","286","87.31","136.52","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.06","125.29","AETNA [1001]","HB AMC AETNA PPO","134.32","80.4","","1261.44","103.12","1514.10","21","87.31","136.52","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.06","125.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","134.32","80.4","","1365.00","1365.00","1365.00","1 through 10","87.31","136.52","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.06","125.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","136.52","81.72","","5157.68","5157.68","5157.68","1 through 10","87.31","136.52","percent of total billed charges",""
"SCREW BONE 4.5X76MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10006404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.06","125.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","136.52","81.72","","431.26","71.26","1459.57","88","87.31","136.52","percent of total billed charges",""
"SCREW BONE 4.5X85MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071399","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.60","130.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","138.01","79.5","","800.18","480.96","1887.97","195","53.82","138.01","percent of total billed charges",""
"SCREW BONE 4.5X85MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071399","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.60","130.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","92.53","53.3","","813.12","216.42","1444.50","81","53.82","138.01","percent of total billed charges",""
"SCREW BONE 4.5X85MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071399","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.60","130.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","53.82","31","","432.60","432.60","432.60","1 through 10","53.82","138.01","percent of total billed charges",""
"SCREW BONE 4.5X85MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071399","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.60","130.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.36","36.5","","148.37","54.89","631.39","94","53.82","138.01","percent of total billed charges",""
"SCREW BONE 4.5X85MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071399","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.60","130.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.49","38.3","","279.30","91.72","1116.77","266","53.82","138.01","percent of total billed charges",""
"SCREW BONE 4.5X85MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071399","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.60","130.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.47","42.9","","731.00","63.70","731.00","1 through 10","53.82","138.01","percent of total billed charges",""
"SCREW BONE 4.5X85MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071399","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.60","130.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.47","42.9","","384.74","384.74","384.74","1 through 10","53.82","138.01","percent of total billed charges",""
"SCREW BONE 4.5X85MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071399","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.60","130.20","WELLPOINT [1015]","HB AMC WELLPOINT","128.08","73.78","","286.63","119.22","1107.45","105","53.82","138.01","percent of total billed charges",""
"SCREW BONE 4.5X85MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.60","130.20","AETNA [1001]","HB AMC AETNA HMO","121.17","69.8","","675.31","184.75","1721.50","286","90.72","141.87","percent of total billed charges",""
"SCREW BONE 4.5X85MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.60","130.20","AETNA [1001]","HB AMC AETNA PPO","139.57","80.4","","1261.44","103.12","1514.10","21","90.72","141.87","percent of total billed charges",""
"SCREW BONE 4.5X85MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.60","130.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","139.57","80.4","","1365.00","1365.00","1365.00","1 through 10","90.72","141.87","percent of total billed charges",""
"SCREW BONE 4.5X85MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.60","130.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","141.87","81.72","","5157.68","5157.68","5157.68","1 through 10","90.72","141.87","percent of total billed charges",""
"SCREW BONE 4.5X85MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.60","130.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","141.87","81.72","","431.26","71.26","1459.57","88","90.72","141.87","percent of total billed charges",""
"SCREW BONE 4.5X8MM SPINE MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10017655","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","278.25","79.5","","800.18","480.96","1887.97","195","108.5","278.25","percent of total billed charges",""
"SCREW BONE 4.5X8MM SPINE MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10017655","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","186.55","53.3","","813.12","216.42","1444.50","81","108.5","278.25","percent of total billed charges",""
"SCREW BONE 4.5X8MM SPINE MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10017655","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","108.50","31","","432.60","432.60","432.60","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 4.5X8MM SPINE MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10017655","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.75","36.5","","148.37","54.89","631.39","94","108.5","278.25","percent of total billed charges",""
"SCREW BONE 4.5X8MM SPINE MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10017655","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","134.05","38.3","","279.30","91.72","1116.77","266","108.5","278.25","percent of total billed charges",""
"SCREW BONE 4.5X8MM SPINE MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10017655","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","731.00","63.70","731.00","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 4.5X8MM SPINE MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10017655","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","384.74","384.74","384.74","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 4.5X8MM SPINE MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10017655","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","WELLPOINT [1015]","HB AMC WELLPOINT","258.23","73.78","","286.63","119.22","1107.45","105","108.5","278.25","percent of total billed charges",""
"SCREW BONE 4.5X8MM SPINE MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10017655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA HMO","244.30","69.8","","675.31","184.75","1721.50","286","182.91","286.02","percent of total billed charges",""
"SCREW BONE 4.5X8MM SPINE MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10017655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA PPO","281.40","80.4","","1261.44","103.12","1514.10","21","182.91","286.02","percent of total billed charges",""
"SCREW BONE 4.5X8MM SPINE MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10017655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","281.40","80.4","","1365.00","1365.00","1365.00","1 through 10","182.91","286.02","percent of total billed charges",""
"SCREW BONE 4.5X8MM SPINE MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10017655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","286.02","81.72","","5157.68","5157.68","5157.68","1 through 10","182.91","286.02","percent of total billed charges",""
"SCREW BONE 4.5X8MM SPINE MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10017655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","286.02","81.72","","431.26","71.26","1459.57","88","182.91","286.02","percent of total billed charges",""
"SCREW BONE 4.5X90MM CORTEX TITANIUM SELF TAPPING","SUP-ITM-10040259","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.89","137.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","146.19","79.5","","800.18","480.96","1887.97","195","57.01","146.19","percent of total billed charges",""
"SCREW BONE 4.5X90MM CORTEX TITANIUM SELF TAPPING","SUP-ITM-10040259","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.89","137.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","98.01","53.3","","813.12","216.42","1444.50","81","57.01","146.19","percent of total billed charges",""
"SCREW BONE 4.5X90MM CORTEX TITANIUM SELF TAPPING","SUP-ITM-10040259","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.89","137.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","57.01","31","","432.60","432.60","432.60","1 through 10","57.01","146.19","percent of total billed charges",""
"SCREW BONE 4.5X90MM CORTEX TITANIUM SELF TAPPING","SUP-ITM-10040259","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.89","137.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.12","36.5","","148.37","54.89","631.39","94","57.01","146.19","percent of total billed charges",""
"SCREW BONE 4.5X90MM CORTEX TITANIUM SELF TAPPING","SUP-ITM-10040259","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.89","137.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.43","38.3","","279.30","91.72","1116.77","266","57.01","146.19","percent of total billed charges",""
"SCREW BONE 4.5X90MM CORTEX TITANIUM SELF TAPPING","SUP-ITM-10040259","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.89","137.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.89","42.9","","731.00","63.70","731.00","1 through 10","57.01","146.19","percent of total billed charges",""
"SCREW BONE 4.5X90MM CORTEX TITANIUM SELF TAPPING","SUP-ITM-10040259","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.89","137.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.89","42.9","","384.74","384.74","384.74","1 through 10","57.01","146.19","percent of total billed charges",""
"SCREW BONE 4.5X90MM CORTEX TITANIUM SELF TAPPING","SUP-ITM-10040259","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.89","137.92","WELLPOINT [1015]","HB AMC WELLPOINT","135.67","73.78","","286.63","119.22","1107.45","105","57.01","146.19","percent of total billed charges",""
"SCREW BONE 4.5X90MM CORTEX TITANIUM SELF TAPPING","SUP-ITM-10040259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.89","137.92","AETNA [1001]","HB AMC AETNA HMO","128.36","69.8","","675.31","184.75","1721.50","286","96.1","150.27","percent of total billed charges",""
"SCREW BONE 4.5X90MM CORTEX TITANIUM SELF TAPPING","SUP-ITM-10040259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.89","137.92","AETNA [1001]","HB AMC AETNA PPO","147.85","80.4","","1261.44","103.12","1514.10","21","96.1","150.27","percent of total billed charges",""
"SCREW BONE 4.5X90MM CORTEX TITANIUM SELF TAPPING","SUP-ITM-10040259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.89","137.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","147.85","80.4","","1365.00","1365.00","1365.00","1 through 10","96.1","150.27","percent of total billed charges",""
"SCREW BONE 4.5X90MM CORTEX TITANIUM SELF TAPPING","SUP-ITM-10040259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.89","137.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","150.27","81.72","","5157.68","5157.68","5157.68","1 through 10","96.1","150.27","percent of total billed charges",""
"SCREW BONE 4.5X90MM CORTEX TITANIUM SELF TAPPING","SUP-ITM-10040259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.89","137.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","150.27","81.72","","431.26","71.26","1459.57","88","96.1","150.27","percent of total billed charges",""
"SCREW BONE 4.5X90MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071400","CDM","C1713","HCPCS","0278","RC","","","","both","","","356.79","267.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","283.65","79.5","","800.18","480.96","1887.97","195","110.6","283.65","percent of total billed charges",""
"SCREW BONE 4.5X90MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071400","CDM","C1713","HCPCS","0278","RC","","","","both","","","356.79","267.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","190.17","53.3","","813.12","216.42","1444.50","81","110.6","283.65","percent of total billed charges",""
"SCREW BONE 4.5X90MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071400","CDM","C1713","HCPCS","0278","RC","","","","both","","","356.79","267.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","110.60","31","","432.60","432.60","432.60","1 through 10","110.6","283.65","percent of total billed charges",""
"SCREW BONE 4.5X90MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071400","CDM","C1713","HCPCS","0278","RC","","","","both","","","356.79","267.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","130.23","36.5","","148.37","54.89","631.39","94","110.6","283.65","percent of total billed charges",""
"SCREW BONE 4.5X90MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071400","CDM","C1713","HCPCS","0278","RC","","","","both","","","356.79","267.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","136.65","38.3","","279.30","91.72","1116.77","266","110.6","283.65","percent of total billed charges",""
"SCREW BONE 4.5X90MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071400","CDM","C1713","HCPCS","0278","RC","","","","both","","","356.79","267.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.06","42.9","","731.00","63.70","731.00","1 through 10","110.6","283.65","percent of total billed charges",""
"SCREW BONE 4.5X90MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071400","CDM","C1713","HCPCS","0278","RC","","","","both","","","356.79","267.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.06","42.9","","384.74","384.74","384.74","1 through 10","110.6","283.65","percent of total billed charges",""
"SCREW BONE 4.5X90MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071400","CDM","C1713","HCPCS","0278","RC","","","","both","","","356.79","267.59","WELLPOINT [1015]","HB AMC WELLPOINT","263.24","73.78","","286.63","119.22","1107.45","105","110.6","283.65","percent of total billed charges",""
"SCREW BONE 4.5X90MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","356.79","267.59","AETNA [1001]","HB AMC AETNA HMO","249.04","69.8","","675.31","184.75","1721.50","286","186.46","291.57","percent of total billed charges",""
"SCREW BONE 4.5X90MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","356.79","267.59","AETNA [1001]","HB AMC AETNA PPO","286.86","80.4","","1261.44","103.12","1514.10","21","186.46","291.57","percent of total billed charges",""
"SCREW BONE 4.5X90MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","356.79","267.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","286.86","80.4","","1365.00","1365.00","1365.00","1 through 10","186.46","291.57","percent of total billed charges",""
"SCREW BONE 4.5X90MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","356.79","267.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","291.57","81.72","","5157.68","5157.68","5157.68","1 through 10","186.46","291.57","percent of total billed charges",""
"SCREW BONE 4.5X90MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","356.79","267.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","291.57","81.72","","431.26","71.26","1459.57","88","186.46","291.57","percent of total billed charges",""
"SCREW BONE 4.6X12MM SPINE CERVICAL CANCELLOUS TI UNIPLATE 2 SELF DRILLING BLUE","SUP-ITM-10019580","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","800.18","480.96","1887.97","195","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.6X12MM SPINE CERVICAL CANCELLOUS TI UNIPLATE 2 SELF DRILLING BLUE","SUP-ITM-10019580","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","813.12","216.42","1444.50","81","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.6X12MM SPINE CERVICAL CANCELLOUS TI UNIPLATE 2 SELF DRILLING BLUE","SUP-ITM-10019580","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","97.65","31","","432.60","432.60","432.60","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.6X12MM SPINE CERVICAL CANCELLOUS TI UNIPLATE 2 SELF DRILLING BLUE","SUP-ITM-10019580","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","148.37","54.89","631.39","94","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.6X12MM SPINE CERVICAL CANCELLOUS TI UNIPLATE 2 SELF DRILLING BLUE","SUP-ITM-10019580","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","279.30","91.72","1116.77","266","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.6X12MM SPINE CERVICAL CANCELLOUS TI UNIPLATE 2 SELF DRILLING BLUE","SUP-ITM-10019580","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","731.00","63.70","731.00","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.6X12MM SPINE CERVICAL CANCELLOUS TI UNIPLATE 2 SELF DRILLING BLUE","SUP-ITM-10019580","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","384.74","384.74","384.74","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.6X12MM SPINE CERVICAL CANCELLOUS TI UNIPLATE 2 SELF DRILLING BLUE","SUP-ITM-10019580","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB AMC WELLPOINT","232.41","73.78","","286.63","119.22","1107.45","105","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4.6X12MM SPINE CERVICAL CANCELLOUS TI UNIPLATE 2 SELF DRILLING BLUE","SUP-ITM-10019580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","675.31","184.75","1721.50","286","164.62","257.42","percent of total billed charges",""
"SCREW BONE 4.6X12MM SPINE CERVICAL CANCELLOUS TI UNIPLATE 2 SELF DRILLING BLUE","SUP-ITM-10019580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA PPO","253.26","80.4","","1261.44","103.12","1514.10","21","164.62","257.42","percent of total billed charges",""
"SCREW BONE 4.6X12MM SPINE CERVICAL CANCELLOUS TI UNIPLATE 2 SELF DRILLING BLUE","SUP-ITM-10019580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","1365.00","1365.00","1365.00","1 through 10","164.62","257.42","percent of total billed charges",""
"SCREW BONE 4.6X12MM SPINE CERVICAL CANCELLOUS TI UNIPLATE 2 SELF DRILLING BLUE","SUP-ITM-10019580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","257.42","81.72","","5157.68","5157.68","5157.68","1 through 10","164.62","257.42","percent of total billed charges",""
"SCREW BONE 4.6X12MM SPINE CERVICAL CANCELLOUS TI UNIPLATE 2 SELF DRILLING BLUE","SUP-ITM-10019580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","431.26","71.26","1459.57","88","164.62","257.42","percent of total billed charges",""
"SCREW BONE 4.7X45MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129736","CDM","C1713","HCPCS","0278","RC","","","","both","","","1935.50","1451.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1538.72","79.5","","800.18","480.96","1887.97","195","600.01","1538.72","percent of total billed charges",""
"SCREW BONE 4.7X45MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129736","CDM","C1713","HCPCS","0278","RC","","","","both","","","1935.50","1451.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1031.62","53.3","","813.12","216.42","1444.50","81","600.01","1538.72","percent of total billed charges",""
"SCREW BONE 4.7X45MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129736","CDM","C1713","HCPCS","0278","RC","","","","both","","","1935.50","1451.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","600.01","31","","432.60","432.60","432.60","1 through 10","600.01","1538.72","percent of total billed charges",""
"SCREW BONE 4.7X45MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129736","CDM","C1713","HCPCS","0278","RC","","","","both","","","1935.50","1451.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","706.46","36.5","","148.37","54.89","631.39","94","600.01","1538.72","percent of total billed charges",""
"SCREW BONE 4.7X45MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129736","CDM","C1713","HCPCS","0278","RC","","","","both","","","1935.50","1451.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","741.30","38.3","","279.30","91.72","1116.77","266","600.01","1538.72","percent of total billed charges",""
"SCREW BONE 4.7X45MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129736","CDM","C1713","HCPCS","0278","RC","","","","both","","","1935.50","1451.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","830.33","42.9","","731.00","63.70","731.00","1 through 10","600.01","1538.72","percent of total billed charges",""
"SCREW BONE 4.7X45MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129736","CDM","C1713","HCPCS","0278","RC","","","","both","","","1935.50","1451.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","830.33","42.9","","384.74","384.74","384.74","1 through 10","600.01","1538.72","percent of total billed charges",""
"SCREW BONE 4.7X45MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129736","CDM","C1713","HCPCS","0278","RC","","","","both","","","1935.50","1451.62","WELLPOINT [1015]","HB AMC WELLPOINT","1428.01","73.78","","286.63","119.22","1107.45","105","600.01","1538.72","percent of total billed charges",""
"SCREW BONE 4.7X45MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1935.50","1451.62","AETNA [1001]","HB AMC AETNA HMO","1350.98","69.8","","675.31","184.75","1721.50","286","1011.49","1581.69","percent of total billed charges",""
"SCREW BONE 4.7X45MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1935.50","1451.62","AETNA [1001]","HB AMC AETNA PPO","1556.14","80.4","","1261.44","103.12","1514.10","21","1011.49","1581.69","percent of total billed charges",""
"SCREW BONE 4.7X45MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1935.50","1451.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1556.14","80.4","","1365.00","1365.00","1365.00","1 through 10","1011.49","1581.69","percent of total billed charges",""
"SCREW BONE 4.7X45MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1935.50","1451.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1581.69","81.72","","5157.68","5157.68","5157.68","1 through 10","1011.49","1581.69","percent of total billed charges",""
"SCREW BONE 4.7X45MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1935.50","1451.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1581.69","81.72","","431.26","71.26","1459.57","88","1011.49","1581.69","percent of total billed charges",""
"SCREW BONE 4.8X30MM HUMERAL CANCELLOUS UNIVERSAL STAIJLESS STEEL","SUP-ITM-10071871","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","341.06","79.5","","800.18","480.96","1887.97","195","132.99","341.06","percent of total billed charges",""
"SCREW BONE 4.8X30MM HUMERAL CANCELLOUS UNIVERSAL STAIJLESS STEEL","SUP-ITM-10071871","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","228.66","53.3","","813.12","216.42","1444.50","81","132.99","341.06","percent of total billed charges",""
"SCREW BONE 4.8X30MM HUMERAL CANCELLOUS UNIVERSAL STAIJLESS STEEL","SUP-ITM-10071871","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","132.99","31","","432.60","432.60","432.60","1 through 10","132.99","341.06","percent of total billed charges",""
"SCREW BONE 4.8X30MM HUMERAL CANCELLOUS UNIVERSAL STAIJLESS STEEL","SUP-ITM-10071871","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","156.59","36.5","","148.37","54.89","631.39","94","132.99","341.06","percent of total billed charges",""
"SCREW BONE 4.8X30MM HUMERAL CANCELLOUS UNIVERSAL STAIJLESS STEEL","SUP-ITM-10071871","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","164.31","38.3","","279.30","91.72","1116.77","266","132.99","341.06","percent of total billed charges",""
"SCREW BONE 4.8X30MM HUMERAL CANCELLOUS UNIVERSAL STAIJLESS STEEL","SUP-ITM-10071871","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","184.04","42.9","","731.00","63.70","731.00","1 through 10","132.99","341.06","percent of total billed charges",""
"SCREW BONE 4.8X30MM HUMERAL CANCELLOUS UNIVERSAL STAIJLESS STEEL","SUP-ITM-10071871","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","184.04","42.9","","384.74","384.74","384.74","1 through 10","132.99","341.06","percent of total billed charges",""
"SCREW BONE 4.8X30MM HUMERAL CANCELLOUS UNIVERSAL STAIJLESS STEEL","SUP-ITM-10071871","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","WELLPOINT [1015]","HB AMC WELLPOINT","316.52","73.78","","286.63","119.22","1107.45","105","132.99","341.06","percent of total billed charges",""
"SCREW BONE 4.8X30MM HUMERAL CANCELLOUS UNIVERSAL STAIJLESS STEEL","SUP-ITM-10071871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.00","321.75","AETNA [1001]","HB AMC AETNA HMO","299.44","69.8","","675.31","184.75","1721.50","286","224.2","350.58","percent of total billed charges",""
"SCREW BONE 4.8X30MM HUMERAL CANCELLOUS UNIVERSAL STAIJLESS STEEL","SUP-ITM-10071871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.00","321.75","AETNA [1001]","HB AMC AETNA PPO","344.92","80.4","","1261.44","103.12","1514.10","21","224.2","350.58","percent of total billed charges",""
"SCREW BONE 4.8X30MM HUMERAL CANCELLOUS UNIVERSAL STAIJLESS STEEL","SUP-ITM-10071871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.00","321.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","344.92","80.4","","1365.00","1365.00","1365.00","1 through 10","224.2","350.58","percent of total billed charges",""
"SCREW BONE 4.8X30MM HUMERAL CANCELLOUS UNIVERSAL STAIJLESS STEEL","SUP-ITM-10071871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.00","321.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","350.58","81.72","","5157.68","5157.68","5157.68","1 through 10","224.2","350.58","percent of total billed charges",""
"SCREW BONE 4.8X30MM HUMERAL CANCELLOUS UNIVERSAL STAIJLESS STEEL","SUP-ITM-10071871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.00","321.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","350.58","81.72","","431.26","71.26","1459.57","88","224.2","350.58","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.51","79.5","","800.18","480.96","1887.97","195","92.23","236.51","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.57","53.3","","813.12","216.42","1444.50","81","92.23","236.51","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","92.23","31","","432.60","432.60","432.60","1 through 10","92.23","236.51","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.59","36.5","","148.37","54.89","631.39","94","92.23","236.51","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.94","38.3","","279.30","91.72","1116.77","266","92.23","236.51","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.63","42.9","","731.00","63.70","731.00","1 through 10","92.23","236.51","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.63","42.9","","384.74","384.74","384.74","1 through 10","92.23","236.51","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","297.50","223.12","WELLPOINT [1015]","HB AMC WELLPOINT","219.50","73.78","","286.63","119.22","1107.45","105","92.23","236.51","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","AETNA [1001]","HB AMC AETNA HMO","207.66","69.8","","675.31","184.75","1721.50","286","155.47","243.12","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","AETNA [1001]","HB AMC AETNA PPO","239.19","80.4","","1261.44","103.12","1514.10","21","155.47","243.12","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","239.19","80.4","","1365.00","1365.00","1365.00","1 through 10","155.47","243.12","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","243.12","81.72","","5157.68","5157.68","5157.68","1 through 10","155.47","243.12","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","297.50","223.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","243.12","81.72","","431.26","71.26","1459.57","88","155.47","243.12","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","800.18","480.96","1887.97","195","162.75","417.38","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","813.12","216.42","1444.50","81","162.75","417.38","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.75","31","","432.60","432.60","432.60","1 through 10","162.75","417.38","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","148.37","54.89","631.39","94","162.75","417.38","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","279.30","91.72","1116.77","266","162.75","417.38","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","731.00","63.70","731.00","1 through 10","162.75","417.38","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","384.74","384.74","384.74","1 through 10","162.75","417.38","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","286.63","119.22","1107.45","105","162.75","417.38","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","675.31","184.75","1721.50","286","274.37","429.03","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA PPO","422.10","80.4","","1261.44","103.12","1514.10","21","274.37","429.03","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1365.00","1365.00","1365.00","1 through 10","274.37","429.03","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","429.03","81.72","","5157.68","5157.68","5157.68","1 through 10","274.37","429.03","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","431.26","71.26","1459.57","88","274.37","429.03","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","1309.77","674.56","6049.93","26","434","1113","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","1901.83","1901.83","2962.25","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1620.31","1620.31","19908.88","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","352.91","352.91","2046.30","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","9668.75","9668.75","9668.75","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","699.88","384.10","3443.31","33","434","1113","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1421.24","264.50","4933.46","29","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1022.97","1022.97","3607.50","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","3010.54","693.88","5019.88","35","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","105.74","79.5","","800.18","480.96","1887.97","195","41.23","105.74","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","70.89","53.3","","813.12","216.42","1444.50","81","41.23","105.74","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","41.23","31","","432.60","432.60","432.60","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.55","36.5","","148.37","54.89","631.39","94","41.23","105.74","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","50.94","38.3","","279.30","91.72","1116.77","266","41.23","105.74","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.06","42.9","","731.00","63.70","731.00","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.06","42.9","","384.74","384.74","384.74","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","WELLPOINT [1015]","HB AMC WELLPOINT","98.13","73.78","","286.63","119.22","1107.45","105","41.23","105.74","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","AETNA [1001]","HB AMC AETNA HMO","92.83","69.8","","675.31","184.75","1721.50","286","69.51","108.69","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","AETNA [1001]","HB AMC AETNA PPO","106.93","80.4","","1261.44","103.12","1514.10","21","69.51","108.69","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","106.93","80.4","","1365.00","1365.00","1365.00","1 through 10","69.51","108.69","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","108.69","81.72","","5157.68","5157.68","5157.68","1 through 10","69.51","108.69","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","108.69","81.72","","431.26","71.26","1459.57","88","69.51","108.69","percent of total billed charges",""
"SCREW BONE 40X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003807","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.02","79.5","","800.18","480.96","1887.97","195","43.29","111.02","percent of total billed charges",""
"SCREW BONE 40X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003807","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.43","53.3","","813.12","216.42","1444.50","81","43.29","111.02","percent of total billed charges",""
"SCREW BONE 40X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003807","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","43.29","31","","432.60","432.60","432.60","1 through 10","43.29","111.02","percent of total billed charges",""
"SCREW BONE 40X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003807","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.97","36.5","","148.37","54.89","631.39","94","43.29","111.02","percent of total billed charges",""
"SCREW BONE 40X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003807","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.49","38.3","","279.30","91.72","1116.77","266","43.29","111.02","percent of total billed charges",""
"SCREW BONE 40X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003807","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.91","42.9","","731.00","63.70","731.00","1 through 10","43.29","111.02","percent of total billed charges",""
"SCREW BONE 40X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003807","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.91","42.9","","384.74","384.74","384.74","1 through 10","43.29","111.02","percent of total billed charges",""
"SCREW BONE 40X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003807","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","WELLPOINT [1015]","HB AMC WELLPOINT","103.03","73.78","","286.63","119.22","1107.45","105","43.29","111.02","percent of total billed charges",""
"SCREW BONE 40X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","AETNA [1001]","HB AMC AETNA HMO","97.48","69.8","","675.31","184.75","1721.50","286","72.98","114.12","percent of total billed charges",""
"SCREW BONE 40X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","AETNA [1001]","HB AMC AETNA PPO","112.28","80.4","","1261.44","103.12","1514.10","21","72.98","114.12","percent of total billed charges",""
"SCREW BONE 40X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.28","80.4","","1365.00","1365.00","1365.00","1 through 10","72.98","114.12","percent of total billed charges",""
"SCREW BONE 40X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.12","81.72","","5157.68","5157.68","5157.68","1 through 10","72.98","114.12","percent of total billed charges",""
"SCREW BONE 40X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.12","81.72","","431.26","71.26","1459.57","88","72.98","114.12","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","218.85","79.5","","800.18","480.96","1887.97","195","85.34","218.85","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","146.72","53.3","","813.12","216.42","1444.50","81","85.34","218.85","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.34","31","","432.60","432.60","432.60","1 through 10","85.34","218.85","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.48","36.5","","148.37","54.89","631.39","94","85.34","218.85","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.43","38.3","","279.30","91.72","1116.77","266","85.34","218.85","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.10","42.9","","731.00","63.70","731.00","1 through 10","85.34","218.85","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.10","42.9","","384.74","384.74","384.74","1 through 10","85.34","218.85","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","275.28","206.46","WELLPOINT [1015]","HB AMC WELLPOINT","203.10","73.78","","286.63","119.22","1107.45","105","85.34","218.85","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","AETNA [1001]","HB AMC AETNA HMO","192.15","69.8","","675.31","184.75","1721.50","286","143.86","224.96","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","AETNA [1001]","HB AMC AETNA PPO","221.33","80.4","","1261.44","103.12","1514.10","21","143.86","224.96","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","221.33","80.4","","1365.00","1365.00","1365.00","1 through 10","143.86","224.96","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","224.96","81.72","","5157.68","5157.68","5157.68","1 through 10","143.86","224.96","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","275.28","206.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","224.96","81.72","","431.26","71.26","1459.57","88","143.86","224.96","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","97.39","79.5","","800.18","480.96","1887.97","195","37.98","97.39","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","65.29","53.3","","813.12","216.42","1444.50","81","37.98","97.39","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","37.98","31","","432.60","432.60","432.60","1 through 10","37.98","97.39","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.71","36.5","","148.37","54.89","631.39","94","37.98","97.39","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.92","38.3","","279.30","91.72","1116.77","266","37.98","97.39","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.55","42.9","","731.00","63.70","731.00","1 through 10","37.98","97.39","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.55","42.9","","384.74","384.74","384.74","1 through 10","37.98","97.39","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.50","91.87","WELLPOINT [1015]","HB AMC WELLPOINT","90.38","73.78","","286.63","119.22","1107.45","105","37.98","97.39","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","AETNA [1001]","HB AMC AETNA HMO","85.51","69.8","","675.31","184.75","1721.50","286","64.02","100.11","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","AETNA [1001]","HB AMC AETNA PPO","98.49","80.4","","1261.44","103.12","1514.10","21","64.02","100.11","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","98.49","80.4","","1365.00","1365.00","1365.00","1 through 10","64.02","100.11","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","100.11","81.72","","5157.68","5157.68","5157.68","1 through 10","64.02","100.11","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.50","91.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","100.11","81.72","","431.26","71.26","1459.57","88","64.02","100.11","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","198.45","148.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","157.77","79.5","","800.18","480.96","1887.97","195","61.52","157.77","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","198.45","148.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","105.77","53.3","","813.12","216.42","1444.50","81","61.52","157.77","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","198.45","148.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","61.52","31","","432.60","432.60","432.60","1 through 10","61.52","157.77","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","198.45","148.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.43","36.5","","148.37","54.89","631.39","94","61.52","157.77","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","198.45","148.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.01","38.3","","279.30","91.72","1116.77","266","61.52","157.77","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","198.45","148.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.14","42.9","","731.00","63.70","731.00","1 through 10","61.52","157.77","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","198.45","148.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.14","42.9","","384.74","384.74","384.74","1 through 10","61.52","157.77","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","198.45","148.84","WELLPOINT [1015]","HB AMC WELLPOINT","146.42","73.78","","286.63","119.22","1107.45","105","61.52","157.77","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","198.45","148.84","AETNA [1001]","HB AMC AETNA HMO","138.52","69.8","","675.31","184.75","1721.50","286","103.71","162.17","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","198.45","148.84","AETNA [1001]","HB AMC AETNA PPO","159.55","80.4","","1261.44","103.12","1514.10","21","103.71","162.17","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","198.45","148.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","159.55","80.4","","1365.00","1365.00","1365.00","1 through 10","103.71","162.17","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","198.45","148.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","162.17","81.72","","5157.68","5157.68","5157.68","1 through 10","103.71","162.17","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","198.45","148.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","162.17","81.72","","431.26","71.26","1459.57","88","103.71","162.17","percent of total billed charges",""
"SCREW BONE 4X120MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10001633","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","172.96","79.5","","800.18","480.96","1887.97","195","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X120MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10001633","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","115.96","53.3","","813.12","216.42","1444.50","81","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X120MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10001633","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","67.44","31","","432.60","432.60","432.60","1 through 10","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X120MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10001633","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","79.41","36.5","","148.37","54.89","631.39","94","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X120MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10001633","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","83.33","38.3","","279.30","91.72","1116.77","266","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X120MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10001633","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.33","42.9","","731.00","63.70","731.00","1 through 10","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X120MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10001633","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.33","42.9","","384.74","384.74","384.74","1 through 10","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X120MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10001633","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","WELLPOINT [1015]","HB AMC WELLPOINT","160.52","73.78","","286.63","119.22","1107.45","105","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X120MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10001633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.56","163.17","AETNA [1001]","HB AMC AETNA HMO","151.86","69.8","","675.31","184.75","1721.50","286","113.7","177.79","percent of total billed charges",""
"SCREW BONE 4X120MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10001633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.56","163.17","AETNA [1001]","HB AMC AETNA PPO","174.92","80.4","","1261.44","103.12","1514.10","21","113.7","177.79","percent of total billed charges",""
"SCREW BONE 4X120MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10001633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.56","163.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","174.92","80.4","","1365.00","1365.00","1365.00","1 through 10","113.7","177.79","percent of total billed charges",""
"SCREW BONE 4X120MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10001633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.56","163.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","177.79","81.72","","5157.68","5157.68","5157.68","1 through 10","113.7","177.79","percent of total billed charges",""
"SCREW BONE 4X120MM SCHANZ EXTERNAL FIXATION THREAD DIAMOND POINT SS","SUP-ITM-10001633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.56","163.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","177.79","81.72","","431.26","71.26","1459.57","88","113.7","177.79","percent of total billed charges",""
"SCREW BONE 4X12MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD","SUP-ITM-10011311","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","800.18","480.96","1887.97","195","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4X12MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD","SUP-ITM-10011311","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","813.12","216.42","1444.50","81","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4X12MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD","SUP-ITM-10011311","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","97.65","31","","432.60","432.60","432.60","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4X12MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD","SUP-ITM-10011311","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","148.37","54.89","631.39","94","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4X12MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD","SUP-ITM-10011311","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","279.30","91.72","1116.77","266","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4X12MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD","SUP-ITM-10011311","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","731.00","63.70","731.00","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4X12MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD","SUP-ITM-10011311","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","384.74","384.74","384.74","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4X12MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD","SUP-ITM-10011311","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB AMC WELLPOINT","232.41","73.78","","286.63","119.22","1107.45","105","97.65","250.43","percent of total billed charges",""
"SCREW BONE 4X12MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD","SUP-ITM-10011311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","675.31","184.75","1721.50","286","164.62","257.42","percent of total billed charges",""
"SCREW BONE 4X12MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD","SUP-ITM-10011311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA PPO","253.26","80.4","","1261.44","103.12","1514.10","21","164.62","257.42","percent of total billed charges",""
"SCREW BONE 4X12MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD","SUP-ITM-10011311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","1365.00","1365.00","1365.00","1 through 10","164.62","257.42","percent of total billed charges",""
"SCREW BONE 4X12MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD","SUP-ITM-10011311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","257.42","81.72","","5157.68","5157.68","5157.68","1 through 10","164.62","257.42","percent of total billed charges",""
"SCREW BONE 4X12MM SPINE TITANIUM CANCELLOUS SELF TAPPING EXPANSION HEAD","SUP-ITM-10011311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","431.26","71.26","1459.57","88","164.62","257.42","percent of total billed charges",""
"SCREW BONE 4X14MM ANTHEM SS CANCELLOUS FULLY THREADED","SUP-ITM-10278049","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.50","70.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","75.13","79.5","","800.18","480.96","1887.97","195","29.3","75.13","percent of total billed charges",""
"SCREW BONE 4X14MM ANTHEM SS CANCELLOUS FULLY THREADED","SUP-ITM-10278049","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.50","70.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","50.37","53.3","","813.12","216.42","1444.50","81","29.3","75.13","percent of total billed charges",""
"SCREW BONE 4X14MM ANTHEM SS CANCELLOUS FULLY THREADED","SUP-ITM-10278049","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.50","70.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","29.30","31","","432.60","432.60","432.60","1 through 10","29.3","75.13","percent of total billed charges",""
"SCREW BONE 4X14MM ANTHEM SS CANCELLOUS FULLY THREADED","SUP-ITM-10278049","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.50","70.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34.49","36.5","","148.37","54.89","631.39","94","29.3","75.13","percent of total billed charges",""
"SCREW BONE 4X14MM ANTHEM SS CANCELLOUS FULLY THREADED","SUP-ITM-10278049","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.50","70.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","36.19","38.3","","279.30","91.72","1116.77","266","29.3","75.13","percent of total billed charges",""
"SCREW BONE 4X14MM ANTHEM SS CANCELLOUS FULLY THREADED","SUP-ITM-10278049","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.50","70.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.54","42.9","","731.00","63.70","731.00","1 through 10","29.3","75.13","percent of total billed charges",""
"SCREW BONE 4X14MM ANTHEM SS CANCELLOUS FULLY THREADED","SUP-ITM-10278049","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.50","70.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.54","42.9","","384.74","384.74","384.74","1 through 10","29.3","75.13","percent of total billed charges",""
"SCREW BONE 4X14MM ANTHEM SS CANCELLOUS FULLY THREADED","SUP-ITM-10278049","CDM","C1713","HCPCS","0278","RC","","","","both","","","94.50","70.87","WELLPOINT [1015]","HB AMC WELLPOINT","69.72","73.78","","286.63","119.22","1107.45","105","29.3","75.13","percent of total billed charges",""
"SCREW BONE 4X14MM ANTHEM SS CANCELLOUS FULLY THREADED","SUP-ITM-10278049","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","94.50","70.87","AETNA [1001]","HB AMC AETNA HMO","65.96","69.8","","675.31","184.75","1721.50","286","49.39","77.23","percent of total billed charges",""
"SCREW BONE 4X14MM ANTHEM SS CANCELLOUS FULLY THREADED","SUP-ITM-10278049","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","94.50","70.87","AETNA [1001]","HB AMC AETNA PPO","75.98","80.4","","1261.44","103.12","1514.10","21","49.39","77.23","percent of total billed charges",""
"SCREW BONE 4X14MM ANTHEM SS CANCELLOUS FULLY THREADED","SUP-ITM-10278049","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","94.50","70.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","75.98","80.4","","1365.00","1365.00","1365.00","1 through 10","49.39","77.23","percent of total billed charges",""
"SCREW BONE 4X14MM ANTHEM SS CANCELLOUS FULLY THREADED","SUP-ITM-10278049","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","94.50","70.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","77.23","81.72","","5157.68","5157.68","5157.68","1 through 10","49.39","77.23","percent of total billed charges",""
"SCREW BONE 4X14MM ANTHEM SS CANCELLOUS FULLY THREADED","SUP-ITM-10278049","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","94.50","70.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","77.23","81.72","","431.26","71.26","1459.57","88","49.39","77.23","percent of total billed charges",""
"SCREW BONE 4X14MM CANNULATED MAXLOCK TI SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083147","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.50","469.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","498.07","79.5","","800.18","480.96","1887.97","195","194.22","498.07","percent of total billed charges",""
"SCREW BONE 4X14MM CANNULATED MAXLOCK TI SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083147","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.50","469.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","333.92","53.3","","813.12","216.42","1444.50","81","194.22","498.07","percent of total billed charges",""
"SCREW BONE 4X14MM CANNULATED MAXLOCK TI SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083147","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.50","469.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","194.22","31","","432.60","432.60","432.60","1 through 10","194.22","498.07","percent of total billed charges",""
"SCREW BONE 4X14MM CANNULATED MAXLOCK TI SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083147","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.50","469.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.67","36.5","","148.37","54.89","631.39","94","194.22","498.07","percent of total billed charges",""
"SCREW BONE 4X14MM CANNULATED MAXLOCK TI SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083147","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.50","469.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.95","38.3","","279.30","91.72","1116.77","266","194.22","498.07","percent of total billed charges",""
"SCREW BONE 4X14MM CANNULATED MAXLOCK TI SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083147","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.50","469.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.77","42.9","","731.00","63.70","731.00","1 through 10","194.22","498.07","percent of total billed charges",""
"SCREW BONE 4X14MM CANNULATED MAXLOCK TI SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083147","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.50","469.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.77","42.9","","384.74","384.74","384.74","1 through 10","194.22","498.07","percent of total billed charges",""
"SCREW BONE 4X14MM CANNULATED MAXLOCK TI SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083147","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.50","469.87","WELLPOINT [1015]","HB AMC WELLPOINT","462.23","73.78","","286.63","119.22","1107.45","105","194.22","498.07","percent of total billed charges",""
"SCREW BONE 4X14MM CANNULATED MAXLOCK TI SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.50","469.87","AETNA [1001]","HB AMC AETNA HMO","437.30","69.8","","675.31","184.75","1721.50","286","327.41","511.98","percent of total billed charges",""
"SCREW BONE 4X14MM CANNULATED MAXLOCK TI SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.50","469.87","AETNA [1001]","HB AMC AETNA PPO","503.71","80.4","","1261.44","103.12","1514.10","21","327.41","511.98","percent of total billed charges",""
"SCREW BONE 4X14MM CANNULATED MAXLOCK TI SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.50","469.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","503.71","80.4","","1365.00","1365.00","1365.00","1 through 10","327.41","511.98","percent of total billed charges",""
"SCREW BONE 4X14MM CANNULATED MAXLOCK TI SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.50","469.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","511.98","81.72","","5157.68","5157.68","5157.68","1 through 10","327.41","511.98","percent of total billed charges",""
"SCREW BONE 4X14MM CANNULATED MAXLOCK TI SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.50","469.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","511.98","81.72","","431.26","71.26","1459.57","88","327.41","511.98","percent of total billed charges",""
"SCREW BONE 4X14MM LOCKING","SUP-ITM-10126065","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","303.29","79.5","","800.18","480.96","1887.97","195","118.27","303.29","percent of total billed charges",""
"SCREW BONE 4X14MM LOCKING","SUP-ITM-10126065","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","203.34","53.3","","813.12","216.42","1444.50","81","118.27","303.29","percent of total billed charges",""
"SCREW BONE 4X14MM LOCKING","SUP-ITM-10126065","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","118.27","31","","432.60","432.60","432.60","1 through 10","118.27","303.29","percent of total billed charges",""
"SCREW BONE 4X14MM LOCKING","SUP-ITM-10126065","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","139.25","36.5","","148.37","54.89","631.39","94","118.27","303.29","percent of total billed charges",""
"SCREW BONE 4X14MM LOCKING","SUP-ITM-10126065","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","146.11","38.3","","279.30","91.72","1116.77","266","118.27","303.29","percent of total billed charges",""
"SCREW BONE 4X14MM LOCKING","SUP-ITM-10126065","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.66","42.9","","731.00","63.70","731.00","1 through 10","118.27","303.29","percent of total billed charges",""
"SCREW BONE 4X14MM LOCKING","SUP-ITM-10126065","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.66","42.9","","384.74","384.74","384.74","1 through 10","118.27","303.29","percent of total billed charges",""
"SCREW BONE 4X14MM LOCKING","SUP-ITM-10126065","CDM","C1713","HCPCS","0278","RC","","","","both","","","381.50","286.12","WELLPOINT [1015]","HB AMC WELLPOINT","281.47","73.78","","286.63","119.22","1107.45","105","118.27","303.29","percent of total billed charges",""
"SCREW BONE 4X14MM LOCKING","SUP-ITM-10126065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","381.50","286.12","AETNA [1001]","HB AMC AETNA HMO","266.29","69.8","","675.31","184.75","1721.50","286","199.37","311.76","percent of total billed charges",""
"SCREW BONE 4X14MM LOCKING","SUP-ITM-10126065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","381.50","286.12","AETNA [1001]","HB AMC AETNA PPO","306.73","80.4","","1261.44","103.12","1514.10","21","199.37","311.76","percent of total billed charges",""
"SCREW BONE 4X14MM LOCKING","SUP-ITM-10126065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","381.50","286.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","306.73","80.4","","1365.00","1365.00","1365.00","1 through 10","199.37","311.76","percent of total billed charges",""
"SCREW BONE 4X14MM LOCKING","SUP-ITM-10126065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","381.50","286.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","311.76","81.72","","5157.68","5157.68","5157.68","1 through 10","199.37","311.76","percent of total billed charges",""
"SCREW BONE 4X14MM LOCKING","SUP-ITM-10126065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","381.50","286.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","311.76","81.72","","431.26","71.26","1459.57","88","199.37","311.76","percent of total billed charges",""
"SCREW BONE 4X150MM SCHANZ EXTERNAL FIXATION THRD DIAMOND POINT SS","SUP-ITM-10016151","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","172.96","79.5","","800.18","480.96","1887.97","195","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X150MM SCHANZ EXTERNAL FIXATION THRD DIAMOND POINT SS","SUP-ITM-10016151","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","115.96","53.3","","813.12","216.42","1444.50","81","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X150MM SCHANZ EXTERNAL FIXATION THRD DIAMOND POINT SS","SUP-ITM-10016151","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","67.44","31","","432.60","432.60","432.60","1 through 10","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X150MM SCHANZ EXTERNAL FIXATION THRD DIAMOND POINT SS","SUP-ITM-10016151","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","79.41","36.5","","148.37","54.89","631.39","94","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X150MM SCHANZ EXTERNAL FIXATION THRD DIAMOND POINT SS","SUP-ITM-10016151","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","83.33","38.3","","279.30","91.72","1116.77","266","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X150MM SCHANZ EXTERNAL FIXATION THRD DIAMOND POINT SS","SUP-ITM-10016151","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.33","42.9","","731.00","63.70","731.00","1 through 10","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X150MM SCHANZ EXTERNAL FIXATION THRD DIAMOND POINT SS","SUP-ITM-10016151","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.33","42.9","","384.74","384.74","384.74","1 through 10","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X150MM SCHANZ EXTERNAL FIXATION THRD DIAMOND POINT SS","SUP-ITM-10016151","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.56","163.17","WELLPOINT [1015]","HB AMC WELLPOINT","160.52","73.78","","286.63","119.22","1107.45","105","67.44","172.96","percent of total billed charges",""
"SCREW BONE 4X150MM SCHANZ EXTERNAL FIXATION THRD DIAMOND POINT SS","SUP-ITM-10016151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.56","163.17","AETNA [1001]","HB AMC AETNA HMO","151.86","69.8","","675.31","184.75","1721.50","286","113.7","177.79","percent of total billed charges",""
"SCREW BONE 4X150MM SCHANZ EXTERNAL FIXATION THRD DIAMOND POINT SS","SUP-ITM-10016151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.56","163.17","AETNA [1001]","HB AMC AETNA PPO","174.92","80.4","","1261.44","103.12","1514.10","21","113.7","177.79","percent of total billed charges",""
"SCREW BONE 4X150MM SCHANZ EXTERNAL FIXATION THRD DIAMOND POINT SS","SUP-ITM-10016151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.56","163.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","174.92","80.4","","1365.00","1365.00","1365.00","1 through 10","113.7","177.79","percent of total billed charges",""
"SCREW BONE 4X150MM SCHANZ EXTERNAL FIXATION THRD DIAMOND POINT SS","SUP-ITM-10016151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.56","163.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","177.79","81.72","","5157.68","5157.68","5157.68","1 through 10","113.7","177.79","percent of total billed charges",""
"SCREW BONE 4X150MM SCHANZ EXTERNAL FIXATION THRD DIAMOND POINT SS","SUP-ITM-10016151","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.56","163.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","177.79","81.72","","431.26","71.26","1459.57","88","113.7","177.79","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","310.92","79.5","","800.18","480.96","1887.97","195","121.24","310.92","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","208.45","53.3","","813.12","216.42","1444.50","81","121.24","310.92","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","121.24","31","","432.60","432.60","432.60","1 through 10","121.24","310.92","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","142.75","36.5","","148.37","54.89","631.39","94","121.24","310.92","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","149.79","38.3","","279.30","91.72","1116.77","266","121.24","310.92","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.78","42.9","","731.00","63.70","731.00","1 through 10","121.24","310.92","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.78","42.9","","384.74","384.74","384.74","1 through 10","121.24","310.92","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","both","","","391.09","293.32","WELLPOINT [1015]","HB AMC WELLPOINT","288.55","73.78","","286.63","119.22","1107.45","105","121.24","310.92","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","391.09","293.32","AETNA [1001]","HB AMC AETNA HMO","272.98","69.8","","675.31","184.75","1721.50","286","204.38","319.6","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","391.09","293.32","AETNA [1001]","HB AMC AETNA PPO","314.44","80.4","","1261.44","103.12","1514.10","21","204.38","319.6","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","391.09","293.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","314.44","80.4","","1365.00","1365.00","1365.00","1 through 10","204.38","319.6","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","391.09","293.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","319.60","81.72","","5157.68","5157.68","5157.68","1 through 10","204.38","319.6","percent of total billed charges",""
"SCREW BONE 4X16MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","391.09","293.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","319.60","81.72","","431.26","71.26","1459.57","88","204.38","319.6","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","306.08","79.5","","800.18","480.96","1887.97","195","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","205.21","53.3","","813.12","216.42","1444.50","81","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","119.35","31","","432.60","432.60","432.60","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","140.53","36.5","","148.37","54.89","631.39","94","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","147.46","38.3","","279.30","91.72","1116.77","266","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","165.17","42.9","","731.00","63.70","731.00","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","165.17","42.9","","384.74","384.74","384.74","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","WELLPOINT [1015]","HB AMC WELLPOINT","284.05","73.78","","286.63","119.22","1107.45","105","119.35","306.08","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","AETNA [1001]","HB AMC AETNA HMO","268.73","69.8","","675.31","184.75","1721.50","286","201.2","314.62","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","AETNA [1001]","HB AMC AETNA PPO","309.54","80.4","","1261.44","103.12","1514.10","21","201.2","314.62","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","309.54","80.4","","1365.00","1365.00","1365.00","1 through 10","201.2","314.62","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","314.62","81.72","","5157.68","5157.68","5157.68","1 through 10","201.2","314.62","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","314.62","81.72","","431.26","71.26","1459.57","88","201.2","314.62","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.84","320.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","340.13","79.5","","800.18","480.96","1887.97","195","132.63","340.13","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.84","320.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","228.04","53.3","","813.12","216.42","1444.50","81","132.63","340.13","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.84","320.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","132.63","31","","432.60","432.60","432.60","1 through 10","132.63","340.13","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.84","320.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","156.16","36.5","","148.37","54.89","631.39","94","132.63","340.13","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.84","320.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","163.86","38.3","","279.30","91.72","1116.77","266","132.63","340.13","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.84","320.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","183.54","42.9","","731.00","63.70","731.00","1 through 10","132.63","340.13","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.84","320.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","183.54","42.9","","384.74","384.74","384.74","1 through 10","132.63","340.13","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.84","320.88","WELLPOINT [1015]","HB AMC WELLPOINT","315.66","73.78","","286.63","119.22","1107.45","105","132.63","340.13","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","427.84","320.88","AETNA [1001]","HB AMC AETNA HMO","298.63","69.8","","675.31","184.75","1721.50","286","223.59","349.63","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","427.84","320.88","AETNA [1001]","HB AMC AETNA PPO","343.98","80.4","","1261.44","103.12","1514.10","21","223.59","349.63","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","427.84","320.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","343.98","80.4","","1365.00","1365.00","1365.00","1 through 10","223.59","349.63","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","427.84","320.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","349.63","81.72","","5157.68","5157.68","5157.68","1 through 10","223.59","349.63","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","427.84","320.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","349.63","81.72","","431.26","71.26","1459.57","88","223.59","349.63","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.78","81.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","86.48","79.5","","800.18","480.96","1887.97","195","33.72","86.48","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.78","81.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","57.98","53.3","","813.12","216.42","1444.50","81","33.72","86.48","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.78","81.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","33.72","31","","432.60","432.60","432.60","1 through 10","33.72","86.48","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.78","81.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","39.70","36.5","","148.37","54.89","631.39","94","33.72","86.48","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.78","81.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","41.66","38.3","","279.30","91.72","1116.77","266","33.72","86.48","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.78","81.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.67","42.9","","731.00","63.70","731.00","1 through 10","33.72","86.48","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.78","81.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.67","42.9","","384.74","384.74","384.74","1 through 10","33.72","86.48","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.78","81.58","WELLPOINT [1015]","HB AMC WELLPOINT","80.26","73.78","","286.63","119.22","1107.45","105","33.72","86.48","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","108.78","81.58","AETNA [1001]","HB AMC AETNA HMO","75.93","69.8","","675.31","184.75","1721.50","286","56.85","88.9","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","108.78","81.58","AETNA [1001]","HB AMC AETNA PPO","87.46","80.4","","1261.44","103.12","1514.10","21","56.85","88.9","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","108.78","81.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","87.46","80.4","","1365.00","1365.00","1365.00","1 through 10","56.85","88.9","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","108.78","81.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","88.90","81.72","","5157.68","5157.68","5157.68","1 through 10","56.85","88.9","percent of total billed charges",""
"SCREW BONE 4X28MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10018109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","108.78","81.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","88.90","81.72","","431.26","71.26","1459.57","88","56.85","88.9","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.40","352.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","373.97","79.5","","800.18","480.96","1887.97","195","145.82","373.97","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.40","352.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","250.72","53.3","","813.12","216.42","1444.50","81","145.82","373.97","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.40","352.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","145.82","31","","432.60","432.60","432.60","1 through 10","145.82","373.97","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.40","352.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","171.70","36.5","","148.37","54.89","631.39","94","145.82","373.97","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.40","352.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","180.16","38.3","","279.30","91.72","1116.77","266","145.82","373.97","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.40","352.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.80","42.9","","731.00","63.70","731.00","1 through 10","145.82","373.97","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.40","352.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.80","42.9","","384.74","384.74","384.74","1 through 10","145.82","373.97","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.40","352.80","WELLPOINT [1015]","HB AMC WELLPOINT","347.06","73.78","","286.63","119.22","1107.45","105","145.82","373.97","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","470.40","352.80","AETNA [1001]","HB AMC AETNA HMO","328.34","69.8","","675.31","184.75","1721.50","286","245.83","384.41","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","470.40","352.80","AETNA [1001]","HB AMC AETNA PPO","378.20","80.4","","1261.44","103.12","1514.10","21","245.83","384.41","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","470.40","352.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","378.20","80.4","","1365.00","1365.00","1365.00","1 through 10","245.83","384.41","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","470.40","352.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","384.41","81.72","","5157.68","5157.68","5157.68","1 through 10","245.83","384.41","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","470.40","352.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","384.41","81.72","","431.26","71.26","1459.57","88","245.83","384.41","percent of total billed charges",""
"SCREW BONE 4X36MM CANNULATED PARTIAL THREAD 110009815","SUP-ITM-10175402","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","567.46","79.5","","800.18","480.96","1887.97","195","221.27","567.46","percent of total billed charges",""
"SCREW BONE 4X36MM CANNULATED PARTIAL THREAD 110009815","SUP-ITM-10175402","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","380.45","53.3","","813.12","216.42","1444.50","81","221.27","567.46","percent of total billed charges",""
"SCREW BONE 4X36MM CANNULATED PARTIAL THREAD 110009815","SUP-ITM-10175402","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","221.27","31","","432.60","432.60","432.60","1 through 10","221.27","567.46","percent of total billed charges",""
"SCREW BONE 4X36MM CANNULATED PARTIAL THREAD 110009815","SUP-ITM-10175402","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","260.53","36.5","","148.37","54.89","631.39","94","221.27","567.46","percent of total billed charges",""
"SCREW BONE 4X36MM CANNULATED PARTIAL THREAD 110009815","SUP-ITM-10175402","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","273.38","38.3","","279.30","91.72","1116.77","266","221.27","567.46","percent of total billed charges",""
"SCREW BONE 4X36MM CANNULATED PARTIAL THREAD 110009815","SUP-ITM-10175402","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","306.22","42.9","","731.00","63.70","731.00","1 through 10","221.27","567.46","percent of total billed charges",""
"SCREW BONE 4X36MM CANNULATED PARTIAL THREAD 110009815","SUP-ITM-10175402","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","306.22","42.9","","384.74","384.74","384.74","1 through 10","221.27","567.46","percent of total billed charges",""
"SCREW BONE 4X36MM CANNULATED PARTIAL THREAD 110009815","SUP-ITM-10175402","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","WELLPOINT [1015]","HB AMC WELLPOINT","526.63","73.78","","286.63","119.22","1107.45","105","221.27","567.46","percent of total billed charges",""
"SCREW BONE 4X36MM CANNULATED PARTIAL THREAD 110009815","SUP-ITM-10175402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","713.79","535.34","AETNA [1001]","HB AMC AETNA HMO","498.23","69.8","","675.31","184.75","1721.50","286","373.03","583.31","percent of total billed charges",""
"SCREW BONE 4X36MM CANNULATED PARTIAL THREAD 110009815","SUP-ITM-10175402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","713.79","535.34","AETNA [1001]","HB AMC AETNA PPO","573.89","80.4","","1261.44","103.12","1514.10","21","373.03","583.31","percent of total billed charges",""
"SCREW BONE 4X36MM CANNULATED PARTIAL THREAD 110009815","SUP-ITM-10175402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","713.79","535.34","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","573.89","80.4","","1365.00","1365.00","1365.00","1 through 10","373.03","583.31","percent of total billed charges",""
"SCREW BONE 4X36MM CANNULATED PARTIAL THREAD 110009815","SUP-ITM-10175402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","713.79","535.34","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","583.31","81.72","","5157.68","5157.68","5157.68","1 through 10","373.03","583.31","percent of total billed charges",""
"SCREW BONE 4X36MM CANNULATED PARTIAL THREAD 110009815","SUP-ITM-10175402","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","713.79","535.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","583.31","81.72","","431.26","71.26","1459.57","88","373.03","583.31","percent of total billed charges",""
"SCREW BONE 4X36MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL","SUP-ITM-10086773","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","1309.77","674.56","6049.93","26","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 4X36MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL","SUP-ITM-10086773","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","1901.83","1901.83","2962.25","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 4X36MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL","SUP-ITM-10086773","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","1620.31","1620.31","19908.88","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 4X36MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL","SUP-ITM-10086773","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","352.91","352.91","2046.30","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 4X36MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL","SUP-ITM-10086773","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","9668.75","9668.75","9668.75","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 4X36MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL","SUP-ITM-10086773","CDM","C1889","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","699.88","384.10","3443.31","33","542.5","1391.25","percent of total billed charges",""
"SCREW BONE 4X36MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL","SUP-ITM-10086773","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","1421.24","264.50","4933.46","29","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 4X36MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL","SUP-ITM-10086773","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","1022.97","1022.97","3607.50","1 through 10","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 4X36MM SPINE CANCELLOUS SYNAPSE TITANIUM POLYAXIAL","SUP-ITM-10086773","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","3010.54","693.88","5019.88","35","914.55","1430.1","percent of total billed charges",""
"SCREW BONE 4X37.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331241","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1018.40","79.5","","800.18","480.96","1887.97","195","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 4X37.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331241","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","682.77","53.3","","813.12","216.42","1444.50","81","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 4X37.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331241","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","397.11","31","","432.60","432.60","432.60","1 through 10","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 4X37.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331241","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","467.57","36.5","","148.37","54.89","631.39","94","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 4X37.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331241","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","490.62","38.3","","279.30","91.72","1116.77","266","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 4X37.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331241","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","549.55","42.9","","731.00","63.70","731.00","1 through 10","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 4X37.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331241","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","549.55","42.9","","384.74","384.74","384.74","1 through 10","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 4X37.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331241","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","WELLPOINT [1015]","HB AMC WELLPOINT","945.12","73.78","","286.63","119.22","1107.45","105","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 4X37.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1281.00","960.75","AETNA [1001]","HB AMC AETNA HMO","894.14","69.8","","675.31","184.75","1721.50","286","669.45","1046.83","percent of total billed charges",""
"SCREW BONE 4X37.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1281.00","960.75","AETNA [1001]","HB AMC AETNA PPO","1029.92","80.4","","1261.44","103.12","1514.10","21","669.45","1046.83","percent of total billed charges",""
"SCREW BONE 4X37.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1281.00","960.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1029.92","80.4","","1365.00","1365.00","1365.00","1 through 10","669.45","1046.83","percent of total billed charges",""
"SCREW BONE 4X37.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1281.00","960.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1046.83","81.72","","5157.68","5157.68","5157.68","1 through 10","669.45","1046.83","percent of total billed charges",""
"SCREW BONE 4X37.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1281.00","960.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1046.83","81.72","","431.26","71.26","1459.57","88","669.45","1046.83","percent of total billed charges",""
"SCREW BONE 4X42MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","804.31","79.5","","800.18","480.96","1887.97","195","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X42MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","539.24","53.3","","813.12","216.42","1444.50","81","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X42MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","313.63","31","","432.60","432.60","432.60","1 through 10","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X42MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","369.27","36.5","","148.37","54.89","631.39","94","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X42MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","387.48","38.3","","279.30","91.72","1116.77","266","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X42MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.02","42.9","","731.00","63.70","731.00","1 through 10","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X42MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.02","42.9","","384.74","384.74","384.74","1 through 10","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X42MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144216","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","WELLPOINT [1015]","HB AMC WELLPOINT","746.44","73.78","","286.63","119.22","1107.45","105","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X42MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","AETNA [1001]","HB AMC AETNA HMO","706.17","69.8","","675.31","184.75","1721.50","286","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X42MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","AETNA [1001]","HB AMC AETNA PPO","813.41","80.4","","1261.44","103.12","1514.10","21","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X42MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","813.41","80.4","","1365.00","1365.00","1365.00","1 through 10","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X42MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","826.77","81.72","","5157.68","5157.68","5157.68","1 through 10","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X42MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","826.77","81.72","","431.26","71.26","1459.57","88","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X42MM AXSOS TITANIUM LOCKING","SUP-ITM-10144922","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","711.96","79.5","","800.18","480.96","1887.97","195","277.62","711.96","percent of total billed charges",""
"SCREW BONE 4X42MM AXSOS TITANIUM LOCKING","SUP-ITM-10144922","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","477.33","53.3","","813.12","216.42","1444.50","81","277.62","711.96","percent of total billed charges",""
"SCREW BONE 4X42MM AXSOS TITANIUM LOCKING","SUP-ITM-10144922","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","277.62","31","","432.60","432.60","432.60","1 through 10","277.62","711.96","percent of total billed charges",""
"SCREW BONE 4X42MM AXSOS TITANIUM LOCKING","SUP-ITM-10144922","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","326.88","36.5","","148.37","54.89","631.39","94","277.62","711.96","percent of total billed charges",""
"SCREW BONE 4X42MM AXSOS TITANIUM LOCKING","SUP-ITM-10144922","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","343.00","38.3","","279.30","91.72","1116.77","266","277.62","711.96","percent of total billed charges",""
"SCREW BONE 4X42MM AXSOS TITANIUM LOCKING","SUP-ITM-10144922","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","384.19","42.9","","731.00","63.70","731.00","1 through 10","277.62","711.96","percent of total billed charges",""
"SCREW BONE 4X42MM AXSOS TITANIUM LOCKING","SUP-ITM-10144922","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","384.19","42.9","","384.74","384.74","384.74","1 through 10","277.62","711.96","percent of total billed charges",""
"SCREW BONE 4X42MM AXSOS TITANIUM LOCKING","SUP-ITM-10144922","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","WELLPOINT [1015]","HB AMC WELLPOINT","660.74","73.78","","286.63","119.22","1107.45","105","277.62","711.96","percent of total billed charges",""
"SCREW BONE 4X42MM AXSOS TITANIUM LOCKING","SUP-ITM-10144922","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","895.55","671.66","AETNA [1001]","HB AMC AETNA HMO","625.09","69.8","","675.31","184.75","1721.50","286","468.01","731.84","percent of total billed charges",""
"SCREW BONE 4X42MM AXSOS TITANIUM LOCKING","SUP-ITM-10144922","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","895.55","671.66","AETNA [1001]","HB AMC AETNA PPO","720.02","80.4","","1261.44","103.12","1514.10","21","468.01","731.84","percent of total billed charges",""
"SCREW BONE 4X42MM AXSOS TITANIUM LOCKING","SUP-ITM-10144922","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","895.55","671.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","720.02","80.4","","1365.00","1365.00","1365.00","1 through 10","468.01","731.84","percent of total billed charges",""
"SCREW BONE 4X42MM AXSOS TITANIUM LOCKING","SUP-ITM-10144922","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","895.55","671.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","731.84","81.72","","5157.68","5157.68","5157.68","1 through 10","468.01","731.84","percent of total billed charges",""
"SCREW BONE 4X42MM AXSOS TITANIUM LOCKING","SUP-ITM-10144922","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","895.55","671.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","731.84","81.72","","431.26","71.26","1459.57","88","468.01","731.84","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","95.83","71.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","76.18","79.5","","800.18","480.96","1887.97","195","29.71","76.18","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","95.83","71.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","51.08","53.3","","813.12","216.42","1444.50","81","29.71","76.18","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","95.83","71.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","29.71","31","","432.60","432.60","432.60","1 through 10","29.71","76.18","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","95.83","71.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34.98","36.5","","148.37","54.89","631.39","94","29.71","76.18","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","95.83","71.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","36.70","38.3","","279.30","91.72","1116.77","266","29.71","76.18","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","95.83","71.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.11","42.9","","731.00","63.70","731.00","1 through 10","29.71","76.18","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","95.83","71.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.11","42.9","","384.74","384.74","384.74","1 through 10","29.71","76.18","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","95.83","71.87","WELLPOINT [1015]","HB AMC WELLPOINT","70.70","73.78","","286.63","119.22","1107.45","105","29.71","76.18","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","95.83","71.87","AETNA [1001]","HB AMC AETNA HMO","66.89","69.8","","675.31","184.75","1721.50","286","50.08","78.31","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","95.83","71.87","AETNA [1001]","HB AMC AETNA PPO","77.05","80.4","","1261.44","103.12","1514.10","21","50.08","78.31","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","95.83","71.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","77.05","80.4","","1365.00","1365.00","1365.00","1 through 10","50.08","78.31","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","95.83","71.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","78.31","81.72","","5157.68","5157.68","5157.68","1 through 10","50.08","78.31","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","95.83","71.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","78.31","81.72","","431.26","71.26","1459.57","88","50.08","78.31","percent of total billed charges",""
"SCREW BONE 4X46MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144218","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","804.31","79.5","","800.18","480.96","1887.97","195","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X46MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144218","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","539.24","53.3","","813.12","216.42","1444.50","81","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X46MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144218","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","313.63","31","","432.60","432.60","432.60","1 through 10","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X46MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144218","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","369.27","36.5","","148.37","54.89","631.39","94","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X46MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144218","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","387.48","38.3","","279.30","91.72","1116.77","266","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X46MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144218","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.02","42.9","","731.00","63.70","731.00","1 through 10","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X46MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144218","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.02","42.9","","384.74","384.74","384.74","1 through 10","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X46MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144218","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","WELLPOINT [1015]","HB AMC WELLPOINT","746.44","73.78","","286.63","119.22","1107.45","105","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X46MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","AETNA [1001]","HB AMC AETNA HMO","706.17","69.8","","675.31","184.75","1721.50","286","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X46MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","AETNA [1001]","HB AMC AETNA PPO","813.41","80.4","","1261.44","103.12","1514.10","21","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X46MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","813.41","80.4","","1365.00","1365.00","1365.00","1 through 10","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X46MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","826.77","81.72","","5157.68","5157.68","5157.68","1 through 10","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X46MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144218","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","826.77","81.72","","431.26","71.26","1459.57","88","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X48MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144220","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","804.31","79.5","","800.18","480.96","1887.97","195","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X48MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144220","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","539.24","53.3","","813.12","216.42","1444.50","81","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X48MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144220","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","313.63","31","","432.60","432.60","432.60","1 through 10","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X48MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144220","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","369.27","36.5","","148.37","54.89","631.39","94","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X48MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144220","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","387.48","38.3","","279.30","91.72","1116.77","266","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X48MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144220","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.02","42.9","","731.00","63.70","731.00","1 through 10","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X48MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144220","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.02","42.9","","384.74","384.74","384.74","1 through 10","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X48MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144220","CDM","C1713","HCPCS","0278","RC","","","","both","","","1011.71","758.78","WELLPOINT [1015]","HB AMC WELLPOINT","746.44","73.78","","286.63","119.22","1107.45","105","313.63","804.31","percent of total billed charges",""
"SCREW BONE 4X48MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","AETNA [1001]","HB AMC AETNA HMO","706.17","69.8","","675.31","184.75","1721.50","286","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X48MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","AETNA [1001]","HB AMC AETNA PPO","813.41","80.4","","1261.44","103.12","1514.10","21","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X48MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","813.41","80.4","","1365.00","1365.00","1365.00","1 through 10","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X48MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","826.77","81.72","","5157.68","5157.68","5157.68","1 through 10","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X48MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1011.71","758.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","826.77","81.72","","431.26","71.26","1459.57","88","528.72","826.77","percent of total billed charges",""
"SCREW BONE 4X60MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144322","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.86","79.5","","800.18","480.96","1887.97","195","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X60MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144322","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","107.85","53.3","","813.12","216.42","1444.50","81","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X60MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144322","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","62.73","31","","432.60","432.60","432.60","1 through 10","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X60MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144322","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.85","36.5","","148.37","54.89","631.39","94","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X60MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144322","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.50","38.3","","279.30","91.72","1116.77","266","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X60MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144322","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.80","42.9","","731.00","63.70","731.00","1 through 10","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X60MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144322","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.80","42.9","","384.74","384.74","384.74","1 through 10","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X60MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144322","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","WELLPOINT [1015]","HB AMC WELLPOINT","149.29","73.78","","286.63","119.22","1107.45","105","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X60MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","AETNA [1001]","HB AMC AETNA HMO","141.23","69.8","","675.31","184.75","1721.50","286","105.74","165.35","percent of total billed charges",""
"SCREW BONE 4X60MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","AETNA [1001]","HB AMC AETNA PPO","162.68","80.4","","1261.44","103.12","1514.10","21","105.74","165.35","percent of total billed charges",""
"SCREW BONE 4X60MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","162.68","80.4","","1365.00","1365.00","1365.00","1 through 10","105.74","165.35","percent of total billed charges",""
"SCREW BONE 4X60MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","165.35","81.72","","5157.68","5157.68","5157.68","1 through 10","105.74","165.35","percent of total billed charges",""
"SCREW BONE 4X60MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.35","81.72","","431.26","71.26","1459.57","88","105.74","165.35","percent of total billed charges",""
"SCREW BONE 4X70MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144324","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.86","79.5","","800.18","480.96","1887.97","195","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X70MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144324","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","107.85","53.3","","813.12","216.42","1444.50","81","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X70MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144324","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","62.73","31","","432.60","432.60","432.60","1 through 10","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X70MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144324","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.85","36.5","","148.37","54.89","631.39","94","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X70MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144324","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.50","38.3","","279.30","91.72","1116.77","266","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X70MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144324","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.80","42.9","","731.00","63.70","731.00","1 through 10","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X70MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144324","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.80","42.9","","384.74","384.74","384.74","1 through 10","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X70MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144324","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","WELLPOINT [1015]","HB AMC WELLPOINT","149.29","73.78","","286.63","119.22","1107.45","105","62.73","160.86","percent of total billed charges",""
"SCREW BONE 4X70MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","AETNA [1001]","HB AMC AETNA HMO","141.23","69.8","","675.31","184.75","1721.50","286","105.74","165.35","percent of total billed charges",""
"SCREW BONE 4X70MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","AETNA [1001]","HB AMC AETNA PPO","162.68","80.4","","1261.44","103.12","1514.10","21","105.74","165.35","percent of total billed charges",""
"SCREW BONE 4X70MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","162.68","80.4","","1365.00","1365.00","1365.00","1 through 10","105.74","165.35","percent of total billed charges",""
"SCREW BONE 4X70MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","165.35","81.72","","5157.68","5157.68","5157.68","1 through 10","105.74","165.35","percent of total billed charges",""
"SCREW BONE 4X70MM CANCELLOUS VARIAX TITANIUM FULL THREAD","SUP-ITM-10144324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.35","81.72","","431.26","71.26","1459.57","88","105.74","165.35","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.13","72.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","77.22","79.5","","800.18","480.96","1887.97","195","30.11","77.22","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.13","72.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","51.77","53.3","","813.12","216.42","1444.50","81","30.11","77.22","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.13","72.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","30.11","31","","432.60","432.60","432.60","1 through 10","30.11","77.22","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.13","72.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","35.45","36.5","","148.37","54.89","631.39","94","30.11","77.22","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.13","72.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37.20","38.3","","279.30","91.72","1116.77","266","30.11","77.22","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.13","72.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.67","42.9","","731.00","63.70","731.00","1 through 10","30.11","77.22","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.13","72.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.67","42.9","","384.74","384.74","384.74","1 through 10","30.11","77.22","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.13","72.85","WELLPOINT [1015]","HB AMC WELLPOINT","71.66","73.78","","286.63","119.22","1107.45","105","30.11","77.22","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.13","72.85","AETNA [1001]","HB AMC AETNA HMO","67.80","69.8","","675.31","184.75","1721.50","286","50.76","79.37","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.13","72.85","AETNA [1001]","HB AMC AETNA PPO","78.09","80.4","","1261.44","103.12","1514.10","21","50.76","79.37","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.13","72.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","78.09","80.4","","1365.00","1365.00","1365.00","1 through 10","50.76","79.37","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.13","72.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","79.37","81.72","","5157.68","5157.68","5157.68","1 through 10","50.76","79.37","percent of total billed charges",""
"SCREW BONE 4X70MM CORTEX SS SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10013639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.13","72.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","79.37","81.72","","431.26","71.26","1459.57","88","50.76","79.37","percent of total billed charges",""
"SCREW BONE 4X75MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144841","CDM","C1713","HCPCS","0278","RC","","","","both","","","1584.17","1188.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1259.42","79.5","","800.18","480.96","1887.97","195","491.09","1259.42","percent of total billed charges",""
"SCREW BONE 4X75MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144841","CDM","C1713","HCPCS","0278","RC","","","","both","","","1584.17","1188.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","844.36","53.3","","813.12","216.42","1444.50","81","491.09","1259.42","percent of total billed charges",""
"SCREW BONE 4X75MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144841","CDM","C1713","HCPCS","0278","RC","","","","both","","","1584.17","1188.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","491.09","31","","432.60","432.60","432.60","1 through 10","491.09","1259.42","percent of total billed charges",""
"SCREW BONE 4X75MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144841","CDM","C1713","HCPCS","0278","RC","","","","both","","","1584.17","1188.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","578.22","36.5","","148.37","54.89","631.39","94","491.09","1259.42","percent of total billed charges",""
"SCREW BONE 4X75MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144841","CDM","C1713","HCPCS","0278","RC","","","","both","","","1584.17","1188.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","606.74","38.3","","279.30","91.72","1116.77","266","491.09","1259.42","percent of total billed charges",""
"SCREW BONE 4X75MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144841","CDM","C1713","HCPCS","0278","RC","","","","both","","","1584.17","1188.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","679.61","42.9","","731.00","63.70","731.00","1 through 10","491.09","1259.42","percent of total billed charges",""
"SCREW BONE 4X75MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144841","CDM","C1713","HCPCS","0278","RC","","","","both","","","1584.17","1188.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","679.61","42.9","","384.74","384.74","384.74","1 through 10","491.09","1259.42","percent of total billed charges",""
"SCREW BONE 4X75MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144841","CDM","C1713","HCPCS","0278","RC","","","","both","","","1584.17","1188.13","WELLPOINT [1015]","HB AMC WELLPOINT","1168.80","73.78","","286.63","119.22","1107.45","105","491.09","1259.42","percent of total billed charges",""
"SCREW BONE 4X75MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1584.17","1188.13","AETNA [1001]","HB AMC AETNA HMO","1105.75","69.8","","675.31","184.75","1721.50","286","827.89","1294.58","percent of total billed charges",""
"SCREW BONE 4X75MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1584.17","1188.13","AETNA [1001]","HB AMC AETNA PPO","1273.67","80.4","","1261.44","103.12","1514.10","21","827.89","1294.58","percent of total billed charges",""
"SCREW BONE 4X75MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1584.17","1188.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1273.67","80.4","","1365.00","1365.00","1365.00","1 through 10","827.89","1294.58","percent of total billed charges",""
"SCREW BONE 4X75MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1584.17","1188.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1294.58","81.72","","5157.68","5157.68","5157.68","1 through 10","827.89","1294.58","percent of total billed charges",""
"SCREW BONE 4X75MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1584.17","1188.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1294.58","81.72","","431.26","71.26","1459.57","88","827.89","1294.58","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.53","130.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","137.96","79.5","","800.18","480.96","1887.97","195","53.79","137.96","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.53","130.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","92.49","53.3","","813.12","216.42","1444.50","81","53.79","137.96","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.53","130.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","53.79","31","","432.60","432.60","432.60","1 through 10","53.79","137.96","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.53","130.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.34","36.5","","148.37","54.89","631.39","94","53.79","137.96","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.53","130.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.46","38.3","","279.30","91.72","1116.77","266","53.79","137.96","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.53","130.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.44","42.9","","731.00","63.70","731.00","1 through 10","53.79","137.96","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.53","130.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.44","42.9","","384.74","384.74","384.74","1 through 10","53.79","137.96","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.53","130.15","WELLPOINT [1015]","HB AMC WELLPOINT","128.03","73.78","","286.63","119.22","1107.45","105","53.79","137.96","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.53","130.15","AETNA [1001]","HB AMC AETNA HMO","121.12","69.8","","675.31","184.75","1721.50","286","90.69","141.81","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.53","130.15","AETNA [1001]","HB AMC AETNA PPO","139.52","80.4","","1261.44","103.12","1514.10","21","90.69","141.81","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.53","130.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","139.52","80.4","","1365.00","1365.00","1365.00","1 through 10","90.69","141.81","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.53","130.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","141.81","81.72","","5157.68","5157.68","5157.68","1 through 10","90.69","141.81","percent of total billed charges",""
"SCREW BONE 4X75MM SS CORTEX SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10037226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.53","130.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","141.81","81.72","","431.26","71.26","1459.57","88","90.69","141.81","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM CONDYLAR","SUP-ITM-10033854","CDM","C1713","HCPCS","0278","RC","","","","both","","","111.65","83.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","88.76","79.5","","800.18","480.96","1887.97","195","34.61","88.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM CONDYLAR","SUP-ITM-10033854","CDM","C1713","HCPCS","0278","RC","","","","both","","","111.65","83.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","59.51","53.3","","813.12","216.42","1444.50","81","34.61","88.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM CONDYLAR","SUP-ITM-10033854","CDM","C1713","HCPCS","0278","RC","","","","both","","","111.65","83.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","34.61","31","","432.60","432.60","432.60","1 through 10","34.61","88.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM CONDYLAR","SUP-ITM-10033854","CDM","C1713","HCPCS","0278","RC","","","","both","","","111.65","83.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","40.75","36.5","","148.37","54.89","631.39","94","34.61","88.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM CONDYLAR","SUP-ITM-10033854","CDM","C1713","HCPCS","0278","RC","","","","both","","","111.65","83.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","42.76","38.3","","279.30","91.72","1116.77","266","34.61","88.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM CONDYLAR","SUP-ITM-10033854","CDM","C1713","HCPCS","0278","RC","","","","both","","","111.65","83.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.90","42.9","","731.00","63.70","731.00","1 through 10","34.61","88.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM CONDYLAR","SUP-ITM-10033854","CDM","C1713","HCPCS","0278","RC","","","","both","","","111.65","83.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.90","42.9","","384.74","384.74","384.74","1 through 10","34.61","88.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM CONDYLAR","SUP-ITM-10033854","CDM","C1713","HCPCS","0278","RC","","","","both","","","111.65","83.74","WELLPOINT [1015]","HB AMC WELLPOINT","82.38","73.78","","286.63","119.22","1107.45","105","34.61","88.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM CONDYLAR","SUP-ITM-10033854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","111.65","83.74","AETNA [1001]","HB AMC AETNA HMO","77.93","69.8","","675.31","184.75","1721.50","286","58.35","91.24","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM CONDYLAR","SUP-ITM-10033854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","111.65","83.74","AETNA [1001]","HB AMC AETNA PPO","89.77","80.4","","1261.44","103.12","1514.10","21","58.35","91.24","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM CONDYLAR","SUP-ITM-10033854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","111.65","83.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","89.77","80.4","","1365.00","1365.00","1365.00","1 through 10","58.35","91.24","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM CONDYLAR","SUP-ITM-10033854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","111.65","83.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","91.24","81.72","","5157.68","5157.68","5157.68","1 through 10","58.35","91.24","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM CONDYLAR","SUP-ITM-10033854","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","111.65","83.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","91.24","81.72","","431.26","71.26","1459.57","88","58.35","91.24","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10028297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","884.76","79.5","","800.18","480.96","1887.97","195","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10028297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","593.18","53.3","","813.12","216.42","1444.50","81","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10028297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","345.00","31","","432.60","432.60","432.60","1 through 10","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10028297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","406.21","36.5","","148.37","54.89","631.39","94","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10028297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","426.24","38.3","","279.30","91.72","1116.77","266","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10028297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","477.43","42.9","","731.00","63.70","731.00","1 through 10","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10028297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","477.43","42.9","","384.74","384.74","384.74","1 through 10","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10028297","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","WELLPOINT [1015]","HB AMC WELLPOINT","821.10","73.78","","286.63","119.22","1107.45","105","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10028297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1112.90","834.67","AETNA [1001]","HB AMC AETNA HMO","776.80","69.8","","675.31","184.75","1721.50","286","581.6","909.46","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10028297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1112.90","834.67","AETNA [1001]","HB AMC AETNA PPO","894.77","80.4","","1261.44","103.12","1514.10","21","581.6","909.46","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10028297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1112.90","834.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","894.77","80.4","","1365.00","1365.00","1365.00","1 through 10","581.6","909.46","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10028297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1112.90","834.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","909.46","81.72","","5157.68","5157.68","5157.68","1 through 10","581.6","909.46","percent of total billed charges",""
"SCREW BONE 5.0X40MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10028297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1112.90","834.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","909.46","81.72","","431.26","71.26","1459.57","88","581.6","909.46","percent of total billed charges",""
"SCREW BONE 5.0X70MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030001","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","884.76","79.5","","800.18","480.96","1887.97","195","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X70MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030001","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","593.18","53.3","","813.12","216.42","1444.50","81","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X70MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030001","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","345.00","31","","432.60","432.60","432.60","1 through 10","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X70MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030001","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","406.21","36.5","","148.37","54.89","631.39","94","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X70MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030001","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","426.24","38.3","","279.30","91.72","1116.77","266","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X70MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030001","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","477.43","42.9","","731.00","63.70","731.00","1 through 10","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X70MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030001","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","477.43","42.9","","384.74","384.74","384.74","1 through 10","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X70MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030001","CDM","C1713","HCPCS","0278","RC","","","","both","","","1112.90","834.67","WELLPOINT [1015]","HB AMC WELLPOINT","821.10","73.78","","286.63","119.22","1107.45","105","345","884.76","percent of total billed charges",""
"SCREW BONE 5.0X70MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1112.90","834.67","AETNA [1001]","HB AMC AETNA HMO","776.80","69.8","","675.31","184.75","1721.50","286","581.6","909.46","percent of total billed charges",""
"SCREW BONE 5.0X70MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1112.90","834.67","AETNA [1001]","HB AMC AETNA PPO","894.77","80.4","","1261.44","103.12","1514.10","21","581.6","909.46","percent of total billed charges",""
"SCREW BONE 5.0X70MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1112.90","834.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","894.77","80.4","","1365.00","1365.00","1365.00","1 through 10","581.6","909.46","percent of total billed charges",""
"SCREW BONE 5.0X70MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1112.90","834.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","909.46","81.72","","5157.68","5157.68","5157.68","1 through 10","581.6","909.46","percent of total billed charges",""
"SCREW BONE 5.0X70MM T2 TITANIUM LOCKING PARTIAL THREAD","SUP-ITM-10030001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1112.90","834.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","909.46","81.72","","431.26","71.26","1459.57","88","581.6","909.46","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM CONDYLAR","SUP-ITM-10016991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","887.73","79.5","","800.18","480.96","1887.97","195","346.16","887.73","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM CONDYLAR","SUP-ITM-10016991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","595.17","53.3","","813.12","216.42","1444.50","81","346.16","887.73","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM CONDYLAR","SUP-ITM-10016991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","346.16","31","","432.60","432.60","432.60","1 through 10","346.16","887.73","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM CONDYLAR","SUP-ITM-10016991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","407.57","36.5","","148.37","54.89","631.39","94","346.16","887.73","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM CONDYLAR","SUP-ITM-10016991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","427.67","38.3","","279.30","91.72","1116.77","266","346.16","887.73","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM CONDYLAR","SUP-ITM-10016991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","479.04","42.9","","731.00","63.70","731.00","1 through 10","346.16","887.73","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM CONDYLAR","SUP-ITM-10016991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","479.04","42.9","","384.74","384.74","384.74","1 through 10","346.16","887.73","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM CONDYLAR","SUP-ITM-10016991","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.64","837.48","WELLPOINT [1015]","HB AMC WELLPOINT","823.86","73.78","","286.63","119.22","1107.45","105","346.16","887.73","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM CONDYLAR","SUP-ITM-10016991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.64","837.48","AETNA [1001]","HB AMC AETNA HMO","779.41","69.8","","675.31","184.75","1721.50","286","583.56","912.52","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM CONDYLAR","SUP-ITM-10016991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.64","837.48","AETNA [1001]","HB AMC AETNA PPO","897.78","80.4","","1261.44","103.12","1514.10","21","583.56","912.52","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM CONDYLAR","SUP-ITM-10016991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.64","837.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","897.78","80.4","","1365.00","1365.00","1365.00","1 through 10","583.56","912.52","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM CONDYLAR","SUP-ITM-10016991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.64","837.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","912.52","81.72","","5157.68","5157.68","5157.68","1 through 10","583.56","912.52","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM CONDYLAR","SUP-ITM-10016991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.64","837.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","912.52","81.72","","431.26","71.26","1459.57","88","583.56","912.52","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","816.22","79.5","","800.18","480.96","1887.97","195","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","547.23","53.3","","813.12","216.42","1444.50","81","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","318.27","31","","432.60","432.60","432.60","1 through 10","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","374.74","36.5","","148.37","54.89","631.39","94","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","393.22","38.3","","279.30","91.72","1116.77","266","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","440.45","42.9","","731.00","63.70","731.00","1 through 10","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","440.45","42.9","","384.74","384.74","384.74","1 through 10","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","WELLPOINT [1015]","HB AMC WELLPOINT","757.49","73.78","","286.63","119.22","1107.45","105","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.69","770.02","AETNA [1001]","HB AMC AETNA HMO","716.63","69.8","","675.31","184.75","1721.50","286","536.55","839.01","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.69","770.02","AETNA [1001]","HB AMC AETNA PPO","825.46","80.4","","1261.44","103.12","1514.10","21","536.55","839.01","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.69","770.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","825.46","80.4","","1365.00","1365.00","1365.00","1 through 10","536.55","839.01","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.69","770.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","839.01","81.72","","5157.68","5157.68","5157.68","1 through 10","536.55","839.01","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.69","770.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","839.01","81.72","","431.26","71.26","1459.57","88","536.55","839.01","percent of total billed charges",""
"SCREW BONE 5.25X12MM SPINE CERVICAL MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10028959","CDM","C1889","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","278.25","79.5","","1309.77","674.56","6049.93","26","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5.25X12MM SPINE CERVICAL MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10028959","CDM","C1889","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","186.55","53.3","","1901.83","1901.83","2962.25","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5.25X12MM SPINE CERVICAL MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10028959","CDM","C1889","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.75","36.5","","1620.31","1620.31","19908.88","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5.25X12MM SPINE CERVICAL MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10028959","CDM","C1889","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","134.05","38.3","","352.91","352.91","2046.30","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5.25X12MM SPINE CERVICAL MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10028959","CDM","C1889","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","9668.75","9668.75","9668.75","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5.25X12MM SPINE CERVICAL MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10028959","CDM","C1889","HCPCS","0278","RC","","","","both","","","350.00","262.50","WELLPOINT [1015]","HB AMC WELLPOINT","258.23","73.78","","699.88","384.10","3443.31","33","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5.25X12MM SPINE CERVICAL MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10028959","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA HMO","244.30","69.8","","1421.24","264.50","4933.46","29","182.91","286.02","percent of total billed charges",""
"SCREW BONE 5.25X12MM SPINE CERVICAL MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10028959","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","281.40","80.4","","1022.97","1022.97","3607.50","1 through 10","182.91","286.02","percent of total billed charges",""
"SCREW BONE 5.25X12MM SPINE CERVICAL MOUNTAINEER TITANIUM FAVORED ANGLE OCCIPITAL","SUP-ITM-10028959","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","286.02","81.72","","3010.54","693.88","5019.88","35","182.91","286.02","percent of total billed charges",""
"SCREW BONE 5.2X12MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM BLUE LG DIAMETER","SUP-ITM-10019752","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","800.18","480.96","1887.97","195","97.65","250.43","percent of total billed charges",""
"SCREW BONE 5.2X12MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM BLUE LG DIAMETER","SUP-ITM-10019752","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","813.12","216.42","1444.50","81","97.65","250.43","percent of total billed charges",""
"SCREW BONE 5.2X12MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM BLUE LG DIAMETER","SUP-ITM-10019752","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","97.65","31","","432.60","432.60","432.60","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 5.2X12MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM BLUE LG DIAMETER","SUP-ITM-10019752","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","148.37","54.89","631.39","94","97.65","250.43","percent of total billed charges",""
"SCREW BONE 5.2X12MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM BLUE LG DIAMETER","SUP-ITM-10019752","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","279.30","91.72","1116.77","266","97.65","250.43","percent of total billed charges",""
"SCREW BONE 5.2X12MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM BLUE LG DIAMETER","SUP-ITM-10019752","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","731.00","63.70","731.00","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 5.2X12MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM BLUE LG DIAMETER","SUP-ITM-10019752","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","384.74","384.74","384.74","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW BONE 5.2X12MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM BLUE LG DIAMETER","SUP-ITM-10019752","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB AMC WELLPOINT","232.41","73.78","","286.63","119.22","1107.45","105","97.65","250.43","percent of total billed charges",""
"SCREW BONE 5.2X12MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM BLUE LG DIAMETER","SUP-ITM-10019752","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","675.31","184.75","1721.50","286","164.62","257.42","percent of total billed charges",""
"SCREW BONE 5.2X12MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM BLUE LG DIAMETER","SUP-ITM-10019752","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA PPO","253.26","80.4","","1261.44","103.12","1514.10","21","164.62","257.42","percent of total billed charges",""
"SCREW BONE 5.2X12MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM BLUE LG DIAMETER","SUP-ITM-10019752","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","1365.00","1365.00","1365.00","1 through 10","164.62","257.42","percent of total billed charges",""
"SCREW BONE 5.2X12MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM BLUE LG DIAMETER","SUP-ITM-10019752","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","257.42","81.72","","5157.68","5157.68","5157.68","1 through 10","164.62","257.42","percent of total billed charges",""
"SCREW BONE 5.2X12MM SPINE CANCELLOUS UNIPLATE 2 TITANIUM BLUE LG DIAMETER","SUP-ITM-10019752","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","431.26","71.26","1459.57","88","164.62","257.42","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","932.14","79.5","","800.18","480.96","1887.97","195","363.48","932.14","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","624.94","53.3","","813.12","216.42","1444.50","81","363.48","932.14","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","363.48","31","","432.60","432.60","432.60","1 through 10","363.48","932.14","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","427.96","36.5","","148.37","54.89","631.39","94","363.48","932.14","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","449.07","38.3","","279.30","91.72","1116.77","266","363.48","932.14","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","503.00","42.9","","731.00","63.70","731.00","1 through 10","363.48","932.14","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","503.00","42.9","","384.74","384.74","384.74","1 through 10","363.48","932.14","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","WELLPOINT [1015]","HB AMC WELLPOINT","865.07","73.78","","286.63","119.22","1107.45","105","363.48","932.14","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1172.50","879.37","AETNA [1001]","HB AMC AETNA HMO","818.41","69.8","","675.31","184.75","1721.50","286","612.75","958.17","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1172.50","879.37","AETNA [1001]","HB AMC AETNA PPO","942.69","80.4","","1261.44","103.12","1514.10","21","612.75","958.17","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1172.50","879.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","942.69","80.4","","1365.00","1365.00","1365.00","1 through 10","612.75","958.17","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1172.50","879.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","958.17","81.72","","5157.68","5157.68","5157.68","1 through 10","612.75","958.17","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1172.50","879.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","958.17","81.72","","431.26","71.26","1459.57","88","612.75","958.17","percent of total billed charges",""
"SCREW BONE 5.5MM LOW PROFILE SELF DRILLING HEXAGONAL FIXATION FIXED ANGLE TITANIUM PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","834.75","79.5","","800.18","480.96","1887.97","195","325.5","834.75","percent of total billed charges",""
"SCREW BONE 5.5MM LOW PROFILE SELF DRILLING HEXAGONAL FIXATION FIXED ANGLE TITANIUM PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","559.65","53.3","","813.12","216.42","1444.50","81","325.5","834.75","percent of total billed charges",""
"SCREW BONE 5.5MM LOW PROFILE SELF DRILLING HEXAGONAL FIXATION FIXED ANGLE TITANIUM PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","325.50","31","","432.60","432.60","432.60","1 through 10","325.5","834.75","percent of total billed charges",""
"SCREW BONE 5.5MM LOW PROFILE SELF DRILLING HEXAGONAL FIXATION FIXED ANGLE TITANIUM PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","148.37","54.89","631.39","94","325.5","834.75","percent of total billed charges",""
"SCREW BONE 5.5MM LOW PROFILE SELF DRILLING HEXAGONAL FIXATION FIXED ANGLE TITANIUM PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","279.30","91.72","1116.77","266","325.5","834.75","percent of total billed charges",""
"SCREW BONE 5.5MM LOW PROFILE SELF DRILLING HEXAGONAL FIXATION FIXED ANGLE TITANIUM PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","731.00","63.70","731.00","1 through 10","325.5","834.75","percent of total billed charges",""
"SCREW BONE 5.5MM LOW PROFILE SELF DRILLING HEXAGONAL FIXATION FIXED ANGLE TITANIUM PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","384.74","384.74","384.74","1 through 10","325.5","834.75","percent of total billed charges",""
"SCREW BONE 5.5MM LOW PROFILE SELF DRILLING HEXAGONAL FIXATION FIXED ANGLE TITANIUM PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB AMC WELLPOINT","774.69","73.78","","286.63","119.22","1107.45","105","325.5","834.75","percent of total billed charges",""
"SCREW BONE 5.5MM LOW PROFILE SELF DRILLING HEXAGONAL FIXATION FIXED ANGLE TITANIUM PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA HMO","732.90","69.8","","675.31","184.75","1721.50","286","548.73","858.06","percent of total billed charges",""
"SCREW BONE 5.5MM LOW PROFILE SELF DRILLING HEXAGONAL FIXATION FIXED ANGLE TITANIUM PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA PPO","844.20","80.4","","1261.44","103.12","1514.10","21","548.73","858.06","percent of total billed charges",""
"SCREW BONE 5.5MM LOW PROFILE SELF DRILLING HEXAGONAL FIXATION FIXED ANGLE TITANIUM PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","844.20","80.4","","1365.00","1365.00","1365.00","1 through 10","548.73","858.06","percent of total billed charges",""
"SCREW BONE 5.5MM LOW PROFILE SELF DRILLING HEXAGONAL FIXATION FIXED ANGLE TITANIUM PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","858.06","81.72","","5157.68","5157.68","5157.68","1 through 10","548.73","858.06","percent of total billed charges",""
"SCREW BONE 5.5MM LOW PROFILE SELF DRILLING HEXAGONAL FIXATION FIXED ANGLE TITANIUM PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","858.06","81.72","","431.26","71.26","1459.57","88","548.73","858.06","percent of total billed charges",""
"SCREW BONE 5.5MMX55MM LOW PROFILE PART THREAD TI","SUP-ITM-10154461","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2212.09","79.5","","800.18","480.96","1887.97","195","862.58","2212.09","percent of total billed charges",""
"SCREW BONE 5.5MMX55MM LOW PROFILE PART THREAD TI","SUP-ITM-10154461","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1483.07","53.3","","813.12","216.42","1444.50","81","862.58","2212.09","percent of total billed charges",""
"SCREW BONE 5.5MMX55MM LOW PROFILE PART THREAD TI","SUP-ITM-10154461","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","862.58","31","","432.60","432.60","432.60","1 through 10","862.58","2212.09","percent of total billed charges",""
"SCREW BONE 5.5MMX55MM LOW PROFILE PART THREAD TI","SUP-ITM-10154461","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1015.61","36.5","","148.37","54.89","631.39","94","862.58","2212.09","percent of total billed charges",""
"SCREW BONE 5.5MMX55MM LOW PROFILE PART THREAD TI","SUP-ITM-10154461","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1065.70","38.3","","279.30","91.72","1116.77","266","862.58","2212.09","percent of total billed charges",""
"SCREW BONE 5.5MMX55MM LOW PROFILE PART THREAD TI","SUP-ITM-10154461","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.69","42.9","","731.00","63.70","731.00","1 through 10","862.58","2212.09","percent of total billed charges",""
"SCREW BONE 5.5MMX55MM LOW PROFILE PART THREAD TI","SUP-ITM-10154461","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.69","42.9","","384.74","384.74","384.74","1 through 10","862.58","2212.09","percent of total billed charges",""
"SCREW BONE 5.5MMX55MM LOW PROFILE PART THREAD TI","SUP-ITM-10154461","CDM","C1713","HCPCS","0278","RC","","","","both","","","2782.50","2086.87","WELLPOINT [1015]","HB AMC WELLPOINT","2052.93","73.78","","286.63","119.22","1107.45","105","862.58","2212.09","percent of total billed charges",""
"SCREW BONE 5.5MMX55MM LOW PROFILE PART THREAD TI","SUP-ITM-10154461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","AETNA [1001]","HB AMC AETNA HMO","1942.19","69.8","","675.31","184.75","1721.50","286","1454.13","2273.86","percent of total billed charges",""
"SCREW BONE 5.5MMX55MM LOW PROFILE PART THREAD TI","SUP-ITM-10154461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","AETNA [1001]","HB AMC AETNA PPO","2237.13","80.4","","1261.44","103.12","1514.10","21","1454.13","2273.86","percent of total billed charges",""
"SCREW BONE 5.5MMX55MM LOW PROFILE PART THREAD TI","SUP-ITM-10154461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2237.13","80.4","","1365.00","1365.00","1365.00","1 through 10","1454.13","2273.86","percent of total billed charges",""
"SCREW BONE 5.5MMX55MM LOW PROFILE PART THREAD TI","SUP-ITM-10154461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2273.86","81.72","","5157.68","5157.68","5157.68","1 through 10","1454.13","2273.86","percent of total billed charges",""
"SCREW BONE 5.5MMX55MM LOW PROFILE PART THREAD TI","SUP-ITM-10154461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2782.50","2086.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2273.86","81.72","","431.26","71.26","1459.57","88","1454.13","2273.86","percent of total billed charges",""
"SCREW BONE 5.5X25.0MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF DRILLING FULL THREAD HEADLESS 30-0021","SUP-ITM-10073357","CDM","C1713","HCPCS","0278","RC","","","","both","","","1865.50","1399.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1483.07","79.5","","800.18","480.96","1887.97","195","578.31","1483.07","percent of total billed charges",""
"SCREW BONE 5.5X25.0MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF DRILLING FULL THREAD HEADLESS 30-0021","SUP-ITM-10073357","CDM","C1713","HCPCS","0278","RC","","","","both","","","1865.50","1399.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","994.31","53.3","","813.12","216.42","1444.50","81","578.31","1483.07","percent of total billed charges",""
"SCREW BONE 5.5X25.0MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF DRILLING FULL THREAD HEADLESS 30-0021","SUP-ITM-10073357","CDM","C1713","HCPCS","0278","RC","","","","both","","","1865.50","1399.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","578.31","31","","432.60","432.60","432.60","1 through 10","578.31","1483.07","percent of total billed charges",""
"SCREW BONE 5.5X25.0MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF DRILLING FULL THREAD HEADLESS 30-0021","SUP-ITM-10073357","CDM","C1713","HCPCS","0278","RC","","","","both","","","1865.50","1399.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","680.91","36.5","","148.37","54.89","631.39","94","578.31","1483.07","percent of total billed charges",""
"SCREW BONE 5.5X25.0MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF DRILLING FULL THREAD HEADLESS 30-0021","SUP-ITM-10073357","CDM","C1713","HCPCS","0278","RC","","","","both","","","1865.50","1399.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","714.49","38.3","","279.30","91.72","1116.77","266","578.31","1483.07","percent of total billed charges",""
"SCREW BONE 5.5X25.0MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF DRILLING FULL THREAD HEADLESS 30-0021","SUP-ITM-10073357","CDM","C1713","HCPCS","0278","RC","","","","both","","","1865.50","1399.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.30","42.9","","731.00","63.70","731.00","1 through 10","578.31","1483.07","percent of total billed charges",""
"SCREW BONE 5.5X25.0MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF DRILLING FULL THREAD HEADLESS 30-0021","SUP-ITM-10073357","CDM","C1713","HCPCS","0278","RC","","","","both","","","1865.50","1399.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.30","42.9","","384.74","384.74","384.74","1 through 10","578.31","1483.07","percent of total billed charges",""
"SCREW BONE 5.5X25.0MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF DRILLING FULL THREAD HEADLESS 30-0021","SUP-ITM-10073357","CDM","C1713","HCPCS","0278","RC","","","","both","","","1865.50","1399.12","WELLPOINT [1015]","HB AMC WELLPOINT","1376.37","73.78","","286.63","119.22","1107.45","105","578.31","1483.07","percent of total billed charges",""
"SCREW BONE 5.5X25.0MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF DRILLING FULL THREAD HEADLESS 30-0021","SUP-ITM-10073357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1865.50","1399.12","AETNA [1001]","HB AMC AETNA HMO","1302.12","69.8","","675.31","184.75","1721.50","286","974.91","1524.49","percent of total billed charges",""
"SCREW BONE 5.5X25.0MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF DRILLING FULL THREAD HEADLESS 30-0021","SUP-ITM-10073357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1865.50","1399.12","AETNA [1001]","HB AMC AETNA PPO","1499.86","80.4","","1261.44","103.12","1514.10","21","974.91","1524.49","percent of total billed charges",""
"SCREW BONE 5.5X25.0MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF DRILLING FULL THREAD HEADLESS 30-0021","SUP-ITM-10073357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1865.50","1399.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1499.86","80.4","","1365.00","1365.00","1365.00","1 through 10","974.91","1524.49","percent of total billed charges",""
"SCREW BONE 5.5X25.0MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF DRILLING FULL THREAD HEADLESS 30-0021","SUP-ITM-10073357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1865.50","1399.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1524.49","81.72","","5157.68","5157.68","5157.68","1 through 10","974.91","1524.49","percent of total billed charges",""
"SCREW BONE 5.5X25.0MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF DRILLING FULL THREAD HEADLESS 30-0021","SUP-ITM-10073357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1865.50","1399.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1524.49","81.72","","431.26","71.26","1459.57","88","974.91","1524.49","percent of total billed charges",""
"SCREW BONE 5.5X25MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017849","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","389.77","79.5","","800.18","480.96","1887.97","195","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X25MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017849","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","261.32","53.3","","813.12","216.42","1444.50","81","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X25MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017849","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","151.99","31","","432.60","432.60","432.60","1 through 10","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X25MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017849","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","178.95","36.5","","148.37","54.89","631.39","94","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X25MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017849","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.78","38.3","","279.30","91.72","1116.77","266","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X25MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017849","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","731.00","63.70","731.00","1 through 10","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X25MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017849","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","384.74","384.74","384.74","1 through 10","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X25MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017849","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","WELLPOINT [1015]","HB AMC WELLPOINT","361.73","73.78","","286.63","119.22","1107.45","105","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X25MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA HMO","342.22","69.8","","675.31","184.75","1721.50","286","256.22","400.66","percent of total billed charges",""
"SCREW BONE 5.5X25MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA PPO","394.19","80.4","","1261.44","103.12","1514.10","21","256.22","400.66","percent of total billed charges",""
"SCREW BONE 5.5X25MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","394.19","80.4","","1365.00","1365.00","1365.00","1 through 10","256.22","400.66","percent of total billed charges",""
"SCREW BONE 5.5X25MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","400.66","81.72","","5157.68","5157.68","5157.68","1 through 10","256.22","400.66","percent of total billed charges",""
"SCREW BONE 5.5X25MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10017849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","400.66","81.72","","431.26","71.26","1459.57","88","256.22","400.66","percent of total billed charges",""
"SCREW BONE 5.5X26MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083174","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","631.63","79.5","","800.18","480.96","1887.97","195","246.3","631.63","percent of total billed charges",""
"SCREW BONE 5.5X26MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083174","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","423.47","53.3","","813.12","216.42","1444.50","81","246.3","631.63","percent of total billed charges",""
"SCREW BONE 5.5X26MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083174","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","246.30","31","","432.60","432.60","432.60","1 through 10","246.3","631.63","percent of total billed charges",""
"SCREW BONE 5.5X26MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083174","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","289.99","36.5","","148.37","54.89","631.39","94","246.3","631.63","percent of total billed charges",""
"SCREW BONE 5.5X26MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083174","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","304.29","38.3","","279.30","91.72","1116.77","266","246.3","631.63","percent of total billed charges",""
"SCREW BONE 5.5X26MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083174","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.84","42.9","","731.00","63.70","731.00","1 through 10","246.3","631.63","percent of total billed charges",""
"SCREW BONE 5.5X26MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083174","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.84","42.9","","384.74","384.74","384.74","1 through 10","246.3","631.63","percent of total billed charges",""
"SCREW BONE 5.5X26MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083174","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.50","595.87","WELLPOINT [1015]","HB AMC WELLPOINT","586.18","73.78","","286.63","119.22","1107.45","105","246.3","631.63","percent of total billed charges",""
"SCREW BONE 5.5X26MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083174","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.50","595.87","AETNA [1001]","HB AMC AETNA HMO","554.56","69.8","","675.31","184.75","1721.50","286","415.21","649.27","percent of total billed charges",""
"SCREW BONE 5.5X26MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083174","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.50","595.87","AETNA [1001]","HB AMC AETNA PPO","638.78","80.4","","1261.44","103.12","1514.10","21","415.21","649.27","percent of total billed charges",""
"SCREW BONE 5.5X26MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083174","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.50","595.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","638.78","80.4","","1365.00","1365.00","1365.00","1 through 10","415.21","649.27","percent of total billed charges",""
"SCREW BONE 5.5X26MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083174","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.50","595.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","649.27","81.72","","5157.68","5157.68","5157.68","1 through 10","415.21","649.27","percent of total billed charges",""
"SCREW BONE 5.5X26MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083174","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.50","595.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","649.27","81.72","","431.26","71.26","1459.57","88","415.21","649.27","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","389.77","79.5","","800.18","480.96","1887.97","195","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","261.32","53.3","","813.12","216.42","1444.50","81","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","151.99","31","","432.60","432.60","432.60","1 through 10","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","178.95","36.5","","148.37","54.89","631.39","94","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","187.78","38.3","","279.30","91.72","1116.77","266","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","731.00","63.70","731.00","1 through 10","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.33","42.9","","384.74","384.74","384.74","1 through 10","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.28","367.71","WELLPOINT [1015]","HB AMC WELLPOINT","361.73","73.78","","286.63","119.22","1107.45","105","151.99","389.77","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA HMO","342.22","69.8","","675.31","184.75","1721.50","286","256.22","400.66","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","AETNA [1001]","HB AMC AETNA PPO","394.19","80.4","","1261.44","103.12","1514.10","21","256.22","400.66","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","394.19","80.4","","1365.00","1365.00","1365.00","1 through 10","256.22","400.66","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","400.66","81.72","","5157.68","5157.68","5157.68","1 through 10","256.22","400.66","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.28","367.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","400.66","81.72","","431.26","71.26","1459.57","88","256.22","400.66","percent of total billed charges",""
"SCREW BONE 5.5X4.35X45MM SPINE CORT CANNULATEDFIX TITANIUM PED POLY","SUP-ITM-10138098","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2253.83","79.5","","800.18","480.96","1887.97","195","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X4.35X45MM SPINE CORT CANNULATEDFIX TITANIUM PED POLY","SUP-ITM-10138098","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1511.06","53.3","","813.12","216.42","1444.50","81","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X4.35X45MM SPINE CORT CANNULATEDFIX TITANIUM PED POLY","SUP-ITM-10138098","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","878.85","31","","432.60","432.60","432.60","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X4.35X45MM SPINE CORT CANNULATEDFIX TITANIUM PED POLY","SUP-ITM-10138098","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1034.78","36.5","","148.37","54.89","631.39","94","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X4.35X45MM SPINE CORT CANNULATEDFIX TITANIUM PED POLY","SUP-ITM-10138098","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1085.81","38.3","","279.30","91.72","1116.77","266","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X4.35X45MM SPINE CORT CANNULATEDFIX TITANIUM PED POLY","SUP-ITM-10138098","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","731.00","63.70","731.00","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X4.35X45MM SPINE CORT CANNULATEDFIX TITANIUM PED POLY","SUP-ITM-10138098","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","384.74","384.74","384.74","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X4.35X45MM SPINE CORT CANNULATEDFIX TITANIUM PED POLY","SUP-ITM-10138098","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB AMC WELLPOINT","2091.66","73.78","","286.63","119.22","1107.45","105","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X4.35X45MM SPINE CORT CANNULATEDFIX TITANIUM PED POLY","SUP-ITM-10138098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA HMO","1978.83","69.8","","675.31","184.75","1721.50","286","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X4.35X45MM SPINE CORT CANNULATEDFIX TITANIUM PED POLY","SUP-ITM-10138098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA PPO","2279.34","80.4","","1261.44","103.12","1514.10","21","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X4.35X45MM SPINE CORT CANNULATEDFIX TITANIUM PED POLY","SUP-ITM-10138098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2279.34","80.4","","1365.00","1365.00","1365.00","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X4.35X45MM SPINE CORT CANNULATEDFIX TITANIUM PED POLY","SUP-ITM-10138098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2316.76","81.72","","5157.68","5157.68","5157.68","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X4.35X45MM SPINE CORT CANNULATEDFIX TITANIUM PED POLY","SUP-ITM-10138098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2316.76","81.72","","431.26","71.26","1459.57","88","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X40MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016946","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","415.57","79.5","","800.18","480.96","1887.97","195","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X40MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016946","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","278.62","53.3","","813.12","216.42","1444.50","81","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X40MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016946","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.05","31","","432.60","432.60","432.60","1 through 10","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X40MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016946","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","190.80","36.5","","148.37","54.89","631.39","94","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X40MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016946","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","200.21","38.3","","279.30","91.72","1116.77","266","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X40MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016946","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.25","42.9","","731.00","63.70","731.00","1 through 10","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X40MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016946","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.25","42.9","","384.74","384.74","384.74","1 through 10","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X40MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016946","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","WELLPOINT [1015]","HB AMC WELLPOINT","385.67","73.78","","286.63","119.22","1107.45","105","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X40MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.73","392.05","AETNA [1001]","HB AMC AETNA HMO","364.87","69.8","","675.31","184.75","1721.50","286","273.18","427.17","percent of total billed charges",""
"SCREW BONE 5.5X40MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.73","392.05","AETNA [1001]","HB AMC AETNA PPO","420.27","80.4","","1261.44","103.12","1514.10","21","273.18","427.17","percent of total billed charges",""
"SCREW BONE 5.5X40MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.73","392.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","420.27","80.4","","1365.00","1365.00","1365.00","1 through 10","273.18","427.17","percent of total billed charges",""
"SCREW BONE 5.5X40MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.73","392.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","427.17","81.72","","5157.68","5157.68","5157.68","1 through 10","273.18","427.17","percent of total billed charges",""
"SCREW BONE 5.5X40MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.73","392.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","427.17","81.72","","431.26","71.26","1459.57","88","273.18","427.17","percent of total billed charges",""
"SCREW BONE 5.5X42MM SZ 0 CORTEX VETERINARY QUICKANCHOR","SUP-ITM-10030993","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","820.84","79.5","","800.18","480.96","1887.97","195","320.08","820.84","percent of total billed charges",""
"SCREW BONE 5.5X42MM SZ 0 CORTEX VETERINARY QUICKANCHOR","SUP-ITM-10030993","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","550.32","53.3","","813.12","216.42","1444.50","81","320.08","820.84","percent of total billed charges",""
"SCREW BONE 5.5X42MM SZ 0 CORTEX VETERINARY QUICKANCHOR","SUP-ITM-10030993","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","320.08","31","","432.60","432.60","432.60","1 through 10","320.08","820.84","percent of total billed charges",""
"SCREW BONE 5.5X42MM SZ 0 CORTEX VETERINARY QUICKANCHOR","SUP-ITM-10030993","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","376.86","36.5","","148.37","54.89","631.39","94","320.08","820.84","percent of total billed charges",""
"SCREW BONE 5.5X42MM SZ 0 CORTEX VETERINARY QUICKANCHOR","SUP-ITM-10030993","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","395.45","38.3","","279.30","91.72","1116.77","266","320.08","820.84","percent of total billed charges",""
"SCREW BONE 5.5X42MM SZ 0 CORTEX VETERINARY QUICKANCHOR","SUP-ITM-10030993","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.94","42.9","","731.00","63.70","731.00","1 through 10","320.08","820.84","percent of total billed charges",""
"SCREW BONE 5.5X42MM SZ 0 CORTEX VETERINARY QUICKANCHOR","SUP-ITM-10030993","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.94","42.9","","384.74","384.74","384.74","1 through 10","320.08","820.84","percent of total billed charges",""
"SCREW BONE 5.5X42MM SZ 0 CORTEX VETERINARY QUICKANCHOR","SUP-ITM-10030993","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","WELLPOINT [1015]","HB AMC WELLPOINT","761.78","73.78","","286.63","119.22","1107.45","105","320.08","820.84","percent of total billed charges",""
"SCREW BONE 5.5X42MM SZ 0 CORTEX VETERINARY QUICKANCHOR","SUP-ITM-10030993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","AETNA [1001]","HB AMC AETNA HMO","720.69","69.8","","675.31","184.75","1721.50","286","539.58","843.76","percent of total billed charges",""
"SCREW BONE 5.5X42MM SZ 0 CORTEX VETERINARY QUICKANCHOR","SUP-ITM-10030993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","AETNA [1001]","HB AMC AETNA PPO","830.13","80.4","","1261.44","103.12","1514.10","21","539.58","843.76","percent of total billed charges",""
"SCREW BONE 5.5X42MM SZ 0 CORTEX VETERINARY QUICKANCHOR","SUP-ITM-10030993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","830.13","80.4","","1365.00","1365.00","1365.00","1 through 10","539.58","843.76","percent of total billed charges",""
"SCREW BONE 5.5X42MM SZ 0 CORTEX VETERINARY QUICKANCHOR","SUP-ITM-10030993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","843.76","81.72","","5157.68","5157.68","5157.68","1 through 10","539.58","843.76","percent of total billed charges",""
"SCREW BONE 5.5X42MM SZ 0 CORTEX VETERINARY QUICKANCHOR","SUP-ITM-10030993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","843.76","81.72","","431.26","71.26","1459.57","88","539.58","843.76","percent of total billed charges",""
"SCREW BONE 5.5X45MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10058739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1766.89","79.5","","800.18","480.96","1887.97","195","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 5.5X45MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10058739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1184.59","53.3","","813.12","216.42","1444.50","81","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 5.5X45MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10058739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","688.98","31","","432.60","432.60","432.60","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 5.5X45MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10058739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","811.21","36.5","","148.37","54.89","631.39","94","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 5.5X45MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10058739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","851.22","38.3","","279.30","91.72","1116.77","266","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 5.5X45MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10058739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.45","42.9","","731.00","63.70","731.00","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 5.5X45MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10058739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.45","42.9","","384.74","384.74","384.74","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 5.5X45MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10058739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","WELLPOINT [1015]","HB AMC WELLPOINT","1639.76","73.78","","286.63","119.22","1107.45","105","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 5.5X45MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10058739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","AETNA [1001]","HB AMC AETNA HMO","1551.31","69.8","","675.31","184.75","1721.50","286","1161.48","1816.23","percent of total billed charges",""
"SCREW BONE 5.5X45MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10058739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","AETNA [1001]","HB AMC AETNA PPO","1786.89","80.4","","1261.44","103.12","1514.10","21","1161.48","1816.23","percent of total billed charges",""
"SCREW BONE 5.5X45MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10058739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1786.89","80.4","","1365.00","1365.00","1365.00","1 through 10","1161.48","1816.23","percent of total billed charges",""
"SCREW BONE 5.5X45MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10058739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1816.23","81.72","","5157.68","5157.68","5157.68","1 through 10","1161.48","1816.23","percent of total billed charges",""
"SCREW BONE 5.5X45MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10058739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1816.23","81.72","","431.26","71.26","1459.57","88","1161.48","1816.23","percent of total billed charges",""
"SCREW BONE 5.5X460MM TI STRAIGHT","SUP-ITM-10252440","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.25","597.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","633.02","79.5","","800.18","480.96","1887.97","195","246.84","633.02","percent of total billed charges",""
"SCREW BONE 5.5X460MM TI STRAIGHT","SUP-ITM-10252440","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.25","597.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","424.40","53.3","","813.12","216.42","1444.50","81","246.84","633.02","percent of total billed charges",""
"SCREW BONE 5.5X460MM TI STRAIGHT","SUP-ITM-10252440","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.25","597.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","246.84","31","","432.60","432.60","432.60","1 through 10","246.84","633.02","percent of total billed charges",""
"SCREW BONE 5.5X460MM TI STRAIGHT","SUP-ITM-10252440","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.25","597.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","290.63","36.5","","148.37","54.89","631.39","94","246.84","633.02","percent of total billed charges",""
"SCREW BONE 5.5X460MM TI STRAIGHT","SUP-ITM-10252440","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.25","597.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","304.96","38.3","","279.30","91.72","1116.77","266","246.84","633.02","percent of total billed charges",""
"SCREW BONE 5.5X460MM TI STRAIGHT","SUP-ITM-10252440","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.25","597.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","341.59","42.9","","731.00","63.70","731.00","1 through 10","246.84","633.02","percent of total billed charges",""
"SCREW BONE 5.5X460MM TI STRAIGHT","SUP-ITM-10252440","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.25","597.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","341.59","42.9","","384.74","384.74","384.74","1 through 10","246.84","633.02","percent of total billed charges",""
"SCREW BONE 5.5X460MM TI STRAIGHT","SUP-ITM-10252440","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.25","597.19","WELLPOINT [1015]","HB AMC WELLPOINT","587.47","73.78","","286.63","119.22","1107.45","105","246.84","633.02","percent of total billed charges",""
"SCREW BONE 5.5X460MM TI STRAIGHT","SUP-ITM-10252440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","796.25","597.19","AETNA [1001]","HB AMC AETNA HMO","555.78","69.8","","675.31","184.75","1721.50","286","416.12","650.7","percent of total billed charges",""
"SCREW BONE 5.5X460MM TI STRAIGHT","SUP-ITM-10252440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","796.25","597.19","AETNA [1001]","HB AMC AETNA PPO","640.19","80.4","","1261.44","103.12","1514.10","21","416.12","650.7","percent of total billed charges",""
"SCREW BONE 5.5X460MM TI STRAIGHT","SUP-ITM-10252440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","796.25","597.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","640.19","80.4","","1365.00","1365.00","1365.00","1 through 10","416.12","650.7","percent of total billed charges",""
"SCREW BONE 5.5X460MM TI STRAIGHT","SUP-ITM-10252440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","796.25","597.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","650.70","81.72","","5157.68","5157.68","5157.68","1 through 10","416.12","650.7","percent of total billed charges",""
"SCREW BONE 5.5X460MM TI STRAIGHT","SUP-ITM-10252440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","796.25","597.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","650.70","81.72","","431.26","71.26","1459.57","88","416.12","650.7","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2253.83","79.5","","1309.77","674.56","6049.93","26","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1511.06","53.3","","1901.83","1901.83","2962.25","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1034.78","36.5","","1620.31","1620.31","19908.88","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1085.81","38.3","","352.91","352.91","2046.30","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","9668.75","9668.75","9668.75","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB AMC WELLPOINT","2091.66","73.78","","699.88","384.10","3443.31","33","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA HMO","1978.83","69.8","","1421.24","264.50","4933.46","29","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2279.34","80.4","","1022.97","1022.97","3607.50","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2316.76","81.72","","3010.54","693.88","5019.88","35","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","415.57","79.5","","800.18","480.96","1887.97","195","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","278.62","53.3","","813.12","216.42","1444.50","81","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.05","31","","432.60","432.60","432.60","1 through 10","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","190.80","36.5","","148.37","54.89","631.39","94","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","200.21","38.3","","279.30","91.72","1116.77","266","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.25","42.9","","731.00","63.70","731.00","1 through 10","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.25","42.9","","384.74","384.74","384.74","1 through 10","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.73","392.05","WELLPOINT [1015]","HB AMC WELLPOINT","385.67","73.78","","286.63","119.22","1107.45","105","162.05","415.57","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.73","392.05","AETNA [1001]","HB AMC AETNA HMO","364.87","69.8","","675.31","184.75","1721.50","286","273.18","427.17","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.73","392.05","AETNA [1001]","HB AMC AETNA PPO","420.27","80.4","","1261.44","103.12","1514.10","21","273.18","427.17","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.73","392.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","420.27","80.4","","1365.00","1365.00","1365.00","1 through 10","273.18","427.17","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.73","392.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","427.17","81.72","","5157.68","5157.68","5157.68","1 through 10","273.18","427.17","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.73","392.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","427.17","81.72","","431.26","71.26","1459.57","88","273.18","427.17","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","208.69","79.5","","800.18","480.96","1887.97","195","81.38","208.69","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.91","53.3","","813.12","216.42","1444.50","81","81.38","208.69","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","81.38","31","","432.60","432.60","432.60","1 through 10","81.38","208.69","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.81","36.5","","148.37","54.89","631.39","94","81.38","208.69","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.54","38.3","","279.30","91.72","1116.77","266","81.38","208.69","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.61","42.9","","731.00","63.70","731.00","1 through 10","81.38","208.69","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.61","42.9","","384.74","384.74","384.74","1 through 10","81.38","208.69","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","WELLPOINT [1015]","HB AMC WELLPOINT","193.67","73.78","","286.63","119.22","1107.45","105","81.38","208.69","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","AETNA [1001]","HB AMC AETNA HMO","183.23","69.8","","675.31","184.75","1721.50","286","137.18","214.52","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","AETNA [1001]","HB AMC AETNA PPO","211.05","80.4","","1261.44","103.12","1514.10","21","137.18","214.52","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","211.05","80.4","","1365.00","1365.00","1365.00","1 through 10","137.18","214.52","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","214.52","81.72","","5157.68","5157.68","5157.68","1 through 10","137.18","214.52","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.52","81.72","","431.26","71.26","1459.57","88","137.18","214.52","percent of total billed charges",""
"SCREW BONE 5.5X51MM SPINE CANCELLOUS TITANIUM LOCKING GREEN","SUP-ITM-10032824","CDM","C1889","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","278.25","79.5","","1309.77","674.56","6049.93","26","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5.5X51MM SPINE CANCELLOUS TITANIUM LOCKING GREEN","SUP-ITM-10032824","CDM","C1889","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","186.55","53.3","","1901.83","1901.83","2962.25","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5.5X51MM SPINE CANCELLOUS TITANIUM LOCKING GREEN","SUP-ITM-10032824","CDM","C1889","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.75","36.5","","1620.31","1620.31","19908.88","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5.5X51MM SPINE CANCELLOUS TITANIUM LOCKING GREEN","SUP-ITM-10032824","CDM","C1889","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","134.05","38.3","","352.91","352.91","2046.30","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5.5X51MM SPINE CANCELLOUS TITANIUM LOCKING GREEN","SUP-ITM-10032824","CDM","C1889","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","9668.75","9668.75","9668.75","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5.5X51MM SPINE CANCELLOUS TITANIUM LOCKING GREEN","SUP-ITM-10032824","CDM","C1889","HCPCS","0278","RC","","","","both","","","350.00","262.50","WELLPOINT [1015]","HB AMC WELLPOINT","258.23","73.78","","699.88","384.10","3443.31","33","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5.5X51MM SPINE CANCELLOUS TITANIUM LOCKING GREEN","SUP-ITM-10032824","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA HMO","244.30","69.8","","1421.24","264.50","4933.46","29","182.91","286.02","percent of total billed charges",""
"SCREW BONE 5.5X51MM SPINE CANCELLOUS TITANIUM LOCKING GREEN","SUP-ITM-10032824","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","281.40","80.4","","1022.97","1022.97","3607.50","1 through 10","182.91","286.02","percent of total billed charges",""
"SCREW BONE 5.5X51MM SPINE CANCELLOUS TITANIUM LOCKING GREEN","SUP-ITM-10032824","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","286.02","81.72","","3010.54","693.88","5019.88","35","182.91","286.02","percent of total billed charges",""
"SCREW BONE 5.5X55MM TITANIUM CANCELLOUS LOCKING FULL THREAD SELF TAPPING","SUP-ITM-10028114","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.40","405.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","429.62","79.5","","800.18","480.96","1887.97","195","167.52","429.62","percent of total billed charges",""
"SCREW BONE 5.5X55MM TITANIUM CANCELLOUS LOCKING FULL THREAD SELF TAPPING","SUP-ITM-10028114","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.40","405.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","288.03","53.3","","813.12","216.42","1444.50","81","167.52","429.62","percent of total billed charges",""
"SCREW BONE 5.5X55MM TITANIUM CANCELLOUS LOCKING FULL THREAD SELF TAPPING","SUP-ITM-10028114","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.40","405.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","167.52","31","","432.60","432.60","432.60","1 through 10","167.52","429.62","percent of total billed charges",""
"SCREW BONE 5.5X55MM TITANIUM CANCELLOUS LOCKING FULL THREAD SELF TAPPING","SUP-ITM-10028114","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.40","405.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","197.25","36.5","","148.37","54.89","631.39","94","167.52","429.62","percent of total billed charges",""
"SCREW BONE 5.5X55MM TITANIUM CANCELLOUS LOCKING FULL THREAD SELF TAPPING","SUP-ITM-10028114","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.40","405.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","206.97","38.3","","279.30","91.72","1116.77","266","167.52","429.62","percent of total billed charges",""
"SCREW BONE 5.5X55MM TITANIUM CANCELLOUS LOCKING FULL THREAD SELF TAPPING","SUP-ITM-10028114","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.40","405.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.83","42.9","","731.00","63.70","731.00","1 through 10","167.52","429.62","percent of total billed charges",""
"SCREW BONE 5.5X55MM TITANIUM CANCELLOUS LOCKING FULL THREAD SELF TAPPING","SUP-ITM-10028114","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.40","405.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.83","42.9","","384.74","384.74","384.74","1 through 10","167.52","429.62","percent of total billed charges",""
"SCREW BONE 5.5X55MM TITANIUM CANCELLOUS LOCKING FULL THREAD SELF TAPPING","SUP-ITM-10028114","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.40","405.30","WELLPOINT [1015]","HB AMC WELLPOINT","398.71","73.78","","286.63","119.22","1107.45","105","167.52","429.62","percent of total billed charges",""
"SCREW BONE 5.5X55MM TITANIUM CANCELLOUS LOCKING FULL THREAD SELF TAPPING","SUP-ITM-10028114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.40","405.30","AETNA [1001]","HB AMC AETNA HMO","377.20","69.8","","675.31","184.75","1721.50","286","282.41","441.61","percent of total billed charges",""
"SCREW BONE 5.5X55MM TITANIUM CANCELLOUS LOCKING FULL THREAD SELF TAPPING","SUP-ITM-10028114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.40","405.30","AETNA [1001]","HB AMC AETNA PPO","434.48","80.4","","1261.44","103.12","1514.10","21","282.41","441.61","percent of total billed charges",""
"SCREW BONE 5.5X55MM TITANIUM CANCELLOUS LOCKING FULL THREAD SELF TAPPING","SUP-ITM-10028114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.40","405.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","434.48","80.4","","1365.00","1365.00","1365.00","1 through 10","282.41","441.61","percent of total billed charges",""
"SCREW BONE 5.5X55MM TITANIUM CANCELLOUS LOCKING FULL THREAD SELF TAPPING","SUP-ITM-10028114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.40","405.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","441.61","81.72","","5157.68","5157.68","5157.68","1 through 10","282.41","441.61","percent of total billed charges",""
"SCREW BONE 5.5X55MM TITANIUM CANCELLOUS LOCKING FULL THREAD SELF TAPPING","SUP-ITM-10028114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.40","405.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","441.61","81.72","","431.26","71.26","1459.57","88","282.41","441.61","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2253.83","79.5","","800.18","480.96","1887.97","195","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1511.06","53.3","","813.12","216.42","1444.50","81","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","878.85","31","","432.60","432.60","432.60","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1034.78","36.5","","148.37","54.89","631.39","94","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1085.81","38.3","","279.30","91.72","1116.77","266","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","731.00","63.70","731.00","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","384.74","384.74","384.74","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB AMC WELLPOINT","2091.66","73.78","","286.63","119.22","1107.45","105","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA HMO","1978.83","69.8","","675.31","184.75","1721.50","286","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA PPO","2279.34","80.4","","1261.44","103.12","1514.10","21","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2279.34","80.4","","1365.00","1365.00","1365.00","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2316.76","81.72","","5157.68","5157.68","5157.68","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2316.76","81.72","","431.26","71.26","1459.57","88","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2253.83","79.5","","1309.77","674.56","6049.93","26","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1511.06","53.3","","1901.83","1901.83","2962.25","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1034.78","36.5","","1620.31","1620.31","19908.88","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1085.81","38.3","","352.91","352.91","2046.30","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","9668.75","9668.75","9668.75","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB AMC WELLPOINT","2091.66","73.78","","699.88","384.10","3443.31","33","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA HMO","1978.83","69.8","","1421.24","264.50","4933.46","29","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2279.34","80.4","","1022.97","1022.97","3607.50","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2316.76","81.72","","3010.54","693.88","5019.88","35","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2253.83","79.5","","1309.77","674.56","6049.93","26","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1511.06","53.3","","1901.83","1901.83","2962.25","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1034.78","36.5","","1620.31","1620.31","19908.88","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1085.81","38.3","","352.91","352.91","2046.30","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","9668.75","9668.75","9668.75","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB AMC WELLPOINT","2091.66","73.78","","699.88","384.10","3443.31","33","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA HMO","1978.83","69.8","","1421.24","264.50","4933.46","29","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2279.34","80.4","","1022.97","1022.97","3607.50","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2316.76","81.72","","3010.54","693.88","5019.88","35","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 5.5X90MM CORTICAL FT STD NON CANNULATEDPROXIMALIMAL VERSANAIL","SUP-ITM-10021801","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.20","555.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","589.25","79.5","","800.18","480.96","1887.97","195","229.77","589.25","percent of total billed charges",""
"SCREW BONE 5.5X90MM CORTICAL FT STD NON CANNULATEDPROXIMALIMAL VERSANAIL","SUP-ITM-10021801","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.20","555.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","395.06","53.3","","813.12","216.42","1444.50","81","229.77","589.25","percent of total billed charges",""
"SCREW BONE 5.5X90MM CORTICAL FT STD NON CANNULATEDPROXIMALIMAL VERSANAIL","SUP-ITM-10021801","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.20","555.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","229.77","31","","432.60","432.60","432.60","1 through 10","229.77","589.25","percent of total billed charges",""
"SCREW BONE 5.5X90MM CORTICAL FT STD NON CANNULATEDPROXIMALIMAL VERSANAIL","SUP-ITM-10021801","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.20","555.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","270.54","36.5","","148.37","54.89","631.39","94","229.77","589.25","percent of total billed charges",""
"SCREW BONE 5.5X90MM CORTICAL FT STD NON CANNULATEDPROXIMALIMAL VERSANAIL","SUP-ITM-10021801","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.20","555.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","283.88","38.3","","279.30","91.72","1116.77","266","229.77","589.25","percent of total billed charges",""
"SCREW BONE 5.5X90MM CORTICAL FT STD NON CANNULATEDPROXIMALIMAL VERSANAIL","SUP-ITM-10021801","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.20","555.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","317.97","42.9","","731.00","63.70","731.00","1 through 10","229.77","589.25","percent of total billed charges",""
"SCREW BONE 5.5X90MM CORTICAL FT STD NON CANNULATEDPROXIMALIMAL VERSANAIL","SUP-ITM-10021801","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.20","555.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","317.97","42.9","","384.74","384.74","384.74","1 through 10","229.77","589.25","percent of total billed charges",""
"SCREW BONE 5.5X90MM CORTICAL FT STD NON CANNULATEDPROXIMALIMAL VERSANAIL","SUP-ITM-10021801","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.20","555.90","WELLPOINT [1015]","HB AMC WELLPOINT","546.86","73.78","","286.63","119.22","1107.45","105","229.77","589.25","percent of total billed charges",""
"SCREW BONE 5.5X90MM CORTICAL FT STD NON CANNULATEDPROXIMALIMAL VERSANAIL","SUP-ITM-10021801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.20","555.90","AETNA [1001]","HB AMC AETNA HMO","517.36","69.8","","675.31","184.75","1721.50","286","387.35","605.71","percent of total billed charges",""
"SCREW BONE 5.5X90MM CORTICAL FT STD NON CANNULATEDPROXIMALIMAL VERSANAIL","SUP-ITM-10021801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.20","555.90","AETNA [1001]","HB AMC AETNA PPO","595.92","80.4","","1261.44","103.12","1514.10","21","387.35","605.71","percent of total billed charges",""
"SCREW BONE 5.5X90MM CORTICAL FT STD NON CANNULATEDPROXIMALIMAL VERSANAIL","SUP-ITM-10021801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.20","555.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","595.92","80.4","","1365.00","1365.00","1365.00","1 through 10","387.35","605.71","percent of total billed charges",""
"SCREW BONE 5.5X90MM CORTICAL FT STD NON CANNULATEDPROXIMALIMAL VERSANAIL","SUP-ITM-10021801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.20","555.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","605.71","81.72","","5157.68","5157.68","5157.68","1 through 10","387.35","605.71","percent of total billed charges",""
"SCREW BONE 5.5X90MM CORTICAL FT STD NON CANNULATEDPROXIMALIMAL VERSANAIL","SUP-ITM-10021801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.20","555.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","605.71","81.72","","431.26","71.26","1459.57","88","387.35","605.71","percent of total billed charges",""
"SCREW BONE 50.0X5.0MM CORTICAL NCB PROTASUL 64 SELF TAPPING","SUP-ITM-10023057","CDM","C1713","HCPCS","0278","RC","","","","both","","","545.09","408.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","433.35","79.5","","800.18","480.96","1887.97","195","168.98","433.35","percent of total billed charges",""
"SCREW BONE 50.0X5.0MM CORTICAL NCB PROTASUL 64 SELF TAPPING","SUP-ITM-10023057","CDM","C1713","HCPCS","0278","RC","","","","both","","","545.09","408.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","290.53","53.3","","813.12","216.42","1444.50","81","168.98","433.35","percent of total billed charges",""
"SCREW BONE 50.0X5.0MM CORTICAL NCB PROTASUL 64 SELF TAPPING","SUP-ITM-10023057","CDM","C1713","HCPCS","0278","RC","","","","both","","","545.09","408.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","168.98","31","","432.60","432.60","432.60","1 through 10","168.98","433.35","percent of total billed charges",""
"SCREW BONE 50.0X5.0MM CORTICAL NCB PROTASUL 64 SELF TAPPING","SUP-ITM-10023057","CDM","C1713","HCPCS","0278","RC","","","","both","","","545.09","408.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","198.96","36.5","","148.37","54.89","631.39","94","168.98","433.35","percent of total billed charges",""
"SCREW BONE 50.0X5.0MM CORTICAL NCB PROTASUL 64 SELF TAPPING","SUP-ITM-10023057","CDM","C1713","HCPCS","0278","RC","","","","both","","","545.09","408.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","208.77","38.3","","279.30","91.72","1116.77","266","168.98","433.35","percent of total billed charges",""
"SCREW BONE 50.0X5.0MM CORTICAL NCB PROTASUL 64 SELF TAPPING","SUP-ITM-10023057","CDM","C1713","HCPCS","0278","RC","","","","both","","","545.09","408.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","233.84","42.9","","731.00","63.70","731.00","1 through 10","168.98","433.35","percent of total billed charges",""
"SCREW BONE 50.0X5.0MM CORTICAL NCB PROTASUL 64 SELF TAPPING","SUP-ITM-10023057","CDM","C1713","HCPCS","0278","RC","","","","both","","","545.09","408.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","233.84","42.9","","384.74","384.74","384.74","1 through 10","168.98","433.35","percent of total billed charges",""
"SCREW BONE 50.0X5.0MM CORTICAL NCB PROTASUL 64 SELF TAPPING","SUP-ITM-10023057","CDM","C1713","HCPCS","0278","RC","","","","both","","","545.09","408.82","WELLPOINT [1015]","HB AMC WELLPOINT","402.17","73.78","","286.63","119.22","1107.45","105","168.98","433.35","percent of total billed charges",""
"SCREW BONE 50.0X5.0MM CORTICAL NCB PROTASUL 64 SELF TAPPING","SUP-ITM-10023057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","545.09","408.82","AETNA [1001]","HB AMC AETNA HMO","380.47","69.8","","675.31","184.75","1721.50","286","284.86","445.45","percent of total billed charges",""
"SCREW BONE 50.0X5.0MM CORTICAL NCB PROTASUL 64 SELF TAPPING","SUP-ITM-10023057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","545.09","408.82","AETNA [1001]","HB AMC AETNA PPO","438.25","80.4","","1261.44","103.12","1514.10","21","284.86","445.45","percent of total billed charges",""
"SCREW BONE 50.0X5.0MM CORTICAL NCB PROTASUL 64 SELF TAPPING","SUP-ITM-10023057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","545.09","408.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","438.25","80.4","","1365.00","1365.00","1365.00","1 through 10","284.86","445.45","percent of total billed charges",""
"SCREW BONE 50.0X5.0MM CORTICAL NCB PROTASUL 64 SELF TAPPING","SUP-ITM-10023057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","545.09","408.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","445.45","81.72","","5157.68","5157.68","5157.68","1 through 10","284.86","445.45","percent of total billed charges",""
"SCREW BONE 50.0X5.0MM CORTICAL NCB PROTASUL 64 SELF TAPPING","SUP-ITM-10023057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","545.09","408.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","445.45","81.72","","431.26","71.26","1459.57","88","284.86","445.45","percent of total billed charges",""
"SCREW BONE 50MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10028108","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","97.44","79.5","","800.18","480.96","1887.97","195","38","97.44","percent of total billed charges",""
"SCREW BONE 50MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10028108","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","65.33","53.3","","813.12","216.42","1444.50","81","38","97.44","percent of total billed charges",""
"SCREW BONE 50MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10028108","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","38.00","31","","432.60","432.60","432.60","1 through 10","38","97.44","percent of total billed charges",""
"SCREW BONE 50MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10028108","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.74","36.5","","148.37","54.89","631.39","94","38","97.44","percent of total billed charges",""
"SCREW BONE 50MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10028108","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.94","38.3","","279.30","91.72","1116.77","266","38","97.44","percent of total billed charges",""
"SCREW BONE 50MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10028108","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.58","42.9","","731.00","63.70","731.00","1 through 10","38","97.44","percent of total billed charges",""
"SCREW BONE 50MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10028108","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.58","42.9","","384.74","384.74","384.74","1 through 10","38","97.44","percent of total billed charges",""
"SCREW BONE 50MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10028108","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.57","91.93","WELLPOINT [1015]","HB AMC WELLPOINT","90.43","73.78","","286.63","119.22","1107.45","105","38","97.44","percent of total billed charges",""
"SCREW BONE 50MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10028108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.57","91.93","AETNA [1001]","HB AMC AETNA HMO","85.55","69.8","","675.31","184.75","1721.50","286","64.06","100.16","percent of total billed charges",""
"SCREW BONE 50MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10028108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.57","91.93","AETNA [1001]","HB AMC AETNA PPO","98.55","80.4","","1261.44","103.12","1514.10","21","64.06","100.16","percent of total billed charges",""
"SCREW BONE 50MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10028108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.57","91.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","98.55","80.4","","1365.00","1365.00","1365.00","1 through 10","64.06","100.16","percent of total billed charges",""
"SCREW BONE 50MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10028108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.57","91.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","100.16","81.72","","5157.68","5157.68","5157.68","1 through 10","64.06","100.16","percent of total billed charges",""
"SCREW BONE 50MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10028108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.57","91.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","100.16","81.72","","431.26","71.26","1459.57","88","64.06","100.16","percent of total billed charges",""
"SCREW BONE 55X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080156","CDM","C1713","HCPCS","0278","RC","","","","both","","","325.50","244.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","258.77","79.5","","800.18","480.96","1887.97","195","100.91","258.77","percent of total billed charges",""
"SCREW BONE 55X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080156","CDM","C1713","HCPCS","0278","RC","","","","both","","","325.50","244.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.49","53.3","","813.12","216.42","1444.50","81","100.91","258.77","percent of total billed charges",""
"SCREW BONE 55X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080156","CDM","C1713","HCPCS","0278","RC","","","","both","","","325.50","244.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","100.91","31","","432.60","432.60","432.60","1 through 10","100.91","258.77","percent of total billed charges",""
"SCREW BONE 55X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080156","CDM","C1713","HCPCS","0278","RC","","","","both","","","325.50","244.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.81","36.5","","148.37","54.89","631.39","94","100.91","258.77","percent of total billed charges",""
"SCREW BONE 55X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080156","CDM","C1713","HCPCS","0278","RC","","","","both","","","325.50","244.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","124.67","38.3","","279.30","91.72","1116.77","266","100.91","258.77","percent of total billed charges",""
"SCREW BONE 55X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080156","CDM","C1713","HCPCS","0278","RC","","","","both","","","325.50","244.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","139.64","42.9","","731.00","63.70","731.00","1 through 10","100.91","258.77","percent of total billed charges",""
"SCREW BONE 55X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080156","CDM","C1713","HCPCS","0278","RC","","","","both","","","325.50","244.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","139.64","42.9","","384.74","384.74","384.74","1 through 10","100.91","258.77","percent of total billed charges",""
"SCREW BONE 55X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080156","CDM","C1713","HCPCS","0278","RC","","","","both","","","325.50","244.12","WELLPOINT [1015]","HB AMC WELLPOINT","240.15","73.78","","286.63","119.22","1107.45","105","100.91","258.77","percent of total billed charges",""
"SCREW BONE 55X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","325.50","244.12","AETNA [1001]","HB AMC AETNA HMO","227.20","69.8","","675.31","184.75","1721.50","286","170.11","266","percent of total billed charges",""
"SCREW BONE 55X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","325.50","244.12","AETNA [1001]","HB AMC AETNA PPO","261.70","80.4","","1261.44","103.12","1514.10","21","170.11","266","percent of total billed charges",""
"SCREW BONE 55X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","325.50","244.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","261.70","80.4","","1365.00","1365.00","1365.00","1 through 10","170.11","266","percent of total billed charges",""
"SCREW BONE 55X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","325.50","244.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","266.00","81.72","","5157.68","5157.68","5157.68","1 through 10","170.11","266","percent of total billed charges",""
"SCREW BONE 55X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","325.50","244.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","266.00","81.72","","431.26","71.26","1459.57","88","170.11","266","percent of total billed charges",""
"SCREW BONE 55X5.5MM CANNULATED LOW PROFILE NONLOCKING","SUP-ITM-10153874","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","208.69","79.5","","800.18","480.96","1887.97","195","81.38","208.69","percent of total billed charges",""
"SCREW BONE 55X5.5MM CANNULATED LOW PROFILE NONLOCKING","SUP-ITM-10153874","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.91","53.3","","813.12","216.42","1444.50","81","81.38","208.69","percent of total billed charges",""
"SCREW BONE 55X5.5MM CANNULATED LOW PROFILE NONLOCKING","SUP-ITM-10153874","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","81.38","31","","432.60","432.60","432.60","1 through 10","81.38","208.69","percent of total billed charges",""
"SCREW BONE 55X5.5MM CANNULATED LOW PROFILE NONLOCKING","SUP-ITM-10153874","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.81","36.5","","148.37","54.89","631.39","94","81.38","208.69","percent of total billed charges",""
"SCREW BONE 55X5.5MM CANNULATED LOW PROFILE NONLOCKING","SUP-ITM-10153874","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.54","38.3","","279.30","91.72","1116.77","266","81.38","208.69","percent of total billed charges",""
"SCREW BONE 55X5.5MM CANNULATED LOW PROFILE NONLOCKING","SUP-ITM-10153874","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.61","42.9","","731.00","63.70","731.00","1 through 10","81.38","208.69","percent of total billed charges",""
"SCREW BONE 55X5.5MM CANNULATED LOW PROFILE NONLOCKING","SUP-ITM-10153874","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.61","42.9","","384.74","384.74","384.74","1 through 10","81.38","208.69","percent of total billed charges",""
"SCREW BONE 55X5.5MM CANNULATED LOW PROFILE NONLOCKING","SUP-ITM-10153874","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.50","196.87","WELLPOINT [1015]","HB AMC WELLPOINT","193.67","73.78","","286.63","119.22","1107.45","105","81.38","208.69","percent of total billed charges",""
"SCREW BONE 55X5.5MM CANNULATED LOW PROFILE NONLOCKING","SUP-ITM-10153874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","AETNA [1001]","HB AMC AETNA HMO","183.23","69.8","","675.31","184.75","1721.50","286","137.18","214.52","percent of total billed charges",""
"SCREW BONE 55X5.5MM CANNULATED LOW PROFILE NONLOCKING","SUP-ITM-10153874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","AETNA [1001]","HB AMC AETNA PPO","211.05","80.4","","1261.44","103.12","1514.10","21","137.18","214.52","percent of total billed charges",""
"SCREW BONE 55X5.5MM CANNULATED LOW PROFILE NONLOCKING","SUP-ITM-10153874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","211.05","80.4","","1365.00","1365.00","1365.00","1 through 10","137.18","214.52","percent of total billed charges",""
"SCREW BONE 55X5.5MM CANNULATED LOW PROFILE NONLOCKING","SUP-ITM-10153874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","214.52","81.72","","5157.68","5157.68","5157.68","1 through 10","137.18","214.52","percent of total billed charges",""
"SCREW BONE 55X5.5MM CANNULATED LOW PROFILE NONLOCKING","SUP-ITM-10153874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.50","196.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.52","81.72","","431.26","71.26","1459.57","88","137.18","214.52","percent of total billed charges",""
"SCREW BONE 55X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023068","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.36","380.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.35","79.5","","800.18","480.96","1887.97","195","157.28","403.35","percent of total billed charges",""
"SCREW BONE 55X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023068","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.36","380.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.42","53.3","","813.12","216.42","1444.50","81","157.28","403.35","percent of total billed charges",""
"SCREW BONE 55X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023068","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.36","380.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","157.28","31","","432.60","432.60","432.60","1 through 10","157.28","403.35","percent of total billed charges",""
"SCREW BONE 55X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023068","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.36","380.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.19","36.5","","148.37","54.89","631.39","94","157.28","403.35","percent of total billed charges",""
"SCREW BONE 55X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023068","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.36","380.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.32","38.3","","279.30","91.72","1116.77","266","157.28","403.35","percent of total billed charges",""
"SCREW BONE 55X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023068","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.36","380.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.66","42.9","","731.00","63.70","731.00","1 through 10","157.28","403.35","percent of total billed charges",""
"SCREW BONE 55X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023068","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.36","380.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.66","42.9","","384.74","384.74","384.74","1 through 10","157.28","403.35","percent of total billed charges",""
"SCREW BONE 55X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023068","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.36","380.52","WELLPOINT [1015]","HB AMC WELLPOINT","374.33","73.78","","286.63","119.22","1107.45","105","157.28","403.35","percent of total billed charges",""
"SCREW BONE 55X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","507.36","380.52","AETNA [1001]","HB AMC AETNA HMO","354.14","69.8","","675.31","184.75","1721.50","286","265.15","414.61","percent of total billed charges",""
"SCREW BONE 55X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","507.36","380.52","AETNA [1001]","HB AMC AETNA PPO","407.92","80.4","","1261.44","103.12","1514.10","21","265.15","414.61","percent of total billed charges",""
"SCREW BONE 55X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","507.36","380.52","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","407.92","80.4","","1365.00","1365.00","1365.00","1 through 10","265.15","414.61","percent of total billed charges",""
"SCREW BONE 55X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","507.36","380.52","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","414.61","81.72","","5157.68","5157.68","5157.68","1 through 10","265.15","414.61","percent of total billed charges",""
"SCREW BONE 55X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","507.36","380.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","414.61","81.72","","431.26","71.26","1459.57","88","265.15","414.61","percent of total billed charges",""
"SCREW BONE 5X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 40MM THREAD","SUP-ITM-10038640","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","326.78","79.5","","800.18","480.96","1887.97","195","127.42","326.78","percent of total billed charges",""
"SCREW BONE 5X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 40MM THREAD","SUP-ITM-10038640","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","219.08","53.3","","813.12","216.42","1444.50","81","127.42","326.78","percent of total billed charges",""
"SCREW BONE 5X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 40MM THREAD","SUP-ITM-10038640","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","127.42","31","","432.60","432.60","432.60","1 through 10","127.42","326.78","percent of total billed charges",""
"SCREW BONE 5X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 40MM THREAD","SUP-ITM-10038640","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","150.03","36.5","","148.37","54.89","631.39","94","127.42","326.78","percent of total billed charges",""
"SCREW BONE 5X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 40MM THREAD","SUP-ITM-10038640","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.43","38.3","","279.30","91.72","1116.77","266","127.42","326.78","percent of total billed charges",""
"SCREW BONE 5X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 40MM THREAD","SUP-ITM-10038640","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.34","42.9","","731.00","63.70","731.00","1 through 10","127.42","326.78","percent of total billed charges",""
"SCREW BONE 5X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 40MM THREAD","SUP-ITM-10038640","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.34","42.9","","384.74","384.74","384.74","1 through 10","127.42","326.78","percent of total billed charges",""
"SCREW BONE 5X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 40MM THREAD","SUP-ITM-10038640","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.04","308.28","WELLPOINT [1015]","HB AMC WELLPOINT","303.27","73.78","","286.63","119.22","1107.45","105","127.42","326.78","percent of total billed charges",""
"SCREW BONE 5X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 40MM THREAD","SUP-ITM-10038640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.04","308.28","AETNA [1001]","HB AMC AETNA HMO","286.91","69.8","","675.31","184.75","1721.50","286","214.81","335.9","percent of total billed charges",""
"SCREW BONE 5X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 40MM THREAD","SUP-ITM-10038640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.04","308.28","AETNA [1001]","HB AMC AETNA PPO","330.48","80.4","","1261.44","103.12","1514.10","21","214.81","335.9","percent of total billed charges",""
"SCREW BONE 5X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 40MM THREAD","SUP-ITM-10038640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.04","308.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","330.48","80.4","","1365.00","1365.00","1365.00","1 through 10","214.81","335.9","percent of total billed charges",""
"SCREW BONE 5X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 40MM THREAD","SUP-ITM-10038640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.04","308.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","335.90","81.72","","5157.68","5157.68","5157.68","1 through 10","214.81","335.9","percent of total billed charges",""
"SCREW BONE 5X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 40MM THREAD","SUP-ITM-10038640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.04","308.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","335.90","81.72","","431.26","71.26","1459.57","88","214.81","335.9","percent of total billed charges",""
"SCREW BONE 5X10MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036560","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.22","501.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","531.23","79.5","","800.18","480.96","1887.97","195","207.15","531.23","percent of total billed charges",""
"SCREW BONE 5X10MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036560","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.22","501.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","356.16","53.3","","813.12","216.42","1444.50","81","207.15","531.23","percent of total billed charges",""
"SCREW BONE 5X10MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036560","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.22","501.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","207.15","31","","432.60","432.60","432.60","1 through 10","207.15","531.23","percent of total billed charges",""
"SCREW BONE 5X10MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036560","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.22","501.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","243.90","36.5","","148.37","54.89","631.39","94","207.15","531.23","percent of total billed charges",""
"SCREW BONE 5X10MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036560","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.22","501.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","255.93","38.3","","279.30","91.72","1116.77","266","207.15","531.23","percent of total billed charges",""
"SCREW BONE 5X10MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036560","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.22","501.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","286.67","42.9","","731.00","63.70","731.00","1 through 10","207.15","531.23","percent of total billed charges",""
"SCREW BONE 5X10MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036560","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.22","501.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","286.67","42.9","","384.74","384.74","384.74","1 through 10","207.15","531.23","percent of total billed charges",""
"SCREW BONE 5X10MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036560","CDM","C1713","HCPCS","0278","RC","","","","both","","","668.22","501.16","WELLPOINT [1015]","HB AMC WELLPOINT","493.01","73.78","","286.63","119.22","1107.45","105","207.15","531.23","percent of total billed charges",""
"SCREW BONE 5X10MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.22","501.16","AETNA [1001]","HB AMC AETNA HMO","466.42","69.8","","675.31","184.75","1721.50","286","349.21","546.07","percent of total billed charges",""
"SCREW BONE 5X10MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.22","501.16","AETNA [1001]","HB AMC AETNA PPO","537.25","80.4","","1261.44","103.12","1514.10","21","349.21","546.07","percent of total billed charges",""
"SCREW BONE 5X10MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.22","501.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","537.25","80.4","","1365.00","1365.00","1365.00","1 through 10","349.21","546.07","percent of total billed charges",""
"SCREW BONE 5X10MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.22","501.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","546.07","81.72","","5157.68","5157.68","5157.68","1 through 10","349.21","546.07","percent of total billed charges",""
"SCREW BONE 5X10MM SS PERIPROSTHESIS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10036560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","668.22","501.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","546.07","81.72","","431.26","71.26","1459.57","88","349.21","546.07","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","164.72","79.5","","800.18","480.96","1887.97","195","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","110.44","53.3","","813.12","216.42","1444.50","81","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","64.23","31","","432.60","432.60","432.60","1 through 10","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","75.63","36.5","","148.37","54.89","631.39","94","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","79.36","38.3","","279.30","91.72","1116.77","266","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.89","42.9","","731.00","63.70","731.00","1 through 10","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.89","42.9","","384.74","384.74","384.74","1 through 10","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","WELLPOINT [1015]","HB AMC WELLPOINT","152.87","73.78","","286.63","119.22","1107.45","105","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","AETNA [1001]","HB AMC AETNA HMO","144.63","69.8","","675.31","184.75","1721.50","286","108.28","169.32","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","AETNA [1001]","HB AMC AETNA PPO","166.59","80.4","","1261.44","103.12","1514.10","21","108.28","169.32","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","166.59","80.4","","1365.00","1365.00","1365.00","1 through 10","108.28","169.32","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","169.32","81.72","","5157.68","5157.68","5157.68","1 through 10","108.28","169.32","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","169.32","81.72","","431.26","71.26","1459.57","88","108.28","169.32","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","164.72","79.5","","800.18","480.96","1887.97","195","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","110.44","53.3","","813.12","216.42","1444.50","81","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","64.23","31","","432.60","432.60","432.60","1 through 10","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","75.63","36.5","","148.37","54.89","631.39","94","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","79.36","38.3","","279.30","91.72","1116.77","266","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.89","42.9","","731.00","63.70","731.00","1 through 10","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.89","42.9","","384.74","384.74","384.74","1 through 10","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.20","155.40","WELLPOINT [1015]","HB AMC WELLPOINT","152.87","73.78","","286.63","119.22","1107.45","105","64.23","164.72","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","AETNA [1001]","HB AMC AETNA HMO","144.63","69.8","","675.31","184.75","1721.50","286","108.28","169.32","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","AETNA [1001]","HB AMC AETNA PPO","166.59","80.4","","1261.44","103.12","1514.10","21","108.28","169.32","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","166.59","80.4","","1365.00","1365.00","1365.00","1 through 10","108.28","169.32","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","169.32","81.72","","5157.68","5157.68","5157.68","1 through 10","108.28","169.32","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.20","155.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","169.32","81.72","","431.26","71.26","1459.57","88","108.28","169.32","percent of total billed charges",""
"SCREW BONE 5X12MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273916","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","619.77","79.5","","800.18","480.96","1887.97","195","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X12MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273916","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","415.52","53.3","","813.12","216.42","1444.50","81","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X12MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273916","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","241.67","31","","432.60","432.60","432.60","1 through 10","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X12MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273916","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","284.55","36.5","","148.37","54.89","631.39","94","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X12MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273916","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","298.58","38.3","","279.30","91.72","1116.77","266","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X12MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273916","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","334.44","42.9","","731.00","63.70","731.00","1 through 10","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X12MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273916","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","334.44","42.9","","384.74","384.74","384.74","1 through 10","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X12MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273916","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","WELLPOINT [1015]","HB AMC WELLPOINT","575.18","73.78","","286.63","119.22","1107.45","105","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X12MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.59","584.69","AETNA [1001]","HB AMC AETNA HMO","544.15","69.8","","675.31","184.75","1721.50","286","407.41","637.08","percent of total billed charges",""
"SCREW BONE 5X12MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.59","584.69","AETNA [1001]","HB AMC AETNA PPO","626.79","80.4","","1261.44","103.12","1514.10","21","407.41","637.08","percent of total billed charges",""
"SCREW BONE 5X12MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.59","584.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","626.79","80.4","","1365.00","1365.00","1365.00","1 through 10","407.41","637.08","percent of total billed charges",""
"SCREW BONE 5X12MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.59","584.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","637.08","81.72","","5157.68","5157.68","5157.68","1 through 10","407.41","637.08","percent of total billed charges",""
"SCREW BONE 5X12MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.59","584.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","637.08","81.72","","431.26","71.26","1459.57","88","407.41","637.08","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.54","265.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","281.06","79.5","","800.18","480.96","1887.97","195","109.6","281.06","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.54","265.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","188.44","53.3","","813.12","216.42","1444.50","81","109.6","281.06","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.54","265.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","109.60","31","","432.60","432.60","432.60","1 through 10","109.6","281.06","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.54","265.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","129.04","36.5","","148.37","54.89","631.39","94","109.6","281.06","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.54","265.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","135.41","38.3","","279.30","91.72","1116.77","266","109.6","281.06","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.54","265.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.67","42.9","","731.00","63.70","731.00","1 through 10","109.6","281.06","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.54","265.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.67","42.9","","384.74","384.74","384.74","1 through 10","109.6","281.06","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.54","265.15","WELLPOINT [1015]","HB AMC WELLPOINT","260.84","73.78","","286.63","119.22","1107.45","105","109.6","281.06","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.54","265.15","AETNA [1001]","HB AMC AETNA HMO","246.77","69.8","","675.31","184.75","1721.50","286","184.76","288.91","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.54","265.15","AETNA [1001]","HB AMC AETNA PPO","284.25","80.4","","1261.44","103.12","1514.10","21","184.76","288.91","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.54","265.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","284.25","80.4","","1365.00","1365.00","1365.00","1 through 10","184.76","288.91","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.54","265.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","288.91","81.72","","5157.68","5157.68","5157.68","1 through 10","184.76","288.91","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.54","265.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","288.91","81.72","","431.26","71.26","1459.57","88","184.76","288.91","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","434.32","79.5","","800.18","480.96","1887.97","195","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","291.19","53.3","","813.12","216.42","1444.50","81","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","169.36","31","","432.60","432.60","432.60","1 through 10","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","199.41","36.5","","148.37","54.89","631.39","94","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","209.24","38.3","","279.30","91.72","1116.77","266","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.37","42.9","","731.00","63.70","731.00","1 through 10","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.37","42.9","","384.74","384.74","384.74","1 through 10","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","WELLPOINT [1015]","HB AMC WELLPOINT","403.07","73.78","","286.63","119.22","1107.45","105","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.32","409.74","AETNA [1001]","HB AMC AETNA HMO","381.33","69.8","","675.31","184.75","1721.50","286","285.51","446.45","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.32","409.74","AETNA [1001]","HB AMC AETNA PPO","439.24","80.4","","1261.44","103.12","1514.10","21","285.51","446.45","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.32","409.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","439.24","80.4","","1365.00","1365.00","1365.00","1 through 10","285.51","446.45","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.32","409.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","446.45","81.72","","5157.68","5157.68","5157.68","1 through 10","285.51","446.45","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.32","409.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","446.45","81.72","","431.26","71.26","1459.57","88","285.51","446.45","percent of total billed charges",""
"SCREW BONE 5X16MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273918","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","619.77","79.5","","800.18","480.96","1887.97","195","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X16MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273918","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","415.52","53.3","","813.12","216.42","1444.50","81","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X16MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273918","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","241.67","31","","432.60","432.60","432.60","1 through 10","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X16MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273918","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","284.55","36.5","","148.37","54.89","631.39","94","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X16MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273918","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","298.58","38.3","","279.30","91.72","1116.77","266","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X16MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273918","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","334.44","42.9","","731.00","63.70","731.00","1 through 10","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X16MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273918","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","334.44","42.9","","384.74","384.74","384.74","1 through 10","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X16MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273918","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.59","584.69","WELLPOINT [1015]","HB AMC WELLPOINT","575.18","73.78","","286.63","119.22","1107.45","105","241.67","619.77","percent of total billed charges",""
"SCREW BONE 5X16MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.59","584.69","AETNA [1001]","HB AMC AETNA HMO","544.15","69.8","","675.31","184.75","1721.50","286","407.41","637.08","percent of total billed charges",""
"SCREW BONE 5X16MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.59","584.69","AETNA [1001]","HB AMC AETNA PPO","626.79","80.4","","1261.44","103.12","1514.10","21","407.41","637.08","percent of total billed charges",""
"SCREW BONE 5X16MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.59","584.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","626.79","80.4","","1365.00","1365.00","1365.00","1 through 10","407.41","637.08","percent of total billed charges",""
"SCREW BONE 5X16MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.59","584.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","637.08","81.72","","5157.68","5157.68","5157.68","1 through 10","407.41","637.08","percent of total billed charges",""
"SCREW BONE 5X16MM LOCKING VARIABLE ANGLE PERIPROSTHETIC SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.59","584.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","637.08","81.72","","431.26","71.26","1459.57","88","407.41","637.08","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","426.22","79.5","","800.18","480.96","1887.97","195","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","285.76","53.3","","813.12","216.42","1444.50","81","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","166.20","31","","432.60","432.60","432.60","1 through 10","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","195.69","36.5","","148.37","54.89","631.39","94","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","205.34","38.3","","279.30","91.72","1116.77","266","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","230.00","42.9","","731.00","63.70","731.00","1 through 10","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","230.00","42.9","","384.74","384.74","384.74","1 through 10","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","WELLPOINT [1015]","HB AMC WELLPOINT","395.56","73.78","","286.63","119.22","1107.45","105","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.13","402.10","AETNA [1001]","HB AMC AETNA HMO","374.22","69.8","","675.31","184.75","1721.50","286","280.18","438.13","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.13","402.10","AETNA [1001]","HB AMC AETNA PPO","431.05","80.4","","1261.44","103.12","1514.10","21","280.18","438.13","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.13","402.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","431.05","80.4","","1365.00","1365.00","1365.00","1 through 10","280.18","438.13","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.13","402.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","438.13","81.72","","5157.68","5157.68","5157.68","1 through 10","280.18","438.13","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.13","402.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","438.13","81.72","","431.26","71.26","1459.57","88","280.18","438.13","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.68","179.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","190.55","79.5","","800.18","480.96","1887.97","195","74.3","190.55","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.68","179.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","127.75","53.3","","813.12","216.42","1444.50","81","74.3","190.55","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.68","179.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","74.30","31","","432.60","432.60","432.60","1 through 10","74.3","190.55","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.68","179.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.48","36.5","","148.37","54.89","631.39","94","74.3","190.55","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.68","179.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.80","38.3","","279.30","91.72","1116.77","266","74.3","190.55","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.68","179.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.82","42.9","","731.00","63.70","731.00","1 through 10","74.3","190.55","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.68","179.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.82","42.9","","384.74","384.74","384.74","1 through 10","74.3","190.55","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.68","179.76","WELLPOINT [1015]","HB AMC WELLPOINT","176.84","73.78","","286.63","119.22","1107.45","105","74.3","190.55","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","239.68","179.76","AETNA [1001]","HB AMC AETNA HMO","167.30","69.8","","675.31","184.75","1721.50","286","125.26","195.87","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","239.68","179.76","AETNA [1001]","HB AMC AETNA PPO","192.70","80.4","","1261.44","103.12","1514.10","21","125.26","195.87","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","239.68","179.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","192.70","80.4","","1365.00","1365.00","1365.00","1 through 10","125.26","195.87","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","239.68","179.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","195.87","81.72","","5157.68","5157.68","5157.68","1 through 10","125.26","195.87","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","239.68","179.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","195.87","81.72","","431.26","71.26","1459.57","88","125.26","195.87","percent of total billed charges",""
"SCREW BONE 5X175MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE SELF DRILLING 60MM THREAD","SUP-ITM-10038644","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.79","605.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","641.40","79.5","","800.18","480.96","1887.97","195","250.1","641.4","percent of total billed charges",""
"SCREW BONE 5X175MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE SELF DRILLING 60MM THREAD","SUP-ITM-10038644","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.79","605.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","430.02","53.3","","813.12","216.42","1444.50","81","250.1","641.4","percent of total billed charges",""
"SCREW BONE 5X175MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE SELF DRILLING 60MM THREAD","SUP-ITM-10038644","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.79","605.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","250.10","31","","432.60","432.60","432.60","1 through 10","250.1","641.4","percent of total billed charges",""
"SCREW BONE 5X175MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE SELF DRILLING 60MM THREAD","SUP-ITM-10038644","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.79","605.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","294.48","36.5","","148.37","54.89","631.39","94","250.1","641.4","percent of total billed charges",""
"SCREW BONE 5X175MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE SELF DRILLING 60MM THREAD","SUP-ITM-10038644","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.79","605.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","309.00","38.3","","279.30","91.72","1116.77","266","250.1","641.4","percent of total billed charges",""
"SCREW BONE 5X175MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE SELF DRILLING 60MM THREAD","SUP-ITM-10038644","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.79","605.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.11","42.9","","731.00","63.70","731.00","1 through 10","250.1","641.4","percent of total billed charges",""
"SCREW BONE 5X175MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE SELF DRILLING 60MM THREAD","SUP-ITM-10038644","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.79","605.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.11","42.9","","384.74","384.74","384.74","1 through 10","250.1","641.4","percent of total billed charges",""
"SCREW BONE 5X175MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE SELF DRILLING 60MM THREAD","SUP-ITM-10038644","CDM","C1713","HCPCS","0278","RC","","","","both","","","806.79","605.09","WELLPOINT [1015]","HB AMC WELLPOINT","595.25","73.78","","286.63","119.22","1107.45","105","250.1","641.4","percent of total billed charges",""
"SCREW BONE 5X175MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE SELF DRILLING 60MM THREAD","SUP-ITM-10038644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","806.79","605.09","AETNA [1001]","HB AMC AETNA HMO","563.14","69.8","","675.31","184.75","1721.50","286","421.63","659.31","percent of total billed charges",""
"SCREW BONE 5X175MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE SELF DRILLING 60MM THREAD","SUP-ITM-10038644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","806.79","605.09","AETNA [1001]","HB AMC AETNA PPO","648.66","80.4","","1261.44","103.12","1514.10","21","421.63","659.31","percent of total billed charges",""
"SCREW BONE 5X175MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE SELF DRILLING 60MM THREAD","SUP-ITM-10038644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","806.79","605.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","648.66","80.4","","1365.00","1365.00","1365.00","1 through 10","421.63","659.31","percent of total billed charges",""
"SCREW BONE 5X175MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE SELF DRILLING 60MM THREAD","SUP-ITM-10038644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","806.79","605.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","659.31","81.72","","5157.68","5157.68","5157.68","1 through 10","421.63","659.31","percent of total billed charges",""
"SCREW BONE 5X175MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE SELF DRILLING 60MM THREAD","SUP-ITM-10038644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","806.79","605.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","659.31","81.72","","431.26","71.26","1459.57","88","421.63","659.31","percent of total billed charges",""
"SCREW BONE 5X18MM CONICAL TI LOCKING SELF TAPPING HEAD HEXAGONAL RECESS","SUP-ITM-10012541","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.05","438.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","464.32","79.5","","800.18","480.96","1887.97","195","181.06","464.32","percent of total billed charges",""
"SCREW BONE 5X18MM CONICAL TI LOCKING SELF TAPPING HEAD HEXAGONAL RECESS","SUP-ITM-10012541","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.05","438.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","311.30","53.3","","813.12","216.42","1444.50","81","181.06","464.32","percent of total billed charges",""
"SCREW BONE 5X18MM CONICAL TI LOCKING SELF TAPPING HEAD HEXAGONAL RECESS","SUP-ITM-10012541","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.05","438.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","181.06","31","","432.60","432.60","432.60","1 through 10","181.06","464.32","percent of total billed charges",""
"SCREW BONE 5X18MM CONICAL TI LOCKING SELF TAPPING HEAD HEXAGONAL RECESS","SUP-ITM-10012541","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.05","438.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","213.18","36.5","","148.37","54.89","631.39","94","181.06","464.32","percent of total billed charges",""
"SCREW BONE 5X18MM CONICAL TI LOCKING SELF TAPPING HEAD HEXAGONAL RECESS","SUP-ITM-10012541","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.05","438.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","223.69","38.3","","279.30","91.72","1116.77","266","181.06","464.32","percent of total billed charges",""
"SCREW BONE 5X18MM CONICAL TI LOCKING SELF TAPPING HEAD HEXAGONAL RECESS","SUP-ITM-10012541","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.05","438.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.56","42.9","","731.00","63.70","731.00","1 through 10","181.06","464.32","percent of total billed charges",""
"SCREW BONE 5X18MM CONICAL TI LOCKING SELF TAPPING HEAD HEXAGONAL RECESS","SUP-ITM-10012541","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.05","438.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.56","42.9","","384.74","384.74","384.74","1 through 10","181.06","464.32","percent of total billed charges",""
"SCREW BONE 5X18MM CONICAL TI LOCKING SELF TAPPING HEAD HEXAGONAL RECESS","SUP-ITM-10012541","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.05","438.04","WELLPOINT [1015]","HB AMC WELLPOINT","430.91","73.78","","286.63","119.22","1107.45","105","181.06","464.32","percent of total billed charges",""
"SCREW BONE 5X18MM CONICAL TI LOCKING SELF TAPPING HEAD HEXAGONAL RECESS","SUP-ITM-10012541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.05","438.04","AETNA [1001]","HB AMC AETNA HMO","407.67","69.8","","675.31","184.75","1721.50","286","305.22","477.29","percent of total billed charges",""
"SCREW BONE 5X18MM CONICAL TI LOCKING SELF TAPPING HEAD HEXAGONAL RECESS","SUP-ITM-10012541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.05","438.04","AETNA [1001]","HB AMC AETNA PPO","469.58","80.4","","1261.44","103.12","1514.10","21","305.22","477.29","percent of total billed charges",""
"SCREW BONE 5X18MM CONICAL TI LOCKING SELF TAPPING HEAD HEXAGONAL RECESS","SUP-ITM-10012541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.05","438.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","469.58","80.4","","1365.00","1365.00","1365.00","1 through 10","305.22","477.29","percent of total billed charges",""
"SCREW BONE 5X18MM CONICAL TI LOCKING SELF TAPPING HEAD HEXAGONAL RECESS","SUP-ITM-10012541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.05","438.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","477.29","81.72","","5157.68","5157.68","5157.68","1 through 10","305.22","477.29","percent of total billed charges",""
"SCREW BONE 5X18MM CONICAL TI LOCKING SELF TAPPING HEAD HEXAGONAL RECESS","SUP-ITM-10012541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.05","438.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","477.29","81.72","","431.26","71.26","1459.57","88","305.22","477.29","percent of total billed charges",""
"SCREW BONE 5X200MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038616","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","426.22","79.5","","800.18","480.96","1887.97","195","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X200MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038616","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","285.76","53.3","","813.12","216.42","1444.50","81","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X200MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038616","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","166.20","31","","432.60","432.60","432.60","1 through 10","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X200MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038616","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","195.69","36.5","","148.37","54.89","631.39","94","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X200MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038616","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","205.34","38.3","","279.30","91.72","1116.77","266","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X200MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038616","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","230.00","42.9","","731.00","63.70","731.00","1 through 10","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X200MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038616","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","230.00","42.9","","384.74","384.74","384.74","1 through 10","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X200MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038616","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.13","402.10","WELLPOINT [1015]","HB AMC WELLPOINT","395.56","73.78","","286.63","119.22","1107.45","105","166.2","426.22","percent of total billed charges",""
"SCREW BONE 5X200MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038616","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.13","402.10","AETNA [1001]","HB AMC AETNA HMO","374.22","69.8","","675.31","184.75","1721.50","286","280.18","438.13","percent of total billed charges",""
"SCREW BONE 5X200MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038616","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.13","402.10","AETNA [1001]","HB AMC AETNA PPO","431.05","80.4","","1261.44","103.12","1514.10","21","280.18","438.13","percent of total billed charges",""
"SCREW BONE 5X200MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038616","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.13","402.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","431.05","80.4","","1365.00","1365.00","1365.00","1 through 10","280.18","438.13","percent of total billed charges",""
"SCREW BONE 5X200MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038616","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.13","402.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","438.13","81.72","","5157.68","5157.68","5157.68","1 through 10","280.18","438.13","percent of total billed charges",""
"SCREW BONE 5X200MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038616","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.13","402.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","438.13","81.72","","431.26","71.26","1459.57","88","280.18","438.13","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.87","533.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","565.94","79.5","","800.18","480.96","1887.97","195","220.68","565.94","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.87","533.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","379.43","53.3","","813.12","216.42","1444.50","81","220.68","565.94","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.87","533.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","220.68","31","","432.60","432.60","432.60","1 through 10","220.68","565.94","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.87","533.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","259.83","36.5","","148.37","54.89","631.39","94","220.68","565.94","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.87","533.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","272.65","38.3","","279.30","91.72","1116.77","266","220.68","565.94","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.87","533.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","305.39","42.9","","731.00","63.70","731.00","1 through 10","220.68","565.94","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.87","533.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","305.39","42.9","","384.74","384.74","384.74","1 through 10","220.68","565.94","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.87","533.90","WELLPOINT [1015]","HB AMC WELLPOINT","525.22","73.78","","286.63","119.22","1107.45","105","220.68","565.94","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.87","533.90","AETNA [1001]","HB AMC AETNA HMO","496.89","69.8","","675.31","184.75","1721.50","286","372.02","581.74","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.87","533.90","AETNA [1001]","HB AMC AETNA PPO","572.34","80.4","","1261.44","103.12","1514.10","21","372.02","581.74","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.87","533.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","572.34","80.4","","1365.00","1365.00","1365.00","1 through 10","372.02","581.74","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.87","533.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","581.74","81.72","","5157.68","5157.68","5157.68","1 through 10","372.02","581.74","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.87","533.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","581.74","81.72","","431.26","71.26","1459.57","88","372.02","581.74","percent of total billed charges",""
"SCREW BONE 5X22.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1018.40","79.5","","800.18","480.96","1887.97","195","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 5X22.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","682.77","53.3","","813.12","216.42","1444.50","81","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 5X22.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","397.11","31","","432.60","432.60","432.60","1 through 10","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 5X22.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","467.57","36.5","","148.37","54.89","631.39","94","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 5X22.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","490.62","38.3","","279.30","91.72","1116.77","266","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 5X22.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","549.55","42.9","","731.00","63.70","731.00","1 through 10","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 5X22.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","549.55","42.9","","384.74","384.74","384.74","1 through 10","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 5X22.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331249","CDM","C1713","HCPCS","0278","RC","","","","both","","","1281.00","960.75","WELLPOINT [1015]","HB AMC WELLPOINT","945.12","73.78","","286.63","119.22","1107.45","105","397.11","1018.4","percent of total billed charges",""
"SCREW BONE 5X22.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1281.00","960.75","AETNA [1001]","HB AMC AETNA HMO","894.14","69.8","","675.31","184.75","1721.50","286","669.45","1046.83","percent of total billed charges",""
"SCREW BONE 5X22.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1281.00","960.75","AETNA [1001]","HB AMC AETNA PPO","1029.92","80.4","","1261.44","103.12","1514.10","21","669.45","1046.83","percent of total billed charges",""
"SCREW BONE 5X22.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1281.00","960.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1029.92","80.4","","1365.00","1365.00","1365.00","1 through 10","669.45","1046.83","percent of total billed charges",""
"SCREW BONE 5X22.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1281.00","960.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1046.83","81.72","","5157.68","5157.68","5157.68","1 through 10","669.45","1046.83","percent of total billed charges",""
"SCREW BONE 5X22.5MM FULL THREAD INTRAMEDULLARY PRECICE","SUP-ITM-10331249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1281.00","960.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1046.83","81.72","","431.26","71.26","1459.57","88","669.45","1046.83","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1252.13","79.5","","800.18","480.96","1887.97","195","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","839.48","53.3","","813.12","216.42","1444.50","81","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","488.25","31","","432.60","432.60","432.60","1 through 10","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","574.88","36.5","","148.37","54.89","631.39","94","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","603.23","38.3","","279.30","91.72","1116.77","266","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","731.00","63.70","731.00","1 through 10","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","384.74","384.74","384.74","1 through 10","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB AMC WELLPOINT","1162.04","73.78","","286.63","119.22","1107.45","105","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA HMO","1099.35","69.8","","675.31","184.75","1721.50","286","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA PPO","1266.30","80.4","","1261.44","103.12","1514.10","21","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1266.30","80.4","","1365.00","1365.00","1365.00","1 through 10","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1287.09","81.72","","5157.68","5157.68","5157.68","1 through 10","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1287.09","81.72","","431.26","71.26","1459.57","88","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","415.93","79.5","","800.18","480.96","1887.97","195","162.19","415.93","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","278.85","53.3","","813.12","216.42","1444.50","81","162.19","415.93","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.19","31","","432.60","432.60","432.60","1 through 10","162.19","415.93","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","190.96","36.5","","148.37","54.89","631.39","94","162.19","415.93","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","200.38","38.3","","279.30","91.72","1116.77","266","162.19","415.93","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.44","42.9","","731.00","63.70","731.00","1 through 10","162.19","415.93","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","224.44","42.9","","384.74","384.74","384.74","1 through 10","162.19","415.93","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","523.18","392.38","WELLPOINT [1015]","HB AMC WELLPOINT","386.00","73.78","","286.63","119.22","1107.45","105","162.19","415.93","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","523.18","392.38","AETNA [1001]","HB AMC AETNA HMO","365.18","69.8","","675.31","184.75","1721.50","286","273.41","427.54","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","523.18","392.38","AETNA [1001]","HB AMC AETNA PPO","420.64","80.4","","1261.44","103.12","1514.10","21","273.41","427.54","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","523.18","392.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","420.64","80.4","","1365.00","1365.00","1365.00","1 through 10","273.41","427.54","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","523.18","392.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","427.54","81.72","","5157.68","5157.68","5157.68","1 through 10","273.41","427.54","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","523.18","392.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","427.54","81.72","","431.26","71.26","1459.57","88","273.41","427.54","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296226","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","648.49","79.5","","800.18","480.96","1887.97","195","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296226","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","434.77","53.3","","813.12","216.42","1444.50","81","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296226","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","252.87","31","","432.60","432.60","432.60","1 through 10","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296226","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","297.73","36.5","","148.37","54.89","631.39","94","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296226","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","312.42","38.3","","279.30","91.72","1116.77","266","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296226","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","349.94","42.9","","731.00","63.70","731.00","1 through 10","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296226","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","349.94","42.9","","384.74","384.74","384.74","1 through 10","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296226","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","WELLPOINT [1015]","HB AMC WELLPOINT","601.83","73.78","","286.63","119.22","1107.45","105","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","AETNA [1001]","HB AMC AETNA HMO","569.37","69.8","","675.31","184.75","1721.50","286","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","AETNA [1001]","HB AMC AETNA PPO","655.83","80.4","","1261.44","103.12","1514.10","21","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","655.83","80.4","","1365.00","1365.00","1365.00","1 through 10","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","666.60","81.72","","5157.68","5157.68","5157.68","1 through 10","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","666.60","81.72","","431.26","71.26","1459.57","88","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.39","429.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","455.05","79.5","","800.18","480.96","1887.97","195","177.44","455.05","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.39","429.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","305.08","53.3","","813.12","216.42","1444.50","81","177.44","455.05","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.39","429.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","177.44","31","","432.60","432.60","432.60","1 through 10","177.44","455.05","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.39","429.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","208.92","36.5","","148.37","54.89","631.39","94","177.44","455.05","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.39","429.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","219.23","38.3","","279.30","91.72","1116.77","266","177.44","455.05","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.39","429.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","245.56","42.9","","731.00","63.70","731.00","1 through 10","177.44","455.05","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.39","429.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","245.56","42.9","","384.74","384.74","384.74","1 through 10","177.44","455.05","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.39","429.29","WELLPOINT [1015]","HB AMC WELLPOINT","422.31","73.78","","286.63","119.22","1107.45","105","177.44","455.05","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.39","429.29","AETNA [1001]","HB AMC AETNA HMO","399.53","69.8","","675.31","184.75","1721.50","286","299.13","467.76","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.39","429.29","AETNA [1001]","HB AMC AETNA PPO","460.20","80.4","","1261.44","103.12","1514.10","21","299.13","467.76","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.39","429.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","460.20","80.4","","1365.00","1365.00","1365.00","1 through 10","299.13","467.76","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.39","429.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","467.76","81.72","","5157.68","5157.68","5157.68","1 through 10","299.13","467.76","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.39","429.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","467.76","81.72","","431.26","71.26","1459.57","88","299.13","467.76","percent of total billed charges",""
"SCREW BONE 5X30MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117069","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1085.18","79.5","","1309.77","674.56","6049.93","26","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 5X30MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117069","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","727.55","53.3","","1901.83","1901.83","2962.25","1 through 10","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 5X30MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117069","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","498.23","36.5","","1620.31","1620.31","19908.88","1 through 10","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 5X30MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117069","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","522.80","38.3","","352.91","352.91","2046.30","1 through 10","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 5X30MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117069","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","9668.75","9668.75","9668.75","1 through 10","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 5X30MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117069","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB AMC WELLPOINT","1007.10","73.78","","699.88","384.10","3443.31","33","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 5X30MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117069","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA HMO","952.77","69.8","","1421.24","264.50","4933.46","29","713.35","1115.48","percent of total billed charges",""
"SCREW BONE 5X30MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117069","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1097.46","80.4","","1022.97","1022.97","3607.50","1 through 10","713.35","1115.48","percent of total billed charges",""
"SCREW BONE 5X30MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117069","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1115.48","81.72","","3010.54","693.88","5019.88","35","713.35","1115.48","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","440.30","330.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","350.04","79.5","","800.18","480.96","1887.97","195","136.49","350.04","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","440.30","330.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","234.68","53.3","","813.12","216.42","1444.50","81","136.49","350.04","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","440.30","330.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","136.49","31","","432.60","432.60","432.60","1 through 10","136.49","350.04","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","440.30","330.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","160.71","36.5","","148.37","54.89","631.39","94","136.49","350.04","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","440.30","330.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","168.63","38.3","","279.30","91.72","1116.77","266","136.49","350.04","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","440.30","330.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.89","42.9","","731.00","63.70","731.00","1 through 10","136.49","350.04","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","440.30","330.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.89","42.9","","384.74","384.74","384.74","1 through 10","136.49","350.04","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","440.30","330.22","WELLPOINT [1015]","HB AMC WELLPOINT","324.85","73.78","","286.63","119.22","1107.45","105","136.49","350.04","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","440.30","330.22","AETNA [1001]","HB AMC AETNA HMO","307.33","69.8","","675.31","184.75","1721.50","286","230.1","359.81","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","440.30","330.22","AETNA [1001]","HB AMC AETNA PPO","354.00","80.4","","1261.44","103.12","1514.10","21","230.1","359.81","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","440.30","330.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","354.00","80.4","","1365.00","1365.00","1365.00","1 through 10","230.1","359.81","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","440.30","330.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","359.81","81.72","","5157.68","5157.68","5157.68","1 through 10","230.1","359.81","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","440.30","330.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","359.81","81.72","","431.26","71.26","1459.57","88","230.1","359.81","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","452.27","79.5","","800.18","480.96","1887.97","195","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","303.22","53.3","","813.12","216.42","1444.50","81","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","176.36","31","","432.60","432.60","432.60","1 through 10","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","207.64","36.5","","148.37","54.89","631.39","94","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","217.88","38.3","","279.30","91.72","1116.77","266","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.05","42.9","","731.00","63.70","731.00","1 through 10","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.05","42.9","","384.74","384.74","384.74","1 through 10","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","WELLPOINT [1015]","HB AMC WELLPOINT","419.73","73.78","","286.63","119.22","1107.45","105","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","AETNA [1001]","HB AMC AETNA HMO","397.09","69.8","","675.31","184.75","1721.50","286","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","AETNA [1001]","HB AMC AETNA PPO","457.39","80.4","","1261.44","103.12","1514.10","21","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","457.39","80.4","","1365.00","1365.00","1365.00","1 through 10","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","464.90","81.72","","5157.68","5157.68","5157.68","1 through 10","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X34MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","464.90","81.72","","431.26","71.26","1459.57","88","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X35MM SPINE MONOAXIAL EXPEDIUM 6.35 SS","SUP-ITM-10025729","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","278.25","79.5","","800.18","480.96","1887.97","195","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5X35MM SPINE MONOAXIAL EXPEDIUM 6.35 SS","SUP-ITM-10025729","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","186.55","53.3","","813.12","216.42","1444.50","81","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5X35MM SPINE MONOAXIAL EXPEDIUM 6.35 SS","SUP-ITM-10025729","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","108.50","31","","432.60","432.60","432.60","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5X35MM SPINE MONOAXIAL EXPEDIUM 6.35 SS","SUP-ITM-10025729","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.75","36.5","","148.37","54.89","631.39","94","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5X35MM SPINE MONOAXIAL EXPEDIUM 6.35 SS","SUP-ITM-10025729","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","134.05","38.3","","279.30","91.72","1116.77","266","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5X35MM SPINE MONOAXIAL EXPEDIUM 6.35 SS","SUP-ITM-10025729","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","731.00","63.70","731.00","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5X35MM SPINE MONOAXIAL EXPEDIUM 6.35 SS","SUP-ITM-10025729","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","384.74","384.74","384.74","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5X35MM SPINE MONOAXIAL EXPEDIUM 6.35 SS","SUP-ITM-10025729","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","WELLPOINT [1015]","HB AMC WELLPOINT","258.23","73.78","","286.63","119.22","1107.45","105","108.5","278.25","percent of total billed charges",""
"SCREW BONE 5X35MM SPINE MONOAXIAL EXPEDIUM 6.35 SS","SUP-ITM-10025729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA HMO","244.30","69.8","","675.31","184.75","1721.50","286","182.91","286.02","percent of total billed charges",""
"SCREW BONE 5X35MM SPINE MONOAXIAL EXPEDIUM 6.35 SS","SUP-ITM-10025729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA PPO","281.40","80.4","","1261.44","103.12","1514.10","21","182.91","286.02","percent of total billed charges",""
"SCREW BONE 5X35MM SPINE MONOAXIAL EXPEDIUM 6.35 SS","SUP-ITM-10025729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","281.40","80.4","","1365.00","1365.00","1365.00","1 through 10","182.91","286.02","percent of total billed charges",""
"SCREW BONE 5X35MM SPINE MONOAXIAL EXPEDIUM 6.35 SS","SUP-ITM-10025729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","286.02","81.72","","5157.68","5157.68","5157.68","1 through 10","182.91","286.02","percent of total billed charges",""
"SCREW BONE 5X35MM SPINE MONOAXIAL EXPEDIUM 6.35 SS","SUP-ITM-10025729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","286.02","81.72","","431.26","71.26","1459.57","88","182.91","286.02","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296726","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","552.77","79.5","","800.18","480.96","1887.97","195","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296726","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","370.60","53.3","","813.12","216.42","1444.50","81","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296726","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","215.55","31","","432.60","432.60","432.60","1 through 10","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296726","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","253.79","36.5","","148.37","54.89","631.39","94","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296726","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","266.30","38.3","","279.30","91.72","1116.77","266","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296726","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.29","42.9","","731.00","63.70","731.00","1 through 10","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296726","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.29","42.9","","384.74","384.74","384.74","1 through 10","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296726","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","WELLPOINT [1015]","HB AMC WELLPOINT","513.00","73.78","","286.63","119.22","1107.45","105","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","AETNA [1001]","HB AMC AETNA HMO","485.33","69.8","","675.31","184.75","1721.50","286","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","AETNA [1001]","HB AMC AETNA PPO","559.03","80.4","","1261.44","103.12","1514.10","21","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","559.03","80.4","","1365.00","1365.00","1365.00","1 through 10","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","568.21","81.72","","5157.68","5157.68","5157.68","1 through 10","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","568.21","81.72","","431.26","71.26","1459.57","88","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","452.99","79.5","","800.18","480.96","1887.97","195","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","303.70","53.3","","813.12","216.42","1444.50","81","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","176.64","31","","432.60","432.60","432.60","1 through 10","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","207.98","36.5","","148.37","54.89","631.39","94","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","218.23","38.3","","279.30","91.72","1116.77","266","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.44","42.9","","731.00","63.70","731.00","1 through 10","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.44","42.9","","384.74","384.74","384.74","1 through 10","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","WELLPOINT [1015]","HB AMC WELLPOINT","420.40","73.78","","286.63","119.22","1107.45","105","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.80","427.35","AETNA [1001]","HB AMC AETNA HMO","397.72","69.8","","675.31","184.75","1721.50","286","297.78","465.64","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.80","427.35","AETNA [1001]","HB AMC AETNA PPO","458.12","80.4","","1261.44","103.12","1514.10","21","297.78","465.64","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.80","427.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","458.12","80.4","","1365.00","1365.00","1365.00","1 through 10","297.78","465.64","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.80","427.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","465.64","81.72","","5157.68","5157.68","5157.68","1 through 10","297.78","465.64","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.80","427.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","465.64","81.72","","431.26","71.26","1459.57","88","297.78","465.64","percent of total billed charges",""
"SCREW BONE 5X37.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10169876","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1252.13","79.5","","800.18","480.96","1887.97","195","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X37.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10169876","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","839.48","53.3","","813.12","216.42","1444.50","81","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X37.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10169876","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","488.25","31","","432.60","432.60","432.60","1 through 10","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X37.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10169876","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","574.88","36.5","","148.37","54.89","631.39","94","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X37.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10169876","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","603.23","38.3","","279.30","91.72","1116.77","266","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X37.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10169876","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","731.00","63.70","731.00","1 through 10","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X37.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10169876","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","384.74","384.74","384.74","1 through 10","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X37.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10169876","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB AMC WELLPOINT","1162.04","73.78","","286.63","119.22","1107.45","105","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X37.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10169876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA HMO","1099.35","69.8","","675.31","184.75","1721.50","286","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X37.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10169876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA PPO","1266.30","80.4","","1261.44","103.12","1514.10","21","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X37.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10169876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1266.30","80.4","","1365.00","1365.00","1365.00","1 through 10","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X37.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10169876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1287.09","81.72","","5157.68","5157.68","5157.68","1 through 10","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X37.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10169876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1287.09","81.72","","431.26","71.26","1459.57","88","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X38MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288220","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","547.99","79.5","","800.18","480.96","1887.97","195","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X38MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288220","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","367.39","53.3","","813.12","216.42","1444.50","81","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X38MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288220","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","213.68","31","","432.60","432.60","432.60","1 through 10","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X38MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288220","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","251.59","36.5","","148.37","54.89","631.39","94","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X38MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288220","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","264.00","38.3","","279.30","91.72","1116.77","266","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X38MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288220","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","295.71","42.9","","731.00","63.70","731.00","1 through 10","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X38MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288220","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","295.71","42.9","","384.74","384.74","384.74","1 through 10","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X38MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288220","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","WELLPOINT [1015]","HB AMC WELLPOINT","508.56","73.78","","286.63","119.22","1107.45","105","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X38MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","AETNA [1001]","HB AMC AETNA HMO","481.12","69.8","","675.31","184.75","1721.50","286","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X38MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","AETNA [1001]","HB AMC AETNA PPO","554.19","80.4","","1261.44","103.12","1514.10","21","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X38MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","554.19","80.4","","1365.00","1365.00","1365.00","1 through 10","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X38MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","563.29","81.72","","5157.68","5157.68","5157.68","1 through 10","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X38MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","563.29","81.72","","431.26","71.26","1459.57","88","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","150.26","79.5","","800.18","480.96","1887.97","195","58.59","150.26","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.74","53.3","","813.12","216.42","1444.50","81","58.59","150.26","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","58.59","31","","432.60","432.60","432.60","1 through 10","58.59","150.26","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.99","36.5","","148.37","54.89","631.39","94","58.59","150.26","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.39","38.3","","279.30","91.72","1116.77","266","58.59","150.26","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","731.00","63.70","731.00","1 through 10","58.59","150.26","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","384.74","384.74","384.74","1 through 10","58.59","150.26","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","WELLPOINT [1015]","HB AMC WELLPOINT","139.44","73.78","","286.63","119.22","1107.45","105","58.59","150.26","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA HMO","131.92","69.8","","675.31","184.75","1721.50","286","98.77","154.45","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA PPO","151.96","80.4","","1261.44","103.12","1514.10","21","98.77","154.45","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","151.96","80.4","","1365.00","1365.00","1365.00","1 through 10","98.77","154.45","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","154.45","81.72","","5157.68","5157.68","5157.68","1 through 10","98.77","154.45","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","154.45","81.72","","431.26","71.26","1459.57","88","98.77","154.45","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","451.96","338.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","359.31","79.5","","800.18","480.96","1887.97","195","140.11","359.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","451.96","338.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","240.89","53.3","","813.12","216.42","1444.50","81","140.11","359.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","451.96","338.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","140.11","31","","432.60","432.60","432.60","1 through 10","140.11","359.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","451.96","338.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","164.97","36.5","","148.37","54.89","631.39","94","140.11","359.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","451.96","338.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","173.10","38.3","","279.30","91.72","1116.77","266","140.11","359.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","451.96","338.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.89","42.9","","731.00","63.70","731.00","1 through 10","140.11","359.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","451.96","338.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.89","42.9","","384.74","384.74","384.74","1 through 10","140.11","359.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","451.96","338.97","WELLPOINT [1015]","HB AMC WELLPOINT","333.46","73.78","","286.63","119.22","1107.45","105","140.11","359.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","451.96","338.97","AETNA [1001]","HB AMC AETNA HMO","315.47","69.8","","675.31","184.75","1721.50","286","236.19","369.34","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","451.96","338.97","AETNA [1001]","HB AMC AETNA PPO","363.38","80.4","","1261.44","103.12","1514.10","21","236.19","369.34","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","451.96","338.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","363.38","80.4","","1365.00","1365.00","1365.00","1 through 10","236.19","369.34","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","451.96","338.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","369.34","81.72","","5157.68","5157.68","5157.68","1 through 10","236.19","369.34","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","451.96","338.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","369.34","81.72","","431.26","71.26","1459.57","88","236.19","369.34","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","547.99","79.5","","800.18","480.96","1887.97","195","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","367.39","53.3","","813.12","216.42","1444.50","81","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","213.68","31","","432.60","432.60","432.60","1 through 10","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","251.59","36.5","","148.37","54.89","631.39","94","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","264.00","38.3","","279.30","91.72","1116.77","266","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","295.71","42.9","","731.00","63.70","731.00","1 through 10","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","295.71","42.9","","384.74","384.74","384.74","1 through 10","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","WELLPOINT [1015]","HB AMC WELLPOINT","508.56","73.78","","286.63","119.22","1107.45","105","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","AETNA [1001]","HB AMC AETNA HMO","481.12","69.8","","675.31","184.75","1721.50","286","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","AETNA [1001]","HB AMC AETNA PPO","554.19","80.4","","1261.44","103.12","1514.10","21","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","554.19","80.4","","1365.00","1365.00","1365.00","1 through 10","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","563.29","81.72","","5157.68","5157.68","5157.68","1 through 10","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","563.29","81.72","","431.26","71.26","1459.57","88","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296212","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","648.49","79.5","","800.18","480.96","1887.97","195","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296212","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","434.77","53.3","","813.12","216.42","1444.50","81","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296212","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","252.87","31","","432.60","432.60","432.60","1 through 10","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296212","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","297.73","36.5","","148.37","54.89","631.39","94","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296212","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","312.42","38.3","","279.30","91.72","1116.77","266","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296212","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","349.94","42.9","","731.00","63.70","731.00","1 through 10","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296212","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","349.94","42.9","","384.74","384.74","384.74","1 through 10","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296212","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","WELLPOINT [1015]","HB AMC WELLPOINT","601.83","73.78","","286.63","119.22","1107.45","105","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","AETNA [1001]","HB AMC AETNA HMO","569.37","69.8","","675.31","184.75","1721.50","286","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","AETNA [1001]","HB AMC AETNA PPO","655.83","80.4","","1261.44","103.12","1514.10","21","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","655.83","80.4","","1365.00","1365.00","1365.00","1 through 10","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","666.60","81.72","","5157.68","5157.68","5157.68","1 through 10","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","666.60","81.72","","431.26","71.26","1459.57","88","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","816.22","79.5","","800.18","480.96","1887.97","195","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","547.23","53.3","","813.12","216.42","1444.50","81","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","318.27","31","","432.60","432.60","432.60","1 through 10","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","374.74","36.5","","148.37","54.89","631.39","94","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","393.22","38.3","","279.30","91.72","1116.77","266","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","440.45","42.9","","731.00","63.70","731.00","1 through 10","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","440.45","42.9","","384.74","384.74","384.74","1 through 10","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.69","770.02","WELLPOINT [1015]","HB AMC WELLPOINT","757.49","73.78","","286.63","119.22","1107.45","105","318.27","816.22","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.69","770.02","AETNA [1001]","HB AMC AETNA HMO","716.63","69.8","","675.31","184.75","1721.50","286","536.55","839.01","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.69","770.02","AETNA [1001]","HB AMC AETNA PPO","825.46","80.4","","1261.44","103.12","1514.10","21","536.55","839.01","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.69","770.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","825.46","80.4","","1365.00","1365.00","1365.00","1 through 10","536.55","839.01","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.69","770.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","839.01","81.72","","5157.68","5157.68","5157.68","1 through 10","536.55","839.01","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.69","770.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","839.01","81.72","","431.26","71.26","1459.57","88","536.55","839.01","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","452.27","79.5","","800.18","480.96","1887.97","195","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","303.22","53.3","","813.12","216.42","1444.50","81","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","176.36","31","","432.60","432.60","432.60","1 through 10","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","207.64","36.5","","148.37","54.89","631.39","94","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","217.88","38.3","","279.30","91.72","1116.77","266","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.05","42.9","","731.00","63.70","731.00","1 through 10","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.05","42.9","","384.74","384.74","384.74","1 through 10","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","WELLPOINT [1015]","HB AMC WELLPOINT","419.73","73.78","","286.63","119.22","1107.45","105","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","AETNA [1001]","HB AMC AETNA HMO","397.09","69.8","","675.31","184.75","1721.50","286","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","AETNA [1001]","HB AMC AETNA PPO","457.39","80.4","","1261.44","103.12","1514.10","21","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","457.39","80.4","","1365.00","1365.00","1365.00","1 through 10","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","464.90","81.72","","5157.68","5157.68","5157.68","1 through 10","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X40MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","464.90","81.72","","431.26","71.26","1459.57","88","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X42MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296210","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","648.49","79.5","","800.18","480.96","1887.97","195","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X42MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296210","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","434.77","53.3","","813.12","216.42","1444.50","81","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X42MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296210","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","252.87","31","","432.60","432.60","432.60","1 through 10","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X42MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296210","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","297.73","36.5","","148.37","54.89","631.39","94","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X42MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296210","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","312.42","38.3","","279.30","91.72","1116.77","266","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X42MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296210","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","349.94","42.9","","731.00","63.70","731.00","1 through 10","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X42MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296210","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","349.94","42.9","","384.74","384.74","384.74","1 through 10","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X42MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296210","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","WELLPOINT [1015]","HB AMC WELLPOINT","601.83","73.78","","286.63","119.22","1107.45","105","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X42MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296210","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","AETNA [1001]","HB AMC AETNA HMO","569.37","69.8","","675.31","184.75","1721.50","286","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X42MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296210","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","AETNA [1001]","HB AMC AETNA PPO","655.83","80.4","","1261.44","103.12","1514.10","21","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X42MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296210","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","655.83","80.4","","1365.00","1365.00","1365.00","1 through 10","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X42MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296210","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","666.60","81.72","","5157.68","5157.68","5157.68","1 through 10","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X42MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE STERILE","SUP-ITM-10296210","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","666.60","81.72","","431.26","71.26","1459.57","88","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X44MM LOCKING IM NAIL","SUP-ITM-10296342","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","547.99","79.5","","800.18","480.96","1887.97","195","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X44MM LOCKING IM NAIL","SUP-ITM-10296342","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","367.39","53.3","","813.12","216.42","1444.50","81","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X44MM LOCKING IM NAIL","SUP-ITM-10296342","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","213.68","31","","432.60","432.60","432.60","1 through 10","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X44MM LOCKING IM NAIL","SUP-ITM-10296342","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","251.59","36.5","","148.37","54.89","631.39","94","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X44MM LOCKING IM NAIL","SUP-ITM-10296342","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","264.00","38.3","","279.30","91.72","1116.77","266","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X44MM LOCKING IM NAIL","SUP-ITM-10296342","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","295.71","42.9","","731.00","63.70","731.00","1 through 10","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X44MM LOCKING IM NAIL","SUP-ITM-10296342","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","295.71","42.9","","384.74","384.74","384.74","1 through 10","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X44MM LOCKING IM NAIL","SUP-ITM-10296342","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","WELLPOINT [1015]","HB AMC WELLPOINT","508.56","73.78","","286.63","119.22","1107.45","105","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X44MM LOCKING IM NAIL","SUP-ITM-10296342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","AETNA [1001]","HB AMC AETNA HMO","481.12","69.8","","675.31","184.75","1721.50","286","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X44MM LOCKING IM NAIL","SUP-ITM-10296342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","AETNA [1001]","HB AMC AETNA PPO","554.19","80.4","","1261.44","103.12","1514.10","21","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X44MM LOCKING IM NAIL","SUP-ITM-10296342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","554.19","80.4","","1365.00","1365.00","1365.00","1 through 10","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X44MM LOCKING IM NAIL","SUP-ITM-10296342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","563.29","81.72","","5157.68","5157.68","5157.68","1 through 10","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X44MM LOCKING IM NAIL","SUP-ITM-10296342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","563.29","81.72","","431.26","71.26","1459.57","88","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.26","396.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","419.97","79.5","","800.18","480.96","1887.97","195","163.76","419.97","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.26","396.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","281.56","53.3","","813.12","216.42","1444.50","81","163.76","419.97","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.26","396.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","163.76","31","","432.60","432.60","432.60","1 through 10","163.76","419.97","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.26","396.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","192.81","36.5","","148.37","54.89","631.39","94","163.76","419.97","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.26","396.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","202.32","38.3","","279.30","91.72","1116.77","266","163.76","419.97","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.26","396.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.62","42.9","","731.00","63.70","731.00","1 through 10","163.76","419.97","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.26","396.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.62","42.9","","384.74","384.74","384.74","1 through 10","163.76","419.97","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.26","396.19","WELLPOINT [1015]","HB AMC WELLPOINT","389.75","73.78","","286.63","119.22","1107.45","105","163.76","419.97","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","528.26","396.19","AETNA [1001]","HB AMC AETNA HMO","368.73","69.8","","675.31","184.75","1721.50","286","276.07","431.69","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","528.26","396.19","AETNA [1001]","HB AMC AETNA PPO","424.72","80.4","","1261.44","103.12","1514.10","21","276.07","431.69","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","528.26","396.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","424.72","80.4","","1365.00","1365.00","1365.00","1 through 10","276.07","431.69","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","528.26","396.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","431.69","81.72","","5157.68","5157.68","5157.68","1 through 10","276.07","431.69","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","528.26","396.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","431.69","81.72","","431.26","71.26","1459.57","88","276.07","431.69","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","452.27","79.5","","800.18","480.96","1887.97","195","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","303.22","53.3","","813.12","216.42","1444.50","81","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","176.36","31","","432.60","432.60","432.60","1 through 10","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","207.64","36.5","","148.37","54.89","631.39","94","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","217.88","38.3","","279.30","91.72","1116.77","266","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.05","42.9","","731.00","63.70","731.00","1 through 10","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.05","42.9","","384.74","384.74","384.74","1 through 10","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","both","","","568.89","426.67","WELLPOINT [1015]","HB AMC WELLPOINT","419.73","73.78","","286.63","119.22","1107.45","105","176.36","452.27","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","AETNA [1001]","HB AMC AETNA HMO","397.09","69.8","","675.31","184.75","1721.50","286","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","AETNA [1001]","HB AMC AETNA PPO","457.39","80.4","","1261.44","103.12","1514.10","21","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","457.39","80.4","","1365.00","1365.00","1365.00","1 through 10","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","464.90","81.72","","5157.68","5157.68","5157.68","1 through 10","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X48MM XL25 LOCKING IM NAIL COMPATIBLE","SUP-ITM-10294937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","568.89","426.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","464.90","81.72","","431.26","71.26","1459.57","88","297.3","464.9","percent of total billed charges",""
"SCREW BONE 5X50MM HIP STARDRIVE TITANIUM SELF TAPPING PARTIAL THREAD BLUNT TIP T25 RECESS","SUP-ITM-10095906","CDM","C1713","HCPCS","0278","RC","","","","both","","","442.89","332.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","352.10","79.5","","800.18","480.96","1887.97","195","137.3","352.1","percent of total billed charges",""
"SCREW BONE 5X50MM HIP STARDRIVE TITANIUM SELF TAPPING PARTIAL THREAD BLUNT TIP T25 RECESS","SUP-ITM-10095906","CDM","C1713","HCPCS","0278","RC","","","","both","","","442.89","332.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","236.06","53.3","","813.12","216.42","1444.50","81","137.3","352.1","percent of total billed charges",""
"SCREW BONE 5X50MM HIP STARDRIVE TITANIUM SELF TAPPING PARTIAL THREAD BLUNT TIP T25 RECESS","SUP-ITM-10095906","CDM","C1713","HCPCS","0278","RC","","","","both","","","442.89","332.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","137.30","31","","432.60","432.60","432.60","1 through 10","137.3","352.1","percent of total billed charges",""
"SCREW BONE 5X50MM HIP STARDRIVE TITANIUM SELF TAPPING PARTIAL THREAD BLUNT TIP T25 RECESS","SUP-ITM-10095906","CDM","C1713","HCPCS","0278","RC","","","","both","","","442.89","332.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","161.65","36.5","","148.37","54.89","631.39","94","137.3","352.1","percent of total billed charges",""
"SCREW BONE 5X50MM HIP STARDRIVE TITANIUM SELF TAPPING PARTIAL THREAD BLUNT TIP T25 RECESS","SUP-ITM-10095906","CDM","C1713","HCPCS","0278","RC","","","","both","","","442.89","332.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","169.63","38.3","","279.30","91.72","1116.77","266","137.3","352.1","percent of total billed charges",""
"SCREW BONE 5X50MM HIP STARDRIVE TITANIUM SELF TAPPING PARTIAL THREAD BLUNT TIP T25 RECESS","SUP-ITM-10095906","CDM","C1713","HCPCS","0278","RC","","","","both","","","442.89","332.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","190.00","42.9","","731.00","63.70","731.00","1 through 10","137.3","352.1","percent of total billed charges",""
"SCREW BONE 5X50MM HIP STARDRIVE TITANIUM SELF TAPPING PARTIAL THREAD BLUNT TIP T25 RECESS","SUP-ITM-10095906","CDM","C1713","HCPCS","0278","RC","","","","both","","","442.89","332.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","190.00","42.9","","384.74","384.74","384.74","1 through 10","137.3","352.1","percent of total billed charges",""
"SCREW BONE 5X50MM HIP STARDRIVE TITANIUM SELF TAPPING PARTIAL THREAD BLUNT TIP T25 RECESS","SUP-ITM-10095906","CDM","C1713","HCPCS","0278","RC","","","","both","","","442.89","332.17","WELLPOINT [1015]","HB AMC WELLPOINT","326.76","73.78","","286.63","119.22","1107.45","105","137.3","352.1","percent of total billed charges",""
"SCREW BONE 5X50MM HIP STARDRIVE TITANIUM SELF TAPPING PARTIAL THREAD BLUNT TIP T25 RECESS","SUP-ITM-10095906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","442.89","332.17","AETNA [1001]","HB AMC AETNA HMO","309.14","69.8","","675.31","184.75","1721.50","286","231.45","361.93","percent of total billed charges",""
"SCREW BONE 5X50MM HIP STARDRIVE TITANIUM SELF TAPPING PARTIAL THREAD BLUNT TIP T25 RECESS","SUP-ITM-10095906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","442.89","332.17","AETNA [1001]","HB AMC AETNA PPO","356.08","80.4","","1261.44","103.12","1514.10","21","231.45","361.93","percent of total billed charges",""
"SCREW BONE 5X50MM HIP STARDRIVE TITANIUM SELF TAPPING PARTIAL THREAD BLUNT TIP T25 RECESS","SUP-ITM-10095906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","442.89","332.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","356.08","80.4","","1365.00","1365.00","1365.00","1 through 10","231.45","361.93","percent of total billed charges",""
"SCREW BONE 5X50MM HIP STARDRIVE TITANIUM SELF TAPPING PARTIAL THREAD BLUNT TIP T25 RECESS","SUP-ITM-10095906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","442.89","332.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","361.93","81.72","","5157.68","5157.68","5157.68","1 through 10","231.45","361.93","percent of total billed charges",""
"SCREW BONE 5X50MM HIP STARDRIVE TITANIUM SELF TAPPING PARTIAL THREAD BLUNT TIP T25 RECESS","SUP-ITM-10095906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","442.89","332.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","361.93","81.72","","431.26","71.26","1459.57","88","231.45","361.93","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING 2360-5050S","SUP-ITM-10232824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","902.62","79.5","","800.18","480.96","1887.97","195","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING 2360-5050S","SUP-ITM-10232824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","605.15","53.3","","813.12","216.42","1444.50","81","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING 2360-5050S","SUP-ITM-10232824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","351.96","31","","432.60","432.60","432.60","1 through 10","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING 2360-5050S","SUP-ITM-10232824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","414.41","36.5","","148.37","54.89","631.39","94","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING 2360-5050S","SUP-ITM-10232824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","434.85","38.3","","279.30","91.72","1116.77","266","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING 2360-5050S","SUP-ITM-10232824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","487.07","42.9","","731.00","63.70","731.00","1 through 10","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING 2360-5050S","SUP-ITM-10232824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","487.07","42.9","","384.74","384.74","384.74","1 through 10","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING 2360-5050S","SUP-ITM-10232824","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","WELLPOINT [1015]","HB AMC WELLPOINT","837.68","73.78","","286.63","119.22","1107.45","105","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING 2360-5050S","SUP-ITM-10232824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","AETNA [1001]","HB AMC AETNA HMO","792.49","69.8","","675.31","184.75","1721.50","286","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING 2360-5050S","SUP-ITM-10232824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","AETNA [1001]","HB AMC AETNA PPO","912.84","80.4","","1261.44","103.12","1514.10","21","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING 2360-5050S","SUP-ITM-10232824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","912.84","80.4","","1365.00","1365.00","1365.00","1 through 10","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING 2360-5050S","SUP-ITM-10232824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","927.82","81.72","","5157.68","5157.68","5157.68","1 through 10","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING 2360-5050S","SUP-ITM-10232824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","927.82","81.72","","431.26","71.26","1459.57","88","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING IM NAIL","SUP-ITM-10296336","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","547.99","79.5","","800.18","480.96","1887.97","195","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING IM NAIL","SUP-ITM-10296336","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","367.39","53.3","","813.12","216.42","1444.50","81","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING IM NAIL","SUP-ITM-10296336","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","213.68","31","","432.60","432.60","432.60","1 through 10","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING IM NAIL","SUP-ITM-10296336","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","251.59","36.5","","148.37","54.89","631.39","94","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING IM NAIL","SUP-ITM-10296336","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","264.00","38.3","","279.30","91.72","1116.77","266","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING IM NAIL","SUP-ITM-10296336","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","295.71","42.9","","731.00","63.70","731.00","1 through 10","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING IM NAIL","SUP-ITM-10296336","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","295.71","42.9","","384.74","384.74","384.74","1 through 10","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING IM NAIL","SUP-ITM-10296336","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.29","516.97","WELLPOINT [1015]","HB AMC WELLPOINT","508.56","73.78","","286.63","119.22","1107.45","105","213.68","547.99","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING IM NAIL","SUP-ITM-10296336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","AETNA [1001]","HB AMC AETNA HMO","481.12","69.8","","675.31","184.75","1721.50","286","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING IM NAIL","SUP-ITM-10296336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","AETNA [1001]","HB AMC AETNA PPO","554.19","80.4","","1261.44","103.12","1514.10","21","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING IM NAIL","SUP-ITM-10296336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","554.19","80.4","","1365.00","1365.00","1365.00","1 through 10","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING IM NAIL","SUP-ITM-10296336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","563.29","81.72","","5157.68","5157.68","5157.68","1 through 10","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X50MM LOCKING IM NAIL","SUP-ITM-10296336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.29","516.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","563.29","81.72","","431.26","71.26","1459.57","88","360.22","563.29","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","411.81","79.5","","800.18","480.96","1887.97","195","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","276.09","53.3","","813.12","216.42","1444.50","81","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","160.58","31","","432.60","432.60","432.60","1 through 10","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","189.07","36.5","","148.37","54.89","631.39","94","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","198.39","38.3","","279.30","91.72","1116.77","266","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.22","42.9","","731.00","63.70","731.00","1 through 10","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.22","42.9","","384.74","384.74","384.74","1 through 10","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","WELLPOINT [1015]","HB AMC WELLPOINT","382.18","73.78","","286.63","119.22","1107.45","105","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","AETNA [1001]","HB AMC AETNA HMO","361.56","69.8","","675.31","184.75","1721.50","286","270.71","423.31","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","AETNA [1001]","HB AMC AETNA PPO","416.47","80.4","","1261.44","103.12","1514.10","21","270.71","423.31","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","416.47","80.4","","1365.00","1365.00","1365.00","1 through 10","270.71","423.31","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","423.31","81.72","","5157.68","5157.68","5157.68","1 through 10","270.71","423.31","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","423.31","81.72","","431.26","71.26","1459.57","88","270.71","423.31","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","411.81","79.5","","800.18","480.96","1887.97","195","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","276.09","53.3","","813.12","216.42","1444.50","81","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","160.58","31","","432.60","432.60","432.60","1 through 10","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","189.07","36.5","","148.37","54.89","631.39","94","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","198.39","38.3","","279.30","91.72","1116.77","266","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.22","42.9","","731.00","63.70","731.00","1 through 10","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.22","42.9","","384.74","384.74","384.74","1 through 10","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","WELLPOINT [1015]","HB AMC WELLPOINT","382.18","73.78","","286.63","119.22","1107.45","105","160.58","411.81","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","AETNA [1001]","HB AMC AETNA HMO","361.56","69.8","","675.31","184.75","1721.50","286","270.71","423.31","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","AETNA [1001]","HB AMC AETNA PPO","416.47","80.4","","1261.44","103.12","1514.10","21","270.71","423.31","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","416.47","80.4","","1365.00","1365.00","1365.00","1 through 10","270.71","423.31","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","423.31","81.72","","5157.68","5157.68","5157.68","1 through 10","270.71","423.31","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","423.31","81.72","","431.26","71.26","1459.57","88","270.71","423.31","percent of total billed charges",""
"SCREW BONE 5X60MM LOCKING","SUP-ITM-10232820","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","902.62","79.5","","800.18","480.96","1887.97","195","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X60MM LOCKING","SUP-ITM-10232820","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","605.15","53.3","","813.12","216.42","1444.50","81","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X60MM LOCKING","SUP-ITM-10232820","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","351.96","31","","432.60","432.60","432.60","1 through 10","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X60MM LOCKING","SUP-ITM-10232820","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","414.41","36.5","","148.37","54.89","631.39","94","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X60MM LOCKING","SUP-ITM-10232820","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","434.85","38.3","","279.30","91.72","1116.77","266","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X60MM LOCKING","SUP-ITM-10232820","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","487.07","42.9","","731.00","63.70","731.00","1 through 10","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X60MM LOCKING","SUP-ITM-10232820","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","487.07","42.9","","384.74","384.74","384.74","1 through 10","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X60MM LOCKING","SUP-ITM-10232820","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","WELLPOINT [1015]","HB AMC WELLPOINT","837.68","73.78","","286.63","119.22","1107.45","105","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X60MM LOCKING","SUP-ITM-10232820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","AETNA [1001]","HB AMC AETNA HMO","792.49","69.8","","675.31","184.75","1721.50","286","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X60MM LOCKING","SUP-ITM-10232820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","AETNA [1001]","HB AMC AETNA PPO","912.84","80.4","","1261.44","103.12","1514.10","21","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X60MM LOCKING","SUP-ITM-10232820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","912.84","80.4","","1365.00","1365.00","1365.00","1 through 10","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X60MM LOCKING","SUP-ITM-10232820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","927.82","81.72","","5157.68","5157.68","5157.68","1 through 10","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X60MM LOCKING","SUP-ITM-10232820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","927.82","81.72","","431.26","71.26","1459.57","88","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","530.95","398.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","422.11","79.5","","800.18","480.96","1887.97","195","164.59","422.11","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","530.95","398.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","283.00","53.3","","813.12","216.42","1444.50","81","164.59","422.11","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","530.95","398.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","164.59","31","","432.60","432.60","432.60","1 through 10","164.59","422.11","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","530.95","398.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","193.80","36.5","","148.37","54.89","631.39","94","164.59","422.11","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","530.95","398.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.35","38.3","","279.30","91.72","1116.77","266","164.59","422.11","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","530.95","398.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","227.78","42.9","","731.00","63.70","731.00","1 through 10","164.59","422.11","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","530.95","398.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","227.78","42.9","","384.74","384.74","384.74","1 through 10","164.59","422.11","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","530.95","398.21","WELLPOINT [1015]","HB AMC WELLPOINT","391.73","73.78","","286.63","119.22","1107.45","105","164.59","422.11","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","530.95","398.21","AETNA [1001]","HB AMC AETNA HMO","370.60","69.8","","675.31","184.75","1721.50","286","277.47","433.89","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","530.95","398.21","AETNA [1001]","HB AMC AETNA PPO","426.88","80.4","","1261.44","103.12","1514.10","21","277.47","433.89","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","530.95","398.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","426.88","80.4","","1365.00","1365.00","1365.00","1 through 10","277.47","433.89","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","530.95","398.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","433.89","81.72","","5157.68","5157.68","5157.68","1 through 10","277.47","433.89","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","530.95","398.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","433.89","81.72","","431.26","71.26","1459.57","88","277.47","433.89","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING ADVANCED","SUP-ITM-10232794","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1137.96","79.5","","800.18","480.96","1887.97","195","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING ADVANCED","SUP-ITM-10232794","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","762.94","53.3","","813.12","216.42","1444.50","81","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING ADVANCED","SUP-ITM-10232794","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","443.73","31","","432.60","432.60","432.60","1 through 10","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING ADVANCED","SUP-ITM-10232794","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.46","36.5","","148.37","54.89","631.39","94","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING ADVANCED","SUP-ITM-10232794","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.23","38.3","","279.30","91.72","1116.77","266","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING ADVANCED","SUP-ITM-10232794","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","614.07","42.9","","731.00","63.70","731.00","1 through 10","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING ADVANCED","SUP-ITM-10232794","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","614.07","42.9","","384.74","384.74","384.74","1 through 10","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING ADVANCED","SUP-ITM-10232794","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","WELLPOINT [1015]","HB AMC WELLPOINT","1056.09","73.78","","286.63","119.22","1107.45","105","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING ADVANCED","SUP-ITM-10232794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1431.40","1073.55","AETNA [1001]","HB AMC AETNA HMO","999.12","69.8","","675.31","184.75","1721.50","286","748.05","1169.74","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING ADVANCED","SUP-ITM-10232794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1431.40","1073.55","AETNA [1001]","HB AMC AETNA PPO","1150.85","80.4","","1261.44","103.12","1514.10","21","748.05","1169.74","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING ADVANCED","SUP-ITM-10232794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1431.40","1073.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1150.85","80.4","","1365.00","1365.00","1365.00","1 through 10","748.05","1169.74","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING ADVANCED","SUP-ITM-10232794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1431.40","1073.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1169.74","81.72","","5157.68","5157.68","5157.68","1 through 10","748.05","1169.74","percent of total billed charges",""
"SCREW BONE 5X65MM LOCKING ADVANCED","SUP-ITM-10232794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1431.40","1073.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1169.74","81.72","","431.26","71.26","1459.57","88","748.05","1169.74","percent of total billed charges",""
"SCREW BONE 5X66MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296186","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","648.49","79.5","","800.18","480.96","1887.97","195","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X66MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296186","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","434.77","53.3","","813.12","216.42","1444.50","81","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X66MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296186","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","252.87","31","","432.60","432.60","432.60","1 through 10","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X66MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296186","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","297.73","36.5","","148.37","54.89","631.39","94","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X66MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296186","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","312.42","38.3","","279.30","91.72","1116.77","266","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X66MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296186","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","349.94","42.9","","731.00","63.70","731.00","1 through 10","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X66MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296186","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","349.94","42.9","","384.74","384.74","384.74","1 through 10","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X66MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296186","CDM","C1713","HCPCS","0278","RC","","","","both","","","815.71","611.78","WELLPOINT [1015]","HB AMC WELLPOINT","601.83","73.78","","286.63","119.22","1107.45","105","252.87","648.49","percent of total billed charges",""
"SCREW BONE 5X66MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","AETNA [1001]","HB AMC AETNA HMO","569.37","69.8","","675.31","184.75","1721.50","286","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X66MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","AETNA [1001]","HB AMC AETNA PPO","655.83","80.4","","1261.44","103.12","1514.10","21","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X66MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","655.83","80.4","","1365.00","1365.00","1365.00","1 through 10","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X66MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","666.60","81.72","","5157.68","5157.68","5157.68","1 through 10","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X66MM LOCKING IM NAIL LOW PROFILE","SUP-ITM-10296186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","815.71","611.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","666.60","81.72","","431.26","71.26","1459.57","88","426.29","666.6","percent of total billed charges",""
"SCREW BONE 5X67.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10136395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1252.13","79.5","","800.18","480.96","1887.97","195","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X67.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10136395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","839.48","53.3","","813.12","216.42","1444.50","81","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X67.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10136395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","488.25","31","","432.60","432.60","432.60","1 through 10","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X67.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10136395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","574.88","36.5","","148.37","54.89","631.39","94","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X67.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10136395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","603.23","38.3","","279.30","91.72","1116.77","266","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X67.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10136395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","731.00","63.70","731.00","1 through 10","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X67.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10136395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.68","42.9","","384.74","384.74","384.74","1 through 10","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X67.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10136395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB AMC WELLPOINT","1162.04","73.78","","286.63","119.22","1107.45","105","488.25","1252.13","percent of total billed charges",""
"SCREW BONE 5X67.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10136395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA HMO","1099.35","69.8","","675.31","184.75","1721.50","286","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X67.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10136395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","AETNA [1001]","HB AMC AETNA PPO","1266.30","80.4","","1261.44","103.12","1514.10","21","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X67.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10136395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1266.30","80.4","","1365.00","1365.00","1365.00","1 through 10","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X67.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10136395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1287.09","81.72","","5157.68","5157.68","5157.68","1 through 10","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X67.5MM TRIGEN SS LOCKING HEX INTERNAL CAPTURED LOW PROFILE GOLD","SUP-ITM-10136395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1287.09","81.72","","431.26","71.26","1459.57","88","823.1","1287.09","percent of total billed charges",""
"SCREW BONE 5X68MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296710","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","552.77","79.5","","800.18","480.96","1887.97","195","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X68MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296710","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","370.60","53.3","","813.12","216.42","1444.50","81","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X68MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296710","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","215.55","31","","432.60","432.60","432.60","1 through 10","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X68MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296710","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","253.79","36.5","","148.37","54.89","631.39","94","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X68MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296710","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","266.30","38.3","","279.30","91.72","1116.77","266","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X68MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296710","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.29","42.9","","731.00","63.70","731.00","1 through 10","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X68MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296710","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.29","42.9","","384.74","384.74","384.74","1 through 10","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X68MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296710","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","WELLPOINT [1015]","HB AMC WELLPOINT","513.00","73.78","","286.63","119.22","1107.45","105","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X68MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","AETNA [1001]","HB AMC AETNA HMO","485.33","69.8","","675.31","184.75","1721.50","286","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X68MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","AETNA [1001]","HB AMC AETNA PPO","559.03","80.4","","1261.44","103.12","1514.10","21","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X68MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","559.03","80.4","","1365.00","1365.00","1365.00","1 through 10","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X68MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","568.21","81.72","","5157.68","5157.68","5157.68","1 through 10","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X68MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","568.21","81.72","","431.26","71.26","1459.57","88","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X74MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA STERILE","SUP-ITM-10036845","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","452.99","79.5","","800.18","480.96","1887.97","195","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X74MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA STERILE","SUP-ITM-10036845","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","303.70","53.3","","813.12","216.42","1444.50","81","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X74MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA STERILE","SUP-ITM-10036845","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","176.64","31","","432.60","432.60","432.60","1 through 10","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X74MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA STERILE","SUP-ITM-10036845","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","207.98","36.5","","148.37","54.89","631.39","94","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X74MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA STERILE","SUP-ITM-10036845","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","218.23","38.3","","279.30","91.72","1116.77","266","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X74MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA STERILE","SUP-ITM-10036845","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.44","42.9","","731.00","63.70","731.00","1 through 10","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X74MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA STERILE","SUP-ITM-10036845","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.44","42.9","","384.74","384.74","384.74","1 through 10","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X74MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA STERILE","SUP-ITM-10036845","CDM","C1713","HCPCS","0278","RC","","","","both","","","569.80","427.35","WELLPOINT [1015]","HB AMC WELLPOINT","420.40","73.78","","286.63","119.22","1107.45","105","176.64","452.99","percent of total billed charges",""
"SCREW BONE 5X74MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA STERILE","SUP-ITM-10036845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.80","427.35","AETNA [1001]","HB AMC AETNA HMO","397.72","69.8","","675.31","184.75","1721.50","286","297.78","465.64","percent of total billed charges",""
"SCREW BONE 5X74MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA STERILE","SUP-ITM-10036845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.80","427.35","AETNA [1001]","HB AMC AETNA PPO","458.12","80.4","","1261.44","103.12","1514.10","21","297.78","465.64","percent of total billed charges",""
"SCREW BONE 5X74MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA STERILE","SUP-ITM-10036845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.80","427.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","458.12","80.4","","1365.00","1365.00","1365.00","1 through 10","297.78","465.64","percent of total billed charges",""
"SCREW BONE 5X74MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA STERILE","SUP-ITM-10036845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.80","427.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","465.64","81.72","","5157.68","5157.68","5157.68","1 through 10","297.78","465.64","percent of total billed charges",""
"SCREW BONE 5X74MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA STERILE","SUP-ITM-10036845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","569.80","427.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","465.64","81.72","","431.26","71.26","1459.57","88","297.78","465.64","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","512.82","384.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","407.69","79.5","","800.18","480.96","1887.97","195","158.97","407.69","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","512.82","384.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","273.33","53.3","","813.12","216.42","1444.50","81","158.97","407.69","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","512.82","384.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","158.97","31","","432.60","432.60","432.60","1 through 10","158.97","407.69","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","512.82","384.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","187.18","36.5","","148.37","54.89","631.39","94","158.97","407.69","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","512.82","384.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","196.41","38.3","","279.30","91.72","1116.77","266","158.97","407.69","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","512.82","384.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.00","42.9","","731.00","63.70","731.00","1 through 10","158.97","407.69","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","512.82","384.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.00","42.9","","384.74","384.74","384.74","1 through 10","158.97","407.69","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","both","","","512.82","384.61","WELLPOINT [1015]","HB AMC WELLPOINT","378.36","73.78","","286.63","119.22","1107.45","105","158.97","407.69","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","512.82","384.61","AETNA [1001]","HB AMC AETNA HMO","357.95","69.8","","675.31","184.75","1721.50","286","268","419.08","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","512.82","384.61","AETNA [1001]","HB AMC AETNA PPO","412.31","80.4","","1261.44","103.12","1514.10","21","268","419.08","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","512.82","384.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","412.31","80.4","","1365.00","1365.00","1365.00","1 through 10","268","419.08","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","512.82","384.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","419.08","81.72","","5157.68","5157.68","5157.68","1 through 10","268","419.08","percent of total billed charges",""
"SCREW BONE 5X75MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","512.82","384.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","419.08","81.72","","431.26","71.26","1459.57","88","268","419.08","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING","SUP-ITM-10232817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","902.62","79.5","","800.18","480.96","1887.97","195","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING","SUP-ITM-10232817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","605.15","53.3","","813.12","216.42","1444.50","81","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING","SUP-ITM-10232817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","351.96","31","","432.60","432.60","432.60","1 through 10","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING","SUP-ITM-10232817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","414.41","36.5","","148.37","54.89","631.39","94","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING","SUP-ITM-10232817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","434.85","38.3","","279.30","91.72","1116.77","266","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING","SUP-ITM-10232817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","487.07","42.9","","731.00","63.70","731.00","1 through 10","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING","SUP-ITM-10232817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","487.07","42.9","","384.74","384.74","384.74","1 through 10","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING","SUP-ITM-10232817","CDM","C1713","HCPCS","0278","RC","","","","both","","","1135.37","851.53","WELLPOINT [1015]","HB AMC WELLPOINT","837.68","73.78","","286.63","119.22","1107.45","105","351.96","902.62","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING","SUP-ITM-10232817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","AETNA [1001]","HB AMC AETNA HMO","792.49","69.8","","675.31","184.75","1721.50","286","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING","SUP-ITM-10232817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","AETNA [1001]","HB AMC AETNA PPO","912.84","80.4","","1261.44","103.12","1514.10","21","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING","SUP-ITM-10232817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","912.84","80.4","","1365.00","1365.00","1365.00","1 through 10","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING","SUP-ITM-10232817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","927.82","81.72","","5157.68","5157.68","5157.68","1 through 10","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING","SUP-ITM-10232817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1135.37","851.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","927.82","81.72","","431.26","71.26","1459.57","88","593.34","927.82","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.87","374.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","397.40","79.5","","800.18","480.96","1887.97","195","154.96","397.4","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.87","374.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","266.43","53.3","","813.12","216.42","1444.50","81","154.96","397.4","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.87","374.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","154.96","31","","432.60","432.60","432.60","1 through 10","154.96","397.4","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.87","374.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","182.45","36.5","","148.37","54.89","631.39","94","154.96","397.4","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.87","374.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","191.45","38.3","","279.30","91.72","1116.77","266","154.96","397.4","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.87","374.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.44","42.9","","731.00","63.70","731.00","1 through 10","154.96","397.4","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.87","374.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.44","42.9","","384.74","384.74","384.74","1 through 10","154.96","397.4","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","both","","","499.87","374.90","WELLPOINT [1015]","HB AMC WELLPOINT","368.80","73.78","","286.63","119.22","1107.45","105","154.96","397.4","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.87","374.90","AETNA [1001]","HB AMC AETNA HMO","348.91","69.8","","675.31","184.75","1721.50","286","261.23","408.49","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.87","374.90","AETNA [1001]","HB AMC AETNA PPO","401.90","80.4","","1261.44","103.12","1514.10","21","261.23","408.49","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.87","374.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","401.90","80.4","","1365.00","1365.00","1365.00","1 through 10","261.23","408.49","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.87","374.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","408.49","81.72","","5157.68","5157.68","5157.68","1 through 10","261.23","408.49","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","499.87","374.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","408.49","81.72","","431.26","71.26","1459.57","88","261.23","408.49","percent of total billed charges",""
"SCREW BONE 5X80MM CORTICAL TITANIUM LOCKING","SUP-ITM-10041064","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.87","434.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","460.20","79.5","","800.18","480.96","1887.97","195","179.45","460.2","percent of total billed charges",""
"SCREW BONE 5X80MM CORTICAL TITANIUM LOCKING","SUP-ITM-10041064","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.87","434.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","308.54","53.3","","813.12","216.42","1444.50","81","179.45","460.2","percent of total billed charges",""
"SCREW BONE 5X80MM CORTICAL TITANIUM LOCKING","SUP-ITM-10041064","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.87","434.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","179.45","31","","432.60","432.60","432.60","1 through 10","179.45","460.2","percent of total billed charges",""
"SCREW BONE 5X80MM CORTICAL TITANIUM LOCKING","SUP-ITM-10041064","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.87","434.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","211.29","36.5","","148.37","54.89","631.39","94","179.45","460.2","percent of total billed charges",""
"SCREW BONE 5X80MM CORTICAL TITANIUM LOCKING","SUP-ITM-10041064","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.87","434.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","221.71","38.3","","279.30","91.72","1116.77","266","179.45","460.2","percent of total billed charges",""
"SCREW BONE 5X80MM CORTICAL TITANIUM LOCKING","SUP-ITM-10041064","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.87","434.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","248.34","42.9","","731.00","63.70","731.00","1 through 10","179.45","460.2","percent of total billed charges",""
"SCREW BONE 5X80MM CORTICAL TITANIUM LOCKING","SUP-ITM-10041064","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.87","434.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","248.34","42.9","","384.74","384.74","384.74","1 through 10","179.45","460.2","percent of total billed charges",""
"SCREW BONE 5X80MM CORTICAL TITANIUM LOCKING","SUP-ITM-10041064","CDM","C1713","HCPCS","0278","RC","","","","both","","","578.87","434.15","WELLPOINT [1015]","HB AMC WELLPOINT","427.09","73.78","","286.63","119.22","1107.45","105","179.45","460.2","percent of total billed charges",""
"SCREW BONE 5X80MM CORTICAL TITANIUM LOCKING","SUP-ITM-10041064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","578.87","434.15","AETNA [1001]","HB AMC AETNA HMO","404.05","69.8","","675.31","184.75","1721.50","286","302.52","473.05","percent of total billed charges",""
"SCREW BONE 5X80MM CORTICAL TITANIUM LOCKING","SUP-ITM-10041064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","578.87","434.15","AETNA [1001]","HB AMC AETNA PPO","465.41","80.4","","1261.44","103.12","1514.10","21","302.52","473.05","percent of total billed charges",""
"SCREW BONE 5X80MM CORTICAL TITANIUM LOCKING","SUP-ITM-10041064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","578.87","434.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","465.41","80.4","","1365.00","1365.00","1365.00","1 through 10","302.52","473.05","percent of total billed charges",""
"SCREW BONE 5X80MM CORTICAL TITANIUM LOCKING","SUP-ITM-10041064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","578.87","434.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","473.05","81.72","","5157.68","5157.68","5157.68","1 through 10","302.52","473.05","percent of total billed charges",""
"SCREW BONE 5X80MM CORTICAL TITANIUM LOCKING","SUP-ITM-10041064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","578.87","434.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","473.05","81.72","","431.26","71.26","1459.57","88","302.52","473.05","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING ADVANCED","SUP-ITM-10232789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1137.96","79.5","","800.18","480.96","1887.97","195","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING ADVANCED","SUP-ITM-10232789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","762.94","53.3","","813.12","216.42","1444.50","81","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING ADVANCED","SUP-ITM-10232789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","443.73","31","","432.60","432.60","432.60","1 through 10","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING ADVANCED","SUP-ITM-10232789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.46","36.5","","148.37","54.89","631.39","94","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING ADVANCED","SUP-ITM-10232789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.23","38.3","","279.30","91.72","1116.77","266","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING ADVANCED","SUP-ITM-10232789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","614.07","42.9","","731.00","63.70","731.00","1 through 10","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING ADVANCED","SUP-ITM-10232789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","614.07","42.9","","384.74","384.74","384.74","1 through 10","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING ADVANCED","SUP-ITM-10232789","CDM","C1713","HCPCS","0278","RC","","","","both","","","1431.40","1073.55","WELLPOINT [1015]","HB AMC WELLPOINT","1056.09","73.78","","286.63","119.22","1107.45","105","443.73","1137.96","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING ADVANCED","SUP-ITM-10232789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1431.40","1073.55","AETNA [1001]","HB AMC AETNA HMO","999.12","69.8","","675.31","184.75","1721.50","286","748.05","1169.74","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING ADVANCED","SUP-ITM-10232789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1431.40","1073.55","AETNA [1001]","HB AMC AETNA PPO","1150.85","80.4","","1261.44","103.12","1514.10","21","748.05","1169.74","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING ADVANCED","SUP-ITM-10232789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1431.40","1073.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1150.85","80.4","","1365.00","1365.00","1365.00","1 through 10","748.05","1169.74","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING ADVANCED","SUP-ITM-10232789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1431.40","1073.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1169.74","81.72","","5157.68","5157.68","5157.68","1 through 10","748.05","1169.74","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING ADVANCED","SUP-ITM-10232789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1431.40","1073.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1169.74","81.72","","431.26","71.26","1459.57","88","748.05","1169.74","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING VARIABLE ANGLE SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273943","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","434.32","79.5","","800.18","480.96","1887.97","195","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING VARIABLE ANGLE SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273943","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","291.19","53.3","","813.12","216.42","1444.50","81","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING VARIABLE ANGLE SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273943","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","169.36","31","","432.60","432.60","432.60","1 through 10","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING VARIABLE ANGLE SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273943","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","199.41","36.5","","148.37","54.89","631.39","94","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING VARIABLE ANGLE SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273943","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","209.24","38.3","","279.30","91.72","1116.77","266","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING VARIABLE ANGLE SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273943","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.37","42.9","","731.00","63.70","731.00","1 through 10","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING VARIABLE ANGLE SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273943","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.37","42.9","","384.74","384.74","384.74","1 through 10","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING VARIABLE ANGLE SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273943","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.32","409.74","WELLPOINT [1015]","HB AMC WELLPOINT","403.07","73.78","","286.63","119.22","1107.45","105","169.36","434.32","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING VARIABLE ANGLE SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.32","409.74","AETNA [1001]","HB AMC AETNA HMO","381.33","69.8","","675.31","184.75","1721.50","286","285.51","446.45","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING VARIABLE ANGLE SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.32","409.74","AETNA [1001]","HB AMC AETNA PPO","439.24","80.4","","1261.44","103.12","1514.10","21","285.51","446.45","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING VARIABLE ANGLE SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.32","409.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","439.24","80.4","","1365.00","1365.00","1365.00","1 through 10","285.51","446.45","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING VARIABLE ANGLE SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.32","409.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","446.45","81.72","","5157.68","5157.68","5157.68","1 through 10","285.51","446.45","percent of total billed charges",""
"SCREW BONE 5X90MM LOCKING VARIABLE ANGLE SELF TAPPING OPTILINK STARDRIVE","SUP-ITM-10273943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.32","409.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","446.45","81.72","","431.26","71.26","1459.57","88","285.51","446.45","percent of total billed charges",""
"SCREW BONE 5X95MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296698","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","552.77","79.5","","800.18","480.96","1887.97","195","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X95MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296698","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","370.60","53.3","","813.12","216.42","1444.50","81","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X95MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296698","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","215.55","31","","432.60","432.60","432.60","1 through 10","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X95MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296698","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","253.79","36.5","","148.37","54.89","631.39","94","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X95MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296698","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","266.30","38.3","","279.30","91.72","1116.77","266","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X95MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296698","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.29","42.9","","731.00","63.70","731.00","1 through 10","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X95MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296698","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.29","42.9","","384.74","384.74","384.74","1 through 10","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X95MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296698","CDM","C1713","HCPCS","0278","RC","","","","both","","","695.31","521.48","WELLPOINT [1015]","HB AMC WELLPOINT","513.00","73.78","","286.63","119.22","1107.45","105","215.55","552.77","percent of total billed charges",""
"SCREW BONE 5X95MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","AETNA [1001]","HB AMC AETNA HMO","485.33","69.8","","675.31","184.75","1721.50","286","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X95MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","AETNA [1001]","HB AMC AETNA PPO","559.03","80.4","","1261.44","103.12","1514.10","21","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X95MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","559.03","80.4","","1365.00","1365.00","1365.00","1 through 10","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X95MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","568.21","81.72","","5157.68","5157.68","5157.68","1 through 10","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X95MM LOCKING HEADLESS LOW PROFILE MEDULLARY NAIL COMPATIBLE","SUP-ITM-10296698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","695.31","521.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","568.21","81.72","","431.26","71.26","1459.57","88","363.37","568.21","percent of total billed charges",""
"SCREW BONE 5X95MM VAL OPTILINK SELF-TAPPING","SUP-ITM-10310930","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.82","522.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","553.97","79.5","","800.18","480.96","1887.97","195","216.01","553.97","percent of total billed charges",""
"SCREW BONE 5X95MM VAL OPTILINK SELF-TAPPING","SUP-ITM-10310930","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.82","522.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","371.41","53.3","","813.12","216.42","1444.50","81","216.01","553.97","percent of total billed charges",""
"SCREW BONE 5X95MM VAL OPTILINK SELF-TAPPING","SUP-ITM-10310930","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.82","522.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","216.01","31","","432.60","432.60","432.60","1 through 10","216.01","553.97","percent of total billed charges",""
"SCREW BONE 5X95MM VAL OPTILINK SELF-TAPPING","SUP-ITM-10310930","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.82","522.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","254.34","36.5","","148.37","54.89","631.39","94","216.01","553.97","percent of total billed charges",""
"SCREW BONE 5X95MM VAL OPTILINK SELF-TAPPING","SUP-ITM-10310930","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.82","522.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","266.88","38.3","","279.30","91.72","1116.77","266","216.01","553.97","percent of total billed charges",""
"SCREW BONE 5X95MM VAL OPTILINK SELF-TAPPING","SUP-ITM-10310930","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.82","522.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.94","42.9","","731.00","63.70","731.00","1 through 10","216.01","553.97","percent of total billed charges",""
"SCREW BONE 5X95MM VAL OPTILINK SELF-TAPPING","SUP-ITM-10310930","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.82","522.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.94","42.9","","384.74","384.74","384.74","1 through 10","216.01","553.97","percent of total billed charges",""
"SCREW BONE 5X95MM VAL OPTILINK SELF-TAPPING","SUP-ITM-10310930","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.82","522.61","WELLPOINT [1015]","HB AMC WELLPOINT","514.11","73.78","","286.63","119.22","1107.45","105","216.01","553.97","percent of total billed charges",""
"SCREW BONE 5X95MM VAL OPTILINK SELF-TAPPING","SUP-ITM-10310930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.82","522.61","AETNA [1001]","HB AMC AETNA HMO","486.38","69.8","","675.31","184.75","1721.50","286","364.16","569.44","percent of total billed charges",""
"SCREW BONE 5X95MM VAL OPTILINK SELF-TAPPING","SUP-ITM-10310930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.82","522.61","AETNA [1001]","HB AMC AETNA PPO","560.24","80.4","","1261.44","103.12","1514.10","21","364.16","569.44","percent of total billed charges",""
"SCREW BONE 5X95MM VAL OPTILINK SELF-TAPPING","SUP-ITM-10310930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.82","522.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","560.24","80.4","","1365.00","1365.00","1365.00","1 through 10","364.16","569.44","percent of total billed charges",""
"SCREW BONE 5X95MM VAL OPTILINK SELF-TAPPING","SUP-ITM-10310930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.82","522.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","569.44","81.72","","5157.68","5157.68","5157.68","1 through 10","364.16","569.44","percent of total billed charges",""
"SCREW BONE 5X95MM VAL OPTILINK SELF-TAPPING","SUP-ITM-10310930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.82","522.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","569.44","81.72","","431.26","71.26","1459.57","88","364.16","569.44","percent of total billed charges",""
"SCREW BONE 6.0X35MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025480","CDM","C1889","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2328.95","79.5","","1309.77","674.56","6049.93","26","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6.0X35MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025480","CDM","C1889","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1561.42","53.3","","1901.83","1901.83","2962.25","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6.0X35MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025480","CDM","C1889","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1069.27","36.5","","1620.31","1620.31","19908.88","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6.0X35MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025480","CDM","C1889","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1122.00","38.3","","352.91","352.91","2046.30","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6.0X35MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025480","CDM","C1889","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","9668.75","9668.75","9668.75","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6.0X35MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025480","CDM","C1889","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","WELLPOINT [1015]","HB AMC WELLPOINT","2161.39","73.78","","699.88","384.10","3443.31","33","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6.0X35MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025480","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA HMO","2044.79","69.8","","1421.24","264.50","4933.46","29","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 6.0X35MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025480","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2355.32","80.4","","1022.97","1022.97","3607.50","1 through 10","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 6.0X35MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025480","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2393.99","81.72","","3010.54","693.88","5019.88","35","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 6.4X100MM CORTICAL TRIGEN TITANIUM ANTEGRADE CAPTURED RECONSTRUCTION BLUE","SUP-ITM-10063493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2017.31","79.5","","800.18","480.96","1887.97","195","786.63","2017.31","percent of total billed charges",""
"SCREW BONE 6.4X100MM CORTICAL TRIGEN TITANIUM ANTEGRADE CAPTURED RECONSTRUCTION BLUE","SUP-ITM-10063493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1352.49","53.3","","813.12","216.42","1444.50","81","786.63","2017.31","percent of total billed charges",""
"SCREW BONE 6.4X100MM CORTICAL TRIGEN TITANIUM ANTEGRADE CAPTURED RECONSTRUCTION BLUE","SUP-ITM-10063493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","786.63","31","","432.60","432.60","432.60","1 through 10","786.63","2017.31","percent of total billed charges",""
"SCREW BONE 6.4X100MM CORTICAL TRIGEN TITANIUM ANTEGRADE CAPTURED RECONSTRUCTION BLUE","SUP-ITM-10063493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","926.19","36.5","","148.37","54.89","631.39","94","786.63","2017.31","percent of total billed charges",""
"SCREW BONE 6.4X100MM CORTICAL TRIGEN TITANIUM ANTEGRADE CAPTURED RECONSTRUCTION BLUE","SUP-ITM-10063493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","971.86","38.3","","279.30","91.72","1116.77","266","786.63","2017.31","percent of total billed charges",""
"SCREW BONE 6.4X100MM CORTICAL TRIGEN TITANIUM ANTEGRADE CAPTURED RECONSTRUCTION BLUE","SUP-ITM-10063493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1088.59","42.9","","731.00","63.70","731.00","1 through 10","786.63","2017.31","percent of total billed charges",""
"SCREW BONE 6.4X100MM CORTICAL TRIGEN TITANIUM ANTEGRADE CAPTURED RECONSTRUCTION BLUE","SUP-ITM-10063493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1088.59","42.9","","384.74","384.74","384.74","1 through 10","786.63","2017.31","percent of total billed charges",""
"SCREW BONE 6.4X100MM CORTICAL TRIGEN TITANIUM ANTEGRADE CAPTURED RECONSTRUCTION BLUE","SUP-ITM-10063493","CDM","C1713","HCPCS","0278","RC","","","","both","","","2537.50","1903.12","WELLPOINT [1015]","HB AMC WELLPOINT","1872.17","73.78","","286.63","119.22","1107.45","105","786.63","2017.31","percent of total billed charges",""
"SCREW BONE 6.4X100MM CORTICAL TRIGEN TITANIUM ANTEGRADE CAPTURED RECONSTRUCTION BLUE","SUP-ITM-10063493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2537.50","1903.12","AETNA [1001]","HB AMC AETNA HMO","1771.18","69.8","","675.31","184.75","1721.50","286","1326.1","2073.65","percent of total billed charges",""
"SCREW BONE 6.4X100MM CORTICAL TRIGEN TITANIUM ANTEGRADE CAPTURED RECONSTRUCTION BLUE","SUP-ITM-10063493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2537.50","1903.12","AETNA [1001]","HB AMC AETNA PPO","2040.15","80.4","","1261.44","103.12","1514.10","21","1326.1","2073.65","percent of total billed charges",""
"SCREW BONE 6.4X100MM CORTICAL TRIGEN TITANIUM ANTEGRADE CAPTURED RECONSTRUCTION BLUE","SUP-ITM-10063493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2537.50","1903.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2040.15","80.4","","1365.00","1365.00","1365.00","1 through 10","1326.1","2073.65","percent of total billed charges",""
"SCREW BONE 6.4X100MM CORTICAL TRIGEN TITANIUM ANTEGRADE CAPTURED RECONSTRUCTION BLUE","SUP-ITM-10063493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2537.50","1903.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2073.65","81.72","","5157.68","5157.68","5157.68","1 through 10","1326.1","2073.65","percent of total billed charges",""
"SCREW BONE 6.4X100MM CORTICAL TRIGEN TITANIUM ANTEGRADE CAPTURED RECONSTRUCTION BLUE","SUP-ITM-10063493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2537.50","1903.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2073.65","81.72","","431.26","71.26","1459.57","88","1326.1","2073.65","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS PARTIAL THREAD TITANIUM LAG DRIVE END","SUP-ITM-10071437","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.00","803.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","851.45","79.5","","800.18","480.96","1887.97","195","332.01","851.45","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS PARTIAL THREAD TITANIUM LAG DRIVE END","SUP-ITM-10071437","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.00","803.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","570.84","53.3","","813.12","216.42","1444.50","81","332.01","851.45","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS PARTIAL THREAD TITANIUM LAG DRIVE END","SUP-ITM-10071437","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.00","803.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","332.01","31","","432.60","432.60","432.60","1 through 10","332.01","851.45","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS PARTIAL THREAD TITANIUM LAG DRIVE END","SUP-ITM-10071437","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.00","803.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","390.92","36.5","","148.37","54.89","631.39","94","332.01","851.45","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS PARTIAL THREAD TITANIUM LAG DRIVE END","SUP-ITM-10071437","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.00","803.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","410.19","38.3","","279.30","91.72","1116.77","266","332.01","851.45","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS PARTIAL THREAD TITANIUM LAG DRIVE END","SUP-ITM-10071437","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.00","803.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","459.46","42.9","","731.00","63.70","731.00","1 through 10","332.01","851.45","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS PARTIAL THREAD TITANIUM LAG DRIVE END","SUP-ITM-10071437","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.00","803.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","459.46","42.9","","384.74","384.74","384.74","1 through 10","332.01","851.45","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS PARTIAL THREAD TITANIUM LAG DRIVE END","SUP-ITM-10071437","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.00","803.25","WELLPOINT [1015]","HB AMC WELLPOINT","790.18","73.78","","286.63","119.22","1107.45","105","332.01","851.45","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS PARTIAL THREAD TITANIUM LAG DRIVE END","SUP-ITM-10071437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.00","803.25","AETNA [1001]","HB AMC AETNA HMO","747.56","69.8","","675.31","184.75","1721.50","286","559.7","875.22","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS PARTIAL THREAD TITANIUM LAG DRIVE END","SUP-ITM-10071437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.00","803.25","AETNA [1001]","HB AMC AETNA PPO","861.08","80.4","","1261.44","103.12","1514.10","21","559.7","875.22","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS PARTIAL THREAD TITANIUM LAG DRIVE END","SUP-ITM-10071437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.00","803.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","861.08","80.4","","1365.00","1365.00","1365.00","1 through 10","559.7","875.22","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS PARTIAL THREAD TITANIUM LAG DRIVE END","SUP-ITM-10071437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.00","803.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","875.22","81.72","","5157.68","5157.68","5157.68","1 through 10","559.7","875.22","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS PARTIAL THREAD TITANIUM LAG DRIVE END","SUP-ITM-10071437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.00","803.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","875.22","81.72","","431.26","71.26","1459.57","88","559.7","875.22","percent of total billed charges",""
"SCREW BONE 6.5X100MM LAG T2 TITANIUM RECONSTRUCTION","SUP-ITM-10033900","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1045.61","79.5","","800.18","480.96","1887.97","195","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X100MM LAG T2 TITANIUM RECONSTRUCTION","SUP-ITM-10033900","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","701.02","53.3","","813.12","216.42","1444.50","81","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X100MM LAG T2 TITANIUM RECONSTRUCTION","SUP-ITM-10033900","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","407.72","31","","432.60","432.60","432.60","1 through 10","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X100MM LAG T2 TITANIUM RECONSTRUCTION","SUP-ITM-10033900","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","480.06","36.5","","148.37","54.89","631.39","94","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X100MM LAG T2 TITANIUM RECONSTRUCTION","SUP-ITM-10033900","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","503.73","38.3","","279.30","91.72","1116.77","266","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X100MM LAG T2 TITANIUM RECONSTRUCTION","SUP-ITM-10033900","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","564.23","42.9","","731.00","63.70","731.00","1 through 10","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X100MM LAG T2 TITANIUM RECONSTRUCTION","SUP-ITM-10033900","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","564.23","42.9","","384.74","384.74","384.74","1 through 10","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X100MM LAG T2 TITANIUM RECONSTRUCTION","SUP-ITM-10033900","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","WELLPOINT [1015]","HB AMC WELLPOINT","970.38","73.78","","286.63","119.22","1107.45","105","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X100MM LAG T2 TITANIUM RECONSTRUCTION","SUP-ITM-10033900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.23","986.42","AETNA [1001]","HB AMC AETNA HMO","918.03","69.8","","675.31","184.75","1721.50","286","687.34","1074.81","percent of total billed charges",""
"SCREW BONE 6.5X100MM LAG T2 TITANIUM RECONSTRUCTION","SUP-ITM-10033900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.23","986.42","AETNA [1001]","HB AMC AETNA PPO","1057.44","80.4","","1261.44","103.12","1514.10","21","687.34","1074.81","percent of total billed charges",""
"SCREW BONE 6.5X100MM LAG T2 TITANIUM RECONSTRUCTION","SUP-ITM-10033900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.23","986.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1057.44","80.4","","1365.00","1365.00","1365.00","1 through 10","687.34","1074.81","percent of total billed charges",""
"SCREW BONE 6.5X100MM LAG T2 TITANIUM RECONSTRUCTION","SUP-ITM-10033900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.23","986.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1074.81","81.72","","5157.68","5157.68","5157.68","1 through 10","687.34","1074.81","percent of total billed charges",""
"SCREW BONE 6.5X100MM LAG T2 TITANIUM RECONSTRUCTION","SUP-ITM-10033900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.23","986.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1074.81","81.72","","431.26","71.26","1459.57","88","687.34","1074.81","percent of total billed charges",""
"SCREW BONE 6.5X105MM 16MM THREAD CANCELLOUS TITANIUM HEXAGONAL SOCKET","SUP-ITM-10002371","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.15","165.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","175.02","79.5","","800.18","480.96","1887.97","195","68.25","175.02","percent of total billed charges",""
"SCREW BONE 6.5X105MM 16MM THREAD CANCELLOUS TITANIUM HEXAGONAL SOCKET","SUP-ITM-10002371","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.15","165.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.34","53.3","","813.12","216.42","1444.50","81","68.25","175.02","percent of total billed charges",""
"SCREW BONE 6.5X105MM 16MM THREAD CANCELLOUS TITANIUM HEXAGONAL SOCKET","SUP-ITM-10002371","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.15","165.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.25","31","","432.60","432.60","432.60","1 through 10","68.25","175.02","percent of total billed charges",""
"SCREW BONE 6.5X105MM 16MM THREAD CANCELLOUS TITANIUM HEXAGONAL SOCKET","SUP-ITM-10002371","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.15","165.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.35","36.5","","148.37","54.89","631.39","94","68.25","175.02","percent of total billed charges",""
"SCREW BONE 6.5X105MM 16MM THREAD CANCELLOUS TITANIUM HEXAGONAL SOCKET","SUP-ITM-10002371","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.15","165.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.32","38.3","","279.30","91.72","1116.77","266","68.25","175.02","percent of total billed charges",""
"SCREW BONE 6.5X105MM 16MM THREAD CANCELLOUS TITANIUM HEXAGONAL SOCKET","SUP-ITM-10002371","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.15","165.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.44","42.9","","731.00","63.70","731.00","1 through 10","68.25","175.02","percent of total billed charges",""
"SCREW BONE 6.5X105MM 16MM THREAD CANCELLOUS TITANIUM HEXAGONAL SOCKET","SUP-ITM-10002371","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.15","165.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.44","42.9","","384.74","384.74","384.74","1 through 10","68.25","175.02","percent of total billed charges",""
"SCREW BONE 6.5X105MM 16MM THREAD CANCELLOUS TITANIUM HEXAGONAL SOCKET","SUP-ITM-10002371","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.15","165.11","WELLPOINT [1015]","HB AMC WELLPOINT","162.43","73.78","","286.63","119.22","1107.45","105","68.25","175.02","percent of total billed charges",""
"SCREW BONE 6.5X105MM 16MM THREAD CANCELLOUS TITANIUM HEXAGONAL SOCKET","SUP-ITM-10002371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.15","165.11","AETNA [1001]","HB AMC AETNA HMO","153.66","69.8","","675.31","184.75","1721.50","286","115.05","179.91","percent of total billed charges",""
"SCREW BONE 6.5X105MM 16MM THREAD CANCELLOUS TITANIUM HEXAGONAL SOCKET","SUP-ITM-10002371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.15","165.11","AETNA [1001]","HB AMC AETNA PPO","177.00","80.4","","1261.44","103.12","1514.10","21","115.05","179.91","percent of total billed charges",""
"SCREW BONE 6.5X105MM 16MM THREAD CANCELLOUS TITANIUM HEXAGONAL SOCKET","SUP-ITM-10002371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.15","165.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","177.00","80.4","","1365.00","1365.00","1365.00","1 through 10","115.05","179.91","percent of total billed charges",""
"SCREW BONE 6.5X105MM 16MM THREAD CANCELLOUS TITANIUM HEXAGONAL SOCKET","SUP-ITM-10002371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.15","165.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.91","81.72","","5157.68","5157.68","5157.68","1 through 10","115.05","179.91","percent of total billed charges",""
"SCREW BONE 6.5X105MM 16MM THREAD CANCELLOUS TITANIUM HEXAGONAL SOCKET","SUP-ITM-10002371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.15","165.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.91","81.72","","431.26","71.26","1459.57","88","115.05","179.91","percent of total billed charges",""
"SCREW BONE 6.5X115MM FULL THREAD ASNIS III TITANIUM","SUP-ITM-10144292","CDM","C1713","HCPCS","0278","RC","","","","both","","","1611.26","1208.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1280.95","79.5","","800.18","480.96","1887.97","195","499.49","1280.95","percent of total billed charges",""
"SCREW BONE 6.5X115MM FULL THREAD ASNIS III TITANIUM","SUP-ITM-10144292","CDM","C1713","HCPCS","0278","RC","","","","both","","","1611.26","1208.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","858.80","53.3","","813.12","216.42","1444.50","81","499.49","1280.95","percent of total billed charges",""
"SCREW BONE 6.5X115MM FULL THREAD ASNIS III TITANIUM","SUP-ITM-10144292","CDM","C1713","HCPCS","0278","RC","","","","both","","","1611.26","1208.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","499.49","31","","432.60","432.60","432.60","1 through 10","499.49","1280.95","percent of total billed charges",""
"SCREW BONE 6.5X115MM FULL THREAD ASNIS III TITANIUM","SUP-ITM-10144292","CDM","C1713","HCPCS","0278","RC","","","","both","","","1611.26","1208.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","588.11","36.5","","148.37","54.89","631.39","94","499.49","1280.95","percent of total billed charges",""
"SCREW BONE 6.5X115MM FULL THREAD ASNIS III TITANIUM","SUP-ITM-10144292","CDM","C1713","HCPCS","0278","RC","","","","both","","","1611.26","1208.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","617.11","38.3","","279.30","91.72","1116.77","266","499.49","1280.95","percent of total billed charges",""
"SCREW BONE 6.5X115MM FULL THREAD ASNIS III TITANIUM","SUP-ITM-10144292","CDM","C1713","HCPCS","0278","RC","","","","both","","","1611.26","1208.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","691.23","42.9","","731.00","63.70","731.00","1 through 10","499.49","1280.95","percent of total billed charges",""
"SCREW BONE 6.5X115MM FULL THREAD ASNIS III TITANIUM","SUP-ITM-10144292","CDM","C1713","HCPCS","0278","RC","","","","both","","","1611.26","1208.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","691.23","42.9","","384.74","384.74","384.74","1 through 10","499.49","1280.95","percent of total billed charges",""
"SCREW BONE 6.5X115MM FULL THREAD ASNIS III TITANIUM","SUP-ITM-10144292","CDM","C1713","HCPCS","0278","RC","","","","both","","","1611.26","1208.44","WELLPOINT [1015]","HB AMC WELLPOINT","1188.79","73.78","","286.63","119.22","1107.45","105","499.49","1280.95","percent of total billed charges",""
"SCREW BONE 6.5X115MM FULL THREAD ASNIS III TITANIUM","SUP-ITM-10144292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1611.26","1208.44","AETNA [1001]","HB AMC AETNA HMO","1124.66","69.8","","675.31","184.75","1721.50","286","842.04","1316.72","percent of total billed charges",""
"SCREW BONE 6.5X115MM FULL THREAD ASNIS III TITANIUM","SUP-ITM-10144292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1611.26","1208.44","AETNA [1001]","HB AMC AETNA PPO","1295.45","80.4","","1261.44","103.12","1514.10","21","842.04","1316.72","percent of total billed charges",""
"SCREW BONE 6.5X115MM FULL THREAD ASNIS III TITANIUM","SUP-ITM-10144292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1611.26","1208.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1295.45","80.4","","1365.00","1365.00","1365.00","1 through 10","842.04","1316.72","percent of total billed charges",""
"SCREW BONE 6.5X115MM FULL THREAD ASNIS III TITANIUM","SUP-ITM-10144292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1611.26","1208.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1316.72","81.72","","5157.68","5157.68","5157.68","1 through 10","842.04","1316.72","percent of total billed charges",""
"SCREW BONE 6.5X115MM FULL THREAD ASNIS III TITANIUM","SUP-ITM-10144292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1611.26","1208.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1316.72","81.72","","431.26","71.26","1459.57","88","842.04","1316.72","percent of total billed charges",""
"SCREW BONE 6.5X115MM LG 16MM THREAD CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10002327","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.46","182.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","193.55","79.5","","800.18","480.96","1887.97","195","75.47","193.55","percent of total billed charges",""
"SCREW BONE 6.5X115MM LG 16MM THREAD CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10002327","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.46","182.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","129.76","53.3","","813.12","216.42","1444.50","81","75.47","193.55","percent of total billed charges",""
"SCREW BONE 6.5X115MM LG 16MM THREAD CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10002327","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.46","182.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","75.47","31","","432.60","432.60","432.60","1 through 10","75.47","193.55","percent of total billed charges",""
"SCREW BONE 6.5X115MM LG 16MM THREAD CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10002327","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.46","182.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","88.86","36.5","","148.37","54.89","631.39","94","75.47","193.55","percent of total billed charges",""
"SCREW BONE 6.5X115MM LG 16MM THREAD CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10002327","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.46","182.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","93.25","38.3","","279.30","91.72","1116.77","266","75.47","193.55","percent of total billed charges",""
"SCREW BONE 6.5X115MM LG 16MM THREAD CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10002327","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.46","182.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.44","42.9","","731.00","63.70","731.00","1 through 10","75.47","193.55","percent of total billed charges",""
"SCREW BONE 6.5X115MM LG 16MM THREAD CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10002327","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.46","182.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.44","42.9","","384.74","384.74","384.74","1 through 10","75.47","193.55","percent of total billed charges",""
"SCREW BONE 6.5X115MM LG 16MM THREAD CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10002327","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.46","182.59","WELLPOINT [1015]","HB AMC WELLPOINT","179.62","73.78","","286.63","119.22","1107.45","105","75.47","193.55","percent of total billed charges",""
"SCREW BONE 6.5X115MM LG 16MM THREAD CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10002327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","243.46","182.59","AETNA [1001]","HB AMC AETNA HMO","169.94","69.8","","675.31","184.75","1721.50","286","127.23","198.96","percent of total billed charges",""
"SCREW BONE 6.5X115MM LG 16MM THREAD CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10002327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","243.46","182.59","AETNA [1001]","HB AMC AETNA PPO","195.74","80.4","","1261.44","103.12","1514.10","21","127.23","198.96","percent of total billed charges",""
"SCREW BONE 6.5X115MM LG 16MM THREAD CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10002327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","243.46","182.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","195.74","80.4","","1365.00","1365.00","1365.00","1 through 10","127.23","198.96","percent of total billed charges",""
"SCREW BONE 6.5X115MM LG 16MM THREAD CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10002327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","243.46","182.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","198.96","81.72","","5157.68","5157.68","5157.68","1 through 10","127.23","198.96","percent of total billed charges",""
"SCREW BONE 6.5X115MM LG 16MM THREAD CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10002327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","243.46","182.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","198.96","81.72","","431.26","71.26","1459.57","88","127.23","198.96","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","800.18","480.96","1887.97","195","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.64","53.3","","813.12","216.42","1444.50","81","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.13","31","","432.60","432.60","432.60","1 through 10","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","148.37","54.89","631.39","94","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","279.30","91.72","1116.77","266","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","731.00","63.70","731.00","1 through 10","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","384.74","384.74","384.74","1 through 10","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","286.63","119.22","1107.45","105","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","675.31","184.75","1721.50","286","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","1261.44","103.12","1514.10","21","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","70.35","80.4","","1365.00","1365.00","1365.00","1 through 10","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","71.51","81.72","","5157.68","5157.68","5157.68","1 through 10","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","431.26","71.26","1459.57","88","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.52","437.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","463.90","79.5","","800.18","480.96","1887.97","195","180.89","463.9","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.52","437.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","311.02","53.3","","813.12","216.42","1444.50","81","180.89","463.9","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.52","437.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","180.89","31","","432.60","432.60","432.60","1 through 10","180.89","463.9","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.52","437.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","212.98","36.5","","148.37","54.89","631.39","94","180.89","463.9","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.52","437.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","223.49","38.3","","279.30","91.72","1116.77","266","180.89","463.9","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.52","437.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.33","42.9","","731.00","63.70","731.00","1 through 10","180.89","463.9","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.52","437.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.33","42.9","","384.74","384.74","384.74","1 through 10","180.89","463.9","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","both","","","583.52","437.64","WELLPOINT [1015]","HB AMC WELLPOINT","430.52","73.78","","286.63","119.22","1107.45","105","180.89","463.9","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","583.52","437.64","AETNA [1001]","HB AMC AETNA HMO","407.30","69.8","","675.31","184.75","1721.50","286","304.95","476.85","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","583.52","437.64","AETNA [1001]","HB AMC AETNA PPO","469.15","80.4","","1261.44","103.12","1514.10","21","304.95","476.85","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","583.52","437.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","469.15","80.4","","1365.00","1365.00","1365.00","1 through 10","304.95","476.85","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","583.52","437.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","476.85","81.72","","5157.68","5157.68","5157.68","1 through 10","304.95","476.85","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","583.52","437.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","476.85","81.72","","431.26","71.26","1459.57","88","304.95","476.85","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS","SUP-ITM-10123786","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","150.26","79.5","","800.18","480.96","1887.97","195","58.59","150.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS","SUP-ITM-10123786","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.74","53.3","","813.12","216.42","1444.50","81","58.59","150.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS","SUP-ITM-10123786","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","58.59","31","","432.60","432.60","432.60","1 through 10","58.59","150.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS","SUP-ITM-10123786","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.99","36.5","","148.37","54.89","631.39","94","58.59","150.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS","SUP-ITM-10123786","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.39","38.3","","279.30","91.72","1116.77","266","58.59","150.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS","SUP-ITM-10123786","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","731.00","63.70","731.00","1 through 10","58.59","150.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS","SUP-ITM-10123786","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.08","42.9","","384.74","384.74","384.74","1 through 10","58.59","150.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS","SUP-ITM-10123786","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.00","141.75","WELLPOINT [1015]","HB AMC WELLPOINT","139.44","73.78","","286.63","119.22","1107.45","105","58.59","150.26","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS","SUP-ITM-10123786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA HMO","131.92","69.8","","675.31","184.75","1721.50","286","98.77","154.45","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS","SUP-ITM-10123786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","AETNA [1001]","HB AMC AETNA PPO","151.96","80.4","","1261.44","103.12","1514.10","21","98.77","154.45","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS","SUP-ITM-10123786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","151.96","80.4","","1365.00","1365.00","1365.00","1 through 10","98.77","154.45","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS","SUP-ITM-10123786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","154.45","81.72","","5157.68","5157.68","5157.68","1 through 10","98.77","154.45","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS","SUP-ITM-10123786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","154.45","81.72","","431.26","71.26","1459.57","88","98.77","154.45","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.02","79.5","","800.18","480.96","1887.97","195","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.43","53.3","","813.12","216.42","1444.50","81","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","43.29","31","","432.60","432.60","432.60","1 through 10","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.97","36.5","","148.37","54.89","631.39","94","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.49","38.3","","279.30","91.72","1116.77","266","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.91","42.9","","731.00","63.70","731.00","1 through 10","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.91","42.9","","384.74","384.74","384.74","1 through 10","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","WELLPOINT [1015]","HB AMC WELLPOINT","103.03","73.78","","286.63","119.22","1107.45","105","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","AETNA [1001]","HB AMC AETNA HMO","97.48","69.8","","675.31","184.75","1721.50","286","72.98","114.12","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","AETNA [1001]","HB AMC AETNA PPO","112.28","80.4","","1261.44","103.12","1514.10","21","72.98","114.12","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.28","80.4","","1365.00","1365.00","1365.00","1 through 10","72.98","114.12","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.12","81.72","","5157.68","5157.68","5157.68","1 through 10","72.98","114.12","percent of total billed charges",""
"SCREW BONE 6.5X15MM HIP CANCELLOUS C2A TAPER ACETABULAR TITANIUM LOW PROFILE THREAD DOME HEAD","SUP-ITM-10022589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.12","81.72","","431.26","71.26","1459.57","88","72.98","114.12","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","310.03","79.5","","800.18","480.96","1887.97","195","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","207.85","53.3","","813.12","216.42","1444.50","81","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","120.89","31","","432.60","432.60","432.60","1 through 10","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","142.34","36.5","","148.37","54.89","631.39","94","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","149.36","38.3","","279.30","91.72","1116.77","266","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.30","42.9","","731.00","63.70","731.00","1 through 10","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.30","42.9","","384.74","384.74","384.74","1 through 10","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","WELLPOINT [1015]","HB AMC WELLPOINT","287.72","73.78","","286.63","119.22","1107.45","105","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.97","292.48","AETNA [1001]","HB AMC AETNA HMO","272.20","69.8","","675.31","184.75","1721.50","286","203.8","318.68","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.97","292.48","AETNA [1001]","HB AMC AETNA PPO","313.54","80.4","","1261.44","103.12","1514.10","21","203.8","318.68","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.97","292.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","313.54","80.4","","1365.00","1365.00","1365.00","1 through 10","203.8","318.68","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.97","292.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","318.68","81.72","","5157.68","5157.68","5157.68","1 through 10","203.8","318.68","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.97","292.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","318.68","81.72","","431.26","71.26","1459.57","88","203.8","318.68","percent of total billed charges",""
"SCREW BONE 6.5X25MM CANCELLOUS TITANIUMLOCKING THREAD","SUP-ITM-10139120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1330.00","997.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1057.35","79.5","","800.18","480.96","1887.97","195","412.3","1057.35","percent of total billed charges",""
"SCREW BONE 6.5X25MM CANCELLOUS TITANIUMLOCKING THREAD","SUP-ITM-10139120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1330.00","997.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","708.89","53.3","","813.12","216.42","1444.50","81","412.3","1057.35","percent of total billed charges",""
"SCREW BONE 6.5X25MM CANCELLOUS TITANIUMLOCKING THREAD","SUP-ITM-10139120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1330.00","997.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","412.30","31","","432.60","432.60","432.60","1 through 10","412.3","1057.35","percent of total billed charges",""
"SCREW BONE 6.5X25MM CANCELLOUS TITANIUMLOCKING THREAD","SUP-ITM-10139120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1330.00","997.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","485.45","36.5","","148.37","54.89","631.39","94","412.3","1057.35","percent of total billed charges",""
"SCREW BONE 6.5X25MM CANCELLOUS TITANIUMLOCKING THREAD","SUP-ITM-10139120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1330.00","997.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","509.39","38.3","","279.30","91.72","1116.77","266","412.3","1057.35","percent of total billed charges",""
"SCREW BONE 6.5X25MM CANCELLOUS TITANIUMLOCKING THREAD","SUP-ITM-10139120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1330.00","997.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","570.57","42.9","","731.00","63.70","731.00","1 through 10","412.3","1057.35","percent of total billed charges",""
"SCREW BONE 6.5X25MM CANCELLOUS TITANIUMLOCKING THREAD","SUP-ITM-10139120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1330.00","997.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","570.57","42.9","","384.74","384.74","384.74","1 through 10","412.3","1057.35","percent of total billed charges",""
"SCREW BONE 6.5X25MM CANCELLOUS TITANIUMLOCKING THREAD","SUP-ITM-10139120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1330.00","997.50","WELLPOINT [1015]","HB AMC WELLPOINT","981.27","73.78","","286.63","119.22","1107.45","105","412.3","1057.35","percent of total billed charges",""
"SCREW BONE 6.5X25MM CANCELLOUS TITANIUMLOCKING THREAD","SUP-ITM-10139120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1330.00","997.50","AETNA [1001]","HB AMC AETNA HMO","928.34","69.8","","675.31","184.75","1721.50","286","695.06","1086.88","percent of total billed charges",""
"SCREW BONE 6.5X25MM CANCELLOUS TITANIUMLOCKING THREAD","SUP-ITM-10139120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1330.00","997.50","AETNA [1001]","HB AMC AETNA PPO","1069.32","80.4","","1261.44","103.12","1514.10","21","695.06","1086.88","percent of total billed charges",""
"SCREW BONE 6.5X25MM CANCELLOUS TITANIUMLOCKING THREAD","SUP-ITM-10139120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1330.00","997.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1069.32","80.4","","1365.00","1365.00","1365.00","1 through 10","695.06","1086.88","percent of total billed charges",""
"SCREW BONE 6.5X25MM CANCELLOUS TITANIUMLOCKING THREAD","SUP-ITM-10139120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1330.00","997.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1086.88","81.72","","5157.68","5157.68","5157.68","1 through 10","695.06","1086.88","percent of total billed charges",""
"SCREW BONE 6.5X25MM CANCELLOUS TITANIUMLOCKING THREAD","SUP-ITM-10139120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1330.00","997.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1086.88","81.72","","431.26","71.26","1459.57","88","695.06","1086.88","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","310.03","79.5","","800.18","480.96","1887.97","195","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","207.85","53.3","","813.12","216.42","1444.50","81","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","120.89","31","","432.60","432.60","432.60","1 through 10","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","142.34","36.5","","148.37","54.89","631.39","94","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","149.36","38.3","","279.30","91.72","1116.77","266","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.30","42.9","","731.00","63.70","731.00","1 through 10","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.30","42.9","","384.74","384.74","384.74","1 through 10","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.97","292.48","WELLPOINT [1015]","HB AMC WELLPOINT","287.72","73.78","","286.63","119.22","1107.45","105","120.89","310.03","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.97","292.48","AETNA [1001]","HB AMC AETNA HMO","272.20","69.8","","675.31","184.75","1721.50","286","203.8","318.68","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.97","292.48","AETNA [1001]","HB AMC AETNA PPO","313.54","80.4","","1261.44","103.12","1514.10","21","203.8","318.68","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.97","292.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","313.54","80.4","","1365.00","1365.00","1365.00","1 through 10","203.8","318.68","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.97","292.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","318.68","81.72","","5157.68","5157.68","5157.68","1 through 10","203.8","318.68","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.97","292.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","318.68","81.72","","431.26","71.26","1459.57","88","203.8","318.68","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.02","79.5","","800.18","480.96","1887.97","195","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.43","53.3","","813.12","216.42","1444.50","81","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","43.29","31","","432.60","432.60","432.60","1 through 10","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.97","36.5","","148.37","54.89","631.39","94","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.49","38.3","","279.30","91.72","1116.77","266","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.91","42.9","","731.00","63.70","731.00","1 through 10","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.91","42.9","","384.74","384.74","384.74","1 through 10","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","139.65","104.74","WELLPOINT [1015]","HB AMC WELLPOINT","103.03","73.78","","286.63","119.22","1107.45","105","43.29","111.02","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","AETNA [1001]","HB AMC AETNA HMO","97.48","69.8","","675.31","184.75","1721.50","286","72.98","114.12","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","AETNA [1001]","HB AMC AETNA PPO","112.28","80.4","","1261.44","103.12","1514.10","21","72.98","114.12","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.28","80.4","","1365.00","1365.00","1365.00","1 through 10","72.98","114.12","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.12","81.72","","5157.68","5157.68","5157.68","1 through 10","72.98","114.12","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","139.65","104.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.12","81.72","","431.26","71.26","1459.57","88","72.98","114.12","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","105.74","79.5","","800.18","480.96","1887.97","195","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","70.89","53.3","","813.12","216.42","1444.50","81","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","41.23","31","","432.60","432.60","432.60","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.55","36.5","","148.37","54.89","631.39","94","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","50.94","38.3","","279.30","91.72","1116.77","266","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.06","42.9","","731.00","63.70","731.00","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.06","42.9","","384.74","384.74","384.74","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","WELLPOINT [1015]","HB AMC WELLPOINT","98.13","73.78","","286.63","119.22","1107.45","105","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","AETNA [1001]","HB AMC AETNA HMO","92.83","69.8","","675.31","184.75","1721.50","286","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","AETNA [1001]","HB AMC AETNA PPO","106.93","80.4","","1261.44","103.12","1514.10","21","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","106.93","80.4","","1365.00","1365.00","1365.00","1 through 10","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","108.69","81.72","","5157.68","5157.68","5157.68","1 through 10","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","108.69","81.72","","431.26","71.26","1459.57","88","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","800.18","480.96","1887.97","195","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.64","53.3","","813.12","216.42","1444.50","81","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.13","31","","432.60","432.60","432.60","1 through 10","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","148.37","54.89","631.39","94","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","279.30","91.72","1116.77","266","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","731.00","63.70","731.00","1 through 10","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","384.74","384.74","384.74","1 through 10","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","286.63","119.22","1107.45","105","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","675.31","184.75","1721.50","286","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","1261.44","103.12","1514.10","21","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","70.35","80.4","","1365.00","1365.00","1365.00","1 through 10","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","71.51","81.72","","5157.68","5157.68","5157.68","1 through 10","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","431.26","71.26","1459.57","88","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X30MM 16MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039896","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.84","467.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","495.95","79.5","","800.18","480.96","1887.97","195","193.39","495.95","percent of total billed charges",""
"SCREW BONE 6.5X30MM 16MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039896","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.84","467.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","332.51","53.3","","813.12","216.42","1444.50","81","193.39","495.95","percent of total billed charges",""
"SCREW BONE 6.5X30MM 16MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039896","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.84","467.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","193.39","31","","432.60","432.60","432.60","1 through 10","193.39","495.95","percent of total billed charges",""
"SCREW BONE 6.5X30MM 16MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039896","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.84","467.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","227.70","36.5","","148.37","54.89","631.39","94","193.39","495.95","percent of total billed charges",""
"SCREW BONE 6.5X30MM 16MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039896","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.84","467.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","238.93","38.3","","279.30","91.72","1116.77","266","193.39","495.95","percent of total billed charges",""
"SCREW BONE 6.5X30MM 16MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039896","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.84","467.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","267.63","42.9","","731.00","63.70","731.00","1 through 10","193.39","495.95","percent of total billed charges",""
"SCREW BONE 6.5X30MM 16MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039896","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.84","467.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","267.63","42.9","","384.74","384.74","384.74","1 through 10","193.39","495.95","percent of total billed charges",""
"SCREW BONE 6.5X30MM 16MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039896","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.84","467.88","WELLPOINT [1015]","HB AMC WELLPOINT","460.27","73.78","","286.63","119.22","1107.45","105","193.39","495.95","percent of total billed charges",""
"SCREW BONE 6.5X30MM 16MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.84","467.88","AETNA [1001]","HB AMC AETNA HMO","435.44","69.8","","675.31","184.75","1721.50","286","326.02","509.8","percent of total billed charges",""
"SCREW BONE 6.5X30MM 16MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.84","467.88","AETNA [1001]","HB AMC AETNA PPO","501.57","80.4","","1261.44","103.12","1514.10","21","326.02","509.8","percent of total billed charges",""
"SCREW BONE 6.5X30MM 16MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.84","467.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","501.57","80.4","","1365.00","1365.00","1365.00","1 through 10","326.02","509.8","percent of total billed charges",""
"SCREW BONE 6.5X30MM 16MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.84","467.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","509.80","81.72","","5157.68","5157.68","5157.68","1 through 10","326.02","509.8","percent of total billed charges",""
"SCREW BONE 6.5X30MM 16MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.84","467.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","509.80","81.72","","431.26","71.26","1459.57","88","326.02","509.8","percent of total billed charges",""
"SCREW BONE 6.5X30MM CANCELLOUS TITANIUM FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001566","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","158.55","79.5","","800.18","480.96","1887.97","195","61.82","158.55","percent of total billed charges",""
"SCREW BONE 6.5X30MM CANCELLOUS TITANIUM FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001566","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.30","53.3","","813.12","216.42","1444.50","81","61.82","158.55","percent of total billed charges",""
"SCREW BONE 6.5X30MM CANCELLOUS TITANIUM FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001566","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","61.82","31","","432.60","432.60","432.60","1 through 10","61.82","158.55","percent of total billed charges",""
"SCREW BONE 6.5X30MM CANCELLOUS TITANIUM FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001566","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","72.79","36.5","","148.37","54.89","631.39","94","61.82","158.55","percent of total billed charges",""
"SCREW BONE 6.5X30MM CANCELLOUS TITANIUM FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001566","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.38","38.3","","279.30","91.72","1116.77","266","61.82","158.55","percent of total billed charges",""
"SCREW BONE 6.5X30MM CANCELLOUS TITANIUM FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001566","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.56","42.9","","731.00","63.70","731.00","1 through 10","61.82","158.55","percent of total billed charges",""
"SCREW BONE 6.5X30MM CANCELLOUS TITANIUM FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001566","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.56","42.9","","384.74","384.74","384.74","1 through 10","61.82","158.55","percent of total billed charges",""
"SCREW BONE 6.5X30MM CANCELLOUS TITANIUM FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001566","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.43","149.57","WELLPOINT [1015]","HB AMC WELLPOINT","147.14","73.78","","286.63","119.22","1107.45","105","61.82","158.55","percent of total billed charges",""
"SCREW BONE 6.5X30MM CANCELLOUS TITANIUM FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.43","149.57","AETNA [1001]","HB AMC AETNA HMO","139.20","69.8","","675.31","184.75","1721.50","286","104.22","162.97","percent of total billed charges",""
"SCREW BONE 6.5X30MM CANCELLOUS TITANIUM FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.43","149.57","AETNA [1001]","HB AMC AETNA PPO","160.34","80.4","","1261.44","103.12","1514.10","21","104.22","162.97","percent of total billed charges",""
"SCREW BONE 6.5X30MM CANCELLOUS TITANIUM FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.43","149.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","160.34","80.4","","1365.00","1365.00","1365.00","1 through 10","104.22","162.97","percent of total billed charges",""
"SCREW BONE 6.5X30MM CANCELLOUS TITANIUM FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.43","149.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","162.97","81.72","","5157.68","5157.68","5157.68","1 through 10","104.22","162.97","percent of total billed charges",""
"SCREW BONE 6.5X30MM CANCELLOUS TITANIUM FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.43","149.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","162.97","81.72","","431.26","71.26","1459.57","88","104.22","162.97","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.84","593.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","629.51","79.5","","800.18","480.96","1887.97","195","245.47","629.51","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.84","593.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","422.05","53.3","","813.12","216.42","1444.50","81","245.47","629.51","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.84","593.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","245.47","31","","432.60","432.60","432.60","1 through 10","245.47","629.51","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.84","593.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","289.02","36.5","","148.37","54.89","631.39","94","245.47","629.51","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.84","593.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","303.27","38.3","","279.30","91.72","1116.77","266","245.47","629.51","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.84","593.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","339.70","42.9","","731.00","63.70","731.00","1 through 10","245.47","629.51","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.84","593.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","339.70","42.9","","384.74","384.74","384.74","1 through 10","245.47","629.51","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","both","","","791.84","593.88","WELLPOINT [1015]","HB AMC WELLPOINT","584.22","73.78","","286.63","119.22","1107.45","105","245.47","629.51","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","791.84","593.88","AETNA [1001]","HB AMC AETNA HMO","552.70","69.8","","675.31","184.75","1721.50","286","413.82","647.09","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","791.84","593.88","AETNA [1001]","HB AMC AETNA PPO","636.64","80.4","","1261.44","103.12","1514.10","21","413.82","647.09","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","791.84","593.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","636.64","80.4","","1365.00","1365.00","1365.00","1 through 10","413.82","647.09","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","791.84","593.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","647.09","81.72","","5157.68","5157.68","5157.68","1 through 10","413.82","647.09","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","791.84","593.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","647.09","81.72","","431.26","71.26","1459.57","88","413.82","647.09","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","182.60","136.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","145.17","79.5","","800.18","480.96","1887.97","195","56.61","145.17","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","182.60","136.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","97.33","53.3","","813.12","216.42","1444.50","81","56.61","145.17","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","182.60","136.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","56.61","31","","432.60","432.60","432.60","1 through 10","56.61","145.17","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","182.60","136.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","66.65","36.5","","148.37","54.89","631.39","94","56.61","145.17","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","182.60","136.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","69.94","38.3","","279.30","91.72","1116.77","266","56.61","145.17","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","182.60","136.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.34","42.9","","731.00","63.70","731.00","1 through 10","56.61","145.17","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","182.60","136.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.34","42.9","","384.74","384.74","384.74","1 through 10","56.61","145.17","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","182.60","136.95","WELLPOINT [1015]","HB AMC WELLPOINT","134.72","73.78","","286.63","119.22","1107.45","105","56.61","145.17","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","182.60","136.95","AETNA [1001]","HB AMC AETNA HMO","127.45","69.8","","675.31","184.75","1721.50","286","95.43","149.22","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","182.60","136.95","AETNA [1001]","HB AMC AETNA PPO","146.81","80.4","","1261.44","103.12","1514.10","21","95.43","149.22","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","182.60","136.95","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","146.81","80.4","","1365.00","1365.00","1365.00","1 through 10","95.43","149.22","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","182.60","136.95","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","149.22","81.72","","5157.68","5157.68","5157.68","1 through 10","95.43","149.22","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","182.60","136.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","149.22","81.72","","431.26","71.26","1459.57","88","95.43","149.22","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.00","855.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","907.10","79.5","","800.18","480.96","1887.97","195","353.71","907.1","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.00","855.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","608.15","53.3","","813.12","216.42","1444.50","81","353.71","907.1","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.00","855.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","353.71","31","","432.60","432.60","432.60","1 through 10","353.71","907.1","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.00","855.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","416.47","36.5","","148.37","54.89","631.39","94","353.71","907.1","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.00","855.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","437.00","38.3","","279.30","91.72","1116.77","266","353.71","907.1","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.00","855.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","489.49","42.9","","731.00","63.70","731.00","1 through 10","353.71","907.1","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.00","855.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","489.49","42.9","","384.74","384.74","384.74","1 through 10","353.71","907.1","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","1141.00","855.75","WELLPOINT [1015]","HB AMC WELLPOINT","841.83","73.78","","286.63","119.22","1107.45","105","353.71","907.1","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1141.00","855.75","AETNA [1001]","HB AMC AETNA HMO","796.42","69.8","","675.31","184.75","1721.50","286","596.29","932.43","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1141.00","855.75","AETNA [1001]","HB AMC AETNA PPO","917.36","80.4","","1261.44","103.12","1514.10","21","596.29","932.43","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1141.00","855.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","917.36","80.4","","1365.00","1365.00","1365.00","1 through 10","596.29","932.43","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1141.00","855.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","932.43","81.72","","5157.68","5157.68","5157.68","1 through 10","596.29","932.43","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1141.00","855.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","932.43","81.72","","431.26","71.26","1459.57","88","596.29","932.43","percent of total billed charges",""
"SCREW BONE 6.5X35MM CORTICAL SELF TAPPING FULLY THREADED TI","SUP-ITM-10071430","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.25","456.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","484.35","79.5","","800.18","480.96","1887.97","195","188.87","484.35","percent of total billed charges",""
"SCREW BONE 6.5X35MM CORTICAL SELF TAPPING FULLY THREADED TI","SUP-ITM-10071430","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.25","456.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","324.73","53.3","","813.12","216.42","1444.50","81","188.87","484.35","percent of total billed charges",""
"SCREW BONE 6.5X35MM CORTICAL SELF TAPPING FULLY THREADED TI","SUP-ITM-10071430","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.25","456.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","188.87","31","","432.60","432.60","432.60","1 through 10","188.87","484.35","percent of total billed charges",""
"SCREW BONE 6.5X35MM CORTICAL SELF TAPPING FULLY THREADED TI","SUP-ITM-10071430","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.25","456.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","222.38","36.5","","148.37","54.89","631.39","94","188.87","484.35","percent of total billed charges",""
"SCREW BONE 6.5X35MM CORTICAL SELF TAPPING FULLY THREADED TI","SUP-ITM-10071430","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.25","456.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","233.34","38.3","","279.30","91.72","1116.77","266","188.87","484.35","percent of total billed charges",""
"SCREW BONE 6.5X35MM CORTICAL SELF TAPPING FULLY THREADED TI","SUP-ITM-10071430","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.25","456.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","261.37","42.9","","731.00","63.70","731.00","1 through 10","188.87","484.35","percent of total billed charges",""
"SCREW BONE 6.5X35MM CORTICAL SELF TAPPING FULLY THREADED TI","SUP-ITM-10071430","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.25","456.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","261.37","42.9","","384.74","384.74","384.74","1 through 10","188.87","484.35","percent of total billed charges",""
"SCREW BONE 6.5X35MM CORTICAL SELF TAPPING FULLY THREADED TI","SUP-ITM-10071430","CDM","C1713","HCPCS","0278","RC","","","","both","","","609.25","456.94","WELLPOINT [1015]","HB AMC WELLPOINT","449.50","73.78","","286.63","119.22","1107.45","105","188.87","484.35","percent of total billed charges",""
"SCREW BONE 6.5X35MM CORTICAL SELF TAPPING FULLY THREADED TI","SUP-ITM-10071430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.25","456.94","AETNA [1001]","HB AMC AETNA HMO","425.26","69.8","","675.31","184.75","1721.50","286","318.39","497.88","percent of total billed charges",""
"SCREW BONE 6.5X35MM CORTICAL SELF TAPPING FULLY THREADED TI","SUP-ITM-10071430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.25","456.94","AETNA [1001]","HB AMC AETNA PPO","489.84","80.4","","1261.44","103.12","1514.10","21","318.39","497.88","percent of total billed charges",""
"SCREW BONE 6.5X35MM CORTICAL SELF TAPPING FULLY THREADED TI","SUP-ITM-10071430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.25","456.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","489.84","80.4","","1365.00","1365.00","1365.00","1 through 10","318.39","497.88","percent of total billed charges",""
"SCREW BONE 6.5X35MM CORTICAL SELF TAPPING FULLY THREADED TI","SUP-ITM-10071430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.25","456.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","497.88","81.72","","5157.68","5157.68","5157.68","1 through 10","318.39","497.88","percent of total billed charges",""
"SCREW BONE 6.5X35MM CORTICAL SELF TAPPING FULLY THREADED TI","SUP-ITM-10071430","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","609.25","456.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","497.88","81.72","","431.26","71.26","1459.57","88","318.39","497.88","percent of total billed charges",""
"SCREW BONE 6.5X35MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10023256","CDM","C1889","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1766.89","79.5","","1309.77","674.56","6049.93","26","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 6.5X35MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10023256","CDM","C1889","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1184.59","53.3","","1901.83","1901.83","2962.25","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 6.5X35MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10023256","CDM","C1889","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","811.21","36.5","","1620.31","1620.31","19908.88","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 6.5X35MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10023256","CDM","C1889","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","851.22","38.3","","352.91","352.91","2046.30","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 6.5X35MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10023256","CDM","C1889","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.45","42.9","","9668.75","9668.75","9668.75","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 6.5X35MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10023256","CDM","C1889","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","WELLPOINT [1015]","HB AMC WELLPOINT","1639.76","73.78","","699.88","384.10","3443.31","33","688.98","1766.89","percent of total billed charges",""
"SCREW BONE 6.5X35MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10023256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","AETNA [1001]","HB AMC AETNA HMO","1551.31","69.8","","1421.24","264.50","4933.46","29","1161.48","1816.23","percent of total billed charges",""
"SCREW BONE 6.5X35MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10023256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1786.89","80.4","","1022.97","1022.97","3607.50","1 through 10","1161.48","1816.23","percent of total billed charges",""
"SCREW BONE 6.5X35MM SPINE CANNULATED CD HORIZON LEGACY MULTIAXIAL TITANIUM OSTEOGRIP DUAL LEAD THREAD PEDICLE","SUP-ITM-10023256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1816.23","81.72","","3010.54","693.88","5019.88","35","1161.48","1816.23","percent of total billed charges",""
"SCREW BONE 6.5X40MM IO FIX PLUS LAG CANNULATED POLYAXIAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091616","CDM","C1713","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2003.40","79.5","","800.18","480.96","1887.97","195","781.2","2003.4","percent of total billed charges",""
"SCREW BONE 6.5X40MM IO FIX PLUS LAG CANNULATED POLYAXIAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091616","CDM","C1713","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1343.16","53.3","","813.12","216.42","1444.50","81","781.2","2003.4","percent of total billed charges",""
"SCREW BONE 6.5X40MM IO FIX PLUS LAG CANNULATED POLYAXIAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091616","CDM","C1713","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","781.20","31","","432.60","432.60","432.60","1 through 10","781.2","2003.4","percent of total billed charges",""
"SCREW BONE 6.5X40MM IO FIX PLUS LAG CANNULATED POLYAXIAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091616","CDM","C1713","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","919.80","36.5","","148.37","54.89","631.39","94","781.2","2003.4","percent of total billed charges",""
"SCREW BONE 6.5X40MM IO FIX PLUS LAG CANNULATED POLYAXIAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091616","CDM","C1713","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","965.16","38.3","","279.30","91.72","1116.77","266","781.2","2003.4","percent of total billed charges",""
"SCREW BONE 6.5X40MM IO FIX PLUS LAG CANNULATED POLYAXIAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091616","CDM","C1713","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1081.08","42.9","","731.00","63.70","731.00","1 through 10","781.2","2003.4","percent of total billed charges",""
"SCREW BONE 6.5X40MM IO FIX PLUS LAG CANNULATED POLYAXIAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091616","CDM","C1713","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1081.08","42.9","","384.74","384.74","384.74","1 through 10","781.2","2003.4","percent of total billed charges",""
"SCREW BONE 6.5X40MM IO FIX PLUS LAG CANNULATED POLYAXIAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091616","CDM","C1713","HCPCS","0278","RC","","","","both","","","2520.00","1890.00","WELLPOINT [1015]","HB AMC WELLPOINT","1859.26","73.78","","286.63","119.22","1107.45","105","781.2","2003.4","percent of total billed charges",""
"SCREW BONE 6.5X40MM IO FIX PLUS LAG CANNULATED POLYAXIAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091616","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2520.00","1890.00","AETNA [1001]","HB AMC AETNA HMO","1758.96","69.8","","675.31","184.75","1721.50","286","1316.95","2059.34","percent of total billed charges",""
"SCREW BONE 6.5X40MM IO FIX PLUS LAG CANNULATED POLYAXIAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091616","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2520.00","1890.00","AETNA [1001]","HB AMC AETNA PPO","2026.08","80.4","","1261.44","103.12","1514.10","21","1316.95","2059.34","percent of total billed charges",""
"SCREW BONE 6.5X40MM IO FIX PLUS LAG CANNULATED POLYAXIAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091616","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2520.00","1890.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2026.08","80.4","","1365.00","1365.00","1365.00","1 through 10","1316.95","2059.34","percent of total billed charges",""
"SCREW BONE 6.5X40MM IO FIX PLUS LAG CANNULATED POLYAXIAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091616","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2520.00","1890.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2059.34","81.72","","5157.68","5157.68","5157.68","1 through 10","1316.95","2059.34","percent of total billed charges",""
"SCREW BONE 6.5X40MM IO FIX PLUS LAG CANNULATED POLYAXIAL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091616","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2520.00","1890.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2059.34","81.72","","431.26","71.26","1459.57","88","1316.95","2059.34","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","105.74","79.5","","800.18","480.96","1887.97","195","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","70.89","53.3","","813.12","216.42","1444.50","81","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","41.23","31","","432.60","432.60","432.60","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.55","36.5","","148.37","54.89","631.39","94","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","50.94","38.3","","279.30","91.72","1116.77","266","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.06","42.9","","731.00","63.70","731.00","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.06","42.9","","384.74","384.74","384.74","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","WELLPOINT [1015]","HB AMC WELLPOINT","98.13","73.78","","286.63","119.22","1107.45","105","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","AETNA [1001]","HB AMC AETNA HMO","92.83","69.8","","675.31","184.75","1721.50","286","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","AETNA [1001]","HB AMC AETNA PPO","106.93","80.4","","1261.44","103.12","1514.10","21","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","106.93","80.4","","1365.00","1365.00","1365.00","1 through 10","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","108.69","81.72","","5157.68","5157.68","5157.68","1 through 10","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS REFLECTION SS SPHERICAL HEAD","SUP-ITM-10021227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","108.69","81.72","","431.26","71.26","1459.57","88","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","800.18","480.96","1887.97","195","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","46.64","53.3","","813.12","216.42","1444.50","81","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27.13","31","","432.60","432.60","432.60","1 through 10","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","148.37","54.89","631.39","94","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","279.30","91.72","1116.77","266","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","731.00","63.70","731.00","1 through 10","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","384.74","384.74","384.74","1 through 10","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","286.63","119.22","1107.45","105","27.13","69.56","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","675.31","184.75","1721.50","286","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","1261.44","103.12","1514.10","21","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","70.35","80.4","","1365.00","1365.00","1365.00","1 through 10","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","71.51","81.72","","5157.68","5157.68","5157.68","1 through 10","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","431.26","71.26","1459.57","88","45.73","71.51","percent of total billed charges",""
"SCREW BONE 6.5X45MM SPINE FIREBIRD TITANIUM MULTIAXIAL SPINAL SELF TAPPING","SUP-ITM-10083353","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1363.43","79.5","","800.18","480.96","1887.97","195","531.65","1363.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM SPINE FIREBIRD TITANIUM MULTIAXIAL SPINAL SELF TAPPING","SUP-ITM-10083353","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","914.10","53.3","","813.12","216.42","1444.50","81","531.65","1363.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM SPINE FIREBIRD TITANIUM MULTIAXIAL SPINAL SELF TAPPING","SUP-ITM-10083353","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","531.65","31","","432.60","432.60","432.60","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM SPINE FIREBIRD TITANIUM MULTIAXIAL SPINAL SELF TAPPING","SUP-ITM-10083353","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","625.98","36.5","","148.37","54.89","631.39","94","531.65","1363.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM SPINE FIREBIRD TITANIUM MULTIAXIAL SPINAL SELF TAPPING","SUP-ITM-10083353","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","656.85","38.3","","279.30","91.72","1116.77","266","531.65","1363.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM SPINE FIREBIRD TITANIUM MULTIAXIAL SPINAL SELF TAPPING","SUP-ITM-10083353","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.74","42.9","","731.00","63.70","731.00","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM SPINE FIREBIRD TITANIUM MULTIAXIAL SPINAL SELF TAPPING","SUP-ITM-10083353","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.74","42.9","","384.74","384.74","384.74","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM SPINE FIREBIRD TITANIUM MULTIAXIAL SPINAL SELF TAPPING","SUP-ITM-10083353","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","WELLPOINT [1015]","HB AMC WELLPOINT","1265.33","73.78","","286.63","119.22","1107.45","105","531.65","1363.43","percent of total billed charges",""
"SCREW BONE 6.5X45MM SPINE FIREBIRD TITANIUM MULTIAXIAL SPINAL SELF TAPPING","SUP-ITM-10083353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","AETNA [1001]","HB AMC AETNA HMO","1197.07","69.8","","675.31","184.75","1721.50","286","896.26","1401.5","percent of total billed charges",""
"SCREW BONE 6.5X45MM SPINE FIREBIRD TITANIUM MULTIAXIAL SPINAL SELF TAPPING","SUP-ITM-10083353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","AETNA [1001]","HB AMC AETNA PPO","1378.86","80.4","","1261.44","103.12","1514.10","21","896.26","1401.5","percent of total billed charges",""
"SCREW BONE 6.5X45MM SPINE FIREBIRD TITANIUM MULTIAXIAL SPINAL SELF TAPPING","SUP-ITM-10083353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1378.86","80.4","","1365.00","1365.00","1365.00","1 through 10","896.26","1401.5","percent of total billed charges",""
"SCREW BONE 6.5X45MM SPINE FIREBIRD TITANIUM MULTIAXIAL SPINAL SELF TAPPING","SUP-ITM-10083353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1401.50","81.72","","5157.68","5157.68","5157.68","1 through 10","896.26","1401.5","percent of total billed charges",""
"SCREW BONE 6.5X45MM SPINE FIREBIRD TITANIUM MULTIAXIAL SPINAL SELF TAPPING","SUP-ITM-10083353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1401.50","81.72","","431.26","71.26","1459.57","88","896.26","1401.5","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","105.74","79.5","","800.18","480.96","1887.97","195","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","70.89","53.3","","813.12","216.42","1444.50","81","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","41.23","31","","432.60","432.60","432.60","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48.55","36.5","","148.37","54.89","631.39","94","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","50.94","38.3","","279.30","91.72","1116.77","266","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.06","42.9","","731.00","63.70","731.00","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.06","42.9","","384.74","384.74","384.74","1 through 10","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","133.00","99.75","WELLPOINT [1015]","HB AMC WELLPOINT","98.13","73.78","","286.63","119.22","1107.45","105","41.23","105.74","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","AETNA [1001]","HB AMC AETNA HMO","92.83","69.8","","675.31","184.75","1721.50","286","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","AETNA [1001]","HB AMC AETNA PPO","106.93","80.4","","1261.44","103.12","1514.10","21","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","106.93","80.4","","1365.00","1365.00","1365.00","1 through 10","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","108.69","81.72","","5157.68","5157.68","5157.68","1 through 10","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","108.69","81.72","","431.26","71.26","1459.57","88","69.51","108.69","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","800.18","480.96","1887.97","195","434","1113","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","813.12","216.42","1444.50","81","434","1113","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","434.00","31","","432.60","432.60","432.60","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","148.37","54.89","631.39","94","434","1113","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","279.30","91.72","1116.77","266","434","1113","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","731.00","63.70","731.00","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","384.74","384.74","384.74","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","286.63","119.22","1107.45","105","434","1113","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","675.31","184.75","1721.50","286","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA PPO","1125.60","80.4","","1261.44","103.12","1514.10","21","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1365.00","1365.00","1365.00","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1144.08","81.72","","5157.68","5157.68","5157.68","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","431.26","71.26","1459.57","88","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 6.5X65MM COMPRESSION TI CANNULATED HEADLESS LONG THREAD","SUP-ITM-10276390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1851.15","1388.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1471.66","79.5","","800.18","480.96","1887.97","195","573.86","1471.66","percent of total billed charges",""
"SCREW BONE 6.5X65MM COMPRESSION TI CANNULATED HEADLESS LONG THREAD","SUP-ITM-10276390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1851.15","1388.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","986.66","53.3","","813.12","216.42","1444.50","81","573.86","1471.66","percent of total billed charges",""
"SCREW BONE 6.5X65MM COMPRESSION TI CANNULATED HEADLESS LONG THREAD","SUP-ITM-10276390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1851.15","1388.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","573.86","31","","432.60","432.60","432.60","1 through 10","573.86","1471.66","percent of total billed charges",""
"SCREW BONE 6.5X65MM COMPRESSION TI CANNULATED HEADLESS LONG THREAD","SUP-ITM-10276390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1851.15","1388.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","675.67","36.5","","148.37","54.89","631.39","94","573.86","1471.66","percent of total billed charges",""
"SCREW BONE 6.5X65MM COMPRESSION TI CANNULATED HEADLESS LONG THREAD","SUP-ITM-10276390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1851.15","1388.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","708.99","38.3","","279.30","91.72","1116.77","266","573.86","1471.66","percent of total billed charges",""
"SCREW BONE 6.5X65MM COMPRESSION TI CANNULATED HEADLESS LONG THREAD","SUP-ITM-10276390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1851.15","1388.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","794.14","42.9","","731.00","63.70","731.00","1 through 10","573.86","1471.66","percent of total billed charges",""
"SCREW BONE 6.5X65MM COMPRESSION TI CANNULATED HEADLESS LONG THREAD","SUP-ITM-10276390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1851.15","1388.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","794.14","42.9","","384.74","384.74","384.74","1 through 10","573.86","1471.66","percent of total billed charges",""
"SCREW BONE 6.5X65MM COMPRESSION TI CANNULATED HEADLESS LONG THREAD","SUP-ITM-10276390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1851.15","1388.36","WELLPOINT [1015]","HB AMC WELLPOINT","1365.78","73.78","","286.63","119.22","1107.45","105","573.86","1471.66","percent of total billed charges",""
"SCREW BONE 6.5X65MM COMPRESSION TI CANNULATED HEADLESS LONG THREAD","SUP-ITM-10276390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1851.15","1388.36","AETNA [1001]","HB AMC AETNA HMO","1292.10","69.8","","675.31","184.75","1721.50","286","967.41","1512.76","percent of total billed charges",""
"SCREW BONE 6.5X65MM COMPRESSION TI CANNULATED HEADLESS LONG THREAD","SUP-ITM-10276390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1851.15","1388.36","AETNA [1001]","HB AMC AETNA PPO","1488.32","80.4","","1261.44","103.12","1514.10","21","967.41","1512.76","percent of total billed charges",""
"SCREW BONE 6.5X65MM COMPRESSION TI CANNULATED HEADLESS LONG THREAD","SUP-ITM-10276390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1851.15","1388.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1488.32","80.4","","1365.00","1365.00","1365.00","1 through 10","967.41","1512.76","percent of total billed charges",""
"SCREW BONE 6.5X65MM COMPRESSION TI CANNULATED HEADLESS LONG THREAD","SUP-ITM-10276390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1851.15","1388.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1512.76","81.72","","5157.68","5157.68","5157.68","1 through 10","967.41","1512.76","percent of total billed charges",""
"SCREW BONE 6.5X65MM COMPRESSION TI CANNULATED HEADLESS LONG THREAD","SUP-ITM-10276390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1851.15","1388.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1512.76","81.72","","431.26","71.26","1459.57","88","967.41","1512.76","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.84","425.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","451.43","79.5","","800.18","480.96","1887.97","195","176.03","451.43","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.84","425.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","302.66","53.3","","813.12","216.42","1444.50","81","176.03","451.43","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.84","425.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","176.03","31","","432.60","432.60","432.60","1 through 10","176.03","451.43","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.84","425.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","207.26","36.5","","148.37","54.89","631.39","94","176.03","451.43","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.84","425.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","217.48","38.3","","279.30","91.72","1116.77","266","176.03","451.43","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.84","425.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","243.60","42.9","","731.00","63.70","731.00","1 through 10","176.03","451.43","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.84","425.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","243.60","42.9","","384.74","384.74","384.74","1 through 10","176.03","451.43","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.84","425.88","WELLPOINT [1015]","HB AMC WELLPOINT","418.95","73.78","","286.63","119.22","1107.45","105","176.03","451.43","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.84","425.88","AETNA [1001]","HB AMC AETNA HMO","396.35","69.8","","675.31","184.75","1721.50","286","296.75","464.04","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.84","425.88","AETNA [1001]","HB AMC AETNA PPO","456.54","80.4","","1261.44","103.12","1514.10","21","296.75","464.04","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.84","425.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","456.54","80.4","","1365.00","1365.00","1365.00","1 through 10","296.75","464.04","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.84","425.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","464.04","81.72","","5157.68","5157.68","5157.68","1 through 10","296.75","464.04","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.84","425.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","464.04","81.72","","431.26","71.26","1459.57","88","296.75","464.04","percent of total billed charges",""
"SCREW BONE 6.5X80MM RECONSTRUCTION WITH T25 STARDRIVE RECESS TITANIUM","SUP-ITM-10030311","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","364.45","79.5","","800.18","480.96","1887.97","195","142.11","364.45","percent of total billed charges",""
"SCREW BONE 6.5X80MM RECONSTRUCTION WITH T25 STARDRIVE RECESS TITANIUM","SUP-ITM-10030311","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","244.34","53.3","","813.12","216.42","1444.50","81","142.11","364.45","percent of total billed charges",""
"SCREW BONE 6.5X80MM RECONSTRUCTION WITH T25 STARDRIVE RECESS TITANIUM","SUP-ITM-10030311","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","142.11","31","","432.60","432.60","432.60","1 through 10","142.11","364.45","percent of total billed charges",""
"SCREW BONE 6.5X80MM RECONSTRUCTION WITH T25 STARDRIVE RECESS TITANIUM","SUP-ITM-10030311","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","167.33","36.5","","148.37","54.89","631.39","94","142.11","364.45","percent of total billed charges",""
"SCREW BONE 6.5X80MM RECONSTRUCTION WITH T25 STARDRIVE RECESS TITANIUM","SUP-ITM-10030311","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","175.58","38.3","","279.30","91.72","1116.77","266","142.11","364.45","percent of total billed charges",""
"SCREW BONE 6.5X80MM RECONSTRUCTION WITH T25 STARDRIVE RECESS TITANIUM","SUP-ITM-10030311","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","196.67","42.9","","731.00","63.70","731.00","1 through 10","142.11","364.45","percent of total billed charges",""
"SCREW BONE 6.5X80MM RECONSTRUCTION WITH T25 STARDRIVE RECESS TITANIUM","SUP-ITM-10030311","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","196.67","42.9","","384.74","384.74","384.74","1 through 10","142.11","364.45","percent of total billed charges",""
"SCREW BONE 6.5X80MM RECONSTRUCTION WITH T25 STARDRIVE RECESS TITANIUM","SUP-ITM-10030311","CDM","C1713","HCPCS","0278","RC","","","","both","","","458.43","343.82","WELLPOINT [1015]","HB AMC WELLPOINT","338.23","73.78","","286.63","119.22","1107.45","105","142.11","364.45","percent of total billed charges",""
"SCREW BONE 6.5X80MM RECONSTRUCTION WITH T25 STARDRIVE RECESS TITANIUM","SUP-ITM-10030311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","458.43","343.82","AETNA [1001]","HB AMC AETNA HMO","319.98","69.8","","675.31","184.75","1721.50","286","239.58","374.63","percent of total billed charges",""
"SCREW BONE 6.5X80MM RECONSTRUCTION WITH T25 STARDRIVE RECESS TITANIUM","SUP-ITM-10030311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","458.43","343.82","AETNA [1001]","HB AMC AETNA PPO","368.58","80.4","","1261.44","103.12","1514.10","21","239.58","374.63","percent of total billed charges",""
"SCREW BONE 6.5X80MM RECONSTRUCTION WITH T25 STARDRIVE RECESS TITANIUM","SUP-ITM-10030311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","458.43","343.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","368.58","80.4","","1365.00","1365.00","1365.00","1 through 10","239.58","374.63","percent of total billed charges",""
"SCREW BONE 6.5X80MM RECONSTRUCTION WITH T25 STARDRIVE RECESS TITANIUM","SUP-ITM-10030311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","458.43","343.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","374.63","81.72","","5157.68","5157.68","5157.68","1 through 10","239.58","374.63","percent of total billed charges",""
"SCREW BONE 6.5X80MM RECONSTRUCTION WITH T25 STARDRIVE RECESS TITANIUM","SUP-ITM-10030311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","458.43","343.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","374.63","81.72","","431.26","71.26","1459.57","88","239.58","374.63","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.84","147.63","CIGNA [1006]","HB AMC CIGNA HMO / PPO","156.49","79.5","","800.18","480.96","1887.97","195","61.02","156.49","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.84","147.63","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","104.92","53.3","","813.12","216.42","1444.50","81","61.02","156.49","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.84","147.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","61.02","31","","432.60","432.60","432.60","1 through 10","61.02","156.49","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.84","147.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.85","36.5","","148.37","54.89","631.39","94","61.02","156.49","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.84","147.63","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.39","38.3","","279.30","91.72","1116.77","266","61.02","156.49","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.84","147.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.44","42.9","","731.00","63.70","731.00","1 through 10","61.02","156.49","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.84","147.63","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.44","42.9","","384.74","384.74","384.74","1 through 10","61.02","156.49","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.84","147.63","WELLPOINT [1015]","HB AMC WELLPOINT","145.23","73.78","","286.63","119.22","1107.45","105","61.02","156.49","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.84","147.63","AETNA [1001]","HB AMC AETNA HMO","137.39","69.8","","675.31","184.75","1721.50","286","102.87","160.86","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.84","147.63","AETNA [1001]","HB AMC AETNA PPO","158.26","80.4","","1261.44","103.12","1514.10","21","102.87","160.86","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.84","147.63","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","158.26","80.4","","1365.00","1365.00","1365.00","1 through 10","102.87","160.86","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.84","147.63","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","160.86","81.72","","5157.68","5157.68","5157.68","1 through 10","102.87","160.86","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.84","147.63","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","160.86","81.72","","431.26","71.26","1459.57","88","102.87","160.86","percent of total billed charges",""
"SCREW BONE 6.5X85MM DARCO TITANIUM COMPRESSION CANNULATED","SUP-ITM-10132507","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.50","942.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","998.92","79.5","","800.18","480.96","1887.97","195","389.52","998.92","percent of total billed charges",""
"SCREW BONE 6.5X85MM DARCO TITANIUM COMPRESSION CANNULATED","SUP-ITM-10132507","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.50","942.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","669.71","53.3","","813.12","216.42","1444.50","81","389.52","998.92","percent of total billed charges",""
"SCREW BONE 6.5X85MM DARCO TITANIUM COMPRESSION CANNULATED","SUP-ITM-10132507","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.50","942.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","389.52","31","","432.60","432.60","432.60","1 through 10","389.52","998.92","percent of total billed charges",""
"SCREW BONE 6.5X85MM DARCO TITANIUM COMPRESSION CANNULATED","SUP-ITM-10132507","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.50","942.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","458.62","36.5","","148.37","54.89","631.39","94","389.52","998.92","percent of total billed charges",""
"SCREW BONE 6.5X85MM DARCO TITANIUM COMPRESSION CANNULATED","SUP-ITM-10132507","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.50","942.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","481.24","38.3","","279.30","91.72","1116.77","266","389.52","998.92","percent of total billed charges",""
"SCREW BONE 6.5X85MM DARCO TITANIUM COMPRESSION CANNULATED","SUP-ITM-10132507","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.50","942.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","539.04","42.9","","731.00","63.70","731.00","1 through 10","389.52","998.92","percent of total billed charges",""
"SCREW BONE 6.5X85MM DARCO TITANIUM COMPRESSION CANNULATED","SUP-ITM-10132507","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.50","942.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","539.04","42.9","","384.74","384.74","384.74","1 through 10","389.52","998.92","percent of total billed charges",""
"SCREW BONE 6.5X85MM DARCO TITANIUM COMPRESSION CANNULATED","SUP-ITM-10132507","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.50","942.37","WELLPOINT [1015]","HB AMC WELLPOINT","927.05","73.78","","286.63","119.22","1107.45","105","389.52","998.92","percent of total billed charges",""
"SCREW BONE 6.5X85MM DARCO TITANIUM COMPRESSION CANNULATED","SUP-ITM-10132507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1256.50","942.37","AETNA [1001]","HB AMC AETNA HMO","877.04","69.8","","675.31","184.75","1721.50","286","656.65","1026.81","percent of total billed charges",""
"SCREW BONE 6.5X85MM DARCO TITANIUM COMPRESSION CANNULATED","SUP-ITM-10132507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1256.50","942.37","AETNA [1001]","HB AMC AETNA PPO","1010.23","80.4","","1261.44","103.12","1514.10","21","656.65","1026.81","percent of total billed charges",""
"SCREW BONE 6.5X85MM DARCO TITANIUM COMPRESSION CANNULATED","SUP-ITM-10132507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1256.50","942.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1010.23","80.4","","1365.00","1365.00","1365.00","1 through 10","656.65","1026.81","percent of total billed charges",""
"SCREW BONE 6.5X85MM DARCO TITANIUM COMPRESSION CANNULATED","SUP-ITM-10132507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1256.50","942.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1026.81","81.72","","5157.68","5157.68","5157.68","1 through 10","656.65","1026.81","percent of total billed charges",""
"SCREW BONE 6.5X85MM DARCO TITANIUM COMPRESSION CANNULATED","SUP-ITM-10132507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1256.50","942.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1026.81","81.72","","431.26","71.26","1459.57","88","656.65","1026.81","percent of total billed charges",""
"SCREW BONE 6.5X95MM LAG T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1045.61","79.5","","800.18","480.96","1887.97","195","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X95MM LAG T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","701.02","53.3","","813.12","216.42","1444.50","81","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X95MM LAG T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","407.72","31","","432.60","432.60","432.60","1 through 10","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X95MM LAG T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","480.06","36.5","","148.37","54.89","631.39","94","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X95MM LAG T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","503.73","38.3","","279.30","91.72","1116.77","266","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X95MM LAG T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","564.23","42.9","","731.00","63.70","731.00","1 through 10","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X95MM LAG T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","564.23","42.9","","384.74","384.74","384.74","1 through 10","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X95MM LAG T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.23","986.42","WELLPOINT [1015]","HB AMC WELLPOINT","970.38","73.78","","286.63","119.22","1107.45","105","407.72","1045.61","percent of total billed charges",""
"SCREW BONE 6.5X95MM LAG T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.23","986.42","AETNA [1001]","HB AMC AETNA HMO","918.03","69.8","","675.31","184.75","1721.50","286","687.34","1074.81","percent of total billed charges",""
"SCREW BONE 6.5X95MM LAG T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.23","986.42","AETNA [1001]","HB AMC AETNA PPO","1057.44","80.4","","1261.44","103.12","1514.10","21","687.34","1074.81","percent of total billed charges",""
"SCREW BONE 6.5X95MM LAG T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.23","986.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1057.44","80.4","","1365.00","1365.00","1365.00","1 through 10","687.34","1074.81","percent of total billed charges",""
"SCREW BONE 6.5X95MM LAG T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.23","986.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1074.81","81.72","","5157.68","5157.68","5157.68","1 through 10","687.34","1074.81","percent of total billed charges",""
"SCREW BONE 6.5X95MM LAG T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.23","986.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1074.81","81.72","","431.26","71.26","1459.57","88","687.34","1074.81","percent of total billed charges",""
"SCREW BONE 6.6X20MM ANKLE POST IOFIX PLUSXGREEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091625","CDM","C1713","HCPCS","0278","RC","","","","both","","","4155.00","3116.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3303.23","79.5","","800.18","480.96","1887.97","195","1288.05","3303.23","percent of total billed charges",""
"SCREW BONE 6.6X20MM ANKLE POST IOFIX PLUSXGREEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091625","CDM","C1713","HCPCS","0278","RC","","","","both","","","4155.00","3116.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2214.62","53.3","","813.12","216.42","1444.50","81","1288.05","3303.23","percent of total billed charges",""
"SCREW BONE 6.6X20MM ANKLE POST IOFIX PLUSXGREEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091625","CDM","C1713","HCPCS","0278","RC","","","","both","","","4155.00","3116.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1288.05","31","","432.60","432.60","432.60","1 through 10","1288.05","3303.23","percent of total billed charges",""
"SCREW BONE 6.6X20MM ANKLE POST IOFIX PLUSXGREEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091625","CDM","C1713","HCPCS","0278","RC","","","","both","","","4155.00","3116.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1516.58","36.5","","148.37","54.89","631.39","94","1288.05","3303.23","percent of total billed charges",""
"SCREW BONE 6.6X20MM ANKLE POST IOFIX PLUSXGREEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091625","CDM","C1713","HCPCS","0278","RC","","","","both","","","4155.00","3116.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1591.37","38.3","","279.30","91.72","1116.77","266","1288.05","3303.23","percent of total billed charges",""
"SCREW BONE 6.6X20MM ANKLE POST IOFIX PLUSXGREEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091625","CDM","C1713","HCPCS","0278","RC","","","","both","","","4155.00","3116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1782.50","42.9","","731.00","63.70","731.00","1 through 10","1288.05","3303.23","percent of total billed charges",""
"SCREW BONE 6.6X20MM ANKLE POST IOFIX PLUSXGREEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091625","CDM","C1713","HCPCS","0278","RC","","","","both","","","4155.00","3116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1782.50","42.9","","384.74","384.74","384.74","1 through 10","1288.05","3303.23","percent of total billed charges",""
"SCREW BONE 6.6X20MM ANKLE POST IOFIX PLUSXGREEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091625","CDM","C1713","HCPCS","0278","RC","","","","both","","","4155.00","3116.25","WELLPOINT [1015]","HB AMC WELLPOINT","3065.56","73.78","","286.63","119.22","1107.45","105","1288.05","3303.23","percent of total billed charges",""
"SCREW BONE 6.6X20MM ANKLE POST IOFIX PLUSXGREEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4155.00","3116.25","AETNA [1001]","HB AMC AETNA HMO","2900.19","69.8","","675.31","184.75","1721.50","286","2171.4","3395.47","percent of total billed charges",""
"SCREW BONE 6.6X20MM ANKLE POST IOFIX PLUSXGREEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4155.00","3116.25","AETNA [1001]","HB AMC AETNA PPO","3340.62","80.4","","1261.44","103.12","1514.10","21","2171.4","3395.47","percent of total billed charges",""
"SCREW BONE 6.6X20MM ANKLE POST IOFIX PLUSXGREEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4155.00","3116.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3340.62","80.4","","1365.00","1365.00","1365.00","1 through 10","2171.4","3395.47","percent of total billed charges",""
"SCREW BONE 6.6X20MM ANKLE POST IOFIX PLUSXGREEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4155.00","3116.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3395.47","81.72","","5157.68","5157.68","5157.68","1 through 10","2171.4","3395.47","percent of total billed charges",""
"SCREW BONE 6.6X20MM ANKLE POST IOFIX PLUSXGREEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4155.00","3116.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3395.47","81.72","","431.26","71.26","1459.57","88","2171.4","3395.47","percent of total billed charges",""
"SCREW BONE 6.7MMX75 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050603","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","800.18","480.96","1887.97","195","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6.7MMX75 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050603","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","813.12","216.42","1444.50","81","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6.7MMX75 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050603","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.25","31","","432.60","432.60","432.60","1 through 10","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6.7MMX75 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050603","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","148.37","54.89","631.39","94","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6.7MMX75 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050603","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","279.30","91.72","1116.77","266","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6.7MMX75 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050603","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","731.00","63.70","731.00","1 through 10","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6.7MMX75 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050603","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","384.74","384.74","384.74","1 through 10","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6.7MMX75 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050603","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","286.63","119.22","1107.45","105","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6.7MMX75 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","675.31","184.75","1721.50","286","457.28","715.05","percent of total billed charges",""
"SCREW BONE 6.7MMX75 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA PPO","703.50","80.4","","1261.44","103.12","1514.10","21","457.28","715.05","percent of total billed charges",""
"SCREW BONE 6.7MMX75 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1365.00","1365.00","1365.00","1 through 10","457.28","715.05","percent of total billed charges",""
"SCREW BONE 6.7MMX75 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","715.05","81.72","","5157.68","5157.68","5157.68","1 through 10","457.28","715.05","percent of total billed charges",""
"SCREW BONE 6.7MMX75 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","431.26","71.26","1459.57","88","457.28","715.05","percent of total billed charges",""
"SCREW BONE 6MM CANCELLOUS USS POLYAXIAL TITANIUM DUAL CORE 100MM THREAD","SUP-ITM-10086711","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","800.18","480.96","1887.97","195","48.83","125.21","percent of total billed charges",""
"SCREW BONE 6MM CANCELLOUS USS POLYAXIAL TITANIUM DUAL CORE 100MM THREAD","SUP-ITM-10086711","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","813.12","216.42","1444.50","81","48.83","125.21","percent of total billed charges",""
"SCREW BONE 6MM CANCELLOUS USS POLYAXIAL TITANIUM DUAL CORE 100MM THREAD","SUP-ITM-10086711","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.83","31","","432.60","432.60","432.60","1 through 10","48.83","125.21","percent of total billed charges",""
"SCREW BONE 6MM CANCELLOUS USS POLYAXIAL TITANIUM DUAL CORE 100MM THREAD","SUP-ITM-10086711","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","148.37","54.89","631.39","94","48.83","125.21","percent of total billed charges",""
"SCREW BONE 6MM CANCELLOUS USS POLYAXIAL TITANIUM DUAL CORE 100MM THREAD","SUP-ITM-10086711","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","279.30","91.72","1116.77","266","48.83","125.21","percent of total billed charges",""
"SCREW BONE 6MM CANCELLOUS USS POLYAXIAL TITANIUM DUAL CORE 100MM THREAD","SUP-ITM-10086711","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","731.00","63.70","731.00","1 through 10","48.83","125.21","percent of total billed charges",""
"SCREW BONE 6MM CANCELLOUS USS POLYAXIAL TITANIUM DUAL CORE 100MM THREAD","SUP-ITM-10086711","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","384.74","384.74","384.74","1 through 10","48.83","125.21","percent of total billed charges",""
"SCREW BONE 6MM CANCELLOUS USS POLYAXIAL TITANIUM DUAL CORE 100MM THREAD","SUP-ITM-10086711","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","286.63","119.22","1107.45","105","48.83","125.21","percent of total billed charges",""
"SCREW BONE 6MM CANCELLOUS USS POLYAXIAL TITANIUM DUAL CORE 100MM THREAD","SUP-ITM-10086711","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","675.31","184.75","1721.50","286","82.31","128.71","percent of total billed charges",""
"SCREW BONE 6MM CANCELLOUS USS POLYAXIAL TITANIUM DUAL CORE 100MM THREAD","SUP-ITM-10086711","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA PPO","126.63","80.4","","1261.44","103.12","1514.10","21","82.31","128.71","percent of total billed charges",""
"SCREW BONE 6MM CANCELLOUS USS POLYAXIAL TITANIUM DUAL CORE 100MM THREAD","SUP-ITM-10086711","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","1365.00","1365.00","1365.00","1 through 10","82.31","128.71","percent of total billed charges",""
"SCREW BONE 6MM CANCELLOUS USS POLYAXIAL TITANIUM DUAL CORE 100MM THREAD","SUP-ITM-10086711","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.71","81.72","","5157.68","5157.68","5157.68","1 through 10","82.31","128.71","percent of total billed charges",""
"SCREW BONE 6MM CANCELLOUS USS POLYAXIAL TITANIUM DUAL CORE 100MM THREAD","SUP-ITM-10086711","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","431.26","71.26","1459.57","88","82.31","128.71","percent of total billed charges",""
"SCREW BONE 6X100MM 30MM THREAD SELF DRILLING TITANIUM","SUP-ITM-10040860","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","396.23","79.5","","800.18","480.96","1887.97","195","154.5","396.23","percent of total billed charges",""
"SCREW BONE 6X100MM 30MM THREAD SELF DRILLING TITANIUM","SUP-ITM-10040860","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","265.65","53.3","","813.12","216.42","1444.50","81","154.5","396.23","percent of total billed charges",""
"SCREW BONE 6X100MM 30MM THREAD SELF DRILLING TITANIUM","SUP-ITM-10040860","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","154.50","31","","432.60","432.60","432.60","1 through 10","154.5","396.23","percent of total billed charges",""
"SCREW BONE 6X100MM 30MM THREAD SELF DRILLING TITANIUM","SUP-ITM-10040860","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","181.92","36.5","","148.37","54.89","631.39","94","154.5","396.23","percent of total billed charges",""
"SCREW BONE 6X100MM 30MM THREAD SELF DRILLING TITANIUM","SUP-ITM-10040860","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","190.89","38.3","","279.30","91.72","1116.77","266","154.5","396.23","percent of total billed charges",""
"SCREW BONE 6X100MM 30MM THREAD SELF DRILLING TITANIUM","SUP-ITM-10040860","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.81","42.9","","731.00","63.70","731.00","1 through 10","154.5","396.23","percent of total billed charges",""
"SCREW BONE 6X100MM 30MM THREAD SELF DRILLING TITANIUM","SUP-ITM-10040860","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","213.81","42.9","","384.74","384.74","384.74","1 through 10","154.5","396.23","percent of total billed charges",""
"SCREW BONE 6X100MM 30MM THREAD SELF DRILLING TITANIUM","SUP-ITM-10040860","CDM","C1713","HCPCS","0278","RC","","","","both","","","498.40","373.80","WELLPOINT [1015]","HB AMC WELLPOINT","367.72","73.78","","286.63","119.22","1107.45","105","154.5","396.23","percent of total billed charges",""
"SCREW BONE 6X100MM 30MM THREAD SELF DRILLING TITANIUM","SUP-ITM-10040860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.40","373.80","AETNA [1001]","HB AMC AETNA HMO","347.88","69.8","","675.31","184.75","1721.50","286","260.46","407.29","percent of total billed charges",""
"SCREW BONE 6X100MM 30MM THREAD SELF DRILLING TITANIUM","SUP-ITM-10040860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.40","373.80","AETNA [1001]","HB AMC AETNA PPO","400.71","80.4","","1261.44","103.12","1514.10","21","260.46","407.29","percent of total billed charges",""
"SCREW BONE 6X100MM 30MM THREAD SELF DRILLING TITANIUM","SUP-ITM-10040860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.40","373.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","400.71","80.4","","1365.00","1365.00","1365.00","1 through 10","260.46","407.29","percent of total billed charges",""
"SCREW BONE 6X100MM 30MM THREAD SELF DRILLING TITANIUM","SUP-ITM-10040860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.40","373.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","407.29","81.72","","5157.68","5157.68","5157.68","1 through 10","260.46","407.29","percent of total billed charges",""
"SCREW BONE 6X100MM 30MM THREAD SELF DRILLING TITANIUM","SUP-ITM-10040860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","498.40","373.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","407.29","81.72","","431.26","71.26","1459.57","88","260.46","407.29","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","171.85","79.5","","800.18","480.96","1887.97","195","67.01","171.85","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","115.21","53.3","","813.12","216.42","1444.50","81","67.01","171.85","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","67.01","31","","432.60","432.60","432.60","1 through 10","67.01","171.85","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","78.90","36.5","","148.37","54.89","631.39","94","67.01","171.85","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","82.79","38.3","","279.30","91.72","1116.77","266","67.01","171.85","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.73","42.9","","731.00","63.70","731.00","1 through 10","67.01","171.85","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.73","42.9","","384.74","384.74","384.74","1 through 10","67.01","171.85","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.16","162.12","WELLPOINT [1015]","HB AMC WELLPOINT","159.48","73.78","","286.63","119.22","1107.45","105","67.01","171.85","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","216.16","162.12","AETNA [1001]","HB AMC AETNA HMO","150.88","69.8","","675.31","184.75","1721.50","286","112.97","176.65","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","216.16","162.12","AETNA [1001]","HB AMC AETNA PPO","173.79","80.4","","1261.44","103.12","1514.10","21","112.97","176.65","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","216.16","162.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","173.79","80.4","","1365.00","1365.00","1365.00","1 through 10","112.97","176.65","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","216.16","162.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","176.65","81.72","","5157.68","5157.68","5157.68","1 through 10","112.97","176.65","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","216.16","162.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","176.65","81.72","","431.26","71.26","1459.57","88","112.97","176.65","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","737.36","79.5","","800.18","480.96","1887.97","195","287.53","737.36","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","494.36","53.3","","813.12","216.42","1444.50","81","287.53","737.36","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","287.53","31","","432.60","432.60","432.60","1 through 10","287.53","737.36","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","338.54","36.5","","148.37","54.89","631.39","94","287.53","737.36","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","355.23","38.3","","279.30","91.72","1116.77","266","287.53","737.36","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","397.90","42.9","","731.00","63.70","731.00","1 through 10","287.53","737.36","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","397.90","42.9","","384.74","384.74","384.74","1 through 10","287.53","737.36","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","WELLPOINT [1015]","HB AMC WELLPOINT","684.31","73.78","","286.63","119.22","1107.45","105","287.53","737.36","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","AETNA [1001]","HB AMC AETNA HMO","647.40","69.8","","675.31","184.75","1721.50","286","484.71","757.95","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","AETNA [1001]","HB AMC AETNA PPO","745.71","80.4","","1261.44","103.12","1514.10","21","484.71","757.95","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","745.71","80.4","","1365.00","1365.00","1365.00","1 through 10","484.71","757.95","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","757.95","81.72","","5157.68","5157.68","5157.68","1 through 10","484.71","757.95","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","757.95","81.72","","431.26","71.26","1459.57","88","484.71","757.95","percent of total billed charges",""
"SCREW BONE 6X250MM 80MM THREAD FIXATION EXTERNAL SCHANZ SS SELF DRILLING","SUP-ITM-10021790","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","349.04","79.5","","800.18","480.96","1887.97","195","136.1","349.04","percent of total billed charges",""
"SCREW BONE 6X250MM 80MM THREAD FIXATION EXTERNAL SCHANZ SS SELF DRILLING","SUP-ITM-10021790","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","234.01","53.3","","813.12","216.42","1444.50","81","136.1","349.04","percent of total billed charges",""
"SCREW BONE 6X250MM 80MM THREAD FIXATION EXTERNAL SCHANZ SS SELF DRILLING","SUP-ITM-10021790","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","136.10","31","","432.60","432.60","432.60","1 through 10","136.1","349.04","percent of total billed charges",""
"SCREW BONE 6X250MM 80MM THREAD FIXATION EXTERNAL SCHANZ SS SELF DRILLING","SUP-ITM-10021790","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","160.25","36.5","","148.37","54.89","631.39","94","136.1","349.04","percent of total billed charges",""
"SCREW BONE 6X250MM 80MM THREAD FIXATION EXTERNAL SCHANZ SS SELF DRILLING","SUP-ITM-10021790","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","168.15","38.3","","279.30","91.72","1116.77","266","136.1","349.04","percent of total billed charges",""
"SCREW BONE 6X250MM 80MM THREAD FIXATION EXTERNAL SCHANZ SS SELF DRILLING","SUP-ITM-10021790","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.35","42.9","","731.00","63.70","731.00","1 through 10","136.1","349.04","percent of total billed charges",""
"SCREW BONE 6X250MM 80MM THREAD FIXATION EXTERNAL SCHANZ SS SELF DRILLING","SUP-ITM-10021790","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.35","42.9","","384.74","384.74","384.74","1 through 10","136.1","349.04","percent of total billed charges",""
"SCREW BONE 6X250MM 80MM THREAD FIXATION EXTERNAL SCHANZ SS SELF DRILLING","SUP-ITM-10021790","CDM","C1713","HCPCS","0278","RC","","","","both","","","439.04","329.28","WELLPOINT [1015]","HB AMC WELLPOINT","323.92","73.78","","286.63","119.22","1107.45","105","136.1","349.04","percent of total billed charges",""
"SCREW BONE 6X250MM 80MM THREAD FIXATION EXTERNAL SCHANZ SS SELF DRILLING","SUP-ITM-10021790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","AETNA [1001]","HB AMC AETNA HMO","306.45","69.8","","675.31","184.75","1721.50","286","229.44","358.78","percent of total billed charges",""
"SCREW BONE 6X250MM 80MM THREAD FIXATION EXTERNAL SCHANZ SS SELF DRILLING","SUP-ITM-10021790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","AETNA [1001]","HB AMC AETNA PPO","352.99","80.4","","1261.44","103.12","1514.10","21","229.44","358.78","percent of total billed charges",""
"SCREW BONE 6X250MM 80MM THREAD FIXATION EXTERNAL SCHANZ SS SELF DRILLING","SUP-ITM-10021790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","352.99","80.4","","1365.00","1365.00","1365.00","1 through 10","229.44","358.78","percent of total billed charges",""
"SCREW BONE 6X250MM 80MM THREAD FIXATION EXTERNAL SCHANZ SS SELF DRILLING","SUP-ITM-10021790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","358.78","81.72","","5157.68","5157.68","5157.68","1 through 10","229.44","358.78","percent of total billed charges",""
"SCREW BONE 6X250MM 80MM THREAD FIXATION EXTERNAL SCHANZ SS SELF DRILLING","SUP-ITM-10021790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","439.04","329.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","358.78","81.72","","431.26","71.26","1459.57","88","229.44","358.78","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","800.18","480.96","1887.97","195","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","813.12","216.42","1444.50","81","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.25","31","","432.60","432.60","432.60","1 through 10","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","148.37","54.89","631.39","94","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","279.30","91.72","1116.77","266","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","731.00","63.70","731.00","1 through 10","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","384.74","384.74","384.74","1 through 10","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","286.63","119.22","1107.45","105","271.25","695.63","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","675.31","184.75","1721.50","286","457.28","715.05","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA PPO","703.50","80.4","","1261.44","103.12","1514.10","21","457.28","715.05","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1365.00","1365.00","1365.00","1 through 10","457.28","715.05","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","715.05","81.72","","5157.68","5157.68","5157.68","1 through 10","457.28","715.05","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","431.26","71.26","1459.57","88","457.28","715.05","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2328.95","79.5","","800.18","480.96","1887.97","195","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1561.42","53.3","","813.12","216.42","1444.50","81","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","908.15","31","","432.60","432.60","432.60","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1069.27","36.5","","148.37","54.89","631.39","94","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1122.00","38.3","","279.30","91.72","1116.77","266","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","731.00","63.70","731.00","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","384.74","384.74","384.74","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","WELLPOINT [1015]","HB AMC WELLPOINT","2161.39","73.78","","286.63","119.22","1107.45","105","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA HMO","2044.79","69.8","","675.31","184.75","1721.50","286","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA PPO","2355.32","80.4","","1261.44","103.12","1514.10","21","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2355.32","80.4","","1365.00","1365.00","1365.00","1 through 10","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2393.99","81.72","","5157.68","5157.68","5157.68","1 through 10","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10025481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2393.99","81.72","","431.26","71.26","1459.57","88","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","1309.77","674.56","6049.93","26","434","1113","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","1901.83","1901.83","2962.25","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1620.31","1620.31","19908.88","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","352.91","352.91","2046.30","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","9668.75","9668.75","9668.75","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","699.88","384.10","3443.31","33","434","1113","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1421.24","264.50","4933.46","29","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1022.97","1022.97","3607.50","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","3010.54","693.88","5019.88","35","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2601.64","79.5","","800.18","480.96","1887.97","195","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1744.24","53.3","","813.12","216.42","1444.50","81","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1014.48","31","","432.60","432.60","432.60","1 through 10","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1194.46","36.5","","148.37","54.89","631.39","94","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1253.37","38.3","","279.30","91.72","1116.77","266","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1403.90","42.9","","731.00","63.70","731.00","1 through 10","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1403.90","42.9","","384.74","384.74","384.74","1 through 10","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","WELLPOINT [1015]","HB AMC WELLPOINT","2414.45","73.78","","286.63","119.22","1107.45","105","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","AETNA [1001]","HB AMC AETNA HMO","2284.21","69.8","","675.31","184.75","1721.50","286","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","AETNA [1001]","HB AMC AETNA PPO","2631.09","80.4","","1261.44","103.12","1514.10","21","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2631.09","80.4","","1365.00","1365.00","1365.00","1 through 10","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2674.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2674.29","81.72","","431.26","71.26","1459.57","88","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2253.83","79.5","","800.18","480.96","1887.97","195","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1511.06","53.3","","813.12","216.42","1444.50","81","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","878.85","31","","432.60","432.60","432.60","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1034.78","36.5","","148.37","54.89","631.39","94","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1085.81","38.3","","279.30","91.72","1116.77","266","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","731.00","63.70","731.00","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","384.74","384.74","384.74","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB AMC WELLPOINT","2091.66","73.78","","286.63","119.22","1107.45","105","878.85","2253.83","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA HMO","1978.83","69.8","","675.31","184.75","1721.50","286","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA PPO","2279.34","80.4","","1261.44","103.12","1514.10","21","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2279.34","80.4","","1365.00","1365.00","1365.00","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2316.76","81.72","","5157.68","5157.68","5157.68","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2316.76","81.72","","431.26","71.26","1459.57","88","1481.57","2316.76","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","800.18","480.96","1887.97","195","434","1113","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","813.12","216.42","1444.50","81","434","1113","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","434.00","31","","432.60","432.60","432.60","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","148.37","54.89","631.39","94","434","1113","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","279.30","91.72","1116.77","266","434","1113","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","731.00","63.70","731.00","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","384.74","384.74","384.74","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","286.63","119.22","1107.45","105","434","1113","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","675.31","184.75","1721.50","286","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA PPO","1125.60","80.4","","1261.44","103.12","1514.10","21","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1365.00","1365.00","1365.00","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1144.08","81.72","","5157.68","5157.68","5157.68","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","431.26","71.26","1459.57","88","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","578.76","79.5","","800.18","480.96","1887.97","195","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","388.02","53.3","","813.12","216.42","1444.50","81","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","225.68","31","","432.60","432.60","432.60","1 through 10","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","265.72","36.5","","148.37","54.89","631.39","94","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","278.82","38.3","","279.30","91.72","1116.77","266","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.31","42.9","","731.00","63.70","731.00","1 through 10","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.31","42.9","","384.74","384.74","384.74","1 through 10","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","WELLPOINT [1015]","HB AMC WELLPOINT","537.12","73.78","","286.63","119.22","1107.45","105","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","AETNA [1001]","HB AMC AETNA HMO","508.14","69.8","","675.31","184.75","1721.50","286","380.45","594.92","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","AETNA [1001]","HB AMC AETNA PPO","585.31","80.4","","1261.44","103.12","1514.10","21","380.45","594.92","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","585.31","80.4","","1365.00","1365.00","1365.00","1 through 10","380.45","594.92","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","594.92","81.72","","5157.68","5157.68","5157.68","1 through 10","380.45","594.92","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","594.92","81.72","","431.26","71.26","1459.57","88","380.45","594.92","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","578.76","79.5","","800.18","480.96","1887.97","195","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","388.02","53.3","","813.12","216.42","1444.50","81","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","225.68","31","","432.60","432.60","432.60","1 through 10","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","265.72","36.5","","148.37","54.89","631.39","94","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","278.82","38.3","","279.30","91.72","1116.77","266","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.31","42.9","","731.00","63.70","731.00","1 through 10","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.31","42.9","","384.74","384.74","384.74","1 through 10","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.00","546.00","WELLPOINT [1015]","HB AMC WELLPOINT","537.12","73.78","","286.63","119.22","1107.45","105","225.68","578.76","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","AETNA [1001]","HB AMC AETNA HMO","508.14","69.8","","675.31","184.75","1721.50","286","380.45","594.92","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","AETNA [1001]","HB AMC AETNA PPO","585.31","80.4","","1261.44","103.12","1514.10","21","380.45","594.92","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","585.31","80.4","","1365.00","1365.00","1365.00","1 through 10","380.45","594.92","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","594.92","81.72","","5157.68","5157.68","5157.68","1 through 10","380.45","594.92","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.00","546.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","594.92","81.72","","431.26","71.26","1459.57","88","380.45","594.92","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","765.19","79.5","","800.18","480.96","1887.97","195","298.38","765.19","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","513.01","53.3","","813.12","216.42","1444.50","81","298.38","765.19","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","298.38","31","","432.60","432.60","432.60","1 through 10","298.38","765.19","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","351.31","36.5","","148.37","54.89","631.39","94","298.38","765.19","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","368.64","38.3","","279.30","91.72","1116.77","266","298.38","765.19","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","731.00","63.70","731.00","1 through 10","298.38","765.19","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.91","42.9","","384.74","384.74","384.74","1 through 10","298.38","765.19","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","both","","","962.50","721.87","WELLPOINT [1015]","HB AMC WELLPOINT","710.13","73.78","","286.63","119.22","1107.45","105","298.38","765.19","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA HMO","671.83","69.8","","675.31","184.75","1721.50","286","503","786.56","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","AETNA [1001]","HB AMC AETNA PPO","773.85","80.4","","1261.44","103.12","1514.10","21","503","786.56","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","773.85","80.4","","1365.00","1365.00","1365.00","1 through 10","503","786.56","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","786.56","81.72","","5157.68","5157.68","5157.68","1 through 10","503","786.56","percent of total billed charges",""
"SCREW BONE 7.0X40MM MAXLOCK TITANIUM CANNULATED SELF DRILLING TAPPING SHORT THREAD","SUP-ITM-10083197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","962.50","721.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","786.56","81.72","","431.26","71.26","1459.57","88","503","786.56","percent of total billed charges",""
"SCREW BONE 7.3X100MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022671","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","561.10","79.5","","800.18","480.96","1887.97","195","218.79","561.1","percent of total billed charges",""
"SCREW BONE 7.3X100MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022671","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","376.18","53.3","","813.12","216.42","1444.50","81","218.79","561.1","percent of total billed charges",""
"SCREW BONE 7.3X100MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022671","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","218.79","31","","432.60","432.60","432.60","1 through 10","218.79","561.1","percent of total billed charges",""
"SCREW BONE 7.3X100MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022671","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","257.61","36.5","","148.37","54.89","631.39","94","218.79","561.1","percent of total billed charges",""
"SCREW BONE 7.3X100MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022671","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","270.31","38.3","","279.30","91.72","1116.77","266","218.79","561.1","percent of total billed charges",""
"SCREW BONE 7.3X100MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022671","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","302.78","42.9","","731.00","63.70","731.00","1 through 10","218.79","561.1","percent of total billed charges",""
"SCREW BONE 7.3X100MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022671","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","302.78","42.9","","384.74","384.74","384.74","1 through 10","218.79","561.1","percent of total billed charges",""
"SCREW BONE 7.3X100MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022671","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.78","529.33","WELLPOINT [1015]","HB AMC WELLPOINT","520.72","73.78","","286.63","119.22","1107.45","105","218.79","561.1","percent of total billed charges",""
"SCREW BONE 7.3X100MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022671","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.78","529.33","AETNA [1001]","HB AMC AETNA HMO","492.63","69.8","","675.31","184.75","1721.50","286","368.84","576.76","percent of total billed charges",""
"SCREW BONE 7.3X100MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022671","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.78","529.33","AETNA [1001]","HB AMC AETNA PPO","567.45","80.4","","1261.44","103.12","1514.10","21","368.84","576.76","percent of total billed charges",""
"SCREW BONE 7.3X100MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022671","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.78","529.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","567.45","80.4","","1365.00","1365.00","1365.00","1 through 10","368.84","576.76","percent of total billed charges",""
"SCREW BONE 7.3X100MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022671","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.78","529.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","576.76","81.72","","5157.68","5157.68","5157.68","1 through 10","368.84","576.76","percent of total billed charges",""
"SCREW BONE 7.3X100MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022671","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.78","529.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","576.76","81.72","","431.26","71.26","1459.57","88","368.84","576.76","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","564.48","423.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","448.76","79.5","","800.18","480.96","1887.97","195","174.99","448.76","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","564.48","423.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","300.87","53.3","","813.12","216.42","1444.50","81","174.99","448.76","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","564.48","423.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","174.99","31","","432.60","432.60","432.60","1 through 10","174.99","448.76","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","564.48","423.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","206.04","36.5","","148.37","54.89","631.39","94","174.99","448.76","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","564.48","423.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","216.20","38.3","","279.30","91.72","1116.77","266","174.99","448.76","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","564.48","423.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","242.16","42.9","","731.00","63.70","731.00","1 through 10","174.99","448.76","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","564.48","423.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","242.16","42.9","","384.74","384.74","384.74","1 through 10","174.99","448.76","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","564.48","423.36","WELLPOINT [1015]","HB AMC WELLPOINT","416.47","73.78","","286.63","119.22","1107.45","105","174.99","448.76","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","564.48","423.36","AETNA [1001]","HB AMC AETNA HMO","394.01","69.8","","675.31","184.75","1721.50","286","295","461.29","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","564.48","423.36","AETNA [1001]","HB AMC AETNA PPO","453.84","80.4","","1261.44","103.12","1514.10","21","295","461.29","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","564.48","423.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","453.84","80.4","","1365.00","1365.00","1365.00","1 through 10","295","461.29","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","564.48","423.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","461.29","81.72","","5157.68","5157.68","5157.68","1 through 10","295","461.29","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","564.48","423.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","461.29","81.72","","431.26","71.26","1459.57","88","295","461.29","percent of total billed charges",""
"SCREW BONE 7.3X150MM SS CANNULATED SEDRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10125716","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.40","436.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","463.01","79.5","","800.18","480.96","1887.97","195","180.54","463.01","percent of total billed charges",""
"SCREW BONE 7.3X150MM SS CANNULATED SEDRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10125716","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.40","436.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","310.42","53.3","","813.12","216.42","1444.50","81","180.54","463.01","percent of total billed charges",""
"SCREW BONE 7.3X150MM SS CANNULATED SEDRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10125716","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.40","436.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","180.54","31","","432.60","432.60","432.60","1 through 10","180.54","463.01","percent of total billed charges",""
"SCREW BONE 7.3X150MM SS CANNULATED SEDRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10125716","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.40","436.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","212.58","36.5","","148.37","54.89","631.39","94","180.54","463.01","percent of total billed charges",""
"SCREW BONE 7.3X150MM SS CANNULATED SEDRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10125716","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.40","436.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","223.06","38.3","","279.30","91.72","1116.77","266","180.54","463.01","percent of total billed charges",""
"SCREW BONE 7.3X150MM SS CANNULATED SEDRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10125716","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.40","436.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.85","42.9","","731.00","63.70","731.00","1 through 10","180.54","463.01","percent of total billed charges",""
"SCREW BONE 7.3X150MM SS CANNULATED SEDRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10125716","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.40","436.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.85","42.9","","384.74","384.74","384.74","1 through 10","180.54","463.01","percent of total billed charges",""
"SCREW BONE 7.3X150MM SS CANNULATED SEDRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10125716","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.40","436.80","WELLPOINT [1015]","HB AMC WELLPOINT","429.69","73.78","","286.63","119.22","1107.45","105","180.54","463.01","percent of total billed charges",""
"SCREW BONE 7.3X150MM SS CANNULATED SEDRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10125716","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.40","436.80","AETNA [1001]","HB AMC AETNA HMO","406.52","69.8","","675.31","184.75","1721.50","286","304.36","475.94","percent of total billed charges",""
"SCREW BONE 7.3X150MM SS CANNULATED SEDRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10125716","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.40","436.80","AETNA [1001]","HB AMC AETNA PPO","468.25","80.4","","1261.44","103.12","1514.10","21","304.36","475.94","percent of total billed charges",""
"SCREW BONE 7.3X150MM SS CANNULATED SEDRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10125716","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.40","436.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","468.25","80.4","","1365.00","1365.00","1365.00","1 through 10","304.36","475.94","percent of total billed charges",""
"SCREW BONE 7.3X150MM SS CANNULATED SEDRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10125716","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.40","436.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","475.94","81.72","","5157.68","5157.68","5157.68","1 through 10","304.36","475.94","percent of total billed charges",""
"SCREW BONE 7.3X150MM SS CANNULATED SEDRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10125716","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.40","436.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","475.94","81.72","","431.26","71.26","1459.57","88","304.36","475.94","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","620.48","465.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","493.28","79.5","","800.18","480.96","1887.97","195","192.35","493.28","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","620.48","465.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","330.72","53.3","","813.12","216.42","1444.50","81","192.35","493.28","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","620.48","465.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","192.35","31","","432.60","432.60","432.60","1 through 10","192.35","493.28","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","620.48","465.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","226.48","36.5","","148.37","54.89","631.39","94","192.35","493.28","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","620.48","465.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","237.64","38.3","","279.30","91.72","1116.77","266","192.35","493.28","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","620.48","465.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.19","42.9","","731.00","63.70","731.00","1 through 10","192.35","493.28","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","620.48","465.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.19","42.9","","384.74","384.74","384.74","1 through 10","192.35","493.28","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","620.48","465.36","WELLPOINT [1015]","HB AMC WELLPOINT","457.79","73.78","","286.63","119.22","1107.45","105","192.35","493.28","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","620.48","465.36","AETNA [1001]","HB AMC AETNA HMO","433.10","69.8","","675.31","184.75","1721.50","286","324.26","507.06","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","620.48","465.36","AETNA [1001]","HB AMC AETNA PPO","498.87","80.4","","1261.44","103.12","1514.10","21","324.26","507.06","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","620.48","465.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","498.87","80.4","","1365.00","1365.00","1365.00","1 through 10","324.26","507.06","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","620.48","465.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","507.06","81.72","","5157.68","5157.68","5157.68","1 through 10","324.26","507.06","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","620.48","465.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","507.06","81.72","","431.26","71.26","1459.57","88","324.26","507.06","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","617.72","463.29","CIGNA [1006]","HB AMC CIGNA HMO / PPO","491.09","79.5","","800.18","480.96","1887.97","195","191.49","491.09","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","617.72","463.29","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","329.24","53.3","","813.12","216.42","1444.50","81","191.49","491.09","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","617.72","463.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","191.49","31","","432.60","432.60","432.60","1 through 10","191.49","491.09","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","617.72","463.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","225.47","36.5","","148.37","54.89","631.39","94","191.49","491.09","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","617.72","463.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","236.59","38.3","","279.30","91.72","1116.77","266","191.49","491.09","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","617.72","463.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.00","42.9","","731.00","63.70","731.00","1 through 10","191.49","491.09","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","617.72","463.29","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.00","42.9","","384.74","384.74","384.74","1 through 10","191.49","491.09","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","617.72","463.29","WELLPOINT [1015]","HB AMC WELLPOINT","455.75","73.78","","286.63","119.22","1107.45","105","191.49","491.09","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","617.72","463.29","AETNA [1001]","HB AMC AETNA HMO","431.17","69.8","","675.31","184.75","1721.50","286","322.82","504.8","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","617.72","463.29","AETNA [1001]","HB AMC AETNA PPO","496.65","80.4","","1261.44","103.12","1514.10","21","322.82","504.8","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","617.72","463.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","496.65","80.4","","1365.00","1365.00","1365.00","1 through 10","322.82","504.8","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","617.72","463.29","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","504.80","81.72","","5157.68","5157.68","5157.68","1 through 10","322.82","504.8","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","617.72","463.29","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","504.80","81.72","","431.26","71.26","1459.57","88","322.82","504.8","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.83","519.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","550.80","79.5","","800.18","480.96","1887.97","195","214.78","550.8","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.83","519.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","369.28","53.3","","813.12","216.42","1444.50","81","214.78","550.8","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.83","519.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","214.78","31","","432.60","432.60","432.60","1 through 10","214.78","550.8","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.83","519.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","252.88","36.5","","148.37","54.89","631.39","94","214.78","550.8","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.83","519.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","265.35","38.3","","279.30","91.72","1116.77","266","214.78","550.8","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.83","519.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","297.22","42.9","","731.00","63.70","731.00","1 through 10","214.78","550.8","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.83","519.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","297.22","42.9","","384.74","384.74","384.74","1 through 10","214.78","550.8","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","692.83","519.62","WELLPOINT [1015]","HB AMC WELLPOINT","511.17","73.78","","286.63","119.22","1107.45","105","214.78","550.8","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","692.83","519.62","AETNA [1001]","HB AMC AETNA HMO","483.60","69.8","","675.31","184.75","1721.50","286","362.07","566.18","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","692.83","519.62","AETNA [1001]","HB AMC AETNA PPO","557.04","80.4","","1261.44","103.12","1514.10","21","362.07","566.18","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","692.83","519.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","557.04","80.4","","1365.00","1365.00","1365.00","1 through 10","362.07","566.18","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","692.83","519.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","566.18","81.72","","5157.68","5157.68","5157.68","1 through 10","362.07","566.18","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","692.83","519.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","566.18","81.72","","431.26","71.26","1459.57","88","362.07","566.18","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.26","474.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","503.44","79.5","","800.18","480.96","1887.97","195","196.31","503.44","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.26","474.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","337.53","53.3","","813.12","216.42","1444.50","81","196.31","503.44","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.26","474.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","196.31","31","","432.60","432.60","432.60","1 through 10","196.31","503.44","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.26","474.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","231.14","36.5","","148.37","54.89","631.39","94","196.31","503.44","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.26","474.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","242.54","38.3","","279.30","91.72","1116.77","266","196.31","503.44","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.26","474.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","271.67","42.9","","731.00","63.70","731.00","1 through 10","196.31","503.44","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.26","474.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","271.67","42.9","","384.74","384.74","384.74","1 through 10","196.31","503.44","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","both","","","633.26","474.94","WELLPOINT [1015]","HB AMC WELLPOINT","467.22","73.78","","286.63","119.22","1107.45","105","196.31","503.44","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","633.26","474.94","AETNA [1001]","HB AMC AETNA HMO","442.02","69.8","","675.31","184.75","1721.50","286","330.94","517.5","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","633.26","474.94","AETNA [1001]","HB AMC AETNA PPO","509.14","80.4","","1261.44","103.12","1514.10","21","330.94","517.5","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","633.26","474.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","509.14","80.4","","1365.00","1365.00","1365.00","1 through 10","330.94","517.5","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","633.26","474.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","517.50","81.72","","5157.68","5157.68","5157.68","1 through 10","330.94","517.5","percent of total billed charges",""
"SCREW BONE 7.3X65MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING PARTIAL THREAD","SUP-ITM-10011682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","633.26","474.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","517.50","81.72","","431.26","71.26","1459.57","88","330.94","517.5","percent of total billed charges",""
"SCREW BONE 7.5MMX45MM SPINE SELF TAPPING CANNULATED","SUP-ITM-10083597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1085.18","79.5","","800.18","480.96","1887.97","195","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 7.5MMX45MM SPINE SELF TAPPING CANNULATED","SUP-ITM-10083597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","727.55","53.3","","813.12","216.42","1444.50","81","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 7.5MMX45MM SPINE SELF TAPPING CANNULATED","SUP-ITM-10083597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","423.15","31","","432.60","432.60","432.60","1 through 10","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 7.5MMX45MM SPINE SELF TAPPING CANNULATED","SUP-ITM-10083597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","498.23","36.5","","148.37","54.89","631.39","94","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 7.5MMX45MM SPINE SELF TAPPING CANNULATED","SUP-ITM-10083597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","522.80","38.3","","279.30","91.72","1116.77","266","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 7.5MMX45MM SPINE SELF TAPPING CANNULATED","SUP-ITM-10083597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","731.00","63.70","731.00","1 through 10","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 7.5MMX45MM SPINE SELF TAPPING CANNULATED","SUP-ITM-10083597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","384.74","384.74","384.74","1 through 10","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 7.5MMX45MM SPINE SELF TAPPING CANNULATED","SUP-ITM-10083597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB AMC WELLPOINT","1007.10","73.78","","286.63","119.22","1107.45","105","423.15","1085.18","percent of total billed charges",""
"SCREW BONE 7.5MMX45MM SPINE SELF TAPPING CANNULATED","SUP-ITM-10083597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA HMO","952.77","69.8","","675.31","184.75","1721.50","286","713.35","1115.48","percent of total billed charges",""
"SCREW BONE 7.5MMX45MM SPINE SELF TAPPING CANNULATED","SUP-ITM-10083597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA PPO","1097.46","80.4","","1261.44","103.12","1514.10","21","713.35","1115.48","percent of total billed charges",""
"SCREW BONE 7.5MMX45MM SPINE SELF TAPPING CANNULATED","SUP-ITM-10083597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1097.46","80.4","","1365.00","1365.00","1365.00","1 through 10","713.35","1115.48","percent of total billed charges",""
"SCREW BONE 7.5MMX45MM SPINE SELF TAPPING CANNULATED","SUP-ITM-10083597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1115.48","81.72","","5157.68","5157.68","5157.68","1 through 10","713.35","1115.48","percent of total billed charges",""
"SCREW BONE 7.5MMX45MM SPINE SELF TAPPING CANNULATED","SUP-ITM-10083597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1115.48","81.72","","431.26","71.26","1459.57","88","713.35","1115.48","percent of total billed charges",""
"SCREW BONE 7.5X100MM DARCO TI COMPRESSION 32MM THREAD","SUP-ITM-10133739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1076.83","79.5","","800.18","480.96","1887.97","195","419.9","1076.83","percent of total billed charges",""
"SCREW BONE 7.5X100MM DARCO TI COMPRESSION 32MM THREAD","SUP-ITM-10133739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","721.95","53.3","","813.12","216.42","1444.50","81","419.9","1076.83","percent of total billed charges",""
"SCREW BONE 7.5X100MM DARCO TI COMPRESSION 32MM THREAD","SUP-ITM-10133739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","419.90","31","","432.60","432.60","432.60","1 through 10","419.9","1076.83","percent of total billed charges",""
"SCREW BONE 7.5X100MM DARCO TI COMPRESSION 32MM THREAD","SUP-ITM-10133739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","494.39","36.5","","148.37","54.89","631.39","94","419.9","1076.83","percent of total billed charges",""
"SCREW BONE 7.5X100MM DARCO TI COMPRESSION 32MM THREAD","SUP-ITM-10133739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","518.77","38.3","","279.30","91.72","1116.77","266","419.9","1076.83","percent of total billed charges",""
"SCREW BONE 7.5X100MM DARCO TI COMPRESSION 32MM THREAD","SUP-ITM-10133739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","581.08","42.9","","731.00","63.70","731.00","1 through 10","419.9","1076.83","percent of total billed charges",""
"SCREW BONE 7.5X100MM DARCO TI COMPRESSION 32MM THREAD","SUP-ITM-10133739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","581.08","42.9","","384.74","384.74","384.74","1 through 10","419.9","1076.83","percent of total billed charges",""
"SCREW BONE 7.5X100MM DARCO TI COMPRESSION 32MM THREAD","SUP-ITM-10133739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.50","1015.87","WELLPOINT [1015]","HB AMC WELLPOINT","999.35","73.78","","286.63","119.22","1107.45","105","419.9","1076.83","percent of total billed charges",""
"SCREW BONE 7.5X100MM DARCO TI COMPRESSION 32MM THREAD","SUP-ITM-10133739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.50","1015.87","AETNA [1001]","HB AMC AETNA HMO","945.44","69.8","","675.31","184.75","1721.50","286","707.86","1106.9","percent of total billed charges",""
"SCREW BONE 7.5X100MM DARCO TI COMPRESSION 32MM THREAD","SUP-ITM-10133739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.50","1015.87","AETNA [1001]","HB AMC AETNA PPO","1089.02","80.4","","1261.44","103.12","1514.10","21","707.86","1106.9","percent of total billed charges",""
"SCREW BONE 7.5X100MM DARCO TI COMPRESSION 32MM THREAD","SUP-ITM-10133739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.50","1015.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1089.02","80.4","","1365.00","1365.00","1365.00","1 through 10","707.86","1106.9","percent of total billed charges",""
"SCREW BONE 7.5X100MM DARCO TI COMPRESSION 32MM THREAD","SUP-ITM-10133739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.50","1015.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1106.90","81.72","","5157.68","5157.68","5157.68","1 through 10","707.86","1106.9","percent of total billed charges",""
"SCREW BONE 7.5X100MM DARCO TI COMPRESSION 32MM THREAD","SUP-ITM-10133739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.50","1015.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1106.90","81.72","","431.26","71.26","1459.57","88","707.86","1106.9","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","1309.77","674.56","6049.93","26","434","1113","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","1901.83","1901.83","2962.25","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1620.31","1620.31","19908.88","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","352.91","352.91","2046.30","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","9668.75","9668.75","9668.75","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","699.88","384.10","3443.31","33","434","1113","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1421.24","264.50","4933.46","29","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1022.97","1022.97","3607.50","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","3010.54","693.88","5019.88","35","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2601.64","79.5","","800.18","480.96","1887.97","195","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1744.24","53.3","","813.12","216.42","1444.50","81","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1014.48","31","","432.60","432.60","432.60","1 through 10","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1194.46","36.5","","148.37","54.89","631.39","94","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1253.37","38.3","","279.30","91.72","1116.77","266","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1403.90","42.9","","731.00","63.70","731.00","1 through 10","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1403.90","42.9","","384.74","384.74","384.74","1 through 10","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","WELLPOINT [1015]","HB AMC WELLPOINT","2414.45","73.78","","286.63","119.22","1107.45","105","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","AETNA [1001]","HB AMC AETNA HMO","2284.21","69.8","","675.31","184.75","1721.50","286","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","AETNA [1001]","HB AMC AETNA PPO","2631.09","80.4","","1261.44","103.12","1514.10","21","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2631.09","80.4","","1365.00","1365.00","1365.00","1 through 10","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2674.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2674.29","81.72","","431.26","71.26","1459.57","88","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7.5X50MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.50","1477.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1566.55","79.5","","800.18","480.96","1887.97","195","610.86","1566.55","percent of total billed charges",""
"SCREW BONE 7.5X50MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.50","1477.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1050.28","53.3","","813.12","216.42","1444.50","81","610.86","1566.55","percent of total billed charges",""
"SCREW BONE 7.5X50MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.50","1477.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","610.86","31","","432.60","432.60","432.60","1 through 10","610.86","1566.55","percent of total billed charges",""
"SCREW BONE 7.5X50MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.50","1477.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","719.23","36.5","","148.37","54.89","631.39","94","610.86","1566.55","percent of total billed charges",""
"SCREW BONE 7.5X50MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.50","1477.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","754.70","38.3","","279.30","91.72","1116.77","266","610.86","1566.55","percent of total billed charges",""
"SCREW BONE 7.5X50MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.50","1477.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","845.34","42.9","","731.00","63.70","731.00","1 through 10","610.86","1566.55","percent of total billed charges",""
"SCREW BONE 7.5X50MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.50","1477.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","845.34","42.9","","384.74","384.74","384.74","1 through 10","610.86","1566.55","percent of total billed charges",""
"SCREW BONE 7.5X50MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1970.50","1477.87","WELLPOINT [1015]","HB AMC WELLPOINT","1453.83","73.78","","286.63","119.22","1107.45","105","610.86","1566.55","percent of total billed charges",""
"SCREW BONE 7.5X50MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1970.50","1477.87","AETNA [1001]","HB AMC AETNA HMO","1375.41","69.8","","675.31","184.75","1721.50","286","1029.78","1610.29","percent of total billed charges",""
"SCREW BONE 7.5X50MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1970.50","1477.87","AETNA [1001]","HB AMC AETNA PPO","1584.28","80.4","","1261.44","103.12","1514.10","21","1029.78","1610.29","percent of total billed charges",""
"SCREW BONE 7.5X50MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1970.50","1477.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1584.28","80.4","","1365.00","1365.00","1365.00","1 through 10","1029.78","1610.29","percent of total billed charges",""
"SCREW BONE 7.5X50MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1970.50","1477.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1610.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1029.78","1610.29","percent of total billed charges",""
"SCREW BONE 7.5X50MM COMPRESSION ACUTRAK 2 TITANIUM CANNULATED SELF CUTTING FULL THREAD HEADLESS","SUP-ITM-10129742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1970.50","1477.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1610.29","81.72","","431.26","71.26","1459.57","88","1029.78","1610.29","percent of total billed charges",""
"SCREW BONE 7.5X50MM CREO FENESTRATED MODULAR","SUP-ITM-10315743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1210.39","79.5","","800.18","480.96","1887.97","195","471.98","1210.39","percent of total billed charges",""
"SCREW BONE 7.5X50MM CREO FENESTRATED MODULAR","SUP-ITM-10315743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","811.49","53.3","","813.12","216.42","1444.50","81","471.98","1210.39","percent of total billed charges",""
"SCREW BONE 7.5X50MM CREO FENESTRATED MODULAR","SUP-ITM-10315743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","471.98","31","","432.60","432.60","432.60","1 through 10","471.98","1210.39","percent of total billed charges",""
"SCREW BONE 7.5X50MM CREO FENESTRATED MODULAR","SUP-ITM-10315743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","555.71","36.5","","148.37","54.89","631.39","94","471.98","1210.39","percent of total billed charges",""
"SCREW BONE 7.5X50MM CREO FENESTRATED MODULAR","SUP-ITM-10315743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","583.12","38.3","","279.30","91.72","1116.77","266","471.98","1210.39","percent of total billed charges",""
"SCREW BONE 7.5X50MM CREO FENESTRATED MODULAR","SUP-ITM-10315743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.15","42.9","","731.00","63.70","731.00","1 through 10","471.98","1210.39","percent of total billed charges",""
"SCREW BONE 7.5X50MM CREO FENESTRATED MODULAR","SUP-ITM-10315743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.15","42.9","","384.74","384.74","384.74","1 through 10","471.98","1210.39","percent of total billed charges",""
"SCREW BONE 7.5X50MM CREO FENESTRATED MODULAR","SUP-ITM-10315743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","WELLPOINT [1015]","HB AMC WELLPOINT","1123.30","73.78","","286.63","119.22","1107.45","105","471.98","1210.39","percent of total billed charges",""
"SCREW BONE 7.5X50MM CREO FENESTRATED MODULAR","SUP-ITM-10315743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","AETNA [1001]","HB AMC AETNA HMO","1062.71","69.8","","675.31","184.75","1721.50","286","795.66","1244.19","percent of total billed charges",""
"SCREW BONE 7.5X50MM CREO FENESTRATED MODULAR","SUP-ITM-10315743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","AETNA [1001]","HB AMC AETNA PPO","1224.09","80.4","","1261.44","103.12","1514.10","21","795.66","1244.19","percent of total billed charges",""
"SCREW BONE 7.5X50MM CREO FENESTRATED MODULAR","SUP-ITM-10315743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1224.09","80.4","","1365.00","1365.00","1365.00","1 through 10","795.66","1244.19","percent of total billed charges",""
"SCREW BONE 7.5X50MM CREO FENESTRATED MODULAR","SUP-ITM-10315743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1244.19","81.72","","5157.68","5157.68","5157.68","1 through 10","795.66","1244.19","percent of total billed charges",""
"SCREW BONE 7.5X50MM CREO FENESTRATED MODULAR","SUP-ITM-10315743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1244.19","81.72","","431.26","71.26","1459.57","88","795.66","1244.19","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2601.64","79.5","","800.18","480.96","1887.97","195","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1744.24","53.3","","813.12","216.42","1444.50","81","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1014.48","31","","432.60","432.60","432.60","1 through 10","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1194.46","36.5","","148.37","54.89","631.39","94","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1253.37","38.3","","279.30","91.72","1116.77","266","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1403.90","42.9","","731.00","63.70","731.00","1 through 10","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1403.90","42.9","","384.74","384.74","384.74","1 through 10","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","WELLPOINT [1015]","HB AMC WELLPOINT","2414.45","73.78","","286.63","119.22","1107.45","105","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","AETNA [1001]","HB AMC AETNA HMO","2284.21","69.8","","675.31","184.75","1721.50","286","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","AETNA [1001]","HB AMC AETNA PPO","2631.09","80.4","","1261.44","103.12","1514.10","21","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2631.09","80.4","","1365.00","1365.00","1365.00","1 through 10","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2674.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2674.29","81.72","","431.26","71.26","1459.57","88","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 75X3.5MM CORTEX DUPONT SS SELF TAPPING FULL THREAD","SUP-ITM-10077573","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.14","120.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","128.11","79.5","","800.18","480.96","1887.97","195","49.95","128.11","percent of total billed charges",""
"SCREW BONE 75X3.5MM CORTEX DUPONT SS SELF TAPPING FULL THREAD","SUP-ITM-10077573","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.14","120.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.89","53.3","","813.12","216.42","1444.50","81","49.95","128.11","percent of total billed charges",""
"SCREW BONE 75X3.5MM CORTEX DUPONT SS SELF TAPPING FULL THREAD","SUP-ITM-10077573","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.14","120.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","49.95","31","","432.60","432.60","432.60","1 through 10","49.95","128.11","percent of total billed charges",""
"SCREW BONE 75X3.5MM CORTEX DUPONT SS SELF TAPPING FULL THREAD","SUP-ITM-10077573","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.14","120.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","58.82","36.5","","148.37","54.89","631.39","94","49.95","128.11","percent of total billed charges",""
"SCREW BONE 75X3.5MM CORTEX DUPONT SS SELF TAPPING FULL THREAD","SUP-ITM-10077573","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.14","120.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","61.72","38.3","","279.30","91.72","1116.77","266","49.95","128.11","percent of total billed charges",""
"SCREW BONE 75X3.5MM CORTEX DUPONT SS SELF TAPPING FULL THREAD","SUP-ITM-10077573","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.14","120.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.13","42.9","","731.00","63.70","731.00","1 through 10","49.95","128.11","percent of total billed charges",""
"SCREW BONE 75X3.5MM CORTEX DUPONT SS SELF TAPPING FULL THREAD","SUP-ITM-10077573","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.14","120.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.13","42.9","","384.74","384.74","384.74","1 through 10","49.95","128.11","percent of total billed charges",""
"SCREW BONE 75X3.5MM CORTEX DUPONT SS SELF TAPPING FULL THREAD","SUP-ITM-10077573","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.14","120.85","WELLPOINT [1015]","HB AMC WELLPOINT","118.89","73.78","","286.63","119.22","1107.45","105","49.95","128.11","percent of total billed charges",""
"SCREW BONE 75X3.5MM CORTEX DUPONT SS SELF TAPPING FULL THREAD","SUP-ITM-10077573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","161.14","120.85","AETNA [1001]","HB AMC AETNA HMO","112.48","69.8","","675.31","184.75","1721.50","286","84.21","131.68","percent of total billed charges",""
"SCREW BONE 75X3.5MM CORTEX DUPONT SS SELF TAPPING FULL THREAD","SUP-ITM-10077573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","161.14","120.85","AETNA [1001]","HB AMC AETNA PPO","129.56","80.4","","1261.44","103.12","1514.10","21","84.21","131.68","percent of total billed charges",""
"SCREW BONE 75X3.5MM CORTEX DUPONT SS SELF TAPPING FULL THREAD","SUP-ITM-10077573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","161.14","120.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","129.56","80.4","","1365.00","1365.00","1365.00","1 through 10","84.21","131.68","percent of total billed charges",""
"SCREW BONE 75X3.5MM CORTEX DUPONT SS SELF TAPPING FULL THREAD","SUP-ITM-10077573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","161.14","120.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","131.68","81.72","","5157.68","5157.68","5157.68","1 through 10","84.21","131.68","percent of total billed charges",""
"SCREW BONE 75X3.5MM CORTEX DUPONT SS SELF TAPPING FULL THREAD","SUP-ITM-10077573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","161.14","120.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","131.68","81.72","","431.26","71.26","1459.57","88","84.21","131.68","percent of total billed charges",""
"SCREW BONE 7MM CANNULA CLEARTRAC BX/10EA","SUP-ITM-10027816","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.35","94.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","100.45","79.5","","800.18","480.96","1887.97","195","39.17","100.45","percent of total billed charges",""
"SCREW BONE 7MM CANNULA CLEARTRAC BX/10EA","SUP-ITM-10027816","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.35","94.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","67.34","53.3","","813.12","216.42","1444.50","81","39.17","100.45","percent of total billed charges",""
"SCREW BONE 7MM CANNULA CLEARTRAC BX/10EA","SUP-ITM-10027816","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.35","94.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","39.17","31","","432.60","432.60","432.60","1 through 10","39.17","100.45","percent of total billed charges",""
"SCREW BONE 7MM CANNULA CLEARTRAC BX/10EA","SUP-ITM-10027816","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.35","94.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","46.12","36.5","","148.37","54.89","631.39","94","39.17","100.45","percent of total billed charges",""
"SCREW BONE 7MM CANNULA CLEARTRAC BX/10EA","SUP-ITM-10027816","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.35","94.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","48.39","38.3","","279.30","91.72","1116.77","266","39.17","100.45","percent of total billed charges",""
"SCREW BONE 7MM CANNULA CLEARTRAC BX/10EA","SUP-ITM-10027816","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.35","94.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.20","42.9","","731.00","63.70","731.00","1 through 10","39.17","100.45","percent of total billed charges",""
"SCREW BONE 7MM CANNULA CLEARTRAC BX/10EA","SUP-ITM-10027816","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.35","94.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.20","42.9","","384.74","384.74","384.74","1 through 10","39.17","100.45","percent of total billed charges",""
"SCREW BONE 7MM CANNULA CLEARTRAC BX/10EA","SUP-ITM-10027816","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.35","94.76","WELLPOINT [1015]","HB AMC WELLPOINT","93.22","73.78","","286.63","119.22","1107.45","105","39.17","100.45","percent of total billed charges",""
"SCREW BONE 7MM CANNULA CLEARTRAC BX/10EA","SUP-ITM-10027816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.35","94.76","AETNA [1001]","HB AMC AETNA HMO","88.19","69.8","","675.31","184.75","1721.50","286","66.03","103.25","percent of total billed charges",""
"SCREW BONE 7MM CANNULA CLEARTRAC BX/10EA","SUP-ITM-10027816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.35","94.76","AETNA [1001]","HB AMC AETNA PPO","101.59","80.4","","1261.44","103.12","1514.10","21","66.03","103.25","percent of total billed charges",""
"SCREW BONE 7MM CANNULA CLEARTRAC BX/10EA","SUP-ITM-10027816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.35","94.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","101.59","80.4","","1365.00","1365.00","1365.00","1 through 10","66.03","103.25","percent of total billed charges",""
"SCREW BONE 7MM CANNULA CLEARTRAC BX/10EA","SUP-ITM-10027816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.35","94.76","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","103.25","81.72","","5157.68","5157.68","5157.68","1 through 10","66.03","103.25","percent of total billed charges",""
"SCREW BONE 7MM CANNULA CLEARTRAC BX/10EA","SUP-ITM-10027816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.35","94.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","103.25","81.72","","431.26","71.26","1459.57","88","66.03","103.25","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.84","551.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","584.99","79.5","","800.18","480.96","1887.97","195","228.11","584.99","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.84","551.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","392.20","53.3","","813.12","216.42","1444.50","81","228.11","584.99","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.84","551.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","228.11","31","","432.60","432.60","432.60","1 through 10","228.11","584.99","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.84","551.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","268.58","36.5","","148.37","54.89","631.39","94","228.11","584.99","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.84","551.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","281.83","38.3","","279.30","91.72","1116.77","266","228.11","584.99","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.84","551.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.68","42.9","","731.00","63.70","731.00","1 through 10","228.11","584.99","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.84","551.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.68","42.9","","384.74","384.74","384.74","1 through 10","228.11","584.99","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.84","551.88","WELLPOINT [1015]","HB AMC WELLPOINT","542.90","73.78","","286.63","119.22","1107.45","105","228.11","584.99","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.84","551.88","AETNA [1001]","HB AMC AETNA HMO","513.62","69.8","","675.31","184.75","1721.50","286","384.55","601.33","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.84","551.88","AETNA [1001]","HB AMC AETNA PPO","591.62","80.4","","1261.44","103.12","1514.10","21","384.55","601.33","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.84","551.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","591.62","80.4","","1365.00","1365.00","1365.00","1 through 10","384.55","601.33","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.84","551.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","601.33","81.72","","5157.68","5157.68","5157.68","1 through 10","384.55","601.33","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.84","551.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","601.33","81.72","","431.26","71.26","1459.57","88","384.55","601.33","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","both","","","757.12","567.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","601.91","79.5","","800.18","480.96","1887.97","195","234.71","601.91","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","both","","","757.12","567.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","403.54","53.3","","813.12","216.42","1444.50","81","234.71","601.91","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","both","","","757.12","567.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","234.71","31","","432.60","432.60","432.60","1 through 10","234.71","601.91","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","both","","","757.12","567.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","276.35","36.5","","148.37","54.89","631.39","94","234.71","601.91","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","both","","","757.12","567.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","289.98","38.3","","279.30","91.72","1116.77","266","234.71","601.91","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","both","","","757.12","567.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","324.80","42.9","","731.00","63.70","731.00","1 through 10","234.71","601.91","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","both","","","757.12","567.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","324.80","42.9","","384.74","384.74","384.74","1 through 10","234.71","601.91","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","both","","","757.12","567.84","WELLPOINT [1015]","HB AMC WELLPOINT","558.60","73.78","","286.63","119.22","1107.45","105","234.71","601.91","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","757.12","567.84","AETNA [1001]","HB AMC AETNA HMO","528.47","69.8","","675.31","184.75","1721.50","286","395.67","618.72","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","757.12","567.84","AETNA [1001]","HB AMC AETNA PPO","608.72","80.4","","1261.44","103.12","1514.10","21","395.67","618.72","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","757.12","567.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","608.72","80.4","","1365.00","1365.00","1365.00","1 through 10","395.67","618.72","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","757.12","567.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","618.72","81.72","","5157.68","5157.68","5157.68","1 through 10","395.67","618.72","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","757.12","567.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","618.72","81.72","","431.26","71.26","1459.57","88","395.67","618.72","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","528.68","79.5","","800.18","480.96","1887.97","195","206.15","528.68","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","354.45","53.3","","813.12","216.42","1444.50","81","206.15","528.68","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","206.15","31","","432.60","432.60","432.60","1 through 10","206.15","528.68","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","242.73","36.5","","148.37","54.89","631.39","94","206.15","528.68","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","254.70","38.3","","279.30","91.72","1116.77","266","206.15","528.68","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","285.29","42.9","","731.00","63.70","731.00","1 through 10","206.15","528.68","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","285.29","42.9","","384.74","384.74","384.74","1 through 10","206.15","528.68","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","WELLPOINT [1015]","HB AMC WELLPOINT","490.64","73.78","","286.63","119.22","1107.45","105","206.15","528.68","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","AETNA [1001]","HB AMC AETNA HMO","464.17","69.8","","675.31","184.75","1721.50","286","347.53","543.44","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","AETNA [1001]","HB AMC AETNA PPO","534.66","80.4","","1261.44","103.12","1514.10","21","347.53","543.44","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","534.66","80.4","","1365.00","1365.00","1365.00","1 through 10","347.53","543.44","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","543.44","81.72","","5157.68","5157.68","5157.68","1 through 10","347.53","543.44","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","543.44","81.72","","431.26","71.26","1459.57","88","347.53","543.44","percent of total billed charges",""
"SCREW BONE 7X25MM SHOULDER BICEPTOR BIOSURE TENODESIS","SUP-ITM-10191570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","800.18","480.96","1887.97","195","271.25","695.63","percent of total billed charges",""
"SCREW BONE 7X25MM SHOULDER BICEPTOR BIOSURE TENODESIS","SUP-ITM-10191570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","813.12","216.42","1444.50","81","271.25","695.63","percent of total billed charges",""
"SCREW BONE 7X25MM SHOULDER BICEPTOR BIOSURE TENODESIS","SUP-ITM-10191570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.25","31","","432.60","432.60","432.60","1 through 10","271.25","695.63","percent of total billed charges",""
"SCREW BONE 7X25MM SHOULDER BICEPTOR BIOSURE TENODESIS","SUP-ITM-10191570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","148.37","54.89","631.39","94","271.25","695.63","percent of total billed charges",""
"SCREW BONE 7X25MM SHOULDER BICEPTOR BIOSURE TENODESIS","SUP-ITM-10191570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","279.30","91.72","1116.77","266","271.25","695.63","percent of total billed charges",""
"SCREW BONE 7X25MM SHOULDER BICEPTOR BIOSURE TENODESIS","SUP-ITM-10191570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","731.00","63.70","731.00","1 through 10","271.25","695.63","percent of total billed charges",""
"SCREW BONE 7X25MM SHOULDER BICEPTOR BIOSURE TENODESIS","SUP-ITM-10191570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","384.74","384.74","384.74","1 through 10","271.25","695.63","percent of total billed charges",""
"SCREW BONE 7X25MM SHOULDER BICEPTOR BIOSURE TENODESIS","SUP-ITM-10191570","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","286.63","119.22","1107.45","105","271.25","695.63","percent of total billed charges",""
"SCREW BONE 7X25MM SHOULDER BICEPTOR BIOSURE TENODESIS","SUP-ITM-10191570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","675.31","184.75","1721.50","286","457.28","715.05","percent of total billed charges",""
"SCREW BONE 7X25MM SHOULDER BICEPTOR BIOSURE TENODESIS","SUP-ITM-10191570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA PPO","703.50","80.4","","1261.44","103.12","1514.10","21","457.28","715.05","percent of total billed charges",""
"SCREW BONE 7X25MM SHOULDER BICEPTOR BIOSURE TENODESIS","SUP-ITM-10191570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1365.00","1365.00","1365.00","1 through 10","457.28","715.05","percent of total billed charges",""
"SCREW BONE 7X25MM SHOULDER BICEPTOR BIOSURE TENODESIS","SUP-ITM-10191570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","715.05","81.72","","5157.68","5157.68","5157.68","1 through 10","457.28","715.05","percent of total billed charges",""
"SCREW BONE 7X25MM SHOULDER BICEPTOR BIOSURE TENODESIS","SUP-ITM-10191570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","431.26","71.26","1459.57","88","457.28","715.05","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2601.64","79.5","","800.18","480.96","1887.97","195","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1744.24","53.3","","813.12","216.42","1444.50","81","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1014.48","31","","432.60","432.60","432.60","1 through 10","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1194.46","36.5","","148.37","54.89","631.39","94","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1253.37","38.3","","279.30","91.72","1116.77","266","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1403.90","42.9","","731.00","63.70","731.00","1 through 10","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1403.90","42.9","","384.74","384.74","384.74","1 through 10","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","3272.50","2454.37","WELLPOINT [1015]","HB AMC WELLPOINT","2414.45","73.78","","286.63","119.22","1107.45","105","1014.48","2601.64","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","AETNA [1001]","HB AMC AETNA HMO","2284.21","69.8","","675.31","184.75","1721.50","286","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","AETNA [1001]","HB AMC AETNA PPO","2631.09","80.4","","1261.44","103.12","1514.10","21","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2631.09","80.4","","1365.00","1365.00","1365.00","1 through 10","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2674.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3272.50","2454.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2674.29","81.72","","431.26","71.26","1459.57","88","1710.21","2674.29","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1933.84","79.5","","800.18","480.96","1887.97","195","754.08","1933.84","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1296.52","53.3","","813.12","216.42","1444.50","81","754.08","1933.84","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","754.08","31","","432.60","432.60","432.60","1 through 10","754.08","1933.84","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","887.86","36.5","","148.37","54.89","631.39","94","754.08","1933.84","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","931.65","38.3","","279.30","91.72","1116.77","266","754.08","1933.84","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1043.54","42.9","","731.00","63.70","731.00","1 through 10","754.08","1933.84","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1043.54","42.9","","384.74","384.74","384.74","1 through 10","754.08","1933.84","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2432.50","1824.37","WELLPOINT [1015]","HB AMC WELLPOINT","1794.70","73.78","","286.63","119.22","1107.45","105","754.08","1933.84","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","AETNA [1001]","HB AMC AETNA HMO","1697.89","69.8","","675.31","184.75","1721.50","286","1271.22","1987.84","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","AETNA [1001]","HB AMC AETNA PPO","1955.73","80.4","","1261.44","103.12","1514.10","21","1271.22","1987.84","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1955.73","80.4","","1365.00","1365.00","1365.00","1 through 10","1271.22","1987.84","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1987.84","81.72","","5157.68","5157.68","5157.68","1 through 10","1271.22","1987.84","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2432.50","1824.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1987.84","81.72","","431.26","71.26","1459.57","88","1271.22","1987.84","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1222.05","79.5","","800.18","480.96","1887.97","195","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","819.31","53.3","","813.12","216.42","1444.50","81","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","476.52","31","","432.60","432.60","432.60","1 through 10","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","561.07","36.5","","148.37","54.89","631.39","94","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","588.74","38.3","","279.30","91.72","1116.77","266","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","659.45","42.9","","731.00","63.70","731.00","1 through 10","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","659.45","42.9","","384.74","384.74","384.74","1 through 10","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","WELLPOINT [1015]","HB AMC WELLPOINT","1134.12","73.78","","286.63","119.22","1107.45","105","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","AETNA [1001]","HB AMC AETNA HMO","1072.94","69.8","","675.31","184.75","1721.50","286","803.33","1256.18","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","AETNA [1001]","HB AMC AETNA PPO","1235.88","80.4","","1261.44","103.12","1514.10","21","803.33","1256.18","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1235.88","80.4","","1365.00","1365.00","1365.00","1 through 10","803.33","1256.18","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1256.18","81.72","","5157.68","5157.68","5157.68","1 through 10","803.33","1256.18","percent of total billed charges",""
"SCREW BONE 85MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244720","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1256.18","81.72","","431.26","71.26","1459.57","88","803.33","1256.18","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","711.96","79.5","","800.18","480.96","1887.97","195","277.62","711.96","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","477.33","53.3","","813.12","216.42","1444.50","81","277.62","711.96","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","277.62","31","","432.60","432.60","432.60","1 through 10","277.62","711.96","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","326.88","36.5","","148.37","54.89","631.39","94","277.62","711.96","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","343.00","38.3","","279.30","91.72","1116.77","266","277.62","711.96","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","384.19","42.9","","731.00","63.70","731.00","1 through 10","277.62","711.96","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","384.19","42.9","","384.74","384.74","384.74","1 through 10","277.62","711.96","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","both","","","895.55","671.66","WELLPOINT [1015]","HB AMC WELLPOINT","660.74","73.78","","286.63","119.22","1107.45","105","277.62","711.96","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","895.55","671.66","AETNA [1001]","HB AMC AETNA HMO","625.09","69.8","","675.31","184.75","1721.50","286","468.01","731.84","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","895.55","671.66","AETNA [1001]","HB AMC AETNA PPO","720.02","80.4","","1261.44","103.12","1514.10","21","468.01","731.84","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","895.55","671.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","720.02","80.4","","1365.00","1365.00","1365.00","1 through 10","468.01","731.84","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","895.55","671.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","731.84","81.72","","5157.68","5157.68","5157.68","1 through 10","468.01","731.84","percent of total billed charges",""
"SCREW BONE 85X4MM AXSOS TITANIUM LOCKING 661065","SUP-ITM-10144929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","895.55","671.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","731.84","81.72","","431.26","71.26","1459.57","88","468.01","731.84","percent of total billed charges",""
"SCREW BONE 85X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023064","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.47","352.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","374.02","79.5","","800.18","480.96","1887.97","195","145.85","374.02","percent of total billed charges",""
"SCREW BONE 85X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023064","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.47","352.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","250.76","53.3","","813.12","216.42","1444.50","81","145.85","374.02","percent of total billed charges",""
"SCREW BONE 85X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023064","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.47","352.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","145.85","31","","432.60","432.60","432.60","1 through 10","145.85","374.02","percent of total billed charges",""
"SCREW BONE 85X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023064","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.47","352.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","171.72","36.5","","148.37","54.89","631.39","94","145.85","374.02","percent of total billed charges",""
"SCREW BONE 85X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023064","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.47","352.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","180.19","38.3","","279.30","91.72","1116.77","266","145.85","374.02","percent of total billed charges",""
"SCREW BONE 85X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023064","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.47","352.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.83","42.9","","731.00","63.70","731.00","1 through 10","145.85","374.02","percent of total billed charges",""
"SCREW BONE 85X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023064","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.47","352.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.83","42.9","","384.74","384.74","384.74","1 through 10","145.85","374.02","percent of total billed charges",""
"SCREW BONE 85X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023064","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.47","352.85","WELLPOINT [1015]","HB AMC WELLPOINT","347.11","73.78","","286.63","119.22","1107.45","105","145.85","374.02","percent of total billed charges",""
"SCREW BONE 85X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","470.47","352.85","AETNA [1001]","HB AMC AETNA HMO","328.39","69.8","","675.31","184.75","1721.50","286","245.87","384.47","percent of total billed charges",""
"SCREW BONE 85X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","470.47","352.85","AETNA [1001]","HB AMC AETNA PPO","378.26","80.4","","1261.44","103.12","1514.10","21","245.87","384.47","percent of total billed charges",""
"SCREW BONE 85X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","470.47","352.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","378.26","80.4","","1365.00","1365.00","1365.00","1 through 10","245.87","384.47","percent of total billed charges",""
"SCREW BONE 85X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","470.47","352.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","384.47","81.72","","5157.68","5157.68","5157.68","1 through 10","245.87","384.47","percent of total billed charges",""
"SCREW BONE 85X5MM CANCELLOUS NCB PROTASUL TITANIUM","SUP-ITM-10023064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","470.47","352.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","384.47","81.72","","431.26","71.26","1459.57","88","245.87","384.47","percent of total billed charges",""
"SCREW BONE 8MM TIBIAL FEMORAL COMPRESSION ADVANCE T2 VITALLIUM","SUP-ITM-10018556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.22","775.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","822.20","79.5","","800.18","480.96","1887.97","195","320.61","822.2","percent of total billed charges",""
"SCREW BONE 8MM TIBIAL FEMORAL COMPRESSION ADVANCE T2 VITALLIUM","SUP-ITM-10018556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.22","775.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","551.24","53.3","","813.12","216.42","1444.50","81","320.61","822.2","percent of total billed charges",""
"SCREW BONE 8MM TIBIAL FEMORAL COMPRESSION ADVANCE T2 VITALLIUM","SUP-ITM-10018556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.22","775.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","320.61","31","","432.60","432.60","432.60","1 through 10","320.61","822.2","percent of total billed charges",""
"SCREW BONE 8MM TIBIAL FEMORAL COMPRESSION ADVANCE T2 VITALLIUM","SUP-ITM-10018556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.22","775.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","377.49","36.5","","148.37","54.89","631.39","94","320.61","822.2","percent of total billed charges",""
"SCREW BONE 8MM TIBIAL FEMORAL COMPRESSION ADVANCE T2 VITALLIUM","SUP-ITM-10018556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.22","775.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","396.11","38.3","","279.30","91.72","1116.77","266","320.61","822.2","percent of total billed charges",""
"SCREW BONE 8MM TIBIAL FEMORAL COMPRESSION ADVANCE T2 VITALLIUM","SUP-ITM-10018556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.22","775.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","443.68","42.9","","731.00","63.70","731.00","1 through 10","320.61","822.2","percent of total billed charges",""
"SCREW BONE 8MM TIBIAL FEMORAL COMPRESSION ADVANCE T2 VITALLIUM","SUP-ITM-10018556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.22","775.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","443.68","42.9","","384.74","384.74","384.74","1 through 10","320.61","822.2","percent of total billed charges",""
"SCREW BONE 8MM TIBIAL FEMORAL COMPRESSION ADVANCE T2 VITALLIUM","SUP-ITM-10018556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.22","775.66","WELLPOINT [1015]","HB AMC WELLPOINT","763.05","73.78","","286.63","119.22","1107.45","105","320.61","822.2","percent of total billed charges",""
"SCREW BONE 8MM TIBIAL FEMORAL COMPRESSION ADVANCE T2 VITALLIUM","SUP-ITM-10018556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.22","775.66","AETNA [1001]","HB AMC AETNA HMO","721.89","69.8","","675.31","184.75","1721.50","286","540.48","845.16","percent of total billed charges",""
"SCREW BONE 8MM TIBIAL FEMORAL COMPRESSION ADVANCE T2 VITALLIUM","SUP-ITM-10018556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.22","775.66","AETNA [1001]","HB AMC AETNA PPO","831.51","80.4","","1261.44","103.12","1514.10","21","540.48","845.16","percent of total billed charges",""
"SCREW BONE 8MM TIBIAL FEMORAL COMPRESSION ADVANCE T2 VITALLIUM","SUP-ITM-10018556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.22","775.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","831.51","80.4","","1365.00","1365.00","1365.00","1 through 10","540.48","845.16","percent of total billed charges",""
"SCREW BONE 8MM TIBIAL FEMORAL COMPRESSION ADVANCE T2 VITALLIUM","SUP-ITM-10018556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.22","775.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","845.16","81.72","","5157.68","5157.68","5157.68","1 through 10","540.48","845.16","percent of total billed charges",""
"SCREW BONE 8MM TIBIAL FEMORAL COMPRESSION ADVANCE T2 VITALLIUM","SUP-ITM-10018556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.22","775.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","845.16","81.72","","431.26","71.26","1459.57","88","540.48","845.16","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191590","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","737.36","79.5","","800.18","480.96","1887.97","195","287.53","737.36","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191590","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","494.36","53.3","","813.12","216.42","1444.50","81","287.53","737.36","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191590","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","287.53","31","","432.60","432.60","432.60","1 through 10","287.53","737.36","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191590","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","338.54","36.5","","148.37","54.89","631.39","94","287.53","737.36","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191590","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","355.23","38.3","","279.30","91.72","1116.77","266","287.53","737.36","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191590","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","397.90","42.9","","731.00","63.70","731.00","1 through 10","287.53","737.36","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191590","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","397.90","42.9","","384.74","384.74","384.74","1 through 10","287.53","737.36","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191590","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.50","695.62","WELLPOINT [1015]","HB AMC WELLPOINT","684.31","73.78","","286.63","119.22","1107.45","105","287.53","737.36","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","AETNA [1001]","HB AMC AETNA HMO","647.40","69.8","","675.31","184.75","1721.50","286","484.71","757.95","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","AETNA [1001]","HB AMC AETNA PPO","745.71","80.4","","1261.44","103.12","1514.10","21","484.71","757.95","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","745.71","80.4","","1365.00","1365.00","1365.00","1 through 10","484.71","757.95","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","757.95","81.72","","5157.68","5157.68","5157.68","1 through 10","484.71","757.95","percent of total billed charges",""
"SCREW BONE 8X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.50","695.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","757.95","81.72","","431.26","71.26","1459.57","88","484.71","757.95","percent of total billed charges",""
"SCREW BONE 8X30MM GUARDSMAN BIOABSORBABLE INTERFERENCE","SUP-ITM-10019682","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.17","342.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","363.45","79.5","","800.18","480.96","1887.97","195","141.72","363.45","percent of total billed charges",""
"SCREW BONE 8X30MM GUARDSMAN BIOABSORBABLE INTERFERENCE","SUP-ITM-10019682","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.17","342.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","243.67","53.3","","813.12","216.42","1444.50","81","141.72","363.45","percent of total billed charges",""
"SCREW BONE 8X30MM GUARDSMAN BIOABSORBABLE INTERFERENCE","SUP-ITM-10019682","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.17","342.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","141.72","31","","432.60","432.60","432.60","1 through 10","141.72","363.45","percent of total billed charges",""
"SCREW BONE 8X30MM GUARDSMAN BIOABSORBABLE INTERFERENCE","SUP-ITM-10019682","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.17","342.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.87","36.5","","148.37","54.89","631.39","94","141.72","363.45","percent of total billed charges",""
"SCREW BONE 8X30MM GUARDSMAN BIOABSORBABLE INTERFERENCE","SUP-ITM-10019682","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.17","342.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","175.10","38.3","","279.30","91.72","1116.77","266","141.72","363.45","percent of total billed charges",""
"SCREW BONE 8X30MM GUARDSMAN BIOABSORBABLE INTERFERENCE","SUP-ITM-10019682","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.17","342.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","196.13","42.9","","731.00","63.70","731.00","1 through 10","141.72","363.45","percent of total billed charges",""
"SCREW BONE 8X30MM GUARDSMAN BIOABSORBABLE INTERFERENCE","SUP-ITM-10019682","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.17","342.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","196.13","42.9","","384.74","384.74","384.74","1 through 10","141.72","363.45","percent of total billed charges",""
"SCREW BONE 8X30MM GUARDSMAN BIOABSORBABLE INTERFERENCE","SUP-ITM-10019682","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.17","342.88","WELLPOINT [1015]","HB AMC WELLPOINT","337.30","73.78","","286.63","119.22","1107.45","105","141.72","363.45","percent of total billed charges",""
"SCREW BONE 8X30MM GUARDSMAN BIOABSORBABLE INTERFERENCE","SUP-ITM-10019682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.17","342.88","AETNA [1001]","HB AMC AETNA HMO","319.10","69.8","","675.31","184.75","1721.50","286","238.92","373.6","percent of total billed charges",""
"SCREW BONE 8X30MM GUARDSMAN BIOABSORBABLE INTERFERENCE","SUP-ITM-10019682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.17","342.88","AETNA [1001]","HB AMC AETNA PPO","367.56","80.4","","1261.44","103.12","1514.10","21","238.92","373.6","percent of total billed charges",""
"SCREW BONE 8X30MM GUARDSMAN BIOABSORBABLE INTERFERENCE","SUP-ITM-10019682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.17","342.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","367.56","80.4","","1365.00","1365.00","1365.00","1 through 10","238.92","373.6","percent of total billed charges",""
"SCREW BONE 8X30MM GUARDSMAN BIOABSORBABLE INTERFERENCE","SUP-ITM-10019682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.17","342.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","373.60","81.72","","5157.68","5157.68","5157.68","1 through 10","238.92","373.6","percent of total billed charges",""
"SCREW BONE 8X30MM GUARDSMAN BIOABSORBABLE INTERFERENCE","SUP-ITM-10019682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.17","342.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","373.60","81.72","","431.26","71.26","1459.57","88","238.92","373.6","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.44","79.5","","800.18","480.96","1887.97","195","406.88","1043.44","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","699.56","53.3","","813.12","216.42","1444.50","81","406.88","1043.44","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","406.88","31","","432.60","432.60","432.60","1 through 10","406.88","1043.44","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","479.06","36.5","","148.37","54.89","631.39","94","406.88","1043.44","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.69","38.3","","279.30","91.72","1116.77","266","406.88","1043.44","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.06","42.9","","731.00","63.70","731.00","1 through 10","406.88","1043.44","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.06","42.9","","384.74","384.74","384.74","1 through 10","406.88","1043.44","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","WELLPOINT [1015]","HB AMC WELLPOINT","968.36","73.78","","286.63","119.22","1107.45","105","406.88","1043.44","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","AETNA [1001]","HB AMC AETNA HMO","916.13","69.8","","675.31","184.75","1721.50","286","685.91","1072.58","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","AETNA [1001]","HB AMC AETNA PPO","1055.25","80.4","","1261.44","103.12","1514.10","21","685.91","1072.58","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1055.25","80.4","","1365.00","1365.00","1365.00","1 through 10","685.91","1072.58","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1072.58","81.72","","5157.68","5157.68","5157.68","1 through 10","685.91","1072.58","percent of total billed charges",""
"SCREW BONE 8X3MM FOOT ANKLE INTERFERENCE BIOCOMPOSITE HANDLED INSERTER BIO TENODESIS","SUP-ITM-10082033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1072.58","81.72","","431.26","71.26","1459.57","88","685.91","1072.58","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1015.61","79.5","","800.18","480.96","1887.97","195","396.03","1015.61","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","680.91","53.3","","813.12","216.42","1444.50","81","396.03","1015.61","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","396.03","31","","432.60","432.60","432.60","1 through 10","396.03","1015.61","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","466.29","36.5","","148.37","54.89","631.39","94","396.03","1015.61","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","489.28","38.3","","279.30","91.72","1116.77","266","396.03","1015.61","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","548.05","42.9","","731.00","63.70","731.00","1 through 10","396.03","1015.61","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","548.05","42.9","","384.74","384.74","384.74","1 through 10","396.03","1015.61","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","WELLPOINT [1015]","HB AMC WELLPOINT","942.54","73.78","","286.63","119.22","1107.45","105","396.03","1015.61","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","AETNA [1001]","HB AMC AETNA HMO","891.70","69.8","","675.31","184.75","1721.50","286","667.62","1043.97","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","AETNA [1001]","HB AMC AETNA PPO","1027.11","80.4","","1261.44","103.12","1514.10","21","667.62","1043.97","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1027.11","80.4","","1365.00","1365.00","1365.00","1 through 10","667.62","1043.97","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1043.97","81.72","","5157.68","5157.68","5157.68","1 through 10","667.62","1043.97","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1043.97","81.72","","431.26","71.26","1459.57","88","667.62","1043.97","percent of total billed charges",""
"SCREW BONE 8X45MM SPINE POLYAXIAL EXPEDIUM 6.35 TITANIUM","SUP-ITM-10030036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","800.18","480.96","1887.97","195","434","1113","percent of total billed charges",""
"SCREW BONE 8X45MM SPINE POLYAXIAL EXPEDIUM 6.35 TITANIUM","SUP-ITM-10030036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","813.12","216.42","1444.50","81","434","1113","percent of total billed charges",""
"SCREW BONE 8X45MM SPINE POLYAXIAL EXPEDIUM 6.35 TITANIUM","SUP-ITM-10030036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","434.00","31","","432.60","432.60","432.60","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 8X45MM SPINE POLYAXIAL EXPEDIUM 6.35 TITANIUM","SUP-ITM-10030036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","148.37","54.89","631.39","94","434","1113","percent of total billed charges",""
"SCREW BONE 8X45MM SPINE POLYAXIAL EXPEDIUM 6.35 TITANIUM","SUP-ITM-10030036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","279.30","91.72","1116.77","266","434","1113","percent of total billed charges",""
"SCREW BONE 8X45MM SPINE POLYAXIAL EXPEDIUM 6.35 TITANIUM","SUP-ITM-10030036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","731.00","63.70","731.00","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 8X45MM SPINE POLYAXIAL EXPEDIUM 6.35 TITANIUM","SUP-ITM-10030036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","384.74","384.74","384.74","1 through 10","434","1113","percent of total billed charges",""
"SCREW BONE 8X45MM SPINE POLYAXIAL EXPEDIUM 6.35 TITANIUM","SUP-ITM-10030036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","286.63","119.22","1107.45","105","434","1113","percent of total billed charges",""
"SCREW BONE 8X45MM SPINE POLYAXIAL EXPEDIUM 6.35 TITANIUM","SUP-ITM-10030036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","675.31","184.75","1721.50","286","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 8X45MM SPINE POLYAXIAL EXPEDIUM 6.35 TITANIUM","SUP-ITM-10030036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA PPO","1125.60","80.4","","1261.44","103.12","1514.10","21","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 8X45MM SPINE POLYAXIAL EXPEDIUM 6.35 TITANIUM","SUP-ITM-10030036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1365.00","1365.00","1365.00","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 8X45MM SPINE POLYAXIAL EXPEDIUM 6.35 TITANIUM","SUP-ITM-10030036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1144.08","81.72","","5157.68","5157.68","5157.68","1 through 10","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 8X45MM SPINE POLYAXIAL EXPEDIUM 6.35 TITANIUM","SUP-ITM-10030036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","431.26","71.26","1459.57","88","731.64","1144.08","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","541.31","405.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","430.34","79.5","","800.18","480.96","1887.97","195","167.81","430.34","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","541.31","405.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","288.52","53.3","","813.12","216.42","1444.50","81","167.81","430.34","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","541.31","405.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","167.81","31","","432.60","432.60","432.60","1 through 10","167.81","430.34","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","541.31","405.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","197.58","36.5","","148.37","54.89","631.39","94","167.81","430.34","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","541.31","405.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","207.32","38.3","","279.30","91.72","1116.77","266","167.81","430.34","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","541.31","405.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","232.22","42.9","","731.00","63.70","731.00","1 through 10","167.81","430.34","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","541.31","405.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","232.22","42.9","","384.74","384.74","384.74","1 through 10","167.81","430.34","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","541.31","405.98","WELLPOINT [1015]","HB AMC WELLPOINT","399.38","73.78","","286.63","119.22","1107.45","105","167.81","430.34","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","541.31","405.98","AETNA [1001]","HB AMC AETNA HMO","377.83","69.8","","675.31","184.75","1721.50","286","282.89","442.36","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","541.31","405.98","AETNA [1001]","HB AMC AETNA PPO","435.21","80.4","","1261.44","103.12","1514.10","21","282.89","442.36","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","541.31","405.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","435.21","80.4","","1365.00","1365.00","1365.00","1 through 10","282.89","442.36","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","541.31","405.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","442.36","81.72","","5157.68","5157.68","5157.68","1 through 10","282.89","442.36","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","541.31","405.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","442.36","81.72","","431.26","71.26","1459.57","88","282.89","442.36","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2328.95","79.5","","800.18","480.96","1887.97","195","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1561.42","53.3","","813.12","216.42","1444.50","81","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","908.15","31","","432.60","432.60","432.60","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1069.27","36.5","","148.37","54.89","631.39","94","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1122.00","38.3","","279.30","91.72","1116.77","266","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","731.00","63.70","731.00","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","384.74","384.74","384.74","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","WELLPOINT [1015]","HB AMC WELLPOINT","2161.39","73.78","","286.63","119.22","1107.45","105","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA HMO","2044.79","69.8","","675.31","184.75","1721.50","286","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA PPO","2355.32","80.4","","1261.44","103.12","1514.10","21","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2355.32","80.4","","1365.00","1365.00","1365.00","1 through 10","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2393.99","81.72","","5157.68","5157.68","5157.68","1 through 10","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2393.99","81.72","","431.26","71.26","1459.57","88","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 9.5X25MM ANKLE FIXATION INTRAOSSEOUS IO FIXXPOST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091632","CDM","C1713","HCPCS","0278","RC","","","","both","","","4985.00","3738.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3963.08","79.5","","800.18","480.96","1887.97","195","1545.35","3963.08","percent of total billed charges",""
"SCREW BONE 9.5X25MM ANKLE FIXATION INTRAOSSEOUS IO FIXXPOST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091632","CDM","C1713","HCPCS","0278","RC","","","","both","","","4985.00","3738.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2657.01","53.3","","813.12","216.42","1444.50","81","1545.35","3963.08","percent of total billed charges",""
"SCREW BONE 9.5X25MM ANKLE FIXATION INTRAOSSEOUS IO FIXXPOST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091632","CDM","C1713","HCPCS","0278","RC","","","","both","","","4985.00","3738.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1545.35","31","","432.60","432.60","432.60","1 through 10","1545.35","3963.08","percent of total billed charges",""
"SCREW BONE 9.5X25MM ANKLE FIXATION INTRAOSSEOUS IO FIXXPOST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091632","CDM","C1713","HCPCS","0278","RC","","","","both","","","4985.00","3738.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1819.53","36.5","","148.37","54.89","631.39","94","1545.35","3963.08","percent of total billed charges",""
"SCREW BONE 9.5X25MM ANKLE FIXATION INTRAOSSEOUS IO FIXXPOST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091632","CDM","C1713","HCPCS","0278","RC","","","","both","","","4985.00","3738.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1909.26","38.3","","279.30","91.72","1116.77","266","1545.35","3963.08","percent of total billed charges",""
"SCREW BONE 9.5X25MM ANKLE FIXATION INTRAOSSEOUS IO FIXXPOST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091632","CDM","C1713","HCPCS","0278","RC","","","","both","","","4985.00","3738.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2138.57","42.9","","731.00","63.70","731.00","1 through 10","1545.35","3963.08","percent of total billed charges",""
"SCREW BONE 9.5X25MM ANKLE FIXATION INTRAOSSEOUS IO FIXXPOST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091632","CDM","C1713","HCPCS","0278","RC","","","","both","","","4985.00","3738.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2138.57","42.9","","384.74","384.74","384.74","1 through 10","1545.35","3963.08","percent of total billed charges",""
"SCREW BONE 9.5X25MM ANKLE FIXATION INTRAOSSEOUS IO FIXXPOST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091632","CDM","C1713","HCPCS","0278","RC","","","","both","","","4985.00","3738.75","WELLPOINT [1015]","HB AMC WELLPOINT","3677.93","73.78","","286.63","119.22","1107.45","105","1545.35","3963.08","percent of total billed charges",""
"SCREW BONE 9.5X25MM ANKLE FIXATION INTRAOSSEOUS IO FIXXPOST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4985.00","3738.75","AETNA [1001]","HB AMC AETNA HMO","3479.53","69.8","","675.31","184.75","1721.50","286","2605.16","4073.74","percent of total billed charges",""
"SCREW BONE 9.5X25MM ANKLE FIXATION INTRAOSSEOUS IO FIXXPOST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4985.00","3738.75","AETNA [1001]","HB AMC AETNA PPO","4007.94","80.4","","1261.44","103.12","1514.10","21","2605.16","4073.74","percent of total billed charges",""
"SCREW BONE 9.5X25MM ANKLE FIXATION INTRAOSSEOUS IO FIXXPOST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4985.00","3738.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4007.94","80.4","","1365.00","1365.00","1365.00","1 through 10","2605.16","4073.74","percent of total billed charges",""
"SCREW BONE 9.5X25MM ANKLE FIXATION INTRAOSSEOUS IO FIXXPOST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4985.00","3738.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4073.74","81.72","","5157.68","5157.68","5157.68","1 through 10","2605.16","4073.74","percent of total billed charges",""
"SCREW BONE 9.5X25MM ANKLE FIXATION INTRAOSSEOUS IO FIXXPOST - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10091632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4985.00","3738.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4073.74","81.72","","431.26","71.26","1459.57","88","2605.16","4073.74","percent of total billed charges",""
"SCREW BONE 90MM FEMORAL NECK ANTIROTATION","SUP-ITM-10297525","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.38","537.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","569.52","79.5","","800.18","480.96","1887.97","195","222.08","569.52","percent of total billed charges",""
"SCREW BONE 90MM FEMORAL NECK ANTIROTATION","SUP-ITM-10297525","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.38","537.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","381.83","53.3","","813.12","216.42","1444.50","81","222.08","569.52","percent of total billed charges",""
"SCREW BONE 90MM FEMORAL NECK ANTIROTATION","SUP-ITM-10297525","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.38","537.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","222.08","31","","432.60","432.60","432.60","1 through 10","222.08","569.52","percent of total billed charges",""
"SCREW BONE 90MM FEMORAL NECK ANTIROTATION","SUP-ITM-10297525","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.38","537.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","261.48","36.5","","148.37","54.89","631.39","94","222.08","569.52","percent of total billed charges",""
"SCREW BONE 90MM FEMORAL NECK ANTIROTATION","SUP-ITM-10297525","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.38","537.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","274.37","38.3","","279.30","91.72","1116.77","266","222.08","569.52","percent of total billed charges",""
"SCREW BONE 90MM FEMORAL NECK ANTIROTATION","SUP-ITM-10297525","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.38","537.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.33","42.9","","731.00","63.70","731.00","1 through 10","222.08","569.52","percent of total billed charges",""
"SCREW BONE 90MM FEMORAL NECK ANTIROTATION","SUP-ITM-10297525","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.38","537.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.33","42.9","","384.74","384.74","384.74","1 through 10","222.08","569.52","percent of total billed charges",""
"SCREW BONE 90MM FEMORAL NECK ANTIROTATION","SUP-ITM-10297525","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.38","537.28","WELLPOINT [1015]","HB AMC WELLPOINT","528.55","73.78","","286.63","119.22","1107.45","105","222.08","569.52","percent of total billed charges",""
"SCREW BONE 90MM FEMORAL NECK ANTIROTATION","SUP-ITM-10297525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.38","537.28","AETNA [1001]","HB AMC AETNA HMO","500.03","69.8","","675.31","184.75","1721.50","286","374.38","585.43","percent of total billed charges",""
"SCREW BONE 90MM FEMORAL NECK ANTIROTATION","SUP-ITM-10297525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.38","537.28","AETNA [1001]","HB AMC AETNA PPO","575.97","80.4","","1261.44","103.12","1514.10","21","374.38","585.43","percent of total billed charges",""
"SCREW BONE 90MM FEMORAL NECK ANTIROTATION","SUP-ITM-10297525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.38","537.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","575.97","80.4","","1365.00","1365.00","1365.00","1 through 10","374.38","585.43","percent of total billed charges",""
"SCREW BONE 90MM FEMORAL NECK ANTIROTATION","SUP-ITM-10297525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.38","537.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","585.43","81.72","","5157.68","5157.68","5157.68","1 through 10","374.38","585.43","percent of total billed charges",""
"SCREW BONE 90MM FEMORAL NECK ANTIROTATION","SUP-ITM-10297525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.38","537.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","585.43","81.72","","431.26","71.26","1459.57","88","374.38","585.43","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1222.05","79.5","","800.18","480.96","1887.97","195","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","819.31","53.3","","813.12","216.42","1444.50","81","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","476.52","31","","432.60","432.60","432.60","1 through 10","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","561.07","36.5","","148.37","54.89","631.39","94","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","588.74","38.3","","279.30","91.72","1116.77","266","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","659.45","42.9","","731.00","63.70","731.00","1 through 10","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","659.45","42.9","","384.74","384.74","384.74","1 through 10","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.17","1152.88","WELLPOINT [1015]","HB AMC WELLPOINT","1134.12","73.78","","286.63","119.22","1107.45","105","476.52","1222.05","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","AETNA [1001]","HB AMC AETNA HMO","1072.94","69.8","","675.31","184.75","1721.50","286","803.33","1256.18","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","AETNA [1001]","HB AMC AETNA PPO","1235.88","80.4","","1261.44","103.12","1514.10","21","803.33","1256.18","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1235.88","80.4","","1365.00","1365.00","1365.00","1 through 10","803.33","1256.18","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1256.18","81.72","","5157.68","5157.68","5157.68","1 through 10","803.33","1256.18","percent of total billed charges",""
"SCREW BONE 95MM TFNA FENESTRATED TFN-ADVANCE","SUP-ITM-10244718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.17","1152.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1256.18","81.72","","431.26","71.26","1459.57","88","803.33","1256.18","percent of total billed charges",""
"SCREW BONE 9X70MM ILIAC VIPER TI T27","SUP-ITM-10210638","CDM","C1889","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2328.95","79.5","","1309.77","674.56","6049.93","26","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 9X70MM ILIAC VIPER TI T27","SUP-ITM-10210638","CDM","C1889","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1561.42","53.3","","1901.83","1901.83","2962.25","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 9X70MM ILIAC VIPER TI T27","SUP-ITM-10210638","CDM","C1889","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1069.27","36.5","","1620.31","1620.31","19908.88","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 9X70MM ILIAC VIPER TI T27","SUP-ITM-10210638","CDM","C1889","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1122.00","38.3","","352.91","352.91","2046.30","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 9X70MM ILIAC VIPER TI T27","SUP-ITM-10210638","CDM","C1889","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","9668.75","9668.75","9668.75","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 9X70MM ILIAC VIPER TI T27","SUP-ITM-10210638","CDM","C1889","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","WELLPOINT [1015]","HB AMC WELLPOINT","2161.39","73.78","","699.88","384.10","3443.31","33","908.15","2328.95","percent of total billed charges",""
"SCREW BONE 9X70MM ILIAC VIPER TI T27","SUP-ITM-10210638","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA HMO","2044.79","69.8","","1421.24","264.50","4933.46","29","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 9X70MM ILIAC VIPER TI T27","SUP-ITM-10210638","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2355.32","80.4","","1022.97","1022.97","3607.50","1 through 10","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE 9X70MM ILIAC VIPER TI T27","SUP-ITM-10210638","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2393.99","81.72","","3010.54","693.88","5019.88","35","1530.96","2393.99","percent of total billed charges",""
"SCREW BONE CONNECTING 357.341","SUP-ITM-10039419","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.14","2673.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2834.29","79.5","","800.18","480.96","1887.97","195","1105.19","2834.29","percent of total billed charges",""
"SCREW BONE CONNECTING 357.341","SUP-ITM-10039419","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.14","2673.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1900.22","53.3","","813.12","216.42","1444.50","81","1105.19","2834.29","percent of total billed charges",""
"SCREW BONE CONNECTING 357.341","SUP-ITM-10039419","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.14","2673.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1105.19","31","","432.60","432.60","432.60","1 through 10","1105.19","2834.29","percent of total billed charges",""
"SCREW BONE CONNECTING 357.341","SUP-ITM-10039419","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.14","2673.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1301.28","36.5","","148.37","54.89","631.39","94","1105.19","2834.29","percent of total billed charges",""
"SCREW BONE CONNECTING 357.341","SUP-ITM-10039419","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.14","2673.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1365.45","38.3","","279.30","91.72","1116.77","266","1105.19","2834.29","percent of total billed charges",""
"SCREW BONE CONNECTING 357.341","SUP-ITM-10039419","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.14","2673.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1529.45","42.9","","731.00","63.70","731.00","1 through 10","1105.19","2834.29","percent of total billed charges",""
"SCREW BONE CONNECTING 357.341","SUP-ITM-10039419","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.14","2673.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1529.45","42.9","","384.74","384.74","384.74","1 through 10","1105.19","2834.29","percent of total billed charges",""
"SCREW BONE CONNECTING 357.341","SUP-ITM-10039419","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.14","2673.85","WELLPOINT [1015]","HB AMC WELLPOINT","2630.36","73.78","","286.63","119.22","1107.45","105","1105.19","2834.29","percent of total billed charges",""
"SCREW BONE CONNECTING 357.341","SUP-ITM-10039419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3565.14","2673.85","AETNA [1001]","HB AMC AETNA HMO","2488.47","69.8","","675.31","184.75","1721.50","286","1863.14","2913.43","percent of total billed charges",""
"SCREW BONE CONNECTING 357.341","SUP-ITM-10039419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3565.14","2673.85","AETNA [1001]","HB AMC AETNA PPO","2866.37","80.4","","1261.44","103.12","1514.10","21","1863.14","2913.43","percent of total billed charges",""
"SCREW BONE CONNECTING 357.341","SUP-ITM-10039419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3565.14","2673.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2866.37","80.4","","1365.00","1365.00","1365.00","1 through 10","1863.14","2913.43","percent of total billed charges",""
"SCREW BONE CONNECTING 357.341","SUP-ITM-10039419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3565.14","2673.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2913.43","81.72","","5157.68","5157.68","5157.68","1 through 10","1863.14","2913.43","percent of total billed charges",""
"SCREW BONE CONNECTING 357.341","SUP-ITM-10039419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3565.14","2673.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2913.43","81.72","","431.26","71.26","1459.57","88","1863.14","2913.43","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1077.34","52.26","","1113.10","1113.10","1113.10","1 through 10","639.07","1638.89","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1638.89","79.5","","1293.60","1148.53","1603.80","1 through 10","639.07","1638.89","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","752.45","36.5","","1023.42","771.29","2068.67","33","639.07","1638.89","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","789.55","38.3","","850.52","759.78","1211.25","66","639.07","1638.89","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","884.38","42.9","","2548.09","2548.09","2548.09","1 through 10","639.07","1638.89","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","884.38","42.9","","956.46","956.46","956.46","1 through 10","639.07","1638.89","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","2061.50","1546.12","WELLPOINT [1015]","HB AMC WELLPOINT","1520.97","73.78","","2344.73","1619.47","2530.35","16","639.07","1638.89","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2061.50","1546.12","AETNA [1001]","HB AMC AETNA HMO","1438.93","69.8","","1523.63","988.41","4330.26","39","1077.34","1684.66","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2061.50","1546.12","AETNA [1001]","HB AMC AETNA PPO","1657.45","80.4","","1670.25","1670.25","1670.25","1 through 10","1077.34","1684.66","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2061.50","1546.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1077.34","52.26","","1113.10","1113.10","1113.10","1 through 10","1077.34","1684.66","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2061.50","1546.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1684.66","81.72","","1738.90","1484.65","2716.94","38","1077.34","1684.66","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","528.68","79.5","","800.18","480.96","1887.97","195","206.15","528.68","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","354.45","53.3","","813.12","216.42","1444.50","81","206.15","528.68","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","206.15","31","","432.60","432.60","432.60","1 through 10","206.15","528.68","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","242.73","36.5","","148.37","54.89","631.39","94","206.15","528.68","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","254.70","38.3","","279.30","91.72","1116.77","266","206.15","528.68","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","285.29","42.9","","731.00","63.70","731.00","1 through 10","206.15","528.68","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","285.29","42.9","","384.74","384.74","384.74","1 through 10","206.15","528.68","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","665.00","498.75","WELLPOINT [1015]","HB AMC WELLPOINT","490.64","73.78","","286.63","119.22","1107.45","105","206.15","528.68","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","AETNA [1001]","HB AMC AETNA HMO","464.17","69.8","","675.31","184.75","1721.50","286","347.53","543.44","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","AETNA [1001]","HB AMC AETNA PPO","534.66","80.4","","1261.44","103.12","1514.10","21","347.53","543.44","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","534.66","80.4","","1365.00","1365.00","1365.00","1 through 10","347.53","543.44","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","543.44","81.72","","5157.68","5157.68","5157.68","1 through 10","347.53","543.44","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","665.00","498.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","543.44","81.72","","431.26","71.26","1459.57","88","347.53","543.44","percent of total billed charges",""
"SCREW BONE KNEE FEMORAL OSS TI STEM LOCKING BIG HEAD SM THREAD","SUP-ITM-10123326","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","619.38","79.5","","800.18","480.96","1887.97","195","241.52","619.38","percent of total billed charges",""
"SCREW BONE KNEE FEMORAL OSS TI STEM LOCKING BIG HEAD SM THREAD","SUP-ITM-10123326","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","415.26","53.3","","813.12","216.42","1444.50","81","241.52","619.38","percent of total billed charges",""
"SCREW BONE KNEE FEMORAL OSS TI STEM LOCKING BIG HEAD SM THREAD","SUP-ITM-10123326","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","241.52","31","","432.60","432.60","432.60","1 through 10","241.52","619.38","percent of total billed charges",""
"SCREW BONE KNEE FEMORAL OSS TI STEM LOCKING BIG HEAD SM THREAD","SUP-ITM-10123326","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","284.37","36.5","","148.37","54.89","631.39","94","241.52","619.38","percent of total billed charges",""
"SCREW BONE KNEE FEMORAL OSS TI STEM LOCKING BIG HEAD SM THREAD","SUP-ITM-10123326","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","298.40","38.3","","279.30","91.72","1116.77","266","241.52","619.38","percent of total billed charges",""
"SCREW BONE KNEE FEMORAL OSS TI STEM LOCKING BIG HEAD SM THREAD","SUP-ITM-10123326","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","334.23","42.9","","731.00","63.70","731.00","1 through 10","241.52","619.38","percent of total billed charges",""
"SCREW BONE KNEE FEMORAL OSS TI STEM LOCKING BIG HEAD SM THREAD","SUP-ITM-10123326","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","334.23","42.9","","384.74","384.74","384.74","1 through 10","241.52","619.38","percent of total billed charges",""
"SCREW BONE KNEE FEMORAL OSS TI STEM LOCKING BIG HEAD SM THREAD","SUP-ITM-10123326","CDM","C1713","HCPCS","0278","RC","","","","both","","","779.10","584.32","WELLPOINT [1015]","HB AMC WELLPOINT","574.82","73.78","","286.63","119.22","1107.45","105","241.52","619.38","percent of total billed charges",""
"SCREW BONE KNEE FEMORAL OSS TI STEM LOCKING BIG HEAD SM THREAD","SUP-ITM-10123326","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","AETNA [1001]","HB AMC AETNA HMO","543.81","69.8","","675.31","184.75","1721.50","286","407.16","636.68","percent of total billed charges",""
"SCREW BONE KNEE FEMORAL OSS TI STEM LOCKING BIG HEAD SM THREAD","SUP-ITM-10123326","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","AETNA [1001]","HB AMC AETNA PPO","626.40","80.4","","1261.44","103.12","1514.10","21","407.16","636.68","percent of total billed charges",""
"SCREW BONE KNEE FEMORAL OSS TI STEM LOCKING BIG HEAD SM THREAD","SUP-ITM-10123326","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","626.40","80.4","","1365.00","1365.00","1365.00","1 through 10","407.16","636.68","percent of total billed charges",""
"SCREW BONE KNEE FEMORAL OSS TI STEM LOCKING BIG HEAD SM THREAD","SUP-ITM-10123326","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","636.68","81.72","","5157.68","5157.68","5157.68","1 through 10","407.16","636.68","percent of total billed charges",""
"SCREW BONE KNEE FEMORAL OSS TI STEM LOCKING BIG HEAD SM THREAD","SUP-ITM-10123326","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","779.10","584.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","636.68","81.72","","431.26","71.26","1459.57","88","407.16","636.68","percent of total billed charges",""
"SCREW BONE LAG 4X26MM CANNULATED LOCKING","SUP-ITM-10081767","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.50","811.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","859.79","79.5","","800.18","480.96","1887.97","195","335.27","859.79","percent of total billed charges",""
"SCREW BONE LAG 4X26MM CANNULATED LOCKING","SUP-ITM-10081767","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.50","811.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","576.44","53.3","","813.12","216.42","1444.50","81","335.27","859.79","percent of total billed charges",""
"SCREW BONE LAG 4X26MM CANNULATED LOCKING","SUP-ITM-10081767","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.50","811.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","335.27","31","","432.60","432.60","432.60","1 through 10","335.27","859.79","percent of total billed charges",""
"SCREW BONE LAG 4X26MM CANNULATED LOCKING","SUP-ITM-10081767","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.50","811.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","394.75","36.5","","148.37","54.89","631.39","94","335.27","859.79","percent of total billed charges",""
"SCREW BONE LAG 4X26MM CANNULATED LOCKING","SUP-ITM-10081767","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.50","811.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","414.21","38.3","","279.30","91.72","1116.77","266","335.27","859.79","percent of total billed charges",""
"SCREW BONE LAG 4X26MM CANNULATED LOCKING","SUP-ITM-10081767","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.50","811.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","463.96","42.9","","731.00","63.70","731.00","1 through 10","335.27","859.79","percent of total billed charges",""
"SCREW BONE LAG 4X26MM CANNULATED LOCKING","SUP-ITM-10081767","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.50","811.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","463.96","42.9","","384.74","384.74","384.74","1 through 10","335.27","859.79","percent of total billed charges",""
"SCREW BONE LAG 4X26MM CANNULATED LOCKING","SUP-ITM-10081767","CDM","C1713","HCPCS","0278","RC","","","","both","","","1081.50","811.12","WELLPOINT [1015]","HB AMC WELLPOINT","797.93","73.78","","286.63","119.22","1107.45","105","335.27","859.79","percent of total billed charges",""
"SCREW BONE LAG 4X26MM CANNULATED LOCKING","SUP-ITM-10081767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1081.50","811.12","AETNA [1001]","HB AMC AETNA HMO","754.89","69.8","","675.31","184.75","1721.50","286","565.19","883.8","percent of total billed charges",""
"SCREW BONE LAG 4X26MM CANNULATED LOCKING","SUP-ITM-10081767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1081.50","811.12","AETNA [1001]","HB AMC AETNA PPO","869.53","80.4","","1261.44","103.12","1514.10","21","565.19","883.8","percent of total billed charges",""
"SCREW BONE LAG 4X26MM CANNULATED LOCKING","SUP-ITM-10081767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1081.50","811.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","869.53","80.4","","1365.00","1365.00","1365.00","1 through 10","565.19","883.8","percent of total billed charges",""
"SCREW BONE LAG 4X26MM CANNULATED LOCKING","SUP-ITM-10081767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1081.50","811.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","883.80","81.72","","5157.68","5157.68","5157.68","1 through 10","565.19","883.8","percent of total billed charges",""
"SCREW BONE LAG 4X26MM CANNULATED LOCKING","SUP-ITM-10081767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1081.50","811.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","883.80","81.72","","431.26","71.26","1459.57","88","565.19","883.8","percent of total billed charges",""
"SCREW BONE SELF DRILL LOCK 2.4X8MM RIBFIX BLU","SUP-ITM-10338526","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.50","517.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","548.15","79.5","","800.18","480.96","1887.97","195","213.75","548.15","percent of total billed charges",""
"SCREW BONE SELF DRILL LOCK 2.4X8MM RIBFIX BLU","SUP-ITM-10338526","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.50","517.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","367.50","53.3","","813.12","216.42","1444.50","81","213.75","548.15","percent of total billed charges",""
"SCREW BONE SELF DRILL LOCK 2.4X8MM RIBFIX BLU","SUP-ITM-10338526","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.50","517.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","213.75","31","","432.60","432.60","432.60","1 through 10","213.75","548.15","percent of total billed charges",""
"SCREW BONE SELF DRILL LOCK 2.4X8MM RIBFIX BLU","SUP-ITM-10338526","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.50","517.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","251.67","36.5","","148.37","54.89","631.39","94","213.75","548.15","percent of total billed charges",""
"SCREW BONE SELF DRILL LOCK 2.4X8MM RIBFIX BLU","SUP-ITM-10338526","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.50","517.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","264.08","38.3","","279.30","91.72","1116.77","266","213.75","548.15","percent of total billed charges",""
"SCREW BONE SELF DRILL LOCK 2.4X8MM RIBFIX BLU","SUP-ITM-10338526","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.50","517.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","295.80","42.9","","731.00","63.70","731.00","1 through 10","213.75","548.15","percent of total billed charges",""
"SCREW BONE SELF DRILL LOCK 2.4X8MM RIBFIX BLU","SUP-ITM-10338526","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.50","517.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","295.80","42.9","","384.74","384.74","384.74","1 through 10","213.75","548.15","percent of total billed charges",""
"SCREW BONE SELF DRILL LOCK 2.4X8MM RIBFIX BLU","SUP-ITM-10338526","CDM","C1713","HCPCS","0278","RC","","","","both","","","689.50","517.12","WELLPOINT [1015]","HB AMC WELLPOINT","508.71","73.78","","286.63","119.22","1107.45","105","213.75","548.15","percent of total billed charges",""
"SCREW BONE SELF DRILL LOCK 2.4X8MM RIBFIX BLU","SUP-ITM-10338526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.50","517.12","AETNA [1001]","HB AMC AETNA HMO","481.27","69.8","","675.31","184.75","1721.50","286","360.33","563.46","percent of total billed charges",""
"SCREW BONE SELF DRILL LOCK 2.4X8MM RIBFIX BLU","SUP-ITM-10338526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.50","517.12","AETNA [1001]","HB AMC AETNA PPO","554.36","80.4","","1261.44","103.12","1514.10","21","360.33","563.46","percent of total billed charges",""
"SCREW BONE SELF DRILL LOCK 2.4X8MM RIBFIX BLU","SUP-ITM-10338526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.50","517.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","554.36","80.4","","1365.00","1365.00","1365.00","1 through 10","360.33","563.46","percent of total billed charges",""
"SCREW BONE SELF DRILL LOCK 2.4X8MM RIBFIX BLU","SUP-ITM-10338526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.50","517.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","563.46","81.72","","5157.68","5157.68","5157.68","1 through 10","360.33","563.46","percent of total billed charges",""
"SCREW BONE SELF DRILL LOCK 2.4X8MM RIBFIX BLU","SUP-ITM-10338526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","689.50","517.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","563.46","81.72","","431.26","71.26","1459.57","88","360.33","563.46","percent of total billed charges",""
"SCREW BONE SPINE CONNECTOR FIXATION ROD XIA II TITANIUM CLOSED CYLINDER LATERAL OFFSET LOW PROFILE","SUP-ITM-10046859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","800.18","480.96","1887.97","195","482.83","1238.21","percent of total billed charges",""
"SCREW BONE SPINE CONNECTOR FIXATION ROD XIA II TITANIUM CLOSED CYLINDER LATERAL OFFSET LOW PROFILE","SUP-ITM-10046859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","813.12","216.42","1444.50","81","482.83","1238.21","percent of total billed charges",""
"SCREW BONE SPINE CONNECTOR FIXATION ROD XIA II TITANIUM CLOSED CYLINDER LATERAL OFFSET LOW PROFILE","SUP-ITM-10046859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","482.83","31","","432.60","432.60","432.60","1 through 10","482.83","1238.21","percent of total billed charges",""
"SCREW BONE SPINE CONNECTOR FIXATION ROD XIA II TITANIUM CLOSED CYLINDER LATERAL OFFSET LOW PROFILE","SUP-ITM-10046859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","148.37","54.89","631.39","94","482.83","1238.21","percent of total billed charges",""
"SCREW BONE SPINE CONNECTOR FIXATION ROD XIA II TITANIUM CLOSED CYLINDER LATERAL OFFSET LOW PROFILE","SUP-ITM-10046859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","279.30","91.72","1116.77","266","482.83","1238.21","percent of total billed charges",""
"SCREW BONE SPINE CONNECTOR FIXATION ROD XIA II TITANIUM CLOSED CYLINDER LATERAL OFFSET LOW PROFILE","SUP-ITM-10046859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","731.00","63.70","731.00","1 through 10","482.83","1238.21","percent of total billed charges",""
"SCREW BONE SPINE CONNECTOR FIXATION ROD XIA II TITANIUM CLOSED CYLINDER LATERAL OFFSET LOW PROFILE","SUP-ITM-10046859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","384.74","384.74","384.74","1 through 10","482.83","1238.21","percent of total billed charges",""
"SCREW BONE SPINE CONNECTOR FIXATION ROD XIA II TITANIUM CLOSED CYLINDER LATERAL OFFSET LOW PROFILE","SUP-ITM-10046859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","286.63","119.22","1107.45","105","482.83","1238.21","percent of total billed charges",""
"SCREW BONE SPINE CONNECTOR FIXATION ROD XIA II TITANIUM CLOSED CYLINDER LATERAL OFFSET LOW PROFILE","SUP-ITM-10046859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","675.31","184.75","1721.50","286","813.95","1272.79","percent of total billed charges",""
"SCREW BONE SPINE CONNECTOR FIXATION ROD XIA II TITANIUM CLOSED CYLINDER LATERAL OFFSET LOW PROFILE","SUP-ITM-10046859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA PPO","1252.23","80.4","","1261.44","103.12","1514.10","21","813.95","1272.79","percent of total billed charges",""
"SCREW BONE SPINE CONNECTOR FIXATION ROD XIA II TITANIUM CLOSED CYLINDER LATERAL OFFSET LOW PROFILE","SUP-ITM-10046859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.23","80.4","","1365.00","1365.00","1365.00","1 through 10","813.95","1272.79","percent of total billed charges",""
"SCREW BONE SPINE CONNECTOR FIXATION ROD XIA II TITANIUM CLOSED CYLINDER LATERAL OFFSET LOW PROFILE","SUP-ITM-10046859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1272.79","81.72","","5157.68","5157.68","5157.68","1 through 10","813.95","1272.79","percent of total billed charges",""
"SCREW BONE SPINE CONNECTOR FIXATION ROD XIA II TITANIUM CLOSED CYLINDER LATERAL OFFSET LOW PROFILE","SUP-ITM-10046859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","431.26","71.26","1459.57","88","813.95","1272.79","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840025535T","SUP-ITM-10171264","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2462.51","79.5","","800.18","480.96","1887.97","195","960.23","2462.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840025535T","SUP-ITM-10171264","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1650.97","53.3","","813.12","216.42","1444.50","81","960.23","2462.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840025535T","SUP-ITM-10171264","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","960.23","31","","432.60","432.60","432.60","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840025535T","SUP-ITM-10171264","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1130.59","36.5","","148.37","54.89","631.39","94","960.23","2462.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840025535T","SUP-ITM-10171264","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1186.34","38.3","","279.30","91.72","1116.77","266","960.23","2462.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840025535T","SUP-ITM-10171264","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1328.83","42.9","","731.00","63.70","731.00","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840025535T","SUP-ITM-10171264","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1328.83","42.9","","384.74","384.74","384.74","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840025535T","SUP-ITM-10171264","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","WELLPOINT [1015]","HB AMC WELLPOINT","2285.34","73.78","","286.63","119.22","1107.45","105","960.23","2462.51","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840025535T","SUP-ITM-10171264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","AETNA [1001]","HB AMC AETNA HMO","2162.06","69.8","","675.31","184.75","1721.50","286","1618.75","2531.28","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840025535T","SUP-ITM-10171264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","AETNA [1001]","HB AMC AETNA PPO","2490.39","80.4","","1261.44","103.12","1514.10","21","1618.75","2531.28","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840025535T","SUP-ITM-10171264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2490.39","80.4","","1365.00","1365.00","1365.00","1 through 10","1618.75","2531.28","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840025535T","SUP-ITM-10171264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2531.28","81.72","","5157.68","5157.68","5157.68","1 through 10","1618.75","2531.28","percent of total billed charges",""
"SCREW BONE SPINE FENESTRATED MAS 55840025535T","SUP-ITM-10171264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2531.28","81.72","","431.26","71.26","1459.57","88","1618.75","2531.28","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","800.18","480.96","1887.97","195","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","813.12","216.42","1444.50","81","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.83","31","","432.60","432.60","432.60","1 through 10","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","148.37","54.89","631.39","94","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","279.30","91.72","1116.77","266","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","731.00","63.70","731.00","1 through 10","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","384.74","384.74","384.74","1 through 10","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","286.63","119.22","1107.45","105","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","675.31","184.75","1721.50","286","82.31","128.71","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA PPO","126.63","80.4","","1261.44","103.12","1514.10","21","82.31","128.71","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","1365.00","1365.00","1365.00","1 through 10","82.31","128.71","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.71","81.72","","5157.68","5157.68","5157.68","1 through 10","82.31","128.71","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","431.26","71.26","1459.57","88","82.31","128.71","percent of total billed charges",""
"SCREW BONE SPINE SPINAL FIXATION SYSTEM LOCKING NON APPROVED ITEM","SUP-ITM-10011231","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","800.18","480.96","1887.97","195","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SPINAL FIXATION SYSTEM LOCKING NON APPROVED ITEM","SUP-ITM-10011231","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","813.12","216.42","1444.50","81","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SPINAL FIXATION SYSTEM LOCKING NON APPROVED ITEM","SUP-ITM-10011231","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.83","31","","432.60","432.60","432.60","1 through 10","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SPINAL FIXATION SYSTEM LOCKING NON APPROVED ITEM","SUP-ITM-10011231","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","148.37","54.89","631.39","94","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SPINAL FIXATION SYSTEM LOCKING NON APPROVED ITEM","SUP-ITM-10011231","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","279.30","91.72","1116.77","266","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SPINAL FIXATION SYSTEM LOCKING NON APPROVED ITEM","SUP-ITM-10011231","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","731.00","63.70","731.00","1 through 10","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SPINAL FIXATION SYSTEM LOCKING NON APPROVED ITEM","SUP-ITM-10011231","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","384.74","384.74","384.74","1 through 10","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SPINAL FIXATION SYSTEM LOCKING NON APPROVED ITEM","SUP-ITM-10011231","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","286.63","119.22","1107.45","105","48.83","125.21","percent of total billed charges",""
"SCREW BONE SPINE SPINAL FIXATION SYSTEM LOCKING NON APPROVED ITEM","SUP-ITM-10011231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","675.31","184.75","1721.50","286","82.31","128.71","percent of total billed charges",""
"SCREW BONE SPINE SPINAL FIXATION SYSTEM LOCKING NON APPROVED ITEM","SUP-ITM-10011231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA PPO","126.63","80.4","","1261.44","103.12","1514.10","21","82.31","128.71","percent of total billed charges",""
"SCREW BONE SPINE SPINAL FIXATION SYSTEM LOCKING NON APPROVED ITEM","SUP-ITM-10011231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","1365.00","1365.00","1365.00","1 through 10","82.31","128.71","percent of total billed charges",""
"SCREW BONE SPINE SPINAL FIXATION SYSTEM LOCKING NON APPROVED ITEM","SUP-ITM-10011231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.71","81.72","","5157.68","5157.68","5157.68","1 through 10","82.31","128.71","percent of total billed charges",""
"SCREW BONE SPINE SPINAL FIXATION SYSTEM LOCKING NON APPROVED ITEM","SUP-ITM-10011231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","431.26","71.26","1459.57","88","82.31","128.71","percent of total billed charges",""
"SCREW BS CNMAS 8.5X100 T/C","SUP-ITM-10259064","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","800.18","480.96","1887.97","195","868","2226","percent of total billed charges",""
"SCREW BS CNMAS 8.5X100 T/C","SUP-ITM-10259064","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1492.40","53.3","","813.12","216.42","1444.50","81","868","2226","percent of total billed charges",""
"SCREW BS CNMAS 8.5X100 T/C","SUP-ITM-10259064","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","868.00","31","","432.60","432.60","432.60","1 through 10","868","2226","percent of total billed charges",""
"SCREW BS CNMAS 8.5X100 T/C","SUP-ITM-10259064","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","148.37","54.89","631.39","94","868","2226","percent of total billed charges",""
"SCREW BS CNMAS 8.5X100 T/C","SUP-ITM-10259064","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","279.30","91.72","1116.77","266","868","2226","percent of total billed charges",""
"SCREW BS CNMAS 8.5X100 T/C","SUP-ITM-10259064","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","731.00","63.70","731.00","1 through 10","868","2226","percent of total billed charges",""
"SCREW BS CNMAS 8.5X100 T/C","SUP-ITM-10259064","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","384.74","384.74","384.74","1 through 10","868","2226","percent of total billed charges",""
"SCREW BS CNMAS 8.5X100 T/C","SUP-ITM-10259064","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","286.63","119.22","1107.45","105","868","2226","percent of total billed charges",""
"SCREW BS CNMAS 8.5X100 T/C","SUP-ITM-10259064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA HMO","1954.40","69.8","","675.31","184.75","1721.50","286","1463.28","2288.16","percent of total billed charges",""
"SCREW BS CNMAS 8.5X100 T/C","SUP-ITM-10259064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA PPO","2251.20","80.4","","1261.44","103.12","1514.10","21","1463.28","2288.16","percent of total billed charges",""
"SCREW BS CNMAS 8.5X100 T/C","SUP-ITM-10259064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2251.20","80.4","","1365.00","1365.00","1365.00","1 through 10","1463.28","2288.16","percent of total billed charges",""
"SCREW BS CNMAS 8.5X100 T/C","SUP-ITM-10259064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2288.16","81.72","","5157.68","5157.68","5157.68","1 through 10","1463.28","2288.16","percent of total billed charges",""
"SCREW BS CNMAS 8.5X100 T/C","SUP-ITM-10259064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","431.26","71.26","1459.57","88","1463.28","2288.16","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7950.00","79.5","","800.18","480.96","1887.97","195","3100","7950","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5330.00","53.3","","813.12","216.42","1444.50","81","3100","7950","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3100.00","31","","432.60","432.60","432.60","1 through 10","3100","7950","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3650.00","36.5","","148.37","54.89","631.39","94","3100","7950","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3830.00","38.3","","279.30","91.72","1116.77","266","3100","7950","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4290.00","42.9","","731.00","63.70","731.00","1 through 10","3100","7950","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4290.00","42.9","","384.74","384.74","384.74","1 through 10","3100","7950","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB AMC WELLPOINT","7378.00","73.78","","286.63","119.22","1107.45","105","3100","7950","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA HMO","6980.00","69.8","","675.31","184.75","1721.50","286","5226","8172","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA PPO","8040.00","80.4","","1261.44","103.12","1514.10","21","5226","8172","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8040.00","80.4","","1365.00","1365.00","1365.00","1 through 10","5226","8172","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8172.00","81.72","","5157.68","5157.68","5157.68","1 through 10","5226","8172","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8172.00","81.72","","431.26","71.26","1459.57","88","5226","8172","percent of total billed charges",""
"SCREW CANNULATED 3.75MMX36MM FULLY THREADED","SUP-ITM-10076211","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","800.18","480.96","1887.97","195","217","556.5","percent of total billed charges",""
"SCREW CANNULATED 3.75MMX36MM FULLY THREADED","SUP-ITM-10076211","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","813.12","216.42","1444.50","81","217","556.5","percent of total billed charges",""
"SCREW CANNULATED 3.75MMX36MM FULLY THREADED","SUP-ITM-10076211","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","217.00","31","","432.60","432.60","432.60","1 through 10","217","556.5","percent of total billed charges",""
"SCREW CANNULATED 3.75MMX36MM FULLY THREADED","SUP-ITM-10076211","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","148.37","54.89","631.39","94","217","556.5","percent of total billed charges",""
"SCREW CANNULATED 3.75MMX36MM FULLY THREADED","SUP-ITM-10076211","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","279.30","91.72","1116.77","266","217","556.5","percent of total billed charges",""
"SCREW CANNULATED 3.75MMX36MM FULLY THREADED","SUP-ITM-10076211","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","731.00","63.70","731.00","1 through 10","217","556.5","percent of total billed charges",""
"SCREW CANNULATED 3.75MMX36MM FULLY THREADED","SUP-ITM-10076211","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","384.74","384.74","384.74","1 through 10","217","556.5","percent of total billed charges",""
"SCREW CANNULATED 3.75MMX36MM FULLY THREADED","SUP-ITM-10076211","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","286.63","119.22","1107.45","105","217","556.5","percent of total billed charges",""
"SCREW CANNULATED 3.75MMX36MM FULLY THREADED","SUP-ITM-10076211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","675.31","184.75","1721.50","286","365.82","572.04","percent of total billed charges",""
"SCREW CANNULATED 3.75MMX36MM FULLY THREADED","SUP-ITM-10076211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA PPO","562.80","80.4","","1261.44","103.12","1514.10","21","365.82","572.04","percent of total billed charges",""
"SCREW CANNULATED 3.75MMX36MM FULLY THREADED","SUP-ITM-10076211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","562.80","80.4","","1365.00","1365.00","1365.00","1 through 10","365.82","572.04","percent of total billed charges",""
"SCREW CANNULATED 3.75MMX36MM FULLY THREADED","SUP-ITM-10076211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","572.04","81.72","","5157.68","5157.68","5157.68","1 through 10","365.82","572.04","percent of total billed charges",""
"SCREW CANNULATED 3.75MMX36MM FULLY THREADED","SUP-ITM-10076211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","431.26","71.26","1459.57","88","365.82","572.04","percent of total billed charges",""
"SCREW CORTEX 1.0MM 4 PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075743","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.72","143.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","152.42","79.5","","800.18","480.96","1887.97","195","59.43","152.42","percent of total billed charges",""
"SCREW CORTEX 1.0MM 4 PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075743","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.72","143.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","102.19","53.3","","813.12","216.42","1444.50","81","59.43","152.42","percent of total billed charges",""
"SCREW CORTEX 1.0MM 4 PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075743","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.72","143.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","59.43","31","","432.60","432.60","432.60","1 through 10","59.43","152.42","percent of total billed charges",""
"SCREW CORTEX 1.0MM 4 PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075743","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.72","143.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","69.98","36.5","","148.37","54.89","631.39","94","59.43","152.42","percent of total billed charges",""
"SCREW CORTEX 1.0MM 4 PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075743","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.72","143.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.43","38.3","","279.30","91.72","1116.77","266","59.43","152.42","percent of total billed charges",""
"SCREW CORTEX 1.0MM 4 PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075743","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.72","143.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.25","42.9","","731.00","63.70","731.00","1 through 10","59.43","152.42","percent of total billed charges",""
"SCREW CORTEX 1.0MM 4 PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075743","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.72","143.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.25","42.9","","384.74","384.74","384.74","1 through 10","59.43","152.42","percent of total billed charges",""
"SCREW CORTEX 1.0MM 4 PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075743","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.72","143.79","WELLPOINT [1015]","HB AMC WELLPOINT","141.45","73.78","","286.63","119.22","1107.45","105","59.43","152.42","percent of total billed charges",""
"SCREW CORTEX 1.0MM 4 PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.72","143.79","AETNA [1001]","HB AMC AETNA HMO","133.82","69.8","","675.31","184.75","1721.50","286","100.19","156.67","percent of total billed charges",""
"SCREW CORTEX 1.0MM 4 PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.72","143.79","AETNA [1001]","HB AMC AETNA PPO","154.14","80.4","","1261.44","103.12","1514.10","21","100.19","156.67","percent of total billed charges",""
"SCREW CORTEX 1.0MM 4 PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.72","143.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","154.14","80.4","","1365.00","1365.00","1365.00","1 through 10","100.19","156.67","percent of total billed charges",""
"SCREW CORTEX 1.0MM 4 PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.72","143.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","156.67","81.72","","5157.68","5157.68","5157.68","1 through 10","100.19","156.67","percent of total billed charges",""
"SCREW CORTEX 1.0MM 4 PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.72","143.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","156.67","81.72","","431.26","71.26","1459.57","88","100.19","156.67","percent of total billed charges",""
"SCREW COUPLING DHS DCS LONG","SUP-ITM-10039332","CDM","C1713","HCPCS","0278","RC","","","","both","","","282.31","211.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","224.44","79.5","","800.18","480.96","1887.97","195","87.52","224.44","percent of total billed charges",""
"SCREW COUPLING DHS DCS LONG","SUP-ITM-10039332","CDM","C1713","HCPCS","0278","RC","","","","both","","","282.31","211.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","150.47","53.3","","813.12","216.42","1444.50","81","87.52","224.44","percent of total billed charges",""
"SCREW COUPLING DHS DCS LONG","SUP-ITM-10039332","CDM","C1713","HCPCS","0278","RC","","","","both","","","282.31","211.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","87.52","31","","432.60","432.60","432.60","1 through 10","87.52","224.44","percent of total billed charges",""
"SCREW COUPLING DHS DCS LONG","SUP-ITM-10039332","CDM","C1713","HCPCS","0278","RC","","","","both","","","282.31","211.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","103.04","36.5","","148.37","54.89","631.39","94","87.52","224.44","percent of total billed charges",""
"SCREW COUPLING DHS DCS LONG","SUP-ITM-10039332","CDM","C1713","HCPCS","0278","RC","","","","both","","","282.31","211.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","108.12","38.3","","279.30","91.72","1116.77","266","87.52","224.44","percent of total billed charges",""
"SCREW COUPLING DHS DCS LONG","SUP-ITM-10039332","CDM","C1713","HCPCS","0278","RC","","","","both","","","282.31","211.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","121.11","42.9","","731.00","63.70","731.00","1 through 10","87.52","224.44","percent of total billed charges",""
"SCREW COUPLING DHS DCS LONG","SUP-ITM-10039332","CDM","C1713","HCPCS","0278","RC","","","","both","","","282.31","211.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","121.11","42.9","","384.74","384.74","384.74","1 through 10","87.52","224.44","percent of total billed charges",""
"SCREW COUPLING DHS DCS LONG","SUP-ITM-10039332","CDM","C1713","HCPCS","0278","RC","","","","both","","","282.31","211.73","WELLPOINT [1015]","HB AMC WELLPOINT","208.29","73.78","","286.63","119.22","1107.45","105","87.52","224.44","percent of total billed charges",""
"SCREW COUPLING DHS DCS LONG","SUP-ITM-10039332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","282.31","211.73","AETNA [1001]","HB AMC AETNA HMO","197.05","69.8","","675.31","184.75","1721.50","286","147.54","230.7","percent of total billed charges",""
"SCREW COUPLING DHS DCS LONG","SUP-ITM-10039332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","282.31","211.73","AETNA [1001]","HB AMC AETNA PPO","226.98","80.4","","1261.44","103.12","1514.10","21","147.54","230.7","percent of total billed charges",""
"SCREW COUPLING DHS DCS LONG","SUP-ITM-10039332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","282.31","211.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","226.98","80.4","","1365.00","1365.00","1365.00","1 through 10","147.54","230.7","percent of total billed charges",""
"SCREW COUPLING DHS DCS LONG","SUP-ITM-10039332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","282.31","211.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","230.70","81.72","","5157.68","5157.68","5157.68","1 through 10","147.54","230.7","percent of total billed charges",""
"SCREW COUPLING DHS DCS LONG","SUP-ITM-10039332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","282.31","211.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","230.70","81.72","","431.26","71.26","1459.57","88","147.54","230.7","percent of total billed charges",""
"SCREW DISTAL 10MM SIZE 3 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10019439","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1299.43","79.5","","800.18","480.96","1887.97","195","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 10MM SIZE 3 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10019439","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","871.19","53.3","","813.12","216.42","1444.50","81","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 10MM SIZE 3 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10019439","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","506.70","31","","432.60","432.60","432.60","1 through 10","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 10MM SIZE 3 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10019439","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","596.59","36.5","","148.37","54.89","631.39","94","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 10MM SIZE 3 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10019439","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","626.01","38.3","","279.30","91.72","1116.77","266","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 10MM SIZE 3 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10019439","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","731.00","63.70","731.00","1 through 10","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 10MM SIZE 3 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10019439","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","384.74","384.74","384.74","1 through 10","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 10MM SIZE 3 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10019439","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","WELLPOINT [1015]","HB AMC WELLPOINT","1205.93","73.78","","286.63","119.22","1107.45","105","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 10MM SIZE 3 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10019439","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA HMO","1140.88","69.8","","675.31","184.75","1721.50","286","854.19","1335.71","percent of total billed charges",""
"SCREW DISTAL 10MM SIZE 3 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10019439","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA PPO","1314.14","80.4","","1261.44","103.12","1514.10","21","854.19","1335.71","percent of total billed charges",""
"SCREW DISTAL 10MM SIZE 3 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10019439","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1314.14","80.4","","1365.00","1365.00","1365.00","1 through 10","854.19","1335.71","percent of total billed charges",""
"SCREW DISTAL 10MM SIZE 3 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10019439","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1335.71","81.72","","5157.68","5157.68","5157.68","1 through 10","854.19","1335.71","percent of total billed charges",""
"SCREW DISTAL 10MM SIZE 3 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10019439","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1335.71","81.72","","431.26","71.26","1459.57","88","854.19","1335.71","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1299.43","79.5","","800.18","480.96","1887.97","195","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","871.19","53.3","","813.12","216.42","1444.50","81","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","506.70","31","","432.60","432.60","432.60","1 through 10","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","596.59","36.5","","148.37","54.89","631.39","94","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","626.01","38.3","","279.30","91.72","1116.77","266","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","731.00","63.70","731.00","1 through 10","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.20","42.9","","384.74","384.74","384.74","1 through 10","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","both","","","1634.50","1225.87","WELLPOINT [1015]","HB AMC WELLPOINT","1205.93","73.78","","286.63","119.22","1107.45","105","506.7","1299.43","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA HMO","1140.88","69.8","","675.31","184.75","1721.50","286","854.19","1335.71","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","AETNA [1001]","HB AMC AETNA PPO","1314.14","80.4","","1261.44","103.12","1514.10","21","854.19","1335.71","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1314.14","80.4","","1365.00","1365.00","1365.00","1 through 10","854.19","1335.71","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1335.71","81.72","","5157.68","5157.68","5157.68","1 through 10","854.19","1335.71","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1634.50","1225.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1335.71","81.72","","431.26","71.26","1459.57","88","854.19","1335.71","percent of total billed charges",""
"SCREW EXTRACTION 7.3MM LONG CONICAL SS SHAFT SELF TAPPING THREADED TIP HEX HEAD","SUP-ITM-10005285","CDM","C1713","HCPCS","0278","RC","","","","both","","","533.75","400.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","424.33","79.5","","800.18","480.96","1887.97","195","165.46","424.33","percent of total billed charges",""
"SCREW EXTRACTION 7.3MM LONG CONICAL SS SHAFT SELF TAPPING THREADED TIP HEX HEAD","SUP-ITM-10005285","CDM","C1713","HCPCS","0278","RC","","","","both","","","533.75","400.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","284.49","53.3","","813.12","216.42","1444.50","81","165.46","424.33","percent of total billed charges",""
"SCREW EXTRACTION 7.3MM LONG CONICAL SS SHAFT SELF TAPPING THREADED TIP HEX HEAD","SUP-ITM-10005285","CDM","C1713","HCPCS","0278","RC","","","","both","","","533.75","400.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","165.46","31","","432.60","432.60","432.60","1 through 10","165.46","424.33","percent of total billed charges",""
"SCREW EXTRACTION 7.3MM LONG CONICAL SS SHAFT SELF TAPPING THREADED TIP HEX HEAD","SUP-ITM-10005285","CDM","C1713","HCPCS","0278","RC","","","","both","","","533.75","400.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.82","36.5","","148.37","54.89","631.39","94","165.46","424.33","percent of total billed charges",""
"SCREW EXTRACTION 7.3MM LONG CONICAL SS SHAFT SELF TAPPING THREADED TIP HEX HEAD","SUP-ITM-10005285","CDM","C1713","HCPCS","0278","RC","","","","both","","","533.75","400.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","204.43","38.3","","279.30","91.72","1116.77","266","165.46","424.33","percent of total billed charges",""
"SCREW EXTRACTION 7.3MM LONG CONICAL SS SHAFT SELF TAPPING THREADED TIP HEX HEAD","SUP-ITM-10005285","CDM","C1713","HCPCS","0278","RC","","","","both","","","533.75","400.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.98","42.9","","731.00","63.70","731.00","1 through 10","165.46","424.33","percent of total billed charges",""
"SCREW EXTRACTION 7.3MM LONG CONICAL SS SHAFT SELF TAPPING THREADED TIP HEX HEAD","SUP-ITM-10005285","CDM","C1713","HCPCS","0278","RC","","","","both","","","533.75","400.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.98","42.9","","384.74","384.74","384.74","1 through 10","165.46","424.33","percent of total billed charges",""
"SCREW EXTRACTION 7.3MM LONG CONICAL SS SHAFT SELF TAPPING THREADED TIP HEX HEAD","SUP-ITM-10005285","CDM","C1713","HCPCS","0278","RC","","","","both","","","533.75","400.31","WELLPOINT [1015]","HB AMC WELLPOINT","393.80","73.78","","286.63","119.22","1107.45","105","165.46","424.33","percent of total billed charges",""
"SCREW EXTRACTION 7.3MM LONG CONICAL SS SHAFT SELF TAPPING THREADED TIP HEX HEAD","SUP-ITM-10005285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","533.75","400.31","AETNA [1001]","HB AMC AETNA HMO","372.56","69.8","","675.31","184.75","1721.50","286","278.94","436.18","percent of total billed charges",""
"SCREW EXTRACTION 7.3MM LONG CONICAL SS SHAFT SELF TAPPING THREADED TIP HEX HEAD","SUP-ITM-10005285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","533.75","400.31","AETNA [1001]","HB AMC AETNA PPO","429.14","80.4","","1261.44","103.12","1514.10","21","278.94","436.18","percent of total billed charges",""
"SCREW EXTRACTION 7.3MM LONG CONICAL SS SHAFT SELF TAPPING THREADED TIP HEX HEAD","SUP-ITM-10005285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","533.75","400.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","429.14","80.4","","1365.00","1365.00","1365.00","1 through 10","278.94","436.18","percent of total billed charges",""
"SCREW EXTRACTION 7.3MM LONG CONICAL SS SHAFT SELF TAPPING THREADED TIP HEX HEAD","SUP-ITM-10005285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","533.75","400.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","436.18","81.72","","5157.68","5157.68","5157.68","1 through 10","278.94","436.18","percent of total billed charges",""
"SCREW EXTRACTION 7.3MM LONG CONICAL SS SHAFT SELF TAPPING THREADED TIP HEX HEAD","SUP-ITM-10005285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","533.75","400.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","436.18","81.72","","431.26","71.26","1459.57","88","278.94","436.18","percent of total billed charges",""
"SCREW EXTRACTOR TIBIAL NAIL EX TITANIUM","SUP-ITM-10039413","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.31","1084.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1149.82","79.5","","800.18","480.96","1887.97","195","448.36","1149.82","percent of total billed charges",""
"SCREW EXTRACTOR TIBIAL NAIL EX TITANIUM","SUP-ITM-10039413","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.31","1084.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","770.88","53.3","","813.12","216.42","1444.50","81","448.36","1149.82","percent of total billed charges",""
"SCREW EXTRACTOR TIBIAL NAIL EX TITANIUM","SUP-ITM-10039413","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.31","1084.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","448.36","31","","432.60","432.60","432.60","1 through 10","448.36","1149.82","percent of total billed charges",""
"SCREW EXTRACTOR TIBIAL NAIL EX TITANIUM","SUP-ITM-10039413","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.31","1084.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","527.90","36.5","","148.37","54.89","631.39","94","448.36","1149.82","percent of total billed charges",""
"SCREW EXTRACTOR TIBIAL NAIL EX TITANIUM","SUP-ITM-10039413","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.31","1084.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","553.94","38.3","","279.30","91.72","1116.77","266","448.36","1149.82","percent of total billed charges",""
"SCREW EXTRACTOR TIBIAL NAIL EX TITANIUM","SUP-ITM-10039413","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.31","1084.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","620.47","42.9","","731.00","63.70","731.00","1 through 10","448.36","1149.82","percent of total billed charges",""
"SCREW EXTRACTOR TIBIAL NAIL EX TITANIUM","SUP-ITM-10039413","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.31","1084.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","620.47","42.9","","384.74","384.74","384.74","1 through 10","448.36","1149.82","percent of total billed charges",""
"SCREW EXTRACTOR TIBIAL NAIL EX TITANIUM","SUP-ITM-10039413","CDM","C1713","HCPCS","0278","RC","","","","both","","","1446.31","1084.73","WELLPOINT [1015]","HB AMC WELLPOINT","1067.09","73.78","","286.63","119.22","1107.45","105","448.36","1149.82","percent of total billed charges",""
"SCREW EXTRACTOR TIBIAL NAIL EX TITANIUM","SUP-ITM-10039413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1446.31","1084.73","AETNA [1001]","HB AMC AETNA HMO","1009.52","69.8","","675.31","184.75","1721.50","286","755.84","1181.92","percent of total billed charges",""
"SCREW EXTRACTOR TIBIAL NAIL EX TITANIUM","SUP-ITM-10039413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1446.31","1084.73","AETNA [1001]","HB AMC AETNA PPO","1162.83","80.4","","1261.44","103.12","1514.10","21","755.84","1181.92","percent of total billed charges",""
"SCREW EXTRACTOR TIBIAL NAIL EX TITANIUM","SUP-ITM-10039413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1446.31","1084.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1162.83","80.4","","1365.00","1365.00","1365.00","1 through 10","755.84","1181.92","percent of total billed charges",""
"SCREW EXTRACTOR TIBIAL NAIL EX TITANIUM","SUP-ITM-10039413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1446.31","1084.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1181.92","81.72","","5157.68","5157.68","5157.68","1 through 10","755.84","1181.92","percent of total billed charges",""
"SCREW EXTRACTOR TIBIAL NAIL EX TITANIUM","SUP-ITM-10039413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1446.31","1084.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1181.92","81.72","","431.26","71.26","1459.57","88","755.84","1181.92","percent of total billed charges",""
"SCREW FASTENER 3.3X22MM LOCKING SELF TAPPING","SUP-ITM-10268661","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","186.43","79.5","","800.18","480.96","1887.97","195","72.7","186.43","percent of total billed charges",""
"SCREW FASTENER 3.3X22MM LOCKING SELF TAPPING","SUP-ITM-10268661","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.99","53.3","","813.12","216.42","1444.50","81","72.7","186.43","percent of total billed charges",""
"SCREW FASTENER 3.3X22MM LOCKING SELF TAPPING","SUP-ITM-10268661","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","72.70","31","","432.60","432.60","432.60","1 through 10","72.7","186.43","percent of total billed charges",""
"SCREW FASTENER 3.3X22MM LOCKING SELF TAPPING","SUP-ITM-10268661","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.59","36.5","","148.37","54.89","631.39","94","72.7","186.43","percent of total billed charges",""
"SCREW FASTENER 3.3X22MM LOCKING SELF TAPPING","SUP-ITM-10268661","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.81","38.3","","279.30","91.72","1116.77","266","72.7","186.43","percent of total billed charges",""
"SCREW FASTENER 3.3X22MM LOCKING SELF TAPPING","SUP-ITM-10268661","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.60","42.9","","731.00","63.70","731.00","1 through 10","72.7","186.43","percent of total billed charges",""
"SCREW FASTENER 3.3X22MM LOCKING SELF TAPPING","SUP-ITM-10268661","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.60","42.9","","384.74","384.74","384.74","1 through 10","72.7","186.43","percent of total billed charges",""
"SCREW FASTENER 3.3X22MM LOCKING SELF TAPPING","SUP-ITM-10268661","CDM","C1713","HCPCS","0278","RC","","","","both","","","234.50","175.87","WELLPOINT [1015]","HB AMC WELLPOINT","173.01","73.78","","286.63","119.22","1107.45","105","72.7","186.43","percent of total billed charges",""
"SCREW FASTENER 3.3X22MM LOCKING SELF TAPPING","SUP-ITM-10268661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","234.50","175.87","AETNA [1001]","HB AMC AETNA HMO","163.68","69.8","","675.31","184.75","1721.50","286","122.55","191.63","percent of total billed charges",""
"SCREW FASTENER 3.3X22MM LOCKING SELF TAPPING","SUP-ITM-10268661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","234.50","175.87","AETNA [1001]","HB AMC AETNA PPO","188.54","80.4","","1261.44","103.12","1514.10","21","122.55","191.63","percent of total billed charges",""
"SCREW FASTENER 3.3X22MM LOCKING SELF TAPPING","SUP-ITM-10268661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","234.50","175.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","188.54","80.4","","1365.00","1365.00","1365.00","1 through 10","122.55","191.63","percent of total billed charges",""
"SCREW FASTENER 3.3X22MM LOCKING SELF TAPPING","SUP-ITM-10268661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","234.50","175.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","191.63","81.72","","5157.68","5157.68","5157.68","1 through 10","122.55","191.63","percent of total billed charges",""
"SCREW FASTENER 3.3X22MM LOCKING SELF TAPPING","SUP-ITM-10268661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","234.50","175.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","191.63","81.72","","431.26","71.26","1459.57","88","122.55","191.63","percent of total billed charges",""
"SCREW FASTENER 3.5X120MM INTERLOCKING SELF TAPPING","SUP-ITM-10276189","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","225.38","79.5","","800.18","480.96","1887.97","195","87.89","225.38","percent of total billed charges",""
"SCREW FASTENER 3.5X120MM INTERLOCKING SELF TAPPING","SUP-ITM-10276189","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","151.11","53.3","","813.12","216.42","1444.50","81","87.89","225.38","percent of total billed charges",""
"SCREW FASTENER 3.5X120MM INTERLOCKING SELF TAPPING","SUP-ITM-10276189","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","87.89","31","","432.60","432.60","432.60","1 through 10","87.89","225.38","percent of total billed charges",""
"SCREW FASTENER 3.5X120MM INTERLOCKING SELF TAPPING","SUP-ITM-10276189","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","103.48","36.5","","148.37","54.89","631.39","94","87.89","225.38","percent of total billed charges",""
"SCREW FASTENER 3.5X120MM INTERLOCKING SELF TAPPING","SUP-ITM-10276189","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","108.58","38.3","","279.30","91.72","1116.77","266","87.89","225.38","percent of total billed charges",""
"SCREW FASTENER 3.5X120MM INTERLOCKING SELF TAPPING","SUP-ITM-10276189","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","121.62","42.9","","731.00","63.70","731.00","1 through 10","87.89","225.38","percent of total billed charges",""
"SCREW FASTENER 3.5X120MM INTERLOCKING SELF TAPPING","SUP-ITM-10276189","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","121.62","42.9","","384.74","384.74","384.74","1 through 10","87.89","225.38","percent of total billed charges",""
"SCREW FASTENER 3.5X120MM INTERLOCKING SELF TAPPING","SUP-ITM-10276189","CDM","C1713","HCPCS","0278","RC","","","","both","","","283.50","212.62","WELLPOINT [1015]","HB AMC WELLPOINT","209.17","73.78","","286.63","119.22","1107.45","105","87.89","225.38","percent of total billed charges",""
"SCREW FASTENER 3.5X120MM INTERLOCKING SELF TAPPING","SUP-ITM-10276189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","283.50","212.62","AETNA [1001]","HB AMC AETNA HMO","197.88","69.8","","675.31","184.75","1721.50","286","148.16","231.68","percent of total billed charges",""
"SCREW FASTENER 3.5X120MM INTERLOCKING SELF TAPPING","SUP-ITM-10276189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","283.50","212.62","AETNA [1001]","HB AMC AETNA PPO","227.93","80.4","","1261.44","103.12","1514.10","21","148.16","231.68","percent of total billed charges",""
"SCREW FASTENER 3.5X120MM INTERLOCKING SELF TAPPING","SUP-ITM-10276189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","283.50","212.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","227.93","80.4","","1365.00","1365.00","1365.00","1 through 10","148.16","231.68","percent of total billed charges",""
"SCREW FASTENER 3.5X120MM INTERLOCKING SELF TAPPING","SUP-ITM-10276189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","283.50","212.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","231.68","81.72","","5157.68","5157.68","5157.68","1 through 10","148.16","231.68","percent of total billed charges",""
"SCREW FASTENER 3.5X120MM INTERLOCKING SELF TAPPING","SUP-ITM-10276189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","283.50","212.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","231.68","81.72","","431.26","71.26","1459.57","88","148.16","231.68","percent of total billed charges",""
"SCREW FASTENER 3.9MM 50MM HEADLESS COMPRESSION","SUP-ITM-10275982","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1015.61","79.5","","800.18","480.96","1887.97","195","396.03","1015.61","percent of total billed charges",""
"SCREW FASTENER 3.9MM 50MM HEADLESS COMPRESSION","SUP-ITM-10275982","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","680.91","53.3","","813.12","216.42","1444.50","81","396.03","1015.61","percent of total billed charges",""
"SCREW FASTENER 3.9MM 50MM HEADLESS COMPRESSION","SUP-ITM-10275982","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","396.03","31","","432.60","432.60","432.60","1 through 10","396.03","1015.61","percent of total billed charges",""
"SCREW FASTENER 3.9MM 50MM HEADLESS COMPRESSION","SUP-ITM-10275982","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","466.29","36.5","","148.37","54.89","631.39","94","396.03","1015.61","percent of total billed charges",""
"SCREW FASTENER 3.9MM 50MM HEADLESS COMPRESSION","SUP-ITM-10275982","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","489.28","38.3","","279.30","91.72","1116.77","266","396.03","1015.61","percent of total billed charges",""
"SCREW FASTENER 3.9MM 50MM HEADLESS COMPRESSION","SUP-ITM-10275982","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","548.05","42.9","","731.00","63.70","731.00","1 through 10","396.03","1015.61","percent of total billed charges",""
"SCREW FASTENER 3.9MM 50MM HEADLESS COMPRESSION","SUP-ITM-10275982","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","548.05","42.9","","384.74","384.74","384.74","1 through 10","396.03","1015.61","percent of total billed charges",""
"SCREW FASTENER 3.9MM 50MM HEADLESS COMPRESSION","SUP-ITM-10275982","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","WELLPOINT [1015]","HB AMC WELLPOINT","942.54","73.78","","286.63","119.22","1107.45","105","396.03","1015.61","percent of total billed charges",""
"SCREW FASTENER 3.9MM 50MM HEADLESS COMPRESSION","SUP-ITM-10275982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","AETNA [1001]","HB AMC AETNA HMO","891.70","69.8","","675.31","184.75","1721.50","286","667.62","1043.97","percent of total billed charges",""
"SCREW FASTENER 3.9MM 50MM HEADLESS COMPRESSION","SUP-ITM-10275982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","AETNA [1001]","HB AMC AETNA PPO","1027.11","80.4","","1261.44","103.12","1514.10","21","667.62","1043.97","percent of total billed charges",""
"SCREW FASTENER 3.9MM 50MM HEADLESS COMPRESSION","SUP-ITM-10275982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1027.11","80.4","","1365.00","1365.00","1365.00","1 through 10","667.62","1043.97","percent of total billed charges",""
"SCREW FASTENER 3.9MM 50MM HEADLESS COMPRESSION","SUP-ITM-10275982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1043.97","81.72","","5157.68","5157.68","5157.68","1 through 10","667.62","1043.97","percent of total billed charges",""
"SCREW FASTENER 3.9MM 50MM HEADLESS COMPRESSION","SUP-ITM-10275982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1043.97","81.72","","431.26","71.26","1459.57","88","667.62","1043.97","percent of total billed charges",""
"SCREW FASTENER 7X145MM 24MM THREAD CANNULATED","SUP-ITM-10276086","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","612.15","79.5","","800.18","480.96","1887.97","195","238.7","612.15","percent of total billed charges",""
"SCREW FASTENER 7X145MM 24MM THREAD CANNULATED","SUP-ITM-10276086","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","410.41","53.3","","813.12","216.42","1444.50","81","238.7","612.15","percent of total billed charges",""
"SCREW FASTENER 7X145MM 24MM THREAD CANNULATED","SUP-ITM-10276086","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","238.70","31","","432.60","432.60","432.60","1 through 10","238.7","612.15","percent of total billed charges",""
"SCREW FASTENER 7X145MM 24MM THREAD CANNULATED","SUP-ITM-10276086","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","281.05","36.5","","148.37","54.89","631.39","94","238.7","612.15","percent of total billed charges",""
"SCREW FASTENER 7X145MM 24MM THREAD CANNULATED","SUP-ITM-10276086","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","294.91","38.3","","279.30","91.72","1116.77","266","238.7","612.15","percent of total billed charges",""
"SCREW FASTENER 7X145MM 24MM THREAD CANNULATED","SUP-ITM-10276086","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","330.33","42.9","","731.00","63.70","731.00","1 through 10","238.7","612.15","percent of total billed charges",""
"SCREW FASTENER 7X145MM 24MM THREAD CANNULATED","SUP-ITM-10276086","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","330.33","42.9","","384.74","384.74","384.74","1 through 10","238.7","612.15","percent of total billed charges",""
"SCREW FASTENER 7X145MM 24MM THREAD CANNULATED","SUP-ITM-10276086","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.00","577.50","WELLPOINT [1015]","HB AMC WELLPOINT","568.11","73.78","","286.63","119.22","1107.45","105","238.7","612.15","percent of total billed charges",""
"SCREW FASTENER 7X145MM 24MM THREAD CANNULATED","SUP-ITM-10276086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","AETNA [1001]","HB AMC AETNA HMO","537.46","69.8","","675.31","184.75","1721.50","286","402.4","629.24","percent of total billed charges",""
"SCREW FASTENER 7X145MM 24MM THREAD CANNULATED","SUP-ITM-10276086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","AETNA [1001]","HB AMC AETNA PPO","619.08","80.4","","1261.44","103.12","1514.10","21","402.4","629.24","percent of total billed charges",""
"SCREW FASTENER 7X145MM 24MM THREAD CANNULATED","SUP-ITM-10276086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","619.08","80.4","","1365.00","1365.00","1365.00","1 through 10","402.4","629.24","percent of total billed charges",""
"SCREW FASTENER 7X145MM 24MM THREAD CANNULATED","SUP-ITM-10276086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","629.24","81.72","","5157.68","5157.68","5157.68","1 through 10","402.4","629.24","percent of total billed charges",""
"SCREW FASTENER 7X145MM 24MM THREAD CANNULATED","SUP-ITM-10276086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","629.24","81.72","","431.26","71.26","1459.57","88","402.4","629.24","percent of total billed charges",""
"SCREW FASTENER 7X145MM 85MM VAR THREAD CANNULATED PK/6EA","SUP-ITM-10276085","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.33","96.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","102.02","79.5","","800.18","480.96","1887.97","195","39.78","102.02","percent of total billed charges",""
"SCREW FASTENER 7X145MM 85MM VAR THREAD CANNULATED PK/6EA","SUP-ITM-10276085","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.33","96.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","68.40","53.3","","813.12","216.42","1444.50","81","39.78","102.02","percent of total billed charges",""
"SCREW FASTENER 7X145MM 85MM VAR THREAD CANNULATED PK/6EA","SUP-ITM-10276085","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.33","96.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","39.78","31","","432.60","432.60","432.60","1 through 10","39.78","102.02","percent of total billed charges",""
"SCREW FASTENER 7X145MM 85MM VAR THREAD CANNULATED PK/6EA","SUP-ITM-10276085","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.33","96.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","46.84","36.5","","148.37","54.89","631.39","94","39.78","102.02","percent of total billed charges",""
"SCREW FASTENER 7X145MM 85MM VAR THREAD CANNULATED PK/6EA","SUP-ITM-10276085","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.33","96.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","49.15","38.3","","279.30","91.72","1116.77","266","39.78","102.02","percent of total billed charges",""
"SCREW FASTENER 7X145MM 85MM VAR THREAD CANNULATED PK/6EA","SUP-ITM-10276085","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.33","96.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.05","42.9","","731.00","63.70","731.00","1 through 10","39.78","102.02","percent of total billed charges",""
"SCREW FASTENER 7X145MM 85MM VAR THREAD CANNULATED PK/6EA","SUP-ITM-10276085","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.33","96.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.05","42.9","","384.74","384.74","384.74","1 through 10","39.78","102.02","percent of total billed charges",""
"SCREW FASTENER 7X145MM 85MM VAR THREAD CANNULATED PK/6EA","SUP-ITM-10276085","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.33","96.25","WELLPOINT [1015]","HB AMC WELLPOINT","94.68","73.78","","286.63","119.22","1107.45","105","39.78","102.02","percent of total billed charges",""
"SCREW FASTENER 7X145MM 85MM VAR THREAD CANNULATED PK/6EA","SUP-ITM-10276085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","128.33","96.25","AETNA [1001]","HB AMC AETNA HMO","89.57","69.8","","675.31","184.75","1721.50","286","67.07","104.87","percent of total billed charges",""
"SCREW FASTENER 7X145MM 85MM VAR THREAD CANNULATED PK/6EA","SUP-ITM-10276085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","128.33","96.25","AETNA [1001]","HB AMC AETNA PPO","103.18","80.4","","1261.44","103.12","1514.10","21","67.07","104.87","percent of total billed charges",""
"SCREW FASTENER 7X145MM 85MM VAR THREAD CANNULATED PK/6EA","SUP-ITM-10276085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","128.33","96.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","103.18","80.4","","1365.00","1365.00","1365.00","1 through 10","67.07","104.87","percent of total billed charges",""
"SCREW FASTENER 7X145MM 85MM VAR THREAD CANNULATED PK/6EA","SUP-ITM-10276085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","128.33","96.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","104.87","81.72","","5157.68","5157.68","5157.68","1 through 10","67.07","104.87","percent of total billed charges",""
"SCREW FASTENER 7X145MM 85MM VAR THREAD CANNULATED PK/6EA","SUP-ITM-10276085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","128.33","96.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","104.87","81.72","","431.26","71.26","1459.57","88","67.07","104.87","percent of total billed charges",""
"SCREW FASTENER 7X150MM FULL THREAD CANNULATED","SUP-ITM-10276084","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","639.98","79.5","","800.18","480.96","1887.97","195","249.55","639.98","percent of total billed charges",""
"SCREW FASTENER 7X150MM FULL THREAD CANNULATED","SUP-ITM-10276084","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","429.07","53.3","","813.12","216.42","1444.50","81","249.55","639.98","percent of total billed charges",""
"SCREW FASTENER 7X150MM FULL THREAD CANNULATED","SUP-ITM-10276084","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","249.55","31","","432.60","432.60","432.60","1 through 10","249.55","639.98","percent of total billed charges",""
"SCREW FASTENER 7X150MM FULL THREAD CANNULATED","SUP-ITM-10276084","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","293.83","36.5","","148.37","54.89","631.39","94","249.55","639.98","percent of total billed charges",""
"SCREW FASTENER 7X150MM FULL THREAD CANNULATED","SUP-ITM-10276084","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","308.32","38.3","","279.30","91.72","1116.77","266","249.55","639.98","percent of total billed charges",""
"SCREW FASTENER 7X150MM FULL THREAD CANNULATED","SUP-ITM-10276084","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","345.35","42.9","","731.00","63.70","731.00","1 through 10","249.55","639.98","percent of total billed charges",""
"SCREW FASTENER 7X150MM FULL THREAD CANNULATED","SUP-ITM-10276084","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","345.35","42.9","","384.74","384.74","384.74","1 through 10","249.55","639.98","percent of total billed charges",""
"SCREW FASTENER 7X150MM FULL THREAD CANNULATED","SUP-ITM-10276084","CDM","C1713","HCPCS","0278","RC","","","","both","","","805.00","603.75","WELLPOINT [1015]","HB AMC WELLPOINT","593.93","73.78","","286.63","119.22","1107.45","105","249.55","639.98","percent of total billed charges",""
"SCREW FASTENER 7X150MM FULL THREAD CANNULATED","SUP-ITM-10276084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","805.00","603.75","AETNA [1001]","HB AMC AETNA HMO","561.89","69.8","","675.31","184.75","1721.50","286","420.69","657.85","percent of total billed charges",""
"SCREW FASTENER 7X150MM FULL THREAD CANNULATED","SUP-ITM-10276084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","805.00","603.75","AETNA [1001]","HB AMC AETNA PPO","647.22","80.4","","1261.44","103.12","1514.10","21","420.69","657.85","percent of total billed charges",""
"SCREW FASTENER 7X150MM FULL THREAD CANNULATED","SUP-ITM-10276084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","805.00","603.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","647.22","80.4","","1365.00","1365.00","1365.00","1 through 10","420.69","657.85","percent of total billed charges",""
"SCREW FASTENER 7X150MM FULL THREAD CANNULATED","SUP-ITM-10276084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","805.00","603.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","657.85","81.72","","5157.68","5157.68","5157.68","1 through 10","420.69","657.85","percent of total billed charges",""
"SCREW FASTENER 7X150MM FULL THREAD CANNULATED","SUP-ITM-10276084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","805.00","603.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","657.85","81.72","","431.26","71.26","1459.57","88","420.69","657.85","percent of total billed charges",""
"SCREW FEMORAL ARCOS PROXIMAL DISTAL MODULAR REVISION","SUP-ITM-10237605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1196.51","52.26","","1113.10","1113.10","1113.10","1 through 10","709.75","1820.18","percent of total billed charges",""
"SCREW FEMORAL ARCOS PROXIMAL DISTAL MODULAR REVISION","SUP-ITM-10237605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1820.18","79.5","","1293.60","1148.53","1603.80","1 through 10","709.75","1820.18","percent of total billed charges",""
"SCREW FEMORAL ARCOS PROXIMAL DISTAL MODULAR REVISION","SUP-ITM-10237605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","835.68","36.5","","1023.42","771.29","2068.67","33","709.75","1820.18","percent of total billed charges",""
"SCREW FEMORAL ARCOS PROXIMAL DISTAL MODULAR REVISION","SUP-ITM-10237605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","876.89","38.3","","850.52","759.78","1211.25","66","709.75","1820.18","percent of total billed charges",""
"SCREW FEMORAL ARCOS PROXIMAL DISTAL MODULAR REVISION","SUP-ITM-10237605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","982.21","42.9","","2548.09","2548.09","2548.09","1 through 10","709.75","1820.18","percent of total billed charges",""
"SCREW FEMORAL ARCOS PROXIMAL DISTAL MODULAR REVISION","SUP-ITM-10237605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","982.21","42.9","","956.46","956.46","956.46","1 through 10","709.75","1820.18","percent of total billed charges",""
"SCREW FEMORAL ARCOS PROXIMAL DISTAL MODULAR REVISION","SUP-ITM-10237605","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.53","1717.15","WELLPOINT [1015]","HB AMC WELLPOINT","1689.22","73.78","","2344.73","1619.47","2530.35","16","709.75","1820.18","percent of total billed charges",""
"SCREW FEMORAL ARCOS PROXIMAL DISTAL MODULAR REVISION","SUP-ITM-10237605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.53","1717.15","AETNA [1001]","HB AMC AETNA HMO","1598.09","69.8","","1523.63","988.41","4330.26","39","1196.51","1871","percent of total billed charges",""
"SCREW FEMORAL ARCOS PROXIMAL DISTAL MODULAR REVISION","SUP-ITM-10237605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.53","1717.15","AETNA [1001]","HB AMC AETNA PPO","1840.78","80.4","","1670.25","1670.25","1670.25","1 through 10","1196.51","1871","percent of total billed charges",""
"SCREW FEMORAL ARCOS PROXIMAL DISTAL MODULAR REVISION","SUP-ITM-10237605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.53","1717.15","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1196.51","52.26","","1113.10","1113.10","1113.10","1 through 10","1196.51","1871","percent of total billed charges",""
"SCREW FEMORAL ARCOS PROXIMAL DISTAL MODULAR REVISION","SUP-ITM-10237605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.53","1717.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1871.00","81.72","","1738.90","1484.65","2716.94","38","1196.51","1871","percent of total billed charges",""
"SCREW FEMORAL CONNECTING","SUP-ITM-10039445","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2213.48","79.5","","800.18","480.96","1887.97","195","863.12","2213.48","percent of total billed charges",""
"SCREW FEMORAL CONNECTING","SUP-ITM-10039445","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1484.01","53.3","","813.12","216.42","1444.50","81","863.12","2213.48","percent of total billed charges",""
"SCREW FEMORAL CONNECTING","SUP-ITM-10039445","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","863.12","31","","432.60","432.60","432.60","1 through 10","863.12","2213.48","percent of total billed charges",""
"SCREW FEMORAL CONNECTING","SUP-ITM-10039445","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1016.25","36.5","","148.37","54.89","631.39","94","863.12","2213.48","percent of total billed charges",""
"SCREW FEMORAL CONNECTING","SUP-ITM-10039445","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1066.37","38.3","","279.30","91.72","1116.77","266","863.12","2213.48","percent of total billed charges",""
"SCREW FEMORAL CONNECTING","SUP-ITM-10039445","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1194.44","42.9","","731.00","63.70","731.00","1 through 10","863.12","2213.48","percent of total billed charges",""
"SCREW FEMORAL CONNECTING","SUP-ITM-10039445","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1194.44","42.9","","384.74","384.74","384.74","1 through 10","863.12","2213.48","percent of total billed charges",""
"SCREW FEMORAL CONNECTING","SUP-ITM-10039445","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.25","2088.19","WELLPOINT [1015]","HB AMC WELLPOINT","2054.22","73.78","","286.63","119.22","1107.45","105","863.12","2213.48","percent of total billed charges",""
"SCREW FEMORAL CONNECTING","SUP-ITM-10039445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.25","2088.19","AETNA [1001]","HB AMC AETNA HMO","1943.41","69.8","","675.31","184.75","1721.50","286","1455.05","2275.29","percent of total billed charges",""
"SCREW FEMORAL CONNECTING","SUP-ITM-10039445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.25","2088.19","AETNA [1001]","HB AMC AETNA PPO","2238.54","80.4","","1261.44","103.12","1514.10","21","1455.05","2275.29","percent of total billed charges",""
"SCREW FEMORAL CONNECTING","SUP-ITM-10039445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.25","2088.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2238.54","80.4","","1365.00","1365.00","1365.00","1 through 10","1455.05","2275.29","percent of total billed charges",""
"SCREW FEMORAL CONNECTING","SUP-ITM-10039445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.25","2088.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2275.29","81.72","","5157.68","5157.68","5157.68","1 through 10","1455.05","2275.29","percent of total billed charges",""
"SCREW FEMORAL CONNECTING","SUP-ITM-10039445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.25","2088.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2275.29","81.72","","431.26","71.26","1459.57","88","1455.05","2275.29","percent of total billed charges",""
"SCREW HIP 70MM REVIVAL LOCKING","SUP-ITM-10197367","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1867.06","79.5","","800.18","480.96","1887.97","195","728.04","1867.06","percent of total billed charges",""
"SCREW HIP 70MM REVIVAL LOCKING","SUP-ITM-10197367","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1251.75","53.3","","813.12","216.42","1444.50","81","728.04","1867.06","percent of total billed charges",""
"SCREW HIP 70MM REVIVAL LOCKING","SUP-ITM-10197367","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","728.04","31","","432.60","432.60","432.60","1 through 10","728.04","1867.06","percent of total billed charges",""
"SCREW HIP 70MM REVIVAL LOCKING","SUP-ITM-10197367","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","857.20","36.5","","148.37","54.89","631.39","94","728.04","1867.06","percent of total billed charges",""
"SCREW HIP 70MM REVIVAL LOCKING","SUP-ITM-10197367","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","899.48","38.3","","279.30","91.72","1116.77","266","728.04","1867.06","percent of total billed charges",""
"SCREW HIP 70MM REVIVAL LOCKING","SUP-ITM-10197367","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1007.51","42.9","","731.00","63.70","731.00","1 through 10","728.04","1867.06","percent of total billed charges",""
"SCREW HIP 70MM REVIVAL LOCKING","SUP-ITM-10197367","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1007.51","42.9","","384.74","384.74","384.74","1 through 10","728.04","1867.06","percent of total billed charges",""
"SCREW HIP 70MM REVIVAL LOCKING","SUP-ITM-10197367","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","WELLPOINT [1015]","HB AMC WELLPOINT","1732.72","73.78","","286.63","119.22","1107.45","105","728.04","1867.06","percent of total billed charges",""
"SCREW HIP 70MM REVIVAL LOCKING","SUP-ITM-10197367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2348.50","1761.37","AETNA [1001]","HB AMC AETNA HMO","1639.25","69.8","","675.31","184.75","1721.50","286","1227.33","1919.19","percent of total billed charges",""
"SCREW HIP 70MM REVIVAL LOCKING","SUP-ITM-10197367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2348.50","1761.37","AETNA [1001]","HB AMC AETNA PPO","1888.19","80.4","","1261.44","103.12","1514.10","21","1227.33","1919.19","percent of total billed charges",""
"SCREW HIP 70MM REVIVAL LOCKING","SUP-ITM-10197367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2348.50","1761.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1888.19","80.4","","1365.00","1365.00","1365.00","1 through 10","1227.33","1919.19","percent of total billed charges",""
"SCREW HIP 70MM REVIVAL LOCKING","SUP-ITM-10197367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2348.50","1761.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1919.19","81.72","","5157.68","5157.68","5157.68","1 through 10","1227.33","1919.19","percent of total billed charges",""
"SCREW HIP 70MM REVIVAL LOCKING","SUP-ITM-10197367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2348.50","1761.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1919.19","81.72","","431.26","71.26","1459.57","88","1227.33","1919.19","percent of total billed charges",""
"SCREW HOLE 7.5MM HIP OCCLUDER TRINITY","SUP-ITM-10115639","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","800.18","480.96","1887.97","195","54.25","139.13","percent of total billed charges",""
"SCREW HOLE 7.5MM HIP OCCLUDER TRINITY","SUP-ITM-10115639","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.28","53.3","","813.12","216.42","1444.50","81","54.25","139.13","percent of total billed charges",""
"SCREW HOLE 7.5MM HIP OCCLUDER TRINITY","SUP-ITM-10115639","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.25","31","","432.60","432.60","432.60","1 through 10","54.25","139.13","percent of total billed charges",""
"SCREW HOLE 7.5MM HIP OCCLUDER TRINITY","SUP-ITM-10115639","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","148.37","54.89","631.39","94","54.25","139.13","percent of total billed charges",""
"SCREW HOLE 7.5MM HIP OCCLUDER TRINITY","SUP-ITM-10115639","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","279.30","91.72","1116.77","266","54.25","139.13","percent of total billed charges",""
"SCREW HOLE 7.5MM HIP OCCLUDER TRINITY","SUP-ITM-10115639","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","731.00","63.70","731.00","1 through 10","54.25","139.13","percent of total billed charges",""
"SCREW HOLE 7.5MM HIP OCCLUDER TRINITY","SUP-ITM-10115639","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","384.74","384.74","384.74","1 through 10","54.25","139.13","percent of total billed charges",""
"SCREW HOLE 7.5MM HIP OCCLUDER TRINITY","SUP-ITM-10115639","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","286.63","119.22","1107.45","105","54.25","139.13","percent of total billed charges",""
"SCREW HOLE 7.5MM HIP OCCLUDER TRINITY","SUP-ITM-10115639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","675.31","184.75","1721.50","286","91.46","143.01","percent of total billed charges",""
"SCREW HOLE 7.5MM HIP OCCLUDER TRINITY","SUP-ITM-10115639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA PPO","140.70","80.4","","1261.44","103.12","1514.10","21","91.46","143.01","percent of total billed charges",""
"SCREW HOLE 7.5MM HIP OCCLUDER TRINITY","SUP-ITM-10115639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","140.70","80.4","","1365.00","1365.00","1365.00","1 through 10","91.46","143.01","percent of total billed charges",""
"SCREW HOLE 7.5MM HIP OCCLUDER TRINITY","SUP-ITM-10115639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.01","81.72","","5157.68","5157.68","5157.68","1 through 10","91.46","143.01","percent of total billed charges",""
"SCREW HOLE 7.5MM HIP OCCLUDER TRINITY","SUP-ITM-10115639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","431.26","71.26","1459.57","88","91.46","143.01","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2328.95","79.5","","800.18","480.96","1887.97","195","908.15","2328.95","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1561.42","53.3","","813.12","216.42","1444.50","81","908.15","2328.95","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","908.15","31","","432.60","432.60","432.60","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1069.27","36.5","","148.37","54.89","631.39","94","908.15","2328.95","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1122.00","38.3","","279.30","91.72","1116.77","266","908.15","2328.95","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","731.00","63.70","731.00","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","384.74","384.74","384.74","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","WELLPOINT [1015]","HB AMC WELLPOINT","2161.39","73.78","","286.63","119.22","1107.45","105","908.15","2328.95","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA HMO","2044.79","69.8","","675.31","184.75","1721.50","286","1530.96","2393.99","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA PPO","2355.32","80.4","","1261.44","103.12","1514.10","21","1530.96","2393.99","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2355.32","80.4","","1365.00","1365.00","1365.00","1 through 10","1530.96","2393.99","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2393.99","81.72","","5157.68","5157.68","5157.68","1 through 10","1530.96","2393.99","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2393.99","81.72","","431.26","71.26","1459.57","88","1530.96","2393.99","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","865.36","79.5","","800.18","480.96","1887.97","195","337.44","865.36","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","580.17","53.3","","813.12","216.42","1444.50","81","337.44","865.36","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","337.44","31","","432.60","432.60","432.60","1 through 10","337.44","865.36","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","397.30","36.5","","148.37","54.89","631.39","94","337.44","865.36","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","416.90","38.3","","279.30","91.72","1116.77","266","337.44","865.36","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.97","42.9","","731.00","63.70","731.00","1 through 10","337.44","865.36","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.97","42.9","","384.74","384.74","384.74","1 through 10","337.44","865.36","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","1088.50","816.37","WELLPOINT [1015]","HB AMC WELLPOINT","803.10","73.78","","286.63","119.22","1107.45","105","337.44","865.36","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1088.50","816.37","AETNA [1001]","HB AMC AETNA HMO","759.77","69.8","","675.31","184.75","1721.50","286","568.85","889.52","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1088.50","816.37","AETNA [1001]","HB AMC AETNA PPO","875.15","80.4","","1261.44","103.12","1514.10","21","568.85","889.52","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1088.50","816.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","875.15","80.4","","1365.00","1365.00","1365.00","1 through 10","568.85","889.52","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1088.50","816.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","889.52","81.72","","5157.68","5157.68","5157.68","1 through 10","568.85","889.52","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1088.50","816.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","889.52","81.72","","431.26","71.26","1459.57","88","568.85","889.52","percent of total billed charges",""
"SCREW INTERFERENCE 7MMX25MM KNEE CANNULATED NON ABSORBABLE TITANIUM ROUND HEAD INTERFERENCE SCREW BX/6EA","SUP-ITM-10001794","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","319.99","79.5","","800.18","480.96","1887.97","195","124.78","319.99","percent of total billed charges",""
"SCREW INTERFERENCE 7MMX25MM KNEE CANNULATED NON ABSORBABLE TITANIUM ROUND HEAD INTERFERENCE SCREW BX/6EA","SUP-ITM-10001794","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","214.53","53.3","","813.12","216.42","1444.50","81","124.78","319.99","percent of total billed charges",""
"SCREW INTERFERENCE 7MMX25MM KNEE CANNULATED NON ABSORBABLE TITANIUM ROUND HEAD INTERFERENCE SCREW BX/6EA","SUP-ITM-10001794","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","124.78","31","","432.60","432.60","432.60","1 through 10","124.78","319.99","percent of total billed charges",""
"SCREW INTERFERENCE 7MMX25MM KNEE CANNULATED NON ABSORBABLE TITANIUM ROUND HEAD INTERFERENCE SCREW BX/6EA","SUP-ITM-10001794","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","146.91","36.5","","148.37","54.89","631.39","94","124.78","319.99","percent of total billed charges",""
"SCREW INTERFERENCE 7MMX25MM KNEE CANNULATED NON ABSORBABLE TITANIUM ROUND HEAD INTERFERENCE SCREW BX/6EA","SUP-ITM-10001794","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","154.16","38.3","","279.30","91.72","1116.77","266","124.78","319.99","percent of total billed charges",""
"SCREW INTERFERENCE 7MMX25MM KNEE CANNULATED NON ABSORBABLE TITANIUM ROUND HEAD INTERFERENCE SCREW BX/6EA","SUP-ITM-10001794","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.67","42.9","","731.00","63.70","731.00","1 through 10","124.78","319.99","percent of total billed charges",""
"SCREW INTERFERENCE 7MMX25MM KNEE CANNULATED NON ABSORBABLE TITANIUM ROUND HEAD INTERFERENCE SCREW BX/6EA","SUP-ITM-10001794","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.67","42.9","","384.74","384.74","384.74","1 through 10","124.78","319.99","percent of total billed charges",""
"SCREW INTERFERENCE 7MMX25MM KNEE CANNULATED NON ABSORBABLE TITANIUM ROUND HEAD INTERFERENCE SCREW BX/6EA","SUP-ITM-10001794","CDM","C1713","HCPCS","0278","RC","","","","both","","","402.50","301.87","WELLPOINT [1015]","HB AMC WELLPOINT","296.96","73.78","","286.63","119.22","1107.45","105","124.78","319.99","percent of total billed charges",""
"SCREW INTERFERENCE 7MMX25MM KNEE CANNULATED NON ABSORBABLE TITANIUM ROUND HEAD INTERFERENCE SCREW BX/6EA","SUP-ITM-10001794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","AETNA [1001]","HB AMC AETNA HMO","280.95","69.8","","675.31","184.75","1721.50","286","210.35","328.92","percent of total billed charges",""
"SCREW INTERFERENCE 7MMX25MM KNEE CANNULATED NON ABSORBABLE TITANIUM ROUND HEAD INTERFERENCE SCREW BX/6EA","SUP-ITM-10001794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","AETNA [1001]","HB AMC AETNA PPO","323.61","80.4","","1261.44","103.12","1514.10","21","210.35","328.92","percent of total billed charges",""
"SCREW INTERFERENCE 7MMX25MM KNEE CANNULATED NON ABSORBABLE TITANIUM ROUND HEAD INTERFERENCE SCREW BX/6EA","SUP-ITM-10001794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","323.61","80.4","","1365.00","1365.00","1365.00","1 through 10","210.35","328.92","percent of total billed charges",""
"SCREW INTERFERENCE 7MMX25MM KNEE CANNULATED NON ABSORBABLE TITANIUM ROUND HEAD INTERFERENCE SCREW BX/6EA","SUP-ITM-10001794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","328.92","81.72","","5157.68","5157.68","5157.68","1 through 10","210.35","328.92","percent of total billed charges",""
"SCREW INTERFERENCE 7MMX25MM KNEE CANNULATED NON ABSORBABLE TITANIUM ROUND HEAD INTERFERENCE SCREW BX/6EA","SUP-ITM-10001794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","402.50","301.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","328.92","81.72","","431.26","71.26","1459.57","88","210.35","328.92","percent of total billed charges",""
"SCREW KREULOCK COMPRESSION SS. 3.5 X 14","SUP-ITM-10319741","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","820.84","79.5","","800.18","480.96","1887.97","195","320.08","820.84","percent of total billed charges",""
"SCREW KREULOCK COMPRESSION SS. 3.5 X 14","SUP-ITM-10319741","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","550.32","53.3","","813.12","216.42","1444.50","81","320.08","820.84","percent of total billed charges",""
"SCREW KREULOCK COMPRESSION SS. 3.5 X 14","SUP-ITM-10319741","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","320.08","31","","432.60","432.60","432.60","1 through 10","320.08","820.84","percent of total billed charges",""
"SCREW KREULOCK COMPRESSION SS. 3.5 X 14","SUP-ITM-10319741","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","376.86","36.5","","148.37","54.89","631.39","94","320.08","820.84","percent of total billed charges",""
"SCREW KREULOCK COMPRESSION SS. 3.5 X 14","SUP-ITM-10319741","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","395.45","38.3","","279.30","91.72","1116.77","266","320.08","820.84","percent of total billed charges",""
"SCREW KREULOCK COMPRESSION SS. 3.5 X 14","SUP-ITM-10319741","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.94","42.9","","731.00","63.70","731.00","1 through 10","320.08","820.84","percent of total billed charges",""
"SCREW KREULOCK COMPRESSION SS. 3.5 X 14","SUP-ITM-10319741","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","442.94","42.9","","384.74","384.74","384.74","1 through 10","320.08","820.84","percent of total billed charges",""
"SCREW KREULOCK COMPRESSION SS. 3.5 X 14","SUP-ITM-10319741","CDM","C1713","HCPCS","0278","RC","","","","both","","","1032.50","774.37","WELLPOINT [1015]","HB AMC WELLPOINT","761.78","73.78","","286.63","119.22","1107.45","105","320.08","820.84","percent of total billed charges",""
"SCREW KREULOCK COMPRESSION SS. 3.5 X 14","SUP-ITM-10319741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","AETNA [1001]","HB AMC AETNA HMO","720.69","69.8","","675.31","184.75","1721.50","286","539.58","843.76","percent of total billed charges",""
"SCREW KREULOCK COMPRESSION SS. 3.5 X 14","SUP-ITM-10319741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","AETNA [1001]","HB AMC AETNA PPO","830.13","80.4","","1261.44","103.12","1514.10","21","539.58","843.76","percent of total billed charges",""
"SCREW KREULOCK COMPRESSION SS. 3.5 X 14","SUP-ITM-10319741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","830.13","80.4","","1365.00","1365.00","1365.00","1 through 10","539.58","843.76","percent of total billed charges",""
"SCREW KREULOCK COMPRESSION SS. 3.5 X 14","SUP-ITM-10319741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","843.76","81.72","","5157.68","5157.68","5157.68","1 through 10","539.58","843.76","percent of total billed charges",""
"SCREW KREULOCK COMPRESSION SS. 3.5 X 14","SUP-ITM-10319741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","843.76","81.72","","431.26","71.26","1459.57","88","539.58","843.76","percent of total billed charges",""
"SCREW LAG 10.5X80MM BONE AFFIXUS TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10117338","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.67","1479.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1568.27","79.5","","800.18","480.96","1887.97","195","611.53","1568.27","percent of total billed charges",""
"SCREW LAG 10.5X80MM BONE AFFIXUS TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10117338","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.67","1479.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1051.43","53.3","","813.12","216.42","1444.50","81","611.53","1568.27","percent of total billed charges",""
"SCREW LAG 10.5X80MM BONE AFFIXUS TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10117338","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.67","1479.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","611.53","31","","432.60","432.60","432.60","1 through 10","611.53","1568.27","percent of total billed charges",""
"SCREW LAG 10.5X80MM BONE AFFIXUS TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10117338","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.67","1479.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","720.02","36.5","","148.37","54.89","631.39","94","611.53","1568.27","percent of total billed charges",""
"SCREW LAG 10.5X80MM BONE AFFIXUS TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10117338","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.67","1479.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","755.53","38.3","","279.30","91.72","1116.77","266","611.53","1568.27","percent of total billed charges",""
"SCREW LAG 10.5X80MM BONE AFFIXUS TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10117338","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.67","1479.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.28","42.9","","731.00","63.70","731.00","1 through 10","611.53","1568.27","percent of total billed charges",""
"SCREW LAG 10.5X80MM BONE AFFIXUS TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10117338","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.67","1479.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.28","42.9","","384.74","384.74","384.74","1 through 10","611.53","1568.27","percent of total billed charges",""
"SCREW LAG 10.5X80MM BONE AFFIXUS TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10117338","CDM","C1713","HCPCS","0278","RC","","","","both","","","1972.67","1479.50","WELLPOINT [1015]","HB AMC WELLPOINT","1455.44","73.78","","286.63","119.22","1107.45","105","611.53","1568.27","percent of total billed charges",""
"SCREW LAG 10.5X80MM BONE AFFIXUS TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10117338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1972.67","1479.50","AETNA [1001]","HB AMC AETNA HMO","1376.92","69.8","","675.31","184.75","1721.50","286","1030.92","1612.07","percent of total billed charges",""
"SCREW LAG 10.5X80MM BONE AFFIXUS TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10117338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1972.67","1479.50","AETNA [1001]","HB AMC AETNA PPO","1586.03","80.4","","1261.44","103.12","1514.10","21","1030.92","1612.07","percent of total billed charges",""
"SCREW LAG 10.5X80MM BONE AFFIXUS TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10117338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1972.67","1479.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1586.03","80.4","","1365.00","1365.00","1365.00","1 through 10","1030.92","1612.07","percent of total billed charges",""
"SCREW LAG 10.5X80MM BONE AFFIXUS TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10117338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1972.67","1479.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1612.07","81.72","","5157.68","5157.68","5157.68","1 through 10","1030.92","1612.07","percent of total billed charges",""
"SCREW LAG 10.5X80MM BONE AFFIXUS TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10117338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1972.67","1479.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1612.07","81.72","","431.26","71.26","1459.57","88","1030.92","1612.07","percent of total billed charges",""
"SCREW LAG D10.5X85MM GAMMA/NAIL","SUP-ITM-10321146","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.95","2351.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2492.29","79.5","","800.18","480.96","1887.97","195","971.83","2492.29","percent of total billed charges",""
"SCREW LAG D10.5X85MM GAMMA/NAIL","SUP-ITM-10321146","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.95","2351.21","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1670.93","53.3","","813.12","216.42","1444.50","81","971.83","2492.29","percent of total billed charges",""
"SCREW LAG D10.5X85MM GAMMA/NAIL","SUP-ITM-10321146","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.95","2351.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","971.83","31","","432.60","432.60","432.60","1 through 10","971.83","2492.29","percent of total billed charges",""
"SCREW LAG D10.5X85MM GAMMA/NAIL","SUP-ITM-10321146","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.95","2351.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1144.26","36.5","","148.37","54.89","631.39","94","971.83","2492.29","percent of total billed charges",""
"SCREW LAG D10.5X85MM GAMMA/NAIL","SUP-ITM-10321146","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.95","2351.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1200.69","38.3","","279.30","91.72","1116.77","266","971.83","2492.29","percent of total billed charges",""
"SCREW LAG D10.5X85MM GAMMA/NAIL","SUP-ITM-10321146","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.95","2351.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1344.89","42.9","","731.00","63.70","731.00","1 through 10","971.83","2492.29","percent of total billed charges",""
"SCREW LAG D10.5X85MM GAMMA/NAIL","SUP-ITM-10321146","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.95","2351.21","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1344.89","42.9","","384.74","384.74","384.74","1 through 10","971.83","2492.29","percent of total billed charges",""
"SCREW LAG D10.5X85MM GAMMA/NAIL","SUP-ITM-10321146","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.95","2351.21","WELLPOINT [1015]","HB AMC WELLPOINT","2312.97","73.78","","286.63","119.22","1107.45","105","971.83","2492.29","percent of total billed charges",""
"SCREW LAG D10.5X85MM GAMMA/NAIL","SUP-ITM-10321146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3134.95","2351.21","AETNA [1001]","HB AMC AETNA HMO","2188.20","69.8","","675.31","184.75","1721.50","286","1638.32","2561.88","percent of total billed charges",""
"SCREW LAG D10.5X85MM GAMMA/NAIL","SUP-ITM-10321146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3134.95","2351.21","AETNA [1001]","HB AMC AETNA PPO","2520.50","80.4","","1261.44","103.12","1514.10","21","1638.32","2561.88","percent of total billed charges",""
"SCREW LAG D10.5X85MM GAMMA/NAIL","SUP-ITM-10321146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3134.95","2351.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2520.50","80.4","","1365.00","1365.00","1365.00","1 through 10","1638.32","2561.88","percent of total billed charges",""
"SCREW LAG D10.5X85MM GAMMA/NAIL","SUP-ITM-10321146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3134.95","2351.21","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2561.88","81.72","","5157.68","5157.68","5157.68","1 through 10","1638.32","2561.88","percent of total billed charges",""
"SCREW LAG D10.5X85MM GAMMA/NAIL","SUP-ITM-10321146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3134.95","2351.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2561.88","81.72","","431.26","71.26","1459.57","88","1638.32","2561.88","percent of total billed charges",""
"SCREW LOCIKNG 56MM 2.7 LONG ANTEROLATERAL CALCANEAL PL LT","SUP-ITM-10164169","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.69","1925.02","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2040.52","79.5","","800.18","480.96","1887.97","195","795.67","2040.52","percent of total billed charges",""
"SCREW LOCIKNG 56MM 2.7 LONG ANTEROLATERAL CALCANEAL PL LT","SUP-ITM-10164169","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.69","1925.02","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1368.05","53.3","","813.12","216.42","1444.50","81","795.67","2040.52","percent of total billed charges",""
"SCREW LOCIKNG 56MM 2.7 LONG ANTEROLATERAL CALCANEAL PL LT","SUP-ITM-10164169","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.69","1925.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","795.67","31","","432.60","432.60","432.60","1 through 10","795.67","2040.52","percent of total billed charges",""
"SCREW LOCIKNG 56MM 2.7 LONG ANTEROLATERAL CALCANEAL PL LT","SUP-ITM-10164169","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.69","1925.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","936.84","36.5","","148.37","54.89","631.39","94","795.67","2040.52","percent of total billed charges",""
"SCREW LOCIKNG 56MM 2.7 LONG ANTEROLATERAL CALCANEAL PL LT","SUP-ITM-10164169","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.69","1925.02","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","983.04","38.3","","279.30","91.72","1116.77","266","795.67","2040.52","percent of total billed charges",""
"SCREW LOCIKNG 56MM 2.7 LONG ANTEROLATERAL CALCANEAL PL LT","SUP-ITM-10164169","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.69","1925.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1101.11","42.9","","731.00","63.70","731.00","1 through 10","795.67","2040.52","percent of total billed charges",""
"SCREW LOCIKNG 56MM 2.7 LONG ANTEROLATERAL CALCANEAL PL LT","SUP-ITM-10164169","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.69","1925.02","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1101.11","42.9","","384.74","384.74","384.74","1 through 10","795.67","2040.52","percent of total billed charges",""
"SCREW LOCIKNG 56MM 2.7 LONG ANTEROLATERAL CALCANEAL PL LT","SUP-ITM-10164169","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.69","1925.02","WELLPOINT [1015]","HB AMC WELLPOINT","1893.70","73.78","","286.63","119.22","1107.45","105","795.67","2040.52","percent of total billed charges",""
"SCREW LOCIKNG 56MM 2.7 LONG ANTEROLATERAL CALCANEAL PL LT","SUP-ITM-10164169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.69","1925.02","AETNA [1001]","HB AMC AETNA HMO","1791.55","69.8","","675.31","184.75","1721.50","286","1341.35","2097.5","percent of total billed charges",""
"SCREW LOCIKNG 56MM 2.7 LONG ANTEROLATERAL CALCANEAL PL LT","SUP-ITM-10164169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.69","1925.02","AETNA [1001]","HB AMC AETNA PPO","2063.62","80.4","","1261.44","103.12","1514.10","21","1341.35","2097.5","percent of total billed charges",""
"SCREW LOCIKNG 56MM 2.7 LONG ANTEROLATERAL CALCANEAL PL LT","SUP-ITM-10164169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.69","1925.02","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2063.62","80.4","","1365.00","1365.00","1365.00","1 through 10","1341.35","2097.5","percent of total billed charges",""
"SCREW LOCIKNG 56MM 2.7 LONG ANTEROLATERAL CALCANEAL PL LT","SUP-ITM-10164169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.69","1925.02","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2097.50","81.72","","5157.68","5157.68","5157.68","1 through 10","1341.35","2097.5","percent of total billed charges",""
"SCREW LOCIKNG 56MM 2.7 LONG ANTEROLATERAL CALCANEAL PL LT","SUP-ITM-10164169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.69","1925.02","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2097.50","81.72","","431.26","71.26","1459.57","88","1341.35","2097.5","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1530.68","52.26","","1113.10","1113.10","1113.10","1 through 10","907.98","2328.54","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2328.54","79.5","","1293.60","1148.53","1603.80","1 through 10","907.98","2328.54","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1069.08","36.5","","1023.42","771.29","2068.67","33","907.98","2328.54","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1121.80","38.3","","850.52","759.78","1211.25","66","907.98","2328.54","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.53","42.9","","2548.09","2548.09","2548.09","1 through 10","907.98","2328.54","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.53","42.9","","956.46","956.46","956.46","1 through 10","907.98","2328.54","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2928.98","2196.73","WELLPOINT [1015]","HB AMC WELLPOINT","2161.00","73.78","","2344.73","1619.47","2530.35","16","907.98","2328.54","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2928.98","2196.73","AETNA [1001]","HB AMC AETNA HMO","2044.43","69.8","","1523.63","988.41","4330.26","39","1530.68","2393.56","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2928.98","2196.73","AETNA [1001]","HB AMC AETNA PPO","2354.90","80.4","","1670.25","1670.25","1670.25","1 through 10","1530.68","2393.56","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2928.98","2196.73","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1530.68","52.26","","1113.10","1113.10","1113.10","1 through 10","1530.68","2393.56","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2928.98","2196.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2393.56","81.72","","1738.90","1484.65","2716.94","38","1530.68","2393.56","percent of total billed charges",""
"SCREW LOCKING 5.0X55MM FULLY THREADED","SUP-ITM-10330827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","818.06","79.5","","800.18","480.96","1887.97","195","318.99","818.06","percent of total billed charges",""
"SCREW LOCKING 5.0X55MM FULLY THREADED","SUP-ITM-10330827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","548.46","53.3","","813.12","216.42","1444.50","81","318.99","818.06","percent of total billed charges",""
"SCREW LOCKING 5.0X55MM FULLY THREADED","SUP-ITM-10330827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","318.99","31","","432.60","432.60","432.60","1 through 10","318.99","818.06","percent of total billed charges",""
"SCREW LOCKING 5.0X55MM FULLY THREADED","SUP-ITM-10330827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","375.59","36.5","","148.37","54.89","631.39","94","318.99","818.06","percent of total billed charges",""
"SCREW LOCKING 5.0X55MM FULLY THREADED","SUP-ITM-10330827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","394.11","38.3","","279.30","91.72","1116.77","266","318.99","818.06","percent of total billed charges",""
"SCREW LOCKING 5.0X55MM FULLY THREADED","SUP-ITM-10330827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","441.44","42.9","","731.00","63.70","731.00","1 through 10","318.99","818.06","percent of total billed charges",""
"SCREW LOCKING 5.0X55MM FULLY THREADED","SUP-ITM-10330827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","441.44","42.9","","384.74","384.74","384.74","1 through 10","318.99","818.06","percent of total billed charges",""
"SCREW LOCKING 5.0X55MM FULLY THREADED","SUP-ITM-10330827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","WELLPOINT [1015]","HB AMC WELLPOINT","759.20","73.78","","286.63","119.22","1107.45","105","318.99","818.06","percent of total billed charges",""
"SCREW LOCKING 5.0X55MM FULLY THREADED","SUP-ITM-10330827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","AETNA [1001]","HB AMC AETNA HMO","718.24","69.8","","675.31","184.75","1721.50","286","537.76","840.9","percent of total billed charges",""
"SCREW LOCKING 5.0X55MM FULLY THREADED","SUP-ITM-10330827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","AETNA [1001]","HB AMC AETNA PPO","827.32","80.4","","1261.44","103.12","1514.10","21","537.76","840.9","percent of total billed charges",""
"SCREW LOCKING 5.0X55MM FULLY THREADED","SUP-ITM-10330827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","827.32","80.4","","1365.00","1365.00","1365.00","1 through 10","537.76","840.9","percent of total billed charges",""
"SCREW LOCKING 5.0X55MM FULLY THREADED","SUP-ITM-10330827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","840.90","81.72","","5157.68","5157.68","5157.68","1 through 10","537.76","840.9","percent of total billed charges",""
"SCREW LOCKING 5.0X55MM FULLY THREADED","SUP-ITM-10330827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","840.90","81.72","","431.26","71.26","1459.57","88","537.76","840.9","percent of total billed charges",""
"SCREW LOCKING 6.0MMX70MM PARTIALLY THREADED HEADLESS","SUP-ITM-10330847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1302.21","79.5","","800.18","480.96","1887.97","195","507.78","1302.21","percent of total billed charges",""
"SCREW LOCKING 6.0MMX70MM PARTIALLY THREADED HEADLESS","SUP-ITM-10330847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","873.05","53.3","","813.12","216.42","1444.50","81","507.78","1302.21","percent of total billed charges",""
"SCREW LOCKING 6.0MMX70MM PARTIALLY THREADED HEADLESS","SUP-ITM-10330847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","507.78","31","","432.60","432.60","432.60","1 through 10","507.78","1302.21","percent of total billed charges",""
"SCREW LOCKING 6.0MMX70MM PARTIALLY THREADED HEADLESS","SUP-ITM-10330847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","597.87","36.5","","148.37","54.89","631.39","94","507.78","1302.21","percent of total billed charges",""
"SCREW LOCKING 6.0MMX70MM PARTIALLY THREADED HEADLESS","SUP-ITM-10330847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","627.35","38.3","","279.30","91.72","1116.77","266","507.78","1302.21","percent of total billed charges",""
"SCREW LOCKING 6.0MMX70MM PARTIALLY THREADED HEADLESS","SUP-ITM-10330847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","702.70","42.9","","731.00","63.70","731.00","1 through 10","507.78","1302.21","percent of total billed charges",""
"SCREW LOCKING 6.0MMX70MM PARTIALLY THREADED HEADLESS","SUP-ITM-10330847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","702.70","42.9","","384.74","384.74","384.74","1 through 10","507.78","1302.21","percent of total billed charges",""
"SCREW LOCKING 6.0MMX70MM PARTIALLY THREADED HEADLESS","SUP-ITM-10330847","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","WELLPOINT [1015]","HB AMC WELLPOINT","1208.52","73.78","","286.63","119.22","1107.45","105","507.78","1302.21","percent of total billed charges",""
"SCREW LOCKING 6.0MMX70MM PARTIALLY THREADED HEADLESS","SUP-ITM-10330847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","AETNA [1001]","HB AMC AETNA HMO","1143.32","69.8","","675.31","184.75","1721.50","286","856.02","1338.57","percent of total billed charges",""
"SCREW LOCKING 6.0MMX70MM PARTIALLY THREADED HEADLESS","SUP-ITM-10330847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","AETNA [1001]","HB AMC AETNA PPO","1316.95","80.4","","1261.44","103.12","1514.10","21","856.02","1338.57","percent of total billed charges",""
"SCREW LOCKING 6.0MMX70MM PARTIALLY THREADED HEADLESS","SUP-ITM-10330847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1316.95","80.4","","1365.00","1365.00","1365.00","1 through 10","856.02","1338.57","percent of total billed charges",""
"SCREW LOCKING 6.0MMX70MM PARTIALLY THREADED HEADLESS","SUP-ITM-10330847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1338.57","81.72","","5157.68","5157.68","5157.68","1 through 10","856.02","1338.57","percent of total billed charges",""
"SCREW LOCKING 6.0MMX70MM PARTIALLY THREADED HEADLESS","SUP-ITM-10330847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1338.57","81.72","","431.26","71.26","1459.57","88","856.02","1338.57","percent of total billed charges",""
"SCREW MACHINE 2.7MM CRANIOMAXILLOFACIAL DISTRACTOR COMPATIBLE TITANIUM","SUP-ITM-10130981","CDM","C1713","HCPCS","0278","RC","","","","both","","","736.89","552.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","585.83","79.5","","800.18","480.96","1887.97","195","228.44","585.83","percent of total billed charges",""
"SCREW MACHINE 2.7MM CRANIOMAXILLOFACIAL DISTRACTOR COMPATIBLE TITANIUM","SUP-ITM-10130981","CDM","C1713","HCPCS","0278","RC","","","","both","","","736.89","552.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","392.76","53.3","","813.12","216.42","1444.50","81","228.44","585.83","percent of total billed charges",""
"SCREW MACHINE 2.7MM CRANIOMAXILLOFACIAL DISTRACTOR COMPATIBLE TITANIUM","SUP-ITM-10130981","CDM","C1713","HCPCS","0278","RC","","","","both","","","736.89","552.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","228.44","31","","432.60","432.60","432.60","1 through 10","228.44","585.83","percent of total billed charges",""
"SCREW MACHINE 2.7MM CRANIOMAXILLOFACIAL DISTRACTOR COMPATIBLE TITANIUM","SUP-ITM-10130981","CDM","C1713","HCPCS","0278","RC","","","","both","","","736.89","552.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","268.96","36.5","","148.37","54.89","631.39","94","228.44","585.83","percent of total billed charges",""
"SCREW MACHINE 2.7MM CRANIOMAXILLOFACIAL DISTRACTOR COMPATIBLE TITANIUM","SUP-ITM-10130981","CDM","C1713","HCPCS","0278","RC","","","","both","","","736.89","552.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","282.23","38.3","","279.30","91.72","1116.77","266","228.44","585.83","percent of total billed charges",""
"SCREW MACHINE 2.7MM CRANIOMAXILLOFACIAL DISTRACTOR COMPATIBLE TITANIUM","SUP-ITM-10130981","CDM","C1713","HCPCS","0278","RC","","","","both","","","736.89","552.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.13","42.9","","731.00","63.70","731.00","1 through 10","228.44","585.83","percent of total billed charges",""
"SCREW MACHINE 2.7MM CRANIOMAXILLOFACIAL DISTRACTOR COMPATIBLE TITANIUM","SUP-ITM-10130981","CDM","C1713","HCPCS","0278","RC","","","","both","","","736.89","552.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.13","42.9","","384.74","384.74","384.74","1 through 10","228.44","585.83","percent of total billed charges",""
"SCREW MACHINE 2.7MM CRANIOMAXILLOFACIAL DISTRACTOR COMPATIBLE TITANIUM","SUP-ITM-10130981","CDM","C1713","HCPCS","0278","RC","","","","both","","","736.89","552.67","WELLPOINT [1015]","HB AMC WELLPOINT","543.68","73.78","","286.63","119.22","1107.45","105","228.44","585.83","percent of total billed charges",""
"SCREW MACHINE 2.7MM CRANIOMAXILLOFACIAL DISTRACTOR COMPATIBLE TITANIUM","SUP-ITM-10130981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","736.89","552.67","AETNA [1001]","HB AMC AETNA HMO","514.35","69.8","","675.31","184.75","1721.50","286","385.1","602.19","percent of total billed charges",""
"SCREW MACHINE 2.7MM CRANIOMAXILLOFACIAL DISTRACTOR COMPATIBLE TITANIUM","SUP-ITM-10130981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","736.89","552.67","AETNA [1001]","HB AMC AETNA PPO","592.46","80.4","","1261.44","103.12","1514.10","21","385.1","602.19","percent of total billed charges",""
"SCREW MACHINE 2.7MM CRANIOMAXILLOFACIAL DISTRACTOR COMPATIBLE TITANIUM","SUP-ITM-10130981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","736.89","552.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","592.46","80.4","","1365.00","1365.00","1365.00","1 through 10","385.1","602.19","percent of total billed charges",""
"SCREW MACHINE 2.7MM CRANIOMAXILLOFACIAL DISTRACTOR COMPATIBLE TITANIUM","SUP-ITM-10130981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","736.89","552.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","602.19","81.72","","5157.68","5157.68","5157.68","1 through 10","385.1","602.19","percent of total billed charges",""
"SCREW MACHINE 2.7MM CRANIOMAXILLOFACIAL DISTRACTOR COMPATIBLE TITANIUM","SUP-ITM-10130981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","736.89","552.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","602.19","81.72","","431.26","71.26","1459.57","88","385.1","602.19","percent of total billed charges",""
"SCREW METAPHYSEAL 2.7MM 75 SELF TAPPING TI T8 STRDRV","SUP-ITM-10125643","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.34","304.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","322.25","79.5","","800.18","480.96","1887.97","195","125.66","322.25","percent of total billed charges",""
"SCREW METAPHYSEAL 2.7MM 75 SELF TAPPING TI T8 STRDRV","SUP-ITM-10125643","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.34","304.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","216.05","53.3","","813.12","216.42","1444.50","81","125.66","322.25","percent of total billed charges",""
"SCREW METAPHYSEAL 2.7MM 75 SELF TAPPING TI T8 STRDRV","SUP-ITM-10125643","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.34","304.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","125.66","31","","432.60","432.60","432.60","1 through 10","125.66","322.25","percent of total billed charges",""
"SCREW METAPHYSEAL 2.7MM 75 SELF TAPPING TI T8 STRDRV","SUP-ITM-10125643","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.34","304.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","147.95","36.5","","148.37","54.89","631.39","94","125.66","322.25","percent of total billed charges",""
"SCREW METAPHYSEAL 2.7MM 75 SELF TAPPING TI T8 STRDRV","SUP-ITM-10125643","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.34","304.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","155.25","38.3","","279.30","91.72","1116.77","266","125.66","322.25","percent of total billed charges",""
"SCREW METAPHYSEAL 2.7MM 75 SELF TAPPING TI T8 STRDRV","SUP-ITM-10125643","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.34","304.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.89","42.9","","731.00","63.70","731.00","1 through 10","125.66","322.25","percent of total billed charges",""
"SCREW METAPHYSEAL 2.7MM 75 SELF TAPPING TI T8 STRDRV","SUP-ITM-10125643","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.34","304.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.89","42.9","","384.74","384.74","384.74","1 through 10","125.66","322.25","percent of total billed charges",""
"SCREW METAPHYSEAL 2.7MM 75 SELF TAPPING TI T8 STRDRV","SUP-ITM-10125643","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.34","304.00","WELLPOINT [1015]","HB AMC WELLPOINT","299.06","73.78","","286.63","119.22","1107.45","105","125.66","322.25","percent of total billed charges",""
"SCREW METAPHYSEAL 2.7MM 75 SELF TAPPING TI T8 STRDRV","SUP-ITM-10125643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.34","304.00","AETNA [1001]","HB AMC AETNA HMO","282.93","69.8","","675.31","184.75","1721.50","286","211.83","331.24","percent of total billed charges",""
"SCREW METAPHYSEAL 2.7MM 75 SELF TAPPING TI T8 STRDRV","SUP-ITM-10125643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.34","304.00","AETNA [1001]","HB AMC AETNA PPO","325.89","80.4","","1261.44","103.12","1514.10","21","211.83","331.24","percent of total billed charges",""
"SCREW METAPHYSEAL 2.7MM 75 SELF TAPPING TI T8 STRDRV","SUP-ITM-10125643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.34","304.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","325.89","80.4","","1365.00","1365.00","1365.00","1 through 10","211.83","331.24","percent of total billed charges",""
"SCREW METAPHYSEAL 2.7MM 75 SELF TAPPING TI T8 STRDRV","SUP-ITM-10125643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.34","304.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","331.24","81.72","","5157.68","5157.68","5157.68","1 through 10","211.83","331.24","percent of total billed charges",""
"SCREW METAPHYSEAL 2.7MM 75 SELF TAPPING TI T8 STRDRV","SUP-ITM-10125643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.34","304.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","331.24","81.72","","431.26","71.26","1459.57","88","211.83","331.24","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED LONG THREADED HEADED 4X60MM","SUP-ITM-10243084","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.38","570.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","604.50","79.5","","800.18","480.96","1887.97","195","235.72","604.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED LONG THREADED HEADED 4X60MM","SUP-ITM-10243084","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.38","570.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","405.28","53.3","","813.12","216.42","1444.50","81","235.72","604.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED LONG THREADED HEADED 4X60MM","SUP-ITM-10243084","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.38","570.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","235.72","31","","432.60","432.60","432.60","1 through 10","235.72","604.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED LONG THREADED HEADED 4X60MM","SUP-ITM-10243084","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.38","570.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","277.54","36.5","","148.37","54.89","631.39","94","235.72","604.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED LONG THREADED HEADED 4X60MM","SUP-ITM-10243084","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.38","570.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","291.23","38.3","","279.30","91.72","1116.77","266","235.72","604.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED LONG THREADED HEADED 4X60MM","SUP-ITM-10243084","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.38","570.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.20","42.9","","731.00","63.70","731.00","1 through 10","235.72","604.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED LONG THREADED HEADED 4X60MM","SUP-ITM-10243084","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.38","570.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.20","42.9","","384.74","384.74","384.74","1 through 10","235.72","604.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED LONG THREADED HEADED 4X60MM","SUP-ITM-10243084","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.38","570.28","WELLPOINT [1015]","HB AMC WELLPOINT","561.01","73.78","","286.63","119.22","1107.45","105","235.72","604.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED LONG THREADED HEADED 4X60MM","SUP-ITM-10243084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.38","570.28","AETNA [1001]","HB AMC AETNA HMO","530.75","69.8","","675.31","184.75","1721.50","286","397.37","621.38","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED LONG THREADED HEADED 4X60MM","SUP-ITM-10243084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.38","570.28","AETNA [1001]","HB AMC AETNA PPO","611.35","80.4","","1261.44","103.12","1514.10","21","397.37","621.38","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED LONG THREADED HEADED 4X60MM","SUP-ITM-10243084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.38","570.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","611.35","80.4","","1365.00","1365.00","1365.00","1 through 10","397.37","621.38","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED LONG THREADED HEADED 4X60MM","SUP-ITM-10243084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.38","570.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","621.38","81.72","","5157.68","5157.68","5157.68","1 through 10","397.37","621.38","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED LONG THREADED HEADED 4X60MM","SUP-ITM-10243084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.38","570.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","621.38","81.72","","431.26","71.26","1459.57","88","397.37","621.38","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X65MM","SUP-ITM-10242910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.00","1039.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1101.87","79.5","","800.18","480.96","1887.97","195","429.66","1101.87","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X65MM","SUP-ITM-10242910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.00","1039.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","738.74","53.3","","813.12","216.42","1444.50","81","429.66","1101.87","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X65MM","SUP-ITM-10242910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.00","1039.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","429.66","31","","432.60","432.60","432.60","1 through 10","429.66","1101.87","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X65MM","SUP-ITM-10242910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.00","1039.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","505.89","36.5","","148.37","54.89","631.39","94","429.66","1101.87","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X65MM","SUP-ITM-10242910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.00","1039.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","530.84","38.3","","279.30","91.72","1116.77","266","429.66","1101.87","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X65MM","SUP-ITM-10242910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.00","1039.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","594.59","42.9","","731.00","63.70","731.00","1 through 10","429.66","1101.87","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X65MM","SUP-ITM-10242910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.00","1039.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","594.59","42.9","","384.74","384.74","384.74","1 through 10","429.66","1101.87","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X65MM","SUP-ITM-10242910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.00","1039.50","WELLPOINT [1015]","HB AMC WELLPOINT","1022.59","73.78","","286.63","119.22","1107.45","105","429.66","1101.87","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X65MM","SUP-ITM-10242910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.00","1039.50","AETNA [1001]","HB AMC AETNA HMO","967.43","69.8","","675.31","184.75","1721.50","286","724.32","1132.64","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X65MM","SUP-ITM-10242910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.00","1039.50","AETNA [1001]","HB AMC AETNA PPO","1114.34","80.4","","1261.44","103.12","1514.10","21","724.32","1132.64","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X65MM","SUP-ITM-10242910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.00","1039.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1114.34","80.4","","1365.00","1365.00","1365.00","1 through 10","724.32","1132.64","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X65MM","SUP-ITM-10242910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.00","1039.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1132.64","81.72","","5157.68","5157.68","5157.68","1 through 10","724.32","1132.64","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X65MM","SUP-ITM-10242910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.00","1039.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1132.64","81.72","","431.26","71.26","1459.57","88","724.32","1132.64","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X88MM","SUP-ITM-10242391","CDM","C1713","HCPCS","0278","RC","","","","both","","","2492.88","1869.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1981.84","79.5","","800.18","480.96","1887.97","195","772.79","1981.84","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X88MM","SUP-ITM-10242391","CDM","C1713","HCPCS","0278","RC","","","","both","","","2492.88","1869.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1328.71","53.3","","813.12","216.42","1444.50","81","772.79","1981.84","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X88MM","SUP-ITM-10242391","CDM","C1713","HCPCS","0278","RC","","","","both","","","2492.88","1869.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","772.79","31","","432.60","432.60","432.60","1 through 10","772.79","1981.84","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X88MM","SUP-ITM-10242391","CDM","C1713","HCPCS","0278","RC","","","","both","","","2492.88","1869.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","909.90","36.5","","148.37","54.89","631.39","94","772.79","1981.84","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X88MM","SUP-ITM-10242391","CDM","C1713","HCPCS","0278","RC","","","","both","","","2492.88","1869.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","954.77","38.3","","279.30","91.72","1116.77","266","772.79","1981.84","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X88MM","SUP-ITM-10242391","CDM","C1713","HCPCS","0278","RC","","","","both","","","2492.88","1869.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1069.45","42.9","","731.00","63.70","731.00","1 through 10","772.79","1981.84","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X88MM","SUP-ITM-10242391","CDM","C1713","HCPCS","0278","RC","","","","both","","","2492.88","1869.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1069.45","42.9","","384.74","384.74","384.74","1 through 10","772.79","1981.84","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X88MM","SUP-ITM-10242391","CDM","C1713","HCPCS","0278","RC","","","","both","","","2492.88","1869.66","WELLPOINT [1015]","HB AMC WELLPOINT","1839.25","73.78","","286.63","119.22","1107.45","105","772.79","1981.84","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X88MM","SUP-ITM-10242391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2492.88","1869.66","AETNA [1001]","HB AMC AETNA HMO","1740.03","69.8","","675.31","184.75","1721.50","286","1302.78","2037.18","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X88MM","SUP-ITM-10242391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2492.88","1869.66","AETNA [1001]","HB AMC AETNA PPO","2004.28","80.4","","1261.44","103.12","1514.10","21","1302.78","2037.18","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X88MM","SUP-ITM-10242391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2492.88","1869.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2004.28","80.4","","1365.00","1365.00","1365.00","1 through 10","1302.78","2037.18","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X88MM","SUP-ITM-10242391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2492.88","1869.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2037.18","81.72","","5157.68","5157.68","5157.68","1 through 10","1302.78","2037.18","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X88MM","SUP-ITM-10242391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2492.88","1869.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2037.18","81.72","","431.26","71.26","1459.57","88","1302.78","2037.18","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X90MM","SUP-ITM-10242440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.38","1147.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1216.65","79.5","","800.18","480.96","1887.97","195","474.42","1216.65","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X90MM","SUP-ITM-10242440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.38","1147.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","815.69","53.3","","813.12","216.42","1444.50","81","474.42","1216.65","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X90MM","SUP-ITM-10242440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.38","1147.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","474.42","31","","432.60","432.60","432.60","1 through 10","474.42","1216.65","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X90MM","SUP-ITM-10242440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.38","1147.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","558.59","36.5","","148.37","54.89","631.39","94","474.42","1216.65","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X90MM","SUP-ITM-10242440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.38","1147.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","586.14","38.3","","279.30","91.72","1116.77","266","474.42","1216.65","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X90MM","SUP-ITM-10242440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.38","1147.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","656.53","42.9","","731.00","63.70","731.00","1 through 10","474.42","1216.65","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X90MM","SUP-ITM-10242440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.38","1147.78","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","656.53","42.9","","384.74","384.74","384.74","1 through 10","474.42","1216.65","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X90MM","SUP-ITM-10242440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.38","1147.78","WELLPOINT [1015]","HB AMC WELLPOINT","1129.11","73.78","","286.63","119.22","1107.45","105","474.42","1216.65","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X90MM","SUP-ITM-10242440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1530.38","1147.78","AETNA [1001]","HB AMC AETNA HMO","1068.21","69.8","","675.31","184.75","1721.50","286","799.78","1250.63","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X90MM","SUP-ITM-10242440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1530.38","1147.78","AETNA [1001]","HB AMC AETNA PPO","1230.43","80.4","","1261.44","103.12","1514.10","21","799.78","1250.63","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X90MM","SUP-ITM-10242440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1530.38","1147.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1230.43","80.4","","1365.00","1365.00","1365.00","1 through 10","799.78","1250.63","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X90MM","SUP-ITM-10242440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1530.38","1147.78","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1250.63","81.72","","5157.68","5157.68","5157.68","1 through 10","799.78","1250.63","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X90MM","SUP-ITM-10242440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1530.38","1147.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1250.63","81.72","","431.26","71.26","1459.57","88","799.78","1250.63","percent of total billed charges",""
"SCREW NON 4.0X26MM LOCKING FULLY THREADED","SUP-ITM-10126081","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.50","265.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","281.03","79.5","","800.18","480.96","1887.97","195","109.59","281.03","percent of total billed charges",""
"SCREW NON 4.0X26MM LOCKING FULLY THREADED","SUP-ITM-10126081","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.50","265.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","188.42","53.3","","813.12","216.42","1444.50","81","109.59","281.03","percent of total billed charges",""
"SCREW NON 4.0X26MM LOCKING FULLY THREADED","SUP-ITM-10126081","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.50","265.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","109.59","31","","432.60","432.60","432.60","1 through 10","109.59","281.03","percent of total billed charges",""
"SCREW NON 4.0X26MM LOCKING FULLY THREADED","SUP-ITM-10126081","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.50","265.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","129.03","36.5","","148.37","54.89","631.39","94","109.59","281.03","percent of total billed charges",""
"SCREW NON 4.0X26MM LOCKING FULLY THREADED","SUP-ITM-10126081","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.50","265.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","135.39","38.3","","279.30","91.72","1116.77","266","109.59","281.03","percent of total billed charges",""
"SCREW NON 4.0X26MM LOCKING FULLY THREADED","SUP-ITM-10126081","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.50","265.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.65","42.9","","731.00","63.70","731.00","1 through 10","109.59","281.03","percent of total billed charges",""
"SCREW NON 4.0X26MM LOCKING FULLY THREADED","SUP-ITM-10126081","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.50","265.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.65","42.9","","384.74","384.74","384.74","1 through 10","109.59","281.03","percent of total billed charges",""
"SCREW NON 4.0X26MM LOCKING FULLY THREADED","SUP-ITM-10126081","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.50","265.12","WELLPOINT [1015]","HB AMC WELLPOINT","260.81","73.78","","286.63","119.22","1107.45","105","109.59","281.03","percent of total billed charges",""
"SCREW NON 4.0X26MM LOCKING FULLY THREADED","SUP-ITM-10126081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.50","265.12","AETNA [1001]","HB AMC AETNA HMO","246.74","69.8","","675.31","184.75","1721.50","286","184.74","288.88","percent of total billed charges",""
"SCREW NON 4.0X26MM LOCKING FULLY THREADED","SUP-ITM-10126081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.50","265.12","AETNA [1001]","HB AMC AETNA PPO","284.21","80.4","","1261.44","103.12","1514.10","21","184.74","288.88","percent of total billed charges",""
"SCREW NON 4.0X26MM LOCKING FULLY THREADED","SUP-ITM-10126081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.50","265.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","284.21","80.4","","1365.00","1365.00","1365.00","1 through 10","184.74","288.88","percent of total billed charges",""
"SCREW NON 4.0X26MM LOCKING FULLY THREADED","SUP-ITM-10126081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.50","265.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","288.88","81.72","","5157.68","5157.68","5157.68","1 through 10","184.74","288.88","percent of total billed charges",""
"SCREW NON 4.0X26MM LOCKING FULLY THREADED","SUP-ITM-10126081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.50","265.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","288.88","81.72","","431.26","71.26","1459.57","88","184.74","288.88","percent of total billed charges",""
"SCREW OSS COMPONENT DIAPHYSEAL KNEE LOCKING","SUP-ITM-10123327","CDM","C1713","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.77","79.5","","800.18","480.96","1887.97","195","483.04","1238.77","percent of total billed charges",""
"SCREW OSS COMPONENT DIAPHYSEAL KNEE LOCKING","SUP-ITM-10123327","CDM","C1713","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.52","53.3","","813.12","216.42","1444.50","81","483.04","1238.77","percent of total billed charges",""
"SCREW OSS COMPONENT DIAPHYSEAL KNEE LOCKING","SUP-ITM-10123327","CDM","C1713","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","483.04","31","","432.60","432.60","432.60","1 through 10","483.04","1238.77","percent of total billed charges",""
"SCREW OSS COMPONENT DIAPHYSEAL KNEE LOCKING","SUP-ITM-10123327","CDM","C1713","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.74","36.5","","148.37","54.89","631.39","94","483.04","1238.77","percent of total billed charges",""
"SCREW OSS COMPONENT DIAPHYSEAL KNEE LOCKING","SUP-ITM-10123327","CDM","C1713","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.79","38.3","","279.30","91.72","1116.77","266","483.04","1238.77","percent of total billed charges",""
"SCREW OSS COMPONENT DIAPHYSEAL KNEE LOCKING","SUP-ITM-10123327","CDM","C1713","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.47","42.9","","731.00","63.70","731.00","1 through 10","483.04","1238.77","percent of total billed charges",""
"SCREW OSS COMPONENT DIAPHYSEAL KNEE LOCKING","SUP-ITM-10123327","CDM","C1713","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.47","42.9","","384.74","384.74","384.74","1 through 10","483.04","1238.77","percent of total billed charges",""
"SCREW OSS COMPONENT DIAPHYSEAL KNEE LOCKING","SUP-ITM-10123327","CDM","C1713","HCPCS","0278","RC","","","","both","","","1558.20","1168.65","WELLPOINT [1015]","HB AMC WELLPOINT","1149.64","73.78","","286.63","119.22","1107.45","105","483.04","1238.77","percent of total billed charges",""
"SCREW OSS COMPONENT DIAPHYSEAL KNEE LOCKING","SUP-ITM-10123327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1558.20","1168.65","AETNA [1001]","HB AMC AETNA HMO","1087.62","69.8","","675.31","184.75","1721.50","286","814.32","1273.36","percent of total billed charges",""
"SCREW OSS COMPONENT DIAPHYSEAL KNEE LOCKING","SUP-ITM-10123327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1558.20","1168.65","AETNA [1001]","HB AMC AETNA PPO","1252.79","80.4","","1261.44","103.12","1514.10","21","814.32","1273.36","percent of total billed charges",""
"SCREW OSS COMPONENT DIAPHYSEAL KNEE LOCKING","SUP-ITM-10123327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1558.20","1168.65","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.79","80.4","","1365.00","1365.00","1365.00","1 through 10","814.32","1273.36","percent of total billed charges",""
"SCREW OSS COMPONENT DIAPHYSEAL KNEE LOCKING","SUP-ITM-10123327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1558.20","1168.65","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1273.36","81.72","","5157.68","5157.68","5157.68","1 through 10","814.32","1273.36","percent of total billed charges",""
"SCREW OSS COMPONENT DIAPHYSEAL KNEE LOCKING","SUP-ITM-10123327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1558.20","1168.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1273.36","81.72","","431.26","71.26","1459.57","88","814.32","1273.36","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2205.50","79.5","","800.18","480.96","1887.97","195","860.01","2205.5","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1478.65","53.3","","813.12","216.42","1444.50","81","860.01","2205.5","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","860.01","31","","432.60","432.60","432.60","1 through 10","860.01","2205.5","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1012.59","36.5","","148.37","54.89","631.39","94","860.01","2205.5","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1062.52","38.3","","279.30","91.72","1116.77","266","860.01","2205.5","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1190.14","42.9","","731.00","63.70","731.00","1 through 10","860.01","2205.5","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1190.14","42.9","","384.74","384.74","384.74","1 through 10","860.01","2205.5","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2774.21","2080.66","WELLPOINT [1015]","HB AMC WELLPOINT","2046.81","73.78","","286.63","119.22","1107.45","105","860.01","2205.5","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","AETNA [1001]","HB AMC AETNA HMO","1936.40","69.8","","675.31","184.75","1721.50","286","1449.8","2267.08","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","AETNA [1001]","HB AMC AETNA PPO","2230.46","80.4","","1261.44","103.12","1514.10","21","1449.8","2267.08","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2230.46","80.4","","1365.00","1365.00","1365.00","1 through 10","1449.8","2267.08","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2267.08","81.72","","5157.68","5157.68","5157.68","1 through 10","1449.8","2267.08","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2774.21","2080.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2267.08","81.72","","431.26","71.26","1459.57","88","1449.8","2267.08","percent of total billed charges",""
"SCREW PLATE 0.4MM 12 HOLE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM ORBITAL RIM","SUP-ITM-10100541","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","635.11","79.5","","800.18","480.96","1887.97","195","247.65","635.11","percent of total billed charges",""
"SCREW PLATE 0.4MM 12 HOLE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM ORBITAL RIM","SUP-ITM-10100541","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","425.80","53.3","","813.12","216.42","1444.50","81","247.65","635.11","percent of total billed charges",""
"SCREW PLATE 0.4MM 12 HOLE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM ORBITAL RIM","SUP-ITM-10100541","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","247.65","31","","432.60","432.60","432.60","1 through 10","247.65","635.11","percent of total billed charges",""
"SCREW PLATE 0.4MM 12 HOLE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM ORBITAL RIM","SUP-ITM-10100541","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","291.59","36.5","","148.37","54.89","631.39","94","247.65","635.11","percent of total billed charges",""
"SCREW PLATE 0.4MM 12 HOLE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM ORBITAL RIM","SUP-ITM-10100541","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","305.97","38.3","","279.30","91.72","1116.77","266","247.65","635.11","percent of total billed charges",""
"SCREW PLATE 0.4MM 12 HOLE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM ORBITAL RIM","SUP-ITM-10100541","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.72","42.9","","731.00","63.70","731.00","1 through 10","247.65","635.11","percent of total billed charges",""
"SCREW PLATE 0.4MM 12 HOLE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM ORBITAL RIM","SUP-ITM-10100541","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.72","42.9","","384.74","384.74","384.74","1 through 10","247.65","635.11","percent of total billed charges",""
"SCREW PLATE 0.4MM 12 HOLE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM ORBITAL RIM","SUP-ITM-10100541","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.88","599.16","WELLPOINT [1015]","HB AMC WELLPOINT","589.41","73.78","","286.63","119.22","1107.45","105","247.65","635.11","percent of total billed charges",""
"SCREW PLATE 0.4MM 12 HOLE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM ORBITAL RIM","SUP-ITM-10100541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.88","599.16","AETNA [1001]","HB AMC AETNA HMO","557.62","69.8","","675.31","184.75","1721.50","286","417.49","652.84","percent of total billed charges",""
"SCREW PLATE 0.4MM 12 HOLE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM ORBITAL RIM","SUP-ITM-10100541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.88","599.16","AETNA [1001]","HB AMC AETNA PPO","642.30","80.4","","1261.44","103.12","1514.10","21","417.49","652.84","percent of total billed charges",""
"SCREW PLATE 0.4MM 12 HOLE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM ORBITAL RIM","SUP-ITM-10100541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.88","599.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","642.30","80.4","","1365.00","1365.00","1365.00","1 through 10","417.49","652.84","percent of total billed charges",""
"SCREW PLATE 0.4MM 12 HOLE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM ORBITAL RIM","SUP-ITM-10100541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.88","599.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","652.84","81.72","","5157.68","5157.68","5157.68","1 through 10","417.49","652.84","percent of total billed charges",""
"SCREW PLATE 0.4MM 12 HOLE CRANIOMAXILLOFACIAL BONE MATRIXMIDFACE TITANIUM ORBITAL RIM","SUP-ITM-10100541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.88","599.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","652.84","81.72","","431.26","71.26","1459.57","88","417.49","652.84","percent of total billed charges",""
"SCREW PLATE 0.4MM 6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM DOUBLE Y","SUP-ITM-10100542","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","519.64","79.5","","800.18","480.96","1887.97","195","202.63","519.64","percent of total billed charges",""
"SCREW PLATE 0.4MM 6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM DOUBLE Y","SUP-ITM-10100542","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","348.38","53.3","","813.12","216.42","1444.50","81","202.63","519.64","percent of total billed charges",""
"SCREW PLATE 0.4MM 6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM DOUBLE Y","SUP-ITM-10100542","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","202.63","31","","432.60","432.60","432.60","1 through 10","202.63","519.64","percent of total billed charges",""
"SCREW PLATE 0.4MM 6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM DOUBLE Y","SUP-ITM-10100542","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","238.57","36.5","","148.37","54.89","631.39","94","202.63","519.64","percent of total billed charges",""
"SCREW PLATE 0.4MM 6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM DOUBLE Y","SUP-ITM-10100542","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","250.34","38.3","","279.30","91.72","1116.77","266","202.63","519.64","percent of total billed charges",""
"SCREW PLATE 0.4MM 6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM DOUBLE Y","SUP-ITM-10100542","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.41","42.9","","731.00","63.70","731.00","1 through 10","202.63","519.64","percent of total billed charges",""
"SCREW PLATE 0.4MM 6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM DOUBLE Y","SUP-ITM-10100542","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.41","42.9","","384.74","384.74","384.74","1 through 10","202.63","519.64","percent of total billed charges",""
"SCREW PLATE 0.4MM 6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM DOUBLE Y","SUP-ITM-10100542","CDM","C1713","HCPCS","0278","RC","","","","both","","","653.63","490.22","WELLPOINT [1015]","HB AMC WELLPOINT","482.25","73.78","","286.63","119.22","1107.45","105","202.63","519.64","percent of total billed charges",""
"SCREW PLATE 0.4MM 6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM DOUBLE Y","SUP-ITM-10100542","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.63","490.22","AETNA [1001]","HB AMC AETNA HMO","456.23","69.8","","675.31","184.75","1721.50","286","341.59","534.15","percent of total billed charges",""
"SCREW PLATE 0.4MM 6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM DOUBLE Y","SUP-ITM-10100542","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.63","490.22","AETNA [1001]","HB AMC AETNA PPO","525.52","80.4","","1261.44","103.12","1514.10","21","341.59","534.15","percent of total billed charges",""
"SCREW PLATE 0.4MM 6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM DOUBLE Y","SUP-ITM-10100542","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.63","490.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","525.52","80.4","","1365.00","1365.00","1365.00","1 through 10","341.59","534.15","percent of total billed charges",""
"SCREW PLATE 0.4MM 6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM DOUBLE Y","SUP-ITM-10100542","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.63","490.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","534.15","81.72","","5157.68","5157.68","5157.68","1 through 10","341.59","534.15","percent of total billed charges",""
"SCREW PLATE 0.4MM 6 HOLE CRANIOMAXILLOFACIAL MATRIXMIDFACE TITANIUM DOUBLE Y","SUP-ITM-10100542","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","653.63","490.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","534.15","81.72","","431.26","71.26","1459.57","88","341.59","534.15","percent of total billed charges",""
"SCREW PLATE 3.0MM DIAMETERX8.0 RECONSTRUCTION MANDIBLE TITANIUM LOCKING DOUBLE LEAD THREAD PK/5EA","SUP-ITM-10076406","CDM","C1889","HCPCS","0278","RC","","","","both","","","1480.50","1110.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1177.00","79.5","","1309.77","674.56","6049.93","26","458.96","1177","percent of total billed charges",""
"SCREW PLATE 3.0MM DIAMETERX8.0 RECONSTRUCTION MANDIBLE TITANIUM LOCKING DOUBLE LEAD THREAD PK/5EA","SUP-ITM-10076406","CDM","C1889","HCPCS","0278","RC","","","","both","","","1480.50","1110.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","789.11","53.3","","1901.83","1901.83","2962.25","1 through 10","458.96","1177","percent of total billed charges",""
"SCREW PLATE 3.0MM DIAMETERX8.0 RECONSTRUCTION MANDIBLE TITANIUM LOCKING DOUBLE LEAD THREAD PK/5EA","SUP-ITM-10076406","CDM","C1889","HCPCS","0278","RC","","","","both","","","1480.50","1110.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","540.38","36.5","","1620.31","1620.31","19908.88","1 through 10","458.96","1177","percent of total billed charges",""
"SCREW PLATE 3.0MM DIAMETERX8.0 RECONSTRUCTION MANDIBLE TITANIUM LOCKING DOUBLE LEAD THREAD PK/5EA","SUP-ITM-10076406","CDM","C1889","HCPCS","0278","RC","","","","both","","","1480.50","1110.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","567.03","38.3","","352.91","352.91","2046.30","1 through 10","458.96","1177","percent of total billed charges",""
"SCREW PLATE 3.0MM DIAMETERX8.0 RECONSTRUCTION MANDIBLE TITANIUM LOCKING DOUBLE LEAD THREAD PK/5EA","SUP-ITM-10076406","CDM","C1889","HCPCS","0278","RC","","","","both","","","1480.50","1110.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","635.13","42.9","","9668.75","9668.75","9668.75","1 through 10","458.96","1177","percent of total billed charges",""
"SCREW PLATE 3.0MM DIAMETERX8.0 RECONSTRUCTION MANDIBLE TITANIUM LOCKING DOUBLE LEAD THREAD PK/5EA","SUP-ITM-10076406","CDM","C1889","HCPCS","0278","RC","","","","both","","","1480.50","1110.37","WELLPOINT [1015]","HB AMC WELLPOINT","1092.31","73.78","","699.88","384.10","3443.31","33","458.96","1177","percent of total billed charges",""
"SCREW PLATE 3.0MM DIAMETERX8.0 RECONSTRUCTION MANDIBLE TITANIUM LOCKING DOUBLE LEAD THREAD PK/5EA","SUP-ITM-10076406","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1480.50","1110.37","AETNA [1001]","HB AMC AETNA HMO","1033.39","69.8","","1421.24","264.50","4933.46","29","773.71","1209.86","percent of total billed charges",""
"SCREW PLATE 3.0MM DIAMETERX8.0 RECONSTRUCTION MANDIBLE TITANIUM LOCKING DOUBLE LEAD THREAD PK/5EA","SUP-ITM-10076406","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1480.50","1110.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1190.32","80.4","","1022.97","1022.97","3607.50","1 through 10","773.71","1209.86","percent of total billed charges",""
"SCREW PLATE 3.0MM DIAMETERX8.0 RECONSTRUCTION MANDIBLE TITANIUM LOCKING DOUBLE LEAD THREAD PK/5EA","SUP-ITM-10076406","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1480.50","1110.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1209.86","81.72","","3010.54","693.88","5019.88","35","773.71","1209.86","percent of total billed charges",""
"SCREW PLATE 306MM SHORT 18 HOLE 95DEG BONE DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005546","CDM","C1713","HCPCS","0278","RC","","","","both","","","4009.32","3006.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3187.41","79.5","","800.18","480.96","1887.97","195","1242.89","3187.41","percent of total billed charges",""
"SCREW PLATE 306MM SHORT 18 HOLE 95DEG BONE DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005546","CDM","C1713","HCPCS","0278","RC","","","","both","","","4009.32","3006.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2136.97","53.3","","813.12","216.42","1444.50","81","1242.89","3187.41","percent of total billed charges",""
"SCREW PLATE 306MM SHORT 18 HOLE 95DEG BONE DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005546","CDM","C1713","HCPCS","0278","RC","","","","both","","","4009.32","3006.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1242.89","31","","432.60","432.60","432.60","1 through 10","1242.89","3187.41","percent of total billed charges",""
"SCREW PLATE 306MM SHORT 18 HOLE 95DEG BONE DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005546","CDM","C1713","HCPCS","0278","RC","","","","both","","","4009.32","3006.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1463.40","36.5","","148.37","54.89","631.39","94","1242.89","3187.41","percent of total billed charges",""
"SCREW PLATE 306MM SHORT 18 HOLE 95DEG BONE DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005546","CDM","C1713","HCPCS","0278","RC","","","","both","","","4009.32","3006.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1535.57","38.3","","279.30","91.72","1116.77","266","1242.89","3187.41","percent of total billed charges",""
"SCREW PLATE 306MM SHORT 18 HOLE 95DEG BONE DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005546","CDM","C1713","HCPCS","0278","RC","","","","both","","","4009.32","3006.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1720.00","42.9","","731.00","63.70","731.00","1 through 10","1242.89","3187.41","percent of total billed charges",""
"SCREW PLATE 306MM SHORT 18 HOLE 95DEG BONE DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005546","CDM","C1713","HCPCS","0278","RC","","","","both","","","4009.32","3006.99","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1720.00","42.9","","384.74","384.74","384.74","1 through 10","1242.89","3187.41","percent of total billed charges",""
"SCREW PLATE 306MM SHORT 18 HOLE 95DEG BONE DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005546","CDM","C1713","HCPCS","0278","RC","","","","both","","","4009.32","3006.99","WELLPOINT [1015]","HB AMC WELLPOINT","2958.08","73.78","","286.63","119.22","1107.45","105","1242.89","3187.41","percent of total billed charges",""
"SCREW PLATE 306MM SHORT 18 HOLE 95DEG BONE DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005546","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4009.32","3006.99","AETNA [1001]","HB AMC AETNA HMO","2798.51","69.8","","675.31","184.75","1721.50","286","2095.27","3276.42","percent of total billed charges",""
"SCREW PLATE 306MM SHORT 18 HOLE 95DEG BONE DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005546","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4009.32","3006.99","AETNA [1001]","HB AMC AETNA PPO","3223.49","80.4","","1261.44","103.12","1514.10","21","2095.27","3276.42","percent of total billed charges",""
"SCREW PLATE 306MM SHORT 18 HOLE 95DEG BONE DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005546","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4009.32","3006.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3223.49","80.4","","1365.00","1365.00","1365.00","1 through 10","2095.27","3276.42","percent of total billed charges",""
"SCREW PLATE 306MM SHORT 18 HOLE 95DEG BONE DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005546","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4009.32","3006.99","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3276.42","81.72","","5157.68","5157.68","5157.68","1 through 10","2095.27","3276.42","percent of total billed charges",""
"SCREW PLATE 306MM SHORT 18 HOLE 95DEG BONE DCS SUPRACONDYLAR COMPRESSION BARREL SS","SUP-ITM-10005546","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4009.32","3006.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3276.42","81.72","","431.26","71.26","1459.57","88","2095.27","3276.42","percent of total billed charges",""
"SCREW POLY 7.5X40MM STERILE FAVORED ANGLE SOLID TRIALTIS","SUP-ITM-10330639","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2253.83","79.5","","800.18","480.96","1887.97","195","878.85","2253.83","percent of total billed charges",""
"SCREW POLY 7.5X40MM STERILE FAVORED ANGLE SOLID TRIALTIS","SUP-ITM-10330639","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1511.06","53.3","","813.12","216.42","1444.50","81","878.85","2253.83","percent of total billed charges",""
"SCREW POLY 7.5X40MM STERILE FAVORED ANGLE SOLID TRIALTIS","SUP-ITM-10330639","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","878.85","31","","432.60","432.60","432.60","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW POLY 7.5X40MM STERILE FAVORED ANGLE SOLID TRIALTIS","SUP-ITM-10330639","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1034.78","36.5","","148.37","54.89","631.39","94","878.85","2253.83","percent of total billed charges",""
"SCREW POLY 7.5X40MM STERILE FAVORED ANGLE SOLID TRIALTIS","SUP-ITM-10330639","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1085.81","38.3","","279.30","91.72","1116.77","266","878.85","2253.83","percent of total billed charges",""
"SCREW POLY 7.5X40MM STERILE FAVORED ANGLE SOLID TRIALTIS","SUP-ITM-10330639","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","731.00","63.70","731.00","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW POLY 7.5X40MM STERILE FAVORED ANGLE SOLID TRIALTIS","SUP-ITM-10330639","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.22","42.9","","384.74","384.74","384.74","1 through 10","878.85","2253.83","percent of total billed charges",""
"SCREW POLY 7.5X40MM STERILE FAVORED ANGLE SOLID TRIALTIS","SUP-ITM-10330639","CDM","C1713","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB AMC WELLPOINT","2091.66","73.78","","286.63","119.22","1107.45","105","878.85","2253.83","percent of total billed charges",""
"SCREW POLY 7.5X40MM STERILE FAVORED ANGLE SOLID TRIALTIS","SUP-ITM-10330639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA HMO","1978.83","69.8","","675.31","184.75","1721.50","286","1481.57","2316.76","percent of total billed charges",""
"SCREW POLY 7.5X40MM STERILE FAVORED ANGLE SOLID TRIALTIS","SUP-ITM-10330639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","AETNA [1001]","HB AMC AETNA PPO","2279.34","80.4","","1261.44","103.12","1514.10","21","1481.57","2316.76","percent of total billed charges",""
"SCREW POLY 7.5X40MM STERILE FAVORED ANGLE SOLID TRIALTIS","SUP-ITM-10330639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2279.34","80.4","","1365.00","1365.00","1365.00","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW POLY 7.5X40MM STERILE FAVORED ANGLE SOLID TRIALTIS","SUP-ITM-10330639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2316.76","81.72","","5157.68","5157.68","5157.68","1 through 10","1481.57","2316.76","percent of total billed charges",""
"SCREW POLY 7.5X40MM STERILE FAVORED ANGLE SOLID TRIALTIS","SUP-ITM-10330639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2316.76","81.72","","431.26","71.26","1459.57","88","1481.57","2316.76","percent of total billed charges",""
"SCREW POLY 9X80MM FAVORED ANGLE DL CANN TRIALTIS","SUP-ITM-10332600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2328.95","79.5","","800.18","480.96","1887.97","195","908.15","2328.95","percent of total billed charges",""
"SCREW POLY 9X80MM FAVORED ANGLE DL CANN TRIALTIS","SUP-ITM-10332600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1561.42","53.3","","813.12","216.42","1444.50","81","908.15","2328.95","percent of total billed charges",""
"SCREW POLY 9X80MM FAVORED ANGLE DL CANN TRIALTIS","SUP-ITM-10332600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","908.15","31","","432.60","432.60","432.60","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW POLY 9X80MM FAVORED ANGLE DL CANN TRIALTIS","SUP-ITM-10332600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1069.27","36.5","","148.37","54.89","631.39","94","908.15","2328.95","percent of total billed charges",""
"SCREW POLY 9X80MM FAVORED ANGLE DL CANN TRIALTIS","SUP-ITM-10332600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1122.00","38.3","","279.30","91.72","1116.77","266","908.15","2328.95","percent of total billed charges",""
"SCREW POLY 9X80MM FAVORED ANGLE DL CANN TRIALTIS","SUP-ITM-10332600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","731.00","63.70","731.00","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW POLY 9X80MM FAVORED ANGLE DL CANN TRIALTIS","SUP-ITM-10332600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","384.74","384.74","384.74","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW POLY 9X80MM FAVORED ANGLE DL CANN TRIALTIS","SUP-ITM-10332600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","WELLPOINT [1015]","HB AMC WELLPOINT","2161.39","73.78","","286.63","119.22","1107.45","105","908.15","2328.95","percent of total billed charges",""
"SCREW POLY 9X80MM FAVORED ANGLE DL CANN TRIALTIS","SUP-ITM-10332600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA HMO","2044.79","69.8","","675.31","184.75","1721.50","286","1530.96","2393.99","percent of total billed charges",""
"SCREW POLY 9X80MM FAVORED ANGLE DL CANN TRIALTIS","SUP-ITM-10332600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA PPO","2355.32","80.4","","1261.44","103.12","1514.10","21","1530.96","2393.99","percent of total billed charges",""
"SCREW POLY 9X80MM FAVORED ANGLE DL CANN TRIALTIS","SUP-ITM-10332600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2355.32","80.4","","1365.00","1365.00","1365.00","1 through 10","1530.96","2393.99","percent of total billed charges",""
"SCREW POLY 9X80MM FAVORED ANGLE DL CANN TRIALTIS","SUP-ITM-10332600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2393.99","81.72","","5157.68","5157.68","5157.68","1 through 10","1530.96","2393.99","percent of total billed charges",""
"SCREW POLY 9X80MM FAVORED ANGLE DL CANN TRIALTIS","SUP-ITM-10332600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2393.99","81.72","","431.26","71.26","1459.57","88","1530.96","2393.99","percent of total billed charges",""
"SCREW RACK SHELL FOR MODULAR GRAPHIC CASE SYSTEM","SUP-ITM-10125899","CDM","C1713","HCPCS","0278","RC","","","","both","","","2170.21","1627.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1725.32","79.5","","800.18","480.96","1887.97","195","672.77","1725.32","percent of total billed charges",""
"SCREW RACK SHELL FOR MODULAR GRAPHIC CASE SYSTEM","SUP-ITM-10125899","CDM","C1713","HCPCS","0278","RC","","","","both","","","2170.21","1627.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1156.72","53.3","","813.12","216.42","1444.50","81","672.77","1725.32","percent of total billed charges",""
"SCREW RACK SHELL FOR MODULAR GRAPHIC CASE SYSTEM","SUP-ITM-10125899","CDM","C1713","HCPCS","0278","RC","","","","both","","","2170.21","1627.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","672.77","31","","432.60","432.60","432.60","1 through 10","672.77","1725.32","percent of total billed charges",""
"SCREW RACK SHELL FOR MODULAR GRAPHIC CASE SYSTEM","SUP-ITM-10125899","CDM","C1713","HCPCS","0278","RC","","","","both","","","2170.21","1627.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","792.13","36.5","","148.37","54.89","631.39","94","672.77","1725.32","percent of total billed charges",""
"SCREW RACK SHELL FOR MODULAR GRAPHIC CASE SYSTEM","SUP-ITM-10125899","CDM","C1713","HCPCS","0278","RC","","","","both","","","2170.21","1627.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","831.19","38.3","","279.30","91.72","1116.77","266","672.77","1725.32","percent of total billed charges",""
"SCREW RACK SHELL FOR MODULAR GRAPHIC CASE SYSTEM","SUP-ITM-10125899","CDM","C1713","HCPCS","0278","RC","","","","both","","","2170.21","1627.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","931.02","42.9","","731.00","63.70","731.00","1 through 10","672.77","1725.32","percent of total billed charges",""
"SCREW RACK SHELL FOR MODULAR GRAPHIC CASE SYSTEM","SUP-ITM-10125899","CDM","C1713","HCPCS","0278","RC","","","","both","","","2170.21","1627.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","931.02","42.9","","384.74","384.74","384.74","1 through 10","672.77","1725.32","percent of total billed charges",""
"SCREW RACK SHELL FOR MODULAR GRAPHIC CASE SYSTEM","SUP-ITM-10125899","CDM","C1713","HCPCS","0278","RC","","","","both","","","2170.21","1627.66","WELLPOINT [1015]","HB AMC WELLPOINT","1601.18","73.78","","286.63","119.22","1107.45","105","672.77","1725.32","percent of total billed charges",""
"SCREW RACK SHELL FOR MODULAR GRAPHIC CASE SYSTEM","SUP-ITM-10125899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2170.21","1627.66","AETNA [1001]","HB AMC AETNA HMO","1514.81","69.8","","675.31","184.75","1721.50","286","1134.15","1773.5","percent of total billed charges",""
"SCREW RACK SHELL FOR MODULAR GRAPHIC CASE SYSTEM","SUP-ITM-10125899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2170.21","1627.66","AETNA [1001]","HB AMC AETNA PPO","1744.85","80.4","","1261.44","103.12","1514.10","21","1134.15","1773.5","percent of total billed charges",""
"SCREW RACK SHELL FOR MODULAR GRAPHIC CASE SYSTEM","SUP-ITM-10125899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2170.21","1627.66","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1744.85","80.4","","1365.00","1365.00","1365.00","1 through 10","1134.15","1773.5","percent of total billed charges",""
"SCREW RACK SHELL FOR MODULAR GRAPHIC CASE SYSTEM","SUP-ITM-10125899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2170.21","1627.66","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1773.50","81.72","","5157.68","5157.68","5157.68","1 through 10","1134.15","1773.5","percent of total billed charges",""
"SCREW RACK SHELL FOR MODULAR GRAPHIC CASE SYSTEM","SUP-ITM-10125899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2170.21","1627.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1773.50","81.72","","431.26","71.26","1459.57","88","1134.15","1773.5","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","758.52","568.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","603.02","79.5","","800.18","480.96","1887.97","195","235.14","603.02","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","758.52","568.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","404.29","53.3","","813.12","216.42","1444.50","81","235.14","603.02","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","758.52","568.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","235.14","31","","432.60","432.60","432.60","1 through 10","235.14","603.02","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","758.52","568.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","276.86","36.5","","148.37","54.89","631.39","94","235.14","603.02","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","758.52","568.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","290.51","38.3","","279.30","91.72","1116.77","266","235.14","603.02","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","758.52","568.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","325.41","42.9","","731.00","63.70","731.00","1 through 10","235.14","603.02","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","758.52","568.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","325.41","42.9","","384.74","384.74","384.74","1 through 10","235.14","603.02","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","758.52","568.89","WELLPOINT [1015]","HB AMC WELLPOINT","559.64","73.78","","286.63","119.22","1107.45","105","235.14","603.02","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","758.52","568.89","AETNA [1001]","HB AMC AETNA HMO","529.45","69.8","","675.31","184.75","1721.50","286","396.4","619.86","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","758.52","568.89","AETNA [1001]","HB AMC AETNA PPO","609.85","80.4","","1261.44","103.12","1514.10","21","396.4","619.86","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","758.52","568.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","609.85","80.4","","1365.00","1365.00","1365.00","1 through 10","396.4","619.86","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","758.52","568.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","619.86","81.72","","5157.68","5157.68","5157.68","1 through 10","396.4","619.86","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","758.52","568.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","619.86","81.72","","431.26","71.26","1459.57","88","396.4","619.86","percent of total billed charges",""
"SCREW SET 5.5 EXP VERSE DI","SUP-ITM-10331596","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","800.18","480.96","1887.97","195","162.75","417.38","percent of total billed charges",""
"SCREW SET 5.5 EXP VERSE DI","SUP-ITM-10331596","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","813.12","216.42","1444.50","81","162.75","417.38","percent of total billed charges",""
"SCREW SET 5.5 EXP VERSE DI","SUP-ITM-10331596","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.75","31","","432.60","432.60","432.60","1 through 10","162.75","417.38","percent of total billed charges",""
"SCREW SET 5.5 EXP VERSE DI","SUP-ITM-10331596","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","148.37","54.89","631.39","94","162.75","417.38","percent of total billed charges",""
"SCREW SET 5.5 EXP VERSE DI","SUP-ITM-10331596","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","279.30","91.72","1116.77","266","162.75","417.38","percent of total billed charges",""
"SCREW SET 5.5 EXP VERSE DI","SUP-ITM-10331596","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","731.00","63.70","731.00","1 through 10","162.75","417.38","percent of total billed charges",""
"SCREW SET 5.5 EXP VERSE DI","SUP-ITM-10331596","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","384.74","384.74","384.74","1 through 10","162.75","417.38","percent of total billed charges",""
"SCREW SET 5.5 EXP VERSE DI","SUP-ITM-10331596","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","286.63","119.22","1107.45","105","162.75","417.38","percent of total billed charges",""
"SCREW SET 5.5 EXP VERSE DI","SUP-ITM-10331596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","675.31","184.75","1721.50","286","274.37","429.03","percent of total billed charges",""
"SCREW SET 5.5 EXP VERSE DI","SUP-ITM-10331596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA PPO","422.10","80.4","","1261.44","103.12","1514.10","21","274.37","429.03","percent of total billed charges",""
"SCREW SET 5.5 EXP VERSE DI","SUP-ITM-10331596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1365.00","1365.00","1365.00","1 through 10","274.37","429.03","percent of total billed charges",""
"SCREW SET 5.5 EXP VERSE DI","SUP-ITM-10331596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","429.03","81.72","","5157.68","5157.68","5157.68","1 through 10","274.37","429.03","percent of total billed charges",""
"SCREW SET 5.5 EXP VERSE DI","SUP-ITM-10331596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","431.26","71.26","1459.57","88","274.37","429.03","percent of total billed charges",""
"SCREW SPINAL 20MM SOLITAIRE PENTALOBE","SUP-ITM-10088246","CDM","C1889","HCPCS","0278","RC","","","","both","","","584.50","438.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","464.68","79.5","","1309.77","674.56","6049.93","26","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 20MM SOLITAIRE PENTALOBE","SUP-ITM-10088246","CDM","C1889","HCPCS","0278","RC","","","","both","","","584.50","438.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","311.54","53.3","","1901.83","1901.83","2962.25","1 through 10","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 20MM SOLITAIRE PENTALOBE","SUP-ITM-10088246","CDM","C1889","HCPCS","0278","RC","","","","both","","","584.50","438.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","213.34","36.5","","1620.31","1620.31","19908.88","1 through 10","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 20MM SOLITAIRE PENTALOBE","SUP-ITM-10088246","CDM","C1889","HCPCS","0278","RC","","","","both","","","584.50","438.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","223.86","38.3","","352.91","352.91","2046.30","1 through 10","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 20MM SOLITAIRE PENTALOBE","SUP-ITM-10088246","CDM","C1889","HCPCS","0278","RC","","","","both","","","584.50","438.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.75","42.9","","9668.75","9668.75","9668.75","1 through 10","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 20MM SOLITAIRE PENTALOBE","SUP-ITM-10088246","CDM","C1889","HCPCS","0278","RC","","","","both","","","584.50","438.37","WELLPOINT [1015]","HB AMC WELLPOINT","431.24","73.78","","699.88","384.10","3443.31","33","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 20MM SOLITAIRE PENTALOBE","SUP-ITM-10088246","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","584.50","438.37","AETNA [1001]","HB AMC AETNA HMO","407.98","69.8","","1421.24","264.50","4933.46","29","305.46","477.65","percent of total billed charges",""
"SCREW SPINAL 20MM SOLITAIRE PENTALOBE","SUP-ITM-10088246","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","584.50","438.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","469.94","80.4","","1022.97","1022.97","3607.50","1 through 10","305.46","477.65","percent of total billed charges",""
"SCREW SPINAL 20MM SOLITAIRE PENTALOBE","SUP-ITM-10088246","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","584.50","438.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","477.65","81.72","","3010.54","693.88","5019.88","35","305.46","477.65","percent of total billed charges",""
"SCREW SPINAL 30MM SOLITAIRE PENTALOBE","SUP-ITM-10088250","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.50","438.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","464.68","79.5","","800.18","480.96","1887.97","195","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 30MM SOLITAIRE PENTALOBE","SUP-ITM-10088250","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.50","438.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","311.54","53.3","","813.12","216.42","1444.50","81","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 30MM SOLITAIRE PENTALOBE","SUP-ITM-10088250","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.50","438.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","181.20","31","","432.60","432.60","432.60","1 through 10","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 30MM SOLITAIRE PENTALOBE","SUP-ITM-10088250","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.50","438.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","213.34","36.5","","148.37","54.89","631.39","94","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 30MM SOLITAIRE PENTALOBE","SUP-ITM-10088250","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.50","438.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","223.86","38.3","","279.30","91.72","1116.77","266","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 30MM SOLITAIRE PENTALOBE","SUP-ITM-10088250","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.50","438.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.75","42.9","","731.00","63.70","731.00","1 through 10","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 30MM SOLITAIRE PENTALOBE","SUP-ITM-10088250","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.50","438.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.75","42.9","","384.74","384.74","384.74","1 through 10","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 30MM SOLITAIRE PENTALOBE","SUP-ITM-10088250","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.50","438.37","WELLPOINT [1015]","HB AMC WELLPOINT","431.24","73.78","","286.63","119.22","1107.45","105","181.2","464.68","percent of total billed charges",""
"SCREW SPINAL 30MM SOLITAIRE PENTALOBE","SUP-ITM-10088250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.50","438.37","AETNA [1001]","HB AMC AETNA HMO","407.98","69.8","","675.31","184.75","1721.50","286","305.46","477.65","percent of total billed charges",""
"SCREW SPINAL 30MM SOLITAIRE PENTALOBE","SUP-ITM-10088250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.50","438.37","AETNA [1001]","HB AMC AETNA PPO","469.94","80.4","","1261.44","103.12","1514.10","21","305.46","477.65","percent of total billed charges",""
"SCREW SPINAL 30MM SOLITAIRE PENTALOBE","SUP-ITM-10088250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.50","438.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","469.94","80.4","","1365.00","1365.00","1365.00","1 through 10","305.46","477.65","percent of total billed charges",""
"SCREW SPINAL 30MM SOLITAIRE PENTALOBE","SUP-ITM-10088250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.50","438.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","477.65","81.72","","5157.68","5157.68","5157.68","1 through 10","305.46","477.65","percent of total billed charges",""
"SCREW SPINAL 30MM SOLITAIRE PENTALOBE","SUP-ITM-10088250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.50","438.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","477.65","81.72","","431.26","71.26","1459.57","88","305.46","477.65","percent of total billed charges",""
"SCREW SPINAL 4X30MM MA RELINE-C","SUP-ITM-10310629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","800.18","480.96","1887.97","195","542.5","1391.25","percent of total billed charges",""
"SCREW SPINAL 4X30MM MA RELINE-C","SUP-ITM-10310629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","813.12","216.42","1444.50","81","542.5","1391.25","percent of total billed charges",""
"SCREW SPINAL 4X30MM MA RELINE-C","SUP-ITM-10310629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","542.50","31","","432.60","432.60","432.60","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW SPINAL 4X30MM MA RELINE-C","SUP-ITM-10310629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","148.37","54.89","631.39","94","542.5","1391.25","percent of total billed charges",""
"SCREW SPINAL 4X30MM MA RELINE-C","SUP-ITM-10310629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","279.30","91.72","1116.77","266","542.5","1391.25","percent of total billed charges",""
"SCREW SPINAL 4X30MM MA RELINE-C","SUP-ITM-10310629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","731.00","63.70","731.00","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW SPINAL 4X30MM MA RELINE-C","SUP-ITM-10310629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","384.74","384.74","384.74","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW SPINAL 4X30MM MA RELINE-C","SUP-ITM-10310629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","286.63","119.22","1107.45","105","542.5","1391.25","percent of total billed charges",""
"SCREW SPINAL 4X30MM MA RELINE-C","SUP-ITM-10310629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","675.31","184.75","1721.50","286","914.55","1430.1","percent of total billed charges",""
"SCREW SPINAL 4X30MM MA RELINE-C","SUP-ITM-10310629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1261.44","103.12","1514.10","21","914.55","1430.1","percent of total billed charges",""
"SCREW SPINAL 4X30MM MA RELINE-C","SUP-ITM-10310629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","1365.00","1365.00","1365.00","1 through 10","914.55","1430.1","percent of total billed charges",""
"SCREW SPINAL 4X30MM MA RELINE-C","SUP-ITM-10310629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1430.10","81.72","","5157.68","5157.68","5157.68","1 through 10","914.55","1430.1","percent of total billed charges",""
"SCREW SPINAL 4X30MM MA RELINE-C","SUP-ITM-10310629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","431.26","71.26","1459.57","88","914.55","1430.1","percent of total billed charges",""
"SCREW SPINAL 5.5X50MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140281","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","347.81","79.5","","800.18","480.96","1887.97","195","135.63","347.81","percent of total billed charges",""
"SCREW SPINAL 5.5X50MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140281","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","233.19","53.3","","813.12","216.42","1444.50","81","135.63","347.81","percent of total billed charges",""
"SCREW SPINAL 5.5X50MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140281","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","135.63","31","","432.60","432.60","432.60","1 through 10","135.63","347.81","percent of total billed charges",""
"SCREW SPINAL 5.5X50MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140281","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","159.69","36.5","","148.37","54.89","631.39","94","135.63","347.81","percent of total billed charges",""
"SCREW SPINAL 5.5X50MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140281","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","167.56","38.3","","279.30","91.72","1116.77","266","135.63","347.81","percent of total billed charges",""
"SCREW SPINAL 5.5X50MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140281","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.69","42.9","","731.00","63.70","731.00","1 through 10","135.63","347.81","percent of total billed charges",""
"SCREW SPINAL 5.5X50MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140281","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.69","42.9","","384.74","384.74","384.74","1 through 10","135.63","347.81","percent of total billed charges",""
"SCREW SPINAL 5.5X50MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140281","CDM","C1713","HCPCS","0278","RC","","","","both","","","437.50","328.12","WELLPOINT [1015]","HB AMC WELLPOINT","322.79","73.78","","286.63","119.22","1107.45","105","135.63","347.81","percent of total billed charges",""
"SCREW SPINAL 5.5X50MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","AETNA [1001]","HB AMC AETNA HMO","305.38","69.8","","675.31","184.75","1721.50","286","228.64","357.53","percent of total billed charges",""
"SCREW SPINAL 5.5X50MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","AETNA [1001]","HB AMC AETNA PPO","351.75","80.4","","1261.44","103.12","1514.10","21","228.64","357.53","percent of total billed charges",""
"SCREW SPINAL 5.5X50MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","351.75","80.4","","1365.00","1365.00","1365.00","1 through 10","228.64","357.53","percent of total billed charges",""
"SCREW SPINAL 5.5X50MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","357.53","81.72","","5157.68","5157.68","5157.68","1 through 10","228.64","357.53","percent of total billed charges",""
"SCREW SPINAL 5.5X50MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","357.53","81.72","","431.26","71.26","1459.57","88","228.64","357.53","percent of total billed charges",""
"SCREW SPINAL 5X40MM VERSE CFX FENESTRATED","SUP-ITM-10243558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2462.51","79.5","","800.18","480.96","1887.97","195","960.23","2462.51","percent of total billed charges",""
"SCREW SPINAL 5X40MM VERSE CFX FENESTRATED","SUP-ITM-10243558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1650.97","53.3","","813.12","216.42","1444.50","81","960.23","2462.51","percent of total billed charges",""
"SCREW SPINAL 5X40MM VERSE CFX FENESTRATED","SUP-ITM-10243558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","960.23","31","","432.60","432.60","432.60","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINAL 5X40MM VERSE CFX FENESTRATED","SUP-ITM-10243558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1130.59","36.5","","148.37","54.89","631.39","94","960.23","2462.51","percent of total billed charges",""
"SCREW SPINAL 5X40MM VERSE CFX FENESTRATED","SUP-ITM-10243558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1186.34","38.3","","279.30","91.72","1116.77","266","960.23","2462.51","percent of total billed charges",""
"SCREW SPINAL 5X40MM VERSE CFX FENESTRATED","SUP-ITM-10243558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1328.83","42.9","","731.00","63.70","731.00","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINAL 5X40MM VERSE CFX FENESTRATED","SUP-ITM-10243558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1328.83","42.9","","384.74","384.74","384.74","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINAL 5X40MM VERSE CFX FENESTRATED","SUP-ITM-10243558","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","WELLPOINT [1015]","HB AMC WELLPOINT","2285.34","73.78","","286.63","119.22","1107.45","105","960.23","2462.51","percent of total billed charges",""
"SCREW SPINAL 5X40MM VERSE CFX FENESTRATED","SUP-ITM-10243558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","AETNA [1001]","HB AMC AETNA HMO","2162.06","69.8","","675.31","184.75","1721.50","286","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINAL 5X40MM VERSE CFX FENESTRATED","SUP-ITM-10243558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","AETNA [1001]","HB AMC AETNA PPO","2490.39","80.4","","1261.44","103.12","1514.10","21","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINAL 5X40MM VERSE CFX FENESTRATED","SUP-ITM-10243558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2490.39","80.4","","1365.00","1365.00","1365.00","1 through 10","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINAL 5X40MM VERSE CFX FENESTRATED","SUP-ITM-10243558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2531.28","81.72","","5157.68","5157.68","5157.68","1 through 10","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINAL 5X40MM VERSE CFX FENESTRATED","SUP-ITM-10243558","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2531.28","81.72","","431.26","71.26","1459.57","88","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 12X4MM COROENT SELF TAPPING","SUP-ITM-10107548","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","370.07","79.5","","800.18","480.96","1887.97","195","144.31","370.07","percent of total billed charges",""
"SCREW SPINE 12X4MM COROENT SELF TAPPING","SUP-ITM-10107548","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","248.11","53.3","","813.12","216.42","1444.50","81","144.31","370.07","percent of total billed charges",""
"SCREW SPINE 12X4MM COROENT SELF TAPPING","SUP-ITM-10107548","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","144.31","31","","432.60","432.60","432.60","1 through 10","144.31","370.07","percent of total billed charges",""
"SCREW SPINE 12X4MM COROENT SELF TAPPING","SUP-ITM-10107548","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","169.91","36.5","","148.37","54.89","631.39","94","144.31","370.07","percent of total billed charges",""
"SCREW SPINE 12X4MM COROENT SELF TAPPING","SUP-ITM-10107548","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","178.29","38.3","","279.30","91.72","1116.77","266","144.31","370.07","percent of total billed charges",""
"SCREW SPINE 12X4MM COROENT SELF TAPPING","SUP-ITM-10107548","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.70","42.9","","731.00","63.70","731.00","1 through 10","144.31","370.07","percent of total billed charges",""
"SCREW SPINE 12X4MM COROENT SELF TAPPING","SUP-ITM-10107548","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.70","42.9","","384.74","384.74","384.74","1 through 10","144.31","370.07","percent of total billed charges",""
"SCREW SPINE 12X4MM COROENT SELF TAPPING","SUP-ITM-10107548","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.50","349.12","WELLPOINT [1015]","HB AMC WELLPOINT","343.45","73.78","","286.63","119.22","1107.45","105","144.31","370.07","percent of total billed charges",""
"SCREW SPINE 12X4MM COROENT SELF TAPPING","SUP-ITM-10107548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.50","349.12","AETNA [1001]","HB AMC AETNA HMO","324.92","69.8","","675.31","184.75","1721.50","286","243.27","380.41","percent of total billed charges",""
"SCREW SPINE 12X4MM COROENT SELF TAPPING","SUP-ITM-10107548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.50","349.12","AETNA [1001]","HB AMC AETNA PPO","374.26","80.4","","1261.44","103.12","1514.10","21","243.27","380.41","percent of total billed charges",""
"SCREW SPINE 12X4MM COROENT SELF TAPPING","SUP-ITM-10107548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.50","349.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","374.26","80.4","","1365.00","1365.00","1365.00","1 through 10","243.27","380.41","percent of total billed charges",""
"SCREW SPINE 12X4MM COROENT SELF TAPPING","SUP-ITM-10107548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.50","349.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","380.41","81.72","","5157.68","5157.68","5157.68","1 through 10","243.27","380.41","percent of total billed charges",""
"SCREW SPINE 12X4MM COROENT SELF TAPPING","SUP-ITM-10107548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.50","349.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","380.41","81.72","","431.26","71.26","1459.57","88","243.27","380.41","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.75","311.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","329.73","79.5","","800.18","480.96","1887.97","195","128.57","329.73","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.75","311.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","221.06","53.3","","813.12","216.42","1444.50","81","128.57","329.73","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.75","311.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","128.57","31","","432.60","432.60","432.60","1 through 10","128.57","329.73","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.75","311.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","151.38","36.5","","148.37","54.89","631.39","94","128.57","329.73","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.75","311.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","158.85","38.3","","279.30","91.72","1116.77","266","128.57","329.73","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.75","311.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","177.93","42.9","","731.00","63.70","731.00","1 through 10","128.57","329.73","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.75","311.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","177.93","42.9","","384.74","384.74","384.74","1 through 10","128.57","329.73","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.75","311.06","WELLPOINT [1015]","HB AMC WELLPOINT","306.00","73.78","","286.63","119.22","1107.45","105","128.57","329.73","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.75","311.06","AETNA [1001]","HB AMC AETNA HMO","289.50","69.8","","675.31","184.75","1721.50","286","216.75","338.93","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.75","311.06","AETNA [1001]","HB AMC AETNA PPO","333.46","80.4","","1261.44","103.12","1514.10","21","216.75","338.93","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.75","311.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","333.46","80.4","","1365.00","1365.00","1365.00","1 through 10","216.75","338.93","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.75","311.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","338.93","81.72","","5157.68","5157.68","5157.68","1 through 10","216.75","338.93","percent of total billed charges",""
"SCREW SPINE 25MM SYNFIX EVOLUTION FINE TIP PK/2EA","SUP-ITM-10191968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.75","311.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","338.93","81.72","","431.26","71.26","1459.57","88","216.75","338.93","percent of total billed charges",""
"SCREW SPINE 3.5X12MM MINI MESA POLYAXIAL COMPONENT","SUP-ITM-10085859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1516.46","79.5","","800.18","480.96","1887.97","195","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 3.5X12MM MINI MESA POLYAXIAL COMPONENT","SUP-ITM-10085859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1016.70","53.3","","813.12","216.42","1444.50","81","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 3.5X12MM MINI MESA POLYAXIAL COMPONENT","SUP-ITM-10085859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","591.33","31","","432.60","432.60","432.60","1 through 10","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 3.5X12MM MINI MESA POLYAXIAL COMPONENT","SUP-ITM-10085859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","696.24","36.5","","148.37","54.89","631.39","94","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 3.5X12MM MINI MESA POLYAXIAL COMPONENT","SUP-ITM-10085859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","730.57","38.3","","279.30","91.72","1116.77","266","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 3.5X12MM MINI MESA POLYAXIAL COMPONENT","SUP-ITM-10085859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","818.32","42.9","","731.00","63.70","731.00","1 through 10","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 3.5X12MM MINI MESA POLYAXIAL COMPONENT","SUP-ITM-10085859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","818.32","42.9","","384.74","384.74","384.74","1 through 10","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 3.5X12MM MINI MESA POLYAXIAL COMPONENT","SUP-ITM-10085859","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","WELLPOINT [1015]","HB AMC WELLPOINT","1407.35","73.78","","286.63","119.22","1107.45","105","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 3.5X12MM MINI MESA POLYAXIAL COMPONENT","SUP-ITM-10085859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","AETNA [1001]","HB AMC AETNA HMO","1331.44","69.8","","675.31","184.75","1721.50","286","996.86","1558.81","percent of total billed charges",""
"SCREW SPINE 3.5X12MM MINI MESA POLYAXIAL COMPONENT","SUP-ITM-10085859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","AETNA [1001]","HB AMC AETNA PPO","1533.63","80.4","","1261.44","103.12","1514.10","21","996.86","1558.81","percent of total billed charges",""
"SCREW SPINE 3.5X12MM MINI MESA POLYAXIAL COMPONENT","SUP-ITM-10085859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1533.63","80.4","","1365.00","1365.00","1365.00","1 through 10","996.86","1558.81","percent of total billed charges",""
"SCREW SPINE 3.5X12MM MINI MESA POLYAXIAL COMPONENT","SUP-ITM-10085859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1558.81","81.72","","5157.68","5157.68","5157.68","1 through 10","996.86","1558.81","percent of total billed charges",""
"SCREW SPINE 3.5X12MM MINI MESA POLYAXIAL COMPONENT","SUP-ITM-10085859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1558.81","81.72","","431.26","71.26","1459.57","88","996.86","1558.81","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","800.18","480.96","1887.97","195","542.5","1391.25","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","813.12","216.42","1444.50","81","542.5","1391.25","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","542.50","31","","432.60","432.60","432.60","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","148.37","54.89","631.39","94","542.5","1391.25","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","279.30","91.72","1116.77","266","542.5","1391.25","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","731.00","63.70","731.00","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","384.74","384.74","384.74","1 through 10","542.5","1391.25","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","286.63","119.22","1107.45","105","542.5","1391.25","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","675.31","184.75","1721.50","286","914.55","1430.1","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1261.44","103.12","1514.10","21","914.55","1430.1","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","1365.00","1365.00","1365.00","1 through 10","914.55","1430.1","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1430.10","81.72","","5157.68","5157.68","5157.68","1 through 10","914.55","1430.1","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","431.26","71.26","1459.57","88","914.55","1430.1","percent of total billed charges",""
"SCREW SPINE 4.5X20MM PEDICLE RESPONSE 4.5/5 UNI","SUP-ITM-10271411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3608.51","79.5","","800.18","480.96","1887.97","195","1407.09","3608.51","percent of total billed charges",""
"SCREW SPINE 4.5X20MM PEDICLE RESPONSE 4.5/5 UNI","SUP-ITM-10271411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2419.29","53.3","","813.12","216.42","1444.50","81","1407.09","3608.51","percent of total billed charges",""
"SCREW SPINE 4.5X20MM PEDICLE RESPONSE 4.5/5 UNI","SUP-ITM-10271411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1407.09","31","","432.60","432.60","432.60","1 through 10","1407.09","3608.51","percent of total billed charges",""
"SCREW SPINE 4.5X20MM PEDICLE RESPONSE 4.5/5 UNI","SUP-ITM-10271411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1656.74","36.5","","148.37","54.89","631.39","94","1407.09","3608.51","percent of total billed charges",""
"SCREW SPINE 4.5X20MM PEDICLE RESPONSE 4.5/5 UNI","SUP-ITM-10271411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1738.44","38.3","","279.30","91.72","1116.77","266","1407.09","3608.51","percent of total billed charges",""
"SCREW SPINE 4.5X20MM PEDICLE RESPONSE 4.5/5 UNI","SUP-ITM-10271411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1947.23","42.9","","731.00","63.70","731.00","1 through 10","1407.09","3608.51","percent of total billed charges",""
"SCREW SPINE 4.5X20MM PEDICLE RESPONSE 4.5/5 UNI","SUP-ITM-10271411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1947.23","42.9","","384.74","384.74","384.74","1 through 10","1407.09","3608.51","percent of total billed charges",""
"SCREW SPINE 4.5X20MM PEDICLE RESPONSE 4.5/5 UNI","SUP-ITM-10271411","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","WELLPOINT [1015]","HB AMC WELLPOINT","3348.87","73.78","","286.63","119.22","1107.45","105","1407.09","3608.51","percent of total billed charges",""
"SCREW SPINE 4.5X20MM PEDICLE RESPONSE 4.5/5 UNI","SUP-ITM-10271411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4539.00","3404.25","AETNA [1001]","HB AMC AETNA HMO","3168.22","69.8","","675.31","184.75","1721.50","286","2372.08","3709.27","percent of total billed charges",""
"SCREW SPINE 4.5X20MM PEDICLE RESPONSE 4.5/5 UNI","SUP-ITM-10271411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4539.00","3404.25","AETNA [1001]","HB AMC AETNA PPO","3649.36","80.4","","1261.44","103.12","1514.10","21","2372.08","3709.27","percent of total billed charges",""
"SCREW SPINE 4.5X20MM PEDICLE RESPONSE 4.5/5 UNI","SUP-ITM-10271411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4539.00","3404.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3649.36","80.4","","1365.00","1365.00","1365.00","1 through 10","2372.08","3709.27","percent of total billed charges",""
"SCREW SPINE 4.5X20MM PEDICLE RESPONSE 4.5/5 UNI","SUP-ITM-10271411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4539.00","3404.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3709.27","81.72","","5157.68","5157.68","5157.68","1 through 10","2372.08","3709.27","percent of total billed charges",""
"SCREW SPINE 4.5X20MM PEDICLE RESPONSE 4.5/5 UNI","SUP-ITM-10271411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4539.00","3404.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3709.27","81.72","","431.26","71.26","1459.57","88","2372.08","3709.27","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","3076.50","2307.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2445.82","79.5","","800.18","480.96","1887.97","195","953.72","2445.82","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","3076.50","2307.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1639.77","53.3","","813.12","216.42","1444.50","81","953.72","2445.82","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","3076.50","2307.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","953.72","31","","432.60","432.60","432.60","1 through 10","953.72","2445.82","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","3076.50","2307.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1122.92","36.5","","148.37","54.89","631.39","94","953.72","2445.82","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","3076.50","2307.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1178.30","38.3","","279.30","91.72","1116.77","266","953.72","2445.82","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","3076.50","2307.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1319.82","42.9","","731.00","63.70","731.00","1 through 10","953.72","2445.82","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","3076.50","2307.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1319.82","42.9","","384.74","384.74","384.74","1 through 10","953.72","2445.82","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","3076.50","2307.37","WELLPOINT [1015]","HB AMC WELLPOINT","2269.84","73.78","","286.63","119.22","1107.45","105","953.72","2445.82","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3076.50","2307.37","AETNA [1001]","HB AMC AETNA HMO","2147.40","69.8","","675.31","184.75","1721.50","286","1607.78","2514.12","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3076.50","2307.37","AETNA [1001]","HB AMC AETNA PPO","2473.51","80.4","","1261.44","103.12","1514.10","21","1607.78","2514.12","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3076.50","2307.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2473.51","80.4","","1365.00","1365.00","1365.00","1 through 10","1607.78","2514.12","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3076.50","2307.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2514.12","81.72","","5157.68","5157.68","5157.68","1 through 10","1607.78","2514.12","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3076.50","2307.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2514.12","81.72","","431.26","71.26","1459.57","88","1607.78","2514.12","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1363.43","79.5","","1309.77","674.56","6049.93","26","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","914.10","53.3","","1901.83","1901.83","2962.25","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","625.98","36.5","","1620.31","1620.31","19908.88","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","656.85","38.3","","352.91","352.91","2046.30","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.74","42.9","","9668.75","9668.75","9668.75","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","WELLPOINT [1015]","HB AMC WELLPOINT","1265.33","73.78","","699.88","384.10","3443.31","33","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","AETNA [1001]","HB AMC AETNA HMO","1197.07","69.8","","1421.24","264.50","4933.46","29","896.26","1401.5","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1378.86","80.4","","1022.97","1022.97","3607.50","1 through 10","896.26","1401.5","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1401.50","81.72","","3010.54","693.88","5019.88","35","896.26","1401.5","percent of total billed charges",""
"SCREW SPINE 4.5X30MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085581","CDM","C1889","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1363.43","79.5","","1309.77","674.56","6049.93","26","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 4.5X30MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085581","CDM","C1889","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","914.10","53.3","","1901.83","1901.83","2962.25","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 4.5X30MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085581","CDM","C1889","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","625.98","36.5","","1620.31","1620.31","19908.88","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 4.5X30MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085581","CDM","C1889","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","656.85","38.3","","352.91","352.91","2046.30","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 4.5X30MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085581","CDM","C1889","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.74","42.9","","9668.75","9668.75","9668.75","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 4.5X30MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085581","CDM","C1889","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","WELLPOINT [1015]","HB AMC WELLPOINT","1265.33","73.78","","699.88","384.10","3443.31","33","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 4.5X30MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085581","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","AETNA [1001]","HB AMC AETNA HMO","1197.07","69.8","","1421.24","264.50","4933.46","29","896.26","1401.5","percent of total billed charges",""
"SCREW SPINE 4.5X30MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085581","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1378.86","80.4","","1022.97","1022.97","3607.50","1 through 10","896.26","1401.5","percent of total billed charges",""
"SCREW SPINE 4.5X30MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085581","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1401.50","81.72","","3010.54","693.88","5019.88","35","896.26","1401.5","percent of total billed charges",""
"SCREW SPINE 4.5X30MM SOLERA TITANIUM FENESTRATED","SUP-ITM-10188743","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2462.51","79.5","","800.18","480.96","1887.97","195","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 4.5X30MM SOLERA TITANIUM FENESTRATED","SUP-ITM-10188743","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1650.97","53.3","","813.12","216.42","1444.50","81","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 4.5X30MM SOLERA TITANIUM FENESTRATED","SUP-ITM-10188743","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","960.23","31","","432.60","432.60","432.60","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 4.5X30MM SOLERA TITANIUM FENESTRATED","SUP-ITM-10188743","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1130.59","36.5","","148.37","54.89","631.39","94","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 4.5X30MM SOLERA TITANIUM FENESTRATED","SUP-ITM-10188743","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1186.34","38.3","","279.30","91.72","1116.77","266","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 4.5X30MM SOLERA TITANIUM FENESTRATED","SUP-ITM-10188743","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1328.83","42.9","","731.00","63.70","731.00","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 4.5X30MM SOLERA TITANIUM FENESTRATED","SUP-ITM-10188743","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1328.83","42.9","","384.74","384.74","384.74","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 4.5X30MM SOLERA TITANIUM FENESTRATED","SUP-ITM-10188743","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","WELLPOINT [1015]","HB AMC WELLPOINT","2285.34","73.78","","286.63","119.22","1107.45","105","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 4.5X30MM SOLERA TITANIUM FENESTRATED","SUP-ITM-10188743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","AETNA [1001]","HB AMC AETNA HMO","2162.06","69.8","","675.31","184.75","1721.50","286","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 4.5X30MM SOLERA TITANIUM FENESTRATED","SUP-ITM-10188743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","AETNA [1001]","HB AMC AETNA PPO","2490.39","80.4","","1261.44","103.12","1514.10","21","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 4.5X30MM SOLERA TITANIUM FENESTRATED","SUP-ITM-10188743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2490.39","80.4","","1365.00","1365.00","1365.00","1 through 10","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 4.5X30MM SOLERA TITANIUM FENESTRATED","SUP-ITM-10188743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2531.28","81.72","","5157.68","5157.68","5157.68","1 through 10","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 4.5X30MM SOLERA TITANIUM FENESTRATED","SUP-ITM-10188743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2531.28","81.72","","431.26","71.26","1459.57","88","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING FIXED","SUP-ITM-10253638","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","800.18","480.96","1887.97","195","97.65","250.43","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING FIXED","SUP-ITM-10253638","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","813.12","216.42","1444.50","81","97.65","250.43","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING FIXED","SUP-ITM-10253638","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","97.65","31","","432.60","432.60","432.60","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING FIXED","SUP-ITM-10253638","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","148.37","54.89","631.39","94","97.65","250.43","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING FIXED","SUP-ITM-10253638","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","279.30","91.72","1116.77","266","97.65","250.43","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING FIXED","SUP-ITM-10253638","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","731.00","63.70","731.00","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING FIXED","SUP-ITM-10253638","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.14","42.9","","384.74","384.74","384.74","1 through 10","97.65","250.43","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING FIXED","SUP-ITM-10253638","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB AMC WELLPOINT","232.41","73.78","","286.63","119.22","1107.45","105","97.65","250.43","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING FIXED","SUP-ITM-10253638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA HMO","219.87","69.8","","675.31","184.75","1721.50","286","164.62","257.42","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING FIXED","SUP-ITM-10253638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","AETNA [1001]","HB AMC AETNA PPO","253.26","80.4","","1261.44","103.12","1514.10","21","164.62","257.42","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING FIXED","SUP-ITM-10253638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.26","80.4","","1365.00","1365.00","1365.00","1 through 10","164.62","257.42","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING FIXED","SUP-ITM-10253638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","257.42","81.72","","5157.68","5157.68","5157.68","1 through 10","164.62","257.42","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING FIXED","SUP-ITM-10253638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","431.26","71.26","1459.57","88","164.62","257.42","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING VARIABLE","SUP-ITM-10253662","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","306.08","79.5","","800.18","480.96","1887.97","195","119.35","306.08","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING VARIABLE","SUP-ITM-10253662","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","205.21","53.3","","813.12","216.42","1444.50","81","119.35","306.08","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING VARIABLE","SUP-ITM-10253662","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","119.35","31","","432.60","432.60","432.60","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING VARIABLE","SUP-ITM-10253662","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","140.53","36.5","","148.37","54.89","631.39","94","119.35","306.08","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING VARIABLE","SUP-ITM-10253662","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","147.46","38.3","","279.30","91.72","1116.77","266","119.35","306.08","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING VARIABLE","SUP-ITM-10253662","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","165.17","42.9","","731.00","63.70","731.00","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING VARIABLE","SUP-ITM-10253662","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","165.17","42.9","","384.74","384.74","384.74","1 through 10","119.35","306.08","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING VARIABLE","SUP-ITM-10253662","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.00","288.75","WELLPOINT [1015]","HB AMC WELLPOINT","284.05","73.78","","286.63","119.22","1107.45","105","119.35","306.08","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING VARIABLE","SUP-ITM-10253662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","AETNA [1001]","HB AMC AETNA HMO","268.73","69.8","","675.31","184.75","1721.50","286","201.2","314.62","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING VARIABLE","SUP-ITM-10253662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","AETNA [1001]","HB AMC AETNA PPO","309.54","80.4","","1261.44","103.12","1514.10","21","201.2","314.62","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING VARIABLE","SUP-ITM-10253662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","309.54","80.4","","1365.00","1365.00","1365.00","1 through 10","201.2","314.62","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING VARIABLE","SUP-ITM-10253662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","314.62","81.72","","5157.68","5157.68","5157.68","1 through 10","201.2","314.62","percent of total billed charges",""
"SCREW SPINE 4X12MM OZARK ANTERIOR CERVICAL SCREWS SELF-STARTING VARIABLE","SUP-ITM-10253662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","314.62","81.72","","431.26","71.26","1459.57","88","201.2","314.62","percent of total billed charges",""
"SCREW SPINE 4X16MM CERVICAL MINI MESA DENALI POLYAXIAL COMPONENT","SUP-ITM-10085873","CDM","C1889","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1516.46","79.5","","1309.77","674.56","6049.93","26","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 4X16MM CERVICAL MINI MESA DENALI POLYAXIAL COMPONENT","SUP-ITM-10085873","CDM","C1889","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1016.70","53.3","","1901.83","1901.83","2962.25","1 through 10","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 4X16MM CERVICAL MINI MESA DENALI POLYAXIAL COMPONENT","SUP-ITM-10085873","CDM","C1889","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","696.24","36.5","","1620.31","1620.31","19908.88","1 through 10","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 4X16MM CERVICAL MINI MESA DENALI POLYAXIAL COMPONENT","SUP-ITM-10085873","CDM","C1889","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","730.57","38.3","","352.91","352.91","2046.30","1 through 10","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 4X16MM CERVICAL MINI MESA DENALI POLYAXIAL COMPONENT","SUP-ITM-10085873","CDM","C1889","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","818.32","42.9","","9668.75","9668.75","9668.75","1 through 10","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 4X16MM CERVICAL MINI MESA DENALI POLYAXIAL COMPONENT","SUP-ITM-10085873","CDM","C1889","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","WELLPOINT [1015]","HB AMC WELLPOINT","1407.35","73.78","","699.88","384.10","3443.31","33","591.33","1516.46","percent of total billed charges",""
"SCREW SPINE 4X16MM CERVICAL MINI MESA DENALI POLYAXIAL COMPONENT","SUP-ITM-10085873","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","AETNA [1001]","HB AMC AETNA HMO","1331.44","69.8","","1421.24","264.50","4933.46","29","996.86","1558.81","percent of total billed charges",""
"SCREW SPINE 4X16MM CERVICAL MINI MESA DENALI POLYAXIAL COMPONENT","SUP-ITM-10085873","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1533.63","80.4","","1022.97","1022.97","3607.50","1 through 10","996.86","1558.81","percent of total billed charges",""
"SCREW SPINE 4X16MM CERVICAL MINI MESA DENALI POLYAXIAL COMPONENT","SUP-ITM-10085873","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1558.81","81.72","","3010.54","693.88","5019.88","35","996.86","1558.81","percent of total billed charges",""
"SCREW SPINE 4X25MM RELINE O TRACTION 13174025","SUP-ITM-10170457","CDM","C1713","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1229.87","79.5","","800.18","480.96","1887.97","195","479.57","1229.87","percent of total billed charges",""
"SCREW SPINE 4X25MM RELINE O TRACTION 13174025","SUP-ITM-10170457","CDM","C1713","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","824.55","53.3","","813.12","216.42","1444.50","81","479.57","1229.87","percent of total billed charges",""
"SCREW SPINE 4X25MM RELINE O TRACTION 13174025","SUP-ITM-10170457","CDM","C1713","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","479.57","31","","432.60","432.60","432.60","1 through 10","479.57","1229.87","percent of total billed charges",""
"SCREW SPINE 4X25MM RELINE O TRACTION 13174025","SUP-ITM-10170457","CDM","C1713","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","564.66","36.5","","148.37","54.89","631.39","94","479.57","1229.87","percent of total billed charges",""
"SCREW SPINE 4X25MM RELINE O TRACTION 13174025","SUP-ITM-10170457","CDM","C1713","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","592.50","38.3","","279.30","91.72","1116.77","266","479.57","1229.87","percent of total billed charges",""
"SCREW SPINE 4X25MM RELINE O TRACTION 13174025","SUP-ITM-10170457","CDM","C1713","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","663.66","42.9","","731.00","63.70","731.00","1 through 10","479.57","1229.87","percent of total billed charges",""
"SCREW SPINE 4X25MM RELINE O TRACTION 13174025","SUP-ITM-10170457","CDM","C1713","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","663.66","42.9","","384.74","384.74","384.74","1 through 10","479.57","1229.87","percent of total billed charges",""
"SCREW SPINE 4X25MM RELINE O TRACTION 13174025","SUP-ITM-10170457","CDM","C1713","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","WELLPOINT [1015]","HB AMC WELLPOINT","1141.38","73.78","","286.63","119.22","1107.45","105","479.57","1229.87","percent of total billed charges",""
"SCREW SPINE 4X25MM RELINE O TRACTION 13174025","SUP-ITM-10170457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1547.00","1160.25","AETNA [1001]","HB AMC AETNA HMO","1079.81","69.8","","675.31","184.75","1721.50","286","808.46","1264.21","percent of total billed charges",""
"SCREW SPINE 4X25MM RELINE O TRACTION 13174025","SUP-ITM-10170457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1547.00","1160.25","AETNA [1001]","HB AMC AETNA PPO","1243.79","80.4","","1261.44","103.12","1514.10","21","808.46","1264.21","percent of total billed charges",""
"SCREW SPINE 4X25MM RELINE O TRACTION 13174025","SUP-ITM-10170457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1547.00","1160.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1243.79","80.4","","1365.00","1365.00","1365.00","1 through 10","808.46","1264.21","percent of total billed charges",""
"SCREW SPINE 4X25MM RELINE O TRACTION 13174025","SUP-ITM-10170457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1547.00","1160.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1264.21","81.72","","5157.68","5157.68","5157.68","1 through 10","808.46","1264.21","percent of total billed charges",""
"SCREW SPINE 4X25MM RELINE O TRACTION 13174025","SUP-ITM-10170457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1547.00","1160.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1264.21","81.72","","431.26","71.26","1459.57","88","808.46","1264.21","percent of total billed charges",""
"SCREW SPINE 5.5X30MM TRAVERSE","SUP-ITM-10091202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1363.43","79.5","","800.18","480.96","1887.97","195","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 5.5X30MM TRAVERSE","SUP-ITM-10091202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","914.10","53.3","","813.12","216.42","1444.50","81","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 5.5X30MM TRAVERSE","SUP-ITM-10091202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","531.65","31","","432.60","432.60","432.60","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 5.5X30MM TRAVERSE","SUP-ITM-10091202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","625.98","36.5","","148.37","54.89","631.39","94","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 5.5X30MM TRAVERSE","SUP-ITM-10091202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","656.85","38.3","","279.30","91.72","1116.77","266","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 5.5X30MM TRAVERSE","SUP-ITM-10091202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.74","42.9","","731.00","63.70","731.00","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 5.5X30MM TRAVERSE","SUP-ITM-10091202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.74","42.9","","384.74","384.74","384.74","1 through 10","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 5.5X30MM TRAVERSE","SUP-ITM-10091202","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","WELLPOINT [1015]","HB AMC WELLPOINT","1265.33","73.78","","286.63","119.22","1107.45","105","531.65","1363.43","percent of total billed charges",""
"SCREW SPINE 5.5X30MM TRAVERSE","SUP-ITM-10091202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","AETNA [1001]","HB AMC AETNA HMO","1197.07","69.8","","675.31","184.75","1721.50","286","896.26","1401.5","percent of total billed charges",""
"SCREW SPINE 5.5X30MM TRAVERSE","SUP-ITM-10091202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","AETNA [1001]","HB AMC AETNA PPO","1378.86","80.4","","1261.44","103.12","1514.10","21","896.26","1401.5","percent of total billed charges",""
"SCREW SPINE 5.5X30MM TRAVERSE","SUP-ITM-10091202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1378.86","80.4","","1365.00","1365.00","1365.00","1 through 10","896.26","1401.5","percent of total billed charges",""
"SCREW SPINE 5.5X30MM TRAVERSE","SUP-ITM-10091202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1401.50","81.72","","5157.68","5157.68","5157.68","1 through 10","896.26","1401.5","percent of total billed charges",""
"SCREW SPINE 5.5X30MM TRAVERSE","SUP-ITM-10091202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1401.50","81.72","","431.26","71.26","1459.57","88","896.26","1401.5","percent of total billed charges",""
"SCREW SPINE 5.5X35MM LIF AMP","SUP-ITM-10272717","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","278.25","79.5","","800.18","480.96","1887.97","195","108.5","278.25","percent of total billed charges",""
"SCREW SPINE 5.5X35MM LIF AMP","SUP-ITM-10272717","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","186.55","53.3","","813.12","216.42","1444.50","81","108.5","278.25","percent of total billed charges",""
"SCREW SPINE 5.5X35MM LIF AMP","SUP-ITM-10272717","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","108.50","31","","432.60","432.60","432.60","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW SPINE 5.5X35MM LIF AMP","SUP-ITM-10272717","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.75","36.5","","148.37","54.89","631.39","94","108.5","278.25","percent of total billed charges",""
"SCREW SPINE 5.5X35MM LIF AMP","SUP-ITM-10272717","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","134.05","38.3","","279.30","91.72","1116.77","266","108.5","278.25","percent of total billed charges",""
"SCREW SPINE 5.5X35MM LIF AMP","SUP-ITM-10272717","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","731.00","63.70","731.00","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW SPINE 5.5X35MM LIF AMP","SUP-ITM-10272717","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.15","42.9","","384.74","384.74","384.74","1 through 10","108.5","278.25","percent of total billed charges",""
"SCREW SPINE 5.5X35MM LIF AMP","SUP-ITM-10272717","CDM","C1713","HCPCS","0278","RC","","","","both","","","350.00","262.50","WELLPOINT [1015]","HB AMC WELLPOINT","258.23","73.78","","286.63","119.22","1107.45","105","108.5","278.25","percent of total billed charges",""
"SCREW SPINE 5.5X35MM LIF AMP","SUP-ITM-10272717","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA HMO","244.30","69.8","","675.31","184.75","1721.50","286","182.91","286.02","percent of total billed charges",""
"SCREW SPINE 5.5X35MM LIF AMP","SUP-ITM-10272717","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","AETNA [1001]","HB AMC AETNA PPO","281.40","80.4","","1261.44","103.12","1514.10","21","182.91","286.02","percent of total billed charges",""
"SCREW SPINE 5.5X35MM LIF AMP","SUP-ITM-10272717","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","281.40","80.4","","1365.00","1365.00","1365.00","1 through 10","182.91","286.02","percent of total billed charges",""
"SCREW SPINE 5.5X35MM LIF AMP","SUP-ITM-10272717","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","286.02","81.72","","5157.68","5157.68","5157.68","1 through 10","182.91","286.02","percent of total billed charges",""
"SCREW SPINE 5.5X35MM LIF AMP","SUP-ITM-10272717","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","286.02","81.72","","431.26","71.26","1459.57","88","182.91","286.02","percent of total billed charges",""
"SCREW SPINE 6.5X30MM 5.5/6 SV ATS","SUP-ITM-10258853","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2643.38","79.5","","800.18","480.96","1887.97","195","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X30MM 5.5/6 SV ATS","SUP-ITM-10258853","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1772.23","53.3","","813.12","216.42","1444.50","81","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X30MM 5.5/6 SV ATS","SUP-ITM-10258853","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1030.75","31","","432.60","432.60","432.60","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X30MM 5.5/6 SV ATS","SUP-ITM-10258853","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1213.63","36.5","","148.37","54.89","631.39","94","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X30MM 5.5/6 SV ATS","SUP-ITM-10258853","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1273.48","38.3","","279.30","91.72","1116.77","266","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X30MM 5.5/6 SV ATS","SUP-ITM-10258853","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","731.00","63.70","731.00","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X30MM 5.5/6 SV ATS","SUP-ITM-10258853","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","384.74","384.74","384.74","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X30MM 5.5/6 SV ATS","SUP-ITM-10258853","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","WELLPOINT [1015]","HB AMC WELLPOINT","2453.19","73.78","","286.63","119.22","1107.45","105","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X30MM 5.5/6 SV ATS","SUP-ITM-10258853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA HMO","2320.85","69.8","","675.31","184.75","1721.50","286","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X30MM 5.5/6 SV ATS","SUP-ITM-10258853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA PPO","2673.30","80.4","","1261.44","103.12","1514.10","21","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X30MM 5.5/6 SV ATS","SUP-ITM-10258853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2673.30","80.4","","1365.00","1365.00","1365.00","1 through 10","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X30MM 5.5/6 SV ATS","SUP-ITM-10258853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2717.19","81.72","","5157.68","5157.68","5157.68","1 through 10","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X30MM 5.5/6 SV ATS","SUP-ITM-10258853","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2717.19","81.72","","431.26","71.26","1459.57","88","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X35MM 5.5/6 SV ATS","SUP-ITM-10258852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2643.38","79.5","","800.18","480.96","1887.97","195","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X35MM 5.5/6 SV ATS","SUP-ITM-10258852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1772.23","53.3","","813.12","216.42","1444.50","81","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X35MM 5.5/6 SV ATS","SUP-ITM-10258852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1030.75","31","","432.60","432.60","432.60","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X35MM 5.5/6 SV ATS","SUP-ITM-10258852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1213.63","36.5","","148.37","54.89","631.39","94","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X35MM 5.5/6 SV ATS","SUP-ITM-10258852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1273.48","38.3","","279.30","91.72","1116.77","266","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X35MM 5.5/6 SV ATS","SUP-ITM-10258852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","731.00","63.70","731.00","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X35MM 5.5/6 SV ATS","SUP-ITM-10258852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","384.74","384.74","384.74","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X35MM 5.5/6 SV ATS","SUP-ITM-10258852","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","WELLPOINT [1015]","HB AMC WELLPOINT","2453.19","73.78","","286.63","119.22","1107.45","105","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X35MM 5.5/6 SV ATS","SUP-ITM-10258852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA HMO","2320.85","69.8","","675.31","184.75","1721.50","286","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X35MM 5.5/6 SV ATS","SUP-ITM-10258852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA PPO","2673.30","80.4","","1261.44","103.12","1514.10","21","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X35MM 5.5/6 SV ATS","SUP-ITM-10258852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2673.30","80.4","","1365.00","1365.00","1365.00","1 through 10","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X35MM 5.5/6 SV ATS","SUP-ITM-10258852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2717.19","81.72","","5157.68","5157.68","5157.68","1 through 10","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X35MM 5.5/6 SV ATS","SUP-ITM-10258852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2717.19","81.72","","431.26","71.26","1459.57","88","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X40MM VOYAGER PEDICLE","SUP-ITM-10212634","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1766.89","79.5","","800.18","480.96","1887.97","195","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X40MM VOYAGER PEDICLE","SUP-ITM-10212634","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1184.59","53.3","","813.12","216.42","1444.50","81","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X40MM VOYAGER PEDICLE","SUP-ITM-10212634","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","688.98","31","","432.60","432.60","432.60","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X40MM VOYAGER PEDICLE","SUP-ITM-10212634","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","811.21","36.5","","148.37","54.89","631.39","94","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X40MM VOYAGER PEDICLE","SUP-ITM-10212634","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","851.22","38.3","","279.30","91.72","1116.77","266","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X40MM VOYAGER PEDICLE","SUP-ITM-10212634","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.45","42.9","","731.00","63.70","731.00","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X40MM VOYAGER PEDICLE","SUP-ITM-10212634","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.45","42.9","","384.74","384.74","384.74","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X40MM VOYAGER PEDICLE","SUP-ITM-10212634","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","WELLPOINT [1015]","HB AMC WELLPOINT","1639.76","73.78","","286.63","119.22","1107.45","105","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X40MM VOYAGER PEDICLE","SUP-ITM-10212634","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","AETNA [1001]","HB AMC AETNA HMO","1551.31","69.8","","675.31","184.75","1721.50","286","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X40MM VOYAGER PEDICLE","SUP-ITM-10212634","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","AETNA [1001]","HB AMC AETNA PPO","1786.89","80.4","","1261.44","103.12","1514.10","21","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X40MM VOYAGER PEDICLE","SUP-ITM-10212634","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1786.89","80.4","","1365.00","1365.00","1365.00","1 through 10","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X40MM VOYAGER PEDICLE","SUP-ITM-10212634","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1816.23","81.72","","5157.68","5157.68","5157.68","1 through 10","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X40MM VOYAGER PEDICLE","SUP-ITM-10212634","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1816.23","81.72","","431.26","71.26","1459.57","88","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X45MM PEDICLE PALISADE CANNULATED POLYAXIAL","SUP-ITM-10168029","CDM","C1889","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1766.89","79.5","","1309.77","674.56","6049.93","26","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM PEDICLE PALISADE CANNULATED POLYAXIAL","SUP-ITM-10168029","CDM","C1889","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1184.59","53.3","","1901.83","1901.83","2962.25","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM PEDICLE PALISADE CANNULATED POLYAXIAL","SUP-ITM-10168029","CDM","C1889","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","811.21","36.5","","1620.31","1620.31","19908.88","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM PEDICLE PALISADE CANNULATED POLYAXIAL","SUP-ITM-10168029","CDM","C1889","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","851.22","38.3","","352.91","352.91","2046.30","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM PEDICLE PALISADE CANNULATED POLYAXIAL","SUP-ITM-10168029","CDM","C1889","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.45","42.9","","9668.75","9668.75","9668.75","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM PEDICLE PALISADE CANNULATED POLYAXIAL","SUP-ITM-10168029","CDM","C1889","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","WELLPOINT [1015]","HB AMC WELLPOINT","1639.76","73.78","","699.88","384.10","3443.31","33","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM PEDICLE PALISADE CANNULATED POLYAXIAL","SUP-ITM-10168029","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","AETNA [1001]","HB AMC AETNA HMO","1551.31","69.8","","1421.24","264.50","4933.46","29","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X45MM PEDICLE PALISADE CANNULATED POLYAXIAL","SUP-ITM-10168029","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1786.89","80.4","","1022.97","1022.97","3607.50","1 through 10","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X45MM PEDICLE PALISADE CANNULATED POLYAXIAL","SUP-ITM-10168029","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1816.23","81.72","","3010.54","693.88","5019.88","35","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","800.18","480.96","1887.97","195","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.85","53.3","","813.12","216.42","1444.50","81","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","759.50","31","","432.60","432.60","432.60","1 through 10","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","148.37","54.89","631.39","94","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","279.30","91.72","1116.77","266","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","731.00","63.70","731.00","1 through 10","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","384.74","384.74","384.74","1 through 10","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","286.63","119.22","1107.45","105","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","675.31","184.75","1721.50","286","1280.37","2002.14","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA PPO","1969.80","80.4","","1261.44","103.12","1514.10","21","1280.37","2002.14","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.80","80.4","","1365.00","1365.00","1365.00","1 through 10","1280.37","2002.14","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2002.14","81.72","","5157.68","5157.68","5157.68","1 through 10","1280.37","2002.14","percent of total billed charges",""
"SCREW SPINE 6.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","431.26","71.26","1459.57","88","1280.37","2002.14","percent of total billed charges",""
"SCREW SPINE 6.5X45MM THRESHOLD CANNULATED POLYAXIAL BLUE","SUP-ITM-10151176","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1766.89","79.5","","800.18","480.96","1887.97","195","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM THRESHOLD CANNULATED POLYAXIAL BLUE","SUP-ITM-10151176","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1184.59","53.3","","813.12","216.42","1444.50","81","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM THRESHOLD CANNULATED POLYAXIAL BLUE","SUP-ITM-10151176","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","688.98","31","","432.60","432.60","432.60","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM THRESHOLD CANNULATED POLYAXIAL BLUE","SUP-ITM-10151176","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","811.21","36.5","","148.37","54.89","631.39","94","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM THRESHOLD CANNULATED POLYAXIAL BLUE","SUP-ITM-10151176","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","851.22","38.3","","279.30","91.72","1116.77","266","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM THRESHOLD CANNULATED POLYAXIAL BLUE","SUP-ITM-10151176","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.45","42.9","","731.00","63.70","731.00","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM THRESHOLD CANNULATED POLYAXIAL BLUE","SUP-ITM-10151176","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.45","42.9","","384.74","384.74","384.74","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM THRESHOLD CANNULATED POLYAXIAL BLUE","SUP-ITM-10151176","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","WELLPOINT [1015]","HB AMC WELLPOINT","1639.76","73.78","","286.63","119.22","1107.45","105","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X45MM THRESHOLD CANNULATED POLYAXIAL BLUE","SUP-ITM-10151176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","AETNA [1001]","HB AMC AETNA HMO","1551.31","69.8","","675.31","184.75","1721.50","286","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X45MM THRESHOLD CANNULATED POLYAXIAL BLUE","SUP-ITM-10151176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","AETNA [1001]","HB AMC AETNA PPO","1786.89","80.4","","1261.44","103.12","1514.10","21","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X45MM THRESHOLD CANNULATED POLYAXIAL BLUE","SUP-ITM-10151176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1786.89","80.4","","1365.00","1365.00","1365.00","1 through 10","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X45MM THRESHOLD CANNULATED POLYAXIAL BLUE","SUP-ITM-10151176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1816.23","81.72","","5157.68","5157.68","5157.68","1 through 10","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X45MM THRESHOLD CANNULATED POLYAXIAL BLUE","SUP-ITM-10151176","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1816.23","81.72","","431.26","71.26","1459.57","88","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X45MM VOYAGR","SUP-ITM-10258850","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2643.38","79.5","","800.18","480.96","1887.97","195","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X45MM VOYAGR","SUP-ITM-10258850","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1772.23","53.3","","813.12","216.42","1444.50","81","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X45MM VOYAGR","SUP-ITM-10258850","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1030.75","31","","432.60","432.60","432.60","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X45MM VOYAGR","SUP-ITM-10258850","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1213.63","36.5","","148.37","54.89","631.39","94","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X45MM VOYAGR","SUP-ITM-10258850","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1273.48","38.3","","279.30","91.72","1116.77","266","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X45MM VOYAGR","SUP-ITM-10258850","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","731.00","63.70","731.00","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X45MM VOYAGR","SUP-ITM-10258850","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","384.74","384.74","384.74","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X45MM VOYAGR","SUP-ITM-10258850","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","WELLPOINT [1015]","HB AMC WELLPOINT","2453.19","73.78","","286.63","119.22","1107.45","105","1030.75","2643.38","percent of total billed charges",""
"SCREW SPINE 6.5X45MM VOYAGR","SUP-ITM-10258850","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA HMO","2320.85","69.8","","675.31","184.75","1721.50","286","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X45MM VOYAGR","SUP-ITM-10258850","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA PPO","2673.30","80.4","","1261.44","103.12","1514.10","21","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X45MM VOYAGR","SUP-ITM-10258850","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2673.30","80.4","","1365.00","1365.00","1365.00","1 through 10","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X45MM VOYAGR","SUP-ITM-10258850","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2717.19","81.72","","5157.68","5157.68","5157.68","1 through 10","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X45MM VOYAGR","SUP-ITM-10258850","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2717.19","81.72","","431.26","71.26","1459.57","88","1737.65","2717.19","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1766.89","79.5","","800.18","480.96","1887.97","195","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1184.59","53.3","","813.12","216.42","1444.50","81","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","688.98","31","","432.60","432.60","432.60","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","811.21","36.5","","148.37","54.89","631.39","94","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","851.22","38.3","","279.30","91.72","1116.77","266","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.45","42.9","","731.00","63.70","731.00","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.45","42.9","","384.74","384.74","384.74","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","WELLPOINT [1015]","HB AMC WELLPOINT","1639.76","73.78","","286.63","119.22","1107.45","105","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","AETNA [1001]","HB AMC AETNA HMO","1551.31","69.8","","675.31","184.75","1721.50","286","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","AETNA [1001]","HB AMC AETNA PPO","1786.89","80.4","","1261.44","103.12","1514.10","21","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1786.89","80.4","","1365.00","1365.00","1365.00","1 through 10","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1816.23","81.72","","5157.68","5157.68","5157.68","1 through 10","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1816.23","81.72","","431.26","71.26","1459.57","88","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 60MM RELINE CONNECTING OPEN","SUP-ITM-10170401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1349.51","79.5","","800.18","480.96","1887.97","195","526.23","1349.51","percent of total billed charges",""
"SCREW SPINE 60MM RELINE CONNECTING OPEN","SUP-ITM-10170401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","904.77","53.3","","813.12","216.42","1444.50","81","526.23","1349.51","percent of total billed charges",""
"SCREW SPINE 60MM RELINE CONNECTING OPEN","SUP-ITM-10170401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","526.23","31","","432.60","432.60","432.60","1 through 10","526.23","1349.51","percent of total billed charges",""
"SCREW SPINE 60MM RELINE CONNECTING OPEN","SUP-ITM-10170401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","619.59","36.5","","148.37","54.89","631.39","94","526.23","1349.51","percent of total billed charges",""
"SCREW SPINE 60MM RELINE CONNECTING OPEN","SUP-ITM-10170401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","650.14","38.3","","279.30","91.72","1116.77","266","526.23","1349.51","percent of total billed charges",""
"SCREW SPINE 60MM RELINE CONNECTING OPEN","SUP-ITM-10170401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.23","42.9","","731.00","63.70","731.00","1 through 10","526.23","1349.51","percent of total billed charges",""
"SCREW SPINE 60MM RELINE CONNECTING OPEN","SUP-ITM-10170401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.23","42.9","","384.74","384.74","384.74","1 through 10","526.23","1349.51","percent of total billed charges",""
"SCREW SPINE 60MM RELINE CONNECTING OPEN","SUP-ITM-10170401","CDM","C1713","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","WELLPOINT [1015]","HB AMC WELLPOINT","1252.42","73.78","","286.63","119.22","1107.45","105","526.23","1349.51","percent of total billed charges",""
"SCREW SPINE 60MM RELINE CONNECTING OPEN","SUP-ITM-10170401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","AETNA [1001]","HB AMC AETNA HMO","1184.86","69.8","","675.31","184.75","1721.50","286","887.11","1387.2","percent of total billed charges",""
"SCREW SPINE 60MM RELINE CONNECTING OPEN","SUP-ITM-10170401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","AETNA [1001]","HB AMC AETNA PPO","1364.79","80.4","","1261.44","103.12","1514.10","21","887.11","1387.2","percent of total billed charges",""
"SCREW SPINE 60MM RELINE CONNECTING OPEN","SUP-ITM-10170401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1364.79","80.4","","1365.00","1365.00","1365.00","1 through 10","887.11","1387.2","percent of total billed charges",""
"SCREW SPINE 60MM RELINE CONNECTING OPEN","SUP-ITM-10170401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1387.20","81.72","","5157.68","5157.68","5157.68","1 through 10","887.11","1387.2","percent of total billed charges",""
"SCREW SPINE 60MM RELINE CONNECTING OPEN","SUP-ITM-10170401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1387.20","81.72","","431.26","71.26","1459.57","88","887.11","1387.2","percent of total billed charges",""
"SCREW SPINE 6X40MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2462.51","79.5","","800.18","480.96","1887.97","195","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 6X40MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1650.97","53.3","","813.12","216.42","1444.50","81","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 6X40MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","960.23","31","","432.60","432.60","432.60","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 6X40MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1130.59","36.5","","148.37","54.89","631.39","94","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 6X40MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1186.34","38.3","","279.30","91.72","1116.77","266","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 6X40MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1328.83","42.9","","731.00","63.70","731.00","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 6X40MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1328.83","42.9","","384.74","384.74","384.74","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 6X40MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","WELLPOINT [1015]","HB AMC WELLPOINT","2285.34","73.78","","286.63","119.22","1107.45","105","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 6X40MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","AETNA [1001]","HB AMC AETNA HMO","2162.06","69.8","","675.31","184.75","1721.50","286","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 6X40MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","AETNA [1001]","HB AMC AETNA PPO","2490.39","80.4","","1261.44","103.12","1514.10","21","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 6X40MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2490.39","80.4","","1365.00","1365.00","1365.00","1 through 10","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 6X40MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2531.28","81.72","","5157.68","5157.68","5157.68","1 through 10","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 6X40MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2531.28","81.72","","431.26","71.26","1459.57","88","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 7.5X40MM RELINE 2FS POLYAXIAL","SUP-ITM-10229311","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2573.81","79.5","","800.18","480.96","1887.97","195","1003.63","2573.81","percent of total billed charges",""
"SCREW SPINE 7.5X40MM RELINE 2FS POLYAXIAL","SUP-ITM-10229311","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1725.59","53.3","","813.12","216.42","1444.50","81","1003.63","2573.81","percent of total billed charges",""
"SCREW SPINE 7.5X40MM RELINE 2FS POLYAXIAL","SUP-ITM-10229311","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1003.63","31","","432.60","432.60","432.60","1 through 10","1003.63","2573.81","percent of total billed charges",""
"SCREW SPINE 7.5X40MM RELINE 2FS POLYAXIAL","SUP-ITM-10229311","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1181.69","36.5","","148.37","54.89","631.39","94","1003.63","2573.81","percent of total billed charges",""
"SCREW SPINE 7.5X40MM RELINE 2FS POLYAXIAL","SUP-ITM-10229311","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1239.96","38.3","","279.30","91.72","1116.77","266","1003.63","2573.81","percent of total billed charges",""
"SCREW SPINE 7.5X40MM RELINE 2FS POLYAXIAL","SUP-ITM-10229311","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1388.89","42.9","","731.00","63.70","731.00","1 through 10","1003.63","2573.81","percent of total billed charges",""
"SCREW SPINE 7.5X40MM RELINE 2FS POLYAXIAL","SUP-ITM-10229311","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1388.89","42.9","","384.74","384.74","384.74","1 through 10","1003.63","2573.81","percent of total billed charges",""
"SCREW SPINE 7.5X40MM RELINE 2FS POLYAXIAL","SUP-ITM-10229311","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","WELLPOINT [1015]","HB AMC WELLPOINT","2388.63","73.78","","286.63","119.22","1107.45","105","1003.63","2573.81","percent of total billed charges",""
"SCREW SPINE 7.5X40MM RELINE 2FS POLYAXIAL","SUP-ITM-10229311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","AETNA [1001]","HB AMC AETNA HMO","2259.78","69.8","","675.31","184.75","1721.50","286","1691.92","2645.69","percent of total billed charges",""
"SCREW SPINE 7.5X40MM RELINE 2FS POLYAXIAL","SUP-ITM-10229311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","AETNA [1001]","HB AMC AETNA PPO","2602.95","80.4","","1261.44","103.12","1514.10","21","1691.92","2645.69","percent of total billed charges",""
"SCREW SPINE 7.5X40MM RELINE 2FS POLYAXIAL","SUP-ITM-10229311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2602.95","80.4","","1365.00","1365.00","1365.00","1 through 10","1691.92","2645.69","percent of total billed charges",""
"SCREW SPINE 7.5X40MM RELINE 2FS POLYAXIAL","SUP-ITM-10229311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2645.69","81.72","","5157.68","5157.68","5157.68","1 through 10","1691.92","2645.69","percent of total billed charges",""
"SCREW SPINE 7.5X40MM RELINE 2FS POLYAXIAL","SUP-ITM-10229311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2645.69","81.72","","431.26","71.26","1459.57","88","1691.92","2645.69","percent of total billed charges",""
"SCREW SPINE 7.5X45MM EVEREST MI CANNULATED POLYAXIAL FENESTRATED","SUP-ITM-10252842","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2462.51","79.5","","800.18","480.96","1887.97","195","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7.5X45MM EVEREST MI CANNULATED POLYAXIAL FENESTRATED","SUP-ITM-10252842","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1650.97","53.3","","813.12","216.42","1444.50","81","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7.5X45MM EVEREST MI CANNULATED POLYAXIAL FENESTRATED","SUP-ITM-10252842","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","960.23","31","","432.60","432.60","432.60","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7.5X45MM EVEREST MI CANNULATED POLYAXIAL FENESTRATED","SUP-ITM-10252842","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1130.59","36.5","","148.37","54.89","631.39","94","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7.5X45MM EVEREST MI CANNULATED POLYAXIAL FENESTRATED","SUP-ITM-10252842","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1186.34","38.3","","279.30","91.72","1116.77","266","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7.5X45MM EVEREST MI CANNULATED POLYAXIAL FENESTRATED","SUP-ITM-10252842","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1328.83","42.9","","731.00","63.70","731.00","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7.5X45MM EVEREST MI CANNULATED POLYAXIAL FENESTRATED","SUP-ITM-10252842","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1328.83","42.9","","384.74","384.74","384.74","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7.5X45MM EVEREST MI CANNULATED POLYAXIAL FENESTRATED","SUP-ITM-10252842","CDM","C1713","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","WELLPOINT [1015]","HB AMC WELLPOINT","2285.34","73.78","","286.63","119.22","1107.45","105","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7.5X45MM EVEREST MI CANNULATED POLYAXIAL FENESTRATED","SUP-ITM-10252842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","AETNA [1001]","HB AMC AETNA HMO","2162.06","69.8","","675.31","184.75","1721.50","286","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 7.5X45MM EVEREST MI CANNULATED POLYAXIAL FENESTRATED","SUP-ITM-10252842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","AETNA [1001]","HB AMC AETNA PPO","2490.39","80.4","","1261.44","103.12","1514.10","21","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 7.5X45MM EVEREST MI CANNULATED POLYAXIAL FENESTRATED","SUP-ITM-10252842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2490.39","80.4","","1365.00","1365.00","1365.00","1 through 10","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 7.5X45MM EVEREST MI CANNULATED POLYAXIAL FENESTRATED","SUP-ITM-10252842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2531.28","81.72","","5157.68","5157.68","5157.68","1 through 10","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 7.5X45MM EVEREST MI CANNULATED POLYAXIAL FENESTRATED","SUP-ITM-10252842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2531.28","81.72","","431.26","71.26","1459.57","88","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 7.5X45MM POLYAXIAL 15004-075-045","SUP-ITM-10244792","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1766.89","79.5","","800.18","480.96","1887.97","195","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 7.5X45MM POLYAXIAL 15004-075-045","SUP-ITM-10244792","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1184.59","53.3","","813.12","216.42","1444.50","81","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 7.5X45MM POLYAXIAL 15004-075-045","SUP-ITM-10244792","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","688.98","31","","432.60","432.60","432.60","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 7.5X45MM POLYAXIAL 15004-075-045","SUP-ITM-10244792","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","811.21","36.5","","148.37","54.89","631.39","94","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 7.5X45MM POLYAXIAL 15004-075-045","SUP-ITM-10244792","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","851.22","38.3","","279.30","91.72","1116.77","266","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 7.5X45MM POLYAXIAL 15004-075-045","SUP-ITM-10244792","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.45","42.9","","731.00","63.70","731.00","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 7.5X45MM POLYAXIAL 15004-075-045","SUP-ITM-10244792","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","953.45","42.9","","384.74","384.74","384.74","1 through 10","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 7.5X45MM POLYAXIAL 15004-075-045","SUP-ITM-10244792","CDM","C1713","HCPCS","0278","RC","","","","both","","","2222.50","1666.87","WELLPOINT [1015]","HB AMC WELLPOINT","1639.76","73.78","","286.63","119.22","1107.45","105","688.98","1766.89","percent of total billed charges",""
"SCREW SPINE 7.5X45MM POLYAXIAL 15004-075-045","SUP-ITM-10244792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","AETNA [1001]","HB AMC AETNA HMO","1551.31","69.8","","675.31","184.75","1721.50","286","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 7.5X45MM POLYAXIAL 15004-075-045","SUP-ITM-10244792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","AETNA [1001]","HB AMC AETNA PPO","1786.89","80.4","","1261.44","103.12","1514.10","21","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 7.5X45MM POLYAXIAL 15004-075-045","SUP-ITM-10244792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1786.89","80.4","","1365.00","1365.00","1365.00","1 through 10","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 7.5X45MM POLYAXIAL 15004-075-045","SUP-ITM-10244792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1816.23","81.72","","5157.68","5157.68","5157.68","1 through 10","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 7.5X45MM POLYAXIAL 15004-075-045","SUP-ITM-10244792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2222.50","1666.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1816.23","81.72","","431.26","71.26","1459.57","88","1161.48","1816.23","percent of total billed charges",""
"SCREW SPINE 7.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","800.18","480.96","1887.97","195","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 7.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.85","53.3","","813.12","216.42","1444.50","81","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 7.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","759.50","31","","432.60","432.60","432.60","1 through 10","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 7.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","148.37","54.89","631.39","94","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 7.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","279.30","91.72","1116.77","266","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 7.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","731.00","63.70","731.00","1 through 10","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 7.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","384.74","384.74","384.74","1 through 10","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 7.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229381","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","286.63","119.22","1107.45","105","759.5","1947.75","percent of total billed charges",""
"SCREW SPINE 7.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","675.31","184.75","1721.50","286","1280.37","2002.14","percent of total billed charges",""
"SCREW SPINE 7.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA PPO","1969.80","80.4","","1261.44","103.12","1514.10","21","1280.37","2002.14","percent of total billed charges",""
"SCREW SPINE 7.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.80","80.4","","1365.00","1365.00","1365.00","1 through 10","1280.37","2002.14","percent of total billed charges",""
"SCREW SPINE 7.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2002.14","81.72","","5157.68","5157.68","5157.68","1 through 10","1280.37","2002.14","percent of total billed charges",""
"SCREW SPINE 7.5X45MM RELINE MAS TRACTION POLY","SUP-ITM-10229381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","431.26","71.26","1459.57","88","1280.37","2002.14","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","800.18","480.96","1887.97","195","868","2226","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1492.40","53.3","","813.12","216.42","1444.50","81","868","2226","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","868.00","31","","432.60","432.60","432.60","1 through 10","868","2226","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","148.37","54.89","631.39","94","868","2226","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","279.30","91.72","1116.77","266","868","2226","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","731.00","63.70","731.00","1 through 10","868","2226","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","384.74","384.74","384.74","1 through 10","868","2226","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","286.63","119.22","1107.45","105","868","2226","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA HMO","1954.40","69.8","","675.31","184.75","1721.50","286","1463.28","2288.16","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA PPO","2251.20","80.4","","1261.44","103.12","1514.10","21","1463.28","2288.16","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2251.20","80.4","","1365.00","1365.00","1365.00","1 through 10","1463.28","2288.16","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2288.16","81.72","","5157.68","5157.68","5157.68","1 through 10","1463.28","2288.16","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","431.26","71.26","1459.57","88","1463.28","2288.16","percent of total billed charges",""
"SCREW SPINE 7X45MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243541","CDM","C1889","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2462.51","79.5","","1309.77","674.56","6049.93","26","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7X45MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243541","CDM","C1889","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1650.97","53.3","","1901.83","1901.83","2962.25","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7X45MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243541","CDM","C1889","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1130.59","36.5","","1620.31","1620.31","19908.88","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7X45MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243541","CDM","C1889","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1186.34","38.3","","352.91","352.91","2046.30","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7X45MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243541","CDM","C1889","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1328.83","42.9","","9668.75","9668.75","9668.75","1 through 10","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7X45MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243541","CDM","C1889","HCPCS","0278","RC","","","","both","","","3097.50","2323.12","WELLPOINT [1015]","HB AMC WELLPOINT","2285.34","73.78","","699.88","384.10","3443.31","33","960.23","2462.51","percent of total billed charges",""
"SCREW SPINE 7X45MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","AETNA [1001]","HB AMC AETNA HMO","2162.06","69.8","","1421.24","264.50","4933.46","29","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 7X45MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2490.39","80.4","","1022.97","1022.97","3607.50","1 through 10","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 7X45MM VIPER PRIME CORTICAL FIX POLYAXIAL FENESTRATE EXTEND TAB 5.5MM ROD","SUP-ITM-10243541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3097.50","2323.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2531.28","81.72","","3010.54","693.88","5019.88","35","1618.75","2531.28","percent of total billed charges",""
"SCREW SPINE 9X70MM VIPER TI SAI POLYAXIAL","SUP-ITM-10243642","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2328.95","79.5","","800.18","480.96","1887.97","195","908.15","2328.95","percent of total billed charges",""
"SCREW SPINE 9X70MM VIPER TI SAI POLYAXIAL","SUP-ITM-10243642","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1561.42","53.3","","813.12","216.42","1444.50","81","908.15","2328.95","percent of total billed charges",""
"SCREW SPINE 9X70MM VIPER TI SAI POLYAXIAL","SUP-ITM-10243642","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","908.15","31","","432.60","432.60","432.60","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW SPINE 9X70MM VIPER TI SAI POLYAXIAL","SUP-ITM-10243642","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1069.27","36.5","","148.37","54.89","631.39","94","908.15","2328.95","percent of total billed charges",""
"SCREW SPINE 9X70MM VIPER TI SAI POLYAXIAL","SUP-ITM-10243642","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1122.00","38.3","","279.30","91.72","1116.77","266","908.15","2328.95","percent of total billed charges",""
"SCREW SPINE 9X70MM VIPER TI SAI POLYAXIAL","SUP-ITM-10243642","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","731.00","63.70","731.00","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW SPINE 9X70MM VIPER TI SAI POLYAXIAL","SUP-ITM-10243642","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1256.76","42.9","","384.74","384.74","384.74","1 through 10","908.15","2328.95","percent of total billed charges",""
"SCREW SPINE 9X70MM VIPER TI SAI POLYAXIAL","SUP-ITM-10243642","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.50","2197.12","WELLPOINT [1015]","HB AMC WELLPOINT","2161.39","73.78","","286.63","119.22","1107.45","105","908.15","2328.95","percent of total billed charges",""
"SCREW SPINE 9X70MM VIPER TI SAI POLYAXIAL","SUP-ITM-10243642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA HMO","2044.79","69.8","","675.31","184.75","1721.50","286","1530.96","2393.99","percent of total billed charges",""
"SCREW SPINE 9X70MM VIPER TI SAI POLYAXIAL","SUP-ITM-10243642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","AETNA [1001]","HB AMC AETNA PPO","2355.32","80.4","","1261.44","103.12","1514.10","21","1530.96","2393.99","percent of total billed charges",""
"SCREW SPINE 9X70MM VIPER TI SAI POLYAXIAL","SUP-ITM-10243642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2355.32","80.4","","1365.00","1365.00","1365.00","1 through 10","1530.96","2393.99","percent of total billed charges",""
"SCREW SPINE 9X70MM VIPER TI SAI POLYAXIAL","SUP-ITM-10243642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2393.99","81.72","","5157.68","5157.68","5157.68","1 through 10","1530.96","2393.99","percent of total billed charges",""
"SCREW SPINE 9X70MM VIPER TI SAI POLYAXIAL","SUP-ITM-10243642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.50","2197.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2393.99","81.72","","431.26","71.26","1459.57","88","1530.96","2393.99","percent of total billed charges",""
"SCREW SPINE MODULAR EXTENDED TAB POLYAXIAL REDUCTION TULIP","SUP-ITM-10272774","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1085.18","79.5","","800.18","480.96","1887.97","195","423.15","1085.18","percent of total billed charges",""
"SCREW SPINE MODULAR EXTENDED TAB POLYAXIAL REDUCTION TULIP","SUP-ITM-10272774","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","727.55","53.3","","813.12","216.42","1444.50","81","423.15","1085.18","percent of total billed charges",""
"SCREW SPINE MODULAR EXTENDED TAB POLYAXIAL REDUCTION TULIP","SUP-ITM-10272774","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","423.15","31","","432.60","432.60","432.60","1 through 10","423.15","1085.18","percent of total billed charges",""
"SCREW SPINE MODULAR EXTENDED TAB POLYAXIAL REDUCTION TULIP","SUP-ITM-10272774","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","498.23","36.5","","148.37","54.89","631.39","94","423.15","1085.18","percent of total billed charges",""
"SCREW SPINE MODULAR EXTENDED TAB POLYAXIAL REDUCTION TULIP","SUP-ITM-10272774","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","522.80","38.3","","279.30","91.72","1116.77","266","423.15","1085.18","percent of total billed charges",""
"SCREW SPINE MODULAR EXTENDED TAB POLYAXIAL REDUCTION TULIP","SUP-ITM-10272774","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","731.00","63.70","731.00","1 through 10","423.15","1085.18","percent of total billed charges",""
"SCREW SPINE MODULAR EXTENDED TAB POLYAXIAL REDUCTION TULIP","SUP-ITM-10272774","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","384.74","384.74","384.74","1 through 10","423.15","1085.18","percent of total billed charges",""
"SCREW SPINE MODULAR EXTENDED TAB POLYAXIAL REDUCTION TULIP","SUP-ITM-10272774","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB AMC WELLPOINT","1007.10","73.78","","286.63","119.22","1107.45","105","423.15","1085.18","percent of total billed charges",""
"SCREW SPINE MODULAR EXTENDED TAB POLYAXIAL REDUCTION TULIP","SUP-ITM-10272774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA HMO","952.77","69.8","","675.31","184.75","1721.50","286","713.35","1115.48","percent of total billed charges",""
"SCREW SPINE MODULAR EXTENDED TAB POLYAXIAL REDUCTION TULIP","SUP-ITM-10272774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA PPO","1097.46","80.4","","1261.44","103.12","1514.10","21","713.35","1115.48","percent of total billed charges",""
"SCREW SPINE MODULAR EXTENDED TAB POLYAXIAL REDUCTION TULIP","SUP-ITM-10272774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1097.46","80.4","","1365.00","1365.00","1365.00","1 through 10","713.35","1115.48","percent of total billed charges",""
"SCREW SPINE MODULAR EXTENDED TAB POLYAXIAL REDUCTION TULIP","SUP-ITM-10272774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1115.48","81.72","","5157.68","5157.68","5157.68","1 through 10","713.35","1115.48","percent of total billed charges",""
"SCREW SPINE MODULAR EXTENDED TAB POLYAXIAL REDUCTION TULIP","SUP-ITM-10272774","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1115.48","81.72","","431.26","71.26","1459.57","88","713.35","1115.48","percent of total billed charges",""
"SCREW SPINE RELINE O MOD REDUCTION TULIP","SUP-ITM-10170530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","932.14","79.5","","800.18","480.96","1887.97","195","363.48","932.14","percent of total billed charges",""
"SCREW SPINE RELINE O MOD REDUCTION TULIP","SUP-ITM-10170530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","624.94","53.3","","813.12","216.42","1444.50","81","363.48","932.14","percent of total billed charges",""
"SCREW SPINE RELINE O MOD REDUCTION TULIP","SUP-ITM-10170530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","363.48","31","","432.60","432.60","432.60","1 through 10","363.48","932.14","percent of total billed charges",""
"SCREW SPINE RELINE O MOD REDUCTION TULIP","SUP-ITM-10170530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","427.96","36.5","","148.37","54.89","631.39","94","363.48","932.14","percent of total billed charges",""
"SCREW SPINE RELINE O MOD REDUCTION TULIP","SUP-ITM-10170530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","449.07","38.3","","279.30","91.72","1116.77","266","363.48","932.14","percent of total billed charges",""
"SCREW SPINE RELINE O MOD REDUCTION TULIP","SUP-ITM-10170530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","503.00","42.9","","731.00","63.70","731.00","1 through 10","363.48","932.14","percent of total billed charges",""
"SCREW SPINE RELINE O MOD REDUCTION TULIP","SUP-ITM-10170530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","503.00","42.9","","384.74","384.74","384.74","1 through 10","363.48","932.14","percent of total billed charges",""
"SCREW SPINE RELINE O MOD REDUCTION TULIP","SUP-ITM-10170530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1172.50","879.37","WELLPOINT [1015]","HB AMC WELLPOINT","865.07","73.78","","286.63","119.22","1107.45","105","363.48","932.14","percent of total billed charges",""
"SCREW SPINE RELINE O MOD REDUCTION TULIP","SUP-ITM-10170530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1172.50","879.37","AETNA [1001]","HB AMC AETNA HMO","818.41","69.8","","675.31","184.75","1721.50","286","612.75","958.17","percent of total billed charges",""
"SCREW SPINE RELINE O MOD REDUCTION TULIP","SUP-ITM-10170530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1172.50","879.37","AETNA [1001]","HB AMC AETNA PPO","942.69","80.4","","1261.44","103.12","1514.10","21","612.75","958.17","percent of total billed charges",""
"SCREW SPINE RELINE O MOD REDUCTION TULIP","SUP-ITM-10170530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1172.50","879.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","942.69","80.4","","1365.00","1365.00","1365.00","1 through 10","612.75","958.17","percent of total billed charges",""
"SCREW SPINE RELINE O MOD REDUCTION TULIP","SUP-ITM-10170530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1172.50","879.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","958.17","81.72","","5157.68","5157.68","5157.68","1 through 10","612.75","958.17","percent of total billed charges",""
"SCREW SPINE RELINE O MOD REDUCTION TULIP","SUP-ITM-10170530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1172.50","879.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","958.17","81.72","","431.26","71.26","1459.57","88","612.75","958.17","percent of total billed charges",""
"SCREW SURGICAL 10X23MM INTRAFIX ADVANCE","SUP-ITM-10194680","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1302.21","79.5","","800.18","480.96","1887.97","195","507.78","1302.21","percent of total billed charges",""
"SCREW SURGICAL 10X23MM INTRAFIX ADVANCE","SUP-ITM-10194680","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","873.05","53.3","","813.12","216.42","1444.50","81","507.78","1302.21","percent of total billed charges",""
"SCREW SURGICAL 10X23MM INTRAFIX ADVANCE","SUP-ITM-10194680","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","507.78","31","","432.60","432.60","432.60","1 through 10","507.78","1302.21","percent of total billed charges",""
"SCREW SURGICAL 10X23MM INTRAFIX ADVANCE","SUP-ITM-10194680","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","597.87","36.5","","148.37","54.89","631.39","94","507.78","1302.21","percent of total billed charges",""
"SCREW SURGICAL 10X23MM INTRAFIX ADVANCE","SUP-ITM-10194680","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","627.35","38.3","","279.30","91.72","1116.77","266","507.78","1302.21","percent of total billed charges",""
"SCREW SURGICAL 10X23MM INTRAFIX ADVANCE","SUP-ITM-10194680","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","702.70","42.9","","731.00","63.70","731.00","1 through 10","507.78","1302.21","percent of total billed charges",""
"SCREW SURGICAL 10X23MM INTRAFIX ADVANCE","SUP-ITM-10194680","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","702.70","42.9","","384.74","384.74","384.74","1 through 10","507.78","1302.21","percent of total billed charges",""
"SCREW SURGICAL 10X23MM INTRAFIX ADVANCE","SUP-ITM-10194680","CDM","C1713","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","WELLPOINT [1015]","HB AMC WELLPOINT","1208.52","73.78","","286.63","119.22","1107.45","105","507.78","1302.21","percent of total billed charges",""
"SCREW SURGICAL 10X23MM INTRAFIX ADVANCE","SUP-ITM-10194680","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","AETNA [1001]","HB AMC AETNA HMO","1143.32","69.8","","675.31","184.75","1721.50","286","856.02","1338.57","percent of total billed charges",""
"SCREW SURGICAL 10X23MM INTRAFIX ADVANCE","SUP-ITM-10194680","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","AETNA [1001]","HB AMC AETNA PPO","1316.95","80.4","","1261.44","103.12","1514.10","21","856.02","1338.57","percent of total billed charges",""
"SCREW SURGICAL 10X23MM INTRAFIX ADVANCE","SUP-ITM-10194680","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1316.95","80.4","","1365.00","1365.00","1365.00","1 through 10","856.02","1338.57","percent of total billed charges",""
"SCREW SURGICAL 10X23MM INTRAFIX ADVANCE","SUP-ITM-10194680","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1338.57","81.72","","5157.68","5157.68","5157.68","1 through 10","856.02","1338.57","percent of total billed charges",""
"SCREW SURGICAL 10X23MM INTRAFIX ADVANCE","SUP-ITM-10194680","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1338.57","81.72","","431.26","71.26","1459.57","88","856.02","1338.57","percent of total billed charges",""
"SCREW TALL SET","SUP-ITM-10243751","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","800.18","480.96","1887.97","195","54.25","139.13","percent of total billed charges",""
"SCREW TALL SET","SUP-ITM-10243751","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.28","53.3","","813.12","216.42","1444.50","81","54.25","139.13","percent of total billed charges",""
"SCREW TALL SET","SUP-ITM-10243751","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.25","31","","432.60","432.60","432.60","1 through 10","54.25","139.13","percent of total billed charges",""
"SCREW TALL SET","SUP-ITM-10243751","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","148.37","54.89","631.39","94","54.25","139.13","percent of total billed charges",""
"SCREW TALL SET","SUP-ITM-10243751","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","279.30","91.72","1116.77","266","54.25","139.13","percent of total billed charges",""
"SCREW TALL SET","SUP-ITM-10243751","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","731.00","63.70","731.00","1 through 10","54.25","139.13","percent of total billed charges",""
"SCREW TALL SET","SUP-ITM-10243751","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","384.74","384.74","384.74","1 through 10","54.25","139.13","percent of total billed charges",""
"SCREW TALL SET","SUP-ITM-10243751","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","286.63","119.22","1107.45","105","54.25","139.13","percent of total billed charges",""
"SCREW TALL SET","SUP-ITM-10243751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","675.31","184.75","1721.50","286","91.46","143.01","percent of total billed charges",""
"SCREW TALL SET","SUP-ITM-10243751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA PPO","140.70","80.4","","1261.44","103.12","1514.10","21","91.46","143.01","percent of total billed charges",""
"SCREW TALL SET","SUP-ITM-10243751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","140.70","80.4","","1365.00","1365.00","1365.00","1 through 10","91.46","143.01","percent of total billed charges",""
"SCREW TALL SET","SUP-ITM-10243751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.01","81.72","","5157.68","5157.68","5157.68","1 through 10","91.46","143.01","percent of total billed charges",""
"SCREW TALL SET","SUP-ITM-10243751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","431.26","71.26","1459.57","88","91.46","143.01","percent of total billed charges",""
"SCREW TAP 110MM CORTICAL","SUP-ITM-10176391","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.50","522.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","553.72","79.5","","800.18","480.96","1887.97","195","215.92","553.72","percent of total billed charges",""
"SCREW TAP 110MM CORTICAL","SUP-ITM-10176391","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.50","522.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","371.23","53.3","","813.12","216.42","1444.50","81","215.92","553.72","percent of total billed charges",""
"SCREW TAP 110MM CORTICAL","SUP-ITM-10176391","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.50","522.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","215.92","31","","432.60","432.60","432.60","1 through 10","215.92","553.72","percent of total billed charges",""
"SCREW TAP 110MM CORTICAL","SUP-ITM-10176391","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.50","522.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","254.22","36.5","","148.37","54.89","631.39","94","215.92","553.72","percent of total billed charges",""
"SCREW TAP 110MM CORTICAL","SUP-ITM-10176391","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.50","522.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","266.76","38.3","","279.30","91.72","1116.77","266","215.92","553.72","percent of total billed charges",""
"SCREW TAP 110MM CORTICAL","SUP-ITM-10176391","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.50","522.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.80","42.9","","731.00","63.70","731.00","1 through 10","215.92","553.72","percent of total billed charges",""
"SCREW TAP 110MM CORTICAL","SUP-ITM-10176391","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.50","522.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.80","42.9","","384.74","384.74","384.74","1 through 10","215.92","553.72","percent of total billed charges",""
"SCREW TAP 110MM CORTICAL","SUP-ITM-10176391","CDM","C1713","HCPCS","0278","RC","","","","both","","","696.50","522.37","WELLPOINT [1015]","HB AMC WELLPOINT","513.88","73.78","","286.63","119.22","1107.45","105","215.92","553.72","percent of total billed charges",""
"SCREW TAP 110MM CORTICAL","SUP-ITM-10176391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.50","522.37","AETNA [1001]","HB AMC AETNA HMO","486.16","69.8","","675.31","184.75","1721.50","286","363.99","569.18","percent of total billed charges",""
"SCREW TAP 110MM CORTICAL","SUP-ITM-10176391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.50","522.37","AETNA [1001]","HB AMC AETNA PPO","559.99","80.4","","1261.44","103.12","1514.10","21","363.99","569.18","percent of total billed charges",""
"SCREW TAP 110MM CORTICAL","SUP-ITM-10176391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.50","522.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","559.99","80.4","","1365.00","1365.00","1365.00","1 through 10","363.99","569.18","percent of total billed charges",""
"SCREW TAP 110MM CORTICAL","SUP-ITM-10176391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.50","522.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","569.18","81.72","","5157.68","5157.68","5157.68","1 through 10","363.99","569.18","percent of total billed charges",""
"SCREW TAP 110MM CORTICAL","SUP-ITM-10176391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","696.50","522.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","569.18","81.72","","431.26","71.26","1459.57","88","363.99","569.18","percent of total billed charges",""
"SCREW TIBIAL LEGION TITANIUM WEDGE","SUP-ITM-10121512","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","155.82","79.5","","800.18","480.96","1887.97","195","60.76","155.82","percent of total billed charges",""
"SCREW TIBIAL LEGION TITANIUM WEDGE","SUP-ITM-10121512","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","104.47","53.3","","813.12","216.42","1444.50","81","60.76","155.82","percent of total billed charges",""
"SCREW TIBIAL LEGION TITANIUM WEDGE","SUP-ITM-10121512","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","60.76","31","","432.60","432.60","432.60","1 through 10","60.76","155.82","percent of total billed charges",""
"SCREW TIBIAL LEGION TITANIUM WEDGE","SUP-ITM-10121512","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","71.54","36.5","","148.37","54.89","631.39","94","60.76","155.82","percent of total billed charges",""
"SCREW TIBIAL LEGION TITANIUM WEDGE","SUP-ITM-10121512","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","75.07","38.3","","279.30","91.72","1116.77","266","60.76","155.82","percent of total billed charges",""
"SCREW TIBIAL LEGION TITANIUM WEDGE","SUP-ITM-10121512","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.08","42.9","","731.00","63.70","731.00","1 through 10","60.76","155.82","percent of total billed charges",""
"SCREW TIBIAL LEGION TITANIUM WEDGE","SUP-ITM-10121512","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","84.08","42.9","","384.74","384.74","384.74","1 through 10","60.76","155.82","percent of total billed charges",""
"SCREW TIBIAL LEGION TITANIUM WEDGE","SUP-ITM-10121512","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.00","147.00","WELLPOINT [1015]","HB AMC WELLPOINT","144.61","73.78","","286.63","119.22","1107.45","105","60.76","155.82","percent of total billed charges",""
"SCREW TIBIAL LEGION TITANIUM WEDGE","SUP-ITM-10121512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","AETNA [1001]","HB AMC AETNA HMO","136.81","69.8","","675.31","184.75","1721.50","286","102.43","160.17","percent of total billed charges",""
"SCREW TIBIAL LEGION TITANIUM WEDGE","SUP-ITM-10121512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","AETNA [1001]","HB AMC AETNA PPO","157.58","80.4","","1261.44","103.12","1514.10","21","102.43","160.17","percent of total billed charges",""
"SCREW TIBIAL LEGION TITANIUM WEDGE","SUP-ITM-10121512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","157.58","80.4","","1365.00","1365.00","1365.00","1 through 10","102.43","160.17","percent of total billed charges",""
"SCREW TIBIAL LEGION TITANIUM WEDGE","SUP-ITM-10121512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","160.17","81.72","","5157.68","5157.68","5157.68","1 through 10","102.43","160.17","percent of total billed charges",""
"SCREW TIBIAL LEGION TITANIUM WEDGE","SUP-ITM-10121512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","160.17","81.72","","431.26","71.26","1459.57","88","102.43","160.17","percent of total billed charges",""
"SEALANT DURAL ADHERUS AUTOSPRAY EXTENDED TIP PK/5EA","SUP-ITM-10281688","CDM","C1889","HCPCS","0278","RC","","","","both","","","2985.68","2239.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2373.62","79.5","","1309.77","674.56","6049.93","26","925.56","2373.62","percent of total billed charges",""
"SEALANT DURAL ADHERUS AUTOSPRAY EXTENDED TIP PK/5EA","SUP-ITM-10281688","CDM","C1889","HCPCS","0278","RC","","","","both","","","2985.68","2239.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1591.37","53.3","","1901.83","1901.83","2962.25","1 through 10","925.56","2373.62","percent of total billed charges",""
"SEALANT DURAL ADHERUS AUTOSPRAY EXTENDED TIP PK/5EA","SUP-ITM-10281688","CDM","C1889","HCPCS","0278","RC","","","","both","","","2985.68","2239.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1089.77","36.5","","1620.31","1620.31","19908.88","1 through 10","925.56","2373.62","percent of total billed charges",""
"SEALANT DURAL ADHERUS AUTOSPRAY EXTENDED TIP PK/5EA","SUP-ITM-10281688","CDM","C1889","HCPCS","0278","RC","","","","both","","","2985.68","2239.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1143.52","38.3","","352.91","352.91","2046.30","1 through 10","925.56","2373.62","percent of total billed charges",""
"SEALANT DURAL ADHERUS AUTOSPRAY EXTENDED TIP PK/5EA","SUP-ITM-10281688","CDM","C1889","HCPCS","0278","RC","","","","both","","","2985.68","2239.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1280.86","42.9","","9668.75","9668.75","9668.75","1 through 10","925.56","2373.62","percent of total billed charges",""
"SEALANT DURAL ADHERUS AUTOSPRAY EXTENDED TIP PK/5EA","SUP-ITM-10281688","CDM","C1889","HCPCS","0278","RC","","","","both","","","2985.68","2239.26","WELLPOINT [1015]","HB AMC WELLPOINT","2202.83","73.78","","699.88","384.10","3443.31","33","925.56","2373.62","percent of total billed charges",""
"SEALANT DURAL ADHERUS AUTOSPRAY EXTENDED TIP PK/5EA","SUP-ITM-10281688","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2985.68","2239.26","AETNA [1001]","HB AMC AETNA HMO","2084.00","69.8","","1421.24","264.50","4933.46","29","1560.32","2439.9","percent of total billed charges",""
"SEALANT DURAL ADHERUS AUTOSPRAY EXTENDED TIP PK/5EA","SUP-ITM-10281688","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2985.68","2239.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2400.49","80.4","","1022.97","1022.97","3607.50","1 through 10","1560.32","2439.9","percent of total billed charges",""
"SEALANT DURAL ADHERUS AUTOSPRAY EXTENDED TIP PK/5EA","SUP-ITM-10281688","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2985.68","2239.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2439.90","81.72","","3010.54","693.88","5019.88","35","1560.32","2439.9","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","both","","","2373.00","1779.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1886.54","79.5","","1309.77","674.56","6049.93","26","735.63","1886.54","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","both","","","2373.00","1779.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1264.81","53.3","","1901.83","1901.83","2962.25","1 through 10","735.63","1886.54","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","both","","","2373.00","1779.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","866.15","36.5","","1620.31","1620.31","19908.88","1 through 10","735.63","1886.54","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","both","","","2373.00","1779.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","908.86","38.3","","352.91","352.91","2046.30","1 through 10","735.63","1886.54","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","both","","","2373.00","1779.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1018.02","42.9","","9668.75","9668.75","9668.75","1 through 10","735.63","1886.54","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","both","","","2373.00","1779.75","WELLPOINT [1015]","HB AMC WELLPOINT","1750.80","73.78","","699.88","384.10","3443.31","33","735.63","1886.54","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2373.00","1779.75","AETNA [1001]","HB AMC AETNA HMO","1656.35","69.8","","1421.24","264.50","4933.46","29","1240.13","1939.22","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2373.00","1779.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1907.89","80.4","","1022.97","1022.97","3607.50","1 through 10","1240.13","1939.22","percent of total billed charges",""
"SEALANT SPINAL FLUID 5ML DURASEAL EXACT SYSTEM BX/5EA","SUP-ITM-10091747","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2373.00","1779.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1939.22","81.72","","3010.54","693.88","5019.88","35","1240.13","1939.22","percent of total billed charges",""
"Secd Clos Surg Wnd Exten/Complic","PX-98301453","CDM","13160","CPT","0983","RC","","","","both","","","4237.00","3177.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2258.32","53.3","","27941.76","10680.91","27941.76","1 through 10","1313.47","3368.42","percent of total billed charges",""
"Secd Clos Surg Wnd Exten/Complic","PX-98301453","CDM","13160","CPT","0983","RC","","","","both","","","4237.00","3177.75","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","1 through 10","1313.47","3368.42","other","OPPS APC"
"Secd Clos Surg Wnd Exten/Complic","PX-98301453","CDM","13160","CPT","0983","RC","","","","both","","","4237.00","3177.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1546.51","36.5","","2008.61","2008.61","2008.61","1 through 10","1313.47","3368.42","percent of total billed charges",""
"Secd Clos Surg Wnd Exten/Complic","PX-98301453","CDM","13160","CPT","0983","RC","","","","both","","","4237.00","3177.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1622.77","38.3","","2046.30","2046.30","2046.30","1 through 10","1313.47","3368.42","percent of total billed charges",""
"Secd Clos Surg Wnd Exten/Complic","PX-98301453","CDM","13160","CPT","0983","RC","","","","outpatient","","","4237.00","3177.75","AETNA [1001]","HB AMC AETNA HMO","2957.43","69.8","","13695.03","13695.03","13695.03","1 through 10","1548.96","5545.35","percent of total billed charges",""
"Secd Clos Surg Wnd Exten/Complic","PX-98301453","CDM","13160","CPT","0983","RC","","","","outpatient","","","4237.00","3177.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3624.12","3624.12","3624.12","1 through 10","1548.96","5545.35","other","ASC"
"Secd Clos Surg Wnd Exten/Complic","PX-98301453","CDM","13160","CPT","0983","RC","","","","outpatient","","","4237.00","3177.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4105.92","2052.96","4105.92","1 through 10","1548.96","5545.35","other","ASC "
"Secd Clos Surg Wnd Exten/Complic","PX-98301453","CDM","13160","CPT","0983","RC","","","","outpatient","","","4237.00","3177.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3593.59","3454.18","3593.59","1 through 10","1548.96","5545.35","other","Multiple Surgery"
"Secd Clos Surg Wnd Exten/Complic","PX-98301453","CDM","13160","CPT","0983","RC","","","","outpatient","","","4237.00","3177.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3462.48","81.72","","22507.11","12537.79","22507.11","1 through 10","1548.96","5545.35","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0300","RC","","","","inpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34.59","78.61","","34.37","34.37","34.37","1 through 10","24.33","34.98","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","31.59","71.8","","30.87","2.38","30.87","1 through 10","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","30.80","70","","18.91","18.91","18.91","1 through 10","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","CHAMPVA [160001]","HB BWH TRICARE","41.80","95","","3.25","3.25","3.25","1 through 10","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","34.98","79.5","","33.84","22.70","33.84","407","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23.45","53.3","","22.70","22.70","33.84","232","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","33.88","77","","99.33","33.11","99.33","1 through 10","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","28.60","65","","22.79","22.79","22.79","1 through 10","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","34.98","79.5","","33.84","33.84","33.84","1 through 10","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","13.64","31","","13.29","13.29","86.00","1 through 10","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16.06","36.5","","16.04","13.63","32.14","303","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.85","38.3","","16.81","16.34","49.02","1082","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","MOLINA [1014]","HB BWH MOLINA","15.40","35","","5.36","5.36","5.36","1 through 10","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","33.88","77","","33.84","2.65","43.00","1 through 10","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","TRICARE [160005]","HB BWH TRICARE","41.80","95","","3.25","3.09","43.00","24","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","41.80","95","","2.70","2.70","2.70","1 through 10","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.88","42.9","","34.37","18.91","34.37","28","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.88","42.9","","18.91","18.91","18.91","1 through 10","2.65","41.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","44.00","33.00","AETNA [1001]","HB AMC AETNA HMO","30.71","69.8","","29.11","20.55","33.54","494","2.8","35.96","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","44.00","33.00","AETNA [1001]","HB AMC AETNA PPO","35.38","80.4","","33.54","22.53","33.54","52","2.8","35.96","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","44.00","33.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","24.60","55.9","","22.53","22.53","22.53","1 through 10","2.8","35.96","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","44.00","33.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","22.99","52.26","","26.61","9.29","26.61","1 through 10","2.8","35.96","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","44.00","33.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","35.38","80.4","","33.54","21.50","33.54","1 through 10","2.8","35.96","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","44.00","33.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","35.96","81.72","","34.37","34.37","43.00","1 through 10","2.8","35.96","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","35.96","81.72","","34.37","18.91","34.37","18","2.8","35.96","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","35.96","81.72","","34.37","18.91","34.37","393","2.8","35.96","percent of total billed charges",""
"Seizure,EXTREME","053","DRG","","","","","","","","inpatient","","","91368.69","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","57913.03","","Standard inlier is a Case rate ($57,913.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,683, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,221.10) for the length of stay and the standard reimbursement.","57913.02","57913.02","57913.02","1 through 10","5318.86","96424.37","case rate",""
"Seizure,EXTREME","053","DRG","","","","","","","","inpatient","","","91368.69","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","65109.85","","Standard inlier is a Case rate ($65,109.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,683, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,241.80) for the length of stay and the standard reimbursement.","65109.85","65109.85","68225.70","1 through 10","5318.86","96424.37","case rate",""
"Seizure,EXTREME","053","DRG","","","","","","","","inpatient","","","91368.69","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10390.2064","","Fee schedule rate ($21,426.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10390.2064","69234.36","69234.36","1 through 10","5318.86","96424.37","case rate",""
"Seizure,EXTREME","053","DRG","","","","","","","","inpatient","","","91368.69","","MASSHEALTH [3001]","HB BWH MEDICAID","25946.56","","Case rate ($28,688.38). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $71,118.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","28681.34","29843.45","113874.14","1 through 10","5318.86","96424.37","case rate",""
"Seizure,EXTREME","053","DRG","","","","","","","","inpatient","","","91368.69","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","25946.56","","Case rate ($28,688.38). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $71,118.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4867.03","4867.03","4867.03","1 through 10","5318.86","96424.37","case rate",""
"Seizure,EXTREME","053","DRG","","","","","","","","inpatient","","","91368.69","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","25946.56","","Case rate ($28,688.38). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $71,118.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","28681.34","28681.34","28681.34","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","69090.37","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","25452.37","","Standard inlier is a Case rate ($25,452.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,440, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,613.12) for the length of stay and the standard reimbursement.","25452.36","23200.76","33305.83","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","69090.37","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","28615.32","","Standard inlier is a Case rate ($28,615.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,440, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,061.71) for the length of stay and the standard reimbursement.","28615.32","26142.56","29192.16","18","5318.86","96424.37","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","69090.37","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","19883.70","19883.70","19883.70","1 through 10","5318.86","96424.37","percent of total billed charges",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","69090.37","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9895.1608","","Fee schedule rate ($20,405.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9895.1608","20405.40","20405.40","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","69090.37","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10390.2064","","Fee schedule rate ($21,426.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10390.2064","21426.28","21426.28","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","69090.37","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","22446.23","","Fee schedule rate ($22,446.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22446.24","22446.24","22446.24","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","69090.37","","MASSHEALTH [3001]","HB BWH MEDICAID","9788.93","","Case rate ($10,823.35). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,253.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10820.69","10820.69","28681.34","11","5318.86","96424.37","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","69090.37","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","9788.93","","Case rate ($10,823.35). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,253.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","1390.58","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","69090.37","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37097.02","","Fee schedule rate ($37,097.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31532.46","31532.46","31532.46","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","69090.37","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9788.93","","Case rate ($10,823.35). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,253.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10820.69","695.29","35058.69","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","64986.57","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","15316.70","","Standard inlier is a Case rate ($15,316.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,559, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,174.30) for the length of stay and the standard reimbursement.","15316.69","15316.69","20271.17","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","64986.57","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","17220.10","","Standard inlier is a Case rate ($17,220.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $23,559, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,444.25) for the length of stay and the standard reimbursement.","17220.09","16122.62","18780.95","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","64986.57","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9895.1608","","Fee schedule rate ($9,895.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9895.1608","9513.80","9895.16","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","64986.57","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10390.2064","","Fee schedule rate ($10,390.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10390.2064","10390.20","10390.20","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","64986.57","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","12208.03","","Fee schedule rate ($12,208.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12369.06","12369.06","12369.06","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","64986.57","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22800.14","","Fee schedule rate ($22,800.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22800.14","22800.14","22800.14","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","64986.57","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23940.37","","Fee schedule rate ($23,940.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23940.37","23940.37","23940.37","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","64986.57","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5318.86","","Case rate ($5,880.91). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $48,310.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5879.47","5879.47","5879.47","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","50692.78","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19533.96","","Standard inlier is a Case rate ($19,533.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,838, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,772.96) for the length of stay and the standard reimbursement.","19533.96","19533.96","19533.96","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","50692.78","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21961.44","","Standard inlier is a Case rate ($21,961.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,838, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,117.24) for the length of stay and the standard reimbursement.","21961.44","20063.67","21961.44","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","50692.78","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9895.1608","","Fee schedule rate ($12,281.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9895.1608","12281.72","12281.72","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","50692.78","","MASSHEALTH [3001]","HB BWH MEDICAID","6158.50","","Case rate ($6,809.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,239.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6807.61","3249.45","8743.94","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","50692.78","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","6158.50","","Case rate ($6,809.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,239.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","50692.78","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27856.28","","Fee schedule rate ($27,856.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27856.28","27856.28","27856.28","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","50692.78","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29249.37","","Fee schedule rate ($29,249.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29249.37","29249.37","29249.37","1 through 10","5318.86","96424.37","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","50692.78","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6158.50","","Case rate ($6,809.28). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,239.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7027.65","6807.60","7216.06","1 through 10","5318.86","96424.37","case rate",""
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","71888.78","53916.58","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","18047.52","","Case rate ($18,047.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,648.26, add-ons for qualifying new technology services are included. If operating cost exceeds $67,292.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,998.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,109.23 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,268.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,558.46. The transfer capital threshold is the transfer adjustment factor * $1,558.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18100.51","18100.51","23329.52","1 through 10","17686.57","29960.1623","other","Inpatient Replacement Plans DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","71888.78","53916.58","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","18047.52","","Case rate ($18,047.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,648.26, add-ons for qualifying new technology services are included. If operating cost exceeds $67,292.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,998.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,109.23 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,268.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,558.46. The transfer capital threshold is the transfer adjustment factor * $1,558.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17956.71","17956.71","17956.71","1 through 10","17686.57","29960.1623","other","Inpatient DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","71888.78","53916.58","ELDER SERVICES [1037]","HB BWH MEDICARE","18047.52","","Case rate ($18,047.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,648.26, add-ons for qualifying new technology services are included. If operating cost exceeds $67,292.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,998.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,109.23 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,268.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,558.46. The transfer capital threshold is the transfer adjustment factor * $1,558.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","95831.70","95831.70","95831.70","1 through 10","17686.57","29960.1623","other","Inpatient Replacement Plans DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","71888.78","53916.58","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","28681.34","28681.34","28681.34","1 through 10","17686.57","29960.1623","case rate",""
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","71888.78","53916.58","HUMANA [1012]","HB BWH MEDICARE","18047.52","","Case rate ($18,047.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,648.26, add-ons for qualifying new technology services are included. If operating cost exceeds $67,292.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,998.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,109.23 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,268.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,558.46. The transfer capital threshold is the transfer adjustment factor * $1,558.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17999.03","17999.03","23195.40","1 through 10","17686.57","29960.1623","other","Inpatient Replacement Plans DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","71888.78","53916.58","MEDICARE [2001]","HB BWH MEDICARE","18047.52","","Case rate ($18,047.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,648.26, add-ons for qualifying new technology services are included. If operating cost exceeds $67,292.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,998.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,109.23 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,268.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,558.46. The transfer capital threshold is the transfer adjustment factor * $1,558.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23683.30","0.03","23718.30","50","17686.57","29960.1623","other","Inpatient Replacement Plans DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","71888.78","53916.58","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","18047.52","","Case rate ($18,047.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,648.26, add-ons for qualifying new technology services are included. If operating cost exceeds $67,292.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,998.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,109.23 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,268.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,558.46. The transfer capital threshold is the transfer adjustment factor * $1,558.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17956.68","17956.68","17956.68","1 through 10","17686.57","29960.1623","other","Inpatient Replacement Plans DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","71888.78","53916.58","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","17686.57","","Case rate ($18,047.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,648.26, add-ons for qualifying new technology services are included. If operating cost exceeds $67,292.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,998.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,109.23 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,268.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,558.46. The transfer capital threshold is the transfer adjustment factor * $1,558.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12345.24","12345.24","12345.24","1 through 10","17686.57","29960.1623","other","Inpatient DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","71888.78","53916.58","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17686.57","","Case rate ($18,047.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,648.26, add-ons for qualifying new technology services are included. If operating cost exceeds $67,292.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,998.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,109.23 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,268.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,558.46. The transfer capital threshold is the transfer adjustment factor * $1,558.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18056.54","17972.10","29043.90","11","17686.57","29960.1623","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","61919.68","46439.76","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","8871.85","","Case rate ($8,613.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,291.48, add-ons for qualifying new technology services are included. If operating cost exceeds $55,935.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,166.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,507.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,911.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.28. The transfer capital threshold is the transfer adjustment factor * $726.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8948.87","8948.87","8954.27","1 through 10","8441.18","14138.33","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","61919.68","46439.76","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","11065.65","","Case rate ($11,065.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,291.48, add-ons for qualifying new technology services are included. If operating cost exceeds $55,935.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,166.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,959.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,911.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.28. The transfer capital threshold is the transfer adjustment factor * $726.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10974.42","10974.42","10974.42","1 through 10","8441.18","14138.33","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","61919.68","46439.76","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8613.45","","Case rate ($8,613.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,291.48, add-ons for qualifying new technology services are included. If operating cost exceeds $55,935.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,166.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,507.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,911.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.28. The transfer capital threshold is the transfer adjustment factor * $726.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8504.90","8471.38","8578.58","1 through 10","8441.18","14138.33","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","61919.68","46439.76","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","11065.65","","Case rate ($11,065.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,291.48, add-ons for qualifying new technology services are included. If operating cost exceeds $55,935.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,166.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,959.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,911.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.28. The transfer capital threshold is the transfer adjustment factor * $726.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8510.95","8510.95","8510.95","1 through 10","8441.18","14138.33","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","61919.68","46439.76","HUMANA [1012]","HB BWH MEDICARE","11065.65","","Case rate ($11,065.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,291.48, add-ons for qualifying new technology services are included. If operating cost exceeds $55,935.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,166.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,959.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,911.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.28. The transfer capital threshold is the transfer adjustment factor * $726.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8494.43","8494.43","8494.43","1 through 10","8441.18","14138.33","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","61919.68","46439.76","MEDICARE [2001]","HB BWH MEDICARE","11065.65","","Case rate ($11,065.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,291.48, add-ons for qualifying new technology services are included. If operating cost exceeds $55,935.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,166.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,959.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,911.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.28. The transfer capital threshold is the transfer adjustment factor * $726.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11144.35","0.03","11160.60","56","8441.18","14138.33","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","61919.68","46439.76","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","11065.65","","Case rate ($11,065.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,291.48, add-ons for qualifying new technology services are included. If operating cost exceeds $55,935.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,166.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,959.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,911.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.28. The transfer capital threshold is the transfer adjustment factor * $726.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8485.67","8485.67","8485.67","1 through 10","8441.18","14138.33","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","61919.68","46439.76","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8441.18","","Case rate ($8,613.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,291.48, add-ons for qualifying new technology services are included. If operating cost exceeds $55,935.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,166.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,507.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,911.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.28. The transfer capital threshold is the transfer adjustment factor * $726.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8571.51","8510.92","8592.14","1 through 10","8441.18","14138.33","other","Inpatient DRG"
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.89","191.14","298.58","1 through 10","25.02","354.35","percent of total billed charges",""
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","191.14","1 through 10","25.02","354.35","percent of total billed charges",""
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.75","135.03","1 through 10","25.02","354.35","percent of total billed charges",""
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","141.54","141.54","1 through 10","25.02","354.35","percent of total billed charges",""
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","159.17","159.17","159.17","1 through 10","25.02","354.35","percent of total billed charges",""
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.07","173.04","245.07","1 through 10","26.33","304.82","percent of total billed charges",""
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","564.72","282.36","564.72","1 through 10","26.33","304.82","percent of total billed charges",""
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","304.82","81.72","","159.17","159.17","159.17","1 through 10","26.33","304.82","percent of total billed charges",""
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.38","1 through 10","26.33","304.82","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","both","","","261.00","195.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","207.50","79.5","","199.11","133.58","199.11","41","15.19","247.95","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","both","","","261.00","195.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.11","53.3","","133.58","133.58","199.11","22","15.19","247.95","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","both","","","261.00","195.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.27","36.5","","94.37","80.20","94.37","28","15.19","247.95","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","both","","","261.00","195.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","99.96","38.3","","98.92","98.92","98.92","107","15.19","247.95","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","both","","","261.00","195.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","200.97","77","","33.29","33.29","33.29","1 through 10","15.19","247.95","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","both","","","261.00","195.75","TRICARE [160005]","HB BWH TRICARE","247.95","95","","17.75","17.75","18.68","1 through 10","15.19","247.95","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","both","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","111.97","42.9","","202.25","202.25","202.25","1 through 10","15.19","247.95","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","both","","","261.00","195.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","111.97","42.9","","202.25","202.25","202.25","1 through 10","15.19","247.95","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","outpatient","","","261.00","195.75","AETNA [1001]","HB AMC AETNA HMO","182.18","69.8","","171.28","120.93","171.28","58","15.99","213.29","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","outpatient","","","261.00","195.75","AETNA [1001]","HB AMC AETNA PPO","209.84","80.4","","197.34","120.93","197.34","1 through 10","15.99","213.29","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","outpatient","","","261.00","195.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","136.40","52.26","","54.65","54.65","54.65","1 through 10","15.99","213.29","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","outpatient","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","213.29","81.72","","202.25","202.25","202.25","1 through 10","15.99","213.29","percent of total billed charges",""
"Semen Analysis Kruger","PX-30000141","CDM","89322","CPT","0300","RC","","","","outpatient","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","213.29","81.72","","202.25","79.90","202.25","57","15.99","213.29","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","both","","","206.00","154.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","163.77","79.5","","157.40","157.40","157.40","1 through 10","11.81","195.7","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","both","","","206.00","154.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.80","53.3","","157.40","105.60","157.40","1 through 10","11.81","195.7","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","both","","","206.00","154.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","75.19","36.5","","74.60","63.40","74.60","1 through 10","11.81","195.7","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","both","","","206.00","154.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.90","38.3","","78.20","78.20","78.20","17","11.81","195.7","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","both","","","206.00","154.50","TRICARE [160005]","HB BWH TRICARE","195.70","95","","14.52","13.79","14.52","1 through 10","11.81","195.7","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","both","","","206.00","154.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.37","42.9","","159.88","87.94","159.88","1 through 10","11.81","195.7","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","outpatient","","","206.00","154.50","AETNA [1001]","HB AMC AETNA HMO","143.79","69.8","","135.40","95.60","156.00","1 through 10","12.43","168.34","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","outpatient","","","206.00","154.50","AETNA [1001]","HB AMC AETNA PPO","165.62","80.4","","156.00","156.00","156.00","1 through 10","12.43","168.34","percent of total billed charges",""
"Semen Analysis Presence/Motility","PX-30000140","CDM","89321","CPT","0300","RC","","","","outpatient","","","206.00","154.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","168.34","81.72","","159.88","87.94","159.88","1 through 10","12.43","168.34","percent of total billed charges",""
"Semen Motility/Count W/O Huhner","PX-30000138","CDM","89310","CPT","0300","RC","","","","both","","","150.00","112.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","119.25","79.5","","94.25","76.56","114.12","1 through 10","8.44","142.5","percent of total billed charges",""
"Semen Motility/Count W/O Huhner","PX-30000138","CDM","89310","CPT","0300","RC","","","","both","","","150.00","112.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","79.95","53.3","","76.56","76.56","76.56","1 through 10","8.44","142.5","percent of total billed charges",""
"Semen Motility/Count W/O Huhner","PX-30000138","CDM","89310","CPT","0300","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54.75","36.5","","45.97","45.97","45.97","1 through 10","8.44","142.5","percent of total billed charges",""
"Semen Motility/Count W/O Huhner","PX-30000138","CDM","89310","CPT","0300","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.45","38.3","","56.70","56.70","56.70","1 through 10","8.44","142.5","percent of total billed charges",""
"Semen Motility/Count W/O Huhner","PX-30000138","CDM","89310","CPT","0300","RC","","","","both","","","150.00","112.50","TRICARE [160005]","HB BWH TRICARE","142.50","95","","9.86","9.86","9.86","1 through 10","8.44","142.5","percent of total billed charges",""
"Semen Motility/Count W/O Huhner","PX-30000138","CDM","89310","CPT","0300","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.35","42.9","","115.91","115.91","115.91","1 through 10","8.44","142.5","percent of total billed charges",""
"Semen Motility/Count W/O Huhner","PX-30000138","CDM","89310","CPT","0300","RC","","","","outpatient","","","150.00","112.50","AETNA [1001]","HB AMC AETNA HMO","104.70","69.8","","98.17","69.31","98.17","14","8.88","122.58","percent of total billed charges",""
"Semen Motility/Count W/O Huhner","PX-30000138","CDM","89310","CPT","0300","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","122.58","81.72","","115.91","39.05","115.91","26","8.88","122.58","percent of total billed charges",""
"SENSOR RESTORE 54X9.0MM STIMULATOR SPINE GENERATOR RECHARGEABLE 16 ELECTRODE","SUP-ITM-10093717","CDM","C1820","HCPCS","0278","RC","","","","both","","","37295.00","27971.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19878.24","53.3","","54287.50","54287.50","54287.50","1 through 10","11561.45","29649.53","percent of total billed charges",""
"SENSOR RESTORE 54X9.0MM STIMULATOR SPINE GENERATOR RECHARGEABLE 16 ELECTRODE","SUP-ITM-10093717","CDM","C1820","HCPCS","0278","RC","","","","both","","","37295.00","27971.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13612.68","36.5","","10467.31","10467.31","10467.31","1 through 10","11561.45","29649.53","percent of total billed charges",""
"SENSOR RESTORE 54X9.0MM STIMULATOR SPINE GENERATOR RECHARGEABLE 16 ELECTRODE","SUP-ITM-10093717","CDM","C1820","HCPCS","0278","RC","","","","both","","","37295.00","27971.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14283.99","38.3","","21505.00","21505.00","21505.00","1 through 10","11561.45","29649.53","percent of total billed charges",""
"SENSOR RESTORE 54X9.0MM STIMULATOR SPINE GENERATOR RECHARGEABLE 16 ELECTRODE","SUP-ITM-10093717","CDM","C1820","HCPCS","0278","RC","","","","both","","","37295.00","27971.25","WELLPOINT [1015]","HB AMC WELLPOINT","27516.25","73.78","","40016.88","40016.88","40016.88","1 through 10","11561.45","29649.53","percent of total billed charges",""
"SENSOR STIMULATOR 54X9.0MM SPINAL CORD RESTORE NEURO SURESCAN MRI SAFE RECHARGEABLE OCTAPOLAR CONNECTOR","SUP-ITM-10124360","CDM","C1820","HCPCS","0278","RC","","","","both","","","40645.00","30483.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","21663.79","53.3","","54287.50","54287.50","54287.50","1 through 10","12599.95","32312.78","percent of total billed charges",""
"SENSOR STIMULATOR 54X9.0MM SPINAL CORD RESTORE NEURO SURESCAN MRI SAFE RECHARGEABLE OCTAPOLAR CONNECTOR","SUP-ITM-10124360","CDM","C1820","HCPCS","0278","RC","","","","both","","","40645.00","30483.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","14835.43","36.5","","10467.31","10467.31","10467.31","1 through 10","12599.95","32312.78","percent of total billed charges",""
"SENSOR STIMULATOR 54X9.0MM SPINAL CORD RESTORE NEURO SURESCAN MRI SAFE RECHARGEABLE OCTAPOLAR CONNECTOR","SUP-ITM-10124360","CDM","C1820","HCPCS","0278","RC","","","","both","","","40645.00","30483.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15567.04","38.3","","21505.00","21505.00","21505.00","1 through 10","12599.95","32312.78","percent of total billed charges",""
"SENSOR STIMULATOR 54X9.0MM SPINAL CORD RESTORE NEURO SURESCAN MRI SAFE RECHARGEABLE OCTAPOLAR CONNECTOR","SUP-ITM-10124360","CDM","C1820","HCPCS","0278","RC","","","","both","","","40645.00","30483.75","WELLPOINT [1015]","HB AMC WELLPOINT","29987.88","73.78","","40016.88","40016.88","40016.88","1 through 10","12599.95","32312.78","percent of total billed charges",""
"Sensorimotor Exam Ocular","PX-51000010","CDM","92060","CPT","0920","RC","","","","both","","","316.00","237.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","168.43","53.3","","161.57","161.57","161.57","1 through 10","67.01","251.22","percent of total billed charges",""
"Sensorimotor Exam Ocular","PX-51000010","CDM","92060","CPT","0920","RC","","","","both","","","316.00","237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.03","38.3","","119.65","119.65","119.65","1 through 10","67.01","251.22","percent of total billed charges",""
"Sensorimotor Exam Ocular","PX-51000010","CDM","92060","CPT","0920","RC","","","","outpatient","","","316.00","237.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","258.24","81.72","","244.62","244.62","244.62","1 through 10","128.42","326.91","percent of total billed charges",""
"Septal Ablation","PX-48000389","CDM","93799","CPT","0480","RC","","","","outpatient","","","1106.00","829.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","608.30","55","","13080.03","13080.03","13080.03","1 through 10","553","912.45","percent of total billed charges",""
"Septal Ablation","PX-48000389","CDM","93799","CPT","0481","RC","","","","both","","","1106.00","829.50","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","879.27","other","OPPS APC"
"Septal Ablation","PX-48000389","CDM","93799","CPT","0481","RC","","","","outpatient","","","1106.00","829.50","AETNA [1001]","HB AMC AETNA HMO","771.99","69.8","","2022.70","2022.70","2022.70","1 through 10","454","903.82","percent of total billed charges",""
"Septal Ablation","PX-48000389","CDM","93799","CPT","0481","RC","","","","outpatient","","","1106.00","829.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","669.68","60.55","","318.03","318.03","2439.77","1 through 10","454","903.82","percent of total billed charges",""
"Septal Ablation","PX-48000389","CDM","93799","CPT","0481","RC","","","","outpatient","","","1106.00","829.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","577.55","52.22","","360.38","360.38","4023.00","1 through 10","454","903.82","percent of total billed charges",""
"Septic Arthritis With Cc","549","MS-DRG","","","","","","","","inpatient","","","75403.82","56552.86","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","14671.79","","Case rate ($14,671.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,636.36, add-ons for qualifying new technology services are included. If operating cost exceeds $59,280.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,411.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,320.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,256.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.38. The transfer capital threshold is the transfer adjustment factor * $971.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11094.80","11094.80","11094.80","1 through 10","11164.21","18186.1641","other","Inpatient DRG"
"Septic Arthritis With Cc","549","MS-DRG","","","","","","","","inpatient","","","75403.82","56552.86","MEDICARE [2001]","HB BWH MEDICARE","14671.79","","Case rate ($14,671.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,636.36, add-ons for qualifying new technology services are included. If operating cost exceeds $59,280.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,411.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,320.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,256.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.38. The transfer capital threshold is the transfer adjustment factor * $971.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1087.89","252.58","1087.89","1 through 10","11164.21","18186.1641","other","Inpatient DRG"
"Septic Arthritis With McC","548","MS-DRG","","","","","","","","inpatient","","","286322.35","214741.76","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17633.86","","Case rate ($17,993.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,583.48, add-ons for qualifying new technology services are included. If operating cost exceeds $67,227.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,993.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $16,060.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,203.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,553.72. The transfer capital threshold is the transfer adjustment factor * $1,553.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18699.66","18699.66","18699.66","1 through 10","17633.86","30245.62","other","Inpatient DRG"
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","128459.16","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","59543.02","","Standard inlier is a Case rate ($59,543.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,951, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,452.49) for the length of stay and the standard reimbursement.","54275.62","54275.62","84481.24","13","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","128459.16","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","66942.40","","Standard inlier is a Case rate ($66,942.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $57,951, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,501.92) for the length of stay and the standard reimbursement.","61157.65","38374.34","73486.18","44","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","128459.16","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","224919.21","224919.21","224919.21","1 through 10","4604.88","124956.33","percent of total billed charges",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","128459.16","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","15122.6354","","Fee schedule rate ($79,518.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15122.6354","83304.22","83304.22","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","128459.16","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14402.1113","","Fee schedule rate ($75,730.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14402.1113","75730.20","75962.88","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","128459.16","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","83304.22","","Fee schedule rate ($83,304.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","83304.22","83304.22","83304.22","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","128459.16","","MASSHEALTH [3001]","HB BWH MEDICAID","20655.12","","Case rate ($22,837.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,267.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22832.18","2345.64","45782.77","39","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","128459.16","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","20655.12","","Case rate ($22,837.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,267.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","2085.87","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","128459.16","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54036.91","","Fee schedule rate ($54,036.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","54036.50","54036.50","54036.50","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","128459.16","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63572.36","","Fee schedule rate ($63,572.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61720.89","61720.89","61720.89","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","128459.16","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66751.38","","Fee schedule rate ($66,751.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","66751.38","66751.38","66751.38","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","128459.16","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","20655.12","","Case rate ($22,837.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,267.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22832.18","1346.57","86141.40","19","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","64782.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","34132.69","","Standard inlier is a Case rate ($34,132.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,190, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,845.34) for the length of stay and the standard reimbursement.","34132.69","31113.19","34132.69","14","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","64782.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","38374.34","","Standard inlier is a Case rate ($38,374.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,190, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,446.92) for the length of stay and the standard reimbursement.","38374.34","35058.27","40059.74","16","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","64782.35","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","19287.30","19287.30","19287.30","1 through 10","4604.88","124956.33","percent of total billed charges",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","64782.35","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14402.1113","","Fee schedule rate ($35,449.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14402.1113","35449.44","35449.46","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","64782.35","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","15122.6354","","Fee schedule rate ($37,222.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15122.6354","37222.96","37222.96","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","64782.35","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","43735.32","","Fee schedule rate ($43,735.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","44312.22","44312.22","44312.22","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","64782.35","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","38994.88","","Fee schedule rate ($38,994.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38994.88","38994.88","38994.88","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","64782.35","","MASSHEALTH [3001]","HB BWH MEDICAID","9871.18","","Case rate ($10,914.29). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,344.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10911.62","1538.43","22455.60","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","64782.35","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","27165.49","","Fee schedule rate ($27,165.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27165.29","27165.29","27165.29","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","64782.35","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31959.16","","Fee schedule rate ($31,959.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31959.16","31959.16","31959.16","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","64782.35","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33557.32","","Fee schedule rate ($33,557.32). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33557.32","33557.32","33557.32","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","64782.35","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9871.18","","Case rate ($10,914.29). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,344.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10911.61","695.29","10911.61","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MINOR","720","DRG","","","","","","","","inpatient","","","18831.21","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4604.88","","Case rate ($5,091.48). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,521.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5090.23","5090.23","5090.23","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","37752.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","23220.84","","Standard inlier is a Case rate ($23,220.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,706, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,296.34) for the length of stay and the standard reimbursement.","21166.64","21166.64","23220.83","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","37752.66","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","26106.48","","Standard inlier is a Case rate ($26,106.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,706, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,705.60) for the length of stay and the standard reimbursement.","26106.48","23850.52","39113.49","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","37752.66","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14402.1113","","Fee schedule rate ($20,696.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14402.1113","20696.20","20696.20","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","37752.66","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","22766.08","","Fee schedule rate ($22,766.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22766.08","22766.08","22766.08","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","37752.66","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21772.65","","Fee schedule rate ($21,772.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21772.65","21772.65","21772.65","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","37752.66","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22861.42","","Fee schedule rate ($22,861.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17751.65","17751.65","17751.65","1 through 10","4604.88","124956.33","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","37752.66","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6160.78","","Case rate ($6,811.80). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,241.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1322.22","1020.93","10911.61","1 through 10","4604.88","124956.33","case rate",""
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","391218.13","293413.60","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","65332.92","","Case rate ($63,430.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $76,279.81, add-ons for qualifying new technology services are included. If operating cost exceeds $121,924.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,001.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $57,488.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $75,899.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,561.64. The transfer capital threshold is the transfer adjustment factor * $5,561.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","65309.04","65309.04","65309.04","1 through 10","62161.42","108266.44","other","Inpatient DRG"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","391218.13","293413.60","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","82208.13","","Case rate ($82,208.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $76,279.81, add-ons for qualifying new technology services are included. If operating cost exceeds $121,924.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,001.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $76,266.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $75,899.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,561.64. The transfer capital threshold is the transfer adjustment factor * $5,561.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","78509.22","78509.22","78509.22","1 through 10","62161.42","108266.44","other","Inpatient DRG"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","391218.13","293413.60","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","63430.02","","Case rate ($63,430.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $76,279.81, add-ons for qualifying new technology services are included. If operating cost exceeds $121,924.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,001.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $57,488.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $75,899.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,561.64. The transfer capital threshold is the transfer adjustment factor * $5,561.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","62237.50","62237.50","71010.54","1 through 10","62161.42","108266.44","other","Inpatient DRG"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","391218.13","293413.60","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","95238.80","95238.80","95238.80","1 through 10","62161.42","108266.44","case rate",""
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","391218.13","293413.60","MEDICARE [2001]","HB BWH MEDICARE","82208.13","","Case rate ($82,208.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $76,279.81, add-ons for qualifying new technology services are included. If operating cost exceeds $121,924.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,001.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $76,266.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $75,899.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,561.64. The transfer capital threshold is the transfer adjustment factor * $5,561.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","82289.54","0.03","109322.47","26","62161.42","108266.44","other","Inpatient DRG"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","391218.13","293413.60","MOLINA [1014]","HB BWH MOLINA","62161.42","","Case rate ($63,430.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $76,279.81, add-ons for qualifying new technology services are included. If operating cost exceeds $121,924.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,001.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $57,488.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $75,899.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,561.64. The transfer capital threshold is the transfer adjustment factor * $5,561.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","125999.13","125999.13","125999.13","1 through 10","62161.42","108266.44","other","Inpatient DRG"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","391218.13","293413.60","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","62161.42","","Case rate ($63,430.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $76,279.81, add-ons for qualifying new technology services are included. If operating cost exceeds $121,924.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,001.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $57,488.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $75,899.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,561.64. The transfer capital threshold is the transfer adjustment factor * $5,561.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","62393.31","62393.31","62393.31","1 through 10","62161.42","108266.44","other","Inpatient DRG"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","391218.13","293413.60","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","62161.42","","Case rate ($63,430.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $76,279.81, add-ons for qualifying new technology services are included. If operating cost exceeds $121,924.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $8,001.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $57,488.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $75,899.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,561.64. The transfer capital threshold is the transfer adjustment factor * $5,561.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","62151.89","43779.94","62369.94","1 through 10","62161.42","108266.44","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","18642.53","","Case rate ($18,099.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,156.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","18661.71","18612.30","18687.04","12","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","23376.96","","Case rate ($23,376.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $21,434.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17892.21","17892.18","33718.55","18","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","22624.43","","Case rate ($18,099.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,156.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","17866.91","17866.91","17866.91","1 through 10","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","18099.54","","Case rate ($18,099.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,156.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","77156.27","17726.03","113879.15","14","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","ELDER SERVICES [1037]","HB BWH MEDICARE","23376.96","","Case rate ($23,376.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $21,434.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","60286.81","60286.81","60286.81","1 through 10","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","FALLON HEALTH [1008]","HB BWH MEDICARE","23376.96","","Case rate ($23,376.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $21,434.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18112.26","18112.26","18112.26","1 through 10","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","23376.96","","Case rate ($23,376.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $21,434.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10465.58","10465.58","10465.58","1 through 10","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","HUMANA [1012]","HB BWH MEDICARE","23376.96","","Case rate ($23,376.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $21,434.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17783.05","17750.04","40541.58","1 through 10","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","MARTIN'S POINT [160007]","HB BWH MEDICARE","23376.96","","Case rate ($23,376.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $21,434.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17820.16","17820.16","17820.16","1 through 10","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","MEDICARE [2001]","HB BWH MEDICARE","23376.96","","Case rate ($23,376.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $21,434.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23409.77","0.03","23444.37","412","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","23376.96","","Case rate ($23,376.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $21,434.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17742.88","17742.88","17785.01","1 through 10","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","MOLINA [1014]","HB BWH MOLINA","17737.55","","Case rate ($18,099.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,156.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","36021.01","35846.99","39291.50","1 through 10","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","17737.55","","Case rate ($18,099.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,156.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17796.79","17731.91","19713.72","28","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","17737.55","","Case rate ($18,099.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,156.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","23965.63","23965.63","23965.63","1 through 10","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17737.55","","Case rate ($18,099.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,710.86, add-ons for qualifying new technology services are included. If operating cost exceeds $67,355.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,003.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,156.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,331.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,563.05. The transfer capital threshold is the transfer adjustment factor * $1,563.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17804.58","17725.86","27129.67","46","17737.55","30427.32","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","100163.25","75122.44","WELLPOINT [1015]","HB AMC WELLPOINT","30427.32","","Fee schedule rate ($30,427.32).","93135.48","29610.05","227081.21","1 through 10","17737.55","30427.32","case rate",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","55069.75","41302.31","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12494.61","","Case rate ($12,494.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,616.92, add-ons for qualifying new technology services are included. If operating cost exceeds $57,261.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,291.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,237.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.41. The transfer capital threshold is the transfer adjustment factor * $823.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12267.51","12267.51","12267.51","1 through 10","9520.2","15558.821","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","55069.75","41302.31","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9714.49","","Case rate ($9,714.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,616.92, add-ons for qualifying new technology services are included. If operating cost exceeds $57,261.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,511.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,237.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.41. The transfer capital threshold is the transfer adjustment factor * $823.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","118223.94","118223.94","118223.94","1 through 10","9520.2","15558.821","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","55069.75","41302.31","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","6810.13","6810.13","6810.13","1 through 10","9520.2","15558.821","case rate",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","55069.75","41302.31","HUMANA [1012]","HB BWH MEDICARE","12494.61","","Case rate ($12,494.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,616.92, add-ons for qualifying new technology services are included. If operating cost exceeds $57,261.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,291.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,237.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.41. The transfer capital threshold is the transfer adjustment factor * $823.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9524.22","9524.22","9524.22","1 through 10","9520.2","15558.821","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","55069.75","41302.31","MEDICARE [2001]","HB BWH MEDICARE","12494.61","","Case rate ($12,494.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,616.92, add-ons for qualifying new technology services are included. If operating cost exceeds $57,261.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,291.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,237.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.41. The transfer capital threshold is the transfer adjustment factor * $823.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12432.90","0.03","12451.08","47","9520.2","15558.821","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","55069.75","41302.31","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","12494.61","","Case rate ($12,494.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,616.92, add-ons for qualifying new technology services are included. If operating cost exceeds $57,261.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $11,291.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,237.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.41. The transfer capital threshold is the transfer adjustment factor * $823.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9465.28","9465.28","9465.28","1 through 10","9520.2","15558.821","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","55069.75","41302.31","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","9520.20","","Case rate ($9,714.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,616.92, add-ons for qualifying new technology services are included. If operating cost exceeds $57,261.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,511.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,237.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.41. The transfer capital threshold is the transfer adjustment factor * $823.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9503.06","9503.06","9503.06","1 through 10","9520.2","15558.821","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","55069.75","41302.31","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9520.20","","Case rate ($9,714.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,616.92, add-ons for qualifying new technology services are included. If operating cost exceeds $57,261.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,263.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,511.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,237.08 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.41. The transfer capital threshold is the transfer adjustment factor * $823.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9538.06","9443.66","37222.96","1 through 10","9520.2","15558.821","other","Inpatient DRG"
"Serotonin","PX-30000670","CDM","84260","CPT","0301","RC","","","","both","","","379.00","284.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","145.16","38.3","","143.89","143.89","143.89","1 through 10","30.36","360.05","percent of total billed charges",""
"Serotonin","PX-30000670","CDM","84260","CPT","0301","RC","","","","both","","","379.00","284.25","TRICARE [160005]","HB BWH TRICARE","360.05","95","","35.46","35.46","35.46","1 through 10","30.36","360.05","percent of total billed charges",""
"Serum Free Kappa L C","PX-30002126","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Serum Free Kappa L C","PX-30002126","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"Serum Free Lambda L C","PX-30002127","CDM","83883","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","60.06","60.06","60.06","1 through 10","11.72","178.6","percent of total billed charges",""
"Serum Free Lambda L C","PX-30002127","CDM","83883","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","246.42","246.42","246.42","1 through 10","11.72","153.63","percent of total billed charges",""
"SET 24FRX40CM THAL QUICK DOUBLE LUMEN CHEST TUBE","SUP-ITM-10258158","CDM","C1729","HCPCS","0272","RC","","","","both","","","705.60","529.20","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","506.62","71.8","","162.24","51.52","162.24","1 through 10","218.74","560.95","percent of total billed charges",""
"SET 24FRX40CM THAL QUICK DOUBLE LUMEN CHEST TUBE","SUP-ITM-10258158","CDM","C1729","HCPCS","0272","RC","","","","both","","","705.60","529.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","257.54","36.5","","94.34","22.19","146.22","26","218.74","560.95","percent of total billed charges",""
"SET 24FRX40CM THAL QUICK DOUBLE LUMEN CHEST TUBE","SUP-ITM-10258158","CDM","C1729","HCPCS","0272","RC","","","","both","","","705.60","529.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","270.24","38.3","","51.52","27.37","51.52","26","218.74","560.95","percent of total billed charges",""
"SET 24FRX40CM THAL QUICK DOUBLE LUMEN CHEST TUBE","SUP-ITM-10258158","CDM","C1729","HCPCS","0272","RC","","","","both","","","705.60","529.20","WELLPOINT [1015]","HB AMC WELLPOINT","520.59","73.78","","207.21","122.12","216.28","14","218.74","560.95","percent of total billed charges",""
"SET 24FRX40CM THAL QUICK DOUBLE LUMEN CHEST TUBE","SUP-ITM-10258158","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","705.60","529.20","AETNA [1001]","HB AMC AETNA HMO","492.51","69.8","","155.96","47.39","155.96","1 through 10","368.75","576.62","percent of total billed charges",""
"SET 24FRX40CM THAL QUICK DOUBLE LUMEN CHEST TUBE","SUP-ITM-10258158","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","705.60","529.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","576.62","81.72","","57.36","51.76","232.23","35","368.75","576.62","percent of total billed charges",""
"SET BEAD TANTALUM","SUP-ITM-10188480","CDM","A4648","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","454.50","151.50","454.50","21","162.75","433.13","percent of total billed charges",""
"SET BEAD TANTALUM","SUP-ITM-10188480","CDM","A4648","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","304.92","207.96","485.88","1 through 10","162.75","433.13","percent of total billed charges",""
"SET BEAD TANTALUM","SUP-ITM-10188480","CDM","A4648","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","183.06","183.06","183.06","1 through 10","162.75","433.13","percent of total billed charges",""
"SET BEAD TANTALUM","SUP-ITM-10188480","CDM","A4648","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","225.81","149.00","234.60","19","162.75","433.13","percent of total billed charges",""
"SET BEAD TANTALUM","SUP-ITM-10188480","CDM","A4648","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","153.88","90.49","192.50","1 through 10","162.75","433.13","percent of total billed charges",""
"SET BEAD TANTALUM","SUP-ITM-10188480","CDM","A4648","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","335.82","153.22","335.82","1 through 10","162.75","433.13","percent of total billed charges",""
"SET BEAD TANTALUM","SUP-ITM-10188480","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","98.37","92.02","150.15","11","262.5","433.13","percent of total billed charges",""
"SET BEAD TANTALUM","SUP-ITM-10188480","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA PPO","422.10","80.4","","333.06","160.52","333.06","1 through 10","262.5","433.13","percent of total billed charges",""
"SET BEAD TANTALUM","SUP-ITM-10188480","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","153.88","84.64","170.39","1 through 10","262.5","433.13","percent of total billed charges",""
"SET CATHETER 10.8CM 20GA IZATION ARTERIAL ARROW POLYURETHANE STRAIGHT TIP FEMORAL BX/25EA","SUP-ITM-10010438","CDM","C1751","HCPCS","0272","RC","","","","both","","","51.87","38.90","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","36.31","70","","1389.50","602.17","3167.85","27","16.08","41.24","percent of total billed charges",""
"SET CATHETER 10.8CM 20GA IZATION ARTERIAL ARROW POLYURETHANE STRAIGHT TIP FEMORAL BX/25EA","SUP-ITM-10010438","CDM","C1751","HCPCS","0272","RC","","","","both","","","51.87","38.90","WELLPOINT [1015]","HB AMC WELLPOINT","38.27","73.78","","1089.20","218.86","1089.20","1 through 10","16.08","41.24","percent of total billed charges",""
"SET CATHETER 10.8CM 20GA IZATION ARTERIAL ARROW POLYURETHANE STRAIGHT TIP FEMORAL BX/25EA","SUP-ITM-10010438","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","51.87","38.90","AETNA [1001]","HB AMC AETNA HMO","36.21","69.8","","1389.50","940.69","1389.50","1 through 10","27.11","42.39","percent of total billed charges",""
"SET CATHETER 10.8CM 20GA IZATION ARTERIAL ARROW POLYURETHANE STRAIGHT TIP FEMORAL BX/25EA","SUP-ITM-10010438","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","51.87","38.90","AETNA [1001]","HB AMC AETNA PPO","41.70","80.4","","190.26","190.26","190.26","1 through 10","27.11","42.39","percent of total billed charges",""
"SET CATHETER 10.8CM 20GA IZATION ARTERIAL ARROW POLYURETHANE STRAIGHT TIP FEMORAL BX/25EA","SUP-ITM-10010438","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","51.87","38.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","42.39","81.72","","1110.77","235.00","1169.52","1 through 10","27.11","42.39","percent of total billed charges",""
"SET CATHETER 2.5MMX18CM PEDIATRIC SM VENTRICULAR SHUNT STYLET RT ANGLE GUIDE DEFLECTOR","SUP-ITM-10127653","CDM","C1889","HCPCS","0278","RC","","","","both","","","990.61","742.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","787.53","79.5","","1309.77","674.56","6049.93","26","307.09","787.53","percent of total billed charges",""
"SET CATHETER 2.5MMX18CM PEDIATRIC SM VENTRICULAR SHUNT STYLET RT ANGLE GUIDE DEFLECTOR","SUP-ITM-10127653","CDM","C1889","HCPCS","0278","RC","","","","both","","","990.61","742.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","528.00","53.3","","1901.83","1901.83","2962.25","1 through 10","307.09","787.53","percent of total billed charges",""
"SET CATHETER 2.5MMX18CM PEDIATRIC SM VENTRICULAR SHUNT STYLET RT ANGLE GUIDE DEFLECTOR","SUP-ITM-10127653","CDM","C1889","HCPCS","0278","RC","","","","both","","","990.61","742.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","361.57","36.5","","1620.31","1620.31","19908.88","1 through 10","307.09","787.53","percent of total billed charges",""
"SET CATHETER 2.5MMX18CM PEDIATRIC SM VENTRICULAR SHUNT STYLET RT ANGLE GUIDE DEFLECTOR","SUP-ITM-10127653","CDM","C1889","HCPCS","0278","RC","","","","both","","","990.61","742.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","379.40","38.3","","352.91","352.91","2046.30","1 through 10","307.09","787.53","percent of total billed charges",""
"SET CATHETER 2.5MMX18CM PEDIATRIC SM VENTRICULAR SHUNT STYLET RT ANGLE GUIDE DEFLECTOR","SUP-ITM-10127653","CDM","C1889","HCPCS","0278","RC","","","","both","","","990.61","742.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","424.97","42.9","","9668.75","9668.75","9668.75","1 through 10","307.09","787.53","percent of total billed charges",""
"SET CATHETER 2.5MMX18CM PEDIATRIC SM VENTRICULAR SHUNT STYLET RT ANGLE GUIDE DEFLECTOR","SUP-ITM-10127653","CDM","C1889","HCPCS","0278","RC","","","","both","","","990.61","742.96","WELLPOINT [1015]","HB AMC WELLPOINT","730.87","73.78","","699.88","384.10","3443.31","33","307.09","787.53","percent of total billed charges",""
"SET CATHETER 2.5MMX18CM PEDIATRIC SM VENTRICULAR SHUNT STYLET RT ANGLE GUIDE DEFLECTOR","SUP-ITM-10127653","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","990.61","742.96","AETNA [1001]","HB AMC AETNA HMO","691.45","69.8","","1421.24","264.50","4933.46","29","517.69","809.53","percent of total billed charges",""
"SET CATHETER 2.5MMX18CM PEDIATRIC SM VENTRICULAR SHUNT STYLET RT ANGLE GUIDE DEFLECTOR","SUP-ITM-10127653","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","990.61","742.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","796.45","80.4","","1022.97","1022.97","3607.50","1 through 10","517.69","809.53","percent of total billed charges",""
"SET CATHETER 2.5MMX18CM PEDIATRIC SM VENTRICULAR SHUNT STYLET RT ANGLE GUIDE DEFLECTOR","SUP-ITM-10127653","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","990.61","742.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","809.53","81.72","","3010.54","693.88","5019.88","35","517.69","809.53","percent of total billed charges",""
"SET CATHETER INOUE BALLOON 28MM .025IN DILATOR GUIDEWIRE BALLOON STRETCHING TUBE SYRINGE CALIPER STYLET MITRAL VALVULOPLASTY","SUP-ITM-10000137","CDM","C1726","HCPCS","0272","RC","","","","both","","","6750.00","5062.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4725.00","70","","863.10","863.10","863.10","1 through 10","2092.5","5366.25","percent of total billed charges",""
"SET CATHETER INOUE BALLOON 28MM .025IN DILATOR GUIDEWIRE BALLOON STRETCHING TUBE SYRINGE CALIPER STYLET MITRAL VALVULOPLASTY","SUP-ITM-10000137","CDM","C1726","HCPCS","0272","RC","","","","both","","","6750.00","5062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5366.25","79.5","","447.66","447.66","447.66","1 through 10","2092.5","5366.25","percent of total billed charges",""
"SET CATHETER INOUE BALLOON 28MM .025IN DILATOR GUIDEWIRE BALLOON STRETCHING TUBE SYRINGE CALIPER STYLET MITRAL VALVULOPLASTY","SUP-ITM-10000137","CDM","C1726","HCPCS","0272","RC","","","","both","","","6750.00","5062.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4387.50","65","","1020.11","1020.11","1020.11","1 through 10","2092.5","5366.25","percent of total billed charges",""
"SET CATHETER INOUE BALLOON 28MM .025IN DILATOR GUIDEWIRE BALLOON STRETCHING TUBE SYRINGE CALIPER STYLET MITRAL VALVULOPLASTY","SUP-ITM-10000137","CDM","C1726","HCPCS","0272","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2092.50","31","","208.83","208.83","208.83","1 through 10","2092.5","5366.25","percent of total billed charges",""
"SET CATHETER INOUE BALLOON 28MM .025IN DILATOR GUIDEWIRE BALLOON STRETCHING TUBE SYRINGE CALIPER STYLET MITRAL VALVULOPLASTY","SUP-ITM-10000137","CDM","C1726","HCPCS","0272","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2463.75","36.5","","312.44","214.23","1086.03","20","2092.5","5366.25","percent of total billed charges",""
"SET CATHETER INOUE BALLOON 28MM .025IN DILATOR GUIDEWIRE BALLOON STRETCHING TUBE SYRINGE CALIPER STYLET MITRAL VALVULOPLASTY","SUP-ITM-10000137","CDM","C1726","HCPCS","0272","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2585.25","38.3","","264.25","227.63","567.11","31","2092.5","5366.25","percent of total billed charges",""
"SET CATHETER INOUE BALLOON 28MM .025IN DILATOR GUIDEWIRE BALLOON STRETCHING TUBE SYRINGE CALIPER STYLET MITRAL VALVULOPLASTY","SUP-ITM-10000137","CDM","C1726","HCPCS","0272","RC","","","","both","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2895.75","42.9","","79.94","79.94","79.94","1 through 10","2092.5","5366.25","percent of total billed charges",""
"SET CATHETER INOUE BALLOON 28MM .025IN DILATOR GUIDEWIRE BALLOON STRETCHING TUBE SYRINGE CALIPER STYLET MITRAL VALVULOPLASTY","SUP-ITM-10000137","CDM","C1726","HCPCS","0272","RC","","","","both","","","6750.00","5062.50","WELLPOINT [1015]","HB AMC WELLPOINT","4980.15","73.78","","174.45","74.45","1168.42","1 through 10","2092.5","5366.25","percent of total billed charges",""
"SET CATHETER INOUE BALLOON 28MM .025IN DILATOR GUIDEWIRE BALLOON STRETCHING TUBE SYRINGE CALIPER STYLET MITRAL VALVULOPLASTY","SUP-ITM-10000137","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","6750.00","5062.50","AETNA [1001]","HB AMC AETNA HMO","4711.50","69.8","","655.01","135.40","784.73","1 through 10","3527.55","5516.1","percent of total billed charges",""
"SET CATHETER INOUE BALLOON 28MM .025IN DILATOR GUIDEWIRE BALLOON STRETCHING TUBE SYRINGE CALIPER STYLET MITRAL VALVULOPLASTY","SUP-ITM-10000137","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5516.10","81.72","","540.25","46.28","897.42","36","3527.55","5516.1","percent of total billed charges",""
"SET COLLAR ADULT UNIVERSAL CERVICAL EXTENDED WEAR VISTA 2 PC PLASTIC POLYURETHANE FOAM PAD REPLACEMENT CS/16EA","SUP-ITM-10024618","CDM","L0172","HCPCS","0274","RC","","","","both","","","138.57","103.93","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","69.29","50","","22.80","22.80","22.80","1 through 10","42.96","297.02","percent of total billed charges",""
"SET COLLAR ADULT UNIVERSAL CERVICAL EXTENDED WEAR VISTA 2 PC PLASTIC POLYURETHANE FOAM PAD REPLACEMENT CS/16EA","SUP-ITM-10024618","CDM","L0172","HCPCS","0274","RC","","","","both","","","138.57","103.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.07","38.3","","17.01","17.01","17.01","1 through 10","42.96","297.02","percent of total billed charges",""
"SET COLLAR ADULT UNIVERSAL CERVICAL EXTENDED WEAR VISTA 2 PC PLASTIC POLYURETHANE FOAM PAD REPLACEMENT CS/16EA","SUP-ITM-10024618","CDM","L0172","HCPCS","0274","RC","","","","both","","","138.57","103.93","WELLPOINT [1015]","HB AMC WELLPOINT","102.24","73.78","","32.39","32.39","32.39","1 through 10","42.96","297.02","percent of total billed charges",""
"SET COLLAR ADULT UNIVERSAL CERVICAL EXTENDED WEAR VISTA 2 PC PLASTIC POLYURETHANE FOAM PAD REPLACEMENT CS/16EA","SUP-ITM-10024618","CDM","L0172","HCPCS","0274","RC","","","","outpatient","","","138.57","103.93","AETNA [1001]","HB AMC AETNA HMO","96.72","69.8","","26.36","26.36","26.36","1 through 10","69.29","297.02","percent of total billed charges",""
"SET COLLAR ADULT UNIVERSAL CERVICAL EXTENDED WEAR VISTA 2 PC PLASTIC POLYURETHANE FOAM PAD REPLACEMENT CS/16EA","SUP-ITM-10024618","CDM","L0172","HCPCS","0274","RC","","","","outpatient","","","138.57","103.93","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","69.29","50","","22.80","22.80","22.80","1 through 10","69.29","297.02","percent of total billed charges",""
"SET COMPONENT 36X35 PFXLT 11.5 4.0MM ARTICULAR HEMICAP PATELLO FEMORAL COBALT OFF","SUP-ITM-10076092","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5226.00","52.26","","1113.10","1113.10","1113.10","1 through 10","3100","7950","percent of total billed charges",""
"SET COMPONENT 36X35 PFXLT 11.5 4.0MM ARTICULAR HEMICAP PATELLO FEMORAL COBALT OFF","SUP-ITM-10076092","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7950.00","79.5","","1293.60","1148.53","1603.80","1 through 10","3100","7950","percent of total billed charges",""
"SET COMPONENT 36X35 PFXLT 11.5 4.0MM ARTICULAR HEMICAP PATELLO FEMORAL COBALT OFF","SUP-ITM-10076092","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3650.00","36.5","","1023.42","771.29","2068.67","33","3100","7950","percent of total billed charges",""
"SET COMPONENT 36X35 PFXLT 11.5 4.0MM ARTICULAR HEMICAP PATELLO FEMORAL COBALT OFF","SUP-ITM-10076092","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3830.00","38.3","","850.52","759.78","1211.25","66","3100","7950","percent of total billed charges",""
"SET COMPONENT 36X35 PFXLT 11.5 4.0MM ARTICULAR HEMICAP PATELLO FEMORAL COBALT OFF","SUP-ITM-10076092","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4290.00","42.9","","2548.09","2548.09","2548.09","1 through 10","3100","7950","percent of total billed charges",""
"SET COMPONENT 36X35 PFXLT 11.5 4.0MM ARTICULAR HEMICAP PATELLO FEMORAL COBALT OFF","SUP-ITM-10076092","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4290.00","42.9","","956.46","956.46","956.46","1 through 10","3100","7950","percent of total billed charges",""
"SET COMPONENT 36X35 PFXLT 11.5 4.0MM ARTICULAR HEMICAP PATELLO FEMORAL COBALT OFF","SUP-ITM-10076092","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB AMC WELLPOINT","7378.00","73.78","","2344.73","1619.47","2530.35","16","3100","7950","percent of total billed charges",""
"SET COMPONENT 36X35 PFXLT 11.5 4.0MM ARTICULAR HEMICAP PATELLO FEMORAL COBALT OFF","SUP-ITM-10076092","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA HMO","6980.00","69.8","","1523.63","988.41","4330.26","39","5226","8172","percent of total billed charges",""
"SET COMPONENT 36X35 PFXLT 11.5 4.0MM ARTICULAR HEMICAP PATELLO FEMORAL COBALT OFF","SUP-ITM-10076092","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA PPO","8040.00","80.4","","1670.25","1670.25","1670.25","1 through 10","5226","8172","percent of total billed charges",""
"SET COMPONENT 36X35 PFXLT 11.5 4.0MM ARTICULAR HEMICAP PATELLO FEMORAL COBALT OFF","SUP-ITM-10076092","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5226.00","52.26","","1113.10","1113.10","1113.10","1 through 10","5226","8172","percent of total billed charges",""
"SET COMPONENT 36X35 PFXLT 11.5 4.0MM ARTICULAR HEMICAP PATELLO FEMORAL COBALT OFF","SUP-ITM-10076092","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8172.00","81.72","","1738.90","1484.65","2716.94","38","5226","8172","percent of total billed charges",""
"SET CVC 7FR 6IN MULTILUMEN POWER BWF CUSTOM CS/5EA","SUP-ITM-10114454","CDM","C1751","HCPCS","0272","RC","","","","both","","","213.15","159.86","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","149.21","70","","1389.50","602.17","3167.85","27","66.08","169.45","percent of total billed charges",""
"SET CVC 7FR 6IN MULTILUMEN POWER BWF CUSTOM CS/5EA","SUP-ITM-10114454","CDM","C1751","HCPCS","0272","RC","","","","both","","","213.15","159.86","WELLPOINT [1015]","HB AMC WELLPOINT","157.26","73.78","","1089.20","218.86","1089.20","1 through 10","66.08","169.45","percent of total billed charges",""
"SET CVC 7FR 6IN MULTILUMEN POWER BWF CUSTOM CS/5EA","SUP-ITM-10114454","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","213.15","159.86","AETNA [1001]","HB AMC AETNA HMO","148.78","69.8","","1389.50","940.69","1389.50","1 through 10","111.39","174.19","percent of total billed charges",""
"SET CVC 7FR 6IN MULTILUMEN POWER BWF CUSTOM CS/5EA","SUP-ITM-10114454","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","213.15","159.86","AETNA [1001]","HB AMC AETNA PPO","171.37","80.4","","190.26","190.26","190.26","1 through 10","111.39","174.19","percent of total billed charges",""
"SET CVC 7FR 6IN MULTILUMEN POWER BWF CUSTOM CS/5EA","SUP-ITM-10114454","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","213.15","159.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.19","81.72","","1110.77","235.00","1169.52","1 through 10","111.39","174.19","percent of total billed charges",""
"SET CVC 8.5FR 16CM QUAD LUMEN POWER BWF CUSTOM CS/5EA","SUP-ITM-10114455","CDM","C1751","HCPCS","0272","RC","","","","both","","","269.99","202.49","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","188.99","70","","1389.50","602.17","3167.85","27","83.7","214.64","percent of total billed charges",""
"SET CVC 8.5FR 16CM QUAD LUMEN POWER BWF CUSTOM CS/5EA","SUP-ITM-10114455","CDM","C1751","HCPCS","0272","RC","","","","both","","","269.99","202.49","WELLPOINT [1015]","HB AMC WELLPOINT","199.20","73.78","","1089.20","218.86","1089.20","1 through 10","83.7","214.64","percent of total billed charges",""
"SET CVC 8.5FR 16CM QUAD LUMEN POWER BWF CUSTOM CS/5EA","SUP-ITM-10114455","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","269.99","202.49","AETNA [1001]","HB AMC AETNA HMO","188.45","69.8","","1389.50","940.69","1389.50","1 through 10","141.1","220.64","percent of total billed charges",""
"SET CVC 8.5FR 16CM QUAD LUMEN POWER BWF CUSTOM CS/5EA","SUP-ITM-10114455","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","269.99","202.49","AETNA [1001]","HB AMC AETNA PPO","217.07","80.4","","190.26","190.26","190.26","1 through 10","141.1","220.64","percent of total billed charges",""
"SET CVC 8.5FR 16CM QUAD LUMEN POWER BWF CUSTOM CS/5EA","SUP-ITM-10114455","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","269.99","202.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","220.64","81.72","","1110.77","235.00","1169.52","1 through 10","141.1","220.64","percent of total billed charges",""
"SET CYLINDER 22CM ZERODEG PROSTHESIS PENILE TITAN TOUCH PUMP SCROTAL","SUP-ITM-10134881","CDM","C1813","HCPCS","0278","RC","","","","both","","","28200.00","21150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10800.60","38.3","","12613.42","12613.42","12613.42","1 through 10","8742","22419","percent of total billed charges",""
"SET CYLINDER 22CM ZERODEG PROSTHESIS PENILE TITAN TOUCH PUMP SCROTAL","SUP-ITM-10134881","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","28200.00","21150.00","AETNA [1001]","HB AMC AETNA HMO","19683.60","69.8","","34275.85","34275.85","50471.26","19","14737.32","23045.04","percent of total billed charges",""
"SET DILATOR 10.4FR 25CM SHEATH BYRD SS PERCUTANEOUS TELESCOPING SIZE B - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10001394","CDM","C1893","HCPCS","0272","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","218.28","218.28","218.28","1 through 10","482.83","1238.21","percent of total billed charges",""
"SET DILATOR 11FR VASCULAR CONTROLLED ROTATION EVOLUTION SS SINGLE END","SUP-ITM-10118119","CDM","C1773","HCPCS","0272","RC","","","","both","","","4995.00","3746.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1823.18","36.5","","114.30","97.14","114.30","1 through 10","1548.45","3971.03","percent of total billed charges",""
"SET DILATOR 11FR VASCULAR CONTROLLED ROTATION EVOLUTION SS SINGLE END","SUP-ITM-10118119","CDM","C1773","HCPCS","0272","RC","","","","both","","","4995.00","3746.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1913.09","38.3","","119.81","116.44","359.43","20","1548.45","3971.03","percent of total billed charges",""
"SET DILATOR 11FR VASCULAR CONTROLLED ROTATION EVOLUTION SS SINGLE END","SUP-ITM-10118119","CDM","C1773","HCPCS","0272","RC","","","","both","","","4995.00","3746.25","WELLPOINT [1015]","HB AMC WELLPOINT","3685.31","73.78","","875.53","228.13","875.53","1 through 10","1548.45","3971.03","percent of total billed charges",""
"SET DILATOR 11FR VASCULAR CONTROLLED ROTATION EVOLUTION SS SINGLE END","SUP-ITM-10118119","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","4995.00","3746.25","AETNA [1001]","HB AMC AETNA HMO","3486.51","69.8","","207.45","207.45","207.45","1 through 10","2610.39","4081.91","percent of total billed charges",""
"SET DILATOR 11FR VASCULAR CONTROLLED ROTATION EVOLUTION SS SINGLE END","SUP-ITM-10118119","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","4995.00","3746.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4081.91","81.72","","244.96","134.74","244.96","1 through 10","2610.39","4081.91","percent of total billed charges",""
"SET DILATOR 16CM RENAL UTEROSCOPY AMPLATZ","SUP-ITM-10001379","CDM","C1726","HCPCS","0272","RC","","","","both","","","894.95","671.21","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","626.47","70","","863.10","863.10","863.10","1 through 10","277.43","711.49","percent of total billed charges",""
"SET DILATOR 16CM RENAL UTEROSCOPY AMPLATZ","SUP-ITM-10001379","CDM","C1726","HCPCS","0272","RC","","","","both","","","894.95","671.21","CIGNA [1006]","HB AMC CIGNA HMO / PPO","711.49","79.5","","447.66","447.66","447.66","1 through 10","277.43","711.49","percent of total billed charges",""
"SET DILATOR 16CM RENAL UTEROSCOPY AMPLATZ","SUP-ITM-10001379","CDM","C1726","HCPCS","0272","RC","","","","both","","","894.95","671.21","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","581.72","65","","1020.11","1020.11","1020.11","1 through 10","277.43","711.49","percent of total billed charges",""
"SET DILATOR 16CM RENAL UTEROSCOPY AMPLATZ","SUP-ITM-10001379","CDM","C1726","HCPCS","0272","RC","","","","both","","","894.95","671.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","277.43","31","","208.83","208.83","208.83","1 through 10","277.43","711.49","percent of total billed charges",""
"SET DILATOR 16CM RENAL UTEROSCOPY AMPLATZ","SUP-ITM-10001379","CDM","C1726","HCPCS","0272","RC","","","","both","","","894.95","671.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","326.66","36.5","","312.44","214.23","1086.03","20","277.43","711.49","percent of total billed charges",""
"SET DILATOR 16CM RENAL UTEROSCOPY AMPLATZ","SUP-ITM-10001379","CDM","C1726","HCPCS","0272","RC","","","","both","","","894.95","671.21","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","342.77","38.3","","264.25","227.63","567.11","31","277.43","711.49","percent of total billed charges",""
"SET DILATOR 16CM RENAL UTEROSCOPY AMPLATZ","SUP-ITM-10001379","CDM","C1726","HCPCS","0272","RC","","","","both","","","894.95","671.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","383.93","42.9","","79.94","79.94","79.94","1 through 10","277.43","711.49","percent of total billed charges",""
"SET DILATOR 16CM RENAL UTEROSCOPY AMPLATZ","SUP-ITM-10001379","CDM","C1726","HCPCS","0272","RC","","","","both","","","894.95","671.21","WELLPOINT [1015]","HB AMC WELLPOINT","660.29","73.78","","174.45","74.45","1168.42","1 through 10","277.43","711.49","percent of total billed charges",""
"SET DILATOR 16CM RENAL UTEROSCOPY AMPLATZ","SUP-ITM-10001379","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","894.95","671.21","AETNA [1001]","HB AMC AETNA HMO","624.68","69.8","","655.01","135.40","784.73","1 through 10","467.7","731.35","percent of total billed charges",""
"SET DILATOR 16CM RENAL UTEROSCOPY AMPLATZ","SUP-ITM-10001379","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","894.95","671.21","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","731.35","81.72","","540.25","46.28","897.42","36","467.7","731.35","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.75","395.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","275.28","52.26","","25.34","25.34","25.34","1 through 10","163.29","418.77","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.75","395.06","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","378.21","71.8","","105.81","105.81","366.90","1 through 10","163.29","418.77","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.75","395.06","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","368.73","70","","512.90","74.70","612.85","1 through 10","163.29","418.77","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.75","395.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","418.77","79.5","","200.27","182.80","200.27","1 through 10","163.29","418.77","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.75","395.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","280.76","53.3","","37.73","37.73","169.33","1 through 10","163.29","418.77","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.75","395.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","342.39","65","","100.27","8.48","494.52","1 through 10","163.29","418.77","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.75","395.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","342.39","65","","160.19","160.19","160.19","1 through 10","163.29","418.77","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.75","395.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","163.29","31","","28.12","28.12","28.12","1 through 10","163.29","418.77","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.75","395.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","192.26","36.5","","101.66","28.85","502.70","121","163.29","418.77","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.75","395.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.75","38.3","","61.58","25.32","328.44","138","163.29","418.77","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.75","395.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.98","42.9","","71.66","71.66","71.66","1 through 10","163.29","418.77","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","both","","","526.75","395.06","WELLPOINT [1015]","HB AMC WELLPOINT","388.64","73.78","","74.75","27.97","425.28","93","163.29","418.77","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","526.75","395.06","AETNA [1001]","HB AMC AETNA HMO","367.67","69.8","","52.67","14.36","414.90","1 through 10","275.28","430.46","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","526.75","395.06","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","275.28","52.26","","25.34","25.34","25.34","1 through 10","275.28","430.46","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","526.75","395.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","423.51","80.4","","478.02","107.84","478.02","1 through 10","275.28","430.46","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","526.75","395.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","430.46","81.72","","32.74","12.33","122.05","1 through 10","275.28","430.46","percent of total billed charges",""
"SET DILATOR 4MM DIA 45CM .035IN GUIDEWIRE VASCULAR W/OUT BALLOON SPINDLE SHAPD OTW SUCCESSIVE DILATN INFLAT DEV FLUOR","SUP-ITM-10074821","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","526.75","395.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","430.46","81.72","","144.95","32.78","676.91","104","275.28","430.46","percent of total billed charges",""
"SET EXTENSION OCTOPUS MICROBORE 6 PORT NEEDLE FREE CS/50EA","SUP-ITM-10194536","CDM","C2618","HCPCS","0272","RC","","","","both","","","42.71","32.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.36","38.3","","1876.80","640.73","1876.80","1 through 10","13.24","33.95","percent of total billed charges",""
"SET EXTENSION OCTOPUS MICROBORE 6 PORT NEEDLE FREE CS/50EA","SUP-ITM-10194536","CDM","C2618","HCPCS","0272","RC","","","","both","","","42.71","32.03","WELLPOINT [1015]","HB AMC WELLPOINT","31.51","73.78","","2802.54","1220.01","4020.30","1 through 10","13.24","33.95","percent of total billed charges",""
"SET EXTENSION OCTOPUS MICROBORE 6 PORT NEEDLE FREE CS/50EA","SUP-ITM-10194536","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","42.71","32.03","AETNA [1001]","HB AMC AETNA HMO","29.81","69.8","","2175.20","2175.20","2175.20","1 through 10","22.32","34.9","percent of total billed charges",""
"SET EXTENSION OCTOPUS MICROBORE 6 PORT NEEDLE FREE CS/50EA","SUP-ITM-10194536","CDM","C2618","HCPCS","0272","RC","","","","outpatient","","","42.71","32.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34.90","81.72","","4750.00","720.54","7250.00","11","22.32","34.9","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","800.18","480.96","1887.97","195","1395","3577.5","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2398.50","53.3","","813.12","216.42","1444.50","81","1395","3577.5","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1395.00","31","","432.60","432.60","432.60","1 through 10","1395","3577.5","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","148.37","54.89","631.39","94","1395","3577.5","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","279.30","91.72","1116.77","266","1395","3577.5","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","731.00","63.70","731.00","1 through 10","1395","3577.5","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","384.74","384.74","384.74","1 through 10","1395","3577.5","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","286.63","119.22","1107.45","105","1395","3577.5","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","675.31","184.75","1721.50","286","2351.7","3677.4","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA PPO","3618.00","80.4","","1261.44","103.12","1514.10","21","2351.7","3677.4","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3618.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3677.40","81.72","","5157.68","5157.68","5157.68","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SET FIXATOR LG EXTERNAL FIXATION DISTAL RADIUS COMPLETE AGEE WRISTJACK","SUP-ITM-10005016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","431.26","71.26","1459.57","88","2351.7","3677.4","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","119.79","52.26","","16.24","16.24","54.15","1 through 10","71.06","182.23","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","164.58","71.8","","86.33","32.67","86.33","1 through 10","71.06","182.23","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","160.45","70","","113.68","63.00","177.34","40","71.06","182.23","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","182.23","79.5","","50.70","21.76","168.00","12","71.06","182.23","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","122.17","53.3","","89.31","89.31","99.75","1 through 10","71.06","182.23","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","148.99","65","","94.41","17.06","2275.00","1 through 10","71.06","182.23","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","71.06","31","","35.13","35.13","35.13","1 through 10","71.06","182.23","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.67","36.5","","40.08","12.40","86.17","108","71.06","182.23","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.79","38.3","","33.25","10.27","68.43","169","71.06","182.23","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.34","42.9","","25.48","14.86","90.88","1 through 10","71.06","182.23","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.34","42.9","","90.88","90.88","90.88","1 through 10","71.06","182.23","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","both","","","229.22","171.91","WELLPOINT [1015]","HB AMC WELLPOINT","169.12","73.78","","84.63","19.55","140.02","123","71.06","182.23","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","AETNA [1001]","HB AMC AETNA HMO","160.00","69.8","","76.96","17.77","113.68","14","119.79","187.32","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","AETNA [1001]","HB AMC AETNA PPO","184.29","80.4","","57.31","57.31","57.31","1 through 10","119.79","187.32","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","119.79","52.26","","16.24","16.24","54.15","1 through 10","119.79","187.32","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","184.29","80.4","","68.25","68.25","87.50","1 through 10","119.79","187.32","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","187.32","81.72","","156.19","156.19","156.19","1 through 10","119.79","187.32","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","187.32","81.72","","82.70","12.06","98.97","13","119.79","187.32","percent of total billed charges",""
"SET INTRODUCER 30CMX16FR .038 GUIDEWIRE CARD LEAD PLACEMENT STR W/OUT HEMSTC VLV PERIPHERAL SINUS ACCESS NDL RADI","SUP-ITM-10087278","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","229.22","171.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","187.32","81.72","","50.47","25.30","134.30","140","119.79","187.32","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","713.35","52.26","","25.34","25.34","25.34","1 through 10","423.15","1085.18","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","980.07","71.8","","105.81","105.81","366.90","1 through 10","423.15","1085.18","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","955.50","70","","512.90","74.70","612.85","1 through 10","423.15","1085.18","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1085.18","79.5","","200.27","182.80","200.27","1 through 10","423.15","1085.18","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","727.55","53.3","","37.73","37.73","169.33","1 through 10","423.15","1085.18","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","887.25","65","","100.27","8.48","494.52","1 through 10","423.15","1085.18","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","887.25","65","","160.19","160.19","160.19","1 through 10","423.15","1085.18","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","423.15","31","","28.12","28.12","28.12","1 through 10","423.15","1085.18","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","498.23","36.5","","101.66","28.85","502.70","121","423.15","1085.18","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","522.80","38.3","","61.58","25.32","328.44","138","423.15","1085.18","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","71.66","71.66","71.66","1 through 10","423.15","1085.18","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB AMC WELLPOINT","1007.10","73.78","","74.75","27.97","425.28","93","423.15","1085.18","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA HMO","952.77","69.8","","52.67","14.36","414.90","1 through 10","713.35","1115.48","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1365.00","1023.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","713.35","52.26","","25.34","25.34","25.34","1 through 10","713.35","1115.48","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1097.46","80.4","","478.02","107.84","478.02","1 through 10","713.35","1115.48","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1115.48","81.72","","32.74","12.33","122.05","1 through 10","713.35","1115.48","percent of total billed charges",""
"SET INTRODUCER 6.5/7/7.5/8MM LOADING DILATOR BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY","SUP-ITM-10287866","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1115.48","81.72","","144.95","32.78","676.91","104","713.35","1115.48","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","137.17","52.26","","16.24","16.24","54.15","1 through 10","81.37","208.66","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","188.45","71.8","","86.33","32.67","86.33","1 through 10","81.37","208.66","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","183.73","70","","113.68","63.00","177.34","40","81.37","208.66","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","208.66","79.5","","50.70","21.76","168.00","12","81.37","208.66","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.90","53.3","","89.31","89.31","99.75","1 through 10","81.37","208.66","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","170.61","65","","94.41","17.06","2275.00","1 through 10","81.37","208.66","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","81.37","31","","35.13","35.13","35.13","1 through 10","81.37","208.66","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.80","36.5","","40.08","12.40","86.17","108","81.37","208.66","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.53","38.3","","33.25","10.27","68.43","169","81.37","208.66","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.60","42.9","","25.48","14.86","90.88","1 through 10","81.37","208.66","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.60","42.9","","90.88","90.88","90.88","1 through 10","81.37","208.66","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","262.47","196.85","WELLPOINT [1015]","HB AMC WELLPOINT","193.65","73.78","","84.63","19.55","140.02","123","81.37","208.66","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","AETNA [1001]","HB AMC AETNA HMO","183.20","69.8","","76.96","17.77","113.68","14","137.17","214.49","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","AETNA [1001]","HB AMC AETNA PPO","211.03","80.4","","57.31","57.31","57.31","1 through 10","137.17","214.49","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","137.17","52.26","","16.24","16.24","54.15","1 through 10","137.17","214.49","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","211.03","80.4","","68.25","68.25","87.50","1 through 10","137.17","214.49","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","214.49","81.72","","156.19","156.19","156.19","1 through 10","137.17","214.49","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","214.49","81.72","","82.70","12.06","98.97","13","137.17","214.49","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","262.47","196.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.49","81.72","","50.47","25.30","134.30","140","137.17","214.49","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","both","","","156.31","117.23","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","81.69","52.26","","16.24","16.24","54.15","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","both","","","156.31","117.23","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","112.23","71.8","","86.33","32.67","86.33","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","both","","","156.31","117.23","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","109.42","70","","113.68","63.00","177.34","40","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","both","","","156.31","117.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.27","79.5","","50.70","21.76","168.00","12","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","both","","","156.31","117.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.31","53.3","","89.31","89.31","99.75","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","both","","","156.31","117.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","101.60","65","","94.41","17.06","2275.00","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","both","","","156.31","117.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.46","31","","35.13","35.13","35.13","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","both","","","156.31","117.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.05","36.5","","40.08","12.40","86.17","108","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","both","","","156.31","117.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","59.87","38.3","","33.25","10.27","68.43","169","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","both","","","156.31","117.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.06","42.9","","25.48","14.86","90.88","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","both","","","156.31","117.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.06","42.9","","90.88","90.88","90.88","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","both","","","156.31","117.23","WELLPOINT [1015]","HB AMC WELLPOINT","115.33","73.78","","84.63","19.55","140.02","123","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","156.31","117.23","AETNA [1001]","HB AMC AETNA HMO","109.10","69.8","","76.96","17.77","113.68","14","81.69","127.74","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","156.31","117.23","AETNA [1001]","HB AMC AETNA PPO","125.67","80.4","","57.31","57.31","57.31","1 through 10","81.69","127.74","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","156.31","117.23","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","81.69","52.26","","16.24","16.24","54.15","1 through 10","81.69","127.74","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","156.31","117.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","125.67","80.4","","68.25","68.25","87.50","1 through 10","81.69","127.74","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","156.31","117.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","127.74","81.72","","156.19","156.19","156.19","1 through 10","81.69","127.74","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","156.31","117.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","127.74","81.72","","82.70","12.06","98.97","13","81.69","127.74","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10036189","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","156.31","117.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","127.74","81.72","","50.47","25.30","134.30","140","81.69","127.74","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","both","","","113.68","85.26","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","59.41","52.26","","16.24","16.24","54.15","1 through 10","35.24","90.38","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","both","","","113.68","85.26","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","81.62","71.8","","86.33","32.67","86.33","1 through 10","35.24","90.38","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","both","","","113.68","85.26","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","79.58","70","","113.68","63.00","177.34","40","35.24","90.38","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","both","","","113.68","85.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","90.38","79.5","","50.70","21.76","168.00","12","35.24","90.38","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","both","","","113.68","85.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","60.59","53.3","","89.31","89.31","99.75","1 through 10","35.24","90.38","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","both","","","113.68","85.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","73.89","65","","94.41","17.06","2275.00","1 through 10","35.24","90.38","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","both","","","113.68","85.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","35.24","31","","35.13","35.13","35.13","1 through 10","35.24","90.38","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","both","","","113.68","85.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.49","36.5","","40.08","12.40","86.17","108","35.24","90.38","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","both","","","113.68","85.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.54","38.3","","33.25","10.27","68.43","169","35.24","90.38","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","both","","","113.68","85.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.77","42.9","","25.48","14.86","90.88","1 through 10","35.24","90.38","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","both","","","113.68","85.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.77","42.9","","90.88","90.88","90.88","1 through 10","35.24","90.38","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","both","","","113.68","85.26","WELLPOINT [1015]","HB AMC WELLPOINT","83.87","73.78","","84.63","19.55","140.02","123","35.24","90.38","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","113.68","85.26","AETNA [1001]","HB AMC AETNA HMO","79.35","69.8","","76.96","17.77","113.68","14","59.41","92.9","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","113.68","85.26","AETNA [1001]","HB AMC AETNA PPO","91.40","80.4","","57.31","57.31","57.31","1 through 10","59.41","92.9","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","113.68","85.26","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","59.41","52.26","","16.24","16.24","54.15","1 through 10","59.41","92.9","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","113.68","85.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","91.40","80.4","","68.25","68.25","87.50","1 through 10","59.41","92.9","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","113.68","85.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","92.90","81.72","","156.19","156.19","156.19","1 through 10","59.41","92.9","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","113.68","85.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","92.90","81.72","","82.70","12.06","98.97","13","59.41","92.9","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019833","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","113.68","85.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","92.90","81.72","","50.47","25.30","134.30","140","59.41","92.9","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","both","","","97.69","73.27","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","51.05","52.26","","16.24","16.24","54.15","1 through 10","30.28","77.66","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","both","","","97.69","73.27","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","70.14","71.8","","86.33","32.67","86.33","1 through 10","30.28","77.66","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","both","","","97.69","73.27","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","68.38","70","","113.68","63.00","177.34","40","30.28","77.66","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","both","","","97.69","73.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","77.66","79.5","","50.70","21.76","168.00","12","30.28","77.66","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","both","","","97.69","73.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","52.07","53.3","","89.31","89.31","99.75","1 through 10","30.28","77.66","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","both","","","97.69","73.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","63.50","65","","94.41","17.06","2275.00","1 through 10","30.28","77.66","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","both","","","97.69","73.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","30.28","31","","35.13","35.13","35.13","1 through 10","30.28","77.66","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","both","","","97.69","73.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","35.66","36.5","","40.08","12.40","86.17","108","30.28","77.66","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","both","","","97.69","73.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37.42","38.3","","33.25","10.27","68.43","169","30.28","77.66","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","both","","","97.69","73.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.91","42.9","","25.48","14.86","90.88","1 through 10","30.28","77.66","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","both","","","97.69","73.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.91","42.9","","90.88","90.88","90.88","1 through 10","30.28","77.66","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","both","","","97.69","73.27","WELLPOINT [1015]","HB AMC WELLPOINT","72.08","73.78","","84.63","19.55","140.02","123","30.28","77.66","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","97.69","73.27","AETNA [1001]","HB AMC AETNA HMO","68.19","69.8","","76.96","17.77","113.68","14","51.05","79.83","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","97.69","73.27","AETNA [1001]","HB AMC AETNA PPO","78.54","80.4","","57.31","57.31","57.31","1 through 10","51.05","79.83","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","97.69","73.27","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","51.05","52.26","","16.24","16.24","54.15","1 through 10","51.05","79.83","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","97.69","73.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","78.54","80.4","","68.25","68.25","87.50","1 through 10","51.05","79.83","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","97.69","73.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","79.83","81.72","","156.19","156.19","156.19","1 through 10","51.05","79.83","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","97.69","73.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","79.83","81.72","","82.70","12.06","98.97","13","51.05","79.83","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP S/S WIRE S/S TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019873","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","97.69","73.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","79.83","81.72","","50.47","25.30","134.30","140","51.05","79.83","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","both","","","156.31","117.23","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","81.69","52.26","","25.34","25.34","25.34","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","both","","","156.31","117.23","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","112.23","71.8","","105.81","105.81","366.90","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","both","","","156.31","117.23","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","109.42","70","","512.90","74.70","612.85","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","both","","","156.31","117.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.27","79.5","","200.27","182.80","200.27","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","both","","","156.31","117.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.31","53.3","","37.73","37.73","169.33","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","both","","","156.31","117.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","101.60","65","","100.27","8.48","494.52","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","both","","","156.31","117.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","101.60","65","","160.19","160.19","160.19","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","both","","","156.31","117.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.46","31","","28.12","28.12","28.12","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","both","","","156.31","117.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.05","36.5","","101.66","28.85","502.70","121","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","both","","","156.31","117.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","59.87","38.3","","61.58","25.32","328.44","138","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","both","","","156.31","117.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.06","42.9","","71.66","71.66","71.66","1 through 10","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","both","","","156.31","117.23","WELLPOINT [1015]","HB AMC WELLPOINT","115.33","73.78","","74.75","27.97","425.28","93","48.46","124.27","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","156.31","117.23","AETNA [1001]","HB AMC AETNA HMO","109.10","69.8","","52.67","14.36","414.90","1 through 10","81.69","127.74","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","156.31","117.23","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","81.69","52.26","","25.34","25.34","25.34","1 through 10","81.69","127.74","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","156.31","117.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","125.67","80.4","","478.02","107.84","478.02","1 through 10","81.69","127.74","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","156.31","117.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","127.74","81.72","","32.74","12.33","122.05","1 through 10","81.69","127.74","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/45CM 21G/7CM ACCESS STIFFENED CANNULA NITINOL WIRE PLATINUM TIP NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10087108","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","156.31","117.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","127.74","81.72","","144.95","32.78","676.91","104","81.69","127.74","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","both","","","101.06","75.79","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","52.81","52.26","","16.24","16.24","54.15","1 through 10","31.33","80.34","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","both","","","101.06","75.79","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","72.56","71.8","","86.33","32.67","86.33","1 through 10","31.33","80.34","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","both","","","101.06","75.79","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","70.74","70","","113.68","63.00","177.34","40","31.33","80.34","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","both","","","101.06","75.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","80.34","79.5","","50.70","21.76","168.00","12","31.33","80.34","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","both","","","101.06","75.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","53.86","53.3","","89.31","89.31","99.75","1 through 10","31.33","80.34","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","both","","","101.06","75.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","65.69","65","","94.41","17.06","2275.00","1 through 10","31.33","80.34","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","both","","","101.06","75.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","31.33","31","","35.13","35.13","35.13","1 through 10","31.33","80.34","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","both","","","101.06","75.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36.89","36.5","","40.08","12.40","86.17","108","31.33","80.34","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","both","","","101.06","75.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38.71","38.3","","33.25","10.27","68.43","169","31.33","80.34","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","both","","","101.06","75.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.35","42.9","","25.48","14.86","90.88","1 through 10","31.33","80.34","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","both","","","101.06","75.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.35","42.9","","90.88","90.88","90.88","1 through 10","31.33","80.34","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","both","","","101.06","75.79","WELLPOINT [1015]","HB AMC WELLPOINT","74.56","73.78","","84.63","19.55","140.02","123","31.33","80.34","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","101.06","75.79","AETNA [1001]","HB AMC AETNA HMO","70.54","69.8","","76.96","17.77","113.68","14","52.81","82.59","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","101.06","75.79","AETNA [1001]","HB AMC AETNA PPO","81.25","80.4","","57.31","57.31","57.31","1 through 10","52.81","82.59","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","101.06","75.79","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","52.81","52.26","","16.24","16.24","54.15","1 through 10","52.81","82.59","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","101.06","75.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","81.25","80.4","","68.25","68.25","87.50","1 through 10","52.81","82.59","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","101.06","75.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","82.59","81.72","","156.19","156.19","156.19","1 through 10","52.81","82.59","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","101.06","75.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","82.59","81.72","","82.70","12.06","98.97","13","52.81","82.59","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/15CM .018IN/60CM 21G/12CM ACCESS MALLINCKRODT MODIFICATION S/S WIRE S/S TIP INCL NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019215","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","101.06","75.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","82.59","81.72","","50.47","25.30","134.30","140","52.81","82.59","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","both","","","204.48","153.36","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","106.86","52.26","","16.24","16.24","54.15","1 through 10","63.39","162.56","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","both","","","204.48","153.36","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","146.82","71.8","","86.33","32.67","86.33","1 through 10","63.39","162.56","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","both","","","204.48","153.36","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","143.14","70","","113.68","63.00","177.34","40","63.39","162.56","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","both","","","204.48","153.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","162.56","79.5","","50.70","21.76","168.00","12","63.39","162.56","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","both","","","204.48","153.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","108.99","53.3","","89.31","89.31","99.75","1 through 10","63.39","162.56","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","both","","","204.48","153.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","132.91","65","","94.41","17.06","2275.00","1 through 10","63.39","162.56","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","both","","","204.48","153.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","63.39","31","","35.13","35.13","35.13","1 through 10","63.39","162.56","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","both","","","204.48","153.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.64","36.5","","40.08","12.40","86.17","108","63.39","162.56","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","both","","","204.48","153.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.32","38.3","","33.25","10.27","68.43","169","63.39","162.56","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","both","","","204.48","153.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.72","42.9","","25.48","14.86","90.88","1 through 10","63.39","162.56","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","both","","","204.48","153.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.72","42.9","","90.88","90.88","90.88","1 through 10","63.39","162.56","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","both","","","204.48","153.36","WELLPOINT [1015]","HB AMC WELLPOINT","150.87","73.78","","84.63","19.55","140.02","123","63.39","162.56","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","204.48","153.36","AETNA [1001]","HB AMC AETNA HMO","142.73","69.8","","76.96","17.77","113.68","14","106.86","167.1","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","204.48","153.36","AETNA [1001]","HB AMC AETNA PPO","164.40","80.4","","57.31","57.31","57.31","1 through 10","106.86","167.1","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","204.48","153.36","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","106.86","52.26","","16.24","16.24","54.15","1 through 10","106.86","167.1","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","204.48","153.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","164.40","80.4","","68.25","68.25","87.50","1 through 10","106.86","167.1","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","204.48","153.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","167.10","81.72","","156.19","156.19","156.19","1 through 10","106.86","167.1","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","204.48","153.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","167.10","81.72","","82.70","12.06","98.97","13","106.86","167.1","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 35CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000451","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","204.48","153.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","167.10","81.72","","50.47","25.30","134.30","140","106.86","167.1","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","both","","","266.07","199.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","139.05","52.26","","16.24","16.24","54.15","1 through 10","82.48","211.53","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","both","","","266.07","199.55","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","191.04","71.8","","86.33","32.67","86.33","1 through 10","82.48","211.53","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","both","","","266.07","199.55","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","186.25","70","","113.68","63.00","177.34","40","82.48","211.53","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","both","","","266.07","199.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","211.53","79.5","","50.70","21.76","168.00","12","82.48","211.53","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","both","","","266.07","199.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","141.82","53.3","","89.31","89.31","99.75","1 through 10","82.48","211.53","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","both","","","266.07","199.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","172.95","65","","94.41","17.06","2275.00","1 through 10","82.48","211.53","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","both","","","266.07","199.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","82.48","31","","35.13","35.13","35.13","1 through 10","82.48","211.53","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","both","","","266.07","199.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","97.12","36.5","","40.08","12.40","86.17","108","82.48","211.53","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","both","","","266.07","199.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","101.90","38.3","","33.25","10.27","68.43","169","82.48","211.53","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","both","","","266.07","199.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.14","42.9","","25.48","14.86","90.88","1 through 10","82.48","211.53","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","both","","","266.07","199.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.14","42.9","","90.88","90.88","90.88","1 through 10","82.48","211.53","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","both","","","266.07","199.55","WELLPOINT [1015]","HB AMC WELLPOINT","196.31","73.78","","84.63","19.55","140.02","123","82.48","211.53","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","266.07","199.55","AETNA [1001]","HB AMC AETNA HMO","185.72","69.8","","76.96","17.77","113.68","14","139.05","217.43","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","266.07","199.55","AETNA [1001]","HB AMC AETNA PPO","213.92","80.4","","57.31","57.31","57.31","1 through 10","139.05","217.43","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","266.07","199.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","139.05","52.26","","16.24","16.24","54.15","1 through 10","139.05","217.43","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","266.07","199.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","213.92","80.4","","68.25","68.25","87.50","1 through 10","139.05","217.43","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","266.07","199.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","217.43","81.72","","156.19","156.19","156.19","1 through 10","139.05","217.43","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","266.07","199.55","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","217.43","81.72","","82.70","12.06","98.97","13","139.05","217.43","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 45CM SHEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10011306","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","266.07","199.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","217.43","81.72","","50.47","25.30","134.30","140","139.05","217.43","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","both","","","287.00","215.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","149.99","52.26","","16.24","16.24","54.15","1 through 10","88.97","228.17","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","both","","","287.00","215.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","206.07","71.8","","86.33","32.67","86.33","1 through 10","88.97","228.17","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","both","","","287.00","215.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","200.90","70","","113.68","63.00","177.34","40","88.97","228.17","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","both","","","287.00","215.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","228.17","79.5","","50.70","21.76","168.00","12","88.97","228.17","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","both","","","287.00","215.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","152.97","53.3","","89.31","89.31","99.75","1 through 10","88.97","228.17","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","both","","","287.00","215.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","186.55","65","","94.41","17.06","2275.00","1 through 10","88.97","228.17","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","88.97","31","","35.13","35.13","35.13","1 through 10","88.97","228.17","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","104.76","36.5","","40.08","12.40","86.17","108","88.97","228.17","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","both","","","287.00","215.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","109.92","38.3","","33.25","10.27","68.43","169","88.97","228.17","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","both","","","287.00","215.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","123.12","42.9","","25.48","14.86","90.88","1 through 10","88.97","228.17","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","both","","","287.00","215.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","123.12","42.9","","90.88","90.88","90.88","1 through 10","88.97","228.17","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","both","","","287.00","215.25","WELLPOINT [1015]","HB AMC WELLPOINT","211.75","73.78","","84.63","19.55","140.02","123","88.97","228.17","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","287.00","215.25","AETNA [1001]","HB AMC AETNA HMO","200.33","69.8","","76.96","17.77","113.68","14","149.99","234.54","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","287.00","215.25","AETNA [1001]","HB AMC AETNA PPO","230.75","80.4","","57.31","57.31","57.31","1 through 10","149.99","234.54","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","287.00","215.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","149.99","52.26","","16.24","16.24","54.15","1 through 10","149.99","234.54","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","287.00","215.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","230.75","80.4","","68.25","68.25","87.50","1 through 10","149.99","234.54","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","287.00","215.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","234.54","81.72","","156.19","156.19","156.19","1 through 10","149.99","234.54","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","287.00","215.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","234.54","81.72","","82.70","12.06","98.97","13","149.99","234.54","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 65CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10065790","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","287.00","215.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","234.54","81.72","","50.47","25.30","134.30","140","149.99","234.54","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.25","56.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","39.33","52.26","","16.24","16.24","54.15","1 through 10","23.33","59.82","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.25","56.44","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","54.03","71.8","","86.33","32.67","86.33","1 through 10","23.33","59.82","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.25","56.44","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","52.68","70","","113.68","63.00","177.34","40","23.33","59.82","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.25","56.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59.82","79.5","","50.70","21.76","168.00","12","23.33","59.82","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.25","56.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","40.11","53.3","","89.31","89.31","99.75","1 through 10","23.33","59.82","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.25","56.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","48.91","65","","94.41","17.06","2275.00","1 through 10","23.33","59.82","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.25","56.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","23.33","31","","35.13","35.13","35.13","1 through 10","23.33","59.82","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.25","56.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.47","36.5","","40.08","12.40","86.17","108","23.33","59.82","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.25","56.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.82","38.3","","33.25","10.27","68.43","169","23.33","59.82","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.25","56.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.28","42.9","","25.48","14.86","90.88","1 through 10","23.33","59.82","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.25","56.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.28","42.9","","90.88","90.88","90.88","1 through 10","23.33","59.82","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.25","56.44","WELLPOINT [1015]","HB AMC WELLPOINT","55.52","73.78","","84.63","19.55","140.02","123","23.33","59.82","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","75.25","56.44","AETNA [1001]","HB AMC AETNA HMO","52.52","69.8","","76.96","17.77","113.68","14","39.33","61.49","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","75.25","56.44","AETNA [1001]","HB AMC AETNA PPO","60.50","80.4","","57.31","57.31","57.31","1 through 10","39.33","61.49","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","75.25","56.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","39.33","52.26","","16.24","16.24","54.15","1 through 10","39.33","61.49","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","75.25","56.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","60.50","80.4","","68.25","68.25","87.50","1 through 10","39.33","61.49","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","75.25","56.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","61.49","81.72","","156.19","156.19","156.19","1 through 10","39.33","61.49","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","75.25","56.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","61.49","81.72","","82.70","12.06","98.97","13","39.33","61.49","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 7FR 11CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP ORANGE CS/10EA","SUP-ITM-10008711","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","75.25","56.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","61.49","81.72","","50.47","25.30","134.30","140","39.33","61.49","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","both","","","3192.63","2394.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2538.14","79.5","","1632.15","1632.15","1632.15","1 through 10","989.72","2538.14","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","both","","","3192.63","2394.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1701.67","53.3","","9709.13","9709.13","9709.13","1 through 10","989.72","2538.14","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","both","","","3192.63","2394.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2075.21","65","","2685.95","2190.09","2685.96","1 through 10","989.72","2538.14","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","both","","","3192.63","2394.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1165.31","36.5","","1495.87","1455.73","1541.33","1 through 10","989.72","2538.14","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","both","","","3192.63","2394.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1222.78","38.3","","1615.71","1615.71","1615.71","1 through 10","989.72","2538.14","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","both","","","3192.63","2394.47","WELLPOINT [1015]","HB AMC WELLPOINT","2355.52","73.78","","3076.44","3076.44","3076.44","1 through 10","989.72","2538.14","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3192.63","2394.47","AETNA [1001]","HB AMC AETNA HMO","2228.46","69.8","","4568.79","2411.14","4568.79","1 through 10","1668.47","2609.02","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3192.63","2394.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2566.87","80.4","","2411.14","1545.60","3223.14","1 through 10","1668.47","2609.02","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3192.63","2394.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2609.02","81.72","","1816.95","1816.95","1816.95","1 through 10","1668.47","2609.02","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3192.63","2394.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2609.02","81.72","","3303.30","3303.30","3303.30","1 through 10","1668.47","2609.02","percent of total billed charges",""
"SET KIT 10FR 19.5CM NEPHROSTOMY PERCUTANEOUS CATHETER LOOP POLYURETHANE CANNULA","SUP-ITM-10078370","CDM","C1729","HCPCS","0272","RC","","","","both","","","357.00","267.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","256.33","71.8","","162.24","51.52","162.24","1 through 10","110.67","283.82","percent of total billed charges",""
"SET KIT 10FR 19.5CM NEPHROSTOMY PERCUTANEOUS CATHETER LOOP POLYURETHANE CANNULA","SUP-ITM-10078370","CDM","C1729","HCPCS","0272","RC","","","","both","","","357.00","267.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","130.31","36.5","","94.34","22.19","146.22","26","110.67","283.82","percent of total billed charges",""
"SET KIT 10FR 19.5CM NEPHROSTOMY PERCUTANEOUS CATHETER LOOP POLYURETHANE CANNULA","SUP-ITM-10078370","CDM","C1729","HCPCS","0272","RC","","","","both","","","357.00","267.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","136.73","38.3","","51.52","27.37","51.52","26","110.67","283.82","percent of total billed charges",""
"SET KIT 10FR 19.5CM NEPHROSTOMY PERCUTANEOUS CATHETER LOOP POLYURETHANE CANNULA","SUP-ITM-10078370","CDM","C1729","HCPCS","0272","RC","","","","both","","","357.00","267.75","WELLPOINT [1015]","HB AMC WELLPOINT","263.39","73.78","","207.21","122.12","216.28","14","110.67","283.82","percent of total billed charges",""
"SET KIT 10FR 19.5CM NEPHROSTOMY PERCUTANEOUS CATHETER LOOP POLYURETHANE CANNULA","SUP-ITM-10078370","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","357.00","267.75","AETNA [1001]","HB AMC AETNA HMO","249.19","69.8","","155.96","47.39","155.96","1 through 10","186.57","291.74","percent of total billed charges",""
"SET KIT 10FR 19.5CM NEPHROSTOMY PERCUTANEOUS CATHETER LOOP POLYURETHANE CANNULA","SUP-ITM-10078370","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","357.00","267.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","291.74","81.72","","57.36","51.76","232.23","35","186.57","291.74","percent of total billed charges",""
"SET KIT 6.0FR 28CM STENT URETERAL RESONANCE METALLIC SHEATH CATHETER COIL DESIGN PIGTAIL RADIOPAQUE TIP","SUP-ITM-10078610","CDM","C2625","HCPCS","0278","RC","","","","both","","","4000.85","3000.64","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2800.60","70","","470.75","470.75","470.75","1 through 10","1240.26","3180.68","percent of total billed charges",""
"SET KIT 6.0FR 28CM STENT URETERAL RESONANCE METALLIC SHEATH CATHETER COIL DESIGN PIGTAIL RADIOPAQUE TIP","SUP-ITM-10078610","CDM","C2625","HCPCS","0278","RC","","","","both","","","4000.85","3000.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1532.33","38.3","","184.07","124.37","184.07","1 through 10","1240.26","3180.68","percent of total billed charges",""
"SET KIT 6.0FR 28CM STENT URETERAL RESONANCE METALLIC SHEATH CATHETER COIL DESIGN PIGTAIL RADIOPAQUE TIP","SUP-ITM-10078610","CDM","C2625","HCPCS","0278","RC","","","","both","","","4000.85","3000.64","WELLPOINT [1015]","HB AMC WELLPOINT","2951.83","73.78","","243.67","243.67","243.67","1 through 10","1240.26","3180.68","percent of total billed charges",""
"SET KIT 6.0FR 28CM STENT URETERAL RESONANCE METALLIC SHEATH CATHETER COIL DESIGN PIGTAIL RADIOPAQUE TIP","SUP-ITM-10078610","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","4000.85","3000.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3269.49","81.72","","376.32","376.32","376.32","1 through 10","2090.84","3269.49","percent of total billed charges",""
"SET KIT 6FRX24CM UNIVERSAL STENT URETERAL UNIVERSA SOFT HYDROPHILIC COATING GUIDEWIRE","SUP-ITM-10078710","CDM","C2617","HCPCS","0278","RC","","","","both","","","364.35","273.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","289.66","79.5","","304.65","204.39","304.65","1 through 10","112.95","289.66","percent of total billed charges",""
"SET KIT 6FRX24CM UNIVERSAL STENT URETERAL UNIVERSA SOFT HYDROPHILIC COATING GUIDEWIRE","SUP-ITM-10078710","CDM","C2617","HCPCS","0278","RC","","","","both","","","364.35","273.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","194.20","53.3","","204.39","204.39","304.65","1 through 10","112.95","289.66","percent of total billed charges",""
"SET KIT 6FRX24CM UNIVERSAL STENT URETERAL UNIVERSA SOFT HYDROPHILIC COATING GUIDEWIRE","SUP-ITM-10078710","CDM","C2617","HCPCS","0278","RC","","","","both","","","364.35","273.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","132.99","36.5","","144.39","122.71","144.39","1 through 10","112.95","289.66","percent of total billed charges",""
"SET KIT 6FRX24CM UNIVERSAL STENT URETERAL UNIVERSA SOFT HYDROPHILIC COATING GUIDEWIRE","SUP-ITM-10078710","CDM","C2617","HCPCS","0278","RC","","","","both","","","364.35","273.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","139.55","38.3","","151.36","147.10","454.08","13","112.95","289.66","percent of total billed charges",""
"SET KIT 6FRX24CM UNIVERSAL STENT URETERAL UNIVERSA SOFT HYDROPHILIC COATING GUIDEWIRE","SUP-ITM-10078710","CDM","C2617","HCPCS","0278","RC","","","","both","","","364.35","273.26","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","280.55","77","","304.65","304.65","304.65","1 through 10","112.95","289.66","percent of total billed charges",""
"SET KIT 6FRX24CM UNIVERSAL STENT URETERAL UNIVERSA SOFT HYDROPHILIC COATING GUIDEWIRE","SUP-ITM-10078710","CDM","C2617","HCPCS","0278","RC","","","","both","","","364.35","273.26","WELLPOINT [1015]","HB AMC WELLPOINT","268.82","73.78","","675.30","288.20","675.30","1 through 10","112.95","289.66","percent of total billed charges",""
"SET KIT 6FRX24CM UNIVERSAL STENT URETERAL UNIVERSA SOFT HYDROPHILIC COATING GUIDEWIRE","SUP-ITM-10078710","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","364.35","273.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","297.75","81.72","","183.26","154.72","309.45","1 through 10","190.41","297.75","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.20","512.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","543.14","79.5","","800.18","480.96","1887.97","195","211.79","543.14","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.20","512.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","364.15","53.3","","813.12","216.42","1444.50","81","211.79","543.14","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.20","512.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","211.79","31","","432.60","432.60","432.60","1 through 10","211.79","543.14","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.20","512.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","249.37","36.5","","148.37","54.89","631.39","94","211.79","543.14","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.20","512.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.67","38.3","","279.30","91.72","1116.77","266","211.79","543.14","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.20","512.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","293.09","42.9","","731.00","63.70","731.00","1 through 10","211.79","543.14","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.20","512.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","293.09","42.9","","384.74","384.74","384.74","1 through 10","211.79","543.14","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","683.20","512.40","WELLPOINT [1015]","HB AMC WELLPOINT","504.06","73.78","","286.63","119.22","1107.45","105","211.79","543.14","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","683.20","512.40","AETNA [1001]","HB AMC AETNA HMO","476.87","69.8","","675.31","184.75","1721.50","286","357.04","558.31","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","683.20","512.40","AETNA [1001]","HB AMC AETNA PPO","549.29","80.4","","1261.44","103.12","1514.10","21","357.04","558.31","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","683.20","512.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","549.29","80.4","","1365.00","1365.00","1365.00","1 through 10","357.04","558.31","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","683.20","512.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","558.31","81.72","","5157.68","5157.68","5157.68","1 through 10","357.04","558.31","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","683.20","512.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","558.31","81.72","","431.26","71.26","1459.57","88","357.04","558.31","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.44","79.5","","800.18","480.96","1887.97","195","406.88","1043.44","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","699.56","53.3","","813.12","216.42","1444.50","81","406.88","1043.44","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","406.88","31","","432.60","432.60","432.60","1 through 10","406.88","1043.44","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","479.06","36.5","","148.37","54.89","631.39","94","406.88","1043.44","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.69","38.3","","279.30","91.72","1116.77","266","406.88","1043.44","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.06","42.9","","731.00","63.70","731.00","1 through 10","406.88","1043.44","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.06","42.9","","384.74","384.74","384.74","1 through 10","406.88","1043.44","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.50","984.37","WELLPOINT [1015]","HB AMC WELLPOINT","968.36","73.78","","286.63","119.22","1107.45","105","406.88","1043.44","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","AETNA [1001]","HB AMC AETNA HMO","916.13","69.8","","675.31","184.75","1721.50","286","685.91","1072.58","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","AETNA [1001]","HB AMC AETNA PPO","1055.25","80.4","","1261.44","103.12","1514.10","21","685.91","1072.58","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1055.25","80.4","","1365.00","1365.00","1365.00","1 through 10","685.91","1072.58","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1072.58","81.72","","5157.68","5157.68","5157.68","1 through 10","685.91","1072.58","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1072.58","81.72","","431.26","71.26","1459.57","88","685.91","1072.58","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","1120.00","840.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","585.31","52.26","","25.34","25.34","25.34","1 through 10","347.2","890.4","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","1120.00","840.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","804.16","71.8","","105.81","105.81","366.90","1 through 10","347.2","890.4","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","1120.00","840.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","784.00","70","","512.90","74.70","612.85","1 through 10","347.2","890.4","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","1120.00","840.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","890.40","79.5","","200.27","182.80","200.27","1 through 10","347.2","890.4","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","1120.00","840.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","596.96","53.3","","37.73","37.73","169.33","1 through 10","347.2","890.4","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","1120.00","840.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","728.00","65","","100.27","8.48","494.52","1 through 10","347.2","890.4","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","1120.00","840.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","728.00","65","","160.19","160.19","160.19","1 through 10","347.2","890.4","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","1120.00","840.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","347.20","31","","28.12","28.12","28.12","1 through 10","347.2","890.4","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","1120.00","840.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","408.80","36.5","","101.66","28.85","502.70","121","347.2","890.4","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","1120.00","840.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","428.96","38.3","","61.58","25.32","328.44","138","347.2","890.4","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","1120.00","840.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","480.48","42.9","","71.66","71.66","71.66","1 through 10","347.2","890.4","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","1120.00","840.00","WELLPOINT [1015]","HB AMC WELLPOINT","826.34","73.78","","74.75","27.97","425.28","93","347.2","890.4","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1120.00","840.00","AETNA [1001]","HB AMC AETNA HMO","781.76","69.8","","52.67","14.36","414.90","1 through 10","585.31","915.26","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1120.00","840.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","585.31","52.26","","25.34","25.34","25.34","1 through 10","585.31","915.26","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1120.00","840.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","900.48","80.4","","478.02","107.84","478.02","1 through 10","585.31","915.26","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1120.00","840.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","915.26","81.72","","32.74","12.33","122.05","1 through 10","585.31","915.26","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1120.00","840.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","915.26","81.72","","144.95","32.78","676.91","104","585.31","915.26","percent of total billed charges",""
"SET PUTTY 3ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10131671","CDM","C1713","HCPCS","0278","RC","","","","both","","","1473.50","1105.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1171.43","79.5","","800.18","480.96","1887.97","195","456.79","1171.43","percent of total billed charges",""
"SET PUTTY 3ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10131671","CDM","C1713","HCPCS","0278","RC","","","","both","","","1473.50","1105.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","785.38","53.3","","813.12","216.42","1444.50","81","456.79","1171.43","percent of total billed charges",""
"SET PUTTY 3ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10131671","CDM","C1713","HCPCS","0278","RC","","","","both","","","1473.50","1105.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","456.79","31","","432.60","432.60","432.60","1 through 10","456.79","1171.43","percent of total billed charges",""
"SET PUTTY 3ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10131671","CDM","C1713","HCPCS","0278","RC","","","","both","","","1473.50","1105.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","537.83","36.5","","148.37","54.89","631.39","94","456.79","1171.43","percent of total billed charges",""
"SET PUTTY 3ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10131671","CDM","C1713","HCPCS","0278","RC","","","","both","","","1473.50","1105.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","564.35","38.3","","279.30","91.72","1116.77","266","456.79","1171.43","percent of total billed charges",""
"SET PUTTY 3ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10131671","CDM","C1713","HCPCS","0278","RC","","","","both","","","1473.50","1105.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","632.13","42.9","","731.00","63.70","731.00","1 through 10","456.79","1171.43","percent of total billed charges",""
"SET PUTTY 3ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10131671","CDM","C1713","HCPCS","0278","RC","","","","both","","","1473.50","1105.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","632.13","42.9","","384.74","384.74","384.74","1 through 10","456.79","1171.43","percent of total billed charges",""
"SET PUTTY 3ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10131671","CDM","C1713","HCPCS","0278","RC","","","","both","","","1473.50","1105.12","WELLPOINT [1015]","HB AMC WELLPOINT","1087.15","73.78","","286.63","119.22","1107.45","105","456.79","1171.43","percent of total billed charges",""
"SET PUTTY 3ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10131671","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1473.50","1105.12","AETNA [1001]","HB AMC AETNA HMO","1028.50","69.8","","675.31","184.75","1721.50","286","770.05","1204.14","percent of total billed charges",""
"SET PUTTY 3ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10131671","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1473.50","1105.12","AETNA [1001]","HB AMC AETNA PPO","1184.69","80.4","","1261.44","103.12","1514.10","21","770.05","1204.14","percent of total billed charges",""
"SET PUTTY 3ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10131671","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1473.50","1105.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1184.69","80.4","","1365.00","1365.00","1365.00","1 through 10","770.05","1204.14","percent of total billed charges",""
"SET PUTTY 3ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10131671","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1473.50","1105.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1204.14","81.72","","5157.68","5157.68","5157.68","1 through 10","770.05","1204.14","percent of total billed charges",""
"SET PUTTY 3ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10131671","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1473.50","1105.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1204.14","81.72","","431.26","71.26","1459.57","88","770.05","1204.14","percent of total billed charges",""
"SET PUTTY 5ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10126262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.26","1654.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1753.98","79.5","","800.18","480.96","1887.97","195","683.94","1753.98","percent of total billed charges",""
"SET PUTTY 5ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10126262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.26","1654.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1175.94","53.3","","813.12","216.42","1444.50","81","683.94","1753.98","percent of total billed charges",""
"SET PUTTY 5ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10126262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.26","1654.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","683.94","31","","432.60","432.60","432.60","1 through 10","683.94","1753.98","percent of total billed charges",""
"SET PUTTY 5ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10126262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.26","1654.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","805.28","36.5","","148.37","54.89","631.39","94","683.94","1753.98","percent of total billed charges",""
"SET PUTTY 5ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10126262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.26","1654.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","845.00","38.3","","279.30","91.72","1116.77","266","683.94","1753.98","percent of total billed charges",""
"SET PUTTY 5ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10126262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.26","1654.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","946.49","42.9","","731.00","63.70","731.00","1 through 10","683.94","1753.98","percent of total billed charges",""
"SET PUTTY 5ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10126262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.26","1654.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","946.49","42.9","","384.74","384.74","384.74","1 through 10","683.94","1753.98","percent of total billed charges",""
"SET PUTTY 5ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10126262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2206.26","1654.69","WELLPOINT [1015]","HB AMC WELLPOINT","1627.78","73.78","","286.63","119.22","1107.45","105","683.94","1753.98","percent of total billed charges",""
"SET PUTTY 5ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10126262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2206.26","1654.69","AETNA [1001]","HB AMC AETNA HMO","1539.97","69.8","","675.31","184.75","1721.50","286","1152.99","1802.96","percent of total billed charges",""
"SET PUTTY 5ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10126262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2206.26","1654.69","AETNA [1001]","HB AMC AETNA PPO","1773.83","80.4","","1261.44","103.12","1514.10","21","1152.99","1802.96","percent of total billed charges",""
"SET PUTTY 5ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10126262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2206.26","1654.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1773.83","80.4","","1365.00","1365.00","1365.00","1 through 10","1152.99","1802.96","percent of total billed charges",""
"SET PUTTY 5ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10126262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2206.26","1654.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1802.96","81.72","","5157.68","5157.68","5157.68","1 through 10","1152.99","1802.96","percent of total billed charges",""
"SET PUTTY 5ML GRAFT BONE CRANIOS REINCED FAST TING SYRINGE","SUP-ITM-10126262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2206.26","1654.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1802.96","81.72","","431.26","71.26","1459.57","88","1152.99","1802.96","percent of total billed charges",""
"SET SCREW 130DEG BONE TITIANIUM TROCHANTERIC FIXATION NAIL","SUP-ITM-10125478","CDM","C1713","HCPCS","0278","RC","","","","both","","","519.23","389.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","412.79","79.5","","800.18","480.96","1887.97","195","160.96","412.79","percent of total billed charges",""
"SET SCREW 130DEG BONE TITIANIUM TROCHANTERIC FIXATION NAIL","SUP-ITM-10125478","CDM","C1713","HCPCS","0278","RC","","","","both","","","519.23","389.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","276.75","53.3","","813.12","216.42","1444.50","81","160.96","412.79","percent of total billed charges",""
"SET SCREW 130DEG BONE TITIANIUM TROCHANTERIC FIXATION NAIL","SUP-ITM-10125478","CDM","C1713","HCPCS","0278","RC","","","","both","","","519.23","389.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","160.96","31","","432.60","432.60","432.60","1 through 10","160.96","412.79","percent of total billed charges",""
"SET SCREW 130DEG BONE TITIANIUM TROCHANTERIC FIXATION NAIL","SUP-ITM-10125478","CDM","C1713","HCPCS","0278","RC","","","","both","","","519.23","389.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","189.52","36.5","","148.37","54.89","631.39","94","160.96","412.79","percent of total billed charges",""
"SET SCREW 130DEG BONE TITIANIUM TROCHANTERIC FIXATION NAIL","SUP-ITM-10125478","CDM","C1713","HCPCS","0278","RC","","","","both","","","519.23","389.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","198.87","38.3","","279.30","91.72","1116.77","266","160.96","412.79","percent of total billed charges",""
"SET SCREW 130DEG BONE TITIANIUM TROCHANTERIC FIXATION NAIL","SUP-ITM-10125478","CDM","C1713","HCPCS","0278","RC","","","","both","","","519.23","389.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.75","42.9","","731.00","63.70","731.00","1 through 10","160.96","412.79","percent of total billed charges",""
"SET SCREW 130DEG BONE TITIANIUM TROCHANTERIC FIXATION NAIL","SUP-ITM-10125478","CDM","C1713","HCPCS","0278","RC","","","","both","","","519.23","389.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.75","42.9","","384.74","384.74","384.74","1 through 10","160.96","412.79","percent of total billed charges",""
"SET SCREW 130DEG BONE TITIANIUM TROCHANTERIC FIXATION NAIL","SUP-ITM-10125478","CDM","C1713","HCPCS","0278","RC","","","","both","","","519.23","389.42","WELLPOINT [1015]","HB AMC WELLPOINT","383.09","73.78","","286.63","119.22","1107.45","105","160.96","412.79","percent of total billed charges",""
"SET SCREW 130DEG BONE TITIANIUM TROCHANTERIC FIXATION NAIL","SUP-ITM-10125478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","519.23","389.42","AETNA [1001]","HB AMC AETNA HMO","362.42","69.8","","675.31","184.75","1721.50","286","271.35","424.31","percent of total billed charges",""
"SET SCREW 130DEG BONE TITIANIUM TROCHANTERIC FIXATION NAIL","SUP-ITM-10125478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","519.23","389.42","AETNA [1001]","HB AMC AETNA PPO","417.46","80.4","","1261.44","103.12","1514.10","21","271.35","424.31","percent of total billed charges",""
"SET SCREW 130DEG BONE TITIANIUM TROCHANTERIC FIXATION NAIL","SUP-ITM-10125478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","519.23","389.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","417.46","80.4","","1365.00","1365.00","1365.00","1 through 10","271.35","424.31","percent of total billed charges",""
"SET SCREW 130DEG BONE TITIANIUM TROCHANTERIC FIXATION NAIL","SUP-ITM-10125478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","519.23","389.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","424.31","81.72","","5157.68","5157.68","5157.68","1 through 10","271.35","424.31","percent of total billed charges",""
"SET SCREW 130DEG BONE TITIANIUM TROCHANTERIC FIXATION NAIL","SUP-ITM-10125478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","519.23","389.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","424.31","81.72","","431.26","71.26","1459.57","88","271.35","424.31","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","800.18","480.96","1887.97","195","54.25","139.13","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.28","53.3","","813.12","216.42","1444.50","81","54.25","139.13","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.25","31","","432.60","432.60","432.60","1 through 10","54.25","139.13","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","148.37","54.89","631.39","94","54.25","139.13","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","279.30","91.72","1116.77","266","54.25","139.13","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","731.00","63.70","731.00","1 through 10","54.25","139.13","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","384.74","384.74","384.74","1 through 10","54.25","139.13","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","286.63","119.22","1107.45","105","54.25","139.13","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","675.31","184.75","1721.50","286","91.46","143.01","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA PPO","140.70","80.4","","1261.44","103.12","1514.10","21","91.46","143.01","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","140.70","80.4","","1365.00","1365.00","1365.00","1 through 10","91.46","143.01","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.01","81.72","","5157.68","5157.68","5157.68","1 through 10","91.46","143.01","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","431.26","71.26","1459.57","88","91.46","143.01","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","973.88","79.5","","800.18","480.96","1887.97","195","379.75","973.88","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","652.93","53.3","","813.12","216.42","1444.50","81","379.75","973.88","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","379.75","31","","432.60","432.60","432.60","1 through 10","379.75","973.88","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","447.13","36.5","","148.37","54.89","631.39","94","379.75","973.88","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","469.18","38.3","","279.30","91.72","1116.77","266","379.75","973.88","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","525.53","42.9","","731.00","63.70","731.00","1 through 10","379.75","973.88","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","525.53","42.9","","384.74","384.74","384.74","1 through 10","379.75","973.88","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1225.00","918.75","WELLPOINT [1015]","HB AMC WELLPOINT","903.81","73.78","","286.63","119.22","1107.45","105","379.75","973.88","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","AETNA [1001]","HB AMC AETNA HMO","855.05","69.8","","675.31","184.75","1721.50","286","640.19","1001.07","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","AETNA [1001]","HB AMC AETNA PPO","984.90","80.4","","1261.44","103.12","1514.10","21","640.19","1001.07","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","984.90","80.4","","1365.00","1365.00","1365.00","1 through 10","640.19","1001.07","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1001.07","81.72","","5157.68","5157.68","5157.68","1 through 10","640.19","1001.07","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1001.07","81.72","","431.26","71.26","1459.57","88","640.19","1001.07","percent of total billed charges",""
"SET SCREW OFF OCCIP CONNECTORS AND EYELETS","SUP-ITM-10188278","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","800.18","480.96","1887.97","195","54.25","139.13","percent of total billed charges",""
"SET SCREW OFF OCCIP CONNECTORS AND EYELETS","SUP-ITM-10188278","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.28","53.3","","813.12","216.42","1444.50","81","54.25","139.13","percent of total billed charges",""
"SET SCREW OFF OCCIP CONNECTORS AND EYELETS","SUP-ITM-10188278","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.25","31","","432.60","432.60","432.60","1 through 10","54.25","139.13","percent of total billed charges",""
"SET SCREW OFF OCCIP CONNECTORS AND EYELETS","SUP-ITM-10188278","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","148.37","54.89","631.39","94","54.25","139.13","percent of total billed charges",""
"SET SCREW OFF OCCIP CONNECTORS AND EYELETS","SUP-ITM-10188278","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","279.30","91.72","1116.77","266","54.25","139.13","percent of total billed charges",""
"SET SCREW OFF OCCIP CONNECTORS AND EYELETS","SUP-ITM-10188278","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","731.00","63.70","731.00","1 through 10","54.25","139.13","percent of total billed charges",""
"SET SCREW OFF OCCIP CONNECTORS AND EYELETS","SUP-ITM-10188278","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","384.74","384.74","384.74","1 through 10","54.25","139.13","percent of total billed charges",""
"SET SCREW OFF OCCIP CONNECTORS AND EYELETS","SUP-ITM-10188278","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","286.63","119.22","1107.45","105","54.25","139.13","percent of total billed charges",""
"SET SCREW OFF OCCIP CONNECTORS AND EYELETS","SUP-ITM-10188278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","675.31","184.75","1721.50","286","91.46","143.01","percent of total billed charges",""
"SET SCREW OFF OCCIP CONNECTORS AND EYELETS","SUP-ITM-10188278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA PPO","140.70","80.4","","1261.44","103.12","1514.10","21","91.46","143.01","percent of total billed charges",""
"SET SCREW OFF OCCIP CONNECTORS AND EYELETS","SUP-ITM-10188278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","140.70","80.4","","1365.00","1365.00","1365.00","1 through 10","91.46","143.01","percent of total billed charges",""
"SET SCREW OFF OCCIP CONNECTORS AND EYELETS","SUP-ITM-10188278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.01","81.72","","5157.68","5157.68","5157.68","1 through 10","91.46","143.01","percent of total billed charges",""
"SET SCREW OFF OCCIP CONNECTORS AND EYELETS","SUP-ITM-10188278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","431.26","71.26","1459.57","88","91.46","143.01","percent of total billed charges",""
"SET SCREW SPINE SOLANAS TITANIUM LOCKING","SUP-ITM-10108726","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","800.18","480.96","1887.97","195","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE SOLANAS TITANIUM LOCKING","SUP-ITM-10108726","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","813.12","216.42","1444.50","81","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE SOLANAS TITANIUM LOCKING","SUP-ITM-10108726","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.83","31","","432.60","432.60","432.60","1 through 10","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE SOLANAS TITANIUM LOCKING","SUP-ITM-10108726","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","148.37","54.89","631.39","94","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE SOLANAS TITANIUM LOCKING","SUP-ITM-10108726","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","279.30","91.72","1116.77","266","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE SOLANAS TITANIUM LOCKING","SUP-ITM-10108726","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","731.00","63.70","731.00","1 through 10","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE SOLANAS TITANIUM LOCKING","SUP-ITM-10108726","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","384.74","384.74","384.74","1 through 10","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE SOLANAS TITANIUM LOCKING","SUP-ITM-10108726","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","286.63","119.22","1107.45","105","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE SOLANAS TITANIUM LOCKING","SUP-ITM-10108726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","675.31","184.75","1721.50","286","82.31","128.71","percent of total billed charges",""
"SET SCREW SPINE SOLANAS TITANIUM LOCKING","SUP-ITM-10108726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA PPO","126.63","80.4","","1261.44","103.12","1514.10","21","82.31","128.71","percent of total billed charges",""
"SET SCREW SPINE SOLANAS TITANIUM LOCKING","SUP-ITM-10108726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","1365.00","1365.00","1365.00","1 through 10","82.31","128.71","percent of total billed charges",""
"SET SCREW SPINE SOLANAS TITANIUM LOCKING","SUP-ITM-10108726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.71","81.72","","5157.68","5157.68","5157.68","1 through 10","82.31","128.71","percent of total billed charges",""
"SET SCREW SPINE SOLANAS TITANIUM LOCKING","SUP-ITM-10108726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","431.26","71.26","1459.57","88","82.31","128.71","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","1309.77","674.56","6049.93","26","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","1901.83","1901.83","2962.25","1 through 10","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","1620.31","1620.31","19908.88","1 through 10","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","352.91","352.91","2046.30","1 through 10","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","9668.75","9668.75","9668.75","1 through 10","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","699.88","384.10","3443.31","33","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","1421.24","264.50","4933.46","29","82.31","128.71","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","1022.97","1022.97","3607.50","1 through 10","82.31","128.71","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","3010.54","693.88","5019.88","35","82.31","128.71","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","1309.77","674.56","6049.93","26","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","1901.83","1901.83","2962.25","1 through 10","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","1620.31","1620.31","19908.88","1 through 10","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","352.91","352.91","2046.30","1 through 10","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","9668.75","9668.75","9668.75","1 through 10","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","699.88","384.10","3443.31","33","48.83","125.21","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","1421.24","264.50","4933.46","29","82.31","128.71","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","1022.97","1022.97","3607.50","1 through 10","82.31","128.71","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","3010.54","693.88","5019.88","35","82.31","128.71","percent of total billed charges",""
"SET SCREW VUEPOINT II GRIT BLAST CROSS CONNECTOR","SUP-ITM-10188266","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","800.18","480.96","1887.97","195","54.25","139.13","percent of total billed charges",""
"SET SCREW VUEPOINT II GRIT BLAST CROSS CONNECTOR","SUP-ITM-10188266","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.28","53.3","","813.12","216.42","1444.50","81","54.25","139.13","percent of total billed charges",""
"SET SCREW VUEPOINT II GRIT BLAST CROSS CONNECTOR","SUP-ITM-10188266","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.25","31","","432.60","432.60","432.60","1 through 10","54.25","139.13","percent of total billed charges",""
"SET SCREW VUEPOINT II GRIT BLAST CROSS CONNECTOR","SUP-ITM-10188266","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","148.37","54.89","631.39","94","54.25","139.13","percent of total billed charges",""
"SET SCREW VUEPOINT II GRIT BLAST CROSS CONNECTOR","SUP-ITM-10188266","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","279.30","91.72","1116.77","266","54.25","139.13","percent of total billed charges",""
"SET SCREW VUEPOINT II GRIT BLAST CROSS CONNECTOR","SUP-ITM-10188266","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","731.00","63.70","731.00","1 through 10","54.25","139.13","percent of total billed charges",""
"SET SCREW VUEPOINT II GRIT BLAST CROSS CONNECTOR","SUP-ITM-10188266","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","384.74","384.74","384.74","1 through 10","54.25","139.13","percent of total billed charges",""
"SET SCREW VUEPOINT II GRIT BLAST CROSS CONNECTOR","SUP-ITM-10188266","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","286.63","119.22","1107.45","105","54.25","139.13","percent of total billed charges",""
"SET SCREW VUEPOINT II GRIT BLAST CROSS CONNECTOR","SUP-ITM-10188266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","675.31","184.75","1721.50","286","91.46","143.01","percent of total billed charges",""
"SET SCREW VUEPOINT II GRIT BLAST CROSS CONNECTOR","SUP-ITM-10188266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA PPO","140.70","80.4","","1261.44","103.12","1514.10","21","91.46","143.01","percent of total billed charges",""
"SET SCREW VUEPOINT II GRIT BLAST CROSS CONNECTOR","SUP-ITM-10188266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","140.70","80.4","","1365.00","1365.00","1365.00","1 through 10","91.46","143.01","percent of total billed charges",""
"SET SCREW VUEPOINT II GRIT BLAST CROSS CONNECTOR","SUP-ITM-10188266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.01","81.72","","5157.68","5157.68","5157.68","1 through 10","91.46","143.01","percent of total billed charges",""
"SET SCREW VUEPOINT II GRIT BLAST CROSS CONNECTOR","SUP-ITM-10188266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","431.26","71.26","1459.57","88","91.46","143.01","percent of total billed charges",""
"SET SHEATH 15.5CM 11FRX20 0.038IN INTRODUCER VASCULAR PEEL AWAY STANDARD","SUP-ITM-10003226","CDM","C1892","HCPCS","0272","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","122.64","36.5","","66.97","66.97","66.97","1 through 10","104.16","267.12","percent of total billed charges",""
"SET SHEATH 15.5CM 11FRX20 0.038IN INTRODUCER VASCULAR PEEL AWAY STANDARD","SUP-ITM-10003226","CDM","C1892","HCPCS","0272","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","128.69","38.3","","70.21","44.61","70.21","1 through 10","104.16","267.12","percent of total billed charges",""
"SET SHEATH 15.5CM 11FRX20 0.038IN INTRODUCER VASCULAR PEEL AWAY STANDARD","SUP-ITM-10003226","CDM","C1892","HCPCS","0272","RC","","","","both","","","336.00","252.00","WELLPOINT [1015]","HB AMC WELLPOINT","247.90","73.78","","84.95","84.95","84.95","1 through 10","104.16","267.12","percent of total billed charges",""
"SET SHEATH 15.5CM 11FRX20 0.038IN INTRODUCER VASCULAR PEEL AWAY STANDARD","SUP-ITM-10003226","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","336.00","252.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","274.58","81.72","","91.21","50.17","91.21","1 through 10","175.59","274.58","percent of total billed charges",""
"SET SHEATH 15.5CM 11FRX20 0.038IN INTRODUCER VASCULAR PEEL AWAY STANDARD","SUP-ITM-10003226","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","336.00","252.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","274.58","81.72","","50.17","50.17","50.17","1 through 10","175.59","274.58","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","1135.30","851.47","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","794.71","70","","863.10","863.10","863.10","1 through 10","351.94","902.56","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","1135.30","851.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","902.56","79.5","","447.66","447.66","447.66","1 through 10","351.94","902.56","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","1135.30","851.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","737.95","65","","1020.11","1020.11","1020.11","1 through 10","351.94","902.56","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","1135.30","851.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","351.94","31","","208.83","208.83","208.83","1 through 10","351.94","902.56","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","1135.30","851.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","414.38","36.5","","312.44","214.23","1086.03","20","351.94","902.56","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","1135.30","851.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","434.82","38.3","","264.25","227.63","567.11","31","351.94","902.56","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","1135.30","851.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","487.04","42.9","","79.94","79.94","79.94","1 through 10","351.94","902.56","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","1135.30","851.47","WELLPOINT [1015]","HB AMC WELLPOINT","837.62","73.78","","174.45","74.45","1168.42","1 through 10","351.94","902.56","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1135.30","851.47","AETNA [1001]","HB AMC AETNA HMO","792.44","69.8","","655.01","135.40","784.73","1 through 10","593.31","927.77","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1135.30","851.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","927.77","81.72","","540.25","46.28","897.42","36","593.31","927.77","percent of total billed charges",""
"SET SHEATH EVOLUTION 13FR 21FR 46.6CM DILATOR RL CONTROLLED ROTATION LEAD EXTRACTION","SUP-ITM-10118120","CDM","C1773","HCPCS","0272","RC","","","","both","","","4995.00","3746.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1823.18","36.5","","114.30","97.14","114.30","1 through 10","1548.45","3971.03","percent of total billed charges",""
"SET SHEATH EVOLUTION 13FR 21FR 46.6CM DILATOR RL CONTROLLED ROTATION LEAD EXTRACTION","SUP-ITM-10118120","CDM","C1773","HCPCS","0272","RC","","","","both","","","4995.00","3746.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1913.09","38.3","","119.81","116.44","359.43","20","1548.45","3971.03","percent of total billed charges",""
"SET SHEATH EVOLUTION 13FR 21FR 46.6CM DILATOR RL CONTROLLED ROTATION LEAD EXTRACTION","SUP-ITM-10118120","CDM","C1773","HCPCS","0272","RC","","","","both","","","4995.00","3746.25","WELLPOINT [1015]","HB AMC WELLPOINT","3685.31","73.78","","875.53","228.13","875.53","1 through 10","1548.45","3971.03","percent of total billed charges",""
"SET SHEATH EVOLUTION 13FR 21FR 46.6CM DILATOR RL CONTROLLED ROTATION LEAD EXTRACTION","SUP-ITM-10118120","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","4995.00","3746.25","AETNA [1001]","HB AMC AETNA HMO","3486.51","69.8","","207.45","207.45","207.45","1 through 10","2610.39","4081.91","percent of total billed charges",""
"SET SHEATH EVOLUTION 13FR 21FR 46.6CM DILATOR RL CONTROLLED ROTATION LEAD EXTRACTION","SUP-ITM-10118120","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","4995.00","3746.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4081.91","81.72","","244.96","134.74","244.96","1 through 10","2610.39","4081.91","percent of total billed charges",""
"SET SHEATH EXPLORATION COMMON DUCT INTRODUCER BALLOON CATHETER GUIDEWIRE HANDLE SYRINGE 3 WAY ADAPTER 4 WIRE BASKET - DISCONTINUED REPLACED BY G08297","SUP-ITM-10011756","CDM","C1726","HCPCS","0272","RC","","","","both","","","3535.00","2651.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2474.50","70","","863.10","863.10","863.10","1 through 10","1095.85","2810.33","percent of total billed charges",""
"SET SHEATH EXPLORATION COMMON DUCT INTRODUCER BALLOON CATHETER GUIDEWIRE HANDLE SYRINGE 3 WAY ADAPTER 4 WIRE BASKET - DISCONTINUED REPLACED BY G08297","SUP-ITM-10011756","CDM","C1726","HCPCS","0272","RC","","","","both","","","3535.00","2651.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2810.33","79.5","","447.66","447.66","447.66","1 through 10","1095.85","2810.33","percent of total billed charges",""
"SET SHEATH EXPLORATION COMMON DUCT INTRODUCER BALLOON CATHETER GUIDEWIRE HANDLE SYRINGE 3 WAY ADAPTER 4 WIRE BASKET - DISCONTINUED REPLACED BY G08297","SUP-ITM-10011756","CDM","C1726","HCPCS","0272","RC","","","","both","","","3535.00","2651.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2297.75","65","","1020.11","1020.11","1020.11","1 through 10","1095.85","2810.33","percent of total billed charges",""
"SET SHEATH EXPLORATION COMMON DUCT INTRODUCER BALLOON CATHETER GUIDEWIRE HANDLE SYRINGE 3 WAY ADAPTER 4 WIRE BASKET - DISCONTINUED REPLACED BY G08297","SUP-ITM-10011756","CDM","C1726","HCPCS","0272","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1095.85","31","","208.83","208.83","208.83","1 through 10","1095.85","2810.33","percent of total billed charges",""
"SET SHEATH EXPLORATION COMMON DUCT INTRODUCER BALLOON CATHETER GUIDEWIRE HANDLE SYRINGE 3 WAY ADAPTER 4 WIRE BASKET - DISCONTINUED REPLACED BY G08297","SUP-ITM-10011756","CDM","C1726","HCPCS","0272","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1290.28","36.5","","312.44","214.23","1086.03","20","1095.85","2810.33","percent of total billed charges",""
"SET SHEATH EXPLORATION COMMON DUCT INTRODUCER BALLOON CATHETER GUIDEWIRE HANDLE SYRINGE 3 WAY ADAPTER 4 WIRE BASKET - DISCONTINUED REPLACED BY G08297","SUP-ITM-10011756","CDM","C1726","HCPCS","0272","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1353.91","38.3","","264.25","227.63","567.11","31","1095.85","2810.33","percent of total billed charges",""
"SET SHEATH EXPLORATION COMMON DUCT INTRODUCER BALLOON CATHETER GUIDEWIRE HANDLE SYRINGE 3 WAY ADAPTER 4 WIRE BASKET - DISCONTINUED REPLACED BY G08297","SUP-ITM-10011756","CDM","C1726","HCPCS","0272","RC","","","","both","","","3535.00","2651.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1516.52","42.9","","79.94","79.94","79.94","1 through 10","1095.85","2810.33","percent of total billed charges",""
"SET SHEATH EXPLORATION COMMON DUCT INTRODUCER BALLOON CATHETER GUIDEWIRE HANDLE SYRINGE 3 WAY ADAPTER 4 WIRE BASKET - DISCONTINUED REPLACED BY G08297","SUP-ITM-10011756","CDM","C1726","HCPCS","0272","RC","","","","both","","","3535.00","2651.25","WELLPOINT [1015]","HB AMC WELLPOINT","2608.12","73.78","","174.45","74.45","1168.42","1 through 10","1095.85","2810.33","percent of total billed charges",""
"SET SHEATH EXPLORATION COMMON DUCT INTRODUCER BALLOON CATHETER GUIDEWIRE HANDLE SYRINGE 3 WAY ADAPTER 4 WIRE BASKET - DISCONTINUED REPLACED BY G08297","SUP-ITM-10011756","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3535.00","2651.25","AETNA [1001]","HB AMC AETNA HMO","2467.43","69.8","","655.01","135.40","784.73","1 through 10","1847.39","2888.8","percent of total billed charges",""
"SET SHEATH EXPLORATION COMMON DUCT INTRODUCER BALLOON CATHETER GUIDEWIRE HANDLE SYRINGE 3 WAY ADAPTER 4 WIRE BASKET - DISCONTINUED REPLACED BY G08297","SUP-ITM-10011756","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3535.00","2651.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2888.80","81.72","","540.25","46.28","897.42","36","1847.39","2888.8","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","841.71","79.5","","800.18","480.96","1887.97","195","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","564.31","53.3","","813.12","216.42","1444.50","81","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","328.21","31","","432.60","432.60","432.60","1 through 10","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","386.44","36.5","","148.37","54.89","631.39","94","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","405.50","38.3","","279.30","91.72","1116.77","266","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","454.20","42.9","","731.00","63.70","731.00","1 through 10","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","454.20","42.9","","384.74","384.74","384.74","1 through 10","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","WELLPOINT [1015]","HB AMC WELLPOINT","781.15","73.78","","286.63","119.22","1107.45","105","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1058.75","794.06","AETNA [1001]","HB AMC AETNA HMO","739.01","69.8","","675.31","184.75","1721.50","286","553.3","865.21","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1058.75","794.06","AETNA [1001]","HB AMC AETNA PPO","851.24","80.4","","1261.44","103.12","1514.10","21","553.3","865.21","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1058.75","794.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","851.24","80.4","","1365.00","1365.00","1365.00","1 through 10","553.3","865.21","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1058.75","794.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","865.21","81.72","","5157.68","5157.68","5157.68","1 through 10","553.3","865.21","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1058.75","794.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","865.21","81.72","","431.26","71.26","1459.57","88","553.3","865.21","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","841.71","79.5","","800.18","480.96","1887.97","195","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","564.31","53.3","","813.12","216.42","1444.50","81","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","328.21","31","","432.60","432.60","432.60","1 through 10","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","386.44","36.5","","148.37","54.89","631.39","94","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","405.50","38.3","","279.30","91.72","1116.77","266","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","454.20","42.9","","731.00","63.70","731.00","1 through 10","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","454.20","42.9","","384.74","384.74","384.74","1 through 10","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","1058.75","794.06","WELLPOINT [1015]","HB AMC WELLPOINT","781.15","73.78","","286.63","119.22","1107.45","105","328.21","841.71","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1058.75","794.06","AETNA [1001]","HB AMC AETNA HMO","739.01","69.8","","675.31","184.75","1721.50","286","553.3","865.21","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1058.75","794.06","AETNA [1001]","HB AMC AETNA PPO","851.24","80.4","","1261.44","103.12","1514.10","21","553.3","865.21","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1058.75","794.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","851.24","80.4","","1365.00","1365.00","1365.00","1 through 10","553.3","865.21","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1058.75","794.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","865.21","81.72","","5157.68","5157.68","5157.68","1 through 10","553.3","865.21","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1058.75","794.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","865.21","81.72","","431.26","71.26","1459.57","88","553.3","865.21","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","988.75","741.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","786.06","79.5","","800.18","480.96","1887.97","195","306.51","786.06","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","988.75","741.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","527.00","53.3","","813.12","216.42","1444.50","81","306.51","786.06","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","988.75","741.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","306.51","31","","432.60","432.60","432.60","1 through 10","306.51","786.06","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","988.75","741.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","360.89","36.5","","148.37","54.89","631.39","94","306.51","786.06","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","988.75","741.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","378.69","38.3","","279.30","91.72","1116.77","266","306.51","786.06","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","988.75","741.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","424.17","42.9","","731.00","63.70","731.00","1 through 10","306.51","786.06","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","988.75","741.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","424.17","42.9","","384.74","384.74","384.74","1 through 10","306.51","786.06","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","988.75","741.56","WELLPOINT [1015]","HB AMC WELLPOINT","729.50","73.78","","286.63","119.22","1107.45","105","306.51","786.06","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","988.75","741.56","AETNA [1001]","HB AMC AETNA HMO","690.15","69.8","","675.31","184.75","1721.50","286","516.72","808.01","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","988.75","741.56","AETNA [1001]","HB AMC AETNA PPO","794.96","80.4","","1261.44","103.12","1514.10","21","516.72","808.01","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","988.75","741.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","794.96","80.4","","1365.00","1365.00","1365.00","1 through 10","516.72","808.01","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","988.75","741.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","808.01","81.72","","5157.68","5157.68","5157.68","1 through 10","516.72","808.01","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","988.75","741.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","808.01","81.72","","431.26","71.26","1459.57","88","516.72","808.01","percent of total billed charges",""
"SET STENT 4.7FR 21 32CM OR 4.75 8 20 URETERAL SOF FLEX PTFE COATED DOUBLE PIGTAIL MULTI","SUP-ITM-10078546","CDM","C2617","HCPCS","0278","RC","","","","both","","","443.45","332.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","352.54","79.5","","304.65","204.39","304.65","1 through 10","137.47","352.54","percent of total billed charges",""
"SET STENT 4.7FR 21 32CM OR 4.75 8 20 URETERAL SOF FLEX PTFE COATED DOUBLE PIGTAIL MULTI","SUP-ITM-10078546","CDM","C2617","HCPCS","0278","RC","","","","both","","","443.45","332.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","236.36","53.3","","204.39","204.39","304.65","1 through 10","137.47","352.54","percent of total billed charges",""
"SET STENT 4.7FR 21 32CM OR 4.75 8 20 URETERAL SOF FLEX PTFE COATED DOUBLE PIGTAIL MULTI","SUP-ITM-10078546","CDM","C2617","HCPCS","0278","RC","","","","both","","","443.45","332.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","161.86","36.5","","144.39","122.71","144.39","1 through 10","137.47","352.54","percent of total billed charges",""
"SET STENT 4.7FR 21 32CM OR 4.75 8 20 URETERAL SOF FLEX PTFE COATED DOUBLE PIGTAIL MULTI","SUP-ITM-10078546","CDM","C2617","HCPCS","0278","RC","","","","both","","","443.45","332.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","169.84","38.3","","151.36","147.10","454.08","13","137.47","352.54","percent of total billed charges",""
"SET STENT 4.7FR 21 32CM OR 4.75 8 20 URETERAL SOF FLEX PTFE COATED DOUBLE PIGTAIL MULTI","SUP-ITM-10078546","CDM","C2617","HCPCS","0278","RC","","","","both","","","443.45","332.59","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","341.46","77","","304.65","304.65","304.65","1 through 10","137.47","352.54","percent of total billed charges",""
"SET STENT 4.7FR 21 32CM OR 4.75 8 20 URETERAL SOF FLEX PTFE COATED DOUBLE PIGTAIL MULTI","SUP-ITM-10078546","CDM","C2617","HCPCS","0278","RC","","","","both","","","443.45","332.59","WELLPOINT [1015]","HB AMC WELLPOINT","327.18","73.78","","675.30","288.20","675.30","1 through 10","137.47","352.54","percent of total billed charges",""
"SET STENT 4.7FR 21 32CM OR 4.75 8 20 URETERAL SOF FLEX PTFE COATED DOUBLE PIGTAIL MULTI","SUP-ITM-10078546","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","443.45","332.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","362.39","81.72","","183.26","154.72","309.45","1 through 10","231.75","362.39","percent of total billed charges",""
"SET STENT 6FRX26CM URETERAL SOF FLEX SS TFE COATED FLEXIBLE KWART RETRO INJECT DOUBLE PIGTAIL","SUP-ITM-10001378","CDM","C2625","HCPCS","0278","RC","","","","both","","","455.00","341.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","318.50","70","","470.75","470.75","470.75","1 through 10","141.05","361.73","percent of total billed charges",""
"SET STENT 6FRX26CM URETERAL SOF FLEX SS TFE COATED FLEXIBLE KWART RETRO INJECT DOUBLE PIGTAIL","SUP-ITM-10001378","CDM","C2625","HCPCS","0278","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.27","38.3","","184.07","124.37","184.07","1 through 10","141.05","361.73","percent of total billed charges",""
"SET STENT 6FRX26CM URETERAL SOF FLEX SS TFE COATED FLEXIBLE KWART RETRO INJECT DOUBLE PIGTAIL","SUP-ITM-10001378","CDM","C2625","HCPCS","0278","RC","","","","both","","","455.00","341.25","WELLPOINT [1015]","HB AMC WELLPOINT","335.70","73.78","","243.67","243.67","243.67","1 through 10","141.05","361.73","percent of total billed charges",""
"SET STENT 6FRX26CM URETERAL SOF FLEX SS TFE COATED FLEXIBLE KWART RETRO INJECT DOUBLE PIGTAIL","SUP-ITM-10001378","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.83","81.72","","376.32","376.32","376.32","1 through 10","237.78","371.83","percent of total billed charges",""
"SET STENT 7.0FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX CLOSED TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154998","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","717.58","79.5","","304.65","204.39","304.65","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 7.0FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX CLOSED TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154998","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","481.10","53.3","","204.39","204.39","304.65","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 7.0FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX CLOSED TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154998","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","329.46","36.5","","144.39","122.71","144.39","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 7.0FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX CLOSED TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154998","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","345.70","38.3","","151.36","147.10","454.08","13","279.81","717.58","percent of total billed charges",""
"SET STENT 7.0FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX CLOSED TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154998","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","695.02","77","","304.65","304.65","304.65","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 7.0FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX CLOSED TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154998","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","WELLPOINT [1015]","HB AMC WELLPOINT","665.95","73.78","","675.30","288.20","675.30","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 7.0FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX CLOSED TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154998","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","902.62","676.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","737.62","81.72","","183.26","154.72","309.45","1 through 10","471.71","737.62","percent of total billed charges",""
"SET STENT 7FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154996","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","717.58","79.5","","304.65","204.39","304.65","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 7FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154996","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","481.10","53.3","","204.39","204.39","304.65","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 7FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154996","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","329.46","36.5","","144.39","122.71","144.39","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 7FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154996","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","345.70","38.3","","151.36","147.10","454.08","13","279.81","717.58","percent of total billed charges",""
"SET STENT 7FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154996","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","695.02","77","","304.65","304.65","304.65","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 7FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154996","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","WELLPOINT [1015]","HB AMC WELLPOINT","665.95","73.78","","675.30","288.20","675.30","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 7FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154996","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","902.62","676.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","737.62","81.72","","183.26","154.72","309.45","1 through 10","471.71","737.62","percent of total billed charges",""
"SET STENT 8FR 80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10140036","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","717.58","79.5","","304.65","204.39","304.65","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 8FR 80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10140036","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","481.10","53.3","","204.39","204.39","304.65","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 8FR 80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10140036","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","329.46","36.5","","144.39","122.71","144.39","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 8FR 80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10140036","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","345.70","38.3","","151.36","147.10","454.08","13","279.81","717.58","percent of total billed charges",""
"SET STENT 8FR 80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10140036","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","695.02","77","","304.65","304.65","304.65","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 8FR 80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10140036","CDM","C2617","HCPCS","0278","RC","","","","both","","","902.62","676.96","WELLPOINT [1015]","HB AMC WELLPOINT","665.95","73.78","","675.30","288.20","675.30","1 through 10","279.81","717.58","percent of total billed charges",""
"SET STENT 8FR 80CM 0.038IN URINARY DIVERSION PERCUFLEX OPEN TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10140036","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","902.62","676.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","737.62","81.72","","183.26","154.72","309.45","1 through 10","471.71","737.62","percent of total billed charges",""
"SET STENT AMPLATZ 10.2FR 10CM .035IN URETERAL RADIOPAQUE BAND HYDROPHILIC COATING ULTRATHANE","SUP-ITM-10114145","CDM","C2625","HCPCS","0278","RC","","","","both","","","1326.50","994.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","928.55","70","","470.75","470.75","470.75","1 through 10","411.22","1054.57","percent of total billed charges",""
"SET STENT AMPLATZ 10.2FR 10CM .035IN URETERAL RADIOPAQUE BAND HYDROPHILIC COATING ULTRATHANE","SUP-ITM-10114145","CDM","C2625","HCPCS","0278","RC","","","","both","","","1326.50","994.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","508.05","38.3","","184.07","124.37","184.07","1 through 10","411.22","1054.57","percent of total billed charges",""
"SET STENT AMPLATZ 10.2FR 10CM .035IN URETERAL RADIOPAQUE BAND HYDROPHILIC COATING ULTRATHANE","SUP-ITM-10114145","CDM","C2625","HCPCS","0278","RC","","","","both","","","1326.50","994.87","WELLPOINT [1015]","HB AMC WELLPOINT","978.69","73.78","","243.67","243.67","243.67","1 through 10","411.22","1054.57","percent of total billed charges",""
"SET STENT AMPLATZ 10.2FR 10CM .035IN URETERAL RADIOPAQUE BAND HYDROPHILIC COATING ULTRATHANE","SUP-ITM-10114145","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","1326.50","994.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1084.02","81.72","","376.32","376.32","376.32","1 through 10","693.23","1084.02","percent of total billed charges",""
"SET STENT AMPLATZ 10.2FR 24CM .038IN URETERAL PIGTAIL TAPER TIP POSITIONER RADIOPAQUE BAND HYDROPHILIC COATING","SUP-ITM-10086957","CDM","C2625","HCPCS","0278","RC","","","","both","","","398.90","299.17","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","279.23","70","","470.75","470.75","470.75","1 through 10","123.66","317.13","percent of total billed charges",""
"SET STENT AMPLATZ 10.2FR 24CM .038IN URETERAL PIGTAIL TAPER TIP POSITIONER RADIOPAQUE BAND HYDROPHILIC COATING","SUP-ITM-10086957","CDM","C2625","HCPCS","0278","RC","","","","both","","","398.90","299.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","152.78","38.3","","184.07","124.37","184.07","1 through 10","123.66","317.13","percent of total billed charges",""
"SET STENT AMPLATZ 10.2FR 24CM .038IN URETERAL PIGTAIL TAPER TIP POSITIONER RADIOPAQUE BAND HYDROPHILIC COATING","SUP-ITM-10086957","CDM","C2625","HCPCS","0278","RC","","","","both","","","398.90","299.17","WELLPOINT [1015]","HB AMC WELLPOINT","294.31","73.78","","243.67","243.67","243.67","1 through 10","123.66","317.13","percent of total billed charges",""
"SET STENT AMPLATZ 10.2FR 24CM .038IN URETERAL PIGTAIL TAPER TIP POSITIONER RADIOPAQUE BAND HYDROPHILIC COATING","SUP-ITM-10086957","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","398.90","299.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","325.98","81.72","","376.32","376.32","376.32","1 through 10","208.47","325.98","percent of total billed charges",""
"SET TIP 10.2FRX30CM 18GA INTRODUCER PNEUMOTHORAX INTRO ULTRATHANE AQ HYDROPHILIC COATED PIGTAIL CATHETER TROCAR NEEDLE","SUP-ITM-10086963","CDM","C1729","HCPCS","0272","RC","","","","both","","","358.44","268.83","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","257.36","71.8","","162.24","51.52","162.24","1 through 10","111.12","284.96","percent of total billed charges",""
"SET TIP 10.2FRX30CM 18GA INTRODUCER PNEUMOTHORAX INTRO ULTRATHANE AQ HYDROPHILIC COATED PIGTAIL CATHETER TROCAR NEEDLE","SUP-ITM-10086963","CDM","C1729","HCPCS","0272","RC","","","","both","","","358.44","268.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","130.83","36.5","","94.34","22.19","146.22","26","111.12","284.96","percent of total billed charges",""
"SET TIP 10.2FRX30CM 18GA INTRODUCER PNEUMOTHORAX INTRO ULTRATHANE AQ HYDROPHILIC COATED PIGTAIL CATHETER TROCAR NEEDLE","SUP-ITM-10086963","CDM","C1729","HCPCS","0272","RC","","","","both","","","358.44","268.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","137.28","38.3","","51.52","27.37","51.52","26","111.12","284.96","percent of total billed charges",""
"SET TIP 10.2FRX30CM 18GA INTRODUCER PNEUMOTHORAX INTRO ULTRATHANE AQ HYDROPHILIC COATED PIGTAIL CATHETER TROCAR NEEDLE","SUP-ITM-10086963","CDM","C1729","HCPCS","0272","RC","","","","both","","","358.44","268.83","WELLPOINT [1015]","HB AMC WELLPOINT","264.46","73.78","","207.21","122.12","216.28","14","111.12","284.96","percent of total billed charges",""
"SET TIP 10.2FRX30CM 18GA INTRODUCER PNEUMOTHORAX INTRO ULTRATHANE AQ HYDROPHILIC COATED PIGTAIL CATHETER TROCAR NEEDLE","SUP-ITM-10086963","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","358.44","268.83","AETNA [1001]","HB AMC AETNA HMO","250.19","69.8","","155.96","47.39","155.96","1 through 10","187.32","292.92","percent of total billed charges",""
"SET TIP 10.2FRX30CM 18GA INTRODUCER PNEUMOTHORAX INTRO ULTRATHANE AQ HYDROPHILIC COATED PIGTAIL CATHETER TROCAR NEEDLE","SUP-ITM-10086963","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","358.44","268.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","292.92","81.72","","57.36","51.76","232.23","35","187.32","292.92","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","both","","","252.00","189.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","163.80","65","","158.60","128.83","158.60","1 through 10","21.3","239.4","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","both","","","252.00","189.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","200.34","79.5","","192.03","128.83","192.03","14","21.3","239.4","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","both","","","252.00","189.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","134.32","53.3","","192.03","128.83","246.44","18","21.3","239.4","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","both","","","252.00","189.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","194.04","77","","187.88","187.88","187.88","1 through 10","21.3","239.4","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91.98","36.5","","91.01","77.35","273.03","17","21.3","239.4","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.52","38.3","","95.40","92.72","95.40","63","21.3","239.4","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","both","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.11","42.9","","107.29","107.29","195.05","1 through 10","21.3","239.4","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","252.00","189.00","AETNA [1001]","HB AMC AETNA HMO","175.90","69.8","","165.19","116.63","165.19","27","22.41","205.93","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","252.00","189.00","AETNA [1001]","HB AMC AETNA PPO","202.61","80.4","","190.32","116.63","190.32","1 through 10","22.41","205.93","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","205.93","81.72","","107.29","107.29","107.29","1 through 10","22.41","205.93","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","252.00","189.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","205.93","81.72","","195.05","107.29","195.05","22","22.41","205.93","percent of total billed charges",""
"Sgmdsc Flx With Endoscopic Mucosal Resection","PX-75000416","CDM","45349","CPT","0750","RC","","","","outpatient","","","3863.00","2897.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2292.44","2292.44","2292.44","1 through 10","979.79","3156.84","other","ASC"
"Sgmdsc Flx With Endoscopic Mucosal Resection","PX-75000416","CDM","45349","CPT","0750","RC","","","","outpatient","","","3863.00","2897.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3409.68","3409.68","3409.68","1 through 10","979.79","3156.84","other","Multiple Surgery"
"Sgmdsc Flx With Endoscopic Mucosal Resection","PX-75000416","CDM","45349","CPT","0750","RC","","","","outpatient","","","3863.00","2897.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","2390.69","2390.69","2390.69","1 through 10","979.79","3156.84","other","Multiple Surgery"
"Sgmdsc Flx With Endoscopic Mucosal Resection","PX-75000416","CDM","45349","CPT","0750","RC","","","","outpatient","","","3863.00","2897.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3156.84","81.72","","1254.13","1254.13","1254.13","1 through 10","979.79","3156.84","percent of total billed charges",""
"Sh3bp2 Gene Sequencing","PX-31000749","CDM","81479","CPT","0310","RC","","","","both","","","582.00","436.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","462.69","79.5","","0.65","0.65","0.65","1 through 10","180.42","552.9","percent of total billed charges",""
"Sh3bp2 Gene Sequencing","PX-31000749","CDM","81479","CPT","0310","RC","","","","both","","","582.00","436.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","310.21","53.3","","0.79","0.79","0.79","1 through 10","180.42","552.9","percent of total billed charges",""
"Sh3bp2 Gene Sequencing","PX-31000749","CDM","81479","CPT","0310","RC","","","","outpatient","","","582.00","436.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","291.00","50","","1.00","1.00","1.00","1 through 10","156.55","480.15","percent of total billed charges",""
"Sh3bp2 Gene Sequencing","PX-31000749","CDM","81479","CPT","0310","RC","","","","outpatient","","","582.00","436.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","305.55","52.5","","1.00","0.53","1.00","1 through 10","156.55","480.15","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.16","914.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","969.23","79.5","","800.18","480.96","1887.97","195","377.94","969.23","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.16","914.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","649.81","53.3","","813.12","216.42","1444.50","81","377.94","969.23","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.16","914.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","377.94","31","","432.60","432.60","432.60","1 through 10","377.94","969.23","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.16","914.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","444.99","36.5","","148.37","54.89","631.39","94","377.94","969.23","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.16","914.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","466.94","38.3","","279.30","91.72","1116.77","266","377.94","969.23","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.16","914.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","523.02","42.9","","731.00","63.70","731.00","1 through 10","377.94","969.23","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.16","914.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","523.02","42.9","","384.74","384.74","384.74","1 through 10","377.94","969.23","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.16","914.37","WELLPOINT [1015]","HB AMC WELLPOINT","899.50","73.78","","286.63","119.22","1107.45","105","377.94","969.23","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.16","914.37","AETNA [1001]","HB AMC AETNA HMO","850.97","69.8","","675.31","184.75","1721.50","286","637.13","996.3","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.16","914.37","AETNA [1001]","HB AMC AETNA PPO","980.20","80.4","","1261.44","103.12","1514.10","21","637.13","996.3","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.16","914.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","980.20","80.4","","1365.00","1365.00","1365.00","1 through 10","637.13","996.3","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.16","914.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","996.30","81.72","","5157.68","5157.68","5157.68","1 through 10","637.13","996.3","percent of total billed charges",""
"SHAFT 2.0MMX65 3 HOLE HEAD 10 PLATE BONE SS T SHAPE","SUP-ITM-10038069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.16","914.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","996.30","81.72","","431.26","71.26","1459.57","88","637.13","996.3","percent of total billed charges",""
"SHAFT FEMORAL 10MMX150 GRAFT BONE ALLOGRAFT FROZEN GREATER THAN","SUP-ITM-10010726","CDM","C1889","HCPCS","0278","RC","","","","both","","","4039.20","3029.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3211.16","79.5","","1309.77","674.56","6049.93","26","1252.15","3211.16","percent of total billed charges",""
"SHAFT FEMORAL 10MMX150 GRAFT BONE ALLOGRAFT FROZEN GREATER THAN","SUP-ITM-10010726","CDM","C1889","HCPCS","0278","RC","","","","both","","","4039.20","3029.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2152.89","53.3","","1901.83","1901.83","2962.25","1 through 10","1252.15","3211.16","percent of total billed charges",""
"SHAFT FEMORAL 10MMX150 GRAFT BONE ALLOGRAFT FROZEN GREATER THAN","SUP-ITM-10010726","CDM","C1889","HCPCS","0278","RC","","","","both","","","4039.20","3029.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1474.31","36.5","","1620.31","1620.31","19908.88","1 through 10","1252.15","3211.16","percent of total billed charges",""
"SHAFT FEMORAL 10MMX150 GRAFT BONE ALLOGRAFT FROZEN GREATER THAN","SUP-ITM-10010726","CDM","C1889","HCPCS","0278","RC","","","","both","","","4039.20","3029.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1547.01","38.3","","352.91","352.91","2046.30","1 through 10","1252.15","3211.16","percent of total billed charges",""
"SHAFT FEMORAL 10MMX150 GRAFT BONE ALLOGRAFT FROZEN GREATER THAN","SUP-ITM-10010726","CDM","C1889","HCPCS","0278","RC","","","","both","","","4039.20","3029.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1732.82","42.9","","9668.75","9668.75","9668.75","1 through 10","1252.15","3211.16","percent of total billed charges",""
"SHAFT FEMORAL 10MMX150 GRAFT BONE ALLOGRAFT FROZEN GREATER THAN","SUP-ITM-10010726","CDM","C1889","HCPCS","0278","RC","","","","both","","","4039.20","3029.40","WELLPOINT [1015]","HB AMC WELLPOINT","2980.12","73.78","","699.88","384.10","3443.31","33","1252.15","3211.16","percent of total billed charges",""
"SHAFT FEMORAL 10MMX150 GRAFT BONE ALLOGRAFT FROZEN GREATER THAN","SUP-ITM-10010726","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4039.20","3029.40","AETNA [1001]","HB AMC AETNA HMO","2819.36","69.8","","1421.24","264.50","4933.46","29","2110.89","3300.83","percent of total billed charges",""
"SHAFT FEMORAL 10MMX150 GRAFT BONE ALLOGRAFT FROZEN GREATER THAN","SUP-ITM-10010726","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4039.20","3029.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3247.52","80.4","","1022.97","1022.97","3607.50","1 through 10","2110.89","3300.83","percent of total billed charges",""
"SHAFT FEMORAL 10MMX150 GRAFT BONE ALLOGRAFT FROZEN GREATER THAN","SUP-ITM-10010726","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4039.20","3029.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3300.83","81.72","","3010.54","693.88","5019.88","35","2110.89","3300.83","percent of total billed charges",""
"SHAFT FEMORAL 200MM GRAFT BONE MATRIGRAFT ALLOGRAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010278","CDM","C1889","HCPCS","0278","RC","","","","both","","","4174.77","3131.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3318.94","79.5","","1309.77","674.56","6049.93","26","1294.18","3318.94","percent of total billed charges",""
"SHAFT FEMORAL 200MM GRAFT BONE MATRIGRAFT ALLOGRAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010278","CDM","C1889","HCPCS","0278","RC","","","","both","","","4174.77","3131.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2225.15","53.3","","1901.83","1901.83","2962.25","1 through 10","1294.18","3318.94","percent of total billed charges",""
"SHAFT FEMORAL 200MM GRAFT BONE MATRIGRAFT ALLOGRAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010278","CDM","C1889","HCPCS","0278","RC","","","","both","","","4174.77","3131.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1523.79","36.5","","1620.31","1620.31","19908.88","1 through 10","1294.18","3318.94","percent of total billed charges",""
"SHAFT FEMORAL 200MM GRAFT BONE MATRIGRAFT ALLOGRAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010278","CDM","C1889","HCPCS","0278","RC","","","","both","","","4174.77","3131.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1598.94","38.3","","352.91","352.91","2046.30","1 through 10","1294.18","3318.94","percent of total billed charges",""
"SHAFT FEMORAL 200MM GRAFT BONE MATRIGRAFT ALLOGRAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010278","CDM","C1889","HCPCS","0278","RC","","","","both","","","4174.77","3131.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1790.98","42.9","","9668.75","9668.75","9668.75","1 through 10","1294.18","3318.94","percent of total billed charges",""
"SHAFT FEMORAL 200MM GRAFT BONE MATRIGRAFT ALLOGRAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010278","CDM","C1889","HCPCS","0278","RC","","","","both","","","4174.77","3131.08","WELLPOINT [1015]","HB AMC WELLPOINT","3080.15","73.78","","699.88","384.10","3443.31","33","1294.18","3318.94","percent of total billed charges",""
"SHAFT FEMORAL 200MM GRAFT BONE MATRIGRAFT ALLOGRAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010278","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4174.77","3131.08","AETNA [1001]","HB AMC AETNA HMO","2913.99","69.8","","1421.24","264.50","4933.46","29","2181.73","3411.62","percent of total billed charges",""
"SHAFT FEMORAL 200MM GRAFT BONE MATRIGRAFT ALLOGRAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010278","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4174.77","3131.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3356.52","80.4","","1022.97","1022.97","3607.50","1 through 10","2181.73","3411.62","percent of total billed charges",""
"SHAFT FEMORAL 200MM GRAFT BONE MATRIGRAFT ALLOGRAFT FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010278","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4174.77","3131.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3411.62","81.72","","3010.54","693.88","5019.88","35","2181.73","3411.62","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","both","","","1874.25","1405.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1490.03","79.5","","1309.77","674.56","6049.93","26","581.02","1490.03","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","both","","","1874.25","1405.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","998.98","53.3","","1901.83","1901.83","2962.25","1 through 10","581.02","1490.03","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","both","","","1874.25","1405.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","684.10","36.5","","1620.31","1620.31","19908.88","1 through 10","581.02","1490.03","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","both","","","1874.25","1405.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","717.84","38.3","","352.91","352.91","2046.30","1 through 10","581.02","1490.03","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","both","","","1874.25","1405.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","804.05","42.9","","9668.75","9668.75","9668.75","1 through 10","581.02","1490.03","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","both","","","1874.25","1405.69","WELLPOINT [1015]","HB AMC WELLPOINT","1382.82","73.78","","699.88","384.10","3443.31","33","581.02","1490.03","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1874.25","1405.69","AETNA [1001]","HB AMC AETNA HMO","1308.23","69.8","","1421.24","264.50","4933.46","29","979.48","1531.64","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1874.25","1405.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1506.90","80.4","","1022.97","1022.97","3607.50","1 through 10","979.48","1531.64","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1874.25","1405.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1531.64","81.72","","3010.54","693.88","5019.88","35","979.48","1531.64","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX40 IMPLANT HUMAN TISSUE BONE FREEZE DRIED","SUP-ITM-10010649","CDM","C1889","HCPCS","0278","RC","","","","both","","","1979.67","1484.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1573.84","79.5","","1309.77","674.56","6049.93","26","613.7","1573.84","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX40 IMPLANT HUMAN TISSUE BONE FREEZE DRIED","SUP-ITM-10010649","CDM","C1889","HCPCS","0278","RC","","","","both","","","1979.67","1484.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1055.16","53.3","","1901.83","1901.83","2962.25","1 through 10","613.7","1573.84","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX40 IMPLANT HUMAN TISSUE BONE FREEZE DRIED","SUP-ITM-10010649","CDM","C1889","HCPCS","0278","RC","","","","both","","","1979.67","1484.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","722.58","36.5","","1620.31","1620.31","19908.88","1 through 10","613.7","1573.84","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX40 IMPLANT HUMAN TISSUE BONE FREEZE DRIED","SUP-ITM-10010649","CDM","C1889","HCPCS","0278","RC","","","","both","","","1979.67","1484.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","758.21","38.3","","352.91","352.91","2046.30","1 through 10","613.7","1573.84","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX40 IMPLANT HUMAN TISSUE BONE FREEZE DRIED","SUP-ITM-10010649","CDM","C1889","HCPCS","0278","RC","","","","both","","","1979.67","1484.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","849.28","42.9","","9668.75","9668.75","9668.75","1 through 10","613.7","1573.84","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX40 IMPLANT HUMAN TISSUE BONE FREEZE DRIED","SUP-ITM-10010649","CDM","C1889","HCPCS","0278","RC","","","","both","","","1979.67","1484.75","WELLPOINT [1015]","HB AMC WELLPOINT","1460.60","73.78","","699.88","384.10","3443.31","33","613.7","1573.84","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX40 IMPLANT HUMAN TISSUE BONE FREEZE DRIED","SUP-ITM-10010649","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1979.67","1484.75","AETNA [1001]","HB AMC AETNA HMO","1381.81","69.8","","1421.24","264.50","4933.46","29","1034.58","1617.79","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX40 IMPLANT HUMAN TISSUE BONE FREEZE DRIED","SUP-ITM-10010649","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1979.67","1484.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1591.65","80.4","","1022.97","1022.97","3607.50","1 through 10","1034.58","1617.79","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX40 IMPLANT HUMAN TISSUE BONE FREEZE DRIED","SUP-ITM-10010649","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1979.67","1484.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1617.79","81.72","","3010.54","693.88","5019.88","35","1034.58","1617.79","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX60 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010652","CDM","C1889","HCPCS","0278","RC","","","","both","","","2125.20","1593.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1689.53","79.5","","1309.77","674.56","6049.93","26","658.81","1689.53","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX60 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010652","CDM","C1889","HCPCS","0278","RC","","","","both","","","2125.20","1593.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1132.73","53.3","","1901.83","1901.83","2962.25","1 through 10","658.81","1689.53","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX60 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010652","CDM","C1889","HCPCS","0278","RC","","","","both","","","2125.20","1593.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","775.70","36.5","","1620.31","1620.31","19908.88","1 through 10","658.81","1689.53","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX60 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010652","CDM","C1889","HCPCS","0278","RC","","","","both","","","2125.20","1593.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","813.95","38.3","","352.91","352.91","2046.30","1 through 10","658.81","1689.53","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX60 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010652","CDM","C1889","HCPCS","0278","RC","","","","both","","","2125.20","1593.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.71","42.9","","9668.75","9668.75","9668.75","1 through 10","658.81","1689.53","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX60 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010652","CDM","C1889","HCPCS","0278","RC","","","","both","","","2125.20","1593.90","WELLPOINT [1015]","HB AMC WELLPOINT","1567.97","73.78","","699.88","384.10","3443.31","33","658.81","1689.53","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX60 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010652","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2125.20","1593.90","AETNA [1001]","HB AMC AETNA HMO","1483.39","69.8","","1421.24","264.50","4933.46","29","1110.63","1736.71","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX60 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010652","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2125.20","1593.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1708.66","80.4","","1022.97","1022.97","3607.50","1 through 10","1110.63","1736.71","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX60 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010652","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2125.20","1593.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1736.71","81.72","","3010.54","693.88","5019.88","35","1110.63","1736.71","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX80 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010654","CDM","C1889","HCPCS","0278","RC","","","","both","","","2266.11","1699.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1801.56","79.5","","1309.77","674.56","6049.93","26","702.49","1801.56","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX80 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010654","CDM","C1889","HCPCS","0278","RC","","","","both","","","2266.11","1699.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1207.84","53.3","","1901.83","1901.83","2962.25","1 through 10","702.49","1801.56","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX80 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010654","CDM","C1889","HCPCS","0278","RC","","","","both","","","2266.11","1699.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","827.13","36.5","","1620.31","1620.31","19908.88","1 through 10","702.49","1801.56","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX80 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010654","CDM","C1889","HCPCS","0278","RC","","","","both","","","2266.11","1699.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","867.92","38.3","","352.91","352.91","2046.30","1 through 10","702.49","1801.56","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX80 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010654","CDM","C1889","HCPCS","0278","RC","","","","both","","","2266.11","1699.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","972.16","42.9","","9668.75","9668.75","9668.75","1 through 10","702.49","1801.56","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX80 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010654","CDM","C1889","HCPCS","0278","RC","","","","both","","","2266.11","1699.58","WELLPOINT [1015]","HB AMC WELLPOINT","1671.94","73.78","","699.88","384.10","3443.31","33","702.49","1801.56","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX80 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010654","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2266.11","1699.58","AETNA [1001]","HB AMC AETNA HMO","1581.74","69.8","","1421.24","264.50","4933.46","29","1184.27","1851.87","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX80 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010654","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2266.11","1699.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1821.95","80.4","","1022.97","1022.97","3607.50","1 through 10","1184.27","1851.87","percent of total billed charges",""
"SHAFT FIBULA 12 TO 13MMX80 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010654","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2266.11","1699.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1851.87","81.72","","3010.54","693.88","5019.88","35","1184.27","1851.87","percent of total billed charges",""
"SHAFT FIBULA 14 TO 18MMX20 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010646","CDM","C1889","HCPCS","0278","RC","","","","both","","","1831.83","1373.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1456.30","79.5","","1309.77","674.56","6049.93","26","567.87","1456.3","percent of total billed charges",""
"SHAFT FIBULA 14 TO 18MMX20 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010646","CDM","C1889","HCPCS","0278","RC","","","","both","","","1831.83","1373.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","976.37","53.3","","1901.83","1901.83","2962.25","1 through 10","567.87","1456.3","percent of total billed charges",""
"SHAFT FIBULA 14 TO 18MMX20 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010646","CDM","C1889","HCPCS","0278","RC","","","","both","","","1831.83","1373.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","668.62","36.5","","1620.31","1620.31","19908.88","1 through 10","567.87","1456.3","percent of total billed charges",""
"SHAFT FIBULA 14 TO 18MMX20 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010646","CDM","C1889","HCPCS","0278","RC","","","","both","","","1831.83","1373.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","701.59","38.3","","352.91","352.91","2046.30","1 through 10","567.87","1456.3","percent of total billed charges",""
"SHAFT FIBULA 14 TO 18MMX20 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010646","CDM","C1889","HCPCS","0278","RC","","","","both","","","1831.83","1373.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","785.86","42.9","","9668.75","9668.75","9668.75","1 through 10","567.87","1456.3","percent of total billed charges",""
"SHAFT FIBULA 14 TO 18MMX20 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010646","CDM","C1889","HCPCS","0278","RC","","","","both","","","1831.83","1373.87","WELLPOINT [1015]","HB AMC WELLPOINT","1351.52","73.78","","699.88","384.10","3443.31","33","567.87","1456.3","percent of total billed charges",""
"SHAFT FIBULA 14 TO 18MMX20 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010646","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1831.83","1373.87","AETNA [1001]","HB AMC AETNA HMO","1278.62","69.8","","1421.24","264.50","4933.46","29","957.31","1496.97","percent of total billed charges",""
"SHAFT FIBULA 14 TO 18MMX20 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010646","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1831.83","1373.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1472.79","80.4","","1022.97","1022.97","3607.50","1 through 10","957.31","1496.97","percent of total billed charges",""
"SHAFT FIBULA 14 TO 18MMX20 GRAFT BONE ALLOGRAFT FREEZE DRIED","SUP-ITM-10010646","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1831.83","1373.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1496.97","81.72","","3010.54","693.88","5019.88","35","957.31","1496.97","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","both","","","1761.73","1321.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1400.58","79.5","","1309.77","674.56","6049.93","26","546.14","1400.58","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","both","","","1761.73","1321.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","939.00","53.3","","1901.83","1901.83","2962.25","1 through 10","546.14","1400.58","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","both","","","1761.73","1321.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","643.03","36.5","","1620.31","1620.31","19908.88","1 through 10","546.14","1400.58","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","both","","","1761.73","1321.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","674.74","38.3","","352.91","352.91","2046.30","1 through 10","546.14","1400.58","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","both","","","1761.73","1321.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","755.78","42.9","","9668.75","9668.75","9668.75","1 through 10","546.14","1400.58","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","both","","","1761.73","1321.30","WELLPOINT [1015]","HB AMC WELLPOINT","1299.80","73.78","","699.88","384.10","3443.31","33","546.14","1400.58","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1761.73","1321.30","AETNA [1001]","HB AMC AETNA HMO","1229.69","69.8","","1421.24","264.50","4933.46","29","920.68","1439.69","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1761.73","1321.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1416.43","80.4","","1022.97","1022.97","3607.50","1 through 10","920.68","1439.69","percent of total billed charges",""
"SHAFT FIBULA 8 15X40MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010285","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1761.73","1321.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1439.69","81.72","","3010.54","693.88","5019.88","35","920.68","1439.69","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4490.49","3367.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3569.94","79.5","","800.18","480.96","1887.97","195","1392.05","3569.94","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4490.49","3367.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2393.43","53.3","","813.12","216.42","1444.50","81","1392.05","3569.94","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4490.49","3367.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1392.05","31","","432.60","432.60","432.60","1 through 10","1392.05","3569.94","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4490.49","3367.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1639.03","36.5","","148.37","54.89","631.39","94","1392.05","3569.94","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4490.49","3367.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1719.86","38.3","","279.30","91.72","1116.77","266","1392.05","3569.94","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4490.49","3367.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1926.42","42.9","","731.00","63.70","731.00","1 through 10","1392.05","3569.94","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4490.49","3367.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1926.42","42.9","","384.74","384.74","384.74","1 through 10","1392.05","3569.94","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4490.49","3367.87","WELLPOINT [1015]","HB AMC WELLPOINT","3313.08","73.78","","286.63","119.22","1107.45","105","1392.05","3569.94","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4490.49","3367.87","AETNA [1001]","HB AMC AETNA HMO","3134.36","69.8","","675.31","184.75","1721.50","286","2346.73","3669.63","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4490.49","3367.87","AETNA [1001]","HB AMC AETNA PPO","3610.35","80.4","","1261.44","103.12","1514.10","21","2346.73","3669.63","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4490.49","3367.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3610.35","80.4","","1365.00","1365.00","1365.00","1 through 10","2346.73","3669.63","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4490.49","3367.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3669.63","81.72","","5157.68","5157.68","5157.68","1 through 10","2346.73","3669.63","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4490.49","3367.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3669.63","81.72","","431.26","71.26","1459.57","88","2346.73","3669.63","percent of total billed charges",""
"SHAFT HUMERUS 20 TO 25MMX100 TISSUE FROZEN STRUCTURAL ALLOGRAFT","SUP-ITM-10010729","CDM","C1889","HCPCS","0278","RC","","","","both","","","3007.62","2255.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2391.06","79.5","","1309.77","674.56","6049.93","26","932.36","2391.06","percent of total billed charges",""
"SHAFT HUMERUS 20 TO 25MMX100 TISSUE FROZEN STRUCTURAL ALLOGRAFT","SUP-ITM-10010729","CDM","C1889","HCPCS","0278","RC","","","","both","","","3007.62","2255.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1603.06","53.3","","1901.83","1901.83","2962.25","1 through 10","932.36","2391.06","percent of total billed charges",""
"SHAFT HUMERUS 20 TO 25MMX100 TISSUE FROZEN STRUCTURAL ALLOGRAFT","SUP-ITM-10010729","CDM","C1889","HCPCS","0278","RC","","","","both","","","3007.62","2255.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1097.78","36.5","","1620.31","1620.31","19908.88","1 through 10","932.36","2391.06","percent of total billed charges",""
"SHAFT HUMERUS 20 TO 25MMX100 TISSUE FROZEN STRUCTURAL ALLOGRAFT","SUP-ITM-10010729","CDM","C1889","HCPCS","0278","RC","","","","both","","","3007.62","2255.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1151.92","38.3","","352.91","352.91","2046.30","1 through 10","932.36","2391.06","percent of total billed charges",""
"SHAFT HUMERUS 20 TO 25MMX100 TISSUE FROZEN STRUCTURAL ALLOGRAFT","SUP-ITM-10010729","CDM","C1889","HCPCS","0278","RC","","","","both","","","3007.62","2255.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1290.27","42.9","","9668.75","9668.75","9668.75","1 through 10","932.36","2391.06","percent of total billed charges",""
"SHAFT HUMERUS 20 TO 25MMX100 TISSUE FROZEN STRUCTURAL ALLOGRAFT","SUP-ITM-10010729","CDM","C1889","HCPCS","0278","RC","","","","both","","","3007.62","2255.71","WELLPOINT [1015]","HB AMC WELLPOINT","2219.02","73.78","","699.88","384.10","3443.31","33","932.36","2391.06","percent of total billed charges",""
"SHAFT HUMERUS 20 TO 25MMX100 TISSUE FROZEN STRUCTURAL ALLOGRAFT","SUP-ITM-10010729","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3007.62","2255.71","AETNA [1001]","HB AMC AETNA HMO","2099.32","69.8","","1421.24","264.50","4933.46","29","1571.78","2457.83","percent of total billed charges",""
"SHAFT HUMERUS 20 TO 25MMX100 TISSUE FROZEN STRUCTURAL ALLOGRAFT","SUP-ITM-10010729","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3007.62","2255.71","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2418.13","80.4","","1022.97","1022.97","3607.50","1 through 10","1571.78","2457.83","percent of total billed charges",""
"SHAFT HUMERUS 20 TO 25MMX100 TISSUE FROZEN STRUCTURAL ALLOGRAFT","SUP-ITM-10010729","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3007.62","2255.71","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2457.83","81.72","","3010.54","693.88","5019.88","35","1571.78","2457.83","percent of total billed charges",""
"SHAFT TIBIAL 10XGREATER THAN 250MM GRAFT ALLOGRAFT FROZEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010736","CDM","C1889","HCPCS","0278","RC","","","","both","","","4818.00","3613.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3830.31","79.5","","1309.77","674.56","6049.93","26","1493.58","3830.31","percent of total billed charges",""
"SHAFT TIBIAL 10XGREATER THAN 250MM GRAFT ALLOGRAFT FROZEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010736","CDM","C1889","HCPCS","0278","RC","","","","both","","","4818.00","3613.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2567.99","53.3","","1901.83","1901.83","2962.25","1 through 10","1493.58","3830.31","percent of total billed charges",""
"SHAFT TIBIAL 10XGREATER THAN 250MM GRAFT ALLOGRAFT FROZEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010736","CDM","C1889","HCPCS","0278","RC","","","","both","","","4818.00","3613.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1758.57","36.5","","1620.31","1620.31","19908.88","1 through 10","1493.58","3830.31","percent of total billed charges",""
"SHAFT TIBIAL 10XGREATER THAN 250MM GRAFT ALLOGRAFT FROZEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010736","CDM","C1889","HCPCS","0278","RC","","","","both","","","4818.00","3613.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1845.29","38.3","","352.91","352.91","2046.30","1 through 10","1493.58","3830.31","percent of total billed charges",""
"SHAFT TIBIAL 10XGREATER THAN 250MM GRAFT ALLOGRAFT FROZEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010736","CDM","C1889","HCPCS","0278","RC","","","","both","","","4818.00","3613.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2066.92","42.9","","9668.75","9668.75","9668.75","1 through 10","1493.58","3830.31","percent of total billed charges",""
"SHAFT TIBIAL 10XGREATER THAN 250MM GRAFT ALLOGRAFT FROZEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010736","CDM","C1889","HCPCS","0278","RC","","","","both","","","4818.00","3613.50","WELLPOINT [1015]","HB AMC WELLPOINT","3554.72","73.78","","699.88","384.10","3443.31","33","1493.58","3830.31","percent of total billed charges",""
"SHAFT TIBIAL 10XGREATER THAN 250MM GRAFT ALLOGRAFT FROZEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010736","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4818.00","3613.50","AETNA [1001]","HB AMC AETNA HMO","3362.96","69.8","","1421.24","264.50","4933.46","29","2517.89","3937.27","percent of total billed charges",""
"SHAFT TIBIAL 10XGREATER THAN 250MM GRAFT ALLOGRAFT FROZEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010736","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4818.00","3613.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3873.67","80.4","","1022.97","1022.97","3607.50","1 through 10","2517.89","3937.27","percent of total billed charges",""
"SHAFT TIBIAL 10XGREATER THAN 250MM GRAFT ALLOGRAFT FROZEN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10010736","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4818.00","3613.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3937.27","81.72","","3010.54","693.88","5019.88","35","2517.89","3937.27","percent of total billed charges",""
"SHANK SPINE 6.5X40MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10117078","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1085.18","79.5","","1309.77","674.56","6049.93","26","423.15","1085.18","percent of total billed charges",""
"SHANK SPINE 6.5X40MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10117078","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","727.55","53.3","","1901.83","1901.83","2962.25","1 through 10","423.15","1085.18","percent of total billed charges",""
"SHANK SPINE 6.5X40MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10117078","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","498.23","36.5","","1620.31","1620.31","19908.88","1 through 10","423.15","1085.18","percent of total billed charges",""
"SHANK SPINE 6.5X40MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10117078","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","522.80","38.3","","352.91","352.91","2046.30","1 through 10","423.15","1085.18","percent of total billed charges",""
"SHANK SPINE 6.5X40MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10117078","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","9668.75","9668.75","9668.75","1 through 10","423.15","1085.18","percent of total billed charges",""
"SHANK SPINE 6.5X40MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10117078","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB AMC WELLPOINT","1007.10","73.78","","699.88","384.10","3443.31","33","423.15","1085.18","percent of total billed charges",""
"SHANK SPINE 6.5X40MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10117078","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA HMO","952.77","69.8","","1421.24","264.50","4933.46","29","713.35","1115.48","percent of total billed charges",""
"SHANK SPINE 6.5X40MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10117078","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1097.46","80.4","","1022.97","1022.97","3607.50","1 through 10","713.35","1115.48","percent of total billed charges",""
"SHANK SPINE 6.5X40MM MAS POSTERIOR LUMBAR INTERBODY FUSION SCREW","SUP-ITM-10117078","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1115.48","81.72","","3010.54","693.88","5019.88","35","713.35","1115.48","percent of total billed charges",""
"Shave Lesn Face/Ear/Lip <0.5cm","PX-76000043","CDM","11310","CPT","0761","RC","","","","both","","","296.00","222.00","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.25","109.25","109.25","1 through 10","91.76","294.93","other","OPPS APC"
"Shave Lesn Face/Ear/Lip <0.5cm","PX-76000043","CDM","11310","CPT","0761","RC","","","","both","","","296.00","222.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.37","38.3","","112.22","112.22","112.22","1 through 10","91.76","294.93","percent of total billed charges",""
"Shave Lesn Face/Ear/Lip <0.5cm","PX-76000043","CDM","11310","CPT","0761","RC","","","","both","","","296.00","222.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","235.97","235.97","235.97","1 through 10","91.76","294.93","other","OPPS APC"
"Shave Lesn Face/Ear/Lip <0.5cm","PX-76000043","CDM","11310","CPT","0761","RC","","","","outpatient","","","296.00","222.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","58.47","58.47","58.47","1 through 10","154.69","350.18","other","ASC "
"Shave Lesn Face/Ear/Lip <0.5cm","PX-76000043","CDM","11310","CPT","0761","RC","","","","outpatient","","","296.00","222.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","241.89","81.72","","229.43","229.43","229.43","1 through 10","154.69","350.18","percent of total billed charges",""
"Shave Lesn Face/Ear/Lip 0.6-1.0cm","PX-76000044","CDM","11311","CPT","0761","RC","","","","both","","","781.00","585.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","117.98","235.97","1 through 10","224.17","620.9","other","OPPS APC"
"Shave Lesn Face/Ear/Lip 0.6-1.0cm","PX-76000044","CDM","11311","CPT","0761","RC","","","","both","","","781.00","585.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","232.88","232.88","232.88","1 through 10","224.17","620.9","other","OPPS APC"
"Shave Lesn Face/Ear/Lip 0.6-1.0cm","PX-76000044","CDM","11311","CPT","0761","RC","","","","outpatient","","","781.00","585.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","472.37","236.19","472.37","1 through 10","176.45","638.23","other","ASC "
"Shave Lesn Face/Ear/Lip 1.1-2.0cm","PX-76000045","CDM","11312","CPT","0761","RC","","","","both","","","766.00","574.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","466.88","466.88","1 through 10","237.46","608.97","other","OPPS APC"
"Shave Lesn Face/Ear/Lip 1.1-2.0cm","PX-76000045","CDM","11312","CPT","0761","RC","","","","both","","","766.00","574.50","MEDICARE [2001]","HB BWH MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","474.47","474.47","1 through 10","237.46","608.97","other","OPPS APC"
"Shave Lesn Sclp/Hnd/Gen <0.5cm","PX-76000039","CDM","11305","CPT","0761","RC","","","","both","","","296.00","222.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","157.77","53.3","","225.87","225.87","225.87","1 through 10","91.76","294.93","percent of total billed charges",""
"Shave Lesn Sclp/Hnd/Gen <0.5cm","PX-76000039","CDM","11305","CPT","0761","RC","","","","both","","","296.00","222.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.37","38.3","","218.12","218.12","218.12","1 through 10","91.76","294.93","percent of total billed charges",""
"Shave Lesn Sclp/Hnd/Gen <0.5cm","PX-76000039","CDM","11305","CPT","0761","RC","","","","outpatient","","","296.00","222.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","233.87","467.73","1 through 10","154.69","350.18","other","ASC "
"Shave Lesn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000040","CDM","11306","CPT","0761","RC","","","","both","","","415.00","311.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","158.95","38.3","","471.54","471.54","471.54","1 through 10","128.65","329.93","percent of total billed charges",""
"Shave Lesn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000040","CDM","11306","CPT","0761","RC","","","","outpatient","","","415.00","311.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","405.38","405.38","1 through 10","176.45","350.18","other","ASC"
"Shave Lesn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000040","CDM","11306","CPT","0761","RC","","","","outpatient","","","415.00","311.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1228.08","204.68","1228.08","1 through 10","176.45","350.18","other","Multiple Surgery"
"Shave Lesn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000041","CDM","11307","CPT","0761","RC","","","","outpatient","","","423.00","317.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","467.73","1 through 10","176.45","350.18","other","ASC "
"Shave Lesn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000041","CDM","11307","CPT","0761","RC","","","","outpatient","","","423.00","317.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","196.74","196.74","196.74","1 through 10","176.45","350.18","other","Multiple Surgery"
"Shave Lesn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000041","CDM","11307","CPT","0761","RC","","","","outpatient","","","423.00","317.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","345.68","81.72","","327.75","327.75","327.75","1 through 10","176.45","350.18","percent of total billed charges",""
"Shave Lesn Trunk/Arm/Leg <0.5cm","PX-76000035","CDM","11300","CPT","0761","RC","","","","both","","","296.00","222.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.37","38.3","","109.06","109.06","109.06","1 through 10","91.76","593.02","percent of total billed charges",""
"Shave Lesn Trunk/Arm/Leg <0.5cm","PX-76000035","CDM","11300","CPT","0761","RC","","","","outpatient","","","296.00","222.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","206.42","202.69","412.84","1 through 10","154.69","350.18","other","ASC"
"Shave Lesn Trunk/Arm/Leg <0.5cm","PX-76000035","CDM","11300","CPT","0761","RC","","","","outpatient","","","296.00","222.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","467.73","1 through 10","154.69","350.18","other","ASC "
"Shave Lesn Trunk/Arm/Leg > 2.0cm","PX-76000038","CDM","11303","CPT","0761","RC","","","","both","","","524.00","393.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","200.69","38.3","","198.63","198.63","198.63","1 through 10","162.44","593.02","percent of total billed charges",""
"Shave Lesn Trunk/Arm/Leg > 2.0cm","PX-76000038","CDM","11303","CPT","0761","RC","","","","outpatient","","","524.00","393.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","832.56","832.56","832.56","1 through 10","273.84","700.33","other","ASC "
"Shave Lesn Trunk/Arm/Leg 0.6-1.0cm","PX-76000036","CDM","11301","CPT","0761","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.41","38.3","","468.03","303.24","468.03","12","127.41","326.75","percent of total billed charges",""
"Shave Lesn Trunk/Arm/Leg 0.6-1.0cm","PX-76000036","CDM","11301","CPT","0761","RC","","","","both","","","411.00","308.25","WELLPOINT [1015]","HB AMC WELLPOINT","303.24","73.78","","699.63","696.06","699.63","1 through 10","127.41","326.75","percent of total billed charges",""
"Shave Lesn Trunk/Arm/Leg 0.6-1.0cm","PX-76000036","CDM","11301","CPT","0761","RC","","","","outpatient","","","411.00","308.25","AETNA [1001]","HB AMC AETNA HMO","286.88","69.8","","270.12","270.12","270.12","1 through 10","176.45","350.18","percent of total billed charges",""
"Shave Lesn Trunk/Arm/Leg 0.6-1.0cm","PX-76000036","CDM","11301","CPT","0761","RC","","","","outpatient","","","411.00","308.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","202.69","412.84","1 through 10","176.45","350.18","other","ASC"
"Shave Lesn Trunk/Arm/Leg 0.6-1.0cm","PX-76000036","CDM","11301","CPT","0761","RC","","","","outpatient","","","411.00","308.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","233.87","472.37","11","176.45","350.18","other","ASC "
"Shave Lesn Trunk/Arm/Leg 0.6-1.0cm","PX-76000036","CDM","11301","CPT","0761","RC","","","","outpatient","","","411.00","308.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1228.08","1228.08","1228.08","1 through 10","176.45","350.18","other","Multiple Surgery"
"Shave Lesn Trunk/Arm/Leg 1.1-2.0cm","PX-76000037","CDM","11302","CPT","0761","RC","","","","both","","","423.00","317.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","131.13","336.29","other","OPPS APC"
"Shave Lesn Trunk/Arm/Leg 1.1-2.0cm","PX-76000037","CDM","11302","CPT","0761","RC","","","","both","","","423.00","317.25","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","218.50","235.97","1 through 10","131.13","336.29","other","OPPS APC"
"Shave Lesn Trunk/Arm/Leg 1.1-2.0cm","PX-76000037","CDM","11302","CPT","0761","RC","","","","both","","","423.00","317.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","162.01","38.3","","480.93","480.93","480.93","1 through 10","131.13","336.29","percent of total billed charges",""
"Shave Lesn Trunk/Arm/Leg 1.1-2.0cm","PX-76000037","CDM","11302","CPT","0761","RC","","","","both","","","423.00","317.25","WELLPOINT [1015]","HB AMC WELLPOINT","312.09","73.78","","715.25","715.25","715.25","1 through 10","131.13","336.29","percent of total billed charges",""
"Shave Lesn Trunk/Arm/Leg 1.1-2.0cm","PX-76000037","CDM","11302","CPT","0761","RC","","","","outpatient","","","423.00","317.25","AETNA [1001]","HB AMC AETNA HMO","295.25","69.8","","277.57","277.57","277.57","1 through 10","176.45","350.18","percent of total billed charges",""
"Shave Lesn Trunk/Arm/Leg 1.1-2.0cm","PX-76000037","CDM","11302","CPT","0761","RC","","","","outpatient","","","423.00","317.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","206.42","412.84","1 through 10","176.45","350.18","other","ASC"
"Shave Lesn Trunk/Arm/Leg 1.1-2.0cm","PX-76000037","CDM","11302","CPT","0761","RC","","","","outpatient","","","423.00","317.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","467.73","1 through 10","176.45","350.18","other","ASC "
"Shave Lesn Trunk/Arm/Leg 1.1-2.0cm","PX-76000037","CDM","11302","CPT","0761","RC","","","","outpatient","","","423.00","317.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1228.08","786.96","1228.08","1 through 10","176.45","350.18","other","Multiple Surgery"
"Shave Lesn Trunk/Arm/Leg 1.1-2.0cm","PX-76000037","CDM","11302","CPT","0761","RC","","","","outpatient","","","423.00","317.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","451.71","451.71","451.71","1 through 10","176.45","350.18","other","Multiple Surgery"
"Shave Lesn Trunk/Arm/Leg 1.1-2.0cm","PX-76000037","CDM","11302","CPT","0761","RC","","","","outpatient","","","423.00","317.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","345.68","81.72","","327.75","327.75","327.75","1 through 10","176.45","350.18","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR 11.0/0.143/3.63 18.3/0.238/6.05 MECHANICAL EXTRACTION PC/1EA","SUP-ITM-10135925","CDM","C1773","HCPCS","0272","RC","","","","both","","","5712.50","4284.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2085.06","36.5","","114.30","97.14","114.30","1 through 10","1770.88","4541.44","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR 11.0/0.143/3.63 18.3/0.238/6.05 MECHANICAL EXTRACTION PC/1EA","SUP-ITM-10135925","CDM","C1773","HCPCS","0272","RC","","","","both","","","5712.50","4284.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2187.89","38.3","","119.81","116.44","359.43","20","1770.88","4541.44","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR 11.0/0.143/3.63 18.3/0.238/6.05 MECHANICAL EXTRACTION PC/1EA","SUP-ITM-10135925","CDM","C1773","HCPCS","0272","RC","","","","both","","","5712.50","4284.37","WELLPOINT [1015]","HB AMC WELLPOINT","4214.68","73.78","","875.53","228.13","875.53","1 through 10","1770.88","4541.44","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR 11.0/0.143/3.63 18.3/0.238/6.05 MECHANICAL EXTRACTION PC/1EA","SUP-ITM-10135925","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","5712.50","4284.37","AETNA [1001]","HB AMC AETNA HMO","3987.33","69.8","","207.45","207.45","207.45","1 through 10","2985.35","4668.26","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR 11.0/0.143/3.63 18.3/0.238/6.05 MECHANICAL EXTRACTION PC/1EA","SUP-ITM-10135925","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","5712.50","4284.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4668.26","81.72","","244.96","134.74","244.96","1 through 10","2985.35","4668.26","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","both","","","4637.50","3478.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2423.56","52.26","","16.24","16.24","54.15","1 through 10","1437.63","3686.81","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","both","","","4637.50","3478.12","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3329.73","71.8","","86.33","32.67","86.33","1 through 10","1437.63","3686.81","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","both","","","4637.50","3478.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3246.25","70","","113.68","63.00","177.34","40","1437.63","3686.81","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","both","","","4637.50","3478.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3686.81","79.5","","50.70","21.76","168.00","12","1437.63","3686.81","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","both","","","4637.50","3478.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2471.79","53.3","","89.31","89.31","99.75","1 through 10","1437.63","3686.81","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","both","","","4637.50","3478.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3014.38","65","","94.41","17.06","2275.00","1 through 10","1437.63","3686.81","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","both","","","4637.50","3478.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1437.63","31","","35.13","35.13","35.13","1 through 10","1437.63","3686.81","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","both","","","4637.50","3478.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1692.69","36.5","","40.08","12.40","86.17","108","1437.63","3686.81","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","both","","","4637.50","3478.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1776.16","38.3","","33.25","10.27","68.43","169","1437.63","3686.81","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","both","","","4637.50","3478.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1989.49","42.9","","25.48","14.86","90.88","1 through 10","1437.63","3686.81","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","both","","","4637.50","3478.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1989.49","42.9","","90.88","90.88","90.88","1 through 10","1437.63","3686.81","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","both","","","4637.50","3478.12","WELLPOINT [1015]","HB AMC WELLPOINT","3421.55","73.78","","84.63","19.55","140.02","123","1437.63","3686.81","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4637.50","3478.12","AETNA [1001]","HB AMC AETNA HMO","3236.98","69.8","","76.96","17.77","113.68","14","2423.56","3789.77","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4637.50","3478.12","AETNA [1001]","HB AMC AETNA PPO","3728.55","80.4","","57.31","57.31","57.31","1 through 10","2423.56","3789.77","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4637.50","3478.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2423.56","52.26","","16.24","16.24","54.15","1 through 10","2423.56","3789.77","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4637.50","3478.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3728.55","80.4","","68.25","68.25","87.50","1 through 10","2423.56","3789.77","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4637.50","3478.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","3789.77","81.72","","156.19","156.19","156.19","1 through 10","2423.56","3789.77","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4637.50","3478.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3789.77","81.72","","82.70","12.06","98.97","13","2423.56","3789.77","percent of total billed charges",""
"SHEATH DILATOR TIGHTRAIL 11FR ROTATING PC/1EA","SUP-ITM-10191556","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4637.50","3478.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3789.77","81.72","","50.47","25.30","134.30","140","2423.56","3789.77","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1415.72","52.26","","16.24","16.24","54.15","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1945.06","71.8","","86.33","32.67","86.33","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1896.30","70","","113.68","63.00","177.34","40","839.79","2153.66","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2153.66","79.5","","50.70","21.76","168.00","12","839.79","2153.66","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1443.90","53.3","","89.31","89.31","99.75","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1760.85","65","","94.41","17.06","2275.00","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","839.79","31","","35.13","35.13","35.13","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","988.79","36.5","","40.08","12.40","86.17","108","839.79","2153.66","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1037.55","38.3","","33.25","10.27","68.43","169","839.79","2153.66","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1162.16","42.9","","25.48","14.86","90.88","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1162.16","42.9","","90.88","90.88","90.88","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","WELLPOINT [1015]","HB AMC WELLPOINT","1998.70","73.78","","84.63","19.55","140.02","123","839.79","2153.66","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","AETNA [1001]","HB AMC AETNA HMO","1890.88","69.8","","76.96","17.77","113.68","14","1415.72","2213.79","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","AETNA [1001]","HB AMC AETNA PPO","2178.04","80.4","","57.31","57.31","57.31","1 through 10","1415.72","2213.79","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1415.72","52.26","","16.24","16.24","54.15","1 through 10","1415.72","2213.79","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2178.04","80.4","","68.25","68.25","87.50","1 through 10","1415.72","2213.79","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","2213.79","81.72","","156.19","156.19","156.19","1 through 10","1415.72","2213.79","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2213.79","81.72","","82.70","12.06","98.97","13","1415.72","2213.79","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2213.79","81.72","","50.47","25.30","134.30","140","1415.72","2213.79","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1610.00","1207.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","841.39","52.26","","16.24","16.24","54.15","1 through 10","499.1","1279.95","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1610.00","1207.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1155.98","71.8","","86.33","32.67","86.33","1 through 10","499.1","1279.95","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1610.00","1207.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1127.00","70","","113.68","63.00","177.34","40","499.1","1279.95","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1610.00","1207.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1279.95","79.5","","50.70","21.76","168.00","12","499.1","1279.95","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1610.00","1207.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","858.13","53.3","","89.31","89.31","99.75","1 through 10","499.1","1279.95","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1610.00","1207.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1046.50","65","","94.41","17.06","2275.00","1 through 10","499.1","1279.95","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1610.00","1207.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","499.10","31","","35.13","35.13","35.13","1 through 10","499.1","1279.95","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1610.00","1207.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","587.65","36.5","","40.08","12.40","86.17","108","499.1","1279.95","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1610.00","1207.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","616.63","38.3","","33.25","10.27","68.43","169","499.1","1279.95","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1610.00","1207.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","690.69","42.9","","25.48","14.86","90.88","1 through 10","499.1","1279.95","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1610.00","1207.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","690.69","42.9","","90.88","90.88","90.88","1 through 10","499.1","1279.95","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","1610.00","1207.50","WELLPOINT [1015]","HB AMC WELLPOINT","1187.86","73.78","","84.63","19.55","140.02","123","499.1","1279.95","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1610.00","1207.50","AETNA [1001]","HB AMC AETNA HMO","1123.78","69.8","","76.96","17.77","113.68","14","841.39","1315.69","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1610.00","1207.50","AETNA [1001]","HB AMC AETNA PPO","1294.44","80.4","","57.31","57.31","57.31","1 through 10","841.39","1315.69","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1610.00","1207.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","841.39","52.26","","16.24","16.24","54.15","1 through 10","841.39","1315.69","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1610.00","1207.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1294.44","80.4","","68.25","68.25","87.50","1 through 10","841.39","1315.69","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1610.00","1207.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1315.69","81.72","","156.19","156.19","156.19","1 through 10","841.39","1315.69","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1610.00","1207.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1315.69","81.72","","82.70","12.06","98.97","13","841.39","1315.69","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1610.00","1207.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1315.69","81.72","","50.47","25.30","134.30","140","841.39","1315.69","percent of total billed charges",""
"SHEATH ENDOSCOPIC 6.5FR 9.0MMX45CM ENDOSYSTEM TOURGUIDE STEERABLE","SUP-ITM-10156230","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1115.75","52.26","","2815.54","2815.54","2815.54","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH ENDOSCOPIC 6.5FR 9.0MMX45CM ENDOSYSTEM TOURGUIDE STEERABLE","SUP-ITM-10156230","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1697.33","79.5","","3771.60","3771.60","3771.60","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH ENDOSCOPIC 6.5FR 9.0MMX45CM ENDOSYSTEM TOURGUIDE STEERABLE","SUP-ITM-10156230","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1387.75","65","","2161.25","2161.25","2161.25","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH ENDOSCOPIC 6.5FR 9.0MMX45CM ENDOSYSTEM TOURGUIDE STEERABLE","SUP-ITM-10156230","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","779.28","36.5","","1697.15","370.76","3720.69","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH ENDOSCOPIC 6.5FR 9.0MMX45CM ENDOSYSTEM TOURGUIDE STEERABLE","SUP-ITM-10156230","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","817.71","38.3","","1779.05","1263.50","3458.00","16","661.85","1697.33","percent of total billed charges",""
"SHEATH ENDOSCOPIC 6.5FR 9.0MMX45CM ENDOSYSTEM TOURGUIDE STEERABLE","SUP-ITM-10156230","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","915.92","42.9","","1512.88","1512.88","1512.88","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH ENDOSCOPIC 6.5FR 9.0MMX45CM ENDOSYSTEM TOURGUIDE STEERABLE","SUP-ITM-10156230","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","WELLPOINT [1015]","HB AMC WELLPOINT","1575.20","73.78","","3387.48","2475.46","3387.48","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH ENDOSCOPIC 6.5FR 9.0MMX45CM ENDOSYSTEM TOURGUIDE STEERABLE","SUP-ITM-10156230","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1115.75","52.26","","2815.54","2815.54","2815.54","1 through 10","1115.75","1744.72","percent of total billed charges",""
"SHEATH ENDOSCOPIC 6.5FR 9.0MMX45CM ENDOSYSTEM TOURGUIDE STEERABLE","SUP-ITM-10156230","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1744.72","81.72","","3637.27","2000.64","3637.27","1 through 10","1115.75","1744.72","percent of total billed charges",""
"SHEATH ENDOSCOPIC 6.5FR 9.0MMX45CM ENDOSYSTEM TOURGUIDE STEERABLE","SUP-ITM-10156230","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1744.72","81.72","","2658.01","2000.64","3637.27","17","1115.75","1744.72","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1110.26","52.26","","16.24","16.24","54.15","1 through 10","658.6","1688.98","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1525.39","71.8","","86.33","32.67","86.33","1 through 10","658.6","1688.98","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1487.15","70","","113.68","63.00","177.34","40","658.6","1688.98","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1688.98","79.5","","50.70","21.76","168.00","12","658.6","1688.98","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1132.36","53.3","","89.31","89.31","99.75","1 through 10","658.6","1688.98","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1380.93","65","","94.41","17.06","2275.00","1 through 10","658.6","1688.98","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","658.60","31","","35.13","35.13","35.13","1 through 10","658.6","1688.98","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","775.44","36.5","","40.08","12.40","86.17","108","658.6","1688.98","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","813.68","38.3","","33.25","10.27","68.43","169","658.6","1688.98","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.41","42.9","","25.48","14.86","90.88","1 through 10","658.6","1688.98","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.41","42.9","","90.88","90.88","90.88","1 through 10","658.6","1688.98","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","both","","","2124.50","1593.37","WELLPOINT [1015]","HB AMC WELLPOINT","1567.46","73.78","","84.63","19.55","140.02","123","658.6","1688.98","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","AETNA [1001]","HB AMC AETNA HMO","1482.90","69.8","","76.96","17.77","113.68","14","1110.26","1736.14","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","AETNA [1001]","HB AMC AETNA PPO","1708.10","80.4","","57.31","57.31","57.31","1 through 10","1110.26","1736.14","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1110.26","52.26","","16.24","16.24","54.15","1 through 10","1110.26","1736.14","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1708.10","80.4","","68.25","68.25","87.50","1 through 10","1110.26","1736.14","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1736.14","81.72","","156.19","156.19","156.19","1 through 10","1110.26","1736.14","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1736.14","81.72","","82.70","12.06","98.97","13","1110.26","1736.14","percent of total billed charges",""
"SHEATH FLEX 26FR 33CM DRYSEAL","SUP-ITM-10169122","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2124.50","1593.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1736.14","81.72","","50.47","25.30","134.30","140","1110.26","1736.14","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","144.48","52.26","","16.24","16.24","54.15","1 through 10","85.71","219.79","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","198.51","71.8","","86.33","32.67","86.33","1 through 10","85.71","219.79","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","193.53","70","","113.68","63.00","177.34","40","85.71","219.79","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","219.79","79.5","","50.70","21.76","168.00","12","85.71","219.79","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.36","53.3","","89.31","89.31","99.75","1 through 10","85.71","219.79","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","179.71","65","","94.41","17.06","2275.00","1 through 10","85.71","219.79","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.71","31","","35.13","35.13","35.13","1 through 10","85.71","219.79","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.91","36.5","","40.08","12.40","86.17","108","85.71","219.79","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.89","38.3","","33.25","10.27","68.43","169","85.71","219.79","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.61","42.9","","25.48","14.86","90.88","1 through 10","85.71","219.79","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.61","42.9","","90.88","90.88","90.88","1 through 10","85.71","219.79","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","both","","","276.47","207.35","WELLPOINT [1015]","HB AMC WELLPOINT","203.98","73.78","","84.63","19.55","140.02","123","85.71","219.79","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","AETNA [1001]","HB AMC AETNA HMO","192.98","69.8","","76.96","17.77","113.68","14","144.48","225.93","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","AETNA [1001]","HB AMC AETNA PPO","222.28","80.4","","57.31","57.31","57.31","1 through 10","144.48","225.93","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","144.48","52.26","","16.24","16.24","54.15","1 through 10","144.48","225.93","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","222.28","80.4","","68.25","68.25","87.50","1 through 10","144.48","225.93","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","225.93","81.72","","156.19","156.19","156.19","1 through 10","144.48","225.93","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","225.93","81.72","","82.70","12.06","98.97","13","144.48","225.93","percent of total billed charges",""
"SHEATH GUIDING 12FR 45CM VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10056603","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","276.47","207.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","225.93","81.72","","50.47","25.30","134.30","140","144.48","225.93","percent of total billed charges",""
"SHEATH GUIDING 6FR 119CM R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10230035","CDM","C1766","HCPCS","0272","RC","","","","both","","","206.85","155.14","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","108.10","52.26","","2815.54","2815.54","2815.54","1 through 10","64.12","164.45","percent of total billed charges",""
"SHEATH GUIDING 6FR 119CM R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10230035","CDM","C1766","HCPCS","0272","RC","","","","both","","","206.85","155.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","164.45","79.5","","3771.60","3771.60","3771.60","1 through 10","64.12","164.45","percent of total billed charges",""
"SHEATH GUIDING 6FR 119CM R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10230035","CDM","C1766","HCPCS","0272","RC","","","","both","","","206.85","155.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","134.45","65","","2161.25","2161.25","2161.25","1 through 10","64.12","164.45","percent of total billed charges",""
"SHEATH GUIDING 6FR 119CM R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10230035","CDM","C1766","HCPCS","0272","RC","","","","both","","","206.85","155.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","75.50","36.5","","1697.15","370.76","3720.69","1 through 10","64.12","164.45","percent of total billed charges",""
"SHEATH GUIDING 6FR 119CM R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10230035","CDM","C1766","HCPCS","0272","RC","","","","both","","","206.85","155.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","79.22","38.3","","1779.05","1263.50","3458.00","16","64.12","164.45","percent of total billed charges",""
"SHEATH GUIDING 6FR 119CM R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10230035","CDM","C1766","HCPCS","0272","RC","","","","both","","","206.85","155.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","88.74","42.9","","1512.88","1512.88","1512.88","1 through 10","64.12","164.45","percent of total billed charges",""
"SHEATH GUIDING 6FR 119CM R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10230035","CDM","C1766","HCPCS","0272","RC","","","","both","","","206.85","155.14","WELLPOINT [1015]","HB AMC WELLPOINT","152.61","73.78","","3387.48","2475.46","3387.48","1 through 10","64.12","164.45","percent of total billed charges",""
"SHEATH GUIDING 6FR 119CM R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10230035","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","206.85","155.14","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","108.10","52.26","","2815.54","2815.54","2815.54","1 through 10","108.1","169.04","percent of total billed charges",""
"SHEATH GUIDING 6FR 119CM R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10230035","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","206.85","155.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","169.04","81.72","","3637.27","2000.64","3637.27","1 through 10","108.1","169.04","percent of total billed charges",""
"SHEATH GUIDING 6FR 119CM R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10230035","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","206.85","155.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","169.04","81.72","","2658.01","2000.64","3637.27","17","108.1","169.04","percent of total billed charges",""
"SHEATH GUIDING 75CM 6FR R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10281324","CDM","C1766","HCPCS","0272","RC","","","","both","","","1034.25","775.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","540.50","52.26","","2815.54","2815.54","2815.54","1 through 10","320.62","822.23","percent of total billed charges",""
"SHEATH GUIDING 75CM 6FR R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10281324","CDM","C1766","HCPCS","0272","RC","","","","both","","","1034.25","775.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","822.23","79.5","","3771.60","3771.60","3771.60","1 through 10","320.62","822.23","percent of total billed charges",""
"SHEATH GUIDING 75CM 6FR R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10281324","CDM","C1766","HCPCS","0272","RC","","","","both","","","1034.25","775.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","672.26","65","","2161.25","2161.25","2161.25","1 through 10","320.62","822.23","percent of total billed charges",""
"SHEATH GUIDING 75CM 6FR R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10281324","CDM","C1766","HCPCS","0272","RC","","","","both","","","1034.25","775.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","377.50","36.5","","1697.15","370.76","3720.69","1 through 10","320.62","822.23","percent of total billed charges",""
"SHEATH GUIDING 75CM 6FR R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10281324","CDM","C1766","HCPCS","0272","RC","","","","both","","","1034.25","775.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","396.12","38.3","","1779.05","1263.50","3458.00","16","320.62","822.23","percent of total billed charges",""
"SHEATH GUIDING 75CM 6FR R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10281324","CDM","C1766","HCPCS","0272","RC","","","","both","","","1034.25","775.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","443.69","42.9","","1512.88","1512.88","1512.88","1 through 10","320.62","822.23","percent of total billed charges",""
"SHEATH GUIDING 75CM 6FR R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10281324","CDM","C1766","HCPCS","0272","RC","","","","both","","","1034.25","775.69","WELLPOINT [1015]","HB AMC WELLPOINT","763.07","73.78","","3387.48","2475.46","3387.48","1 through 10","320.62","822.23","percent of total billed charges",""
"SHEATH GUIDING 75CM 6FR R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10281324","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","1034.25","775.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","540.50","52.26","","2815.54","2815.54","2815.54","1 through 10","540.5","845.19","percent of total billed charges",""
"SHEATH GUIDING 75CM 6FR R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10281324","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","1034.25","775.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","845.19","81.72","","3637.27","2000.64","3637.27","1 through 10","540.5","845.19","percent of total billed charges",""
"SHEATH GUIDING 75CM 6FR R2P DESTINATION SLENDER STRAIGHT BX/1EA","SUP-ITM-10281324","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","1034.25","775.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","845.19","81.72","","2658.01","2000.64","3637.27","17","540.5","845.19","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","164.60","52.26","","16.24","16.24","54.15","1 through 10","97.64","250.4","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","226.15","71.8","","86.33","32.67","86.33","1 through 10","97.64","250.4","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","220.48","70","","113.68","63.00","177.34","40","97.64","250.4","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.40","79.5","","50.70","21.76","168.00","12","97.64","250.4","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.88","53.3","","89.31","89.31","99.75","1 through 10","97.64","250.4","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","204.73","65","","94.41","17.06","2275.00","1 through 10","97.64","250.4","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","97.64","31","","35.13","35.13","35.13","1 through 10","97.64","250.4","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.96","36.5","","40.08","12.40","86.17","108","97.64","250.4","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.63","38.3","","33.25","10.27","68.43","169","97.64","250.4","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.12","42.9","","25.48","14.86","90.88","1 through 10","97.64","250.4","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.12","42.9","","90.88","90.88","90.88","1 through 10","97.64","250.4","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","both","","","314.97","236.23","WELLPOINT [1015]","HB AMC WELLPOINT","232.38","73.78","","84.63","19.55","140.02","123","97.64","250.4","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","AETNA [1001]","HB AMC AETNA HMO","219.85","69.8","","76.96","17.77","113.68","14","164.6","257.39","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","AETNA [1001]","HB AMC AETNA PPO","253.24","80.4","","57.31","57.31","57.31","1 through 10","164.6","257.39","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","164.60","52.26","","16.24","16.24","54.15","1 through 10","164.6","257.39","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","253.24","80.4","","68.25","68.25","87.50","1 through 10","164.6","257.39","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","257.39","81.72","","156.19","156.19","156.19","1 through 10","164.6","257.39","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","257.39","81.72","","82.70","12.06","98.97","13","164.6","257.39","percent of total billed charges",""
"SHEATH GUIDING 8FRX70CM INTRODUCER VASCULAR FLEXOR ANSEL CHECK FLO VALVE HIGH FLEX DILATOR MULTIPURPOSE TIP","SUP-ITM-10087195","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","314.97","236.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.39","81.72","","50.47","25.30","134.30","140","164.6","257.39","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","both","","","175.00","131.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","91.46","52.26","","16.24","16.24","54.15","1 through 10","54.25","139.13","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","both","","","175.00","131.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","125.65","71.8","","86.33","32.67","86.33","1 through 10","54.25","139.13","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","both","","","175.00","131.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","122.50","70","","113.68","63.00","177.34","40","54.25","139.13","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","50.70","21.76","168.00","12","54.25","139.13","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","both","","","175.00","131.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.28","53.3","","89.31","89.31","99.75","1 through 10","54.25","139.13","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","both","","","175.00","131.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","113.75","65","","94.41","17.06","2275.00","1 through 10","54.25","139.13","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.25","31","","35.13","35.13","35.13","1 through 10","54.25","139.13","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","40.08","12.40","86.17","108","54.25","139.13","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","33.25","10.27","68.43","169","54.25","139.13","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","25.48","14.86","90.88","1 through 10","54.25","139.13","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","90.88","90.88","90.88","1 through 10","54.25","139.13","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","84.63","19.55","140.02","123","54.25","139.13","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","76.96","17.77","113.68","14","91.46","143.01","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA PPO","140.70","80.4","","57.31","57.31","57.31","1 through 10","91.46","143.01","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","175.00","131.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","91.46","52.26","","16.24","16.24","54.15","1 through 10","91.46","143.01","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","175.00","131.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","140.70","80.4","","68.25","68.25","87.50","1 through 10","91.46","143.01","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","175.00","131.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","143.01","81.72","","156.19","156.19","156.19","1 through 10","91.46","143.01","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.01","81.72","","82.70","12.06","98.97","13","91.46","143.01","percent of total billed charges",""
"SHEATH INTRODUCER 10CMX6FR SLENDER STRAIGHT SPRING .021IN GUIDEWIRE 22GA NEEDLE KIT GLIDESHEATH HYDROPHILIC RADIAL ACCESS BX/5EA","SUP-ITM-10124353","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","50.47","25.30","134.30","140","91.46","143.01","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","both","","","3262.00","2446.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1704.72","52.26","","16.24","16.24","54.15","1 through 10","1011.22","2593.29","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","both","","","3262.00","2446.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2342.12","71.8","","86.33","32.67","86.33","1 through 10","1011.22","2593.29","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","both","","","3262.00","2446.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2283.40","70","","113.68","63.00","177.34","40","1011.22","2593.29","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","both","","","3262.00","2446.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2593.29","79.5","","50.70","21.76","168.00","12","1011.22","2593.29","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","both","","","3262.00","2446.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1738.65","53.3","","89.31","89.31","99.75","1 through 10","1011.22","2593.29","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","both","","","3262.00","2446.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2120.30","65","","94.41","17.06","2275.00","1 through 10","1011.22","2593.29","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","both","","","3262.00","2446.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1011.22","31","","35.13","35.13","35.13","1 through 10","1011.22","2593.29","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","both","","","3262.00","2446.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1190.63","36.5","","40.08","12.40","86.17","108","1011.22","2593.29","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","both","","","3262.00","2446.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1249.35","38.3","","33.25","10.27","68.43","169","1011.22","2593.29","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","both","","","3262.00","2446.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1399.40","42.9","","25.48","14.86","90.88","1 through 10","1011.22","2593.29","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","both","","","3262.00","2446.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1399.40","42.9","","90.88","90.88","90.88","1 through 10","1011.22","2593.29","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","both","","","3262.00","2446.50","WELLPOINT [1015]","HB AMC WELLPOINT","2406.70","73.78","","84.63","19.55","140.02","123","1011.22","2593.29","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3262.00","2446.50","AETNA [1001]","HB AMC AETNA HMO","2276.88","69.8","","76.96","17.77","113.68","14","1704.72","2665.71","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3262.00","2446.50","AETNA [1001]","HB AMC AETNA PPO","2622.65","80.4","","57.31","57.31","57.31","1 through 10","1704.72","2665.71","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3262.00","2446.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1704.72","52.26","","16.24","16.24","54.15","1 through 10","1704.72","2665.71","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3262.00","2446.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2622.65","80.4","","68.25","68.25","87.50","1 through 10","1704.72","2665.71","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3262.00","2446.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","2665.71","81.72","","156.19","156.19","156.19","1 through 10","1704.72","2665.71","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3262.00","2446.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2665.71","81.72","","82.70","12.06","98.97","13","1704.72","2665.71","percent of total billed charges",""
"SHEATH INTRODUCER 20FR 65CM DRYSEAL FLEX","SUP-ITM-10169117","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3262.00","2446.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2665.71","81.72","","50.47","25.30","134.30","140","1704.72","2665.71","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","both","","","1925.00","1443.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1006.01","52.26","","16.24","16.24","54.15","1 through 10","596.75","1530.38","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","both","","","1925.00","1443.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1382.15","71.8","","86.33","32.67","86.33","1 through 10","596.75","1530.38","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","both","","","1925.00","1443.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1347.50","70","","113.68","63.00","177.34","40","596.75","1530.38","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","both","","","1925.00","1443.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1530.38","79.5","","50.70","21.76","168.00","12","596.75","1530.38","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","both","","","1925.00","1443.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1026.03","53.3","","89.31","89.31","99.75","1 through 10","596.75","1530.38","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","both","","","1925.00","1443.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1251.25","65","","94.41","17.06","2275.00","1 through 10","596.75","1530.38","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","596.75","31","","35.13","35.13","35.13","1 through 10","596.75","1530.38","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","702.63","36.5","","40.08","12.40","86.17","108","596.75","1530.38","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","737.28","38.3","","33.25","10.27","68.43","169","596.75","1530.38","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","25.48","14.86","90.88","1 through 10","596.75","1530.38","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","90.88","90.88","90.88","1 through 10","596.75","1530.38","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","both","","","1925.00","1443.75","WELLPOINT [1015]","HB AMC WELLPOINT","1420.27","73.78","","84.63","19.55","140.02","123","596.75","1530.38","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA HMO","1343.65","69.8","","76.96","17.77","113.68","14","1006.01","1573.11","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA PPO","1547.70","80.4","","57.31","57.31","57.31","1 through 10","1006.01","1573.11","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1925.00","1443.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1006.01","52.26","","16.24","16.24","54.15","1 through 10","1006.01","1573.11","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1925.00","1443.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1547.70","80.4","","68.25","68.25","87.50","1 through 10","1006.01","1573.11","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1925.00","1443.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1573.11","81.72","","156.19","156.19","156.19","1 through 10","1006.01","1573.11","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1573.11","81.72","","82.70","12.06","98.97","13","1006.01","1573.11","percent of total billed charges",""
"SHEATH INTRODUCER 23FR 55.7CM MICRA HYDROPHILIC COATING","SUP-ITM-10168052","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1573.11","81.72","","50.47","25.30","134.30","140","1006.01","1573.11","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1415.72","52.26","","16.24","16.24","54.15","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1945.06","71.8","","86.33","32.67","86.33","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1896.30","70","","113.68","63.00","177.34","40","839.79","2153.66","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2153.66","79.5","","50.70","21.76","168.00","12","839.79","2153.66","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1443.90","53.3","","89.31","89.31","99.75","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1760.85","65","","94.41","17.06","2275.00","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","839.79","31","","35.13","35.13","35.13","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","988.79","36.5","","40.08","12.40","86.17","108","839.79","2153.66","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1037.55","38.3","","33.25","10.27","68.43","169","839.79","2153.66","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1162.16","42.9","","25.48","14.86","90.88","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1162.16","42.9","","90.88","90.88","90.88","1 through 10","839.79","2153.66","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","both","","","2709.00","2031.75","WELLPOINT [1015]","HB AMC WELLPOINT","1998.70","73.78","","84.63","19.55","140.02","123","839.79","2153.66","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","AETNA [1001]","HB AMC AETNA HMO","1890.88","69.8","","76.96","17.77","113.68","14","1415.72","2213.79","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","AETNA [1001]","HB AMC AETNA PPO","2178.04","80.4","","57.31","57.31","57.31","1 through 10","1415.72","2213.79","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1415.72","52.26","","16.24","16.24","54.15","1 through 10","1415.72","2213.79","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2178.04","80.4","","68.25","68.25","87.50","1 through 10","1415.72","2213.79","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","2213.79","81.72","","156.19","156.19","156.19","1 through 10","1415.72","2213.79","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2213.79","81.72","","82.70","12.06","98.97","13","1415.72","2213.79","percent of total billed charges",""
"SHEATH INTRODUCER 45CM 10FR DRYSEAL FLEX HYDROPHILIC COATING","SUP-ITM-10276449","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","2709.00","2031.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2213.79","81.72","","50.47","25.30","134.30","140","1415.72","2213.79","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","both","","","84.00","63.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","43.90","52.26","","16.24","16.24","54.15","1 through 10","26.04","66.78","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","both","","","84.00","63.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","60.31","71.8","","86.33","32.67","86.33","1 through 10","26.04","66.78","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","both","","","84.00","63.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","58.80","70","","113.68","63.00","177.34","40","26.04","66.78","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","both","","","84.00","63.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","66.78","79.5","","50.70","21.76","168.00","12","26.04","66.78","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","both","","","84.00","63.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","44.77","53.3","","89.31","89.31","99.75","1 through 10","26.04","66.78","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","both","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","54.60","65","","94.41","17.06","2275.00","1 through 10","26.04","66.78","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","26.04","31","","35.13","35.13","35.13","1 through 10","26.04","66.78","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30.66","36.5","","40.08","12.40","86.17","108","26.04","66.78","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.17","38.3","","33.25","10.27","68.43","169","26.04","66.78","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","both","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.04","42.9","","25.48","14.86","90.88","1 through 10","26.04","66.78","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","both","","","84.00","63.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.04","42.9","","90.88","90.88","90.88","1 through 10","26.04","66.78","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","both","","","84.00","63.00","WELLPOINT [1015]","HB AMC WELLPOINT","61.98","73.78","","84.63","19.55","140.02","123","26.04","66.78","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","AETNA [1001]","HB AMC AETNA HMO","58.63","69.8","","76.96","17.77","113.68","14","43.9","68.64","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","AETNA [1001]","HB AMC AETNA PPO","67.54","80.4","","57.31","57.31","57.31","1 through 10","43.9","68.64","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","43.90","52.26","","16.24","16.24","54.15","1 through 10","43.9","68.64","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","67.54","80.4","","68.25","68.25","87.50","1 through 10","43.9","68.64","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","68.64","81.72","","156.19","156.19","156.19","1 through 10","43.9","68.64","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","68.64","81.72","","82.70","12.06","98.97","13","43.9","68.64","percent of total billed charges",""
"SHEATH INTRODUCER 6FR 23CM CATHETER AVANTI PLUS SS OBTURATOR BX/5EA","SUP-ITM-10134970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","68.64","81.72","","50.47","25.30","134.30","140","43.9","68.64","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.50","23.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","16.46","52.26","","16.24","16.24","54.15","1 through 10","9.77","25.04","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.50","23.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","22.62","71.8","","86.33","32.67","86.33","1 through 10","9.77","25.04","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.50","23.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","22.05","70","","113.68","63.00","177.34","40","9.77","25.04","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.50","23.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","25.04","79.5","","50.70","21.76","168.00","12","9.77","25.04","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.50","23.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16.79","53.3","","89.31","89.31","99.75","1 through 10","9.77","25.04","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.50","23.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","20.48","65","","94.41","17.06","2275.00","1 through 10","9.77","25.04","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.50","23.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","9.77","31","","35.13","35.13","35.13","1 through 10","9.77","25.04","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.50","23.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11.50","36.5","","40.08","12.40","86.17","108","9.77","25.04","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.50","23.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12.06","38.3","","33.25","10.27","68.43","169","9.77","25.04","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.50","23.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13.51","42.9","","25.48","14.86","90.88","1 through 10","9.77","25.04","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.50","23.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13.51","42.9","","90.88","90.88","90.88","1 through 10","9.77","25.04","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.50","23.62","WELLPOINT [1015]","HB AMC WELLPOINT","23.24","73.78","","84.63","19.55","140.02","123","9.77","25.04","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","31.50","23.62","AETNA [1001]","HB AMC AETNA HMO","21.99","69.8","","76.96","17.77","113.68","14","16.46","25.74","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","31.50","23.62","AETNA [1001]","HB AMC AETNA PPO","25.33","80.4","","57.31","57.31","57.31","1 through 10","16.46","25.74","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","31.50","23.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","16.46","52.26","","16.24","16.24","54.15","1 through 10","16.46","25.74","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","31.50","23.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","25.33","80.4","","68.25","68.25","87.50","1 through 10","16.46","25.74","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","31.50","23.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","25.74","81.72","","156.19","156.19","156.19","1 through 10","16.46","25.74","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","31.50","23.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","25.74","81.72","","82.70","12.06","98.97","13","16.46","25.74","percent of total billed charges",""
"SHEATH PINNACLE 10FR 10CM 2.5CM .038IN INTRODUCER MINI GUIDEWIRE DILATOR CORONARY BX/10EA","SUP-ITM-10076129","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","31.50","23.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","25.74","81.72","","50.47","25.30","134.30","140","16.46","25.74","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","both","","","80.50","60.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","42.07","52.26","","16.24","16.24","54.15","1 through 10","24.96","64","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","both","","","80.50","60.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","57.80","71.8","","86.33","32.67","86.33","1 through 10","24.96","64","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","both","","","80.50","60.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","56.35","70","","113.68","63.00","177.34","40","24.96","64","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","both","","","80.50","60.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","64.00","79.5","","50.70","21.76","168.00","12","24.96","64","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","both","","","80.50","60.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","42.91","53.3","","89.31","89.31","99.75","1 through 10","24.96","64","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","both","","","80.50","60.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","52.33","65","","94.41","17.06","2275.00","1 through 10","24.96","64","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","both","","","80.50","60.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","24.96","31","","35.13","35.13","35.13","1 through 10","24.96","64","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","both","","","80.50","60.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29.38","36.5","","40.08","12.40","86.17","108","24.96","64","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","both","","","80.50","60.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30.83","38.3","","33.25","10.27","68.43","169","24.96","64","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","both","","","80.50","60.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.53","42.9","","25.48","14.86","90.88","1 through 10","24.96","64","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","both","","","80.50","60.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.53","42.9","","90.88","90.88","90.88","1 through 10","24.96","64","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","both","","","80.50","60.37","WELLPOINT [1015]","HB AMC WELLPOINT","59.39","73.78","","84.63","19.55","140.02","123","24.96","64","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","80.50","60.37","AETNA [1001]","HB AMC AETNA HMO","56.19","69.8","","76.96","17.77","113.68","14","42.07","65.78","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","80.50","60.37","AETNA [1001]","HB AMC AETNA PPO","64.72","80.4","","57.31","57.31","57.31","1 through 10","42.07","65.78","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","80.50","60.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","42.07","52.26","","16.24","16.24","54.15","1 through 10","42.07","65.78","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","80.50","60.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","64.72","80.4","","68.25","68.25","87.50","1 through 10","42.07","65.78","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","80.50","60.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","65.78","81.72","","156.19","156.19","156.19","1 through 10","42.07","65.78","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","80.50","60.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","65.78","81.72","","82.70","12.06","98.97","13","42.07","65.78","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10012775","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","80.50","60.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","65.78","81.72","","50.47","25.30","134.30","140","42.07","65.78","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.99","228.74","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","159.39","52.26","","16.24","16.24","54.15","1 through 10","94.55","242.47","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.99","228.74","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","218.98","71.8","","86.33","32.67","86.33","1 through 10","94.55","242.47","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.99","228.74","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","213.49","70","","113.68","63.00","177.34","40","94.55","242.47","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.99","228.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","242.47","79.5","","50.70","21.76","168.00","12","94.55","242.47","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.99","228.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","162.56","53.3","","89.31","89.31","99.75","1 through 10","94.55","242.47","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.99","228.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","198.24","65","","94.41","17.06","2275.00","1 through 10","94.55","242.47","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.99","228.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","94.55","31","","35.13","35.13","35.13","1 through 10","94.55","242.47","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.99","228.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","111.32","36.5","","40.08","12.40","86.17","108","94.55","242.47","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.99","228.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","116.81","38.3","","33.25","10.27","68.43","169","94.55","242.47","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.99","228.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.84","42.9","","25.48","14.86","90.88","1 through 10","94.55","242.47","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.99","228.74","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.84","42.9","","90.88","90.88","90.88","1 through 10","94.55","242.47","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.99","228.74","WELLPOINT [1015]","HB AMC WELLPOINT","225.02","73.78","","84.63","19.55","140.02","123","94.55","242.47","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.99","228.74","AETNA [1001]","HB AMC AETNA HMO","212.88","69.8","","76.96","17.77","113.68","14","159.39","249.24","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.99","228.74","AETNA [1001]","HB AMC AETNA PPO","245.21","80.4","","57.31","57.31","57.31","1 through 10","159.39","249.24","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.99","228.74","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","159.39","52.26","","16.24","16.24","54.15","1 through 10","159.39","249.24","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.99","228.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","245.21","80.4","","68.25","68.25","87.50","1 through 10","159.39","249.24","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.99","228.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","249.24","81.72","","156.19","156.19","156.19","1 through 10","159.39","249.24","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.99","228.74","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","249.24","81.72","","82.70","12.06","98.97","13","159.39","249.24","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.99","228.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","249.24","81.72","","50.47","25.30","134.30","140","159.39","249.24","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","759.50","569.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","603.80","79.5","","800.18","480.96","1887.97","195","235.45","603.8","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","759.50","569.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","404.81","53.3","","813.12","216.42","1444.50","81","235.45","603.8","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","759.50","569.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","235.45","31","","432.60","432.60","432.60","1 through 10","235.45","603.8","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","759.50","569.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","277.22","36.5","","148.37","54.89","631.39","94","235.45","603.8","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","759.50","569.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","290.89","38.3","","279.30","91.72","1116.77","266","235.45","603.8","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","759.50","569.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","325.83","42.9","","731.00","63.70","731.00","1 through 10","235.45","603.8","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","759.50","569.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","325.83","42.9","","384.74","384.74","384.74","1 through 10","235.45","603.8","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","759.50","569.62","WELLPOINT [1015]","HB AMC WELLPOINT","560.36","73.78","","286.63","119.22","1107.45","105","235.45","603.8","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","759.50","569.62","AETNA [1001]","HB AMC AETNA HMO","530.13","69.8","","675.31","184.75","1721.50","286","396.91","620.66","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","759.50","569.62","AETNA [1001]","HB AMC AETNA PPO","610.64","80.4","","1261.44","103.12","1514.10","21","396.91","620.66","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","759.50","569.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","610.64","80.4","","1365.00","1365.00","1365.00","1 through 10","396.91","620.66","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","759.50","569.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","620.66","81.72","","5157.68","5157.68","5157.68","1 through 10","396.91","620.66","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","759.50","569.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","620.66","81.72","","431.26","71.26","1459.57","88","396.91","620.66","percent of total billed charges",""
"SHEATH TOURGUIDE 7FR 9MM 55CM STEERABLE VASCULAR","SUP-ITM-10156224","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1532.93","71.8","","28.28","27.13","28.28","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH TOURGUIDE 7FR 9MM 55CM STEERABLE VASCULAR","SUP-ITM-10156224","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1494.50","70","","44.63","35.78","44.63","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH TOURGUIDE 7FR 9MM 55CM STEERABLE VASCULAR","SUP-ITM-10156224","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1697.33","79.5","","1342.89","271.64","6954.67","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH TOURGUIDE 7FR 9MM 55CM STEERABLE VASCULAR","SUP-ITM-10156224","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1137.96","53.3","","4550.00","30.49","4550.00","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH TOURGUIDE 7FR 9MM 55CM STEERABLE VASCULAR","SUP-ITM-10156224","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1387.75","65","","42.09","0.04","5453.50","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH TOURGUIDE 7FR 9MM 55CM STEERABLE VASCULAR","SUP-ITM-10156224","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","779.28","36.5","","310.94","18.54","1259.30","62","661.85","1697.33","percent of total billed charges",""
"SHEATH TOURGUIDE 7FR 9MM 55CM STEERABLE VASCULAR","SUP-ITM-10156224","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","817.71","38.3","","146.86","22.58","1753.45","65","661.85","1697.33","percent of total billed charges",""
"SHEATH TOURGUIDE 7FR 9MM 55CM STEERABLE VASCULAR","SUP-ITM-10156224","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","WELLPOINT [1015]","HB AMC WELLPOINT","1575.20","73.78","","247.29","33.09","909.09","53","661.85","1697.33","percent of total billed charges",""
"SHEATH TOURGUIDE 7FR 9MM 55CM STEERABLE VASCULAR","SUP-ITM-10156224","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","AETNA [1001]","HB AMC AETNA HMO","1490.23","69.8","","30.69","30.21","30.69","1 through 10","1115.75","1744.72","percent of total billed charges",""
"SHEATH TOURGUIDE 7FR 9MM 55CM STEERABLE VASCULAR","SUP-ITM-10156224","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1716.54","80.4","","82.69","82.69","82.69","1 through 10","1115.75","1744.72","percent of total billed charges",""
"SHEATH TOURGUIDE 7FR 9MM 55CM STEERABLE VASCULAR","SUP-ITM-10156224","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1744.72","81.72","","751.01","74.72","751.01","1 through 10","1115.75","1744.72","percent of total billed charges",""
"SHEATH TOURGUIDE 7FR 9MM 55CM STEERABLE VASCULAR","SUP-ITM-10156224","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1744.72","81.72","","328.92","46.17","2701.97","59","1115.75","1744.72","percent of total billed charges",""
"SHEATH TOURGUIDE 8.5FR 90CM 17MM STEERABLE","SUP-ITM-10213315","CDM","C1766","HCPCS","0272","RC","","","","both","","","2226.00","1669.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1163.31","52.26","","2815.54","2815.54","2815.54","1 through 10","690.06","1769.67","percent of total billed charges",""
"SHEATH TOURGUIDE 8.5FR 90CM 17MM STEERABLE","SUP-ITM-10213315","CDM","C1766","HCPCS","0272","RC","","","","both","","","2226.00","1669.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1769.67","79.5","","3771.60","3771.60","3771.60","1 through 10","690.06","1769.67","percent of total billed charges",""
"SHEATH TOURGUIDE 8.5FR 90CM 17MM STEERABLE","SUP-ITM-10213315","CDM","C1766","HCPCS","0272","RC","","","","both","","","2226.00","1669.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1446.90","65","","2161.25","2161.25","2161.25","1 through 10","690.06","1769.67","percent of total billed charges",""
"SHEATH TOURGUIDE 8.5FR 90CM 17MM STEERABLE","SUP-ITM-10213315","CDM","C1766","HCPCS","0272","RC","","","","both","","","2226.00","1669.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","812.49","36.5","","1697.15","370.76","3720.69","1 through 10","690.06","1769.67","percent of total billed charges",""
"SHEATH TOURGUIDE 8.5FR 90CM 17MM STEERABLE","SUP-ITM-10213315","CDM","C1766","HCPCS","0272","RC","","","","both","","","2226.00","1669.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","852.56","38.3","","1779.05","1263.50","3458.00","16","690.06","1769.67","percent of total billed charges",""
"SHEATH TOURGUIDE 8.5FR 90CM 17MM STEERABLE","SUP-ITM-10213315","CDM","C1766","HCPCS","0272","RC","","","","both","","","2226.00","1669.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","954.95","42.9","","1512.88","1512.88","1512.88","1 through 10","690.06","1769.67","percent of total billed charges",""
"SHEATH TOURGUIDE 8.5FR 90CM 17MM STEERABLE","SUP-ITM-10213315","CDM","C1766","HCPCS","0272","RC","","","","both","","","2226.00","1669.50","WELLPOINT [1015]","HB AMC WELLPOINT","1642.34","73.78","","3387.48","2475.46","3387.48","1 through 10","690.06","1769.67","percent of total billed charges",""
"SHEATH TOURGUIDE 8.5FR 90CM 17MM STEERABLE","SUP-ITM-10213315","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","2226.00","1669.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1163.31","52.26","","2815.54","2815.54","2815.54","1 through 10","1163.31","1819.09","percent of total billed charges",""
"SHEATH TOURGUIDE 8.5FR 90CM 17MM STEERABLE","SUP-ITM-10213315","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","2226.00","1669.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1819.09","81.72","","3637.27","2000.64","3637.27","1 through 10","1163.31","1819.09","percent of total billed charges",""
"SHEATH TOURGUIDE 8.5FR 90CM 17MM STEERABLE","SUP-ITM-10213315","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","2226.00","1669.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1819.09","81.72","","2658.01","2000.64","3637.27","17","1163.31","1819.09","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","584.12","438.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","464.38","79.5","","19.51","1.19","19.51","1 through 10","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","584.12","438.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","379.68","65","","0.94","0.94","0.94","1 through 10","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","584.12","438.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","213.20","36.5","","12.11","1.56","53.50","35","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","584.12","438.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","223.72","38.3","","1.65","0.56","14.07","55","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","584.12","438.09","WELLPOINT [1015]","HB AMC WELLPOINT","430.96","73.78","","24.17","1.07","130.81","14","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","584.12","438.09","AETNA [1001]","HB AMC AETNA HMO","407.72","69.8","","1.83","0.82","15.71","1 through 10","305.26","477.34","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","584.12","438.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","469.63","80.4","","0.72","0.72","0.72","1 through 10","305.26","477.34","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","584.12","438.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","477.34","81.72","","10.92","1.37","10.92","1 through 10","305.26","477.34","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","584.12","438.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","477.34","81.72","","19.84","1.15","26.27","14","305.26","477.34","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","both","","","467.35","350.51","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","244.24","52.26","","16.24","16.24","54.15","1 through 10","144.88","371.54","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","both","","","467.35","350.51","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","335.56","71.8","","86.33","32.67","86.33","1 through 10","144.88","371.54","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","both","","","467.35","350.51","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","327.15","70","","113.68","63.00","177.34","40","144.88","371.54","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","both","","","467.35","350.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","371.54","79.5","","50.70","21.76","168.00","12","144.88","371.54","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","both","","","467.35","350.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","249.10","53.3","","89.31","89.31","99.75","1 through 10","144.88","371.54","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","both","","","467.35","350.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","303.78","65","","94.41","17.06","2275.00","1 through 10","144.88","371.54","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","both","","","467.35","350.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","144.88","31","","35.13","35.13","35.13","1 through 10","144.88","371.54","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","both","","","467.35","350.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","170.58","36.5","","40.08","12.40","86.17","108","144.88","371.54","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","both","","","467.35","350.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","179.00","38.3","","33.25","10.27","68.43","169","144.88","371.54","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","both","","","467.35","350.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.49","42.9","","25.48","14.86","90.88","1 through 10","144.88","371.54","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","both","","","467.35","350.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.49","42.9","","90.88","90.88","90.88","1 through 10","144.88","371.54","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","both","","","467.35","350.51","WELLPOINT [1015]","HB AMC WELLPOINT","344.81","73.78","","84.63","19.55","140.02","123","144.88","371.54","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","467.35","350.51","AETNA [1001]","HB AMC AETNA HMO","326.21","69.8","","76.96","17.77","113.68","14","244.24","381.92","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","467.35","350.51","AETNA [1001]","HB AMC AETNA PPO","375.75","80.4","","57.31","57.31","57.31","1 through 10","244.24","381.92","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","467.35","350.51","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","244.24","52.26","","16.24","16.24","54.15","1 through 10","244.24","381.92","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","467.35","350.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","375.75","80.4","","68.25","68.25","87.50","1 through 10","244.24","381.92","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","467.35","350.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","381.92","81.72","","156.19","156.19","156.19","1 through 10","244.24","381.92","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","467.35","350.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","381.92","81.72","","82.70","12.06","98.97","13","244.24","381.92","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 46CM ACCESS UROPASS SS HYDROPHILIC COATING REINFORCED COLLAPSE RESISTANT BX/5EA","SUP-ITM-10149114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","467.35","350.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","381.92","81.72","","50.47","25.30","134.30","140","244.24","381.92","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","584.12","438.09","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","305.26","52.26","","16.24","16.24","54.15","1 through 10","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","584.12","438.09","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","419.40","71.8","","86.33","32.67","86.33","1 through 10","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","584.12","438.09","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","408.88","70","","113.68","63.00","177.34","40","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","584.12","438.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","464.38","79.5","","50.70","21.76","168.00","12","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","584.12","438.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","311.34","53.3","","89.31","89.31","99.75","1 through 10","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","584.12","438.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","379.68","65","","94.41","17.06","2275.00","1 through 10","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","584.12","438.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","181.08","31","","35.13","35.13","35.13","1 through 10","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","584.12","438.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","213.20","36.5","","40.08","12.40","86.17","108","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","584.12","438.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","223.72","38.3","","33.25","10.27","68.43","169","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","584.12","438.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.59","42.9","","25.48","14.86","90.88","1 through 10","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","584.12","438.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","250.59","42.9","","90.88","90.88","90.88","1 through 10","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","584.12","438.09","WELLPOINT [1015]","HB AMC WELLPOINT","430.96","73.78","","84.63","19.55","140.02","123","181.08","464.38","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","584.12","438.09","AETNA [1001]","HB AMC AETNA HMO","407.72","69.8","","76.96","17.77","113.68","14","305.26","477.34","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","584.12","438.09","AETNA [1001]","HB AMC AETNA PPO","469.63","80.4","","57.31","57.31","57.31","1 through 10","305.26","477.34","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","584.12","438.09","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","305.26","52.26","","16.24","16.24","54.15","1 through 10","305.26","477.34","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","584.12","438.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","469.63","80.4","","68.25","68.25","87.50","1 through 10","305.26","477.34","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","584.12","438.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","477.34","81.72","","156.19","156.19","156.19","1 through 10","305.26","477.34","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","584.12","438.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","477.34","81.72","","82.70","12.06","98.97","13","305.26","477.34","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","584.12","438.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","477.34","81.72","","50.47","25.30","134.30","140","305.26","477.34","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","both","","","114.45","85.84","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","59.81","52.26","","16.24","16.24","54.15","1 through 10","35.48","90.99","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","both","","","114.45","85.84","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","82.18","71.8","","86.33","32.67","86.33","1 through 10","35.48","90.99","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","both","","","114.45","85.84","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","80.12","70","","113.68","63.00","177.34","40","35.48","90.99","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","both","","","114.45","85.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","90.99","79.5","","50.70","21.76","168.00","12","35.48","90.99","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","both","","","114.45","85.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","61.00","53.3","","89.31","89.31","99.75","1 through 10","35.48","90.99","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","both","","","114.45","85.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","74.39","65","","94.41","17.06","2275.00","1 through 10","35.48","90.99","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","both","","","114.45","85.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","35.48","31","","35.13","35.13","35.13","1 through 10","35.48","90.99","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","both","","","114.45","85.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.77","36.5","","40.08","12.40","86.17","108","35.48","90.99","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","both","","","114.45","85.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.83","38.3","","33.25","10.27","68.43","169","35.48","90.99","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","both","","","114.45","85.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.10","42.9","","25.48","14.86","90.88","1 through 10","35.48","90.99","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","both","","","114.45","85.84","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.10","42.9","","90.88","90.88","90.88","1 through 10","35.48","90.99","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","both","","","114.45","85.84","WELLPOINT [1015]","HB AMC WELLPOINT","84.44","73.78","","84.63","19.55","140.02","123","35.48","90.99","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","114.45","85.84","AETNA [1001]","HB AMC AETNA HMO","79.89","69.8","","76.96","17.77","113.68","14","59.81","93.53","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","114.45","85.84","AETNA [1001]","HB AMC AETNA PPO","92.02","80.4","","57.31","57.31","57.31","1 through 10","59.81","93.53","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","114.45","85.84","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","59.81","52.26","","16.24","16.24","54.15","1 through 10","59.81","93.53","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","114.45","85.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","92.02","80.4","","68.25","68.25","87.50","1 through 10","59.81","93.53","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","114.45","85.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","93.53","81.72","","156.19","156.19","156.19","1 through 10","59.81","93.53","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","114.45","85.84","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","93.53","81.72","","82.70","12.06","98.97","13","59.81","93.53","percent of total billed charges",""
"SHEATH UROLOGICAL 30FR 30CM OPAQUE HYDROPHILIC RADIOPAQUE CONTINUOUS FLOW OBLIQUE BEAK OUTER W/OUT OBTURATOR","SUP-ITM-10049196","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","114.45","85.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.53","81.72","","50.47","25.30","134.30","140","59.81","93.53","percent of total billed charges",""
"SHEATH VASCULAR 6.5FR 55CM TOURGUIDE STEERABLE TG0655509","SUP-ITM-10156228","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1115.75","52.26","","2815.54","2815.54","2815.54","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 6.5FR 55CM TOURGUIDE STEERABLE TG0655509","SUP-ITM-10156228","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1697.33","79.5","","3771.60","3771.60","3771.60","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 6.5FR 55CM TOURGUIDE STEERABLE TG0655509","SUP-ITM-10156228","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1387.75","65","","2161.25","2161.25","2161.25","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 6.5FR 55CM TOURGUIDE STEERABLE TG0655509","SUP-ITM-10156228","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","779.28","36.5","","1697.15","370.76","3720.69","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 6.5FR 55CM TOURGUIDE STEERABLE TG0655509","SUP-ITM-10156228","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","817.71","38.3","","1779.05","1263.50","3458.00","16","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 6.5FR 55CM TOURGUIDE STEERABLE TG0655509","SUP-ITM-10156228","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","915.92","42.9","","1512.88","1512.88","1512.88","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 6.5FR 55CM TOURGUIDE STEERABLE TG0655509","SUP-ITM-10156228","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","WELLPOINT [1015]","HB AMC WELLPOINT","1575.20","73.78","","3387.48","2475.46","3387.48","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 6.5FR 55CM TOURGUIDE STEERABLE TG0655509","SUP-ITM-10156228","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1115.75","52.26","","2815.54","2815.54","2815.54","1 through 10","1115.75","1744.72","percent of total billed charges",""
"SHEATH VASCULAR 6.5FR 55CM TOURGUIDE STEERABLE TG0655509","SUP-ITM-10156228","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1744.72","81.72","","3637.27","2000.64","3637.27","1 through 10","1115.75","1744.72","percent of total billed charges",""
"SHEATH VASCULAR 6.5FR 55CM TOURGUIDE STEERABLE TG0655509","SUP-ITM-10156228","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1744.72","81.72","","2658.01","2000.64","3637.27","17","1115.75","1744.72","percent of total billed charges",""
"SHEATH VASCULAR 7FR 45CM TOURGUIDE STEERABLE","SUP-ITM-10156226","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1532.93","71.8","","28.28","27.13","28.28","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 7FR 45CM TOURGUIDE STEERABLE","SUP-ITM-10156226","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1494.50","70","","44.63","35.78","44.63","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 7FR 45CM TOURGUIDE STEERABLE","SUP-ITM-10156226","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1697.33","79.5","","1342.89","271.64","6954.67","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 7FR 45CM TOURGUIDE STEERABLE","SUP-ITM-10156226","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1137.96","53.3","","4550.00","30.49","4550.00","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 7FR 45CM TOURGUIDE STEERABLE","SUP-ITM-10156226","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1387.75","65","","42.09","0.04","5453.50","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 7FR 45CM TOURGUIDE STEERABLE","SUP-ITM-10156226","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","779.28","36.5","","310.94","18.54","1259.30","62","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 7FR 45CM TOURGUIDE STEERABLE","SUP-ITM-10156226","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","817.71","38.3","","146.86","22.58","1753.45","65","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 7FR 45CM TOURGUIDE STEERABLE","SUP-ITM-10156226","CDM","C1887","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","WELLPOINT [1015]","HB AMC WELLPOINT","1575.20","73.78","","247.29","33.09","909.09","53","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 7FR 45CM TOURGUIDE STEERABLE","SUP-ITM-10156226","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","AETNA [1001]","HB AMC AETNA HMO","1490.23","69.8","","30.69","30.21","30.69","1 through 10","1115.75","1744.72","percent of total billed charges",""
"SHEATH VASCULAR 7FR 45CM TOURGUIDE STEERABLE","SUP-ITM-10156226","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1716.54","80.4","","82.69","82.69","82.69","1 through 10","1115.75","1744.72","percent of total billed charges",""
"SHEATH VASCULAR 7FR 45CM TOURGUIDE STEERABLE","SUP-ITM-10156226","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1744.72","81.72","","751.01","74.72","751.01","1 through 10","1115.75","1744.72","percent of total billed charges",""
"SHEATH VASCULAR 7FR 45CM TOURGUIDE STEERABLE","SUP-ITM-10156226","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1744.72","81.72","","328.92","46.17","2701.97","59","1115.75","1744.72","percent of total billed charges",""
"SHEATH VASCULAR 8.5FR 17MMX55CM TOURGUIDE STEERABLE","SUP-ITM-10156221","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1115.75","52.26","","2815.54","2815.54","2815.54","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 8.5FR 17MMX55CM TOURGUIDE STEERABLE","SUP-ITM-10156221","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1697.33","79.5","","3771.60","3771.60","3771.60","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 8.5FR 17MMX55CM TOURGUIDE STEERABLE","SUP-ITM-10156221","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1387.75","65","","2161.25","2161.25","2161.25","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 8.5FR 17MMX55CM TOURGUIDE STEERABLE","SUP-ITM-10156221","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","779.28","36.5","","1697.15","370.76","3720.69","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 8.5FR 17MMX55CM TOURGUIDE STEERABLE","SUP-ITM-10156221","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","817.71","38.3","","1779.05","1263.50","3458.00","16","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 8.5FR 17MMX55CM TOURGUIDE STEERABLE","SUP-ITM-10156221","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","915.92","42.9","","1512.88","1512.88","1512.88","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 8.5FR 17MMX55CM TOURGUIDE STEERABLE","SUP-ITM-10156221","CDM","C1766","HCPCS","0272","RC","","","","both","","","2135.00","1601.25","WELLPOINT [1015]","HB AMC WELLPOINT","1575.20","73.78","","3387.48","2475.46","3387.48","1 through 10","661.85","1697.33","percent of total billed charges",""
"SHEATH VASCULAR 8.5FR 17MMX55CM TOURGUIDE STEERABLE","SUP-ITM-10156221","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1115.75","52.26","","2815.54","2815.54","2815.54","1 through 10","1115.75","1744.72","percent of total billed charges",""
"SHEATH VASCULAR 8.5FR 17MMX55CM TOURGUIDE STEERABLE","SUP-ITM-10156221","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1744.72","81.72","","3637.27","2000.64","3637.27","1 through 10","1115.75","1744.72","percent of total billed charges",""
"SHEATH VASCULAR 8.5FR 17MMX55CM TOURGUIDE STEERABLE","SUP-ITM-10156221","CDM","C1766","HCPCS","0272","RC","","","","outpatient","","","2135.00","1601.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1744.72","81.72","","2658.01","2000.64","3637.27","17","1115.75","1744.72","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","both","","","945.00","708.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","493.86","52.26","","16.24","16.24","54.15","1 through 10","292.95","751.28","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","both","","","945.00","708.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","678.51","71.8","","86.33","32.67","86.33","1 through 10","292.95","751.28","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","both","","","945.00","708.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","661.50","70","","113.68","63.00","177.34","40","292.95","751.28","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","both","","","945.00","708.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","751.28","79.5","","50.70","21.76","168.00","12","292.95","751.28","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","both","","","945.00","708.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","503.69","53.3","","89.31","89.31","99.75","1 through 10","292.95","751.28","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","614.25","65","","94.41","17.06","2275.00","1 through 10","292.95","751.28","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","292.95","31","","35.13","35.13","35.13","1 through 10","292.95","751.28","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","344.93","36.5","","40.08","12.40","86.17","108","292.95","751.28","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","361.94","38.3","","33.25","10.27","68.43","169","292.95","751.28","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","405.41","42.9","","25.48","14.86","90.88","1 through 10","292.95","751.28","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","405.41","42.9","","90.88","90.88","90.88","1 through 10","292.95","751.28","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","both","","","945.00","708.75","WELLPOINT [1015]","HB AMC WELLPOINT","697.22","73.78","","84.63","19.55","140.02","123","292.95","751.28","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","945.00","708.75","AETNA [1001]","HB AMC AETNA HMO","659.61","69.8","","76.96","17.77","113.68","14","493.86","772.25","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","945.00","708.75","AETNA [1001]","HB AMC AETNA PPO","759.78","80.4","","57.31","57.31","57.31","1 through 10","493.86","772.25","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","945.00","708.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","493.86","52.26","","16.24","16.24","54.15","1 through 10","493.86","772.25","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","759.78","80.4","","68.25","68.25","87.50","1 through 10","493.86","772.25","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","772.25","81.72","","156.19","156.19","156.19","1 through 10","493.86","772.25","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","772.25","81.72","","82.70","12.06","98.97","13","493.86","772.25","percent of total billed charges",""
"SHEATH VISISHEATH L 17.9FR 5.9MM .236IN 43CM DILATOR PC/1EA","SUP-ITM-10074355","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","772.25","81.72","","50.47","25.30","134.30","140","493.86","772.25","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","261.10","70","","311.32","311.32","311.32","1 through 10","26.86","354.35","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","296.54","79.5","","284.90","191.14","1216.69","147","26.86","354.35","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.81","53.3","","191.14","191.14","284.90","64","26.86","354.35","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","242.45","65","","470.60","470.60","470.60","1 through 10","26.86","354.35","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","115.63","31","","724.00","724.00","724.00","1 through 10","26.86","354.35","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","136.15","36.5","","135.03","114.76","182.32","136","26.86","354.35","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.86","38.3","","141.54","137.56","141.54","419","26.86","354.35","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","287.21","77","","2258.88","980.30","2258.88","1 through 10","26.86","354.35","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","TRICARE [160005]","HB BWH TRICARE","354.35","95","","42.28","40.17","42.28","13","26.86","354.35","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","both","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","42.9","","289.39","159.17","289.39","1 through 10","26.86","354.35","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA HMO","260.35","69.8","","245.08","173.04","282.36","77","26.86","304.82","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA PPO","299.89","80.4","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","208.51","55.9","","189.69","189.69","189.69","1 through 10","26.86","304.82","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","304.82","81.72","","1448.00","1448.00","1448.00","1 through 10","26.86","304.82","percent of total billed charges",""
"Shiga Toxin, Molecular Detection, Pcr, Feces","PX-30003655","CDM","87798","CPT","0306","RC","","","","outpatient","","","373.00","279.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","304.82","81.72","","289.38","159.17","289.39","201","26.86","304.82","percent of total billed charges",""
"SHOULDER 37X13.5MM LOW OFFSET AEQUALIS SPECIAL ORDER 04 NC","SUP-ITM-10136236","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1463.28","52.26","","1113.10","1113.10","1113.10","1 through 10","868","2226","percent of total billed charges",""
"SHOULDER 37X13.5MM LOW OFFSET AEQUALIS SPECIAL ORDER 04 NC","SUP-ITM-10136236","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","1293.60","1148.53","1603.80","1 through 10","868","2226","percent of total billed charges",""
"SHOULDER 37X13.5MM LOW OFFSET AEQUALIS SPECIAL ORDER 04 NC","SUP-ITM-10136236","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","1023.42","771.29","2068.67","33","868","2226","percent of total billed charges",""
"SHOULDER 37X13.5MM LOW OFFSET AEQUALIS SPECIAL ORDER 04 NC","SUP-ITM-10136236","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","850.52","759.78","1211.25","66","868","2226","percent of total billed charges",""
"SHOULDER 37X13.5MM LOW OFFSET AEQUALIS SPECIAL ORDER 04 NC","SUP-ITM-10136236","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","2548.09","2548.09","2548.09","1 through 10","868","2226","percent of total billed charges",""
"SHOULDER 37X13.5MM LOW OFFSET AEQUALIS SPECIAL ORDER 04 NC","SUP-ITM-10136236","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","956.46","956.46","956.46","1 through 10","868","2226","percent of total billed charges",""
"SHOULDER 37X13.5MM LOW OFFSET AEQUALIS SPECIAL ORDER 04 NC","SUP-ITM-10136236","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","2344.73","1619.47","2530.35","16","868","2226","percent of total billed charges",""
"SHOULDER 37X13.5MM LOW OFFSET AEQUALIS SPECIAL ORDER 04 NC","SUP-ITM-10136236","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA HMO","1954.40","69.8","","1523.63","988.41","4330.26","39","1463.28","2288.16","percent of total billed charges",""
"SHOULDER 37X13.5MM LOW OFFSET AEQUALIS SPECIAL ORDER 04 NC","SUP-ITM-10136236","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA PPO","2251.20","80.4","","1670.25","1670.25","1670.25","1 through 10","1463.28","2288.16","percent of total billed charges",""
"SHOULDER 37X13.5MM LOW OFFSET AEQUALIS SPECIAL ORDER 04 NC","SUP-ITM-10136236","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1463.28","52.26","","1113.10","1113.10","1113.10","1 through 10","1463.28","2288.16","percent of total billed charges",""
"SHOULDER 37X13.5MM LOW OFFSET AEQUALIS SPECIAL ORDER 04 NC","SUP-ITM-10136236","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","1738.90","1484.65","2716.94","38","1463.28","2288.16","percent of total billed charges",""
"SHOULDER 41X15MM AEQUALIS MODEL TITANIUM SPECIAL ORDER ONC 22","SUP-ITM-10123484","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3646.44","52.26","","1113.10","1113.10","1113.10","1 through 10","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 41X15MM AEQUALIS MODEL TITANIUM SPECIAL ORDER ONC 22","SUP-ITM-10123484","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5547.11","79.5","","1293.60","1148.53","1603.80","1 through 10","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 41X15MM AEQUALIS MODEL TITANIUM SPECIAL ORDER ONC 22","SUP-ITM-10123484","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2546.79","36.5","","1023.42","771.29","2068.67","33","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 41X15MM AEQUALIS MODEL TITANIUM SPECIAL ORDER ONC 22","SUP-ITM-10123484","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2672.38","38.3","","850.52","759.78","1211.25","66","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 41X15MM AEQUALIS MODEL TITANIUM SPECIAL ORDER ONC 22","SUP-ITM-10123484","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2993.35","42.9","","2548.09","2548.09","2548.09","1 through 10","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 41X15MM AEQUALIS MODEL TITANIUM SPECIAL ORDER ONC 22","SUP-ITM-10123484","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2993.35","42.9","","956.46","956.46","956.46","1 through 10","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 41X15MM AEQUALIS MODEL TITANIUM SPECIAL ORDER ONC 22","SUP-ITM-10123484","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","WELLPOINT [1015]","HB AMC WELLPOINT","5148.00","73.78","","2344.73","1619.47","2530.35","16","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 41X15MM AEQUALIS MODEL TITANIUM SPECIAL ORDER ONC 22","SUP-ITM-10123484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6977.50","5233.12","AETNA [1001]","HB AMC AETNA HMO","4870.30","69.8","","1523.63","988.41","4330.26","39","3646.44","5702.01","percent of total billed charges",""
"SHOULDER 41X15MM AEQUALIS MODEL TITANIUM SPECIAL ORDER ONC 22","SUP-ITM-10123484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6977.50","5233.12","AETNA [1001]","HB AMC AETNA PPO","5609.91","80.4","","1670.25","1670.25","1670.25","1 through 10","3646.44","5702.01","percent of total billed charges",""
"SHOULDER 41X15MM AEQUALIS MODEL TITANIUM SPECIAL ORDER ONC 22","SUP-ITM-10123484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6977.50","5233.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3646.44","52.26","","1113.10","1113.10","1113.10","1 through 10","3646.44","5702.01","percent of total billed charges",""
"SHOULDER 41X15MM AEQUALIS MODEL TITANIUM SPECIAL ORDER ONC 22","SUP-ITM-10123484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6977.50","5233.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5702.01","81.72","","1738.90","1484.65","2716.94","38","3646.44","5702.01","percent of total billed charges",""
"SHOULDER 43MMX16 AEQUALIS TITANIUM","SUP-ITM-10093967","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3646.44","52.26","","1113.10","1113.10","1113.10","1 through 10","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 43MMX16 AEQUALIS TITANIUM","SUP-ITM-10093967","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5547.11","79.5","","1293.60","1148.53","1603.80","1 through 10","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 43MMX16 AEQUALIS TITANIUM","SUP-ITM-10093967","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2546.79","36.5","","1023.42","771.29","2068.67","33","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 43MMX16 AEQUALIS TITANIUM","SUP-ITM-10093967","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2672.38","38.3","","850.52","759.78","1211.25","66","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 43MMX16 AEQUALIS TITANIUM","SUP-ITM-10093967","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2993.35","42.9","","2548.09","2548.09","2548.09","1 through 10","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 43MMX16 AEQUALIS TITANIUM","SUP-ITM-10093967","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2993.35","42.9","","956.46","956.46","956.46","1 through 10","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 43MMX16 AEQUALIS TITANIUM","SUP-ITM-10093967","CDM","C1776","HCPCS","0278","RC","","","","both","","","6977.50","5233.12","WELLPOINT [1015]","HB AMC WELLPOINT","5148.00","73.78","","2344.73","1619.47","2530.35","16","2163.03","5547.11","percent of total billed charges",""
"SHOULDER 43MMX16 AEQUALIS TITANIUM","SUP-ITM-10093967","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6977.50","5233.12","AETNA [1001]","HB AMC AETNA HMO","4870.30","69.8","","1523.63","988.41","4330.26","39","3646.44","5702.01","percent of total billed charges",""
"SHOULDER 43MMX16 AEQUALIS TITANIUM","SUP-ITM-10093967","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6977.50","5233.12","AETNA [1001]","HB AMC AETNA PPO","5609.91","80.4","","1670.25","1670.25","1670.25","1 through 10","3646.44","5702.01","percent of total billed charges",""
"SHOULDER 43MMX16 AEQUALIS TITANIUM","SUP-ITM-10093967","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6977.50","5233.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3646.44","52.26","","1113.10","1113.10","1113.10","1 through 10","3646.44","5702.01","percent of total billed charges",""
"SHOULDER 43MMX16 AEQUALIS TITANIUM","SUP-ITM-10093967","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6977.50","5233.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5702.01","81.72","","1738.90","1484.65","2716.94","38","3646.44","5702.01","percent of total billed charges",""
"SHOULDER 48MMX18 AEQUALIS COBALT ALLOY HYDROXYAPATITE","SUP-ITM-10024830","CDM","C1776","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","808.46","52.26","","1113.10","1113.10","1113.10","1 through 10","479.57","1229.87","percent of total billed charges",""
"SHOULDER 48MMX18 AEQUALIS COBALT ALLOY HYDROXYAPATITE","SUP-ITM-10024830","CDM","C1776","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1229.87","79.5","","1293.60","1148.53","1603.80","1 through 10","479.57","1229.87","percent of total billed charges",""
"SHOULDER 48MMX18 AEQUALIS COBALT ALLOY HYDROXYAPATITE","SUP-ITM-10024830","CDM","C1776","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","564.66","36.5","","1023.42","771.29","2068.67","33","479.57","1229.87","percent of total billed charges",""
"SHOULDER 48MMX18 AEQUALIS COBALT ALLOY HYDROXYAPATITE","SUP-ITM-10024830","CDM","C1776","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","592.50","38.3","","850.52","759.78","1211.25","66","479.57","1229.87","percent of total billed charges",""
"SHOULDER 48MMX18 AEQUALIS COBALT ALLOY HYDROXYAPATITE","SUP-ITM-10024830","CDM","C1776","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","663.66","42.9","","2548.09","2548.09","2548.09","1 through 10","479.57","1229.87","percent of total billed charges",""
"SHOULDER 48MMX18 AEQUALIS COBALT ALLOY HYDROXYAPATITE","SUP-ITM-10024830","CDM","C1776","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","663.66","42.9","","956.46","956.46","956.46","1 through 10","479.57","1229.87","percent of total billed charges",""
"SHOULDER 48MMX18 AEQUALIS COBALT ALLOY HYDROXYAPATITE","SUP-ITM-10024830","CDM","C1776","HCPCS","0278","RC","","","","both","","","1547.00","1160.25","WELLPOINT [1015]","HB AMC WELLPOINT","1141.38","73.78","","2344.73","1619.47","2530.35","16","479.57","1229.87","percent of total billed charges",""
"SHOULDER 48MMX18 AEQUALIS COBALT ALLOY HYDROXYAPATITE","SUP-ITM-10024830","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1547.00","1160.25","AETNA [1001]","HB AMC AETNA HMO","1079.81","69.8","","1523.63","988.41","4330.26","39","808.46","1264.21","percent of total billed charges",""
"SHOULDER 48MMX18 AEQUALIS COBALT ALLOY HYDROXYAPATITE","SUP-ITM-10024830","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1547.00","1160.25","AETNA [1001]","HB AMC AETNA PPO","1243.79","80.4","","1670.25","1670.25","1670.25","1 through 10","808.46","1264.21","percent of total billed charges",""
"SHOULDER 48MMX18 AEQUALIS COBALT ALLOY HYDROXYAPATITE","SUP-ITM-10024830","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1547.00","1160.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","808.46","52.26","","1113.10","1113.10","1113.10","1 through 10","808.46","1264.21","percent of total billed charges",""
"SHOULDER 48MMX18 AEQUALIS COBALT ALLOY HYDROXYAPATITE","SUP-ITM-10024830","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1547.00","1160.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1264.21","81.72","","1738.90","1484.65","2716.94","38","808.46","1264.21","percent of total billed charges",""
"SHOULDER 52X23MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1395","3577.5","percent of total billed charges",""
"SHOULDER 52X23MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1395","3577.5","percent of total billed charges",""
"SHOULDER 52X23MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","1023.42","771.29","2068.67","33","1395","3577.5","percent of total billed charges",""
"SHOULDER 52X23MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","850.52","759.78","1211.25","66","1395","3577.5","percent of total billed charges",""
"SHOULDER 52X23MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1395","3577.5","percent of total billed charges",""
"SHOULDER 52X23MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","956.46","956.46","956.46","1 through 10","1395","3577.5","percent of total billed charges",""
"SHOULDER 52X23MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","2344.73","1619.47","2530.35","16","1395","3577.5","percent of total billed charges",""
"SHOULDER 52X23MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136050","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","1523.63","988.41","4330.26","39","2351.7","3677.4","percent of total billed charges",""
"SHOULDER 52X23MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136050","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA PPO","3618.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SHOULDER 52X23MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136050","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SHOULDER 52X23MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136050","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","1738.90","1484.65","2716.94","38","2351.7","3677.4","percent of total billed charges",""
"SHOULDER ANCHOR SZ 48 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED GLENOID PE CEMENTED","SUP-ITM-10159259","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4272.26","52.26","","1113.10","1113.10","1113.10","1 through 10","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 48 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED GLENOID PE CEMENTED","SUP-ITM-10159259","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6499.13","79.5","","1293.60","1148.53","1603.80","1 through 10","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 48 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED GLENOID PE CEMENTED","SUP-ITM-10159259","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2983.88","36.5","","1023.42","771.29","2068.67","33","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 48 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED GLENOID PE CEMENTED","SUP-ITM-10159259","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3131.03","38.3","","850.52","759.78","1211.25","66","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 48 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED GLENOID PE CEMENTED","SUP-ITM-10159259","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3507.08","42.9","","2548.09","2548.09","2548.09","1 through 10","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 48 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED GLENOID PE CEMENTED","SUP-ITM-10159259","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3507.08","42.9","","956.46","956.46","956.46","1 through 10","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 48 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED GLENOID PE CEMENTED","SUP-ITM-10159259","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","WELLPOINT [1015]","HB AMC WELLPOINT","6031.52","73.78","","2344.73","1619.47","2530.35","16","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 48 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED GLENOID PE CEMENTED","SUP-ITM-10159259","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8175.00","6131.25","AETNA [1001]","HB AMC AETNA HMO","5706.15","69.8","","1523.63","988.41","4330.26","39","4272.26","6680.61","percent of total billed charges",""
"SHOULDER ANCHOR SZ 48 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED GLENOID PE CEMENTED","SUP-ITM-10159259","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8175.00","6131.25","AETNA [1001]","HB AMC AETNA PPO","6572.70","80.4","","1670.25","1670.25","1670.25","1 through 10","4272.26","6680.61","percent of total billed charges",""
"SHOULDER ANCHOR SZ 48 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED GLENOID PE CEMENTED","SUP-ITM-10159259","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8175.00","6131.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4272.26","52.26","","1113.10","1113.10","1113.10","1 through 10","4272.26","6680.61","percent of total billed charges",""
"SHOULDER ANCHOR SZ 48 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED GLENOID PE CEMENTED","SUP-ITM-10159259","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8175.00","6131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6680.61","81.72","","1738.90","1484.65","2716.94","38","4272.26","6680.61","percent of total billed charges",""
"SHOULDER ANCHOR SZ 52 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED PE CEMENTED","SUP-ITM-10152881","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4272.26","52.26","","1113.10","1113.10","1113.10","1 through 10","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 52 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED PE CEMENTED","SUP-ITM-10152881","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6499.13","79.5","","1293.60","1148.53","1603.80","1 through 10","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 52 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED PE CEMENTED","SUP-ITM-10152881","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2983.88","36.5","","1023.42","771.29","2068.67","33","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 52 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED PE CEMENTED","SUP-ITM-10152881","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3131.03","38.3","","850.52","759.78","1211.25","66","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 52 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED PE CEMENTED","SUP-ITM-10152881","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3507.08","42.9","","2548.09","2548.09","2548.09","1 through 10","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 52 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED PE CEMENTED","SUP-ITM-10152881","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3507.08","42.9","","956.46","956.46","956.46","1 through 10","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 52 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED PE CEMENTED","SUP-ITM-10152881","CDM","C1776","HCPCS","0278","RC","","","","both","","","8175.00","6131.25","WELLPOINT [1015]","HB AMC WELLPOINT","6031.52","73.78","","2344.73","1619.47","2530.35","16","2534.25","6499.13","percent of total billed charges",""
"SHOULDER ANCHOR SZ 52 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED PE CEMENTED","SUP-ITM-10152881","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8175.00","6131.25","AETNA [1001]","HB AMC AETNA HMO","5706.15","69.8","","1523.63","988.41","4330.26","39","4272.26","6680.61","percent of total billed charges",""
"SHOULDER ANCHOR SZ 52 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED PE CEMENTED","SUP-ITM-10152881","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8175.00","6131.25","AETNA [1001]","HB AMC AETNA PPO","6572.70","80.4","","1670.25","1670.25","1670.25","1 through 10","4272.26","6680.61","percent of total billed charges",""
"SHOULDER ANCHOR SZ 52 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED PE CEMENTED","SUP-ITM-10152881","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8175.00","6131.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4272.26","52.26","","1113.10","1113.10","1113.10","1 through 10","4272.26","6680.61","percent of total billed charges",""
"SHOULDER ANCHOR SZ 52 PLUS 3MM RT GLOBAL STEPTECH APG PREMIERONXLINKED PE CEMENTED","SUP-ITM-10152881","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8175.00","6131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6680.61","81.72","","1738.90","1484.65","2716.94","38","4272.26","6680.61","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2469.29","52.26","","1113.10","1113.10","1113.10","1 through 10","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3756.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1724.63","36.5","","1023.42","771.29","2068.67","33","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1809.68","38.3","","850.52","759.78","1211.25","66","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","2548.09","2548.09","2548.09","1 through 10","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","956.46","956.46","956.46","1 through 10","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","WELLPOINT [1015]","HB AMC WELLPOINT","3486.11","73.78","","2344.73","1619.47","2530.35","16","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA HMO","3298.05","69.8","","1523.63","988.41","4330.26","39","2469.29","3861.27","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA PPO","3798.90","80.4","","1670.25","1670.25","1670.25","1 through 10","2469.29","3861.27","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2469.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2469.29","3861.27","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3861.27","81.72","","1738.90","1484.65","2716.94","38","2469.29","3861.27","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275286","CDM","C1776","HCPCS","0278","RC","","","","both","","","5280.00","3960.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2759.33","52.26","","1113.10","1113.10","1113.10","1 through 10","1636.8","4197.6","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275286","CDM","C1776","HCPCS","0278","RC","","","","both","","","5280.00","3960.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4197.60","79.5","","1293.60","1148.53","1603.80","1 through 10","1636.8","4197.6","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275286","CDM","C1776","HCPCS","0278","RC","","","","both","","","5280.00","3960.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1927.20","36.5","","1023.42","771.29","2068.67","33","1636.8","4197.6","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275286","CDM","C1776","HCPCS","0278","RC","","","","both","","","5280.00","3960.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2022.24","38.3","","850.52","759.78","1211.25","66","1636.8","4197.6","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275286","CDM","C1776","HCPCS","0278","RC","","","","both","","","5280.00","3960.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2265.12","42.9","","2548.09","2548.09","2548.09","1 through 10","1636.8","4197.6","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275286","CDM","C1776","HCPCS","0278","RC","","","","both","","","5280.00","3960.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2265.12","42.9","","956.46","956.46","956.46","1 through 10","1636.8","4197.6","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275286","CDM","C1776","HCPCS","0278","RC","","","","both","","","5280.00","3960.00","WELLPOINT [1015]","HB AMC WELLPOINT","3895.58","73.78","","2344.73","1619.47","2530.35","16","1636.8","4197.6","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275286","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5280.00","3960.00","AETNA [1001]","HB AMC AETNA HMO","3685.44","69.8","","1523.63","988.41","4330.26","39","2759.33","4314.82","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275286","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5280.00","3960.00","AETNA [1001]","HB AMC AETNA PPO","4245.12","80.4","","1670.25","1670.25","1670.25","1 through 10","2759.33","4314.82","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275286","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5280.00","3960.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2759.33","52.26","","1113.10","1113.10","1113.10","1 through 10","2759.33","4314.82","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 20DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275286","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5280.00","3960.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4314.82","81.72","","1738.90","1484.65","2716.94","38","2759.33","4314.82","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2055.98","52.26","","1113.10","1113.10","1113.10","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3127.64","79.5","","1293.60","1148.53","1603.80","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1435.96","36.5","","1023.42","771.29","2068.67","33","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1506.78","38.3","","850.52","759.78","1211.25","66","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.75","42.9","","2548.09","2548.09","2548.09","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.75","42.9","","956.46","956.46","956.46","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","WELLPOINT [1015]","HB AMC WELLPOINT","2902.61","73.78","","2344.73","1619.47","2530.35","16","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","AETNA [1001]","HB AMC AETNA HMO","2746.03","69.8","","1523.63","988.41","4330.26","39","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","AETNA [1001]","HB AMC AETNA PPO","3163.05","80.4","","1670.25","1670.25","1670.25","1 through 10","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2055.98","52.26","","1113.10","1113.10","1113.10","1 through 10","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3214.98","81.72","","1738.90","1484.65","2716.94","38","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3527.55","52.26","","1113.10","1113.10","1113.10","1 through 10","2092.5","5366.25","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5366.25","79.5","","1293.60","1148.53","1603.80","1 through 10","2092.5","5366.25","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2463.75","36.5","","1023.42","771.29","2068.67","33","2092.5","5366.25","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2585.25","38.3","","850.52","759.78","1211.25","66","2092.5","5366.25","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2895.75","42.9","","2548.09","2548.09","2548.09","1 through 10","2092.5","5366.25","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2895.75","42.9","","956.46","956.46","956.46","1 through 10","2092.5","5366.25","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","WELLPOINT [1015]","HB AMC WELLPOINT","4980.15","73.78","","2344.73","1619.47","2530.35","16","2092.5","5366.25","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","AETNA [1001]","HB AMC AETNA HMO","4711.50","69.8","","1523.63","988.41","4330.26","39","3527.55","5516.1","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","AETNA [1001]","HB AMC AETNA PPO","5427.00","80.4","","1670.25","1670.25","1670.25","1 through 10","3527.55","5516.1","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3527.55","52.26","","1113.10","1113.10","1113.10","1 through 10","3527.55","5516.1","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5516.10","81.72","","1738.90","1484.65","2716.94","38","3527.55","5516.1","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2469.29","52.26","","1113.10","1113.10","1113.10","1 through 10","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3756.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1724.63","36.5","","1023.42","771.29","2068.67","33","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1809.68","38.3","","850.52","759.78","1211.25","66","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","2548.09","2548.09","2548.09","1 through 10","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","956.46","956.46","956.46","1 through 10","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","WELLPOINT [1015]","HB AMC WELLPOINT","3486.11","73.78","","2344.73","1619.47","2530.35","16","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA HMO","3298.05","69.8","","1523.63","988.41","4330.26","39","2469.29","3861.27","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA PPO","3798.90","80.4","","1670.25","1670.25","1670.25","1 through 10","2469.29","3861.27","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2469.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2469.29","3861.27","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3861.27","81.72","","1738.90","1484.65","2716.94","38","2469.29","3861.27","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2469.29","52.26","","1113.10","1113.10","1113.10","1 through 10","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3756.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1724.63","36.5","","1023.42","771.29","2068.67","33","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1809.68","38.3","","850.52","759.78","1211.25","66","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","2548.09","2548.09","2548.09","1 through 10","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","956.46","956.46","956.46","1 through 10","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","WELLPOINT [1015]","HB AMC WELLPOINT","3486.11","73.78","","2344.73","1619.47","2530.35","16","1464.75","3756.38","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA HMO","3298.05","69.8","","1523.63","988.41","4330.26","39","2469.29","3861.27","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA PPO","3798.90","80.4","","1670.25","1670.25","1670.25","1 through 10","2469.29","3861.27","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2469.29","52.26","","1113.10","1113.10","1113.10","1 through 10","2469.29","3861.27","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3861.27","81.72","","1738.90","1484.65","2716.94","38","2469.29","3861.27","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2116.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3219.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1478.25","36.5","","1023.42","771.29","2068.67","33","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1551.15","38.3","","850.52","759.78","1211.25","66","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1737.45","42.9","","2548.09","2548.09","2548.09","1 through 10","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1737.45","42.9","","956.46","956.46","956.46","1 through 10","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","WELLPOINT [1015]","HB AMC WELLPOINT","2988.09","73.78","","2344.73","1619.47","2530.35","16","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4050.00","3037.50","AETNA [1001]","HB AMC AETNA HMO","2826.90","69.8","","1523.63","988.41","4330.26","39","2116.53","3309.66","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4050.00","3037.50","AETNA [1001]","HB AMC AETNA PPO","3256.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2116.53","3309.66","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4050.00","3037.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2116.53","52.26","","1113.10","1113.10","1113.10","1 through 10","2116.53","3309.66","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4050.00","3037.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3309.66","81.72","","1738.90","1484.65","2716.94","38","2116.53","3309.66","percent of total billed charges",""
"SHOULDER BASEPLATE 28MMX105MM LOCKING","SUP-ITM-10311666","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2116.53","52.26","","1113.10","1113.10","1113.10","1 through 10","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MMX105MM LOCKING","SUP-ITM-10311666","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3219.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MMX105MM LOCKING","SUP-ITM-10311666","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1478.25","36.5","","1023.42","771.29","2068.67","33","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MMX105MM LOCKING","SUP-ITM-10311666","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1551.15","38.3","","850.52","759.78","1211.25","66","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MMX105MM LOCKING","SUP-ITM-10311666","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1737.45","42.9","","2548.09","2548.09","2548.09","1 through 10","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MMX105MM LOCKING","SUP-ITM-10311666","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1737.45","42.9","","956.46","956.46","956.46","1 through 10","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MMX105MM LOCKING","SUP-ITM-10311666","CDM","C1776","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","WELLPOINT [1015]","HB AMC WELLPOINT","2988.09","73.78","","2344.73","1619.47","2530.35","16","1255.5","3219.75","percent of total billed charges",""
"SHOULDER BASEPLATE 28MMX105MM LOCKING","SUP-ITM-10311666","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4050.00","3037.50","AETNA [1001]","HB AMC AETNA HMO","2826.90","69.8","","1523.63","988.41","4330.26","39","2116.53","3309.66","percent of total billed charges",""
"SHOULDER BASEPLATE 28MMX105MM LOCKING","SUP-ITM-10311666","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4050.00","3037.50","AETNA [1001]","HB AMC AETNA PPO","3256.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2116.53","3309.66","percent of total billed charges",""
"SHOULDER BASEPLATE 28MMX105MM LOCKING","SUP-ITM-10311666","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4050.00","3037.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2116.53","52.26","","1113.10","1113.10","1113.10","1 through 10","2116.53","3309.66","percent of total billed charges",""
"SHOULDER BASEPLATE 28MMX105MM LOCKING","SUP-ITM-10311666","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4050.00","3037.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3309.66","81.72","","1738.90","1484.65","2716.94","38","2116.53","3309.66","percent of total billed charges",""
"SHOULDER BASEPLATE 36MM 2.0 GLENOID HUMERAL AEQUALIS SPHERE ECCENTRIC PLUS","SUP-ITM-10082643","CDM","C1776","HCPCS","0278","RC","","","","both","","","6280.00","4710.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3281.93","52.26","","1113.10","1113.10","1113.10","1 through 10","1946.8","4992.6","percent of total billed charges",""
"SHOULDER BASEPLATE 36MM 2.0 GLENOID HUMERAL AEQUALIS SPHERE ECCENTRIC PLUS","SUP-ITM-10082643","CDM","C1776","HCPCS","0278","RC","","","","both","","","6280.00","4710.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4992.60","79.5","","1293.60","1148.53","1603.80","1 through 10","1946.8","4992.6","percent of total billed charges",""
"SHOULDER BASEPLATE 36MM 2.0 GLENOID HUMERAL AEQUALIS SPHERE ECCENTRIC PLUS","SUP-ITM-10082643","CDM","C1776","HCPCS","0278","RC","","","","both","","","6280.00","4710.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2292.20","36.5","","1023.42","771.29","2068.67","33","1946.8","4992.6","percent of total billed charges",""
"SHOULDER BASEPLATE 36MM 2.0 GLENOID HUMERAL AEQUALIS SPHERE ECCENTRIC PLUS","SUP-ITM-10082643","CDM","C1776","HCPCS","0278","RC","","","","both","","","6280.00","4710.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2405.24","38.3","","850.52","759.78","1211.25","66","1946.8","4992.6","percent of total billed charges",""
"SHOULDER BASEPLATE 36MM 2.0 GLENOID HUMERAL AEQUALIS SPHERE ECCENTRIC PLUS","SUP-ITM-10082643","CDM","C1776","HCPCS","0278","RC","","","","both","","","6280.00","4710.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2694.12","42.9","","2548.09","2548.09","2548.09","1 through 10","1946.8","4992.6","percent of total billed charges",""
"SHOULDER BASEPLATE 36MM 2.0 GLENOID HUMERAL AEQUALIS SPHERE ECCENTRIC PLUS","SUP-ITM-10082643","CDM","C1776","HCPCS","0278","RC","","","","both","","","6280.00","4710.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2694.12","42.9","","956.46","956.46","956.46","1 through 10","1946.8","4992.6","percent of total billed charges",""
"SHOULDER BASEPLATE 36MM 2.0 GLENOID HUMERAL AEQUALIS SPHERE ECCENTRIC PLUS","SUP-ITM-10082643","CDM","C1776","HCPCS","0278","RC","","","","both","","","6280.00","4710.00","WELLPOINT [1015]","HB AMC WELLPOINT","4633.38","73.78","","2344.73","1619.47","2530.35","16","1946.8","4992.6","percent of total billed charges",""
"SHOULDER BASEPLATE 36MM 2.0 GLENOID HUMERAL AEQUALIS SPHERE ECCENTRIC PLUS","SUP-ITM-10082643","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6280.00","4710.00","AETNA [1001]","HB AMC AETNA HMO","4383.44","69.8","","1523.63","988.41","4330.26","39","3281.93","5132.02","percent of total billed charges",""
"SHOULDER BASEPLATE 36MM 2.0 GLENOID HUMERAL AEQUALIS SPHERE ECCENTRIC PLUS","SUP-ITM-10082643","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6280.00","4710.00","AETNA [1001]","HB AMC AETNA PPO","5049.12","80.4","","1670.25","1670.25","1670.25","1 through 10","3281.93","5132.02","percent of total billed charges",""
"SHOULDER BASEPLATE 36MM 2.0 GLENOID HUMERAL AEQUALIS SPHERE ECCENTRIC PLUS","SUP-ITM-10082643","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6280.00","4710.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3281.93","52.26","","1113.10","1113.10","1113.10","1 through 10","3281.93","5132.02","percent of total billed charges",""
"SHOULDER BASEPLATE 36MM 2.0 GLENOID HUMERAL AEQUALIS SPHERE ECCENTRIC PLUS","SUP-ITM-10082643","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6280.00","4710.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5132.02","81.72","","1738.90","1484.65","2716.94","38","3281.93","5132.02","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2320.03","52.26","","1113.10","1113.10","1113.10","1 through 10","1376.21","3529.32","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3529.32","79.5","","1293.60","1148.53","1603.80","1 through 10","1376.21","3529.32","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1620.38","36.5","","1023.42","771.29","2068.67","33","1376.21","3529.32","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1700.29","38.3","","850.52","759.78","1211.25","66","1376.21","3529.32","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1904.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1376.21","3529.32","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1904.50","42.9","","956.46","956.46","956.46","1 through 10","1376.21","3529.32","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","4439.40","3329.55","WELLPOINT [1015]","HB AMC WELLPOINT","3275.39","73.78","","2344.73","1619.47","2530.35","16","1376.21","3529.32","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4439.40","3329.55","AETNA [1001]","HB AMC AETNA HMO","3098.70","69.8","","1523.63","988.41","4330.26","39","2320.03","3627.88","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4439.40","3329.55","AETNA [1001]","HB AMC AETNA PPO","3569.28","80.4","","1670.25","1670.25","1670.25","1 through 10","2320.03","3627.88","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4439.40","3329.55","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2320.03","52.26","","1113.10","1113.10","1113.10","1 through 10","2320.03","3627.88","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4439.40","3329.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3627.88","81.72","","1738.90","1484.65","2716.94","38","2320.03","3627.88","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II 10 TILTED SPHERE REVERSE 05","SUP-ITM-10123473","CDM","C1776","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1783.37","52.26","","1113.10","1113.10","1113.10","1 through 10","1057.88","2712.94","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II 10 TILTED SPHERE REVERSE 05","SUP-ITM-10123473","CDM","C1776","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2712.94","79.5","","1293.60","1148.53","1603.80","1 through 10","1057.88","2712.94","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II 10 TILTED SPHERE REVERSE 05","SUP-ITM-10123473","CDM","C1776","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1245.56","36.5","","1023.42","771.29","2068.67","33","1057.88","2712.94","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II 10 TILTED SPHERE REVERSE 05","SUP-ITM-10123473","CDM","C1776","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1306.99","38.3","","850.52","759.78","1211.25","66","1057.88","2712.94","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II 10 TILTED SPHERE REVERSE 05","SUP-ITM-10123473","CDM","C1776","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1463.96","42.9","","2548.09","2548.09","2548.09","1 through 10","1057.88","2712.94","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II 10 TILTED SPHERE REVERSE 05","SUP-ITM-10123473","CDM","C1776","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1463.96","42.9","","956.46","956.46","956.46","1 through 10","1057.88","2712.94","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II 10 TILTED SPHERE REVERSE 05","SUP-ITM-10123473","CDM","C1776","HCPCS","0278","RC","","","","both","","","3412.50","2559.37","WELLPOINT [1015]","HB AMC WELLPOINT","2517.74","73.78","","2344.73","1619.47","2530.35","16","1057.88","2712.94","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II 10 TILTED SPHERE REVERSE 05","SUP-ITM-10123473","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3412.50","2559.37","AETNA [1001]","HB AMC AETNA HMO","2381.93","69.8","","1523.63","988.41","4330.26","39","1783.37","2788.7","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II 10 TILTED SPHERE REVERSE 05","SUP-ITM-10123473","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3412.50","2559.37","AETNA [1001]","HB AMC AETNA PPO","2743.65","80.4","","1670.25","1670.25","1670.25","1 through 10","1783.37","2788.7","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II 10 TILTED SPHERE REVERSE 05","SUP-ITM-10123473","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3412.50","2559.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1783.37","52.26","","1113.10","1113.10","1113.10","1 through 10","1783.37","2788.7","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II 10 TILTED SPHERE REVERSE 05","SUP-ITM-10123473","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3412.50","2559.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2788.70","81.72","","1738.90","1484.65","2716.94","38","1783.37","2788.7","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II ECCENTRIC SPHERE + +2 REVERSE 05 NC","SUP-ITM-10123474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","5456.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3801.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2255.25","5783.63","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II ECCENTRIC SPHERE + +2 REVERSE 05 NC","SUP-ITM-10123474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","5456.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5783.63","79.5","","1293.60","1148.53","1603.80","1 through 10","2255.25","5783.63","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II ECCENTRIC SPHERE + +2 REVERSE 05 NC","SUP-ITM-10123474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","5456.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2655.38","36.5","","1023.42","771.29","2068.67","33","2255.25","5783.63","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II ECCENTRIC SPHERE + +2 REVERSE 05 NC","SUP-ITM-10123474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","5456.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2786.33","38.3","","850.52","759.78","1211.25","66","2255.25","5783.63","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II ECCENTRIC SPHERE + +2 REVERSE 05 NC","SUP-ITM-10123474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","5456.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3120.98","42.9","","2548.09","2548.09","2548.09","1 through 10","2255.25","5783.63","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II ECCENTRIC SPHERE + +2 REVERSE 05 NC","SUP-ITM-10123474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","5456.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3120.98","42.9","","956.46","956.46","956.46","1 through 10","2255.25","5783.63","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II ECCENTRIC SPHERE + +2 REVERSE 05 NC","SUP-ITM-10123474","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","5456.25","WELLPOINT [1015]","HB AMC WELLPOINT","5367.50","73.78","","2344.73","1619.47","2530.35","16","2255.25","5783.63","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II ECCENTRIC SPHERE + +2 REVERSE 05 NC","SUP-ITM-10123474","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","5456.25","AETNA [1001]","HB AMC AETNA HMO","5077.95","69.8","","1523.63","988.41","4330.26","39","3801.92","5945.13","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II ECCENTRIC SPHERE + +2 REVERSE 05 NC","SUP-ITM-10123474","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","5456.25","AETNA [1001]","HB AMC AETNA PPO","5849.10","80.4","","1670.25","1670.25","1670.25","1 through 10","3801.92","5945.13","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II ECCENTRIC SPHERE + +2 REVERSE 05 NC","SUP-ITM-10123474","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","5456.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3801.92","52.26","","1113.10","1113.10","1113.10","1 through 10","3801.92","5945.13","percent of total billed charges",""
"SHOULDER BASEPLATE DIAMETER 42MM 25 AEQUALIS REVERSED II ECCENTRIC SPHERE + +2 REVERSE 05 NC","SUP-ITM-10123474","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","5456.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5945.13","81.72","","1738.90","1484.65","2716.94","38","3801.92","5945.13","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2055.98","52.26","","1113.10","1113.10","1113.10","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3127.64","79.5","","1293.60","1148.53","1603.80","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1435.96","36.5","","1023.42","771.29","2068.67","33","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1506.78","38.3","","850.52","759.78","1211.25","66","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.75","42.9","","2548.09","2548.09","2548.09","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.75","42.9","","956.46","956.46","956.46","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","WELLPOINT [1015]","HB AMC WELLPOINT","2902.61","73.78","","2344.73","1619.47","2530.35","16","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","AETNA [1001]","HB AMC AETNA HMO","2746.03","69.8","","1523.63","988.41","4330.26","39","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","AETNA [1001]","HB AMC AETNA PPO","3163.05","80.4","","1670.25","1670.25","1670.25","1 through 10","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2055.98","52.26","","1113.10","1113.10","1113.10","1 through 10","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3214.98","81.72","","1738.90","1484.65","2716.94","38","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1193.5","3060.75","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1193.5","3060.75","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","1023.42","771.29","2068.67","33","1193.5","3060.75","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","850.52","759.78","1211.25","66","1193.5","3060.75","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","2548.09","2548.09","2548.09","1 through 10","1193.5","3060.75","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","956.46","956.46","956.46","1 through 10","1193.5","3060.75","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","2344.73","1619.47","2530.35","16","1193.5","3060.75","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA HMO","2687.30","69.8","","1523.63","988.41","4330.26","39","2012.01","3146.22","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA PPO","3095.40","80.4","","1670.25","1670.25","1670.25","1 through 10","2012.01","3146.22","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","2012.01","3146.22","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","1738.90","1484.65","2716.94","38","2012.01","3146.22","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3127.64","79.5","","800.18","480.96","1887.97","195","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2096.90","53.3","","813.12","216.42","1444.50","81","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1219.58","31","","432.60","432.60","432.60","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1435.96","36.5","","148.37","54.89","631.39","94","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1506.78","38.3","","279.30","91.72","1116.77","266","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.75","42.9","","731.00","63.70","731.00","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.75","42.9","","384.74","384.74","384.74","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","WELLPOINT [1015]","HB AMC WELLPOINT","2902.61","73.78","","286.63","119.22","1107.45","105","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","AETNA [1001]","HB AMC AETNA HMO","2746.03","69.8","","675.31","184.75","1721.50","286","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","AETNA [1001]","HB AMC AETNA PPO","3163.05","80.4","","1261.44","103.12","1514.10","21","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3163.05","80.4","","1365.00","1365.00","1365.00","1 through 10","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3214.98","81.72","","5157.68","5157.68","5157.68","1 through 10","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3214.98","81.72","","431.26","71.26","1459.57","88","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2055.98","52.26","","1113.10","1113.10","1113.10","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3127.64","79.5","","1293.60","1148.53","1603.80","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1435.96","36.5","","1023.42","771.29","2068.67","33","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1506.78","38.3","","850.52","759.78","1211.25","66","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.75","42.9","","2548.09","2548.09","2548.09","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.75","42.9","","956.46","956.46","956.46","1 through 10","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3934.14","2950.60","WELLPOINT [1015]","HB AMC WELLPOINT","2902.61","73.78","","2344.73","1619.47","2530.35","16","1219.58","3127.64","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","AETNA [1001]","HB AMC AETNA HMO","2746.03","69.8","","1523.63","988.41","4330.26","39","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","AETNA [1001]","HB AMC AETNA PPO","3163.05","80.4","","1670.25","1670.25","1670.25","1 through 10","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2055.98","52.26","","1113.10","1113.10","1113.10","1 through 10","2055.98","3214.98","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3934.14","2950.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3214.98","81.72","","1738.90","1484.65","2716.94","38","2055.98","3214.98","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","5392.80","4044.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2818.28","52.26","","1113.10","1113.10","1113.10","1 through 10","1671.77","4287.28","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","5392.80","4044.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4287.28","79.5","","1293.60","1148.53","1603.80","1 through 10","1671.77","4287.28","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","5392.80","4044.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1968.37","36.5","","1023.42","771.29","2068.67","33","1671.77","4287.28","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","5392.80","4044.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2065.44","38.3","","850.52","759.78","1211.25","66","1671.77","4287.28","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","5392.80","4044.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2313.51","42.9","","2548.09","2548.09","2548.09","1 through 10","1671.77","4287.28","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","5392.80","4044.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2313.51","42.9","","956.46","956.46","956.46","1 through 10","1671.77","4287.28","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","5392.80","4044.60","WELLPOINT [1015]","HB AMC WELLPOINT","3978.81","73.78","","2344.73","1619.47","2530.35","16","1671.77","4287.28","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5392.80","4044.60","AETNA [1001]","HB AMC AETNA HMO","3764.17","69.8","","1523.63","988.41","4330.26","39","2818.28","4407","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5392.80","4044.60","AETNA [1001]","HB AMC AETNA PPO","4335.81","80.4","","1670.25","1670.25","1670.25","1 through 10","2818.28","4407","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5392.80","4044.60","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2818.28","52.26","","1113.10","1113.10","1113.10","1 through 10","2818.28","4407","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5392.80","4044.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4407.00","81.72","","1738.90","1484.65","2716.94","38","2818.28","4407","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2209.55","52.26","","1113.10","1113.10","1113.10","1 through 10","1310.68","3361.26","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3361.26","79.5","","1293.60","1148.53","1603.80","1 through 10","1310.68","3361.26","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1543.22","36.5","","1023.42","771.29","2068.67","33","1310.68","3361.26","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1619.32","38.3","","850.52","759.78","1211.25","66","1310.68","3361.26","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.81","42.9","","2548.09","2548.09","2548.09","1 through 10","1310.68","3361.26","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.81","42.9","","956.46","956.46","956.46","1 through 10","1310.68","3361.26","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","WELLPOINT [1015]","HB AMC WELLPOINT","3119.42","73.78","","2344.73","1619.47","2530.35","16","1310.68","3361.26","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","AETNA [1001]","HB AMC AETNA HMO","2951.14","69.8","","1523.63","988.41","4330.26","39","2209.55","3455.12","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","AETNA [1001]","HB AMC AETNA PPO","3399.31","80.4","","1670.25","1670.25","1670.25","1 through 10","2209.55","3455.12","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2209.55","52.26","","1113.10","1113.10","1113.10","1 through 10","2209.55","3455.12","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3455.12","81.72","","1738.90","1484.65","2716.94","38","2209.55","3455.12","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","1113.10","1113.10","1113.10","1 through 10","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","1293.60","1148.53","1603.80","1 through 10","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","1023.42","771.29","2068.67","33","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","850.52","759.78","1211.25","66","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","2548.09","2548.09","2548.09","1 through 10","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","956.46","956.46","956.46","1 through 10","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","2344.73","1619.47","2530.35","16","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","1523.63","988.41","4330.26","39","914.55","1430.1","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1670.25","1670.25","1670.25","1 through 10","914.55","1430.1","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","1113.10","1113.10","1113.10","1 through 10","914.55","1430.1","percent of total billed charges",""
"SHOULDER COMPONENT 40MM GLENOID AFFINITI","SUP-ITM-10100512","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","1738.90","1484.65","2716.94","38","914.55","1430.1","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","1113.10","1113.10","1113.10","1 through 10","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","1293.60","1148.53","1603.80","1 through 10","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","1023.42","771.29","2068.67","33","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","850.52","759.78","1211.25","66","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","2548.09","2548.09","2548.09","1 through 10","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","956.46","956.46","956.46","1 through 10","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","2344.73","1619.47","2530.35","16","542.5","1391.25","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","1523.63","988.41","4330.26","39","914.55","1430.1","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1670.25","1670.25","1670.25","1 through 10","914.55","1430.1","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","914.55","52.26","","1113.10","1113.10","1113.10","1 through 10","914.55","1430.1","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","1738.90","1484.65","2716.94","38","914.55","1430.1","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1384.63","52.26","","1113.10","1113.10","1113.10","1 through 10","821.35","2106.35","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2106.35","79.5","","1293.60","1148.53","1603.80","1 through 10","821.35","2106.35","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","967.07","36.5","","1023.42","771.29","2068.67","33","821.35","2106.35","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1014.76","38.3","","850.52","759.78","1211.25","66","821.35","2106.35","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1136.64","42.9","","2548.09","2548.09","2548.09","1 through 10","821.35","2106.35","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1136.64","42.9","","956.46","956.46","956.46","1 through 10","821.35","2106.35","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2649.50","1987.12","WELLPOINT [1015]","HB AMC WELLPOINT","1954.80","73.78","","2344.73","1619.47","2530.35","16","821.35","2106.35","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2649.50","1987.12","AETNA [1001]","HB AMC AETNA HMO","1849.35","69.8","","1523.63","988.41","4330.26","39","1384.63","2165.17","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2649.50","1987.12","AETNA [1001]","HB AMC AETNA PPO","2130.20","80.4","","1670.25","1670.25","1670.25","1 through 10","1384.63","2165.17","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2649.50","1987.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1384.63","52.26","","1113.10","1113.10","1113.10","1 through 10","1384.63","2165.17","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2649.50","1987.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2165.17","81.72","","1738.90","1484.65","2716.94","38","1384.63","2165.17","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9.15","52.26","","1113.10","1113.10","1113.10","1 through 10","5.43","13.91","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13.91","79.5","","1293.60","1148.53","1603.80","1 through 10","5.43","13.91","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6.39","36.5","","1023.42","771.29","2068.67","33","5.43","13.91","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6.70","38.3","","850.52","759.78","1211.25","66","5.43","13.91","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7.51","42.9","","2548.09","2548.09","2548.09","1 through 10","5.43","13.91","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7.51","42.9","","956.46","956.46","956.46","1 through 10","5.43","13.91","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","both","","","17.50","13.12","WELLPOINT [1015]","HB AMC WELLPOINT","12.91","73.78","","2344.73","1619.47","2530.35","16","5.43","13.91","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17.50","13.12","AETNA [1001]","HB AMC AETNA HMO","12.22","69.8","","1523.63","988.41","4330.26","39","9.15","14.3","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17.50","13.12","AETNA [1001]","HB AMC AETNA PPO","14.07","80.4","","1670.25","1670.25","1670.25","1 through 10","9.15","14.3","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17.50","13.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","9.15","52.26","","1113.10","1113.10","1113.10","1 through 10","9.15","14.3","percent of total billed charges",""
"SHOULDER COMPONENT GLENOID","SUP-ITM-10174754","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17.50","13.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14.30","81.72","","1738.90","1484.65","2716.94","38","9.15","14.3","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2531.84","52.26","","1113.10","1113.10","1113.10","1 through 10","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3851.54","79.5","","1293.60","1148.53","1603.80","1 through 10","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1768.32","36.5","","1023.42","771.29","2068.67","33","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1855.52","38.3","","850.52","759.78","1211.25","66","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2078.38","42.9","","2548.09","2548.09","2548.09","1 through 10","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2078.38","42.9","","956.46","956.46","956.46","1 through 10","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","WELLPOINT [1015]","HB AMC WELLPOINT","3574.42","73.78","","2344.73","1619.47","2530.35","16","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4844.70","3633.52","AETNA [1001]","HB AMC AETNA HMO","3381.60","69.8","","1523.63","988.41","4330.26","39","2531.84","3959.09","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4844.70","3633.52","AETNA [1001]","HB AMC AETNA PPO","3895.14","80.4","","1670.25","1670.25","1670.25","1 through 10","2531.84","3959.09","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4844.70","3633.52","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2531.84","52.26","","1113.10","1113.10","1113.10","1 through 10","2531.84","3959.09","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4844.70","3633.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3959.09","81.72","","1738.90","1484.65","2716.94","38","2531.84","3959.09","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2140.05","52.26","","1113.10","1113.10","1113.10","1 through 10","1269.45","3255.53","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3255.53","79.5","","1293.60","1148.53","1603.80","1 through 10","1269.45","3255.53","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1494.68","36.5","","1023.42","771.29","2068.67","33","1269.45","3255.53","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1568.39","38.3","","850.52","759.78","1211.25","66","1269.45","3255.53","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1756.76","42.9","","2548.09","2548.09","2548.09","1 through 10","1269.45","3255.53","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1756.76","42.9","","956.46","956.46","956.46","1 through 10","1269.45","3255.53","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","4095.00","3071.25","WELLPOINT [1015]","HB AMC WELLPOINT","3021.29","73.78","","2344.73","1619.47","2530.35","16","1269.45","3255.53","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4095.00","3071.25","AETNA [1001]","HB AMC AETNA HMO","2858.31","69.8","","1523.63","988.41","4330.26","39","2140.05","3346.43","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4095.00","3071.25","AETNA [1001]","HB AMC AETNA PPO","3292.38","80.4","","1670.25","1670.25","1670.25","1 through 10","2140.05","3346.43","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4095.00","3071.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2140.05","52.26","","1113.10","1113.10","1113.10","1 through 10","2140.05","3346.43","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4095.00","3071.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3346.43","81.72","","1738.90","1484.65","2716.94","38","2140.05","3346.43","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3608.50","2706.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1885.80","52.26","","1113.10","1113.10","1113.10","1 through 10","1118.64","2868.76","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3608.50","2706.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2868.76","79.5","","1293.60","1148.53","1603.80","1 through 10","1118.64","2868.76","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3608.50","2706.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1317.10","36.5","","1023.42","771.29","2068.67","33","1118.64","2868.76","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3608.50","2706.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1382.06","38.3","","850.52","759.78","1211.25","66","1118.64","2868.76","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3608.50","2706.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1548.05","42.9","","2548.09","2548.09","2548.09","1 through 10","1118.64","2868.76","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3608.50","2706.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1548.05","42.9","","956.46","956.46","956.46","1 through 10","1118.64","2868.76","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3608.50","2706.37","WELLPOINT [1015]","HB AMC WELLPOINT","2662.35","73.78","","2344.73","1619.47","2530.35","16","1118.64","2868.76","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3608.50","2706.37","AETNA [1001]","HB AMC AETNA HMO","2518.73","69.8","","1523.63","988.41","4330.26","39","1885.8","2948.87","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3608.50","2706.37","AETNA [1001]","HB AMC AETNA PPO","2901.23","80.4","","1670.25","1670.25","1670.25","1 through 10","1885.8","2948.87","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3608.50","2706.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1885.80","52.26","","1113.10","1113.10","1113.10","1 through 10","1885.8","2948.87","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3608.50","2706.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2948.87","81.72","","1738.90","1484.65","2716.94","38","1885.8","2948.87","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2531.84","52.26","","1113.10","1113.10","1113.10","1 through 10","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3851.54","79.5","","1293.60","1148.53","1603.80","1 through 10","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1768.32","36.5","","1023.42","771.29","2068.67","33","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1855.52","38.3","","850.52","759.78","1211.25","66","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2078.38","42.9","","2548.09","2548.09","2548.09","1 through 10","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2078.38","42.9","","956.46","956.46","956.46","1 through 10","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4844.70","3633.52","WELLPOINT [1015]","HB AMC WELLPOINT","3574.42","73.78","","2344.73","1619.47","2530.35","16","1501.86","3851.54","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4844.70","3633.52","AETNA [1001]","HB AMC AETNA HMO","3381.60","69.8","","1523.63","988.41","4330.26","39","2531.84","3959.09","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4844.70","3633.52","AETNA [1001]","HB AMC AETNA PPO","3895.14","80.4","","1670.25","1670.25","1670.25","1 through 10","2531.84","3959.09","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4844.70","3633.52","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2531.84","52.26","","1113.10","1113.10","1113.10","1 through 10","2531.84","3959.09","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4844.70","3633.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3959.09","81.72","","1738.90","1484.65","2716.94","38","2531.84","3959.09","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","4094.72","3071.04","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2139.90","52.26","","1113.10","1113.10","1113.10","1 through 10","1269.36","3255.3","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","4094.72","3071.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3255.30","79.5","","1293.60","1148.53","1603.80","1 through 10","1269.36","3255.3","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","4094.72","3071.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1494.57","36.5","","1023.42","771.29","2068.67","33","1269.36","3255.3","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","4094.72","3071.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1568.28","38.3","","850.52","759.78","1211.25","66","1269.36","3255.3","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","4094.72","3071.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1756.63","42.9","","2548.09","2548.09","2548.09","1 through 10","1269.36","3255.3","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","4094.72","3071.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1756.63","42.9","","956.46","956.46","956.46","1 through 10","1269.36","3255.3","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","4094.72","3071.04","WELLPOINT [1015]","HB AMC WELLPOINT","3021.08","73.78","","2344.73","1619.47","2530.35","16","1269.36","3255.3","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4094.72","3071.04","AETNA [1001]","HB AMC AETNA HMO","2858.11","69.8","","1523.63","988.41","4330.26","39","2139.9","3346.21","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4094.72","3071.04","AETNA [1001]","HB AMC AETNA PPO","3292.15","80.4","","1670.25","1670.25","1670.25","1 through 10","2139.9","3346.21","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4094.72","3071.04","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2139.90","52.26","","1113.10","1113.10","1113.10","1 through 10","2139.9","3346.21","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4094.72","3071.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3346.21","81.72","","1738.90","1484.65","2716.94","38","2139.9","3346.21","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2157.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1280.02","3282.64","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3282.64","79.5","","1293.60","1148.53","1603.80","1 through 10","1280.02","3282.64","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1507.13","36.5","","1023.42","771.29","2068.67","33","1280.02","3282.64","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1581.45","38.3","","850.52","759.78","1211.25","66","1280.02","3282.64","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1771.39","42.9","","2548.09","2548.09","2548.09","1 through 10","1280.02","3282.64","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1771.39","42.9","","956.46","956.46","956.46","1 through 10","1280.02","3282.64","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","WELLPOINT [1015]","HB AMC WELLPOINT","3046.46","73.78","","2344.73","1619.47","2530.35","16","1280.02","3282.64","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4129.11","3096.83","AETNA [1001]","HB AMC AETNA HMO","2882.12","69.8","","1523.63","988.41","4330.26","39","2157.87","3374.31","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4129.11","3096.83","AETNA [1001]","HB AMC AETNA PPO","3319.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2157.87","3374.31","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4129.11","3096.83","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2157.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2157.87","3374.31","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4129.11","3096.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3374.31","81.72","","1738.90","1484.65","2716.94","38","2157.87","3374.31","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2077.34","52.26","","1113.10","1113.10","1113.10","1 through 10","1232.25","3160.13","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3160.13","79.5","","1293.60","1148.53","1603.80","1 through 10","1232.25","3160.13","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1450.88","36.5","","1023.42","771.29","2068.67","33","1232.25","3160.13","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1522.43","38.3","","850.52","759.78","1211.25","66","1232.25","3160.13","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1705.28","42.9","","2548.09","2548.09","2548.09","1 through 10","1232.25","3160.13","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1705.28","42.9","","956.46","956.46","956.46","1 through 10","1232.25","3160.13","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","WELLPOINT [1015]","HB AMC WELLPOINT","2932.76","73.78","","2344.73","1619.47","2530.35","16","1232.25","3160.13","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3975.00","2981.25","AETNA [1001]","HB AMC AETNA HMO","2774.55","69.8","","1523.63","988.41","4330.26","39","2077.34","3248.37","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3975.00","2981.25","AETNA [1001]","HB AMC AETNA PPO","3195.90","80.4","","1670.25","1670.25","1670.25","1 through 10","2077.34","3248.37","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3975.00","2981.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2077.34","52.26","","1113.10","1113.10","1113.10","1 through 10","2077.34","3248.37","percent of total billed charges",""
"SHOULDER HEAD 1.0X19 20MM IMPLANT ARTICULAR GLENOID 58/55 REVERSE 05","SUP-ITM-10094382","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3975.00","2981.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3248.37","81.72","","1738.90","1484.65","2716.94","38","2077.34","3248.37","percent of total billed charges",""
"SHOULDER HEAD 35X7 8MM COMPONENT HEMICAP ARTICULAR HUMERAL","SUP-ITM-10028006","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4246.13","52.26","","1113.10","1113.10","1113.10","1 through 10","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 35X7 8MM COMPONENT HEMICAP ARTICULAR HUMERAL","SUP-ITM-10028006","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6459.38","79.5","","1293.60","1148.53","1603.80","1 through 10","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 35X7 8MM COMPONENT HEMICAP ARTICULAR HUMERAL","SUP-ITM-10028006","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2965.63","36.5","","1023.42","771.29","2068.67","33","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 35X7 8MM COMPONENT HEMICAP ARTICULAR HUMERAL","SUP-ITM-10028006","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3111.88","38.3","","850.52","759.78","1211.25","66","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 35X7 8MM COMPONENT HEMICAP ARTICULAR HUMERAL","SUP-ITM-10028006","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3485.63","42.9","","2548.09","2548.09","2548.09","1 through 10","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 35X7 8MM COMPONENT HEMICAP ARTICULAR HUMERAL","SUP-ITM-10028006","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3485.63","42.9","","956.46","956.46","956.46","1 through 10","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 35X7 8MM COMPONENT HEMICAP ARTICULAR HUMERAL","SUP-ITM-10028006","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","WELLPOINT [1015]","HB AMC WELLPOINT","5994.63","73.78","","2344.73","1619.47","2530.35","16","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 35X7 8MM COMPONENT HEMICAP ARTICULAR HUMERAL","SUP-ITM-10028006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","AETNA [1001]","HB AMC AETNA HMO","5671.25","69.8","","1523.63","988.41","4330.26","39","4246.13","6639.75","percent of total billed charges",""
"SHOULDER HEAD 35X7 8MM COMPONENT HEMICAP ARTICULAR HUMERAL","SUP-ITM-10028006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","AETNA [1001]","HB AMC AETNA PPO","6532.50","80.4","","1670.25","1670.25","1670.25","1 through 10","4246.13","6639.75","percent of total billed charges",""
"SHOULDER HEAD 35X7 8MM COMPONENT HEMICAP ARTICULAR HUMERAL","SUP-ITM-10028006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4246.13","52.26","","1113.10","1113.10","1113.10","1 through 10","4246.13","6639.75","percent of total billed charges",""
"SHOULDER HEAD 35X7 8MM COMPONENT HEMICAP ARTICULAR HUMERAL","SUP-ITM-10028006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6639.75","81.72","","1738.90","1484.65","2716.94","38","4246.13","6639.75","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2157.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1280.02","3282.64","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3282.64","79.5","","1293.60","1148.53","1603.80","1 through 10","1280.02","3282.64","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1507.13","36.5","","1023.42","771.29","2068.67","33","1280.02","3282.64","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1581.45","38.3","","850.52","759.78","1211.25","66","1280.02","3282.64","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1771.39","42.9","","2548.09","2548.09","2548.09","1 through 10","1280.02","3282.64","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1771.39","42.9","","956.46","956.46","956.46","1 through 10","1280.02","3282.64","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4129.11","3096.83","WELLPOINT [1015]","HB AMC WELLPOINT","3046.46","73.78","","2344.73","1619.47","2530.35","16","1280.02","3282.64","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4129.11","3096.83","AETNA [1001]","HB AMC AETNA HMO","2882.12","69.8","","1523.63","988.41","4330.26","39","2157.87","3374.31","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4129.11","3096.83","AETNA [1001]","HB AMC AETNA PPO","3319.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2157.87","3374.31","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4129.11","3096.83","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2157.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2157.87","3374.31","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4129.11","3096.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3374.31","81.72","","1738.90","1484.65","2716.94","38","2157.87","3374.31","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3713.07","52.26","","1113.10","1113.10","1113.10","1 through 10","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5648.48","79.5","","1293.60","1148.53","1603.80","1 through 10","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2593.33","36.5","","1023.42","771.29","2068.67","33","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2721.22","38.3","","850.52","759.78","1211.25","66","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3048.05","42.9","","2548.09","2548.09","2548.09","1 through 10","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3048.05","42.9","","956.46","956.46","956.46","1 through 10","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","WELLPOINT [1015]","HB AMC WELLPOINT","5242.07","73.78","","2344.73","1619.47","2530.35","16","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7105.00","5328.75","AETNA [1001]","HB AMC AETNA HMO","4959.29","69.8","","1523.63","988.41","4330.26","39","3713.07","5806.21","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7105.00","5328.75","AETNA [1001]","HB AMC AETNA PPO","5712.42","80.4","","1670.25","1670.25","1670.25","1 through 10","3713.07","5806.21","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7105.00","5328.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3713.07","52.26","","1113.10","1113.10","1113.10","1 through 10","3713.07","5806.21","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7105.00","5328.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5806.21","81.72","","1738.90","1484.65","2716.94","38","3713.07","5806.21","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3713.07","52.26","","1113.10","1113.10","1113.10","1 through 10","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5648.48","79.5","","1293.60","1148.53","1603.80","1 through 10","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2593.33","36.5","","1023.42","771.29","2068.67","33","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2721.22","38.3","","850.52","759.78","1211.25","66","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3048.05","42.9","","2548.09","2548.09","2548.09","1 through 10","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3048.05","42.9","","956.46","956.46","956.46","1 through 10","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","7105.00","5328.75","WELLPOINT [1015]","HB AMC WELLPOINT","5242.07","73.78","","2344.73","1619.47","2530.35","16","2202.55","5648.48","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7105.00","5328.75","AETNA [1001]","HB AMC AETNA HMO","4959.29","69.8","","1523.63","988.41","4330.26","39","3713.07","5806.21","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7105.00","5328.75","AETNA [1001]","HB AMC AETNA PPO","5712.42","80.4","","1670.25","1670.25","1670.25","1 through 10","3713.07","5806.21","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7105.00","5328.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3713.07","52.26","","1113.10","1113.10","1113.10","1 through 10","3713.07","5806.21","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7105.00","5328.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5806.21","81.72","","1738.90","1484.65","2716.94","38","3713.07","5806.21","percent of total billed charges",""
"SHOULDER HEAD 50X24 52MM MODULAR OFFSET 04","SUP-ITM-10100161","CDM","C1776","HCPCS","0278","RC","","","","both","","","1911.00","1433.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","998.69","52.26","","1113.10","1113.10","1113.10","1 through 10","592.41","1519.25","percent of total billed charges",""
"SHOULDER HEAD 50X24 52MM MODULAR OFFSET 04","SUP-ITM-10100161","CDM","C1776","HCPCS","0278","RC","","","","both","","","1911.00","1433.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1519.25","79.5","","1293.60","1148.53","1603.80","1 through 10","592.41","1519.25","percent of total billed charges",""
"SHOULDER HEAD 50X24 52MM MODULAR OFFSET 04","SUP-ITM-10100161","CDM","C1776","HCPCS","0278","RC","","","","both","","","1911.00","1433.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","697.52","36.5","","1023.42","771.29","2068.67","33","592.41","1519.25","percent of total billed charges",""
"SHOULDER HEAD 50X24 52MM MODULAR OFFSET 04","SUP-ITM-10100161","CDM","C1776","HCPCS","0278","RC","","","","both","","","1911.00","1433.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","731.91","38.3","","850.52","759.78","1211.25","66","592.41","1519.25","percent of total billed charges",""
"SHOULDER HEAD 50X24 52MM MODULAR OFFSET 04","SUP-ITM-10100161","CDM","C1776","HCPCS","0278","RC","","","","both","","","1911.00","1433.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","819.82","42.9","","2548.09","2548.09","2548.09","1 through 10","592.41","1519.25","percent of total billed charges",""
"SHOULDER HEAD 50X24 52MM MODULAR OFFSET 04","SUP-ITM-10100161","CDM","C1776","HCPCS","0278","RC","","","","both","","","1911.00","1433.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","819.82","42.9","","956.46","956.46","956.46","1 through 10","592.41","1519.25","percent of total billed charges",""
"SHOULDER HEAD 50X24 52MM MODULAR OFFSET 04","SUP-ITM-10100161","CDM","C1776","HCPCS","0278","RC","","","","both","","","1911.00","1433.25","WELLPOINT [1015]","HB AMC WELLPOINT","1409.94","73.78","","2344.73","1619.47","2530.35","16","592.41","1519.25","percent of total billed charges",""
"SHOULDER HEAD 50X24 52MM MODULAR OFFSET 04","SUP-ITM-10100161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1911.00","1433.25","AETNA [1001]","HB AMC AETNA HMO","1333.88","69.8","","1523.63","988.41","4330.26","39","998.69","1561.67","percent of total billed charges",""
"SHOULDER HEAD 50X24 52MM MODULAR OFFSET 04","SUP-ITM-10100161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1911.00","1433.25","AETNA [1001]","HB AMC AETNA PPO","1536.44","80.4","","1670.25","1670.25","1670.25","1 through 10","998.69","1561.67","percent of total billed charges",""
"SHOULDER HEAD 50X24 52MM MODULAR OFFSET 04","SUP-ITM-10100161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1911.00","1433.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","998.69","52.26","","1113.10","1113.10","1113.10","1 through 10","998.69","1561.67","percent of total billed charges",""
"SHOULDER HEAD 50X24 52MM MODULAR OFFSET 04","SUP-ITM-10100161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1911.00","1433.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1561.67","81.72","","1738.90","1484.65","2716.94","38","998.69","1561.67","percent of total billed charges",""
"SHOULDER HEAD 52X48MM HUMERAL","SUP-ITM-10094378","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4246.13","52.26","","1113.10","1113.10","1113.10","1 through 10","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 52X48MM HUMERAL","SUP-ITM-10094378","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6459.38","79.5","","1293.60","1148.53","1603.80","1 through 10","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 52X48MM HUMERAL","SUP-ITM-10094378","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2965.63","36.5","","1023.42","771.29","2068.67","33","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 52X48MM HUMERAL","SUP-ITM-10094378","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3111.88","38.3","","850.52","759.78","1211.25","66","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 52X48MM HUMERAL","SUP-ITM-10094378","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3485.63","42.9","","2548.09","2548.09","2548.09","1 through 10","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 52X48MM HUMERAL","SUP-ITM-10094378","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3485.63","42.9","","956.46","956.46","956.46","1 through 10","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 52X48MM HUMERAL","SUP-ITM-10094378","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","WELLPOINT [1015]","HB AMC WELLPOINT","5994.63","73.78","","2344.73","1619.47","2530.35","16","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 52X48MM HUMERAL","SUP-ITM-10094378","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","AETNA [1001]","HB AMC AETNA HMO","5671.25","69.8","","1523.63","988.41","4330.26","39","4246.13","6639.75","percent of total billed charges",""
"SHOULDER HEAD 52X48MM HUMERAL","SUP-ITM-10094378","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","AETNA [1001]","HB AMC AETNA PPO","6532.50","80.4","","1670.25","1670.25","1670.25","1 through 10","4246.13","6639.75","percent of total billed charges",""
"SHOULDER HEAD 52X48MM HUMERAL","SUP-ITM-10094378","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4246.13","52.26","","1113.10","1113.10","1113.10","1 through 10","4246.13","6639.75","percent of total billed charges",""
"SHOULDER HEAD 52X48MM HUMERAL","SUP-ITM-10094378","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6639.75","81.72","","1738.90","1484.65","2716.94","38","4246.13","6639.75","percent of total billed charges",""
"SHOULDER HEAD 54X21MM SHORT HUMERAL AEQUALIS ASCEND FLEXIBLE TUBULAR BONE OFFSET HIGH","SUP-ITM-10135941","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2822.04","52.26","","1113.10","1113.10","1113.10","1 through 10","1674","4293","percent of total billed charges",""
"SHOULDER HEAD 54X21MM SHORT HUMERAL AEQUALIS ASCEND FLEXIBLE TUBULAR BONE OFFSET HIGH","SUP-ITM-10135941","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4293.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1674","4293","percent of total billed charges",""
"SHOULDER HEAD 54X21MM SHORT HUMERAL AEQUALIS ASCEND FLEXIBLE TUBULAR BONE OFFSET HIGH","SUP-ITM-10135941","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1971.00","36.5","","1023.42","771.29","2068.67","33","1674","4293","percent of total billed charges",""
"SHOULDER HEAD 54X21MM SHORT HUMERAL AEQUALIS ASCEND FLEXIBLE TUBULAR BONE OFFSET HIGH","SUP-ITM-10135941","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2068.20","38.3","","850.52","759.78","1211.25","66","1674","4293","percent of total billed charges",""
"SHOULDER HEAD 54X21MM SHORT HUMERAL AEQUALIS ASCEND FLEXIBLE TUBULAR BONE OFFSET HIGH","SUP-ITM-10135941","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","2548.09","2548.09","2548.09","1 through 10","1674","4293","percent of total billed charges",""
"SHOULDER HEAD 54X21MM SHORT HUMERAL AEQUALIS ASCEND FLEXIBLE TUBULAR BONE OFFSET HIGH","SUP-ITM-10135941","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","956.46","956.46","956.46","1 through 10","1674","4293","percent of total billed charges",""
"SHOULDER HEAD 54X21MM SHORT HUMERAL AEQUALIS ASCEND FLEXIBLE TUBULAR BONE OFFSET HIGH","SUP-ITM-10135941","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB AMC WELLPOINT","3984.12","73.78","","2344.73","1619.47","2530.35","16","1674","4293","percent of total billed charges",""
"SHOULDER HEAD 54X21MM SHORT HUMERAL AEQUALIS ASCEND FLEXIBLE TUBULAR BONE OFFSET HIGH","SUP-ITM-10135941","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA HMO","3769.20","69.8","","1523.63","988.41","4330.26","39","2822.04","4412.88","percent of total billed charges",""
"SHOULDER HEAD 54X21MM SHORT HUMERAL AEQUALIS ASCEND FLEXIBLE TUBULAR BONE OFFSET HIGH","SUP-ITM-10135941","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA PPO","4341.60","80.4","","1670.25","1670.25","1670.25","1 through 10","2822.04","4412.88","percent of total billed charges",""
"SHOULDER HEAD 54X21MM SHORT HUMERAL AEQUALIS ASCEND FLEXIBLE TUBULAR BONE OFFSET HIGH","SUP-ITM-10135941","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2822.04","52.26","","1113.10","1113.10","1113.10","1 through 10","2822.04","4412.88","percent of total billed charges",""
"SHOULDER HEAD 54X21MM SHORT HUMERAL AEQUALIS ASCEND FLEXIBLE TUBULAR BONE OFFSET HIGH","SUP-ITM-10135941","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4412.88","81.72","","1738.90","1484.65","2716.94","38","2822.04","4412.88","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4246.13","52.26","","1113.10","1113.10","1113.10","1 through 10","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6459.38","79.5","","1293.60","1148.53","1603.80","1 through 10","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2965.63","36.5","","1023.42","771.29","2068.67","33","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3111.88","38.3","","850.52","759.78","1211.25","66","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3485.63","42.9","","2548.09","2548.09","2548.09","1 through 10","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3485.63","42.9","","956.46","956.46","956.46","1 through 10","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","8125.00","6093.75","WELLPOINT [1015]","HB AMC WELLPOINT","5994.63","73.78","","2344.73","1619.47","2530.35","16","2518.75","6459.38","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","AETNA [1001]","HB AMC AETNA HMO","5671.25","69.8","","1523.63","988.41","4330.26","39","4246.13","6639.75","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","AETNA [1001]","HB AMC AETNA PPO","6532.50","80.4","","1670.25","1670.25","1670.25","1 through 10","4246.13","6639.75","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4246.13","52.26","","1113.10","1113.10","1113.10","1 through 10","4246.13","6639.75","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8125.00","6093.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6639.75","81.72","","1738.90","1484.65","2716.94","38","4246.13","6639.75","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2748.88","52.26","","1113.10","1113.10","1113.10","1 through 10","1630.6","4181.7","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4181.70","79.5","","1293.60","1148.53","1603.80","1 through 10","1630.6","4181.7","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1919.90","36.5","","1023.42","771.29","2068.67","33","1630.6","4181.7","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2014.58","38.3","","850.52","759.78","1211.25","66","1630.6","4181.7","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2256.54","42.9","","2548.09","2548.09","2548.09","1 through 10","1630.6","4181.7","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2256.54","42.9","","956.46","956.46","956.46","1 through 10","1630.6","4181.7","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","5260.00","3945.00","WELLPOINT [1015]","HB AMC WELLPOINT","3880.83","73.78","","2344.73","1619.47","2530.35","16","1630.6","4181.7","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5260.00","3945.00","AETNA [1001]","HB AMC AETNA HMO","3671.48","69.8","","1523.63","988.41","4330.26","39","2748.88","4298.47","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5260.00","3945.00","AETNA [1001]","HB AMC AETNA PPO","4229.04","80.4","","1670.25","1670.25","1670.25","1 through 10","2748.88","4298.47","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5260.00","3945.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2748.88","52.26","","1113.10","1113.10","1113.10","1 through 10","2748.88","4298.47","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5260.00","3945.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4298.47","81.72","","1738.90","1484.65","2716.94","38","2748.88","4298.47","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2209.55","52.26","","1113.10","1113.10","1113.10","1 through 10","1310.68","3361.26","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3361.26","79.5","","1293.60","1148.53","1603.80","1 through 10","1310.68","3361.26","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1543.22","36.5","","1023.42","771.29","2068.67","33","1310.68","3361.26","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1619.32","38.3","","850.52","759.78","1211.25","66","1310.68","3361.26","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.81","42.9","","2548.09","2548.09","2548.09","1 through 10","1310.68","3361.26","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.81","42.9","","956.46","956.46","956.46","1 through 10","1310.68","3361.26","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","WELLPOINT [1015]","HB AMC WELLPOINT","3119.42","73.78","","2344.73","1619.47","2530.35","16","1310.68","3361.26","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","AETNA [1001]","HB AMC AETNA HMO","2951.14","69.8","","1523.63","988.41","4330.26","39","2209.55","3455.12","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","AETNA [1001]","HB AMC AETNA PPO","3399.31","80.4","","1670.25","1670.25","1670.25","1 through 10","2209.55","3455.12","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2209.55","52.26","","1113.10","1113.10","1113.10","1 through 10","2209.55","3455.12","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3455.12","81.72","","1738.90","1484.65","2716.94","38","2209.55","3455.12","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2482.35","52.26","","1113.10","1113.10","1113.10","1 through 10","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3776.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1733.75","36.5","","1023.42","771.29","2068.67","33","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1819.25","38.3","","850.52","759.78","1211.25","66","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2037.75","42.9","","2548.09","2548.09","2548.09","1 through 10","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2037.75","42.9","","956.46","956.46","956.46","1 through 10","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","WELLPOINT [1015]","HB AMC WELLPOINT","3504.55","73.78","","2344.73","1619.47","2530.35","16","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4750.00","3562.50","AETNA [1001]","HB AMC AETNA HMO","3315.50","69.8","","1523.63","988.41","4330.26","39","2482.35","3881.7","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4750.00","3562.50","AETNA [1001]","HB AMC AETNA PPO","3819.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2482.35","3881.7","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4750.00","3562.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2482.35","52.26","","1113.10","1113.10","1113.10","1 through 10","2482.35","3881.7","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4750.00","3562.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3881.70","81.72","","1738.90","1484.65","2716.94","38","2482.35","3881.7","percent of total billed charges",""
"SHOULDER IMPLANT 40X15MM HUMERAL","SUP-ITM-10122567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4853.63","3640.22","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2536.51","52.26","","1113.10","1113.10","1113.10","1 through 10","1504.63","3858.64","percent of total billed charges",""
"SHOULDER IMPLANT 40X15MM HUMERAL","SUP-ITM-10122567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4853.63","3640.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3858.64","79.5","","1293.60","1148.53","1603.80","1 through 10","1504.63","3858.64","percent of total billed charges",""
"SHOULDER IMPLANT 40X15MM HUMERAL","SUP-ITM-10122567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4853.63","3640.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1771.57","36.5","","1023.42","771.29","2068.67","33","1504.63","3858.64","percent of total billed charges",""
"SHOULDER IMPLANT 40X15MM HUMERAL","SUP-ITM-10122567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4853.63","3640.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1858.94","38.3","","850.52","759.78","1211.25","66","1504.63","3858.64","percent of total billed charges",""
"SHOULDER IMPLANT 40X15MM HUMERAL","SUP-ITM-10122567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4853.63","3640.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2082.21","42.9","","2548.09","2548.09","2548.09","1 through 10","1504.63","3858.64","percent of total billed charges",""
"SHOULDER IMPLANT 40X15MM HUMERAL","SUP-ITM-10122567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4853.63","3640.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2082.21","42.9","","956.46","956.46","956.46","1 through 10","1504.63","3858.64","percent of total billed charges",""
"SHOULDER IMPLANT 40X15MM HUMERAL","SUP-ITM-10122567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4853.63","3640.22","WELLPOINT [1015]","HB AMC WELLPOINT","3581.01","73.78","","2344.73","1619.47","2530.35","16","1504.63","3858.64","percent of total billed charges",""
"SHOULDER IMPLANT 40X15MM HUMERAL","SUP-ITM-10122567","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4853.63","3640.22","AETNA [1001]","HB AMC AETNA HMO","3387.83","69.8","","1523.63","988.41","4330.26","39","2536.51","3966.39","percent of total billed charges",""
"SHOULDER IMPLANT 40X15MM HUMERAL","SUP-ITM-10122567","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4853.63","3640.22","AETNA [1001]","HB AMC AETNA PPO","3902.32","80.4","","1670.25","1670.25","1670.25","1 through 10","2536.51","3966.39","percent of total billed charges",""
"SHOULDER IMPLANT 40X15MM HUMERAL","SUP-ITM-10122567","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4853.63","3640.22","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2536.51","52.26","","1113.10","1113.10","1113.10","1 through 10","2536.51","3966.39","percent of total billed charges",""
"SHOULDER IMPLANT 40X15MM HUMERAL","SUP-ITM-10122567","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4853.63","3640.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3966.39","81.72","","1738.90","1484.65","2716.94","38","2536.51","3966.39","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","4512.90","3384.67","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2358.44","52.26","","1113.10","1113.10","1113.10","1 through 10","1399","3587.76","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","4512.90","3384.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3587.76","79.5","","1293.60","1148.53","1603.80","1 through 10","1399","3587.76","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","4512.90","3384.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1647.21","36.5","","1023.42","771.29","2068.67","33","1399","3587.76","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","4512.90","3384.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1728.44","38.3","","850.52","759.78","1211.25","66","1399","3587.76","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","4512.90","3384.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1936.03","42.9","","2548.09","2548.09","2548.09","1 through 10","1399","3587.76","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","4512.90","3384.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1936.03","42.9","","956.46","956.46","956.46","1 through 10","1399","3587.76","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","4512.90","3384.67","WELLPOINT [1015]","HB AMC WELLPOINT","3329.62","73.78","","2344.73","1619.47","2530.35","16","1399","3587.76","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4512.90","3384.67","AETNA [1001]","HB AMC AETNA HMO","3150.00","69.8","","1523.63","988.41","4330.26","39","2358.44","3687.94","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4512.90","3384.67","AETNA [1001]","HB AMC AETNA PPO","3628.37","80.4","","1670.25","1670.25","1670.25","1 through 10","2358.44","3687.94","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4512.90","3384.67","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2358.44","52.26","","1113.10","1113.10","1113.10","1 through 10","2358.44","3687.94","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4512.90","3384.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3687.94","81.72","","1738.90","1484.65","2716.94","38","2358.44","3687.94","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2482.35","52.26","","1113.10","1113.10","1113.10","1 through 10","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3776.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1733.75","36.5","","1023.42","771.29","2068.67","33","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1819.25","38.3","","850.52","759.78","1211.25","66","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2037.75","42.9","","2548.09","2548.09","2548.09","1 through 10","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2037.75","42.9","","956.46","956.46","956.46","1 through 10","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","4750.00","3562.50","WELLPOINT [1015]","HB AMC WELLPOINT","3504.55","73.78","","2344.73","1619.47","2530.35","16","1472.5","3776.25","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4750.00","3562.50","AETNA [1001]","HB AMC AETNA HMO","3315.50","69.8","","1523.63","988.41","4330.26","39","2482.35","3881.7","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4750.00","3562.50","AETNA [1001]","HB AMC AETNA PPO","3819.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2482.35","3881.7","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4750.00","3562.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2482.35","52.26","","1113.10","1113.10","1113.10","1 through 10","2482.35","3881.7","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4750.00","3562.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3881.70","81.72","","1738.90","1484.65","2716.94","38","2482.35","3881.7","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3903.00","2927.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2039.71","52.26","","1113.10","1113.10","1113.10","1 through 10","1209.93","3102.89","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3903.00","2927.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3102.89","79.5","","1293.60","1148.53","1603.80","1 through 10","1209.93","3102.89","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3903.00","2927.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1424.60","36.5","","1023.42","771.29","2068.67","33","1209.93","3102.89","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3903.00","2927.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1494.85","38.3","","850.52","759.78","1211.25","66","1209.93","3102.89","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3903.00","2927.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1674.39","42.9","","2548.09","2548.09","2548.09","1 through 10","1209.93","3102.89","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3903.00","2927.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1674.39","42.9","","956.46","956.46","956.46","1 through 10","1209.93","3102.89","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3903.00","2927.25","WELLPOINT [1015]","HB AMC WELLPOINT","2879.63","73.78","","2344.73","1619.47","2530.35","16","1209.93","3102.89","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3903.00","2927.25","AETNA [1001]","HB AMC AETNA HMO","2724.29","69.8","","1523.63","988.41","4330.26","39","2039.71","3189.53","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3903.00","2927.25","AETNA [1001]","HB AMC AETNA PPO","3138.01","80.4","","1670.25","1670.25","1670.25","1 through 10","2039.71","3189.53","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3903.00","2927.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2039.71","52.26","","1113.10","1113.10","1113.10","1 through 10","2039.71","3189.53","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3903.00","2927.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3189.53","81.72","","1738.90","1484.65","2716.94","38","2039.71","3189.53","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","651","1669.5","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1293.60","1148.53","1603.80","1 through 10","651","1669.5","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1023.42","771.29","2068.67","33","651","1669.5","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","850.52","759.78","1211.25","66","651","1669.5","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","2548.09","2548.09","2548.09","1 through 10","651","1669.5","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","956.46","956.46","956.46","1 through 10","651","1669.5","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","2344.73","1619.47","2530.35","16","651","1669.5","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1523.63","988.41","4330.26","39","1097.46","1716.12","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1670.25","1670.25","1670.25","1 through 10","1097.46","1716.12","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1097.46","1716.12","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1738.90","1484.65","2716.94","38","1097.46","1716.12","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1216.81","52.26","","1113.10","1113.10","1113.10","1 through 10","721.8","1851.06","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1851.06","79.5","","1293.60","1148.53","1603.80","1 through 10","721.8","1851.06","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","849.86","36.5","","1023.42","771.29","2068.67","33","721.8","1851.06","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","891.77","38.3","","850.52","759.78","1211.25","66","721.8","1851.06","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","998.88","42.9","","2548.09","2548.09","2548.09","1 through 10","721.8","1851.06","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","998.88","42.9","","956.46","956.46","956.46","1 through 10","721.8","1851.06","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","2328.38","1746.28","WELLPOINT [1015]","HB AMC WELLPOINT","1717.88","73.78","","2344.73","1619.47","2530.35","16","721.8","1851.06","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2328.38","1746.28","AETNA [1001]","HB AMC AETNA HMO","1625.21","69.8","","1523.63","988.41","4330.26","39","1216.81","1902.75","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2328.38","1746.28","AETNA [1001]","HB AMC AETNA PPO","1872.02","80.4","","1670.25","1670.25","1670.25","1 through 10","1216.81","1902.75","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2328.38","1746.28","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1216.81","52.26","","1113.10","1113.10","1113.10","1 through 10","1216.81","1902.75","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2328.38","1746.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1902.75","81.72","","1738.90","1484.65","2716.94","38","1216.81","1902.75","percent of total billed charges",""
"SHOULDER INSERT SZ 3/4 REVERSED PERFORM","SUP-ITM-10298038","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1395","3577.5","percent of total billed charges",""
"SHOULDER INSERT SZ 3/4 REVERSED PERFORM","SUP-ITM-10298038","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1395","3577.5","percent of total billed charges",""
"SHOULDER INSERT SZ 3/4 REVERSED PERFORM","SUP-ITM-10298038","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","1023.42","771.29","2068.67","33","1395","3577.5","percent of total billed charges",""
"SHOULDER INSERT SZ 3/4 REVERSED PERFORM","SUP-ITM-10298038","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","850.52","759.78","1211.25","66","1395","3577.5","percent of total billed charges",""
"SHOULDER INSERT SZ 3/4 REVERSED PERFORM","SUP-ITM-10298038","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1395","3577.5","percent of total billed charges",""
"SHOULDER INSERT SZ 3/4 REVERSED PERFORM","SUP-ITM-10298038","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","956.46","956.46","956.46","1 through 10","1395","3577.5","percent of total billed charges",""
"SHOULDER INSERT SZ 3/4 REVERSED PERFORM","SUP-ITM-10298038","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","2344.73","1619.47","2530.35","16","1395","3577.5","percent of total billed charges",""
"SHOULDER INSERT SZ 3/4 REVERSED PERFORM","SUP-ITM-10298038","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","1523.63","988.41","4330.26","39","2351.7","3677.4","percent of total billed charges",""
"SHOULDER INSERT SZ 3/4 REVERSED PERFORM","SUP-ITM-10298038","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA PPO","3618.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SHOULDER INSERT SZ 3/4 REVERSED PERFORM","SUP-ITM-10298038","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SHOULDER INSERT SZ 3/4 REVERSED PERFORM","SUP-ITM-10298038","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","1738.90","1484.65","2716.94","38","2351.7","3677.4","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4342.91","3257.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3452.61","79.5","","800.18","480.96","1887.97","195","1346.3","3452.61","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4342.91","3257.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2314.77","53.3","","813.12","216.42","1444.50","81","1346.3","3452.61","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4342.91","3257.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1346.30","31","","432.60","432.60","432.60","1 through 10","1346.3","3452.61","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4342.91","3257.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1585.16","36.5","","148.37","54.89","631.39","94","1346.3","3452.61","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4342.91","3257.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1663.33","38.3","","279.30","91.72","1116.77","266","1346.3","3452.61","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4342.91","3257.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1863.11","42.9","","731.00","63.70","731.00","1 through 10","1346.3","3452.61","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4342.91","3257.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1863.11","42.9","","384.74","384.74","384.74","1 through 10","1346.3","3452.61","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","4342.91","3257.18","WELLPOINT [1015]","HB AMC WELLPOINT","3204.20","73.78","","286.63","119.22","1107.45","105","1346.3","3452.61","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4342.91","3257.18","AETNA [1001]","HB AMC AETNA HMO","3031.35","69.8","","675.31","184.75","1721.50","286","2269.6","3549.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4342.91","3257.18","AETNA [1001]","HB AMC AETNA PPO","3491.70","80.4","","1261.44","103.12","1514.10","21","2269.6","3549.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4342.91","3257.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3491.70","80.4","","1365.00","1365.00","1365.00","1 through 10","2269.6","3549.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4342.91","3257.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3549.03","81.72","","5157.68","5157.68","5157.68","1 through 10","2269.6","3549.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4342.91","3257.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3549.03","81.72","","431.26","71.26","1459.57","88","2269.6","3549.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","4135.59","3101.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3287.79","79.5","","800.18","480.96","1887.97","195","1282.03","3287.79","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","4135.59","3101.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2204.27","53.3","","813.12","216.42","1444.50","81","1282.03","3287.79","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","4135.59","3101.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1282.03","31","","432.60","432.60","432.60","1 through 10","1282.03","3287.79","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","4135.59","3101.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1509.49","36.5","","148.37","54.89","631.39","94","1282.03","3287.79","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","4135.59","3101.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1583.93","38.3","","279.30","91.72","1116.77","266","1282.03","3287.79","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","4135.59","3101.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1774.17","42.9","","731.00","63.70","731.00","1 through 10","1282.03","3287.79","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","4135.59","3101.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1774.17","42.9","","384.74","384.74","384.74","1 through 10","1282.03","3287.79","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","4135.59","3101.69","WELLPOINT [1015]","HB AMC WELLPOINT","3051.24","73.78","","286.63","119.22","1107.45","105","1282.03","3287.79","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4135.59","3101.69","AETNA [1001]","HB AMC AETNA HMO","2886.64","69.8","","675.31","184.75","1721.50","286","2161.26","3379.6","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4135.59","3101.69","AETNA [1001]","HB AMC AETNA PPO","3325.01","80.4","","1261.44","103.12","1514.10","21","2161.26","3379.6","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4135.59","3101.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3325.01","80.4","","1365.00","1365.00","1365.00","1 through 10","2161.26","3379.6","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4135.59","3101.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3379.60","81.72","","5157.68","5157.68","5157.68","1 through 10","2161.26","3379.6","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4135.59","3101.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3379.60","81.72","","431.26","71.26","1459.57","88","2161.26","3379.6","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.47","3211.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3404.56","79.5","","800.18","480.96","1887.97","195","1327.57","3404.56","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.47","3211.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2282.56","53.3","","813.12","216.42","1444.50","81","1327.57","3404.56","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.47","3211.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1327.57","31","","432.60","432.60","432.60","1 through 10","1327.57","3404.56","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.47","3211.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1563.10","36.5","","148.37","54.89","631.39","94","1327.57","3404.56","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.47","3211.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1640.19","38.3","","279.30","91.72","1116.77","266","1327.57","3404.56","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.47","3211.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1837.18","42.9","","731.00","63.70","731.00","1 through 10","1327.57","3404.56","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.47","3211.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1837.18","42.9","","384.74","384.74","384.74","1 through 10","1327.57","3404.56","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.47","3211.85","WELLPOINT [1015]","HB AMC WELLPOINT","3159.61","73.78","","286.63","119.22","1107.45","105","1327.57","3404.56","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4282.47","3211.85","AETNA [1001]","HB AMC AETNA HMO","2989.16","69.8","","675.31","184.75","1721.50","286","2238.02","3499.63","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4282.47","3211.85","AETNA [1001]","HB AMC AETNA PPO","3443.11","80.4","","1261.44","103.12","1514.10","21","2238.02","3499.63","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4282.47","3211.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3443.11","80.4","","1365.00","1365.00","1365.00","1 through 10","2238.02","3499.63","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4282.47","3211.85","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3499.63","81.72","","5157.68","5157.68","5157.68","1 through 10","2238.02","3499.63","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4282.47","3211.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3499.63","81.72","","431.26","71.26","1459.57","88","2238.02","3499.63","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","5091.63","3818.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4047.85","79.5","","800.18","480.96","1887.97","195","1578.41","4047.85","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","5091.63","3818.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2713.84","53.3","","813.12","216.42","1444.50","81","1578.41","4047.85","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","5091.63","3818.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1578.41","31","","432.60","432.60","432.60","1 through 10","1578.41","4047.85","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","5091.63","3818.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1858.44","36.5","","148.37","54.89","631.39","94","1578.41","4047.85","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","5091.63","3818.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1950.09","38.3","","279.30","91.72","1116.77","266","1578.41","4047.85","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","5091.63","3818.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2184.31","42.9","","731.00","63.70","731.00","1 through 10","1578.41","4047.85","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","5091.63","3818.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2184.31","42.9","","384.74","384.74","384.74","1 through 10","1578.41","4047.85","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","5091.63","3818.72","WELLPOINT [1015]","HB AMC WELLPOINT","3756.60","73.78","","286.63","119.22","1107.45","105","1578.41","4047.85","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5091.63","3818.72","AETNA [1001]","HB AMC AETNA HMO","3553.96","69.8","","675.31","184.75","1721.50","286","2660.89","4160.88","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5091.63","3818.72","AETNA [1001]","HB AMC AETNA PPO","4093.67","80.4","","1261.44","103.12","1514.10","21","2660.89","4160.88","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5091.63","3818.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4093.67","80.4","","1365.00","1365.00","1365.00","1 through 10","2660.89","4160.88","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5091.63","3818.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4160.88","81.72","","5157.68","5157.68","5157.68","1 through 10","2660.89","4160.88","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5091.63","3818.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4160.88","81.72","","431.26","71.26","1459.57","88","2660.89","4160.88","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.93","3344.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3544.85","79.5","","800.18","480.96","1887.97","195","1382.27","3544.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.93","3344.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2376.61","53.3","","813.12","216.42","1444.50","81","1382.27","3544.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.93","3344.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1382.27","31","","432.60","432.60","432.60","1 through 10","1382.27","3544.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.93","3344.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1627.51","36.5","","148.37","54.89","631.39","94","1382.27","3544.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.93","3344.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1707.77","38.3","","279.30","91.72","1116.77","266","1382.27","3544.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.93","3344.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1912.88","42.9","","731.00","63.70","731.00","1 through 10","1382.27","3544.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.93","3344.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1912.88","42.9","","384.74","384.74","384.74","1 through 10","1382.27","3544.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","4458.93","3344.20","WELLPOINT [1015]","HB AMC WELLPOINT","3289.80","73.78","","286.63","119.22","1107.45","105","1382.27","3544.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4458.93","3344.20","AETNA [1001]","HB AMC AETNA HMO","3112.33","69.8","","675.31","184.75","1721.50","286","2330.24","3643.84","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4458.93","3344.20","AETNA [1001]","HB AMC AETNA PPO","3584.98","80.4","","1261.44","103.12","1514.10","21","2330.24","3643.84","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4458.93","3344.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3584.98","80.4","","1365.00","1365.00","1365.00","1 through 10","2330.24","3643.84","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4458.93","3344.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3643.84","81.72","","5157.68","5157.68","5157.68","1 through 10","2330.24","3643.84","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4458.93","3344.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3643.84","81.72","","431.26","71.26","1459.57","88","2330.24","3643.84","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.00","3107.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3293.69","79.5","","800.18","480.96","1887.97","195","1284.33","3293.69","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.00","3107.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2208.22","53.3","","813.12","216.42","1444.50","81","1284.33","3293.69","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.00","3107.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1284.33","31","","432.60","432.60","432.60","1 through 10","1284.33","3293.69","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.00","3107.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1512.20","36.5","","148.37","54.89","631.39","94","1284.33","3293.69","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.00","3107.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1586.77","38.3","","279.30","91.72","1116.77","266","1284.33","3293.69","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.00","3107.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1777.35","42.9","","731.00","63.70","731.00","1 through 10","1284.33","3293.69","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.00","3107.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1777.35","42.9","","384.74","384.74","384.74","1 through 10","1284.33","3293.69","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.00","3107.25","WELLPOINT [1015]","HB AMC WELLPOINT","3056.71","73.78","","286.63","119.22","1107.45","105","1284.33","3293.69","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4143.00","3107.25","AETNA [1001]","HB AMC AETNA HMO","2891.81","69.8","","675.31","184.75","1721.50","286","2165.13","3385.66","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4143.00","3107.25","AETNA [1001]","HB AMC AETNA PPO","3330.97","80.4","","1261.44","103.12","1514.10","21","2165.13","3385.66","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4143.00","3107.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3330.97","80.4","","1365.00","1365.00","1365.00","1 through 10","2165.13","3385.66","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4143.00","3107.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3385.66","81.72","","5157.68","5157.68","5157.68","1 through 10","2165.13","3385.66","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4143.00","3107.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3385.66","81.72","","431.26","71.26","1459.57","88","2165.13","3385.66","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2781.98","2086.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1453.86","52.26","","1113.10","1113.10","1113.10","1 through 10","862.41","2211.67","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2781.98","2086.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2211.67","79.5","","1293.60","1148.53","1603.80","1 through 10","862.41","2211.67","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2781.98","2086.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1015.42","36.5","","1023.42","771.29","2068.67","33","862.41","2211.67","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2781.98","2086.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1065.50","38.3","","850.52","759.78","1211.25","66","862.41","2211.67","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2781.98","2086.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.47","42.9","","2548.09","2548.09","2548.09","1 through 10","862.41","2211.67","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2781.98","2086.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.47","42.9","","956.46","956.46","956.46","1 through 10","862.41","2211.67","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2781.98","2086.48","WELLPOINT [1015]","HB AMC WELLPOINT","2052.54","73.78","","2344.73","1619.47","2530.35","16","862.41","2211.67","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2781.98","2086.48","AETNA [1001]","HB AMC AETNA HMO","1941.82","69.8","","1523.63","988.41","4330.26","39","1453.86","2273.43","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2781.98","2086.48","AETNA [1001]","HB AMC AETNA PPO","2236.71","80.4","","1670.25","1670.25","1670.25","1 through 10","1453.86","2273.43","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2781.98","2086.48","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1453.86","52.26","","1113.10","1113.10","1113.10","1 through 10","1453.86","2273.43","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2781.98","2086.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2273.43","81.72","","1738.90","1484.65","2716.94","38","1453.86","2273.43","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1463.28","52.26","","1113.10","1113.10","1113.10","1 through 10","868","2226","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","1293.60","1148.53","1603.80","1 through 10","868","2226","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","1023.42","771.29","2068.67","33","868","2226","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","850.52","759.78","1211.25","66","868","2226","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","2548.09","2548.09","2548.09","1 through 10","868","2226","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","956.46","956.46","956.46","1 through 10","868","2226","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","2344.73","1619.47","2530.35","16","868","2226","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA HMO","1954.40","69.8","","1523.63","988.41","4330.26","39","1463.28","2288.16","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA PPO","2251.20","80.4","","1670.25","1670.25","1670.25","1 through 10","1463.28","2288.16","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1463.28","52.26","","1113.10","1113.10","1113.10","1 through 10","1463.28","2288.16","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","1738.90","1484.65","2716.94","38","1463.28","2288.16","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1023.42","771.29","2068.67","33","1085","2782.5","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","850.52","759.78","1211.25","66","1085","2782.5","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","956.46","956.46","956.46","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2344.73","1619.47","2530.35","16","1085","2782.5","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1523.63","988.41","4330.26","39","1829.1","2860.2","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1829.1","2860.2","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1829.1","2860.2","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","1738.90","1484.65","2716.94","38","1829.1","2860.2","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2573.81","79.5","","800.18","480.96","1887.97","195","1003.63","2573.81","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1725.59","53.3","","813.12","216.42","1444.50","81","1003.63","2573.81","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1003.63","31","","432.60","432.60","432.60","1 through 10","1003.63","2573.81","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1181.69","36.5","","148.37","54.89","631.39","94","1003.63","2573.81","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1239.96","38.3","","279.30","91.72","1116.77","266","1003.63","2573.81","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1388.89","42.9","","731.00","63.70","731.00","1 through 10","1003.63","2573.81","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1388.89","42.9","","384.74","384.74","384.74","1 through 10","1003.63","2573.81","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","3237.50","2428.12","WELLPOINT [1015]","HB AMC WELLPOINT","2388.63","73.78","","286.63","119.22","1107.45","105","1003.63","2573.81","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","AETNA [1001]","HB AMC AETNA HMO","2259.78","69.8","","675.31","184.75","1721.50","286","1691.92","2645.69","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","AETNA [1001]","HB AMC AETNA PPO","2602.95","80.4","","1261.44","103.12","1514.10","21","1691.92","2645.69","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2602.95","80.4","","1365.00","1365.00","1365.00","1 through 10","1691.92","2645.69","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2645.69","81.72","","5157.68","5157.68","5157.68","1 through 10","1691.92","2645.69","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3237.50","2428.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2645.69","81.72","","431.26","71.26","1459.57","88","1691.92","2645.69","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","777.37","52.26","","1113.10","1113.10","1113.10","1 through 10","461.13","1182.56","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1182.56","79.5","","1293.60","1148.53","1603.80","1 through 10","461.13","1182.56","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","542.94","36.5","","1023.42","771.29","2068.67","33","461.13","1182.56","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","569.71","38.3","","850.52","759.78","1211.25","66","461.13","1182.56","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","638.14","42.9","","2548.09","2548.09","2548.09","1 through 10","461.13","1182.56","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","638.14","42.9","","956.46","956.46","956.46","1 through 10","461.13","1182.56","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","both","","","1487.50","1115.62","WELLPOINT [1015]","HB AMC WELLPOINT","1097.48","73.78","","2344.73","1619.47","2530.35","16","461.13","1182.56","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","AETNA [1001]","HB AMC AETNA HMO","1038.28","69.8","","1523.63","988.41","4330.26","39","777.37","1215.59","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","AETNA [1001]","HB AMC AETNA PPO","1195.95","80.4","","1670.25","1670.25","1670.25","1 through 10","777.37","1215.59","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","777.37","52.26","","1113.10","1113.10","1113.10","1 through 10","777.37","1215.59","percent of total billed charges",""
"SHOULDER POST TAPER 15.6MMX32 LG HEMICAP RESURFACING OVO FIXATION COMPONENT","SUP-ITM-10123421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1487.50","1115.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1215.59","81.72","","1738.90","1484.65","2716.94","38","777.37","1215.59","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL 8MM PLUS OFFSET REVERSE PROSTHESIS","SUP-ITM-10021989","CDM","C1776","HCPCS","0278","RC","","","","both","","","3773.00","2829.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1971.77","52.26","","1113.10","1113.10","1113.10","1 through 10","1169.63","2999.54","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL 8MM PLUS OFFSET REVERSE PROSTHESIS","SUP-ITM-10021989","CDM","C1776","HCPCS","0278","RC","","","","both","","","3773.00","2829.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2999.54","79.5","","1293.60","1148.53","1603.80","1 through 10","1169.63","2999.54","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL 8MM PLUS OFFSET REVERSE PROSTHESIS","SUP-ITM-10021989","CDM","C1776","HCPCS","0278","RC","","","","both","","","3773.00","2829.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1377.15","36.5","","1023.42","771.29","2068.67","33","1169.63","2999.54","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL 8MM PLUS OFFSET REVERSE PROSTHESIS","SUP-ITM-10021989","CDM","C1776","HCPCS","0278","RC","","","","both","","","3773.00","2829.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1445.06","38.3","","850.52","759.78","1211.25","66","1169.63","2999.54","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL 8MM PLUS OFFSET REVERSE PROSTHESIS","SUP-ITM-10021989","CDM","C1776","HCPCS","0278","RC","","","","both","","","3773.00","2829.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1618.62","42.9","","2548.09","2548.09","2548.09","1 through 10","1169.63","2999.54","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL 8MM PLUS OFFSET REVERSE PROSTHESIS","SUP-ITM-10021989","CDM","C1776","HCPCS","0278","RC","","","","both","","","3773.00","2829.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1618.62","42.9","","956.46","956.46","956.46","1 through 10","1169.63","2999.54","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL 8MM PLUS OFFSET REVERSE PROSTHESIS","SUP-ITM-10021989","CDM","C1776","HCPCS","0278","RC","","","","both","","","3773.00","2829.75","WELLPOINT [1015]","HB AMC WELLPOINT","2783.72","73.78","","2344.73","1619.47","2530.35","16","1169.63","2999.54","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL 8MM PLUS OFFSET REVERSE PROSTHESIS","SUP-ITM-10021989","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3773.00","2829.75","AETNA [1001]","HB AMC AETNA HMO","2633.55","69.8","","1523.63","988.41","4330.26","39","1971.77","3083.3","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL 8MM PLUS OFFSET REVERSE PROSTHESIS","SUP-ITM-10021989","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3773.00","2829.75","AETNA [1001]","HB AMC AETNA PPO","3033.49","80.4","","1670.25","1670.25","1670.25","1 through 10","1971.77","3083.3","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL 8MM PLUS OFFSET REVERSE PROSTHESIS","SUP-ITM-10021989","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3773.00","2829.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1971.77","52.26","","1113.10","1113.10","1113.10","1 through 10","1971.77","3083.3","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL 8MM PLUS OFFSET REVERSE PROSTHESIS","SUP-ITM-10021989","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3773.00","2829.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3083.30","81.72","","1738.90","1484.65","2716.94","38","1971.77","3083.3","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL NECK NEUTRAL SHOULDER TURON IMPLANTABLE RUPTURED SUBSCAPULAR","SUP-ITM-10081035","CDM","C1776","HCPCS","0278","RC","","","","both","","","1312.50","984.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","685.91","52.26","","1113.10","1113.10","1113.10","1 through 10","406.88","1043.44","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL NECK NEUTRAL SHOULDER TURON IMPLANTABLE RUPTURED SUBSCAPULAR","SUP-ITM-10081035","CDM","C1776","HCPCS","0278","RC","","","","both","","","1312.50","984.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1043.44","79.5","","1293.60","1148.53","1603.80","1 through 10","406.88","1043.44","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL NECK NEUTRAL SHOULDER TURON IMPLANTABLE RUPTURED SUBSCAPULAR","SUP-ITM-10081035","CDM","C1776","HCPCS","0278","RC","","","","both","","","1312.50","984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","479.06","36.5","","1023.42","771.29","2068.67","33","406.88","1043.44","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL NECK NEUTRAL SHOULDER TURON IMPLANTABLE RUPTURED SUBSCAPULAR","SUP-ITM-10081035","CDM","C1776","HCPCS","0278","RC","","","","both","","","1312.50","984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","502.69","38.3","","850.52","759.78","1211.25","66","406.88","1043.44","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL NECK NEUTRAL SHOULDER TURON IMPLANTABLE RUPTURED SUBSCAPULAR","SUP-ITM-10081035","CDM","C1776","HCPCS","0278","RC","","","","both","","","1312.50","984.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.06","42.9","","2548.09","2548.09","2548.09","1 through 10","406.88","1043.44","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL NECK NEUTRAL SHOULDER TURON IMPLANTABLE RUPTURED SUBSCAPULAR","SUP-ITM-10081035","CDM","C1776","HCPCS","0278","RC","","","","both","","","1312.50","984.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.06","42.9","","956.46","956.46","956.46","1 through 10","406.88","1043.44","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL NECK NEUTRAL SHOULDER TURON IMPLANTABLE RUPTURED SUBSCAPULAR","SUP-ITM-10081035","CDM","C1776","HCPCS","0278","RC","","","","both","","","1312.50","984.37","WELLPOINT [1015]","HB AMC WELLPOINT","968.36","73.78","","2344.73","1619.47","2530.35","16","406.88","1043.44","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL NECK NEUTRAL SHOULDER TURON IMPLANTABLE RUPTURED SUBSCAPULAR","SUP-ITM-10081035","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","AETNA [1001]","HB AMC AETNA HMO","916.13","69.8","","1523.63","988.41","4330.26","39","685.91","1072.58","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL NECK NEUTRAL SHOULDER TURON IMPLANTABLE RUPTURED SUBSCAPULAR","SUP-ITM-10081035","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","AETNA [1001]","HB AMC AETNA PPO","1055.25","80.4","","1670.25","1670.25","1670.25","1 through 10","685.91","1072.58","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL NECK NEUTRAL SHOULDER TURON IMPLANTABLE RUPTURED SUBSCAPULAR","SUP-ITM-10081035","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","685.91","52.26","","1113.10","1113.10","1113.10","1 through 10","685.91","1072.58","percent of total billed charges",""
"SHOULDER SOCKET HUMERAL NECK NEUTRAL SHOULDER TURON IMPLANTABLE RUPTURED SUBSCAPULAR","SUP-ITM-10081035","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1312.50","984.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1072.58","81.72","","1738.90","1484.65","2716.94","38","685.91","1072.58","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","896.26","52.26","","1113.10","1113.10","1113.10","1 through 10","531.65","1363.43","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1363.43","79.5","","1293.60","1148.53","1603.80","1 through 10","531.65","1363.43","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","625.98","36.5","","1023.42","771.29","2068.67","33","531.65","1363.43","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","656.85","38.3","","850.52","759.78","1211.25","66","531.65","1363.43","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.74","42.9","","2548.09","2548.09","2548.09","1 through 10","531.65","1363.43","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","735.74","42.9","","956.46","956.46","956.46","1 through 10","531.65","1363.43","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1715.00","1286.25","WELLPOINT [1015]","HB AMC WELLPOINT","1265.33","73.78","","2344.73","1619.47","2530.35","16","531.65","1363.43","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","AETNA [1001]","HB AMC AETNA HMO","1197.07","69.8","","1523.63","988.41","4330.26","39","896.26","1401.5","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","AETNA [1001]","HB AMC AETNA PPO","1378.86","80.4","","1670.25","1670.25","1670.25","1 through 10","896.26","1401.5","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","896.26","52.26","","1113.10","1113.10","1113.10","1 through 10","896.26","1401.5","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1715.00","1286.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1401.50","81.72","","1738.90","1484.65","2716.94","38","896.26","1401.5","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","1136.21","852.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","593.78","52.26","","1113.10","1113.10","1113.10","1 through 10","352.23","903.29","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","1136.21","852.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","903.29","79.5","","1293.60","1148.53","1603.80","1 through 10","352.23","903.29","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","1136.21","852.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","414.72","36.5","","1023.42","771.29","2068.67","33","352.23","903.29","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","1136.21","852.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","435.17","38.3","","850.52","759.78","1211.25","66","352.23","903.29","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","1136.21","852.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","487.43","42.9","","2548.09","2548.09","2548.09","1 through 10","352.23","903.29","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","1136.21","852.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","487.43","42.9","","956.46","956.46","956.46","1 through 10","352.23","903.29","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","1136.21","852.16","WELLPOINT [1015]","HB AMC WELLPOINT","838.30","73.78","","2344.73","1619.47","2530.35","16","352.23","903.29","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1136.21","852.16","AETNA [1001]","HB AMC AETNA HMO","793.07","69.8","","1523.63","988.41","4330.26","39","593.78","928.51","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1136.21","852.16","AETNA [1001]","HB AMC AETNA PPO","913.51","80.4","","1670.25","1670.25","1670.25","1 through 10","593.78","928.51","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1136.21","852.16","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","593.78","52.26","","1113.10","1113.10","1113.10","1 through 10","593.78","928.51","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1136.21","852.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","928.51","81.72","","1738.90","1484.65","2716.94","38","593.78","928.51","percent of total billed charges",""
"SHOULDER SPACER 42MM 9 HUMERAL AEQUALIS GLENOID REVERSED PLUS","SUP-ITM-10031437","CDM","C1889","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1309.77","674.56","6049.93","26","1085","2782.5","percent of total billed charges",""
"SHOULDER SPACER 42MM 9 HUMERAL AEQUALIS GLENOID REVERSED PLUS","SUP-ITM-10031437","CDM","C1889","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1865.50","53.3","","1901.83","1901.83","2962.25","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER SPACER 42MM 9 HUMERAL AEQUALIS GLENOID REVERSED PLUS","SUP-ITM-10031437","CDM","C1889","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1620.31","1620.31","19908.88","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER SPACER 42MM 9 HUMERAL AEQUALIS GLENOID REVERSED PLUS","SUP-ITM-10031437","CDM","C1889","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","352.91","352.91","2046.30","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER SPACER 42MM 9 HUMERAL AEQUALIS GLENOID REVERSED PLUS","SUP-ITM-10031437","CDM","C1889","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","9668.75","9668.75","9668.75","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER SPACER 42MM 9 HUMERAL AEQUALIS GLENOID REVERSED PLUS","SUP-ITM-10031437","CDM","C1889","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","699.88","384.10","3443.31","33","1085","2782.5","percent of total billed charges",""
"SHOULDER SPACER 42MM 9 HUMERAL AEQUALIS GLENOID REVERSED PLUS","SUP-ITM-10031437","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1421.24","264.50","4933.46","29","1829.1","2860.2","percent of total billed charges",""
"SHOULDER SPACER 42MM 9 HUMERAL AEQUALIS GLENOID REVERSED PLUS","SUP-ITM-10031437","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2814.00","80.4","","1022.97","1022.97","3607.50","1 through 10","1829.1","2860.2","percent of total billed charges",""
"SHOULDER SPACER 42MM 9 HUMERAL AEQUALIS GLENOID REVERSED PLUS","SUP-ITM-10031437","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","3010.54","693.88","5019.88","35","1829.1","2860.2","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1023.42","771.29","2068.67","33","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","850.52","759.78","1211.25","66","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","956.46","956.46","956.46","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2344.73","1619.47","2530.35","16","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1523.63","988.41","4330.26","39","1829.1","2860.2","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1829.1","2860.2","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1829.1","2860.2","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","1738.90","1484.65","2716.94","38","1829.1","2860.2","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","1023.42","771.29","2068.67","33","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","850.52","759.78","1211.25","66","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","956.46","956.46","956.46","1 through 10","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","2344.73","1619.47","2530.35","16","1085","2782.5","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","1523.63","988.41","4330.26","39","1829.1","2860.2","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","1670.25","1670.25","1670.25","1 through 10","1829.1","2860.2","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","1113.10","1113.10","1113.10","1 through 10","1829.1","2860.2","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","1738.90","1484.65","2716.94","38","1829.1","2860.2","percent of total billed charges",""
"SHOULDER SPHERE GLENOID 40MM DIA REGULAR REVERSE STD SCREW LOCKING TI RSP","SUP-ITM-10021998","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2209.55","52.26","","1113.10","1113.10","1113.10","1 through 10","1310.68","3361.26","percent of total billed charges",""
"SHOULDER SPHERE GLENOID 40MM DIA REGULAR REVERSE STD SCREW LOCKING TI RSP","SUP-ITM-10021998","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3361.26","79.5","","1293.60","1148.53","1603.80","1 through 10","1310.68","3361.26","percent of total billed charges",""
"SHOULDER SPHERE GLENOID 40MM DIA REGULAR REVERSE STD SCREW LOCKING TI RSP","SUP-ITM-10021998","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1543.22","36.5","","1023.42","771.29","2068.67","33","1310.68","3361.26","percent of total billed charges",""
"SHOULDER SPHERE GLENOID 40MM DIA REGULAR REVERSE STD SCREW LOCKING TI RSP","SUP-ITM-10021998","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1619.32","38.3","","850.52","759.78","1211.25","66","1310.68","3361.26","percent of total billed charges",""
"SHOULDER SPHERE GLENOID 40MM DIA REGULAR REVERSE STD SCREW LOCKING TI RSP","SUP-ITM-10021998","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.81","42.9","","2548.09","2548.09","2548.09","1 through 10","1310.68","3361.26","percent of total billed charges",""
"SHOULDER SPHERE GLENOID 40MM DIA REGULAR REVERSE STD SCREW LOCKING TI RSP","SUP-ITM-10021998","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1813.81","42.9","","956.46","956.46","956.46","1 through 10","1310.68","3361.26","percent of total billed charges",""
"SHOULDER SPHERE GLENOID 40MM DIA REGULAR REVERSE STD SCREW LOCKING TI RSP","SUP-ITM-10021998","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","WELLPOINT [1015]","HB AMC WELLPOINT","3119.42","73.78","","2344.73","1619.47","2530.35","16","1310.68","3361.26","percent of total billed charges",""
"SHOULDER SPHERE GLENOID 40MM DIA REGULAR REVERSE STD SCREW LOCKING TI RSP","SUP-ITM-10021998","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","AETNA [1001]","HB AMC AETNA HMO","2951.14","69.8","","1523.63","988.41","4330.26","39","2209.55","3455.12","percent of total billed charges",""
"SHOULDER SPHERE GLENOID 40MM DIA REGULAR REVERSE STD SCREW LOCKING TI RSP","SUP-ITM-10021998","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","AETNA [1001]","HB AMC AETNA PPO","3399.31","80.4","","1670.25","1670.25","1670.25","1 through 10","2209.55","3455.12","percent of total billed charges",""
"SHOULDER SPHERE GLENOID 40MM DIA REGULAR REVERSE STD SCREW LOCKING TI RSP","SUP-ITM-10021998","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2209.55","52.26","","1113.10","1113.10","1113.10","1 through 10","2209.55","3455.12","percent of total billed charges",""
"SHOULDER SPHERE GLENOID 40MM DIA REGULAR REVERSE STD SCREW LOCKING TI RSP","SUP-ITM-10021998","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3455.12","81.72","","1738.90","1484.65","2716.94","38","2209.55","3455.12","percent of total billed charges",""
"SHOULDER STEM 15MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136084","CDM","C1776","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3919.50","52.26","","1113.10","1113.10","1113.10","1 through 10","2325","5962.5","percent of total billed charges",""
"SHOULDER STEM 15MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136084","CDM","C1776","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5962.50","79.5","","1293.60","1148.53","1603.80","1 through 10","2325","5962.5","percent of total billed charges",""
"SHOULDER STEM 15MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136084","CDM","C1776","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2737.50","36.5","","1023.42","771.29","2068.67","33","2325","5962.5","percent of total billed charges",""
"SHOULDER STEM 15MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136084","CDM","C1776","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2872.50","38.3","","850.52","759.78","1211.25","66","2325","5962.5","percent of total billed charges",""
"SHOULDER STEM 15MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136084","CDM","C1776","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3217.50","42.9","","2548.09","2548.09","2548.09","1 through 10","2325","5962.5","percent of total billed charges",""
"SHOULDER STEM 15MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136084","CDM","C1776","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3217.50","42.9","","956.46","956.46","956.46","1 through 10","2325","5962.5","percent of total billed charges",""
"SHOULDER STEM 15MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136084","CDM","C1776","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","WELLPOINT [1015]","HB AMC WELLPOINT","5533.50","73.78","","2344.73","1619.47","2530.35","16","2325","5962.5","percent of total billed charges",""
"SHOULDER STEM 15MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136084","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","AETNA [1001]","HB AMC AETNA HMO","5235.00","69.8","","1523.63","988.41","4330.26","39","3919.5","6129","percent of total billed charges",""
"SHOULDER STEM 15MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136084","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","AETNA [1001]","HB AMC AETNA PPO","6030.00","80.4","","1670.25","1670.25","1670.25","1 through 10","3919.5","6129","percent of total billed charges",""
"SHOULDER STEM 15MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136084","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3919.50","52.26","","1113.10","1113.10","1113.10","1 through 10","3919.5","6129","percent of total billed charges",""
"SHOULDER STEM 15MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136084","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6129.00","81.72","","1738.90","1484.65","2716.94","38","3919.5","6129","percent of total billed charges",""
"SHOULDER STEM 42MM HUMERAL AEQUALIS CEMENTED METAPHYSIS REVERSED","SUP-ITM-10031436","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1737.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SHOULDER STEM 42MM HUMERAL AEQUALIS CEMENTED METAPHYSIS REVERSED","SUP-ITM-10031436","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2643.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SHOULDER STEM 42MM HUMERAL AEQUALIS CEMENTED METAPHYSIS REVERSED","SUP-ITM-10031436","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1213.63","36.5","","1023.42","771.29","2068.67","33","1030.75","2643.38","percent of total billed charges",""
"SHOULDER STEM 42MM HUMERAL AEQUALIS CEMENTED METAPHYSIS REVERSED","SUP-ITM-10031436","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1273.48","38.3","","850.52","759.78","1211.25","66","1030.75","2643.38","percent of total billed charges",""
"SHOULDER STEM 42MM HUMERAL AEQUALIS CEMENTED METAPHYSIS REVERSED","SUP-ITM-10031436","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","2548.09","2548.09","2548.09","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SHOULDER STEM 42MM HUMERAL AEQUALIS CEMENTED METAPHYSIS REVERSED","SUP-ITM-10031436","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","956.46","956.46","956.46","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SHOULDER STEM 42MM HUMERAL AEQUALIS CEMENTED METAPHYSIS REVERSED","SUP-ITM-10031436","CDM","C1776","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","WELLPOINT [1015]","HB AMC WELLPOINT","2453.19","73.78","","2344.73","1619.47","2530.35","16","1030.75","2643.38","percent of total billed charges",""
"SHOULDER STEM 42MM HUMERAL AEQUALIS CEMENTED METAPHYSIS REVERSED","SUP-ITM-10031436","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA HMO","2320.85","69.8","","1523.63","988.41","4330.26","39","1737.65","2717.19","percent of total billed charges",""
"SHOULDER STEM 42MM HUMERAL AEQUALIS CEMENTED METAPHYSIS REVERSED","SUP-ITM-10031436","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA PPO","2673.30","80.4","","1670.25","1670.25","1670.25","1 through 10","1737.65","2717.19","percent of total billed charges",""
"SHOULDER STEM 42MM HUMERAL AEQUALIS CEMENTED METAPHYSIS REVERSED","SUP-ITM-10031436","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1737.65","52.26","","1113.10","1113.10","1113.10","1 through 10","1737.65","2717.19","percent of total billed charges",""
"SHOULDER STEM 42MM HUMERAL AEQUALIS CEMENTED METAPHYSIS REVERSED","SUP-ITM-10031436","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2717.19","81.72","","1738.90","1484.65","2716.94","38","1737.65","2717.19","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX210 AEQUALIS CEMENT REVERSED","SUP-ITM-10136089","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2613.00","52.26","","1113.10","1113.10","1113.10","1 through 10","1550","3975","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX210 AEQUALIS CEMENT REVERSED","SUP-ITM-10136089","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1550","3975","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX210 AEQUALIS CEMENT REVERSED","SUP-ITM-10136089","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","1023.42","771.29","2068.67","33","1550","3975","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX210 AEQUALIS CEMENT REVERSED","SUP-ITM-10136089","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","850.52","759.78","1211.25","66","1550","3975","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX210 AEQUALIS CEMENT REVERSED","SUP-ITM-10136089","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","2548.09","2548.09","2548.09","1 through 10","1550","3975","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX210 AEQUALIS CEMENT REVERSED","SUP-ITM-10136089","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","956.46","956.46","956.46","1 through 10","1550","3975","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX210 AEQUALIS CEMENT REVERSED","SUP-ITM-10136089","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","2344.73","1619.47","2530.35","16","1550","3975","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX210 AEQUALIS CEMENT REVERSED","SUP-ITM-10136089","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","1523.63","988.41","4330.26","39","2613","4086","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX210 AEQUALIS CEMENT REVERSED","SUP-ITM-10136089","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA PPO","4020.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2613","4086","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX210 AEQUALIS CEMENT REVERSED","SUP-ITM-10136089","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2613.00","52.26","","1113.10","1113.10","1113.10","1 through 10","2613","4086","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX210 AEQUALIS CEMENT REVERSED","SUP-ITM-10136089","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","1738.90","1484.65","2716.94","38","2613","4086","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5879.25","52.26","","1113.10","1113.10","1113.10","1 through 10","3487.5","8943.75","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8943.75","79.5","","1293.60","1148.53","1603.80","1 through 10","3487.5","8943.75","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4106.25","36.5","","1023.42","771.29","2068.67","33","3487.5","8943.75","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4308.75","38.3","","850.52","759.78","1211.25","66","3487.5","8943.75","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4826.25","42.9","","2548.09","2548.09","2548.09","1 through 10","3487.5","8943.75","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4826.25","42.9","","956.46","956.46","956.46","1 through 10","3487.5","8943.75","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","11250.00","8437.50","WELLPOINT [1015]","HB AMC WELLPOINT","8300.25","73.78","","2344.73","1619.47","2530.35","16","3487.5","8943.75","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11250.00","8437.50","AETNA [1001]","HB AMC AETNA HMO","7852.50","69.8","","1523.63","988.41","4330.26","39","5879.25","9193.5","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11250.00","8437.50","AETNA [1001]","HB AMC AETNA PPO","9045.00","80.4","","1670.25","1670.25","1670.25","1 through 10","5879.25","9193.5","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11250.00","8437.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","5879.25","52.26","","1113.10","1113.10","1113.10","1 through 10","5879.25","9193.5","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11250.00","8437.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9193.50","81.72","","1738.90","1484.65","2716.94","38","5879.25","9193.5","percent of total billed charges",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","","","","inpatient","","","135628.68","101721.51","MEDICARE [2001]","HB BWH MEDICARE","24997.71","","Case rate ($24,997.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,214.18, add-ons for qualifying new technology services are included. If operating cost exceeds $68,858.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,113.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $22,944.65 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,834.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,673.21. The transfer capital threshold is the transfer adjustment factor * $1,673.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23426.45","23399.17","23433.75","1 through 10","18961.39","29596.4692","other","Inpatient DRG"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With McC","510","MS-DRG","","","","","","","","inpatient","","","161856.33","121392.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","27933.16","","Case rate ($27,933.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $33,548.60, add-ons for qualifying new technology services are included. If operating cost exceeds $79,193.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,870.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $25,122.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $33,168.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,430.47. The transfer capital threshold is the transfer adjustment factor * $2,430.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25935.87","25935.87","25935.87","1 through 10","27374.5","43131.5871","other","Inpatient Replacement Plans DRG"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With McC","510","MS-DRG","","","","","","","","inpatient","","","161856.33","121392.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","27933.16","","Case rate ($27,933.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $33,548.60, add-ons for qualifying new technology services are included. If operating cost exceeds $79,193.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,870.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $25,122.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $33,168.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,430.47. The transfer capital threshold is the transfer adjustment factor * $2,430.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25729.50","25729.50","25729.50","1 through 10","27374.5","43131.5871","other","Inpatient DRG"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With McC","510","MS-DRG","","","","","","","","inpatient","","","161856.33","121392.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","27374.50","","Case rate ($27,933.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $33,548.60, add-ons for qualifying new technology services are included. If operating cost exceeds $79,193.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,870.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $25,122.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $33,168.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,430.47. The transfer capital threshold is the transfer adjustment factor * $2,430.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25229.64","25229.64","25229.64","1 through 10","27374.5","43131.5871","other","Inpatient DRG"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/McC","512","MS-DRG","","","","","","","","inpatient","","","84744.31","63558.23","MEDICARE [2001]","HB BWH MEDICARE","19977.99","","Case rate ($19,977.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,558.15, add-ons for qualifying new technology services are included. If operating cost exceeds $64,202.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,772.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $18,266.13 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,178.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,332.03. The transfer capital threshold is the transfer adjustment factor * $1,332.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19261.23","19261.23","19261.23","1 through 10","15170.96","24263.3098","other","Inpatient DRG"
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,EXTREME","315","DRG","","","","","","","","inpatient","","","161856.33","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","19599.067","","Fee schedule rate ($61,690.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19599.067","132299.00","132299.00","1 through 10","10228.75","132492.2","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MAJOR","315","DRG","","","","","","","","inpatient","","","184347.11","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","72476.18","","Standard inlier is a Case rate ($72,476.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $68,007, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,288.43) for the length of stay and the standard reimbursement.","66064.68","66064.68","66064.68","1 through 10","10228.75","132492.2","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MAJOR","315","DRG","","","","","","","","inpatient","","","184347.11","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","81482.76","","Standard inlier is a Case rate ($81,482.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $68,007, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,565.80) for the length of stay and the standard reimbursement.","9427.88","9427.88","9427.88","1 through 10","10228.75","132492.2","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MAJOR","315","DRG","","","","","","","","inpatient","","","184347.11","","MASSHEALTH [3001]","HB BWH MEDICAID","24060.51","","Case rate ($26,603.03). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $69,033.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29910.25","29910.25","29910.25","1 through 10","10228.75","132492.2","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MAJOR","315","DRG","","","","","","","","inpatient","","","184347.11","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","24060.51","","Case rate ($26,603.03). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $69,033.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","10228.75","132492.2","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MAJOR","315","DRG","","","","","","","","inpatient","","","184347.11","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66134.42","","Fee schedule rate ($66,134.42). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","66134.42","66134.42","66134.42","1 through 10","10228.75","132492.2","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MAJOR","315","DRG","","","","","","","","inpatient","","","184347.11","","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","19599.067","","Fee schedule rate ($61,690.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19599.067","62137.22","62137.22","1 through 10","10228.75","132492.2","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MINOR","315","DRG","","","","","","","","inpatient","","","89258.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","34167.49","","Standard inlier is a Case rate ($34,167.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,282, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,849.79) for the length of stay and the standard reimbursement.","34167.49","34167.49","34167.49","1 through 10","10228.75","132492.2","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MODERATE","315","DRG","","","","","","","","inpatient","","","104886.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","48640.86","","Standard inlier is a Case rate ($48,640.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,472, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,904.86) for the length of stay and the standard reimbursement.","44337.92","44337.92","44337.92","1 through 10","10228.75","132492.2","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MODERATE","315","DRG","","","","","","","","inpatient","","","104886.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","54685.44","","Standard inlier is a Case rate ($54,685.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $49,472, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,762.14) for the length of stay and the standard reimbursement.","54685.44","54685.44","54685.44","1 through 10","10228.75","132492.2","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MODERATE","315","DRG","","","","","","","","inpatient","","","104886.86","","MASSHEALTH [3001]","HB BWH MEDICAID","14102.51","","Case rate ($15,592.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,022.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2353.65","2353.65","2353.65","1 through 10","10228.75","132492.2","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MODERATE","315","DRG","","","","","","","","inpatient","","","104886.86","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","14102.51","","Case rate ($15,592.75). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,022.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16524.26","16524.26","16524.26","1 through 10","10228.75","132492.2","case rate",""
"Shox (Ghd) Dna Seq/Del","PX-31000261","CDM","81479","CPT","0310","RC","","","","both","","","1716.00","1287.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1364.22","79.5","","0.65","0.65","0.65","1 through 10","531.96","1630.2","percent of total billed charges",""
"Shox (Ghd) Dna Seq/Del","PX-31000261","CDM","81479","CPT","0310","RC","","","","both","","","1716.00","1287.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","914.63","53.3","","0.79","0.79","0.79","1 through 10","531.96","1630.2","percent of total billed charges",""
"Shox (Ghd) Dna Seq/Del","PX-31000261","CDM","81479","CPT","0310","RC","","","","outpatient","","","1716.00","1287.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","858.00","50","","1.00","1.00","1.00","1 through 10","156.55","1415.7","percent of total billed charges",""
"Shox (Ghd) Dna Seq/Del","PX-31000261","CDM","81479","CPT","0310","RC","","","","outpatient","","","1716.00","1287.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","900.90","52.5","","1.00","0.53","1.00","1 through 10","156.55","1415.7","percent of total billed charges",""
"SHUNT ARTERIOTOMY 1.25X14MM INTRACORONARY CLEARVIEW PK/5EA","SUP-ITM-10129697","CDM","C1889","HCPCS","0278","RC","","","","both","","","203.00","152.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","161.39","79.5","","1309.77","674.56","6049.93","26","62.93","161.39","percent of total billed charges",""
"SHUNT ARTERIOTOMY 1.25X14MM INTRACORONARY CLEARVIEW PK/5EA","SUP-ITM-10129697","CDM","C1889","HCPCS","0278","RC","","","","both","","","203.00","152.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","108.20","53.3","","1901.83","1901.83","2962.25","1 through 10","62.93","161.39","percent of total billed charges",""
"SHUNT ARTERIOTOMY 1.25X14MM INTRACORONARY CLEARVIEW PK/5EA","SUP-ITM-10129697","CDM","C1889","HCPCS","0278","RC","","","","both","","","203.00","152.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.10","36.5","","1620.31","1620.31","19908.88","1 through 10","62.93","161.39","percent of total billed charges",""
"SHUNT ARTERIOTOMY 1.25X14MM INTRACORONARY CLEARVIEW PK/5EA","SUP-ITM-10129697","CDM","C1889","HCPCS","0278","RC","","","","both","","","203.00","152.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.75","38.3","","352.91","352.91","2046.30","1 through 10","62.93","161.39","percent of total billed charges",""
"SHUNT ARTERIOTOMY 1.25X14MM INTRACORONARY CLEARVIEW PK/5EA","SUP-ITM-10129697","CDM","C1889","HCPCS","0278","RC","","","","both","","","203.00","152.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.09","42.9","","9668.75","9668.75","9668.75","1 through 10","62.93","161.39","percent of total billed charges",""
"SHUNT ARTERIOTOMY 1.25X14MM INTRACORONARY CLEARVIEW PK/5EA","SUP-ITM-10129697","CDM","C1889","HCPCS","0278","RC","","","","both","","","203.00","152.25","WELLPOINT [1015]","HB AMC WELLPOINT","149.77","73.78","","699.88","384.10","3443.31","33","62.93","161.39","percent of total billed charges",""
"SHUNT ARTERIOTOMY 1.25X14MM INTRACORONARY CLEARVIEW PK/5EA","SUP-ITM-10129697","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","203.00","152.25","AETNA [1001]","HB AMC AETNA HMO","141.69","69.8","","1421.24","264.50","4933.46","29","106.09","165.89","percent of total billed charges",""
"SHUNT ARTERIOTOMY 1.25X14MM INTRACORONARY CLEARVIEW PK/5EA","SUP-ITM-10129697","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","203.00","152.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","163.21","80.4","","1022.97","1022.97","3607.50","1 through 10","106.09","165.89","percent of total billed charges",""
"SHUNT ARTERIOTOMY 1.25X14MM INTRACORONARY CLEARVIEW PK/5EA","SUP-ITM-10129697","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","203.00","152.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.89","81.72","","3010.54","693.88","5019.88","35","106.09","165.89","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","865.13","648.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","687.78","79.5","","1309.77","674.56","6049.93","26","268.19","687.78","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","865.13","648.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","461.11","53.3","","1901.83","1901.83","2962.25","1 through 10","268.19","687.78","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","865.13","648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","315.77","36.5","","1620.31","1620.31","19908.88","1 through 10","268.19","687.78","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","865.13","648.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","331.34","38.3","","352.91","352.91","2046.30","1 through 10","268.19","687.78","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","865.13","648.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","371.14","42.9","","9668.75","9668.75","9668.75","1 through 10","268.19","687.78","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","865.13","648.85","WELLPOINT [1015]","HB AMC WELLPOINT","638.29","73.78","","699.88","384.10","3443.31","33","268.19","687.78","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","865.13","648.85","AETNA [1001]","HB AMC AETNA HMO","603.86","69.8","","1421.24","264.50","4933.46","29","452.12","706.98","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","865.13","648.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","695.56","80.4","","1022.97","1022.97","3607.50","1 through 10","452.12","706.98","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","865.13","648.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","706.98","81.72","","3010.54","693.88","5019.88","35","452.12","706.98","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4922.58","3691.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3913.45","79.5","","1309.77","674.56","6049.93","26","1526","3913.45","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4922.58","3691.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2623.74","53.3","","1901.83","1901.83","2962.25","1 through 10","1526","3913.45","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4922.58","3691.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1796.74","36.5","","1620.31","1620.31","19908.88","1 through 10","1526","3913.45","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4922.58","3691.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1885.35","38.3","","352.91","352.91","2046.30","1 through 10","1526","3913.45","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4922.58","3691.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2111.79","42.9","","9668.75","9668.75","9668.75","1 through 10","1526","3913.45","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4922.58","3691.93","WELLPOINT [1015]","HB AMC WELLPOINT","3631.88","73.78","","699.88","384.10","3443.31","33","1526","3913.45","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4922.58","3691.93","AETNA [1001]","HB AMC AETNA HMO","3435.96","69.8","","1421.24","264.50","4933.46","29","2572.54","4022.73","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4922.58","3691.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3957.75","80.4","","1022.97","1022.97","3607.50","1 through 10","2572.54","4022.73","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4922.58","3691.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4022.73","81.72","","3010.54","693.88","5019.88","35","2572.54","4022.73","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","5637.10","4227.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4481.49","79.5","","1309.77","674.56","6049.93","26","1747.5","4481.49","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","5637.10","4227.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3004.57","53.3","","1901.83","1901.83","2962.25","1 through 10","1747.5","4481.49","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","5637.10","4227.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2057.54","36.5","","1620.31","1620.31","19908.88","1 through 10","1747.5","4481.49","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","5637.10","4227.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2159.01","38.3","","352.91","352.91","2046.30","1 through 10","1747.5","4481.49","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","5637.10","4227.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2418.32","42.9","","9668.75","9668.75","9668.75","1 through 10","1747.5","4481.49","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","5637.10","4227.82","WELLPOINT [1015]","HB AMC WELLPOINT","4159.05","73.78","","699.88","384.10","3443.31","33","1747.5","4481.49","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5637.10","4227.82","AETNA [1001]","HB AMC AETNA HMO","3934.70","69.8","","1421.24","264.50","4933.46","29","2945.95","4606.64","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5637.10","4227.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4532.23","80.4","","1022.97","1022.97","3607.50","1 through 10","2945.95","4606.64","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5637.10","4227.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4606.64","81.72","","3010.54","693.88","5019.88","35","2945.95","4606.64","percent of total billed charges",""
"SHUNT CAROTID 1CM 4.0X5.0MM 30 SUNDT EXTERNAL SILICONE SS LOOP NONREINFORCE CENTER ENDARTERECTOMY","SUP-ITM-10042530","CDM","C1889","HCPCS","0278","RC","","","","both","","","2619.47","1964.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2082.48","79.5","","1309.77","674.56","6049.93","26","812.04","2082.48","percent of total billed charges",""
"SHUNT CAROTID 1CM 4.0X5.0MM 30 SUNDT EXTERNAL SILICONE SS LOOP NONREINFORCE CENTER ENDARTERECTOMY","SUP-ITM-10042530","CDM","C1889","HCPCS","0278","RC","","","","both","","","2619.47","1964.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1396.18","53.3","","1901.83","1901.83","2962.25","1 through 10","812.04","2082.48","percent of total billed charges",""
"SHUNT CAROTID 1CM 4.0X5.0MM 30 SUNDT EXTERNAL SILICONE SS LOOP NONREINFORCE CENTER ENDARTERECTOMY","SUP-ITM-10042530","CDM","C1889","HCPCS","0278","RC","","","","both","","","2619.47","1964.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","956.11","36.5","","1620.31","1620.31","19908.88","1 through 10","812.04","2082.48","percent of total billed charges",""
"SHUNT CAROTID 1CM 4.0X5.0MM 30 SUNDT EXTERNAL SILICONE SS LOOP NONREINFORCE CENTER ENDARTERECTOMY","SUP-ITM-10042530","CDM","C1889","HCPCS","0278","RC","","","","both","","","2619.47","1964.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1003.26","38.3","","352.91","352.91","2046.30","1 through 10","812.04","2082.48","percent of total billed charges",""
"SHUNT CAROTID 1CM 4.0X5.0MM 30 SUNDT EXTERNAL SILICONE SS LOOP NONREINFORCE CENTER ENDARTERECTOMY","SUP-ITM-10042530","CDM","C1889","HCPCS","0278","RC","","","","both","","","2619.47","1964.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1123.75","42.9","","9668.75","9668.75","9668.75","1 through 10","812.04","2082.48","percent of total billed charges",""
"SHUNT CAROTID 1CM 4.0X5.0MM 30 SUNDT EXTERNAL SILICONE SS LOOP NONREINFORCE CENTER ENDARTERECTOMY","SUP-ITM-10042530","CDM","C1889","HCPCS","0278","RC","","","","both","","","2619.47","1964.60","WELLPOINT [1015]","HB AMC WELLPOINT","1932.64","73.78","","699.88","384.10","3443.31","33","812.04","2082.48","percent of total billed charges",""
"SHUNT CAROTID 1CM 4.0X5.0MM 30 SUNDT EXTERNAL SILICONE SS LOOP NONREINFORCE CENTER ENDARTERECTOMY","SUP-ITM-10042530","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2619.47","1964.60","AETNA [1001]","HB AMC AETNA HMO","1828.39","69.8","","1421.24","264.50","4933.46","29","1368.94","2140.63","percent of total billed charges",""
"SHUNT CAROTID 1CM 4.0X5.0MM 30 SUNDT EXTERNAL SILICONE SS LOOP NONREINFORCE CENTER ENDARTERECTOMY","SUP-ITM-10042530","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2619.47","1964.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2106.05","80.4","","1022.97","1022.97","3607.50","1 through 10","1368.94","2140.63","percent of total billed charges",""
"SHUNT CAROTID 1CM 4.0X5.0MM 30 SUNDT EXTERNAL SILICONE SS LOOP NONREINFORCE CENTER ENDARTERECTOMY","SUP-ITM-10042530","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2619.47","1964.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2140.63","81.72","","3010.54","693.88","5019.88","35","1368.94","2140.63","percent of total billed charges",""
"SHUNT CAROTID 3X4MM LENGTH 30CM ENDARTERECTOMY SUNDT SILICONE SS EXTERNAL LOOP FULL SPRING REINFORCED","SUP-ITM-10008824","CDM","C1889","HCPCS","0278","RC","","","","both","","","2121.42","1591.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1686.53","79.5","","1309.77","674.56","6049.93","26","657.64","1686.53","percent of total billed charges",""
"SHUNT CAROTID 3X4MM LENGTH 30CM ENDARTERECTOMY SUNDT SILICONE SS EXTERNAL LOOP FULL SPRING REINFORCED","SUP-ITM-10008824","CDM","C1889","HCPCS","0278","RC","","","","both","","","2121.42","1591.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1130.72","53.3","","1901.83","1901.83","2962.25","1 through 10","657.64","1686.53","percent of total billed charges",""
"SHUNT CAROTID 3X4MM LENGTH 30CM ENDARTERECTOMY SUNDT SILICONE SS EXTERNAL LOOP FULL SPRING REINFORCED","SUP-ITM-10008824","CDM","C1889","HCPCS","0278","RC","","","","both","","","2121.42","1591.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","774.32","36.5","","1620.31","1620.31","19908.88","1 through 10","657.64","1686.53","percent of total billed charges",""
"SHUNT CAROTID 3X4MM LENGTH 30CM ENDARTERECTOMY SUNDT SILICONE SS EXTERNAL LOOP FULL SPRING REINFORCED","SUP-ITM-10008824","CDM","C1889","HCPCS","0278","RC","","","","both","","","2121.42","1591.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","812.50","38.3","","352.91","352.91","2046.30","1 through 10","657.64","1686.53","percent of total billed charges",""
"SHUNT CAROTID 3X4MM LENGTH 30CM ENDARTERECTOMY SUNDT SILICONE SS EXTERNAL LOOP FULL SPRING REINFORCED","SUP-ITM-10008824","CDM","C1889","HCPCS","0278","RC","","","","both","","","2121.42","1591.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","910.09","42.9","","9668.75","9668.75","9668.75","1 through 10","657.64","1686.53","percent of total billed charges",""
"SHUNT CAROTID 3X4MM LENGTH 30CM ENDARTERECTOMY SUNDT SILICONE SS EXTERNAL LOOP FULL SPRING REINFORCED","SUP-ITM-10008824","CDM","C1889","HCPCS","0278","RC","","","","both","","","2121.42","1591.06","WELLPOINT [1015]","HB AMC WELLPOINT","1565.18","73.78","","699.88","384.10","3443.31","33","657.64","1686.53","percent of total billed charges",""
"SHUNT CAROTID 3X4MM LENGTH 30CM ENDARTERECTOMY SUNDT SILICONE SS EXTERNAL LOOP FULL SPRING REINFORCED","SUP-ITM-10008824","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2121.42","1591.06","AETNA [1001]","HB AMC AETNA HMO","1480.75","69.8","","1421.24","264.50","4933.46","29","1108.65","1733.62","percent of total billed charges",""
"SHUNT CAROTID 3X4MM LENGTH 30CM ENDARTERECTOMY SUNDT SILICONE SS EXTERNAL LOOP FULL SPRING REINFORCED","SUP-ITM-10008824","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2121.42","1591.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1705.62","80.4","","1022.97","1022.97","3607.50","1 through 10","1108.65","1733.62","percent of total billed charges",""
"SHUNT CAROTID 3X4MM LENGTH 30CM ENDARTERECTOMY SUNDT SILICONE SS EXTERNAL LOOP FULL SPRING REINFORCED","SUP-ITM-10008824","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2121.42","1591.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1733.62","81.72","","3010.54","693.88","5019.88","35","1108.65","1733.62","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3197.09","79.5","","1309.77","674.56","6049.93","26","1246.67","3197.09","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2143.46","53.3","","1901.83","1901.83","2962.25","1 through 10","1246.67","3197.09","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1467.85","36.5","","1620.31","1620.31","19908.88","1 through 10","1246.67","3197.09","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1540.23","38.3","","352.91","352.91","2046.30","1 through 10","1246.67","3197.09","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1725.22","42.9","","9668.75","9668.75","9668.75","1 through 10","1246.67","3197.09","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","both","","","4021.50","3016.12","WELLPOINT [1015]","HB AMC WELLPOINT","2967.06","73.78","","699.88","384.10","3443.31","33","1246.67","3197.09","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4021.50","3016.12","AETNA [1001]","HB AMC AETNA HMO","2807.01","69.8","","1421.24","264.50","4933.46","29","2101.64","3286.37","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4021.50","3016.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3233.29","80.4","","1022.97","1022.97","3607.50","1 through 10","2101.64","3286.37","percent of total billed charges",""
"SHUNT CAROTID 9.0FR 31CM PRUITT F3 T PORT","SUP-ITM-10139753","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4021.50","3016.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3286.37","81.72","","3010.54","693.88","5019.88","35","2101.64","3286.37","percent of total billed charges",""
"SHUNT CEREBRAL 0X90CM LEVEL 1 SPINAL FLUID DELTA ASSEMBLY REGULAR CATHETER OPEN END WALL SLIT","SUP-ITM-10023088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3075.96","2306.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2445.39","79.5","","1309.77","674.56","6049.93","26","953.55","2445.39","percent of total billed charges",""
"SHUNT CEREBRAL 0X90CM LEVEL 1 SPINAL FLUID DELTA ASSEMBLY REGULAR CATHETER OPEN END WALL SLIT","SUP-ITM-10023088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3075.96","2306.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1639.49","53.3","","1901.83","1901.83","2962.25","1 through 10","953.55","2445.39","percent of total billed charges",""
"SHUNT CEREBRAL 0X90CM LEVEL 1 SPINAL FLUID DELTA ASSEMBLY REGULAR CATHETER OPEN END WALL SLIT","SUP-ITM-10023088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3075.96","2306.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1122.73","36.5","","1620.31","1620.31","19908.88","1 through 10","953.55","2445.39","percent of total billed charges",""
"SHUNT CEREBRAL 0X90CM LEVEL 1 SPINAL FLUID DELTA ASSEMBLY REGULAR CATHETER OPEN END WALL SLIT","SUP-ITM-10023088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3075.96","2306.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1178.09","38.3","","352.91","352.91","2046.30","1 through 10","953.55","2445.39","percent of total billed charges",""
"SHUNT CEREBRAL 0X90CM LEVEL 1 SPINAL FLUID DELTA ASSEMBLY REGULAR CATHETER OPEN END WALL SLIT","SUP-ITM-10023088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3075.96","2306.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1319.59","42.9","","9668.75","9668.75","9668.75","1 through 10","953.55","2445.39","percent of total billed charges",""
"SHUNT CEREBRAL 0X90CM LEVEL 1 SPINAL FLUID DELTA ASSEMBLY REGULAR CATHETER OPEN END WALL SLIT","SUP-ITM-10023088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3075.96","2306.97","WELLPOINT [1015]","HB AMC WELLPOINT","2269.44","73.78","","699.88","384.10","3443.31","33","953.55","2445.39","percent of total billed charges",""
"SHUNT CEREBRAL 0X90CM LEVEL 1 SPINAL FLUID DELTA ASSEMBLY REGULAR CATHETER OPEN END WALL SLIT","SUP-ITM-10023088","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3075.96","2306.97","AETNA [1001]","HB AMC AETNA HMO","2147.02","69.8","","1421.24","264.50","4933.46","29","1607.5","2513.67","percent of total billed charges",""
"SHUNT CEREBRAL 0X90CM LEVEL 1 SPINAL FLUID DELTA ASSEMBLY REGULAR CATHETER OPEN END WALL SLIT","SUP-ITM-10023088","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3075.96","2306.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2473.07","80.4","","1022.97","1022.97","3607.50","1 through 10","1607.5","2513.67","percent of total billed charges",""
"SHUNT CEREBRAL 0X90CM LEVEL 1 SPINAL FLUID DELTA ASSEMBLY REGULAR CATHETER OPEN END WALL SLIT","SUP-ITM-10023088","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3075.96","2306.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2513.67","81.72","","3010.54","693.88","5019.88","35","1607.5","2513.67","percent of total billed charges",""
"SHUNT CORONARY 1.25X16.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10010573","CDM","C1889","HCPCS","0278","RC","","","","both","","","354.83","266.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","282.09","79.5","","1309.77","674.56","6049.93","26","110","282.09","percent of total billed charges",""
"SHUNT CORONARY 1.25X16.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10010573","CDM","C1889","HCPCS","0278","RC","","","","both","","","354.83","266.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","189.12","53.3","","1901.83","1901.83","2962.25","1 through 10","110","282.09","percent of total billed charges",""
"SHUNT CORONARY 1.25X16.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10010573","CDM","C1889","HCPCS","0278","RC","","","","both","","","354.83","266.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","129.51","36.5","","1620.31","1620.31","19908.88","1 through 10","110","282.09","percent of total billed charges",""
"SHUNT CORONARY 1.25X16.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10010573","CDM","C1889","HCPCS","0278","RC","","","","both","","","354.83","266.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","135.90","38.3","","352.91","352.91","2046.30","1 through 10","110","282.09","percent of total billed charges",""
"SHUNT CORONARY 1.25X16.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10010573","CDM","C1889","HCPCS","0278","RC","","","","both","","","354.83","266.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","152.22","42.9","","9668.75","9668.75","9668.75","1 through 10","110","282.09","percent of total billed charges",""
"SHUNT CORONARY 1.25X16.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10010573","CDM","C1889","HCPCS","0278","RC","","","","both","","","354.83","266.12","WELLPOINT [1015]","HB AMC WELLPOINT","261.79","73.78","","699.88","384.10","3443.31","33","110","282.09","percent of total billed charges",""
"SHUNT CORONARY 1.25X16.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10010573","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","354.83","266.12","AETNA [1001]","HB AMC AETNA HMO","247.67","69.8","","1421.24","264.50","4933.46","29","185.43","289.97","percent of total billed charges",""
"SHUNT CORONARY 1.25X16.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10010573","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","354.83","266.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","285.28","80.4","","1022.97","1022.97","3607.50","1 through 10","185.43","289.97","percent of total billed charges",""
"SHUNT CORONARY 1.25X16.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10010573","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","354.83","266.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","289.97","81.72","","3010.54","693.88","5019.88","35","185.43","289.97","percent of total billed charges",""
"SHUNT CORONARY 1.5X16.25 20.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005673","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","256.08","79.5","","1309.77","674.56","6049.93","26","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 1.5X16.25 20.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005673","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","171.68","53.3","","1901.83","1901.83","2962.25","1 through 10","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 1.5X16.25 20.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005673","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","117.57","36.5","","1620.31","1620.31","19908.88","1 through 10","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 1.5X16.25 20.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005673","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","123.37","38.3","","352.91","352.91","2046.30","1 through 10","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 1.5X16.25 20.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005673","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.19","42.9","","9668.75","9668.75","9668.75","1 through 10","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 1.5X16.25 20.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005673","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","WELLPOINT [1015]","HB AMC WELLPOINT","237.65","73.78","","699.88","384.10","3443.31","33","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 1.5X16.25 20.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005673","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","322.11","241.58","AETNA [1001]","HB AMC AETNA HMO","224.83","69.8","","1421.24","264.50","4933.46","29","168.33","263.23","percent of total billed charges",""
"SHUNT CORONARY 1.5X16.25 20.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005673","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","322.11","241.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","258.98","80.4","","1022.97","1022.97","3607.50","1 through 10","168.33","263.23","percent of total billed charges",""
"SHUNT CORONARY 1.5X16.25 20.25MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005673","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","322.11","241.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","263.23","81.72","","3010.54","693.88","5019.88","35","168.33","263.23","percent of total billed charges",""
"SHUNT CORONARY 1.75X17.5MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005674","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","256.08","79.5","","1309.77","674.56","6049.93","26","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 1.75X17.5MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005674","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","171.68","53.3","","1901.83","1901.83","2962.25","1 through 10","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 1.75X17.5MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005674","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","117.57","36.5","","1620.31","1620.31","19908.88","1 through 10","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 1.75X17.5MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005674","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","123.37","38.3","","352.91","352.91","2046.30","1 through 10","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 1.75X17.5MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005674","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.19","42.9","","9668.75","9668.75","9668.75","1 through 10","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 1.75X17.5MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005674","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","WELLPOINT [1015]","HB AMC WELLPOINT","237.65","73.78","","699.88","384.10","3443.31","33","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 1.75X17.5MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005674","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","322.11","241.58","AETNA [1001]","HB AMC AETNA HMO","224.83","69.8","","1421.24","264.50","4933.46","29","168.33","263.23","percent of total billed charges",""
"SHUNT CORONARY 1.75X17.5MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005674","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","322.11","241.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","258.98","80.4","","1022.97","1022.97","3607.50","1 through 10","168.33","263.23","percent of total billed charges",""
"SHUNT CORONARY 1.75X17.5MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10005674","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","322.11","241.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","263.23","81.72","","3010.54","693.88","5019.88","35","168.33","263.23","percent of total billed charges",""
"SHUNT CORONARY 2.25X18.50MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10006213","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","256.08","79.5","","1309.77","674.56","6049.93","26","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 2.25X18.50MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10006213","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","171.68","53.3","","1901.83","1901.83","2962.25","1 through 10","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 2.25X18.50MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10006213","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","117.57","36.5","","1620.31","1620.31","19908.88","1 through 10","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 2.25X18.50MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10006213","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","123.37","38.3","","352.91","352.91","2046.30","1 through 10","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 2.25X18.50MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10006213","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.19","42.9","","9668.75","9668.75","9668.75","1 through 10","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 2.25X18.50MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10006213","CDM","C1889","HCPCS","0278","RC","","","","both","","","322.11","241.58","WELLPOINT [1015]","HB AMC WELLPOINT","237.65","73.78","","699.88","384.10","3443.31","33","99.85","256.08","percent of total billed charges",""
"SHUNT CORONARY 2.25X18.50MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10006213","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","322.11","241.58","AETNA [1001]","HB AMC AETNA HMO","224.83","69.8","","1421.24","264.50","4933.46","29","168.33","263.23","percent of total billed charges",""
"SHUNT CORONARY 2.25X18.50MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10006213","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","322.11","241.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","258.98","80.4","","1022.97","1022.97","3607.50","1 through 10","168.33","263.23","percent of total billed charges",""
"SHUNT CORONARY 2.25X18.50MM AXIUS POLYMER TUBE SS COIL BX/5EA","SUP-ITM-10006213","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","322.11","241.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","263.23","81.72","","3010.54","693.88","5019.88","35","168.33","263.23","percent of total billed charges",""
"SHUNT INTRACORONARY 1MM CLEARVIEW ARTERIOTOMY PK/5EA","SUP-ITM-10041886","CDM","C1889","HCPCS","0278","RC","","","","both","","","203.00","152.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","161.39","79.5","","1309.77","674.56","6049.93","26","62.93","161.39","percent of total billed charges",""
"SHUNT INTRACORONARY 1MM CLEARVIEW ARTERIOTOMY PK/5EA","SUP-ITM-10041886","CDM","C1889","HCPCS","0278","RC","","","","both","","","203.00","152.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","108.20","53.3","","1901.83","1901.83","2962.25","1 through 10","62.93","161.39","percent of total billed charges",""
"SHUNT INTRACORONARY 1MM CLEARVIEW ARTERIOTOMY PK/5EA","SUP-ITM-10041886","CDM","C1889","HCPCS","0278","RC","","","","both","","","203.00","152.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.10","36.5","","1620.31","1620.31","19908.88","1 through 10","62.93","161.39","percent of total billed charges",""
"SHUNT INTRACORONARY 1MM CLEARVIEW ARTERIOTOMY PK/5EA","SUP-ITM-10041886","CDM","C1889","HCPCS","0278","RC","","","","both","","","203.00","152.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.75","38.3","","352.91","352.91","2046.30","1 through 10","62.93","161.39","percent of total billed charges",""
"SHUNT INTRACORONARY 1MM CLEARVIEW ARTERIOTOMY PK/5EA","SUP-ITM-10041886","CDM","C1889","HCPCS","0278","RC","","","","both","","","203.00","152.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.09","42.9","","9668.75","9668.75","9668.75","1 through 10","62.93","161.39","percent of total billed charges",""
"SHUNT INTRACORONARY 1MM CLEARVIEW ARTERIOTOMY PK/5EA","SUP-ITM-10041886","CDM","C1889","HCPCS","0278","RC","","","","both","","","203.00","152.25","WELLPOINT [1015]","HB AMC WELLPOINT","149.77","73.78","","699.88","384.10","3443.31","33","62.93","161.39","percent of total billed charges",""
"SHUNT INTRACORONARY 1MM CLEARVIEW ARTERIOTOMY PK/5EA","SUP-ITM-10041886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","203.00","152.25","AETNA [1001]","HB AMC AETNA HMO","141.69","69.8","","1421.24","264.50","4933.46","29","106.09","165.89","percent of total billed charges",""
"SHUNT INTRACORONARY 1MM CLEARVIEW ARTERIOTOMY PK/5EA","SUP-ITM-10041886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","203.00","152.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","163.21","80.4","","1022.97","1022.97","3607.50","1 through 10","106.09","165.89","percent of total billed charges",""
"SHUNT INTRACORONARY 1MM CLEARVIEW ARTERIOTOMY PK/5EA","SUP-ITM-10041886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","203.00","152.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.89","81.72","","3010.54","693.88","5019.88","35","106.09","165.89","percent of total billed charges",""
"SHUNT LUMBOPERITONEAL 80CM LOW PROGRAMMABLE","SUP-ITM-10001347","CDM","C1889","HCPCS","0278","RC","","","","both","","","2655.84","1991.88","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2111.39","79.5","","1309.77","674.56","6049.93","26","823.31","2111.39","percent of total billed charges",""
"SHUNT LUMBOPERITONEAL 80CM LOW PROGRAMMABLE","SUP-ITM-10001347","CDM","C1889","HCPCS","0278","RC","","","","both","","","2655.84","1991.88","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1415.56","53.3","","1901.83","1901.83","2962.25","1 through 10","823.31","2111.39","percent of total billed charges",""
"SHUNT LUMBOPERITONEAL 80CM LOW PROGRAMMABLE","SUP-ITM-10001347","CDM","C1889","HCPCS","0278","RC","","","","both","","","2655.84","1991.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","969.38","36.5","","1620.31","1620.31","19908.88","1 through 10","823.31","2111.39","percent of total billed charges",""
"SHUNT LUMBOPERITONEAL 80CM LOW PROGRAMMABLE","SUP-ITM-10001347","CDM","C1889","HCPCS","0278","RC","","","","both","","","2655.84","1991.88","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1017.19","38.3","","352.91","352.91","2046.30","1 through 10","823.31","2111.39","percent of total billed charges",""
"SHUNT LUMBOPERITONEAL 80CM LOW PROGRAMMABLE","SUP-ITM-10001347","CDM","C1889","HCPCS","0278","RC","","","","both","","","2655.84","1991.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1139.36","42.9","","9668.75","9668.75","9668.75","1 through 10","823.31","2111.39","percent of total billed charges",""
"SHUNT LUMBOPERITONEAL 80CM LOW PROGRAMMABLE","SUP-ITM-10001347","CDM","C1889","HCPCS","0278","RC","","","","both","","","2655.84","1991.88","WELLPOINT [1015]","HB AMC WELLPOINT","1959.48","73.78","","699.88","384.10","3443.31","33","823.31","2111.39","percent of total billed charges",""
"SHUNT LUMBOPERITONEAL 80CM LOW PROGRAMMABLE","SUP-ITM-10001347","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2655.84","1991.88","AETNA [1001]","HB AMC AETNA HMO","1853.78","69.8","","1421.24","264.50","4933.46","29","1387.94","2170.35","percent of total billed charges",""
"SHUNT LUMBOPERITONEAL 80CM LOW PROGRAMMABLE","SUP-ITM-10001347","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2655.84","1991.88","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2135.30","80.4","","1022.97","1022.97","3607.50","1 through 10","1387.94","2170.35","percent of total billed charges",""
"SHUNT LUMBOPERITONEAL 80CM LOW PROGRAMMABLE","SUP-ITM-10001347","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2655.84","1991.88","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2170.35","81.72","","3010.54","693.88","5019.88","35","1387.94","2170.35","percent of total billed charges",""
"SHUNT NEUROSURGICAL MICRO PROGRAMABLE VALVE ANTI SIPHON DEVICE UNITIZED RICKMAN RESERVOIR IMPLANTABLE","SUP-ITM-10075274","CDM","C1889","HCPCS","0278","RC","","","","both","","","10567.73","7925.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8401.35","79.5","","1309.77","674.56","6049.93","26","3276","8401.35","percent of total billed charges",""
"SHUNT NEUROSURGICAL MICRO PROGRAMABLE VALVE ANTI SIPHON DEVICE UNITIZED RICKMAN RESERVOIR IMPLANTABLE","SUP-ITM-10075274","CDM","C1889","HCPCS","0278","RC","","","","both","","","10567.73","7925.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5632.60","53.3","","1901.83","1901.83","2962.25","1 through 10","3276","8401.35","percent of total billed charges",""
"SHUNT NEUROSURGICAL MICRO PROGRAMABLE VALVE ANTI SIPHON DEVICE UNITIZED RICKMAN RESERVOIR IMPLANTABLE","SUP-ITM-10075274","CDM","C1889","HCPCS","0278","RC","","","","both","","","10567.73","7925.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3857.22","36.5","","1620.31","1620.31","19908.88","1 through 10","3276","8401.35","percent of total billed charges",""
"SHUNT NEUROSURGICAL MICRO PROGRAMABLE VALVE ANTI SIPHON DEVICE UNITIZED RICKMAN RESERVOIR IMPLANTABLE","SUP-ITM-10075274","CDM","C1889","HCPCS","0278","RC","","","","both","","","10567.73","7925.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4047.44","38.3","","352.91","352.91","2046.30","1 through 10","3276","8401.35","percent of total billed charges",""
"SHUNT NEUROSURGICAL MICRO PROGRAMABLE VALVE ANTI SIPHON DEVICE UNITIZED RICKMAN RESERVOIR IMPLANTABLE","SUP-ITM-10075274","CDM","C1889","HCPCS","0278","RC","","","","both","","","10567.73","7925.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4533.56","42.9","","9668.75","9668.75","9668.75","1 through 10","3276","8401.35","percent of total billed charges",""
"SHUNT NEUROSURGICAL MICRO PROGRAMABLE VALVE ANTI SIPHON DEVICE UNITIZED RICKMAN RESERVOIR IMPLANTABLE","SUP-ITM-10075274","CDM","C1889","HCPCS","0278","RC","","","","both","","","10567.73","7925.80","WELLPOINT [1015]","HB AMC WELLPOINT","7796.87","73.78","","699.88","384.10","3443.31","33","3276","8401.35","percent of total billed charges",""
"SHUNT NEUROSURGICAL MICRO PROGRAMABLE VALVE ANTI SIPHON DEVICE UNITIZED RICKMAN RESERVOIR IMPLANTABLE","SUP-ITM-10075274","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10567.73","7925.80","AETNA [1001]","HB AMC AETNA HMO","7376.28","69.8","","1421.24","264.50","4933.46","29","5522.7","8635.95","percent of total billed charges",""
"SHUNT NEUROSURGICAL MICRO PROGRAMABLE VALVE ANTI SIPHON DEVICE UNITIZED RICKMAN RESERVOIR IMPLANTABLE","SUP-ITM-10075274","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10567.73","7925.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8496.45","80.4","","1022.97","1022.97","3607.50","1 through 10","5522.7","8635.95","percent of total billed charges",""
"SHUNT NEUROSURGICAL MICRO PROGRAMABLE VALVE ANTI SIPHON DEVICE UNITIZED RICKMAN RESERVOIR IMPLANTABLE","SUP-ITM-10075274","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10567.73","7925.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8635.95","81.72","","3010.54","693.88","5019.88","35","5522.7","8635.95","percent of total billed charges",""
"SHUNT SYSTEM 0 TO 40CM VALVE PROSA NO DIFFERENTIAL PRESSURE UNIT PC/1EA","SUP-ITM-10126464","CDM","C1889","HCPCS","0278","RC","","","","both","","","7479.65","5609.74","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5946.32","79.5","","1309.77","674.56","6049.93","26","2318.69","5946.32","percent of total billed charges",""
"SHUNT SYSTEM 0 TO 40CM VALVE PROSA NO DIFFERENTIAL PRESSURE UNIT PC/1EA","SUP-ITM-10126464","CDM","C1889","HCPCS","0278","RC","","","","both","","","7479.65","5609.74","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3986.65","53.3","","1901.83","1901.83","2962.25","1 through 10","2318.69","5946.32","percent of total billed charges",""
"SHUNT SYSTEM 0 TO 40CM VALVE PROSA NO DIFFERENTIAL PRESSURE UNIT PC/1EA","SUP-ITM-10126464","CDM","C1889","HCPCS","0278","RC","","","","both","","","7479.65","5609.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2730.07","36.5","","1620.31","1620.31","19908.88","1 through 10","2318.69","5946.32","percent of total billed charges",""
"SHUNT SYSTEM 0 TO 40CM VALVE PROSA NO DIFFERENTIAL PRESSURE UNIT PC/1EA","SUP-ITM-10126464","CDM","C1889","HCPCS","0278","RC","","","","both","","","7479.65","5609.74","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2864.71","38.3","","352.91","352.91","2046.30","1 through 10","2318.69","5946.32","percent of total billed charges",""
"SHUNT SYSTEM 0 TO 40CM VALVE PROSA NO DIFFERENTIAL PRESSURE UNIT PC/1EA","SUP-ITM-10126464","CDM","C1889","HCPCS","0278","RC","","","","both","","","7479.65","5609.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3208.77","42.9","","9668.75","9668.75","9668.75","1 through 10","2318.69","5946.32","percent of total billed charges",""
"SHUNT SYSTEM 0 TO 40CM VALVE PROSA NO DIFFERENTIAL PRESSURE UNIT PC/1EA","SUP-ITM-10126464","CDM","C1889","HCPCS","0278","RC","","","","both","","","7479.65","5609.74","WELLPOINT [1015]","HB AMC WELLPOINT","5518.49","73.78","","699.88","384.10","3443.31","33","2318.69","5946.32","percent of total billed charges",""
"SHUNT SYSTEM 0 TO 40CM VALVE PROSA NO DIFFERENTIAL PRESSURE UNIT PC/1EA","SUP-ITM-10126464","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7479.65","5609.74","AETNA [1001]","HB AMC AETNA HMO","5220.80","69.8","","1421.24","264.50","4933.46","29","3908.87","6112.37","percent of total billed charges",""
"SHUNT SYSTEM 0 TO 40CM VALVE PROSA NO DIFFERENTIAL PRESSURE UNIT PC/1EA","SUP-ITM-10126464","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7479.65","5609.74","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6013.64","80.4","","1022.97","1022.97","3607.50","1 through 10","3908.87","6112.37","percent of total billed charges",""
"SHUNT SYSTEM 0 TO 40CM VALVE PROSA NO DIFFERENTIAL PRESSURE UNIT PC/1EA","SUP-ITM-10126464","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7479.65","5609.74","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6112.37","81.72","","3010.54","693.88","5019.88","35","3908.87","6112.37","percent of total billed charges",""
"SHUNT SYSTEM PEDIATRIC RESVR W/O GRAVITATIONAL UNIT PROGAV 2.0 PC/1EA","SUP-ITM-10171203","CDM","C1889","HCPCS","0278","RC","","","","both","","","5904.50","4428.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4694.08","79.5","","1309.77","674.56","6049.93","26","1830.4","4694.08","percent of total billed charges",""
"SHUNT SYSTEM PEDIATRIC RESVR W/O GRAVITATIONAL UNIT PROGAV 2.0 PC/1EA","SUP-ITM-10171203","CDM","C1889","HCPCS","0278","RC","","","","both","","","5904.50","4428.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3147.10","53.3","","1901.83","1901.83","2962.25","1 through 10","1830.4","4694.08","percent of total billed charges",""
"SHUNT SYSTEM PEDIATRIC RESVR W/O GRAVITATIONAL UNIT PROGAV 2.0 PC/1EA","SUP-ITM-10171203","CDM","C1889","HCPCS","0278","RC","","","","both","","","5904.50","4428.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2155.14","36.5","","1620.31","1620.31","19908.88","1 through 10","1830.4","4694.08","percent of total billed charges",""
"SHUNT SYSTEM PEDIATRIC RESVR W/O GRAVITATIONAL UNIT PROGAV 2.0 PC/1EA","SUP-ITM-10171203","CDM","C1889","HCPCS","0278","RC","","","","both","","","5904.50","4428.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2261.42","38.3","","352.91","352.91","2046.30","1 through 10","1830.4","4694.08","percent of total billed charges",""
"SHUNT SYSTEM PEDIATRIC RESVR W/O GRAVITATIONAL UNIT PROGAV 2.0 PC/1EA","SUP-ITM-10171203","CDM","C1889","HCPCS","0278","RC","","","","both","","","5904.50","4428.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2533.03","42.9","","9668.75","9668.75","9668.75","1 through 10","1830.4","4694.08","percent of total billed charges",""
"SHUNT SYSTEM PEDIATRIC RESVR W/O GRAVITATIONAL UNIT PROGAV 2.0 PC/1EA","SUP-ITM-10171203","CDM","C1889","HCPCS","0278","RC","","","","both","","","5904.50","4428.37","WELLPOINT [1015]","HB AMC WELLPOINT","4356.34","73.78","","699.88","384.10","3443.31","33","1830.4","4694.08","percent of total billed charges",""
"SHUNT SYSTEM PEDIATRIC RESVR W/O GRAVITATIONAL UNIT PROGAV 2.0 PC/1EA","SUP-ITM-10171203","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5904.50","4428.37","AETNA [1001]","HB AMC AETNA HMO","4121.34","69.8","","1421.24","264.50","4933.46","29","3085.69","4825.16","percent of total billed charges",""
"SHUNT SYSTEM PEDIATRIC RESVR W/O GRAVITATIONAL UNIT PROGAV 2.0 PC/1EA","SUP-ITM-10171203","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5904.50","4428.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4747.22","80.4","","1022.97","1022.97","3607.50","1 through 10","3085.69","4825.16","percent of total billed charges",""
"SHUNT SYSTEM PEDIATRIC RESVR W/O GRAVITATIONAL UNIT PROGAV 2.0 PC/1EA","SUP-ITM-10171203","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5904.50","4428.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4825.16","81.72","","3010.54","693.88","5019.88","35","3085.69","4825.16","percent of total billed charges",""
"SHUNT TI 12MM COVER BURR HOLE CRANIAL MATRIXNEURO DRAINAGE","SUP-ITM-10076535","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.92","459.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","487.27","79.5","","800.18","480.96","1887.97","195","190.01","487.27","percent of total billed charges",""
"SHUNT TI 12MM COVER BURR HOLE CRANIAL MATRIXNEURO DRAINAGE","SUP-ITM-10076535","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.92","459.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","326.69","53.3","","813.12","216.42","1444.50","81","190.01","487.27","percent of total billed charges",""
"SHUNT TI 12MM COVER BURR HOLE CRANIAL MATRIXNEURO DRAINAGE","SUP-ITM-10076535","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.92","459.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","190.01","31","","432.60","432.60","432.60","1 through 10","190.01","487.27","percent of total billed charges",""
"SHUNT TI 12MM COVER BURR HOLE CRANIAL MATRIXNEURO DRAINAGE","SUP-ITM-10076535","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.92","459.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.72","36.5","","148.37","54.89","631.39","94","190.01","487.27","percent of total billed charges",""
"SHUNT TI 12MM COVER BURR HOLE CRANIAL MATRIXNEURO DRAINAGE","SUP-ITM-10076535","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.92","459.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.75","38.3","","279.30","91.72","1116.77","266","190.01","487.27","percent of total billed charges",""
"SHUNT TI 12MM COVER BURR HOLE CRANIAL MATRIXNEURO DRAINAGE","SUP-ITM-10076535","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.92","459.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","262.94","42.9","","731.00","63.70","731.00","1 through 10","190.01","487.27","percent of total billed charges",""
"SHUNT TI 12MM COVER BURR HOLE CRANIAL MATRIXNEURO DRAINAGE","SUP-ITM-10076535","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.92","459.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","262.94","42.9","","384.74","384.74","384.74","1 through 10","190.01","487.27","percent of total billed charges",""
"SHUNT TI 12MM COVER BURR HOLE CRANIAL MATRIXNEURO DRAINAGE","SUP-ITM-10076535","CDM","C1713","HCPCS","0278","RC","","","","both","","","612.92","459.69","WELLPOINT [1015]","HB AMC WELLPOINT","452.21","73.78","","286.63","119.22","1107.45","105","190.01","487.27","percent of total billed charges",""
"SHUNT TI 12MM COVER BURR HOLE CRANIAL MATRIXNEURO DRAINAGE","SUP-ITM-10076535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.92","459.69","AETNA [1001]","HB AMC AETNA HMO","427.82","69.8","","675.31","184.75","1721.50","286","320.31","500.88","percent of total billed charges",""
"SHUNT TI 12MM COVER BURR HOLE CRANIAL MATRIXNEURO DRAINAGE","SUP-ITM-10076535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.92","459.69","AETNA [1001]","HB AMC AETNA PPO","492.79","80.4","","1261.44","103.12","1514.10","21","320.31","500.88","percent of total billed charges",""
"SHUNT TI 12MM COVER BURR HOLE CRANIAL MATRIXNEURO DRAINAGE","SUP-ITM-10076535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.92","459.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","492.79","80.4","","1365.00","1365.00","1365.00","1 through 10","320.31","500.88","percent of total billed charges",""
"SHUNT TI 12MM COVER BURR HOLE CRANIAL MATRIXNEURO DRAINAGE","SUP-ITM-10076535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.92","459.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","500.88","81.72","","5157.68","5157.68","5157.68","1 through 10","320.31","500.88","percent of total billed charges",""
"SHUNT TI 12MM COVER BURR HOLE CRANIAL MATRIXNEURO DRAINAGE","SUP-ITM-10076535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","612.92","459.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","500.88","81.72","","431.26","71.26","1459.57","88","320.31","500.88","percent of total billed charges",""
"SHUNT VALVE 120CM ASSEMBLY STRATA2 PERITONEAL CATHETER PASSER REGULAR","SUP-ITM-10018104","CDM","C1889","HCPCS","0278","RC","","","","both","","","4916.42","3687.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3908.55","79.5","","1309.77","674.56","6049.93","26","1524.09","3908.55","percent of total billed charges",""
"SHUNT VALVE 120CM ASSEMBLY STRATA2 PERITONEAL CATHETER PASSER REGULAR","SUP-ITM-10018104","CDM","C1889","HCPCS","0278","RC","","","","both","","","4916.42","3687.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2620.45","53.3","","1901.83","1901.83","2962.25","1 through 10","1524.09","3908.55","percent of total billed charges",""
"SHUNT VALVE 120CM ASSEMBLY STRATA2 PERITONEAL CATHETER PASSER REGULAR","SUP-ITM-10018104","CDM","C1889","HCPCS","0278","RC","","","","both","","","4916.42","3687.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1794.49","36.5","","1620.31","1620.31","19908.88","1 through 10","1524.09","3908.55","percent of total billed charges",""
"SHUNT VALVE 120CM ASSEMBLY STRATA2 PERITONEAL CATHETER PASSER REGULAR","SUP-ITM-10018104","CDM","C1889","HCPCS","0278","RC","","","","both","","","4916.42","3687.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1882.99","38.3","","352.91","352.91","2046.30","1 through 10","1524.09","3908.55","percent of total billed charges",""
"SHUNT VALVE 120CM ASSEMBLY STRATA2 PERITONEAL CATHETER PASSER REGULAR","SUP-ITM-10018104","CDM","C1889","HCPCS","0278","RC","","","","both","","","4916.42","3687.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2109.14","42.9","","9668.75","9668.75","9668.75","1 through 10","1524.09","3908.55","percent of total billed charges",""
"SHUNT VALVE 120CM ASSEMBLY STRATA2 PERITONEAL CATHETER PASSER REGULAR","SUP-ITM-10018104","CDM","C1889","HCPCS","0278","RC","","","","both","","","4916.42","3687.31","WELLPOINT [1015]","HB AMC WELLPOINT","3627.33","73.78","","699.88","384.10","3443.31","33","1524.09","3908.55","percent of total billed charges",""
"SHUNT VALVE 120CM ASSEMBLY STRATA2 PERITONEAL CATHETER PASSER REGULAR","SUP-ITM-10018104","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4916.42","3687.31","AETNA [1001]","HB AMC AETNA HMO","3431.66","69.8","","1421.24","264.50","4933.46","29","2569.32","4017.7","percent of total billed charges",""
"SHUNT VALVE 120CM ASSEMBLY STRATA2 PERITONEAL CATHETER PASSER REGULAR","SUP-ITM-10018104","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4916.42","3687.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3952.80","80.4","","1022.97","1022.97","3607.50","1 through 10","2569.32","4017.7","percent of total billed charges",""
"SHUNT VALVE 120CM ASSEMBLY STRATA2 PERITONEAL CATHETER PASSER REGULAR","SUP-ITM-10018104","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4916.42","3687.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4017.70","81.72","","3010.54","693.88","5019.88","35","2569.32","4017.7","percent of total billed charges",""
"SHUNT VALVE 13.8FRX2.3CM 15 ASSISTANT TITANIUM SINGLE 2 CONNECTIONS HYDROCEPHALUS PC/1EA","SUP-ITM-10127672","CDM","C1889","HCPCS","0278","RC","","","","both","","","4189.22","3141.91","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3330.43","79.5","","1309.77","674.56","6049.93","26","1298.66","3330.43","percent of total billed charges",""
"SHUNT VALVE 13.8FRX2.3CM 15 ASSISTANT TITANIUM SINGLE 2 CONNECTIONS HYDROCEPHALUS PC/1EA","SUP-ITM-10127672","CDM","C1889","HCPCS","0278","RC","","","","both","","","4189.22","3141.91","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2232.85","53.3","","1901.83","1901.83","2962.25","1 through 10","1298.66","3330.43","percent of total billed charges",""
"SHUNT VALVE 13.8FRX2.3CM 15 ASSISTANT TITANIUM SINGLE 2 CONNECTIONS HYDROCEPHALUS PC/1EA","SUP-ITM-10127672","CDM","C1889","HCPCS","0278","RC","","","","both","","","4189.22","3141.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1529.07","36.5","","1620.31","1620.31","19908.88","1 through 10","1298.66","3330.43","percent of total billed charges",""
"SHUNT VALVE 13.8FRX2.3CM 15 ASSISTANT TITANIUM SINGLE 2 CONNECTIONS HYDROCEPHALUS PC/1EA","SUP-ITM-10127672","CDM","C1889","HCPCS","0278","RC","","","","both","","","4189.22","3141.91","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1604.47","38.3","","352.91","352.91","2046.30","1 through 10","1298.66","3330.43","percent of total billed charges",""
"SHUNT VALVE 13.8FRX2.3CM 15 ASSISTANT TITANIUM SINGLE 2 CONNECTIONS HYDROCEPHALUS PC/1EA","SUP-ITM-10127672","CDM","C1889","HCPCS","0278","RC","","","","both","","","4189.22","3141.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1797.18","42.9","","9668.75","9668.75","9668.75","1 through 10","1298.66","3330.43","percent of total billed charges",""
"SHUNT VALVE 13.8FRX2.3CM 15 ASSISTANT TITANIUM SINGLE 2 CONNECTIONS HYDROCEPHALUS PC/1EA","SUP-ITM-10127672","CDM","C1889","HCPCS","0278","RC","","","","both","","","4189.22","3141.91","WELLPOINT [1015]","HB AMC WELLPOINT","3090.81","73.78","","699.88","384.10","3443.31","33","1298.66","3330.43","percent of total billed charges",""
"SHUNT VALVE 13.8FRX2.3CM 15 ASSISTANT TITANIUM SINGLE 2 CONNECTIONS HYDROCEPHALUS PC/1EA","SUP-ITM-10127672","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4189.22","3141.91","AETNA [1001]","HB AMC AETNA HMO","2924.08","69.8","","1421.24","264.50","4933.46","29","2189.29","3423.43","percent of total billed charges",""
"SHUNT VALVE 13.8FRX2.3CM 15 ASSISTANT TITANIUM SINGLE 2 CONNECTIONS HYDROCEPHALUS PC/1EA","SUP-ITM-10127672","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4189.22","3141.91","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3368.13","80.4","","1022.97","1022.97","3607.50","1 through 10","2189.29","3423.43","percent of total billed charges",""
"SHUNT VALVE 13.8FRX2.3CM 15 ASSISTANT TITANIUM SINGLE 2 CONNECTIONS HYDROCEPHALUS PC/1EA","SUP-ITM-10127672","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4189.22","3141.91","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3423.43","81.72","","3010.54","693.88","5019.88","35","2189.29","3423.43","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","both","","","7557.48","5668.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6008.20","79.5","","1309.77","674.56","6049.93","26","2342.82","6008.2","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","both","","","7557.48","5668.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4028.14","53.3","","1901.83","1901.83","2962.25","1 through 10","2342.82","6008.2","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","both","","","7557.48","5668.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2758.48","36.5","","1620.31","1620.31","19908.88","1 through 10","2342.82","6008.2","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","both","","","7557.48","5668.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2894.51","38.3","","352.91","352.91","2046.30","1 through 10","2342.82","6008.2","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","both","","","7557.48","5668.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3242.16","42.9","","9668.75","9668.75","9668.75","1 through 10","2342.82","6008.2","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","both","","","7557.48","5668.11","WELLPOINT [1015]","HB AMC WELLPOINT","5575.91","73.78","","699.88","384.10","3443.31","33","2342.82","6008.2","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7557.48","5668.11","AETNA [1001]","HB AMC AETNA HMO","5275.12","69.8","","1421.24","264.50","4933.46","29","3949.54","6175.97","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7557.48","5668.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6076.21","80.4","","1022.97","1022.97","3607.50","1 through 10","3949.54","6175.97","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7557.48","5668.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6175.97","81.72","","3010.54","693.88","5019.88","35","3949.54","6175.97","percent of total billed charges",""
"Sickle Cell Anemia Crisis,EXTREME","662","DRG","","","","","","","","inpatient","","","162474.01","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","18244.73","","Case rate ($20,172.68). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $62,602.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20167.73","20167.73","20167.73","1 through 10","7135.22","129141.48","case rate",""
"Sickle Cell Anemia Crisis,MAJOR","662","DRG","","","","","","","","inpatient","","","88778.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","30604.29","","Standard inlier is a Case rate ($30,604.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,447, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,344.46) for the length of stay and the standard reimbursement.","30604.28","30604.28","30604.28","1 through 10","7135.22","129141.48","case rate",""
"Sickle Cell Anemia Crisis,MAJOR","662","DRG","","","","","","","","inpatient","","","88778.58","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","34407.47","","Standard inlier is a Case rate ($34,407.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,447, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,883.85) for the length of stay and the standard reimbursement.","34407.46","34407.46","106306.69","1 through 10","7135.22","129141.48","case rate",""
"Sickle Cell Anemia Crisis,MAJOR","662","DRG","","","","","","","","inpatient","","","88778.58","","MASSHEALTH [3001]","HB BWH MEDICAID","13107.51","","Case rate ($14,492.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,922.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14489.05","14489.05","14489.05","1 through 10","7135.22","129141.48","case rate",""
"Sickle Cell Anemia Crisis,MAJOR","662","DRG","","","","","","","","inpatient","","","88778.58","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35085.80","","Fee schedule rate ($35,085.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35085.80","35085.80","35085.80","1 through 10","7135.22","129141.48","case rate",""
"Sickle Cell Anemia Crisis,MAJOR","662","DRG","","","","","","","","inpatient","","","88778.58","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","13107.51","","Case rate ($14,492.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,922.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14489.05","1002.70","14489.05","1 through 10","7135.22","129141.48","case rate",""
"Sickle Cell Anemia Crisis,MINOR","662","DRG","","","","","","","","inpatient","","","27627.07","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","19008.72","","Fee schedule rate ($19,008.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18454.91","18454.91","18454.91","1 through 10","7135.22","129141.48","case rate",""
"Sickle Cell Anemia Crisis,MINOR","662","DRG","","","","","","","","inpatient","","","27627.07","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7135.22","","Case rate ($7,889.21). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,319.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7887.27","7887.27","16733.51","1 through 10","7135.22","129141.48","case rate",""
"Sickle Cell Anemia Crisis,MODERATE","662","DRG","","","","","","","","inpatient","","","38714.57","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24266.66","","Standard inlier is a Case rate ($24,266.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,432, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,444.45) for the length of stay and the standard reimbursement.","24266.66","22169.69","24266.66","1 through 10","7135.22","129141.48","case rate",""
"Sickle Cell Anemia Crisis,MODERATE","662","DRG","","","","","","","","inpatient","","","38714.57","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","","40","","64326.81","64326.81","64326.81","1 through 10","7135.22","129141.48","percent of total billed charges",""
"Sickle Cell Anemia Crisis,MODERATE","662","DRG","","","","","","","","inpatient","","","38714.57","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14276.8561","","Fee schedule rate ($19,946.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14276.8561","19946.88","19946.88","1 through 10","7135.22","129141.48","case rate",""
"Sickle Cell Anemia Crisis,MODERATE","662","DRG","","","","","","","","inpatient","","","38714.57","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24804.88","","Fee schedule rate ($24,804.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24804.88","24804.88","24804.88","1 through 10","7135.22","129141.48","case rate",""
"Sickle Cell Anemia Crisis,MODERATE","662","DRG","","","","","","","","inpatient","","","38714.57","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10341.84","","Case rate ($11,434.68). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,864.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11431.87","11431.87","11431.87","1 through 10","7135.22","129141.48","case rate",""
"Sickle Cell RBC","PX-30001125","CDM","85660","CPT","0305","RC","","","","both","","","93.00","69.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","73.94","79.5","","47.52","47.52","47.52","1 through 10","5.4","88.35","percent of total billed charges",""
"Sickle Cell RBC","PX-30001125","CDM","85660","CPT","0305","RC","","","","both","","","93.00","69.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","49.57","53.3","","47.52","47.52","47.52","1 through 10","5.4","88.35","percent of total billed charges",""
"Sickle Cell RBC","PX-30001125","CDM","85660","CPT","0305","RC","","","","both","","","93.00","69.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","33.95","36.5","","33.57","33.57","33.57","1 through 10","5.4","88.35","percent of total billed charges",""
"Sickle Cell RBC","PX-30001125","CDM","85660","CPT","0305","RC","","","","both","","","93.00","69.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","35.62","38.3","","35.19","35.19","35.19","1 through 10","5.4","88.35","percent of total billed charges",""
"Sickle Cell RBC","PX-30001125","CDM","85660","CPT","0305","RC","","","","outpatient","","","93.00","69.75","AETNA [1001]","HB AMC AETNA HMO","64.91","69.8","","43.02","43.02","60.93","1 through 10","5.69","76","percent of total billed charges",""
"Sickle Cell RBC","PX-30001125","CDM","85660","CPT","0305","RC","","","","outpatient","","","93.00","69.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","76.00","81.72","","71.95","39.57","71.95","1 through 10","5.69","76","percent of total billed charges",""
"Sigmoidoscopy Aspiration/Biopsy","PX-75000191","CDM","45342","CPT","0750","RC","","","","both","","","2768.00","2076.00","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1287.95","1287.95","1287.95","1 through 10","858.08","2200.56","other","OPPS APC"
"Sigmoidoscopy Aspiration/Biopsy","PX-75000191","CDM","45342","CPT","0750","RC","","","","both","","","2768.00","2076.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1060.14","38.3","","1049.44","1049.44","1049.44","1 through 10","858.08","2200.56","percent of total billed charges",""
"Sigmoidoscopy Aspiration/Biopsy","PX-75000191","CDM","45342","CPT","0750","RC","","","","outpatient","","","2768.00","2076.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2292.44","2292.44","2292.44","1 through 10","979.79","2384.07","other","ASC"
"Sigmoidoscopy Aspiration/Biopsy","PX-75000191","CDM","45342","CPT","0750","RC","","","","outpatient","","","2768.00","2076.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2622.97","2597.20","2622.97","1 through 10","979.79","2384.07","other","ASC "
"Sigmoidoscopy Aspiration/Biopsy","PX-75000191","CDM","45342","CPT","0750","RC","","","","outpatient","","","2768.00","2076.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2262.01","81.72","","2508.26","2508.26","2508.26","1 through 10","979.79","2384.07","percent of total billed charges",""
"Sigmoidoscopy Flex W/Submucosal Inj","PX-75000185","CDM","45335","CPT","0750","RC","","","","both","","","1638.00","1228.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1114.11","1114.11","1 through 10","507.78","1459.48","other","OPPS APC"
"Sigmoidoscopy Flex W/Submucosal Inj","PX-75000185","CDM","45335","CPT","0750","RC","","","","both","","","1638.00","1228.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1302.21","79.5","","1249.76","1249.76","1249.76","1 through 10","507.78","1459.48","percent of total billed charges",""
"Sigmoidoscopy Flex W/Submucosal Inj","PX-75000185","CDM","45335","CPT","0750","RC","","","","outpatient","","","1638.00","1228.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1742.82","1711.31","1742.82","1 through 10","744.89","1338.57","other","ASC"
"Sigmoidoscopy Flex W/Submucosal Inj","PX-75000185","CDM","45335","CPT","0750","RC","","","","outpatient","","","1638.00","1228.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2592.21","2592.21","2592.21","1 through 10","744.89","1338.57","other","Multiple Surgery"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1652.00","1239.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1114.11","1114.11","1 through 10","512.12","1459.48","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1652.00","1239.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","532.70","532.70","532.70","1 through 10","512.12","1459.48","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1652.00","1239.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1156.40","70","","1281.60","1281.60","1281.60","1 through 10","512.12","1459.48","percent of total billed charges",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1652.00","1239.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1313.34","79.5","","1260.77","1260.77","6495.98","1 through 10","512.12","1459.48","percent of total billed charges",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1652.00","1239.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","880.52","53.3","","1260.77","845.86","1260.77","1 through 10","512.12","1459.48","percent of total billed charges",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1652.00","1239.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1061.06","1061.06","1061.06","1 through 10","512.12","1459.48","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1652.00","1239.00","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","1082.71","1082.71","14","512.12","1459.48","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1652.00","1239.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","602.98","36.5","","597.55","597.55","597.55","1 through 10","512.12","1459.48","percent of total billed charges",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1652.00","1239.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","632.72","38.3","","626.38","626.38","626.38","1 through 10","512.12","1459.48","percent of total billed charges",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1652.00","1239.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","1061.06","1082.71","1 through 10","512.12","1459.48","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1652.00","1239.00","AETNA [1001]","HB AMC AETNA HMO","1153.10","69.8","","1084.55","765.76","1084.55","1 through 10","744.89","2384.07","percent of total billed charges",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1652.00","1239.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1711.31","1711.31","1742.82","1 through 10","744.89","2384.07","other","ASC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1652.00","1239.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1974.52","1974.52","1994.11","17","744.89","2384.07","other","ASC "
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1652.00","1239.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1728.14","864.07","1728.14","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1652.00","1239.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1817.53","1817.53","1817.53","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1652.00","1239.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1350.01","81.72","","47009.79","47009.79","47009.79","1 through 10","744.89","2384.07","percent of total billed charges",""
"Sigmoidoscopy Flx Ablation Tumor Polyp/Oth Les","PX-75000414","CDM","45346","CPT","0750","RC","","","","both","","","2927.00","2195.25","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1287.95","1400.23","1 through 10","907.37","2326.97","other","OPPS APC"
"Sigmoidoscopy Flx Ablation Tumor Polyp/Oth Les","PX-75000414","CDM","45346","CPT","0750","RC","","","","both","","","2927.00","2195.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1377.83","1377.83","1377.83","1 through 10","907.37","2326.97","other","OPPS APC"
"Sigmoidoscopy Flx Ablation Tumor Polyp/Oth Les","PX-75000414","CDM","45346","CPT","0750","RC","","","","both","","","2927.00","2195.25","WELLPOINT [1015]","HB AMC WELLPOINT","2159.54","73.78","","2112.89","2112.89","2112.89","1 through 10","907.37","2326.97","percent of total billed charges",""
"Sigmoidoscopy Flx Ablation Tumor Polyp/Oth Les","PX-75000414","CDM","45346","CPT","0750","RC","","","","outpatient","","","2927.00","2195.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2622.97","2622.97","2622.97","1 through 10","979.79","2391.94","other","ASC "
"Sigmoidoscopy Flx Ablation Tumor Polyp/Oth Les","PX-75000414","CDM","45346","CPT","0750","RC","","","","outpatient","","","2927.00","2195.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2391.94","81.72","","2121.63","2121.63","2121.63","1 through 10","979.79","2391.94","percent of total billed charges",""
"Sigmoidoscopy Flx Placement of Endoscopic Stent","PX-75000415","CDM","45347","CPT","0750","RC","","","","outpatient","","","1589.00","1191.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5141.51","","Case rate ($5,141.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","11918.02","11918.02","11918.02","1 through 10","830.41","5141.51","other","ASC "
"Sigmoidoscopy Flx Tndsc Balo Dilat","PX-75000189","CDM","45340","CPT","0750","RC","","","","both","","","2847.00","2135.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1379.63","1379.63","1379.63","1 through 10","882.57","2263.37","other","OPPS APC"
"Sigmoidoscopy Flx Tndsc Balo Dilat","PX-75000189","CDM","45340","CPT","0750","RC","","","","outpatient","","","2847.00","2135.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6819.33","6819.33","6819.33","1 through 10","979.79","2384.07","other","Multiple Surgery"
"Sigmoidoscopy Flx Tndsc Balo Dilat","PX-75000189","CDM","45340","CPT","0750","RC","","","","outpatient","","","2847.00","2135.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2326.57","81.72","","2207.14","2207.14","2207.14","1 through 10","979.79","2384.07","percent of total billed charges",""
"Sigmoidoscopy Flx W/Rmvl Foreign Body","PX-75000182","CDM","45332","CPT","0750","RC","","","","both","","","2768.00","2076.00","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1287.95","1287.95","1287.95","1 through 10","858.08","2200.56","other","OPPS APC"
"Sigmoidoscopy Flx W/Rmvl Foreign Body","PX-75000182","CDM","45332","CPT","0750","RC","","","","outpatient","","","2768.00","2076.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2622.97","2622.97","2622.97","1 through 10","979.79","2262.01","other","ASC "
"Sigmoidoscopy Flx W/Rmvl Foreign Body","PX-75000182","CDM","45332","CPT","0750","RC","","","","outpatient","","","2768.00","2076.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6819.33","2273.11","6819.33","1 through 10","979.79","2262.01","other","Multiple Surgery"
"Sigmoidoscopy Flx With Band Ligation(S)","PX-75000434","CDM","45350","CPT","0750","RC","","","","both","","","2869.00","2151.75","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1287.95","1287.95","1287.95","1 through 10","889.39","2280.86","other","OPPS APC"
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","both","","","2769.00","2076.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2201.36","79.5","","2113.10","2113.10","2113.10","1 through 10","858.39","2201.36","percent of total billed charges",""
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","both","","","2769.00","2076.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1475.88","53.3","","1355.93","1355.93","1355.93","1 through 10","858.39","2201.36","percent of total billed charges",""
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","both","","","2769.00","2076.75","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","858.39","2201.36","other","OPPS APC"
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","both","","","2769.00","2076.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","1372.23","1372.23","1 through 10","858.39","2201.36","other","OPPS APC"
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","outpatient","","","2769.00","2076.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2250.98","2250.98","2250.98","1 through 10","979.79","2384.07","other","ASC"
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","outpatient","","","2769.00","2076.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2597.20","2597.20","2597.20","1 through 10","979.79","2384.07","other","ASC "
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","outpatient","","","2769.00","2076.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2262.83","81.72","","2685.00","2685.00","2685.00","1 through 10","979.79","2384.07","percent of total billed charges",""
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1703.00","1277.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1114.11","1114.11","1 through 10","527.93","1459.48","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1703.00","1277.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1192.10","70","","1878.40","1878.40","1878.40","1 through 10","527.93","1459.48","percent of total billed charges",""
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1703.00","1277.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1353.89","79.5","","1299.34","871.73","1299.34","1 through 10","527.93","1459.48","percent of total billed charges",""
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1703.00","1277.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","907.70","53.3","","1299.34","871.73","1299.34","1 through 10","527.93","1459.48","percent of total billed charges",""
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1703.00","1277.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","853.39","853.39","853.39","1 through 10","527.93","1459.48","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1703.00","1277.25","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","38","527.93","1459.48","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1703.00","1277.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","621.60","36.5","","615.82","597.66","615.82","1 through 10","527.93","1459.48","percent of total billed charges",""
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1703.00","1277.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","652.25","38.3","","645.54","627.38","645.54","12","527.93","1459.48","percent of total billed charges",""
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1703.00","1277.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1067.06","1067.06","1067.06","1 through 10","527.93","1459.48","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1703.00","1277.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","977.56","1061.06","1 through 10","527.93","1459.48","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1703.00","1277.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","730.59","42.9","","725.94","725.94","725.94","1 through 10","527.93","1459.48","percent of total billed charges",""
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1703.00","1277.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","977.56","1082.71","1 through 10","527.93","1459.48","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1703.00","1277.25","AETNA [1001]","HB AMC AETNA HMO","1188.69","69.8","","789.18","789.18","1287.78","1 through 10","744.89","2384.07","percent of total billed charges",""
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1703.00","1277.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1742.82","871.41","1742.82","15","744.89","2384.07","other","ASC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1703.00","1277.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1974.52","987.26","1994.11","21","744.89","2384.07","other","ASC "
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1703.00","1277.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1728.14","864.07","2592.21","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1703.00","1277.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1817.53","1750.49","1817.53","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1703.00","1277.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","1039.12","1039.12","1039.12","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1703.00","1277.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1373.13","1373.13","1373.13","1 through 10","744.89","2384.07","other","Multiple Surgery"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1703.00","1277.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1369.21","80.4","","825.50","825.50","825.50","1 through 10","744.89","2384.07","percent of total billed charges",""
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1703.00","1277.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1391.69","81.72","","1319.81","725.94","1319.81","1 through 10","744.89","2384.07","percent of total billed charges",""
"Sigmoidoscopy W/Control Bleeding","PX-75000184","CDM","45334","CPT","0750","RC","","","","both","","","2767.00","2075.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1474.81","53.3","","1416.62","1416.62","1416.62","1 through 10","857.77","2199.77","percent of total billed charges",""
"Sigmoidoscopy W/Control Bleeding","PX-75000184","CDM","45334","CPT","0750","RC","","","","both","","","2767.00","2075.25","MEDICARE [2001]","HB BWH MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","857.77","2199.77","other","OPPS APC"
"Sigmoidoscopy W/Control Bleeding","PX-75000184","CDM","45334","CPT","0750","RC","","","","both","","","2767.00","2075.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1377.83","1377.83","1377.83","1 through 10","857.77","2199.77","other","OPPS APC"
"Sigmoidoscopy W/Control Bleeding","PX-75000184","CDM","45334","CPT","0750","RC","","","","both","","","2767.00","2075.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1262.20","1262.20","1376.23","1 through 10","857.77","2199.77","other","OPPS APC"
"Sigmoidoscopy W/Control Bleeding","PX-75000184","CDM","45334","CPT","0750","RC","","","","outpatient","","","2767.00","2075.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","2273.11","2273.11","2273.11","1 through 10","979.79","2384.07","other","Multiple Surgery"
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","both","","","2768.00","2076.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1115.08","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1114.11","1114.11","1 through 10","858.08","2200.56","other","OPPS APC"
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","both","","","2768.00","2076.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","1065.39","1065.39","1 through 10","858.08","2200.56","other","OPPS APC"
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","both","","","2768.00","2076.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2200.56","79.5","","1417.15","1417.15","1417.15","1 through 10","858.08","2200.56","percent of total billed charges",""
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","both","","","2768.00","2076.00","MEDICARE [2001]","HB BWH MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","1082.71","1082.71","1 through 10","858.08","2200.56","other","OPPS APC"
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","both","","","2768.00","2076.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","541.36","1061.06","1 through 10","858.08","2200.56","other","OPPS APC"
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","outpatient","","","2768.00","2076.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","2250.98","2250.98","2292.44","1 through 10","979.79","2384.07","other","ASC"
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","outpatient","","","2768.00","2076.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2597.20","2597.20","2622.97","1 through 10","979.79","2384.07","other","ASC "
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","outpatient","","","2768.00","2076.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6819.33","6819.33","6819.33","1 through 10","979.79","2384.07","other","Multiple Surgery"
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","outpatient","","","2768.00","2076.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2262.01","81.72","","2145.59","2145.59","2145.59","1 through 10","979.79","2384.07","percent of total billed charges",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With McC","555","MS-DRG","","","","","","","","inpatient","","","63303.82","47477.86","MEDICARE [2001]","HB BWH MEDICARE","12437.44","","Case rate ($12,437.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,894.81, add-ons for qualifying new technology services are included. If operating cost exceeds $60,539.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,503.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,994.00 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,514.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,063.60. The transfer capital threshold is the transfer adjustment factor * $1,063.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16172.30","581.43","36596.96","1 through 10","12188.69","20704.68","other","Inpatient Replacement Plans DRG"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With McC","555","MS-DRG","","","","","","","","inpatient","","","63303.82","47477.86","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12188.69","","Case rate ($12,437.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,894.81, add-ons for qualifying new technology services are included. If operating cost exceeds $60,539.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,503.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,994.00 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,514.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,063.60. The transfer capital threshold is the transfer adjustment factor * $1,063.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12251.08","12251.08","12251.08","1 through 10","12188.69","20704.68","other","Inpatient DRG"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC","556","MS-DRG","","","","","","","","inpatient","","","34721.89","26041.42","HUMANA [1012]","HB BWH MEDICARE","10213.25","","Case rate ($10,213.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,500.83, add-ons for qualifying new technology services are included. If operating cost exceeds $55,145.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,108.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $9,165.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,121.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.35. The transfer capital threshold is the transfer adjustment factor * $668.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12852.67","12852.67","12852.67","1 through 10","7797.53","12321.8015","other","Inpatient DRG"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC","556","MS-DRG","","","","","","","","inpatient","","","34721.89","26041.42","MEDICARE [2001]","HB BWH MEDICARE","10213.25","","Case rate ($10,213.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,500.83, add-ons for qualifying new technology services are included. If operating cost exceeds $55,145.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,108.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $9,165.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,121.00 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.35. The transfer capital threshold is the transfer adjustment factor * $668.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9904.11","9904.11","9918.52","1 through 10","7797.53","12321.8015","other","Inpatient DRG"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","80920.77","60690.58","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","11959.44","","Case rate ($11,959.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,319.40, add-ons for qualifying new technology services are included. If operating cost exceeds $59,963.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,461.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $10,558.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,939.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,021.43. The transfer capital threshold is the transfer adjustment factor * $1,021.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11713.73","11713.73","11729.49","1 through 10","11720.25","19883.88","other","Inpatient DRG"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","80920.77","60690.58","HUMANA [1012]","HB BWH MEDICARE","15408.17","","Case rate ($15,408.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,319.40, add-ons for qualifying new technology services are included. If operating cost exceeds $59,963.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,461.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $14,006.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,939.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,021.43. The transfer capital threshold is the transfer adjustment factor * $1,021.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11729.49","11729.49","11729.49","1 through 10","11720.25","19883.88","other","Inpatient DRG"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","80920.77","60690.58","MEDICARE [2001]","HB BWH MEDICARE","15408.17","","Case rate ($15,408.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,319.40, add-ons for qualifying new technology services are included. If operating cost exceeds $59,963.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,461.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $14,006.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,939.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,021.43. The transfer capital threshold is the transfer adjustment factor * $1,021.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15441.50","0.03","15464.17","34","11720.25","19883.88","other","Inpatient DRG"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","80920.77","60690.58","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","15408.17","","Case rate ($15,408.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,319.40, add-ons for qualifying new technology services are included. If operating cost exceeds $59,963.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,461.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $14,006.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,939.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,021.43. The transfer capital threshold is the transfer adjustment factor * $1,021.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11752.81","11752.81","11752.81","1 through 10","11720.25","19883.88","other","Inpatient DRG"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","80920.77","60690.58","MOLINA [1014]","HB BWH MOLINA","11720.25","","Case rate ($11,959.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,319.40, add-ons for qualifying new technology services are included. If operating cost exceeds $59,963.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,461.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $10,558.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,939.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,021.43. The transfer capital threshold is the transfer adjustment factor * $1,021.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","28076.49","28076.49","28076.49","1 through 10","11720.25","19883.88","other","Inpatient DRG"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","80920.77","60690.58","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11720.25","","Case rate ($11,959.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,319.40, add-ons for qualifying new technology services are included. If operating cost exceeds $59,963.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,461.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $10,558.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,939.56 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,021.43. The transfer capital threshold is the transfer adjustment factor * $1,021.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","28028.89","28028.89","28028.89","1 through 10","11720.25","19883.88","other","Inpatient DRG"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","42768.98","32076.73","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7912.55","","Case rate ($7,682.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,170.30, add-ons for qualifying new technology services are included. If operating cost exceeds $54,814.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,084.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,658.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,790.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.13. The transfer capital threshold is the transfer adjustment factor * $644.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7813.50","7813.50","7813.50","1 through 10","7528.45","11989.7995","other","Inpatient DRG"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","42768.98","32076.73","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","9602.61","","Case rate ($7,682.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,170.30, add-ons for qualifying new technology services are included. If operating cost exceeds $54,814.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,084.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,658.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,790.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.13. The transfer capital threshold is the transfer adjustment factor * $644.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","7523.53","7523.53","7523.53","1 through 10","7528.45","11989.7995","other","Inpatient DRG"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","42768.98","32076.73","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7682.09","","Case rate ($7,682.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,170.30, add-ons for qualifying new technology services are included. If operating cost exceeds $54,814.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,084.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,658.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,790.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.13. The transfer capital threshold is the transfer adjustment factor * $644.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","43670.04","7435.39","108507.94","1 through 10","7528.45","11989.7995","other","Inpatient DRG"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","42768.98","32076.73","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10281.49","10281.49","10281.49","1 through 10","7528.45","11989.7995","case rate",""
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","42768.98","32076.73","FALLON HEALTH [1008]","HB BWH MEDICARE","7682.09","","Case rate ($7,682.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,170.30, add-ons for qualifying new technology services are included. If operating cost exceeds $54,814.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,084.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,658.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,790.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.13. The transfer capital threshold is the transfer adjustment factor * $644.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7499.65","7499.65","7499.65","1 through 10","7528.45","11989.7995","other","Inpatient Replacement Plans DRG"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","42768.98","32076.73","MEDICARE [2001]","HB BWH MEDICARE","7682.09","","Case rate ($7,682.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,170.30, add-ons for qualifying new technology services are included. If operating cost exceeds $54,814.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,084.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,658.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,790.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.13. The transfer capital threshold is the transfer adjustment factor * $644.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9644.76","0.03","9658.76","56","7528.45","11989.7995","other","Inpatient Replacement Plans DRG"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","42768.98","32076.73","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","7682.09","","Case rate ($7,682.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,170.30, add-ons for qualifying new technology services are included. If operating cost exceeds $54,814.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,084.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,658.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,790.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.13. The transfer capital threshold is the transfer adjustment factor * $644.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7349.66","7349.66","7349.66","1 through 10","7528.45","11989.7995","other","Inpatient Replacement Plans DRG"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","42768.98","32076.73","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7528.45","","Case rate ($7,682.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,170.30, add-ons for qualifying new technology services are included. If operating cost exceeds $54,814.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,084.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,658.12 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,790.46 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.13. The transfer capital threshold is the transfer adjustment factor * $644.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7373.27","7373.06","7388.65","1 through 10","7528.45","11989.7995","other","Inpatient DRG"
"Signs, Symptoms And Other Factors Influencing Health Status,EXTREME","861","DRG","","","","","","","","inpatient","","","117399.28","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32262.23","","Standard inlier is a Case rate ($32,262.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,962, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,579.36) for the length of stay and the standard reimbursement.","182234.48","182234.48","182234.48","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,EXTREME","861","DRG","","","","","","","","inpatient","","","117399.28","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9069.8185","","Fee schedule rate ($52,819.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9069.8185","52819.68","52819.68","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,EXTREME","861","DRG","","","","","","","","inpatient","","","117399.28","","MASSHEALTH [3001]","HB BWH MEDICAID","19289.99","","Case rate ($21,328.40). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,758.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21323.17","21323.17","21323.17","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,EXTREME","861","DRG","","","","","","","","inpatient","","","117399.28","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","19289.99","","Case rate ($21,328.40). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $63,758.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MAJOR","861","DRG","","","","","","","","inpatient","","","63178.47","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","26568.13","","Standard inlier is a Case rate ($26,568.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,307, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,771.51) for the length of stay and the standard reimbursement.","26157.60","24217.82","26568.13","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MAJOR","861","DRG","","","","","","","","inpatient","","","63178.47","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","29869.74","","Standard inlier is a Case rate ($29,869.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,307, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,239.76) for the length of stay and the standard reimbursement.","29869.74","27288.58","29869.74","12","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MAJOR","861","DRG","","","","","","","","inpatient","","","63178.47","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","","65","","37505.50","37505.50","37505.50","1 through 10","4767.09","87153.52","percent of total billed charges",""
"Signs, Symptoms And Other Factors Influencing Health Status,MAJOR","861","DRG","","","","","","","","inpatient","","","63178.47","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9069.8185","","Fee schedule rate ($21,581.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9069.8185","21581.92","52819.68","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MAJOR","861","DRG","","","","","","","","inpatient","","","63178.47","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","9523.573","","Fee schedule rate ($22,661.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9523.573","22661.64","22661.64","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MAJOR","861","DRG","","","","","","","","inpatient","","","63178.47","","MASSHEALTH [3001]","HB BWH MEDICAID","9301.14","","Case rate ($10,284.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,714.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10281.49","10281.49","10281.49","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MAJOR","861","DRG","","","","","","","","inpatient","","","63178.47","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9301.14","","Case rate ($10,284.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,714.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10281.49","1164.94","10384.41","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MINOR","861","DRG","","","","","","","","inpatient","","","3.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","10957.13","","Standard inlier is a Case rate ($10,957.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $20,168, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,555.43) for the length of stay and the standard reimbursement.","9987.82","9987.82","9987.82","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MINOR","861","DRG","","","","","","","","inpatient","","","3.50","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","12318.77","","Standard inlier is a Case rate ($12,318.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $20,168, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,748.55) for the length of stay and the standard reimbursement.","16844.09","16844.09","16844.09","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MINOR","861","DRG","","","","","","","","inpatient","","","3.50","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","9523.573","","Fee schedule rate ($9,523.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9523.573","639.58","639.58","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","31802.56","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","18990.64","","Standard inlier is a Case rate ($18,990.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,416, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,695.84) for the length of stay and the standard reimbursement.","17310.65","17310.65","17310.65","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","31802.56","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21350.59","","Standard inlier is a Case rate ($21,350.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,416, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,030.54) for the length of stay and the standard reimbursement.","19505.60","19505.60","21350.59","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","31802.56","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9069.8185","","Fee schedule rate ($13,422.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9069.8185","2249.71","2249.71","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","31802.56","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","9523.573","","Fee schedule rate ($14,093.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9523.573","13550.24","13550.24","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","31802.56","","MASSHEALTH [3001]","HB BWH MEDICAID","6144.79","","Case rate ($6,794.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,224.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6792.45","522.88","6792.45","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","31802.56","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","6144.79","","Case rate ($6,794.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,224.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2085.87","2085.87","2085.87","1 through 10","4767.09","87153.52","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","31802.56","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6144.79","","Case rate ($6,794.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,224.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6792.45","6792.45","6792.45","1 through 10","4767.09","87153.52","case rate",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","41033.75","30775.31","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7963.29","","Case rate ($7,731.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,229.60, add-ons for qualifying new technology services are included. If operating cost exceeds $54,874.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,088.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,703.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,849.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $648.47. The transfer capital threshold is the transfer adjustment factor * $648.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7959.82","7959.82","7959.82","1 through 10","7576.72","12407.8202","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","41033.75","30775.31","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","7731.35","","Case rate ($7,731.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,229.60, add-ons for qualifying new technology services are included. If operating cost exceeds $54,874.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,088.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,703.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,849.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $648.47. The transfer capital threshold is the transfer adjustment factor * $648.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7651.89","7651.89","7651.89","1 through 10","7576.72","12407.8202","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","41033.75","30775.31","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7731.35","","Case rate ($7,731.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,229.60, add-ons for qualifying new technology services are included. If operating cost exceeds $54,874.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,088.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,703.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,849.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $648.47. The transfer capital threshold is the transfer adjustment factor * $648.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7648.78","7648.78","7771.21","1 through 10","7576.72","12407.8202","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","41033.75","30775.31","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","14254.17","14254.17","14254.17","1 through 10","7576.72","12407.8202","case rate",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","41033.75","30775.31","FALLON HEALTH [1008]","HB BWH MEDICARE","7731.35","","Case rate ($7,731.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,229.60, add-ons for qualifying new technology services are included. If operating cost exceeds $54,874.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,088.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,703.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,849.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $648.47. The transfer capital threshold is the transfer adjustment factor * $648.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12025.07","12025.07","12025.07","1 through 10","7576.72","12407.8202","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","41033.75","30775.31","HUMANA [1012]","HB BWH MEDICARE","7731.35","","Case rate ($7,731.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,229.60, add-ons for qualifying new technology services are included. If operating cost exceeds $54,874.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,088.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,703.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,849.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $648.47. The transfer capital threshold is the transfer adjustment factor * $648.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12052.08","12052.08","12052.08","1 through 10","7576.72","12407.8202","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","41033.75","30775.31","MEDICARE [2001]","HB BWH MEDICARE","7731.35","","Case rate ($7,731.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,229.60, add-ons for qualifying new technology services are included. If operating cost exceeds $54,874.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,088.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,703.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,849.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $648.47. The transfer capital threshold is the transfer adjustment factor * $648.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9959.84","0.03","9959.84","60","7576.72","12407.8202","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","41033.75","30775.31","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","7731.35","","Case rate ($7,731.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,229.60, add-ons for qualifying new technology services are included. If operating cost exceeds $54,874.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,088.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,703.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,849.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $648.47. The transfer capital threshold is the transfer adjustment factor * $648.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7579.80","7579.80","7579.80","1 through 10","7576.72","12407.8202","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","41033.75","30775.31","MOLINA [1014]","HB BWH MOLINA","7576.72","","Case rate ($7,731.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,229.60, add-ons for qualifying new technology services are included. If operating cost exceeds $54,874.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,088.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,703.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,849.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $648.47. The transfer capital threshold is the transfer adjustment factor * $648.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11140.52","11140.52","11140.52","1 through 10","7576.72","12407.8202","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","41033.75","30775.31","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","7576.72","","Case rate ($7,731.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,229.60, add-ons for qualifying new technology services are included. If operating cost exceeds $54,874.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,088.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,703.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,849.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $648.47. The transfer capital threshold is the transfer adjustment factor * $648.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7618.14","7618.14","7618.14","1 through 10","7576.72","12407.8202","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","41033.75","30775.31","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7576.72","","Case rate ($7,731.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,229.60, add-ons for qualifying new technology services are included. If operating cost exceeds $54,874.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,088.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,703.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,849.76 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $648.47. The transfer capital threshold is the transfer adjustment factor * $648.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7597.23","7566.73","11061.35","15","7576.72","12407.8202","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","62714.66","47035.99","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","12741.03","","Case rate ($12,369.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,813.55, add-ons for qualifying new technology services are included. If operating cost exceeds $60,457.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,497.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,932.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,433.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,057.64. The transfer capital threshold is the transfer adjustment factor * $1,057.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12610.55","12593.54","12660.05","1 through 10","12122.53","20588.76","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","62714.66","47035.99","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","12369.93","","Case rate ($12,369.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,813.55, add-ons for qualifying new technology services are included. If operating cost exceeds $60,457.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,497.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,932.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,433.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,057.64. The transfer capital threshold is the transfer adjustment factor * $1,057.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12105.89","12105.89","12105.89","1 through 10","12122.53","20588.76","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","62714.66","47035.99","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","12369.93","","Case rate ($12,369.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,813.55, add-ons for qualifying new technology services are included. If operating cost exceeds $60,457.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,497.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,932.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,433.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,057.64. The transfer capital threshold is the transfer adjustment factor * $1,057.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11993.89","11993.89","12051.39","1 through 10","12122.53","20588.76","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","62714.66","47035.99","FALLON HEALTH [1008]","HB BWH MEDICARE","12369.93","","Case rate ($12,369.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,813.55, add-ons for qualifying new technology services are included. If operating cost exceeds $60,457.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,497.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,932.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,433.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,057.64. The transfer capital threshold is the transfer adjustment factor * $1,057.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12049.05","12049.05","12049.05","1 through 10","12122.53","20588.76","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","62714.66","47035.99","HUMANA [1012]","HB BWH MEDICARE","12369.93","","Case rate ($12,369.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,813.55, add-ons for qualifying new technology services are included. If operating cost exceeds $60,457.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,497.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,932.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,433.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,057.64. The transfer capital threshold is the transfer adjustment factor * $1,057.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12032.08","12027.33","12133.56","1 through 10","12122.53","20588.76","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","62714.66","47035.99","MEDICARE [2001]","HB BWH MEDICARE","12369.93","","Case rate ($12,369.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,813.55, add-ons for qualifying new technology services are included. If operating cost exceeds $60,457.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,497.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,932.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,433.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,057.64. The transfer capital threshold is the transfer adjustment factor * $1,057.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15836.08","1011.85","15836.08","114","12122.53","20588.76","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","62714.66","47035.99","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","12369.93","","Case rate ($12,369.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,813.55, add-ons for qualifying new technology services are included. If operating cost exceeds $60,457.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,497.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,932.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,433.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,057.64. The transfer capital threshold is the transfer adjustment factor * $1,057.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12010.05","12010.05","12010.05","1 through 10","12122.53","20588.76","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","62714.66","47035.99","MOLINA [1014]","HB BWH MOLINA","12122.53","","Case rate ($12,369.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,813.55, add-ons for qualifying new technology services are included. If operating cost exceeds $60,457.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,497.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,932.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,433.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,057.64. The transfer capital threshold is the transfer adjustment factor * $1,057.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","35982.88","35982.88","35982.88","1 through 10","12122.53","20588.76","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","62714.66","47035.99","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12122.53","","Case rate ($12,369.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,813.55, add-ons for qualifying new technology services are included. If operating cost exceeds $60,457.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,497.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,932.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,433.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,057.64. The transfer capital threshold is the transfer adjustment factor * $1,057.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12032.78","11997.84","17742.88","1 through 10","12122.53","20588.76","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","62714.66","47035.99","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12122.53","","Case rate ($12,369.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,813.55, add-ons for qualifying new technology services are included. If operating cost exceeds $60,457.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,497.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,932.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,433.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,057.64. The transfer capital threshold is the transfer adjustment factor * $1,057.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12090.34","12041.24","12236.02","16","12122.53","20588.76","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","62714.66","47035.99","WELLSENSE [1003]","HB BWH MEDICARE","12369.93","","Case rate ($12,369.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,813.55, add-ons for qualifying new technology services are included. If operating cost exceeds $60,457.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,497.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,932.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,433.71 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,057.64. The transfer capital threshold is the transfer adjustment factor * $1,057.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12425.91","12425.91","12425.91","1 through 10","12122.53","20588.76","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","31270.25","23452.69","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","6296.49","","Case rate ($6,113.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,281.54, add-ons for qualifying new technology services are included. If operating cost exceeds $52,925.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,945.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,227.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,901.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.73. The transfer capital threshold is the transfer adjustment factor * $505.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6141.92","6141.92","6141.92","1 through 10","5990.84","9397.1657","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","31270.25","23452.69","MEDICARE [2001]","HB BWH MEDICARE","6113.10","","Case rate ($6,113.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,281.54, add-ons for qualifying new technology services are included. If operating cost exceeds $52,925.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,945.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,227.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,901.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.73. The transfer capital threshold is the transfer adjustment factor * $505.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","881.13","538.18","7630.35","1 through 10","5990.84","9397.1657","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","31270.25","23452.69","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","5990.84","","Case rate ($6,113.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,281.54, add-ons for qualifying new technology services are included. If operating cost exceeds $52,925.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,945.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,227.52 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $6,901.69 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.73. The transfer capital threshold is the transfer adjustment factor * $505.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5858.33","5858.33","5858.33","1 through 10","5990.84","9397.1657","other","Inpatient DRG"
"Sincalide Vl 5mcg","PX-63600174","CDM","J2805","HCPCS","0636","RC","","","","both","","","224.70","168.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","82.02","36.5","","46.21","46.21","46.21","1 through 10","69.66","316.5","percent of total billed charges",""
"Sincalide Vl 5mcg","PX-63600174","CDM","J2805","HCPCS","0636","RC","","","","both","","","224.70","168.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","86.06","38.3","","65.03","44.40","68.62","1 through 10","69.66","316.5","percent of total billed charges",""
"Sincalide Vl 5mcg","PX-63600174","CDM","J2805","HCPCS","0636","RC","","","","outpatient","","","224.70","168.52","AETNA [1001]","HB AMC AETNA HMO","156.84","69.8","","98.52","78.95","117.09","1 through 10","105.38","292.34","percent of total billed charges",""
"Sincalide Vl 5mcg","PX-63600174","CDM","J2805","HCPCS","0636","RC","","","","outpatient","","","224.70","168.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","157.07","69.9","","92.40","92.40","92.40","1 through 10","105.38","292.34","percent of total billed charges",""
"Sincalide Vl 5mcg","PX-63600174","CDM","J2805","HCPCS","0636","RC","","","","outpatient","","","224.70","168.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","105.38","46.9","","62.27","62.27","62.27","1 through 10","105.38","292.34","percent of total billed charges",""
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","121428.81","91071.61","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","38166.93","","Case rate ($37,055.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $44,529.82, add-ons for qualifying new technology services are included. If operating cost exceeds $90,174.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,675.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $33,440.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $44,149.98 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,235.13. The transfer capital threshold is the transfer adjustment factor * $3,235.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","36880.52","36873.39","36922.06","1 through 10","36314.16","62977.11","other","Inpatient DRG"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","121428.81","91071.61","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","47978.24","","Case rate ($47,978.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $44,529.82, add-ons for qualifying new technology services are included. If operating cost exceeds $90,174.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,675.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $44,363.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $44,149.98 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,235.13. The transfer capital threshold is the transfer adjustment factor * $3,235.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35402.85","35402.82","45699.35","1 through 10","36314.16","62977.11","other","Inpatient DRG"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","121428.81","91071.61","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","37055.27","","Case rate ($37,055.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $44,529.82, add-ons for qualifying new technology services are included. If operating cost exceeds $90,174.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,675.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $33,440.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $44,149.98 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,235.13. The transfer capital threshold is the transfer adjustment factor * $3,235.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","785.02","785.02","785.02","1 through 10","36314.16","62977.11","other","Inpatient DRG"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","121428.81","91071.61","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","47978.24","","Case rate ($47,978.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $44,529.82, add-ons for qualifying new technology services are included. If operating cost exceeds $90,174.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,675.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $44,363.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $44,149.98 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,235.13. The transfer capital threshold is the transfer adjustment factor * $3,235.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35183.73","35183.73","35183.73","1 through 10","36314.16","62977.11","other","Inpatient DRG"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","121428.81","91071.61","MEDICARE [2001]","HB BWH MEDICARE","47978.24","","Case rate ($47,978.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $44,529.82, add-ons for qualifying new technology services are included. If operating cost exceeds $90,174.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,675.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $44,363.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $44,149.98 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,235.13. The transfer capital threshold is the transfer adjustment factor * $3,235.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","46399.83","0.03","46468.80","83","36314.16","62977.11","other","Inpatient DRG"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","121428.81","91071.61","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","47978.24","","Case rate ($47,978.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $44,529.82, add-ons for qualifying new technology services are included. If operating cost exceeds $90,174.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,675.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $44,363.27 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $44,149.98 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,235.13. The transfer capital threshold is the transfer adjustment factor * $3,235.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35120.25","35120.25","35129.47","1 through 10","36314.16","62977.11","other","Inpatient DRG"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","121428.81","91071.61","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","36314.16","","Case rate ($37,055.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $44,529.82, add-ons for qualifying new technology services are included. If operating cost exceeds $90,174.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,675.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $33,440.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $44,149.98 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,235.13. The transfer capital threshold is the transfer adjustment factor * $3,235.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","35107.39","35107.39","35107.39","1 through 10","36314.16","62977.11","other","Inpatient DRG"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","121428.81","91071.61","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","36314.16","","Case rate ($37,055.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $44,529.82, add-ons for qualifying new technology services are included. If operating cost exceeds $90,174.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,675.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $33,440.30 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $44,149.98 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,235.13. The transfer capital threshold is the transfer adjustment factor * $3,235.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","35181.65","35167.56","46771.82","1 through 10","36314.16","62977.11","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","450","MS-DRG","","","","","","","","inpatient","","","129440.27","97080.20","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","50466.92","","Case rate ($48,997.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,905.33, add-ons for qualifying new technology services are included. If operating cost exceeds $104,549.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,728.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $44,328.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $58,525.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,288.51. The transfer capital threshold is the transfer adjustment factor * $4,288.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","48503.89","48503.89","48503.89","1 through 10","48017.07","77720.1591","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","450","MS-DRG","","","","","","","","inpatient","","","129440.27","97080.20","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","48997.01","","Case rate ($48,997.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,905.33, add-ons for qualifying new technology services are included. If operating cost exceeds $104,549.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,728.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $44,328.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $58,525.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,288.51. The transfer capital threshold is the transfer adjustment factor * $4,288.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","46218.63","46218.63","46218.63","1 through 10","48017.07","77720.1591","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","450","MS-DRG","","","","","","","","inpatient","","","129440.27","97080.20","MEDICARE [2001]","HB BWH MEDICARE","63476.57","","Case rate ($63,476.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,905.33, add-ons for qualifying new technology services are included. If operating cost exceeds $104,549.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,728.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $58,808.23 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $58,525.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,288.51. The transfer capital threshold is the transfer adjustment factor * $4,288.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","60993.60","1104.59","61084.42","1 through 10","48017.07","77720.1591","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","450","MS-DRG","","","","","","","","inpatient","","","129440.27","97080.20","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","48017.07","","Case rate ($48,997.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,905.33, add-ons for qualifying new technology services are included. If operating cost exceeds $104,549.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,728.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $44,328.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $58,525.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,288.51. The transfer capital threshold is the transfer adjustment factor * $4,288.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","46179.01","46121.58","46236.73","1 through 10","48017.07","77720.1591","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","450","MS-DRG","","","","","","","","inpatient","","","129440.27","97080.20","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","48017.07","","Case rate ($48,997.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $58,905.33, add-ons for qualifying new technology services are included. If operating cost exceeds $104,549.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,728.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $44,328.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $58,525.49 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,288.51. The transfer capital threshold is the transfer adjustment factor * $4,288.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","46225.49","46225.49","46225.49","1 through 10","48017.07","77720.1591","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","115641.94","86731.45","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","30743.32","","Case rate ($29,847.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,853.55, add-ons for qualifying new technology services are included. If operating cost exceeds $81,497.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,039.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,868.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,473.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,599.37. The transfer capital threshold is the transfer adjustment factor * $2,599.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","29158.81","29149.22","29188.68","1 through 10","29250.92","50600.99","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","115641.94","86731.45","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","38624.29","","Case rate ($38,624.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,853.55, add-ons for qualifying new technology services are included. If operating cost exceeds $81,497.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,039.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $35,645.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,473.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,599.37. The transfer capital threshold is the transfer adjustment factor * $2,599.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27984.11","27984.08","27984.11","1 through 10","29250.92","50600.99","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","115641.94","86731.45","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","29847.88","","Case rate ($29,847.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,853.55, add-ons for qualifying new technology services are included. If operating cost exceeds $81,497.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,039.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,868.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,473.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,599.37. The transfer capital threshold is the transfer adjustment factor * $2,599.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20144.17","20144.17","20144.17","1 through 10","29250.92","50600.99","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","115641.94","86731.45","MEDICARE [2001]","HB BWH MEDICARE","38624.29","","Case rate ($38,624.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,853.55, add-ons for qualifying new technology services are included. If operating cost exceeds $81,497.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,039.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $35,645.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,473.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,599.37. The transfer capital threshold is the transfer adjustment factor * $2,599.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36714.04","0.03","36714.04","56","29250.92","50600.99","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","115641.94","86731.45","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","38624.29","","Case rate ($38,624.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,853.55, add-ons for qualifying new technology services are included. If operating cost exceeds $81,497.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,039.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $35,645.10 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,473.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,599.37. The transfer capital threshold is the transfer adjustment factor * $2,599.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36653.82","36653.82","36653.82","1 through 10","29250.92","50600.99","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","115641.94","86731.45","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","29250.92","","Case rate ($29,847.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,853.55, add-ons for qualifying new technology services are included. If operating cost exceeds $81,497.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,039.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,868.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,473.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,599.37. The transfer capital threshold is the transfer adjustment factor * $2,599.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","27807.91","27794.86","27825.84","1 through 10","29250.92","50600.99","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","115641.94","86731.45","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","29250.92","","Case rate ($29,847.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,853.55, add-ons for qualifying new technology services are included. If operating cost exceeds $81,497.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,039.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $26,868.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $35,473.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,599.37. The transfer capital threshold is the transfer adjustment factor * $2,599.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","27819.86","27762.69","40699.09","1 through 10","29250.92","50600.99","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","115641.94","86731.45","WELLPOINT [1015]","HB AMC WELLPOINT","50600.99","","Fee schedule rate ($50,600.99).","81273.54","81273.54","81273.54","1 through 10","29250.92","50600.99","case rate",""
"Sinus And Mastoid Procedures With Cc/McC","135","MS-DRG","","","","","","","","inpatient","","","139022.88","104267.16","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","20780.04","","Case rate ($20,174.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,209.08, add-ons for qualifying new technology services are included. If operating cost exceeds $69,853.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,186.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $18,048.86 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,829.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,746.11. The transfer capital threshold is the transfer adjustment factor * $1,746.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","22805.89","22805.89","22805.89","1 through 10","19771.3","33990.88","other","Inpatient DRG"
"Sinus And Mastoid Procedures With Cc/McC","135","MS-DRG","","","","","","","","inpatient","","","139022.88","104267.16","MEDICARE [2001]","HB BWH MEDICARE","26070.30","","Case rate ($26,070.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,209.08, add-ons for qualifying new technology services are included. If operating cost exceeds $69,853.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,186.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $23,944.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,829.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,746.11. The transfer capital threshold is the transfer adjustment factor * $1,746.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28745.64","28745.64","28745.64","1 through 10","19771.3","33990.88","other","Inpatient DRG"
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","219.82","79.5","","800.18","480.96","1887.97","195","85.72","219.82","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.37","53.3","","813.12","216.42","1444.50","81","85.72","219.82","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.72","31","","432.60","432.60","432.60","1 through 10","85.72","219.82","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.92","36.5","","148.37","54.89","631.39","94","85.72","219.82","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.90","38.3","","279.30","91.72","1116.77","266","85.72","219.82","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.62","42.9","","731.00","63.70","731.00","1 through 10","85.72","219.82","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","118.62","42.9","","384.74","384.74","384.74","1 through 10","85.72","219.82","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.50","207.37","WELLPOINT [1015]","HB AMC WELLPOINT","204.00","73.78","","286.63","119.22","1107.45","105","85.72","219.82","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","AETNA [1001]","HB AMC AETNA HMO","193.00","69.8","","675.31","184.75","1721.50","286","144.5","225.96","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","AETNA [1001]","HB AMC AETNA PPO","222.31","80.4","","1261.44","103.12","1514.10","21","144.5","225.96","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","222.31","80.4","","1365.00","1365.00","1365.00","1 through 10","144.5","225.96","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","225.96","81.72","","5157.68","5157.68","5157.68","1 through 10","144.5","225.96","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.50","207.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","225.96","81.72","","431.26","71.26","1459.57","88","144.5","225.96","percent of total billed charges",""
"Skin Debridement With Cc","571","MS-DRG","","","","","","","","inpatient","","","100520.88","75390.66","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15791.64","","Case rate ($15,791.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,932.61, add-ons for qualifying new technology services are included. If operating cost exceeds $64,577.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,799.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $14,052.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,552.77 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,359.47. The transfer capital threshold is the transfer adjustment factor * $1,359.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9423.83","9423.83","9423.83","1 through 10","15475.81","25266.8613","other","Inpatient DRG"
"Skin Debridement With Cc","571","MS-DRG","","","","","","","","inpatient","","","100520.88","75390.66","MEDICARE [2001]","HB BWH MEDICARE","15791.64","","Case rate ($15,791.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,932.61, add-ons for qualifying new technology services are included. If operating cost exceeds $64,577.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,799.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $14,052.33 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,552.77 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,359.47. The transfer capital threshold is the transfer adjustment factor * $1,359.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20016.86","20016.86","20016.86","1 through 10","15475.81","25266.8613","other","Inpatient Replacement Plans DRG"
"Skin Debridement With McC","570","MS-DRG","","","","","","","","inpatient","","","95241.66","71431.24","HUMANA [1012]","HB BWH MEDICARE","27208.87","","Case rate ($27,208.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,676.70, add-ons for qualifying new technology services are included. If operating cost exceeds $78,321.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,806.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,462.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $32,296.86 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,366.58. The transfer capital threshold is the transfer adjustment factor * $2,366.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27260.09","27260.09","27260.09","1 through 10","26664.69","45426.9282","other","Inpatient Replacement Plans DRG"
"Skin Debridement With McC","570","MS-DRG","","","","","","","","inpatient","","","95241.66","71431.24","MEDICARE [2001]","HB BWH MEDICARE","27208.87","","Case rate ($27,208.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,676.70, add-ons for qualifying new technology services are included. If operating cost exceeds $78,321.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,806.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $24,462.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $32,296.86 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,366.58. The transfer capital threshold is the transfer adjustment factor * $2,366.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35765.99","35765.99","35819.08","1 through 10","26664.69","45426.9282","other","Inpatient Replacement Plans DRG"
"Skin Debridement Without Cc/McC","572","MS-DRG","","","","","","","","inpatient","","","82357.64","61768.23","MEDICARE [2001]","HB BWH MEDICARE","10836.51","","Case rate ($10,836.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,967.61, add-ons for qualifying new technology services are included. If operating cost exceeds $58,612.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,362.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $9,534.29 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,587.77 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $922.38. The transfer capital threshold is the transfer adjustment factor * $922.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","10619.78","17239.9584","other","Inpatient Replacement Plans DRG"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","","","","inpatient","","","111351.86","83513.89","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","25296.60","","Case rate ($24,559.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $29,487.75, add-ons for qualifying new technology services are included. If operating cost exceeds $75,132.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,573.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $22,047.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,107.91 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,132.91. The transfer capital threshold is the transfer adjustment factor * $2,132.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","25230.60","25230.60","25230.60","1 through 10","24068.61","41520.56","other","Inpatient DRG"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","","","","inpatient","","","111351.86","83513.89","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","24559.81","","Case rate ($24,559.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $29,487.75, add-ons for qualifying new technology services are included. If operating cost exceeds $75,132.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,573.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $22,047.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,107.91 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,132.91. The transfer capital threshold is the transfer adjustment factor * $2,132.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23992.22","23992.22","23992.22","1 through 10","24068.61","41520.56","other","Inpatient DRG"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","","","","inpatient","","","111351.86","83513.89","HUMANA [1012]","HB BWH MEDICARE","24559.81","","Case rate ($24,559.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $29,487.75, add-ons for qualifying new technology services are included. If operating cost exceeds $75,132.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,573.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $22,047.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,107.91 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,132.91. The transfer capital threshold is the transfer adjustment factor * $2,132.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24098.39","24098.39","24098.39","1 through 10","24068.61","41520.56","other","Inpatient Replacement Plans DRG"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","","","","inpatient","","","111351.86","83513.89","MEDICARE [2001]","HB BWH MEDICARE","24559.81","","Case rate ($24,559.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $29,487.75, add-ons for qualifying new technology services are included. If operating cost exceeds $75,132.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,573.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $22,047.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,107.91 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,132.91. The transfer capital threshold is the transfer adjustment factor * $2,132.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","31717.40","0.03","31717.40","18","24068.61","41520.56","other","Inpatient Replacement Plans DRG"
"Skin Graft Except For Skin Ulcer Or Cellulitis With McC","576","MS-DRG","","","","","","","","inpatient","","","108579.37","81434.53","MEDICARE [2001]","HB BWH MEDICARE","45089.10","","Case rate ($45,089.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $54,200.98, add-ons for qualifying new technology services are included. If operating cost exceeds $99,845.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,383.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $40,765.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $53,821.14 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,943.79. The transfer capital threshold is the transfer adjustment factor * $3,943.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","63979.46","63979.46","63979.46","1 through 10","44187.32","76772.4","other","Inpatient Replacement Plans DRG"
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/McC","578","MS-DRG","","","","","","","","inpatient","","","92096.78","69072.58","MEDICARE [2001]","HB BWH MEDICARE","15033.59","","Case rate ($15,033.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,020.07, add-ons for qualifying new technology services are included. If operating cost exceeds $63,664.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,732.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $13,361.15 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,640.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,292.60. The transfer capital threshold is the transfer adjustment factor * $1,292.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20206.67","20206.67","20236.47","1 through 10","14732.92","25162.65","other","Inpatient Replacement Plans DRG"
"Skin Graft For Musculoskeletal And Connective Tissue Diagnoses,EXTREME","312","DRG","","","","","","","","inpatient","","","1499038.27","","MASSHEALTH [3001]","HB BWH MEDICAID","86053.29","","Case rate ($95,146.70). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $137,576.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","95123.35","95123.35","95123.35","1 through 10","16077.8856","491536.25","case rate",""
"Skin Graft For Musculoskeletal And Connective Tissue Diagnoses,EXTREME","312","DRG","","","","","","","","inpatient","","","1499038.27","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","86053.29","","Case rate ($95,146.70). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $137,576.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2085.87","2085.87","2085.87","1 through 10","16077.8856","491536.25","case rate",""
"Skin Graft For Musculoskeletal And Connective Tissue Diagnoses,MAJOR","312","DRG","","","","","","","","inpatient","","","91409.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","96453.80","","Standard inlier is a Case rate ($96,453.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $86,655, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,692.20) for the length of stay and the standard reimbursement.","87921.15","87921.15","87921.15","1 through 10","16077.8856","491536.25","case rate",""
"Skin Graft For Musculoskeletal And Connective Tissue Diagnoses,MINOR","312","DRG","","","","","","","","inpatient","","","105734.53","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","35646.25","","Standard inlier is a Case rate ($35,646.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $39,367, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,060.20) for the length of stay and the standard reimbursement.","35646.25","35646.25","35646.25","1 through 10","16077.8856","491536.25","case rate",""
"Skin Graft For Musculoskeletal And Connective Tissue Diagnoses,MINOR","312","DRG","","","","","","","","inpatient","","","105734.53","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","32154.6826","","Fee schedule rate ($32,154.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32154.6826","65287.26","65287.26","1 through 10","16077.8856","491536.25","case rate",""
"Skin Graft For Musculoskeletal And Connective Tissue Diagnoses,MINOR","312","DRG","","","","","","","","inpatient","","","105734.53","","MASSHEALTH [3001]","HB BWH MEDICAID","17465.63","","Case rate ($19,311.26). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,741.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6383.76","6383.76","6383.76","1 through 10","16077.8856","491536.25","case rate",""
"Skin Graft For Musculoskeletal And Connective Tissue Diagnoses,MINOR","312","DRG","","","","","","","","inpatient","","","105734.53","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","17465.63","","Case rate ($19,311.26). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $61,741.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19306.52","19306.52","19306.52","1 through 10","16077.8856","491536.25","case rate",""
"Skin Graft For Musculoskeletal And Connective Tissue Diagnoses,MODERATE","312","DRG","","","","","","","","inpatient","","","196906.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","64200.85","","Standard inlier is a Case rate ($64,200.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,054, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,112.78) for the length of stay and the standard reimbursement.","64200.85","64200.85","64200.85","1 through 10","16077.8856","491536.25","case rate",""
"Skin Graft For Skin And Subcutaneous Tissue Diagnoses,EXTREME","361","DRG","","","","","","","","inpatient","","","528118.44","","MASSHEALTH [3001]","HB BWH MEDICAID","80290.05","","Case rate ($88,774.46). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $131,204.46, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $12,906.46 and the sum of the standard inlier and any outlier amount.","103144.51","103144.51","103144.51","1 through 10","13100.65","376920.98","case rate",""
"Skin Graft For Skin And Subcutaneous Tissue Diagnoses,MAJOR","361","DRG","","","","","","","","inpatient","","","236838.23","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","82388.70","","Standard inlier is a Case rate ($82,388.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $75,716, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,695.57) for the length of stay and the standard reimbursement.","9532.74","9532.74","9532.74","1 through 10","13100.65","376920.98","case rate",""
"Skin Graft For Skin And Subcutaneous Tissue Diagnoses,MAJOR","361","DRG","","","","","","","","inpatient","","","236838.23","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","92627.10","","Standard inlier is a Case rate ($92,627.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $75,716, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,147.65) for the length of stay and the standard reimbursement.","58819.57","58819.57","58819.57","1 through 10","13100.65","376920.98","case rate",""
"Skin Graft For Skin And Subcutaneous Tissue Diagnoses,MAJOR","361","DRG","","","","","","","","inpatient","","","236838.23","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70153.69","","Fee schedule rate ($70,153.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","68109.80","68109.80","68109.80","1 through 10","13100.65","376920.98","case rate",""
"Skin Graft For Skin And Subcutaneous Tissue Diagnoses,MAJOR","361","DRG","","","","","","","","inpatient","","","236838.23","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","36784.19","","Case rate ($40,671.24). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $83,101.24, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,990.34 and the sum of the standard inlier and any outlier amount.","40661.26","40661.26","40661.26","1 through 10","13100.65","376920.98","case rate",""
"Skin Graft For Skin And Subcutaneous Tissue Diagnoses,MINOR","361","DRG","","","","","","","","inpatient","","","90920.97","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","48904.20","","Standard inlier is a Case rate ($48,904.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,475, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,941.55) for the length of stay and the standard reimbursement.","44678.21","44678.21","44678.21","1 through 10","13100.65","376920.98","case rate",""
"Skin Graft For Skin And Subcutaneous Tissue Diagnoses,MINOR","361","DRG","","","","","","","","inpatient","","","90920.97","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","29470.7592","","Fee schedule rate ($29,470.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29470.7592","29470.76","43906.44","1 through 10","13100.65","376920.98","case rate",""
"Skin Graft For Skin And Subcutaneous Tissue Diagnoses,MINOR","361","DRG","","","","","","","","inpatient","","","90920.97","","MASSHEALTH [3001]","HB BWH MEDICAID","13100.65","","Case rate ($14,485.02). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,915.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14481.47","14481.47","14481.47","1 through 10","13100.65","376920.98","case rate",""
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","","","","inpatient","","","80550.76","60413.07","MEDICARE [2001]","HB BWH MEDICARE","41477.49","","Case rate ($41,477.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $38,500.03, add-ons for qualifying new technology services are included. If operating cost exceeds $84,144.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,233.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $38,304.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $38,120.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,793.29. The transfer capital threshold is the transfer adjustment factor * $2,793.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","41187.62","41187.62","41187.62","1 through 10","31405.39","52288.8059","other","Inpatient DRG"
"Skin Graft For Skin Ulcer Or Cellulitis With McC","573","MS-DRG","","","","","","","","inpatient","","","329307.13","246980.35","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","60142.40","","Case rate ($60,142.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $72,322.18, add-ons for qualifying new technology services are included. If operating cost exceeds $117,966.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,711.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12. The base transfer operating payment is the transfer adjustment factor * $54,490.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $71,942.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,271.64. The transfer capital threshold is the transfer adjustment factor * $5,271.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27546.13","27546.13","27546.13","1 through 10","58939.55","92933.3962","other","Inpatient DRG"
"Skin Graft For Skin Ulcer Or Cellulitis With McC","573","MS-DRG","","","","","","","","inpatient","","","329307.13","246980.35","HUMANA [1012]","HB BWH MEDICARE","60142.40","","Case rate ($60,142.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $72,322.18, add-ons for qualifying new technology services are included. If operating cost exceeds $117,966.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,711.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12. The base transfer operating payment is the transfer adjustment factor * $54,490.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $71,942.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,271.64. The transfer capital threshold is the transfer adjustment factor * $5,271.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","207018.56","207018.56","207018.56","1 through 10","58939.55","92933.3962","other","Inpatient Replacement Plans DRG"
"Skin Graft For Skin Ulcer Or Cellulitis With McC","573","MS-DRG","","","","","","","","inpatient","","","329307.13","246980.35","MEDICARE [2001]","HB BWH MEDICARE","60142.40","","Case rate ($60,142.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $72,322.18, add-ons for qualifying new technology services are included. If operating cost exceeds $117,966.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,711.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12. The base transfer operating payment is the transfer adjustment factor * $54,490.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $71,942.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,271.64. The transfer capital threshold is the transfer adjustment factor * $5,271.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","72986.84","72986.84","72986.84","1 through 10","58939.55","92933.3962","other","Inpatient Replacement Plans DRG"
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/McC","575","MS-DRG","","","","","","","","inpatient","","","64918.60","48688.95","MEDICARE [2001]","HB BWH MEDICARE","21654.38","","Case rate ($21,654.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,113.08, add-ons for qualifying new technology services are included. If operating cost exceeds $65,757.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,886.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $19,828.58 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,733.25 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,445.97. The transfer capital threshold is the transfer adjustment factor * $1,445.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23852.90","23852.90","23852.90","1 through 10","16436.81","28148.21","other","Inpatient DRG"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","","","","inpatient","","","98841.06","74130.79","MEDICARE [2001]","HB BWH MEDICARE","21617.68","","Case rate ($21,617.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,079.04, add-ons for qualifying new technology services are included. If operating cost exceeds $65,723.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,883.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $19,794.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,699.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,443.48. The transfer capital threshold is the transfer adjustment factor * $1,443.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22828.57","10323.89","22862.29","1 through 10","16409.1","28099.65","other","Inpatient DRG"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","","","","inpatient","","","98841.06","74130.79","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16409.10","","Case rate ($16,743.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,079.04, add-ons for qualifying new technology services are included. If operating cost exceeds $65,723.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,883.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $14,920.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,699.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,443.48. The transfer capital threshold is the transfer adjustment factor * $1,443.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6598.97","6598.97","6598.97","1 through 10","16409.1","28099.65","other","Inpatient DRG"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With McC","622","MS-DRG","","","","","","","","inpatient","","","121156.37","90867.28","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","32847.24","","Case rate ($32,847.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,464.18, add-ons for qualifying new technology services are included. If operating cost exceeds $85,108.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,304.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $29,603.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,084.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,863.94. The transfer capital threshold is the transfer adjustment factor * $2,863.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22675.44","22675.44","22675.44","1 through 10","32190.3","55751.31","other","Inpatient Replacement Plans DRG"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With McC","622","MS-DRG","","","","","","","","inpatient","","","121156.37","90867.28","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","32847.24","","Case rate ($32,847.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,464.18, add-ons for qualifying new technology services are included. If operating cost exceeds $85,108.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,304.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $29,603.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,084.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,863.94. The transfer capital threshold is the transfer adjustment factor * $2,863.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","174408.99","174408.99","174408.99","1 through 10","32190.3","55751.31","other","Inpatient Replacement Plans DRG"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With McC","622","MS-DRG","","","","","","","","inpatient","","","121156.37","90867.28","MEDICARE [2001]","HB BWH MEDICARE","32847.24","","Case rate ($32,847.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,464.18, add-ons for qualifying new technology services are included. If operating cost exceeds $85,108.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,304.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $29,603.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,084.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,863.94. The transfer capital threshold is the transfer adjustment factor * $2,863.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","44459.30","44459.30","44459.30","1 through 10","32190.3","55751.31","other","Inpatient Replacement Plans DRG"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With McC","622","MS-DRG","","","","","","","","inpatient","","","121156.37","90867.28","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","32190.30","","Case rate ($32,847.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,464.18, add-ons for qualifying new technology services are included. If operating cost exceeds $85,108.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,304.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $29,603.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,084.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,863.94. The transfer capital threshold is the transfer adjustment factor * $2,863.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","33783.65","33783.65","33783.65","1 through 10","32190.3","55751.31","other","Inpatient DRG"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/McC","624","MS-DRG","","","","","","","","inpatient","","","55169.29","41376.97","MEDICARE [2001]","HB BWH MEDICARE","15201.00","","Case rate ($15,201). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,127.23, add-ons for qualifying new technology services are included. If operating cost exceeds $59,771.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,447.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $13,813.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,747.38 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,007.35. The transfer capital threshold is the transfer adjustment factor * $1,007.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9374.61","9374.61","9374.61","1 through 10","11563.81","15201","other","Inpatient DRG"
"Skin Grafts For Injuries With Cc/McC","904","MS-DRG","","","","","","","","inpatient","","","96292.85","72219.64","MARTIN'S POINT [160007]","HB BWH MEDICARE","43865.39","","Case rate ($43,865.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,714.94, add-ons for qualifying new technology services are included. If operating cost exceeds $86,359.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,395.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $40,529.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $40,335.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,955.59. The transfer capital threshold is the transfer adjustment factor * $2,955.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14871.12","14871.12","14871.12","1 through 10","33208.52","57535.44","other","Inpatient DRG"
"Skin Grafts For Injuries With Cc/McC","904","MS-DRG","","","","","","","","inpatient","","","96292.85","72219.64","MEDICARE [2001]","HB BWH MEDICARE","43865.39","","Case rate ($43,865.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $40,714.94, add-ons for qualifying new technology services are included. If operating cost exceeds $86,359.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,395.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $40,529.96 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $40,335.11 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,955.59. The transfer capital threshold is the transfer adjustment factor * $2,955.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","45865.48","45865.48","45865.48","1 through 10","33208.52","57535.44","other","Inpatient DRG"
"Skin Grafts For Injuries Without Cc/McC","905","MS-DRG","","","","","","","","inpatient","","","104624.82","78468.61","MEDICARE [2001]","HB BWH MEDICARE","17941.68","","Case rate ($17,941.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,669.37, add-ons for qualifying new technology services are included. If operating cost exceeds $62,313.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,633.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $16,368.23 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,289.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,193.63. The transfer capital threshold is the transfer adjustment factor * $1,193.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","13633.32","23235.98","other","Inpatient DRG"
"Skin Test Tuberculosis Intradermal","PX-30000875","CDM","86580","CPT","0302","RC","","","","both","","","80.00","60.00","AETNA [1001]","HB AMC AETNA PPO","64.32","80.4","","40.87","40.87","40.87","1 through 10","24.8","64.32","percent of total billed charges",""
"Skin Test Tuberculosis Intradermal","PX-30000875","CDM","86580","CPT","0302","RC","","","","both","","","80.00","60.00","MEDICARE [2001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","78.00","78.00","78.00","1 through 10","24.8","64.32","other","OPPS APC"
"Skin Test Tuberculosis Intradermal","PX-30000875","CDM","86580","CPT","0302","RC","","","","both","","","80.00","60.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30.64","38.3","","30.50","30.50","30.50","1 through 10","24.8","64.32","percent of total billed charges",""
"Skin Test Tuberculosis Intradermal","PX-30000875","CDM","86580","CPT","0302","RC","","","","both","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","28.50","28.50","1 through 10","24.8","64.32","other","OPPS APC"
"Skin Test Tuberculosis Intradermal","PX-30000875","CDM","86580","CPT","0302","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","65.38","81.72","","34.17","34.17","34.17","1 through 10","12.33","105.25","percent of total billed charges",""
"Skin Ulcers With Cc","593","MS-DRG","","","","","","","","inpatient","","","48690.32","36517.74","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","11537.42","","Case rate ($11,201.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,406.85, add-ons for qualifying new technology services are included. If operating cost exceeds $59,051.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,394.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,866.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,027.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $954.57. The transfer capital threshold is the transfer adjustment factor * $954.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11706.31","11706.31","11706.31","1 through 10","10977.35","18582.2","other","Inpatient DRG"
"Skin Ulcers With Cc","593","MS-DRG","","","","","","","","inpatient","","","48690.32","36517.74","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","11201.38","","Case rate ($11,201.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,406.85, add-ons for qualifying new technology services are included. If operating cost exceeds $59,051.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,394.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,866.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,027.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $954.57. The transfer capital threshold is the transfer adjustment factor * $954.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10886.55","10886.55","10886.55","1 through 10","10977.35","18582.2","other","Inpatient DRG"
"Skin Ulcers With Cc","593","MS-DRG","","","","","","","","inpatient","","","48690.32","36517.74","MEDICARE [2001]","HB BWH MEDICARE","11201.38","","Case rate ($11,201.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,406.85, add-ons for qualifying new technology services are included. If operating cost exceeds $59,051.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,394.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,866.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,027.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $954.57. The transfer capital threshold is the transfer adjustment factor * $954.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14714.45","14714.45","14714.45","1 through 10","10977.35","18582.2","other","Inpatient Replacement Plans DRG"
"Skin Ulcers With Cc","593","MS-DRG","","","","","","","","inpatient","","","48690.32","36517.74","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10977.35","","Case rate ($11,201.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,406.85, add-ons for qualifying new technology services are included. If operating cost exceeds $59,051.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,394.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $9,866.99 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,027.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $954.57. The transfer capital threshold is the transfer adjustment factor * $954.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11187.24","11182.55","15161.65","1 through 10","10977.35","18582.2","other","Inpatient DRG"
"Skin Ulcers With McC","592","MS-DRG","","","","","","","","inpatient","","","73941.75","55456.31","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","22542.30","","Case rate ($18,033.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,631.78, add-ons for qualifying new technology services are included. If operating cost exceeds $67,276.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,997.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $16,096.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,251.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,557.26. The transfer capital threshold is the transfer adjustment factor * $1,557.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","13192.77","13192.77","13192.77","1 through 10","17673.16","30314.54","other","Inpatient DRG"
"Skin Ulcers With McC","592","MS-DRG","","","","","","","","inpatient","","","73941.75","55456.31","MEDICARE [2001]","HB BWH MEDICARE","18033.84","","Case rate ($18,033.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,631.78, add-ons for qualifying new technology services are included. If operating cost exceeds $67,276.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,997.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $16,096.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,251.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,557.26. The transfer capital threshold is the transfer adjustment factor * $1,557.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24556.58","24556.58","24556.58","1 through 10","17673.16","30314.54","other","Inpatient Replacement Plans DRG"
"Skin Ulcers With McC","592","MS-DRG","","","","","","","","inpatient","","","73941.75","55456.31","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","17673.16","","Case rate ($18,033.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,631.78, add-ons for qualifying new technology services are included. If operating cost exceeds $67,276.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,997.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $16,096.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,251.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,557.26. The transfer capital threshold is the transfer adjustment factor * $1,557.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18825.22","18825.22","18825.22","1 through 10","17673.16","30314.54","other","Inpatient DRG"
"Skin Ulcers With McC","592","MS-DRG","","","","","","","","inpatient","","","73941.75","55456.31","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17673.16","","Case rate ($18,033.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,631.78, add-ons for qualifying new technology services are included. If operating cost exceeds $67,276.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,997.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $16,096.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,251.95 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,557.26. The transfer capital threshold is the transfer adjustment factor * $1,557.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18635.88","18635.88","18635.88","1 through 10","17673.16","30314.54","other","Inpatient DRG"
"Skin Ulcers,EXTREME","380","DRG","","","","","","","","inpatient","","","72903.78","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14724.1961","","Fee schedule rate ($67,626.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14724.1961","67626.64","67626.64","1 through 10","6699.98","155323.69","case rate",""
"Skin Ulcers,MAJOR","380","DRG","","","","","","","","inpatient","","","145811.86","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35149.21","","Standard inlier is a Case rate ($35,149.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,960, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,989.14) for the length of stay and the standard reimbursement.","40331.10","40331.10","40331.10","1 through 10","6699.98","155323.69","case rate",""
"Skin Ulcers,MODERATE","380","DRG","","","","","","","","inpatient","","","37640.20","","MASSHEALTH [3001]","HB BWH MEDICAID","6699.98","","Case rate ($7,407.98). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,837.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7406.16","7406.16","7406.16","1 through 10","6699.98","155323.69","case rate",""
"Skin Ulcers,MODERATE","380","DRG","","","","","","","","inpatient","","","37640.20","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29949.03","","Fee schedule rate ($29,949.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21279.65","21279.65","21279.65","1 through 10","6699.98","155323.69","case rate",""
"Skin/Muc Mem/Subq Tissue Unlstd","PX-76001780","CDM","17999","CPT","0761","RC","","","","both","","","2536.00","1902.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4490.63","3878.56","4490.63","1 through 10","224.17","2016.12","other","OPPS APC"
"Skin/Muc Mem/Subq Tissue Unlstd","PX-76001780","CDM","17999","CPT","0761","RC","","","","outpatient","","","2536.00","1902.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1324.30","52.22","","467.73","465.00","467.73","1 through 10","700.33","2092.2","percent of total billed charges",""
"Slc12a3 Full Gene Sequencing Analysis + Mlpa Duplication/Deletion Analysis","PX-31000820","CDM","81479","CPT","0310","RC","","","","both","","","732.00","549.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","581.94","79.5","","0.65","0.65","0.65","1 through 10","226.92","695.4","percent of total billed charges",""
"Slc12a3 Full Gene Sequencing Analysis + Mlpa Duplication/Deletion Analysis","PX-31000820","CDM","81479","CPT","0310","RC","","","","both","","","732.00","549.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","390.16","53.3","","0.79","0.79","0.79","1 through 10","226.92","695.4","percent of total billed charges",""
"Slc12a3 Full Gene Sequencing Analysis + Mlpa Duplication/Deletion Analysis","PX-31000820","CDM","81479","CPT","0310","RC","","","","outpatient","","","732.00","549.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","366.00","50","","1.00","1.00","1.00","1 through 10","156.55","603.9","percent of total billed charges",""
"Slc12a3 Full Gene Sequencing Analysis + Mlpa Duplication/Deletion Analysis","PX-31000820","CDM","81479","CPT","0310","RC","","","","outpatient","","","732.00","549.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","384.30","52.5","","1.00","0.53","1.00","1 through 10","156.55","603.9","percent of total billed charges",""
"Slctv Cath Intrnl Carotid Art Angio","PX-48000227","CDM","36224","CPT","0361","RC","","","","both","","","17016.00","12762.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6290.57","","APC Price ($6,418.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6299.10","6299.10","6299.10","1 through 10","5274.96","13527.72","other","OPPS APC"
"Slctv Cath Intrnl Carotid Art Angio","PX-48000227","CDM","36224","CPT","0361","RC","","","","outpatient","","","17016.00","12762.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","13905.48","81.72","","7255.49","7255.49","7255.49","1 through 10","5004.8","16762.07","percent of total billed charges",""
"Slctv Cath Intrnl Carotid Art Angio|BILATERAL PROCEDURE","PX-48000227","CDM","36224","CPT","0361","RC","","","50","outpatient","","","17016.00","12762.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","7507.20","","Case rate ($7,507.20). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","17574.36","17574.36","17574.36","1 through 10","7507.2","29195.37","other","ASC "
"Slctv Cath Subclavian Art Angio Ver","PX-48000228","CDM","36225","CPT","0361","RC","","","","both","","","10043.00","7532.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3417.22","3417.22","3417.22","1 through 10","3113.33","7984.19","other","OPPS APC"
"Slctv Cath Vertebral Art Angio Vert","PX-48000229","CDM","36226","CPT","0361","RC","","","","both","","","15969.00","11976.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6290.57","","APC Price ($6,418.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6304.04","6304.04","6304.04","1 through 10","4950.39","12695.36","other","OPPS APC"
"SLEEVE CERAMIC PLUS 7 DELTA OPTION","SUP-ITM-10207384","CDM","C1776","HCPCS","0278","RC","","","","both","","","477.75","358.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","249.67","52.26","","1113.10","1113.10","1113.10","1 through 10","148.1","379.81","percent of total billed charges",""
"SLEEVE CERAMIC PLUS 7 DELTA OPTION","SUP-ITM-10207384","CDM","C1776","HCPCS","0278","RC","","","","both","","","477.75","358.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","379.81","79.5","","1293.60","1148.53","1603.80","1 through 10","148.1","379.81","percent of total billed charges",""
"SLEEVE CERAMIC PLUS 7 DELTA OPTION","SUP-ITM-10207384","CDM","C1776","HCPCS","0278","RC","","","","both","","","477.75","358.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","174.38","36.5","","1023.42","771.29","2068.67","33","148.1","379.81","percent of total billed charges",""
"SLEEVE CERAMIC PLUS 7 DELTA OPTION","SUP-ITM-10207384","CDM","C1776","HCPCS","0278","RC","","","","both","","","477.75","358.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","182.98","38.3","","850.52","759.78","1211.25","66","148.1","379.81","percent of total billed charges",""
"SLEEVE CERAMIC PLUS 7 DELTA OPTION","SUP-ITM-10207384","CDM","C1776","HCPCS","0278","RC","","","","both","","","477.75","358.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.95","42.9","","2548.09","2548.09","2548.09","1 through 10","148.1","379.81","percent of total billed charges",""
"SLEEVE CERAMIC PLUS 7 DELTA OPTION","SUP-ITM-10207384","CDM","C1776","HCPCS","0278","RC","","","","both","","","477.75","358.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.95","42.9","","956.46","956.46","956.46","1 through 10","148.1","379.81","percent of total billed charges",""
"SLEEVE CERAMIC PLUS 7 DELTA OPTION","SUP-ITM-10207384","CDM","C1776","HCPCS","0278","RC","","","","both","","","477.75","358.31","WELLPOINT [1015]","HB AMC WELLPOINT","352.48","73.78","","2344.73","1619.47","2530.35","16","148.1","379.81","percent of total billed charges",""
"SLEEVE CERAMIC PLUS 7 DELTA OPTION","SUP-ITM-10207384","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","477.75","358.31","AETNA [1001]","HB AMC AETNA HMO","333.47","69.8","","1523.63","988.41","4330.26","39","249.67","390.42","percent of total billed charges",""
"SLEEVE CERAMIC PLUS 7 DELTA OPTION","SUP-ITM-10207384","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","477.75","358.31","AETNA [1001]","HB AMC AETNA PPO","384.11","80.4","","1670.25","1670.25","1670.25","1 through 10","249.67","390.42","percent of total billed charges",""
"SLEEVE CERAMIC PLUS 7 DELTA OPTION","SUP-ITM-10207384","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","477.75","358.31","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","249.67","52.26","","1113.10","1113.10","1113.10","1 through 10","249.67","390.42","percent of total billed charges",""
"SLEEVE CERAMIC PLUS 7 DELTA OPTION","SUP-ITM-10207384","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","477.75","358.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","390.42","81.72","","1738.90","1484.65","2716.94","38","249.67","390.42","percent of total billed charges",""
"SLEEVE COMPRESSION 2.4MM HEADLESS SCREW","SUP-ITM-10095807","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.32","555.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","588.55","79.5","","800.18","480.96","1887.97","195","229.5","588.55","percent of total billed charges",""
"SLEEVE COMPRESSION 2.4MM HEADLESS SCREW","SUP-ITM-10095807","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.32","555.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","394.59","53.3","","813.12","216.42","1444.50","81","229.5","588.55","percent of total billed charges",""
"SLEEVE COMPRESSION 2.4MM HEADLESS SCREW","SUP-ITM-10095807","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.32","555.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","229.50","31","","432.60","432.60","432.60","1 through 10","229.5","588.55","percent of total billed charges",""
"SLEEVE COMPRESSION 2.4MM HEADLESS SCREW","SUP-ITM-10095807","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.32","555.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","270.22","36.5","","148.37","54.89","631.39","94","229.5","588.55","percent of total billed charges",""
"SLEEVE COMPRESSION 2.4MM HEADLESS SCREW","SUP-ITM-10095807","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.32","555.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","283.54","38.3","","279.30","91.72","1116.77","266","229.5","588.55","percent of total billed charges",""
"SLEEVE COMPRESSION 2.4MM HEADLESS SCREW","SUP-ITM-10095807","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.32","555.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","317.60","42.9","","731.00","63.70","731.00","1 through 10","229.5","588.55","percent of total billed charges",""
"SLEEVE COMPRESSION 2.4MM HEADLESS SCREW","SUP-ITM-10095807","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.32","555.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","317.60","42.9","","384.74","384.74","384.74","1 through 10","229.5","588.55","percent of total billed charges",""
"SLEEVE COMPRESSION 2.4MM HEADLESS SCREW","SUP-ITM-10095807","CDM","C1713","HCPCS","0278","RC","","","","both","","","740.32","555.24","WELLPOINT [1015]","HB AMC WELLPOINT","546.21","73.78","","286.63","119.22","1107.45","105","229.5","588.55","percent of total billed charges",""
"SLEEVE COMPRESSION 2.4MM HEADLESS SCREW","SUP-ITM-10095807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","740.32","555.24","AETNA [1001]","HB AMC AETNA HMO","516.74","69.8","","675.31","184.75","1721.50","286","386.89","604.99","percent of total billed charges",""
"SLEEVE COMPRESSION 2.4MM HEADLESS SCREW","SUP-ITM-10095807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","740.32","555.24","AETNA [1001]","HB AMC AETNA PPO","595.22","80.4","","1261.44","103.12","1514.10","21","386.89","604.99","percent of total billed charges",""
"SLEEVE COMPRESSION 2.4MM HEADLESS SCREW","SUP-ITM-10095807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","740.32","555.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","595.22","80.4","","1365.00","1365.00","1365.00","1 through 10","386.89","604.99","percent of total billed charges",""
"SLEEVE COMPRESSION 2.4MM HEADLESS SCREW","SUP-ITM-10095807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","740.32","555.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","604.99","81.72","","5157.68","5157.68","5157.68","1 through 10","386.89","604.99","percent of total billed charges",""
"SLEEVE COMPRESSION 2.4MM HEADLESS SCREW","SUP-ITM-10095807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","740.32","555.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","604.99","81.72","","431.26","71.26","1459.57","88","386.89","604.99","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","1023.42","771.29","2068.67","33","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","850.52","759.78","1211.25","66","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","956.46","956.46","956.46","1 through 10","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","2344.73","1619.47","2530.35","16","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","1523.63","988.41","4330.26","39","2351.7","3677.4","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA PPO","3618.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","1738.90","1484.65","2716.94","38","2351.7","3677.4","percent of total billed charges",""
"SLEEVE FEMORAL 35MM ATTUNE M/L POROCOAT FULLY COATED","SUP-ITM-10274644","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","1534.5","3935.25","percent of total billed charges",""
"SLEEVE FEMORAL 35MM ATTUNE M/L POROCOAT FULLY COATED","SUP-ITM-10274644","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1534.5","3935.25","percent of total billed charges",""
"SLEEVE FEMORAL 35MM ATTUNE M/L POROCOAT FULLY COATED","SUP-ITM-10274644","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","1023.42","771.29","2068.67","33","1534.5","3935.25","percent of total billed charges",""
"SLEEVE FEMORAL 35MM ATTUNE M/L POROCOAT FULLY COATED","SUP-ITM-10274644","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","850.52","759.78","1211.25","66","1534.5","3935.25","percent of total billed charges",""
"SLEEVE FEMORAL 35MM ATTUNE M/L POROCOAT FULLY COATED","SUP-ITM-10274644","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1534.5","3935.25","percent of total billed charges",""
"SLEEVE FEMORAL 35MM ATTUNE M/L POROCOAT FULLY COATED","SUP-ITM-10274644","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","956.46","956.46","956.46","1 through 10","1534.5","3935.25","percent of total billed charges",""
"SLEEVE FEMORAL 35MM ATTUNE M/L POROCOAT FULLY COATED","SUP-ITM-10274644","CDM","C1776","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","2344.73","1619.47","2530.35","16","1534.5","3935.25","percent of total billed charges",""
"SLEEVE FEMORAL 35MM ATTUNE M/L POROCOAT FULLY COATED","SUP-ITM-10274644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","1523.63","988.41","4330.26","39","2586.87","4045.14","percent of total billed charges",""
"SLEEVE FEMORAL 35MM ATTUNE M/L POROCOAT FULLY COATED","SUP-ITM-10274644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA PPO","3979.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2586.87","4045.14","percent of total billed charges",""
"SLEEVE FEMORAL 35MM ATTUNE M/L POROCOAT FULLY COATED","SUP-ITM-10274644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2586.87","52.26","","1113.10","1113.10","1113.10","1 through 10","2586.87","4045.14","percent of total billed charges",""
"SLEEVE FEMORAL 35MM ATTUNE M/L POROCOAT FULLY COATED","SUP-ITM-10274644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","1738.90","1484.65","2716.94","38","2586.87","4045.14","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","1113.10","1113.10","1113.10","1 through 10","27.13","69.56","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","69.56","79.5","","1293.60","1148.53","1603.80","1 through 10","27.13","69.56","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.94","36.5","","1023.42","771.29","2068.67","33","27.13","69.56","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","33.51","38.3","","850.52","759.78","1211.25","66","27.13","69.56","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","2548.09","2548.09","2548.09","1 through 10","27.13","69.56","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.54","42.9","","956.46","956.46","956.46","1 through 10","27.13","69.56","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","87.50","65.62","WELLPOINT [1015]","HB AMC WELLPOINT","64.56","73.78","","2344.73","1619.47","2530.35","16","27.13","69.56","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA HMO","61.08","69.8","","1523.63","988.41","4330.26","39","45.73","71.51","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","AETNA [1001]","HB AMC AETNA PPO","70.35","80.4","","1670.25","1670.25","1670.25","1 through 10","45.73","71.51","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","45.73","52.26","","1113.10","1113.10","1113.10","1 through 10","45.73","71.51","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","87.50","65.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","71.51","81.72","","1738.90","1484.65","2716.94","38","45.73","71.51","percent of total billed charges",""
"SLEEVE FEMORAL 40MM DISTALLY POROUS UNIVERSAL","SUP-ITM-10050128","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 40MM DISTALLY POROUS UNIVERSAL","SUP-ITM-10050128","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 40MM DISTALLY POROUS UNIVERSAL","SUP-ITM-10050128","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","1023.42","771.29","2068.67","33","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 40MM DISTALLY POROUS UNIVERSAL","SUP-ITM-10050128","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","850.52","759.78","1211.25","66","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 40MM DISTALLY POROUS UNIVERSAL","SUP-ITM-10050128","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 40MM DISTALLY POROUS UNIVERSAL","SUP-ITM-10050128","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","956.46","956.46","956.46","1 through 10","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 40MM DISTALLY POROUS UNIVERSAL","SUP-ITM-10050128","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","2344.73","1619.47","2530.35","16","1395","3577.5","percent of total billed charges",""
"SLEEVE FEMORAL 40MM DISTALLY POROUS UNIVERSAL","SUP-ITM-10050128","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","1523.63","988.41","4330.26","39","2351.7","3677.4","percent of total billed charges",""
"SLEEVE FEMORAL 40MM DISTALLY POROUS UNIVERSAL","SUP-ITM-10050128","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA PPO","3618.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SLEEVE FEMORAL 40MM DISTALLY POROUS UNIVERSAL","SUP-ITM-10050128","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SLEEVE FEMORAL 40MM DISTALLY POROUS UNIVERSAL","SUP-ITM-10050128","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","1738.90","1484.65","2716.94","38","2351.7","3677.4","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1463.28","52.26","","1113.10","1113.10","1113.10","1 through 10","868","2226","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","1293.60","1148.53","1603.80","1 through 10","868","2226","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","1023.42","771.29","2068.67","33","868","2226","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","850.52","759.78","1211.25","66","868","2226","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","2548.09","2548.09","2548.09","1 through 10","868","2226","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","956.46","956.46","956.46","1 through 10","868","2226","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","2344.73","1619.47","2530.35","16","868","2226","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA HMO","1954.40","69.8","","1523.63","988.41","4330.26","39","1463.28","2288.16","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA PPO","2251.20","80.4","","1670.25","1670.25","1670.25","1 through 10","1463.28","2288.16","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1463.28","52.26","","1113.10","1113.10","1113.10","1 through 10","1463.28","2288.16","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","1738.90","1484.65","2716.94","38","1463.28","2288.16","percent of total billed charges",""
"SLEEVE PACEMAKER CONNECTOR REAL TIME LEAD IS-4 DF4","SUP-ITM-10211189","CDM","C1883","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","153.30","36.5","","1073.15","1073.15","1073.15","1 through 10","130.2","333.9","percent of total billed charges",""
"SLEEVE PACEMAKER CONNECTOR REAL TIME LEAD IS-4 DF4","SUP-ITM-10211189","CDM","C1883","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","160.86","38.3","","1808.38","1642.20","1808.38","1 through 10","130.2","333.9","percent of total billed charges",""
"SLEEVE PACEMAKER CONNECTOR REAL TIME LEAD IS-4 DF4","SUP-ITM-10211189","CDM","C1883","HCPCS","0278","RC","","","","both","","","420.00","315.00","WELLPOINT [1015]","HB AMC WELLPOINT","309.88","73.78","","625.38","625.38","625.38","1 through 10","130.2","333.9","percent of total billed charges",""
"SLEEVE POSITIONING 8MM COMPREHENSIVE SHOULDER HUMERAL FIXATION FRACTURE","SUP-ITM-10017956","CDM","C1776","HCPCS","0278","RC","","","","both","","","437.50","328.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","228.64","52.26","","1113.10","1113.10","1113.10","1 through 10","135.63","347.81","percent of total billed charges",""
"SLEEVE POSITIONING 8MM COMPREHENSIVE SHOULDER HUMERAL FIXATION FRACTURE","SUP-ITM-10017956","CDM","C1776","HCPCS","0278","RC","","","","both","","","437.50","328.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","347.81","79.5","","1293.60","1148.53","1603.80","1 through 10","135.63","347.81","percent of total billed charges",""
"SLEEVE POSITIONING 8MM COMPREHENSIVE SHOULDER HUMERAL FIXATION FRACTURE","SUP-ITM-10017956","CDM","C1776","HCPCS","0278","RC","","","","both","","","437.50","328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","159.69","36.5","","1023.42","771.29","2068.67","33","135.63","347.81","percent of total billed charges",""
"SLEEVE POSITIONING 8MM COMPREHENSIVE SHOULDER HUMERAL FIXATION FRACTURE","SUP-ITM-10017956","CDM","C1776","HCPCS","0278","RC","","","","both","","","437.50","328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","167.56","38.3","","850.52","759.78","1211.25","66","135.63","347.81","percent of total billed charges",""
"SLEEVE POSITIONING 8MM COMPREHENSIVE SHOULDER HUMERAL FIXATION FRACTURE","SUP-ITM-10017956","CDM","C1776","HCPCS","0278","RC","","","","both","","","437.50","328.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.69","42.9","","2548.09","2548.09","2548.09","1 through 10","135.63","347.81","percent of total billed charges",""
"SLEEVE POSITIONING 8MM COMPREHENSIVE SHOULDER HUMERAL FIXATION FRACTURE","SUP-ITM-10017956","CDM","C1776","HCPCS","0278","RC","","","","both","","","437.50","328.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.69","42.9","","956.46","956.46","956.46","1 through 10","135.63","347.81","percent of total billed charges",""
"SLEEVE POSITIONING 8MM COMPREHENSIVE SHOULDER HUMERAL FIXATION FRACTURE","SUP-ITM-10017956","CDM","C1776","HCPCS","0278","RC","","","","both","","","437.50","328.12","WELLPOINT [1015]","HB AMC WELLPOINT","322.79","73.78","","2344.73","1619.47","2530.35","16","135.63","347.81","percent of total billed charges",""
"SLEEVE POSITIONING 8MM COMPREHENSIVE SHOULDER HUMERAL FIXATION FRACTURE","SUP-ITM-10017956","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","AETNA [1001]","HB AMC AETNA HMO","305.38","69.8","","1523.63","988.41","4330.26","39","228.64","357.53","percent of total billed charges",""
"SLEEVE POSITIONING 8MM COMPREHENSIVE SHOULDER HUMERAL FIXATION FRACTURE","SUP-ITM-10017956","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","AETNA [1001]","HB AMC AETNA PPO","351.75","80.4","","1670.25","1670.25","1670.25","1 through 10","228.64","357.53","percent of total billed charges",""
"SLEEVE POSITIONING 8MM COMPREHENSIVE SHOULDER HUMERAL FIXATION FRACTURE","SUP-ITM-10017956","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","228.64","52.26","","1113.10","1113.10","1113.10","1 through 10","228.64","357.53","percent of total billed charges",""
"SLEEVE POSITIONING 8MM COMPREHENSIVE SHOULDER HUMERAL FIXATION FRACTURE","SUP-ITM-10017956","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","357.53","81.72","","1738.90","1484.65","2716.94","38","228.64","357.53","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","1395","3577.5","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1395","3577.5","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","1023.42","771.29","2068.67","33","1395","3577.5","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","850.52","759.78","1211.25","66","1395","3577.5","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1395","3577.5","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","956.46","956.46","956.46","1 through 10","1395","3577.5","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","2344.73","1619.47","2530.35","16","1395","3577.5","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","1523.63","988.41","4330.26","39","2351.7","3677.4","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA PPO","3618.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2351.70","52.26","","1113.10","1113.10","1113.10","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","1738.90","1484.65","2716.94","38","2351.7","3677.4","percent of total billed charges",""
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","both","","","12281.00","9210.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","9763.4","other","OPPS APC"
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","both","","","12281.00","9210.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","9763.4","other","OPPS APC"
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","both","","","12281.00","9210.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9763.40","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","9763.4","percent of total billed charges",""
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","both","","","12281.00","9210.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","9763.4","other","OPPS APC"
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","both","","","12281.00","9210.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","9763.4","other","OPPS APC"
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","both","","","12281.00","9210.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4482.57","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","9763.4","percent of total billed charges",""
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","both","","","12281.00","9210.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4703.62","38.3","","2723.31","1555.62","2741.61","12","1057.74","9763.4","percent of total billed charges",""
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","both","","","12281.00","9210.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","9763.4","other","OPPS APC"
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","both","","","12281.00","9210.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","9763.4","other","OPPS APC"
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","both","","","12281.00","9210.75","WELLPOINT [1015]","HB AMC WELLPOINT","9060.92","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","9763.4","percent of total billed charges",""
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","outpatient","","","12281.00","9210.75","AETNA [1001]","HB AMC AETNA PPO","9873.92","80.4","","1163.76","1163.76","1163.76","1 through 10","2384.07","10131.83","percent of total billed charges",""
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","outpatient","","","12281.00","9210.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","7436.15","60.55","","1781.82","1492.00","4331.00","1 through 10","2384.07","10131.83","percent of total billed charges",""
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","outpatient","","","12281.00","9210.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6413.14","52.22","","3144.00","1492.00","3610.00","13","2384.07","10131.83","percent of total billed charges",""
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","outpatient","","","12281.00","9210.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","6447.53","52.5","","1182.28","1182.28","1182.28","1 through 10","2384.07","10131.83","percent of total billed charges",""
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","outpatient","","","12281.00","9210.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6140.50","50","","3610.00","2269.44","3610.00","1 through 10","2384.07","10131.83","percent of total billed charges",""
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","outpatient","","","12281.00","9210.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6447.53","52.5","","3610.00","2382.05","4331.00","1 through 10","2384.07","10131.83","percent of total billed charges",""
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","outpatient","","","12281.00","9210.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","6754.55","55","","4810.75","3363.17","4810.75","1 through 10","2384.07","10131.83","percent of total billed charges",""
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","outpatient","","","12281.00","9210.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","10036.03","81.72","","8894.69","8894.69","8894.69","1 through 10","2384.07","10131.83","percent of total billed charges",""
"Sleeve-in-Sleeve Sis) Gastric Sleeve Revision","PX-75000540","CDM","43999","CPT","0750","RC","","","","outpatient","","","12281.00","9210.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10036.03","81.72","","2885.83","2132.00","3462.21","1 through 10","2384.07","10131.83","percent of total billed charges",""
"SLING ARM 1X37IN 8 17 MD CANVAS ENVELOPE FOAM PAD THUMB LOOP STRAP","SUP-ITM-10016753","CDM","A4565","HCPCS","0274","RC","","","","both","","","13.20","9.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4.82","36.5","","4.78","4.78","4.78","1 through 10","4.09","10.49","percent of total billed charges",""
"SLING ARM 1X37IN 8 17 MD CANVAS ENVELOPE FOAM PAD THUMB LOOP STRAP","SUP-ITM-10016753","CDM","A4565","HCPCS","0274","RC","","","","both","","","13.20","9.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5.06","38.3","","5.02","4.78","5.02","1 through 10","4.09","10.49","percent of total billed charges",""
"SLING ARM 1X37IN 8 17 MD CANVAS ENVELOPE FOAM PAD THUMB LOOP STRAP","SUP-ITM-10016753","CDM","A4565","HCPCS","0274","RC","","","","both","","","13.20","9.90","WELLPOINT [1015]","HB AMC WELLPOINT","9.74","73.78","","9.83","9.83","9.83","1 through 10","4.09","10.49","percent of total billed charges",""
"SLING ARM 1X37IN 8 17 MD CANVAS ENVELOPE FOAM PAD THUMB LOOP STRAP","SUP-ITM-10016753","CDM","A4565","HCPCS","0274","RC","","","","outpatient","","","13.20","9.90","AETNA [1001]","HB AMC AETNA HMO","9.21","69.8","","13.20","6.31","13.20","1 through 10","5.66","10.79","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","both","","","4168.04","3126.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3313.59","79.5","","1632.15","1632.15","1632.15","1 through 10","1292.09","3313.59","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","both","","","4168.04","3126.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2221.57","53.3","","9709.13","9709.13","9709.13","1 through 10","1292.09","3313.59","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","both","","","4168.04","3126.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2709.23","65","","2685.95","2190.09","2685.96","1 through 10","1292.09","3313.59","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","both","","","4168.04","3126.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1521.33","36.5","","1495.87","1455.73","1541.33","1 through 10","1292.09","3313.59","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","both","","","4168.04","3126.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1596.36","38.3","","1615.71","1615.71","1615.71","1 through 10","1292.09","3313.59","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","both","","","4168.04","3126.03","WELLPOINT [1015]","HB AMC WELLPOINT","3075.18","73.78","","3076.44","3076.44","3076.44","1 through 10","1292.09","3313.59","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4168.04","3126.03","AETNA [1001]","HB AMC AETNA HMO","2909.29","69.8","","4568.79","2411.14","4568.79","1 through 10","2178.22","3406.12","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4168.04","3126.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3351.10","80.4","","2411.14","1545.60","3223.14","1 through 10","2178.22","3406.12","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4168.04","3126.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3406.12","81.72","","1816.95","1816.95","1816.95","1 through 10","2178.22","3406.12","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4168.04","3126.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3406.12","81.72","","3303.30","3303.30","3303.30","1 through 10","2178.22","3406.12","percent of total billed charges",""
"SLING SHOULDER 11IN UNIVERSAL SM ULTRA III MESH PADDED DEROTATION STRAP UP","SUP-ITM-10008597","CDM","L3670","HCPCS","0274","RC","","","","both","","","180.08","135.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.73","36.5","","54.89","54.89","54.89","1 through 10","55.82","258.84","percent of total billed charges",""
"SLING SHOULDER 13 15IN UNIVERSAL LG ULTRA III MESH PADDED DEROTATION STRAP","SUP-ITM-10018171","CDM","L3670","HCPCS","0274","RC","","","","both","","","162.05","121.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","59.15","36.5","","54.89","54.89","54.89","1 through 10","50.24","258.84","percent of total billed charges",""
"SLING SHOULDER 15IN DONJOY ULTRASLING II MESH PADDED DEROTATION STRAP UNIVERSAL BLACK XL PLUS EA/1","SUP-ITM-10140127","CDM","A4565","HCPCS","0274","RC","","","","both","","","184.52","138.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.35","36.5","","4.78","4.78","4.78","1 through 10","57.2","146.69","percent of total billed charges",""
"SLING SHOULDER 15IN DONJOY ULTRASLING II MESH PADDED DEROTATION STRAP UNIVERSAL BLACK XL PLUS EA/1","SUP-ITM-10140127","CDM","A4565","HCPCS","0274","RC","","","","both","","","184.52","138.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.67","38.3","","5.02","4.78","5.02","1 through 10","57.2","146.69","percent of total billed charges",""
"SLING SHOULDER 15IN DONJOY ULTRASLING II MESH PADDED DEROTATION STRAP UNIVERSAL BLACK XL PLUS EA/1","SUP-ITM-10140127","CDM","A4565","HCPCS","0274","RC","","","","both","","","184.52","138.39","WELLPOINT [1015]","HB AMC WELLPOINT","136.14","73.78","","9.83","9.83","9.83","1 through 10","57.2","146.69","percent of total billed charges",""
"SLING SHOULDER 15IN DONJOY ULTRASLING II MESH PADDED DEROTATION STRAP UNIVERSAL BLACK XL PLUS EA/1","SUP-ITM-10140127","CDM","A4565","HCPCS","0274","RC","","","","outpatient","","","184.52","138.39","AETNA [1001]","HB AMC AETNA HMO","128.79","69.8","","13.20","6.31","13.20","1 through 10","79.16","150.79","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","both","","","4132.24","3099.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3285.13","79.5","","1632.15","1632.15","1632.15","1 through 10","1280.99","3285.13","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","both","","","4132.24","3099.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2202.48","53.3","","9709.13","9709.13","9709.13","1 through 10","1280.99","3285.13","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","both","","","4132.24","3099.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2685.96","65","","2685.95","2190.09","2685.96","1 through 10","1280.99","3285.13","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","both","","","4132.24","3099.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1508.27","36.5","","1495.87","1455.73","1541.33","1 through 10","1280.99","3285.13","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","both","","","4132.24","3099.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1582.65","38.3","","1615.71","1615.71","1615.71","1 through 10","1280.99","3285.13","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","both","","","4132.24","3099.18","WELLPOINT [1015]","HB AMC WELLPOINT","3048.77","73.78","","3076.44","3076.44","3076.44","1 through 10","1280.99","3285.13","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4132.24","3099.18","AETNA [1001]","HB AMC AETNA HMO","2884.30","69.8","","4568.79","2411.14","4568.79","1 through 10","2159.51","3376.87","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4132.24","3099.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3322.32","80.4","","2411.14","1545.60","3223.14","1 through 10","2159.51","3376.87","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4132.24","3099.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3376.87","81.72","","1816.95","1816.95","1816.95","1 through 10","2159.51","3376.87","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4132.24","3099.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3376.87","81.72","","3303.30","3303.30","3303.30","1 through 10","2159.51","3376.87","percent of total billed charges",""
"SLITTER CATHETER AGILIS HISPRO STEERABLE CATHETER COMPATIBLE","SUP-ITM-10317781","CDM","C1887","HCPCS","0272","RC","","","","both","","","147.00","110.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","105.55","71.8","","28.28","27.13","28.28","1 through 10","45.57","116.87","percent of total billed charges",""
"SLITTER CATHETER AGILIS HISPRO STEERABLE CATHETER COMPATIBLE","SUP-ITM-10317781","CDM","C1887","HCPCS","0272","RC","","","","both","","","147.00","110.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","102.90","70","","44.63","35.78","44.63","1 through 10","45.57","116.87","percent of total billed charges",""
"SLITTER CATHETER AGILIS HISPRO STEERABLE CATHETER COMPATIBLE","SUP-ITM-10317781","CDM","C1887","HCPCS","0272","RC","","","","both","","","147.00","110.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.87","79.5","","1342.89","271.64","6954.67","1 through 10","45.57","116.87","percent of total billed charges",""
"SLITTER CATHETER AGILIS HISPRO STEERABLE CATHETER COMPATIBLE","SUP-ITM-10317781","CDM","C1887","HCPCS","0272","RC","","","","both","","","147.00","110.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.35","53.3","","4550.00","30.49","4550.00","1 through 10","45.57","116.87","percent of total billed charges",""
"SLITTER CATHETER AGILIS HISPRO STEERABLE CATHETER COMPATIBLE","SUP-ITM-10317781","CDM","C1887","HCPCS","0272","RC","","","","both","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","95.55","65","","42.09","0.04","5453.50","1 through 10","45.57","116.87","percent of total billed charges",""
"SLITTER CATHETER AGILIS HISPRO STEERABLE CATHETER COMPATIBLE","SUP-ITM-10317781","CDM","C1887","HCPCS","0272","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.66","36.5","","310.94","18.54","1259.30","62","45.57","116.87","percent of total billed charges",""
"SLITTER CATHETER AGILIS HISPRO STEERABLE CATHETER COMPATIBLE","SUP-ITM-10317781","CDM","C1887","HCPCS","0272","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.30","38.3","","146.86","22.58","1753.45","65","45.57","116.87","percent of total billed charges",""
"SLITTER CATHETER AGILIS HISPRO STEERABLE CATHETER COMPATIBLE","SUP-ITM-10317781","CDM","C1887","HCPCS","0272","RC","","","","both","","","147.00","110.25","WELLPOINT [1015]","HB AMC WELLPOINT","108.46","73.78","","247.29","33.09","909.09","53","45.57","116.87","percent of total billed charges",""
"SLITTER CATHETER AGILIS HISPRO STEERABLE CATHETER COMPATIBLE","SUP-ITM-10317781","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA HMO","102.61","69.8","","30.69","30.21","30.69","1 through 10","76.82","120.13","percent of total billed charges",""
"SLITTER CATHETER AGILIS HISPRO STEERABLE CATHETER COMPATIBLE","SUP-ITM-10317781","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","118.19","80.4","","82.69","82.69","82.69","1 through 10","76.82","120.13","percent of total billed charges",""
"SLITTER CATHETER AGILIS HISPRO STEERABLE CATHETER COMPATIBLE","SUP-ITM-10317781","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","120.13","81.72","","751.01","74.72","751.01","1 through 10","76.82","120.13","percent of total billed charges",""
"SLITTER CATHETER AGILIS HISPRO STEERABLE CATHETER COMPATIBLE","SUP-ITM-10317781","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","120.13","81.72","","328.92","46.17","2701.97","59","76.82","120.13","percent of total billed charges",""
"SLITTER CATHETER GUIDE ADJUSTABLE","SUP-ITM-10051552","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.00","63.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","60.31","71.8","","28.28","27.13","28.28","1 through 10","26.04","66.78","percent of total billed charges",""
"SLITTER CATHETER GUIDE ADJUSTABLE","SUP-ITM-10051552","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.00","63.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","58.80","70","","44.63","35.78","44.63","1 through 10","26.04","66.78","percent of total billed charges",""
"SLITTER CATHETER GUIDE ADJUSTABLE","SUP-ITM-10051552","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.00","63.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","66.78","79.5","","1342.89","271.64","6954.67","1 through 10","26.04","66.78","percent of total billed charges",""
"SLITTER CATHETER GUIDE ADJUSTABLE","SUP-ITM-10051552","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.00","63.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","44.77","53.3","","4550.00","30.49","4550.00","1 through 10","26.04","66.78","percent of total billed charges",""
"SLITTER CATHETER GUIDE ADJUSTABLE","SUP-ITM-10051552","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","54.60","65","","42.09","0.04","5453.50","1 through 10","26.04","66.78","percent of total billed charges",""
"SLITTER CATHETER GUIDE ADJUSTABLE","SUP-ITM-10051552","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30.66","36.5","","310.94","18.54","1259.30","62","26.04","66.78","percent of total billed charges",""
"SLITTER CATHETER GUIDE ADJUSTABLE","SUP-ITM-10051552","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.17","38.3","","146.86","22.58","1753.45","65","26.04","66.78","percent of total billed charges",""
"SLITTER CATHETER GUIDE ADJUSTABLE","SUP-ITM-10051552","CDM","C1887","HCPCS","0272","RC","","","","both","","","84.00","63.00","WELLPOINT [1015]","HB AMC WELLPOINT","61.98","73.78","","247.29","33.09","909.09","53","26.04","66.78","percent of total billed charges",""
"SLITTER CATHETER GUIDE ADJUSTABLE","SUP-ITM-10051552","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","AETNA [1001]","HB AMC AETNA HMO","58.63","69.8","","30.69","30.21","30.69","1 through 10","43.9","68.64","percent of total billed charges",""
"SLITTER CATHETER GUIDE ADJUSTABLE","SUP-ITM-10051552","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","67.54","80.4","","82.69","82.69","82.69","1 through 10","43.9","68.64","percent of total billed charges",""
"SLITTER CATHETER GUIDE ADJUSTABLE","SUP-ITM-10051552","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","68.64","81.72","","751.01","74.72","751.01","1 through 10","43.9","68.64","percent of total billed charges",""
"SLITTER CATHETER GUIDE ADJUSTABLE","SUP-ITM-10051552","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","68.64","81.72","","328.92","46.17","2701.97","59","43.9","68.64","percent of total billed charges",""
"Slm Infliximab Level 80299","PX-30003297","CDM","80299","CPT","0300","RC","","","","both","","","276.00","207.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","219.42","79.5","","106.25","71.28","106.25","1 through 10","14.12","262.2","percent of total billed charges",""
"Slm Infliximab Level 80299","PX-30003297","CDM","80299","CPT","0300","RC","","","","both","","","276.00","207.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","147.11","53.3","","106.25","71.28","106.25","1 through 10","14.12","262.2","percent of total billed charges",""
"Slm Infliximab Level 80299","PX-30003297","CDM","80299","CPT","0300","RC","","","","both","","","276.00","207.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.74","36.5","","50.36","42.80","92.50","13","14.12","262.2","percent of total billed charges",""
"Slm Infliximab Level 80299","PX-30003297","CDM","80299","CPT","0300","RC","","","","both","","","276.00","207.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.71","38.3","","52.79","44.55","158.37","30","14.12","262.2","percent of total billed charges",""
"Slm Infliximab Level 80299","PX-30003297","CDM","80299","CPT","0300","RC","","","","outpatient","","","276.00","207.00","AETNA [1001]","HB AMC AETNA HMO","192.65","69.8","","91.40","64.53","105.30","14","14.12","225.55","percent of total billed charges",""
"Slm Infliximab Level 80299","PX-30003297","CDM","80299","CPT","0300","RC","","","","outpatient","","","276.00","207.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","221.90","80.4","","105.30","105.30","105.30","1 through 10","14.12","225.55","percent of total billed charges",""
"Slm Infliximab Level 80299","PX-30003297","CDM","80299","CPT","0300","RC","","","","outpatient","","","276.00","207.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","225.55","81.72","","59.36","15.50","59.36","1 through 10","14.12","225.55","percent of total billed charges",""
"Slm Jak2 Exon 12 Mutation, B 81403","PX-31000782","CDM","81479","CPT","0310","RC","","","","both","","","667.00","500.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","530.27","79.5","","0.65","0.65","0.65","1 through 10","206.77","633.65","percent of total billed charges",""
"Slm Jak2 Exon 12 Mutation, B 81403","PX-31000782","CDM","81479","CPT","0310","RC","","","","both","","","667.00","500.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","355.51","53.3","","0.79","0.79","0.79","1 through 10","206.77","633.65","percent of total billed charges",""
"Slm Jak2 Exon 12 Mutation, B 81403","PX-31000782","CDM","81479","CPT","0310","RC","","","","outpatient","","","667.00","500.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","333.50","50","","1.00","1.00","1.00","1 through 10","156.55","550.28","percent of total billed charges",""
"Slm Jak2 Exon 12 Mutation, B 81403","PX-31000782","CDM","81479","CPT","0310","RC","","","","outpatient","","","667.00","500.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","350.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","550.28","percent of total billed charges",""
"Sm Bowel Endoscopy With Ec Dilation of Fistula (Non-Endoscopic)","PX-75000537","CDM","44799","CPT","0750","RC","","","","both","","","4496.00","3372.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1057.74","3574.32","other","OPPS APC"
"Sm Bowel Endoscopy With Ec Dilation of Fistula (Non-Endoscopic)","PX-75000537","CDM","44799","CPT","0750","RC","","","","both","","","4496.00","3372.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","3574.32","other","OPPS APC"
"Sm Bowel Endoscopy With Ec Dilation of Fistula (Non-Endoscopic)","PX-75000537","CDM","44799","CPT","0750","RC","","","","both","","","4496.00","3372.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3574.32","other","OPPS APC"
"Sm Bowel Endoscopy With Ec Dilation of Fistula (Non-Endoscopic)","PX-75000537","CDM","44799","CPT","0750","RC","","","","both","","","4496.00","3372.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1057.74","3574.32","other","OPPS APC"
"Sm Bowel Endoscopy With Ec Dilation of Fistula (Non-Endoscopic)","PX-75000537","CDM","44799","CPT","0750","RC","","","","both","","","4496.00","3372.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1928.78","42.9","","1932.92","1932.92","1932.92","1 through 10","1057.74","3574.32","percent of total billed charges",""
"Sm Bowel Endoscopy With Ec Dilation of Fistula (Non-Endoscopic)","PX-75000537","CDM","44799","CPT","0750","RC","","","","both","","","4496.00","3372.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1057.74","3574.32","other","OPPS APC"
"Sm Bowel Endoscopy With Ec Dilation of Fistula (Non-Endoscopic)","PX-75000537","CDM","44799","CPT","0750","RC","","","","both","","","4496.00","3372.00","WELLPOINT [1015]","HB AMC WELLPOINT","3317.15","73.78","","2222.33","2222.33","2222.33","1 through 10","1057.74","3574.32","percent of total billed charges",""
"Sm Bowel Endoscopy With Ec Dilation of Fistula (Non-Endoscopic)","PX-75000537","CDM","44799","CPT","0750","RC","","","","outpatient","","","4496.00","3372.00","AETNA [1001]","HB AMC AETNA HMO","3138.21","69.8","","2238.60","2238.60","2238.60","1 through 10","2248","8899.59","percent of total billed charges",""
"Sm Bowel Endoscopy With Ec Dilation of Fistula (Non-Endoscopic)","PX-75000537","CDM","44799","CPT","0750","RC","","","","outpatient","","","4496.00","3372.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2722.33","60.55","","3144.00","2870.00","3286.00","1 through 10","2248","8899.59","percent of total billed charges",""
"Sm Bowel Endoscopy With Ec Dilation of Fistula (Non-Endoscopic)","PX-75000537","CDM","44799","CPT","0750","RC","","","","outpatient","","","4496.00","3372.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2349.61","52.26","","1775.96","1775.96","1775.96","1 through 10","2248","8899.59","percent of total billed charges",""
"Sm Bowel Endoscopy With Ec Dilation of Fistula (Non-Endoscopic)","PX-75000537","CDM","44799","CPT","0750","RC","","","","outpatient","","","4496.00","3372.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2347.81","52.22","","3286.00","2018.70","5898.00","1 through 10","2248","8899.59","percent of total billed charges",""
"Sm Bowel Endoscopy With Ec Dilation of Fistula (Non-Endoscopic)","PX-75000537","CDM","44799","CPT","0750","RC","","","","outpatient","","","4496.00","3372.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2360.40","52.5","","8340.00","8340.00","8340.00","1 through 10","2248","8899.59","percent of total billed charges",""
"Sm Bowel Endoscopy With Ec Dilation of Fistula (Non-Endoscopic)","PX-75000537","CDM","44799","CPT","0750","RC","","","","outpatient","","","4496.00","3372.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3674.13","81.72","","2294.28","682.69","2294.28","1 through 10","2248","8899.59","percent of total billed charges",""
"Sm Bowel Enteroscopy (Antegrade) to Ileum With Dilation of Jejunum","PX-75000538","CDM","44799","CPT","0750","RC","","","","both","","","6082.00","4561.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1057.74","4835.19","other","OPPS APC"
"Sm Bowel Enteroscopy (Antegrade) to Ileum With Dilation of Jejunum","PX-75000538","CDM","44799","CPT","0750","RC","","","","both","","","6082.00","4561.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","4835.19","other","OPPS APC"
"Sm Bowel Enteroscopy (Antegrade) to Ileum With Dilation of Jejunum","PX-75000538","CDM","44799","CPT","0750","RC","","","","both","","","6082.00","4561.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","4835.19","other","OPPS APC"
"Sm Bowel Enteroscopy (Antegrade) to Ileum With Dilation of Jejunum","PX-75000538","CDM","44799","CPT","0750","RC","","","","both","","","6082.00","4561.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1057.74","4835.19","other","OPPS APC"
"Sm Bowel Enteroscopy (Antegrade) to Ileum With Dilation of Jejunum","PX-75000538","CDM","44799","CPT","0750","RC","","","","both","","","6082.00","4561.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2609.18","42.9","","1932.92","1932.92","1932.92","1 through 10","1057.74","4835.19","percent of total billed charges",""
"Sm Bowel Enteroscopy (Antegrade) to Ileum With Dilation of Jejunum","PX-75000538","CDM","44799","CPT","0750","RC","","","","both","","","6082.00","4561.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1057.74","4835.19","other","OPPS APC"
"Sm Bowel Enteroscopy (Antegrade) to Ileum With Dilation of Jejunum","PX-75000538","CDM","44799","CPT","0750","RC","","","","both","","","6082.00","4561.50","WELLPOINT [1015]","HB AMC WELLPOINT","4487.30","73.78","","2222.33","2222.33","2222.33","1 through 10","1057.74","4835.19","percent of total billed charges",""
"Sm Bowel Enteroscopy (Antegrade) to Ileum With Dilation of Jejunum","PX-75000538","CDM","44799","CPT","0750","RC","","","","outpatient","","","6082.00","4561.50","AETNA [1001]","HB AMC AETNA HMO","4245.24","69.8","","2238.60","2238.60","2238.60","1 through 10","3041","8899.59","percent of total billed charges",""
"Sm Bowel Enteroscopy (Antegrade) to Ileum With Dilation of Jejunum","PX-75000538","CDM","44799","CPT","0750","RC","","","","outpatient","","","6082.00","4561.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3682.65","60.55","","3144.00","2870.00","3286.00","1 through 10","3041","8899.59","percent of total billed charges",""
"Sm Bowel Enteroscopy (Antegrade) to Ileum With Dilation of Jejunum","PX-75000538","CDM","44799","CPT","0750","RC","","","","outpatient","","","6082.00","4561.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3178.45","52.26","","1775.96","1775.96","1775.96","1 through 10","3041","8899.59","percent of total billed charges",""
"Sm Bowel Enteroscopy (Antegrade) to Ileum With Dilation of Jejunum","PX-75000538","CDM","44799","CPT","0750","RC","","","","outpatient","","","6082.00","4561.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3176.02","52.22","","3286.00","2018.70","5898.00","1 through 10","3041","8899.59","percent of total billed charges",""
"Sm Bowel Enteroscopy (Antegrade) to Ileum With Dilation of Jejunum","PX-75000538","CDM","44799","CPT","0750","RC","","","","outpatient","","","6082.00","4561.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3193.05","52.5","","8340.00","8340.00","8340.00","1 through 10","3041","8899.59","percent of total billed charges",""
"Sm Bowel Enteroscopy (Antegrade) to Ileum With Dilation of Jejunum","PX-75000538","CDM","44799","CPT","0750","RC","","","","outpatient","","","6082.00","4561.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4970.21","81.72","","2294.28","682.69","2294.28","1 through 10","3041","8899.59","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","both","","","80.00","60.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","52.00","65","","152.10","152.10","152.10","1 through 10","5.28","76","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","both","","","80.00","60.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","56.00","70","","78.00","78.00","78.00","1 through 10","5.28","76","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","both","","","80.00","60.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","63.60","79.5","","181.02","61.39","242.41","29","5.28","76","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","both","","","80.00","60.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","42.64","53.3","","61.39","41.18","61.39","1 through 10","5.28","76","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","both","","","80.00","60.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","52.00","65","","101.40","101.40","101.40","1 through 10","5.28","76","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","both","","","80.00","60.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","63.60","79.5","","61.39","61.39","61.39","1 through 10","5.28","76","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","both","","","80.00","60.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29.20","36.5","","29.09","24.73","58.18","20","5.28","76","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","both","","","80.00","60.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30.64","38.3","","30.50","29.64","91.50","24","5.28","76","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","both","","","80.00","60.00","MOLINA [1014]","HB BWH MOLINA","28.00","35","","10.69","10.69","10.69","1 through 10","5.28","76","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","both","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.32","42.9","","62.35","62.35","62.35","1 through 10","5.28","76","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","outpatient","","","80.00","60.00","AETNA [1001]","HB AMC AETNA HMO","55.84","69.8","","52.81","52.81","105.62","14","5.55","65.38","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","65.38","81.72","","62.35","34.30","62.35","21","5.55","65.38","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","76.00","57.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","49.40","65","","144.30","39.07","144.30","1 through 10","4.18","72.2","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","76.00","57.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","53.20","70","","74.00","74.00","74.00","1 through 10","4.18","72.2","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","76.00","57.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","60.42","79.5","","58.24","58.24","203.84","55","4.18","72.2","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","76.00","57.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","40.51","53.3","","39.07","39.07","163.15","38","4.18","72.2","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","76.00","57.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","58.52","77","","56.98","56.98","56.98","1 through 10","4.18","72.2","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","76.00","57.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","49.40","65","","96.20","96.20","96.20","1 through 10","4.18","72.2","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","76.00","57.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","60.42","79.5","","58.24","58.24","58.24","1 through 10","4.18","72.2","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","23.56","31","","68.61","22.87","68.61","1 through 10","4.18","72.2","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.74","36.5","","27.60","23.46","82.80","58","4.18","72.2","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.11","38.3","","28.93","28.12","28.94","117","4.18","72.2","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","76.00","57.00","MOLINA [1014]","HB BWH MOLINA","26.60","35","","8.47","8.47","8.47","1 through 10","4.18","72.2","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.60","42.9","","59.16","32.54","59.16","1 through 10","4.18","72.2","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","76.00","57.00","AETNA [1001]","HB AMC AETNA HMO","53.05","69.8","","50.10","35.37","57.72","60","4.4","62.11","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","76.00","57.00","AETNA [1001]","HB AMC AETNA PPO","61.10","80.4","","57.72","57.72","77.56","1 through 10","4.4","62.11","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","76.00","57.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","39.72","52.26","","45.79","45.79","45.79","1 through 10","4.4","62.11","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","62.11","81.72","","32.54","32.54","32.54","1 through 10","4.4","62.11","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","62.11","81.72","","59.16","32.54","59.16","65","4.4","62.11","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","both","","","146.00","109.50","CHAMPVA [160001]","HB BWH TRICARE","138.70","95","","10.72","10.72","10.72","1 through 10","8.72","138.7","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","both","","","146.00","109.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.07","79.5","","111.75","74.98","335.25","46","8.72","138.7","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","both","","","146.00","109.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.82","53.3","","74.98","74.98","111.75","20","8.72","138.7","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.26","31","","51.40","51.40","51.40","1 through 10","8.72","138.7","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.29","36.5","","52.97","45.01","101.96","35","8.72","138.7","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.92","38.3","","55.52","53.96","55.52","115","8.72","138.7","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","both","","","146.00","109.50","TRICARE [160005]","HB BWH TRICARE","138.70","95","","10.18","10.18","10.72","1 through 10","8.72","138.7","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","both","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.63","42.9","","62.44","40.35","113.52","1 through 10","8.72","138.7","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA HMO","101.91","69.8","","96.13","67.88","110.76","55","9.17","119.31","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA PPO","117.38","80.4","","110.76","67.88","110.76","1 through 10","9.17","119.31","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","81.61","55.9","","74.41","74.41","74.41","1 through 10","9.17","119.31","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","146.00","109.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","76.30","52.26","","87.87","87.87","87.87","1 through 10","9.17","119.31","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","119.31","81.72","","62.44","62.44","113.51","1 through 10","9.17","119.31","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","119.31","81.72","","113.51","62.44","113.52","52","9.17","119.31","percent of total billed charges",""
"Smear Wet Mount Infectious Agent","PX-30001196","CDM","87210","CPT","0306","RC","","","","both","","","74.00","55.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.01","36.5","","26.86","22.82","26.86","1 through 10","4.4","70.3","percent of total billed charges",""
"Smear Wet Mount Infectious Agent","PX-30001196","CDM","87210","CPT","0306","RC","","","","both","","","74.00","55.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.34","38.3","","86.79","28.12","86.79","1 through 10","4.4","70.3","percent of total billed charges",""
"Smear Wet Mount Infectious Agent","PX-30001196","CDM","87210","CPT","0306","RC","","","","outpatient","","","74.00","55.50","AETNA [1001]","HB AMC AETNA PPO","59.50","80.4","","113.10","38.78","113.10","1 through 10","4.4","60.47","percent of total billed charges",""
"Smear Wet Mount Infectious Agent","PX-30001196","CDM","87210","CPT","0306","RC","","","","outpatient","","","74.00","55.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","60.47","81.72","","31.66","31.66","31.66","1 through 10","4.4","60.47","percent of total billed charges",""
"Smo & Akt1 Gene Analysis","PX-31000780","CDM","81479","CPT","0310","RC","","","","both","","","5662.00","4246.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4501.29","79.5","","0.65","0.65","0.65","1 through 10","1755.22","5378.9","percent of total billed charges",""
"Smo & Akt1 Gene Analysis","PX-31000780","CDM","81479","CPT","0310","RC","","","","both","","","5662.00","4246.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3017.85","53.3","","0.79","0.79","0.79","1 through 10","1755.22","5378.9","percent of total billed charges",""
"Smo & Akt1 Gene Analysis","PX-31000780","CDM","81479","CPT","0310","RC","","","","outpatient","","","5662.00","4246.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3428.34","60.55","","1.00","1.00","1.00","1 through 10","2740.41","4671.15","percent of total billed charges",""
"Smo & Akt1 Gene Analysis","PX-31000780","CDM","81479","CPT","0310","RC","","","","outpatient","","","5662.00","4246.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2956.70","52.22","","1.00","1.00","1.00","1 through 10","2740.41","4671.15","percent of total billed charges",""
"Smo & Akt1 Gene Analysis","PX-31000780","CDM","81479","CPT","0310","RC","","","","outpatient","","","5662.00","4246.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2831.00","50","","1.00","1.00","1.00","1 through 10","2740.41","4671.15","percent of total billed charges",""
"Smo & Akt1 Gene Analysis","PX-31000780","CDM","81479","CPT","0310","RC","","","","outpatient","","","5662.00","4246.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2972.55","52.5","","1.00","0.53","1.00","1 through 10","2740.41","4671.15","percent of total billed charges",""
"Smoking Cess Coun Inter >3min","PX-98300630","CDM","99406","CPT","0983","RC","","","","both","","","51.00","38.25","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","35.37","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12.15","12.15","12.15","1 through 10","15.81","44.22","other","OPPS APC"
"Smoking Cess Coun Inter >3min","PX-98300630","CDM","99406","CPT","0983","RC","","","","both","","","51.00","38.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","34.67","","APC Price ($35.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","11.91","11.91","12.26","1 through 10","15.81","44.22","other","OPPS APC"
"SNARE NEEDLES EYE 16FR 13MM 94CM CHECK-FLO INTRODUCER FEMORAL AND WORKSTATION LEAD EXTRACTION","SUP-ITM-10012754","CDM","C1773","HCPCS","0272","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1971.00","36.5","","114.30","97.14","114.30","1 through 10","1674","4293","percent of total billed charges",""
"SNARE NEEDLES EYE 16FR 13MM 94CM CHECK-FLO INTRODUCER FEMORAL AND WORKSTATION LEAD EXTRACTION","SUP-ITM-10012754","CDM","C1773","HCPCS","0272","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2068.20","38.3","","119.81","116.44","359.43","20","1674","4293","percent of total billed charges",""
"SNARE NEEDLES EYE 16FR 13MM 94CM CHECK-FLO INTRODUCER FEMORAL AND WORKSTATION LEAD EXTRACTION","SUP-ITM-10012754","CDM","C1773","HCPCS","0272","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB AMC WELLPOINT","3984.12","73.78","","875.53","228.13","875.53","1 through 10","1674","4293","percent of total billed charges",""
"SNARE NEEDLES EYE 16FR 13MM 94CM CHECK-FLO INTRODUCER FEMORAL AND WORKSTATION LEAD EXTRACTION","SUP-ITM-10012754","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA HMO","3769.20","69.8","","207.45","207.45","207.45","1 through 10","2822.04","4412.88","percent of total billed charges",""
"SNARE NEEDLES EYE 16FR 13MM 94CM CHECK-FLO INTRODUCER FEMORAL AND WORKSTATION LEAD EXTRACTION","SUP-ITM-10012754","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4412.88","81.72","","244.96","134.74","244.96","1 through 10","2822.04","4412.88","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","both","","","1829.73","1372.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1454.64","79.5","","1309.77","674.56","6049.93","26","567.22","1454.64","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","both","","","1829.73","1372.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","975.25","53.3","","1901.83","1901.83","2962.25","1 through 10","567.22","1454.64","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","both","","","1829.73","1372.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","667.85","36.5","","1620.31","1620.31","19908.88","1 through 10","567.22","1454.64","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","both","","","1829.73","1372.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","700.79","38.3","","352.91","352.91","2046.30","1 through 10","567.22","1454.64","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","both","","","1829.73","1372.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","784.95","42.9","","9668.75","9668.75","9668.75","1 through 10","567.22","1454.64","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","both","","","1829.73","1372.30","WELLPOINT [1015]","HB AMC WELLPOINT","1349.97","73.78","","699.88","384.10","3443.31","33","567.22","1454.64","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","1829.73","1372.30","AETNA [1001]","HB AMC AETNA HMO","1277.15","69.8","","1421.24","264.50","4933.46","29","956.22","1495.26","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","1829.73","1372.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1471.10","80.4","","1022.97","1022.97","3607.50","1 through 10","956.22","1495.26","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","1829.73","1372.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1495.26","81.72","","3010.54","693.88","5019.88","35","956.22","1495.26","percent of total billed charges",""
"SNARE VASCULAR 3.2FR 2-4MM 175CM 150CM 3 EN INTERLACED NITINOL LOOPS","SUP-ITM-10010231","CDM","C1773","HCPCS","0272","RC","","","","both","","","2310.00","1732.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","843.15","36.5","","114.30","97.14","114.30","1 through 10","716.1","1836.45","percent of total billed charges",""
"SNARE VASCULAR 3.2FR 2-4MM 175CM 150CM 3 EN INTERLACED NITINOL LOOPS","SUP-ITM-10010231","CDM","C1773","HCPCS","0272","RC","","","","both","","","2310.00","1732.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","884.73","38.3","","119.81","116.44","359.43","20","716.1","1836.45","percent of total billed charges",""
"SNARE VASCULAR 3.2FR 2-4MM 175CM 150CM 3 EN INTERLACED NITINOL LOOPS","SUP-ITM-10010231","CDM","C1773","HCPCS","0272","RC","","","","both","","","2310.00","1732.50","WELLPOINT [1015]","HB AMC WELLPOINT","1704.32","73.78","","875.53","228.13","875.53","1 through 10","716.1","1836.45","percent of total billed charges",""
"SNARE VASCULAR 3.2FR 2-4MM 175CM 150CM 3 EN INTERLACED NITINOL LOOPS","SUP-ITM-10010231","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","2310.00","1732.50","AETNA [1001]","HB AMC AETNA HMO","1612.38","69.8","","207.45","207.45","207.45","1 through 10","1207.21","1887.73","percent of total billed charges",""
"SNARE VASCULAR 3.2FR 2-4MM 175CM 150CM 3 EN INTERLACED NITINOL LOOPS","SUP-ITM-10010231","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","2310.00","1732.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1887.73","81.72","","244.96","134.74","244.96","1 through 10","1207.21","1887.73","percent of total billed charges",""
"SNARE VASCULAR 6FR 12-20MM 120CM 100CM 3 EN INTERLACED NITINOL LOOPS","SUP-ITM-10080253","CDM","C1773","HCPCS","0272","RC","","","","both","","","1176.00","882.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","429.24","36.5","","114.30","97.14","114.30","1 through 10","364.56","934.92","percent of total billed charges",""
"SNARE VASCULAR 6FR 12-20MM 120CM 100CM 3 EN INTERLACED NITINOL LOOPS","SUP-ITM-10080253","CDM","C1773","HCPCS","0272","RC","","","","both","","","1176.00","882.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","450.41","38.3","","119.81","116.44","359.43","20","364.56","934.92","percent of total billed charges",""
"SNARE VASCULAR 6FR 12-20MM 120CM 100CM 3 EN INTERLACED NITINOL LOOPS","SUP-ITM-10080253","CDM","C1773","HCPCS","0272","RC","","","","both","","","1176.00","882.00","WELLPOINT [1015]","HB AMC WELLPOINT","867.65","73.78","","875.53","228.13","875.53","1 through 10","364.56","934.92","percent of total billed charges",""
"SNARE VASCULAR 6FR 12-20MM 120CM 100CM 3 EN INTERLACED NITINOL LOOPS","SUP-ITM-10080253","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1176.00","882.00","AETNA [1001]","HB AMC AETNA HMO","820.85","69.8","","207.45","207.45","207.45","1 through 10","614.58","961.03","percent of total billed charges",""
"SNARE VASCULAR 6FR 12-20MM 120CM 100CM 3 EN INTERLACED NITINOL LOOPS","SUP-ITM-10080253","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1176.00","882.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","961.03","81.72","","244.96","134.74","244.96","1 through 10","614.58","961.03","percent of total billed charges",""
"SNARE VASCULAR 6FR 120CM 15MM 100CM NITINOL PLATED TUNGSTEN SINGLE LOOP RETRIEVAL SYSTEM","SUP-ITM-10116879","CDM","C1773","HCPCS","0272","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","376.86","36.5","","114.30","97.14","114.30","1 through 10","320.08","820.84","percent of total billed charges",""
"SNARE VASCULAR 6FR 120CM 15MM 100CM NITINOL PLATED TUNGSTEN SINGLE LOOP RETRIEVAL SYSTEM","SUP-ITM-10116879","CDM","C1773","HCPCS","0272","RC","","","","both","","","1032.50","774.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","395.45","38.3","","119.81","116.44","359.43","20","320.08","820.84","percent of total billed charges",""
"SNARE VASCULAR 6FR 120CM 15MM 100CM NITINOL PLATED TUNGSTEN SINGLE LOOP RETRIEVAL SYSTEM","SUP-ITM-10116879","CDM","C1773","HCPCS","0272","RC","","","","both","","","1032.50","774.37","WELLPOINT [1015]","HB AMC WELLPOINT","761.78","73.78","","875.53","228.13","875.53","1 through 10","320.08","820.84","percent of total billed charges",""
"SNARE VASCULAR 6FR 120CM 15MM 100CM NITINOL PLATED TUNGSTEN SINGLE LOOP RETRIEVAL SYSTEM","SUP-ITM-10116879","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1032.50","774.37","AETNA [1001]","HB AMC AETNA HMO","720.69","69.8","","207.45","207.45","207.45","1 through 10","539.58","843.76","percent of total billed charges",""
"SNARE VASCULAR 6FR 120CM 15MM 100CM NITINOL PLATED TUNGSTEN SINGLE LOOP RETRIEVAL SYSTEM","SUP-ITM-10116879","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1032.50","774.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","843.76","81.72","","244.96","134.74","244.96","1 through 10","539.58","843.76","percent of total billed charges",""
"So Athena, 6520 Amyotrophic Lateral Sclerosos Adv Eval Als 17 Gene Panel","PX-31001324","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","both","","","82.00","61.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","53.79","65.6","","62.40","62.40","62.40","1 through 10","4.71","77.9","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","both","","","82.00","61.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","57.40","70","","80.00","80.00","80.00","1 through 10","4.71","77.9","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","both","","","82.00","61.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","65.19","79.5","","91.60","62.96","91.60","53","4.71","77.9","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","both","","","82.00","61.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","43.71","53.3","","42.24","42.24","42.24","1 through 10","4.71","77.9","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29.93","36.5","","25.36","25.36","25.36","1 through 10","4.71","77.9","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31.41","38.3","","31.28","31.28","31.28","69","4.71","77.9","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","both","","","82.00","61.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","63.14","77","","62.96","62.96","62.96","1 through 10","4.71","77.9","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","both","","","82.00","61.50","TRICARE [160005]","HB BWH TRICARE","77.90","95","","5.80","5.51","5.80","1 through 10","4.71","77.9","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","outpatient","","","82.00","61.50","AETNA [1001]","HB AMC AETNA HMO","57.24","69.8","","54.16","39.52","187.20","18","4.97","67.01","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","outpatient","","","82.00","61.50","AETNA [1001]","HB AMC AETNA PPO","65.93","80.4","","62.40","62.40","62.40","1 through 10","4.97","67.01","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","outpatient","","","82.00","61.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","65.93","80.4","","62.40","62.40","62.40","1 through 10","4.97","67.01","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","outpatient","","","82.00","61.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","67.01","81.72","","845.43","845.43","845.43","1 through 10","4.97","67.01","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","outpatient","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","67.01","81.72","","63.95","63.95","63.95","1 through 10","4.97","67.01","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","both","","","78.00","58.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","54.60","70","","109.44","109.44","109.44","1 through 10","4.96","74.1","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","both","","","78.00","58.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","62.01","79.5","","40.13","38.00","59.81","1 through 10","4.96","74.1","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","both","","","78.00","58.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","41.57","53.3","","40.13","38.38","63.42","1 through 10","4.96","74.1","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28.47","36.5","","28.35","24.09","72.27","13","4.96","74.1","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.87","38.3","","29.72","28.88","89.16","30","4.96","74.1","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","outpatient","","","78.00","58.50","AETNA [1001]","HB AMC AETNA HMO","54.44","69.8","","51.45","36.33","72.66","20","5.03","63.74","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","outpatient","","","78.00","58.50","AETNA [1001]","HB AMC AETNA PPO","62.71","80.4","","59.28","59.28","59.28","1 through 10","5.03","63.74","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","outpatient","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","63.74","81.72","","60.75","33.42","60.75","1 through 10","5.03","63.74","percent of total billed charges",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","","","","inpatient","","","127890.97","95918.23","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","16326.20","","Case rate ($16,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,576.10, add-ons for qualifying new technology services are included. If operating cost exceeds $65,220.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,846.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,539.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,196.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,406.62. The transfer capital threshold is the transfer adjustment factor * $1,406.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15954.21","15954.21","15954.21","1 through 10","15999.68","27382.24","other","Inpatient Replacement Plans DRG"
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","","","","inpatient","","","127890.97","95918.23","MEDICARE [2001]","HB BWH MEDICARE","16326.20","","Case rate ($16,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,576.10, add-ons for qualifying new technology services are included. If operating cost exceeds $65,220.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,846.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,539.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,196.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,406.62. The transfer capital threshold is the transfer adjustment factor * $1,406.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21092.78","0.03","21349.85","1 through 10","15999.68","27382.24","other","Inpatient Replacement Plans DRG"
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","","","","inpatient","","","127890.97","95918.23","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","16326.20","","Case rate ($16,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,576.10, add-ons for qualifying new technology services are included. If operating cost exceeds $65,220.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,846.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,539.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,196.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,406.62. The transfer capital threshold is the transfer adjustment factor * $1,406.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","68.78","68.78","68.78","1 through 10","15999.68","27382.24","other","Inpatient Replacement Plans DRG"
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","","","","inpatient","","","127890.97","95918.23","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","15999.68","","Case rate ($16,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,576.10, add-ons for qualifying new technology services are included. If operating cost exceeds $65,220.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,846.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,539.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,196.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,406.62. The transfer capital threshold is the transfer adjustment factor * $1,406.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16270.69","16270.69","16270.69","1 through 10","15999.68","27382.24","other","Inpatient DRG"
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","","","","inpatient","","","127890.97","95918.23","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15999.68","","Case rate ($16,326.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,576.10, add-ons for qualifying new technology services are included. If operating cost exceeds $65,220.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,846.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,539.73 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,196.26 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,406.62. The transfer capital threshold is the transfer adjustment factor * $1,406.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16294.52","16294.52","16294.52","1 through 10","15999.68","27382.24","other","Inpatient DRG"
"Soft Tissue Procedures With McC","500","MS-DRG","","","","","","","","inpatient","","","189382.21","142036.66","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","37847.68","","Case rate ($37,847.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,133.19, add-ons for qualifying new technology services are included. If operating cost exceeds $80,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,986.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $34,921.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,753.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,546.58. The transfer capital threshold is the transfer adjustment factor * $2,546.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","37250.38","37250.38","37250.38","1 through 10","28664.5","47818.8517","other","Inpatient DRG"
"Soft Tissue Procedures With McC","500","MS-DRG","","","","","","","","inpatient","","","189382.21","142036.66","MEDICARE [2001]","HB BWH MEDICARE","37847.68","","Case rate ($37,847.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,133.19, add-ons for qualifying new technology services are included. If operating cost exceeds $80,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,986.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $34,921.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,753.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,546.58. The transfer capital threshold is the transfer adjustment factor * $2,546.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","37634.56","26330.55","81579.71","1 through 10","28664.5","47818.8517","other","Inpatient DRG"
"Soft Tissue Procedures With McC","500","MS-DRG","","","","","","","","inpatient","","","189382.21","142036.66","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28664.50","","Case rate ($29,249.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $35,133.19, add-ons for qualifying new technology services are included. If operating cost exceeds $80,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,986.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,323.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,753.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,546.58. The transfer capital threshold is the transfer adjustment factor * $2,546.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","28513.49","28513.49","28513.49","1 through 10","28664.5","47818.8517","other","Inpatient DRG"
"Soft Tissue Procedures Without Cc/McC","502","MS-DRG","","","","","","","","inpatient","","","71050.53","53287.90","MARTIN'S POINT [160007]","HB BWH MEDICARE","12657.29","","Case rate ($12,657.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,159.46, add-ons for qualifying new technology services are included. If operating cost exceeds $60,803.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,523.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,194.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,779.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,082.99. The transfer capital threshold is the transfer adjustment factor * $1,082.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12779.39","12779.39","12779.39","1 through 10","12404.14","20866.3257","other","Inpatient Replacement Plans DRG"
"Soft Tissue Procedures Without Cc/McC","502","MS-DRG","","","","","","","","inpatient","","","71050.53","53287.90","MEDICARE [2001]","HB BWH MEDICARE","12657.29","","Case rate ($12,657.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,159.46, add-ons for qualifying new technology services are included. If operating cost exceeds $60,803.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,523.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,194.45 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,779.62 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,082.99. The transfer capital threshold is the transfer adjustment factor * $1,082.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16774.73","16774.73","16774.73","1 through 10","12404.14","20866.3257","other","Inpatient Replacement Plans DRG"
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4277.35","52.26","","1113.10","1113.10","1113.10","1 through 10","2537.27","6506.88","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6506.88","79.5","","1293.60","1148.53","1603.80","1 through 10","2537.27","6506.88","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2987.43","36.5","","1023.42","771.29","2068.67","33","2537.27","6506.88","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3134.76","38.3","","850.52","759.78","1211.25","66","2537.27","6506.88","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3511.26","42.9","","2548.09","2548.09","2548.09","1 through 10","2537.27","6506.88","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3511.26","42.9","","956.46","956.46","956.46","1 through 10","2537.27","6506.88","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","8184.75","6138.56","WELLPOINT [1015]","HB AMC WELLPOINT","6038.71","73.78","","2344.73","1619.47","2530.35","16","2537.27","6506.88","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8184.75","6138.56","AETNA [1001]","HB AMC AETNA HMO","5712.96","69.8","","1523.63","988.41","4330.26","39","4277.35","6688.58","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8184.75","6138.56","AETNA [1001]","HB AMC AETNA PPO","6580.54","80.4","","1670.25","1670.25","1670.25","1 through 10","4277.35","6688.58","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8184.75","6138.56","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4277.35","52.26","","1113.10","1113.10","1113.10","1 through 10","4277.35","6688.58","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8184.75","6138.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6688.58","81.72","","1738.90","1484.65","2716.94","38","4277.35","6688.58","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","285.00","213.75","CHAMPVA [160001]","HB BWH TRICARE","270.75","95","","25.62","25.62","25.62","1 through 10","17.43","270.75","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","285.00","213.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","226.58","79.5","","217.21","145.73","217.21","22","17.43","270.75","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","285.00","213.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","151.91","53.3","","145.73","145.73","217.21","15","17.43","270.75","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","285.00","213.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","88.35","31","","85.28","85.28","85.28","1 through 10","17.43","270.75","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","285.00","213.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","104.03","36.5","","102.95","87.49","308.85","27","17.43","270.75","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","285.00","213.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","109.16","38.3","","107.92","104.88","107.92","52","17.43","270.75","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","285.00","213.75","MOLINA [1014]","HB BWH MOLINA","99.75","35","","42.18","42.18","42.18","1 through 10","17.43","270.75","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","285.00","213.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","219.45","77","","217.21","217.21","217.21","1 through 10","17.43","270.75","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","285.00","213.75","TRICARE [160005]","HB BWH TRICARE","270.75","95","","24.34","24.34","25.62","1 through 10","17.43","270.75","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","285.00","213.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","122.27","42.9","","220.63","121.36","220.63","1 through 10","17.43","270.75","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","285.00","213.75","AETNA [1001]","HB AMC AETNA HMO","198.93","69.8","","186.85","131.93","215.28","53","17.43","232.9","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","285.00","213.75","AETNA [1001]","HB AMC AETNA PPO","229.14","80.4","","215.28","144.62","215.28","1 through 10","17.43","232.9","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","285.00","213.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","232.90","81.72","","220.63","121.36","220.63","24","17.43","232.9","percent of total billed charges",""
"Somatosensory Study, Up & Low Limbs","PX-92000080","CDM","95938","CPT","0922","RC","","","","both","","","2405.00","1803.75","WELLPOINT [1015]","HB AMC WELLPOINT","1774.41","73.78","","4068.17","1736.17","4068.17","1 through 10","598.61","1911.98","percent of total billed charges",""
"Somatostatin","PX-30000678","CDM","84307","CPT","0301","RC","","","","both","","","275.00","206.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.33","38.3","","104.40","104.40","104.40","1 through 10","17.43","261.25","percent of total billed charges",""
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","126.29","1 through 10","31.62","231.74","other","OPPS APC"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","66.91","65.6","","498.95","498.95","498.95","1 through 10","31.62","231.74","percent of total billed charges",""
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","81.09","79.5","","580.02","389.14","580.02","131","31.62","231.74","percent of total billed charges",""
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","54.37","53.3","","580.02","389.14","580.02","53","31.62","231.74","percent of total billed charges",""
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","81.09","79.5","","580.02","580.02","580.02","1 through 10","31.62","231.74","percent of total billed charges",""
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","20","31.62","231.74","other","OPPS APC"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","31.62","31","","227.73","227.73","227.73","1 through 10","31.62","231.74","percent of total billed charges",""
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37.23","36.5","","266.79","233.63","1374.50","24","31.62","231.74","percent of total billed charges",""
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39.07","38.3","","288.17","280.06","288.17","117","31.62","231.74","percent of total billed charges",""
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.26","125.26","125.26","1 through 10","31.62","231.74","other","OPPS APC"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","31.62","231.74","other","Tricare OPPS"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","31.62","231.74","other","OPPS APC"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.76","42.9","","589.16","589.15","589.16","1 through 10","31.62","231.74","percent of total billed charges",""
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","118.07","126.29","1 through 10","31.62","231.74","other","OPPS APC"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","both","","","102.00","76.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.76","42.9","","589.16","589.16","589.16","1 through 10","31.62","231.74","percent of total billed charges",""
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","outpatient","","","102.00","76.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","352.29","352.29","498.95","13","83.35","333.74","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","outpatient","","","102.00","76.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","111","83.35","333.74","other","Multiple Imaging"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","outpatient","","","102.00","76.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","458","83.35","333.74","other","Multiple Imaging"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","outpatient","","","102.00","76.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","382.53","336.40","382.53","1 through 10","83.35","333.74","other","Multiple Radiology"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","outpatient","","","102.00","76.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","293.65","597.42","69","83.35","333.74","other","Multiple Radiology"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","outpatient","","","102.00","76.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","308.28","616.56","30","83.35","333.74","other","Multiple Radiology"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","outpatient","","","102.00","76.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","505.17","505.17","505.17","1 through 10","83.35","333.74","other","Multiple Radiology"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","outpatient","","","102.00","76.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","336.40","336.40","50","83.35","333.74","other","Multiple Radiology"
"Sono Pelvis Limited","PX-98301399","CDM","76857","CPT","0983","RC","","","","outpatient","","","102.00","76.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","83.35","81.72","","589.16","324.06","589.16","83","83.35","333.74","percent of total billed charges",""
"Sotos Syndrome 2 (Sotos2)","PX-31000684","CDM","81479","CPT","0310","RC","","","","both","","","1416.00","1062.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1125.72","79.5","","0.65","0.65","0.65","1 through 10","438.96","1345.2","percent of total billed charges",""
"Sotos Syndrome 2 (Sotos2)","PX-31000684","CDM","81479","CPT","0310","RC","","","","both","","","1416.00","1062.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","754.73","53.3","","0.79","0.79","0.79","1 through 10","438.96","1345.2","percent of total billed charges",""
"Sotos Syndrome 2 (Sotos2)","PX-31000684","CDM","81479","CPT","0310","RC","","","","outpatient","","","1416.00","1062.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","708.00","50","","1.00","1.00","1.00","1 through 10","156.55","1168.2","percent of total billed charges",""
"Sotos Syndrome 2 (Sotos2)","PX-31000684","CDM","81479","CPT","0310","RC","","","","outpatient","","","1416.00","1062.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","743.40","52.5","","1.00","0.53","1.00","1 through 10","156.55","1168.2","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","114.88","71.8","","51.31","51.31","51.31","1 through 10","49.6","152","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","104.00","65","","292.50","292.50","292.50","1 through 10","49.6","152","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","112.00","70","","5094.00","150.00","5094.00","1 through 10","49.6","152","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","127.20","79.5","","118.05","79.20","265.82","20","49.6","152","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","85.28","53.3","","79.20","75.75","281.42","21","49.6","152","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","104.00","65","","297.70","297.70","297.70","1 through 10","49.6","152","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","TRICARE [160005]","HB BWH TRICARE","152.00","95","","61.83","58.74","61.83","1 through 10","49.6","152","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.64","42.9","","119.91","65.96","119.91","1 through 10","49.6","152","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","AETNA [1001]","HB AMC AETNA HMO","111.68","69.8","","71.10","51.36","102.72","33","58.08","130.75","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","AETNA [1001]","HB AMC AETNA PPO","128.64","80.4","","78.60","51.36","117.00","1 through 10","58.08","130.75","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","83.62","52.26","","92.38","92.38","92.38","1 through 10","58.08","130.75","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","CIGNA ALTERNATE [1018]","HB AMC TUFTS CIGNA CARELINK HYBRID","58.08","36.3","","54.45","54.45","54.45","1 through 10","58.08","130.75","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","130.75","81.72","","119.91","65.96","119.91","1 through 10","58.08","130.75","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","130.75","81.72","","119.91","65.96","450.00","48","58.08","130.75","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","80.42","71.8","","51.31","51.31","51.31","1 through 10","34.72","106.4","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","72.80","65","","292.50","292.50","292.50","1 through 10","34.72","106.4","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","78.40","70","","5094.00","150.00","5094.00","1 through 10","34.72","106.4","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","89.04","79.5","","118.05","79.20","265.82","20","34.72","106.4","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","59.70","53.3","","79.20","75.75","281.42","21","34.72","106.4","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","72.80","65","","297.70","297.70","297.70","1 through 10","34.72","106.4","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","TRICARE [160005]","HB BWH TRICARE","106.40","95","","61.83","58.74","61.83","1 through 10","34.72","106.4","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.05","42.9","","119.91","65.96","119.91","1 through 10","34.72","106.4","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","AETNA [1001]","HB AMC AETNA HMO","78.18","69.8","","71.10","51.36","102.72","33","40.66","92.38","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","AETNA [1001]","HB AMC AETNA PPO","90.05","80.4","","78.60","51.36","117.00","1 through 10","40.66","92.38","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","58.53","52.26","","92.38","92.38","92.38","1 through 10","40.66","92.38","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","CIGNA ALTERNATE [1018]","HB AMC TUFTS CIGNA CARELINK HYBRID","40.66","36.3","","54.45","54.45","54.45","1 through 10","40.66","92.38","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","91.53","81.72","","119.91","65.96","119.91","1 through 10","40.66","92.38","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","91.53","81.72","","119.91","65.96","450.00","48","40.66","92.38","percent of total billed charges",""
"Sp Domestic Basic Life and/or Disability Exam","PX-51000567","CDM","99499","CPT","0999","RC","","","","both","","","2500.00","1875.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1987.50","79.5","","3.72","3.72","3.72","1 through 10","775","2375","percent of total billed charges",""
"Sp Domestic Basic Life and/or Disability Exam","PX-51000567","CDM","99499","CPT","0999","RC","","","","both","","","2500.00","1875.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1332.50","53.3","","6.01","6.01","6.01","1 through 10","775","2375","percent of total billed charges",""
"Sp Domestic Basic Life and/or Disability Exam","PX-51000567","CDM","99499","CPT","0999","RC","","","","both","","","2500.00","1875.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1625.00","65","","1625.00","1625.00","1625.00","1 through 10","775","2375","percent of total billed charges",""
"Sp Domestic Basic Life and/or Disability Exam","PX-51000567","CDM","99499","CPT","0999","RC","","","","outpatient","","","2500.00","1875.00","AETNA [1001]","HB AMC AETNA HMO","1745.00","69.8","","133.13","133.13","133.13","1 through 10","1000","2043","percent of total billed charges",""
"Sp Domestic Basic Life and/or Disability Exam","PX-51000567","CDM","99499","CPT","0999","RC","","","","outpatient","","","2500.00","1875.00","AETNA [1001]","HB AMC AETNA PPO","2010.00","80.4","","137.90","26.36","151.63","1 through 10","1000","2043","percent of total billed charges",""
"Sp Domestic Basic Life and/or Disability Exam","PX-51000567","CDM","99499","CPT","0999","RC","","","","outpatient","","","2500.00","1875.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2010.00","80.4","","1250.00","1250.00","1250.00","1 through 10","1000","2043","percent of total billed charges",""
"Sp Extended Physical Exam per 30 Min","PX-51000569","CDM","99499","CPT","0510","RC","","","","both","","","850.00","637.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","675.75","79.5","","3.72","3.72","3.72","1 through 10","263.5","807.5","percent of total billed charges",""
"Sp Extended Physical Exam per 30 Min","PX-51000569","CDM","99499","CPT","0510","RC","","","","both","","","850.00","637.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","453.05","53.3","","6.01","6.01","6.01","1 through 10","263.5","807.5","percent of total billed charges",""
"Sp Extended Physical Exam per 30 Min","PX-51000569","CDM","99499","CPT","0510","RC","","","","both","","","850.00","637.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","552.50","65","","1625.00","1625.00","1625.00","1 through 10","263.5","807.5","percent of total billed charges",""
"Sp Extended Physical Exam per 30 Min","PX-51000569","CDM","99499","CPT","0510","RC","","","","outpatient","","","850.00","637.50","AETNA [1001]","HB AMC AETNA HMO","593.30","69.8","","133.13","133.13","133.13","1 through 10","340","694.62","percent of total billed charges",""
"Sp Extended Physical Exam per 30 Min","PX-51000569","CDM","99499","CPT","0510","RC","","","","outpatient","","","850.00","637.50","AETNA [1001]","HB AMC AETNA PPO","683.40","80.4","","137.90","26.36","151.63","1 through 10","340","694.62","percent of total billed charges",""
"Sp Extended Physical Exam per 30 Min","PX-51000569","CDM","99499","CPT","0510","RC","","","","outpatient","","","850.00","637.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","683.40","80.4","","1250.00","1250.00","1250.00","1 through 10","340","694.62","percent of total billed charges",""
"Sp Intnl Basic Life and/or Disability Exam","PX-51000568","CDM","99499","CPT","0999","RC","","","","both","","","3000.00","2250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2385.00","79.5","","3.72","3.72","3.72","1 through 10","930","2850","percent of total billed charges",""
"Sp Intnl Basic Life and/or Disability Exam","PX-51000568","CDM","99499","CPT","0999","RC","","","","both","","","3000.00","2250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1599.00","53.3","","6.01","6.01","6.01","1 through 10","930","2850","percent of total billed charges",""
"Sp Intnl Basic Life and/or Disability Exam","PX-51000568","CDM","99499","CPT","0999","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1950.00","65","","1625.00","1625.00","1625.00","1 through 10","930","2850","percent of total billed charges",""
"Sp Intnl Basic Life and/or Disability Exam","PX-51000568","CDM","99499","CPT","0999","RC","","","","outpatient","","","3000.00","2250.00","AETNA [1001]","HB AMC AETNA HMO","2094.00","69.8","","133.13","133.13","133.13","1 through 10","1200","2451.6","percent of total billed charges",""
"Sp Intnl Basic Life and/or Disability Exam","PX-51000568","CDM","99499","CPT","0999","RC","","","","outpatient","","","3000.00","2250.00","AETNA [1001]","HB AMC AETNA PPO","2412.00","80.4","","137.90","26.36","151.63","1 through 10","1200","2451.6","percent of total billed charges",""
"Sp Intnl Basic Life and/or Disability Exam","PX-51000568","CDM","99499","CPT","0999","RC","","","","outpatient","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2412.00","80.4","","1250.00","1250.00","1250.00","1 through 10","1200","2451.6","percent of total billed charges",""
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","both","","","5960.00","4470.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1018.05","1018.05","1018.05","1 through 10","1057.74","4738.2","other","OPPS APC"
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","both","","","5960.00","4470.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","973.53","973.53","973.53","1 through 10","1057.74","4738.2","other","OPPS APC"
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","both","","","5960.00","4470.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4738.20","79.5","","2814.50","2346.50","2814.50","1 through 10","1057.74","4738.2","percent of total billed charges",""
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","both","","","5960.00","4470.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","7938.66","1 through 10","1057.74","4738.2","other","OPPS APC"
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","both","","","5960.00","4470.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","11","1057.74","4738.2","other","OPPS APC"
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","both","","","5960.00","4470.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2175.40","36.5","","2677.58","1482.13","2910.89","1 through 10","1057.74","4738.2","percent of total billed charges",""
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","both","","","5960.00","4470.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2282.68","38.3","","2723.31","1555.62","2741.61","12","1057.74","4738.2","percent of total billed charges",""
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","both","","","5960.00","4470.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","953.35","953.35","953.35","1 through 10","1057.74","4738.2","other","OPPS APC"
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","both","","","5960.00","4470.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","484.79","1100.05","1 through 10","1057.74","4738.2","other","OPPS APC"
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","both","","","5960.00","4470.00","WELLPOINT [1015]","HB AMC WELLPOINT","4397.29","73.78","","2687.65","2687.64","3224.43","1 through 10","1057.74","4738.2","percent of total billed charges",""
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","outpatient","","","5960.00","4470.00","AETNA [1001]","HB AMC AETNA PPO","4791.84","80.4","","1163.76","1163.76","1163.76","1 through 10","2384.07","4870.51","percent of total billed charges",""
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","outpatient","","","5960.00","4470.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3608.78","60.55","","1781.82","1492.00","4331.00","1 through 10","2384.07","4870.51","percent of total billed charges",""
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","outpatient","","","5960.00","4470.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3112.31","52.22","","3144.00","1492.00","3610.00","13","2384.07","4870.51","percent of total billed charges",""
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","outpatient","","","5960.00","4470.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4870.51","81.72","","8894.69","8894.69","8894.69","1 through 10","2384.07","4870.51","percent of total billed charges",""
"Sp Orbera Ballon Insertion and Removal","PX-99900384","CDM","43999","CPT","0999","RC","","","","outpatient","","","5960.00","4470.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4870.51","81.72","","2885.83","2132.00","3462.21","1 through 10","2384.07","4870.51","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","1309.77","674.56","6049.93","26","1395","3577.5","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2398.50","53.3","","1901.83","1901.83","2962.25","1 through 10","1395","3577.5","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","1620.31","1620.31","19908.88","1 through 10","1395","3577.5","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","352.91","352.91","2046.30","1 through 10","1395","3577.5","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","9668.75","9668.75","9668.75","1 through 10","1395","3577.5","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","699.88","384.10","3443.31","33","1395","3577.5","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","1421.24","264.50","4933.46","29","2351.7","3677.4","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3618.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","3010.54","693.88","5019.88","35","2351.7","3677.4","percent of total billed charges",""
"SPACER LUMBAR 26X33X52MM SYNMESH TITANIUM MESH OBLONG THORACU","SUP-ITM-10086698","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1309.77","674.56","6049.93","26","1627.5","4173.75","percent of total billed charges",""
"SPACER LUMBAR 26X33X52MM SYNMESH TITANIUM MESH OBLONG THORACU","SUP-ITM-10086698","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","1901.83","1901.83","2962.25","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPACER LUMBAR 26X33X52MM SYNMESH TITANIUM MESH OBLONG THORACU","SUP-ITM-10086698","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1620.31","1620.31","19908.88","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPACER LUMBAR 26X33X52MM SYNMESH TITANIUM MESH OBLONG THORACU","SUP-ITM-10086698","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","352.91","352.91","2046.30","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPACER LUMBAR 26X33X52MM SYNMESH TITANIUM MESH OBLONG THORACU","SUP-ITM-10086698","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","9668.75","9668.75","9668.75","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPACER LUMBAR 26X33X52MM SYNMESH TITANIUM MESH OBLONG THORACU","SUP-ITM-10086698","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","699.88","384.10","3443.31","33","1627.5","4173.75","percent of total billed charges",""
"SPACER LUMBAR 26X33X52MM SYNMESH TITANIUM MESH OBLONG THORACU","SUP-ITM-10086698","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1421.24","264.50","4933.46","29","2743.65","4290.3","percent of total billed charges",""
"SPACER LUMBAR 26X33X52MM SYNMESH TITANIUM MESH OBLONG THORACU","SUP-ITM-10086698","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4221.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2743.65","4290.3","percent of total billed charges",""
"SPACER LUMBAR 26X33X52MM SYNMESH TITANIUM MESH OBLONG THORACU","SUP-ITM-10086698","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","3010.54","693.88","5019.88","35","2743.65","4290.3","percent of total billed charges",""
"SPACER SPINE 10X32MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032848","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1309.77","674.56","6049.93","26","1627.5","4173.75","percent of total billed charges",""
"SPACER SPINE 10X32MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032848","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","1901.83","1901.83","2962.25","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPACER SPINE 10X32MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032848","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1620.31","1620.31","19908.88","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPACER SPINE 10X32MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032848","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","352.91","352.91","2046.30","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPACER SPINE 10X32MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032848","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","9668.75","9668.75","9668.75","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPACER SPINE 10X32MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032848","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","699.88","384.10","3443.31","33","1627.5","4173.75","percent of total billed charges",""
"SPACER SPINE 10X32MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1421.24","264.50","4933.46","29","2743.65","4290.3","percent of total billed charges",""
"SPACER SPINE 10X32MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4221.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2743.65","4290.3","percent of total billed charges",""
"SPACER SPINE 10X32MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10032848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","3010.54","693.88","5019.88","35","2743.65","4290.3","percent of total billed charges",""
"SPACER SPINE 12X18MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHTTI","SUP-ITM-10032849","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1309.77","674.56","6049.93","26","1627.5","4173.75","percent of total billed charges",""
"SPACER SPINE 12X18MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHTTI","SUP-ITM-10032849","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","1901.83","1901.83","2962.25","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPACER SPINE 12X18MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHTTI","SUP-ITM-10032849","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1620.31","1620.31","19908.88","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPACER SPINE 12X18MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHTTI","SUP-ITM-10032849","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","352.91","352.91","2046.30","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPACER SPINE 12X18MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHTTI","SUP-ITM-10032849","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","9668.75","9668.75","9668.75","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPACER SPINE 12X18MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHTTI","SUP-ITM-10032849","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","699.88","384.10","3443.31","33","1627.5","4173.75","percent of total billed charges",""
"SPACER SPINE 12X18MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHTTI","SUP-ITM-10032849","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1421.24","264.50","4933.46","29","2743.65","4290.3","percent of total billed charges",""
"SPACER SPINE 12X18MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHTTI","SUP-ITM-10032849","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4221.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2743.65","4290.3","percent of total billed charges",""
"SPACER SPINE 12X18MM THORACOLUMBAR SYNMESH MESH ROUND HEIGHTTI","SUP-ITM-10032849","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","3010.54","693.88","5019.88","35","2743.65","4290.3","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8546.25","79.5","","1309.77","674.56","6049.93","26","3332.5","8546.25","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5729.75","53.3","","1901.83","1901.83","2962.25","1 through 10","3332.5","8546.25","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3923.75","36.5","","1620.31","1620.31","19908.88","1 through 10","3332.5","8546.25","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4117.25","38.3","","352.91","352.91","2046.30","1 through 10","3332.5","8546.25","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4611.75","42.9","","9668.75","9668.75","9668.75","1 through 10","3332.5","8546.25","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","WELLPOINT [1015]","HB AMC WELLPOINT","7931.35","73.78","","699.88","384.10","3443.31","33","3332.5","8546.25","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10750.00","8062.50","AETNA [1001]","HB AMC AETNA HMO","7503.50","69.8","","1421.24","264.50","4933.46","29","5617.95","8784.9","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10750.00","8062.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8643.00","80.4","","1022.97","1022.97","3607.50","1 through 10","5617.95","8784.9","percent of total billed charges",""
"SPACER SPINE 12X5.9MM 2.9CC MED 14DEG SYNFIX EVOLUTION BLUE","SUP-ITM-10192195","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10750.00","8062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8784.90","81.72","","3010.54","693.88","5019.88","35","5617.95","8784.9","percent of total billed charges",""
"SPACER SPINE 15X7.9MM 2.3CC SM 18DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192214","CDM","C1889","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8546.25","79.5","","1309.77","674.56","6049.93","26","3332.5","8546.25","percent of total billed charges",""
"SPACER SPINE 15X7.9MM 2.3CC SM 18DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192214","CDM","C1889","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5729.75","53.3","","1901.83","1901.83","2962.25","1 through 10","3332.5","8546.25","percent of total billed charges",""
"SPACER SPINE 15X7.9MM 2.3CC SM 18DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192214","CDM","C1889","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3923.75","36.5","","1620.31","1620.31","19908.88","1 through 10","3332.5","8546.25","percent of total billed charges",""
"SPACER SPINE 15X7.9MM 2.3CC SM 18DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192214","CDM","C1889","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4117.25","38.3","","352.91","352.91","2046.30","1 through 10","3332.5","8546.25","percent of total billed charges",""
"SPACER SPINE 15X7.9MM 2.3CC SM 18DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192214","CDM","C1889","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4611.75","42.9","","9668.75","9668.75","9668.75","1 through 10","3332.5","8546.25","percent of total billed charges",""
"SPACER SPINE 15X7.9MM 2.3CC SM 18DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192214","CDM","C1889","HCPCS","0278","RC","","","","both","","","10750.00","8062.50","WELLPOINT [1015]","HB AMC WELLPOINT","7931.35","73.78","","699.88","384.10","3443.31","33","3332.5","8546.25","percent of total billed charges",""
"SPACER SPINE 15X7.9MM 2.3CC SM 18DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192214","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10750.00","8062.50","AETNA [1001]","HB AMC AETNA HMO","7503.50","69.8","","1421.24","264.50","4933.46","29","5617.95","8784.9","percent of total billed charges",""
"SPACER SPINE 15X7.9MM 2.3CC SM 18DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192214","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10750.00","8062.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8643.00","80.4","","1022.97","1022.97","3607.50","1 through 10","5617.95","8784.9","percent of total billed charges",""
"SPACER SPINE 15X7.9MM 2.3CC SM 18DEG SYNFIX EVOLUTION DARK BLUE","SUP-ITM-10192214","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10750.00","8062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8784.90","81.72","","3010.54","693.88","5019.88","35","5617.95","8784.9","percent of total billed charges",""
"SPACER SPINE 22-27MM MED SZ 4 0DEG TRIAL CENTRAL XRL TITANIUM","SUP-ITM-10134935","CDM","C1821","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5962.50","79.5","","9828.00","9828.00","9828.00","1 through 10","2325","7125","percent of total billed charges",""
"SPACER SPINE 22-27MM MED SZ 4 0DEG TRIAL CENTRAL XRL TITANIUM","SUP-ITM-10134935","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6129.00","81.72","","1958.53","1886.75","1958.53","1 through 10","3919.5","6129","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.50","79.5","","1309.77","674.56","6049.93","26","1395","3577.5","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2398.50","53.3","","1901.83","1901.83","2962.25","1 through 10","1395","3577.5","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.50","36.5","","1620.31","1620.31","19908.88","1 through 10","1395","3577.5","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.50","38.3","","352.91","352.91","2046.30","1 through 10","1395","3577.5","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.50","42.9","","9668.75","9668.75","9668.75","1 through 10","1395","3577.5","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB AMC WELLPOINT","3320.10","73.78","","699.88","384.10","3443.31","33","1395","3577.5","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","AETNA [1001]","HB AMC AETNA HMO","3141.00","69.8","","1421.24","264.50","4933.46","29","2351.7","3677.4","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3618.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2351.7","3677.4","percent of total billed charges",""
"SPACER SPINE 5MM ZERO P PEEK OPTIMA LORDOTIC","SUP-ITM-10030565","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.40","81.72","","3010.54","693.88","5019.88","35","2351.7","3677.4","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","1309.77","674.56","6049.93","26","922.25","2365.13","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1585.68","53.3","","1901.83","1901.83","2962.25","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","1620.31","1620.31","19908.88","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","352.91","352.91","2046.30","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","9668.75","9668.75","9668.75","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","WELLPOINT [1015]","HB AMC WELLPOINT","2194.96","73.78","","699.88","384.10","3443.31","33","922.25","2365.13","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","1421.24","264.50","4933.46","29","1554.74","2431.17","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2391.90","80.4","","1022.97","1022.97","3607.50","1 through 10","1554.74","2431.17","percent of total billed charges",""
"SPACER SPINE 6MM 4DEG CIF UI S","SUP-ITM-10243852","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","3010.54","693.88","5019.88","35","1554.74","2431.17","percent of total billed charges",""
"SPACER TRIAL 6MM SM 6DEG ENDOSKELETON TC NANOLOCK","SUP-ITM-10287926","CDM","C1821","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","9828.00","9828.00","9828.00","1 through 10","1193.5","3657.5","percent of total billed charges",""
"SPACER TRIAL 6MM SM 6DEG ENDOSKELETON TC NANOLOCK","SUP-ITM-10287926","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","1958.53","1886.75","1958.53","1 through 10","2012.01","3146.22","percent of total billed charges",""
"SPACER TRIAL 7MM SM 6DEG ENDOSKELETON TC NANOLOCK","SUP-ITM-10287927","CDM","C1821","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","9828.00","9828.00","9828.00","1 through 10","1193.5","3657.5","percent of total billed charges",""
"SPACER TRIAL 7MM SM 6DEG ENDOSKELETON TC NANOLOCK","SUP-ITM-10287927","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","1958.53","1886.75","1958.53","1 through 10","2012.01","3146.22","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","both","","","103.00","77.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","72.10","70","","100.00","100.00","100.00","1 through 10","5.87","97.85","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","both","","","103.00","77.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","81.89","79.5","","78.70","78.70","78.70","1 through 10","5.87","97.85","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","both","","","103.00","77.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","54.90","53.3","","78.70","78.70","78.70","1 through 10","5.87","97.85","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37.60","36.5","","37.30","36.20","37.30","1 through 10","5.87","97.85","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39.45","38.3","","39.10","39.10","117.30","24","5.87","97.85","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","outpatient","","","103.00","77.25","AETNA [1001]","HB AMC AETNA HMO","71.89","69.8","","47.80","47.80","78.00","1 through 10","6.19","84.17","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","outpatient","","","103.00","77.25","AETNA [1001]","HB AMC AETNA PPO","82.81","80.4","","78.00","78.00","78.00","1 through 10","6.19","84.17","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","outpatient","","","103.00","77.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","84.17","81.72","","100.00","100.00","100.00","1 through 10","6.19","84.17","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","outpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","84.17","81.72","","79.94","43.97","79.94","1 through 10","6.19","84.17","percent of total billed charges",""
"Special Histochem Stain W/Frozen","PX-31000028","CDM","88314","CPT","0312","RC","","","","both","","","308.00","231.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","112.42","36.5","","111.53","108.24","111.53","1 through 10","95.48","244.86","percent of total billed charges",""
"Special Histochem Stain W/Frozen","PX-31000028","CDM","88314","CPT","0312","RC","","","","both","","","308.00","231.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.13","42.9","","717.06","717.06","717.06","1 through 10","95.48","244.86","percent of total billed charges",""
"Special Histochem Stain W/Frozen","PX-31000028","CDM","88314","CPT","0312","RC","","","","both","","","308.00","231.00","WELLPOINT [1015]","HB AMC WELLPOINT","227.24","73.78","","222.61","222.61","222.61","1 through 10","95.48","244.86","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","305.00","228.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16.66","15.61","50.90","12","60.28","242.48","other","OPPS APC"
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","305.00","228.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","213.50","70","","213.12","213.12","213.12","1 through 10","60.28","242.48","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","305.00","228.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","242.48","79.5","","232.95","156.29","465.90","35","60.28","242.48","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","305.00","228.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","162.57","53.3","","156.29","156.29","232.95","1 through 10","60.28","242.48","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","305.00","228.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","198.25","65","","1154.40","221.65","1154.40","1 through 10","60.28","242.48","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","305.00","228.75","MEDICARE [2001]","HB BWH MEDICARE","63.44","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","31.73","21.15","63.45","1 through 10","60.28","242.48","other","OPPS APC"
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","305.00","228.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","94.55","31","","91.46","91.46","91.46","1 through 10","60.28","242.48","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","305.00","228.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","111.33","36.5","","110.41","93.83","281.49","48","60.28","242.48","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","305.00","228.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","116.82","38.3","","115.74","112.48","347.21","130","60.28","242.48","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","305.00","228.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","68.08","68.08","68.08","1 through 10","60.28","242.48","other","OPPS APC"
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","305.00","228.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","130.85","42.9","","416.00","236.62","416.00","1 through 10","60.28","242.48","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","305.00","228.75","WELLPOINT [1015]","HB AMC WELLPOINT","225.03","73.78","","516.37","220.37","1108.37","46","60.28","242.48","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","305.00","228.75","AETNA [1001]","HB AMC AETNA HMO","212.89","69.8","","400.78","141.49","2010.20","1 through 10","104.94","312.51","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","305.00","228.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","159.39","52.26","","183.16","104.94","183.16","1 through 10","104.94","312.51","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","305.00","228.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","249.25","81.72","","236.62","236.62","236.62","1 through 10","104.94","312.51","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","305.00","228.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","249.25","81.72","","236.62","236.62","236.62","1 through 10","104.94","312.51","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","305.00","228.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","249.25","81.72","","236.62","130.15","236.62","53","104.94","312.51","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","290.00","32.85","290.00","11","92.69","237.71","other","OPPS APC"
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","194.35","65","","188.50","188.50","188.50","1 through 10","92.69","237.71","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","209.30","70","","208.80","203.04","208.80","1 through 10","92.69","237.71","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","191.33","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","42.27","42.27","42.27","1 through 10","92.69","237.71","other","OPPS APC"
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","237.71","79.5","","228.23","188.50","684.69","31","92.69","237.71","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","159.37","53.3","","228.23","146.45","290.00","22","92.69","237.71","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","230.23","77","","434.28","434.28","434.28","1 through 10","92.69","237.71","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","194.35","65","","188.50","188.50","565.50","1 through 10","92.69","237.71","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","76.54","44.51","153.08","23","92.69","237.71","other","OPPS APC"
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","109.14","36.5","","108.17","91.93","108.17","34","92.69","237.71","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","114.52","38.3","","113.39","110.20","113.39","67","92.69","237.71","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","MOLINA [1014]","HB BWH MOLINA","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","132.45","132.45","132.45","1 through 10","92.69","237.71","other","OPPS APC"
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","128.27","42.9","","231.83","231.83","231.83","1 through 10","92.69","237.71","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","75.01","75.01","75.01","1 through 10","92.69","237.71","other","OPPS APC"
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","299.00","224.25","WELLPOINT [1015]","HB AMC WELLPOINT","220.60","73.78","","215.91","215.90","1375.91","24","92.69","237.71","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","outpatient","","","299.00","224.25","AETNA [1001]","HB AMC AETNA HMO","208.70","69.8","","196.33","196.33","785.32","1 through 10","66.11","244.34","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","outpatient","","","299.00","224.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","240.40","80.4","","226.20","226.20","226.20","1 through 10","66.11","244.34","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","outpatient","","","299.00","224.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","244.34","81.72","","127.51","127.51","127.51","1 through 10","66.11","244.34","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","outpatient","","","299.00","224.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","244.34","81.72","","231.83","127.51","231.83","37","66.11","244.34","percent of total billed charges",""
"Special Stain, Group III Enzyme Con","PX-31000030","CDM","88319","CPT","0312","RC","","","","both","","","325.00","243.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","173.23","53.3","","166.32","166.32","166.32","1 through 10","100.75","1212.52","percent of total billed charges",""
"Special Stain, Group III Enzyme Con","PX-31000030","CDM","88319","CPT","0312","RC","","","","both","","","325.00","243.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","970.02","","APC Price ($970.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","316.94","316.94","316.94","1 through 10","100.75","1212.52","other","OPPS APC"
"Special Stain, Group III Enzyme Con","PX-31000030","CDM","88319","CPT","0312","RC","","","","both","","","325.00","243.75","MEDICARE [2001]","HB BWH MEDICARE","970.02","","APC Price ($970.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","323.37","312.83","646.75","28","100.75","1212.52","other","OPPS APC"
"Special Stain, Group III Enzyme Con","PX-31000030","CDM","88319","CPT","0312","RC","","","","both","","","325.00","243.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.63","36.5","","117.50","114.03","117.50","1 through 10","100.75","1212.52","percent of total billed charges",""
"Special Stain, Group III Enzyme Con","PX-31000030","CDM","88319","CPT","0312","RC","","","","both","","","325.00","243.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","950.62","","APC Price ($970.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","316.91","306.58","316.91","1 through 10","100.75","1212.52","other","OPPS APC"
"Special Stain, Group III Enzyme Con","PX-31000030","CDM","88319","CPT","0312","RC","","","","both","","","325.00","243.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","139.43","42.9","","755.43","755.43","755.43","1 through 10","100.75","1212.52","percent of total billed charges",""
"Special Stain, Group III Enzyme Con","PX-31000030","CDM","88319","CPT","0312","RC","","","","both","","","325.00","243.75","WELLPOINT [1015]","HB AMC WELLPOINT","239.79","73.78","","234.52","234.52","234.52","1 through 10","100.75","1212.52","percent of total billed charges",""
"Spectrophotometry","PX-30000679","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","1 through 10","6.67","101.65","percent of total billed charges",""
"Spectrophotometry","PX-30000679","CDM","84311","CPT","0301","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.90","42.9","","47.32","47.32","47.32","1 through 10","6.67","101.65","percent of total billed charges",""
"Spectrophotometry","PX-30000679","CDM","84311","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","87.44","81.72","","45.73","45.73","45.73","1 through 10","6.67","87.44","percent of total billed charges",""
"Speech Sound Lang Comprehen","PX-44000060","CDM","92523","CPT","0444","RC","","","","both","","","1464.00","1098.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","780.31","53.3","","1117.54","1117.54","1117.54","1 through 10","242.36","1390.8","percent of total billed charges",""
"Speech Sound Lang Comprehen","PX-44000060","CDM","92523","CPT","0444","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","534.36","36.5","","529.66","514.04","529.66","1 through 10","242.36","1390.8","percent of total billed charges",""
"Speech Sound Lang Comprehen","PX-44000060","CDM","92523","CPT","0444","RC","","","","both","","","1464.00","1098.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","242.36","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($247.31). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($189.82). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","243.37","242.77","247.29","1 through 10","242.36","1390.8","fee schedule",""
"Sperm ID Aspiration Nonseminal","PX-30000125","CDM","89257","CPT","0300","RC","","","","both","","","417.00","312.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","222.26","53.3","","213.31","213.31","213.31","1 through 10","62.18","396.15","percent of total billed charges",""
"Sperm ID Aspiration Nonseminal","PX-30000125","CDM","89257","CPT","0300","RC","","","","both","","","417.00","312.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","152.21","36.5","","452.07","452.07","452.07","1 through 10","62.18","396.15","percent of total billed charges",""
"Sperm ID Aspiration Nonseminal","PX-30000125","CDM","89257","CPT","0300","RC","","","","both","","","417.00","312.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","159.71","38.3","","157.96","157.96","157.96","1 through 10","62.18","396.15","percent of total billed charges",""
"Sperm ID Aspiration Nonseminal","PX-30000125","CDM","89257","CPT","0300","RC","","","","outpatient","","","417.00","312.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","340.77","81.72","","322.96","322.96","322.96","1 through 10","104.94","340.77","percent of total billed charges",""
"Sperm Isolation Complex Prep","PX-30000129","CDM","89261","CPT","0300","RC","","","","both","","","855.00","641.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","679.73","79.5","","652.42","437.71","652.42","21","62.18","812.25","percent of total billed charges",""
"Sperm Isolation Complex Prep","PX-30000129","CDM","89261","CPT","0300","RC","","","","both","","","855.00","641.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","455.72","53.3","","652.42","437.71","652.42","1 through 10","62.18","812.25","percent of total billed charges",""
"Sperm Isolation Complex Prep","PX-30000129","CDM","89261","CPT","0300","RC","","","","both","","","855.00","641.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.80","42.9","","662.70","662.70","662.70","1 through 10","62.18","812.25","percent of total billed charges",""
"Sperm Isolation Complex Prep","PX-30000129","CDM","89261","CPT","0300","RC","","","","both","","","855.00","641.25","WELLPOINT [1015]","HB AMC WELLPOINT","630.82","73.78","","617.19","617.19","1446.19","1 through 10","62.18","812.25","percent of total billed charges",""
"Sperm Isolation Complex Prep","PX-30000129","CDM","89261","CPT","0300","RC","","","","outpatient","","","855.00","641.25","AETNA [1001]","HB AMC AETNA HMO","596.79","69.8","","561.23","396.26","561.23","1 through 10","91.15","698.71","percent of total billed charges",""
"Sperm Isolation Complex Prep","PX-30000129","CDM","89261","CPT","0300","RC","","","","outpatient","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","698.71","81.72","","662.70","364.51","662.70","25","91.15","698.71","percent of total billed charges",""
"Sperm Isolation Smp Prep","PX-30000128","CDM","89260","CPT","0300","RC","","","","both","","","425.00","318.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","337.88","79.5","","324.24","217.54","412.00","1 through 10","32.82","403.75","percent of total billed charges",""
"Sperm Isolation Smp Prep","PX-30000128","CDM","89260","CPT","0300","RC","","","","both","","","425.00","318.75","WELLPOINT [1015]","HB AMC WELLPOINT","313.57","73.78","","718.73","718.73","718.73","1 through 10","32.82","403.75","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","both","","","540.00","405.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","167.4","438.15","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","both","","","540.00","405.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","167.4","438.15","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","both","","","540.00","405.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","287.82","53.3","","477.31","477.31","477.31","1 through 10","167.4","438.15","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","both","","","540.00","405.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","167.4","438.15","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","both","","","540.00","405.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","167.4","438.15","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","both","","","540.00","405.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","197.10","36.5","","1095.87","337.19","1095.87","1 through 10","167.4","438.15","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","both","","","540.00","405.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","206.82","38.3","","343.52","323.76","353.46","1 through 10","167.4","438.15","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","both","","","540.00","405.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","167.4","438.15","other","Tricare OPPS"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","both","","","540.00","405.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","167.4","438.15","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","both","","","540.00","405.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","167.4","438.15","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","both","","","540.00","405.00","WELLPOINT [1015]","HB AMC WELLPOINT","398.41","73.78","","673.03","673.03","673.03","1 through 10","167.4","438.15","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","outpatient","","","540.00","405.00","AETNA [1001]","HB AMC AETNA HMO","376.92","69.8","","612.01","612.01","1224.02","1 through 10","270","700.33","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","outpatient","","","540.00","405.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","326.97","60.55","","579.04","568.57","904.00","30","270","700.33","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","outpatient","","","540.00","405.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","281.99","52.22","","904.00","656.02","2938.00","26","270","700.33","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","outpatient","","","540.00","405.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","270.00","50","","1421.10","875.08","2368.50","15","270","700.33","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","outpatient","","","540.00","405.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","283.50","52.5","","2985.00","904.00","2985.00","1 through 10","270","700.33","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","outpatient","","","540.00","405.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","441.29","81.72","","722.66","722.66","17449.00","1 through 10","270","700.33","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","both","","","445.00","333.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","137.95","438.15","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","both","","","445.00","333.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","137.95","438.15","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","both","","","445.00","333.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","237.19","53.3","","477.31","477.31","477.31","1 through 10","137.95","438.15","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","both","","","445.00","333.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","137.95","438.15","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","both","","","445.00","333.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","137.95","438.15","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","both","","","445.00","333.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","162.43","36.5","","1095.87","337.19","1095.87","1 through 10","137.95","438.15","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","both","","","445.00","333.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","170.44","38.3","","343.52","323.76","353.46","1 through 10","137.95","438.15","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","both","","","445.00","333.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","137.95","438.15","other","Tricare OPPS"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","both","","","445.00","333.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","137.95","438.15","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","both","","","445.00","333.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","137.95","438.15","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","both","","","445.00","333.75","WELLPOINT [1015]","HB AMC WELLPOINT","328.32","73.78","","673.03","673.03","673.03","1 through 10","137.95","438.15","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","outpatient","","","445.00","333.75","AETNA [1001]","HB AMC AETNA HMO","310.61","69.8","","612.01","612.01","1224.02","1 through 10","222.5","700.33","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","outpatient","","","445.00","333.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","269.45","60.55","","579.04","568.57","904.00","30","222.5","700.33","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","outpatient","","","445.00","333.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","232.38","52.22","","904.00","656.02","2938.00","26","222.5","700.33","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","outpatient","","","445.00","333.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","222.50","50","","1421.10","875.08","2368.50","15","222.5","700.33","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","outpatient","","","445.00","333.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","233.63","52.5","","2985.00","904.00","2985.00","1 through 10","222.5","700.33","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-98302483","CDM","64999","CPT","0983","RC","","","","outpatient","","","445.00","333.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","363.65","81.72","","722.66","722.66","17449.00","1 through 10","222.5","700.33","percent of total billed charges",""
"SPINAL BOLT 5X20MM MODULUS ALIF","SUP-ITM-10287123","CDM","C1821","HCPCS","0278","RC","","","","both","","","1277.50","958.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1015.61","79.5","","9828.00","9828.00","9828.00","1 through 10","396.03","1213.63","percent of total billed charges",""
"SPINAL BOLT 5X20MM MODULUS ALIF","SUP-ITM-10287123","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1043.97","81.72","","1958.53","1886.75","1958.53","1 through 10","667.62","1043.97","percent of total billed charges",""
"SPINAL BOLT 5X25MM MODULUS ALIF","SUP-ITM-10287121","CDM","C1821","HCPCS","0278","RC","","","","both","","","1277.50","958.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1015.61","79.5","","9828.00","9828.00","9828.00","1 through 10","396.03","1213.63","percent of total billed charges",""
"SPINAL BOLT 5X25MM MODULUS ALIF","SUP-ITM-10287121","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1043.97","81.72","","1958.53","1886.75","1958.53","1 through 10","667.62","1043.97","percent of total billed charges",""
"SPINAL CAGE 18X14X12DEGX7MM CERVICAL STANDALONE ASSEMBLY INTERFIXATED","SUP-ITM-10311160","CDM","C1821","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3875.63","79.5","","9828.00","9828.00","9828.00","1 through 10","1511.25","4631.25","percent of total billed charges",""
"SPINAL CAGE 18X14X12DEGX7MM CERVICAL STANDALONE ASSEMBLY INTERFIXATED","SUP-ITM-10311160","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","4875.00","3656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3983.85","81.72","","1958.53","1886.75","1958.53","1 through 10","2547.68","3983.85","percent of total billed charges",""
"SPINAL CAGE 23X26X9MM 6DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103563","CDM","C1889","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7353.75","79.5","","1309.77","674.56","6049.93","26","2867.5","7353.75","percent of total billed charges",""
"SPINAL CAGE 23X26X9MM 6DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103563","CDM","C1889","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4930.25","53.3","","1901.83","1901.83","2962.25","1 through 10","2867.5","7353.75","percent of total billed charges",""
"SPINAL CAGE 23X26X9MM 6DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103563","CDM","C1889","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3376.25","36.5","","1620.31","1620.31","19908.88","1 through 10","2867.5","7353.75","percent of total billed charges",""
"SPINAL CAGE 23X26X9MM 6DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103563","CDM","C1889","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3542.75","38.3","","352.91","352.91","2046.30","1 through 10","2867.5","7353.75","percent of total billed charges",""
"SPINAL CAGE 23X26X9MM 6DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103563","CDM","C1889","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3968.25","42.9","","9668.75","9668.75","9668.75","1 through 10","2867.5","7353.75","percent of total billed charges",""
"SPINAL CAGE 23X26X9MM 6DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103563","CDM","C1889","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","WELLPOINT [1015]","HB AMC WELLPOINT","6824.65","73.78","","699.88","384.10","3443.31","33","2867.5","7353.75","percent of total billed charges",""
"SPINAL CAGE 23X26X9MM 6DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103563","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9250.00","6937.50","AETNA [1001]","HB AMC AETNA HMO","6456.50","69.8","","1421.24","264.50","4933.46","29","4834.05","7559.1","percent of total billed charges",""
"SPINAL CAGE 23X26X9MM 6DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103563","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9250.00","6937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7437.00","80.4","","1022.97","1022.97","3607.50","1 through 10","4834.05","7559.1","percent of total billed charges",""
"SPINAL CAGE 23X26X9MM 6DEG ROI-A MEDIAN LORDOTIC ANTERIOR LUMBAR","SUP-ITM-10103563","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9250.00","6937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7559.10","81.72","","3010.54","693.88","5019.88","35","4834.05","7559.1","percent of total billed charges",""
"SPINAL CONNECTOR 4X50MM INVICTUS CROSS ROD TO ROD VARIABLE","SUP-ITM-10290629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","800.18","480.96","1887.97","195","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR 4X50MM INVICTUS CROSS ROD TO ROD VARIABLE","SUP-ITM-10290629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","813.12","216.42","1444.50","81","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR 4X50MM INVICTUS CROSS ROD TO ROD VARIABLE","SUP-ITM-10290629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","482.83","31","","432.60","432.60","432.60","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR 4X50MM INVICTUS CROSS ROD TO ROD VARIABLE","SUP-ITM-10290629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","148.37","54.89","631.39","94","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR 4X50MM INVICTUS CROSS ROD TO ROD VARIABLE","SUP-ITM-10290629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","279.30","91.72","1116.77","266","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR 4X50MM INVICTUS CROSS ROD TO ROD VARIABLE","SUP-ITM-10290629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","731.00","63.70","731.00","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR 4X50MM INVICTUS CROSS ROD TO ROD VARIABLE","SUP-ITM-10290629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","384.74","384.74","384.74","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR 4X50MM INVICTUS CROSS ROD TO ROD VARIABLE","SUP-ITM-10290629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","286.63","119.22","1107.45","105","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR 4X50MM INVICTUS CROSS ROD TO ROD VARIABLE","SUP-ITM-10290629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","675.31","184.75","1721.50","286","813.95","1272.79","percent of total billed charges",""
"SPINAL CONNECTOR 4X50MM INVICTUS CROSS ROD TO ROD VARIABLE","SUP-ITM-10290629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA PPO","1252.23","80.4","","1261.44","103.12","1514.10","21","813.95","1272.79","percent of total billed charges",""
"SPINAL CONNECTOR 4X50MM INVICTUS CROSS ROD TO ROD VARIABLE","SUP-ITM-10290629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.23","80.4","","1365.00","1365.00","1365.00","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINAL CONNECTOR 4X50MM INVICTUS CROSS ROD TO ROD VARIABLE","SUP-ITM-10290629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1272.79","81.72","","5157.68","5157.68","5157.68","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINAL CONNECTOR 4X50MM INVICTUS CROSS ROD TO ROD VARIABLE","SUP-ITM-10290629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","431.26","71.26","1459.57","88","813.95","1272.79","percent of total billed charges",""
"SPINAL CONNECTOR 6.35MM SLEEVE SET SCREW","SUP-ITM-10103407","CDM","C1889","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1224.30","79.5","","1309.77","674.56","6049.93","26","477.4","1224.3","percent of total billed charges",""
"SPINAL CONNECTOR 6.35MM SLEEVE SET SCREW","SUP-ITM-10103407","CDM","C1889","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","820.82","53.3","","1901.83","1901.83","2962.25","1 through 10","477.4","1224.3","percent of total billed charges",""
"SPINAL CONNECTOR 6.35MM SLEEVE SET SCREW","SUP-ITM-10103407","CDM","C1889","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","562.10","36.5","","1620.31","1620.31","19908.88","1 through 10","477.4","1224.3","percent of total billed charges",""
"SPINAL CONNECTOR 6.35MM SLEEVE SET SCREW","SUP-ITM-10103407","CDM","C1889","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","589.82","38.3","","352.91","352.91","2046.30","1 through 10","477.4","1224.3","percent of total billed charges",""
"SPINAL CONNECTOR 6.35MM SLEEVE SET SCREW","SUP-ITM-10103407","CDM","C1889","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","660.66","42.9","","9668.75","9668.75","9668.75","1 through 10","477.4","1224.3","percent of total billed charges",""
"SPINAL CONNECTOR 6.35MM SLEEVE SET SCREW","SUP-ITM-10103407","CDM","C1889","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","WELLPOINT [1015]","HB AMC WELLPOINT","1136.21","73.78","","699.88","384.10","3443.31","33","477.4","1224.3","percent of total billed charges",""
"SPINAL CONNECTOR 6.35MM SLEEVE SET SCREW","SUP-ITM-10103407","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1540.00","1155.00","AETNA [1001]","HB AMC AETNA HMO","1074.92","69.8","","1421.24","264.50","4933.46","29","804.8","1258.49","percent of total billed charges",""
"SPINAL CONNECTOR 6.35MM SLEEVE SET SCREW","SUP-ITM-10103407","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1540.00","1155.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1238.16","80.4","","1022.97","1022.97","3607.50","1 through 10","804.8","1258.49","percent of total billed charges",""
"SPINAL CONNECTOR 6.35MM SLEEVE SET SCREW","SUP-ITM-10103407","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1540.00","1155.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1258.49","81.72","","3010.54","693.88","5019.88","35","804.8","1258.49","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","1309.77","674.56","6049.93","26","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","1901.83","1901.83","2962.25","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","1620.31","1620.31","19908.88","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","352.91","352.91","2046.30","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","9668.75","9668.75","9668.75","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","699.88","384.10","3443.31","33","482.83","1238.21","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","1421.24","264.50","4933.46","29","813.95","1272.79","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.23","80.4","","1022.97","1022.97","3607.50","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","3010.54","693.88","5019.88","35","813.95","1272.79","percent of total billed charges",""
"Spinal Disorders And Injuries With Cc/McC","052","MS-DRG","","","","","","","","inpatient","","","67534.86","50651.14","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","17409.79","","Case rate ($16,902.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,270.12, add-ons for qualifying new technology services are included. If operating cost exceeds $65,914.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,897.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $15,065.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,890.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,457.48. The transfer capital threshold is the transfer adjustment factor * $1,457.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","19144.73","19144.73","19144.73","1 through 10","16564.66","28372.2","other","Inpatient DRG"
"Spinal Disorders And Injuries With Cc/McC","052","MS-DRG","","","","","","","","inpatient","","","67534.86","50651.14","MEDICARE [2001]","HB BWH MEDICARE","21823.69","","Case rate ($21,823.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,270.12, add-ons for qualifying new technology services are included. If operating cost exceeds $65,914.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,897.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $19,986.37 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,890.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,457.48. The transfer capital threshold is the transfer adjustment factor * $1,457.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24039.44","24039.44","24039.44","1 through 10","16564.66","28372.2","other","Inpatient DRG"
"Spinal Disorders And Injuries With Cc/McC","052","MS-DRG","","","","","","","","inpatient","","","67534.86","50651.14","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16564.66","","Case rate ($16,902.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,270.12, add-ons for qualifying new technology services are included. If operating cost exceeds $65,914.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,897.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $15,065.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,890.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,457.48. The transfer capital threshold is the transfer adjustment factor * $1,457.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8912.26","8912.26","8912.26","1 through 10","16564.66","28372.2","other","Inpatient DRG"
"Spinal Disorders And Injuries Without Cc/McC","053","MS-DRG","","","","","","","","inpatient","","","16539.41","12404.56","MEDICARE [2001]","HB BWH MEDICARE","11972.52","","Case rate ($11,972.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,132.65, add-ons for qualifying new technology services are included. If operating cost exceeds $56,777.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,228.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $10,804.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,752.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $787.92. The transfer capital threshold is the transfer adjustment factor * $787.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","9125.97","13904.8474","other","Inpatient DRG"
"Spinal Disorders And Injuries,MAJOR","040","DRG","","","","","","","","inpatient","","","88665.16","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","60873.91","","Standard inlier is a Case rate ($60,873.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $53,753, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,640.55) for the length of stay and the standard reimbursement.","60873.91","60873.91","60873.91","1 through 10","10147.64","120922.69","case rate",""
"Spinal Disorders And Injuries,MAJOR","040","DRG","","","","","","","","inpatient","","","88665.16","","MASSHEALTH [3001]","HB BWH MEDICAID","15216.32","","Case rate ($16,824.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,254.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20047.10","20047.10","20047.10","1 through 10","10147.64","120922.69","case rate",""
"Spinal Disorders And Injuries,MAJOR","040","DRG","","","","","","","","inpatient","","","88665.16","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","15216.32","","Case rate ($16,824.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $59,254.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5562.32","5562.32","5562.32","1 through 10","10147.64","120922.69","case rate",""
"Spinal Disorders And Injuries,MINOR","040","DRG","","","","","","","","inpatient","","","40116.73","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","31167.79","","Standard inlier is a Case rate ($31,167.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $33,205, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,424.01) for the length of stay and the standard reimbursement.","28474.46","28474.46","28474.46","1 through 10","10147.64","120922.69","case rate",""
"Spinal Disorders And Injuries,MODERATE","040","DRG","","","","","","","","inpatient","","","71259.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","38990.31","","Standard inlier is a Case rate ($38,990.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,967, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,534.91) for the length of stay and the standard reimbursement.","38990.30","38990.30","38990.30","1 through 10","10147.64","120922.69","case rate",""
"Spinal Disorders And Injuries,MODERATE","040","DRG","","","","","","","","inpatient","","","71259.85","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","43835.62","","Standard inlier is a Case rate ($43,835.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,967, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,222.10) for the length of stay and the standard reimbursement.","5071.95","5071.95","5071.95","1 through 10","10147.64","120922.69","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,EXTREME","321","DRG","","","","","","","","inpatient","","","317451.68","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","144512.52","","Standard inlier is a Case rate ($144,512.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $124,027, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($20,514.42) for the length of stay and the standard reimbursement.","144512.52","144512.52","144512.52","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,EXTREME","321","DRG","","","","","","","","inpatient","","","317451.68","","MASSHEALTH [3001]","HB BWH MEDICAID","41456.46","","Case rate ($45,837.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $88,267.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17143.71","17143.71","17143.71","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,EXTREME","321","DRG","","","","","","","","inpatient","","","317451.68","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","41456.46","","Case rate ($45,837.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $88,267.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2085.87","2085.87","2085.87","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,EXTREME","321","DRG","","","","","","","","inpatient","","","317451.68","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","41456.46","","Case rate ($45,837.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $88,267.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","50057.73","50057.73","50057.73","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MAJOR","321","DRG","","","","","","","","inpatient","","","123595.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","92433.81","","Standard inlier is a Case rate ($92,433.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $83,527, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,121.54) for the length of stay and the standard reimbursement.","84268.98","84268.98","92433.81","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MAJOR","321","DRG","","","","","","","","inpatient","","","123595.51","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","103920.52","","Standard inlier is a Case rate ($103,920.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $83,527, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,750.65) for the length of stay and the standard reimbursement.","103920.51","103920.51","103920.51","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MAJOR","321","DRG","","","","","","","","inpatient","","","123595.51","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37294.7358","","Fee schedule rate ($79,912.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37294.7358","79912.80","79912.80","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MAJOR","321","DRG","","","","","","","","inpatient","","","123595.51","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","39160.5564","","Fee schedule rate ($83,910.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","39160.5564","83910.80","83910.80","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MAJOR","321","DRG","","","","","","","","inpatient","","","123595.51","","MASSHEALTH [3001]","HB BWH MEDICAID","27941.13","","Case rate ($30,893.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $73,323.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","49935.06","49935.06","49935.06","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MAJOR","321","DRG","","","","","","","","inpatient","","","123595.51","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","27941.13","","Case rate ($30,893.72). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $73,323.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","30886.14","30886.14","30886.14","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MINOR","321","DRG","","","","","","","","inpatient","","","109688.23","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","55358.09","","Standard inlier is a Case rate ($55,358.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,858.41) for the length of stay and the standard reimbursement.","55358.08","55358.08","55358.08","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MINOR","321","DRG","","","","","","","","inpatient","","","109688.23","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","62237.41","","Standard inlier is a Case rate ($62,237.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,834.08) for the length of stay and the standard reimbursement.","62237.41","62237.41","62237.41","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MINOR","321","DRG","","","","","","","","inpatient","","","109688.23","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37294.7358","","Fee schedule rate ($50,952.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37294.7358","37294.72","37294.72","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MINOR","321","DRG","","","","","","","","inpatient","","","109688.23","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64322.63","","Fee schedule rate ($64,322.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","54169.12","54169.12","54169.12","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MINOR","321","DRG","","","","","","","","inpatient","","","109688.23","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67539.82","","Fee schedule rate ($67,539.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","56878.47","56878.47","56878.47","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","111983.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","67149.62","","Standard inlier is a Case rate ($67,149.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,865, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,532.29) for the length of stay and the standard reimbursement.","61209.32","61209.32","67149.61","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","111983.84","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","75494.27","","Standard inlier is a Case rate ($75,494.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,865, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,715.78) for the length of stay and the standard reimbursement.","75494.26","68970.53","75494.26","14","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","111983.84","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37294.7358","","Fee schedule rate ($50,952.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37294.7358","50952.04","50952.04","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","111983.84","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","39160.5564","","Fee schedule rate ($53,501.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","39160.5564","53501.12","53501.12","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","111983.84","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","56047.91","","Fee schedule rate ($56,047.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","56047.91","56047.91","56047.91","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","111983.84","","MASSHEALTH [3001]","HB BWH MEDICAID","20556.88","","Case rate ($22,729.16). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,159.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16040.18","4619.75","22723.58","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","111983.84","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64322.63","","Fee schedule rate ($64,322.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","64322.63","64322.63","64322.63","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","111983.84","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67539.82","","Fee schedule rate ($67,539.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","67539.82","67539.82","67539.82","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","111983.84","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","20556.88","","Case rate ($22,729.16). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $65,159.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22723.58","22723.58","22723.58","1 through 10","17846.04","359099.07","case rate",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With Cc","457","MS-DRG","","","","","","","","inpatient","","","165266.02","123949.51","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54775.87","","Case rate ($54,775.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $65,861.94, add-ons for qualifying new technology services are included. If operating cost exceeds $111,506.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,238.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $49,597.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,482.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,798.26. The transfer capital threshold is the transfer adjustment factor * $4,798.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","51809.93","51809.90","51856.25","1 through 10","53680.35","86613.2854","other","Inpatient Replacement Plans DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With Cc","457","MS-DRG","","","","","","","","inpatient","","","165266.02","123949.51","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54775.87","","Case rate ($54,775.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $65,861.94, add-ons for qualifying new technology services are included. If operating cost exceeds $111,506.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,238.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $49,597.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,482.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,798.26. The transfer capital threshold is the transfer adjustment factor * $4,798.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","51484.27","51484.27","51484.27","1 through 10","53680.35","86613.2854","other","Inpatient DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With Cc","457","MS-DRG","","","","","","","","inpatient","","","165266.02","123949.51","MEDICARE [2001]","HB BWH MEDICARE","54775.87","","Case rate ($54,775.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $65,861.94, add-ons for qualifying new technology services are included. If operating cost exceeds $111,506.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,238.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $49,597.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,482.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,798.26. The transfer capital threshold is the transfer adjustment factor * $4,798.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","67940.96","0.03","68042.17","17","53680.35","86613.2854","other","Inpatient Replacement Plans DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With Cc","457","MS-DRG","","","","","","","","inpatient","","","165266.02","123949.51","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54775.87","","Case rate ($54,775.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $65,861.94, add-ons for qualifying new technology services are included. If operating cost exceeds $111,506.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,238.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $49,597.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,482.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,798.26. The transfer capital threshold is the transfer adjustment factor * $4,798.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","51429.70","51429.70","51429.70","1 through 10","53680.35","86613.2854","other","Inpatient Replacement Plans DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With Cc","457","MS-DRG","","","","","","","","inpatient","","","165266.02","123949.51","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53680.35","","Case rate ($54,775.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $65,861.94, add-ons for qualifying new technology services are included. If operating cost exceeds $111,506.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,238.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $49,597.77 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,482.09 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,798.26. The transfer capital threshold is the transfer adjustment factor * $4,798.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","63723.35","51400.09","73148.82","1 through 10","53680.35","86613.2854","other","Inpatient DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With Cc","457","MS-DRG","","","","","","","","inpatient","","","165266.02","123949.51","WELLPOINT [1015]","HB AMC WELLPOINT","86613.2854","","Fee schedule rate ($93,406.00).","86613.2854","126140.93","126140.93","1 through 10","53680.35","86613.2854","case rate",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With McC","456","MS-DRG","","","","","","","","inpatient","","","276889.67","207667.25","MEDICARE [2001]","HB BWH MEDICARE","77036.54","","Case rate ($77,036.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $92,659.39, add-ons for qualifying new technology services are included. If operating cost exceeds $138,303.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $9,202.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $69,894.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $92,279.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,761.87. The transfer capital threshold is the transfer adjustment factor * $6,761.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","100122.98","0.03","100272.33","13","75495.81","131630.86","other","Inpatient Replacement Plans DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With McC","456","MS-DRG","","","","","","","","inpatient","","","276889.67","207667.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","75495.81","","Case rate ($77,036.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $92,659.39, add-ons for qualifying new technology services are included. If operating cost exceeds $138,303.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $9,202.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $69,894.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $92,279.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $6,761.87. The transfer capital threshold is the transfer adjustment factor * $6,761.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","75607.54","75607.54","75607.54","1 through 10","75495.81","131630.86","other","Inpatient DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions Without Cc/McC","458","MS-DRG","","","","","","","","inpatient","","","137278.67","102959.00","HUMANA [1012]","HB BWH MEDICARE","38442.73","","Case rate ($38,442.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,200.06, add-ons for qualifying new technology services are included. If operating cost exceeds $91,844.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,797.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $34,705.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,820.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,357.52. The transfer capital threshold is the transfer adjustment factor * $3,357.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10125.29","10125.29","10125.29","1 through 10","37673.88","65359.61","other","Inpatient Replacement Plans DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions Without Cc/McC","458","MS-DRG","","","","","","","","inpatient","","","137278.67","102959.00","MEDICARE [2001]","HB BWH MEDICARE","38442.73","","Case rate ($38,442.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,200.06, add-ons for qualifying new technology services are included. If operating cost exceeds $91,844.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,797.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $34,705.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,820.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,357.52. The transfer capital threshold is the transfer adjustment factor * $3,357.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","51243.94","1 through 10","37673.88","65359.61","other","Inpatient Replacement Plans DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions Without Cc/McC","458","MS-DRG","","","","","","","","inpatient","","","137278.67","102959.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","37673.88","","Case rate ($38,442.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,200.06, add-ons for qualifying new technology services are included. If operating cost exceeds $91,844.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,797.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $34,705.38 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $45,820.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,357.52. The transfer capital threshold is the transfer adjustment factor * $3,357.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","38765.30","38765.30","38765.30","1 through 10","37673.88","65359.61","other","Inpatient DRG"
"SPINAL PLATE 20MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108073","CDM","C1889","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1641.68","79.5","","1309.77","674.56","6049.93","26","640.15","1641.68","percent of total billed charges",""
"SPINAL PLATE 20MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108073","CDM","C1889","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1100.65","53.3","","1901.83","1901.83","2962.25","1 through 10","640.15","1641.68","percent of total billed charges",""
"SPINAL PLATE 20MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108073","CDM","C1889","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","753.73","36.5","","1620.31","1620.31","19908.88","1 through 10","640.15","1641.68","percent of total billed charges",""
"SPINAL PLATE 20MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108073","CDM","C1889","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","790.90","38.3","","352.91","352.91","2046.30","1 through 10","640.15","1641.68","percent of total billed charges",""
"SPINAL PLATE 20MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108073","CDM","C1889","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.89","42.9","","9668.75","9668.75","9668.75","1 through 10","640.15","1641.68","percent of total billed charges",""
"SPINAL PLATE 20MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108073","CDM","C1889","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","WELLPOINT [1015]","HB AMC WELLPOINT","1523.56","73.78","","699.88","384.10","3443.31","33","640.15","1641.68","percent of total billed charges",""
"SPINAL PLATE 20MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108073","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","AETNA [1001]","HB AMC AETNA HMO","1441.37","69.8","","1421.24","264.50","4933.46","29","1079.17","1687.52","percent of total billed charges",""
"SPINAL PLATE 20MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108073","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1660.26","80.4","","1022.97","1022.97","3607.50","1 through 10","1079.17","1687.52","percent of total billed charges",""
"SPINAL PLATE 20MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108073","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1687.52","81.72","","3010.54","693.88","5019.88","35","1079.17","1687.52","percent of total billed charges",""
"SPINAL PLATE 35-45MM 6 HOLE OCCIPITAL TITANIUM LOCKING ALTIUS CERVICAL","SUP-ITM-10048696","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","1309.77","674.56","6049.93","26","922.25","2365.13","percent of total billed charges",""
"SPINAL PLATE 35-45MM 6 HOLE OCCIPITAL TITANIUM LOCKING ALTIUS CERVICAL","SUP-ITM-10048696","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1585.68","53.3","","1901.83","1901.83","2962.25","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINAL PLATE 35-45MM 6 HOLE OCCIPITAL TITANIUM LOCKING ALTIUS CERVICAL","SUP-ITM-10048696","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","1620.31","1620.31","19908.88","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINAL PLATE 35-45MM 6 HOLE OCCIPITAL TITANIUM LOCKING ALTIUS CERVICAL","SUP-ITM-10048696","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","352.91","352.91","2046.30","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINAL PLATE 35-45MM 6 HOLE OCCIPITAL TITANIUM LOCKING ALTIUS CERVICAL","SUP-ITM-10048696","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","9668.75","9668.75","9668.75","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINAL PLATE 35-45MM 6 HOLE OCCIPITAL TITANIUM LOCKING ALTIUS CERVICAL","SUP-ITM-10048696","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","WELLPOINT [1015]","HB AMC WELLPOINT","2194.96","73.78","","699.88","384.10","3443.31","33","922.25","2365.13","percent of total billed charges",""
"SPINAL PLATE 35-45MM 6 HOLE OCCIPITAL TITANIUM LOCKING ALTIUS CERVICAL","SUP-ITM-10048696","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","1421.24","264.50","4933.46","29","1554.74","2431.17","percent of total billed charges",""
"SPINAL PLATE 35-45MM 6 HOLE OCCIPITAL TITANIUM LOCKING ALTIUS CERVICAL","SUP-ITM-10048696","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2391.90","80.4","","1022.97","1022.97","3607.50","1 through 10","1554.74","2431.17","percent of total billed charges",""
"SPINAL PLATE 35-45MM 6 HOLE OCCIPITAL TITANIUM LOCKING ALTIUS CERVICAL","SUP-ITM-10048696","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","3010.54","693.88","5019.88","35","1554.74","2431.17","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1641.68","79.5","","1309.77","674.56","6049.93","26","640.15","1641.68","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1100.65","53.3","","1901.83","1901.83","2962.25","1 through 10","640.15","1641.68","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","753.73","36.5","","1620.31","1620.31","19908.88","1 through 10","640.15","1641.68","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","790.90","38.3","","352.91","352.91","2046.30","1 through 10","640.15","1641.68","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","885.89","42.9","","9668.75","9668.75","9668.75","1 through 10","640.15","1641.68","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","both","","","2065.00","1548.75","WELLPOINT [1015]","HB AMC WELLPOINT","1523.56","73.78","","699.88","384.10","3443.31","33","640.15","1641.68","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","AETNA [1001]","HB AMC AETNA HMO","1441.37","69.8","","1421.24","264.50","4933.46","29","1079.17","1687.52","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1660.26","80.4","","1022.97","1022.97","3607.50","1 through 10","1079.17","1687.52","percent of total billed charges",""
"SPINAL PLATE 38MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108082","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2065.00","1548.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1687.52","81.72","","3010.54","693.88","5019.88","35","1079.17","1687.52","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1878.19","79.5","","1309.77","674.56","6049.93","26","732.38","1878.19","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1259.21","53.3","","1901.83","1901.83","2962.25","1 through 10","732.38","1878.19","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","862.31","36.5","","1620.31","1620.31","19908.88","1 through 10","732.38","1878.19","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","904.84","38.3","","352.91","352.91","2046.30","1 through 10","732.38","1878.19","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","9668.75","9668.75","9668.75","1 through 10","732.38","1878.19","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","WELLPOINT [1015]","HB AMC WELLPOINT","1743.05","73.78","","699.88","384.10","3443.31","33","732.38","1878.19","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA HMO","1649.03","69.8","","1421.24","264.50","4933.46","29","1234.64","1930.64","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1899.45","80.4","","1022.97","1022.97","3607.50","1 through 10","1234.64","1930.64","percent of total billed charges",""
"SPINAL PLATE 39MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1930.64","81.72","","3010.54","693.88","5019.88","35","1234.64","1930.64","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1015.61","79.5","","800.18","480.96","1887.97","195","396.03","1015.61","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","680.91","53.3","","813.12","216.42","1444.50","81","396.03","1015.61","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","396.03","31","","432.60","432.60","432.60","1 through 10","396.03","1015.61","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","466.29","36.5","","148.37","54.89","631.39","94","396.03","1015.61","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","489.28","38.3","","279.30","91.72","1116.77","266","396.03","1015.61","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","548.05","42.9","","731.00","63.70","731.00","1 through 10","396.03","1015.61","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","548.05","42.9","","384.74","384.74","384.74","1 through 10","396.03","1015.61","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","both","","","1277.50","958.12","WELLPOINT [1015]","HB AMC WELLPOINT","942.54","73.78","","286.63","119.22","1107.45","105","396.03","1015.61","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","AETNA [1001]","HB AMC AETNA HMO","891.70","69.8","","675.31","184.75","1721.50","286","667.62","1043.97","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","AETNA [1001]","HB AMC AETNA PPO","1027.11","80.4","","1261.44","103.12","1514.10","21","667.62","1043.97","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1027.11","80.4","","1365.00","1365.00","1365.00","1 through 10","667.62","1043.97","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1043.97","81.72","","5157.68","5157.68","5157.68","1 through 10","667.62","1043.97","percent of total billed charges",""
"SPINAL PLATE 5MM MED ROI-A VERTEBRIDGE","SUP-ITM-10088571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1277.50","958.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1043.97","81.72","","431.26","71.26","1459.57","88","667.62","1043.97","percent of total billed charges",""
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","","","","inpatient","","","152724.08","114543.06","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","32445.84","","Case rate ($31,500.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $37,843.36, add-ons for qualifying new technology services are included. If operating cost exceeds $83,487.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,185.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,375.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,463.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,745.17. The transfer capital threshold is the transfer adjustment factor * $2,745.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","31681.02","31681.02","31681.02","1 through 10","30870.8","50655.9597","other","Inpatient DRG"
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","","","","inpatient","","","152724.08","114543.06","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","40769.52","","Case rate ($40,769.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $37,843.36, add-ons for qualifying new technology services are included. If operating cost exceeds $83,487.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,185.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,644.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,463.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,745.17. The transfer capital threshold is the transfer adjustment factor * $2,745.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30402.53","30402.53","30402.53","1 through 10","30870.8","50655.9597","other","Inpatient DRG"
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","","","","inpatient","","","152724.08","114543.06","MEDICARE [2001]","HB BWH MEDICARE","40769.52","","Case rate ($40,769.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $37,843.36, add-ons for qualifying new technology services are included. If operating cost exceeds $83,487.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,185.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $37,644.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,463.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,745.17. The transfer capital threshold is the transfer adjustment factor * $2,745.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","39850.94","0.03","39910.12","17","30870.8","50655.9597","other","Inpatient DRG"
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","","","","inpatient","","","152724.08","114543.06","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","30870.80","","Case rate ($31,500.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $37,843.36, add-ons for qualifying new technology services are included. If operating cost exceeds $83,487.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,185.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,375.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,463.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,745.17. The transfer capital threshold is the transfer adjustment factor * $2,745.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","30322.78","30322.78","30322.78","1 through 10","30870.8","50655.9597","other","Inpatient DRG"
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","","","","inpatient","","","152724.08","114543.06","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","30870.80","","Case rate ($31,500.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $37,843.36, add-ons for qualifying new technology services are included. If operating cost exceeds $83,487.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,185.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $28,375.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $37,463.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,745.17. The transfer capital threshold is the transfer adjustment factor * $2,745.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","27769.22","27769.22","27769.22","1 through 10","30870.8","50655.9597","other","Inpatient DRG"
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","TRIS-DRG","","","","","","","","inpatient","","","217192.77","","TRICARE [160005]","HB BWH TRICARE","21005.59","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($36,897.51). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $5,765.24, and the first day is paid a rate of $29,979.22. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $11,530.47, and the first day is paid a rate of $23,060.94. The transfer payment is capped at $26,556.43. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $80,624.51 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a special pay post-acute discharge disposition, the outlier threshold is multiplied by (((LOS / 3.20000004768372) + 1) * 0.5). For stays with a transfer discharge disposition, the outlier threshold is multiplied by (LOS / 3.20000004768372). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: , capped at $26,556.43. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $5,765.24, and the first day is paid a rate of $29,979.22. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $11,530.47, and the first day is paid a rate of $23,060.94. The transfer payment is capped at $26,556.43. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $80,624.51 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a special pay post-acute discharge disposition, the outlier threshold is multiplied by (((LOS / 3.20000004768372) + 1) * 0.5). For stays with a transfer discharge disposition, the outlier threshold is multiplied by (LOS / 3.20000004768372). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","40971.87","40971.87","40971.87","1 through 10","21005.59","21005.59","other","Inpatient DRGs"
"Spinal Procedures With McC","028","MS-DRG","","","","","","","","inpatient","","","287917.72","215938.29","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56843.84","","Case rate ($55,188.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $66,358.28, add-ons for qualifying new technology services are included. If operating cost exceeds $112,002.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,274.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $49,973.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,978.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,834.63. The transfer capital threshold is the transfer adjustment factor * $4,834.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","57196.42","57196.42","57196.42","1 through 10","54084.43","91745.7345","other","Inpatient DRG"
"Spinal Procedures With McC","028","MS-DRG","","","","","","","","inpatient","","","287917.72","215938.29","MEDICARE [2001]","HB BWH MEDICARE","71511.66","","Case rate ($71,511.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $66,358.28, add-ons for qualifying new technology services are included. If operating cost exceeds $112,002.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,274.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $66,297.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,978.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,834.63. The transfer capital threshold is the transfer adjustment factor * $4,834.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","71950.43","71950.43","72057.64","12","54084.43","91745.7345","other","Inpatient DRG"
"Spinal Procedures With McC","028","MS-DRG","","","","","","","","inpatient","","","287917.72","215938.29","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","54084.43","","Case rate ($55,188.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $66,358.28, add-ons for qualifying new technology services are included. If operating cost exceeds $112,002.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,274.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $49,973.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,978.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,834.63. The transfer capital threshold is the transfer adjustment factor * $4,834.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","74297.90","74297.90","74297.90","1 through 10","54084.43","91745.7345","other","Inpatient DRG"
"Spinal Procedures With McC","028","MS-DRG","","","","","","","","inpatient","","","287917.72","215938.29","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","54084.43","","Case rate ($55,188.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $66,358.28, add-ons for qualifying new technology services are included. If operating cost exceeds $112,002.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,274.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.5. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 9.5)) / 2. The base transfer operating payment is the transfer adjustment factor * $49,973.72 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $65,978.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,834.63. The transfer capital threshold is the transfer adjustment factor * $4,834.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","32938.47","32938.47","32938.47","1 through 10","54084.43","91745.7345","other","Inpatient DRG"
"Spinal Procedures Without Cc/McC","030","MS-DRG","","","","","","","","inpatient","","","112549.74","84412.30","MEDICARE [2001]","HB BWH MEDICARE","20404.69","","Case rate ($20,404.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $24,485.80, add-ons for qualifying new technology services are included. If operating cost exceeds $70,130.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,206.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,258.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,105.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,766.39. The transfer capital threshold is the transfer adjustment factor * $1,766.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26513.88","26513.88","26513.88","1 through 10","19996.6","33583.5114","other","Inpatient Replacement Plans DRG"
"Spinal Procedures,EXTREME","023","DRG","","","","","","","","inpatient","","","503682.24","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","186419.99","","Standard inlier is a Case rate ($186,419.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $156,616, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($26,463.44) for the length of stay and the standard reimbursement.","169928.61","169928.61","169928.61","1 through 10","16960.71","308460.35","case rate",""
"Spinal Procedures,EXTREME","023","DRG","","","","","","","","inpatient","","","503682.24","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","209586.31","","Standard inlier is a Case rate ($209,586.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $156,616, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($29,749.04) for the length of stay and the standard reimbursement.","221809.90","221809.90","221809.90","1 through 10","16960.71","308460.35","case rate",""
"Spinal Procedures,EXTREME","023","DRG","","","","","","","","inpatient","","","503682.24","","MASSHEALTH [3001]","HB BWH MEDICAID","50909.54","","Case rate ($56,289.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $98,719.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $12,984.07 and the sum of the standard inlier and any outlier amount.","66537.87","66537.87","66537.87","1 through 10","16960.71","308460.35","case rate",""
"Spinal Procedures,MAJOR","023","DRG","","","","","","","","inpatient","","","235459.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","114551.82","","Standard inlier is a Case rate ($114,551.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $100,728, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,261.32) for the length of stay and the standard reimbursement.","114551.82","114551.82","114551.82","1 through 10","16960.71","308460.35","case rate",""
"Spinal Procedures,MAJOR","023","DRG","","","","","","","","inpatient","","","235459.06","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","128787.12","","Standard inlier is a Case rate ($128,787.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $100,728, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,280.26) for the length of stay and the standard reimbursement.","128787.12","128787.12","128787.12","1 through 10","16960.71","308460.35","case rate",""
"Spinal Procedures,MAJOR","023","DRG","","","","","","","","inpatient","","","235459.06","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","39533.9838","","Fee schedule rate ($88,408.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","39533.9838","84997.88","84997.88","1 through 10","16960.71","308460.35","case rate",""
"Spinal Procedures,MAJOR","023","DRG","","","","","","","","inpatient","","","235459.06","","MASSHEALTH [3001]","HB BWH MEDICAID","37984.81","","Case rate ($41,998.74). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $84,428.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $6,185.38 and the sum of the standard inlier and any outlier amount.","44508.04","44508.04","44508.04","1 through 10","16960.71","308460.35","case rate",""
"Spinal Procedures,MINOR","023","DRG","","","","","","","","inpatient","","","112549.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","49601.39","","Standard inlier is a Case rate ($49,601.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,219, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,041.22) for the length of stay and the standard reimbursement.","45429.87","45429.87","45429.87","1 through 10","16960.71","308460.35","case rate",""
"Spinal Procedures,MINOR","023","DRG","","","","","","","","inpatient","","","112549.74","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","55765.33","","Standard inlier is a Case rate ($55,765.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,219, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,915.43) for the length of stay and the standard reimbursement.","50959.14","50959.14","50959.14","1 through 10","16960.71","308460.35","case rate",""
"Spinal Procedures,MINOR","023","DRG","","","","","","","","inpatient","","","112549.74","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37650.3711","","Fee schedule rate ($37,650.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37650.3711","37650.36","37650.36","1 through 10","16960.71","308460.35","case rate",""
"Spinal Procedures,MODERATE","023","DRG","","","","","","","","inpatient","","","132183.42","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","68000.19","","Standard inlier is a Case rate ($68,000.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $64,527, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,653.04) for the length of stay and the standard reimbursement.","61984.64","61984.64","68000.18","1 through 10","16960.71","308460.35","case rate",""
"Spinal Procedures,MODERATE","023","DRG","","","","","","","","inpatient","","","132183.42","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","76450.54","","Standard inlier is a Case rate ($76,450.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $64,527, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,851.52) for the length of stay and the standard reimbursement.","69844.16","69844.16","69844.16","1 through 10","16960.71","308460.35","case rate",""
"Spinal Procedures,MODERATE","023","DRG","","","","","","","","inpatient","","","132183.42","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","37650.3711","","Fee schedule rate ($48,502.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","37650.3711","48502.84","48502.84","1 through 10","16960.71","308460.35","case rate",""
"Spinal Procedures,MODERATE","023","DRG","","","","","","","","inpatient","","","132183.42","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64890.15","","Fee schedule rate ($64,890.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","64890.15","64890.15","64890.15","1 through 10","16960.71","308460.35","case rate",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","1309.77","674.56","6049.93","26","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","1901.83","1901.83","2962.25","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","1620.31","1620.31","19908.88","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","352.91","352.91","2046.30","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","9668.75","9668.75","9668.75","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","699.88","384.10","3443.31","33","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","1421.24","264.50","4933.46","29","438.98","686.45","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1022.97","1022.97","3607.50","1 through 10","438.98","686.45","percent of total billed charges",""
"SPINAL ROD 3.5X40MM LINEUM HF OFFSET TITANIUM","SUP-ITM-10108104","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","3010.54","693.88","5019.88","35","438.98","686.45","percent of total billed charges",""
"SPINAL ROD 3.5X5.5MM 75DEG FIXATION LINEUM COBALT OCCIPITAL PRECONTOURED","SUP-ITM-10108117","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","1309.77","674.56","6049.93","26","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 3.5X5.5MM 75DEG FIXATION LINEUM COBALT OCCIPITAL PRECONTOURED","SUP-ITM-10108117","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","1901.83","1901.83","2962.25","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 3.5X5.5MM 75DEG FIXATION LINEUM COBALT OCCIPITAL PRECONTOURED","SUP-ITM-10108117","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","1620.31","1620.31","19908.88","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 3.5X5.5MM 75DEG FIXATION LINEUM COBALT OCCIPITAL PRECONTOURED","SUP-ITM-10108117","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","352.91","352.91","2046.30","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 3.5X5.5MM 75DEG FIXATION LINEUM COBALT OCCIPITAL PRECONTOURED","SUP-ITM-10108117","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","9668.75","9668.75","9668.75","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 3.5X5.5MM 75DEG FIXATION LINEUM COBALT OCCIPITAL PRECONTOURED","SUP-ITM-10108117","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","699.88","384.10","3443.31","33","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 3.5X5.5MM 75DEG FIXATION LINEUM COBALT OCCIPITAL PRECONTOURED","SUP-ITM-10108117","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","1421.24","264.50","4933.46","29","438.98","686.45","percent of total billed charges",""
"SPINAL ROD 3.5X5.5MM 75DEG FIXATION LINEUM COBALT OCCIPITAL PRECONTOURED","SUP-ITM-10108117","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1022.97","1022.97","3607.50","1 through 10","438.98","686.45","percent of total billed charges",""
"SPINAL ROD 3.5X5.5MM 75DEG FIXATION LINEUM COBALT OCCIPITAL PRECONTOURED","SUP-ITM-10108117","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","3010.54","693.88","5019.88","35","438.98","686.45","percent of total billed charges",""
"SPINAL ROD 4X100MM PRE-BENT RELINE-C TI","SUP-ITM-10310465","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","800.18","480.96","1887.97","195","162.75","417.38","percent of total billed charges",""
"SPINAL ROD 4X100MM PRE-BENT RELINE-C TI","SUP-ITM-10310465","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","813.12","216.42","1444.50","81","162.75","417.38","percent of total billed charges",""
"SPINAL ROD 4X100MM PRE-BENT RELINE-C TI","SUP-ITM-10310465","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.75","31","","432.60","432.60","432.60","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINAL ROD 4X100MM PRE-BENT RELINE-C TI","SUP-ITM-10310465","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","148.37","54.89","631.39","94","162.75","417.38","percent of total billed charges",""
"SPINAL ROD 4X100MM PRE-BENT RELINE-C TI","SUP-ITM-10310465","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","279.30","91.72","1116.77","266","162.75","417.38","percent of total billed charges",""
"SPINAL ROD 4X100MM PRE-BENT RELINE-C TI","SUP-ITM-10310465","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","731.00","63.70","731.00","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINAL ROD 4X100MM PRE-BENT RELINE-C TI","SUP-ITM-10310465","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","384.74","384.74","384.74","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINAL ROD 4X100MM PRE-BENT RELINE-C TI","SUP-ITM-10310465","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","286.63","119.22","1107.45","105","162.75","417.38","percent of total billed charges",""
"SPINAL ROD 4X100MM PRE-BENT RELINE-C TI","SUP-ITM-10310465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","675.31","184.75","1721.50","286","274.37","429.03","percent of total billed charges",""
"SPINAL ROD 4X100MM PRE-BENT RELINE-C TI","SUP-ITM-10310465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA PPO","422.10","80.4","","1261.44","103.12","1514.10","21","274.37","429.03","percent of total billed charges",""
"SPINAL ROD 4X100MM PRE-BENT RELINE-C TI","SUP-ITM-10310465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1365.00","1365.00","1365.00","1 through 10","274.37","429.03","percent of total billed charges",""
"SPINAL ROD 4X100MM PRE-BENT RELINE-C TI","SUP-ITM-10310465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","429.03","81.72","","5157.68","5157.68","5157.68","1 through 10","274.37","429.03","percent of total billed charges",""
"SPINAL ROD 4X100MM PRE-BENT RELINE-C TI","SUP-ITM-10310465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","431.26","71.26","1459.57","88","274.37","429.03","percent of total billed charges",""
"SPINAL ROD 5.5X150MM STRAIGHT MIS CREO TITANIUM ALLOY","SUP-ITM-10316514","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","800.18","480.96","1887.97","195","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 5.5X150MM STRAIGHT MIS CREO TITANIUM ALLOY","SUP-ITM-10316514","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","813.12","216.42","1444.50","81","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 5.5X150MM STRAIGHT MIS CREO TITANIUM ALLOY","SUP-ITM-10316514","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","260.40","31","","432.60","432.60","432.60","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 5.5X150MM STRAIGHT MIS CREO TITANIUM ALLOY","SUP-ITM-10316514","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","148.37","54.89","631.39","94","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 5.5X150MM STRAIGHT MIS CREO TITANIUM ALLOY","SUP-ITM-10316514","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","279.30","91.72","1116.77","266","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 5.5X150MM STRAIGHT MIS CREO TITANIUM ALLOY","SUP-ITM-10316514","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","731.00","63.70","731.00","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 5.5X150MM STRAIGHT MIS CREO TITANIUM ALLOY","SUP-ITM-10316514","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","384.74","384.74","384.74","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 5.5X150MM STRAIGHT MIS CREO TITANIUM ALLOY","SUP-ITM-10316514","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","286.63","119.22","1107.45","105","260.4","667.8","percent of total billed charges",""
"SPINAL ROD 5.5X150MM STRAIGHT MIS CREO TITANIUM ALLOY","SUP-ITM-10316514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","675.31","184.75","1721.50","286","438.98","686.45","percent of total billed charges",""
"SPINAL ROD 5.5X150MM STRAIGHT MIS CREO TITANIUM ALLOY","SUP-ITM-10316514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA PPO","675.36","80.4","","1261.44","103.12","1514.10","21","438.98","686.45","percent of total billed charges",""
"SPINAL ROD 5.5X150MM STRAIGHT MIS CREO TITANIUM ALLOY","SUP-ITM-10316514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1365.00","1365.00","1365.00","1 through 10","438.98","686.45","percent of total billed charges",""
"SPINAL ROD 5.5X150MM STRAIGHT MIS CREO TITANIUM ALLOY","SUP-ITM-10316514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","686.45","81.72","","5157.68","5157.68","5157.68","1 through 10","438.98","686.45","percent of total billed charges",""
"SPINAL ROD 5.5X150MM STRAIGHT MIS CREO TITANIUM ALLOY","SUP-ITM-10316514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","431.26","71.26","1459.57","88","438.98","686.45","percent of total billed charges",""
"SPINAL ROD 6.35 120MM BONE SPINE STRAIGHT HEX EXPEDIUM SS","SUP-ITM-10046462","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1349.51","79.5","","1309.77","674.56","6049.93","26","526.23","1349.51","percent of total billed charges",""
"SPINAL ROD 6.35 120MM BONE SPINE STRAIGHT HEX EXPEDIUM SS","SUP-ITM-10046462","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","904.77","53.3","","1901.83","1901.83","2962.25","1 through 10","526.23","1349.51","percent of total billed charges",""
"SPINAL ROD 6.35 120MM BONE SPINE STRAIGHT HEX EXPEDIUM SS","SUP-ITM-10046462","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","619.59","36.5","","1620.31","1620.31","19908.88","1 through 10","526.23","1349.51","percent of total billed charges",""
"SPINAL ROD 6.35 120MM BONE SPINE STRAIGHT HEX EXPEDIUM SS","SUP-ITM-10046462","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","650.14","38.3","","352.91","352.91","2046.30","1 through 10","526.23","1349.51","percent of total billed charges",""
"SPINAL ROD 6.35 120MM BONE SPINE STRAIGHT HEX EXPEDIUM SS","SUP-ITM-10046462","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.23","42.9","","9668.75","9668.75","9668.75","1 through 10","526.23","1349.51","percent of total billed charges",""
"SPINAL ROD 6.35 120MM BONE SPINE STRAIGHT HEX EXPEDIUM SS","SUP-ITM-10046462","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","WELLPOINT [1015]","HB AMC WELLPOINT","1252.42","73.78","","699.88","384.10","3443.31","33","526.23","1349.51","percent of total billed charges",""
"SPINAL ROD 6.35 120MM BONE SPINE STRAIGHT HEX EXPEDIUM SS","SUP-ITM-10046462","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","AETNA [1001]","HB AMC AETNA HMO","1184.86","69.8","","1421.24","264.50","4933.46","29","887.11","1387.2","percent of total billed charges",""
"SPINAL ROD 6.35 120MM BONE SPINE STRAIGHT HEX EXPEDIUM SS","SUP-ITM-10046462","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1364.79","80.4","","1022.97","1022.97","3607.50","1 through 10","887.11","1387.2","percent of total billed charges",""
"SPINAL ROD 6.35 120MM BONE SPINE STRAIGHT HEX EXPEDIUM SS","SUP-ITM-10046462","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1387.20","81.72","","3010.54","693.88","5019.88","35","887.11","1387.2","percent of total billed charges",""
"SPINAL ROD 6X350MM DUAL BEND TITANIUM","SUP-ITM-10285769","CDM","C1713","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4293.00","79.5","","800.18","480.96","1887.97","195","1674","4293","percent of total billed charges",""
"SPINAL ROD 6X350MM DUAL BEND TITANIUM","SUP-ITM-10285769","CDM","C1713","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2878.20","53.3","","813.12","216.42","1444.50","81","1674","4293","percent of total billed charges",""
"SPINAL ROD 6X350MM DUAL BEND TITANIUM","SUP-ITM-10285769","CDM","C1713","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1674.00","31","","432.60","432.60","432.60","1 through 10","1674","4293","percent of total billed charges",""
"SPINAL ROD 6X350MM DUAL BEND TITANIUM","SUP-ITM-10285769","CDM","C1713","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1971.00","36.5","","148.37","54.89","631.39","94","1674","4293","percent of total billed charges",""
"SPINAL ROD 6X350MM DUAL BEND TITANIUM","SUP-ITM-10285769","CDM","C1713","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2068.20","38.3","","279.30","91.72","1116.77","266","1674","4293","percent of total billed charges",""
"SPINAL ROD 6X350MM DUAL BEND TITANIUM","SUP-ITM-10285769","CDM","C1713","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","731.00","63.70","731.00","1 through 10","1674","4293","percent of total billed charges",""
"SPINAL ROD 6X350MM DUAL BEND TITANIUM","SUP-ITM-10285769","CDM","C1713","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","384.74","384.74","384.74","1 through 10","1674","4293","percent of total billed charges",""
"SPINAL ROD 6X350MM DUAL BEND TITANIUM","SUP-ITM-10285769","CDM","C1713","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB AMC WELLPOINT","3984.12","73.78","","286.63","119.22","1107.45","105","1674","4293","percent of total billed charges",""
"SPINAL ROD 6X350MM DUAL BEND TITANIUM","SUP-ITM-10285769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA HMO","3769.20","69.8","","675.31","184.75","1721.50","286","2822.04","4412.88","percent of total billed charges",""
"SPINAL ROD 6X350MM DUAL BEND TITANIUM","SUP-ITM-10285769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA PPO","4341.60","80.4","","1261.44","103.12","1514.10","21","2822.04","4412.88","percent of total billed charges",""
"SPINAL ROD 6X350MM DUAL BEND TITANIUM","SUP-ITM-10285769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4341.60","80.4","","1365.00","1365.00","1365.00","1 through 10","2822.04","4412.88","percent of total billed charges",""
"SPINAL ROD 6X350MM DUAL BEND TITANIUM","SUP-ITM-10285769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4412.88","81.72","","5157.68","5157.68","5157.68","1 through 10","2822.04","4412.88","percent of total billed charges",""
"SPINAL ROD 6X350MM DUAL BEND TITANIUM","SUP-ITM-10285769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4412.88","81.72","","431.26","71.26","1459.57","88","2822.04","4412.88","percent of total billed charges",""
"SPINAL SHANK 5.5X45MM THREAD ATS","SUP-ITM-10307414","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1808.63","79.5","","800.18","480.96","1887.97","195","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 5.5X45MM THREAD ATS","SUP-ITM-10307414","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1212.58","53.3","","813.12","216.42","1444.50","81","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 5.5X45MM THREAD ATS","SUP-ITM-10307414","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","705.25","31","","432.60","432.60","432.60","1 through 10","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 5.5X45MM THREAD ATS","SUP-ITM-10307414","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","830.38","36.5","","148.37","54.89","631.39","94","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 5.5X45MM THREAD ATS","SUP-ITM-10307414","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","871.33","38.3","","279.30","91.72","1116.77","266","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 5.5X45MM THREAD ATS","SUP-ITM-10307414","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","975.98","42.9","","731.00","63.70","731.00","1 through 10","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 5.5X45MM THREAD ATS","SUP-ITM-10307414","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","975.98","42.9","","384.74","384.74","384.74","1 through 10","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 5.5X45MM THREAD ATS","SUP-ITM-10307414","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","WELLPOINT [1015]","HB AMC WELLPOINT","1678.50","73.78","","286.63","119.22","1107.45","105","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 5.5X45MM THREAD ATS","SUP-ITM-10307414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","AETNA [1001]","HB AMC AETNA HMO","1587.95","69.8","","675.31","184.75","1721.50","286","1188.92","1859.13","percent of total billed charges",""
"SPINAL SHANK 5.5X45MM THREAD ATS","SUP-ITM-10307414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","AETNA [1001]","HB AMC AETNA PPO","1829.10","80.4","","1261.44","103.12","1514.10","21","1188.92","1859.13","percent of total billed charges",""
"SPINAL SHANK 5.5X45MM THREAD ATS","SUP-ITM-10307414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1829.10","80.4","","1365.00","1365.00","1365.00","1 through 10","1188.92","1859.13","percent of total billed charges",""
"SPINAL SHANK 5.5X45MM THREAD ATS","SUP-ITM-10307414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1859.13","81.72","","5157.68","5157.68","5157.68","1 through 10","1188.92","1859.13","percent of total billed charges",""
"SPINAL SHANK 5.5X45MM THREAD ATS","SUP-ITM-10307414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1859.13","81.72","","431.26","71.26","1459.57","88","1188.92","1859.13","percent of total billed charges",""
"SPINAL SHANK 7.5X45MM THREAD ATS","SUP-ITM-10307404","CDM","C1889","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1808.63","79.5","","1309.77","674.56","6049.93","26","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X45MM THREAD ATS","SUP-ITM-10307404","CDM","C1889","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1212.58","53.3","","1901.83","1901.83","2962.25","1 through 10","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X45MM THREAD ATS","SUP-ITM-10307404","CDM","C1889","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","830.38","36.5","","1620.31","1620.31","19908.88","1 through 10","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X45MM THREAD ATS","SUP-ITM-10307404","CDM","C1889","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","871.33","38.3","","352.91","352.91","2046.30","1 through 10","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X45MM THREAD ATS","SUP-ITM-10307404","CDM","C1889","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","975.98","42.9","","9668.75","9668.75","9668.75","1 through 10","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X45MM THREAD ATS","SUP-ITM-10307404","CDM","C1889","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","WELLPOINT [1015]","HB AMC WELLPOINT","1678.50","73.78","","699.88","384.10","3443.31","33","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X45MM THREAD ATS","SUP-ITM-10307404","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","AETNA [1001]","HB AMC AETNA HMO","1587.95","69.8","","1421.24","264.50","4933.46","29","1188.92","1859.13","percent of total billed charges",""
"SPINAL SHANK 7.5X45MM THREAD ATS","SUP-ITM-10307404","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1829.10","80.4","","1022.97","1022.97","3607.50","1 through 10","1188.92","1859.13","percent of total billed charges",""
"SPINAL SHANK 7.5X45MM THREAD ATS","SUP-ITM-10307404","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1859.13","81.72","","3010.54","693.88","5019.88","35","1188.92","1859.13","percent of total billed charges",""
"SPINAL SHANK 7.5X50MM THREAD ATS","SUP-ITM-10307403","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1808.63","79.5","","800.18","480.96","1887.97","195","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X50MM THREAD ATS","SUP-ITM-10307403","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1212.58","53.3","","813.12","216.42","1444.50","81","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X50MM THREAD ATS","SUP-ITM-10307403","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","705.25","31","","432.60","432.60","432.60","1 through 10","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X50MM THREAD ATS","SUP-ITM-10307403","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","830.38","36.5","","148.37","54.89","631.39","94","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X50MM THREAD ATS","SUP-ITM-10307403","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","871.33","38.3","","279.30","91.72","1116.77","266","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X50MM THREAD ATS","SUP-ITM-10307403","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","975.98","42.9","","731.00","63.70","731.00","1 through 10","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X50MM THREAD ATS","SUP-ITM-10307403","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","975.98","42.9","","384.74","384.74","384.74","1 through 10","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X50MM THREAD ATS","SUP-ITM-10307403","CDM","C1713","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","WELLPOINT [1015]","HB AMC WELLPOINT","1678.50","73.78","","286.63","119.22","1107.45","105","705.25","1808.63","percent of total billed charges",""
"SPINAL SHANK 7.5X50MM THREAD ATS","SUP-ITM-10307403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","AETNA [1001]","HB AMC AETNA HMO","1587.95","69.8","","675.31","184.75","1721.50","286","1188.92","1859.13","percent of total billed charges",""
"SPINAL SHANK 7.5X50MM THREAD ATS","SUP-ITM-10307403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","AETNA [1001]","HB AMC AETNA PPO","1829.10","80.4","","1261.44","103.12","1514.10","21","1188.92","1859.13","percent of total billed charges",""
"SPINAL SHANK 7.5X50MM THREAD ATS","SUP-ITM-10307403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1829.10","80.4","","1365.00","1365.00","1365.00","1 through 10","1188.92","1859.13","percent of total billed charges",""
"SPINAL SHANK 7.5X50MM THREAD ATS","SUP-ITM-10307403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1859.13","81.72","","5157.68","5157.68","5157.68","1 through 10","1188.92","1859.13","percent of total billed charges",""
"SPINAL SHANK 7.5X50MM THREAD ATS","SUP-ITM-10307403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1859.13","81.72","","431.26","71.26","1459.57","88","1188.92","1859.13","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","1309.77","674.56","6049.93","26","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.85","53.3","","1901.83","1901.83","2962.25","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","1620.31","1620.31","19908.88","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","352.91","352.91","2046.30","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","9668.75","9668.75","9668.75","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","699.88","384.10","3443.31","33","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","1421.24","264.50","4933.46","29","1280.37","2002.14","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.80","80.4","","1022.97","1022.97","3607.50","1 through 10","1280.37","2002.14","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","3010.54","693.88","5019.88","35","1280.37","2002.14","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","1309.77","674.56","6049.93","26","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.85","53.3","","1901.83","1901.83","2962.25","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","1620.31","1620.31","19908.88","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","352.91","352.91","2046.30","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","9668.75","9668.75","9668.75","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","699.88","384.10","3443.31","33","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","1421.24","264.50","4933.46","29","1280.37","2002.14","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.80","80.4","","1022.97","1022.97","3607.50","1 through 10","1280.37","2002.14","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","3010.54","693.88","5019.88","35","1280.37","2002.14","percent of total billed charges",""
"SPINAL SPACER 12MM 12DEG LUMBAR PEEK SOLITAIRE NARROW","SUP-ITM-10036257","CDM","C1889","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7353.75","79.5","","1309.77","674.56","6049.93","26","2867.5","7353.75","percent of total billed charges",""
"SPINAL SPACER 12MM 12DEG LUMBAR PEEK SOLITAIRE NARROW","SUP-ITM-10036257","CDM","C1889","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4930.25","53.3","","1901.83","1901.83","2962.25","1 through 10","2867.5","7353.75","percent of total billed charges",""
"SPINAL SPACER 12MM 12DEG LUMBAR PEEK SOLITAIRE NARROW","SUP-ITM-10036257","CDM","C1889","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3376.25","36.5","","1620.31","1620.31","19908.88","1 through 10","2867.5","7353.75","percent of total billed charges",""
"SPINAL SPACER 12MM 12DEG LUMBAR PEEK SOLITAIRE NARROW","SUP-ITM-10036257","CDM","C1889","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3542.75","38.3","","352.91","352.91","2046.30","1 through 10","2867.5","7353.75","percent of total billed charges",""
"SPINAL SPACER 12MM 12DEG LUMBAR PEEK SOLITAIRE NARROW","SUP-ITM-10036257","CDM","C1889","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3968.25","42.9","","9668.75","9668.75","9668.75","1 through 10","2867.5","7353.75","percent of total billed charges",""
"SPINAL SPACER 12MM 12DEG LUMBAR PEEK SOLITAIRE NARROW","SUP-ITM-10036257","CDM","C1889","HCPCS","0278","RC","","","","both","","","9250.00","6937.50","WELLPOINT [1015]","HB AMC WELLPOINT","6824.65","73.78","","699.88","384.10","3443.31","33","2867.5","7353.75","percent of total billed charges",""
"SPINAL SPACER 12MM 12DEG LUMBAR PEEK SOLITAIRE NARROW","SUP-ITM-10036257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9250.00","6937.50","AETNA [1001]","HB AMC AETNA HMO","6456.50","69.8","","1421.24","264.50","4933.46","29","4834.05","7559.1","percent of total billed charges",""
"SPINAL SPACER 12MM 12DEG LUMBAR PEEK SOLITAIRE NARROW","SUP-ITM-10036257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9250.00","6937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7437.00","80.4","","1022.97","1022.97","3607.50","1 through 10","4834.05","7559.1","percent of total billed charges",""
"SPINAL SPACER 12MM 12DEG LUMBAR PEEK SOLITAIRE NARROW","SUP-ITM-10036257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9250.00","6937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7559.10","81.72","","3010.54","693.88","5019.88","35","4834.05","7559.1","percent of total billed charges",""
"SPINAL SPACER 18X50MM 7-14MM RISE-L","SUP-ITM-10314456","CDM","C1889","HCPCS","0278","RC","","","","both","","","11500.00","8625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9142.50","79.5","","1309.77","674.56","6049.93","26","3565","9142.5","percent of total billed charges",""
"SPINAL SPACER 18X50MM 7-14MM RISE-L","SUP-ITM-10314456","CDM","C1889","HCPCS","0278","RC","","","","both","","","11500.00","8625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6129.50","53.3","","1901.83","1901.83","2962.25","1 through 10","3565","9142.5","percent of total billed charges",""
"SPINAL SPACER 18X50MM 7-14MM RISE-L","SUP-ITM-10314456","CDM","C1889","HCPCS","0278","RC","","","","both","","","11500.00","8625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4197.50","36.5","","1620.31","1620.31","19908.88","1 through 10","3565","9142.5","percent of total billed charges",""
"SPINAL SPACER 18X50MM 7-14MM RISE-L","SUP-ITM-10314456","CDM","C1889","HCPCS","0278","RC","","","","both","","","11500.00","8625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4404.50","38.3","","352.91","352.91","2046.30","1 through 10","3565","9142.5","percent of total billed charges",""
"SPINAL SPACER 18X50MM 7-14MM RISE-L","SUP-ITM-10314456","CDM","C1889","HCPCS","0278","RC","","","","both","","","11500.00","8625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4933.50","42.9","","9668.75","9668.75","9668.75","1 through 10","3565","9142.5","percent of total billed charges",""
"SPINAL SPACER 18X50MM 7-14MM RISE-L","SUP-ITM-10314456","CDM","C1889","HCPCS","0278","RC","","","","both","","","11500.00","8625.00","WELLPOINT [1015]","HB AMC WELLPOINT","8484.70","73.78","","699.88","384.10","3443.31","33","3565","9142.5","percent of total billed charges",""
"SPINAL SPACER 18X50MM 7-14MM RISE-L","SUP-ITM-10314456","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11500.00","8625.00","AETNA [1001]","HB AMC AETNA HMO","8027.00","69.8","","1421.24","264.50","4933.46","29","6009.9","9397.8","percent of total billed charges",""
"SPINAL SPACER 18X50MM 7-14MM RISE-L","SUP-ITM-10314456","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11500.00","8625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9246.00","80.4","","1022.97","1022.97","3607.50","1 through 10","6009.9","9397.8","percent of total billed charges",""
"SPINAL SPACER 18X50MM 7-14MM RISE-L","SUP-ITM-10314456","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11500.00","8625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9397.80","81.72","","3010.54","693.88","5019.88","35","6009.9","9397.8","percent of total billed charges",""
"SPINAL SPACER 5MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048664","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","1309.77","674.56","6049.93","26","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 5MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048664","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.85","53.3","","1901.83","1901.83","2962.25","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 5MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048664","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","1620.31","1620.31","19908.88","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 5MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048664","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","352.91","352.91","2046.30","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 5MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048664","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","9668.75","9668.75","9668.75","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 5MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048664","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","699.88","384.10","3443.31","33","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 5MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048664","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","1421.24","264.50","4933.46","29","1280.37","2002.14","percent of total billed charges",""
"SPINAL SPACER 5MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048664","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.80","80.4","","1022.97","1022.97","3607.50","1 through 10","1280.37","2002.14","percent of total billed charges",""
"SPINAL SPACER 5MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048664","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","3010.54","693.88","5019.88","35","1280.37","2002.14","percent of total billed charges",""
"SPINAL SPACER 7MM CATALYFT PL LONG","SUP-ITM-10307453","CDM","C1821","HCPCS","0278","RC","","","","both","","","13000.00","9750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10335.00","79.5","","9828.00","9828.00","9828.00","1 through 10","4030","12350","percent of total billed charges",""
"SPINAL SPACER 7MM CATALYFT PL LONG","SUP-ITM-10307453","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","13000.00","9750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10623.60","81.72","","1958.53","1886.75","1958.53","1 through 10","6793.8","10623.6","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","1309.77","674.56","6049.93","26","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.85","53.3","","1901.83","1901.83","2962.25","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","1620.31","1620.31","19908.88","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","352.91","352.91","2046.30","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","9668.75","9668.75","9668.75","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","699.88","384.10","3443.31","33","759.5","1947.75","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","1421.24","264.50","4933.46","29","1280.37","2002.14","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.80","80.4","","1022.97","1022.97","3607.50","1 through 10","1280.37","2002.14","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","3010.54","693.88","5019.88","35","1280.37","2002.14","percent of total billed charges",""
"SPINAL SPACER 9MM CATALYFT PL40 LONG","SUP-ITM-10307445","CDM","C1889","HCPCS","0278","RC","","","","both","","","13000.00","9750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10335.00","79.5","","1309.77","674.56","6049.93","26","4030","10335","percent of total billed charges",""
"SPINAL SPACER 9MM CATALYFT PL40 LONG","SUP-ITM-10307445","CDM","C1889","HCPCS","0278","RC","","","","both","","","13000.00","9750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6929.00","53.3","","1901.83","1901.83","2962.25","1 through 10","4030","10335","percent of total billed charges",""
"SPINAL SPACER 9MM CATALYFT PL40 LONG","SUP-ITM-10307445","CDM","C1889","HCPCS","0278","RC","","","","both","","","13000.00","9750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4745.00","36.5","","1620.31","1620.31","19908.88","1 through 10","4030","10335","percent of total billed charges",""
"SPINAL SPACER 9MM CATALYFT PL40 LONG","SUP-ITM-10307445","CDM","C1889","HCPCS","0278","RC","","","","both","","","13000.00","9750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4979.00","38.3","","352.91","352.91","2046.30","1 through 10","4030","10335","percent of total billed charges",""
"SPINAL SPACER 9MM CATALYFT PL40 LONG","SUP-ITM-10307445","CDM","C1889","HCPCS","0278","RC","","","","both","","","13000.00","9750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5577.00","42.9","","9668.75","9668.75","9668.75","1 through 10","4030","10335","percent of total billed charges",""
"SPINAL SPACER 9MM CATALYFT PL40 LONG","SUP-ITM-10307445","CDM","C1889","HCPCS","0278","RC","","","","both","","","13000.00","9750.00","WELLPOINT [1015]","HB AMC WELLPOINT","9591.40","73.78","","699.88","384.10","3443.31","33","4030","10335","percent of total billed charges",""
"SPINAL SPACER 9MM CATALYFT PL40 LONG","SUP-ITM-10307445","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13000.00","9750.00","AETNA [1001]","HB AMC AETNA HMO","9074.00","69.8","","1421.24","264.50","4933.46","29","6793.8","10623.6","percent of total billed charges",""
"SPINAL SPACER 9MM CATALYFT PL40 LONG","SUP-ITM-10307445","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13000.00","9750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10452.00","80.4","","1022.97","1022.97","3607.50","1 through 10","6793.8","10623.6","percent of total billed charges",""
"SPINAL SPACER 9MM CATALYFT PL40 LONG","SUP-ITM-10307445","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13000.00","9750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10623.60","81.72","","3010.54","693.88","5019.88","35","6793.8","10623.6","percent of total billed charges",""
"SPINAL SPACER 9MM SHORT CATALYFT PL","SUP-ITM-10307452","CDM","C1889","HCPCS","0278","RC","","","","both","","","13000.00","9750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10335.00","79.5","","1309.77","674.56","6049.93","26","4030","10335","percent of total billed charges",""
"SPINAL SPACER 9MM SHORT CATALYFT PL","SUP-ITM-10307452","CDM","C1889","HCPCS","0278","RC","","","","both","","","13000.00","9750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6929.00","53.3","","1901.83","1901.83","2962.25","1 through 10","4030","10335","percent of total billed charges",""
"SPINAL SPACER 9MM SHORT CATALYFT PL","SUP-ITM-10307452","CDM","C1889","HCPCS","0278","RC","","","","both","","","13000.00","9750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4745.00","36.5","","1620.31","1620.31","19908.88","1 through 10","4030","10335","percent of total billed charges",""
"SPINAL SPACER 9MM SHORT CATALYFT PL","SUP-ITM-10307452","CDM","C1889","HCPCS","0278","RC","","","","both","","","13000.00","9750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4979.00","38.3","","352.91","352.91","2046.30","1 through 10","4030","10335","percent of total billed charges",""
"SPINAL SPACER 9MM SHORT CATALYFT PL","SUP-ITM-10307452","CDM","C1889","HCPCS","0278","RC","","","","both","","","13000.00","9750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5577.00","42.9","","9668.75","9668.75","9668.75","1 through 10","4030","10335","percent of total billed charges",""
"SPINAL SPACER 9MM SHORT CATALYFT PL","SUP-ITM-10307452","CDM","C1889","HCPCS","0278","RC","","","","both","","","13000.00","9750.00","WELLPOINT [1015]","HB AMC WELLPOINT","9591.40","73.78","","699.88","384.10","3443.31","33","4030","10335","percent of total billed charges",""
"SPINAL SPACER 9MM SHORT CATALYFT PL","SUP-ITM-10307452","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13000.00","9750.00","AETNA [1001]","HB AMC AETNA HMO","9074.00","69.8","","1421.24","264.50","4933.46","29","6793.8","10623.6","percent of total billed charges",""
"SPINAL SPACER 9MM SHORT CATALYFT PL","SUP-ITM-10307452","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13000.00","9750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10452.00","80.4","","1022.97","1022.97","3607.50","1 through 10","6793.8","10623.6","percent of total billed charges",""
"SPINAL SPACER 9MM SHORT CATALYFT PL","SUP-ITM-10307452","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13000.00","9750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10623.60","81.72","","3010.54","693.88","5019.88","35","6793.8","10623.6","percent of total billed charges",""
"SPINAL SPACER SZ12 COFLEX INTERLAMINAR TITANIUM","SUP-ITM-10175721","CDM","C1821","HCPCS","0278","RC","","","","both","","","12250.00","9187.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9738.75","79.5","","9828.00","9828.00","9828.00","1 through 10","3797.5","11637.5","percent of total billed charges",""
"SPINAL SPACER SZ12 COFLEX INTERLAMINAR TITANIUM","SUP-ITM-10175721","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","12250.00","9187.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10010.70","81.72","","1958.53","1886.75","1958.53","1 through 10","6401.85","10010.7","percent of total billed charges",""
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","both","","","724.00","543.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","224.44","575.58","other","OPPS APC"
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","both","","","724.00","543.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","224.44","575.58","other","OPPS APC"
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","both","","","724.00","543.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","385.89","53.3","","477.31","477.31","477.31","1 through 10","224.44","575.58","percent of total billed charges",""
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","both","","","724.00","543.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","224.44","575.58","other","OPPS APC"
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","both","","","724.00","543.00","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","224.44","575.58","other","OPPS APC"
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","both","","","724.00","543.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","264.26","36.5","","1095.87","337.19","1095.87","1 through 10","224.44","575.58","percent of total billed charges",""
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","both","","","724.00","543.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","277.29","38.3","","343.52","323.76","353.46","1 through 10","224.44","575.58","percent of total billed charges",""
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","both","","","724.00","543.00","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","224.44","575.58","other","Tricare OPPS"
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","both","","","724.00","543.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","224.44","575.58","other","OPPS APC"
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","both","","","724.00","543.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","224.44","575.58","other","OPPS APC"
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","both","","","724.00","543.00","WELLPOINT [1015]","HB AMC WELLPOINT","534.17","73.78","","673.03","673.03","673.03","1 through 10","224.44","575.58","percent of total billed charges",""
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","outpatient","","","724.00","543.00","AETNA [1001]","HB AMC AETNA HMO","505.35","69.8","","612.01","612.01","1224.02","1 through 10","362","700.33","percent of total billed charges",""
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","outpatient","","","724.00","543.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","438.38","60.55","","579.04","568.57","904.00","30","362","700.33","percent of total billed charges",""
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","outpatient","","","724.00","543.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","378.07","52.22","","904.00","656.02","2938.00","26","362","700.33","percent of total billed charges",""
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","outpatient","","","724.00","543.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","362.00","50","","1421.10","875.08","2368.50","15","362","700.33","percent of total billed charges",""
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","outpatient","","","724.00","543.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","380.10","52.5","","2985.00","904.00","2985.00","1 through 10","362","700.33","percent of total billed charges",""
"Spinal Synovial Cyst Aspiration","PX-76002609","CDM","64999","CPT","0761","RC","","","","outpatient","","","724.00","543.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","591.65","81.72","","722.66","722.66","17449.00","1 through 10","362","700.33","percent of total billed charges",""
"SPINE CAGE 10X10X30MM 12DEG MODULUS TLIF-O","SUP-ITM-10212235","CDM","C1821","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5962.50","79.5","","9828.00","9828.00","9828.00","1 through 10","2325","7125","percent of total billed charges",""
"SPINE CAGE 10X10X30MM 12DEG MODULUS TLIF-O","SUP-ITM-10212235","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6129.00","81.72","","1958.53","1886.75","1958.53","1 through 10","3919.5","6129","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4372.50","79.5","","1309.77","674.56","6049.93","26","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2931.50","53.3","","1901.83","1901.83","2962.25","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2007.50","36.5","","1620.31","1620.31","19908.88","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2106.50","38.3","","352.91","352.91","2046.30","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2359.50","42.9","","9668.75","9668.75","9668.75","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","WELLPOINT [1015]","HB AMC WELLPOINT","4057.90","73.78","","699.88","384.10","3443.31","33","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","AETNA [1001]","HB AMC AETNA HMO","3839.00","69.8","","1421.24","264.50","4933.46","29","2874.3","4494.6","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4422.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2874.3","4494.6","percent of total billed charges",""
"SPINE CAGE 10X10X30MM LUMBAR TRANSFORAMINAL TI OBLIQUE FUSION 12DEG","SUP-ITM-10188007","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4494.60","81.72","","3010.54","693.88","5019.88","35","2874.3","4494.6","percent of total billed charges",""
"SPINE CAGE 10X18X55MM 10DEG MODULUS XL","SUP-ITM-10212298","CDM","C1821","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7403.44","79.5","","9828.00","9828.00","9828.00","1 through 10","2886.88","8846.88","percent of total billed charges",""
"SPINE CAGE 10X18X55MM 10DEG MODULUS XL","SUP-ITM-10212298","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","9312.50","6984.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7610.18","81.72","","1958.53","1886.75","1958.53","1 through 10","4866.71","7610.18","percent of total billed charges",""
"SPINE CAGE 10X30MM DEVICE FUSION INTERBOXY PYRAMESH TI MESH ROUND","SUP-ITM-10019750","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6161.25","79.5","","1309.77","674.56","6049.93","26","2402.5","6161.25","percent of total billed charges",""
"SPINE CAGE 10X30MM DEVICE FUSION INTERBOXY PYRAMESH TI MESH ROUND","SUP-ITM-10019750","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4130.75","53.3","","1901.83","1901.83","2962.25","1 through 10","2402.5","6161.25","percent of total billed charges",""
"SPINE CAGE 10X30MM DEVICE FUSION INTERBOXY PYRAMESH TI MESH ROUND","SUP-ITM-10019750","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2828.75","36.5","","1620.31","1620.31","19908.88","1 through 10","2402.5","6161.25","percent of total billed charges",""
"SPINE CAGE 10X30MM DEVICE FUSION INTERBOXY PYRAMESH TI MESH ROUND","SUP-ITM-10019750","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2968.25","38.3","","352.91","352.91","2046.30","1 through 10","2402.5","6161.25","percent of total billed charges",""
"SPINE CAGE 10X30MM DEVICE FUSION INTERBOXY PYRAMESH TI MESH ROUND","SUP-ITM-10019750","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3324.75","42.9","","9668.75","9668.75","9668.75","1 through 10","2402.5","6161.25","percent of total billed charges",""
"SPINE CAGE 10X30MM DEVICE FUSION INTERBOXY PYRAMESH TI MESH ROUND","SUP-ITM-10019750","CDM","C1889","HCPCS","0278","RC","","","","both","","","7750.00","5812.50","WELLPOINT [1015]","HB AMC WELLPOINT","5717.95","73.78","","699.88","384.10","3443.31","33","2402.5","6161.25","percent of total billed charges",""
"SPINE CAGE 10X30MM DEVICE FUSION INTERBOXY PYRAMESH TI MESH ROUND","SUP-ITM-10019750","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","AETNA [1001]","HB AMC AETNA HMO","5409.50","69.8","","1421.24","264.50","4933.46","29","4050.15","6333.3","percent of total billed charges",""
"SPINE CAGE 10X30MM DEVICE FUSION INTERBOXY PYRAMESH TI MESH ROUND","SUP-ITM-10019750","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6231.00","80.4","","1022.97","1022.97","3607.50","1 through 10","4050.15","6333.3","percent of total billed charges",""
"SPINE CAGE 10X30MM DEVICE FUSION INTERBOXY PYRAMESH TI MESH ROUND","SUP-ITM-10019750","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7750.00","5812.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6333.30","81.72","","3010.54","693.88","5019.88","35","4050.15","6333.3","percent of total billed charges",""
"SPINE CAGE 11MM 12DEG 26/9 IBF UI H","SUP-ITM-10243876","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","1309.77","674.56","6049.93","26","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 12DEG 26/9 IBF UI H","SUP-ITM-10243876","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2665.00","53.3","","1901.83","1901.83","2962.25","1 through 10","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 12DEG 26/9 IBF UI H","SUP-ITM-10243876","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 12DEG 26/9 IBF UI H","SUP-ITM-10243876","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","352.91","352.91","2046.30","1 through 10","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 12DEG 26/9 IBF UI H","SUP-ITM-10243876","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","9668.75","9668.75","9668.75","1 through 10","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 12DEG 26/9 IBF UI H","SUP-ITM-10243876","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","699.88","384.10","3443.31","33","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 12DEG 26/9 IBF UI H","SUP-ITM-10243876","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","1421.24","264.50","4933.46","29","2613","4086","percent of total billed charges",""
"SPINE CAGE 11MM 12DEG 26/9 IBF UI H","SUP-ITM-10243876","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4020.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2613","4086","percent of total billed charges",""
"SPINE CAGE 11MM 12DEG 26/9 IBF UI H","SUP-ITM-10243876","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","3010.54","693.88","5019.88","35","2613","4086","percent of total billed charges",""
"SPINE CAGE 11MM 4DEG 22/9 IBF UI H","SUP-ITM-10243895","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","800.18","480.96","1887.97","195","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 4DEG 22/9 IBF UI H","SUP-ITM-10243895","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2665.00","53.3","","813.12","216.42","1444.50","81","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 4DEG 22/9 IBF UI H","SUP-ITM-10243895","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1550.00","31","","432.60","432.60","432.60","1 through 10","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 4DEG 22/9 IBF UI H","SUP-ITM-10243895","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","148.37","54.89","631.39","94","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 4DEG 22/9 IBF UI H","SUP-ITM-10243895","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","279.30","91.72","1116.77","266","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 4DEG 22/9 IBF UI H","SUP-ITM-10243895","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","731.00","63.70","731.00","1 through 10","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 4DEG 22/9 IBF UI H","SUP-ITM-10243895","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","384.74","384.74","384.74","1 through 10","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 4DEG 22/9 IBF UI H","SUP-ITM-10243895","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","286.63","119.22","1107.45","105","1550","3975","percent of total billed charges",""
"SPINE CAGE 11MM 4DEG 22/9 IBF UI H","SUP-ITM-10243895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","675.31","184.75","1721.50","286","2613","4086","percent of total billed charges",""
"SPINE CAGE 11MM 4DEG 22/9 IBF UI H","SUP-ITM-10243895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA PPO","4020.00","80.4","","1261.44","103.12","1514.10","21","2613","4086","percent of total billed charges",""
"SPINE CAGE 11MM 4DEG 22/9 IBF UI H","SUP-ITM-10243895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4020.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2613","4086","percent of total billed charges",""
"SPINE CAGE 11MM 4DEG 22/9 IBF UI H","SUP-ITM-10243895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4086.00","81.72","","5157.68","5157.68","5157.68","1 through 10","2613","4086","percent of total billed charges",""
"SPINE CAGE 11MM 4DEG 22/9 IBF UI H","SUP-ITM-10243895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","431.26","71.26","1459.57","88","2613","4086","percent of total billed charges",""
"SPINE CAGE 12MM 55/18 8DEG LUMBAR LLIF CONDUIT H","SUP-ITM-10269870","CDM","C1821","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7403.44","79.5","","9828.00","9828.00","9828.00","1 through 10","2886.88","8846.88","percent of total billed charges",""
"SPINE CAGE 12MM 55/18 8DEG LUMBAR LLIF CONDUIT H","SUP-ITM-10269870","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","9312.50","6984.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7610.18","81.72","","1958.53","1886.75","1958.53","1 through 10","4866.71","7610.18","percent of total billed charges",""
"SPINE CAGE 12X10X30MM 4DEG MODULUS TLIF-O","SUP-ITM-10212225","CDM","C1821","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5962.50","79.5","","9828.00","9828.00","9828.00","1 through 10","2325","7125","percent of total billed charges",""
"SPINE CAGE 12X10X30MM 4DEG MODULUS TLIF-O","SUP-ITM-10212225","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6129.00","81.72","","1958.53","1886.75","1958.53","1 through 10","3919.5","6129","percent of total billed charges",""
"SPINE CAGE 12X22X55MM 15DEG MODULUS XLW","SUP-ITM-10212253","CDM","C1821","HCPCS","0278","RC","","","","both","","","11500.00","8625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9142.50","79.5","","9828.00","9828.00","9828.00","1 through 10","3565","10925","percent of total billed charges",""
"SPINE CAGE 12X22X55MM 15DEG MODULUS XLW","SUP-ITM-10212253","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","11500.00","8625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9397.80","81.72","","1958.53","1886.75","1958.53","1 through 10","6009.9","9397.8","percent of total billed charges",""
"SPINE CAGE 12X9X30MM 8DEG COROENT ANT TLIF PEEK","SUP-ITM-10252345","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","1309.77","674.56","6049.93","26","1550","3975","percent of total billed charges",""
"SPINE CAGE 12X9X30MM 8DEG COROENT ANT TLIF PEEK","SUP-ITM-10252345","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2665.00","53.3","","1901.83","1901.83","2962.25","1 through 10","1550","3975","percent of total billed charges",""
"SPINE CAGE 12X9X30MM 8DEG COROENT ANT TLIF PEEK","SUP-ITM-10252345","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1550","3975","percent of total billed charges",""
"SPINE CAGE 12X9X30MM 8DEG COROENT ANT TLIF PEEK","SUP-ITM-10252345","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","352.91","352.91","2046.30","1 through 10","1550","3975","percent of total billed charges",""
"SPINE CAGE 12X9X30MM 8DEG COROENT ANT TLIF PEEK","SUP-ITM-10252345","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","9668.75","9668.75","9668.75","1 through 10","1550","3975","percent of total billed charges",""
"SPINE CAGE 12X9X30MM 8DEG COROENT ANT TLIF PEEK","SUP-ITM-10252345","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","699.88","384.10","3443.31","33","1550","3975","percent of total billed charges",""
"SPINE CAGE 12X9X30MM 8DEG COROENT ANT TLIF PEEK","SUP-ITM-10252345","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","1421.24","264.50","4933.46","29","2613","4086","percent of total billed charges",""
"SPINE CAGE 12X9X30MM 8DEG COROENT ANT TLIF PEEK","SUP-ITM-10252345","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4020.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2613","4086","percent of total billed charges",""
"SPINE CAGE 12X9X30MM 8DEG COROENT ANT TLIF PEEK","SUP-ITM-10252345","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","3010.54","693.88","5019.88","35","2613","4086","percent of total billed charges",""
"SPINE CAGE 13X16MM 18-21MM 0DEG 0-20DEG CAPRI SMALL CERVICAL EXPANDABLE 3D CORPECTOMY WITH SET SCREW","SUP-ITM-10253766","CDM","C1821","HCPCS","0278","RC","","","","both","","","10562.50","7921.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8397.19","79.5","","9828.00","9828.00","9828.00","1 through 10","3274.38","10034.38","percent of total billed charges",""
"SPINE CAGE 13X16MM 18-21MM 0DEG 0-20DEG CAPRI SMALL CERVICAL EXPANDABLE 3D CORPECTOMY WITH SET SCREW","SUP-ITM-10253766","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","10562.50","7921.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8631.68","81.72","","1958.53","1886.75","1958.53","1 through 10","5519.96","8631.68","percent of total billed charges",""
"SPINE CAGE 13X16MM 38-54MM 5DEG 0-20DEG CAPRI SMALL CERVICAL EXPANDABLE 3D CORPECTOMY WITH SET SCREW","SUP-ITM-10253761","CDM","C1821","HCPCS","0278","RC","","","","both","","","10562.50","7921.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8397.19","79.5","","9828.00","9828.00","9828.00","1 through 10","3274.38","10034.38","percent of total billed charges",""
"SPINE CAGE 13X16MM 38-54MM 5DEG 0-20DEG CAPRI SMALL CERVICAL EXPANDABLE 3D CORPECTOMY WITH SET SCREW","SUP-ITM-10253761","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","10562.50","7921.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8631.68","81.72","","1958.53","1886.75","1958.53","1 through 10","5519.96","8631.68","percent of total billed charges",""
"SPINE CAGE 18X32MM INTERBODY FUSION VLIFT TITANIUM EXPANSION ANTERIOR LUMBAR","SUP-ITM-10020894","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5962.50","79.5","","1309.77","674.56","6049.93","26","2325","5962.5","percent of total billed charges",""
"SPINE CAGE 18X32MM INTERBODY FUSION VLIFT TITANIUM EXPANSION ANTERIOR LUMBAR","SUP-ITM-10020894","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3997.50","53.3","","1901.83","1901.83","2962.25","1 through 10","2325","5962.5","percent of total billed charges",""
"SPINE CAGE 18X32MM INTERBODY FUSION VLIFT TITANIUM EXPANSION ANTERIOR LUMBAR","SUP-ITM-10020894","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2737.50","36.5","","1620.31","1620.31","19908.88","1 through 10","2325","5962.5","percent of total billed charges",""
"SPINE CAGE 18X32MM INTERBODY FUSION VLIFT TITANIUM EXPANSION ANTERIOR LUMBAR","SUP-ITM-10020894","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2872.50","38.3","","352.91","352.91","2046.30","1 through 10","2325","5962.5","percent of total billed charges",""
"SPINE CAGE 18X32MM INTERBODY FUSION VLIFT TITANIUM EXPANSION ANTERIOR LUMBAR","SUP-ITM-10020894","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3217.50","42.9","","9668.75","9668.75","9668.75","1 through 10","2325","5962.5","percent of total billed charges",""
"SPINE CAGE 18X32MM INTERBODY FUSION VLIFT TITANIUM EXPANSION ANTERIOR LUMBAR","SUP-ITM-10020894","CDM","C1889","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","WELLPOINT [1015]","HB AMC WELLPOINT","5533.50","73.78","","699.88","384.10","3443.31","33","2325","5962.5","percent of total billed charges",""
"SPINE CAGE 18X32MM INTERBODY FUSION VLIFT TITANIUM EXPANSION ANTERIOR LUMBAR","SUP-ITM-10020894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","AETNA [1001]","HB AMC AETNA HMO","5235.00","69.8","","1421.24","264.50","4933.46","29","3919.5","6129","percent of total billed charges",""
"SPINE CAGE 18X32MM INTERBODY FUSION VLIFT TITANIUM EXPANSION ANTERIOR LUMBAR","SUP-ITM-10020894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6030.00","80.4","","1022.97","1022.97","3607.50","1 through 10","3919.5","6129","percent of total billed charges",""
"SPINE CAGE 18X32MM INTERBODY FUSION VLIFT TITANIUM EXPANSION ANTERIOR LUMBAR","SUP-ITM-10020894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6129.00","81.72","","3010.54","693.88","5019.88","35","3919.5","6129","percent of total billed charges",""
"SPINE CAGE 21X25MM 25-270DEG CAPRI CORPECTOMY HOUSING EXTERNAL HOUSING","SUP-ITM-10254727","CDM","C1821","HCPCS","0278","RC","","","","both","","","10562.50","7921.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8397.19","79.5","","9828.00","9828.00","9828.00","1 through 10","3274.38","10034.38","percent of total billed charges",""
"SPINE CAGE 21X25MM 25-270DEG CAPRI CORPECTOMY HOUSING EXTERNAL HOUSING","SUP-ITM-10254727","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","10562.50","7921.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8631.68","81.72","","1958.53","1886.75","1958.53","1 through 10","5519.96","8631.68","percent of total billed charges",""
"SPINE CAGE 23X31MM SM 5DEG IMPLANT OPEN WITH ENDPLATE TITANIUM SYNEX","SUP-ITM-10007175","CDM","C1821","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7850.63","79.5","","9828.00","9828.00","9828.00","1 through 10","3061.25","9381.25","percent of total billed charges",""
"SPINE CAGE 23X31MM SM 5DEG IMPLANT OPEN WITH ENDPLATE TITANIUM SYNEX","SUP-ITM-10007175","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","9875.00","7406.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8069.85","81.72","","1958.53","1886.75","1958.53","1 through 10","5160.68","8069.85","percent of total billed charges",""
"SPINE CAGE 24X11MM LUMBAR SURGICAL TITANIUM","SUP-ITM-10175780","CDM","C1821","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","9828.00","9828.00","9828.00","1 through 10","1550","4750","percent of total billed charges",""
"SPINE CAGE 24X11MM LUMBAR SURGICAL TITANIUM","SUP-ITM-10175780","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","1958.53","1886.75","1958.53","1 through 10","2613","4086","percent of total billed charges",""
"SPINE CAGE 36X56MM SM 5DEG SYNEX TITANIUM ANTERIOR THOROCOLUMBAR MINUS","SUP-ITM-10018944","CDM","C1821","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7850.63","79.5","","9828.00","9828.00","9828.00","1 through 10","3061.25","9381.25","percent of total billed charges",""
"SPINE CAGE 36X56MM SM 5DEG SYNEX TITANIUM ANTERIOR THOROCOLUMBAR MINUS","SUP-ITM-10018944","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","9875.00","7406.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8069.85","81.72","","1958.53","1886.75","1958.53","1 through 10","5160.68","8069.85","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","1309.77","674.56","6049.93","26","759.5","1947.75","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.85","53.3","","1901.83","1901.83","2962.25","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","1620.31","1620.31","19908.88","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","352.91","352.91","2046.30","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","9668.75","9668.75","9668.75","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","699.88","384.10","3443.31","33","759.5","1947.75","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","1421.24","264.50","4933.46","29","1280.37","2002.14","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.80","80.4","","1022.97","1022.97","3607.50","1 through 10","1280.37","2002.14","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","3010.54","693.88","5019.88","35","1280.37","2002.14","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3875.63","79.5","","1309.77","674.56","6049.93","26","1511.25","3875.63","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2598.38","53.3","","1901.83","1901.83","2962.25","1 through 10","1511.25","3875.63","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1779.38","36.5","","1620.31","1620.31","19908.88","1 through 10","1511.25","3875.63","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1867.13","38.3","","352.91","352.91","2046.30","1 through 10","1511.25","3875.63","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2091.38","42.9","","9668.75","9668.75","9668.75","1 through 10","1511.25","3875.63","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","both","","","4875.00","3656.25","WELLPOINT [1015]","HB AMC WELLPOINT","3596.78","73.78","","699.88","384.10","3443.31","33","1511.25","3875.63","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4875.00","3656.25","AETNA [1001]","HB AMC AETNA HMO","3402.75","69.8","","1421.24","264.50","4933.46","29","2547.68","3983.85","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4875.00","3656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3919.50","80.4","","1022.97","1022.97","3607.50","1 through 10","2547.68","3983.85","percent of total billed charges",""
"SPINE CAGE 6.0X17 14MM COROENT SI LORDOTIC","SUP-ITM-10086907","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4875.00","3656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3983.85","81.72","","3010.54","693.88","5019.88","35","2547.68","3983.85","percent of total billed charges",""
"SPINE CAGE 6X16 25MM XL COROENT PEEK THORACIC","SUP-ITM-10088614","CDM","C1889","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8514.45","79.5","","1309.77","674.56","6049.93","26","3320.1","8514.45","percent of total billed charges",""
"SPINE CAGE 6X16 25MM XL COROENT PEEK THORACIC","SUP-ITM-10088614","CDM","C1889","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5708.43","53.3","","1901.83","1901.83","2962.25","1 through 10","3320.1","8514.45","percent of total billed charges",""
"SPINE CAGE 6X16 25MM XL COROENT PEEK THORACIC","SUP-ITM-10088614","CDM","C1889","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3909.15","36.5","","1620.31","1620.31","19908.88","1 through 10","3320.1","8514.45","percent of total billed charges",""
"SPINE CAGE 6X16 25MM XL COROENT PEEK THORACIC","SUP-ITM-10088614","CDM","C1889","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4101.93","38.3","","352.91","352.91","2046.30","1 through 10","3320.1","8514.45","percent of total billed charges",""
"SPINE CAGE 6X16 25MM XL COROENT PEEK THORACIC","SUP-ITM-10088614","CDM","C1889","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","9668.75","9668.75","9668.75","1 through 10","3320.1","8514.45","percent of total billed charges",""
"SPINE CAGE 6X16 25MM XL COROENT PEEK THORACIC","SUP-ITM-10088614","CDM","C1889","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","WELLPOINT [1015]","HB AMC WELLPOINT","7901.84","73.78","","699.88","384.10","3443.31","33","3320.1","8514.45","percent of total billed charges",""
"SPINE CAGE 6X16 25MM XL COROENT PEEK THORACIC","SUP-ITM-10088614","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA HMO","7475.58","69.8","","1421.24","264.50","4933.46","29","5597.05","8752.21","percent of total billed charges",""
"SPINE CAGE 6X16 25MM XL COROENT PEEK THORACIC","SUP-ITM-10088614","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8610.84","80.4","","1022.97","1022.97","3607.50","1 through 10","5597.05","8752.21","percent of total billed charges",""
"SPINE CAGE 6X16 25MM XL COROENT PEEK THORACIC","SUP-ITM-10088614","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8752.21","81.72","","3010.54","693.88","5019.88","35","5597.05","8752.21","percent of total billed charges",""
"SPINE CAGE 7MM 8DEG CERVICAL CIF","SUP-ITM-10243866","CDM","C1821","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","9828.00","9828.00","9828.00","1 through 10","922.25","2826.25","percent of total billed charges",""
"SPINE CAGE 7MM 8DEG CERVICAL CIF","SUP-ITM-10243866","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","1958.53","1886.75","1958.53","1 through 10","1554.74","2431.17","percent of total billed charges",""
"SPINE CAGE 8X10X25MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187735","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4372.50","79.5","","800.18","480.96","1887.97","195","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X25MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187735","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2931.50","53.3","","813.12","216.42","1444.50","81","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X25MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187735","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1705.00","31","","432.60","432.60","432.60","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X25MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187735","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2007.50","36.5","","148.37","54.89","631.39","94","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X25MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187735","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2106.50","38.3","","279.30","91.72","1116.77","266","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X25MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187735","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2359.50","42.9","","731.00","63.70","731.00","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X25MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187735","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2359.50","42.9","","384.74","384.74","384.74","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X25MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187735","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","WELLPOINT [1015]","HB AMC WELLPOINT","4057.90","73.78","","286.63","119.22","1107.45","105","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X25MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","AETNA [1001]","HB AMC AETNA HMO","3839.00","69.8","","675.31","184.75","1721.50","286","2874.3","4494.6","percent of total billed charges",""
"SPINE CAGE 8X10X25MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","AETNA [1001]","HB AMC AETNA PPO","4422.00","80.4","","1261.44","103.12","1514.10","21","2874.3","4494.6","percent of total billed charges",""
"SPINE CAGE 8X10X25MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4422.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2874.3","4494.6","percent of total billed charges",""
"SPINE CAGE 8X10X25MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4494.60","81.72","","5157.68","5157.68","5157.68","1 through 10","2874.3","4494.6","percent of total billed charges",""
"SPINE CAGE 8X10X25MM LUMBAR TRANSFORAMINAL TITANIUM OBLIQUE FUSION 4 DEG","SUP-ITM-10187735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4494.60","81.72","","431.26","71.26","1459.57","88","2874.3","4494.6","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158310","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4372.50","79.5","","800.18","480.96","1887.97","195","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158310","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2931.50","53.3","","813.12","216.42","1444.50","81","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158310","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1705.00","31","","432.60","432.60","432.60","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158310","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2007.50","36.5","","148.37","54.89","631.39","94","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158310","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2106.50","38.3","","279.30","91.72","1116.77","266","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158310","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2359.50","42.9","","731.00","63.70","731.00","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158310","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2359.50","42.9","","384.74","384.74","384.74","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158310","CDM","C1713","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","WELLPOINT [1015]","HB AMC WELLPOINT","4057.90","73.78","","286.63","119.22","1107.45","105","1705","4372.5","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","AETNA [1001]","HB AMC AETNA HMO","3839.00","69.8","","675.31","184.75","1721.50","286","2874.3","4494.6","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","AETNA [1001]","HB AMC AETNA PPO","4422.00","80.4","","1261.44","103.12","1514.10","21","2874.3","4494.6","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4422.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2874.3","4494.6","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4494.60","81.72","","5157.68","5157.68","5157.68","1 through 10","2874.3","4494.6","percent of total billed charges",""
"SPINE CAGE 8X10X30MM LUMBAR TRANSFORAMINAL OBLIQUE FUSION 4 DEG","SUP-ITM-10158310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4494.60","81.72","","431.26","71.26","1459.57","88","2874.3","4494.6","percent of total billed charges",""
"SPINE CAGE 9X17X14MM 7DEG MODULUS C","SUP-ITM-10212213","CDM","C1821","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","9828.00","9828.00","9828.00","1 through 10","759.5","2327.5","percent of total billed charges",""
"SPINE CAGE 9X17X14MM 7DEG MODULUS C","SUP-ITM-10212213","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","1958.53","1886.75","1958.53","1 through 10","1280.37","2002.14","percent of total billed charges",""
"SPINE CAGE H 22MM OD 13 CAP END SPINAL TITANIUM IMPL 13C T2 ALTITUDE CENTERPIECE","SUP-ITM-10111155","CDM","C1889","HCPCS","0278","RC","","","","both","","","9125.00","6843.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7254.38","79.5","","1309.77","674.56","6049.93","26","2828.75","7254.38","percent of total billed charges",""
"SPINE CAGE H 22MM OD 13 CAP END SPINAL TITANIUM IMPL 13C T2 ALTITUDE CENTERPIECE","SUP-ITM-10111155","CDM","C1889","HCPCS","0278","RC","","","","both","","","9125.00","6843.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4863.63","53.3","","1901.83","1901.83","2962.25","1 through 10","2828.75","7254.38","percent of total billed charges",""
"SPINE CAGE H 22MM OD 13 CAP END SPINAL TITANIUM IMPL 13C T2 ALTITUDE CENTERPIECE","SUP-ITM-10111155","CDM","C1889","HCPCS","0278","RC","","","","both","","","9125.00","6843.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3330.63","36.5","","1620.31","1620.31","19908.88","1 through 10","2828.75","7254.38","percent of total billed charges",""
"SPINE CAGE H 22MM OD 13 CAP END SPINAL TITANIUM IMPL 13C T2 ALTITUDE CENTERPIECE","SUP-ITM-10111155","CDM","C1889","HCPCS","0278","RC","","","","both","","","9125.00","6843.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3494.88","38.3","","352.91","352.91","2046.30","1 through 10","2828.75","7254.38","percent of total billed charges",""
"SPINE CAGE H 22MM OD 13 CAP END SPINAL TITANIUM IMPL 13C T2 ALTITUDE CENTERPIECE","SUP-ITM-10111155","CDM","C1889","HCPCS","0278","RC","","","","both","","","9125.00","6843.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3914.63","42.9","","9668.75","9668.75","9668.75","1 through 10","2828.75","7254.38","percent of total billed charges",""
"SPINE CAGE H 22MM OD 13 CAP END SPINAL TITANIUM IMPL 13C T2 ALTITUDE CENTERPIECE","SUP-ITM-10111155","CDM","C1889","HCPCS","0278","RC","","","","both","","","9125.00","6843.75","WELLPOINT [1015]","HB AMC WELLPOINT","6732.43","73.78","","699.88","384.10","3443.31","33","2828.75","7254.38","percent of total billed charges",""
"SPINE CAGE H 22MM OD 13 CAP END SPINAL TITANIUM IMPL 13C T2 ALTITUDE CENTERPIECE","SUP-ITM-10111155","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9125.00","6843.75","AETNA [1001]","HB AMC AETNA HMO","6369.25","69.8","","1421.24","264.50","4933.46","29","4768.73","7456.95","percent of total billed charges",""
"SPINE CAGE H 22MM OD 13 CAP END SPINAL TITANIUM IMPL 13C T2 ALTITUDE CENTERPIECE","SUP-ITM-10111155","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9125.00","6843.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7336.50","80.4","","1022.97","1022.97","3607.50","1 through 10","4768.73","7456.95","percent of total billed charges",""
"SPINE CAGE H 22MM OD 13 CAP END SPINAL TITANIUM IMPL 13C T2 ALTITUDE CENTERPIECE","SUP-ITM-10111155","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9125.00","6843.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7456.95","81.72","","3010.54","693.88","5019.88","35","4768.73","7456.95","percent of total billed charges",""
"SPINE CAGE SZ D 13MM CENTERPIECE","SUP-ITM-10258793","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10931.25","79.5","","1309.77","674.56","6049.93","26","4262.5","10931.25","percent of total billed charges",""
"SPINE CAGE SZ D 13MM CENTERPIECE","SUP-ITM-10258793","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7328.75","53.3","","1901.83","1901.83","2962.25","1 through 10","4262.5","10931.25","percent of total billed charges",""
"SPINE CAGE SZ D 13MM CENTERPIECE","SUP-ITM-10258793","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5018.75","36.5","","1620.31","1620.31","19908.88","1 through 10","4262.5","10931.25","percent of total billed charges",""
"SPINE CAGE SZ D 13MM CENTERPIECE","SUP-ITM-10258793","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5266.25","38.3","","352.91","352.91","2046.30","1 through 10","4262.5","10931.25","percent of total billed charges",""
"SPINE CAGE SZ D 13MM CENTERPIECE","SUP-ITM-10258793","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5898.75","42.9","","9668.75","9668.75","9668.75","1 through 10","4262.5","10931.25","percent of total billed charges",""
"SPINE CAGE SZ D 13MM CENTERPIECE","SUP-ITM-10258793","CDM","C1889","HCPCS","0278","RC","","","","both","","","13750.00","10312.50","WELLPOINT [1015]","HB AMC WELLPOINT","10144.75","73.78","","699.88","384.10","3443.31","33","4262.5","10931.25","percent of total billed charges",""
"SPINE CAGE SZ D 13MM CENTERPIECE","SUP-ITM-10258793","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13750.00","10312.50","AETNA [1001]","HB AMC AETNA HMO","9597.50","69.8","","1421.24","264.50","4933.46","29","7185.75","11236.5","percent of total billed charges",""
"SPINE CAGE SZ D 13MM CENTERPIECE","SUP-ITM-10258793","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13750.00","10312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11055.00","80.4","","1022.97","1022.97","3607.50","1 through 10","7185.75","11236.5","percent of total billed charges",""
"SPINE CAGE SZ D 13MM CENTERPIECE","SUP-ITM-10258793","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13750.00","10312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11236.50","81.72","","3010.54","693.88","5019.88","35","7185.75","11236.5","percent of total billed charges",""
"SPINE CONNECTOR 15MM OPEN OFFSET","SUP-ITM-10156077","CDM","C1889","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1224.30","79.5","","1309.77","674.56","6049.93","26","477.4","1224.3","percent of total billed charges",""
"SPINE CONNECTOR 15MM OPEN OFFSET","SUP-ITM-10156077","CDM","C1889","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","820.82","53.3","","1901.83","1901.83","2962.25","1 through 10","477.4","1224.3","percent of total billed charges",""
"SPINE CONNECTOR 15MM OPEN OFFSET","SUP-ITM-10156077","CDM","C1889","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","562.10","36.5","","1620.31","1620.31","19908.88","1 through 10","477.4","1224.3","percent of total billed charges",""
"SPINE CONNECTOR 15MM OPEN OFFSET","SUP-ITM-10156077","CDM","C1889","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","589.82","38.3","","352.91","352.91","2046.30","1 through 10","477.4","1224.3","percent of total billed charges",""
"SPINE CONNECTOR 15MM OPEN OFFSET","SUP-ITM-10156077","CDM","C1889","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","660.66","42.9","","9668.75","9668.75","9668.75","1 through 10","477.4","1224.3","percent of total billed charges",""
"SPINE CONNECTOR 15MM OPEN OFFSET","SUP-ITM-10156077","CDM","C1889","HCPCS","0278","RC","","","","both","","","1540.00","1155.00","WELLPOINT [1015]","HB AMC WELLPOINT","1136.21","73.78","","699.88","384.10","3443.31","33","477.4","1224.3","percent of total billed charges",""
"SPINE CONNECTOR 15MM OPEN OFFSET","SUP-ITM-10156077","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1540.00","1155.00","AETNA [1001]","HB AMC AETNA HMO","1074.92","69.8","","1421.24","264.50","4933.46","29","804.8","1258.49","percent of total billed charges",""
"SPINE CONNECTOR 15MM OPEN OFFSET","SUP-ITM-10156077","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1540.00","1155.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1238.16","80.4","","1022.97","1022.97","3607.50","1 through 10","804.8","1258.49","percent of total billed charges",""
"SPINE CONNECTOR 15MM OPEN OFFSET","SUP-ITM-10156077","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1540.00","1155.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1258.49","81.72","","3010.54","693.88","5019.88","35","804.8","1258.49","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 4MM ROD REDUCTION SYMPHONY OCT SYSTEM","SUP-ITM-10282901","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","834.75","79.5","","800.18","480.96","1887.97","195","325.5","834.75","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 4MM ROD REDUCTION SYMPHONY OCT SYSTEM","SUP-ITM-10282901","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","559.65","53.3","","813.12","216.42","1444.50","81","325.5","834.75","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 4MM ROD REDUCTION SYMPHONY OCT SYSTEM","SUP-ITM-10282901","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","325.50","31","","432.60","432.60","432.60","1 through 10","325.5","834.75","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 4MM ROD REDUCTION SYMPHONY OCT SYSTEM","SUP-ITM-10282901","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","148.37","54.89","631.39","94","325.5","834.75","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 4MM ROD REDUCTION SYMPHONY OCT SYSTEM","SUP-ITM-10282901","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","279.30","91.72","1116.77","266","325.5","834.75","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 4MM ROD REDUCTION SYMPHONY OCT SYSTEM","SUP-ITM-10282901","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","731.00","63.70","731.00","1 through 10","325.5","834.75","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 4MM ROD REDUCTION SYMPHONY OCT SYSTEM","SUP-ITM-10282901","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","384.74","384.74","384.74","1 through 10","325.5","834.75","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 4MM ROD REDUCTION SYMPHONY OCT SYSTEM","SUP-ITM-10282901","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB AMC WELLPOINT","774.69","73.78","","286.63","119.22","1107.45","105","325.5","834.75","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 4MM ROD REDUCTION SYMPHONY OCT SYSTEM","SUP-ITM-10282901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA HMO","732.90","69.8","","675.31","184.75","1721.50","286","548.73","858.06","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 4MM ROD REDUCTION SYMPHONY OCT SYSTEM","SUP-ITM-10282901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA PPO","844.20","80.4","","1261.44","103.12","1514.10","21","548.73","858.06","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 4MM ROD REDUCTION SYMPHONY OCT SYSTEM","SUP-ITM-10282901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","844.20","80.4","","1365.00","1365.00","1365.00","1 through 10","548.73","858.06","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 4MM ROD REDUCTION SYMPHONY OCT SYSTEM","SUP-ITM-10282901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","858.06","81.72","","5157.68","5157.68","5157.68","1 through 10","548.73","858.06","percent of total billed charges",""
"SPINE CONNECTOR 3.5 TO 4MM ROD REDUCTION SYMPHONY OCT SYSTEM","SUP-ITM-10282901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","858.06","81.72","","431.26","71.26","1459.57","88","548.73","858.06","percent of total billed charges",""
"SPINE CONNECTOR 3.5-4 TO 3.5-4 S PARALLEL","SUP-ITM-10243433","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","800.18","480.96","1887.97","195","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5-4 TO 3.5-4 S PARALLEL","SUP-ITM-10243433","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","813.12","216.42","1444.50","81","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5-4 TO 3.5-4 S PARALLEL","SUP-ITM-10243433","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.25","31","","432.60","432.60","432.60","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5-4 TO 3.5-4 S PARALLEL","SUP-ITM-10243433","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","148.37","54.89","631.39","94","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5-4 TO 3.5-4 S PARALLEL","SUP-ITM-10243433","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","279.30","91.72","1116.77","266","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5-4 TO 3.5-4 S PARALLEL","SUP-ITM-10243433","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","731.00","63.70","731.00","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5-4 TO 3.5-4 S PARALLEL","SUP-ITM-10243433","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","384.74","384.74","384.74","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5-4 TO 3.5-4 S PARALLEL","SUP-ITM-10243433","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","286.63","119.22","1107.45","105","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5-4 TO 3.5-4 S PARALLEL","SUP-ITM-10243433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","675.31","184.75","1721.50","286","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 3.5-4 TO 3.5-4 S PARALLEL","SUP-ITM-10243433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA PPO","703.50","80.4","","1261.44","103.12","1514.10","21","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 3.5-4 TO 3.5-4 S PARALLEL","SUP-ITM-10243433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1365.00","1365.00","1365.00","1 through 10","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 3.5-4 TO 3.5-4 S PARALLEL","SUP-ITM-10243433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","715.05","81.72","","5157.68","5157.68","5157.68","1 through 10","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 3.5-4 TO 3.5-4 S PARALLEL","SUP-ITM-10243433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","431.26","71.26","1459.57","88","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 3.5MM TI OPEN ROD PARALLEL","SUP-ITM-10033101","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","1309.77","674.56","6049.93","26","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5MM TI OPEN ROD PARALLEL","SUP-ITM-10033101","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","1901.83","1901.83","2962.25","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5MM TI OPEN ROD PARALLEL","SUP-ITM-10033101","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","1620.31","1620.31","19908.88","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5MM TI OPEN ROD PARALLEL","SUP-ITM-10033101","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","352.91","352.91","2046.30","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5MM TI OPEN ROD PARALLEL","SUP-ITM-10033101","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","9668.75","9668.75","9668.75","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5MM TI OPEN ROD PARALLEL","SUP-ITM-10033101","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","699.88","384.10","3443.31","33","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 3.5MM TI OPEN ROD PARALLEL","SUP-ITM-10033101","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","1421.24","264.50","4933.46","29","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 3.5MM TI OPEN ROD PARALLEL","SUP-ITM-10033101","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1022.97","1022.97","3607.50","1 through 10","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 3.5MM TI OPEN ROD PARALLEL","SUP-ITM-10033101","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","3010.54","693.88","5019.88","35","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 30 TO 42MM CROSS H2H","SUP-ITM-10243755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.50","1346.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1427.42","79.5","","800.18","480.96","1887.97","195","556.61","1427.42","percent of total billed charges",""
"SPINE CONNECTOR 30 TO 42MM CROSS H2H","SUP-ITM-10243755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.50","1346.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","957.00","53.3","","813.12","216.42","1444.50","81","556.61","1427.42","percent of total billed charges",""
"SPINE CONNECTOR 30 TO 42MM CROSS H2H","SUP-ITM-10243755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.50","1346.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","556.61","31","","432.60","432.60","432.60","1 through 10","556.61","1427.42","percent of total billed charges",""
"SPINE CONNECTOR 30 TO 42MM CROSS H2H","SUP-ITM-10243755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.50","1346.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","655.36","36.5","","148.37","54.89","631.39","94","556.61","1427.42","percent of total billed charges",""
"SPINE CONNECTOR 30 TO 42MM CROSS H2H","SUP-ITM-10243755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.50","1346.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","687.68","38.3","","279.30","91.72","1116.77","266","556.61","1427.42","percent of total billed charges",""
"SPINE CONNECTOR 30 TO 42MM CROSS H2H","SUP-ITM-10243755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.50","1346.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","770.27","42.9","","731.00","63.70","731.00","1 through 10","556.61","1427.42","percent of total billed charges",""
"SPINE CONNECTOR 30 TO 42MM CROSS H2H","SUP-ITM-10243755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.50","1346.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","770.27","42.9","","384.74","384.74","384.74","1 through 10","556.61","1427.42","percent of total billed charges",""
"SPINE CONNECTOR 30 TO 42MM CROSS H2H","SUP-ITM-10243755","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.50","1346.62","WELLPOINT [1015]","HB AMC WELLPOINT","1324.72","73.78","","286.63","119.22","1107.45","105","556.61","1427.42","percent of total billed charges",""
"SPINE CONNECTOR 30 TO 42MM CROSS H2H","SUP-ITM-10243755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1795.50","1346.62","AETNA [1001]","HB AMC AETNA HMO","1253.26","69.8","","675.31","184.75","1721.50","286","938.33","1467.28","percent of total billed charges",""
"SPINE CONNECTOR 30 TO 42MM CROSS H2H","SUP-ITM-10243755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1795.50","1346.62","AETNA [1001]","HB AMC AETNA PPO","1443.58","80.4","","1261.44","103.12","1514.10","21","938.33","1467.28","percent of total billed charges",""
"SPINE CONNECTOR 30 TO 42MM CROSS H2H","SUP-ITM-10243755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1795.50","1346.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1443.58","80.4","","1365.00","1365.00","1365.00","1 through 10","938.33","1467.28","percent of total billed charges",""
"SPINE CONNECTOR 30 TO 42MM CROSS H2H","SUP-ITM-10243755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1795.50","1346.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1467.28","81.72","","5157.68","5157.68","5157.68","1 through 10","938.33","1467.28","percent of total billed charges",""
"SPINE CONNECTOR 30 TO 42MM CROSS H2H","SUP-ITM-10243755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1795.50","1346.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1467.28","81.72","","431.26","71.26","1459.57","88","938.33","1467.28","percent of total billed charges",""
"SPINE CONNECTOR 40 TO 49MM CROSS R2R","SUP-ITM-10243762","CDM","C1713","HCPCS","0278","RC","","","","both","","","2244.38","1683.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1784.28","79.5","","800.18","480.96","1887.97","195","695.76","1784.28","percent of total billed charges",""
"SPINE CONNECTOR 40 TO 49MM CROSS R2R","SUP-ITM-10243762","CDM","C1713","HCPCS","0278","RC","","","","both","","","2244.38","1683.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1196.25","53.3","","813.12","216.42","1444.50","81","695.76","1784.28","percent of total billed charges",""
"SPINE CONNECTOR 40 TO 49MM CROSS R2R","SUP-ITM-10243762","CDM","C1713","HCPCS","0278","RC","","","","both","","","2244.38","1683.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","695.76","31","","432.60","432.60","432.60","1 through 10","695.76","1784.28","percent of total billed charges",""
"SPINE CONNECTOR 40 TO 49MM CROSS R2R","SUP-ITM-10243762","CDM","C1713","HCPCS","0278","RC","","","","both","","","2244.38","1683.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","819.20","36.5","","148.37","54.89","631.39","94","695.76","1784.28","percent of total billed charges",""
"SPINE CONNECTOR 40 TO 49MM CROSS R2R","SUP-ITM-10243762","CDM","C1713","HCPCS","0278","RC","","","","both","","","2244.38","1683.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","859.60","38.3","","279.30","91.72","1116.77","266","695.76","1784.28","percent of total billed charges",""
"SPINE CONNECTOR 40 TO 49MM CROSS R2R","SUP-ITM-10243762","CDM","C1713","HCPCS","0278","RC","","","","both","","","2244.38","1683.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","962.84","42.9","","731.00","63.70","731.00","1 through 10","695.76","1784.28","percent of total billed charges",""
"SPINE CONNECTOR 40 TO 49MM CROSS R2R","SUP-ITM-10243762","CDM","C1713","HCPCS","0278","RC","","","","both","","","2244.38","1683.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","962.84","42.9","","384.74","384.74","384.74","1 through 10","695.76","1784.28","percent of total billed charges",""
"SPINE CONNECTOR 40 TO 49MM CROSS R2R","SUP-ITM-10243762","CDM","C1713","HCPCS","0278","RC","","","","both","","","2244.38","1683.28","WELLPOINT [1015]","HB AMC WELLPOINT","1655.90","73.78","","286.63","119.22","1107.45","105","695.76","1784.28","percent of total billed charges",""
"SPINE CONNECTOR 40 TO 49MM CROSS R2R","SUP-ITM-10243762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2244.38","1683.28","AETNA [1001]","HB AMC AETNA HMO","1566.58","69.8","","675.31","184.75","1721.50","286","1172.91","1834.11","percent of total billed charges",""
"SPINE CONNECTOR 40 TO 49MM CROSS R2R","SUP-ITM-10243762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2244.38","1683.28","AETNA [1001]","HB AMC AETNA PPO","1804.48","80.4","","1261.44","103.12","1514.10","21","1172.91","1834.11","percent of total billed charges",""
"SPINE CONNECTOR 40 TO 49MM CROSS R2R","SUP-ITM-10243762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2244.38","1683.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1804.48","80.4","","1365.00","1365.00","1365.00","1 through 10","1172.91","1834.11","percent of total billed charges",""
"SPINE CONNECTOR 40 TO 49MM CROSS R2R","SUP-ITM-10243762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2244.38","1683.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1834.11","81.72","","5157.68","5157.68","5157.68","1 through 10","1172.91","1834.11","percent of total billed charges",""
"SPINE CONNECTOR 40 TO 49MM CROSS R2R","SUP-ITM-10243762","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2244.38","1683.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1834.11","81.72","","431.26","71.26","1459.57","88","1172.91","1834.11","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","1309.77","674.56","6049.93","26","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","1901.83","1901.83","2962.25","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","1620.31","1620.31","19908.88","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","352.91","352.91","2046.30","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","9668.75","9668.75","9668.75","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","699.88","384.10","3443.31","33","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","1421.24","264.50","4933.46","29","813.95","1272.79","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.23","80.4","","1022.97","1022.97","3607.50","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","3010.54","693.88","5019.88","35","813.95","1272.79","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1349.51","79.5","","1309.77","674.56","6049.93","26","526.23","1349.51","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","904.77","53.3","","1901.83","1901.83","2962.25","1 through 10","526.23","1349.51","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","619.59","36.5","","1620.31","1620.31","19908.88","1 through 10","526.23","1349.51","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","650.14","38.3","","352.91","352.91","2046.30","1 through 10","526.23","1349.51","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.23","42.9","","9668.75","9668.75","9668.75","1 through 10","526.23","1349.51","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","WELLPOINT [1015]","HB AMC WELLPOINT","1252.42","73.78","","699.88","384.10","3443.31","33","526.23","1349.51","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","AETNA [1001]","HB AMC AETNA HMO","1184.86","69.8","","1421.24","264.50","4933.46","29","887.11","1387.2","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1364.79","80.4","","1022.97","1022.97","3607.50","1 through 10","887.11","1387.2","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1387.20","81.72","","3010.54","693.88","5019.88","35","887.11","1387.2","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.46","79.5","","1309.77","674.56","6049.93","26","157.33","403.46","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.50","53.3","","1901.83","1901.83","2962.25","1 through 10","157.33","403.46","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.24","36.5","","1620.31","1620.31","19908.88","1 through 10","157.33","403.46","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.37","38.3","","352.91","352.91","2046.30","1 through 10","157.33","403.46","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.72","42.9","","9668.75","9668.75","9668.75","1 through 10","157.33","403.46","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","WELLPOINT [1015]","HB AMC WELLPOINT","374.43","73.78","","699.88","384.10","3443.31","33","157.33","403.46","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","AETNA [1001]","HB AMC AETNA HMO","354.24","69.8","","1421.24","264.50","4933.46","29","265.22","414.73","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","408.03","80.4","","1022.97","1022.97","3607.50","1 through 10","265.22","414.73","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","414.73","81.72","","3010.54","693.88","5019.88","35","265.22","414.73","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","1309.77","674.56","6049.93","26","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","1901.83","1901.83","2962.25","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","1620.31","1620.31","19908.88","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","352.91","352.91","2046.30","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","9668.75","9668.75","9668.75","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","699.88","384.10","3443.31","33","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","1421.24","264.50","4933.46","29","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1022.97","1022.97","3607.50","1 through 10","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","3010.54","693.88","5019.88","35","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","1309.77","674.56","6049.93","26","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","1901.83","1901.83","2962.25","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","1620.31","1620.31","19908.88","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","352.91","352.91","2046.30","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","9668.75","9668.75","9668.75","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","699.88","384.10","3443.31","33","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","1421.24","264.50","4933.46","29","813.95","1272.79","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.23","80.4","","1022.97","1022.97","3607.50","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINE CONNECTOR 51 67MM TITANIUM MULTIAXIAL OPEN CROSS ADJUSTABLE STANDARD","SUP-ITM-10021528","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","3010.54","693.88","5019.88","35","813.95","1272.79","percent of total billed charges",""
"SPINE CONNECTOR 6 TO 6MM TI EXTENSION","SUP-ITM-10024958","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","1309.77","674.56","6049.93","26","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 6 TO 6MM TI EXTENSION","SUP-ITM-10024958","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","1901.83","1901.83","2962.25","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 6 TO 6MM TI EXTENSION","SUP-ITM-10024958","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","1620.31","1620.31","19908.88","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 6 TO 6MM TI EXTENSION","SUP-ITM-10024958","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","352.91","352.91","2046.30","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 6 TO 6MM TI EXTENSION","SUP-ITM-10024958","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","9668.75","9668.75","9668.75","1 through 10","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 6 TO 6MM TI EXTENSION","SUP-ITM-10024958","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","699.88","384.10","3443.31","33","271.25","695.63","percent of total billed charges",""
"SPINE CONNECTOR 6 TO 6MM TI EXTENSION","SUP-ITM-10024958","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","1421.24","264.50","4933.46","29","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 6 TO 6MM TI EXTENSION","SUP-ITM-10024958","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1022.97","1022.97","3607.50","1 through 10","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 6 TO 6MM TI EXTENSION","SUP-ITM-10024958","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","3010.54","693.88","5019.88","35","457.28","715.05","percent of total billed charges",""
"SPINE CONNECTOR 6.35X20.0MM EXPEDIUM TITANIUM CLOSED","SUP-ITM-10029146","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.46","79.5","","1309.77","674.56","6049.93","26","157.33","403.46","percent of total billed charges",""
"SPINE CONNECTOR 6.35X20.0MM EXPEDIUM TITANIUM CLOSED","SUP-ITM-10029146","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.50","53.3","","1901.83","1901.83","2962.25","1 through 10","157.33","403.46","percent of total billed charges",""
"SPINE CONNECTOR 6.35X20.0MM EXPEDIUM TITANIUM CLOSED","SUP-ITM-10029146","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.24","36.5","","1620.31","1620.31","19908.88","1 through 10","157.33","403.46","percent of total billed charges",""
"SPINE CONNECTOR 6.35X20.0MM EXPEDIUM TITANIUM CLOSED","SUP-ITM-10029146","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.37","38.3","","352.91","352.91","2046.30","1 through 10","157.33","403.46","percent of total billed charges",""
"SPINE CONNECTOR 6.35X20.0MM EXPEDIUM TITANIUM CLOSED","SUP-ITM-10029146","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.72","42.9","","9668.75","9668.75","9668.75","1 through 10","157.33","403.46","percent of total billed charges",""
"SPINE CONNECTOR 6.35X20.0MM EXPEDIUM TITANIUM CLOSED","SUP-ITM-10029146","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","WELLPOINT [1015]","HB AMC WELLPOINT","374.43","73.78","","699.88","384.10","3443.31","33","157.33","403.46","percent of total billed charges",""
"SPINE CONNECTOR 6.35X20.0MM EXPEDIUM TITANIUM CLOSED","SUP-ITM-10029146","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","AETNA [1001]","HB AMC AETNA HMO","354.24","69.8","","1421.24","264.50","4933.46","29","265.22","414.73","percent of total billed charges",""
"SPINE CONNECTOR 6.35X20.0MM EXPEDIUM TITANIUM CLOSED","SUP-ITM-10029146","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","408.03","80.4","","1022.97","1022.97","3607.50","1 through 10","265.22","414.73","percent of total billed charges",""
"SPINE CONNECTOR 6.35X20.0MM EXPEDIUM TITANIUM CLOSED","SUP-ITM-10029146","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","414.73","81.72","","3010.54","693.88","5019.88","35","265.22","414.73","percent of total billed charges",""
"SPINE CONNECTOR 66.0MM MAC LX FIXATION TITANIUM MULTIAXIAL CROSSLINK MONOBLOCK","SUP-ITM-10021546","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","1309.77","674.56","6049.93","26","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 66.0MM MAC LX FIXATION TITANIUM MULTIAXIAL CROSSLINK MONOBLOCK","SUP-ITM-10021546","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","1901.83","1901.83","2962.25","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 66.0MM MAC LX FIXATION TITANIUM MULTIAXIAL CROSSLINK MONOBLOCK","SUP-ITM-10021546","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","1620.31","1620.31","19908.88","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 66.0MM MAC LX FIXATION TITANIUM MULTIAXIAL CROSSLINK MONOBLOCK","SUP-ITM-10021546","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","352.91","352.91","2046.30","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 66.0MM MAC LX FIXATION TITANIUM MULTIAXIAL CROSSLINK MONOBLOCK","SUP-ITM-10021546","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","9668.75","9668.75","9668.75","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 66.0MM MAC LX FIXATION TITANIUM MULTIAXIAL CROSSLINK MONOBLOCK","SUP-ITM-10021546","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","699.88","384.10","3443.31","33","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR 66.0MM MAC LX FIXATION TITANIUM MULTIAXIAL CROSSLINK MONOBLOCK","SUP-ITM-10021546","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","1421.24","264.50","4933.46","29","813.95","1272.79","percent of total billed charges",""
"SPINE CONNECTOR 66.0MM MAC LX FIXATION TITANIUM MULTIAXIAL CROSSLINK MONOBLOCK","SUP-ITM-10021546","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.23","80.4","","1022.97","1022.97","3607.50","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINE CONNECTOR 66.0MM MAC LX FIXATION TITANIUM MULTIAXIAL CROSSLINK MONOBLOCK","SUP-ITM-10021546","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","3010.54","693.88","5019.88","35","813.95","1272.79","percent of total billed charges",""
"SPINE CONNECTOR 6MM ROD TI L","SUP-ITM-10032558","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1349.51","79.5","","1309.77","674.56","6049.93","26","526.23","1349.51","percent of total billed charges",""
"SPINE CONNECTOR 6MM ROD TI L","SUP-ITM-10032558","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","904.77","53.3","","1901.83","1901.83","2962.25","1 through 10","526.23","1349.51","percent of total billed charges",""
"SPINE CONNECTOR 6MM ROD TI L","SUP-ITM-10032558","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","619.59","36.5","","1620.31","1620.31","19908.88","1 through 10","526.23","1349.51","percent of total billed charges",""
"SPINE CONNECTOR 6MM ROD TI L","SUP-ITM-10032558","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","650.14","38.3","","352.91","352.91","2046.30","1 through 10","526.23","1349.51","percent of total billed charges",""
"SPINE CONNECTOR 6MM ROD TI L","SUP-ITM-10032558","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","728.23","42.9","","9668.75","9668.75","9668.75","1 through 10","526.23","1349.51","percent of total billed charges",""
"SPINE CONNECTOR 6MM ROD TI L","SUP-ITM-10032558","CDM","C1889","HCPCS","0278","RC","","","","both","","","1697.50","1273.12","WELLPOINT [1015]","HB AMC WELLPOINT","1252.42","73.78","","699.88","384.10","3443.31","33","526.23","1349.51","percent of total billed charges",""
"SPINE CONNECTOR 6MM ROD TI L","SUP-ITM-10032558","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","AETNA [1001]","HB AMC AETNA HMO","1184.86","69.8","","1421.24","264.50","4933.46","29","887.11","1387.2","percent of total billed charges",""
"SPINE CONNECTOR 6MM ROD TI L","SUP-ITM-10032558","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1364.79","80.4","","1022.97","1022.97","3607.50","1 through 10","887.11","1387.2","percent of total billed charges",""
"SPINE CONNECTOR 6MM ROD TI L","SUP-ITM-10032558","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1697.50","1273.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1387.20","81.72","","3010.54","693.88","5019.88","35","887.11","1387.2","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","1309.77","674.56","6049.93","26","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","1901.83","1901.83","2962.25","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","1620.31","1620.31","19908.88","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","352.91","352.91","2046.30","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","9668.75","9668.75","9668.75","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","699.88","384.10","3443.31","33","482.83","1238.21","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","1421.24","264.50","4933.46","29","813.95","1272.79","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.23","80.4","","1022.97","1022.97","3607.50","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","3010.54","693.88","5019.88","35","813.95","1272.79","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","both","","","11702.50","8776.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9303.49","79.5","","1309.77","674.56","6049.93","26","3627.78","9303.49","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","both","","","11702.50","8776.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6237.43","53.3","","1901.83","1901.83","2962.25","1 through 10","3627.78","9303.49","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","both","","","11702.50","8776.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4271.41","36.5","","1620.31","1620.31","19908.88","1 through 10","3627.78","9303.49","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","both","","","11702.50","8776.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4482.06","38.3","","352.91","352.91","2046.30","1 through 10","3627.78","9303.49","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","both","","","11702.50","8776.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5020.37","42.9","","9668.75","9668.75","9668.75","1 through 10","3627.78","9303.49","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","both","","","11702.50","8776.87","WELLPOINT [1015]","HB AMC WELLPOINT","8634.10","73.78","","699.88","384.10","3443.31","33","3627.78","9303.49","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11702.50","8776.87","AETNA [1001]","HB AMC AETNA HMO","8168.35","69.8","","1421.24","264.50","4933.46","29","6115.73","9563.28","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11702.50","8776.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9408.81","80.4","","1022.97","1022.97","3607.50","1 through 10","6115.73","9563.28","percent of total billed charges",""
"SPINE DISC 5MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.025S","SUP-ITM-10077245","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11702.50","8776.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9563.28","81.72","","3010.54","693.88","5019.88","35","6115.73","9563.28","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.036S","SUP-ITM-10041399","CDM","C1889","HCPCS","0278","RC","","","","both","","","11702.50","8776.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9303.49","79.5","","1309.77","674.56","6049.93","26","3627.78","9303.49","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.036S","SUP-ITM-10041399","CDM","C1889","HCPCS","0278","RC","","","","both","","","11702.50","8776.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6237.43","53.3","","1901.83","1901.83","2962.25","1 through 10","3627.78","9303.49","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.036S","SUP-ITM-10041399","CDM","C1889","HCPCS","0278","RC","","","","both","","","11702.50","8776.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4271.41","36.5","","1620.31","1620.31","19908.88","1 through 10","3627.78","9303.49","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.036S","SUP-ITM-10041399","CDM","C1889","HCPCS","0278","RC","","","","both","","","11702.50","8776.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4482.06","38.3","","352.91","352.91","2046.30","1 through 10","3627.78","9303.49","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.036S","SUP-ITM-10041399","CDM","C1889","HCPCS","0278","RC","","","","both","","","11702.50","8776.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5020.37","42.9","","9668.75","9668.75","9668.75","1 through 10","3627.78","9303.49","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.036S","SUP-ITM-10041399","CDM","C1889","HCPCS","0278","RC","","","","both","","","11702.50","8776.87","WELLPOINT [1015]","HB AMC WELLPOINT","8634.10","73.78","","699.88","384.10","3443.31","33","3627.78","9303.49","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.036S","SUP-ITM-10041399","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11702.50","8776.87","AETNA [1001]","HB AMC AETNA HMO","8168.35","69.8","","1421.24","264.50","4933.46","29","6115.73","9563.28","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.036S","SUP-ITM-10041399","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11702.50","8776.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9408.81","80.4","","1022.97","1022.97","3607.50","1 through 10","6115.73","9563.28","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.036S","SUP-ITM-10041399","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11702.50","8776.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9563.28","81.72","","3010.54","693.88","5019.88","35","6115.73","9563.28","percent of total billed charges",""
"SPINE ENDPLATE 26X30MM MED 0DEG XRL INTERBODY FUSION DEVICE ROUND CENTRAL BODY","SUP-ITM-10134959","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2114.70","79.5","","1309.77","674.56","6049.93","26","824.6","2114.7","percent of total billed charges",""
"SPINE ENDPLATE 26X30MM MED 0DEG XRL INTERBODY FUSION DEVICE ROUND CENTRAL BODY","SUP-ITM-10134959","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1417.78","53.3","","1901.83","1901.83","2962.25","1 through 10","824.6","2114.7","percent of total billed charges",""
"SPINE ENDPLATE 26X30MM MED 0DEG XRL INTERBODY FUSION DEVICE ROUND CENTRAL BODY","SUP-ITM-10134959","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","970.90","36.5","","1620.31","1620.31","19908.88","1 through 10","824.6","2114.7","percent of total billed charges",""
"SPINE ENDPLATE 26X30MM MED 0DEG XRL INTERBODY FUSION DEVICE ROUND CENTRAL BODY","SUP-ITM-10134959","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1018.78","38.3","","352.91","352.91","2046.30","1 through 10","824.6","2114.7","percent of total billed charges",""
"SPINE ENDPLATE 26X30MM MED 0DEG XRL INTERBODY FUSION DEVICE ROUND CENTRAL BODY","SUP-ITM-10134959","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1141.14","42.9","","9668.75","9668.75","9668.75","1 through 10","824.6","2114.7","percent of total billed charges",""
"SPINE ENDPLATE 26X30MM MED 0DEG XRL INTERBODY FUSION DEVICE ROUND CENTRAL BODY","SUP-ITM-10134959","CDM","C1889","HCPCS","0278","RC","","","","both","","","2660.00","1995.00","WELLPOINT [1015]","HB AMC WELLPOINT","1962.55","73.78","","699.88","384.10","3443.31","33","824.6","2114.7","percent of total billed charges",""
"SPINE ENDPLATE 26X30MM MED 0DEG XRL INTERBODY FUSION DEVICE ROUND CENTRAL BODY","SUP-ITM-10134959","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2660.00","1995.00","AETNA [1001]","HB AMC AETNA HMO","1856.68","69.8","","1421.24","264.50","4933.46","29","1390.12","2173.75","percent of total billed charges",""
"SPINE ENDPLATE 26X30MM MED 0DEG XRL INTERBODY FUSION DEVICE ROUND CENTRAL BODY","SUP-ITM-10134959","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2660.00","1995.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2138.64","80.4","","1022.97","1022.97","3607.50","1 through 10","1390.12","2173.75","percent of total billed charges",""
"SPINE ENDPLATE 26X30MM MED 0DEG XRL INTERBODY FUSION DEVICE ROUND CENTRAL BODY","SUP-ITM-10134959","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2660.00","1995.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2173.75","81.72","","3010.54","693.88","5019.88","35","1390.12","2173.75","percent of total billed charges",""
"SPINE HOOK 8MM LAMINA VUEPOINT II","SUP-ITM-10187148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","800.18","480.96","1887.97","195","434","1113","percent of total billed charges",""
"SPINE HOOK 8MM LAMINA VUEPOINT II","SUP-ITM-10187148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","813.12","216.42","1444.50","81","434","1113","percent of total billed charges",""
"SPINE HOOK 8MM LAMINA VUEPOINT II","SUP-ITM-10187148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","434.00","31","","432.60","432.60","432.60","1 through 10","434","1113","percent of total billed charges",""
"SPINE HOOK 8MM LAMINA VUEPOINT II","SUP-ITM-10187148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","148.37","54.89","631.39","94","434","1113","percent of total billed charges",""
"SPINE HOOK 8MM LAMINA VUEPOINT II","SUP-ITM-10187148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","279.30","91.72","1116.77","266","434","1113","percent of total billed charges",""
"SPINE HOOK 8MM LAMINA VUEPOINT II","SUP-ITM-10187148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","731.00","63.70","731.00","1 through 10","434","1113","percent of total billed charges",""
"SPINE HOOK 8MM LAMINA VUEPOINT II","SUP-ITM-10187148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","384.74","384.74","384.74","1 through 10","434","1113","percent of total billed charges",""
"SPINE HOOK 8MM LAMINA VUEPOINT II","SUP-ITM-10187148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","286.63","119.22","1107.45","105","434","1113","percent of total billed charges",""
"SPINE HOOK 8MM LAMINA VUEPOINT II","SUP-ITM-10187148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","675.31","184.75","1721.50","286","731.64","1144.08","percent of total billed charges",""
"SPINE HOOK 8MM LAMINA VUEPOINT II","SUP-ITM-10187148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA PPO","1125.60","80.4","","1261.44","103.12","1514.10","21","731.64","1144.08","percent of total billed charges",""
"SPINE HOOK 8MM LAMINA VUEPOINT II","SUP-ITM-10187148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1125.60","80.4","","1365.00","1365.00","1365.00","1 through 10","731.64","1144.08","percent of total billed charges",""
"SPINE HOOK 8MM LAMINA VUEPOINT II","SUP-ITM-10187148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1144.08","81.72","","5157.68","5157.68","5157.68","1 through 10","731.64","1144.08","percent of total billed charges",""
"SPINE HOOK 8MM LAMINA VUEPOINT II","SUP-ITM-10187148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","431.26","71.26","1459.57","88","731.64","1144.08","percent of total billed charges",""
"SPINE IMPLANT 16MM SUPERION INDIRECT DECOMPRESSION SYSTEM","SUP-ITM-10281291","CDM","C1821","HCPCS","0278","RC","","","","both","","","31237.50","23428.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24833.81","79.5","","9828.00","9828.00","9828.00","1 through 10","9683.63","29675.63","percent of total billed charges",""
"SPINE IMPLANT 16MM SUPERION INDIRECT DECOMPRESSION SYSTEM","SUP-ITM-10281291","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","31237.50","23428.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","25527.29","81.72","","1958.53","1886.75","1958.53","1 through 10","16324.72","25527.29","percent of total billed charges",""
"SPINE IMPLANT 3.5MM TRANSVERSE BAR T TI","SUP-ITM-10031061","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","403.46","79.5","","1309.77","674.56","6049.93","26","157.33","403.46","percent of total billed charges",""
"SPINE IMPLANT 3.5MM TRANSVERSE BAR T TI","SUP-ITM-10031061","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","270.50","53.3","","1901.83","1901.83","2962.25","1 through 10","157.33","403.46","percent of total billed charges",""
"SPINE IMPLANT 3.5MM TRANSVERSE BAR T TI","SUP-ITM-10031061","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.24","36.5","","1620.31","1620.31","19908.88","1 through 10","157.33","403.46","percent of total billed charges",""
"SPINE IMPLANT 3.5MM TRANSVERSE BAR T TI","SUP-ITM-10031061","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.37","38.3","","352.91","352.91","2046.30","1 through 10","157.33","403.46","percent of total billed charges",""
"SPINE IMPLANT 3.5MM TRANSVERSE BAR T TI","SUP-ITM-10031061","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.72","42.9","","9668.75","9668.75","9668.75","1 through 10","157.33","403.46","percent of total billed charges",""
"SPINE IMPLANT 3.5MM TRANSVERSE BAR T TI","SUP-ITM-10031061","CDM","C1889","HCPCS","0278","RC","","","","both","","","507.50","380.62","WELLPOINT [1015]","HB AMC WELLPOINT","374.43","73.78","","699.88","384.10","3443.31","33","157.33","403.46","percent of total billed charges",""
"SPINE IMPLANT 3.5MM TRANSVERSE BAR T TI","SUP-ITM-10031061","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","AETNA [1001]","HB AMC AETNA HMO","354.24","69.8","","1421.24","264.50","4933.46","29","265.22","414.73","percent of total billed charges",""
"SPINE IMPLANT 3.5MM TRANSVERSE BAR T TI","SUP-ITM-10031061","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","408.03","80.4","","1022.97","1022.97","3607.50","1 through 10","265.22","414.73","percent of total billed charges",""
"SPINE IMPLANT 3.5MM TRANSVERSE BAR T TI","SUP-ITM-10031061","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","507.50","380.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","414.73","81.72","","3010.54","693.88","5019.88","35","265.22","414.73","percent of total billed charges",""
"SPINE IMPLANT 4X120 80MM T BAR ROD BONE EXERNAL FIXATION CARBON FIBER ANGLED","SUP-ITM-10039576","CDM","C1889","HCPCS","0278","RC","","","","both","","","915.57","686.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","727.88","79.5","","1309.77","674.56","6049.93","26","283.83","727.88","percent of total billed charges",""
"SPINE IMPLANT 4X120 80MM T BAR ROD BONE EXERNAL FIXATION CARBON FIBER ANGLED","SUP-ITM-10039576","CDM","C1889","HCPCS","0278","RC","","","","both","","","915.57","686.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","488.00","53.3","","1901.83","1901.83","2962.25","1 through 10","283.83","727.88","percent of total billed charges",""
"SPINE IMPLANT 4X120 80MM T BAR ROD BONE EXERNAL FIXATION CARBON FIBER ANGLED","SUP-ITM-10039576","CDM","C1889","HCPCS","0278","RC","","","","both","","","915.57","686.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","334.18","36.5","","1620.31","1620.31","19908.88","1 through 10","283.83","727.88","percent of total billed charges",""
"SPINE IMPLANT 4X120 80MM T BAR ROD BONE EXERNAL FIXATION CARBON FIBER ANGLED","SUP-ITM-10039576","CDM","C1889","HCPCS","0278","RC","","","","both","","","915.57","686.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","350.66","38.3","","352.91","352.91","2046.30","1 through 10","283.83","727.88","percent of total billed charges",""
"SPINE IMPLANT 4X120 80MM T BAR ROD BONE EXERNAL FIXATION CARBON FIBER ANGLED","SUP-ITM-10039576","CDM","C1889","HCPCS","0278","RC","","","","both","","","915.57","686.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.78","42.9","","9668.75","9668.75","9668.75","1 through 10","283.83","727.88","percent of total billed charges",""
"SPINE IMPLANT 4X120 80MM T BAR ROD BONE EXERNAL FIXATION CARBON FIBER ANGLED","SUP-ITM-10039576","CDM","C1889","HCPCS","0278","RC","","","","both","","","915.57","686.68","WELLPOINT [1015]","HB AMC WELLPOINT","675.51","73.78","","699.88","384.10","3443.31","33","283.83","727.88","percent of total billed charges",""
"SPINE IMPLANT 4X120 80MM T BAR ROD BONE EXERNAL FIXATION CARBON FIBER ANGLED","SUP-ITM-10039576","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","915.57","686.68","AETNA [1001]","HB AMC AETNA HMO","639.07","69.8","","1421.24","264.50","4933.46","29","478.48","748.2","percent of total billed charges",""
"SPINE IMPLANT 4X120 80MM T BAR ROD BONE EXERNAL FIXATION CARBON FIBER ANGLED","SUP-ITM-10039576","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","915.57","686.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","736.12","80.4","","1022.97","1022.97","3607.50","1 through 10","478.48","748.2","percent of total billed charges",""
"SPINE IMPLANT 4X120 80MM T BAR ROD BONE EXERNAL FIXATION CARBON FIBER ANGLED","SUP-ITM-10039576","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","915.57","686.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","748.20","81.72","","3010.54","693.88","5019.88","35","478.48","748.2","percent of total billed charges",""
"SPINE IMPLANT 4X50 80MM 45DEG T BAR ROD BONE EXERNAL FIXATION CARBON FIBER CURVED","SUP-ITM-10039575","CDM","C1889","HCPCS","0278","RC","","","","both","","","1008.81","756.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","802.00","79.5","","1309.77","674.56","6049.93","26","312.73","802","percent of total billed charges",""
"SPINE IMPLANT 4X50 80MM 45DEG T BAR ROD BONE EXERNAL FIXATION CARBON FIBER CURVED","SUP-ITM-10039575","CDM","C1889","HCPCS","0278","RC","","","","both","","","1008.81","756.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","537.70","53.3","","1901.83","1901.83","2962.25","1 through 10","312.73","802","percent of total billed charges",""
"SPINE IMPLANT 4X50 80MM 45DEG T BAR ROD BONE EXERNAL FIXATION CARBON FIBER CURVED","SUP-ITM-10039575","CDM","C1889","HCPCS","0278","RC","","","","both","","","1008.81","756.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","368.22","36.5","","1620.31","1620.31","19908.88","1 through 10","312.73","802","percent of total billed charges",""
"SPINE IMPLANT 4X50 80MM 45DEG T BAR ROD BONE EXERNAL FIXATION CARBON FIBER CURVED","SUP-ITM-10039575","CDM","C1889","HCPCS","0278","RC","","","","both","","","1008.81","756.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","386.37","38.3","","352.91","352.91","2046.30","1 through 10","312.73","802","percent of total billed charges",""
"SPINE IMPLANT 4X50 80MM 45DEG T BAR ROD BONE EXERNAL FIXATION CARBON FIBER CURVED","SUP-ITM-10039575","CDM","C1889","HCPCS","0278","RC","","","","both","","","1008.81","756.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","432.78","42.9","","9668.75","9668.75","9668.75","1 through 10","312.73","802","percent of total billed charges",""
"SPINE IMPLANT 4X50 80MM 45DEG T BAR ROD BONE EXERNAL FIXATION CARBON FIBER CURVED","SUP-ITM-10039575","CDM","C1889","HCPCS","0278","RC","","","","both","","","1008.81","756.61","WELLPOINT [1015]","HB AMC WELLPOINT","744.30","73.78","","699.88","384.10","3443.31","33","312.73","802","percent of total billed charges",""
"SPINE IMPLANT 4X50 80MM 45DEG T BAR ROD BONE EXERNAL FIXATION CARBON FIBER CURVED","SUP-ITM-10039575","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1008.81","756.61","AETNA [1001]","HB AMC AETNA HMO","704.15","69.8","","1421.24","264.50","4933.46","29","527.2","824.4","percent of total billed charges",""
"SPINE IMPLANT 4X50 80MM 45DEG T BAR ROD BONE EXERNAL FIXATION CARBON FIBER CURVED","SUP-ITM-10039575","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1008.81","756.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","811.08","80.4","","1022.97","1022.97","3607.50","1 through 10","527.2","824.4","percent of total billed charges",""
"SPINE IMPLANT 4X50 80MM 45DEG T BAR ROD BONE EXERNAL FIXATION CARBON FIBER CURVED","SUP-ITM-10039575","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1008.81","756.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","824.40","81.72","","3010.54","693.88","5019.88","35","527.2","824.4","percent of total billed charges",""
"SPINE IMPLANT 7MM MED LONG DISC M6-C","SUP-ITM-10273949","CDM","C1713","HCPCS","0278","RC","","","","both","","","11730.00","8797.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9325.35","79.5","","800.18","480.96","1887.97","195","3636.3","9325.35","percent of total billed charges",""
"SPINE IMPLANT 7MM MED LONG DISC M6-C","SUP-ITM-10273949","CDM","C1713","HCPCS","0278","RC","","","","both","","","11730.00","8797.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6252.09","53.3","","813.12","216.42","1444.50","81","3636.3","9325.35","percent of total billed charges",""
"SPINE IMPLANT 7MM MED LONG DISC M6-C","SUP-ITM-10273949","CDM","C1713","HCPCS","0278","RC","","","","both","","","11730.00","8797.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3636.30","31","","432.60","432.60","432.60","1 through 10","3636.3","9325.35","percent of total billed charges",""
"SPINE IMPLANT 7MM MED LONG DISC M6-C","SUP-ITM-10273949","CDM","C1713","HCPCS","0278","RC","","","","both","","","11730.00","8797.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4281.45","36.5","","148.37","54.89","631.39","94","3636.3","9325.35","percent of total billed charges",""
"SPINE IMPLANT 7MM MED LONG DISC M6-C","SUP-ITM-10273949","CDM","C1713","HCPCS","0278","RC","","","","both","","","11730.00","8797.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4492.59","38.3","","279.30","91.72","1116.77","266","3636.3","9325.35","percent of total billed charges",""
"SPINE IMPLANT 7MM MED LONG DISC M6-C","SUP-ITM-10273949","CDM","C1713","HCPCS","0278","RC","","","","both","","","11730.00","8797.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5032.17","42.9","","731.00","63.70","731.00","1 through 10","3636.3","9325.35","percent of total billed charges",""
"SPINE IMPLANT 7MM MED LONG DISC M6-C","SUP-ITM-10273949","CDM","C1713","HCPCS","0278","RC","","","","both","","","11730.00","8797.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5032.17","42.9","","384.74","384.74","384.74","1 through 10","3636.3","9325.35","percent of total billed charges",""
"SPINE IMPLANT 7MM MED LONG DISC M6-C","SUP-ITM-10273949","CDM","C1713","HCPCS","0278","RC","","","","both","","","11730.00","8797.50","WELLPOINT [1015]","HB AMC WELLPOINT","8654.39","73.78","","286.63","119.22","1107.45","105","3636.3","9325.35","percent of total billed charges",""
"SPINE IMPLANT 7MM MED LONG DISC M6-C","SUP-ITM-10273949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11730.00","8797.50","AETNA [1001]","HB AMC AETNA HMO","8187.54","69.8","","675.31","184.75","1721.50","286","6130.1","9585.76","percent of total billed charges",""
"SPINE IMPLANT 7MM MED LONG DISC M6-C","SUP-ITM-10273949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11730.00","8797.50","AETNA [1001]","HB AMC AETNA PPO","9430.92","80.4","","1261.44","103.12","1514.10","21","6130.1","9585.76","percent of total billed charges",""
"SPINE IMPLANT 7MM MED LONG DISC M6-C","SUP-ITM-10273949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11730.00","8797.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9430.92","80.4","","1365.00","1365.00","1365.00","1 through 10","6130.1","9585.76","percent of total billed charges",""
"SPINE IMPLANT 7MM MED LONG DISC M6-C","SUP-ITM-10273949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11730.00","8797.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","9585.76","81.72","","5157.68","5157.68","5157.68","1 through 10","6130.1","9585.76","percent of total billed charges",""
"SPINE IMPLANT 7MM MED LONG DISC M6-C","SUP-ITM-10273949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11730.00","8797.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9585.76","81.72","","431.26","71.26","1459.57","88","6130.1","9585.76","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 10 DEG","SUP-ITM-10187788","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7950.00","79.5","","1309.77","674.56","6049.93","26","3100","7950","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 10 DEG","SUP-ITM-10187788","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5330.00","53.3","","1901.83","1901.83","2962.25","1 through 10","3100","7950","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 10 DEG","SUP-ITM-10187788","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3650.00","36.5","","1620.31","1620.31","19908.88","1 through 10","3100","7950","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 10 DEG","SUP-ITM-10187788","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3830.00","38.3","","352.91","352.91","2046.30","1 through 10","3100","7950","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 10 DEG","SUP-ITM-10187788","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4290.00","42.9","","9668.75","9668.75","9668.75","1 through 10","3100","7950","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 10 DEG","SUP-ITM-10187788","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB AMC WELLPOINT","7378.00","73.78","","699.88","384.10","3443.31","33","3100","7950","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 10 DEG","SUP-ITM-10187788","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA HMO","6980.00","69.8","","1421.24","264.50","4933.46","29","5226","8172","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 10 DEG","SUP-ITM-10187788","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8040.00","80.4","","1022.97","1022.97","3607.50","1 through 10","5226","8172","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM BASE TITANIUM 10 DEG","SUP-ITM-10187788","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8172.00","81.72","","3010.54","693.88","5019.88","35","5226","8172","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM HL TITANIUM BASE 20 DEG","SUP-ITM-10187951","CDM","C1889","HCPCS","0278","RC","","","","both","","","11500.00","8625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9142.50","79.5","","1309.77","674.56","6049.93","26","3565","9142.5","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM HL TITANIUM BASE 20 DEG","SUP-ITM-10187951","CDM","C1889","HCPCS","0278","RC","","","","both","","","11500.00","8625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6129.50","53.3","","1901.83","1901.83","2962.25","1 through 10","3565","9142.5","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM HL TITANIUM BASE 20 DEG","SUP-ITM-10187951","CDM","C1889","HCPCS","0278","RC","","","","both","","","11500.00","8625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4197.50","36.5","","1620.31","1620.31","19908.88","1 through 10","3565","9142.5","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM HL TITANIUM BASE 20 DEG","SUP-ITM-10187951","CDM","C1889","HCPCS","0278","RC","","","","both","","","11500.00","8625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4404.50","38.3","","352.91","352.91","2046.30","1 through 10","3565","9142.5","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM HL TITANIUM BASE 20 DEG","SUP-ITM-10187951","CDM","C1889","HCPCS","0278","RC","","","","both","","","11500.00","8625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4933.50","42.9","","9668.75","9668.75","9668.75","1 through 10","3565","9142.5","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM HL TITANIUM BASE 20 DEG","SUP-ITM-10187951","CDM","C1889","HCPCS","0278","RC","","","","both","","","11500.00","8625.00","WELLPOINT [1015]","HB AMC WELLPOINT","8484.70","73.78","","699.88","384.10","3443.31","33","3565","9142.5","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM HL TITANIUM BASE 20 DEG","SUP-ITM-10187951","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11500.00","8625.00","AETNA [1001]","HB AMC AETNA HMO","8027.00","69.8","","1421.24","264.50","4933.46","29","6009.9","9397.8","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM HL TITANIUM BASE 20 DEG","SUP-ITM-10187951","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11500.00","8625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9246.00","80.4","","1022.97","1022.97","3607.50","1 through 10","6009.9","9397.8","percent of total billed charges",""
"SPINE IMPLANT 8X42X30MM HL TITANIUM BASE 20 DEG","SUP-ITM-10187951","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11500.00","8625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9397.80","81.72","","3010.54","693.88","5019.88","35","6009.9","9397.8","percent of total billed charges",""
"SPINE INTERBODY 8X34X24MM 10DEG MODULUS 3DP INTERFIXATED ALIF","SUP-ITM-10280450","CDM","C1821","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7950.00","79.5","","9828.00","9828.00","9828.00","1 through 10","3100","9500","percent of total billed charges",""
"SPINE INTERBODY 8X34X24MM 10DEG MODULUS 3DP INTERFIXATED ALIF","SUP-ITM-10280450","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8172.00","81.72","","1958.53","1886.75","1958.53","1 through 10","5226","8172","percent of total billed charges",""
"SPINE PLATE 10 5.5X34 36MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10059505","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","800.18","480.96","1887.97","195","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X34 36MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10059505","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","813.12","216.42","1444.50","81","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X34 36MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10059505","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","482.83","31","","432.60","432.60","432.60","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X34 36MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10059505","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","148.37","54.89","631.39","94","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X34 36MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10059505","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","279.30","91.72","1116.77","266","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X34 36MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10059505","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","731.00","63.70","731.00","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X34 36MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10059505","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","384.74","384.74","384.74","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X34 36MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10059505","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","286.63","119.22","1107.45","105","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X34 36MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10059505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","675.31","184.75","1721.50","286","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 5.5X34 36MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10059505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA PPO","1252.23","80.4","","1261.44","103.12","1514.10","21","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 5.5X34 36MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10059505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.23","80.4","","1365.00","1365.00","1365.00","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 5.5X34 36MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10059505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1272.79","81.72","","5157.68","5157.68","5157.68","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 5.5X34 36MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10059505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","431.26","71.26","1459.57","88","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 5.5X58 81MM CROSSLINK LOW PROFILE MULTISPAN TITANIUM","SUP-ITM-10059506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","800.18","480.96","1887.97","195","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X58 81MM CROSSLINK LOW PROFILE MULTISPAN TITANIUM","SUP-ITM-10059506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","813.12","216.42","1444.50","81","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X58 81MM CROSSLINK LOW PROFILE MULTISPAN TITANIUM","SUP-ITM-10059506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","482.83","31","","432.60","432.60","432.60","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X58 81MM CROSSLINK LOW PROFILE MULTISPAN TITANIUM","SUP-ITM-10059506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","148.37","54.89","631.39","94","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X58 81MM CROSSLINK LOW PROFILE MULTISPAN TITANIUM","SUP-ITM-10059506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","279.30","91.72","1116.77","266","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X58 81MM CROSSLINK LOW PROFILE MULTISPAN TITANIUM","SUP-ITM-10059506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","731.00","63.70","731.00","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X58 81MM CROSSLINK LOW PROFILE MULTISPAN TITANIUM","SUP-ITM-10059506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","384.74","384.74","384.74","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X58 81MM CROSSLINK LOW PROFILE MULTISPAN TITANIUM","SUP-ITM-10059506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","286.63","119.22","1107.45","105","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 5.5X58 81MM CROSSLINK LOW PROFILE MULTISPAN TITANIUM","SUP-ITM-10059506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","675.31","184.75","1721.50","286","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 5.5X58 81MM CROSSLINK LOW PROFILE MULTISPAN TITANIUM","SUP-ITM-10059506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA PPO","1252.23","80.4","","1261.44","103.12","1514.10","21","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 5.5X58 81MM CROSSLINK LOW PROFILE MULTISPAN TITANIUM","SUP-ITM-10059506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.23","80.4","","1365.00","1365.00","1365.00","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 5.5X58 81MM CROSSLINK LOW PROFILE MULTISPAN TITANIUM","SUP-ITM-10059506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1272.79","81.72","","5157.68","5157.68","5157.68","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 5.5X58 81MM CROSSLINK LOW PROFILE MULTISPAN TITANIUM","SUP-ITM-10059506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","431.26","71.26","1459.57","88","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 6.35X30 TO 34MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10050445","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","800.18","480.96","1887.97","195","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 6.35X30 TO 34MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10050445","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","813.12","216.42","1444.50","81","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 6.35X30 TO 34MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10050445","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","482.83","31","","432.60","432.60","432.60","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 6.35X30 TO 34MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10050445","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","148.37","54.89","631.39","94","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 6.35X30 TO 34MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10050445","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","279.30","91.72","1116.77","266","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 6.35X30 TO 34MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10050445","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","731.00","63.70","731.00","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 6.35X30 TO 34MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10050445","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","384.74","384.74","384.74","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 6.35X30 TO 34MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10050445","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","286.63","119.22","1107.45","105","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 10 6.35X30 TO 34MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10050445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","675.31","184.75","1721.50","286","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 6.35X30 TO 34MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10050445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA PPO","1252.23","80.4","","1261.44","103.12","1514.10","21","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 6.35X30 TO 34MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10050445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.23","80.4","","1365.00","1365.00","1365.00","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 6.35X30 TO 34MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10050445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1272.79","81.72","","5157.68","5157.68","5157.68","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10 6.35X30 TO 34MM CROSSLINK TITANIUM MULTI SPAN FIXED LOW PROFILE","SUP-ITM-10050445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","431.26","71.26","1459.57","88","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.00","971.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1029.53","79.5","","800.18","480.96","1887.97","195","401.45","1029.53","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.00","971.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","690.24","53.3","","813.12","216.42","1444.50","81","401.45","1029.53","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.00","971.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","401.45","31","","432.60","432.60","432.60","1 through 10","401.45","1029.53","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.00","971.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","472.68","36.5","","148.37","54.89","631.39","94","401.45","1029.53","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.00","971.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","495.99","38.3","","279.30","91.72","1116.77","266","401.45","1029.53","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.00","971.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","555.56","42.9","","731.00","63.70","731.00","1 through 10","401.45","1029.53","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.00","971.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","555.56","42.9","","384.74","384.74","384.74","1 through 10","401.45","1029.53","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.00","971.25","WELLPOINT [1015]","HB AMC WELLPOINT","955.45","73.78","","286.63","119.22","1107.45","105","401.45","1029.53","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","AETNA [1001]","HB AMC AETNA HMO","903.91","69.8","","675.31","184.75","1721.50","286","676.77","1058.27","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","AETNA [1001]","HB AMC AETNA PPO","1041.18","80.4","","1261.44","103.12","1514.10","21","676.77","1058.27","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1041.18","80.4","","1365.00","1365.00","1365.00","1 through 10","676.77","1058.27","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1058.27","81.72","","5157.68","5157.68","5157.68","1 through 10","676.77","1058.27","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1295.00","971.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1058.27","81.72","","431.26","71.26","1459.57","88","676.77","1058.27","percent of total billed charges",""
"SPINE PLATE 10MM XLIF MODULUS DUAL SIDED MOD","SUP-ITM-10275379","CDM","C1821","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","9828.00","9828.00","9828.00","1 through 10","1627.5","4987.5","percent of total billed charges",""
"SPINE PLATE 10MM XLIF MODULUS DUAL SIDED MOD","SUP-ITM-10275379","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","1958.53","1886.75","1958.53","1 through 10","2743.65","4290.3","percent of total billed charges",""
"SPINE PLATE 16MM UNI LEVEL 1","SUP-ITM-10140408","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1391.25","79.5","","800.18","480.96","1887.97","195","542.5","1391.25","percent of total billed charges",""
"SPINE PLATE 16MM UNI LEVEL 1","SUP-ITM-10140408","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","932.75","53.3","","813.12","216.42","1444.50","81","542.5","1391.25","percent of total billed charges",""
"SPINE PLATE 16MM UNI LEVEL 1","SUP-ITM-10140408","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","542.50","31","","432.60","432.60","432.60","1 through 10","542.5","1391.25","percent of total billed charges",""
"SPINE PLATE 16MM UNI LEVEL 1","SUP-ITM-10140408","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","638.75","36.5","","148.37","54.89","631.39","94","542.5","1391.25","percent of total billed charges",""
"SPINE PLATE 16MM UNI LEVEL 1","SUP-ITM-10140408","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","670.25","38.3","","279.30","91.72","1116.77","266","542.5","1391.25","percent of total billed charges",""
"SPINE PLATE 16MM UNI LEVEL 1","SUP-ITM-10140408","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","731.00","63.70","731.00","1 through 10","542.5","1391.25","percent of total billed charges",""
"SPINE PLATE 16MM UNI LEVEL 1","SUP-ITM-10140408","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","750.75","42.9","","384.74","384.74","384.74","1 through 10","542.5","1391.25","percent of total billed charges",""
"SPINE PLATE 16MM UNI LEVEL 1","SUP-ITM-10140408","CDM","C1713","HCPCS","0278","RC","","","","both","","","1750.00","1312.50","WELLPOINT [1015]","HB AMC WELLPOINT","1291.15","73.78","","286.63","119.22","1107.45","105","542.5","1391.25","percent of total billed charges",""
"SPINE PLATE 16MM UNI LEVEL 1","SUP-ITM-10140408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA HMO","1221.50","69.8","","675.31","184.75","1721.50","286","914.55","1430.1","percent of total billed charges",""
"SPINE PLATE 16MM UNI LEVEL 1","SUP-ITM-10140408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","AETNA [1001]","HB AMC AETNA PPO","1407.00","80.4","","1261.44","103.12","1514.10","21","914.55","1430.1","percent of total billed charges",""
"SPINE PLATE 16MM UNI LEVEL 1","SUP-ITM-10140408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1407.00","80.4","","1365.00","1365.00","1365.00","1 through 10","914.55","1430.1","percent of total billed charges",""
"SPINE PLATE 16MM UNI LEVEL 1","SUP-ITM-10140408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1430.10","81.72","","5157.68","5157.68","5157.68","1 through 10","914.55","1430.1","percent of total billed charges",""
"SPINE PLATE 16MM UNI LEVEL 1","SUP-ITM-10140408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1750.00","1312.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1430.10","81.72","","431.26","71.26","1459.57","88","914.55","1430.1","percent of total billed charges",""
"SPINE PLATE 2.1H 98MM 5 LEVEL ACP","SUP-ITM-10280865","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2504.25","79.5","","800.18","480.96","1887.97","195","976.5","2504.25","percent of total billed charges",""
"SPINE PLATE 2.1H 98MM 5 LEVEL ACP","SUP-ITM-10280865","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1678.95","53.3","","813.12","216.42","1444.50","81","976.5","2504.25","percent of total billed charges",""
"SPINE PLATE 2.1H 98MM 5 LEVEL ACP","SUP-ITM-10280865","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","976.50","31","","432.60","432.60","432.60","1 through 10","976.5","2504.25","percent of total billed charges",""
"SPINE PLATE 2.1H 98MM 5 LEVEL ACP","SUP-ITM-10280865","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1149.75","36.5","","148.37","54.89","631.39","94","976.5","2504.25","percent of total billed charges",""
"SPINE PLATE 2.1H 98MM 5 LEVEL ACP","SUP-ITM-10280865","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1206.45","38.3","","279.30","91.72","1116.77","266","976.5","2504.25","percent of total billed charges",""
"SPINE PLATE 2.1H 98MM 5 LEVEL ACP","SUP-ITM-10280865","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","731.00","63.70","731.00","1 through 10","976.5","2504.25","percent of total billed charges",""
"SPINE PLATE 2.1H 98MM 5 LEVEL ACP","SUP-ITM-10280865","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","384.74","384.74","384.74","1 through 10","976.5","2504.25","percent of total billed charges",""
"SPINE PLATE 2.1H 98MM 5 LEVEL ACP","SUP-ITM-10280865","CDM","C1713","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","WELLPOINT [1015]","HB AMC WELLPOINT","2324.07","73.78","","286.63","119.22","1107.45","105","976.5","2504.25","percent of total billed charges",""
"SPINE PLATE 2.1H 98MM 5 LEVEL ACP","SUP-ITM-10280865","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA HMO","2198.70","69.8","","675.31","184.75","1721.50","286","1646.19","2574.18","percent of total billed charges",""
"SPINE PLATE 2.1H 98MM 5 LEVEL ACP","SUP-ITM-10280865","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA PPO","2532.60","80.4","","1261.44","103.12","1514.10","21","1646.19","2574.18","percent of total billed charges",""
"SPINE PLATE 2.1H 98MM 5 LEVEL ACP","SUP-ITM-10280865","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2532.60","80.4","","1365.00","1365.00","1365.00","1 through 10","1646.19","2574.18","percent of total billed charges",""
"SPINE PLATE 2.1H 98MM 5 LEVEL ACP","SUP-ITM-10280865","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2574.18","81.72","","5157.68","5157.68","5157.68","1 through 10","1646.19","2574.18","percent of total billed charges",""
"SPINE PLATE 2.1H 98MM 5 LEVEL ACP","SUP-ITM-10280865","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2574.18","81.72","","431.26","71.26","1459.57","88","1646.19","2574.18","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","800.18","480.96","1887.97","195","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1585.68","53.3","","813.12","216.42","1444.50","81","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","922.25","31","","432.60","432.60","432.60","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","148.37","54.89","631.39","94","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","279.30","91.72","1116.77","266","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","731.00","63.70","731.00","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","384.74","384.74","384.74","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","WELLPOINT [1015]","HB AMC WELLPOINT","2194.96","73.78","","286.63","119.22","1107.45","105","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","675.31","184.75","1721.50","286","1554.74","2431.17","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA PPO","2391.90","80.4","","1261.44","103.12","1514.10","21","1554.74","2431.17","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2391.90","80.4","","1365.00","1365.00","1365.00","1 through 10","1554.74","2431.17","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2431.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1554.74","2431.17","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","431.26","71.26","1459.57","88","1554.74","2431.17","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5962.50","79.5","","800.18","480.96","1887.97","195","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3997.50","53.3","","813.12","216.42","1444.50","81","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2325.00","31","","432.60","432.60","432.60","1 through 10","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2737.50","36.5","","148.37","54.89","631.39","94","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2872.50","38.3","","279.30","91.72","1116.77","266","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3217.50","42.9","","731.00","63.70","731.00","1 through 10","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3217.50","42.9","","384.74","384.74","384.74","1 through 10","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","WELLPOINT [1015]","HB AMC WELLPOINT","5533.50","73.78","","286.63","119.22","1107.45","105","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","AETNA [1001]","HB AMC AETNA HMO","5235.00","69.8","","675.31","184.75","1721.50","286","3919.5","6129","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","AETNA [1001]","HB AMC AETNA PPO","6030.00","80.4","","1261.44","103.12","1514.10","21","3919.5","6129","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6030.00","80.4","","1365.00","1365.00","1365.00","1 through 10","3919.5","6129","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6129.00","81.72","","5157.68","5157.68","5157.68","1 through 10","3919.5","6129","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6129.00","81.72","","431.26","71.26","1459.57","88","3919.5","6129","percent of total billed charges",""
"SPINE PLATE 4.0CM VANTAGE ATL TITANIUM THORACIC LUMBAR ANTERIOR FIXATION","SUP-ITM-10060070","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","800.18","480.96","1887.97","195","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 4.0CM VANTAGE ATL TITANIUM THORACIC LUMBAR ANTERIOR FIXATION","SUP-ITM-10060070","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","813.12","216.42","1444.50","81","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 4.0CM VANTAGE ATL TITANIUM THORACIC LUMBAR ANTERIOR FIXATION","SUP-ITM-10060070","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1627.50","31","","432.60","432.60","432.60","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 4.0CM VANTAGE ATL TITANIUM THORACIC LUMBAR ANTERIOR FIXATION","SUP-ITM-10060070","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","148.37","54.89","631.39","94","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 4.0CM VANTAGE ATL TITANIUM THORACIC LUMBAR ANTERIOR FIXATION","SUP-ITM-10060070","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","279.30","91.72","1116.77","266","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 4.0CM VANTAGE ATL TITANIUM THORACIC LUMBAR ANTERIOR FIXATION","SUP-ITM-10060070","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","731.00","63.70","731.00","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 4.0CM VANTAGE ATL TITANIUM THORACIC LUMBAR ANTERIOR FIXATION","SUP-ITM-10060070","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","384.74","384.74","384.74","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 4.0CM VANTAGE ATL TITANIUM THORACIC LUMBAR ANTERIOR FIXATION","SUP-ITM-10060070","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","286.63","119.22","1107.45","105","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 4.0CM VANTAGE ATL TITANIUM THORACIC LUMBAR ANTERIOR FIXATION","SUP-ITM-10060070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","675.31","184.75","1721.50","286","2743.65","4290.3","percent of total billed charges",""
"SPINE PLATE 4.0CM VANTAGE ATL TITANIUM THORACIC LUMBAR ANTERIOR FIXATION","SUP-ITM-10060070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA PPO","4221.00","80.4","","1261.44","103.12","1514.10","21","2743.65","4290.3","percent of total billed charges",""
"SPINE PLATE 4.0CM VANTAGE ATL TITANIUM THORACIC LUMBAR ANTERIOR FIXATION","SUP-ITM-10060070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4221.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2743.65","4290.3","percent of total billed charges",""
"SPINE PLATE 4.0CM VANTAGE ATL TITANIUM THORACIC LUMBAR ANTERIOR FIXATION","SUP-ITM-10060070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4290.30","81.72","","5157.68","5157.68","5157.68","1 through 10","2743.65","4290.3","percent of total billed charges",""
"SPINE PLATE 4.0CM VANTAGE ATL TITANIUM THORACIC LUMBAR ANTERIOR FIXATION","SUP-ITM-10060070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","431.26","71.26","1459.57","88","2743.65","4290.3","percent of total billed charges",""
"SPINE PLATE 5.5X16MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10059500","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","1309.77","674.56","6049.93","26","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 5.5X16MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10059500","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","1901.83","1901.83","2962.25","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 5.5X16MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10059500","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","1620.31","1620.31","19908.88","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 5.5X16MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10059500","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","352.91","352.91","2046.30","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 5.5X16MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10059500","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","9668.75","9668.75","9668.75","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 5.5X16MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10059500","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","699.88","384.10","3443.31","33","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 5.5X16MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10059500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","1421.24","264.50","4933.46","29","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 5.5X16MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10059500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.23","80.4","","1022.97","1022.97","3607.50","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 5.5X16MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10059500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","3010.54","693.88","5019.88","35","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 5.5X28MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10020375","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","1309.77","674.56","6049.93","26","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 5.5X28MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10020375","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","1901.83","1901.83","2962.25","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 5.5X28MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10020375","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","1620.31","1620.31","19908.88","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 5.5X28MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10020375","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","352.91","352.91","2046.30","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 5.5X28MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10020375","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","9668.75","9668.75","9668.75","1 through 10","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 5.5X28MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10020375","CDM","C1889","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","699.88","384.10","3443.31","33","482.83","1238.21","percent of total billed charges",""
"SPINE PLATE 5.5X28MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10020375","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","1421.24","264.50","4933.46","29","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 5.5X28MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10020375","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1252.23","80.4","","1022.97","1022.97","3607.50","1 through 10","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 5.5X28MM CROSSLINK X10 TITANIUM FIXED LOW PROFILE","SUP-ITM-10020375","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","3010.54","693.88","5019.88","35","813.95","1272.79","percent of total billed charges",""
"SPINE PLATE 50MM 0XCHILD 4HOLE PEDILOC SS LOCKING CANNULATED BLADE ADOLESCENT","SUP-ITM-10136984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4413.00","3309.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3508.34","79.5","","800.18","480.96","1887.97","195","1368.03","3508.34","percent of total billed charges",""
"SPINE PLATE 50MM 0XCHILD 4HOLE PEDILOC SS LOCKING CANNULATED BLADE ADOLESCENT","SUP-ITM-10136984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4413.00","3309.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2352.13","53.3","","813.12","216.42","1444.50","81","1368.03","3508.34","percent of total billed charges",""
"SPINE PLATE 50MM 0XCHILD 4HOLE PEDILOC SS LOCKING CANNULATED BLADE ADOLESCENT","SUP-ITM-10136984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4413.00","3309.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1368.03","31","","432.60","432.60","432.60","1 through 10","1368.03","3508.34","percent of total billed charges",""
"SPINE PLATE 50MM 0XCHILD 4HOLE PEDILOC SS LOCKING CANNULATED BLADE ADOLESCENT","SUP-ITM-10136984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4413.00","3309.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1610.75","36.5","","148.37","54.89","631.39","94","1368.03","3508.34","percent of total billed charges",""
"SPINE PLATE 50MM 0XCHILD 4HOLE PEDILOC SS LOCKING CANNULATED BLADE ADOLESCENT","SUP-ITM-10136984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4413.00","3309.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1690.18","38.3","","279.30","91.72","1116.77","266","1368.03","3508.34","percent of total billed charges",""
"SPINE PLATE 50MM 0XCHILD 4HOLE PEDILOC SS LOCKING CANNULATED BLADE ADOLESCENT","SUP-ITM-10136984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4413.00","3309.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1893.18","42.9","","731.00","63.70","731.00","1 through 10","1368.03","3508.34","percent of total billed charges",""
"SPINE PLATE 50MM 0XCHILD 4HOLE PEDILOC SS LOCKING CANNULATED BLADE ADOLESCENT","SUP-ITM-10136984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4413.00","3309.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1893.18","42.9","","384.74","384.74","384.74","1 through 10","1368.03","3508.34","percent of total billed charges",""
"SPINE PLATE 50MM 0XCHILD 4HOLE PEDILOC SS LOCKING CANNULATED BLADE ADOLESCENT","SUP-ITM-10136984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4413.00","3309.75","WELLPOINT [1015]","HB AMC WELLPOINT","3255.91","73.78","","286.63","119.22","1107.45","105","1368.03","3508.34","percent of total billed charges",""
"SPINE PLATE 50MM 0XCHILD 4HOLE PEDILOC SS LOCKING CANNULATED BLADE ADOLESCENT","SUP-ITM-10136984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4413.00","3309.75","AETNA [1001]","HB AMC AETNA HMO","3080.27","69.8","","675.31","184.75","1721.50","286","2306.23","3606.3","percent of total billed charges",""
"SPINE PLATE 50MM 0XCHILD 4HOLE PEDILOC SS LOCKING CANNULATED BLADE ADOLESCENT","SUP-ITM-10136984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4413.00","3309.75","AETNA [1001]","HB AMC AETNA PPO","3548.05","80.4","","1261.44","103.12","1514.10","21","2306.23","3606.3","percent of total billed charges",""
"SPINE PLATE 50MM 0XCHILD 4HOLE PEDILOC SS LOCKING CANNULATED BLADE ADOLESCENT","SUP-ITM-10136984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4413.00","3309.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3548.05","80.4","","1365.00","1365.00","1365.00","1 through 10","2306.23","3606.3","percent of total billed charges",""
"SPINE PLATE 50MM 0XCHILD 4HOLE PEDILOC SS LOCKING CANNULATED BLADE ADOLESCENT","SUP-ITM-10136984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4413.00","3309.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3606.30","81.72","","5157.68","5157.68","5157.68","1 through 10","2306.23","3606.3","percent of total billed charges",""
"SPINE PLATE 50MM 0XCHILD 4HOLE PEDILOC SS LOCKING CANNULATED BLADE ADOLESCENT","SUP-ITM-10136984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4413.00","3309.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3606.30","81.72","","431.26","71.26","1459.57","88","2306.23","3606.3","percent of total billed charges",""
"SPINE PLATE 55MM AFFIX II","SUP-ITM-10107877","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5962.50","79.5","","800.18","480.96","1887.97","195","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 55MM AFFIX II","SUP-ITM-10107877","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3997.50","53.3","","813.12","216.42","1444.50","81","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 55MM AFFIX II","SUP-ITM-10107877","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2325.00","31","","432.60","432.60","432.60","1 through 10","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 55MM AFFIX II","SUP-ITM-10107877","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2737.50","36.5","","148.37","54.89","631.39","94","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 55MM AFFIX II","SUP-ITM-10107877","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2872.50","38.3","","279.30","91.72","1116.77","266","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 55MM AFFIX II","SUP-ITM-10107877","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3217.50","42.9","","731.00","63.70","731.00","1 through 10","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 55MM AFFIX II","SUP-ITM-10107877","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3217.50","42.9","","384.74","384.74","384.74","1 through 10","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 55MM AFFIX II","SUP-ITM-10107877","CDM","C1713","HCPCS","0278","RC","","","","both","","","7500.00","5625.00","WELLPOINT [1015]","HB AMC WELLPOINT","5533.50","73.78","","286.63","119.22","1107.45","105","2325","5962.5","percent of total billed charges",""
"SPINE PLATE 55MM AFFIX II","SUP-ITM-10107877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","AETNA [1001]","HB AMC AETNA HMO","5235.00","69.8","","675.31","184.75","1721.50","286","3919.5","6129","percent of total billed charges",""
"SPINE PLATE 55MM AFFIX II","SUP-ITM-10107877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","AETNA [1001]","HB AMC AETNA PPO","6030.00","80.4","","1261.44","103.12","1514.10","21","3919.5","6129","percent of total billed charges",""
"SPINE PLATE 55MM AFFIX II","SUP-ITM-10107877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6030.00","80.4","","1365.00","1365.00","1365.00","1 through 10","3919.5","6129","percent of total billed charges",""
"SPINE PLATE 55MM AFFIX II","SUP-ITM-10107877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6129.00","81.72","","5157.68","5157.68","5157.68","1 through 10","3919.5","6129","percent of total billed charges",""
"SPINE PLATE 55MM AFFIX II","SUP-ITM-10107877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7500.00","5625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6129.00","81.72","","431.26","71.26","1459.57","88","3919.5","6129","percent of total billed charges",""
"SPINE PLATE 67MM BONE THORACOLUMBAR LOCKING TI","SUP-ITM-10016611","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","800.18","480.96","1887.97","195","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 67MM BONE THORACOLUMBAR LOCKING TI","SUP-ITM-10016611","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","813.12","216.42","1444.50","81","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 67MM BONE THORACOLUMBAR LOCKING TI","SUP-ITM-10016611","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1627.50","31","","432.60","432.60","432.60","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 67MM BONE THORACOLUMBAR LOCKING TI","SUP-ITM-10016611","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","148.37","54.89","631.39","94","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 67MM BONE THORACOLUMBAR LOCKING TI","SUP-ITM-10016611","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","279.30","91.72","1116.77","266","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 67MM BONE THORACOLUMBAR LOCKING TI","SUP-ITM-10016611","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","731.00","63.70","731.00","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 67MM BONE THORACOLUMBAR LOCKING TI","SUP-ITM-10016611","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","384.74","384.74","384.74","1 through 10","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 67MM BONE THORACOLUMBAR LOCKING TI","SUP-ITM-10016611","CDM","C1713","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","286.63","119.22","1107.45","105","1627.5","4173.75","percent of total billed charges",""
"SPINE PLATE 67MM BONE THORACOLUMBAR LOCKING TI","SUP-ITM-10016611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","675.31","184.75","1721.50","286","2743.65","4290.3","percent of total billed charges",""
"SPINE PLATE 67MM BONE THORACOLUMBAR LOCKING TI","SUP-ITM-10016611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA PPO","4221.00","80.4","","1261.44","103.12","1514.10","21","2743.65","4290.3","percent of total billed charges",""
"SPINE PLATE 67MM BONE THORACOLUMBAR LOCKING TI","SUP-ITM-10016611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4221.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2743.65","4290.3","percent of total billed charges",""
"SPINE PLATE 67MM BONE THORACOLUMBAR LOCKING TI","SUP-ITM-10016611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4290.30","81.72","","5157.68","5157.68","5157.68","1 through 10","2743.65","4290.3","percent of total billed charges",""
"SPINE PLATE 67MM BONE THORACOLUMBAR LOCKING TI","SUP-ITM-10016611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","431.26","71.26","1459.57","88","2743.65","4290.3","percent of total billed charges",""
"SPINE PLATE VUEPOINT II TITANIUM ALLOY FIXATION ADJUSTABLE KEEL POSTERIOR CERVICAL","SUP-ITM-10188271","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","800.18","480.96","1887.97","195","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE VUEPOINT II TITANIUM ALLOY FIXATION ADJUSTABLE KEEL POSTERIOR CERVICAL","SUP-ITM-10188271","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1585.68","53.3","","813.12","216.42","1444.50","81","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE VUEPOINT II TITANIUM ALLOY FIXATION ADJUSTABLE KEEL POSTERIOR CERVICAL","SUP-ITM-10188271","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","922.25","31","","432.60","432.60","432.60","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE VUEPOINT II TITANIUM ALLOY FIXATION ADJUSTABLE KEEL POSTERIOR CERVICAL","SUP-ITM-10188271","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","148.37","54.89","631.39","94","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE VUEPOINT II TITANIUM ALLOY FIXATION ADJUSTABLE KEEL POSTERIOR CERVICAL","SUP-ITM-10188271","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","279.30","91.72","1116.77","266","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE VUEPOINT II TITANIUM ALLOY FIXATION ADJUSTABLE KEEL POSTERIOR CERVICAL","SUP-ITM-10188271","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","731.00","63.70","731.00","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE VUEPOINT II TITANIUM ALLOY FIXATION ADJUSTABLE KEEL POSTERIOR CERVICAL","SUP-ITM-10188271","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","384.74","384.74","384.74","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE VUEPOINT II TITANIUM ALLOY FIXATION ADJUSTABLE KEEL POSTERIOR CERVICAL","SUP-ITM-10188271","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","WELLPOINT [1015]","HB AMC WELLPOINT","2194.96","73.78","","286.63","119.22","1107.45","105","922.25","2365.13","percent of total billed charges",""
"SPINE PLATE VUEPOINT II TITANIUM ALLOY FIXATION ADJUSTABLE KEEL POSTERIOR CERVICAL","SUP-ITM-10188271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","675.31","184.75","1721.50","286","1554.74","2431.17","percent of total billed charges",""
"SPINE PLATE VUEPOINT II TITANIUM ALLOY FIXATION ADJUSTABLE KEEL POSTERIOR CERVICAL","SUP-ITM-10188271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA PPO","2391.90","80.4","","1261.44","103.12","1514.10","21","1554.74","2431.17","percent of total billed charges",""
"SPINE PLATE VUEPOINT II TITANIUM ALLOY FIXATION ADJUSTABLE KEEL POSTERIOR CERVICAL","SUP-ITM-10188271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2391.90","80.4","","1365.00","1365.00","1365.00","1 through 10","1554.74","2431.17","percent of total billed charges",""
"SPINE PLATE VUEPOINT II TITANIUM ALLOY FIXATION ADJUSTABLE KEEL POSTERIOR CERVICAL","SUP-ITM-10188271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2431.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1554.74","2431.17","percent of total billed charges",""
"SPINE PLATE VUEPOINT II TITANIUM ALLOY FIXATION ADJUSTABLE KEEL POSTERIOR CERVICAL","SUP-ITM-10188271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","431.26","71.26","1459.57","88","1554.74","2431.17","percent of total billed charges",""
"SPINE RING 12MM DIA 2.5DEG SYNMESH TI PRESS FIT ROUND","SUP-ITM-10007259","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","361.73","79.5","","1309.77","674.56","6049.93","26","141.05","361.73","percent of total billed charges",""
"SPINE RING 12MM DIA 2.5DEG SYNMESH TI PRESS FIT ROUND","SUP-ITM-10007259","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","242.52","53.3","","1901.83","1901.83","2962.25","1 through 10","141.05","361.73","percent of total billed charges",""
"SPINE RING 12MM DIA 2.5DEG SYNMESH TI PRESS FIT ROUND","SUP-ITM-10007259","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.08","36.5","","1620.31","1620.31","19908.88","1 through 10","141.05","361.73","percent of total billed charges",""
"SPINE RING 12MM DIA 2.5DEG SYNMESH TI PRESS FIT ROUND","SUP-ITM-10007259","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.27","38.3","","352.91","352.91","2046.30","1 through 10","141.05","361.73","percent of total billed charges",""
"SPINE RING 12MM DIA 2.5DEG SYNMESH TI PRESS FIT ROUND","SUP-ITM-10007259","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.20","42.9","","9668.75","9668.75","9668.75","1 through 10","141.05","361.73","percent of total billed charges",""
"SPINE RING 12MM DIA 2.5DEG SYNMESH TI PRESS FIT ROUND","SUP-ITM-10007259","CDM","C1889","HCPCS","0278","RC","","","","both","","","455.00","341.25","WELLPOINT [1015]","HB AMC WELLPOINT","335.70","73.78","","699.88","384.10","3443.31","33","141.05","361.73","percent of total billed charges",""
"SPINE RING 12MM DIA 2.5DEG SYNMESH TI PRESS FIT ROUND","SUP-ITM-10007259","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","1421.24","264.50","4933.46","29","237.78","371.83","percent of total billed charges",""
"SPINE RING 12MM DIA 2.5DEG SYNMESH TI PRESS FIT ROUND","SUP-ITM-10007259","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","365.82","80.4","","1022.97","1022.97","3607.50","1 through 10","237.78","371.83","percent of total billed charges",""
"SPINE RING 12MM DIA 2.5DEG SYNMESH TI PRESS FIT ROUND","SUP-ITM-10007259","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.83","81.72","","3010.54","693.88","5019.88","35","237.78","371.83","percent of total billed charges",""
"SPINE RING UNIVERSAL THORACIC HALF LOCKING TI","SUP-ITM-10006033","CDM","C1889","HCPCS","0278","RC","","","","both","","","1225.00","918.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","973.88","79.5","","1309.77","674.56","6049.93","26","379.75","973.88","percent of total billed charges",""
"SPINE RING UNIVERSAL THORACIC HALF LOCKING TI","SUP-ITM-10006033","CDM","C1889","HCPCS","0278","RC","","","","both","","","1225.00","918.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","652.93","53.3","","1901.83","1901.83","2962.25","1 through 10","379.75","973.88","percent of total billed charges",""
"SPINE RING UNIVERSAL THORACIC HALF LOCKING TI","SUP-ITM-10006033","CDM","C1889","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","447.13","36.5","","1620.31","1620.31","19908.88","1 through 10","379.75","973.88","percent of total billed charges",""
"SPINE RING UNIVERSAL THORACIC HALF LOCKING TI","SUP-ITM-10006033","CDM","C1889","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","469.18","38.3","","352.91","352.91","2046.30","1 through 10","379.75","973.88","percent of total billed charges",""
"SPINE RING UNIVERSAL THORACIC HALF LOCKING TI","SUP-ITM-10006033","CDM","C1889","HCPCS","0278","RC","","","","both","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","525.53","42.9","","9668.75","9668.75","9668.75","1 through 10","379.75","973.88","percent of total billed charges",""
"SPINE RING UNIVERSAL THORACIC HALF LOCKING TI","SUP-ITM-10006033","CDM","C1889","HCPCS","0278","RC","","","","both","","","1225.00","918.75","WELLPOINT [1015]","HB AMC WELLPOINT","903.81","73.78","","699.88","384.10","3443.31","33","379.75","973.88","percent of total billed charges",""
"SPINE RING UNIVERSAL THORACIC HALF LOCKING TI","SUP-ITM-10006033","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","AETNA [1001]","HB AMC AETNA HMO","855.05","69.8","","1421.24","264.50","4933.46","29","640.19","1001.07","percent of total billed charges",""
"SPINE RING UNIVERSAL THORACIC HALF LOCKING TI","SUP-ITM-10006033","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","984.90","80.4","","1022.97","1022.97","3607.50","1 through 10","640.19","1001.07","percent of total billed charges",""
"SPINE RING UNIVERSAL THORACIC HALF LOCKING TI","SUP-ITM-10006033","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1001.07","81.72","","3010.54","693.88","5019.88","35","640.19","1001.07","percent of total billed charges",""
"SPINE ROD 3.5 6X120.0 175MM SYNAPSE TI CONNECTING HARD","SUP-ITM-10046836","CDM","C1889","HCPCS","0278","RC","","","","both","","","548.63","411.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","436.16","79.5","","1309.77","674.56","6049.93","26","170.08","436.16","percent of total billed charges",""
"SPINE ROD 3.5 6X120.0 175MM SYNAPSE TI CONNECTING HARD","SUP-ITM-10046836","CDM","C1889","HCPCS","0278","RC","","","","both","","","548.63","411.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","292.42","53.3","","1901.83","1901.83","2962.25","1 through 10","170.08","436.16","percent of total billed charges",""
"SPINE ROD 3.5 6X120.0 175MM SYNAPSE TI CONNECTING HARD","SUP-ITM-10046836","CDM","C1889","HCPCS","0278","RC","","","","both","","","548.63","411.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","200.25","36.5","","1620.31","1620.31","19908.88","1 through 10","170.08","436.16","percent of total billed charges",""
"SPINE ROD 3.5 6X120.0 175MM SYNAPSE TI CONNECTING HARD","SUP-ITM-10046836","CDM","C1889","HCPCS","0278","RC","","","","both","","","548.63","411.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","210.13","38.3","","352.91","352.91","2046.30","1 through 10","170.08","436.16","percent of total billed charges",""
"SPINE ROD 3.5 6X120.0 175MM SYNAPSE TI CONNECTING HARD","SUP-ITM-10046836","CDM","C1889","HCPCS","0278","RC","","","","both","","","548.63","411.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","235.36","42.9","","9668.75","9668.75","9668.75","1 through 10","170.08","436.16","percent of total billed charges",""
"SPINE ROD 3.5 6X120.0 175MM SYNAPSE TI CONNECTING HARD","SUP-ITM-10046836","CDM","C1889","HCPCS","0278","RC","","","","both","","","548.63","411.47","WELLPOINT [1015]","HB AMC WELLPOINT","404.78","73.78","","699.88","384.10","3443.31","33","170.08","436.16","percent of total billed charges",""
"SPINE ROD 3.5 6X120.0 175MM SYNAPSE TI CONNECTING HARD","SUP-ITM-10046836","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","548.63","411.47","AETNA [1001]","HB AMC AETNA HMO","382.94","69.8","","1421.24","264.50","4933.46","29","286.71","448.34","percent of total billed charges",""
"SPINE ROD 3.5 6X120.0 175MM SYNAPSE TI CONNECTING HARD","SUP-ITM-10046836","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","548.63","411.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","441.10","80.4","","1022.97","1022.97","3607.50","1 through 10","286.71","448.34","percent of total billed charges",""
"SPINE ROD 3.5 6X120.0 175MM SYNAPSE TI CONNECTING HARD","SUP-ITM-10046836","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","548.63","411.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","448.34","81.72","","3010.54","693.88","5019.88","35","286.71","448.34","percent of total billed charges",""
"SPINE ROD 3.5 TO 5.5X600MM OASYS VITALLIUM TRANSITION","SUP-ITM-10132614","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1309.77","674.56","6049.93","26","651","1669.5","percent of total billed charges",""
"SPINE ROD 3.5 TO 5.5X600MM OASYS VITALLIUM TRANSITION","SUP-ITM-10132614","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1119.30","53.3","","1901.83","1901.83","2962.25","1 through 10","651","1669.5","percent of total billed charges",""
"SPINE ROD 3.5 TO 5.5X600MM OASYS VITALLIUM TRANSITION","SUP-ITM-10132614","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1620.31","1620.31","19908.88","1 through 10","651","1669.5","percent of total billed charges",""
"SPINE ROD 3.5 TO 5.5X600MM OASYS VITALLIUM TRANSITION","SUP-ITM-10132614","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","352.91","352.91","2046.30","1 through 10","651","1669.5","percent of total billed charges",""
"SPINE ROD 3.5 TO 5.5X600MM OASYS VITALLIUM TRANSITION","SUP-ITM-10132614","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","9668.75","9668.75","9668.75","1 through 10","651","1669.5","percent of total billed charges",""
"SPINE ROD 3.5 TO 5.5X600MM OASYS VITALLIUM TRANSITION","SUP-ITM-10132614","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","699.88","384.10","3443.31","33","651","1669.5","percent of total billed charges",""
"SPINE ROD 3.5 TO 5.5X600MM OASYS VITALLIUM TRANSITION","SUP-ITM-10132614","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1421.24","264.50","4933.46","29","1097.46","1716.12","percent of total billed charges",""
"SPINE ROD 3.5 TO 5.5X600MM OASYS VITALLIUM TRANSITION","SUP-ITM-10132614","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1688.40","80.4","","1022.97","1022.97","3607.50","1 through 10","1097.46","1716.12","percent of total billed charges",""
"SPINE ROD 3.5 TO 5.5X600MM OASYS VITALLIUM TRANSITION","SUP-ITM-10132614","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","3010.54","693.88","5019.88","35","1097.46","1716.12","percent of total billed charges",""
"SPINE ROD 3.5X120MM CONTOURED","SUP-ITM-10254931","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","800.18","480.96","1887.97","195","162.75","417.38","percent of total billed charges",""
"SPINE ROD 3.5X120MM CONTOURED","SUP-ITM-10254931","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","813.12","216.42","1444.50","81","162.75","417.38","percent of total billed charges",""
"SPINE ROD 3.5X120MM CONTOURED","SUP-ITM-10254931","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.75","31","","432.60","432.60","432.60","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 3.5X120MM CONTOURED","SUP-ITM-10254931","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","148.37","54.89","631.39","94","162.75","417.38","percent of total billed charges",""
"SPINE ROD 3.5X120MM CONTOURED","SUP-ITM-10254931","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","279.30","91.72","1116.77","266","162.75","417.38","percent of total billed charges",""
"SPINE ROD 3.5X120MM CONTOURED","SUP-ITM-10254931","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","731.00","63.70","731.00","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 3.5X120MM CONTOURED","SUP-ITM-10254931","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","384.74","384.74","384.74","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 3.5X120MM CONTOURED","SUP-ITM-10254931","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","286.63","119.22","1107.45","105","162.75","417.38","percent of total billed charges",""
"SPINE ROD 3.5X120MM CONTOURED","SUP-ITM-10254931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","675.31","184.75","1721.50","286","274.37","429.03","percent of total billed charges",""
"SPINE ROD 3.5X120MM CONTOURED","SUP-ITM-10254931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA PPO","422.10","80.4","","1261.44","103.12","1514.10","21","274.37","429.03","percent of total billed charges",""
"SPINE ROD 3.5X120MM CONTOURED","SUP-ITM-10254931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1365.00","1365.00","1365.00","1 through 10","274.37","429.03","percent of total billed charges",""
"SPINE ROD 3.5X120MM CONTOURED","SUP-ITM-10254931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","429.03","81.72","","5157.68","5157.68","5157.68","1 through 10","274.37","429.03","percent of total billed charges",""
"SPINE ROD 3.5X120MM CONTOURED","SUP-ITM-10254931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","431.26","71.26","1459.57","88","274.37","429.03","percent of total billed charges",""
"SPINE ROD 3.5X220 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046432","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1085.18","79.5","","1309.77","674.56","6049.93","26","423.15","1085.18","percent of total billed charges",""
"SPINE ROD 3.5X220 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046432","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","727.55","53.3","","1901.83","1901.83","2962.25","1 through 10","423.15","1085.18","percent of total billed charges",""
"SPINE ROD 3.5X220 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046432","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","498.23","36.5","","1620.31","1620.31","19908.88","1 through 10","423.15","1085.18","percent of total billed charges",""
"SPINE ROD 3.5X220 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046432","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","522.80","38.3","","352.91","352.91","2046.30","1 through 10","423.15","1085.18","percent of total billed charges",""
"SPINE ROD 3.5X220 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046432","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","9668.75","9668.75","9668.75","1 through 10","423.15","1085.18","percent of total billed charges",""
"SPINE ROD 3.5X220 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046432","CDM","C1889","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB AMC WELLPOINT","1007.10","73.78","","699.88","384.10","3443.31","33","423.15","1085.18","percent of total billed charges",""
"SPINE ROD 3.5X220 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046432","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","AETNA [1001]","HB AMC AETNA HMO","952.77","69.8","","1421.24","264.50","4933.46","29","713.35","1115.48","percent of total billed charges",""
"SPINE ROD 3.5X220 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046432","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1097.46","80.4","","1022.97","1022.97","3607.50","1 through 10","713.35","1115.48","percent of total billed charges",""
"SPINE ROD 3.5X220 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046432","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1115.48","81.72","","3010.54","693.88","5019.88","35","713.35","1115.48","percent of total billed charges",""
"SPINE ROD 3.5X30MM OCCIPITAL FIXATION PRE BENT TI AXON II","SUP-ITM-10032556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","800.18","480.96","1887.97","195","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 3.5X30MM OCCIPITAL FIXATION PRE BENT TI AXON II","SUP-ITM-10032556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1585.68","53.3","","813.12","216.42","1444.50","81","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 3.5X30MM OCCIPITAL FIXATION PRE BENT TI AXON II","SUP-ITM-10032556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","922.25","31","","432.60","432.60","432.60","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 3.5X30MM OCCIPITAL FIXATION PRE BENT TI AXON II","SUP-ITM-10032556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","148.37","54.89","631.39","94","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 3.5X30MM OCCIPITAL FIXATION PRE BENT TI AXON II","SUP-ITM-10032556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","279.30","91.72","1116.77","266","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 3.5X30MM OCCIPITAL FIXATION PRE BENT TI AXON II","SUP-ITM-10032556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","731.00","63.70","731.00","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 3.5X30MM OCCIPITAL FIXATION PRE BENT TI AXON II","SUP-ITM-10032556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","384.74","384.74","384.74","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 3.5X30MM OCCIPITAL FIXATION PRE BENT TI AXON II","SUP-ITM-10032556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","WELLPOINT [1015]","HB AMC WELLPOINT","2194.96","73.78","","286.63","119.22","1107.45","105","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 3.5X30MM OCCIPITAL FIXATION PRE BENT TI AXON II","SUP-ITM-10032556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","675.31","184.75","1721.50","286","1554.74","2431.17","percent of total billed charges",""
"SPINE ROD 3.5X30MM OCCIPITAL FIXATION PRE BENT TI AXON II","SUP-ITM-10032556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA PPO","2391.90","80.4","","1261.44","103.12","1514.10","21","1554.74","2431.17","percent of total billed charges",""
"SPINE ROD 3.5X30MM OCCIPITAL FIXATION PRE BENT TI AXON II","SUP-ITM-10032556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2391.90","80.4","","1365.00","1365.00","1365.00","1 through 10","1554.74","2431.17","percent of total billed charges",""
"SPINE ROD 3.5X30MM OCCIPITAL FIXATION PRE BENT TI AXON II","SUP-ITM-10032556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2431.17","81.72","","5157.68","5157.68","5157.68","1 through 10","1554.74","2431.17","percent of total billed charges",""
"SPINE ROD 3.5X30MM OCCIPITAL FIXATION PRE BENT TI AXON II","SUP-ITM-10032556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","431.26","71.26","1459.57","88","1554.74","2431.17","percent of total billed charges",""
"SPINE ROD 3.5X350MM OASYS","SUP-ITM-10115558","CDM","C1889","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2643.38","79.5","","1309.77","674.56","6049.93","26","1030.75","2643.38","percent of total billed charges",""
"SPINE ROD 3.5X350MM OASYS","SUP-ITM-10115558","CDM","C1889","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1772.23","53.3","","1901.83","1901.83","2962.25","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SPINE ROD 3.5X350MM OASYS","SUP-ITM-10115558","CDM","C1889","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1213.63","36.5","","1620.31","1620.31","19908.88","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SPINE ROD 3.5X350MM OASYS","SUP-ITM-10115558","CDM","C1889","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1273.48","38.3","","352.91","352.91","2046.30","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SPINE ROD 3.5X350MM OASYS","SUP-ITM-10115558","CDM","C1889","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","9668.75","9668.75","9668.75","1 through 10","1030.75","2643.38","percent of total billed charges",""
"SPINE ROD 3.5X350MM OASYS","SUP-ITM-10115558","CDM","C1889","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","WELLPOINT [1015]","HB AMC WELLPOINT","2453.19","73.78","","699.88","384.10","3443.31","33","1030.75","2643.38","percent of total billed charges",""
"SPINE ROD 3.5X350MM OASYS","SUP-ITM-10115558","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA HMO","2320.85","69.8","","1421.24","264.50","4933.46","29","1737.65","2717.19","percent of total billed charges",""
"SPINE ROD 3.5X350MM OASYS","SUP-ITM-10115558","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2673.30","80.4","","1022.97","1022.97","3607.50","1 through 10","1737.65","2717.19","percent of total billed charges",""
"SPINE ROD 3.5X350MM OASYS","SUP-ITM-10115558","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2717.19","81.72","","3010.54","693.88","5019.88","35","1737.65","2717.19","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","1309.77","674.56","6049.93","26","162.75","417.38","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","1901.83","1901.83","2962.25","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","1620.31","1620.31","19908.88","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","352.91","352.91","2046.30","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","9668.75","9668.75","9668.75","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","699.88","384.10","3443.31","33","162.75","417.38","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","1421.24","264.50","4933.46","29","274.37","429.03","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1022.97","1022.97","3607.50","1 through 10","274.37","429.03","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","3010.54","693.88","5019.88","35","274.37","429.03","percent of total billed charges",""
"SPINE ROD 35.5X500MM MESA DENALI ROTATION DUAL HEXAGONIAL END STRAIGHT TITANIUM GRADE","SUP-ITM-10086023","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","1309.77","674.56","6049.93","26","217","556.5","percent of total billed charges",""
"SPINE ROD 35.5X500MM MESA DENALI ROTATION DUAL HEXAGONIAL END STRAIGHT TITANIUM GRADE","SUP-ITM-10086023","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","1901.83","1901.83","2962.25","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 35.5X500MM MESA DENALI ROTATION DUAL HEXAGONIAL END STRAIGHT TITANIUM GRADE","SUP-ITM-10086023","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","1620.31","1620.31","19908.88","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 35.5X500MM MESA DENALI ROTATION DUAL HEXAGONIAL END STRAIGHT TITANIUM GRADE","SUP-ITM-10086023","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","352.91","352.91","2046.30","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 35.5X500MM MESA DENALI ROTATION DUAL HEXAGONIAL END STRAIGHT TITANIUM GRADE","SUP-ITM-10086023","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","9668.75","9668.75","9668.75","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 35.5X500MM MESA DENALI ROTATION DUAL HEXAGONIAL END STRAIGHT TITANIUM GRADE","SUP-ITM-10086023","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","699.88","384.10","3443.31","33","217","556.5","percent of total billed charges",""
"SPINE ROD 35.5X500MM MESA DENALI ROTATION DUAL HEXAGONIAL END STRAIGHT TITANIUM GRADE","SUP-ITM-10086023","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","1421.24","264.50","4933.46","29","365.82","572.04","percent of total billed charges",""
"SPINE ROD 35.5X500MM MESA DENALI ROTATION DUAL HEXAGONIAL END STRAIGHT TITANIUM GRADE","SUP-ITM-10086023","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","562.80","80.4","","1022.97","1022.97","3607.50","1 through 10","365.82","572.04","percent of total billed charges",""
"SPINE ROD 35.5X500MM MESA DENALI ROTATION DUAL HEXAGONIAL END STRAIGHT TITANIUM GRADE","SUP-ITM-10086023","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","3010.54","693.88","5019.88","35","365.82","572.04","percent of total billed charges",""
"SPINE ROD 4-5.5X500MM TITANIUM TAPERED EXTRA HARD","SUP-ITM-10113178","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","800.18","480.96","1887.97","195","217","556.5","percent of total billed charges",""
"SPINE ROD 4-5.5X500MM TITANIUM TAPERED EXTRA HARD","SUP-ITM-10113178","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","813.12","216.42","1444.50","81","217","556.5","percent of total billed charges",""
"SPINE ROD 4-5.5X500MM TITANIUM TAPERED EXTRA HARD","SUP-ITM-10113178","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","217.00","31","","432.60","432.60","432.60","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 4-5.5X500MM TITANIUM TAPERED EXTRA HARD","SUP-ITM-10113178","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","148.37","54.89","631.39","94","217","556.5","percent of total billed charges",""
"SPINE ROD 4-5.5X500MM TITANIUM TAPERED EXTRA HARD","SUP-ITM-10113178","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","279.30","91.72","1116.77","266","217","556.5","percent of total billed charges",""
"SPINE ROD 4-5.5X500MM TITANIUM TAPERED EXTRA HARD","SUP-ITM-10113178","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","731.00","63.70","731.00","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 4-5.5X500MM TITANIUM TAPERED EXTRA HARD","SUP-ITM-10113178","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","384.74","384.74","384.74","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 4-5.5X500MM TITANIUM TAPERED EXTRA HARD","SUP-ITM-10113178","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","286.63","119.22","1107.45","105","217","556.5","percent of total billed charges",""
"SPINE ROD 4-5.5X500MM TITANIUM TAPERED EXTRA HARD","SUP-ITM-10113178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","675.31","184.75","1721.50","286","365.82","572.04","percent of total billed charges",""
"SPINE ROD 4-5.5X500MM TITANIUM TAPERED EXTRA HARD","SUP-ITM-10113178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA PPO","562.80","80.4","","1261.44","103.12","1514.10","21","365.82","572.04","percent of total billed charges",""
"SPINE ROD 4-5.5X500MM TITANIUM TAPERED EXTRA HARD","SUP-ITM-10113178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","562.80","80.4","","1365.00","1365.00","1365.00","1 through 10","365.82","572.04","percent of total billed charges",""
"SPINE ROD 4-5.5X500MM TITANIUM TAPERED EXTRA HARD","SUP-ITM-10113178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","572.04","81.72","","5157.68","5157.68","5157.68","1 through 10","365.82","572.04","percent of total billed charges",""
"SPINE ROD 4-5.5X500MM TITANIUM TAPERED EXTRA HARD","SUP-ITM-10113178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","431.26","71.26","1459.57","88","365.82","572.04","percent of total billed charges",""
"SPINE ROD 4.5X200MM LONG SPINAL XIA TITANIUM LUMBAR POSTERIOR","SUP-ITM-10021668","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","1309.77","674.56","6049.93","26","162.75","417.38","percent of total billed charges",""
"SPINE ROD 4.5X200MM LONG SPINAL XIA TITANIUM LUMBAR POSTERIOR","SUP-ITM-10021668","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","1901.83","1901.83","2962.25","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 4.5X200MM LONG SPINAL XIA TITANIUM LUMBAR POSTERIOR","SUP-ITM-10021668","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","1620.31","1620.31","19908.88","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 4.5X200MM LONG SPINAL XIA TITANIUM LUMBAR POSTERIOR","SUP-ITM-10021668","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","352.91","352.91","2046.30","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 4.5X200MM LONG SPINAL XIA TITANIUM LUMBAR POSTERIOR","SUP-ITM-10021668","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","9668.75","9668.75","9668.75","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 4.5X200MM LONG SPINAL XIA TITANIUM LUMBAR POSTERIOR","SUP-ITM-10021668","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","699.88","384.10","3443.31","33","162.75","417.38","percent of total billed charges",""
"SPINE ROD 4.5X200MM LONG SPINAL XIA TITANIUM LUMBAR POSTERIOR","SUP-ITM-10021668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","1421.24","264.50","4933.46","29","274.37","429.03","percent of total billed charges",""
"SPINE ROD 4.5X200MM LONG SPINAL XIA TITANIUM LUMBAR POSTERIOR","SUP-ITM-10021668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1022.97","1022.97","3607.50","1 through 10","274.37","429.03","percent of total billed charges",""
"SPINE ROD 4.5X200MM LONG SPINAL XIA TITANIUM LUMBAR POSTERIOR","SUP-ITM-10021668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","3010.54","693.88","5019.88","35","274.37","429.03","percent of total billed charges",""
"SPINE ROD 4.5X600MM VITALLIUM","SUP-ITM-10021354","CDM","C1889","HCPCS","0278","RC","","","","both","","","1687.00","1265.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1341.17","79.5","","1309.77","674.56","6049.93","26","522.97","1341.17","percent of total billed charges",""
"SPINE ROD 4.5X600MM VITALLIUM","SUP-ITM-10021354","CDM","C1889","HCPCS","0278","RC","","","","both","","","1687.00","1265.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","899.17","53.3","","1901.83","1901.83","2962.25","1 through 10","522.97","1341.17","percent of total billed charges",""
"SPINE ROD 4.5X600MM VITALLIUM","SUP-ITM-10021354","CDM","C1889","HCPCS","0278","RC","","","","both","","","1687.00","1265.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","615.76","36.5","","1620.31","1620.31","19908.88","1 through 10","522.97","1341.17","percent of total billed charges",""
"SPINE ROD 4.5X600MM VITALLIUM","SUP-ITM-10021354","CDM","C1889","HCPCS","0278","RC","","","","both","","","1687.00","1265.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","646.12","38.3","","352.91","352.91","2046.30","1 through 10","522.97","1341.17","percent of total billed charges",""
"SPINE ROD 4.5X600MM VITALLIUM","SUP-ITM-10021354","CDM","C1889","HCPCS","0278","RC","","","","both","","","1687.00","1265.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","723.72","42.9","","9668.75","9668.75","9668.75","1 through 10","522.97","1341.17","percent of total billed charges",""
"SPINE ROD 4.5X600MM VITALLIUM","SUP-ITM-10021354","CDM","C1889","HCPCS","0278","RC","","","","both","","","1687.00","1265.25","WELLPOINT [1015]","HB AMC WELLPOINT","1244.67","73.78","","699.88","384.10","3443.31","33","522.97","1341.17","percent of total billed charges",""
"SPINE ROD 4.5X600MM VITALLIUM","SUP-ITM-10021354","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1687.00","1265.25","AETNA [1001]","HB AMC AETNA HMO","1177.53","69.8","","1421.24","264.50","4933.46","29","881.63","1378.62","percent of total billed charges",""
"SPINE ROD 4.5X600MM VITALLIUM","SUP-ITM-10021354","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1687.00","1265.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1356.35","80.4","","1022.97","1022.97","3607.50","1 through 10","881.63","1378.62","percent of total billed charges",""
"SPINE ROD 4.5X600MM VITALLIUM","SUP-ITM-10021354","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1687.00","1265.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1378.62","81.72","","3010.54","693.88","5019.88","35","881.63","1378.62","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","142.45","106.84","CIGNA [1006]","HB AMC CIGNA HMO / PPO","113.25","79.5","","1309.77","674.56","6049.93","26","44.16","113.25","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","142.45","106.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","75.93","53.3","","1901.83","1901.83","2962.25","1 through 10","44.16","113.25","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","142.45","106.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.99","36.5","","1620.31","1620.31","19908.88","1 through 10","44.16","113.25","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","142.45","106.84","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.56","38.3","","352.91","352.91","2046.30","1 through 10","44.16","113.25","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","142.45","106.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.11","42.9","","9668.75","9668.75","9668.75","1 through 10","44.16","113.25","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","142.45","106.84","WELLPOINT [1015]","HB AMC WELLPOINT","105.10","73.78","","699.88","384.10","3443.31","33","44.16","113.25","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","142.45","106.84","AETNA [1001]","HB AMC AETNA HMO","99.43","69.8","","1421.24","264.50","4933.46","29","74.44","116.41","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","142.45","106.84","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","114.53","80.4","","1022.97","1022.97","3607.50","1 through 10","74.44","116.41","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","142.45","106.84","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","116.41","81.72","","3010.54","693.88","5019.88","35","74.44","116.41","percent of total billed charges",""
"SPINE ROD 4MM ORTHOPEDIC MANDIBLE PREBENT ONE HALF FIXATION EXTERNAL TI","SUP-ITM-10025214","CDM","C1889","HCPCS","0278","RC","","","","both","","","1069.01","801.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","849.86","79.5","","1309.77","674.56","6049.93","26","331.39","849.86","percent of total billed charges",""
"SPINE ROD 4MM ORTHOPEDIC MANDIBLE PREBENT ONE HALF FIXATION EXTERNAL TI","SUP-ITM-10025214","CDM","C1889","HCPCS","0278","RC","","","","both","","","1069.01","801.76","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","569.78","53.3","","1901.83","1901.83","2962.25","1 through 10","331.39","849.86","percent of total billed charges",""
"SPINE ROD 4MM ORTHOPEDIC MANDIBLE PREBENT ONE HALF FIXATION EXTERNAL TI","SUP-ITM-10025214","CDM","C1889","HCPCS","0278","RC","","","","both","","","1069.01","801.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","390.19","36.5","","1620.31","1620.31","19908.88","1 through 10","331.39","849.86","percent of total billed charges",""
"SPINE ROD 4MM ORTHOPEDIC MANDIBLE PREBENT ONE HALF FIXATION EXTERNAL TI","SUP-ITM-10025214","CDM","C1889","HCPCS","0278","RC","","","","both","","","1069.01","801.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","409.43","38.3","","352.91","352.91","2046.30","1 through 10","331.39","849.86","percent of total billed charges",""
"SPINE ROD 4MM ORTHOPEDIC MANDIBLE PREBENT ONE HALF FIXATION EXTERNAL TI","SUP-ITM-10025214","CDM","C1889","HCPCS","0278","RC","","","","both","","","1069.01","801.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","458.61","42.9","","9668.75","9668.75","9668.75","1 through 10","331.39","849.86","percent of total billed charges",""
"SPINE ROD 4MM ORTHOPEDIC MANDIBLE PREBENT ONE HALF FIXATION EXTERNAL TI","SUP-ITM-10025214","CDM","C1889","HCPCS","0278","RC","","","","both","","","1069.01","801.76","WELLPOINT [1015]","HB AMC WELLPOINT","788.72","73.78","","699.88","384.10","3443.31","33","331.39","849.86","percent of total billed charges",""
"SPINE ROD 4MM ORTHOPEDIC MANDIBLE PREBENT ONE HALF FIXATION EXTERNAL TI","SUP-ITM-10025214","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1069.01","801.76","AETNA [1001]","HB AMC AETNA HMO","746.17","69.8","","1421.24","264.50","4933.46","29","558.66","873.59","percent of total billed charges",""
"SPINE ROD 4MM ORTHOPEDIC MANDIBLE PREBENT ONE HALF FIXATION EXTERNAL TI","SUP-ITM-10025214","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1069.01","801.76","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","859.48","80.4","","1022.97","1022.97","3607.50","1 through 10","558.66","873.59","percent of total billed charges",""
"SPINE ROD 4MM ORTHOPEDIC MANDIBLE PREBENT ONE HALF FIXATION EXTERNAL TI","SUP-ITM-10025214","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1069.01","801.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","873.59","81.72","","3010.54","693.88","5019.88","35","558.66","873.59","percent of total billed charges",""
"SPINE ROD 4MM TITANIUM","SUP-ITM-10086840","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","1309.77","674.56","6049.93","26","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 4MM TITANIUM","SUP-ITM-10086840","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1585.68","53.3","","1901.83","1901.83","2962.25","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 4MM TITANIUM","SUP-ITM-10086840","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","1620.31","1620.31","19908.88","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 4MM TITANIUM","SUP-ITM-10086840","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","352.91","352.91","2046.30","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 4MM TITANIUM","SUP-ITM-10086840","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","9668.75","9668.75","9668.75","1 through 10","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 4MM TITANIUM","SUP-ITM-10086840","CDM","C1889","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","WELLPOINT [1015]","HB AMC WELLPOINT","2194.96","73.78","","699.88","384.10","3443.31","33","922.25","2365.13","percent of total billed charges",""
"SPINE ROD 4MM TITANIUM","SUP-ITM-10086840","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","1421.24","264.50","4933.46","29","1554.74","2431.17","percent of total billed charges",""
"SPINE ROD 4MM TITANIUM","SUP-ITM-10086840","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2391.90","80.4","","1022.97","1022.97","3607.50","1 through 10","1554.74","2431.17","percent of total billed charges",""
"SPINE ROD 4MM TITANIUM","SUP-ITM-10086840","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","3010.54","693.88","5019.88","35","1554.74","2431.17","percent of total billed charges",""
"SPINE ROD 4X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086812","CDM","C1889","HCPCS","0278","RC","","","","both","","","577.50","433.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","459.11","79.5","","1309.77","674.56","6049.93","26","179.03","459.11","percent of total billed charges",""
"SPINE ROD 4X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086812","CDM","C1889","HCPCS","0278","RC","","","","both","","","577.50","433.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","307.81","53.3","","1901.83","1901.83","2962.25","1 through 10","179.03","459.11","percent of total billed charges",""
"SPINE ROD 4X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086812","CDM","C1889","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","210.79","36.5","","1620.31","1620.31","19908.88","1 through 10","179.03","459.11","percent of total billed charges",""
"SPINE ROD 4X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086812","CDM","C1889","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","221.18","38.3","","352.91","352.91","2046.30","1 through 10","179.03","459.11","percent of total billed charges",""
"SPINE ROD 4X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086812","CDM","C1889","HCPCS","0278","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.75","42.9","","9668.75","9668.75","9668.75","1 through 10","179.03","459.11","percent of total billed charges",""
"SPINE ROD 4X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086812","CDM","C1889","HCPCS","0278","RC","","","","both","","","577.50","433.12","WELLPOINT [1015]","HB AMC WELLPOINT","426.08","73.78","","699.88","384.10","3443.31","33","179.03","459.11","percent of total billed charges",""
"SPINE ROD 4X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086812","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","AETNA [1001]","HB AMC AETNA HMO","403.10","69.8","","1421.24","264.50","4933.46","29","301.8","471.93","percent of total billed charges",""
"SPINE ROD 4X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086812","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","464.31","80.4","","1022.97","1022.97","3607.50","1 through 10","301.8","471.93","percent of total billed charges",""
"SPINE ROD 4X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086812","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","471.93","81.72","","3010.54","693.88","5019.88","35","301.8","471.93","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","800.18","480.96","1887.97","195","162.75","417.38","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","813.12","216.42","1444.50","81","162.75","417.38","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.75","31","","432.60","432.60","432.60","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","148.37","54.89","631.39","94","162.75","417.38","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","279.30","91.72","1116.77","266","162.75","417.38","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","731.00","63.70","731.00","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","384.74","384.74","384.74","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","286.63","119.22","1107.45","105","162.75","417.38","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","675.31","184.75","1721.50","286","274.37","429.03","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA PPO","422.10","80.4","","1261.44","103.12","1514.10","21","274.37","429.03","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1365.00","1365.00","1365.00","1 through 10","274.37","429.03","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","429.03","81.72","","5157.68","5157.68","5157.68","1 through 10","274.37","429.03","percent of total billed charges",""
"SPINE ROD 5.4X100MM HEXAGONAL COCHR STRAIGHT PK/2EA","SUP-ITM-10102083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","431.26","71.26","1459.57","88","274.37","429.03","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","1309.77","674.56","6049.93","26","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","1901.83","1901.83","2962.25","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","1620.31","1620.31","19908.88","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","352.91","352.91","2046.30","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","9668.75","9668.75","9668.75","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","699.88","384.10","3443.31","33","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","1421.24","264.50","4933.46","29","438.98","686.45","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1022.97","1022.97","3607.50","1 through 10","438.98","686.45","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","3010.54","693.88","5019.88","35","438.98","686.45","percent of total billed charges",""
"SPINE ROD 5.5X385MM EXPEDIUM COBALT CHROME CONTOURED","SUP-ITM-10179366","CDM","C1889","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3806.06","79.5","","1309.77","674.56","6049.93","26","1484.13","3806.06","percent of total billed charges",""
"SPINE ROD 5.5X385MM EXPEDIUM COBALT CHROME CONTOURED","SUP-ITM-10179366","CDM","C1889","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2551.74","53.3","","1901.83","1901.83","2962.25","1 through 10","1484.13","3806.06","percent of total billed charges",""
"SPINE ROD 5.5X385MM EXPEDIUM COBALT CHROME CONTOURED","SUP-ITM-10179366","CDM","C1889","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1747.44","36.5","","1620.31","1620.31","19908.88","1 through 10","1484.13","3806.06","percent of total billed charges",""
"SPINE ROD 5.5X385MM EXPEDIUM COBALT CHROME CONTOURED","SUP-ITM-10179366","CDM","C1889","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1833.61","38.3","","352.91","352.91","2046.30","1 through 10","1484.13","3806.06","percent of total billed charges",""
"SPINE ROD 5.5X385MM EXPEDIUM COBALT CHROME CONTOURED","SUP-ITM-10179366","CDM","C1889","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2053.84","42.9","","9668.75","9668.75","9668.75","1 through 10","1484.13","3806.06","percent of total billed charges",""
"SPINE ROD 5.5X385MM EXPEDIUM COBALT CHROME CONTOURED","SUP-ITM-10179366","CDM","C1889","HCPCS","0278","RC","","","","both","","","4787.50","3590.62","WELLPOINT [1015]","HB AMC WELLPOINT","3532.22","73.78","","699.88","384.10","3443.31","33","1484.13","3806.06","percent of total billed charges",""
"SPINE ROD 5.5X385MM EXPEDIUM COBALT CHROME CONTOURED","SUP-ITM-10179366","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4787.50","3590.62","AETNA [1001]","HB AMC AETNA HMO","3341.68","69.8","","1421.24","264.50","4933.46","29","2501.95","3912.35","percent of total billed charges",""
"SPINE ROD 5.5X385MM EXPEDIUM COBALT CHROME CONTOURED","SUP-ITM-10179366","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4787.50","3590.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3849.15","80.4","","1022.97","1022.97","3607.50","1 through 10","2501.95","3912.35","percent of total billed charges",""
"SPINE ROD 5.5X385MM EXPEDIUM COBALT CHROME CONTOURED","SUP-ITM-10179366","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4787.50","3590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3912.35","81.72","","3010.54","693.88","5019.88","35","2501.95","3912.35","percent of total billed charges",""
"SPINE ROD 5.5X45MM SERENGETI CONTOURED BULLET NOSE HEX END","SUP-ITM-10086064","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","800.18","480.96","1887.97","195","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X45MM SERENGETI CONTOURED BULLET NOSE HEX END","SUP-ITM-10086064","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","813.12","216.42","1444.50","81","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X45MM SERENGETI CONTOURED BULLET NOSE HEX END","SUP-ITM-10086064","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","260.40","31","","432.60","432.60","432.60","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X45MM SERENGETI CONTOURED BULLET NOSE HEX END","SUP-ITM-10086064","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","148.37","54.89","631.39","94","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X45MM SERENGETI CONTOURED BULLET NOSE HEX END","SUP-ITM-10086064","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","279.30","91.72","1116.77","266","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X45MM SERENGETI CONTOURED BULLET NOSE HEX END","SUP-ITM-10086064","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","731.00","63.70","731.00","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X45MM SERENGETI CONTOURED BULLET NOSE HEX END","SUP-ITM-10086064","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","384.74","384.74","384.74","1 through 10","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X45MM SERENGETI CONTOURED BULLET NOSE HEX END","SUP-ITM-10086064","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","286.63","119.22","1107.45","105","260.4","667.8","percent of total billed charges",""
"SPINE ROD 5.5X45MM SERENGETI CONTOURED BULLET NOSE HEX END","SUP-ITM-10086064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","675.31","184.75","1721.50","286","438.98","686.45","percent of total billed charges",""
"SPINE ROD 5.5X45MM SERENGETI CONTOURED BULLET NOSE HEX END","SUP-ITM-10086064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA PPO","675.36","80.4","","1261.44","103.12","1514.10","21","438.98","686.45","percent of total billed charges",""
"SPINE ROD 5.5X45MM SERENGETI CONTOURED BULLET NOSE HEX END","SUP-ITM-10086064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1365.00","1365.00","1365.00","1 through 10","438.98","686.45","percent of total billed charges",""
"SPINE ROD 5.5X45MM SERENGETI CONTOURED BULLET NOSE HEX END","SUP-ITM-10086064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","686.45","81.72","","5157.68","5157.68","5157.68","1 through 10","438.98","686.45","percent of total billed charges",""
"SPINE ROD 5.5X45MM SERENGETI CONTOURED BULLET NOSE HEX END","SUP-ITM-10086064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","431.26","71.26","1459.57","88","438.98","686.45","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","1309.77","674.56","6049.93","26","217","556.5","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","1901.83","1901.83","2962.25","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","1620.31","1620.31","19908.88","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","352.91","352.91","2046.30","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","9668.75","9668.75","9668.75","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","699.88","384.10","3443.31","33","217","556.5","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","1421.24","264.50","4933.46","29","365.82","572.04","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","562.80","80.4","","1022.97","1022.97","3607.50","1 through 10","365.82","572.04","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","3010.54","693.88","5019.88","35","365.82","572.04","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","770.00","577.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","612.15","79.5","","1309.77","674.56","6049.93","26","238.7","612.15","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","770.00","577.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","410.41","53.3","","1901.83","1901.83","2962.25","1 through 10","238.7","612.15","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","281.05","36.5","","1620.31","1620.31","19908.88","1 through 10","238.7","612.15","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","770.00","577.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","294.91","38.3","","352.91","352.91","2046.30","1 through 10","238.7","612.15","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","330.33","42.9","","9668.75","9668.75","9668.75","1 through 10","238.7","612.15","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","770.00","577.50","WELLPOINT [1015]","HB AMC WELLPOINT","568.11","73.78","","699.88","384.10","3443.31","33","238.7","612.15","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","AETNA [1001]","HB AMC AETNA HMO","537.46","69.8","","1421.24","264.50","4933.46","29","402.4","629.24","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","619.08","80.4","","1022.97","1022.97","3607.50","1 through 10","402.4","629.24","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","770.00","577.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","629.24","81.72","","3010.54","693.88","5019.88","35","402.4","629.24","percent of total billed charges",""
"SPINE ROD 5X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086813","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","1309.77","674.56","6049.93","26","217","556.5","percent of total billed charges",""
"SPINE ROD 5X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086813","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","1901.83","1901.83","2962.25","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 5X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086813","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","1620.31","1620.31","19908.88","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 5X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086813","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","352.91","352.91","2046.30","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 5X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086813","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","9668.75","9668.75","9668.75","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 5X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086813","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","699.88","384.10","3443.31","33","217","556.5","percent of total billed charges",""
"SPINE ROD 5X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086813","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","1421.24","264.50","4933.46","29","365.82","572.04","percent of total billed charges",""
"SPINE ROD 5X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086813","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","562.80","80.4","","1022.97","1022.97","3607.50","1 through 10","365.82","572.04","percent of total billed charges",""
"SPINE ROD 5X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10086813","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","3010.54","693.88","5019.88","35","365.82","572.04","percent of total billed charges",""
"SPINE ROD 5X50X400MM SS STRAIGHT SECTION PRECONTOURED","SUP-ITM-10031508","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","1309.77","674.56","6049.93","26","217","556.5","percent of total billed charges",""
"SPINE ROD 5X50X400MM SS STRAIGHT SECTION PRECONTOURED","SUP-ITM-10031508","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","1901.83","1901.83","2962.25","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 5X50X400MM SS STRAIGHT SECTION PRECONTOURED","SUP-ITM-10031508","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","1620.31","1620.31","19908.88","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 5X50X400MM SS STRAIGHT SECTION PRECONTOURED","SUP-ITM-10031508","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","352.91","352.91","2046.30","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 5X50X400MM SS STRAIGHT SECTION PRECONTOURED","SUP-ITM-10031508","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","9668.75","9668.75","9668.75","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 5X50X400MM SS STRAIGHT SECTION PRECONTOURED","SUP-ITM-10031508","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","699.88","384.10","3443.31","33","217","556.5","percent of total billed charges",""
"SPINE ROD 5X50X400MM SS STRAIGHT SECTION PRECONTOURED","SUP-ITM-10031508","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","1421.24","264.50","4933.46","29","365.82","572.04","percent of total billed charges",""
"SPINE ROD 5X50X400MM SS STRAIGHT SECTION PRECONTOURED","SUP-ITM-10031508","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","562.80","80.4","","1022.97","1022.97","3607.50","1 through 10","365.82","572.04","percent of total billed charges",""
"SPINE ROD 5X50X400MM SS STRAIGHT SECTION PRECONTOURED","SUP-ITM-10031508","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","3010.54","693.88","5019.88","35","365.82","572.04","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","1309.77","674.56","6049.93","26","162.75","417.38","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","1901.83","1901.83","2962.25","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","1620.31","1620.31","19908.88","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","352.91","352.91","2046.30","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","9668.75","9668.75","9668.75","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","699.88","384.10","3443.31","33","162.75","417.38","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","1421.24","264.50","4933.46","29","274.37","429.03","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1022.97","1022.97","3607.50","1 through 10","274.37","429.03","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","3010.54","693.88","5019.88","35","274.37","429.03","percent of total billed charges",""
"SPINE ROD 6.35MMX31XM DANEK","SUP-ITM-10030704","CDM","C1889","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","1309.77","674.56","6049.93","26","1193.5","3060.75","percent of total billed charges",""
"SPINE ROD 6.35MMX31XM DANEK","SUP-ITM-10030704","CDM","C1889","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2052.05","53.3","","1901.83","1901.83","2962.25","1 through 10","1193.5","3060.75","percent of total billed charges",""
"SPINE ROD 6.35MMX31XM DANEK","SUP-ITM-10030704","CDM","C1889","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","1620.31","1620.31","19908.88","1 through 10","1193.5","3060.75","percent of total billed charges",""
"SPINE ROD 6.35MMX31XM DANEK","SUP-ITM-10030704","CDM","C1889","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","352.91","352.91","2046.30","1 through 10","1193.5","3060.75","percent of total billed charges",""
"SPINE ROD 6.35MMX31XM DANEK","SUP-ITM-10030704","CDM","C1889","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","9668.75","9668.75","9668.75","1 through 10","1193.5","3060.75","percent of total billed charges",""
"SPINE ROD 6.35MMX31XM DANEK","SUP-ITM-10030704","CDM","C1889","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","699.88","384.10","3443.31","33","1193.5","3060.75","percent of total billed charges",""
"SPINE ROD 6.35MMX31XM DANEK","SUP-ITM-10030704","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA HMO","2687.30","69.8","","1421.24","264.50","4933.46","29","2012.01","3146.22","percent of total billed charges",""
"SPINE ROD 6.35MMX31XM DANEK","SUP-ITM-10030704","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3095.40","80.4","","1022.97","1022.97","3607.50","1 through 10","2012.01","3146.22","percent of total billed charges",""
"SPINE ROD 6.35MMX31XM DANEK","SUP-ITM-10030704","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","3010.54","693.88","5019.88","35","2012.01","3146.22","percent of total billed charges",""
"SPINE ROD 6X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10076779","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","1309.77","674.56","6049.93","26","217","556.5","percent of total billed charges",""
"SPINE ROD 6X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10076779","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","1901.83","1901.83","2962.25","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 6X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10076779","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","1620.31","1620.31","19908.88","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 6X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10076779","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","352.91","352.91","2046.30","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 6X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10076779","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","9668.75","9668.75","9668.75","1 through 10","217","556.5","percent of total billed charges",""
"SPINE ROD 6X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10076779","CDM","C1889","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","699.88","384.10","3443.31","33","217","556.5","percent of total billed charges",""
"SPINE ROD 6X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10076779","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","1421.24","264.50","4933.46","29","365.82","572.04","percent of total billed charges",""
"SPINE ROD 6X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10076779","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","562.80","80.4","","1022.97","1022.97","3607.50","1 through 10","365.82","572.04","percent of total billed charges",""
"SPINE ROD 6X175MM SYNAPSE TITANIUM STRAIGHT HARD","SUP-ITM-10076779","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","3010.54","693.88","5019.88","35","365.82","572.04","percent of total billed charges",""
"SPINE ROD 6X200MM CURVED SMOOTH SS HEX END","SUP-ITM-10031518","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","1309.77","674.56","6049.93","26","162.75","417.38","percent of total billed charges",""
"SPINE ROD 6X200MM CURVED SMOOTH SS HEX END","SUP-ITM-10031518","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","1901.83","1901.83","2962.25","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 6X200MM CURVED SMOOTH SS HEX END","SUP-ITM-10031518","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","1620.31","1620.31","19908.88","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 6X200MM CURVED SMOOTH SS HEX END","SUP-ITM-10031518","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","352.91","352.91","2046.30","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 6X200MM CURVED SMOOTH SS HEX END","SUP-ITM-10031518","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","9668.75","9668.75","9668.75","1 through 10","162.75","417.38","percent of total billed charges",""
"SPINE ROD 6X200MM CURVED SMOOTH SS HEX END","SUP-ITM-10031518","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","699.88","384.10","3443.31","33","162.75","417.38","percent of total billed charges",""
"SPINE ROD 6X200MM CURVED SMOOTH SS HEX END","SUP-ITM-10031518","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","1421.24","264.50","4933.46","29","274.37","429.03","percent of total billed charges",""
"SPINE ROD 6X200MM CURVED SMOOTH SS HEX END","SUP-ITM-10031518","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1022.97","1022.97","3607.50","1 through 10","274.37","429.03","percent of total billed charges",""
"SPINE ROD 6X200MM CURVED SMOOTH SS HEX END","SUP-ITM-10031518","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","3010.54","693.88","5019.88","35","274.37","429.03","percent of total billed charges",""
"SPINE ROD 6X500MM SMOOTH J POSTERIOR RIGHT","SUP-ITM-10031547","CDM","C1889","HCPCS","0278","RC","","","","both","","","4572.50","3429.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3635.14","79.5","","1309.77","674.56","6049.93","26","1417.48","3635.14","percent of total billed charges",""
"SPINE ROD 6X500MM SMOOTH J POSTERIOR RIGHT","SUP-ITM-10031547","CDM","C1889","HCPCS","0278","RC","","","","both","","","4572.50","3429.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2437.14","53.3","","1901.83","1901.83","2962.25","1 through 10","1417.48","3635.14","percent of total billed charges",""
"SPINE ROD 6X500MM SMOOTH J POSTERIOR RIGHT","SUP-ITM-10031547","CDM","C1889","HCPCS","0278","RC","","","","both","","","4572.50","3429.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1668.96","36.5","","1620.31","1620.31","19908.88","1 through 10","1417.48","3635.14","percent of total billed charges",""
"SPINE ROD 6X500MM SMOOTH J POSTERIOR RIGHT","SUP-ITM-10031547","CDM","C1889","HCPCS","0278","RC","","","","both","","","4572.50","3429.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1751.27","38.3","","352.91","352.91","2046.30","1 through 10","1417.48","3635.14","percent of total billed charges",""
"SPINE ROD 6X500MM SMOOTH J POSTERIOR RIGHT","SUP-ITM-10031547","CDM","C1889","HCPCS","0278","RC","","","","both","","","4572.50","3429.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1961.60","42.9","","9668.75","9668.75","9668.75","1 through 10","1417.48","3635.14","percent of total billed charges",""
"SPINE ROD 6X500MM SMOOTH J POSTERIOR RIGHT","SUP-ITM-10031547","CDM","C1889","HCPCS","0278","RC","","","","both","","","4572.50","3429.37","WELLPOINT [1015]","HB AMC WELLPOINT","3373.59","73.78","","699.88","384.10","3443.31","33","1417.48","3635.14","percent of total billed charges",""
"SPINE ROD 6X500MM SMOOTH J POSTERIOR RIGHT","SUP-ITM-10031547","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4572.50","3429.37","AETNA [1001]","HB AMC AETNA HMO","3191.61","69.8","","1421.24","264.50","4933.46","29","2389.59","3736.65","percent of total billed charges",""
"SPINE ROD 6X500MM SMOOTH J POSTERIOR RIGHT","SUP-ITM-10031547","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4572.50","3429.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3676.29","80.4","","1022.97","1022.97","3607.50","1 through 10","2389.59","3736.65","percent of total billed charges",""
"SPINE ROD 6X500MM SMOOTH J POSTERIOR RIGHT","SUP-ITM-10031547","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4572.50","3429.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3736.65","81.72","","3010.54","693.88","5019.88","35","2389.59","3736.65","percent of total billed charges",""
"SPINE ROD 6X60MM TI ALLOY POSTERIOR Y LT PRE CURVED SMOOTH PELVIC","SUP-ITM-10032562","CDM","C1889","HCPCS","0278","RC","","","","both","","","2509.50","1882.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1995.05","79.5","","1309.77","674.56","6049.93","26","777.95","1995.05","percent of total billed charges",""
"SPINE ROD 6X60MM TI ALLOY POSTERIOR Y LT PRE CURVED SMOOTH PELVIC","SUP-ITM-10032562","CDM","C1889","HCPCS","0278","RC","","","","both","","","2509.50","1882.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1337.56","53.3","","1901.83","1901.83","2962.25","1 through 10","777.95","1995.05","percent of total billed charges",""
"SPINE ROD 6X60MM TI ALLOY POSTERIOR Y LT PRE CURVED SMOOTH PELVIC","SUP-ITM-10032562","CDM","C1889","HCPCS","0278","RC","","","","both","","","2509.50","1882.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","915.97","36.5","","1620.31","1620.31","19908.88","1 through 10","777.95","1995.05","percent of total billed charges",""
"SPINE ROD 6X60MM TI ALLOY POSTERIOR Y LT PRE CURVED SMOOTH PELVIC","SUP-ITM-10032562","CDM","C1889","HCPCS","0278","RC","","","","both","","","2509.50","1882.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","961.14","38.3","","352.91","352.91","2046.30","1 through 10","777.95","1995.05","percent of total billed charges",""
"SPINE ROD 6X60MM TI ALLOY POSTERIOR Y LT PRE CURVED SMOOTH PELVIC","SUP-ITM-10032562","CDM","C1889","HCPCS","0278","RC","","","","both","","","2509.50","1882.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1076.58","42.9","","9668.75","9668.75","9668.75","1 through 10","777.95","1995.05","percent of total billed charges",""
"SPINE ROD 6X60MM TI ALLOY POSTERIOR Y LT PRE CURVED SMOOTH PELVIC","SUP-ITM-10032562","CDM","C1889","HCPCS","0278","RC","","","","both","","","2509.50","1882.12","WELLPOINT [1015]","HB AMC WELLPOINT","1851.51","73.78","","699.88","384.10","3443.31","33","777.95","1995.05","percent of total billed charges",""
"SPINE ROD 6X60MM TI ALLOY POSTERIOR Y LT PRE CURVED SMOOTH PELVIC","SUP-ITM-10032562","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2509.50","1882.12","AETNA [1001]","HB AMC AETNA HMO","1751.63","69.8","","1421.24","264.50","4933.46","29","1311.46","2050.76","percent of total billed charges",""
"SPINE ROD 6X60MM TI ALLOY POSTERIOR Y LT PRE CURVED SMOOTH PELVIC","SUP-ITM-10032562","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2509.50","1882.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2017.64","80.4","","1022.97","1022.97","3607.50","1 through 10","1311.46","2050.76","percent of total billed charges",""
"SPINE ROD 6X60MM TI ALLOY POSTERIOR Y LT PRE CURVED SMOOTH PELVIC","SUP-ITM-10032562","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2509.50","1882.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2050.76","81.72","","3010.54","693.88","5019.88","35","1311.46","2050.76","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","210.00","157.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","109.75","52.26","","1113.10","1113.10","1113.10","1 through 10","65.1","166.95","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","210.00","157.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","166.95","79.5","","1293.60","1148.53","1603.80","1 through 10","65.1","166.95","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","76.65","36.5","","1023.42","771.29","2068.67","33","65.1","166.95","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","80.43","38.3","","850.52","759.78","1211.25","66","65.1","166.95","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","2548.09","2548.09","2548.09","1 through 10","65.1","166.95","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.09","42.9","","956.46","956.46","956.46","1 through 10","65.1","166.95","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB AMC WELLPOINT","154.94","73.78","","2344.73","1619.47","2530.35","16","65.1","166.95","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA HMO","146.58","69.8","","1523.63","988.41","4330.26","39","109.75","171.61","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","AETNA [1001]","HB AMC AETNA PPO","168.84","80.4","","1670.25","1670.25","1670.25","1 through 10","109.75","171.61","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","109.75","52.26","","1113.10","1113.10","1113.10","1 through 10","109.75","171.61","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","171.61","81.72","","1738.90","1484.65","2716.94","38","109.75","171.61","percent of total billed charges",""
"SPINE SET 1.3X4.7MM 40CM EXT STIMLTR CORD IMPL INLINE SCRW PASS TUNNELING OBTRTR TRQ WRENCH BOOT OCTAPOLAR","SUP-ITM-10016454","CDM","C1883","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","760.11","36.5","","1073.15","1073.15","1073.15","1 through 10","645.58","1655.59","percent of total billed charges",""
"SPINE SET 1.3X4.7MM 40CM EXT STIMLTR CORD IMPL INLINE SCRW PASS TUNNELING OBTRTR TRQ WRENCH BOOT OCTAPOLAR","SUP-ITM-10016454","CDM","C1883","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","797.60","38.3","","1808.38","1642.20","1808.38","1 through 10","645.58","1655.59","percent of total billed charges",""
"SPINE SET 1.3X4.7MM 40CM EXT STIMLTR CORD IMPL INLINE SCRW PASS TUNNELING OBTRTR TRQ WRENCH BOOT OCTAPOLAR","SUP-ITM-10016454","CDM","C1883","HCPCS","0278","RC","","","","both","","","2082.50","1561.87","WELLPOINT [1015]","HB AMC WELLPOINT","1536.47","73.78","","625.38","625.38","625.38","1 through 10","645.58","1655.59","percent of total billed charges",""
"SPINE SPACER 10X31 10-14MM 8DEG ALTERA","SUP-ITM-10137663","CDM","C1889","HCPCS","0278","RC","","","","both","","","14500.00","10875.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11527.50","79.5","","1309.77","674.56","6049.93","26","4495","11527.5","percent of total billed charges",""
"SPINE SPACER 10X31 10-14MM 8DEG ALTERA","SUP-ITM-10137663","CDM","C1889","HCPCS","0278","RC","","","","both","","","14500.00","10875.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7728.50","53.3","","1901.83","1901.83","2962.25","1 through 10","4495","11527.5","percent of total billed charges",""
"SPINE SPACER 10X31 10-14MM 8DEG ALTERA","SUP-ITM-10137663","CDM","C1889","HCPCS","0278","RC","","","","both","","","14500.00","10875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5292.50","36.5","","1620.31","1620.31","19908.88","1 through 10","4495","11527.5","percent of total billed charges",""
"SPINE SPACER 10X31 10-14MM 8DEG ALTERA","SUP-ITM-10137663","CDM","C1889","HCPCS","0278","RC","","","","both","","","14500.00","10875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5553.50","38.3","","352.91","352.91","2046.30","1 through 10","4495","11527.5","percent of total billed charges",""
"SPINE SPACER 10X31 10-14MM 8DEG ALTERA","SUP-ITM-10137663","CDM","C1889","HCPCS","0278","RC","","","","both","","","14500.00","10875.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6220.50","42.9","","9668.75","9668.75","9668.75","1 through 10","4495","11527.5","percent of total billed charges",""
"SPINE SPACER 10X31 10-14MM 8DEG ALTERA","SUP-ITM-10137663","CDM","C1889","HCPCS","0278","RC","","","","both","","","14500.00","10875.00","WELLPOINT [1015]","HB AMC WELLPOINT","10698.10","73.78","","699.88","384.10","3443.31","33","4495","11527.5","percent of total billed charges",""
"SPINE SPACER 10X31 10-14MM 8DEG ALTERA","SUP-ITM-10137663","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14500.00","10875.00","AETNA [1001]","HB AMC AETNA HMO","10121.00","69.8","","1421.24","264.50","4933.46","29","7577.7","11849.4","percent of total billed charges",""
"SPINE SPACER 10X31 10-14MM 8DEG ALTERA","SUP-ITM-10137663","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14500.00","10875.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11658.00","80.4","","1022.97","1022.97","3607.50","1 through 10","7577.7","11849.4","percent of total billed charges",""
"SPINE SPACER 10X31 10-14MM 8DEG ALTERA","SUP-ITM-10137663","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14500.00","10875.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11849.40","81.72","","3010.54","693.88","5019.88","35","7577.7","11849.4","percent of total billed charges",""
"SPINE SPACER 10X34X24MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082711","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7950.00","79.5","","1309.77","674.56","6049.93","26","3100","7950","percent of total billed charges",""
"SPINE SPACER 10X34X24MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082711","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5330.00","53.3","","1901.83","1901.83","2962.25","1 through 10","3100","7950","percent of total billed charges",""
"SPINE SPACER 10X34X24MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082711","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3650.00","36.5","","1620.31","1620.31","19908.88","1 through 10","3100","7950","percent of total billed charges",""
"SPINE SPACER 10X34X24MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082711","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3830.00","38.3","","352.91","352.91","2046.30","1 through 10","3100","7950","percent of total billed charges",""
"SPINE SPACER 10X34X24MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082711","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4290.00","42.9","","9668.75","9668.75","9668.75","1 through 10","3100","7950","percent of total billed charges",""
"SPINE SPACER 10X34X24MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082711","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB AMC WELLPOINT","7378.00","73.78","","699.88","384.10","3443.31","33","3100","7950","percent of total billed charges",""
"SPINE SPACER 10X34X24MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082711","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA HMO","6980.00","69.8","","1421.24","264.50","4933.46","29","5226","8172","percent of total billed charges",""
"SPINE SPACER 10X34X24MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082711","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8040.00","80.4","","1022.97","1022.97","3607.50","1 through 10","5226","8172","percent of total billed charges",""
"SPINE SPACER 10X34X24MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082711","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8172.00","81.72","","3010.54","693.88","5019.88","35","5226","8172","percent of total billed charges",""
"SPINE SPACER 11.0X25.0 9.0MM SHORT GRAFT BIO AVS UNILIF PL","SUP-ITM-10114190","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5565.00","79.5","","1309.77","674.56","6049.93","26","2170","5565","percent of total billed charges",""
"SPINE SPACER 11.0X25.0 9.0MM SHORT GRAFT BIO AVS UNILIF PL","SUP-ITM-10114190","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3731.00","53.3","","1901.83","1901.83","2962.25","1 through 10","2170","5565","percent of total billed charges",""
"SPINE SPACER 11.0X25.0 9.0MM SHORT GRAFT BIO AVS UNILIF PL","SUP-ITM-10114190","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2555.00","36.5","","1620.31","1620.31","19908.88","1 through 10","2170","5565","percent of total billed charges",""
"SPINE SPACER 11.0X25.0 9.0MM SHORT GRAFT BIO AVS UNILIF PL","SUP-ITM-10114190","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2681.00","38.3","","352.91","352.91","2046.30","1 through 10","2170","5565","percent of total billed charges",""
"SPINE SPACER 11.0X25.0 9.0MM SHORT GRAFT BIO AVS UNILIF PL","SUP-ITM-10114190","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3003.00","42.9","","9668.75","9668.75","9668.75","1 through 10","2170","5565","percent of total billed charges",""
"SPINE SPACER 11.0X25.0 9.0MM SHORT GRAFT BIO AVS UNILIF PL","SUP-ITM-10114190","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","WELLPOINT [1015]","HB AMC WELLPOINT","5164.60","73.78","","699.88","384.10","3443.31","33","2170","5565","percent of total billed charges",""
"SPINE SPACER 11.0X25.0 9.0MM SHORT GRAFT BIO AVS UNILIF PL","SUP-ITM-10114190","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","AETNA [1001]","HB AMC AETNA HMO","4886.00","69.8","","1421.24","264.50","4933.46","29","3658.2","5720.4","percent of total billed charges",""
"SPINE SPACER 11.0X25.0 9.0MM SHORT GRAFT BIO AVS UNILIF PL","SUP-ITM-10114190","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5628.00","80.4","","1022.97","1022.97","3607.50","1 through 10","3658.2","5720.4","percent of total billed charges",""
"SPINE SPACER 11.0X25.0 9.0MM SHORT GRAFT BIO AVS UNILIF PL","SUP-ITM-10114190","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5720.40","81.72","","3010.54","693.88","5019.88","35","3658.2","5720.4","percent of total billed charges",""
"SPINE SPACER 12X14 5MMDEG ALLOGRAFT CERVICAL ANTERIOR WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3078.50","2308.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2447.41","79.5","","1309.77","674.56","6049.93","26","954.34","2447.41","percent of total billed charges",""
"SPINE SPACER 12X14 5MMDEG ALLOGRAFT CERVICAL ANTERIOR WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3078.50","2308.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1640.84","53.3","","1901.83","1901.83","2962.25","1 through 10","954.34","2447.41","percent of total billed charges",""
"SPINE SPACER 12X14 5MMDEG ALLOGRAFT CERVICAL ANTERIOR WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3078.50","2308.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1123.65","36.5","","1620.31","1620.31","19908.88","1 through 10","954.34","2447.41","percent of total billed charges",""
"SPINE SPACER 12X14 5MMDEG ALLOGRAFT CERVICAL ANTERIOR WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3078.50","2308.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1179.07","38.3","","352.91","352.91","2046.30","1 through 10","954.34","2447.41","percent of total billed charges",""
"SPINE SPACER 12X14 5MMDEG ALLOGRAFT CERVICAL ANTERIOR WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3078.50","2308.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1320.68","42.9","","9668.75","9668.75","9668.75","1 through 10","954.34","2447.41","percent of total billed charges",""
"SPINE SPACER 12X14 5MMDEG ALLOGRAFT CERVICAL ANTERIOR WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048828","CDM","C1889","HCPCS","0278","RC","","","","both","","","3078.50","2308.87","WELLPOINT [1015]","HB AMC WELLPOINT","2271.32","73.78","","699.88","384.10","3443.31","33","954.34","2447.41","percent of total billed charges",""
"SPINE SPACER 12X14 5MMDEG ALLOGRAFT CERVICAL ANTERIOR WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048828","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3078.50","2308.87","AETNA [1001]","HB AMC AETNA HMO","2148.79","69.8","","1421.24","264.50","4933.46","29","1608.82","2515.75","percent of total billed charges",""
"SPINE SPACER 12X14 5MMDEG ALLOGRAFT CERVICAL ANTERIOR WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048828","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3078.50","2308.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2475.11","80.4","","1022.97","1022.97","3607.50","1 through 10","1608.82","2515.75","percent of total billed charges",""
"SPINE SPACER 12X14 5MMDEG ALLOGRAFT CERVICAL ANTERIOR WEDGE LORDOTIC FREEZE DRY","SUP-ITM-10048828","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3078.50","2308.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2515.75","81.72","","3010.54","693.88","5019.88","35","1608.82","2515.75","percent of total billed charges",""
"SPINE SPACER 12X42X30MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082746","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7950.00","79.5","","1309.77","674.56","6049.93","26","3100","7950","percent of total billed charges",""
"SPINE SPACER 12X42X30MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082746","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5330.00","53.3","","1901.83","1901.83","2962.25","1 through 10","3100","7950","percent of total billed charges",""
"SPINE SPACER 12X42X30MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082746","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3650.00","36.5","","1620.31","1620.31","19908.88","1 through 10","3100","7950","percent of total billed charges",""
"SPINE SPACER 12X42X30MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082746","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3830.00","38.3","","352.91","352.91","2046.30","1 through 10","3100","7950","percent of total billed charges",""
"SPINE SPACER 12X42X30MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082746","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4290.00","42.9","","9668.75","9668.75","9668.75","1 through 10","3100","7950","percent of total billed charges",""
"SPINE SPACER 12X42X30MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082746","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB AMC WELLPOINT","7378.00","73.78","","699.88","384.10","3443.31","33","3100","7950","percent of total billed charges",""
"SPINE SPACER 12X42X30MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082746","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA HMO","6980.00","69.8","","1421.24","264.50","4933.46","29","5226","8172","percent of total billed charges",""
"SPINE SPACER 12X42X30MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082746","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8040.00","80.4","","1022.97","1022.97","3607.50","1 through 10","5226","8172","percent of total billed charges",""
"SPINE SPACER 12X42X30MM LUMBAR 8DEG BRIGADE","SUP-ITM-10082746","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8172.00","81.72","","3010.54","693.88","5019.88","35","5226","8172","percent of total billed charges",""
"SPINE SPACER 30X10MM LUMBAR FUSION CRESCENT POLYETHER ETHER KETONE","SUP-ITM-10111192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","800.18","480.96","1887.97","195","1550","3975","percent of total billed charges",""
"SPINE SPACER 30X10MM LUMBAR FUSION CRESCENT POLYETHER ETHER KETONE","SUP-ITM-10111192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2665.00","53.3","","813.12","216.42","1444.50","81","1550","3975","percent of total billed charges",""
"SPINE SPACER 30X10MM LUMBAR FUSION CRESCENT POLYETHER ETHER KETONE","SUP-ITM-10111192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1550.00","31","","432.60","432.60","432.60","1 through 10","1550","3975","percent of total billed charges",""
"SPINE SPACER 30X10MM LUMBAR FUSION CRESCENT POLYETHER ETHER KETONE","SUP-ITM-10111192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","148.37","54.89","631.39","94","1550","3975","percent of total billed charges",""
"SPINE SPACER 30X10MM LUMBAR FUSION CRESCENT POLYETHER ETHER KETONE","SUP-ITM-10111192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","279.30","91.72","1116.77","266","1550","3975","percent of total billed charges",""
"SPINE SPACER 30X10MM LUMBAR FUSION CRESCENT POLYETHER ETHER KETONE","SUP-ITM-10111192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","731.00","63.70","731.00","1 through 10","1550","3975","percent of total billed charges",""
"SPINE SPACER 30X10MM LUMBAR FUSION CRESCENT POLYETHER ETHER KETONE","SUP-ITM-10111192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","384.74","384.74","384.74","1 through 10","1550","3975","percent of total billed charges",""
"SPINE SPACER 30X10MM LUMBAR FUSION CRESCENT POLYETHER ETHER KETONE","SUP-ITM-10111192","CDM","C1713","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","286.63","119.22","1107.45","105","1550","3975","percent of total billed charges",""
"SPINE SPACER 30X10MM LUMBAR FUSION CRESCENT POLYETHER ETHER KETONE","SUP-ITM-10111192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","675.31","184.75","1721.50","286","2613","4086","percent of total billed charges",""
"SPINE SPACER 30X10MM LUMBAR FUSION CRESCENT POLYETHER ETHER KETONE","SUP-ITM-10111192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA PPO","4020.00","80.4","","1261.44","103.12","1514.10","21","2613","4086","percent of total billed charges",""
"SPINE SPACER 30X10MM LUMBAR FUSION CRESCENT POLYETHER ETHER KETONE","SUP-ITM-10111192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4020.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2613","4086","percent of total billed charges",""
"SPINE SPACER 30X10MM LUMBAR FUSION CRESCENT POLYETHER ETHER KETONE","SUP-ITM-10111192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4086.00","81.72","","5157.68","5157.68","5157.68","1 through 10","2613","4086","percent of total billed charges",""
"SPINE SPACER 30X10MM LUMBAR FUSION CRESCENT POLYETHER ETHER KETONE","SUP-ITM-10111192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","431.26","71.26","1459.57","88","2613","4086","percent of total billed charges",""
"SPINE SPACER 5MM CERVICAL 4DEG PLUG","SUP-ITM-10100956","CDM","C1889","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2504.25","79.5","","1309.77","674.56","6049.93","26","976.5","2504.25","percent of total billed charges",""
"SPINE SPACER 5MM CERVICAL 4DEG PLUG","SUP-ITM-10100956","CDM","C1889","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1678.95","53.3","","1901.83","1901.83","2962.25","1 through 10","976.5","2504.25","percent of total billed charges",""
"SPINE SPACER 5MM CERVICAL 4DEG PLUG","SUP-ITM-10100956","CDM","C1889","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1149.75","36.5","","1620.31","1620.31","19908.88","1 through 10","976.5","2504.25","percent of total billed charges",""
"SPINE SPACER 5MM CERVICAL 4DEG PLUG","SUP-ITM-10100956","CDM","C1889","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1206.45","38.3","","352.91","352.91","2046.30","1 through 10","976.5","2504.25","percent of total billed charges",""
"SPINE SPACER 5MM CERVICAL 4DEG PLUG","SUP-ITM-10100956","CDM","C1889","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","9668.75","9668.75","9668.75","1 through 10","976.5","2504.25","percent of total billed charges",""
"SPINE SPACER 5MM CERVICAL 4DEG PLUG","SUP-ITM-10100956","CDM","C1889","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","WELLPOINT [1015]","HB AMC WELLPOINT","2324.07","73.78","","699.88","384.10","3443.31","33","976.5","2504.25","percent of total billed charges",""
"SPINE SPACER 5MM CERVICAL 4DEG PLUG","SUP-ITM-10100956","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA HMO","2198.70","69.8","","1421.24","264.50","4933.46","29","1646.19","2574.18","percent of total billed charges",""
"SPINE SPACER 5MM CERVICAL 4DEG PLUG","SUP-ITM-10100956","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2532.60","80.4","","1022.97","1022.97","3607.50","1 through 10","1646.19","2574.18","percent of total billed charges",""
"SPINE SPACER 5MM CERVICAL 4DEG PLUG","SUP-ITM-10100956","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2574.18","81.72","","3010.54","693.88","5019.88","35","1646.19","2574.18","percent of total billed charges",""
"SPINE SPACER 6MM CERVICAL 4DEG PLUG","SUP-ITM-10100957","CDM","C1889","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2504.25","79.5","","1309.77","674.56","6049.93","26","976.5","2504.25","percent of total billed charges",""
"SPINE SPACER 6MM CERVICAL 4DEG PLUG","SUP-ITM-10100957","CDM","C1889","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1678.95","53.3","","1901.83","1901.83","2962.25","1 through 10","976.5","2504.25","percent of total billed charges",""
"SPINE SPACER 6MM CERVICAL 4DEG PLUG","SUP-ITM-10100957","CDM","C1889","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1149.75","36.5","","1620.31","1620.31","19908.88","1 through 10","976.5","2504.25","percent of total billed charges",""
"SPINE SPACER 6MM CERVICAL 4DEG PLUG","SUP-ITM-10100957","CDM","C1889","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1206.45","38.3","","352.91","352.91","2046.30","1 through 10","976.5","2504.25","percent of total billed charges",""
"SPINE SPACER 6MM CERVICAL 4DEG PLUG","SUP-ITM-10100957","CDM","C1889","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","9668.75","9668.75","9668.75","1 through 10","976.5","2504.25","percent of total billed charges",""
"SPINE SPACER 6MM CERVICAL 4DEG PLUG","SUP-ITM-10100957","CDM","C1889","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","WELLPOINT [1015]","HB AMC WELLPOINT","2324.07","73.78","","699.88","384.10","3443.31","33","976.5","2504.25","percent of total billed charges",""
"SPINE SPACER 6MM CERVICAL 4DEG PLUG","SUP-ITM-10100957","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA HMO","2198.70","69.8","","1421.24","264.50","4933.46","29","1646.19","2574.18","percent of total billed charges",""
"SPINE SPACER 6MM CERVICAL 4DEG PLUG","SUP-ITM-10100957","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2532.60","80.4","","1022.97","1022.97","3607.50","1 through 10","1646.19","2574.18","percent of total billed charges",""
"SPINE SPACER 6MM CERVICAL 4DEG PLUG","SUP-ITM-10100957","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2574.18","81.72","","3010.54","693.88","5019.88","35","1646.19","2574.18","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","both","","","9592.68","7194.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7626.18","79.5","","1309.77","674.56","6049.93","26","2973.73","7626.18","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","both","","","9592.68","7194.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5112.90","53.3","","1901.83","1901.83","2962.25","1 through 10","2973.73","7626.18","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","both","","","9592.68","7194.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3501.33","36.5","","1620.31","1620.31","19908.88","1 through 10","2973.73","7626.18","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","both","","","9592.68","7194.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3674.00","38.3","","352.91","352.91","2046.30","1 through 10","2973.73","7626.18","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","both","","","9592.68","7194.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4115.26","42.9","","9668.75","9668.75","9668.75","1 through 10","2973.73","7626.18","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","both","","","9592.68","7194.51","WELLPOINT [1015]","HB AMC WELLPOINT","7077.48","73.78","","699.88","384.10","3443.31","33","2973.73","7626.18","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9592.68","7194.51","AETNA [1001]","HB AMC AETNA HMO","6695.69","69.8","","1421.24","264.50","4933.46","29","5013.13","7839.14","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9592.68","7194.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7712.51","80.4","","1022.97","1022.97","3607.50","1 through 10","5013.13","7839.14","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9592.68","7194.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7839.14","81.72","","3010.54","693.88","5019.88","35","5013.13","7839.14","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7403.44","79.5","","1309.77","674.56","6049.93","26","2886.88","7403.44","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4963.56","53.3","","1901.83","1901.83","2962.25","1 through 10","2886.88","7403.44","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3399.06","36.5","","1620.31","1620.31","19908.88","1 through 10","2886.88","7403.44","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3566.69","38.3","","352.91","352.91","2046.30","1 through 10","2886.88","7403.44","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3995.06","42.9","","9668.75","9668.75","9668.75","1 through 10","2886.88","7403.44","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","both","","","9312.50","6984.37","WELLPOINT [1015]","HB AMC WELLPOINT","6870.76","73.78","","699.88","384.10","3443.31","33","2886.88","7403.44","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9312.50","6984.37","AETNA [1001]","HB AMC AETNA HMO","6500.13","69.8","","1421.24","264.50","4933.46","29","4866.71","7610.18","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9312.50","6984.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7487.25","80.4","","1022.97","1022.97","3607.50","1 through 10","4866.71","7610.18","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9312.50","6984.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7610.18","81.72","","3010.54","693.88","5019.88","35","4866.71","7610.18","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4372.50","79.5","","1309.77","674.56","6049.93","26","1705","4372.5","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2931.50","53.3","","1901.83","1901.83","2962.25","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2007.50","36.5","","1620.31","1620.31","19908.88","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2106.50","38.3","","352.91","352.91","2046.30","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2359.50","42.9","","9668.75","9668.75","9668.75","1 through 10","1705","4372.5","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","WELLPOINT [1015]","HB AMC WELLPOINT","4057.90","73.78","","699.88","384.10","3443.31","33","1705","4372.5","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","AETNA [1001]","HB AMC AETNA HMO","3839.00","69.8","","1421.24","264.50","4933.46","29","2874.3","4494.6","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4422.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2874.3","4494.6","percent of total billed charges",""
"SPINE SPACER 8.0X9.0 20MM LG 4.0DEG DEVICE INTERVERTEBRAL COROENT PEEK IMPACT NARROW","SUP-ITM-10077066","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4494.60","81.72","","3010.54","693.88","5019.88","35","2874.3","4494.6","percent of total billed charges",""
"SPINE SPACER 8MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261679","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","800.18","480.96","1887.97","195","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 8MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261679","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.85","53.3","","813.12","216.42","1444.50","81","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 8MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261679","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","759.50","31","","432.60","432.60","432.60","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 8MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261679","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","148.37","54.89","631.39","94","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 8MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261679","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","279.30","91.72","1116.77","266","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 8MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261679","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","731.00","63.70","731.00","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 8MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261679","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","384.74","384.74","384.74","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 8MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261679","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","286.63","119.22","1107.45","105","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 8MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","675.31","184.75","1721.50","286","1280.37","2002.14","percent of total billed charges",""
"SPINE SPACER 8MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA PPO","1969.80","80.4","","1261.44","103.12","1514.10","21","1280.37","2002.14","percent of total billed charges",""
"SPINE SPACER 8MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.80","80.4","","1365.00","1365.00","1365.00","1 through 10","1280.37","2002.14","percent of total billed charges",""
"SPINE SPACER 8MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2002.14","81.72","","5157.68","5157.68","5157.68","1 through 10","1280.37","2002.14","percent of total billed charges",""
"SPINE SPACER 8MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","431.26","71.26","1459.57","88","1280.37","2002.14","percent of total billed charges",""
"SPINE SPACER 8X18 45MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057509","CDM","C1889","HCPCS","0278","RC","","","","both","","","10612.50","7959.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8436.94","79.5","","1309.77","674.56","6049.93","26","3289.88","8436.94","percent of total billed charges",""
"SPINE SPACER 8X18 45MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057509","CDM","C1889","HCPCS","0278","RC","","","","both","","","10612.50","7959.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5656.46","53.3","","1901.83","1901.83","2962.25","1 through 10","3289.88","8436.94","percent of total billed charges",""
"SPINE SPACER 8X18 45MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057509","CDM","C1889","HCPCS","0278","RC","","","","both","","","10612.50","7959.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3873.56","36.5","","1620.31","1620.31","19908.88","1 through 10","3289.88","8436.94","percent of total billed charges",""
"SPINE SPACER 8X18 45MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057509","CDM","C1889","HCPCS","0278","RC","","","","both","","","10612.50","7959.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4064.59","38.3","","352.91","352.91","2046.30","1 through 10","3289.88","8436.94","percent of total billed charges",""
"SPINE SPACER 8X18 45MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057509","CDM","C1889","HCPCS","0278","RC","","","","both","","","10612.50","7959.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4552.76","42.9","","9668.75","9668.75","9668.75","1 through 10","3289.88","8436.94","percent of total billed charges",""
"SPINE SPACER 8X18 45MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057509","CDM","C1889","HCPCS","0278","RC","","","","both","","","10612.50","7959.37","WELLPOINT [1015]","HB AMC WELLPOINT","7829.90","73.78","","699.88","384.10","3443.31","33","3289.88","8436.94","percent of total billed charges",""
"SPINE SPACER 8X18 45MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057509","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10612.50","7959.37","AETNA [1001]","HB AMC AETNA HMO","7407.53","69.8","","1421.24","264.50","4933.46","29","5546.09","8672.54","percent of total billed charges",""
"SPINE SPACER 8X18 45MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057509","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10612.50","7959.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8532.45","80.4","","1022.97","1022.97","3607.50","1 through 10","5546.09","8672.54","percent of total billed charges",""
"SPINE SPACER 8X18 45MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057509","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10612.50","7959.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8672.54","81.72","","3010.54","693.88","5019.88","35","5546.09","8672.54","percent of total billed charges",""
"SPINE SPACER 8X26X45MM LUMBAR LATERAL COROENT POLYETHER ETHER KETONE FUSION","SUP-ITM-10107606","CDM","C1889","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8514.45","79.5","","1309.77","674.56","6049.93","26","3320.1","8514.45","percent of total billed charges",""
"SPINE SPACER 8X26X45MM LUMBAR LATERAL COROENT POLYETHER ETHER KETONE FUSION","SUP-ITM-10107606","CDM","C1889","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5708.43","53.3","","1901.83","1901.83","2962.25","1 through 10","3320.1","8514.45","percent of total billed charges",""
"SPINE SPACER 8X26X45MM LUMBAR LATERAL COROENT POLYETHER ETHER KETONE FUSION","SUP-ITM-10107606","CDM","C1889","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3909.15","36.5","","1620.31","1620.31","19908.88","1 through 10","3320.1","8514.45","percent of total billed charges",""
"SPINE SPACER 8X26X45MM LUMBAR LATERAL COROENT POLYETHER ETHER KETONE FUSION","SUP-ITM-10107606","CDM","C1889","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4101.93","38.3","","352.91","352.91","2046.30","1 through 10","3320.1","8514.45","percent of total billed charges",""
"SPINE SPACER 8X26X45MM LUMBAR LATERAL COROENT POLYETHER ETHER KETONE FUSION","SUP-ITM-10107606","CDM","C1889","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4594.59","42.9","","9668.75","9668.75","9668.75","1 through 10","3320.1","8514.45","percent of total billed charges",""
"SPINE SPACER 8X26X45MM LUMBAR LATERAL COROENT POLYETHER ETHER KETONE FUSION","SUP-ITM-10107606","CDM","C1889","HCPCS","0278","RC","","","","both","","","10710.00","8032.50","WELLPOINT [1015]","HB AMC WELLPOINT","7901.84","73.78","","699.88","384.10","3443.31","33","3320.1","8514.45","percent of total billed charges",""
"SPINE SPACER 8X26X45MM LUMBAR LATERAL COROENT POLYETHER ETHER KETONE FUSION","SUP-ITM-10107606","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","AETNA [1001]","HB AMC AETNA HMO","7475.58","69.8","","1421.24","264.50","4933.46","29","5597.05","8752.21","percent of total billed charges",""
"SPINE SPACER 8X26X45MM LUMBAR LATERAL COROENT POLYETHER ETHER KETONE FUSION","SUP-ITM-10107606","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8610.84","80.4","","1022.97","1022.97","3607.50","1 through 10","5597.05","8752.21","percent of total billed charges",""
"SPINE SPACER 8X26X45MM LUMBAR LATERAL COROENT POLYETHER ETHER KETONE FUSION","SUP-ITM-10107606","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10710.00","8032.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8752.21","81.72","","3010.54","693.88","5019.88","35","5597.05","8752.21","percent of total billed charges",""
"SPINE SPACER 9MM 5DEG ALLOGRAFT LORDOTIC CERVICAL ANTERIOR CORTICO CANCELLOUS FREEZE DRIED","SUP-ITM-10048848","CDM","C1889","HCPCS","0278","RC","","","","both","","","3809.86","2857.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3028.84","79.5","","1309.77","674.56","6049.93","26","1181.06","3028.84","percent of total billed charges",""
"SPINE SPACER 9MM 5DEG ALLOGRAFT LORDOTIC CERVICAL ANTERIOR CORTICO CANCELLOUS FREEZE DRIED","SUP-ITM-10048848","CDM","C1889","HCPCS","0278","RC","","","","both","","","3809.86","2857.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2030.66","53.3","","1901.83","1901.83","2962.25","1 through 10","1181.06","3028.84","percent of total billed charges",""
"SPINE SPACER 9MM 5DEG ALLOGRAFT LORDOTIC CERVICAL ANTERIOR CORTICO CANCELLOUS FREEZE DRIED","SUP-ITM-10048848","CDM","C1889","HCPCS","0278","RC","","","","both","","","3809.86","2857.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1390.60","36.5","","1620.31","1620.31","19908.88","1 through 10","1181.06","3028.84","percent of total billed charges",""
"SPINE SPACER 9MM 5DEG ALLOGRAFT LORDOTIC CERVICAL ANTERIOR CORTICO CANCELLOUS FREEZE DRIED","SUP-ITM-10048848","CDM","C1889","HCPCS","0278","RC","","","","both","","","3809.86","2857.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1459.18","38.3","","352.91","352.91","2046.30","1 through 10","1181.06","3028.84","percent of total billed charges",""
"SPINE SPACER 9MM 5DEG ALLOGRAFT LORDOTIC CERVICAL ANTERIOR CORTICO CANCELLOUS FREEZE DRIED","SUP-ITM-10048848","CDM","C1889","HCPCS","0278","RC","","","","both","","","3809.86","2857.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1634.43","42.9","","9668.75","9668.75","9668.75","1 through 10","1181.06","3028.84","percent of total billed charges",""
"SPINE SPACER 9MM 5DEG ALLOGRAFT LORDOTIC CERVICAL ANTERIOR CORTICO CANCELLOUS FREEZE DRIED","SUP-ITM-10048848","CDM","C1889","HCPCS","0278","RC","","","","both","","","3809.86","2857.39","WELLPOINT [1015]","HB AMC WELLPOINT","2810.91","73.78","","699.88","384.10","3443.31","33","1181.06","3028.84","percent of total billed charges",""
"SPINE SPACER 9MM 5DEG ALLOGRAFT LORDOTIC CERVICAL ANTERIOR CORTICO CANCELLOUS FREEZE DRIED","SUP-ITM-10048848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3809.86","2857.39","AETNA [1001]","HB AMC AETNA HMO","2659.28","69.8","","1421.24","264.50","4933.46","29","1991.03","3113.42","percent of total billed charges",""
"SPINE SPACER 9MM 5DEG ALLOGRAFT LORDOTIC CERVICAL ANTERIOR CORTICO CANCELLOUS FREEZE DRIED","SUP-ITM-10048848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3809.86","2857.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3063.13","80.4","","1022.97","1022.97","3607.50","1 through 10","1991.03","3113.42","percent of total billed charges",""
"SPINE SPACER 9MM 5DEG ALLOGRAFT LORDOTIC CERVICAL ANTERIOR CORTICO CANCELLOUS FREEZE DRIED","SUP-ITM-10048848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3809.86","2857.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3113.42","81.72","","3010.54","693.88","5019.88","35","1991.03","3113.42","percent of total billed charges",""
"SPINE SPACER 9MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261678","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","1309.77","674.56","6049.93","26","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 9MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261678","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.85","53.3","","1901.83","1901.83","2962.25","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 9MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261678","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","1620.31","1620.31","19908.88","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 9MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261678","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","352.91","352.91","2046.30","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 9MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261678","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","9668.75","9668.75","9668.75","1 through 10","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 9MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261678","CDM","C1889","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","699.88","384.10","3443.31","33","759.5","1947.75","percent of total billed charges",""
"SPINE SPACER 9MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261678","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","1421.24","264.50","4933.46","29","1280.37","2002.14","percent of total billed charges",""
"SPINE SPACER 9MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261678","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.80","80.4","","1022.97","1022.97","3607.50","1 through 10","1280.37","2002.14","percent of total billed charges",""
"SPINE SPACER 9MM ACIS PEEK OPTIMA LORDOTIC ANTERIOR STD","SUP-ITM-10261678","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","3010.54","693.88","5019.88","35","1280.37","2002.14","percent of total billed charges",""
"SPINE SPACER 9MM ALLOGRAFT BONE CERVICAL CANCELLOUS FREEZE DRIED","SUP-ITM-10048887","CDM","C1889","HCPCS","0278","RC","","","","both","","","3384.85","2538.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2690.96","79.5","","1309.77","674.56","6049.93","26","1049.3","2690.96","percent of total billed charges",""
"SPINE SPACER 9MM ALLOGRAFT BONE CERVICAL CANCELLOUS FREEZE DRIED","SUP-ITM-10048887","CDM","C1889","HCPCS","0278","RC","","","","both","","","3384.85","2538.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1804.13","53.3","","1901.83","1901.83","2962.25","1 through 10","1049.3","2690.96","percent of total billed charges",""
"SPINE SPACER 9MM ALLOGRAFT BONE CERVICAL CANCELLOUS FREEZE DRIED","SUP-ITM-10048887","CDM","C1889","HCPCS","0278","RC","","","","both","","","3384.85","2538.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1235.47","36.5","","1620.31","1620.31","19908.88","1 through 10","1049.3","2690.96","percent of total billed charges",""
"SPINE SPACER 9MM ALLOGRAFT BONE CERVICAL CANCELLOUS FREEZE DRIED","SUP-ITM-10048887","CDM","C1889","HCPCS","0278","RC","","","","both","","","3384.85","2538.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1296.40","38.3","","352.91","352.91","2046.30","1 through 10","1049.3","2690.96","percent of total billed charges",""
"SPINE SPACER 9MM ALLOGRAFT BONE CERVICAL CANCELLOUS FREEZE DRIED","SUP-ITM-10048887","CDM","C1889","HCPCS","0278","RC","","","","both","","","3384.85","2538.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1452.10","42.9","","9668.75","9668.75","9668.75","1 through 10","1049.3","2690.96","percent of total billed charges",""
"SPINE SPACER 9MM ALLOGRAFT BONE CERVICAL CANCELLOUS FREEZE DRIED","SUP-ITM-10048887","CDM","C1889","HCPCS","0278","RC","","","","both","","","3384.85","2538.64","WELLPOINT [1015]","HB AMC WELLPOINT","2497.34","73.78","","699.88","384.10","3443.31","33","1049.3","2690.96","percent of total billed charges",""
"SPINE SPACER 9MM ALLOGRAFT BONE CERVICAL CANCELLOUS FREEZE DRIED","SUP-ITM-10048887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3384.85","2538.64","AETNA [1001]","HB AMC AETNA HMO","2362.63","69.8","","1421.24","264.50","4933.46","29","1768.92","2766.1","percent of total billed charges",""
"SPINE SPACER 9MM ALLOGRAFT BONE CERVICAL CANCELLOUS FREEZE DRIED","SUP-ITM-10048887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3384.85","2538.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2721.42","80.4","","1022.97","1022.97","3607.50","1 through 10","1768.92","2766.1","percent of total billed charges",""
"SPINE SPACER 9MM ALLOGRAFT BONE CERVICAL CANCELLOUS FREEZE DRIED","SUP-ITM-10048887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3384.85","2538.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2766.10","81.72","","3010.54","693.88","5019.88","35","1768.92","2766.1","percent of total billed charges",""
"SPINE SPACER 9MM LUMBAR NARROW","SUP-ITM-10048763","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6075.06","79.5","","1309.77","674.56","6049.93","26","2368.89","6075.06","percent of total billed charges",""
"SPINE SPACER 9MM LUMBAR NARROW","SUP-ITM-10048763","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4072.96","53.3","","1901.83","1901.83","2962.25","1 through 10","2368.89","6075.06","percent of total billed charges",""
"SPINE SPACER 9MM LUMBAR NARROW","SUP-ITM-10048763","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2789.18","36.5","","1620.31","1620.31","19908.88","1 through 10","2368.89","6075.06","percent of total billed charges",""
"SPINE SPACER 9MM LUMBAR NARROW","SUP-ITM-10048763","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2926.73","38.3","","352.91","352.91","2046.30","1 through 10","2368.89","6075.06","percent of total billed charges",""
"SPINE SPACER 9MM LUMBAR NARROW","SUP-ITM-10048763","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3278.24","42.9","","9668.75","9668.75","9668.75","1 through 10","2368.89","6075.06","percent of total billed charges",""
"SPINE SPACER 9MM LUMBAR NARROW","SUP-ITM-10048763","CDM","C1889","HCPCS","0278","RC","","","","both","","","7641.58","5731.18","WELLPOINT [1015]","HB AMC WELLPOINT","5637.96","73.78","","699.88","384.10","3443.31","33","2368.89","6075.06","percent of total billed charges",""
"SPINE SPACER 9MM LUMBAR NARROW","SUP-ITM-10048763","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7641.58","5731.18","AETNA [1001]","HB AMC AETNA HMO","5333.82","69.8","","1421.24","264.50","4933.46","29","3993.49","6244.7","percent of total billed charges",""
"SPINE SPACER 9MM LUMBAR NARROW","SUP-ITM-10048763","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7641.58","5731.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6143.83","80.4","","1022.97","1022.97","3607.50","1 through 10","3993.49","6244.7","percent of total billed charges",""
"SPINE SPACER 9MM LUMBAR NARROW","SUP-ITM-10048763","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7641.58","5731.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6244.70","81.72","","3010.54","693.88","5019.88","35","3993.49","6244.7","percent of total billed charges",""
"SPINE SPACER 9MM THORACOLUMBAR POSTERIOR ALLOGRAFT FREEZE DRIED","SUP-ITM-10048798","CDM","C1889","HCPCS","0278","RC","","","","both","","","9049.48","6787.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7194.34","79.5","","1309.77","674.56","6049.93","26","2805.34","7194.34","percent of total billed charges",""
"SPINE SPACER 9MM THORACOLUMBAR POSTERIOR ALLOGRAFT FREEZE DRIED","SUP-ITM-10048798","CDM","C1889","HCPCS","0278","RC","","","","both","","","9049.48","6787.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4823.37","53.3","","1901.83","1901.83","2962.25","1 through 10","2805.34","7194.34","percent of total billed charges",""
"SPINE SPACER 9MM THORACOLUMBAR POSTERIOR ALLOGRAFT FREEZE DRIED","SUP-ITM-10048798","CDM","C1889","HCPCS","0278","RC","","","","both","","","9049.48","6787.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3303.06","36.5","","1620.31","1620.31","19908.88","1 through 10","2805.34","7194.34","percent of total billed charges",""
"SPINE SPACER 9MM THORACOLUMBAR POSTERIOR ALLOGRAFT FREEZE DRIED","SUP-ITM-10048798","CDM","C1889","HCPCS","0278","RC","","","","both","","","9049.48","6787.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3465.95","38.3","","352.91","352.91","2046.30","1 through 10","2805.34","7194.34","percent of total billed charges",""
"SPINE SPACER 9MM THORACOLUMBAR POSTERIOR ALLOGRAFT FREEZE DRIED","SUP-ITM-10048798","CDM","C1889","HCPCS","0278","RC","","","","both","","","9049.48","6787.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3882.23","42.9","","9668.75","9668.75","9668.75","1 through 10","2805.34","7194.34","percent of total billed charges",""
"SPINE SPACER 9MM THORACOLUMBAR POSTERIOR ALLOGRAFT FREEZE DRIED","SUP-ITM-10048798","CDM","C1889","HCPCS","0278","RC","","","","both","","","9049.48","6787.11","WELLPOINT [1015]","HB AMC WELLPOINT","6676.71","73.78","","699.88","384.10","3443.31","33","2805.34","7194.34","percent of total billed charges",""
"SPINE SPACER 9MM THORACOLUMBAR POSTERIOR ALLOGRAFT FREEZE DRIED","SUP-ITM-10048798","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9049.48","6787.11","AETNA [1001]","HB AMC AETNA HMO","6316.54","69.8","","1421.24","264.50","4933.46","29","4729.26","7395.24","percent of total billed charges",""
"SPINE SPACER 9MM THORACOLUMBAR POSTERIOR ALLOGRAFT FREEZE DRIED","SUP-ITM-10048798","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9049.48","6787.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7275.78","80.4","","1022.97","1022.97","3607.50","1 through 10","4729.26","7395.24","percent of total billed charges",""
"SPINE SPACER 9MM THORACOLUMBAR POSTERIOR ALLOGRAFT FREEZE DRIED","SUP-ITM-10048798","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9049.48","6787.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7395.24","81.72","","3010.54","693.88","5019.88","35","4729.26","7395.24","percent of total billed charges",""
"SPINE SPACER 9X30X11MM LUMBAR BIO AVS","SUP-ITM-10114185","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5565.00","79.5","","1309.77","674.56","6049.93","26","2170","5565","percent of total billed charges",""
"SPINE SPACER 9X30X11MM LUMBAR BIO AVS","SUP-ITM-10114185","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3731.00","53.3","","1901.83","1901.83","2962.25","1 through 10","2170","5565","percent of total billed charges",""
"SPINE SPACER 9X30X11MM LUMBAR BIO AVS","SUP-ITM-10114185","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2555.00","36.5","","1620.31","1620.31","19908.88","1 through 10","2170","5565","percent of total billed charges",""
"SPINE SPACER 9X30X11MM LUMBAR BIO AVS","SUP-ITM-10114185","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2681.00","38.3","","352.91","352.91","2046.30","1 through 10","2170","5565","percent of total billed charges",""
"SPINE SPACER 9X30X11MM LUMBAR BIO AVS","SUP-ITM-10114185","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3003.00","42.9","","9668.75","9668.75","9668.75","1 through 10","2170","5565","percent of total billed charges",""
"SPINE SPACER 9X30X11MM LUMBAR BIO AVS","SUP-ITM-10114185","CDM","C1889","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","WELLPOINT [1015]","HB AMC WELLPOINT","5164.60","73.78","","699.88","384.10","3443.31","33","2170","5565","percent of total billed charges",""
"SPINE SPACER 9X30X11MM LUMBAR BIO AVS","SUP-ITM-10114185","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","AETNA [1001]","HB AMC AETNA HMO","4886.00","69.8","","1421.24","264.50","4933.46","29","3658.2","5720.4","percent of total billed charges",""
"SPINE SPACER 9X30X11MM LUMBAR BIO AVS","SUP-ITM-10114185","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5628.00","80.4","","1022.97","1022.97","3607.50","1 through 10","3658.2","5720.4","percent of total billed charges",""
"SPINE SPACER 9X30X11MM LUMBAR BIO AVS","SUP-ITM-10114185","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5720.40","81.72","","3010.54","693.88","5019.88","35","3658.2","5720.4","percent of total billed charges",""
"SPINE SPACER COREX12MM 15 20 TITANIUM ENDCAP MINI","SUP-ITM-10107688","CDM","C1889","HCPCS","0278","RC","","","","both","","","10500.00","7875.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8347.50","79.5","","1309.77","674.56","6049.93","26","3255","8347.5","percent of total billed charges",""
"SPINE SPACER COREX12MM 15 20 TITANIUM ENDCAP MINI","SUP-ITM-10107688","CDM","C1889","HCPCS","0278","RC","","","","both","","","10500.00","7875.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5596.50","53.3","","1901.83","1901.83","2962.25","1 through 10","3255","8347.5","percent of total billed charges",""
"SPINE SPACER COREX12MM 15 20 TITANIUM ENDCAP MINI","SUP-ITM-10107688","CDM","C1889","HCPCS","0278","RC","","","","both","","","10500.00","7875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3832.50","36.5","","1620.31","1620.31","19908.88","1 through 10","3255","8347.5","percent of total billed charges",""
"SPINE SPACER COREX12MM 15 20 TITANIUM ENDCAP MINI","SUP-ITM-10107688","CDM","C1889","HCPCS","0278","RC","","","","both","","","10500.00","7875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4021.50","38.3","","352.91","352.91","2046.30","1 through 10","3255","8347.5","percent of total billed charges",""
"SPINE SPACER COREX12MM 15 20 TITANIUM ENDCAP MINI","SUP-ITM-10107688","CDM","C1889","HCPCS","0278","RC","","","","both","","","10500.00","7875.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4504.50","42.9","","9668.75","9668.75","9668.75","1 through 10","3255","8347.5","percent of total billed charges",""
"SPINE SPACER COREX12MM 15 20 TITANIUM ENDCAP MINI","SUP-ITM-10107688","CDM","C1889","HCPCS","0278","RC","","","","both","","","10500.00","7875.00","WELLPOINT [1015]","HB AMC WELLPOINT","7746.90","73.78","","699.88","384.10","3443.31","33","3255","8347.5","percent of total billed charges",""
"SPINE SPACER COREX12MM 15 20 TITANIUM ENDCAP MINI","SUP-ITM-10107688","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10500.00","7875.00","AETNA [1001]","HB AMC AETNA HMO","7329.00","69.8","","1421.24","264.50","4933.46","29","5487.3","8580.6","percent of total billed charges",""
"SPINE SPACER COREX12MM 15 20 TITANIUM ENDCAP MINI","SUP-ITM-10107688","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10500.00","7875.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8442.00","80.4","","1022.97","1022.97","3607.50","1 through 10","5487.3","8580.6","percent of total billed charges",""
"SPINE SPACER COREX12MM 15 20 TITANIUM ENDCAP MINI","SUP-ITM-10107688","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10500.00","7875.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8580.60","81.72","","3010.54","693.88","5019.88","35","5487.3","8580.6","percent of total billed charges",""
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","1276.00","957.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","345.44","345.44","345.44","1 through 10","351.32","1014.42","other","OPPS APC"
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","1276.00","957.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","680.11","53.3","","653.14","653.14","653.14","1 through 10","351.32","1014.42","percent of total billed charges",""
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","1276.00","957.00","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","351.32","1014.42","other","OPPS APC"
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","1276.00","957.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","465.74","36.5","","461.40","461.40","461.40","1 through 10","351.32","1014.42","percent of total billed charges",""
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","1276.00","957.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","488.71","38.3","","483.67","483.67","653.80","1 through 10","351.32","1014.42","percent of total billed charges",""
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","1276.00","957.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.62","362.62","362.62","1 through 10","351.32","1014.42","other","OPPS APC"
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","outpatient","","","1276.00","957.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1042.75","81.72","","543.91","426.44","543.91","1 through 10","579.66","1239.56","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","337.09","363.89","40","197.14","797.39","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","462.21","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","25.00","25.00","25.00","1 through 10","197.14","797.39","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","797.39","79.5","","765.75","513.74","765.75","24","197.14","797.39","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","534.60","53.3","","765.75","513.74","2099.50","19","197.14","797.39","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","294.27","363.89","13","197.14","797.39","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","ELDER SERVICES [1037]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","335.72","335.72","335.72","1 through 10","197.14","797.39","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","FALLON HEALTH [1008]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1109.43","1027.71","1109.43","1 through 10","197.14","797.39","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","772.31","77","","2247.63","2247.63","2247.63","1 through 10","197.14","797.39","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","HUMANA [1012]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","362.41","362.41","1 through 10","197.14","797.39","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","651.95","65","","515.69","515.69","515.69","1 through 10","197.14","797.39","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","1109.43","385","197.14","797.39","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","366.10","36.5","","362.93","308.44","1829.28","24","197.14","797.39","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","384.15","38.3","","380.44","380.44","380.44","59","197.14","797.39","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","336.12","362.81","20","197.14","797.39","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","MOLINA [1014]","HB BWH MOLINA","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","733.70","685.14","733.70","1 through 10","197.14","797.39","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","TRICARE [160005]","HB BWH TRICARE","351.32","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","369.81","369.81","369.81","1 through 10","197.14","797.39","other","Tricare OPPS"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","363.01","362.41","1088.43","18","197.14","797.39","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","1003.00","752.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","362.41","363.89","78","197.14","797.39","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","1003.00","752.25","AETNA [1001]","HB AMC AETNA HMO","700.09","69.8","","658.72","658.72","658.72","1 through 10","524.17","966.35","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","1003.00","752.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","819.65","81.72","","427.83","427.83","427.83","1 through 10","524.17","966.35","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","1003.00","752.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","819.65","81.72","","777.82","427.83","777.82","15","524.17","966.35","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","17.51","182.84","36","176.52","461.1","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","416.44","71.8","","403.52","403.52","403.52","1 through 10","176.52","461.1","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","380.48","65.6","","268.64","268.64","268.64","1 through 10","176.52","461.1","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","377.00","65","","890.22","442.29","890.22","1 through 10","176.52","461.1","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","406.00","70","","438.36","241.66","438.36","1 through 10","176.52","461.1","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","232.23","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","57.61","15.05","369.81","1 through 10","176.52","461.1","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","461.10","79.5","","442.29","296.74","442.29","70","176.52","461.1","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","309.14","53.3","","296.74","296.74","442.29","29","176.52","461.1","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","153.96","182.84","1 through 10","176.52","461.1","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","ELDER SERVICES [1037]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","176.52","461.1","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.09","182.09","182.09","1 through 10","176.52","461.1","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","446.60","77","","432.74","432.74","1298.22","1 through 10","176.52","461.1","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","HUMANA [1012]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.21","183.21","183.21","1 through 10","176.52","461.1","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","461.10","79.5","","442.29","442.29","442.29","1 through 10","176.52","461.1","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","281","176.52","461.1","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","179.80","31","","173.66","173.66","173.66","1 through 10","176.52","461.1","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","211.70","36.5","","209.63","178.15","628.89","67","176.52","461.1","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","222.14","38.3","","219.74","213.56","219.74","171","176.52","461.1","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.09","167.47","182.49","14","176.52","461.1","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","MOLINA [1014]","HB BWH MOLINA","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","368.65","368.65","368.65","1 through 10","176.52","461.1","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","446.60","77","","313.43","256.70","313.43","1 through 10","176.52","461.1","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","TRICARE [160005]","HB BWH TRICARE","176.52","","APC Price ($185.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","17.01","17.01","17.01","1 through 10","176.52","461.1","other","Tricare OPPS"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.49","182.09","549.15","20","176.52","461.1","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","248.82","42.9","","247.11","247.11","247.11","1 through 10","176.52","461.1","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","580.00","435.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.60","182.09","183.10","82","176.52","461.1","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","580.00","435.00","AETNA [1001]","HB AMC AETNA HMO","404.84","69.8","","460.84","306.71","760.94","17","303.11","520.69","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","580.00","435.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","303.11","52.26","","347.77","347.77","347.77","1 through 10","303.11","520.69","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","580.00","435.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","466.32","80.4","","281.00","281.00","281.00","1 through 10","303.11","520.69","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","580.00","435.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","473.98","81.72","","247.11","247.11","247.11","1 through 10","303.11","520.69","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","580.00","435.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","473.98","81.72","","449.26","247.11","449.26","96","303.11","520.69","percent of total billed charges",""
"Splenic Procedures With Cc","800","MS-DRG","","","","","","","","inpatient","","","111163.25","83372.44","MEDICARE [2001]","HB BWH MEDICARE","26007.48","","Case rate ($26,007.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $31,230.47, add-ons for qualifying new technology services are included. If operating cost exceeds $76,874.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,700.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $23,367.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $30,850.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,260.61. The transfer capital threshold is the transfer adjustment factor * $2,260.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10163.60","10163.60","10163.60","1 through 10","25487.33","44006.44","other","Inpatient Replacement Plans DRG"
"Splenic Procedures,MAJOR","650","DRG","","","","","","","","inpatient","","","111163.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","84312.99","","Standard inlier is a Case rate ($84,312.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $77,213, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,968.74) for the length of stay and the standard reimbursement.","84312.98","84312.98","84312.98","1 through 10","21197.74","106466.43","case rate",""
"Splenic Procedures,MAJOR","650","DRG","","","","","","","","inpatient","","","111163.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","94790.52","","Standard inlier is a Case rate ($94,790.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $77,213, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,454.73) for the length of stay and the standard reimbursement.","94790.52","94790.52","94790.52","1 through 10","21197.74","106466.43","case rate",""
"Splenic Procedures,MODERATE","650","DRG","","","","","","","","inpatient","","","99486.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","64324.48","","Standard inlier is a Case rate ($64,324.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $56,140, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,130.33) for the length of stay and the standard reimbursement.","58765.96","58765.96","58765.96","1 through 10","21197.74","106466.43","case rate",""
"Splint of Lux/Avuls/Tooth","PX-76001989","CDM","41899","CPT","0510","RC","","","","outpatient","","","2928.00","2196.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1772.90","60.55","","481.00","481.00","481.00","1 through 10","700.33","2415.6","percent of total billed charges",""
"SPLINT RIB 4MM MEDIUM MATRIX TITANIUM INTRAMEDULLARY","SUP-ITM-10082409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.22","980.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1039.24","79.5","","800.18","480.96","1887.97","195","405.24","1039.24","percent of total billed charges",""
"SPLINT RIB 4MM MEDIUM MATRIX TITANIUM INTRAMEDULLARY","SUP-ITM-10082409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.22","980.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","696.75","53.3","","813.12","216.42","1444.50","81","405.24","1039.24","percent of total billed charges",""
"SPLINT RIB 4MM MEDIUM MATRIX TITANIUM INTRAMEDULLARY","SUP-ITM-10082409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.22","980.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","405.24","31","","432.60","432.60","432.60","1 through 10","405.24","1039.24","percent of total billed charges",""
"SPLINT RIB 4MM MEDIUM MATRIX TITANIUM INTRAMEDULLARY","SUP-ITM-10082409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.22","980.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","477.14","36.5","","148.37","54.89","631.39","94","405.24","1039.24","percent of total billed charges",""
"SPLINT RIB 4MM MEDIUM MATRIX TITANIUM INTRAMEDULLARY","SUP-ITM-10082409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.22","980.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","500.67","38.3","","279.30","91.72","1116.77","266","405.24","1039.24","percent of total billed charges",""
"SPLINT RIB 4MM MEDIUM MATRIX TITANIUM INTRAMEDULLARY","SUP-ITM-10082409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.22","980.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","560.80","42.9","","731.00","63.70","731.00","1 through 10","405.24","1039.24","percent of total billed charges",""
"SPLINT RIB 4MM MEDIUM MATRIX TITANIUM INTRAMEDULLARY","SUP-ITM-10082409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.22","980.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","560.80","42.9","","384.74","384.74","384.74","1 through 10","405.24","1039.24","percent of total billed charges",""
"SPLINT RIB 4MM MEDIUM MATRIX TITANIUM INTRAMEDULLARY","SUP-ITM-10082409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1307.22","980.41","WELLPOINT [1015]","HB AMC WELLPOINT","964.47","73.78","","286.63","119.22","1107.45","105","405.24","1039.24","percent of total billed charges",""
"SPLINT RIB 4MM MEDIUM MATRIX TITANIUM INTRAMEDULLARY","SUP-ITM-10082409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1307.22","980.41","AETNA [1001]","HB AMC AETNA HMO","912.44","69.8","","675.31","184.75","1721.50","286","683.15","1068.26","percent of total billed charges",""
"SPLINT RIB 4MM MEDIUM MATRIX TITANIUM INTRAMEDULLARY","SUP-ITM-10082409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1307.22","980.41","AETNA [1001]","HB AMC AETNA PPO","1051.00","80.4","","1261.44","103.12","1514.10","21","683.15","1068.26","percent of total billed charges",""
"SPLINT RIB 4MM MEDIUM MATRIX TITANIUM INTRAMEDULLARY","SUP-ITM-10082409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1307.22","980.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1051.00","80.4","","1365.00","1365.00","1365.00","1 through 10","683.15","1068.26","percent of total billed charges",""
"SPLINT RIB 4MM MEDIUM MATRIX TITANIUM INTRAMEDULLARY","SUP-ITM-10082409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1307.22","980.41","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1068.26","81.72","","5157.68","5157.68","5157.68","1 through 10","683.15","1068.26","percent of total billed charges",""
"SPLINT RIB 4MM MEDIUM MATRIX TITANIUM INTRAMEDULLARY","SUP-ITM-10082409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1307.22","980.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1068.26","81.72","","431.26","71.26","1459.57","88","683.15","1068.26","percent of total billed charges",""
"Split Grft,Head,Fac,Hand,Feet <100 Sqcm","PX-98301348","CDM","15120","CPT","0983","RC","","","","both","","","3095.00","2321.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","4347.18","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4278.06","3852.97","4278.06","1 through 10","959.45","5433.98","other","OPPS APC"
"Split Grft,Head,Fac,Hand,Feet <100 Sqcm","PX-98301348","CDM","15120","CPT","0983","RC","","","","both","","","3095.00","2321.25","MEDICARE [2001]","HB BWH MEDICARE","4347.18","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4347.62","4347.62","4347.62","1 through 10","959.45","5433.98","other","OPPS APC"
"Split Grft,Head,Fac,Hand,Feet <100 Sqcm","PX-98301348","CDM","15120","CPT","0983","RC","","","","both","","","3095.00","2321.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1185.39","38.3","","8361.33","8361.33","8361.33","1 through 10","959.45","5433.98","percent of total billed charges",""
"Split Grft,Head,Fac,Hand,Feet <100 Sqcm","PX-98301348","CDM","15120","CPT","0983","RC","","","","both","","","3095.00","2321.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4260.24","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3837.31","3837.31","3837.31","1 through 10","959.45","5433.98","other","OPPS APC"
"Split Grft,Head,Fac,Hand,Feet <100 Sqcm","PX-98301348","CDM","15120","CPT","0983","RC","","","","outpatient","","","3095.00","2321.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","8021.78","8021.78","8021.78","1 through 10","1730.11","5545.35","other","Multiple Surgery"
"Split Grft,Head,Fac,Hand,Feet <100 Sqcm","PX-98301348","CDM","15120","CPT","0983","RC","","","","outpatient","","","3095.00","2321.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3208.71","3208.71","3208.71","1 through 10","1730.11","5545.35","other","Multiple Surgery"
"Split Grft,Head,Fac,Hand,Feet <100 Sqcm","PX-98301348","CDM","15120","CPT","0983","RC","","","","outpatient","","","3095.00","2321.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2488.38","80.4","","5953.74","5953.74","5953.74","1 through 10","1730.11","5545.35","percent of total billed charges",""
"Split Grft,Head,Fac,Hand,Feet <100 Sqcm","PX-98301348","CDM","15120","CPT","0983","RC","","","","outpatient","","","3095.00","2321.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2529.23","81.72","","3402.34","3402.34","3402.34","1 through 10","1730.11","5545.35","percent of total billed charges",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/McC","537","MS-DRG","","","","","","","","inpatient","","","58191.09","43643.32","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","10893.09","10893.09","10893.09","1 through 10","8903.35","13868.629","case rate",""
"Sprint Pns System, Dual Lead","PX-27002375","CDM","C1778","HCPCS","0278","RC","","","","both","","","21250.00","15937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11326.25","53.3","","5279.78","5279.78","5279.78","1 through 10","6587.5","16893.75","percent of total billed charges",""
"Sprint Pns System, Dual Lead","PX-27002375","CDM","C1778","HCPCS","0278","RC","","","","both","","","21250.00","15937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","16893.75","79.5","","15789.05","15789.05","15789.05","1 through 10","6587.5","16893.75","percent of total billed charges",""
"Sprint Pns System, Dual Lead","PX-27002375","CDM","C1778","HCPCS","0278","RC","","","","both","","","21250.00","15937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7756.25","36.5","","2482.78","1657.12","2482.78","1 through 10","6587.5","16893.75","percent of total billed charges",""
"Sprint Pns System, Dual Lead","PX-27002375","CDM","C1778","HCPCS","0278","RC","","","","both","","","21250.00","15937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8138.75","38.3","","2602.60","2602.60","2602.60","1 through 10","6587.5","16893.75","percent of total billed charges",""
"Sprint Pns System, Dual Lead","PX-27002375","CDM","C1778","HCPCS","0278","RC","","","","both","","","21250.00","15937.50","WELLPOINT [1015]","HB AMC WELLPOINT","15678.25","73.78","","4955.58","3845.35","9119.37","1 through 10","6587.5","16893.75","percent of total billed charges",""
"Sprint Pns System, Dual Lead","PX-27002375","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","21250.00","15937.50","AETNA [1001]","HB AMC AETNA HMO","14832.50","69.8","","8631.75","8631.75","8631.75","1 through 10","11105.25","17365.5","percent of total billed charges",""
"Sprint Pns System, Single Lead","PX-27002374","CDM","C1778","HCPCS","0278","RC","","","","both","","","12750.00","9562.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6795.75","53.3","","5279.78","5279.78","5279.78","1 through 10","3952.5","10136.25","percent of total billed charges",""
"Sprint Pns System, Single Lead","PX-27002374","CDM","C1778","HCPCS","0278","RC","","","","both","","","12750.00","9562.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","10136.25","79.5","","15789.05","15789.05","15789.05","1 through 10","3952.5","10136.25","percent of total billed charges",""
"Sprint Pns System, Single Lead","PX-27002374","CDM","C1778","HCPCS","0278","RC","","","","both","","","12750.00","9562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4653.75","36.5","","2482.78","1657.12","2482.78","1 through 10","3952.5","10136.25","percent of total billed charges",""
"Sprint Pns System, Single Lead","PX-27002374","CDM","C1778","HCPCS","0278","RC","","","","both","","","12750.00","9562.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4883.25","38.3","","2602.60","2602.60","2602.60","1 through 10","3952.5","10136.25","percent of total billed charges",""
"Sprint Pns System, Single Lead","PX-27002374","CDM","C1778","HCPCS","0278","RC","","","","both","","","12750.00","9562.50","WELLPOINT [1015]","HB AMC WELLPOINT","9406.95","73.78","","4955.58","3845.35","9119.37","1 through 10","3952.5","10136.25","percent of total billed charges",""
"Sprint Pns System, Single Lead","PX-27002374","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","12750.00","9562.50","AETNA [1001]","HB AMC AETNA HMO","8899.50","69.8","","8631.75","8631.75","8631.75","1 through 10","6663.15","10419.3","percent of total billed charges",""
"Sputum Obtain Specimen Aero Induced","PX-30000117","CDM","89220","CPT","0300","RC","","","","both","","","525.00","393.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","209.58","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","209.41","209.41","209.41","1 through 10","162.75","417.38","other","OPPS APC"
"Sputum Obtain Specimen Aero Induced","PX-30000117","CDM","89220","CPT","0300","RC","","","","both","","","525.00","393.75","MEDICARE [2001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","186.42","203.50","31","162.75","417.38","other","OPPS APC"
"Sputum Obtain Specimen Aero Induced","PX-30000117","CDM","89220","CPT","0300","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","189.86","189.86","189.86","1 through 10","162.75","417.38","percent of total billed charges",""
"Sputum Obtain Specimen Aero Induced","PX-30000117","CDM","89220","CPT","0300","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","199.02","167.97","199.02","1 through 10","162.75","417.38","percent of total billed charges",""
"Sputum Obtain Specimen Aero Induced","PX-30000117","CDM","89220","CPT","0300","RC","","","","both","","","525.00","393.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","199.43","199.43","1 through 10","162.75","417.38","other","OPPS APC"
"Sputum Obtain Specimen Aero Induced","PX-30000117","CDM","89220","CPT","0300","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.69","182.69","182.69","1 through 10","162.75","417.38","other","OPPS APC"
"Ssp High Resolution Typing","PX-31001432","CDM","81381","CPT","0310","RC","","","","both","","","759.00","569.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","404.55","53.3","","579.23","579.23","579.23","1 through 10","166.5","721.05","percent of total billed charges",""
"Ssp High Resolution Typing","PX-31001432","CDM","81381","CPT","0310","RC","","","","both","","","759.00","569.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","290.70","38.3","","287.78","279.68","287.78","1 through 10","166.5","721.05","percent of total billed charges",""
"Ssp High Resolution Typing","PX-31001432","CDM","81381","CPT","0310","RC","","","","outpatient","","","759.00","569.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","610.24","80.4","","368.00","368.00","368.00","1 through 10","319.11","1041.49","percent of total billed charges",""
"St Eval Oral/Swallow Function","PX-44000011","CDM","92610","CPT","0444","RC","","","","both","","","603.00","452.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","321.40","53.3","","460.40","308.88","482.95","1 through 10","74.05","572.85","percent of total billed charges",""
"St Eval Oral/Swallow Function","PX-44000011","CDM","92610","CPT","0444","RC","","","","both","","","603.00","452.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","220.10","36.5","","218.21","185.45","218.21","12","74.05","572.85","percent of total billed charges",""
"St Eval Oral/Swallow Function","PX-44000011","CDM","92610","CPT","0444","RC","","","","both","","","603.00","452.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","230.95","38.3","","228.74","222.30","228.74","31","74.05","572.85","percent of total billed charges",""
"St Eval Oral/Swallow Function","PX-44000011","CDM","92610","CPT","0444","RC","","","","both","","","603.00","452.25","TRICARE [160005]","HB BWH TRICARE","572.85","95","","72.73","72.73","72.73","1 through 10","74.05","572.85","percent of total billed charges",""
"St Eval Oral/Swallow Function","PX-44000011","CDM","92610","CPT","0444","RC","","","","both","","","603.00","452.25","WELLPOINT [1015]","HB AMC WELLPOINT","444.89","73.78","","435.53","435.53","435.53","1 through 10","74.05","572.85","percent of total billed charges",""
"St Eval Oral/Swallow Function","PX-44000011","CDM","92610","CPT","0444","RC","","","","outpatient","","","603.00","452.25","AETNA [1001]","HB AMC AETNA HMO","420.89","69.8","","396.05","279.63","456.30","19","244.15","958.12","percent of total billed charges",""
"St Eval Oral/Swallow Function","PX-44000011","CDM","92610","CPT","0444","RC","","","","outpatient","","","603.00","452.25","AETNA [1001]","HB AMC AETNA PPO","484.81","80.4","","396.05","396.05","456.30","1 through 10","244.15","958.12","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","both","","","670.00","502.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","435.50","65","","1029.60","1029.60","1029.60","1 through 10","97.28","636.5","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","both","","","670.00","502.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","357.11","53.3","","343.20","343.20","343.20","1 through 10","97.28","636.5","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","both","","","670.00","502.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","244.55","36.5","","206.05","206.05","206.05","1 through 10","97.28","636.5","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","both","","","670.00","502.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","256.61","38.3","","254.15","247.00","254.15","1 through 10","97.28","636.5","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","both","","","670.00","502.50","TRICARE [160005]","HB BWH TRICARE","636.50","95","","99.26","99.26","99.26","1 through 10","97.28","636.5","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","both","","","670.00","502.50","WELLPOINT [1015]","HB AMC WELLPOINT","494.33","73.78","","483.93","483.93","483.93","1 through 10","97.28","636.5","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","outpatient","","","670.00","502.50","AETNA [1001]","HB AMC AETNA HMO","467.66","69.8","","310.70","310.70","440.05","1 through 10","256.5","958.12","percent of total billed charges",""
"St Treat Swallow/Oral","PX-44000001","CDM","92526","CPT","0441","RC","","","","both","","","302.00","226.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","160.97","53.3","","154.70","154.70","154.70","1 through 10","90.27","286.9","percent of total billed charges",""
"St Treat Swallow/Oral","PX-44000001","CDM","92526","CPT","0441","RC","","","","both","","","302.00","226.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","110.23","36.5","","109.29","92.88","109.29","1 through 10","90.27","286.9","percent of total billed charges",""
"St Treat Swallow/Oral","PX-44000001","CDM","92526","CPT","0441","RC","","","","both","","","302.00","226.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","115.67","38.3","","114.56","114.56","114.56","29","90.27","286.9","percent of total billed charges",""
"St Treat Swallow/Oral","PX-44000001","CDM","92526","CPT","0441","RC","","","","both","","","302.00","226.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","90.27","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($92.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($69.07). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","90.27","90.27","90.27","1 through 10","90.27","286.9","fee schedule",""
"St Treat Swallow/Oral","PX-44000001","CDM","92526","CPT","0441","RC","","","","outpatient","","","302.00","226.50","AETNA [1001]","HB AMC AETNA HMO","210.80","69.8","","140.05","107.50","198.36","1 through 10","157.83","577.02","percent of total billed charges",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","both","","","736.00","552.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","392.29","53.3","","561.92","561.92","561.92","1 through 10","81.36","699.2","percent of total billed charges",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","both","","","736.00","552.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","268.64","36.5","","258.47","258.47","266.32","1 through 10","81.36","699.2","percent of total billed charges",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","both","","","736.00","552.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","81.36","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($83.02). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($63.85). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","81.76","81.36","83.02","1 through 10","81.36","699.2","fee schedule",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","outpatient","","","736.00","552.00","AETNA [1001]","HB AMC AETNA HMO","513.73","69.8","","556.92","556.92","556.92","1 through 10","256.5","601.46","percent of total billed charges",""
"Stab Phlebetomy <10 Incisions","PX-76001906","CDM","37799","CPT","0761","RC","","","","outpatient","","","2787.00","2090.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1455.37","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","2299.28","percent of total billed charges",""
"Stab Phlebetomy <10 Incisions","PX-76001906","CDM","37799","CPT","0761","RC","","","","outpatient","","","2787.00","2090.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1463.18","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","2299.28","percent of total billed charges",""
"STABILIZER KNEE SIZE 3 76 4103 LTOTAL FEMORAL COMPONENT 07","SUP-ITM-10020381","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2952.69","52.26","","1113.10","1113.10","1113.10","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER KNEE SIZE 3 76 4103 LTOTAL FEMORAL COMPONENT 07","SUP-ITM-10020381","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4491.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER KNEE SIZE 3 76 4103 LTOTAL FEMORAL COMPONENT 07","SUP-ITM-10020381","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2062.25","36.5","","1023.42","771.29","2068.67","33","1751.5","4491.75","percent of total billed charges",""
"STABILIZER KNEE SIZE 3 76 4103 LTOTAL FEMORAL COMPONENT 07","SUP-ITM-10020381","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2163.95","38.3","","850.52","759.78","1211.25","66","1751.5","4491.75","percent of total billed charges",""
"STABILIZER KNEE SIZE 3 76 4103 LTOTAL FEMORAL COMPONENT 07","SUP-ITM-10020381","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2423.85","42.9","","2548.09","2548.09","2548.09","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER KNEE SIZE 3 76 4103 LTOTAL FEMORAL COMPONENT 07","SUP-ITM-10020381","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2423.85","42.9","","956.46","956.46","956.46","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER KNEE SIZE 3 76 4103 LTOTAL FEMORAL COMPONENT 07","SUP-ITM-10020381","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","WELLPOINT [1015]","HB AMC WELLPOINT","4168.57","73.78","","2344.73","1619.47","2530.35","16","1751.5","4491.75","percent of total billed charges",""
"STABILIZER KNEE SIZE 3 76 4103 LTOTAL FEMORAL COMPONENT 07","SUP-ITM-10020381","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","AETNA [1001]","HB AMC AETNA HMO","3943.70","69.8","","1523.63","988.41","4330.26","39","2952.69","4617.18","percent of total billed charges",""
"STABILIZER KNEE SIZE 3 76 4103 LTOTAL FEMORAL COMPONENT 07","SUP-ITM-10020381","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","AETNA [1001]","HB AMC AETNA PPO","4542.60","80.4","","1670.25","1670.25","1670.25","1 through 10","2952.69","4617.18","percent of total billed charges",""
"STABILIZER KNEE SIZE 3 76 4103 LTOTAL FEMORAL COMPONENT 07","SUP-ITM-10020381","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2952.69","52.26","","1113.10","1113.10","1113.10","1 through 10","2952.69","4617.18","percent of total billed charges",""
"STABILIZER KNEE SIZE 3 76 4103 LTOTAL FEMORAL COMPONENT 07","SUP-ITM-10020381","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4617.18","81.72","","1738.90","1484.65","2716.94","38","2952.69","4617.18","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2952.69","52.26","","1113.10","1113.10","1113.10","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4491.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2062.25","36.5","","1023.42","771.29","2068.67","33","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2163.95","38.3","","850.52","759.78","1211.25","66","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2423.85","42.9","","2548.09","2548.09","2548.09","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2423.85","42.9","","956.46","956.46","956.46","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","WELLPOINT [1015]","HB AMC WELLPOINT","4168.57","73.78","","2344.73","1619.47","2530.35","16","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","AETNA [1001]","HB AMC AETNA HMO","3943.70","69.8","","1523.63","988.41","4330.26","39","2952.69","4617.18","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","AETNA [1001]","HB AMC AETNA PPO","4542.60","80.4","","1670.25","1670.25","1670.25","1 through 10","2952.69","4617.18","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2952.69","52.26","","1113.10","1113.10","1113.10","1 through 10","2952.69","4617.18","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4617.18","81.72","","1738.90","1484.65","2716.94","38","2952.69","4617.18","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2952.69","52.26","","1113.10","1113.10","1113.10","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4491.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2062.25","36.5","","1023.42","771.29","2068.67","33","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2163.95","38.3","","850.52","759.78","1211.25","66","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2423.85","42.9","","2548.09","2548.09","2548.09","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2423.85","42.9","","956.46","956.46","956.46","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","WELLPOINT [1015]","HB AMC WELLPOINT","4168.57","73.78","","2344.73","1619.47","2530.35","16","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","AETNA [1001]","HB AMC AETNA HMO","3943.70","69.8","","1523.63","988.41","4330.26","39","2952.69","4617.18","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","AETNA [1001]","HB AMC AETNA PPO","4542.60","80.4","","1670.25","1670.25","1670.25","1 through 10","2952.69","4617.18","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2952.69","52.26","","1113.10","1113.10","1113.10","1 through 10","2952.69","4617.18","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4617.18","81.72","","1738.90","1484.65","2716.94","38","2952.69","4617.18","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2952.69","52.26","","1113.10","1113.10","1113.10","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4491.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2062.25","36.5","","1023.42","771.29","2068.67","33","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2163.95","38.3","","850.52","759.78","1211.25","66","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2423.85","42.9","","2548.09","2548.09","2548.09","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2423.85","42.9","","956.46","956.46","956.46","1 through 10","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","5650.00","4237.50","WELLPOINT [1015]","HB AMC WELLPOINT","4168.57","73.78","","2344.73","1619.47","2530.35","16","1751.5","4491.75","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","AETNA [1001]","HB AMC AETNA HMO","3943.70","69.8","","1523.63","988.41","4330.26","39","2952.69","4617.18","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","AETNA [1001]","HB AMC AETNA PPO","4542.60","80.4","","1670.25","1670.25","1670.25","1 through 10","2952.69","4617.18","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2952.69","52.26","","1113.10","1113.10","1113.10","1 through 10","2952.69","4617.18","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5650.00","4237.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4617.18","81.72","","1738.90","1484.65","2716.94","38","2952.69","4617.18","percent of total billed charges",""
"Standard Tracheostomy/Laryngectomy Tube, Cuffed, Pvc","PX-27001156","CDM","A7521","HCPCS","0274","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30.66","36.5","","31.33","31.33","31.33","1 through 10","26.04","82.16","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1516.46","79.5","","800.18","480.96","1887.97","195","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1016.70","53.3","","813.12","216.42","1444.50","81","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","591.33","31","","432.60","432.60","432.60","1 through 10","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","696.24","36.5","","148.37","54.89","631.39","94","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","730.57","38.3","","279.30","91.72","1116.77","266","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","818.32","42.9","","731.00","63.70","731.00","1 through 10","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","818.32","42.9","","384.74","384.74","384.74","1 through 10","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","WELLPOINT [1015]","HB AMC WELLPOINT","1407.35","73.78","","286.63","119.22","1107.45","105","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","AETNA [1001]","HB AMC AETNA HMO","1331.44","69.8","","675.31","184.75","1721.50","286","996.86","1558.81","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","AETNA [1001]","HB AMC AETNA PPO","1533.63","80.4","","1261.44","103.12","1514.10","21","996.86","1558.81","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1533.63","80.4","","1365.00","1365.00","1365.00","1 through 10","996.86","1558.81","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1558.81","81.72","","5157.68","5157.68","5157.68","1 through 10","996.86","1558.81","percent of total billed charges",""
"STAPLE BONE 1.0X0 1/4IN XSMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1558.81","81.72","","431.26","71.26","1459.57","88","996.86","1558.81","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1516.46","79.5","","800.18","480.96","1887.97","195","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1016.70","53.3","","813.12","216.42","1444.50","81","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","591.33","31","","432.60","432.60","432.60","1 through 10","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","696.24","36.5","","148.37","54.89","631.39","94","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","730.57","38.3","","279.30","91.72","1116.77","266","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","818.32","42.9","","731.00","63.70","731.00","1 through 10","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","818.32","42.9","","384.74","384.74","384.74","1 through 10","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","both","","","1907.50","1430.62","WELLPOINT [1015]","HB AMC WELLPOINT","1407.35","73.78","","286.63","119.22","1107.45","105","591.33","1516.46","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","AETNA [1001]","HB AMC AETNA HMO","1331.44","69.8","","675.31","184.75","1721.50","286","996.86","1558.81","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","AETNA [1001]","HB AMC AETNA PPO","1533.63","80.4","","1261.44","103.12","1514.10","21","996.86","1558.81","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1533.63","80.4","","1365.00","1365.00","1365.00","1 through 10","996.86","1558.81","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1558.81","81.72","","5157.68","5157.68","5157.68","1 through 10","996.86","1558.81","percent of total billed charges",""
"STAPLE BONE 11X23.2MM MD FIXATION RICHARDS COBALT SPIKELESS","SUP-ITM-10003834","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1907.50","1430.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1558.81","81.72","","431.26","71.26","1459.57","88","996.86","1558.81","percent of total billed charges",""
"STAPLE BONE 13X16MM SMALL FIXATION RICHARDS COBALT TABLE","SUP-ITM-10011278","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","800.18","480.96","1887.97","195","759.5","1947.75","percent of total billed charges",""
"STAPLE BONE 13X16MM SMALL FIXATION RICHARDS COBALT TABLE","SUP-ITM-10011278","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1305.85","53.3","","813.12","216.42","1444.50","81","759.5","1947.75","percent of total billed charges",""
"STAPLE BONE 13X16MM SMALL FIXATION RICHARDS COBALT TABLE","SUP-ITM-10011278","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","759.50","31","","432.60","432.60","432.60","1 through 10","759.5","1947.75","percent of total billed charges",""
"STAPLE BONE 13X16MM SMALL FIXATION RICHARDS COBALT TABLE","SUP-ITM-10011278","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","148.37","54.89","631.39","94","759.5","1947.75","percent of total billed charges",""
"STAPLE BONE 13X16MM SMALL FIXATION RICHARDS COBALT TABLE","SUP-ITM-10011278","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","279.30","91.72","1116.77","266","759.5","1947.75","percent of total billed charges",""
"STAPLE BONE 13X16MM SMALL FIXATION RICHARDS COBALT TABLE","SUP-ITM-10011278","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","731.00","63.70","731.00","1 through 10","759.5","1947.75","percent of total billed charges",""
"STAPLE BONE 13X16MM SMALL FIXATION RICHARDS COBALT TABLE","SUP-ITM-10011278","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","384.74","384.74","384.74","1 through 10","759.5","1947.75","percent of total billed charges",""
"STAPLE BONE 13X16MM SMALL FIXATION RICHARDS COBALT TABLE","SUP-ITM-10011278","CDM","C1713","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","WELLPOINT [1015]","HB AMC WELLPOINT","1807.61","73.78","","286.63","119.22","1107.45","105","759.5","1947.75","percent of total billed charges",""
"STAPLE BONE 13X16MM SMALL FIXATION RICHARDS COBALT TABLE","SUP-ITM-10011278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","675.31","184.75","1721.50","286","1280.37","2002.14","percent of total billed charges",""
"STAPLE BONE 13X16MM SMALL FIXATION RICHARDS COBALT TABLE","SUP-ITM-10011278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA PPO","1969.80","80.4","","1261.44","103.12","1514.10","21","1280.37","2002.14","percent of total billed charges",""
"STAPLE BONE 13X16MM SMALL FIXATION RICHARDS COBALT TABLE","SUP-ITM-10011278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1969.80","80.4","","1365.00","1365.00","1365.00","1 through 10","1280.37","2002.14","percent of total billed charges",""
"STAPLE BONE 13X16MM SMALL FIXATION RICHARDS COBALT TABLE","SUP-ITM-10011278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2002.14","81.72","","5157.68","5157.68","5157.68","1 through 10","1280.37","2002.14","percent of total billed charges",""
"STAPLE BONE 13X16MM SMALL FIXATION RICHARDS COBALT TABLE","SUP-ITM-10011278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","431.26","71.26","1459.57","88","1280.37","2002.14","percent of total billed charges",""
"STAPLE BONE 13X20MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004534","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.78","377.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","399.71","79.5","","800.18","480.96","1887.97","195","155.86","399.71","percent of total billed charges",""
"STAPLE BONE 13X20MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004534","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.78","377.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","267.98","53.3","","813.12","216.42","1444.50","81","155.86","399.71","percent of total billed charges",""
"STAPLE BONE 13X20MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004534","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.78","377.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","155.86","31","","432.60","432.60","432.60","1 through 10","155.86","399.71","percent of total billed charges",""
"STAPLE BONE 13X20MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004534","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.78","377.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","183.51","36.5","","148.37","54.89","631.39","94","155.86","399.71","percent of total billed charges",""
"STAPLE BONE 13X20MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004534","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.78","377.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","192.56","38.3","","279.30","91.72","1116.77","266","155.86","399.71","percent of total billed charges",""
"STAPLE BONE 13X20MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004534","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.78","377.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","215.69","42.9","","731.00","63.70","731.00","1 through 10","155.86","399.71","percent of total billed charges",""
"STAPLE BONE 13X20MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004534","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.78","377.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","215.69","42.9","","384.74","384.74","384.74","1 through 10","155.86","399.71","percent of total billed charges",""
"STAPLE BONE 13X20MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004534","CDM","C1713","HCPCS","0278","RC","","","","both","","","502.78","377.08","WELLPOINT [1015]","HB AMC WELLPOINT","370.95","73.78","","286.63","119.22","1107.45","105","155.86","399.71","percent of total billed charges",""
"STAPLE BONE 13X20MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.78","377.08","AETNA [1001]","HB AMC AETNA HMO","350.94","69.8","","675.31","184.75","1721.50","286","262.75","410.87","percent of total billed charges",""
"STAPLE BONE 13X20MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.78","377.08","AETNA [1001]","HB AMC AETNA PPO","404.24","80.4","","1261.44","103.12","1514.10","21","262.75","410.87","percent of total billed charges",""
"STAPLE BONE 13X20MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.78","377.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","404.24","80.4","","1365.00","1365.00","1365.00","1 through 10","262.75","410.87","percent of total billed charges",""
"STAPLE BONE 13X20MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.78","377.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","410.87","81.72","","5157.68","5157.68","5157.68","1 through 10","262.75","410.87","percent of total billed charges",""
"STAPLE BONE 13X20MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","502.78","377.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","410.87","81.72","","431.26","71.26","1459.57","88","262.75","410.87","percent of total billed charges",""
"STAPLE BONE 15X16MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004535","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.55","619.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","656.31","79.5","","800.18","480.96","1887.97","195","255.92","656.31","percent of total billed charges",""
"STAPLE BONE 15X16MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004535","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.55","619.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","440.02","53.3","","813.12","216.42","1444.50","81","255.92","656.31","percent of total billed charges",""
"STAPLE BONE 15X16MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004535","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.55","619.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","255.92","31","","432.60","432.60","432.60","1 through 10","255.92","656.31","percent of total billed charges",""
"STAPLE BONE 15X16MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004535","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.55","619.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","301.33","36.5","","148.37","54.89","631.39","94","255.92","656.31","percent of total billed charges",""
"STAPLE BONE 15X16MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004535","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.55","619.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","316.19","38.3","","279.30","91.72","1116.77","266","255.92","656.31","percent of total billed charges",""
"STAPLE BONE 15X16MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004535","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.55","619.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","354.16","42.9","","731.00","63.70","731.00","1 through 10","255.92","656.31","percent of total billed charges",""
"STAPLE BONE 15X16MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004535","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.55","619.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","354.16","42.9","","384.74","384.74","384.74","1 through 10","255.92","656.31","percent of total billed charges",""
"STAPLE BONE 15X16MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004535","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.55","619.16","WELLPOINT [1015]","HB AMC WELLPOINT","609.09","73.78","","286.63","119.22","1107.45","105","255.92","656.31","percent of total billed charges",""
"STAPLE BONE 15X16MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.55","619.16","AETNA [1001]","HB AMC AETNA HMO","576.23","69.8","","675.31","184.75","1721.50","286","431.43","674.64","percent of total billed charges",""
"STAPLE BONE 15X16MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.55","619.16","AETNA [1001]","HB AMC AETNA PPO","663.74","80.4","","1261.44","103.12","1514.10","21","431.43","674.64","percent of total billed charges",""
"STAPLE BONE 15X16MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.55","619.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","663.74","80.4","","1365.00","1365.00","1365.00","1 through 10","431.43","674.64","percent of total billed charges",""
"STAPLE BONE 15X16MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.55","619.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","674.64","81.72","","5157.68","5157.68","5157.68","1 through 10","431.43","674.64","percent of total billed charges",""
"STAPLE BONE 15X16MM TITANIUM CARTRIDGE BX/3EA","SUP-ITM-10004535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.55","619.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","674.64","81.72","","431.26","71.26","1459.57","88","431.43","674.64","percent of total billed charges",""
"STAPLE DYNANITE 11X11MM NITINOL INSTRUMENT","SUP-ITM-10212187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3565.58","79.5","","800.18","480.96","1887.97","195","1390.35","3565.58","percent of total billed charges",""
"STAPLE DYNANITE 11X11MM NITINOL INSTRUMENT","SUP-ITM-10212187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2390.51","53.3","","813.12","216.42","1444.50","81","1390.35","3565.58","percent of total billed charges",""
"STAPLE DYNANITE 11X11MM NITINOL INSTRUMENT","SUP-ITM-10212187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1390.35","31","","432.60","432.60","432.60","1 through 10","1390.35","3565.58","percent of total billed charges",""
"STAPLE DYNANITE 11X11MM NITINOL INSTRUMENT","SUP-ITM-10212187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1637.03","36.5","","148.37","54.89","631.39","94","1390.35","3565.58","percent of total billed charges",""
"STAPLE DYNANITE 11X11MM NITINOL INSTRUMENT","SUP-ITM-10212187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1717.76","38.3","","279.30","91.72","1116.77","266","1390.35","3565.58","percent of total billed charges",""
"STAPLE DYNANITE 11X11MM NITINOL INSTRUMENT","SUP-ITM-10212187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1924.07","42.9","","731.00","63.70","731.00","1 through 10","1390.35","3565.58","percent of total billed charges",""
"STAPLE DYNANITE 11X11MM NITINOL INSTRUMENT","SUP-ITM-10212187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1924.07","42.9","","384.74","384.74","384.74","1 through 10","1390.35","3565.58","percent of total billed charges",""
"STAPLE DYNANITE 11X11MM NITINOL INSTRUMENT","SUP-ITM-10212187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","WELLPOINT [1015]","HB AMC WELLPOINT","3309.03","73.78","","286.63","119.22","1107.45","105","1390.35","3565.58","percent of total billed charges",""
"STAPLE DYNANITE 11X11MM NITINOL INSTRUMENT","SUP-ITM-10212187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","AETNA [1001]","HB AMC AETNA HMO","3130.53","69.8","","675.31","184.75","1721.50","286","2343.86","3665.14","percent of total billed charges",""
"STAPLE DYNANITE 11X11MM NITINOL INSTRUMENT","SUP-ITM-10212187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","AETNA [1001]","HB AMC AETNA PPO","3605.94","80.4","","1261.44","103.12","1514.10","21","2343.86","3665.14","percent of total billed charges",""
"STAPLE DYNANITE 11X11MM NITINOL INSTRUMENT","SUP-ITM-10212187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3605.94","80.4","","1365.00","1365.00","1365.00","1 through 10","2343.86","3665.14","percent of total billed charges",""
"STAPLE DYNANITE 11X11MM NITINOL INSTRUMENT","SUP-ITM-10212187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3665.14","81.72","","5157.68","5157.68","5157.68","1 through 10","2343.86","3665.14","percent of total billed charges",""
"STAPLE DYNANITE 11X11MM NITINOL INSTRUMENT","SUP-ITM-10212187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3665.14","81.72","","431.26","71.26","1459.57","88","2343.86","3665.14","percent of total billed charges",""
"STAPLE SPINE 7MM SS SCREW","SUP-ITM-10033003","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","1309.77","674.56","6049.93","26","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE 7MM SS SCREW","SUP-ITM-10033003","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","1901.83","1901.83","2962.25","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE 7MM SS SCREW","SUP-ITM-10033003","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","1620.31","1620.31","19908.88","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE 7MM SS SCREW","SUP-ITM-10033003","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","352.91","352.91","2046.30","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE 7MM SS SCREW","SUP-ITM-10033003","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","9668.75","9668.75","9668.75","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE 7MM SS SCREW","SUP-ITM-10033003","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","699.88","384.10","3443.31","33","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE 7MM SS SCREW","SUP-ITM-10033003","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","1421.24","264.50","4933.46","29","457.28","715.05","percent of total billed charges",""
"STAPLE SPINE 7MM SS SCREW","SUP-ITM-10033003","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1022.97","1022.97","3607.50","1 through 10","457.28","715.05","percent of total billed charges",""
"STAPLE SPINE 7MM SS SCREW","SUP-ITM-10033003","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","3010.54","693.88","5019.88","35","457.28","715.05","percent of total billed charges",""
"STAPLE SPINE MEDIUM EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10046287","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","1309.77","674.56","6049.93","26","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE MEDIUM EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10046287","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","1901.83","1901.83","2962.25","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE MEDIUM EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10046287","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","1620.31","1620.31","19908.88","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE MEDIUM EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10046287","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","352.91","352.91","2046.30","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE MEDIUM EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10046287","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","9668.75","9668.75","9668.75","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE MEDIUM EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10046287","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","699.88","384.10","3443.31","33","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE MEDIUM EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10046287","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","1421.24","264.50","4933.46","29","457.28","715.05","percent of total billed charges",""
"STAPLE SPINE MEDIUM EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10046287","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1022.97","1022.97","3607.50","1 through 10","457.28","715.05","percent of total billed charges",""
"STAPLE SPINE MEDIUM EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10046287","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","3010.54","693.88","5019.88","35","457.28","715.05","percent of total billed charges",""
"STAPLE SPINE SMALL EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10020991","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","1309.77","674.56","6049.93","26","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE SMALL EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10020991","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","1901.83","1901.83","2962.25","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE SMALL EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10020991","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","1620.31","1620.31","19908.88","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE SMALL EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10020991","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","352.91","352.91","2046.30","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE SMALL EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10020991","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","9668.75","9668.75","9668.75","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE SMALL EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10020991","CDM","C1889","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","699.88","384.10","3443.31","33","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE SMALL EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10020991","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","1421.24","264.50","4933.46","29","457.28","715.05","percent of total billed charges",""
"STAPLE SPINE SMALL EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10020991","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1022.97","1022.97","3607.50","1 through 10","457.28","715.05","percent of total billed charges",""
"STAPLE SPINE SMALL EXPEDIUM THORACOLUMBAR ANTERIOR DUAL HOLE ROSTRAL","SUP-ITM-10020991","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","3010.54","693.88","5019.88","35","457.28","715.05","percent of total billed charges",""
"STAPLE SPINE VANTAGE TITANIUM ROSTRAL THORACIC","SUP-ITM-10018117","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","800.18","480.96","1887.97","195","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE VANTAGE TITANIUM ROSTRAL THORACIC","SUP-ITM-10018117","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","466.38","53.3","","813.12","216.42","1444.50","81","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE VANTAGE TITANIUM ROSTRAL THORACIC","SUP-ITM-10018117","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","271.25","31","","432.60","432.60","432.60","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE VANTAGE TITANIUM ROSTRAL THORACIC","SUP-ITM-10018117","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","148.37","54.89","631.39","94","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE VANTAGE TITANIUM ROSTRAL THORACIC","SUP-ITM-10018117","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","279.30","91.72","1116.77","266","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE VANTAGE TITANIUM ROSTRAL THORACIC","SUP-ITM-10018117","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","731.00","63.70","731.00","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE VANTAGE TITANIUM ROSTRAL THORACIC","SUP-ITM-10018117","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","384.74","384.74","384.74","1 through 10","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE VANTAGE TITANIUM ROSTRAL THORACIC","SUP-ITM-10018117","CDM","C1713","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","286.63","119.22","1107.45","105","271.25","695.63","percent of total billed charges",""
"STAPLE SPINE VANTAGE TITANIUM ROSTRAL THORACIC","SUP-ITM-10018117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","675.31","184.75","1721.50","286","457.28","715.05","percent of total billed charges",""
"STAPLE SPINE VANTAGE TITANIUM ROSTRAL THORACIC","SUP-ITM-10018117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA PPO","703.50","80.4","","1261.44","103.12","1514.10","21","457.28","715.05","percent of total billed charges",""
"STAPLE SPINE VANTAGE TITANIUM ROSTRAL THORACIC","SUP-ITM-10018117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","703.50","80.4","","1365.00","1365.00","1365.00","1 through 10","457.28","715.05","percent of total billed charges",""
"STAPLE SPINE VANTAGE TITANIUM ROSTRAL THORACIC","SUP-ITM-10018117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","715.05","81.72","","5157.68","5157.68","5157.68","1 through 10","457.28","715.05","percent of total billed charges",""
"STAPLE SPINE VANTAGE TITANIUM ROSTRAL THORACIC","SUP-ITM-10018117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","431.26","71.26","1459.57","88","457.28","715.05","percent of total billed charges",""
"Stat3 Gene Sequencing","PX-31000823","CDM","81479","CPT","0310","RC","","","","both","","","2454.00","1840.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1950.93","79.5","","0.65","0.65","0.65","1 through 10","760.74","2331.3","percent of total billed charges",""
"Stat3 Gene Sequencing","PX-31000823","CDM","81479","CPT","0310","RC","","","","both","","","2454.00","1840.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1307.98","53.3","","0.79","0.79","0.79","1 through 10","760.74","2331.3","percent of total billed charges",""
"Stat3 Gene Sequencing","PX-31000823","CDM","81479","CPT","0310","RC","","","","outpatient","","","2454.00","1840.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1227.00","50","","1.00","1.00","1.00","1 through 10","156.55","2024.55","percent of total billed charges",""
"Stat3 Gene Sequencing","PX-31000823","CDM","81479","CPT","0310","RC","","","","outpatient","","","2454.00","1840.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1288.35","52.5","","1.00","0.53","1.00","1 through 10","156.55","2024.55","percent of total billed charges",""
"Stem Cells Total","PX-30000855","CDM","86367","CPT","0302","RC","","","","both","","","288.00","216.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","187.20","65","","181.35","147.31","181.35","1 through 10","11.81","273.6","percent of total billed charges",""
"Stem Cells Total","PX-30000855","CDM","86367","CPT","0302","RC","","","","both","","","288.00","216.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","201.60","70","","200.88","119.97","641.70","23","11.81","273.6","percent of total billed charges",""
"Stem Cells Total","PX-30000855","CDM","86367","CPT","0302","RC","","","","both","","","288.00","216.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","228.96","79.5","","219.57","219.57","219.57","1 through 10","11.81","273.6","percent of total billed charges",""
"Stem Cells Total","PX-30000855","CDM","86367","CPT","0302","RC","","","","both","","","288.00","216.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","153.50","53.3","","140.90","140.90","140.90","1 through 10","11.81","273.6","percent of total billed charges",""
"Stem Cells Total","PX-30000855","CDM","86367","CPT","0302","RC","","","","both","","","288.00","216.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","187.20","65","","175.50","175.50","175.50","1 through 10","11.81","273.6","percent of total billed charges",""
"Stem Cells Total","PX-30000855","CDM","86367","CPT","0302","RC","","","","outpatient","","","288.00","216.00","AETNA [1001]","HB AMC AETNA HMO","201.02","69.8","","188.88","188.88","217.62","11","11.81","476.79","percent of total billed charges",""
"Stem Cells Total","PX-30000855","CDM","86367","CPT","0302","RC","","","","outpatient","","","288.00","216.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","150.51","52.26","","172.65","172.65","172.65","1 through 10","11.81","476.79","percent of total billed charges",""
"Stem Cells Total","PX-30000855","CDM","86367","CPT","0302","RC","","","","outpatient","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","235.35","81.72","","223.03","223.03","223.03","1 through 10","11.81","476.79","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2822.04","52.26","","1113.10","1113.10","1113.10","1 through 10","1674","4293","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4293.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1674","4293","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1971.00","36.5","","1023.42","771.29","2068.67","33","1674","4293","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2068.20","38.3","","850.52","759.78","1211.25","66","1674","4293","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","2548.09","2548.09","2548.09","1 through 10","1674","4293","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2316.60","42.9","","956.46","956.46","956.46","1 through 10","1674","4293","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB AMC WELLPOINT","3984.12","73.78","","2344.73","1619.47","2530.35","16","1674","4293","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA HMO","3769.20","69.8","","1523.63","988.41","4330.26","39","2822.04","4412.88","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","AETNA [1001]","HB AMC AETNA PPO","4341.60","80.4","","1670.25","1670.25","1670.25","1 through 10","2822.04","4412.88","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2822.04","52.26","","1113.10","1113.10","1113.10","1 through 10","2822.04","4412.88","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4412.88","81.72","","1738.90","1484.65","2716.94","38","2822.04","4412.88","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 1 COLLARED HIGH OFFSET","SUP-ITM-10335462","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2613.00","52.26","","1113.10","1113.10","1113.10","1 through 10","1550","3975","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 1 COLLARED HIGH OFFSET","SUP-ITM-10335462","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1550","3975","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 1 COLLARED HIGH OFFSET","SUP-ITM-10335462","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","1023.42","771.29","2068.67","33","1550","3975","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 1 COLLARED HIGH OFFSET","SUP-ITM-10335462","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","850.52","759.78","1211.25","66","1550","3975","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 1 COLLARED HIGH OFFSET","SUP-ITM-10335462","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","2548.09","2548.09","2548.09","1 through 10","1550","3975","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 1 COLLARED HIGH OFFSET","SUP-ITM-10335462","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","956.46","956.46","956.46","1 through 10","1550","3975","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 1 COLLARED HIGH OFFSET","SUP-ITM-10335462","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","2344.73","1619.47","2530.35","16","1550","3975","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 1 COLLARED HIGH OFFSET","SUP-ITM-10335462","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","1523.63","988.41","4330.26","39","2613","4086","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 1 COLLARED HIGH OFFSET","SUP-ITM-10335462","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA PPO","4020.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2613","4086","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 1 COLLARED HIGH OFFSET","SUP-ITM-10335462","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2613.00","52.26","","1113.10","1113.10","1113.10","1 through 10","2613","4086","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 1 COLLARED HIGH OFFSET","SUP-ITM-10335462","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","1738.90","1484.65","2716.94","38","2613","4086","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2782.85","52.26","","1113.10","1113.10","1113.10","1 through 10","1650.75","4233.38","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4233.38","79.5","","1293.60","1148.53","1603.80","1 through 10","1650.75","4233.38","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1943.63","36.5","","1023.42","771.29","2068.67","33","1650.75","4233.38","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2039.48","38.3","","850.52","759.78","1211.25","66","1650.75","4233.38","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2284.43","42.9","","2548.09","2548.09","2548.09","1 through 10","1650.75","4233.38","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2284.43","42.9","","956.46","956.46","956.46","1 through 10","1650.75","4233.38","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","WELLPOINT [1015]","HB AMC WELLPOINT","3928.79","73.78","","2344.73","1619.47","2530.35","16","1650.75","4233.38","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5325.00","3993.75","AETNA [1001]","HB AMC AETNA HMO","3716.85","69.8","","1523.63","988.41","4330.26","39","2782.85","4351.59","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5325.00","3993.75","AETNA [1001]","HB AMC AETNA PPO","4281.30","80.4","","1670.25","1670.25","1670.25","1 through 10","2782.85","4351.59","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5325.00","3993.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2782.85","52.26","","1113.10","1113.10","1113.10","1 through 10","2782.85","4351.59","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5325.00","3993.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4351.59","81.72","","1738.90","1484.65","2716.94","38","2782.85","4351.59","percent of total billed charges",""
"STEM HUMERAL 10X123MM RFX REUNION","SUP-ITM-10209191","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4945.76","52.26","","1113.10","1113.10","1113.10","1 through 10","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 10X123MM RFX REUNION","SUP-ITM-10209191","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7523.68","79.5","","1293.60","1148.53","1603.80","1 through 10","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 10X123MM RFX REUNION","SUP-ITM-10209191","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3454.27","36.5","","1023.42","771.29","2068.67","33","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 10X123MM RFX REUNION","SUP-ITM-10209191","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3624.62","38.3","","850.52","759.78","1211.25","66","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 10X123MM RFX REUNION","SUP-ITM-10209191","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4059.95","42.9","","2548.09","2548.09","2548.09","1 through 10","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 10X123MM RFX REUNION","SUP-ITM-10209191","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4059.95","42.9","","956.46","956.46","956.46","1 through 10","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 10X123MM RFX REUNION","SUP-ITM-10209191","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","WELLPOINT [1015]","HB AMC WELLPOINT","6982.35","73.78","","2344.73","1619.47","2530.35","16","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 10X123MM RFX REUNION","SUP-ITM-10209191","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9463.75","7097.81","AETNA [1001]","HB AMC AETNA HMO","6605.70","69.8","","1523.63","988.41","4330.26","39","4945.76","7733.78","percent of total billed charges",""
"STEM HUMERAL 10X123MM RFX REUNION","SUP-ITM-10209191","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9463.75","7097.81","AETNA [1001]","HB AMC AETNA PPO","7608.86","80.4","","1670.25","1670.25","1670.25","1 through 10","4945.76","7733.78","percent of total billed charges",""
"STEM HUMERAL 10X123MM RFX REUNION","SUP-ITM-10209191","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9463.75","7097.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4945.76","52.26","","1113.10","1113.10","1113.10","1 through 10","4945.76","7733.78","percent of total billed charges",""
"STEM HUMERAL 10X123MM RFX REUNION","SUP-ITM-10209191","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9463.75","7097.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7733.78","81.72","","1738.90","1484.65","2716.94","38","4945.76","7733.78","percent of total billed charges",""
"STEM HUMERAL 8X118MM RFX REUNION","SUP-ITM-10282056","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4945.76","52.26","","1113.10","1113.10","1113.10","1 through 10","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 8X118MM RFX REUNION","SUP-ITM-10282056","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7523.68","79.5","","1293.60","1148.53","1603.80","1 through 10","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 8X118MM RFX REUNION","SUP-ITM-10282056","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3454.27","36.5","","1023.42","771.29","2068.67","33","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 8X118MM RFX REUNION","SUP-ITM-10282056","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3624.62","38.3","","850.52","759.78","1211.25","66","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 8X118MM RFX REUNION","SUP-ITM-10282056","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4059.95","42.9","","2548.09","2548.09","2548.09","1 through 10","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 8X118MM RFX REUNION","SUP-ITM-10282056","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4059.95","42.9","","956.46","956.46","956.46","1 through 10","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 8X118MM RFX REUNION","SUP-ITM-10282056","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","WELLPOINT [1015]","HB AMC WELLPOINT","6982.35","73.78","","2344.73","1619.47","2530.35","16","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 8X118MM RFX REUNION","SUP-ITM-10282056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9463.75","7097.81","AETNA [1001]","HB AMC AETNA HMO","6605.70","69.8","","1523.63","988.41","4330.26","39","4945.76","7733.78","percent of total billed charges",""
"STEM HUMERAL 8X118MM RFX REUNION","SUP-ITM-10282056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9463.75","7097.81","AETNA [1001]","HB AMC AETNA PPO","7608.86","80.4","","1670.25","1670.25","1670.25","1 through 10","4945.76","7733.78","percent of total billed charges",""
"STEM HUMERAL 8X118MM RFX REUNION","SUP-ITM-10282056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9463.75","7097.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4945.76","52.26","","1113.10","1113.10","1113.10","1 through 10","4945.76","7733.78","percent of total billed charges",""
"STEM HUMERAL 8X118MM RFX REUNION","SUP-ITM-10282056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9463.75","7097.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7733.78","81.72","","1738.90","1484.65","2716.94","38","4945.76","7733.78","percent of total billed charges",""
"STEM HUMERAL 9X118MM RFX REUNION","SUP-ITM-10276255","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4945.76","52.26","","1113.10","1113.10","1113.10","1 through 10","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 9X118MM RFX REUNION","SUP-ITM-10276255","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7523.68","79.5","","1293.60","1148.53","1603.80","1 through 10","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 9X118MM RFX REUNION","SUP-ITM-10276255","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3454.27","36.5","","1023.42","771.29","2068.67","33","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 9X118MM RFX REUNION","SUP-ITM-10276255","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3624.62","38.3","","850.52","759.78","1211.25","66","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 9X118MM RFX REUNION","SUP-ITM-10276255","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4059.95","42.9","","2548.09","2548.09","2548.09","1 through 10","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 9X118MM RFX REUNION","SUP-ITM-10276255","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4059.95","42.9","","956.46","956.46","956.46","1 through 10","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 9X118MM RFX REUNION","SUP-ITM-10276255","CDM","C1776","HCPCS","0278","RC","","","","both","","","9463.75","7097.81","WELLPOINT [1015]","HB AMC WELLPOINT","6982.35","73.78","","2344.73","1619.47","2530.35","16","2933.76","7523.68","percent of total billed charges",""
"STEM HUMERAL 9X118MM RFX REUNION","SUP-ITM-10276255","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9463.75","7097.81","AETNA [1001]","HB AMC AETNA HMO","6605.70","69.8","","1523.63","988.41","4330.26","39","4945.76","7733.78","percent of total billed charges",""
"STEM HUMERAL 9X118MM RFX REUNION","SUP-ITM-10276255","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9463.75","7097.81","AETNA [1001]","HB AMC AETNA PPO","7608.86","80.4","","1670.25","1670.25","1670.25","1 through 10","4945.76","7733.78","percent of total billed charges",""
"STEM HUMERAL 9X118MM RFX REUNION","SUP-ITM-10276255","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9463.75","7097.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4945.76","52.26","","1113.10","1113.10","1113.10","1 through 10","4945.76","7733.78","percent of total billed charges",""
"STEM HUMERAL 9X118MM RFX REUNION","SUP-ITM-10276255","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9463.75","7097.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7733.78","81.72","","1738.90","1484.65","2716.94","38","4945.76","7733.78","percent of total billed charges",""
"STEM KNEE 20X110MM ATTUNE STRAIGHT PRESSFIT","SUP-ITM-10274676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","1193.5","3060.75","percent of total billed charges",""
"STEM KNEE 20X110MM ATTUNE STRAIGHT PRESSFIT","SUP-ITM-10274676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3060.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1193.5","3060.75","percent of total billed charges",""
"STEM KNEE 20X110MM ATTUNE STRAIGHT PRESSFIT","SUP-ITM-10274676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1405.25","36.5","","1023.42","771.29","2068.67","33","1193.5","3060.75","percent of total billed charges",""
"STEM KNEE 20X110MM ATTUNE STRAIGHT PRESSFIT","SUP-ITM-10274676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1474.55","38.3","","850.52","759.78","1211.25","66","1193.5","3060.75","percent of total billed charges",""
"STEM KNEE 20X110MM ATTUNE STRAIGHT PRESSFIT","SUP-ITM-10274676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","2548.09","2548.09","2548.09","1 through 10","1193.5","3060.75","percent of total billed charges",""
"STEM KNEE 20X110MM ATTUNE STRAIGHT PRESSFIT","SUP-ITM-10274676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.65","42.9","","956.46","956.46","956.46","1 through 10","1193.5","3060.75","percent of total billed charges",""
"STEM KNEE 20X110MM ATTUNE STRAIGHT PRESSFIT","SUP-ITM-10274676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3850.00","2887.50","WELLPOINT [1015]","HB AMC WELLPOINT","2840.53","73.78","","2344.73","1619.47","2530.35","16","1193.5","3060.75","percent of total billed charges",""
"STEM KNEE 20X110MM ATTUNE STRAIGHT PRESSFIT","SUP-ITM-10274676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA HMO","2687.30","69.8","","1523.63","988.41","4330.26","39","2012.01","3146.22","percent of total billed charges",""
"STEM KNEE 20X110MM ATTUNE STRAIGHT PRESSFIT","SUP-ITM-10274676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","AETNA [1001]","HB AMC AETNA PPO","3095.40","80.4","","1670.25","1670.25","1670.25","1 through 10","2012.01","3146.22","percent of total billed charges",""
"STEM KNEE 20X110MM ATTUNE STRAIGHT PRESSFIT","SUP-ITM-10274676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2012.01","52.26","","1113.10","1113.10","1113.10","1 through 10","2012.01","3146.22","percent of total billed charges",""
"STEM KNEE 20X110MM ATTUNE STRAIGHT PRESSFIT","SUP-ITM-10274676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3850.00","2887.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3146.22","81.72","","1738.90","1484.65","2716.94","38","2012.01","3146.22","percent of total billed charges",""
"STEM RADIO 1CM 4.5MM JOINT EXTENDED DISTAL RADIAL ULNAR","SUP-ITM-10077536","CDM","C1776","HCPCS","0278","RC","","","","both","","","6687.50","5015.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3494.89","52.26","","1113.10","1113.10","1113.10","1 through 10","2073.13","5316.56","percent of total billed charges",""
"STEM RADIO 1CM 4.5MM JOINT EXTENDED DISTAL RADIAL ULNAR","SUP-ITM-10077536","CDM","C1776","HCPCS","0278","RC","","","","both","","","6687.50","5015.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5316.56","79.5","","1293.60","1148.53","1603.80","1 through 10","2073.13","5316.56","percent of total billed charges",""
"STEM RADIO 1CM 4.5MM JOINT EXTENDED DISTAL RADIAL ULNAR","SUP-ITM-10077536","CDM","C1776","HCPCS","0278","RC","","","","both","","","6687.50","5015.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2440.94","36.5","","1023.42","771.29","2068.67","33","2073.13","5316.56","percent of total billed charges",""
"STEM RADIO 1CM 4.5MM JOINT EXTENDED DISTAL RADIAL ULNAR","SUP-ITM-10077536","CDM","C1776","HCPCS","0278","RC","","","","both","","","6687.50","5015.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2561.31","38.3","","850.52","759.78","1211.25","66","2073.13","5316.56","percent of total billed charges",""
"STEM RADIO 1CM 4.5MM JOINT EXTENDED DISTAL RADIAL ULNAR","SUP-ITM-10077536","CDM","C1776","HCPCS","0278","RC","","","","both","","","6687.50","5015.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2868.94","42.9","","2548.09","2548.09","2548.09","1 through 10","2073.13","5316.56","percent of total billed charges",""
"STEM RADIO 1CM 4.5MM JOINT EXTENDED DISTAL RADIAL ULNAR","SUP-ITM-10077536","CDM","C1776","HCPCS","0278","RC","","","","both","","","6687.50","5015.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2868.94","42.9","","956.46","956.46","956.46","1 through 10","2073.13","5316.56","percent of total billed charges",""
"STEM RADIO 1CM 4.5MM JOINT EXTENDED DISTAL RADIAL ULNAR","SUP-ITM-10077536","CDM","C1776","HCPCS","0278","RC","","","","both","","","6687.50","5015.62","WELLPOINT [1015]","HB AMC WELLPOINT","4934.04","73.78","","2344.73","1619.47","2530.35","16","2073.13","5316.56","percent of total billed charges",""
"STEM RADIO 1CM 4.5MM JOINT EXTENDED DISTAL RADIAL ULNAR","SUP-ITM-10077536","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6687.50","5015.62","AETNA [1001]","HB AMC AETNA HMO","4667.88","69.8","","1523.63","988.41","4330.26","39","3494.89","5465.03","percent of total billed charges",""
"STEM RADIO 1CM 4.5MM JOINT EXTENDED DISTAL RADIAL ULNAR","SUP-ITM-10077536","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6687.50","5015.62","AETNA [1001]","HB AMC AETNA PPO","5376.75","80.4","","1670.25","1670.25","1670.25","1 through 10","3494.89","5465.03","percent of total billed charges",""
"STEM RADIO 1CM 4.5MM JOINT EXTENDED DISTAL RADIAL ULNAR","SUP-ITM-10077536","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6687.50","5015.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3494.89","52.26","","1113.10","1113.10","1113.10","1 through 10","3494.89","5465.03","percent of total billed charges",""
"STEM RADIO 1CM 4.5MM JOINT EXTENDED DISTAL RADIAL ULNAR","SUP-ITM-10077536","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6687.50","5015.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5465.03","81.72","","1738.90","1484.65","2716.94","38","3494.89","5465.03","percent of total billed charges",""
"STENT AAA TREO 15/20X140MM GRAFT LEG EXTENSION","SUP-ITM-10283001","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6940.38","65","","6652.80","6652.80","6652.80","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/20X140MM GRAFT LEG EXTENSION","SUP-ITM-10283001","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8488.61","79.5","","2612.61","795.38","2612.61","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/20X140MM GRAFT LEG EXTENSION","SUP-ITM-10283001","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5691.11","53.3","","1101.80","1101.80","1101.80","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/20X140MM GRAFT LEG EXTENSION","SUP-ITM-10283001","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6940.38","65","","1820.00","910.00","1820.00","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/20X140MM GRAFT LEG EXTENSION","SUP-ITM-10283001","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3897.29","36.5","","1257.80","693.44","2424.50","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/20X140MM GRAFT LEG EXTENSION","SUP-ITM-10283001","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4089.48","38.3","","1950.11","547.40","2346.00","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/20X140MM GRAFT LEG EXTENSION","SUP-ITM-10283001","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4580.65","42.9","","5096.18","5096.18","5096.18","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/20X140MM GRAFT LEG EXTENSION","SUP-ITM-10283001","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","WELLPOINT [1015]","HB AMC WELLPOINT","7877.86","73.78","","1172.59","1172.59","4829.94","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/20X140MM GRAFT LEG EXTENSION","SUP-ITM-10283001","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10677.50","8008.12","AETNA [1001]","HB AMC AETNA HMO","7452.90","69.8","","1806.84","947.80","5091.72","1 through 10","5580.06","8725.65","percent of total billed charges",""
"STENT AAA TREO 15/20X140MM GRAFT LEG EXTENSION","SUP-ITM-10283001","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10677.50","8008.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8725.65","81.72","","1259.05","615.58","4586.56","1 through 10","5580.06","8725.65","percent of total billed charges",""
"STENT AAA TREO 15/24X100MM GRAFT LEG EXTENSION","SUP-ITM-10282998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6940.38","65","","6652.80","6652.80","6652.80","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/24X100MM GRAFT LEG EXTENSION","SUP-ITM-10282998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8488.61","79.5","","2612.61","795.38","2612.61","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/24X100MM GRAFT LEG EXTENSION","SUP-ITM-10282998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5691.11","53.3","","1101.80","1101.80","1101.80","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/24X100MM GRAFT LEG EXTENSION","SUP-ITM-10282998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6940.38","65","","1820.00","910.00","1820.00","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/24X100MM GRAFT LEG EXTENSION","SUP-ITM-10282998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3897.29","36.5","","1257.80","693.44","2424.50","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/24X100MM GRAFT LEG EXTENSION","SUP-ITM-10282998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4089.48","38.3","","1950.11","547.40","2346.00","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/24X100MM GRAFT LEG EXTENSION","SUP-ITM-10282998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4580.65","42.9","","5096.18","5096.18","5096.18","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/24X100MM GRAFT LEG EXTENSION","SUP-ITM-10282998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10677.50","8008.12","WELLPOINT [1015]","HB AMC WELLPOINT","7877.86","73.78","","1172.59","1172.59","4829.94","1 through 10","3310.03","8488.61","percent of total billed charges",""
"STENT AAA TREO 15/24X100MM GRAFT LEG EXTENSION","SUP-ITM-10282998","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10677.50","8008.12","AETNA [1001]","HB AMC AETNA HMO","7452.90","69.8","","1806.84","947.80","5091.72","1 through 10","5580.06","8725.65","percent of total billed charges",""
"STENT AAA TREO 15/24X100MM GRAFT LEG EXTENSION","SUP-ITM-10282998","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10677.50","8008.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8725.65","81.72","","1259.05","615.58","4586.56","1 through 10","5580.06","8725.65","percent of total billed charges",""
"STENT AAA TREO 26X80MM GRAFT BIFURCATE","SUP-ITM-10283068","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","12912.25","65","","6652.80","6652.80","6652.80","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 26X80MM GRAFT BIFURCATE","SUP-ITM-10283068","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15792.68","79.5","","2612.61","795.38","2612.61","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 26X80MM GRAFT BIFURCATE","SUP-ITM-10283068","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10588.05","53.3","","1101.80","1101.80","1101.80","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 26X80MM GRAFT BIFURCATE","SUP-ITM-10283068","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","12912.25","65","","1820.00","910.00","1820.00","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 26X80MM GRAFT BIFURCATE","SUP-ITM-10283068","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7250.73","36.5","","1257.80","693.44","2424.50","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 26X80MM GRAFT BIFURCATE","SUP-ITM-10283068","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7608.30","38.3","","1950.11","547.40","2346.00","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 26X80MM GRAFT BIFURCATE","SUP-ITM-10283068","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8522.09","42.9","","5096.18","5096.18","5096.18","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 26X80MM GRAFT BIFURCATE","SUP-ITM-10283068","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","WELLPOINT [1015]","HB AMC WELLPOINT","14656.40","73.78","","1172.59","1172.59","4829.94","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 26X80MM GRAFT BIFURCATE","SUP-ITM-10283068","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19865.00","14898.75","AETNA [1001]","HB AMC AETNA HMO","13865.77","69.8","","1806.84","947.80","5091.72","1 through 10","10381.45","16233.68","percent of total billed charges",""
"STENT AAA TREO 26X80MM GRAFT BIFURCATE","SUP-ITM-10283068","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19865.00","14898.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16233.68","81.72","","1259.05","615.58","4586.56","1 through 10","10381.45","16233.68","percent of total billed charges",""
"STENT AAA TREO 30X100MM GRAFT BIFURCATE","SUP-ITM-10283061","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","12912.25","65","","6652.80","6652.80","6652.80","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 30X100MM GRAFT BIFURCATE","SUP-ITM-10283061","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15792.68","79.5","","2612.61","795.38","2612.61","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 30X100MM GRAFT BIFURCATE","SUP-ITM-10283061","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10588.05","53.3","","1101.80","1101.80","1101.80","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 30X100MM GRAFT BIFURCATE","SUP-ITM-10283061","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","12912.25","65","","1820.00","910.00","1820.00","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 30X100MM GRAFT BIFURCATE","SUP-ITM-10283061","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7250.73","36.5","","1257.80","693.44","2424.50","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 30X100MM GRAFT BIFURCATE","SUP-ITM-10283061","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7608.30","38.3","","1950.11","547.40","2346.00","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 30X100MM GRAFT BIFURCATE","SUP-ITM-10283061","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8522.09","42.9","","5096.18","5096.18","5096.18","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 30X100MM GRAFT BIFURCATE","SUP-ITM-10283061","CDM","C1874","HCPCS","0278","RC","","","","both","","","19865.00","14898.75","WELLPOINT [1015]","HB AMC WELLPOINT","14656.40","73.78","","1172.59","1172.59","4829.94","1 through 10","6158.15","15792.68","percent of total billed charges",""
"STENT AAA TREO 30X100MM GRAFT BIFURCATE","SUP-ITM-10283061","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19865.00","14898.75","AETNA [1001]","HB AMC AETNA HMO","13865.77","69.8","","1806.84","947.80","5091.72","1 through 10","10381.45","16233.68","percent of total billed charges",""
"STENT AAA TREO 30X100MM GRAFT BIFURCATE","SUP-ITM-10283061","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19865.00","14898.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16233.68","81.72","","1259.05","615.58","4586.56","1 through 10","10381.45","16233.68","percent of total billed charges",""
"STENT ABSOLUTE PRO 6MM 40MM 80CM .035IN OTW VASCULAR NICKEL TITANIUM SELF-EXPANDING EXTERNAL ILIAC ARTERY TRI AXIAL RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10094844","CDM","C1876","HCPCS","0278","RC","","","","both","","","1465.63","1099.22","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","961.45","65.6","","751.18","751.18","751.18","1 through 10","454.35","1165.18","percent of total billed charges",""
"STENT ABSOLUTE PRO 6MM 40MM 80CM .035IN OTW VASCULAR NICKEL TITANIUM SELF-EXPANDING EXTERNAL ILIAC ARTERY TRI AXIAL RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10094844","CDM","C1876","HCPCS","0278","RC","","","","both","","","1465.63","1099.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1165.18","79.5","","4820.38","3211.27","4820.38","1 through 10","454.35","1165.18","percent of total billed charges",""
"STENT ABSOLUTE PRO 6MM 40MM 80CM .035IN OTW VASCULAR NICKEL TITANIUM SELF-EXPANDING EXTERNAL ILIAC ARTERY TRI AXIAL RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10094844","CDM","C1876","HCPCS","0278","RC","","","","both","","","1465.63","1099.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","534.95","36.5","","641.00","641.00","641.00","1 through 10","454.35","1165.18","percent of total billed charges",""
"STENT ABSOLUTE PRO 6MM 40MM 80CM .035IN OTW VASCULAR NICKEL TITANIUM SELF-EXPANDING EXTERNAL ILIAC ARTERY TRI AXIAL RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10094844","CDM","C1876","HCPCS","0278","RC","","","","both","","","1465.63","1099.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","561.34","38.3","","1098.43","1098.43","1098.43","1 through 10","454.35","1165.18","percent of total billed charges",""
"STENT ABSOLUTE PRO 6MM 40MM 80CM .035IN OTW VASCULAR NICKEL TITANIUM SELF-EXPANDING EXTERNAL ILIAC ARTERY TRI AXIAL RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10094844","CDM","C1876","HCPCS","0278","RC","","","","both","","","1465.63","1099.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","628.76","42.9","","4896.33","4896.33","4896.33","1 through 10","454.35","1165.18","percent of total billed charges",""
"STENT ABSOLUTE PRO 6MM 40MM 80CM .035IN OTW VASCULAR NICKEL TITANIUM SELF-EXPANDING EXTERNAL ILIAC ARTERY TRI AXIAL RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10094844","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1465.63","1099.22","AETNA [1001]","HB AMC AETNA HMO","1023.01","69.8","","175.60","163.11","1063.91","1 through 10","765.94","1197.71","percent of total billed charges",""
"STENT ABSOLUTE PRO 6MM 40MM 80CM .035IN OTW VASCULAR NICKEL TITANIUM SELF-EXPANDING EXTERNAL ILIAC ARTERY TRI AXIAL RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10094844","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1465.63","1099.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1197.71","81.72","","105.94","85.10","105.94","1 through 10","765.94","1197.71","percent of total billed charges",""
"STENT ADVANIX 10FR 10CM RX BILIARY DOUBLE PIGTAIL POLYETHYLENE NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139057","CDM","C1876","HCPCS","0278","RC","","","","both","","","193.55","145.16","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","126.97","65.6","","751.18","751.18","751.18","1 through 10","60","153.87","percent of total billed charges",""
"STENT ADVANIX 10FR 10CM RX BILIARY DOUBLE PIGTAIL POLYETHYLENE NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139057","CDM","C1876","HCPCS","0278","RC","","","","both","","","193.55","145.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","153.87","79.5","","4820.38","3211.27","4820.38","1 through 10","60","153.87","percent of total billed charges",""
"STENT ADVANIX 10FR 10CM RX BILIARY DOUBLE PIGTAIL POLYETHYLENE NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139057","CDM","C1876","HCPCS","0278","RC","","","","both","","","193.55","145.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70.65","36.5","","641.00","641.00","641.00","1 through 10","60","153.87","percent of total billed charges",""
"STENT ADVANIX 10FR 10CM RX BILIARY DOUBLE PIGTAIL POLYETHYLENE NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139057","CDM","C1876","HCPCS","0278","RC","","","","both","","","193.55","145.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","74.13","38.3","","1098.43","1098.43","1098.43","1 through 10","60","153.87","percent of total billed charges",""
"STENT ADVANIX 10FR 10CM RX BILIARY DOUBLE PIGTAIL POLYETHYLENE NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139057","CDM","C1876","HCPCS","0278","RC","","","","both","","","193.55","145.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.03","42.9","","4896.33","4896.33","4896.33","1 through 10","60","153.87","percent of total billed charges",""
"STENT ADVANIX 10FR 10CM RX BILIARY DOUBLE PIGTAIL POLYETHYLENE NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139057","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","193.55","145.16","AETNA [1001]","HB AMC AETNA HMO","135.10","69.8","","175.60","163.11","1063.91","1 through 10","101.15","158.17","percent of total billed charges",""
"STENT ADVANIX 10FR 10CM RX BILIARY DOUBLE PIGTAIL POLYETHYLENE NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139057","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","193.55","145.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","158.17","81.72","","105.94","85.10","105.94","1 through 10","101.15","158.17","percent of total billed charges",""
"STENT ADVANIX 10FR 202.5CM RX BILIARY NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139017","CDM","C1876","HCPCS","0278","RC","","","","both","","","288.30","216.22","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","189.12","65.6","","751.18","751.18","751.18","1 through 10","89.37","229.2","percent of total billed charges",""
"STENT ADVANIX 10FR 202.5CM RX BILIARY NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139017","CDM","C1876","HCPCS","0278","RC","","","","both","","","288.30","216.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","229.20","79.5","","4820.38","3211.27","4820.38","1 through 10","89.37","229.2","percent of total billed charges",""
"STENT ADVANIX 10FR 202.5CM RX BILIARY NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139017","CDM","C1876","HCPCS","0278","RC","","","","both","","","288.30","216.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.23","36.5","","641.00","641.00","641.00","1 through 10","89.37","229.2","percent of total billed charges",""
"STENT ADVANIX 10FR 202.5CM RX BILIARY NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139017","CDM","C1876","HCPCS","0278","RC","","","","both","","","288.30","216.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","110.42","38.3","","1098.43","1098.43","1098.43","1 through 10","89.37","229.2","percent of total billed charges",""
"STENT ADVANIX 10FR 202.5CM RX BILIARY NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139017","CDM","C1876","HCPCS","0278","RC","","","","both","","","288.30","216.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","123.68","42.9","","4896.33","4896.33","4896.33","1 through 10","89.37","229.2","percent of total billed charges",""
"STENT ADVANIX 10FR 202.5CM RX BILIARY NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139017","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","288.30","216.22","AETNA [1001]","HB AMC AETNA HMO","201.23","69.8","","175.60","163.11","1063.91","1 through 10","150.67","235.6","percent of total billed charges",""
"STENT ADVANIX 10FR 202.5CM RX BILIARY NAVIFLEX DELIVERY SYSTEM","SUP-ITM-10139017","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","288.30","216.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","235.60","81.72","","105.94","85.10","105.94","1 through 10","150.67","235.6","percent of total billed charges",""
"STENT ADVANIX 10FR 7CM RX BILIARY NAVIFLEX POLYETHYLENE PLASTIC PRELOAD TAPERED DUODENAL BEND","SUP-ITM-10139004","CDM","C2625","HCPCS","0278","RC","","","","both","","","470.75","353.06","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","329.53","70","","470.75","470.75","470.75","1 through 10","145.93","374.25","percent of total billed charges",""
"STENT ADVANIX 10FR 7CM RX BILIARY NAVIFLEX POLYETHYLENE PLASTIC PRELOAD TAPERED DUODENAL BEND","SUP-ITM-10139004","CDM","C2625","HCPCS","0278","RC","","","","both","","","470.75","353.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","180.30","38.3","","184.07","124.37","184.07","1 through 10","145.93","374.25","percent of total billed charges",""
"STENT ADVANIX 10FR 7CM RX BILIARY NAVIFLEX POLYETHYLENE PLASTIC PRELOAD TAPERED DUODENAL BEND","SUP-ITM-10139004","CDM","C2625","HCPCS","0278","RC","","","","both","","","470.75","353.06","WELLPOINT [1015]","HB AMC WELLPOINT","347.32","73.78","","243.67","243.67","243.67","1 through 10","145.93","374.25","percent of total billed charges",""
"STENT ADVANIX 10FR 7CM RX BILIARY NAVIFLEX POLYETHYLENE PLASTIC PRELOAD TAPERED DUODENAL BEND","SUP-ITM-10139004","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","470.75","353.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","384.70","81.72","","376.32","376.32","376.32","1 through 10","246.01","384.7","percent of total billed charges",""
"STENT ADVANIX 5FR 3CM PANCREATIC STRAIGHT LEADING BARB TRAILING RADIOPAQUE MARKER","SUP-ITM-10147659","CDM","C2625","HCPCS","0278","RC","","","","both","","","276.22","207.16","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","193.35","70","","470.75","470.75","470.75","1 through 10","85.63","219.59","percent of total billed charges",""
"STENT ADVANIX 5FR 3CM PANCREATIC STRAIGHT LEADING BARB TRAILING RADIOPAQUE MARKER","SUP-ITM-10147659","CDM","C2625","HCPCS","0278","RC","","","","both","","","276.22","207.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.79","38.3","","184.07","124.37","184.07","1 through 10","85.63","219.59","percent of total billed charges",""
"STENT ADVANIX 5FR 3CM PANCREATIC STRAIGHT LEADING BARB TRAILING RADIOPAQUE MARKER","SUP-ITM-10147659","CDM","C2625","HCPCS","0278","RC","","","","both","","","276.22","207.16","WELLPOINT [1015]","HB AMC WELLPOINT","203.80","73.78","","243.67","243.67","243.67","1 through 10","85.63","219.59","percent of total billed charges",""
"STENT ADVANIX 5FR 3CM PANCREATIC STRAIGHT LEADING BARB TRAILING RADIOPAQUE MARKER","SUP-ITM-10147659","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","276.22","207.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","225.73","81.72","","376.32","376.32","376.32","1 through 10","144.35","225.73","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","both","","","288.30","216.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","229.20","79.5","","304.65","204.39","304.65","1 through 10","89.37","229.2","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","both","","","288.30","216.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","153.66","53.3","","204.39","204.39","304.65","1 through 10","89.37","229.2","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","both","","","288.30","216.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.23","36.5","","144.39","122.71","144.39","1 through 10","89.37","229.2","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","both","","","288.30","216.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","110.42","38.3","","151.36","147.10","454.08","13","89.37","229.2","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","both","","","288.30","216.22","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","221.99","77","","304.65","304.65","304.65","1 through 10","89.37","229.2","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","both","","","288.30","216.22","WELLPOINT [1015]","HB AMC WELLPOINT","212.71","73.78","","675.30","288.20","675.30","1 through 10","89.37","229.2","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","288.30","216.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","235.60","81.72","","183.26","154.72","309.45","1 through 10","150.67","235.6","percent of total billed charges",""
"STENT AIRWAY 10MMX2CM BONA TB","SUP-ITM-10194740","CDM","C1876","HCPCS","0278","RC","","","","both","","","6125.00","4593.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4018.00","65.6","","751.18","751.18","751.18","1 through 10","1898.75","4869.38","percent of total billed charges",""
"STENT AIRWAY 10MMX2CM BONA TB","SUP-ITM-10194740","CDM","C1876","HCPCS","0278","RC","","","","both","","","6125.00","4593.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4869.38","79.5","","4820.38","3211.27","4820.38","1 through 10","1898.75","4869.38","percent of total billed charges",""
"STENT AIRWAY 10MMX2CM BONA TB","SUP-ITM-10194740","CDM","C1876","HCPCS","0278","RC","","","","both","","","6125.00","4593.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2235.63","36.5","","641.00","641.00","641.00","1 through 10","1898.75","4869.38","percent of total billed charges",""
"STENT AIRWAY 10MMX2CM BONA TB","SUP-ITM-10194740","CDM","C1876","HCPCS","0278","RC","","","","both","","","6125.00","4593.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2345.88","38.3","","1098.43","1098.43","1098.43","1 through 10","1898.75","4869.38","percent of total billed charges",""
"STENT AIRWAY 10MMX2CM BONA TB","SUP-ITM-10194740","CDM","C1876","HCPCS","0278","RC","","","","both","","","6125.00","4593.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2627.63","42.9","","4896.33","4896.33","4896.33","1 through 10","1898.75","4869.38","percent of total billed charges",""
"STENT AIRWAY 10MMX2CM BONA TB","SUP-ITM-10194740","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","6125.00","4593.75","AETNA [1001]","HB AMC AETNA HMO","4275.25","69.8","","175.60","163.11","1063.91","1 through 10","3200.93","5005.35","percent of total billed charges",""
"STENT AIRWAY 10MMX2CM BONA TB","SUP-ITM-10194740","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","6125.00","4593.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5005.35","81.72","","105.94","85.10","105.94","1 through 10","3200.93","5005.35","percent of total billed charges",""
"STENT AIRWAY 3D CUSTOM","SUP-ITM-10289166","CDM","C1876","HCPCS","0278","RC","","","","both","","","11237.50","8428.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","7371.80","65.6","","751.18","751.18","751.18","1 through 10","3483.63","8933.81","percent of total billed charges",""
"STENT AIRWAY 3D CUSTOM","SUP-ITM-10289166","CDM","C1876","HCPCS","0278","RC","","","","both","","","11237.50","8428.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8933.81","79.5","","4820.38","3211.27","4820.38","1 through 10","3483.63","8933.81","percent of total billed charges",""
"STENT AIRWAY 3D CUSTOM","SUP-ITM-10289166","CDM","C1876","HCPCS","0278","RC","","","","both","","","11237.50","8428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4101.69","36.5","","641.00","641.00","641.00","1 through 10","3483.63","8933.81","percent of total billed charges",""
"STENT AIRWAY 3D CUSTOM","SUP-ITM-10289166","CDM","C1876","HCPCS","0278","RC","","","","both","","","11237.50","8428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4303.96","38.3","","1098.43","1098.43","1098.43","1 through 10","3483.63","8933.81","percent of total billed charges",""
"STENT AIRWAY 3D CUSTOM","SUP-ITM-10289166","CDM","C1876","HCPCS","0278","RC","","","","both","","","11237.50","8428.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4820.89","42.9","","4896.33","4896.33","4896.33","1 through 10","3483.63","8933.81","percent of total billed charges",""
"STENT AIRWAY 3D CUSTOM","SUP-ITM-10289166","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","11237.50","8428.12","AETNA [1001]","HB AMC AETNA HMO","7843.78","69.8","","175.60","163.11","1063.91","1 through 10","5872.72","9183.29","percent of total billed charges",""
"STENT AIRWAY 3D CUSTOM","SUP-ITM-10289166","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","11237.50","8428.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9183.29","81.72","","105.94","85.10","105.94","1 through 10","5872.72","9183.29","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 100MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10020122","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4387.50","65","","6652.80","6652.80","6652.80","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 100MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10020122","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5366.25","79.5","","2612.61","795.38","2612.61","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 100MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10020122","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3597.75","53.3","","1101.80","1101.80","1101.80","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 100MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10020122","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4387.50","65","","1820.00","910.00","1820.00","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 100MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10020122","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2463.75","36.5","","1257.80","693.44","2424.50","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 100MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10020122","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2585.25","38.3","","1950.11","547.40","2346.00","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 100MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10020122","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2895.75","42.9","","5096.18","5096.18","5096.18","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 100MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10020122","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","WELLPOINT [1015]","HB AMC WELLPOINT","4980.15","73.78","","1172.59","1172.59","4829.94","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 100MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10020122","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","AETNA [1001]","HB AMC AETNA HMO","4711.50","69.8","","1806.84","947.80","5091.72","1 through 10","3527.55","5516.1","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 100MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10020122","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5516.10","81.72","","1259.05","615.58","4586.56","1 through 10","3527.55","5516.1","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 70MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10022846","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4387.50","65","","6652.80","6652.80","6652.80","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 70MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10022846","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5366.25","79.5","","2612.61","795.38","2612.61","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 70MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10022846","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3597.75","53.3","","1101.80","1101.80","1101.80","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 70MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10022846","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4387.50","65","","1820.00","910.00","1820.00","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 70MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10022846","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2463.75","36.5","","1257.80","693.44","2424.50","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 70MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10022846","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2585.25","38.3","","1950.11","547.40","2346.00","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 70MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10022846","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2895.75","42.9","","5096.18","5096.18","5096.18","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 70MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10022846","CDM","C1874","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","WELLPOINT [1015]","HB AMC WELLPOINT","4980.15","73.78","","1172.59","1172.59","4829.94","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 70MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10022846","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","AETNA [1001]","HB AMC AETNA HMO","4711.50","69.8","","1806.84","947.80","5091.72","1 through 10","3527.55","5516.1","percent of total billed charges",""
"STENT ALIMAXX ES 18MM 70MM OTW ESOPHAGEAL FULLY COVERED NITINOL POLYURETHANE SELF EXPANDING","SUP-ITM-10022846","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5516.10","81.72","","1259.05","615.58","4586.56","1 through 10","3527.55","5516.1","percent of total billed charges",""
"STENT AORTIC 4.5X22MM CP COVERED","SUP-ITM-10175020","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","13771.06","65","","6652.80","6652.80","6652.80","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT AORTIC 4.5X22MM CP COVERED","SUP-ITM-10175020","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","16843.07","79.5","","2612.61","795.38","2612.61","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT AORTIC 4.5X22MM CP COVERED","SUP-ITM-10175020","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11292.27","53.3","","1101.80","1101.80","1101.80","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT AORTIC 4.5X22MM CP COVERED","SUP-ITM-10175020","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","13771.06","65","","1820.00","910.00","1820.00","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT AORTIC 4.5X22MM CP COVERED","SUP-ITM-10175020","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7732.98","36.5","","1257.80","693.44","2424.50","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT AORTIC 4.5X22MM CP COVERED","SUP-ITM-10175020","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8114.33","38.3","","1950.11","547.40","2346.00","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT AORTIC 4.5X22MM CP COVERED","SUP-ITM-10175020","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9088.90","42.9","","5096.18","5096.18","5096.18","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT AORTIC 4.5X22MM CP COVERED","SUP-ITM-10175020","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","WELLPOINT [1015]","HB AMC WELLPOINT","15631.22","73.78","","1172.59","1172.59","4829.94","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT AORTIC 4.5X22MM CP COVERED","SUP-ITM-10175020","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","21186.25","15889.69","AETNA [1001]","HB AMC AETNA HMO","14788.00","69.8","","1806.84","947.80","5091.72","1 through 10","11071.93","17313.4","percent of total billed charges",""
"STENT AORTIC 4.5X22MM CP COVERED","SUP-ITM-10175020","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","21186.25","15889.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","17313.40","81.72","","1259.05","615.58","4586.56","1 through 10","11071.93","17313.4","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","193.55","145.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","153.87","79.5","","304.65","204.39","304.65","1 through 10","60","153.87","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","193.55","145.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","103.16","53.3","","204.39","204.39","304.65","1 through 10","60","153.87","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","193.55","145.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","70.65","36.5","","144.39","122.71","144.39","1 through 10","60","153.87","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","193.55","145.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","74.13","38.3","","151.36","147.10","454.08","13","60","153.87","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","193.55","145.16","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","149.03","77","","304.65","304.65","304.65","1 through 10","60","153.87","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","193.55","145.16","WELLPOINT [1015]","HB AMC WELLPOINT","142.80","73.78","","675.30","288.20","675.30","1 through 10","60","153.87","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","193.55","145.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","158.17","81.72","","183.26","154.72","309.45","1 through 10","101.15","158.17","percent of total billed charges",""
"STENT BILIARY 10FR 7CM 0.035IN FLEXIMA DUODENAL BEND RX","SUP-ITM-10008864","CDM","C2625","HCPCS","0278","RC","","","","both","","","368.48","276.36","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","257.94","70","","470.75","470.75","470.75","1 through 10","114.23","292.94","percent of total billed charges",""
"STENT BILIARY 10FR 7CM 0.035IN FLEXIMA DUODENAL BEND RX","SUP-ITM-10008864","CDM","C2625","HCPCS","0278","RC","","","","both","","","368.48","276.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","141.13","38.3","","184.07","124.37","184.07","1 through 10","114.23","292.94","percent of total billed charges",""
"STENT BILIARY 10FR 7CM 0.035IN FLEXIMA DUODENAL BEND RX","SUP-ITM-10008864","CDM","C2625","HCPCS","0278","RC","","","","both","","","368.48","276.36","WELLPOINT [1015]","HB AMC WELLPOINT","271.86","73.78","","243.67","243.67","243.67","1 through 10","114.23","292.94","percent of total billed charges",""
"STENT BILIARY 10FR 7CM 0.035IN FLEXIMA DUODENAL BEND RX","SUP-ITM-10008864","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","368.48","276.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","301.12","81.72","","376.32","376.32","376.32","1 through 10","192.57","301.12","percent of total billed charges",""
"STENT BILIARY 10FRX4CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287627","CDM","C2617","HCPCS","0278","RC","","","","both","","","437.50","328.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","347.81","79.5","","304.65","204.39","304.65","1 through 10","135.63","347.81","percent of total billed charges",""
"STENT BILIARY 10FRX4CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287627","CDM","C2617","HCPCS","0278","RC","","","","both","","","437.50","328.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","233.19","53.3","","204.39","204.39","304.65","1 through 10","135.63","347.81","percent of total billed charges",""
"STENT BILIARY 10FRX4CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287627","CDM","C2617","HCPCS","0278","RC","","","","both","","","437.50","328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","159.69","36.5","","144.39","122.71","144.39","1 through 10","135.63","347.81","percent of total billed charges",""
"STENT BILIARY 10FRX4CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287627","CDM","C2617","HCPCS","0278","RC","","","","both","","","437.50","328.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","167.56","38.3","","151.36","147.10","454.08","13","135.63","347.81","percent of total billed charges",""
"STENT BILIARY 10FRX4CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287627","CDM","C2617","HCPCS","0278","RC","","","","both","","","437.50","328.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","336.88","77","","304.65","304.65","304.65","1 through 10","135.63","347.81","percent of total billed charges",""
"STENT BILIARY 10FRX4CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287627","CDM","C2617","HCPCS","0278","RC","","","","both","","","437.50","328.12","WELLPOINT [1015]","HB AMC WELLPOINT","322.79","73.78","","675.30","288.20","675.30","1 through 10","135.63","347.81","percent of total billed charges",""
"STENT BILIARY 10FRX4CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287627","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","437.50","328.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","357.53","81.72","","183.26","154.72","309.45","1 through 10","228.64","357.53","percent of total billed charges",""
"STENT BILIARY 10FRX7CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287628","CDM","C2617","HCPCS","0278","RC","","","","both","","","185.50","139.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","147.47","79.5","","304.65","204.39","304.65","1 through 10","57.51","147.47","percent of total billed charges",""
"STENT BILIARY 10FRX7CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287628","CDM","C2617","HCPCS","0278","RC","","","","both","","","185.50","139.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","98.87","53.3","","204.39","204.39","304.65","1 through 10","57.51","147.47","percent of total billed charges",""
"STENT BILIARY 10FRX7CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287628","CDM","C2617","HCPCS","0278","RC","","","","both","","","185.50","139.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.71","36.5","","144.39","122.71","144.39","1 through 10","57.51","147.47","percent of total billed charges",""
"STENT BILIARY 10FRX7CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287628","CDM","C2617","HCPCS","0278","RC","","","","both","","","185.50","139.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","71.05","38.3","","151.36","147.10","454.08","13","57.51","147.47","percent of total billed charges",""
"STENT BILIARY 10FRX7CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287628","CDM","C2617","HCPCS","0278","RC","","","","both","","","185.50","139.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","142.84","77","","304.65","304.65","304.65","1 through 10","57.51","147.47","percent of total billed charges",""
"STENT BILIARY 10FRX7CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287628","CDM","C2617","HCPCS","0278","RC","","","","both","","","185.50","139.12","WELLPOINT [1015]","HB AMC WELLPOINT","136.86","73.78","","675.30","288.20","675.30","1 through 10","57.51","147.47","percent of total billed charges",""
"STENT BILIARY 10FRX7CM PIGTAIL FLEXIBLE BIOCOMPATIBLE MATERIAL MR SAFE","SUP-ITM-10287628","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","185.50","139.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","151.59","81.72","","183.26","154.72","309.45","1 through 10","96.94","151.59","percent of total billed charges",""
"STENT BILIARY 10X100MM 8.5FR WALLFLEX RX PLATINOL ALLOY UNCOVERED PERMALUME COATED BALLOON","SUP-ITM-10027636","CDM","C1874","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3217.50","65","","6652.80","6652.80","6652.80","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT BILIARY 10X100MM 8.5FR WALLFLEX RX PLATINOL ALLOY UNCOVERED PERMALUME COATED BALLOON","SUP-ITM-10027636","CDM","C1874","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","2612.61","795.38","2612.61","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT BILIARY 10X100MM 8.5FR WALLFLEX RX PLATINOL ALLOY UNCOVERED PERMALUME COATED BALLOON","SUP-ITM-10027636","CDM","C1874","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2638.35","53.3","","1101.80","1101.80","1101.80","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT BILIARY 10X100MM 8.5FR WALLFLEX RX PLATINOL ALLOY UNCOVERED PERMALUME COATED BALLOON","SUP-ITM-10027636","CDM","C1874","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3217.50","65","","1820.00","910.00","1820.00","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT BILIARY 10X100MM 8.5FR WALLFLEX RX PLATINOL ALLOY UNCOVERED PERMALUME COATED BALLOON","SUP-ITM-10027636","CDM","C1874","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","1257.80","693.44","2424.50","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT BILIARY 10X100MM 8.5FR WALLFLEX RX PLATINOL ALLOY UNCOVERED PERMALUME COATED BALLOON","SUP-ITM-10027636","CDM","C1874","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","1950.11","547.40","2346.00","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT BILIARY 10X100MM 8.5FR WALLFLEX RX PLATINOL ALLOY UNCOVERED PERMALUME COATED BALLOON","SUP-ITM-10027636","CDM","C1874","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","5096.18","5096.18","5096.18","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT BILIARY 10X100MM 8.5FR WALLFLEX RX PLATINOL ALLOY UNCOVERED PERMALUME COATED BALLOON","SUP-ITM-10027636","CDM","C1874","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","1172.59","1172.59","4829.94","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT BILIARY 10X100MM 8.5FR WALLFLEX RX PLATINOL ALLOY UNCOVERED PERMALUME COATED BALLOON","SUP-ITM-10027636","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","1806.84","947.80","5091.72","1 through 10","2586.87","4045.14","percent of total billed charges",""
"STENT BILIARY 10X100MM 8.5FR WALLFLEX RX PLATINOL ALLOY UNCOVERED PERMALUME COATED BALLOON","SUP-ITM-10027636","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","1259.05","615.58","4586.56","1 through 10","2586.87","4045.14","percent of total billed charges",""
"STENT BILIARY 11.5FR 9CM COTTON HUIBREGTSE ONLY B/W FLAPS","SUP-ITM-10073813","CDM","C2617","HCPCS","0278","RC","","","","both","","","532.00","399.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","422.94","79.5","","304.65","204.39","304.65","1 through 10","164.92","422.94","percent of total billed charges",""
"STENT BILIARY 11.5FR 9CM COTTON HUIBREGTSE ONLY B/W FLAPS","SUP-ITM-10073813","CDM","C2617","HCPCS","0278","RC","","","","both","","","532.00","399.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","283.56","53.3","","204.39","204.39","304.65","1 through 10","164.92","422.94","percent of total billed charges",""
"STENT BILIARY 11.5FR 9CM COTTON HUIBREGTSE ONLY B/W FLAPS","SUP-ITM-10073813","CDM","C2617","HCPCS","0278","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.18","36.5","","144.39","122.71","144.39","1 through 10","164.92","422.94","percent of total billed charges",""
"STENT BILIARY 11.5FR 9CM COTTON HUIBREGTSE ONLY B/W FLAPS","SUP-ITM-10073813","CDM","C2617","HCPCS","0278","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.76","38.3","","151.36","147.10","454.08","13","164.92","422.94","percent of total billed charges",""
"STENT BILIARY 11.5FR 9CM COTTON HUIBREGTSE ONLY B/W FLAPS","SUP-ITM-10073813","CDM","C2617","HCPCS","0278","RC","","","","both","","","532.00","399.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","409.64","77","","304.65","304.65","304.65","1 through 10","164.92","422.94","percent of total billed charges",""
"STENT BILIARY 11.5FR 9CM COTTON HUIBREGTSE ONLY B/W FLAPS","SUP-ITM-10073813","CDM","C2617","HCPCS","0278","RC","","","","both","","","532.00","399.00","WELLPOINT [1015]","HB AMC WELLPOINT","392.51","73.78","","675.30","288.20","675.30","1 through 10","164.92","422.94","percent of total billed charges",""
"STENT BILIARY 11.5FR 9CM COTTON HUIBREGTSE ONLY B/W FLAPS","SUP-ITM-10073813","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","434.75","81.72","","183.26","154.72","309.45","1 through 10","278.02","434.75","percent of total billed charges",""
"STENT BILIARY 12FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003492","CDM","C2617","HCPCS","0278","RC","","","","both","","","574.00","430.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","456.33","79.5","","304.65","204.39","304.65","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 12FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003492","CDM","C2617","HCPCS","0278","RC","","","","both","","","574.00","430.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","305.94","53.3","","204.39","204.39","304.65","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 12FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003492","CDM","C2617","HCPCS","0278","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","209.51","36.5","","144.39","122.71","144.39","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 12FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003492","CDM","C2617","HCPCS","0278","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","219.84","38.3","","151.36","147.10","454.08","13","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 12FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003492","CDM","C2617","HCPCS","0278","RC","","","","both","","","574.00","430.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","441.98","77","","304.65","304.65","304.65","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 12FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003492","CDM","C2617","HCPCS","0278","RC","","","","both","","","574.00","430.50","WELLPOINT [1015]","HB AMC WELLPOINT","423.50","73.78","","675.30","288.20","675.30","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 12FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003492","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","469.07","81.72","","183.26","154.72","309.45","1 through 10","299.97","469.07","percent of total billed charges",""
"STENT BILIARY 14FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003493","CDM","C2617","HCPCS","0278","RC","","","","both","","","574.00","430.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","456.33","79.5","","304.65","204.39","304.65","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 14FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003493","CDM","C2617","HCPCS","0278","RC","","","","both","","","574.00","430.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","305.94","53.3","","204.39","204.39","304.65","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 14FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003493","CDM","C2617","HCPCS","0278","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","209.51","36.5","","144.39","122.71","144.39","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 14FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003493","CDM","C2617","HCPCS","0278","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","219.84","38.3","","151.36","147.10","454.08","13","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 14FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003493","CDM","C2617","HCPCS","0278","RC","","","","both","","","574.00","430.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","441.98","77","","304.65","304.65","304.65","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 14FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003493","CDM","C2617","HCPCS","0278","RC","","","","both","","","574.00","430.50","WELLPOINT [1015]","HB AMC WELLPOINT","423.50","73.78","","675.30","288.20","675.30","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 14FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003493","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","469.07","81.72","","183.26","154.72","309.45","1 through 10","299.97","469.07","percent of total billed charges",""
"STENT BILIARY 16FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003494","CDM","C2617","HCPCS","0278","RC","","","","both","","","1851.50","1388.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1471.94","79.5","","304.65","204.39","304.65","1 through 10","573.97","1471.94","percent of total billed charges",""
"STENT BILIARY 16FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003494","CDM","C2617","HCPCS","0278","RC","","","","both","","","1851.50","1388.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","986.85","53.3","","204.39","204.39","304.65","1 through 10","573.97","1471.94","percent of total billed charges",""
"STENT BILIARY 16FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003494","CDM","C2617","HCPCS","0278","RC","","","","both","","","1851.50","1388.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","675.80","36.5","","144.39","122.71","144.39","1 through 10","573.97","1471.94","percent of total billed charges",""
"STENT BILIARY 16FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003494","CDM","C2617","HCPCS","0278","RC","","","","both","","","1851.50","1388.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","709.12","38.3","","151.36","147.10","454.08","13","573.97","1471.94","percent of total billed charges",""
"STENT BILIARY 16FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003494","CDM","C2617","HCPCS","0278","RC","","","","both","","","1851.50","1388.62","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1425.66","77","","304.65","304.65","304.65","1 through 10","573.97","1471.94","percent of total billed charges",""
"STENT BILIARY 16FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003494","CDM","C2617","HCPCS","0278","RC","","","","both","","","1851.50","1388.62","WELLPOINT [1015]","HB AMC WELLPOINT","1366.04","73.78","","675.30","288.20","675.30","1 through 10","573.97","1471.94","percent of total billed charges",""
"STENT BILIARY 16FR SILICONE SOFT SIDEHOLE CUT END PLASTIC LUER LOCK ADAPTER RADIOPAQUE MARKER STERILE","SUP-ITM-10003494","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1851.50","1388.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1513.05","81.72","","183.26","154.72","309.45","1 through 10","967.59","1513.05","percent of total billed charges",""
"STENT BILIARY 19FR SILICONE RADIOPAQUE TANTALUM MARKER PROXIMALIMAL SIDEHOLE","SUP-ITM-10091776","CDM","C1729","HCPCS","0272","RC","","","","both","","","574.00","430.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","412.13","71.8","","162.24","51.52","162.24","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 19FR SILICONE RADIOPAQUE TANTALUM MARKER PROXIMALIMAL SIDEHOLE","SUP-ITM-10091776","CDM","C1729","HCPCS","0272","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","209.51","36.5","","94.34","22.19","146.22","26","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 19FR SILICONE RADIOPAQUE TANTALUM MARKER PROXIMALIMAL SIDEHOLE","SUP-ITM-10091776","CDM","C1729","HCPCS","0272","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","219.84","38.3","","51.52","27.37","51.52","26","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 19FR SILICONE RADIOPAQUE TANTALUM MARKER PROXIMALIMAL SIDEHOLE","SUP-ITM-10091776","CDM","C1729","HCPCS","0272","RC","","","","both","","","574.00","430.50","WELLPOINT [1015]","HB AMC WELLPOINT","423.50","73.78","","207.21","122.12","216.28","14","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 19FR SILICONE RADIOPAQUE TANTALUM MARKER PROXIMALIMAL SIDEHOLE","SUP-ITM-10091776","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","574.00","430.50","AETNA [1001]","HB AMC AETNA HMO","400.65","69.8","","155.96","47.39","155.96","1 through 10","299.97","469.07","percent of total billed charges",""
"STENT BILIARY 19FR SILICONE RADIOPAQUE TANTALUM MARKER PROXIMALIMAL SIDEHOLE","SUP-ITM-10091776","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","469.07","81.72","","57.36","51.76","232.23","35","299.97","469.07","percent of total billed charges",""
"STENT BILIARY 20FR 24MM SILICONE RADIOPAQUE TANTALUM MARKER PROXIMALIMAL SIDEHOLE","SUP-ITM-10022544","CDM","C1729","HCPCS","0272","RC","","","","both","","","574.00","430.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","412.13","71.8","","162.24","51.52","162.24","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 20FR 24MM SILICONE RADIOPAQUE TANTALUM MARKER PROXIMALIMAL SIDEHOLE","SUP-ITM-10022544","CDM","C1729","HCPCS","0272","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","209.51","36.5","","94.34","22.19","146.22","26","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 20FR 24MM SILICONE RADIOPAQUE TANTALUM MARKER PROXIMALIMAL SIDEHOLE","SUP-ITM-10022544","CDM","C1729","HCPCS","0272","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","219.84","38.3","","51.52","27.37","51.52","26","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 20FR 24MM SILICONE RADIOPAQUE TANTALUM MARKER PROXIMALIMAL SIDEHOLE","SUP-ITM-10022544","CDM","C1729","HCPCS","0272","RC","","","","both","","","574.00","430.50","WELLPOINT [1015]","HB AMC WELLPOINT","423.50","73.78","","207.21","122.12","216.28","14","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 20FR 24MM SILICONE RADIOPAQUE TANTALUM MARKER PROXIMALIMAL SIDEHOLE","SUP-ITM-10022544","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","574.00","430.50","AETNA [1001]","HB AMC AETNA HMO","400.65","69.8","","155.96","47.39","155.96","1 through 10","299.97","469.07","percent of total billed charges",""
"STENT BILIARY 20FR 24MM SILICONE RADIOPAQUE TANTALUM MARKER PROXIMALIMAL SIDEHOLE","SUP-ITM-10022544","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","469.07","81.72","","57.36","51.76","232.23","35","299.97","469.07","percent of total billed charges",""
"STENT BILIARY 2MMX20 7FR PLASTIC CURLS CATHETER SELF EXP ZIMMON","SUP-ITM-10074212","CDM","C2625","HCPCS","0278","RC","","","","both","","","574.00","430.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","401.80","70","","470.75","470.75","470.75","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 2MMX20 7FR PLASTIC CURLS CATHETER SELF EXP ZIMMON","SUP-ITM-10074212","CDM","C2625","HCPCS","0278","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","219.84","38.3","","184.07","124.37","184.07","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 2MMX20 7FR PLASTIC CURLS CATHETER SELF EXP ZIMMON","SUP-ITM-10074212","CDM","C2625","HCPCS","0278","RC","","","","both","","","574.00","430.50","WELLPOINT [1015]","HB AMC WELLPOINT","423.50","73.78","","243.67","243.67","243.67","1 through 10","177.94","456.33","percent of total billed charges",""
"STENT BILIARY 2MMX20 7FR PLASTIC CURLS CATHETER SELF EXP ZIMMON","SUP-ITM-10074212","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","469.07","81.72","","376.32","376.32","376.32","1 through 10","299.97","469.07","percent of total billed charges",""
"STENT BILIARY 3.3MMX180 10FR ADVANIX POLYETHYLENE PLASTIC NAVYFLEX PRELOAD RAPID EXCHANGE TAPERED CENTER BEND","SUP-ITM-10091869","CDM","C2625","HCPCS","0278","RC","","","","both","","","470.75","353.06","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","329.53","70","","470.75","470.75","470.75","1 through 10","145.93","374.25","percent of total billed charges",""
"STENT BILIARY 3.3MMX180 10FR ADVANIX POLYETHYLENE PLASTIC NAVYFLEX PRELOAD RAPID EXCHANGE TAPERED CENTER BEND","SUP-ITM-10091869","CDM","C2625","HCPCS","0278","RC","","","","both","","","470.75","353.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","180.30","38.3","","184.07","124.37","184.07","1 through 10","145.93","374.25","percent of total billed charges",""
"STENT BILIARY 3.3MMX180 10FR ADVANIX POLYETHYLENE PLASTIC NAVYFLEX PRELOAD RAPID EXCHANGE TAPERED CENTER BEND","SUP-ITM-10091869","CDM","C2625","HCPCS","0278","RC","","","","both","","","470.75","353.06","WELLPOINT [1015]","HB AMC WELLPOINT","347.32","73.78","","243.67","243.67","243.67","1 through 10","145.93","374.25","percent of total billed charges",""
"STENT BILIARY 3.3MMX180 10FR ADVANIX POLYETHYLENE PLASTIC NAVYFLEX PRELOAD RAPID EXCHANGE TAPERED CENTER BEND","SUP-ITM-10091869","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","470.75","353.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","384.70","81.72","","376.32","376.32","376.32","1 through 10","246.01","384.7","percent of total billed charges",""
"STENT BILIARY 7FR 12X40MM 120CM .035IN SMART CONTROL NITINOL SELF EXPANDING","SUP-ITM-10075951","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1567.02","65.6","","751.18","751.18","751.18","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT BILIARY 7FR 12X40MM 120CM .035IN SMART CONTROL NITINOL SELF EXPANDING","SUP-ITM-10075951","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1899.06","79.5","","4820.38","3211.27","4820.38","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT BILIARY 7FR 12X40MM 120CM .035IN SMART CONTROL NITINOL SELF EXPANDING","SUP-ITM-10075951","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","871.89","36.5","","641.00","641.00","641.00","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT BILIARY 7FR 12X40MM 120CM .035IN SMART CONTROL NITINOL SELF EXPANDING","SUP-ITM-10075951","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","914.89","38.3","","1098.43","1098.43","1098.43","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT BILIARY 7FR 12X40MM 120CM .035IN SMART CONTROL NITINOL SELF EXPANDING","SUP-ITM-10075951","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1024.77","42.9","","4896.33","4896.33","4896.33","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT BILIARY 7FR 12X40MM 120CM .035IN SMART CONTROL NITINOL SELF EXPANDING","SUP-ITM-10075951","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2388.75","1791.56","AETNA [1001]","HB AMC AETNA HMO","1667.35","69.8","","175.60","163.11","1063.91","1 through 10","1248.36","1952.09","percent of total billed charges",""
"STENT BILIARY 7FR 12X40MM 120CM .035IN SMART CONTROL NITINOL SELF EXPANDING","SUP-ITM-10075951","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2388.75","1791.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1952.09","81.72","","105.94","85.10","105.94","1 through 10","1248.36","1952.09","percent of total billed charges",""
"STENT BILIARY 7FR 7CM DOUBLE PIGTAIL","SUP-ITM-10235852","CDM","C2617","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","150.26","79.5","","304.65","204.39","304.65","1 through 10","58.59","150.26","percent of total billed charges",""
"STENT BILIARY 7FR 7CM DOUBLE PIGTAIL","SUP-ITM-10235852","CDM","C2617","HCPCS","0278","RC","","","","both","","","189.00","141.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.74","53.3","","204.39","204.39","304.65","1 through 10","58.59","150.26","percent of total billed charges",""
"STENT BILIARY 7FR 7CM DOUBLE PIGTAIL","SUP-ITM-10235852","CDM","C2617","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.99","36.5","","144.39","122.71","144.39","1 through 10","58.59","150.26","percent of total billed charges",""
"STENT BILIARY 7FR 7CM DOUBLE PIGTAIL","SUP-ITM-10235852","CDM","C2617","HCPCS","0278","RC","","","","both","","","189.00","141.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.39","38.3","","151.36","147.10","454.08","13","58.59","150.26","percent of total billed charges",""
"STENT BILIARY 7FR 7CM DOUBLE PIGTAIL","SUP-ITM-10235852","CDM","C2617","HCPCS","0278","RC","","","","both","","","189.00","141.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","145.53","77","","304.65","304.65","304.65","1 through 10","58.59","150.26","percent of total billed charges",""
"STENT BILIARY 7FR 7CM DOUBLE PIGTAIL","SUP-ITM-10235852","CDM","C2617","HCPCS","0278","RC","","","","both","","","189.00","141.75","WELLPOINT [1015]","HB AMC WELLPOINT","139.44","73.78","","675.30","288.20","675.30","1 through 10","58.59","150.26","percent of total billed charges",""
"STENT BILIARY 7FR 7CM DOUBLE PIGTAIL","SUP-ITM-10235852","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","154.45","81.72","","183.26","154.72","309.45","1 through 10","98.77","154.45","percent of total billed charges",""
"STENT BILIARY 8X30MM 26MM 80CM .035IN PALMAZ GENESIS TRANSHEPATIC S/S EXPANDABLE BALLOON","SUP-ITM-10007528","CDM","C1876","HCPCS","0278","RC","","","","both","","","2664.38","1998.28","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1747.83","65.6","","751.18","751.18","751.18","1 through 10","825.96","2118.18","percent of total billed charges",""
"STENT BILIARY 8X30MM 26MM 80CM .035IN PALMAZ GENESIS TRANSHEPATIC S/S EXPANDABLE BALLOON","SUP-ITM-10007528","CDM","C1876","HCPCS","0278","RC","","","","both","","","2664.38","1998.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2118.18","79.5","","4820.38","3211.27","4820.38","1 through 10","825.96","2118.18","percent of total billed charges",""
"STENT BILIARY 8X30MM 26MM 80CM .035IN PALMAZ GENESIS TRANSHEPATIC S/S EXPANDABLE BALLOON","SUP-ITM-10007528","CDM","C1876","HCPCS","0278","RC","","","","both","","","2664.38","1998.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","972.50","36.5","","641.00","641.00","641.00","1 through 10","825.96","2118.18","percent of total billed charges",""
"STENT BILIARY 8X30MM 26MM 80CM .035IN PALMAZ GENESIS TRANSHEPATIC S/S EXPANDABLE BALLOON","SUP-ITM-10007528","CDM","C1876","HCPCS","0278","RC","","","","both","","","2664.38","1998.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1020.46","38.3","","1098.43","1098.43","1098.43","1 through 10","825.96","2118.18","percent of total billed charges",""
"STENT BILIARY 8X30MM 26MM 80CM .035IN PALMAZ GENESIS TRANSHEPATIC S/S EXPANDABLE BALLOON","SUP-ITM-10007528","CDM","C1876","HCPCS","0278","RC","","","","both","","","2664.38","1998.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1143.02","42.9","","4896.33","4896.33","4896.33","1 through 10","825.96","2118.18","percent of total billed charges",""
"STENT BILIARY 8X30MM 26MM 80CM .035IN PALMAZ GENESIS TRANSHEPATIC S/S EXPANDABLE BALLOON","SUP-ITM-10007528","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2664.38","1998.28","AETNA [1001]","HB AMC AETNA HMO","1859.74","69.8","","175.60","163.11","1063.91","1 through 10","1392.4","2177.33","percent of total billed charges",""
"STENT BILIARY 8X30MM 26MM 80CM .035IN PALMAZ GENESIS TRANSHEPATIC S/S EXPANDABLE BALLOON","SUP-ITM-10007528","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2664.38","1998.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2177.33","81.72","","105.94","85.10","105.94","1 through 10","1392.4","2177.33","percent of total billed charges",""
"STENT BILIARY 8X60MM BALLOON 80CM TRANSHEPATIC PALMAZ GENESIS STAINLESS STEEL EXPANDABLE","SUP-ITM-10008519","CDM","C1876","HCPCS","0278","RC","","","","both","","","2664.38","1998.28","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1747.83","65.6","","751.18","751.18","751.18","1 through 10","825.96","2118.18","percent of total billed charges",""
"STENT BILIARY 8X60MM BALLOON 80CM TRANSHEPATIC PALMAZ GENESIS STAINLESS STEEL EXPANDABLE","SUP-ITM-10008519","CDM","C1876","HCPCS","0278","RC","","","","both","","","2664.38","1998.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2118.18","79.5","","4820.38","3211.27","4820.38","1 through 10","825.96","2118.18","percent of total billed charges",""
"STENT BILIARY 8X60MM BALLOON 80CM TRANSHEPATIC PALMAZ GENESIS STAINLESS STEEL EXPANDABLE","SUP-ITM-10008519","CDM","C1876","HCPCS","0278","RC","","","","both","","","2664.38","1998.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","972.50","36.5","","641.00","641.00","641.00","1 through 10","825.96","2118.18","percent of total billed charges",""
"STENT BILIARY 8X60MM BALLOON 80CM TRANSHEPATIC PALMAZ GENESIS STAINLESS STEEL EXPANDABLE","SUP-ITM-10008519","CDM","C1876","HCPCS","0278","RC","","","","both","","","2664.38","1998.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1020.46","38.3","","1098.43","1098.43","1098.43","1 through 10","825.96","2118.18","percent of total billed charges",""
"STENT BILIARY 8X60MM BALLOON 80CM TRANSHEPATIC PALMAZ GENESIS STAINLESS STEEL EXPANDABLE","SUP-ITM-10008519","CDM","C1876","HCPCS","0278","RC","","","","both","","","2664.38","1998.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1143.02","42.9","","4896.33","4896.33","4896.33","1 through 10","825.96","2118.18","percent of total billed charges",""
"STENT BILIARY 8X60MM BALLOON 80CM TRANSHEPATIC PALMAZ GENESIS STAINLESS STEEL EXPANDABLE","SUP-ITM-10008519","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2664.38","1998.28","AETNA [1001]","HB AMC AETNA HMO","1859.74","69.8","","175.60","163.11","1063.91","1 through 10","1392.4","2177.33","percent of total billed charges",""
"STENT BILIARY 8X60MM BALLOON 80CM TRANSHEPATIC PALMAZ GENESIS STAINLESS STEEL EXPANDABLE","SUP-ITM-10008519","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2664.38","1998.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2177.33","81.72","","105.94","85.10","105.94","1 through 10","1392.4","2177.33","percent of total billed charges",""
"STENT BILIARY 9 TO 12X26MM ULTRA DOUBLE STRUT","SUP-ITM-10168981","CDM","C1874","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1797.25","65","","6652.80","6652.80","6652.80","1 through 10","857.15","2198.18","percent of total billed charges",""
"STENT BILIARY 9 TO 12X26MM ULTRA DOUBLE STRUT","SUP-ITM-10168981","CDM","C1874","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2198.18","79.5","","2612.61","795.38","2612.61","1 through 10","857.15","2198.18","percent of total billed charges",""
"STENT BILIARY 9 TO 12X26MM ULTRA DOUBLE STRUT","SUP-ITM-10168981","CDM","C1874","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1473.75","53.3","","1101.80","1101.80","1101.80","1 through 10","857.15","2198.18","percent of total billed charges",""
"STENT BILIARY 9 TO 12X26MM ULTRA DOUBLE STRUT","SUP-ITM-10168981","CDM","C1874","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1797.25","65","","1820.00","910.00","1820.00","1 through 10","857.15","2198.18","percent of total billed charges",""
"STENT BILIARY 9 TO 12X26MM ULTRA DOUBLE STRUT","SUP-ITM-10168981","CDM","C1874","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1009.23","36.5","","1257.80","693.44","2424.50","1 through 10","857.15","2198.18","percent of total billed charges",""
"STENT BILIARY 9 TO 12X26MM ULTRA DOUBLE STRUT","SUP-ITM-10168981","CDM","C1874","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1059.00","38.3","","1950.11","547.40","2346.00","1 through 10","857.15","2198.18","percent of total billed charges",""
"STENT BILIARY 9 TO 12X26MM ULTRA DOUBLE STRUT","SUP-ITM-10168981","CDM","C1874","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1186.19","42.9","","5096.18","5096.18","5096.18","1 through 10","857.15","2198.18","percent of total billed charges",""
"STENT BILIARY 9 TO 12X26MM ULTRA DOUBLE STRUT","SUP-ITM-10168981","CDM","C1874","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","WELLPOINT [1015]","HB AMC WELLPOINT","2040.02","73.78","","1172.59","1172.59","4829.94","1 through 10","857.15","2198.18","percent of total billed charges",""
"STENT BILIARY 9 TO 12X26MM ULTRA DOUBLE STRUT","SUP-ITM-10168981","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2765.00","2073.75","AETNA [1001]","HB AMC AETNA HMO","1929.97","69.8","","1806.84","947.80","5091.72","1 through 10","1444.99","2259.56","percent of total billed charges",""
"STENT BILIARY 9 TO 12X26MM ULTRA DOUBLE STRUT","SUP-ITM-10168981","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2765.00","2073.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2259.56","81.72","","1259.05","615.58","4586.56","1 through 10","1444.99","2259.56","percent of total billed charges",""
"STENT BRONCHIAL 10FRX14MM 110 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10017812","CDM","C1874","HCPCS","0278","RC","","","","both","","","4063.50","3047.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2641.28","65","","6652.80","6652.80","6652.80","1 through 10","1259.69","3230.48","percent of total billed charges",""
"STENT BRONCHIAL 10FRX14MM 110 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10017812","CDM","C1874","HCPCS","0278","RC","","","","both","","","4063.50","3047.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3230.48","79.5","","2612.61","795.38","2612.61","1 through 10","1259.69","3230.48","percent of total billed charges",""
"STENT BRONCHIAL 10FRX14MM 110 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10017812","CDM","C1874","HCPCS","0278","RC","","","","both","","","4063.50","3047.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2165.85","53.3","","1101.80","1101.80","1101.80","1 through 10","1259.69","3230.48","percent of total billed charges",""
"STENT BRONCHIAL 10FRX14MM 110 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10017812","CDM","C1874","HCPCS","0278","RC","","","","both","","","4063.50","3047.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2641.28","65","","1820.00","910.00","1820.00","1 through 10","1259.69","3230.48","percent of total billed charges",""
"STENT BRONCHIAL 10FRX14MM 110 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10017812","CDM","C1874","HCPCS","0278","RC","","","","both","","","4063.50","3047.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1483.18","36.5","","1257.80","693.44","2424.50","1 through 10","1259.69","3230.48","percent of total billed charges",""
"STENT BRONCHIAL 10FRX14MM 110 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10017812","CDM","C1874","HCPCS","0278","RC","","","","both","","","4063.50","3047.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1556.32","38.3","","1950.11","547.40","2346.00","1 through 10","1259.69","3230.48","percent of total billed charges",""
"STENT BRONCHIAL 10FRX14MM 110 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10017812","CDM","C1874","HCPCS","0278","RC","","","","both","","","4063.50","3047.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1743.24","42.9","","5096.18","5096.18","5096.18","1 through 10","1259.69","3230.48","percent of total billed charges",""
"STENT BRONCHIAL 10FRX14MM 110 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10017812","CDM","C1874","HCPCS","0278","RC","","","","both","","","4063.50","3047.62","WELLPOINT [1015]","HB AMC WELLPOINT","2998.05","73.78","","1172.59","1172.59","4829.94","1 through 10","1259.69","3230.48","percent of total billed charges",""
"STENT BRONCHIAL 10FRX14MM 110 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10017812","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4063.50","3047.62","AETNA [1001]","HB AMC AETNA HMO","2836.32","69.8","","1806.84","947.80","5091.72","1 through 10","2123.59","3320.69","percent of total billed charges",""
"STENT BRONCHIAL 10FRX14MM 110 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10017812","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4063.50","3047.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3320.69","81.72","","1259.05","615.58","4586.56","1 through 10","2123.59","3320.69","percent of total billed charges",""
"STENT BRONCHIAL 10X20MM WITH POST ULTRA SMOOTH","SUP-ITM-10274497","CDM","C1874","HCPCS","0278","RC","","","","both","","","1225.00","918.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","796.25","65","","6652.80","6652.80","6652.80","1 through 10","379.75","973.88","percent of total billed charges",""
"STENT BRONCHIAL 10X20MM WITH POST ULTRA SMOOTH","SUP-ITM-10274497","CDM","C1874","HCPCS","0278","RC","","","","both","","","1225.00","918.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","973.88","79.5","","2612.61","795.38","2612.61","1 through 10","379.75","973.88","percent of total billed charges",""
"STENT BRONCHIAL 10X20MM WITH POST ULTRA SMOOTH","SUP-ITM-10274497","CDM","C1874","HCPCS","0278","RC","","","","both","","","1225.00","918.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","652.93","53.3","","1101.80","1101.80","1101.80","1 through 10","379.75","973.88","percent of total billed charges",""
"STENT BRONCHIAL 10X20MM WITH POST ULTRA SMOOTH","SUP-ITM-10274497","CDM","C1874","HCPCS","0278","RC","","","","both","","","1225.00","918.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","796.25","65","","1820.00","910.00","1820.00","1 through 10","379.75","973.88","percent of total billed charges",""
"STENT BRONCHIAL 10X20MM WITH POST ULTRA SMOOTH","SUP-ITM-10274497","CDM","C1874","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","447.13","36.5","","1257.80","693.44","2424.50","1 through 10","379.75","973.88","percent of total billed charges",""
"STENT BRONCHIAL 10X20MM WITH POST ULTRA SMOOTH","SUP-ITM-10274497","CDM","C1874","HCPCS","0278","RC","","","","both","","","1225.00","918.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","469.18","38.3","","1950.11","547.40","2346.00","1 through 10","379.75","973.88","percent of total billed charges",""
"STENT BRONCHIAL 10X20MM WITH POST ULTRA SMOOTH","SUP-ITM-10274497","CDM","C1874","HCPCS","0278","RC","","","","both","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","525.53","42.9","","5096.18","5096.18","5096.18","1 through 10","379.75","973.88","percent of total billed charges",""
"STENT BRONCHIAL 10X20MM WITH POST ULTRA SMOOTH","SUP-ITM-10274497","CDM","C1874","HCPCS","0278","RC","","","","both","","","1225.00","918.75","WELLPOINT [1015]","HB AMC WELLPOINT","903.81","73.78","","1172.59","1172.59","4829.94","1 through 10","379.75","973.88","percent of total billed charges",""
"STENT BRONCHIAL 10X20MM WITH POST ULTRA SMOOTH","SUP-ITM-10274497","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","AETNA [1001]","HB AMC AETNA HMO","855.05","69.8","","1806.84","947.80","5091.72","1 through 10","640.19","1001.07","percent of total billed charges",""
"STENT BRONCHIAL 10X20MM WITH POST ULTRA SMOOTH","SUP-ITM-10274497","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1225.00","918.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1001.07","81.72","","1259.05","615.58","4586.56","1 through 10","640.19","1001.07","percent of total billed charges",""
"STENT BRONCHIAL 10X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10083824","CDM","C1874","HCPCS","0278","RC","","","","both","","","1255.63","941.72","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","816.16","65","","6652.80","6652.80","6652.80","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 10X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10083824","CDM","C1874","HCPCS","0278","RC","","","","both","","","1255.63","941.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","998.23","79.5","","2612.61","795.38","2612.61","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 10X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10083824","CDM","C1874","HCPCS","0278","RC","","","","both","","","1255.63","941.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","669.25","53.3","","1101.80","1101.80","1101.80","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 10X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10083824","CDM","C1874","HCPCS","0278","RC","","","","both","","","1255.63","941.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","816.16","65","","1820.00","910.00","1820.00","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 10X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10083824","CDM","C1874","HCPCS","0278","RC","","","","both","","","1255.63","941.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","458.30","36.5","","1257.80","693.44","2424.50","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 10X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10083824","CDM","C1874","HCPCS","0278","RC","","","","both","","","1255.63","941.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","480.91","38.3","","1950.11","547.40","2346.00","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 10X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10083824","CDM","C1874","HCPCS","0278","RC","","","","both","","","1255.63","941.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","538.67","42.9","","5096.18","5096.18","5096.18","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 10X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10083824","CDM","C1874","HCPCS","0278","RC","","","","both","","","1255.63","941.72","WELLPOINT [1015]","HB AMC WELLPOINT","926.40","73.78","","1172.59","1172.59","4829.94","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 10X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10083824","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1255.63","941.72","AETNA [1001]","HB AMC AETNA HMO","876.43","69.8","","1806.84","947.80","5091.72","1 through 10","656.19","1026.1","percent of total billed charges",""
"STENT BRONCHIAL 10X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10083824","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1255.63","941.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1026.10","81.72","","1259.05","615.58","4586.56","1 through 10","656.19","1026.1","percent of total billed charges",""
"STENT BRONCHIAL 12X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10268601","CDM","C1876","HCPCS","0278","RC","","","","both","","","1255.63","941.72","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","823.69","65.6","","751.18","751.18","751.18","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 12X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10268601","CDM","C1876","HCPCS","0278","RC","","","","both","","","1255.63","941.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","998.23","79.5","","4820.38","3211.27","4820.38","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 12X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10268601","CDM","C1876","HCPCS","0278","RC","","","","both","","","1255.63","941.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","458.30","36.5","","641.00","641.00","641.00","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 12X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10268601","CDM","C1876","HCPCS","0278","RC","","","","both","","","1255.63","941.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","480.91","38.3","","1098.43","1098.43","1098.43","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 12X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10268601","CDM","C1876","HCPCS","0278","RC","","","","both","","","1255.63","941.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","538.67","42.9","","4896.33","4896.33","4896.33","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 12X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10268601","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1255.63","941.72","AETNA [1001]","HB AMC AETNA HMO","876.43","69.8","","175.60","163.11","1063.91","1 through 10","656.19","1026.1","percent of total billed charges",""
"STENT BRONCHIAL 12X30MM WITH POST ULTRA SMOOTH","SUP-ITM-10268601","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1255.63","941.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1026.10","81.72","","105.94","85.10","105.94","1 through 10","656.19","1026.1","percent of total billed charges",""
"STENT BRONCHIAL 12X40MM WITH POST","SUP-ITM-10297195","CDM","C2625","HCPCS","0278","RC","","","","both","","","1255.63","941.72","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","878.94","70","","470.75","470.75","470.75","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 12X40MM WITH POST","SUP-ITM-10297195","CDM","C2625","HCPCS","0278","RC","","","","both","","","1255.63","941.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","480.91","38.3","","184.07","124.37","184.07","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 12X40MM WITH POST","SUP-ITM-10297195","CDM","C2625","HCPCS","0278","RC","","","","both","","","1255.63","941.72","WELLPOINT [1015]","HB AMC WELLPOINT","926.40","73.78","","243.67","243.67","243.67","1 through 10","389.25","998.23","percent of total billed charges",""
"STENT BRONCHIAL 12X40MM WITH POST","SUP-ITM-10297195","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","1255.63","941.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1026.10","81.72","","376.32","376.32","376.32","1 through 10","656.19","1026.1","percent of total billed charges",""
"STENT BRONCHIAL 16X13MM 108 50 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10018057","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2400.13","65","","6652.80","6652.80","6652.80","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT BRONCHIAL 16X13MM 108 50 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10018057","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2935.54","79.5","","2612.61","795.38","2612.61","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT BRONCHIAL 16X13MM 108 50 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10018057","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1968.10","53.3","","1101.80","1101.80","1101.80","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT BRONCHIAL 16X13MM 108 50 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10018057","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2400.13","65","","1820.00","910.00","1820.00","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT BRONCHIAL 16X13MM 108 50 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10018057","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1347.76","36.5","","1257.80","693.44","2424.50","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT BRONCHIAL 16X13MM 108 50 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10018057","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1414.23","38.3","","1950.11","547.40","2346.00","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT BRONCHIAL 16X13MM 108 50 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10018057","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1584.08","42.9","","5096.18","5096.18","5096.18","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT BRONCHIAL 16X13MM 108 50 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10018057","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","WELLPOINT [1015]","HB AMC WELLPOINT","2724.33","73.78","","1172.59","1172.59","4829.94","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT BRONCHIAL 16X13MM 108 50 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10018057","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","3692.50","2769.37","AETNA [1001]","HB AMC AETNA HMO","2577.37","69.8","","1806.84","947.80","5091.72","1 through 10","1929.7","3017.51","percent of total billed charges",""
"STENT BRONCHIAL 16X13MM 108 50 DUMON Y IMPLANT GRADE SILICONE TRACHEAL","SUP-ITM-10018057","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","3692.50","2769.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3017.51","81.72","","1259.05","615.58","4586.56","1 through 10","1929.7","3017.51","percent of total billed charges",""
"STENT BRONCHIAL 20X16MM Y ULTRA-SMOOTH","SUP-ITM-10287870","CDM","C1876","HCPCS","0278","RC","","","","both","","","2167.52","1625.64","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1421.89","65.6","","751.18","751.18","751.18","1 through 10","671.93","1723.18","percent of total billed charges",""
"STENT BRONCHIAL 20X16MM Y ULTRA-SMOOTH","SUP-ITM-10287870","CDM","C1876","HCPCS","0278","RC","","","","both","","","2167.52","1625.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1723.18","79.5","","4820.38","3211.27","4820.38","1 through 10","671.93","1723.18","percent of total billed charges",""
"STENT BRONCHIAL 20X16MM Y ULTRA-SMOOTH","SUP-ITM-10287870","CDM","C1876","HCPCS","0278","RC","","","","both","","","2167.52","1625.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","791.14","36.5","","641.00","641.00","641.00","1 through 10","671.93","1723.18","percent of total billed charges",""
"STENT BRONCHIAL 20X16MM Y ULTRA-SMOOTH","SUP-ITM-10287870","CDM","C1876","HCPCS","0278","RC","","","","both","","","2167.52","1625.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","830.16","38.3","","1098.43","1098.43","1098.43","1 through 10","671.93","1723.18","percent of total billed charges",""
"STENT BRONCHIAL 20X16MM Y ULTRA-SMOOTH","SUP-ITM-10287870","CDM","C1876","HCPCS","0278","RC","","","","both","","","2167.52","1625.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","929.87","42.9","","4896.33","4896.33","4896.33","1 through 10","671.93","1723.18","percent of total billed charges",""
"STENT BRONCHIAL 20X16MM Y ULTRA-SMOOTH","SUP-ITM-10287870","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2167.52","1625.64","AETNA [1001]","HB AMC AETNA HMO","1512.93","69.8","","175.60","163.11","1063.91","1 through 10","1132.75","1771.3","percent of total billed charges",""
"STENT BRONCHIAL 20X16MM Y ULTRA-SMOOTH","SUP-ITM-10287870","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2167.52","1625.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1771.30","81.72","","105.94","85.10","105.94","1 through 10","1132.75","1771.3","percent of total billed charges",""
"STENT BRONCHIAL 8X19MM WITH RINGS","SUP-ITM-10086426","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","787.95","65","","6652.80","6652.80","6652.80","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT BRONCHIAL 8X19MM WITH RINGS","SUP-ITM-10086426","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","963.72","79.5","","2612.61","795.38","2612.61","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT BRONCHIAL 8X19MM WITH RINGS","SUP-ITM-10086426","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","646.12","53.3","","1101.80","1101.80","1101.80","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT BRONCHIAL 8X19MM WITH RINGS","SUP-ITM-10086426","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","787.95","65","","1820.00","910.00","1820.00","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT BRONCHIAL 8X19MM WITH RINGS","SUP-ITM-10086426","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","442.46","36.5","","1257.80","693.44","2424.50","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT BRONCHIAL 8X19MM WITH RINGS","SUP-ITM-10086426","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","464.28","38.3","","1950.11","547.40","2346.00","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT BRONCHIAL 8X19MM WITH RINGS","SUP-ITM-10086426","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.05","42.9","","5096.18","5096.18","5096.18","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT BRONCHIAL 8X19MM WITH RINGS","SUP-ITM-10086426","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","WELLPOINT [1015]","HB AMC WELLPOINT","894.38","73.78","","1172.59","1172.59","4829.94","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT BRONCHIAL 8X19MM WITH RINGS","SUP-ITM-10086426","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1212.23","909.17","AETNA [1001]","HB AMC AETNA HMO","846.14","69.8","","1806.84","947.80","5091.72","1 through 10","633.51","990.63","percent of total billed charges",""
"STENT BRONCHIAL 8X19MM WITH RINGS","SUP-ITM-10086426","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1212.23","909.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","990.63","81.72","","1259.05","615.58","4586.56","1 through 10","633.51","990.63","percent of total billed charges",""
"STENT BX2 6MMX79MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321079","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5534.75","65","","6652.80","6652.80","6652.80","1 through 10","2639.65","6769.43","percent of total billed charges",""
"STENT BX2 6MMX79MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321079","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6769.43","79.5","","2612.61","795.38","2612.61","1 through 10","2639.65","6769.43","percent of total billed charges",""
"STENT BX2 6MMX79MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321079","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4538.50","53.3","","1101.80","1101.80","1101.80","1 through 10","2639.65","6769.43","percent of total billed charges",""
"STENT BX2 6MMX79MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321079","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5534.75","65","","1820.00","910.00","1820.00","1 through 10","2639.65","6769.43","percent of total billed charges",""
"STENT BX2 6MMX79MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321079","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3107.98","36.5","","1257.80","693.44","2424.50","1 through 10","2639.65","6769.43","percent of total billed charges",""
"STENT BX2 6MMX79MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321079","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3261.25","38.3","","1950.11","547.40","2346.00","1 through 10","2639.65","6769.43","percent of total billed charges",""
"STENT BX2 6MMX79MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321079","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3652.94","42.9","","5096.18","5096.18","5096.18","1 through 10","2639.65","6769.43","percent of total billed charges",""
"STENT BX2 6MMX79MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321079","CDM","C1874","HCPCS","0278","RC","","","","both","","","8515.00","6386.25","WELLPOINT [1015]","HB AMC WELLPOINT","6282.37","73.78","","1172.59","1172.59","4829.94","1 through 10","2639.65","6769.43","percent of total billed charges",""
"STENT BX2 6MMX79MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321079","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8515.00","6386.25","AETNA [1001]","HB AMC AETNA HMO","5943.47","69.8","","1806.84","947.80","5091.72","1 through 10","4449.94","6958.46","percent of total billed charges",""
"STENT BX2 6MMX79MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321079","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8515.00","6386.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6958.46","81.72","","1259.05","615.58","4586.56","1 through 10","4449.94","6958.46","percent of total billed charges",""
"STENT BX2 7MMX29MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321073","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4907.50","65","","6652.80","6652.80","6652.80","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX29MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321073","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6002.25","79.5","","2612.61","795.38","2612.61","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX29MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321073","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4024.15","53.3","","1101.80","1101.80","1101.80","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX29MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321073","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4907.50","65","","1820.00","910.00","1820.00","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX29MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321073","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2755.75","36.5","","1257.80","693.44","2424.50","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX29MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321073","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2891.65","38.3","","1950.11","547.40","2346.00","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX29MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321073","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3238.95","42.9","","5096.18","5096.18","5096.18","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX29MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321073","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","WELLPOINT [1015]","HB AMC WELLPOINT","5570.39","73.78","","1172.59","1172.59","4829.94","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX29MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321073","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7550.00","5662.50","AETNA [1001]","HB AMC AETNA HMO","5269.90","69.8","","1806.84","947.80","5091.72","1 through 10","3945.63","6169.86","percent of total billed charges",""
"STENT BX2 7MMX29MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321073","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7550.00","5662.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6169.86","81.72","","1259.05","615.58","4586.56","1 through 10","3945.63","6169.86","percent of total billed charges",""
"STENT BX2 7MMX39MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321071","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4907.50","65","","6652.80","6652.80","6652.80","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX39MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321071","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6002.25","79.5","","2612.61","795.38","2612.61","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX39MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321071","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4024.15","53.3","","1101.80","1101.80","1101.80","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX39MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321071","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4907.50","65","","1820.00","910.00","1820.00","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX39MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321071","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2755.75","36.5","","1257.80","693.44","2424.50","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX39MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321071","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2891.65","38.3","","1950.11","547.40","2346.00","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX39MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321071","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3238.95","42.9","","5096.18","5096.18","5096.18","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX39MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321071","CDM","C1874","HCPCS","0278","RC","","","","both","","","7550.00","5662.50","WELLPOINT [1015]","HB AMC WELLPOINT","5570.39","73.78","","1172.59","1172.59","4829.94","1 through 10","2340.5","6002.25","percent of total billed charges",""
"STENT BX2 7MMX39MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321071","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7550.00","5662.50","AETNA [1001]","HB AMC AETNA HMO","5269.90","69.8","","1806.84","947.80","5091.72","1 through 10","3945.63","6169.86","percent of total billed charges",""
"STENT BX2 7MMX39MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321071","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7550.00","5662.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6169.86","81.72","","1259.05","615.58","4586.56","1 through 10","3945.63","6169.86","percent of total billed charges",""
"STENT CAROTID 7X30MMX135CM .014IN RX BARE METAL NITINOL SELF-EXPANDING STRAIGHT PRECISE PRO","SUP-ITM-10025298","CDM","C1876","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3345.60","65.6","","751.18","751.18","751.18","1 through 10","1581","4054.5","percent of total billed charges",""
"STENT CAROTID 7X30MMX135CM .014IN RX BARE METAL NITINOL SELF-EXPANDING STRAIGHT PRECISE PRO","SUP-ITM-10025298","CDM","C1876","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4054.50","79.5","","4820.38","3211.27","4820.38","1 through 10","1581","4054.5","percent of total billed charges",""
"STENT CAROTID 7X30MMX135CM .014IN RX BARE METAL NITINOL SELF-EXPANDING STRAIGHT PRECISE PRO","SUP-ITM-10025298","CDM","C1876","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1861.50","36.5","","641.00","641.00","641.00","1 through 10","1581","4054.5","percent of total billed charges",""
"STENT CAROTID 7X30MMX135CM .014IN RX BARE METAL NITINOL SELF-EXPANDING STRAIGHT PRECISE PRO","SUP-ITM-10025298","CDM","C1876","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1953.30","38.3","","1098.43","1098.43","1098.43","1 through 10","1581","4054.5","percent of total billed charges",""
"STENT CAROTID 7X30MMX135CM .014IN RX BARE METAL NITINOL SELF-EXPANDING STRAIGHT PRECISE PRO","SUP-ITM-10025298","CDM","C1876","HCPCS","0278","RC","","","","both","","","5100.00","3825.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2187.90","42.9","","4896.33","4896.33","4896.33","1 through 10","1581","4054.5","percent of total billed charges",""
"STENT CAROTID 7X30MMX135CM .014IN RX BARE METAL NITINOL SELF-EXPANDING STRAIGHT PRECISE PRO","SUP-ITM-10025298","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","AETNA [1001]","HB AMC AETNA HMO","3559.80","69.8","","175.60","163.11","1063.91","1 through 10","2665.26","4167.72","percent of total billed charges",""
"STENT CAROTID 7X30MMX135CM .014IN RX BARE METAL NITINOL SELF-EXPANDING STRAIGHT PRECISE PRO","SUP-ITM-10025298","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","5100.00","3825.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4167.72","81.72","","105.94","85.10","105.94","1 through 10","2665.26","4167.72","percent of total billed charges",""
"STENT COPE NEPHROURETEROSTOMY 10.2FR 24CM .038IN MAC LOC LOCKING LOOP RADIOPAQUE BAND HYDROPHILIC COATING","SUP-ITM-10028652","CDM","C2625","HCPCS","0278","RC","","","","both","","","327.29","245.47","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","229.10","70","","470.75","470.75","470.75","1 through 10","101.46","260.2","percent of total billed charges",""
"STENT COPE NEPHROURETEROSTOMY 10.2FR 24CM .038IN MAC LOC LOCKING LOOP RADIOPAQUE BAND HYDROPHILIC COATING","SUP-ITM-10028652","CDM","C2625","HCPCS","0278","RC","","","","both","","","327.29","245.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","125.35","38.3","","184.07","124.37","184.07","1 through 10","101.46","260.2","percent of total billed charges",""
"STENT COPE NEPHROURETEROSTOMY 10.2FR 24CM .038IN MAC LOC LOCKING LOOP RADIOPAQUE BAND HYDROPHILIC COATING","SUP-ITM-10028652","CDM","C2625","HCPCS","0278","RC","","","","both","","","327.29","245.47","WELLPOINT [1015]","HB AMC WELLPOINT","241.47","73.78","","243.67","243.67","243.67","1 through 10","101.46","260.2","percent of total billed charges",""
"STENT COPE NEPHROURETEROSTOMY 10.2FR 24CM .038IN MAC LOC LOCKING LOOP RADIOPAQUE BAND HYDROPHILIC COATING","SUP-ITM-10028652","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","327.29","245.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","267.46","81.72","","376.32","376.32","376.32","1 through 10","171.04","267.46","percent of total billed charges",""
"STENT COPE NEPHROURETEROSTOMY 10.2FR 28CM .038IN MAC LOC LOCKING LOOP RADIOPAQUE BAND HYDROPHILIC COATING","SUP-ITM-10087113","CDM","C2625","HCPCS","0278","RC","","","","both","","","327.29","245.47","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","229.10","70","","470.75","470.75","470.75","1 through 10","101.46","260.2","percent of total billed charges",""
"STENT COPE NEPHROURETEROSTOMY 10.2FR 28CM .038IN MAC LOC LOCKING LOOP RADIOPAQUE BAND HYDROPHILIC COATING","SUP-ITM-10087113","CDM","C2625","HCPCS","0278","RC","","","","both","","","327.29","245.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","125.35","38.3","","184.07","124.37","184.07","1 through 10","101.46","260.2","percent of total billed charges",""
"STENT COPE NEPHROURETEROSTOMY 10.2FR 28CM .038IN MAC LOC LOCKING LOOP RADIOPAQUE BAND HYDROPHILIC COATING","SUP-ITM-10087113","CDM","C2625","HCPCS","0278","RC","","","","both","","","327.29","245.47","WELLPOINT [1015]","HB AMC WELLPOINT","241.47","73.78","","243.67","243.67","243.67","1 through 10","101.46","260.2","percent of total billed charges",""
"STENT COPE NEPHROURETEROSTOMY 10.2FR 28CM .038IN MAC LOC LOCKING LOOP RADIOPAQUE BAND HYDROPHILIC COATING","SUP-ITM-10087113","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","327.29","245.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","267.46","81.72","","376.32","376.32","376.32","1 through 10","171.04","267.46","percent of total billed charges",""
"STENT CORONARY 2.5X15MM RESOLUTE ONYX RX","SUP-ITM-10190915","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1308.13","65","","6652.80","6652.80","6652.80","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 2.5X15MM RESOLUTE ONYX RX","SUP-ITM-10190915","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1599.94","79.5","","2612.61","795.38","2612.61","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 2.5X15MM RESOLUTE ONYX RX","SUP-ITM-10190915","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1072.66","53.3","","1101.80","1101.80","1101.80","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 2.5X15MM RESOLUTE ONYX RX","SUP-ITM-10190915","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1308.13","65","","1820.00","910.00","1820.00","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 2.5X15MM RESOLUTE ONYX RX","SUP-ITM-10190915","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","734.56","36.5","","1257.80","693.44","2424.50","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 2.5X15MM RESOLUTE ONYX RX","SUP-ITM-10190915","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","770.79","38.3","","1950.11","547.40","2346.00","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 2.5X15MM RESOLUTE ONYX RX","SUP-ITM-10190915","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","863.36","42.9","","5096.18","5096.18","5096.18","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 2.5X15MM RESOLUTE ONYX RX","SUP-ITM-10190915","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","WELLPOINT [1015]","HB AMC WELLPOINT","1484.82","73.78","","1172.59","1172.59","4829.94","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 2.5X15MM RESOLUTE ONYX RX","SUP-ITM-10190915","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2012.50","1509.37","AETNA [1001]","HB AMC AETNA HMO","1404.73","69.8","","1806.84","947.80","5091.72","1 through 10","1051.73","1644.62","percent of total billed charges",""
"STENT CORONARY 2.5X15MM RESOLUTE ONYX RX","SUP-ITM-10190915","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2012.50","1509.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1644.62","81.72","","1259.05","615.58","4586.56","1 through 10","1051.73","1644.62","percent of total billed charges",""
"STENT CORONARY 4X22MM ONYX FRONTEIR RX DRUG ELUTING","SUP-ITM-10298094","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1308.13","65","","6652.80","6652.80","6652.80","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 4X22MM ONYX FRONTEIR RX DRUG ELUTING","SUP-ITM-10298094","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1599.94","79.5","","2612.61","795.38","2612.61","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 4X22MM ONYX FRONTEIR RX DRUG ELUTING","SUP-ITM-10298094","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1072.66","53.3","","1101.80","1101.80","1101.80","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 4X22MM ONYX FRONTEIR RX DRUG ELUTING","SUP-ITM-10298094","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1308.13","65","","1820.00","910.00","1820.00","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 4X22MM ONYX FRONTEIR RX DRUG ELUTING","SUP-ITM-10298094","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","734.56","36.5","","1257.80","693.44","2424.50","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 4X22MM ONYX FRONTEIR RX DRUG ELUTING","SUP-ITM-10298094","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","770.79","38.3","","1950.11","547.40","2346.00","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 4X22MM ONYX FRONTEIR RX DRUG ELUTING","SUP-ITM-10298094","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","863.36","42.9","","5096.18","5096.18","5096.18","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 4X22MM ONYX FRONTEIR RX DRUG ELUTING","SUP-ITM-10298094","CDM","C1874","HCPCS","0278","RC","","","","both","","","2012.50","1509.37","WELLPOINT [1015]","HB AMC WELLPOINT","1484.82","73.78","","1172.59","1172.59","4829.94","1 through 10","623.88","1599.94","percent of total billed charges",""
"STENT CORONARY 4X22MM ONYX FRONTEIR RX DRUG ELUTING","SUP-ITM-10298094","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2012.50","1509.37","AETNA [1001]","HB AMC AETNA HMO","1404.73","69.8","","1806.84","947.80","5091.72","1 through 10","1051.73","1644.62","percent of total billed charges",""
"STENT CORONARY 4X22MM ONYX FRONTEIR RX DRUG ELUTING","SUP-ITM-10298094","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2012.50","1509.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1644.62","81.72","","1259.05","615.58","4586.56","1 through 10","1051.73","1644.62","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T1","PX-27000145","CDM","C1874","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1365.00","65","","6652.80","6652.80","6652.80","1 through 10","651","1669.5","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T1","PX-27000145","CDM","C1874","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","2612.61","795.38","2612.61","1 through 10","651","1669.5","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T1","PX-27000145","CDM","C1874","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1119.30","53.3","","1101.80","1101.80","1101.80","1 through 10","651","1669.5","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T1","PX-27000145","CDM","C1874","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1365.00","65","","1820.00","910.00","1820.00","1 through 10","651","1669.5","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T1","PX-27000145","CDM","C1874","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1257.80","693.44","2424.50","1 through 10","651","1669.5","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T1","PX-27000145","CDM","C1874","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","1950.11","547.40","2346.00","1 through 10","651","1669.5","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T1","PX-27000145","CDM","C1874","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","5096.18","5096.18","5096.18","1 through 10","651","1669.5","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T1","PX-27000145","CDM","C1874","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","1172.59","1172.59","4829.94","1 through 10","651","1669.5","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T1","PX-27000145","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1806.84","947.80","5091.72","1 through 10","1097.46","1716.12","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T1","PX-27000145","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1259.05","615.58","4586.56","1 through 10","1097.46","1716.12","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T2","PX-27000146","CDM","C1874","HCPCS","0278","RC","","","","both","","","4367.91","3275.93","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2839.14","65","","6652.80","6652.80","6652.80","1 through 10","1354.05","3472.49","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T2","PX-27000146","CDM","C1874","HCPCS","0278","RC","","","","both","","","4367.91","3275.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3472.49","79.5","","2612.61","795.38","2612.61","1 through 10","1354.05","3472.49","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T2","PX-27000146","CDM","C1874","HCPCS","0278","RC","","","","both","","","4367.91","3275.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2328.10","53.3","","1101.80","1101.80","1101.80","1 through 10","1354.05","3472.49","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T2","PX-27000146","CDM","C1874","HCPCS","0278","RC","","","","both","","","4367.91","3275.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2839.14","65","","1820.00","910.00","1820.00","1 through 10","1354.05","3472.49","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T2","PX-27000146","CDM","C1874","HCPCS","0278","RC","","","","both","","","4367.91","3275.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1594.29","36.5","","1257.80","693.44","2424.50","1 through 10","1354.05","3472.49","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T2","PX-27000146","CDM","C1874","HCPCS","0278","RC","","","","both","","","4367.91","3275.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1672.91","38.3","","1950.11","547.40","2346.00","1 through 10","1354.05","3472.49","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T2","PX-27000146","CDM","C1874","HCPCS","0278","RC","","","","both","","","4367.91","3275.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1873.83","42.9","","5096.18","5096.18","5096.18","1 through 10","1354.05","3472.49","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T2","PX-27000146","CDM","C1874","HCPCS","0278","RC","","","","both","","","4367.91","3275.93","WELLPOINT [1015]","HB AMC WELLPOINT","3222.64","73.78","","1172.59","1172.59","4829.94","1 through 10","1354.05","3472.49","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T2","PX-27000146","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4367.91","3275.93","AETNA [1001]","HB AMC AETNA HMO","3048.80","69.8","","1806.84","947.80","5091.72","1 through 10","2282.67","3569.46","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T2","PX-27000146","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4367.91","3275.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3569.46","81.72","","1259.05","615.58","4586.56","1 through 10","2282.67","3569.46","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T3","PX-27000147","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3891.88","65","","6652.80","6652.80","6652.80","1 through 10","1856.13","4760.06","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T3","PX-27000147","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4760.06","79.5","","2612.61","795.38","2612.61","1 through 10","1856.13","4760.06","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T3","PX-27000147","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3191.34","53.3","","1101.80","1101.80","1101.80","1 through 10","1856.13","4760.06","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T3","PX-27000147","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3891.88","65","","1820.00","910.00","1820.00","1 through 10","1856.13","4760.06","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T3","PX-27000147","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2185.44","36.5","","1257.80","693.44","2424.50","1 through 10","1856.13","4760.06","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T3","PX-27000147","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2293.21","38.3","","1950.11","547.40","2346.00","1 through 10","1856.13","4760.06","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T3","PX-27000147","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2568.64","42.9","","5096.18","5096.18","5096.18","1 through 10","1856.13","4760.06","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T3","PX-27000147","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","WELLPOINT [1015]","HB AMC WELLPOINT","4417.58","73.78","","1172.59","1172.59","4829.94","1 through 10","1856.13","4760.06","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T3","PX-27000147","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5987.50","4490.62","AETNA [1001]","HB AMC AETNA HMO","4179.28","69.8","","1806.84","947.80","5091.72","1 through 10","3129.07","4892.99","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T3","PX-27000147","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5987.50","4490.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4892.99","81.72","","1259.05","615.58","4586.56","1 through 10","3129.07","4892.99","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 2CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10008614","CDM","C2617","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","250.43","79.5","","304.65","204.39","304.65","1 through 10","97.65","250.43","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 2CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10008614","CDM","C2617","HCPCS","0278","RC","","","","both","","","315.00","236.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","167.90","53.3","","204.39","204.39","304.65","1 through 10","97.65","250.43","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 2CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10008614","CDM","C2617","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","114.98","36.5","","144.39","122.71","144.39","1 through 10","97.65","250.43","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 2CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10008614","CDM","C2617","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","120.65","38.3","","151.36","147.10","454.08","13","97.65","250.43","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 2CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10008614","CDM","C2617","HCPCS","0278","RC","","","","both","","","315.00","236.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","242.55","77","","304.65","304.65","304.65","1 through 10","97.65","250.43","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 2CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10008614","CDM","C2617","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB AMC WELLPOINT","232.41","73.78","","675.30","288.20","675.30","1 through 10","97.65","250.43","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 2CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10008614","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","257.42","81.72","","183.26","154.72","309.45","1 through 10","164.62","257.42","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","both","","","273.00","204.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","217.04","79.5","","304.65","204.39","304.65","1 through 10","84.63","217.04","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","both","","","273.00","204.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","145.51","53.3","","204.39","204.39","304.65","1 through 10","84.63","217.04","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","both","","","273.00","204.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","99.65","36.5","","144.39","122.71","144.39","1 through 10","84.63","217.04","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","both","","","273.00","204.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","104.56","38.3","","151.36","147.10","454.08","13","84.63","217.04","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","both","","","273.00","204.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","210.21","77","","304.65","304.65","304.65","1 through 10","84.63","217.04","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","both","","","273.00","204.75","WELLPOINT [1015]","HB AMC WELLPOINT","201.42","73.78","","675.30","288.20","675.30","1 through 10","84.63","217.04","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","273.00","204.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","223.10","81.72","","183.26","154.72","309.45","1 through 10","142.67","223.1","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","both","","","5983.70","4487.77","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3889.41","65","","6652.80","6652.80","6652.80","1 through 10","1854.95","4757.04","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","both","","","5983.70","4487.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4757.04","79.5","","2612.61","795.38","2612.61","1 through 10","1854.95","4757.04","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","both","","","5983.70","4487.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3189.31","53.3","","1101.80","1101.80","1101.80","1 through 10","1854.95","4757.04","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","both","","","5983.70","4487.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3889.41","65","","1820.00","910.00","1820.00","1 through 10","1854.95","4757.04","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","both","","","5983.70","4487.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2184.05","36.5","","1257.80","693.44","2424.50","1 through 10","1854.95","4757.04","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","both","","","5983.70","4487.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2291.76","38.3","","1950.11","547.40","2346.00","1 through 10","1854.95","4757.04","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","both","","","5983.70","4487.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2567.01","42.9","","5096.18","5096.18","5096.18","1 through 10","1854.95","4757.04","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","both","","","5983.70","4487.77","WELLPOINT [1015]","HB AMC WELLPOINT","4414.77","73.78","","1172.59","1172.59","4829.94","1 through 10","1854.95","4757.04","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5983.70","4487.77","AETNA [1001]","HB AMC AETNA HMO","4176.62","69.8","","1806.84","947.80","5091.72","1 through 10","3127.08","4889.88","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5983.70","4487.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4889.88","81.72","","1259.05","615.58","4586.56","1 through 10","3127.08","4889.88","percent of total billed charges",""
"STENT COVERED 8MMX38MMX80CM ICAST","SUP-ITM-10327619","CDM","C1874","HCPCS","0278","RC","","","","both","","","6238.33","4678.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4054.91","65","","6652.80","6652.80","6652.80","1 through 10","1933.88","4959.47","percent of total billed charges",""
"STENT COVERED 8MMX38MMX80CM ICAST","SUP-ITM-10327619","CDM","C1874","HCPCS","0278","RC","","","","both","","","6238.33","4678.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4959.47","79.5","","2612.61","795.38","2612.61","1 through 10","1933.88","4959.47","percent of total billed charges",""
"STENT COVERED 8MMX38MMX80CM ICAST","SUP-ITM-10327619","CDM","C1874","HCPCS","0278","RC","","","","both","","","6238.33","4678.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3325.03","53.3","","1101.80","1101.80","1101.80","1 through 10","1933.88","4959.47","percent of total billed charges",""
"STENT COVERED 8MMX38MMX80CM ICAST","SUP-ITM-10327619","CDM","C1874","HCPCS","0278","RC","","","","both","","","6238.33","4678.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4054.91","65","","1820.00","910.00","1820.00","1 through 10","1933.88","4959.47","percent of total billed charges",""
"STENT COVERED 8MMX38MMX80CM ICAST","SUP-ITM-10327619","CDM","C1874","HCPCS","0278","RC","","","","both","","","6238.33","4678.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2276.99","36.5","","1257.80","693.44","2424.50","1 through 10","1933.88","4959.47","percent of total billed charges",""
"STENT COVERED 8MMX38MMX80CM ICAST","SUP-ITM-10327619","CDM","C1874","HCPCS","0278","RC","","","","both","","","6238.33","4678.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2389.28","38.3","","1950.11","547.40","2346.00","1 through 10","1933.88","4959.47","percent of total billed charges",""
"STENT COVERED 8MMX38MMX80CM ICAST","SUP-ITM-10327619","CDM","C1874","HCPCS","0278","RC","","","","both","","","6238.33","4678.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2676.24","42.9","","5096.18","5096.18","5096.18","1 through 10","1933.88","4959.47","percent of total billed charges",""
"STENT COVERED 8MMX38MMX80CM ICAST","SUP-ITM-10327619","CDM","C1874","HCPCS","0278","RC","","","","both","","","6238.33","4678.75","WELLPOINT [1015]","HB AMC WELLPOINT","4602.64","73.78","","1172.59","1172.59","4829.94","1 through 10","1933.88","4959.47","percent of total billed charges",""
"STENT COVERED 8MMX38MMX80CM ICAST","SUP-ITM-10327619","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6238.33","4678.75","AETNA [1001]","HB AMC AETNA HMO","4354.35","69.8","","1806.84","947.80","5091.72","1 through 10","3260.15","5097.96","percent of total billed charges",""
"STENT COVERED 8MMX38MMX80CM ICAST","SUP-ITM-10327619","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6238.33","4678.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5097.96","81.72","","1259.05","615.58","4586.56","1 through 10","3260.15","5097.96","percent of total billed charges",""
"STENT COVERED 9MMX59MMX120CM ICAST","SUP-ITM-10327623","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.58","5060.68","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4385.93","65","","6652.80","6652.80","6652.80","1 through 10","2091.75","5364.33","percent of total billed charges",""
"STENT COVERED 9MMX59MMX120CM ICAST","SUP-ITM-10327623","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.58","5060.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5364.33","79.5","","2612.61","795.38","2612.61","1 through 10","2091.75","5364.33","percent of total billed charges",""
"STENT COVERED 9MMX59MMX120CM ICAST","SUP-ITM-10327623","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.58","5060.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3596.46","53.3","","1101.80","1101.80","1101.80","1 through 10","2091.75","5364.33","percent of total billed charges",""
"STENT COVERED 9MMX59MMX120CM ICAST","SUP-ITM-10327623","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.58","5060.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4385.93","65","","1820.00","910.00","1820.00","1 through 10","2091.75","5364.33","percent of total billed charges",""
"STENT COVERED 9MMX59MMX120CM ICAST","SUP-ITM-10327623","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.58","5060.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2462.87","36.5","","1257.80","693.44","2424.50","1 through 10","2091.75","5364.33","percent of total billed charges",""
"STENT COVERED 9MMX59MMX120CM ICAST","SUP-ITM-10327623","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.58","5060.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2584.32","38.3","","1950.11","547.40","2346.00","1 through 10","2091.75","5364.33","percent of total billed charges",""
"STENT COVERED 9MMX59MMX120CM ICAST","SUP-ITM-10327623","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.58","5060.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2894.71","42.9","","5096.18","5096.18","5096.18","1 through 10","2091.75","5364.33","percent of total billed charges",""
"STENT COVERED 9MMX59MMX120CM ICAST","SUP-ITM-10327623","CDM","C1874","HCPCS","0278","RC","","","","both","","","6747.58","5060.68","WELLPOINT [1015]","HB AMC WELLPOINT","4978.36","73.78","","1172.59","1172.59","4829.94","1 through 10","2091.75","5364.33","percent of total billed charges",""
"STENT COVERED 9MMX59MMX120CM ICAST","SUP-ITM-10327623","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6747.58","5060.68","AETNA [1001]","HB AMC AETNA HMO","4709.81","69.8","","1806.84","947.80","5091.72","1 through 10","3526.29","5514.12","percent of total billed charges",""
"STENT COVERED 9MMX59MMX120CM ICAST","SUP-ITM-10327623","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6747.58","5060.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5514.12","81.72","","1259.05","615.58","4586.56","1 through 10","3526.29","5514.12","percent of total billed charges",""
"STENT CP 14FR 24MM 4.5CM 110CM .035IN CMCP034 MOUNTED COVERED","SUP-ITM-10166377","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","13771.06","65","","6652.80","6652.80","6652.80","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT CP 14FR 24MM 4.5CM 110CM .035IN CMCP034 MOUNTED COVERED","SUP-ITM-10166377","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","16843.07","79.5","","2612.61","795.38","2612.61","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT CP 14FR 24MM 4.5CM 110CM .035IN CMCP034 MOUNTED COVERED","SUP-ITM-10166377","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11292.27","53.3","","1101.80","1101.80","1101.80","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT CP 14FR 24MM 4.5CM 110CM .035IN CMCP034 MOUNTED COVERED","SUP-ITM-10166377","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","13771.06","65","","1820.00","910.00","1820.00","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT CP 14FR 24MM 4.5CM 110CM .035IN CMCP034 MOUNTED COVERED","SUP-ITM-10166377","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7732.98","36.5","","1257.80","693.44","2424.50","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT CP 14FR 24MM 4.5CM 110CM .035IN CMCP034 MOUNTED COVERED","SUP-ITM-10166377","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8114.33","38.3","","1950.11","547.40","2346.00","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT CP 14FR 24MM 4.5CM 110CM .035IN CMCP034 MOUNTED COVERED","SUP-ITM-10166377","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9088.90","42.9","","5096.18","5096.18","5096.18","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT CP 14FR 24MM 4.5CM 110CM .035IN CMCP034 MOUNTED COVERED","SUP-ITM-10166377","CDM","C1874","HCPCS","0278","RC","","","","both","","","21186.25","15889.69","WELLPOINT [1015]","HB AMC WELLPOINT","15631.22","73.78","","1172.59","1172.59","4829.94","1 through 10","6567.74","16843.07","percent of total billed charges",""
"STENT CP 14FR 24MM 4.5CM 110CM .035IN CMCP034 MOUNTED COVERED","SUP-ITM-10166377","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","21186.25","15889.69","AETNA [1001]","HB AMC AETNA HMO","14788.00","69.8","","1806.84","947.80","5091.72","1 through 10","11071.93","17313.4","percent of total billed charges",""
"STENT CP 14FR 24MM 4.5CM 110CM .035IN CMCP034 MOUNTED COVERED","SUP-ITM-10166377","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","21186.25","15889.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","17313.40","81.72","","1259.05","615.58","4586.56","1 through 10","11071.93","17313.4","percent of total billed charges",""
"STENT CUSTOM Y HARRELL POST 14X9.5MM","SUP-ITM-10030670","CDM","C1874","HCPCS","0278","RC","","","","both","","","1643.32","1232.49","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1068.16","65","","6652.80","6652.80","6652.80","1 through 10","509.43","1306.44","percent of total billed charges",""
"STENT CUSTOM Y HARRELL POST 14X9.5MM","SUP-ITM-10030670","CDM","C1874","HCPCS","0278","RC","","","","both","","","1643.32","1232.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1306.44","79.5","","2612.61","795.38","2612.61","1 through 10","509.43","1306.44","percent of total billed charges",""
"STENT CUSTOM Y HARRELL POST 14X9.5MM","SUP-ITM-10030670","CDM","C1874","HCPCS","0278","RC","","","","both","","","1643.32","1232.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","875.89","53.3","","1101.80","1101.80","1101.80","1 through 10","509.43","1306.44","percent of total billed charges",""
"STENT CUSTOM Y HARRELL POST 14X9.5MM","SUP-ITM-10030670","CDM","C1874","HCPCS","0278","RC","","","","both","","","1643.32","1232.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1068.16","65","","1820.00","910.00","1820.00","1 through 10","509.43","1306.44","percent of total billed charges",""
"STENT CUSTOM Y HARRELL POST 14X9.5MM","SUP-ITM-10030670","CDM","C1874","HCPCS","0278","RC","","","","both","","","1643.32","1232.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","599.81","36.5","","1257.80","693.44","2424.50","1 through 10","509.43","1306.44","percent of total billed charges",""
"STENT CUSTOM Y HARRELL POST 14X9.5MM","SUP-ITM-10030670","CDM","C1874","HCPCS","0278","RC","","","","both","","","1643.32","1232.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","629.39","38.3","","1950.11","547.40","2346.00","1 through 10","509.43","1306.44","percent of total billed charges",""
"STENT CUSTOM Y HARRELL POST 14X9.5MM","SUP-ITM-10030670","CDM","C1874","HCPCS","0278","RC","","","","both","","","1643.32","1232.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","704.98","42.9","","5096.18","5096.18","5096.18","1 through 10","509.43","1306.44","percent of total billed charges",""
"STENT CUSTOM Y HARRELL POST 14X9.5MM","SUP-ITM-10030670","CDM","C1874","HCPCS","0278","RC","","","","both","","","1643.32","1232.49","WELLPOINT [1015]","HB AMC WELLPOINT","1212.44","73.78","","1172.59","1172.59","4829.94","1 through 10","509.43","1306.44","percent of total billed charges",""
"STENT CUSTOM Y HARRELL POST 14X9.5MM","SUP-ITM-10030670","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1643.32","1232.49","AETNA [1001]","HB AMC AETNA HMO","1147.04","69.8","","1806.84","947.80","5091.72","1 through 10","858.8","1342.92","percent of total billed charges",""
"STENT CUSTOM Y HARRELL POST 14X9.5MM","SUP-ITM-10030670","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1643.32","1232.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1342.92","81.72","","1259.05","615.58","4586.56","1 through 10","858.8","1342.92","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","1236.69","927.52","CIGNA [1006]","HB AMC CIGNA HMO / PPO","983.17","79.5","","304.65","204.39","304.65","1 through 10","383.37","983.17","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","1236.69","927.52","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","659.16","53.3","","204.39","204.39","304.65","1 through 10","383.37","983.17","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","1236.69","927.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","451.39","36.5","","144.39","122.71","144.39","1 through 10","383.37","983.17","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","1236.69","927.52","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","473.65","38.3","","151.36","147.10","454.08","13","383.37","983.17","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","1236.69","927.52","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","952.25","77","","304.65","304.65","304.65","1 through 10","383.37","983.17","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","1236.69","927.52","WELLPOINT [1015]","HB AMC WELLPOINT","912.43","73.78","","675.30","288.20","675.30","1 through 10","383.37","983.17","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1236.69","927.52","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1010.62","81.72","","183.26","154.72","309.45","1 through 10","646.29","1010.62","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T1","PX-27000148","CDM","C1874","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2695.88","65","","6652.80","6652.80","6652.80","1 through 10","1285.73","3297.26","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T1","PX-27000148","CDM","C1874","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3297.26","79.5","","2612.61","795.38","2612.61","1 through 10","1285.73","3297.26","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T1","PX-27000148","CDM","C1874","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2210.62","53.3","","1101.80","1101.80","1101.80","1 through 10","1285.73","3297.26","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T1","PX-27000148","CDM","C1874","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2695.88","65","","1820.00","910.00","1820.00","1 through 10","1285.73","3297.26","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T1","PX-27000148","CDM","C1874","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1513.84","36.5","","1257.80","693.44","2424.50","1 through 10","1285.73","3297.26","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T1","PX-27000148","CDM","C1874","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1588.49","38.3","","1950.11","547.40","2346.00","1 through 10","1285.73","3297.26","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T1","PX-27000148","CDM","C1874","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1779.28","42.9","","5096.18","5096.18","5096.18","1 through 10","1285.73","3297.26","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T1","PX-27000148","CDM","C1874","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","WELLPOINT [1015]","HB AMC WELLPOINT","3060.03","73.78","","1172.59","1172.59","4829.94","1 through 10","1285.73","3297.26","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T1","PX-27000148","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4147.50","3110.62","AETNA [1001]","HB AMC AETNA HMO","2894.96","69.8","","1806.84","947.80","5091.72","1 through 10","2167.48","3389.34","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T1","PX-27000148","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4147.50","3110.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3389.34","81.72","","1259.05","615.58","4586.56","1 through 10","2167.48","3389.34","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T2","PX-27000149","CDM","C1874","HCPCS","0278","RC","","","","both","","","5253.42","3940.06","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3414.72","65","","6652.80","6652.80","6652.80","1 through 10","1628.56","4176.47","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T2","PX-27000149","CDM","C1874","HCPCS","0278","RC","","","","both","","","5253.42","3940.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4176.47","79.5","","2612.61","795.38","2612.61","1 through 10","1628.56","4176.47","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T2","PX-27000149","CDM","C1874","HCPCS","0278","RC","","","","both","","","5253.42","3940.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2800.07","53.3","","1101.80","1101.80","1101.80","1 through 10","1628.56","4176.47","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T2","PX-27000149","CDM","C1874","HCPCS","0278","RC","","","","both","","","5253.42","3940.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3414.72","65","","1820.00","910.00","1820.00","1 through 10","1628.56","4176.47","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T2","PX-27000149","CDM","C1874","HCPCS","0278","RC","","","","both","","","5253.42","3940.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1917.50","36.5","","1257.80","693.44","2424.50","1 through 10","1628.56","4176.47","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T2","PX-27000149","CDM","C1874","HCPCS","0278","RC","","","","both","","","5253.42","3940.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2012.06","38.3","","1950.11","547.40","2346.00","1 through 10","1628.56","4176.47","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T2","PX-27000149","CDM","C1874","HCPCS","0278","RC","","","","both","","","5253.42","3940.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2253.72","42.9","","5096.18","5096.18","5096.18","1 through 10","1628.56","4176.47","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T2","PX-27000149","CDM","C1874","HCPCS","0278","RC","","","","both","","","5253.42","3940.06","WELLPOINT [1015]","HB AMC WELLPOINT","3875.97","73.78","","1172.59","1172.59","4829.94","1 through 10","1628.56","4176.47","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T2","PX-27000149","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5253.42","3940.06","AETNA [1001]","HB AMC AETNA HMO","3666.89","69.8","","1806.84","947.80","5091.72","1 through 10","2745.44","4293.09","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T2","PX-27000149","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5253.42","3940.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4293.09","81.72","","1259.05","615.58","4586.56","1 through 10","2745.44","4293.09","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T3","PX-27000150","CDM","C1874","HCPCS","0278","RC","","","","both","","","7443.58","5582.68","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4838.33","65","","6652.80","6652.80","6652.80","1 through 10","2307.51","5917.65","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T3","PX-27000150","CDM","C1874","HCPCS","0278","RC","","","","both","","","7443.58","5582.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5917.65","79.5","","2612.61","795.38","2612.61","1 through 10","2307.51","5917.65","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T3","PX-27000150","CDM","C1874","HCPCS","0278","RC","","","","both","","","7443.58","5582.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3967.43","53.3","","1101.80","1101.80","1101.80","1 through 10","2307.51","5917.65","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T3","PX-27000150","CDM","C1874","HCPCS","0278","RC","","","","both","","","7443.58","5582.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4838.33","65","","1820.00","910.00","1820.00","1 through 10","2307.51","5917.65","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T3","PX-27000150","CDM","C1874","HCPCS","0278","RC","","","","both","","","7443.58","5582.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2716.91","36.5","","1257.80","693.44","2424.50","1 through 10","2307.51","5917.65","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T3","PX-27000150","CDM","C1874","HCPCS","0278","RC","","","","both","","","7443.58","5582.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2850.89","38.3","","1950.11","547.40","2346.00","1 through 10","2307.51","5917.65","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T3","PX-27000150","CDM","C1874","HCPCS","0278","RC","","","","both","","","7443.58","5582.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3193.30","42.9","","5096.18","5096.18","5096.18","1 through 10","2307.51","5917.65","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T3","PX-27000150","CDM","C1874","HCPCS","0278","RC","","","","both","","","7443.58","5582.68","WELLPOINT [1015]","HB AMC WELLPOINT","5491.87","73.78","","1172.59","1172.59","4829.94","1 through 10","2307.51","5917.65","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T3","PX-27000150","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7443.58","5582.68","AETNA [1001]","HB AMC AETNA HMO","5195.62","69.8","","1806.84","947.80","5091.72","1 through 10","3890.01","6082.89","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T3","PX-27000150","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7443.58","5582.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6082.89","81.72","","1259.05","615.58","4586.56","1 through 10","3890.01","6082.89","percent of total billed charges",""
"STENT DUMON 10X30 1.0MM CB CARINA BRONCHUS WALL THICKNESS","SUP-ITM-10169906","CDM","C1876","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1021.72","65.6","","751.18","751.18","751.18","1 through 10","482.83","1238.21","percent of total billed charges",""
"STENT DUMON 10X30 1.0MM CB CARINA BRONCHUS WALL THICKNESS","SUP-ITM-10169906","CDM","C1876","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","4820.38","3211.27","4820.38","1 through 10","482.83","1238.21","percent of total billed charges",""
"STENT DUMON 10X30 1.0MM CB CARINA BRONCHUS WALL THICKNESS","SUP-ITM-10169906","CDM","C1876","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","641.00","641.00","641.00","1 through 10","482.83","1238.21","percent of total billed charges",""
"STENT DUMON 10X30 1.0MM CB CARINA BRONCHUS WALL THICKNESS","SUP-ITM-10169906","CDM","C1876","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","1098.43","1098.43","1098.43","1 through 10","482.83","1238.21","percent of total billed charges",""
"STENT DUMON 10X30 1.0MM CB CARINA BRONCHUS WALL THICKNESS","SUP-ITM-10169906","CDM","C1876","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","4896.33","4896.33","4896.33","1 through 10","482.83","1238.21","percent of total billed charges",""
"STENT DUMON 10X30 1.0MM CB CARINA BRONCHUS WALL THICKNESS","SUP-ITM-10169906","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","175.60","163.11","1063.91","1 through 10","813.95","1272.79","percent of total billed charges",""
"STENT DUMON 10X30 1.0MM CB CARINA BRONCHUS WALL THICKNESS","SUP-ITM-10169906","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","105.94","85.10","105.94","1 through 10","813.95","1272.79","percent of total billed charges",""
"STENT DUMON 9MM 30MM 1MM CB CARINA BRONCHUS","SUP-ITM-10233444","CDM","C1874","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1012.38","65","","6652.80","6652.80","6652.80","1 through 10","482.83","1238.21","percent of total billed charges",""
"STENT DUMON 9MM 30MM 1MM CB CARINA BRONCHUS","SUP-ITM-10233444","CDM","C1874","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1238.21","79.5","","2612.61","795.38","2612.61","1 through 10","482.83","1238.21","percent of total billed charges",""
"STENT DUMON 9MM 30MM 1MM CB CARINA BRONCHUS","SUP-ITM-10233444","CDM","C1874","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","830.15","53.3","","1101.80","1101.80","1101.80","1 through 10","482.83","1238.21","percent of total billed charges",""
"STENT DUMON 9MM 30MM 1MM CB CARINA BRONCHUS","SUP-ITM-10233444","CDM","C1874","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1012.38","65","","1820.00","910.00","1820.00","1 through 10","482.83","1238.21","percent of total billed charges",""
"STENT DUMON 9MM 30MM 1MM CB CARINA BRONCHUS","SUP-ITM-10233444","CDM","C1874","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.49","36.5","","1257.80","693.44","2424.50","1 through 10","482.83","1238.21","percent of total billed charges",""
"STENT DUMON 9MM 30MM 1MM CB CARINA BRONCHUS","SUP-ITM-10233444","CDM","C1874","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","596.52","38.3","","1950.11","547.40","2346.00","1 through 10","482.83","1238.21","percent of total billed charges",""
"STENT DUMON 9MM 30MM 1MM CB CARINA BRONCHUS","SUP-ITM-10233444","CDM","C1874","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.17","42.9","","5096.18","5096.18","5096.18","1 through 10","482.83","1238.21","percent of total billed charges",""
"STENT DUMON 9MM 30MM 1MM CB CARINA BRONCHUS","SUP-ITM-10233444","CDM","C1874","HCPCS","0278","RC","","","","both","","","1557.50","1168.12","WELLPOINT [1015]","HB AMC WELLPOINT","1149.12","73.78","","1172.59","1172.59","4829.94","1 through 10","482.83","1238.21","percent of total billed charges",""
"STENT DUMON 9MM 30MM 1MM CB CARINA BRONCHUS","SUP-ITM-10233444","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","AETNA [1001]","HB AMC AETNA HMO","1087.14","69.8","","1806.84","947.80","5091.72","1 through 10","813.95","1272.79","percent of total billed charges",""
"STENT DUMON 9MM 30MM 1MM CB CARINA BRONCHUS","SUP-ITM-10233444","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1557.50","1168.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1272.79","81.72","","1259.05","615.58","4586.56","1 through 10","813.95","1272.79","percent of total billed charges",""
"STENT ELUVIA 7MM 120MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269503","CDM","C1874","HCPCS","0278","RC","","","","both","","","7237.50","5428.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4704.38","65","","6652.80","6652.80","6652.80","1 through 10","2243.63","5753.81","percent of total billed charges",""
"STENT ELUVIA 7MM 120MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269503","CDM","C1874","HCPCS","0278","RC","","","","both","","","7237.50","5428.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5753.81","79.5","","2612.61","795.38","2612.61","1 through 10","2243.63","5753.81","percent of total billed charges",""
"STENT ELUVIA 7MM 120MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269503","CDM","C1874","HCPCS","0278","RC","","","","both","","","7237.50","5428.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3857.59","53.3","","1101.80","1101.80","1101.80","1 through 10","2243.63","5753.81","percent of total billed charges",""
"STENT ELUVIA 7MM 120MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269503","CDM","C1874","HCPCS","0278","RC","","","","both","","","7237.50","5428.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4704.38","65","","1820.00","910.00","1820.00","1 through 10","2243.63","5753.81","percent of total billed charges",""
"STENT ELUVIA 7MM 120MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269503","CDM","C1874","HCPCS","0278","RC","","","","both","","","7237.50","5428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2641.69","36.5","","1257.80","693.44","2424.50","1 through 10","2243.63","5753.81","percent of total billed charges",""
"STENT ELUVIA 7MM 120MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269503","CDM","C1874","HCPCS","0278","RC","","","","both","","","7237.50","5428.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2771.96","38.3","","1950.11","547.40","2346.00","1 through 10","2243.63","5753.81","percent of total billed charges",""
"STENT ELUVIA 7MM 120MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269503","CDM","C1874","HCPCS","0278","RC","","","","both","","","7237.50","5428.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3104.89","42.9","","5096.18","5096.18","5096.18","1 through 10","2243.63","5753.81","percent of total billed charges",""
"STENT ELUVIA 7MM 120MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269503","CDM","C1874","HCPCS","0278","RC","","","","both","","","7237.50","5428.12","WELLPOINT [1015]","HB AMC WELLPOINT","5339.83","73.78","","1172.59","1172.59","4829.94","1 through 10","2243.63","5753.81","percent of total billed charges",""
"STENT ELUVIA 7MM 120MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269503","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7237.50","5428.12","AETNA [1001]","HB AMC AETNA HMO","5051.78","69.8","","1806.84","947.80","5091.72","1 through 10","3782.32","5914.49","percent of total billed charges",""
"STENT ELUVIA 7MM 120MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269503","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7237.50","5428.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5914.49","81.72","","1259.05","615.58","4586.56","1 through 10","3782.32","5914.49","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4712.50","65","","6652.80","6652.80","6652.80","1 through 10","2247.5","5763.75","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5763.75","79.5","","2612.61","795.38","2612.61","1 through 10","2247.5","5763.75","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3864.25","53.3","","1101.80","1101.80","1101.80","1 through 10","2247.5","5763.75","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4712.50","65","","1820.00","910.00","1820.00","1 through 10","2247.5","5763.75","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2646.25","36.5","","1257.80","693.44","2424.50","1 through 10","2247.5","5763.75","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2776.75","38.3","","1950.11","547.40","2346.00","1 through 10","2247.5","5763.75","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3110.25","42.9","","5096.18","5096.18","5096.18","1 through 10","2247.5","5763.75","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","WELLPOINT [1015]","HB AMC WELLPOINT","5349.05","73.78","","1172.59","1172.59","4829.94","1 through 10","2247.5","5763.75","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","AETNA [1001]","HB AMC AETNA HMO","5060.50","69.8","","1806.84","947.80","5091.72","1 through 10","3788.85","5924.7","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5924.70","81.72","","1259.05","615.58","4586.56","1 through 10","3788.85","5924.7","percent of total billed charges",""
"STENT EPIC 6FR 6MM 40MM 120CM ILIAC ARTERY VASCULAR SELF EXPANDING","SUP-ITM-10100333","CDM","C1876","HCPCS","0278","RC","","","","both","","","3762.50","2821.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2468.20","65.6","","751.18","751.18","751.18","1 through 10","1166.38","2991.19","percent of total billed charges",""
"STENT EPIC 6FR 6MM 40MM 120CM ILIAC ARTERY VASCULAR SELF EXPANDING","SUP-ITM-10100333","CDM","C1876","HCPCS","0278","RC","","","","both","","","3762.50","2821.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2991.19","79.5","","4820.38","3211.27","4820.38","1 through 10","1166.38","2991.19","percent of total billed charges",""
"STENT EPIC 6FR 6MM 40MM 120CM ILIAC ARTERY VASCULAR SELF EXPANDING","SUP-ITM-10100333","CDM","C1876","HCPCS","0278","RC","","","","both","","","3762.50","2821.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1373.31","36.5","","641.00","641.00","641.00","1 through 10","1166.38","2991.19","percent of total billed charges",""
"STENT EPIC 6FR 6MM 40MM 120CM ILIAC ARTERY VASCULAR SELF EXPANDING","SUP-ITM-10100333","CDM","C1876","HCPCS","0278","RC","","","","both","","","3762.50","2821.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1441.04","38.3","","1098.43","1098.43","1098.43","1 through 10","1166.38","2991.19","percent of total billed charges",""
"STENT EPIC 6FR 6MM 40MM 120CM ILIAC ARTERY VASCULAR SELF EXPANDING","SUP-ITM-10100333","CDM","C1876","HCPCS","0278","RC","","","","both","","","3762.50","2821.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1614.11","42.9","","4896.33","4896.33","4896.33","1 through 10","1166.38","2991.19","percent of total billed charges",""
"STENT EPIC 6FR 6MM 40MM 120CM ILIAC ARTERY VASCULAR SELF EXPANDING","SUP-ITM-10100333","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3762.50","2821.87","AETNA [1001]","HB AMC AETNA HMO","2626.23","69.8","","175.60","163.11","1063.91","1 through 10","1966.28","3074.72","percent of total billed charges",""
"STENT EPIC 6FR 6MM 40MM 120CM ILIAC ARTERY VASCULAR SELF EXPANDING","SUP-ITM-10100333","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3762.50","2821.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3074.72","81.72","","105.94","85.10","105.94","1 through 10","1966.28","3074.72","percent of total billed charges",""
"STENT ESOPHAGEAL 10.5FR 20MMX6CM FULLY COVERED TAEWOONG NITI-S THROUGH THE SCOPE TTS","SUP-ITM-10238984","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4537.00","65","","6652.80","6652.80","6652.80","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT ESOPHAGEAL 10.5FR 20MMX6CM FULLY COVERED TAEWOONG NITI-S THROUGH THE SCOPE TTS","SUP-ITM-10238984","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5549.10","79.5","","2612.61","795.38","2612.61","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT ESOPHAGEAL 10.5FR 20MMX6CM FULLY COVERED TAEWOONG NITI-S THROUGH THE SCOPE TTS","SUP-ITM-10238984","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3720.34","53.3","","1101.80","1101.80","1101.80","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT ESOPHAGEAL 10.5FR 20MMX6CM FULLY COVERED TAEWOONG NITI-S THROUGH THE SCOPE TTS","SUP-ITM-10238984","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4537.00","65","","1820.00","910.00","1820.00","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT ESOPHAGEAL 10.5FR 20MMX6CM FULLY COVERED TAEWOONG NITI-S THROUGH THE SCOPE TTS","SUP-ITM-10238984","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2547.70","36.5","","1257.80","693.44","2424.50","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT ESOPHAGEAL 10.5FR 20MMX6CM FULLY COVERED TAEWOONG NITI-S THROUGH THE SCOPE TTS","SUP-ITM-10238984","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2673.34","38.3","","1950.11","547.40","2346.00","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT ESOPHAGEAL 10.5FR 20MMX6CM FULLY COVERED TAEWOONG NITI-S THROUGH THE SCOPE TTS","SUP-ITM-10238984","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2994.42","42.9","","5096.18","5096.18","5096.18","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT ESOPHAGEAL 10.5FR 20MMX6CM FULLY COVERED TAEWOONG NITI-S THROUGH THE SCOPE TTS","SUP-ITM-10238984","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","WELLPOINT [1015]","HB AMC WELLPOINT","5149.84","73.78","","1172.59","1172.59","4829.94","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT ESOPHAGEAL 10.5FR 20MMX6CM FULLY COVERED TAEWOONG NITI-S THROUGH THE SCOPE TTS","SUP-ITM-10238984","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6980.00","5235.00","AETNA [1001]","HB AMC AETNA HMO","4872.04","69.8","","1806.84","947.80","5091.72","1 through 10","3647.75","5704.06","percent of total billed charges",""
"STENT ESOPHAGEAL 10.5FR 20MMX6CM FULLY COVERED TAEWOONG NITI-S THROUGH THE SCOPE TTS","SUP-ITM-10238984","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6980.00","5235.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5704.06","81.72","","1259.05","615.58","4586.56","1 through 10","3647.75","5704.06","percent of total billed charges",""
"STENT ESOPHAGEAL 20X12CM 180 HANAROSTENT TTS FULLY COVERED","SUP-ITM-10285657","CDM","C1874","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4225.00","65","","6652.80","6652.80","6652.80","1 through 10","2015","5167.5","percent of total billed charges",""
"STENT ESOPHAGEAL 20X12CM 180 HANAROSTENT TTS FULLY COVERED","SUP-ITM-10285657","CDM","C1874","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5167.50","79.5","","2612.61","795.38","2612.61","1 through 10","2015","5167.5","percent of total billed charges",""
"STENT ESOPHAGEAL 20X12CM 180 HANAROSTENT TTS FULLY COVERED","SUP-ITM-10285657","CDM","C1874","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3464.50","53.3","","1101.80","1101.80","1101.80","1 through 10","2015","5167.5","percent of total billed charges",""
"STENT ESOPHAGEAL 20X12CM 180 HANAROSTENT TTS FULLY COVERED","SUP-ITM-10285657","CDM","C1874","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4225.00","65","","1820.00","910.00","1820.00","1 through 10","2015","5167.5","percent of total billed charges",""
"STENT ESOPHAGEAL 20X12CM 180 HANAROSTENT TTS FULLY COVERED","SUP-ITM-10285657","CDM","C1874","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2372.50","36.5","","1257.80","693.44","2424.50","1 through 10","2015","5167.5","percent of total billed charges",""
"STENT ESOPHAGEAL 20X12CM 180 HANAROSTENT TTS FULLY COVERED","SUP-ITM-10285657","CDM","C1874","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2489.50","38.3","","1950.11","547.40","2346.00","1 through 10","2015","5167.5","percent of total billed charges",""
"STENT ESOPHAGEAL 20X12CM 180 HANAROSTENT TTS FULLY COVERED","SUP-ITM-10285657","CDM","C1874","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2788.50","42.9","","5096.18","5096.18","5096.18","1 through 10","2015","5167.5","percent of total billed charges",""
"STENT ESOPHAGEAL 20X12CM 180 HANAROSTENT TTS FULLY COVERED","SUP-ITM-10285657","CDM","C1874","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","WELLPOINT [1015]","HB AMC WELLPOINT","4795.70","73.78","","1172.59","1172.59","4829.94","1 through 10","2015","5167.5","percent of total billed charges",""
"STENT ESOPHAGEAL 20X12CM 180 HANAROSTENT TTS FULLY COVERED","SUP-ITM-10285657","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6500.00","4875.00","AETNA [1001]","HB AMC AETNA HMO","4537.00","69.8","","1806.84","947.80","5091.72","1 through 10","3396.9","5311.8","percent of total billed charges",""
"STENT ESOPHAGEAL 20X12CM 180 HANAROSTENT TTS FULLY COVERED","SUP-ITM-10285657","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6500.00","4875.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5311.80","81.72","","1259.05","615.58","4586.56","1 through 10","3396.9","5311.8","percent of total billed charges",""
"STENT ESOPHAGEAL 80MMX700 18 24 6 HOOK CRSS TECHNOLOGY REDUCED SHORTENING RATE SEGMENTAL COMPRESN RADIOPQ MARK","SUP-ITM-10079653","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3241.88","65","","6652.80","6652.80","6652.80","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ESOPHAGEAL 80MMX700 18 24 6 HOOK CRSS TECHNOLOGY REDUCED SHORTENING RATE SEGMENTAL COMPRESN RADIOPQ MARK","SUP-ITM-10079653","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3965.06","79.5","","2612.61","795.38","2612.61","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ESOPHAGEAL 80MMX700 18 24 6 HOOK CRSS TECHNOLOGY REDUCED SHORTENING RATE SEGMENTAL COMPRESN RADIOPQ MARK","SUP-ITM-10079653","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2658.34","53.3","","1101.80","1101.80","1101.80","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ESOPHAGEAL 80MMX700 18 24 6 HOOK CRSS TECHNOLOGY REDUCED SHORTENING RATE SEGMENTAL COMPRESN RADIOPQ MARK","SUP-ITM-10079653","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3241.88","65","","1820.00","910.00","1820.00","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ESOPHAGEAL 80MMX700 18 24 6 HOOK CRSS TECHNOLOGY REDUCED SHORTENING RATE SEGMENTAL COMPRESN RADIOPQ MARK","SUP-ITM-10079653","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1820.44","36.5","","1257.80","693.44","2424.50","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ESOPHAGEAL 80MMX700 18 24 6 HOOK CRSS TECHNOLOGY REDUCED SHORTENING RATE SEGMENTAL COMPRESN RADIOPQ MARK","SUP-ITM-10079653","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1910.21","38.3","","1950.11","547.40","2346.00","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ESOPHAGEAL 80MMX700 18 24 6 HOOK CRSS TECHNOLOGY REDUCED SHORTENING RATE SEGMENTAL COMPRESN RADIOPQ MARK","SUP-ITM-10079653","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2139.64","42.9","","5096.18","5096.18","5096.18","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ESOPHAGEAL 80MMX700 18 24 6 HOOK CRSS TECHNOLOGY REDUCED SHORTENING RATE SEGMENTAL COMPRESN RADIOPQ MARK","SUP-ITM-10079653","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","WELLPOINT [1015]","HB AMC WELLPOINT","3679.78","73.78","","1172.59","1172.59","4829.94","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ESOPHAGEAL 80MMX700 18 24 6 HOOK CRSS TECHNOLOGY REDUCED SHORTENING RATE SEGMENTAL COMPRESN RADIOPQ MARK","SUP-ITM-10079653","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4987.50","3740.62","AETNA [1001]","HB AMC AETNA HMO","3481.28","69.8","","1806.84","947.80","5091.72","1 through 10","2606.47","4075.79","percent of total billed charges",""
"STENT ESOPHAGEAL 80MMX700 18 24 6 HOOK CRSS TECHNOLOGY REDUCED SHORTENING RATE SEGMENTAL COMPRESN RADIOPQ MARK","SUP-ITM-10079653","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4987.50","3740.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4075.79","81.72","","1259.05","615.58","4586.56","1 through 10","2606.47","4075.79","percent of total billed charges",""
"STENT ESOPHAGEAL L 100X12 XSEC 16FR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10117153","CDM","C1876","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4428.00","65.6","","751.18","751.18","751.18","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ESOPHAGEAL L 100X12 XSEC 16FR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10117153","CDM","C1876","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5366.25","79.5","","4820.38","3211.27","4820.38","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ESOPHAGEAL L 100X12 XSEC 16FR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10117153","CDM","C1876","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2463.75","36.5","","641.00","641.00","641.00","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ESOPHAGEAL L 100X12 XSEC 16FR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10117153","CDM","C1876","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2585.25","38.3","","1098.43","1098.43","1098.43","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ESOPHAGEAL L 100X12 XSEC 16FR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10117153","CDM","C1876","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2895.75","42.9","","4896.33","4896.33","4896.33","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ESOPHAGEAL L 100X12 XSEC 16FR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10117153","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","AETNA [1001]","HB AMC AETNA HMO","4711.50","69.8","","175.60","163.11","1063.91","1 through 10","3527.55","5516.1","percent of total billed charges",""
"STENT ESOPHAGEAL L 100X12 XSEC 16FR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10117153","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5516.10","81.72","","105.94","85.10","105.94","1 through 10","3527.55","5516.1","percent of total billed charges",""
"STENT ESOPHAGEAL L 10CM 7 23MM OD18 XSEC COVERED PROXIMALIMAL RELEASE ULTRAFLEX","SUP-ITM-10012334","CDM","C1874","HCPCS","0278","RC","","","","both","","","5113.95","3835.46","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3324.07","65","","6652.80","6652.80","6652.80","1 through 10","1585.32","4065.59","percent of total billed charges",""
"STENT ESOPHAGEAL L 10CM 7 23MM OD18 XSEC COVERED PROXIMALIMAL RELEASE ULTRAFLEX","SUP-ITM-10012334","CDM","C1874","HCPCS","0278","RC","","","","both","","","5113.95","3835.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4065.59","79.5","","2612.61","795.38","2612.61","1 through 10","1585.32","4065.59","percent of total billed charges",""
"STENT ESOPHAGEAL L 10CM 7 23MM OD18 XSEC COVERED PROXIMALIMAL RELEASE ULTRAFLEX","SUP-ITM-10012334","CDM","C1874","HCPCS","0278","RC","","","","both","","","5113.95","3835.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2725.74","53.3","","1101.80","1101.80","1101.80","1 through 10","1585.32","4065.59","percent of total billed charges",""
"STENT ESOPHAGEAL L 10CM 7 23MM OD18 XSEC COVERED PROXIMALIMAL RELEASE ULTRAFLEX","SUP-ITM-10012334","CDM","C1874","HCPCS","0278","RC","","","","both","","","5113.95","3835.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3324.07","65","","1820.00","910.00","1820.00","1 through 10","1585.32","4065.59","percent of total billed charges",""
"STENT ESOPHAGEAL L 10CM 7 23MM OD18 XSEC COVERED PROXIMALIMAL RELEASE ULTRAFLEX","SUP-ITM-10012334","CDM","C1874","HCPCS","0278","RC","","","","both","","","5113.95","3835.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1866.59","36.5","","1257.80","693.44","2424.50","1 through 10","1585.32","4065.59","percent of total billed charges",""
"STENT ESOPHAGEAL L 10CM 7 23MM OD18 XSEC COVERED PROXIMALIMAL RELEASE ULTRAFLEX","SUP-ITM-10012334","CDM","C1874","HCPCS","0278","RC","","","","both","","","5113.95","3835.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1958.64","38.3","","1950.11","547.40","2346.00","1 through 10","1585.32","4065.59","percent of total billed charges",""
"STENT ESOPHAGEAL L 10CM 7 23MM OD18 XSEC COVERED PROXIMALIMAL RELEASE ULTRAFLEX","SUP-ITM-10012334","CDM","C1874","HCPCS","0278","RC","","","","both","","","5113.95","3835.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2193.88","42.9","","5096.18","5096.18","5096.18","1 through 10","1585.32","4065.59","percent of total billed charges",""
"STENT ESOPHAGEAL L 10CM 7 23MM OD18 XSEC COVERED PROXIMALIMAL RELEASE ULTRAFLEX","SUP-ITM-10012334","CDM","C1874","HCPCS","0278","RC","","","","both","","","5113.95","3835.46","WELLPOINT [1015]","HB AMC WELLPOINT","3773.07","73.78","","1172.59","1172.59","4829.94","1 through 10","1585.32","4065.59","percent of total billed charges",""
"STENT ESOPHAGEAL L 10CM 7 23MM OD18 XSEC COVERED PROXIMALIMAL RELEASE ULTRAFLEX","SUP-ITM-10012334","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5113.95","3835.46","AETNA [1001]","HB AMC AETNA HMO","3569.54","69.8","","1806.84","947.80","5091.72","1 through 10","2672.55","4179.12","percent of total billed charges",""
"STENT ESOPHAGEAL L 10CM 7 23MM OD18 XSEC COVERED PROXIMALIMAL RELEASE ULTRAFLEX","SUP-ITM-10012334","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5113.95","3835.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4179.12","81.72","","1259.05","615.58","4586.56","1 through 10","2672.55","4179.12","percent of total billed charges",""
"STENT ESOPHAGEAL L 120X16 XSECFR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10090034","CDM","C1876","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4428.00","65.6","","751.18","751.18","751.18","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ESOPHAGEAL L 120X16 XSECFR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10090034","CDM","C1876","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5366.25","79.5","","4820.38","3211.27","4820.38","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ESOPHAGEAL L 120X16 XSECFR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10090034","CDM","C1876","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2463.75","36.5","","641.00","641.00","641.00","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ESOPHAGEAL L 120X16 XSECFR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10090034","CDM","C1876","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2585.25","38.3","","1098.43","1098.43","1098.43","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ESOPHAGEAL L 120X16 XSECFR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10090034","CDM","C1876","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2895.75","42.9","","4896.33","4896.33","4896.33","1 through 10","2092.5","5366.25","percent of total billed charges",""
"STENT ESOPHAGEAL L 120X16 XSECFR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10090034","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","AETNA [1001]","HB AMC AETNA HMO","4711.50","69.8","","175.60","163.11","1063.91","1 through 10","3527.55","5516.1","percent of total billed charges",""
"STENT ESOPHAGEAL L 120X16 XSECFR FLLY COVRD PROXIMAL SUT KNOT A MIGRATION STRUT LO PROFL ALIMAXX ES POLYURET SIL","SUP-ITM-10090034","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5516.10","81.72","","105.94","85.10","105.94","1 through 10","3527.55","5516.1","percent of total billed charges",""
"STENT ESOPHAGEAL L 70MM 90CM 19 XSEC 24FR OTW FULLY COVERED LOW PROFILE TAPERED TIP FLEXIBLE PRELOADED DESIGN ENDOMAXX","SUP-ITM-10113425","CDM","C1874","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4550.00","65","","6652.80","6652.80","6652.80","1 through 10","2170","5565","percent of total billed charges",""
"STENT ESOPHAGEAL L 70MM 90CM 19 XSEC 24FR OTW FULLY COVERED LOW PROFILE TAPERED TIP FLEXIBLE PRELOADED DESIGN ENDOMAXX","SUP-ITM-10113425","CDM","C1874","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5565.00","79.5","","2612.61","795.38","2612.61","1 through 10","2170","5565","percent of total billed charges",""
"STENT ESOPHAGEAL L 70MM 90CM 19 XSEC 24FR OTW FULLY COVERED LOW PROFILE TAPERED TIP FLEXIBLE PRELOADED DESIGN ENDOMAXX","SUP-ITM-10113425","CDM","C1874","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3731.00","53.3","","1101.80","1101.80","1101.80","1 through 10","2170","5565","percent of total billed charges",""
"STENT ESOPHAGEAL L 70MM 90CM 19 XSEC 24FR OTW FULLY COVERED LOW PROFILE TAPERED TIP FLEXIBLE PRELOADED DESIGN ENDOMAXX","SUP-ITM-10113425","CDM","C1874","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4550.00","65","","1820.00","910.00","1820.00","1 through 10","2170","5565","percent of total billed charges",""
"STENT ESOPHAGEAL L 70MM 90CM 19 XSEC 24FR OTW FULLY COVERED LOW PROFILE TAPERED TIP FLEXIBLE PRELOADED DESIGN ENDOMAXX","SUP-ITM-10113425","CDM","C1874","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2555.00","36.5","","1257.80","693.44","2424.50","1 through 10","2170","5565","percent of total billed charges",""
"STENT ESOPHAGEAL L 70MM 90CM 19 XSEC 24FR OTW FULLY COVERED LOW PROFILE TAPERED TIP FLEXIBLE PRELOADED DESIGN ENDOMAXX","SUP-ITM-10113425","CDM","C1874","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2681.00","38.3","","1950.11","547.40","2346.00","1 through 10","2170","5565","percent of total billed charges",""
"STENT ESOPHAGEAL L 70MM 90CM 19 XSEC 24FR OTW FULLY COVERED LOW PROFILE TAPERED TIP FLEXIBLE PRELOADED DESIGN ENDOMAXX","SUP-ITM-10113425","CDM","C1874","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3003.00","42.9","","5096.18","5096.18","5096.18","1 through 10","2170","5565","percent of total billed charges",""
"STENT ESOPHAGEAL L 70MM 90CM 19 XSEC 24FR OTW FULLY COVERED LOW PROFILE TAPERED TIP FLEXIBLE PRELOADED DESIGN ENDOMAXX","SUP-ITM-10113425","CDM","C1874","HCPCS","0278","RC","","","","both","","","7000.00","5250.00","WELLPOINT [1015]","HB AMC WELLPOINT","5164.60","73.78","","1172.59","1172.59","4829.94","1 through 10","2170","5565","percent of total billed charges",""
"STENT ESOPHAGEAL L 70MM 90CM 19 XSEC 24FR OTW FULLY COVERED LOW PROFILE TAPERED TIP FLEXIBLE PRELOADED DESIGN ENDOMAXX","SUP-ITM-10113425","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","AETNA [1001]","HB AMC AETNA HMO","4886.00","69.8","","1806.84","947.80","5091.72","1 through 10","3658.2","5720.4","percent of total billed charges",""
"STENT ESOPHAGEAL L 70MM 90CM 19 XSEC 24FR OTW FULLY COVERED LOW PROFILE TAPERED TIP FLEXIBLE PRELOADED DESIGN ENDOMAXX","SUP-ITM-10113425","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7000.00","5250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5720.40","81.72","","1259.05","615.58","4586.56","1 through 10","3658.2","5720.4","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 150MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10019231","CDM","C1876","HCPCS","0278","RC","","","","both","","","1571.50","1178.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1030.90","65.6","","751.18","751.18","751.18","1 through 10","487.17","1249.34","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 150MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10019231","CDM","C1876","HCPCS","0278","RC","","","","both","","","1571.50","1178.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1249.34","79.5","","4820.38","3211.27","4820.38","1 through 10","487.17","1249.34","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 150MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10019231","CDM","C1876","HCPCS","0278","RC","","","","both","","","1571.50","1178.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","573.60","36.5","","641.00","641.00","641.00","1 through 10","487.17","1249.34","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 150MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10019231","CDM","C1876","HCPCS","0278","RC","","","","both","","","1571.50","1178.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","601.88","38.3","","1098.43","1098.43","1098.43","1 through 10","487.17","1249.34","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 150MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10019231","CDM","C1876","HCPCS","0278","RC","","","","both","","","1571.50","1178.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","674.17","42.9","","4896.33","4896.33","4896.33","1 through 10","487.17","1249.34","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 150MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10019231","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1571.50","1178.62","AETNA [1001]","HB AMC AETNA HMO","1096.91","69.8","","175.60","163.11","1063.91","1 through 10","821.27","1284.23","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 150MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10019231","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1571.50","1178.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1284.23","81.72","","105.94","85.10","105.94","1 through 10","821.27","1284.23","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 200MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10101191","CDM","C1876","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3188.16","65.6","","751.18","751.18","751.18","1 through 10","1506.6","3863.7","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 200MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10101191","CDM","C1876","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3863.70","79.5","","4820.38","3211.27","4820.38","1 through 10","1506.6","3863.7","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 200MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10101191","CDM","C1876","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1773.90","36.5","","641.00","641.00","641.00","1 through 10","1506.6","3863.7","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 200MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10101191","CDM","C1876","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1861.38","38.3","","1098.43","1098.43","1098.43","1 through 10","1506.6","3863.7","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 200MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10101191","CDM","C1876","HCPCS","0278","RC","","","","both","","","4860.00","3645.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2084.94","42.9","","4896.33","4896.33","4896.33","1 through 10","1506.6","3863.7","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 200MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10101191","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4860.00","3645.00","AETNA [1001]","HB AMC AETNA HMO","3392.28","69.8","","175.60","163.11","1063.91","1 through 10","2539.84","3971.59","percent of total billed charges",""
"STENT EVERFLEX 6FR 6MM 200MM 120CM .035IN OTW PERIPHERAL SELF-EXPANDING","SUP-ITM-10101191","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4860.00","3645.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3971.59","81.72","","105.94","85.10","105.94","1 through 10","2539.84","3971.59","percent of total billed charges",""
"STENT EXCLUDER 12MM 7CMENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166186","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5003.38","65","","6652.80","6652.80","6652.80","1 through 10","2386.23","6119.51","percent of total billed charges",""
"STENT EXCLUDER 12MM 7CMENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166186","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6119.51","79.5","","2612.61","795.38","2612.61","1 through 10","2386.23","6119.51","percent of total billed charges",""
"STENT EXCLUDER 12MM 7CMENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166186","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4102.77","53.3","","1101.80","1101.80","1101.80","1 through 10","2386.23","6119.51","percent of total billed charges",""
"STENT EXCLUDER 12MM 7CMENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166186","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5003.38","65","","1820.00","910.00","1820.00","1 through 10","2386.23","6119.51","percent of total billed charges",""
"STENT EXCLUDER 12MM 7CMENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166186","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2809.59","36.5","","1257.80","693.44","2424.50","1 through 10","2386.23","6119.51","percent of total billed charges",""
"STENT EXCLUDER 12MM 7CMENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166186","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2948.14","38.3","","1950.11","547.40","2346.00","1 through 10","2386.23","6119.51","percent of total billed charges",""
"STENT EXCLUDER 12MM 7CMENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166186","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3302.23","42.9","","5096.18","5096.18","5096.18","1 through 10","2386.23","6119.51","percent of total billed charges",""
"STENT EXCLUDER 12MM 7CMENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166186","CDM","C1874","HCPCS","0278","RC","","","","both","","","7697.50","5773.12","WELLPOINT [1015]","HB AMC WELLPOINT","5679.22","73.78","","1172.59","1172.59","4829.94","1 through 10","2386.23","6119.51","percent of total billed charges",""
"STENT EXCLUDER 12MM 7CMENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166186","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7697.50","5773.12","AETNA [1001]","HB AMC AETNA HMO","5372.86","69.8","","1806.84","947.80","5091.72","1 through 10","4022.71","6290.4","percent of total billed charges",""
"STENT EXCLUDER 12MM 7CMENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166186","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7697.50","5773.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6290.40","81.72","","1259.05","615.58","4586.56","1 through 10","4022.71","6290.4","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","17407.00","65","","6652.80","6652.80","6652.80","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21290.10","79.5","","2612.61","795.38","2612.61","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14273.74","53.3","","1101.80","1101.80","1101.80","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","17407.00","65","","1820.00","910.00","1820.00","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9774.70","36.5","","1257.80","693.44","2424.50","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10256.74","38.3","","1950.11","547.40","2346.00","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11488.62","42.9","","5096.18","5096.18","5096.18","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","WELLPOINT [1015]","HB AMC WELLPOINT","19758.28","73.78","","1172.59","1172.59","4829.94","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","26780.00","20085.00","AETNA [1001]","HB AMC AETNA HMO","18692.44","69.8","","1806.84","947.80","5091.72","1 through 10","13995.23","21884.62","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","26780.00","20085.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21884.62","81.72","","1259.05","615.58","4586.56","1 through 10","13995.23","21884.62","percent of total billed charges",""
"STENT EXPRESS LD ILIAC 6IN 7MM 17MM 135CM OTW BILIARY CATHETER PREMOUNTED SYSTEM","SUP-ITM-10022972","CDM","C1876","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1607.20","65.6","","751.18","751.18","751.18","1 through 10","759.5","1947.75","percent of total billed charges",""
"STENT EXPRESS LD ILIAC 6IN 7MM 17MM 135CM OTW BILIARY CATHETER PREMOUNTED SYSTEM","SUP-ITM-10022972","CDM","C1876","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1947.75","79.5","","4820.38","3211.27","4820.38","1 through 10","759.5","1947.75","percent of total billed charges",""
"STENT EXPRESS LD ILIAC 6IN 7MM 17MM 135CM OTW BILIARY CATHETER PREMOUNTED SYSTEM","SUP-ITM-10022972","CDM","C1876","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","894.25","36.5","","641.00","641.00","641.00","1 through 10","759.5","1947.75","percent of total billed charges",""
"STENT EXPRESS LD ILIAC 6IN 7MM 17MM 135CM OTW BILIARY CATHETER PREMOUNTED SYSTEM","SUP-ITM-10022972","CDM","C1876","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","938.35","38.3","","1098.43","1098.43","1098.43","1 through 10","759.5","1947.75","percent of total billed charges",""
"STENT EXPRESS LD ILIAC 6IN 7MM 17MM 135CM OTW BILIARY CATHETER PREMOUNTED SYSTEM","SUP-ITM-10022972","CDM","C1876","HCPCS","0278","RC","","","","both","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1051.05","42.9","","4896.33","4896.33","4896.33","1 through 10","759.5","1947.75","percent of total billed charges",""
"STENT EXPRESS LD ILIAC 6IN 7MM 17MM 135CM OTW BILIARY CATHETER PREMOUNTED SYSTEM","SUP-ITM-10022972","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","AETNA [1001]","HB AMC AETNA HMO","1710.10","69.8","","175.60","163.11","1063.91","1 through 10","1280.37","2002.14","percent of total billed charges",""
"STENT EXPRESS LD ILIAC 6IN 7MM 17MM 135CM OTW BILIARY CATHETER PREMOUNTED SYSTEM","SUP-ITM-10022972","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2450.00","1837.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2002.14","81.72","","105.94","85.10","105.94","1 through 10","1280.37","2002.14","percent of total billed charges",""
"STENT GASTROINTESTINAL 6X8MM AXIOS ELECTROCAUTERY","SUP-ITM-10286233","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8360.38","65","","6652.80","6652.80","6652.80","1 through 10","3987.26","10225.39","percent of total billed charges",""
"STENT GASTROINTESTINAL 6X8MM AXIOS ELECTROCAUTERY","SUP-ITM-10286233","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10225.39","79.5","","2612.61","795.38","2612.61","1 through 10","3987.26","10225.39","percent of total billed charges",""
"STENT GASTROINTESTINAL 6X8MM AXIOS ELECTROCAUTERY","SUP-ITM-10286233","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6855.52","53.3","","1101.80","1101.80","1101.80","1 through 10","3987.26","10225.39","percent of total billed charges",""
"STENT GASTROINTESTINAL 6X8MM AXIOS ELECTROCAUTERY","SUP-ITM-10286233","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8360.38","65","","1820.00","910.00","1820.00","1 through 10","3987.26","10225.39","percent of total billed charges",""
"STENT GASTROINTESTINAL 6X8MM AXIOS ELECTROCAUTERY","SUP-ITM-10286233","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4694.68","36.5","","1257.80","693.44","2424.50","1 through 10","3987.26","10225.39","percent of total billed charges",""
"STENT GASTROINTESTINAL 6X8MM AXIOS ELECTROCAUTERY","SUP-ITM-10286233","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4926.20","38.3","","1950.11","547.40","2346.00","1 through 10","3987.26","10225.39","percent of total billed charges",""
"STENT GASTROINTESTINAL 6X8MM AXIOS ELECTROCAUTERY","SUP-ITM-10286233","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5517.85","42.9","","5096.18","5096.18","5096.18","1 through 10","3987.26","10225.39","percent of total billed charges",""
"STENT GASTROINTESTINAL 6X8MM AXIOS ELECTROCAUTERY","SUP-ITM-10286233","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","WELLPOINT [1015]","HB AMC WELLPOINT","9489.68","73.78","","1172.59","1172.59","4829.94","1 through 10","3987.26","10225.39","percent of total billed charges",""
"STENT GASTROINTESTINAL 6X8MM AXIOS ELECTROCAUTERY","SUP-ITM-10286233","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12862.13","9646.60","AETNA [1001]","HB AMC AETNA HMO","8977.77","69.8","","1806.84","947.80","5091.72","1 through 10","6721.75","10510.93","percent of total billed charges",""
"STENT GASTROINTESTINAL 6X8MM AXIOS ELECTROCAUTERY","SUP-ITM-10286233","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12862.13","9646.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10510.93","81.72","","1259.05","615.58","4586.56","1 through 10","6721.75","10510.93","percent of total billed charges",""
"STENT GRAFT 106X28 12MM ENDOVASCULAR BIFURCATED FENESTRATED IPSILATERAL DISTAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101357","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6859.13","65","","6652.80","6652.80","6652.80","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 106X28 12MM ENDOVASCULAR BIFURCATED FENESTRATED IPSILATERAL DISTAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101357","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8389.24","79.5","","2612.61","795.38","2612.61","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 106X28 12MM ENDOVASCULAR BIFURCATED FENESTRATED IPSILATERAL DISTAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101357","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5624.48","53.3","","1101.80","1101.80","1101.80","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 106X28 12MM ENDOVASCULAR BIFURCATED FENESTRATED IPSILATERAL DISTAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101357","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6859.13","65","","1820.00","910.00","1820.00","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 106X28 12MM ENDOVASCULAR BIFURCATED FENESTRATED IPSILATERAL DISTAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101357","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3851.66","36.5","","1257.80","693.44","2424.50","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 106X28 12MM ENDOVASCULAR BIFURCATED FENESTRATED IPSILATERAL DISTAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101357","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4041.61","38.3","","1950.11","547.40","2346.00","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 106X28 12MM ENDOVASCULAR BIFURCATED FENESTRATED IPSILATERAL DISTAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101357","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4527.02","42.9","","5096.18","5096.18","5096.18","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 106X28 12MM ENDOVASCULAR BIFURCATED FENESTRATED IPSILATERAL DISTAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101357","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","WELLPOINT [1015]","HB AMC WELLPOINT","7785.63","73.78","","1172.59","1172.59","4829.94","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 106X28 12MM ENDOVASCULAR BIFURCATED FENESTRATED IPSILATERAL DISTAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101357","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10552.50","7914.37","AETNA [1001]","HB AMC AETNA HMO","7365.65","69.8","","1806.84","947.80","5091.72","1 through 10","5514.74","8623.5","percent of total billed charges",""
"STENT GRAFT 106X28 12MM ENDOVASCULAR BIFURCATED FENESTRATED IPSILATERAL DISTAL ZENITH IMPLANTABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10101357","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10552.50","7914.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8623.50","81.72","","1259.05","615.58","4586.56","1 through 10","5514.74","8623.5","percent of total billed charges",""
"STENT GRAFT 14FR 10X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED ILIAC","SUP-ITM-10117145","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7858.50","65","","6652.80","6652.80","6652.80","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 10X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED ILIAC","SUP-ITM-10117145","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9611.55","79.5","","2612.61","795.38","2612.61","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 10X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED ILIAC","SUP-ITM-10117145","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6443.97","53.3","","1101.80","1101.80","1101.80","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 10X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED ILIAC","SUP-ITM-10117145","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7858.50","65","","1820.00","910.00","1820.00","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 10X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED ILIAC","SUP-ITM-10117145","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4412.85","36.5","","1257.80","693.44","2424.50","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 10X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED ILIAC","SUP-ITM-10117145","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4630.47","38.3","","1950.11","547.40","2346.00","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 10X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED ILIAC","SUP-ITM-10117145","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5186.61","42.9","","5096.18","5096.18","5096.18","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 10X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED ILIAC","SUP-ITM-10117145","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","WELLPOINT [1015]","HB AMC WELLPOINT","8920.00","73.78","","1172.59","1172.59","4829.94","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 10X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED ILIAC","SUP-ITM-10117145","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12090.00","9067.50","AETNA [1001]","HB AMC AETNA HMO","8438.82","69.8","","1806.84","947.80","5091.72","1 through 10","6318.23","9879.95","percent of total billed charges",""
"STENT GRAFT 14FR 10X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED ILIAC","SUP-ITM-10117145","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12090.00","9067.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9879.95","81.72","","1259.05","615.58","4586.56","1 through 10","6318.23","9879.95","percent of total billed charges",""
"STENT GRAFT 14FR 11X56MM ENDOVASCULAR ZENITH SPIRAL Z AAA SS POLYESTER LEG","SUP-ITM-10094505","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6175.81","65","","6652.80","6652.80","6652.80","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRAFT 14FR 11X56MM ENDOVASCULAR ZENITH SPIRAL Z AAA SS POLYESTER LEG","SUP-ITM-10094505","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7553.49","79.5","","2612.61","795.38","2612.61","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRAFT 14FR 11X56MM ENDOVASCULAR ZENITH SPIRAL Z AAA SS POLYESTER LEG","SUP-ITM-10094505","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5064.17","53.3","","1101.80","1101.80","1101.80","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRAFT 14FR 11X56MM ENDOVASCULAR ZENITH SPIRAL Z AAA SS POLYESTER LEG","SUP-ITM-10094505","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6175.81","65","","1820.00","910.00","1820.00","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRAFT 14FR 11X56MM ENDOVASCULAR ZENITH SPIRAL Z AAA SS POLYESTER LEG","SUP-ITM-10094505","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3467.96","36.5","","1257.80","693.44","2424.50","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRAFT 14FR 11X56MM ENDOVASCULAR ZENITH SPIRAL Z AAA SS POLYESTER LEG","SUP-ITM-10094505","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3638.98","38.3","","1950.11","547.40","2346.00","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRAFT 14FR 11X56MM ENDOVASCULAR ZENITH SPIRAL Z AAA SS POLYESTER LEG","SUP-ITM-10094505","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4076.04","42.9","","5096.18","5096.18","5096.18","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRAFT 14FR 11X56MM ENDOVASCULAR ZENITH SPIRAL Z AAA SS POLYESTER LEG","SUP-ITM-10094505","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","WELLPOINT [1015]","HB AMC WELLPOINT","7010.02","73.78","","1172.59","1172.59","4829.94","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRAFT 14FR 11X56MM ENDOVASCULAR ZENITH SPIRAL Z AAA SS POLYESTER LEG","SUP-ITM-10094505","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9501.25","7125.94","AETNA [1001]","HB AMC AETNA HMO","6631.87","69.8","","1806.84","947.80","5091.72","1 through 10","4965.35","7764.42","percent of total billed charges",""
"STENT GRAFT 14FR 11X56MM ENDOVASCULAR ZENITH SPIRAL Z AAA SS POLYESTER LEG","SUP-ITM-10094505","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9501.25","7125.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7764.42","81.72","","1259.05","615.58","4586.56","1 through 10","4965.35","7764.42","percent of total billed charges",""
"STENT GRAFT 14FR 13X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101019","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7858.50","65","","6652.80","6652.80","6652.80","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 13X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101019","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9611.55","79.5","","2612.61","795.38","2612.61","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 13X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101019","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6443.97","53.3","","1101.80","1101.80","1101.80","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 13X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101019","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7858.50","65","","1820.00","910.00","1820.00","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 13X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101019","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4412.85","36.5","","1257.80","693.44","2424.50","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 13X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101019","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4630.47","38.3","","1950.11","547.40","2346.00","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 13X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101019","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5186.61","42.9","","5096.18","5096.18","5096.18","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 13X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101019","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","WELLPOINT [1015]","HB AMC WELLPOINT","8920.00","73.78","","1172.59","1172.59","4829.94","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 14FR 13X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101019","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12090.00","9067.50","AETNA [1001]","HB AMC AETNA HMO","8438.82","69.8","","1806.84","947.80","5091.72","1 through 10","6318.23","9879.95","percent of total billed charges",""
"STENT GRAFT 14FR 13X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101019","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12090.00","9067.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9879.95","81.72","","1259.05","615.58","4586.56","1 through 10","6318.23","9879.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 199MM AORTIC ENDURANT II CONTRALATERAL ILIAC LIMB","SUP-ITM-10113770","CDM","C1874","HCPCS","0278","RC","","","","both","","","16887.50","12665.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","10976.88","65","","6652.80","6652.80","6652.80","1 through 10","5235.13","13425.56","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 199MM AORTIC ENDURANT II CONTRALATERAL ILIAC LIMB","SUP-ITM-10113770","CDM","C1874","HCPCS","0278","RC","","","","both","","","16887.50","12665.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13425.56","79.5","","2612.61","795.38","2612.61","1 through 10","5235.13","13425.56","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 199MM AORTIC ENDURANT II CONTRALATERAL ILIAC LIMB","SUP-ITM-10113770","CDM","C1874","HCPCS","0278","RC","","","","both","","","16887.50","12665.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9001.04","53.3","","1101.80","1101.80","1101.80","1 through 10","5235.13","13425.56","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 199MM AORTIC ENDURANT II CONTRALATERAL ILIAC LIMB","SUP-ITM-10113770","CDM","C1874","HCPCS","0278","RC","","","","both","","","16887.50","12665.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","10976.88","65","","1820.00","910.00","1820.00","1 through 10","5235.13","13425.56","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 199MM AORTIC ENDURANT II CONTRALATERAL ILIAC LIMB","SUP-ITM-10113770","CDM","C1874","HCPCS","0278","RC","","","","both","","","16887.50","12665.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6163.94","36.5","","1257.80","693.44","2424.50","1 through 10","5235.13","13425.56","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 199MM AORTIC ENDURANT II CONTRALATERAL ILIAC LIMB","SUP-ITM-10113770","CDM","C1874","HCPCS","0278","RC","","","","both","","","16887.50","12665.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6467.91","38.3","","1950.11","547.40","2346.00","1 through 10","5235.13","13425.56","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 199MM AORTIC ENDURANT II CONTRALATERAL ILIAC LIMB","SUP-ITM-10113770","CDM","C1874","HCPCS","0278","RC","","","","both","","","16887.50","12665.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7244.74","42.9","","5096.18","5096.18","5096.18","1 through 10","5235.13","13425.56","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 199MM AORTIC ENDURANT II CONTRALATERAL ILIAC LIMB","SUP-ITM-10113770","CDM","C1874","HCPCS","0278","RC","","","","both","","","16887.50","12665.62","WELLPOINT [1015]","HB AMC WELLPOINT","12459.60","73.78","","1172.59","1172.59","4829.94","1 through 10","5235.13","13425.56","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 199MM AORTIC ENDURANT II CONTRALATERAL ILIAC LIMB","SUP-ITM-10113770","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16887.50","12665.62","AETNA [1001]","HB AMC AETNA HMO","11787.48","69.8","","1806.84","947.80","5091.72","1 through 10","8825.41","13800.47","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 199MM AORTIC ENDURANT II CONTRALATERAL ILIAC LIMB","SUP-ITM-10113770","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16887.50","12665.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13800.47","81.72","","1259.05","615.58","4586.56","1 through 10","8825.41","13800.47","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100991","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8196.50","65","","6652.80","6652.80","6652.80","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100991","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10024.95","79.5","","2612.61","795.38","2612.61","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100991","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6721.13","53.3","","1101.80","1101.80","1101.80","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100991","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8196.50","65","","1820.00","910.00","1820.00","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100991","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4602.65","36.5","","1257.80","693.44","2424.50","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100991","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4829.63","38.3","","1950.11","547.40","2346.00","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100991","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5409.69","42.9","","5096.18","5096.18","5096.18","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100991","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","WELLPOINT [1015]","HB AMC WELLPOINT","9303.66","73.78","","1172.59","1172.59","4829.94","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100991","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12610.00","9457.50","AETNA [1001]","HB AMC AETNA HMO","8801.78","69.8","","1806.84","947.80","5091.72","1 through 10","6589.99","10304.89","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100991","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12610.00","9457.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10304.89","81.72","","1259.05","615.58","4586.56","1 through 10","6589.99","10304.89","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10114156","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8323.25","65","","6652.80","6652.80","6652.80","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10114156","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10179.98","79.5","","2612.61","795.38","2612.61","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10114156","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6825.07","53.3","","1101.80","1101.80","1101.80","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10114156","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8323.25","65","","1820.00","910.00","1820.00","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10114156","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4673.83","36.5","","1257.80","693.44","2424.50","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10114156","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4904.32","38.3","","1950.11","547.40","2346.00","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10114156","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5493.35","42.9","","5096.18","5096.18","5096.18","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10114156","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","WELLPOINT [1015]","HB AMC WELLPOINT","9447.53","73.78","","1172.59","1172.59","4829.94","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10114156","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12805.00","9603.75","AETNA [1001]","HB AMC AETNA HMO","8937.89","69.8","","1806.84","947.80","5091.72","1 through 10","6691.89","10464.25","percent of total billed charges",""
"STENT GRAFT 14FR 16X10 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10114156","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12805.00","9603.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10464.25","81.72","","1259.05","615.58","4586.56","1 through 10","6691.89","10464.25","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8196.50","65","","6652.80","6652.80","6652.80","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10024.95","79.5","","2612.61","795.38","2612.61","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6721.13","53.3","","1101.80","1101.80","1101.80","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8196.50","65","","1820.00","910.00","1820.00","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4602.65","36.5","","1257.80","693.44","2424.50","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4829.63","38.3","","1950.11","547.40","2346.00","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5409.69","42.9","","5096.18","5096.18","5096.18","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","both","","","12610.00","9457.50","WELLPOINT [1015]","HB AMC WELLPOINT","9303.66","73.78","","1172.59","1172.59","4829.94","1 through 10","3909.1","10024.95","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12610.00","9457.50","AETNA [1001]","HB AMC AETNA HMO","8801.78","69.8","","1806.84","947.80","5091.72","1 through 10","6589.99","10304.89","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12610.00","9457.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10304.89","81.72","","1259.05","615.58","4586.56","1 through 10","6589.99","10304.89","percent of total billed charges",""
"STENT GRAFT 14FR 23X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7055.75","65","","6652.80","6652.80","6652.80","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 23X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8629.73","79.5","","2612.61","795.38","2612.61","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 23X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5785.72","53.3","","1101.80","1101.80","1101.80","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 23X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7055.75","65","","1820.00","910.00","1820.00","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 23X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3962.08","36.5","","1257.80","693.44","2424.50","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 23X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4157.47","38.3","","1950.11","547.40","2346.00","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 23X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4656.80","42.9","","5096.18","5096.18","5096.18","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 23X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100998","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","WELLPOINT [1015]","HB AMC WELLPOINT","8008.82","73.78","","1172.59","1172.59","4829.94","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 23X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100998","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10855.00","8141.25","AETNA [1001]","HB AMC AETNA HMO","7576.79","69.8","","1806.84","947.80","5091.72","1 through 10","5672.82","8870.71","percent of total billed charges",""
"STENT GRAFT 14FR 23X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100998","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10855.00","8141.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8870.71","81.72","","1259.05","615.58","4586.56","1 through 10","5672.82","8870.71","percent of total billed charges",""
"STENT GRAFT 14FR 25X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100999","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7055.75","65","","6652.80","6652.80","6652.80","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 25X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100999","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8629.73","79.5","","2612.61","795.38","2612.61","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 25X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100999","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5785.72","53.3","","1101.80","1101.80","1101.80","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 25X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100999","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7055.75","65","","1820.00","910.00","1820.00","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 25X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100999","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3962.08","36.5","","1257.80","693.44","2424.50","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 25X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100999","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4157.47","38.3","","1950.11","547.40","2346.00","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 25X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100999","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4656.80","42.9","","5096.18","5096.18","5096.18","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 25X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100999","CDM","C1874","HCPCS","0278","RC","","","","both","","","10855.00","8141.25","WELLPOINT [1015]","HB AMC WELLPOINT","8008.82","73.78","","1172.59","1172.59","4829.94","1 through 10","3365.05","8629.73","percent of total billed charges",""
"STENT GRAFT 14FR 25X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100999","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10855.00","8141.25","AETNA [1001]","HB AMC AETNA HMO","7576.79","69.8","","1806.84","947.80","5091.72","1 through 10","5672.82","8870.71","percent of total billed charges",""
"STENT GRAFT 14FR 25X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100999","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10855.00","8141.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8870.71","81.72","","1259.05","615.58","4586.56","1 through 10","5672.82","8870.71","percent of total billed charges",""
"STENT GRAFT 14FR 28X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101000","CDM","C1874","HCPCS","0278","RC","","","","both","","","11115.00","8336.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7224.75","65","","6652.80","6652.80","6652.80","1 through 10","3445.65","8836.43","percent of total billed charges",""
"STENT GRAFT 14FR 28X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101000","CDM","C1874","HCPCS","0278","RC","","","","both","","","11115.00","8336.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8836.43","79.5","","2612.61","795.38","2612.61","1 through 10","3445.65","8836.43","percent of total billed charges",""
"STENT GRAFT 14FR 28X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101000","CDM","C1874","HCPCS","0278","RC","","","","both","","","11115.00","8336.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5924.30","53.3","","1101.80","1101.80","1101.80","1 through 10","3445.65","8836.43","percent of total billed charges",""
"STENT GRAFT 14FR 28X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101000","CDM","C1874","HCPCS","0278","RC","","","","both","","","11115.00","8336.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7224.75","65","","1820.00","910.00","1820.00","1 through 10","3445.65","8836.43","percent of total billed charges",""
"STENT GRAFT 14FR 28X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101000","CDM","C1874","HCPCS","0278","RC","","","","both","","","11115.00","8336.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4056.98","36.5","","1257.80","693.44","2424.50","1 through 10","3445.65","8836.43","percent of total billed charges",""
"STENT GRAFT 14FR 28X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101000","CDM","C1874","HCPCS","0278","RC","","","","both","","","11115.00","8336.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4257.05","38.3","","1950.11","547.40","2346.00","1 through 10","3445.65","8836.43","percent of total billed charges",""
"STENT GRAFT 14FR 28X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101000","CDM","C1874","HCPCS","0278","RC","","","","both","","","11115.00","8336.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4768.34","42.9","","5096.18","5096.18","5096.18","1 through 10","3445.65","8836.43","percent of total billed charges",""
"STENT GRAFT 14FR 28X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101000","CDM","C1874","HCPCS","0278","RC","","","","both","","","11115.00","8336.25","WELLPOINT [1015]","HB AMC WELLPOINT","8200.65","73.78","","1172.59","1172.59","4829.94","1 through 10","3445.65","8836.43","percent of total billed charges",""
"STENT GRAFT 14FR 28X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101000","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11115.00","8336.25","AETNA [1001]","HB AMC AETNA HMO","7758.27","69.8","","1806.84","947.80","5091.72","1 through 10","5808.7","9083.18","percent of total billed charges",""
"STENT GRAFT 14FR 28X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101000","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11115.00","8336.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9083.18","81.72","","1259.05","615.58","4586.56","1 through 10","5808.7","9083.18","percent of total billed charges",""
"STENT GRAFT 14FR 32X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101001","CDM","C1874","HCPCS","0278","RC","","","","both","","","11895.00","8921.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7731.75","65","","6652.80","6652.80","6652.80","1 through 10","3687.45","9456.53","percent of total billed charges",""
"STENT GRAFT 14FR 32X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101001","CDM","C1874","HCPCS","0278","RC","","","","both","","","11895.00","8921.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9456.53","79.5","","2612.61","795.38","2612.61","1 through 10","3687.45","9456.53","percent of total billed charges",""
"STENT GRAFT 14FR 32X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101001","CDM","C1874","HCPCS","0278","RC","","","","both","","","11895.00","8921.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6340.04","53.3","","1101.80","1101.80","1101.80","1 through 10","3687.45","9456.53","percent of total billed charges",""
"STENT GRAFT 14FR 32X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101001","CDM","C1874","HCPCS","0278","RC","","","","both","","","11895.00","8921.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7731.75","65","","1820.00","910.00","1820.00","1 through 10","3687.45","9456.53","percent of total billed charges",""
"STENT GRAFT 14FR 32X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101001","CDM","C1874","HCPCS","0278","RC","","","","both","","","11895.00","8921.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4341.68","36.5","","1257.80","693.44","2424.50","1 through 10","3687.45","9456.53","percent of total billed charges",""
"STENT GRAFT 14FR 32X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101001","CDM","C1874","HCPCS","0278","RC","","","","both","","","11895.00","8921.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4555.79","38.3","","1950.11","547.40","2346.00","1 through 10","3687.45","9456.53","percent of total billed charges",""
"STENT GRAFT 14FR 32X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101001","CDM","C1874","HCPCS","0278","RC","","","","both","","","11895.00","8921.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5102.96","42.9","","5096.18","5096.18","5096.18","1 through 10","3687.45","9456.53","percent of total billed charges",""
"STENT GRAFT 14FR 32X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101001","CDM","C1874","HCPCS","0278","RC","","","","both","","","11895.00","8921.25","WELLPOINT [1015]","HB AMC WELLPOINT","8776.13","73.78","","1172.59","1172.59","4829.94","1 through 10","3687.45","9456.53","percent of total billed charges",""
"STENT GRAFT 14FR 32X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101001","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11895.00","8921.25","AETNA [1001]","HB AMC AETNA HMO","8302.71","69.8","","1806.84","947.80","5091.72","1 through 10","6216.33","9720.59","percent of total billed charges",""
"STENT GRAFT 14FR 32X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101001","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11895.00","8921.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9720.59","81.72","","1259.05","615.58","4586.56","1 through 10","6216.33","9720.59","percent of total billed charges",""
"STENT GRAFT 16 XMM 14FR 82 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100993","CDM","C1874","HCPCS","0278","RC","","","","both","","","11635.00","8726.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7562.75","65","","6652.80","6652.80","6652.80","1 through 10","3606.85","9249.83","percent of total billed charges",""
"STENT GRAFT 16 XMM 14FR 82 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100993","CDM","C1874","HCPCS","0278","RC","","","","both","","","11635.00","8726.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9249.83","79.5","","2612.61","795.38","2612.61","1 through 10","3606.85","9249.83","percent of total billed charges",""
"STENT GRAFT 16 XMM 14FR 82 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100993","CDM","C1874","HCPCS","0278","RC","","","","both","","","11635.00","8726.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6201.46","53.3","","1101.80","1101.80","1101.80","1 through 10","3606.85","9249.83","percent of total billed charges",""
"STENT GRAFT 16 XMM 14FR 82 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100993","CDM","C1874","HCPCS","0278","RC","","","","both","","","11635.00","8726.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7562.75","65","","1820.00","910.00","1820.00","1 through 10","3606.85","9249.83","percent of total billed charges",""
"STENT GRAFT 16 XMM 14FR 82 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100993","CDM","C1874","HCPCS","0278","RC","","","","both","","","11635.00","8726.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4246.78","36.5","","1257.80","693.44","2424.50","1 through 10","3606.85","9249.83","percent of total billed charges",""
"STENT GRAFT 16 XMM 14FR 82 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100993","CDM","C1874","HCPCS","0278","RC","","","","both","","","11635.00","8726.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4456.21","38.3","","1950.11","547.40","2346.00","1 through 10","3606.85","9249.83","percent of total billed charges",""
"STENT GRAFT 16 XMM 14FR 82 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100993","CDM","C1874","HCPCS","0278","RC","","","","both","","","11635.00","8726.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4991.42","42.9","","5096.18","5096.18","5096.18","1 through 10","3606.85","9249.83","percent of total billed charges",""
"STENT GRAFT 16 XMM 14FR 82 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100993","CDM","C1874","HCPCS","0278","RC","","","","both","","","11635.00","8726.25","WELLPOINT [1015]","HB AMC WELLPOINT","8584.30","73.78","","1172.59","1172.59","4829.94","1 through 10","3606.85","9249.83","percent of total billed charges",""
"STENT GRAFT 16 XMM 14FR 82 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100993","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11635.00","8726.25","AETNA [1001]","HB AMC AETNA HMO","8121.23","69.8","","1806.84","947.80","5091.72","1 through 10","6080.45","9508.12","percent of total billed charges",""
"STENT GRAFT 16 XMM 14FR 82 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100993","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11635.00","8726.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9508.12","81.72","","1259.05","615.58","4586.56","1 through 10","6080.45","9508.12","percent of total billed charges",""
"STENT GRAFT 16 XMMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100994","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8323.25","65","","6652.80","6652.80","6652.80","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16 XMMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100994","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10179.98","79.5","","2612.61","795.38","2612.61","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16 XMMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100994","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6825.07","53.3","","1101.80","1101.80","1101.80","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16 XMMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100994","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8323.25","65","","1820.00","910.00","1820.00","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16 XMMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100994","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4673.83","36.5","","1257.80","693.44","2424.50","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16 XMMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100994","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4904.32","38.3","","1950.11","547.40","2346.00","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16 XMMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100994","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5493.35","42.9","","5096.18","5096.18","5096.18","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16 XMMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100994","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","WELLPOINT [1015]","HB AMC WELLPOINT","9447.53","73.78","","1172.59","1172.59","4829.94","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16 XMMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100994","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12805.00","9603.75","AETNA [1001]","HB AMC AETNA HMO","8937.89","69.8","","1806.84","947.80","5091.72","1 through 10","6691.89","10464.25","percent of total billed charges",""
"STENT GRAFT 16 XMMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100994","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12805.00","9603.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10464.25","81.72","","1259.05","615.58","4586.56","1 through 10","6691.89","10464.25","percent of total billed charges",""
"STENT GRAFT 16FRX13 156MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10104829","CDM","C1874","HCPCS","0278","RC","","","","both","","","16640.00","12480.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","10816.00","65","","6652.80","6652.80","6652.80","1 through 10","5158.4","13228.8","percent of total billed charges",""
"STENT GRAFT 16FRX13 156MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10104829","CDM","C1874","HCPCS","0278","RC","","","","both","","","16640.00","12480.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13228.80","79.5","","2612.61","795.38","2612.61","1 through 10","5158.4","13228.8","percent of total billed charges",""
"STENT GRAFT 16FRX13 156MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10104829","CDM","C1874","HCPCS","0278","RC","","","","both","","","16640.00","12480.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8869.12","53.3","","1101.80","1101.80","1101.80","1 through 10","5158.4","13228.8","percent of total billed charges",""
"STENT GRAFT 16FRX13 156MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10104829","CDM","C1874","HCPCS","0278","RC","","","","both","","","16640.00","12480.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","10816.00","65","","1820.00","910.00","1820.00","1 through 10","5158.4","13228.8","percent of total billed charges",""
"STENT GRAFT 16FRX13 156MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10104829","CDM","C1874","HCPCS","0278","RC","","","","both","","","16640.00","12480.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6073.60","36.5","","1257.80","693.44","2424.50","1 through 10","5158.4","13228.8","percent of total billed charges",""
"STENT GRAFT 16FRX13 156MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10104829","CDM","C1874","HCPCS","0278","RC","","","","both","","","16640.00","12480.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6373.12","38.3","","1950.11","547.40","2346.00","1 through 10","5158.4","13228.8","percent of total billed charges",""
"STENT GRAFT 16FRX13 156MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10104829","CDM","C1874","HCPCS","0278","RC","","","","both","","","16640.00","12480.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7138.56","42.9","","5096.18","5096.18","5096.18","1 through 10","5158.4","13228.8","percent of total billed charges",""
"STENT GRAFT 16FRX13 156MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10104829","CDM","C1874","HCPCS","0278","RC","","","","both","","","16640.00","12480.00","WELLPOINT [1015]","HB AMC WELLPOINT","12276.99","73.78","","1172.59","1172.59","4829.94","1 through 10","5158.4","13228.8","percent of total billed charges",""
"STENT GRAFT 16FRX13 156MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10104829","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16640.00","12480.00","AETNA [1001]","HB AMC AETNA HMO","11614.72","69.8","","1806.84","947.80","5091.72","1 through 10","8696.06","13598.21","percent of total billed charges",""
"STENT GRAFT 16FRX13 156MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10104829","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16640.00","12480.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13598.21","81.72","","1259.05","615.58","4586.56","1 through 10","8696.06","13598.21","percent of total billed charges",""
"STENT GRAFT 16FRX24 124MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100996","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8407.75","65","","6652.80","6652.80","6652.80","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16FRX24 124MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100996","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10283.33","79.5","","2612.61","795.38","2612.61","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16FRX24 124MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100996","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6894.36","53.3","","1101.80","1101.80","1101.80","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16FRX24 124MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100996","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8407.75","65","","1820.00","910.00","1820.00","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16FRX24 124MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100996","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4721.28","36.5","","1257.80","693.44","2424.50","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16FRX24 124MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100996","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4954.11","38.3","","1950.11","547.40","2346.00","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16FRX24 124MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100996","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5549.12","42.9","","5096.18","5096.18","5096.18","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16FRX24 124MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100996","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","WELLPOINT [1015]","HB AMC WELLPOINT","9543.44","73.78","","1172.59","1172.59","4829.94","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16FRX24 124MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100996","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12935.00","9701.25","AETNA [1001]","HB AMC AETNA HMO","9028.63","69.8","","1806.84","947.80","5091.72","1 through 10","6759.83","10570.48","percent of total billed charges",""
"STENT GRAFT 16FRX24 124MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100996","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12935.00","9701.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10570.48","81.72","","1259.05","615.58","4586.56","1 through 10","6759.83","10570.48","percent of total billed charges",""
"STENT GRAFT 16FRX28 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100997","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8323.25","65","","6652.80","6652.80","6652.80","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16FRX28 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100997","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10179.98","79.5","","2612.61","795.38","2612.61","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16FRX28 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100997","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6825.07","53.3","","1101.80","1101.80","1101.80","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16FRX28 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100997","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8323.25","65","","1820.00","910.00","1820.00","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16FRX28 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100997","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4673.83","36.5","","1257.80","693.44","2424.50","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16FRX28 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100997","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4904.32","38.3","","1950.11","547.40","2346.00","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16FRX28 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100997","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5493.35","42.9","","5096.18","5096.18","5096.18","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16FRX28 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100997","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","WELLPOINT [1015]","HB AMC WELLPOINT","9447.53","73.78","","1172.59","1172.59","4829.94","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16FRX28 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100997","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12805.00","9603.75","AETNA [1001]","HB AMC AETNA HMO","8937.89","69.8","","1806.84","947.80","5091.72","1 through 10","6691.89","10464.25","percent of total billed charges",""
"STENT GRAFT 16FRX28 93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10100997","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12805.00","9603.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10464.25","81.72","","1259.05","615.58","4586.56","1 through 10","6691.89","10464.25","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7858.50","65","","6652.80","6652.80","6652.80","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9611.55","79.5","","2612.61","795.38","2612.61","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6443.97","53.3","","1101.80","1101.80","1101.80","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7858.50","65","","1820.00","910.00","1820.00","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4412.85","36.5","","1257.80","693.44","2424.50","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4630.47","38.3","","1950.11","547.40","2346.00","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5186.61","42.9","","5096.18","5096.18","5096.18","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","both","","","12090.00","9067.50","WELLPOINT [1015]","HB AMC WELLPOINT","8920.00","73.78","","1172.59","1172.59","4829.94","1 through 10","3747.9","9611.55","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12090.00","9067.50","AETNA [1001]","HB AMC AETNA HMO","8438.82","69.8","","1806.84","947.80","5091.72","1 through 10","6318.23","9879.95","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12090.00","9067.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9879.95","81.72","","1259.05","615.58","4586.56","1 through 10","6318.23","9879.95","percent of total billed charges",""
"STENT GRAFT 16MM 10 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114970","CDM","C1874","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5066.75","65","","6652.80","6652.80","6652.80","1 through 10","2416.45","6197.03","percent of total billed charges",""
"STENT GRAFT 16MM 10 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114970","CDM","C1874","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6197.03","79.5","","2612.61","795.38","2612.61","1 through 10","2416.45","6197.03","percent of total billed charges",""
"STENT GRAFT 16MM 10 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114970","CDM","C1874","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4154.74","53.3","","1101.80","1101.80","1101.80","1 through 10","2416.45","6197.03","percent of total billed charges",""
"STENT GRAFT 16MM 10 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114970","CDM","C1874","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5066.75","65","","1820.00","910.00","1820.00","1 through 10","2416.45","6197.03","percent of total billed charges",""
"STENT GRAFT 16MM 10 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114970","CDM","C1874","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2845.18","36.5","","1257.80","693.44","2424.50","1 through 10","2416.45","6197.03","percent of total billed charges",""
"STENT GRAFT 16MM 10 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114970","CDM","C1874","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2985.49","38.3","","1950.11","547.40","2346.00","1 through 10","2416.45","6197.03","percent of total billed charges",""
"STENT GRAFT 16MM 10 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114970","CDM","C1874","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3344.06","42.9","","5096.18","5096.18","5096.18","1 through 10","2416.45","6197.03","percent of total billed charges",""
"STENT GRAFT 16MM 10 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114970","CDM","C1874","HCPCS","0278","RC","","","","both","","","7795.00","5846.25","WELLPOINT [1015]","HB AMC WELLPOINT","5751.15","73.78","","1172.59","1172.59","4829.94","1 through 10","2416.45","6197.03","percent of total billed charges",""
"STENT GRAFT 16MM 10 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114970","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7795.00","5846.25","AETNA [1001]","HB AMC AETNA HMO","5440.91","69.8","","1806.84","947.80","5091.72","1 through 10","4073.67","6370.07","percent of total billed charges",""
"STENT GRAFT 16MM 10 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114970","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7795.00","5846.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6370.07","81.72","","1259.05","615.58","4586.56","1 through 10","4073.67","6370.07","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7195.50","65","","6652.80","6652.80","6652.80","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8800.65","79.5","","2612.61","795.38","2612.61","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5900.31","53.3","","1101.80","1101.80","1101.80","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7195.50","65","","1820.00","910.00","1820.00","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4040.55","36.5","","1257.80","693.44","2424.50","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4239.81","38.3","","1950.11","547.40","2346.00","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4749.03","42.9","","5096.18","5096.18","5096.18","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","WELLPOINT [1015]","HB AMC WELLPOINT","8167.45","73.78","","1172.59","1172.59","4829.94","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11070.00","8302.50","AETNA [1001]","HB AMC AETNA HMO","7726.86","69.8","","1806.84","947.80","5091.72","1 through 10","5785.18","9046.4","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11070.00","8302.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9046.40","81.72","","1259.05","615.58","4586.56","1 through 10","5785.18","9046.4","percent of total billed charges",""
"STENT GRAFT 16X13MM 14FR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100992","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8407.75","65","","6652.80","6652.80","6652.80","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X13MM 14FR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100992","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10283.33","79.5","","2612.61","795.38","2612.61","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X13MM 14FR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100992","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6894.36","53.3","","1101.80","1101.80","1101.80","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X13MM 14FR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100992","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8407.75","65","","1820.00","910.00","1820.00","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X13MM 14FR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100992","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4721.28","36.5","","1257.80","693.44","2424.50","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X13MM 14FR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100992","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4954.11","38.3","","1950.11","547.40","2346.00","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X13MM 14FR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100992","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5549.12","42.9","","5096.18","5096.18","5096.18","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X13MM 14FR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100992","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","WELLPOINT [1015]","HB AMC WELLPOINT","9543.44","73.78","","1172.59","1172.59","4829.94","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X13MM 14FR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100992","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12935.00","9701.25","AETNA [1001]","HB AMC AETNA HMO","9028.63","69.8","","1806.84","947.80","5091.72","1 through 10","6759.83","10570.48","percent of total billed charges",""
"STENT GRAFT 16X13MM 14FR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10100992","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12935.00","9701.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10570.48","81.72","","1259.05","615.58","4586.56","1 through 10","6759.83","10570.48","percent of total billed charges",""
"STENT GRAFT 16X13MMFR 93 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10113261","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8323.25","65","","6652.80","6652.80","6652.80","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16X13MMFR 93 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10113261","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10179.98","79.5","","2612.61","795.38","2612.61","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16X13MMFR 93 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10113261","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6825.07","53.3","","1101.80","1101.80","1101.80","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16X13MMFR 93 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10113261","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8323.25","65","","1820.00","910.00","1820.00","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16X13MMFR 93 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10113261","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4673.83","36.5","","1257.80","693.44","2424.50","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16X13MMFR 93 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10113261","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4904.32","38.3","","1950.11","547.40","2346.00","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16X13MMFR 93 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10113261","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5493.35","42.9","","5096.18","5096.18","5096.18","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16X13MMFR 93 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10113261","CDM","C1874","HCPCS","0278","RC","","","","both","","","12805.00","9603.75","WELLPOINT [1015]","HB AMC WELLPOINT","9447.53","73.78","","1172.59","1172.59","4829.94","1 through 10","3969.55","10179.98","percent of total billed charges",""
"STENT GRAFT 16X13MMFR 93 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10113261","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12805.00","9603.75","AETNA [1001]","HB AMC AETNA HMO","8937.89","69.8","","1806.84","947.80","5091.72","1 through 10","6691.89","10464.25","percent of total billed charges",""
"STENT GRAFT 16X13MMFR 93 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10113261","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12805.00","9603.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10464.25","81.72","","1259.05","615.58","4586.56","1 through 10","6691.89","10464.25","percent of total billed charges",""
"STENT GRAFT 16X20MMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10101982","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8407.75","65","","6652.80","6652.80","6652.80","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X20MMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10101982","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10283.33","79.5","","2612.61","795.38","2612.61","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X20MMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10101982","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6894.36","53.3","","1101.80","1101.80","1101.80","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X20MMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10101982","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8407.75","65","","1820.00","910.00","1820.00","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X20MMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10101982","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4721.28","36.5","","1257.80","693.44","2424.50","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X20MMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10101982","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4954.11","38.3","","1950.11","547.40","2346.00","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X20MMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10101982","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5549.12","42.9","","5096.18","5096.18","5096.18","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X20MMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10101982","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","WELLPOINT [1015]","HB AMC WELLPOINT","9543.44","73.78","","1172.59","1172.59","4829.94","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 16X20MMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10101982","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12935.00","9701.25","AETNA [1001]","HB AMC AETNA HMO","9028.63","69.8","","1806.84","947.80","5091.72","1 through 10","6759.83","10570.48","percent of total billed charges",""
"STENT GRAFT 16X20MMFR 124 AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB BALLOON","SUP-ITM-10101982","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12935.00","9701.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10570.48","81.72","","1259.05","615.58","4586.56","1 through 10","6759.83","10570.48","percent of total billed charges",""
"STENT GRAFT 18FR 23X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138636","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","16857.75","65","","6652.80","6652.80","6652.80","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 23X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138636","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20618.33","79.5","","2612.61","795.38","2612.61","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 23X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138636","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13823.36","53.3","","1101.80","1101.80","1101.80","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 23X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138636","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","16857.75","65","","1820.00","910.00","1820.00","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 23X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138636","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9466.28","36.5","","1257.80","693.44","2424.50","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 23X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138636","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9933.11","38.3","","1950.11","547.40","2346.00","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 23X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138636","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11126.12","42.9","","5096.18","5096.18","5096.18","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 23X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138636","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","WELLPOINT [1015]","HB AMC WELLPOINT","19134.84","73.78","","1172.59","1172.59","4829.94","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 23X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138636","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25935.00","19451.25","AETNA [1001]","HB AMC AETNA HMO","18102.63","69.8","","1806.84","947.80","5091.72","1 through 10","13553.63","21194.08","percent of total billed charges",""
"STENT GRAFT 18FR 23X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138636","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25935.00","19451.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21194.08","81.72","","1259.05","615.58","4586.56","1 through 10","13553.63","21194.08","percent of total billed charges",""
"STENT GRAFT 18FR 23X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101003","CDM","C1874","HCPCS","0278","RC","","","","both","","","19435.00","14576.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","12632.75","65","","6652.80","6652.80","6652.80","1 through 10","6024.85","15450.83","percent of total billed charges",""
"STENT GRAFT 18FR 23X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101003","CDM","C1874","HCPCS","0278","RC","","","","both","","","19435.00","14576.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15450.83","79.5","","2612.61","795.38","2612.61","1 through 10","6024.85","15450.83","percent of total billed charges",""
"STENT GRAFT 18FR 23X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101003","CDM","C1874","HCPCS","0278","RC","","","","both","","","19435.00","14576.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10358.86","53.3","","1101.80","1101.80","1101.80","1 through 10","6024.85","15450.83","percent of total billed charges",""
"STENT GRAFT 18FR 23X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101003","CDM","C1874","HCPCS","0278","RC","","","","both","","","19435.00","14576.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","12632.75","65","","1820.00","910.00","1820.00","1 through 10","6024.85","15450.83","percent of total billed charges",""
"STENT GRAFT 18FR 23X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101003","CDM","C1874","HCPCS","0278","RC","","","","both","","","19435.00","14576.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7093.78","36.5","","1257.80","693.44","2424.50","1 through 10","6024.85","15450.83","percent of total billed charges",""
"STENT GRAFT 18FR 23X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101003","CDM","C1874","HCPCS","0278","RC","","","","both","","","19435.00","14576.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7443.61","38.3","","1950.11","547.40","2346.00","1 through 10","6024.85","15450.83","percent of total billed charges",""
"STENT GRAFT 18FR 23X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101003","CDM","C1874","HCPCS","0278","RC","","","","both","","","19435.00","14576.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8337.62","42.9","","5096.18","5096.18","5096.18","1 through 10","6024.85","15450.83","percent of total billed charges",""
"STENT GRAFT 18FR 23X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101003","CDM","C1874","HCPCS","0278","RC","","","","both","","","19435.00","14576.25","WELLPOINT [1015]","HB AMC WELLPOINT","14339.14","73.78","","1172.59","1172.59","4829.94","1 through 10","6024.85","15450.83","percent of total billed charges",""
"STENT GRAFT 18FR 23X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101003","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19435.00","14576.25","AETNA [1001]","HB AMC AETNA HMO","13565.63","69.8","","1806.84","947.80","5091.72","1 through 10","10156.73","15882.28","percent of total billed charges",""
"STENT GRAFT 18FR 23X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101003","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19435.00","14576.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15882.28","81.72","","1259.05","615.58","4586.56","1 through 10","10156.73","15882.28","percent of total billed charges",""
"STENT GRAFT 18FR 25X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101018","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","16857.75","65","","6652.80","6652.80","6652.80","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101018","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20618.33","79.5","","2612.61","795.38","2612.61","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101018","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13823.36","53.3","","1101.80","1101.80","1101.80","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101018","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","16857.75","65","","1820.00","910.00","1820.00","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101018","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9466.28","36.5","","1257.80","693.44","2424.50","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101018","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9933.11","38.3","","1950.11","547.40","2346.00","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101018","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11126.12","42.9","","5096.18","5096.18","5096.18","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101018","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","WELLPOINT [1015]","HB AMC WELLPOINT","19134.84","73.78","","1172.59","1172.59","4829.94","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101018","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25935.00","19451.25","AETNA [1001]","HB AMC AETNA HMO","18102.63","69.8","","1806.84","947.80","5091.72","1 through 10","13553.63","21194.08","percent of total billed charges",""
"STENT GRAFT 18FR 25X13 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101018","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25935.00","19451.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21194.08","81.72","","1259.05","615.58","4586.56","1 through 10","13553.63","21194.08","percent of total billed charges",""
"STENT GRAFT 18FR 25X16 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100987","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","16857.75","65","","6652.80","6652.80","6652.80","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X16 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100987","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20618.33","79.5","","2612.61","795.38","2612.61","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X16 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100987","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13823.36","53.3","","1101.80","1101.80","1101.80","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X16 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100987","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","16857.75","65","","1820.00","910.00","1820.00","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X16 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100987","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9466.28","36.5","","1257.80","693.44","2424.50","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X16 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100987","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9933.11","38.3","","1950.11","547.40","2346.00","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X16 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100987","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11126.12","42.9","","5096.18","5096.18","5096.18","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X16 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100987","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","WELLPOINT [1015]","HB AMC WELLPOINT","19134.84","73.78","","1172.59","1172.59","4829.94","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 25X16 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100987","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25935.00","19451.25","AETNA [1001]","HB AMC AETNA HMO","18102.63","69.8","","1806.84","947.80","5091.72","1 through 10","13553.63","21194.08","percent of total billed charges",""
"STENT GRAFT 18FR 25X16 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10100987","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25935.00","19451.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21194.08","81.72","","1259.05","615.58","4586.56","1 through 10","13553.63","21194.08","percent of total billed charges",""
"STENT GRAFT 18FR 28X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101004","CDM","C1874","HCPCS","0278","RC","","","","both","","","19695.00","14771.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","12801.75","65","","6652.80","6652.80","6652.80","1 through 10","6105.45","15657.53","percent of total billed charges",""
"STENT GRAFT 18FR 28X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101004","CDM","C1874","HCPCS","0278","RC","","","","both","","","19695.00","14771.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15657.53","79.5","","2612.61","795.38","2612.61","1 through 10","6105.45","15657.53","percent of total billed charges",""
"STENT GRAFT 18FR 28X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101004","CDM","C1874","HCPCS","0278","RC","","","","both","","","19695.00","14771.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10497.44","53.3","","1101.80","1101.80","1101.80","1 through 10","6105.45","15657.53","percent of total billed charges",""
"STENT GRAFT 18FR 28X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101004","CDM","C1874","HCPCS","0278","RC","","","","both","","","19695.00","14771.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","12801.75","65","","1820.00","910.00","1820.00","1 through 10","6105.45","15657.53","percent of total billed charges",""
"STENT GRAFT 18FR 28X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101004","CDM","C1874","HCPCS","0278","RC","","","","both","","","19695.00","14771.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7188.68","36.5","","1257.80","693.44","2424.50","1 through 10","6105.45","15657.53","percent of total billed charges",""
"STENT GRAFT 18FR 28X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101004","CDM","C1874","HCPCS","0278","RC","","","","both","","","19695.00","14771.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7543.19","38.3","","1950.11","547.40","2346.00","1 through 10","6105.45","15657.53","percent of total billed charges",""
"STENT GRAFT 18FR 28X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101004","CDM","C1874","HCPCS","0278","RC","","","","both","","","19695.00","14771.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8449.16","42.9","","5096.18","5096.18","5096.18","1 through 10","6105.45","15657.53","percent of total billed charges",""
"STENT GRAFT 18FR 28X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101004","CDM","C1874","HCPCS","0278","RC","","","","both","","","19695.00","14771.25","WELLPOINT [1015]","HB AMC WELLPOINT","14530.97","73.78","","1172.59","1172.59","4829.94","1 through 10","6105.45","15657.53","percent of total billed charges",""
"STENT GRAFT 18FR 28X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101004","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19695.00","14771.25","AETNA [1001]","HB AMC AETNA HMO","13747.11","69.8","","1806.84","947.80","5091.72","1 through 10","10292.61","16094.75","percent of total billed charges",""
"STENT GRAFT 18FR 28X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101004","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19695.00","14771.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16094.75","81.72","","1259.05","615.58","4586.56","1 through 10","10292.61","16094.75","percent of total billed charges",""
"STENT GRAFT 18FR 28X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138645","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8407.75","65","","6652.80","6652.80","6652.80","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 18FR 28X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138645","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10283.33","79.5","","2612.61","795.38","2612.61","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 18FR 28X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138645","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6894.36","53.3","","1101.80","1101.80","1101.80","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 18FR 28X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138645","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8407.75","65","","1820.00","910.00","1820.00","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 18FR 28X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138645","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4721.28","36.5","","1257.80","693.44","2424.50","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 18FR 28X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138645","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4954.11","38.3","","1950.11","547.40","2346.00","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 18FR 28X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138645","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5549.12","42.9","","5096.18","5096.18","5096.18","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 18FR 28X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138645","CDM","C1874","HCPCS","0278","RC","","","","both","","","12935.00","9701.25","WELLPOINT [1015]","HB AMC WELLPOINT","9543.44","73.78","","1172.59","1172.59","4829.94","1 through 10","4009.85","10283.33","percent of total billed charges",""
"STENT GRAFT 18FR 28X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138645","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12935.00","9701.25","AETNA [1001]","HB AMC AETNA HMO","9028.63","69.8","","1806.84","947.80","5091.72","1 through 10","6759.83","10570.48","percent of total billed charges",""
"STENT GRAFT 18FR 28X82MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138645","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12935.00","9701.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10570.48","81.72","","1259.05","615.58","4586.56","1 through 10","6759.83","10570.48","percent of total billed charges",""
"STENT GRAFT 18FR 32X20 145MM AORTIC ENDURANT II BIFURCATED","SUP-ITM-10104831","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","16857.75","65","","6652.80","6652.80","6652.80","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 32X20 145MM AORTIC ENDURANT II BIFURCATED","SUP-ITM-10104831","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20618.33","79.5","","2612.61","795.38","2612.61","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 32X20 145MM AORTIC ENDURANT II BIFURCATED","SUP-ITM-10104831","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13823.36","53.3","","1101.80","1101.80","1101.80","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 32X20 145MM AORTIC ENDURANT II BIFURCATED","SUP-ITM-10104831","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","16857.75","65","","1820.00","910.00","1820.00","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 32X20 145MM AORTIC ENDURANT II BIFURCATED","SUP-ITM-10104831","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9466.28","36.5","","1257.80","693.44","2424.50","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 32X20 145MM AORTIC ENDURANT II BIFURCATED","SUP-ITM-10104831","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9933.11","38.3","","1950.11","547.40","2346.00","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 32X20 145MM AORTIC ENDURANT II BIFURCATED","SUP-ITM-10104831","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11126.12","42.9","","5096.18","5096.18","5096.18","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 32X20 145MM AORTIC ENDURANT II BIFURCATED","SUP-ITM-10104831","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","WELLPOINT [1015]","HB AMC WELLPOINT","19134.84","73.78","","1172.59","1172.59","4829.94","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 32X20 145MM AORTIC ENDURANT II BIFURCATED","SUP-ITM-10104831","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25935.00","19451.25","AETNA [1001]","HB AMC AETNA HMO","18102.63","69.8","","1806.84","947.80","5091.72","1 through 10","13553.63","21194.08","percent of total billed charges",""
"STENT GRAFT 18FR 32X20 145MM AORTIC ENDURANT II BIFURCATED","SUP-ITM-10104831","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25935.00","19451.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21194.08","81.72","","1259.05","615.58","4586.56","1 through 10","13553.63","21194.08","percent of total billed charges",""
"STENT GRAFT 18FR 36X20 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138644","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","16857.75","65","","6652.80","6652.80","6652.80","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 36X20 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138644","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20618.33","79.5","","2612.61","795.38","2612.61","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 36X20 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138644","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13823.36","53.3","","1101.80","1101.80","1101.80","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 36X20 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138644","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","16857.75","65","","1820.00","910.00","1820.00","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 36X20 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138644","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9466.28","36.5","","1257.80","693.44","2424.50","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 36X20 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138644","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9933.11","38.3","","1950.11","547.40","2346.00","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 36X20 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138644","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11126.12","42.9","","5096.18","5096.18","5096.18","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 36X20 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138644","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","WELLPOINT [1015]","HB AMC WELLPOINT","19134.84","73.78","","1172.59","1172.59","4829.94","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT GRAFT 18FR 36X20 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138644","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25935.00","19451.25","AETNA [1001]","HB AMC AETNA HMO","18102.63","69.8","","1806.84","947.80","5091.72","1 through 10","13553.63","21194.08","percent of total billed charges",""
"STENT GRAFT 18FR 36X20 145MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10138644","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25935.00","19451.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21194.08","81.72","","1259.05","615.58","4586.56","1 through 10","13553.63","21194.08","percent of total billed charges",""
"STENT GRAFT 20FR 36X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101002","CDM","C1874","HCPCS","0278","RC","","","","both","","","12155.00","9116.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7900.75","65","","6652.80","6652.80","6652.80","1 through 10","3768.05","9663.23","percent of total billed charges",""
"STENT GRAFT 20FR 36X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101002","CDM","C1874","HCPCS","0278","RC","","","","both","","","12155.00","9116.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9663.23","79.5","","2612.61","795.38","2612.61","1 through 10","3768.05","9663.23","percent of total billed charges",""
"STENT GRAFT 20FR 36X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101002","CDM","C1874","HCPCS","0278","RC","","","","both","","","12155.00","9116.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6478.62","53.3","","1101.80","1101.80","1101.80","1 through 10","3768.05","9663.23","percent of total billed charges",""
"STENT GRAFT 20FR 36X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101002","CDM","C1874","HCPCS","0278","RC","","","","both","","","12155.00","9116.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7900.75","65","","1820.00","910.00","1820.00","1 through 10","3768.05","9663.23","percent of total billed charges",""
"STENT GRAFT 20FR 36X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101002","CDM","C1874","HCPCS","0278","RC","","","","both","","","12155.00","9116.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4436.58","36.5","","1257.80","693.44","2424.50","1 through 10","3768.05","9663.23","percent of total billed charges",""
"STENT GRAFT 20FR 36X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101002","CDM","C1874","HCPCS","0278","RC","","","","both","","","12155.00","9116.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4655.37","38.3","","1950.11","547.40","2346.00","1 through 10","3768.05","9663.23","percent of total billed charges",""
"STENT GRAFT 20FR 36X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101002","CDM","C1874","HCPCS","0278","RC","","","","both","","","12155.00","9116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5214.50","42.9","","5096.18","5096.18","5096.18","1 through 10","3768.05","9663.23","percent of total billed charges",""
"STENT GRAFT 20FR 36X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101002","CDM","C1874","HCPCS","0278","RC","","","","both","","","12155.00","9116.25","WELLPOINT [1015]","HB AMC WELLPOINT","8967.96","73.78","","1172.59","1172.59","4829.94","1 through 10","3768.05","9663.23","percent of total billed charges",""
"STENT GRAFT 20FR 36X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101002","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12155.00","9116.25","AETNA [1001]","HB AMC AETNA HMO","8484.19","69.8","","1806.84","947.80","5091.72","1 through 10","6352.2","9933.07","percent of total billed charges",""
"STENT GRAFT 20FR 36X49MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101002","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12155.00","9116.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9933.07","81.72","","1259.05","615.58","4586.56","1 through 10","6352.2","9933.07","percent of total billed charges",""
"STENT GRAFT 20FR 36X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101005","CDM","C1874","HCPCS","0278","RC","","","","both","","","20085.00","15063.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","13055.25","65","","6652.80","6652.80","6652.80","1 through 10","6226.35","15967.58","percent of total billed charges",""
"STENT GRAFT 20FR 36X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101005","CDM","C1874","HCPCS","0278","RC","","","","both","","","20085.00","15063.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15967.58","79.5","","2612.61","795.38","2612.61","1 through 10","6226.35","15967.58","percent of total billed charges",""
"STENT GRAFT 20FR 36X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101005","CDM","C1874","HCPCS","0278","RC","","","","both","","","20085.00","15063.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10705.31","53.3","","1101.80","1101.80","1101.80","1 through 10","6226.35","15967.58","percent of total billed charges",""
"STENT GRAFT 20FR 36X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101005","CDM","C1874","HCPCS","0278","RC","","","","both","","","20085.00","15063.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","13055.25","65","","1820.00","910.00","1820.00","1 through 10","6226.35","15967.58","percent of total billed charges",""
"STENT GRAFT 20FR 36X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101005","CDM","C1874","HCPCS","0278","RC","","","","both","","","20085.00","15063.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7331.03","36.5","","1257.80","693.44","2424.50","1 through 10","6226.35","15967.58","percent of total billed charges",""
"STENT GRAFT 20FR 36X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101005","CDM","C1874","HCPCS","0278","RC","","","","both","","","20085.00","15063.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7692.56","38.3","","1950.11","547.40","2346.00","1 through 10","6226.35","15967.58","percent of total billed charges",""
"STENT GRAFT 20FR 36X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101005","CDM","C1874","HCPCS","0278","RC","","","","both","","","20085.00","15063.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8616.47","42.9","","5096.18","5096.18","5096.18","1 through 10","6226.35","15967.58","percent of total billed charges",""
"STENT GRAFT 20FR 36X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101005","CDM","C1874","HCPCS","0278","RC","","","","both","","","20085.00","15063.75","WELLPOINT [1015]","HB AMC WELLPOINT","14818.71","73.78","","1172.59","1172.59","4829.94","1 through 10","6226.35","15967.58","percent of total billed charges",""
"STENT GRAFT 20FR 36X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101005","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","20085.00","15063.75","AETNA [1001]","HB AMC AETNA HMO","14019.33","69.8","","1806.84","947.80","5091.72","1 through 10","10496.42","16413.46","percent of total billed charges",""
"STENT GRAFT 20FR 36X70MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101005","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","20085.00","15063.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","16413.46","81.72","","1259.05","615.58","4586.56","1 through 10","10496.42","16413.46","percent of total billed charges",""
"STENT GRAFT 22FR 24X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138117","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","29989.38","65","","6652.80","6652.80","6652.80","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 22FR 24X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138117","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","36679.31","79.5","","2612.61","795.38","2612.61","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 22FR 24X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138117","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","24591.29","53.3","","1101.80","1101.80","1101.80","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 22FR 24X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138117","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","29989.38","65","","1820.00","910.00","1820.00","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 22FR 24X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138117","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16840.19","36.5","","1257.80","693.44","2424.50","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 22FR 24X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138117","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17670.66","38.3","","1950.11","547.40","2346.00","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 22FR 24X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138117","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19792.99","42.9","","5096.18","5096.18","5096.18","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 22FR 24X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138117","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","WELLPOINT [1015]","HB AMC WELLPOINT","34040.25","73.78","","1172.59","1172.59","4829.94","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 22FR 24X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138117","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46137.50","34603.12","AETNA [1001]","HB AMC AETNA HMO","32203.98","69.8","","1806.84","947.80","5091.72","1 through 10","24111.46","37703.57","percent of total billed charges",""
"STENT GRAFT 22FR 24X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138117","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46137.50","34603.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","37703.57","81.72","","1259.05","615.58","4586.56","1 through 10","24111.46","37703.57","percent of total billed charges",""
"STENT GRAFT 22FR 30X100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10099132","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","28721.88","65","","6652.80","6652.80","6652.80","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FR 30X100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10099132","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","35129.06","79.5","","2612.61","795.38","2612.61","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FR 30X100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10099132","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23551.94","53.3","","1101.80","1101.80","1101.80","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FR 30X100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10099132","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","28721.88","65","","1820.00","910.00","1820.00","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FR 30X100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10099132","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16128.44","36.5","","1257.80","693.44","2424.50","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FR 30X100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10099132","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16923.81","38.3","","1950.11","547.40","2346.00","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FR 30X100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10099132","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18956.44","42.9","","5096.18","5096.18","5096.18","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FR 30X100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10099132","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","WELLPOINT [1015]","HB AMC WELLPOINT","32601.54","73.78","","1172.59","1172.59","4829.94","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FR 30X100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10099132","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","44187.50","33140.62","AETNA [1001]","HB AMC AETNA HMO","30842.88","69.8","","1806.84","947.80","5091.72","1 through 10","23092.39","36110.03","percent of total billed charges",""
"STENT GRAFT 22FR 30X100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10099132","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","44187.50","33140.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","36110.03","81.72","","1259.05","615.58","4586.56","1 through 10","23092.39","36110.03","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10126296","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","27454.38","65","","6652.80","6652.80","6652.80","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10126296","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33578.81","79.5","","2612.61","795.38","2612.61","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10126296","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22512.59","53.3","","1101.80","1101.80","1101.80","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10126296","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","27454.38","65","","1820.00","910.00","1820.00","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10126296","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15416.69","36.5","","1257.80","693.44","2424.50","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10126296","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16176.96","38.3","","1950.11","547.40","2346.00","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10126296","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18119.89","42.9","","5096.18","5096.18","5096.18","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10126296","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","WELLPOINT [1015]","HB AMC WELLPOINT","31162.83","73.78","","1172.59","1172.59","4829.94","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10126296","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42237.50","31678.12","AETNA [1001]","HB AMC AETNA HMO","29481.78","69.8","","1806.84","947.80","5091.72","1 through 10","22073.32","34516.49","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10126296","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42237.50","31678.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34516.49","81.72","","1259.05","615.58","4586.56","1 through 10","22073.32","34516.49","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10099133","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","27454.38","65","","6652.80","6652.80","6652.80","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10099133","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33578.81","79.5","","2612.61","795.38","2612.61","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10099133","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22512.59","53.3","","1101.80","1101.80","1101.80","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10099133","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","27454.38","65","","1820.00","910.00","1820.00","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10099133","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15416.69","36.5","","1257.80","693.44","2424.50","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10099133","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16176.96","38.3","","1950.11","547.40","2346.00","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10099133","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18119.89","42.9","","5096.18","5096.18","5096.18","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10099133","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","WELLPOINT [1015]","HB AMC WELLPOINT","31162.83","73.78","","1172.59","1172.59","4829.94","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10099133","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42237.50","31678.12","AETNA [1001]","HB AMC AETNA HMO","29481.78","69.8","","1806.84","947.80","5091.72","1 through 10","22073.32","34516.49","percent of total billed charges",""
"STENT GRAFT 22FR 32X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10099133","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42237.50","31678.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34516.49","81.72","","1259.05","615.58","4586.56","1 through 10","22073.32","34516.49","percent of total billed charges",""
"STENT GRAFT 22FRX100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10111818","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","28721.88","65","","6652.80","6652.80","6652.80","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FRX100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10111818","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","35129.06","79.5","","2612.61","795.38","2612.61","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FRX100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10111818","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23551.94","53.3","","1101.80","1101.80","1101.80","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FRX100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10111818","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","28721.88","65","","1820.00","910.00","1820.00","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FRX100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10111818","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16128.44","36.5","","1257.80","693.44","2424.50","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FRX100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10111818","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16923.81","38.3","","1950.11","547.40","2346.00","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FRX100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10111818","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18956.44","42.9","","5096.18","5096.18","5096.18","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FRX100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10111818","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","WELLPOINT [1015]","HB AMC WELLPOINT","32601.54","73.78","","1172.59","1172.59","4829.94","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 22FRX100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10111818","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","44187.50","33140.62","AETNA [1001]","HB AMC AETNA HMO","30842.88","69.8","","1806.84","947.80","5091.72","1 through 10","23092.39","36110.03","percent of total billed charges",""
"STENT GRAFT 22FRX100MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10111818","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","44187.50","33140.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","36110.03","81.72","","1259.05","615.58","4586.56","1 through 10","23092.39","36110.03","percent of total billed charges",""
"STENT GRAFT 22FRX24 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138116","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","27454.38","65","","6652.80","6652.80","6652.80","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FRX24 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138116","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33578.81","79.5","","2612.61","795.38","2612.61","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FRX24 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138116","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22512.59","53.3","","1101.80","1101.80","1101.80","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FRX24 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138116","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","27454.38","65","","1820.00","910.00","1820.00","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FRX24 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138116","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15416.69","36.5","","1257.80","693.44","2424.50","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FRX24 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138116","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16176.96","38.3","","1950.11","547.40","2346.00","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FRX24 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138116","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18119.89","42.9","","5096.18","5096.18","5096.18","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FRX24 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138116","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","WELLPOINT [1015]","HB AMC WELLPOINT","31162.83","73.78","","1172.59","1172.59","4829.94","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 22FRX24 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138116","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42237.50","31678.12","AETNA [1001]","HB AMC AETNA HMO","29481.78","69.8","","1806.84","947.80","5091.72","1 through 10","22073.32","34516.49","percent of total billed charges",""
"STENT GRAFT 22FRX24 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138116","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42237.50","31678.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34516.49","81.72","","1259.05","615.58","4586.56","1 through 10","22073.32","34516.49","percent of total billed charges",""
"STENT GRAFT 23MMX14.5 12CM VASCULAR EXCLUDER EPTFE C3 COATED DELIVERY SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135312","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","17407.00","65","","6652.80","6652.80","6652.80","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 23MMX14.5 12CM VASCULAR EXCLUDER EPTFE C3 COATED DELIVERY SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135312","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21290.10","79.5","","2612.61","795.38","2612.61","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 23MMX14.5 12CM VASCULAR EXCLUDER EPTFE C3 COATED DELIVERY SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135312","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14273.74","53.3","","1101.80","1101.80","1101.80","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 23MMX14.5 12CM VASCULAR EXCLUDER EPTFE C3 COATED DELIVERY SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135312","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","17407.00","65","","1820.00","910.00","1820.00","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 23MMX14.5 12CM VASCULAR EXCLUDER EPTFE C3 COATED DELIVERY SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135312","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9774.70","36.5","","1257.80","693.44","2424.50","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 23MMX14.5 12CM VASCULAR EXCLUDER EPTFE C3 COATED DELIVERY SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135312","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10256.74","38.3","","1950.11","547.40","2346.00","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 23MMX14.5 12CM VASCULAR EXCLUDER EPTFE C3 COATED DELIVERY SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135312","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11488.62","42.9","","5096.18","5096.18","5096.18","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 23MMX14.5 12CM VASCULAR EXCLUDER EPTFE C3 COATED DELIVERY SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135312","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","WELLPOINT [1015]","HB AMC WELLPOINT","19758.28","73.78","","1172.59","1172.59","4829.94","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 23MMX14.5 12CM VASCULAR EXCLUDER EPTFE C3 COATED DELIVERY SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135312","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","26780.00","20085.00","AETNA [1001]","HB AMC AETNA HMO","18692.44","69.8","","1806.84","947.80","5091.72","1 through 10","13995.23","21884.62","percent of total billed charges",""
"STENT GRAFT 23MMX14.5 12CM VASCULAR EXCLUDER EPTFE C3 COATED DELIVERY SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135312","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","26780.00","20085.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21884.62","81.72","","1259.05","615.58","4586.56","1 through 10","13995.23","21884.62","percent of total billed charges",""
"STENT GRAFT 24 XMM 22FR 100 THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113797","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","28721.88","65","","6652.80","6652.80","6652.80","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 24 XMM 22FR 100 THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113797","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","35129.06","79.5","","2612.61","795.38","2612.61","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 24 XMM 22FR 100 THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113797","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","23551.94","53.3","","1101.80","1101.80","1101.80","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 24 XMM 22FR 100 THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113797","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","28721.88","65","","1820.00","910.00","1820.00","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 24 XMM 22FR 100 THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113797","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16128.44","36.5","","1257.80","693.44","2424.50","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 24 XMM 22FR 100 THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113797","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16923.81","38.3","","1950.11","547.40","2346.00","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 24 XMM 22FR 100 THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113797","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18956.44","42.9","","5096.18","5096.18","5096.18","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 24 XMM 22FR 100 THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113797","CDM","C1874","HCPCS","0278","RC","","","","both","","","44187.50","33140.62","WELLPOINT [1015]","HB AMC WELLPOINT","32601.54","73.78","","1172.59","1172.59","4829.94","1 through 10","13698.13","35129.06","percent of total billed charges",""
"STENT GRAFT 24 XMM 22FR 100 THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113797","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","44187.50","33140.62","AETNA [1001]","HB AMC AETNA HMO","30842.88","69.8","","1806.84","947.80","5091.72","1 through 10","23092.39","36110.03","percent of total billed charges",""
"STENT GRAFT 24 XMM 22FR 100 THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113797","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","44187.50","33140.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","36110.03","81.72","","1259.05","615.58","4586.56","1 through 10","23092.39","36110.03","percent of total billed charges",""
"STENT GRAFT 24FR 36X150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113392","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","31256.88","65","","6652.80","6652.80","6652.80","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 24FR 36X150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113392","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","38229.56","79.5","","2612.61","795.38","2612.61","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 24FR 36X150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113392","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","25630.64","53.3","","1101.80","1101.80","1101.80","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 24FR 36X150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113392","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","31256.88","65","","1820.00","910.00","1820.00","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 24FR 36X150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113392","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17551.94","36.5","","1257.80","693.44","2424.50","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 24FR 36X150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113392","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18417.51","38.3","","1950.11","547.40","2346.00","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 24FR 36X150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113392","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20629.54","42.9","","5096.18","5096.18","5096.18","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 24FR 36X150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113392","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","WELLPOINT [1015]","HB AMC WELLPOINT","35478.96","73.78","","1172.59","1172.59","4829.94","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 24FR 36X150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113392","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","48087.50","36065.62","AETNA [1001]","HB AMC AETNA HMO","33565.08","69.8","","1806.84","947.80","5091.72","1 through 10","25130.53","39297.11","percent of total billed charges",""
"STENT GRAFT 24FR 36X150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10113392","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","48087.50","36065.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","39297.11","81.72","","1259.05","615.58","4586.56","1 through 10","25130.53","39297.11","percent of total billed charges",""
"STENT GRAFT 24FR 38X200MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10114151","CDM","C1874","HCPCS","0278","RC","","","","both","","","50687.50","38015.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","32946.88","65","","6652.80","6652.80","6652.80","1 through 10","15713.13","40296.56","percent of total billed charges",""
"STENT GRAFT 24FR 38X200MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10114151","CDM","C1874","HCPCS","0278","RC","","","","both","","","50687.50","38015.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","40296.56","79.5","","2612.61","795.38","2612.61","1 through 10","15713.13","40296.56","percent of total billed charges",""
"STENT GRAFT 24FR 38X200MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10114151","CDM","C1874","HCPCS","0278","RC","","","","both","","","50687.50","38015.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","27016.44","53.3","","1101.80","1101.80","1101.80","1 through 10","15713.13","40296.56","percent of total billed charges",""
"STENT GRAFT 24FR 38X200MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10114151","CDM","C1874","HCPCS","0278","RC","","","","both","","","50687.50","38015.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","32946.88","65","","1820.00","910.00","1820.00","1 through 10","15713.13","40296.56","percent of total billed charges",""
"STENT GRAFT 24FR 38X200MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10114151","CDM","C1874","HCPCS","0278","RC","","","","both","","","50687.50","38015.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","18500.94","36.5","","1257.80","693.44","2424.50","1 through 10","15713.13","40296.56","percent of total billed charges",""
"STENT GRAFT 24FR 38X200MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10114151","CDM","C1874","HCPCS","0278","RC","","","","both","","","50687.50","38015.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","19413.31","38.3","","1950.11","547.40","2346.00","1 through 10","15713.13","40296.56","percent of total billed charges",""
"STENT GRAFT 24FR 38X200MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10114151","CDM","C1874","HCPCS","0278","RC","","","","both","","","50687.50","38015.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21744.94","42.9","","5096.18","5096.18","5096.18","1 through 10","15713.13","40296.56","percent of total billed charges",""
"STENT GRAFT 24FR 38X200MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10114151","CDM","C1874","HCPCS","0278","RC","","","","both","","","50687.50","38015.62","WELLPOINT [1015]","HB AMC WELLPOINT","37397.24","73.78","","1172.59","1172.59","4829.94","1 through 10","15713.13","40296.56","percent of total billed charges",""
"STENT GRAFT 24FR 38X200MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10114151","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","50687.50","38015.62","AETNA [1001]","HB AMC AETNA HMO","35379.88","69.8","","1806.84","947.80","5091.72","1 through 10","26489.29","41421.83","percent of total billed charges",""
"STENT GRAFT 24FR 38X200MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10114151","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","50687.50","38015.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","41421.83","81.72","","1259.05","615.58","4586.56","1 through 10","26489.29","41421.83","percent of total billed charges",""
"STENT GRAFT 24FR 40X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138679","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","29989.38","65","","6652.80","6652.80","6652.80","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FR 40X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138679","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","36679.31","79.5","","2612.61","795.38","2612.61","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FR 40X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138679","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","24591.29","53.3","","1101.80","1101.80","1101.80","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FR 40X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138679","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","29989.38","65","","1820.00","910.00","1820.00","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FR 40X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138679","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16840.19","36.5","","1257.80","693.44","2424.50","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FR 40X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138679","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17670.66","38.3","","1950.11","547.40","2346.00","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FR 40X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138679","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19792.99","42.9","","5096.18","5096.18","5096.18","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FR 40X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138679","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","WELLPOINT [1015]","HB AMC WELLPOINT","34040.25","73.78","","1172.59","1172.59","4829.94","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FR 40X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138679","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46137.50","34603.12","AETNA [1001]","HB AMC AETNA HMO","32203.98","69.8","","1806.84","947.80","5091.72","1 through 10","24111.46","37703.57","percent of total billed charges",""
"STENT GRAFT 24FR 40X150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10138679","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46137.50","34603.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","37703.57","81.72","","1259.05","615.58","4586.56","1 through 10","24111.46","37703.57","percent of total billed charges",""
"STENT GRAFT 24FRX34 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114435","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","29989.38","65","","6652.80","6652.80","6652.80","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FRX34 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114435","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","36679.31","79.5","","2612.61","795.38","2612.61","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FRX34 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114435","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","24591.29","53.3","","1101.80","1101.80","1101.80","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FRX34 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114435","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","29989.38","65","","1820.00","910.00","1820.00","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FRX34 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114435","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16840.19","36.5","","1257.80","693.44","2424.50","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FRX34 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114435","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17670.66","38.3","","1950.11","547.40","2346.00","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FRX34 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114435","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19792.99","42.9","","5096.18","5096.18","5096.18","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FRX34 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114435","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","WELLPOINT [1015]","HB AMC WELLPOINT","34040.25","73.78","","1172.59","1172.59","4829.94","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 24FRX34 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114435","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46137.50","34603.12","AETNA [1001]","HB AMC AETNA HMO","32203.98","69.8","","1806.84","947.80","5091.72","1 through 10","24111.46","37703.57","percent of total billed charges",""
"STENT GRAFT 24FRX34 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114435","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46137.50","34603.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","37703.57","81.72","","1259.05","615.58","4586.56","1 through 10","24111.46","37703.57","percent of total billed charges",""
"STENT GRAFT 25FR 42X38 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB TAPER","SUP-ITM-10101014","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","29989.38","65","","6652.80","6652.80","6652.80","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FR 42X38 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB TAPER","SUP-ITM-10101014","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","36679.31","79.5","","2612.61","795.38","2612.61","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FR 42X38 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB TAPER","SUP-ITM-10101014","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","24591.29","53.3","","1101.80","1101.80","1101.80","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FR 42X38 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB TAPER","SUP-ITM-10101014","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","29989.38","65","","1820.00","910.00","1820.00","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FR 42X38 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB TAPER","SUP-ITM-10101014","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16840.19","36.5","","1257.80","693.44","2424.50","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FR 42X38 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB TAPER","SUP-ITM-10101014","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17670.66","38.3","","1950.11","547.40","2346.00","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FR 42X38 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB TAPER","SUP-ITM-10101014","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19792.99","42.9","","5096.18","5096.18","5096.18","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FR 42X38 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB TAPER","SUP-ITM-10101014","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","WELLPOINT [1015]","HB AMC WELLPOINT","34040.25","73.78","","1172.59","1172.59","4829.94","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FR 42X38 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB TAPER","SUP-ITM-10101014","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46137.50","34603.12","AETNA [1001]","HB AMC AETNA HMO","32203.98","69.8","","1806.84","947.80","5091.72","1 through 10","24111.46","37703.57","percent of total billed charges",""
"STENT GRAFT 25FR 42X38 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB TAPER","SUP-ITM-10101014","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46137.50","34603.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","37703.57","81.72","","1259.05","615.58","4586.56","1 through 10","24111.46","37703.57","percent of total billed charges",""
"STENT GRAFT 25FR 46X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10114434","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","27454.38","65","","6652.80","6652.80","6652.80","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FR 46X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10114434","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33578.81","79.5","","2612.61","795.38","2612.61","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FR 46X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10114434","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22512.59","53.3","","1101.80","1101.80","1101.80","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FR 46X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10114434","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","27454.38","65","","1820.00","910.00","1820.00","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FR 46X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10114434","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15416.69","36.5","","1257.80","693.44","2424.50","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FR 46X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10114434","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16176.96","38.3","","1950.11","547.40","2346.00","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FR 46X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10114434","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18119.89","42.9","","5096.18","5096.18","5096.18","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FR 46X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10114434","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","WELLPOINT [1015]","HB AMC WELLPOINT","31162.83","73.78","","1172.59","1172.59","4829.94","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FR 46X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10114434","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42237.50","31678.12","AETNA [1001]","HB AMC AETNA HMO","29481.78","69.8","","1806.84","947.80","5091.72","1 through 10","22073.32","34516.49","percent of total billed charges",""
"STENT GRAFT 25FR 46X100MM THORACIC VALIANT CAPTIVIA DISTAL BARE SPRING STRAIGHT","SUP-ITM-10114434","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42237.50","31678.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34516.49","81.72","","1259.05","615.58","4586.56","1 through 10","22073.32","34516.49","percent of total billed charges",""
"STENT GRAFT 25FRX44 150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10094033","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","31256.88","65","","6652.80","6652.80","6652.80","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 25FRX44 150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10094033","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","38229.56","79.5","","2612.61","795.38","2612.61","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 25FRX44 150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10094033","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","25630.64","53.3","","1101.80","1101.80","1101.80","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 25FRX44 150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10094033","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","31256.88","65","","1820.00","910.00","1820.00","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 25FRX44 150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10094033","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17551.94","36.5","","1257.80","693.44","2424.50","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 25FRX44 150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10094033","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18417.51","38.3","","1950.11","547.40","2346.00","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 25FRX44 150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10094033","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20629.54","42.9","","5096.18","5096.18","5096.18","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 25FRX44 150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10094033","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","WELLPOINT [1015]","HB AMC WELLPOINT","35478.96","73.78","","1172.59","1172.59","4829.94","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 25FRX44 150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10094033","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","48087.50","36065.62","AETNA [1001]","HB AMC AETNA HMO","33565.08","69.8","","1806.84","947.80","5091.72","1 through 10","25130.53","39297.11","percent of total billed charges",""
"STENT GRAFT 25FRX44 150MM THORACIC VALIANT CAPTIVIA PROXIMALIMAL FREEFLO STRAIGHT","SUP-ITM-10094033","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","48087.50","36065.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","39297.11","81.72","","1259.05","615.58","4586.56","1 through 10","25130.53","39297.11","percent of total billed charges",""
"STENT GRAFT 25FRX44 200MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10113393","CDM","C1874","HCPCS","0278","RC","","","","both","","","48737.50","36553.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","31679.38","65","","6652.80","6652.80","6652.80","1 through 10","15108.63","38746.31","percent of total billed charges",""
"STENT GRAFT 25FRX44 200MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10113393","CDM","C1874","HCPCS","0278","RC","","","","both","","","48737.50","36553.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","38746.31","79.5","","2612.61","795.38","2612.61","1 through 10","15108.63","38746.31","percent of total billed charges",""
"STENT GRAFT 25FRX44 200MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10113393","CDM","C1874","HCPCS","0278","RC","","","","both","","","48737.50","36553.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","25977.09","53.3","","1101.80","1101.80","1101.80","1 through 10","15108.63","38746.31","percent of total billed charges",""
"STENT GRAFT 25FRX44 200MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10113393","CDM","C1874","HCPCS","0278","RC","","","","both","","","48737.50","36553.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","31679.38","65","","1820.00","910.00","1820.00","1 through 10","15108.63","38746.31","percent of total billed charges",""
"STENT GRAFT 25FRX44 200MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10113393","CDM","C1874","HCPCS","0278","RC","","","","both","","","48737.50","36553.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17789.19","36.5","","1257.80","693.44","2424.50","1 through 10","15108.63","38746.31","percent of total billed charges",""
"STENT GRAFT 25FRX44 200MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10113393","CDM","C1874","HCPCS","0278","RC","","","","both","","","48737.50","36553.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18666.46","38.3","","1950.11","547.40","2346.00","1 through 10","15108.63","38746.31","percent of total billed charges",""
"STENT GRAFT 25FRX44 200MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10113393","CDM","C1874","HCPCS","0278","RC","","","","both","","","48737.50","36553.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20908.39","42.9","","5096.18","5096.18","5096.18","1 through 10","15108.63","38746.31","percent of total billed charges",""
"STENT GRAFT 25FRX44 200MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10113393","CDM","C1874","HCPCS","0278","RC","","","","both","","","48737.50","36553.12","WELLPOINT [1015]","HB AMC WELLPOINT","35958.53","73.78","","1172.59","1172.59","4829.94","1 through 10","15108.63","38746.31","percent of total billed charges",""
"STENT GRAFT 25FRX44 200MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10113393","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","48737.50","36553.12","AETNA [1001]","HB AMC AETNA HMO","34018.78","69.8","","1806.84","947.80","5091.72","1 through 10","25470.22","39828.29","percent of total billed charges",""
"STENT GRAFT 25FRX44 200MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10113393","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","48737.50","36553.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","39828.29","81.72","","1259.05","615.58","4586.56","1 through 10","25470.22","39828.29","percent of total billed charges",""
"STENT GRAFT 25FRX46 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114301","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","27454.38","65","","6652.80","6652.80","6652.80","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FRX46 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114301","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33578.81","79.5","","2612.61","795.38","2612.61","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FRX46 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114301","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22512.59","53.3","","1101.80","1101.80","1101.80","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FRX46 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114301","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","27454.38","65","","1820.00","910.00","1820.00","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FRX46 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114301","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15416.69","36.5","","1257.80","693.44","2424.50","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FRX46 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114301","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16176.96","38.3","","1950.11","547.40","2346.00","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FRX46 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114301","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18119.89","42.9","","5096.18","5096.18","5096.18","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FRX46 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114301","CDM","C1874","HCPCS","0278","RC","","","","both","","","42237.50","31678.12","WELLPOINT [1015]","HB AMC WELLPOINT","31162.83","73.78","","1172.59","1172.59","4829.94","1 through 10","13093.63","33578.81","percent of total billed charges",""
"STENT GRAFT 25FRX46 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114301","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42237.50","31678.12","AETNA [1001]","HB AMC AETNA HMO","29481.78","69.8","","1806.84","947.80","5091.72","1 through 10","22073.32","34516.49","percent of total billed charges",""
"STENT GRAFT 25FRX46 100MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10114301","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","42237.50","31678.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34516.49","81.72","","1259.05","615.58","4586.56","1 through 10","22073.32","34516.49","percent of total billed charges",""
"STENT GRAFT 25FRX46 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10094034","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","29989.38","65","","6652.80","6652.80","6652.80","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FRX46 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10094034","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","36679.31","79.5","","2612.61","795.38","2612.61","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FRX46 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10094034","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","24591.29","53.3","","1101.80","1101.80","1101.80","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FRX46 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10094034","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","29989.38","65","","1820.00","910.00","1820.00","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FRX46 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10094034","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","16840.19","36.5","","1257.80","693.44","2424.50","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FRX46 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10094034","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","17670.66","38.3","","1950.11","547.40","2346.00","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FRX46 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10094034","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19792.99","42.9","","5096.18","5096.18","5096.18","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FRX46 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10094034","CDM","C1874","HCPCS","0278","RC","","","","both","","","46137.50","34603.12","WELLPOINT [1015]","HB AMC WELLPOINT","34040.25","73.78","","1172.59","1172.59","4829.94","1 through 10","14302.63","36679.31","percent of total billed charges",""
"STENT GRAFT 25FRX46 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10094034","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46137.50","34603.12","AETNA [1001]","HB AMC AETNA HMO","32203.98","69.8","","1806.84","947.80","5091.72","1 through 10","24111.46","37703.57","percent of total billed charges",""
"STENT GRAFT 25FRX46 150MM THORACIC VALIANT CAPTIVIA CLOSED WEB STRAIGHT","SUP-ITM-10094034","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","46137.50","34603.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","37703.57","81.72","","1259.05","615.58","4586.56","1 through 10","24111.46","37703.57","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","17407.00","65","","6652.80","6652.80","6652.80","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","21290.10","79.5","","2612.61","795.38","2612.61","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","14273.74","53.3","","1101.80","1101.80","1101.80","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","17407.00","65","","1820.00","910.00","1820.00","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9774.70","36.5","","1257.80","693.44","2424.50","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10256.74","38.3","","1950.11","547.40","2346.00","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11488.62","42.9","","5096.18","5096.18","5096.18","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","both","","","26780.00","20085.00","WELLPOINT [1015]","HB AMC WELLPOINT","19758.28","73.78","","1172.59","1172.59","4829.94","1 through 10","8301.8","21290.1","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","26780.00","20085.00","AETNA [1001]","HB AMC AETNA HMO","18692.44","69.8","","1806.84","947.80","5091.72","1 through 10","13995.23","21884.62","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","26780.00","20085.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21884.62","81.72","","1259.05","615.58","4586.56","1 through 10","13995.23","21884.62","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7195.50","65","","6652.80","6652.80","6652.80","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8800.65","79.5","","2612.61","795.38","2612.61","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5900.31","53.3","","1101.80","1101.80","1101.80","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7195.50","65","","1820.00","910.00","1820.00","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4040.55","36.5","","1257.80","693.44","2424.50","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4239.81","38.3","","1950.11","547.40","2346.00","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4749.03","42.9","","5096.18","5096.18","5096.18","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","both","","","11070.00","8302.50","WELLPOINT [1015]","HB AMC WELLPOINT","8167.45","73.78","","1172.59","1172.59","4829.94","1 through 10","3431.7","8800.65","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11070.00","8302.50","AETNA [1001]","HB AMC AETNA HMO","7726.86","69.8","","1806.84","947.80","5091.72","1 through 10","5785.18","9046.4","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11070.00","8302.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9046.40","81.72","","1259.05","615.58","4586.56","1 through 10","5785.18","9046.4","percent of total billed charges",""
"STENT GRAFT 28MM DIA 124X2 AAA ENDOVASCULAR ZENITH FENESTRATED SS POLYESTER H L B ONE SHOT PROXIMALIMAL","SUP-ITM-10101343","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","19773.81","65","","6652.80","6652.80","6652.80","1 through 10","9430.59","24184.89","percent of total billed charges",""
"STENT GRAFT 28MM DIA 124X2 AAA ENDOVASCULAR ZENITH FENESTRATED SS POLYESTER H L B ONE SHOT PROXIMALIMAL","SUP-ITM-10101343","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","24184.89","79.5","","2612.61","795.38","2612.61","1 through 10","9430.59","24184.89","percent of total billed charges",""
"STENT GRAFT 28MM DIA 124X2 AAA ENDOVASCULAR ZENITH FENESTRATED SS POLYESTER H L B ONE SHOT PROXIMALIMAL","SUP-ITM-10101343","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16214.53","53.3","","1101.80","1101.80","1101.80","1 through 10","9430.59","24184.89","percent of total billed charges",""
"STENT GRAFT 28MM DIA 124X2 AAA ENDOVASCULAR ZENITH FENESTRATED SS POLYESTER H L B ONE SHOT PROXIMALIMAL","SUP-ITM-10101343","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","19773.81","65","","1820.00","910.00","1820.00","1 through 10","9430.59","24184.89","percent of total billed charges",""
"STENT GRAFT 28MM DIA 124X2 AAA ENDOVASCULAR ZENITH FENESTRATED SS POLYESTER H L B ONE SHOT PROXIMALIMAL","SUP-ITM-10101343","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11103.76","36.5","","1257.80","693.44","2424.50","1 through 10","9430.59","24184.89","percent of total billed charges",""
"STENT GRAFT 28MM DIA 124X2 AAA ENDOVASCULAR ZENITH FENESTRATED SS POLYESTER H L B ONE SHOT PROXIMALIMAL","SUP-ITM-10101343","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11651.34","38.3","","1950.11","547.40","2346.00","1 through 10","9430.59","24184.89","percent of total billed charges",""
"STENT GRAFT 28MM DIA 124X2 AAA ENDOVASCULAR ZENITH FENESTRATED SS POLYESTER H L B ONE SHOT PROXIMALIMAL","SUP-ITM-10101343","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13050.72","42.9","","5096.18","5096.18","5096.18","1 through 10","9430.59","24184.89","percent of total billed charges",""
"STENT GRAFT 28MM DIA 124X2 AAA ENDOVASCULAR ZENITH FENESTRATED SS POLYESTER H L B ONE SHOT PROXIMALIMAL","SUP-ITM-10101343","CDM","C1874","HCPCS","0278","RC","","","","both","","","30421.25","22815.94","WELLPOINT [1015]","HB AMC WELLPOINT","22444.80","73.78","","1172.59","1172.59","4829.94","1 through 10","9430.59","24184.89","percent of total billed charges",""
"STENT GRAFT 28MM DIA 124X2 AAA ENDOVASCULAR ZENITH FENESTRATED SS POLYESTER H L B ONE SHOT PROXIMALIMAL","SUP-ITM-10101343","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30421.25","22815.94","AETNA [1001]","HB AMC AETNA HMO","21234.03","69.8","","1806.84","947.80","5091.72","1 through 10","15898.15","24860.25","percent of total billed charges",""
"STENT GRAFT 28MM DIA 124X2 AAA ENDOVASCULAR ZENITH FENESTRATED SS POLYESTER H L B ONE SHOT PROXIMALIMAL","SUP-ITM-10101343","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","30421.25","22815.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24860.25","81.72","","1259.05","615.58","4586.56","1 through 10","15898.15","24860.25","percent of total billed charges",""
"STENT GRAFT 28X80 OVATION CONTRALATERAL LIMB","SUP-ITM-10188400","CDM","C1874","HCPCS","0278","RC","","","","both","","","10250.00","7687.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6662.50","65","","6652.80","6652.80","6652.80","1 through 10","3177.5","8148.75","percent of total billed charges",""
"STENT GRAFT 28X80 OVATION CONTRALATERAL LIMB","SUP-ITM-10188400","CDM","C1874","HCPCS","0278","RC","","","","both","","","10250.00","7687.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8148.75","79.5","","2612.61","795.38","2612.61","1 through 10","3177.5","8148.75","percent of total billed charges",""
"STENT GRAFT 28X80 OVATION CONTRALATERAL LIMB","SUP-ITM-10188400","CDM","C1874","HCPCS","0278","RC","","","","both","","","10250.00","7687.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5463.25","53.3","","1101.80","1101.80","1101.80","1 through 10","3177.5","8148.75","percent of total billed charges",""
"STENT GRAFT 28X80 OVATION CONTRALATERAL LIMB","SUP-ITM-10188400","CDM","C1874","HCPCS","0278","RC","","","","both","","","10250.00","7687.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6662.50","65","","1820.00","910.00","1820.00","1 through 10","3177.5","8148.75","percent of total billed charges",""
"STENT GRAFT 28X80 OVATION CONTRALATERAL LIMB","SUP-ITM-10188400","CDM","C1874","HCPCS","0278","RC","","","","both","","","10250.00","7687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3741.25","36.5","","1257.80","693.44","2424.50","1 through 10","3177.5","8148.75","percent of total billed charges",""
"STENT GRAFT 28X80 OVATION CONTRALATERAL LIMB","SUP-ITM-10188400","CDM","C1874","HCPCS","0278","RC","","","","both","","","10250.00","7687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3925.75","38.3","","1950.11","547.40","2346.00","1 through 10","3177.5","8148.75","percent of total billed charges",""
"STENT GRAFT 28X80 OVATION CONTRALATERAL LIMB","SUP-ITM-10188400","CDM","C1874","HCPCS","0278","RC","","","","both","","","10250.00","7687.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4397.25","42.9","","5096.18","5096.18","5096.18","1 through 10","3177.5","8148.75","percent of total billed charges",""
"STENT GRAFT 28X80 OVATION CONTRALATERAL LIMB","SUP-ITM-10188400","CDM","C1874","HCPCS","0278","RC","","","","both","","","10250.00","7687.50","WELLPOINT [1015]","HB AMC WELLPOINT","7562.45","73.78","","1172.59","1172.59","4829.94","1 through 10","3177.5","8148.75","percent of total billed charges",""
"STENT GRAFT 28X80 OVATION CONTRALATERAL LIMB","SUP-ITM-10188400","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10250.00","7687.50","AETNA [1001]","HB AMC AETNA HMO","7154.50","69.8","","1806.84","947.80","5091.72","1 through 10","5356.65","8376.3","percent of total billed charges",""
"STENT GRAFT 28X80 OVATION CONTRALATERAL LIMB","SUP-ITM-10188400","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10250.00","7687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8376.30","81.72","","1259.05","615.58","4586.56","1 through 10","5356.65","8376.3","percent of total billed charges",""
"STENT GRAFT 36MM 4.5CM VASCULAR EXCLUDER EPTFE EXTENDER AORTIC","SUP-ITM-10114948","CDM","C1874","HCPCS","0278","RC","","","","both","","","7727.50","5795.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5022.88","65","","6652.80","6652.80","6652.80","1 through 10","2395.53","6143.36","percent of total billed charges",""
"STENT GRAFT 36MM 4.5CM VASCULAR EXCLUDER EPTFE EXTENDER AORTIC","SUP-ITM-10114948","CDM","C1874","HCPCS","0278","RC","","","","both","","","7727.50","5795.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6143.36","79.5","","2612.61","795.38","2612.61","1 through 10","2395.53","6143.36","percent of total billed charges",""
"STENT GRAFT 36MM 4.5CM VASCULAR EXCLUDER EPTFE EXTENDER AORTIC","SUP-ITM-10114948","CDM","C1874","HCPCS","0278","RC","","","","both","","","7727.50","5795.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4118.76","53.3","","1101.80","1101.80","1101.80","1 through 10","2395.53","6143.36","percent of total billed charges",""
"STENT GRAFT 36MM 4.5CM VASCULAR EXCLUDER EPTFE EXTENDER AORTIC","SUP-ITM-10114948","CDM","C1874","HCPCS","0278","RC","","","","both","","","7727.50","5795.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5022.88","65","","1820.00","910.00","1820.00","1 through 10","2395.53","6143.36","percent of total billed charges",""
"STENT GRAFT 36MM 4.5CM VASCULAR EXCLUDER EPTFE EXTENDER AORTIC","SUP-ITM-10114948","CDM","C1874","HCPCS","0278","RC","","","","both","","","7727.50","5795.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2820.54","36.5","","1257.80","693.44","2424.50","1 through 10","2395.53","6143.36","percent of total billed charges",""
"STENT GRAFT 36MM 4.5CM VASCULAR EXCLUDER EPTFE EXTENDER AORTIC","SUP-ITM-10114948","CDM","C1874","HCPCS","0278","RC","","","","both","","","7727.50","5795.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2959.63","38.3","","1950.11","547.40","2346.00","1 through 10","2395.53","6143.36","percent of total billed charges",""
"STENT GRAFT 36MM 4.5CM VASCULAR EXCLUDER EPTFE EXTENDER AORTIC","SUP-ITM-10114948","CDM","C1874","HCPCS","0278","RC","","","","both","","","7727.50","5795.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3315.10","42.9","","5096.18","5096.18","5096.18","1 through 10","2395.53","6143.36","percent of total billed charges",""
"STENT GRAFT 36MM 4.5CM VASCULAR EXCLUDER EPTFE EXTENDER AORTIC","SUP-ITM-10114948","CDM","C1874","HCPCS","0278","RC","","","","both","","","7727.50","5795.62","WELLPOINT [1015]","HB AMC WELLPOINT","5701.35","73.78","","1172.59","1172.59","4829.94","1 through 10","2395.53","6143.36","percent of total billed charges",""
"STENT GRAFT 36MM 4.5CM VASCULAR EXCLUDER EPTFE EXTENDER AORTIC","SUP-ITM-10114948","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7727.50","5795.62","AETNA [1001]","HB AMC AETNA HMO","5393.80","69.8","","1806.84","947.80","5091.72","1 through 10","4038.39","6314.91","percent of total billed charges",""
"STENT GRAFT 36MM 4.5CM VASCULAR EXCLUDER EPTFE EXTENDER AORTIC","SUP-ITM-10114948","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7727.50","5795.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6314.91","81.72","","1259.05","615.58","4586.56","1 through 10","4038.39","6314.91","percent of total billed charges",""
"STENT GRAFT 39X32 XSEC 7.7MM IDSEC 20FR ENDOVASCULAR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10014572","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3722.88","65","","6652.80","6652.80","6652.80","1 through 10","1775.53","4553.36","percent of total billed charges",""
"STENT GRAFT 39X32 XSEC 7.7MM IDSEC 20FR ENDOVASCULAR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10014572","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4553.36","79.5","","2612.61","795.38","2612.61","1 through 10","1775.53","4553.36","percent of total billed charges",""
"STENT GRAFT 39X32 XSEC 7.7MM IDSEC 20FR ENDOVASCULAR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10014572","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3052.76","53.3","","1101.80","1101.80","1101.80","1 through 10","1775.53","4553.36","percent of total billed charges",""
"STENT GRAFT 39X32 XSEC 7.7MM IDSEC 20FR ENDOVASCULAR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10014572","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3722.88","65","","1820.00","910.00","1820.00","1 through 10","1775.53","4553.36","percent of total billed charges",""
"STENT GRAFT 39X32 XSEC 7.7MM IDSEC 20FR ENDOVASCULAR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10014572","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2090.54","36.5","","1257.80","693.44","2424.50","1 through 10","1775.53","4553.36","percent of total billed charges",""
"STENT GRAFT 39X32 XSEC 7.7MM IDSEC 20FR ENDOVASCULAR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10014572","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2193.63","38.3","","1950.11","547.40","2346.00","1 through 10","1775.53","4553.36","percent of total billed charges",""
"STENT GRAFT 39X32 XSEC 7.7MM IDSEC 20FR ENDOVASCULAR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10014572","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2457.10","42.9","","5096.18","5096.18","5096.18","1 through 10","1775.53","4553.36","percent of total billed charges",""
"STENT GRAFT 39X32 XSEC 7.7MM IDSEC 20FR ENDOVASCULAR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10014572","CDM","C1874","HCPCS","0278","RC","","","","both","","","5727.50","4295.62","WELLPOINT [1015]","HB AMC WELLPOINT","4225.75","73.78","","1172.59","1172.59","4829.94","1 through 10","1775.53","4553.36","percent of total billed charges",""
"STENT GRAFT 39X32 XSEC 7.7MM IDSEC 20FR ENDOVASCULAR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10014572","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5727.50","4295.62","AETNA [1001]","HB AMC AETNA HMO","3997.80","69.8","","1806.84","947.80","5091.72","1 through 10","2993.19","4680.51","percent of total billed charges",""
"STENT GRAFT 39X32 XSEC 7.7MM IDSEC 20FR ENDOVASCULAR MAIN BODY EXT INTRO SHEATH Z TRAK INTRODUCTION SYST ZENITH FLX IMPL","SUP-ITM-10014572","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5727.50","4295.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4680.51","81.72","","1259.05","615.58","4586.56","1 through 10","2993.19","4680.51","percent of total billed charges",""
"STENT GRAFT 46MMX42 150 VALIANT CAPTIVIA PROXIMALIMAL TAPERED FREE FLOW","SUP-ITM-10130438","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","31256.88","65","","6652.80","6652.80","6652.80","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 46MMX42 150 VALIANT CAPTIVIA PROXIMALIMAL TAPERED FREE FLOW","SUP-ITM-10130438","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","38229.56","79.5","","2612.61","795.38","2612.61","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 46MMX42 150 VALIANT CAPTIVIA PROXIMALIMAL TAPERED FREE FLOW","SUP-ITM-10130438","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","25630.64","53.3","","1101.80","1101.80","1101.80","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 46MMX42 150 VALIANT CAPTIVIA PROXIMALIMAL TAPERED FREE FLOW","SUP-ITM-10130438","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","31256.88","65","","1820.00","910.00","1820.00","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 46MMX42 150 VALIANT CAPTIVIA PROXIMALIMAL TAPERED FREE FLOW","SUP-ITM-10130438","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17551.94","36.5","","1257.80","693.44","2424.50","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 46MMX42 150 VALIANT CAPTIVIA PROXIMALIMAL TAPERED FREE FLOW","SUP-ITM-10130438","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18417.51","38.3","","1950.11","547.40","2346.00","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 46MMX42 150 VALIANT CAPTIVIA PROXIMALIMAL TAPERED FREE FLOW","SUP-ITM-10130438","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20629.54","42.9","","5096.18","5096.18","5096.18","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 46MMX42 150 VALIANT CAPTIVIA PROXIMALIMAL TAPERED FREE FLOW","SUP-ITM-10130438","CDM","C1874","HCPCS","0278","RC","","","","both","","","48087.50","36065.62","WELLPOINT [1015]","HB AMC WELLPOINT","35478.96","73.78","","1172.59","1172.59","4829.94","1 through 10","14907.13","38229.56","percent of total billed charges",""
"STENT GRAFT 46MMX42 150 VALIANT CAPTIVIA PROXIMALIMAL TAPERED FREE FLOW","SUP-ITM-10130438","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","48087.50","36065.62","AETNA [1001]","HB AMC AETNA HMO","33565.08","69.8","","1806.84","947.80","5091.72","1 through 10","25130.53","39297.11","percent of total billed charges",""
"STENT GRAFT 46MMX42 150 VALIANT CAPTIVIA PROXIMALIMAL TAPERED FREE FLOW","SUP-ITM-10130438","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","48087.50","36065.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","39297.11","81.72","","1259.05","615.58","4586.56","1 through 10","25130.53","39297.11","percent of total billed charges",""
"STENT GRAFT 91X28CM 12MM ENDOVASCULAR BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR","SUP-ITM-10101360","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6859.13","65","","6652.80","6652.80","6652.80","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 91X28CM 12MM ENDOVASCULAR BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR","SUP-ITM-10101360","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8389.24","79.5","","2612.61","795.38","2612.61","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 91X28CM 12MM ENDOVASCULAR BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR","SUP-ITM-10101360","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5624.48","53.3","","1101.80","1101.80","1101.80","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 91X28CM 12MM ENDOVASCULAR BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR","SUP-ITM-10101360","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6859.13","65","","1820.00","910.00","1820.00","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 91X28CM 12MM ENDOVASCULAR BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR","SUP-ITM-10101360","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3851.66","36.5","","1257.80","693.44","2424.50","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 91X28CM 12MM ENDOVASCULAR BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR","SUP-ITM-10101360","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4041.61","38.3","","1950.11","547.40","2346.00","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 91X28CM 12MM ENDOVASCULAR BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR","SUP-ITM-10101360","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4527.02","42.9","","5096.18","5096.18","5096.18","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 91X28CM 12MM ENDOVASCULAR BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR","SUP-ITM-10101360","CDM","C1874","HCPCS","0278","RC","","","","both","","","10552.50","7914.37","WELLPOINT [1015]","HB AMC WELLPOINT","7785.63","73.78","","1172.59","1172.59","4829.94","1 through 10","3271.28","8389.24","percent of total billed charges",""
"STENT GRAFT 91X28CM 12MM ENDOVASCULAR BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR","SUP-ITM-10101360","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10552.50","7914.37","AETNA [1001]","HB AMC AETNA HMO","7365.65","69.8","","1806.84","947.80","5091.72","1 through 10","5514.74","8623.5","percent of total billed charges",""
"STENT GRAFT 91X28CM 12MM ENDOVASCULAR BIFRCTD FEN IPSILATERAL DISTL ZENITH IMPLANT ABDL AORTC ANEUR","SUP-ITM-10101360","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10552.50","7914.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8623.50","81.72","","1259.05","615.58","4586.56","1 through 10","5514.74","8623.5","percent of total billed charges",""
"Stent Graft Endovascular T3","PX-27000720","CDM","C1874","HCPCS","0278","RC","","","","both","","","13054.23","9790.67","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8485.25","65","","6652.80","6652.80","6652.80","1 through 10","4046.81","10378.11","percent of total billed charges",""
"Stent Graft Endovascular T3","PX-27000720","CDM","C1874","HCPCS","0278","RC","","","","both","","","13054.23","9790.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10378.11","79.5","","2612.61","795.38","2612.61","1 through 10","4046.81","10378.11","percent of total billed charges",""
"Stent Graft Endovascular T3","PX-27000720","CDM","C1874","HCPCS","0278","RC","","","","both","","","13054.23","9790.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6957.90","53.3","","1101.80","1101.80","1101.80","1 through 10","4046.81","10378.11","percent of total billed charges",""
"Stent Graft Endovascular T3","PX-27000720","CDM","C1874","HCPCS","0278","RC","","","","both","","","13054.23","9790.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8485.25","65","","1820.00","910.00","1820.00","1 through 10","4046.81","10378.11","percent of total billed charges",""
"Stent Graft Endovascular T3","PX-27000720","CDM","C1874","HCPCS","0278","RC","","","","both","","","13054.23","9790.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4764.79","36.5","","1257.80","693.44","2424.50","1 through 10","4046.81","10378.11","percent of total billed charges",""
"Stent Graft Endovascular T3","PX-27000720","CDM","C1874","HCPCS","0278","RC","","","","both","","","13054.23","9790.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4999.77","38.3","","1950.11","547.40","2346.00","1 through 10","4046.81","10378.11","percent of total billed charges",""
"Stent Graft Endovascular T3","PX-27000720","CDM","C1874","HCPCS","0278","RC","","","","both","","","13054.23","9790.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5600.26","42.9","","5096.18","5096.18","5096.18","1 through 10","4046.81","10378.11","percent of total billed charges",""
"Stent Graft Endovascular T3","PX-27000720","CDM","C1874","HCPCS","0278","RC","","","","both","","","13054.23","9790.67","WELLPOINT [1015]","HB AMC WELLPOINT","9631.41","73.78","","1172.59","1172.59","4829.94","1 through 10","4046.81","10378.11","percent of total billed charges",""
"Stent Graft Endovascular T3","PX-27000720","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13054.23","9790.67","AETNA [1001]","HB AMC AETNA HMO","9111.85","69.8","","1806.84","947.80","5091.72","1 through 10","6822.14","10667.92","percent of total billed charges",""
"Stent Graft Endovascular T3","PX-27000720","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13054.23","9790.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10667.92","81.72","","1259.05","615.58","4586.56","1 through 10","6822.14","10667.92","percent of total billed charges",""
"STENT GRFT 39X20 XSEC 6MM IDSEC 5.3 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094520","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6175.81","65","","6652.80","6652.80","6652.80","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 39X20 XSEC 6MM IDSEC 5.3 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094520","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7553.49","79.5","","2612.61","795.38","2612.61","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 39X20 XSEC 6MM IDSEC 5.3 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094520","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5064.17","53.3","","1101.80","1101.80","1101.80","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 39X20 XSEC 6MM IDSEC 5.3 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094520","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6175.81","65","","1820.00","910.00","1820.00","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 39X20 XSEC 6MM IDSEC 5.3 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094520","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3467.96","36.5","","1257.80","693.44","2424.50","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 39X20 XSEC 6MM IDSEC 5.3 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094520","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3638.98","38.3","","1950.11","547.40","2346.00","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 39X20 XSEC 6MM IDSEC 5.3 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094520","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4076.04","42.9","","5096.18","5096.18","5096.18","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 39X20 XSEC 6MM IDSEC 5.3 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094520","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","WELLPOINT [1015]","HB AMC WELLPOINT","7010.02","73.78","","1172.59","1172.59","4829.94","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 39X20 XSEC 6MM IDSEC 5.3 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094520","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9501.25","7125.94","AETNA [1001]","HB AMC AETNA HMO","6631.87","69.8","","1806.84","947.80","5091.72","1 through 10","4965.35","7764.42","percent of total billed charges",""
"STENT GRFT 39X20 XSEC 6MM IDSEC 5.3 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094520","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9501.25","7125.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7764.42","81.72","","1259.05","615.58","4586.56","1 through 10","4965.35","7764.42","percent of total billed charges",""
"STENT GRFT 74X11 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094506","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6175.81","65","","6652.80","6652.80","6652.80","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X11 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094506","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7553.49","79.5","","2612.61","795.38","2612.61","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X11 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094506","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5064.17","53.3","","1101.80","1101.80","1101.80","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X11 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094506","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6175.81","65","","1820.00","910.00","1820.00","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X11 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094506","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3467.96","36.5","","1257.80","693.44","2424.50","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X11 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094506","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3638.98","38.3","","1950.11","547.40","2346.00","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X11 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094506","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4076.04","42.9","","5096.18","5096.18","5096.18","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X11 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094506","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","WELLPOINT [1015]","HB AMC WELLPOINT","7010.02","73.78","","1172.59","1172.59","4829.94","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X11 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094506","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9501.25","7125.94","AETNA [1001]","HB AMC AETNA HMO","6631.87","69.8","","1806.84","947.80","5091.72","1 through 10","4965.35","7764.42","percent of total billed charges",""
"STENT GRFT 74X11 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094506","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9501.25","7125.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7764.42","81.72","","1259.05","615.58","4586.56","1 through 10","4965.35","7764.42","percent of total billed charges",""
"STENT GRFT 74X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094500","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6175.81","65","","6652.80","6652.80","6652.80","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094500","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7553.49","79.5","","2612.61","795.38","2612.61","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094500","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5064.17","53.3","","1101.80","1101.80","1101.80","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094500","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6175.81","65","","1820.00","910.00","1820.00","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094500","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3467.96","36.5","","1257.80","693.44","2424.50","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094500","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3638.98","38.3","","1950.11","547.40","2346.00","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094500","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4076.04","42.9","","5096.18","5096.18","5096.18","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094500","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","WELLPOINT [1015]","HB AMC WELLPOINT","7010.02","73.78","","1172.59","1172.59","4829.94","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 74X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094500","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9501.25","7125.94","AETNA [1001]","HB AMC AETNA HMO","6631.87","69.8","","1806.84","947.80","5091.72","1 through 10","4965.35","7764.42","percent of total billed charges",""
"STENT GRFT 74X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094500","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9501.25","7125.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7764.42","81.72","","1259.05","615.58","4586.56","1 through 10","4965.35","7764.42","percent of total billed charges",""
"STENT GRFT 90X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094501","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6175.81","65","","6652.80","6652.80","6652.80","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 90X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094501","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7553.49","79.5","","2612.61","795.38","2612.61","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 90X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094501","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5064.17","53.3","","1101.80","1101.80","1101.80","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 90X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094501","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6175.81","65","","1820.00","910.00","1820.00","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 90X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094501","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3467.96","36.5","","1257.80","693.44","2424.50","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 90X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094501","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3638.98","38.3","","1950.11","547.40","2346.00","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 90X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094501","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4076.04","42.9","","5096.18","5096.18","5096.18","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 90X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094501","CDM","C1874","HCPCS","0278","RC","","","","both","","","9501.25","7125.94","WELLPOINT [1015]","HB AMC WELLPOINT","7010.02","73.78","","1172.59","1172.59","4829.94","1 through 10","2945.39","7553.49","percent of total billed charges",""
"STENT GRFT 90X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094501","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9501.25","7125.94","AETNA [1001]","HB AMC AETNA HMO","6631.87","69.8","","1806.84","947.80","5091.72","1 through 10","4965.35","7764.42","percent of total billed charges",""
"STENT GRFT 90X9 XSEC 5.4MM IDSEC 4.7 ENDOVASCULAR INTRO SHEATH CONTRALATERAL IPSILATERAL Z TRAK INTRODUCTION SYST ILIAC","SUP-ITM-10094501","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9501.25","7125.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7764.42","81.72","","1259.05","615.58","4586.56","1 through 10","4965.35","7764.42","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 5 CM UNCOVERED BILIARY","SUP-ITM-10211969","CDM","C1876","HCPCS","0278","RC","","","","both","","","3878.42","2908.81","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2544.24","65.6","","751.18","751.18","751.18","1 through 10","1202.31","3083.34","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 5 CM UNCOVERED BILIARY","SUP-ITM-10211969","CDM","C1876","HCPCS","0278","RC","","","","both","","","3878.42","2908.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3083.34","79.5","","4820.38","3211.27","4820.38","1 through 10","1202.31","3083.34","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 5 CM UNCOVERED BILIARY","SUP-ITM-10211969","CDM","C1876","HCPCS","0278","RC","","","","both","","","3878.42","2908.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1415.62","36.5","","641.00","641.00","641.00","1 through 10","1202.31","3083.34","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 5 CM UNCOVERED BILIARY","SUP-ITM-10211969","CDM","C1876","HCPCS","0278","RC","","","","both","","","3878.42","2908.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1485.43","38.3","","1098.43","1098.43","1098.43","1 through 10","1202.31","3083.34","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 5 CM UNCOVERED BILIARY","SUP-ITM-10211969","CDM","C1876","HCPCS","0278","RC","","","","both","","","3878.42","2908.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1663.84","42.9","","4896.33","4896.33","4896.33","1 through 10","1202.31","3083.34","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 5 CM UNCOVERED BILIARY","SUP-ITM-10211969","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3878.42","2908.81","AETNA [1001]","HB AMC AETNA HMO","2707.14","69.8","","175.60","163.11","1063.91","1 through 10","2026.86","3169.44","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 5 CM UNCOVERED BILIARY","SUP-ITM-10211969","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3878.42","2908.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3169.44","81.72","","105.94","85.10","105.94","1 through 10","2026.86","3169.44","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 7 CM UNCOVERED BILIARY","SUP-ITM-10211967","CDM","C1876","HCPCS","0278","RC","","","","both","","","3878.42","2908.81","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2544.24","65.6","","751.18","751.18","751.18","1 through 10","1202.31","3083.34","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 7 CM UNCOVERED BILIARY","SUP-ITM-10211967","CDM","C1876","HCPCS","0278","RC","","","","both","","","3878.42","2908.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3083.34","79.5","","4820.38","3211.27","4820.38","1 through 10","1202.31","3083.34","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 7 CM UNCOVERED BILIARY","SUP-ITM-10211967","CDM","C1876","HCPCS","0278","RC","","","","both","","","3878.42","2908.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1415.62","36.5","","641.00","641.00","641.00","1 through 10","1202.31","3083.34","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 7 CM UNCOVERED BILIARY","SUP-ITM-10211967","CDM","C1876","HCPCS","0278","RC","","","","both","","","3878.42","2908.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1485.43","38.3","","1098.43","1098.43","1098.43","1 through 10","1202.31","3083.34","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 7 CM UNCOVERED BILIARY","SUP-ITM-10211967","CDM","C1876","HCPCS","0278","RC","","","","both","","","3878.42","2908.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1663.84","42.9","","4896.33","4896.33","4896.33","1 through 10","1202.31","3083.34","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 7 CM UNCOVERED BILIARY","SUP-ITM-10211967","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3878.42","2908.81","AETNA [1001]","HB AMC AETNA HMO","2707.14","69.8","","175.60","163.11","1063.91","1 through 10","2026.86","3169.44","percent of total billed charges",""
"STENT HANAROSTENT BIL 10 DM 7 CM UNCOVERED BILIARY","SUP-ITM-10211967","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3878.42","2908.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3169.44","81.72","","105.94","85.10","105.94","1 through 10","2026.86","3169.44","percent of total billed charges",""
"STENT HARRELL Y14X12X50X25X35MM WITH POSTS","SUP-ITM-10030669","CDM","C1874","HCPCS","0278","RC","","","","both","","","2544.71","1908.53","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1654.06","65","","6652.80","6652.80","6652.80","1 through 10","788.86","2023.04","percent of total billed charges",""
"STENT HARRELL Y14X12X50X25X35MM WITH POSTS","SUP-ITM-10030669","CDM","C1874","HCPCS","0278","RC","","","","both","","","2544.71","1908.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2023.04","79.5","","2612.61","795.38","2612.61","1 through 10","788.86","2023.04","percent of total billed charges",""
"STENT HARRELL Y14X12X50X25X35MM WITH POSTS","SUP-ITM-10030669","CDM","C1874","HCPCS","0278","RC","","","","both","","","2544.71","1908.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1356.33","53.3","","1101.80","1101.80","1101.80","1 through 10","788.86","2023.04","percent of total billed charges",""
"STENT HARRELL Y14X12X50X25X35MM WITH POSTS","SUP-ITM-10030669","CDM","C1874","HCPCS","0278","RC","","","","both","","","2544.71","1908.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1654.06","65","","1820.00","910.00","1820.00","1 through 10","788.86","2023.04","percent of total billed charges",""
"STENT HARRELL Y14X12X50X25X35MM WITH POSTS","SUP-ITM-10030669","CDM","C1874","HCPCS","0278","RC","","","","both","","","2544.71","1908.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","928.82","36.5","","1257.80","693.44","2424.50","1 through 10","788.86","2023.04","percent of total billed charges",""
"STENT HARRELL Y14X12X50X25X35MM WITH POSTS","SUP-ITM-10030669","CDM","C1874","HCPCS","0278","RC","","","","both","","","2544.71","1908.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","974.62","38.3","","1950.11","547.40","2346.00","1 through 10","788.86","2023.04","percent of total billed charges",""
"STENT HARRELL Y14X12X50X25X35MM WITH POSTS","SUP-ITM-10030669","CDM","C1874","HCPCS","0278","RC","","","","both","","","2544.71","1908.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1091.68","42.9","","5096.18","5096.18","5096.18","1 through 10","788.86","2023.04","percent of total billed charges",""
"STENT HARRELL Y14X12X50X25X35MM WITH POSTS","SUP-ITM-10030669","CDM","C1874","HCPCS","0278","RC","","","","both","","","2544.71","1908.53","WELLPOINT [1015]","HB AMC WELLPOINT","1877.49","73.78","","1172.59","1172.59","4829.94","1 through 10","788.86","2023.04","percent of total billed charges",""
"STENT HARRELL Y14X12X50X25X35MM WITH POSTS","SUP-ITM-10030669","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2544.71","1908.53","AETNA [1001]","HB AMC AETNA HMO","1776.21","69.8","","1806.84","947.80","5091.72","1 through 10","1329.87","2079.54","percent of total billed charges",""
"STENT HARRELL Y14X12X50X25X35MM WITH POSTS","SUP-ITM-10030669","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2544.71","1908.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2079.54","81.72","","1259.05","615.58","4586.56","1 through 10","1329.87","2079.54","percent of total billed charges",""
"STENT HERCULINK 6MM 18MM 135CM RX BILIARY COBALT CHROMIUM BALLOON EXPANDING CATHETER","SUP-ITM-10018154","CDM","C1876","HCPCS","0278","RC","","","","both","","","2809.28","2106.96","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1842.89","65.6","","751.18","751.18","751.18","1 through 10","870.88","2233.38","percent of total billed charges",""
"STENT HERCULINK 6MM 18MM 135CM RX BILIARY COBALT CHROMIUM BALLOON EXPANDING CATHETER","SUP-ITM-10018154","CDM","C1876","HCPCS","0278","RC","","","","both","","","2809.28","2106.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2233.38","79.5","","4820.38","3211.27","4820.38","1 through 10","870.88","2233.38","percent of total billed charges",""
"STENT HERCULINK 6MM 18MM 135CM RX BILIARY COBALT CHROMIUM BALLOON EXPANDING CATHETER","SUP-ITM-10018154","CDM","C1876","HCPCS","0278","RC","","","","both","","","2809.28","2106.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1025.39","36.5","","641.00","641.00","641.00","1 through 10","870.88","2233.38","percent of total billed charges",""
"STENT HERCULINK 6MM 18MM 135CM RX BILIARY COBALT CHROMIUM BALLOON EXPANDING CATHETER","SUP-ITM-10018154","CDM","C1876","HCPCS","0278","RC","","","","both","","","2809.28","2106.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1075.95","38.3","","1098.43","1098.43","1098.43","1 through 10","870.88","2233.38","percent of total billed charges",""
"STENT HERCULINK 6MM 18MM 135CM RX BILIARY COBALT CHROMIUM BALLOON EXPANDING CATHETER","SUP-ITM-10018154","CDM","C1876","HCPCS","0278","RC","","","","both","","","2809.28","2106.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1205.18","42.9","","4896.33","4896.33","4896.33","1 through 10","870.88","2233.38","percent of total billed charges",""
"STENT HERCULINK 6MM 18MM 135CM RX BILIARY COBALT CHROMIUM BALLOON EXPANDING CATHETER","SUP-ITM-10018154","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2809.28","2106.96","AETNA [1001]","HB AMC AETNA HMO","1960.88","69.8","","175.60","163.11","1063.91","1 through 10","1468.13","2295.74","percent of total billed charges",""
"STENT HERCULINK 6MM 18MM 135CM RX BILIARY COBALT CHROMIUM BALLOON EXPANDING CATHETER","SUP-ITM-10018154","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2809.28","2106.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2295.74","81.72","","105.94","85.10","105.94","1 through 10","1468.13","2295.74","percent of total billed charges",""
"STENT HOURGLASS 18X16 15 20MM TRACHEOBRONCHIAL DUMON","SUP-ITM-10175595","CDM","C1876","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1549.80","65.6","","751.18","751.18","751.18","1 through 10","732.38","1878.19","percent of total billed charges",""
"STENT HOURGLASS 18X16 15 20MM TRACHEOBRONCHIAL DUMON","SUP-ITM-10175595","CDM","C1876","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1878.19","79.5","","4820.38","3211.27","4820.38","1 through 10","732.38","1878.19","percent of total billed charges",""
"STENT HOURGLASS 18X16 15 20MM TRACHEOBRONCHIAL DUMON","SUP-ITM-10175595","CDM","C1876","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","862.31","36.5","","641.00","641.00","641.00","1 through 10","732.38","1878.19","percent of total billed charges",""
"STENT HOURGLASS 18X16 15 20MM TRACHEOBRONCHIAL DUMON","SUP-ITM-10175595","CDM","C1876","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","904.84","38.3","","1098.43","1098.43","1098.43","1 through 10","732.38","1878.19","percent of total billed charges",""
"STENT HOURGLASS 18X16 15 20MM TRACHEOBRONCHIAL DUMON","SUP-ITM-10175595","CDM","C1876","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","4896.33","4896.33","4896.33","1 through 10","732.38","1878.19","percent of total billed charges",""
"STENT HOURGLASS 18X16 15 20MM TRACHEOBRONCHIAL DUMON","SUP-ITM-10175595","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA HMO","1649.03","69.8","","175.60","163.11","1063.91","1 through 10","1234.64","1930.64","percent of total billed charges",""
"STENT HOURGLASS 18X16 15 20MM TRACHEOBRONCHIAL DUMON","SUP-ITM-10175595","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1930.64","81.72","","105.94","85.10","105.94","1 through 10","1234.64","1930.64","percent of total billed charges",""
"STENT ILIAC 6FR 6X20MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART","SUP-ITM-10118153","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1567.02","65.6","","751.18","751.18","751.18","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT ILIAC 6FR 6X20MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART","SUP-ITM-10118153","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1899.06","79.5","","4820.38","3211.27","4820.38","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT ILIAC 6FR 6X20MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART","SUP-ITM-10118153","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","871.89","36.5","","641.00","641.00","641.00","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT ILIAC 6FR 6X20MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART","SUP-ITM-10118153","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","914.89","38.3","","1098.43","1098.43","1098.43","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT ILIAC 6FR 6X20MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART","SUP-ITM-10118153","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1024.77","42.9","","4896.33","4896.33","4896.33","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT ILIAC 6FR 6X20MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART","SUP-ITM-10118153","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2388.75","1791.56","AETNA [1001]","HB AMC AETNA HMO","1667.35","69.8","","175.60","163.11","1063.91","1 through 10","1248.36","1952.09","percent of total billed charges",""
"STENT ILIAC 6FR 6X20MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART","SUP-ITM-10118153","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2388.75","1791.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1952.09","81.72","","105.94","85.10","105.94","1 through 10","1248.36","1952.09","percent of total billed charges",""
"STENT ILIAC 6FR 6X60MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART CS/1EA","SUP-ITM-10022634","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1567.02","65.6","","751.18","751.18","751.18","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT ILIAC 6FR 6X60MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART CS/1EA","SUP-ITM-10022634","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1899.06","79.5","","4820.38","3211.27","4820.38","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT ILIAC 6FR 6X60MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART CS/1EA","SUP-ITM-10022634","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","871.89","36.5","","641.00","641.00","641.00","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT ILIAC 6FR 6X60MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART CS/1EA","SUP-ITM-10022634","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","914.89","38.3","","1098.43","1098.43","1098.43","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT ILIAC 6FR 6X60MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART CS/1EA","SUP-ITM-10022634","CDM","C1876","HCPCS","0278","RC","","","","both","","","2388.75","1791.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1024.77","42.9","","4896.33","4896.33","4896.33","1 through 10","740.51","1899.06","percent of total billed charges",""
"STENT ILIAC 6FR 6X60MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART CS/1EA","SUP-ITM-10022634","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2388.75","1791.56","AETNA [1001]","HB AMC AETNA HMO","1667.35","69.8","","175.60","163.11","1063.91","1 through 10","1248.36","1952.09","percent of total billed charges",""
"STENT ILIAC 6FR 6X60MMX120CM .035IN SDS NITINOL SELF EXP OTW STRAIGHT HYDROPHILIC BARE METAL SMART CS/1EA","SUP-ITM-10022634","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2388.75","1791.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1952.09","81.72","","105.94","85.10","105.94","1 through 10","1248.36","1952.09","percent of total billed charges",""
"STENT INTEGRITY 4MM 15MM RX CORONARY BARE METAL COBALT CHROMIUM","SUP-ITM-10081673","CDM","C1876","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","941.36","65.6","","751.18","751.18","751.18","1 through 10","444.85","1140.83","percent of total billed charges",""
"STENT INTEGRITY 4MM 15MM RX CORONARY BARE METAL COBALT CHROMIUM","SUP-ITM-10081673","CDM","C1876","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1140.83","79.5","","4820.38","3211.27","4820.38","1 through 10","444.85","1140.83","percent of total billed charges",""
"STENT INTEGRITY 4MM 15MM RX CORONARY BARE METAL COBALT CHROMIUM","SUP-ITM-10081673","CDM","C1876","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","523.78","36.5","","641.00","641.00","641.00","1 through 10","444.85","1140.83","percent of total billed charges",""
"STENT INTEGRITY 4MM 15MM RX CORONARY BARE METAL COBALT CHROMIUM","SUP-ITM-10081673","CDM","C1876","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","549.61","38.3","","1098.43","1098.43","1098.43","1 through 10","444.85","1140.83","percent of total billed charges",""
"STENT INTEGRITY 4MM 15MM RX CORONARY BARE METAL COBALT CHROMIUM","SUP-ITM-10081673","CDM","C1876","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","615.62","42.9","","4896.33","4896.33","4896.33","1 through 10","444.85","1140.83","percent of total billed charges",""
"STENT INTEGRITY 4MM 15MM RX CORONARY BARE METAL COBALT CHROMIUM","SUP-ITM-10081673","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1435.00","1076.25","AETNA [1001]","HB AMC AETNA HMO","1001.63","69.8","","175.60","163.11","1063.91","1 through 10","749.93","1172.68","percent of total billed charges",""
"STENT INTEGRITY 4MM 15MM RX CORONARY BARE METAL COBALT CHROMIUM","SUP-ITM-10081673","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1435.00","1076.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1172.68","81.72","","105.94","85.10","105.94","1 through 10","749.93","1172.68","percent of total billed charges",""
"STENT INTRA LD 12MM 16MM MAX BILIARY S/S","SUP-ITM-10049211","CDM","C1876","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1813.84","65.6","","751.18","751.18","751.18","1 through 10","857.15","2198.18","percent of total billed charges",""
"STENT INTRA LD 12MM 16MM MAX BILIARY S/S","SUP-ITM-10049211","CDM","C1876","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2198.18","79.5","","4820.38","3211.27","4820.38","1 through 10","857.15","2198.18","percent of total billed charges",""
"STENT INTRA LD 12MM 16MM MAX BILIARY S/S","SUP-ITM-10049211","CDM","C1876","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1009.23","36.5","","641.00","641.00","641.00","1 through 10","857.15","2198.18","percent of total billed charges",""
"STENT INTRA LD 12MM 16MM MAX BILIARY S/S","SUP-ITM-10049211","CDM","C1876","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1059.00","38.3","","1098.43","1098.43","1098.43","1 through 10","857.15","2198.18","percent of total billed charges",""
"STENT INTRA LD 12MM 16MM MAX BILIARY S/S","SUP-ITM-10049211","CDM","C1876","HCPCS","0278","RC","","","","both","","","2765.00","2073.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1186.19","42.9","","4896.33","4896.33","4896.33","1 through 10","857.15","2198.18","percent of total billed charges",""
"STENT INTRA LD 12MM 16MM MAX BILIARY S/S","SUP-ITM-10049211","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2765.00","2073.75","AETNA [1001]","HB AMC AETNA HMO","1929.97","69.8","","175.60","163.11","1063.91","1 through 10","1444.99","2259.56","percent of total billed charges",""
"STENT INTRA LD 12MM 16MM MAX BILIARY S/S","SUP-ITM-10049211","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2765.00","2073.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2259.56","81.72","","105.94","85.10","105.94","1 through 10","1444.99","2259.56","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 100MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019733","CDM","C1876","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1492.40","65.6","","751.18","751.18","751.18","1 through 10","705.25","1808.63","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 100MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019733","CDM","C1876","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1808.63","79.5","","4820.38","3211.27","4820.38","1 through 10","705.25","1808.63","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 100MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019733","CDM","C1876","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","830.38","36.5","","641.00","641.00","641.00","1 through 10","705.25","1808.63","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 100MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019733","CDM","C1876","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","871.33","38.3","","1098.43","1098.43","1098.43","1 through 10","705.25","1808.63","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 100MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019733","CDM","C1876","HCPCS","0278","RC","","","","both","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","975.98","42.9","","4896.33","4896.33","4896.33","1 through 10","705.25","1808.63","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 100MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019733","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","AETNA [1001]","HB AMC AETNA HMO","1587.95","69.8","","175.60","163.11","1063.91","1 through 10","1188.92","1859.13","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 100MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019733","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2275.00","1706.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1859.13","81.72","","105.94","85.10","105.94","1 through 10","1188.92","1859.13","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 120MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019734","CDM","C1876","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1722.00","65.6","","751.18","751.18","751.18","1 through 10","813.75","2086.88","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 120MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019734","CDM","C1876","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2086.88","79.5","","4820.38","3211.27","4820.38","1 through 10","813.75","2086.88","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 120MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019734","CDM","C1876","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","958.13","36.5","","641.00","641.00","641.00","1 through 10","813.75","2086.88","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 120MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019734","CDM","C1876","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1005.38","38.3","","1098.43","1098.43","1098.43","1 through 10","813.75","2086.88","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 120MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019734","CDM","C1876","HCPCS","0278","RC","","","","both","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1126.13","42.9","","4896.33","4896.33","4896.33","1 through 10","813.75","2086.88","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 120MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019734","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","AETNA [1001]","HB AMC AETNA HMO","1832.25","69.8","","175.60","163.11","1063.91","1 through 10","1371.83","2145.15","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 120MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019734","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2625.00","1968.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2145.15","81.72","","105.94","85.10","105.94","1 through 10","1371.83","2145.15","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 150MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019735","CDM","C1876","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1951.60","65.6","","751.18","751.18","751.18","1 through 10","922.25","2365.13","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 150MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019735","CDM","C1876","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","4820.38","3211.27","4820.38","1 through 10","922.25","2365.13","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 150MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019735","CDM","C1876","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","641.00","641.00","641.00","1 through 10","922.25","2365.13","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 150MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019735","CDM","C1876","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","1098.43","1098.43","1098.43","1 through 10","922.25","2365.13","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 150MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019735","CDM","C1876","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","4896.33","4896.33","4896.33","1 through 10","922.25","2365.13","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 150MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019735","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","175.60","163.11","1063.91","1 through 10","1554.74","2431.17","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 150MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019735","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","105.94","85.10","105.94","1 through 10","1554.74","2431.17","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 170MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10051742","CDM","C1876","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2181.20","65.6","","751.18","751.18","751.18","1 through 10","1030.75","2643.38","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 170MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10051742","CDM","C1876","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2643.38","79.5","","4820.38","3211.27","4820.38","1 through 10","1030.75","2643.38","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 170MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10051742","CDM","C1876","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1213.63","36.5","","641.00","641.00","641.00","1 through 10","1030.75","2643.38","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 170MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10051742","CDM","C1876","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1273.48","38.3","","1098.43","1098.43","1098.43","1 through 10","1030.75","2643.38","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 170MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10051742","CDM","C1876","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","4896.33","4896.33","4896.33","1 through 10","1030.75","2643.38","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 170MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10051742","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA HMO","2320.85","69.8","","175.60","163.11","1063.91","1 through 10","1737.65","2717.19","percent of total billed charges",""
"STENT LIFESTENT 6FR 6MM 170MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10051742","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2717.19","81.72","","105.94","85.10","105.94","1 through 10","1737.65","2717.19","percent of total billed charges",""
"STENT LIFESTENT 6FR 7MM 60MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019282","CDM","C1876","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1262.80","65.6","","751.18","751.18","751.18","1 through 10","596.75","1530.38","percent of total billed charges",""
"STENT LIFESTENT 6FR 7MM 60MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019282","CDM","C1876","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1530.38","79.5","","4820.38","3211.27","4820.38","1 through 10","596.75","1530.38","percent of total billed charges",""
"STENT LIFESTENT 6FR 7MM 60MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019282","CDM","C1876","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","702.63","36.5","","641.00","641.00","641.00","1 through 10","596.75","1530.38","percent of total billed charges",""
"STENT LIFESTENT 6FR 7MM 60MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019282","CDM","C1876","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","737.28","38.3","","1098.43","1098.43","1098.43","1 through 10","596.75","1530.38","percent of total billed charges",""
"STENT LIFESTENT 6FR 7MM 60MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019282","CDM","C1876","HCPCS","0278","RC","","","","both","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","825.83","42.9","","4896.33","4896.33","4896.33","1 through 10","596.75","1530.38","percent of total billed charges",""
"STENT LIFESTENT 6FR 7MM 60MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019282","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","AETNA [1001]","HB AMC AETNA HMO","1343.65","69.8","","175.60","163.11","1063.91","1 through 10","1006.01","1573.11","percent of total billed charges",""
"STENT LIFESTENT 6FR 7MM 60MM 130CM .035IN OTW VASCULAR BILIARY SELF EXPANDING NITINOL","SUP-ITM-10019282","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1925.00","1443.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1573.11","81.72","","105.94","85.10","105.94","1 through 10","1006.01","1573.11","percent of total billed charges",""
"STENT MONORAIL 6FR 6MM 18MM 90CM OTW BILIARY CATHETER EXPRESS SD RENAL PREMOUNTED SYSTEM","SUP-ITM-10012380","CDM","C1876","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2181.20","65.6","","751.18","751.18","751.18","1 through 10","1030.75","2643.38","percent of total billed charges",""
"STENT MONORAIL 6FR 6MM 18MM 90CM OTW BILIARY CATHETER EXPRESS SD RENAL PREMOUNTED SYSTEM","SUP-ITM-10012380","CDM","C1876","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2643.38","79.5","","4820.38","3211.27","4820.38","1 through 10","1030.75","2643.38","percent of total billed charges",""
"STENT MONORAIL 6FR 6MM 18MM 90CM OTW BILIARY CATHETER EXPRESS SD RENAL PREMOUNTED SYSTEM","SUP-ITM-10012380","CDM","C1876","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1213.63","36.5","","641.00","641.00","641.00","1 through 10","1030.75","2643.38","percent of total billed charges",""
"STENT MONORAIL 6FR 6MM 18MM 90CM OTW BILIARY CATHETER EXPRESS SD RENAL PREMOUNTED SYSTEM","SUP-ITM-10012380","CDM","C1876","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1273.48","38.3","","1098.43","1098.43","1098.43","1 through 10","1030.75","2643.38","percent of total billed charges",""
"STENT MONORAIL 6FR 6MM 18MM 90CM OTW BILIARY CATHETER EXPRESS SD RENAL PREMOUNTED SYSTEM","SUP-ITM-10012380","CDM","C1876","HCPCS","0278","RC","","","","both","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1426.43","42.9","","4896.33","4896.33","4896.33","1 through 10","1030.75","2643.38","percent of total billed charges",""
"STENT MONORAIL 6FR 6MM 18MM 90CM OTW BILIARY CATHETER EXPRESS SD RENAL PREMOUNTED SYSTEM","SUP-ITM-10012380","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","AETNA [1001]","HB AMC AETNA HMO","2320.85","69.8","","175.60","163.11","1063.91","1 through 10","1737.65","2717.19","percent of total billed charges",""
"STENT MONORAIL 6FR 6MM 18MM 90CM OTW BILIARY CATHETER EXPRESS SD RENAL PREMOUNTED SYSTEM","SUP-ITM-10012380","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3325.00","2493.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2717.19","81.72","","105.94","85.10","105.94","1 through 10","1737.65","2717.19","percent of total billed charges",""
"STENT NEUROFORM EZ 4MM 20MM OTW STRAIGHT HYDROPHILIC BARE METAL NITINOL SELF EXPANDING","SUP-ITM-10080039","CDM","C1874","HCPCS","0278","RC","","","","both","","","21662.30","16246.72","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","14080.50","65","","6652.80","6652.80","6652.80","1 through 10","6715.31","17221.53","percent of total billed charges",""
"STENT NEUROFORM EZ 4MM 20MM OTW STRAIGHT HYDROPHILIC BARE METAL NITINOL SELF EXPANDING","SUP-ITM-10080039","CDM","C1874","HCPCS","0278","RC","","","","both","","","21662.30","16246.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","17221.53","79.5","","2612.61","795.38","2612.61","1 through 10","6715.31","17221.53","percent of total billed charges",""
"STENT NEUROFORM EZ 4MM 20MM OTW STRAIGHT HYDROPHILIC BARE METAL NITINOL SELF EXPANDING","SUP-ITM-10080039","CDM","C1874","HCPCS","0278","RC","","","","both","","","21662.30","16246.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","11546.01","53.3","","1101.80","1101.80","1101.80","1 through 10","6715.31","17221.53","percent of total billed charges",""
"STENT NEUROFORM EZ 4MM 20MM OTW STRAIGHT HYDROPHILIC BARE METAL NITINOL SELF EXPANDING","SUP-ITM-10080039","CDM","C1874","HCPCS","0278","RC","","","","both","","","21662.30","16246.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","14080.50","65","","1820.00","910.00","1820.00","1 through 10","6715.31","17221.53","percent of total billed charges",""
"STENT NEUROFORM EZ 4MM 20MM OTW STRAIGHT HYDROPHILIC BARE METAL NITINOL SELF EXPANDING","SUP-ITM-10080039","CDM","C1874","HCPCS","0278","RC","","","","both","","","21662.30","16246.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7906.74","36.5","","1257.80","693.44","2424.50","1 through 10","6715.31","17221.53","percent of total billed charges",""
"STENT NEUROFORM EZ 4MM 20MM OTW STRAIGHT HYDROPHILIC BARE METAL NITINOL SELF EXPANDING","SUP-ITM-10080039","CDM","C1874","HCPCS","0278","RC","","","","both","","","21662.30","16246.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8296.66","38.3","","1950.11","547.40","2346.00","1 through 10","6715.31","17221.53","percent of total billed charges",""
"STENT NEUROFORM EZ 4MM 20MM OTW STRAIGHT HYDROPHILIC BARE METAL NITINOL SELF EXPANDING","SUP-ITM-10080039","CDM","C1874","HCPCS","0278","RC","","","","both","","","21662.30","16246.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9293.13","42.9","","5096.18","5096.18","5096.18","1 through 10","6715.31","17221.53","percent of total billed charges",""
"STENT NEUROFORM EZ 4MM 20MM OTW STRAIGHT HYDROPHILIC BARE METAL NITINOL SELF EXPANDING","SUP-ITM-10080039","CDM","C1874","HCPCS","0278","RC","","","","both","","","21662.30","16246.72","WELLPOINT [1015]","HB AMC WELLPOINT","15982.44","73.78","","1172.59","1172.59","4829.94","1 through 10","6715.31","17221.53","percent of total billed charges",""
"STENT NEUROFORM EZ 4MM 20MM OTW STRAIGHT HYDROPHILIC BARE METAL NITINOL SELF EXPANDING","SUP-ITM-10080039","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","21662.30","16246.72","AETNA [1001]","HB AMC AETNA HMO","15120.29","69.8","","1806.84","947.80","5091.72","1 through 10","11320.72","17702.43","percent of total billed charges",""
"STENT NEUROFORM EZ 4MM 20MM OTW STRAIGHT HYDROPHILIC BARE METAL NITINOL SELF EXPANDING","SUP-ITM-10080039","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","21662.30","16246.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","17702.43","81.72","","1259.05","615.58","4586.56","1 through 10","11320.72","17702.43","percent of total billed charges",""
"STENT OMNILINK ELITE 6MM 29MM 80CM .035IN OTW VASCULAR BALLOON-EXPANDABLE COBALT CHROMIUM ILIAC ARTERY RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10113467","CDM","C1876","HCPCS","0278","RC","","","","both","","","1718.50","1288.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1127.34","65.6","","751.18","751.18","751.18","1 through 10","532.74","1366.21","percent of total billed charges",""
"STENT OMNILINK ELITE 6MM 29MM 80CM .035IN OTW VASCULAR BALLOON-EXPANDABLE COBALT CHROMIUM ILIAC ARTERY RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10113467","CDM","C1876","HCPCS","0278","RC","","","","both","","","1718.50","1288.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1366.21","79.5","","4820.38","3211.27","4820.38","1 through 10","532.74","1366.21","percent of total billed charges",""
"STENT OMNILINK ELITE 6MM 29MM 80CM .035IN OTW VASCULAR BALLOON-EXPANDABLE COBALT CHROMIUM ILIAC ARTERY RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10113467","CDM","C1876","HCPCS","0278","RC","","","","both","","","1718.50","1288.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","627.25","36.5","","641.00","641.00","641.00","1 through 10","532.74","1366.21","percent of total billed charges",""
"STENT OMNILINK ELITE 6MM 29MM 80CM .035IN OTW VASCULAR BALLOON-EXPANDABLE COBALT CHROMIUM ILIAC ARTERY RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10113467","CDM","C1876","HCPCS","0278","RC","","","","both","","","1718.50","1288.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","658.19","38.3","","1098.43","1098.43","1098.43","1 through 10","532.74","1366.21","percent of total billed charges",""
"STENT OMNILINK ELITE 6MM 29MM 80CM .035IN OTW VASCULAR BALLOON-EXPANDABLE COBALT CHROMIUM ILIAC ARTERY RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10113467","CDM","C1876","HCPCS","0278","RC","","","","both","","","1718.50","1288.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","737.24","42.9","","4896.33","4896.33","4896.33","1 through 10","532.74","1366.21","percent of total billed charges",""
"STENT OMNILINK ELITE 6MM 29MM 80CM .035IN OTW VASCULAR BALLOON-EXPANDABLE COBALT CHROMIUM ILIAC ARTERY RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10113467","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1718.50","1288.87","AETNA [1001]","HB AMC AETNA HMO","1199.51","69.8","","175.60","163.11","1063.91","1 through 10","898.09","1404.36","percent of total billed charges",""
"STENT OMNILINK ELITE 6MM 29MM 80CM .035IN OTW VASCULAR BALLOON-EXPANDABLE COBALT CHROMIUM ILIAC ARTERY RADIOPAQUE MARKER STERILE DISP","SUP-ITM-10113467","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1718.50","1288.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1404.36","81.72","","105.94","85.10","105.94","1 through 10","898.09","1404.36","percent of total billed charges",""
"STENT PANCREATIC 7FR 3CM ADVANIX LB STRAIGHT","SUP-ITM-10147670","CDM","C2625","HCPCS","0278","RC","","","","both","","","312.10","234.07","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","218.47","70","","470.75","470.75","470.75","1 through 10","96.75","248.12","percent of total billed charges",""
"STENT PANCREATIC 7FR 3CM ADVANIX LB STRAIGHT","SUP-ITM-10147670","CDM","C2625","HCPCS","0278","RC","","","","both","","","312.10","234.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.53","38.3","","184.07","124.37","184.07","1 through 10","96.75","248.12","percent of total billed charges",""
"STENT PANCREATIC 7FR 3CM ADVANIX LB STRAIGHT","SUP-ITM-10147670","CDM","C2625","HCPCS","0278","RC","","","","both","","","312.10","234.07","WELLPOINT [1015]","HB AMC WELLPOINT","230.27","73.78","","243.67","243.67","243.67","1 through 10","96.75","248.12","percent of total billed charges",""
"STENT PANCREATIC 7FR 3CM ADVANIX LB STRAIGHT","SUP-ITM-10147670","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","312.10","234.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","255.05","81.72","","376.32","376.32","376.32","1 through 10","163.1","255.05","percent of total billed charges",""
"STENT PERIPHERAL 6MMX140CM ZILVER PTX 35 DRUG ELUTING BX/1EA","SUP-ITM-10212068","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3891.88","65","","6652.80","6652.80","6652.80","1 through 10","1856.13","4760.06","percent of total billed charges",""
"STENT PERIPHERAL 6MMX140CM ZILVER PTX 35 DRUG ELUTING BX/1EA","SUP-ITM-10212068","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4760.06","79.5","","2612.61","795.38","2612.61","1 through 10","1856.13","4760.06","percent of total billed charges",""
"STENT PERIPHERAL 6MMX140CM ZILVER PTX 35 DRUG ELUTING BX/1EA","SUP-ITM-10212068","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3191.34","53.3","","1101.80","1101.80","1101.80","1 through 10","1856.13","4760.06","percent of total billed charges",""
"STENT PERIPHERAL 6MMX140CM ZILVER PTX 35 DRUG ELUTING BX/1EA","SUP-ITM-10212068","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3891.88","65","","1820.00","910.00","1820.00","1 through 10","1856.13","4760.06","percent of total billed charges",""
"STENT PERIPHERAL 6MMX140CM ZILVER PTX 35 DRUG ELUTING BX/1EA","SUP-ITM-10212068","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2185.44","36.5","","1257.80","693.44","2424.50","1 through 10","1856.13","4760.06","percent of total billed charges",""
"STENT PERIPHERAL 6MMX140CM ZILVER PTX 35 DRUG ELUTING BX/1EA","SUP-ITM-10212068","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2293.21","38.3","","1950.11","547.40","2346.00","1 through 10","1856.13","4760.06","percent of total billed charges",""
"STENT PERIPHERAL 6MMX140CM ZILVER PTX 35 DRUG ELUTING BX/1EA","SUP-ITM-10212068","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2568.64","42.9","","5096.18","5096.18","5096.18","1 through 10","1856.13","4760.06","percent of total billed charges",""
"STENT PERIPHERAL 6MMX140CM ZILVER PTX 35 DRUG ELUTING BX/1EA","SUP-ITM-10212068","CDM","C1874","HCPCS","0278","RC","","","","both","","","5987.50","4490.62","WELLPOINT [1015]","HB AMC WELLPOINT","4417.58","73.78","","1172.59","1172.59","4829.94","1 through 10","1856.13","4760.06","percent of total billed charges",""
"STENT PERIPHERAL 6MMX140CM ZILVER PTX 35 DRUG ELUTING BX/1EA","SUP-ITM-10212068","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5987.50","4490.62","AETNA [1001]","HB AMC AETNA HMO","4179.28","69.8","","1806.84","947.80","5091.72","1 through 10","3129.07","4892.99","percent of total billed charges",""
"STENT PERIPHERAL 6MMX140CM ZILVER PTX 35 DRUG ELUTING BX/1EA","SUP-ITM-10212068","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5987.50","4490.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4892.99","81.72","","1259.05","615.58","4586.56","1 through 10","3129.07","4892.99","percent of total billed charges",""
"STENT PK PAPYRUS 5FR 4MM 15CM SYSTEM COVERED CORONARY","SUP-ITM-10239750","CDM","C1874","HCPCS","0278","RC","","","","both","","","9075.00","6806.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5898.75","65","","6652.80","6652.80","6652.80","1 through 10","2813.25","7214.63","percent of total billed charges",""
"STENT PK PAPYRUS 5FR 4MM 15CM SYSTEM COVERED CORONARY","SUP-ITM-10239750","CDM","C1874","HCPCS","0278","RC","","","","both","","","9075.00","6806.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7214.63","79.5","","2612.61","795.38","2612.61","1 through 10","2813.25","7214.63","percent of total billed charges",""
"STENT PK PAPYRUS 5FR 4MM 15CM SYSTEM COVERED CORONARY","SUP-ITM-10239750","CDM","C1874","HCPCS","0278","RC","","","","both","","","9075.00","6806.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4836.98","53.3","","1101.80","1101.80","1101.80","1 through 10","2813.25","7214.63","percent of total billed charges",""
"STENT PK PAPYRUS 5FR 4MM 15CM SYSTEM COVERED CORONARY","SUP-ITM-10239750","CDM","C1874","HCPCS","0278","RC","","","","both","","","9075.00","6806.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5898.75","65","","1820.00","910.00","1820.00","1 through 10","2813.25","7214.63","percent of total billed charges",""
"STENT PK PAPYRUS 5FR 4MM 15CM SYSTEM COVERED CORONARY","SUP-ITM-10239750","CDM","C1874","HCPCS","0278","RC","","","","both","","","9075.00","6806.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3312.38","36.5","","1257.80","693.44","2424.50","1 through 10","2813.25","7214.63","percent of total billed charges",""
"STENT PK PAPYRUS 5FR 4MM 15CM SYSTEM COVERED CORONARY","SUP-ITM-10239750","CDM","C1874","HCPCS","0278","RC","","","","both","","","9075.00","6806.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3475.73","38.3","","1950.11","547.40","2346.00","1 through 10","2813.25","7214.63","percent of total billed charges",""
"STENT PK PAPYRUS 5FR 4MM 15CM SYSTEM COVERED CORONARY","SUP-ITM-10239750","CDM","C1874","HCPCS","0278","RC","","","","both","","","9075.00","6806.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3893.18","42.9","","5096.18","5096.18","5096.18","1 through 10","2813.25","7214.63","percent of total billed charges",""
"STENT PK PAPYRUS 5FR 4MM 15CM SYSTEM COVERED CORONARY","SUP-ITM-10239750","CDM","C1874","HCPCS","0278","RC","","","","both","","","9075.00","6806.25","WELLPOINT [1015]","HB AMC WELLPOINT","6695.54","73.78","","1172.59","1172.59","4829.94","1 through 10","2813.25","7214.63","percent of total billed charges",""
"STENT PK PAPYRUS 5FR 4MM 15CM SYSTEM COVERED CORONARY","SUP-ITM-10239750","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9075.00","6806.25","AETNA [1001]","HB AMC AETNA HMO","6334.35","69.8","","1806.84","947.80","5091.72","1 through 10","4742.6","7416.09","percent of total billed charges",""
"STENT PK PAPYRUS 5FR 4MM 15CM SYSTEM COVERED CORONARY","SUP-ITM-10239750","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9075.00","6806.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7416.09","81.72","","1259.05","615.58","4586.56","1 through 10","4742.6","7416.09","percent of total billed charges",""
"STENT PROMUS ELITE 3MM 38MM .014IN DRUG ELUTING US MR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10230685","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","910.00","65","","6652.80","6652.80","6652.80","1 through 10","434","1113","percent of total billed charges",""
"STENT PROMUS ELITE 3MM 38MM .014IN DRUG ELUTING US MR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10230685","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","2612.61","795.38","2612.61","1 through 10","434","1113","percent of total billed charges",""
"STENT PROMUS ELITE 3MM 38MM .014IN DRUG ELUTING US MR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10230685","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","1101.80","1101.80","1101.80","1 through 10","434","1113","percent of total billed charges",""
"STENT PROMUS ELITE 3MM 38MM .014IN DRUG ELUTING US MR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10230685","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","910.00","65","","1820.00","910.00","1820.00","1 through 10","434","1113","percent of total billed charges",""
"STENT PROMUS ELITE 3MM 38MM .014IN DRUG ELUTING US MR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10230685","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1257.80","693.44","2424.50","1 through 10","434","1113","percent of total billed charges",""
"STENT PROMUS ELITE 3MM 38MM .014IN DRUG ELUTING US MR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10230685","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","1950.11","547.40","2346.00","1 through 10","434","1113","percent of total billed charges",""
"STENT PROMUS ELITE 3MM 38MM .014IN DRUG ELUTING US MR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10230685","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","5096.18","5096.18","5096.18","1 through 10","434","1113","percent of total billed charges",""
"STENT PROMUS ELITE 3MM 38MM .014IN DRUG ELUTING US MR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10230685","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","1172.59","1172.59","4829.94","1 through 10","434","1113","percent of total billed charges",""
"STENT PROMUS ELITE 3MM 38MM .014IN DRUG ELUTING US MR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10230685","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1806.84","947.80","5091.72","1 through 10","731.64","1144.08","percent of total billed charges",""
"STENT PROMUS ELITE 3MM 38MM .014IN DRUG ELUTING US MR - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10230685","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","1259.05","615.58","4586.56","1 through 10","731.64","1144.08","percent of total billed charges",""
"STENT PROTEGE RX 6FR 8MM 30MM 135CM .014IN RX CAROTID SELF-EXPANDING STRAIGHT","SUP-ITM-10020489","CDM","C1876","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2841.79","65.6","","751.18","751.18","751.18","1 through 10","1342.92","3443.94","percent of total billed charges",""
"STENT PROTEGE RX 6FR 8MM 30MM 135CM .014IN RX CAROTID SELF-EXPANDING STRAIGHT","SUP-ITM-10020489","CDM","C1876","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3443.94","79.5","","4820.38","3211.27","4820.38","1 through 10","1342.92","3443.94","percent of total billed charges",""
"STENT PROTEGE RX 6FR 8MM 30MM 135CM .014IN RX CAROTID SELF-EXPANDING STRAIGHT","SUP-ITM-10020489","CDM","C1876","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1581.18","36.5","","641.00","641.00","641.00","1 through 10","1342.92","3443.94","percent of total billed charges",""
"STENT PROTEGE RX 6FR 8MM 30MM 135CM .014IN RX CAROTID SELF-EXPANDING STRAIGHT","SUP-ITM-10020489","CDM","C1876","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1659.16","38.3","","1098.43","1098.43","1098.43","1 through 10","1342.92","3443.94","percent of total billed charges",""
"STENT PROTEGE RX 6FR 8MM 30MM 135CM .014IN RX CAROTID SELF-EXPANDING STRAIGHT","SUP-ITM-10020489","CDM","C1876","HCPCS","0278","RC","","","","both","","","4332.00","3249.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1858.43","42.9","","4896.33","4896.33","4896.33","1 through 10","1342.92","3443.94","percent of total billed charges",""
"STENT PROTEGE RX 6FR 8MM 30MM 135CM .014IN RX CAROTID SELF-EXPANDING STRAIGHT","SUP-ITM-10020489","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4332.00","3249.00","AETNA [1001]","HB AMC AETNA HMO","3023.74","69.8","","175.60","163.11","1063.91","1 through 10","2263.9","3540.11","percent of total billed charges",""
"STENT PROTEGE RX 6FR 8MM 30MM 135CM .014IN RX CAROTID SELF-EXPANDING STRAIGHT","SUP-ITM-10020489","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4332.00","3249.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3540.11","81.72","","105.94","85.10","105.94","1 through 10","2263.9","3540.11","percent of total billed charges",""
"STENT SOLUS 10FR 3CM .035 BILIARY DOUBLE PIGTAIL PLASTIC INTRODUCER RADIOPAQUE BAND BX/1EA","SUP-ITM-10024582","CDM","C2625","HCPCS","0278","RC","","","","both","","","532.00","399.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","372.40","70","","470.75","470.75","470.75","1 through 10","164.92","422.94","percent of total billed charges",""
"STENT SOLUS 10FR 3CM .035 BILIARY DOUBLE PIGTAIL PLASTIC INTRODUCER RADIOPAQUE BAND BX/1EA","SUP-ITM-10024582","CDM","C2625","HCPCS","0278","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.76","38.3","","184.07","124.37","184.07","1 through 10","164.92","422.94","percent of total billed charges",""
"STENT SOLUS 10FR 3CM .035 BILIARY DOUBLE PIGTAIL PLASTIC INTRODUCER RADIOPAQUE BAND BX/1EA","SUP-ITM-10024582","CDM","C2625","HCPCS","0278","RC","","","","both","","","532.00","399.00","WELLPOINT [1015]","HB AMC WELLPOINT","392.51","73.78","","243.67","243.67","243.67","1 through 10","164.92","422.94","percent of total billed charges",""
"STENT SOLUS 10FR 3CM .035 BILIARY DOUBLE PIGTAIL PLASTIC INTRODUCER RADIOPAQUE BAND BX/1EA","SUP-ITM-10024582","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","532.00","399.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","434.75","81.72","","376.32","376.32","376.32","1 through 10","278.02","434.75","percent of total billed charges",""
"STENT SUPERA 6FR 4.5MM 20MM 120CM .014IN OTW VASCULAR PERIPHERAL NITINOL SELF EXPANDING CLOSED END BRAIDED","SUP-ITM-10132707","CDM","C1876","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2378.66","65.6","","751.18","751.18","751.18","1 through 10","1124.06","2882.67","percent of total billed charges",""
"STENT SUPERA 6FR 4.5MM 20MM 120CM .014IN OTW VASCULAR PERIPHERAL NITINOL SELF EXPANDING CLOSED END BRAIDED","SUP-ITM-10132707","CDM","C1876","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2882.67","79.5","","4820.38","3211.27","4820.38","1 through 10","1124.06","2882.67","percent of total billed charges",""
"STENT SUPERA 6FR 4.5MM 20MM 120CM .014IN OTW VASCULAR PERIPHERAL NITINOL SELF EXPANDING CLOSED END BRAIDED","SUP-ITM-10132707","CDM","C1876","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1323.49","36.5","","641.00","641.00","641.00","1 through 10","1124.06","2882.67","percent of total billed charges",""
"STENT SUPERA 6FR 4.5MM 20MM 120CM .014IN OTW VASCULAR PERIPHERAL NITINOL SELF EXPANDING CLOSED END BRAIDED","SUP-ITM-10132707","CDM","C1876","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1388.76","38.3","","1098.43","1098.43","1098.43","1 through 10","1124.06","2882.67","percent of total billed charges",""
"STENT SUPERA 6FR 4.5MM 20MM 120CM .014IN OTW VASCULAR PERIPHERAL NITINOL SELF EXPANDING CLOSED END BRAIDED","SUP-ITM-10132707","CDM","C1876","HCPCS","0278","RC","","","","both","","","3626.00","2719.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1555.55","42.9","","4896.33","4896.33","4896.33","1 through 10","1124.06","2882.67","percent of total billed charges",""
"STENT SUPERA 6FR 4.5MM 20MM 120CM .014IN OTW VASCULAR PERIPHERAL NITINOL SELF EXPANDING CLOSED END BRAIDED","SUP-ITM-10132707","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","AETNA [1001]","HB AMC AETNA HMO","2530.95","69.8","","175.60","163.11","1063.91","1 through 10","1894.95","2963.17","percent of total billed charges",""
"STENT SUPERA 6FR 4.5MM 20MM 120CM .014IN OTW VASCULAR PERIPHERAL NITINOL SELF EXPANDING CLOSED END BRAIDED","SUP-ITM-10132707","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3626.00","2719.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2963.17","81.72","","105.94","85.10","105.94","1 through 10","1894.95","2963.17","percent of total billed charges",""
"STENT SYNERGY 4X38MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US CORONARY","SUP-ITM-10277577","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","910.00","65","","6652.80","6652.80","6652.80","1 through 10","434","1113","percent of total billed charges",""
"STENT SYNERGY 4X38MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US CORONARY","SUP-ITM-10277577","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","2612.61","795.38","2612.61","1 through 10","434","1113","percent of total billed charges",""
"STENT SYNERGY 4X38MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US CORONARY","SUP-ITM-10277577","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","1101.80","1101.80","1101.80","1 through 10","434","1113","percent of total billed charges",""
"STENT SYNERGY 4X38MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US CORONARY","SUP-ITM-10277577","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","910.00","65","","1820.00","910.00","1820.00","1 through 10","434","1113","percent of total billed charges",""
"STENT SYNERGY 4X38MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US CORONARY","SUP-ITM-10277577","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1257.80","693.44","2424.50","1 through 10","434","1113","percent of total billed charges",""
"STENT SYNERGY 4X38MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US CORONARY","SUP-ITM-10277577","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","1950.11","547.40","2346.00","1 through 10","434","1113","percent of total billed charges",""
"STENT SYNERGY 4X38MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US CORONARY","SUP-ITM-10277577","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","5096.18","5096.18","5096.18","1 through 10","434","1113","percent of total billed charges",""
"STENT SYNERGY 4X38MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US CORONARY","SUP-ITM-10277577","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","1172.59","1172.59","4829.94","1 through 10","434","1113","percent of total billed charges",""
"STENT SYNERGY 4X38MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US CORONARY","SUP-ITM-10277577","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1806.84","947.80","5091.72","1 through 10","731.64","1144.08","percent of total billed charges",""
"STENT SYNERGY 4X38MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US CORONARY","SUP-ITM-10277577","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","1259.05","615.58","4586.56","1 through 10","731.64","1144.08","percent of total billed charges",""
"STENT SYNERGY 4X48MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US","SUP-ITM-10277572","CDM","C1874","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1820.00","65","","6652.80","6652.80","6652.80","1 through 10","868","2226","percent of total billed charges",""
"STENT SYNERGY 4X48MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US","SUP-ITM-10277572","CDM","C1874","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","2612.61","795.38","2612.61","1 through 10","868","2226","percent of total billed charges",""
"STENT SYNERGY 4X48MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US","SUP-ITM-10277572","CDM","C1874","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1492.40","53.3","","1101.80","1101.80","1101.80","1 through 10","868","2226","percent of total billed charges",""
"STENT SYNERGY 4X48MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US","SUP-ITM-10277572","CDM","C1874","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1820.00","65","","1820.00","910.00","1820.00","1 through 10","868","2226","percent of total billed charges",""
"STENT SYNERGY 4X48MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US","SUP-ITM-10277572","CDM","C1874","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","1257.80","693.44","2424.50","1 through 10","868","2226","percent of total billed charges",""
"STENT SYNERGY 4X48MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US","SUP-ITM-10277572","CDM","C1874","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","1950.11","547.40","2346.00","1 through 10","868","2226","percent of total billed charges",""
"STENT SYNERGY 4X48MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US","SUP-ITM-10277572","CDM","C1874","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","5096.18","5096.18","5096.18","1 through 10","868","2226","percent of total billed charges",""
"STENT SYNERGY 4X48MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US","SUP-ITM-10277572","CDM","C1874","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","1172.59","1172.59","4829.94","1 through 10","868","2226","percent of total billed charges",""
"STENT SYNERGY 4X48MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US","SUP-ITM-10277572","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA HMO","1954.40","69.8","","1806.84","947.80","5091.72","1 through 10","1463.28","2288.16","percent of total billed charges",""
"STENT SYNERGY 4X48MM XD DRUG ELUTING EVEROLIMUS PLATINUM CHROMIUM MR US","SUP-ITM-10277572","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","1259.05","615.58","4586.56","1 through 10","1463.28","2288.16","percent of total billed charges",""
"STENT SYNERGY MEGATRON 3.5X32MM CORONARY PLATINUM CHROMIUM EVEROLIMUS ELUTING US MR","SUP-ITM-10282530","CDM","C1874","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1933.75","65","","6652.80","6652.80","6652.80","1 through 10","922.25","2365.13","percent of total billed charges",""
"STENT SYNERGY MEGATRON 3.5X32MM CORONARY PLATINUM CHROMIUM EVEROLIMUS ELUTING US MR","SUP-ITM-10282530","CDM","C1874","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2365.13","79.5","","2612.61","795.38","2612.61","1 through 10","922.25","2365.13","percent of total billed charges",""
"STENT SYNERGY MEGATRON 3.5X32MM CORONARY PLATINUM CHROMIUM EVEROLIMUS ELUTING US MR","SUP-ITM-10282530","CDM","C1874","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1585.68","53.3","","1101.80","1101.80","1101.80","1 through 10","922.25","2365.13","percent of total billed charges",""
"STENT SYNERGY MEGATRON 3.5X32MM CORONARY PLATINUM CHROMIUM EVEROLIMUS ELUTING US MR","SUP-ITM-10282530","CDM","C1874","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1933.75","65","","1820.00","910.00","1820.00","1 through 10","922.25","2365.13","percent of total billed charges",""
"STENT SYNERGY MEGATRON 3.5X32MM CORONARY PLATINUM CHROMIUM EVEROLIMUS ELUTING US MR","SUP-ITM-10282530","CDM","C1874","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1085.88","36.5","","1257.80","693.44","2424.50","1 through 10","922.25","2365.13","percent of total billed charges",""
"STENT SYNERGY MEGATRON 3.5X32MM CORONARY PLATINUM CHROMIUM EVEROLIMUS ELUTING US MR","SUP-ITM-10282530","CDM","C1874","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1139.43","38.3","","1950.11","547.40","2346.00","1 through 10","922.25","2365.13","percent of total billed charges",""
"STENT SYNERGY MEGATRON 3.5X32MM CORONARY PLATINUM CHROMIUM EVEROLIMUS ELUTING US MR","SUP-ITM-10282530","CDM","C1874","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1276.28","42.9","","5096.18","5096.18","5096.18","1 through 10","922.25","2365.13","percent of total billed charges",""
"STENT SYNERGY MEGATRON 3.5X32MM CORONARY PLATINUM CHROMIUM EVEROLIMUS ELUTING US MR","SUP-ITM-10282530","CDM","C1874","HCPCS","0278","RC","","","","both","","","2975.00","2231.25","WELLPOINT [1015]","HB AMC WELLPOINT","2194.96","73.78","","1172.59","1172.59","4829.94","1 through 10","922.25","2365.13","percent of total billed charges",""
"STENT SYNERGY MEGATRON 3.5X32MM CORONARY PLATINUM CHROMIUM EVEROLIMUS ELUTING US MR","SUP-ITM-10282530","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","AETNA [1001]","HB AMC AETNA HMO","2076.55","69.8","","1806.84","947.80","5091.72","1 through 10","1554.74","2431.17","percent of total billed charges",""
"STENT SYNERGY MEGATRON 3.5X32MM CORONARY PLATINUM CHROMIUM EVEROLIMUS ELUTING US MR","SUP-ITM-10282530","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2975.00","2231.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2431.17","81.72","","1259.05","615.58","4586.56","1 through 10","1554.74","2431.17","percent of total billed charges",""
"STENT TAEWOONG NITI-S 10.5FR 20MM 15CM 180CM ESOPHAGEAL FULLY COVERED THROUGH THE SCOPE","SUP-ITM-10238966","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4537.00","65","","6652.80","6652.80","6652.80","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT TAEWOONG NITI-S 10.5FR 20MM 15CM 180CM ESOPHAGEAL FULLY COVERED THROUGH THE SCOPE","SUP-ITM-10238966","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5549.10","79.5","","2612.61","795.38","2612.61","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT TAEWOONG NITI-S 10.5FR 20MM 15CM 180CM ESOPHAGEAL FULLY COVERED THROUGH THE SCOPE","SUP-ITM-10238966","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3720.34","53.3","","1101.80","1101.80","1101.80","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT TAEWOONG NITI-S 10.5FR 20MM 15CM 180CM ESOPHAGEAL FULLY COVERED THROUGH THE SCOPE","SUP-ITM-10238966","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4537.00","65","","1820.00","910.00","1820.00","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT TAEWOONG NITI-S 10.5FR 20MM 15CM 180CM ESOPHAGEAL FULLY COVERED THROUGH THE SCOPE","SUP-ITM-10238966","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2547.70","36.5","","1257.80","693.44","2424.50","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT TAEWOONG NITI-S 10.5FR 20MM 15CM 180CM ESOPHAGEAL FULLY COVERED THROUGH THE SCOPE","SUP-ITM-10238966","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2673.34","38.3","","1950.11","547.40","2346.00","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT TAEWOONG NITI-S 10.5FR 20MM 15CM 180CM ESOPHAGEAL FULLY COVERED THROUGH THE SCOPE","SUP-ITM-10238966","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2994.42","42.9","","5096.18","5096.18","5096.18","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT TAEWOONG NITI-S 10.5FR 20MM 15CM 180CM ESOPHAGEAL FULLY COVERED THROUGH THE SCOPE","SUP-ITM-10238966","CDM","C1874","HCPCS","0278","RC","","","","both","","","6980.00","5235.00","WELLPOINT [1015]","HB AMC WELLPOINT","5149.84","73.78","","1172.59","1172.59","4829.94","1 through 10","2163.8","5549.1","percent of total billed charges",""
"STENT TAEWOONG NITI-S 10.5FR 20MM 15CM 180CM ESOPHAGEAL FULLY COVERED THROUGH THE SCOPE","SUP-ITM-10238966","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6980.00","5235.00","AETNA [1001]","HB AMC AETNA HMO","4872.04","69.8","","1806.84","947.80","5091.72","1 through 10","3647.75","5704.06","percent of total billed charges",""
"STENT TAEWOONG NITI-S 10.5FR 20MM 15CM 180CM ESOPHAGEAL FULLY COVERED THROUGH THE SCOPE","SUP-ITM-10238966","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6980.00","5235.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5704.06","81.72","","1259.05","615.58","4586.56","1 through 10","3647.75","5704.06","percent of total billed charges",""
"STENT TRACHEAL 10X20MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10297062","CDM","C2625","HCPCS","0278","RC","","","","both","","","1212.23","909.17","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","848.56","70","","470.75","470.75","470.75","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 10X20MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10297062","CDM","C2625","HCPCS","0278","RC","","","","both","","","1212.23","909.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","464.28","38.3","","184.07","124.37","184.07","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 10X20MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10297062","CDM","C2625","HCPCS","0278","RC","","","","both","","","1212.23","909.17","WELLPOINT [1015]","HB AMC WELLPOINT","894.38","73.78","","243.67","243.67","243.67","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 10X20MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10297062","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","1212.23","909.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","990.63","81.72","","376.32","376.32","376.32","1 through 10","633.51","990.63","percent of total billed charges",""
"STENT TRACHEAL 10X40MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10295916","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","787.95","65","","6652.80","6652.80","6652.80","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 10X40MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10295916","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","963.72","79.5","","2612.61","795.38","2612.61","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 10X40MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10295916","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","646.12","53.3","","1101.80","1101.80","1101.80","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 10X40MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10295916","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","787.95","65","","1820.00","910.00","1820.00","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 10X40MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10295916","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","442.46","36.5","","1257.80","693.44","2424.50","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 10X40MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10295916","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","464.28","38.3","","1950.11","547.40","2346.00","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 10X40MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10295916","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.05","42.9","","5096.18","5096.18","5096.18","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 10X40MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10295916","CDM","C1874","HCPCS","0278","RC","","","","both","","","1212.23","909.17","WELLPOINT [1015]","HB AMC WELLPOINT","894.38","73.78","","1172.59","1172.59","4829.94","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 10X40MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10295916","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1212.23","909.17","AETNA [1001]","HB AMC AETNA HMO","846.14","69.8","","1806.84","947.80","5091.72","1 through 10","633.51","990.63","percent of total billed charges",""
"STENT TRACHEAL 10X40MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10295916","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1212.23","909.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","990.63","81.72","","1259.05","615.58","4586.56","1 through 10","633.51","990.63","percent of total billed charges",""
"STENT TRACHEAL 12MM-10MM-12MM POST HOURGLASS","SUP-ITM-10211308","CDM","C1876","HCPCS","0278","RC","","","","both","","","1564.15","1173.11","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1026.08","65.6","","751.18","751.18","751.18","1 through 10","484.89","1243.5","percent of total billed charges",""
"STENT TRACHEAL 12MM-10MM-12MM POST HOURGLASS","SUP-ITM-10211308","CDM","C1876","HCPCS","0278","RC","","","","both","","","1564.15","1173.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1243.50","79.5","","4820.38","3211.27","4820.38","1 through 10","484.89","1243.5","percent of total billed charges",""
"STENT TRACHEAL 12MM-10MM-12MM POST HOURGLASS","SUP-ITM-10211308","CDM","C1876","HCPCS","0278","RC","","","","both","","","1564.15","1173.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","570.91","36.5","","641.00","641.00","641.00","1 through 10","484.89","1243.5","percent of total billed charges",""
"STENT TRACHEAL 12MM-10MM-12MM POST HOURGLASS","SUP-ITM-10211308","CDM","C1876","HCPCS","0278","RC","","","","both","","","1564.15","1173.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","599.07","38.3","","1098.43","1098.43","1098.43","1 through 10","484.89","1243.5","percent of total billed charges",""
"STENT TRACHEAL 12MM-10MM-12MM POST HOURGLASS","SUP-ITM-10211308","CDM","C1876","HCPCS","0278","RC","","","","both","","","1564.15","1173.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","671.02","42.9","","4896.33","4896.33","4896.33","1 through 10","484.89","1243.5","percent of total billed charges",""
"STENT TRACHEAL 12MM-10MM-12MM POST HOURGLASS","SUP-ITM-10211308","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1564.15","1173.11","AETNA [1001]","HB AMC AETNA HMO","1091.78","69.8","","175.60","163.11","1063.91","1 through 10","817.42","1278.22","percent of total billed charges",""
"STENT TRACHEAL 12MM-10MM-12MM POST HOURGLASS","SUP-ITM-10211308","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1564.15","1173.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1278.22","81.72","","105.94","85.10","105.94","1 through 10","817.42","1278.22","percent of total billed charges",""
"STENT TRACHEAL 12X10X40X17MM REDUCING DIAMETER W/ POSTS AND ULTRA SMOOTH PLUS","SUP-ITM-10088547","CDM","C1876","HCPCS","0278","RC","","","","both","","","1453.20","1089.90","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","953.30","65.6","","751.18","751.18","751.18","1 through 10","450.49","1155.29","percent of total billed charges",""
"STENT TRACHEAL 12X10X40X17MM REDUCING DIAMETER W/ POSTS AND ULTRA SMOOTH PLUS","SUP-ITM-10088547","CDM","C1876","HCPCS","0278","RC","","","","both","","","1453.20","1089.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1155.29","79.5","","4820.38","3211.27","4820.38","1 through 10","450.49","1155.29","percent of total billed charges",""
"STENT TRACHEAL 12X10X40X17MM REDUCING DIAMETER W/ POSTS AND ULTRA SMOOTH PLUS","SUP-ITM-10088547","CDM","C1876","HCPCS","0278","RC","","","","both","","","1453.20","1089.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","530.42","36.5","","641.00","641.00","641.00","1 through 10","450.49","1155.29","percent of total billed charges",""
"STENT TRACHEAL 12X10X40X17MM REDUCING DIAMETER W/ POSTS AND ULTRA SMOOTH PLUS","SUP-ITM-10088547","CDM","C1876","HCPCS","0278","RC","","","","both","","","1453.20","1089.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","556.58","38.3","","1098.43","1098.43","1098.43","1 through 10","450.49","1155.29","percent of total billed charges",""
"STENT TRACHEAL 12X10X40X17MM REDUCING DIAMETER W/ POSTS AND ULTRA SMOOTH PLUS","SUP-ITM-10088547","CDM","C1876","HCPCS","0278","RC","","","","both","","","1453.20","1089.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","623.42","42.9","","4896.33","4896.33","4896.33","1 through 10","450.49","1155.29","percent of total billed charges",""
"STENT TRACHEAL 12X10X40X17MM REDUCING DIAMETER W/ POSTS AND ULTRA SMOOTH PLUS","SUP-ITM-10088547","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1453.20","1089.90","AETNA [1001]","HB AMC AETNA HMO","1014.33","69.8","","175.60","163.11","1063.91","1 through 10","759.44","1187.56","percent of total billed charges",""
"STENT TRACHEAL 12X10X40X17MM REDUCING DIAMETER W/ POSTS AND ULTRA SMOOTH PLUS","SUP-ITM-10088547","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1453.20","1089.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1187.56","81.72","","105.94","85.10","105.94","1 through 10","759.44","1187.56","percent of total billed charges",""
"STENT TRACHEAL 12X20MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10297064","CDM","C1876","HCPCS","0278","RC","","","","both","","","1212.23","909.17","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","795.22","65.6","","751.18","751.18","751.18","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 12X20MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10297064","CDM","C1876","HCPCS","0278","RC","","","","both","","","1212.23","909.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","963.72","79.5","","4820.38","3211.27","4820.38","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 12X20MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10297064","CDM","C1876","HCPCS","0278","RC","","","","both","","","1212.23","909.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","442.46","36.5","","641.00","641.00","641.00","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 12X20MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10297064","CDM","C1876","HCPCS","0278","RC","","","","both","","","1212.23","909.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","464.28","38.3","","1098.43","1098.43","1098.43","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 12X20MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10297064","CDM","C1876","HCPCS","0278","RC","","","","both","","","1212.23","909.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.05","42.9","","4896.33","4896.33","4896.33","1 through 10","375.79","963.72","percent of total billed charges",""
"STENT TRACHEAL 12X20MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10297064","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1212.23","909.17","AETNA [1001]","HB AMC AETNA HMO","846.14","69.8","","175.60","163.11","1063.91","1 through 10","633.51","990.63","percent of total billed charges",""
"STENT TRACHEAL 12X20MM RING IMPLANT-GRADE SILICONE","SUP-ITM-10297064","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1212.23","909.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","990.63","81.72","","105.94","85.10","105.94","1 through 10","633.51","990.63","percent of total billed charges",""
"STENT TRACHEAL 14X25MM WITH RING","SUP-ITM-10282185","CDM","C1874","HCPCS","0278","RC","","","","both","","","1182.65","886.99","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","768.72","65","","6652.80","6652.80","6652.80","1 through 10","366.62","940.21","percent of total billed charges",""
"STENT TRACHEAL 14X25MM WITH RING","SUP-ITM-10282185","CDM","C1874","HCPCS","0278","RC","","","","both","","","1182.65","886.99","CIGNA [1006]","HB AMC CIGNA HMO / PPO","940.21","79.5","","2612.61","795.38","2612.61","1 through 10","366.62","940.21","percent of total billed charges",""
"STENT TRACHEAL 14X25MM WITH RING","SUP-ITM-10282185","CDM","C1874","HCPCS","0278","RC","","","","both","","","1182.65","886.99","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","630.35","53.3","","1101.80","1101.80","1101.80","1 through 10","366.62","940.21","percent of total billed charges",""
"STENT TRACHEAL 14X25MM WITH RING","SUP-ITM-10282185","CDM","C1874","HCPCS","0278","RC","","","","both","","","1182.65","886.99","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","768.72","65","","1820.00","910.00","1820.00","1 through 10","366.62","940.21","percent of total billed charges",""
"STENT TRACHEAL 14X25MM WITH RING","SUP-ITM-10282185","CDM","C1874","HCPCS","0278","RC","","","","both","","","1182.65","886.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","431.67","36.5","","1257.80","693.44","2424.50","1 through 10","366.62","940.21","percent of total billed charges",""
"STENT TRACHEAL 14X25MM WITH RING","SUP-ITM-10282185","CDM","C1874","HCPCS","0278","RC","","","","both","","","1182.65","886.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","452.95","38.3","","1950.11","547.40","2346.00","1 through 10","366.62","940.21","percent of total billed charges",""
"STENT TRACHEAL 14X25MM WITH RING","SUP-ITM-10282185","CDM","C1874","HCPCS","0278","RC","","","","both","","","1182.65","886.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","507.36","42.9","","5096.18","5096.18","5096.18","1 through 10","366.62","940.21","percent of total billed charges",""
"STENT TRACHEAL 14X25MM WITH RING","SUP-ITM-10282185","CDM","C1874","HCPCS","0278","RC","","","","both","","","1182.65","886.99","WELLPOINT [1015]","HB AMC WELLPOINT","872.56","73.78","","1172.59","1172.59","4829.94","1 through 10","366.62","940.21","percent of total billed charges",""
"STENT TRACHEAL 14X25MM WITH RING","SUP-ITM-10282185","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1182.65","886.99","AETNA [1001]","HB AMC AETNA HMO","825.49","69.8","","1806.84","947.80","5091.72","1 through 10","618.05","966.46","percent of total billed charges",""
"STENT TRACHEAL 14X25MM WITH RING","SUP-ITM-10282185","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1182.65","886.99","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","966.46","81.72","","1259.05","615.58","4586.56","1 through 10","618.05","966.46","percent of total billed charges",""
"STENT TRACHEAL 16X40MM Y-SHAPED","SUP-ITM-10304222","CDM","C1874","HCPCS","0278","RC","","","","both","","","12487.50","9365.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8116.88","65","","6652.80","6652.80","6652.80","1 through 10","3871.13","9927.56","percent of total billed charges",""
"STENT TRACHEAL 16X40MM Y-SHAPED","SUP-ITM-10304222","CDM","C1874","HCPCS","0278","RC","","","","both","","","12487.50","9365.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9927.56","79.5","","2612.61","795.38","2612.61","1 through 10","3871.13","9927.56","percent of total billed charges",""
"STENT TRACHEAL 16X40MM Y-SHAPED","SUP-ITM-10304222","CDM","C1874","HCPCS","0278","RC","","","","both","","","12487.50","9365.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6655.84","53.3","","1101.80","1101.80","1101.80","1 through 10","3871.13","9927.56","percent of total billed charges",""
"STENT TRACHEAL 16X40MM Y-SHAPED","SUP-ITM-10304222","CDM","C1874","HCPCS","0278","RC","","","","both","","","12487.50","9365.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8116.88","65","","1820.00","910.00","1820.00","1 through 10","3871.13","9927.56","percent of total billed charges",""
"STENT TRACHEAL 16X40MM Y-SHAPED","SUP-ITM-10304222","CDM","C1874","HCPCS","0278","RC","","","","both","","","12487.50","9365.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4557.94","36.5","","1257.80","693.44","2424.50","1 through 10","3871.13","9927.56","percent of total billed charges",""
"STENT TRACHEAL 16X40MM Y-SHAPED","SUP-ITM-10304222","CDM","C1874","HCPCS","0278","RC","","","","both","","","12487.50","9365.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4782.71","38.3","","1950.11","547.40","2346.00","1 through 10","3871.13","9927.56","percent of total billed charges",""
"STENT TRACHEAL 16X40MM Y-SHAPED","SUP-ITM-10304222","CDM","C1874","HCPCS","0278","RC","","","","both","","","12487.50","9365.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5357.14","42.9","","5096.18","5096.18","5096.18","1 through 10","3871.13","9927.56","percent of total billed charges",""
"STENT TRACHEAL 16X40MM Y-SHAPED","SUP-ITM-10304222","CDM","C1874","HCPCS","0278","RC","","","","both","","","12487.50","9365.62","WELLPOINT [1015]","HB AMC WELLPOINT","9213.28","73.78","","1172.59","1172.59","4829.94","1 through 10","3871.13","9927.56","percent of total billed charges",""
"STENT TRACHEAL 16X40MM Y-SHAPED","SUP-ITM-10304222","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12487.50","9365.62","AETNA [1001]","HB AMC AETNA HMO","8716.28","69.8","","1806.84","947.80","5091.72","1 through 10","6525.97","10204.79","percent of total billed charges",""
"STENT TRACHEAL 16X40MM Y-SHAPED","SUP-ITM-10304222","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12487.50","9365.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10204.79","81.72","","1259.05","615.58","4586.56","1 through 10","6525.97","10204.79","percent of total billed charges",""
"STENT TRACHEAL 18OMM 70MM WITH POSTS AND MESH","SUP-ITM-10237497","CDM","C1876","HCPCS","0278","RC","","","","both","","","1396.29","1047.22","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","915.97","65.6","","751.18","751.18","751.18","1 through 10","432.85","1110.05","percent of total billed charges",""
"STENT TRACHEAL 18OMM 70MM WITH POSTS AND MESH","SUP-ITM-10237497","CDM","C1876","HCPCS","0278","RC","","","","both","","","1396.29","1047.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1110.05","79.5","","4820.38","3211.27","4820.38","1 through 10","432.85","1110.05","percent of total billed charges",""
"STENT TRACHEAL 18OMM 70MM WITH POSTS AND MESH","SUP-ITM-10237497","CDM","C1876","HCPCS","0278","RC","","","","both","","","1396.29","1047.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","509.65","36.5","","641.00","641.00","641.00","1 through 10","432.85","1110.05","percent of total billed charges",""
"STENT TRACHEAL 18OMM 70MM WITH POSTS AND MESH","SUP-ITM-10237497","CDM","C1876","HCPCS","0278","RC","","","","both","","","1396.29","1047.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","534.78","38.3","","1098.43","1098.43","1098.43","1 through 10","432.85","1110.05","percent of total billed charges",""
"STENT TRACHEAL 18OMM 70MM WITH POSTS AND MESH","SUP-ITM-10237497","CDM","C1876","HCPCS","0278","RC","","","","both","","","1396.29","1047.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","599.01","42.9","","4896.33","4896.33","4896.33","1 through 10","432.85","1110.05","percent of total billed charges",""
"STENT TRACHEAL 18OMM 70MM WITH POSTS AND MESH","SUP-ITM-10237497","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1396.29","1047.22","AETNA [1001]","HB AMC AETNA HMO","974.61","69.8","","175.60","163.11","1063.91","1 through 10","729.7","1141.05","percent of total billed charges",""
"STENT TRACHEAL 18OMM 70MM WITH POSTS AND MESH","SUP-ITM-10237497","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1396.29","1047.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1141.05","81.72","","105.94","85.10","105.94","1 through 10","729.7","1141.05","percent of total billed charges",""
"STENT TRACHEAL 18X16X17MM HOURGLASS WITH POSTS","SUP-ITM-10230735","CDM","C1876","HCPCS","0278","RC","","","","both","","","1850.63","1387.97","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1214.01","65.6","","751.18","751.18","751.18","1 through 10","573.7","1471.25","percent of total billed charges",""
"STENT TRACHEAL 18X16X17MM HOURGLASS WITH POSTS","SUP-ITM-10230735","CDM","C1876","HCPCS","0278","RC","","","","both","","","1850.63","1387.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1471.25","79.5","","4820.38","3211.27","4820.38","1 through 10","573.7","1471.25","percent of total billed charges",""
"STENT TRACHEAL 18X16X17MM HOURGLASS WITH POSTS","SUP-ITM-10230735","CDM","C1876","HCPCS","0278","RC","","","","both","","","1850.63","1387.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","675.48","36.5","","641.00","641.00","641.00","1 through 10","573.7","1471.25","percent of total billed charges",""
"STENT TRACHEAL 18X16X17MM HOURGLASS WITH POSTS","SUP-ITM-10230735","CDM","C1876","HCPCS","0278","RC","","","","both","","","1850.63","1387.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","708.79","38.3","","1098.43","1098.43","1098.43","1 through 10","573.7","1471.25","percent of total billed charges",""
"STENT TRACHEAL 18X16X17MM HOURGLASS WITH POSTS","SUP-ITM-10230735","CDM","C1876","HCPCS","0278","RC","","","","both","","","1850.63","1387.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","793.92","42.9","","4896.33","4896.33","4896.33","1 through 10","573.7","1471.25","percent of total billed charges",""
"STENT TRACHEAL 18X16X17MM HOURGLASS WITH POSTS","SUP-ITM-10230735","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1850.63","1387.97","AETNA [1001]","HB AMC AETNA HMO","1291.74","69.8","","175.60","163.11","1063.91","1 through 10","967.14","1512.33","percent of total billed charges",""
"STENT TRACHEAL 18X16X17MM HOURGLASS WITH POSTS","SUP-ITM-10230735","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1850.63","1387.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1512.33","81.72","","105.94","85.10","105.94","1 through 10","967.14","1512.33","percent of total billed charges",""
"STENT TRACHEAL 19X17X19MM HOURGLASS WITH POSTS","SUP-ITM-10249696","CDM","C1876","HCPCS","0278","RC","","","","both","","","1526.00","1144.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1001.06","65.6","","751.18","751.18","751.18","1 through 10","473.06","1213.17","percent of total billed charges",""
"STENT TRACHEAL 19X17X19MM HOURGLASS WITH POSTS","SUP-ITM-10249696","CDM","C1876","HCPCS","0278","RC","","","","both","","","1526.00","1144.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1213.17","79.5","","4820.38","3211.27","4820.38","1 through 10","473.06","1213.17","percent of total billed charges",""
"STENT TRACHEAL 19X17X19MM HOURGLASS WITH POSTS","SUP-ITM-10249696","CDM","C1876","HCPCS","0278","RC","","","","both","","","1526.00","1144.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","556.99","36.5","","641.00","641.00","641.00","1 through 10","473.06","1213.17","percent of total billed charges",""
"STENT TRACHEAL 19X17X19MM HOURGLASS WITH POSTS","SUP-ITM-10249696","CDM","C1876","HCPCS","0278","RC","","","","both","","","1526.00","1144.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","584.46","38.3","","1098.43","1098.43","1098.43","1 through 10","473.06","1213.17","percent of total billed charges",""
"STENT TRACHEAL 19X17X19MM HOURGLASS WITH POSTS","SUP-ITM-10249696","CDM","C1876","HCPCS","0278","RC","","","","both","","","1526.00","1144.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","654.65","42.9","","4896.33","4896.33","4896.33","1 through 10","473.06","1213.17","percent of total billed charges",""
"STENT TRACHEAL 19X17X19MM HOURGLASS WITH POSTS","SUP-ITM-10249696","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1526.00","1144.50","AETNA [1001]","HB AMC AETNA HMO","1065.15","69.8","","175.60","163.11","1063.91","1 through 10","797.49","1247.05","percent of total billed charges",""
"STENT TRACHEAL 19X17X19MM HOURGLASS WITH POSTS","SUP-ITM-10249696","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1526.00","1144.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1247.05","81.72","","105.94","85.10","105.94","1 through 10","797.49","1247.05","percent of total billed charges",""
"STENT TRACHEAL 20X18X20MM HOURGLASS WITH POST","SUP-ITM-10283107","CDM","C1876","HCPCS","0278","RC","","","","both","","","1968.40","1476.30","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1291.27","65.6","","751.18","751.18","751.18","1 through 10","610.2","1564.88","percent of total billed charges",""
"STENT TRACHEAL 20X18X20MM HOURGLASS WITH POST","SUP-ITM-10283107","CDM","C1876","HCPCS","0278","RC","","","","both","","","1968.40","1476.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1564.88","79.5","","4820.38","3211.27","4820.38","1 through 10","610.2","1564.88","percent of total billed charges",""
"STENT TRACHEAL 20X18X20MM HOURGLASS WITH POST","SUP-ITM-10283107","CDM","C1876","HCPCS","0278","RC","","","","both","","","1968.40","1476.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","718.47","36.5","","641.00","641.00","641.00","1 through 10","610.2","1564.88","percent of total billed charges",""
"STENT TRACHEAL 20X18X20MM HOURGLASS WITH POST","SUP-ITM-10283107","CDM","C1876","HCPCS","0278","RC","","","","both","","","1968.40","1476.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","753.90","38.3","","1098.43","1098.43","1098.43","1 through 10","610.2","1564.88","percent of total billed charges",""
"STENT TRACHEAL 20X18X20MM HOURGLASS WITH POST","SUP-ITM-10283107","CDM","C1876","HCPCS","0278","RC","","","","both","","","1968.40","1476.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","844.44","42.9","","4896.33","4896.33","4896.33","1 through 10","610.2","1564.88","percent of total billed charges",""
"STENT TRACHEAL 20X18X20MM HOURGLASS WITH POST","SUP-ITM-10283107","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1968.40","1476.30","AETNA [1001]","HB AMC AETNA HMO","1373.94","69.8","","175.60","163.11","1063.91","1 through 10","1028.69","1608.58","percent of total billed charges",""
"STENT TRACHEAL 20X18X20MM HOURGLASS WITH POST","SUP-ITM-10283107","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1968.40","1476.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1608.58","81.72","","105.94","85.10","105.94","1 through 10","1028.69","1608.58","percent of total billed charges",""
"STENT TRACHEAL SZ 16 T-TUBE STEM ANGLED ULTRA SMOOTH","SUP-ITM-10295692","CDM","C1874","HCPCS","0278","RC","","","","both","","","822.61","616.96","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","534.70","65","","6652.80","6652.80","6652.80","1 through 10","255.01","653.97","percent of total billed charges",""
"STENT TRACHEAL SZ 16 T-TUBE STEM ANGLED ULTRA SMOOTH","SUP-ITM-10295692","CDM","C1874","HCPCS","0278","RC","","","","both","","","822.61","616.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","653.97","79.5","","2612.61","795.38","2612.61","1 through 10","255.01","653.97","percent of total billed charges",""
"STENT TRACHEAL SZ 16 T-TUBE STEM ANGLED ULTRA SMOOTH","SUP-ITM-10295692","CDM","C1874","HCPCS","0278","RC","","","","both","","","822.61","616.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","438.45","53.3","","1101.80","1101.80","1101.80","1 through 10","255.01","653.97","percent of total billed charges",""
"STENT TRACHEAL SZ 16 T-TUBE STEM ANGLED ULTRA SMOOTH","SUP-ITM-10295692","CDM","C1874","HCPCS","0278","RC","","","","both","","","822.61","616.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","534.70","65","","1820.00","910.00","1820.00","1 through 10","255.01","653.97","percent of total billed charges",""
"STENT TRACHEAL SZ 16 T-TUBE STEM ANGLED ULTRA SMOOTH","SUP-ITM-10295692","CDM","C1874","HCPCS","0278","RC","","","","both","","","822.61","616.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","300.25","36.5","","1257.80","693.44","2424.50","1 through 10","255.01","653.97","percent of total billed charges",""
"STENT TRACHEAL SZ 16 T-TUBE STEM ANGLED ULTRA SMOOTH","SUP-ITM-10295692","CDM","C1874","HCPCS","0278","RC","","","","both","","","822.61","616.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","315.06","38.3","","1950.11","547.40","2346.00","1 through 10","255.01","653.97","percent of total billed charges",""
"STENT TRACHEAL SZ 16 T-TUBE STEM ANGLED ULTRA SMOOTH","SUP-ITM-10295692","CDM","C1874","HCPCS","0278","RC","","","","both","","","822.61","616.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","352.90","42.9","","5096.18","5096.18","5096.18","1 through 10","255.01","653.97","percent of total billed charges",""
"STENT TRACHEAL SZ 16 T-TUBE STEM ANGLED ULTRA SMOOTH","SUP-ITM-10295692","CDM","C1874","HCPCS","0278","RC","","","","both","","","822.61","616.96","WELLPOINT [1015]","HB AMC WELLPOINT","606.92","73.78","","1172.59","1172.59","4829.94","1 through 10","255.01","653.97","percent of total billed charges",""
"STENT TRACHEAL SZ 16 T-TUBE STEM ANGLED ULTRA SMOOTH","SUP-ITM-10295692","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","822.61","616.96","AETNA [1001]","HB AMC AETNA HMO","574.18","69.8","","1806.84","947.80","5091.72","1 through 10","429.9","672.24","percent of total billed charges",""
"STENT TRACHEAL SZ 16 T-TUBE STEM ANGLED ULTRA SMOOTH","SUP-ITM-10295692","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","822.61","616.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","672.24","81.72","","1259.05","615.58","4586.56","1 through 10","429.9","672.24","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 16MM 25FR 60 5.1 .035IN GUIDEWIRE COVER DISTAL RELEASE AIRWAY ULTRAFLEX ACCEPTS","SUP-ITM-10158659","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5021.25","65","","6652.80","6652.80","6652.80","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 16MM 25FR 60 5.1 .035IN GUIDEWIRE COVER DISTAL RELEASE AIRWAY ULTRAFLEX ACCEPTS","SUP-ITM-10158659","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6141.38","79.5","","2612.61","795.38","2612.61","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 16MM 25FR 60 5.1 .035IN GUIDEWIRE COVER DISTAL RELEASE AIRWAY ULTRAFLEX ACCEPTS","SUP-ITM-10158659","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4117.43","53.3","","1101.80","1101.80","1101.80","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 16MM 25FR 60 5.1 .035IN GUIDEWIRE COVER DISTAL RELEASE AIRWAY ULTRAFLEX ACCEPTS","SUP-ITM-10158659","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5021.25","65","","1820.00","910.00","1820.00","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 16MM 25FR 60 5.1 .035IN GUIDEWIRE COVER DISTAL RELEASE AIRWAY ULTRAFLEX ACCEPTS","SUP-ITM-10158659","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2819.63","36.5","","1257.80","693.44","2424.50","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 16MM 25FR 60 5.1 .035IN GUIDEWIRE COVER DISTAL RELEASE AIRWAY ULTRAFLEX ACCEPTS","SUP-ITM-10158659","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2958.68","38.3","","1950.11","547.40","2346.00","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 16MM 25FR 60 5.1 .035IN GUIDEWIRE COVER DISTAL RELEASE AIRWAY ULTRAFLEX ACCEPTS","SUP-ITM-10158659","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3314.03","42.9","","5096.18","5096.18","5096.18","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 16MM 25FR 60 5.1 .035IN GUIDEWIRE COVER DISTAL RELEASE AIRWAY ULTRAFLEX ACCEPTS","SUP-ITM-10158659","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","WELLPOINT [1015]","HB AMC WELLPOINT","5699.51","73.78","","1172.59","1172.59","4829.94","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 16MM 25FR 60 5.1 .035IN GUIDEWIRE COVER DISTAL RELEASE AIRWAY ULTRAFLEX ACCEPTS","SUP-ITM-10158659","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","AETNA [1001]","HB AMC AETNA HMO","5392.05","69.8","","1806.84","947.80","5091.72","1 through 10","4037.09","6312.87","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 16MM 25FR 60 5.1 .035IN GUIDEWIRE COVER DISTAL RELEASE AIRWAY ULTRAFLEX ACCEPTS","SUP-ITM-10158659","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6312.87","81.72","","1259.05","615.58","4586.56","1 through 10","4037.09","6312.87","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18MM DYNAMIC Y SILICON SS STRUT BIFURCATED","SUP-ITM-10151163","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2400.13","65","","6652.80","6652.80","6652.80","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18MM DYNAMIC Y SILICON SS STRUT BIFURCATED","SUP-ITM-10151163","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2935.54","79.5","","2612.61","795.38","2612.61","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18MM DYNAMIC Y SILICON SS STRUT BIFURCATED","SUP-ITM-10151163","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1968.10","53.3","","1101.80","1101.80","1101.80","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18MM DYNAMIC Y SILICON SS STRUT BIFURCATED","SUP-ITM-10151163","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2400.13","65","","1820.00","910.00","1820.00","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18MM DYNAMIC Y SILICON SS STRUT BIFURCATED","SUP-ITM-10151163","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1347.76","36.5","","1257.80","693.44","2424.50","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18MM DYNAMIC Y SILICON SS STRUT BIFURCATED","SUP-ITM-10151163","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1414.23","38.3","","1950.11","547.40","2346.00","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18MM DYNAMIC Y SILICON SS STRUT BIFURCATED","SUP-ITM-10151163","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1584.08","42.9","","5096.18","5096.18","5096.18","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18MM DYNAMIC Y SILICON SS STRUT BIFURCATED","SUP-ITM-10151163","CDM","C1874","HCPCS","0278","RC","","","","both","","","3692.50","2769.37","WELLPOINT [1015]","HB AMC WELLPOINT","2724.33","73.78","","1172.59","1172.59","4829.94","1 through 10","1144.68","2935.54","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18MM DYNAMIC Y SILICON SS STRUT BIFURCATED","SUP-ITM-10151163","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","3692.50","2769.37","AETNA [1001]","HB AMC AETNA HMO","2577.37","69.8","","1806.84","947.80","5091.72","1 through 10","1929.7","3017.51","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18MM DYNAMIC Y SILICON SS STRUT BIFURCATED","SUP-ITM-10151163","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","3692.50","2769.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3017.51","81.72","","1259.05","615.58","4586.56","1 through 10","1929.7","3017.51","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18X60MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10151436","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5021.25","65","","6652.80","6652.80","6652.80","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18X60MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10151436","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6141.38","79.5","","2612.61","795.38","2612.61","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18X60MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10151436","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4117.43","53.3","","1101.80","1101.80","1101.80","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18X60MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10151436","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5021.25","65","","1820.00","910.00","1820.00","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18X60MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10151436","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2819.63","36.5","","1257.80","693.44","2424.50","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18X60MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10151436","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2958.68","38.3","","1950.11","547.40","2346.00","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18X60MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10151436","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3314.03","42.9","","5096.18","5096.18","5096.18","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18X60MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10151436","CDM","C1874","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","WELLPOINT [1015]","HB AMC WELLPOINT","5699.51","73.78","","1172.59","1172.59","4829.94","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18X60MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10151436","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","AETNA [1001]","HB AMC AETNA HMO","5392.05","69.8","","1806.84","947.80","5091.72","1 through 10","4037.09","6312.87","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 18X60MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10151436","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6312.87","81.72","","1259.05","615.58","4586.56","1 through 10","4037.09","6312.87","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X10 XSEC 16FR AERO COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030630","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4062.50","65","","6652.80","6652.80","6652.80","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X10 XSEC 16FR AERO COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030630","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4968.75","79.5","","2612.61","795.38","2612.61","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X10 XSEC 16FR AERO COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030630","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3331.25","53.3","","1101.80","1101.80","1101.80","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X10 XSEC 16FR AERO COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030630","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4062.50","65","","1820.00","910.00","1820.00","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X10 XSEC 16FR AERO COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030630","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.25","36.5","","1257.80","693.44","2424.50","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X10 XSEC 16FR AERO COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030630","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2393.75","38.3","","1950.11","547.40","2346.00","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X10 XSEC 16FR AERO COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030630","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.25","42.9","","5096.18","5096.18","5096.18","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X10 XSEC 16FR AERO COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030630","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","WELLPOINT [1015]","HB AMC WELLPOINT","4611.25","73.78","","1172.59","1172.59","4829.94","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X10 XSEC 16FR AERO COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030630","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","AETNA [1001]","HB AMC AETNA HMO","4362.50","69.8","","1806.84","947.80","5091.72","1 through 10","3266.25","5107.5","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X10 XSEC 16FR AERO COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030630","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5107.50","81.72","","1259.05","615.58","4586.56","1 through 10","3266.25","5107.5","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X40X25MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10210715","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6141.38","79.5","","800.18","480.96","1887.97","195","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X40X25MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10210715","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4117.43","53.3","","813.12","216.42","1444.50","81","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X40X25MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10210715","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2394.75","31","","432.60","432.60","432.60","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X40X25MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10210715","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2819.63","36.5","","148.37","54.89","631.39","94","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X40X25MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10210715","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2958.68","38.3","","279.30","91.72","1116.77","266","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X40X25MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10210715","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3314.03","42.9","","731.00","63.70","731.00","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X40X25MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10210715","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3314.03","42.9","","384.74","384.74","384.74","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X40X25MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10210715","CDM","C1713","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","WELLPOINT [1015]","HB AMC WELLPOINT","5699.51","73.78","","286.63","119.22","1107.45","105","2394.75","6141.38","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X40X25MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10210715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","AETNA [1001]","HB AMC AETNA HMO","5392.05","69.8","","675.31","184.75","1721.50","286","4037.09","6312.87","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X40X25MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10210715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","AETNA [1001]","HB AMC AETNA PPO","6210.90","80.4","","1261.44","103.12","1514.10","21","4037.09","6312.87","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X40X25MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10210715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6210.90","80.4","","1365.00","1365.00","1365.00","1 through 10","4037.09","6312.87","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X40X25MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10210715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6312.87","81.72","","5157.68","5157.68","5157.68","1 through 10","4037.09","6312.87","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 20X40X25MM ULTRAFLEX COVERED DISTAL RELEASE","SUP-ITM-10210715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6312.87","81.72","","431.26","71.26","1459.57","88","4037.09","6312.87","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 40X20 XSEC 22FR AERO NITINOL POLYURETHANE COATED OVER THE WIRE FULLY COVERED","SUP-ITM-10134567","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4062.50","65","","6652.80","6652.80","6652.80","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 40X20 XSEC 22FR AERO NITINOL POLYURETHANE COATED OVER THE WIRE FULLY COVERED","SUP-ITM-10134567","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4968.75","79.5","","2612.61","795.38","2612.61","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 40X20 XSEC 22FR AERO NITINOL POLYURETHANE COATED OVER THE WIRE FULLY COVERED","SUP-ITM-10134567","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3331.25","53.3","","1101.80","1101.80","1101.80","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 40X20 XSEC 22FR AERO NITINOL POLYURETHANE COATED OVER THE WIRE FULLY COVERED","SUP-ITM-10134567","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4062.50","65","","1820.00","910.00","1820.00","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 40X20 XSEC 22FR AERO NITINOL POLYURETHANE COATED OVER THE WIRE FULLY COVERED","SUP-ITM-10134567","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.25","36.5","","1257.80","693.44","2424.50","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 40X20 XSEC 22FR AERO NITINOL POLYURETHANE COATED OVER THE WIRE FULLY COVERED","SUP-ITM-10134567","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2393.75","38.3","","1950.11","547.40","2346.00","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 40X20 XSEC 22FR AERO NITINOL POLYURETHANE COATED OVER THE WIRE FULLY COVERED","SUP-ITM-10134567","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.25","42.9","","5096.18","5096.18","5096.18","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 40X20 XSEC 22FR AERO NITINOL POLYURETHANE COATED OVER THE WIRE FULLY COVERED","SUP-ITM-10134567","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","WELLPOINT [1015]","HB AMC WELLPOINT","4611.25","73.78","","1172.59","1172.59","4829.94","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 40X20 XSEC 22FR AERO NITINOL POLYURETHANE COATED OVER THE WIRE FULLY COVERED","SUP-ITM-10134567","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","AETNA [1001]","HB AMC AETNA HMO","4362.50","69.8","","1806.84","947.80","5091.72","1 through 10","3266.25","5107.5","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 40X20 XSEC 22FR AERO NITINOL POLYURETHANE COATED OVER THE WIRE FULLY COVERED","SUP-ITM-10134567","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5107.50","81.72","","1259.05","615.58","4586.56","1 through 10","3266.25","5107.5","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8.0X15MM PULMONARY AEROMINI FULLY COVERED","SUP-ITM-10169959","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4143.75","65","","6652.80","6652.80","6652.80","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8.0X15MM PULMONARY AEROMINI FULLY COVERED","SUP-ITM-10169959","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5068.13","79.5","","2612.61","795.38","2612.61","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8.0X15MM PULMONARY AEROMINI FULLY COVERED","SUP-ITM-10169959","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3397.88","53.3","","1101.80","1101.80","1101.80","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8.0X15MM PULMONARY AEROMINI FULLY COVERED","SUP-ITM-10169959","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4143.75","65","","1820.00","910.00","1820.00","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8.0X15MM PULMONARY AEROMINI FULLY COVERED","SUP-ITM-10169959","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2326.88","36.5","","1257.80","693.44","2424.50","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8.0X15MM PULMONARY AEROMINI FULLY COVERED","SUP-ITM-10169959","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2441.63","38.3","","1950.11","547.40","2346.00","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8.0X15MM PULMONARY AEROMINI FULLY COVERED","SUP-ITM-10169959","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2734.88","42.9","","5096.18","5096.18","5096.18","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8.0X15MM PULMONARY AEROMINI FULLY COVERED","SUP-ITM-10169959","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","WELLPOINT [1015]","HB AMC WELLPOINT","4703.48","73.78","","1172.59","1172.59","4829.94","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8.0X15MM PULMONARY AEROMINI FULLY COVERED","SUP-ITM-10169959","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6375.00","4781.25","AETNA [1001]","HB AMC AETNA HMO","4449.75","69.8","","1806.84","947.80","5091.72","1 through 10","3331.58","5209.65","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8.0X15MM PULMONARY AEROMINI FULLY COVERED","SUP-ITM-10169959","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6375.00","4781.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5209.65","81.72","","1259.05","615.58","4586.56","1 through 10","3331.58","5209.65","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 80X18 XSEC 22FR AERO FULLY COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030604","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4062.50","65","","6652.80","6652.80","6652.80","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 80X18 XSEC 22FR AERO FULLY COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030604","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4968.75","79.5","","2612.61","795.38","2612.61","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 80X18 XSEC 22FR AERO FULLY COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030604","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3331.25","53.3","","1101.80","1101.80","1101.80","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 80X18 XSEC 22FR AERO FULLY COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030604","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4062.50","65","","1820.00","910.00","1820.00","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 80X18 XSEC 22FR AERO FULLY COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030604","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.25","36.5","","1257.80","693.44","2424.50","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 80X18 XSEC 22FR AERO FULLY COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030604","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2393.75","38.3","","1950.11","547.40","2346.00","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 80X18 XSEC 22FR AERO FULLY COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030604","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.25","42.9","","5096.18","5096.18","5096.18","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 80X18 XSEC 22FR AERO FULLY COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030604","CDM","C1874","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","WELLPOINT [1015]","HB AMC WELLPOINT","4611.25","73.78","","1172.59","1172.59","4829.94","1 through 10","1937.5","4968.75","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 80X18 XSEC 22FR AERO FULLY COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030604","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","AETNA [1001]","HB AMC AETNA HMO","4362.50","69.8","","1806.84","947.80","5091.72","1 through 10","3266.25","5107.5","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 80X18 XSEC 22FR AERO FULLY COVERED NITINOL POLYURETHANE COATED OVER THE WIRE","SUP-ITM-10030604","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5107.50","81.72","","1259.05","615.58","4586.56","1 through 10","3266.25","5107.5","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8MMX10MM AEROMINI COVERED OVER THE WIRE","SUP-ITM-10258476","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4143.75","65","","6652.80","6652.80","6652.80","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8MMX10MM AEROMINI COVERED OVER THE WIRE","SUP-ITM-10258476","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5068.13","79.5","","2612.61","795.38","2612.61","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8MMX10MM AEROMINI COVERED OVER THE WIRE","SUP-ITM-10258476","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3397.88","53.3","","1101.80","1101.80","1101.80","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8MMX10MM AEROMINI COVERED OVER THE WIRE","SUP-ITM-10258476","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4143.75","65","","1820.00","910.00","1820.00","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8MMX10MM AEROMINI COVERED OVER THE WIRE","SUP-ITM-10258476","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2326.88","36.5","","1257.80","693.44","2424.50","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8MMX10MM AEROMINI COVERED OVER THE WIRE","SUP-ITM-10258476","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2441.63","38.3","","1950.11","547.40","2346.00","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8MMX10MM AEROMINI COVERED OVER THE WIRE","SUP-ITM-10258476","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2734.88","42.9","","5096.18","5096.18","5096.18","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8MMX10MM AEROMINI COVERED OVER THE WIRE","SUP-ITM-10258476","CDM","C1874","HCPCS","0278","RC","","","","both","","","6375.00","4781.25","WELLPOINT [1015]","HB AMC WELLPOINT","4703.48","73.78","","1172.59","1172.59","4829.94","1 through 10","1976.25","5068.13","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8MMX10MM AEROMINI COVERED OVER THE WIRE","SUP-ITM-10258476","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6375.00","4781.25","AETNA [1001]","HB AMC AETNA HMO","4449.75","69.8","","1806.84","947.80","5091.72","1 through 10","3331.58","5209.65","percent of total billed charges",""
"STENT TRACHEOBRONCHIAL 8MMX10MM AEROMINI COVERED OVER THE WIRE","SUP-ITM-10258476","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6375.00","4781.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5209.65","81.72","","1259.05","615.58","4586.56","1 through 10","3331.58","5209.65","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 15MM 30MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10151101","CDM","C1876","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","5067.60","65.6","","751.18","751.18","751.18","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 15MM 30MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10151101","CDM","C1876","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6141.38","79.5","","4820.38","3211.27","4820.38","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 15MM 30MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10151101","CDM","C1876","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2819.63","36.5","","641.00","641.00","641.00","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 15MM 30MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10151101","CDM","C1876","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2958.68","38.3","","1098.43","1098.43","1098.43","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 15MM 30MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10151101","CDM","C1876","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3314.03","42.9","","4896.33","4896.33","4896.33","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 15MM 30MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10151101","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","AETNA [1001]","HB AMC AETNA HMO","5392.05","69.8","","175.60","163.11","1063.91","1 through 10","4037.09","6312.87","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 15MM 30MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10151101","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6312.87","81.72","","105.94","85.10","105.94","1 through 10","4037.09","6312.87","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 20MM 95CM TRACHEOBRONCHIAL NITINOL WIRE UNCOVERED PROXIMAL RELEASE","SUP-ITM-10138836","CDM","C1876","HCPCS","0278","RC","","","","both","","","6270.13","4702.60","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4113.21","65.6","","751.18","751.18","751.18","1 through 10","1943.74","4984.75","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 20MM 95CM TRACHEOBRONCHIAL NITINOL WIRE UNCOVERED PROXIMAL RELEASE","SUP-ITM-10138836","CDM","C1876","HCPCS","0278","RC","","","","both","","","6270.13","4702.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4984.75","79.5","","4820.38","3211.27","4820.38","1 through 10","1943.74","4984.75","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 20MM 95CM TRACHEOBRONCHIAL NITINOL WIRE UNCOVERED PROXIMAL RELEASE","SUP-ITM-10138836","CDM","C1876","HCPCS","0278","RC","","","","both","","","6270.13","4702.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2288.60","36.5","","641.00","641.00","641.00","1 through 10","1943.74","4984.75","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 20MM 95CM TRACHEOBRONCHIAL NITINOL WIRE UNCOVERED PROXIMAL RELEASE","SUP-ITM-10138836","CDM","C1876","HCPCS","0278","RC","","","","both","","","6270.13","4702.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2401.46","38.3","","1098.43","1098.43","1098.43","1 through 10","1943.74","4984.75","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 20MM 95CM TRACHEOBRONCHIAL NITINOL WIRE UNCOVERED PROXIMAL RELEASE","SUP-ITM-10138836","CDM","C1876","HCPCS","0278","RC","","","","both","","","6270.13","4702.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2689.89","42.9","","4896.33","4896.33","4896.33","1 through 10","1943.74","4984.75","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 20MM 95CM TRACHEOBRONCHIAL NITINOL WIRE UNCOVERED PROXIMAL RELEASE","SUP-ITM-10138836","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","6270.13","4702.60","AETNA [1001]","HB AMC AETNA HMO","4376.55","69.8","","175.60","163.11","1063.91","1 through 10","3276.77","5123.95","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 20MM 95CM TRACHEOBRONCHIAL NITINOL WIRE UNCOVERED PROXIMAL RELEASE","SUP-ITM-10138836","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","6270.13","4702.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5123.95","81.72","","105.94","85.10","105.94","1 through 10","3276.77","5123.95","percent of total billed charges",""
"STENT ULTRAFLEX 14MM 25MM 40MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10154560","CDM","C1876","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","5067.60","65.6","","751.18","751.18","751.18","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT ULTRAFLEX 14MM 25MM 40MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10154560","CDM","C1876","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6141.38","79.5","","4820.38","3211.27","4820.38","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT ULTRAFLEX 14MM 25MM 40MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10154560","CDM","C1876","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2819.63","36.5","","641.00","641.00","641.00","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT ULTRAFLEX 14MM 25MM 40MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10154560","CDM","C1876","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2958.68","38.3","","1098.43","1098.43","1098.43","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT ULTRAFLEX 14MM 25MM 40MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10154560","CDM","C1876","HCPCS","0278","RC","","","","both","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3314.03","42.9","","4896.33","4896.33","4896.33","1 through 10","2394.75","6141.38","percent of total billed charges",""
"STENT ULTRAFLEX 14MM 25MM 40MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10154560","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","AETNA [1001]","HB AMC AETNA HMO","5392.05","69.8","","175.60","163.11","1063.91","1 through 10","4037.09","6312.87","percent of total billed charges",""
"STENT ULTRAFLEX 14MM 25MM 40MM 95CM TRACHEOBRONCHIAL PARTIALLY COVERED DISTAL RELEASE","SUP-ITM-10154560","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","7725.00","5793.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6312.87","81.72","","105.94","85.10","105.94","1 through 10","4037.09","6312.87","percent of total billed charges",""
"STENT UNISTEP PLUS 7MM 34 6FR 75CM WALL METALLIC SELF EXPANDING DELIVERY SYSTEM ILIAC","SUP-ITM-10008299","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2755.20","65.6","","751.18","751.18","751.18","1 through 10","1302","3339","percent of total billed charges",""
"STENT UNISTEP PLUS 7MM 34 6FR 75CM WALL METALLIC SELF EXPANDING DELIVERY SYSTEM ILIAC","SUP-ITM-10008299","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","4820.38","3211.27","4820.38","1 through 10","1302","3339","percent of total billed charges",""
"STENT UNISTEP PLUS 7MM 34 6FR 75CM WALL METALLIC SELF EXPANDING DELIVERY SYSTEM ILIAC","SUP-ITM-10008299","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","641.00","641.00","641.00","1 through 10","1302","3339","percent of total billed charges",""
"STENT UNISTEP PLUS 7MM 34 6FR 75CM WALL METALLIC SELF EXPANDING DELIVERY SYSTEM ILIAC","SUP-ITM-10008299","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","1098.43","1098.43","1098.43","1 through 10","1302","3339","percent of total billed charges",""
"STENT UNISTEP PLUS 7MM 34 6FR 75CM WALL METALLIC SELF EXPANDING DELIVERY SYSTEM ILIAC","SUP-ITM-10008299","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","4896.33","4896.33","4896.33","1 through 10","1302","3339","percent of total billed charges",""
"STENT UNISTEP PLUS 7MM 34 6FR 75CM WALL METALLIC SELF EXPANDING DELIVERY SYSTEM ILIAC","SUP-ITM-10008299","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","175.60","163.11","1063.91","1 through 10","2194.92","3432.24","percent of total billed charges",""
"STENT UNISTEP PLUS 7MM 34 6FR 75CM WALL METALLIC SELF EXPANDING DELIVERY SYSTEM ILIAC","SUP-ITM-10008299","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","105.94","85.10","105.94","1 through 10","2194.92","3432.24","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","704.59","528.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","560.15","79.5","","304.65","204.39","304.65","1 through 10","218.42","560.15","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","704.59","528.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","375.55","53.3","","204.39","204.39","304.65","1 through 10","218.42","560.15","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","704.59","528.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","257.18","36.5","","144.39","122.71","144.39","1 through 10","218.42","560.15","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","704.59","528.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","269.86","38.3","","151.36","147.10","454.08","13","218.42","560.15","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","704.59","528.44","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","542.53","77","","304.65","304.65","304.65","1 through 10","218.42","560.15","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","704.59","528.44","WELLPOINT [1015]","HB AMC WELLPOINT","519.85","73.78","","675.30","288.20","675.30","1 through 10","218.42","560.15","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","704.59","528.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","575.79","81.72","","183.26","154.72","309.45","1 through 10","368.22","575.79","percent of total billed charges",""
"STENT URETERAL 6FR 30CM SILICONE LUB FLEXIBLE OP","SUP-ITM-10003669","CDM","C2617","HCPCS","0278","RC","","","","both","","","518.21","388.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","411.98","79.5","","304.65","204.39","304.65","1 through 10","160.65","411.98","percent of total billed charges",""
"STENT URETERAL 6FR 30CM SILICONE LUB FLEXIBLE OP","SUP-ITM-10003669","CDM","C2617","HCPCS","0278","RC","","","","both","","","518.21","388.66","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","276.21","53.3","","204.39","204.39","304.65","1 through 10","160.65","411.98","percent of total billed charges",""
"STENT URETERAL 6FR 30CM SILICONE LUB FLEXIBLE OP","SUP-ITM-10003669","CDM","C2617","HCPCS","0278","RC","","","","both","","","518.21","388.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","189.15","36.5","","144.39","122.71","144.39","1 through 10","160.65","411.98","percent of total billed charges",""
"STENT URETERAL 6FR 30CM SILICONE LUB FLEXIBLE OP","SUP-ITM-10003669","CDM","C2617","HCPCS","0278","RC","","","","both","","","518.21","388.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","198.47","38.3","","151.36","147.10","454.08","13","160.65","411.98","percent of total billed charges",""
"STENT URETERAL 6FR 30CM SILICONE LUB FLEXIBLE OP","SUP-ITM-10003669","CDM","C2617","HCPCS","0278","RC","","","","both","","","518.21","388.66","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","399.02","77","","304.65","304.65","304.65","1 through 10","160.65","411.98","percent of total billed charges",""
"STENT URETERAL 6FR 30CM SILICONE LUB FLEXIBLE OP","SUP-ITM-10003669","CDM","C2617","HCPCS","0278","RC","","","","both","","","518.21","388.66","WELLPOINT [1015]","HB AMC WELLPOINT","382.34","73.78","","675.30","288.20","675.30","1 through 10","160.65","411.98","percent of total billed charges",""
"STENT URETERAL 6FR 30CM SILICONE LUB FLEXIBLE OP","SUP-ITM-10003669","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","518.21","388.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","423.48","81.72","","183.26","154.72","309.45","1 through 10","270.82","423.48","percent of total billed charges",""
"STENT URETERAL 6FRX.038 PERCUFLEX DOUBLE PIGTAIL FLEX TIP GUIDEWIRE PTFE STIFF SUTURE HYDROPHILIC POLYMER COATING","SUP-ITM-10155701","CDM","C2617","HCPCS","0278","RC","","","","both","","","628.43","471.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","499.60","79.5","","304.65","204.39","304.65","1 through 10","194.81","499.6","percent of total billed charges",""
"STENT URETERAL 6FRX.038 PERCUFLEX DOUBLE PIGTAIL FLEX TIP GUIDEWIRE PTFE STIFF SUTURE HYDROPHILIC POLYMER COATING","SUP-ITM-10155701","CDM","C2617","HCPCS","0278","RC","","","","both","","","628.43","471.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","334.95","53.3","","204.39","204.39","304.65","1 through 10","194.81","499.6","percent of total billed charges",""
"STENT URETERAL 6FRX.038 PERCUFLEX DOUBLE PIGTAIL FLEX TIP GUIDEWIRE PTFE STIFF SUTURE HYDROPHILIC POLYMER COATING","SUP-ITM-10155701","CDM","C2617","HCPCS","0278","RC","","","","both","","","628.43","471.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","229.38","36.5","","144.39","122.71","144.39","1 through 10","194.81","499.6","percent of total billed charges",""
"STENT URETERAL 6FRX.038 PERCUFLEX DOUBLE PIGTAIL FLEX TIP GUIDEWIRE PTFE STIFF SUTURE HYDROPHILIC POLYMER COATING","SUP-ITM-10155701","CDM","C2617","HCPCS","0278","RC","","","","both","","","628.43","471.32","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","240.69","38.3","","151.36","147.10","454.08","13","194.81","499.6","percent of total billed charges",""
"STENT URETERAL 6FRX.038 PERCUFLEX DOUBLE PIGTAIL FLEX TIP GUIDEWIRE PTFE STIFF SUTURE HYDROPHILIC POLYMER COATING","SUP-ITM-10155701","CDM","C2617","HCPCS","0278","RC","","","","both","","","628.43","471.32","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","483.89","77","","304.65","304.65","304.65","1 through 10","194.81","499.6","percent of total billed charges",""
"STENT URETERAL 6FRX.038 PERCUFLEX DOUBLE PIGTAIL FLEX TIP GUIDEWIRE PTFE STIFF SUTURE HYDROPHILIC POLYMER COATING","SUP-ITM-10155701","CDM","C2617","HCPCS","0278","RC","","","","both","","","628.43","471.32","WELLPOINT [1015]","HB AMC WELLPOINT","463.66","73.78","","675.30","288.20","675.30","1 through 10","194.81","499.6","percent of total billed charges",""
"STENT URETERAL 6FRX.038 PERCUFLEX DOUBLE PIGTAIL FLEX TIP GUIDEWIRE PTFE STIFF SUTURE HYDROPHILIC POLYMER COATING","SUP-ITM-10155701","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","628.43","471.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","513.55","81.72","","183.26","154.72","309.45","1 through 10","328.42","513.55","percent of total billed charges",""
"STENT URETERAL 6FRX20CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072426","CDM","C2617","HCPCS","0278","RC","","","","both","","","704.59","528.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","560.15","79.5","","304.65","204.39","304.65","1 through 10","218.42","560.15","percent of total billed charges",""
"STENT URETERAL 6FRX20CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072426","CDM","C2617","HCPCS","0278","RC","","","","both","","","704.59","528.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","375.55","53.3","","204.39","204.39","304.65","1 through 10","218.42","560.15","percent of total billed charges",""
"STENT URETERAL 6FRX20CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072426","CDM","C2617","HCPCS","0278","RC","","","","both","","","704.59","528.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","257.18","36.5","","144.39","122.71","144.39","1 through 10","218.42","560.15","percent of total billed charges",""
"STENT URETERAL 6FRX20CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072426","CDM","C2617","HCPCS","0278","RC","","","","both","","","704.59","528.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","269.86","38.3","","151.36","147.10","454.08","13","218.42","560.15","percent of total billed charges",""
"STENT URETERAL 6FRX20CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072426","CDM","C2617","HCPCS","0278","RC","","","","both","","","704.59","528.44","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","542.53","77","","304.65","304.65","304.65","1 through 10","218.42","560.15","percent of total billed charges",""
"STENT URETERAL 6FRX20CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072426","CDM","C2617","HCPCS","0278","RC","","","","both","","","704.59","528.44","WELLPOINT [1015]","HB AMC WELLPOINT","519.85","73.78","","675.30","288.20","675.30","1 through 10","218.42","560.15","percent of total billed charges",""
"STENT URETERAL 6FRX20CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072426","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","704.59","528.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","575.79","81.72","","183.26","154.72","309.45","1 through 10","368.22","575.79","percent of total billed charges",""
"STENT URETERAL 6FRX22CM 0.038IN DOUBLE PIGTAIL LUBE SOFT GUIDEWIRE SUTURE C FLEX POSITIONER CATHETER","SUP-ITM-10014230","CDM","C2625","HCPCS","0278","RC","","","","both","","","673.93","505.45","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","471.75","70","","470.75","470.75","470.75","1 through 10","208.92","535.77","percent of total billed charges",""
"STENT URETERAL 6FRX22CM 0.038IN DOUBLE PIGTAIL LUBE SOFT GUIDEWIRE SUTURE C FLEX POSITIONER CATHETER","SUP-ITM-10014230","CDM","C2625","HCPCS","0278","RC","","","","both","","","673.93","505.45","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","258.12","38.3","","184.07","124.37","184.07","1 through 10","208.92","535.77","percent of total billed charges",""
"STENT URETERAL 6FRX22CM 0.038IN DOUBLE PIGTAIL LUBE SOFT GUIDEWIRE SUTURE C FLEX POSITIONER CATHETER","SUP-ITM-10014230","CDM","C2625","HCPCS","0278","RC","","","","both","","","673.93","505.45","WELLPOINT [1015]","HB AMC WELLPOINT","497.23","73.78","","243.67","243.67","243.67","1 through 10","208.92","535.77","percent of total billed charges",""
"STENT URETERAL 6FRX22CM 0.038IN DOUBLE PIGTAIL LUBE SOFT GUIDEWIRE SUTURE C FLEX POSITIONER CATHETER","SUP-ITM-10014230","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","673.93","505.45","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","550.74","81.72","","376.32","376.32","376.32","1 through 10","352.2","550.74","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","1235.96","926.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","982.59","79.5","","304.65","204.39","304.65","1 through 10","383.15","982.59","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","1235.96","926.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","658.77","53.3","","204.39","204.39","304.65","1 through 10","383.15","982.59","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","1235.96","926.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","451.13","36.5","","144.39","122.71","144.39","1 through 10","383.15","982.59","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","1235.96","926.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","473.37","38.3","","151.36","147.10","454.08","13","383.15","982.59","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","1235.96","926.97","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","951.69","77","","304.65","304.65","304.65","1 through 10","383.15","982.59","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","1235.96","926.97","WELLPOINT [1015]","HB AMC WELLPOINT","911.89","73.78","","675.30","288.20","675.30","1 through 10","383.15","982.59","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1235.96","926.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1010.03","81.72","","183.26","154.72","309.45","1 through 10","645.91","1010.03","percent of total billed charges",""
"STENT URETERAL 7FRX20CM DOUBLE PIGTAIL SUTURE PERCUFLEX POSITIONER","SUP-ITM-10154751","CDM","C2617","HCPCS","0278","RC","","","","both","","","504.18","378.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","400.82","79.5","","304.65","204.39","304.65","1 through 10","156.3","400.82","percent of total billed charges",""
"STENT URETERAL 7FRX20CM DOUBLE PIGTAIL SUTURE PERCUFLEX POSITIONER","SUP-ITM-10154751","CDM","C2617","HCPCS","0278","RC","","","","both","","","504.18","378.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","268.73","53.3","","204.39","204.39","304.65","1 through 10","156.3","400.82","percent of total billed charges",""
"STENT URETERAL 7FRX20CM DOUBLE PIGTAIL SUTURE PERCUFLEX POSITIONER","SUP-ITM-10154751","CDM","C2617","HCPCS","0278","RC","","","","both","","","504.18","378.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","184.03","36.5","","144.39","122.71","144.39","1 through 10","156.3","400.82","percent of total billed charges",""
"STENT URETERAL 7FRX20CM DOUBLE PIGTAIL SUTURE PERCUFLEX POSITIONER","SUP-ITM-10154751","CDM","C2617","HCPCS","0278","RC","","","","both","","","504.18","378.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","193.10","38.3","","151.36","147.10","454.08","13","156.3","400.82","percent of total billed charges",""
"STENT URETERAL 7FRX20CM DOUBLE PIGTAIL SUTURE PERCUFLEX POSITIONER","SUP-ITM-10154751","CDM","C2617","HCPCS","0278","RC","","","","both","","","504.18","378.13","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","388.22","77","","304.65","304.65","304.65","1 through 10","156.3","400.82","percent of total billed charges",""
"STENT URETERAL 7FRX20CM DOUBLE PIGTAIL SUTURE PERCUFLEX POSITIONER","SUP-ITM-10154751","CDM","C2617","HCPCS","0278","RC","","","","both","","","504.18","378.13","WELLPOINT [1015]","HB AMC WELLPOINT","371.98","73.78","","675.30","288.20","675.30","1 through 10","156.3","400.82","percent of total billed charges",""
"STENT URETERAL 7FRX20CM DOUBLE PIGTAIL SUTURE PERCUFLEX POSITIONER","SUP-ITM-10154751","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","504.18","378.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","412.02","81.72","","183.26","154.72","309.45","1 through 10","263.48","412.02","percent of total billed charges",""
"STENT URETERAL 8FRX22CM FIRM TRIA","SUP-ITM-10273871","CDM","C2617","HCPCS","0278","RC","","","","both","","","1235.96","926.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","982.59","79.5","","304.65","204.39","304.65","1 through 10","383.15","982.59","percent of total billed charges",""
"STENT URETERAL 8FRX22CM FIRM TRIA","SUP-ITM-10273871","CDM","C2617","HCPCS","0278","RC","","","","both","","","1235.96","926.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","658.77","53.3","","204.39","204.39","304.65","1 through 10","383.15","982.59","percent of total billed charges",""
"STENT URETERAL 8FRX22CM FIRM TRIA","SUP-ITM-10273871","CDM","C2617","HCPCS","0278","RC","","","","both","","","1235.96","926.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","451.13","36.5","","144.39","122.71","144.39","1 through 10","383.15","982.59","percent of total billed charges",""
"STENT URETERAL 8FRX22CM FIRM TRIA","SUP-ITM-10273871","CDM","C2617","HCPCS","0278","RC","","","","both","","","1235.96","926.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","473.37","38.3","","151.36","147.10","454.08","13","383.15","982.59","percent of total billed charges",""
"STENT URETERAL 8FRX22CM FIRM TRIA","SUP-ITM-10273871","CDM","C2617","HCPCS","0278","RC","","","","both","","","1235.96","926.97","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","951.69","77","","304.65","304.65","304.65","1 through 10","383.15","982.59","percent of total billed charges",""
"STENT URETERAL 8FRX22CM FIRM TRIA","SUP-ITM-10273871","CDM","C2617","HCPCS","0278","RC","","","","both","","","1235.96","926.97","WELLPOINT [1015]","HB AMC WELLPOINT","911.89","73.78","","675.30","288.20","675.30","1 through 10","383.15","982.59","percent of total billed charges",""
"STENT URETERAL 8FRX22CM FIRM TRIA","SUP-ITM-10273871","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1235.96","926.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1010.03","81.72","","183.26","154.72","309.45","1 through 10","645.91","1010.03","percent of total billed charges",""
"STENT URETHRAL 10FRX12CM ZAONTZ POST OP DRAINAGE HYPOSPADIAS EPISPADIAS REPAIR","SUP-ITM-10043021","CDM","C2617","HCPCS","0278","RC","","","","both","","","120.05","90.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","95.44","79.5","","304.65","204.39","304.65","1 through 10","37.22","95.44","percent of total billed charges",""
"STENT URETHRAL 10FRX12CM ZAONTZ POST OP DRAINAGE HYPOSPADIAS EPISPADIAS REPAIR","SUP-ITM-10043021","CDM","C2617","HCPCS","0278","RC","","","","both","","","120.05","90.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","63.99","53.3","","204.39","204.39","304.65","1 through 10","37.22","95.44","percent of total billed charges",""
"STENT URETHRAL 10FRX12CM ZAONTZ POST OP DRAINAGE HYPOSPADIAS EPISPADIAS REPAIR","SUP-ITM-10043021","CDM","C2617","HCPCS","0278","RC","","","","both","","","120.05","90.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","43.82","36.5","","144.39","122.71","144.39","1 through 10","37.22","95.44","percent of total billed charges",""
"STENT URETHRAL 10FRX12CM ZAONTZ POST OP DRAINAGE HYPOSPADIAS EPISPADIAS REPAIR","SUP-ITM-10043021","CDM","C2617","HCPCS","0278","RC","","","","both","","","120.05","90.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","45.98","38.3","","151.36","147.10","454.08","13","37.22","95.44","percent of total billed charges",""
"STENT URETHRAL 10FRX12CM ZAONTZ POST OP DRAINAGE HYPOSPADIAS EPISPADIAS REPAIR","SUP-ITM-10043021","CDM","C2617","HCPCS","0278","RC","","","","both","","","120.05","90.04","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","92.44","77","","304.65","304.65","304.65","1 through 10","37.22","95.44","percent of total billed charges",""
"STENT URETHRAL 10FRX12CM ZAONTZ POST OP DRAINAGE HYPOSPADIAS EPISPADIAS REPAIR","SUP-ITM-10043021","CDM","C2617","HCPCS","0278","RC","","","","both","","","120.05","90.04","WELLPOINT [1015]","HB AMC WELLPOINT","88.57","73.78","","675.30","288.20","675.30","1 through 10","37.22","95.44","percent of total billed charges",""
"STENT URETHRAL 10FRX12CM ZAONTZ POST OP DRAINAGE HYPOSPADIAS EPISPADIAS REPAIR","SUP-ITM-10043021","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","120.05","90.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","98.10","81.72","","183.26","154.72","309.45","1 through 10","62.74","98.1","percent of total billed charges",""
"STENT UROLOGICAL 6FRX20CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10041553","CDM","C2617","HCPCS","0278","RC","","","","both","","","590.31","442.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","469.30","79.5","","304.65","204.39","304.65","1 through 10","183","469.3","percent of total billed charges",""
"STENT UROLOGICAL 6FRX20CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10041553","CDM","C2617","HCPCS","0278","RC","","","","both","","","590.31","442.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","314.64","53.3","","204.39","204.39","304.65","1 through 10","183","469.3","percent of total billed charges",""
"STENT UROLOGICAL 6FRX20CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10041553","CDM","C2617","HCPCS","0278","RC","","","","both","","","590.31","442.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","215.46","36.5","","144.39","122.71","144.39","1 through 10","183","469.3","percent of total billed charges",""
"STENT UROLOGICAL 6FRX20CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10041553","CDM","C2617","HCPCS","0278","RC","","","","both","","","590.31","442.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","226.09","38.3","","151.36","147.10","454.08","13","183","469.3","percent of total billed charges",""
"STENT UROLOGICAL 6FRX20CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10041553","CDM","C2617","HCPCS","0278","RC","","","","both","","","590.31","442.73","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","454.54","77","","304.65","304.65","304.65","1 through 10","183","469.3","percent of total billed charges",""
"STENT UROLOGICAL 6FRX20CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10041553","CDM","C2617","HCPCS","0278","RC","","","","both","","","590.31","442.73","WELLPOINT [1015]","HB AMC WELLPOINT","435.53","73.78","","675.30","288.20","675.30","1 through 10","183","469.3","percent of total billed charges",""
"STENT UROLOGICAL 6FRX20CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10041553","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","590.31","442.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","482.40","81.72","","183.26","154.72","309.45","1 through 10","308.5","482.4","percent of total billed charges",""
"STENT UROLOGICAL 6FRX26CM DOUBLE J CLOSED ENDED TIP THREADED Y","SUP-ITM-10003623","CDM","C2625","HCPCS","0278","RC","","","","both","","","649.88","487.41","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","454.92","70","","470.75","470.75","470.75","1 through 10","201.46","516.65","percent of total billed charges",""
"STENT UROLOGICAL 6FRX26CM DOUBLE J CLOSED ENDED TIP THREADED Y","SUP-ITM-10003623","CDM","C2625","HCPCS","0278","RC","","","","both","","","649.88","487.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","248.90","38.3","","184.07","124.37","184.07","1 through 10","201.46","516.65","percent of total billed charges",""
"STENT UROLOGICAL 6FRX26CM DOUBLE J CLOSED ENDED TIP THREADED Y","SUP-ITM-10003623","CDM","C2625","HCPCS","0278","RC","","","","both","","","649.88","487.41","WELLPOINT [1015]","HB AMC WELLPOINT","479.48","73.78","","243.67","243.67","243.67","1 through 10","201.46","516.65","percent of total billed charges",""
"STENT UROLOGICAL 6FRX26CM DOUBLE J CLOSED ENDED TIP THREADED Y","SUP-ITM-10003623","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","649.88","487.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","531.08","81.72","","376.32","376.32","376.32","1 through 10","339.63","531.08","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","both","","","590.31","442.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","469.30","79.5","","304.65","204.39","304.65","1 through 10","183","469.3","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","both","","","590.31","442.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","314.64","53.3","","204.39","204.39","304.65","1 through 10","183","469.3","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","both","","","590.31","442.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","215.46","36.5","","144.39","122.71","144.39","1 through 10","183","469.3","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","both","","","590.31","442.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","226.09","38.3","","151.36","147.10","454.08","13","183","469.3","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","both","","","590.31","442.73","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","454.54","77","","304.65","304.65","304.65","1 through 10","183","469.3","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","both","","","590.31","442.73","WELLPOINT [1015]","HB AMC WELLPOINT","435.53","73.78","","675.30","288.20","675.30","1 through 10","183","469.3","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","590.31","442.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","482.40","81.72","","183.26","154.72","309.45","1 through 10","308.5","482.4","percent of total billed charges",""
"STENT VASCULAR 18FR 23X16 145MM LIFE NITINOL TUBULAR MESH SELF EXPANDING HELICAL SHEATH DELIVERY SYSTEM PERIPHERAL","SUP-ITM-10100986","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","16857.75","65","","6652.80","6652.80","6652.80","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT VASCULAR 18FR 23X16 145MM LIFE NITINOL TUBULAR MESH SELF EXPANDING HELICAL SHEATH DELIVERY SYSTEM PERIPHERAL","SUP-ITM-10100986","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20618.33","79.5","","2612.61","795.38","2612.61","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT VASCULAR 18FR 23X16 145MM LIFE NITINOL TUBULAR MESH SELF EXPANDING HELICAL SHEATH DELIVERY SYSTEM PERIPHERAL","SUP-ITM-10100986","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13823.36","53.3","","1101.80","1101.80","1101.80","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT VASCULAR 18FR 23X16 145MM LIFE NITINOL TUBULAR MESH SELF EXPANDING HELICAL SHEATH DELIVERY SYSTEM PERIPHERAL","SUP-ITM-10100986","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","16857.75","65","","1820.00","910.00","1820.00","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT VASCULAR 18FR 23X16 145MM LIFE NITINOL TUBULAR MESH SELF EXPANDING HELICAL SHEATH DELIVERY SYSTEM PERIPHERAL","SUP-ITM-10100986","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9466.28","36.5","","1257.80","693.44","2424.50","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT VASCULAR 18FR 23X16 145MM LIFE NITINOL TUBULAR MESH SELF EXPANDING HELICAL SHEATH DELIVERY SYSTEM PERIPHERAL","SUP-ITM-10100986","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9933.11","38.3","","1950.11","547.40","2346.00","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT VASCULAR 18FR 23X16 145MM LIFE NITINOL TUBULAR MESH SELF EXPANDING HELICAL SHEATH DELIVERY SYSTEM PERIPHERAL","SUP-ITM-10100986","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","11126.12","42.9","","5096.18","5096.18","5096.18","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT VASCULAR 18FR 23X16 145MM LIFE NITINOL TUBULAR MESH SELF EXPANDING HELICAL SHEATH DELIVERY SYSTEM PERIPHERAL","SUP-ITM-10100986","CDM","C1874","HCPCS","0278","RC","","","","both","","","25935.00","19451.25","WELLPOINT [1015]","HB AMC WELLPOINT","19134.84","73.78","","1172.59","1172.59","4829.94","1 through 10","8039.85","20618.33","percent of total billed charges",""
"STENT VASCULAR 18FR 23X16 145MM LIFE NITINOL TUBULAR MESH SELF EXPANDING HELICAL SHEATH DELIVERY SYSTEM PERIPHERAL","SUP-ITM-10100986","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25935.00","19451.25","AETNA [1001]","HB AMC AETNA HMO","18102.63","69.8","","1806.84","947.80","5091.72","1 through 10","13553.63","21194.08","percent of total billed charges",""
"STENT VASCULAR 18FR 23X16 145MM LIFE NITINOL TUBULAR MESH SELF EXPANDING HELICAL SHEATH DELIVERY SYSTEM PERIPHERAL","SUP-ITM-10100986","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25935.00","19451.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","21194.08","81.72","","1259.05","615.58","4586.56","1 through 10","13553.63","21194.08","percent of total billed charges",""
"STENT VASCULAR 4.00MM 12 0.014IN CORONARY MULTI LINK MINI VISION RX COBALT CHROMIUM BALLOON","SUP-ITM-10011987","CDM","C1876","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","941.36","65.6","","751.18","751.18","751.18","1 through 10","444.85","1140.83","percent of total billed charges",""
"STENT VASCULAR 4.00MM 12 0.014IN CORONARY MULTI LINK MINI VISION RX COBALT CHROMIUM BALLOON","SUP-ITM-10011987","CDM","C1876","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1140.83","79.5","","4820.38","3211.27","4820.38","1 through 10","444.85","1140.83","percent of total billed charges",""
"STENT VASCULAR 4.00MM 12 0.014IN CORONARY MULTI LINK MINI VISION RX COBALT CHROMIUM BALLOON","SUP-ITM-10011987","CDM","C1876","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","523.78","36.5","","641.00","641.00","641.00","1 through 10","444.85","1140.83","percent of total billed charges",""
"STENT VASCULAR 4.00MM 12 0.014IN CORONARY MULTI LINK MINI VISION RX COBALT CHROMIUM BALLOON","SUP-ITM-10011987","CDM","C1876","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","549.61","38.3","","1098.43","1098.43","1098.43","1 through 10","444.85","1140.83","percent of total billed charges",""
"STENT VASCULAR 4.00MM 12 0.014IN CORONARY MULTI LINK MINI VISION RX COBALT CHROMIUM BALLOON","SUP-ITM-10011987","CDM","C1876","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","615.62","42.9","","4896.33","4896.33","4896.33","1 through 10","444.85","1140.83","percent of total billed charges",""
"STENT VASCULAR 4.00MM 12 0.014IN CORONARY MULTI LINK MINI VISION RX COBALT CHROMIUM BALLOON","SUP-ITM-10011987","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1435.00","1076.25","AETNA [1001]","HB AMC AETNA HMO","1001.63","69.8","","175.60","163.11","1063.91","1 through 10","749.93","1172.68","percent of total billed charges",""
"STENT VASCULAR 4.00MM 12 0.014IN CORONARY MULTI LINK MINI VISION RX COBALT CHROMIUM BALLOON","SUP-ITM-10011987","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1435.00","1076.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1172.68","81.72","","105.94","85.10","105.94","1 through 10","749.93","1172.68","percent of total billed charges",""
"STENT VASCULAR 6X20MM 0.014IN ACCULINK CAROTID RAPID EXCHANGE NITINOL SELF EXPANDING STRAIGHT","SUP-ITM-10013537","CDM","C1876","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3099.60","65.6","","751.18","751.18","751.18","1 through 10","1464.75","3756.38","percent of total billed charges",""
"STENT VASCULAR 6X20MM 0.014IN ACCULINK CAROTID RAPID EXCHANGE NITINOL SELF EXPANDING STRAIGHT","SUP-ITM-10013537","CDM","C1876","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3756.38","79.5","","4820.38","3211.27","4820.38","1 through 10","1464.75","3756.38","percent of total billed charges",""
"STENT VASCULAR 6X20MM 0.014IN ACCULINK CAROTID RAPID EXCHANGE NITINOL SELF EXPANDING STRAIGHT","SUP-ITM-10013537","CDM","C1876","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1724.63","36.5","","641.00","641.00","641.00","1 through 10","1464.75","3756.38","percent of total billed charges",""
"STENT VASCULAR 6X20MM 0.014IN ACCULINK CAROTID RAPID EXCHANGE NITINOL SELF EXPANDING STRAIGHT","SUP-ITM-10013537","CDM","C1876","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1809.68","38.3","","1098.43","1098.43","1098.43","1 through 10","1464.75","3756.38","percent of total billed charges",""
"STENT VASCULAR 6X20MM 0.014IN ACCULINK CAROTID RAPID EXCHANGE NITINOL SELF EXPANDING STRAIGHT","SUP-ITM-10013537","CDM","C1876","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","4896.33","4896.33","4896.33","1 through 10","1464.75","3756.38","percent of total billed charges",""
"STENT VASCULAR 6X20MM 0.014IN ACCULINK CAROTID RAPID EXCHANGE NITINOL SELF EXPANDING STRAIGHT","SUP-ITM-10013537","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA HMO","3298.05","69.8","","175.60","163.11","1063.91","1 through 10","2469.29","3861.27","percent of total billed charges",""
"STENT VASCULAR 6X20MM 0.014IN ACCULINK CAROTID RAPID EXCHANGE NITINOL SELF EXPANDING STRAIGHT","SUP-ITM-10013537","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3861.27","81.72","","105.94","85.10","105.94","1 through 10","2469.29","3861.27","percent of total billed charges",""
"STENT VASCULAR 7X20MM 0.014IN ACCULINK NICKEL TITANIUM RAPID EXCHANGE SELF EXPANDING STRAIGHT CAROTID","SUP-ITM-10013539","CDM","C1876","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3099.60","65.6","","751.18","751.18","751.18","1 through 10","1464.75","3756.38","percent of total billed charges",""
"STENT VASCULAR 7X20MM 0.014IN ACCULINK NICKEL TITANIUM RAPID EXCHANGE SELF EXPANDING STRAIGHT CAROTID","SUP-ITM-10013539","CDM","C1876","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3756.38","79.5","","4820.38","3211.27","4820.38","1 through 10","1464.75","3756.38","percent of total billed charges",""
"STENT VASCULAR 7X20MM 0.014IN ACCULINK NICKEL TITANIUM RAPID EXCHANGE SELF EXPANDING STRAIGHT CAROTID","SUP-ITM-10013539","CDM","C1876","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1724.63","36.5","","641.00","641.00","641.00","1 through 10","1464.75","3756.38","percent of total billed charges",""
"STENT VASCULAR 7X20MM 0.014IN ACCULINK NICKEL TITANIUM RAPID EXCHANGE SELF EXPANDING STRAIGHT CAROTID","SUP-ITM-10013539","CDM","C1876","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1809.68","38.3","","1098.43","1098.43","1098.43","1 through 10","1464.75","3756.38","percent of total billed charges",""
"STENT VASCULAR 7X20MM 0.014IN ACCULINK NICKEL TITANIUM RAPID EXCHANGE SELF EXPANDING STRAIGHT CAROTID","SUP-ITM-10013539","CDM","C1876","HCPCS","0278","RC","","","","both","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2027.03","42.9","","4896.33","4896.33","4896.33","1 through 10","1464.75","3756.38","percent of total billed charges",""
"STENT VASCULAR 7X20MM 0.014IN ACCULINK NICKEL TITANIUM RAPID EXCHANGE SELF EXPANDING STRAIGHT CAROTID","SUP-ITM-10013539","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","AETNA [1001]","HB AMC AETNA HMO","3298.05","69.8","","175.60","163.11","1063.91","1 through 10","2469.29","3861.27","percent of total billed charges",""
"STENT VASCULAR 7X20MM 0.014IN ACCULINK NICKEL TITANIUM RAPID EXCHANGE SELF EXPANDING STRAIGHT CAROTID","SUP-ITM-10013539","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4725.00","3543.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3861.27","81.72","","105.94","85.10","105.94","1 through 10","2469.29","3861.27","percent of total billed charges",""
"STENT VENOUS 12X40X75CM WALLSTENT","SUP-ITM-10274344","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2755.20","65.6","","751.18","751.18","751.18","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOUS 12X40X75CM WALLSTENT","SUP-ITM-10274344","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","4820.38","3211.27","4820.38","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOUS 12X40X75CM WALLSTENT","SUP-ITM-10274344","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","641.00","641.00","641.00","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOUS 12X40X75CM WALLSTENT","SUP-ITM-10274344","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","1098.43","1098.43","1098.43","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOUS 12X40X75CM WALLSTENT","SUP-ITM-10274344","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","4896.33","4896.33","4896.33","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOUS 12X40X75CM WALLSTENT","SUP-ITM-10274344","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","175.60","163.11","1063.91","1 through 10","2194.92","3432.24","percent of total billed charges",""
"STENT VENOUS 12X40X75CM WALLSTENT","SUP-ITM-10274344","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","105.94","85.10","105.94","1 through 10","2194.92","3432.24","percent of total billed charges",""
"STENT VENOUS 16MM X 60MM ABRE","SUP-ITM-10278995","CDM","C1876","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2656.80","65.6","","751.18","751.18","751.18","1 through 10","1255.5","3219.75","percent of total billed charges",""
"STENT VENOUS 16MM X 60MM ABRE","SUP-ITM-10278995","CDM","C1876","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3219.75","79.5","","4820.38","3211.27","4820.38","1 through 10","1255.5","3219.75","percent of total billed charges",""
"STENT VENOUS 16MM X 60MM ABRE","SUP-ITM-10278995","CDM","C1876","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1478.25","36.5","","641.00","641.00","641.00","1 through 10","1255.5","3219.75","percent of total billed charges",""
"STENT VENOUS 16MM X 60MM ABRE","SUP-ITM-10278995","CDM","C1876","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1551.15","38.3","","1098.43","1098.43","1098.43","1 through 10","1255.5","3219.75","percent of total billed charges",""
"STENT VENOUS 16MM X 60MM ABRE","SUP-ITM-10278995","CDM","C1876","HCPCS","0278","RC","","","","both","","","4050.00","3037.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1737.45","42.9","","4896.33","4896.33","4896.33","1 through 10","1255.5","3219.75","percent of total billed charges",""
"STENT VENOUS 16MM X 60MM ABRE","SUP-ITM-10278995","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4050.00","3037.50","AETNA [1001]","HB AMC AETNA HMO","2826.90","69.8","","175.60","163.11","1063.91","1 through 10","2116.53","3309.66","percent of total billed charges",""
"STENT VENOUS 16MM X 60MM ABRE","SUP-ITM-10278995","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4050.00","3037.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3309.66","81.72","","105.94","85.10","105.94","1 through 10","2116.53","3309.66","percent of total billed charges",""
"STENT VENOUS 16X60X75CM WALLSTENT","SUP-ITM-10274333","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2755.20","65.6","","751.18","751.18","751.18","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOUS 16X60X75CM WALLSTENT","SUP-ITM-10274333","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","4820.38","3211.27","4820.38","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOUS 16X60X75CM WALLSTENT","SUP-ITM-10274333","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","641.00","641.00","641.00","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOUS 16X60X75CM WALLSTENT","SUP-ITM-10274333","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","1098.43","1098.43","1098.43","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOUS 16X60X75CM WALLSTENT","SUP-ITM-10274333","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","4896.33","4896.33","4896.33","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOUS 16X60X75CM WALLSTENT","SUP-ITM-10274333","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","175.60","163.11","1063.91","1 through 10","2194.92","3432.24","percent of total billed charges",""
"STENT VENOUS 16X60X75CM WALLSTENT","SUP-ITM-10274333","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","105.94","85.10","105.94","1 through 10","2194.92","3432.24","percent of total billed charges",""
"STENT VENOVO 10FR 20MM 40MM .035IN 120CM CATHETER VASCULAR","SUP-ITM-10238693","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2755.20","65.6","","751.18","751.18","751.18","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOVO 10FR 20MM 40MM .035IN 120CM CATHETER VASCULAR","SUP-ITM-10238693","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","4820.38","3211.27","4820.38","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOVO 10FR 20MM 40MM .035IN 120CM CATHETER VASCULAR","SUP-ITM-10238693","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","641.00","641.00","641.00","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOVO 10FR 20MM 40MM .035IN 120CM CATHETER VASCULAR","SUP-ITM-10238693","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","1098.43","1098.43","1098.43","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOVO 10FR 20MM 40MM .035IN 120CM CATHETER VASCULAR","SUP-ITM-10238693","CDM","C1876","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","4896.33","4896.33","4896.33","1 through 10","1302","3339","percent of total billed charges",""
"STENT VENOVO 10FR 20MM 40MM .035IN 120CM CATHETER VASCULAR","SUP-ITM-10238693","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","175.60","163.11","1063.91","1 through 10","2194.92","3432.24","percent of total billed charges",""
"STENT VENOVO 10FR 20MM 40MM .035IN 120CM CATHETER VASCULAR","SUP-ITM-10238693","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","105.94","85.10","105.94","1 through 10","2194.92","3432.24","percent of total billed charges",""
"STENT VIABAHN 6MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135267","CDM","C1874","HCPCS","0278","RC","","","","both","","","8917.50","6688.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5796.38","65","","6652.80","6652.80","6652.80","1 through 10","2764.43","7089.41","percent of total billed charges",""
"STENT VIABAHN 6MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135267","CDM","C1874","HCPCS","0278","RC","","","","both","","","8917.50","6688.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7089.41","79.5","","2612.61","795.38","2612.61","1 through 10","2764.43","7089.41","percent of total billed charges",""
"STENT VIABAHN 6MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135267","CDM","C1874","HCPCS","0278","RC","","","","both","","","8917.50","6688.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4753.03","53.3","","1101.80","1101.80","1101.80","1 through 10","2764.43","7089.41","percent of total billed charges",""
"STENT VIABAHN 6MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135267","CDM","C1874","HCPCS","0278","RC","","","","both","","","8917.50","6688.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5796.38","65","","1820.00","910.00","1820.00","1 through 10","2764.43","7089.41","percent of total billed charges",""
"STENT VIABAHN 6MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135267","CDM","C1874","HCPCS","0278","RC","","","","both","","","8917.50","6688.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3254.89","36.5","","1257.80","693.44","2424.50","1 through 10","2764.43","7089.41","percent of total billed charges",""
"STENT VIABAHN 6MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135267","CDM","C1874","HCPCS","0278","RC","","","","both","","","8917.50","6688.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3415.40","38.3","","1950.11","547.40","2346.00","1 through 10","2764.43","7089.41","percent of total billed charges",""
"STENT VIABAHN 6MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135267","CDM","C1874","HCPCS","0278","RC","","","","both","","","8917.50","6688.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3825.61","42.9","","5096.18","5096.18","5096.18","1 through 10","2764.43","7089.41","percent of total billed charges",""
"STENT VIABAHN 6MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135267","CDM","C1874","HCPCS","0278","RC","","","","both","","","8917.50","6688.12","WELLPOINT [1015]","HB AMC WELLPOINT","6579.33","73.78","","1172.59","1172.59","4829.94","1 through 10","2764.43","7089.41","percent of total billed charges",""
"STENT VIABAHN 6MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135267","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8917.50","6688.12","AETNA [1001]","HB AMC AETNA HMO","6224.42","69.8","","1806.84","947.80","5091.72","1 through 10","4660.29","7287.38","percent of total billed charges",""
"STENT VIABAHN 6MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135267","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8917.50","6688.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7287.38","81.72","","1259.05","615.58","4586.56","1 through 10","4660.29","7287.38","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","both","","","7970.00","5977.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5180.50","65","","6652.80","6652.80","6652.80","1 through 10","2470.7","6336.15","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","both","","","7970.00","5977.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6336.15","79.5","","2612.61","795.38","2612.61","1 through 10","2470.7","6336.15","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","both","","","7970.00","5977.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4248.01","53.3","","1101.80","1101.80","1101.80","1 through 10","2470.7","6336.15","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","both","","","7970.00","5977.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5180.50","65","","1820.00","910.00","1820.00","1 through 10","2470.7","6336.15","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","both","","","7970.00","5977.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2909.05","36.5","","1257.80","693.44","2424.50","1 through 10","2470.7","6336.15","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","both","","","7970.00","5977.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3052.51","38.3","","1950.11","547.40","2346.00","1 through 10","2470.7","6336.15","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","both","","","7970.00","5977.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3419.13","42.9","","5096.18","5096.18","5096.18","1 through 10","2470.7","6336.15","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","both","","","7970.00","5977.50","WELLPOINT [1015]","HB AMC WELLPOINT","5880.27","73.78","","1172.59","1172.59","4829.94","1 through 10","2470.7","6336.15","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7970.00","5977.50","AETNA [1001]","HB AMC AETNA HMO","5563.06","69.8","","1806.84","947.80","5091.72","1 through 10","4165.12","6513.08","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7970.00","5977.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6513.08","81.72","","1259.05","615.58","4586.56","1 through 10","4165.12","6513.08","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5609.50","65","","6652.80","6652.80","6652.80","1 through 10","2675.3","6860.85","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6860.85","79.5","","2612.61","795.38","2612.61","1 through 10","2675.3","6860.85","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4599.79","53.3","","1101.80","1101.80","1101.80","1 through 10","2675.3","6860.85","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5609.50","65","","1820.00","910.00","1820.00","1 through 10","2675.3","6860.85","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3149.95","36.5","","1257.80","693.44","2424.50","1 through 10","2675.3","6860.85","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3305.29","38.3","","1950.11","547.40","2346.00","1 through 10","2675.3","6860.85","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3702.27","42.9","","5096.18","5096.18","5096.18","1 through 10","2675.3","6860.85","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","both","","","8630.00","6472.50","WELLPOINT [1015]","HB AMC WELLPOINT","6367.21","73.78","","1172.59","1172.59","4829.94","1 through 10","2675.3","6860.85","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8630.00","6472.50","AETNA [1001]","HB AMC AETNA HMO","6023.74","69.8","","1806.84","947.80","5091.72","1 through 10","4510.04","7052.44","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","8630.00","6472.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7052.44","81.72","","1259.05","615.58","4586.56","1 through 10","4510.04","7052.44","percent of total billed charges",""
"STENT VIABAHN 8MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135278","CDM","C1874","HCPCS","0278","RC","","","","both","","","9987.50","7490.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6491.88","65","","6652.80","6652.80","6652.80","1 through 10","3096.13","7940.06","percent of total billed charges",""
"STENT VIABAHN 8MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135278","CDM","C1874","HCPCS","0278","RC","","","","both","","","9987.50","7490.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7940.06","79.5","","2612.61","795.38","2612.61","1 through 10","3096.13","7940.06","percent of total billed charges",""
"STENT VIABAHN 8MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135278","CDM","C1874","HCPCS","0278","RC","","","","both","","","9987.50","7490.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5323.34","53.3","","1101.80","1101.80","1101.80","1 through 10","3096.13","7940.06","percent of total billed charges",""
"STENT VIABAHN 8MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135278","CDM","C1874","HCPCS","0278","RC","","","","both","","","9987.50","7490.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6491.88","65","","1820.00","910.00","1820.00","1 through 10","3096.13","7940.06","percent of total billed charges",""
"STENT VIABAHN 8MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135278","CDM","C1874","HCPCS","0278","RC","","","","both","","","9987.50","7490.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3645.44","36.5","","1257.80","693.44","2424.50","1 through 10","3096.13","7940.06","percent of total billed charges",""
"STENT VIABAHN 8MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135278","CDM","C1874","HCPCS","0278","RC","","","","both","","","9987.50","7490.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3825.21","38.3","","1950.11","547.40","2346.00","1 through 10","3096.13","7940.06","percent of total billed charges",""
"STENT VIABAHN 8MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135278","CDM","C1874","HCPCS","0278","RC","","","","both","","","9987.50","7490.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4284.64","42.9","","5096.18","5096.18","5096.18","1 through 10","3096.13","7940.06","percent of total billed charges",""
"STENT VIABAHN 8MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135278","CDM","C1874","HCPCS","0278","RC","","","","both","","","9987.50","7490.62","WELLPOINT [1015]","HB AMC WELLPOINT","7368.78","73.78","","1172.59","1172.59","4829.94","1 through 10","3096.13","7940.06","percent of total billed charges",""
"STENT VIABAHN 8MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135278","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9987.50","7490.62","AETNA [1001]","HB AMC AETNA HMO","6971.28","69.8","","1806.84","947.80","5091.72","1 through 10","5219.47","8161.79","percent of total billed charges",""
"STENT VIABAHN 8MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135278","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9987.50","7490.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8161.79","81.72","","1259.05","615.58","4586.56","1 through 10","5219.47","8161.79","percent of total billed charges",""
"STENT VIABAHN 8MM 2.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135252","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5005.00","65","","6652.80","6652.80","6652.80","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 2.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135252","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6121.50","79.5","","2612.61","795.38","2612.61","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 2.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135252","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4104.10","53.3","","1101.80","1101.80","1101.80","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 2.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135252","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5005.00","65","","1820.00","910.00","1820.00","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 2.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135252","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2810.50","36.5","","1257.80","693.44","2424.50","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 2.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135252","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2949.10","38.3","","1950.11","547.40","2346.00","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 2.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135252","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3303.30","42.9","","5096.18","5096.18","5096.18","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 2.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135252","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","WELLPOINT [1015]","HB AMC WELLPOINT","5681.06","73.78","","1172.59","1172.59","4829.94","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 2.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135252","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7700.00","5775.00","AETNA [1001]","HB AMC AETNA HMO","5374.60","69.8","","1806.84","947.80","5091.72","1 through 10","4024.02","6292.44","percent of total billed charges",""
"STENT VIABAHN 8MM 2.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135252","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7700.00","5775.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6292.44","81.72","","1259.05","615.58","4586.56","1 through 10","4024.02","6292.44","percent of total billed charges",""
"STENT VIABAHN 8MM 25CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135279","CDM","C1874","HCPCS","0278","RC","","","","both","","","16375.00","12281.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","10643.75","65","","6652.80","6652.80","6652.80","1 through 10","5076.25","13018.13","percent of total billed charges",""
"STENT VIABAHN 8MM 25CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135279","CDM","C1874","HCPCS","0278","RC","","","","both","","","16375.00","12281.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","13018.13","79.5","","2612.61","795.38","2612.61","1 through 10","5076.25","13018.13","percent of total billed charges",""
"STENT VIABAHN 8MM 25CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135279","CDM","C1874","HCPCS","0278","RC","","","","both","","","16375.00","12281.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8727.88","53.3","","1101.80","1101.80","1101.80","1 through 10","5076.25","13018.13","percent of total billed charges",""
"STENT VIABAHN 8MM 25CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135279","CDM","C1874","HCPCS","0278","RC","","","","both","","","16375.00","12281.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","10643.75","65","","1820.00","910.00","1820.00","1 through 10","5076.25","13018.13","percent of total billed charges",""
"STENT VIABAHN 8MM 25CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135279","CDM","C1874","HCPCS","0278","RC","","","","both","","","16375.00","12281.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5976.88","36.5","","1257.80","693.44","2424.50","1 through 10","5076.25","13018.13","percent of total billed charges",""
"STENT VIABAHN 8MM 25CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135279","CDM","C1874","HCPCS","0278","RC","","","","both","","","16375.00","12281.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6271.63","38.3","","1950.11","547.40","2346.00","1 through 10","5076.25","13018.13","percent of total billed charges",""
"STENT VIABAHN 8MM 25CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135279","CDM","C1874","HCPCS","0278","RC","","","","both","","","16375.00","12281.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7024.88","42.9","","5096.18","5096.18","5096.18","1 through 10","5076.25","13018.13","percent of total billed charges",""
"STENT VIABAHN 8MM 25CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135279","CDM","C1874","HCPCS","0278","RC","","","","both","","","16375.00","12281.25","WELLPOINT [1015]","HB AMC WELLPOINT","12081.48","73.78","","1172.59","1172.59","4829.94","1 through 10","5076.25","13018.13","percent of total billed charges",""
"STENT VIABAHN 8MM 25CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135279","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16375.00","12281.25","AETNA [1001]","HB AMC AETNA HMO","11429.75","69.8","","1806.84","947.80","5091.72","1 through 10","8557.58","13381.65","percent of total billed charges",""
"STENT VIABAHN 8MM 25CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135279","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16375.00","12281.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13381.65","81.72","","1259.05","615.58","4586.56","1 through 10","8557.58","13381.65","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 75CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135253","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","5005.00","65","","6652.80","6652.80","6652.80","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 75CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135253","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6121.50","79.5","","2612.61","795.38","2612.61","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 75CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135253","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4104.10","53.3","","1101.80","1101.80","1101.80","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 75CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135253","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5005.00","65","","1820.00","910.00","1820.00","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 75CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135253","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2810.50","36.5","","1257.80","693.44","2424.50","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 75CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135253","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2949.10","38.3","","1950.11","547.40","2346.00","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 75CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135253","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3303.30","42.9","","5096.18","5096.18","5096.18","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 75CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135253","CDM","C1874","HCPCS","0278","RC","","","","both","","","7700.00","5775.00","WELLPOINT [1015]","HB AMC WELLPOINT","5681.06","73.78","","1172.59","1172.59","4829.94","1 through 10","2387","6121.5","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 75CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135253","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7700.00","5775.00","AETNA [1001]","HB AMC AETNA HMO","5374.60","69.8","","1806.84","947.80","5091.72","1 through 10","4024.02","6292.44","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 75CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135253","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7700.00","5775.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6292.44","81.72","","1259.05","615.58","4586.56","1 through 10","4024.02","6292.44","percent of total billed charges",""
"STENT VIABIL 10CM 8MM CATHETER 200CM SHORT WIRE NO HOLE BILIARY CS/1EA","SUP-ITM-10211895","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3900.00","65","","6652.80","6652.80","6652.80","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10CM 8MM CATHETER 200CM SHORT WIRE NO HOLE BILIARY CS/1EA","SUP-ITM-10211895","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4770.00","79.5","","2612.61","795.38","2612.61","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10CM 8MM CATHETER 200CM SHORT WIRE NO HOLE BILIARY CS/1EA","SUP-ITM-10211895","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3198.00","53.3","","1101.80","1101.80","1101.80","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10CM 8MM CATHETER 200CM SHORT WIRE NO HOLE BILIARY CS/1EA","SUP-ITM-10211895","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3900.00","65","","1820.00","910.00","1820.00","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10CM 8MM CATHETER 200CM SHORT WIRE NO HOLE BILIARY CS/1EA","SUP-ITM-10211895","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2190.00","36.5","","1257.80","693.44","2424.50","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10CM 8MM CATHETER 200CM SHORT WIRE NO HOLE BILIARY CS/1EA","SUP-ITM-10211895","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2298.00","38.3","","1950.11","547.40","2346.00","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10CM 8MM CATHETER 200CM SHORT WIRE NO HOLE BILIARY CS/1EA","SUP-ITM-10211895","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2574.00","42.9","","5096.18","5096.18","5096.18","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10CM 8MM CATHETER 200CM SHORT WIRE NO HOLE BILIARY CS/1EA","SUP-ITM-10211895","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB AMC WELLPOINT","4426.80","73.78","","1172.59","1172.59","4829.94","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10CM 8MM CATHETER 200CM SHORT WIRE NO HOLE BILIARY CS/1EA","SUP-ITM-10211895","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","AETNA [1001]","HB AMC AETNA HMO","4188.00","69.8","","1806.84","947.80","5091.72","1 through 10","3135.6","4903.2","percent of total billed charges",""
"STENT VIABIL 10CM 8MM CATHETER 200CM SHORT WIRE NO HOLE BILIARY CS/1EA","SUP-ITM-10211895","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4903.20","81.72","","1259.05","615.58","4586.56","1 through 10","3135.6","4903.2","percent of total billed charges",""
"STENT VIABIL 10MM 60MM 200CM BILIARY COVERED SHORT WIRE ENDOPROSTHESIS","SUP-ITM-10192385","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3900.00","65","","6652.80","6652.80","6652.80","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MM 60MM 200CM BILIARY COVERED SHORT WIRE ENDOPROSTHESIS","SUP-ITM-10192385","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4770.00","79.5","","2612.61","795.38","2612.61","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MM 60MM 200CM BILIARY COVERED SHORT WIRE ENDOPROSTHESIS","SUP-ITM-10192385","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3198.00","53.3","","1101.80","1101.80","1101.80","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MM 60MM 200CM BILIARY COVERED SHORT WIRE ENDOPROSTHESIS","SUP-ITM-10192385","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3900.00","65","","1820.00","910.00","1820.00","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MM 60MM 200CM BILIARY COVERED SHORT WIRE ENDOPROSTHESIS","SUP-ITM-10192385","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2190.00","36.5","","1257.80","693.44","2424.50","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MM 60MM 200CM BILIARY COVERED SHORT WIRE ENDOPROSTHESIS","SUP-ITM-10192385","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2298.00","38.3","","1950.11","547.40","2346.00","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MM 60MM 200CM BILIARY COVERED SHORT WIRE ENDOPROSTHESIS","SUP-ITM-10192385","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2574.00","42.9","","5096.18","5096.18","5096.18","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MM 60MM 200CM BILIARY COVERED SHORT WIRE ENDOPROSTHESIS","SUP-ITM-10192385","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB AMC WELLPOINT","4426.80","73.78","","1172.59","1172.59","4829.94","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MM 60MM 200CM BILIARY COVERED SHORT WIRE ENDOPROSTHESIS","SUP-ITM-10192385","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","AETNA [1001]","HB AMC AETNA HMO","4188.00","69.8","","1806.84","947.80","5091.72","1 through 10","3135.6","4903.2","percent of total billed charges",""
"STENT VIABIL 10MM 60MM 200CM BILIARY COVERED SHORT WIRE ENDOPROSTHESIS","SUP-ITM-10192385","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4903.20","81.72","","1259.05","615.58","4586.56","1 through 10","3135.6","4903.2","percent of total billed charges",""
"STENT VIABIL 10MMX10CM BILIARY","SUP-ITM-10211359","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3900.00","65","","6652.80","6652.80","6652.80","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MMX10CM BILIARY","SUP-ITM-10211359","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4770.00","79.5","","2612.61","795.38","2612.61","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MMX10CM BILIARY","SUP-ITM-10211359","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3198.00","53.3","","1101.80","1101.80","1101.80","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MMX10CM BILIARY","SUP-ITM-10211359","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3900.00","65","","1820.00","910.00","1820.00","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MMX10CM BILIARY","SUP-ITM-10211359","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2190.00","36.5","","1257.80","693.44","2424.50","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MMX10CM BILIARY","SUP-ITM-10211359","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2298.00","38.3","","1950.11","547.40","2346.00","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MMX10CM BILIARY","SUP-ITM-10211359","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2574.00","42.9","","5096.18","5096.18","5096.18","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MMX10CM BILIARY","SUP-ITM-10211359","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB AMC WELLPOINT","4426.80","73.78","","1172.59","1172.59","4829.94","1 through 10","1860","4770","percent of total billed charges",""
"STENT VIABIL 10MMX10CM BILIARY","SUP-ITM-10211359","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","AETNA [1001]","HB AMC AETNA HMO","4188.00","69.8","","1806.84","947.80","5091.72","1 through 10","3135.6","4903.2","percent of total billed charges",""
"STENT VIABIL 10MMX10CM BILIARY","SUP-ITM-10211359","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4903.20","81.72","","1259.05","615.58","4586.56","1 through 10","3135.6","4903.2","percent of total billed charges",""
"STENT VIATORR TIPS 10FR 8-10MM 8/2CM .035IN ENDOPROSTHESI STRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT NITINOL SELF EXPANDING","SUP-ITM-10188045","CDM","C1874","HCPCS","0278","RC","","","","both","","","12600.00","9450.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8190.00","65","","6652.80","6652.80","6652.80","1 through 10","3906","10017","percent of total billed charges",""
"STENT VIATORR TIPS 10FR 8-10MM 8/2CM .035IN ENDOPROSTHESI STRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT NITINOL SELF EXPANDING","SUP-ITM-10188045","CDM","C1874","HCPCS","0278","RC","","","","both","","","12600.00","9450.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10017.00","79.5","","2612.61","795.38","2612.61","1 through 10","3906","10017","percent of total billed charges",""
"STENT VIATORR TIPS 10FR 8-10MM 8/2CM .035IN ENDOPROSTHESI STRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT NITINOL SELF EXPANDING","SUP-ITM-10188045","CDM","C1874","HCPCS","0278","RC","","","","both","","","12600.00","9450.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6715.80","53.3","","1101.80","1101.80","1101.80","1 through 10","3906","10017","percent of total billed charges",""
"STENT VIATORR TIPS 10FR 8-10MM 8/2CM .035IN ENDOPROSTHESI STRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT NITINOL SELF EXPANDING","SUP-ITM-10188045","CDM","C1874","HCPCS","0278","RC","","","","both","","","12600.00","9450.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8190.00","65","","1820.00","910.00","1820.00","1 through 10","3906","10017","percent of total billed charges",""
"STENT VIATORR TIPS 10FR 8-10MM 8/2CM .035IN ENDOPROSTHESI STRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT NITINOL SELF EXPANDING","SUP-ITM-10188045","CDM","C1874","HCPCS","0278","RC","","","","both","","","12600.00","9450.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4599.00","36.5","","1257.80","693.44","2424.50","1 through 10","3906","10017","percent of total billed charges",""
"STENT VIATORR TIPS 10FR 8-10MM 8/2CM .035IN ENDOPROSTHESI STRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT NITINOL SELF EXPANDING","SUP-ITM-10188045","CDM","C1874","HCPCS","0278","RC","","","","both","","","12600.00","9450.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4825.80","38.3","","1950.11","547.40","2346.00","1 through 10","3906","10017","percent of total billed charges",""
"STENT VIATORR TIPS 10FR 8-10MM 8/2CM .035IN ENDOPROSTHESI STRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT NITINOL SELF EXPANDING","SUP-ITM-10188045","CDM","C1874","HCPCS","0278","RC","","","","both","","","12600.00","9450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5405.40","42.9","","5096.18","5096.18","5096.18","1 through 10","3906","10017","percent of total billed charges",""
"STENT VIATORR TIPS 10FR 8-10MM 8/2CM .035IN ENDOPROSTHESI STRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT NITINOL SELF EXPANDING","SUP-ITM-10188045","CDM","C1874","HCPCS","0278","RC","","","","both","","","12600.00","9450.00","WELLPOINT [1015]","HB AMC WELLPOINT","9296.28","73.78","","1172.59","1172.59","4829.94","1 through 10","3906","10017","percent of total billed charges",""
"STENT VIATORR TIPS 10FR 8-10MM 8/2CM .035IN ENDOPROSTHESI STRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT NITINOL SELF EXPANDING","SUP-ITM-10188045","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12600.00","9450.00","AETNA [1001]","HB AMC AETNA HMO","8794.80","69.8","","1806.84","947.80","5091.72","1 through 10","6584.76","10296.72","percent of total billed charges",""
"STENT VIATORR TIPS 10FR 8-10MM 8/2CM .035IN ENDOPROSTHESI STRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT NITINOL SELF EXPANDING","SUP-ITM-10188045","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12600.00","9450.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10296.72","81.72","","1259.05","615.58","4586.56","1 through 10","6584.76","10296.72","percent of total billed charges",""
"STENT WALLFLEX 10FR 25MM 30MM 60MM 230CM .035IN COLONIC SINGLE USE","SUP-ITM-10021568","CDM","C1876","HCPCS","0278","RC","","","","both","","","6159.53","4619.65","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4040.65","65.6","","751.18","751.18","751.18","1 through 10","1909.45","4896.83","percent of total billed charges",""
"STENT WALLFLEX 10FR 25MM 30MM 60MM 230CM .035IN COLONIC SINGLE USE","SUP-ITM-10021568","CDM","C1876","HCPCS","0278","RC","","","","both","","","6159.53","4619.65","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4896.83","79.5","","4820.38","3211.27","4820.38","1 through 10","1909.45","4896.83","percent of total billed charges",""
"STENT WALLFLEX 10FR 25MM 30MM 60MM 230CM .035IN COLONIC SINGLE USE","SUP-ITM-10021568","CDM","C1876","HCPCS","0278","RC","","","","both","","","6159.53","4619.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2248.23","36.5","","641.00","641.00","641.00","1 through 10","1909.45","4896.83","percent of total billed charges",""
"STENT WALLFLEX 10FR 25MM 30MM 60MM 230CM .035IN COLONIC SINGLE USE","SUP-ITM-10021568","CDM","C1876","HCPCS","0278","RC","","","","both","","","6159.53","4619.65","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2359.10","38.3","","1098.43","1098.43","1098.43","1 through 10","1909.45","4896.83","percent of total billed charges",""
"STENT WALLFLEX 10FR 25MM 30MM 60MM 230CM .035IN COLONIC SINGLE USE","SUP-ITM-10021568","CDM","C1876","HCPCS","0278","RC","","","","both","","","6159.53","4619.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2642.44","42.9","","4896.33","4896.33","4896.33","1 through 10","1909.45","4896.83","percent of total billed charges",""
"STENT WALLFLEX 10FR 25MM 30MM 60MM 230CM .035IN COLONIC SINGLE USE","SUP-ITM-10021568","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","6159.53","4619.65","AETNA [1001]","HB AMC AETNA HMO","4299.35","69.8","","175.60","163.11","1063.91","1 through 10","3218.97","5033.57","percent of total billed charges",""
"STENT WALLFLEX 10FR 25MM 30MM 60MM 230CM .035IN COLONIC SINGLE USE","SUP-ITM-10021568","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","6159.53","4619.65","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5033.57","81.72","","105.94","85.10","105.94","1 through 10","3218.97","5033.57","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3656.25","65","","6652.80","6652.80","6652.80","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4471.88","79.5","","2612.61","795.38","2612.61","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2998.13","53.3","","1101.80","1101.80","1101.80","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3656.25","65","","1820.00","910.00","1820.00","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2053.13","36.5","","1257.80","693.44","2424.50","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2154.38","38.3","","1950.11","547.40","2346.00","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2413.13","42.9","","5096.18","5096.18","5096.18","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","WELLPOINT [1015]","HB AMC WELLPOINT","4150.13","73.78","","1172.59","1172.59","4829.94","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","AETNA [1001]","HB AMC AETNA HMO","3926.25","69.8","","1806.84","947.80","5091.72","1 through 10","2939.63","4596.75","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4596.75","81.72","","1259.05","615.58","4586.56","1 through 10","2939.63","4596.75","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 12CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049113","CDM","C1874","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3575.00","65","","6652.80","6652.80","6652.80","1 through 10","1705","4372.5","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 12CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049113","CDM","C1874","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4372.50","79.5","","2612.61","795.38","2612.61","1 through 10","1705","4372.5","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 12CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049113","CDM","C1874","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2931.50","53.3","","1101.80","1101.80","1101.80","1 through 10","1705","4372.5","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 12CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049113","CDM","C1874","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3575.00","65","","1820.00","910.00","1820.00","1 through 10","1705","4372.5","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 12CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049113","CDM","C1874","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2007.50","36.5","","1257.80","693.44","2424.50","1 through 10","1705","4372.5","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 12CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049113","CDM","C1874","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2106.50","38.3","","1950.11","547.40","2346.00","1 through 10","1705","4372.5","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 12CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049113","CDM","C1874","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2359.50","42.9","","5096.18","5096.18","5096.18","1 through 10","1705","4372.5","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 12CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049113","CDM","C1874","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","WELLPOINT [1015]","HB AMC WELLPOINT","4057.90","73.78","","1172.59","1172.59","4829.94","1 through 10","1705","4372.5","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 12CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049113","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","AETNA [1001]","HB AMC AETNA HMO","3839.00","69.8","","1806.84","947.80","5091.72","1 through 10","2874.3","4494.6","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 12CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049113","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4494.60","81.72","","1259.05","615.58","4586.56","1 through 10","2874.3","4494.6","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 15CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073306","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3656.25","65","","6652.80","6652.80","6652.80","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 15CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073306","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4471.88","79.5","","2612.61","795.38","2612.61","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 15CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073306","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2998.13","53.3","","1101.80","1101.80","1101.80","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 15CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073306","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3656.25","65","","1820.00","910.00","1820.00","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 15CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073306","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2053.13","36.5","","1257.80","693.44","2424.50","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 15CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073306","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2154.38","38.3","","1950.11","547.40","2346.00","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 15CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073306","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2413.13","42.9","","5096.18","5096.18","5096.18","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 15CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073306","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","WELLPOINT [1015]","HB AMC WELLPOINT","4150.13","73.78","","1172.59","1172.59","4829.94","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 15CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073306","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","AETNA [1001]","HB AMC AETNA HMO","3926.25","69.8","","1806.84","947.80","5091.72","1 through 10","2939.63","4596.75","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 15CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073306","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4596.75","81.72","","1259.05","615.58","4586.56","1 through 10","2939.63","4596.75","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 23MM 15CM 28MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073344","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3656.25","65","","6652.80","6652.80","6652.80","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 23MM 15CM 28MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073344","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4471.88","79.5","","2612.61","795.38","2612.61","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 23MM 15CM 28MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073344","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2998.13","53.3","","1101.80","1101.80","1101.80","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 23MM 15CM 28MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073344","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3656.25","65","","1820.00","910.00","1820.00","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 23MM 15CM 28MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073344","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2053.13","36.5","","1257.80","693.44","2424.50","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 23MM 15CM 28MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073344","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2154.38","38.3","","1950.11","547.40","2346.00","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 23MM 15CM 28MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073344","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2413.13","42.9","","5096.18","5096.18","5096.18","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 23MM 15CM 28MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073344","CDM","C1874","HCPCS","0278","RC","","","","both","","","5625.00","4218.75","WELLPOINT [1015]","HB AMC WELLPOINT","4150.13","73.78","","1172.59","1172.59","4829.94","1 through 10","1743.75","4471.88","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 23MM 15CM 28MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073344","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","AETNA [1001]","HB AMC AETNA HMO","3926.25","69.8","","1806.84","947.80","5091.72","1 through 10","2939.63","4596.75","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 23MM 15CM 28MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073344","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5625.00","4218.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4596.75","81.72","","1259.05","615.58","4586.56","1 through 10","2939.63","4596.75","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3900.00","65","","6652.80","6652.80","6652.80","1 through 10","1860","4770","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4770.00","79.5","","2612.61","795.38","2612.61","1 through 10","1860","4770","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3198.00","53.3","","1101.80","1101.80","1101.80","1 through 10","1860","4770","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3900.00","65","","1820.00","910.00","1820.00","1 through 10","1860","4770","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2190.00","36.5","","1257.80","693.44","2424.50","1 through 10","1860","4770","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2298.00","38.3","","1950.11","547.40","2346.00","1 through 10","1860","4770","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2574.00","42.9","","5096.18","5096.18","5096.18","1 through 10","1860","4770","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB AMC WELLPOINT","4426.80","73.78","","1172.59","1172.59","4829.94","1 through 10","1860","4770","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","AETNA [1001]","HB AMC AETNA HMO","4188.00","69.8","","1806.84","947.80","5091.72","1 through 10","3135.6","4903.2","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4903.20","81.72","","1259.05","615.58","4586.56","1 through 10","3135.6","4903.2","percent of total billed charges",""
"STENT WALLFLEX 8FR 10MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10022705","CDM","C1876","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3247.20","65.6","","751.18","751.18","751.18","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT WALLFLEX 8FR 10MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10022705","CDM","C1876","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","4820.38","3211.27","4820.38","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT WALLFLEX 8FR 10MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10022705","CDM","C1876","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","641.00","641.00","641.00","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT WALLFLEX 8FR 10MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10022705","CDM","C1876","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","1098.43","1098.43","1098.43","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT WALLFLEX 8FR 10MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10022705","CDM","C1876","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","4896.33","4896.33","4896.33","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT WALLFLEX 8FR 10MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10022705","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","175.60","163.11","1063.91","1 through 10","2586.87","4045.14","percent of total billed charges",""
"STENT WALLFLEX 8FR 10MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10022705","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","105.94","85.10","105.94","1 through 10","2586.87","4045.14","percent of total billed charges",""
"STENT WALLFLEX 8FR 8MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10027635","CDM","C1876","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3247.20","65.6","","751.18","751.18","751.18","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT WALLFLEX 8FR 8MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10027635","CDM","C1876","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","4820.38","3211.27","4820.38","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT WALLFLEX 8FR 8MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10027635","CDM","C1876","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","641.00","641.00","641.00","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT WALLFLEX 8FR 8MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10027635","CDM","C1876","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","1098.43","1098.43","1098.43","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT WALLFLEX 8FR 8MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10027635","CDM","C1876","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","4896.33","4896.33","4896.33","1 through 10","1534.5","3935.25","percent of total billed charges",""
"STENT WALLFLEX 8FR 8MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10027635","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","175.60","163.11","1063.91","1 through 10","2586.87","4045.14","percent of total billed charges",""
"STENT WALLFLEX 8FR 8MM 80MM 194CM .035IN RX UNCOVERED BILIARY","SUP-ITM-10027635","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","105.94","85.10","105.94","1 through 10","2586.87","4045.14","percent of total billed charges",""
"STENT WALLSTENT 12FR 24MM 70MM 100CM TRACHEOBRONCHIAL METALLIC SELF EXPANDING UNISTEP PLUS DELIVERY SYSTEM","SUP-ITM-10013583","CDM","C1876","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3148.80","65.6","","751.18","751.18","751.18","1 through 10","1488","3816","percent of total billed charges",""
"STENT WALLSTENT 12FR 24MM 70MM 100CM TRACHEOBRONCHIAL METALLIC SELF EXPANDING UNISTEP PLUS DELIVERY SYSTEM","SUP-ITM-10013583","CDM","C1876","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3816.00","79.5","","4820.38","3211.27","4820.38","1 through 10","1488","3816","percent of total billed charges",""
"STENT WALLSTENT 12FR 24MM 70MM 100CM TRACHEOBRONCHIAL METALLIC SELF EXPANDING UNISTEP PLUS DELIVERY SYSTEM","SUP-ITM-10013583","CDM","C1876","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1752.00","36.5","","641.00","641.00","641.00","1 through 10","1488","3816","percent of total billed charges",""
"STENT WALLSTENT 12FR 24MM 70MM 100CM TRACHEOBRONCHIAL METALLIC SELF EXPANDING UNISTEP PLUS DELIVERY SYSTEM","SUP-ITM-10013583","CDM","C1876","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1838.40","38.3","","1098.43","1098.43","1098.43","1 through 10","1488","3816","percent of total billed charges",""
"STENT WALLSTENT 12FR 24MM 70MM 100CM TRACHEOBRONCHIAL METALLIC SELF EXPANDING UNISTEP PLUS DELIVERY SYSTEM","SUP-ITM-10013583","CDM","C1876","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2059.20","42.9","","4896.33","4896.33","4896.33","1 through 10","1488","3816","percent of total billed charges",""
"STENT WALLSTENT 12FR 24MM 70MM 100CM TRACHEOBRONCHIAL METALLIC SELF EXPANDING UNISTEP PLUS DELIVERY SYSTEM","SUP-ITM-10013583","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","AETNA [1001]","HB AMC AETNA HMO","3350.40","69.8","","175.60","163.11","1063.91","1 through 10","2508.48","3922.56","percent of total billed charges",""
"STENT WALLSTENT 12FR 24MM 70MM 100CM TRACHEOBRONCHIAL METALLIC SELF EXPANDING UNISTEP PLUS DELIVERY SYSTEM","SUP-ITM-10013583","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3922.56","81.72","","105.94","85.10","105.94","1 through 10","2508.48","3922.56","percent of total billed charges",""
"STENT XACT 6-8FR 10MM 30MM 136CM STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019260","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3348.55","65.6","","751.18","751.18","751.18","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 10MM 30MM 136CM STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019260","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4058.08","79.5","","4820.38","3211.27","4820.38","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 10MM 30MM 136CM STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019260","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1863.14","36.5","","641.00","641.00","641.00","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 10MM 30MM 136CM STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019260","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1955.02","38.3","","1098.43","1098.43","1098.43","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 10MM 30MM 136CM STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019260","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2189.83","42.9","","4896.33","4896.33","4896.33","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 10MM 30MM 136CM STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019260","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","5104.50","3828.37","AETNA [1001]","HB AMC AETNA HMO","3562.94","69.8","","175.60","163.11","1063.91","1 through 10","2667.61","4171.4","percent of total billed charges",""
"STENT XACT 6-8FR 10MM 30MM 136CM STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019260","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","5104.50","3828.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4171.40","81.72","","105.94","85.10","105.94","1 through 10","2667.61","4171.4","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 20MM 136CM .014IN STRAIGHT CAROTID NITINOL RX SELF EXPANDING","SUP-ITM-10018125","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3348.55","65.6","","751.18","751.18","751.18","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 20MM 136CM .014IN STRAIGHT CAROTID NITINOL RX SELF EXPANDING","SUP-ITM-10018125","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4058.08","79.5","","4820.38","3211.27","4820.38","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 20MM 136CM .014IN STRAIGHT CAROTID NITINOL RX SELF EXPANDING","SUP-ITM-10018125","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1863.14","36.5","","641.00","641.00","641.00","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 20MM 136CM .014IN STRAIGHT CAROTID NITINOL RX SELF EXPANDING","SUP-ITM-10018125","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1955.02","38.3","","1098.43","1098.43","1098.43","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 20MM 136CM .014IN STRAIGHT CAROTID NITINOL RX SELF EXPANDING","SUP-ITM-10018125","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2189.83","42.9","","4896.33","4896.33","4896.33","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 20MM 136CM .014IN STRAIGHT CAROTID NITINOL RX SELF EXPANDING","SUP-ITM-10018125","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","5104.50","3828.37","AETNA [1001]","HB AMC AETNA HMO","3562.94","69.8","","175.60","163.11","1063.91","1 through 10","2667.61","4171.4","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 20MM 136CM .014IN STRAIGHT CAROTID NITINOL RX SELF EXPANDING","SUP-ITM-10018125","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","5104.50","3828.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4171.40","81.72","","105.94","85.10","105.94","1 through 10","2667.61","4171.4","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 30MM 135CM .014IN STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019986","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3348.55","65.6","","751.18","751.18","751.18","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 30MM 135CM .014IN STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019986","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4058.08","79.5","","4820.38","3211.27","4820.38","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 30MM 135CM .014IN STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019986","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1863.14","36.5","","641.00","641.00","641.00","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 30MM 135CM .014IN STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019986","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1955.02","38.3","","1098.43","1098.43","1098.43","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 30MM 135CM .014IN STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019986","CDM","C1876","HCPCS","0278","RC","","","","both","","","5104.50","3828.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2189.83","42.9","","4896.33","4896.33","4896.33","1 through 10","1582.4","4058.08","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 30MM 135CM .014IN STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019986","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","5104.50","3828.37","AETNA [1001]","HB AMC AETNA HMO","3562.94","69.8","","175.60","163.11","1063.91","1 through 10","2667.61","4171.4","percent of total billed charges",""
"STENT XACT 6-8FR 8MM 30MM 135CM .014IN STRAIGHT CAROTID NITINOL RX BARE METAL SELF EXPANDING","SUP-ITM-10019986","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","5104.50","3828.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4171.40","81.72","","105.94","85.10","105.94","1 through 10","2667.61","4171.4","percent of total billed charges",""
"STENT XIENCE SIERRA 3.50X33MM RAPID EXCHANGE CORONARY EVEROL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10212097","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","910.00","65","","6652.80","6652.80","6652.80","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SIERRA 3.50X33MM RAPID EXCHANGE CORONARY EVEROL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10212097","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","2612.61","795.38","2612.61","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SIERRA 3.50X33MM RAPID EXCHANGE CORONARY EVEROL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10212097","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","1101.80","1101.80","1101.80","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SIERRA 3.50X33MM RAPID EXCHANGE CORONARY EVEROL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10212097","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","910.00","65","","1820.00","910.00","1820.00","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SIERRA 3.50X33MM RAPID EXCHANGE CORONARY EVEROL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10212097","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1257.80","693.44","2424.50","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SIERRA 3.50X33MM RAPID EXCHANGE CORONARY EVEROL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10212097","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","1950.11","547.40","2346.00","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SIERRA 3.50X33MM RAPID EXCHANGE CORONARY EVEROL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10212097","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","5096.18","5096.18","5096.18","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SIERRA 3.50X33MM RAPID EXCHANGE CORONARY EVEROL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10212097","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","1172.59","1172.59","4829.94","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SIERRA 3.50X33MM RAPID EXCHANGE CORONARY EVEROL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10212097","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1806.84","947.80","5091.72","1 through 10","731.64","1144.08","percent of total billed charges",""
"STENT XIENCE SIERRA 3.50X33MM RAPID EXCHANGE CORONARY EVEROL - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10212097","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","1259.05","615.58","4586.56","1 through 10","731.64","1144.08","percent of total billed charges",""
"STENT XIENCE SKYPOINT 4.00MMX15MM RAPID-EXCHANGE EVEROLIMUS ELUTING CORONARY","SUP-ITM-10283473","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","910.00","65","","6652.80","6652.80","6652.80","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SKYPOINT 4.00MMX15MM RAPID-EXCHANGE EVEROLIMUS ELUTING CORONARY","SUP-ITM-10283473","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","2612.61","795.38","2612.61","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SKYPOINT 4.00MMX15MM RAPID-EXCHANGE EVEROLIMUS ELUTING CORONARY","SUP-ITM-10283473","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","746.20","53.3","","1101.80","1101.80","1101.80","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SKYPOINT 4.00MMX15MM RAPID-EXCHANGE EVEROLIMUS ELUTING CORONARY","SUP-ITM-10283473","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","910.00","65","","1820.00","910.00","1820.00","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SKYPOINT 4.00MMX15MM RAPID-EXCHANGE EVEROLIMUS ELUTING CORONARY","SUP-ITM-10283473","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1257.80","693.44","2424.50","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SKYPOINT 4.00MMX15MM RAPID-EXCHANGE EVEROLIMUS ELUTING CORONARY","SUP-ITM-10283473","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","1950.11","547.40","2346.00","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SKYPOINT 4.00MMX15MM RAPID-EXCHANGE EVEROLIMUS ELUTING CORONARY","SUP-ITM-10283473","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","5096.18","5096.18","5096.18","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SKYPOINT 4.00MMX15MM RAPID-EXCHANGE EVEROLIMUS ELUTING CORONARY","SUP-ITM-10283473","CDM","C1874","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","1172.59","1172.59","4829.94","1 through 10","434","1113","percent of total billed charges",""
"STENT XIENCE SKYPOINT 4.00MMX15MM RAPID-EXCHANGE EVEROLIMUS ELUTING CORONARY","SUP-ITM-10283473","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1806.84","947.80","5091.72","1 through 10","731.64","1144.08","percent of total billed charges",""
"STENT XIENCE SKYPOINT 4.00MMX15MM RAPID-EXCHANGE EVEROLIMUS ELUTING CORONARY","SUP-ITM-10283473","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","1259.05","615.58","4586.56","1 through 10","731.64","1144.08","percent of total billed charges",""
"STENT ZENITH 36DIA 120MM DISSECTION AORTIC BARE METAL ENDOVASCULAR","SUP-ITM-10257817","CDM","C1876","HCPCS","0278","RC","","","","both","","","41247.50","30935.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","27058.36","65.6","","751.18","751.18","751.18","1 through 10","12786.73","32791.76","percent of total billed charges",""
"STENT ZENITH 36DIA 120MM DISSECTION AORTIC BARE METAL ENDOVASCULAR","SUP-ITM-10257817","CDM","C1876","HCPCS","0278","RC","","","","both","","","41247.50","30935.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","32791.76","79.5","","4820.38","3211.27","4820.38","1 through 10","12786.73","32791.76","percent of total billed charges",""
"STENT ZENITH 36DIA 120MM DISSECTION AORTIC BARE METAL ENDOVASCULAR","SUP-ITM-10257817","CDM","C1876","HCPCS","0278","RC","","","","both","","","41247.50","30935.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15055.34","36.5","","641.00","641.00","641.00","1 through 10","12786.73","32791.76","percent of total billed charges",""
"STENT ZENITH 36DIA 120MM DISSECTION AORTIC BARE METAL ENDOVASCULAR","SUP-ITM-10257817","CDM","C1876","HCPCS","0278","RC","","","","both","","","41247.50","30935.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15797.79","38.3","","1098.43","1098.43","1098.43","1 through 10","12786.73","32791.76","percent of total billed charges",""
"STENT ZENITH 36DIA 120MM DISSECTION AORTIC BARE METAL ENDOVASCULAR","SUP-ITM-10257817","CDM","C1876","HCPCS","0278","RC","","","","both","","","41247.50","30935.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17695.18","42.9","","4896.33","4896.33","4896.33","1 through 10","12786.73","32791.76","percent of total billed charges",""
"STENT ZENITH 36DIA 120MM DISSECTION AORTIC BARE METAL ENDOVASCULAR","SUP-ITM-10257817","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","41247.50","30935.62","AETNA [1001]","HB AMC AETNA HMO","28790.76","69.8","","175.60","163.11","1063.91","1 through 10","21555.94","33707.46","percent of total billed charges",""
"STENT ZENITH 36DIA 120MM DISSECTION AORTIC BARE METAL ENDOVASCULAR","SUP-ITM-10257817","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","41247.50","30935.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","33707.46","81.72","","105.94","85.10","105.94","1 through 10","21555.94","33707.46","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 120MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159415","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3241.88","65","","6652.80","6652.80","6652.80","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 120MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159415","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3965.06","79.5","","2612.61","795.38","2612.61","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 120MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159415","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2658.34","53.3","","1101.80","1101.80","1101.80","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 120MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159415","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3241.88","65","","1820.00","910.00","1820.00","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 120MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159415","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1820.44","36.5","","1257.80","693.44","2424.50","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 120MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159415","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1910.21","38.3","","1950.11","547.40","2346.00","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 120MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159415","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2139.64","42.9","","5096.18","5096.18","5096.18","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 120MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159415","CDM","C1874","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","WELLPOINT [1015]","HB AMC WELLPOINT","3679.78","73.78","","1172.59","1172.59","4829.94","1 through 10","1546.13","3965.06","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 120MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159415","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4987.50","3740.62","AETNA [1001]","HB AMC AETNA HMO","3481.28","69.8","","1806.84","947.80","5091.72","1 through 10","2606.47","4075.79","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 120MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159415","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4987.50","3740.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4075.79","81.72","","1259.05","615.58","4586.56","1 through 10","2606.47","4075.79","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 40MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159411","CDM","C1874","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2673.13","65","","6652.80","6652.80","6652.80","1 through 10","1274.88","3269.44","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 40MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159411","CDM","C1874","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3269.44","79.5","","2612.61","795.38","2612.61","1 through 10","1274.88","3269.44","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 40MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159411","CDM","C1874","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2191.96","53.3","","1101.80","1101.80","1101.80","1 through 10","1274.88","3269.44","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 40MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159411","CDM","C1874","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2673.13","65","","1820.00","910.00","1820.00","1 through 10","1274.88","3269.44","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 40MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159411","CDM","C1874","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1501.06","36.5","","1257.80","693.44","2424.50","1 through 10","1274.88","3269.44","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 40MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159411","CDM","C1874","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1575.09","38.3","","1950.11","547.40","2346.00","1 through 10","1274.88","3269.44","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 40MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159411","CDM","C1874","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1764.26","42.9","","5096.18","5096.18","5096.18","1 through 10","1274.88","3269.44","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 40MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159411","CDM","C1874","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","WELLPOINT [1015]","HB AMC WELLPOINT","3034.20","73.78","","1172.59","1172.59","4829.94","1 through 10","1274.88","3269.44","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 40MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159411","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4112.50","3084.37","AETNA [1001]","HB AMC AETNA HMO","2870.53","69.8","","1806.84","947.80","5091.72","1 through 10","2149.19","3360.74","percent of total billed charges",""
"STENT ZILVER PTX 6FR 6MM 40MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159411","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4112.50","3084.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3360.74","81.72","","1259.05","615.58","4586.56","1 through 10","2149.19","3360.74","percent of total billed charges",""
"STENT ZILVER PTX 6FR 7MM 60MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159417","CDM","C1874","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","2915.25","65","","6652.80","6652.80","6652.80","1 through 10","1390.35","3565.58","percent of total billed charges",""
"STENT ZILVER PTX 6FR 7MM 60MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159417","CDM","C1874","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3565.58","79.5","","2612.61","795.38","2612.61","1 through 10","1390.35","3565.58","percent of total billed charges",""
"STENT ZILVER PTX 6FR 7MM 60MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159417","CDM","C1874","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2390.51","53.3","","1101.80","1101.80","1101.80","1 through 10","1390.35","3565.58","percent of total billed charges",""
"STENT ZILVER PTX 6FR 7MM 60MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159417","CDM","C1874","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2915.25","65","","1820.00","910.00","1820.00","1 through 10","1390.35","3565.58","percent of total billed charges",""
"STENT ZILVER PTX 6FR 7MM 60MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159417","CDM","C1874","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1637.03","36.5","","1257.80","693.44","2424.50","1 through 10","1390.35","3565.58","percent of total billed charges",""
"STENT ZILVER PTX 6FR 7MM 60MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159417","CDM","C1874","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1717.76","38.3","","1950.11","547.40","2346.00","1 through 10","1390.35","3565.58","percent of total billed charges",""
"STENT ZILVER PTX 6FR 7MM 60MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159417","CDM","C1874","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1924.07","42.9","","5096.18","5096.18","5096.18","1 through 10","1390.35","3565.58","percent of total billed charges",""
"STENT ZILVER PTX 6FR 7MM 60MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159417","CDM","C1874","HCPCS","0278","RC","","","","both","","","4485.00","3363.75","WELLPOINT [1015]","HB AMC WELLPOINT","3309.03","73.78","","1172.59","1172.59","4829.94","1 through 10","1390.35","3565.58","percent of total billed charges",""
"STENT ZILVER PTX 6FR 7MM 60MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159417","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","AETNA [1001]","HB AMC AETNA HMO","3130.53","69.8","","1806.84","947.80","5091.72","1 through 10","2343.86","3665.14","percent of total billed charges",""
"STENT ZILVER PTX 6FR 7MM 60MM .035IN OTW DRUG ELUTING PERIPHERAL BX/1EA","SUP-ITM-10159417","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4485.00","3363.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3665.14","81.72","","1259.05","615.58","4586.56","1 through 10","2343.86","3665.14","percent of total billed charges",""
"Ster Procedure Upper GI","PX-75000533","CDM","43499","CPT","0750","RC","","","","both","","","10992.00","8244.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5858.74","53.3","","0.07","0.07","0.07","30","1057.74","8738.64","percent of total billed charges",""
"Ster Procedure Upper GI","PX-75000533","CDM","43499","CPT","0750","RC","","","","both","","","10992.00","8244.00","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","8738.64","other","OPPS APC"
"Ster Procedure Upper GI","PX-75000533","CDM","43499","CPT","0750","RC","","","","both","","","10992.00","8244.00","WELLPOINT [1015]","HB AMC WELLPOINT","8109.90","73.78","","2340.71","2340.71","2340.71","1 through 10","1057.74","8738.64","percent of total billed charges",""
"Ster Procedure Upper GI","PX-75000533","CDM","43499","CPT","0750","RC","","","","outpatient","","","10992.00","8244.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5740.02","52.22","","6151.50","2038.73","10659.00","1 through 10","2384.07","9068.4","percent of total billed charges",""
"Ster Procedure Upper GI","PX-75000533","CDM","43499","CPT","0750","RC","","","","outpatient","","","10992.00","8244.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","5496.00","50","","3144.00","3144.00","3144.00","1 through 10","2384.07","9068.4","percent of total billed charges",""
"Ster Procedure Upper GI","PX-75000533","CDM","43499","CPT","0750","RC","","","","outpatient","","","10992.00","8244.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8982.66","81.72","","1810.95","1810.95","1810.95","1 through 10","2384.07","9068.4","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2085.04","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2051.89","1916.33","2051.89","151","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","22303.40","70","","24718.40","24447.40","24718.40","15","1980.99","25330.29","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","25330.29","79.5","","24316.73","16314.14","24316.73","23","1980.99","25330.29","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","16982.45","53.3","","24316.73","16314.14","24316.73","33","1980.99","25330.29","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","2085.04","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2051.89","1672.92","2051.89","20","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","ELDER SERVICES [1037]","HB BWH MEDICARE","2085.04","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1947.49","1480.90","1947.49","1 through 10","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","FALLON HEALTH [1008]","HB BWH MEDICARE","2085.04","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6255.75","2043.54","6255.75","21","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","2085.04","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2060.23","2060.23","2060.23","1 through 10","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","2085.04","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2043.54","2043.54","2043.54","1 through 10","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","HUMANA [1012]","HB BWH MEDICARE","2085.04","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2043.54","2043.54","2051.89","20","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","2085.04","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2051.89","2043.54","2051.89","1 through 10","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","MEDICARE [2001]","HB BWH MEDICARE","2085.04","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2085.25","1947.49","2085.25","1591","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","9877.22","31","","9547.48","9547.48","9547.48","1 through 10","1980.99","25330.29","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11629.63","36.5","","11524.95","11524.95","11524.95","22","1980.99","25330.29","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12203.15","38.3","","12081.12","11741.24","12081.12","41","1980.99","25330.29","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2085.04","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1908.54","1908.54","2043.54","17","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","MOLINA [1014]","HB BWH MOLINA","2043.34","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4137.14","4137.14","4137.14","16","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","TRICARE [160005]","HB BWH TRICARE","1980.99","","APC Price ($2,085.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","5266.13","5266.13","5266.13","1 through 10","1980.99","25330.29","other","Tricare OPPS"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","1980.99","","APC Price ($2,085.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2085.25","2085.25","2085.25","1 through 10","1980.99","25330.29","other","Tricare OPPS"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2043.34","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2044.74","2043.54","6168.26","154","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","2043.34","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7106.54","7106.54","14213.08","1 through 10","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13668.80","42.9","","13585.85","13585.85","13585.85","1 through 10","1980.99","25330.29","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2043.34","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2047.72","1916.34","2085.25","208","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","WELLPOINT [1015]","HB AMC WELLPOINT","23507.78","73.78","","23003.56","22066.53","23003.56","44","1980.99","25330.29","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","31862.00","23896.50","WELLSENSE [1003]","HB BWH MEDICARE","2085.04","","APC Price ($2,085.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2106.10","2106.10","2106.10","1 through 10","1980.99","25330.29","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","outpatient","","","31862.00","23896.50","AETNA [1001]","HB AMC AETNA HMO","22239.68","69.8","","20917.95","5892.76","20917.95","1 through 10","4598.35","26037.63","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","outpatient","","","31862.00","23896.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","26037.63","81.72","","24699.86","24699.86","24699.86","1 through 10","4598.35","26037.63","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","outpatient","","","31862.00","23896.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","26037.63","81.72","","24699.86","5747.94","24699.86","41","4598.35","26037.63","percent of total billed charges",""
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","9077.37","","APC Price ($9,077.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8933.04","4861.43","41302.00","1 through 10","8624.38","33859.85","other","OPPS APC"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","29813.70","70","","33041.60","33041.60","33041.60","1 through 10","8624.38","33859.85","percent of total billed charges",""
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33859.85","79.5","","32504.67","32504.67","32504.67","1 through 10","8624.38","33859.85","percent of total billed charges",""
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22701.00","53.3","","21807.46","21807.46","21807.46","1 through 10","8624.38","33859.85","percent of total billed charges",""
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","9077.37","","APC Price ($9,077.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8896.72","8896.72","8896.72","1 through 10","8624.38","33859.85","other","OPPS APC"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","FALLON HEALTH [1008]","HB BWH MEDICARE","9077.37","","APC Price ($9,077.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8896.72","8896.72","8896.72","1 through 10","8624.38","33859.85","other","OPPS APC"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","32795.07","77","","31802.54","31802.54","31802.54","1 through 10","8624.38","33859.85","percent of total billed charges",""
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","HUMANA [1012]","HB BWH MEDICARE","9077.37","","APC Price ($9,077.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8929.74","8896.72","8933.04","1 through 10","8624.38","33859.85","other","OPPS APC"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","MEDICARE [2001]","HB BWH MEDICARE","9077.37","","APC Price ($9,077.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9078.29","9078.29","9078.29","69","8624.38","33859.85","other","OPPS APC"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15545.72","36.5","","15405.65","15405.65","15405.65","1 through 10","8624.38","33859.85","percent of total billed charges",""
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16312.35","38.3","","16149.08","16149.08","16149.08","1 through 10","8624.38","33859.85","percent of total billed charges",""
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","TRICARE [160005]","HB BWH TRICARE","8624.38","","APC Price ($9,078.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","8624.38","8624.38","8624.38","1 through 10","8624.38","33859.85","other","Tricare OPPS"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8895.83","","APC Price ($9,077.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8896.72","8330.42","8896.72","1 through 10","8624.38","33859.85","other","OPPS APC"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","42591.00","31943.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8895.83","","APC Price ($9,077.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8933.04","8329.22","9078.29","12","8624.38","33859.85","other","OPPS APC"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","outpatient","","","42591.00","31943.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","6879.82","","Case rate ($6,879.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","18713.11","18713.11","18713.11","1 through 10","6879.82","37720.13","other","Multiple Surgery"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","outpatient","","","42591.00","31943.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6879.82","","Case rate ($6,879.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","19607.49","19607.49","19607.49","1 through 10","6879.82","37720.13","other","Multiple Surgery"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","outpatient","","","42591.00","31943.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","6879.82","","Case rate ($6,879.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","23391.39","20570.66","23391.39","1 through 10","6879.82","37720.13","other","Multiple Surgery"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","outpatient","","","42591.00","31943.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34805.37","81.72","","33016.82","18160.49","33016.82","1 through 10","6879.82","37720.13","percent of total billed charges",""
"Stickler Syndrome, Type III","PX-31000938","CDM","81479","CPT","0310","RC","","","","both","","","1737.00","1302.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1380.92","79.5","","0.65","0.65","0.65","1 through 10","538.47","1650.15","percent of total billed charges",""
"Stickler Syndrome, Type III","PX-31000938","CDM","81479","CPT","0310","RC","","","","both","","","1737.00","1302.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","925.82","53.3","","0.79","0.79","0.79","1 through 10","538.47","1650.15","percent of total billed charges",""
"Stickler Syndrome, Type III","PX-31000938","CDM","81479","CPT","0310","RC","","","","outpatient","","","1737.00","1302.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","868.50","50","","1.00","1.00","1.00","1 through 10","156.55","1433.03","percent of total billed charges",""
"Stickler Syndrome, Type III","PX-31000938","CDM","81479","CPT","0310","RC","","","","outpatient","","","1737.00","1302.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","911.93","52.5","","1.00","0.53","1.00","1 through 10","156.55","1433.03","percent of total billed charges",""
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","both","","","1058.00","793.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","327.98","841.11","other","OPPS APC"
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","both","","","1058.00","793.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","327.98","841.11","other","OPPS APC"
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","both","","","1058.00","793.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","563.91","53.3","","477.31","477.31","477.31","1 through 10","327.98","841.11","percent of total billed charges",""
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","both","","","1058.00","793.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","327.98","841.11","other","OPPS APC"
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","both","","","1058.00","793.50","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","327.98","841.11","other","OPPS APC"
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","both","","","1058.00","793.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","386.17","36.5","","1095.87","337.19","1095.87","1 through 10","327.98","841.11","percent of total billed charges",""
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","both","","","1058.00","793.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","405.21","38.3","","343.52","323.76","353.46","1 through 10","327.98","841.11","percent of total billed charges",""
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","both","","","1058.00","793.50","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","327.98","841.11","other","Tricare OPPS"
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","both","","","1058.00","793.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","327.98","841.11","other","OPPS APC"
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","both","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","327.98","841.11","other","OPPS APC"
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","both","","","1058.00","793.50","WELLPOINT [1015]","HB AMC WELLPOINT","780.59","73.78","","673.03","673.03","673.03","1 through 10","327.98","841.11","percent of total billed charges",""
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","outpatient","","","1058.00","793.50","AETNA [1001]","HB AMC AETNA HMO","738.48","69.8","","612.01","612.01","1224.02","1 through 10","529","872.85","percent of total billed charges",""
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","outpatient","","","1058.00","793.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","640.62","60.55","","579.04","568.57","904.00","30","529","872.85","percent of total billed charges",""
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","outpatient","","","1058.00","793.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","552.49","52.22","","904.00","656.02","2938.00","26","529","872.85","percent of total billed charges",""
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","outpatient","","","1058.00","793.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","529.00","50","","1421.10","875.08","2368.50","15","529","872.85","percent of total billed charges",""
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","outpatient","","","1058.00","793.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","555.45","52.5","","2985.00","904.00","2985.00","1 through 10","529","872.85","percent of total billed charges",""
"Stimpod Trial Peripheral Nerve Stimulator","PX-76002979","CDM","64999","CPT","0761","RC","","","","outpatient","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","864.60","81.72","","722.66","722.66","17449.00","1 through 10","529","872.85","percent of total billed charges",""
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","both","","","497.00","372.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","361.04","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","332.63","332.63","332.63","1 through 10","154.07","438.15","other","OPPS APC"
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","both","","","497.00","372.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","318.09","344.95","1 through 10","154.07","438.15","other","OPPS APC"
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","both","","","497.00","372.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","264.90","53.3","","477.31","477.31","477.31","1 through 10","154.07","438.15","percent of total billed charges",""
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","both","","","497.00","372.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","154.07","438.15","other","OPPS APC"
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","both","","","497.00","372.75","MEDICARE [2001]","HB BWH MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","154.07","438.15","other","OPPS APC"
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","both","","","497.00","372.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","181.41","36.5","","1095.87","337.19","1095.87","1 through 10","154.07","438.15","percent of total billed charges",""
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","both","","","497.00","372.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","190.35","38.3","","343.52","323.76","353.46","1 through 10","154.07","438.15","percent of total billed charges",""
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","both","","","497.00","372.75","TRICARE [160005]","HB BWH TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","2938.00","2938.00","2938.00","1 through 10","154.07","438.15","other","Tricare OPPS"
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","both","","","497.00","372.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.55","317.79","350.56","1 through 10","154.07","438.15","other","OPPS APC"
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","both","","","497.00","372.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","318.09","350.56","1 through 10","154.07","438.15","other","OPPS APC"
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","both","","","497.00","372.75","WELLPOINT [1015]","HB AMC WELLPOINT","366.69","73.78","","673.03","673.03","673.03","1 through 10","154.07","438.15","percent of total billed charges",""
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","outpatient","","","497.00","372.75","AETNA [1001]","HB AMC AETNA HMO","346.91","69.8","","612.01","612.01","1224.02","1 through 10","248.5","700.33","percent of total billed charges",""
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","outpatient","","","497.00","372.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","300.93","60.55","","579.04","568.57","904.00","30","248.5","700.33","percent of total billed charges",""
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","outpatient","","","497.00","372.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","259.53","52.22","","904.00","656.02","2938.00","26","248.5","700.33","percent of total billed charges",""
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","outpatient","","","497.00","372.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","248.50","50","","1421.10","875.08","2368.50","15","248.5","700.33","percent of total billed charges",""
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","outpatient","","","497.00","372.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","260.93","52.5","","2985.00","904.00","2985.00","1 through 10","248.5","700.33","percent of total billed charges",""
"Stimpod Triam Peripheral Nerve Stimulator","PX-98302522","CDM","64999","CPT","0983","RC","","","","outpatient","","","497.00","372.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","406.15","81.72","","722.66","722.66","17449.00","1 through 10","248.5","700.33","percent of total billed charges",""
"STIMULATOR BRAIN 11X54MM ACTIVA RC NEURO DEEP DUAL CHANNEL OCTAPOLAR CONNECTOR RECHARGEABLE","SUP-ITM-10079959","CDM","C1820","HCPCS","0278","RC","","","","both","","","63535.00","47651.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33864.16","53.3","","54287.50","54287.50","54287.50","1 through 10","19695.85","50510.33","percent of total billed charges",""
"STIMULATOR BRAIN 11X54MM ACTIVA RC NEURO DEEP DUAL CHANNEL OCTAPOLAR CONNECTOR RECHARGEABLE","SUP-ITM-10079959","CDM","C1820","HCPCS","0278","RC","","","","both","","","63535.00","47651.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23190.28","36.5","","10467.31","10467.31","10467.31","1 through 10","19695.85","50510.33","percent of total billed charges",""
"STIMULATOR BRAIN 11X54MM ACTIVA RC NEURO DEEP DUAL CHANNEL OCTAPOLAR CONNECTOR RECHARGEABLE","SUP-ITM-10079959","CDM","C1820","HCPCS","0278","RC","","","","both","","","63535.00","47651.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24333.91","38.3","","21505.00","21505.00","21505.00","1 through 10","19695.85","50510.33","percent of total billed charges",""
"STIMULATOR BRAIN 11X54MM ACTIVA RC NEURO DEEP DUAL CHANNEL OCTAPOLAR CONNECTOR RECHARGEABLE","SUP-ITM-10079959","CDM","C1820","HCPCS","0278","RC","","","","both","","","63535.00","47651.25","WELLPOINT [1015]","HB AMC WELLPOINT","46876.12","73.78","","40016.88","40016.88","40016.88","1 through 10","19695.85","50510.33","percent of total billed charges",""
"STIMULATOR BRAIN 11X55 60MM ACTIVA SC NEURO DEEP SINGLE CHANNEL 1 BORE OCTAPOLAR CONNECTOR","SUP-ITM-10094749","CDM","C1767","HCPCS","0278","RC","","","","both","","","21812.50","16359.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7961.56","36.5","","18081.90","16994.81","18081.90","1 through 10","6761.88","17340.94","percent of total billed charges",""
"STIMULATOR BRAIN 11X55 60MM ACTIVA SC NEURO DEEP SINGLE CHANNEL 1 BORE OCTAPOLAR CONNECTOR","SUP-ITM-10094749","CDM","C1767","HCPCS","0278","RC","","","","both","","","21812.50","16359.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8354.19","38.3","","17814.94","17448.38","17814.94","1 through 10","6761.88","17340.94","percent of total billed charges",""
"STIMULATOR BRAIN 11X55 60MM ACTIVA SC NEURO DEEP SINGLE CHANNEL 1 BORE OCTAPOLAR CONNECTOR","SUP-ITM-10094749","CDM","C1767","HCPCS","0278","RC","","","","both","","","21812.50","16359.37","WELLPOINT [1015]","HB AMC WELLPOINT","16093.26","73.78","","33921.28","33921.28","33921.28","1 through 10","6761.88","17340.94","percent of total billed charges",""
"STIMULATOR BRAIN 11X55 60MM ACTIVA SC NEURO DEEP SINGLE CHANNEL 2 BORE QUADRIPOLAR CONNECTOR","SUP-ITM-10094718","CDM","C1767","HCPCS","0278","RC","","","","both","","","21812.50","16359.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7961.56","36.5","","18081.90","16994.81","18081.90","1 through 10","6761.88","17340.94","percent of total billed charges",""
"STIMULATOR BRAIN 11X55 60MM ACTIVA SC NEURO DEEP SINGLE CHANNEL 2 BORE QUADRIPOLAR CONNECTOR","SUP-ITM-10094718","CDM","C1767","HCPCS","0278","RC","","","","both","","","21812.50","16359.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8354.19","38.3","","17814.94","17448.38","17814.94","1 through 10","6761.88","17340.94","percent of total billed charges",""
"STIMULATOR BRAIN 11X55 60MM ACTIVA SC NEURO DEEP SINGLE CHANNEL 2 BORE QUADRIPOLAR CONNECTOR","SUP-ITM-10094718","CDM","C1767","HCPCS","0278","RC","","","","both","","","21812.50","16359.37","WELLPOINT [1015]","HB AMC WELLPOINT","16093.26","73.78","","33921.28","33921.28","33921.28","1 through 10","6761.88","17340.94","percent of total billed charges",""
"STIMULATOR BRAIN 65 49X15MM ACTIVA PC NEURO DEEP DUAL CHANNEL","SUP-ITM-10079667","CDM","C1767","HCPCS","0278","RC","","","","both","","","42437.50","31828.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15489.69","36.5","","18081.90","16994.81","18081.90","1 through 10","13155.63","33737.81","percent of total billed charges",""
"STIMULATOR BRAIN 65 49X15MM ACTIVA PC NEURO DEEP DUAL CHANNEL","SUP-ITM-10079667","CDM","C1767","HCPCS","0278","RC","","","","both","","","42437.50","31828.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16253.56","38.3","","17814.94","17448.38","17814.94","1 through 10","13155.63","33737.81","percent of total billed charges",""
"STIMULATOR BRAIN 65 49X15MM ACTIVA PC NEURO DEEP DUAL CHANNEL","SUP-ITM-10079667","CDM","C1767","HCPCS","0278","RC","","","","both","","","42437.50","31828.12","WELLPOINT [1015]","HB AMC WELLPOINT","31310.39","73.78","","33921.28","33921.28","33921.28","1 through 10","13155.63","33737.81","percent of total billed charges",""
"STIMULATOR CORD 11X55 60MM 44G ITREL 4 SPINAL NEURO PRIMARY CELL BATTERY","SUP-ITM-10126058","CDM","C1767","HCPCS","0278","RC","","","","both","","","17670.00","13252.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6449.55","36.5","","18081.90","16994.81","18081.90","1 through 10","5477.7","14047.65","percent of total billed charges",""
"STIMULATOR CORD 11X55 60MM 44G ITREL 4 SPINAL NEURO PRIMARY CELL BATTERY","SUP-ITM-10126058","CDM","C1767","HCPCS","0278","RC","","","","both","","","17670.00","13252.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6767.61","38.3","","17814.94","17448.38","17814.94","1 through 10","5477.7","14047.65","percent of total billed charges",""
"STIMULATOR CORD 11X55 60MM 44G ITREL 4 SPINAL NEURO PRIMARY CELL BATTERY","SUP-ITM-10126058","CDM","C1767","HCPCS","0278","RC","","","","both","","","17670.00","13252.50","WELLPOINT [1015]","HB AMC WELLPOINT","13036.93","73.78","","33921.28","33921.28","33921.28","1 through 10","5477.7","14047.65","percent of total billed charges",""
"STIMULATOR NEURO 65X49 15MM SURESCAN PRIMEADVANCED MRI SAFE","SUP-ITM-10125958","CDM","C1767","HCPCS","0278","RC","","","","both","","","31200.00","23400.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11388.00","36.5","","18081.90","16994.81","18081.90","1 through 10","9672","24804","percent of total billed charges",""
"STIMULATOR NEURO 65X49 15MM SURESCAN PRIMEADVANCED MRI SAFE","SUP-ITM-10125958","CDM","C1767","HCPCS","0278","RC","","","","both","","","31200.00","23400.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11949.60","38.3","","17814.94","17448.38","17814.94","1 through 10","9672","24804","percent of total billed charges",""
"STIMULATOR NEURO 65X49 15MM SURESCAN PRIMEADVANCED MRI SAFE","SUP-ITM-10125958","CDM","C1767","HCPCS","0278","RC","","","","both","","","31200.00","23400.00","WELLPOINT [1015]","HB AMC WELLPOINT","23019.36","73.78","","33921.28","33921.28","33921.28","1 through 10","9672","24804","percent of total billed charges",""
"STIMULATOR NEURO SURESCAN RECHARGER SYSTEM ANTENNA BELT","SUP-ITM-10124362","CDM","C1820","HCPCS","0278","RC","","","","both","","","4510.00","3382.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2403.83","53.3","","54287.50","54287.50","54287.50","1 through 10","1398.1","3585.45","percent of total billed charges",""
"STIMULATOR NEURO SURESCAN RECHARGER SYSTEM ANTENNA BELT","SUP-ITM-10124362","CDM","C1820","HCPCS","0278","RC","","","","both","","","4510.00","3382.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1646.15","36.5","","10467.31","10467.31","10467.31","1 through 10","1398.1","3585.45","percent of total billed charges",""
"STIMULATOR NEURO SURESCAN RECHARGER SYSTEM ANTENNA BELT","SUP-ITM-10124362","CDM","C1820","HCPCS","0278","RC","","","","both","","","4510.00","3382.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1727.33","38.3","","21505.00","21505.00","21505.00","1 through 10","1398.1","3585.45","percent of total billed charges",""
"STIMULATOR NEURO SURESCAN RECHARGER SYSTEM ANTENNA BELT","SUP-ITM-10124362","CDM","C1820","HCPCS","0278","RC","","","","both","","","4510.00","3382.50","WELLPOINT [1015]","HB AMC WELLPOINT","3327.48","73.78","","40016.88","40016.88","40016.88","1 through 10","1398.1","3585.45","percent of total billed charges",""
"Stomach, Esophageal And Duodenal Procedures Age >17 With Cc","327","TRIS-DRG","","","","","","","","inpatient","","","169397.98","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","19708.73","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($34,619.48). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $12,822.03, and the first day is paid a rate of $25,644.06. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $12,822.03, and the first day is paid a rate of $25,644.06. The transfer payment is capped at $24,916.86. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $78,346.48 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.70000004768372). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($16,485.47), capped at $24,916.86. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $12,822.03, and the first day is paid a rate of $25,644.06. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $12,822.03, and the first day is paid a rate of $25,644.06. The transfer payment is capped at $24,916.86. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $78,346.48 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.70000004768372). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","74559.74","74559.74","74559.74","1 through 10","19708.73","19708.73","other","Inpatient DRGs"
"Stomach, Esophageal And Duodenal Procedures Age >17 With McC","326","TRIS-DRG","","","","","","","","inpatient","","","244628.79","","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","32226.14","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($56,607.02). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $7,754.39, and the first day is paid a rate of $15,508.77. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $7,754.39, and the first day is paid a rate of $15,508.77. The transfer payment is capped at $40,742.06. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $100,334.02 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 7.30000019073486). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: , capped at $40,742.06. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $7,754.39, and the first day is paid a rate of $15,508.77. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $7,754.39, and the first day is paid a rate of $15,508.77. The transfer payment is capped at $40,742.06. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $100,334.02 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 7.30000019073486). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","74559.74","74559.74","74559.74","1 through 10","32226.14","32226.14","other","Inpatient DRGs"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","111043.56","83282.67","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","23356.36","","Case rate ($22,676.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,220.12, add-ons for qualifying new technology services are included. If operating cost exceeds $72,864.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,406.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $20,329.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,840.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,966.75. The transfer capital threshold is the transfer adjustment factor * $1,966.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","23004.18","22981.57","23427.07","1 through 10","22222.56","36642.4571","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","111043.56","83282.67","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","22676.08","","Case rate ($22,676.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,220.12, add-ons for qualifying new technology services are included. If operating cost exceeds $72,864.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,406.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $20,329.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,840.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,966.75. The transfer capital threshold is the transfer adjustment factor * $1,966.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22076.59","22054.92","22088.46","1 through 10","22222.56","36642.4571","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","111043.56","83282.67","HUMANA [1012]","HB BWH MEDICARE","22676.08","","Case rate ($22,676.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,220.12, add-ons for qualifying new technology services are included. If operating cost exceeds $72,864.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,406.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $20,329.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,840.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,966.75. The transfer capital threshold is the transfer adjustment factor * $1,966.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21944.62","21944.62","21944.62","1 through 10","22222.56","36642.4571","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","111043.56","83282.67","MEDICARE [2001]","HB BWH MEDICARE","22676.08","","Case rate ($22,676.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,220.12, add-ons for qualifying new technology services are included. If operating cost exceeds $72,864.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,406.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $20,329.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,840.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,966.75. The transfer capital threshold is the transfer adjustment factor * $1,966.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28903.53","0.03","28946.34","101","22222.56","36642.4571","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","111043.56","83282.67","MOLINA [1014]","HB BWH MOLINA","22222.56","","Case rate ($22,676.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,220.12, add-ons for qualifying new technology services are included. If operating cost exceeds $72,864.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,406.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $20,329.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,840.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,966.75. The transfer capital threshold is the transfer adjustment factor * $1,966.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","44376.77","44376.77","44376.77","1 through 10","22222.56","36642.4571","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","111043.56","83282.67","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","22222.56","","Case rate ($22,676.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,220.12, add-ons for qualifying new technology services are included. If operating cost exceeds $72,864.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,406.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $20,329.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,840.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,966.75. The transfer capital threshold is the transfer adjustment factor * $1,966.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21993.46","21985.67","22006.34","1 through 10","22222.56","36642.4571","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","111043.56","83282.67","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","22222.56","","Case rate ($22,676.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $27,220.12, add-ons for qualifying new technology services are included. If operating cost exceeds $72,864.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,406.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $20,329.50 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $26,840.29 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,966.75. The transfer capital threshold is the transfer adjustment factor * $1,966.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21946.80","21898.65","22014.22","17","22222.56","36642.4571","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","111043.56","83282.67","WELLPOINT [1015]","HB AMC WELLPOINT","36642.4571","","Fee schedule rate ($38,285.95).","36642.4571","36642.45","137034.96","1 through 10","22222.56","36642.4571","case rate",""
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","221161.29","165870.97","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","47251.69","","Case rate ($45,875.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $55,147.56, add-ons for qualifying new technology services are included. If operating cost exceeds $100,792.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,453.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $41,482.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,767.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,013.15. The transfer capital threshold is the transfer adjustment factor * $4,013.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","47792.91","47792.91","47792.91","1 through 10","44957.92","78122.63","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","221161.29","165870.97","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","45875.43","","Case rate ($45,875.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $55,147.56, add-ons for qualifying new technology services are included. If operating cost exceeds $100,792.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,453.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $41,482.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,767.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,013.15. The transfer capital threshold is the transfer adjustment factor * $4,013.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","45879.97","45879.94","46545.93","1 through 10","44957.92","78122.63","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","221161.29","165870.97","HUMANA [1012]","HB BWH MEDICARE","45875.43","","Case rate ($45,875.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $55,147.56, add-ons for qualifying new technology services are included. If operating cost exceeds $100,792.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,453.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $41,482.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,767.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,013.15. The transfer capital threshold is the transfer adjustment factor * $4,013.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","121219.94","121219.94","121219.94","1 through 10","44957.92","78122.63","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","221161.29","165870.97","MARTIN'S POINT [160007]","HB BWH MEDICARE","45875.43","","Case rate ($45,875.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $55,147.56, add-ons for qualifying new technology services are included. If operating cost exceeds $100,792.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,453.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $41,482.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,767.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,013.15. The transfer capital threshold is the transfer adjustment factor * $4,013.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","45658.87","45658.87","45658.87","1 through 10","44957.92","78122.63","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","221161.29","165870.97","MEDICARE [2001]","HB BWH MEDICARE","45875.43","","Case rate ($45,875.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $55,147.56, add-ons for qualifying new technology services are included. If operating cost exceeds $100,792.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,453.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $41,482.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,767.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,013.15. The transfer capital threshold is the transfer adjustment factor * $4,013.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","60155.39","0.03","60244.97","59","44957.92","78122.63","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","221161.29","165870.97","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","45875.43","","Case rate ($45,875.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $55,147.56, add-ons for qualifying new technology services are included. If operating cost exceeds $100,792.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,453.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $41,482.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,767.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,013.15. The transfer capital threshold is the transfer adjustment factor * $4,013.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","45451.19","45451.19","45451.19","1 through 10","44957.92","78122.63","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","221161.29","165870.97","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","44957.92","","Case rate ($45,875.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $55,147.56, add-ons for qualifying new technology services are included. If operating cost exceeds $100,792.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,453.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $41,482.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,767.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,013.15. The transfer capital threshold is the transfer adjustment factor * $4,013.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25439.78","78.23","83004.90","1 through 10","44957.92","78122.63","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","221161.29","165870.97","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","44957.92","","Case rate ($45,875.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $55,147.56, add-ons for qualifying new technology services are included. If operating cost exceeds $100,792.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,453.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $41,482.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,767.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,013.15. The transfer capital threshold is the transfer adjustment factor * $4,013.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","55439.71","55439.71","55439.71","1 through 10","44957.92","78122.63","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","221161.29","165870.97","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","44957.92","","Case rate ($45,875.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $55,147.56, add-ons for qualifying new technology services are included. If operating cost exceeds $100,792.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,453.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $41,482.44 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $54,767.72 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,013.15. The transfer capital threshold is the transfer adjustment factor * $4,013.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","45599.43","45599.43","45735.88","1 through 10","44957.92","78122.63","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","78378.90","58784.17","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","15446.07","","Case rate ($14,996.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,975.04, add-ons for qualifying new technology services are included. If operating cost exceeds $63,619.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,729.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $13,327.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,595.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.30. The transfer capital threshold is the transfer adjustment factor * $1,289.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15187.01","15187.01","22981.21","1 through 10","14696.26","24104.8543","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","78378.90","58784.17","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","19349.34","","Case rate ($19,349.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,975.04, add-ons for qualifying new technology services are included. If operating cost exceeds $63,619.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,729.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,680.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,595.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.30. The transfer capital threshold is the transfer adjustment factor * $1,289.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14582.43","14582.43","14582.43","1 through 10","14696.26","24104.8543","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","78378.90","58784.17","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","8176.45","8176.45","8176.45","1 through 10","14696.26","24104.8543","case rate",""
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","78378.90","58784.17","HUMANA [1012]","HB BWH MEDICARE","19349.34","","Case rate ($19,349.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,975.04, add-ons for qualifying new technology services are included. If operating cost exceeds $63,619.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,729.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,680.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,595.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.30. The transfer capital threshold is the transfer adjustment factor * $1,289.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5162.66","5162.66","5162.66","1 through 10","14696.26","24104.8543","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","78378.90","58784.17","MEDICARE [2001]","HB BWH MEDICARE","19349.34","","Case rate ($19,349.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,975.04, add-ons for qualifying new technology services are included. If operating cost exceeds $63,619.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,729.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,680.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,595.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.30. The transfer capital threshold is the transfer adjustment factor * $1,289.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12366.45","0.03","19092.40","52","14696.26","24104.8543","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","78378.90","58784.17","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","19349.34","","Case rate ($19,349.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,975.04, add-ons for qualifying new technology services are included. If operating cost exceeds $63,619.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,729.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $17,680.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,595.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.30. The transfer capital threshold is the transfer adjustment factor * $1,289.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14471.73","14471.73","14471.73","1 through 10","14696.26","24104.8543","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","78378.90","58784.17","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","14696.26","","Case rate ($14,996.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,975.04, add-ons for qualifying new technology services are included. If operating cost exceeds $63,619.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,729.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $13,327.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,595.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.30. The transfer capital threshold is the transfer adjustment factor * $1,289.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14523.65","14523.65","14523.65","1 through 10","14696.26","24104.8543","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","78378.90","58784.17","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","14696.26","","Case rate ($14,996.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,975.04, add-ons for qualifying new technology services are included. If operating cost exceeds $63,619.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,729.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $13,327.05 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,595.20 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.30. The transfer capital threshold is the transfer adjustment factor * $1,289.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14505.72","14476.24","20090.95","1 through 10","14696.26","24104.8543","other","Inpatient DRG"
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","both","","","826.00","619.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","578.20","70","","640.80","640.80","640.80","1 through 10","199.41","784.7","percent of total billed charges",""
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","both","","","826.00","619.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","656.67","79.5","","630.39","630.39","630.39","1 through 10","199.41","784.7","percent of total billed charges",""
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","both","","","826.00","619.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","440.26","53.3","","630.39","422.93","630.39","1 through 10","199.41","784.7","percent of total billed charges",""
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","both","","","826.00","619.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","167.93","167.93","167.93","1 through 10","199.41","784.7","other","OPPS APC"
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","both","","","826.00","619.50","HUMANA [1012]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.43","199.43","199.43","1 through 10","199.41","784.7","other","OPPS APC"
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","both","","","826.00","619.50","MEDICARE [2001]","HB BWH MEDICARE","203.48","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","203.50","203.50","1 through 10","199.41","784.7","other","OPPS APC"
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","both","","","826.00","619.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","301.49","36.5","","298.77","253.92","298.77","13","199.41","784.7","percent of total billed charges",""
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","both","","","826.00","619.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","316.36","38.3","","313.19","313.19","313.19","18","199.41","784.7","percent of total billed charges",""
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","both","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","354.35","42.9","","364.46","284.90","640.32","1 through 10","199.41","784.7","percent of total billed charges",""
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","both","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","199.41","","APC Price ($203.48). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","203.50","199.43","203.50","1 through 10","199.41","784.7","other","OPPS APC"
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","both","","","826.00","619.50","WELLPOINT [1015]","HB AMC WELLPOINT","609.42","73.78","","596.34","596.34","596.34","1 through 10","199.41","784.7","percent of total billed charges",""
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","outpatient","","","826.00","619.50","AETNA [1001]","HB AMC AETNA HMO","576.55","69.8","","542.28","542.28","542.28","1 through 10","297.92","887.19","percent of total billed charges",""
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","outpatient","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","675.01","81.72","","640.32","640.32","640.32","1 through 10","297.92","887.19","percent of total billed charges",""
"Storage per Year Sperm/Semen","PX-30000149","CDM","89343","CPT","0300","RC","","","","outpatient","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","675.01","81.72","","640.32","640.32","640.32","24","297.92","887.19","percent of total billed charges",""
"Str Genotyping","PX-31001281","CDM","81265","CPT","0310","RC","","","","outpatient","","","1341.00","1005.75","AETNA [1001]","HB AMC AETNA HMO","936.02","69.8","","880.10","880.10","880.10","1 through 10","648.65","1464.7","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1977.50","1483.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1384.25","70","","134.04","134.04","134.04","1 through 10","613.03","1572.11","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1977.50","1483.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1572.11","79.5","","948.87","198.19","1805.30","1 through 10","613.03","1572.11","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1977.50","1483.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1054.01","53.3","","462.00","170.45","3253.37","1 through 10","613.03","1572.11","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1977.50","1483.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","721.79","36.5","","245.50","107.19","1371.45","1 through 10","613.03","1572.11","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1977.50","1483.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","757.38","38.3","","200.79","72.79","355.81","22","613.03","1572.11","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1977.50","1483.12","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1522.68","77","","477.18","477.18","477.18","1 through 10","613.03","1572.11","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1977.50","1483.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","848.35","42.9","","1045.91","1045.91","1045.91","1 through 10","613.03","1572.11","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1977.50","1483.12","WELLPOINT [1015]","HB AMC WELLPOINT","1459.00","73.78","","1726.50","1726.50","1726.50","1 through 10","613.03","1572.11","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1977.50","1483.12","AETNA [1001]","HB AMC AETNA HMO","1380.30","69.8","","915.80","263.76","2881.00","1 through 10","1033.44","1616.01","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1977.50","1483.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1616.01","81.72","","1531.57","410.52","8841.36","1 through 10","1033.44","1616.01","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1666.00","70","","134.04","134.04","134.04","1 through 10","737.8","1892.1","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1892.10","79.5","","948.87","198.19","1805.30","1 through 10","737.8","1892.1","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1268.54","53.3","","462.00","170.45","3253.37","1 through 10","737.8","1892.1","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","868.70","36.5","","245.50","107.19","1371.45","1 through 10","737.8","1892.1","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","911.54","38.3","","200.79","72.79","355.81","22","737.8","1892.1","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1832.60","77","","477.18","477.18","477.18","1 through 10","737.8","1892.1","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1021.02","42.9","","1045.91","1045.91","1045.91","1 through 10","737.8","1892.1","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2380.00","1785.00","WELLPOINT [1015]","HB AMC WELLPOINT","1755.96","73.78","","1726.50","1726.50","1726.50","1 through 10","737.8","1892.1","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2380.00","1785.00","AETNA [1001]","HB AMC AETNA HMO","1661.24","69.8","","915.80","263.76","2881.00","1 through 10","1243.79","1944.94","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2380.00","1785.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1944.94","81.72","","1531.57","410.52","8841.36","1 through 10","1243.79","1944.94","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2131.50","70","","134.04","134.04","134.04","1 through 10","943.95","2420.78","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2420.78","79.5","","948.87","198.19","1805.30","1 through 10","943.95","2420.78","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1622.99","53.3","","462.00","170.45","3253.37","1 through 10","943.95","2420.78","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1111.43","36.5","","245.50","107.19","1371.45","1 through 10","943.95","2420.78","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1166.24","38.3","","200.79","72.79","355.81","22","943.95","2420.78","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2344.65","77","","477.18","477.18","477.18","1 through 10","943.95","2420.78","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1306.31","42.9","","1045.91","1045.91","1045.91","1 through 10","943.95","2420.78","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","WELLPOINT [1015]","HB AMC WELLPOINT","2246.60","73.78","","1726.50","1726.50","1726.50","1 through 10","943.95","2420.78","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3045.00","2283.75","AETNA [1001]","HB AMC AETNA HMO","2125.41","69.8","","915.80","263.76","2881.00","1 through 10","1591.32","2488.37","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3045.00","2283.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2488.37","81.72","","1531.57","410.52","8841.36","1 through 10","1591.32","2488.37","percent of total billed charges",""
"STRAP WAIST 13 15IN LG IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10007778","CDM","L3670","HCPCS","0274","RC","","","","both","","","180.08","135.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.73","36.5","","54.89","54.89","54.89","1 through 10","55.82","258.84","percent of total billed charges",""
"Strapping Unna Boot","PX-76000725","CDM","29580","CPT","0761","RC","","","","both","","","492.00","369.00","MEDICARE [2001]","HB BWH MEDICARE","187.37","","APC Price ($187.37). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.39","187.39","187.39","1 through 10","152.52","391.14","other","OPPS APC"
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","127.09","71.8","","370.50","123.50","370.50","14","14.69","168.15","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","115.05","65","","111.80","111.80","111.80","1 through 10","14.69","168.15","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","123.90","70","","74.26","74.26","172.00","27","14.69","168.15","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","140.72","79.5","","135.37","111.80","406.10","20","14.69","168.15","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","94.34","53.3","","135.37","90.82","406.10","15","14.69","168.15","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","115.05","65","","111.80","111.80","152.10","1 through 10","14.69","168.15","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.61","36.5","","62.26","54.01","64.16","15","14.69","168.15","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.79","38.3","","67.25","56.76","201.75","42","14.69","168.15","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","outpatient","","","177.00","132.75","AETNA [1001]","HB AMC AETNA HMO","123.55","69.8","","232.89","82.22","232.89","43","15.46","144.64","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","outpatient","","","177.00","132.75","AETNA [1001]","HB AMC AETNA PPO","142.31","80.4","","180.26","90.13","270.39","13","15.46","144.64","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","outpatient","","","177.00","132.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","142.31","80.4","","86.00","86.00","86.00","1 through 10","15.46","144.64","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","outpatient","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","144.64","81.72","","137.50","137.50","137.50","1 through 10","15.46","144.64","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","outpatient","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","144.64","81.72","","137.50","50.56","137.50","14","15.46","144.64","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","353.38","363.89","31","351.32","1326.06","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1197.62","71.8","","1161.72","1161.72","1161.72","1 through 10","351.32","1326.06","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1084.20","65","","1051.70","1051.70","1051.70","1 through 10","351.32","1326.06","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","462.21","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","283.56","50.00","283.56","1 through 10","351.32","1326.06","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1326.06","79.5","","1273.37","854.30","1273.37","41","351.32","1326.06","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","889.04","53.3","","854.30","854.30","1273.37","31","351.32","1326.06","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","1 through 10","351.32","1326.06","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1284.36","77","","1245.86","1245.86","1245.86","1 through 10","351.32","1326.06","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","HUMANA [1012]","HB BWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1524.05","1524.05","1524.05","1 through 10","351.32","1326.06","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1084.20","65","","1051.70","1051.70","1051.70","1 through 10","351.32","1326.06","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","83","351.32","1326.06","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","608.82","36.5","","603.51","512.91","603.51","43","351.32","1326.06","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","638.84","38.3","","632.64","632.64","1897.92","145","351.32","1326.06","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.81","362.41","362.81","1 through 10","351.32","1326.06","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","1284.36","77","","1219.97","1219.97","1219.97","1 through 10","351.32","1326.06","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","TRICARE [160005]","HB BWH TRICARE","351.32","","APC Price ($369.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","369.81","351.32","369.81","1 through 10","351.32","1326.06","other","Tricare OPPS"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","363.01","362.41","1088.43","14","351.32","1326.06","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","372.14","372.14","372.14","1 through 10","351.32","1326.06","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","715.57","42.9","","1293.43","711.43","1293.43","1 through 10","351.32","1326.06","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","336.52","363.42","32","351.32","1326.06","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1668.00","1251.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","715.57","42.9","","711.43","711.43","711.43","1 through 10","351.32","1326.06","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","1668.00","1251.00","AETNA [1001]","HB AMC AETNA HMO","1164.26","69.8","","1095.39","773.40","1095.39","1 through 10","579.66","1543.73","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","1668.00","1251.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","871.70","52.26","","1001.22","668.81","1001.22","1 through 10","579.66","1543.73","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","1668.00","1251.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1341.07","80.4","","1262.04","1262.04","1262.04","1 through 10","579.66","1543.73","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","1668.00","1251.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","1363.09","81.72","","1293.43","1293.43","1293.43","1 through 10","579.66","1543.73","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","1668.00","1251.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1363.09","81.72","","1293.43","711.43","1293.43","38","579.66","1543.73","percent of total billed charges",""
"Stress Test Tracing Only|REDUCED SERVICES","PX-48000173","CDM","93017","CPT","0482","RC","","","52","both","","","1668.00","1251.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","181.21","181.21","181.21","1 through 10","351.32","462.21","other","OPPS APC"
"STRIP BICORTICAL 60X22MM 3 GRAFT BONE ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010666","CDM","C1889","HCPCS","0278","RC","","","","both","","","3294.06","2470.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2618.78","79.5","","1309.77","674.56","6049.93","26","1021.16","2618.78","percent of total billed charges",""
"STRIP BICORTICAL 60X22MM 3 GRAFT BONE ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010666","CDM","C1889","HCPCS","0278","RC","","","","both","","","3294.06","2470.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1755.73","53.3","","1901.83","1901.83","2962.25","1 through 10","1021.16","2618.78","percent of total billed charges",""
"STRIP BICORTICAL 60X22MM 3 GRAFT BONE ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010666","CDM","C1889","HCPCS","0278","RC","","","","both","","","3294.06","2470.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1202.33","36.5","","1620.31","1620.31","19908.88","1 through 10","1021.16","2618.78","percent of total billed charges",""
"STRIP BICORTICAL 60X22MM 3 GRAFT BONE ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010666","CDM","C1889","HCPCS","0278","RC","","","","both","","","3294.06","2470.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1261.62","38.3","","352.91","352.91","2046.30","1 through 10","1021.16","2618.78","percent of total billed charges",""
"STRIP BICORTICAL 60X22MM 3 GRAFT BONE ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010666","CDM","C1889","HCPCS","0278","RC","","","","both","","","3294.06","2470.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1413.15","42.9","","9668.75","9668.75","9668.75","1 through 10","1021.16","2618.78","percent of total billed charges",""
"STRIP BICORTICAL 60X22MM 3 GRAFT BONE ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010666","CDM","C1889","HCPCS","0278","RC","","","","both","","","3294.06","2470.54","WELLPOINT [1015]","HB AMC WELLPOINT","2430.36","73.78","","699.88","384.10","3443.31","33","1021.16","2618.78","percent of total billed charges",""
"STRIP BICORTICAL 60X22MM 3 GRAFT BONE ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3294.06","2470.54","AETNA [1001]","HB AMC AETNA HMO","2299.25","69.8","","1421.24","264.50","4933.46","29","1721.48","2691.91","percent of total billed charges",""
"STRIP BICORTICAL 60X22MM 3 GRAFT BONE ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3294.06","2470.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2648.42","80.4","","1022.97","1022.97","3607.50","1 through 10","1721.48","2691.91","percent of total billed charges",""
"STRIP BICORTICAL 60X22MM 3 GRAFT BONE ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3294.06","2470.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2691.91","81.72","","3010.54","693.88","5019.88","35","1721.48","2691.91","percent of total billed charges",""
"STRIP TRICORTICAL 60X20TO24MMX5TO30MM GRAFT ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010674","CDM","C1889","HCPCS","0278","RC","","","","both","","","5296.50","3972.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4210.72","79.5","","1309.77","674.56","6049.93","26","1641.92","4210.72","percent of total billed charges",""
"STRIP TRICORTICAL 60X20TO24MMX5TO30MM GRAFT ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010674","CDM","C1889","HCPCS","0278","RC","","","","both","","","5296.50","3972.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2823.03","53.3","","1901.83","1901.83","2962.25","1 through 10","1641.92","4210.72","percent of total billed charges",""
"STRIP TRICORTICAL 60X20TO24MMX5TO30MM GRAFT ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010674","CDM","C1889","HCPCS","0278","RC","","","","both","","","5296.50","3972.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1933.22","36.5","","1620.31","1620.31","19908.88","1 through 10","1641.92","4210.72","percent of total billed charges",""
"STRIP TRICORTICAL 60X20TO24MMX5TO30MM GRAFT ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010674","CDM","C1889","HCPCS","0278","RC","","","","both","","","5296.50","3972.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2028.56","38.3","","352.91","352.91","2046.30","1 through 10","1641.92","4210.72","percent of total billed charges",""
"STRIP TRICORTICAL 60X20TO24MMX5TO30MM GRAFT ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010674","CDM","C1889","HCPCS","0278","RC","","","","both","","","5296.50","3972.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2272.20","42.9","","9668.75","9668.75","9668.75","1 through 10","1641.92","4210.72","percent of total billed charges",""
"STRIP TRICORTICAL 60X20TO24MMX5TO30MM GRAFT ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010674","CDM","C1889","HCPCS","0278","RC","","","","both","","","5296.50","3972.37","WELLPOINT [1015]","HB AMC WELLPOINT","3907.76","73.78","","699.88","384.10","3443.31","33","1641.92","4210.72","percent of total billed charges",""
"STRIP TRICORTICAL 60X20TO24MMX5TO30MM GRAFT ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010674","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5296.50","3972.37","AETNA [1001]","HB AMC AETNA HMO","3696.96","69.8","","1421.24","264.50","4933.46","29","2767.95","4328.3","percent of total billed charges",""
"STRIP TRICORTICAL 60X20TO24MMX5TO30MM GRAFT ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010674","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5296.50","3972.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4258.39","80.4","","1022.97","1022.97","3607.50","1 through 10","2767.95","4328.3","percent of total billed charges",""
"STRIP TRICORTICAL 60X20TO24MMX5TO30MM GRAFT ALLOGRAFT ILIUM FREEZE DRIED","SUP-ITM-10010674","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5296.50","3972.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4328.30","81.72","","3010.54","693.88","5019.88","35","2767.95","4328.3","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","both","","","103.00","77.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","81.89","79.5","","78.70","52.80","310.87","21","31.93","97.85","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","both","","","103.00","77.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","54.90","53.3","","78.70","52.80","78.70","1 through 10","31.93","97.85","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","37.60","36.5","","31.70","31.40","37.30","1 through 10","31.93","97.85","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","both","","","103.00","77.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","39.45","38.3","","39.10","33.00","39.10","20","31.93","97.85","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","both","","","103.00","77.25","WELLPOINT [1015]","HB AMC WELLPOINT","75.99","73.78","","174.45","74.45","274.45","16","31.93","97.85","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","outpatient","","","103.00","77.25","AETNA [1001]","HB AMC AETNA HMO","71.89","69.8","","67.70","47.80","78.00","16","38.52","84.98","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","outpatient","","","103.00","77.25","AETNA [1001]","HB AMC AETNA PPO","82.81","80.4","","78.00","52.40","104.80","1 through 10","38.52","84.98","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","outpatient","","","103.00","77.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","54.08","52.5","","65.50","57.60","65.50","1 through 10","38.52","84.98","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","outpatient","","","103.00","77.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","56.65","55","","57.60","57.60","57.60","1 through 10","38.52","84.98","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","outpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","84.17","81.72","","79.94","43.97","79.94","1 through 10","38.52","84.98","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","outpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","84.17","81.72","","79.94","43.97","79.94","11","38.52","84.98","percent of total billed charges",""
"Study Voiding Pressure Intra-Abdom","PX-76001274","CDM","51797","CPT","0761","RC","","","","both","","","1013.00","759.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","805.34","79.5","","772.83","772.83","772.83","1 through 10","314.03","805.34","percent of total billed charges",""
"Study Voiding Pressure Intra-Abdom","PX-76001274","CDM","51797","CPT","0761","RC","","","","both","","","1013.00","759.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","539.93","53.3","","772.83","518.50","772.83","1 through 10","314.03","805.34","percent of total billed charges",""
"Study Voiding Pressure Intra-Abdom","PX-76001274","CDM","51797","CPT","0761","RC","","","","both","","","1013.00","759.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","658.45","65","","638.30","520.46","638.30","1 through 10","314.03","805.34","percent of total billed charges",""
"Study Voiding Pressure Intra-Abdom","PX-76001274","CDM","51797","CPT","0761","RC","","","","both","","","1013.00","759.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","369.75","36.5","","366.29","311.29","366.29","1 through 10","314.03","805.34","percent of total billed charges",""
"Study Voiding Pressure Intra-Abdom","PX-76001274","CDM","51797","CPT","0761","RC","","","","both","","","1013.00","759.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","387.98","38.3","","383.96","383.96","1151.88","1 through 10","314.03","805.34","percent of total billed charges",""
"Study Voiding Pressure Intra-Abdom","PX-76001274","CDM","51797","CPT","0761","RC","","","","both","","","1013.00","759.75","WELLPOINT [1015]","HB AMC WELLPOINT","747.39","73.78","","731.10","731.10","731.10","1 through 10","314.03","805.34","percent of total billed charges",""
"Study Voiding Pressure Intra-Abdom","PX-76001274","CDM","51797","CPT","0761","RC","","","","outpatient","","","1013.00","759.75","AETNA [1001]","HB AMC AETNA HMO","707.07","69.8","","704.49","704.49","704.49","1 through 10","179.12","827.82","percent of total billed charges",""
"Study Voiding Pressure Intra-Abdom","PX-76001274","CDM","51797","CPT","0761","RC","","","","outpatient","","","1013.00","759.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","814.45","80.4","","765.96","491.00","765.96","1 through 10","179.12","827.82","percent of total billed charges",""
"Study Voiding Pressure Intra-Abdom","PX-76001274","CDM","51797","CPT","0761","RC","","","","outpatient","","","1013.00","759.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","827.82","81.72","","785.01","785.01","785.01","1 through 10","179.12","827.82","percent of total billed charges",""
"STYLET SHUNT 23CM AXIEM SINGLE","SUP-ITM-10321251","CDM","C1889","HCPCS","0278","RC","","","","both","","","1271.18","953.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1010.59","79.5","","1309.77","674.56","6049.93","26","394.07","1010.59","percent of total billed charges",""
"STYLET SHUNT 23CM AXIEM SINGLE","SUP-ITM-10321251","CDM","C1889","HCPCS","0278","RC","","","","both","","","1271.18","953.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","677.54","53.3","","1901.83","1901.83","2962.25","1 through 10","394.07","1010.59","percent of total billed charges",""
"STYLET SHUNT 23CM AXIEM SINGLE","SUP-ITM-10321251","CDM","C1889","HCPCS","0278","RC","","","","both","","","1271.18","953.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","463.98","36.5","","1620.31","1620.31","19908.88","1 through 10","394.07","1010.59","percent of total billed charges",""
"STYLET SHUNT 23CM AXIEM SINGLE","SUP-ITM-10321251","CDM","C1889","HCPCS","0278","RC","","","","both","","","1271.18","953.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","486.86","38.3","","352.91","352.91","2046.30","1 through 10","394.07","1010.59","percent of total billed charges",""
"STYLET SHUNT 23CM AXIEM SINGLE","SUP-ITM-10321251","CDM","C1889","HCPCS","0278","RC","","","","both","","","1271.18","953.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","545.34","42.9","","9668.75","9668.75","9668.75","1 through 10","394.07","1010.59","percent of total billed charges",""
"STYLET SHUNT 23CM AXIEM SINGLE","SUP-ITM-10321251","CDM","C1889","HCPCS","0278","RC","","","","both","","","1271.18","953.38","WELLPOINT [1015]","HB AMC WELLPOINT","937.88","73.78","","699.88","384.10","3443.31","33","394.07","1010.59","percent of total billed charges",""
"STYLET SHUNT 23CM AXIEM SINGLE","SUP-ITM-10321251","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1271.18","953.38","AETNA [1001]","HB AMC AETNA HMO","887.28","69.8","","1421.24","264.50","4933.46","29","664.32","1038.81","percent of total billed charges",""
"STYLET SHUNT 23CM AXIEM SINGLE","SUP-ITM-10321251","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1271.18","953.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1022.03","80.4","","1022.97","1022.97","3607.50","1 through 10","664.32","1038.81","percent of total billed charges",""
"STYLET SHUNT 23CM AXIEM SINGLE","SUP-ITM-10321251","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1271.18","953.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1038.81","81.72","","3010.54","693.88","5019.88","35","664.32","1038.81","percent of total billed charges",""
"Sub Grft F/S/N/H/F/G/M/D <100scm 1st 25 Scm","PX-98302100","CDM","15275","CPT","0983","RC","","","","both","","","407.00","305.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","323.57","79.5","","7878.66","7878.66","7878.66","1 through 10","126.17","2715.13","percent of total billed charges",""
"Sub Grft F/S/N/H/F/G/M/D <100scm 1st 25 Scm","PX-98302100","CDM","15275","CPT","0983","RC","","","","both","","","407.00","305.25","HUMANA [1012]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2141.91","2141.91","2141.91","1 through 10","126.17","2715.13","other","OPPS APC"
"Sub Grft F/S/N/H/F/G/M/D <100scm 1st 25 Scm","PX-98302100","CDM","15275","CPT","0983","RC","","","","both","","","407.00","305.25","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","1086.16","2172.32","1 through 10","126.17","2715.13","other","OPPS APC"
"Sub Grft F/S/N/H/F/G/M/D <100scm 1st 25 Scm","PX-98302100","CDM","15275","CPT","0983","RC","","","","both","","","407.00","305.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","155.88","38.3","","5504.30","1810.33","5504.30","1 through 10","126.17","2715.13","percent of total billed charges",""
"Sub Grft F/S/N/H/F/G/M/D <100scm 1st 25 Scm","PX-98302100","CDM","15275","CPT","0983","RC","","","","both","","","407.00","305.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2128.87","2128.87","2128.87","1 through 10","126.17","2715.13","other","OPPS APC"
"Sub Grft F/S/N/H/F/G/M/D <100scm 1st 25 Scm","PX-98302100","CDM","15275","CPT","0983","RC","","","","outpatient","","","407.00","305.25","AETNA [1001]","HB AMC AETNA HMO","284.09","69.8","","12526.02","12526.02","12526.02","1 through 10","227.51","2384.07","percent of total billed charges",""
"Sub Grft F/S/N/H/F/G/M/D <100scm 1st 25 Scm","PX-98302100","CDM","15275","CPT","0983","RC","","","","outpatient","","","407.00","305.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","4321.60","4321.60","4321.60","1 through 10","227.51","2384.07","other","Multiple Surgery"
"Sub Grft F/S/N/H/F/G/M/D <100scm 1st 25 Scm","PX-98302100","CDM","15275","CPT","0983","RC","","","","outpatient","","","407.00","305.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","332.60","81.72","","7000.00","1577.42","7000.00","1 through 10","227.51","2384.07","percent of total billed charges",""
"Succinate Dehydrogenase Complex Subunit B","PX-31001364","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"Succinate Dehydrogenase Complex Subunit B","PX-31001364","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Succinate Dehydrogenase Complex Subunit D","PX-31001345","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Sugars Single Ql","PX-30000683","CDM","84376","CPT","0301","RC","","","","both","","","95.00","71.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","75.53","79.5","","48.58","48.58","48.58","1 through 10","5.39","90.25","percent of total billed charges",""
"Sugars Single Ql","PX-30000683","CDM","84376","CPT","0301","RC","","","","outpatient","","","95.00","71.25","AETNA [1001]","HB AMC AETNA HMO","66.31","69.8","","62.28","62.28","62.28","1 through 10","5.67","77.63","percent of total billed charges",""
"Sugars Single Ql","PX-30000683","CDM","84376","CPT","0301","RC","","","","outpatient","","","95.00","71.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","77.63","81.72","","73.54","40.45","73.54","1 through 10","5.67","77.63","percent of total billed charges",""
"Sumatriptan Succinate / 6 Mg","PX-63601029","CDM","J3030","HCPCS","0636","RC","","","","outpatient","","","52.00","39.00","AETNA [1001]","HB AMC AETNA HMO","36.30","69.8","","734.91","11.93","734.91","1 through 10","24.39","352.08","percent of total billed charges",""
"Superficial Venous Malf Sclero","PX-76001993","CDM","37799","CPT","0761","RC","","","","outpatient","","","9913.00","7434.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","5176.57","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","8178.23","percent of total billed charges",""
"Superficial Venous Malf Sclero","PX-76001993","CDM","37799","CPT","0761","RC","","","","outpatient","","","9913.00","7434.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","5204.33","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","8178.23","percent of total billed charges",""
"Supply Misc Pm/Pbu Cord #103860","PX-27001060","CDM","Q0508","HCPCS","0274","RC","","","","both","","","122.50","91.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","79.63","65","","1092.00","1092.00","1092.00","1 through 10","37.98","116.38","percent of total billed charges",""
"Supply Misc Pm/Pbu Cord #103860","PX-27001060","CDM","Q0508","HCPCS","0274","RC","","","","both","","","122.50","91.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","85.75","70","","51.84","51.84","51.84","21","37.98","116.38","percent of total billed charges",""
"Supply Misc Pm/Pbu Cord #103860","PX-27001060","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","122.50","91.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","74.17","60.55","","48.41","48.41","48.41","1 through 10","49","101.06","percent of total billed charges",""
"Supply Misc Pm/Pbu Cord #103860","PX-27001060","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","122.50","91.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","63.97","52.22","","43.55","43.55","43.55","24","49","101.06","percent of total billed charges",""
"Supply Misc Pm/Pbu Cord #103860","PX-27001060","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","122.50","91.87","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","61.25","50","","37.73","37.73","188.64","1 through 10","49","101.06","percent of total billed charges",""
"Supply Misc Pm/Pbu Cord #1225","PX-27001061","CDM","Q0508","HCPCS","0278","RC","","","","both","","","1137.50","853.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","739.38","65","","1092.00","1092.00","1092.00","1 through 10","352.63","1080.63","percent of total billed charges",""
"Supply Misc Pm/Pbu Cord #1225","PX-27001061","CDM","Q0508","HCPCS","0278","RC","","","","both","","","1137.50","853.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","796.25","70","","51.84","51.84","51.84","21","352.63","1080.63","percent of total billed charges",""
"Supply Misc Pm/Pbu Cord #1225","PX-27001061","CDM","Q0508","HCPCS","0278","RC","","","","outpatient","","","1137.50","853.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","688.76","60.55","","48.41","48.41","48.41","1 through 10","455","938.44","percent of total billed charges",""
"Supply Misc Pm/Pbu Cord #1225","PX-27001061","CDM","Q0508","HCPCS","0278","RC","","","","outpatient","","","1137.50","853.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","594.00","52.22","","43.55","43.55","43.55","24","455","938.44","percent of total billed charges",""
"Supply Misc Pm/Pbu Cord #1225","PX-27001061","CDM","Q0508","HCPCS","0278","RC","","","","outpatient","","","1137.50","853.12","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","568.75","50","","37.73","37.73","188.64","1 through 10","455","938.44","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","both","","","3400.15","2550.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2703.12","79.5","","1632.15","1632.15","1632.15","1 through 10","1054.05","2703.12","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","both","","","3400.15","2550.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1812.28","53.3","","9709.13","9709.13","9709.13","1 through 10","1054.05","2703.12","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","both","","","3400.15","2550.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2210.10","65","","2685.95","2190.09","2685.96","1 through 10","1054.05","2703.12","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","both","","","3400.15","2550.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1241.05","36.5","","1495.87","1455.73","1541.33","1 through 10","1054.05","2703.12","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","both","","","3400.15","2550.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1302.26","38.3","","1615.71","1615.71","1615.71","1 through 10","1054.05","2703.12","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","both","","","3400.15","2550.11","WELLPOINT [1015]","HB AMC WELLPOINT","2508.63","73.78","","3076.44","3076.44","3076.44","1 through 10","1054.05","2703.12","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3400.15","2550.11","AETNA [1001]","HB AMC AETNA HMO","2373.30","69.8","","4568.79","2411.14","4568.79","1 through 10","1776.92","2778.6","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3400.15","2550.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2733.72","80.4","","2411.14","1545.60","3223.14","1 through 10","1776.92","2778.6","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3400.15","2550.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2778.60","81.72","","1816.95","1816.95","1816.95","1 through 10","1776.92","2778.6","percent of total billed charges",""
"SUPPORT URETHRAL 45CMX1.1 IMPLANT POLIGLERAPRONE RETRO PUBIC GYNECARE BX/1EA","SUP-ITM-10011283","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3400.15","2550.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2778.60","81.72","","3303.30","3303.30","3303.30","1 through 10","1776.92","2778.6","percent of total billed charges",""
"Surfactant Deficiency (Abca3 Gene Sequence)","PX-31000755","CDM","81479","CPT","0310","RC","","","","both","","","1998.00","1498.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1588.41","79.5","","0.65","0.65","0.65","1 through 10","619.38","1898.1","percent of total billed charges",""
"Surfactant Deficiency (Abca3 Gene Sequence)","PX-31000755","CDM","81479","CPT","0310","RC","","","","both","","","1998.00","1498.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1064.93","53.3","","0.79","0.79","0.79","1 through 10","619.38","1898.1","percent of total billed charges",""
"Surfactant Deficiency (Abca3 Gene Sequence)","PX-31000755","CDM","81479","CPT","0310","RC","","","","outpatient","","","1998.00","1498.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","999.00","50","","1.00","1.00","1.00","1 through 10","156.55","1648.35","percent of total billed charges",""
"Surfactant Deficiency (Abca3 Gene Sequence)","PX-31000755","CDM","81479","CPT","0310","RC","","","","outpatient","","","1998.00","1498.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1048.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","1648.35","percent of total billed charges",""
"Surfactant Protein B (Sftpb Gene Sequence)","PX-31000754","CDM","81479","CPT","0310","RC","","","","both","","","1998.00","1498.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1588.41","79.5","","0.65","0.65","0.65","1 through 10","619.38","1898.1","percent of total billed charges",""
"Surfactant Protein B (Sftpb Gene Sequence)","PX-31000754","CDM","81479","CPT","0310","RC","","","","both","","","1998.00","1498.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1064.93","53.3","","0.79","0.79","0.79","1 through 10","619.38","1898.1","percent of total billed charges",""
"Surfactant Protein B (Sftpb Gene Sequence)","PX-31000754","CDM","81479","CPT","0310","RC","","","","outpatient","","","1998.00","1498.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","999.00","50","","1.00","1.00","1.00","1 through 10","156.55","1648.35","percent of total billed charges",""
"Surfactant Protein B (Sftpb Gene Sequence)","PX-31000754","CDM","81479","CPT","0310","RC","","","","outpatient","","","1998.00","1498.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1048.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","1648.35","percent of total billed charges",""
"Surfactant Protein C (Sftpc Gene Sequence)","PX-31000753","CDM","81479","CPT","0310","RC","","","","both","","","1998.00","1498.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1588.41","79.5","","0.65","0.65","0.65","1 through 10","619.38","1898.1","percent of total billed charges",""
"Surfactant Protein C (Sftpc Gene Sequence)","PX-31000753","CDM","81479","CPT","0310","RC","","","","both","","","1998.00","1498.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1064.93","53.3","","0.79","0.79","0.79","1 through 10","619.38","1898.1","percent of total billed charges",""
"Surfactant Protein C (Sftpc Gene Sequence)","PX-31000753","CDM","81479","CPT","0310","RC","","","","outpatient","","","1998.00","1498.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","999.00","50","","1.00","1.00","1.00","1 through 10","156.55","1648.35","percent of total billed charges",""
"Surfactant Protein C (Sftpc Gene Sequence)","PX-31000753","CDM","81479","CPT","0310","RC","","","","outpatient","","","1998.00","1498.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1048.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","1648.35","percent of total billed charges",""
"Surg Diagnostic Exam, Anorectal","PX-75000520","CDM","45990","CPT","0750","RC","","","","outpatient","","","1514.00","1135.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","790.61","52.22","","6188.43","6188.43","6188.43","1 through 10","605.6","1237.24","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4930.00","3697.50","AETNA [1001]","HB AMC AETNA HMO","3441.14","69.8","","5880.83","2285.32","5880.83","1 through 10","1528.3","4719.38","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4930.00","3697.50","AETNA [1001]","HB AMC AETNA PPO","3963.72","80.4","","9596.34","9596.34","9596.34","1 through 10","1528.3","4719.38","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4930.00","3697.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3919.35","79.5","","12458.17","2524.37","32222.92","1 through 10","1528.3","4719.38","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4930.00","3697.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2627.69","53.3","","7575.35","7575.35","7575.35","1 through 10","1528.3","4719.38","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4930.00","3697.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1799.45","36.5","","15554.10","5349.93","15554.10","1 through 10","1528.3","4719.38","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4930.00","3697.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1888.19","38.3","","5608.11","1869.37","42323.01","1 through 10","1528.3","4719.38","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4930.00","3697.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5424.80","2712.40","6321.29","1 through 10","2125.14","9843.6","other","ASC"
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4930.00","3697.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6259.18","4781.00","6321.29","31","2125.14","9843.6","other","ASC "
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4930.00","3697.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","6162.91","6162.91","6162.91","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4930.00","3697.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","24651.60","4930.32","24651.60","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4930.00","3697.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5794.16","4994.08","15556.02","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4930.00","3697.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","6162.91","6162.91","6162.91","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4930.00","3697.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","10678.27","5440.36","10678.27","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4930.00","3697.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4028.80","81.72","","5440.36","4781.00","16171.06","1 through 10","2125.14","9843.6","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","5916.00","4437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4703.22","79.5","","13545.31","6560.09","13647.15","63","1833.96","4719.38","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","5916.00","4437.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3153.23","53.3","","15146.20","15145.88","15146.20","84","1833.96","4719.38","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","5916.00","4437.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1833.96","31","","5318.19","5318.19","5318.19","1 through 10","1833.96","4719.38","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","5916.00","4437.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2159.34","36.5","","6419.70","4153.58","9332.46","27","1833.96","4719.38","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","5916.00","4437.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2265.83","38.3","","6729.51","6338.40","15846.00","96","1833.96","4719.38","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","5916.00","4437.00","TRICARE [160005]","HB BWH TRICARE","3587.09","","APC Price ($3,775.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3241.57","3241.57","3241.57","1 through 10","1833.96","4719.38","other","Tricare OPPS"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","5916.00","4437.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","3587.09","","APC Price ($3,775.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3775.88","3775.88","3775.88","1 through 10","1833.96","4719.38","other","Tricare OPPS"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","5916.00","4437.00","WELLPOINT [1015]","HB AMC WELLPOINT","4364.82","73.78","","15745.20","5570.00","15745.20","13","1833.96","4719.38","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","5916.00","4437.00","AETNA [1001]","HB AMC AETNA HMO","4129.37","69.8","","3883.95","2742.29","5484.58","15","2125.14","9843.6","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","5916.00","4437.00","AETNA [1001]","HB AMC AETNA PPO","4756.46","80.4","","4474.86","4474.86","4474.86","1 through 10","2125.14","9843.6","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","5916.00","4437.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5524.71","5424.80","5524.71","42","2125.14","9843.6","other","ASC"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","5916.00","4437.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6259.18","6259.18","6321.29","93","2125.14","9843.6","other","ASC "
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","5916.00","4437.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","7396.21","6162.91","7396.21","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","5916.00","4437.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","14790.96","9478.12","24651.60","50","2125.14","9843.6","other","Multiple Surgery"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","5916.00","4437.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","15556.02","9101.25","25926.70","28","2125.14","9843.6","other","Multiple Surgery"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","5916.00","4437.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","6162.91","6162.91","6162.91","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","5916.00","4437.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4994.08","4994.08","4994.08","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","5916.00","4437.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","5440.36","5440.36","10880.72","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","5916.00","4437.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","4586.15","4586.15","4586.15","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","5916.00","4437.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4834.56","81.72","","4586.16","2522.56","4586.16","1 through 10","2125.14","9843.6","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","5916.00","4437.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4834.56","81.72","","4586.16","4586.16","5227.84","12","2125.14","9843.6","percent of total billed charges",""
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","both","","","8960.00","6720.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3270.40","36.5","","9723.00","3241.00","9723.00","1 through 10","2777.6","7123.2","percent of total billed charges",""
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","both","","","8960.00","6720.00","WELLPOINT [1015]","HB AMC WELLPOINT","6610.69","73.78","","15157.96","15157.96","15157.96","1 through 10","2777.6","7123.2","percent of total billed charges",""
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","outpatient","","","8960.00","6720.00","AETNA [1001]","HB AMC AETNA HMO","6254.08","69.8","","4153.34","4153.34","4153.34","1 through 10","2125.14","9843.6","percent of total billed charges",""
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","outpatient","","","8960.00","6720.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5524.71","5524.71","5524.71","1 through 10","2125.14","9843.6","other","ASC"
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","outpatient","","","8960.00","6720.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6259.18","6259.18","6321.29","1 through 10","2125.14","9843.6","other","ASC "
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","outpatient","","","8960.00","6720.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","6162.91","6162.91","6162.91","1 through 10","2125.14","9843.6","other","Multiple Surgery"
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","outpatient","","","8960.00","6720.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7322.11","81.72","","6945.99","3452.51","6945.99","1 through 10","2125.14","9843.6","percent of total billed charges",""
"Surgical Arthroscopy Shoulder Xtnsv Dbrdmt 3+","PX-76002368","CDM","29823","CPT","0761","RC","","","","both","","","5168.00","3876.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4043.80","","APC Price ($4,126.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6584.52","6584.52","6584.52","1 through 10","1602.08","5157.91","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","420.35","386.03","427.19","28","405.83","1462.01","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1462.01","79.5","","1403.22","1344.38","5648.54","17","405.83","1462.01","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","980.19","53.3","","5647.31","1403.22","5647.31","1 through 10","405.83","1462.01","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","418.65","418.65","1 through 10","405.83","1462.01","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","FALLON HEALTH [1008]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","418.65","418.65","1 through 10","405.83","1462.01","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1416.03","77","","8237.46","1372.91","8237.46","1 through 10","405.83","1462.01","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","HUMANA [1012]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","418.65","418.65","1 through 10","405.83","1462.01","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.75","418.75","418.75","1 through 10","405.83","1462.01","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","MEDICARE [2001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.19","392.31","427.19","175","405.83","1462.01","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","570.09","31","","3305.68","3305.68","3305.68","1 through 10","405.83","1462.01","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","671.24","36.5","","665.06","565.21","3990.35","1 through 10","405.83","1462.01","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","704.34","38.3","","697.15","677.54","4182.92","13","405.83","1462.01","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","427.15","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.65","418.65","418.65","1 through 10","405.83","1462.01","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","TRICARE [160005]","HB BWH TRICARE","405.83","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","427.19","427.19","427.19","1 through 10","405.83","1462.01","other","Tricare OPPS"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","384.46","1263.63","14","405.83","1462.01","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","410.09","410.09","410.09","1 through 10","405.83","1462.01","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","418.60","","APC Price ($427.15). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","418.65","419.51","30","405.83","1462.01","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1839.00","1379.25","WELLPOINT [1015]","HB AMC WELLPOINT","1356.81","73.78","","1327.44","1327.44","1327.44","19","405.83","1462.01","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","outpatient","","","1839.00","1379.25","AETNA [1001]","HB AMC AETNA HMO","1283.62","69.8","","16163.03","1207.09","16163.03","1 through 10","564.46","1502.83","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","outpatient","","","1839.00","1379.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","961.06","52.26","","1103.33","564.46","1103.33","1 through 10","564.46","1502.83","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","outpatient","","","1839.00","1379.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1478.56","80.4","","5349.00","5349.00","5349.00","1 through 10","564.46","1502.83","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","outpatient","","","1839.00","1379.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1502.83","81.72","","783.99","783.99","783.99","1 through 10","564.46","1502.83","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","outpatient","","","1839.00","1379.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1502.83","81.72","","1425.33","783.99","8551.98","21","564.46","1502.83","percent of total billed charges",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","both","","","6649.00","4986.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5285.96","79.5","","6400.67","6400.67","6400.67","1 through 10","2061.19","5285.96","percent of total billed charges",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","both","","","6649.00","4986.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2546.57","38.3","","12558.14","12558.14","12558.14","1 through 10","2061.19","5285.96","percent of total billed charges",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","outpatient","","","6649.00","4986.75","AETNA [1001]","HB AMC AETNA HMO","4641.00","69.8","","11563.78","11563.78","11563.78","1 through 10","2659.6","5433.56","percent of total billed charges",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","outpatient","","","6649.00","4986.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4025.97","60.55","","5462.27","5363.49","5462.27","1 through 10","2659.6","5433.56","percent of total billed charges",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","outpatient","","","6649.00","4986.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3472.11","52.22","","6188.43","6188.43","6249.84","1 through 10","2659.6","5433.56","percent of total billed charges",""
"Susceptibility Agar","PX-30001183","CDM","87181","CPT","0306","RC","","","","both","","","82.00","61.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","58.88","71.8","","57.44","4.19","119.07","1 through 10","4.66","77.9","percent of total billed charges",""
"Susceptibility Agar","PX-30001183","CDM","87181","CPT","0306","RC","","","","both","","","82.00","61.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","65.19","79.5","","62.96","62.96","232.95","1 through 10","4.66","77.9","percent of total billed charges",""
"Susceptibility Agar","PX-30001183","CDM","87181","CPT","0306","RC","","","","both","","","82.00","61.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","43.71","53.3","","42.24","42.24","42.24","1 through 10","4.66","77.9","percent of total billed charges",""
"Susceptibility Agar","PX-30001183","CDM","87181","CPT","0306","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29.93","36.5","","25.36","25.36","29.84","1 through 10","4.66","77.9","percent of total billed charges",""
"Susceptibility Agar","PX-30001183","CDM","87181","CPT","0306","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31.41","38.3","","31.28","30.40","31.28","13","4.66","77.9","percent of total billed charges",""
"Susceptibility Agar","PX-30001183","CDM","87181","CPT","0306","RC","","","","both","","","82.00","61.50","MOLINA [1014]","HB BWH MOLINA","28.70","35","","4.75","4.75","4.75","1 through 10","4.66","77.9","percent of total billed charges",""
"Susceptibility Agar","PX-30001183","CDM","87181","CPT","0306","RC","","","","both","","","82.00","61.50","TRICARE [160005]","HB BWH TRICARE","77.90","95","","5.43","5.43","5.43","1 through 10","4.66","77.9","percent of total billed charges",""
"Susceptibility Agar","PX-30001183","CDM","87181","CPT","0306","RC","","","","outpatient","","","82.00","61.50","AETNA [1001]","HB AMC AETNA HMO","57.24","69.8","","50.44","38.24","54.16","1 through 10","4.89","67.01","percent of total billed charges",""
"Susceptibility Agar","PX-30001183","CDM","87181","CPT","0306","RC","","","","outpatient","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","67.01","81.72","","63.95","35.18","63.95","1 through 10","4.89","67.01","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","both","","","114.00","85.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","79.80","70","","50.72","47.73","50.72","1 through 10","7.11","108.3","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","both","","","114.00","85.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","90.63","79.5","","87.36","58.61","87.36","55","7.11","108.3","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","both","","","114.00","85.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","60.76","53.3","","87.36","56.06","175.83","34","7.11","108.3","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","35.34","31","","34.30","34.30","34.30","1 through 10","7.11","108.3","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.61","36.5","","40.18","35.19","41.40","61","7.11","108.3","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.66","38.3","","43.40","42.18","43.40","256","7.11","108.3","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","both","","","114.00","85.50","MOLINA [1014]","HB BWH MOLINA","39.90","35","","14.84","14.84","14.84","1 through 10","7.11","108.3","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","both","","","114.00","85.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","87.78","77","","86.58","75.15","86.58","1 through 10","7.11","108.3","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","both","","","114.00","85.50","TRICARE [160005]","HB BWH TRICARE","108.30","95","","9.01","8.56","9.01","1 through 10","7.11","108.3","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.91","42.9","","48.81","48.81","48.81","1 through 10","7.11","108.3","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.91","42.9","","48.81","48.81","48.81","1 through 10","7.11","108.3","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","outpatient","","","114.00","85.50","AETNA [1001]","HB AMC AETNA HMO","79.57","69.8","","75.15","58.16","75.15","1 through 10","7.11","93.16","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","outpatient","","","114.00","85.50","AETNA [1001]","HB AMC AETNA PPO","91.66","80.4","","58.16","58.16","58.16","11","7.11","93.16","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","outpatient","","","114.00","85.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","59.58","52.26","","24.75","24.75","24.75","1 through 10","7.11","93.16","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","outpatient","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","93.16","81.72","","83.17","83.17","83.17","1 through 10","7.11","93.16","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","93.16","81.72","","48.81","48.81","48.81","1 through 10","7.11","93.16","percent of total billed charges",""
"Susceptibility Disk Kirby Bauer","PX-30001184","CDM","87184","CPT","0306","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.16","81.72","","88.73","48.81","88.73","77","7.11","93.16","percent of total billed charges",""
"Susceptibility Enzyme Detection","PX-30001185","CDM","87185","CPT","0306","RC","","","","both","","","71.00","53.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","46.15","65","","36.43","36.43","36.43","1 through 10","4.66","67.45","percent of total billed charges",""
"Susceptibility Enzyme Detection","PX-30001185","CDM","87185","CPT","0306","RC","","","","both","","","71.00","53.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","56.45","79.5","","36.43","36.43","36.43","1 through 10","4.66","67.45","percent of total billed charges",""
"Susceptibility Enzyme Detection","PX-30001185","CDM","87185","CPT","0306","RC","","","","both","","","71.00","53.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37.84","53.3","","54.30","36.43","54.30","1 through 10","4.66","67.45","percent of total billed charges",""
"Susceptibility Enzyme Detection","PX-30001185","CDM","87185","CPT","0306","RC","","","","both","","","71.00","53.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","22.01","31","","63.96","63.96","63.96","1 through 10","4.66","67.45","percent of total billed charges",""
"Susceptibility Enzyme Detection","PX-30001185","CDM","87185","CPT","0306","RC","","","","both","","","71.00","53.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27.19","38.3","","26.98","26.22","26.98","1 through 10","4.66","67.45","percent of total billed charges",""
"Susceptibility Enzyme Detection","PX-30001185","CDM","87185","CPT","0306","RC","","","","outpatient","","","71.00","53.25","AETNA [1001]","HB AMC AETNA HMO","49.56","69.8","","32.98","32.98","32.98","1 through 10","4.89","58.02","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","147.00","110.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","102.90","70","","143.00","143.00","143.00","1 through 10","8.48","139.65","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","147.00","110.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.87","79.5","","112.54","75.50","112.54","54","8.48","139.65","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","147.00","110.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.35","53.3","","92.95","75.50","112.54","47","8.48","139.65","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.57","31","","44.19","44.19","44.19","1 through 10","8.48","139.65","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.66","36.5","","53.34","45.33","53.34","72","8.48","139.65","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.30","38.3","","55.91","54.34","55.92","200","8.48","139.65","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","147.00","110.25","MOLINA [1014]","HB BWH MOLINA","51.45","35","","17.16","17.16","17.16","1 through 10","8.48","139.65","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","147.00","110.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","113.19","77","","96.81","96.81","96.81","1 through 10","8.48","139.65","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","147.00","110.25","TRICARE [160005]","HB BWH TRICARE","139.65","95","","20.84","20.84","20.84","1 through 10","8.48","139.65","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.06","42.9","","114.31","114.31","114.32","14","8.48","139.65","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA HMO","102.61","69.8","","96.81","68.35","111.54","88","8.92","120.13","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA PPO","118.19","80.4","","74.93","68.35","111.54","1 through 10","8.92","120.13","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","82.17","55.9","","74.93","74.93","74.93","1 through 10","8.92","120.13","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","147.00","110.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","76.82","52.26","","30.92","30.92","30.92","1 through 10","8.92","120.13","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","120.13","81.72","","62.88","35.65","114.31","1 through 10","8.92","120.13","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","120.13","81.72","","114.31","62.88","114.32","89","8.92","120.13","percent of total billed charges",""
"SUTURE CINCH - LONG 1PK","SUP-ITM-10340598","CDM","C1713","HCPCS","0278","RC","","","","both","","","638.75","479.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","507.81","79.5","","800.18","480.96","1887.97","195","198.01","507.81","percent of total billed charges",""
"SUTURE CINCH - LONG 1PK","SUP-ITM-10340598","CDM","C1713","HCPCS","0278","RC","","","","both","","","638.75","479.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","340.45","53.3","","813.12","216.42","1444.50","81","198.01","507.81","percent of total billed charges",""
"SUTURE CINCH - LONG 1PK","SUP-ITM-10340598","CDM","C1713","HCPCS","0278","RC","","","","both","","","638.75","479.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","198.01","31","","432.60","432.60","432.60","1 through 10","198.01","507.81","percent of total billed charges",""
"SUTURE CINCH - LONG 1PK","SUP-ITM-10340598","CDM","C1713","HCPCS","0278","RC","","","","both","","","638.75","479.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","233.14","36.5","","148.37","54.89","631.39","94","198.01","507.81","percent of total billed charges",""
"SUTURE CINCH - LONG 1PK","SUP-ITM-10340598","CDM","C1713","HCPCS","0278","RC","","","","both","","","638.75","479.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","244.64","38.3","","279.30","91.72","1116.77","266","198.01","507.81","percent of total billed charges",""
"SUTURE CINCH - LONG 1PK","SUP-ITM-10340598","CDM","C1713","HCPCS","0278","RC","","","","both","","","638.75","479.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.02","42.9","","731.00","63.70","731.00","1 through 10","198.01","507.81","percent of total billed charges",""
"SUTURE CINCH - LONG 1PK","SUP-ITM-10340598","CDM","C1713","HCPCS","0278","RC","","","","both","","","638.75","479.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.02","42.9","","384.74","384.74","384.74","1 through 10","198.01","507.81","percent of total billed charges",""
"SUTURE CINCH - LONG 1PK","SUP-ITM-10340598","CDM","C1713","HCPCS","0278","RC","","","","both","","","638.75","479.06","WELLPOINT [1015]","HB AMC WELLPOINT","471.27","73.78","","286.63","119.22","1107.45","105","198.01","507.81","percent of total billed charges",""
"SUTURE CINCH - LONG 1PK","SUP-ITM-10340598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","638.75","479.06","AETNA [1001]","HB AMC AETNA HMO","445.85","69.8","","675.31","184.75","1721.50","286","333.81","521.99","percent of total billed charges",""
"SUTURE CINCH - LONG 1PK","SUP-ITM-10340598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","638.75","479.06","AETNA [1001]","HB AMC AETNA PPO","513.56","80.4","","1261.44","103.12","1514.10","21","333.81","521.99","percent of total billed charges",""
"SUTURE CINCH - LONG 1PK","SUP-ITM-10340598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","638.75","479.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","513.56","80.4","","1365.00","1365.00","1365.00","1 through 10","333.81","521.99","percent of total billed charges",""
"SUTURE CINCH - LONG 1PK","SUP-ITM-10340598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","638.75","479.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","521.99","81.72","","5157.68","5157.68","5157.68","1 through 10","333.81","521.99","percent of total billed charges",""
"SUTURE CINCH - LONG 1PK","SUP-ITM-10340598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","638.75","479.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","521.99","81.72","","431.26","71.26","1459.57","88","333.81","521.99","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.35","6.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6.64","79.5","","800.18","480.96","1887.97","195","2.59","6.64","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.35","6.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4.45","53.3","","813.12","216.42","1444.50","81","2.59","6.64","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.35","6.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2.59","31","","432.60","432.60","432.60","1 through 10","2.59","6.64","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.35","6.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3.05","36.5","","148.37","54.89","631.39","94","2.59","6.64","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.35","6.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3.20","38.3","","279.30","91.72","1116.77","266","2.59","6.64","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.35","6.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3.58","42.9","","731.00","63.70","731.00","1 through 10","2.59","6.64","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.35","6.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3.58","42.9","","384.74","384.74","384.74","1 through 10","2.59","6.64","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","8.35","6.26","WELLPOINT [1015]","HB AMC WELLPOINT","6.16","73.78","","286.63","119.22","1107.45","105","2.59","6.64","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8.35","6.26","AETNA [1001]","HB AMC AETNA HMO","5.83","69.8","","675.31","184.75","1721.50","286","4.36","6.82","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8.35","6.26","AETNA [1001]","HB AMC AETNA PPO","6.71","80.4","","1261.44","103.12","1514.10","21","4.36","6.82","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8.35","6.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6.71","80.4","","1365.00","1365.00","1365.00","1 through 10","4.36","6.82","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8.35","6.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","6.82","81.72","","5157.68","5157.68","5157.68","1 through 10","4.36","6.82","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8.35","6.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6.82","81.72","","431.26","71.26","1459.57","88","4.36","6.82","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.30","79.5","","800.18","480.96","1887.97","195","43.4","111.3","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.62","53.3","","813.12","216.42","1444.50","81","43.4","111.3","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","43.40","31","","432.60","432.60","432.60","1 through 10","43.4","111.3","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.10","36.5","","148.37","54.89","631.39","94","43.4","111.3","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.62","38.3","","279.30","91.72","1116.77","266","43.4","111.3","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.06","42.9","","731.00","63.70","731.00","1 through 10","43.4","111.3","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.06","42.9","","384.74","384.74","384.74","1 through 10","43.4","111.3","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.00","105.00","WELLPOINT [1015]","HB AMC WELLPOINT","103.29","73.78","","286.63","119.22","1107.45","105","43.4","111.3","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA HMO","97.72","69.8","","675.31","184.75","1721.50","286","73.16","114.41","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA PPO","112.56","80.4","","1261.44","103.12","1514.10","21","73.16","114.41","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.56","80.4","","1365.00","1365.00","1365.00","1 through 10","73.16","114.41","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","114.41","81.72","","5157.68","5157.68","5157.68","1 through 10","73.16","114.41","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.41","81.72","","431.26","71.26","1459.57","88","73.16","114.41","percent of total billed charges",""
"Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-51000666","CDM","98015","CPT","0510","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.18","36.5","","202.17","202.17","202.17","1 through 10","164.92","505.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-51000666","CDM","98015","CPT","0510","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.76","38.3","","211.92","211.92","211.92","1 through 10","164.92","505.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-51000666","CDM","98015","CPT","0510","RC","","","","outpatient","","","532.00","399.00","AETNA [1001]","HB AMC AETNA HMO","371.34","69.8","","422.76","366.93","422.76","1 through 10","40.19","438.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-51000666","CDM","98015","CPT","0510","RC","","","","outpatient","","","532.00","399.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","181.41","34.1","","438.56","438.56","438.56","1 through 10","40.19","438.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-51000666","CDM","98015","CPT","0510","RC","","","","outpatient","","","532.00","399.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","266.00","50","","284.01","165.48","284.01","1 through 10","40.19","438.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-98302544","CDM","98015","CPT","0983","RC","","","","both","","","550.00","412.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","437.25","79.5","","438.56","438.56","438.56","1 through 10","170.5","522.5","percent of total billed charges",""
"Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-98302544","CDM","98015","CPT","0983","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","200.75","36.5","","202.17","202.17","202.17","1 through 10","170.5","522.5","percent of total billed charges",""
"Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-98302544","CDM","98015","CPT","0983","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","210.65","38.3","","211.92","211.92","211.92","1 through 10","170.5","522.5","percent of total billed charges",""
"Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-98302544","CDM","98015","CPT","0983","RC","","","","outpatient","","","550.00","412.50","AETNA [1001]","HB AMC AETNA HMO","383.90","69.8","","422.76","366.93","422.76","1 through 10","220","453.75","percent of total billed charges",""
"Synchronous Audio-Only Visit Est High Mdm 40 Min","PX-98302544","CDM","98015","CPT","0983","RC","","","","outpatient","","","550.00","412.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","275.00","50","","284.01","165.48","284.01","1 through 10","220","453.75","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-51000664","CDM","98013","CPT","0510","RC","","","","both","","","333.00","249.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","239.09","71.8","","178.06","178.06","178.06","1 through 10","103.23","316.35","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-51000664","CDM","98013","CPT","0510","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.55","36.5","","92.50","78.62","92.50","21","103.23","316.35","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-51000664","CDM","98013","CPT","0510","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.54","38.3","","96.97","96.97","96.97","43","103.23","316.35","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-51000664","CDM","98013","CPT","0510","RC","","","","both","","","333.00","249.75","WELLPOINT [1015]","HB AMC WELLPOINT","245.69","73.78","","184.64","184.64","184.64","1 through 10","103.23","316.35","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-51000664","CDM","98013","CPT","0510","RC","","","","outpatient","","","333.00","249.75","AETNA [1001]","HB AMC AETNA HMO","232.43","69.8","","167.90","118.54","193.44","12","40.19","274.73","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-51000664","CDM","98013","CPT","0510","RC","","","","outpatient","","","333.00","249.75","AETNA [1001]","HB AMC AETNA PPO","267.73","80.4","","193.44","129.95","193.44","1 through 10","40.19","274.73","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-51000664","CDM","98013","CPT","0510","RC","","","","outpatient","","","333.00","249.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","113.55","34.1","","211.42","211.42","211.42","15","40.19","274.73","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-51000664","CDM","98013","CPT","0510","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","166.50","50","","129.95","124.00","218.51","69","40.19","274.73","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-51000664","CDM","98013","CPT","0510","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","174.83","52.5","","136.40","136.40","229.35","13","40.19","274.73","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-51000664","CDM","98013","CPT","0510","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","183.15","55","","131.19","131.19","131.19","1 through 10","40.19","274.73","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-98302542","CDM","98013","CPT","0983","RC","","","","both","","","252.00","189.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","180.94","71.8","","178.06","178.06","178.06","1 through 10","78.12","239.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-98302542","CDM","98013","CPT","0983","RC","","","","both","","","252.00","189.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","200.34","79.5","","211.42","211.42","211.42","15","78.12","239.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-98302542","CDM","98013","CPT","0983","RC","","","","both","","","252.00","189.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","134.32","53.3","","211.42","211.42","211.42","1 through 10","78.12","239.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-98302542","CDM","98013","CPT","0983","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","91.98","36.5","","92.50","78.62","92.50","21","78.12","239.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-98302542","CDM","98013","CPT","0983","RC","","","","both","","","252.00","189.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","96.52","38.3","","96.97","96.97","96.97","43","78.12","239.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-98302542","CDM","98013","CPT","0983","RC","","","","both","","","252.00","189.00","WELLPOINT [1015]","HB AMC WELLPOINT","185.93","73.78","","184.64","184.64","184.64","1 through 10","78.12","239.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-98302542","CDM","98013","CPT","0983","RC","","","","outpatient","","","252.00","189.00","AETNA [1001]","HB AMC AETNA HMO","175.90","69.8","","167.90","118.54","193.44","12","100.8","207.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-98302542","CDM","98013","CPT","0983","RC","","","","outpatient","","","252.00","189.00","AETNA [1001]","HB AMC AETNA PPO","202.61","80.4","","193.44","129.95","193.44","1 through 10","100.8","207.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-98302542","CDM","98013","CPT","0983","RC","","","","outpatient","","","252.00","189.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","126.00","50","","129.95","124.00","218.51","69","100.8","207.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-98302542","CDM","98013","CPT","0983","RC","","","","outpatient","","","252.00","189.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","132.30","52.5","","136.40","136.40","229.35","13","100.8","207.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-98302542","CDM","98013","CPT","0983","RC","","","","outpatient","","","252.00","189.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","138.60","55","","131.19","131.19","131.19","1 through 10","100.8","207.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-51000665","CDM","98014","CPT","0510","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.06","36.5","","136.89","116.34","136.89","56","157.17","481.65","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-51000665","CDM","98014","CPT","0510","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.18","38.3","","143.50","143.50","143.50","77","157.17","481.65","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-51000665","CDM","98014","CPT","0510","RC","","","","both","","","507.00","380.25","WELLPOINT [1015]","HB AMC WELLPOINT","374.06","73.78","","273.23","273.23","273.23","1 through 10","157.17","481.65","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-51000665","CDM","98014","CPT","0510","RC","","","","outpatient","","","507.00","380.25","AETNA [1001]","HB AMC AETNA HMO","353.89","69.8","","286.26","248.46","286.26","1 through 10","40.19","418.28","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-51000665","CDM","98014","CPT","0510","RC","","","","outpatient","","","507.00","380.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","172.89","34.1","","271.75","271.75","349.83","20","40.19","418.28","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-51000665","CDM","98014","CPT","0510","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","253.50","50","","192.31","192.31","192.31","66","40.19","418.28","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-51000665","CDM","98014","CPT","0510","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","266.18","52.5","","201.85","201.85","201.85","1 through 10","40.19","418.28","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-51000665","CDM","98014","CPT","0510","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","316.88","62.5","","194.14","194.14","194.14","1 through 10","40.19","418.28","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-51000665","CDM","98014","CPT","0510","RC","","","","outpatient","","","507.00","380.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","414.32","81.72","","293.38","293.38","293.38","1 through 10","40.19","418.28","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-98302543","CDM","98014","CPT","0983","RC","","","","both","","","372.00","279.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","295.74","79.5","","271.75","271.75","349.83","20","115.32","353.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-98302543","CDM","98014","CPT","0983","RC","","","","both","","","372.00","279.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","198.28","53.3","","271.75","271.75","271.75","1 through 10","115.32","353.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-98302543","CDM","98014","CPT","0983","RC","","","","both","","","372.00","279.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","135.78","36.5","","136.89","116.34","136.89","56","115.32","353.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-98302543","CDM","98014","CPT","0983","RC","","","","both","","","372.00","279.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","142.48","38.3","","143.50","143.50","143.50","77","115.32","353.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-98302543","CDM","98014","CPT","0983","RC","","","","both","","","372.00","279.00","WELLPOINT [1015]","HB AMC WELLPOINT","274.46","73.78","","273.23","273.23","273.23","1 through 10","115.32","353.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-98302543","CDM","98014","CPT","0983","RC","","","","outpatient","","","372.00","279.00","AETNA [1001]","HB AMC AETNA HMO","259.66","69.8","","286.26","248.46","286.26","1 through 10","148.8","306.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-98302543","CDM","98014","CPT","0983","RC","","","","outpatient","","","372.00","279.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","186.00","50","","192.31","192.31","192.31","66","148.8","306.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-98302543","CDM","98014","CPT","0983","RC","","","","outpatient","","","372.00","279.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","195.30","52.5","","201.85","201.85","201.85","1 through 10","148.8","306.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-98302543","CDM","98014","CPT","0983","RC","","","","outpatient","","","372.00","279.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","232.50","62.5","","194.14","194.14","194.14","1 through 10","148.8","306.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-98302543","CDM","98014","CPT","0983","RC","","","","outpatient","","","372.00","279.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","304.00","81.72","","293.38","293.38","293.38","1 through 10","148.8","306.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-51000663","CDM","98012","CPT","0510","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.38","36.5","","50.73","50.73","50.73","1 through 10","65.72","201.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-51000663","CDM","98012","CPT","0510","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.20","38.3","","53.18","53.18","53.18","1 through 10","65.72","201.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-51000663","CDM","98012","CPT","0510","RC","","","","both","","","212.00","159.00","WELLPOINT [1015]","HB AMC WELLPOINT","156.41","73.78","","101.25","101.25","101.25","1 through 10","65.72","201.4","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-51000663","CDM","98012","CPT","0510","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA HMO","147.98","69.8","","65.01","65.01","65.01","1 through 10","40.19","174.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-51000663","CDM","98012","CPT","0510","RC","","","","outpatient","","","212.00","159.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","106.00","50","","71.26","71.26","71.26","14","40.19","174.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-51000663","CDM","98012","CPT","0510","RC","","","","outpatient","","","212.00","159.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","111.30","52.5","","74.80","74.80","74.80","1 through 10","40.19","174.9","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-98302541","CDM","98012","CPT","0983","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.37","36.5","","50.73","50.73","50.73","1 through 10","42.78","131.1","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-98302541","CDM","98012","CPT","0983","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","52.85","38.3","","53.18","53.18","53.18","1 through 10","42.78","131.1","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-98302541","CDM","98012","CPT","0983","RC","","","","both","","","138.00","103.50","WELLPOINT [1015]","HB AMC WELLPOINT","101.82","73.78","","101.25","101.25","101.25","1 through 10","42.78","131.1","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-98302541","CDM","98012","CPT","0983","RC","","","","outpatient","","","138.00","103.50","AETNA [1001]","HB AMC AETNA HMO","96.32","69.8","","65.01","65.01","65.01","1 through 10","55.2","113.85","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-98302541","CDM","98012","CPT","0983","RC","","","","outpatient","","","138.00","103.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","69.00","50","","71.26","71.26","71.26","14","55.2","113.85","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Sf Mdm 10 Min","PX-98302541","CDM","98012","CPT","0983","RC","","","","outpatient","","","138.00","103.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","72.45","52.5","","74.80","74.80","74.80","1 through 10","55.2","113.85","percent of total billed charges",""
"Synchronous Audio-Only Visit New Mod Mdm 45 Min","PX-51000661","CDM","98010","CPT","0510","RC","","","","both","","","834.00","625.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","304.41","36.5","","188.74","188.74","188.74","1 through 10","258.54","792.3","percent of total billed charges",""
"Synchronous Audio-Only Visit New Mod Mdm 45 Min","PX-51000661","CDM","98010","CPT","0510","RC","","","","outpatient","","","834.00","625.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","437.85","52.5","","278.30","278.30","278.30","1 through 10","40.19","688.05","percent of total billed charges",""
"Synchronous Audio-Only Visit New Mod Mdm 45 Min","PX-98302539","CDM","98010","CPT","0983","RC","","","","both","","","513.00","384.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","187.25","36.5","","188.74","188.74","188.74","1 through 10","159.03","487.35","percent of total billed charges",""
"Synchronous Audio-Only Visit New Mod Mdm 45 Min","PX-98302539","CDM","98010","CPT","0983","RC","","","","outpatient","","","513.00","384.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","269.33","52.5","","278.30","278.30","278.30","1 through 10","205.2","423.23","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-51000656","CDM","98005","CPT","0510","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","121.55","36.5","","100.71","85.59","100.71","14","103.23","316.35","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-51000656","CDM","98005","CPT","0510","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","127.54","38.3","","105.57","105.57","105.57","13","103.23","316.35","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-51000656","CDM","98005","CPT","0510","RC","","","","both","","","333.00","249.75","WELLPOINT [1015]","HB AMC WELLPOINT","245.69","73.78","","201.02","201.02","201.02","1 through 10","103.23","316.35","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-51000656","CDM","98005","CPT","0510","RC","","","","outpatient","","","333.00","249.75","AETNA [1001]","HB AMC AETNA HMO","232.43","69.8","","182.79","182.79","182.79","1 through 10","40.19","274.73","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-51000656","CDM","98005","CPT","0510","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","166.50","50","","141.48","135.00","141.48","29","40.19","274.73","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-51000656","CDM","98005","CPT","0510","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","174.83","52.5","","148.50","135.00","148.50","1 through 10","40.19","274.73","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-51000656","CDM","98005","CPT","0510","RC","","","","outpatient","","","333.00","249.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","183.15","55","","142.83","142.83","142.83","1 through 10","40.19","274.73","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-98302534","CDM","98005","CPT","0983","RC","","","","both","","","274.00","205.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","146.04","53.3","","136.89","136.89","136.89","1 through 10","84.94","260.3","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-98302534","CDM","98005","CPT","0983","RC","","","","both","","","274.00","205.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.01","36.5","","100.71","85.59","100.71","14","84.94","260.3","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-98302534","CDM","98005","CPT","0983","RC","","","","both","","","274.00","205.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","104.94","38.3","","105.57","105.57","105.57","13","84.94","260.3","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-98302534","CDM","98005","CPT","0983","RC","","","","both","","","274.00","205.50","WELLPOINT [1015]","HB AMC WELLPOINT","202.16","73.78","","201.02","201.02","201.02","1 through 10","84.94","260.3","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-98302534","CDM","98005","CPT","0983","RC","","","","outpatient","","","274.00","205.50","AETNA [1001]","HB AMC AETNA HMO","191.25","69.8","","182.79","182.79","182.79","1 through 10","109.6","226.05","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-98302534","CDM","98005","CPT","0983","RC","","","","outpatient","","","274.00","205.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","137.00","50","","141.48","135.00","141.48","29","109.6","226.05","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-98302534","CDM","98005","CPT","0983","RC","","","","outpatient","","","274.00","205.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","143.85","52.5","","148.50","135.00","148.50","1 through 10","109.6","226.05","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-98302534","CDM","98005","CPT","0983","RC","","","","outpatient","","","274.00","205.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","150.70","55","","142.83","142.83","142.83","1 through 10","109.6","226.05","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-51000657","CDM","98006","CPT","0510","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","185.06","36.5","","149.57","127.12","149.57","28","157.17","481.65","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-51000657","CDM","98006","CPT","0510","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","194.18","38.3","","156.79","156.79","156.79","48","157.17","481.65","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-51000657","CDM","98006","CPT","0510","RC","","","","both","","","507.00","380.25","WELLPOINT [1015]","HB AMC WELLPOINT","374.06","73.78","","298.54","298.54","298.54","1 through 10","157.17","481.65","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-51000657","CDM","98006","CPT","0510","RC","","","","outpatient","","","507.00","380.25","AETNA [1001]","HB AMC AETNA HMO","353.89","69.8","","312.78","191.68","312.78","15","40.19","418.28","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-51000657","CDM","98006","CPT","0510","RC","","","","outpatient","","","507.00","380.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","283.41","55.9","","210.12","210.12","210.12","1 through 10","40.19","418.28","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-51000657","CDM","98006","CPT","0510","RC","","","","outpatient","","","507.00","380.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","172.89","34.1","","288.99","288.99","367.07","1 through 10","40.19","418.28","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-51000657","CDM","98006","CPT","0510","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","253.50","50","","210.12","210.12","210.12","63","40.19","418.28","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-51000657","CDM","98006","CPT","0510","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","266.18","52.5","","220.55","220.55","220.55","19","40.19","418.28","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-51000657","CDM","98006","CPT","0510","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","266.18","52.5","","212.13","212.13","212.13","1 through 10","40.19","418.28","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-51000657","CDM","98006","CPT","0510","RC","","","","outpatient","","","507.00","380.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","278.85","55","","212.13","212.13","212.13","1 through 10","40.19","418.28","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-98302535","CDM","98006","CPT","0983","RC","","","","both","","","407.00","305.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","323.57","79.5","","288.99","288.99","367.07","1 through 10","126.17","386.65","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-98302535","CDM","98006","CPT","0983","RC","","","","both","","","407.00","305.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","216.93","53.3","","858.99","858.99","858.99","1 through 10","126.17","386.65","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-98302535","CDM","98006","CPT","0983","RC","","","","both","","","407.00","305.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","148.56","36.5","","149.57","127.12","149.57","28","126.17","386.65","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-98302535","CDM","98006","CPT","0983","RC","","","","both","","","407.00","305.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","155.88","38.3","","156.79","156.79","156.79","48","126.17","386.65","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-98302535","CDM","98006","CPT","0983","RC","","","","both","","","407.00","305.25","WELLPOINT [1015]","HB AMC WELLPOINT","300.28","73.78","","298.54","298.54","298.54","1 through 10","126.17","386.65","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-98302535","CDM","98006","CPT","0983","RC","","","","outpatient","","","407.00","305.25","AETNA [1001]","HB AMC AETNA HMO","284.09","69.8","","312.78","191.68","312.78","15","162.8","335.78","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-98302535","CDM","98006","CPT","0983","RC","","","","outpatient","","","407.00","305.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","227.51","55.9","","210.12","210.12","210.12","1 through 10","162.8","335.78","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-98302535","CDM","98006","CPT","0983","RC","","","","outpatient","","","407.00","305.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","203.50","50","","210.12","210.12","210.12","63","162.8","335.78","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-98302535","CDM","98006","CPT","0983","RC","","","","outpatient","","","407.00","305.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","213.68","52.5","","220.55","220.55","220.55","19","162.8","335.78","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-98302535","CDM","98006","CPT","0983","RC","","","","outpatient","","","407.00","305.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","213.68","52.5","","212.13","212.13","212.13","1 through 10","162.8","335.78","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-98302535","CDM","98006","CPT","0983","RC","","","","outpatient","","","407.00","305.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","223.85","55","","212.13","212.13","212.13","1 through 10","162.8","335.78","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Sf Mdm 10 Min","PX-51000655","CDM","98004","CPT","0510","RC","","","","both","","","212.00","159.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.20","38.3","","56.70","56.70","56.70","1 through 10","65.72","201.4","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Sf Mdm 10 Min","PX-51000655","CDM","98004","CPT","0510","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA HMO","147.98","69.8","","113.10","113.10","113.10","1 through 10","40.19","174.9","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Sf Mdm 10 Min","PX-51000655","CDM","98004","CPT","0510","RC","","","","outpatient","","","212.00","159.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","106.00","50","","75.98","75.98","75.98","1 through 10","40.19","174.9","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Sf Mdm 10 Min","PX-98302533","CDM","98004","CPT","0983","RC","","","","both","","","147.00","110.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.30","38.3","","56.70","56.70","56.70","1 through 10","45.57","139.65","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Sf Mdm 10 Min","PX-98302533","CDM","98004","CPT","0983","RC","","","","outpatient","","","147.00","110.25","AETNA [1001]","HB AMC AETNA HMO","102.61","69.8","","113.10","113.10","113.10","1 through 10","58.8","121.28","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Sf Mdm 10 Min","PX-98302533","CDM","98004","CPT","0983","RC","","","","outpatient","","","147.00","110.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","73.50","50","","75.98","75.98","75.98","1 through 10","58.8","121.28","percent of total billed charges",""
"Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-51000653","CDM","98002","CPT","0510","RC","","","","both","","","834.00","625.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","319.42","38.3","","211.92","211.92","211.92","1 through 10","258.54","792.3","percent of total billed charges",""
"Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-51000653","CDM","98002","CPT","0510","RC","","","","outpatient","","","834.00","625.50","AETNA [1001]","HB AMC AETNA HMO","582.13","69.8","","366.93","366.93","366.93","1 through 10","40.19","688.05","percent of total billed charges",""
"Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-51000653","CDM","98002","CPT","0510","RC","","","","outpatient","","","834.00","625.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","417.00","50","","284.01","284.01","284.01","1 through 10","40.19","688.05","percent of total billed charges",""
"Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-98302531","CDM","98002","CPT","0983","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","210.65","38.3","","211.92","211.92","211.92","1 through 10","170.5","522.5","percent of total billed charges",""
"Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-98302531","CDM","98002","CPT","0983","RC","","","","outpatient","","","550.00","412.50","AETNA [1001]","HB AMC AETNA HMO","383.90","69.8","","366.93","366.93","366.93","1 through 10","220","453.75","percent of total billed charges",""
"Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-98302531","CDM","98002","CPT","0983","RC","","","","outpatient","","","550.00","412.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","275.00","50","","284.01","284.01","284.01","1 through 10","220","453.75","percent of total billed charges",""
"Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-51000658","CDM","98007","CPT","0510","RC","","","","both","","","532.00","399.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","422.94","79.5","","360.48","360.48","360.48","1 through 10","164.92","505.4","percent of total billed charges",""
"Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-51000658","CDM","98007","CPT","0510","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.18","36.5","","171.81","171.81","171.81","1 through 10","164.92","505.4","percent of total billed charges",""
"Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-51000658","CDM","98007","CPT","0510","RC","","","","both","","","532.00","399.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","203.76","38.3","","211.92","211.92","211.92","1 through 10","164.92","505.4","percent of total billed charges",""
"Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-51000658","CDM","98007","CPT","0510","RC","","","","both","","","532.00","399.00","WELLPOINT [1015]","HB AMC WELLPOINT","392.51","73.78","","403.52","403.52","403.52","1 through 10","164.92","505.4","percent of total billed charges",""
"Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-51000658","CDM","98007","CPT","0510","RC","","","","outpatient","","","532.00","399.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","266.00","50","","284.01","284.01","284.01","1 through 10","40.19","438.9","percent of total billed charges",""
"Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-51000658","CDM","98007","CPT","0510","RC","","","","outpatient","","","532.00","399.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","279.30","52.5","","298.10","298.10","298.10","1 through 10","40.19","438.9","percent of total billed charges",""
"Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-98302536","CDM","98007","CPT","0983","RC","","","","both","","","550.00","412.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","437.25","79.5","","360.48","360.48","360.48","1 through 10","170.5","522.5","percent of total billed charges",""
"Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-98302536","CDM","98007","CPT","0983","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","200.75","36.5","","171.81","171.81","171.81","1 through 10","170.5","522.5","percent of total billed charges",""
"Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-98302536","CDM","98007","CPT","0983","RC","","","","both","","","550.00","412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","210.65","38.3","","211.92","211.92","211.92","1 through 10","170.5","522.5","percent of total billed charges",""
"Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-98302536","CDM","98007","CPT","0983","RC","","","","both","","","550.00","412.50","WELLPOINT [1015]","HB AMC WELLPOINT","405.79","73.78","","403.52","403.52","403.52","1 through 10","170.5","522.5","percent of total billed charges",""
"Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-98302536","CDM","98007","CPT","0983","RC","","","","outpatient","","","550.00","412.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","275.00","50","","284.01","284.01","284.01","1 through 10","220","453.75","percent of total billed charges",""
"Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-98302536","CDM","98007","CPT","0983","RC","","","","outpatient","","","550.00","412.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","288.75","52.5","","298.10","298.10","298.10","1 through 10","220","453.75","percent of total billed charges",""
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","47089.38","35317.03","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","8580.58","","Case rate ($8,330.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,951.07, add-ons for qualifying new technology services are included. If operating cost exceeds $55,595.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,141.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,249.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,571.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $701.34. The transfer capital threshold is the transfer adjustment factor * $701.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8465.16","8465.16","8465.16","1 through 10","8164.05","13148.7883","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","47089.38","35317.03","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","10698.64","","Case rate ($10,698.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,951.07, add-ons for qualifying new technology services are included. If operating cost exceeds $55,595.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,141.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,617.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,571.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $701.34. The transfer capital threshold is the transfer adjustment factor * $701.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10398.13","10398.13","10398.13","1 through 10","8164.05","13148.7883","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","47089.38","35317.03","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","10413.33","","Case rate ($8,330.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,951.07, add-ons for qualifying new technology services are included. If operating cost exceeds $55,595.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,141.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,249.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,571.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $701.34. The transfer capital threshold is the transfer adjustment factor * $701.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 125%.","8049.37","8049.37","8049.37","1 through 10","8164.05","13148.7883","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","47089.38","35317.03","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8330.66","","Case rate ($8,330.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,951.07, add-ons for qualifying new technology services are included. If operating cost exceeds $55,595.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,141.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,249.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,571.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $701.34. The transfer capital threshold is the transfer adjustment factor * $701.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8089.94","8089.94","8089.94","1 through 10","8164.05","13148.7883","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","47089.38","35317.03","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","10698.64","","Case rate ($10,698.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,951.07, add-ons for qualifying new technology services are included. If operating cost exceeds $55,595.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,141.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,617.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,571.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $701.34. The transfer capital threshold is the transfer adjustment factor * $701.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8064.95","8064.95","8064.95","1 through 10","8164.05","13148.7883","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","47089.38","35317.03","MEDICARE [2001]","HB BWH MEDICARE","10698.64","","Case rate ($10,698.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,951.07, add-ons for qualifying new technology services are included. If operating cost exceeds $55,595.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,141.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $9,617.47 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,571.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $701.34. The transfer capital threshold is the transfer adjustment factor * $701.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10550.17","728.09","10565.54","60","8164.05","13148.7883","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","47089.38","35317.03","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8164.05","","Case rate ($8,330.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,951.07, add-ons for qualifying new technology services are included. If operating cost exceeds $55,595.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,141.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,249.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,571.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $701.34. The transfer capital threshold is the transfer adjustment factor * $701.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8088.32","8080.53","8181.81","1 through 10","8164.05","13148.7883","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","47089.38","35317.03","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8164.05","","Case rate ($8,330.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,951.07, add-ons for qualifying new technology services are included. If operating cost exceeds $55,595.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,141.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,249.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,571.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $701.34. The transfer capital threshold is the transfer adjustment factor * $701.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8095.75","8023.09","10922.16","1 through 10","8164.05","13148.7883","other","Inpatient DRG"
"Syncope And Collapse,EXTREME","204","DRG","","","","","","","","inpatient","","","140681.19","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","46399.00","","Standard inlier is a Case rate ($46,399.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $43,742, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,585.95) for the length of stay and the standard reimbursement.","153450.66","153450.66","153450.66","1 through 10","3836.07","61573.97","case rate",""
"Syncope And Collapse,MAJOR","204","DRG","","","","","","","","inpatient","","","61830.59","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20442.75","","Standard inlier is a Case rate ($20,442.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,546, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,901.97) for the length of stay and the standard reimbursement.","24008.51","24008.51","24008.51","1 through 10","3836.07","61573.97","case rate",""
"Syncope And Collapse,MAJOR","204","DRG","","","","","","","","inpatient","","","61830.59","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22983.16","","Standard inlier is a Case rate ($22,983.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,546, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,262.27) for the length of stay and the standard reimbursement.","29611.58","29611.58","29611.58","1 through 10","3836.07","61573.97","case rate",""
"Syncope And Collapse,MAJOR","204","DRG","","","","","","","","inpatient","","","61830.59","","MASSHEALTH [3001]","HB BWH MEDICAID","5029.84","","Case rate ($5,561.35). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,991.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7941.57","7941.57","7941.57","1 through 10","3836.07","61573.97","case rate",""
"Syncope And Collapse,MAJOR","204","DRG","","","","","","","","inpatient","","","61830.59","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5029.84","","Case rate ($5,561.35). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,991.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7941.57","7941.57","7941.57","1 through 10","3836.07","61573.97","case rate",""
"Syncope And Collapse,MINOR","204","DRG","","","","","","","","inpatient","","","57410.96","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","19550.77","","Standard inlier is a Case rate ($19,550.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,170, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,775.07) for the length of stay and the standard reimbursement.","17861.31","17861.31","17861.31","1 through 10","3836.07","61573.97","case rate",""
"Syncope And Collapse,MODERATE","204","DRG","","","","","","","","inpatient","","","40868.76","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22983.16","","Standard inlier is a Case rate ($22,983.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,546, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,262.27) for the length of stay and the standard reimbursement.","22983.15","22983.15","22983.15","1 through 10","3836.07","61573.97","case rate",""
"Syncope And Collapse,MODERATE","204","DRG","","","","","","","","inpatient","","","40868.76","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","13948.01","","Fee schedule rate ($13,948.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13948.01","13948.01","13948.01","1 through 10","3836.07","61573.97","case rate",""
"Syncope And Collapse,MODERATE","204","DRG","","","","","","","","inpatient","","","40868.76","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","5029.84","","Case rate ($5,561.35). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,991.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","7941.57","1 through 10","3836.07","61573.97","case rate",""
"SYNDESMOSIS PLATE ORTHOLOC 3DI","SUP-ITM-10132378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.50","837.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","887.62","79.5","","800.18","480.96","1887.97","195","346.12","887.62","percent of total billed charges",""
"SYNDESMOSIS PLATE ORTHOLOC 3DI","SUP-ITM-10132378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.50","837.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","595.09","53.3","","813.12","216.42","1444.50","81","346.12","887.62","percent of total billed charges",""
"SYNDESMOSIS PLATE ORTHOLOC 3DI","SUP-ITM-10132378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.50","837.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","346.12","31","","432.60","432.60","432.60","1 through 10","346.12","887.62","percent of total billed charges",""
"SYNDESMOSIS PLATE ORTHOLOC 3DI","SUP-ITM-10132378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.50","837.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","407.52","36.5","","148.37","54.89","631.39","94","346.12","887.62","percent of total billed charges",""
"SYNDESMOSIS PLATE ORTHOLOC 3DI","SUP-ITM-10132378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.50","837.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","427.62","38.3","","279.30","91.72","1116.77","266","346.12","887.62","percent of total billed charges",""
"SYNDESMOSIS PLATE ORTHOLOC 3DI","SUP-ITM-10132378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.50","837.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","478.98","42.9","","731.00","63.70","731.00","1 through 10","346.12","887.62","percent of total billed charges",""
"SYNDESMOSIS PLATE ORTHOLOC 3DI","SUP-ITM-10132378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.50","837.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","478.98","42.9","","384.74","384.74","384.74","1 through 10","346.12","887.62","percent of total billed charges",""
"SYNDESMOSIS PLATE ORTHOLOC 3DI","SUP-ITM-10132378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1116.50","837.37","WELLPOINT [1015]","HB AMC WELLPOINT","823.75","73.78","","286.63","119.22","1107.45","105","346.12","887.62","percent of total billed charges",""
"SYNDESMOSIS PLATE ORTHOLOC 3DI","SUP-ITM-10132378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.50","837.37","AETNA [1001]","HB AMC AETNA HMO","779.32","69.8","","675.31","184.75","1721.50","286","583.48","912.4","percent of total billed charges",""
"SYNDESMOSIS PLATE ORTHOLOC 3DI","SUP-ITM-10132378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.50","837.37","AETNA [1001]","HB AMC AETNA PPO","897.67","80.4","","1261.44","103.12","1514.10","21","583.48","912.4","percent of total billed charges",""
"SYNDESMOSIS PLATE ORTHOLOC 3DI","SUP-ITM-10132378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.50","837.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","897.67","80.4","","1365.00","1365.00","1365.00","1 through 10","583.48","912.4","percent of total billed charges",""
"SYNDESMOSIS PLATE ORTHOLOC 3DI","SUP-ITM-10132378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.50","837.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","912.40","81.72","","5157.68","5157.68","5157.68","1 through 10","583.48","912.4","percent of total billed charges",""
"SYNDESMOSIS PLATE ORTHOLOC 3DI","SUP-ITM-10132378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1116.50","837.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","912.40","81.72","","431.26","71.26","1459.57","88","583.48","912.4","percent of total billed charges",""
"Syndromic Microphthalmia via the Otx2 Gene","PX-31000803","CDM","81479","CPT","0310","RC","","","","both","","","816.00","612.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","648.72","79.5","","0.65","0.65","0.65","1 through 10","252.96","775.2","percent of total billed charges",""
"Syndromic Microphthalmia via the Otx2 Gene","PX-31000803","CDM","81479","CPT","0310","RC","","","","both","","","816.00","612.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","434.93","53.3","","0.79","0.79","0.79","1 through 10","252.96","775.2","percent of total billed charges",""
"Syndromic Microphthalmia via the Otx2 Gene","PX-31000803","CDM","81479","CPT","0310","RC","","","","outpatient","","","816.00","612.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","408.00","50","","1.00","1.00","1.00","1 through 10","156.55","673.2","percent of total billed charges",""
"Syndromic Microphthalmia via the Otx2 Gene","PX-31000803","CDM","81479","CPT","0310","RC","","","","outpatient","","","816.00","612.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","428.40","52.5","","1.00","0.53","1.00","1 through 10","156.55","673.2","percent of total billed charges",""
"Syphilis Vdrl/Rpr Ql","PX-30000877","CDM","86592","CPT","0302","RC","","","","both","","","75.00","56.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39.98","53.3","","57.45","38.54","57.45","1 through 10","4.18","71.25","percent of total billed charges",""
"Syphilis Vdrl/Rpr Ql","PX-30000877","CDM","86592","CPT","0302","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.38","36.5","","23.14","23.14","23.14","1 through 10","4.18","71.25","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","both","","","78.00","58.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","56.00","71.8","","54.57","54.57","54.57","1 through 10","4.31","74.1","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","both","","","78.00","58.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","54.60","70","","54.72","54.72","54.72","1 through 10","4.31","74.1","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","both","","","78.00","58.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","62.01","79.5","","59.81","40.13","59.81","1 through 10","4.31","74.1","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","both","","","78.00","58.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","41.57","53.3","","59.81","59.81","59.81","1 through 10","4.31","74.1","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28.47","36.5","","28.35","24.09","28.35","1 through 10","4.31","74.1","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.87","38.3","","29.72","29.72","89.16","30","4.31","74.1","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","outpatient","","","78.00","58.50","AETNA [1001]","HB AMC AETNA HMO","54.44","69.8","","51.45","51.45","59.28","1 through 10","4.53","63.74","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","outpatient","","","78.00","58.50","AETNA [1001]","HB AMC AETNA PPO","62.71","80.4","","39.82","39.82","39.82","1 through 10","4.53","63.74","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","outpatient","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","63.74","81.72","","60.76","60.76","60.76","1 through 10","4.53","63.74","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","outpatient","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","63.74","81.72","","60.75","33.42","60.75","1 through 10","4.53","63.74","percent of total billed charges",""
"SYSTEM ARTHROPLASTY SZ 1 PLUS 4MM WRIST ARTICULATING ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE","SUP-ITM-10139575","CDM","C1776","HCPCS","0278","RC","","","","both","","","4515.35","3386.51","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2359.72","52.26","","1113.10","1113.10","1113.10","1 through 10","1399.76","3589.7","percent of total billed charges",""
"SYSTEM ARTHROPLASTY SZ 1 PLUS 4MM WRIST ARTICULATING ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE","SUP-ITM-10139575","CDM","C1776","HCPCS","0278","RC","","","","both","","","4515.35","3386.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3589.70","79.5","","1293.60","1148.53","1603.80","1 through 10","1399.76","3589.7","percent of total billed charges",""
"SYSTEM ARTHROPLASTY SZ 1 PLUS 4MM WRIST ARTICULATING ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE","SUP-ITM-10139575","CDM","C1776","HCPCS","0278","RC","","","","both","","","4515.35","3386.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1648.10","36.5","","1023.42","771.29","2068.67","33","1399.76","3589.7","percent of total billed charges",""
"SYSTEM ARTHROPLASTY SZ 1 PLUS 4MM WRIST ARTICULATING ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE","SUP-ITM-10139575","CDM","C1776","HCPCS","0278","RC","","","","both","","","4515.35","3386.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1729.38","38.3","","850.52","759.78","1211.25","66","1399.76","3589.7","percent of total billed charges",""
"SYSTEM ARTHROPLASTY SZ 1 PLUS 4MM WRIST ARTICULATING ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE","SUP-ITM-10139575","CDM","C1776","HCPCS","0278","RC","","","","both","","","4515.35","3386.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1937.09","42.9","","2548.09","2548.09","2548.09","1 through 10","1399.76","3589.7","percent of total billed charges",""
"SYSTEM ARTHROPLASTY SZ 1 PLUS 4MM WRIST ARTICULATING ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE","SUP-ITM-10139575","CDM","C1776","HCPCS","0278","RC","","","","both","","","4515.35","3386.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1937.09","42.9","","956.46","956.46","956.46","1 through 10","1399.76","3589.7","percent of total billed charges",""
"SYSTEM ARTHROPLASTY SZ 1 PLUS 4MM WRIST ARTICULATING ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE","SUP-ITM-10139575","CDM","C1776","HCPCS","0278","RC","","","","both","","","4515.35","3386.51","WELLPOINT [1015]","HB AMC WELLPOINT","3331.43","73.78","","2344.73","1619.47","2530.35","16","1399.76","3589.7","percent of total billed charges",""
"SYSTEM ARTHROPLASTY SZ 1 PLUS 4MM WRIST ARTICULATING ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE","SUP-ITM-10139575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4515.35","3386.51","AETNA [1001]","HB AMC AETNA HMO","3151.71","69.8","","1523.63","988.41","4330.26","39","2359.72","3689.94","percent of total billed charges",""
"SYSTEM ARTHROPLASTY SZ 1 PLUS 4MM WRIST ARTICULATING ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE","SUP-ITM-10139575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4515.35","3386.51","AETNA [1001]","HB AMC AETNA PPO","3630.34","80.4","","1670.25","1670.25","1670.25","1 through 10","2359.72","3689.94","percent of total billed charges",""
"SYSTEM ARTHROPLASTY SZ 1 PLUS 4MM WRIST ARTICULATING ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE","SUP-ITM-10139575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4515.35","3386.51","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2359.72","52.26","","1113.10","1113.10","1113.10","1 through 10","2359.72","3689.94","percent of total billed charges",""
"SYSTEM ARTHROPLASTY SZ 1 PLUS 4MM WRIST ARTICULATING ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE","SUP-ITM-10139575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4515.35","3386.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3689.94","81.72","","1738.90","1484.65","2716.94","38","2359.72","3689.94","percent of total billed charges",""
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","8737.50","6553.12","MEDICARE [2001]","HB BWH MEDICARE","","38.40","38.4% of billed.","1198.19","1154.50","8587.60","1 through 10","2708.63","6946.31","other","OPPS APC"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","8737.50","6553.12","MOLINA [1014]","HB BWH MOLINA","","38.40","38.4% of billed. Final payment is multiplied by 98%.","12297.51","2290.53","12297.51","1 through 10","2708.63","6946.31","other","OPPS APC"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","8737.50","6553.12","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","","38.40","38.4% of billed. Final payment is multiplied by 98%.","1136.03","1136.03","1136.03","1 through 10","2708.63","6946.31","other","OPPS APC"
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","both","","","8495.00","6371.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6753.53","79.5","","1309.77","674.56","6049.93","26","2633.45","6753.53","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","both","","","8495.00","6371.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4527.84","53.3","","1901.83","1901.83","2962.25","1 through 10","2633.45","6753.53","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","both","","","8495.00","6371.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3100.68","36.5","","1620.31","1620.31","19908.88","1 through 10","2633.45","6753.53","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","both","","","8495.00","6371.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3253.59","38.3","","352.91","352.91","2046.30","1 through 10","2633.45","6753.53","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","both","","","8495.00","6371.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3644.36","42.9","","9668.75","9668.75","9668.75","1 through 10","2633.45","6753.53","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","both","","","8495.00","6371.25","WELLPOINT [1015]","HB AMC WELLPOINT","6267.61","73.78","","699.88","384.10","3443.31","33","2633.45","6753.53","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","8495.00","6371.25","AETNA [1001]","HB AMC AETNA HMO","5929.51","69.8","","1421.24","264.50","4933.46","29","4439.49","6942.11","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","8495.00","6371.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6829.98","80.4","","1022.97","1022.97","3607.50","1 through 10","4439.49","6942.11","percent of total billed charges",""
"SYSTEM CDS W KYPHOPAK 10/2 EXPRESS II OI","SUP-ITM-10209318","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","8495.00","6371.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6942.11","81.72","","3010.54","693.88","5019.88","35","4439.49","6942.11","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","5247.90","3935.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4172.08","79.5","","800.18","480.96","1887.97","195","1626.85","4172.08","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","5247.90","3935.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2797.13","53.3","","813.12","216.42","1444.50","81","1626.85","4172.08","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","5247.90","3935.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1626.85","31","","432.60","432.60","432.60","1 through 10","1626.85","4172.08","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","5247.90","3935.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1915.48","36.5","","148.37","54.89","631.39","94","1626.85","4172.08","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","5247.90","3935.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2009.95","38.3","","279.30","91.72","1116.77","266","1626.85","4172.08","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","5247.90","3935.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2251.35","42.9","","731.00","63.70","731.00","1 through 10","1626.85","4172.08","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","5247.90","3935.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2251.35","42.9","","384.74","384.74","384.74","1 through 10","1626.85","4172.08","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","both","","","5247.90","3935.92","WELLPOINT [1015]","HB AMC WELLPOINT","3871.90","73.78","","286.63","119.22","1107.45","105","1626.85","4172.08","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5247.90","3935.92","AETNA [1001]","HB AMC AETNA HMO","3663.03","69.8","","675.31","184.75","1721.50","286","2742.55","4288.58","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5247.90","3935.92","AETNA [1001]","HB AMC AETNA PPO","4219.31","80.4","","1261.44","103.12","1514.10","21","2742.55","4288.58","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5247.90","3935.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4219.31","80.4","","1365.00","1365.00","1365.00","1 through 10","2742.55","4288.58","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5247.90","3935.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4288.58","81.72","","5157.68","5157.68","5157.68","1 through 10","2742.55","4288.58","percent of total billed charges",""
"SYSTEM CEMENT TEKNIMED HIGHV SPINE","SUP-ITM-10249755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5247.90","3935.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4288.58","81.72","","431.26","71.26","1459.57","88","2742.55","4288.58","percent of total billed charges",""
"SYSTEM CLOSURE 5FR VASCADE EXTRAVASCULAR FEMORAL ACCESS BIOABSORBABLE SYSTEM BX/5EA","SUP-ITM-10303381","CDM","C1760","HCPCS","0278","RC","","","","both","","","700.00","525.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","365.82","52.26","","487.31","487.31","487.31","1 through 10","217","556.5","percent of total billed charges",""
"SYSTEM CLOSURE 5FR VASCADE EXTRAVASCULAR FEMORAL ACCESS BIOABSORBABLE SYSTEM BX/5EA","SUP-ITM-10303381","CDM","C1760","HCPCS","0278","RC","","","","both","","","700.00","525.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","502.60","71.8","","612.50","612.50","612.50","1 through 10","217","556.5","percent of total billed charges",""
"SYSTEM CLOSURE 5FR VASCADE EXTRAVASCULAR FEMORAL ACCESS BIOABSORBABLE SYSTEM BX/5EA","SUP-ITM-10303381","CDM","C1760","HCPCS","0278","RC","","","","both","","","700.00","525.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","490.00","70","","612.50","612.50","612.50","1 through 10","217","556.5","percent of total billed charges",""
"SYSTEM CLOSURE 5FR VASCADE EXTRAVASCULAR FEMORAL ACCESS BIOABSORBABLE SYSTEM BX/5EA","SUP-ITM-10303381","CDM","C1760","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","556.50","79.5","","742.96","323.40","1446.12","32","217","556.5","percent of total billed charges",""
"SYSTEM CLOSURE 5FR VASCADE EXTRAVASCULAR FEMORAL ACCESS BIOABSORBABLE SYSTEM BX/5EA","SUP-ITM-10303381","CDM","C1760","HCPCS","0278","RC","","","","both","","","700.00","525.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","373.10","53.3","","323.40","323.40","550.90","13","217","556.5","percent of total billed charges",""
"SYSTEM CLOSURE 5FR VASCADE EXTRAVASCULAR FEMORAL ACCESS BIOABSORBABLE SYSTEM BX/5EA","SUP-ITM-10303381","CDM","C1760","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","255.50","36.5","","285.08","194.16","582.48","27","217","556.5","percent of total billed charges",""
"SYSTEM CLOSURE 5FR VASCADE EXTRAVASCULAR FEMORAL ACCESS BIOABSORBABLE SYSTEM BX/5EA","SUP-ITM-10303381","CDM","C1760","HCPCS","0278","RC","","","","both","","","700.00","525.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","268.10","38.3","","239.49","233.98","600.08","52","217","556.5","percent of total billed charges",""
"SYSTEM CLOSURE 5FR VASCADE EXTRAVASCULAR FEMORAL ACCESS BIOABSORBABLE SYSTEM BX/5EA","SUP-ITM-10303381","CDM","C1760","HCPCS","0278","RC","","","","both","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.30","42.9","","278.69","278.69","278.69","1 through 10","217","556.5","percent of total billed charges",""
"SYSTEM CLOSURE 5FR VASCADE EXTRAVASCULAR FEMORAL ACCESS BIOABSORBABLE SYSTEM BX/5EA","SUP-ITM-10303381","CDM","C1760","HCPCS","0278","RC","","","","both","","","700.00","525.00","WELLPOINT [1015]","HB AMC WELLPOINT","516.46","73.78","","456.01","456.01","456.01","33","217","556.5","percent of total billed charges",""
"SYSTEM CLOSURE 5FR VASCADE EXTRAVASCULAR FEMORAL ACCESS BIOABSORBABLE SYSTEM BX/5EA","SUP-ITM-10303381","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","AETNA [1001]","HB AMC AETNA HMO","488.60","69.8","","290.33","290.33","1575.00","1 through 10","365.82","572.04","percent of total billed charges",""
"SYSTEM CLOSURE 5FR VASCADE EXTRAVASCULAR FEMORAL ACCESS BIOABSORBABLE SYSTEM BX/5EA","SUP-ITM-10303381","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","365.82","52.26","","487.31","487.31","487.31","1 through 10","365.82","572.04","percent of total billed charges",""
"SYSTEM CLOSURE 5FR VASCADE EXTRAVASCULAR FEMORAL ACCESS BIOABSORBABLE SYSTEM BX/5EA","SUP-ITM-10303381","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","572.04","81.72","","489.63","489.63","489.63","1 through 10","365.82","572.04","percent of total billed charges",""
"SYSTEM CLOSURE 5FR VASCADE EXTRAVASCULAR FEMORAL ACCESS BIOABSORBABLE SYSTEM BX/5EA","SUP-ITM-10303381","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","700.00","525.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","572.04","81.72","","489.64","489.63","1888.58","19","365.82","572.04","percent of total billed charges",""
"SYSTEM CLOSURE 6-12FR VASCULAR VASCADE MVP VENOUS BX/10EA","SUP-ITM-10240464","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","411.55","52.26","","487.31","487.31","487.31","1 through 10","244.13","626.06","percent of total billed charges",""
"SYSTEM CLOSURE 6-12FR VASCULAR VASCADE MVP VENOUS BX/10EA","SUP-ITM-10240464","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","565.43","71.8","","612.50","612.50","612.50","1 through 10","244.13","626.06","percent of total billed charges",""
"SYSTEM CLOSURE 6-12FR VASCULAR VASCADE MVP VENOUS BX/10EA","SUP-ITM-10240464","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","551.25","70","","612.50","612.50","612.50","1 through 10","244.13","626.06","percent of total billed charges",""
"SYSTEM CLOSURE 6-12FR VASCULAR VASCADE MVP VENOUS BX/10EA","SUP-ITM-10240464","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","626.06","79.5","","742.96","323.40","1446.12","32","244.13","626.06","percent of total billed charges",""
"SYSTEM CLOSURE 6-12FR VASCULAR VASCADE MVP VENOUS BX/10EA","SUP-ITM-10240464","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","419.74","53.3","","323.40","323.40","550.90","13","244.13","626.06","percent of total billed charges",""
"SYSTEM CLOSURE 6-12FR VASCULAR VASCADE MVP VENOUS BX/10EA","SUP-ITM-10240464","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","287.44","36.5","","285.08","194.16","582.48","27","244.13","626.06","percent of total billed charges",""
"SYSTEM CLOSURE 6-12FR VASCULAR VASCADE MVP VENOUS BX/10EA","SUP-ITM-10240464","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","301.61","38.3","","239.49","233.98","600.08","52","244.13","626.06","percent of total billed charges",""
"SYSTEM CLOSURE 6-12FR VASCULAR VASCADE MVP VENOUS BX/10EA","SUP-ITM-10240464","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.84","42.9","","278.69","278.69","278.69","1 through 10","244.13","626.06","percent of total billed charges",""
"SYSTEM CLOSURE 6-12FR VASCULAR VASCADE MVP VENOUS BX/10EA","SUP-ITM-10240464","CDM","C1760","HCPCS","0278","RC","","","","both","","","787.50","590.62","WELLPOINT [1015]","HB AMC WELLPOINT","581.02","73.78","","456.01","456.01","456.01","33","244.13","626.06","percent of total billed charges",""
"SYSTEM CLOSURE 6-12FR VASCULAR VASCADE MVP VENOUS BX/10EA","SUP-ITM-10240464","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","AETNA [1001]","HB AMC AETNA HMO","549.68","69.8","","290.33","290.33","1575.00","1 through 10","411.55","643.55","percent of total billed charges",""
"SYSTEM CLOSURE 6-12FR VASCULAR VASCADE MVP VENOUS BX/10EA","SUP-ITM-10240464","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","411.55","52.26","","487.31","487.31","487.31","1 through 10","411.55","643.55","percent of total billed charges",""
"SYSTEM CLOSURE 6-12FR VASCULAR VASCADE MVP VENOUS BX/10EA","SUP-ITM-10240464","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","643.55","81.72","","489.63","489.63","489.63","1 through 10","411.55","643.55","percent of total billed charges",""
"SYSTEM CLOSURE 6-12FR VASCULAR VASCADE MVP VENOUS BX/10EA","SUP-ITM-10240464","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","643.55","81.72","","489.64","489.63","1888.58","19","411.55","643.55","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","320.09","52.26","","487.31","487.31","487.31","1 through 10","189.88","486.94","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","439.78","71.8","","612.50","612.50","612.50","1 through 10","189.88","486.94","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","428.75","70","","612.50","612.50","612.50","1 through 10","189.88","486.94","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","486.94","79.5","","742.96","323.40","1446.12","32","189.88","486.94","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","326.46","53.3","","323.40","323.40","550.90","13","189.88","486.94","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.56","36.5","","285.08","194.16","582.48","27","189.88","486.94","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.59","38.3","","239.49","233.98","600.08","52","189.88","486.94","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","262.76","42.9","","278.69","278.69","278.69","1 through 10","189.88","486.94","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","WELLPOINT [1015]","HB AMC WELLPOINT","451.90","73.78","","456.01","456.01","456.01","33","189.88","486.94","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","AETNA [1001]","HB AMC AETNA HMO","427.53","69.8","","290.33","290.33","1575.00","1 through 10","320.09","500.54","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","320.09","52.26","","487.31","487.31","487.31","1 through 10","320.09","500.54","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","500.54","81.72","","489.63","489.63","489.63","1 through 10","320.09","500.54","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","500.54","81.72","","489.64","489.63","1888.58","19","320.09","500.54","percent of total billed charges",""
"SYSTEM DELIVERY 23/26/29MM EVOLUTTM PRO FOR VALVE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266584","CDM","C1725","HCPCS","0272","RC","","","","both","","","5275.00","3956.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","3787.45","71.8","","175.91","175.91","175.91","1 through 10","1635.25","4193.63","percent of total billed charges",""
"SYSTEM DELIVERY 23/26/29MM EVOLUTTM PRO FOR VALVE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266584","CDM","C1725","HCPCS","0272","RC","","","","both","","","5275.00","3956.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3428.75","65","","147.88","147.88","1296.75","1 through 10","1635.25","4193.63","percent of total billed charges",""
"SYSTEM DELIVERY 23/26/29MM EVOLUTTM PRO FOR VALVE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266584","CDM","C1725","HCPCS","0272","RC","","","","both","","","5275.00","3956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1925.38","36.5","","181.40","177.87","181.40","21","1635.25","4193.63","percent of total billed charges",""
"SYSTEM DELIVERY 23/26/29MM EVOLUTTM PRO FOR VALVE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266584","CDM","C1725","HCPCS","0272","RC","","","","both","","","5275.00","3956.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2020.33","38.3","","170.15","88.95","424.24","16","1635.25","4193.63","percent of total billed charges",""
"SYSTEM DELIVERY 23/26/29MM EVOLUTTM PRO FOR VALVE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266584","CDM","C1725","HCPCS","0272","RC","","","","both","","","5275.00","3956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2262.98","42.9","","699.48","699.48","699.48","12","1635.25","4193.63","percent of total billed charges",""
"SYSTEM DELIVERY 23/26/29MM EVOLUTTM PRO FOR VALVE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266584","CDM","C1725","HCPCS","0272","RC","","","","both","","","5275.00","3956.25","WELLPOINT [1015]","HB AMC WELLPOINT","3891.90","73.78","","576.52","182.40","651.44","14","1635.25","4193.63","percent of total billed charges",""
"SYSTEM DELIVERY 23/26/29MM EVOLUTTM PRO FOR VALVE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266584","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","5275.00","3956.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4310.73","81.72","","181.86","100.03","402.41","21","2756.72","4310.73","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","both","","","11330.00","8497.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","7364.50","65","","6652.80","6652.80","6652.80","1 through 10","3512.3","9007.35","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","both","","","11330.00","8497.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9007.35","79.5","","2612.61","795.38","2612.61","1 through 10","3512.3","9007.35","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","both","","","11330.00","8497.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6038.89","53.3","","1101.80","1101.80","1101.80","1 through 10","3512.3","9007.35","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","both","","","11330.00","8497.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","7364.50","65","","1820.00","910.00","1820.00","1 through 10","3512.3","9007.35","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","both","","","11330.00","8497.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4135.45","36.5","","1257.80","693.44","2424.50","1 through 10","3512.3","9007.35","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","both","","","11330.00","8497.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4339.39","38.3","","1950.11","547.40","2346.00","1 through 10","3512.3","9007.35","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","both","","","11330.00","8497.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4860.57","42.9","","5096.18","5096.18","5096.18","1 through 10","3512.3","9007.35","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","both","","","11330.00","8497.50","WELLPOINT [1015]","HB AMC WELLPOINT","8359.27","73.78","","1172.59","1172.59","4829.94","1 through 10","3512.3","9007.35","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11330.00","8497.50","AETNA [1001]","HB AMC AETNA HMO","7908.34","69.8","","1806.84","947.80","5091.72","1 through 10","5921.06","9258.88","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11330.00","8497.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9258.88","81.72","","1259.05","615.58","4586.56","1 through 10","5921.06","9258.88","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 24MM 15MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5375","SUP-ITM-10135915","CDM","C1874","HCPCS","0278","RC","","","","both","","","9785.00","7338.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","6360.25","65","","6652.80","6652.80","6652.80","1 through 10","3033.35","7779.08","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 24MM 15MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5375","SUP-ITM-10135915","CDM","C1874","HCPCS","0278","RC","","","","both","","","9785.00","7338.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7779.08","79.5","","2612.61","795.38","2612.61","1 through 10","3033.35","7779.08","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 24MM 15MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5375","SUP-ITM-10135915","CDM","C1874","HCPCS","0278","RC","","","","both","","","9785.00","7338.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5215.41","53.3","","1101.80","1101.80","1101.80","1 through 10","3033.35","7779.08","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 24MM 15MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5375","SUP-ITM-10135915","CDM","C1874","HCPCS","0278","RC","","","","both","","","9785.00","7338.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","6360.25","65","","1820.00","910.00","1820.00","1 through 10","3033.35","7779.08","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 24MM 15MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5375","SUP-ITM-10135915","CDM","C1874","HCPCS","0278","RC","","","","both","","","9785.00","7338.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3571.53","36.5","","1257.80","693.44","2424.50","1 through 10","3033.35","7779.08","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 24MM 15MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5375","SUP-ITM-10135915","CDM","C1874","HCPCS","0278","RC","","","","both","","","9785.00","7338.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3747.66","38.3","","1950.11","547.40","2346.00","1 through 10","3033.35","7779.08","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 24MM 15MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5375","SUP-ITM-10135915","CDM","C1874","HCPCS","0278","RC","","","","both","","","9785.00","7338.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4197.77","42.9","","5096.18","5096.18","5096.18","1 through 10","3033.35","7779.08","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 24MM 15MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5375","SUP-ITM-10135915","CDM","C1874","HCPCS","0278","RC","","","","both","","","9785.00","7338.75","WELLPOINT [1015]","HB AMC WELLPOINT","7219.37","73.78","","1172.59","1172.59","4829.94","1 through 10","3033.35","7779.08","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 24MM 15MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5375","SUP-ITM-10135915","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9785.00","7338.75","AETNA [1001]","HB AMC AETNA HMO","6829.93","69.8","","1806.84","947.80","5091.72","1 through 10","5113.64","7996.3","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 24MM 15MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5375","SUP-ITM-10135915","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","9785.00","7338.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7996.30","81.72","","1259.05","615.58","4586.56","1 through 10","5113.64","7996.3","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","8360.38","65","","6652.80","6652.80","6652.80","1 through 10","3987.26","10225.39","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10225.39","79.5","","2612.61","795.38","2612.61","1 through 10","3987.26","10225.39","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6855.52","53.3","","1101.80","1101.80","1101.80","1 through 10","3987.26","10225.39","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","8360.38","65","","1820.00","910.00","1820.00","1 through 10","3987.26","10225.39","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4694.68","36.5","","1257.80","693.44","2424.50","1 through 10","3987.26","10225.39","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4926.20","38.3","","1950.11","547.40","2346.00","1 through 10","3987.26","10225.39","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5517.85","42.9","","5096.18","5096.18","5096.18","1 through 10","3987.26","10225.39","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","both","","","12862.13","9646.60","WELLPOINT [1015]","HB AMC WELLPOINT","9489.68","73.78","","1172.59","1172.59","4829.94","1 through 10","3987.26","10225.39","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12862.13","9646.60","AETNA [1001]","HB AMC AETNA HMO","8977.77","69.8","","1806.84","947.80","5091.72","1 through 10","6721.75","10510.93","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12862.13","9646.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10510.93","81.72","","1259.05","615.58","4586.56","1 through 10","6721.75","10510.93","percent of total billed charges",""
"SYSTEM DELIVERY BEACON 22G EUS NEEDLE FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND","SUP-ITM-10165181","CDM","A4648","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1474.73","79.5","","454.50","151.50","454.50","21","575.05","1530.38","percent of total billed charges",""
"SYSTEM DELIVERY BEACON 22G EUS NEEDLE FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND","SUP-ITM-10165181","CDM","A4648","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","988.72","53.3","","304.92","207.96","485.88","1 through 10","575.05","1530.38","percent of total billed charges",""
"SYSTEM DELIVERY BEACON 22G EUS NEEDLE FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND","SUP-ITM-10165181","CDM","A4648","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","677.08","36.5","","183.06","183.06","183.06","1 through 10","575.05","1530.38","percent of total billed charges",""
"SYSTEM DELIVERY BEACON 22G EUS NEEDLE FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND","SUP-ITM-10165181","CDM","A4648","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","710.47","38.3","","225.81","149.00","234.60","19","575.05","1530.38","percent of total billed charges",""
"SYSTEM DELIVERY BEACON 22G EUS NEEDLE FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND","SUP-ITM-10165181","CDM","A4648","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","795.80","42.9","","153.88","90.49","192.50","1 through 10","575.05","1530.38","percent of total billed charges",""
"SYSTEM DELIVERY BEACON 22G EUS NEEDLE FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND","SUP-ITM-10165181","CDM","A4648","HCPCS","0278","RC","","","","both","","","1855.00","1391.25","WELLPOINT [1015]","HB AMC WELLPOINT","1368.62","73.78","","335.82","153.22","335.82","1 through 10","575.05","1530.38","percent of total billed charges",""
"SYSTEM DELIVERY BEACON 22G EUS NEEDLE FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND","SUP-ITM-10165181","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1855.00","1391.25","AETNA [1001]","HB AMC AETNA HMO","1294.79","69.8","","98.37","92.02","150.15","11","927.5","1530.38","percent of total billed charges",""
"SYSTEM DELIVERY BEACON 22G EUS NEEDLE FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND","SUP-ITM-10165181","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1855.00","1391.25","AETNA [1001]","HB AMC AETNA PPO","1491.42","80.4","","333.06","160.52","333.06","1 through 10","927.5","1530.38","percent of total billed charges",""
"SYSTEM DELIVERY BEACON 22G EUS NEEDLE FINE FNF PRE-LOADED FIDUCIAL ENDOSCOPIC ULTRASOUND","SUP-ITM-10165181","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1855.00","1391.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1515.91","81.72","","153.88","84.64","170.39","1 through 10","927.5","1530.38","percent of total billed charges",""
"SYSTEM DELIVERY ENDOVASCULAR CAP AFX2 INCLUDES 1 AFX2 BIF 1 AFX EXTENSION LIMB","SUP-ITM-10213263","CDM","C1874","HCPCS","0278","RC","","","","both","","","37337.50","28003.12","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","24269.38","65","","6652.80","6652.80","6652.80","1 through 10","11574.63","29683.31","percent of total billed charges",""
"SYSTEM DELIVERY ENDOVASCULAR CAP AFX2 INCLUDES 1 AFX2 BIF 1 AFX EXTENSION LIMB","SUP-ITM-10213263","CDM","C1874","HCPCS","0278","RC","","","","both","","","37337.50","28003.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","29683.31","79.5","","2612.61","795.38","2612.61","1 through 10","11574.63","29683.31","percent of total billed charges",""
"SYSTEM DELIVERY ENDOVASCULAR CAP AFX2 INCLUDES 1 AFX2 BIF 1 AFX EXTENSION LIMB","SUP-ITM-10213263","CDM","C1874","HCPCS","0278","RC","","","","both","","","37337.50","28003.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19900.89","53.3","","1101.80","1101.80","1101.80","1 through 10","11574.63","29683.31","percent of total billed charges",""
"SYSTEM DELIVERY ENDOVASCULAR CAP AFX2 INCLUDES 1 AFX2 BIF 1 AFX EXTENSION LIMB","SUP-ITM-10213263","CDM","C1874","HCPCS","0278","RC","","","","both","","","37337.50","28003.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","24269.38","65","","1820.00","910.00","1820.00","1 through 10","11574.63","29683.31","percent of total billed charges",""
"SYSTEM DELIVERY ENDOVASCULAR CAP AFX2 INCLUDES 1 AFX2 BIF 1 AFX EXTENSION LIMB","SUP-ITM-10213263","CDM","C1874","HCPCS","0278","RC","","","","both","","","37337.50","28003.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13628.19","36.5","","1257.80","693.44","2424.50","1 through 10","11574.63","29683.31","percent of total billed charges",""
"SYSTEM DELIVERY ENDOVASCULAR CAP AFX2 INCLUDES 1 AFX2 BIF 1 AFX EXTENSION LIMB","SUP-ITM-10213263","CDM","C1874","HCPCS","0278","RC","","","","both","","","37337.50","28003.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14300.26","38.3","","1950.11","547.40","2346.00","1 through 10","11574.63","29683.31","percent of total billed charges",""
"SYSTEM DELIVERY ENDOVASCULAR CAP AFX2 INCLUDES 1 AFX2 BIF 1 AFX EXTENSION LIMB","SUP-ITM-10213263","CDM","C1874","HCPCS","0278","RC","","","","both","","","37337.50","28003.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16017.79","42.9","","5096.18","5096.18","5096.18","1 through 10","11574.63","29683.31","percent of total billed charges",""
"SYSTEM DELIVERY ENDOVASCULAR CAP AFX2 INCLUDES 1 AFX2 BIF 1 AFX EXTENSION LIMB","SUP-ITM-10213263","CDM","C1874","HCPCS","0278","RC","","","","both","","","37337.50","28003.12","WELLPOINT [1015]","HB AMC WELLPOINT","27547.61","73.78","","1172.59","1172.59","4829.94","1 through 10","11574.63","29683.31","percent of total billed charges",""
"SYSTEM DELIVERY ENDOVASCULAR CAP AFX2 INCLUDES 1 AFX2 BIF 1 AFX EXTENSION LIMB","SUP-ITM-10213263","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","37337.50","28003.12","AETNA [1001]","HB AMC AETNA HMO","26061.58","69.8","","1806.84","947.80","5091.72","1 through 10","19512.58","30512.21","percent of total billed charges",""
"SYSTEM DELIVERY ENDOVASCULAR CAP AFX2 INCLUDES 1 AFX2 BIF 1 AFX EXTENSION LIMB","SUP-ITM-10213263","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","37337.50","28003.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","30512.21","81.72","","1259.05","615.58","4586.56","1 through 10","19512.58","30512.21","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","both","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","16.24","16.24","54.15","1 through 10","1085","2782.5","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","both","","","3500.00","2625.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2513.00","71.8","","86.33","32.67","86.33","1 through 10","1085","2782.5","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","both","","","3500.00","2625.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2450.00","70","","113.68","63.00","177.34","40","1085","2782.5","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","both","","","3500.00","2625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2782.50","79.5","","50.70","21.76","168.00","12","1085","2782.5","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","both","","","3500.00","2625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1865.50","53.3","","89.31","89.31","99.75","1 through 10","1085","2782.5","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2275.00","65","","94.41","17.06","2275.00","1 through 10","1085","2782.5","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1085.00","31","","35.13","35.13","35.13","1 through 10","1085","2782.5","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1277.50","36.5","","40.08","12.40","86.17","108","1085","2782.5","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1340.50","38.3","","33.25","10.27","68.43","169","1085","2782.5","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","25.48","14.86","90.88","1 through 10","1085","2782.5","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","both","","","3500.00","2625.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1501.50","42.9","","90.88","90.88","90.88","1 through 10","1085","2782.5","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB AMC WELLPOINT","2582.30","73.78","","84.63","19.55","140.02","123","1085","2782.5","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA HMO","2443.00","69.8","","76.96","17.77","113.68","14","1829.1","2860.2","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3500.00","2625.00","AETNA [1001]","HB AMC AETNA PPO","2814.00","80.4","","57.31","57.31","57.31","1 through 10","1829.1","2860.2","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3500.00","2625.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1829.10","52.26","","16.24","16.24","54.15","1 through 10","1829.1","2860.2","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2814.00","80.4","","68.25","68.25","87.50","1 through 10","1829.1","2860.2","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","2860.20","81.72","","156.19","156.19","156.19","1 through 10","1829.1","2860.2","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2860.20","81.72","","82.70","12.06","98.97","13","1829.1","2860.2","percent of total billed charges",""
"SYSTEM DELIVERY S-ICD ELECTRODE EMBLEM","SUP-ITM-10235032","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2860.20","81.72","","50.47","25.30","134.30","140","1829.1","2860.2","percent of total billed charges",""
"SYSTEM DELIVERY SINUS MINI PROPEL IMPLANT PROPEL MOMETASONE FUROATE BIOABSORBABLE","SUP-ITM-10148116","CDM","C2625","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2842.00","70","","470.75","470.75","470.75","1 through 10","1258.6","3227.7","percent of total billed charges",""
"SYSTEM DELIVERY SINUS MINI PROPEL IMPLANT PROPEL MOMETASONE FUROATE BIOABSORBABLE","SUP-ITM-10148116","CDM","C2625","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1554.98","38.3","","184.07","124.37","184.07","1 through 10","1258.6","3227.7","percent of total billed charges",""
"SYSTEM DELIVERY SINUS MINI PROPEL IMPLANT PROPEL MOMETASONE FUROATE BIOABSORBABLE","SUP-ITM-10148116","CDM","C2625","HCPCS","0278","RC","","","","both","","","4060.00","3045.00","WELLPOINT [1015]","HB AMC WELLPOINT","2995.47","73.78","","243.67","243.67","243.67","1 through 10","1258.6","3227.7","percent of total billed charges",""
"SYSTEM DELIVERY SINUS MINI PROPEL IMPLANT PROPEL MOMETASONE FUROATE BIOABSORBABLE","SUP-ITM-10148116","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","4060.00","3045.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3317.83","81.72","","376.32","376.32","376.32","1 through 10","2121.76","3317.83","percent of total billed charges",""
"SYSTEM DRAINAGE HAKIM PROGRAMABLE VALVE CATHETER INLINE VALVE SIPHONGUARD PRIMING ADAPTER STRAIGHT CONNECTOR","SUP-ITM-10045309","CDM","C1889","HCPCS","0278","RC","","","","both","","","9193.10","6894.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7308.51","79.5","","1309.77","674.56","6049.93","26","2849.86","7308.51","percent of total billed charges",""
"SYSTEM DRAINAGE HAKIM PROGRAMABLE VALVE CATHETER INLINE VALVE SIPHONGUARD PRIMING ADAPTER STRAIGHT CONNECTOR","SUP-ITM-10045309","CDM","C1889","HCPCS","0278","RC","","","","both","","","9193.10","6894.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4899.92","53.3","","1901.83","1901.83","2962.25","1 through 10","2849.86","7308.51","percent of total billed charges",""
"SYSTEM DRAINAGE HAKIM PROGRAMABLE VALVE CATHETER INLINE VALVE SIPHONGUARD PRIMING ADAPTER STRAIGHT CONNECTOR","SUP-ITM-10045309","CDM","C1889","HCPCS","0278","RC","","","","both","","","9193.10","6894.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3355.48","36.5","","1620.31","1620.31","19908.88","1 through 10","2849.86","7308.51","percent of total billed charges",""
"SYSTEM DRAINAGE HAKIM PROGRAMABLE VALVE CATHETER INLINE VALVE SIPHONGUARD PRIMING ADAPTER STRAIGHT CONNECTOR","SUP-ITM-10045309","CDM","C1889","HCPCS","0278","RC","","","","both","","","9193.10","6894.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3520.96","38.3","","352.91","352.91","2046.30","1 through 10","2849.86","7308.51","percent of total billed charges",""
"SYSTEM DRAINAGE HAKIM PROGRAMABLE VALVE CATHETER INLINE VALVE SIPHONGUARD PRIMING ADAPTER STRAIGHT CONNECTOR","SUP-ITM-10045309","CDM","C1889","HCPCS","0278","RC","","","","both","","","9193.10","6894.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3943.84","42.9","","9668.75","9668.75","9668.75","1 through 10","2849.86","7308.51","percent of total billed charges",""
"SYSTEM DRAINAGE HAKIM PROGRAMABLE VALVE CATHETER INLINE VALVE SIPHONGUARD PRIMING ADAPTER STRAIGHT CONNECTOR","SUP-ITM-10045309","CDM","C1889","HCPCS","0278","RC","","","","both","","","9193.10","6894.82","WELLPOINT [1015]","HB AMC WELLPOINT","6782.67","73.78","","699.88","384.10","3443.31","33","2849.86","7308.51","percent of total billed charges",""
"SYSTEM DRAINAGE HAKIM PROGRAMABLE VALVE CATHETER INLINE VALVE SIPHONGUARD PRIMING ADAPTER STRAIGHT CONNECTOR","SUP-ITM-10045309","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9193.10","6894.82","AETNA [1001]","HB AMC AETNA HMO","6416.78","69.8","","1421.24","264.50","4933.46","29","4804.31","7512.6","percent of total billed charges",""
"SYSTEM DRAINAGE HAKIM PROGRAMABLE VALVE CATHETER INLINE VALVE SIPHONGUARD PRIMING ADAPTER STRAIGHT CONNECTOR","SUP-ITM-10045309","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9193.10","6894.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7391.25","80.4","","1022.97","1022.97","3607.50","1 through 10","4804.31","7512.6","percent of total billed charges",""
"SYSTEM DRAINAGE HAKIM PROGRAMABLE VALVE CATHETER INLINE VALVE SIPHONGUARD PRIMING ADAPTER STRAIGHT CONNECTOR","SUP-ITM-10045309","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9193.10","6894.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7512.60","81.72","","3010.54","693.88","5019.88","35","4804.31","7512.6","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","both","","","2631.22","1973.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2091.82","79.5","","1309.77","674.56","6049.93","26","815.68","2091.82","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","both","","","2631.22","1973.41","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1402.44","53.3","","1901.83","1901.83","2962.25","1 through 10","815.68","2091.82","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","both","","","2631.22","1973.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","960.40","36.5","","1620.31","1620.31","19908.88","1 through 10","815.68","2091.82","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","both","","","2631.22","1973.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1007.76","38.3","","352.91","352.91","2046.30","1 through 10","815.68","2091.82","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","both","","","2631.22","1973.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1128.79","42.9","","9668.75","9668.75","9668.75","1 through 10","815.68","2091.82","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","both","","","2631.22","1973.41","WELLPOINT [1015]","HB AMC WELLPOINT","1941.31","73.78","","699.88","384.10","3443.31","33","815.68","2091.82","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2631.22","1973.41","AETNA [1001]","HB AMC AETNA HMO","1836.59","69.8","","1421.24","264.50","4933.46","29","1375.08","2150.23","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2631.22","1973.41","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2115.50","80.4","","1022.97","1022.97","3607.50","1 through 10","1375.08","2150.23","percent of total billed charges",""
"SYSTEM DURASEAL 5ML DURAL SEALANT STANDARD BX/5EA","SUP-ITM-10018592","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2631.22","1973.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2150.23","81.72","","3010.54","693.88","5019.88","35","1375.08","2150.23","percent of total billed charges",""
"SYSTEM ENROUTE TRANSCAROTID NEUROPROTECTION FLOW REVERSAL PLUS","SUP-ITM-10321626","CDM","C1876","HCPCS","0278","RC","","","","both","","","9347.50","7010.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","6131.96","65.6","","751.18","751.18","751.18","1 through 10","2897.73","7431.26","percent of total billed charges",""
"SYSTEM ENROUTE TRANSCAROTID NEUROPROTECTION FLOW REVERSAL PLUS","SUP-ITM-10321626","CDM","C1876","HCPCS","0278","RC","","","","both","","","9347.50","7010.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7431.26","79.5","","4820.38","3211.27","4820.38","1 through 10","2897.73","7431.26","percent of total billed charges",""
"SYSTEM ENROUTE TRANSCAROTID NEUROPROTECTION FLOW REVERSAL PLUS","SUP-ITM-10321626","CDM","C1876","HCPCS","0278","RC","","","","both","","","9347.50","7010.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3411.84","36.5","","641.00","641.00","641.00","1 through 10","2897.73","7431.26","percent of total billed charges",""
"SYSTEM ENROUTE TRANSCAROTID NEUROPROTECTION FLOW REVERSAL PLUS","SUP-ITM-10321626","CDM","C1876","HCPCS","0278","RC","","","","both","","","9347.50","7010.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3580.09","38.3","","1098.43","1098.43","1098.43","1 through 10","2897.73","7431.26","percent of total billed charges",""
"SYSTEM ENROUTE TRANSCAROTID NEUROPROTECTION FLOW REVERSAL PLUS","SUP-ITM-10321626","CDM","C1876","HCPCS","0278","RC","","","","both","","","9347.50","7010.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4010.08","42.9","","4896.33","4896.33","4896.33","1 through 10","2897.73","7431.26","percent of total billed charges",""
"SYSTEM ENROUTE TRANSCAROTID NEUROPROTECTION FLOW REVERSAL PLUS","SUP-ITM-10321626","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","9347.50","7010.62","AETNA [1001]","HB AMC AETNA HMO","6524.56","69.8","","175.60","163.11","1063.91","1 through 10","4885","7638.78","percent of total billed charges",""
"SYSTEM ENROUTE TRANSCAROTID NEUROPROTECTION FLOW REVERSAL PLUS","SUP-ITM-10321626","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","9347.50","7010.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7638.78","81.72","","105.94","85.10","105.94","1 through 10","4885","7638.78","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4233.38","79.5","","800.18","480.96","1887.97","195","1650.75","4233.38","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2838.23","53.3","","813.12","216.42","1444.50","81","1650.75","4233.38","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1650.75","31","","432.60","432.60","432.60","1 through 10","1650.75","4233.38","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1943.63","36.5","","148.37","54.89","631.39","94","1650.75","4233.38","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2039.48","38.3","","279.30","91.72","1116.77","266","1650.75","4233.38","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2284.43","42.9","","731.00","63.70","731.00","1 through 10","1650.75","4233.38","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2284.43","42.9","","384.74","384.74","384.74","1 through 10","1650.75","4233.38","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","5325.00","3993.75","WELLPOINT [1015]","HB AMC WELLPOINT","3928.79","73.78","","286.63","119.22","1107.45","105","1650.75","4233.38","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5325.00","3993.75","AETNA [1001]","HB AMC AETNA HMO","3716.85","69.8","","675.31","184.75","1721.50","286","2782.85","4351.59","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5325.00","3993.75","AETNA [1001]","HB AMC AETNA PPO","4281.30","80.4","","1261.44","103.12","1514.10","21","2782.85","4351.59","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5325.00","3993.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4281.30","80.4","","1365.00","1365.00","1365.00","1 through 10","2782.85","4351.59","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5325.00","3993.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4351.59","81.72","","5157.68","5157.68","5157.68","1 through 10","2782.85","4351.59","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5325.00","3993.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4351.59","81.72","","431.26","71.26","1459.57","88","2782.85","4351.59","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","834.75","79.5","","1309.77","674.56","6049.93","26","325.5","834.75","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","559.65","53.3","","1901.83","1901.83","2962.25","1 through 10","325.5","834.75","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","1620.31","1620.31","19908.88","1 through 10","325.5","834.75","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","352.91","352.91","2046.30","1 through 10","325.5","834.75","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","9668.75","9668.75","9668.75","1 through 10","325.5","834.75","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB AMC WELLPOINT","774.69","73.78","","699.88","384.10","3443.31","33","325.5","834.75","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA HMO","732.90","69.8","","1421.24","264.50","4933.46","29","548.73","858.06","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","844.20","80.4","","1022.97","1022.97","3607.50","1 through 10","548.73","858.06","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","858.06","81.72","","3010.54","693.88","5019.88","35","548.73","858.06","percent of total billed charges",""
"SYSTEM GRAFT 26MM STENT AORTIC BODY ALTO PMA","SUP-ITM-10273825","CDM","C1874","HCPCS","0278","RC","","","","both","","","32247.50","24185.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","20960.88","65","","6652.80","6652.80","6652.80","1 through 10","9996.73","25636.76","percent of total billed charges",""
"SYSTEM GRAFT 26MM STENT AORTIC BODY ALTO PMA","SUP-ITM-10273825","CDM","C1874","HCPCS","0278","RC","","","","both","","","32247.50","24185.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","25636.76","79.5","","2612.61","795.38","2612.61","1 through 10","9996.73","25636.76","percent of total billed charges",""
"SYSTEM GRAFT 26MM STENT AORTIC BODY ALTO PMA","SUP-ITM-10273825","CDM","C1874","HCPCS","0278","RC","","","","both","","","32247.50","24185.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","17187.92","53.3","","1101.80","1101.80","1101.80","1 through 10","9996.73","25636.76","percent of total billed charges",""
"SYSTEM GRAFT 26MM STENT AORTIC BODY ALTO PMA","SUP-ITM-10273825","CDM","C1874","HCPCS","0278","RC","","","","both","","","32247.50","24185.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","20960.88","65","","1820.00","910.00","1820.00","1 through 10","9996.73","25636.76","percent of total billed charges",""
"SYSTEM GRAFT 26MM STENT AORTIC BODY ALTO PMA","SUP-ITM-10273825","CDM","C1874","HCPCS","0278","RC","","","","both","","","32247.50","24185.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11770.34","36.5","","1257.80","693.44","2424.50","1 through 10","9996.73","25636.76","percent of total billed charges",""
"SYSTEM GRAFT 26MM STENT AORTIC BODY ALTO PMA","SUP-ITM-10273825","CDM","C1874","HCPCS","0278","RC","","","","both","","","32247.50","24185.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12350.79","38.3","","1950.11","547.40","2346.00","1 through 10","9996.73","25636.76","percent of total billed charges",""
"SYSTEM GRAFT 26MM STENT AORTIC BODY ALTO PMA","SUP-ITM-10273825","CDM","C1874","HCPCS","0278","RC","","","","both","","","32247.50","24185.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13834.18","42.9","","5096.18","5096.18","5096.18","1 through 10","9996.73","25636.76","percent of total billed charges",""
"SYSTEM GRAFT 26MM STENT AORTIC BODY ALTO PMA","SUP-ITM-10273825","CDM","C1874","HCPCS","0278","RC","","","","both","","","32247.50","24185.62","WELLPOINT [1015]","HB AMC WELLPOINT","23792.21","73.78","","1172.59","1172.59","4829.94","1 through 10","9996.73","25636.76","percent of total billed charges",""
"SYSTEM GRAFT 26MM STENT AORTIC BODY ALTO PMA","SUP-ITM-10273825","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","32247.50","24185.62","AETNA [1001]","HB AMC AETNA HMO","22508.76","69.8","","1806.84","947.80","5091.72","1 through 10","16852.54","26352.66","percent of total billed charges",""
"SYSTEM GRAFT 26MM STENT AORTIC BODY ALTO PMA","SUP-ITM-10273825","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","32247.50","24185.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","26352.66","81.72","","1259.05","615.58","4586.56","1 through 10","16852.54","26352.66","percent of total billed charges",""
"SYSTEM IMPLANT 4.75 LNT BC KL SWIVELOCK","SUP-ITM-10310240","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2392.95","79.5","","800.18","480.96","1887.97","195","933.1","2392.95","percent of total billed charges",""
"SYSTEM IMPLANT 4.75 LNT BC KL SWIVELOCK","SUP-ITM-10310240","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1604.33","53.3","","813.12","216.42","1444.50","81","933.1","2392.95","percent of total billed charges",""
"SYSTEM IMPLANT 4.75 LNT BC KL SWIVELOCK","SUP-ITM-10310240","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","933.10","31","","432.60","432.60","432.60","1 through 10","933.1","2392.95","percent of total billed charges",""
"SYSTEM IMPLANT 4.75 LNT BC KL SWIVELOCK","SUP-ITM-10310240","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1098.65","36.5","","148.37","54.89","631.39","94","933.1","2392.95","percent of total billed charges",""
"SYSTEM IMPLANT 4.75 LNT BC KL SWIVELOCK","SUP-ITM-10310240","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1152.83","38.3","","279.30","91.72","1116.77","266","933.1","2392.95","percent of total billed charges",""
"SYSTEM IMPLANT 4.75 LNT BC KL SWIVELOCK","SUP-ITM-10310240","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1291.29","42.9","","731.00","63.70","731.00","1 through 10","933.1","2392.95","percent of total billed charges",""
"SYSTEM IMPLANT 4.75 LNT BC KL SWIVELOCK","SUP-ITM-10310240","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1291.29","42.9","","384.74","384.74","384.74","1 through 10","933.1","2392.95","percent of total billed charges",""
"SYSTEM IMPLANT 4.75 LNT BC KL SWIVELOCK","SUP-ITM-10310240","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","WELLPOINT [1015]","HB AMC WELLPOINT","2220.78","73.78","","286.63","119.22","1107.45","105","933.1","2392.95","percent of total billed charges",""
"SYSTEM IMPLANT 4.75 LNT BC KL SWIVELOCK","SUP-ITM-10310240","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","AETNA [1001]","HB AMC AETNA HMO","2100.98","69.8","","675.31","184.75","1721.50","286","1573.03","2459.77","percent of total billed charges",""
"SYSTEM IMPLANT 4.75 LNT BC KL SWIVELOCK","SUP-ITM-10310240","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","AETNA [1001]","HB AMC AETNA PPO","2420.04","80.4","","1261.44","103.12","1514.10","21","1573.03","2459.77","percent of total billed charges",""
"SYSTEM IMPLANT 4.75 LNT BC KL SWIVELOCK","SUP-ITM-10310240","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2420.04","80.4","","1365.00","1365.00","1365.00","1 through 10","1573.03","2459.77","percent of total billed charges",""
"SYSTEM IMPLANT 4.75 LNT BC KL SWIVELOCK","SUP-ITM-10310240","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2459.77","81.72","","5157.68","5157.68","5157.68","1 through 10","1573.03","2459.77","percent of total billed charges",""
"SYSTEM IMPLANT 4.75 LNT BC KL SWIVELOCK","SUP-ITM-10310240","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2459.77","81.72","","431.26","71.26","1459.57","88","1573.03","2459.77","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4149.90","79.5","","800.18","480.96","1887.97","195","1618.2","4149.9","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2782.26","53.3","","813.12","216.42","1444.50","81","1618.2","4149.9","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1618.20","31","","432.60","432.60","432.60","1 through 10","1618.2","4149.9","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1905.30","36.5","","148.37","54.89","631.39","94","1618.2","4149.9","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1999.26","38.3","","279.30","91.72","1116.77","266","1618.2","4149.9","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2239.38","42.9","","731.00","63.70","731.00","1 through 10","1618.2","4149.9","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2239.38","42.9","","384.74","384.74","384.74","1 through 10","1618.2","4149.9","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","both","","","5220.00","3915.00","WELLPOINT [1015]","HB AMC WELLPOINT","3851.32","73.78","","286.63","119.22","1107.45","105","1618.2","4149.9","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5220.00","3915.00","AETNA [1001]","HB AMC AETNA HMO","3643.56","69.8","","675.31","184.75","1721.50","286","2727.97","4265.78","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5220.00","3915.00","AETNA [1001]","HB AMC AETNA PPO","4196.88","80.4","","1261.44","103.12","1514.10","21","2727.97","4265.78","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5220.00","3915.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4196.88","80.4","","1365.00","1365.00","1365.00","1 through 10","2727.97","4265.78","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5220.00","3915.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4265.78","81.72","","5157.68","5157.68","5157.68","1 through 10","2727.97","4265.78","percent of total billed charges",""
"SYSTEM IMPLANT ACHILLES SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10091741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5220.00","3915.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4265.78","81.72","","431.26","71.26","1459.57","88","2727.97","4265.78","percent of total billed charges",""
"SYSTEM KYLEENA 19.5MG LEVONORGESTREL-RELEASING INTRAUTERINE","SUP-ITM-10240784","CDM","J7296","HCPCS","0270","RC","","","","both","","","3400.95","2550.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1241.35","36.5","","3850.98","1925.49","3850.98","1 through 10","1054.29","2618.73","percent of total billed charges",""
"SYSTEM KYLEENA 19.5MG LEVONORGESTREL-RELEASING INTRAUTERINE","SUP-ITM-10240784","CDM","J7296","HCPCS","0270","RC","","","","both","","","3400.95","2550.71","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1302.56","38.3","","4036.82","1868.22","5766.90","32","1054.29","2618.73","percent of total billed charges",""
"SYSTEM KYLEENA 19.5MG LEVONORGESTREL-RELEASING INTRAUTERINE","SUP-ITM-10240784","CDM","J7296","HCPCS","0270","RC","","","","both","","","3400.95","2550.71","WELLPOINT [1015]","HB AMC WELLPOINT","2509.22","73.78","","9005.42","9005.42","9005.42","1 through 10","1054.29","2618.73","percent of total billed charges",""
"SYSTEM KYLEENA 19.5MG LEVONORGESTREL-RELEASING INTRAUTERINE","SUP-ITM-10240784","CDM","J7296","HCPCS","0270","RC","","","","outpatient","","","3400.95","2550.71","AETNA [1001]","HB AMC AETNA HMO","2373.86","69.8","","3494.80","2467.52","5162.18","1 through 10","1419.97","3133.75","percent of total billed charges",""
"SYSTEM KYLEENA 19.5MG LEVONORGESTREL-RELEASING INTRAUTERINE","SUP-ITM-10240784","CDM","J7296","HCPCS","0270","RC","","","","outpatient","","","3400.95","2550.71","AETNA [1001]","HB AMC AETNA PPO","2734.36","80.4","","2576.17","2576.17","2576.17","1 through 10","1419.97","3133.75","percent of total billed charges",""
"SYSTEM KYLEENA 19.5MG LEVONORGESTREL-RELEASING INTRAUTERINE","SUP-ITM-10240784","CDM","J7296","HCPCS","0270","RC","","","","outpatient","","","3400.95","2550.71","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2377.26","69.9","","7315.45","3407.04","10732.17","1 through 10","1419.97","3133.75","percent of total billed charges",""
"SYSTEM KYLEENA 19.5MG LEVONORGESTREL-RELEASING INTRAUTERINE","SUP-ITM-10240784","CDM","J7296","HCPCS","0270","RC","","","","outpatient","","","3400.95","2550.71","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1595.05","46.9","","2482.76","2482.76","2482.76","1 through 10","1419.97","3133.75","percent of total billed charges",""
"SYSTEM LIQUID ONYX 1.5ML EMBOLIC GLUE EMBOLIZATION NON-ADHESIVE 18 6% EVOH DMSO","SUP-ITM-10016384","CDM","C1889","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3965.06","79.5","","1309.77","674.56","6049.93","26","1546.13","3965.06","percent of total billed charges",""
"SYSTEM LIQUID ONYX 1.5ML EMBOLIC GLUE EMBOLIZATION NON-ADHESIVE 18 6% EVOH DMSO","SUP-ITM-10016384","CDM","C1889","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2658.34","53.3","","1901.83","1901.83","2962.25","1 through 10","1546.13","3965.06","percent of total billed charges",""
"SYSTEM LIQUID ONYX 1.5ML EMBOLIC GLUE EMBOLIZATION NON-ADHESIVE 18 6% EVOH DMSO","SUP-ITM-10016384","CDM","C1889","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1820.44","36.5","","1620.31","1620.31","19908.88","1 through 10","1546.13","3965.06","percent of total billed charges",""
"SYSTEM LIQUID ONYX 1.5ML EMBOLIC GLUE EMBOLIZATION NON-ADHESIVE 18 6% EVOH DMSO","SUP-ITM-10016384","CDM","C1889","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1910.21","38.3","","352.91","352.91","2046.30","1 through 10","1546.13","3965.06","percent of total billed charges",""
"SYSTEM LIQUID ONYX 1.5ML EMBOLIC GLUE EMBOLIZATION NON-ADHESIVE 18 6% EVOH DMSO","SUP-ITM-10016384","CDM","C1889","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2139.64","42.9","","9668.75","9668.75","9668.75","1 through 10","1546.13","3965.06","percent of total billed charges",""
"SYSTEM LIQUID ONYX 1.5ML EMBOLIC GLUE EMBOLIZATION NON-ADHESIVE 18 6% EVOH DMSO","SUP-ITM-10016384","CDM","C1889","HCPCS","0278","RC","","","","both","","","4987.50","3740.62","WELLPOINT [1015]","HB AMC WELLPOINT","3679.78","73.78","","699.88","384.10","3443.31","33","1546.13","3965.06","percent of total billed charges",""
"SYSTEM LIQUID ONYX 1.5ML EMBOLIC GLUE EMBOLIZATION NON-ADHESIVE 18 6% EVOH DMSO","SUP-ITM-10016384","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4987.50","3740.62","AETNA [1001]","HB AMC AETNA HMO","3481.28","69.8","","1421.24","264.50","4933.46","29","2606.47","4075.79","percent of total billed charges",""
"SYSTEM LIQUID ONYX 1.5ML EMBOLIC GLUE EMBOLIZATION NON-ADHESIVE 18 6% EVOH DMSO","SUP-ITM-10016384","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4987.50","3740.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4009.95","80.4","","1022.97","1022.97","3607.50","1 through 10","2606.47","4075.79","percent of total billed charges",""
"SYSTEM LIQUID ONYX 1.5ML EMBOLIC GLUE EMBOLIZATION NON-ADHESIVE 18 6% EVOH DMSO","SUP-ITM-10016384","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4987.50","3740.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4075.79","81.72","","3010.54","693.88","5019.88","35","2606.47","4075.79","percent of total billed charges",""
"SYSTEM LOADING 23/26/29MM ENVEOTM PRO FOR VALV - DISCONTINUED PER SUPPLIER/CONTRACTSE","SUP-ITM-10266578","CDM","C1725","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","980.07","71.8","","175.91","175.91","175.91","1 through 10","423.15","1085.18","percent of total billed charges",""
"SYSTEM LOADING 23/26/29MM ENVEOTM PRO FOR VALV - DISCONTINUED PER SUPPLIER/CONTRACTSE","SUP-ITM-10266578","CDM","C1725","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","887.25","65","","147.88","147.88","1296.75","1 through 10","423.15","1085.18","percent of total billed charges",""
"SYSTEM LOADING 23/26/29MM ENVEOTM PRO FOR VALV - DISCONTINUED PER SUPPLIER/CONTRACTSE","SUP-ITM-10266578","CDM","C1725","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","498.23","36.5","","181.40","177.87","181.40","21","423.15","1085.18","percent of total billed charges",""
"SYSTEM LOADING 23/26/29MM ENVEOTM PRO FOR VALV - DISCONTINUED PER SUPPLIER/CONTRACTSE","SUP-ITM-10266578","CDM","C1725","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","522.80","38.3","","170.15","88.95","424.24","16","423.15","1085.18","percent of total billed charges",""
"SYSTEM LOADING 23/26/29MM ENVEOTM PRO FOR VALV - DISCONTINUED PER SUPPLIER/CONTRACTSE","SUP-ITM-10266578","CDM","C1725","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","585.59","42.9","","699.48","699.48","699.48","12","423.15","1085.18","percent of total billed charges",""
"SYSTEM LOADING 23/26/29MM ENVEOTM PRO FOR VALV - DISCONTINUED PER SUPPLIER/CONTRACTSE","SUP-ITM-10266578","CDM","C1725","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB AMC WELLPOINT","1007.10","73.78","","576.52","182.40","651.44","14","423.15","1085.18","percent of total billed charges",""
"SYSTEM LOADING 23/26/29MM ENVEOTM PRO FOR VALV - DISCONTINUED PER SUPPLIER/CONTRACTSE","SUP-ITM-10266578","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1115.48","81.72","","181.86","100.03","402.41","21","713.35","1115.48","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1140.83","79.5","","800.18","480.96","1887.97","195","444.85","1140.83","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","764.86","53.3","","813.12","216.42","1444.50","81","444.85","1140.83","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","444.85","31","","432.60","432.60","432.60","1 through 10","444.85","1140.83","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","523.78","36.5","","148.37","54.89","631.39","94","444.85","1140.83","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","549.61","38.3","","279.30","91.72","1116.77","266","444.85","1140.83","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","615.62","42.9","","731.00","63.70","731.00","1 through 10","444.85","1140.83","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","615.62","42.9","","384.74","384.74","384.74","1 through 10","444.85","1140.83","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1435.00","1076.25","WELLPOINT [1015]","HB AMC WELLPOINT","1058.74","73.78","","286.63","119.22","1107.45","105","444.85","1140.83","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1435.00","1076.25","AETNA [1001]","HB AMC AETNA HMO","1001.63","69.8","","675.31","184.75","1721.50","286","749.93","1172.68","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1435.00","1076.25","AETNA [1001]","HB AMC AETNA PPO","1153.74","80.4","","1261.44","103.12","1514.10","21","749.93","1172.68","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1435.00","1076.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1153.74","80.4","","1365.00","1365.00","1365.00","1 through 10","749.93","1172.68","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1435.00","1076.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1172.68","81.72","","5157.68","5157.68","5157.68","1 through 10","749.93","1172.68","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1435.00","1076.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1172.68","81.72","","431.26","71.26","1459.57","88","749.93","1172.68","percent of total billed charges",""
"SYSTEM PACEMAKER MICRA AV2 LEADLESS","SUP-ITM-10328699","CDM","C1786","HCPCS","0275","RC","","","","both","","","30550.00","22912.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11700.65","38.3","","330.52","330.52","330.52","1 through 10","9470.5","24287.25","percent of total billed charges",""
"SYSTEM PACEMAKER MICRA AV2 LEADLESS","SUP-ITM-10328699","CDM","C1786","HCPCS","0275","RC","","","","both","","","30550.00","22912.50","WELLPOINT [1015]","HB AMC WELLPOINT","22539.79","73.78","","22527.75","22527.75","22527.75","1 through 10","9470.5","24287.25","percent of total billed charges",""
"SYSTEM PACING 105CM TRANSCATHETER MICRO","SUP-ITM-10210749","CDM","C1786","HCPCS","0275","RC","","","","both","","","21875.00","16406.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8378.13","38.3","","330.52","330.52","330.52","1 through 10","6781.25","17390.63","percent of total billed charges",""
"SYSTEM PACING 105CM TRANSCATHETER MICRO","SUP-ITM-10210749","CDM","C1786","HCPCS","0275","RC","","","","both","","","21875.00","16406.25","WELLPOINT [1015]","HB AMC WELLPOINT","16139.38","73.78","","22527.75","22527.75","22527.75","1 through 10","6781.25","17390.63","percent of total billed charges",""
"SYSTEM POSITIONING 6X8IN MESH ELLIPSE ECHO 2 VENTRALIGHT ST CS/1EA","SUP-ITM-10275502","CDM","C1781","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3622.50","70","","134.04","134.04","134.04","1 through 10","1604.25","4114.13","percent of total billed charges",""
"SYSTEM POSITIONING 6X8IN MESH ELLIPSE ECHO 2 VENTRALIGHT ST CS/1EA","SUP-ITM-10275502","CDM","C1781","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4114.13","79.5","","948.87","198.19","1805.30","1 through 10","1604.25","4114.13","percent of total billed charges",""
"SYSTEM POSITIONING 6X8IN MESH ELLIPSE ECHO 2 VENTRALIGHT ST CS/1EA","SUP-ITM-10275502","CDM","C1781","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2758.28","53.3","","462.00","170.45","3253.37","1 through 10","1604.25","4114.13","percent of total billed charges",""
"SYSTEM POSITIONING 6X8IN MESH ELLIPSE ECHO 2 VENTRALIGHT ST CS/1EA","SUP-ITM-10275502","CDM","C1781","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1888.88","36.5","","245.50","107.19","1371.45","1 through 10","1604.25","4114.13","percent of total billed charges",""
"SYSTEM POSITIONING 6X8IN MESH ELLIPSE ECHO 2 VENTRALIGHT ST CS/1EA","SUP-ITM-10275502","CDM","C1781","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1982.03","38.3","","200.79","72.79","355.81","22","1604.25","4114.13","percent of total billed charges",""
"SYSTEM POSITIONING 6X8IN MESH ELLIPSE ECHO 2 VENTRALIGHT ST CS/1EA","SUP-ITM-10275502","CDM","C1781","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3984.75","77","","477.18","477.18","477.18","1 through 10","1604.25","4114.13","percent of total billed charges",""
"SYSTEM POSITIONING 6X8IN MESH ELLIPSE ECHO 2 VENTRALIGHT ST CS/1EA","SUP-ITM-10275502","CDM","C1781","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2220.08","42.9","","1045.91","1045.91","1045.91","1 through 10","1604.25","4114.13","percent of total billed charges",""
"SYSTEM POSITIONING 6X8IN MESH ELLIPSE ECHO 2 VENTRALIGHT ST CS/1EA","SUP-ITM-10275502","CDM","C1781","HCPCS","0278","RC","","","","both","","","5175.00","3881.25","WELLPOINT [1015]","HB AMC WELLPOINT","3818.12","73.78","","1726.50","1726.50","1726.50","1 through 10","1604.25","4114.13","percent of total billed charges",""
"SYSTEM POSITIONING 6X8IN MESH ELLIPSE ECHO 2 VENTRALIGHT ST CS/1EA","SUP-ITM-10275502","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5175.00","3881.25","AETNA [1001]","HB AMC AETNA HMO","3612.15","69.8","","915.80","263.76","2881.00","1 through 10","2704.46","4229.01","percent of total billed charges",""
"SYSTEM POSITIONING 6X8IN MESH ELLIPSE ECHO 2 VENTRALIGHT ST CS/1EA","SUP-ITM-10275502","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5175.00","3881.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4229.01","81.72","","1531.57","410.52","8841.36","1 through 10","2704.46","4229.01","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1878.19","79.5","","800.18","480.96","1887.97","195","732.38","1878.19","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1259.21","53.3","","813.12","216.42","1444.50","81","732.38","1878.19","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","732.38","31","","432.60","432.60","432.60","1 through 10","732.38","1878.19","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","862.31","36.5","","148.37","54.89","631.39","94","732.38","1878.19","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","904.84","38.3","","279.30","91.72","1116.77","266","732.38","1878.19","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","731.00","63.70","731.00","1 through 10","732.38","1878.19","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.51","42.9","","384.74","384.74","384.74","1 through 10","732.38","1878.19","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","WELLPOINT [1015]","HB AMC WELLPOINT","1743.05","73.78","","286.63","119.22","1107.45","105","732.38","1878.19","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA HMO","1649.03","69.8","","675.31","184.75","1721.50","286","1234.64","1930.64","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","AETNA [1001]","HB AMC AETNA PPO","1899.45","80.4","","1261.44","103.12","1514.10","21","1234.64","1930.64","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1899.45","80.4","","1365.00","1365.00","1365.00","1 through 10","1234.64","1930.64","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1930.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1234.64","1930.64","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1930.64","81.72","","431.26","71.26","1459.57","88","1234.64","1930.64","percent of total billed charges",""
"SYSTEM REPAIR 6FR PERCLOSE PROSTYLE SUTURE-MEDIATED KNOT PUSH - SOLD IN MULTIPLES OF 10EA","SUP-ITM-10286067","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","320.09","52.26","","487.31","487.31","487.31","1 through 10","189.88","486.94","percent of total billed charges",""
"SYSTEM REPAIR 6FR PERCLOSE PROSTYLE SUTURE-MEDIATED KNOT PUSH - SOLD IN MULTIPLES OF 10EA","SUP-ITM-10286067","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","439.78","71.8","","612.50","612.50","612.50","1 through 10","189.88","486.94","percent of total billed charges",""
"SYSTEM REPAIR 6FR PERCLOSE PROSTYLE SUTURE-MEDIATED KNOT PUSH - SOLD IN MULTIPLES OF 10EA","SUP-ITM-10286067","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","428.75","70","","612.50","612.50","612.50","1 through 10","189.88","486.94","percent of total billed charges",""
"SYSTEM REPAIR 6FR PERCLOSE PROSTYLE SUTURE-MEDIATED KNOT PUSH - SOLD IN MULTIPLES OF 10EA","SUP-ITM-10286067","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","486.94","79.5","","742.96","323.40","1446.12","32","189.88","486.94","percent of total billed charges",""
"SYSTEM REPAIR 6FR PERCLOSE PROSTYLE SUTURE-MEDIATED KNOT PUSH - SOLD IN MULTIPLES OF 10EA","SUP-ITM-10286067","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","326.46","53.3","","323.40","323.40","550.90","13","189.88","486.94","percent of total billed charges",""
"SYSTEM REPAIR 6FR PERCLOSE PROSTYLE SUTURE-MEDIATED KNOT PUSH - SOLD IN MULTIPLES OF 10EA","SUP-ITM-10286067","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.56","36.5","","285.08","194.16","582.48","27","189.88","486.94","percent of total billed charges",""
"SYSTEM REPAIR 6FR PERCLOSE PROSTYLE SUTURE-MEDIATED KNOT PUSH - SOLD IN MULTIPLES OF 10EA","SUP-ITM-10286067","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.59","38.3","","239.49","233.98","600.08","52","189.88","486.94","percent of total billed charges",""
"SYSTEM REPAIR 6FR PERCLOSE PROSTYLE SUTURE-MEDIATED KNOT PUSH - SOLD IN MULTIPLES OF 10EA","SUP-ITM-10286067","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","262.76","42.9","","278.69","278.69","278.69","1 through 10","189.88","486.94","percent of total billed charges",""
"SYSTEM REPAIR 6FR PERCLOSE PROSTYLE SUTURE-MEDIATED KNOT PUSH - SOLD IN MULTIPLES OF 10EA","SUP-ITM-10286067","CDM","C1760","HCPCS","0278","RC","","","","both","","","612.50","459.37","WELLPOINT [1015]","HB AMC WELLPOINT","451.90","73.78","","456.01","456.01","456.01","33","189.88","486.94","percent of total billed charges",""
"SYSTEM REPAIR 6FR PERCLOSE PROSTYLE SUTURE-MEDIATED KNOT PUSH - SOLD IN MULTIPLES OF 10EA","SUP-ITM-10286067","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","AETNA [1001]","HB AMC AETNA HMO","427.53","69.8","","290.33","290.33","1575.00","1 through 10","320.09","500.54","percent of total billed charges",""
"SYSTEM REPAIR 6FR PERCLOSE PROSTYLE SUTURE-MEDIATED KNOT PUSH - SOLD IN MULTIPLES OF 10EA","SUP-ITM-10286067","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","320.09","52.26","","487.31","487.31","487.31","1 through 10","320.09","500.54","percent of total billed charges",""
"SYSTEM REPAIR 6FR PERCLOSE PROSTYLE SUTURE-MEDIATED KNOT PUSH - SOLD IN MULTIPLES OF 10EA","SUP-ITM-10286067","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","500.54","81.72","","489.63","489.63","489.63","1 through 10","320.09","500.54","percent of total billed charges",""
"SYSTEM REPAIR 6FR PERCLOSE PROSTYLE SUTURE-MEDIATED KNOT PUSH - SOLD IN MULTIPLES OF 10EA","SUP-ITM-10286067","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","500.54","81.72","","489.64","489.63","1888.58","19","320.09","500.54","percent of total billed charges",""
"System Septal Defect Intracardiac T1","PX-27000138","CDM","C1817","HCPCS","0278","RC","","","","both","","","2114.00","1585.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1680.63","79.5","","17412.37","11682.00","17412.38","1 through 10","655.34","1680.63","percent of total billed charges",""
"System Septal Defect Intracardiac T1","PX-27000138","CDM","C1817","HCPCS","0278","RC","","","","both","","","2114.00","1585.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1126.76","53.3","","11682.00","11682.00","11682.00","1 through 10","655.34","1680.63","percent of total billed charges",""
"System Septal Defect Intracardiac T1","PX-27000138","CDM","C1817","HCPCS","0278","RC","","","","both","","","2114.00","1585.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","809.66","38.3","","8650.88","8650.88","9853.20","1 through 10","655.34","1680.63","percent of total billed charges",""
"System Septal Defect Intracardiac T1","PX-27000138","CDM","C1817","HCPCS","0278","RC","","","","both","","","2114.00","1585.50","WELLPOINT [1015]","HB AMC WELLPOINT","1559.71","73.78","","16472.06","16472.06","16472.06","1 through 10","655.34","1680.63","percent of total billed charges",""
"System Septal Defect Intracardiac T1","PX-27000138","CDM","C1817","HCPCS","0278","RC","","","","outpatient","","","2114.00","1585.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1727.56","81.72","","17686.73","17686.73","17686.73","1 through 10","1104.78","1727.56","percent of total billed charges",""
"System Septal Defect Intracardiac T2","PX-27000139","CDM","C1817","HCPCS","0278","RC","","","","both","","","4992.00","3744.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3968.64","79.5","","17412.37","11682.00","17412.38","1 through 10","1547.52","3968.64","percent of total billed charges",""
"System Septal Defect Intracardiac T2","PX-27000139","CDM","C1817","HCPCS","0278","RC","","","","both","","","4992.00","3744.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2660.74","53.3","","11682.00","11682.00","11682.00","1 through 10","1547.52","3968.64","percent of total billed charges",""
"System Septal Defect Intracardiac T2","PX-27000139","CDM","C1817","HCPCS","0278","RC","","","","both","","","4992.00","3744.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1911.94","38.3","","8650.88","8650.88","9853.20","1 through 10","1547.52","3968.64","percent of total billed charges",""
"System Septal Defect Intracardiac T2","PX-27000139","CDM","C1817","HCPCS","0278","RC","","","","both","","","4992.00","3744.00","WELLPOINT [1015]","HB AMC WELLPOINT","3683.10","73.78","","16472.06","16472.06","16472.06","1 through 10","1547.52","3968.64","percent of total billed charges",""
"System Septal Defect Intracardiac T2","PX-27000139","CDM","C1817","HCPCS","0278","RC","","","","outpatient","","","4992.00","3744.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4079.46","81.72","","17686.73","17686.73","17686.73","1 through 10","2608.82","4079.46","percent of total billed charges",""
"System Septal Defect Intracardiac T3","PX-27000140","CDM","C1817","HCPCS","0278","RC","","","","both","","","14401.53","10801.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11449.22","79.5","","17412.37","11682.00","17412.38","1 through 10","4464.47","11449.22","percent of total billed charges",""
"System Septal Defect Intracardiac T3","PX-27000140","CDM","C1817","HCPCS","0278","RC","","","","both","","","14401.53","10801.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7676.02","53.3","","11682.00","11682.00","11682.00","1 through 10","4464.47","11449.22","percent of total billed charges",""
"System Septal Defect Intracardiac T3","PX-27000140","CDM","C1817","HCPCS","0278","RC","","","","both","","","14401.53","10801.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5515.79","38.3","","8650.88","8650.88","9853.20","1 through 10","4464.47","11449.22","percent of total billed charges",""
"System Septal Defect Intracardiac T3","PX-27000140","CDM","C1817","HCPCS","0278","RC","","","","both","","","14401.53","10801.15","WELLPOINT [1015]","HB AMC WELLPOINT","10625.45","73.78","","16472.06","16472.06","16472.06","1 through 10","4464.47","11449.22","percent of total billed charges",""
"System Septal Defect Intracardiac T3","PX-27000140","CDM","C1817","HCPCS","0278","RC","","","","outpatient","","","14401.53","10801.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11768.93","81.72","","17686.73","17686.73","17686.73","1 through 10","7526.24","11768.93","percent of total billed charges",""
"SYSTEM SHOULDER 44+8MM INHANCE REVERSE HUMERAL SHELL X-LARGE","SUP-ITM-10320882","CDM","C1776","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2874.30","52.26","","1113.10","1113.10","1113.10","1 through 10","1705","4372.5","percent of total billed charges",""
"SYSTEM SHOULDER 44+8MM INHANCE REVERSE HUMERAL SHELL X-LARGE","SUP-ITM-10320882","CDM","C1776","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4372.50","79.5","","1293.60","1148.53","1603.80","1 through 10","1705","4372.5","percent of total billed charges",""
"SYSTEM SHOULDER 44+8MM INHANCE REVERSE HUMERAL SHELL X-LARGE","SUP-ITM-10320882","CDM","C1776","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2007.50","36.5","","1023.42","771.29","2068.67","33","1705","4372.5","percent of total billed charges",""
"SYSTEM SHOULDER 44+8MM INHANCE REVERSE HUMERAL SHELL X-LARGE","SUP-ITM-10320882","CDM","C1776","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2106.50","38.3","","850.52","759.78","1211.25","66","1705","4372.5","percent of total billed charges",""
"SYSTEM SHOULDER 44+8MM INHANCE REVERSE HUMERAL SHELL X-LARGE","SUP-ITM-10320882","CDM","C1776","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2359.50","42.9","","2548.09","2548.09","2548.09","1 through 10","1705","4372.5","percent of total billed charges",""
"SYSTEM SHOULDER 44+8MM INHANCE REVERSE HUMERAL SHELL X-LARGE","SUP-ITM-10320882","CDM","C1776","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2359.50","42.9","","956.46","956.46","956.46","1 through 10","1705","4372.5","percent of total billed charges",""
"SYSTEM SHOULDER 44+8MM INHANCE REVERSE HUMERAL SHELL X-LARGE","SUP-ITM-10320882","CDM","C1776","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","WELLPOINT [1015]","HB AMC WELLPOINT","4057.90","73.78","","2344.73","1619.47","2530.35","16","1705","4372.5","percent of total billed charges",""
"SYSTEM SHOULDER 44+8MM INHANCE REVERSE HUMERAL SHELL X-LARGE","SUP-ITM-10320882","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","AETNA [1001]","HB AMC AETNA HMO","3839.00","69.8","","1523.63","988.41","4330.26","39","2874.3","4494.6","percent of total billed charges",""
"SYSTEM SHOULDER 44+8MM INHANCE REVERSE HUMERAL SHELL X-LARGE","SUP-ITM-10320882","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","AETNA [1001]","HB AMC AETNA PPO","4422.00","80.4","","1670.25","1670.25","1670.25","1 through 10","2874.3","4494.6","percent of total billed charges",""
"SYSTEM SHOULDER 44+8MM INHANCE REVERSE HUMERAL SHELL X-LARGE","SUP-ITM-10320882","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2874.30","52.26","","1113.10","1113.10","1113.10","1 through 10","2874.3","4494.6","percent of total billed charges",""
"SYSTEM SHOULDER 44+8MM INHANCE REVERSE HUMERAL SHELL X-LARGE","SUP-ITM-10320882","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4494.60","81.72","","1738.90","1484.65","2716.94","38","2874.3","4494.6","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","875.00","656.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","457.28","52.26","","1113.10","1113.10","1113.10","1 through 10","271.25","695.63","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","875.00","656.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","695.63","79.5","","1293.60","1148.53","1603.80","1 through 10","271.25","695.63","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","319.38","36.5","","1023.42","771.29","2068.67","33","271.25","695.63","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","875.00","656.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","335.13","38.3","","850.52","759.78","1211.25","66","271.25","695.63","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","2548.09","2548.09","2548.09","1 through 10","271.25","695.63","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","875.00","656.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.38","42.9","","956.46","956.46","956.46","1 through 10","271.25","695.63","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","875.00","656.25","WELLPOINT [1015]","HB AMC WELLPOINT","645.58","73.78","","2344.73","1619.47","2530.35","16","271.25","695.63","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA HMO","610.75","69.8","","1523.63","988.41","4330.26","39","457.28","715.05","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","AETNA [1001]","HB AMC AETNA PPO","703.50","80.4","","1670.25","1670.25","1670.25","1 through 10","457.28","715.05","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","457.28","52.26","","1113.10","1113.10","1113.10","1 through 10","457.28","715.05","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","875.00","656.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","715.05","81.72","","1738.90","1484.65","2716.94","38","457.28","715.05","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","1302","3339","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3339.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1302","3339","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1533.00","36.5","","1023.42","771.29","2068.67","33","1302","3339","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1608.60","38.3","","850.52","759.78","1211.25","66","1302","3339","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","2548.09","2548.09","2548.09","1 through 10","1302","3339","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1801.80","42.9","","956.46","956.46","956.46","1 through 10","1302","3339","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB AMC WELLPOINT","3098.76","73.78","","2344.73","1619.47","2530.35","16","1302","3339","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA HMO","2931.60","69.8","","1523.63","988.41","4330.26","39","2194.92","3432.24","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","AETNA [1001]","HB AMC AETNA PPO","3376.80","80.4","","1670.25","1670.25","1670.25","1 through 10","2194.92","3432.24","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2194.92","52.26","","1113.10","1113.10","1113.10","1 through 10","2194.92","3432.24","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3432.24","81.72","","1738.90","1484.65","2716.94","38","2194.92","3432.24","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3135.60","52.26","","1113.10","1113.10","1113.10","1 through 10","1860","4770","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4770.00","79.5","","1293.60","1148.53","1603.80","1 through 10","1860","4770","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2190.00","36.5","","1023.42","771.29","2068.67","33","1860","4770","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2298.00","38.3","","850.52","759.78","1211.25","66","1860","4770","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2574.00","42.9","","2548.09","2548.09","2548.09","1 through 10","1860","4770","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2574.00","42.9","","956.46","956.46","956.46","1 through 10","1860","4770","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB AMC WELLPOINT","4426.80","73.78","","2344.73","1619.47","2530.35","16","1860","4770","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","AETNA [1001]","HB AMC AETNA HMO","4188.00","69.8","","1523.63","988.41","4330.26","39","3135.6","4903.2","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","AETNA [1001]","HB AMC AETNA PPO","4824.00","80.4","","1670.25","1670.25","1670.25","1 through 10","3135.6","4903.2","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3135.60","52.26","","1113.10","1113.10","1113.10","1 through 10","3135.6","4903.2","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4903.20","81.72","","1738.90","1484.65","2716.94","38","3135.6","4903.2","percent of total billed charges",""
"SYSTEM SHUNT 2 PROGAV PED WITH BURRHOLE RESERVOIR PC/1EA","SUP-ITM-10285710","CDM","C1889","HCPCS","0278","RC","","","","both","","","6299.75","4724.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5008.30","79.5","","1309.77","674.56","6049.93","26","1952.92","5008.3","percent of total billed charges",""
"SYSTEM SHUNT 2 PROGAV PED WITH BURRHOLE RESERVOIR PC/1EA","SUP-ITM-10285710","CDM","C1889","HCPCS","0278","RC","","","","both","","","6299.75","4724.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3357.77","53.3","","1901.83","1901.83","2962.25","1 through 10","1952.92","5008.3","percent of total billed charges",""
"SYSTEM SHUNT 2 PROGAV PED WITH BURRHOLE RESERVOIR PC/1EA","SUP-ITM-10285710","CDM","C1889","HCPCS","0278","RC","","","","both","","","6299.75","4724.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2299.41","36.5","","1620.31","1620.31","19908.88","1 through 10","1952.92","5008.3","percent of total billed charges",""
"SYSTEM SHUNT 2 PROGAV PED WITH BURRHOLE RESERVOIR PC/1EA","SUP-ITM-10285710","CDM","C1889","HCPCS","0278","RC","","","","both","","","6299.75","4724.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2412.80","38.3","","352.91","352.91","2046.30","1 through 10","1952.92","5008.3","percent of total billed charges",""
"SYSTEM SHUNT 2 PROGAV PED WITH BURRHOLE RESERVOIR PC/1EA","SUP-ITM-10285710","CDM","C1889","HCPCS","0278","RC","","","","both","","","6299.75","4724.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2702.59","42.9","","9668.75","9668.75","9668.75","1 through 10","1952.92","5008.3","percent of total billed charges",""
"SYSTEM SHUNT 2 PROGAV PED WITH BURRHOLE RESERVOIR PC/1EA","SUP-ITM-10285710","CDM","C1889","HCPCS","0278","RC","","","","both","","","6299.75","4724.81","WELLPOINT [1015]","HB AMC WELLPOINT","4647.96","73.78","","699.88","384.10","3443.31","33","1952.92","5008.3","percent of total billed charges",""
"SYSTEM SHUNT 2 PROGAV PED WITH BURRHOLE RESERVOIR PC/1EA","SUP-ITM-10285710","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6299.75","4724.81","AETNA [1001]","HB AMC AETNA HMO","4397.23","69.8","","1421.24","264.50","4933.46","29","3292.25","5148.16","percent of total billed charges",""
"SYSTEM SHUNT 2 PROGAV PED WITH BURRHOLE RESERVOIR PC/1EA","SUP-ITM-10285710","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6299.75","4724.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5065.00","80.4","","1022.97","1022.97","3607.50","1 through 10","3292.25","5148.16","percent of total billed charges",""
"SYSTEM SHUNT 2 PROGAV PED WITH BURRHOLE RESERVOIR PC/1EA","SUP-ITM-10285710","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6299.75","4724.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5148.16","81.72","","3010.54","693.88","5019.88","35","3292.25","5148.16","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED PRECHAMBER W/O GRAVITATIONAL UNIT PROGAV PC/1EA","SUP-ITM-10237590","CDM","C1889","HCPCS","0278","RC","","","","both","","","5769.50","4327.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4586.75","79.5","","1309.77","674.56","6049.93","26","1788.55","4586.75","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED PRECHAMBER W/O GRAVITATIONAL UNIT PROGAV PC/1EA","SUP-ITM-10237590","CDM","C1889","HCPCS","0278","RC","","","","both","","","5769.50","4327.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3075.14","53.3","","1901.83","1901.83","2962.25","1 through 10","1788.55","4586.75","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED PRECHAMBER W/O GRAVITATIONAL UNIT PROGAV PC/1EA","SUP-ITM-10237590","CDM","C1889","HCPCS","0278","RC","","","","both","","","5769.50","4327.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2105.87","36.5","","1620.31","1620.31","19908.88","1 through 10","1788.55","4586.75","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED PRECHAMBER W/O GRAVITATIONAL UNIT PROGAV PC/1EA","SUP-ITM-10237590","CDM","C1889","HCPCS","0278","RC","","","","both","","","5769.50","4327.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2209.72","38.3","","352.91","352.91","2046.30","1 through 10","1788.55","4586.75","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED PRECHAMBER W/O GRAVITATIONAL UNIT PROGAV PC/1EA","SUP-ITM-10237590","CDM","C1889","HCPCS","0278","RC","","","","both","","","5769.50","4327.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2475.12","42.9","","9668.75","9668.75","9668.75","1 through 10","1788.55","4586.75","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED PRECHAMBER W/O GRAVITATIONAL UNIT PROGAV PC/1EA","SUP-ITM-10237590","CDM","C1889","HCPCS","0278","RC","","","","both","","","5769.50","4327.12","WELLPOINT [1015]","HB AMC WELLPOINT","4256.74","73.78","","699.88","384.10","3443.31","33","1788.55","4586.75","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED PRECHAMBER W/O GRAVITATIONAL UNIT PROGAV PC/1EA","SUP-ITM-10237590","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5769.50","4327.12","AETNA [1001]","HB AMC AETNA HMO","4027.11","69.8","","1421.24","264.50","4933.46","29","3015.14","4714.84","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED PRECHAMBER W/O GRAVITATIONAL UNIT PROGAV PC/1EA","SUP-ITM-10237590","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5769.50","4327.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4638.68","80.4","","1022.97","1022.97","3607.50","1 through 10","3015.14","4714.84","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED PRECHAMBER W/O GRAVITATIONAL UNIT PROGAV PC/1EA","SUP-ITM-10237590","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5769.50","4327.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4714.84","81.72","","3010.54","693.88","5019.88","35","3015.14","4714.84","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED WITH PRECHAMBER PROGAV PC/1EA","SUP-ITM-10217367","CDM","C1889","HCPCS","0278","RC","","","","both","","","6300.00","4725.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5008.50","79.5","","1309.77","674.56","6049.93","26","1953","5008.5","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED WITH PRECHAMBER PROGAV PC/1EA","SUP-ITM-10217367","CDM","C1889","HCPCS","0278","RC","","","","both","","","6300.00","4725.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3357.90","53.3","","1901.83","1901.83","2962.25","1 through 10","1953","5008.5","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED WITH PRECHAMBER PROGAV PC/1EA","SUP-ITM-10217367","CDM","C1889","HCPCS","0278","RC","","","","both","","","6300.00","4725.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2299.50","36.5","","1620.31","1620.31","19908.88","1 through 10","1953","5008.5","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED WITH PRECHAMBER PROGAV PC/1EA","SUP-ITM-10217367","CDM","C1889","HCPCS","0278","RC","","","","both","","","6300.00","4725.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2412.90","38.3","","352.91","352.91","2046.30","1 through 10","1953","5008.5","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED WITH PRECHAMBER PROGAV PC/1EA","SUP-ITM-10217367","CDM","C1889","HCPCS","0278","RC","","","","both","","","6300.00","4725.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2702.70","42.9","","9668.75","9668.75","9668.75","1 through 10","1953","5008.5","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED WITH PRECHAMBER PROGAV PC/1EA","SUP-ITM-10217367","CDM","C1889","HCPCS","0278","RC","","","","both","","","6300.00","4725.00","WELLPOINT [1015]","HB AMC WELLPOINT","4648.14","73.78","","699.88","384.10","3443.31","33","1953","5008.5","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED WITH PRECHAMBER PROGAV PC/1EA","SUP-ITM-10217367","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6300.00","4725.00","AETNA [1001]","HB AMC AETNA HMO","4397.40","69.8","","1421.24","264.50","4933.46","29","3292.38","5148.36","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED WITH PRECHAMBER PROGAV PC/1EA","SUP-ITM-10217367","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6300.00","4725.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5065.20","80.4","","1022.97","1022.97","3607.50","1 through 10","3292.38","5148.36","percent of total billed charges",""
"SYSTEM SHUNT 2.0 PED WITH PRECHAMBER PROGAV PC/1EA","SUP-ITM-10217367","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6300.00","4725.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5148.36","81.72","","3010.54","693.88","5019.88","35","3292.38","5148.36","percent of total billed charges",""
"SYSTEM SHUNT PROGAV 2.0 W/ SA2.0 15 A. PRECHAMBER FX538T","SUP-ITM-10279965","CDM","C1889","HCPCS","0278","RC","","","","both","","","8312.50","6234.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6608.44","79.5","","1309.77","674.56","6049.93","26","2576.88","6608.44","percent of total billed charges",""
"SYSTEM SHUNT PROGAV 2.0 W/ SA2.0 15 A. PRECHAMBER FX538T","SUP-ITM-10279965","CDM","C1889","HCPCS","0278","RC","","","","both","","","8312.50","6234.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4430.56","53.3","","1901.83","1901.83","2962.25","1 through 10","2576.88","6608.44","percent of total billed charges",""
"SYSTEM SHUNT PROGAV 2.0 W/ SA2.0 15 A. PRECHAMBER FX538T","SUP-ITM-10279965","CDM","C1889","HCPCS","0278","RC","","","","both","","","8312.50","6234.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3034.06","36.5","","1620.31","1620.31","19908.88","1 through 10","2576.88","6608.44","percent of total billed charges",""
"SYSTEM SHUNT PROGAV 2.0 W/ SA2.0 15 A. PRECHAMBER FX538T","SUP-ITM-10279965","CDM","C1889","HCPCS","0278","RC","","","","both","","","8312.50","6234.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3183.69","38.3","","352.91","352.91","2046.30","1 through 10","2576.88","6608.44","percent of total billed charges",""
"SYSTEM SHUNT PROGAV 2.0 W/ SA2.0 15 A. PRECHAMBER FX538T","SUP-ITM-10279965","CDM","C1889","HCPCS","0278","RC","","","","both","","","8312.50","6234.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3566.06","42.9","","9668.75","9668.75","9668.75","1 through 10","2576.88","6608.44","percent of total billed charges",""
"SYSTEM SHUNT PROGAV 2.0 W/ SA2.0 15 A. PRECHAMBER FX538T","SUP-ITM-10279965","CDM","C1889","HCPCS","0278","RC","","","","both","","","8312.50","6234.37","WELLPOINT [1015]","HB AMC WELLPOINT","6132.96","73.78","","699.88","384.10","3443.31","33","2576.88","6608.44","percent of total billed charges",""
"SYSTEM SHUNT PROGAV 2.0 W/ SA2.0 15 A. PRECHAMBER FX538T","SUP-ITM-10279965","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8312.50","6234.37","AETNA [1001]","HB AMC AETNA HMO","5802.13","69.8","","1421.24","264.50","4933.46","29","4344.11","6792.98","percent of total billed charges",""
"SYSTEM SHUNT PROGAV 2.0 W/ SA2.0 15 A. PRECHAMBER FX538T","SUP-ITM-10279965","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8312.50","6234.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6683.25","80.4","","1022.97","1022.97","3607.50","1 through 10","4344.11","6792.98","percent of total billed charges",""
"SYSTEM SHUNT PROGAV 2.0 W/ SA2.0 15 A. PRECHAMBER FX538T","SUP-ITM-10279965","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8312.50","6234.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6792.98","81.72","","3010.54","693.88","5019.88","35","4344.11","6792.98","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","both","","","4852.21","3639.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3857.51","79.5","","1632.15","1632.15","1632.15","1 through 10","1504.19","3857.51","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","both","","","4852.21","3639.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2586.23","53.3","","9709.13","9709.13","9709.13","1 through 10","1504.19","3857.51","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","both","","","4852.21","3639.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3153.94","65","","2685.95","2190.09","2685.96","1 through 10","1504.19","3857.51","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","both","","","4852.21","3639.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1771.06","36.5","","1495.87","1455.73","1541.33","1 through 10","1504.19","3857.51","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","both","","","4852.21","3639.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1858.40","38.3","","1615.71","1615.71","1615.71","1 through 10","1504.19","3857.51","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","both","","","4852.21","3639.16","WELLPOINT [1015]","HB AMC WELLPOINT","3579.96","73.78","","3076.44","3076.44","3076.44","1 through 10","1504.19","3857.51","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4852.21","3639.16","AETNA [1001]","HB AMC AETNA HMO","3386.84","69.8","","4568.79","2411.14","4568.79","1 through 10","2535.76","3965.23","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4852.21","3639.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3901.18","80.4","","2411.14","1545.60","3223.14","1 through 10","2535.76","3965.23","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4852.21","3639.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3965.23","81.72","","1816.95","1816.95","1816.95","1 through 10","2535.76","3965.23","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4852.21","3639.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3965.23","81.72","","3303.30","3303.30","3303.30","1 through 10","2535.76","3965.23","percent of total billed charges",""
"SYSTEM SLING BLUE ADVANTAGE","SUP-ITM-10211688","CDM","C1771","HCPCS","0278","RC","","","","both","","","3973.33","2980.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3158.80","79.5","","1632.15","1632.15","1632.15","1 through 10","1231.73","3158.8","percent of total billed charges",""
"SYSTEM SLING BLUE ADVANTAGE","SUP-ITM-10211688","CDM","C1771","HCPCS","0278","RC","","","","both","","","3973.33","2980.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2117.78","53.3","","9709.13","9709.13","9709.13","1 through 10","1231.73","3158.8","percent of total billed charges",""
"SYSTEM SLING BLUE ADVANTAGE","SUP-ITM-10211688","CDM","C1771","HCPCS","0278","RC","","","","both","","","3973.33","2980.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2582.66","65","","2685.95","2190.09","2685.96","1 through 10","1231.73","3158.8","percent of total billed charges",""
"SYSTEM SLING BLUE ADVANTAGE","SUP-ITM-10211688","CDM","C1771","HCPCS","0278","RC","","","","both","","","3973.33","2980.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1450.27","36.5","","1495.87","1455.73","1541.33","1 through 10","1231.73","3158.8","percent of total billed charges",""
"SYSTEM SLING BLUE ADVANTAGE","SUP-ITM-10211688","CDM","C1771","HCPCS","0278","RC","","","","both","","","3973.33","2980.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1521.79","38.3","","1615.71","1615.71","1615.71","1 through 10","1231.73","3158.8","percent of total billed charges",""
"SYSTEM SLING BLUE ADVANTAGE","SUP-ITM-10211688","CDM","C1771","HCPCS","0278","RC","","","","both","","","3973.33","2980.00","WELLPOINT [1015]","HB AMC WELLPOINT","2931.52","73.78","","3076.44","3076.44","3076.44","1 through 10","1231.73","3158.8","percent of total billed charges",""
"SYSTEM SLING BLUE ADVANTAGE","SUP-ITM-10211688","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3973.33","2980.00","AETNA [1001]","HB AMC AETNA HMO","2773.38","69.8","","4568.79","2411.14","4568.79","1 through 10","2076.46","3247.01","percent of total billed charges",""
"SYSTEM SLING BLUE ADVANTAGE","SUP-ITM-10211688","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3973.33","2980.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3194.56","80.4","","2411.14","1545.60","3223.14","1 through 10","2076.46","3247.01","percent of total billed charges",""
"SYSTEM SLING BLUE ADVANTAGE","SUP-ITM-10211688","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3973.33","2980.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3247.01","81.72","","1816.95","1816.95","1816.95","1 through 10","2076.46","3247.01","percent of total billed charges",""
"SYSTEM SLING BLUE ADVANTAGE","SUP-ITM-10211688","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3973.33","2980.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3247.01","81.72","","3303.30","3303.30","3303.30","1 through 10","2076.46","3247.01","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","both","","","18388.50","13791.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","14618.86","79.5","","1632.15","1632.15","1632.15","1 through 10","5700.44","14618.86","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","both","","","18388.50","13791.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9801.07","53.3","","9709.13","9709.13","9709.13","1 through 10","5700.44","14618.86","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","both","","","18388.50","13791.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","11952.53","65","","2685.95","2190.09","2685.96","1 through 10","5700.44","14618.86","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","both","","","18388.50","13791.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6711.80","36.5","","1495.87","1455.73","1541.33","1 through 10","5700.44","14618.86","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","both","","","18388.50","13791.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7042.80","38.3","","1615.71","1615.71","1615.71","1 through 10","5700.44","14618.86","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","both","","","18388.50","13791.37","WELLPOINT [1015]","HB AMC WELLPOINT","13567.04","73.78","","3076.44","3076.44","3076.44","1 through 10","5700.44","14618.86","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","18388.50","13791.37","AETNA [1001]","HB AMC AETNA HMO","12835.17","69.8","","4568.79","2411.14","4568.79","1 through 10","9609.83","15027.08","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","18388.50","13791.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","14784.35","80.4","","2411.14","1545.60","3223.14","1 through 10","9609.83","15027.08","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","18388.50","13791.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","15027.08","81.72","","1816.95","1816.95","1816.95","1 through 10","9609.83","15027.08","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","18388.50","13791.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15027.08","81.72","","3303.30","3303.30","3303.30","1 through 10","9609.83","15027.08","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","both","","","3936.20","2952.15","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3129.28","79.5","","1632.15","1632.15","1632.15","1 through 10","1220.22","3129.28","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","both","","","3936.20","2952.15","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2097.99","53.3","","9709.13","9709.13","9709.13","1 through 10","1220.22","3129.28","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","both","","","3936.20","2952.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2558.53","65","","2685.95","2190.09","2685.96","1 through 10","1220.22","3129.28","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","both","","","3936.20","2952.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1436.71","36.5","","1495.87","1455.73","1541.33","1 through 10","1220.22","3129.28","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","both","","","3936.20","2952.15","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1507.56","38.3","","1615.71","1615.71","1615.71","1 through 10","1220.22","3129.28","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","both","","","3936.20","2952.15","WELLPOINT [1015]","HB AMC WELLPOINT","2904.13","73.78","","3076.44","3076.44","3076.44","1 through 10","1220.22","3129.28","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3936.20","2952.15","AETNA [1001]","HB AMC AETNA HMO","2747.47","69.8","","4568.79","2411.14","4568.79","1 through 10","2057.06","3216.66","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3936.20","2952.15","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3164.70","80.4","","2411.14","1545.60","3223.14","1 through 10","2057.06","3216.66","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3936.20","2952.15","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3216.66","81.72","","1816.95","1816.95","1816.95","1 through 10","2057.06","3216.66","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3936.20","2952.15","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3216.66","81.72","","3303.30","3303.30","3303.30","1 through 10","2057.06","3216.66","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX15.0CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312095","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4712.50","65","","6652.80","6652.80","6652.80","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX15.0CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312095","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5763.75","79.5","","2612.61","795.38","2612.61","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX15.0CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312095","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3864.25","53.3","","1101.80","1101.80","1101.80","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX15.0CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312095","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4712.50","65","","1820.00","910.00","1820.00","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX15.0CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312095","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2646.25","36.5","","1257.80","693.44","2424.50","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX15.0CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312095","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2776.75","38.3","","1950.11","547.40","2346.00","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX15.0CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312095","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3110.25","42.9","","5096.18","5096.18","5096.18","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX15.0CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312095","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","WELLPOINT [1015]","HB AMC WELLPOINT","5349.05","73.78","","1172.59","1172.59","4829.94","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX15.0CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312095","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","AETNA [1001]","HB AMC AETNA HMO","5060.50","69.8","","1806.84","947.80","5091.72","1 through 10","3788.85","5924.7","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX15.0CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312095","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5924.70","81.72","","1259.05","615.58","4586.56","1 through 10","3788.85","5924.7","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX6.2CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312092","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","4712.50","65","","6652.80","6652.80","6652.80","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX6.2CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312092","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5763.75","79.5","","2612.61","795.38","2612.61","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX6.2CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312092","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3864.25","53.3","","1101.80","1101.80","1101.80","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX6.2CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312092","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4712.50","65","","1820.00","910.00","1820.00","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX6.2CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312092","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2646.25","36.5","","1257.80","693.44","2424.50","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX6.2CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312092","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2776.75","38.3","","1950.11","547.40","2346.00","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX6.2CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312092","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3110.25","42.9","","5096.18","5096.18","5096.18","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX6.2CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312092","CDM","C1874","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","WELLPOINT [1015]","HB AMC WELLPOINT","5349.05","73.78","","1172.59","1172.59","4829.94","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX6.2CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312092","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","AETNA [1001]","HB AMC AETNA HMO","5060.50","69.8","","1806.84","947.80","5091.72","1 through 10","3788.85","5924.7","percent of total billed charges",""
"SYSTEM STENT 18.5FR 23MMX6.2CM ESOPHAGEAL AGILE OTW FULLY COVERED","SUP-ITM-10312092","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5924.70","81.72","","1259.05","615.58","4586.56","1 through 10","3788.85","5924.7","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL FULLY COVERED","SUP-ITM-10280387","CDM","C1876","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4756.00","65.6","","751.18","751.18","751.18","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL FULLY COVERED","SUP-ITM-10280387","CDM","C1876","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5763.75","79.5","","4820.38","3211.27","4820.38","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL FULLY COVERED","SUP-ITM-10280387","CDM","C1876","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2646.25","36.5","","641.00","641.00","641.00","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL FULLY COVERED","SUP-ITM-10280387","CDM","C1876","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2776.75","38.3","","1098.43","1098.43","1098.43","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL FULLY COVERED","SUP-ITM-10280387","CDM","C1876","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3110.25","42.9","","4896.33","4896.33","4896.33","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL FULLY COVERED","SUP-ITM-10280387","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","AETNA [1001]","HB AMC AETNA HMO","5060.50","69.8","","175.60","163.11","1063.91","1 through 10","3788.85","5924.7","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL FULLY COVERED","SUP-ITM-10280387","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5924.70","81.72","","105.94","85.10","105.94","1 through 10","3788.85","5924.7","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL PARTIALLY COVERED","SUP-ITM-10280386","CDM","C1876","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4756.00","65.6","","751.18","751.18","751.18","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL PARTIALLY COVERED","SUP-ITM-10280386","CDM","C1876","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5763.75","79.5","","4820.38","3211.27","4820.38","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL PARTIALLY COVERED","SUP-ITM-10280386","CDM","C1876","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2646.25","36.5","","641.00","641.00","641.00","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL PARTIALLY COVERED","SUP-ITM-10280386","CDM","C1876","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2776.75","38.3","","1098.43","1098.43","1098.43","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL PARTIALLY COVERED","SUP-ITM-10280386","CDM","C1876","HCPCS","0278","RC","","","","both","","","7250.00","5437.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3110.25","42.9","","4896.33","4896.33","4896.33","1 through 10","2247.5","5763.75","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL PARTIALLY COVERED","SUP-ITM-10280386","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","AETNA [1001]","HB AMC AETNA HMO","5060.50","69.8","","175.60","163.11","1063.91","1 through 10","3788.85","5924.7","percent of total billed charges",""
"SYSTEM STENT 23/18MMX10CM AGILE ESOPHAGEAL PARTIALLY COVERED","SUP-ITM-10280386","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","7250.00","5437.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5924.70","81.72","","105.94","85.10","105.94","1 through 10","3788.85","5924.7","percent of total billed charges",""
"SYSTEM STENT 6FR 7.5MMX60MMX120CM SUPERA PERIPHERAL","SUP-ITM-10321522","CDM","C1876","HCPCS","0278","RC","","","","both","","","4532.50","3399.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","2973.32","65.6","","751.18","751.18","751.18","1 through 10","1405.08","3603.34","percent of total billed charges",""
"SYSTEM STENT 6FR 7.5MMX60MMX120CM SUPERA PERIPHERAL","SUP-ITM-10321522","CDM","C1876","HCPCS","0278","RC","","","","both","","","4532.50","3399.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3603.34","79.5","","4820.38","3211.27","4820.38","1 through 10","1405.08","3603.34","percent of total billed charges",""
"SYSTEM STENT 6FR 7.5MMX60MMX120CM SUPERA PERIPHERAL","SUP-ITM-10321522","CDM","C1876","HCPCS","0278","RC","","","","both","","","4532.50","3399.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1654.36","36.5","","641.00","641.00","641.00","1 through 10","1405.08","3603.34","percent of total billed charges",""
"SYSTEM STENT 6FR 7.5MMX60MMX120CM SUPERA PERIPHERAL","SUP-ITM-10321522","CDM","C1876","HCPCS","0278","RC","","","","both","","","4532.50","3399.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1735.95","38.3","","1098.43","1098.43","1098.43","1 through 10","1405.08","3603.34","percent of total billed charges",""
"SYSTEM STENT 6FR 7.5MMX60MMX120CM SUPERA PERIPHERAL","SUP-ITM-10321522","CDM","C1876","HCPCS","0278","RC","","","","both","","","4532.50","3399.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.44","42.9","","4896.33","4896.33","4896.33","1 through 10","1405.08","3603.34","percent of total billed charges",""
"SYSTEM STENT 6FR 7.5MMX60MMX120CM SUPERA PERIPHERAL","SUP-ITM-10321522","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4532.50","3399.37","AETNA [1001]","HB AMC AETNA HMO","3163.69","69.8","","175.60","163.11","1063.91","1 through 10","2368.68","3703.96","percent of total billed charges",""
"SYSTEM STENT 6FR 7.5MMX60MMX120CM SUPERA PERIPHERAL","SUP-ITM-10321522","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4532.50","3399.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3703.96","81.72","","105.94","85.10","105.94","1 through 10","2368.68","3703.96","percent of total billed charges",""
"SYSTEM STENT ENROUTE 7MM 40MM TRANSCAROTID","SUP-ITM-10159270","CDM","C1876","HCPCS","0278","RC","","","","both","","","6125.00","4593.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","4018.00","65.6","","751.18","751.18","751.18","1 through 10","1898.75","4869.38","percent of total billed charges",""
"SYSTEM STENT ENROUTE 7MM 40MM TRANSCAROTID","SUP-ITM-10159270","CDM","C1876","HCPCS","0278","RC","","","","both","","","6125.00","4593.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4869.38","79.5","","4820.38","3211.27","4820.38","1 through 10","1898.75","4869.38","percent of total billed charges",""
"SYSTEM STENT ENROUTE 7MM 40MM TRANSCAROTID","SUP-ITM-10159270","CDM","C1876","HCPCS","0278","RC","","","","both","","","6125.00","4593.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2235.63","36.5","","641.00","641.00","641.00","1 through 10","1898.75","4869.38","percent of total billed charges",""
"SYSTEM STENT ENROUTE 7MM 40MM TRANSCAROTID","SUP-ITM-10159270","CDM","C1876","HCPCS","0278","RC","","","","both","","","6125.00","4593.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2345.88","38.3","","1098.43","1098.43","1098.43","1 through 10","1898.75","4869.38","percent of total billed charges",""
"SYSTEM STENT ENROUTE 7MM 40MM TRANSCAROTID","SUP-ITM-10159270","CDM","C1876","HCPCS","0278","RC","","","","both","","","6125.00","4593.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2627.63","42.9","","4896.33","4896.33","4896.33","1 through 10","1898.75","4869.38","percent of total billed charges",""
"SYSTEM STENT ENROUTE 7MM 40MM TRANSCAROTID","SUP-ITM-10159270","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","6125.00","4593.75","AETNA [1001]","HB AMC AETNA HMO","4275.25","69.8","","175.60","163.11","1063.91","1 through 10","3200.93","5005.35","percent of total billed charges",""
"SYSTEM STENT ENROUTE 7MM 40MM TRANSCAROTID","SUP-ITM-10159270","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","6125.00","4593.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5005.35","81.72","","105.94","85.10","105.94","1 through 10","3200.93","5005.35","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 10FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000376","CDM","C2617","HCPCS","0278","RC","","","","both","","","348.46","261.34","CIGNA [1006]","HB AMC CIGNA HMO / PPO","277.03","79.5","","304.65","204.39","304.65","1 through 10","108.02","277.03","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 10FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000376","CDM","C2617","HCPCS","0278","RC","","","","both","","","348.46","261.34","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","185.73","53.3","","204.39","204.39","304.65","1 through 10","108.02","277.03","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 10FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000376","CDM","C2617","HCPCS","0278","RC","","","","both","","","348.46","261.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.19","36.5","","144.39","122.71","144.39","1 through 10","108.02","277.03","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 10FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000376","CDM","C2617","HCPCS","0278","RC","","","","both","","","348.46","261.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","133.46","38.3","","151.36","147.10","454.08","13","108.02","277.03","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 10FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000376","CDM","C2617","HCPCS","0278","RC","","","","both","","","348.46","261.34","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","268.31","77","","304.65","304.65","304.65","1 through 10","108.02","277.03","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 10FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000376","CDM","C2617","HCPCS","0278","RC","","","","both","","","348.46","261.34","WELLPOINT [1015]","HB AMC WELLPOINT","257.09","73.78","","675.30","288.20","675.30","1 through 10","108.02","277.03","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 10FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000376","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","348.46","261.34","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","284.76","81.72","","183.26","154.72","309.45","1 through 10","182.11","284.76","percent of total billed charges",""
"SYSTEM STIMULATOR EVOKE G4 CLOSED LOOP","SUP-ITM-10328866","CDM","C1820","HCPCS","0278","RC","","","","both","","","67500.00","50625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","35977.50","53.3","","54287.50","54287.50","54287.50","1 through 10","20925","53662.5","percent of total billed charges",""
"SYSTEM STIMULATOR EVOKE G4 CLOSED LOOP","SUP-ITM-10328866","CDM","C1820","HCPCS","0278","RC","","","","both","","","67500.00","50625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24637.50","36.5","","10467.31","10467.31","10467.31","1 through 10","20925","53662.5","percent of total billed charges",""
"SYSTEM STIMULATOR EVOKE G4 CLOSED LOOP","SUP-ITM-10328866","CDM","C1820","HCPCS","0278","RC","","","","both","","","67500.00","50625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25852.50","38.3","","21505.00","21505.00","21505.00","1 through 10","20925","53662.5","percent of total billed charges",""
"SYSTEM STIMULATOR EVOKE G4 CLOSED LOOP","SUP-ITM-10328866","CDM","C1820","HCPCS","0278","RC","","","","both","","","67500.00","50625.00","WELLPOINT [1015]","HB AMC WELLPOINT","49801.50","73.78","","40016.88","40016.88","40016.88","1 through 10","20925","53662.5","percent of total billed charges",""
"SYSTEM SURGICAL VASCULAR PROSTAR XL10F PERCUTANEOUS PK/5EA","SUP-ITM-10321258","CDM","C1760","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1819.95","52.26","","487.31","487.31","487.31","1 through 10","1079.58","2768.59","percent of total billed charges",""
"SYSTEM SURGICAL VASCULAR PROSTAR XL10F PERCUTANEOUS PK/5EA","SUP-ITM-10321258","CDM","C1760","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","2500.44","71.8","","612.50","612.50","612.50","1 through 10","1079.58","2768.59","percent of total billed charges",""
"SYSTEM SURGICAL VASCULAR PROSTAR XL10F PERCUTANEOUS PK/5EA","SUP-ITM-10321258","CDM","C1760","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2437.75","70","","612.50","612.50","612.50","1 through 10","1079.58","2768.59","percent of total billed charges",""
"SYSTEM SURGICAL VASCULAR PROSTAR XL10F PERCUTANEOUS PK/5EA","SUP-ITM-10321258","CDM","C1760","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2768.59","79.5","","742.96","323.40","1446.12","32","1079.58","2768.59","percent of total billed charges",""
"SYSTEM SURGICAL VASCULAR PROSTAR XL10F PERCUTANEOUS PK/5EA","SUP-ITM-10321258","CDM","C1760","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1856.17","53.3","","323.40","323.40","550.90","13","1079.58","2768.59","percent of total billed charges",""
"SYSTEM SURGICAL VASCULAR PROSTAR XL10F PERCUTANEOUS PK/5EA","SUP-ITM-10321258","CDM","C1760","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1271.11","36.5","","285.08","194.16","582.48","27","1079.58","2768.59","percent of total billed charges",""
"SYSTEM SURGICAL VASCULAR PROSTAR XL10F PERCUTANEOUS PK/5EA","SUP-ITM-10321258","CDM","C1760","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1333.80","38.3","","239.49","233.98","600.08","52","1079.58","2768.59","percent of total billed charges",""
"SYSTEM SURGICAL VASCULAR PROSTAR XL10F PERCUTANEOUS PK/5EA","SUP-ITM-10321258","CDM","C1760","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1493.99","42.9","","278.69","278.69","278.69","1 through 10","1079.58","2768.59","percent of total billed charges",""
"SYSTEM SURGICAL VASCULAR PROSTAR XL10F PERCUTANEOUS PK/5EA","SUP-ITM-10321258","CDM","C1760","HCPCS","0278","RC","","","","both","","","3482.50","2611.87","WELLPOINT [1015]","HB AMC WELLPOINT","2569.39","73.78","","456.01","456.01","456.01","33","1079.58","2768.59","percent of total billed charges",""
"SYSTEM SURGICAL VASCULAR PROSTAR XL10F PERCUTANEOUS PK/5EA","SUP-ITM-10321258","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","3482.50","2611.87","AETNA [1001]","HB AMC AETNA HMO","2430.79","69.8","","290.33","290.33","1575.00","1 through 10","1819.95","2845.9","percent of total billed charges",""
"SYSTEM SURGICAL VASCULAR PROSTAR XL10F PERCUTANEOUS PK/5EA","SUP-ITM-10321258","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","3482.50","2611.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1819.95","52.26","","487.31","487.31","487.31","1 through 10","1819.95","2845.9","percent of total billed charges",""
"SYSTEM SURGICAL VASCULAR PROSTAR XL10F PERCUTANEOUS PK/5EA","SUP-ITM-10321258","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","3482.50","2611.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2845.90","81.72","","489.63","489.63","489.63","1 through 10","1819.95","2845.9","percent of total billed charges",""
"SYSTEM SURGICAL VASCULAR PROSTAR XL10F PERCUTANEOUS PK/5EA","SUP-ITM-10321258","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","3482.50","2611.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2845.90","81.72","","489.64","489.63","1888.58","19","1819.95","2845.9","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4785.00","3588.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3804.08","79.5","","800.18","480.96","1887.97","195","1483.35","3804.08","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4785.00","3588.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2550.41","53.3","","813.12","216.42","1444.50","81","1483.35","3804.08","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4785.00","3588.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1483.35","31","","432.60","432.60","432.60","1 through 10","1483.35","3804.08","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4785.00","3588.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1746.53","36.5","","148.37","54.89","631.39","94","1483.35","3804.08","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4785.00","3588.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1832.66","38.3","","279.30","91.72","1116.77","266","1483.35","3804.08","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4785.00","3588.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2052.77","42.9","","731.00","63.70","731.00","1 through 10","1483.35","3804.08","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4785.00","3588.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2052.77","42.9","","384.74","384.74","384.74","1 through 10","1483.35","3804.08","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","4785.00","3588.75","WELLPOINT [1015]","HB AMC WELLPOINT","3530.37","73.78","","286.63","119.22","1107.45","105","1483.35","3804.08","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4785.00","3588.75","AETNA [1001]","HB AMC AETNA HMO","3339.93","69.8","","675.31","184.75","1721.50","286","2500.64","3910.3","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4785.00","3588.75","AETNA [1001]","HB AMC AETNA PPO","3847.14","80.4","","1261.44","103.12","1514.10","21","2500.64","3910.3","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4785.00","3588.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3847.14","80.4","","1365.00","1365.00","1365.00","1 through 10","2500.64","3910.3","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4785.00","3588.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3910.30","81.72","","5157.68","5157.68","5157.68","1 through 10","2500.64","3910.3","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4785.00","3588.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3910.30","81.72","","431.26","71.26","1459.57","88","2500.64","3910.3","percent of total billed charges",""
"SYSTEM TRANSCATHETER PACING MICRA AV","SUP-ITM-10269588","CDM","C1786","HCPCS","0275","RC","","","","both","","","28125.00","21093.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10771.88","38.3","","330.52","330.52","330.52","1 through 10","8718.75","22359.38","percent of total billed charges",""
"SYSTEM TRANSCATHETER PACING MICRA AV","SUP-ITM-10269588","CDM","C1786","HCPCS","0275","RC","","","","both","","","28125.00","21093.75","WELLPOINT [1015]","HB AMC WELLPOINT","20750.63","73.78","","22527.75","22527.75","22527.75","1 through 10","8718.75","22359.38","percent of total billed charges",""
"SYSTEM TRIALING 60CM EVOKE","SUP-ITM-10317742","CDM","C1897","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","2260.50","2260.50","2260.50","1 through 10","1550","3975","percent of total billed charges",""
"SYSTEM VALVE 14GA 46CM 91CM LUMBAR WATER 2 VALVE CATHETER CLOSED TIP PERITONEAL CATHETER SS STRAIGHT STEPDOWN","SUP-ITM-10001357","CDM","C1889","HCPCS","0278","RC","","","","both","","","4783.80","3587.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3803.12","79.5","","1309.77","674.56","6049.93","26","1482.98","3803.12","percent of total billed charges",""
"SYSTEM VALVE 14GA 46CM 91CM LUMBAR WATER 2 VALVE CATHETER CLOSED TIP PERITONEAL CATHETER SS STRAIGHT STEPDOWN","SUP-ITM-10001357","CDM","C1889","HCPCS","0278","RC","","","","both","","","4783.80","3587.85","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2549.77","53.3","","1901.83","1901.83","2962.25","1 through 10","1482.98","3803.12","percent of total billed charges",""
"SYSTEM VALVE 14GA 46CM 91CM LUMBAR WATER 2 VALVE CATHETER CLOSED TIP PERITONEAL CATHETER SS STRAIGHT STEPDOWN","SUP-ITM-10001357","CDM","C1889","HCPCS","0278","RC","","","","both","","","4783.80","3587.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1746.09","36.5","","1620.31","1620.31","19908.88","1 through 10","1482.98","3803.12","percent of total billed charges",""
"SYSTEM VALVE 14GA 46CM 91CM LUMBAR WATER 2 VALVE CATHETER CLOSED TIP PERITONEAL CATHETER SS STRAIGHT STEPDOWN","SUP-ITM-10001357","CDM","C1889","HCPCS","0278","RC","","","","both","","","4783.80","3587.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1832.20","38.3","","352.91","352.91","2046.30","1 through 10","1482.98","3803.12","percent of total billed charges",""
"SYSTEM VALVE 14GA 46CM 91CM LUMBAR WATER 2 VALVE CATHETER CLOSED TIP PERITONEAL CATHETER SS STRAIGHT STEPDOWN","SUP-ITM-10001357","CDM","C1889","HCPCS","0278","RC","","","","both","","","4783.80","3587.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2052.25","42.9","","9668.75","9668.75","9668.75","1 through 10","1482.98","3803.12","percent of total billed charges",""
"SYSTEM VALVE 14GA 46CM 91CM LUMBAR WATER 2 VALVE CATHETER CLOSED TIP PERITONEAL CATHETER SS STRAIGHT STEPDOWN","SUP-ITM-10001357","CDM","C1889","HCPCS","0278","RC","","","","both","","","4783.80","3587.85","WELLPOINT [1015]","HB AMC WELLPOINT","3529.49","73.78","","699.88","384.10","3443.31","33","1482.98","3803.12","percent of total billed charges",""
"SYSTEM VALVE 14GA 46CM 91CM LUMBAR WATER 2 VALVE CATHETER CLOSED TIP PERITONEAL CATHETER SS STRAIGHT STEPDOWN","SUP-ITM-10001357","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4783.80","3587.85","AETNA [1001]","HB AMC AETNA HMO","3339.09","69.8","","1421.24","264.50","4933.46","29","2500.01","3909.32","percent of total billed charges",""
"SYSTEM VALVE 14GA 46CM 91CM LUMBAR WATER 2 VALVE CATHETER CLOSED TIP PERITONEAL CATHETER SS STRAIGHT STEPDOWN","SUP-ITM-10001357","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4783.80","3587.85","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3846.18","80.4","","1022.97","1022.97","3607.50","1 through 10","2500.01","3909.32","percent of total billed charges",""
"SYSTEM VALVE 14GA 46CM 91CM LUMBAR WATER 2 VALVE CATHETER CLOSED TIP PERITONEAL CATHETER SS STRAIGHT STEPDOWN","SUP-ITM-10001357","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4783.80","3587.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3909.32","81.72","","3010.54","693.88","5019.88","35","2500.01","3909.32","percent of total billed charges",""
"SYSTEM VALVE 5MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10268999","CDM","C1889","HCPCS","0278","RC","","","","both","","","6625.00","4968.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5266.88","79.5","","1309.77","674.56","6049.93","26","2053.75","5266.88","percent of total billed charges",""
"SYSTEM VALVE 5MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10268999","CDM","C1889","HCPCS","0278","RC","","","","both","","","6625.00","4968.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3531.13","53.3","","1901.83","1901.83","2962.25","1 through 10","2053.75","5266.88","percent of total billed charges",""
"SYSTEM VALVE 5MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10268999","CDM","C1889","HCPCS","0278","RC","","","","both","","","6625.00","4968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2418.13","36.5","","1620.31","1620.31","19908.88","1 through 10","2053.75","5266.88","percent of total billed charges",""
"SYSTEM VALVE 5MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10268999","CDM","C1889","HCPCS","0278","RC","","","","both","","","6625.00","4968.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2537.38","38.3","","352.91","352.91","2046.30","1 through 10","2053.75","5266.88","percent of total billed charges",""
"SYSTEM VALVE 5MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10268999","CDM","C1889","HCPCS","0278","RC","","","","both","","","6625.00","4968.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2842.13","42.9","","9668.75","9668.75","9668.75","1 through 10","2053.75","5266.88","percent of total billed charges",""
"SYSTEM VALVE 5MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10268999","CDM","C1889","HCPCS","0278","RC","","","","both","","","6625.00","4968.75","WELLPOINT [1015]","HB AMC WELLPOINT","4887.93","73.78","","699.88","384.10","3443.31","33","2053.75","5266.88","percent of total billed charges",""
"SYSTEM VALVE 5MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10268999","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6625.00","4968.75","AETNA [1001]","HB AMC AETNA HMO","4624.25","69.8","","1421.24","264.50","4933.46","29","3462.23","5413.95","percent of total billed charges",""
"SYSTEM VALVE 5MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10268999","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6625.00","4968.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5326.50","80.4","","1022.97","1022.97","3607.50","1 through 10","3462.23","5413.95","percent of total billed charges",""
"SYSTEM VALVE 5MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10268999","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6625.00","4968.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5413.95","81.72","","3010.54","693.88","5019.88","35","3462.23","5413.95","percent of total billed charges",""
"SYSTEM VALVE 9MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10269002","CDM","C1889","HCPCS","0278","RC","","","","both","","","8625.00","6468.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6856.88","79.5","","1309.77","674.56","6049.93","26","2673.75","6856.88","percent of total billed charges",""
"SYSTEM VALVE 9MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10269002","CDM","C1889","HCPCS","0278","RC","","","","both","","","8625.00","6468.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4597.13","53.3","","1901.83","1901.83","2962.25","1 through 10","2673.75","6856.88","percent of total billed charges",""
"SYSTEM VALVE 9MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10269002","CDM","C1889","HCPCS","0278","RC","","","","both","","","8625.00","6468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3148.13","36.5","","1620.31","1620.31","19908.88","1 through 10","2673.75","6856.88","percent of total billed charges",""
"SYSTEM VALVE 9MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10269002","CDM","C1889","HCPCS","0278","RC","","","","both","","","8625.00","6468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3303.38","38.3","","352.91","352.91","2046.30","1 through 10","2673.75","6856.88","percent of total billed charges",""
"SYSTEM VALVE 9MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10269002","CDM","C1889","HCPCS","0278","RC","","","","both","","","8625.00","6468.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3700.13","42.9","","9668.75","9668.75","9668.75","1 through 10","2673.75","6856.88","percent of total billed charges",""
"SYSTEM VALVE 9MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10269002","CDM","C1889","HCPCS","0278","RC","","","","both","","","8625.00","6468.75","WELLPOINT [1015]","HB AMC WELLPOINT","6363.53","73.78","","699.88","384.10","3443.31","33","2673.75","6856.88","percent of total billed charges",""
"SYSTEM VALVE 9MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10269002","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8625.00","6468.75","AETNA [1001]","HB AMC AETNA HMO","6020.25","69.8","","1421.24","264.50","4933.46","29","4507.43","7048.35","percent of total billed charges",""
"SYSTEM VALVE 9MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10269002","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8625.00","6468.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6934.50","80.4","","1022.97","1022.97","3607.50","1 through 10","4507.43","7048.35","percent of total billed charges",""
"SYSTEM VALVE 9MM IN CARTRIDGE ASPIRATION RESPIRATORY HUD","SUP-ITM-10269002","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8625.00","6468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7048.35","81.72","","3010.54","693.88","5019.88","35","4507.43","7048.35","percent of total billed charges",""
"SYTEM SLING 1.1X60CM SUPRIS RETROPUBIC SYNTHETIC PERMANENT MIDURETHRAL","SUP-ITM-10212657","CDM","C1771","HCPCS","0278","RC","","","","both","","","3293.50","2470.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2618.33","79.5","","1632.15","1632.15","1632.15","1 through 10","1020.99","2618.33","percent of total billed charges",""
"SYTEM SLING 1.1X60CM SUPRIS RETROPUBIC SYNTHETIC PERMANENT MIDURETHRAL","SUP-ITM-10212657","CDM","C1771","HCPCS","0278","RC","","","","both","","","3293.50","2470.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1755.44","53.3","","9709.13","9709.13","9709.13","1 through 10","1020.99","2618.33","percent of total billed charges",""
"SYTEM SLING 1.1X60CM SUPRIS RETROPUBIC SYNTHETIC PERMANENT MIDURETHRAL","SUP-ITM-10212657","CDM","C1771","HCPCS","0278","RC","","","","both","","","3293.50","2470.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2140.78","65","","2685.95","2190.09","2685.96","1 through 10","1020.99","2618.33","percent of total billed charges",""
"SYTEM SLING 1.1X60CM SUPRIS RETROPUBIC SYNTHETIC PERMANENT MIDURETHRAL","SUP-ITM-10212657","CDM","C1771","HCPCS","0278","RC","","","","both","","","3293.50","2470.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1202.13","36.5","","1495.87","1455.73","1541.33","1 through 10","1020.99","2618.33","percent of total billed charges",""
"SYTEM SLING 1.1X60CM SUPRIS RETROPUBIC SYNTHETIC PERMANENT MIDURETHRAL","SUP-ITM-10212657","CDM","C1771","HCPCS","0278","RC","","","","both","","","3293.50","2470.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1261.41","38.3","","1615.71","1615.71","1615.71","1 through 10","1020.99","2618.33","percent of total billed charges",""
"SYTEM SLING 1.1X60CM SUPRIS RETROPUBIC SYNTHETIC PERMANENT MIDURETHRAL","SUP-ITM-10212657","CDM","C1771","HCPCS","0278","RC","","","","both","","","3293.50","2470.12","WELLPOINT [1015]","HB AMC WELLPOINT","2429.94","73.78","","3076.44","3076.44","3076.44","1 through 10","1020.99","2618.33","percent of total billed charges",""
"SYTEM SLING 1.1X60CM SUPRIS RETROPUBIC SYNTHETIC PERMANENT MIDURETHRAL","SUP-ITM-10212657","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3293.50","2470.12","AETNA [1001]","HB AMC AETNA HMO","2298.86","69.8","","4568.79","2411.14","4568.79","1 through 10","1721.18","2691.45","percent of total billed charges",""
"SYTEM SLING 1.1X60CM SUPRIS RETROPUBIC SYNTHETIC PERMANENT MIDURETHRAL","SUP-ITM-10212657","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3293.50","2470.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2647.97","80.4","","2411.14","1545.60","3223.14","1 through 10","1721.18","2691.45","percent of total billed charges",""
"SYTEM SLING 1.1X60CM SUPRIS RETROPUBIC SYNTHETIC PERMANENT MIDURETHRAL","SUP-ITM-10212657","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3293.50","2470.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2691.45","81.72","","1816.95","1816.95","1816.95","1 through 10","1721.18","2691.45","percent of total billed charges",""
"SYTEM SLING 1.1X60CM SUPRIS RETROPUBIC SYNTHETIC PERMANENT MIDURETHRAL","SUP-ITM-10212657","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3293.50","2470.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2691.45","81.72","","3303.30","3303.30","3303.30","1 through 10","1721.18","2691.45","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","both","","","357.00","267.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","249.90","70","","346.00","212.98","346.00","1 through 10","14.19","339.15","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","both","","","357.00","267.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","283.82","79.5","","272.30","182.69","272.30","13","14.19","339.15","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","both","","","357.00","267.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","190.28","53.3","","272.30","174.73","272.30","1 through 10","14.19","339.15","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","both","","","357.00","267.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","110.67","31","","422.32","422.32","422.32","1 through 10","14.19","339.15","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","both","","","357.00","267.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","130.31","36.5","","129.06","109.68","329.04","24","14.19","339.15","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","both","","","357.00","267.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","136.73","38.3","","135.29","135.29","405.87","60","14.19","339.15","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","both","","","357.00","267.75","TRICARE [160005]","HB BWH TRICARE","339.15","95","","53.78","53.78","53.78","1 through 10","14.19","339.15","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","both","","","357.00","267.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.15","42.9","","276.59","152.14","276.59","1 through 10","14.19","339.15","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","outpatient","","","357.00","267.75","AETNA [1001]","HB AMC AETNA HMO","249.19","69.8","","234.24","165.39","234.24","37","14.19","319.99","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","outpatient","","","357.00","267.75","AETNA [1001]","HB AMC AETNA PPO","287.03","80.4","","269.88","181.30","543.90","1 through 10","14.19","319.99","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","outpatient","","","357.00","267.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","291.74","81.72","","276.59","152.14","346.00","1 through 10","14.19","319.99","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","outpatient","","","357.00","267.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","291.74","81.72","","276.59","152.14","276.59","39","14.19","319.99","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","both","","","222.00","166.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","155.40","70","","205.40","171.03","215.00","1 through 10","11.81","210.9","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","both","","","222.00","166.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","176.49","79.5","","169.21","113.52","169.21","14","11.81","210.9","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","both","","","222.00","166.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","118.33","53.3","","169.21","113.52","169.21","1 through 10","11.81","210.9","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","both","","","222.00","166.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.82","31","","262.42","262.42","262.42","1 through 10","11.81","210.9","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","both","","","222.00","166.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","81.03","36.5","","80.20","68.16","204.48","22","11.81","210.9","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","both","","","222.00","166.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","85.03","38.3","","84.07","84.07","252.21","59","11.81","210.9","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","both","","","222.00","166.50","TRICARE [160005]","HB BWH TRICARE","210.90","95","","43.19","43.19","43.19","1 through 10","11.81","210.9","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","both","","","222.00","166.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","95.24","42.9","","171.87","94.54","171.87","1 through 10","11.81","210.9","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","outpatient","","","222.00","166.50","AETNA [1001]","HB AMC AETNA HMO","154.96","69.8","","145.56","102.77","145.56","36","11.81","256.97","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","outpatient","","","222.00","166.50","AETNA [1001]","HB AMC AETNA PPO","178.49","80.4","","167.70","112.66","337.98","1 through 10","11.81","256.97","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","outpatient","","","222.00","166.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","181.42","81.72","","171.87","94.54","215.00","1 through 10","11.81","256.97","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","outpatient","","","222.00","166.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","181.42","81.72","","171.87","94.54","171.87","36","11.81","256.97","percent of total billed charges",""
"Tachycardia Site Mapping","PX-48000151","CDM","93609","CPT","0481","RC","","","","both","","","5881.00","4410.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2252.42","38.3","","2109.60","2109.60","2109.60","1 through 10","1823.11","7754.56","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.50","354.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","375.64","79.5","","800.18","480.96","1887.97","195","146.48","375.64","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.50","354.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","251.84","53.3","","813.12","216.42","1444.50","81","146.48","375.64","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.50","354.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","146.48","31","","432.60","432.60","432.60","1 through 10","146.48","375.64","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.50","354.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","172.46","36.5","","148.37","54.89","631.39","94","146.48","375.64","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.50","354.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","180.97","38.3","","279.30","91.72","1116.77","266","146.48","375.64","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.50","354.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.70","42.9","","731.00","63.70","731.00","1 through 10","146.48","375.64","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.50","354.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.70","42.9","","384.74","384.74","384.74","1 through 10","146.48","375.64","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","472.50","354.37","WELLPOINT [1015]","HB AMC WELLPOINT","348.61","73.78","","286.63","119.22","1107.45","105","146.48","375.64","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.50","354.37","AETNA [1001]","HB AMC AETNA HMO","329.81","69.8","","675.31","184.75","1721.50","286","246.93","386.13","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.50","354.37","AETNA [1001]","HB AMC AETNA PPO","379.89","80.4","","1261.44","103.12","1514.10","21","246.93","386.13","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.50","354.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","379.89","80.4","","1365.00","1365.00","1365.00","1 through 10","246.93","386.13","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.50","354.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","386.13","81.72","","5157.68","5157.68","5157.68","1 through 10","246.93","386.13","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","472.50","354.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","386.13","81.72","","431.26","71.26","1459.57","88","246.93","386.13","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","93.34","71.8","","90.47","36.33","271.41","52","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","85.28","65.6","","85.30","60.23","85.30","16","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","84.50","65","","81.90","66.53","245.70","116","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","91.00","70","","126.00","54.18","162.54","70","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","103.35","79.5","","81.90","66.53","99.16","30","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","69.29","53.3","","66.53","66.53","99.16","40","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","100.10","77","","175.56","97.02","175.56","1 through 10","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","84.50","65","","81.90","81.90","81.90","1 through 10","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","40.30","31","","38.93","38.93","38.93","1 through 10","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","47.45","36.5","","47.00","39.94","47.00","39","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","49.79","38.3","","49.27","47.88","90.47","83","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","MOLINA [1014]","HB BWH MOLINA","45.50","35","","40.75","27.24","54.70","17","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","100.10","77","","103.32","98.28","103.32","1 through 10","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","TRICARE [160005]","HB BWH TRICARE","123.50","95","","16.54","15.71","16.54","1 through 10","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","130.00","97.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.77","42.9","","100.72","55.40","100.72","15","7.52","123.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","outpatient","","","130.00","97.50","AETNA [1001]","HB AMC AETNA HMO","90.74","69.8","","85.30","60.23","98.28","122","7.52","106.24","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","outpatient","","","130.00","97.50","AETNA [1001]","HB AMC AETNA PPO","104.52","80.4","","60.23","60.23","98.28","1 through 10","7.52","106.24","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","outpatient","","","130.00","97.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","104.52","80.4","","98.28","63.00","98.28","1 through 10","7.52","106.24","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","outpatient","","","130.00","97.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","106.24","81.72","","55.40","55.40","55.40","1 through 10","7.52","106.24","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","outpatient","","","130.00","97.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","106.24","81.72","","100.72","55.40","100.72","93","7.52","106.24","percent of total billed charges",""
"Tacrolimus Imme Rel Oral 1mg","PX-63601088","CDM","J7507","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.38","38.3","","1.18","0.48","1.62","32","0.31","0.77","percent of total billed charges",""
"Tacrolimus Imme Rel Oral 1mg","PX-63601088","CDM","J7507","HCPCS","0636","RC","","","","both","","","1.00","0.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","0.77","77","","0.61","0.61","0.61","1 through 10","0.31","0.77","percent of total billed charges",""
"TAG TBE 15MMX6CM 8MM PORTAL SIDE BRANCH HEPARIN","SUP-ITM-10317866","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","12675.00","65","","6652.80","6652.80","6652.80","1 through 10","6045","15502.5","percent of total billed charges",""
"TAG TBE 15MMX6CM 8MM PORTAL SIDE BRANCH HEPARIN","SUP-ITM-10317866","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15502.50","79.5","","2612.61","795.38","2612.61","1 through 10","6045","15502.5","percent of total billed charges",""
"TAG TBE 15MMX6CM 8MM PORTAL SIDE BRANCH HEPARIN","SUP-ITM-10317866","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10393.50","53.3","","1101.80","1101.80","1101.80","1 through 10","6045","15502.5","percent of total billed charges",""
"TAG TBE 15MMX6CM 8MM PORTAL SIDE BRANCH HEPARIN","SUP-ITM-10317866","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","12675.00","65","","1820.00","910.00","1820.00","1 through 10","6045","15502.5","percent of total billed charges",""
"TAG TBE 15MMX6CM 8MM PORTAL SIDE BRANCH HEPARIN","SUP-ITM-10317866","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7117.50","36.5","","1257.80","693.44","2424.50","1 through 10","6045","15502.5","percent of total billed charges",""
"TAG TBE 15MMX6CM 8MM PORTAL SIDE BRANCH HEPARIN","SUP-ITM-10317866","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7468.50","38.3","","1950.11","547.40","2346.00","1 through 10","6045","15502.5","percent of total billed charges",""
"TAG TBE 15MMX6CM 8MM PORTAL SIDE BRANCH HEPARIN","SUP-ITM-10317866","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8365.50","42.9","","5096.18","5096.18","5096.18","1 through 10","6045","15502.5","percent of total billed charges",""
"TAG TBE 15MMX6CM 8MM PORTAL SIDE BRANCH HEPARIN","SUP-ITM-10317866","CDM","C1874","HCPCS","0278","RC","","","","both","","","19500.00","14625.00","WELLPOINT [1015]","HB AMC WELLPOINT","14387.10","73.78","","1172.59","1172.59","4829.94","1 through 10","6045","15502.5","percent of total billed charges",""
"TAG TBE 15MMX6CM 8MM PORTAL SIDE BRANCH HEPARIN","SUP-ITM-10317866","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19500.00","14625.00","AETNA [1001]","HB AMC AETNA HMO","13611.00","69.8","","1806.84","947.80","5091.72","1 through 10","10190.7","15935.4","percent of total billed charges",""
"TAG TBE 15MMX6CM 8MM PORTAL SIDE BRANCH HEPARIN","SUP-ITM-10317866","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19500.00","14625.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15935.40","81.72","","1259.05","615.58","4586.56","1 through 10","10190.7","15935.4","percent of total billed charges",""
"TALUS PLATE NECK VARIAX LOCKING POLYAXIAL 626880","SUP-ITM-10186954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4300.59","3225.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3418.97","79.5","","800.18","480.96","1887.97","195","1333.18","3418.97","percent of total billed charges",""
"TALUS PLATE NECK VARIAX LOCKING POLYAXIAL 626880","SUP-ITM-10186954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4300.59","3225.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2292.21","53.3","","813.12","216.42","1444.50","81","1333.18","3418.97","percent of total billed charges",""
"TALUS PLATE NECK VARIAX LOCKING POLYAXIAL 626880","SUP-ITM-10186954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4300.59","3225.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1333.18","31","","432.60","432.60","432.60","1 through 10","1333.18","3418.97","percent of total billed charges",""
"TALUS PLATE NECK VARIAX LOCKING POLYAXIAL 626880","SUP-ITM-10186954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4300.59","3225.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1569.72","36.5","","148.37","54.89","631.39","94","1333.18","3418.97","percent of total billed charges",""
"TALUS PLATE NECK VARIAX LOCKING POLYAXIAL 626880","SUP-ITM-10186954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4300.59","3225.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1647.13","38.3","","279.30","91.72","1116.77","266","1333.18","3418.97","percent of total billed charges",""
"TALUS PLATE NECK VARIAX LOCKING POLYAXIAL 626880","SUP-ITM-10186954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4300.59","3225.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1844.95","42.9","","731.00","63.70","731.00","1 through 10","1333.18","3418.97","percent of total billed charges",""
"TALUS PLATE NECK VARIAX LOCKING POLYAXIAL 626880","SUP-ITM-10186954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4300.59","3225.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1844.95","42.9","","384.74","384.74","384.74","1 through 10","1333.18","3418.97","percent of total billed charges",""
"TALUS PLATE NECK VARIAX LOCKING POLYAXIAL 626880","SUP-ITM-10186954","CDM","C1713","HCPCS","0278","RC","","","","both","","","4300.59","3225.44","WELLPOINT [1015]","HB AMC WELLPOINT","3172.98","73.78","","286.63","119.22","1107.45","105","1333.18","3418.97","percent of total billed charges",""
"TALUS PLATE NECK VARIAX LOCKING POLYAXIAL 626880","SUP-ITM-10186954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4300.59","3225.44","AETNA [1001]","HB AMC AETNA HMO","3001.81","69.8","","675.31","184.75","1721.50","286","2247.49","3514.44","percent of total billed charges",""
"TALUS PLATE NECK VARIAX LOCKING POLYAXIAL 626880","SUP-ITM-10186954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4300.59","3225.44","AETNA [1001]","HB AMC AETNA PPO","3457.67","80.4","","1261.44","103.12","1514.10","21","2247.49","3514.44","percent of total billed charges",""
"TALUS PLATE NECK VARIAX LOCKING POLYAXIAL 626880","SUP-ITM-10186954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4300.59","3225.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3457.67","80.4","","1365.00","1365.00","1365.00","1 through 10","2247.49","3514.44","percent of total billed charges",""
"TALUS PLATE NECK VARIAX LOCKING POLYAXIAL 626880","SUP-ITM-10186954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4300.59","3225.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3514.44","81.72","","5157.68","5157.68","5157.68","1 through 10","2247.49","3514.44","percent of total billed charges",""
"TALUS PLATE NECK VARIAX LOCKING POLYAXIAL 626880","SUP-ITM-10186954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4300.59","3225.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3514.44","81.72","","431.26","71.26","1459.57","88","2247.49","3514.44","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-76002566","CDM","11103","CPT","0761","RC","","","","both","","","178.00","133.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","141.51","79.5","","408.45","136.15","408.45","18","55.18","141.51","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-76002566","CDM","11103","CPT","0761","RC","","","","both","","","178.00","133.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","94.87","53.3","","790.93","182.69","790.93","13","55.18","141.51","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-76002566","CDM","11103","CPT","0761","RC","","","","both","","","178.00","133.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","115.70","65","","224.90","224.90","224.90","1 through 10","55.18","141.51","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-76002566","CDM","11103","CPT","0761","RC","","","","both","","","178.00","133.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","141.51","79.5","","120.92","120.92","122.09","1 through 10","55.18","141.51","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-76002566","CDM","11103","CPT","0761","RC","","","","both","","","178.00","133.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","64.97","36.5","","187.88","164.52","193.59","30","55.18","141.51","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-76002566","CDM","11103","CPT","0761","RC","","","","both","","","178.00","133.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.17","38.3","","202.92","197.22","202.94","126","55.18","141.51","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-76002566","CDM","11103","CPT","0761","RC","","","","both","","","178.00","133.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","137.06","77","","266.42","266.42","266.42","1 through 10","55.18","141.51","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-76002566","CDM","11103","CPT","0761","RC","","","","both","","","178.00","133.50","WELLPOINT [1015]","HB AMC WELLPOINT","131.33","73.78","","301.80","128.80","474.80","20","55.18","141.51","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-76002566","CDM","11103","CPT","0761","RC","","","","outpatient","","","178.00","133.50","AETNA [1001]","HB AMC AETNA HMO","124.24","69.8","","117.12","117.12","134.94","14","39.03","145.46","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-76002566","CDM","11103","CPT","0761","RC","","","","outpatient","","","178.00","133.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","39.03","","Case rate ($39.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","90.47","90.47","90.47","1 through 10","39.03","145.46","other","ASC "
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-76002566","CDM","11103","CPT","0761","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","145.46","81.72","","76.07","76.07","76.07","1 through 10","39.03","145.46","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-76002566","CDM","11103","CPT","0761","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","145.46","81.72","","138.30","76.07","138.30","12","39.03","145.46","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-98301818","CDM","11103","CPT","0983","RC","","","","both","","","95.00","71.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","75.53","79.5","","408.45","136.15","408.45","18","29.45","75.53","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-98301818","CDM","11103","CPT","0983","RC","","","","both","","","95.00","71.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","50.64","53.3","","790.93","182.69","790.93","13","29.45","75.53","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-98301818","CDM","11103","CPT","0983","RC","","","","both","","","95.00","71.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","61.75","65","","224.90","224.90","224.90","1 through 10","29.45","75.53","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-98301818","CDM","11103","CPT","0983","RC","","","","both","","","95.00","71.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","75.53","79.5","","120.92","120.92","122.09","1 through 10","29.45","75.53","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-98301818","CDM","11103","CPT","0983","RC","","","","both","","","95.00","71.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","34.68","36.5","","187.88","164.52","193.59","30","29.45","75.53","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-98301818","CDM","11103","CPT","0983","RC","","","","both","","","95.00","71.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","36.39","38.3","","202.92","197.22","202.94","126","29.45","75.53","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-98301818","CDM","11103","CPT","0983","RC","","","","both","","","95.00","71.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","73.15","77","","266.42","266.42","266.42","1 through 10","29.45","75.53","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-98301818","CDM","11103","CPT","0983","RC","","","","both","","","95.00","71.25","WELLPOINT [1015]","HB AMC WELLPOINT","70.09","73.78","","301.80","128.80","474.80","20","29.45","75.53","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-98301818","CDM","11103","CPT","0983","RC","","","","outpatient","","","95.00","71.25","AETNA [1001]","HB AMC AETNA HMO","66.31","69.8","","117.12","117.12","134.94","14","53.11","77.63","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-98301818","CDM","11103","CPT","0983","RC","","","","outpatient","","","95.00","71.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","77.63","81.72","","76.07","76.07","76.07","1 through 10","53.11","77.63","percent of total billed charges",""
"Tangential Biopsy Skin Ea Sep/Additional Lesion","PX-98301818","CDM","11103","CPT","0983","RC","","","","outpatient","","","95.00","71.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","77.63","81.72","","138.30","76.07","138.30","12","53.11","77.63","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","242.81","242.81","243.71","38","185.38","475.41","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","63","185.38","475.41","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","418.60","70","","563.00","563.00","563.00","1 through 10","185.38","475.41","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","475.41","79.5","","1170.96","306.24","1751.86","92","185.38","475.41","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","318.73","53.3","","918.72","306.24","1369.38","55","185.38","475.41","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","187.70","232.87","1 through 10","185.38","475.41","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","ELDER SERVICES [1037]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","231.25","231.25","1 through 10","185.38","475.41","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","FALLON HEALTH [1008]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","707.91","235.97","707.91","1 through 10","185.38","475.41","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","185.38","475.41","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","460.46","77","","1339.80","1339.80","1339.80","1 through 10","185.38","475.41","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","HUMANA [1012]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.67","231.25","235.97","1 through 10","185.38","475.41","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","388.70","65","","109.85","109.85","109.85","1 through 10","185.38","475.41","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","475.41","79.5","","409.12","405.40","409.12","1 through 10","185.38","475.41","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1019","185.38","475.41","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","185.38","31","","179.22","179.22","179.22","1 through 10","185.38","475.41","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","218.27","36.5","","649.02","419.92","649.02","131","185.38","475.41","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","229.03","38.3","","680.34","440.80","680.34","591","185.38","475.41","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","214.13","655.04","21","185.38","475.41","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","460.46","77","","893.20","446.60","893.20","1 through 10","185.38","475.41","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","TRICARE [160005]","HB BWH TRICARE","224.17","","APC Price ($235.97). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","235.97","224.17","235.97","1 through 10","185.38","475.41","other","Tricare OPPS"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.25","231.25","693.75","17","185.38","475.41","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","233.26","117.99","235.97","116","185.38","475.41","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","both","","","598.00","448.50","WELLPOINT [1015]","HB AMC WELLPOINT","441.20","73.78","","1011.81","580.00","1011.81","57","185.38","475.41","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","AETNA [1001]","HB AMC AETNA HMO","417.40","69.8","","392.66","277.24","785.32","73","176.45","700.33","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","AETNA [1001]","HB AMC AETNA PPO","480.79","80.4","","452.40","452.40","452.40","1 through 10","176.45","700.33","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","405.38","405.38","412.84","202","176.45","700.33","other","ASC"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","467.73","467.73","472.37","426","176.45","700.33","other","ASC "
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","451.71","451.71","511.71","1 through 10","176.45","700.33","other","Multiple Surgery"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1228.08","409.36","1228.08","307","176.45","700.33","other","Multiple Surgery"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1291.62","430.54","1291.62","160","176.45","700.33","other","Multiple Surgery"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","511.71","511.71","965.00","1 through 10","176.45","700.33","other","Multiple Surgery"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","176.45","700.33","other","Multiple Surgery"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","451.71","349.79","801.50","67","176.45","700.33","other","Multiple Surgery"
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","480.79","80.4","","290.00","290.00","290.00","1 through 10","176.45","700.33","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","488.69","81.72","","463.65","255.03","463.65","1 through 10","176.45","700.33","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","488.69","81.72","","463.65","255.03","463.65","62","176.45","700.33","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-76002565","CDM","11102","CPT","0761","RC","","","","outpatient","","","598.00","448.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","984.60","984.60","984.60","1 through 10","176.45","700.33","other","Multiple Surgery"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","243.02","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","242.81","242.81","243.71","38","51.15","294.93","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","63","51.15","294.93","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","115.50","70","","563.00","563.00","563.00","1 through 10","51.15","294.93","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","131.18","79.5","","1170.96","306.24","1751.86","92","51.15","294.93","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","87.95","53.3","","918.72","306.24","1369.38","55","51.15","294.93","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","187.70","232.87","1 through 10","51.15","294.93","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","ELDER SERVICES [1037]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","231.25","231.25","1 through 10","51.15","294.93","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","FALLON HEALTH [1008]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","707.91","235.97","707.91","1 through 10","51.15","294.93","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.19","232.19","232.19","1 through 10","51.15","294.93","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","127.05","77","","1339.80","1339.80","1339.80","1 through 10","51.15","294.93","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","HUMANA [1012]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.67","231.25","235.97","1 through 10","51.15","294.93","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","107.25","65","","109.85","109.85","109.85","1 through 10","51.15","294.93","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","131.18","79.5","","409.12","405.40","409.12","1 through 10","51.15","294.93","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","MEDICARE [2001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1019","51.15","294.93","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","51.15","31","","179.22","179.22","179.22","1 through 10","51.15","294.93","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","60.23","36.5","","649.02","419.92","649.02","131","51.15","294.93","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","63.20","38.3","","680.34","440.80","680.34","591","51.15","294.93","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","214.13","655.04","21","51.15","294.93","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","127.05","77","","893.20","446.60","893.20","1 through 10","51.15","294.93","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","TRICARE [160005]","HB BWH TRICARE","224.17","","APC Price ($235.97). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","235.97","224.17","235.97","1 through 10","51.15","294.93","other","Tricare OPPS"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","231.25","231.25","693.75","17","51.15","294.93","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","231.23","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","233.26","117.99","235.97","116","51.15","294.93","other","OPPS APC"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","both","","","165.00","123.75","WELLPOINT [1015]","HB AMC WELLPOINT","121.74","73.78","","1011.81","580.00","1011.81","57","51.15","294.93","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","outpatient","","","165.00","123.75","AETNA [1001]","HB AMC AETNA HMO","115.17","69.8","","392.66","277.24","785.32","73","92.24","700.33","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","outpatient","","","165.00","123.75","AETNA [1001]","HB AMC AETNA PPO","132.66","80.4","","452.40","452.40","452.40","1 through 10","92.24","700.33","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","outpatient","","","165.00","123.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","451.71","451.71","511.71","1 through 10","92.24","700.33","other","Multiple Surgery"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","outpatient","","","165.00","123.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1228.08","409.36","1228.08","307","92.24","700.33","other","Multiple Surgery"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","outpatient","","","165.00","123.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1291.62","430.54","1291.62","160","92.24","700.33","other","Multiple Surgery"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","outpatient","","","165.00","123.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","511.71","511.71","965.00","1 through 10","92.24","700.33","other","Multiple Surgery"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","outpatient","","","165.00","123.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","430.54","430.54","430.54","1 through 10","92.24","700.33","other","Multiple Surgery"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","outpatient","","","165.00","123.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","451.71","349.79","801.50","67","92.24","700.33","other","Multiple Surgery"
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","outpatient","","","165.00","123.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","132.66","80.4","","290.00","290.00","290.00","1 through 10","92.24","700.33","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","134.84","81.72","","463.65","255.03","463.65","1 through 10","92.24","700.33","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","134.84","81.72","","463.65","255.03","463.65","62","92.24","700.33","percent of total billed charges",""
"Tangential Biopsy Skin Single Lesion","PX-98301817","CDM","11102","CPT","0983","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","984.60","984.60","984.60","1 through 10","92.24","700.33","other","Multiple Surgery"
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","497.73","79.5","","800.18","480.96","1887.97","195","194.08","497.73","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","333.70","53.3","","813.12","216.42","1444.50","81","194.08","497.73","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","194.08","31","","432.60","432.60","432.60","1 through 10","194.08","497.73","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","228.52","36.5","","148.37","54.89","631.39","94","194.08","497.73","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.79","38.3","","279.30","91.72","1116.77","266","194.08","497.73","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.59","42.9","","731.00","63.70","731.00","1 through 10","194.08","497.73","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.59","42.9","","384.74","384.74","384.74","1 through 10","194.08","497.73","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.08","469.56","WELLPOINT [1015]","HB AMC WELLPOINT","461.92","73.78","","286.63","119.22","1107.45","105","194.08","497.73","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.08","469.56","AETNA [1001]","HB AMC AETNA HMO","437.00","69.8","","675.31","184.75","1721.50","286","327.19","511.63","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.08","469.56","AETNA [1001]","HB AMC AETNA PPO","503.37","80.4","","1261.44","103.12","1514.10","21","327.19","511.63","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.08","469.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","503.37","80.4","","1365.00","1365.00","1365.00","1 through 10","327.19","511.63","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.08","469.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","511.63","81.72","","5157.68","5157.68","5157.68","1 through 10","327.19","511.63","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.08","469.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","511.63","81.72","","431.26","71.26","1459.57","88","327.19","511.63","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.08","1330.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1410.39","79.5","","800.18","480.96","1887.97","195","549.96","1410.39","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.08","1330.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","945.58","53.3","","813.12","216.42","1444.50","81","549.96","1410.39","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.08","1330.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","549.96","31","","432.60","432.60","432.60","1 through 10","549.96","1410.39","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.08","1330.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","647.54","36.5","","148.37","54.89","631.39","94","549.96","1410.39","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.08","1330.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","679.47","38.3","","279.30","91.72","1116.77","266","549.96","1410.39","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.08","1330.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","761.08","42.9","","731.00","63.70","731.00","1 through 10","549.96","1410.39","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.08","1330.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","761.08","42.9","","384.74","384.74","384.74","1 through 10","549.96","1410.39","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.08","1330.56","WELLPOINT [1015]","HB AMC WELLPOINT","1308.92","73.78","","286.63","119.22","1107.45","105","549.96","1410.39","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.08","1330.56","AETNA [1001]","HB AMC AETNA HMO","1238.31","69.8","","675.31","184.75","1721.50","286","927.13","1449.78","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.08","1330.56","AETNA [1001]","HB AMC AETNA PPO","1426.36","80.4","","1261.44","103.12","1514.10","21","927.13","1449.78","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.08","1330.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1426.36","80.4","","1365.00","1365.00","1365.00","1 through 10","927.13","1449.78","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.08","1330.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1449.78","81.72","","5157.68","5157.68","5157.68","1 through 10","927.13","1449.78","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.08","1330.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1449.78","81.72","","431.26","71.26","1459.57","88","927.13","1449.78","percent of total billed charges",""
"TAP SCREW LONG 2X100MM BONE STAINLESS CORTICAL","SUP-ITM-10002104","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.77","399.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","423.55","79.5","","800.18","480.96","1887.97","195","165.16","423.55","percent of total billed charges",""
"TAP SCREW LONG 2X100MM BONE STAINLESS CORTICAL","SUP-ITM-10002104","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.77","399.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","283.97","53.3","","813.12","216.42","1444.50","81","165.16","423.55","percent of total billed charges",""
"TAP SCREW LONG 2X100MM BONE STAINLESS CORTICAL","SUP-ITM-10002104","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.77","399.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","165.16","31","","432.60","432.60","432.60","1 through 10","165.16","423.55","percent of total billed charges",""
"TAP SCREW LONG 2X100MM BONE STAINLESS CORTICAL","SUP-ITM-10002104","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.77","399.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.46","36.5","","148.37","54.89","631.39","94","165.16","423.55","percent of total billed charges",""
"TAP SCREW LONG 2X100MM BONE STAINLESS CORTICAL","SUP-ITM-10002104","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.77","399.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","204.05","38.3","","279.30","91.72","1116.77","266","165.16","423.55","percent of total billed charges",""
"TAP SCREW LONG 2X100MM BONE STAINLESS CORTICAL","SUP-ITM-10002104","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.77","399.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.56","42.9","","731.00","63.70","731.00","1 through 10","165.16","423.55","percent of total billed charges",""
"TAP SCREW LONG 2X100MM BONE STAINLESS CORTICAL","SUP-ITM-10002104","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.77","399.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.56","42.9","","384.74","384.74","384.74","1 through 10","165.16","423.55","percent of total billed charges",""
"TAP SCREW LONG 2X100MM BONE STAINLESS CORTICAL","SUP-ITM-10002104","CDM","C1713","HCPCS","0278","RC","","","","both","","","532.77","399.58","WELLPOINT [1015]","HB AMC WELLPOINT","393.08","73.78","","286.63","119.22","1107.45","105","165.16","423.55","percent of total billed charges",""
"TAP SCREW LONG 2X100MM BONE STAINLESS CORTICAL","SUP-ITM-10002104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","532.77","399.58","AETNA [1001]","HB AMC AETNA HMO","371.87","69.8","","675.31","184.75","1721.50","286","278.43","435.38","percent of total billed charges",""
"TAP SCREW LONG 2X100MM BONE STAINLESS CORTICAL","SUP-ITM-10002104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","532.77","399.58","AETNA [1001]","HB AMC AETNA PPO","428.35","80.4","","1261.44","103.12","1514.10","21","278.43","435.38","percent of total billed charges",""
"TAP SCREW LONG 2X100MM BONE STAINLESS CORTICAL","SUP-ITM-10002104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","532.77","399.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","428.35","80.4","","1365.00","1365.00","1365.00","1 through 10","278.43","435.38","percent of total billed charges",""
"TAP SCREW LONG 2X100MM BONE STAINLESS CORTICAL","SUP-ITM-10002104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","532.77","399.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","435.38","81.72","","5157.68","5157.68","5157.68","1 through 10","278.43","435.38","percent of total billed charges",""
"TAP SCREW LONG 2X100MM BONE STAINLESS CORTICAL","SUP-ITM-10002104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","532.77","399.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","435.38","81.72","","431.26","71.26","1459.57","88","278.43","435.38","percent of total billed charges",""
"TAPER 32MM 4.0 HIP FEMORAL PLUS 4 IMPLANT HD COBALT 12TO14 05","SUP-ITM-10015372","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","731.64","52.26","","1113.10","1113.10","1113.10","1 through 10","434","1113","percent of total billed charges",""
"TAPER 32MM 4.0 HIP FEMORAL PLUS 4 IMPLANT HD COBALT 12TO14 05","SUP-ITM-10015372","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1113.00","79.5","","1293.60","1148.53","1603.80","1 through 10","434","1113","percent of total billed charges",""
"TAPER 32MM 4.0 HIP FEMORAL PLUS 4 IMPLANT HD COBALT 12TO14 05","SUP-ITM-10015372","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","511.00","36.5","","1023.42","771.29","2068.67","33","434","1113","percent of total billed charges",""
"TAPER 32MM 4.0 HIP FEMORAL PLUS 4 IMPLANT HD COBALT 12TO14 05","SUP-ITM-10015372","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","536.20","38.3","","850.52","759.78","1211.25","66","434","1113","percent of total billed charges",""
"TAPER 32MM 4.0 HIP FEMORAL PLUS 4 IMPLANT HD COBALT 12TO14 05","SUP-ITM-10015372","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","2548.09","2548.09","2548.09","1 through 10","434","1113","percent of total billed charges",""
"TAPER 32MM 4.0 HIP FEMORAL PLUS 4 IMPLANT HD COBALT 12TO14 05","SUP-ITM-10015372","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.60","42.9","","956.46","956.46","956.46","1 through 10","434","1113","percent of total billed charges",""
"TAPER 32MM 4.0 HIP FEMORAL PLUS 4 IMPLANT HD COBALT 12TO14 05","SUP-ITM-10015372","CDM","C1776","HCPCS","0278","RC","","","","both","","","1400.00","1050.00","WELLPOINT [1015]","HB AMC WELLPOINT","1032.92","73.78","","2344.73","1619.47","2530.35","16","434","1113","percent of total billed charges",""
"TAPER 32MM 4.0 HIP FEMORAL PLUS 4 IMPLANT HD COBALT 12TO14 05","SUP-ITM-10015372","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA HMO","977.20","69.8","","1523.63","988.41","4330.26","39","731.64","1144.08","percent of total billed charges",""
"TAPER 32MM 4.0 HIP FEMORAL PLUS 4 IMPLANT HD COBALT 12TO14 05","SUP-ITM-10015372","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","AETNA [1001]","HB AMC AETNA PPO","1125.60","80.4","","1670.25","1670.25","1670.25","1 through 10","731.64","1144.08","percent of total billed charges",""
"TAPER 32MM 4.0 HIP FEMORAL PLUS 4 IMPLANT HD COBALT 12TO14 05","SUP-ITM-10015372","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","731.64","52.26","","1113.10","1113.10","1113.10","1 through 10","731.64","1144.08","percent of total billed charges",""
"TAPER 32MM 4.0 HIP FEMORAL PLUS 4 IMPLANT HD COBALT 12TO14 05","SUP-ITM-10015372","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1400.00","1050.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1144.08","81.72","","1738.90","1484.65","2716.94","38","731.64","1144.08","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.45","259.09","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","180.53","52.26","","1113.10","1113.10","1113.10","1 through 10","107.09","274.63","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.45","259.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","274.63","79.5","","1293.60","1148.53","1603.80","1 through 10","107.09","274.63","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.45","259.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","126.09","36.5","","1023.42","771.29","2068.67","33","107.09","274.63","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.45","259.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","132.31","38.3","","850.52","759.78","1211.25","66","107.09","274.63","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.45","259.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.20","42.9","","2548.09","2548.09","2548.09","1 through 10","107.09","274.63","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.45","259.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.20","42.9","","956.46","956.46","956.46","1 through 10","107.09","274.63","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.45","259.09","WELLPOINT [1015]","HB AMC WELLPOINT","254.87","73.78","","2344.73","1619.47","2530.35","16","107.09","274.63","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.45","259.09","AETNA [1001]","HB AMC AETNA HMO","241.12","69.8","","1523.63","988.41","4330.26","39","180.53","282.3","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.45","259.09","AETNA [1001]","HB AMC AETNA PPO","277.74","80.4","","1670.25","1670.25","1670.25","1 through 10","180.53","282.3","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.45","259.09","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","180.53","52.26","","1113.10","1113.10","1113.10","1 through 10","180.53","282.3","percent of total billed charges",""
"TAPER 6.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 PLUS","SUP-ITM-10090420","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.45","259.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","282.30","81.72","","1738.90","1484.65","2716.94","38","180.53","282.3","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","548.73","52.26","","1113.10","1113.10","1113.10","1 through 10","325.5","834.75","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","834.75","79.5","","1293.60","1148.53","1603.80","1 through 10","325.5","834.75","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","1023.42","771.29","2068.67","33","325.5","834.75","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","850.52","759.78","1211.25","66","325.5","834.75","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","2548.09","2548.09","2548.09","1 through 10","325.5","834.75","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","956.46","956.46","956.46","1 through 10","325.5","834.75","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB AMC WELLPOINT","774.69","73.78","","2344.73","1619.47","2530.35","16","325.5","834.75","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA HMO","732.90","69.8","","1523.63","988.41","4330.26","39","548.73","858.06","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA PPO","844.20","80.4","","1670.25","1670.25","1670.25","1 through 10","548.73","858.06","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","548.73","52.26","","1113.10","1113.10","1113.10","1 through 10","548.73","858.06","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","858.06","81.72","","1738.90","1484.65","2716.94","38","548.73","858.06","percent of total billed charges",""
"TAPER CALCAR 12/14X46MM FEMORAL HIP TIVANIUM POROUS EXTENDED OFFSET B","SUP-ITM-10006238","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1227.33","52.26","","1113.10","1113.10","1113.10","1 through 10","728.04","1867.06","percent of total billed charges",""
"TAPER CALCAR 12/14X46MM FEMORAL HIP TIVANIUM POROUS EXTENDED OFFSET B","SUP-ITM-10006238","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1867.06","79.5","","1293.60","1148.53","1603.80","1 through 10","728.04","1867.06","percent of total billed charges",""
"TAPER CALCAR 12/14X46MM FEMORAL HIP TIVANIUM POROUS EXTENDED OFFSET B","SUP-ITM-10006238","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","857.20","36.5","","1023.42","771.29","2068.67","33","728.04","1867.06","percent of total billed charges",""
"TAPER CALCAR 12/14X46MM FEMORAL HIP TIVANIUM POROUS EXTENDED OFFSET B","SUP-ITM-10006238","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","899.48","38.3","","850.52","759.78","1211.25","66","728.04","1867.06","percent of total billed charges",""
"TAPER CALCAR 12/14X46MM FEMORAL HIP TIVANIUM POROUS EXTENDED OFFSET B","SUP-ITM-10006238","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1007.51","42.9","","2548.09","2548.09","2548.09","1 through 10","728.04","1867.06","percent of total billed charges",""
"TAPER CALCAR 12/14X46MM FEMORAL HIP TIVANIUM POROUS EXTENDED OFFSET B","SUP-ITM-10006238","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1007.51","42.9","","956.46","956.46","956.46","1 through 10","728.04","1867.06","percent of total billed charges",""
"TAPER CALCAR 12/14X46MM FEMORAL HIP TIVANIUM POROUS EXTENDED OFFSET B","SUP-ITM-10006238","CDM","C1776","HCPCS","0278","RC","","","","both","","","2348.50","1761.37","WELLPOINT [1015]","HB AMC WELLPOINT","1732.72","73.78","","2344.73","1619.47","2530.35","16","728.04","1867.06","percent of total billed charges",""
"TAPER CALCAR 12/14X46MM FEMORAL HIP TIVANIUM POROUS EXTENDED OFFSET B","SUP-ITM-10006238","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2348.50","1761.37","AETNA [1001]","HB AMC AETNA HMO","1639.25","69.8","","1523.63","988.41","4330.26","39","1227.33","1919.19","percent of total billed charges",""
"TAPER CALCAR 12/14X46MM FEMORAL HIP TIVANIUM POROUS EXTENDED OFFSET B","SUP-ITM-10006238","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2348.50","1761.37","AETNA [1001]","HB AMC AETNA PPO","1888.19","80.4","","1670.25","1670.25","1670.25","1 through 10","1227.33","1919.19","percent of total billed charges",""
"TAPER CALCAR 12/14X46MM FEMORAL HIP TIVANIUM POROUS EXTENDED OFFSET B","SUP-ITM-10006238","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2348.50","1761.37","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1227.33","52.26","","1113.10","1113.10","1113.10","1 through 10","1227.33","1919.19","percent of total billed charges",""
"TAPER CALCAR 12/14X46MM FEMORAL HIP TIVANIUM POROUS EXTENDED OFFSET B","SUP-ITM-10006238","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2348.50","1761.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1919.19","81.72","","1738.90","1484.65","2716.94","38","1227.33","1919.19","percent of total billed charges",""
"TAPER FLEX SIZE 3 GRAFT BONE SYNTHETIC KNEE NEXGEN MIS INTRAMEDULLARY MGII TIVANIUM ALLOY","SUP-ITM-10012214","CDM","C1776","HCPCS","0278","RC","","","","both","","","951.83","713.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","497.43","52.26","","1113.10","1113.10","1113.10","1 through 10","295.07","756.7","percent of total billed charges",""
"TAPER FLEX SIZE 3 GRAFT BONE SYNTHETIC KNEE NEXGEN MIS INTRAMEDULLARY MGII TIVANIUM ALLOY","SUP-ITM-10012214","CDM","C1776","HCPCS","0278","RC","","","","both","","","951.83","713.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","756.70","79.5","","1293.60","1148.53","1603.80","1 through 10","295.07","756.7","percent of total billed charges",""
"TAPER FLEX SIZE 3 GRAFT BONE SYNTHETIC KNEE NEXGEN MIS INTRAMEDULLARY MGII TIVANIUM ALLOY","SUP-ITM-10012214","CDM","C1776","HCPCS","0278","RC","","","","both","","","951.83","713.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","347.42","36.5","","1023.42","771.29","2068.67","33","295.07","756.7","percent of total billed charges",""
"TAPER FLEX SIZE 3 GRAFT BONE SYNTHETIC KNEE NEXGEN MIS INTRAMEDULLARY MGII TIVANIUM ALLOY","SUP-ITM-10012214","CDM","C1776","HCPCS","0278","RC","","","","both","","","951.83","713.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","364.55","38.3","","850.52","759.78","1211.25","66","295.07","756.7","percent of total billed charges",""
"TAPER FLEX SIZE 3 GRAFT BONE SYNTHETIC KNEE NEXGEN MIS INTRAMEDULLARY MGII TIVANIUM ALLOY","SUP-ITM-10012214","CDM","C1776","HCPCS","0278","RC","","","","both","","","951.83","713.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","408.34","42.9","","2548.09","2548.09","2548.09","1 through 10","295.07","756.7","percent of total billed charges",""
"TAPER FLEX SIZE 3 GRAFT BONE SYNTHETIC KNEE NEXGEN MIS INTRAMEDULLARY MGII TIVANIUM ALLOY","SUP-ITM-10012214","CDM","C1776","HCPCS","0278","RC","","","","both","","","951.83","713.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","408.34","42.9","","956.46","956.46","956.46","1 through 10","295.07","756.7","percent of total billed charges",""
"TAPER FLEX SIZE 3 GRAFT BONE SYNTHETIC KNEE NEXGEN MIS INTRAMEDULLARY MGII TIVANIUM ALLOY","SUP-ITM-10012214","CDM","C1776","HCPCS","0278","RC","","","","both","","","951.83","713.87","WELLPOINT [1015]","HB AMC WELLPOINT","702.26","73.78","","2344.73","1619.47","2530.35","16","295.07","756.7","percent of total billed charges",""
"TAPER FLEX SIZE 3 GRAFT BONE SYNTHETIC KNEE NEXGEN MIS INTRAMEDULLARY MGII TIVANIUM ALLOY","SUP-ITM-10012214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","951.83","713.87","AETNA [1001]","HB AMC AETNA HMO","664.38","69.8","","1523.63","988.41","4330.26","39","497.43","777.84","percent of total billed charges",""
"TAPER FLEX SIZE 3 GRAFT BONE SYNTHETIC KNEE NEXGEN MIS INTRAMEDULLARY MGII TIVANIUM ALLOY","SUP-ITM-10012214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","951.83","713.87","AETNA [1001]","HB AMC AETNA PPO","765.27","80.4","","1670.25","1670.25","1670.25","1 through 10","497.43","777.84","percent of total billed charges",""
"TAPER FLEX SIZE 3 GRAFT BONE SYNTHETIC KNEE NEXGEN MIS INTRAMEDULLARY MGII TIVANIUM ALLOY","SUP-ITM-10012214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","951.83","713.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","497.43","52.26","","1113.10","1113.10","1113.10","1 through 10","497.43","777.84","percent of total billed charges",""
"TAPER FLEX SIZE 3 GRAFT BONE SYNTHETIC KNEE NEXGEN MIS INTRAMEDULLARY MGII TIVANIUM ALLOY","SUP-ITM-10012214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","951.83","713.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","777.84","81.72","","1738.90","1484.65","2716.94","38","497.43","777.84","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2883.45","52.26","","1113.10","1113.10","1113.10","1 through 10","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4386.41","79.5","","1293.60","1148.53","1603.80","1 through 10","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2013.89","36.5","","1023.42","771.29","2068.67","33","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2113.20","38.3","","850.52","759.78","1211.25","66","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2367.01","42.9","","2548.09","2548.09","2548.09","1 through 10","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2367.01","42.9","","956.46","956.46","956.46","1 through 10","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","WELLPOINT [1015]","HB AMC WELLPOINT","4070.81","73.78","","2344.73","1619.47","2530.35","16","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5517.50","4138.12","AETNA [1001]","HB AMC AETNA HMO","3851.22","69.8","","1523.63","988.41","4330.26","39","2883.45","4508.9","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5517.50","4138.12","AETNA [1001]","HB AMC AETNA PPO","4436.07","80.4","","1670.25","1670.25","1670.25","1 through 10","2883.45","4508.9","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5517.50","4138.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2883.45","52.26","","1113.10","1113.10","1113.10","1 through 10","2883.45","4508.9","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5517.50","4138.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4508.90","81.72","","1738.90","1484.65","2716.94","38","2883.45","4508.9","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2883.45","52.26","","1113.10","1113.10","1113.10","1 through 10","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4386.41","79.5","","1293.60","1148.53","1603.80","1 through 10","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2013.89","36.5","","1023.42","771.29","2068.67","33","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2113.20","38.3","","850.52","759.78","1211.25","66","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2367.01","42.9","","2548.09","2548.09","2548.09","1 through 10","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2367.01","42.9","","956.46","956.46","956.46","1 through 10","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","5517.50","4138.12","WELLPOINT [1015]","HB AMC WELLPOINT","4070.81","73.78","","2344.73","1619.47","2530.35","16","1710.43","4386.41","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5517.50","4138.12","AETNA [1001]","HB AMC AETNA HMO","3851.22","69.8","","1523.63","988.41","4330.26","39","2883.45","4508.9","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5517.50","4138.12","AETNA [1001]","HB AMC AETNA PPO","4436.07","80.4","","1670.25","1670.25","1670.25","1 through 10","2883.45","4508.9","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5517.50","4138.12","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2883.45","52.26","","1113.10","1113.10","1113.10","1 through 10","2883.45","4508.9","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5517.50","4138.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4508.90","81.72","","1738.90","1484.65","2716.94","38","2883.45","4508.9","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","795.66","52.26","","1113.10","1113.10","1113.10","1 through 10","471.98","1210.39","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1210.39","79.5","","1293.60","1148.53","1603.80","1 through 10","471.98","1210.39","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","555.71","36.5","","1023.42","771.29","2068.67","33","471.98","1210.39","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","583.12","38.3","","850.52","759.78","1211.25","66","471.98","1210.39","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.15","42.9","","2548.09","2548.09","2548.09","1 through 10","471.98","1210.39","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.15","42.9","","956.46","956.46","956.46","1 through 10","471.98","1210.39","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1522.50","1141.87","WELLPOINT [1015]","HB AMC WELLPOINT","1123.30","73.78","","2344.73","1619.47","2530.35","16","471.98","1210.39","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","AETNA [1001]","HB AMC AETNA HMO","1062.71","69.8","","1523.63","988.41","4330.26","39","795.66","1244.19","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","AETNA [1001]","HB AMC AETNA PPO","1224.09","80.4","","1670.25","1670.25","1670.25","1 through 10","795.66","1244.19","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","795.66","52.26","","1113.10","1113.10","1113.10","1 through 10","795.66","1244.19","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1522.50","1141.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1244.19","81.72","","1738.90","1484.65","2716.94","38","795.66","1244.19","percent of total billed charges",""
"Tarsal Tunnel Injection","PX-76001894","CDM","28899","CPT","0761","RC","","","","outpatient","","","743.00","557.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","371.50","50","","377.80","377.80","377.80","1 through 10","371.5","700.33","percent of total billed charges",""
"Tau Phosphorylated Each","PX-30003839","CDM","84393","CPT","0301","RC","","","","both","","","722.00","541.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","573.99","79.5","","1652.70","1652.70","1652.70","1 through 10","223.82","685.9","percent of total billed charges",""
"Tau Phosphorylated Each","PX-30003839","CDM","84393","CPT","0301","RC","","","","outpatient","","","722.00","541.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","451.25","62.5","","455.00","455.00","455.00","1 through 10","288.8","595.65","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","543.53","71.8","","1581.03","527.01","1581.03","16","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","496.59","65.6","","572.52","572.52","572.52","1 through 10","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","492.05","65","","477.10","477.10","577.66","1 through 10","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","529.90","70","","692.96","262.00","734.00","1 through 10","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","601.82","79.5","","577.66","387.55","735.90","118","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","403.48","53.3","","387.55","387.55","1162.65","72","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","582.89","77","","565.18","565.18","565.18","1 through 10","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","492.05","65","","477.10","477.10","634.40","1 through 10","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","601.82","79.5","","577.66","577.66","577.66","1 through 10","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","234.67","31","","226.81","226.81","226.81","1 through 10","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","276.31","36.5","","273.78","232.68","734.00","147","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","289.93","38.3","","286.99","286.99","836.76","542","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","582.89","77","","577.66","572.52","734.00","1 through 10","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","TRICARE [160005]","HB BWH TRICARE","719.15","95","","120.50","114.48","120.50","1 through 10","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","324.75","42.9","","322.74","322.74","586.76","1 through 10","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","757.00","567.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","324.75","42.9","","322.74","322.74","322.74","1 through 10","77.26","719.15","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","outpatient","","","757.00","567.75","AETNA [1001]","HB AMC AETNA HMO","528.39","69.8","","496.92","350.85","572.52","152","77.26","618.62","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","outpatient","","","757.00","567.75","AETNA [1001]","HB AMC AETNA PPO","608.63","80.4","","572.52","384.62","734.00","24","77.26","618.62","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","outpatient","","","757.00","567.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","395.61","52.26","","454.20","454.20","454.20","1 through 10","77.26","618.62","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","outpatient","","","757.00","567.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","608.63","80.4","","367.00","367.00","367.00","1 through 10","77.26","618.62","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","outpatient","","","757.00","567.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","618.62","81.72","","322.74","182.22","586.76","1 through 10","77.26","618.62","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","outpatient","","","757.00","567.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","618.62","81.72","","586.76","322.74","586.76","140","77.26","618.62","percent of total billed charges",""
"Tbs Technical Calculation Only","PX-32000450","CDM","77091","CPT","0320","RC","","","","both","","","469.00","351.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","372.86","79.5","","358.09","358.09","358.09","1 through 10","99.34","372.86","percent of total billed charges",""
"Tbs Technical Calculation Only","PX-32000450","CDM","77091","CPT","0320","RC","","","","both","","","469.00","351.75","MEDICARE [2001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","28","99.34","372.86","other","OPPS APC"
"Tbs Technical Calculation Only","PX-32000450","CDM","77091","CPT","0320","RC","","","","both","","","469.00","351.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.77","102.77","102.77","1 through 10","99.34","372.86","other","OPPS APC"
"Tbs Technical Calculation Only","PX-32000450","CDM","77091","CPT","0320","RC","","","","both","","","469.00","351.75","TRICARE [160005]","HB BWH TRICARE","99.34","","APC Price ($104.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","99.33","99.33","99.33","1 through 10","99.34","372.86","other","Tricare OPPS"
"Tbs Technical Calculation Only","PX-32000450","CDM","77091","CPT","0320","RC","","","","outpatient","","","469.00","351.75","AETNA [1001]","HB AMC AETNA HMO","327.36","69.8","","308.04","308.04","308.04","1 through 10","131.46","386.93","percent of total billed charges",""
"Tbs Technical Calculation Only","PX-32000450","CDM","77091","CPT","0320","RC","","","","outpatient","","","469.00","351.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","283.98","60.55","","244.93","244.93","244.93","1 through 10","131.46","386.93","percent of total billed charges",""
"Tbs Technical Calculation Only","PX-32000450","CDM","77091","CPT","0320","RC","","","","outpatient","","","469.00","351.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","244.91","52.22","","314.50","244.93","314.50","1 through 10","131.46","386.93","percent of total billed charges",""
"Tbs Technical Calculation Only","PX-32000450","CDM","77091","CPT","0320","RC","","","","outpatient","","","469.00","351.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","246.23","52.5","","262.08","262.08","262.08","1 through 10","131.46","386.93","percent of total billed charges",""
"Tbs Technical Calculation Only","PX-32000450","CDM","77091","CPT","0320","RC","","","","outpatient","","","469.00","351.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","234.50","50","","238.42","238.42","238.42","1 through 10","131.46","386.93","percent of total billed charges",""
"Tbs Technical Calculation Only","PX-32000450","CDM","77091","CPT","0320","RC","","","","outpatient","","","469.00","351.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","246.23","52.5","","940.56","940.56","940.56","1 through 10","131.46","386.93","percent of total billed charges",""
"Tbs Technical Calculation Only","PX-32000450","CDM","77091","CPT","0320","RC","","","","outpatient","","","469.00","351.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","257.95","55","","262.08","262.08","262.08","1 through 10","131.46","386.93","percent of total billed charges",""
"Tcat Impl Wrls P-Art Prs Snr L-T Hemodyn Mntr","PX-36000447","CDM","33289","CPT","0361","RC","","","","both","","","8900.00","6675.00","MEDICARE [2001]","HB BWH MEDICARE","33756.94","","APC Price ($33,756.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","33760.35","33760.35","63443.44","1 through 10","2759","42196.17","other","OPPS APC"
"Tcat Insj Perm 1chmbr Ldls Pacemaker R Atrial","PX-48000514","CDM","0823T","CPT","0480","RC","","","","both","","","13271.00","9953.25","MEDICARE [2001]","HB BWH MEDICARE","22645.86","","APC Price ($22,645.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","42533.22","22648.15","42533.22","1 through 10","4114.01","28307.32","other","OPPS APC"
"Tcat Insj Perm 1chmbr Ldls Pacemaker R Atrial","PX-48000514","CDM","0823T","CPT","0480","RC","","","","outpatient","","","13271.00","9953.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","20022.71","","Case rate ($20,022.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","40225.62","40225.62","40225.62","1 through 10","5308.4","60939.55","other","ASC"
"Tcat Insj/Rpl Perm Leadless Pacemaker Rv W/Img","PX-48000463","CDM","33274","CPT","0480","RC","","","","both","","","15016.00","11262.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","23325.23","","APC Price ($22,645.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","21883.34","21883.34","21883.34","1 through 10","4654.96","28307.32","other","OPPS APC"
"Tcat Insj/Rpl Perm Leadless Pacemaker Rv W/Img","PX-48000463","CDM","33274","CPT","0480","RC","","","","both","","","15016.00","11262.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","22645.86","","APC Price ($22,645.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","22285.78","4039.95","22285.78","1 through 10","4654.96","28307.32","other","OPPS APC"
"Tcat Insj/Rpl Perm Leadless Pacemaker Rv W/Img","PX-48000463","CDM","33274","CPT","0480","RC","","","","both","","","15016.00","11262.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","22192.94","","APC Price ($22,645.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","22203.09","20849.18","22203.09","1 through 10","4654.96","28307.32","other","OPPS APC"
"Tcat Insj/Rpl Perm Leadless Pacemaker Rv W/Img","PX-48000463","CDM","33274","CPT","0480","RC","","","","both","","","15016.00","11262.00","WELLPOINT [1015]","HB AMC WELLPOINT","11078.80","73.78","","9617.23","9617.23","9617.23","1 through 10","4654.96","28307.32","percent of total billed charges",""
"Tcat Insj/Rpl Perm Leadless Pacemaker Rv W/Img","PX-48000463","CDM","33274","CPT","0480","RC","","","","outpatient","","","15016.00","11262.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","13819.05","","Case rate ($13,819.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","134873.92","134873.92","134873.92","1 through 10","7847.36","43419","other","Multiple Surgery"
"Tcd Std Icr Art Ven-Artl Shnt Detcj IV Mbubb Njx","PX-92000190","CDM","93893","CPT","0921","RC","","","","both","","","1727.00","1295.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1122.55","65","","1088.75","1088.75","1088.75","1 through 10","119.97","1372.97","percent of total billed charges",""
"Tcd Std Icr Art Ven-Artl Shnt Detcj IV Mbubb Njx","PX-92000190","CDM","93893","CPT","0921","RC","","","","both","","","1727.00","1295.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1372.97","79.5","","1318.23","884.40","1318.23","1 through 10","119.97","1372.97","percent of total billed charges",""
"Tcd Std Icr Art Ven-Artl Shnt Detcj IV Mbubb Njx","PX-92000190","CDM","93893","CPT","0921","RC","","","","both","","","1727.00","1295.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","920.49","53.3","","884.40","884.40","884.40","1 through 10","119.97","1372.97","percent of total billed charges",""
"Tcd Std Icr Art Ven-Artl Shnt Detcj IV Mbubb Njx","PX-92000190","CDM","93893","CPT","0921","RC","","","","both","","","1727.00","1295.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1329.79","77","","1289.75","1289.75","1289.75","1 through 10","119.97","1372.97","percent of total billed charges",""
"Tcd Std Icr Art Ven-Artl Shnt Detcj IV Mbubb Njx","PX-92000190","CDM","93893","CPT","0921","RC","","","","both","","","1727.00","1295.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","1372.97","other","OPPS APC"
"Tcd Std Icr Art Ven-Artl Shnt Detcj IV Mbubb Njx","PX-92000190","CDM","93893","CPT","0921","RC","","","","both","","","1727.00","1295.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","661.44","38.3","","654.93","654.93","654.93","1 through 10","119.97","1372.97","percent of total billed charges",""
"Tcd Std Icr Art Ven-Artl Shnt Detcj IV Mbubb Njx","PX-92000190","CDM","93893","CPT","0921","RC","","","","both","","","1727.00","1295.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","740.88","42.9","","1339.00","1339.00","1339.00","1 through 10","119.97","1372.97","percent of total billed charges",""
"Tcd Std Icr Art Ven-Artl Shnt Detcj IV Mbubb Njx","PX-92000190","CDM","93893","CPT","0921","RC","","","","outpatient","","","1727.00","1295.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1411.30","81.72","","2065.65","1339.00","2065.65","1 through 10","258.48","1411.3","percent of total billed charges",""
"Tcell Recp Exc Circle","PX-31001181","CDM","81479","CPT","0310","RC","","","","both","","","2168.00","1626.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1723.56","79.5","","0.65","0.65","0.65","1 through 10","672.08","2059.6","percent of total billed charges",""
"Tcell Recp Exc Circle","PX-31001181","CDM","81479","CPT","0310","RC","","","","both","","","2168.00","1626.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1155.54","53.3","","0.79","0.79","0.79","1 through 10","672.08","2059.6","percent of total billed charges",""
"Tcell Recp Exc Circle","PX-31001181","CDM","81479","CPT","0310","RC","","","","outpatient","","","2168.00","1626.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1084.00","50","","1.00","1.00","1.00","1 through 10","156.55","1788.6","percent of total billed charges",""
"Tcell Recp Exc Circle","PX-31001181","CDM","81479","CPT","0310","RC","","","","outpatient","","","2168.00","1626.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1138.20","52.5","","1.00","0.53","1.00","1 through 10","156.55","1788.6","percent of total billed charges",""
"Td Vaccine Prsrv Free 7 Yrs or Older for Im Use","PX-63601068","CDM","90714","CPT","0636","RC","","","","both","","","66.38","49.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24.23","36.5","","24.76","21.04","24.76","15","20.58","70.26","percent of total billed charges",""
"Td Vaccine Prsrv Free 7 Yrs or Older for Im Use","PX-63601068","CDM","90714","CPT","0636","RC","","","","both","","","66.38","49.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25.42","38.3","","25.95","25.95","75.66","20","20.58","70.26","percent of total billed charges",""
"Td Vaccine Prsrv Free 7 Yrs or Older for Im Use","PX-63601068","CDM","90714","CPT","0636","RC","","","","outpatient","","","66.38","49.78","AETNA [1001]","HB AMC AETNA HMO","46.33","69.8","","44.94","44.94","51.78","1 through 10","31.13","54.25","percent of total billed charges",""
"Td Vaccine Prsrv Free 7 Yrs or Older for Im Use","PX-63601068","CDM","90714","CPT","0636","RC","","","","outpatient","","","66.38","49.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46.40","69.9","","46.00","30.80","46.00","1 through 10","31.13","54.25","percent of total billed charges",""
"Td Vaccine Prsrv Free 7 Yrs or Older for Im Use","PX-63601068","CDM","90714","CPT","0636","RC","","","","outpatient","","","66.38","49.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","31.13","46.9","","30.80","30.80","30.80","1 through 10","31.13","54.25","percent of total billed charges",""
"Td Vaccine Prsrv Free 7 Yrs or Older for Im Use","PX-63601068","CDM","90714","CPT","0636","RC","","","","outpatient","","","66.38","49.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","54.25","81.72","","59.81","59.81","71.98","1 through 10","31.13","54.25","percent of total billed charges",""
"TDA NOS Apixaban (eg. ELIQUIS)","PX-30003542","CDM","80299","CPT","0301","RC","","","","both","","","256.00","192.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","203.52","79.5","","106.25","71.28","106.25","1 through 10","14.12","243.2","percent of total billed charges",""
"TDA NOS Apixaban (eg. ELIQUIS)","PX-30003542","CDM","80299","CPT","0301","RC","","","","both","","","256.00","192.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","136.45","53.3","","106.25","71.28","106.25","1 through 10","14.12","243.2","percent of total billed charges",""
"TDA NOS Apixaban (eg. ELIQUIS)","PX-30003542","CDM","80299","CPT","0301","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","93.44","36.5","","50.36","42.80","92.50","13","14.12","243.2","percent of total billed charges",""
"TDA NOS Apixaban (eg. ELIQUIS)","PX-30003542","CDM","80299","CPT","0301","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","98.05","38.3","","52.79","44.55","158.37","30","14.12","243.2","percent of total billed charges",""
"TDA NOS Apixaban (eg. ELIQUIS)","PX-30003542","CDM","80299","CPT","0301","RC","","","","outpatient","","","256.00","192.00","AETNA [1001]","HB AMC AETNA HMO","178.69","69.8","","91.40","64.53","105.30","14","14.12","209.2","percent of total billed charges",""
"TDA NOS Apixaban (eg. ELIQUIS)","PX-30003542","CDM","80299","CPT","0301","RC","","","","outpatient","","","256.00","192.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","205.82","80.4","","105.30","105.30","105.30","1 through 10","14.12","209.2","percent of total billed charges",""
"TDA NOS Apixaban (eg. ELIQUIS)","PX-30003542","CDM","80299","CPT","0301","RC","","","","outpatient","","","256.00","192.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","209.20","81.72","","59.36","15.50","59.36","1 through 10","14.12","209.2","percent of total billed charges",""
"Tda Nos Eslicarbazepine (Eg. Aptiom)","PX-30003547","CDM","80299","CPT","0301","RC","","","","both","","","206.00","154.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","163.77","79.5","","106.25","71.28","106.25","1 through 10","14.12","195.7","percent of total billed charges",""
"Tda Nos Eslicarbazepine (Eg. Aptiom)","PX-30003547","CDM","80299","CPT","0301","RC","","","","both","","","206.00","154.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.80","53.3","","106.25","71.28","106.25","1 through 10","14.12","195.7","percent of total billed charges",""
"Tda Nos Eslicarbazepine (Eg. Aptiom)","PX-30003547","CDM","80299","CPT","0301","RC","","","","both","","","206.00","154.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","75.19","36.5","","50.36","42.80","92.50","13","14.12","195.7","percent of total billed charges",""
"Tda Nos Eslicarbazepine (Eg. Aptiom)","PX-30003547","CDM","80299","CPT","0301","RC","","","","both","","","206.00","154.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.90","38.3","","52.79","44.55","158.37","30","14.12","195.7","percent of total billed charges",""
"Tda Nos Eslicarbazepine (Eg. Aptiom)","PX-30003547","CDM","80299","CPT","0301","RC","","","","outpatient","","","206.00","154.50","AETNA [1001]","HB AMC AETNA HMO","143.79","69.8","","91.40","64.53","105.30","14","14.12","168.34","percent of total billed charges",""
"Tda Nos Eslicarbazepine (Eg. Aptiom)","PX-30003547","CDM","80299","CPT","0301","RC","","","","outpatient","","","206.00","154.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","165.62","80.4","","105.30","105.30","105.30","1 through 10","14.12","168.34","percent of total billed charges",""
"Tda Nos Eslicarbazepine (Eg. Aptiom)","PX-30003547","CDM","80299","CPT","0301","RC","","","","outpatient","","","206.00","154.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","168.34","81.72","","59.36","15.50","59.36","1 through 10","14.12","168.34","percent of total billed charges",""
"Tda Nos Rivaroxaban","PX-30003518","CDM","80299","CPT","0301","RC","","","","both","","","256.00","192.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","203.52","79.5","","106.25","71.28","106.25","1 through 10","14.12","243.2","percent of total billed charges",""
"Tda Nos Rivaroxaban","PX-30003518","CDM","80299","CPT","0301","RC","","","","both","","","256.00","192.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","136.45","53.3","","106.25","71.28","106.25","1 through 10","14.12","243.2","percent of total billed charges",""
"Tda Nos Rivaroxaban","PX-30003518","CDM","80299","CPT","0301","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","93.44","36.5","","50.36","42.80","92.50","13","14.12","243.2","percent of total billed charges",""
"Tda Nos Rivaroxaban","PX-30003518","CDM","80299","CPT","0301","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","98.05","38.3","","52.79","44.55","158.37","30","14.12","243.2","percent of total billed charges",""
"Tda Nos Rivaroxaban","PX-30003518","CDM","80299","CPT","0301","RC","","","","outpatient","","","256.00","192.00","AETNA [1001]","HB AMC AETNA HMO","178.69","69.8","","91.40","64.53","105.30","14","14.12","209.2","percent of total billed charges",""
"Tda Nos Rivaroxaban","PX-30003518","CDM","80299","CPT","0301","RC","","","","outpatient","","","256.00","192.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","205.82","80.4","","105.30","105.30","105.30","1 through 10","14.12","209.2","percent of total billed charges",""
"Tda Nos Rivaroxaban","PX-30003518","CDM","80299","CPT","0301","RC","","","","outpatient","","","256.00","192.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","209.20","81.72","","59.36","15.50","59.36","1 through 10","14.12","209.2","percent of total billed charges",""
"Tda Nos Synthetic Glucocorticoid Screen, Urine","PX-30003623","CDM","80299","CPT","0301","RC","","","","both","","","233.00","174.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","185.24","79.5","","106.25","71.28","106.25","1 through 10","14.12","221.35","percent of total billed charges",""
"Tda Nos Synthetic Glucocorticoid Screen, Urine","PX-30003623","CDM","80299","CPT","0301","RC","","","","both","","","233.00","174.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","124.19","53.3","","106.25","71.28","106.25","1 through 10","14.12","221.35","percent of total billed charges",""
"Tda Nos Synthetic Glucocorticoid Screen, Urine","PX-30003623","CDM","80299","CPT","0301","RC","","","","both","","","233.00","174.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","85.05","36.5","","50.36","42.80","92.50","13","14.12","221.35","percent of total billed charges",""
"Tda Nos Synthetic Glucocorticoid Screen, Urine","PX-30003623","CDM","80299","CPT","0301","RC","","","","both","","","233.00","174.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","89.24","38.3","","52.79","44.55","158.37","30","14.12","221.35","percent of total billed charges",""
"Tda Nos Synthetic Glucocorticoid Screen, Urine","PX-30003623","CDM","80299","CPT","0301","RC","","","","outpatient","","","233.00","174.75","AETNA [1001]","HB AMC AETNA HMO","162.63","69.8","","91.40","64.53","105.30","14","14.12","190.41","percent of total billed charges",""
"Tda Nos Synthetic Glucocorticoid Screen, Urine","PX-30003623","CDM","80299","CPT","0301","RC","","","","outpatient","","","233.00","174.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","187.33","80.4","","105.30","105.30","105.30","1 through 10","14.12","190.41","percent of total billed charges",""
"Tda Nos Synthetic Glucocorticoid Screen, Urine","PX-30003623","CDM","80299","CPT","0301","RC","","","","outpatient","","","233.00","174.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","190.41","81.72","","59.36","15.50","59.36","1 through 10","14.12","190.41","percent of total billed charges",""
"Tda Nos Ustekinumab and Anti-Ustekinumab Antibodies, Serum (Eg. Stelara)","PX-30003558","CDM","80299","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","106.25","71.28","106.25","1 through 10","14.12","282.15","percent of total billed charges",""
"Tda Nos Ustekinumab and Anti-Ustekinumab Antibodies, Serum (Eg. Stelara)","PX-30003558","CDM","80299","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","106.25","71.28","106.25","1 through 10","14.12","282.15","percent of total billed charges",""
"Tda Nos Ustekinumab and Anti-Ustekinumab Antibodies, Serum (Eg. Stelara)","PX-30003558","CDM","80299","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","50.36","42.80","92.50","13","14.12","282.15","percent of total billed charges",""
"Tda Nos Ustekinumab and Anti-Ustekinumab Antibodies, Serum (Eg. Stelara)","PX-30003558","CDM","80299","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","52.79","44.55","158.37","30","14.12","282.15","percent of total billed charges",""
"Tda Nos Ustekinumab and Anti-Ustekinumab Antibodies, Serum (Eg. Stelara)","PX-30003558","CDM","80299","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","91.40","64.53","105.30","14","14.12","242.71","percent of total billed charges",""
"Tda Nos Ustekinumab and Anti-Ustekinumab Antibodies, Serum (Eg. Stelara)","PX-30003558","CDM","80299","CPT","0301","RC","","","","outpatient","","","297.00","222.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","238.79","80.4","","105.30","105.30","105.30","1 through 10","14.12","242.71","percent of total billed charges",""
"Tda Nos Ustekinumab and Anti-Ustekinumab Antibodies, Serum (Eg. Stelara)","PX-30003558","CDM","80299","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","59.36","15.50","59.36","1 through 10","14.12","242.71","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","both","","","72.36","54.27","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","55.72","77","","55.72","55.72","55.72","1 through 10","22.43","94.85","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","both","","","72.36","54.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","22.43","31","","22.36","21.50","67.08","1 through 10","22.43","94.85","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","both","","","72.36","54.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.41","36.5","","26.99","22.94","26.99","92","22.43","94.85","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","both","","","72.36","54.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27.71","38.3","","28.29","27.50","55.14","348","22.43","94.85","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","both","","","72.36","54.27","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","55.72","77","","55.72","55.72","55.72","1 through 10","22.43","94.85","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","both","","","72.36","54.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.04","42.9","","83.05","83.05","83.05","1 through 10","22.43","94.85","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","both","","","72.36","54.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.04","42.9","","82.32","82.32","82.32","1 through 10","22.43","94.85","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","outpatient","","","72.36","54.27","AETNA [1001]","HB AMC AETNA HMO","50.51","69.8","","48.99","34.59","56.44","104","33.94","59.13","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","outpatient","","","72.36","54.27","AETNA [1001]","HB AMC AETNA PPO","58.18","80.4","","56.44","56.44","56.44","11","33.94","59.13","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","outpatient","","","72.36","54.27","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","37.82","52.26","","44.78","44.78","44.78","1 through 10","33.94","59.13","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","outpatient","","","72.36","54.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","50.58","69.9","","50.15","33.58","54.56","59","33.94","59.13","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","outpatient","","","72.36","54.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33.94","46.9","","36.54","33.58","50.15","40","33.94","59.13","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","outpatient","","","72.36","54.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","50.58","69.9","","52.64","52.64","52.64","1 through 10","33.94","59.13","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","outpatient","","","72.36","54.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","59.13","81.72","","83.05","82.32","83.05","1 through 10","33.94","59.13","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","outpatient","","","72.36","54.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","59.13","81.72","","83.05","82.32","84.00","76","33.94","59.13","percent of total billed charges",""
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","3018.00","2263.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.77","396.82","427.77","1 through 10","412.99","2399.31","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","3018.00","2263.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2399.31","79.5","","2303.55","2303.55","2303.55","1 through 10","412.99","2399.31","percent of total billed charges",""
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","3018.00","2263.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1608.59","53.3","","2303.55","1478.14","2303.55","1 through 10","412.99","2399.31","percent of total billed charges",""
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","3018.00","2263.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.77","346.42","427.77","1 through 10","412.99","2399.31","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","3018.00","2263.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","2172.96","72","","2107.44","2107.44","2107.44","1 through 10","412.99","2399.31","percent of total billed charges",""
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","3018.00","2263.50","MARTIN'S POINT [160007]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","428.64","428.64","428.64","1 through 10","412.99","2399.31","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","3018.00","2263.50","MEDICARE [2001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","434.73","434.73","434.73","39","412.99","2399.31","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","3018.00","2263.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1101.57","36.5","","1091.77","927.86","1091.77","1 through 10","412.99","2399.31","percent of total billed charges",""
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","3018.00","2263.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1155.89","38.3","","1144.46","1144.46","1144.46","12","412.99","2399.31","percent of total billed charges",""
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","3018.00","2263.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","426.04","426.04","426.04","1 through 10","412.99","2399.31","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","3018.00","2263.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1294.72","42.9","","2339.84","1287.00","2339.84","1 through 10","412.99","2399.31","percent of total billed charges",""
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","3018.00","2263.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","426.04","395.20","427.78","1 through 10","412.99","2399.31","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","outpatient","","","3018.00","2263.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2466.31","81.72","","2339.84","2339.84","2339.84","1 through 10","875.35","2466.31","percent of total billed charges",""
"Telomere Defects Gene Ngs Panel","PX-31001055","CDM","81479","CPT","0310","RC","","","","both","","","6312.00","4734.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5018.04","79.5","","0.65","0.65","0.65","1 through 10","1956.72","5996.4","percent of total billed charges",""
"Telomere Defects Gene Ngs Panel","PX-31001055","CDM","81479","CPT","0310","RC","","","","both","","","6312.00","4734.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3364.30","53.3","","0.79","0.79","0.79","1 through 10","1956.72","5996.4","percent of total billed charges",""
"Telomere Defects Gene Ngs Panel","PX-31001055","CDM","81479","CPT","0310","RC","","","","outpatient","","","6312.00","4734.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3156.00","50","","1.00","1.00","1.00","1 through 10","156.55","5207.4","percent of total billed charges",""
"Telomere Defects Gene Ngs Panel","PX-31001055","CDM","81479","CPT","0310","RC","","","","outpatient","","","6312.00","4734.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3313.80","52.5","","1.00","0.53","1.00","1 through 10","156.55","5207.4","percent of total billed charges",""
"Telomere-Related Pulmonary Fibrosis","PX-31000825","CDM","81479","CPT","0310","RC","","","","both","","","1829.00","1371.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1454.06","79.5","","0.65","0.65","0.65","1 through 10","566.99","1737.55","percent of total billed charges",""
"Telomere-Related Pulmonary Fibrosis","PX-31000825","CDM","81479","CPT","0310","RC","","","","both","","","1829.00","1371.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","974.86","53.3","","0.79","0.79","0.79","1 through 10","566.99","1737.55","percent of total billed charges",""
"Telomere-Related Pulmonary Fibrosis","PX-31000825","CDM","81479","CPT","0310","RC","","","","outpatient","","","1829.00","1371.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","914.50","50","","1.00","1.00","1.00","1 through 10","156.55","1508.93","percent of total billed charges",""
"Telomere-Related Pulmonary Fibrosis","PX-31000825","CDM","81479","CPT","0310","RC","","","","outpatient","","","1829.00","1371.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","960.23","52.5","","1.00","0.53","1.00","1 through 10","156.55","1508.93","percent of total billed charges",""
"TEMPLATE ROD MULTILEVEL ASF","SUP-ITM-10187543","CDM","C1889","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","626.06","79.5","","1309.77","674.56","6049.93","26","244.13","626.06","percent of total billed charges",""
"TEMPLATE ROD MULTILEVEL ASF","SUP-ITM-10187543","CDM","C1889","HCPCS","0278","RC","","","","both","","","787.50","590.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","419.74","53.3","","1901.83","1901.83","2962.25","1 through 10","244.13","626.06","percent of total billed charges",""
"TEMPLATE ROD MULTILEVEL ASF","SUP-ITM-10187543","CDM","C1889","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","287.44","36.5","","1620.31","1620.31","19908.88","1 through 10","244.13","626.06","percent of total billed charges",""
"TEMPLATE ROD MULTILEVEL ASF","SUP-ITM-10187543","CDM","C1889","HCPCS","0278","RC","","","","both","","","787.50","590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","301.61","38.3","","352.91","352.91","2046.30","1 through 10","244.13","626.06","percent of total billed charges",""
"TEMPLATE ROD MULTILEVEL ASF","SUP-ITM-10187543","CDM","C1889","HCPCS","0278","RC","","","","both","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","337.84","42.9","","9668.75","9668.75","9668.75","1 through 10","244.13","626.06","percent of total billed charges",""
"TEMPLATE ROD MULTILEVEL ASF","SUP-ITM-10187543","CDM","C1889","HCPCS","0278","RC","","","","both","","","787.50","590.62","WELLPOINT [1015]","HB AMC WELLPOINT","581.02","73.78","","699.88","384.10","3443.31","33","244.13","626.06","percent of total billed charges",""
"TEMPLATE ROD MULTILEVEL ASF","SUP-ITM-10187543","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","AETNA [1001]","HB AMC AETNA HMO","549.68","69.8","","1421.24","264.50","4933.46","29","411.55","643.55","percent of total billed charges",""
"TEMPLATE ROD MULTILEVEL ASF","SUP-ITM-10187543","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","633.15","80.4","","1022.97","1022.97","3607.50","1 through 10","411.55","643.55","percent of total billed charges",""
"TEMPLATE ROD MULTILEVEL ASF","SUP-ITM-10187543","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","787.50","590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","643.55","81.72","","3010.54","693.88","5019.88","35","411.55","643.55","percent of total billed charges",""
"TEMPLATE SIZING 12 HOLE RIBFIX BLU","SUP-ITM-10338527","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.00","346.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","367.29","79.5","","800.18","480.96","1887.97","195","143.22","367.29","percent of total billed charges",""
"TEMPLATE SIZING 12 HOLE RIBFIX BLU","SUP-ITM-10338527","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.00","346.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","246.25","53.3","","813.12","216.42","1444.50","81","143.22","367.29","percent of total billed charges",""
"TEMPLATE SIZING 12 HOLE RIBFIX BLU","SUP-ITM-10338527","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.00","346.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","143.22","31","","432.60","432.60","432.60","1 through 10","143.22","367.29","percent of total billed charges",""
"TEMPLATE SIZING 12 HOLE RIBFIX BLU","SUP-ITM-10338527","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.00","346.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","168.63","36.5","","148.37","54.89","631.39","94","143.22","367.29","percent of total billed charges",""
"TEMPLATE SIZING 12 HOLE RIBFIX BLU","SUP-ITM-10338527","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.00","346.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","176.95","38.3","","279.30","91.72","1116.77","266","143.22","367.29","percent of total billed charges",""
"TEMPLATE SIZING 12 HOLE RIBFIX BLU","SUP-ITM-10338527","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.00","346.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.20","42.9","","731.00","63.70","731.00","1 through 10","143.22","367.29","percent of total billed charges",""
"TEMPLATE SIZING 12 HOLE RIBFIX BLU","SUP-ITM-10338527","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.00","346.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.20","42.9","","384.74","384.74","384.74","1 through 10","143.22","367.29","percent of total billed charges",""
"TEMPLATE SIZING 12 HOLE RIBFIX BLU","SUP-ITM-10338527","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.00","346.50","WELLPOINT [1015]","HB AMC WELLPOINT","340.86","73.78","","286.63","119.22","1107.45","105","143.22","367.29","percent of total billed charges",""
"TEMPLATE SIZING 12 HOLE RIBFIX BLU","SUP-ITM-10338527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.00","346.50","AETNA [1001]","HB AMC AETNA HMO","322.48","69.8","","675.31","184.75","1721.50","286","241.44","377.55","percent of total billed charges",""
"TEMPLATE SIZING 12 HOLE RIBFIX BLU","SUP-ITM-10338527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.00","346.50","AETNA [1001]","HB AMC AETNA PPO","371.45","80.4","","1261.44","103.12","1514.10","21","241.44","377.55","percent of total billed charges",""
"TEMPLATE SIZING 12 HOLE RIBFIX BLU","SUP-ITM-10338527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.00","346.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","371.45","80.4","","1365.00","1365.00","1365.00","1 through 10","241.44","377.55","percent of total billed charges",""
"TEMPLATE SIZING 12 HOLE RIBFIX BLU","SUP-ITM-10338527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.00","346.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","377.55","81.72","","5157.68","5157.68","5157.68","1 through 10","241.44","377.55","percent of total billed charges",""
"TEMPLATE SIZING 12 HOLE RIBFIX BLU","SUP-ITM-10338527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.00","346.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","377.55","81.72","","431.26","71.26","1459.57","88","241.44","377.55","percent of total billed charges",""
"TEMPLATE SPINAL RELINE O SINGLE LEVEL","SUP-ITM-10170044","CDM","C1889","HCPCS","0278","RC","","","","both","","","612.50","459.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","486.94","79.5","","1309.77","674.56","6049.93","26","189.88","486.94","percent of total billed charges",""
"TEMPLATE SPINAL RELINE O SINGLE LEVEL","SUP-ITM-10170044","CDM","C1889","HCPCS","0278","RC","","","","both","","","612.50","459.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","326.46","53.3","","1901.83","1901.83","2962.25","1 through 10","189.88","486.94","percent of total billed charges",""
"TEMPLATE SPINAL RELINE O SINGLE LEVEL","SUP-ITM-10170044","CDM","C1889","HCPCS","0278","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.56","36.5","","1620.31","1620.31","19908.88","1 through 10","189.88","486.94","percent of total billed charges",""
"TEMPLATE SPINAL RELINE O SINGLE LEVEL","SUP-ITM-10170044","CDM","C1889","HCPCS","0278","RC","","","","both","","","612.50","459.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","234.59","38.3","","352.91","352.91","2046.30","1 through 10","189.88","486.94","percent of total billed charges",""
"TEMPLATE SPINAL RELINE O SINGLE LEVEL","SUP-ITM-10170044","CDM","C1889","HCPCS","0278","RC","","","","both","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","262.76","42.9","","9668.75","9668.75","9668.75","1 through 10","189.88","486.94","percent of total billed charges",""
"TEMPLATE SPINAL RELINE O SINGLE LEVEL","SUP-ITM-10170044","CDM","C1889","HCPCS","0278","RC","","","","both","","","612.50","459.37","WELLPOINT [1015]","HB AMC WELLPOINT","451.90","73.78","","699.88","384.10","3443.31","33","189.88","486.94","percent of total billed charges",""
"TEMPLATE SPINAL RELINE O SINGLE LEVEL","SUP-ITM-10170044","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","AETNA [1001]","HB AMC AETNA HMO","427.53","69.8","","1421.24","264.50","4933.46","29","320.09","500.54","percent of total billed charges",""
"TEMPLATE SPINAL RELINE O SINGLE LEVEL","SUP-ITM-10170044","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","492.45","80.4","","1022.97","1022.97","3607.50","1 through 10","320.09","500.54","percent of total billed charges",""
"TEMPLATE SPINAL RELINE O SINGLE LEVEL","SUP-ITM-10170044","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","612.50","459.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","500.54","81.72","","3010.54","693.88","5019.88","35","320.09","500.54","percent of total billed charges",""
"Temporal Artery Ligatn or Bx","PX-98301543","CDM","37609","CPT","0983","RC","","","","outpatient","","","953.00","714.75","AETNA [1001]","HB AMC AETNA HMO","665.19","69.8","","1942.99","1942.99","1942.99","1 through 10","532.73","5545.35","percent of total billed charges",""
"Tendon Sheath Incision","PX-76002357","CDM","26055","CPT","0761","RC","","","","both","","","4442.00","3331.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1862.38","","APC Price ($1,900.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1870.07","1867.57","1870.07","1 through 10","1377.02","3531.39","other","OPPS APC"
"Tendon Sheath Incision","PX-76002357","CDM","26055","CPT","0761","RC","","","","outpatient","","","4442.00","3331.50","AETNA [1001]","HB AMC AETNA HMO","3100.52","69.8","","5646.18","5646.18","5646.18","1 through 10","1182.01","5545.35","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3350.13","79.5","","800.18","480.96","1887.97","195","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2246.06","53.3","","813.12","216.42","1444.50","81","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1306.34","31","","432.60","432.60","432.60","1 through 10","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1538.11","36.5","","148.37","54.89","631.39","94","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1613.96","38.3","","279.30","91.72","1116.77","266","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1807.81","42.9","","731.00","63.70","731.00","1 through 10","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1807.81","42.9","","384.74","384.74","384.74","1 through 10","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","WELLPOINT [1015]","HB AMC WELLPOINT","3109.09","73.78","","286.63","119.22","1107.45","105","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","AETNA [1001]","HB AMC AETNA HMO","2941.37","69.8","","675.31","184.75","1721.50","286","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","AETNA [1001]","HB AMC AETNA PPO","3388.06","80.4","","1261.44","103.12","1514.10","21","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3388.06","80.4","","1365.00","1365.00","1365.00","1 through 10","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3443.68","81.72","","5157.68","5157.68","5157.68","1 through 10","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 3MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10025015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3443.68","81.72","","431.26","71.26","1459.57","88","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3350.13","79.5","","800.18","480.96","1887.97","195","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2246.06","53.3","","813.12","216.42","1444.50","81","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1306.34","31","","432.60","432.60","432.60","1 through 10","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1538.11","36.5","","148.37","54.89","631.39","94","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1613.96","38.3","","279.30","91.72","1116.77","266","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1807.81","42.9","","731.00","63.70","731.00","1 through 10","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1807.81","42.9","","384.74","384.74","384.74","1 through 10","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","WELLPOINT [1015]","HB AMC WELLPOINT","3109.09","73.78","","286.63","119.22","1107.45","105","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","AETNA [1001]","HB AMC AETNA HMO","2941.37","69.8","","675.31","184.75","1721.50","286","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","AETNA [1001]","HB AMC AETNA PPO","3388.06","80.4","","1261.44","103.12","1514.10","21","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3388.06","80.4","","1365.00","1365.00","1365.00","1 through 10","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3443.68","81.72","","5157.68","5157.68","5157.68","1 through 10","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 4MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10002017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3443.68","81.72","","431.26","71.26","1459.57","88","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3350.13","79.5","","800.18","480.96","1887.97","195","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2246.06","53.3","","813.12","216.42","1444.50","81","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1306.34","31","","432.60","432.60","432.60","1 through 10","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1538.11","36.5","","148.37","54.89","631.39","94","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1613.96","38.3","","279.30","91.72","1116.77","266","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1807.81","42.9","","731.00","63.70","731.00","1 through 10","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1807.81","42.9","","384.74","384.74","384.74","1 through 10","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","both","","","4214.00","3160.50","WELLPOINT [1015]","HB AMC WELLPOINT","3109.09","73.78","","286.63","119.22","1107.45","105","1306.34","3350.13","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","AETNA [1001]","HB AMC AETNA HMO","2941.37","69.8","","675.31","184.75","1721.50","286","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","AETNA [1001]","HB AMC AETNA PPO","3388.06","80.4","","1261.44","103.12","1514.10","21","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3388.06","80.4","","1365.00","1365.00","1365.00","1 through 10","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3443.68","81.72","","5157.68","5157.68","5157.68","1 through 10","2202.24","3443.68","percent of total billed charges",""
"TENDON SPACER 6MMX24CM FINGER SWANSON SILICONE ROD","SUP-ITM-10026067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4214.00","3160.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3443.68","81.72","","431.26","71.26","1459.57","88","2202.24","3443.68","percent of total billed charges",""
"Tendon, Muscle And Other Soft Tissue Procedures,EXTREME","317","DRG","","","","","","","","inpatient","","","157331.07","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","51717.19","","Case rate ($57,182.25). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $99,612.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $8,458.91 and the sum of the standard inlier and any outlier amount.","64480.68","64480.68","64480.68","1 through 10","7729","131857.76","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MAJOR","317","DRG","","","","","","","","inpatient","","","113970.78","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","67160.56","","Standard inlier is a Case rate ($67,160.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $58,102, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,532.88) for the length of stay and the standard reimbursement.","64260.70","64260.70","64260.70","1 through 10","7729","131857.76","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MAJOR","317","DRG","","","","","","","","inpatient","","","113970.78","","MASSHEALTH [3001]","HB BWH MEDICAID","20022.25","","Case rate ($22,138.04). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,568.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13627.84","13627.84","22132.61","1 through 10","7729","131857.76","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MAJOR","317","DRG","","","","","","","","inpatient","","","113970.78","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","20022.25","","Case rate ($22,138.04). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $64,568.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2085.87","2085.87","2085.87","1 through 10","7729","131857.76","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MINOR","317","DRG","","","","","","","","inpatient","","","60882.68","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18768.1497","","Fee schedule rate ($18,768.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18768.1497","18768.16","18768.16","1 through 10","7729","131857.76","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MINOR","317","DRG","","","","","","","","inpatient","","","60882.68","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","19707.1026","","Fee schedule rate ($19,707.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19707.1026","19707.12","19707.12","1 through 10","7729","131857.76","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MINOR","317","DRG","","","","","","","","inpatient","","","60882.68","","MASSHEALTH [3001]","HB BWH MEDICAID","10379.54","","Case rate ($11,476.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,906.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11473.55","11473.55","11473.55","1 through 10","7729","131857.76","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MINOR","317","DRG","","","","","","","","inpatient","","","60882.68","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10379.54","","Case rate ($11,476.36). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,906.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11130.92","11130.92","11130.92","1 through 10","7729","131857.76","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MODERATE","317","DRG","","","","","","","","inpatient","","","109203.62","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","43737.44","","Standard inlier is a Case rate ($43,737.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $41,899, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,208.17) for the length of stay and the standard reimbursement.","43421.43","43421.43","43421.43","1 through 10","7729","131857.76","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MODERATE","317","DRG","","","","","","","","inpatient","","","109203.62","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18768.1497","","Fee schedule rate ($32,819.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18768.1497","32819.08","32819.08","1 through 10","7729","131857.76","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MODERATE","317","DRG","","","","","","","","inpatient","","","109203.62","","MASSHEALTH [3001]","HB BWH MEDICAID","12484.92","","Case rate ($13,804.22). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,234.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13800.83","13800.83","13800.83","1 through 10","7729","131857.76","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MODERATE","317","DRG","","","","","","","","inpatient","","","109203.62","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41138.35","","Fee schedule rate ($41,138.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31551.77","31551.77","31551.77","1 through 10","7729","131857.76","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MODERATE","317","DRG","","","","","","","","inpatient","","","109203.62","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12484.92","","Case rate ($13,804.22). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,234.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13800.84","13800.84","13800.84","1 through 10","7729","131857.76","case rate",""
"Tendonitis, Myositis And Bursitis With McC","557","MS-DRG","","","","","","","","inpatient","","","69149.71","51862.28","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","13943.51","","Case rate ($13,943.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,707.82, add-ons for qualifying new technology services are included. If operating cost exceeds $62,352.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,636.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $12,367.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,327.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,196.45. The transfer capital threshold is the transfer adjustment factor * $1,196.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14189.81","14189.81","14189.81","1 through 10","13664.64","23290.8","other","Inpatient DRG"
"Tendonitis, Myositis And Bursitis With McC","557","MS-DRG","","","","","","","","inpatient","","","69149.71","51862.28","MEDICARE [2001]","HB BWH MEDICARE","17983.15","","Case rate ($17,983.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,707.82, add-ons for qualifying new technology services are included. If operating cost exceeds $62,352.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,636.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $16,406.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,327.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,196.45. The transfer capital threshold is the transfer adjustment factor * $1,196.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","18547.93","1 through 10","13664.64","23290.8","other","Inpatient DRG"
"Tendonitis, Myositis And Bursitis With McC","557","MS-DRG","","","","","","","","inpatient","","","69149.71","51862.28","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","13664.64","","Case rate ($13,943.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,707.82, add-ons for qualifying new technology services are included. If operating cost exceeds $62,352.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,636.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $12,367.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,327.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,196.45. The transfer capital threshold is the transfer adjustment factor * $1,196.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19509.18","19509.18","19509.18","1 through 10","13664.64","23290.8","other","Inpatient DRG"
"Tendonitis, Myositis And Bursitis With McC","557","MS-DRG","","","","","","","","inpatient","","","69149.71","51862.28","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13664.64","","Case rate ($13,943.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,707.82, add-ons for qualifying new technology services are included. If operating cost exceeds $62,352.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,636.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $12,367.21 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,327.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,196.45. The transfer capital threshold is the transfer adjustment factor * $1,196.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20407.88","20407.88","20407.88","1 through 10","13664.64","23290.8","other","Inpatient DRG"
"Tendonitis, Myositis And Bursitis Without McC","558","MS-DRG","","","","","","","","inpatient","","","35092.76","26319.57","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8527.70","","Case rate ($8,527.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,188.26, add-ons for qualifying new technology services are included. If operating cost exceeds $55,832.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,158.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,429.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,808.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.72. The transfer capital threshold is the transfer adjustment factor * $718.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38394.23","38394.23","38394.23","1 through 10","8357.15","13035.6058","other","Inpatient Replacement Plans DRG"
"Tendonitis, Myositis And Bursitis Without McC","558","MS-DRG","","","","","","","","inpatient","","","35092.76","26319.57","MEDICARE [2001]","HB BWH MEDICARE","8527.70","","Case rate ($8,527.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,188.26, add-ons for qualifying new technology services are included. If operating cost exceeds $55,832.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,158.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,429.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,808.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.72. The transfer capital threshold is the transfer adjustment factor * $718.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1033.09","179.74","10476.99","1 through 10","8357.15","13035.6058","other","Inpatient Replacement Plans DRG"
"Tendonitis, Myositis And Bursitis Without McC","558","MS-DRG","","","","","","","","inpatient","","","35092.76","26319.57","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8357.15","","Case rate ($8,527.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,188.26, add-ons for qualifying new technology services are included. If operating cost exceeds $55,832.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,158.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,429.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,808.42 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $718.72. The transfer capital threshold is the transfer adjustment factor * $718.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9071.57","9071.57","9071.57","1 through 10","8357.15","13035.6058","other","Inpatient DRG"
"Tenex Procedure Foot/Toes","PX-36000492","CDM","28899","CPT","0361","RC","","","","outpatient","","","6027.00","4520.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3013.50","50","","377.80","377.80","377.80","1 through 10","700.33","4972.28","percent of total billed charges",""
"Tenex Procedure Foot/Toes","PX-98302464","CDM","28899","CPT","0983","RC","","","","outpatient","","","962.00","721.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","481.00","50","","377.80","377.80","377.80","1 through 10","481","793.65","percent of total billed charges",""
"Tenex Procedure Hip","PX-36000490","CDM","27299","CPT","0361","RC","","","","both","","","4188.00","3141.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","3329.46","other","OPPS APC"
"Tenex Procedure Hip","PX-98302462","CDM","27299","CPT","0983","RC","","","","both","","","1887.00","1415.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","1500.17","other","OPPS APC"
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","both","","","91.00","68.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","72.35","79.5","","69.26","46.46","69.26","114","28.21","88.17","percent of total billed charges",""
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","both","","","91.00","68.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","48.50","53.3","","69.26","46.46","69.26","47","28.21","88.17","percent of total billed charges",""
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","both","","","91.00","68.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5.78","5.78","5.78","12","28.21","88.17","other","OPPS APC"
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","both","","","91.00","68.25","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10.08","10.08","10.08","1 through 10","28.21","88.17","other","OPPS APC"
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","both","","","91.00","68.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","34.85","38.3","","68.82","66.88","68.82","64","28.21","88.17","percent of total billed charges",""
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","both","","","91.00","68.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","70.07","77","","612.48","612.48","612.48","1 through 10","28.21","88.17","percent of total billed charges",""
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","both","","","91.00","68.25","WELLPOINT [1015]","HB AMC WELLPOINT","67.14","73.78","","65.52","65.52","65.52","29","28.21","88.17","percent of total billed charges",""
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA HMO","63.52","69.8","","59.58","42.06","68.64","51","45.5","197.92","percent of total billed charges",""
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","outpatient","","","91.00","68.25","AETNA [1001]","HB AMC AETNA PPO","73.16","80.4","","92.22","92.22","92.22","26","45.5","197.92","percent of total billed charges",""
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","outpatient","","","91.00","68.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","47.78","52.5","","50.69","50.69","50.69","1 through 10","45.5","197.92","percent of total billed charges",""
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","outpatient","","","91.00","68.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","56.88","62.5","","55.35","6.14","57.64","32","45.5","197.92","percent of total billed charges",""
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","outpatient","","","91.00","68.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","50.05","55","","48.75","48.75","50.69","39","45.5","197.92","percent of total billed charges",""
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","outpatient","","","91.00","68.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","73.16","80.4","","68.64","68.64","68.64","1 through 10","45.5","197.92","percent of total billed charges",""
"Test Allergy Intracut W/Allergenic","PX-92000095","CDM","95024","CPT","0924","RC","","","","outpatient","","","91.00","68.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","74.37","81.72","","70.35","38.69","70.35","153","45.5","197.92","percent of total billed charges",""
"Test Allergy Patch","PX-92000098","CDM","95044","CPT","0924","RC","","","","both","","","107.00","80.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","85.07","79.5","","81.85","81.85","81.85","12","33.17","1510.11","percent of total billed charges",""
"Test Allergy Patch","PX-92000098","CDM","95044","CPT","0924","RC","","","","both","","","107.00","80.25","MEDICARE [2001]","HB BWH MEDICARE","1208.09","","APC Price ($1,208.09). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","604.11","604.11","604.11","1 through 10","33.17","1510.11","other","OPPS APC"
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","both","","","153.00","114.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","100.37","65.6","","310.81","310.81","310.81","1 through 10","47.43","1510.11","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","both","","","153.00","114.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","121.64","79.5","","116.48","78.14","116.48","371","47.43","1510.11","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","both","","","153.00","114.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","81.55","53.3","","116.48","78.14","116.48","138","47.43","1510.11","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","both","","","153.00","114.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","1208.09","","APC Price ($1,208.09). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.04","54.04","54.04","23","47.43","1510.11","other","OPPS APC"
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","both","","","153.00","114.75","HUMANA [1012]","HB BWH MEDICARE","1208.09","","APC Price ($1,208.09). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","59.20","59.20","59.20","20","47.43","1510.11","other","OPPS APC"
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","both","","","153.00","114.75","MEDICARE [2001]","HB BWH MEDICARE","1208.09","","APC Price ($1,208.09). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.92","30.21","60.41","244","47.43","1510.11","other","OPPS APC"
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.60","38.3","","112.48","112.48","115.74","248","47.43","1510.11","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","both","","","153.00","114.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","117.81","77","","2832.72","2832.72","2832.72","1 through 10","47.43","1510.11","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","both","","","153.00","114.75","WELLPOINT [1015]","HB AMC WELLPOINT","112.88","73.78","","110.19","110.19","3070.19","158","47.43","1510.11","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA HMO","106.79","69.8","","100.20","70.74","115.44","144","76.5","197.92","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA PPO","123.01","80.4","","155.10","115.44","155.10","112","76.5","197.92","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","outpatient","","","153.00","114.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","85.53","55.9","","77.55","77.55","77.55","1 through 10","76.5","197.92","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","outpatient","","","153.00","114.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","80.33","52.5","","85.25","85.25","96.94","44","76.5","197.92","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","outpatient","","","153.00","114.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","95.63","62.5","","96.94","93.09","125.26","64","76.5","197.92","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","outpatient","","","153.00","114.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","84.15","55","","85.25","81.99","85.25","120","76.5","197.92","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","outpatient","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","123.01","80.4","","115.44","115.44","115.44","22","76.5","197.92","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","80.33","52.5","","93.09","93.09","93.09","28","76.5","197.92","percent of total billed charges",""
"Test Allergy Perc W/Allergenic","PX-92000094","CDM","95004","CPT","0924","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.03","81.72","","118.31","65.08","118.31","547","76.5","197.92","percent of total billed charges",""
"Test Intradermal Allergen Delayed","PX-92000097","CDM","95028","CPT","0924","RC","","","","both","","","132.00","99.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","70.36","53.3","","100.74","100.74","100.74","1 through 10","40.92","104.94","percent of total billed charges",""
"Test Intradermal Allergen Delayed","PX-92000097","CDM","95028","CPT","0924","RC","","","","outpatient","","","132.00","99.00","AETNA [1001]","HB AMC AETNA HMO","92.14","69.8","","86.66","86.66","86.66","1 through 10","68.98","197.92","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","682.00","511.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","542.19","79.5","","520.21","349.01","520.21","115","211.42","647.9","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","682.00","511.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","363.51","53.3","","349.01","349.01","520.21","57","211.42","647.9","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","682.00","511.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.08","235.08","235.08","1 through 10","211.42","647.9","other","OPPS APC"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","682.00","511.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","542.19","79.5","","520.21","520.21","520.21","1 through 10","211.42","647.9","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","682.00","511.50","MEDICARE [2001]","HB BWH MEDICARE","238.88","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","217.48","179.18","238.90","18","211.42","647.9","other","OPPS APC"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","682.00","511.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","248.93","36.5","","246.55","209.54","246.56","59","211.42","647.9","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","682.00","511.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","261.21","38.3","","258.45","258.45","258.45","383","211.42","647.9","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","682.00","511.50","TRICARE [160005]","HB BWH TRICARE","647.90","95","","14.03","13.33","14.03","12","211.42","647.9","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","682.00","511.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.58","42.9","","528.40","528.40","528.40","1 through 10","211.42","647.9","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","682.00","511.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","234.10","","APC Price ($238.88). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","238.90","235.08","238.90","1 through 10","211.42","647.9","other","OPPS APC"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","682.00","511.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.58","42.9","","290.64","290.64","290.64","1 through 10","211.42","647.9","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","682.00","511.50","WELLPOINT [1015]","HB AMC WELLPOINT","503.18","73.78","","492.11","492.11","1153.11","55","211.42","647.9","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","682.00","511.50","AETNA [1001]","HB AMC AETNA HMO","476.04","69.8","","447.50","315.96","631.92","17","165.93","880.53","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","682.00","511.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","356.41","52.26","","409.03","409.03","444.20","1 through 10","165.93","880.53","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","682.00","511.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","424.78","408.19","481.20","26","165.93","880.53","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","682.00","511.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","384.96","288.72","769.92","176","165.93","880.53","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","682.00","511.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","389.94","779.88","69","165.93","880.53","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","682.00","511.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","481.20","481.20","635.51","20","165.93","880.53","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","682.00","511.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","404.87","404.87","404.87","1 through 10","165.93","880.53","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","682.00","511.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","424.78","285.35","424.78","52","165.93","880.53","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","682.00","511.50","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","462.94","462.94","462.94","1 through 10","165.93","880.53","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","682.00","511.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","557.33","81.72","","528.40","290.64","528.40","1 through 10","165.93","880.53","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","682.00","511.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","557.33","81.72","","528.40","290.64","528.41","175","165.93","880.53","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","682.00","511.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","462.94","462.94","462.94","1 through 10","165.93","880.53","other","Multiple Surgery"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","682.00","511.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","408.19","408.19","408.19","1 through 10","165.93","880.53","other","Multiple Surgery"
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","both","","","2176.00","1632.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","369.81","1 through 10","351.32","1729.92","other","OPPS APC"
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","both","","","2176.00","1632.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1523.20","70","","1688.00","1688.00","1688.00","1 through 10","351.32","1729.92","percent of total billed charges",""
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","both","","","2176.00","1632.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1729.92","79.5","","1660.57","1114.08","1660.57","1 through 10","351.32","1729.92","percent of total billed charges",""
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","both","","","2176.00","1632.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","1 through 10","351.32","1729.92","other","OPPS APC"
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","both","","","2176.00","1632.00","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","369.81","33","351.32","1729.92","other","OPPS APC"
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","both","","","2176.00","1632.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","794.24","36.5","","787.03","787.03","787.03","1 through 10","351.32","1729.92","percent of total billed charges",""
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","both","","","2176.00","1632.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","833.41","38.3","","801.80","801.80","825.01","1 through 10","351.32","1729.92","percent of total billed charges",""
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","both","","","2176.00","1632.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.81","362.81","362.81","1 through 10","351.32","1729.92","other","OPPS APC"
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","both","","","2176.00","1632.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.41","335.72","369.81","1 through 10","351.32","1729.92","other","OPPS APC"
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","both","","","2176.00","1632.00","WELLPOINT [1015]","HB AMC WELLPOINT","1605.45","73.78","","1570.90","1570.90","1570.90","1 through 10","351.32","1729.92","percent of total billed charges",""
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","outpatient","","","2176.00","1632.00","AETNA [1001]","HB AMC AETNA HMO","1518.85","69.8","","1428.47","1428.47","1428.47","1 through 10","312.34","1778.23","percent of total billed charges",""
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","outpatient","","","2176.00","1632.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1137.18","52.26","","1305.67","1305.67","1305.67","1 through 10","312.34","1778.23","percent of total billed charges",""
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","outpatient","","","2176.00","1632.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1778.23","81.72","","927.77","927.77","927.77","1 through 10","312.34","1778.23","percent of total billed charges",""
"Test Rectal Sensation Tone Complian","PX-75000323","CDM","91120","CPT","0750","RC","","","","outpatient","","","2176.00","1632.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1778.23","81.72","","1686.74","1686.73","1686.74","1 through 10","312.34","1778.23","percent of total billed charges",""
"Testes Procedures With Cc/McC","711","MS-DRG","","","","","","","","inpatient","","","120776.40","90582.30","MEDICARE [2001]","HB BWH MEDICARE","19388.49","","Case rate ($19,388.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,262.50, add-ons for qualifying new technology services are included. If operating cost exceeds $68,906.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,116.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,331.90 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,882.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,676.75. The transfer capital threshold is the transfer adjustment factor * $1,676.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22836.33","22836.33","22836.33","1 through 10","19000.72","28832.8646","other","Inpatient Replacement Plans DRG"
"Testicular Sperm Extraction","PX-76003017","CDM","55899","CPT","0761","RC","","","","both","","","6045.00","4533.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2206.43","36.5","","16414.61","16414.61","16414.61","1 through 10","274.39","4805.78","percent of total billed charges",""
"Testicular Sperm Extraction","PX-76003017","CDM","55899","CPT","0761","RC","","","","outpatient","","","6045.00","4533.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3660.25","60.55","","24192.00","270.73","32118.00","1 through 10","700.33","4987.13","percent of total billed charges",""
"Testicular Sperm Extraction","PX-76003017","CDM","55899","CPT","0761","RC","","","","outpatient","","","6045.00","4533.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3156.70","52.22","","24192.00","613.44","32118.00","1 through 10","700.33","4987.13","percent of total billed charges",""
"Testicular Sperm Extraction","PX-76003017","CDM","55899","CPT","0761","RC","","","","outpatient","","","6045.00","4533.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3022.50","50","","18860.73","18860.73","18860.73","1 through 10","700.33","4987.13","percent of total billed charges",""
"Testicular Sperm Extraction","PX-76003017","CDM","55899","CPT","0761","RC","","","","outpatient","","","6045.00","4533.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4939.97","81.72","","28843.15","22507.11","28843.15","1 through 10","700.33","4987.13","percent of total billed charges",""
"Testing for Known Mutation/Familial Variant","PX-31000761","CDM","81479","CPT","0310","RC","","","","both","","","424.00","318.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","337.08","79.5","","0.65","0.65","0.65","1 through 10","131.44","402.8","percent of total billed charges",""
"Testing for Known Mutation/Familial Variant","PX-31000761","CDM","81479","CPT","0310","RC","","","","both","","","424.00","318.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","225.99","53.3","","0.79","0.79","0.79","1 through 10","131.44","402.8","percent of total billed charges",""
"Testing for Known Mutation/Familial Variant","PX-31000761","CDM","81479","CPT","0310","RC","","","","outpatient","","","424.00","318.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","212.00","50","","1.00","1.00","1.00","1 through 10","156.55","349.8","percent of total billed charges",""
"Testing for Known Mutation/Familial Variant","PX-31000761","CDM","81479","CPT","0310","RC","","","","outpatient","","","424.00","318.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","222.60","52.5","","1.00","0.53","1.00","1 through 10","156.55","349.8","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","295.00","221.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","211.81","71.8","","44.92","44.92","44.92","1 through 10","24.96","280.25","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","295.00","221.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","191.75","65","","185.90","151.01","185.90","1 through 10","24.96","280.25","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","295.00","221.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","206.50","70","","286.00","286.00","286.00","1 through 10","24.96","280.25","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","295.00","221.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","234.53","79.5","","225.08","151.01","225.08","103","24.96","280.25","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","295.00","221.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","157.24","53.3","","151.01","151.01","288.86","48","24.96","280.25","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","295.00","221.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","227.15","77","","220.22","220.22","220.22","1 through 10","24.96","280.25","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","295.00","221.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","234.53","79.5","","143.00","143.00","143.00","1 through 10","24.96","280.25","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","295.00","221.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","107.68","36.5","","106.68","90.66","106.68","96","24.96","280.25","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","295.00","221.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","112.99","38.3","","111.83","108.68","326.04","250","24.96","280.25","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","295.00","221.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","227.15","77","","225.08","19.03","446.16","1 through 10","24.96","280.25","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","295.00","221.25","TRICARE [160005]","HB BWH TRICARE","280.25","95","","30.69","29.16","30.69","1 through 10","24.96","280.25","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","295.00","221.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.56","42.9","","228.63","125.75","228.63","1 through 10","24.96","280.25","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","295.00","221.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.56","42.9","","125.75","125.75","125.75","1 through 10","24.96","280.25","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","295.00","221.25","AETNA [1001]","HB AMC AETNA HMO","205.91","69.8","","193.62","136.71","223.08","144","26.26","241.07","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","295.00","221.25","AETNA [1001]","HB AMC AETNA PPO","237.18","80.4","","223.08","149.86","223.08","14","26.26","241.07","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","295.00","221.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","237.18","80.4","","223.08","223.08","223.08","1 through 10","26.26","241.07","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","295.00","221.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","241.07","81.72","","228.63","125.75","228.63","1 through 10","26.26","241.07","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","295.00","221.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","241.07","81.72","","228.63","125.75","228.63","103","26.26","241.07","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","217.55","71.8","","45.52","45.52","45.52","1 through 10","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","196.95","65","","191.10","155.23","191.10","1 through 10","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","212.10","70","","294.00","294.00","294.00","1 through 10","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","CHAMPVA [160001]","HB BWH TRICARE","287.85","95","","31.10","31.10","31.10","1 through 10","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","240.89","79.5","","231.38","155.23","231.38","182","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","161.50","53.3","","155.23","155.23","296.94","92","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","233.31","77","","679.14","226.38","679.14","1 through 10","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","240.89","79.5","","147.00","147.00","147.00","1 through 10","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","93.93","31","","90.85","90.85","90.85","1 through 10","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","110.60","36.5","","109.66","93.20","109.66","141","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","116.05","38.3","","114.95","111.72","344.85","389","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","MOLINA [1014]","HB BWH MOLINA","106.05","35","","51.21","51.21","51.21","1 through 10","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","233.31","77","","231.38","19.56","458.64","1 through 10","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","TRICARE [160005]","HB BWH TRICARE","287.85","95","","29.55","29.55","31.10","14","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.99","42.9","","235.02","97.02","235.03","1 through 10","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","303.00","227.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.99","42.9","","129.27","129.27","129.27","1 through 10","25.29","287.85","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","303.00","227.25","AETNA [1001]","HB AMC AETNA HMO","211.49","69.8","","199.04","140.53","229.32","231","26.62","247.61","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","303.00","227.25","AETNA [1001]","HB AMC AETNA PPO","243.61","80.4","","229.32","140.53","229.32","28","26.62","247.61","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","303.00","227.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","169.38","55.9","","154.06","154.06","154.06","1 through 10","26.62","247.61","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","303.00","227.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","158.35","52.26","","181.93","90.74","181.93","1 through 10","26.62","247.61","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","303.00","227.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","243.61","80.4","","229.32","147.00","229.32","1 through 10","26.62","247.61","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","247.61","81.72","","235.02","129.27","235.02","1 through 10","26.62","247.61","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","247.61","81.72","","235.02","129.27","235.02","167","26.62","247.61","percent of total billed charges",""
"Tevar Fenestration Closure Repair","PX-48000457","CDM","37799","CPT","0481","RC","","","","outpatient","","","26875.00","20156.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","14034.13","52.22","","28155.00","28155.00","28155.00","1 through 10","700.33","22171.88","percent of total billed charges",""
"Tevar Fenestration Closure Repair","PX-48000457","CDM","37799","CPT","0481","RC","","","","outpatient","","","26875.00","20156.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","14109.38","52.5","","2271.00","2271.00","2271.00","1 through 10","700.33","22171.88","percent of total billed charges",""
"TGFBR1 GENE SEQUENCING LOEYS DIETZ SYNDROME CHROMOSOME 9q33 q34 TGF1S LMM","PX-31001365","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"TGFBR1 GENE SEQUENCING LOEYS DIETZ SYNDROME CHROMOSOME 9q33 q34 TGF1S LMM","PX-31001365","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"TGFBR2 GENE SEQUENCING LOEYS DIETZ SYNDROME CHROMOSOME 3p22 TGF2S LMM","PX-31001366","CDM","81405","CPT","0310","RC","","","","both","","","4062.00","3046.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3229.29","79.5","","3099.99","2560.35","3099.99","1 through 10","295.32","3858.9","percent of total billed charges",""
"TGFBR2 GENE SEQUENCING LOEYS DIETZ SYNDROME CHROMOSOME 3p22 TGF2S LMM","PX-31001366","CDM","81405","CPT","0310","RC","","","","outpatient","","","4062.00","3046.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3319.47","81.72","","3148.84","3148.84","3148.84","1 through 10","862","3319.47","percent of total billed charges",""
"Tgsap Solid Organ Neoplasm 5-50 Dna/Dna&Rna Alys","PX-30002912","CDM","81445","CPT","0310","RC","","","","both","","","4507.00","3380.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3583.07","79.5","","3439.98","2207.36","3439.98","1 through 10","585.95","4281.65","percent of total billed charges",""
"Tgsap Solid Organ Neoplasm 5-50 Dna/Dna&Rna Alys","PX-30002912","CDM","81445","CPT","0310","RC","","","","both","","","4507.00","3380.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2402.23","53.3","","2307.89","2307.89","3439.98","1 through 10","585.95","4281.65","percent of total billed charges",""
"Tgsap Solid Organ Neoplasm 5-50 Dna/Dna&Rna Alys","PX-30002912","CDM","81445","CPT","0310","RC","","","","both","","","4507.00","3380.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1645.06","36.5","","1385.61","1385.61","1385.61","1 through 10","585.95","4281.65","percent of total billed charges",""
"Tgsap Solid Organ Neoplasm 5-50 Dna/Dna&Rna Alys","PX-30002912","CDM","81445","CPT","0310","RC","","","","both","","","4507.00","3380.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","3470.39","77","","4143.46","4143.46","4143.46","1 through 10","585.95","4281.65","percent of total billed charges",""
"Tgsap Solid Organ Neoplasm 5-50 Dna/Dna&Rna Alys","PX-30002912","CDM","81445","CPT","0310","RC","","","","outpatient","","","4507.00","3380.25","AETNA [1001]","HB AMC AETNA HMO","3145.89","69.8","","2089.34","2089.34","2089.34","1 through 10","1966","3683.12","percent of total billed charges",""
"Tgsap Solid Organ Neoplasm 5-50 Dna/Dna&Rna Alys","PX-30002912","CDM","81445","CPT","0310","RC","","","","outpatient","","","4507.00","3380.25","AETNA [1001]","HB AMC AETNA PPO","3623.63","80.4","","3802.77","3802.77","3802.77","1 through 10","1966","3683.12","percent of total billed charges",""
"Tgsap Solid Organ Neoplasm 5-50 Dna/Dna&Rna Alys","PX-30002912","CDM","81445","CPT","0310","RC","","","","outpatient","","","4507.00","3380.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3623.63","80.4","","3409.38","3409.38","4371.00","1 through 10","1966","3683.12","percent of total billed charges",""
"Thawing of Cryopreserved Embryo(S)","PX-30000152","CDM","89352","CPT","0300","RC","","","","both","","","1050.00","787.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","834.75","79.5","","801.17","537.50","801.17","11","199.41","997.5","percent of total billed charges",""
"Thawing of Cryopreserved Embryo(S)","PX-30000152","CDM","89352","CPT","0300","RC","","","","both","","","1050.00","787.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","559.65","53.3","","537.50","537.50","537.50","1 through 10","199.41","997.5","percent of total billed charges",""
"Thawing of Cryopreserved Embryo(S)","PX-30000152","CDM","89352","CPT","0300","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","383.25","36.5","","379.71","368.52","737.04","1 through 10","199.41","997.5","percent of total billed charges",""
"Thawing of Cryopreserved Embryo(S)","PX-30000152","CDM","89352","CPT","0300","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","402.15","38.3","","398.04","386.84","398.04","1 through 10","199.41","997.5","percent of total billed charges",""
"Thawing of Cryopreserved Embryo(S)","PX-30000152","CDM","89352","CPT","0300","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.45","42.9","","813.79","813.79","813.79","1 through 10","199.41","997.5","percent of total billed charges",""
"Thawing of Cryopreserved Embryo(S)","PX-30000152","CDM","89352","CPT","0300","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB AMC WELLPOINT","774.69","73.78","","757.90","757.90","1775.90","1 through 10","199.41","997.5","percent of total billed charges",""
"Thawing of Cryopreserved Embryo(S)","PX-30000152","CDM","89352","CPT","0300","RC","","","","outpatient","","","1050.00","787.50","AETNA [1001]","HB AMC AETNA HMO","732.90","69.8","","486.60","486.60","486.60","1 through 10","297.92","887.19","percent of total billed charges",""
"Thawing of Cryopreserved Embryo(S)","PX-30000152","CDM","89352","CPT","0300","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","858.06","81.72","","447.61","447.61","447.61","1 through 10","297.92","887.19","percent of total billed charges",""
"Thawing of Cryopreserved Embryo(S)","PX-30000152","CDM","89352","CPT","0300","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","858.06","81.72","","813.79","447.61","813.79","14","297.92","887.19","percent of total billed charges",""
"Thawing of Sperm/Semen","PX-30000153","CDM","89353","CPT","0300","RC","","","","both","","","218.00","163.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","152.60","70","","137.90","137.90","137.90","1 through 10","62.18","207.1","percent of total billed charges",""
"Thawing of Sperm/Semen","PX-30000153","CDM","89353","CPT","0300","RC","","","","both","","","218.00","163.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","173.31","79.5","","111.41","111.41","211.00","1 through 10","62.18","207.1","percent of total billed charges",""
"Thawing of Sperm/Semen","PX-30000153","CDM","89353","CPT","0300","RC","","","","both","","","218.00","163.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","116.19","53.3","","111.41","111.41","111.41","1 through 10","62.18","207.1","percent of total billed charges",""
"Thawing of Sperm/Semen","PX-30000153","CDM","89353","CPT","0300","RC","","","","both","","","218.00","163.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","79.57","36.5","","78.70","66.89","78.70","1 through 10","62.18","207.1","percent of total billed charges",""
"Thawing of Sperm/Semen","PX-30000153","CDM","89353","CPT","0300","RC","","","","both","","","218.00","163.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","83.49","38.3","","82.50","82.50","82.50","1 through 10","62.18","207.1","percent of total billed charges",""
"Thawing of Sperm/Semen","PX-30000153","CDM","89353","CPT","0300","RC","","","","both","","","218.00","163.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","62.18","","APC Price ($63.44). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","63.45","63.45","63.45","1 through 10","62.18","207.1","other","OPPS APC"
"Thawing of Sperm/Semen","PX-30000153","CDM","89353","CPT","0300","RC","","","","both","","","218.00","163.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.52","42.9","","168.67","168.67","168.67","1 through 10","62.18","207.1","percent of total billed charges",""
"Thawing of Sperm/Semen","PX-30000153","CDM","89353","CPT","0300","RC","","","","both","","","218.00","163.50","WELLPOINT [1015]","HB AMC WELLPOINT","160.84","73.78","","157.09","157.09","368.09","1 through 10","62.18","207.1","percent of total billed charges",""
"Thawing of Sperm/Semen","PX-30000153","CDM","89353","CPT","0300","RC","","","","outpatient","","","218.00","163.50","AETNA [1001]","HB AMC AETNA HMO","152.16","69.8","","100.86","100.86","142.85","1 through 10","104.94","420.84","percent of total billed charges",""
"Thawing of Sperm/Semen","PX-30000153","CDM","89353","CPT","0300","RC","","","","outpatient","","","218.00","163.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","178.15","81.72","","168.67","168.67","208.00","18","104.94","420.84","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.77","427.77","5269.00","20","412.99","4319.24","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","3564.05","65.6","","3567.11","2518.58","3567.11","1 through 10","412.99","4319.24","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","3531.45","65","","4146.70","4146.70","4146.70","1 through 10","412.99","4319.24","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3803.10","70","","3793.68","592.40","5269.00","1 through 10","412.99","4319.24","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4319.24","79.5","","4146.70","2583.58","8675.88","13","412.99","4319.24","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2895.79","53.3","","4146.70","2432.19","4146.70","1 through 10","412.99","4319.24","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.77","426.04","5260.92","1 through 10","412.99","4319.24","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","ELDER SERVICES [1037]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","434.73","434.73","434.73","1 through 10","412.99","4319.24","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","FALLON HEALTH [1008]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","434.73","434.73","434.73","1 through 10","412.99","4319.24","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","428.64","428.64","428.64","1 through 10","412.99","4319.24","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","HUMANA [1012]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","426.38","426.04","426.38","1 through 10","412.99","4319.24","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","3911.76","72","","3793.68","3793.68","3793.68","1 through 10","412.99","4319.24","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","428.64","395.20","428.64","1 through 10","412.99","4319.24","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","MEDICARE [2001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","434.73","434.73","869.46","211","412.99","4319.24","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1983.05","36.5","","1965.34","1670.27","1965.34","1 through 10","412.99","4319.24","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2080.84","38.3","","2060.18","2060.18","2060.18","24","412.99","4319.24","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","426.04","426.04","426.04","1 through 10","412.99","4319.24","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","MOLINA [1014]","HB BWH MOLINA","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","862.50","434.73","862.50","1 through 10","412.99","4319.24","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","TRICARE [160005]","HB BWH TRICARE","412.99","","APC Price ($434.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","412.99","412.99","412.99","1 through 10","412.99","4319.24","other","Tricare OPPS"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","426.04","426.04","1278.12","23","412.99","4319.24","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1211.87","1211.87","1211.87","1 through 10","412.99","4319.24","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2330.76","42.9","","2316.78","2316.78","2316.78","1 through 10","412.99","4319.24","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","5433.00","4074.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","426.04","395.21","427.78","26","412.99","4319.24","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","outpatient","","","5433.00","4074.75","AETNA [1001]","HB AMC AETNA HMO","3792.23","69.8","","2518.58","2518.58","2518.58","1 through 10","875.35","4439.85","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","outpatient","","","5433.00","4074.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2839.29","52.26","","3260.46","3260.46","3260.46","1 through 10","875.35","4439.85","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","outpatient","","","5433.00","4074.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","4439.85","81.72","","4212.04","4212.04","4212.04","1 through 10","875.35","4439.85","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","outpatient","","","5433.00","4074.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4439.85","81.72","","4212.04","2316.78","4212.04","18","875.35","4439.85","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.15","155.15","2847.00","11","149.79","2334.12","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1908.40","65","","1850.55","1850.55","1850.55","1 through 10","149.79","2334.12","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2055.20","70","","2847.00","1061.93","2847.00","1 through 10","149.79","2334.12","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2334.12","79.5","","2240.59","1503.22","2240.59","1 through 10","149.79","2334.12","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1564.89","53.3","","2875.48","2240.59","2875.48","1 through 10","149.79","2334.12","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.15","154.52","155.15","1 through 10","149.79","2334.12","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","ELDER SERVICES [1037]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","157.67","157.67","157.67","1 through 10","149.79","2334.12","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","FALLON HEALTH [1008]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","157.67","157.67","157.67","1 through 10","149.79","2334.12","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.46","155.46","155.46","1 through 10","149.79","2334.12","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.46","155.46","155.46","1 through 10","149.79","2334.12","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","MEDICARE [2001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","157.67","157.67","157.67","109","149.79","2334.12","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1071.64","36.5","","902.50","902.50","902.50","1 through 10","149.79","2334.12","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1124.49","38.3","","1113.18","1113.18","2226.36","13","149.79","2334.12","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","154.52","154.52","154.52","1 through 10","149.79","2334.12","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","MOLINA [1014]","HB BWH MOLINA","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","312.82","157.67","312.82","1 through 10","149.79","2334.12","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","154.52","145.13","155.15","1 through 10","149.79","2334.12","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1259.54","42.9","","1251.83","1251.83","1251.83","1 through 10","149.79","2334.12","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","154.52","145.13","155.15","22","149.79","2334.12","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2936.00","2202.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1259.54","42.9","","1251.83","1251.83","1251.83","1 through 10","149.79","2334.12","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","outpatient","","","2936.00","2202.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1534.35","52.26","","1761.72","1761.72","1761.72","1 through 10","336.65","2399.3","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","outpatient","","","2936.00","2202.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2399.30","81.72","","2275.89","1251.83","2275.89","12","336.65","2399.3","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","both","","","139.00","104.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.09","53.3","","106.25","71.28","106.25","1 through 10","14.12","132.05","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","42.80","92.50","13","14.12","132.05","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.24","38.3","","52.79","44.55","158.37","30","14.12","132.05","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","outpatient","","","139.00","104.25","AETNA [1001]","HB AMC AETNA HMO","97.02","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","outpatient","","","139.00","104.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.76","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.59","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","86.97","43.67","87.33","49","75.72","218.63","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.59","37.83","84.52","91","75.72","218.63","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","197.45","71.8","","191.71","191.71","191.71","1 through 10","75.72","218.63","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","180.40","65.6","","87.33","87.33","87.33","1 through 10","75.72","218.63","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","192.50","70","","192.24","114.81","207.77","13","75.72","218.63","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","105.64","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","84.52","59.94","84.52","1 through 10","75.72","218.63","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","218.63","79.5","","210.13","140.98","630.39","72","75.72","218.63","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","146.58","53.3","","210.13","140.98","210.13","34","75.72","218.63","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.59","20.79","83.17","41","75.72","218.63","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","ELDER SERVICES [1037]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","76.89","76.89","76.89","1 through 10","75.72","218.63","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.70","150.70","150.70","1 through 10","75.72","218.63","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","HUMANA [1012]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","83.34","82.83","84.52","1 through 10","75.72","218.63","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","178.75","65","","0.74","0.74","0.74","1 through 10","75.72","218.63","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","38.45","84.52","1857","75.72","218.63","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","85.25","31","","82.51","82.51","82.51","1 through 10","75.72","218.63","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","100.38","36.5","","99.59","84.64","99.59","145","75.72","218.63","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","105.33","38.3","","104.40","104.40","208.79","403","75.72","218.63","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.83","75.35","248.49","30","75.72","218.63","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","TRICARE [160005]","HB BWH TRICARE","80.29","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","80.29","73.04","80.29","1 through 10","75.72","218.63","other","Tricare OPPS"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","41.42","20.71","151.32","73","75.72","218.63","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","184.23","61.41","184.23","1 through 10","75.72","218.63","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.98","42.9","","117.40","117.40","213.44","19","75.72","218.63","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","41.59","84.52","301","75.72","218.63","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","inpatient","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","216.18","78.61","","2744.02","2744.02","2744.02","1 through 10","152.08","218.63","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","275.00","206.25","AETNA [1001]","HB AMC AETNA HMO","191.95","69.8","","180.76","127.63","208.26","140","137.27","315.07","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","275.00","206.25","AETNA [1001]","HB AMC AETNA PPO","221.10","80.4","","208.26","86.97","208.26","1 through 10","137.27","315.07","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","275.00","206.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","143.72","52.26","","159.96","158.39","165.22","1 through 10","137.27","315.07","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","275.00","206.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","221.10","80.4","","208.26","208.26","208.26","1 through 10","137.27","315.07","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","224.73","81.72","","213.44","213.44","213.44","1 through 10","137.27","315.07","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","275.00","206.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","224.73","81.72","","213.44","117.40","267.00","74","137.27","315.07","percent of total billed charges",""
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","both","","","1864.00","1398.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","847.06","847.06","847.06","1 through 10","577.84","1481.88","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","both","","","1864.00","1398.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","809.25","809.25","1 through 10","577.84","1481.88","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","both","","","1864.00","1398.00","FALLON HEALTH [1008]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2467.23","2467.23","2467.23","1 through 10","577.84","1481.88","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","both","","","1864.00","1398.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","809.25","809.25","1 through 10","577.84","1481.88","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","both","","","1864.00","1398.00","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","22","577.84","1481.88","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","both","","","1864.00","1398.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.76","813.76","813.76","1 through 10","577.84","1481.88","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","both","","","1864.00","1398.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","809.26","741.68","814.97","1 through 10","577.84","1481.88","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","outpatient","","","1864.00","1398.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","685.02","","Case rate ($685.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","700.78","700.78","700.78","1 through 10","598.81","2384.07","other","ASC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","outpatient","","","1864.00","1398.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","685.02","","Case rate ($685.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1603.63","1603.63","1603.63","1 through 10","598.81","2384.07","other","ASC "
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","outpatient","","","1864.00","1398.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1389.24","1389.24","1389.24","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","outpatient","","","1864.00","1398.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1461.10","1461.10","1461.10","1 through 10","598.81","2384.07","other","Multiple Surgery"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","outpatient","","","1864.00","1398.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1523.26","81.72","","1445.32","1445.32","1445.32","1 through 10","598.81","2384.07","percent of total billed charges",""
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-98301898","CDM","62329","CPT","0983","RC","","","","both","","","588.00","441.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","847.00","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","847.06","847.06","847.06","1 through 10","182.28","1027.91","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-98301898","CDM","62329","CPT","0983","RC","","","","both","","","588.00","441.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","809.25","809.25","1 through 10","182.28","1027.91","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-98301898","CDM","62329","CPT","0983","RC","","","","both","","","588.00","441.00","FALLON HEALTH [1008]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2467.23","2467.23","2467.23","1 through 10","182.28","1027.91","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-98301898","CDM","62329","CPT","0983","RC","","","","both","","","588.00","441.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","809.25","809.25","1 through 10","182.28","1027.91","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-98301898","CDM","62329","CPT","0983","RC","","","","both","","","588.00","441.00","MEDICARE [2001]","HB BWH MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","22","182.28","1027.91","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-98301898","CDM","62329","CPT","0983","RC","","","","both","","","588.00","441.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.76","813.76","813.76","1 through 10","182.28","1027.91","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-98301898","CDM","62329","CPT","0983","RC","","","","both","","","588.00","441.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","805.88","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","809.26","741.68","814.97","1 through 10","182.28","1027.91","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-98301898","CDM","62329","CPT","0983","RC","","","","outpatient","","","588.00","441.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","1389.24","1389.24","1389.24","1 through 10","328.69","2384.07","other","Multiple Surgery"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-98301898","CDM","62329","CPT","0983","RC","","","","outpatient","","","588.00","441.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1461.10","1461.10","1461.10","1 through 10","328.69","2384.07","other","Multiple Surgery"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-98301898","CDM","62329","CPT","0983","RC","","","","outpatient","","","588.00","441.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","480.51","81.72","","1445.32","1445.32","1445.32","1 through 10","328.69","2384.07","percent of total billed charges",""
"Thermal Dstrj Intraosseous Bvn Ea Addl Lmbr/Sac","PX-76002781","CDM","64629","CPT","0761","RC","","","","both","","","1649.00","1236.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","631.57","38.3","","11702.43","11702.43","11702.43","1 through 10","511.19","1310.96","percent of total billed charges",""
"Thoracentesis Needle/Cath Pleura W/Imaging","PX-98301026","CDM","32555","CPT","0983","RC","","","","both","","","810.00","607.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","643.95","79.5","","1351.28","1351.28","1351.28","1 through 10","251.1","917.68","percent of total billed charges",""
"Thoracentesis Needle/Cath Pleura W/Imaging","PX-98301026","CDM","32555","CPT","0983","RC","","","","both","","","810.00","607.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","719.46","","APC Price ($734.15). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","720.53","671.93","721.54","12","251.1","917.68","other","OPPS APC"
"Thoracentesis Needle/Cath Pleura W/Imaging","PX-98301026","CDM","32555","CPT","0983","RC","","","","outpatient","","","810.00","607.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1512.82","1512.82","1512.82","1 through 10","452.79","2384.07","other","Multiple Surgery"
"Thoracentesis Needle/Cath Pleura W/Imaging","PX-98301026","CDM","32555","CPT","0983","RC","","","","outpatient","","","810.00","607.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1525.22","1525.22","1525.22","1 through 10","452.79","2384.07","other","Multiple Surgery"
"Thoracentesis W/Imaging Guidance","PX-76001812","CDM","32555","CPT","0761","RC","","","","both","","","1771.00","1328.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","1407.95","79.5","","1351.28","1351.28","1351.28","1 through 10","549.01","1407.95","percent of total billed charges",""
"Thoracentesis W/Imaging Guidance","PX-76001812","CDM","32555","CPT","0761","RC","","","","both","","","1771.00","1328.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","719.46","","APC Price ($734.15). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","720.53","671.93","721.54","12","549.01","1407.95","other","OPPS APC"
"Thoracentesis W/Imaging Guidance","PX-76001812","CDM","32555","CPT","0761","RC","","","","outpatient","","","1771.00","1328.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","1512.82","1512.82","1512.82","1 through 10","620.01","2384.07","other","Multiple Surgery"
"Thoracentesis W/Imaging Guidance","PX-76001812","CDM","32555","CPT","0761","RC","","","","outpatient","","","1771.00","1328.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","1525.22","1525.22","1525.22","1 through 10","620.01","2384.07","other","Multiple Surgery"
"Thoracentesis W/O Imaging Guidance|BILATERAL PROCEDURE","PX-76001811","CDM","32554","CPT","0761","RC","","","50","outpatient","","","1826.00","1369.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1063.53","","Case rate ($1,063.53). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2465.26","2465.26","2465.26","1 through 10","1063.53","4434.37","other","ASC "
"THORACIC AORTIC BRANCH 40MMX15CMX8MM","SUP-ITM-10317980","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","52000.00","65","","6652.80","6652.80","6652.80","1 through 10","24800","63600","percent of total billed charges",""
"THORACIC AORTIC BRANCH 40MMX15CMX8MM","SUP-ITM-10317980","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","63600.00","79.5","","2612.61","795.38","2612.61","1 through 10","24800","63600","percent of total billed charges",""
"THORACIC AORTIC BRANCH 40MMX15CMX8MM","SUP-ITM-10317980","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","42640.00","53.3","","1101.80","1101.80","1101.80","1 through 10","24800","63600","percent of total billed charges",""
"THORACIC AORTIC BRANCH 40MMX15CMX8MM","SUP-ITM-10317980","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","52000.00","65","","1820.00","910.00","1820.00","1 through 10","24800","63600","percent of total billed charges",""
"THORACIC AORTIC BRANCH 40MMX15CMX8MM","SUP-ITM-10317980","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29200.00","36.5","","1257.80","693.44","2424.50","1 through 10","24800","63600","percent of total billed charges",""
"THORACIC AORTIC BRANCH 40MMX15CMX8MM","SUP-ITM-10317980","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","30640.00","38.3","","1950.11","547.40","2346.00","1 through 10","24800","63600","percent of total billed charges",""
"THORACIC AORTIC BRANCH 40MMX15CMX8MM","SUP-ITM-10317980","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34320.00","42.9","","5096.18","5096.18","5096.18","1 through 10","24800","63600","percent of total billed charges",""
"THORACIC AORTIC BRANCH 40MMX15CMX8MM","SUP-ITM-10317980","CDM","C1874","HCPCS","0278","RC","","","","both","","","80000.00","60000.00","WELLPOINT [1015]","HB AMC WELLPOINT","59024.00","73.78","","1172.59","1172.59","4829.94","1 through 10","24800","63600","percent of total billed charges",""
"THORACIC AORTIC BRANCH 40MMX15CMX8MM","SUP-ITM-10317980","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","80000.00","60000.00","AETNA [1001]","HB AMC AETNA HMO","55840.00","69.8","","1806.84","947.80","5091.72","1 through 10","41808","65376","percent of total billed charges",""
"THORACIC AORTIC BRANCH 40MMX15CMX8MM","SUP-ITM-10317980","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","80000.00","60000.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","65376.00","81.72","","1259.05","615.58","4586.56","1 through 10","41808","65376","percent of total billed charges",""
"Thoracic Fascial Plane Block Bi Injection","PX-76002990","CDM","64468","CPT","0761","RC","","","","both","","","595.00","446.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.26","42.9","","479.97","479.97","479.97","1 through 10","184.45","565.25","percent of total billed charges",""
"Thoracic Fascial Plane Block Bi Injection","PX-76002990","CDM","64468","CPT","0761","RC","","","","outpatient","","","595.00","446.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","312.38","52.5","","317.35","317.35","317.35","1 through 10","238","490.88","percent of total billed charges",""
"THORACOLUMBAR CAGE 11MM LG 4DEG BENGAL LORDOTIC STACKABLE 177304211","SUP-ITM-10045537","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4372.50","79.5","","1309.77","674.56","6049.93","26","1705","4372.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 11MM LG 4DEG BENGAL LORDOTIC STACKABLE 177304211","SUP-ITM-10045537","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2931.50","53.3","","1901.83","1901.83","2962.25","1 through 10","1705","4372.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 11MM LG 4DEG BENGAL LORDOTIC STACKABLE 177304211","SUP-ITM-10045537","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2007.50","36.5","","1620.31","1620.31","19908.88","1 through 10","1705","4372.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 11MM LG 4DEG BENGAL LORDOTIC STACKABLE 177304211","SUP-ITM-10045537","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2106.50","38.3","","352.91","352.91","2046.30","1 through 10","1705","4372.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 11MM LG 4DEG BENGAL LORDOTIC STACKABLE 177304211","SUP-ITM-10045537","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2359.50","42.9","","9668.75","9668.75","9668.75","1 through 10","1705","4372.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 11MM LG 4DEG BENGAL LORDOTIC STACKABLE 177304211","SUP-ITM-10045537","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","WELLPOINT [1015]","HB AMC WELLPOINT","4057.90","73.78","","699.88","384.10","3443.31","33","1705","4372.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 11MM LG 4DEG BENGAL LORDOTIC STACKABLE 177304211","SUP-ITM-10045537","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","AETNA [1001]","HB AMC AETNA HMO","3839.00","69.8","","1421.24","264.50","4933.46","29","2874.3","4494.6","percent of total billed charges",""
"THORACOLUMBAR CAGE 11MM LG 4DEG BENGAL LORDOTIC STACKABLE 177304211","SUP-ITM-10045537","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4422.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2874.3","4494.6","percent of total billed charges",""
"THORACOLUMBAR CAGE 11MM LG 4DEG BENGAL LORDOTIC STACKABLE 177304211","SUP-ITM-10045537","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4494.60","81.72","","3010.54","693.88","5019.88","35","2874.3","4494.6","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X24 34MM 8DEG BRIGADE","SUP-ITM-10082712","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7950.00","79.5","","1309.77","674.56","6049.93","26","3100","7950","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X24 34MM 8DEG BRIGADE","SUP-ITM-10082712","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5330.00","53.3","","1901.83","1901.83","2962.25","1 through 10","3100","7950","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X24 34MM 8DEG BRIGADE","SUP-ITM-10082712","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3650.00","36.5","","1620.31","1620.31","19908.88","1 through 10","3100","7950","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X24 34MM 8DEG BRIGADE","SUP-ITM-10082712","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3830.00","38.3","","352.91","352.91","2046.30","1 through 10","3100","7950","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X24 34MM 8DEG BRIGADE","SUP-ITM-10082712","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4290.00","42.9","","9668.75","9668.75","9668.75","1 through 10","3100","7950","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X24 34MM 8DEG BRIGADE","SUP-ITM-10082712","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB AMC WELLPOINT","7378.00","73.78","","699.88","384.10","3443.31","33","3100","7950","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X24 34MM 8DEG BRIGADE","SUP-ITM-10082712","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","AETNA [1001]","HB AMC AETNA HMO","6980.00","69.8","","1421.24","264.50","4933.46","29","5226","8172","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X24 34MM 8DEG BRIGADE","SUP-ITM-10082712","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8040.00","80.4","","1022.97","1022.97","3607.50","1 through 10","5226","8172","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X24 34MM 8DEG BRIGADE","SUP-ITM-10082712","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8172.00","81.72","","3010.54","693.88","5019.88","35","5226","8172","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X88MM SPACER SYNMESH TI MESH ROUND","SUP-ITM-10007198","CDM","C1821","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","9828.00","9828.00","9828.00","1 through 10","1627.5","4987.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X88MM SPACER SYNMESH TI MESH ROUND","SUP-ITM-10007198","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","1958.53","1886.75","1958.53","1 through 10","2743.65","4290.3","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X8MM SPACER SYNMESH TI MESH ROUND","SUP-ITM-10007193","CDM","C1821","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","9828.00","9828.00","9828.00","1 through 10","868","2660","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X8MM SPACER SYNMESH TI MESH ROUND","SUP-ITM-10007193","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","1958.53","1886.75","1958.53","1 through 10","1463.28","2288.16","percent of total billed charges",""
"THORACOLUMBAR CAGE 17X22 32MM SPACER SYNMESH TI MESH OBLONG","SUP-ITM-10007241","CDM","C1821","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","9828.00","9828.00","9828.00","1 through 10","1627.5","4987.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 17X22 32MM SPACER SYNMESH TI MESH OBLONG","SUP-ITM-10007241","CDM","C1821","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","1958.53","1886.75","1958.53","1 through 10","2743.65","4290.3","percent of total billed charges",""
"THORACOLUMBAR CAGE 33 TO 46MM MD 0DEGXMESH EXPANDABLE TITANIUM LORDOTIC","SUP-ITM-10105847","CDM","C1889","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7850.63","79.5","","1309.77","674.56","6049.93","26","3061.25","7850.63","percent of total billed charges",""
"THORACOLUMBAR CAGE 33 TO 46MM MD 0DEGXMESH EXPANDABLE TITANIUM LORDOTIC","SUP-ITM-10105847","CDM","C1889","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5263.38","53.3","","1901.83","1901.83","2962.25","1 through 10","3061.25","7850.63","percent of total billed charges",""
"THORACOLUMBAR CAGE 33 TO 46MM MD 0DEGXMESH EXPANDABLE TITANIUM LORDOTIC","SUP-ITM-10105847","CDM","C1889","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3604.38","36.5","","1620.31","1620.31","19908.88","1 through 10","3061.25","7850.63","percent of total billed charges",""
"THORACOLUMBAR CAGE 33 TO 46MM MD 0DEGXMESH EXPANDABLE TITANIUM LORDOTIC","SUP-ITM-10105847","CDM","C1889","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3782.13","38.3","","352.91","352.91","2046.30","1 through 10","3061.25","7850.63","percent of total billed charges",""
"THORACOLUMBAR CAGE 33 TO 46MM MD 0DEGXMESH EXPANDABLE TITANIUM LORDOTIC","SUP-ITM-10105847","CDM","C1889","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4236.38","42.9","","9668.75","9668.75","9668.75","1 through 10","3061.25","7850.63","percent of total billed charges",""
"THORACOLUMBAR CAGE 33 TO 46MM MD 0DEGXMESH EXPANDABLE TITANIUM LORDOTIC","SUP-ITM-10105847","CDM","C1889","HCPCS","0278","RC","","","","both","","","9875.00","7406.25","WELLPOINT [1015]","HB AMC WELLPOINT","7285.78","73.78","","699.88","384.10","3443.31","33","3061.25","7850.63","percent of total billed charges",""
"THORACOLUMBAR CAGE 33 TO 46MM MD 0DEGXMESH EXPANDABLE TITANIUM LORDOTIC","SUP-ITM-10105847","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9875.00","7406.25","AETNA [1001]","HB AMC AETNA HMO","6892.75","69.8","","1421.24","264.50","4933.46","29","5160.68","8069.85","percent of total billed charges",""
"THORACOLUMBAR CAGE 33 TO 46MM MD 0DEGXMESH EXPANDABLE TITANIUM LORDOTIC","SUP-ITM-10105847","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9875.00","7406.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7939.50","80.4","","1022.97","1022.97","3607.50","1 through 10","5160.68","8069.85","percent of total billed charges",""
"THORACOLUMBAR CAGE 33 TO 46MM MD 0DEGXMESH EXPANDABLE TITANIUM LORDOTIC","SUP-ITM-10105847","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9875.00","7406.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8069.85","81.72","","3010.54","693.88","5019.88","35","5160.68","8069.85","percent of total billed charges",""
"THORACOLUMBAR CAGE 50.0MM BENGAL LORDOTIC STACKABLE STANDARD","SUP-ITM-10045564","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4372.50","79.5","","1309.77","674.56","6049.93","26","1705","4372.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 50.0MM BENGAL LORDOTIC STACKABLE STANDARD","SUP-ITM-10045564","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2931.50","53.3","","1901.83","1901.83","2962.25","1 through 10","1705","4372.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 50.0MM BENGAL LORDOTIC STACKABLE STANDARD","SUP-ITM-10045564","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2007.50","36.5","","1620.31","1620.31","19908.88","1 through 10","1705","4372.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 50.0MM BENGAL LORDOTIC STACKABLE STANDARD","SUP-ITM-10045564","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2106.50","38.3","","352.91","352.91","2046.30","1 through 10","1705","4372.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 50.0MM BENGAL LORDOTIC STACKABLE STANDARD","SUP-ITM-10045564","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2359.50","42.9","","9668.75","9668.75","9668.75","1 through 10","1705","4372.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 50.0MM BENGAL LORDOTIC STACKABLE STANDARD","SUP-ITM-10045564","CDM","C1889","HCPCS","0278","RC","","","","both","","","5500.00","4125.00","WELLPOINT [1015]","HB AMC WELLPOINT","4057.90","73.78","","699.88","384.10","3443.31","33","1705","4372.5","percent of total billed charges",""
"THORACOLUMBAR CAGE 50.0MM BENGAL LORDOTIC STACKABLE STANDARD","SUP-ITM-10045564","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","AETNA [1001]","HB AMC AETNA HMO","3839.00","69.8","","1421.24","264.50","4933.46","29","2874.3","4494.6","percent of total billed charges",""
"THORACOLUMBAR CAGE 50.0MM BENGAL LORDOTIC STACKABLE STANDARD","SUP-ITM-10045564","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4422.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2874.3","4494.6","percent of total billed charges",""
"THORACOLUMBAR CAGE 50.0MM BENGAL LORDOTIC STACKABLE STANDARD","SUP-ITM-10045564","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5500.00","4125.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4494.60","81.72","","3010.54","693.88","5019.88","35","2874.3","4494.6","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X70MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107816","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","800.18","480.96","1887.97","195","260.4","667.8","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X70MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107816","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","813.12","216.42","1444.50","81","260.4","667.8","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X70MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107816","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","260.40","31","","432.60","432.60","432.60","1 through 10","260.4","667.8","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X70MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107816","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","148.37","54.89","631.39","94","260.4","667.8","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X70MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107816","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","279.30","91.72","1116.77","266","260.4","667.8","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X70MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107816","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","731.00","63.70","731.00","1 through 10","260.4","667.8","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X70MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107816","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","384.74","384.74","384.74","1 through 10","260.4","667.8","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X70MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107816","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","286.63","119.22","1107.45","105","260.4","667.8","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X70MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","675.31","184.75","1721.50","286","438.98","686.45","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X70MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA PPO","675.36","80.4","","1261.44","103.12","1514.10","21","438.98","686.45","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X70MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1365.00","1365.00","1365.00","1 through 10","438.98","686.45","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X70MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","686.45","81.72","","5157.68","5157.68","5157.68","1 through 10","438.98","686.45","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X70MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107816","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","431.26","71.26","1459.57","88","438.98","686.45","percent of total billed charges",""
"THORACOLUMBAR SPACER 10X6MM SYNMESH TI MESH ROUND","SUP-ITM-10007186","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","1309.77","674.56","6049.93","26","868","2226","percent of total billed charges",""
"THORACOLUMBAR SPACER 10X6MM SYNMESH TI MESH ROUND","SUP-ITM-10007186","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1492.40","53.3","","1901.83","1901.83","2962.25","1 through 10","868","2226","percent of total billed charges",""
"THORACOLUMBAR SPACER 10X6MM SYNMESH TI MESH ROUND","SUP-ITM-10007186","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","1620.31","1620.31","19908.88","1 through 10","868","2226","percent of total billed charges",""
"THORACOLUMBAR SPACER 10X6MM SYNMESH TI MESH ROUND","SUP-ITM-10007186","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","352.91","352.91","2046.30","1 through 10","868","2226","percent of total billed charges",""
"THORACOLUMBAR SPACER 10X6MM SYNMESH TI MESH ROUND","SUP-ITM-10007186","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","9668.75","9668.75","9668.75","1 through 10","868","2226","percent of total billed charges",""
"THORACOLUMBAR SPACER 10X6MM SYNMESH TI MESH ROUND","SUP-ITM-10007186","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","699.88","384.10","3443.31","33","868","2226","percent of total billed charges",""
"THORACOLUMBAR SPACER 10X6MM SYNMESH TI MESH ROUND","SUP-ITM-10007186","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA HMO","1954.40","69.8","","1421.24","264.50","4933.46","29","1463.28","2288.16","percent of total billed charges",""
"THORACOLUMBAR SPACER 10X6MM SYNMESH TI MESH ROUND","SUP-ITM-10007186","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2251.20","80.4","","1022.97","1022.97","3607.50","1 through 10","1463.28","2288.16","percent of total billed charges",""
"THORACOLUMBAR SPACER 10X6MM SYNMESH TI MESH ROUND","SUP-ITM-10007186","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","3010.54","693.88","5019.88","35","1463.28","2288.16","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2226.00","79.5","","1309.77","674.56","6049.93","26","868","2226","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1492.40","53.3","","1901.83","1901.83","2962.25","1 through 10","868","2226","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1022.00","36.5","","1620.31","1620.31","19908.88","1 through 10","868","2226","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1072.40","38.3","","352.91","352.91","2046.30","1 through 10","868","2226","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1201.20","42.9","","9668.75","9668.75","9668.75","1 through 10","868","2226","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.00","2100.00","WELLPOINT [1015]","HB AMC WELLPOINT","2065.84","73.78","","699.88","384.10","3443.31","33","868","2226","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","AETNA [1001]","HB AMC AETNA HMO","1954.40","69.8","","1421.24","264.50","4933.46","29","1463.28","2288.16","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2251.20","80.4","","1022.97","1022.97","3607.50","1 through 10","1463.28","2288.16","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2800.00","2100.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2288.16","81.72","","3010.54","693.88","5019.88","35","1463.28","2288.16","percent of total billed charges",""
"THORACOLUMBAR SPACER 17MMX22 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007239","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1309.77","674.56","6049.93","26","1627.5","4173.75","percent of total billed charges",""
"THORACOLUMBAR SPACER 17MMX22 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007239","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","1901.83","1901.83","2962.25","1 through 10","1627.5","4173.75","percent of total billed charges",""
"THORACOLUMBAR SPACER 17MMX22 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007239","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1620.31","1620.31","19908.88","1 through 10","1627.5","4173.75","percent of total billed charges",""
"THORACOLUMBAR SPACER 17MMX22 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007239","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","352.91","352.91","2046.30","1 through 10","1627.5","4173.75","percent of total billed charges",""
"THORACOLUMBAR SPACER 17MMX22 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007239","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","9668.75","9668.75","9668.75","1 through 10","1627.5","4173.75","percent of total billed charges",""
"THORACOLUMBAR SPACER 17MMX22 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007239","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","699.88","384.10","3443.31","33","1627.5","4173.75","percent of total billed charges",""
"THORACOLUMBAR SPACER 17MMX22 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007239","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1421.24","264.50","4933.46","29","2743.65","4290.3","percent of total billed charges",""
"THORACOLUMBAR SPACER 17MMX22 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007239","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4221.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2743.65","4290.3","percent of total billed charges",""
"THORACOLUMBAR SPACER 17MMX22 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007239","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","3010.54","693.88","5019.88","35","2743.65","4290.3","percent of total billed charges",""
"THORACOLUMBAR SPACER 22MMX28 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007243","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4173.75","79.5","","1309.77","674.56","6049.93","26","1627.5","4173.75","percent of total billed charges",""
"THORACOLUMBAR SPACER 22MMX28 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007243","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2798.25","53.3","","1901.83","1901.83","2962.25","1 through 10","1627.5","4173.75","percent of total billed charges",""
"THORACOLUMBAR SPACER 22MMX28 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007243","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1916.25","36.5","","1620.31","1620.31","19908.88","1 through 10","1627.5","4173.75","percent of total billed charges",""
"THORACOLUMBAR SPACER 22MMX28 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007243","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2010.75","38.3","","352.91","352.91","2046.30","1 through 10","1627.5","4173.75","percent of total billed charges",""
"THORACOLUMBAR SPACER 22MMX28 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007243","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2252.25","42.9","","9668.75","9668.75","9668.75","1 through 10","1627.5","4173.75","percent of total billed charges",""
"THORACOLUMBAR SPACER 22MMX28 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007243","CDM","C1889","HCPCS","0278","RC","","","","both","","","5250.00","3937.50","WELLPOINT [1015]","HB AMC WELLPOINT","3873.45","73.78","","699.88","384.10","3443.31","33","1627.5","4173.75","percent of total billed charges",""
"THORACOLUMBAR SPACER 22MMX28 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007243","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","AETNA [1001]","HB AMC AETNA HMO","3664.50","69.8","","1421.24","264.50","4933.46","29","2743.65","4290.3","percent of total billed charges",""
"THORACOLUMBAR SPACER 22MMX28 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007243","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4221.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2743.65","4290.3","percent of total billed charges",""
"THORACOLUMBAR SPACER 22MMX28 8 SYNMESH MESH OBLONG THORACULUMBAR HEIGHT TI","SUP-ITM-10007243","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5250.00","3937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4290.30","81.72","","3010.54","693.88","5019.88","35","2743.65","4290.3","percent of total billed charges",""
"THORACOLUMBAR SPACER 7MM ALLOGRAFT FREEZE DRIED","SUP-ITM-10048797","CDM","C1889","HCPCS","0278","RC","","","","both","","","9049.48","6787.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7194.34","79.5","","1309.77","674.56","6049.93","26","2805.34","7194.34","percent of total billed charges",""
"THORACOLUMBAR SPACER 7MM ALLOGRAFT FREEZE DRIED","SUP-ITM-10048797","CDM","C1889","HCPCS","0278","RC","","","","both","","","9049.48","6787.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4823.37","53.3","","1901.83","1901.83","2962.25","1 through 10","2805.34","7194.34","percent of total billed charges",""
"THORACOLUMBAR SPACER 7MM ALLOGRAFT FREEZE DRIED","SUP-ITM-10048797","CDM","C1889","HCPCS","0278","RC","","","","both","","","9049.48","6787.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3303.06","36.5","","1620.31","1620.31","19908.88","1 through 10","2805.34","7194.34","percent of total billed charges",""
"THORACOLUMBAR SPACER 7MM ALLOGRAFT FREEZE DRIED","SUP-ITM-10048797","CDM","C1889","HCPCS","0278","RC","","","","both","","","9049.48","6787.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3465.95","38.3","","352.91","352.91","2046.30","1 through 10","2805.34","7194.34","percent of total billed charges",""
"THORACOLUMBAR SPACER 7MM ALLOGRAFT FREEZE DRIED","SUP-ITM-10048797","CDM","C1889","HCPCS","0278","RC","","","","both","","","9049.48","6787.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3882.23","42.9","","9668.75","9668.75","9668.75","1 through 10","2805.34","7194.34","percent of total billed charges",""
"THORACOLUMBAR SPACER 7MM ALLOGRAFT FREEZE DRIED","SUP-ITM-10048797","CDM","C1889","HCPCS","0278","RC","","","","both","","","9049.48","6787.11","WELLPOINT [1015]","HB AMC WELLPOINT","6676.71","73.78","","699.88","384.10","3443.31","33","2805.34","7194.34","percent of total billed charges",""
"THORACOLUMBAR SPACER 7MM ALLOGRAFT FREEZE DRIED","SUP-ITM-10048797","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9049.48","6787.11","AETNA [1001]","HB AMC AETNA HMO","6316.54","69.8","","1421.24","264.50","4933.46","29","4729.26","7395.24","percent of total billed charges",""
"THORACOLUMBAR SPACER 7MM ALLOGRAFT FREEZE DRIED","SUP-ITM-10048797","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9049.48","6787.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7275.78","80.4","","1022.97","1022.97","3607.50","1 through 10","4729.26","7395.24","percent of total billed charges",""
"THORACOLUMBAR SPACER 7MM ALLOGRAFT FREEZE DRIED","SUP-ITM-10048797","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9049.48","6787.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7395.24","81.72","","3010.54","693.88","5019.88","35","4729.26","7395.24","percent of total billed charges",""
"THORACOLUMBAR SPACER 9X26MM VERTE STACK PEEK","SUP-ITM-10110972","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","1309.77","674.56","6049.93","26","1550","3975","percent of total billed charges",""
"THORACOLUMBAR SPACER 9X26MM VERTE STACK PEEK","SUP-ITM-10110972","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2665.00","53.3","","1901.83","1901.83","2962.25","1 through 10","1550","3975","percent of total billed charges",""
"THORACOLUMBAR SPACER 9X26MM VERTE STACK PEEK","SUP-ITM-10110972","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1550","3975","percent of total billed charges",""
"THORACOLUMBAR SPACER 9X26MM VERTE STACK PEEK","SUP-ITM-10110972","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","352.91","352.91","2046.30","1 through 10","1550","3975","percent of total billed charges",""
"THORACOLUMBAR SPACER 9X26MM VERTE STACK PEEK","SUP-ITM-10110972","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","9668.75","9668.75","9668.75","1 through 10","1550","3975","percent of total billed charges",""
"THORACOLUMBAR SPACER 9X26MM VERTE STACK PEEK","SUP-ITM-10110972","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","699.88","384.10","3443.31","33","1550","3975","percent of total billed charges",""
"THORACOLUMBAR SPACER 9X26MM VERTE STACK PEEK","SUP-ITM-10110972","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","1421.24","264.50","4933.46","29","2613","4086","percent of total billed charges",""
"THORACOLUMBAR SPACER 9X26MM VERTE STACK PEEK","SUP-ITM-10110972","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4020.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2613","4086","percent of total billed charges",""
"THORACOLUMBAR SPACER 9X26MM VERTE STACK PEEK","SUP-ITM-10110972","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","3010.54","693.88","5019.88","35","2613","4086","percent of total billed charges",""
"Thrombect Venous Mechanical","PX-76001132","CDM","37187","CPT","0361","RC","","","","both","","","12628.00","9471.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13196.92","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20905.69","20905.69","20905.69","1 through 10","3914.68","16832.81","other","OPPS APC"
"Thrombectomy Coronary Artery","PX-48000390","CDM","93799","CPT","0480","RC","","","","outpatient","","","5425.00","4068.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2983.75","55","","13080.03","13080.03","13080.03","1 through 10","2712.5","4475.63","percent of total billed charges",""
"Thrombectomy Coronary Artery","PX-48000390","CDM","93799","CPT","0481","RC","","","","both","","","5425.00","4068.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","4312.88","other","OPPS APC"
"Thrombectomy Coronary Artery","PX-48000390","CDM","93799","CPT","0481","RC","","","","outpatient","","","5425.00","4068.75","AETNA [1001]","HB AMC AETNA HMO","3786.65","69.8","","2022.70","2022.70","2022.70","1 through 10","454","4433.31","percent of total billed charges",""
"Thrombectomy Coronary Artery","PX-48000390","CDM","93799","CPT","0481","RC","","","","outpatient","","","5425.00","4068.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3284.84","60.55","","318.03","318.03","2439.77","1 through 10","454","4433.31","percent of total billed charges",""
"Thrombectomy Coronary Artery","PX-48000390","CDM","93799","CPT","0481","RC","","","","outpatient","","","5425.00","4068.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2832.94","52.22","","360.38","360.38","4023.00","1 through 10","454","4433.31","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","both","","","106.00","79.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","84.27","79.5","","81.06","54.38","103.00","1 through 10","5.65","100.7","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","both","","","106.00","79.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","56.50","53.3","","54.38","54.38","54.38","1 through 10","5.65","100.7","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","both","","","106.00","79.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","68.90","65","","66.95","66.95","66.95","1 through 10","5.65","100.7","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","both","","","106.00","79.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","84.27","79.5","","81.06","81.06","81.06","1 through 10","5.65","100.7","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","both","","","106.00","79.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.69","36.5","","32.65","32.65","38.42","1 through 10","5.65","100.7","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","both","","","106.00","79.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.60","38.3","","40.27","40.27","120.81","28","5.65","100.7","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","both","","","106.00","79.50","TRICARE [160005]","HB BWH TRICARE","100.70","95","","6.60","6.60","6.60","1 through 10","5.65","100.7","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","both","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.47","42.9","","82.34","82.34","82.34","1 through 10","5.65","100.7","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","outpatient","","","106.00","79.50","AETNA [1001]","HB AMC AETNA HMO","73.99","69.8","","69.73","49.23","80.34","13","5.95","86.62","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","outpatient","","","106.00","79.50","AETNA [1001]","HB AMC AETNA PPO","85.22","80.4","","80.34","53.97","80.34","1 through 10","5.95","86.62","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","outpatient","","","106.00","79.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","85.22","80.4","","80.34","80.34","80.34","1 through 10","5.95","86.62","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","outpatient","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","86.62","81.72","","82.34","45.29","82.34","11","5.95","86.62","percent of total billed charges",""
"Thrombocytosis Gene Sequencing Panel","PX-31001173","CDM","81479","CPT","0310","RC","","","","both","","","2038.00","1528.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1620.21","79.5","","0.65","0.65","0.65","1 through 10","631.78","1936.1","percent of total billed charges",""
"Thrombocytosis Gene Sequencing Panel","PX-31001173","CDM","81479","CPT","0310","RC","","","","both","","","2038.00","1528.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1086.25","53.3","","0.79","0.79","0.79","1 through 10","631.78","1936.1","percent of total billed charges",""
"Thrombocytosis Gene Sequencing Panel","PX-31001173","CDM","81479","CPT","0310","RC","","","","outpatient","","","2038.00","1528.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1019.00","50","","1.00","1.00","1.00","1 through 10","156.55","1681.35","percent of total billed charges",""
"Thrombocytosis Gene Sequencing Panel","PX-31001173","CDM","81479","CPT","0310","RC","","","","outpatient","","","2038.00","1528.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1069.95","52.5","","1.00","0.53","1.00","1 through 10","156.55","1681.35","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","both","","","188.00","141.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","134.98","71.8","","130.68","130.68","130.68","1 through 10","15.74","178.6","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","both","","","188.00","141.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","149.46","79.5","","143.23","96.10","143.23","58","15.74","178.6","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","both","","","188.00","141.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.20","53.3","","96.10","96.10","288.30","26","15.74","178.6","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","both","","","188.00","141.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","122.20","65","","118.30","118.30","118.30","1 through 10","15.74","178.6","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","58.28","31","","168.72","168.72","168.72","1 through 10","15.74","178.6","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.62","36.5","","67.89","57.69","67.89","36","15.74","178.6","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","71.16","71.16","213.48","67","15.74","178.6","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","both","","","188.00","141.00","TRICARE [160005]","HB BWH TRICARE","178.60","95","","18.38","18.38","18.38","1 through 10","15.74","178.6","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","both","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.65","42.9","","80.03","80.03","80.03","1 through 10","15.74","178.6","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","123.21","87.00","141.96","83","16.56","153.63","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA PPO","151.15","80.4","","95.37","87.00","141.96","1 through 10","16.56","153.63","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","outpatient","","","188.00","141.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","153.63","81.72","","145.49","145.49","145.49","1 through 10","16.56","153.63","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","outpatient","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","153.63","81.72","","145.49","80.03","145.49","62","16.56","153.63","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","173.00","129.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","124.21","71.8","","120.62","120.62","120.62","1 through 10","15.29","164.35","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","173.00","129.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","137.54","79.5","","132.22","88.70","549.34","97","15.29","164.35","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","173.00","129.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","92.21","53.3","","88.70","88.70","132.22","34","15.29","164.35","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","112.45","65","","109.20","109.20","109.20","1 through 10","15.29","164.35","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","173.00","129.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","53.63","31","","155.73","155.73","155.73","1 through 10","15.29","164.35","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","173.00","129.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.15","36.5","","62.66","53.26","62.66","49","15.29","164.35","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","173.00","129.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.26","38.3","","65.69","63.84","197.07","116","15.29","164.35","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","173.00","129.75","TRICARE [160005]","HB BWH TRICARE","164.35","95","","18.21","18.21","19.17","1 through 10","15.29","164.35","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.22","42.9","","73.87","73.87","73.87","1 through 10","15.29","164.35","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","173.00","129.75","AETNA [1001]","HB AMC AETNA HMO","120.75","69.8","","113.74","80.30","131.04","104","15.29","141.38","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","173.00","129.75","AETNA [1001]","HB AMC AETNA PPO","139.09","80.4","","131.04","88.03","176.06","13","15.29","141.38","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","139.09","80.4","","174.17","174.17","174.17","1 through 10","15.29","141.38","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","141.38","81.72","","134.30","134.30","134.30","1 through 10","15.29","141.38","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","141.38","81.72","","134.30","73.87","134.30","1 through 10","15.29","141.38","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","141.38","81.72","","134.30","73.87","134.30","77","15.29","141.38","percent of total billed charges",""
"Thyroid Activity (Tbg)","PX-30000700","CDM","84442","CPT","0301","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.70","36.5","","54.95","54.95","54.95","1 through 10","14.48","171","percent of total billed charges",""
"Thyroid Activity (Tbg)","PX-30000700","CDM","84442","CPT","0301","RC","","","","both","","","180.00","135.00","TRICARE [160005]","HB BWH TRICARE","171.00","95","","16.92","16.92","16.92","1 through 10","14.48","171","percent of total billed charges",""
"Thyroid Activity (Tbg)","PX-30000700","CDM","84442","CPT","0301","RC","","","","outpatient","","","180.00","135.00","AETNA [1001]","HB AMC AETNA PPO","144.72","80.4","","183.40","183.40","183.40","1 through 10","15.25","147.1","percent of total billed charges",""
"Thyroid Disorders,MAJOR","427","DRG","","","","","","","","inpatient","","","65303.14","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35200.12","","Standard inlier is a Case rate ($35,200.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $35,995, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,996.36) for the length of stay and the standard reimbursement.","32158.34","32158.34","32158.34","1 through 10","4352.41","35200.12","case rate",""
"Thyroid Disorders,MAJOR","427","DRG","","","","","","","","inpatient","","","65303.14","","MASSHEALTH [3001]","HB BWH MEDICAID","11211.18","","Case rate ($12,395.89). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,825.89, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8117.58","8117.58","8117.58","1 through 10","4352.41","35200.12","case rate",""
"Thyroid Disorders,MAJOR","427","DRG","","","","","","","","inpatient","","","65303.14","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31142.62","","Fee schedule rate ($31,142.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31142.62","31142.62","31142.62","1 through 10","4352.41","35200.12","case rate",""
"Thyroid Disorders,MAJOR","427","DRG","","","","","","","","inpatient","","","65303.14","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","11211.18","","Case rate ($12,395.89). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,825.89, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12392.84","12392.84","12392.84","1 through 10","4352.41","35200.12","case rate",""
"Thyroid Disorders,MINOR","427","DRG","","","","","","","","inpatient","","","28513.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","16020.22","","Standard inlier is a Case rate ($16,020.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,729, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,273.94) for the length of stay and the standard reimbursement.","14635.85","14635.85","14635.85","1 through 10","4352.41","35200.12","case rate",""
"Thyroid Disorders,MODERATE","427","DRG","","","","","","","","inpatient","","","19227.30","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","19656.86","","Standard inlier is a Case rate ($19,656.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,933, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,790.41) for the length of stay and the standard reimbursement.","17917.94","17917.94","17917.94","1 through 10","4352.41","35200.12","case rate",""
"Thyroid Hormone Uptake/Ratio","PX-30000710","CDM","84479","CPT","0301","RC","","","","both","","","85.00","63.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.56","38.3","","32.06","32.06","32.06","1 through 10","6.34","80.75","percent of total billed charges",""
"Thyroid Hormone Uptake/Ratio","PX-30000710","CDM","84479","CPT","0301","RC","","","","outpatient","","","85.00","63.75","AETNA [1001]","HB AMC AETNA HMO","59.33","69.8","","55.51","55.51","55.51","1 through 10","6.67","69.46","percent of total billed charges",""
"Thyroid Hormone Uptake/Ratio","PX-30000710","CDM","84479","CPT","0301","RC","","","","outpatient","","","85.00","63.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","69.46","81.72","","65.55","65.55","65.55","1 through 10","6.67","69.46","percent of total billed charges",""
"Thyroid Lobectomy,Unilat","PX-76002285","CDM","60220","CPT","0761","RC","","","","outpatient","","","12897.00","9672.75","AETNA [1001]","HB AMC AETNA HMO","9002.11","69.8","","24426.84","24426.84","24426.84","1 through 10","5158.8","10539.43","percent of total billed charges",""
"Thyroid Lobectomy,Unilat","PX-76002285","CDM","60220","CPT","0761","RC","","","","outpatient","","","12897.00","9672.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6734.81","52.22","","12303.41","12303.41","12303.41","1 through 10","5158.8","10539.43","percent of total billed charges",""
"Thyroid Nodule Injection","PX-76002463","CDM","38999","CPT","0761","RC","","","","outpatient","","","1361.00","1020.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","710.71","52.22","","512.50","512.50","512.50","1 through 10","680.5","1234.13","percent of total billed charges",""
"Thyroid Nodule Injection","PX-76002463","CDM","38999","CPT","0761","RC","","","","outpatient","","","1361.00","1020.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","680.50","50","","6776.11","6776.11","6776.11","1 through 10","680.5","1234.13","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","143.60","71.8","","139.29","75.85","139.29","1 through 10","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","131.20","65.6","","17.29","17.29","17.29","1 through 10","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","140.00","70","","194.00","119.80","419.04","1 through 10","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","CHAMPVA [160001]","HB BWH TRICARE","190.00","95","","20.24","20.24","20.24","1 through 10","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","152.68","102.43","152.68","1232","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","106.60","53.3","","102.43","102.43","307.29","714","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","154.00","77","","149.38","149.38","149.38","1 through 10","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","130.00","65","","126.10","97.50","126.10","1 through 10","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","159.00","79.5","","152.68","152.68","287.81","1 through 10","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","62.00","31","","59.95","59.95","179.85","60","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","72.36","61.50","190.94","1204","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","73.72","227.55","4040","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","MOLINA [1014]","HB BWH MOLINA","70.00","35","","33.33","33.33","33.60","12","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","154.00","77","","151.32","16.81","198.30","1 through 10","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","TRICARE [160005]","HB BWH TRICARE","190.00","95","","19.23","19.23","20.24","54","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","190.00","95","","16.80","16.80","16.80","1 through 10","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","85.30","155.08","66","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","85.30","85.30","85.30","15","16.46","190","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","131.34","92.73","151.32","1833","17.33","163.44","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA PPO","160.80","80.4","","151.32","92.73","151.32","166","17.33","163.44","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","111.80","55.9","","101.66","101.66","203.32","11","17.33","163.44","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","200.00","150.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","104.52","52.26","","59.80","59.80","120.05","23","17.33","163.44","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","200.00","150.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","160.80","80.4","","151.32","97.00","151.32","1 through 10","17.33","163.44","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","200.00","150.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","155.08","202.54","1 through 10","17.33","163.44","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","163.44","81.72","","85.30","85.30","155.09","53","17.33","163.44","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","85.30","155.08","1132","17.33","163.44","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","both","","","601.00","450.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","477.80","79.5","","458.82","307.82","458.82","15","49.84","570.95","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","both","","","601.00","450.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","320.33","53.3","","307.82","294.42","307.82","1 through 10","49.84","570.95","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","both","","","601.00","450.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","219.37","36.5","","217.46","184.81","217.46","12","49.84","570.95","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","both","","","601.00","450.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","230.18","38.3","","227.95","221.54","683.85","48","49.84","570.95","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","both","","","601.00","450.75","TRICARE [160005]","HB BWH TRICARE","570.95","95","","58.23","58.23","58.23","1 through 10","49.84","570.95","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","outpatient","","","601.00","450.75","AETNA [1001]","HB AMC AETNA HMO","419.50","69.8","","394.69","278.67","454.74","28","52.45","491.14","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","outpatient","","","601.00","450.75","AETNA [1001]","HB AMC AETNA PPO","483.20","80.4","","454.74","417.63","610.98","1 through 10","52.45","491.14","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","outpatient","","","601.00","450.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","491.14","81.72","","466.05","466.05","466.05","1 through 10","52.45","491.14","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","outpatient","","","601.00","450.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","491.14","81.72","","466.05","256.35","466.05","15","52.45","491.14","percent of total billed charges",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","","","","inpatient","","","123250.99","92438.24","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","13831.14","13831.14","13831.14","1 through 10","13776.39","22776.8463","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","","","","inpatient","","","123250.99","92438.24","MEDICARE [2001]","HB BWH MEDICARE","18131.14","","Case rate ($18,131.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,845.08, add-ons for qualifying new technology services are included. If operating cost exceeds $62,489.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,646.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $16,544.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,465.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,206.51. The transfer capital threshold is the transfer adjustment factor * $1,206.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18098.26","18071.66","18098.26","1 through 10","13776.39","22776.8463","other","Inpatient DRG"
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","","","","inpatient","","","123250.99","92438.24","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","13776.39","","Case rate ($14,057.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,845.08, add-ons for qualifying new technology services are included. If operating cost exceeds $62,489.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,646.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,471.18 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,465.24 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,206.51. The transfer capital threshold is the transfer adjustment factor * $1,206.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13730.54","13730.54","13730.54","1 through 10","13776.39","22776.8463","other","Inpatient DRG"
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/McC","627","MS-DRG","","","","","","","","inpatient","","","73695.21","55271.41","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","12871.63","","Case rate ($12,496.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,966.19, add-ons for qualifying new technology services are included. If operating cost exceeds $60,610.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,508.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $11,048.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,586.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,068.83. The transfer capital threshold is the transfer adjustment factor * $1,068.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12135.44","12135.44","12135.44","1 through 10","12246.8","20806.49","other","Inpatient DRG"
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/McC","627","MS-DRG","","","","","","","","inpatient","","","73695.21","55271.41","MEDICARE [2001]","HB BWH MEDICARE","12496.73","","Case rate ($12,496.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,966.19, add-ons for qualifying new technology services are included. If operating cost exceeds $60,610.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,508.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $11,048.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,586.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,068.83. The transfer capital threshold is the transfer adjustment factor * $1,068.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15236.31","15236.31","15236.31","1 through 10","12246.8","20806.49","other","Inpatient Replacement Plans DRG"
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/McC","627","MS-DRG","","","","","","","","inpatient","","","73695.21","55271.41","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12246.80","","Case rate ($12,496.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,966.19, add-ons for qualifying new technology services are included. If operating cost exceeds $60,610.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,508.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $11,048.06 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,586.35 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,068.83. The transfer capital threshold is the transfer adjustment factor * $1,068.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11558.66","11558.66","11558.66","1 through 10","12246.8","20806.49","other","Inpatient DRG"
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/McC","627","TRIS-DRG","","","","","","","","inpatient","","","65875.22","","TRICARE [160005]","HB BWH TRICARE","10579.04","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($18,582.68). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $62,309.68 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($28,588.73), capped at $13,374.60. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $62,309.68 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","20413.87","20413.87","20413.87","1 through 10","10579.04","10579.04","other","Inpatient DRGs"
"Thyroid, Parathyroid And Thyroglossal Procedures,MAJOR","404","DRG","","","","","","","","inpatient","","","156452.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","72220.69","","Standard inlier is a Case rate ($72,220.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $67,809, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,252.16) for the length of stay and the standard reimbursement.","65831.78","65831.78","65831.78","1 through 10","7793.22","81195.52","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures,MAJOR","404","DRG","","","","","","","","inpatient","","","156452.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","81195.52","","Standard inlier is a Case rate ($81,195.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $67,809, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,525.03) for the length of stay and the standard reimbursement.","81195.51","9394.65","81195.51","1 through 10","7793.22","81195.52","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures,MAJOR","404","DRG","","","","","","","","inpatient","","","156452.43","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","59977.73","","Fee schedule rate ($59,977.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","60768.89","60768.89","60768.89","1 through 10","7793.22","81195.52","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures,MINOR","404","DRG","","","","","","","","inpatient","","","59520.12","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","32982.16","","Standard inlier is a Case rate ($32,982.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,460, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,681.54) for the length of stay and the standard reimbursement.","32982.15","32982.15","32982.15","1 through 10","7793.22","81195.52","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures,MINOR","404","DRG","","","","","","","","inpatient","","","59520.12","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","15308.1748","","Fee schedule rate ($15,308.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15308.1748","14717.64","14717.64","1 through 10","7793.22","81195.52","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures,MINOR","404","DRG","","","","","","","","inpatient","","","59520.12","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","30345.45","","Fee schedule rate ($30,345.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30345.45","30345.45","30345.45","1 through 10","7793.22","81195.52","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures,MODERATE","404","DRG","","","","","","","","inpatient","","","101814.12","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","43036.17","","Standard inlier is a Case rate ($43,036.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,115, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,109.24) for the length of stay and the standard reimbursement.","43036.16","43036.16","43036.16","1 through 10","7793.22","81195.52","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures,MODERATE","404","DRG","","","","","","","","inpatient","","","101814.12","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","48384.25","","Standard inlier is a Case rate ($48,384.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $45,115, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,867.74) for the length of stay and the standard reimbursement.","48384.25","44203.19","48384.25","1 through 10","7793.22","81195.52","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures,MODERATE","404","DRG","","","","","","","","inpatient","","","101814.12","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","14578.8106","","Fee schedule rate ($18,976.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14578.8106","18976.16","18976.16","1 through 10","7793.22","81195.52","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures,MODERATE","404","DRG","","","","","","","","inpatient","","","101814.12","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","15308.1748","","Fee schedule rate ($19,925.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15308.1748","19925.52","19925.52","1 through 10","7793.22","81195.52","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures,MODERATE","404","DRG","","","","","","","","inpatient","","","101814.12","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","20874.03","","Fee schedule rate ($20,874.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20069.75","20069.75","20069.75","1 through 10","7793.22","81195.52","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures,MODERATE","404","DRG","","","","","","","","inpatient","","","101814.12","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41952.51","","Fee schedule rate ($41,952.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","41952.51","41952.51","41952.51","1 through 10","7793.22","81195.52","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures,MODERATE","404","DRG","","","","","","","","inpatient","","","101814.12","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44050.82","","Fee schedule rate ($44,050.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","44050.82","44050.82","44050.82","1 through 10","7793.22","81195.52","case rate",""
"Thyroid, Parathyroid And Thyroglossal Procedures,MODERATE","404","DRG","","","","","","","","inpatient","","","101814.12","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12512.33","","Case rate ($13,834.54). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,264.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13831.14","13831.14","13831.14","1 through 10","7793.22","81195.52","case rate",""
"Thyrotropin Alpha Vl 0.9mg(1.1mg)","PX-63600184","CDM","J3240","HCPCS","0636","RC","","","","both","","","1879.79","1409.84","TRICARE [160005]","HB BWH TRICARE","2007.58","","APC Price ($2,113.24). Final payment is multiplied by 95%.","2113.24","2113.24","2113.24","1 through 10","582.73","4933.29","other","Tricare OPPS"
"Thyrotropin Alpha Vl 0.9mg(1.1mg)","PX-63600184","CDM","J3240","HCPCS","0636","RC","","","","outpatient","","","1879.79","1409.84","AETNA [1001]","HB AMC AETNA HMO","1312.09","69.8","","9023.73","9023.73","9023.73","1 through 10","881.62","4543.47","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","108.42","71.8","","104.83","104.83","104.83","1 through 10","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","99.06","65.6","","9.28","9.28","9.28","1 through 10","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","105.70","70","","315.36","146.00","315.36","1 through 10","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","120.05","79.5","","114.90","77.09","114.90","472","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","80.48","53.3","","77.09","77.09","147.46","231","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","116.27","77","","112.42","112.42","112.42","1 through 10","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","120.05","79.5","","129.27","129.27","129.27","1 through 10","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","46.81","31","","45.11","45.11","135.33","14","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.12","36.5","","54.46","46.28","138.84","347","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.83","38.3","","57.09","55.48","166.44","1176","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","MOLINA [1014]","HB BWH MOLINA","52.85","35","","17.90","17.90","18.04","1 through 10","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","116.27","77","","113.88","22.85","113.88","1 through 10","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","TRICARE [160005]","HB BWH TRICARE","143.45","95","","10.87","10.33","10.87","25","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.78","42.9","","116.71","64.20","116.71","18","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","151.00","113.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.78","42.9","","64.20","64.20","64.20","1 through 10","8.84","143.45","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","151.00","113.25","AETNA [1001]","HB AMC AETNA HMO","105.40","69.8","","98.84","69.79","113.88","607","9.29","123.4","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","151.00","113.25","AETNA [1001]","HB AMC AETNA PPO","121.40","80.4","","113.88","74.41","153.00","54","9.29","123.4","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","151.00","113.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","84.41","55.9","","76.50","74.41","76.50","1 through 10","9.29","123.4","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","151.00","113.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","78.91","52.26","","31.97","31.97","90.35","1 through 10","9.29","123.4","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","151.00","113.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","123.40","81.72","","116.71","116.71","116.71","1 through 10","9.29","123.4","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","123.40","81.72","","116.71","64.20","116.71","12","9.29","123.4","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","123.40","81.72","","116.71","64.20","116.71","428","9.29","123.4","percent of total billed charges",""
"Thyroxine (T-4) Total","PX-30000697","CDM","84436","CPT","0301","RC","","","","both","","","115.00","86.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","91.43","79.5","","59.14","59.14","59.14","1 through 10","6.73","109.25","percent of total billed charges",""
"Thyroxine (T-4) Total","PX-30000697","CDM","84436","CPT","0301","RC","","","","both","","","115.00","86.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","61.30","53.3","","59.14","59.14","59.14","1 through 10","6.73","109.25","percent of total billed charges",""
"Thyroxine (T-4) Total","PX-30000697","CDM","84436","CPT","0301","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.98","36.5","","41.78","35.50","45.63","12","6.73","109.25","percent of total billed charges",""
"Thyroxine (T-4) Total","PX-30000697","CDM","84436","CPT","0301","RC","","","","both","","","115.00","86.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44.05","38.3","","43.79","43.79","43.79","18","6.73","109.25","percent of total billed charges",""
"Thyroxine (T-4) Total","PX-30000697","CDM","84436","CPT","0301","RC","","","","outpatient","","","115.00","86.25","AETNA [1001]","HB AMC AETNA HMO","80.27","69.8","","53.54","53.54","75.82","1 through 10","7.08","93.98","percent of total billed charges",""
"Thyroxine (T-4) Total","PX-30000697","CDM","84436","CPT","0301","RC","","","","outpatient","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","93.98","81.72","","89.53","49.25","89.53","1 through 10","7.08","93.98","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 45MM","SUP-ITM-10245316","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","667.80","79.5","","800.18","480.96","1887.97","195","260.4","667.8","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 45MM","SUP-ITM-10245316","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","447.72","53.3","","813.12","216.42","1444.50","81","260.4","667.8","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 45MM","SUP-ITM-10245316","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","260.40","31","","432.60","432.60","432.60","1 through 10","260.4","667.8","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 45MM","SUP-ITM-10245316","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","306.60","36.5","","148.37","54.89","631.39","94","260.4","667.8","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 45MM","SUP-ITM-10245316","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","321.72","38.3","","279.30","91.72","1116.77","266","260.4","667.8","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 45MM","SUP-ITM-10245316","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","731.00","63.70","731.00","1 through 10","260.4","667.8","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 45MM","SUP-ITM-10245316","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.36","42.9","","384.74","384.74","384.74","1 through 10","260.4","667.8","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 45MM","SUP-ITM-10245316","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB AMC WELLPOINT","619.75","73.78","","286.63","119.22","1107.45","105","260.4","667.8","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 45MM","SUP-ITM-10245316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA HMO","586.32","69.8","","675.31","184.75","1721.50","286","438.98","686.45","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 45MM","SUP-ITM-10245316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","AETNA [1001]","HB AMC AETNA PPO","675.36","80.4","","1261.44","103.12","1514.10","21","438.98","686.45","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 45MM","SUP-ITM-10245316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","675.36","80.4","","1365.00","1365.00","1365.00","1 through 10","438.98","686.45","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 45MM","SUP-ITM-10245316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","686.45","81.72","","5157.68","5157.68","5157.68","1 through 10","438.98","686.45","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 45MM","SUP-ITM-10245316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","686.45","81.72","","431.26","71.26","1459.57","88","438.98","686.45","percent of total billed charges",""
"TIBIA AUGMENT SZ E TRIATHALON MEDIAL LEFT LATERAL","SUP-ITM-10208926","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3966.53","52.26","","1113.10","1113.10","1113.10","1 through 10","2352.9","6034.05","percent of total billed charges",""
"TIBIA AUGMENT SZ E TRIATHALON MEDIAL LEFT LATERAL","SUP-ITM-10208926","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6034.05","79.5","","1293.60","1148.53","1603.80","1 through 10","2352.9","6034.05","percent of total billed charges",""
"TIBIA AUGMENT SZ E TRIATHALON MEDIAL LEFT LATERAL","SUP-ITM-10208926","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2770.35","36.5","","1023.42","771.29","2068.67","33","2352.9","6034.05","percent of total billed charges",""
"TIBIA AUGMENT SZ E TRIATHALON MEDIAL LEFT LATERAL","SUP-ITM-10208926","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2906.97","38.3","","850.52","759.78","1211.25","66","2352.9","6034.05","percent of total billed charges",""
"TIBIA AUGMENT SZ E TRIATHALON MEDIAL LEFT LATERAL","SUP-ITM-10208926","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3256.11","42.9","","2548.09","2548.09","2548.09","1 through 10","2352.9","6034.05","percent of total billed charges",""
"TIBIA AUGMENT SZ E TRIATHALON MEDIAL LEFT LATERAL","SUP-ITM-10208926","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3256.11","42.9","","956.46","956.46","956.46","1 through 10","2352.9","6034.05","percent of total billed charges",""
"TIBIA AUGMENT SZ E TRIATHALON MEDIAL LEFT LATERAL","SUP-ITM-10208926","CDM","C1776","HCPCS","0278","RC","","","","both","","","7590.00","5692.50","WELLPOINT [1015]","HB AMC WELLPOINT","5599.90","73.78","","2344.73","1619.47","2530.35","16","2352.9","6034.05","percent of total billed charges",""
"TIBIA AUGMENT SZ E TRIATHALON MEDIAL LEFT LATERAL","SUP-ITM-10208926","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7590.00","5692.50","AETNA [1001]","HB AMC AETNA HMO","5297.82","69.8","","1523.63","988.41","4330.26","39","3966.53","6202.55","percent of total billed charges",""
"TIBIA AUGMENT SZ E TRIATHALON MEDIAL LEFT LATERAL","SUP-ITM-10208926","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7590.00","5692.50","AETNA [1001]","HB AMC AETNA PPO","6102.36","80.4","","1670.25","1670.25","1670.25","1 through 10","3966.53","6202.55","percent of total billed charges",""
"TIBIA AUGMENT SZ E TRIATHALON MEDIAL LEFT LATERAL","SUP-ITM-10208926","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7590.00","5692.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3966.53","52.26","","1113.10","1113.10","1113.10","1 through 10","3966.53","6202.55","percent of total billed charges",""
"TIBIA AUGMENT SZ E TRIATHALON MEDIAL LEFT LATERAL","SUP-ITM-10208926","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7590.00","5692.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6202.55","81.72","","1738.90","1484.65","2716.94","38","3966.53","6202.55","percent of total billed charges",""
"TIBIA BEARING 12MM OSS","SUP-ITM-10124186","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1924.40","52.26","","1113.10","1113.10","1113.10","1 through 10","1141.53","2927.47","percent of total billed charges",""
"TIBIA BEARING 12MM OSS","SUP-ITM-10124186","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2927.47","79.5","","1293.60","1148.53","1603.80","1 through 10","1141.53","2927.47","percent of total billed charges",""
"TIBIA BEARING 12MM OSS","SUP-ITM-10124186","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1344.06","36.5","","1023.42","771.29","2068.67","33","1141.53","2927.47","percent of total billed charges",""
"TIBIA BEARING 12MM OSS","SUP-ITM-10124186","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1410.34","38.3","","850.52","759.78","1211.25","66","1141.53","2927.47","percent of total billed charges",""
"TIBIA BEARING 12MM OSS","SUP-ITM-10124186","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1579.73","42.9","","2548.09","2548.09","2548.09","1 through 10","1141.53","2927.47","percent of total billed charges",""
"TIBIA BEARING 12MM OSS","SUP-ITM-10124186","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1579.73","42.9","","956.46","956.46","956.46","1 through 10","1141.53","2927.47","percent of total billed charges",""
"TIBIA BEARING 12MM OSS","SUP-ITM-10124186","CDM","C1776","HCPCS","0278","RC","","","","both","","","3682.35","2761.76","WELLPOINT [1015]","HB AMC WELLPOINT","2716.84","73.78","","2344.73","1619.47","2530.35","16","1141.53","2927.47","percent of total billed charges",""
"TIBIA BEARING 12MM OSS","SUP-ITM-10124186","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","AETNA [1001]","HB AMC AETNA HMO","2570.28","69.8","","1523.63","988.41","4330.26","39","1924.4","3009.22","percent of total billed charges",""
"TIBIA BEARING 12MM OSS","SUP-ITM-10124186","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","AETNA [1001]","HB AMC AETNA PPO","2960.61","80.4","","1670.25","1670.25","1670.25","1 through 10","1924.4","3009.22","percent of total billed charges",""
"TIBIA BEARING 12MM OSS","SUP-ITM-10124186","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1924.40","52.26","","1113.10","1113.10","1113.10","1 through 10","1924.4","3009.22","percent of total billed charges",""
"TIBIA BEARING 12MM OSS","SUP-ITM-10124186","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3682.35","2761.76","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3009.22","81.72","","1738.90","1484.65","2716.94","38","1924.4","3009.22","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.89","3135.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3323.81","79.5","","800.18","480.96","1887.97","195","1296.08","3323.81","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.89","3135.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2228.41","53.3","","813.12","216.42","1444.50","81","1296.08","3323.81","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.89","3135.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1296.08","31","","432.60","432.60","432.60","1 through 10","1296.08","3323.81","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.89","3135.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1526.02","36.5","","148.37","54.89","631.39","94","1296.08","3323.81","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.89","3135.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1601.28","38.3","","279.30","91.72","1116.77","266","1296.08","3323.81","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.89","3135.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1793.60","42.9","","731.00","63.70","731.00","1 through 10","1296.08","3323.81","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.89","3135.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1793.60","42.9","","384.74","384.74","384.74","1 through 10","1296.08","3323.81","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","4180.89","3135.67","WELLPOINT [1015]","HB AMC WELLPOINT","3084.66","73.78","","286.63","119.22","1107.45","105","1296.08","3323.81","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4180.89","3135.67","AETNA [1001]","HB AMC AETNA HMO","2918.26","69.8","","675.31","184.75","1721.50","286","2184.93","3416.62","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4180.89","3135.67","AETNA [1001]","HB AMC AETNA PPO","3361.44","80.4","","1261.44","103.12","1514.10","21","2184.93","3416.62","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4180.89","3135.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3361.44","80.4","","1365.00","1365.00","1365.00","1 through 10","2184.93","3416.62","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4180.89","3135.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3416.62","81.72","","5157.68","5157.68","5157.68","1 through 10","2184.93","3416.62","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4180.89","3135.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3416.62","81.72","","431.26","71.26","1459.57","88","2184.93","3416.62","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4092.12","3069.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3253.24","79.5","","800.18","480.96","1887.97","195","1268.56","3253.24","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4092.12","3069.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2181.10","53.3","","813.12","216.42","1444.50","81","1268.56","3253.24","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4092.12","3069.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1268.56","31","","432.60","432.60","432.60","1 through 10","1268.56","3253.24","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4092.12","3069.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1493.62","36.5","","148.37","54.89","631.39","94","1268.56","3253.24","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4092.12","3069.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1567.28","38.3","","279.30","91.72","1116.77","266","1268.56","3253.24","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4092.12","3069.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1755.52","42.9","","731.00","63.70","731.00","1 through 10","1268.56","3253.24","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4092.12","3069.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1755.52","42.9","","384.74","384.74","384.74","1 through 10","1268.56","3253.24","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","both","","","4092.12","3069.09","WELLPOINT [1015]","HB AMC WELLPOINT","3019.17","73.78","","286.63","119.22","1107.45","105","1268.56","3253.24","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4092.12","3069.09","AETNA [1001]","HB AMC AETNA HMO","2856.30","69.8","","675.31","184.75","1721.50","286","2138.54","3344.08","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4092.12","3069.09","AETNA [1001]","HB AMC AETNA PPO","3290.06","80.4","","1261.44","103.12","1514.10","21","2138.54","3344.08","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4092.12","3069.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3290.06","80.4","","1365.00","1365.00","1365.00","1 through 10","2138.54","3344.08","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4092.12","3069.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3344.08","81.72","","5157.68","5157.68","5157.68","1 through 10","2138.54","3344.08","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4092.12","3069.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3344.08","81.72","","431.26","71.26","1459.57","88","2138.54","3344.08","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3928.05","2946.04","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3122.80","79.5","","800.18","480.96","1887.97","195","1217.7","3122.8","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3928.05","2946.04","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2093.65","53.3","","813.12","216.42","1444.50","81","1217.7","3122.8","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3928.05","2946.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1217.70","31","","432.60","432.60","432.60","1 through 10","1217.7","3122.8","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3928.05","2946.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1433.74","36.5","","148.37","54.89","631.39","94","1217.7","3122.8","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3928.05","2946.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1504.44","38.3","","279.30","91.72","1116.77","266","1217.7","3122.8","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3928.05","2946.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1685.13","42.9","","731.00","63.70","731.00","1 through 10","1217.7","3122.8","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3928.05","2946.04","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1685.13","42.9","","384.74","384.74","384.74","1 through 10","1217.7","3122.8","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3928.05","2946.04","WELLPOINT [1015]","HB AMC WELLPOINT","2898.12","73.78","","286.63","119.22","1107.45","105","1217.7","3122.8","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3928.05","2946.04","AETNA [1001]","HB AMC AETNA HMO","2741.78","69.8","","675.31","184.75","1721.50","286","2052.8","3210","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3928.05","2946.04","AETNA [1001]","HB AMC AETNA PPO","3158.15","80.4","","1261.44","103.12","1514.10","21","2052.8","3210","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3928.05","2946.04","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3158.15","80.4","","1365.00","1365.00","1365.00","1 through 10","2052.8","3210","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3928.05","2946.04","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3210.00","81.72","","5157.68","5157.68","5157.68","1 through 10","2052.8","3210","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3928.05","2946.04","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3210.00","81.72","","431.26","71.26","1459.57","88","2052.8","3210","percent of total billed charges",""
"TIBIA PLATE 4.5X142MM 6 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037893","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.48","3107.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3294.07","79.5","","800.18","480.96","1887.97","195","1284.48","3294.07","percent of total billed charges",""
"TIBIA PLATE 4.5X142MM 6 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037893","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.48","3107.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2208.47","53.3","","813.12","216.42","1444.50","81","1284.48","3294.07","percent of total billed charges",""
"TIBIA PLATE 4.5X142MM 6 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037893","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.48","3107.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1284.48","31","","432.60","432.60","432.60","1 through 10","1284.48","3294.07","percent of total billed charges",""
"TIBIA PLATE 4.5X142MM 6 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037893","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.48","3107.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1512.37","36.5","","148.37","54.89","631.39","94","1284.48","3294.07","percent of total billed charges",""
"TIBIA PLATE 4.5X142MM 6 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037893","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.48","3107.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1586.95","38.3","","279.30","91.72","1116.77","266","1284.48","3294.07","percent of total billed charges",""
"TIBIA PLATE 4.5X142MM 6 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037893","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.48","3107.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1777.55","42.9","","731.00","63.70","731.00","1 through 10","1284.48","3294.07","percent of total billed charges",""
"TIBIA PLATE 4.5X142MM 6 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037893","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.48","3107.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1777.55","42.9","","384.74","384.74","384.74","1 through 10","1284.48","3294.07","percent of total billed charges",""
"TIBIA PLATE 4.5X142MM 6 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037893","CDM","C1713","HCPCS","0278","RC","","","","both","","","4143.48","3107.61","WELLPOINT [1015]","HB AMC WELLPOINT","3057.06","73.78","","286.63","119.22","1107.45","105","1284.48","3294.07","percent of total billed charges",""
"TIBIA PLATE 4.5X142MM 6 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4143.48","3107.61","AETNA [1001]","HB AMC AETNA HMO","2892.15","69.8","","675.31","184.75","1721.50","286","2165.38","3386.05","percent of total billed charges",""
"TIBIA PLATE 4.5X142MM 6 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4143.48","3107.61","AETNA [1001]","HB AMC AETNA PPO","3331.36","80.4","","1261.44","103.12","1514.10","21","2165.38","3386.05","percent of total billed charges",""
"TIBIA PLATE 4.5X142MM 6 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4143.48","3107.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3331.36","80.4","","1365.00","1365.00","1365.00","1 through 10","2165.38","3386.05","percent of total billed charges",""
"TIBIA PLATE 4.5X142MM 6 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4143.48","3107.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3386.05","81.72","","5157.68","5157.68","5157.68","1 through 10","2165.38","3386.05","percent of total billed charges",""
"TIBIA PLATE 4.5X142MM 6 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4143.48","3107.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3386.05","81.72","","431.26","71.26","1459.57","88","2165.38","3386.05","percent of total billed charges",""
"TIBIA PLATE 4.5X161MM 8 HOLE L LEFT","SUP-ITM-10030859","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.41","2523.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2674.71","79.5","","800.18","480.96","1887.97","195","1042.97","2674.71","percent of total billed charges",""
"TIBIA PLATE 4.5X161MM 8 HOLE L LEFT","SUP-ITM-10030859","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.41","2523.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1793.23","53.3","","813.12","216.42","1444.50","81","1042.97","2674.71","percent of total billed charges",""
"TIBIA PLATE 4.5X161MM 8 HOLE L LEFT","SUP-ITM-10030859","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.41","2523.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1042.97","31","","432.60","432.60","432.60","1 through 10","1042.97","2674.71","percent of total billed charges",""
"TIBIA PLATE 4.5X161MM 8 HOLE L LEFT","SUP-ITM-10030859","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.41","2523.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1228.01","36.5","","148.37","54.89","631.39","94","1042.97","2674.71","percent of total billed charges",""
"TIBIA PLATE 4.5X161MM 8 HOLE L LEFT","SUP-ITM-10030859","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.41","2523.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1288.57","38.3","","279.30","91.72","1116.77","266","1042.97","2674.71","percent of total billed charges",""
"TIBIA PLATE 4.5X161MM 8 HOLE L LEFT","SUP-ITM-10030859","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.41","2523.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1443.33","42.9","","731.00","63.70","731.00","1 through 10","1042.97","2674.71","percent of total billed charges",""
"TIBIA PLATE 4.5X161MM 8 HOLE L LEFT","SUP-ITM-10030859","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.41","2523.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1443.33","42.9","","384.74","384.74","384.74","1 through 10","1042.97","2674.71","percent of total billed charges",""
"TIBIA PLATE 4.5X161MM 8 HOLE L LEFT","SUP-ITM-10030859","CDM","C1713","HCPCS","0278","RC","","","","both","","","3364.41","2523.31","WELLPOINT [1015]","HB AMC WELLPOINT","2482.26","73.78","","286.63","119.22","1107.45","105","1042.97","2674.71","percent of total billed charges",""
"TIBIA PLATE 4.5X161MM 8 HOLE L LEFT","SUP-ITM-10030859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.41","2523.31","AETNA [1001]","HB AMC AETNA HMO","2348.36","69.8","","675.31","184.75","1721.50","286","1758.24","2749.4","percent of total billed charges",""
"TIBIA PLATE 4.5X161MM 8 HOLE L LEFT","SUP-ITM-10030859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.41","2523.31","AETNA [1001]","HB AMC AETNA PPO","2704.99","80.4","","1261.44","103.12","1514.10","21","1758.24","2749.4","percent of total billed charges",""
"TIBIA PLATE 4.5X161MM 8 HOLE L LEFT","SUP-ITM-10030859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.41","2523.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2704.99","80.4","","1365.00","1365.00","1365.00","1 through 10","1758.24","2749.4","percent of total billed charges",""
"TIBIA PLATE 4.5X161MM 8 HOLE L LEFT","SUP-ITM-10030859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.41","2523.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2749.40","81.72","","5157.68","5157.68","5157.68","1 through 10","1758.24","2749.4","percent of total billed charges",""
"TIBIA PLATE 4.5X161MM 8 HOLE L LEFT","SUP-ITM-10030859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3364.41","2523.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2749.40","81.72","","431.26","71.26","1459.57","88","1758.24","2749.4","percent of total billed charges",""
"TIBIA PLATE 4.5X178MM 9 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037897","CDM","C1713","HCPCS","0278","RC","","","","both","","","4187.34","3140.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3328.94","79.5","","800.18","480.96","1887.97","195","1298.08","3328.94","percent of total billed charges",""
"TIBIA PLATE 4.5X178MM 9 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037897","CDM","C1713","HCPCS","0278","RC","","","","both","","","4187.34","3140.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2231.85","53.3","","813.12","216.42","1444.50","81","1298.08","3328.94","percent of total billed charges",""
"TIBIA PLATE 4.5X178MM 9 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037897","CDM","C1713","HCPCS","0278","RC","","","","both","","","4187.34","3140.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1298.08","31","","432.60","432.60","432.60","1 through 10","1298.08","3328.94","percent of total billed charges",""
"TIBIA PLATE 4.5X178MM 9 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037897","CDM","C1713","HCPCS","0278","RC","","","","both","","","4187.34","3140.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1528.38","36.5","","148.37","54.89","631.39","94","1298.08","3328.94","percent of total billed charges",""
"TIBIA PLATE 4.5X178MM 9 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037897","CDM","C1713","HCPCS","0278","RC","","","","both","","","4187.34","3140.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1603.75","38.3","","279.30","91.72","1116.77","266","1298.08","3328.94","percent of total billed charges",""
"TIBIA PLATE 4.5X178MM 9 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037897","CDM","C1713","HCPCS","0278","RC","","","","both","","","4187.34","3140.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1796.37","42.9","","731.00","63.70","731.00","1 through 10","1298.08","3328.94","percent of total billed charges",""
"TIBIA PLATE 4.5X178MM 9 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037897","CDM","C1713","HCPCS","0278","RC","","","","both","","","4187.34","3140.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1796.37","42.9","","384.74","384.74","384.74","1 through 10","1298.08","3328.94","percent of total billed charges",""
"TIBIA PLATE 4.5X178MM 9 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037897","CDM","C1713","HCPCS","0278","RC","","","","both","","","4187.34","3140.50","WELLPOINT [1015]","HB AMC WELLPOINT","3089.42","73.78","","286.63","119.22","1107.45","105","1298.08","3328.94","percent of total billed charges",""
"TIBIA PLATE 4.5X178MM 9 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037897","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4187.34","3140.50","AETNA [1001]","HB AMC AETNA HMO","2922.76","69.8","","675.31","184.75","1721.50","286","2188.3","3421.89","percent of total billed charges",""
"TIBIA PLATE 4.5X178MM 9 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037897","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4187.34","3140.50","AETNA [1001]","HB AMC AETNA PPO","3366.62","80.4","","1261.44","103.12","1514.10","21","2188.3","3421.89","percent of total billed charges",""
"TIBIA PLATE 4.5X178MM 9 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037897","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4187.34","3140.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3366.62","80.4","","1365.00","1365.00","1365.00","1 through 10","2188.3","3421.89","percent of total billed charges",""
"TIBIA PLATE 4.5X178MM 9 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037897","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4187.34","3140.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3421.89","81.72","","5157.68","5157.68","5157.68","1 through 10","2188.3","3421.89","percent of total billed charges",""
"TIBIA PLATE 4.5X178MM 9 HOLE L LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037897","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4187.34","3140.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3421.89","81.72","","431.26","71.26","1459.57","88","2188.3","3421.89","percent of total billed charges",""
"TIBIA PLATE 4.5X214MM 10 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037900","CDM","C1713","HCPCS","0278","RC","","","","both","","","4232.49","3174.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3364.83","79.5","","800.18","480.96","1887.97","195","1312.07","3364.83","percent of total billed charges",""
"TIBIA PLATE 4.5X214MM 10 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037900","CDM","C1713","HCPCS","0278","RC","","","","both","","","4232.49","3174.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2255.92","53.3","","813.12","216.42","1444.50","81","1312.07","3364.83","percent of total billed charges",""
"TIBIA PLATE 4.5X214MM 10 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037900","CDM","C1713","HCPCS","0278","RC","","","","both","","","4232.49","3174.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1312.07","31","","432.60","432.60","432.60","1 through 10","1312.07","3364.83","percent of total billed charges",""
"TIBIA PLATE 4.5X214MM 10 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037900","CDM","C1713","HCPCS","0278","RC","","","","both","","","4232.49","3174.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1544.86","36.5","","148.37","54.89","631.39","94","1312.07","3364.83","percent of total billed charges",""
"TIBIA PLATE 4.5X214MM 10 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037900","CDM","C1713","HCPCS","0278","RC","","","","both","","","4232.49","3174.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1621.04","38.3","","279.30","91.72","1116.77","266","1312.07","3364.83","percent of total billed charges",""
"TIBIA PLATE 4.5X214MM 10 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037900","CDM","C1713","HCPCS","0278","RC","","","","both","","","4232.49","3174.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1815.74","42.9","","731.00","63.70","731.00","1 through 10","1312.07","3364.83","percent of total billed charges",""
"TIBIA PLATE 4.5X214MM 10 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037900","CDM","C1713","HCPCS","0278","RC","","","","both","","","4232.49","3174.37","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1815.74","42.9","","384.74","384.74","384.74","1 through 10","1312.07","3364.83","percent of total billed charges",""
"TIBIA PLATE 4.5X214MM 10 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037900","CDM","C1713","HCPCS","0278","RC","","","","both","","","4232.49","3174.37","WELLPOINT [1015]","HB AMC WELLPOINT","3122.73","73.78","","286.63","119.22","1107.45","105","1312.07","3364.83","percent of total billed charges",""
"TIBIA PLATE 4.5X214MM 10 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4232.49","3174.37","AETNA [1001]","HB AMC AETNA HMO","2954.28","69.8","","675.31","184.75","1721.50","286","2211.9","3458.79","percent of total billed charges",""
"TIBIA PLATE 4.5X214MM 10 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4232.49","3174.37","AETNA [1001]","HB AMC AETNA PPO","3402.92","80.4","","1261.44","103.12","1514.10","21","2211.9","3458.79","percent of total billed charges",""
"TIBIA PLATE 4.5X214MM 10 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4232.49","3174.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3402.92","80.4","","1365.00","1365.00","1365.00","1 through 10","2211.9","3458.79","percent of total billed charges",""
"TIBIA PLATE 4.5X214MM 10 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4232.49","3174.37","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3458.79","81.72","","5157.68","5157.68","5157.68","1 through 10","2211.9","3458.79","percent of total billed charges",""
"TIBIA PLATE 4.5X214MM 10 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4232.49","3174.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3458.79","81.72","","431.26","71.26","1459.57","88","2211.9","3458.79","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4522.74","3392.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3595.58","79.5","","800.18","480.96","1887.97","195","1402.05","3595.58","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4522.74","3392.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2410.62","53.3","","813.12","216.42","1444.50","81","1402.05","3595.58","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4522.74","3392.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1402.05","31","","432.60","432.60","432.60","1 through 10","1402.05","3595.58","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4522.74","3392.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1650.80","36.5","","148.37","54.89","631.39","94","1402.05","3595.58","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4522.74","3392.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1732.21","38.3","","279.30","91.72","1116.77","266","1402.05","3595.58","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4522.74","3392.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1940.26","42.9","","731.00","63.70","731.00","1 through 10","1402.05","3595.58","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4522.74","3392.05","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1940.26","42.9","","384.74","384.74","384.74","1 through 10","1402.05","3595.58","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","4522.74","3392.05","WELLPOINT [1015]","HB AMC WELLPOINT","3336.88","73.78","","286.63","119.22","1107.45","105","1402.05","3595.58","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4522.74","3392.05","AETNA [1001]","HB AMC AETNA HMO","3156.87","69.8","","675.31","184.75","1721.50","286","2363.58","3695.98","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4522.74","3392.05","AETNA [1001]","HB AMC AETNA PPO","3636.28","80.4","","1261.44","103.12","1514.10","21","2363.58","3695.98","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4522.74","3392.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3636.28","80.4","","1365.00","1365.00","1365.00","1 through 10","2363.58","3695.98","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4522.74","3392.05","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3695.98","81.72","","5157.68","5157.68","5157.68","1 through 10","2363.58","3695.98","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4522.74","3392.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3695.98","81.72","","431.26","71.26","1459.57","88","2363.58","3695.98","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1446.90","79.5","","800.18","480.96","1887.97","195","564.2","1446.9","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","970.06","53.3","","813.12","216.42","1444.50","81","564.2","1446.9","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","564.20","31","","432.60","432.60","432.60","1 through 10","564.2","1446.9","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","664.30","36.5","","148.37","54.89","631.39","94","564.2","1446.9","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","697.06","38.3","","279.30","91.72","1116.77","266","564.2","1446.9","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","780.78","42.9","","731.00","63.70","731.00","1 through 10","564.2","1446.9","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","780.78","42.9","","384.74","384.74","384.74","1 through 10","564.2","1446.9","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1820.00","1365.00","WELLPOINT [1015]","HB AMC WELLPOINT","1342.80","73.78","","286.63","119.22","1107.45","105","564.2","1446.9","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1820.00","1365.00","AETNA [1001]","HB AMC AETNA HMO","1270.36","69.8","","675.31","184.75","1721.50","286","951.13","1487.3","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1820.00","1365.00","AETNA [1001]","HB AMC AETNA PPO","1463.28","80.4","","1261.44","103.12","1514.10","21","951.13","1487.3","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1820.00","1365.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1463.28","80.4","","1365.00","1365.00","1365.00","1 through 10","951.13","1487.3","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1820.00","1365.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1487.30","81.72","","5157.68","5157.68","5157.68","1 through 10","951.13","1487.3","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1820.00","1365.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1487.30","81.72","","431.26","71.26","1459.57","88","951.13","1487.3","percent of total billed charges",""
"TIBIA PLATE MEDIUM MEDIAL DISTAL MAXLOCK EXTREME LEFT","SUP-ITM-10118171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4371.00","3278.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3474.95","79.5","","800.18","480.96","1887.97","195","1355.01","3474.95","percent of total billed charges",""
"TIBIA PLATE MEDIUM MEDIAL DISTAL MAXLOCK EXTREME LEFT","SUP-ITM-10118171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4371.00","3278.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2329.74","53.3","","813.12","216.42","1444.50","81","1355.01","3474.95","percent of total billed charges",""
"TIBIA PLATE MEDIUM MEDIAL DISTAL MAXLOCK EXTREME LEFT","SUP-ITM-10118171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4371.00","3278.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1355.01","31","","432.60","432.60","432.60","1 through 10","1355.01","3474.95","percent of total billed charges",""
"TIBIA PLATE MEDIUM MEDIAL DISTAL MAXLOCK EXTREME LEFT","SUP-ITM-10118171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4371.00","3278.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1595.42","36.5","","148.37","54.89","631.39","94","1355.01","3474.95","percent of total billed charges",""
"TIBIA PLATE MEDIUM MEDIAL DISTAL MAXLOCK EXTREME LEFT","SUP-ITM-10118171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4371.00","3278.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1674.09","38.3","","279.30","91.72","1116.77","266","1355.01","3474.95","percent of total billed charges",""
"TIBIA PLATE MEDIUM MEDIAL DISTAL MAXLOCK EXTREME LEFT","SUP-ITM-10118171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4371.00","3278.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1875.16","42.9","","731.00","63.70","731.00","1 through 10","1355.01","3474.95","percent of total billed charges",""
"TIBIA PLATE MEDIUM MEDIAL DISTAL MAXLOCK EXTREME LEFT","SUP-ITM-10118171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4371.00","3278.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1875.16","42.9","","384.74","384.74","384.74","1 through 10","1355.01","3474.95","percent of total billed charges",""
"TIBIA PLATE MEDIUM MEDIAL DISTAL MAXLOCK EXTREME LEFT","SUP-ITM-10118171","CDM","C1713","HCPCS","0278","RC","","","","both","","","4371.00","3278.25","WELLPOINT [1015]","HB AMC WELLPOINT","3224.92","73.78","","286.63","119.22","1107.45","105","1355.01","3474.95","percent of total billed charges",""
"TIBIA PLATE MEDIUM MEDIAL DISTAL MAXLOCK EXTREME LEFT","SUP-ITM-10118171","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4371.00","3278.25","AETNA [1001]","HB AMC AETNA HMO","3050.96","69.8","","675.31","184.75","1721.50","286","2284.28","3571.98","percent of total billed charges",""
"TIBIA PLATE MEDIUM MEDIAL DISTAL MAXLOCK EXTREME LEFT","SUP-ITM-10118171","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4371.00","3278.25","AETNA [1001]","HB AMC AETNA PPO","3514.28","80.4","","1261.44","103.12","1514.10","21","2284.28","3571.98","percent of total billed charges",""
"TIBIA PLATE MEDIUM MEDIAL DISTAL MAXLOCK EXTREME LEFT","SUP-ITM-10118171","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4371.00","3278.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3514.28","80.4","","1365.00","1365.00","1365.00","1 through 10","2284.28","3571.98","percent of total billed charges",""
"TIBIA PLATE MEDIUM MEDIAL DISTAL MAXLOCK EXTREME LEFT","SUP-ITM-10118171","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4371.00","3278.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3571.98","81.72","","5157.68","5157.68","5157.68","1 through 10","2284.28","3571.98","percent of total billed charges",""
"TIBIA PLATE MEDIUM MEDIAL DISTAL MAXLOCK EXTREME LEFT","SUP-ITM-10118171","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4371.00","3278.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3571.98","81.72","","431.26","71.26","1459.57","88","2284.28","3571.98","percent of total billed charges",""
"TIBIA PLATE SM ANTERIOR ORTHOLOC 3DI","SUP-ITM-10132383","CDM","C1713","HCPCS","0278","RC","","","","both","","","3517.50","2638.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2796.41","79.5","","800.18","480.96","1887.97","195","1090.43","2796.41","percent of total billed charges",""
"TIBIA PLATE SM ANTERIOR ORTHOLOC 3DI","SUP-ITM-10132383","CDM","C1713","HCPCS","0278","RC","","","","both","","","3517.50","2638.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1874.83","53.3","","813.12","216.42","1444.50","81","1090.43","2796.41","percent of total billed charges",""
"TIBIA PLATE SM ANTERIOR ORTHOLOC 3DI","SUP-ITM-10132383","CDM","C1713","HCPCS","0278","RC","","","","both","","","3517.50","2638.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1090.43","31","","432.60","432.60","432.60","1 through 10","1090.43","2796.41","percent of total billed charges",""
"TIBIA PLATE SM ANTERIOR ORTHOLOC 3DI","SUP-ITM-10132383","CDM","C1713","HCPCS","0278","RC","","","","both","","","3517.50","2638.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1283.89","36.5","","148.37","54.89","631.39","94","1090.43","2796.41","percent of total billed charges",""
"TIBIA PLATE SM ANTERIOR ORTHOLOC 3DI","SUP-ITM-10132383","CDM","C1713","HCPCS","0278","RC","","","","both","","","3517.50","2638.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1347.20","38.3","","279.30","91.72","1116.77","266","1090.43","2796.41","percent of total billed charges",""
"TIBIA PLATE SM ANTERIOR ORTHOLOC 3DI","SUP-ITM-10132383","CDM","C1713","HCPCS","0278","RC","","","","both","","","3517.50","2638.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1509.01","42.9","","731.00","63.70","731.00","1 through 10","1090.43","2796.41","percent of total billed charges",""
"TIBIA PLATE SM ANTERIOR ORTHOLOC 3DI","SUP-ITM-10132383","CDM","C1713","HCPCS","0278","RC","","","","both","","","3517.50","2638.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1509.01","42.9","","384.74","384.74","384.74","1 through 10","1090.43","2796.41","percent of total billed charges",""
"TIBIA PLATE SM ANTERIOR ORTHOLOC 3DI","SUP-ITM-10132383","CDM","C1713","HCPCS","0278","RC","","","","both","","","3517.50","2638.12","WELLPOINT [1015]","HB AMC WELLPOINT","2595.21","73.78","","286.63","119.22","1107.45","105","1090.43","2796.41","percent of total billed charges",""
"TIBIA PLATE SM ANTERIOR ORTHOLOC 3DI","SUP-ITM-10132383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3517.50","2638.12","AETNA [1001]","HB AMC AETNA HMO","2455.22","69.8","","675.31","184.75","1721.50","286","1838.25","2874.5","percent of total billed charges",""
"TIBIA PLATE SM ANTERIOR ORTHOLOC 3DI","SUP-ITM-10132383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3517.50","2638.12","AETNA [1001]","HB AMC AETNA PPO","2828.07","80.4","","1261.44","103.12","1514.10","21","1838.25","2874.5","percent of total billed charges",""
"TIBIA PLATE SM ANTERIOR ORTHOLOC 3DI","SUP-ITM-10132383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3517.50","2638.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2828.07","80.4","","1365.00","1365.00","1365.00","1 through 10","1838.25","2874.5","percent of total billed charges",""
"TIBIA PLATE SM ANTERIOR ORTHOLOC 3DI","SUP-ITM-10132383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3517.50","2638.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2874.50","81.72","","5157.68","5157.68","5157.68","1 through 10","1838.25","2874.5","percent of total billed charges",""
"TIBIA PLATE SM ANTERIOR ORTHOLOC 3DI","SUP-ITM-10132383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3517.50","2638.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2874.50","81.72","","431.26","71.26","1459.57","88","1838.25","2874.5","percent of total billed charges",""
"TIBIA PLATE SM ORTHOLOC 3DI ANTERIOLATERAL LEFT","SUP-ITM-10132157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3608.51","79.5","","800.18","480.96","1887.97","195","1407.09","3608.51","percent of total billed charges",""
"TIBIA PLATE SM ORTHOLOC 3DI ANTERIOLATERAL LEFT","SUP-ITM-10132157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2419.29","53.3","","813.12","216.42","1444.50","81","1407.09","3608.51","percent of total billed charges",""
"TIBIA PLATE SM ORTHOLOC 3DI ANTERIOLATERAL LEFT","SUP-ITM-10132157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1407.09","31","","432.60","432.60","432.60","1 through 10","1407.09","3608.51","percent of total billed charges",""
"TIBIA PLATE SM ORTHOLOC 3DI ANTERIOLATERAL LEFT","SUP-ITM-10132157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1656.74","36.5","","148.37","54.89","631.39","94","1407.09","3608.51","percent of total billed charges",""
"TIBIA PLATE SM ORTHOLOC 3DI ANTERIOLATERAL LEFT","SUP-ITM-10132157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1738.44","38.3","","279.30","91.72","1116.77","266","1407.09","3608.51","percent of total billed charges",""
"TIBIA PLATE SM ORTHOLOC 3DI ANTERIOLATERAL LEFT","SUP-ITM-10132157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1947.23","42.9","","731.00","63.70","731.00","1 through 10","1407.09","3608.51","percent of total billed charges",""
"TIBIA PLATE SM ORTHOLOC 3DI ANTERIOLATERAL LEFT","SUP-ITM-10132157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1947.23","42.9","","384.74","384.74","384.74","1 through 10","1407.09","3608.51","percent of total billed charges",""
"TIBIA PLATE SM ORTHOLOC 3DI ANTERIOLATERAL LEFT","SUP-ITM-10132157","CDM","C1713","HCPCS","0278","RC","","","","both","","","4539.00","3404.25","WELLPOINT [1015]","HB AMC WELLPOINT","3348.87","73.78","","286.63","119.22","1107.45","105","1407.09","3608.51","percent of total billed charges",""
"TIBIA PLATE SM ORTHOLOC 3DI ANTERIOLATERAL LEFT","SUP-ITM-10132157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4539.00","3404.25","AETNA [1001]","HB AMC AETNA HMO","3168.22","69.8","","675.31","184.75","1721.50","286","2372.08","3709.27","percent of total billed charges",""
"TIBIA PLATE SM ORTHOLOC 3DI ANTERIOLATERAL LEFT","SUP-ITM-10132157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4539.00","3404.25","AETNA [1001]","HB AMC AETNA PPO","3649.36","80.4","","1261.44","103.12","1514.10","21","2372.08","3709.27","percent of total billed charges",""
"TIBIA PLATE SM ORTHOLOC 3DI ANTERIOLATERAL LEFT","SUP-ITM-10132157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4539.00","3404.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3649.36","80.4","","1365.00","1365.00","1365.00","1 through 10","2372.08","3709.27","percent of total billed charges",""
"TIBIA PLATE SM ORTHOLOC 3DI ANTERIOLATERAL LEFT","SUP-ITM-10132157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4539.00","3404.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3709.27","81.72","","5157.68","5157.68","5157.68","1 through 10","2372.08","3709.27","percent of total billed charges",""
"TIBIA PLATE SM ORTHOLOC 3DI ANTERIOLATERAL LEFT","SUP-ITM-10132157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4539.00","3404.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3709.27","81.72","","431.26","71.26","1459.57","88","2372.08","3709.27","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1626.07","52.26","","1113.10","1113.10","1113.10","1 through 10","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2473.64","79.5","","1293.60","1148.53","1603.80","1 through 10","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1135.70","36.5","","1023.42","771.29","2068.67","33","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1191.70","38.3","","850.52","759.78","1211.25","66","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1334.83","42.9","","2548.09","2548.09","2548.09","1 through 10","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1334.83","42.9","","956.46","956.46","956.46","1 through 10","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","WELLPOINT [1015]","HB AMC WELLPOINT","2295.66","73.78","","2344.73","1619.47","2530.35","16","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3111.50","2333.62","AETNA [1001]","HB AMC AETNA HMO","2171.83","69.8","","1523.63","988.41","4330.26","39","1626.07","2542.72","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3111.50","2333.62","AETNA [1001]","HB AMC AETNA PPO","2501.65","80.4","","1670.25","1670.25","1670.25","1 through 10","1626.07","2542.72","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3111.50","2333.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1626.07","52.26","","1113.10","1113.10","1113.10","1 through 10","1626.07","2542.72","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3111.50","2333.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2542.72","81.72","","1738.90","1484.65","2716.94","38","1626.07","2542.72","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1626.07","52.26","","1113.10","1113.10","1113.10","1 through 10","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2473.64","79.5","","1293.60","1148.53","1603.80","1 through 10","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1135.70","36.5","","1023.42","771.29","2068.67","33","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1191.70","38.3","","850.52","759.78","1211.25","66","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1334.83","42.9","","2548.09","2548.09","2548.09","1 through 10","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1334.83","42.9","","956.46","956.46","956.46","1 through 10","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","WELLPOINT [1015]","HB AMC WELLPOINT","2295.66","73.78","","2344.73","1619.47","2530.35","16","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3111.50","2333.62","AETNA [1001]","HB AMC AETNA HMO","2171.83","69.8","","1523.63","988.41","4330.26","39","1626.07","2542.72","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3111.50","2333.62","AETNA [1001]","HB AMC AETNA PPO","2501.65","80.4","","1670.25","1670.25","1670.25","1 through 10","1626.07","2542.72","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3111.50","2333.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1626.07","52.26","","1113.10","1113.10","1113.10","1 through 10","1626.07","2542.72","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3111.50","2333.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2542.72","81.72","","1738.90","1484.65","2716.94","38","1626.07","2542.72","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1626.07","52.26","","1113.10","1113.10","1113.10","1 through 10","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2473.64","79.5","","1293.60","1148.53","1603.80","1 through 10","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1135.70","36.5","","1023.42","771.29","2068.67","33","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1191.70","38.3","","850.52","759.78","1211.25","66","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1334.83","42.9","","2548.09","2548.09","2548.09","1 through 10","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1334.83","42.9","","956.46","956.46","956.46","1 through 10","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3111.50","2333.62","WELLPOINT [1015]","HB AMC WELLPOINT","2295.66","73.78","","2344.73","1619.47","2530.35","16","964.57","2473.64","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3111.50","2333.62","AETNA [1001]","HB AMC AETNA HMO","2171.83","69.8","","1523.63","988.41","4330.26","39","1626.07","2542.72","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3111.50","2333.62","AETNA [1001]","HB AMC AETNA PPO","2501.65","80.4","","1670.25","1670.25","1670.25","1 through 10","1626.07","2542.72","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3111.50","2333.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1626.07","52.26","","1113.10","1113.10","1113.10","1 through 10","1626.07","2542.72","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3111.50","2333.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2542.72","81.72","","1738.90","1484.65","2716.94","38","1626.07","2542.72","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10017213","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3138.74","52.26","","1113.10","1113.10","1113.10","1 through 10","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10017213","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4774.77","79.5","","1293.60","1148.53","1603.80","1 through 10","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10017213","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2192.19","36.5","","1023.42","771.29","2068.67","33","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10017213","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2300.30","38.3","","850.52","759.78","1211.25","66","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10017213","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2576.57","42.9","","2548.09","2548.09","2548.09","1 through 10","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10017213","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2576.57","42.9","","956.46","956.46","956.46","1 through 10","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10017213","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","WELLPOINT [1015]","HB AMC WELLPOINT","4431.23","73.78","","2344.73","1619.47","2530.35","16","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10017213","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6006.00","4504.50","AETNA [1001]","HB AMC AETNA HMO","4192.19","69.8","","1523.63","988.41","4330.26","39","3138.74","4908.1","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10017213","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6006.00","4504.50","AETNA [1001]","HB AMC AETNA PPO","4828.82","80.4","","1670.25","1670.25","1670.25","1 through 10","3138.74","4908.1","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10017213","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6006.00","4504.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3138.74","52.26","","1113.10","1113.10","1113.10","1 through 10","3138.74","4908.1","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL LT LATERAL RT MEDIAL","SUP-ITM-10017213","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6006.00","4504.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4908.10","81.72","","1738.90","1484.65","2716.94","38","3138.74","4908.1","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL RT LATERAL LT MEDIAL","SUP-ITM-10017209","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3138.74","52.26","","1113.10","1113.10","1113.10","1 through 10","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL RT LATERAL LT MEDIAL","SUP-ITM-10017209","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4774.77","79.5","","1293.60","1148.53","1603.80","1 through 10","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL RT LATERAL LT MEDIAL","SUP-ITM-10017209","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2192.19","36.5","","1023.42","771.29","2068.67","33","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL RT LATERAL LT MEDIAL","SUP-ITM-10017209","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2300.30","38.3","","850.52","759.78","1211.25","66","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL RT LATERAL LT MEDIAL","SUP-ITM-10017209","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2576.57","42.9","","2548.09","2548.09","2548.09","1 through 10","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL RT LATERAL LT MEDIAL","SUP-ITM-10017209","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2576.57","42.9","","956.46","956.46","956.46","1 through 10","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL RT LATERAL LT MEDIAL","SUP-ITM-10017209","CDM","C1776","HCPCS","0278","RC","","","","both","","","6006.00","4504.50","WELLPOINT [1015]","HB AMC WELLPOINT","4431.23","73.78","","2344.73","1619.47","2530.35","16","1861.86","4774.77","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL RT LATERAL LT MEDIAL","SUP-ITM-10017209","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6006.00","4504.50","AETNA [1001]","HB AMC AETNA HMO","4192.19","69.8","","1523.63","988.41","4330.26","39","3138.74","4908.1","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL RT LATERAL LT MEDIAL","SUP-ITM-10017209","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6006.00","4504.50","AETNA [1001]","HB AMC AETNA PPO","4828.82","80.4","","1670.25","1670.25","1670.25","1 through 10","3138.74","4908.1","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL RT LATERAL LT MEDIAL","SUP-ITM-10017209","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6006.00","4504.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3138.74","52.26","","1113.10","1113.10","1113.10","1 through 10","3138.74","4908.1","percent of total billed charges",""
"TIBIAL AUGMENT 7 20MM SIZE BLOCK ORTHO TRABECULAR METAL RT LATERAL LT MEDIAL","SUP-ITM-10017209","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6006.00","4504.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4908.10","81.72","","1738.90","1484.65","2716.94","38","3138.74","4908.1","percent of total billed charges",""
"TIBIAL AUGMENT BLOCK 10MM SIZE 5 16DEG NEXGEN TIVANIUM ALLOY HALF ORTHO","SUP-ITM-10079070","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","896.90","52.26","","1113.10","1113.10","1113.10","1 through 10","532.03","1364.4","percent of total billed charges",""
"TIBIAL AUGMENT BLOCK 10MM SIZE 5 16DEG NEXGEN TIVANIUM ALLOY HALF ORTHO","SUP-ITM-10079070","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1364.40","79.5","","1293.60","1148.53","1603.80","1 through 10","532.03","1364.4","percent of total billed charges",""
"TIBIAL AUGMENT BLOCK 10MM SIZE 5 16DEG NEXGEN TIVANIUM ALLOY HALF ORTHO","SUP-ITM-10079070","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","626.42","36.5","","1023.42","771.29","2068.67","33","532.03","1364.4","percent of total billed charges",""
"TIBIAL AUGMENT BLOCK 10MM SIZE 5 16DEG NEXGEN TIVANIUM ALLOY HALF ORTHO","SUP-ITM-10079070","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","657.32","38.3","","850.52","759.78","1211.25","66","532.03","1364.4","percent of total billed charges",""
"TIBIAL AUGMENT BLOCK 10MM SIZE 5 16DEG NEXGEN TIVANIUM ALLOY HALF ORTHO","SUP-ITM-10079070","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","736.26","42.9","","2548.09","2548.09","2548.09","1 through 10","532.03","1364.4","percent of total billed charges",""
"TIBIAL AUGMENT BLOCK 10MM SIZE 5 16DEG NEXGEN TIVANIUM ALLOY HALF ORTHO","SUP-ITM-10079070","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","736.26","42.9","","956.46","956.46","956.46","1 through 10","532.03","1364.4","percent of total billed charges",""
"TIBIAL AUGMENT BLOCK 10MM SIZE 5 16DEG NEXGEN TIVANIUM ALLOY HALF ORTHO","SUP-ITM-10079070","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.23","1287.17","WELLPOINT [1015]","HB AMC WELLPOINT","1266.23","73.78","","2344.73","1619.47","2530.35","16","532.03","1364.4","percent of total billed charges",""
"TIBIAL AUGMENT BLOCK 10MM SIZE 5 16DEG NEXGEN TIVANIUM ALLOY HALF ORTHO","SUP-ITM-10079070","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","AETNA [1001]","HB AMC AETNA HMO","1197.93","69.8","","1523.63","988.41","4330.26","39","896.9","1402.5","percent of total billed charges",""
"TIBIAL AUGMENT BLOCK 10MM SIZE 5 16DEG NEXGEN TIVANIUM ALLOY HALF ORTHO","SUP-ITM-10079070","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","AETNA [1001]","HB AMC AETNA PPO","1379.85","80.4","","1670.25","1670.25","1670.25","1 through 10","896.9","1402.5","percent of total billed charges",""
"TIBIAL AUGMENT BLOCK 10MM SIZE 5 16DEG NEXGEN TIVANIUM ALLOY HALF ORTHO","SUP-ITM-10079070","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","896.90","52.26","","1113.10","1113.10","1113.10","1 through 10","896.9","1402.5","percent of total billed charges",""
"TIBIAL AUGMENT BLOCK 10MM SIZE 5 16DEG NEXGEN TIVANIUM ALLOY HALF ORTHO","SUP-ITM-10079070","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.23","1287.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1402.50","81.72","","1738.90","1484.65","2716.94","38","896.9","1402.5","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5965.00","4473.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3117.31","52.26","","1113.10","1113.10","1113.10","1 through 10","1849.15","4742.18","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5965.00","4473.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4742.18","79.5","","1293.60","1148.53","1603.80","1 through 10","1849.15","4742.18","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5965.00","4473.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2177.23","36.5","","1023.42","771.29","2068.67","33","1849.15","4742.18","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5965.00","4473.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2284.60","38.3","","850.52","759.78","1211.25","66","1849.15","4742.18","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5965.00","4473.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2558.99","42.9","","2548.09","2548.09","2548.09","1 through 10","1849.15","4742.18","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5965.00","4473.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2558.99","42.9","","956.46","956.46","956.46","1 through 10","1849.15","4742.18","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","5965.00","4473.75","WELLPOINT [1015]","HB AMC WELLPOINT","4400.98","73.78","","2344.73","1619.47","2530.35","16","1849.15","4742.18","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5965.00","4473.75","AETNA [1001]","HB AMC AETNA HMO","4163.57","69.8","","1523.63","988.41","4330.26","39","3117.31","4874.6","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5965.00","4473.75","AETNA [1001]","HB AMC AETNA PPO","4795.86","80.4","","1670.25","1670.25","1670.25","1 through 10","3117.31","4874.6","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5965.00","4473.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3117.31","52.26","","1113.10","1113.10","1113.10","1 through 10","3117.31","4874.6","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5965.00","4473.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4874.60","81.72","","1738.90","1484.65","2716.94","38","3117.31","4874.6","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 RIGHT PRESS FIT EMPOWR","SUP-ITM-10312099","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2377.83","52.26","","1113.10","1113.10","1113.10","1 through 10","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 RIGHT PRESS FIT EMPOWR","SUP-ITM-10312099","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3617.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 RIGHT PRESS FIT EMPOWR","SUP-ITM-10312099","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1660.75","36.5","","1023.42","771.29","2068.67","33","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 RIGHT PRESS FIT EMPOWR","SUP-ITM-10312099","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1742.65","38.3","","850.52","759.78","1211.25","66","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 RIGHT PRESS FIT EMPOWR","SUP-ITM-10312099","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.95","42.9","","2548.09","2548.09","2548.09","1 through 10","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 RIGHT PRESS FIT EMPOWR","SUP-ITM-10312099","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.95","42.9","","956.46","956.46","956.46","1 through 10","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 RIGHT PRESS FIT EMPOWR","SUP-ITM-10312099","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","WELLPOINT [1015]","HB AMC WELLPOINT","3356.99","73.78","","2344.73","1619.47","2530.35","16","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 RIGHT PRESS FIT EMPOWR","SUP-ITM-10312099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","AETNA [1001]","HB AMC AETNA HMO","3175.90","69.8","","1523.63","988.41","4330.26","39","2377.83","3718.26","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 RIGHT PRESS FIT EMPOWR","SUP-ITM-10312099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","AETNA [1001]","HB AMC AETNA PPO","3658.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2377.83","3718.26","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 RIGHT PRESS FIT EMPOWR","SUP-ITM-10312099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2377.83","52.26","","1113.10","1113.10","1113.10","1 through 10","2377.83","3718.26","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 RIGHT PRESS FIT EMPOWR","SUP-ITM-10312099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3718.26","81.72","","1738.90","1484.65","2716.94","38","2377.83","3718.26","percent of total billed charges",""
"TIBIAL BASEPLATE SZ6 RIGHT PRESSFIT EMPOWR","SUP-ITM-10321329","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2377.83","52.26","","1113.10","1113.10","1113.10","1 through 10","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ6 RIGHT PRESSFIT EMPOWR","SUP-ITM-10321329","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3617.25","79.5","","1293.60","1148.53","1603.80","1 through 10","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ6 RIGHT PRESSFIT EMPOWR","SUP-ITM-10321329","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1660.75","36.5","","1023.42","771.29","2068.67","33","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ6 RIGHT PRESSFIT EMPOWR","SUP-ITM-10321329","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1742.65","38.3","","850.52","759.78","1211.25","66","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ6 RIGHT PRESSFIT EMPOWR","SUP-ITM-10321329","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.95","42.9","","2548.09","2548.09","2548.09","1 through 10","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ6 RIGHT PRESSFIT EMPOWR","SUP-ITM-10321329","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1951.95","42.9","","956.46","956.46","956.46","1 through 10","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ6 RIGHT PRESSFIT EMPOWR","SUP-ITM-10321329","CDM","C1776","HCPCS","0278","RC","","","","both","","","4550.00","3412.50","WELLPOINT [1015]","HB AMC WELLPOINT","3356.99","73.78","","2344.73","1619.47","2530.35","16","1410.5","3617.25","percent of total billed charges",""
"TIBIAL BASEPLATE SZ6 RIGHT PRESSFIT EMPOWR","SUP-ITM-10321329","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","AETNA [1001]","HB AMC AETNA HMO","3175.90","69.8","","1523.63","988.41","4330.26","39","2377.83","3718.26","percent of total billed charges",""
"TIBIAL BASEPLATE SZ6 RIGHT PRESSFIT EMPOWR","SUP-ITM-10321329","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","AETNA [1001]","HB AMC AETNA PPO","3658.20","80.4","","1670.25","1670.25","1670.25","1 through 10","2377.83","3718.26","percent of total billed charges",""
"TIBIAL BASEPLATE SZ6 RIGHT PRESSFIT EMPOWR","SUP-ITM-10321329","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2377.83","52.26","","1113.10","1113.10","1113.10","1 through 10","2377.83","3718.26","percent of total billed charges",""
"TIBIAL BASEPLATE SZ6 RIGHT PRESSFIT EMPOWR","SUP-ITM-10321329","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4550.00","3412.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3718.26","81.72","","1738.90","1484.65","2716.94","38","2377.83","3718.26","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1324.47","79.5","","1293.60","1148.53","1603.80","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","608.09","36.5","","1023.42","771.29","2068.67","33","516.46","1324.47","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","638.08","38.3","","850.52","759.78","1211.25","66","516.46","1324.47","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","2548.09","2548.09","2548.09","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","956.46","956.46","956.46","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","WELLPOINT [1015]","HB AMC WELLPOINT","1229.17","73.78","","2344.73","1619.47","2530.35","16","516.46","1324.47","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA HMO","1162.87","69.8","","1523.63","988.41","4330.26","39","870.65","1361.46","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA PPO","1339.46","80.4","","1670.25","1670.25","1670.25","1 through 10","870.65","1361.46","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","870.65","1361.46","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1361.46","81.72","","1738.90","1484.65","2716.94","38","870.65","1361.46","percent of total billed charges",""
"TIBIAL BEARING SZ 1 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197893","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1152.33","52.26","","1113.10","1113.10","1113.10","1 through 10","683.55","1752.98","percent of total billed charges",""
"TIBIAL BEARING SZ 1 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197893","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1752.98","79.5","","1293.60","1148.53","1603.80","1 through 10","683.55","1752.98","percent of total billed charges",""
"TIBIAL BEARING SZ 1 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197893","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","804.83","36.5","","1023.42","771.29","2068.67","33","683.55","1752.98","percent of total billed charges",""
"TIBIAL BEARING SZ 1 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197893","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","844.52","38.3","","850.52","759.78","1211.25","66","683.55","1752.98","percent of total billed charges",""
"TIBIAL BEARING SZ 1 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197893","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","945.95","42.9","","2548.09","2548.09","2548.09","1 through 10","683.55","1752.98","percent of total billed charges",""
"TIBIAL BEARING SZ 1 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197893","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","945.95","42.9","","956.46","956.46","956.46","1 through 10","683.55","1752.98","percent of total billed charges",""
"TIBIAL BEARING SZ 1 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197893","CDM","C1776","HCPCS","0278","RC","","","","both","","","2205.00","1653.75","WELLPOINT [1015]","HB AMC WELLPOINT","1626.85","73.78","","2344.73","1619.47","2530.35","16","683.55","1752.98","percent of total billed charges",""
"TIBIAL BEARING SZ 1 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197893","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","AETNA [1001]","HB AMC AETNA HMO","1539.09","69.8","","1523.63","988.41","4330.26","39","1152.33","1801.93","percent of total billed charges",""
"TIBIAL BEARING SZ 1 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197893","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","AETNA [1001]","HB AMC AETNA PPO","1772.82","80.4","","1670.25","1670.25","1670.25","1 through 10","1152.33","1801.93","percent of total billed charges",""
"TIBIAL BEARING SZ 1 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197893","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1152.33","52.26","","1113.10","1113.10","1113.10","1 through 10","1152.33","1801.93","percent of total billed charges",""
"TIBIAL BEARING SZ 1 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197893","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2205.00","1653.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1801.93","81.72","","1738.90","1484.65","2716.94","38","1152.33","1801.93","percent of total billed charges",""
"TIBIAL BEARING SZ 7 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197904","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2033.96","52.26","","1113.10","1113.10","1113.10","1 through 10","1206.52","3094.14","percent of total billed charges",""
"TIBIAL BEARING SZ 7 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197904","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3094.14","79.5","","1293.60","1148.53","1603.80","1 through 10","1206.52","3094.14","percent of total billed charges",""
"TIBIAL BEARING SZ 7 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197904","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1420.58","36.5","","1023.42","771.29","2068.67","33","1206.52","3094.14","percent of total billed charges",""
"TIBIAL BEARING SZ 7 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197904","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1490.64","38.3","","850.52","759.78","1211.25","66","1206.52","3094.14","percent of total billed charges",""
"TIBIAL BEARING SZ 7 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197904","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.67","42.9","","2548.09","2548.09","2548.09","1 through 10","1206.52","3094.14","percent of total billed charges",""
"TIBIAL BEARING SZ 7 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197904","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.67","42.9","","956.46","956.46","956.46","1 through 10","1206.52","3094.14","percent of total billed charges",""
"TIBIAL BEARING SZ 7 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197904","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","WELLPOINT [1015]","HB AMC WELLPOINT","2871.52","73.78","","2344.73","1619.47","2530.35","16","1206.52","3094.14","percent of total billed charges",""
"TIBIAL BEARING SZ 7 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197904","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","AETNA [1001]","HB AMC AETNA HMO","2716.62","69.8","","1523.63","988.41","4330.26","39","2033.96","3180.54","percent of total billed charges",""
"TIBIAL BEARING SZ 7 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197904","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","AETNA [1001]","HB AMC AETNA PPO","3129.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2033.96","3180.54","percent of total billed charges",""
"TIBIAL BEARING SZ 7 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197904","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2033.96","52.26","","1113.10","1113.10","1113.10","1 through 10","2033.96","3180.54","percent of total billed charges",""
"TIBIAL BEARING SZ 7 BASE ATTUNE CRUCIATE SACRIFICING FIXED CEMENTED","SUP-ITM-10197904","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3180.54","81.72","","1738.90","1484.65","2716.94","38","2033.96","3180.54","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.60","331.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","351.07","79.5","","800.18","480.96","1887.97","195","136.9","351.07","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.60","331.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","235.37","53.3","","813.12","216.42","1444.50","81","136.9","351.07","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.60","331.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","136.90","31","","432.60","432.60","432.60","1 through 10","136.9","351.07","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.60","331.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","161.18","36.5","","148.37","54.89","631.39","94","136.9","351.07","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.60","331.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","169.13","38.3","","279.30","91.72","1116.77","266","136.9","351.07","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.60","331.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.45","42.9","","731.00","63.70","731.00","1 through 10","136.9","351.07","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.60","331.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.45","42.9","","384.74","384.74","384.74","1 through 10","136.9","351.07","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","both","","","441.60","331.20","WELLPOINT [1015]","HB AMC WELLPOINT","325.81","73.78","","286.63","119.22","1107.45","105","136.9","351.07","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","441.60","331.20","AETNA [1001]","HB AMC AETNA HMO","308.24","69.8","","675.31","184.75","1721.50","286","230.78","360.88","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","441.60","331.20","AETNA [1001]","HB AMC AETNA PPO","355.05","80.4","","1261.44","103.12","1514.10","21","230.78","360.88","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","441.60","331.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","355.05","80.4","","1365.00","1365.00","1365.00","1 through 10","230.78","360.88","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","441.60","331.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","360.88","81.72","","5157.68","5157.68","5157.68","1 through 10","230.78","360.88","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","441.60","331.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","360.88","81.72","","431.26","71.26","1459.57","88","230.78","360.88","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.78","2995.33","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3175.06","79.5","","800.18","480.96","1887.97","195","1238.07","3175.06","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.78","2995.33","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2128.68","53.3","","813.12","216.42","1444.50","81","1238.07","3175.06","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.78","2995.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1238.07","31","","432.60","432.60","432.60","1 through 10","1238.07","3175.06","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.78","2995.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1457.73","36.5","","148.37","54.89","631.39","94","1238.07","3175.06","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.78","2995.33","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1529.62","38.3","","279.30","91.72","1116.77","266","1238.07","3175.06","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.78","2995.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1713.33","42.9","","731.00","63.70","731.00","1 through 10","1238.07","3175.06","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.78","2995.33","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1713.33","42.9","","384.74","384.74","384.74","1 through 10","1238.07","3175.06","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","both","","","3993.78","2995.33","WELLPOINT [1015]","HB AMC WELLPOINT","2946.61","73.78","","286.63","119.22","1107.45","105","1238.07","3175.06","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3993.78","2995.33","AETNA [1001]","HB AMC AETNA HMO","2787.66","69.8","","675.31","184.75","1721.50","286","2087.15","3263.72","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3993.78","2995.33","AETNA [1001]","HB AMC AETNA PPO","3211.00","80.4","","1261.44","103.12","1514.10","21","2087.15","3263.72","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3993.78","2995.33","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3211.00","80.4","","1365.00","1365.00","1365.00","1 through 10","2087.15","3263.72","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3993.78","2995.33","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3263.72","81.72","","5157.68","5157.68","5157.68","1 through 10","2087.15","3263.72","percent of total billed charges",""
"TIBIAL HEAD PLATE 149MM 7 HOLE SS BUTTRESS LATERAL DCP LEFT","SUP-ITM-10001525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3993.78","2995.33","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3263.72","81.72","","431.26","71.26","1459.57","88","2087.15","3263.72","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","4079.25","3059.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3243.00","79.5","","800.18","480.96","1887.97","195","1264.57","3243","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","4079.25","3059.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2174.24","53.3","","813.12","216.42","1444.50","81","1264.57","3243","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","4079.25","3059.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1264.57","31","","432.60","432.60","432.60","1 through 10","1264.57","3243","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","4079.25","3059.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1488.93","36.5","","148.37","54.89","631.39","94","1264.57","3243","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","4079.25","3059.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1562.35","38.3","","279.30","91.72","1116.77","266","1264.57","3243","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","4079.25","3059.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1750.00","42.9","","731.00","63.70","731.00","1 through 10","1264.57","3243","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","4079.25","3059.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1750.00","42.9","","384.74","384.74","384.74","1 through 10","1264.57","3243","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","both","","","4079.25","3059.44","WELLPOINT [1015]","HB AMC WELLPOINT","3009.67","73.78","","286.63","119.22","1107.45","105","1264.57","3243","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4079.25","3059.44","AETNA [1001]","HB AMC AETNA HMO","2847.32","69.8","","675.31","184.75","1721.50","286","2131.82","3333.56","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4079.25","3059.44","AETNA [1001]","HB AMC AETNA PPO","3279.72","80.4","","1261.44","103.12","1514.10","21","2131.82","3333.56","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4079.25","3059.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3279.72","80.4","","1365.00","1365.00","1365.00","1 through 10","2131.82","3333.56","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4079.25","3059.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3333.56","81.72","","5157.68","5157.68","5157.68","1 through 10","2131.82","3333.56","percent of total billed charges",""
"TIBIAL HEAD PLATE 181MM 9 HOLE SS BUTTRESS LATERAL DCP RIGHT","SUP-ITM-10001597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4079.25","3059.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3333.56","81.72","","431.26","71.26","1459.57","88","2131.82","3333.56","percent of total billed charges",""
"TIBIAL HINGE 16MM MED S-ROM ROTATING PLATEAU","SUP-ITM-10018275","CDM","C1776","HCPCS","0278","RC","","","","both","","","5147.50","3860.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2690.08","52.26","","1113.10","1113.10","1113.10","1 through 10","1595.73","4092.26","percent of total billed charges",""
"TIBIAL HINGE 16MM MED S-ROM ROTATING PLATEAU","SUP-ITM-10018275","CDM","C1776","HCPCS","0278","RC","","","","both","","","5147.50","3860.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4092.26","79.5","","1293.60","1148.53","1603.80","1 through 10","1595.73","4092.26","percent of total billed charges",""
"TIBIAL HINGE 16MM MED S-ROM ROTATING PLATEAU","SUP-ITM-10018275","CDM","C1776","HCPCS","0278","RC","","","","both","","","5147.50","3860.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1878.84","36.5","","1023.42","771.29","2068.67","33","1595.73","4092.26","percent of total billed charges",""
"TIBIAL HINGE 16MM MED S-ROM ROTATING PLATEAU","SUP-ITM-10018275","CDM","C1776","HCPCS","0278","RC","","","","both","","","5147.50","3860.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1971.49","38.3","","850.52","759.78","1211.25","66","1595.73","4092.26","percent of total billed charges",""
"TIBIAL HINGE 16MM MED S-ROM ROTATING PLATEAU","SUP-ITM-10018275","CDM","C1776","HCPCS","0278","RC","","","","both","","","5147.50","3860.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2208.28","42.9","","2548.09","2548.09","2548.09","1 through 10","1595.73","4092.26","percent of total billed charges",""
"TIBIAL HINGE 16MM MED S-ROM ROTATING PLATEAU","SUP-ITM-10018275","CDM","C1776","HCPCS","0278","RC","","","","both","","","5147.50","3860.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2208.28","42.9","","956.46","956.46","956.46","1 through 10","1595.73","4092.26","percent of total billed charges",""
"TIBIAL HINGE 16MM MED S-ROM ROTATING PLATEAU","SUP-ITM-10018275","CDM","C1776","HCPCS","0278","RC","","","","both","","","5147.50","3860.62","WELLPOINT [1015]","HB AMC WELLPOINT","3797.83","73.78","","2344.73","1619.47","2530.35","16","1595.73","4092.26","percent of total billed charges",""
"TIBIAL HINGE 16MM MED S-ROM ROTATING PLATEAU","SUP-ITM-10018275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5147.50","3860.62","AETNA [1001]","HB AMC AETNA HMO","3592.96","69.8","","1523.63","988.41","4330.26","39","2690.08","4206.54","percent of total billed charges",""
"TIBIAL HINGE 16MM MED S-ROM ROTATING PLATEAU","SUP-ITM-10018275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5147.50","3860.62","AETNA [1001]","HB AMC AETNA PPO","4138.59","80.4","","1670.25","1670.25","1670.25","1 through 10","2690.08","4206.54","percent of total billed charges",""
"TIBIAL HINGE 16MM MED S-ROM ROTATING PLATEAU","SUP-ITM-10018275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5147.50","3860.62","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2690.08","52.26","","1113.10","1113.10","1113.10","1 through 10","2690.08","4206.54","percent of total billed charges",""
"TIBIAL HINGE 16MM MED S-ROM ROTATING PLATEAU","SUP-ITM-10018275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5147.50","3860.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4206.54","81.72","","1738.90","1484.65","2716.94","38","2690.08","4206.54","percent of total billed charges",""
"TIBIAL INSERT 10MM SZ 7 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR","SUP-ITM-10317849","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","651","1669.5","percent of total billed charges",""
"TIBIAL INSERT 10MM SZ 7 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR","SUP-ITM-10317849","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","1293.60","1148.53","1603.80","1 through 10","651","1669.5","percent of total billed charges",""
"TIBIAL INSERT 10MM SZ 7 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR","SUP-ITM-10317849","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","1023.42","771.29","2068.67","33","651","1669.5","percent of total billed charges",""
"TIBIAL INSERT 10MM SZ 7 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR","SUP-ITM-10317849","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","850.52","759.78","1211.25","66","651","1669.5","percent of total billed charges",""
"TIBIAL INSERT 10MM SZ 7 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR","SUP-ITM-10317849","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","2548.09","2548.09","2548.09","1 through 10","651","1669.5","percent of total billed charges",""
"TIBIAL INSERT 10MM SZ 7 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR","SUP-ITM-10317849","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","956.46","956.46","956.46","1 through 10","651","1669.5","percent of total billed charges",""
"TIBIAL INSERT 10MM SZ 7 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR","SUP-ITM-10317849","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","2344.73","1619.47","2530.35","16","651","1669.5","percent of total billed charges",""
"TIBIAL INSERT 10MM SZ 7 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR","SUP-ITM-10317849","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","1523.63","988.41","4330.26","39","1097.46","1716.12","percent of total billed charges",""
"TIBIAL INSERT 10MM SZ 7 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR","SUP-ITM-10317849","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA PPO","1688.40","80.4","","1670.25","1670.25","1670.25","1 through 10","1097.46","1716.12","percent of total billed charges",""
"TIBIAL INSERT 10MM SZ 7 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR","SUP-ITM-10317849","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","1113.10","1113.10","1113.10","1 through 10","1097.46","1716.12","percent of total billed charges",""
"TIBIAL INSERT 10MM SZ 7 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR","SUP-ITM-10317849","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","1738.90","1484.65","2716.94","38","1097.46","1716.12","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2185.51","52.26","","1113.10","1113.10","1113.10","1 through 10","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3324.69","79.5","","1293.60","1148.53","1603.80","1 through 10","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1526.43","36.5","","1023.42","771.29","2068.67","33","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1601.71","38.3","","850.52","759.78","1211.25","66","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1794.08","42.9","","2548.09","2548.09","2548.09","1 through 10","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1794.08","42.9","","956.46","956.46","956.46","1 through 10","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","WELLPOINT [1015]","HB AMC WELLPOINT","3085.48","73.78","","2344.73","1619.47","2530.35","16","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4182.00","3136.50","AETNA [1001]","HB AMC AETNA HMO","2919.04","69.8","","1523.63","988.41","4330.26","39","2185.51","3417.53","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4182.00","3136.50","AETNA [1001]","HB AMC AETNA PPO","3362.33","80.4","","1670.25","1670.25","1670.25","1 through 10","2185.51","3417.53","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4182.00","3136.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2185.51","52.26","","1113.10","1113.10","1113.10","1 through 10","2185.51","3417.53","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4182.00","3136.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3417.53","81.72","","1738.90","1484.65","2716.94","38","2185.51","3417.53","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2185.51","52.26","","1113.10","1113.10","1113.10","1 through 10","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3324.69","79.5","","1293.60","1148.53","1603.80","1 through 10","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1526.43","36.5","","1023.42","771.29","2068.67","33","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1601.71","38.3","","850.52","759.78","1211.25","66","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1794.08","42.9","","2548.09","2548.09","2548.09","1 through 10","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1794.08","42.9","","956.46","956.46","956.46","1 through 10","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","WELLPOINT [1015]","HB AMC WELLPOINT","3085.48","73.78","","2344.73","1619.47","2530.35","16","1296.42","3324.69","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4182.00","3136.50","AETNA [1001]","HB AMC AETNA HMO","2919.04","69.8","","1523.63","988.41","4330.26","39","2185.51","3417.53","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4182.00","3136.50","AETNA [1001]","HB AMC AETNA PPO","3362.33","80.4","","1670.25","1670.25","1670.25","1 through 10","2185.51","3417.53","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4182.00","3136.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2185.51","52.26","","1113.10","1113.10","1113.10","1 through 10","2185.51","3417.53","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4182.00","3136.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3417.53","81.72","","1738.90","1484.65","2716.94","38","2185.51","3417.53","percent of total billed charges",""
"TIBIAL INSERT 16MM LG DURACON DURATION ALL POLY LIPPED","SUP-ITM-10009799","CDM","C1776","HCPCS","0278","RC","","","","both","","","2647.75","1985.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1383.71","52.26","","1113.10","1113.10","1113.10","1 through 10","820.8","2104.96","percent of total billed charges",""
"TIBIAL INSERT 16MM LG DURACON DURATION ALL POLY LIPPED","SUP-ITM-10009799","CDM","C1776","HCPCS","0278","RC","","","","both","","","2647.75","1985.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2104.96","79.5","","1293.60","1148.53","1603.80","1 through 10","820.8","2104.96","percent of total billed charges",""
"TIBIAL INSERT 16MM LG DURACON DURATION ALL POLY LIPPED","SUP-ITM-10009799","CDM","C1776","HCPCS","0278","RC","","","","both","","","2647.75","1985.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","966.43","36.5","","1023.42","771.29","2068.67","33","820.8","2104.96","percent of total billed charges",""
"TIBIAL INSERT 16MM LG DURACON DURATION ALL POLY LIPPED","SUP-ITM-10009799","CDM","C1776","HCPCS","0278","RC","","","","both","","","2647.75","1985.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1014.09","38.3","","850.52","759.78","1211.25","66","820.8","2104.96","percent of total billed charges",""
"TIBIAL INSERT 16MM LG DURACON DURATION ALL POLY LIPPED","SUP-ITM-10009799","CDM","C1776","HCPCS","0278","RC","","","","both","","","2647.75","1985.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1135.88","42.9","","2548.09","2548.09","2548.09","1 through 10","820.8","2104.96","percent of total billed charges",""
"TIBIAL INSERT 16MM LG DURACON DURATION ALL POLY LIPPED","SUP-ITM-10009799","CDM","C1776","HCPCS","0278","RC","","","","both","","","2647.75","1985.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1135.88","42.9","","956.46","956.46","956.46","1 through 10","820.8","2104.96","percent of total billed charges",""
"TIBIAL INSERT 16MM LG DURACON DURATION ALL POLY LIPPED","SUP-ITM-10009799","CDM","C1776","HCPCS","0278","RC","","","","both","","","2647.75","1985.81","WELLPOINT [1015]","HB AMC WELLPOINT","1953.51","73.78","","2344.73","1619.47","2530.35","16","820.8","2104.96","percent of total billed charges",""
"TIBIAL INSERT 16MM LG DURACON DURATION ALL POLY LIPPED","SUP-ITM-10009799","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2647.75","1985.81","AETNA [1001]","HB AMC AETNA HMO","1848.13","69.8","","1523.63","988.41","4330.26","39","1383.71","2163.74","percent of total billed charges",""
"TIBIAL INSERT 16MM LG DURACON DURATION ALL POLY LIPPED","SUP-ITM-10009799","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2647.75","1985.81","AETNA [1001]","HB AMC AETNA PPO","2128.79","80.4","","1670.25","1670.25","1670.25","1 through 10","1383.71","2163.74","percent of total billed charges",""
"TIBIAL INSERT 16MM LG DURACON DURATION ALL POLY LIPPED","SUP-ITM-10009799","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2647.75","1985.81","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1383.71","52.26","","1113.10","1113.10","1113.10","1 through 10","1383.71","2163.74","percent of total billed charges",""
"TIBIAL INSERT 16MM LG DURACON DURATION ALL POLY LIPPED","SUP-ITM-10009799","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2647.75","1985.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2163.74","81.72","","1738.90","1484.65","2716.94","38","1383.71","2163.74","percent of total billed charges",""
"TIBIAL INSERT 17.5MM SZ 4 STABLE SIGMA ROTATING PLATFORM AOX 08","SUP-ITM-10119655","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 17.5MM SZ 4 STABLE SIGMA ROTATING PLATFORM AOX 08","SUP-ITM-10119655","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1324.47","79.5","","1293.60","1148.53","1603.80","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 17.5MM SZ 4 STABLE SIGMA ROTATING PLATFORM AOX 08","SUP-ITM-10119655","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","608.09","36.5","","1023.42","771.29","2068.67","33","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 17.5MM SZ 4 STABLE SIGMA ROTATING PLATFORM AOX 08","SUP-ITM-10119655","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","638.08","38.3","","850.52","759.78","1211.25","66","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 17.5MM SZ 4 STABLE SIGMA ROTATING PLATFORM AOX 08","SUP-ITM-10119655","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","2548.09","2548.09","2548.09","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 17.5MM SZ 4 STABLE SIGMA ROTATING PLATFORM AOX 08","SUP-ITM-10119655","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","956.46","956.46","956.46","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 17.5MM SZ 4 STABLE SIGMA ROTATING PLATFORM AOX 08","SUP-ITM-10119655","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","WELLPOINT [1015]","HB AMC WELLPOINT","1229.17","73.78","","2344.73","1619.47","2530.35","16","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 17.5MM SZ 4 STABLE SIGMA ROTATING PLATFORM AOX 08","SUP-ITM-10119655","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA HMO","1162.87","69.8","","1523.63","988.41","4330.26","39","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 17.5MM SZ 4 STABLE SIGMA ROTATING PLATFORM AOX 08","SUP-ITM-10119655","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA PPO","1339.46","80.4","","1670.25","1670.25","1670.25","1 through 10","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 17.5MM SZ 4 STABLE SIGMA ROTATING PLATFORM AOX 08","SUP-ITM-10119655","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 17.5MM SZ 4 STABLE SIGMA ROTATING PLATFORM AOX 08","SUP-ITM-10119655","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1361.46","81.72","","1738.90","1484.65","2716.94","38","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 6MM SZ 2 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2022.98","52.26","","1113.10","1113.10","1113.10","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 6MM SZ 2 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3077.45","79.5","","1293.60","1148.53","1603.80","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 6MM SZ 2 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1412.92","36.5","","1023.42","771.29","2068.67","33","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 6MM SZ 2 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1482.59","38.3","","850.52","759.78","1211.25","66","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 6MM SZ 2 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.66","42.9","","2548.09","2548.09","2548.09","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 6MM SZ 2 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.66","42.9","","956.46","956.46","956.46","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 6MM SZ 2 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","WELLPOINT [1015]","HB AMC WELLPOINT","2856.02","73.78","","2344.73","1619.47","2530.35","16","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 6MM SZ 2 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","AETNA [1001]","HB AMC AETNA HMO","2701.96","69.8","","1523.63","988.41","4330.26","39","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 6MM SZ 2 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","AETNA [1001]","HB AMC AETNA PPO","3112.28","80.4","","1670.25","1670.25","1670.25","1 through 10","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 6MM SZ 2 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2022.98","52.26","","1113.10","1113.10","1113.10","1 through 10","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 6MM SZ 2 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3163.38","81.72","","1738.90","1484.65","2716.94","38","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1324.47","79.5","","1293.60","1148.53","1603.80","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","608.09","36.5","","1023.42","771.29","2068.67","33","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","638.08","38.3","","850.52","759.78","1211.25","66","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","2548.09","2548.09","2548.09","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","956.46","956.46","956.46","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","WELLPOINT [1015]","HB AMC WELLPOINT","1229.17","73.78","","2344.73","1619.47","2530.35","16","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA HMO","1162.87","69.8","","1523.63","988.41","4330.26","39","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA PPO","1339.46","80.4","","1670.25","1670.25","1670.25","1 through 10","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1361.46","81.72","","1738.90","1484.65","2716.94","38","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1324.47","79.5","","1293.60","1148.53","1603.80","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","608.09","36.5","","1023.42","771.29","2068.67","33","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","638.08","38.3","","850.52","759.78","1211.25","66","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","2548.09","2548.09","2548.09","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","956.46","956.46","956.46","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","WELLPOINT [1015]","HB AMC WELLPOINT","1229.17","73.78","","2344.73","1619.47","2530.35","16","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA HMO","1162.87","69.8","","1523.63","988.41","4330.26","39","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA PPO","1339.46","80.4","","1670.25","1670.25","1670.25","1 through 10","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1361.46","81.72","","1738.90","1484.65","2716.94","38","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2022.98","52.26","","1113.10","1113.10","1113.10","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3077.45","79.5","","1293.60","1148.53","1603.80","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1412.92","36.5","","1023.42","771.29","2068.67","33","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1482.59","38.3","","850.52","759.78","1211.25","66","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.66","42.9","","2548.09","2548.09","2548.09","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.66","42.9","","956.46","956.46","956.46","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","WELLPOINT [1015]","HB AMC WELLPOINT","2856.02","73.78","","2344.73","1619.47","2530.35","16","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","AETNA [1001]","HB AMC AETNA HMO","2701.96","69.8","","1523.63","988.41","4330.26","39","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","AETNA [1001]","HB AMC AETNA PPO","3112.28","80.4","","1670.25","1670.25","1670.25","1 through 10","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2022.98","52.26","","1113.10","1113.10","1113.10","1 through 10","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3163.38","81.72","","1738.90","1484.65","2716.94","38","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1324.47","79.5","","1293.60","1148.53","1603.80","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","608.09","36.5","","1023.42","771.29","2068.67","33","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","638.08","38.3","","850.52","759.78","1211.25","66","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","2548.09","2548.09","2548.09","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.71","42.9","","956.46","956.46","956.46","1 through 10","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1666.00","1249.50","WELLPOINT [1015]","HB AMC WELLPOINT","1229.17","73.78","","2344.73","1619.47","2530.35","16","516.46","1324.47","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA HMO","1162.87","69.8","","1523.63","988.41","4330.26","39","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","AETNA [1001]","HB AMC AETNA PPO","1339.46","80.4","","1670.25","1670.25","1670.25","1 through 10","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","870.65","52.26","","1113.10","1113.10","1113.10","1 through 10","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1666.00","1249.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1361.46","81.72","","1738.90","1484.65","2716.94","38","870.65","1361.46","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 4 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282707","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3077.45","79.5","","800.18","480.96","1887.97","195","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 4 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282707","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2063.24","53.3","","813.12","216.42","1444.50","81","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 4 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282707","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1200.01","31","","432.60","432.60","432.60","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 4 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282707","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1412.92","36.5","","148.37","54.89","631.39","94","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 4 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282707","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1482.59","38.3","","279.30","91.72","1116.77","266","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 4 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282707","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.66","42.9","","731.00","63.70","731.00","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 4 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282707","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.66","42.9","","384.74","384.74","384.74","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 4 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282707","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","WELLPOINT [1015]","HB AMC WELLPOINT","2856.02","73.78","","286.63","119.22","1107.45","105","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 4 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","AETNA [1001]","HB AMC AETNA HMO","2701.96","69.8","","675.31","184.75","1721.50","286","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 4 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","AETNA [1001]","HB AMC AETNA PPO","3112.28","80.4","","1261.44","103.12","1514.10","21","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 4 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3112.28","80.4","","1365.00","1365.00","1365.00","1 through 10","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 4 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3163.38","81.72","","5157.68","5157.68","5157.68","1 through 10","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 4 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3163.38","81.72","","431.26","71.26","1459.57","88","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2022.98","52.26","","1113.10","1113.10","1113.10","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3077.45","79.5","","1293.60","1148.53","1603.80","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1412.92","36.5","","1023.42","771.29","2068.67","33","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1482.59","38.3","","850.52","759.78","1211.25","66","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.66","42.9","","2548.09","2548.09","2548.09","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.66","42.9","","956.46","956.46","956.46","1 through 10","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.00","2903.25","WELLPOINT [1015]","HB AMC WELLPOINT","2856.02","73.78","","2344.73","1619.47","2530.35","16","1200.01","3077.45","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","AETNA [1001]","HB AMC AETNA HMO","2701.96","69.8","","1523.63","988.41","4330.26","39","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","AETNA [1001]","HB AMC AETNA PPO","3112.28","80.4","","1670.25","1670.25","1670.25","1 through 10","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2022.98","52.26","","1113.10","1113.10","1113.10","1 through 10","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.00","2903.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3163.38","81.72","","1738.90","1484.65","2716.94","38","2022.98","3163.38","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","397.25","297.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","207.60","52.26","","1113.10","1113.10","1113.10","1 through 10","123.15","315.81","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","397.25","297.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","315.81","79.5","","1293.60","1148.53","1603.80","1 through 10","123.15","315.81","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","397.25","297.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","145.00","36.5","","1023.42","771.29","2068.67","33","123.15","315.81","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","397.25","297.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","152.15","38.3","","850.52","759.78","1211.25","66","123.15","315.81","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","397.25","297.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.42","42.9","","2548.09","2548.09","2548.09","1 through 10","123.15","315.81","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","397.25","297.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.42","42.9","","956.46","956.46","956.46","1 through 10","123.15","315.81","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","397.25","297.94","WELLPOINT [1015]","HB AMC WELLPOINT","293.09","73.78","","2344.73","1619.47","2530.35","16","123.15","315.81","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","397.25","297.94","AETNA [1001]","HB AMC AETNA HMO","277.28","69.8","","1523.63","988.41","4330.26","39","207.6","324.63","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","397.25","297.94","AETNA [1001]","HB AMC AETNA PPO","319.39","80.4","","1670.25","1670.25","1670.25","1 through 10","207.6","324.63","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","397.25","297.94","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","207.60","52.26","","1113.10","1113.10","1113.10","1 through 10","207.6","324.63","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","397.25","297.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","324.63","81.72","","1738.90","1484.65","2716.94","38","207.6","324.63","percent of total billed charges",""
"TIBIAL INSERT SM 13MM DURACON DURATION POSTERIOR LIPPED","SUP-ITM-10016782","CDM","C1776","HCPCS","0278","RC","","","","both","","","3078.25","2308.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1608.69","52.26","","1113.10","1113.10","1113.10","1 through 10","954.26","2447.21","percent of total billed charges",""
"TIBIAL INSERT SM 13MM DURACON DURATION POSTERIOR LIPPED","SUP-ITM-10016782","CDM","C1776","HCPCS","0278","RC","","","","both","","","3078.25","2308.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2447.21","79.5","","1293.60","1148.53","1603.80","1 through 10","954.26","2447.21","percent of total billed charges",""
"TIBIAL INSERT SM 13MM DURACON DURATION POSTERIOR LIPPED","SUP-ITM-10016782","CDM","C1776","HCPCS","0278","RC","","","","both","","","3078.25","2308.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1123.56","36.5","","1023.42","771.29","2068.67","33","954.26","2447.21","percent of total billed charges",""
"TIBIAL INSERT SM 13MM DURACON DURATION POSTERIOR LIPPED","SUP-ITM-10016782","CDM","C1776","HCPCS","0278","RC","","","","both","","","3078.25","2308.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1178.97","38.3","","850.52","759.78","1211.25","66","954.26","2447.21","percent of total billed charges",""
"TIBIAL INSERT SM 13MM DURACON DURATION POSTERIOR LIPPED","SUP-ITM-10016782","CDM","C1776","HCPCS","0278","RC","","","","both","","","3078.25","2308.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1320.57","42.9","","2548.09","2548.09","2548.09","1 through 10","954.26","2447.21","percent of total billed charges",""
"TIBIAL INSERT SM 13MM DURACON DURATION POSTERIOR LIPPED","SUP-ITM-10016782","CDM","C1776","HCPCS","0278","RC","","","","both","","","3078.25","2308.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1320.57","42.9","","956.46","956.46","956.46","1 through 10","954.26","2447.21","percent of total billed charges",""
"TIBIAL INSERT SM 13MM DURACON DURATION POSTERIOR LIPPED","SUP-ITM-10016782","CDM","C1776","HCPCS","0278","RC","","","","both","","","3078.25","2308.69","WELLPOINT [1015]","HB AMC WELLPOINT","2271.13","73.78","","2344.73","1619.47","2530.35","16","954.26","2447.21","percent of total billed charges",""
"TIBIAL INSERT SM 13MM DURACON DURATION POSTERIOR LIPPED","SUP-ITM-10016782","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3078.25","2308.69","AETNA [1001]","HB AMC AETNA HMO","2148.62","69.8","","1523.63","988.41","4330.26","39","1608.69","2515.55","percent of total billed charges",""
"TIBIAL INSERT SM 13MM DURACON DURATION POSTERIOR LIPPED","SUP-ITM-10016782","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3078.25","2308.69","AETNA [1001]","HB AMC AETNA PPO","2474.91","80.4","","1670.25","1670.25","1670.25","1 through 10","1608.69","2515.55","percent of total billed charges",""
"TIBIAL INSERT SM 13MM DURACON DURATION POSTERIOR LIPPED","SUP-ITM-10016782","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3078.25","2308.69","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1608.69","52.26","","1113.10","1113.10","1113.10","1 through 10","1608.69","2515.55","percent of total billed charges",""
"TIBIAL INSERT SM 13MM DURACON DURATION POSTERIOR LIPPED","SUP-ITM-10016782","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3078.25","2308.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2515.55","81.72","","1738.90","1484.65","2716.94","38","1608.69","2515.55","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","455.00","341.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","237.78","52.26","","1113.10","1113.10","1113.10","1 through 10","141.05","361.73","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","455.00","341.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","361.73","79.5","","1293.60","1148.53","1603.80","1 through 10","141.05","361.73","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","166.08","36.5","","1023.42","771.29","2068.67","33","141.05","361.73","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","455.00","341.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","174.27","38.3","","850.52","759.78","1211.25","66","141.05","361.73","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.20","42.9","","2548.09","2548.09","2548.09","1 through 10","141.05","361.73","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","455.00","341.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.20","42.9","","956.46","956.46","956.46","1 through 10","141.05","361.73","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","455.00","341.25","WELLPOINT [1015]","HB AMC WELLPOINT","335.70","73.78","","2344.73","1619.47","2530.35","16","141.05","361.73","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA HMO","317.59","69.8","","1523.63","988.41","4330.26","39","237.78","371.83","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","AETNA [1001]","HB AMC AETNA PPO","365.82","80.4","","1670.25","1670.25","1670.25","1 through 10","237.78","371.83","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","237.78","52.26","","1113.10","1113.10","1113.10","1 through 10","237.78","371.83","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","455.00","341.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","371.83","81.72","","1738.90","1484.65","2716.94","38","237.78","371.83","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.06","3012.79","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3193.56","79.5","","800.18","480.96","1887.97","195","1245.29","3193.56","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.06","3012.79","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2141.09","53.3","","813.12","216.42","1444.50","81","1245.29","3193.56","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.06","3012.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1245.29","31","","432.60","432.60","432.60","1 through 10","1245.29","3193.56","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.06","3012.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1466.23","36.5","","148.37","54.89","631.39","94","1245.29","3193.56","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.06","3012.79","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1538.53","38.3","","279.30","91.72","1116.77","266","1245.29","3193.56","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.06","3012.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1723.32","42.9","","731.00","63.70","731.00","1 through 10","1245.29","3193.56","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.06","3012.79","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1723.32","42.9","","384.74","384.74","384.74","1 through 10","1245.29","3193.56","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","both","","","4017.06","3012.79","WELLPOINT [1015]","HB AMC WELLPOINT","2963.79","73.78","","286.63","119.22","1107.45","105","1245.29","3193.56","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4017.06","3012.79","AETNA [1001]","HB AMC AETNA HMO","2803.91","69.8","","675.31","184.75","1721.50","286","2099.32","3282.74","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4017.06","3012.79","AETNA [1001]","HB AMC AETNA PPO","3229.72","80.4","","1261.44","103.12","1514.10","21","2099.32","3282.74","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4017.06","3012.79","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3229.72","80.4","","1365.00","1365.00","1365.00","1 through 10","2099.32","3282.74","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4017.06","3012.79","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3282.74","81.72","","5157.68","5157.68","5157.68","1 through 10","2099.32","3282.74","percent of total billed charges",""
"TIBIAL PLATE 133X3.5MM 8 HOLE LCP STAINLESS IMAL RIGHT","SUP-ITM-10013144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4017.06","3012.79","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3282.74","81.72","","431.26","71.26","1459.57","88","2099.32","3282.74","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040356","CDM","C1713","HCPCS","0278","RC","","","","both","","","4496.42","3372.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3574.65","79.5","","800.18","480.96","1887.97","195","1393.89","3574.65","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040356","CDM","C1713","HCPCS","0278","RC","","","","both","","","4496.42","3372.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2396.59","53.3","","813.12","216.42","1444.50","81","1393.89","3574.65","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040356","CDM","C1713","HCPCS","0278","RC","","","","both","","","4496.42","3372.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1393.89","31","","432.60","432.60","432.60","1 through 10","1393.89","3574.65","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040356","CDM","C1713","HCPCS","0278","RC","","","","both","","","4496.42","3372.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1641.19","36.5","","148.37","54.89","631.39","94","1393.89","3574.65","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040356","CDM","C1713","HCPCS","0278","RC","","","","both","","","4496.42","3372.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1722.13","38.3","","279.30","91.72","1116.77","266","1393.89","3574.65","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040356","CDM","C1713","HCPCS","0278","RC","","","","both","","","4496.42","3372.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1928.96","42.9","","731.00","63.70","731.00","1 through 10","1393.89","3574.65","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040356","CDM","C1713","HCPCS","0278","RC","","","","both","","","4496.42","3372.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1928.96","42.9","","384.74","384.74","384.74","1 through 10","1393.89","3574.65","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040356","CDM","C1713","HCPCS","0278","RC","","","","both","","","4496.42","3372.31","WELLPOINT [1015]","HB AMC WELLPOINT","3317.46","73.78","","286.63","119.22","1107.45","105","1393.89","3574.65","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4496.42","3372.31","AETNA [1001]","HB AMC AETNA HMO","3138.50","69.8","","675.31","184.75","1721.50","286","2349.83","3674.47","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4496.42","3372.31","AETNA [1001]","HB AMC AETNA PPO","3615.12","80.4","","1261.44","103.12","1514.10","21","2349.83","3674.47","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4496.42","3372.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3615.12","80.4","","1365.00","1365.00","1365.00","1 through 10","2349.83","3674.47","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4496.42","3372.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3674.47","81.72","","5157.68","5157.68","5157.68","1 through 10","2349.83","3674.47","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4496.42","3372.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3674.47","81.72","","431.26","71.26","1459.57","88","2349.83","3674.47","percent of total billed charges",""
"TIBIAL PLATE 180MM 7 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040360","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.62","3171.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3361.75","79.5","","800.18","480.96","1887.97","195","1310.87","3361.75","percent of total billed charges",""
"TIBIAL PLATE 180MM 7 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040360","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.62","3171.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2253.85","53.3","","813.12","216.42","1444.50","81","1310.87","3361.75","percent of total billed charges",""
"TIBIAL PLATE 180MM 7 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040360","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.62","3171.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1310.87","31","","432.60","432.60","432.60","1 through 10","1310.87","3361.75","percent of total billed charges",""
"TIBIAL PLATE 180MM 7 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040360","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.62","3171.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1543.45","36.5","","148.37","54.89","631.39","94","1310.87","3361.75","percent of total billed charges",""
"TIBIAL PLATE 180MM 7 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040360","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.62","3171.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1619.56","38.3","","279.30","91.72","1116.77","266","1310.87","3361.75","percent of total billed charges",""
"TIBIAL PLATE 180MM 7 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040360","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.62","3171.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1814.08","42.9","","731.00","63.70","731.00","1 through 10","1310.87","3361.75","percent of total billed charges",""
"TIBIAL PLATE 180MM 7 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040360","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.62","3171.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1814.08","42.9","","384.74","384.74","384.74","1 through 10","1310.87","3361.75","percent of total billed charges",""
"TIBIAL PLATE 180MM 7 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040360","CDM","C1713","HCPCS","0278","RC","","","","both","","","4228.62","3171.46","WELLPOINT [1015]","HB AMC WELLPOINT","3119.88","73.78","","286.63","119.22","1107.45","105","1310.87","3361.75","percent of total billed charges",""
"TIBIAL PLATE 180MM 7 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.62","3171.46","AETNA [1001]","HB AMC AETNA HMO","2951.58","69.8","","675.31","184.75","1721.50","286","2209.88","3455.63","percent of total billed charges",""
"TIBIAL PLATE 180MM 7 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.62","3171.46","AETNA [1001]","HB AMC AETNA PPO","3399.81","80.4","","1261.44","103.12","1514.10","21","2209.88","3455.63","percent of total billed charges",""
"TIBIAL PLATE 180MM 7 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.62","3171.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3399.81","80.4","","1365.00","1365.00","1365.00","1 through 10","2209.88","3455.63","percent of total billed charges",""
"TIBIAL PLATE 180MM 7 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.62","3171.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3455.63","81.72","","5157.68","5157.68","5157.68","1 through 10","2209.88","3455.63","percent of total billed charges",""
"TIBIAL PLATE 180MM 7 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4228.62","3171.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3455.63","81.72","","431.26","71.26","1459.57","88","2209.88","3455.63","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.70","3608.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3825.30","79.5","","800.18","480.96","1887.97","195","1491.63","3825.3","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.70","3608.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2564.64","53.3","","813.12","216.42","1444.50","81","1491.63","3825.3","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.70","3608.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1491.63","31","","432.60","432.60","432.60","1 through 10","1491.63","3825.3","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.70","3608.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1756.27","36.5","","148.37","54.89","631.39","94","1491.63","3825.3","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.70","3608.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1842.88","38.3","","279.30","91.72","1116.77","266","1491.63","3825.3","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.70","3608.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2064.22","42.9","","731.00","63.70","731.00","1 through 10","1491.63","3825.3","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.70","3608.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2064.22","42.9","","384.74","384.74","384.74","1 through 10","1491.63","3825.3","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.70","3608.77","WELLPOINT [1015]","HB AMC WELLPOINT","3550.07","73.78","","286.63","119.22","1107.45","105","1491.63","3825.3","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.70","3608.77","AETNA [1001]","HB AMC AETNA HMO","3358.57","69.8","","675.31","184.75","1721.50","286","2514.59","3932.12","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.70","3608.77","AETNA [1001]","HB AMC AETNA PPO","3868.61","80.4","","1261.44","103.12","1514.10","21","2514.59","3932.12","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.70","3608.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3868.61","80.4","","1365.00","1365.00","1365.00","1 through 10","2514.59","3932.12","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.70","3608.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3932.12","81.72","","5157.68","5157.68","5157.68","1 through 10","2514.59","3932.12","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.70","3608.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3932.12","81.72","","431.26","71.26","1459.57","88","2514.59","3932.12","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA LEFT","SUP-ITM-10124998","CDM","C1813","HCPCS","0278","RC","","","","both","","","4908.45","3681.34","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1879.94","38.3","","12613.42","12613.42","12613.42","1 through 10","1521.62","3902.22","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA LEFT","SUP-ITM-10124998","CDM","C1813","HCPCS","0278","RC","","","","outpatient","","","4908.45","3681.34","AETNA [1001]","HB AMC AETNA HMO","3426.10","69.8","","34275.85","34275.85","50471.26","19","2565.16","4011.19","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","both","","","4536.93","3402.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3606.86","79.5","","800.18","480.96","1887.97","195","1406.45","3606.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","both","","","4536.93","3402.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2418.18","53.3","","813.12","216.42","1444.50","81","1406.45","3606.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","both","","","4536.93","3402.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1406.45","31","","432.60","432.60","432.60","1 through 10","1406.45","3606.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","both","","","4536.93","3402.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1655.98","36.5","","148.37","54.89","631.39","94","1406.45","3606.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","both","","","4536.93","3402.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1737.64","38.3","","279.30","91.72","1116.77","266","1406.45","3606.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","both","","","4536.93","3402.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1946.34","42.9","","731.00","63.70","731.00","1 through 10","1406.45","3606.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","both","","","4536.93","3402.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1946.34","42.9","","384.74","384.74","384.74","1 through 10","1406.45","3606.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","both","","","4536.93","3402.70","WELLPOINT [1015]","HB AMC WELLPOINT","3347.35","73.78","","286.63","119.22","1107.45","105","1406.45","3606.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4536.93","3402.70","AETNA [1001]","HB AMC AETNA HMO","3166.78","69.8","","675.31","184.75","1721.50","286","2371","3707.58","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4536.93","3402.70","AETNA [1001]","HB AMC AETNA PPO","3647.69","80.4","","1261.44","103.12","1514.10","21","2371","3707.58","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4536.93","3402.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3647.69","80.4","","1365.00","1365.00","1365.00","1 through 10","2371","3707.58","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4536.93","3402.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3707.58","81.72","","5157.68","5157.68","5157.68","1 through 10","2371","3707.58","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4536.93","3402.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3707.58","81.72","","431.26","71.26","1459.57","88","2371","3707.58","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","both","","","4840.08","3630.06","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3847.86","79.5","","800.18","480.96","1887.97","195","1500.42","3847.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","both","","","4840.08","3630.06","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2579.76","53.3","","813.12","216.42","1444.50","81","1500.42","3847.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","both","","","4840.08","3630.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1500.42","31","","432.60","432.60","432.60","1 through 10","1500.42","3847.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","both","","","4840.08","3630.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1766.63","36.5","","148.37","54.89","631.39","94","1500.42","3847.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","both","","","4840.08","3630.06","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1853.75","38.3","","279.30","91.72","1116.77","266","1500.42","3847.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","both","","","4840.08","3630.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2076.39","42.9","","731.00","63.70","731.00","1 through 10","1500.42","3847.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","both","","","4840.08","3630.06","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2076.39","42.9","","384.74","384.74","384.74","1 through 10","1500.42","3847.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","both","","","4840.08","3630.06","WELLPOINT [1015]","HB AMC WELLPOINT","3571.01","73.78","","286.63","119.22","1107.45","105","1500.42","3847.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4840.08","3630.06","AETNA [1001]","HB AMC AETNA HMO","3378.38","69.8","","675.31","184.75","1721.50","286","2529.43","3955.31","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4840.08","3630.06","AETNA [1001]","HB AMC AETNA PPO","3891.42","80.4","","1261.44","103.12","1514.10","21","2529.43","3955.31","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4840.08","3630.06","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3891.42","80.4","","1365.00","1365.00","1365.00","1 through 10","2529.43","3955.31","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4840.08","3630.06","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3955.31","81.72","","5157.68","5157.68","5157.68","1 through 10","2529.43","3955.31","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4840.08","3630.06","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3955.31","81.72","","431.26","71.26","1459.57","88","2529.43","3955.31","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4501.03","3375.77","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3578.32","79.5","","800.18","480.96","1887.97","195","1395.32","3578.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4501.03","3375.77","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2399.05","53.3","","813.12","216.42","1444.50","81","1395.32","3578.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4501.03","3375.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1395.32","31","","432.60","432.60","432.60","1 through 10","1395.32","3578.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4501.03","3375.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.88","36.5","","148.37","54.89","631.39","94","1395.32","3578.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4501.03","3375.77","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.89","38.3","","279.30","91.72","1116.77","266","1395.32","3578.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4501.03","3375.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.94","42.9","","731.00","63.70","731.00","1 through 10","1395.32","3578.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4501.03","3375.77","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.94","42.9","","384.74","384.74","384.74","1 through 10","1395.32","3578.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","both","","","4501.03","3375.77","WELLPOINT [1015]","HB AMC WELLPOINT","3320.86","73.78","","286.63","119.22","1107.45","105","1395.32","3578.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4501.03","3375.77","AETNA [1001]","HB AMC AETNA HMO","3141.72","69.8","","675.31","184.75","1721.50","286","2352.24","3678.24","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4501.03","3375.77","AETNA [1001]","HB AMC AETNA PPO","3618.83","80.4","","1261.44","103.12","1514.10","21","2352.24","3678.24","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4501.03","3375.77","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3618.83","80.4","","1365.00","1365.00","1365.00","1 through 10","2352.24","3678.24","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4501.03","3375.77","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3678.24","81.72","","5157.68","5157.68","5157.68","1 through 10","2352.24","3678.24","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4501.03","3375.77","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3678.24","81.72","","431.26","71.26","1459.57","88","2352.24","3678.24","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5216.76","3912.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4147.32","79.5","","800.18","480.96","1887.97","195","1617.2","4147.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5216.76","3912.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2780.53","53.3","","813.12","216.42","1444.50","81","1617.2","4147.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5216.76","3912.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1617.20","31","","432.60","432.60","432.60","1 through 10","1617.2","4147.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5216.76","3912.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1904.12","36.5","","148.37","54.89","631.39","94","1617.2","4147.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5216.76","3912.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1998.02","38.3","","279.30","91.72","1116.77","266","1617.2","4147.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5216.76","3912.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2237.99","42.9","","731.00","63.70","731.00","1 through 10","1617.2","4147.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5216.76","3912.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2237.99","42.9","","384.74","384.74","384.74","1 through 10","1617.2","4147.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","both","","","5216.76","3912.57","WELLPOINT [1015]","HB AMC WELLPOINT","3848.93","73.78","","286.63","119.22","1107.45","105","1617.2","4147.32","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5216.76","3912.57","AETNA [1001]","HB AMC AETNA HMO","3641.30","69.8","","675.31","184.75","1721.50","286","2726.28","4263.14","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5216.76","3912.57","AETNA [1001]","HB AMC AETNA PPO","4194.28","80.4","","1261.44","103.12","1514.10","21","2726.28","4263.14","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5216.76","3912.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4194.28","80.4","","1365.00","1365.00","1365.00","1 through 10","2726.28","4263.14","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5216.76","3912.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4263.14","81.72","","5157.68","5157.68","5157.68","1 through 10","2726.28","4263.14","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5216.76","3912.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4263.14","81.72","","431.26","71.26","1459.57","88","2726.28","4263.14","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","both","","","4133.16","3099.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3285.86","79.5","","800.18","480.96","1887.97","195","1281.28","3285.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","both","","","4133.16","3099.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2202.97","53.3","","813.12","216.42","1444.50","81","1281.28","3285.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","both","","","4133.16","3099.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1281.28","31","","432.60","432.60","432.60","1 through 10","1281.28","3285.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","both","","","4133.16","3099.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1508.60","36.5","","148.37","54.89","631.39","94","1281.28","3285.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","both","","","4133.16","3099.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1583.00","38.3","","279.30","91.72","1116.77","266","1281.28","3285.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","both","","","4133.16","3099.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1773.13","42.9","","731.00","63.70","731.00","1 through 10","1281.28","3285.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","both","","","4133.16","3099.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1773.13","42.9","","384.74","384.74","384.74","1 through 10","1281.28","3285.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","both","","","4133.16","3099.87","WELLPOINT [1015]","HB AMC WELLPOINT","3049.45","73.78","","286.63","119.22","1107.45","105","1281.28","3285.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4133.16","3099.87","AETNA [1001]","HB AMC AETNA HMO","2884.95","69.8","","675.31","184.75","1721.50","286","2159.99","3377.62","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4133.16","3099.87","AETNA [1001]","HB AMC AETNA PPO","3323.06","80.4","","1261.44","103.12","1514.10","21","2159.99","3377.62","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4133.16","3099.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3323.06","80.4","","1365.00","1365.00","1365.00","1 through 10","2159.99","3377.62","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4133.16","3099.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3377.62","81.72","","5157.68","5157.68","5157.68","1 through 10","2159.99","3377.62","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4133.16","3099.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3377.62","81.72","","431.26","71.26","1459.57","88","2159.99","3377.62","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LCP SS RIGHT PROXIMALIMAL LATERAL","SUP-ITM-10037610","CDM","C1713","HCPCS","0278","RC","","","","both","","","3943.28","2957.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3134.91","79.5","","800.18","480.96","1887.97","195","1222.42","3134.91","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LCP SS RIGHT PROXIMALIMAL LATERAL","SUP-ITM-10037610","CDM","C1713","HCPCS","0278","RC","","","","both","","","3943.28","2957.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2101.77","53.3","","813.12","216.42","1444.50","81","1222.42","3134.91","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LCP SS RIGHT PROXIMALIMAL LATERAL","SUP-ITM-10037610","CDM","C1713","HCPCS","0278","RC","","","","both","","","3943.28","2957.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1222.42","31","","432.60","432.60","432.60","1 through 10","1222.42","3134.91","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LCP SS RIGHT PROXIMALIMAL LATERAL","SUP-ITM-10037610","CDM","C1713","HCPCS","0278","RC","","","","both","","","3943.28","2957.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1439.30","36.5","","148.37","54.89","631.39","94","1222.42","3134.91","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LCP SS RIGHT PROXIMALIMAL LATERAL","SUP-ITM-10037610","CDM","C1713","HCPCS","0278","RC","","","","both","","","3943.28","2957.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1510.28","38.3","","279.30","91.72","1116.77","266","1222.42","3134.91","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LCP SS RIGHT PROXIMALIMAL LATERAL","SUP-ITM-10037610","CDM","C1713","HCPCS","0278","RC","","","","both","","","3943.28","2957.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1691.67","42.9","","731.00","63.70","731.00","1 through 10","1222.42","3134.91","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LCP SS RIGHT PROXIMALIMAL LATERAL","SUP-ITM-10037610","CDM","C1713","HCPCS","0278","RC","","","","both","","","3943.28","2957.46","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1691.67","42.9","","384.74","384.74","384.74","1 through 10","1222.42","3134.91","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LCP SS RIGHT PROXIMALIMAL LATERAL","SUP-ITM-10037610","CDM","C1713","HCPCS","0278","RC","","","","both","","","3943.28","2957.46","WELLPOINT [1015]","HB AMC WELLPOINT","2909.35","73.78","","286.63","119.22","1107.45","105","1222.42","3134.91","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LCP SS RIGHT PROXIMALIMAL LATERAL","SUP-ITM-10037610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3943.28","2957.46","AETNA [1001]","HB AMC AETNA HMO","2752.41","69.8","","675.31","184.75","1721.50","286","2060.76","3222.45","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LCP SS RIGHT PROXIMALIMAL LATERAL","SUP-ITM-10037610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3943.28","2957.46","AETNA [1001]","HB AMC AETNA PPO","3170.40","80.4","","1261.44","103.12","1514.10","21","2060.76","3222.45","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LCP SS RIGHT PROXIMALIMAL LATERAL","SUP-ITM-10037610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3943.28","2957.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3170.40","80.4","","1365.00","1365.00","1365.00","1 through 10","2060.76","3222.45","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LCP SS RIGHT PROXIMALIMAL LATERAL","SUP-ITM-10037610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3943.28","2957.46","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3222.45","81.72","","5157.68","5157.68","5157.68","1 through 10","2060.76","3222.45","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LCP SS RIGHT PROXIMALIMAL LATERAL","SUP-ITM-10037610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3943.28","2957.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3222.45","81.72","","431.26","71.26","1459.57","88","2060.76","3222.45","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040364","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.92","3239.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3433.54","79.5","","800.18","480.96","1887.97","195","1338.87","3433.54","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040364","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.92","3239.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2301.98","53.3","","813.12","216.42","1444.50","81","1338.87","3433.54","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040364","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.92","3239.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1338.87","31","","432.60","432.60","432.60","1 through 10","1338.87","3433.54","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040364","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.92","3239.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1576.41","36.5","","148.37","54.89","631.39","94","1338.87","3433.54","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040364","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.92","3239.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1654.15","38.3","","279.30","91.72","1116.77","266","1338.87","3433.54","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040364","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.92","3239.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1852.82","42.9","","731.00","63.70","731.00","1 through 10","1338.87","3433.54","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040364","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.92","3239.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1852.82","42.9","","384.74","384.74","384.74","1 through 10","1338.87","3433.54","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040364","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.92","3239.19","WELLPOINT [1015]","HB AMC WELLPOINT","3186.50","73.78","","286.63","119.22","1107.45","105","1338.87","3433.54","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.92","3239.19","AETNA [1001]","HB AMC AETNA HMO","3014.61","69.8","","675.31","184.75","1721.50","286","2257.07","3529.42","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.92","3239.19","AETNA [1001]","HB AMC AETNA PPO","3472.41","80.4","","1261.44","103.12","1514.10","21","2257.07","3529.42","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.92","3239.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3472.41","80.4","","1365.00","1365.00","1365.00","1 through 10","2257.07","3529.42","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.92","3239.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3529.42","81.72","","5157.68","5157.68","5157.68","1 through 10","2257.07","3529.42","percent of total billed charges",""
"TIBIAL PLATE 220MM 9 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.92","3239.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3529.42","81.72","","431.26","71.26","1459.57","88","2257.07","3529.42","percent of total billed charges",""
"TIBIAL PLATE 246MM 13 HOLE TIBAIL HEAD BUTTRESS LATERAL DCP SS LEFT","SUP-ITM-10041359","CDM","C1713","HCPCS","0278","RC","","","","both","","","4235.95","3176.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3367.58","79.5","","800.18","480.96","1887.97","195","1313.14","3367.58","percent of total billed charges",""
"TIBIAL PLATE 246MM 13 HOLE TIBAIL HEAD BUTTRESS LATERAL DCP SS LEFT","SUP-ITM-10041359","CDM","C1713","HCPCS","0278","RC","","","","both","","","4235.95","3176.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2257.76","53.3","","813.12","216.42","1444.50","81","1313.14","3367.58","percent of total billed charges",""
"TIBIAL PLATE 246MM 13 HOLE TIBAIL HEAD BUTTRESS LATERAL DCP SS LEFT","SUP-ITM-10041359","CDM","C1713","HCPCS","0278","RC","","","","both","","","4235.95","3176.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1313.14","31","","432.60","432.60","432.60","1 through 10","1313.14","3367.58","percent of total billed charges",""
"TIBIAL PLATE 246MM 13 HOLE TIBAIL HEAD BUTTRESS LATERAL DCP SS LEFT","SUP-ITM-10041359","CDM","C1713","HCPCS","0278","RC","","","","both","","","4235.95","3176.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1546.12","36.5","","148.37","54.89","631.39","94","1313.14","3367.58","percent of total billed charges",""
"TIBIAL PLATE 246MM 13 HOLE TIBAIL HEAD BUTTRESS LATERAL DCP SS LEFT","SUP-ITM-10041359","CDM","C1713","HCPCS","0278","RC","","","","both","","","4235.95","3176.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1622.37","38.3","","279.30","91.72","1116.77","266","1313.14","3367.58","percent of total billed charges",""
"TIBIAL PLATE 246MM 13 HOLE TIBAIL HEAD BUTTRESS LATERAL DCP SS LEFT","SUP-ITM-10041359","CDM","C1713","HCPCS","0278","RC","","","","both","","","4235.95","3176.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1817.22","42.9","","731.00","63.70","731.00","1 through 10","1313.14","3367.58","percent of total billed charges",""
"TIBIAL PLATE 246MM 13 HOLE TIBAIL HEAD BUTTRESS LATERAL DCP SS LEFT","SUP-ITM-10041359","CDM","C1713","HCPCS","0278","RC","","","","both","","","4235.95","3176.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1817.22","42.9","","384.74","384.74","384.74","1 through 10","1313.14","3367.58","percent of total billed charges",""
"TIBIAL PLATE 246MM 13 HOLE TIBAIL HEAD BUTTRESS LATERAL DCP SS LEFT","SUP-ITM-10041359","CDM","C1713","HCPCS","0278","RC","","","","both","","","4235.95","3176.96","WELLPOINT [1015]","HB AMC WELLPOINT","3125.28","73.78","","286.63","119.22","1107.45","105","1313.14","3367.58","percent of total billed charges",""
"TIBIAL PLATE 246MM 13 HOLE TIBAIL HEAD BUTTRESS LATERAL DCP SS LEFT","SUP-ITM-10041359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4235.95","3176.96","AETNA [1001]","HB AMC AETNA HMO","2956.69","69.8","","675.31","184.75","1721.50","286","2213.71","3461.62","percent of total billed charges",""
"TIBIAL PLATE 246MM 13 HOLE TIBAIL HEAD BUTTRESS LATERAL DCP SS LEFT","SUP-ITM-10041359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4235.95","3176.96","AETNA [1001]","HB AMC AETNA PPO","3405.70","80.4","","1261.44","103.12","1514.10","21","2213.71","3461.62","percent of total billed charges",""
"TIBIAL PLATE 246MM 13 HOLE TIBAIL HEAD BUTTRESS LATERAL DCP SS LEFT","SUP-ITM-10041359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4235.95","3176.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3405.70","80.4","","1365.00","1365.00","1365.00","1 through 10","2213.71","3461.62","percent of total billed charges",""
"TIBIAL PLATE 246MM 13 HOLE TIBAIL HEAD BUTTRESS LATERAL DCP SS LEFT","SUP-ITM-10041359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4235.95","3176.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3461.62","81.72","","5157.68","5157.68","5157.68","1 through 10","2213.71","3461.62","percent of total billed charges",""
"TIBIAL PLATE 246MM 13 HOLE TIBAIL HEAD BUTTRESS LATERAL DCP SS LEFT","SUP-ITM-10041359","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4235.95","3176.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3461.62","81.72","","431.26","71.26","1459.57","88","2213.71","3461.62","percent of total billed charges",""
"TIBIAL PLATE 260MM 11 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040368","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.69","3067.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3251.30","79.5","","800.18","480.96","1887.97","195","1267.8","3251.3","percent of total billed charges",""
"TIBIAL PLATE 260MM 11 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040368","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.69","3067.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2179.80","53.3","","813.12","216.42","1444.50","81","1267.8","3251.3","percent of total billed charges",""
"TIBIAL PLATE 260MM 11 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040368","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.69","3067.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1267.80","31","","432.60","432.60","432.60","1 through 10","1267.8","3251.3","percent of total billed charges",""
"TIBIAL PLATE 260MM 11 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040368","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.69","3067.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1492.74","36.5","","148.37","54.89","631.39","94","1267.8","3251.3","percent of total billed charges",""
"TIBIAL PLATE 260MM 11 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040368","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.69","3067.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1566.35","38.3","","279.30","91.72","1116.77","266","1267.8","3251.3","percent of total billed charges",""
"TIBIAL PLATE 260MM 11 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040368","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.69","3067.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1754.48","42.9","","731.00","63.70","731.00","1 through 10","1267.8","3251.3","percent of total billed charges",""
"TIBIAL PLATE 260MM 11 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040368","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.69","3067.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1754.48","42.9","","384.74","384.74","384.74","1 through 10","1267.8","3251.3","percent of total billed charges",""
"TIBIAL PLATE 260MM 11 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040368","CDM","C1713","HCPCS","0278","RC","","","","both","","","4089.69","3067.27","WELLPOINT [1015]","HB AMC WELLPOINT","3017.37","73.78","","286.63","119.22","1107.45","105","1267.8","3251.3","percent of total billed charges",""
"TIBIAL PLATE 260MM 11 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040368","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4089.69","3067.27","AETNA [1001]","HB AMC AETNA HMO","2854.60","69.8","","675.31","184.75","1721.50","286","2137.27","3342.09","percent of total billed charges",""
"TIBIAL PLATE 260MM 11 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040368","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4089.69","3067.27","AETNA [1001]","HB AMC AETNA PPO","3288.11","80.4","","1261.44","103.12","1514.10","21","2137.27","3342.09","percent of total billed charges",""
"TIBIAL PLATE 260MM 11 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040368","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4089.69","3067.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3288.11","80.4","","1365.00","1365.00","1365.00","1 through 10","2137.27","3342.09","percent of total billed charges",""
"TIBIAL PLATE 260MM 11 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040368","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4089.69","3067.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3342.09","81.72","","5157.68","5157.68","5157.68","1 through 10","2137.27","3342.09","percent of total billed charges",""
"TIBIAL PLATE 260MM 11 HOLE LOCKING COMPRESSION LATERAL RT TITANIUM","SUP-ITM-10040368","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4089.69","3067.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3342.09","81.72","","431.26","71.26","1459.57","88","2137.27","3342.09","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /14 H /237 SM LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4847.18","3635.38","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2533.14","52.26","","1113.10","1113.10","1113.10","1 through 10","1502.63","3853.51","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /14 H /237 SM LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4847.18","3635.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3853.51","79.5","","1293.60","1148.53","1603.80","1 through 10","1502.63","3853.51","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /14 H /237 SM LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4847.18","3635.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1769.22","36.5","","1023.42","771.29","2068.67","33","1502.63","3853.51","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /14 H /237 SM LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4847.18","3635.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1856.47","38.3","","850.52","759.78","1211.25","66","1502.63","3853.51","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /14 H /237 SM LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4847.18","3635.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2079.44","42.9","","2548.09","2548.09","2548.09","1 through 10","1502.63","3853.51","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /14 H /237 SM LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4847.18","3635.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2079.44","42.9","","956.46","956.46","956.46","1 through 10","1502.63","3853.51","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /14 H /237 SM LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4847.18","3635.38","WELLPOINT [1015]","HB AMC WELLPOINT","3576.25","73.78","","2344.73","1619.47","2530.35","16","1502.63","3853.51","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /14 H /237 SM LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4847.18","3635.38","AETNA [1001]","HB AMC AETNA HMO","3383.33","69.8","","1523.63","988.41","4330.26","39","2533.14","3961.12","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /14 H /237 SM LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4847.18","3635.38","AETNA [1001]","HB AMC AETNA PPO","3897.13","80.4","","1670.25","1670.25","1670.25","1 through 10","2533.14","3961.12","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /14 H /237 SM LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4847.18","3635.38","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2533.14","52.26","","1113.10","1113.10","1113.10","1 through 10","2533.14","3961.12","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /14 H /237 SM LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4847.18","3635.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3961.12","81.72","","1738.90","1484.65","2716.94","38","2533.14","3961.12","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2063.19","52.26","","1113.10","1113.10","1113.10","1 through 10","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3138.61","79.5","","1293.60","1148.53","1603.80","1 through 10","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1441.00","36.5","","1023.42","771.29","2068.67","33","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1512.06","38.3","","850.52","759.78","1211.25","66","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1693.67","42.9","","2548.09","2548.09","2548.09","1 through 10","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1693.67","42.9","","956.46","956.46","956.46","1 through 10","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","WELLPOINT [1015]","HB AMC WELLPOINT","2912.79","73.78","","2344.73","1619.47","2530.35","16","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3947.94","2960.95","AETNA [1001]","HB AMC AETNA HMO","2755.66","69.8","","1523.63","988.41","4330.26","39","2063.19","3226.26","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3947.94","2960.95","AETNA [1001]","HB AMC AETNA PPO","3174.14","80.4","","1670.25","1670.25","1670.25","1 through 10","2063.19","3226.26","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3947.94","2960.95","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2063.19","52.26","","1113.10","1113.10","1113.10","1 through 10","2063.19","3226.26","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3947.94","2960.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3226.26","81.72","","1738.90","1484.65","2716.94","38","2063.19","3226.26","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 17 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040754","CDM","C1713","HCPCS","0278","RC","","","","both","","","4538.98","3404.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3608.49","79.5","","800.18","480.96","1887.97","195","1407.08","3608.49","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 17 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040754","CDM","C1713","HCPCS","0278","RC","","","","both","","","4538.98","3404.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2419.28","53.3","","813.12","216.42","1444.50","81","1407.08","3608.49","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 17 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040754","CDM","C1713","HCPCS","0278","RC","","","","both","","","4538.98","3404.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1407.08","31","","432.60","432.60","432.60","1 through 10","1407.08","3608.49","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 17 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040754","CDM","C1713","HCPCS","0278","RC","","","","both","","","4538.98","3404.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1656.73","36.5","","148.37","54.89","631.39","94","1407.08","3608.49","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 17 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040754","CDM","C1713","HCPCS","0278","RC","","","","both","","","4538.98","3404.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1738.43","38.3","","279.30","91.72","1116.77","266","1407.08","3608.49","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 17 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040754","CDM","C1713","HCPCS","0278","RC","","","","both","","","4538.98","3404.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1947.22","42.9","","731.00","63.70","731.00","1 through 10","1407.08","3608.49","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 17 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040754","CDM","C1713","HCPCS","0278","RC","","","","both","","","4538.98","3404.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1947.22","42.9","","384.74","384.74","384.74","1 through 10","1407.08","3608.49","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 17 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040754","CDM","C1713","HCPCS","0278","RC","","","","both","","","4538.98","3404.23","WELLPOINT [1015]","HB AMC WELLPOINT","3348.86","73.78","","286.63","119.22","1107.45","105","1407.08","3608.49","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 17 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4538.98","3404.23","AETNA [1001]","HB AMC AETNA HMO","3168.21","69.8","","675.31","184.75","1721.50","286","2372.07","3709.25","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 17 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4538.98","3404.23","AETNA [1001]","HB AMC AETNA PPO","3649.34","80.4","","1261.44","103.12","1514.10","21","2372.07","3709.25","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 17 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4538.98","3404.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3649.34","80.4","","1365.00","1365.00","1365.00","1 through 10","2372.07","3709.25","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 17 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4538.98","3404.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3709.25","81.72","","5157.68","5157.68","5157.68","1 through 10","2372.07","3709.25","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 17 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4538.98","3404.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3709.25","81.72","","431.26","71.26","1459.57","88","2372.07","3709.25","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 19 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040756","CDM","C1713","HCPCS","0278","RC","","","","both","","","3920.52","2940.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3116.81","79.5","","800.18","480.96","1887.97","195","1215.36","3116.81","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 19 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040756","CDM","C1713","HCPCS","0278","RC","","","","both","","","3920.52","2940.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2089.64","53.3","","813.12","216.42","1444.50","81","1215.36","3116.81","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 19 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040756","CDM","C1713","HCPCS","0278","RC","","","","both","","","3920.52","2940.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1215.36","31","","432.60","432.60","432.60","1 through 10","1215.36","3116.81","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 19 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040756","CDM","C1713","HCPCS","0278","RC","","","","both","","","3920.52","2940.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1430.99","36.5","","148.37","54.89","631.39","94","1215.36","3116.81","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 19 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040756","CDM","C1713","HCPCS","0278","RC","","","","both","","","3920.52","2940.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1501.56","38.3","","279.30","91.72","1116.77","266","1215.36","3116.81","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 19 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040756","CDM","C1713","HCPCS","0278","RC","","","","both","","","3920.52","2940.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1681.90","42.9","","731.00","63.70","731.00","1 through 10","1215.36","3116.81","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 19 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040756","CDM","C1713","HCPCS","0278","RC","","","","both","","","3920.52","2940.39","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1681.90","42.9","","384.74","384.74","384.74","1 through 10","1215.36","3116.81","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 19 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040756","CDM","C1713","HCPCS","0278","RC","","","","both","","","3920.52","2940.39","WELLPOINT [1015]","HB AMC WELLPOINT","2892.56","73.78","","286.63","119.22","1107.45","105","1215.36","3116.81","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 19 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3920.52","2940.39","AETNA [1001]","HB AMC AETNA HMO","2736.52","69.8","","675.31","184.75","1721.50","286","2048.86","3203.85","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 19 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3920.52","2940.39","AETNA [1001]","HB AMC AETNA PPO","3152.10","80.4","","1261.44","103.12","1514.10","21","2048.86","3203.85","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 19 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3920.52","2940.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3152.10","80.4","","1365.00","1365.00","1365.00","1 through 10","2048.86","3203.85","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 19 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3920.52","2940.39","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3203.85","81.72","","5157.68","5157.68","5157.68","1 through 10","2048.86","3203.85","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 19 HOLE L LCP TITANIUM DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3920.52","2940.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3203.85","81.72","","431.26","71.26","1459.57","88","2048.86","3203.85","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 21 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040758","CDM","C1713","HCPCS","0278","RC","","","","both","","","3959.37","2969.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3147.70","79.5","","800.18","480.96","1887.97","195","1227.4","3147.7","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 21 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040758","CDM","C1713","HCPCS","0278","RC","","","","both","","","3959.37","2969.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2110.34","53.3","","813.12","216.42","1444.50","81","1227.4","3147.7","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 21 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040758","CDM","C1713","HCPCS","0278","RC","","","","both","","","3959.37","2969.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1227.40","31","","432.60","432.60","432.60","1 through 10","1227.4","3147.7","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 21 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040758","CDM","C1713","HCPCS","0278","RC","","","","both","","","3959.37","2969.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1445.17","36.5","","148.37","54.89","631.39","94","1227.4","3147.7","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 21 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040758","CDM","C1713","HCPCS","0278","RC","","","","both","","","3959.37","2969.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1516.44","38.3","","279.30","91.72","1116.77","266","1227.4","3147.7","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 21 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040758","CDM","C1713","HCPCS","0278","RC","","","","both","","","3959.37","2969.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.57","42.9","","731.00","63.70","731.00","1 through 10","1227.4","3147.7","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 21 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040758","CDM","C1713","HCPCS","0278","RC","","","","both","","","3959.37","2969.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.57","42.9","","384.74","384.74","384.74","1 through 10","1227.4","3147.7","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 21 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040758","CDM","C1713","HCPCS","0278","RC","","","","both","","","3959.37","2969.53","WELLPOINT [1015]","HB AMC WELLPOINT","2921.22","73.78","","286.63","119.22","1107.45","105","1227.4","3147.7","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 21 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3959.37","2969.53","AETNA [1001]","HB AMC AETNA HMO","2763.64","69.8","","675.31","184.75","1721.50","286","2069.17","3235.6","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 21 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3959.37","2969.53","AETNA [1001]","HB AMC AETNA PPO","3183.33","80.4","","1261.44","103.12","1514.10","21","2069.17","3235.6","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 21 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3959.37","2969.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3183.33","80.4","","1365.00","1365.00","1365.00","1 through 10","2069.17","3235.6","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 21 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3959.37","2969.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3235.60","81.72","","5157.68","5157.68","5157.68","1 through 10","2069.17","3235.6","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 21 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3959.37","2969.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3235.60","81.72","","431.26","71.26","1459.57","88","2069.17","3235.6","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 5 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.37","3191.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3383.02","79.5","","800.18","480.96","1887.97","195","1319.16","3383.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 5 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.37","3191.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2268.11","53.3","","813.12","216.42","1444.50","81","1319.16","3383.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 5 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.37","3191.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1319.16","31","","432.60","432.60","432.60","1 through 10","1319.16","3383.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 5 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.37","3191.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1553.21","36.5","","148.37","54.89","631.39","94","1319.16","3383.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 5 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.37","3191.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1629.81","38.3","","279.30","91.72","1116.77","266","1319.16","3383.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 5 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.37","3191.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1825.55","42.9","","731.00","63.70","731.00","1 through 10","1319.16","3383.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 5 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.37","3191.53","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1825.55","42.9","","384.74","384.74","384.74","1 through 10","1319.16","3383.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 5 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040742","CDM","C1713","HCPCS","0278","RC","","","","both","","","4255.37","3191.53","WELLPOINT [1015]","HB AMC WELLPOINT","3139.61","73.78","","286.63","119.22","1107.45","105","1319.16","3383.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 5 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4255.37","3191.53","AETNA [1001]","HB AMC AETNA HMO","2970.25","69.8","","675.31","184.75","1721.50","286","2223.86","3477.49","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 5 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4255.37","3191.53","AETNA [1001]","HB AMC AETNA PPO","3421.32","80.4","","1261.44","103.12","1514.10","21","2223.86","3477.49","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 5 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4255.37","3191.53","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3421.32","80.4","","1365.00","1365.00","1365.00","1 through 10","2223.86","3477.49","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 5 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4255.37","3191.53","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3477.49","81.72","","5157.68","5157.68","5157.68","1 through 10","2223.86","3477.49","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 5 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4255.37","3191.53","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3477.49","81.72","","431.26","71.26","1459.57","88","2223.86","3477.49","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 60 4 HOLE LEG LCP STAINLESS PROXIMAL RIGHT","SUP-ITM-10005741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.20","2486.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2635.58","79.5","","800.18","480.96","1887.97","195","1027.71","2635.58","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 60 4 HOLE LEG LCP STAINLESS PROXIMAL RIGHT","SUP-ITM-10005741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.20","2486.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1767.00","53.3","","813.12","216.42","1444.50","81","1027.71","2635.58","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 60 4 HOLE LEG LCP STAINLESS PROXIMAL RIGHT","SUP-ITM-10005741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.20","2486.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1027.71","31","","432.60","432.60","432.60","1 through 10","1027.71","2635.58","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 60 4 HOLE LEG LCP STAINLESS PROXIMAL RIGHT","SUP-ITM-10005741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.20","2486.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1210.05","36.5","","148.37","54.89","631.39","94","1027.71","2635.58","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 60 4 HOLE LEG LCP STAINLESS PROXIMAL RIGHT","SUP-ITM-10005741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.20","2486.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1269.72","38.3","","279.30","91.72","1116.77","266","1027.71","2635.58","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 60 4 HOLE LEG LCP STAINLESS PROXIMAL RIGHT","SUP-ITM-10005741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.20","2486.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1422.22","42.9","","731.00","63.70","731.00","1 through 10","1027.71","2635.58","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 60 4 HOLE LEG LCP STAINLESS PROXIMAL RIGHT","SUP-ITM-10005741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.20","2486.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1422.22","42.9","","384.74","384.74","384.74","1 through 10","1027.71","2635.58","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 60 4 HOLE LEG LCP STAINLESS PROXIMAL RIGHT","SUP-ITM-10005741","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.20","2486.40","WELLPOINT [1015]","HB AMC WELLPOINT","2445.95","73.78","","286.63","119.22","1107.45","105","1027.71","2635.58","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 60 4 HOLE LEG LCP STAINLESS PROXIMAL RIGHT","SUP-ITM-10005741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3315.20","2486.40","AETNA [1001]","HB AMC AETNA HMO","2314.01","69.8","","675.31","184.75","1721.50","286","1732.52","2709.18","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 60 4 HOLE LEG LCP STAINLESS PROXIMAL RIGHT","SUP-ITM-10005741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3315.20","2486.40","AETNA [1001]","HB AMC AETNA PPO","2665.42","80.4","","1261.44","103.12","1514.10","21","1732.52","2709.18","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 60 4 HOLE LEG LCP STAINLESS PROXIMAL RIGHT","SUP-ITM-10005741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3315.20","2486.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2665.42","80.4","","1365.00","1365.00","1365.00","1 through 10","1732.52","2709.18","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 60 4 HOLE LEG LCP STAINLESS PROXIMAL RIGHT","SUP-ITM-10005741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3315.20","2486.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2709.18","81.72","","5157.68","5157.68","5157.68","1 through 10","1732.52","2709.18","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 60 4 HOLE LEG LCP STAINLESS PROXIMAL RIGHT","SUP-ITM-10005741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3315.20","2486.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2709.18","81.72","","431.26","71.26","1459.57","88","1732.52","2709.18","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 7 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3309.93","79.5","","800.18","480.96","1887.97","195","1290.66","3309.93","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 7 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2219.11","53.3","","813.12","216.42","1444.50","81","1290.66","3309.93","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 7 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1290.66","31","","432.60","432.60","432.60","1 through 10","1290.66","3309.93","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 7 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1519.65","36.5","","148.37","54.89","631.39","94","1290.66","3309.93","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 7 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1594.59","38.3","","279.30","91.72","1116.77","266","1290.66","3309.93","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 7 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1786.11","42.9","","731.00","63.70","731.00","1 through 10","1290.66","3309.93","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 7 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1786.11","42.9","","384.74","384.74","384.74","1 through 10","1290.66","3309.93","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 7 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040744","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.43","3122.57","WELLPOINT [1015]","HB AMC WELLPOINT","3071.78","73.78","","286.63","119.22","1107.45","105","1290.66","3309.93","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 7 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","AETNA [1001]","HB AMC AETNA HMO","2906.07","69.8","","675.31","184.75","1721.50","286","2175.81","3402.35","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 7 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","AETNA [1001]","HB AMC AETNA PPO","3347.40","80.4","","1261.44","103.12","1514.10","21","2175.81","3402.35","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 7 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3347.40","80.4","","1365.00","1365.00","1365.00","1 through 10","2175.81","3402.35","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 7 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3402.35","81.72","","5157.68","5157.68","5157.68","1 through 10","2175.81","3402.35","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 7 HOLE L LCP RI DISTAL ANTEROLATERAL RIGHT","SUP-ITM-10040744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.43","3122.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3402.35","81.72","","431.26","71.26","1459.57","88","2175.81","3402.35","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.43","2869.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3041.22","79.5","","800.18","480.96","1887.97","195","1185.88","3041.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.43","2869.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2038.95","53.3","","813.12","216.42","1444.50","81","1185.88","3041.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.43","2869.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1185.88","31","","432.60","432.60","432.60","1 through 10","1185.88","3041.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.43","2869.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1396.28","36.5","","148.37","54.89","631.39","94","1185.88","3041.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.43","2869.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1465.14","38.3","","279.30","91.72","1116.77","266","1185.88","3041.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.43","2869.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1641.11","42.9","","731.00","63.70","731.00","1 through 10","1185.88","3041.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.43","2869.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1641.11","42.9","","384.74","384.74","384.74","1 through 10","1185.88","3041.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3825.43","2869.07","WELLPOINT [1015]","HB AMC WELLPOINT","2822.40","73.78","","286.63","119.22","1107.45","105","1185.88","3041.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3825.43","2869.07","AETNA [1001]","HB AMC AETNA HMO","2670.15","69.8","","675.31","184.75","1721.50","286","1999.17","3126.14","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3825.43","2869.07","AETNA [1001]","HB AMC AETNA PPO","3075.65","80.4","","1261.44","103.12","1514.10","21","1999.17","3126.14","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3825.43","2869.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3075.65","80.4","","1365.00","1365.00","1365.00","1 through 10","1999.17","3126.14","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3825.43","2869.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3126.14","81.72","","5157.68","5157.68","5157.68","1 through 10","1999.17","3126.14","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3825.43","2869.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3126.14","81.72","","431.26","71.26","1459.57","88","1999.17","3126.14","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097003","CDM","C1713","HCPCS","0278","RC","","","","both","","","4208.75","3156.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3345.96","79.5","","800.18","480.96","1887.97","195","1304.71","3345.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097003","CDM","C1713","HCPCS","0278","RC","","","","both","","","4208.75","3156.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2243.26","53.3","","813.12","216.42","1444.50","81","1304.71","3345.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097003","CDM","C1713","HCPCS","0278","RC","","","","both","","","4208.75","3156.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1304.71","31","","432.60","432.60","432.60","1 through 10","1304.71","3345.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097003","CDM","C1713","HCPCS","0278","RC","","","","both","","","4208.75","3156.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1536.19","36.5","","148.37","54.89","631.39","94","1304.71","3345.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097003","CDM","C1713","HCPCS","0278","RC","","","","both","","","4208.75","3156.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1611.95","38.3","","279.30","91.72","1116.77","266","1304.71","3345.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097003","CDM","C1713","HCPCS","0278","RC","","","","both","","","4208.75","3156.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1805.55","42.9","","731.00","63.70","731.00","1 through 10","1304.71","3345.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097003","CDM","C1713","HCPCS","0278","RC","","","","both","","","4208.75","3156.56","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1805.55","42.9","","384.74","384.74","384.74","1 through 10","1304.71","3345.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097003","CDM","C1713","HCPCS","0278","RC","","","","both","","","4208.75","3156.56","WELLPOINT [1015]","HB AMC WELLPOINT","3105.22","73.78","","286.63","119.22","1107.45","105","1304.71","3345.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4208.75","3156.56","AETNA [1001]","HB AMC AETNA HMO","2937.71","69.8","","675.31","184.75","1721.50","286","2199.49","3439.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4208.75","3156.56","AETNA [1001]","HB AMC AETNA PPO","3383.84","80.4","","1261.44","103.12","1514.10","21","2199.49","3439.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4208.75","3156.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3383.84","80.4","","1365.00","1365.00","1365.00","1 through 10","2199.49","3439.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4208.75","3156.56","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3439.39","81.72","","5157.68","5157.68","5157.68","1 through 10","2199.49","3439.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4208.75","3156.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3439.39","81.72","","431.26","71.26","1459.57","88","2199.49","3439.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096139","CDM","C1713","HCPCS","0278","RC","","","","both","","","4099.97","3074.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3259.48","79.5","","800.18","480.96","1887.97","195","1270.99","3259.48","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096139","CDM","C1713","HCPCS","0278","RC","","","","both","","","4099.97","3074.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2185.28","53.3","","813.12","216.42","1444.50","81","1270.99","3259.48","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096139","CDM","C1713","HCPCS","0278","RC","","","","both","","","4099.97","3074.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1270.99","31","","432.60","432.60","432.60","1 through 10","1270.99","3259.48","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096139","CDM","C1713","HCPCS","0278","RC","","","","both","","","4099.97","3074.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1496.49","36.5","","148.37","54.89","631.39","94","1270.99","3259.48","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096139","CDM","C1713","HCPCS","0278","RC","","","","both","","","4099.97","3074.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1570.29","38.3","","279.30","91.72","1116.77","266","1270.99","3259.48","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096139","CDM","C1713","HCPCS","0278","RC","","","","both","","","4099.97","3074.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1758.89","42.9","","731.00","63.70","731.00","1 through 10","1270.99","3259.48","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096139","CDM","C1713","HCPCS","0278","RC","","","","both","","","4099.97","3074.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1758.89","42.9","","384.74","384.74","384.74","1 through 10","1270.99","3259.48","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096139","CDM","C1713","HCPCS","0278","RC","","","","both","","","4099.97","3074.98","WELLPOINT [1015]","HB AMC WELLPOINT","3024.96","73.78","","286.63","119.22","1107.45","105","1270.99","3259.48","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4099.97","3074.98","AETNA [1001]","HB AMC AETNA HMO","2861.78","69.8","","675.31","184.75","1721.50","286","2142.64","3350.5","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4099.97","3074.98","AETNA [1001]","HB AMC AETNA PPO","3296.38","80.4","","1261.44","103.12","1514.10","21","2142.64","3350.5","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4099.97","3074.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3296.38","80.4","","1365.00","1365.00","1365.00","1 through 10","2142.64","3350.5","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4099.97","3074.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3350.50","81.72","","5157.68","5157.68","5157.68","1 through 10","2142.64","3350.5","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4099.97","3074.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3350.50","81.72","","431.26","71.26","1459.57","88","2142.64","3350.5","percent of total billed charges",""
"TIBIAL PLATE 3.5X106MM 7 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.29","2838.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3009.31","79.5","","800.18","480.96","1887.97","195","1173.44","3009.31","percent of total billed charges",""
"TIBIAL PLATE 3.5X106MM 7 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.29","2838.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2017.56","53.3","","813.12","216.42","1444.50","81","1173.44","3009.31","percent of total billed charges",""
"TIBIAL PLATE 3.5X106MM 7 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.29","2838.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1173.44","31","","432.60","432.60","432.60","1 through 10","1173.44","3009.31","percent of total billed charges",""
"TIBIAL PLATE 3.5X106MM 7 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.29","2838.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1381.63","36.5","","148.37","54.89","631.39","94","1173.44","3009.31","percent of total billed charges",""
"TIBIAL PLATE 3.5X106MM 7 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.29","2838.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1449.77","38.3","","279.30","91.72","1116.77","266","1173.44","3009.31","percent of total billed charges",""
"TIBIAL PLATE 3.5X106MM 7 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.29","2838.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1623.89","42.9","","731.00","63.70","731.00","1 through 10","1173.44","3009.31","percent of total billed charges",""
"TIBIAL PLATE 3.5X106MM 7 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.29","2838.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1623.89","42.9","","384.74","384.74","384.74","1 through 10","1173.44","3009.31","percent of total billed charges",""
"TIBIAL PLATE 3.5X106MM 7 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019989","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.29","2838.97","WELLPOINT [1015]","HB AMC WELLPOINT","2792.79","73.78","","286.63","119.22","1107.45","105","1173.44","3009.31","percent of total billed charges",""
"TIBIAL PLATE 3.5X106MM 7 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.29","2838.97","AETNA [1001]","HB AMC AETNA HMO","2642.13","69.8","","675.31","184.75","1721.50","286","1978.19","3093.34","percent of total billed charges",""
"TIBIAL PLATE 3.5X106MM 7 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.29","2838.97","AETNA [1001]","HB AMC AETNA PPO","3043.37","80.4","","1261.44","103.12","1514.10","21","1978.19","3093.34","percent of total billed charges",""
"TIBIAL PLATE 3.5X106MM 7 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.29","2838.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3043.37","80.4","","1365.00","1365.00","1365.00","1 through 10","1978.19","3093.34","percent of total billed charges",""
"TIBIAL PLATE 3.5X106MM 7 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.29","2838.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3093.34","81.72","","5157.68","5157.68","5157.68","1 through 10","1978.19","3093.34","percent of total billed charges",""
"TIBIAL PLATE 3.5X106MM 7 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.29","2838.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3093.34","81.72","","431.26","71.26","1459.57","88","1978.19","3093.34","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","4448.78","3336.58","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3536.78","79.5","","800.18","480.96","1887.97","195","1379.12","3536.78","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","4448.78","3336.58","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2371.20","53.3","","813.12","216.42","1444.50","81","1379.12","3536.78","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","4448.78","3336.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1379.12","31","","432.60","432.60","432.60","1 through 10","1379.12","3536.78","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","4448.78","3336.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1623.80","36.5","","148.37","54.89","631.39","94","1379.12","3536.78","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","4448.78","3336.58","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1703.88","38.3","","279.30","91.72","1116.77","266","1379.12","3536.78","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","4448.78","3336.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1908.53","42.9","","731.00","63.70","731.00","1 through 10","1379.12","3536.78","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","4448.78","3336.58","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1908.53","42.9","","384.74","384.74","384.74","1 through 10","1379.12","3536.78","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","both","","","4448.78","3336.58","WELLPOINT [1015]","HB AMC WELLPOINT","3282.31","73.78","","286.63","119.22","1107.45","105","1379.12","3536.78","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4448.78","3336.58","AETNA [1001]","HB AMC AETNA HMO","3105.25","69.8","","675.31","184.75","1721.50","286","2324.93","3635.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4448.78","3336.58","AETNA [1001]","HB AMC AETNA PPO","3576.82","80.4","","1261.44","103.12","1514.10","21","2324.93","3635.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4448.78","3336.58","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3576.82","80.4","","1365.00","1365.00","1365.00","1 through 10","2324.93","3635.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4448.78","3336.58","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3635.54","81.72","","5157.68","5157.68","5157.68","1 through 10","2324.93","3635.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X107MM 6 HOLE IMAL LCP SS RIGHT","SUP-ITM-10014647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4448.78","3336.58","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3635.54","81.72","","431.26","71.26","1459.57","88","2324.93","3635.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 3 HOLE SS IMAL RIGHT","SUP-ITM-10005738","CDM","C1713","HCPCS","0278","RC","","","","both","","","3719.24","2789.43","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2956.80","79.5","","800.18","480.96","1887.97","195","1152.96","2956.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 3 HOLE SS IMAL RIGHT","SUP-ITM-10005738","CDM","C1713","HCPCS","0278","RC","","","","both","","","3719.24","2789.43","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1982.35","53.3","","813.12","216.42","1444.50","81","1152.96","2956.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 3 HOLE SS IMAL RIGHT","SUP-ITM-10005738","CDM","C1713","HCPCS","0278","RC","","","","both","","","3719.24","2789.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1152.96","31","","432.60","432.60","432.60","1 through 10","1152.96","2956.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 3 HOLE SS IMAL RIGHT","SUP-ITM-10005738","CDM","C1713","HCPCS","0278","RC","","","","both","","","3719.24","2789.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1357.52","36.5","","148.37","54.89","631.39","94","1152.96","2956.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 3 HOLE SS IMAL RIGHT","SUP-ITM-10005738","CDM","C1713","HCPCS","0278","RC","","","","both","","","3719.24","2789.43","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1424.47","38.3","","279.30","91.72","1116.77","266","1152.96","2956.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 3 HOLE SS IMAL RIGHT","SUP-ITM-10005738","CDM","C1713","HCPCS","0278","RC","","","","both","","","3719.24","2789.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1595.55","42.9","","731.00","63.70","731.00","1 through 10","1152.96","2956.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 3 HOLE SS IMAL RIGHT","SUP-ITM-10005738","CDM","C1713","HCPCS","0278","RC","","","","both","","","3719.24","2789.43","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1595.55","42.9","","384.74","384.74","384.74","1 through 10","1152.96","2956.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 3 HOLE SS IMAL RIGHT","SUP-ITM-10005738","CDM","C1713","HCPCS","0278","RC","","","","both","","","3719.24","2789.43","WELLPOINT [1015]","HB AMC WELLPOINT","2744.06","73.78","","286.63","119.22","1107.45","105","1152.96","2956.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 3 HOLE SS IMAL RIGHT","SUP-ITM-10005738","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3719.24","2789.43","AETNA [1001]","HB AMC AETNA HMO","2596.03","69.8","","675.31","184.75","1721.50","286","1943.67","3039.36","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 3 HOLE SS IMAL RIGHT","SUP-ITM-10005738","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3719.24","2789.43","AETNA [1001]","HB AMC AETNA PPO","2990.27","80.4","","1261.44","103.12","1514.10","21","1943.67","3039.36","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 3 HOLE SS IMAL RIGHT","SUP-ITM-10005738","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3719.24","2789.43","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2990.27","80.4","","1365.00","1365.00","1365.00","1 through 10","1943.67","3039.36","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 3 HOLE SS IMAL RIGHT","SUP-ITM-10005738","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3719.24","2789.43","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3039.36","81.72","","5157.68","5157.68","5157.68","1 through 10","1943.67","3039.36","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 3 HOLE SS IMAL RIGHT","SUP-ITM-10005738","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3719.24","2789.43","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3039.36","81.72","","431.26","71.26","1459.57","88","1943.67","3039.36","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3396.79","2547.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2700.45","79.5","","800.18","480.96","1887.97","195","1053","2700.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3396.79","2547.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1810.49","53.3","","813.12","216.42","1444.50","81","1053","2700.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3396.79","2547.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1053.00","31","","432.60","432.60","432.60","1 through 10","1053","2700.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3396.79","2547.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1239.83","36.5","","148.37","54.89","631.39","94","1053","2700.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3396.79","2547.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1300.97","38.3","","279.30","91.72","1116.77","266","1053","2700.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3396.79","2547.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1457.22","42.9","","731.00","63.70","731.00","1 through 10","1053","2700.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3396.79","2547.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1457.22","42.9","","384.74","384.74","384.74","1 through 10","1053","2700.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","both","","","3396.79","2547.59","WELLPOINT [1015]","HB AMC WELLPOINT","2506.15","73.78","","286.63","119.22","1107.45","105","1053","2700.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3396.79","2547.59","AETNA [1001]","HB AMC AETNA HMO","2370.96","69.8","","675.31","184.75","1721.50","286","1775.16","2775.86","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3396.79","2547.59","AETNA [1001]","HB AMC AETNA PPO","2731.02","80.4","","1261.44","103.12","1514.10","21","1775.16","2775.86","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3396.79","2547.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2731.02","80.4","","1365.00","1365.00","1365.00","1 through 10","1775.16","2775.86","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3396.79","2547.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2775.86","81.72","","5157.68","5157.68","5157.68","1 through 10","1775.16","2775.86","percent of total billed charges",""
"TIBIAL PLATE 3.5X109MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3396.79","2547.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2775.86","81.72","","431.26","71.26","1459.57","88","1775.16","2775.86","percent of total billed charges",""
"TIBIAL PLATE 3.5X111MM 8 HOLE SS IMAL LEFT","SUP-ITM-10005746","CDM","C1713","HCPCS","0278","RC","","","","both","","","3392.90","2544.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2697.36","79.5","","800.18","480.96","1887.97","195","1051.8","2697.36","percent of total billed charges",""
"TIBIAL PLATE 3.5X111MM 8 HOLE SS IMAL LEFT","SUP-ITM-10005746","CDM","C1713","HCPCS","0278","RC","","","","both","","","3392.90","2544.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1808.42","53.3","","813.12","216.42","1444.50","81","1051.8","2697.36","percent of total billed charges",""
"TIBIAL PLATE 3.5X111MM 8 HOLE SS IMAL LEFT","SUP-ITM-10005746","CDM","C1713","HCPCS","0278","RC","","","","both","","","3392.90","2544.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1051.80","31","","432.60","432.60","432.60","1 through 10","1051.8","2697.36","percent of total billed charges",""
"TIBIAL PLATE 3.5X111MM 8 HOLE SS IMAL LEFT","SUP-ITM-10005746","CDM","C1713","HCPCS","0278","RC","","","","both","","","3392.90","2544.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1238.41","36.5","","148.37","54.89","631.39","94","1051.8","2697.36","percent of total billed charges",""
"TIBIAL PLATE 3.5X111MM 8 HOLE SS IMAL LEFT","SUP-ITM-10005746","CDM","C1713","HCPCS","0278","RC","","","","both","","","3392.90","2544.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1299.48","38.3","","279.30","91.72","1116.77","266","1051.8","2697.36","percent of total billed charges",""
"TIBIAL PLATE 3.5X111MM 8 HOLE SS IMAL LEFT","SUP-ITM-10005746","CDM","C1713","HCPCS","0278","RC","","","","both","","","3392.90","2544.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1455.55","42.9","","731.00","63.70","731.00","1 through 10","1051.8","2697.36","percent of total billed charges",""
"TIBIAL PLATE 3.5X111MM 8 HOLE SS IMAL LEFT","SUP-ITM-10005746","CDM","C1713","HCPCS","0278","RC","","","","both","","","3392.90","2544.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1455.55","42.9","","384.74","384.74","384.74","1 through 10","1051.8","2697.36","percent of total billed charges",""
"TIBIAL PLATE 3.5X111MM 8 HOLE SS IMAL LEFT","SUP-ITM-10005746","CDM","C1713","HCPCS","0278","RC","","","","both","","","3392.90","2544.67","WELLPOINT [1015]","HB AMC WELLPOINT","2503.28","73.78","","286.63","119.22","1107.45","105","1051.8","2697.36","percent of total billed charges",""
"TIBIAL PLATE 3.5X111MM 8 HOLE SS IMAL LEFT","SUP-ITM-10005746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3392.90","2544.67","AETNA [1001]","HB AMC AETNA HMO","2368.24","69.8","","675.31","184.75","1721.50","286","1773.13","2772.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X111MM 8 HOLE SS IMAL LEFT","SUP-ITM-10005746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3392.90","2544.67","AETNA [1001]","HB AMC AETNA PPO","2727.89","80.4","","1261.44","103.12","1514.10","21","1773.13","2772.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X111MM 8 HOLE SS IMAL LEFT","SUP-ITM-10005746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3392.90","2544.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2727.89","80.4","","1365.00","1365.00","1365.00","1 through 10","1773.13","2772.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X111MM 8 HOLE SS IMAL LEFT","SUP-ITM-10005746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3392.90","2544.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2772.68","81.72","","5157.68","5157.68","5157.68","1 through 10","1773.13","2772.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X111MM 8 HOLE SS IMAL LEFT","SUP-ITM-10005746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3392.90","2544.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2772.68","81.72","","431.26","71.26","1459.57","88","1773.13","2772.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.09","2683.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2844.58","79.5","","800.18","480.96","1887.97","195","1109.21","2844.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.09","2683.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1907.12","53.3","","813.12","216.42","1444.50","81","1109.21","2844.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.09","2683.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1109.21","31","","432.60","432.60","432.60","1 through 10","1109.21","2844.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.09","2683.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1306.00","36.5","","148.37","54.89","631.39","94","1109.21","2844.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.09","2683.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1370.41","38.3","","279.30","91.72","1116.77","266","1109.21","2844.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.09","2683.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1535.00","42.9","","731.00","63.70","731.00","1 through 10","1109.21","2844.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.09","2683.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1535.00","42.9","","384.74","384.74","384.74","1 through 10","1109.21","2844.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","both","","","3578.09","2683.57","WELLPOINT [1015]","HB AMC WELLPOINT","2639.91","73.78","","286.63","119.22","1107.45","105","1109.21","2844.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3578.09","2683.57","AETNA [1001]","HB AMC AETNA HMO","2497.51","69.8","","675.31","184.75","1721.50","286","1869.91","2924.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3578.09","2683.57","AETNA [1001]","HB AMC AETNA PPO","2876.78","80.4","","1261.44","103.12","1514.10","21","1869.91","2924.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3578.09","2683.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2876.78","80.4","","1365.00","1365.00","1365.00","1 through 10","1869.91","2924.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3578.09","2683.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2924.02","81.72","","5157.68","5157.68","5157.68","1 through 10","1869.91","2924.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X116MM 4 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10018456","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3578.09","2683.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2924.02","81.72","","431.26","71.26","1459.57","88","1869.91","2924.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM LG 6 HOLE VA LCP SS BEND IMAL LEFT","SUP-ITM-10125084","CDM","C1776","HCPCS","0278","RC","","","","both","","","4614.33","3460.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2411.45","52.26","","1113.10","1113.10","1113.10","1 through 10","1430.44","3668.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM LG 6 HOLE VA LCP SS BEND IMAL LEFT","SUP-ITM-10125084","CDM","C1776","HCPCS","0278","RC","","","","both","","","4614.33","3460.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3668.39","79.5","","1293.60","1148.53","1603.80","1 through 10","1430.44","3668.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM LG 6 HOLE VA LCP SS BEND IMAL LEFT","SUP-ITM-10125084","CDM","C1776","HCPCS","0278","RC","","","","both","","","4614.33","3460.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1684.23","36.5","","1023.42","771.29","2068.67","33","1430.44","3668.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM LG 6 HOLE VA LCP SS BEND IMAL LEFT","SUP-ITM-10125084","CDM","C1776","HCPCS","0278","RC","","","","both","","","4614.33","3460.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1767.29","38.3","","850.52","759.78","1211.25","66","1430.44","3668.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM LG 6 HOLE VA LCP SS BEND IMAL LEFT","SUP-ITM-10125084","CDM","C1776","HCPCS","0278","RC","","","","both","","","4614.33","3460.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1979.55","42.9","","2548.09","2548.09","2548.09","1 through 10","1430.44","3668.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM LG 6 HOLE VA LCP SS BEND IMAL LEFT","SUP-ITM-10125084","CDM","C1776","HCPCS","0278","RC","","","","both","","","4614.33","3460.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1979.55","42.9","","956.46","956.46","956.46","1 through 10","1430.44","3668.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM LG 6 HOLE VA LCP SS BEND IMAL LEFT","SUP-ITM-10125084","CDM","C1776","HCPCS","0278","RC","","","","both","","","4614.33","3460.75","WELLPOINT [1015]","HB AMC WELLPOINT","3404.45","73.78","","2344.73","1619.47","2530.35","16","1430.44","3668.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM LG 6 HOLE VA LCP SS BEND IMAL LEFT","SUP-ITM-10125084","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4614.33","3460.75","AETNA [1001]","HB AMC AETNA HMO","3220.80","69.8","","1523.63","988.41","4330.26","39","2411.45","3770.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM LG 6 HOLE VA LCP SS BEND IMAL LEFT","SUP-ITM-10125084","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4614.33","3460.75","AETNA [1001]","HB AMC AETNA PPO","3709.92","80.4","","1670.25","1670.25","1670.25","1 through 10","2411.45","3770.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM LG 6 HOLE VA LCP SS BEND IMAL LEFT","SUP-ITM-10125084","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4614.33","3460.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2411.45","52.26","","1113.10","1113.10","1113.10","1 through 10","2411.45","3770.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM LG 6 HOLE VA LCP SS BEND IMAL LEFT","SUP-ITM-10125084","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4614.33","3460.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3770.83","81.72","","1738.90","1484.65","2716.94","38","2411.45","3770.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3138.61","79.5","","800.18","480.96","1887.97","195","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2104.25","53.3","","813.12","216.42","1444.50","81","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1223.86","31","","432.60","432.60","432.60","1 through 10","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1441.00","36.5","","148.37","54.89","631.39","94","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1512.06","38.3","","279.30","91.72","1116.77","266","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1693.67","42.9","","731.00","63.70","731.00","1 through 10","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1693.67","42.9","","384.74","384.74","384.74","1 through 10","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","both","","","3947.94","2960.95","WELLPOINT [1015]","HB AMC WELLPOINT","2912.79","73.78","","286.63","119.22","1107.45","105","1223.86","3138.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3947.94","2960.95","AETNA [1001]","HB AMC AETNA HMO","2755.66","69.8","","675.31","184.75","1721.50","286","2063.19","3226.26","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3947.94","2960.95","AETNA [1001]","HB AMC AETNA PPO","3174.14","80.4","","1261.44","103.12","1514.10","21","2063.19","3226.26","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3947.94","2960.95","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3174.14","80.4","","1365.00","1365.00","1365.00","1 through 10","2063.19","3226.26","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3947.94","2960.95","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3226.26","81.72","","5157.68","5157.68","5157.68","1 through 10","2063.19","3226.26","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3947.94","2960.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3226.26","81.72","","431.26","71.26","1459.57","88","2063.19","3226.26","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.32","3024.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3205.69","79.5","","800.18","480.96","1887.97","195","1250.02","3205.69","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.32","3024.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2149.23","53.3","","813.12","216.42","1444.50","81","1250.02","3205.69","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.32","3024.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1250.02","31","","432.60","432.60","432.60","1 through 10","1250.02","3205.69","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.32","3024.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1471.80","36.5","","148.37","54.89","631.39","94","1250.02","3205.69","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.32","3024.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1544.38","38.3","","279.30","91.72","1116.77","266","1250.02","3205.69","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.32","3024.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1729.87","42.9","","731.00","63.70","731.00","1 through 10","1250.02","3205.69","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.32","3024.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1729.87","42.9","","384.74","384.74","384.74","1 through 10","1250.02","3205.69","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.32","3024.24","WELLPOINT [1015]","HB AMC WELLPOINT","2975.05","73.78","","286.63","119.22","1107.45","105","1250.02","3205.69","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4032.32","3024.24","AETNA [1001]","HB AMC AETNA HMO","2814.56","69.8","","675.31","184.75","1721.50","286","2107.29","3295.21","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4032.32","3024.24","AETNA [1001]","HB AMC AETNA PPO","3241.99","80.4","","1261.44","103.12","1514.10","21","2107.29","3295.21","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4032.32","3024.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3241.99","80.4","","1365.00","1365.00","1365.00","1 through 10","2107.29","3295.21","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4032.32","3024.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3295.21","81.72","","5157.68","5157.68","5157.68","1 through 10","2107.29","3295.21","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4032.32","3024.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3295.21","81.72","","431.26","71.26","1459.57","88","2107.29","3295.21","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","4507.48","3380.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3583.45","79.5","","800.18","480.96","1887.97","195","1397.32","3583.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","4507.48","3380.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2402.49","53.3","","813.12","216.42","1444.50","81","1397.32","3583.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","4507.48","3380.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1397.32","31","","432.60","432.60","432.60","1 through 10","1397.32","3583.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","4507.48","3380.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1645.23","36.5","","148.37","54.89","631.39","94","1397.32","3583.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","4507.48","3380.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1726.36","38.3","","279.30","91.72","1116.77","266","1397.32","3583.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","4507.48","3380.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1933.71","42.9","","731.00","63.70","731.00","1 through 10","1397.32","3583.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","4507.48","3380.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1933.71","42.9","","384.74","384.74","384.74","1 through 10","1397.32","3583.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","4507.48","3380.61","WELLPOINT [1015]","HB AMC WELLPOINT","3325.62","73.78","","286.63","119.22","1107.45","105","1397.32","3583.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4507.48","3380.61","AETNA [1001]","HB AMC AETNA HMO","3146.22","69.8","","675.31","184.75","1721.50","286","2355.61","3683.51","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4507.48","3380.61","AETNA [1001]","HB AMC AETNA PPO","3624.01","80.4","","1261.44","103.12","1514.10","21","2355.61","3683.51","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4507.48","3380.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3624.01","80.4","","1365.00","1365.00","1365.00","1 through 10","2355.61","3683.51","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4507.48","3380.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3683.51","81.72","","5157.68","5157.68","5157.68","1 through 10","2355.61","3683.51","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4507.48","3380.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3683.51","81.72","","431.26","71.26","1459.57","88","2355.61","3683.51","percent of total billed charges",""
"TIBIAL PLATE 3.5X121MM 8 HOLE LCP LEG SS MEDIAL DISTAL RIGHT","SUP-ITM-10006693","CDM","C1713","HCPCS","0278","RC","","","","both","","","3139.08","2354.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2495.57","79.5","","800.18","480.96","1887.97","195","973.11","2495.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X121MM 8 HOLE LCP LEG SS MEDIAL DISTAL RIGHT","SUP-ITM-10006693","CDM","C1713","HCPCS","0278","RC","","","","both","","","3139.08","2354.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1673.13","53.3","","813.12","216.42","1444.50","81","973.11","2495.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X121MM 8 HOLE LCP LEG SS MEDIAL DISTAL RIGHT","SUP-ITM-10006693","CDM","C1713","HCPCS","0278","RC","","","","both","","","3139.08","2354.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","973.11","31","","432.60","432.60","432.60","1 through 10","973.11","2495.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X121MM 8 HOLE LCP LEG SS MEDIAL DISTAL RIGHT","SUP-ITM-10006693","CDM","C1713","HCPCS","0278","RC","","","","both","","","3139.08","2354.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1145.76","36.5","","148.37","54.89","631.39","94","973.11","2495.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X121MM 8 HOLE LCP LEG SS MEDIAL DISTAL RIGHT","SUP-ITM-10006693","CDM","C1713","HCPCS","0278","RC","","","","both","","","3139.08","2354.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1202.27","38.3","","279.30","91.72","1116.77","266","973.11","2495.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X121MM 8 HOLE LCP LEG SS MEDIAL DISTAL RIGHT","SUP-ITM-10006693","CDM","C1713","HCPCS","0278","RC","","","","both","","","3139.08","2354.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1346.67","42.9","","731.00","63.70","731.00","1 through 10","973.11","2495.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X121MM 8 HOLE LCP LEG SS MEDIAL DISTAL RIGHT","SUP-ITM-10006693","CDM","C1713","HCPCS","0278","RC","","","","both","","","3139.08","2354.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1346.67","42.9","","384.74","384.74","384.74","1 through 10","973.11","2495.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X121MM 8 HOLE LCP LEG SS MEDIAL DISTAL RIGHT","SUP-ITM-10006693","CDM","C1713","HCPCS","0278","RC","","","","both","","","3139.08","2354.31","WELLPOINT [1015]","HB AMC WELLPOINT","2316.01","73.78","","286.63","119.22","1107.45","105","973.11","2495.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X121MM 8 HOLE LCP LEG SS MEDIAL DISTAL RIGHT","SUP-ITM-10006693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3139.08","2354.31","AETNA [1001]","HB AMC AETNA HMO","2191.08","69.8","","675.31","184.75","1721.50","286","1640.48","2565.26","percent of total billed charges",""
"TIBIAL PLATE 3.5X121MM 8 HOLE LCP LEG SS MEDIAL DISTAL RIGHT","SUP-ITM-10006693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3139.08","2354.31","AETNA [1001]","HB AMC AETNA PPO","2523.82","80.4","","1261.44","103.12","1514.10","21","1640.48","2565.26","percent of total billed charges",""
"TIBIAL PLATE 3.5X121MM 8 HOLE LCP LEG SS MEDIAL DISTAL RIGHT","SUP-ITM-10006693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3139.08","2354.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2523.82","80.4","","1365.00","1365.00","1365.00","1 through 10","1640.48","2565.26","percent of total billed charges",""
"TIBIAL PLATE 3.5X121MM 8 HOLE LCP LEG SS MEDIAL DISTAL RIGHT","SUP-ITM-10006693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3139.08","2354.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2565.26","81.72","","5157.68","5157.68","5157.68","1 through 10","1640.48","2565.26","percent of total billed charges",""
"TIBIAL PLATE 3.5X121MM 8 HOLE LCP LEG SS MEDIAL DISTAL RIGHT","SUP-ITM-10006693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3139.08","2354.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2565.26","81.72","","431.26","71.26","1459.57","88","1640.48","2565.26","percent of total billed charges",""
"TIBIAL PLATE 3.5X128MM 8 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091041","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.31","2990.48","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3169.91","79.5","","800.18","480.96","1887.97","195","1236.07","3169.91","percent of total billed charges",""
"TIBIAL PLATE 3.5X128MM 8 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091041","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.31","2990.48","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2125.24","53.3","","813.12","216.42","1444.50","81","1236.07","3169.91","percent of total billed charges",""
"TIBIAL PLATE 3.5X128MM 8 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091041","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.31","2990.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1236.07","31","","432.60","432.60","432.60","1 through 10","1236.07","3169.91","percent of total billed charges",""
"TIBIAL PLATE 3.5X128MM 8 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091041","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.31","2990.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1455.37","36.5","","148.37","54.89","631.39","94","1236.07","3169.91","percent of total billed charges",""
"TIBIAL PLATE 3.5X128MM 8 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091041","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.31","2990.48","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1527.14","38.3","","279.30","91.72","1116.77","266","1236.07","3169.91","percent of total billed charges",""
"TIBIAL PLATE 3.5X128MM 8 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091041","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.31","2990.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1710.56","42.9","","731.00","63.70","731.00","1 through 10","1236.07","3169.91","percent of total billed charges",""
"TIBIAL PLATE 3.5X128MM 8 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091041","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.31","2990.48","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1710.56","42.9","","384.74","384.74","384.74","1 through 10","1236.07","3169.91","percent of total billed charges",""
"TIBIAL PLATE 3.5X128MM 8 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091041","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.31","2990.48","WELLPOINT [1015]","HB AMC WELLPOINT","2941.84","73.78","","286.63","119.22","1107.45","105","1236.07","3169.91","percent of total billed charges",""
"TIBIAL PLATE 3.5X128MM 8 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.31","2990.48","AETNA [1001]","HB AMC AETNA HMO","2783.14","69.8","","675.31","184.75","1721.50","286","2083.77","3258.43","percent of total billed charges",""
"TIBIAL PLATE 3.5X128MM 8 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.31","2990.48","AETNA [1001]","HB AMC AETNA PPO","3205.80","80.4","","1261.44","103.12","1514.10","21","2083.77","3258.43","percent of total billed charges",""
"TIBIAL PLATE 3.5X128MM 8 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.31","2990.48","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3205.80","80.4","","1365.00","1365.00","1365.00","1 through 10","2083.77","3258.43","percent of total billed charges",""
"TIBIAL PLATE 3.5X128MM 8 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.31","2990.48","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3258.43","81.72","","5157.68","5157.68","5157.68","1 through 10","2083.77","3258.43","percent of total billed charges",""
"TIBIAL PLATE 3.5X128MM 8 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.31","2990.48","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3258.43","81.72","","431.26","71.26","1459.57","88","2083.77","3258.43","percent of total billed charges",""
"TIBIAL PLATE 3.5X132MM 9 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3824.14","2868.10","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3040.19","79.5","","800.18","480.96","1887.97","195","1185.48","3040.19","percent of total billed charges",""
"TIBIAL PLATE 3.5X132MM 9 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3824.14","2868.10","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2038.27","53.3","","813.12","216.42","1444.50","81","1185.48","3040.19","percent of total billed charges",""
"TIBIAL PLATE 3.5X132MM 9 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3824.14","2868.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1185.48","31","","432.60","432.60","432.60","1 through 10","1185.48","3040.19","percent of total billed charges",""
"TIBIAL PLATE 3.5X132MM 9 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3824.14","2868.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1395.81","36.5","","148.37","54.89","631.39","94","1185.48","3040.19","percent of total billed charges",""
"TIBIAL PLATE 3.5X132MM 9 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3824.14","2868.10","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1464.65","38.3","","279.30","91.72","1116.77","266","1185.48","3040.19","percent of total billed charges",""
"TIBIAL PLATE 3.5X132MM 9 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3824.14","2868.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1640.56","42.9","","731.00","63.70","731.00","1 through 10","1185.48","3040.19","percent of total billed charges",""
"TIBIAL PLATE 3.5X132MM 9 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3824.14","2868.10","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1640.56","42.9","","384.74","384.74","384.74","1 through 10","1185.48","3040.19","percent of total billed charges",""
"TIBIAL PLATE 3.5X132MM 9 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3824.14","2868.10","WELLPOINT [1015]","HB AMC WELLPOINT","2821.45","73.78","","286.63","119.22","1107.45","105","1185.48","3040.19","percent of total billed charges",""
"TIBIAL PLATE 3.5X132MM 9 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3824.14","2868.10","AETNA [1001]","HB AMC AETNA HMO","2669.25","69.8","","675.31","184.75","1721.50","286","1998.5","3125.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X132MM 9 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3824.14","2868.10","AETNA [1001]","HB AMC AETNA PPO","3074.61","80.4","","1261.44","103.12","1514.10","21","1998.5","3125.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X132MM 9 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3824.14","2868.10","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3074.61","80.4","","1365.00","1365.00","1365.00","1 through 10","1998.5","3125.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X132MM 9 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3824.14","2868.10","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3125.09","81.72","","5157.68","5157.68","5157.68","1 through 10","1998.5","3125.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X132MM 9 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3824.14","2868.10","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3125.09","81.72","","431.26","71.26","1459.57","88","1998.5","3125.09","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.64","2576.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2731.33","79.5","","800.18","480.96","1887.97","195","1065.05","2731.33","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.64","2576.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1831.20","53.3","","813.12","216.42","1444.50","81","1065.05","2731.33","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.64","2576.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1065.05","31","","432.60","432.60","432.60","1 through 10","1065.05","2731.33","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.64","2576.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1254.01","36.5","","148.37","54.89","631.39","94","1065.05","2731.33","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.64","2576.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1315.85","38.3","","279.30","91.72","1116.77","266","1065.05","2731.33","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.64","2576.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1473.89","42.9","","731.00","63.70","731.00","1 through 10","1065.05","2731.33","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.64","2576.73","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1473.89","42.9","","384.74","384.74","384.74","1 through 10","1065.05","2731.33","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","3435.64","2576.73","WELLPOINT [1015]","HB AMC WELLPOINT","2534.82","73.78","","286.63","119.22","1107.45","105","1065.05","2731.33","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3435.64","2576.73","AETNA [1001]","HB AMC AETNA HMO","2398.08","69.8","","675.31","184.75","1721.50","286","1795.47","2807.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3435.64","2576.73","AETNA [1001]","HB AMC AETNA PPO","2762.25","80.4","","1261.44","103.12","1514.10","21","1795.47","2807.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3435.64","2576.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2762.25","80.4","","1365.00","1365.00","1365.00","1 through 10","1795.47","2807.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3435.64","2576.73","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2807.61","81.72","","5157.68","5157.68","5157.68","1 through 10","1795.47","2807.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3435.64","2576.73","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2807.61","81.72","","431.26","71.26","1459.57","88","1795.47","2807.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.94","2712.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2875.47","79.5","","800.18","480.96","1887.97","195","1121.25","2875.47","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.94","2712.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1927.83","53.3","","813.12","216.42","1444.50","81","1121.25","2875.47","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.94","2712.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1121.25","31","","432.60","432.60","432.60","1 through 10","1121.25","2875.47","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.94","2712.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1320.18","36.5","","148.37","54.89","631.39","94","1121.25","2875.47","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.94","2712.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1385.29","38.3","","279.30","91.72","1116.77","266","1121.25","2875.47","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.94","2712.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1551.67","42.9","","731.00","63.70","731.00","1 through 10","1121.25","2875.47","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.94","2712.70","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1551.67","42.9","","384.74","384.74","384.74","1 through 10","1121.25","2875.47","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3616.94","2712.70","WELLPOINT [1015]","HB AMC WELLPOINT","2668.58","73.78","","286.63","119.22","1107.45","105","1121.25","2875.47","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3616.94","2712.70","AETNA [1001]","HB AMC AETNA HMO","2524.62","69.8","","675.31","184.75","1721.50","286","1890.21","2955.76","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3616.94","2712.70","AETNA [1001]","HB AMC AETNA PPO","2908.02","80.4","","1261.44","103.12","1514.10","21","1890.21","2955.76","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3616.94","2712.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2908.02","80.4","","1365.00","1365.00","1365.00","1 through 10","1890.21","2955.76","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3616.94","2712.70","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2955.76","81.72","","5157.68","5157.68","5157.68","1 through 10","1890.21","2955.76","percent of total billed charges",""
"TIBIAL PLATE 3.5X142MM 6 HOLE L LCP WITHOUT TAB RIGHT","SUP-ITM-10017928","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3616.94","2712.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2955.76","81.72","","431.26","71.26","1459.57","88","1890.21","2955.76","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.39","2990.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3169.98","79.5","","800.18","480.96","1887.97","195","1236.09","3169.98","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.39","2990.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2125.28","53.3","","813.12","216.42","1444.50","81","1236.09","3169.98","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.39","2990.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1236.09","31","","432.60","432.60","432.60","1 through 10","1236.09","3169.98","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.39","2990.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1455.40","36.5","","148.37","54.89","631.39","94","1236.09","3169.98","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.39","2990.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1527.17","38.3","","279.30","91.72","1116.77","266","1236.09","3169.98","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.39","2990.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1710.59","42.9","","731.00","63.70","731.00","1 through 10","1236.09","3169.98","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.39","2990.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1710.59","42.9","","384.74","384.74","384.74","1 through 10","1236.09","3169.98","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.39","2990.54","WELLPOINT [1015]","HB AMC WELLPOINT","2941.90","73.78","","286.63","119.22","1107.45","105","1236.09","3169.98","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.39","2990.54","AETNA [1001]","HB AMC AETNA HMO","2783.20","69.8","","675.31","184.75","1721.50","286","2083.81","3258.5","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.39","2990.54","AETNA [1001]","HB AMC AETNA PPO","3205.86","80.4","","1261.44","103.12","1514.10","21","2083.81","3258.5","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.39","2990.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3205.86","80.4","","1365.00","1365.00","1365.00","1 through 10","2083.81","3258.5","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.39","2990.54","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3258.50","81.72","","5157.68","5157.68","5157.68","1 through 10","2083.81","3258.5","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.39","2990.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3258.50","81.72","","431.26","71.26","1459.57","88","2083.81","3258.5","percent of total billed charges",""
"TIBIAL PLATE 3.5X147MM 10 HOLE LCP SS LOCKING STRAIGHT RIGHT","SUP-ITM-10006704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3580.68","2685.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2846.64","79.5","","800.18","480.96","1887.97","195","1110.01","2846.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X147MM 10 HOLE LCP SS LOCKING STRAIGHT RIGHT","SUP-ITM-10006704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3580.68","2685.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1908.50","53.3","","813.12","216.42","1444.50","81","1110.01","2846.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X147MM 10 HOLE LCP SS LOCKING STRAIGHT RIGHT","SUP-ITM-10006704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3580.68","2685.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1110.01","31","","432.60","432.60","432.60","1 through 10","1110.01","2846.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X147MM 10 HOLE LCP SS LOCKING STRAIGHT RIGHT","SUP-ITM-10006704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3580.68","2685.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1306.95","36.5","","148.37","54.89","631.39","94","1110.01","2846.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X147MM 10 HOLE LCP SS LOCKING STRAIGHT RIGHT","SUP-ITM-10006704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3580.68","2685.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1371.40","38.3","","279.30","91.72","1116.77","266","1110.01","2846.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X147MM 10 HOLE LCP SS LOCKING STRAIGHT RIGHT","SUP-ITM-10006704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3580.68","2685.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1536.11","42.9","","731.00","63.70","731.00","1 through 10","1110.01","2846.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X147MM 10 HOLE LCP SS LOCKING STRAIGHT RIGHT","SUP-ITM-10006704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3580.68","2685.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1536.11","42.9","","384.74","384.74","384.74","1 through 10","1110.01","2846.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X147MM 10 HOLE LCP SS LOCKING STRAIGHT RIGHT","SUP-ITM-10006704","CDM","C1713","HCPCS","0278","RC","","","","both","","","3580.68","2685.51","WELLPOINT [1015]","HB AMC WELLPOINT","2641.83","73.78","","286.63","119.22","1107.45","105","1110.01","2846.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X147MM 10 HOLE LCP SS LOCKING STRAIGHT RIGHT","SUP-ITM-10006704","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3580.68","2685.51","AETNA [1001]","HB AMC AETNA HMO","2499.31","69.8","","675.31","184.75","1721.50","286","1871.26","2926.13","percent of total billed charges",""
"TIBIAL PLATE 3.5X147MM 10 HOLE LCP SS LOCKING STRAIGHT RIGHT","SUP-ITM-10006704","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3580.68","2685.51","AETNA [1001]","HB AMC AETNA PPO","2878.87","80.4","","1261.44","103.12","1514.10","21","1871.26","2926.13","percent of total billed charges",""
"TIBIAL PLATE 3.5X147MM 10 HOLE LCP SS LOCKING STRAIGHT RIGHT","SUP-ITM-10006704","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3580.68","2685.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2878.87","80.4","","1365.00","1365.00","1365.00","1 through 10","1871.26","2926.13","percent of total billed charges",""
"TIBIAL PLATE 3.5X147MM 10 HOLE LCP SS LOCKING STRAIGHT RIGHT","SUP-ITM-10006704","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3580.68","2685.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2926.13","81.72","","5157.68","5157.68","5157.68","1 through 10","1871.26","2926.13","percent of total billed charges",""
"TIBIAL PLATE 3.5X147MM 10 HOLE LCP SS LOCKING STRAIGHT RIGHT","SUP-ITM-10006704","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3580.68","2685.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2926.13","81.72","","431.26","71.26","1459.57","88","1871.26","2926.13","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE BONE LCP SS LOW BEND PROXIMALIMAL RIGHT","SUP-ITM-10091043","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.73","3064.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3248.16","79.5","","800.18","480.96","1887.97","195","1266.58","3248.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE BONE LCP SS LOW BEND PROXIMALIMAL RIGHT","SUP-ITM-10091043","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.73","3064.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2177.69","53.3","","813.12","216.42","1444.50","81","1266.58","3248.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE BONE LCP SS LOW BEND PROXIMALIMAL RIGHT","SUP-ITM-10091043","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.73","3064.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1266.58","31","","432.60","432.60","432.60","1 through 10","1266.58","3248.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE BONE LCP SS LOW BEND PROXIMALIMAL RIGHT","SUP-ITM-10091043","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.73","3064.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1491.29","36.5","","148.37","54.89","631.39","94","1266.58","3248.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE BONE LCP SS LOW BEND PROXIMALIMAL RIGHT","SUP-ITM-10091043","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.73","3064.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1564.83","38.3","","279.30","91.72","1116.77","266","1266.58","3248.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE BONE LCP SS LOW BEND PROXIMALIMAL RIGHT","SUP-ITM-10091043","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.73","3064.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1752.78","42.9","","731.00","63.70","731.00","1 through 10","1266.58","3248.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE BONE LCP SS LOW BEND PROXIMALIMAL RIGHT","SUP-ITM-10091043","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.73","3064.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1752.78","42.9","","384.74","384.74","384.74","1 through 10","1266.58","3248.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE BONE LCP SS LOW BEND PROXIMALIMAL RIGHT","SUP-ITM-10091043","CDM","C1713","HCPCS","0278","RC","","","","both","","","4085.73","3064.30","WELLPOINT [1015]","HB AMC WELLPOINT","3014.45","73.78","","286.63","119.22","1107.45","105","1266.58","3248.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE BONE LCP SS LOW BEND PROXIMALIMAL RIGHT","SUP-ITM-10091043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.73","3064.30","AETNA [1001]","HB AMC AETNA HMO","2851.84","69.8","","675.31","184.75","1721.50","286","2135.2","3338.86","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE BONE LCP SS LOW BEND PROXIMALIMAL RIGHT","SUP-ITM-10091043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.73","3064.30","AETNA [1001]","HB AMC AETNA PPO","3284.93","80.4","","1261.44","103.12","1514.10","21","2135.2","3338.86","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE BONE LCP SS LOW BEND PROXIMALIMAL RIGHT","SUP-ITM-10091043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.73","3064.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3284.93","80.4","","1365.00","1365.00","1365.00","1 through 10","2135.2","3338.86","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE BONE LCP SS LOW BEND PROXIMALIMAL RIGHT","SUP-ITM-10091043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.73","3064.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3338.86","81.72","","5157.68","5157.68","5157.68","1 through 10","2135.2","3338.86","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE BONE LCP SS LOW BEND PROXIMALIMAL RIGHT","SUP-ITM-10091043","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4085.73","3064.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3338.86","81.72","","431.26","71.26","1459.57","88","2135.2","3338.86","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096143","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.62","3142.96","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3331.54","79.5","","800.18","480.96","1887.97","195","1299.09","3331.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096143","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.62","3142.96","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2233.60","53.3","","813.12","216.42","1444.50","81","1299.09","3331.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096143","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.62","3142.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1299.09","31","","432.60","432.60","432.60","1 through 10","1299.09","3331.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096143","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.62","3142.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1529.58","36.5","","148.37","54.89","631.39","94","1299.09","3331.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096143","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.62","3142.96","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1605.01","38.3","","279.30","91.72","1116.77","266","1299.09","3331.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096143","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.62","3142.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1797.78","42.9","","731.00","63.70","731.00","1 through 10","1299.09","3331.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096143","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.62","3142.96","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1797.78","42.9","","384.74","384.74","384.74","1 through 10","1299.09","3331.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096143","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.62","3142.96","WELLPOINT [1015]","HB AMC WELLPOINT","3091.84","73.78","","286.63","119.22","1107.45","105","1299.09","3331.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4190.62","3142.96","AETNA [1001]","HB AMC AETNA HMO","2925.05","69.8","","675.31","184.75","1721.50","286","2190.02","3424.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4190.62","3142.96","AETNA [1001]","HB AMC AETNA PPO","3369.26","80.4","","1261.44","103.12","1514.10","21","2190.02","3424.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4190.62","3142.96","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3369.26","80.4","","1365.00","1365.00","1365.00","1 through 10","2190.02","3424.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4190.62","3142.96","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3424.57","81.72","","5157.68","5157.68","5157.68","1 through 10","2190.02","3424.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X154MM 10 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4190.62","3142.96","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3424.57","81.72","","431.26","71.26","1459.57","88","2190.02","3424.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X158MM 11 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10018535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3857.81","2893.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3066.96","79.5","","800.18","480.96","1887.97","195","1195.92","3066.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X158MM 11 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10018535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3857.81","2893.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2056.21","53.3","","813.12","216.42","1444.50","81","1195.92","3066.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X158MM 11 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10018535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3857.81","2893.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1195.92","31","","432.60","432.60","432.60","1 through 10","1195.92","3066.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X158MM 11 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10018535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3857.81","2893.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1408.10","36.5","","148.37","54.89","631.39","94","1195.92","3066.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X158MM 11 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10018535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3857.81","2893.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1477.54","38.3","","279.30","91.72","1116.77","266","1195.92","3066.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X158MM 11 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10018535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3857.81","2893.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1655.00","42.9","","731.00","63.70","731.00","1 through 10","1195.92","3066.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X158MM 11 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10018535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3857.81","2893.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1655.00","42.9","","384.74","384.74","384.74","1 through 10","1195.92","3066.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X158MM 11 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10018535","CDM","C1713","HCPCS","0278","RC","","","","both","","","3857.81","2893.36","WELLPOINT [1015]","HB AMC WELLPOINT","2846.29","73.78","","286.63","119.22","1107.45","105","1195.92","3066.96","percent of total billed charges",""
"TIBIAL PLATE 3.5X158MM 11 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10018535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3857.81","2893.36","AETNA [1001]","HB AMC AETNA HMO","2692.75","69.8","","675.31","184.75","1721.50","286","2016.09","3152.6","percent of total billed charges",""
"TIBIAL PLATE 3.5X158MM 11 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10018535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3857.81","2893.36","AETNA [1001]","HB AMC AETNA PPO","3101.68","80.4","","1261.44","103.12","1514.10","21","2016.09","3152.6","percent of total billed charges",""
"TIBIAL PLATE 3.5X158MM 11 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10018535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3857.81","2893.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3101.68","80.4","","1365.00","1365.00","1365.00","1 through 10","2016.09","3152.6","percent of total billed charges",""
"TIBIAL PLATE 3.5X158MM 11 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10018535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3857.81","2893.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3152.60","81.72","","5157.68","5157.68","5157.68","1 through 10","2016.09","3152.6","percent of total billed charges",""
"TIBIAL PLATE 3.5X158MM 11 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10018535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3857.81","2893.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3152.60","81.72","","431.26","71.26","1459.57","88","2016.09","3152.6","percent of total billed charges",""
"TIBIAL PLATE 3.5X159MM 10 HOLE IMAL LCP SS LEFT","SUP-ITM-10018926","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.75","3071.81","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3256.12","79.5","","800.18","480.96","1887.97","195","1269.68","3256.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X159MM 10 HOLE IMAL LCP SS LEFT","SUP-ITM-10018926","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.75","3071.81","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2183.03","53.3","","813.12","216.42","1444.50","81","1269.68","3256.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X159MM 10 HOLE IMAL LCP SS LEFT","SUP-ITM-10018926","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.75","3071.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1269.68","31","","432.60","432.60","432.60","1 through 10","1269.68","3256.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X159MM 10 HOLE IMAL LCP SS LEFT","SUP-ITM-10018926","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.75","3071.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1494.95","36.5","","148.37","54.89","631.39","94","1269.68","3256.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X159MM 10 HOLE IMAL LCP SS LEFT","SUP-ITM-10018926","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.75","3071.81","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1568.67","38.3","","279.30","91.72","1116.77","266","1269.68","3256.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X159MM 10 HOLE IMAL LCP SS LEFT","SUP-ITM-10018926","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.75","3071.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1757.08","42.9","","731.00","63.70","731.00","1 through 10","1269.68","3256.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X159MM 10 HOLE IMAL LCP SS LEFT","SUP-ITM-10018926","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.75","3071.81","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1757.08","42.9","","384.74","384.74","384.74","1 through 10","1269.68","3256.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X159MM 10 HOLE IMAL LCP SS LEFT","SUP-ITM-10018926","CDM","C1713","HCPCS","0278","RC","","","","both","","","4095.75","3071.81","WELLPOINT [1015]","HB AMC WELLPOINT","3021.84","73.78","","286.63","119.22","1107.45","105","1269.68","3256.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X159MM 10 HOLE IMAL LCP SS LEFT","SUP-ITM-10018926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4095.75","3071.81","AETNA [1001]","HB AMC AETNA HMO","2858.83","69.8","","675.31","184.75","1721.50","286","2140.44","3347.05","percent of total billed charges",""
"TIBIAL PLATE 3.5X159MM 10 HOLE IMAL LCP SS LEFT","SUP-ITM-10018926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4095.75","3071.81","AETNA [1001]","HB AMC AETNA PPO","3292.98","80.4","","1261.44","103.12","1514.10","21","2140.44","3347.05","percent of total billed charges",""
"TIBIAL PLATE 3.5X159MM 10 HOLE IMAL LCP SS LEFT","SUP-ITM-10018926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4095.75","3071.81","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3292.98","80.4","","1365.00","1365.00","1365.00","1 through 10","2140.44","3347.05","percent of total billed charges",""
"TIBIAL PLATE 3.5X159MM 10 HOLE IMAL LCP SS LEFT","SUP-ITM-10018926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4095.75","3071.81","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3347.05","81.72","","5157.68","5157.68","5157.68","1 through 10","2140.44","3347.05","percent of total billed charges",""
"TIBIAL PLATE 3.5X159MM 10 HOLE IMAL LCP SS LEFT","SUP-ITM-10018926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4095.75","3071.81","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3347.05","81.72","","431.26","71.26","1459.57","88","2140.44","3347.05","percent of total billed charges",""
"TIBIAL PLATE 3.5X161MM 8 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095113","CDM","C1713","HCPCS","0278","RC","","","","both","","","3469.31","2601.98","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2758.10","79.5","","800.18","480.96","1887.97","195","1075.49","2758.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X161MM 8 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095113","CDM","C1713","HCPCS","0278","RC","","","","both","","","3469.31","2601.98","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1849.14","53.3","","813.12","216.42","1444.50","81","1075.49","2758.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X161MM 8 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095113","CDM","C1713","HCPCS","0278","RC","","","","both","","","3469.31","2601.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1075.49","31","","432.60","432.60","432.60","1 through 10","1075.49","2758.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X161MM 8 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095113","CDM","C1713","HCPCS","0278","RC","","","","both","","","3469.31","2601.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1266.30","36.5","","148.37","54.89","631.39","94","1075.49","2758.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X161MM 8 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095113","CDM","C1713","HCPCS","0278","RC","","","","both","","","3469.31","2601.98","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1328.75","38.3","","279.30","91.72","1116.77","266","1075.49","2758.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X161MM 8 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095113","CDM","C1713","HCPCS","0278","RC","","","","both","","","3469.31","2601.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1488.33","42.9","","731.00","63.70","731.00","1 through 10","1075.49","2758.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X161MM 8 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095113","CDM","C1713","HCPCS","0278","RC","","","","both","","","3469.31","2601.98","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1488.33","42.9","","384.74","384.74","384.74","1 through 10","1075.49","2758.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X161MM 8 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095113","CDM","C1713","HCPCS","0278","RC","","","","both","","","3469.31","2601.98","WELLPOINT [1015]","HB AMC WELLPOINT","2559.66","73.78","","286.63","119.22","1107.45","105","1075.49","2758.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X161MM 8 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3469.31","2601.98","AETNA [1001]","HB AMC AETNA HMO","2421.58","69.8","","675.31","184.75","1721.50","286","1813.06","2835.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X161MM 8 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3469.31","2601.98","AETNA [1001]","HB AMC AETNA PPO","2789.33","80.4","","1261.44","103.12","1514.10","21","1813.06","2835.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X161MM 8 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3469.31","2601.98","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2789.33","80.4","","1365.00","1365.00","1365.00","1 through 10","1813.06","2835.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X161MM 8 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3469.31","2601.98","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2835.12","81.72","","5157.68","5157.68","5157.68","1 through 10","1813.06","2835.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X161MM 8 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL RIGHT","SUP-ITM-10095113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3469.31","2601.98","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2835.12","81.72","","431.26","71.26","1459.57","88","1813.06","2835.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X163MM 12 HOLE IMAL RT SS","SUP-ITM-10005794","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.78","2606.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2763.25","79.5","","800.18","480.96","1887.97","195","1077.49","2763.25","percent of total billed charges",""
"TIBIAL PLATE 3.5X163MM 12 HOLE IMAL RT SS","SUP-ITM-10005794","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.78","2606.83","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1852.59","53.3","","813.12","216.42","1444.50","81","1077.49","2763.25","percent of total billed charges",""
"TIBIAL PLATE 3.5X163MM 12 HOLE IMAL RT SS","SUP-ITM-10005794","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.78","2606.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1077.49","31","","432.60","432.60","432.60","1 through 10","1077.49","2763.25","percent of total billed charges",""
"TIBIAL PLATE 3.5X163MM 12 HOLE IMAL RT SS","SUP-ITM-10005794","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.78","2606.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1268.66","36.5","","148.37","54.89","631.39","94","1077.49","2763.25","percent of total billed charges",""
"TIBIAL PLATE 3.5X163MM 12 HOLE IMAL RT SS","SUP-ITM-10005794","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.78","2606.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1331.22","38.3","","279.30","91.72","1116.77","266","1077.49","2763.25","percent of total billed charges",""
"TIBIAL PLATE 3.5X163MM 12 HOLE IMAL RT SS","SUP-ITM-10005794","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.78","2606.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1491.11","42.9","","731.00","63.70","731.00","1 through 10","1077.49","2763.25","percent of total billed charges",""
"TIBIAL PLATE 3.5X163MM 12 HOLE IMAL RT SS","SUP-ITM-10005794","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.78","2606.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1491.11","42.9","","384.74","384.74","384.74","1 through 10","1077.49","2763.25","percent of total billed charges",""
"TIBIAL PLATE 3.5X163MM 12 HOLE IMAL RT SS","SUP-ITM-10005794","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.78","2606.83","WELLPOINT [1015]","HB AMC WELLPOINT","2564.43","73.78","","286.63","119.22","1107.45","105","1077.49","2763.25","percent of total billed charges",""
"TIBIAL PLATE 3.5X163MM 12 HOLE IMAL RT SS","SUP-ITM-10005794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3475.78","2606.83","AETNA [1001]","HB AMC AETNA HMO","2426.09","69.8","","675.31","184.75","1721.50","286","1816.44","2840.41","percent of total billed charges",""
"TIBIAL PLATE 3.5X163MM 12 HOLE IMAL RT SS","SUP-ITM-10005794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3475.78","2606.83","AETNA [1001]","HB AMC AETNA PPO","2794.53","80.4","","1261.44","103.12","1514.10","21","1816.44","2840.41","percent of total billed charges",""
"TIBIAL PLATE 3.5X163MM 12 HOLE IMAL RT SS","SUP-ITM-10005794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3475.78","2606.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2794.53","80.4","","1365.00","1365.00","1365.00","1 through 10","1816.44","2840.41","percent of total billed charges",""
"TIBIAL PLATE 3.5X163MM 12 HOLE IMAL RT SS","SUP-ITM-10005794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3475.78","2606.83","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2840.41","81.72","","5157.68","5157.68","5157.68","1 through 10","1816.44","2840.41","percent of total billed charges",""
"TIBIAL PLATE 3.5X163MM 12 HOLE IMAL RT SS","SUP-ITM-10005794","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3475.78","2606.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2840.41","81.72","","431.26","71.26","1459.57","88","1816.44","2840.41","percent of total billed charges",""
"TIBIAL PLATE 3.5X168MM 8 HOLE L LCP WITHOUT TAB LEFT","SUP-ITM-10018537","CDM","C1713","HCPCS","0278","RC","","","","both","","","3653.20","2739.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2904.29","79.5","","800.18","480.96","1887.97","195","1132.49","2904.29","percent of total billed charges",""
"TIBIAL PLATE 3.5X168MM 8 HOLE L LCP WITHOUT TAB LEFT","SUP-ITM-10018537","CDM","C1713","HCPCS","0278","RC","","","","both","","","3653.20","2739.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1947.16","53.3","","813.12","216.42","1444.50","81","1132.49","2904.29","percent of total billed charges",""
"TIBIAL PLATE 3.5X168MM 8 HOLE L LCP WITHOUT TAB LEFT","SUP-ITM-10018537","CDM","C1713","HCPCS","0278","RC","","","","both","","","3653.20","2739.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1132.49","31","","432.60","432.60","432.60","1 through 10","1132.49","2904.29","percent of total billed charges",""
"TIBIAL PLATE 3.5X168MM 8 HOLE L LCP WITHOUT TAB LEFT","SUP-ITM-10018537","CDM","C1713","HCPCS","0278","RC","","","","both","","","3653.20","2739.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1333.42","36.5","","148.37","54.89","631.39","94","1132.49","2904.29","percent of total billed charges",""
"TIBIAL PLATE 3.5X168MM 8 HOLE L LCP WITHOUT TAB LEFT","SUP-ITM-10018537","CDM","C1713","HCPCS","0278","RC","","","","both","","","3653.20","2739.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1399.18","38.3","","279.30","91.72","1116.77","266","1132.49","2904.29","percent of total billed charges",""
"TIBIAL PLATE 3.5X168MM 8 HOLE L LCP WITHOUT TAB LEFT","SUP-ITM-10018537","CDM","C1713","HCPCS","0278","RC","","","","both","","","3653.20","2739.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1567.22","42.9","","731.00","63.70","731.00","1 through 10","1132.49","2904.29","percent of total billed charges",""
"TIBIAL PLATE 3.5X168MM 8 HOLE L LCP WITHOUT TAB LEFT","SUP-ITM-10018537","CDM","C1713","HCPCS","0278","RC","","","","both","","","3653.20","2739.90","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1567.22","42.9","","384.74","384.74","384.74","1 through 10","1132.49","2904.29","percent of total billed charges",""
"TIBIAL PLATE 3.5X168MM 8 HOLE L LCP WITHOUT TAB LEFT","SUP-ITM-10018537","CDM","C1713","HCPCS","0278","RC","","","","both","","","3653.20","2739.90","WELLPOINT [1015]","HB AMC WELLPOINT","2695.33","73.78","","286.63","119.22","1107.45","105","1132.49","2904.29","percent of total billed charges",""
"TIBIAL PLATE 3.5X168MM 8 HOLE L LCP WITHOUT TAB LEFT","SUP-ITM-10018537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3653.20","2739.90","AETNA [1001]","HB AMC AETNA HMO","2549.93","69.8","","675.31","184.75","1721.50","286","1909.16","2985.4","percent of total billed charges",""
"TIBIAL PLATE 3.5X168MM 8 HOLE L LCP WITHOUT TAB LEFT","SUP-ITM-10018537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3653.20","2739.90","AETNA [1001]","HB AMC AETNA PPO","2937.17","80.4","","1261.44","103.12","1514.10","21","1909.16","2985.4","percent of total billed charges",""
"TIBIAL PLATE 3.5X168MM 8 HOLE L LCP WITHOUT TAB LEFT","SUP-ITM-10018537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3653.20","2739.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2937.17","80.4","","1365.00","1365.00","1365.00","1 through 10","1909.16","2985.4","percent of total billed charges",""
"TIBIAL PLATE 3.5X168MM 8 HOLE L LCP WITHOUT TAB LEFT","SUP-ITM-10018537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3653.20","2739.90","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2985.40","81.72","","5157.68","5157.68","5157.68","1 through 10","1909.16","2985.4","percent of total billed charges",""
"TIBIAL PLATE 3.5X168MM 8 HOLE L LCP WITHOUT TAB LEFT","SUP-ITM-10018537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3653.20","2739.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2985.40","81.72","","431.26","71.26","1459.57","88","1909.16","2985.4","percent of total billed charges",""
"TIBIAL PLATE 3.5X171MM 10 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.69","3058.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3241.76","79.5","","800.18","480.96","1887.97","195","1264.08","3241.76","percent of total billed charges",""
"TIBIAL PLATE 3.5X171MM 10 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.69","3058.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2173.41","53.3","","813.12","216.42","1444.50","81","1264.08","3241.76","percent of total billed charges",""
"TIBIAL PLATE 3.5X171MM 10 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.69","3058.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1264.08","31","","432.60","432.60","432.60","1 through 10","1264.08","3241.76","percent of total billed charges",""
"TIBIAL PLATE 3.5X171MM 10 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.69","3058.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1488.36","36.5","","148.37","54.89","631.39","94","1264.08","3241.76","percent of total billed charges",""
"TIBIAL PLATE 3.5X171MM 10 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.69","3058.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1561.76","38.3","","279.30","91.72","1116.77","266","1264.08","3241.76","percent of total billed charges",""
"TIBIAL PLATE 3.5X171MM 10 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.69","3058.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1749.33","42.9","","731.00","63.70","731.00","1 through 10","1264.08","3241.76","percent of total billed charges",""
"TIBIAL PLATE 3.5X171MM 10 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.69","3058.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1749.33","42.9","","384.74","384.74","384.74","1 through 10","1264.08","3241.76","percent of total billed charges",""
"TIBIAL PLATE 3.5X171MM 10 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021424","CDM","C1713","HCPCS","0278","RC","","","","both","","","4077.69","3058.27","WELLPOINT [1015]","HB AMC WELLPOINT","3008.52","73.78","","286.63","119.22","1107.45","105","1264.08","3241.76","percent of total billed charges",""
"TIBIAL PLATE 3.5X171MM 10 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.69","3058.27","AETNA [1001]","HB AMC AETNA HMO","2846.23","69.8","","675.31","184.75","1721.50","286","2131","3332.29","percent of total billed charges",""
"TIBIAL PLATE 3.5X171MM 10 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.69","3058.27","AETNA [1001]","HB AMC AETNA PPO","3278.46","80.4","","1261.44","103.12","1514.10","21","2131","3332.29","percent of total billed charges",""
"TIBIAL PLATE 3.5X171MM 10 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.69","3058.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3278.46","80.4","","1365.00","1365.00","1365.00","1 through 10","2131","3332.29","percent of total billed charges",""
"TIBIAL PLATE 3.5X171MM 10 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.69","3058.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3332.29","81.72","","5157.68","5157.68","5157.68","1 through 10","2131","3332.29","percent of total billed charges",""
"TIBIAL PLATE 3.5X171MM 10 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4077.69","3058.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3332.29","81.72","","431.26","71.26","1459.57","88","2131","3332.29","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4958.76","3719.07","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2591.45","52.26","","1113.10","1113.10","1113.10","1 through 10","1537.22","3942.21","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4958.76","3719.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3942.21","79.5","","1293.60","1148.53","1603.80","1 through 10","1537.22","3942.21","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4958.76","3719.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1809.95","36.5","","1023.42","771.29","2068.67","33","1537.22","3942.21","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4958.76","3719.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1899.21","38.3","","850.52","759.78","1211.25","66","1537.22","3942.21","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4958.76","3719.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2127.31","42.9","","2548.09","2548.09","2548.09","1 through 10","1537.22","3942.21","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4958.76","3719.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2127.31","42.9","","956.46","956.46","956.46","1 through 10","1537.22","3942.21","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4958.76","3719.07","WELLPOINT [1015]","HB AMC WELLPOINT","3658.57","73.78","","2344.73","1619.47","2530.35","16","1537.22","3942.21","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4958.76","3719.07","AETNA [1001]","HB AMC AETNA HMO","3461.21","69.8","","1523.63","988.41","4330.26","39","2591.45","4052.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4958.76","3719.07","AETNA [1001]","HB AMC AETNA PPO","3986.84","80.4","","1670.25","1670.25","1670.25","1 through 10","2591.45","4052.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4958.76","3719.07","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2591.45","52.26","","1113.10","1113.10","1113.10","1 through 10","2591.45","4052.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4958.76","3719.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4052.30","81.72","","1738.90","1484.65","2716.94","38","2591.45","4052.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091739","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.30","3243.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3438.61","79.5","","800.18","480.96","1887.97","195","1340.84","3438.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091739","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.30","3243.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2305.38","53.3","","813.12","216.42","1444.50","81","1340.84","3438.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091739","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.30","3243.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1340.84","31","","432.60","432.60","432.60","1 through 10","1340.84","3438.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091739","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.30","3243.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1578.73","36.5","","148.37","54.89","631.39","94","1340.84","3438.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091739","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.30","3243.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1656.59","38.3","","279.30","91.72","1116.77","266","1340.84","3438.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091739","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.30","3243.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1855.55","42.9","","731.00","63.70","731.00","1 through 10","1340.84","3438.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091739","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.30","3243.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1855.55","42.9","","384.74","384.74","384.74","1 through 10","1340.84","3438.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091739","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.30","3243.97","WELLPOINT [1015]","HB AMC WELLPOINT","3191.21","73.78","","286.63","119.22","1107.45","105","1340.84","3438.61","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.30","3243.97","AETNA [1001]","HB AMC AETNA HMO","3019.06","69.8","","675.31","184.75","1721.50","286","2260.4","3534.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.30","3243.97","AETNA [1001]","HB AMC AETNA PPO","3477.54","80.4","","1261.44","103.12","1514.10","21","2260.4","3534.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.30","3243.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3477.54","80.4","","1365.00","1365.00","1365.00","1 through 10","2260.4","3534.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.30","3243.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3534.64","81.72","","5157.68","5157.68","5157.68","1 through 10","2260.4","3534.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.30","3243.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3534.64","81.72","","431.26","71.26","1459.57","88","2260.4","3534.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4388.76","3291.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3489.06","79.5","","800.18","480.96","1887.97","195","1360.52","3489.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4388.76","3291.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2339.21","53.3","","813.12","216.42","1444.50","81","1360.52","3489.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4388.76","3291.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1360.52","31","","432.60","432.60","432.60","1 through 10","1360.52","3489.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4388.76","3291.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1601.90","36.5","","148.37","54.89","631.39","94","1360.52","3489.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4388.76","3291.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1680.90","38.3","","279.30","91.72","1116.77","266","1360.52","3489.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4388.76","3291.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1882.78","42.9","","731.00","63.70","731.00","1 through 10","1360.52","3489.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4388.76","3291.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1882.78","42.9","","384.74","384.74","384.74","1 through 10","1360.52","3489.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4388.76","3291.57","WELLPOINT [1015]","HB AMC WELLPOINT","3238.03","73.78","","286.63","119.22","1107.45","105","1360.52","3489.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4388.76","3291.57","AETNA [1001]","HB AMC AETNA HMO","3063.35","69.8","","675.31","184.75","1721.50","286","2293.57","3586.49","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4388.76","3291.57","AETNA [1001]","HB AMC AETNA PPO","3528.56","80.4","","1261.44","103.12","1514.10","21","2293.57","3586.49","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4388.76","3291.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3528.56","80.4","","1365.00","1365.00","1365.00","1 through 10","2293.57","3586.49","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4388.76","3291.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3586.49","81.72","","5157.68","5157.68","5157.68","1 through 10","2293.57","3586.49","percent of total billed charges",""
"TIBIAL PLATE 3.5X180MM 12 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4388.76","3291.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3586.49","81.72","","431.26","71.26","1459.57","88","2293.57","3586.49","percent of total billed charges",""
"TIBIAL PLATE 3.5X184MM 13 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3903.13","2927.35","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3102.99","79.5","","800.18","480.96","1887.97","195","1209.97","3102.99","percent of total billed charges",""
"TIBIAL PLATE 3.5X184MM 13 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3903.13","2927.35","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2080.37","53.3","","813.12","216.42","1444.50","81","1209.97","3102.99","percent of total billed charges",""
"TIBIAL PLATE 3.5X184MM 13 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3903.13","2927.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1209.97","31","","432.60","432.60","432.60","1 through 10","1209.97","3102.99","percent of total billed charges",""
"TIBIAL PLATE 3.5X184MM 13 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3903.13","2927.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1424.64","36.5","","148.37","54.89","631.39","94","1209.97","3102.99","percent of total billed charges",""
"TIBIAL PLATE 3.5X184MM 13 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3903.13","2927.35","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1494.90","38.3","","279.30","91.72","1116.77","266","1209.97","3102.99","percent of total billed charges",""
"TIBIAL PLATE 3.5X184MM 13 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3903.13","2927.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1674.44","42.9","","731.00","63.70","731.00","1 through 10","1209.97","3102.99","percent of total billed charges",""
"TIBIAL PLATE 3.5X184MM 13 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3903.13","2927.35","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1674.44","42.9","","384.74","384.74","384.74","1 through 10","1209.97","3102.99","percent of total billed charges",""
"TIBIAL PLATE 3.5X184MM 13 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3903.13","2927.35","WELLPOINT [1015]","HB AMC WELLPOINT","2879.73","73.78","","286.63","119.22","1107.45","105","1209.97","3102.99","percent of total billed charges",""
"TIBIAL PLATE 3.5X184MM 13 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3903.13","2927.35","AETNA [1001]","HB AMC AETNA HMO","2724.38","69.8","","675.31","184.75","1721.50","286","2039.78","3189.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X184MM 13 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3903.13","2927.35","AETNA [1001]","HB AMC AETNA PPO","3138.12","80.4","","1261.44","103.12","1514.10","21","2039.78","3189.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X184MM 13 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3903.13","2927.35","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3138.12","80.4","","1365.00","1365.00","1365.00","1 through 10","2039.78","3189.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X184MM 13 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3903.13","2927.35","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3189.64","81.72","","5157.68","5157.68","5157.68","1 through 10","2039.78","3189.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X184MM 13 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3903.13","2927.35","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3189.64","81.72","","431.26","71.26","1459.57","88","2039.78","3189.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X185MM 12 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018927","CDM","C1713","HCPCS","0278","RC","","","","both","","","4173.15","3129.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3317.65","79.5","","800.18","480.96","1887.97","195","1293.68","3317.65","percent of total billed charges",""
"TIBIAL PLATE 3.5X185MM 12 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018927","CDM","C1713","HCPCS","0278","RC","","","","both","","","4173.15","3129.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2224.29","53.3","","813.12","216.42","1444.50","81","1293.68","3317.65","percent of total billed charges",""
"TIBIAL PLATE 3.5X185MM 12 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018927","CDM","C1713","HCPCS","0278","RC","","","","both","","","4173.15","3129.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1293.68","31","","432.60","432.60","432.60","1 through 10","1293.68","3317.65","percent of total billed charges",""
"TIBIAL PLATE 3.5X185MM 12 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018927","CDM","C1713","HCPCS","0278","RC","","","","both","","","4173.15","3129.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1523.20","36.5","","148.37","54.89","631.39","94","1293.68","3317.65","percent of total billed charges",""
"TIBIAL PLATE 3.5X185MM 12 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018927","CDM","C1713","HCPCS","0278","RC","","","","both","","","4173.15","3129.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1598.32","38.3","","279.30","91.72","1116.77","266","1293.68","3317.65","percent of total billed charges",""
"TIBIAL PLATE 3.5X185MM 12 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018927","CDM","C1713","HCPCS","0278","RC","","","","both","","","4173.15","3129.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1790.28","42.9","","731.00","63.70","731.00","1 through 10","1293.68","3317.65","percent of total billed charges",""
"TIBIAL PLATE 3.5X185MM 12 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018927","CDM","C1713","HCPCS","0278","RC","","","","both","","","4173.15","3129.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1790.28","42.9","","384.74","384.74","384.74","1 through 10","1293.68","3317.65","percent of total billed charges",""
"TIBIAL PLATE 3.5X185MM 12 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018927","CDM","C1713","HCPCS","0278","RC","","","","both","","","4173.15","3129.86","WELLPOINT [1015]","HB AMC WELLPOINT","3078.95","73.78","","286.63","119.22","1107.45","105","1293.68","3317.65","percent of total billed charges",""
"TIBIAL PLATE 3.5X185MM 12 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4173.15","3129.86","AETNA [1001]","HB AMC AETNA HMO","2912.86","69.8","","675.31","184.75","1721.50","286","2180.89","3410.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X185MM 12 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4173.15","3129.86","AETNA [1001]","HB AMC AETNA PPO","3355.21","80.4","","1261.44","103.12","1514.10","21","2180.89","3410.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X185MM 12 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4173.15","3129.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3355.21","80.4","","1365.00","1365.00","1365.00","1 through 10","2180.89","3410.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X185MM 12 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4173.15","3129.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3410.30","81.72","","5157.68","5157.68","5157.68","1 through 10","2180.89","3410.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X185MM 12 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4173.15","3129.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3410.30","81.72","","431.26","71.26","1459.57","88","2180.89","3410.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X189MM 14 HOLE IMAL RT SS","SUP-ITM-10005913","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.04","2634.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2792.07","79.5","","800.18","480.96","1887.97","195","1088.73","2792.07","percent of total billed charges",""
"TIBIAL PLATE 3.5X189MM 14 HOLE IMAL RT SS","SUP-ITM-10005913","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.04","2634.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1871.92","53.3","","813.12","216.42","1444.50","81","1088.73","2792.07","percent of total billed charges",""
"TIBIAL PLATE 3.5X189MM 14 HOLE IMAL RT SS","SUP-ITM-10005913","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.04","2634.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1088.73","31","","432.60","432.60","432.60","1 through 10","1088.73","2792.07","percent of total billed charges",""
"TIBIAL PLATE 3.5X189MM 14 HOLE IMAL RT SS","SUP-ITM-10005913","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.04","2634.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1281.89","36.5","","148.37","54.89","631.39","94","1088.73","2792.07","percent of total billed charges",""
"TIBIAL PLATE 3.5X189MM 14 HOLE IMAL RT SS","SUP-ITM-10005913","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.04","2634.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1345.11","38.3","","279.30","91.72","1116.77","266","1088.73","2792.07","percent of total billed charges",""
"TIBIAL PLATE 3.5X189MM 14 HOLE IMAL RT SS","SUP-ITM-10005913","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.04","2634.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1506.67","42.9","","731.00","63.70","731.00","1 through 10","1088.73","2792.07","percent of total billed charges",""
"TIBIAL PLATE 3.5X189MM 14 HOLE IMAL RT SS","SUP-ITM-10005913","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.04","2634.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1506.67","42.9","","384.74","384.74","384.74","1 through 10","1088.73","2792.07","percent of total billed charges",""
"TIBIAL PLATE 3.5X189MM 14 HOLE IMAL RT SS","SUP-ITM-10005913","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.04","2634.03","WELLPOINT [1015]","HB AMC WELLPOINT","2591.18","73.78","","286.63","119.22","1107.45","105","1088.73","2792.07","percent of total billed charges",""
"TIBIAL PLATE 3.5X189MM 14 HOLE IMAL RT SS","SUP-ITM-10005913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.04","2634.03","AETNA [1001]","HB AMC AETNA HMO","2451.40","69.8","","675.31","184.75","1721.50","286","1835.39","2870.04","percent of total billed charges",""
"TIBIAL PLATE 3.5X189MM 14 HOLE IMAL RT SS","SUP-ITM-10005913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.04","2634.03","AETNA [1001]","HB AMC AETNA PPO","2823.68","80.4","","1261.44","103.12","1514.10","21","1835.39","2870.04","percent of total billed charges",""
"TIBIAL PLATE 3.5X189MM 14 HOLE IMAL RT SS","SUP-ITM-10005913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.04","2634.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2823.68","80.4","","1365.00","1365.00","1365.00","1 through 10","1835.39","2870.04","percent of total billed charges",""
"TIBIAL PLATE 3.5X189MM 14 HOLE IMAL RT SS","SUP-ITM-10005913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.04","2634.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2870.04","81.72","","5157.68","5157.68","5157.68","1 through 10","1835.39","2870.04","percent of total billed charges",""
"TIBIAL PLATE 3.5X189MM 14 HOLE IMAL RT SS","SUP-ITM-10005913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.04","2634.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2870.04","81.72","","431.26","71.26","1459.57","88","1835.39","2870.04","percent of total billed charges",""
"TIBIAL PLATE 3.5X210MM 15 HOLE LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10022136","CDM","C1713","HCPCS","0278","RC","","","","both","","","3954.93","2966.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3144.17","79.5","","800.18","480.96","1887.97","195","1226.03","3144.17","percent of total billed charges",""
"TIBIAL PLATE 3.5X210MM 15 HOLE LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10022136","CDM","C1713","HCPCS","0278","RC","","","","both","","","3954.93","2966.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2107.98","53.3","","813.12","216.42","1444.50","81","1226.03","3144.17","percent of total billed charges",""
"TIBIAL PLATE 3.5X210MM 15 HOLE LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10022136","CDM","C1713","HCPCS","0278","RC","","","","both","","","3954.93","2966.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1226.03","31","","432.60","432.60","432.60","1 through 10","1226.03","3144.17","percent of total billed charges",""
"TIBIAL PLATE 3.5X210MM 15 HOLE LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10022136","CDM","C1713","HCPCS","0278","RC","","","","both","","","3954.93","2966.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1443.55","36.5","","148.37","54.89","631.39","94","1226.03","3144.17","percent of total billed charges",""
"TIBIAL PLATE 3.5X210MM 15 HOLE LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10022136","CDM","C1713","HCPCS","0278","RC","","","","both","","","3954.93","2966.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1514.74","38.3","","279.30","91.72","1116.77","266","1226.03","3144.17","percent of total billed charges",""
"TIBIAL PLATE 3.5X210MM 15 HOLE LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10022136","CDM","C1713","HCPCS","0278","RC","","","","both","","","3954.93","2966.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1696.66","42.9","","731.00","63.70","731.00","1 through 10","1226.03","3144.17","percent of total billed charges",""
"TIBIAL PLATE 3.5X210MM 15 HOLE LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10022136","CDM","C1713","HCPCS","0278","RC","","","","both","","","3954.93","2966.20","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1696.66","42.9","","384.74","384.74","384.74","1 through 10","1226.03","3144.17","percent of total billed charges",""
"TIBIAL PLATE 3.5X210MM 15 HOLE LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10022136","CDM","C1713","HCPCS","0278","RC","","","","both","","","3954.93","2966.20","WELLPOINT [1015]","HB AMC WELLPOINT","2917.95","73.78","","286.63","119.22","1107.45","105","1226.03","3144.17","percent of total billed charges",""
"TIBIAL PLATE 3.5X210MM 15 HOLE LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10022136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3954.93","2966.20","AETNA [1001]","HB AMC AETNA HMO","2760.54","69.8","","675.31","184.75","1721.50","286","2066.85","3231.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X210MM 15 HOLE LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10022136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3954.93","2966.20","AETNA [1001]","HB AMC AETNA PPO","3179.76","80.4","","1261.44","103.12","1514.10","21","2066.85","3231.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X210MM 15 HOLE LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10022136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3954.93","2966.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3179.76","80.4","","1365.00","1365.00","1365.00","1 through 10","2066.85","3231.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X210MM 15 HOLE LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10022136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3954.93","2966.20","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3231.97","81.72","","5157.68","5157.68","5157.68","1 through 10","2066.85","3231.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X210MM 15 HOLE LCP SS ANTEROLATERAL DISTAL LEFT","SUP-ITM-10022136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3954.93","2966.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3231.97","81.72","","431.26","71.26","1459.57","88","2066.85","3231.97","percent of total billed charges",""
"TIBIAL PLATE 3.5X211MM 14 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018929","CDM","C1713","HCPCS","0278","RC","","","","both","","","4231.20","3173.40","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3363.80","79.5","","800.18","480.96","1887.97","195","1311.67","3363.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X211MM 14 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018929","CDM","C1713","HCPCS","0278","RC","","","","both","","","4231.20","3173.40","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2255.23","53.3","","813.12","216.42","1444.50","81","1311.67","3363.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X211MM 14 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018929","CDM","C1713","HCPCS","0278","RC","","","","both","","","4231.20","3173.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1311.67","31","","432.60","432.60","432.60","1 through 10","1311.67","3363.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X211MM 14 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018929","CDM","C1713","HCPCS","0278","RC","","","","both","","","4231.20","3173.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1544.39","36.5","","148.37","54.89","631.39","94","1311.67","3363.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X211MM 14 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018929","CDM","C1713","HCPCS","0278","RC","","","","both","","","4231.20","3173.40","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1620.55","38.3","","279.30","91.72","1116.77","266","1311.67","3363.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X211MM 14 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018929","CDM","C1713","HCPCS","0278","RC","","","","both","","","4231.20","3173.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1815.18","42.9","","731.00","63.70","731.00","1 through 10","1311.67","3363.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X211MM 14 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018929","CDM","C1713","HCPCS","0278","RC","","","","both","","","4231.20","3173.40","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1815.18","42.9","","384.74","384.74","384.74","1 through 10","1311.67","3363.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X211MM 14 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018929","CDM","C1713","HCPCS","0278","RC","","","","both","","","4231.20","3173.40","WELLPOINT [1015]","HB AMC WELLPOINT","3121.78","73.78","","286.63","119.22","1107.45","105","1311.67","3363.8","percent of total billed charges",""
"TIBIAL PLATE 3.5X211MM 14 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4231.20","3173.40","AETNA [1001]","HB AMC AETNA HMO","2953.38","69.8","","675.31","184.75","1721.50","286","2211.23","3457.74","percent of total billed charges",""
"TIBIAL PLATE 3.5X211MM 14 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4231.20","3173.40","AETNA [1001]","HB AMC AETNA PPO","3401.88","80.4","","1261.44","103.12","1514.10","21","2211.23","3457.74","percent of total billed charges",""
"TIBIAL PLATE 3.5X211MM 14 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4231.20","3173.40","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3401.88","80.4","","1365.00","1365.00","1365.00","1 through 10","2211.23","3457.74","percent of total billed charges",""
"TIBIAL PLATE 3.5X211MM 14 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4231.20","3173.40","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3457.74","81.72","","5157.68","5157.68","5157.68","1 through 10","2211.23","3457.74","percent of total billed charges",""
"TIBIAL PLATE 3.5X211MM 14 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4231.20","3173.40","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3457.74","81.72","","431.26","71.26","1459.57","88","2211.23","3457.74","percent of total billed charges",""
"TIBIAL PLATE 3.5X215MM 16 HOLE SS IMAL LEFT","SUP-ITM-10005910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3758.09","2818.57","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2987.68","79.5","","800.18","480.96","1887.97","195","1165.01","2987.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X215MM 16 HOLE SS IMAL LEFT","SUP-ITM-10005910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3758.09","2818.57","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2003.06","53.3","","813.12","216.42","1444.50","81","1165.01","2987.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X215MM 16 HOLE SS IMAL LEFT","SUP-ITM-10005910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3758.09","2818.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1165.01","31","","432.60","432.60","432.60","1 through 10","1165.01","2987.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X215MM 16 HOLE SS IMAL LEFT","SUP-ITM-10005910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3758.09","2818.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1371.70","36.5","","148.37","54.89","631.39","94","1165.01","2987.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X215MM 16 HOLE SS IMAL LEFT","SUP-ITM-10005910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3758.09","2818.57","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1439.35","38.3","","279.30","91.72","1116.77","266","1165.01","2987.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X215MM 16 HOLE SS IMAL LEFT","SUP-ITM-10005910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3758.09","2818.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1612.22","42.9","","731.00","63.70","731.00","1 through 10","1165.01","2987.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X215MM 16 HOLE SS IMAL LEFT","SUP-ITM-10005910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3758.09","2818.57","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1612.22","42.9","","384.74","384.74","384.74","1 through 10","1165.01","2987.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X215MM 16 HOLE SS IMAL LEFT","SUP-ITM-10005910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3758.09","2818.57","WELLPOINT [1015]","HB AMC WELLPOINT","2772.72","73.78","","286.63","119.22","1107.45","105","1165.01","2987.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X215MM 16 HOLE SS IMAL LEFT","SUP-ITM-10005910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3758.09","2818.57","AETNA [1001]","HB AMC AETNA HMO","2623.15","69.8","","675.31","184.75","1721.50","286","1963.98","3071.11","percent of total billed charges",""
"TIBIAL PLATE 3.5X215MM 16 HOLE SS IMAL LEFT","SUP-ITM-10005910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3758.09","2818.57","AETNA [1001]","HB AMC AETNA PPO","3021.50","80.4","","1261.44","103.12","1514.10","21","1963.98","3071.11","percent of total billed charges",""
"TIBIAL PLATE 3.5X215MM 16 HOLE SS IMAL LEFT","SUP-ITM-10005910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3758.09","2818.57","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3021.50","80.4","","1365.00","1365.00","1365.00","1 through 10","1963.98","3071.11","percent of total billed charges",""
"TIBIAL PLATE 3.5X215MM 16 HOLE SS IMAL LEFT","SUP-ITM-10005910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3758.09","2818.57","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3071.11","81.72","","5157.68","5157.68","5157.68","1 through 10","1963.98","3071.11","percent of total billed charges",""
"TIBIAL PLATE 3.5X215MM 16 HOLE SS IMAL LEFT","SUP-ITM-10005910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3758.09","2818.57","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3071.11","81.72","","431.26","71.26","1459.57","88","1963.98","3071.11","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE LCP SS LOW BEND IMAL RT","SUP-ITM-10091768","CDM","C1713","HCPCS","0278","RC","","","","both","","","4545.45","3409.09","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3613.63","79.5","","800.18","480.96","1887.97","195","1409.09","3613.63","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE LCP SS LOW BEND IMAL RT","SUP-ITM-10091768","CDM","C1713","HCPCS","0278","RC","","","","both","","","4545.45","3409.09","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2422.72","53.3","","813.12","216.42","1444.50","81","1409.09","3613.63","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE LCP SS LOW BEND IMAL RT","SUP-ITM-10091768","CDM","C1713","HCPCS","0278","RC","","","","both","","","4545.45","3409.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1409.09","31","","432.60","432.60","432.60","1 through 10","1409.09","3613.63","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE LCP SS LOW BEND IMAL RT","SUP-ITM-10091768","CDM","C1713","HCPCS","0278","RC","","","","both","","","4545.45","3409.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1659.09","36.5","","148.37","54.89","631.39","94","1409.09","3613.63","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE LCP SS LOW BEND IMAL RT","SUP-ITM-10091768","CDM","C1713","HCPCS","0278","RC","","","","both","","","4545.45","3409.09","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1740.91","38.3","","279.30","91.72","1116.77","266","1409.09","3613.63","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE LCP SS LOW BEND IMAL RT","SUP-ITM-10091768","CDM","C1713","HCPCS","0278","RC","","","","both","","","4545.45","3409.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1950.00","42.9","","731.00","63.70","731.00","1 through 10","1409.09","3613.63","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE LCP SS LOW BEND IMAL RT","SUP-ITM-10091768","CDM","C1713","HCPCS","0278","RC","","","","both","","","4545.45","3409.09","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1950.00","42.9","","384.74","384.74","384.74","1 through 10","1409.09","3613.63","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE LCP SS LOW BEND IMAL RT","SUP-ITM-10091768","CDM","C1713","HCPCS","0278","RC","","","","both","","","4545.45","3409.09","WELLPOINT [1015]","HB AMC WELLPOINT","3353.63","73.78","","286.63","119.22","1107.45","105","1409.09","3613.63","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE LCP SS LOW BEND IMAL RT","SUP-ITM-10091768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4545.45","3409.09","AETNA [1001]","HB AMC AETNA HMO","3172.72","69.8","","675.31","184.75","1721.50","286","2375.45","3714.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE LCP SS LOW BEND IMAL RT","SUP-ITM-10091768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4545.45","3409.09","AETNA [1001]","HB AMC AETNA PPO","3654.54","80.4","","1261.44","103.12","1514.10","21","2375.45","3714.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE LCP SS LOW BEND IMAL RT","SUP-ITM-10091768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4545.45","3409.09","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3654.54","80.4","","1365.00","1365.00","1365.00","1 through 10","2375.45","3714.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE LCP SS LOW BEND IMAL RT","SUP-ITM-10091768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4545.45","3409.09","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3714.54","81.72","","5157.68","5157.68","5157.68","1 through 10","2375.45","3714.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE LCP SS LOW BEND IMAL RT","SUP-ITM-10091768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4545.45","3409.09","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3714.54","81.72","","431.26","71.26","1459.57","88","2375.45","3714.54","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.84","2950.38","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3127.40","79.5","","800.18","480.96","1887.97","195","1219.49","3127.4","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.84","2950.38","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2096.74","53.3","","813.12","216.42","1444.50","81","1219.49","3127.4","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.84","2950.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1219.49","31","","432.60","432.60","432.60","1 through 10","1219.49","3127.4","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.84","2950.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1435.85","36.5","","148.37","54.89","631.39","94","1219.49","3127.4","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.84","2950.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1506.66","38.3","","279.30","91.72","1116.77","266","1219.49","3127.4","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.84","2950.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.62","42.9","","731.00","63.70","731.00","1 through 10","1219.49","3127.4","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.84","2950.38","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.62","42.9","","384.74","384.74","384.74","1 through 10","1219.49","3127.4","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3933.84","2950.38","WELLPOINT [1015]","HB AMC WELLPOINT","2902.39","73.78","","286.63","119.22","1107.45","105","1219.49","3127.4","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3933.84","2950.38","AETNA [1001]","HB AMC AETNA HMO","2745.82","69.8","","675.31","184.75","1721.50","286","2055.82","3214.73","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3933.84","2950.38","AETNA [1001]","HB AMC AETNA PPO","3162.81","80.4","","1261.44","103.12","1514.10","21","2055.82","3214.73","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3933.84","2950.38","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3162.81","80.4","","1365.00","1365.00","1365.00","1 through 10","2055.82","3214.73","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3933.84","2950.38","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3214.73","81.72","","5157.68","5157.68","5157.68","1 through 10","2055.82","3214.73","percent of total billed charges",""
"TIBIAL PLATE 3.5X232MM 16 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3933.84","2950.38","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3214.73","81.72","","431.26","71.26","1459.57","88","2055.82","3214.73","percent of total billed charges",""
"TIBIAL PLATE 3.5X237MM 16 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018931","CDM","C1713","HCPCS","0278","RC","","","","both","","","4527.90","3395.92","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3599.68","79.5","","800.18","480.96","1887.97","195","1403.65","3599.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X237MM 16 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018931","CDM","C1713","HCPCS","0278","RC","","","","both","","","4527.90","3395.92","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2413.37","53.3","","813.12","216.42","1444.50","81","1403.65","3599.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X237MM 16 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018931","CDM","C1713","HCPCS","0278","RC","","","","both","","","4527.90","3395.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1403.65","31","","432.60","432.60","432.60","1 through 10","1403.65","3599.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X237MM 16 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018931","CDM","C1713","HCPCS","0278","RC","","","","both","","","4527.90","3395.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1652.68","36.5","","148.37","54.89","631.39","94","1403.65","3599.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X237MM 16 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018931","CDM","C1713","HCPCS","0278","RC","","","","both","","","4527.90","3395.92","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1734.19","38.3","","279.30","91.72","1116.77","266","1403.65","3599.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X237MM 16 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018931","CDM","C1713","HCPCS","0278","RC","","","","both","","","4527.90","3395.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1942.47","42.9","","731.00","63.70","731.00","1 through 10","1403.65","3599.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X237MM 16 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018931","CDM","C1713","HCPCS","0278","RC","","","","both","","","4527.90","3395.92","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1942.47","42.9","","384.74","384.74","384.74","1 through 10","1403.65","3599.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X237MM 16 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018931","CDM","C1713","HCPCS","0278","RC","","","","both","","","4527.90","3395.92","WELLPOINT [1015]","HB AMC WELLPOINT","3340.68","73.78","","286.63","119.22","1107.45","105","1403.65","3599.68","percent of total billed charges",""
"TIBIAL PLATE 3.5X237MM 16 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4527.90","3395.92","AETNA [1001]","HB AMC AETNA HMO","3160.47","69.8","","675.31","184.75","1721.50","286","2366.28","3700.2","percent of total billed charges",""
"TIBIAL PLATE 3.5X237MM 16 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4527.90","3395.92","AETNA [1001]","HB AMC AETNA PPO","3640.43","80.4","","1261.44","103.12","1514.10","21","2366.28","3700.2","percent of total billed charges",""
"TIBIAL PLATE 3.5X237MM 16 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4527.90","3395.92","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3640.43","80.4","","1365.00","1365.00","1365.00","1 through 10","2366.28","3700.2","percent of total billed charges",""
"TIBIAL PLATE 3.5X237MM 16 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4527.90","3395.92","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3700.20","81.72","","5157.68","5157.68","5157.68","1 through 10","2366.28","3700.2","percent of total billed charges",""
"TIBIAL PLATE 3.5X237MM 16 HOLE IMAL LCP SS RIGHT","SUP-ITM-10018931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4527.90","3395.92","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3700.20","81.72","","431.26","71.26","1459.57","88","2366.28","3700.2","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3812.48","2859.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3030.92","79.5","","800.18","480.96","1887.97","195","1181.87","3030.92","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3812.48","2859.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2032.05","53.3","","813.12","216.42","1444.50","81","1181.87","3030.92","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3812.48","2859.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1181.87","31","","432.60","432.60","432.60","1 through 10","1181.87","3030.92","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3812.48","2859.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1391.56","36.5","","148.37","54.89","631.39","94","1181.87","3030.92","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3812.48","2859.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1460.18","38.3","","279.30","91.72","1116.77","266","1181.87","3030.92","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3812.48","2859.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1635.55","42.9","","731.00","63.70","731.00","1 through 10","1181.87","3030.92","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3812.48","2859.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1635.55","42.9","","384.74","384.74","384.74","1 through 10","1181.87","3030.92","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","both","","","3812.48","2859.36","WELLPOINT [1015]","HB AMC WELLPOINT","2812.85","73.78","","286.63","119.22","1107.45","105","1181.87","3030.92","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3812.48","2859.36","AETNA [1001]","HB AMC AETNA HMO","2661.11","69.8","","675.31","184.75","1721.50","286","1992.4","3115.56","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3812.48","2859.36","AETNA [1001]","HB AMC AETNA PPO","3065.23","80.4","","1261.44","103.12","1514.10","21","1992.4","3115.56","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3812.48","2859.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3065.23","80.4","","1365.00","1365.00","1365.00","1 through 10","1992.4","3115.56","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3812.48","2859.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3115.56","81.72","","5157.68","5157.68","5157.68","1 through 10","1992.4","3115.56","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE L LCP SS LOW BEND IMAL LEFT","SUP-ITM-10091038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3812.48","2859.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3115.56","81.72","","431.26","71.26","1459.57","88","1992.4","3115.56","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4191.92","3143.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3332.58","79.5","","800.18","480.96","1887.97","195","1299.5","3332.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4191.92","3143.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2234.29","53.3","","813.12","216.42","1444.50","81","1299.5","3332.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4191.92","3143.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1299.50","31","","432.60","432.60","432.60","1 through 10","1299.5","3332.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4191.92","3143.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1530.05","36.5","","148.37","54.89","631.39","94","1299.5","3332.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4191.92","3143.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1605.51","38.3","","279.30","91.72","1116.77","266","1299.5","3332.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4191.92","3143.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1798.33","42.9","","731.00","63.70","731.00","1 through 10","1299.5","3332.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4191.92","3143.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1798.33","42.9","","384.74","384.74","384.74","1 through 10","1299.5","3332.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4191.92","3143.94","WELLPOINT [1015]","HB AMC WELLPOINT","3092.80","73.78","","286.63","119.22","1107.45","105","1299.5","3332.58","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4191.92","3143.94","AETNA [1001]","HB AMC AETNA HMO","2925.96","69.8","","675.31","184.75","1721.50","286","2190.7","3425.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4191.92","3143.94","AETNA [1001]","HB AMC AETNA PPO","3370.30","80.4","","1261.44","103.12","1514.10","21","2190.7","3425.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4191.92","3143.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3370.30","80.4","","1365.00","1365.00","1365.00","1 through 10","2190.7","3425.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4191.92","3143.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3425.64","81.72","","5157.68","5157.68","5157.68","1 through 10","2190.7","3425.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10097001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4191.92","3143.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3425.64","81.72","","431.26","71.26","1459.57","88","2190.7","3425.64","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.17","3036.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3218.30","79.5","","800.18","480.96","1887.97","195","1254.93","3218.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.17","3036.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2157.67","53.3","","813.12","216.42","1444.50","81","1254.93","3218.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.17","3036.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1254.93","31","","432.60","432.60","432.60","1 through 10","1254.93","3218.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.17","3036.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1477.58","36.5","","148.37","54.89","631.39","94","1254.93","3218.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.17","3036.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1550.45","38.3","","279.30","91.72","1116.77","266","1254.93","3218.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.17","3036.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1736.66","42.9","","731.00","63.70","731.00","1 through 10","1254.93","3218.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.17","3036.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1736.66","42.9","","384.74","384.74","384.74","1 through 10","1254.93","3218.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096137","CDM","C1713","HCPCS","0278","RC","","","","both","","","4048.17","3036.13","WELLPOINT [1015]","HB AMC WELLPOINT","2986.74","73.78","","286.63","119.22","1107.45","105","1254.93","3218.3","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4048.17","3036.13","AETNA [1001]","HB AMC AETNA HMO","2825.62","69.8","","675.31","184.75","1721.50","286","2115.57","3308.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4048.17","3036.13","AETNA [1001]","HB AMC AETNA PPO","3254.73","80.4","","1261.44","103.12","1514.10","21","2115.57","3308.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4048.17","3036.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3254.73","80.4","","1365.00","1365.00","1365.00","1 through 10","2115.57","3308.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4048.17","3036.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3308.16","81.72","","5157.68","5157.68","5157.68","1 through 10","2115.57","3308.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X76MM 4 HOLE PROXIMAL LOW BEND LCP TITANIUM RIGHT","SUP-ITM-10096137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4048.17","3036.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3308.16","81.72","","431.26","71.26","1459.57","88","2115.57","3308.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019987","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3075.20","79.5","","800.18","480.96","1887.97","195","1199.13","3075.2","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019987","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2061.73","53.3","","813.12","216.42","1444.50","81","1199.13","3075.2","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019987","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1199.13","31","","432.60","432.60","432.60","1 through 10","1199.13","3075.2","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019987","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1411.88","36.5","","148.37","54.89","631.39","94","1199.13","3075.2","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019987","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1481.51","38.3","","279.30","91.72","1116.77","266","1199.13","3075.2","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019987","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1659.44","42.9","","731.00","63.70","731.00","1 through 10","1199.13","3075.2","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019987","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1659.44","42.9","","384.74","384.74","384.74","1 through 10","1199.13","3075.2","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019987","CDM","C1713","HCPCS","0278","RC","","","","both","","","3868.17","2901.13","WELLPOINT [1015]","HB AMC WELLPOINT","2853.94","73.78","","286.63","119.22","1107.45","105","1199.13","3075.2","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019987","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3868.17","2901.13","AETNA [1001]","HB AMC AETNA HMO","2699.98","69.8","","675.31","184.75","1721.50","286","2021.51","3161.07","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019987","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3868.17","2901.13","AETNA [1001]","HB AMC AETNA PPO","3110.01","80.4","","1261.44","103.12","1514.10","21","2021.51","3161.07","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019987","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3868.17","2901.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3110.01","80.4","","1365.00","1365.00","1365.00","1 through 10","2021.51","3161.07","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019987","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3868.17","2901.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3161.07","81.72","","5157.68","5157.68","5157.68","1 through 10","2021.51","3161.07","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP RIGHT","SUP-ITM-10019987","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3868.17","2901.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3161.07","81.72","","431.26","71.26","1459.57","88","2021.51","3161.07","percent of total billed charges",""
"TIBIAL PLATE 3.5X81MM 4 HOLE IMAL LCP SS LEFT","SUP-ITM-10018590","CDM","C1713","HCPCS","0278","RC","","","","both","","","4393.10","3294.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3492.51","79.5","","800.18","480.96","1887.97","195","1361.86","3492.51","percent of total billed charges",""
"TIBIAL PLATE 3.5X81MM 4 HOLE IMAL LCP SS LEFT","SUP-ITM-10018590","CDM","C1713","HCPCS","0278","RC","","","","both","","","4393.10","3294.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2341.52","53.3","","813.12","216.42","1444.50","81","1361.86","3492.51","percent of total billed charges",""
"TIBIAL PLATE 3.5X81MM 4 HOLE IMAL LCP SS LEFT","SUP-ITM-10018590","CDM","C1713","HCPCS","0278","RC","","","","both","","","4393.10","3294.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1361.86","31","","432.60","432.60","432.60","1 through 10","1361.86","3492.51","percent of total billed charges",""
"TIBIAL PLATE 3.5X81MM 4 HOLE IMAL LCP SS LEFT","SUP-ITM-10018590","CDM","C1713","HCPCS","0278","RC","","","","both","","","4393.10","3294.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1603.48","36.5","","148.37","54.89","631.39","94","1361.86","3492.51","percent of total billed charges",""
"TIBIAL PLATE 3.5X81MM 4 HOLE IMAL LCP SS LEFT","SUP-ITM-10018590","CDM","C1713","HCPCS","0278","RC","","","","both","","","4393.10","3294.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1682.56","38.3","","279.30","91.72","1116.77","266","1361.86","3492.51","percent of total billed charges",""
"TIBIAL PLATE 3.5X81MM 4 HOLE IMAL LCP SS LEFT","SUP-ITM-10018590","CDM","C1713","HCPCS","0278","RC","","","","both","","","4393.10","3294.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1884.64","42.9","","731.00","63.70","731.00","1 through 10","1361.86","3492.51","percent of total billed charges",""
"TIBIAL PLATE 3.5X81MM 4 HOLE IMAL LCP SS LEFT","SUP-ITM-10018590","CDM","C1713","HCPCS","0278","RC","","","","both","","","4393.10","3294.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1884.64","42.9","","384.74","384.74","384.74","1 through 10","1361.86","3492.51","percent of total billed charges",""
"TIBIAL PLATE 3.5X81MM 4 HOLE IMAL LCP SS LEFT","SUP-ITM-10018590","CDM","C1713","HCPCS","0278","RC","","","","both","","","4393.10","3294.82","WELLPOINT [1015]","HB AMC WELLPOINT","3241.23","73.78","","286.63","119.22","1107.45","105","1361.86","3492.51","percent of total billed charges",""
"TIBIAL PLATE 3.5X81MM 4 HOLE IMAL LCP SS LEFT","SUP-ITM-10018590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4393.10","3294.82","AETNA [1001]","HB AMC AETNA HMO","3066.38","69.8","","675.31","184.75","1721.50","286","2295.83","3590.04","percent of total billed charges",""
"TIBIAL PLATE 3.5X81MM 4 HOLE IMAL LCP SS LEFT","SUP-ITM-10018590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4393.10","3294.82","AETNA [1001]","HB AMC AETNA PPO","3532.05","80.4","","1261.44","103.12","1514.10","21","2295.83","3590.04","percent of total billed charges",""
"TIBIAL PLATE 3.5X81MM 4 HOLE IMAL LCP SS LEFT","SUP-ITM-10018590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4393.10","3294.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3532.05","80.4","","1365.00","1365.00","1365.00","1 through 10","2295.83","3590.04","percent of total billed charges",""
"TIBIAL PLATE 3.5X81MM 4 HOLE IMAL LCP SS LEFT","SUP-ITM-10018590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4393.10","3294.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3590.04","81.72","","5157.68","5157.68","5157.68","1 through 10","2295.83","3590.04","percent of total billed charges",""
"TIBIAL PLATE 3.5X81MM 4 HOLE IMAL LCP SS LEFT","SUP-ITM-10018590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4393.10","3294.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3590.04","81.72","","431.26","71.26","1459.57","88","2295.83","3590.04","percent of total billed charges",""
"TIBIAL PLATE 3.5X85MM 6 HOLE SS IMAL LEFT","SUP-ITM-10037938","CDM","C1713","HCPCS","0278","RC","","","","both","","","3820.25","2865.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3037.10","79.5","","800.18","480.96","1887.97","195","1184.28","3037.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X85MM 6 HOLE SS IMAL LEFT","SUP-ITM-10037938","CDM","C1713","HCPCS","0278","RC","","","","both","","","3820.25","2865.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2036.19","53.3","","813.12","216.42","1444.50","81","1184.28","3037.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X85MM 6 HOLE SS IMAL LEFT","SUP-ITM-10037938","CDM","C1713","HCPCS","0278","RC","","","","both","","","3820.25","2865.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1184.28","31","","432.60","432.60","432.60","1 through 10","1184.28","3037.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X85MM 6 HOLE SS IMAL LEFT","SUP-ITM-10037938","CDM","C1713","HCPCS","0278","RC","","","","both","","","3820.25","2865.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1394.39","36.5","","148.37","54.89","631.39","94","1184.28","3037.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X85MM 6 HOLE SS IMAL LEFT","SUP-ITM-10037938","CDM","C1713","HCPCS","0278","RC","","","","both","","","3820.25","2865.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1463.16","38.3","","279.30","91.72","1116.77","266","1184.28","3037.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X85MM 6 HOLE SS IMAL LEFT","SUP-ITM-10037938","CDM","C1713","HCPCS","0278","RC","","","","both","","","3820.25","2865.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1638.89","42.9","","731.00","63.70","731.00","1 through 10","1184.28","3037.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X85MM 6 HOLE SS IMAL LEFT","SUP-ITM-10037938","CDM","C1713","HCPCS","0278","RC","","","","both","","","3820.25","2865.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1638.89","42.9","","384.74","384.74","384.74","1 through 10","1184.28","3037.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X85MM 6 HOLE SS IMAL LEFT","SUP-ITM-10037938","CDM","C1713","HCPCS","0278","RC","","","","both","","","3820.25","2865.19","WELLPOINT [1015]","HB AMC WELLPOINT","2818.58","73.78","","286.63","119.22","1107.45","105","1184.28","3037.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X85MM 6 HOLE SS IMAL LEFT","SUP-ITM-10037938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3820.25","2865.19","AETNA [1001]","HB AMC AETNA HMO","2666.53","69.8","","675.31","184.75","1721.50","286","1996.46","3121.91","percent of total billed charges",""
"TIBIAL PLATE 3.5X85MM 6 HOLE SS IMAL LEFT","SUP-ITM-10037938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3820.25","2865.19","AETNA [1001]","HB AMC AETNA PPO","3071.48","80.4","","1261.44","103.12","1514.10","21","1996.46","3121.91","percent of total billed charges",""
"TIBIAL PLATE 3.5X85MM 6 HOLE SS IMAL LEFT","SUP-ITM-10037938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3820.25","2865.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3071.48","80.4","","1365.00","1365.00","1365.00","1 through 10","1996.46","3121.91","percent of total billed charges",""
"TIBIAL PLATE 3.5X85MM 6 HOLE SS IMAL LEFT","SUP-ITM-10037938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3820.25","2865.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3121.91","81.72","","5157.68","5157.68","5157.68","1 through 10","1996.46","3121.91","percent of total billed charges",""
"TIBIAL PLATE 3.5X85MM 6 HOLE SS IMAL LEFT","SUP-ITM-10037938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3820.25","2865.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3121.91","81.72","","431.26","71.26","1459.57","88","1996.46","3121.91","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE PROXIMAL MEDIAL LCP STAILNESS STEEL RIGHT","SUP-ITM-10019285","CDM","C1713","HCPCS","0278","RC","","","","both","","","3978.77","2984.08","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3163.12","79.5","","800.18","480.96","1887.97","195","1233.42","3163.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE PROXIMAL MEDIAL LCP STAILNESS STEEL RIGHT","SUP-ITM-10019285","CDM","C1713","HCPCS","0278","RC","","","","both","","","3978.77","2984.08","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2120.68","53.3","","813.12","216.42","1444.50","81","1233.42","3163.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE PROXIMAL MEDIAL LCP STAILNESS STEEL RIGHT","SUP-ITM-10019285","CDM","C1713","HCPCS","0278","RC","","","","both","","","3978.77","2984.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1233.42","31","","432.60","432.60","432.60","1 through 10","1233.42","3163.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE PROXIMAL MEDIAL LCP STAILNESS STEEL RIGHT","SUP-ITM-10019285","CDM","C1713","HCPCS","0278","RC","","","","both","","","3978.77","2984.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1452.25","36.5","","148.37","54.89","631.39","94","1233.42","3163.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE PROXIMAL MEDIAL LCP STAILNESS STEEL RIGHT","SUP-ITM-10019285","CDM","C1713","HCPCS","0278","RC","","","","both","","","3978.77","2984.08","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1523.87","38.3","","279.30","91.72","1116.77","266","1233.42","3163.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE PROXIMAL MEDIAL LCP STAILNESS STEEL RIGHT","SUP-ITM-10019285","CDM","C1713","HCPCS","0278","RC","","","","both","","","3978.77","2984.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1706.89","42.9","","731.00","63.70","731.00","1 through 10","1233.42","3163.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE PROXIMAL MEDIAL LCP STAILNESS STEEL RIGHT","SUP-ITM-10019285","CDM","C1713","HCPCS","0278","RC","","","","both","","","3978.77","2984.08","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1706.89","42.9","","384.74","384.74","384.74","1 through 10","1233.42","3163.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE PROXIMAL MEDIAL LCP STAILNESS STEEL RIGHT","SUP-ITM-10019285","CDM","C1713","HCPCS","0278","RC","","","","both","","","3978.77","2984.08","WELLPOINT [1015]","HB AMC WELLPOINT","2935.54","73.78","","286.63","119.22","1107.45","105","1233.42","3163.12","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE PROXIMAL MEDIAL LCP STAILNESS STEEL RIGHT","SUP-ITM-10019285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3978.77","2984.08","AETNA [1001]","HB AMC AETNA HMO","2777.18","69.8","","675.31","184.75","1721.50","286","2079.31","3251.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE PROXIMAL MEDIAL LCP STAILNESS STEEL RIGHT","SUP-ITM-10019285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3978.77","2984.08","AETNA [1001]","HB AMC AETNA PPO","3198.93","80.4","","1261.44","103.12","1514.10","21","2079.31","3251.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE PROXIMAL MEDIAL LCP STAILNESS STEEL RIGHT","SUP-ITM-10019285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3978.77","2984.08","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3198.93","80.4","","1365.00","1365.00","1365.00","1 through 10","2079.31","3251.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE PROXIMAL MEDIAL LCP STAILNESS STEEL RIGHT","SUP-ITM-10019285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3978.77","2984.08","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3251.45","81.72","","5157.68","5157.68","5157.68","1 through 10","2079.31","3251.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE PROXIMAL MEDIAL LCP STAILNESS STEEL RIGHT","SUP-ITM-10019285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3978.77","2984.08","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3251.45","81.72","","431.26","71.26","1459.57","88","2079.31","3251.45","percent of total billed charges",""
"TIBIAL PLATE 3.5X95MM 6 HOLE LCP LEG SS RIGHT MEDIAL DISTAL","SUP-ITM-10006691","CDM","C1713","HCPCS","0278","RC","","","","both","","","2701.37","2026.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2147.59","79.5","","800.18","480.96","1887.97","195","837.42","2147.59","percent of total billed charges",""
"TIBIAL PLATE 3.5X95MM 6 HOLE LCP LEG SS RIGHT MEDIAL DISTAL","SUP-ITM-10006691","CDM","C1713","HCPCS","0278","RC","","","","both","","","2701.37","2026.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1439.83","53.3","","813.12","216.42","1444.50","81","837.42","2147.59","percent of total billed charges",""
"TIBIAL PLATE 3.5X95MM 6 HOLE LCP LEG SS RIGHT MEDIAL DISTAL","SUP-ITM-10006691","CDM","C1713","HCPCS","0278","RC","","","","both","","","2701.37","2026.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","837.42","31","","432.60","432.60","432.60","1 through 10","837.42","2147.59","percent of total billed charges",""
"TIBIAL PLATE 3.5X95MM 6 HOLE LCP LEG SS RIGHT MEDIAL DISTAL","SUP-ITM-10006691","CDM","C1713","HCPCS","0278","RC","","","","both","","","2701.37","2026.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","986.00","36.5","","148.37","54.89","631.39","94","837.42","2147.59","percent of total billed charges",""
"TIBIAL PLATE 3.5X95MM 6 HOLE LCP LEG SS RIGHT MEDIAL DISTAL","SUP-ITM-10006691","CDM","C1713","HCPCS","0278","RC","","","","both","","","2701.37","2026.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1034.62","38.3","","279.30","91.72","1116.77","266","837.42","2147.59","percent of total billed charges",""
"TIBIAL PLATE 3.5X95MM 6 HOLE LCP LEG SS RIGHT MEDIAL DISTAL","SUP-ITM-10006691","CDM","C1713","HCPCS","0278","RC","","","","both","","","2701.37","2026.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1158.89","42.9","","731.00","63.70","731.00","1 through 10","837.42","2147.59","percent of total billed charges",""
"TIBIAL PLATE 3.5X95MM 6 HOLE LCP LEG SS RIGHT MEDIAL DISTAL","SUP-ITM-10006691","CDM","C1713","HCPCS","0278","RC","","","","both","","","2701.37","2026.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1158.89","42.9","","384.74","384.74","384.74","1 through 10","837.42","2147.59","percent of total billed charges",""
"TIBIAL PLATE 3.5X95MM 6 HOLE LCP LEG SS RIGHT MEDIAL DISTAL","SUP-ITM-10006691","CDM","C1713","HCPCS","0278","RC","","","","both","","","2701.37","2026.03","WELLPOINT [1015]","HB AMC WELLPOINT","1993.07","73.78","","286.63","119.22","1107.45","105","837.42","2147.59","percent of total billed charges",""
"TIBIAL PLATE 3.5X95MM 6 HOLE LCP LEG SS RIGHT MEDIAL DISTAL","SUP-ITM-10006691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2701.37","2026.03","AETNA [1001]","HB AMC AETNA HMO","1885.56","69.8","","675.31","184.75","1721.50","286","1411.74","2207.56","percent of total billed charges",""
"TIBIAL PLATE 3.5X95MM 6 HOLE LCP LEG SS RIGHT MEDIAL DISTAL","SUP-ITM-10006691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2701.37","2026.03","AETNA [1001]","HB AMC AETNA PPO","2171.90","80.4","","1261.44","103.12","1514.10","21","1411.74","2207.56","percent of total billed charges",""
"TIBIAL PLATE 3.5X95MM 6 HOLE LCP LEG SS RIGHT MEDIAL DISTAL","SUP-ITM-10006691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2701.37","2026.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2171.90","80.4","","1365.00","1365.00","1365.00","1 through 10","1411.74","2207.56","percent of total billed charges",""
"TIBIAL PLATE 3.5X95MM 6 HOLE LCP LEG SS RIGHT MEDIAL DISTAL","SUP-ITM-10006691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2701.37","2026.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2207.56","81.72","","5157.68","5157.68","5157.68","1 through 10","1411.74","2207.56","percent of total billed charges",""
"TIBIAL PLATE 3.5X95MM 6 HOLE LCP LEG SS RIGHT MEDIAL DISTAL","SUP-ITM-10006691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2701.37","2026.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2207.56","81.72","","431.26","71.26","1459.57","88","1411.74","2207.56","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.98","2627.23","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2784.87","79.5","","800.18","480.96","1887.97","195","1085.92","2784.87","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.98","2627.23","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1867.09","53.3","","813.12","216.42","1444.50","81","1085.92","2784.87","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.98","2627.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1085.92","31","","432.60","432.60","432.60","1 through 10","1085.92","2784.87","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.98","2627.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1278.59","36.5","","148.37","54.89","631.39","94","1085.92","2784.87","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.98","2627.23","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1341.64","38.3","","279.30","91.72","1116.77","266","1085.92","2784.87","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.98","2627.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1502.78","42.9","","731.00","63.70","731.00","1 through 10","1085.92","2784.87","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.98","2627.23","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1502.78","42.9","","384.74","384.74","384.74","1 through 10","1085.92","2784.87","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.98","2627.23","WELLPOINT [1015]","HB AMC WELLPOINT","2584.50","73.78","","286.63","119.22","1107.45","105","1085.92","2784.87","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.98","2627.23","AETNA [1001]","HB AMC AETNA HMO","2445.08","69.8","","675.31","184.75","1721.50","286","1830.66","2862.64","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.98","2627.23","AETNA [1001]","HB AMC AETNA PPO","2816.40","80.4","","1261.44","103.12","1514.10","21","1830.66","2862.64","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.98","2627.23","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2816.40","80.4","","1365.00","1365.00","1365.00","1 through 10","1830.66","2862.64","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.98","2627.23","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2862.64","81.72","","5157.68","5157.68","5157.68","1 through 10","1830.66","2862.64","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.98","2627.23","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2862.64","81.72","","431.26","71.26","1459.57","88","1830.66","2862.64","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10030079","CDM","C1713","HCPCS","0278","RC","","","","both","","","4499.52","3374.64","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3577.12","79.5","","800.18","480.96","1887.97","195","1394.85","3577.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10030079","CDM","C1713","HCPCS","0278","RC","","","","both","","","4499.52","3374.64","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2398.24","53.3","","813.12","216.42","1444.50","81","1394.85","3577.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10030079","CDM","C1713","HCPCS","0278","RC","","","","both","","","4499.52","3374.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1394.85","31","","432.60","432.60","432.60","1 through 10","1394.85","3577.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10030079","CDM","C1713","HCPCS","0278","RC","","","","both","","","4499.52","3374.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1642.32","36.5","","148.37","54.89","631.39","94","1394.85","3577.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10030079","CDM","C1713","HCPCS","0278","RC","","","","both","","","4499.52","3374.64","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1723.32","38.3","","279.30","91.72","1116.77","266","1394.85","3577.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10030079","CDM","C1713","HCPCS","0278","RC","","","","both","","","4499.52","3374.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.29","42.9","","731.00","63.70","731.00","1 through 10","1394.85","3577.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10030079","CDM","C1713","HCPCS","0278","RC","","","","both","","","4499.52","3374.64","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1930.29","42.9","","384.74","384.74","384.74","1 through 10","1394.85","3577.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10030079","CDM","C1713","HCPCS","0278","RC","","","","both","","","4499.52","3374.64","WELLPOINT [1015]","HB AMC WELLPOINT","3319.75","73.78","","286.63","119.22","1107.45","105","1394.85","3577.12","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10030079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4499.52","3374.64","AETNA [1001]","HB AMC AETNA HMO","3140.66","69.8","","675.31","184.75","1721.50","286","2351.45","3677.01","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10030079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4499.52","3374.64","AETNA [1001]","HB AMC AETNA PPO","3617.61","80.4","","1261.44","103.12","1514.10","21","2351.45","3677.01","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10030079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4499.52","3374.64","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3617.61","80.4","","1365.00","1365.00","1365.00","1 through 10","2351.45","3677.01","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10030079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4499.52","3374.64","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3677.01","81.72","","5157.68","5157.68","5157.68","1 through 10","2351.45","3677.01","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10030079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4499.52","3374.64","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3677.01","81.72","","431.26","71.26","1459.57","88","2351.45","3677.01","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4090.59","3067.94","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3252.02","79.5","","800.18","480.96","1887.97","195","1268.08","3252.02","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4090.59","3067.94","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2180.28","53.3","","813.12","216.42","1444.50","81","1268.08","3252.02","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4090.59","3067.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1268.08","31","","432.60","432.60","432.60","1 through 10","1268.08","3252.02","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4090.59","3067.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1493.07","36.5","","148.37","54.89","631.39","94","1268.08","3252.02","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4090.59","3067.94","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1566.70","38.3","","279.30","91.72","1116.77","266","1268.08","3252.02","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4090.59","3067.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1754.86","42.9","","731.00","63.70","731.00","1 through 10","1268.08","3252.02","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4090.59","3067.94","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1754.86","42.9","","384.74","384.74","384.74","1 through 10","1268.08","3252.02","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037890","CDM","C1713","HCPCS","0278","RC","","","","both","","","4090.59","3067.94","WELLPOINT [1015]","HB AMC WELLPOINT","3018.04","73.78","","286.63","119.22","1107.45","105","1268.08","3252.02","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4090.59","3067.94","AETNA [1001]","HB AMC AETNA HMO","2855.23","69.8","","675.31","184.75","1721.50","286","2137.74","3342.83","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4090.59","3067.94","AETNA [1001]","HB AMC AETNA PPO","3288.83","80.4","","1261.44","103.12","1514.10","21","2137.74","3342.83","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4090.59","3067.94","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3288.83","80.4","","1365.00","1365.00","1365.00","1 through 10","2137.74","3342.83","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4090.59","3067.94","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3342.83","81.72","","5157.68","5157.68","5157.68","1 through 10","2137.74","3342.83","percent of total billed charges",""
"TIBIAL PLATE 4.5X106MM 4 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10037890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4090.59","3067.94","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3342.83","81.72","","431.26","71.26","1459.57","88","2137.74","3342.83","percent of total billed charges",""
"TIBIAL PLATE 4.5X109MM 6 HOLE SS IMAL RIGHT","SUP-ITM-10005751","CDM","C1713","HCPCS","0278","RC","","","","both","","","3596.22","2697.16","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2858.99","79.5","","800.18","480.96","1887.97","195","1114.83","2858.99","percent of total billed charges",""
"TIBIAL PLATE 4.5X109MM 6 HOLE SS IMAL RIGHT","SUP-ITM-10005751","CDM","C1713","HCPCS","0278","RC","","","","both","","","3596.22","2697.16","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1916.79","53.3","","813.12","216.42","1444.50","81","1114.83","2858.99","percent of total billed charges",""
"TIBIAL PLATE 4.5X109MM 6 HOLE SS IMAL RIGHT","SUP-ITM-10005751","CDM","C1713","HCPCS","0278","RC","","","","both","","","3596.22","2697.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1114.83","31","","432.60","432.60","432.60","1 through 10","1114.83","2858.99","percent of total billed charges",""
"TIBIAL PLATE 4.5X109MM 6 HOLE SS IMAL RIGHT","SUP-ITM-10005751","CDM","C1713","HCPCS","0278","RC","","","","both","","","3596.22","2697.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1312.62","36.5","","148.37","54.89","631.39","94","1114.83","2858.99","percent of total billed charges",""
"TIBIAL PLATE 4.5X109MM 6 HOLE SS IMAL RIGHT","SUP-ITM-10005751","CDM","C1713","HCPCS","0278","RC","","","","both","","","3596.22","2697.16","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1377.35","38.3","","279.30","91.72","1116.77","266","1114.83","2858.99","percent of total billed charges",""
"TIBIAL PLATE 4.5X109MM 6 HOLE SS IMAL RIGHT","SUP-ITM-10005751","CDM","C1713","HCPCS","0278","RC","","","","both","","","3596.22","2697.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1542.78","42.9","","731.00","63.70","731.00","1 through 10","1114.83","2858.99","percent of total billed charges",""
"TIBIAL PLATE 4.5X109MM 6 HOLE SS IMAL RIGHT","SUP-ITM-10005751","CDM","C1713","HCPCS","0278","RC","","","","both","","","3596.22","2697.16","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1542.78","42.9","","384.74","384.74","384.74","1 through 10","1114.83","2858.99","percent of total billed charges",""
"TIBIAL PLATE 4.5X109MM 6 HOLE SS IMAL RIGHT","SUP-ITM-10005751","CDM","C1713","HCPCS","0278","RC","","","","both","","","3596.22","2697.16","WELLPOINT [1015]","HB AMC WELLPOINT","2653.29","73.78","","286.63","119.22","1107.45","105","1114.83","2858.99","percent of total billed charges",""
"TIBIAL PLATE 4.5X109MM 6 HOLE SS IMAL RIGHT","SUP-ITM-10005751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3596.22","2697.16","AETNA [1001]","HB AMC AETNA HMO","2510.16","69.8","","675.31","184.75","1721.50","286","1879.38","2938.83","percent of total billed charges",""
"TIBIAL PLATE 4.5X109MM 6 HOLE SS IMAL RIGHT","SUP-ITM-10005751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3596.22","2697.16","AETNA [1001]","HB AMC AETNA PPO","2891.36","80.4","","1261.44","103.12","1514.10","21","1879.38","2938.83","percent of total billed charges",""
"TIBIAL PLATE 4.5X109MM 6 HOLE SS IMAL RIGHT","SUP-ITM-10005751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3596.22","2697.16","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2891.36","80.4","","1365.00","1365.00","1365.00","1 through 10","1879.38","2938.83","percent of total billed charges",""
"TIBIAL PLATE 4.5X109MM 6 HOLE SS IMAL RIGHT","SUP-ITM-10005751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3596.22","2697.16","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2938.83","81.72","","5157.68","5157.68","5157.68","1 through 10","1879.38","2938.83","percent of total billed charges",""
"TIBIAL PLATE 4.5X109MM 6 HOLE SS IMAL RIGHT","SUP-ITM-10005751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3596.22","2697.16","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2938.83","81.72","","431.26","71.26","1459.57","88","1879.38","2938.83","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","4044.81","3033.61","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3215.62","79.5","","800.18","480.96","1887.97","195","1253.89","3215.62","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","4044.81","3033.61","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2155.88","53.3","","813.12","216.42","1444.50","81","1253.89","3215.62","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","4044.81","3033.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1253.89","31","","432.60","432.60","432.60","1 through 10","1253.89","3215.62","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","4044.81","3033.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1476.36","36.5","","148.37","54.89","631.39","94","1253.89","3215.62","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","4044.81","3033.61","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1549.16","38.3","","279.30","91.72","1116.77","266","1253.89","3215.62","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","4044.81","3033.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1735.22","42.9","","731.00","63.70","731.00","1 through 10","1253.89","3215.62","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","4044.81","3033.61","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1735.22","42.9","","384.74","384.74","384.74","1 through 10","1253.89","3215.62","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","4044.81","3033.61","WELLPOINT [1015]","HB AMC WELLPOINT","2984.26","73.78","","286.63","119.22","1107.45","105","1253.89","3215.62","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4044.81","3033.61","AETNA [1001]","HB AMC AETNA HMO","2823.28","69.8","","675.31","184.75","1721.50","286","2113.82","3305.42","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4044.81","3033.61","AETNA [1001]","HB AMC AETNA PPO","3252.03","80.4","","1261.44","103.12","1514.10","21","2113.82","3305.42","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4044.81","3033.61","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3252.03","80.4","","1365.00","1365.00","1365.00","1 through 10","2113.82","3305.42","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4044.81","3033.61","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3305.42","81.72","","5157.68","5157.68","5157.68","1 through 10","2113.82","3305.42","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4044.81","3033.61","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3305.42","81.72","","431.26","71.26","1459.57","88","2113.82","3305.42","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3147.26","79.5","","800.18","480.96","1887.97","195","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2110.05","53.3","","813.12","216.42","1444.50","81","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1227.23","31","","432.60","432.60","432.60","1 through 10","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1444.97","36.5","","148.37","54.89","631.39","94","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1516.23","38.3","","279.30","91.72","1116.77","266","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.33","42.9","","731.00","63.70","731.00","1 through 10","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.33","42.9","","384.74","384.74","384.74","1 through 10","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007495","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","WELLPOINT [1015]","HB AMC WELLPOINT","2920.82","73.78","","286.63","119.22","1107.45","105","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007495","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3958.82","2969.11","AETNA [1001]","HB AMC AETNA HMO","2763.26","69.8","","675.31","184.75","1721.50","286","2068.88","3235.15","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007495","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3958.82","2969.11","AETNA [1001]","HB AMC AETNA PPO","3182.89","80.4","","1261.44","103.12","1514.10","21","2068.88","3235.15","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007495","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3958.82","2969.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3182.89","80.4","","1365.00","1365.00","1365.00","1 through 10","2068.88","3235.15","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007495","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3958.82","2969.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3235.15","81.72","","5157.68","5157.68","5157.68","1 through 10","2068.88","3235.15","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007495","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3958.82","2969.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3235.15","81.72","","431.26","71.26","1459.57","88","2068.88","3235.15","percent of total billed charges",""
"TIBIAL PLATE 4.5X142MM 6 HOLE MEDIAL PROXIMAL LCP SS LEFT","SUP-ITM-10037896","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.99","3416.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3621.22","79.5","","800.18","480.96","1887.97","195","1412.05","3621.22","percent of total billed charges",""
"TIBIAL PLATE 4.5X142MM 6 HOLE MEDIAL PROXIMAL LCP SS LEFT","SUP-ITM-10037896","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.99","3416.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2427.81","53.3","","813.12","216.42","1444.50","81","1412.05","3621.22","percent of total billed charges",""
"TIBIAL PLATE 4.5X142MM 6 HOLE MEDIAL PROXIMAL LCP SS LEFT","SUP-ITM-10037896","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.99","3416.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1412.05","31","","432.60","432.60","432.60","1 through 10","1412.05","3621.22","percent of total billed charges",""
"TIBIAL PLATE 4.5X142MM 6 HOLE MEDIAL PROXIMAL LCP SS LEFT","SUP-ITM-10037896","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.99","3416.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1662.57","36.5","","148.37","54.89","631.39","94","1412.05","3621.22","percent of total billed charges",""
"TIBIAL PLATE 4.5X142MM 6 HOLE MEDIAL PROXIMAL LCP SS LEFT","SUP-ITM-10037896","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.99","3416.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1744.56","38.3","","279.30","91.72","1116.77","266","1412.05","3621.22","percent of total billed charges",""
"TIBIAL PLATE 4.5X142MM 6 HOLE MEDIAL PROXIMAL LCP SS LEFT","SUP-ITM-10037896","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.99","3416.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1954.09","42.9","","731.00","63.70","731.00","1 through 10","1412.05","3621.22","percent of total billed charges",""
"TIBIAL PLATE 4.5X142MM 6 HOLE MEDIAL PROXIMAL LCP SS LEFT","SUP-ITM-10037896","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.99","3416.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1954.09","42.9","","384.74","384.74","384.74","1 through 10","1412.05","3621.22","percent of total billed charges",""
"TIBIAL PLATE 4.5X142MM 6 HOLE MEDIAL PROXIMAL LCP SS LEFT","SUP-ITM-10037896","CDM","C1713","HCPCS","0278","RC","","","","both","","","4554.99","3416.24","WELLPOINT [1015]","HB AMC WELLPOINT","3360.67","73.78","","286.63","119.22","1107.45","105","1412.05","3621.22","percent of total billed charges",""
"TIBIAL PLATE 4.5X142MM 6 HOLE MEDIAL PROXIMAL LCP SS LEFT","SUP-ITM-10037896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4554.99","3416.24","AETNA [1001]","HB AMC AETNA HMO","3179.38","69.8","","675.31","184.75","1721.50","286","2380.44","3722.34","percent of total billed charges",""
"TIBIAL PLATE 4.5X142MM 6 HOLE MEDIAL PROXIMAL LCP SS LEFT","SUP-ITM-10037896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4554.99","3416.24","AETNA [1001]","HB AMC AETNA PPO","3662.21","80.4","","1261.44","103.12","1514.10","21","2380.44","3722.34","percent of total billed charges",""
"TIBIAL PLATE 4.5X142MM 6 HOLE MEDIAL PROXIMAL LCP SS LEFT","SUP-ITM-10037896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4554.99","3416.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3662.21","80.4","","1365.00","1365.00","1365.00","1 through 10","2380.44","3722.34","percent of total billed charges",""
"TIBIAL PLATE 4.5X142MM 6 HOLE MEDIAL PROXIMAL LCP SS LEFT","SUP-ITM-10037896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4554.99","3416.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3722.34","81.72","","5157.68","5157.68","5157.68","1 through 10","2380.44","3722.34","percent of total billed charges",""
"TIBIAL PLATE 4.5X142MM 6 HOLE MEDIAL PROXIMAL LCP SS LEFT","SUP-ITM-10037896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4554.99","3416.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3722.34","81.72","","431.26","71.26","1459.57","88","2380.44","3722.34","percent of total billed charges",""
"TIBIAL PLATE 4.5X145MM 8 HOLE SS IMAL RIGHT","SUP-ITM-10005753","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.36","2727.27","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2890.91","79.5","","800.18","480.96","1887.97","195","1127.27","2890.91","percent of total billed charges",""
"TIBIAL PLATE 4.5X145MM 8 HOLE SS IMAL RIGHT","SUP-ITM-10005753","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.36","2727.27","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1938.18","53.3","","813.12","216.42","1444.50","81","1127.27","2890.91","percent of total billed charges",""
"TIBIAL PLATE 4.5X145MM 8 HOLE SS IMAL RIGHT","SUP-ITM-10005753","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.36","2727.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1127.27","31","","432.60","432.60","432.60","1 through 10","1127.27","2890.91","percent of total billed charges",""
"TIBIAL PLATE 4.5X145MM 8 HOLE SS IMAL RIGHT","SUP-ITM-10005753","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.36","2727.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1327.27","36.5","","148.37","54.89","631.39","94","1127.27","2890.91","percent of total billed charges",""
"TIBIAL PLATE 4.5X145MM 8 HOLE SS IMAL RIGHT","SUP-ITM-10005753","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.36","2727.27","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1392.73","38.3","","279.30","91.72","1116.77","266","1127.27","2890.91","percent of total billed charges",""
"TIBIAL PLATE 4.5X145MM 8 HOLE SS IMAL RIGHT","SUP-ITM-10005753","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.36","2727.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1560.00","42.9","","731.00","63.70","731.00","1 through 10","1127.27","2890.91","percent of total billed charges",""
"TIBIAL PLATE 4.5X145MM 8 HOLE SS IMAL RIGHT","SUP-ITM-10005753","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.36","2727.27","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1560.00","42.9","","384.74","384.74","384.74","1 through 10","1127.27","2890.91","percent of total billed charges",""
"TIBIAL PLATE 4.5X145MM 8 HOLE SS IMAL RIGHT","SUP-ITM-10005753","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.36","2727.27","WELLPOINT [1015]","HB AMC WELLPOINT","2682.91","73.78","","286.63","119.22","1107.45","105","1127.27","2890.91","percent of total billed charges",""
"TIBIAL PLATE 4.5X145MM 8 HOLE SS IMAL RIGHT","SUP-ITM-10005753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3636.36","2727.27","AETNA [1001]","HB AMC AETNA HMO","2538.18","69.8","","675.31","184.75","1721.50","286","1900.36","2971.63","percent of total billed charges",""
"TIBIAL PLATE 4.5X145MM 8 HOLE SS IMAL RIGHT","SUP-ITM-10005753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3636.36","2727.27","AETNA [1001]","HB AMC AETNA PPO","2923.63","80.4","","1261.44","103.12","1514.10","21","1900.36","2971.63","percent of total billed charges",""
"TIBIAL PLATE 4.5X145MM 8 HOLE SS IMAL RIGHT","SUP-ITM-10005753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3636.36","2727.27","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2923.63","80.4","","1365.00","1365.00","1365.00","1 through 10","1900.36","2971.63","percent of total billed charges",""
"TIBIAL PLATE 4.5X145MM 8 HOLE SS IMAL RIGHT","SUP-ITM-10005753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3636.36","2727.27","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2971.63","81.72","","5157.68","5157.68","5157.68","1 through 10","1900.36","2971.63","percent of total billed charges",""
"TIBIAL PLATE 4.5X145MM 8 HOLE SS IMAL RIGHT","SUP-ITM-10005753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3636.36","2727.27","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2971.63","81.72","","431.26","71.26","1459.57","88","1900.36","2971.63","percent of total billed charges",""
"TIBIAL PLATE 4.5X190MM 10 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4134.06","3100.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3286.58","79.5","","800.18","480.96","1887.97","195","1281.56","3286.58","percent of total billed charges",""
"TIBIAL PLATE 4.5X190MM 10 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4134.06","3100.54","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2203.45","53.3","","813.12","216.42","1444.50","81","1281.56","3286.58","percent of total billed charges",""
"TIBIAL PLATE 4.5X190MM 10 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4134.06","3100.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1281.56","31","","432.60","432.60","432.60","1 through 10","1281.56","3286.58","percent of total billed charges",""
"TIBIAL PLATE 4.5X190MM 10 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4134.06","3100.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1508.93","36.5","","148.37","54.89","631.39","94","1281.56","3286.58","percent of total billed charges",""
"TIBIAL PLATE 4.5X190MM 10 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4134.06","3100.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1583.34","38.3","","279.30","91.72","1116.77","266","1281.56","3286.58","percent of total billed charges",""
"TIBIAL PLATE 4.5X190MM 10 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4134.06","3100.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1773.51","42.9","","731.00","63.70","731.00","1 through 10","1281.56","3286.58","percent of total billed charges",""
"TIBIAL PLATE 4.5X190MM 10 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4134.06","3100.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1773.51","42.9","","384.74","384.74","384.74","1 through 10","1281.56","3286.58","percent of total billed charges",""
"TIBIAL PLATE 4.5X190MM 10 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009187","CDM","C1713","HCPCS","0278","RC","","","","both","","","4134.06","3100.54","WELLPOINT [1015]","HB AMC WELLPOINT","3050.11","73.78","","286.63","119.22","1107.45","105","1281.56","3286.58","percent of total billed charges",""
"TIBIAL PLATE 4.5X190MM 10 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4134.06","3100.54","AETNA [1001]","HB AMC AETNA HMO","2885.57","69.8","","675.31","184.75","1721.50","286","2160.46","3378.35","percent of total billed charges",""
"TIBIAL PLATE 4.5X190MM 10 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4134.06","3100.54","AETNA [1001]","HB AMC AETNA PPO","3323.78","80.4","","1261.44","103.12","1514.10","21","2160.46","3378.35","percent of total billed charges",""
"TIBIAL PLATE 4.5X190MM 10 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4134.06","3100.54","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3323.78","80.4","","1365.00","1365.00","1365.00","1 through 10","2160.46","3378.35","percent of total billed charges",""
"TIBIAL PLATE 4.5X190MM 10 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4134.06","3100.54","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3378.35","81.72","","5157.68","5157.68","5157.68","1 through 10","2160.46","3378.35","percent of total billed charges",""
"TIBIAL PLATE 4.5X190MM 10 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4134.06","3100.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3378.35","81.72","","431.26","71.26","1459.57","88","2160.46","3378.35","percent of total billed charges",""
"TIBIAL PLATE 4.5X220MM 9 HOLE LISS TITANIUM IMAL LEFT","SUP-ITM-10007498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3147.26","79.5","","800.18","480.96","1887.97","195","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X220MM 9 HOLE LISS TITANIUM IMAL LEFT","SUP-ITM-10007498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2110.05","53.3","","813.12","216.42","1444.50","81","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X220MM 9 HOLE LISS TITANIUM IMAL LEFT","SUP-ITM-10007498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1227.23","31","","432.60","432.60","432.60","1 through 10","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X220MM 9 HOLE LISS TITANIUM IMAL LEFT","SUP-ITM-10007498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1444.97","36.5","","148.37","54.89","631.39","94","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X220MM 9 HOLE LISS TITANIUM IMAL LEFT","SUP-ITM-10007498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1516.23","38.3","","279.30","91.72","1116.77","266","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X220MM 9 HOLE LISS TITANIUM IMAL LEFT","SUP-ITM-10007498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.33","42.9","","731.00","63.70","731.00","1 through 10","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X220MM 9 HOLE LISS TITANIUM IMAL LEFT","SUP-ITM-10007498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1698.33","42.9","","384.74","384.74","384.74","1 through 10","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X220MM 9 HOLE LISS TITANIUM IMAL LEFT","SUP-ITM-10007498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3958.82","2969.11","WELLPOINT [1015]","HB AMC WELLPOINT","2920.82","73.78","","286.63","119.22","1107.45","105","1227.23","3147.26","percent of total billed charges",""
"TIBIAL PLATE 4.5X220MM 9 HOLE LISS TITANIUM IMAL LEFT","SUP-ITM-10007498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3958.82","2969.11","AETNA [1001]","HB AMC AETNA HMO","2763.26","69.8","","675.31","184.75","1721.50","286","2068.88","3235.15","percent of total billed charges",""
"TIBIAL PLATE 4.5X220MM 9 HOLE LISS TITANIUM IMAL LEFT","SUP-ITM-10007498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3958.82","2969.11","AETNA [1001]","HB AMC AETNA PPO","3182.89","80.4","","1261.44","103.12","1514.10","21","2068.88","3235.15","percent of total billed charges",""
"TIBIAL PLATE 4.5X220MM 9 HOLE LISS TITANIUM IMAL LEFT","SUP-ITM-10007498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3958.82","2969.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3182.89","80.4","","1365.00","1365.00","1365.00","1 through 10","2068.88","3235.15","percent of total billed charges",""
"TIBIAL PLATE 4.5X220MM 9 HOLE LISS TITANIUM IMAL LEFT","SUP-ITM-10007498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3958.82","2969.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3235.15","81.72","","5157.68","5157.68","5157.68","1 through 10","2068.88","3235.15","percent of total billed charges",""
"TIBIAL PLATE 4.5X220MM 9 HOLE LISS TITANIUM IMAL LEFT","SUP-ITM-10007498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3958.82","2969.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3235.15","81.72","","431.26","71.26","1459.57","88","2068.88","3235.15","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS LEFT","SUP-ITM-10009190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4184.04","3138.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3326.31","79.5","","800.18","480.96","1887.97","195","1297.05","3326.31","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS LEFT","SUP-ITM-10009190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4184.04","3138.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2230.09","53.3","","813.12","216.42","1444.50","81","1297.05","3326.31","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS LEFT","SUP-ITM-10009190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4184.04","3138.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1297.05","31","","432.60","432.60","432.60","1 through 10","1297.05","3326.31","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS LEFT","SUP-ITM-10009190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4184.04","3138.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1527.17","36.5","","148.37","54.89","631.39","94","1297.05","3326.31","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS LEFT","SUP-ITM-10009190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4184.04","3138.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1602.49","38.3","","279.30","91.72","1116.77","266","1297.05","3326.31","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS LEFT","SUP-ITM-10009190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4184.04","3138.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1794.95","42.9","","731.00","63.70","731.00","1 through 10","1297.05","3326.31","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS LEFT","SUP-ITM-10009190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4184.04","3138.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1794.95","42.9","","384.74","384.74","384.74","1 through 10","1297.05","3326.31","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS LEFT","SUP-ITM-10009190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4184.04","3138.03","WELLPOINT [1015]","HB AMC WELLPOINT","3086.98","73.78","","286.63","119.22","1107.45","105","1297.05","3326.31","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS LEFT","SUP-ITM-10009190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4184.04","3138.03","AETNA [1001]","HB AMC AETNA HMO","2920.46","69.8","","675.31","184.75","1721.50","286","2186.58","3419.2","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS LEFT","SUP-ITM-10009190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4184.04","3138.03","AETNA [1001]","HB AMC AETNA PPO","3363.97","80.4","","1261.44","103.12","1514.10","21","2186.58","3419.2","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS LEFT","SUP-ITM-10009190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4184.04","3138.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3363.97","80.4","","1365.00","1365.00","1365.00","1 through 10","2186.58","3419.2","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS LEFT","SUP-ITM-10009190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4184.04","3138.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3419.20","81.72","","5157.68","5157.68","5157.68","1 through 10","2186.58","3419.2","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS LEFT","SUP-ITM-10009190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4184.04","3138.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3419.20","81.72","","431.26","71.26","1459.57","88","2186.58","3419.2","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009189","CDM","C1713","HCPCS","0278","RC","","","","both","","","4301.99","3226.49","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3420.08","79.5","","800.18","480.96","1887.97","195","1333.62","3420.08","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009189","CDM","C1713","HCPCS","0278","RC","","","","both","","","4301.99","3226.49","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2292.96","53.3","","813.12","216.42","1444.50","81","1333.62","3420.08","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009189","CDM","C1713","HCPCS","0278","RC","","","","both","","","4301.99","3226.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1333.62","31","","432.60","432.60","432.60","1 through 10","1333.62","3420.08","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009189","CDM","C1713","HCPCS","0278","RC","","","","both","","","4301.99","3226.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1570.23","36.5","","148.37","54.89","631.39","94","1333.62","3420.08","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009189","CDM","C1713","HCPCS","0278","RC","","","","both","","","4301.99","3226.49","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1647.66","38.3","","279.30","91.72","1116.77","266","1333.62","3420.08","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009189","CDM","C1713","HCPCS","0278","RC","","","","both","","","4301.99","3226.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1845.55","42.9","","731.00","63.70","731.00","1 through 10","1333.62","3420.08","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009189","CDM","C1713","HCPCS","0278","RC","","","","both","","","4301.99","3226.49","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1845.55","42.9","","384.74","384.74","384.74","1 through 10","1333.62","3420.08","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009189","CDM","C1713","HCPCS","0278","RC","","","","both","","","4301.99","3226.49","WELLPOINT [1015]","HB AMC WELLPOINT","3174.01","73.78","","286.63","119.22","1107.45","105","1333.62","3420.08","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4301.99","3226.49","AETNA [1001]","HB AMC AETNA HMO","3002.79","69.8","","675.31","184.75","1721.50","286","2248.22","3515.59","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4301.99","3226.49","AETNA [1001]","HB AMC AETNA PPO","3458.80","80.4","","1261.44","103.12","1514.10","21","2248.22","3515.59","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4301.99","3226.49","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3458.80","80.4","","1365.00","1365.00","1365.00","1 through 10","2248.22","3515.59","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4301.99","3226.49","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3515.59","81.72","","5157.68","5157.68","5157.68","1 through 10","2248.22","3515.59","percent of total billed charges",""
"TIBIAL PLATE 4.5X226MM 12 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4301.99","3226.49","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3515.59","81.72","","431.26","71.26","1459.57","88","2248.22","3515.59","percent of total billed charges",""
"TIBIAL PLATE 4.5X253MM 14 HOLE SS PROXIMALIAML LEFT","SUP-ITM-10005795","CDM","C1713","HCPCS","0278","RC","","","","both","","","3756.80","2817.60","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2986.66","79.5","","800.18","480.96","1887.97","195","1164.61","2986.66","percent of total billed charges",""
"TIBIAL PLATE 4.5X253MM 14 HOLE SS PROXIMALIAML LEFT","SUP-ITM-10005795","CDM","C1713","HCPCS","0278","RC","","","","both","","","3756.80","2817.60","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2002.37","53.3","","813.12","216.42","1444.50","81","1164.61","2986.66","percent of total billed charges",""
"TIBIAL PLATE 4.5X253MM 14 HOLE SS PROXIMALIAML LEFT","SUP-ITM-10005795","CDM","C1713","HCPCS","0278","RC","","","","both","","","3756.80","2817.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1164.61","31","","432.60","432.60","432.60","1 through 10","1164.61","2986.66","percent of total billed charges",""
"TIBIAL PLATE 4.5X253MM 14 HOLE SS PROXIMALIAML LEFT","SUP-ITM-10005795","CDM","C1713","HCPCS","0278","RC","","","","both","","","3756.80","2817.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1371.23","36.5","","148.37","54.89","631.39","94","1164.61","2986.66","percent of total billed charges",""
"TIBIAL PLATE 4.5X253MM 14 HOLE SS PROXIMALIAML LEFT","SUP-ITM-10005795","CDM","C1713","HCPCS","0278","RC","","","","both","","","3756.80","2817.60","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1438.85","38.3","","279.30","91.72","1116.77","266","1164.61","2986.66","percent of total billed charges",""
"TIBIAL PLATE 4.5X253MM 14 HOLE SS PROXIMALIAML LEFT","SUP-ITM-10005795","CDM","C1713","HCPCS","0278","RC","","","","both","","","3756.80","2817.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1611.67","42.9","","731.00","63.70","731.00","1 through 10","1164.61","2986.66","percent of total billed charges",""
"TIBIAL PLATE 4.5X253MM 14 HOLE SS PROXIMALIAML LEFT","SUP-ITM-10005795","CDM","C1713","HCPCS","0278","RC","","","","both","","","3756.80","2817.60","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1611.67","42.9","","384.74","384.74","384.74","1 through 10","1164.61","2986.66","percent of total billed charges",""
"TIBIAL PLATE 4.5X253MM 14 HOLE SS PROXIMALIAML LEFT","SUP-ITM-10005795","CDM","C1713","HCPCS","0278","RC","","","","both","","","3756.80","2817.60","WELLPOINT [1015]","HB AMC WELLPOINT","2771.77","73.78","","286.63","119.22","1107.45","105","1164.61","2986.66","percent of total billed charges",""
"TIBIAL PLATE 4.5X253MM 14 HOLE SS PROXIMALIAML LEFT","SUP-ITM-10005795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3756.80","2817.60","AETNA [1001]","HB AMC AETNA HMO","2622.25","69.8","","675.31","184.75","1721.50","286","1963.3","3070.06","percent of total billed charges",""
"TIBIAL PLATE 4.5X253MM 14 HOLE SS PROXIMALIAML LEFT","SUP-ITM-10005795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3756.80","2817.60","AETNA [1001]","HB AMC AETNA PPO","3020.47","80.4","","1261.44","103.12","1514.10","21","1963.3","3070.06","percent of total billed charges",""
"TIBIAL PLATE 4.5X253MM 14 HOLE SS PROXIMALIAML LEFT","SUP-ITM-10005795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3756.80","2817.60","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3020.47","80.4","","1365.00","1365.00","1365.00","1 through 10","1963.3","3070.06","percent of total billed charges",""
"TIBIAL PLATE 4.5X253MM 14 HOLE SS PROXIMALIAML LEFT","SUP-ITM-10005795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3756.80","2817.60","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3070.06","81.72","","5157.68","5157.68","5157.68","1 through 10","1963.3","3070.06","percent of total billed charges",""
"TIBIAL PLATE 4.5X253MM 14 HOLE SS PROXIMALIAML LEFT","SUP-ITM-10005795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3756.80","2817.60","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3070.06","81.72","","431.26","71.26","1459.57","88","1963.3","3070.06","percent of total billed charges",""
"TIBIAL PLATE 4.5X300MM 13 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007499","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.99","3032.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3214.18","79.5","","800.18","480.96","1887.97","195","1253.33","3214.18","percent of total billed charges",""
"TIBIAL PLATE 4.5X300MM 13 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007499","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.99","3032.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2154.91","53.3","","813.12","216.42","1444.50","81","1253.33","3214.18","percent of total billed charges",""
"TIBIAL PLATE 4.5X300MM 13 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007499","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.99","3032.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1253.33","31","","432.60","432.60","432.60","1 through 10","1253.33","3214.18","percent of total billed charges",""
"TIBIAL PLATE 4.5X300MM 13 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007499","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.99","3032.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1475.69","36.5","","148.37","54.89","631.39","94","1253.33","3214.18","percent of total billed charges",""
"TIBIAL PLATE 4.5X300MM 13 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007499","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.99","3032.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1548.47","38.3","","279.30","91.72","1116.77","266","1253.33","3214.18","percent of total billed charges",""
"TIBIAL PLATE 4.5X300MM 13 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007499","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.99","3032.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.44","42.9","","731.00","63.70","731.00","1 through 10","1253.33","3214.18","percent of total billed charges",""
"TIBIAL PLATE 4.5X300MM 13 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007499","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.99","3032.24","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.44","42.9","","384.74","384.74","384.74","1 through 10","1253.33","3214.18","percent of total billed charges",""
"TIBIAL PLATE 4.5X300MM 13 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007499","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.99","3032.24","WELLPOINT [1015]","HB AMC WELLPOINT","2982.92","73.78","","286.63","119.22","1107.45","105","1253.33","3214.18","percent of total billed charges",""
"TIBIAL PLATE 4.5X300MM 13 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.99","3032.24","AETNA [1001]","HB AMC AETNA HMO","2822.01","69.8","","675.31","184.75","1721.50","286","2112.87","3303.93","percent of total billed charges",""
"TIBIAL PLATE 4.5X300MM 13 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.99","3032.24","AETNA [1001]","HB AMC AETNA PPO","3250.56","80.4","","1261.44","103.12","1514.10","21","2112.87","3303.93","percent of total billed charges",""
"TIBIAL PLATE 4.5X300MM 13 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.99","3032.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3250.56","80.4","","1365.00","1365.00","1365.00","1 through 10","2112.87","3303.93","percent of total billed charges",""
"TIBIAL PLATE 4.5X300MM 13 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.99","3032.24","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3303.93","81.72","","5157.68","5157.68","5157.68","1 through 10","2112.87","3303.93","percent of total billed charges",""
"TIBIAL PLATE 4.5X300MM 13 HOLE IMAL LISS TITANIUM RIGHT","SUP-ITM-10007499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.99","3032.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3303.93","81.72","","431.26","71.26","1459.57","88","2112.87","3303.93","percent of total billed charges",""
"TIBIAL PLATE 4.5X41MM 2 HOLE SS IMAL RIGHT","SUP-ITM-10005747","CDM","C1713","HCPCS","0278","RC","","","","both","","","3550.89","2663.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2822.96","79.5","","800.18","480.96","1887.97","195","1100.78","2822.96","percent of total billed charges",""
"TIBIAL PLATE 4.5X41MM 2 HOLE SS IMAL RIGHT","SUP-ITM-10005747","CDM","C1713","HCPCS","0278","RC","","","","both","","","3550.89","2663.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1892.62","53.3","","813.12","216.42","1444.50","81","1100.78","2822.96","percent of total billed charges",""
"TIBIAL PLATE 4.5X41MM 2 HOLE SS IMAL RIGHT","SUP-ITM-10005747","CDM","C1713","HCPCS","0278","RC","","","","both","","","3550.89","2663.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1100.78","31","","432.60","432.60","432.60","1 through 10","1100.78","2822.96","percent of total billed charges",""
"TIBIAL PLATE 4.5X41MM 2 HOLE SS IMAL RIGHT","SUP-ITM-10005747","CDM","C1713","HCPCS","0278","RC","","","","both","","","3550.89","2663.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1296.07","36.5","","148.37","54.89","631.39","94","1100.78","2822.96","percent of total billed charges",""
"TIBIAL PLATE 4.5X41MM 2 HOLE SS IMAL RIGHT","SUP-ITM-10005747","CDM","C1713","HCPCS","0278","RC","","","","both","","","3550.89","2663.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1359.99","38.3","","279.30","91.72","1116.77","266","1100.78","2822.96","percent of total billed charges",""
"TIBIAL PLATE 4.5X41MM 2 HOLE SS IMAL RIGHT","SUP-ITM-10005747","CDM","C1713","HCPCS","0278","RC","","","","both","","","3550.89","2663.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1523.33","42.9","","731.00","63.70","731.00","1 through 10","1100.78","2822.96","percent of total billed charges",""
"TIBIAL PLATE 4.5X41MM 2 HOLE SS IMAL RIGHT","SUP-ITM-10005747","CDM","C1713","HCPCS","0278","RC","","","","both","","","3550.89","2663.17","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1523.33","42.9","","384.74","384.74","384.74","1 through 10","1100.78","2822.96","percent of total billed charges",""
"TIBIAL PLATE 4.5X41MM 2 HOLE SS IMAL RIGHT","SUP-ITM-10005747","CDM","C1713","HCPCS","0278","RC","","","","both","","","3550.89","2663.17","WELLPOINT [1015]","HB AMC WELLPOINT","2619.85","73.78","","286.63","119.22","1107.45","105","1100.78","2822.96","percent of total billed charges",""
"TIBIAL PLATE 4.5X41MM 2 HOLE SS IMAL RIGHT","SUP-ITM-10005747","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3550.89","2663.17","AETNA [1001]","HB AMC AETNA HMO","2478.52","69.8","","675.31","184.75","1721.50","286","1855.7","2901.79","percent of total billed charges",""
"TIBIAL PLATE 4.5X41MM 2 HOLE SS IMAL RIGHT","SUP-ITM-10005747","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3550.89","2663.17","AETNA [1001]","HB AMC AETNA PPO","2854.92","80.4","","1261.44","103.12","1514.10","21","1855.7","2901.79","percent of total billed charges",""
"TIBIAL PLATE 4.5X41MM 2 HOLE SS IMAL RIGHT","SUP-ITM-10005747","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3550.89","2663.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2854.92","80.4","","1365.00","1365.00","1365.00","1 through 10","1855.7","2901.79","percent of total billed charges",""
"TIBIAL PLATE 4.5X41MM 2 HOLE SS IMAL RIGHT","SUP-ITM-10005747","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3550.89","2663.17","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2901.79","81.72","","5157.68","5157.68","5157.68","1 through 10","1855.7","2901.79","percent of total billed charges",""
"TIBIAL PLATE 4.5X41MM 2 HOLE SS IMAL RIGHT","SUP-ITM-10005747","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3550.89","2663.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2901.79","81.72","","431.26","71.26","1459.57","88","1855.7","2901.79","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.83","2996.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3175.89","79.5","","800.18","480.96","1887.97","195","1238.4","3175.89","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.83","2996.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2129.24","53.3","","813.12","216.42","1444.50","81","1238.4","3175.89","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.83","2996.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1238.40","31","","432.60","432.60","432.60","1 through 10","1238.4","3175.89","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.83","2996.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1458.11","36.5","","148.37","54.89","631.39","94","1238.4","3175.89","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.83","2996.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1530.02","38.3","","279.30","91.72","1116.77","266","1238.4","3175.89","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.83","2996.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1713.78","42.9","","731.00","63.70","731.00","1 through 10","1238.4","3175.89","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.83","2996.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1713.78","42.9","","384.74","384.74","384.74","1 through 10","1238.4","3175.89","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3994.83","2996.12","WELLPOINT [1015]","HB AMC WELLPOINT","2947.39","73.78","","286.63","119.22","1107.45","105","1238.4","3175.89","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3994.83","2996.12","AETNA [1001]","HB AMC AETNA HMO","2788.39","69.8","","675.31","184.75","1721.50","286","2087.7","3264.58","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3994.83","2996.12","AETNA [1001]","HB AMC AETNA PPO","3211.84","80.4","","1261.44","103.12","1514.10","21","2087.7","3264.58","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3994.83","2996.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3211.84","80.4","","1365.00","1365.00","1365.00","1 through 10","2087.7","3264.58","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3994.83","2996.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3264.58","81.72","","5157.68","5157.68","5157.68","1 through 10","2087.7","3264.58","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3994.83","2996.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3264.58","81.72","","431.26","71.26","1459.57","88","2087.7","3264.58","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL LEFT","SUP-ITM-10186913","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4842.93","79.5","","800.18","480.96","1887.97","195","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL LEFT","SUP-ITM-10186913","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3246.89","53.3","","813.12","216.42","1444.50","81","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL LEFT","SUP-ITM-10186913","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1888.44","31","","432.60","432.60","432.60","1 through 10","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL LEFT","SUP-ITM-10186913","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2223.48","36.5","","148.37","54.89","631.39","94","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL LEFT","SUP-ITM-10186913","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2333.13","38.3","","279.30","91.72","1116.77","266","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL LEFT","SUP-ITM-10186913","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2613.35","42.9","","731.00","63.70","731.00","1 through 10","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL LEFT","SUP-ITM-10186913","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2613.35","42.9","","384.74","384.74","384.74","1 through 10","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL LEFT","SUP-ITM-10186913","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","WELLPOINT [1015]","HB AMC WELLPOINT","4494.48","73.78","","286.63","119.22","1107.45","105","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL LEFT","SUP-ITM-10186913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6091.73","4568.80","AETNA [1001]","HB AMC AETNA HMO","4252.03","69.8","","675.31","184.75","1721.50","286","3183.54","4978.16","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL LEFT","SUP-ITM-10186913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6091.73","4568.80","AETNA [1001]","HB AMC AETNA PPO","4897.75","80.4","","1261.44","103.12","1514.10","21","3183.54","4978.16","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL LEFT","SUP-ITM-10186913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6091.73","4568.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4897.75","80.4","","1365.00","1365.00","1365.00","1 through 10","3183.54","4978.16","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL LEFT","SUP-ITM-10186913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6091.73","4568.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4978.16","81.72","","5157.68","5157.68","5157.68","1 through 10","3183.54","4978.16","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL LEFT","SUP-ITM-10186913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6091.73","4568.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4978.16","81.72","","431.26","71.26","1459.57","88","3183.54","4978.16","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL RIGHT","SUP-ITM-10186906","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4842.93","79.5","","800.18","480.96","1887.97","195","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL RIGHT","SUP-ITM-10186906","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3246.89","53.3","","813.12","216.42","1444.50","81","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL RIGHT","SUP-ITM-10186906","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1888.44","31","","432.60","432.60","432.60","1 through 10","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL RIGHT","SUP-ITM-10186906","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2223.48","36.5","","148.37","54.89","631.39","94","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL RIGHT","SUP-ITM-10186906","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2333.13","38.3","","279.30","91.72","1116.77","266","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL RIGHT","SUP-ITM-10186906","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2613.35","42.9","","731.00","63.70","731.00","1 through 10","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL RIGHT","SUP-ITM-10186906","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2613.35","42.9","","384.74","384.74","384.74","1 through 10","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL RIGHT","SUP-ITM-10186906","CDM","C1713","HCPCS","0278","RC","","","","both","","","6091.73","4568.80","WELLPOINT [1015]","HB AMC WELLPOINT","4494.48","73.78","","286.63","119.22","1107.45","105","1888.44","4842.93","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL RIGHT","SUP-ITM-10186906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6091.73","4568.80","AETNA [1001]","HB AMC AETNA HMO","4252.03","69.8","","675.31","184.75","1721.50","286","3183.54","4978.16","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL RIGHT","SUP-ITM-10186906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6091.73","4568.80","AETNA [1001]","HB AMC AETNA PPO","4897.75","80.4","","1261.44","103.12","1514.10","21","3183.54","4978.16","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL RIGHT","SUP-ITM-10186906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6091.73","4568.80","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4897.75","80.4","","1365.00","1365.00","1365.00","1 through 10","3183.54","4978.16","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL RIGHT","SUP-ITM-10186906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6091.73","4568.80","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4978.16","81.72","","5157.68","5157.68","5157.68","1 through 10","3183.54","4978.16","percent of total billed charges",""
"TIBIAL PLATE L 97MM 6 HOLE IMAL RIGHT","SUP-ITM-10186906","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6091.73","4568.80","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4978.16","81.72","","431.26","71.26","1459.57","88","3183.54","4978.16","percent of total billed charges",""
"TIBIAL STEM 13.5X90MM STRAIGHT INTRAMEDULLARY OSS POROUS COATED INTERLOCK SCREW","SUP-ITM-10121994","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3429.56","52.26","","1113.10","1113.10","1113.10","1 through 10","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 13.5X90MM STRAIGHT INTRAMEDULLARY OSS POROUS COATED INTERLOCK SCREW","SUP-ITM-10121994","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5217.19","79.5","","1293.60","1148.53","1603.80","1 through 10","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 13.5X90MM STRAIGHT INTRAMEDULLARY OSS POROUS COATED INTERLOCK SCREW","SUP-ITM-10121994","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2395.31","36.5","","1023.42","771.29","2068.67","33","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 13.5X90MM STRAIGHT INTRAMEDULLARY OSS POROUS COATED INTERLOCK SCREW","SUP-ITM-10121994","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2513.44","38.3","","850.52","759.78","1211.25","66","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 13.5X90MM STRAIGHT INTRAMEDULLARY OSS POROUS COATED INTERLOCK SCREW","SUP-ITM-10121994","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2815.31","42.9","","2548.09","2548.09","2548.09","1 through 10","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 13.5X90MM STRAIGHT INTRAMEDULLARY OSS POROUS COATED INTERLOCK SCREW","SUP-ITM-10121994","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2815.31","42.9","","956.46","956.46","956.46","1 through 10","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 13.5X90MM STRAIGHT INTRAMEDULLARY OSS POROUS COATED INTERLOCK SCREW","SUP-ITM-10121994","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","WELLPOINT [1015]","HB AMC WELLPOINT","4841.81","73.78","","2344.73","1619.47","2530.35","16","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 13.5X90MM STRAIGHT INTRAMEDULLARY OSS POROUS COATED INTERLOCK SCREW","SUP-ITM-10121994","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","AETNA [1001]","HB AMC AETNA HMO","4580.63","69.8","","1523.63","988.41","4330.26","39","3429.56","5362.88","percent of total billed charges",""
"TIBIAL STEM 13.5X90MM STRAIGHT INTRAMEDULLARY OSS POROUS COATED INTERLOCK SCREW","SUP-ITM-10121994","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","AETNA [1001]","HB AMC AETNA PPO","5276.25","80.4","","1670.25","1670.25","1670.25","1 through 10","3429.56","5362.88","percent of total billed charges",""
"TIBIAL STEM 13.5X90MM STRAIGHT INTRAMEDULLARY OSS POROUS COATED INTERLOCK SCREW","SUP-ITM-10121994","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3429.56","52.26","","1113.10","1113.10","1113.10","1 through 10","3429.56","5362.88","percent of total billed charges",""
"TIBIAL STEM 13.5X90MM STRAIGHT INTRAMEDULLARY OSS POROUS COATED INTERLOCK SCREW","SUP-ITM-10121994","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5362.88","81.72","","1738.90","1484.65","2716.94","38","3429.56","5362.88","percent of total billed charges",""
"TIBIAL STEM 15.5X150MM IMPLANT BOWED INTRAMEDULLARY OSS POROUS COATED INTERLOCK WITH SCREW ONC 03B","SUP-ITM-10036214","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3429.56","52.26","","1113.10","1113.10","1113.10","1 through 10","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 15.5X150MM IMPLANT BOWED INTRAMEDULLARY OSS POROUS COATED INTERLOCK WITH SCREW ONC 03B","SUP-ITM-10036214","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5217.19","79.5","","1293.60","1148.53","1603.80","1 through 10","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 15.5X150MM IMPLANT BOWED INTRAMEDULLARY OSS POROUS COATED INTERLOCK WITH SCREW ONC 03B","SUP-ITM-10036214","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2395.31","36.5","","1023.42","771.29","2068.67","33","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 15.5X150MM IMPLANT BOWED INTRAMEDULLARY OSS POROUS COATED INTERLOCK WITH SCREW ONC 03B","SUP-ITM-10036214","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2513.44","38.3","","850.52","759.78","1211.25","66","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 15.5X150MM IMPLANT BOWED INTRAMEDULLARY OSS POROUS COATED INTERLOCK WITH SCREW ONC 03B","SUP-ITM-10036214","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2815.31","42.9","","2548.09","2548.09","2548.09","1 through 10","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 15.5X150MM IMPLANT BOWED INTRAMEDULLARY OSS POROUS COATED INTERLOCK WITH SCREW ONC 03B","SUP-ITM-10036214","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2815.31","42.9","","956.46","956.46","956.46","1 through 10","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 15.5X150MM IMPLANT BOWED INTRAMEDULLARY OSS POROUS COATED INTERLOCK WITH SCREW ONC 03B","SUP-ITM-10036214","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","WELLPOINT [1015]","HB AMC WELLPOINT","4841.81","73.78","","2344.73","1619.47","2530.35","16","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 15.5X150MM IMPLANT BOWED INTRAMEDULLARY OSS POROUS COATED INTERLOCK WITH SCREW ONC 03B","SUP-ITM-10036214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","AETNA [1001]","HB AMC AETNA HMO","4580.63","69.8","","1523.63","988.41","4330.26","39","3429.56","5362.88","percent of total billed charges",""
"TIBIAL STEM 15.5X150MM IMPLANT BOWED INTRAMEDULLARY OSS POROUS COATED INTERLOCK WITH SCREW ONC 03B","SUP-ITM-10036214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","AETNA [1001]","HB AMC AETNA PPO","5276.25","80.4","","1670.25","1670.25","1670.25","1 through 10","3429.56","5362.88","percent of total billed charges",""
"TIBIAL STEM 15.5X150MM IMPLANT BOWED INTRAMEDULLARY OSS POROUS COATED INTERLOCK WITH SCREW ONC 03B","SUP-ITM-10036214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3429.56","52.26","","1113.10","1113.10","1113.10","1 through 10","3429.56","5362.88","percent of total billed charges",""
"TIBIAL STEM 15.5X150MM IMPLANT BOWED INTRAMEDULLARY OSS POROUS COATED INTERLOCK WITH SCREW ONC 03B","SUP-ITM-10036214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5362.88","81.72","","1738.90","1484.65","2716.94","38","3429.56","5362.88","percent of total billed charges",""
"TIBIAL STEM 152MMX16.5 EXTENDER MODULAR REVISION FINNED POROUS Y","SUP-ITM-10132488","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3266.25","52.26","","1113.10","1113.10","1113.10","1 through 10","1937.5","4968.75","percent of total billed charges",""
"TIBIAL STEM 152MMX16.5 EXTENDER MODULAR REVISION FINNED POROUS Y","SUP-ITM-10132488","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4968.75","79.5","","1293.60","1148.53","1603.80","1 through 10","1937.5","4968.75","percent of total billed charges",""
"TIBIAL STEM 152MMX16.5 EXTENDER MODULAR REVISION FINNED POROUS Y","SUP-ITM-10132488","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2281.25","36.5","","1023.42","771.29","2068.67","33","1937.5","4968.75","percent of total billed charges",""
"TIBIAL STEM 152MMX16.5 EXTENDER MODULAR REVISION FINNED POROUS Y","SUP-ITM-10132488","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2393.75","38.3","","850.52","759.78","1211.25","66","1937.5","4968.75","percent of total billed charges",""
"TIBIAL STEM 152MMX16.5 EXTENDER MODULAR REVISION FINNED POROUS Y","SUP-ITM-10132488","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.25","42.9","","2548.09","2548.09","2548.09","1 through 10","1937.5","4968.75","percent of total billed charges",""
"TIBIAL STEM 152MMX16.5 EXTENDER MODULAR REVISION FINNED POROUS Y","SUP-ITM-10132488","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2681.25","42.9","","956.46","956.46","956.46","1 through 10","1937.5","4968.75","percent of total billed charges",""
"TIBIAL STEM 152MMX16.5 EXTENDER MODULAR REVISION FINNED POROUS Y","SUP-ITM-10132488","CDM","C1776","HCPCS","0278","RC","","","","both","","","6250.00","4687.50","WELLPOINT [1015]","HB AMC WELLPOINT","4611.25","73.78","","2344.73","1619.47","2530.35","16","1937.5","4968.75","percent of total billed charges",""
"TIBIAL STEM 152MMX16.5 EXTENDER MODULAR REVISION FINNED POROUS Y","SUP-ITM-10132488","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","AETNA [1001]","HB AMC AETNA HMO","4362.50","69.8","","1523.63","988.41","4330.26","39","3266.25","5107.5","percent of total billed charges",""
"TIBIAL STEM 152MMX16.5 EXTENDER MODULAR REVISION FINNED POROUS Y","SUP-ITM-10132488","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","AETNA [1001]","HB AMC AETNA PPO","5025.00","80.4","","1670.25","1670.25","1670.25","1 through 10","3266.25","5107.5","percent of total billed charges",""
"TIBIAL STEM 152MMX16.5 EXTENDER MODULAR REVISION FINNED POROUS Y","SUP-ITM-10132488","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3266.25","52.26","","1113.10","1113.10","1113.10","1 through 10","3266.25","5107.5","percent of total billed charges",""
"TIBIAL STEM 152MMX16.5 EXTENDER MODULAR REVISION FINNED POROUS Y","SUP-ITM-10132488","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6250.00","4687.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5107.50","81.72","","1738.90","1484.65","2716.94","38","3266.25","5107.5","percent of total billed charges",""
"TIBIAL STEM 16X80MM EXTENSION VANGUARD 360 VERSION 2 TITANIUM ALLOY SPLINED REVISION","SUP-ITM-10117803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1855.26","52.26","","1113.10","1113.10","1113.10","1 through 10","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM 16X80MM EXTENSION VANGUARD 360 VERSION 2 TITANIUM ALLOY SPLINED REVISION","SUP-ITM-10117803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2822.29","79.5","","1293.60","1148.53","1603.80","1 through 10","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM 16X80MM EXTENSION VANGUARD 360 VERSION 2 TITANIUM ALLOY SPLINED REVISION","SUP-ITM-10117803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1295.77","36.5","","1023.42","771.29","2068.67","33","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM 16X80MM EXTENSION VANGUARD 360 VERSION 2 TITANIUM ALLOY SPLINED REVISION","SUP-ITM-10117803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1359.67","38.3","","850.52","759.78","1211.25","66","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM 16X80MM EXTENSION VANGUARD 360 VERSION 2 TITANIUM ALLOY SPLINED REVISION","SUP-ITM-10117803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1522.97","42.9","","2548.09","2548.09","2548.09","1 through 10","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM 16X80MM EXTENSION VANGUARD 360 VERSION 2 TITANIUM ALLOY SPLINED REVISION","SUP-ITM-10117803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1522.97","42.9","","956.46","956.46","956.46","1 through 10","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM 16X80MM EXTENSION VANGUARD 360 VERSION 2 TITANIUM ALLOY SPLINED REVISION","SUP-ITM-10117803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","WELLPOINT [1015]","HB AMC WELLPOINT","2619.23","73.78","","2344.73","1619.47","2530.35","16","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM 16X80MM EXTENSION VANGUARD 360 VERSION 2 TITANIUM ALLOY SPLINED REVISION","SUP-ITM-10117803","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3550.05","2662.54","AETNA [1001]","HB AMC AETNA HMO","2477.93","69.8","","1523.63","988.41","4330.26","39","1855.26","2901.1","percent of total billed charges",""
"TIBIAL STEM 16X80MM EXTENSION VANGUARD 360 VERSION 2 TITANIUM ALLOY SPLINED REVISION","SUP-ITM-10117803","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3550.05","2662.54","AETNA [1001]","HB AMC AETNA PPO","2854.24","80.4","","1670.25","1670.25","1670.25","1 through 10","1855.26","2901.1","percent of total billed charges",""
"TIBIAL STEM 16X80MM EXTENSION VANGUARD 360 VERSION 2 TITANIUM ALLOY SPLINED REVISION","SUP-ITM-10117803","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3550.05","2662.54","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1855.26","52.26","","1113.10","1113.10","1113.10","1 through 10","1855.26","2901.1","percent of total billed charges",""
"TIBIAL STEM 16X80MM EXTENSION VANGUARD 360 VERSION 2 TITANIUM ALLOY SPLINED REVISION","SUP-ITM-10117803","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3550.05","2662.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2901.10","81.72","","1738.90","1484.65","2716.94","38","1855.26","2901.1","percent of total billed charges",""
"TIBIAL STEM 9X90MM OSS TITANIUM BOWED CEMENT INTRAMEDULLARY","SUP-ITM-10121974","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3429.56","52.26","","1113.10","1113.10","1113.10","1 through 10","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 9X90MM OSS TITANIUM BOWED CEMENT INTRAMEDULLARY","SUP-ITM-10121974","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5217.19","79.5","","1293.60","1148.53","1603.80","1 through 10","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 9X90MM OSS TITANIUM BOWED CEMENT INTRAMEDULLARY","SUP-ITM-10121974","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2395.31","36.5","","1023.42","771.29","2068.67","33","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 9X90MM OSS TITANIUM BOWED CEMENT INTRAMEDULLARY","SUP-ITM-10121974","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2513.44","38.3","","850.52","759.78","1211.25","66","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 9X90MM OSS TITANIUM BOWED CEMENT INTRAMEDULLARY","SUP-ITM-10121974","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2815.31","42.9","","2548.09","2548.09","2548.09","1 through 10","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 9X90MM OSS TITANIUM BOWED CEMENT INTRAMEDULLARY","SUP-ITM-10121974","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2815.31","42.9","","956.46","956.46","956.46","1 through 10","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 9X90MM OSS TITANIUM BOWED CEMENT INTRAMEDULLARY","SUP-ITM-10121974","CDM","C1776","HCPCS","0278","RC","","","","both","","","6562.50","4921.87","WELLPOINT [1015]","HB AMC WELLPOINT","4841.81","73.78","","2344.73","1619.47","2530.35","16","2034.38","5217.19","percent of total billed charges",""
"TIBIAL STEM 9X90MM OSS TITANIUM BOWED CEMENT INTRAMEDULLARY","SUP-ITM-10121974","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","AETNA [1001]","HB AMC AETNA HMO","4580.63","69.8","","1523.63","988.41","4330.26","39","3429.56","5362.88","percent of total billed charges",""
"TIBIAL STEM 9X90MM OSS TITANIUM BOWED CEMENT INTRAMEDULLARY","SUP-ITM-10121974","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","AETNA [1001]","HB AMC AETNA PPO","5276.25","80.4","","1670.25","1670.25","1670.25","1 through 10","3429.56","5362.88","percent of total billed charges",""
"TIBIAL STEM 9X90MM OSS TITANIUM BOWED CEMENT INTRAMEDULLARY","SUP-ITM-10121974","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","3429.56","52.26","","1113.10","1113.10","1113.10","1 through 10","3429.56","5362.88","percent of total billed charges",""
"TIBIAL STEM 9X90MM OSS TITANIUM BOWED CEMENT INTRAMEDULLARY","SUP-ITM-10121974","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6562.50","4921.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5362.88","81.72","","1738.90","1484.65","2716.94","38","3429.56","5362.88","percent of total billed charges",""
"TIBIAL STEM L 175MM 130 OD 20 EXTENDER TIVANIUM FEMORAL FLUTED SHARP SCREW PRIMARY IMPL NEXGEN","SUP-ITM-10025177","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1855.26","52.26","","1113.10","1113.10","1113.10","1 through 10","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM L 175MM 130 OD 20 EXTENDER TIVANIUM FEMORAL FLUTED SHARP SCREW PRIMARY IMPL NEXGEN","SUP-ITM-10025177","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2822.29","79.5","","1293.60","1148.53","1603.80","1 through 10","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM L 175MM 130 OD 20 EXTENDER TIVANIUM FEMORAL FLUTED SHARP SCREW PRIMARY IMPL NEXGEN","SUP-ITM-10025177","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1295.77","36.5","","1023.42","771.29","2068.67","33","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM L 175MM 130 OD 20 EXTENDER TIVANIUM FEMORAL FLUTED SHARP SCREW PRIMARY IMPL NEXGEN","SUP-ITM-10025177","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1359.67","38.3","","850.52","759.78","1211.25","66","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM L 175MM 130 OD 20 EXTENDER TIVANIUM FEMORAL FLUTED SHARP SCREW PRIMARY IMPL NEXGEN","SUP-ITM-10025177","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1522.97","42.9","","2548.09","2548.09","2548.09","1 through 10","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM L 175MM 130 OD 20 EXTENDER TIVANIUM FEMORAL FLUTED SHARP SCREW PRIMARY IMPL NEXGEN","SUP-ITM-10025177","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1522.97","42.9","","956.46","956.46","956.46","1 through 10","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM L 175MM 130 OD 20 EXTENDER TIVANIUM FEMORAL FLUTED SHARP SCREW PRIMARY IMPL NEXGEN","SUP-ITM-10025177","CDM","C1776","HCPCS","0278","RC","","","","both","","","3550.05","2662.54","WELLPOINT [1015]","HB AMC WELLPOINT","2619.23","73.78","","2344.73","1619.47","2530.35","16","1100.52","2822.29","percent of total billed charges",""
"TIBIAL STEM L 175MM 130 OD 20 EXTENDER TIVANIUM FEMORAL FLUTED SHARP SCREW PRIMARY IMPL NEXGEN","SUP-ITM-10025177","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3550.05","2662.54","AETNA [1001]","HB AMC AETNA HMO","2477.93","69.8","","1523.63","988.41","4330.26","39","1855.26","2901.1","percent of total billed charges",""
"TIBIAL STEM L 175MM 130 OD 20 EXTENDER TIVANIUM FEMORAL FLUTED SHARP SCREW PRIMARY IMPL NEXGEN","SUP-ITM-10025177","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3550.05","2662.54","AETNA [1001]","HB AMC AETNA PPO","2854.24","80.4","","1670.25","1670.25","1670.25","1 through 10","1855.26","2901.1","percent of total billed charges",""
"TIBIAL STEM L 175MM 130 OD 20 EXTENDER TIVANIUM FEMORAL FLUTED SHARP SCREW PRIMARY IMPL NEXGEN","SUP-ITM-10025177","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3550.05","2662.54","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1855.26","52.26","","1113.10","1113.10","1113.10","1 through 10","1855.26","2901.1","percent of total billed charges",""
"TIBIAL STEM L 175MM 130 OD 20 EXTENDER TIVANIUM FEMORAL FLUTED SHARP SCREW PRIMARY IMPL NEXGEN","SUP-ITM-10025177","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3550.05","2662.54","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2901.10","81.72","","1738.90","1484.65","2716.94","38","1855.26","2901.1","percent of total billed charges",""
"TIBIAL TRAY 69.6X61.8X15MM SZ 3 PLUS 15 REVISION MOBILE BEARING CEMENTED","SUP-ITM-10042832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2033.96","52.26","","1113.10","1113.10","1113.10","1 through 10","1206.52","3094.14","percent of total billed charges",""
"TIBIAL TRAY 69.6X61.8X15MM SZ 3 PLUS 15 REVISION MOBILE BEARING CEMENTED","SUP-ITM-10042832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3094.14","79.5","","1293.60","1148.53","1603.80","1 through 10","1206.52","3094.14","percent of total billed charges",""
"TIBIAL TRAY 69.6X61.8X15MM SZ 3 PLUS 15 REVISION MOBILE BEARING CEMENTED","SUP-ITM-10042832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1420.58","36.5","","1023.42","771.29","2068.67","33","1206.52","3094.14","percent of total billed charges",""
"TIBIAL TRAY 69.6X61.8X15MM SZ 3 PLUS 15 REVISION MOBILE BEARING CEMENTED","SUP-ITM-10042832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1490.64","38.3","","850.52","759.78","1211.25","66","1206.52","3094.14","percent of total billed charges",""
"TIBIAL TRAY 69.6X61.8X15MM SZ 3 PLUS 15 REVISION MOBILE BEARING CEMENTED","SUP-ITM-10042832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.67","42.9","","2548.09","2548.09","2548.09","1 through 10","1206.52","3094.14","percent of total billed charges",""
"TIBIAL TRAY 69.6X61.8X15MM SZ 3 PLUS 15 REVISION MOBILE BEARING CEMENTED","SUP-ITM-10042832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1669.67","42.9","","956.46","956.46","956.46","1 through 10","1206.52","3094.14","percent of total billed charges",""
"TIBIAL TRAY 69.6X61.8X15MM SZ 3 PLUS 15 REVISION MOBILE BEARING CEMENTED","SUP-ITM-10042832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3892.00","2919.00","WELLPOINT [1015]","HB AMC WELLPOINT","2871.52","73.78","","2344.73","1619.47","2530.35","16","1206.52","3094.14","percent of total billed charges",""
"TIBIAL TRAY 69.6X61.8X15MM SZ 3 PLUS 15 REVISION MOBILE BEARING CEMENTED","SUP-ITM-10042832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","AETNA [1001]","HB AMC AETNA HMO","2716.62","69.8","","1523.63","988.41","4330.26","39","2033.96","3180.54","percent of total billed charges",""
"TIBIAL TRAY 69.6X61.8X15MM SZ 3 PLUS 15 REVISION MOBILE BEARING CEMENTED","SUP-ITM-10042832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","AETNA [1001]","HB AMC AETNA PPO","3129.17","80.4","","1670.25","1670.25","1670.25","1 through 10","2033.96","3180.54","percent of total billed charges",""
"TIBIAL TRAY 69.6X61.8X15MM SZ 3 PLUS 15 REVISION MOBILE BEARING CEMENTED","SUP-ITM-10042832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2033.96","52.26","","1113.10","1113.10","1113.10","1 through 10","2033.96","3180.54","percent of total billed charges",""
"TIBIAL TRAY 69.6X61.8X15MM SZ 3 PLUS 15 REVISION MOBILE BEARING CEMENTED","SUP-ITM-10042832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3892.00","2919.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3180.54","81.72","","1738.90","1484.65","2716.94","38","2033.96","3180.54","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10018411","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1701.06","52.26","","1113.10","1113.10","1113.10","1 through 10","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10018411","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2587.73","79.5","","1293.60","1148.53","1603.80","1 through 10","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10018411","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1188.08","36.5","","1023.42","771.29","2068.67","33","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10018411","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1246.67","38.3","","850.52","759.78","1211.25","66","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10018411","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1396.40","42.9","","2548.09","2548.09","2548.09","1 through 10","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10018411","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1396.40","42.9","","956.46","956.46","956.46","1 through 10","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10018411","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","WELLPOINT [1015]","HB AMC WELLPOINT","2401.54","73.78","","2344.73","1619.47","2530.35","16","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10018411","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","AETNA [1001]","HB AMC AETNA HMO","2271.99","69.8","","1523.63","988.41","4330.26","39","1701.06","2659.99","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10018411","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","AETNA [1001]","HB AMC AETNA PPO","2617.02","80.4","","1670.25","1670.25","1670.25","1 through 10","1701.06","2659.99","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10018411","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1701.06","52.26","","1113.10","1113.10","1113.10","1 through 10","1701.06","2659.99","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10018411","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2659.99","81.72","","1738.90","1484.65","2716.94","38","1701.06","2659.99","percent of total billed charges",""
"TIBIAL TRAY SZ 4 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1701.06","52.26","","1113.10","1113.10","1113.10","1 through 10","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 4 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2587.73","79.5","","1293.60","1148.53","1603.80","1 through 10","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 4 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1188.08","36.5","","1023.42","771.29","2068.67","33","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 4 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1246.67","38.3","","850.52","759.78","1211.25","66","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 4 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1396.40","42.9","","2548.09","2548.09","2548.09","1 through 10","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 4 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1396.40","42.9","","956.46","956.46","956.46","1 through 10","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 4 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","WELLPOINT [1015]","HB AMC WELLPOINT","2401.54","73.78","","2344.73","1619.47","2530.35","16","1009.05","2587.73","percent of total billed charges",""
"TIBIAL TRAY SZ 4 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","AETNA [1001]","HB AMC AETNA HMO","2271.99","69.8","","1523.63","988.41","4330.26","39","1701.06","2659.99","percent of total billed charges",""
"TIBIAL TRAY SZ 4 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","AETNA [1001]","HB AMC AETNA PPO","2617.02","80.4","","1670.25","1670.25","1670.25","1 through 10","1701.06","2659.99","percent of total billed charges",""
"TIBIAL TRAY SZ 4 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1701.06","52.26","","1113.10","1113.10","1113.10","1 through 10","1701.06","2659.99","percent of total billed charges",""
"TIBIAL TRAY SZ 4 KNEE LCS COMPLETE MBT CEMENTED KEEL","SUP-ITM-10006311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2659.99","81.72","","1738.90","1484.65","2716.94","38","1701.06","2659.99","percent of total billed charges",""
"TIBIAL WEDGE 5MM SZ 1 SM MODULAR HEMI FLAT DURACON LT","SUP-ITM-10018018","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1360.85","52.26","","1113.10","1113.10","1113.10","1 through 10","807.24","2070.18","percent of total billed charges",""
"TIBIAL WEDGE 5MM SZ 1 SM MODULAR HEMI FLAT DURACON LT","SUP-ITM-10018018","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2070.18","79.5","","1293.60","1148.53","1603.80","1 through 10","807.24","2070.18","percent of total billed charges",""
"TIBIAL WEDGE 5MM SZ 1 SM MODULAR HEMI FLAT DURACON LT","SUP-ITM-10018018","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","950.46","36.5","","1023.42","771.29","2068.67","33","807.24","2070.18","percent of total billed charges",""
"TIBIAL WEDGE 5MM SZ 1 SM MODULAR HEMI FLAT DURACON LT","SUP-ITM-10018018","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","997.33","38.3","","850.52","759.78","1211.25","66","807.24","2070.18","percent of total billed charges",""
"TIBIAL WEDGE 5MM SZ 1 SM MODULAR HEMI FLAT DURACON LT","SUP-ITM-10018018","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1117.12","42.9","","2548.09","2548.09","2548.09","1 through 10","807.24","2070.18","percent of total billed charges",""
"TIBIAL WEDGE 5MM SZ 1 SM MODULAR HEMI FLAT DURACON LT","SUP-ITM-10018018","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1117.12","42.9","","956.46","956.46","956.46","1 through 10","807.24","2070.18","percent of total billed charges",""
"TIBIAL WEDGE 5MM SZ 1 SM MODULAR HEMI FLAT DURACON LT","SUP-ITM-10018018","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","WELLPOINT [1015]","HB AMC WELLPOINT","1921.23","73.78","","2344.73","1619.47","2530.35","16","807.24","2070.18","percent of total billed charges",""
"TIBIAL WEDGE 5MM SZ 1 SM MODULAR HEMI FLAT DURACON LT","SUP-ITM-10018018","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2604.00","1953.00","AETNA [1001]","HB AMC AETNA HMO","1817.59","69.8","","1523.63","988.41","4330.26","39","1360.85","2127.99","percent of total billed charges",""
"TIBIAL WEDGE 5MM SZ 1 SM MODULAR HEMI FLAT DURACON LT","SUP-ITM-10018018","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2604.00","1953.00","AETNA [1001]","HB AMC AETNA PPO","2093.62","80.4","","1670.25","1670.25","1670.25","1 through 10","1360.85","2127.99","percent of total billed charges",""
"TIBIAL WEDGE 5MM SZ 1 SM MODULAR HEMI FLAT DURACON LT","SUP-ITM-10018018","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2604.00","1953.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1360.85","52.26","","1113.10","1113.10","1113.10","1 through 10","1360.85","2127.99","percent of total billed charges",""
"TIBIAL WEDGE 5MM SZ 1 SM MODULAR HEMI FLAT DURACON LT","SUP-ITM-10018018","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2604.00","1953.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2127.99","81.72","","1738.90","1484.65","2716.94","38","1360.85","2127.99","percent of total billed charges",""
"TIP FEMORAL 23X250MM ARCOS BALANCED LIGAMENTOUS TENSION DISTAL","SUP-ITM-10201957","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4133.31","52.26","","1113.10","1113.10","1113.10","1 through 10","2451.83","6287.76","percent of total billed charges",""
"TIP FEMORAL 23X250MM ARCOS BALANCED LIGAMENTOUS TENSION DISTAL","SUP-ITM-10201957","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6287.76","79.5","","1293.60","1148.53","1603.80","1 through 10","2451.83","6287.76","percent of total billed charges",""
"TIP FEMORAL 23X250MM ARCOS BALANCED LIGAMENTOUS TENSION DISTAL","SUP-ITM-10201957","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2886.83","36.5","","1023.42","771.29","2068.67","33","2451.83","6287.76","percent of total billed charges",""
"TIP FEMORAL 23X250MM ARCOS BALANCED LIGAMENTOUS TENSION DISTAL","SUP-ITM-10201957","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3029.20","38.3","","850.52","759.78","1211.25","66","2451.83","6287.76","percent of total billed charges",""
"TIP FEMORAL 23X250MM ARCOS BALANCED LIGAMENTOUS TENSION DISTAL","SUP-ITM-10201957","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3393.02","42.9","","2548.09","2548.09","2548.09","1 through 10","2451.83","6287.76","percent of total billed charges",""
"TIP FEMORAL 23X250MM ARCOS BALANCED LIGAMENTOUS TENSION DISTAL","SUP-ITM-10201957","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3393.02","42.9","","956.46","956.46","956.46","1 through 10","2451.83","6287.76","percent of total billed charges",""
"TIP FEMORAL 23X250MM ARCOS BALANCED LIGAMENTOUS TENSION DISTAL","SUP-ITM-10201957","CDM","C1776","HCPCS","0278","RC","","","","both","","","7909.13","5931.85","WELLPOINT [1015]","HB AMC WELLPOINT","5835.36","73.78","","2344.73","1619.47","2530.35","16","2451.83","6287.76","percent of total billed charges",""
"TIP FEMORAL 23X250MM ARCOS BALANCED LIGAMENTOUS TENSION DISTAL","SUP-ITM-10201957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7909.13","5931.85","AETNA [1001]","HB AMC AETNA HMO","5520.57","69.8","","1523.63","988.41","4330.26","39","4133.31","6463.34","percent of total billed charges",""
"TIP FEMORAL 23X250MM ARCOS BALANCED LIGAMENTOUS TENSION DISTAL","SUP-ITM-10201957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7909.13","5931.85","AETNA [1001]","HB AMC AETNA PPO","6358.94","80.4","","1670.25","1670.25","1670.25","1 through 10","4133.31","6463.34","percent of total billed charges",""
"TIP FEMORAL 23X250MM ARCOS BALANCED LIGAMENTOUS TENSION DISTAL","SUP-ITM-10201957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7909.13","5931.85","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4133.31","52.26","","1113.10","1113.10","1113.10","1 through 10","4133.31","6463.34","percent of total billed charges",""
"TIP FEMORAL 23X250MM ARCOS BALANCED LIGAMENTOUS TENSION DISTAL","SUP-ITM-10201957","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7909.13","5931.85","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6463.34","81.72","","1738.90","1484.65","2716.94","38","4133.31","6463.34","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","both","","","854.00","640.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","678.93","79.5","","1309.77","674.56","6049.93","26","264.74","678.93","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","both","","","854.00","640.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","455.18","53.3","","1901.83","1901.83","2962.25","1 through 10","264.74","678.93","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","both","","","854.00","640.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","311.71","36.5","","1620.31","1620.31","19908.88","1 through 10","264.74","678.93","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","both","","","854.00","640.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","327.08","38.3","","352.91","352.91","2046.30","1 through 10","264.74","678.93","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","both","","","854.00","640.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.37","42.9","","9668.75","9668.75","9668.75","1 through 10","264.74","678.93","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","both","","","854.00","640.50","WELLPOINT [1015]","HB AMC WELLPOINT","630.08","73.78","","699.88","384.10","3443.31","33","264.74","678.93","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","854.00","640.50","AETNA [1001]","HB AMC AETNA HMO","596.09","69.8","","1421.24","264.50","4933.46","29","446.3","697.89","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","854.00","640.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","686.62","80.4","","1022.97","1022.97","3607.50","1 through 10","446.3","697.89","percent of total billed charges",""
"TIP GRAFT BONE 3/4 FILL DIVERTED TUBE G2 IMPLANTABLE","SUP-ITM-10077518","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","854.00","640.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","697.89","81.72","","3010.54","693.88","5019.88","35","446.3","697.89","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","29510.00","22132.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","23460.45","79.5","","1309.77","674.56","6049.93","26","9148.1","23460.45","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","29510.00","22132.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","15728.83","53.3","","1901.83","1901.83","2962.25","1 through 10","9148.1","23460.45","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","29510.00","22132.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10771.15","36.5","","1620.31","1620.31","19908.88","1 through 10","9148.1","23460.45","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","29510.00","22132.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11302.33","38.3","","352.91","352.91","2046.30","1 through 10","9148.1","23460.45","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","29510.00","22132.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12659.79","42.9","","9668.75","9668.75","9668.75","1 through 10","9148.1","23460.45","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","29510.00","22132.50","WELLPOINT [1015]","HB AMC WELLPOINT","21772.48","73.78","","699.88","384.10","3443.31","33","9148.1","23460.45","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","29510.00","22132.50","AETNA [1001]","HB AMC AETNA HMO","20597.98","69.8","","1421.24","264.50","4933.46","29","15421.93","24115.57","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","29510.00","22132.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","23726.04","80.4","","1022.97","1022.97","3607.50","1 through 10","15421.93","24115.57","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","29510.00","22132.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24115.57","81.72","","3010.54","693.88","5019.88","35","15421.93","24115.57","percent of total billed charges",""
"Tissue Connective Human T1","PX-27000073","CDM","C1762","HCPCS","0278","RC","","","","both","","","1601.95","1201.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","853.84","53.3","","1112.50","1112.50","1112.50","1 through 10","496.6","1273.55","percent of total billed charges",""
"Tissue Connective Human T1","PX-27000073","CDM","C1762","HCPCS","0278","RC","","","","both","","","1601.95","1201.46","WELLPOINT [1015]","HB AMC WELLPOINT","1181.92","73.78","","1568.66","1568.66","1568.66","1 through 10","496.6","1273.55","percent of total billed charges",""
"Tissue Connective Human T1","PX-27000073","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","1601.95","1201.46","AETNA [1001]","HB AMC AETNA HMO","1118.16","69.8","","1281.90","1281.90","1281.90","1 through 10","837.18","1309.11","percent of total billed charges",""
"Tissue Connective Human T2","PX-27000074","CDM","C1762","HCPCS","0278","RC","","","","both","","","4824.00","3618.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2571.19","53.3","","1112.50","1112.50","1112.50","1 through 10","1495.44","3835.08","percent of total billed charges",""
"Tissue Connective Human T2","PX-27000074","CDM","C1762","HCPCS","0278","RC","","","","both","","","4824.00","3618.00","WELLPOINT [1015]","HB AMC WELLPOINT","3559.15","73.78","","1568.66","1568.66","1568.66","1 through 10","1495.44","3835.08","percent of total billed charges",""
"Tissue Connective Human T2","PX-27000074","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","4824.00","3618.00","AETNA [1001]","HB AMC AETNA HMO","3367.15","69.8","","1281.90","1281.90","1281.90","1 through 10","2521.02","3942.17","percent of total billed charges",""
"Tissue Connective Human T3","PX-27000075","CDM","C1762","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2638.35","53.3","","1112.50","1112.50","1112.50","1 through 10","1534.5","3935.25","percent of total billed charges",""
"Tissue Connective Human T3","PX-27000075","CDM","C1762","HCPCS","0278","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","1568.66","1568.66","1568.66","1 through 10","1534.5","3935.25","percent of total billed charges",""
"Tissue Connective Human T3","PX-27000075","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","1281.90","1281.90","1281.90","1 through 10","2586.87","4045.14","percent of total billed charges",""
"Tissue Connective Non-Human T1","PX-27000076","CDM","C1763","HCPCS","0278","RC","","","","both","","","1556.91","1167.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1011.99","65","","2028.23","1653.70","2028.23","1 through 10","482.64","1237.74","percent of total billed charges",""
"Tissue Connective Non-Human T1","PX-27000076","CDM","C1763","HCPCS","0278","RC","","","","both","","","1556.91","1167.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","568.27","36.5","","1163.89","1163.89","1163.89","1 through 10","482.64","1237.74","percent of total billed charges",""
"Tissue Connective Non-Human T1","PX-27000076","CDM","C1763","HCPCS","0278","RC","","","","both","","","1556.91","1167.68","WELLPOINT [1015]","HB AMC WELLPOINT","1148.69","73.78","","4280.87","4280.87","4280.87","1 through 10","482.64","1237.74","percent of total billed charges",""
"Tissue Connective Non-Human T2","PX-27000077","CDM","C1763","HCPCS","0278","RC","","","","both","","","4521.72","3391.29","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","2939.12","65","","2028.23","1653.70","2028.23","1 through 10","1401.73","3594.77","percent of total billed charges",""
"Tissue Connective Non-Human T2","PX-27000077","CDM","C1763","HCPCS","0278","RC","","","","both","","","4521.72","3391.29","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1650.43","36.5","","1163.89","1163.89","1163.89","1 through 10","1401.73","3594.77","percent of total billed charges",""
"Tissue Connective Non-Human T2","PX-27000077","CDM","C1763","HCPCS","0278","RC","","","","both","","","4521.72","3391.29","WELLPOINT [1015]","HB AMC WELLPOINT","3336.13","73.78","","4280.87","4280.87","4280.87","1 through 10","1401.73","3594.77","percent of total billed charges",""
"Tissue Connective Non-Human T3","PX-27000078","CDM","C1763","HCPCS","0278","RC","","","","both","","","8039.33","6029.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","5225.56","65","","2028.23","1653.70","2028.23","1 through 10","2492.19","6391.27","percent of total billed charges",""
"Tissue Connective Non-Human T3","PX-27000078","CDM","C1763","HCPCS","0278","RC","","","","both","","","8039.33","6029.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2934.36","36.5","","1163.89","1163.89","1163.89","1 through 10","2492.19","6391.27","percent of total billed charges",""
"Tissue Connective Non-Human T3","PX-27000078","CDM","C1763","HCPCS","0278","RC","","","","both","","","8039.33","6029.50","WELLPOINT [1015]","HB AMC WELLPOINT","5931.42","73.78","","4280.87","4280.87","4280.87","1 through 10","2492.19","6391.27","percent of total billed charges",""
"Tissue Cult Skin/Othr Solid Tiss Bi","PX-31000109","CDM","88233","CPT","0311","RC","","","","both","","","1058.00","793.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","841.11","79.5","","807.46","807.22","807.46","1 through 10","137.92","1005.1","percent of total billed charges",""
"Tissue Cult Skin/Othr Solid Tiss Bi","PX-31000109","CDM","88233","CPT","0311","RC","","","","both","","","1058.00","793.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","563.91","53.3","","541.73","541.73","541.73","1 through 10","137.92","1005.1","percent of total billed charges",""
"Tissue Cult Skin/Othr Solid Tiss Bi","PX-31000109","CDM","88233","CPT","0311","RC","","","","both","","","1058.00","793.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","386.17","36.5","","382.70","325.24","382.70","1 through 10","137.92","1005.1","percent of total billed charges",""
"Tissue Cult Skin/Othr Solid Tiss Bi","PX-31000109","CDM","88233","CPT","0311","RC","","","","both","","","1058.00","793.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","405.21","38.3","","401.17","401.17","1203.51","21","137.92","1005.1","percent of total billed charges",""
"Tissue Cult Skin/Othr Solid Tiss Bi","PX-31000109","CDM","88233","CPT","0311","RC","","","","outpatient","","","1058.00","793.50","AETNA [1001]","HB AMC AETNA HMO","738.48","69.8","","490.43","490.43","694.60","1 through 10","497","958.49","percent of total billed charges",""
"Tissue Cult Skin/Othr Solid Tiss Bi","PX-31000109","CDM","88233","CPT","0311","RC","","","","outpatient","","","1058.00","793.50","AETNA [1001]","HB AMC AETNA PPO","850.63","80.4","","800.28","800.28","800.28","1 through 10","497","958.49","percent of total billed charges",""
"Tissue Cult Skin/Othr Solid Tiss Bi","PX-31000109","CDM","88233","CPT","0311","RC","","","","outpatient","","","1058.00","793.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","864.60","81.72","","820.18","820.18","820.18","1 through 10","497","958.49","percent of total billed charges",""
"Tissue Culture Amniotic","PX-31000111","CDM","88235","CPT","0311","RC","","","","both","","","1053.00","789.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","837.14","79.5","","803.53","306.77","803.53","1 through 10","147.29","1000.35","percent of total billed charges",""
"Tissue Culture Amniotic","PX-31000111","CDM","88235","CPT","0311","RC","","","","both","","","1053.00","789.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","561.25","53.3","","684.78","515.61","1897.63","1 through 10","147.29","1000.35","percent of total billed charges",""
"Tissue Culture Amniotic","PX-31000111","CDM","88235","CPT","0311","RC","","","","both","","","1053.00","789.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","384.35","36.5","","1142.49","323.66","1142.49","11","147.29","1000.35","percent of total billed charges",""
"Tissue Culture Amniotic","PX-31000111","CDM","88235","CPT","0311","RC","","","","both","","","1053.00","789.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","403.30","38.3","","399.21","387.98","1197.63","35","147.29","1000.35","percent of total billed charges",""
"Tissue Culture Amniotic","PX-31000111","CDM","88235","CPT","0311","RC","","","","both","","","1053.00","789.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","451.74","42.9","","816.19","816.19","816.19","1 through 10","147.29","1000.35","percent of total billed charges",""
"Tissue Culture Amniotic","PX-31000111","CDM","88235","CPT","0311","RC","","","","outpatient","","","1053.00","789.75","AETNA [1001]","HB AMC AETNA HMO","734.99","69.8","","691.22","488.04","2389.14","18","519.68","1003.05","percent of total billed charges",""
"Tissue Culture Amniotic","PX-31000111","CDM","88235","CPT","0311","RC","","","","outpatient","","","1053.00","789.75","AETNA [1001]","HB AMC AETNA PPO","846.61","80.4","","3185.52","535.01","3185.52","1 through 10","519.68","1003.05","percent of total billed charges",""
"Tissue Culture Amniotic","PX-31000111","CDM","88235","CPT","0311","RC","","","","outpatient","","","1053.00","789.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","860.51","81.72","","816.19","816.19","1049.82","1 through 10","519.68","1003.05","percent of total billed charges",""
"Tissue Culture Bone Marrow Analys","PX-31000113","CDM","88237","CPT","0311","RC","","","","both","","","861.00","645.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","564.82","65.6","","565.30","565.30","565.30","1 through 10","140.88","817.95","percent of total billed charges",""
"Tissue Culture Bone Marrow Analys","PX-31000113","CDM","88237","CPT","0311","RC","","","","both","","","861.00","645.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","684.50","79.5","","1508.69","440.88","1508.69","1 through 10","140.88","817.95","percent of total billed charges",""
"Tissue Culture Bone Marrow Analys","PX-31000113","CDM","88237","CPT","0311","RC","","","","both","","","861.00","645.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","458.91","53.3","","1500.03","1500.03","1500.03","21","140.88","817.95","percent of total billed charges",""
"Tissue Culture Bone Marrow Analys","PX-31000113","CDM","88237","CPT","0311","RC","","","","both","","","861.00","645.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","329.76","38.3","","317.30","317.30","317.30","1 through 10","140.88","817.95","percent of total billed charges",""
"Tissue Culture Bone Marrow Analys","PX-31000113","CDM","88237","CPT","0311","RC","","","","outpatient","","","861.00","645.75","AETNA [1001]","HB AMC AETNA HMO","600.98","69.8","","565.30","565.30","565.30","1 through 10","326.93","881.19","percent of total billed charges",""
"Tissue Culture Bone Marrow Analys","PX-31000113","CDM","88237","CPT","0311","RC","","","","outpatient","","","861.00","645.75","AETNA [1001]","HB AMC AETNA PPO","692.24","80.4","","665.03","665.03","665.03","1 through 10","326.93","881.19","percent of total billed charges",""
"Tissue Culture Bone Marrow Analys","PX-31000113","CDM","88237","CPT","0311","RC","","","","outpatient","","","861.00","645.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","703.61","81.72","","667.50","667.50","5125.16","1 through 10","326.93","881.19","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","both","","","615.00","461.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","488.93","79.5","","469.05","314.69","469.05","13","114.16","584.25","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","both","","","615.00","461.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","327.80","53.3","","314.69","314.69","314.69","1 through 10","114.16","584.25","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","both","","","615.00","461.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","224.48","36.5","","1111.55","188.93","1111.55","18","114.16","584.25","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","both","","","615.00","461.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","235.55","38.3","","233.04","226.48","233.04","41","114.16","584.25","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","both","","","615.00","461.25","TRICARE [160005]","HB BWH TRICARE","584.25","95","","133.35","133.35","133.35","1 through 10","114.16","584.25","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","outpatient","","","615.00","461.25","AETNA [1001]","HB AMC AETNA HMO","429.27","69.8","","403.49","284.89","806.98","19","283.29","793.47","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","outpatient","","","615.00","461.25","AETNA [1001]","HB AMC AETNA PPO","494.46","80.4","","464.88","464.88","464.88","1 through 10","283.29","793.47","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","outpatient","","","615.00","461.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","502.58","81.72","","476.44","262.06","476.44","20","283.29","793.47","percent of total billed charges",""
"Tissue Culture Solid Tumor","PX-31000114","CDM","88239","CPT","0311","RC","","","","both","","","1955.00","1466.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1554.23","79.5","","1491.73","1491.73","1491.73","1 through 10","144.57","1857.25","percent of total billed charges",""
"Tissue Culture Solid Tumor","PX-31000114","CDM","88239","CPT","0311","RC","","","","outpatient","","","1955.00","1466.25","AETNA [1001]","HB AMC AETNA HMO","1364.59","69.8","","1478.88","1478.88","1478.88","1 through 10","520.7","1597.63","percent of total billed charges",""
"Tissue Culture Solid Tumor","PX-31000114","CDM","88239","CPT","0311","RC","","","","outpatient","","","1955.00","1466.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1597.63","81.72","","1515.66","833.67","1515.66","1 through 10","520.7","1597.63","percent of total billed charges",""
"Tissue Exam Koh Skin/Hair/Nail","PX-30001197","CDM","87220","CPT","0306","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.73","38.3","","28.54","28.54","28.54","1 through 10","4.18","71.25","percent of total billed charges",""
"TISSUE GRAFT 150MMX30 MEDIUM READI ALLO FASCIA LATA MUSCLE COVERING","SUP-ITM-10010296","CDM","C1762","HCPCS","0278","RC","","","","both","","","1388.24","1041.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","739.93","53.3","","1112.50","1112.50","1112.50","1 through 10","430.35","1103.65","percent of total billed charges",""
"TISSUE GRAFT 150MMX30 MEDIUM READI ALLO FASCIA LATA MUSCLE COVERING","SUP-ITM-10010296","CDM","C1762","HCPCS","0278","RC","","","","both","","","1388.24","1041.18","WELLPOINT [1015]","HB AMC WELLPOINT","1024.24","73.78","","1568.66","1568.66","1568.66","1 through 10","430.35","1103.65","percent of total billed charges",""
"TISSUE GRAFT 150MMX30 MEDIUM READI ALLO FASCIA LATA MUSCLE COVERING","SUP-ITM-10010296","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","1388.24","1041.18","AETNA [1001]","HB AMC AETNA HMO","968.99","69.8","","1281.90","1281.90","1281.90","1 through 10","725.49","1134.47","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","4282.89","3212.17","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3404.90","79.5","","1309.77","674.56","6049.93","26","1327.7","3404.9","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","4282.89","3212.17","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2282.78","53.3","","1901.83","1901.83","2962.25","1 through 10","1327.7","3404.9","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","4282.89","3212.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1563.25","36.5","","1620.31","1620.31","19908.88","1 through 10","1327.7","3404.9","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","4282.89","3212.17","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1640.35","38.3","","352.91","352.91","2046.30","1 through 10","1327.7","3404.9","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","4282.89","3212.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1837.36","42.9","","9668.75","9668.75","9668.75","1 through 10","1327.7","3404.9","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","4282.89","3212.17","WELLPOINT [1015]","HB AMC WELLPOINT","3159.92","73.78","","699.88","384.10","3443.31","33","1327.7","3404.9","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4282.89","3212.17","AETNA [1001]","HB AMC AETNA HMO","2989.46","69.8","","1421.24","264.50","4933.46","29","2238.24","3499.98","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4282.89","3212.17","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3443.44","80.4","","1022.97","1022.97","3607.50","1 through 10","2238.24","3499.98","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4282.89","3212.17","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3499.98","81.72","","3010.54","693.88","5019.88","35","2238.24","3499.98","percent of total billed charges",""
"TISSUE GRAFT 20MM FLEXI ALLO LIGAMENT PATELLAR WHOLE FROZEN MINIMUM INSERTION WIDTH","SUP-ITM-10010308","CDM","C1889","HCPCS","0278","RC","","","","both","","","7687.33","5765.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6111.43","79.5","","1309.77","674.56","6049.93","26","2383.07","6111.43","percent of total billed charges",""
"TISSUE GRAFT 20MM FLEXI ALLO LIGAMENT PATELLAR WHOLE FROZEN MINIMUM INSERTION WIDTH","SUP-ITM-10010308","CDM","C1889","HCPCS","0278","RC","","","","both","","","7687.33","5765.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4097.35","53.3","","1901.83","1901.83","2962.25","1 through 10","2383.07","6111.43","percent of total billed charges",""
"TISSUE GRAFT 20MM FLEXI ALLO LIGAMENT PATELLAR WHOLE FROZEN MINIMUM INSERTION WIDTH","SUP-ITM-10010308","CDM","C1889","HCPCS","0278","RC","","","","both","","","7687.33","5765.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2805.88","36.5","","1620.31","1620.31","19908.88","1 through 10","2383.07","6111.43","percent of total billed charges",""
"TISSUE GRAFT 20MM FLEXI ALLO LIGAMENT PATELLAR WHOLE FROZEN MINIMUM INSERTION WIDTH","SUP-ITM-10010308","CDM","C1889","HCPCS","0278","RC","","","","both","","","7687.33","5765.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2944.25","38.3","","352.91","352.91","2046.30","1 through 10","2383.07","6111.43","percent of total billed charges",""
"TISSUE GRAFT 20MM FLEXI ALLO LIGAMENT PATELLAR WHOLE FROZEN MINIMUM INSERTION WIDTH","SUP-ITM-10010308","CDM","C1889","HCPCS","0278","RC","","","","both","","","7687.33","5765.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3297.86","42.9","","9668.75","9668.75","9668.75","1 through 10","2383.07","6111.43","percent of total billed charges",""
"TISSUE GRAFT 20MM FLEXI ALLO LIGAMENT PATELLAR WHOLE FROZEN MINIMUM INSERTION WIDTH","SUP-ITM-10010308","CDM","C1889","HCPCS","0278","RC","","","","both","","","7687.33","5765.50","WELLPOINT [1015]","HB AMC WELLPOINT","5671.71","73.78","","699.88","384.10","3443.31","33","2383.07","6111.43","percent of total billed charges",""
"TISSUE GRAFT 20MM FLEXI ALLO LIGAMENT PATELLAR WHOLE FROZEN MINIMUM INSERTION WIDTH","SUP-ITM-10010308","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7687.33","5765.50","AETNA [1001]","HB AMC AETNA HMO","5365.76","69.8","","1421.24","264.50","4933.46","29","4017.4","6282.09","percent of total billed charges",""
"TISSUE GRAFT 20MM FLEXI ALLO LIGAMENT PATELLAR WHOLE FROZEN MINIMUM INSERTION WIDTH","SUP-ITM-10010308","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7687.33","5765.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6180.61","80.4","","1022.97","1022.97","3607.50","1 through 10","4017.4","6282.09","percent of total billed charges",""
"TISSUE GRAFT 20MM FLEXI ALLO LIGAMENT PATELLAR WHOLE FROZEN MINIMUM INSERTION WIDTH","SUP-ITM-10010308","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7687.33","5765.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6282.09","81.72","","3010.54","693.88","5019.88","35","4017.4","6282.09","percent of total billed charges",""
"TISSUE GRAFT 3.0 10MMX20 38CM ALLO GRACILIS FROZEN","SUP-ITM-10010695","CDM","C1889","HCPCS","0278","RC","","","","both","","","4498.38","3373.78","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3576.21","79.5","","1309.77","674.56","6049.93","26","1394.5","3576.21","percent of total billed charges",""
"TISSUE GRAFT 3.0 10MMX20 38CM ALLO GRACILIS FROZEN","SUP-ITM-10010695","CDM","C1889","HCPCS","0278","RC","","","","both","","","4498.38","3373.78","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2397.64","53.3","","1901.83","1901.83","2962.25","1 through 10","1394.5","3576.21","percent of total billed charges",""
"TISSUE GRAFT 3.0 10MMX20 38CM ALLO GRACILIS FROZEN","SUP-ITM-10010695","CDM","C1889","HCPCS","0278","RC","","","","both","","","4498.38","3373.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1641.91","36.5","","1620.31","1620.31","19908.88","1 through 10","1394.5","3576.21","percent of total billed charges",""
"TISSUE GRAFT 3.0 10MMX20 38CM ALLO GRACILIS FROZEN","SUP-ITM-10010695","CDM","C1889","HCPCS","0278","RC","","","","both","","","4498.38","3373.78","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1722.88","38.3","","352.91","352.91","2046.30","1 through 10","1394.5","3576.21","percent of total billed charges",""
"TISSUE GRAFT 3.0 10MMX20 38CM ALLO GRACILIS FROZEN","SUP-ITM-10010695","CDM","C1889","HCPCS","0278","RC","","","","both","","","4498.38","3373.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1929.81","42.9","","9668.75","9668.75","9668.75","1 through 10","1394.5","3576.21","percent of total billed charges",""
"TISSUE GRAFT 3.0 10MMX20 38CM ALLO GRACILIS FROZEN","SUP-ITM-10010695","CDM","C1889","HCPCS","0278","RC","","","","both","","","4498.38","3373.78","WELLPOINT [1015]","HB AMC WELLPOINT","3318.90","73.78","","699.88","384.10","3443.31","33","1394.5","3576.21","percent of total billed charges",""
"TISSUE GRAFT 3.0 10MMX20 38CM ALLO GRACILIS FROZEN","SUP-ITM-10010695","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4498.38","3373.78","AETNA [1001]","HB AMC AETNA HMO","3139.87","69.8","","1421.24","264.50","4933.46","29","2350.85","3676.08","percent of total billed charges",""
"TISSUE GRAFT 3.0 10MMX20 38CM ALLO GRACILIS FROZEN","SUP-ITM-10010695","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4498.38","3373.78","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3616.70","80.4","","1022.97","1022.97","3607.50","1 through 10","2350.85","3676.08","percent of total billed charges",""
"TISSUE GRAFT 3.0 10MMX20 38CM ALLO GRACILIS FROZEN","SUP-ITM-10010695","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4498.38","3373.78","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3676.08","81.72","","3010.54","693.88","5019.88","35","2350.85","3676.08","percent of total billed charges",""
"TISSUE GRAFT 60MMX30 SM READI ALLO FASCIA LATA MUSCLE COVERING","SUP-ITM-10010297","CDM","C1762","HCPCS","0278","RC","","","","both","","","706.30","529.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","376.46","53.3","","1112.50","1112.50","1112.50","1 through 10","218.95","561.51","percent of total billed charges",""
"TISSUE GRAFT 60MMX30 SM READI ALLO FASCIA LATA MUSCLE COVERING","SUP-ITM-10010297","CDM","C1762","HCPCS","0278","RC","","","","both","","","706.30","529.72","WELLPOINT [1015]","HB AMC WELLPOINT","521.11","73.78","","1568.66","1568.66","1568.66","1 through 10","218.95","561.51","percent of total billed charges",""
"TISSUE GRAFT 60MMX30 SM READI ALLO FASCIA LATA MUSCLE COVERING","SUP-ITM-10010297","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","706.30","529.72","AETNA [1001]","HB AMC AETNA HMO","493.00","69.8","","1281.90","1281.90","1281.90","1 through 10","369.11","577.19","percent of total billed charges",""
"TISSUE GRAFT 80X200MM LG FASCIA LATA MUSCLE COVERING","SUP-ITM-10010295","CDM","C1762","HCPCS","0278","RC","","","","both","","","3938.45","2953.84","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2099.19","53.3","","1112.50","1112.50","1112.50","1 through 10","1220.92","3131.07","percent of total billed charges",""
"TISSUE GRAFT 80X200MM LG FASCIA LATA MUSCLE COVERING","SUP-ITM-10010295","CDM","C1762","HCPCS","0278","RC","","","","both","","","3938.45","2953.84","WELLPOINT [1015]","HB AMC WELLPOINT","2905.79","73.78","","1568.66","1568.66","1568.66","1 through 10","1220.92","3131.07","percent of total billed charges",""
"TISSUE GRAFT 80X200MM LG FASCIA LATA MUSCLE COVERING","SUP-ITM-10010295","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","3938.45","2953.84","AETNA [1001]","HB AMC AETNA HMO","2749.04","69.8","","1281.90","1281.90","1281.90","1 through 10","2058.23","3218.5","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","4532.01","3399.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3602.95","79.5","","1309.77","674.56","6049.93","26","1404.92","3602.95","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","4532.01","3399.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2415.56","53.3","","1901.83","1901.83","2962.25","1 through 10","1404.92","3602.95","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","4532.01","3399.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1654.18","36.5","","1620.31","1620.31","19908.88","1 through 10","1404.92","3602.95","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","4532.01","3399.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1735.76","38.3","","352.91","352.91","2046.30","1 through 10","1404.92","3602.95","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","4532.01","3399.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.23","42.9","","9668.75","9668.75","9668.75","1 through 10","1404.92","3602.95","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","4532.01","3399.01","WELLPOINT [1015]","HB AMC WELLPOINT","3343.72","73.78","","699.88","384.10","3443.31","33","1404.92","3602.95","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4532.01","3399.01","AETNA [1001]","HB AMC AETNA HMO","3163.34","69.8","","1421.24","264.50","4933.46","29","2368.43","3703.56","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4532.01","3399.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3643.74","80.4","","1022.97","1022.97","3607.50","1 through 10","2368.43","3703.56","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4532.01","3399.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3703.56","81.72","","3010.54","693.88","5019.88","35","2368.43","3703.56","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","4681.65","3511.24","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3721.91","79.5","","1309.77","674.56","6049.93","26","1451.31","3721.91","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","4681.65","3511.24","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2495.32","53.3","","1901.83","1901.83","2962.25","1 through 10","1451.31","3721.91","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","4681.65","3511.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1708.80","36.5","","1620.31","1620.31","19908.88","1 through 10","1451.31","3721.91","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","4681.65","3511.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1793.07","38.3","","352.91","352.91","2046.30","1 through 10","1451.31","3721.91","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","4681.65","3511.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2008.43","42.9","","9668.75","9668.75","9668.75","1 through 10","1451.31","3721.91","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","4681.65","3511.24","WELLPOINT [1015]","HB AMC WELLPOINT","3454.12","73.78","","699.88","384.10","3443.31","33","1451.31","3721.91","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4681.65","3511.24","AETNA [1001]","HB AMC AETNA HMO","3267.79","69.8","","1421.24","264.50","4933.46","29","2446.63","3825.84","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4681.65","3511.24","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3764.05","80.4","","1022.97","1022.97","3607.50","1 through 10","2446.63","3825.84","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4681.65","3511.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3825.84","81.72","","3010.54","693.88","5019.88","35","2446.63","3825.84","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","5361.35","4021.01","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4262.27","79.5","","1309.77","674.56","6049.93","26","1662.02","4262.27","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","5361.35","4021.01","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2857.60","53.3","","1901.83","1901.83","2962.25","1 through 10","1662.02","4262.27","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","5361.35","4021.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1956.89","36.5","","1620.31","1620.31","19908.88","1 through 10","1662.02","4262.27","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","5361.35","4021.01","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2053.40","38.3","","352.91","352.91","2046.30","1 through 10","1662.02","4262.27","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","5361.35","4021.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2300.02","42.9","","9668.75","9668.75","9668.75","1 through 10","1662.02","4262.27","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","5361.35","4021.01","WELLPOINT [1015]","HB AMC WELLPOINT","3955.60","73.78","","699.88","384.10","3443.31","33","1662.02","4262.27","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5361.35","4021.01","AETNA [1001]","HB AMC AETNA HMO","3742.22","69.8","","1421.24","264.50","4933.46","29","2801.84","4381.3","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5361.35","4021.01","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4310.53","80.4","","1022.97","1022.97","3607.50","1 through 10","2801.84","4381.3","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5361.35","4021.01","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4381.30","81.72","","3010.54","693.88","5019.88","35","2801.84","4381.3","percent of total billed charges",""
"TISSUE MATRIX 16X20CM REGENERATIVE ALLODERM THICK 2.4 / 0.4MM","SUP-ITM-10132960","CDM","Q4116","HCPCS","0636","RC","","","","both","","","22892.50","17169.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8355.76","36.5","","23.35","23.35","23.35","264","7096.68","17627.23","percent of total billed charges",""
"TISSUE MATRIX 16X20CM REGENERATIVE ALLODERM THICK 2.4 / 0.4MM","SUP-ITM-10132960","CDM","Q4116","HCPCS","0636","RC","","","","both","","","22892.50","17169.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8767.83","38.3","","350.11","350.11","350.11","1108","7096.68","17627.23","percent of total billed charges",""
"TISSUE MATRIX 16X20CM REGENERATIVE ALLODERM THICK 2.4 / 0.4MM","SUP-ITM-10132960","CDM","Q4116","HCPCS","0636","RC","","","","both","","","22892.50","17169.37","WELLPOINT [1015]","HB AMC WELLPOINT","16890.09","73.78","","77.77","77.77","77.77","528","7096.68","17627.23","percent of total billed charges",""
"TISSUE MATRIX 16X20CM REGENERATIVE ALLODERM THICK 2.4 / 0.4MM","SUP-ITM-10132960","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","22892.50","17169.37","AETNA [1001]","HB AMC AETNA HMO","15978.97","69.8","","35.22","35.22","35.22","397","10736.58","18405.57","percent of total billed charges",""
"TISSUE MATRIX 16X20CM REGENERATIVE ALLODERM THICK 2.4 / 0.4MM","SUP-ITM-10132960","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","22892.50","17169.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","16001.86","69.9","","34.18","34.18","34.18","1057","10736.58","18405.57","percent of total billed charges",""
"TISSUE MATRIX 16X20CM REGENERATIVE ALLODERM THICK 2.4 / 0.4MM","SUP-ITM-10132960","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","22892.50","17169.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10736.58","46.9","","34.18","34.18","34.18","528","10736.58","18405.57","percent of total billed charges",""
"Tissue Typing 10 Yr Donor Storage","PX-30003740","CDM","86849","CPT","0302","RC","","","","both","","","54569.00","40926.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","35797.26","65.6","","298.56","298.56","298.56","1 through 10","16916.39","43382.36","percent of total billed charges",""
"Tissue Typing 10 Yr Donor Storage","PX-30003740","CDM","86849","CPT","0302","RC","","","","both","","","54569.00","40926.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","35469.85","65","","286.65","286.65","347.07","11","16916.39","43382.36","percent of total billed charges",""
"Tissue Typing 10 Yr Donor Storage","PX-30003740","CDM","86849","CPT","0302","RC","","","","both","","","54569.00","40926.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","38198.30","70","","317.52","189.63","317.52","1 through 10","16916.39","43382.36","percent of total billed charges",""
"Tissue Typing 10 Yr Donor Storage","PX-30003740","CDM","86849","CPT","0302","RC","","","","both","","","54569.00","40926.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","35469.85","65","","286.65","270.40","286.65","12","16916.39","43382.36","percent of total billed charges",""
"Tissue Typing 10 Yr Donor Storage","PX-30003740","CDM","86849","CPT","0302","RC","","","","both","","","54569.00","40926.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","35469.85","65","","286.65","286.65","286.65","1 through 10","16916.39","43382.36","percent of total billed charges",""
"Tissue Typing 10 Yr Donor Storage","PX-30003740","CDM","86849","CPT","0302","RC","","","","both","","","54569.00","40926.75","WELLPOINT [1015]","HB AMC WELLPOINT","40261.01","73.78","","328.32","306.01","328.32","1 through 10","16916.39","43382.36","percent of total billed charges",""
"Tissue Typing 10 Yr Donor Storage","PX-30003740","CDM","86849","CPT","0302","RC","","","","outpatient","","","54569.00","40926.75","AETNA [1001]","HB AMC AETNA HMO","38089.16","69.8","","298.56","298.56","343.98","1 through 10","27284.5","45019.43","percent of total billed charges",""
"Tissue Typing 10 Yr Donor Storage","PX-30003740","CDM","86849","CPT","0302","RC","","","","outpatient","","","54569.00","40926.75","AETNA [1001]","HB AMC AETNA PPO","43873.48","80.4","","343.98","343.98","343.98","1 through 10","27284.5","45019.43","percent of total billed charges",""
"Tissue Typing 10 Yr Donor Storage","PX-30003740","CDM","86849","CPT","0302","RC","","","","outpatient","","","54569.00","40926.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","27284.50","50","","441.00","441.00","441.00","12","27284.5","45019.43","percent of total billed charges",""
"Tissue Typing 10 Yr Donor Storage","PX-30003740","CDM","86849","CPT","0302","RC","","","","outpatient","","","54569.00","40926.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","28648.73","52.5","","441.00","441.00","441.00","1 through 10","27284.5","45019.43","percent of total billed charges",""
"Tissue Typing 10 Yr Donor Storage","PX-30003740","CDM","86849","CPT","0302","RC","","","","outpatient","","","54569.00","40926.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","30012.95","55","","254.02","254.02","254.02","1 through 10","27284.5","45019.43","percent of total billed charges",""
"Tissue Typing 10 Yr Donor Storage","PX-30003740","CDM","86849","CPT","0302","RC","","","","outpatient","","","54569.00","40926.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","43873.48","80.4","","343.98","343.98","343.98","1 through 10","27284.5","45019.43","percent of total billed charges",""
"Tissue Typing 10 Yr Donor Storage","PX-30003740","CDM","86849","CPT","0302","RC","","","","outpatient","","","54569.00","40926.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","34105.63","62.5","","288.86","277.39","288.86","1 through 10","27284.5","45019.43","percent of total billed charges",""
"TITAN MEDPOR 1.0MM PLATE CRANIOMAXILLOFACIAL BARRIER BIOMATERIAL IUM MESH ORBITAL FLOOR FAN","SUP-ITM-10094001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.38","3060.28","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3243.90","79.5","","800.18","480.96","1887.97","195","1264.92","3243.9","percent of total billed charges",""
"TITAN MEDPOR 1.0MM PLATE CRANIOMAXILLOFACIAL BARRIER BIOMATERIAL IUM MESH ORBITAL FLOOR FAN","SUP-ITM-10094001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.38","3060.28","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2174.84","53.3","","813.12","216.42","1444.50","81","1264.92","3243.9","percent of total billed charges",""
"TITAN MEDPOR 1.0MM PLATE CRANIOMAXILLOFACIAL BARRIER BIOMATERIAL IUM MESH ORBITAL FLOOR FAN","SUP-ITM-10094001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.38","3060.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1264.92","31","","432.60","432.60","432.60","1 through 10","1264.92","3243.9","percent of total billed charges",""
"TITAN MEDPOR 1.0MM PLATE CRANIOMAXILLOFACIAL BARRIER BIOMATERIAL IUM MESH ORBITAL FLOOR FAN","SUP-ITM-10094001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.38","3060.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1489.34","36.5","","148.37","54.89","631.39","94","1264.92","3243.9","percent of total billed charges",""
"TITAN MEDPOR 1.0MM PLATE CRANIOMAXILLOFACIAL BARRIER BIOMATERIAL IUM MESH ORBITAL FLOOR FAN","SUP-ITM-10094001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.38","3060.28","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1562.79","38.3","","279.30","91.72","1116.77","266","1264.92","3243.9","percent of total billed charges",""
"TITAN MEDPOR 1.0MM PLATE CRANIOMAXILLOFACIAL BARRIER BIOMATERIAL IUM MESH ORBITAL FLOOR FAN","SUP-ITM-10094001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.38","3060.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1750.48","42.9","","731.00","63.70","731.00","1 through 10","1264.92","3243.9","percent of total billed charges",""
"TITAN MEDPOR 1.0MM PLATE CRANIOMAXILLOFACIAL BARRIER BIOMATERIAL IUM MESH ORBITAL FLOOR FAN","SUP-ITM-10094001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.38","3060.28","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1750.48","42.9","","384.74","384.74","384.74","1 through 10","1264.92","3243.9","percent of total billed charges",""
"TITAN MEDPOR 1.0MM PLATE CRANIOMAXILLOFACIAL BARRIER BIOMATERIAL IUM MESH ORBITAL FLOOR FAN","SUP-ITM-10094001","CDM","C1713","HCPCS","0278","RC","","","","both","","","4080.38","3060.28","WELLPOINT [1015]","HB AMC WELLPOINT","3010.50","73.78","","286.63","119.22","1107.45","105","1264.92","3243.9","percent of total billed charges",""
"TITAN MEDPOR 1.0MM PLATE CRANIOMAXILLOFACIAL BARRIER BIOMATERIAL IUM MESH ORBITAL FLOOR FAN","SUP-ITM-10094001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4080.38","3060.28","AETNA [1001]","HB AMC AETNA HMO","2848.11","69.8","","675.31","184.75","1721.50","286","2132.41","3334.49","percent of total billed charges",""
"TITAN MEDPOR 1.0MM PLATE CRANIOMAXILLOFACIAL BARRIER BIOMATERIAL IUM MESH ORBITAL FLOOR FAN","SUP-ITM-10094001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4080.38","3060.28","AETNA [1001]","HB AMC AETNA PPO","3280.63","80.4","","1261.44","103.12","1514.10","21","2132.41","3334.49","percent of total billed charges",""
"TITAN MEDPOR 1.0MM PLATE CRANIOMAXILLOFACIAL BARRIER BIOMATERIAL IUM MESH ORBITAL FLOOR FAN","SUP-ITM-10094001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4080.38","3060.28","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3280.63","80.4","","1365.00","1365.00","1365.00","1 through 10","2132.41","3334.49","percent of total billed charges",""
"TITAN MEDPOR 1.0MM PLATE CRANIOMAXILLOFACIAL BARRIER BIOMATERIAL IUM MESH ORBITAL FLOOR FAN","SUP-ITM-10094001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4080.38","3060.28","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3334.49","81.72","","5157.68","5157.68","5157.68","1 through 10","2132.41","3334.49","percent of total billed charges",""
"TITAN MEDPOR 1.0MM PLATE CRANIOMAXILLOFACIAL BARRIER BIOMATERIAL IUM MESH ORBITAL FLOOR FAN","SUP-ITM-10094001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4080.38","3060.28","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3334.49","81.72","","431.26","71.26","1459.57","88","2132.41","3334.49","percent of total billed charges",""
"TITAN MEDPORE 76MMX50 1.6 PLATE CRANIOMAXILLOFACIAL IUM MTB MESH POROUS POLYETHYLENE MATRIX","SUP-ITM-10094000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4132.26","3099.19","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3285.15","79.5","","800.18","480.96","1887.97","195","1281","3285.15","percent of total billed charges",""
"TITAN MEDPORE 76MMX50 1.6 PLATE CRANIOMAXILLOFACIAL IUM MTB MESH POROUS POLYETHYLENE MATRIX","SUP-ITM-10094000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4132.26","3099.19","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2202.49","53.3","","813.12","216.42","1444.50","81","1281","3285.15","percent of total billed charges",""
"TITAN MEDPORE 76MMX50 1.6 PLATE CRANIOMAXILLOFACIAL IUM MTB MESH POROUS POLYETHYLENE MATRIX","SUP-ITM-10094000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4132.26","3099.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1281.00","31","","432.60","432.60","432.60","1 through 10","1281","3285.15","percent of total billed charges",""
"TITAN MEDPORE 76MMX50 1.6 PLATE CRANIOMAXILLOFACIAL IUM MTB MESH POROUS POLYETHYLENE MATRIX","SUP-ITM-10094000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4132.26","3099.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1508.27","36.5","","148.37","54.89","631.39","94","1281","3285.15","percent of total billed charges",""
"TITAN MEDPORE 76MMX50 1.6 PLATE CRANIOMAXILLOFACIAL IUM MTB MESH POROUS POLYETHYLENE MATRIX","SUP-ITM-10094000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4132.26","3099.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1582.66","38.3","","279.30","91.72","1116.77","266","1281","3285.15","percent of total billed charges",""
"TITAN MEDPORE 76MMX50 1.6 PLATE CRANIOMAXILLOFACIAL IUM MTB MESH POROUS POLYETHYLENE MATRIX","SUP-ITM-10094000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4132.26","3099.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1772.74","42.9","","731.00","63.70","731.00","1 through 10","1281","3285.15","percent of total billed charges",""
"TITAN MEDPORE 76MMX50 1.6 PLATE CRANIOMAXILLOFACIAL IUM MTB MESH POROUS POLYETHYLENE MATRIX","SUP-ITM-10094000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4132.26","3099.19","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1772.74","42.9","","384.74","384.74","384.74","1 through 10","1281","3285.15","percent of total billed charges",""
"TITAN MEDPORE 76MMX50 1.6 PLATE CRANIOMAXILLOFACIAL IUM MTB MESH POROUS POLYETHYLENE MATRIX","SUP-ITM-10094000","CDM","C1713","HCPCS","0278","RC","","","","both","","","4132.26","3099.19","WELLPOINT [1015]","HB AMC WELLPOINT","3048.78","73.78","","286.63","119.22","1107.45","105","1281","3285.15","percent of total billed charges",""
"TITAN MEDPORE 76MMX50 1.6 PLATE CRANIOMAXILLOFACIAL IUM MTB MESH POROUS POLYETHYLENE MATRIX","SUP-ITM-10094000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4132.26","3099.19","AETNA [1001]","HB AMC AETNA HMO","2884.32","69.8","","675.31","184.75","1721.50","286","2159.52","3376.88","percent of total billed charges",""
"TITAN MEDPORE 76MMX50 1.6 PLATE CRANIOMAXILLOFACIAL IUM MTB MESH POROUS POLYETHYLENE MATRIX","SUP-ITM-10094000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4132.26","3099.19","AETNA [1001]","HB AMC AETNA PPO","3322.34","80.4","","1261.44","103.12","1514.10","21","2159.52","3376.88","percent of total billed charges",""
"TITAN MEDPORE 76MMX50 1.6 PLATE CRANIOMAXILLOFACIAL IUM MTB MESH POROUS POLYETHYLENE MATRIX","SUP-ITM-10094000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4132.26","3099.19","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3322.34","80.4","","1365.00","1365.00","1365.00","1 through 10","2159.52","3376.88","percent of total billed charges",""
"TITAN MEDPORE 76MMX50 1.6 PLATE CRANIOMAXILLOFACIAL IUM MTB MESH POROUS POLYETHYLENE MATRIX","SUP-ITM-10094000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4132.26","3099.19","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3376.88","81.72","","5157.68","5157.68","5157.68","1 through 10","2159.52","3376.88","percent of total billed charges",""
"TITAN MEDPORE 76MMX50 1.6 PLATE CRANIOMAXILLOFACIAL IUM MTB MESH POROUS POLYETHYLENE MATRIX","SUP-ITM-10094000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4132.26","3099.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3376.88","81.72","","431.26","71.26","1459.57","88","2159.52","3376.88","percent of total billed charges",""
"Tocilizumab Vl 1mg","PX-63600187","CDM","J3262","HCPCS","0636","RC","","","","both","","","13.60","10.20","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","5.88","","APC Price ($5.71). Final payment is multiplied by 103%.","6.13","6.05","6.14","5590","4.22","15.18","other","OPPS APC"
"Tocilizumab Vl 1mg","PX-63600187","CDM","J3262","HCPCS","0636","RC","","","","both","","","13.60","10.20","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","5.71","","APC Price ($5.71).","5.87","5.69","5.87","8420","4.22","15.18","other","OPPS APC"
"Tocilizumab Vl 1mg","PX-63600187","CDM","J3262","HCPCS","0636","RC","","","","both","","","13.60","10.20","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","5.71","","APC Price ($5.71).","5.79","5.69","5.87","6060","4.22","15.18","other","OPPS APC"
"Tocilizumab Vl 1mg","PX-63600187","CDM","J3262","HCPCS","0636","RC","","","","both","","","13.60","10.20","MEDICARE [2001]","HB BWH MEDICARE","5.71","","APC Price ($5.71).","5.96","5.88","5.97","85480","4.22","15.18","other","OPPS APC"
"Tocilizumab Vl 1mg","PX-63600187","CDM","J3262","HCPCS","0636","RC","","","","both","","","13.60","10.20","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","5.71","","APC Price ($5.71).","70.45","5.87","70.45","2337","4.22","15.18","other","OPPS APC"
"Tocilizumab Vl 1mg","PX-63600187","CDM","J3262","HCPCS","0636","RC","","","","both","","","13.60","10.20","TRICARE [160005]","HB BWH TRICARE","5.50","","APC Price ($5.79). Final payment is multiplied by 95%.","117.60","117.60","3343.20","35","4.22","15.18","other","Tricare OPPS"
"Tocilizumab Vl 1mg","PX-63600187","CDM","J3262","HCPCS","0636","RC","","","","both","","","13.60","10.20","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","5.59","","APC Price ($5.71). Final payment is multiplied by 98%.","5.84","5.76","5.85","4710","4.22","15.18","other","OPPS APC"
"Tocilizumab Vl 1mg","PX-63600187","CDM","J3262","HCPCS","0636","RC","","","","both","","","13.60","10.20","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","5.59","","APC Price ($5.71). Final payment is multiplied by 98%.","5.84","5.76","5.85","9780","4.22","15.18","other","OPPS APC"
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","both","","","8625.00","6468.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6856.88","79.5","","1309.77","674.56","6049.93","26","2673.75","6856.88","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","both","","","8625.00","6468.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4597.13","53.3","","1901.83","1901.83","2962.25","1 through 10","2673.75","6856.88","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","both","","","8625.00","6468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3148.13","36.5","","1620.31","1620.31","19908.88","1 through 10","2673.75","6856.88","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","both","","","8625.00","6468.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3303.38","38.3","","352.91","352.91","2046.30","1 through 10","2673.75","6856.88","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","both","","","8625.00","6468.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3700.13","42.9","","9668.75","9668.75","9668.75","1 through 10","2673.75","6856.88","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","both","","","8625.00","6468.75","WELLPOINT [1015]","HB AMC WELLPOINT","6363.53","73.78","","699.88","384.10","3443.31","33","2673.75","6856.88","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8625.00","6468.75","AETNA [1001]","HB AMC AETNA HMO","6020.25","69.8","","1421.24","264.50","4933.46","29","4507.43","7048.35","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8625.00","6468.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6934.50","80.4","","1022.97","1022.97","3607.50","1 through 10","4507.43","7048.35","percent of total billed charges",""
"TOE IMPLANT 8MM CARTIVA MTP","SUP-ITM-10239266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8625.00","6468.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7048.35","81.72","","3010.54","693.88","5019.88","35","4507.43","7048.35","percent of total billed charges",""
"TOE WEDGE 18X8MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3625.20","79.5","","800.18","480.96","1887.97","195","1413.6","3625.2","percent of total billed charges",""
"TOE WEDGE 18X8MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2430.48","53.3","","813.12","216.42","1444.50","81","1413.6","3625.2","percent of total billed charges",""
"TOE WEDGE 18X8MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1413.60","31","","432.60","432.60","432.60","1 through 10","1413.6","3625.2","percent of total billed charges",""
"TOE WEDGE 18X8MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1664.40","36.5","","148.37","54.89","631.39","94","1413.6","3625.2","percent of total billed charges",""
"TOE WEDGE 18X8MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1746.48","38.3","","279.30","91.72","1116.77","266","1413.6","3625.2","percent of total billed charges",""
"TOE WEDGE 18X8MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1956.24","42.9","","731.00","63.70","731.00","1 through 10","1413.6","3625.2","percent of total billed charges",""
"TOE WEDGE 18X8MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1956.24","42.9","","384.74","384.74","384.74","1 through 10","1413.6","3625.2","percent of total billed charges",""
"TOE WEDGE 18X8MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057074","CDM","C1713","HCPCS","0278","RC","","","","both","","","4560.00","3420.00","WELLPOINT [1015]","HB AMC WELLPOINT","3364.37","73.78","","286.63","119.22","1107.45","105","1413.6","3625.2","percent of total billed charges",""
"TOE WEDGE 18X8MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4560.00","3420.00","AETNA [1001]","HB AMC AETNA HMO","3182.88","69.8","","675.31","184.75","1721.50","286","2383.06","3726.43","percent of total billed charges",""
"TOE WEDGE 18X8MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4560.00","3420.00","AETNA [1001]","HB AMC AETNA PPO","3666.24","80.4","","1261.44","103.12","1514.10","21","2383.06","3726.43","percent of total billed charges",""
"TOE WEDGE 18X8MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4560.00","3420.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3666.24","80.4","","1365.00","1365.00","1365.00","1 through 10","2383.06","3726.43","percent of total billed charges",""
"TOE WEDGE 18X8MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4560.00","3420.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3726.43","81.72","","5157.68","5157.68","5157.68","1 through 10","2383.06","3726.43","percent of total billed charges",""
"TOE WEDGE 18X8MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4560.00","3420.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3726.43","81.72","","431.26","71.26","1459.57","88","2383.06","3726.43","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","25.34","25.34","25.34","1 through 10","651","1669.5","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","both","","","2100.00","1575.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1507.80","71.8","","105.81","105.81","366.90","1 through 10","651","1669.5","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","both","","","2100.00","1575.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1470.00","70","","512.90","74.70","612.85","1 through 10","651","1669.5","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","both","","","2100.00","1575.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1669.50","79.5","","200.27","182.80","200.27","1 through 10","651","1669.5","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","both","","","2100.00","1575.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1119.30","53.3","","37.73","37.73","169.33","1 through 10","651","1669.5","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1365.00","65","","100.27","8.48","494.52","1 through 10","651","1669.5","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","1365.00","65","","160.19","160.19","160.19","1 through 10","651","1669.5","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","651.00","31","","28.12","28.12","28.12","1 through 10","651","1669.5","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","766.50","36.5","","101.66","28.85","502.70","121","651","1669.5","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","804.30","38.3","","61.58","25.32","328.44","138","651","1669.5","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.90","42.9","","71.66","71.66","71.66","1 through 10","651","1669.5","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB AMC WELLPOINT","1549.38","73.78","","74.75","27.97","425.28","93","651","1669.5","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2100.00","1575.00","AETNA [1001]","HB AMC AETNA HMO","1465.80","69.8","","52.67","14.36","414.90","1 through 10","1097.46","1716.12","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1097.46","52.26","","25.34","25.34","25.34","1 through 10","1097.46","1716.12","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1688.40","80.4","","478.02","107.84","478.02","1 through 10","1097.46","1716.12","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1716.12","81.72","","32.74","12.33","122.05","1 through 10","1097.46","1716.12","percent of total billed charges",""
"TOOL IMPLANTATION 27CM EPICARDIAL PRECISE LEAD PLACEMENT FASTAC","SUP-ITM-10020903","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1716.12","81.72","","144.95","32.78","676.91","104","1097.46","1716.12","percent of total billed charges",""
"Tooth Transplant Incl Reimplant From One Site to Another","PX-51000150","CDM","41899","CPT","0512","RC","","","","outpatient","","","542.00","406.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","328.18","60.55","","481.00","481.00","481.00","1 through 10","184.82","700.33","percent of total billed charges",""
"Topiramate","PX-30000037","CDM","80201","CPT","0301","RC","","","","both","","","171.00","128.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","135.95","79.5","","130.64","87.65","130.64","1 through 10","11.68","162.45","percent of total billed charges",""
"Topiramate","PX-30000037","CDM","80201","CPT","0301","RC","","","","both","","","171.00","128.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","91.14","53.3","","87.65","87.65","87.65","1 through 10","11.68","162.45","percent of total billed charges",""
"Topiramate","PX-30000037","CDM","80201","CPT","0301","RC","","","","both","","","171.00","128.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","62.42","36.5","","61.92","61.92","61.92","1 through 10","11.68","162.45","percent of total billed charges",""
"Topiramate","PX-30000037","CDM","80201","CPT","0301","RC","","","","both","","","171.00","128.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","65.49","38.3","","64.91","63.08","64.91","1 through 10","11.68","162.45","percent of total billed charges",""
"Topiramate","PX-30000037","CDM","80201","CPT","0301","RC","","","","outpatient","","","171.00","128.25","AETNA [1001]","HB AMC AETNA HMO","119.36","69.8","","112.38","79.35","112.38","1 through 10","12.3","139.74","percent of total billed charges",""
"Topiramate","PX-30000037","CDM","80201","CPT","0301","RC","","","","outpatient","","","171.00","128.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","139.74","81.72","","132.70","132.70","132.70","1 through 10","12.3","139.74","percent of total billed charges",""
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","152.06","152.06","152.06","1 through 10","18.62","282.15","percent of total billed charges",""
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","112.61","112.61","1 through 10","18.62","282.15","percent of total billed charges",""
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","126.63","126.63","126.63","1 through 10","18.62","282.15","percent of total billed charges",""
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","224.64","194.98","224.64","1 through 10","18.62","242.71","percent of total billed charges",""
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","449.28","449.28","449.28","1 through 10","18.62","242.71","percent of total billed charges",""
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","230.23","230.23","230.23","1 through 10","18.62","242.71","percent of total billed charges",""
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","126.63","126.63","126.63","1 through 10","18.62","242.71","percent of total billed charges",""
"Total Tau (Ttau)","PX-30003840","CDM","84394","CPT","0301","RC","","","","both","","","424.00","318.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","337.08","79.5","","970.38","970.38","970.38","1 through 10","131.44","402.8","percent of total billed charges",""
"Total Tau (Ttau)","PX-30003840","CDM","84394","CPT","0301","RC","","","","outpatient","","","424.00","318.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","265.00","62.5","","267.15","267.15","267.15","1 through 10","169.6","349.8","percent of total billed charges",""
"TOWER SPINE SHORT THORACIC PHOENIX OPEN BODY GREEN","SUP-ITM-10083535","CDM","C1889","HCPCS","0278","RC","","","","both","","","857.50","643.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","681.71","79.5","","1309.77","674.56","6049.93","26","265.83","681.71","percent of total billed charges",""
"TOWER SPINE SHORT THORACIC PHOENIX OPEN BODY GREEN","SUP-ITM-10083535","CDM","C1889","HCPCS","0278","RC","","","","both","","","857.50","643.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","457.05","53.3","","1901.83","1901.83","2962.25","1 through 10","265.83","681.71","percent of total billed charges",""
"TOWER SPINE SHORT THORACIC PHOENIX OPEN BODY GREEN","SUP-ITM-10083535","CDM","C1889","HCPCS","0278","RC","","","","both","","","857.50","643.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","312.99","36.5","","1620.31","1620.31","19908.88","1 through 10","265.83","681.71","percent of total billed charges",""
"TOWER SPINE SHORT THORACIC PHOENIX OPEN BODY GREEN","SUP-ITM-10083535","CDM","C1889","HCPCS","0278","RC","","","","both","","","857.50","643.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","328.42","38.3","","352.91","352.91","2046.30","1 through 10","265.83","681.71","percent of total billed charges",""
"TOWER SPINE SHORT THORACIC PHOENIX OPEN BODY GREEN","SUP-ITM-10083535","CDM","C1889","HCPCS","0278","RC","","","","both","","","857.50","643.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","367.87","42.9","","9668.75","9668.75","9668.75","1 through 10","265.83","681.71","percent of total billed charges",""
"TOWER SPINE SHORT THORACIC PHOENIX OPEN BODY GREEN","SUP-ITM-10083535","CDM","C1889","HCPCS","0278","RC","","","","both","","","857.50","643.12","WELLPOINT [1015]","HB AMC WELLPOINT","632.66","73.78","","699.88","384.10","3443.31","33","265.83","681.71","percent of total billed charges",""
"TOWER SPINE SHORT THORACIC PHOENIX OPEN BODY GREEN","SUP-ITM-10083535","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","AETNA [1001]","HB AMC AETNA HMO","598.54","69.8","","1421.24","264.50","4933.46","29","448.13","700.75","percent of total billed charges",""
"TOWER SPINE SHORT THORACIC PHOENIX OPEN BODY GREEN","SUP-ITM-10083535","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","689.43","80.4","","1022.97","1022.97","3607.50","1 through 10","448.13","700.75","percent of total billed charges",""
"TOWER SPINE SHORT THORACIC PHOENIX OPEN BODY GREEN","SUP-ITM-10083535","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","857.50","643.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","700.75","81.72","","3010.54","693.88","5019.88","35","448.13","700.75","percent of total billed charges",""
"Toxic Effects Of Non-Medicinal Substances,EXTREME","816","DRG","","","","","","","","inpatient","","","120608.03","","MASSHEALTH [3001]","HB BWH MEDICAID","14635.99","","Case rate ($16,182.61). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $58,612.61, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16178.63","16178.63","16178.63","1 through 10","3774.38","254946.65","case rate",""
"Toxic Effects Of Non-Medicinal Substances,MAJOR","816","DRG","","","","","","","","inpatient","","","31865.01","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22965.34","","Standard inlier is a Case rate ($22,965.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,506, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,260.07) for the length of stay and the standard reimbursement.","23588.10","23588.10","23588.10","1 through 10","3774.38","254946.65","case rate",""
"Toxic Effects Of Non-Medicinal Substances,MAJOR","816","DRG","","","","","","","","inpatient","","","31865.01","","MASSHEALTH [3001]","HB BWH MEDICAID","6486.35","","Case rate ($7,171.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,601.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7170.02","7170.02","7170.02","1 through 10","3774.38","254946.65","case rate",""
"Toxic Effects Of Non-Medicinal Substances,MODERATE","816","DRG","","","","","","","","inpatient","","","36919.63","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","19536.23","","Standard inlier is a Case rate ($19,536.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,162, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,773.01) for the length of stay and the standard reimbursement.","19536.22","19536.22","19536.22","1 through 10","3774.38","254946.65","case rate",""
"Toxin or Antitoxin Assay","PX-30001198","CDM","87230","CPT","0306","RC","","","","both","","","326.00","244.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","118.99","36.5","","114.39","114.39","114.39","1 through 10","19.35","309.7","percent of total billed charges",""
"Toxin or Antitoxin Assay","PX-30001198","CDM","87230","CPT","0306","RC","","","","outpatient","","","326.00","244.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","266.41","81.72","","252.61","252.61","252.61","1 through 10","20.15","266.41","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","both","","","191.00","143.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","133.70","70","","185.00","133.20","399.60","1 through 10","14.1","181.45","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","both","","","191.00","143.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","151.85","79.5","","185.00","99.59","436.80","1 through 10","14.1","181.45","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","both","","","191.00","143.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","101.80","53.3","","145.60","145.60","145.60","1 through 10","14.1","181.45","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","both","","","191.00","143.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","69.72","36.5","","69.01","69.01","69.01","1 through 10","14.1","181.45","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","both","","","191.00","143.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","73.15","38.3","","72.34","70.30","217.02","23","14.1","181.45","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","outpatient","","","191.00","143.25","AETNA [1001]","HB AMC AETNA HMO","133.32","69.8","","125.25","88.43","144.30","1 through 10","14.84","156.09","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","outpatient","","","191.00","143.25","AETNA [1001]","HB AMC AETNA PPO","153.56","80.4","","144.30","144.30","144.30","1 through 10","14.84","156.09","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","outpatient","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","156.09","81.72","","147.89","81.34","147.89","11","14.84","156.09","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","both","","","179.00","134.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","125.30","70","","160.46","125.28","160.46","1 through 10","14.12","170.05","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","both","","","179.00","134.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","142.31","79.5","","174.00","91.87","410.82","1 through 10","14.12","170.05","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","both","","","179.00","134.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","95.41","53.3","","136.94","136.94","136.94","1 through 10","14.12","170.05","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","65.34","36.5","","64.90","64.90","64.90","1 through 10","14.12","170.05","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","both","","","179.00","134.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","68.56","38.3","","68.03","66.12","204.09","22","14.12","170.05","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","outpatient","","","179.00","134.25","AETNA [1001]","HB AMC AETNA HMO","124.94","69.8","","117.80","83.17","135.72","1 through 10","14.84","146.28","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","outpatient","","","179.00","134.25","AETNA [1001]","HB AMC AETNA PPO","143.92","80.4","","135.72","135.72","135.72","1 through 10","14.84","146.28","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","outpatient","","","179.00","134.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","146.28","81.72","","139.10","65.32","139.10","1 through 10","14.84","146.28","percent of total billed charges",""
"Tprnl Plmt Biodegradable Matrl Periprostatic","PX-33000131","CDM","55874","CPT","0333","RC","","","","both","","","6146.00","4609.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","6036.49","","APC Price ($6,036.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10805.85","10805.85","10805.85","1 through 10","1905.26","7545.62","other","OPPS APC"
"Tprnl Plmt Biodegradable Matrl Periprostatic","PX-33000131","CDM","55874","CPT","0333","RC","","","","both","","","6146.00","4609.50","MEDICARE [2001]","HB BWH MEDICARE","6036.49","","APC Price ($6,036.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","32944.65","10981.55","54907.75","11","1905.26","7545.62","other","OPPS APC"
"Tprnl Plmt Biodegradable Matrl Periprostatic","PX-33000131","CDM","55874","CPT","0333","RC","","","","both","","","6146.00","4609.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","5915.76","","APC Price ($6,036.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","10761.92","10761.92","10761.92","1 through 10","1905.26","7545.62","other","OPPS APC"
"Tprnl Plmt Biodegradable Matrl Periprostatic","PX-33000131","CDM","55874","CPT","0333","RC","","","","outpatient","","","6146.00","4609.50","AETNA [1001]","HB AMC AETNA HMO","4289.91","69.8","","4034.92","4034.92","4034.92","1 through 10","3211.9","9843.6","percent of total billed charges",""
"Tprnl Plmt Biodegradable Matrl Periprostatic","PX-33000131","CDM","55874","CPT","0333","RC","","","","outpatient","","","6146.00","4609.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","4597.72","","Case rate ($4,597.72). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","4618.41","4618.41","4618.41","1 through 10","3211.9","9843.6","other","ASC"
"Tprnl Plmt Biodegradable Matrl Periprostatic","PX-33000131","CDM","55874","CPT","0333","RC","","","","outpatient","","","6146.00","4609.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","4597.72","","Case rate ($4,597.72). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","5328.76","5328.76","5328.76","1 through 10","3211.9","9843.6","other","ASC "
"Tprnl Plmt Biodegradable Matrl Periprostatic","PX-33000131","CDM","55874","CPT","0333","RC","","","","outpatient","","","6146.00","4609.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","4020.54","","Case rate ($4,020.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","9327.65","9327.65","9327.65","1 through 10","3211.9","9843.6","other","Multiple Surgery"
"Tracheostomy","PX-76000776","CDM","31600","CPT","0761","RC","","","","outpatient","","","6473.00","4854.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3380.20","52.22","","5973.25","5973.25","5973.25","1 through 10","2589.2","5289.74","percent of total billed charges",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","","","","inpatient","","","346585.54","259939.15","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","38838.64","","Case rate ($38,838.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,676.64, add-ons for qualifying new technology services are included. If operating cost exceeds $92,321.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,832.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $35,066.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,296.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,392.44. The transfer capital threshold is the transfer adjustment factor * $3,392.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36957.57","36957.57","36957.57","1 through 10","38061.87","61928.9367","other","Inpatient Replacement Plans DRG"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","","","","inpatient","","","346585.54","259939.15","HUMANA [1012]","HB BWH MEDICARE","38838.64","","Case rate ($38,838.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,676.64, add-ons for qualifying new technology services are included. If operating cost exceeds $92,321.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,832.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $35,066.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,296.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,392.44. The transfer capital threshold is the transfer adjustment factor * $3,392.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28984.63","28984.63","28984.63","1 through 10","38061.87","61928.9367","other","Inpatient Replacement Plans DRG"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","","","","inpatient","","","346585.54","259939.15","MEDICARE [2001]","HB BWH MEDICARE","38838.64","","Case rate ($38,838.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,676.64, add-ons for qualifying new technology services are included. If operating cost exceeds $92,321.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,832.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $35,066.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,296.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,392.44. The transfer capital threshold is the transfer adjustment factor * $3,392.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","48729.81","48729.81","52703.17","1 through 10","38061.87","61928.9367","other","Inpatient Replacement Plans DRG"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","","","","inpatient","","","346585.54","259939.15","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","38061.87","","Case rate ($38,838.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,676.64, add-ons for qualifying new technology services are included. If operating cost exceeds $92,321.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,832.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $35,066.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,296.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,392.44. The transfer capital threshold is the transfer adjustment factor * $3,392.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","36775.79","36775.79","36775.79","1 through 10","38061.87","61928.9367","other","Inpatient DRG"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","","","","inpatient","","","346585.54","259939.15","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","38061.87","","Case rate ($38,838.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,676.64, add-ons for qualifying new technology services are included. If operating cost exceeds $92,321.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,832.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $35,066.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,296.81 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,392.44. The transfer capital threshold is the transfer adjustment factor * $3,392.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","36920.32","36920.32","36920.32","1 through 10","38061.87","61928.9367","other","Inpatient DRG"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With McC","011","MS-DRG","","","","","","","","inpatient","","","333294.77","249971.08","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","51636.69","","Case rate ($50,132.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,272.49, add-ons for qualifying new technology services are included. If operating cost exceeds $105,916.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,828.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $45,364.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $59,892.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,388.69. The transfer capital threshold is the transfer adjustment factor * $4,388.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","50792.81","50792.81","50792.81","1 through 10","49130.06","81429.5269","other","Inpatient DRG"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With McC","011","MS-DRG","","","","","","","","inpatient","","","333294.77","249971.08","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","50132.71","","Case rate ($50,132.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,272.49, add-ons for qualifying new technology services are included. If operating cost exceeds $105,916.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,828.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $45,364.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $59,892.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,388.69. The transfer capital threshold is the transfer adjustment factor * $4,388.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","49255.17","49255.17","49255.17","1 through 10","49130.06","81429.5269","other","Inpatient Replacement Plans DRG"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With McC","011","MS-DRG","","","","","","","","inpatient","","","333294.77","249971.08","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","50132.71","","Case rate ($50,132.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,272.49, add-ons for qualifying new technology services are included. If operating cost exceeds $105,916.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,828.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $45,364.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $59,892.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,388.69. The transfer capital threshold is the transfer adjustment factor * $4,388.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","48658.77","48658.77","48658.77","1 through 10","49130.06","81429.5269","other","Inpatient Replacement Plans DRG"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With McC","011","MS-DRG","","","","","","","","inpatient","","","333294.77","249971.08","HUMANA [1012]","HB BWH MEDICARE","50132.71","","Case rate ($50,132.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,272.49, add-ons for qualifying new technology services are included. If operating cost exceeds $105,916.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,828.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $45,364.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $59,892.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,388.69. The transfer capital threshold is the transfer adjustment factor * $4,388.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","64735.78","64735.78","64735.78","1 through 10","49130.06","81429.5269","other","Inpatient Replacement Plans DRG"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With McC","011","MS-DRG","","","","","","","","inpatient","","","333294.77","249971.08","MEDICARE [2001]","HB BWH MEDICARE","50132.71","","Case rate ($50,132.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,272.49, add-ons for qualifying new technology services are included. If operating cost exceeds $105,916.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,828.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $45,364.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $59,892.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,388.69. The transfer capital threshold is the transfer adjustment factor * $4,388.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","63966.47","63891.38","66189.57","1 through 10","49130.06","81429.5269","other","Inpatient Replacement Plans DRG"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With McC","011","MS-DRG","","","","","","","","inpatient","","","333294.77","249971.08","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","49130.06","","Case rate ($50,132.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,272.49, add-ons for qualifying new technology services are included. If operating cost exceeds $105,916.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,828.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $45,364.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $59,892.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,388.69. The transfer capital threshold is the transfer adjustment factor * $4,388.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","48316.83","48316.83","48316.83","1 through 10","49130.06","81429.5269","other","Inpatient DRG"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With McC","011","MS-DRG","","","","","","","","inpatient","","","333294.77","249971.08","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","49130.06","","Case rate ($50,132.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $60,272.49, add-ons for qualifying new technology services are included. If operating cost exceeds $105,916.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,828.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.4. The base transfer operating payment is the transfer adjustment factor * $45,364.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $59,892.65 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,388.69. The transfer capital threshold is the transfer adjustment factor * $4,388.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","69099.24","69099.24","69099.24","1 through 10","49130.06","81429.5269","other","Inpatient DRG"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/McC","013","MS-DRG","","","","","","","","inpatient","","","249064.59","186798.44","MEDICARE [2001]","HB BWH MEDICARE","34497.25","","Case rate ($34,497.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,025.51, add-ons for qualifying new technology services are included. If operating cost exceeds $77,669.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,759.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $31,798.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,645.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,318.87. The transfer capital threshold is the transfer adjustment factor * $2,318.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.03","0.03","0.03","1 through 10","26134.56","39991.15","other","Inpatient DRG"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/McC","013","MS-DRG","","","","","","","","inpatient","","","249064.59","186798.44","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","26134.56","","Case rate ($26,667.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,025.51, add-ons for qualifying new technology services are included. If operating cost exceeds $77,669.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,759.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $23,969.22 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $31,645.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,318.87. The transfer capital threshold is the transfer adjustment factor * $2,318.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","23916.69","23916.69","23916.69","1 through 10","26134.56","39991.15","other","Inpatient DRG"
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R. Procedures","004","MS-DRG","","","","","","","","inpatient","","","750464.04","562848.03","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126733.79","","Case rate ($126,733.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $152,485.07, add-ons for qualifying new technology services are included. If operating cost exceeds $198,129.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $13,585.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $115,208.29 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $152,105.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $11,145.65. The transfer capital threshold is the transfer adjustment factor * $11,145.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","129059.55","129059.55","129059.55","1 through 10","124199.11","216968.33","other","Inpatient Replacement Plans DRG"
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R. Procedures","004","MS-DRG","","","","","","","","inpatient","","","750464.04","562848.03","MEDICARE [2001]","HB BWH MEDICARE","126733.79","","Case rate ($126,733.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $152,485.07, add-ons for qualifying new technology services are included. If operating cost exceeds $198,129.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $13,585.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $115,208.29 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $152,105.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $11,145.65. The transfer capital threshold is the transfer adjustment factor * $11,145.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","166859.04","0.03","251863.69","14","124199.11","216968.33","other","Inpatient Replacement Plans DRG"
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R. Procedures","004","MS-DRG","","","","","","","","inpatient","","","750464.04","562848.03","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","124199.11","","Case rate ($126,733.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $152,485.07, add-ons for qualifying new technology services are included. If operating cost exceeds $198,129.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $13,585.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $115,208.29 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $152,105.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $11,145.65. The transfer capital threshold is the transfer adjustment factor * $11,145.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","126398.69","126398.69","126398.69","1 through 10","124199.11","216968.33","other","Inpatient DRG"
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R. Procedures","004","MS-DRG","","","","","","","","inpatient","","","750464.04","562848.03","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","124199.11","","Case rate ($126,733.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $152,485.07, add-ons for qualifying new technology services are included. If operating cost exceeds $198,129.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $13,585.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $115,208.29 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $152,105.22 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $11,145.65. The transfer capital threshold is the transfer adjustment factor * $11,145.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","141186.78","141186.78","280853.36","1 through 10","124199.11","216968.33","other","Inpatient DRG"
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R. Procedures","004","MS-DRG","","","","","","","","inpatient","","","750464.04","562848.03","WELLPOINT [1015]","HB AMC WELLPOINT","216968.33","","Fee schedule rate ($216,968.33).","326079.18","326079.18","326079.18","1 through 10","124199.11","216968.33","case rate",""
"Tracheostomy With Mv >96 Hours With Extensive Procedure,EXTREME","004","DRG","","","","","","","","inpatient","","","1336462.04","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","471560.89","","Standard inlier is a Case rate ($471,560.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $378,352, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($66,940.91) for the length of stay and the standard reimbursement.","471560.88","471560.88","471560.88","1 through 10","140776.05","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours With Extensive Procedure,EXTREME","004","DRG","","","","","","","","inpatient","","","1336462.04","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","530161.52","","Standard inlier is a Case rate ($530,161.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $378,352, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($75,252.02) for the length of stay and the standard reimbursement.","530161.52","530161.52","598026.23","1 through 10","140776.05","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours With Extensive Procedure,EXTREME","004","DRG","","","","","","","","inpatient","","","1336462.04","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","194378.1768","","Fee schedule rate ($439,301.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","194378.1768","422371.12","907220.14","1 through 10","140776.05","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours With Extensive Procedure,EXTREME","004","DRG","","","","","","","","inpatient","","","1336462.04","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","204102.7344","","Fee schedule rate ($461,279.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","204102.7344","839219.54","839219.54","1 through 10","140776.05","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours With Extensive Procedure,EXTREME","004","DRG","","","","","","","","inpatient","","","1336462.04","","MASSHEALTH [3001]","HB BWH MEDICAID","211649.58","","Case rate ($234,014.99). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $276,444.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","431900.94","233957.56","478062.10","1 through 10","140776.05","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours With Extensive Procedure,EXTREME","004","DRG","","","","","","","","inpatient","","","1336462.04","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","211649.58","","Case rate ($234,014.99). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $276,444.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","233957.56","187836.43","513444.31","1 through 10","140776.05","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours With Extensive Procedure,MAJOR","004","DRG","","","","","","","","inpatient","","","396490.90","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","194378.1768","","Fee schedule rate ($250,982.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","194378.1768","250982.36","250982.36","1 through 10","140776.05","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours With Extensive Procedure,MAJOR","004","DRG","","","","","","","","inpatient","","","396490.90","","MASSHEALTH [3001]","HB BWH MEDICAID","140776.05","","Case rate ($155,652.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $198,082.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,812.14 and the sum of the standard inlier and any outlier amount.","155613.92","155613.92","155613.92","1 through 10","140776.05","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours With Extensive Procedure,MAJOR","004","DRG","","","","","","","","inpatient","","","396490.90","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","140776.05","","Case rate ($155,652.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $198,082.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,812.14 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","140776.05","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours With Extensive Procedure,MAJOR","004","DRG","","","","","","","","inpatient","","","396490.90","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","140776.05","","Case rate ($155,652.12). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $198,082.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,812.14 and the sum of the standard inlier and any outlier amount.","139248.51","139248.51","139248.51","1 through 10","140776.05","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours Without Extensive Procedure,EXTREME","005","DRG","","","","","","","","inpatient","","","833837.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","310767.90","","Standard inlier is a Case rate ($310,767.90). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $253,313, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($44,115.38) for the length of stay and the standard reimbursement.","283276.26","283276.26","283276.26","1 through 10","136578.99","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours Without Extensive Procedure,EXTREME","005","DRG","","","","","","","","inpatient","","","833837.55","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","349386.88","","Standard inlier is a Case rate ($349,386.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $253,313, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($49,592.57) for the length of stay and the standard reimbursement.","319195.08","319195.08","349386.87","1 through 10","136578.99","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours Without Extensive Procedure,EXTREME","005","DRG","","","","","","","","inpatient","","","833837.55","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","439301.30","","Fee schedule rate ($439,301.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","314820.00","314820.00","314820.00","1 through 10","136578.99","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours Without Extensive Procedure,EXTREME","005","DRG","","","","","","","","inpatient","","","833837.55","","MASSHEALTH [3001]","HB BWH MEDICAID","136578.99","","Case rate ($151,011.56). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $193,441.56, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,403.74 and the sum of the standard inlier and any outlier amount.","153861.27","150974.50","216601.40","1 through 10","136578.99","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours Without Extensive Procedure,EXTREME","005","DRG","","","","","","","","inpatient","","","833837.55","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","136578.99","","Case rate ($151,011.56). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $193,441.56, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,403.74 and the sum of the standard inlier and any outlier amount.","3951.69","3951.69","3951.69","1 through 10","136578.99","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours Without Extensive Procedure,EXTREME","005","DRG","","","","","","","","inpatient","","","833837.55","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","400153.34","","Fee schedule rate ($400,153.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","543681.40","543681.40","543681.40","1 through 10","136578.99","724855.98","case rate",""
"Tracheostomy With Mv >96 Hours Without Extensive Procedure,EXTREME","005","DRG","","","","","","","","inpatient","","","833837.55","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","136578.99","","Case rate ($151,011.56). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $193,441.56, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,403.74 and the sum of the standard inlier and any outlier amount.","98932.61","98932.61","98932.61","1 through 10","136578.99","724855.98","case rate",""
"Tracheotomy Tube Change","PX-98301765","CDM","31502","CPT","0983","RC","","","","both","","","326.00","244.50","MEDICARE [2001]","HB BWH MEDICARE","275.75","","APC Price ($275.75). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","275.78","275.78","275.78","1 through 10","101.06","344.68","other","OPPS APC"
"Tracheotomy Tube Change","PX-98301765","CDM","31502","CPT","0983","RC","","","","outpatient","","","326.00","244.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","206.14","","Case rate ($206.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","229.85","229.85","229.85","1 through 10","182.23","700.33","other","Multiple Surgery"
"Trans G-Tube Endo W Emr","PX-75000472","CDM","44799","CPT","0750","RC","","","","both","","","2750.00","2062.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","852.5","2186.25","other","OPPS APC"
"Trans G-Tube Endo W Emr","PX-75000472","CDM","44799","CPT","0750","RC","","","","both","","","2750.00","2062.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","852.5","2186.25","other","OPPS APC"
"Trans G-Tube Endo W Emr","PX-75000472","CDM","44799","CPT","0750","RC","","","","both","","","2750.00","2062.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","852.5","2186.25","other","OPPS APC"
"Trans G-Tube Endo W Emr","PX-75000472","CDM","44799","CPT","0750","RC","","","","both","","","2750.00","2062.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","852.5","2186.25","other","OPPS APC"
"Trans G-Tube Endo W Emr","PX-75000472","CDM","44799","CPT","0750","RC","","","","both","","","2750.00","2062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1179.75","42.9","","1932.92","1932.92","1932.92","1 through 10","852.5","2186.25","percent of total billed charges",""
"Trans G-Tube Endo W Emr","PX-75000472","CDM","44799","CPT","0750","RC","","","","both","","","2750.00","2062.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","852.5","2186.25","other","OPPS APC"
"Trans G-Tube Endo W Emr","PX-75000472","CDM","44799","CPT","0750","RC","","","","both","","","2750.00","2062.50","WELLPOINT [1015]","HB AMC WELLPOINT","2028.95","73.78","","2222.33","2222.33","2222.33","1 through 10","852.5","2186.25","percent of total billed charges",""
"Trans G-Tube Endo W Emr","PX-75000472","CDM","44799","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","AETNA [1001]","HB AMC AETNA HMO","1919.50","69.8","","2238.60","2238.60","2238.60","1 through 10","1375","8899.59","percent of total billed charges",""
"Trans G-Tube Endo W Emr","PX-75000472","CDM","44799","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1665.13","60.55","","3144.00","2870.00","3286.00","1 through 10","1375","8899.59","percent of total billed charges",""
"Trans G-Tube Endo W Emr","PX-75000472","CDM","44799","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1437.15","52.26","","1775.96","1775.96","1775.96","1 through 10","1375","8899.59","percent of total billed charges",""
"Trans G-Tube Endo W Emr","PX-75000472","CDM","44799","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1436.05","52.22","","3286.00","2018.70","5898.00","1 through 10","1375","8899.59","percent of total billed charges",""
"Trans G-Tube Endo W Emr","PX-75000472","CDM","44799","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1443.75","52.5","","8340.00","8340.00","8340.00","1 through 10","1375","8899.59","percent of total billed charges",""
"Trans G-Tube Endo W Emr","PX-75000472","CDM","44799","CPT","0750","RC","","","","outpatient","","","2750.00","2062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2247.30","81.72","","2294.28","682.69","2294.28","1 through 10","1375","8899.59","percent of total billed charges",""
"Transcath Closure of Non-Congenital Asd","PX-48000499","CDM","93799","CPT","0481","RC","","","","both","","","48877.00","36657.75","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","38857.22","other","OPPS APC"
"Transcath Closure of Non-Congenital Asd","PX-48000499","CDM","93799","CPT","0481","RC","","","","outpatient","","","48877.00","36657.75","AETNA [1001]","HB AMC AETNA HMO","34116.15","69.8","","2022.70","2022.70","2022.70","1 through 10","454","40323.53","percent of total billed charges",""
"Transcath Closure of Non-Congenital Asd","PX-48000499","CDM","93799","CPT","0481","RC","","","","outpatient","","","48877.00","36657.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","29595.02","60.55","","318.03","318.03","2439.77","1 through 10","454","40323.53","percent of total billed charges",""
"Transcath Closure of Non-Congenital Asd","PX-48000499","CDM","93799","CPT","0481","RC","","","","outpatient","","","48877.00","36657.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","25523.57","52.22","","360.38","360.38","4023.00","1 through 10","454","40323.53","percent of total billed charges",""
"Transcath Closure of Non-Congenital Asd","PX-48000499","CDM","93799","CPT","0481","RC","","","","outpatient","","","48877.00","36657.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","26882.35","55","","13080.03","13080.03","13080.03","1 through 10","454","40323.53","percent of total billed charges",""
"Transcath Closure of Non-Congenital Vsd","PX-48000540","CDM","93799","CPT","0480","RC","","","","both","","","39884.00","29913.00","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","31707.78","other","OPPS APC"
"Transcath Closure of Non-Congenital Vsd","PX-48000540","CDM","93799","CPT","0480","RC","","","","outpatient","","","39884.00","29913.00","AETNA [1001]","HB AMC AETNA HMO","27839.03","69.8","","2022.70","2022.70","2022.70","1 through 10","454","32904.3","percent of total billed charges",""
"Transcath Closure of Non-Congenital Vsd","PX-48000540","CDM","93799","CPT","0480","RC","","","","outpatient","","","39884.00","29913.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24149.76","60.55","","318.03","318.03","2439.77","1 through 10","454","32904.3","percent of total billed charges",""
"Transcath Closure of Non-Congenital Vsd","PX-48000540","CDM","93799","CPT","0480","RC","","","","outpatient","","","39884.00","29913.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","20827.42","52.22","","360.38","360.38","4023.00","1 through 10","454","32904.3","percent of total billed charges",""
"Transcath Closure of Non-Congenital Vsd","PX-48000540","CDM","93799","CPT","0480","RC","","","","outpatient","","","39884.00","29913.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","21936.20","55","","13080.03","13080.03","13080.03","1 through 10","454","32904.3","percent of total billed charges",""
"Transcath Emboliz Microspher","PX-76002016","CDM","S2095","HCPCS","0761","RC","","","","both","","","36768.00","27576.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14082.14","38.3","","45862.50","45862.50","45862.50","1 through 10","11398.08","29230.56","percent of total billed charges",""
"Transcath Mitral Valve Replacement","PX-48000436","CDM","93799","CPT","0481","RC","","","","both","","","50335.00","37751.25","MEDICARE [2001]","HB BWH MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","170.48","170.48","170.48","1 through 10","176.52","40016.33","other","OPPS APC"
"Transcath Mitral Valve Replacement","PX-48000436","CDM","93799","CPT","0481","RC","","","","outpatient","","","50335.00","37751.25","AETNA [1001]","HB AMC AETNA HMO","35133.83","69.8","","2022.70","2022.70","2022.70","1 through 10","454","41526.38","percent of total billed charges",""
"Transcath Mitral Valve Replacement","PX-48000436","CDM","93799","CPT","0481","RC","","","","outpatient","","","50335.00","37751.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","30477.84","60.55","","318.03","318.03","2439.77","1 through 10","454","41526.38","percent of total billed charges",""
"Transcath Mitral Valve Replacement","PX-48000436","CDM","93799","CPT","0481","RC","","","","outpatient","","","50335.00","37751.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","26284.94","52.22","","360.38","360.38","4023.00","1 through 10","454","41526.38","percent of total billed charges",""
"Transcath Mitral Valve Replacement","PX-48000436","CDM","93799","CPT","0481","RC","","","","outpatient","","","50335.00","37751.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","27684.25","55","","13080.03","13080.03","13080.03","1 through 10","454","41526.38","percent of total billed charges",""
"Transcath Placement Brachy Device","PX-48000104","CDM","92974","CPT","0481","RC","","","","outpatient","","","3821.00","2865.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3122.52","81.72","","2961.78","2961.78","2961.78","1 through 10","1996.85","3122.52","percent of total billed charges",""
"Transcranial Mag Stim Ther Tx Initl","PX-90000001","CDM","90867","CPT","0900","RC","","","","both","","","1122.00","841.50","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","347.82","891.99","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Per","PX-90000002","CDM","90868","CPT","0900","RC","","","","both","","","1122.00","841.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","31","347.82","891.99","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Per","PX-90000002","CDM","90868","CPT","0900","RC","","","","both","","","1122.00","841.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.90","1 through 10","347.82","891.99","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Per","PX-90000002","CDM","90868","CPT","0900","RC","","","","both","","","1122.00","841.50","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","369.81","155","347.82","891.99","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Redet","PX-90000003","CDM","90869","CPT","0900","RC","","","","both","","","830.00","622.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","13","257.3","659.85","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Redet","PX-90000003","CDM","90869","CPT","0900","RC","","","","both","","","830.00","622.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","1 through 10","257.3","659.85","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Redet","PX-90000003","CDM","90869","CPT","0900","RC","","","","both","","","830.00","622.50","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","369.81","58","257.3","659.85","other","OPPS APC"
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","both","","","1310.00","982.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","29.95","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2542.00","30.53","2542.00","1 through 10","27.63","1041.45","other","OPPS APC"
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","both","","","1310.00","982.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","1 through 10","27.63","1041.45","other","OPPS APC"
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","both","","","1310.00","982.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","698.23","53.3","","1342.18","1342.18","1342.18","1 through 10","27.63","1041.45","percent of total billed charges",""
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","both","","","1310.00","982.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.61","28.61","28.61","1 through 10","27.63","1041.45","other","OPPS APC"
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","both","","","1310.00","982.50","HUMANA [1012]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","1 through 10","27.63","1041.45","other","OPPS APC"
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","both","","","1310.00","982.50","MEDICARE [2001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","32.50","97","27.63","1041.45","other","OPPS APC"
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","both","","","1310.00","982.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.50","28.50","28.50","1 through 10","27.63","1041.45","other","OPPS APC"
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","both","","","1310.00","982.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.90","28.50","28.90","1 through 10","27.63","1041.45","other","OPPS APC"
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","both","","","1310.00","982.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","29.00","28.50","31.85","11","27.63","1041.45","other","OPPS APC"
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","both","","","1310.00","982.50","WELLPOINT [1015]","HB AMC WELLPOINT","966.52","73.78","","1892.52","1892.52","1892.52","1 through 10","27.63","1041.45","percent of total billed charges",""
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","outpatient","","","1310.00","982.50","AETNA [1001]","HB AMC AETNA HMO","914.38","69.8","","1215.08","1135.70","1215.08","1 through 10","39.83","1070.53","percent of total billed charges",""
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","outpatient","","","1310.00","982.50","AETNA [1001]","HB AMC AETNA PPO","1053.24","80.4","","30.04","30.04","30.04","1 through 10","39.83","1070.53","percent of total billed charges",""
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","outpatient","","","1310.00","982.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","793.21","60.55","","39.44","39.44","39.44","1 through 10","39.83","1070.53","percent of total billed charges",""
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","outpatient","","","1310.00","982.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","684.08","52.22","","45.95","45.50","45.95","1 through 10","39.83","1070.53","percent of total billed charges",""
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","outpatient","","","1310.00","982.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1070.53","81.72","","1117.72","1117.72","1117.72","1 through 10","39.83","1070.53","percent of total billed charges",""
"Transcutaneous Monitoring, Continuous; per Day","PX-92000181","CDM","93998","CPT","0920","RC","","","","outpatient","","","1310.00","982.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1070.53","81.72","","2032.07","1117.72","2032.08","1 through 10","39.83","1070.53","percent of total billed charges",""
"Transfer Tissue Trunk <10cm","PX-76000154","CDM","14000","CPT","0761","RC","","","","both","","","4774.00","3580.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2237.26","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2236.12","2236.12","2236.12","1 through 10","1479.94","3795.33","other","OPPS APC"
"Transfer Tissue Trunk <10cm","PX-76000154","CDM","14000","CPT","0761","RC","","","","both","","","4774.00","3580.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1828.44","38.3","","10698.90","7909.54","10698.90","1 through 10","1479.94","3795.33","percent of total billed charges",""
"Transfer Tissue Trunk <10cm","PX-76000154","CDM","14000","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","AETNA [1001]","HB AMC AETNA HMO","3332.25","69.8","","1942.99","1942.99","1942.99","1 through 10","1548.96","5545.35","percent of total billed charges",""
"Transfer Tissue Trunk <10cm","PX-76000154","CDM","14000","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","1812.06","1779.29","1812.06","1 through 10","1548.96","5545.35","other","ASC"
"Transfer Tissue Trunk <10cm","PX-76000154","CDM","14000","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4146.66","2073.33","4146.66","1 through 10","1548.96","5545.35","other","ASC "
"Transfer Tissue Trunk 10.1-30.0cm","PX-76000155","CDM","14001","CPT","0761","RC","","","","both","","","4987.00","3740.25","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","1 through 10","1545.97","3964.67","other","OPPS APC"
"Transfer Tissue Trunk 10.1-30.0cm","PX-76000155","CDM","14001","CPT","0761","RC","","","","outpatient","","","4987.00","3740.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3558.58","1779.29","3558.58","1 through 10","1548.96","8899.59","other","ASC"
"Transfer Tissue Trunk 10.1-30.0cm","PX-76000155","CDM","14001","CPT","0761","RC","","","","outpatient","","","4987.00","3740.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4075.38","81.72","","6501.52","6501.52","6501.52","1 through 10","1548.96","8899.59","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1722.00","1291.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","519.13","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","510.87","510.87","510.87","1 through 10","493.22","1368.99","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1722.00","1291.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","1236.40","71.8","","1199.06","1199.06","1199.06","1 through 10","493.22","1368.99","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1722.00","1291.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1368.99","79.5","","1313.94","1219.22","1314.29","1 through 10","493.22","1368.99","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1722.00","1291.50","MEDICARE [2001]","HB BWH MEDICARE","519.13","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","483.71","480.51","1557.54","26","493.22","1368.99","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1722.00","1291.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","659.53","38.3","","652.97","652.97","652.97","1 through 10","493.22","1368.99","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1722.00","1291.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","519.13","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.80","508.80","508.80","1 through 10","493.22","1368.99","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1722.00","1291.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","508.74","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","508.80","508.80","508.80","1 through 10","493.22","1368.99","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1722.00","1291.50","WELLPOINT [1015]","HB AMC WELLPOINT","1270.49","73.78","","1243.32","1243.32","1243.32","1 through 10","493.22","1368.99","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","outpatient","","","1722.00","1291.50","AETNA [1001]","HB AMC AETNA HMO","1201.96","69.8","","1130.59","798.26","1130.59","1 through 10","437.87","1931.12","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","outpatient","","","1722.00","1291.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","437.87","","Case rate ($437.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","895.88","879.68","895.88","1 through 10","437.87","1931.12","other","ASC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","outpatient","","","1722.00","1291.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","899.92","52.26","","1014.98","1014.98","1014.98","1 through 10","437.87","1931.12","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","outpatient","","","1722.00","1291.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","437.87","","Case rate ($437.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1025.05","1014.98","1025.05","14","437.87","1931.12","other","ASC "
"Transfusion Fetal Intrauterine","PX-39100002","CDM","36460","CPT","0391","RC","","","","outpatient","","","2388.00","1791.00","AETNA [1001]","HB AMC AETNA HMO","1666.82","69.8","","1107.05","1107.05","1107.05","1 through 10","437.87","5545.35","percent of total billed charges",""
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","","","","inpatient","","","48896.26","36672.19","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","7666.58","","Case rate ($7,666.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,151.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,796.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,082.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,643.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,771.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.76. The transfer capital threshold is the transfer adjustment factor * $642.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19266.41","19266.41","19266.41","1 through 10","7513.25","12074.3091","other","Inpatient Replacement Plans DRG"
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","","","","inpatient","","","48896.26","36672.19","MEDICARE [2001]","HB BWH MEDICARE","7666.58","","Case rate ($7,666.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,151.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,796.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,082.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,643.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,771.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.76. The transfer capital threshold is the transfer adjustment factor * $642.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9710.79","1022.12","9724.90","1 through 10","7513.25","12074.3091","other","Inpatient Replacement Plans DRG"
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","","","","inpatient","","","48896.26","36672.19","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7513.25","","Case rate ($7,666.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,151.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,796.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,082.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,643.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,771.80 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $642.76. The transfer capital threshold is the transfer adjustment factor * $642.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10057.75","10057.75","10057.75","1 through 10","7513.25","12074.3091","other","Inpatient DRG"
"Transient Ischemia,MAJOR","047","DRG","","","","","","","","inpatient","","","32472.92","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","33196.68","","Standard inlier is a Case rate ($33,196.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $34,610, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,711.99) for the length of stay and the standard reimbursement.","33196.68","33196.68","33196.68","1 through 10","4704.26","33196.68","case rate",""
"Transient Ischemia,MODERATE","047","DRG","","","","","","","","inpatient","","","52408.02","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","23511.91","","Standard inlier is a Case rate ($23,511.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,932, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,337.66) for the length of stay and the standard reimbursement.","23511.90","23511.90","23511.90","1 through 10","4704.26","33196.68","case rate",""
"Transient Ischemia,MODERATE","047","DRG","","","","","","","","inpatient","","","52408.02","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24240.93","","Fee schedule rate ($24,240.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24240.93","24240.93","24240.93","1 through 10","4704.26","33196.68","case rate",""
"Transient Ischemia,MODERATE","047","DRG","","","","","","","","inpatient","","","52408.02","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4704.26","","Case rate ($5,201.37). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,631.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5200.10","5200.10","5200.10","1 through 10","4704.26","33196.68","case rate",""
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-51000137","CDM","99496","CPT","0510","RC","","","","both","","","808.00","606.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","157.62","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","202.73","157.48","202.73","1 through 10","145.39","622.16","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-51000137","CDM","99496","CPT","0510","RC","","","","both","","","808.00","606.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","191.28","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","144.28","144.28","144.28","1 through 10","145.39","622.16","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-51000137","CDM","99496","CPT","0510","RC","","","","both","","","808.00","606.00","MEDICARE [2001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.04","153.04","153.04","38","145.39","622.16","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-51000137","CDM","99496","CPT","0510","RC","","","","both","","","808.00","606.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","197.02","167.47","203.15","1 through 10","145.39","622.16","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-51000137","CDM","99496","CPT","0510","RC","","","","both","","","808.00","606.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","294.92","36.5","","292.43","248.53","302.88","1 through 10","145.39","622.16","percent of total billed charges",""
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-51000137","CDM","99496","CPT","0510","RC","","","","both","","","808.00","606.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","309.46","38.3","","306.54","297.92","306.54","13","145.39","622.16","percent of total billed charges",""
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-51000137","CDM","99496","CPT","0510","RC","","","","both","","","808.00","606.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","164.12","164.12","164.12","1 through 10","145.39","622.16","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-51000137","CDM","99496","CPT","0510","RC","","","","both","","","808.00","606.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","149.98","141.40","193.08","27","145.39","622.16","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-98300600","CDM","99496","CPT","0983","RC","","","","both","","","822.00","616.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","157.62","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","202.73","157.48","202.73","1 through 10","145.39","653.49","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-98300600","CDM","99496","CPT","0983","RC","","","","both","","","822.00","616.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","191.28","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","144.28","144.28","144.28","1 through 10","145.39","653.49","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-98300600","CDM","99496","CPT","0983","RC","","","","both","","","822.00","616.50","MEDICARE [2001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.04","153.04","153.04","38","145.39","653.49","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-98300600","CDM","99496","CPT","0983","RC","","","","both","","","822.00","616.50","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","197.02","167.47","203.15","1 through 10","145.39","653.49","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-98300600","CDM","99496","CPT","0983","RC","","","","both","","","822.00","616.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","300.03","36.5","","292.43","248.53","302.88","1 through 10","145.39","653.49","percent of total billed charges",""
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-98300600","CDM","99496","CPT","0983","RC","","","","both","","","822.00","616.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","314.83","38.3","","306.54","297.92","306.54","13","145.39","653.49","percent of total billed charges",""
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-98300600","CDM","99496","CPT","0983","RC","","","","both","","","822.00","616.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","164.12","164.12","164.12","1 through 10","145.39","653.49","other","OPPS APC"
"Transj Care Mgmt High Mdm F2f 7 Cal D Discharge","PX-98300600","CDM","99496","CPT","0983","RC","","","","both","","","822.00","616.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","149.98","141.40","193.08","27","145.39","653.49","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-51000136","CDM","99495","CPT","0510","RC","","","","both","","","556.00","417.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","157.62","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","157.48","149.28","158.38","1 through 10","145.39","428.12","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-51000136","CDM","99495","CPT","0510","RC","","","","both","","","556.00","417.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.59","141.97","150.59","1 through 10","145.39","428.12","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-51000136","CDM","99495","CPT","0510","RC","","","","both","","","556.00","417.00","MEDICARE [2001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.04","144.28","153.04","40","145.39","428.12","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-51000136","CDM","99495","CPT","0510","RC","","","","both","","","556.00","417.00","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","145.08","123.32","145.08","13","145.39","428.12","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-51000136","CDM","99495","CPT","0510","RC","","","","both","","","556.00","417.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","202.94","36.5","","201.05","201.05","223.05","1 through 10","145.39","428.12","percent of total billed charges",""
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-51000136","CDM","99495","CPT","0510","RC","","","","both","","","556.00","417.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","212.95","38.3","","210.75","210.75","210.75","1 through 10","145.39","428.12","percent of total billed charges",""
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-51000136","CDM","99495","CPT","0510","RC","","","","both","","","556.00","417.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","149.98","142.18","149.98","21","145.39","428.12","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-98300599","CDM","99495","CPT","0983","RC","","","","both","","","605.00","453.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","157.62","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","157.48","149.28","158.38","1 through 10","145.39","480.98","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-98300599","CDM","99495","CPT","0983","RC","","","","both","","","605.00","453.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.59","141.97","150.59","1 through 10","145.39","480.98","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-98300599","CDM","99495","CPT","0983","RC","","","","both","","","605.00","453.75","MEDICARE [2001]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.04","144.28","153.04","40","145.39","480.98","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-98300599","CDM","99495","CPT","0983","RC","","","","both","","","605.00","453.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","153.03","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","145.08","123.32","145.08","13","145.39","480.98","other","OPPS APC"
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-98300599","CDM","99495","CPT","0983","RC","","","","both","","","605.00","453.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","220.83","36.5","","201.05","201.05","223.05","1 through 10","145.39","480.98","percent of total billed charges",""
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-98300599","CDM","99495","CPT","0983","RC","","","","both","","","605.00","453.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","231.72","38.3","","210.75","210.75","210.75","1 through 10","145.39","480.98","percent of total billed charges",""
"Transj Care Mgmt Mod Mdm F2f 14 Cal D Discharge","PX-98300599","CDM","99495","CPT","0983","RC","","","","both","","","605.00","453.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","149.96","","APC Price ($153.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","149.98","142.18","149.98","21","145.39","480.98","other","OPPS APC"
"Transurethral Procedures With Cc","669","MS-DRG","","","","","","","","inpatient","","","75590.19","56692.64","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","14973.46","","Case rate ($14,537.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,422.68, add-ons for qualifying new technology services are included. If operating cost exceeds $63,067.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,688.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,908.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,042.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,248.83. The transfer capital threshold is the transfer adjustment factor * $1,248.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14789.47","14789.47","14789.47","1 through 10","14246.59","23353.3225","other","Inpatient DRG"
"Transurethral Procedures With Cc","669","MS-DRG","","","","","","","","inpatient","","","75590.19","56692.64","MEDICARE [2001]","HB BWH MEDICARE","14537.34","","Case rate ($14,537.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $17,422.68, add-ons for qualifying new technology services are included. If operating cost exceeds $63,067.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,688.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,908.68 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,042.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,248.83. The transfer capital threshold is the transfer adjustment factor * $1,248.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18521.98","0.03","18549.28","1 through 10","14246.59","23353.3225","other","Inpatient Replacement Plans DRG"
"Transurethral Procedures With McC","668","MS-DRG","","","","","","","","inpatient","","","266652.37","199989.28","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","27826.88","","Case rate ($27,016.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,444.99, add-ons for qualifying new technology services are included. If operating cost exceeds $78,089.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,789.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $24,286.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $32,065.15 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,349.60. The transfer capital threshold is the transfer adjustment factor * $2,349.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","27562.03","27562.03","27562.03","1 through 10","26476.06","44009.8833","other","Inpatient DRG"
"Transurethral Procedures With McC","668","MS-DRG","","","","","","","","inpatient","","","266652.37","199989.28","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","27016.39","","Case rate ($27,016.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,444.99, add-ons for qualifying new technology services are included. If operating cost exceeds $78,089.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,789.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $24,286.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $32,065.15 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,349.60. The transfer capital threshold is the transfer adjustment factor * $2,349.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","42895.88","42895.88","42895.88","1 through 10","26476.06","44009.8833","other","Inpatient Replacement Plans DRG"
"Transurethral Procedures With McC","668","MS-DRG","","","","","","","","inpatient","","","266652.37","199989.28","MEDICARE [2001]","HB BWH MEDICARE","27016.39","","Case rate ($27,016.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,444.99, add-ons for qualifying new technology services are included. If operating cost exceeds $78,089.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,789.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $24,286.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $32,065.15 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,349.60. The transfer capital threshold is the transfer adjustment factor * $2,349.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34658.99","34658.99","34710.42","1 through 10","26476.06","44009.8833","other","Inpatient Replacement Plans DRG"
"Transurethral Procedures With McC","668","MS-DRG","","","","","","","","inpatient","","","266652.37","199989.28","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","26476.06","","Case rate ($27,016.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $32,444.99, add-ons for qualifying new technology services are included. If operating cost exceeds $78,089.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,789.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $24,286.95 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $32,065.15 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,349.60. The transfer capital threshold is the transfer adjustment factor * $2,349.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26319.67","26319.67","26319.67","1 through 10","26476.06","44009.8833","other","Inpatient DRG"
"Transurethral Procedures Without Cc/McC","670","MS-DRG","","","","","","","","inpatient","","","49140.97","36855.73","MEDICARE [2001]","HB BWH MEDICARE","11950.03","","Case rate ($11,950.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,111.79, add-ons for qualifying new technology services are included. If operating cost exceeds $56,756.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,226.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,783.79 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,731.94 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $786.39. The transfer capital threshold is the transfer adjustment factor * $786.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11545.19","11545.19","11545.19","1 through 10","9108.98","14422.4687","other","Inpatient DRG"
"Transurethral Prostatectomy With Cc/McC","713","MS-DRG","","","","","","","","inpatient","","","51448.41","38586.31","MEDICARE [2001]","HB BWH MEDICARE","18178.47","","Case rate ($18,178.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,889, add-ons for qualifying new technology services are included. If operating cost exceeds $62,533.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,649.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $16,588.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,509.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,209.72. The transfer capital threshold is the transfer adjustment factor * $1,209.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17350.91","17350.91","76098.37","1 through 10","13812.12","21821.586","other","Inpatient DRG"
"Transurethral Prostatectomy Without Cc/McC","714","MS-DRG","","","","","","","","inpatient","","","37398.33","28048.75","MEDICARE [2001]","HB BWH MEDICARE","12898.33","","Case rate ($12,898.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $11,991.39, add-ons for qualifying new technology services are included. If operating cost exceeds $57,635.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,291.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $11,667.63 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,611.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $850.85. The transfer capital threshold is the transfer adjustment factor * $850.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11373.12","11373.12","11373.12","1 through 10","9825.05","14181.0127","other","Inpatient DRG"
"Transurethral Prostatectomy,MAJOR","482","DRG","","","","","","","","inpatient","","","38426.70","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","56772.50","","Fee schedule rate ($56,772.50). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($6,568.81) multiplied by length of stay and the outlier percent (100%).","6568.80","6568.80","6568.80","1 through 10","12905.7506","74210.58","case rate",""
"Transurethral Prostatectomy,MAJOR","482","DRG","","","","","","","","inpatient","","","38426.70","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","13422.4367","","Fee schedule rate ($44,975.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13422.4367","44975.56","44975.56","1 through 10","12905.7506","74210.58","case rate",""
"Trauma To The Skin, Subcutaneous Tissue And Breast With McC","604","MS-DRG","","","","","","","","inpatient","","","47372.62","35529.46","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","14222.73","","Case rate ($13,808.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,545.28, add-ons for qualifying new technology services are included. If operating cost exceeds $62,189.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,624.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,244.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,165.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,184.54. The transfer capital threshold is the transfer adjustment factor * $1,184.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14195.96","14195.96","14195.96","1 through 10","13532.31","22420.6987","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast With McC","604","MS-DRG","","","","","","","","inpatient","","","47372.62","35529.46","MEDICARE [2001]","HB BWH MEDICARE","13808.48","","Case rate ($13,808.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,545.28, add-ons for qualifying new technology services are included. If operating cost exceeds $62,189.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,624.69, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,244.11 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,165.45 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,184.54. The transfer capital threshold is the transfer adjustment factor * $1,184.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17793.42","0.03","17819.62","1 through 10","13532.31","22420.6987","other","Inpatient Replacement Plans DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without McC","605","MS-DRG","","","","","","","","inpatient","","","30716.21","23037.16","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8735.69","","Case rate ($8,735.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,438.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,083.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,177.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,618.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,058.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $737.07. The transfer capital threshold is the transfer adjustment factor * $737.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8489.17","8489.17","8489.17","1 through 10","8560.98","14348.22","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without McC","605","MS-DRG","","","","","","","","inpatient","","","30716.21","23037.16","MEDICARE [2001]","HB BWH MEDICARE","11224.30","","Case rate ($11,224.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,438.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,083.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,177.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,107.39 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,058.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $737.07. The transfer capital threshold is the transfer adjustment factor * $737.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11184.22","11167.93","11184.22","1 through 10","8560.98","14348.22","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without McC","605","MS-DRG","","","","","","","","inpatient","","","30716.21","23037.16","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8560.98","","Case rate ($8,735.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,438.64, add-ons for qualifying new technology services are included. If operating cost exceeds $56,083.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,177.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,618.78 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,058.79 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $737.07. The transfer capital threshold is the transfer adjustment factor * $737.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8549.73","8549.73","8549.73","1 through 10","8560.98","14348.22","other","Inpatient DRG"
"Traumatic Injury With McC","913","MS-DRG","","","","","","","","inpatient","","","56468.86","42351.64","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15290.84","","Case rate ($15,290.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,329.74, add-ons for qualifying new technology services are included. If operating cost exceeds $63,974.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,755.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,595.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,949.90 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,315.30. The transfer capital threshold is the transfer adjustment factor * $1,315.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14735.41","14735.41","14735.41","1 through 10","14985.02","24421.7653","other","Inpatient DRG"
"Traumatic Injury With McC","913","MS-DRG","","","","","","","","inpatient","","","56468.86","42351.64","MEDICARE [2001]","HB BWH MEDICARE","19731.75","","Case rate ($19,731.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,329.74, add-ons for qualifying new technology services are included. If operating cost exceeds $63,974.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,755.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $18,036.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $17,949.90 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,315.30. The transfer capital threshold is the transfer adjustment factor * $1,315.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19385.20","19385.20","19385.20","1 through 10","14985.02","24421.7653","other","Inpatient DRG"
"Traumatic Injury Without McC","914","MS-DRG","","","","","","","","inpatient","","","49219.65","36914.74","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","10863.22","","Case rate ($10,863.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,103.71, add-ons for qualifying new technology services are included. If operating cost exceeds $55,748.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,152.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $9,770.84 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,723.87 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $712.53. The transfer capital threshold is the transfer adjustment factor * $712.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8446.18","8446.18","8446.18","1 through 10","8288.33","13698.1007","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","","","","inpatient","","","43713.83","32785.37","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","12631.11","","Case rate ($12,263.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,685.07, add-ons for qualifying new technology services are included. If operating cost exceeds $60,329.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,488.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,835.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,305.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.23. The transfer capital threshold is the transfer adjustment factor * $1,048.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12553.54","12553.54","12553.54","1 through 10","12017.95","19793.3556","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","","","","inpatient","","","43713.83","32785.37","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","15802.41","","Case rate ($15,802.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,685.07, add-ons for qualifying new technology services are included. If operating cost exceeds $60,329.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,488.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $14,374.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,305.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.23. The transfer capital threshold is the transfer adjustment factor * $1,048.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15530.99","15530.99","15530.99","1 through 10","12017.95","19793.3556","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","","","","inpatient","","","43713.83","32785.37","MEDICARE [2001]","HB BWH MEDICARE","15802.41","","Case rate ($15,802.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,685.07, add-ons for qualifying new technology services are included. If operating cost exceeds $60,329.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,488.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $14,374.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,305.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.23. The transfer capital threshold is the transfer adjustment factor * $1,048.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15740.93","0.03","15740.93","14","12017.95","19793.3556","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","","","","inpatient","","","43713.83","32785.37","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","15802.41","","Case rate ($15,802.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,685.07, add-ons for qualifying new technology services are included. If operating cost exceeds $60,329.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,488.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $14,374.34 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,305.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.23. The transfer capital threshold is the transfer adjustment factor * $1,048.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8061.76","8061.76","8061.76","1 through 10","12017.95","19793.3556","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","","","","inpatient","","","43713.83","32785.37","MOLINA [1014]","HB BWH MOLINA","12017.95","","Case rate ($12,263.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,685.07, add-ons for qualifying new technology services are included. If operating cost exceeds $60,329.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,488.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,835.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,305.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.23. The transfer capital threshold is the transfer adjustment factor * $1,048.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16337.37","16337.37","16337.37","1 through 10","12017.95","19793.3556","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","","","","inpatient","","","43713.83","32785.37","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12017.95","","Case rate ($12,263.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,685.07, add-ons for qualifying new technology services are included. If operating cost exceeds $60,329.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,488.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,835.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,305.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.23. The transfer capital threshold is the transfer adjustment factor * $1,048.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11974.64","11971.53","11998.69","1 through 10","12017.95","19793.3556","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","","","","inpatient","","","43713.83","32785.37","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12017.95","","Case rate ($12,263.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,685.07, add-ons for qualifying new technology services are included. If operating cost exceeds $60,329.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,488.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,835.14 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,305.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.23. The transfer capital threshold is the transfer adjustment factor * $1,048.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12251.36","12251.36","12251.36","1 through 10","12017.95","19793.3556","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With McC","085","MS-DRG","","","","","","","","inpatient","","","75759.90","56819.92","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","21737.48","","Case rate ($21,104.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,328.06, add-ons for qualifying new technology services are included. If operating cost exceeds $70,972.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,268.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $18,896.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,948.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,828.10. The transfer capital threshold is the transfer adjustment factor * $1,828.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","21510.80","21510.80","21510.80","1 through 10","20682.26","35587.04","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With McC","085","MS-DRG","","","","","","","","inpatient","","","75759.90","56819.92","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","27276.69","","Case rate ($27,276.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,328.06, add-ons for qualifying new technology services are included. If operating cost exceeds $70,972.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,268.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $25,068.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,948.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,828.10. The transfer capital threshold is the transfer adjustment factor * $1,828.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","118396.18","118396.18","118396.18","1 through 10","20682.26","35587.04","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With McC","085","MS-DRG","","","","","","","","inpatient","","","75759.90","56819.92","MEDICARE [2001]","HB BWH MEDICARE","27276.69","","Case rate ($27,276.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,328.06, add-ons for qualifying new technology services are included. If operating cost exceeds $70,972.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,268.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $25,068.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,948.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,828.10. The transfer capital threshold is the transfer adjustment factor * $1,828.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26992.51","11907.33","27032.47","15","20682.26","35587.04","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With McC","085","MS-DRG","","","","","","","","inpatient","","","75759.90","56819.92","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","20682.26","","Case rate ($21,104.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,328.06, add-ons for qualifying new technology services are included. If operating cost exceeds $70,972.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,268.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $18,896.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,948.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,828.10. The transfer capital threshold is the transfer adjustment factor * $1,828.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20464.83","20464.83","20464.83","1 through 10","20682.26","35587.04","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With McC","085","MS-DRG","","","","","","","","inpatient","","","75759.90","56819.92","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20682.26","","Case rate ($21,104.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,328.06, add-ons for qualifying new technology services are included. If operating cost exceeds $70,972.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,268.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $18,896.41 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $24,948.23 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,828.10. The transfer capital threshold is the transfer adjustment factor * $1,828.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20502.92","20502.92","20502.92","1 through 10","20682.26","35587.04","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour Without Cc/McC","087","MS-DRG","","","","","","","","inpatient","","","24806.50","18604.87","MEDICARE [2001]","HB BWH MEDICARE","8723.82","","Case rate ($8,723.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,424.35, add-ons for qualifying new technology services are included. If operating cost exceeds $56,068.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,176.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,607.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,044.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.02. The transfer capital threshold is the transfer adjustment factor * $736.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10699.89","10699.89","10712.19","1 through 10","8549.34","13340.444","other","Inpatient Replacement Plans DRG"
"Traumatic Stupor And Coma <1 Hour Without Cc/McC","087","MS-DRG","","","","","","","","inpatient","","","24806.50","18604.87","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8549.34","","Case rate ($8,723.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,424.35, add-ons for qualifying new technology services are included. If operating cost exceeds $56,068.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,176.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $7,607.97 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,044.52 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.02. The transfer capital threshold is the transfer adjustment factor * $736.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12187.85","12187.85","12187.85","1 through 10","8549.34","13340.444","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","","","","inpatient","","","48620.51","36465.38","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","13112.47","","Case rate ($13,112.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,707.42, add-ons for qualifying new technology services are included. If operating cost exceeds $61,351.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,609.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,327.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,123.14. The transfer capital threshold is the transfer adjustment factor * $1,123.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","106308.09","106308.09","106308.09","1 through 10","12850.22","21863.81","other","Inpatient Replacement Plans DRG"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","","","","inpatient","","","48620.51","36465.38","HUMANA [1012]","HB BWH MEDICARE","13112.47","","Case rate ($13,112.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,707.42, add-ons for qualifying new technology services are included. If operating cost exceeds $61,351.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,609.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,327.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,123.14. The transfer capital threshold is the transfer adjustment factor * $1,123.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8808.85","8808.85","8808.85","1 through 10","12850.22","21863.81","other","Inpatient Replacement Plans DRG"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","","","","inpatient","","","48620.51","36465.38","MEDICARE [2001]","HB BWH MEDICARE","13112.47","","Case rate ($13,112.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,707.42, add-ons for qualifying new technology services are included. If operating cost exceeds $61,351.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,609.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,327.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,123.14. The transfer capital threshold is the transfer adjustment factor * $1,123.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16669.91","0.03","16694.42","27","12850.22","21863.81","other","Inpatient Replacement Plans DRG"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","","","","inpatient","","","48620.51","36465.38","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","12850.22","","Case rate ($13,112.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,707.42, add-ons for qualifying new technology services are included. If operating cost exceeds $61,351.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,609.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,327.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,123.14. The transfer capital threshold is the transfer adjustment factor * $1,123.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12640.54","12640.54","12640.54","1 through 10","12850.22","21863.81","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","","","","inpatient","","","48620.51","36465.38","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","12850.22","","Case rate ($13,112.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,707.42, add-ons for qualifying new technology services are included. If operating cost exceeds $61,351.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,563.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,609.49 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,327.58 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,123.14. The transfer capital threshold is the transfer adjustment factor * $1,123.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12640.53","12640.53","12640.53","1 through 10","12850.22","21863.81","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With McC","082","MS-DRG","","","","","","","","inpatient","","","85708.17","64281.13","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","27438.89","","Case rate ($27,438.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,478.51, add-ons for qualifying new technology services are included. If operating cost exceeds $71,122.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,279.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $25,219.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,098.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,839.13. The transfer capital threshold is the transfer adjustment factor * $1,839.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27222.90","27222.90","27222.90","1 through 10","20804.74","35801.64","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With McC","082","MS-DRG","","","","","","","","inpatient","","","85708.17","64281.13","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","21229.33","","Case rate ($21,229.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,478.51, add-ons for qualifying new technology services are included. If operating cost exceeds $71,122.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,279.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $19,010.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,098.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,839.13. The transfer capital threshold is the transfer adjustment factor * $1,839.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20978.76","20978.76","20978.76","1 through 10","20804.74","35801.64","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With McC","082","MS-DRG","","","","","","","","inpatient","","","85708.17","64281.13","MEDICARE [2001]","HB BWH MEDICARE","27438.89","","Case rate ($27,438.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,478.51, add-ons for qualifying new technology services are included. If operating cost exceeds $71,122.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,279.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $25,219.92 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,098.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,839.13. The transfer capital threshold is the transfer adjustment factor * $1,839.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27631.47","0.03","27672.38","31","20804.74","35801.64","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With McC","082","MS-DRG","","","","","","","","inpatient","","","85708.17","64281.13","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","20804.74","","Case rate ($21,229.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,478.51, add-ons for qualifying new technology services are included. If operating cost exceeds $71,122.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,279.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $19,010.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,098.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,839.13. The transfer capital threshold is the transfer adjustment factor * $1,839.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20998.34","20985.90","28011.11","1 through 10","20804.74","35801.64","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With McC","082","MS-DRG","","","","","","","","inpatient","","","85708.17","64281.13","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20804.74","","Case rate ($21,229.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $25,478.51, add-ons for qualifying new technology services are included. If operating cost exceeds $71,122.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,279.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $19,010.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $25,098.67 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,839.13. The transfer capital threshold is the transfer adjustment factor * $1,839.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20986.28","20935.24","21050.96","1 through 10","20804.74","35801.64","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour Without Cc/McC","084","MS-DRG","","","","","","","","inpatient","","","32472.00","24354.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","11695.49","","Case rate ($11,695.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,875.69, add-ons for qualifying new technology services are included. If operating cost exceeds $56,520.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,209.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,546.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,495.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.09. The transfer capital threshold is the transfer adjustment factor * $769.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8863.92","8863.92","8863.92","1 through 10","8916.78","14971.65","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour Without Cc/McC","084","MS-DRG","","","","","","","","inpatient","","","32472.00","24354.00","MEDICARE [2001]","HB BWH MEDICARE","11695.49","","Case rate ($11,695.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,875.69, add-ons for qualifying new technology services are included. If operating cost exceeds $56,520.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,209.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,546.55 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,495.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.09. The transfer capital threshold is the transfer adjustment factor * $769.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1305.65","126.29","11549.90","1 through 10","8916.78","14971.65","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour Without Cc/McC","084","MS-DRG","","","","","","","","inpatient","","","32472.00","24354.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8916.78","","Case rate ($9,098.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $10,875.69, add-ons for qualifying new technology services are included. If operating cost exceeds $56,520.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,209.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,949.82 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $10,495.85 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.09. The transfer capital threshold is the transfer adjustment factor * $769.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21017.69","21017.69","21017.69","1 through 10","8916.78","14971.65","other","Inpatient DRG"
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","976.5","2504.25","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2504.25","79.5","","1293.60","1148.53","1603.80","1 through 10","976.5","2504.25","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1149.75","36.5","","1023.42","771.29","2068.67","33","976.5","2504.25","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1206.45","38.3","","850.52","759.78","1211.25","66","976.5","2504.25","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","2548.09","2548.09","2548.09","1 through 10","976.5","2504.25","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","956.46","956.46","956.46","1 through 10","976.5","2504.25","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","WELLPOINT [1015]","HB AMC WELLPOINT","2324.07","73.78","","2344.73","1619.47","2530.35","16","976.5","2504.25","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA HMO","2198.70","69.8","","1523.63","988.41","4330.26","39","1646.19","2574.18","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA PPO","2532.60","80.4","","1670.25","1670.25","1670.25","1 through 10","1646.19","2574.18","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","1646.19","2574.18","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2574.18","81.72","","1738.90","1484.65","2716.94","38","1646.19","2574.18","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","976.5","2504.25","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2504.25","79.5","","1293.60","1148.53","1603.80","1 through 10","976.5","2504.25","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1149.75","36.5","","1023.42","771.29","2068.67","33","976.5","2504.25","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1206.45","38.3","","850.52","759.78","1211.25","66","976.5","2504.25","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","2548.09","2548.09","2548.09","1 through 10","976.5","2504.25","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.35","42.9","","956.46","956.46","956.46","1 through 10","976.5","2504.25","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","WELLPOINT [1015]","HB AMC WELLPOINT","2324.07","73.78","","2344.73","1619.47","2530.35","16","976.5","2504.25","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA HMO","2198.70","69.8","","1523.63","988.41","4330.26","39","1646.19","2574.18","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","AETNA [1001]","HB AMC AETNA PPO","2532.60","80.4","","1670.25","1670.25","1670.25","1 through 10","1646.19","2574.18","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1646.19","52.26","","1113.10","1113.10","1113.10","1 through 10","1646.19","2574.18","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2574.18","81.72","","1738.90","1484.65","2716.94","38","1646.19","2574.18","percent of total billed charges",""
"TRAY 67MM TIBIAL KNEE VANGUARD 360 REVISION SYSTEM","SUP-ITM-10117735","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.66","52.26","","1113.10","1113.10","1113.10","1 through 10","1266.85","3248.85","percent of total billed charges",""
"TRAY 67MM TIBIAL KNEE VANGUARD 360 REVISION SYSTEM","SUP-ITM-10117735","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3248.85","79.5","","1293.60","1148.53","1603.80","1 through 10","1266.85","3248.85","percent of total billed charges",""
"TRAY 67MM TIBIAL KNEE VANGUARD 360 REVISION SYSTEM","SUP-ITM-10117735","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1491.61","36.5","","1023.42","771.29","2068.67","33","1266.85","3248.85","percent of total billed charges",""
"TRAY 67MM TIBIAL KNEE VANGUARD 360 REVISION SYSTEM","SUP-ITM-10117735","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1565.17","38.3","","850.52","759.78","1211.25","66","1266.85","3248.85","percent of total billed charges",""
"TRAY 67MM TIBIAL KNEE VANGUARD 360 REVISION SYSTEM","SUP-ITM-10117735","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.15","42.9","","2548.09","2548.09","2548.09","1 through 10","1266.85","3248.85","percent of total billed charges",""
"TRAY 67MM TIBIAL KNEE VANGUARD 360 REVISION SYSTEM","SUP-ITM-10117735","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.15","42.9","","956.46","956.46","956.46","1 through 10","1266.85","3248.85","percent of total billed charges",""
"TRAY 67MM TIBIAL KNEE VANGUARD 360 REVISION SYSTEM","SUP-ITM-10117735","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","WELLPOINT [1015]","HB AMC WELLPOINT","3015.09","73.78","","2344.73","1619.47","2530.35","16","1266.85","3248.85","percent of total billed charges",""
"TRAY 67MM TIBIAL KNEE VANGUARD 360 REVISION SYSTEM","SUP-ITM-10117735","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","AETNA [1001]","HB AMC AETNA HMO","2852.45","69.8","","1523.63","988.41","4330.26","39","2135.66","3339.57","percent of total billed charges",""
"TRAY 67MM TIBIAL KNEE VANGUARD 360 REVISION SYSTEM","SUP-ITM-10117735","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","AETNA [1001]","HB AMC AETNA PPO","3285.63","80.4","","1670.25","1670.25","1670.25","1 through 10","2135.66","3339.57","percent of total billed charges",""
"TRAY 67MM TIBIAL KNEE VANGUARD 360 REVISION SYSTEM","SUP-ITM-10117735","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.66","52.26","","1113.10","1113.10","1113.10","1 through 10","2135.66","3339.57","percent of total billed charges",""
"TRAY 67MM TIBIAL KNEE VANGUARD 360 REVISION SYSTEM","SUP-ITM-10117735","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3339.57","81.72","","1738.90","1484.65","2716.94","38","2135.66","3339.57","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2286.38","52.26","","1113.10","1113.10","1113.10","1 through 10","1356.25","3478.13","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3478.13","79.5","","1293.60","1148.53","1603.80","1 through 10","1356.25","3478.13","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1596.88","36.5","","1023.42","771.29","2068.67","33","1356.25","3478.13","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1675.63","38.3","","850.52","759.78","1211.25","66","1356.25","3478.13","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1876.88","42.9","","2548.09","2548.09","2548.09","1 through 10","1356.25","3478.13","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1876.88","42.9","","956.46","956.46","956.46","1 through 10","1356.25","3478.13","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB AMC WELLPOINT","3227.88","73.78","","2344.73","1619.47","2530.35","16","1356.25","3478.13","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","AETNA [1001]","HB AMC AETNA HMO","3053.75","69.8","","1523.63","988.41","4330.26","39","2286.38","3575.25","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","AETNA [1001]","HB AMC AETNA PPO","3517.50","80.4","","1670.25","1670.25","1670.25","1 through 10","2286.38","3575.25","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2286.38","52.26","","1113.10","1113.10","1113.10","1 through 10","2286.38","3575.25","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3575.25","81.72","","1738.90","1484.65","2716.94","38","2286.38","3575.25","percent of total billed charges",""
"TRAY BASEPLANTEXSIZE 3.0 BASEPLATE TIBIAL KNEE NEGEN MIS TRABECULAR METAL POROUS FIED BEARING","SUP-ITM-10086423","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.66","52.26","","1113.10","1113.10","1113.10","1 through 10","1266.85","3248.85","percent of total billed charges",""
"TRAY BASEPLANTEXSIZE 3.0 BASEPLATE TIBIAL KNEE NEGEN MIS TRABECULAR METAL POROUS FIED BEARING","SUP-ITM-10086423","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3248.85","79.5","","1293.60","1148.53","1603.80","1 through 10","1266.85","3248.85","percent of total billed charges",""
"TRAY BASEPLANTEXSIZE 3.0 BASEPLATE TIBIAL KNEE NEGEN MIS TRABECULAR METAL POROUS FIED BEARING","SUP-ITM-10086423","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1491.61","36.5","","1023.42","771.29","2068.67","33","1266.85","3248.85","percent of total billed charges",""
"TRAY BASEPLANTEXSIZE 3.0 BASEPLATE TIBIAL KNEE NEGEN MIS TRABECULAR METAL POROUS FIED BEARING","SUP-ITM-10086423","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1565.17","38.3","","850.52","759.78","1211.25","66","1266.85","3248.85","percent of total billed charges",""
"TRAY BASEPLANTEXSIZE 3.0 BASEPLATE TIBIAL KNEE NEGEN MIS TRABECULAR METAL POROUS FIED BEARING","SUP-ITM-10086423","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.15","42.9","","2548.09","2548.09","2548.09","1 through 10","1266.85","3248.85","percent of total billed charges",""
"TRAY BASEPLANTEXSIZE 3.0 BASEPLATE TIBIAL KNEE NEGEN MIS TRABECULAR METAL POROUS FIED BEARING","SUP-ITM-10086423","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1753.15","42.9","","956.46","956.46","956.46","1 through 10","1266.85","3248.85","percent of total billed charges",""
"TRAY BASEPLANTEXSIZE 3.0 BASEPLATE TIBIAL KNEE NEGEN MIS TRABECULAR METAL POROUS FIED BEARING","SUP-ITM-10086423","CDM","C1776","HCPCS","0278","RC","","","","both","","","4086.60","3064.95","WELLPOINT [1015]","HB AMC WELLPOINT","3015.09","73.78","","2344.73","1619.47","2530.35","16","1266.85","3248.85","percent of total billed charges",""
"TRAY BASEPLANTEXSIZE 3.0 BASEPLATE TIBIAL KNEE NEGEN MIS TRABECULAR METAL POROUS FIED BEARING","SUP-ITM-10086423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","AETNA [1001]","HB AMC AETNA HMO","2852.45","69.8","","1523.63","988.41","4330.26","39","2135.66","3339.57","percent of total billed charges",""
"TRAY BASEPLANTEXSIZE 3.0 BASEPLATE TIBIAL KNEE NEGEN MIS TRABECULAR METAL POROUS FIED BEARING","SUP-ITM-10086423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","AETNA [1001]","HB AMC AETNA PPO","3285.63","80.4","","1670.25","1670.25","1670.25","1 through 10","2135.66","3339.57","percent of total billed charges",""
"TRAY BASEPLANTEXSIZE 3.0 BASEPLATE TIBIAL KNEE NEGEN MIS TRABECULAR METAL POROUS FIED BEARING","SUP-ITM-10086423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2135.66","52.26","","1113.10","1113.10","1113.10","1 through 10","2135.66","3339.57","percent of total billed charges",""
"TRAY BASEPLANTEXSIZE 3.0 BASEPLATE TIBIAL KNEE NEGEN MIS TRABECULAR METAL POROUS FIED BEARING","SUP-ITM-10086423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4086.60","3064.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3339.57","81.72","","1738.90","1484.65","2716.94","38","2135.66","3339.57","percent of total billed charges",""
"TRAY BIOPSY 10G 11MM ACCESS 4CM BIOPSY BONE LESION ONCONTROL BX/6EA","SUP-ITM-10104816","CDM","C1830","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","955.50","70","","2532.60","2532.60","2532.60","1 through 10","423.15","1085.18","percent of total billed charges",""
"TRAY BIOPSY 10G 11MM ACCESS 4CM BIOPSY BONE LESION ONCONTROL BX/6EA","SUP-ITM-10104816","CDM","C1830","HCPCS","0272","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","522.80","38.3","","497.42","497.42","497.42","1 through 10","423.15","1085.18","percent of total billed charges",""
"TRAY CATHETER 10FR 90CM DUAL LUMEN CENTRL VEN LEONARD INGRWTH CUF STYLET INTRO NDL INJ CAP 2 CONCTR INSTRUC - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000259","CDM","C1751","HCPCS","0272","RC","","","","both","","","483.00","362.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","338.10","70","","1389.50","602.17","3167.85","27","149.73","383.99","percent of total billed charges",""
"TRAY CATHETER 10FR 90CM DUAL LUMEN CENTRL VEN LEONARD INGRWTH CUF STYLET INTRO NDL INJ CAP 2 CONCTR INSTRUC - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000259","CDM","C1751","HCPCS","0272","RC","","","","both","","","483.00","362.25","WELLPOINT [1015]","HB AMC WELLPOINT","356.36","73.78","","1089.20","218.86","1089.20","1 through 10","149.73","383.99","percent of total billed charges",""
"TRAY CATHETER 10FR 90CM DUAL LUMEN CENTRL VEN LEONARD INGRWTH CUF STYLET INTRO NDL INJ CAP 2 CONCTR INSTRUC - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000259","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","483.00","362.25","AETNA [1001]","HB AMC AETNA HMO","337.13","69.8","","1389.50","940.69","1389.50","1 through 10","252.42","394.71","percent of total billed charges",""
"TRAY CATHETER 10FR 90CM DUAL LUMEN CENTRL VEN LEONARD INGRWTH CUF STYLET INTRO NDL INJ CAP 2 CONCTR INSTRUC - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000259","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","483.00","362.25","AETNA [1001]","HB AMC AETNA PPO","388.33","80.4","","190.26","190.26","190.26","1 through 10","252.42","394.71","percent of total billed charges",""
"TRAY CATHETER 10FR 90CM DUAL LUMEN CENTRL VEN LEONARD INGRWTH CUF STYLET INTRO NDL INJ CAP 2 CONCTR INSTRUC - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10000259","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","483.00","362.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","394.71","81.72","","1110.77","235.00","1169.52","1 through 10","252.42","394.71","percent of total billed charges",""
"TRAY CATHETER 12.5FR 16CM MAHURKAR ELITE TRIPLE LUMEN CURVED EXTENSIONS","SUP-ITM-10209412","CDM","C1750","HCPCS","0278","RC","","","","both","","","487.10","365.32","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","254.56","52.26","","154.36","154.36","154.36","1 through 10","151","387.24","percent of total billed charges",""
"TRAY CATHETER 12.5FR 16CM MAHURKAR ELITE TRIPLE LUMEN CURVED EXTENSIONS","SUP-ITM-10209412","CDM","C1750","HCPCS","0278","RC","","","","both","","","487.10","365.32","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","316.62","65","","1371.74","196.32","1371.74","1 through 10","151","387.24","percent of total billed charges",""
"TRAY CATHETER 12.5FR 16CM MAHURKAR ELITE TRIPLE LUMEN CURVED EXTENSIONS","SUP-ITM-10209412","CDM","C1750","HCPCS","0278","RC","","","","both","","","487.10","365.32","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","340.97","70","","249.45","107.26","1254.96","14","151","387.24","percent of total billed charges",""
"TRAY CATHETER 12.5FR 16CM MAHURKAR ELITE TRIPLE LUMEN CURVED EXTENSIONS","SUP-ITM-10209412","CDM","C1750","HCPCS","0278","RC","","","","both","","","487.10","365.32","CIGNA [1006]","HB AMC CIGNA HMO / PPO","387.24","79.5","","196.32","85.01","196.32","1 through 10","151","387.24","percent of total billed charges",""
"TRAY CATHETER 12.5FR 16CM MAHURKAR ELITE TRIPLE LUMEN CURVED EXTENSIONS","SUP-ITM-10209412","CDM","C1750","HCPCS","0278","RC","","","","both","","","487.10","365.32","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","259.62","53.3","","1132.95","1132.95","1132.95","1 through 10","151","387.24","percent of total billed charges",""
"TRAY CATHETER 12.5FR 16CM MAHURKAR ELITE TRIPLE LUMEN CURVED EXTENSIONS","SUP-ITM-10209412","CDM","C1750","HCPCS","0278","RC","","","","both","","","487.10","365.32","WELLPOINT [1015]","HB AMC WELLPOINT","359.38","73.78","","1297.66","185.72","1297.66","1 through 10","151","387.24","percent of total billed charges",""
"TRAY CATHETER 12.5FR 16CM MAHURKAR ELITE TRIPLE LUMEN CURVED EXTENSIONS","SUP-ITM-10209412","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","487.10","365.32","AETNA [1001]","HB AMC AETNA HMO","340.00","69.8","","76.96","76.96","76.96","1 through 10","254.56","398.06","percent of total billed charges",""
"TRAY CATHETER 12.5FR 16CM MAHURKAR ELITE TRIPLE LUMEN CURVED EXTENSIONS","SUP-ITM-10209412","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","487.10","365.32","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","254.56","52.26","","154.36","154.36","154.36","1 through 10","254.56","398.06","percent of total billed charges",""
"TRAY CATHETER 12.5FR 16CM MAHURKAR ELITE TRIPLE LUMEN CURVED EXTENSIONS","SUP-ITM-10209412","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","487.10","365.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","398.06","81.72","","199.41","199.41","199.41","1 through 10","254.56","398.06","percent of total billed charges",""
"TRAY CATHETER 13.5FR 20CM MAHURKAR ELITE HIGH FLOW DUAL PASS CT/1EA","SUP-ITM-10237198","CDM","C1752","HCPCS","0278","RC","","","","both","","","479.19","359.39","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","311.47","65","","131.71","131.71","131.71","1 through 10","148.55","380.96","percent of total billed charges",""
"TRAY CATHETER 13.5FR 20CM MAHURKAR ELITE HIGH FLOW DUAL PASS CT/1EA","SUP-ITM-10237198","CDM","C1752","HCPCS","0278","RC","","","","both","","","479.19","359.39","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","335.43","70","","249.44","163.91","249.45","1 through 10","148.55","380.96","percent of total billed charges",""
"TRAY CATHETER 13.5FR 20CM MAHURKAR ELITE HIGH FLOW DUAL PASS CT/1EA","SUP-ITM-10237198","CDM","C1752","HCPCS","0278","RC","","","","both","","","479.19","359.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","380.96","79.5","","162.14","162.14","162.14","1 through 10","148.55","380.96","percent of total billed charges",""
"TRAY CATHETER 13.5FR 20CM MAHURKAR ELITE HIGH FLOW DUAL PASS CT/1EA","SUP-ITM-10237198","CDM","C1752","HCPCS","0278","RC","","","","both","","","479.19","359.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","311.47","65","","193.56","193.56","193.56","1 through 10","148.55","380.96","percent of total billed charges",""
"TRAY CATHETER 13.5FR 20CM MAHURKAR ELITE HIGH FLOW DUAL PASS CT/1EA","SUP-ITM-10237198","CDM","C1752","HCPCS","0278","RC","","","","both","","","479.19","359.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","148.55","31","","77.08","77.08","77.08","1 through 10","148.55","380.96","percent of total billed charges",""
"TRAY CATHETER 13.5FR 20CM MAHURKAR ELITE HIGH FLOW DUAL PASS CT/1EA","SUP-ITM-10237198","CDM","C1752","HCPCS","0278","RC","","","","both","","","479.19","359.39","WELLPOINT [1015]","HB AMC WELLPOINT","353.55","73.78","","185.72","185.72","185.72","1 through 10","148.55","380.96","percent of total billed charges",""
"TRAY CATHETER 13.5FR 20CM MAHURKAR ELITE HIGH FLOW DUAL PASS CT/1EA","SUP-ITM-10237198","CDM","C1752","HCPCS","0278","RC","","","","outpatient","","","479.19","359.39","AETNA [1001]","HB AMC AETNA HMO","334.47","69.8","","185.24","185.24","185.24","1 through 10","250.42","391.59","percent of total billed charges",""
"TRAY CATHETER 16X20CM SINGLE LUMEN 16GA CENTRAL VENOUS CS/5EA","SUP-ITM-10114453","CDM","C1751","HCPCS","0272","RC","","","","both","","","136.43","102.32","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","95.50","70","","1389.50","602.17","3167.85","27","42.29","108.46","percent of total billed charges",""
"TRAY CATHETER 16X20CM SINGLE LUMEN 16GA CENTRAL VENOUS CS/5EA","SUP-ITM-10114453","CDM","C1751","HCPCS","0272","RC","","","","both","","","136.43","102.32","WELLPOINT [1015]","HB AMC WELLPOINT","100.66","73.78","","1089.20","218.86","1089.20","1 through 10","42.29","108.46","percent of total billed charges",""
"TRAY CATHETER 16X20CM SINGLE LUMEN 16GA CENTRAL VENOUS CS/5EA","SUP-ITM-10114453","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","136.43","102.32","AETNA [1001]","HB AMC AETNA HMO","95.23","69.8","","1389.50","940.69","1389.50","1 through 10","71.3","111.49","percent of total billed charges",""
"TRAY CATHETER 16X20CM SINGLE LUMEN 16GA CENTRAL VENOUS CS/5EA","SUP-ITM-10114453","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","136.43","102.32","AETNA [1001]","HB AMC AETNA PPO","109.69","80.4","","190.26","190.26","190.26","1 through 10","71.3","111.49","percent of total billed charges",""
"TRAY CATHETER 16X20CM SINGLE LUMEN 16GA CENTRAL VENOUS CS/5EA","SUP-ITM-10114453","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","136.43","102.32","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","111.49","81.72","","1110.77","235.00","1169.52","1 through 10","71.3","111.49","percent of total billed charges",""
"TRAY CATHETER 2.7FR SILICONE LUMEN BROVIAC INGROWTH CUFF STYLET INTRODUCER NEEDLE INJ CAP 2 CONNECTOR INSTRUCTION","SUP-ITM-10000069","CDM","C1751","HCPCS","0272","RC","","","","both","","","276.50","207.37","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","193.55","70","","1389.50","602.17","3167.85","27","85.72","219.82","percent of total billed charges",""
"TRAY CATHETER 2.7FR SILICONE LUMEN BROVIAC INGROWTH CUFF STYLET INTRODUCER NEEDLE INJ CAP 2 CONNECTOR INSTRUCTION","SUP-ITM-10000069","CDM","C1751","HCPCS","0272","RC","","","","both","","","276.50","207.37","WELLPOINT [1015]","HB AMC WELLPOINT","204.00","73.78","","1089.20","218.86","1089.20","1 through 10","85.72","219.82","percent of total billed charges",""
"TRAY CATHETER 2.7FR SILICONE LUMEN BROVIAC INGROWTH CUFF STYLET INTRODUCER NEEDLE INJ CAP 2 CONNECTOR INSTRUCTION","SUP-ITM-10000069","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","276.50","207.37","AETNA [1001]","HB AMC AETNA HMO","193.00","69.8","","1389.50","940.69","1389.50","1 through 10","144.5","225.96","percent of total billed charges",""
"TRAY CATHETER 2.7FR SILICONE LUMEN BROVIAC INGROWTH CUFF STYLET INTRODUCER NEEDLE INJ CAP 2 CONNECTOR INSTRUCTION","SUP-ITM-10000069","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","276.50","207.37","AETNA [1001]","HB AMC AETNA PPO","222.31","80.4","","190.26","190.26","190.26","1 through 10","144.5","225.96","percent of total billed charges",""
"TRAY CATHETER 2.7FR SILICONE LUMEN BROVIAC INGROWTH CUFF STYLET INTRODUCER NEEDLE INJ CAP 2 CONNECTOR INSTRUCTION","SUP-ITM-10000069","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","276.50","207.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","225.96","81.72","","1110.77","235.00","1169.52","1 through 10","144.5","225.96","percent of total billed charges",""
"TRAY CATHETER 4.2FR SINGLE LUMEN BROVIAC INGROWTH CUFF STYLET PEEL APART INTRODUCER NEEDLE INJ CAP 2 CONNECTOR INSTRUCTION","SUP-ITM-10000068","CDM","C1751","HCPCS","0272","RC","","","","both","","","451.50","338.62","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","316.05","70","","1389.50","602.17","3167.85","27","139.97","358.94","percent of total billed charges",""
"TRAY CATHETER 4.2FR SINGLE LUMEN BROVIAC INGROWTH CUFF STYLET PEEL APART INTRODUCER NEEDLE INJ CAP 2 CONNECTOR INSTRUCTION","SUP-ITM-10000068","CDM","C1751","HCPCS","0272","RC","","","","both","","","451.50","338.62","WELLPOINT [1015]","HB AMC WELLPOINT","333.12","73.78","","1089.20","218.86","1089.20","1 through 10","139.97","358.94","percent of total billed charges",""
"TRAY CATHETER 4.2FR SINGLE LUMEN BROVIAC INGROWTH CUFF STYLET PEEL APART INTRODUCER NEEDLE INJ CAP 2 CONNECTOR INSTRUCTION","SUP-ITM-10000068","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","451.50","338.62","AETNA [1001]","HB AMC AETNA HMO","315.15","69.8","","1389.50","940.69","1389.50","1 through 10","235.95","368.97","percent of total billed charges",""
"TRAY CATHETER 4.2FR SINGLE LUMEN BROVIAC INGROWTH CUFF STYLET PEEL APART INTRODUCER NEEDLE INJ CAP 2 CONNECTOR INSTRUCTION","SUP-ITM-10000068","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","451.50","338.62","AETNA [1001]","HB AMC AETNA PPO","363.01","80.4","","190.26","190.26","190.26","1 through 10","235.95","368.97","percent of total billed charges",""
"TRAY CATHETER 4.2FR SINGLE LUMEN BROVIAC INGROWTH CUFF STYLET PEEL APART INTRODUCER NEEDLE INJ CAP 2 CONNECTOR INSTRUCTION","SUP-ITM-10000068","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","451.50","338.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","368.97","81.72","","1110.77","235.00","1169.52","1 through 10","235.95","368.97","percent of total billed charges",""
"TRAY CATHETER 5FR CENTRAL VENOUS POWERPICC DUAL LUMEN MAXIMAL BARRIER SHERLOCK STYLET CS/3EA","SUP-ITM-10093968","CDM","C1751","HCPCS","0272","RC","","","","both","","","757.40","568.05","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","530.18","70","","1389.50","602.17","3167.85","27","234.79","602.13","percent of total billed charges",""
"TRAY CATHETER 5FR CENTRAL VENOUS POWERPICC DUAL LUMEN MAXIMAL BARRIER SHERLOCK STYLET CS/3EA","SUP-ITM-10093968","CDM","C1751","HCPCS","0272","RC","","","","both","","","757.40","568.05","WELLPOINT [1015]","HB AMC WELLPOINT","558.81","73.78","","1089.20","218.86","1089.20","1 through 10","234.79","602.13","percent of total billed charges",""
"TRAY CATHETER 5FR CENTRAL VENOUS POWERPICC DUAL LUMEN MAXIMAL BARRIER SHERLOCK STYLET CS/3EA","SUP-ITM-10093968","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","757.40","568.05","AETNA [1001]","HB AMC AETNA HMO","528.67","69.8","","1389.50","940.69","1389.50","1 through 10","395.82","618.95","percent of total billed charges",""
"TRAY CATHETER 5FR CENTRAL VENOUS POWERPICC DUAL LUMEN MAXIMAL BARRIER SHERLOCK STYLET CS/3EA","SUP-ITM-10093968","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","757.40","568.05","AETNA [1001]","HB AMC AETNA PPO","608.95","80.4","","190.26","190.26","190.26","1 through 10","395.82","618.95","percent of total billed charges",""
"TRAY CATHETER 5FR CENTRAL VENOUS POWERPICC DUAL LUMEN MAXIMAL BARRIER SHERLOCK STYLET CS/3EA","SUP-ITM-10093968","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","757.40","568.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","618.95","81.72","","1110.77","235.00","1169.52","1 through 10","395.82","618.95","percent of total billed charges",""
"TRAY CATHETER 9.6FR 90CM SINGLE LUMEN HICKMAN INGRWTH CUF STR J TIP GUIDWR PEEL APRT INTRO VSL DILATR INJ C","SUP-ITM-10000064","CDM","C1751","HCPCS","0272","RC","","","","both","","","385.00","288.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","269.50","70","","1389.50","602.17","3167.85","27","119.35","306.08","percent of total billed charges",""
"TRAY CATHETER 9.6FR 90CM SINGLE LUMEN HICKMAN INGRWTH CUF STR J TIP GUIDWR PEEL APRT INTRO VSL DILATR INJ C","SUP-ITM-10000064","CDM","C1751","HCPCS","0272","RC","","","","both","","","385.00","288.75","WELLPOINT [1015]","HB AMC WELLPOINT","284.05","73.78","","1089.20","218.86","1089.20","1 through 10","119.35","306.08","percent of total billed charges",""
"TRAY CATHETER 9.6FR 90CM SINGLE LUMEN HICKMAN INGRWTH CUF STR J TIP GUIDWR PEEL APRT INTRO VSL DILATR INJ C","SUP-ITM-10000064","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","385.00","288.75","AETNA [1001]","HB AMC AETNA HMO","268.73","69.8","","1389.50","940.69","1389.50","1 through 10","201.2","314.62","percent of total billed charges",""
"TRAY CATHETER 9.6FR 90CM SINGLE LUMEN HICKMAN INGRWTH CUF STR J TIP GUIDWR PEEL APRT INTRO VSL DILATR INJ C","SUP-ITM-10000064","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","385.00","288.75","AETNA [1001]","HB AMC AETNA PPO","309.54","80.4","","190.26","190.26","190.26","1 through 10","201.2","314.62","percent of total billed charges",""
"TRAY CATHETER 9.6FR 90CM SINGLE LUMEN HICKMAN INGRWTH CUF STR J TIP GUIDWR PEEL APRT INTRO VSL DILATR INJ C","SUP-ITM-10000064","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","314.62","81.72","","1110.77","235.00","1169.52","1 through 10","201.2","314.62","percent of total billed charges",""
"TRAY CATHETER POWERLINE 5FR CENTRAL VENOUS SINGLE LUMEN POLYURETHANE TISSUE INGROWTH CUFF STRAIGHT GUIDEWIRE SCALPEL MICRO INTRODUCER FENESTRATED DRAPES GAUZE","SUP-ITM-10027871","CDM","C1751","HCPCS","0272","RC","","","","both","","","903.00","677.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","632.10","70","","1389.50","602.17","3167.85","27","279.93","717.89","percent of total billed charges",""
"TRAY CATHETER POWERLINE 5FR CENTRAL VENOUS SINGLE LUMEN POLYURETHANE TISSUE INGROWTH CUFF STRAIGHT GUIDEWIRE SCALPEL MICRO INTRODUCER FENESTRATED DRAPES GAUZE","SUP-ITM-10027871","CDM","C1751","HCPCS","0272","RC","","","","both","","","903.00","677.25","WELLPOINT [1015]","HB AMC WELLPOINT","666.23","73.78","","1089.20","218.86","1089.20","1 through 10","279.93","717.89","percent of total billed charges",""
"TRAY CATHETER POWERLINE 5FR CENTRAL VENOUS SINGLE LUMEN POLYURETHANE TISSUE INGROWTH CUFF STRAIGHT GUIDEWIRE SCALPEL MICRO INTRODUCER FENESTRATED DRAPES GAUZE","SUP-ITM-10027871","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","903.00","677.25","AETNA [1001]","HB AMC AETNA HMO","630.29","69.8","","1389.50","940.69","1389.50","1 through 10","471.91","737.93","percent of total billed charges",""
"TRAY CATHETER POWERLINE 5FR CENTRAL VENOUS SINGLE LUMEN POLYURETHANE TISSUE INGROWTH CUFF STRAIGHT GUIDEWIRE SCALPEL MICRO INTRODUCER FENESTRATED DRAPES GAUZE","SUP-ITM-10027871","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","903.00","677.25","AETNA [1001]","HB AMC AETNA PPO","726.01","80.4","","190.26","190.26","190.26","1 through 10","471.91","737.93","percent of total billed charges",""
"TRAY CATHETER POWERLINE 5FR CENTRAL VENOUS SINGLE LUMEN POLYURETHANE TISSUE INGROWTH CUFF STRAIGHT GUIDEWIRE SCALPEL MICRO INTRODUCER FENESTRATED DRAPES GAUZE","SUP-ITM-10027871","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","903.00","677.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","737.93","81.72","","1110.77","235.00","1169.52","1 through 10","471.91","737.93","percent of total billed charges",""
"TRAY CATHETER POWERLINE 6FR CENTRAL VENOUS DOUBLE LUMEN POLYURETHANE TISSUE INGROWTH CUFF STRAIGHT GUIDEWIRE SCALPEL MICRO INTRODUCER FENESTRATED DRAPES GAUZE HY","SUP-ITM-10019409","CDM","C1751","HCPCS","0272","RC","","","","both","","","973.00","729.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","681.10","70","","1389.50","602.17","3167.85","27","301.63","773.54","percent of total billed charges",""
"TRAY CATHETER POWERLINE 6FR CENTRAL VENOUS DOUBLE LUMEN POLYURETHANE TISSUE INGROWTH CUFF STRAIGHT GUIDEWIRE SCALPEL MICRO INTRODUCER FENESTRATED DRAPES GAUZE HY","SUP-ITM-10019409","CDM","C1751","HCPCS","0272","RC","","","","both","","","973.00","729.75","WELLPOINT [1015]","HB AMC WELLPOINT","717.88","73.78","","1089.20","218.86","1089.20","1 through 10","301.63","773.54","percent of total billed charges",""
"TRAY CATHETER POWERLINE 6FR CENTRAL VENOUS DOUBLE LUMEN POLYURETHANE TISSUE INGROWTH CUFF STRAIGHT GUIDEWIRE SCALPEL MICRO INTRODUCER FENESTRATED DRAPES GAUZE HY","SUP-ITM-10019409","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","973.00","729.75","AETNA [1001]","HB AMC AETNA HMO","679.15","69.8","","1389.50","940.69","1389.50","1 through 10","508.49","795.14","percent of total billed charges",""
"TRAY CATHETER POWERLINE 6FR CENTRAL VENOUS DOUBLE LUMEN POLYURETHANE TISSUE INGROWTH CUFF STRAIGHT GUIDEWIRE SCALPEL MICRO INTRODUCER FENESTRATED DRAPES GAUZE HY","SUP-ITM-10019409","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","973.00","729.75","AETNA [1001]","HB AMC AETNA PPO","782.29","80.4","","190.26","190.26","190.26","1 through 10","508.49","795.14","percent of total billed charges",""
"TRAY CATHETER POWERLINE 6FR CENTRAL VENOUS DOUBLE LUMEN POLYURETHANE TISSUE INGROWTH CUFF STRAIGHT GUIDEWIRE SCALPEL MICRO INTRODUCER FENESTRATED DRAPES GAUZE HY","SUP-ITM-10019409","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","973.00","729.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","795.14","81.72","","1110.77","235.00","1169.52","1 through 10","508.49","795.14","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1209.95","52.26","","1113.10","1113.10","1113.10","1 through 10","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1840.62","79.5","","1293.60","1148.53","1603.80","1 through 10","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","845.07","36.5","","1023.42","771.29","2068.67","33","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","886.74","38.3","","850.52","759.78","1211.25","66","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.24","42.9","","2548.09","2548.09","2548.09","1 through 10","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.24","42.9","","956.46","956.46","956.46","1 through 10","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","WELLPOINT [1015]","HB AMC WELLPOINT","1708.19","73.78","","2344.73","1619.47","2530.35","16","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","AETNA [1001]","HB AMC AETNA HMO","1616.04","69.8","","1523.63","988.41","4330.26","39","1209.95","1892.02","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","AETNA [1001]","HB AMC AETNA PPO","1861.46","80.4","","1670.25","1670.25","1670.25","1 through 10","1209.95","1892.02","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1209.95","52.26","","1113.10","1113.10","1113.10","1 through 10","1209.95","1892.02","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1892.02","81.72","","1738.90","1484.65","2716.94","38","1209.95","1892.02","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1209.95","52.26","","1113.10","1113.10","1113.10","1 through 10","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1840.62","79.5","","1293.60","1148.53","1603.80","1 through 10","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","845.07","36.5","","1023.42","771.29","2068.67","33","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","886.74","38.3","","850.52","759.78","1211.25","66","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.24","42.9","","2548.09","2548.09","2548.09","1 through 10","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.24","42.9","","956.46","956.46","956.46","1 through 10","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","WELLPOINT [1015]","HB AMC WELLPOINT","1708.19","73.78","","2344.73","1619.47","2530.35","16","717.73","1840.62","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","AETNA [1001]","HB AMC AETNA HMO","1616.04","69.8","","1523.63","988.41","4330.26","39","1209.95","1892.02","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","AETNA [1001]","HB AMC AETNA PPO","1861.46","80.4","","1670.25","1670.25","1670.25","1 through 10","1209.95","1892.02","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1209.95","52.26","","1113.10","1113.10","1113.10","1 through 10","1209.95","1892.02","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1892.02","81.72","","1738.90","1484.65","2716.94","38","1209.95","1892.02","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.00","2682.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1869.34","52.26","","1113.10","1113.10","1113.10","1 through 10","1108.87","2843.72","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.00","2682.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2843.72","79.5","","1293.60","1148.53","1603.80","1 through 10","1108.87","2843.72","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.00","2682.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1305.61","36.5","","1023.42","771.29","2068.67","33","1108.87","2843.72","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.00","2682.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1369.99","38.3","","850.52","759.78","1211.25","66","1108.87","2843.72","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.00","2682.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1534.53","42.9","","2548.09","2548.09","2548.09","1 through 10","1108.87","2843.72","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.00","2682.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1534.53","42.9","","956.46","956.46","956.46","1 through 10","1108.87","2843.72","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.00","2682.75","WELLPOINT [1015]","HB AMC WELLPOINT","2639.11","73.78","","2344.73","1619.47","2530.35","16","1108.87","2843.72","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.00","2682.75","AETNA [1001]","HB AMC AETNA HMO","2496.75","69.8","","1523.63","988.41","4330.26","39","1869.34","2923.12","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.00","2682.75","AETNA [1001]","HB AMC AETNA PPO","2875.91","80.4","","1670.25","1670.25","1670.25","1 through 10","1869.34","2923.12","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.00","2682.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1869.34","52.26","","1113.10","1113.10","1113.10","1 through 10","1869.34","2923.12","percent of total billed charges",""
"TRAY ITOTAL IDENTITY CR TIBIAL","SUP-ITM-10283858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.00","2682.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2923.12","81.72","","1738.90","1484.65","2716.94","38","1869.34","2923.12","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2528.86","52.26","","1113.10","1113.10","1113.10","1 through 10","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3847.01","79.5","","1293.60","1148.53","1603.80","1 through 10","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1766.24","36.5","","1023.42","771.29","2068.67","33","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1853.34","38.3","","850.52","759.78","1211.25","66","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2075.93","42.9","","2548.09","2548.09","2548.09","1 through 10","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2075.93","42.9","","956.46","956.46","956.46","1 through 10","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","WELLPOINT [1015]","HB AMC WELLPOINT","3570.21","73.78","","2344.73","1619.47","2530.35","16","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4839.00","3629.25","AETNA [1001]","HB AMC AETNA HMO","3377.62","69.8","","1523.63","988.41","4330.26","39","2528.86","3954.43","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4839.00","3629.25","AETNA [1001]","HB AMC AETNA PPO","3890.56","80.4","","1670.25","1670.25","1670.25","1 through 10","2528.86","3954.43","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4839.00","3629.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2528.86","52.26","","1113.10","1113.10","1113.10","1 through 10","2528.86","3954.43","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4839.00","3629.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3954.43","81.72","","1738.90","1484.65","2716.94","38","2528.86","3954.43","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2528.86","52.26","","1113.10","1113.10","1113.10","1 through 10","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3847.01","79.5","","1293.60","1148.53","1603.80","1 through 10","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1766.24","36.5","","1023.42","771.29","2068.67","33","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1853.34","38.3","","850.52","759.78","1211.25","66","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2075.93","42.9","","2548.09","2548.09","2548.09","1 through 10","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2075.93","42.9","","956.46","956.46","956.46","1 through 10","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4839.00","3629.25","WELLPOINT [1015]","HB AMC WELLPOINT","3570.21","73.78","","2344.73","1619.47","2530.35","16","1500.09","3847.01","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4839.00","3629.25","AETNA [1001]","HB AMC AETNA HMO","3377.62","69.8","","1523.63","988.41","4330.26","39","2528.86","3954.43","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4839.00","3629.25","AETNA [1001]","HB AMC AETNA PPO","3890.56","80.4","","1670.25","1670.25","1670.25","1 through 10","2528.86","3954.43","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4839.00","3629.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2528.86","52.26","","1113.10","1113.10","1113.10","1 through 10","2528.86","3954.43","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4839.00","3629.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3954.43","81.72","","1738.90","1484.65","2716.94","38","2528.86","3954.43","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11247.14","79.5","","800.18","480.96","1887.97","195","4385.68","11247.14","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7540.54","53.3","","813.12","216.42","1444.50","81","4385.68","11247.14","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4385.68","31","","432.60","432.60","432.60","1 through 10","4385.68","11247.14","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5163.78","36.5","","148.37","54.89","631.39","94","4385.68","11247.14","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5418.44","38.3","","279.30","91.72","1116.77","266","4385.68","11247.14","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6069.21","42.9","","731.00","63.70","731.00","1 through 10","4385.68","11247.14","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6069.21","42.9","","384.74","384.74","384.74","1 through 10","4385.68","11247.14","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","14147.35","10610.51","WELLPOINT [1015]","HB AMC WELLPOINT","10437.91","73.78","","286.63","119.22","1107.45","105","4385.68","11247.14","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14147.35","10610.51","AETNA [1001]","HB AMC AETNA HMO","9874.85","69.8","","675.31","184.75","1721.50","286","7393.41","11561.21","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14147.35","10610.51","AETNA [1001]","HB AMC AETNA PPO","11374.47","80.4","","1261.44","103.12","1514.10","21","7393.41","11561.21","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14147.35","10610.51","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","11374.47","80.4","","1365.00","1365.00","1365.00","1 through 10","7393.41","11561.21","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14147.35","10610.51","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","11561.21","81.72","","5157.68","5157.68","5157.68","1 through 10","7393.41","11561.21","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14147.35","10610.51","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11561.21","81.72","","431.26","71.26","1459.57","88","7393.41","11561.21","percent of total billed charges",""
"TRAY SET 65CMX7FR PEDIATRIC DOUBLE LUMEN CATH CENTRL VEN TUNNELED INTRO SILCONE NON COTD SURECUFF PWR INJ","SUP-ITM-10000065","CDM","C1751","HCPCS","0272","RC","","","","both","","","497.00","372.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","347.90","70","","1389.50","602.17","3167.85","27","154.07","395.12","percent of total billed charges",""
"TRAY SET 65CMX7FR PEDIATRIC DOUBLE LUMEN CATH CENTRL VEN TUNNELED INTRO SILCONE NON COTD SURECUFF PWR INJ","SUP-ITM-10000065","CDM","C1751","HCPCS","0272","RC","","","","both","","","497.00","372.75","WELLPOINT [1015]","HB AMC WELLPOINT","366.69","73.78","","1089.20","218.86","1089.20","1 through 10","154.07","395.12","percent of total billed charges",""
"TRAY SET 65CMX7FR PEDIATRIC DOUBLE LUMEN CATH CENTRL VEN TUNNELED INTRO SILCONE NON COTD SURECUFF PWR INJ","SUP-ITM-10000065","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","497.00","372.75","AETNA [1001]","HB AMC AETNA HMO","346.91","69.8","","1389.50","940.69","1389.50","1 through 10","259.73","406.15","percent of total billed charges",""
"TRAY SET 65CMX7FR PEDIATRIC DOUBLE LUMEN CATH CENTRL VEN TUNNELED INTRO SILCONE NON COTD SURECUFF PWR INJ","SUP-ITM-10000065","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","497.00","372.75","AETNA [1001]","HB AMC AETNA PPO","399.59","80.4","","190.26","190.26","190.26","1 through 10","259.73","406.15","percent of total billed charges",""
"TRAY SET 65CMX7FR PEDIATRIC DOUBLE LUMEN CATH CENTRL VEN TUNNELED INTRO SILCONE NON COTD SURECUFF PWR INJ","SUP-ITM-10000065","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","497.00","372.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","406.15","81.72","","1110.77","235.00","1169.52","1 through 10","259.73","406.15","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1209.95","52.26","","1113.10","1113.10","1113.10","1 through 10","717.73","1840.62","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1840.62","79.5","","1293.60","1148.53","1603.80","1 through 10","717.73","1840.62","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","845.07","36.5","","1023.42","771.29","2068.67","33","717.73","1840.62","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","886.74","38.3","","850.52","759.78","1211.25","66","717.73","1840.62","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.24","42.9","","2548.09","2548.09","2548.09","1 through 10","717.73","1840.62","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.24","42.9","","956.46","956.46","956.46","1 through 10","717.73","1840.62","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","2315.25","1736.44","WELLPOINT [1015]","HB AMC WELLPOINT","1708.19","73.78","","2344.73","1619.47","2530.35","16","717.73","1840.62","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","AETNA [1001]","HB AMC AETNA HMO","1616.04","69.8","","1523.63","988.41","4330.26","39","1209.95","1892.02","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","AETNA [1001]","HB AMC AETNA PPO","1861.46","80.4","","1670.25","1670.25","1670.25","1 through 10","1209.95","1892.02","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1209.95","52.26","","1113.10","1113.10","1113.10","1 through 10","1209.95","1892.02","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2315.25","1736.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1892.02","81.72","","1738.90","1484.65","2716.94","38","1209.95","1892.02","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.77","396.82","427.78","107","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1821.71","65.6","","1823.16","1823.16","1823.16","1 through 10","412.99","2207.72","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","1805.05","65","","2119.39","2119.39","2119.39","1 through 10","412.99","2207.72","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1943.90","70","","1157.99","494.90","2693.00","18","412.99","2207.72","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2207.72","79.5","","2119.39","2119.39","2119.39","55","412.99","2207.72","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1480.14","53.3","","2119.39","614.45","6358.17","65","412.99","2207.72","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.78","396.82","427.78","45","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","FALLON HEALTH [1008]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","434.73","426.04","434.73","1 through 10","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","428.65","428.64","950.22","1 through 10","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","2138.29","77","","2073.61","2073.61","2073.61","1 through 10","412.99","2207.72","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.77","427.77","427.77","1 through 10","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","HUMANA [1012]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","426.04","426.04","427.77","11","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","1999.44","72","","7755.84","5816.88","7755.84","1 through 10","412.99","2207.72","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","428.64","426.04","428.64","1 through 10","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","MEDICARE [2001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","434.73","434.73","434.73","1283","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","860.87","31","","832.14","832.14","832.14","1 through 10","412.99","2207.72","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1013.61","36.5","","1004.49","853.68","1004.49","41","412.99","2207.72","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1063.59","38.3","","1052.96","1052.96","1052.96","133","412.99","2207.72","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.24","395.20","427.24","1 through 10","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","MOLINA [1014]","HB BWH MOLINA","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","862.50","862.50","862.50","12","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","2138.29","77","","2119.39","296.23","2119.39","1 through 10","412.99","2207.72","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","TRICARE [160005]","HB BWH TRICARE","412.99","","APC Price ($434.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","412.99","412.99","434.73","1 through 10","412.99","2207.72","other","Tricare OPPS"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","412.99","","APC Price ($434.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","434.73","434.73","434.73","1 through 10","412.99","2207.72","other","Tricare OPPS"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","426.04","395.21","1278.11","119","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","619.39","619.39","619.39","1 through 10","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1191.33","42.9","","1184.11","1184.11","2152.79","14","412.99","2207.72","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","425.99","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","426.04","395.41","427.78","179","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2777.00","2082.75","WELLSENSE [1003]","HB BWH MEDICARE","434.69","","APC Price ($434.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","439.08","439.08","439.08","1 through 10","412.99","2207.72","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","outpatient","","","2777.00","2082.75","AETNA [1001]","HB AMC AETNA HMO","1938.35","69.8","","1823.16","1287.25","2693.00","1 through 10","875.35","2269.36","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","outpatient","","","2777.00","2082.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1451.26","52.26","","1666.43","1666.43","1666.43","1 through 10","875.35","2269.36","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","outpatient","","","2777.00","2082.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2232.71","80.4","","5620.55","1750.45","5620.55","1 through 10","875.35","2269.36","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","outpatient","","","2777.00","2082.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","2269.36","81.72","","2152.78","2152.78","2152.78","1 through 10","875.35","2269.36","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","outpatient","","","2777.00","2082.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2269.36","81.72","","2152.78","2152.78","2152.78","1 through 10","875.35","2269.36","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","outpatient","","","2777.00","2082.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2269.36","81.72","","2152.78","1184.11","4305.57","76","875.35","2269.36","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.15","155.15","155.15","44","149.79","1074.05","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1074.05","79.5","","1030.97","691.68","1030.97","16","149.79","1074.05","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","720.08","53.3","","1030.97","536.14","1030.97","1 through 10","149.79","1074.05","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.15","131.14","155.15","1 through 10","149.79","1074.05","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","ELDER SERVICES [1037]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","157.67","157.67","157.67","1 through 10","149.79","1074.05","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","FALLON HEALTH [1008]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","157.67","154.52","157.67","1 through 10","149.79","1074.05","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","155.15","155.15","155.15","1 through 10","149.79","1074.05","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","HUMANA [1012]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","154.52","154.52","155.46","1 through 10","149.79","1074.05","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","972.72","72","","943.20","943.20","943.20","1 through 10","149.79","1074.05","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","154.52","154.52","155.46","1 through 10","149.79","1074.05","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","MEDICARE [2001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","157.67","157.67","444.27","285","149.79","1074.05","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","493.12","36.5","","488.63","488.63","488.63","1 through 10","149.79","1074.05","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","517.43","38.3","","512.21","512.21","1536.63","39","149.79","1074.05","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","157.66","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","154.52","154.52","154.52","1 through 10","149.79","1074.05","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","MOLINA [1014]","HB BWH MOLINA","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","312.82","157.67","312.82","11","149.79","1074.05","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","154.52","145.13","463.56","32","149.79","1074.05","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","301.30","301.30","301.30","1 through 10","149.79","1074.05","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","579.58","42.9","","576.01","576.01","576.01","1 through 10","149.79","1074.05","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","154.50","","APC Price ($157.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","154.52","145.13","155.15","41","149.79","1074.05","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","1351.00","1013.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","579.58","42.9","","576.01","576.01","576.01","1 through 10","149.79","1074.05","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","outpatient","","","1351.00","1013.25","AETNA [1001]","HB AMC AETNA HMO","943.00","69.8","","886.87","626.18","886.87","1 through 10","336.65","1239.61","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","outpatient","","","1351.00","1013.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","706.03","52.26","","810.63","810.63","810.63","1 through 10","336.65","1239.61","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","outpatient","","","1351.00","1013.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1104.04","81.72","","1047.21","576.01","1047.21","24","336.65","1239.61","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0300","RC","","","","inpatient","","","155.00","116.25","AETNA [1001]","HB AMC AETNA HMO","107.11","69.1","","71.70","71.70","71.70","1 through 10","85.72","123.23","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","111.29","71.8","","323.10","107.70","323.10","20","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","101.68","65.6","","101.55","101.55","117.00","1 through 10","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","100.75","65","","97.50","97.50","97.50","1 through 10","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","108.50","70","","150.00","108.00","324.00","17","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","CHAMPVA [160001]","HB BWH TRICARE","147.25","95","","15.95","15.95","15.95","1 through 10","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","123.23","79.5","","118.05","79.20","118.05","503","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","82.62","53.3","","118.05","79.20","237.60","204","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","119.35","77","","115.50","115.50","115.50","1 through 10","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","100.75","65","","97.50","97.50","133.90","1 through 10","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","123.23","79.5","","118.05","118.05","118.05","1 through 10","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.05","31","","46.35","46.35","139.05","17","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56.58","36.5","","55.95","47.55","162.90","570","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","59.37","38.3","","58.65","57.00","175.95","2054","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","MOLINA [1014]","HB BWH MOLINA","54.25","35","","26.27","26.27","26.27","1 through 10","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","119.35","77","","122.00","18.54","122.00","1 through 10","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","TRICARE [160005]","HB BWH TRICARE","147.25","95","","15.95","15.15","15.95","80","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.50","42.9","","119.91","65.96","269.91","21","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.50","42.9","","65.96","65.96","65.96","1 through 10","12.98","147.25","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","155.00","116.25","AETNA [1001]","HB AMC AETNA HMO","108.19","69.8","","101.55","71.70","117.00","806","13.65","126.67","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","155.00","116.25","AETNA [1001]","HB AMC AETNA PPO","124.62","80.4","","117.00","78.60","157.20","90","13.65","126.67","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","155.00","116.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","86.65","55.9","","78.60","78.60","78.60","1 through 10","13.65","126.67","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","155.00","116.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","81.00","52.26","","46.40","46.40","92.82","1 through 10","13.65","126.67","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","124.62","80.4","","75.00","75.00","75.00","1 through 10","13.65","126.67","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","126.67","81.72","","150.00","119.91","150.00","1 through 10","13.65","126.67","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","126.67","81.72","","65.96","65.96","119.92","21","13.65","126.67","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","126.67","81.72","","119.91","65.96","119.91","578","13.65","126.67","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2077.34","52.26","","1113.10","1113.10","1113.10","1 through 10","1232.25","3160.13","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3160.13","79.5","","1293.60","1148.53","1603.80","1 through 10","1232.25","3160.13","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1450.88","36.5","","1023.42","771.29","2068.67","33","1232.25","3160.13","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1522.43","38.3","","850.52","759.78","1211.25","66","1232.25","3160.13","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1705.28","42.9","","2548.09","2548.09","2548.09","1 through 10","1232.25","3160.13","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1705.28","42.9","","956.46","956.46","956.46","1 through 10","1232.25","3160.13","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3975.00","2981.25","WELLPOINT [1015]","HB AMC WELLPOINT","2932.76","73.78","","2344.73","1619.47","2530.35","16","1232.25","3160.13","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3975.00","2981.25","AETNA [1001]","HB AMC AETNA HMO","2774.55","69.8","","1523.63","988.41","4330.26","39","2077.34","3248.37","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3975.00","2981.25","AETNA [1001]","HB AMC AETNA PPO","3195.90","80.4","","1670.25","1670.25","1670.25","1 through 10","2077.34","3248.37","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3975.00","2981.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2077.34","52.26","","1113.10","1113.10","1113.10","1 through 10","2077.34","3248.37","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3975.00","2981.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3248.37","81.72","","1738.90","1484.65","2716.94","38","2077.34","3248.37","percent of total billed charges",""
"Triamcinolone Ace Inj 10mg","PX-63600188","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.98","6.73","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","6.91","77","","3.64","3.64","3.64","1 through 10","2.78","6.91","percent of total billed charges",""
"Triamcinolone Ace Inj 10mg","PX-63600188","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.98","6.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2.78","31","","2.94","0.15","4.88","1 through 10","2.78","6.91","percent of total billed charges",""
"Triamcinolone Ace Inj 10mg","PX-63600188","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.98","6.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3.28","36.5","","1.26","0.73","3.39","218","2.78","6.91","percent of total billed charges",""
"Triamcinolone Ace Inj 10mg","PX-63600188","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.98","6.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3.44","38.3","","1.43","0.77","3.72","759","2.78","6.91","percent of total billed charges",""
"Triamcinolone Ace Inj 10mg","PX-63600188","CDM","J3301","HCPCS","0636","RC","","","","outpatient","","","8.98","6.73","AETNA [1001]","HB AMC AETNA HMO","6.27","69.8","","3.18","0.94","6.36","101","1.85","7.22","percent of total billed charges",""
"Triamcinolone Ace Inj 10mg","PX-63600188","CDM","J3301","HCPCS","0636","RC","","","","outpatient","","","8.98","6.73","AETNA [1001]","HB AMC AETNA PPO","7.22","80.4","","2.65","0.74","2.65","13","1.85","7.22","percent of total billed charges",""
"Triamcinolone Ace Inj 10mg","PX-63600188","CDM","J3301","HCPCS","0636","RC","","","","outpatient","","","8.98","6.73","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","5.02","55.9","","4.94","2.49","4.94","1 through 10","1.85","7.22","percent of total billed charges",""
"Triamcinolone Ace Inj 10mg","PX-63600188","CDM","J3301","HCPCS","0636","RC","","","","outpatient","","","8.98","6.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6.28","69.9","","2.34","0.87","5.50","61","1.85","7.22","percent of total billed charges",""
"Triamcinolone Ace Inj 10mg","PX-63600188","CDM","J3301","HCPCS","0636","RC","","","","outpatient","","","8.98","6.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4.21","46.9","","3.37","0.20","7.66","33","1.85","7.22","percent of total billed charges",""
"Triamcinolone Ace Inj 10mg","PX-63600188","CDM","J3301","HCPCS","0636","RC","","","","outpatient","","","8.98","6.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7.22","80.4","","15.09","15.09","15.09","1 through 10","1.85","7.22","percent of total billed charges",""
"Triamcinolone Ace Vl 40mg/Ml 1ml","PX-63600331","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.98","6.73","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","6.91","77","","3.64","3.64","3.64","1 through 10","2.78","6.91","percent of total billed charges",""
"Triamcinolone Ace Vl 40mg/Ml 1ml","PX-63600331","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.98","6.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","2.78","31","","2.94","0.15","4.88","1 through 10","2.78","6.91","percent of total billed charges",""
"Triamcinolone Ace Vl 40mg/Ml 1ml","PX-63600331","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.98","6.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3.28","36.5","","1.26","0.73","3.39","218","2.78","6.91","percent of total billed charges",""
"Triamcinolone Ace Vl 40mg/Ml 1ml","PX-63600331","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.98","6.73","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3.44","38.3","","1.43","0.77","3.72","759","2.78","6.91","percent of total billed charges",""
"Triamcinolone Ace Vl 40mg/Ml 1ml","PX-63600331","CDM","J3301","HCPCS","0636","RC","","","","outpatient","","","8.98","6.73","AETNA [1001]","HB AMC AETNA HMO","6.27","69.8","","3.18","0.94","6.36","101","1.85","7.22","percent of total billed charges",""
"Triamcinolone Ace Vl 40mg/Ml 1ml","PX-63600331","CDM","J3301","HCPCS","0636","RC","","","","outpatient","","","8.98","6.73","AETNA [1001]","HB AMC AETNA PPO","7.22","80.4","","2.65","0.74","2.65","13","1.85","7.22","percent of total billed charges",""
"Triamcinolone Ace Vl 40mg/Ml 1ml","PX-63600331","CDM","J3301","HCPCS","0636","RC","","","","outpatient","","","8.98","6.73","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","5.02","55.9","","4.94","2.49","4.94","1 through 10","1.85","7.22","percent of total billed charges",""
"Triamcinolone Ace Vl 40mg/Ml 1ml","PX-63600331","CDM","J3301","HCPCS","0636","RC","","","","outpatient","","","8.98","6.73","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6.28","69.9","","2.34","0.87","5.50","61","1.85","7.22","percent of total billed charges",""
"Triamcinolone Ace Vl 40mg/Ml 1ml","PX-63600331","CDM","J3301","HCPCS","0636","RC","","","","outpatient","","","8.98","6.73","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4.21","46.9","","3.37","0.20","7.66","33","1.85","7.22","percent of total billed charges",""
"Triamcinolone Ace Vl 40mg/Ml 1ml","PX-63600331","CDM","J3301","HCPCS","0636","RC","","","","outpatient","","","8.98","6.73","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7.22","80.4","","15.09","15.09","15.09","1 through 10","1.85","7.22","percent of total billed charges",""
"Trichinella Antibody","PX-30001004","CDM","86784","CPT","0302","RC","","","","outpatient","","","212.00","159.00","AETNA [1001]","HB AMC AETNA HMO","147.98","69.8","","98.47","98.47","98.47","1 through 10","12.96","173.25","percent of total billed charges",""
"Trichinella Antibody","PX-30001004","CDM","86784","CPT","0302","RC","","","","outpatient","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","173.25","81.72","","90.58","90.58","90.58","1 through 10","12.96","173.25","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","both","","","101.00","75.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","70.70","70","","70.56","70.56","70.56","1 through 10","5.63","95.95","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","both","","","101.00","75.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","80.30","79.5","","77.13","51.74","231.39","15","5.63","95.95","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","both","","","101.00","75.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","53.83","53.3","","77.13","51.74","77.13","11","5.63","95.95","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","both","","","101.00","75.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","36.87","36.5","","31.07","31.07","31.07","1 through 10","5.63","95.95","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","both","","","101.00","75.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","38.68","38.3","","38.32","37.24","38.32","44","5.63","95.95","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","both","","","101.00","75.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","77.77","77","","77.13","77.13","77.13","1 through 10","5.63","95.95","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","both","","","101.00","75.75","TRICARE [160005]","HB BWH TRICARE","95.95","95","","6.92","6.92","6.92","1 through 10","5.63","95.95","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","both","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.33","42.9","","78.34","78.34","78.34","1 through 10","5.63","95.95","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","outpatient","","","101.00","75.75","AETNA [1001]","HB AMC AETNA HMO","70.50","69.8","","66.35","46.84","66.35","23","5.92","82.54","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","outpatient","","","101.00","75.75","AETNA [1001]","HB AMC AETNA PPO","81.20","80.4","","76.44","76.44","76.44","1 through 10","5.92","82.54","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","outpatient","","","101.00","75.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","81.20","80.4","","76.44","76.44","76.44","1 through 10","5.92","82.54","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","outpatient","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","82.54","81.72","","78.34","43.09","78.34","20","5.92","82.54","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","both","","","205.00","153.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","162.98","79.5","","156.61","156.61","156.61","23","16.6","194.75","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","both","","","205.00","153.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","109.27","53.3","","105.07","105.07","105.07","1 through 10","16.6","194.75","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","74.83","36.5","","74.23","63.08","74.23","1 through 10","16.6","194.75","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","both","","","205.00","153.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","78.52","38.3","","77.81","75.62","233.43","23","16.6","194.75","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","both","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.95","42.9","","87.50","87.50","87.50","1 through 10","16.6","194.75","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","205.00","153.75","AETNA [1001]","HB AMC AETNA HMO","143.09","69.8","","134.72","95.12","134.72","14","17.47","167.53","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","205.00","153.75","AETNA [1001]","HB AMC AETNA PPO","164.82","80.4","","155.22","155.22","155.22","1 through 10","17.47","167.53","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","167.53","81.72","","159.08","87.50","159.08","1 through 10","17.47","167.53","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","167.53","81.72","","159.08","159.08","218.88","1 through 10","17.47","167.53","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","133.79","89.76","133.79","1 through 10","15.44","166.25","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","both","","","175.00","131.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.28","53.3","","89.76","89.76","89.76","1 through 10","15.44","166.25","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","63.41","63.41","63.41","1 through 10","15.44","166.25","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","66.47","66.47","66.47","1 through 10","15.44","166.25","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","74.75","74.75","74.75","1 through 10","15.44","166.25","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","81.26","81.26","132.60","1 through 10","15.7","143.01","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA PPO","140.70","80.4","","132.60","132.60","132.60","1 through 10","15.7","143.01","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.01","81.72","","135.90","74.75","135.90","1 through 10","15.7","143.01","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","135.90","74.75","135.90","1 through 10","15.7","143.01","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","181.00","135.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","126.70","70","","380.16","380.16","380.16","1 through 10","13.9","171.95","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","181.00","135.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","143.90","79.5","","138.51","92.93","138.51","78","13.9","171.95","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","181.00","135.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","96.47","53.3","","92.93","92.93","138.51","31","13.9","171.95","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","181.00","135.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","56.11","31","","54.38","54.38","54.38","1 through 10","13.9","171.95","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","181.00","135.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","66.07","36.5","","65.65","55.79","191.13","56","13.9","171.95","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","181.00","135.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","69.32","38.3","","68.82","68.82","206.46","141","13.9","171.95","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","181.00","135.75","MOLINA [1014]","HB BWH MOLINA","63.35","35","","28.13","28.13","28.13","1 through 10","13.9","171.95","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.65","42.9","","140.69","140.69","140.69","1 through 10","13.9","171.95","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","181.00","135.75","AETNA [1001]","HB AMC AETNA HMO","126.34","69.8","","119.15","84.13","137.28","80","14.61","147.91","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","181.00","135.75","AETNA [1001]","HB AMC AETNA PPO","145.52","80.4","","137.28","92.22","184.44","13","14.61","147.91","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","181.00","135.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","101.18","55.9","","117.90","92.22","117.90","1 through 10","14.61","147.91","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","181.00","135.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","94.59","52.26","","50.53","50.53","50.53","1 through 10","14.61","147.91","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","147.91","81.72","","140.69","77.39","140.69","1 through 10","14.61","147.91","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","147.91","81.72","","140.69","77.39","140.69","56","14.61","147.91","percent of total billed charges",""
"Trimethoprim, Serum","PX-31000757","CDM","80299","CPT","0301","RC","","","","both","","","76.00","57.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","60.42","79.5","","106.25","71.28","106.25","1 through 10","14.12","72.2","percent of total billed charges",""
"Trimethoprim, Serum","PX-31000757","CDM","80299","CPT","0301","RC","","","","both","","","76.00","57.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","40.51","53.3","","106.25","71.28","106.25","1 through 10","14.12","72.2","percent of total billed charges",""
"Trimethoprim, Serum","PX-31000757","CDM","80299","CPT","0301","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.74","36.5","","50.36","42.80","92.50","13","14.12","72.2","percent of total billed charges",""
"Trimethoprim, Serum","PX-31000757","CDM","80299","CPT","0301","RC","","","","both","","","76.00","57.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.11","38.3","","52.79","44.55","158.37","30","14.12","72.2","percent of total billed charges",""
"Trimethoprim, Serum","PX-31000757","CDM","80299","CPT","0301","RC","","","","outpatient","","","76.00","57.00","AETNA [1001]","HB AMC AETNA HMO","53.05","69.8","","91.40","64.53","105.30","14","14.12","114.26","percent of total billed charges",""
"Trimethoprim, Serum","PX-31000757","CDM","80299","CPT","0301","RC","","","","outpatient","","","76.00","57.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","61.10","80.4","","105.30","105.30","105.30","1 through 10","14.12","114.26","percent of total billed charges",""
"Trimethoprim, Serum","PX-31000757","CDM","80299","CPT","0301","RC","","","","outpatient","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","62.11","81.72","","59.36","15.50","59.36","1 through 10","14.12","114.26","percent of total billed charges",""
"Trimethylaminuria via the Fmo3 Gene","PX-31000677","CDM","81479","CPT","0310","RC","","","","both","","","1283.00","962.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1019.99","79.5","","0.65","0.65","0.65","1 through 10","397.73","1218.85","percent of total billed charges",""
"Trimethylaminuria via the Fmo3 Gene","PX-31000677","CDM","81479","CPT","0310","RC","","","","both","","","1283.00","962.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","683.84","53.3","","0.79","0.79","0.79","1 through 10","397.73","1218.85","percent of total billed charges",""
"Trimethylaminuria via the Fmo3 Gene","PX-31000677","CDM","81479","CPT","0310","RC","","","","outpatient","","","1283.00","962.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","641.50","50","","1.00","1.00","1.00","1 through 10","156.55","1058.48","percent of total billed charges",""
"Trimethylaminuria via the Fmo3 Gene","PX-31000677","CDM","81479","CPT","0310","RC","","","","outpatient","","","1283.00","962.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","673.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","1058.48","percent of total billed charges",""
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","both","","","57.00","42.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","72.65","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","54.70","6.80","54.70","1 through 10","17.67","88.17","other","OPPS APC"
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","both","","","57.00","42.75","MEDICARE [2001]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","66.76","66.76","66.76","1 through 10","17.67","88.17","other","OPPS APC"
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","both","","","57.00","42.75","MEDICARE ALTERNATE [2002]","HB BWH MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7.57","7.57","7.57","21","17.67","88.17","other","OPPS APC"
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","both","","","57.00","42.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","20.81","36.5","","17.44","9.83","20.52","1 through 10","17.67","88.17","percent of total billed charges",""
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","both","","","57.00","42.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","69.12","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.13","7.42","69.13","53","17.67","88.17","other","OPPS APC"
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","outpatient","","","57.00","42.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","63.92","","Case rate ($63.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","95.42","95.42","95.42","1 through 10","19.44","247.15","other","ASC "
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","outpatient","","","57.00","42.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","55.90","","Case rate ($55.90). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","64.85","4.51","129.69","1 through 10","19.44","247.15","other","Multiple Surgery"
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","outpatient","","","216.00","162.00","AETNA [1001]","HB AMC AETNA HMO","150.77","69.8","","141.49","141.49","141.49","1 through 10","55.9","350.18","percent of total billed charges",""
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","outpatient","","","216.00","162.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","63.92","","Case rate ($63.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","149.64","148.17","149.64","1 through 10","55.9","350.18","other","ASC "
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","outpatient","","","216.00","162.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","55.90","","Case rate ($55.90). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","136.40","136.40","136.40","1 through 10","55.9","350.18","other","Multiple Surgery"
"Trlml Balo Angiop Open/Perq Img S&I 1st Art","PX-36000416","CDM","37246","CPT","0361","RC","","","","both","","","9291.00","6968.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6634.81","","APC Price ($6,770.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13205.26","6643.39","13205.26","1 through 10","2880.21","8462.77","other","OPPS APC"
"Trlml Balo Angiop Open/Perq W/Img S&I 1st Vein","PX-36000418","CDM","37248","CPT","0361","RC","","","","both","","","8431.00","6323.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6634.81","","APC Price ($6,770.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6642.99","6642.99","6642.99","1 through 10","2613.61","8462.77","other","OPPS APC"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","8029.00","6021.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","4477.60","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4473.70","4473.70","4473.70","1 through 10","2488.99","6383.06","other","OPPS APC"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","8029.00","6021.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6383.06","79.5","","37896.14","5539.50","37896.14","1 through 10","2488.99","6383.06","percent of total billed charges",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","8029.00","6021.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4279.46","53.3","","12638.43","7098.94","12638.43","1 through 10","2488.99","6383.06","percent of total billed charges",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","8029.00","6021.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","4347.18","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4278.06","4278.06","4278.06","1 through 10","2488.99","6383.06","other","OPPS APC"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","8029.00","6021.75","MEDICARE [2001]","HB BWH MEDICARE","4347.18","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4347.62","3915.62","11746.86","34","2488.99","6383.06","other","OPPS APC"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","8029.00","6021.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2930.59","36.5","","6949.74","5718.84","9141.30","1 through 10","2488.99","6383.06","percent of total billed charges",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","8029.00","6021.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3075.11","38.3","","6999.88","3044.33","7770.80","1 through 10","2488.99","6383.06","percent of total billed charges",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","8029.00","6021.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","4260.24","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","12782.01","3840.31","12782.01","1 through 10","2488.99","6383.06","other","OPPS APC"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","8029.00","6021.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","4260.24","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4263.31","4260.67","4347.62","1 through 10","2488.99","6383.06","other","OPPS APC"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","8029.00","6021.75","AETNA [1001]","HB AMC AETNA HMO","5604.24","69.8","","10251.27","3429.65","16377.98","1 through 10","2766.13","9843.6","percent of total billed charges",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","8029.00","6021.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","3163.23","","Case rate ($3,163.23). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3235.99","3177.47","6471.97","18","2766.13","9843.6","other","ASC"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","8029.00","6021.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","3163.23","","Case rate ($3,163.23). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","3702.56","3666.19","7405.12","33","2766.13","9843.6","other","ASC "
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","8029.00","6021.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","6417.42","3208.71","19252.26","14","2766.13","9843.6","other","Multiple Surgery"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","8029.00","6021.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","20248.08","6500.41","20248.08","1 through 10","2766.13","9843.6","other","Multiple Surgery"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","8029.00","6021.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","8021.78","8021.78","8021.78","1 through 10","2766.13","9843.6","other","Multiple Surgery"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","8029.00","6021.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6561.30","81.72","","7006.53","3402.34","15367.27","1 through 10","2766.13","9843.6","percent of total billed charges",""
"Trnsf Tissue Any Area Ea Addl 30","PX-76000163","CDM","14302","CPT","0761","RC","","","","both","","","1713.00","1284.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1361.84","79.5","","41154.42","7878.66","41154.42","1 through 10","531.03","1361.84","percent of total billed charges",""
"Trnsf Tissue Any Area Ea Addl 30","PX-76000163","CDM","14302","CPT","0761","RC","","","","both","","","1713.00","1284.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","913.03","53.3","","7098.94","7098.94","7098.94","1 through 10","531.03","1361.84","percent of total billed charges",""
"Trnsf Tissue Any Area Ea Addl 30","PX-76000163","CDM","14302","CPT","0761","RC","","","","both","","","1713.00","1284.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","625.25","36.5","","6949.74","5718.84","9141.30","1 through 10","531.03","1361.84","percent of total billed charges",""
"Trnsf Tissue Any Area Ea Addl 30","PX-76000163","CDM","14302","CPT","0761","RC","","","","both","","","1713.00","1284.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","656.08","38.3","","6999.88","4417.32","7770.79","1 through 10","531.03","1361.84","percent of total billed charges",""
"Trnsf Tissue Any Area Ea Addl 30","PX-76000163","CDM","14302","CPT","0761","RC","","","","outpatient","","","1713.00","1284.75","AETNA [1001]","HB AMC AETNA HMO","1195.67","69.8","","16377.98","5506.04","16377.98","1 through 10","373.2","1399.86","percent of total billed charges",""
"Trnsf Tissue Any Area Ea Addl 30","PX-76000163","CDM","14302","CPT","0761","RC","","","","outpatient","","","1713.00","1284.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1399.86","81.72","","7006.53","6418.78","15367.27","1 through 10","373.2","1399.86","percent of total billed charges",""
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","both","","","4870.00","3652.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2237.26","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2235.32","2235.32","2235.32","1 through 10","1509.7","3871.65","other","OPPS APC"
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","both","","","4870.00","3652.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2137.56","2137.56","2137.56","1 through 10","1509.7","3871.65","other","OPPS APC"
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","both","","","4870.00","3652.50","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","37","1509.7","3871.65","other","OPPS APC"
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","both","","","4870.00","3652.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1865.21","38.3","","1846.69","1846.69","1846.69","1 through 10","1509.7","3871.65","percent of total billed charges",""
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","both","","","4870.00","3652.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2128.87","2128.87","2128.87","1 through 10","1509.7","3871.65","other","OPPS APC"
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","both","","","4870.00","3652.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2134.78","1950.54","2136.78","1 through 10","1509.7","3871.65","other","OPPS APC"
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","both","","","4870.00","3652.50","WELLPOINT [1015]","HB AMC WELLPOINT","3593.09","73.78","","3516.27","3516.27","3516.27","1 through 10","1509.7","3871.65","percent of total billed charges",""
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3558.58","3558.58","4105.92","1 through 10","1548.96","8899.59","other","ASC"
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4105.92","4105.92","4146.66","11","1548.96","8899.59","other","ASC "
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3593.59","1727.09","10780.77","1 through 10","1548.96","8899.59","other","Multiple Surgery"
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","11338.38","3779.46","11338.38","1 through 10","1548.96","8899.59","other","Multiple Surgery"
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3965.34","3965.34","3965.34","1 through 10","1548.96","8899.59","other","Multiple Surgery"
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3915.48","80.4","","3683.94","3683.94","3683.94","1 through 10","1548.96","8899.59","percent of total billed charges",""
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3979.76","81.72","","3775.57","1577.42","7000.00","1 through 10","1548.96","8899.59","percent of total billed charges",""
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","both","","","6870.00","5152.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2237.26","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2236.60","2049.56","2236.60","1 through 10","2063.7","5461.65","other","OPPS APC"
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","both","","","6870.00","5152.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","4809.00","70","","6662.00","6662.00","6662.00","1 through 10","2063.7","5461.65","percent of total billed charges",""
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","both","","","6870.00","5152.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3661.71","53.3","","21143.23","21143.23","21143.23","1 through 10","2063.7","5461.65","percent of total billed charges",""
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","both","","","6870.00","5152.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","885.65","885.65","885.65","1 through 10","2063.7","5461.65","other","OPPS APC"
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","both","","","6870.00","5152.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","4465.50","65","","4330.30","3530.86","4330.30","1 through 10","2063.7","5461.65","percent of total billed charges",""
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","both","","","6870.00","5152.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","5461.65","79.5","","1917.24","1917.24","1917.24","1 through 10","2063.7","5461.65","percent of total billed charges",""
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","both","","","6870.00","5152.50","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","1990.34","2172.32","1 through 10","2063.7","5461.65","other","OPPS APC"
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","both","","","6870.00","5152.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2130.87","2129.87","2130.87","1 through 10","2063.7","5461.65","other","OPPS APC"
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","outpatient","","","6870.00","5152.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3624.12","3624.12","3624.12","1 through 10","1548.96","8899.59","other","ASC"
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","outpatient","","","6870.00","5152.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4105.92","2052.96","4105.92","1 through 10","1548.96","8899.59","other","ASC "
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","outpatient","","","6870.00","5152.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5523.48","80.4","","3331.00","3331.00","3331.00","1 through 10","1548.96","8899.59","percent of total billed charges",""
"Trnsf Tissue Eye/Nose/Ear/Lip 10-30","PX-76000161","CDM","14061","CPT","0761","RC","","","","outpatient","","","6870.00","5152.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5614.16","81.72","","32011.17","5325.60","32011.17","1 through 10","1548.96","8899.59","percent of total billed charges",""
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","both","","","4870.00","3652.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2237.26","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2244.44","2244.44","2244.44","1 through 10","1509.7","3871.65","other","OPPS APC"
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","both","","","4870.00","3652.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2137.56","2137.56","2137.56","1 through 10","1509.7","3871.65","other","OPPS APC"
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","both","","","4870.00","3652.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3165.50","65","","13148.85","13148.85","13148.85","1 through 10","1509.7","3871.65","percent of total billed charges",""
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","both","","","4870.00","3652.50","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","2172.32","17","1509.7","3871.65","other","OPPS APC"
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","both","","","4870.00","3652.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2128.87","2128.87","2128.87","1 through 10","1509.7","3871.65","other","OPPS APC"
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","both","","","4870.00","3652.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2134.27","2134.27","2134.27","1 through 10","1509.7","3871.65","other","OPPS APC"
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","both","","","4870.00","3652.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2136.38","2133.22","2136.38","1 through 10","1509.7","3871.65","other","OPPS APC"
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3558.58","1779.29","3624.12","1 through 10","1548.96","5545.35","other","ASC"
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4146.66","2073.33","4146.66","1 through 10","1548.96","5545.35","other","ASC "
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","3593.59","3593.59","3593.59","1 through 10","1548.96","5545.35","other","Multiple Surgery"
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","outpatient","","","4870.00","3652.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","3965.34","1982.67","3965.34","1 through 10","1548.96","5545.35","other","Multiple Surgery"
"Trnsf Tissue Head/Hand/Foot 10-30cm","PX-76000159","CDM","14041","CPT","0761","RC","","","","both","","","6349.00","4761.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2237.26","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2235.32","2235.32","2235.32","1 through 10","1968.19","5047.46","other","OPPS APC"
"Trnsf Tissue Head/Hand/Foot 10-30cm","PX-76000159","CDM","14041","CPT","0761","RC","","","","both","","","6349.00","4761.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2137.56","1958.49","2137.56","1 through 10","1968.19","5047.46","other","OPPS APC"
"Trnsf Tissue Head/Hand/Foot 10-30cm","PX-76000159","CDM","14041","CPT","0761","RC","","","","both","","","6349.00","4761.75","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","2172.32","6516.96","26","1968.19","5047.46","other","OPPS APC"
"Trnsf Tissue Head/Hand/Foot 10-30cm","PX-76000159","CDM","14041","CPT","0761","RC","","","","both","","","6349.00","4761.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2317.39","36.5","","18201.66","18201.66","18201.66","1 through 10","1968.19","5047.46","percent of total billed charges",""
"Trnsf Tissue Head/Hand/Foot 10-30cm","PX-76000159","CDM","14041","CPT","0761","RC","","","","both","","","6349.00","4761.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2129.87","2129.87","2129.87","1 through 10","1968.19","5047.46","other","OPPS APC"
"Trnsf Tissue Head/Hand/Foot 10-30cm","PX-76000159","CDM","14041","CPT","0761","RC","","","","both","","","6349.00","4761.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","2128.66","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2172.32","2136.38","2172.32","1 through 10","1968.19","5047.46","other","OPPS APC"
"Trnsf Tissue Head/Hand/Foot 10-30cm","PX-76000159","CDM","14041","CPT","0761","RC","","","","outpatient","","","6349.00","4761.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3558.58","3558.58","3558.58","1 through 10","1548.96","8899.59","other","ASC"
"Trnsf Tissue Head/Hand/Foot 10-30cm","PX-76000159","CDM","14041","CPT","0761","RC","","","","outpatient","","","6349.00","4761.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4105.92","2052.96","4146.66","1 through 10","1548.96","8899.59","other","ASC "
"Trnsf Tissue Head/Hand/Foot 10-30cm","PX-76000159","CDM","14041","CPT","0761","RC","","","","outpatient","","","6349.00","4761.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","10780.77","10780.77","10780.77","1 through 10","1548.96","8899.59","other","Multiple Surgery"
"Trnsf Tissue Head/Hand/Foot 10-30cm","PX-76000159","CDM","14041","CPT","0761","RC","","","","outpatient","","","6349.00","4761.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5188.40","81.72","","4921.91","4921.91","4921.91","1 through 10","1548.96","8899.59","percent of total billed charges",""
"Trnsf Tissue Sclp/Arm/Lg <10cm","PX-76000156","CDM","14020","CPT","0761","RC","","","","both","","","4774.00","3580.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","2237.26","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2235.32","2235.32","2235.32","1 through 10","1479.94","3795.33","other","OPPS APC"
"Trnsf Tissue Sclp/Arm/Lg <10cm","PX-76000156","CDM","14020","CPT","0761","RC","","","","both","","","4774.00","3580.50","WELLPOINT [1015]","HB AMC WELLPOINT","3522.26","73.78","","11867.03","11867.03","11867.03","1 through 10","1479.94","3795.33","percent of total billed charges",""
"Trnsf Tissue Sclp/Arm/Lg <10cm","PX-76000156","CDM","14020","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3624.12","3624.12","3624.12","1 through 10","1548.96","8899.59","other","ASC"
"Trnsf Tissue Sclp/Arm/Lg <10cm","PX-76000156","CDM","14020","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4595.34","2073.33","4595.34","1 through 10","1548.96","8899.59","other","ASC "
"Trnsf Tissue Sclp/Arm/Lg <10cm","PX-76000156","CDM","14020","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","10780.77","10780.77","10780.77","1 through 10","1548.96","8899.59","other","Multiple Surgery"
"Trnsf Tissue Sclp/Arm/Lg <10cm","PX-76000156","CDM","14020","CPT","0761","RC","","","","outpatient","","","4774.00","3580.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3838.30","80.4","","3611.40","3611.40","3611.40","1 through 10","1548.96","8899.59","percent of total billed charges",""
"Trnsf Tissue Sclp/Arm/Lg 10-30cm","PX-76000157","CDM","14021","CPT","0761","RC","","","","both","","","5760.00","4320.00","FALLON HEALTH [1008]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16224.09","16224.09","16224.09","1 through 10","1785.6","4579.2","other","OPPS APC"
"Trnsf Tissue Sclp/Arm/Lg 10-30cm","PX-76000157","CDM","14021","CPT","0761","RC","","","","both","","","5760.00","4320.00","MEDICARE [2001]","HB BWH MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2172.32","1990.34","2172.32","1 through 10","1785.6","4579.2","other","OPPS APC"
"Trnsf Tissue Sclp/Arm/Lg 10-30cm","PX-76000157","CDM","14021","CPT","0761","RC","","","","both","","","5760.00","4320.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2206.08","38.3","","6102.42","6102.42","6102.42","1 through 10","1785.6","4579.2","percent of total billed charges",""
"Trnsf Tissue Sclp/Arm/Lg 10-30cm","PX-76000157","CDM","14021","CPT","0761","RC","","","","both","","","5760.00","4320.00","WELLPOINT [1015]","HB AMC WELLPOINT","4249.73","73.78","","4158.78","4158.78","4158.78","1 through 10","1785.6","4579.2","percent of total billed charges",""
"Trnsf Tissue Sclp/Arm/Lg 10-30cm","PX-76000157","CDM","14021","CPT","0761","RC","","","","outpatient","","","5760.00","4320.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","3624.12","1812.06","3624.12","1 through 10","1548.96","8899.59","other","ASC"
"Trnsf Tissue Sclp/Arm/Lg 10-30cm","PX-76000157","CDM","14021","CPT","0761","RC","","","","outpatient","","","5760.00","4320.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","4105.92","4105.92","4105.92","1 through 10","1548.96","8899.59","other","ASC "
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","both","","","1064.00","798.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","519.13","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","510.87","510.87","510.87","1 through 10","329.84","845.88","other","OPPS APC"
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","both","","","1064.00","798.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","691.60","65","","670.80","544.90","670.80","1 through 10","329.84","845.88","percent of total billed charges",""
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","both","","","1064.00","798.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","744.80","70","","743.04","443.76","1630.56","25","329.84","845.88","percent of total billed charges",""
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","both","","","1064.00","798.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","845.88","79.5","","812.18","812.18","812.18","1 through 10","329.84","845.88","percent of total billed charges",""
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","both","","","1064.00","798.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","519.13","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","510.87","406.99","510.87","1 through 10","329.84","845.88","other","OPPS APC"
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","both","","","1064.00","798.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","519.13","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","512.95","512.95","512.95","1 through 10","329.84","845.88","other","OPPS APC"
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","both","","","1064.00","798.00","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","519.13","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1907.81","1907.81","1907.81","1 through 10","329.84","845.88","other","OPPS APC"
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","both","","","1064.00","798.00","MEDICARE [2001]","HB BWH MEDICARE","519.13","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","519.18","473.79","519.18","20","329.84","845.88","other","OPPS APC"
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","both","","","1064.00","798.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","519.13","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.80","508.80","508.80","1 through 10","329.84","845.88","other","OPPS APC"
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","both","","","1064.00","798.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","508.74","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","519.18","473.79","519.18","1 through 10","329.84","845.88","other","OPPS APC"
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","both","","","1064.00","798.00","WELLPOINT [1015]","HB AMC WELLPOINT","785.02","73.78","","768.32","768.32","768.32","1 through 10","329.84","845.88","percent of total billed charges",""
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","both","","","1064.00","798.00","WELLSENSE [1003]","HB BWH MEDICARE","519.13","","APC Price ($519.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","524.37","524.37","524.37","1 through 10","329.84","845.88","other","OPPS APC"
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","outpatient","","","1064.00","798.00","AETNA [1001]","HB AMC AETNA HMO","742.67","69.8","","1032.00","698.66","1032.00","11","437.87","1466.51","percent of total billed charges",""
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","outpatient","","","1064.00","798.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","437.87","","Case rate ($437.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","879.68","879.68","895.88","12","437.87","1466.51","other","ASC"
"Trnspl Cryopres/Store Progen Cell","PX-76001187","CDM","38207","CPT","0362","RC","","","","outpatient","","","1064.00","798.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","437.87","","Case rate ($437.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","1014.98","1014.98","1025.05","43","437.87","1466.51","other","ASC "
"TROCHANTER PLATE 131.0MM UNIVERSAL STABILIZATION UNIV LOCKING","SUP-ITM-10037419","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1939.63","79.5","","800.18","480.96","1887.97","195","756.33","1939.63","percent of total billed charges",""
"TROCHANTER PLATE 131.0MM UNIVERSAL STABILIZATION UNIV LOCKING","SUP-ITM-10037419","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1300.40","53.3","","813.12","216.42","1444.50","81","756.33","1939.63","percent of total billed charges",""
"TROCHANTER PLATE 131.0MM UNIVERSAL STABILIZATION UNIV LOCKING","SUP-ITM-10037419","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","756.33","31","","432.60","432.60","432.60","1 through 10","756.33","1939.63","percent of total billed charges",""
"TROCHANTER PLATE 131.0MM UNIVERSAL STABILIZATION UNIV LOCKING","SUP-ITM-10037419","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","890.52","36.5","","148.37","54.89","631.39","94","756.33","1939.63","percent of total billed charges",""
"TROCHANTER PLATE 131.0MM UNIVERSAL STABILIZATION UNIV LOCKING","SUP-ITM-10037419","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","934.44","38.3","","279.30","91.72","1116.77","266","756.33","1939.63","percent of total billed charges",""
"TROCHANTER PLATE 131.0MM UNIVERSAL STABILIZATION UNIV LOCKING","SUP-ITM-10037419","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1046.67","42.9","","731.00","63.70","731.00","1 through 10","756.33","1939.63","percent of total billed charges",""
"TROCHANTER PLATE 131.0MM UNIVERSAL STABILIZATION UNIV LOCKING","SUP-ITM-10037419","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1046.67","42.9","","384.74","384.74","384.74","1 through 10","756.33","1939.63","percent of total billed charges",""
"TROCHANTER PLATE 131.0MM UNIVERSAL STABILIZATION UNIV LOCKING","SUP-ITM-10037419","CDM","C1713","HCPCS","0278","RC","","","","both","","","2439.78","1829.83","WELLPOINT [1015]","HB AMC WELLPOINT","1800.07","73.78","","286.63","119.22","1107.45","105","756.33","1939.63","percent of total billed charges",""
"TROCHANTER PLATE 131.0MM UNIVERSAL STABILIZATION UNIV LOCKING","SUP-ITM-10037419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","AETNA [1001]","HB AMC AETNA HMO","1702.97","69.8","","675.31","184.75","1721.50","286","1275.03","1993.79","percent of total billed charges",""
"TROCHANTER PLATE 131.0MM UNIVERSAL STABILIZATION UNIV LOCKING","SUP-ITM-10037419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","AETNA [1001]","HB AMC AETNA PPO","1961.58","80.4","","1261.44","103.12","1514.10","21","1275.03","1993.79","percent of total billed charges",""
"TROCHANTER PLATE 131.0MM UNIVERSAL STABILIZATION UNIV LOCKING","SUP-ITM-10037419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1961.58","80.4","","1365.00","1365.00","1365.00","1 through 10","1275.03","1993.79","percent of total billed charges",""
"TROCHANTER PLATE 131.0MM UNIVERSAL STABILIZATION UNIV LOCKING","SUP-ITM-10037419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1993.79","81.72","","5157.68","5157.68","5157.68","1 through 10","1275.03","1993.79","percent of total billed charges",""
"TROCHANTER PLATE 131.0MM UNIVERSAL STABILIZATION UNIV LOCKING","SUP-ITM-10037419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2439.78","1829.83","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1993.79","81.72","","431.26","71.26","1459.57","88","1275.03","1993.79","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","169.00","126.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","121.34","71.8","","11.00","11.00","11.00","1 through 10","10.14","160.55","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","169.00","126.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","118.30","70","","118.08","118.08","118.08","1 through 10","10.14","160.55","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","169.00","126.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","134.36","79.5","","129.07","116.16","494.62","74","10.14","160.55","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","169.00","126.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","90.08","53.3","","129.07","86.59","436.35","48","10.14","160.55","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","169.00","126.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","130.13","77","","126.28","126.28","126.28","1 through 10","10.14","160.55","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","169.00","126.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","52.39","31","","152.03","50.68","152.04","17","10.14","160.55","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","169.00","126.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","61.69","36.5","","61.17","51.99","61.17","78","10.14","160.55","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","169.00","126.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64.73","38.3","","64.13","64.12","192.38","231","10.14","160.55","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","169.00","126.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","130.13","77","","370.97","123.66","370.97","1 through 10","10.14","160.55","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","169.00","126.75","AETNA [1001]","HB AMC AETNA HMO","117.96","69.8","","111.03","78.39","127.92","93","10.14","138.11","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","169.00","126.75","AETNA [1001]","HB AMC AETNA PPO","135.88","80.4","","127.92","85.94","127.92","17","10.14","138.11","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","169.00","126.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","88.32","52.26","","101.49","101.49","101.49","1 through 10","10.14","138.11","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","169.00","126.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","138.11","81.72","","243.35","121.68","393.30","1 through 10","10.14","138.11","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","169.00","126.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","138.11","81.72","","131.10","72.11","164.00","1 through 10","10.14","138.11","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","169.00","126.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","138.11","81.72","","131.10","72.11","262.20","33","10.14","138.11","percent of total billed charges",""
"TRUFILL N-BUTYL CYANOACRYLATE 1GR LIQUID EMBOLIC SYSTEM VIAL BX/1EA","SUP-ITM-10021398","CDM","C1889","HCPCS","0278","RC","","","","both","","","9487.50","7115.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7542.56","79.5","","1309.77","674.56","6049.93","26","2941.13","7542.56","percent of total billed charges",""
"TRUFILL N-BUTYL CYANOACRYLATE 1GR LIQUID EMBOLIC SYSTEM VIAL BX/1EA","SUP-ITM-10021398","CDM","C1889","HCPCS","0278","RC","","","","both","","","9487.50","7115.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5056.84","53.3","","1901.83","1901.83","2962.25","1 through 10","2941.13","7542.56","percent of total billed charges",""
"TRUFILL N-BUTYL CYANOACRYLATE 1GR LIQUID EMBOLIC SYSTEM VIAL BX/1EA","SUP-ITM-10021398","CDM","C1889","HCPCS","0278","RC","","","","both","","","9487.50","7115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3462.94","36.5","","1620.31","1620.31","19908.88","1 through 10","2941.13","7542.56","percent of total billed charges",""
"TRUFILL N-BUTYL CYANOACRYLATE 1GR LIQUID EMBOLIC SYSTEM VIAL BX/1EA","SUP-ITM-10021398","CDM","C1889","HCPCS","0278","RC","","","","both","","","9487.50","7115.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3633.71","38.3","","352.91","352.91","2046.30","1 through 10","2941.13","7542.56","percent of total billed charges",""
"TRUFILL N-BUTYL CYANOACRYLATE 1GR LIQUID EMBOLIC SYSTEM VIAL BX/1EA","SUP-ITM-10021398","CDM","C1889","HCPCS","0278","RC","","","","both","","","9487.50","7115.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4070.14","42.9","","9668.75","9668.75","9668.75","1 through 10","2941.13","7542.56","percent of total billed charges",""
"TRUFILL N-BUTYL CYANOACRYLATE 1GR LIQUID EMBOLIC SYSTEM VIAL BX/1EA","SUP-ITM-10021398","CDM","C1889","HCPCS","0278","RC","","","","both","","","9487.50","7115.62","WELLPOINT [1015]","HB AMC WELLPOINT","6999.88","73.78","","699.88","384.10","3443.31","33","2941.13","7542.56","percent of total billed charges",""
"TRUFILL N-BUTYL CYANOACRYLATE 1GR LIQUID EMBOLIC SYSTEM VIAL BX/1EA","SUP-ITM-10021398","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9487.50","7115.62","AETNA [1001]","HB AMC AETNA HMO","6622.28","69.8","","1421.24","264.50","4933.46","29","4958.17","7753.19","percent of total billed charges",""
"TRUFILL N-BUTYL CYANOACRYLATE 1GR LIQUID EMBOLIC SYSTEM VIAL BX/1EA","SUP-ITM-10021398","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9487.50","7115.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7627.95","80.4","","1022.97","1022.97","3607.50","1 through 10","4958.17","7753.19","percent of total billed charges",""
"TRUFILL N-BUTYL CYANOACRYLATE 1GR LIQUID EMBOLIC SYSTEM VIAL BX/1EA","SUP-ITM-10021398","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9487.50","7115.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7753.19","81.72","","3010.54","693.88","5019.88","35","4958.17","7753.19","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Tt Chimerism Grans-Bld","PX-31001291","CDM","81268","CPT","0310","RC","","","","both","","","1601.00","1200.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1272.80","79.5","","1222.21","1222.21","1222.21","1 through 10","255.57","1520.95","percent of total billed charges",""
"Tt Chimerism Grans-Bm","PX-31001294","CDM","81268","CPT","0310","RC","","","","both","","","1601.00","1200.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1272.80","79.5","","1222.21","1222.21","1222.21","1 through 10","255.57","1520.95","percent of total billed charges",""
"Tt Chimerism Tcells-Bld","PX-31001292","CDM","81268","CPT","0310","RC","","","","both","","","1601.00","1200.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1272.80","79.5","","1222.21","1222.21","1222.21","1 through 10","255.57","1520.95","percent of total billed charges",""
"Tt Chimerism Tcells-Bm","PX-31001295","CDM","81268","CPT","0310","RC","","","","both","","","1601.00","1200.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1272.80","79.5","","1222.21","1222.21","1222.21","1 through 10","255.57","1520.95","percent of total billed charges",""
"Tt Str Genotyping","PX-31001283","CDM","81265","CPT","0310","RC","","","","outpatient","","","1341.00","1005.75","AETNA [1001]","HB AMC AETNA HMO","936.02","69.8","","880.10","880.10","880.10","1 through 10","648.65","1464.7","percent of total billed charges",""
"TUBE CHEST 24FR 41CM DRAINAGE THAL QUICK PERCUTANEOUS ENTRY 4 SIDEPORTS TRAY DISPOSABLE","SUP-ITM-10258048","CDM","C1729","HCPCS","0272","RC","","","","both","","","712.25","534.19","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","511.40","71.8","","162.24","51.52","162.24","1 through 10","220.8","566.24","percent of total billed charges",""
"TUBE CHEST 24FR 41CM DRAINAGE THAL QUICK PERCUTANEOUS ENTRY 4 SIDEPORTS TRAY DISPOSABLE","SUP-ITM-10258048","CDM","C1729","HCPCS","0272","RC","","","","both","","","712.25","534.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","259.97","36.5","","94.34","22.19","146.22","26","220.8","566.24","percent of total billed charges",""
"TUBE CHEST 24FR 41CM DRAINAGE THAL QUICK PERCUTANEOUS ENTRY 4 SIDEPORTS TRAY DISPOSABLE","SUP-ITM-10258048","CDM","C1729","HCPCS","0272","RC","","","","both","","","712.25","534.19","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","272.79","38.3","","51.52","27.37","51.52","26","220.8","566.24","percent of total billed charges",""
"TUBE CHEST 24FR 41CM DRAINAGE THAL QUICK PERCUTANEOUS ENTRY 4 SIDEPORTS TRAY DISPOSABLE","SUP-ITM-10258048","CDM","C1729","HCPCS","0272","RC","","","","both","","","712.25","534.19","WELLPOINT [1015]","HB AMC WELLPOINT","525.50","73.78","","207.21","122.12","216.28","14","220.8","566.24","percent of total billed charges",""
"TUBE CHEST 24FR 41CM DRAINAGE THAL QUICK PERCUTANEOUS ENTRY 4 SIDEPORTS TRAY DISPOSABLE","SUP-ITM-10258048","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","712.25","534.19","AETNA [1001]","HB AMC AETNA HMO","497.15","69.8","","155.96","47.39","155.96","1 through 10","372.22","582.05","percent of total billed charges",""
"TUBE CHEST 24FR 41CM DRAINAGE THAL QUICK PERCUTANEOUS ENTRY 4 SIDEPORTS TRAY DISPOSABLE","SUP-ITM-10258048","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","712.25","534.19","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","582.05","81.72","","57.36","51.76","232.23","35","372.22","582.05","percent of total billed charges",""
"TUBE EAR 1.02MM VENTILATION SHEA PAPARELLA TAB DRAIN NOTCHE FLANGE TWIST SILICONE BX/6EA","SUP-ITM-10017946","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","51.00","38.25","AETNA [1001]","HB AMC AETNA HMO","35.60","69.8","","1013.24","1013.24","1013.24","1 through 10","25.5","42.08","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","both","","","4950.00","3712.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","3465.00","70","","863.10","863.10","863.10","1 through 10","1534.5","3935.25","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","both","","","4950.00","3712.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3935.25","79.5","","447.66","447.66","447.66","1 through 10","1534.5","3935.25","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","both","","","4950.00","3712.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3217.50","65","","1020.11","1020.11","1020.11","1 through 10","1534.5","3935.25","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1534.50","31","","208.83","208.83","208.83","1 through 10","1534.5","3935.25","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1806.75","36.5","","312.44","214.23","1086.03","20","1534.5","3935.25","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","both","","","4950.00","3712.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1895.85","38.3","","264.25","227.63","567.11","31","1534.5","3935.25","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","both","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2123.55","42.9","","79.94","79.94","79.94","1 through 10","1534.5","3935.25","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","both","","","4950.00","3712.50","WELLPOINT [1015]","HB AMC WELLPOINT","3652.11","73.78","","174.45","74.45","1168.42","1 through 10","1534.5","3935.25","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","4950.00","3712.50","AETNA [1001]","HB AMC AETNA HMO","3455.10","69.8","","655.01","135.40","784.73","1 through 10","2586.87","4045.14","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","4950.00","3712.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4045.14","81.72","","540.25","46.28","897.42","36","2586.87","4045.14","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","581.00","435.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","461.90","79.5","","800.18","480.96","1887.97","195","180.11","461.9","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","581.00","435.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","309.67","53.3","","813.12","216.42","1444.50","81","180.11","461.9","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","581.00","435.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","180.11","31","","432.60","432.60","432.60","1 through 10","180.11","461.9","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","581.00","435.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","212.07","36.5","","148.37","54.89","631.39","94","180.11","461.9","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","581.00","435.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","222.52","38.3","","279.30","91.72","1116.77","266","180.11","461.9","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.25","42.9","","731.00","63.70","731.00","1 through 10","180.11","461.9","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","581.00","435.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.25","42.9","","384.74","384.74","384.74","1 through 10","180.11","461.9","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","both","","","581.00","435.75","WELLPOINT [1015]","HB AMC WELLPOINT","428.66","73.78","","286.63","119.22","1107.45","105","180.11","461.9","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","581.00","435.75","AETNA [1001]","HB AMC AETNA HMO","405.54","69.8","","675.31","184.75","1721.50","286","303.63","474.79","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","581.00","435.75","AETNA [1001]","HB AMC AETNA PPO","467.12","80.4","","1261.44","103.12","1514.10","21","303.63","474.79","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","581.00","435.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","467.12","80.4","","1365.00","1365.00","1365.00","1 through 10","303.63","474.79","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","474.79","81.72","","5157.68","5157.68","5157.68","1 through 10","303.63","474.79","percent of total billed charges",""
"TUBE SPINE AFT STRAIGHT","SUP-ITM-10077517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","474.79","81.72","","431.26","71.26","1459.57","88","303.63","474.79","percent of total billed charges",""
"TUBE TRACHEOSTOMY 6MM BLUSELECT CUFFED","SUP-ITM-10307481","CDM","A7521","HCPCS","0274","RC","","","","both","","","127.40","95.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","46.50","36.5","","31.33","31.33","31.33","1 through 10","39.49","101.28","percent of total billed charges",""
"TUBE TRACHEOSTOMY 6X9.2X110MM ADULT BIVONA TTS ADJUSTABLE NECK FLANGE HYPERFLEX","SUP-ITM-10024891","CDM","A7521","HCPCS","0274","RC","","","","both","","","589.75","442.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","215.26","36.5","","31.33","31.33","31.33","1 through 10","64.42","468.85","percent of total billed charges",""
"TUBE TRACHEOSTOMY 7MM BLUSELECT CUFFED CS/1EA","SUP-ITM-10307463","CDM","A7521","HCPCS","0274","RC","","","","both","","","123.17","92.38","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.96","36.5","","31.33","31.33","31.33","1 through 10","38.18","97.92","percent of total billed charges",""
"TUBE TRACHEOSTOMY 7X10X80MM ADULT BIVONA TTS SILICONE CUFFED","SUP-ITM-10024469","CDM","A7521","HCPCS","0274","RC","","","","both","","","270.66","202.99","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","98.79","36.5","","31.33","31.33","31.33","1 through 10","64.42","215.17","percent of total billed charges",""
"TUBE TRACHEOSTOMY 8X11 88MM ADULT BIVONA TTS SILICONE CUFFED","SUP-ITM-10043032","CDM","A7521","HCPCS","0274","RC","","","","both","","","241.92","181.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","88.30","36.5","","31.33","31.33","31.33","1 through 10","64.42","192.33","percent of total billed charges",""
"TUBE TRACHEOSTOMY 9MM BLUSELECT CUFFED","SUP-ITM-10307483","CDM","A7521","HCPCS","0274","RC","","","","both","","","113.40","85.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.39","36.5","","31.33","31.33","31.33","1 through 10","35.15","90.15","percent of total billed charges",""
"TUBE TRACHEOSTOMY 9X98MM ADULT BIVONA TTS SILICONE CUFFED","SUP-ITM-10043033","CDM","A7521","HCPCS","0274","RC","","","","both","","","248.19","186.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","90.59","36.5","","31.33","31.33","31.33","1 through 10","64.42","197.31","percent of total billed charges",""
"TUBE TRACHEOSTOMY SZ 9.0 12.9X140.0MM AIRE-CUF HYPERFLEX SILICONE ADJUSTABLE NECK FLANGE ADULT","SUP-ITM-10149070","CDM","A7521","HCPCS","0274","RC","","","","both","","","610.96","458.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","223.00","36.5","","31.33","31.33","31.33","1 through 10","64.42","485.71","percent of total billed charges",""
"Tumor Genotyping Panel Egfr Kras","PX-30003008","CDM","81479","CPT","0301","RC","","","","both","","","5020.00","3765.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3990.90","79.5","","0.65","0.65","0.65","1 through 10","1556.2","4769","percent of total billed charges",""
"Tumor Genotyping Panel Egfr Kras","PX-30003008","CDM","81479","CPT","0301","RC","","","","both","","","5020.00","3765.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2675.66","53.3","","0.79","0.79","0.79","1 through 10","1556.2","4769","percent of total billed charges",""
"Tumor Genotyping Panel Egfr Kras","PX-30003008","CDM","81479","CPT","0301","RC","","","","outpatient","","","5020.00","3765.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2510.00","50","","1.00","1.00","1.00","1 through 10","156.55","4141.5","percent of total billed charges",""
"Tumor Genotyping Panel Egfr Kras","PX-30003008","CDM","81479","CPT","0301","RC","","","","outpatient","","","5020.00","3765.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2635.50","52.5","","1.00","0.53","1.00","1 through 10","156.55","4141.5","percent of total billed charges",""
"Tunneled J-Tube Exchange","PX-76010311","CDM","44799","CPT","0761","RC","","","","both","","","4442.00","3331.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1057.74","3531.39","other","OPPS APC"
"Tunneled J-Tube Exchange","PX-76010311","CDM","44799","CPT","0761","RC","","","","both","","","4442.00","3331.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","3531.39","other","OPPS APC"
"Tunneled J-Tube Exchange","PX-76010311","CDM","44799","CPT","0761","RC","","","","both","","","4442.00","3331.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3531.39","other","OPPS APC"
"Tunneled J-Tube Exchange","PX-76010311","CDM","44799","CPT","0761","RC","","","","both","","","4442.00","3331.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1057.74","3531.39","other","OPPS APC"
"Tunneled J-Tube Exchange","PX-76010311","CDM","44799","CPT","0761","RC","","","","both","","","4442.00","3331.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1905.62","42.9","","1932.92","1932.92","1932.92","1 through 10","1057.74","3531.39","percent of total billed charges",""
"Tunneled J-Tube Exchange","PX-76010311","CDM","44799","CPT","0761","RC","","","","both","","","4442.00","3331.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1057.74","3531.39","other","OPPS APC"
"Tunneled J-Tube Exchange","PX-76010311","CDM","44799","CPT","0761","RC","","","","both","","","4442.00","3331.50","WELLPOINT [1015]","HB AMC WELLPOINT","3277.31","73.78","","2222.33","2222.33","2222.33","1 through 10","1057.74","3531.39","percent of total billed charges",""
"Tunneled J-Tube Exchange","PX-76010311","CDM","44799","CPT","0761","RC","","","","outpatient","","","4442.00","3331.50","AETNA [1001]","HB AMC AETNA HMO","3100.52","69.8","","2238.60","2238.60","2238.60","1 through 10","2221","8899.59","percent of total billed charges",""
"Tunneled J-Tube Exchange","PX-76010311","CDM","44799","CPT","0761","RC","","","","outpatient","","","4442.00","3331.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2689.63","60.55","","3144.00","2870.00","3286.00","1 through 10","2221","8899.59","percent of total billed charges",""
"Tunneled J-Tube Exchange","PX-76010311","CDM","44799","CPT","0761","RC","","","","outpatient","","","4442.00","3331.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2321.39","52.26","","1775.96","1775.96","1775.96","1 through 10","2221","8899.59","percent of total billed charges",""
"Tunneled J-Tube Exchange","PX-76010311","CDM","44799","CPT","0761","RC","","","","outpatient","","","4442.00","3331.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2319.61","52.22","","3286.00","2018.70","5898.00","1 through 10","2221","8899.59","percent of total billed charges",""
"Tunneled J-Tube Exchange","PX-76010311","CDM","44799","CPT","0761","RC","","","","outpatient","","","4442.00","3331.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2332.05","52.5","","8340.00","8340.00","8340.00","1 through 10","2221","8899.59","percent of total billed charges",""
"Tunneled J-Tube Exchange","PX-76010311","CDM","44799","CPT","0761","RC","","","","outpatient","","","4442.00","3331.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3630.00","81.72","","2294.28","682.69","2294.28","1 through 10","2221","8899.59","percent of total billed charges",""
"Tunneled J-Tube Placement","PX-76010310","CDM","44799","CPT","0761","RC","","","","both","","","13326.00","9994.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1146.70","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1152.70","1152.70","4396.00","1 through 10","1057.74","10594.17","other","OPPS APC"
"Tunneled J-Tube Placement","PX-76010310","CDM","44799","CPT","0761","RC","","","","both","","","13326.00","9994.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","10594.17","other","OPPS APC"
"Tunneled J-Tube Placement","PX-76010310","CDM","44799","CPT","0761","RC","","","","both","","","13326.00","9994.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","10594.17","other","OPPS APC"
"Tunneled J-Tube Placement","PX-76010310","CDM","44799","CPT","0761","RC","","","","both","","","13326.00","9994.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","1098.54","1 through 10","1057.74","10594.17","other","OPPS APC"
"Tunneled J-Tube Placement","PX-76010310","CDM","44799","CPT","0761","RC","","","","both","","","13326.00","9994.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5716.85","42.9","","1932.92","1932.92","1932.92","1 through 10","1057.74","10594.17","percent of total billed charges",""
"Tunneled J-Tube Placement","PX-76010310","CDM","44799","CPT","0761","RC","","","","both","","","13326.00","9994.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1099.05","1099.05","1099.05","1 through 10","1057.74","10594.17","other","OPPS APC"
"Tunneled J-Tube Placement","PX-76010310","CDM","44799","CPT","0761","RC","","","","both","","","13326.00","9994.50","WELLPOINT [1015]","HB AMC WELLPOINT","9831.92","73.78","","2222.33","2222.33","2222.33","1 through 10","1057.74","10594.17","percent of total billed charges",""
"Tunneled J-Tube Placement","PX-76010310","CDM","44799","CPT","0761","RC","","","","outpatient","","","13326.00","9994.50","AETNA [1001]","HB AMC AETNA HMO","9301.55","69.8","","2238.60","2238.60","2238.60","1 through 10","6663","10993.95","percent of total billed charges",""
"Tunneled J-Tube Placement","PX-76010310","CDM","44799","CPT","0761","RC","","","","outpatient","","","13326.00","9994.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","8068.89","60.55","","3144.00","2870.00","3286.00","1 through 10","6663","10993.95","percent of total billed charges",""
"Tunneled J-Tube Placement","PX-76010310","CDM","44799","CPT","0761","RC","","","","outpatient","","","13326.00","9994.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","6964.17","52.26","","1775.96","1775.96","1775.96","1 through 10","6663","10993.95","percent of total billed charges",""
"Tunneled J-Tube Placement","PX-76010310","CDM","44799","CPT","0761","RC","","","","outpatient","","","13326.00","9994.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","6958.84","52.22","","3286.00","2018.70","5898.00","1 through 10","6663","10993.95","percent of total billed charges",""
"Tunneled J-Tube Placement","PX-76010310","CDM","44799","CPT","0761","RC","","","","outpatient","","","13326.00","9994.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","6996.15","52.5","","8340.00","8340.00","8340.00","1 through 10","6663","10993.95","percent of total billed charges",""
"Tunneled J-Tube Placement","PX-76010310","CDM","44799","CPT","0761","RC","","","","outpatient","","","13326.00","9994.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10890.01","81.72","","2294.28","682.69","2294.28","1 through 10","6663","10993.95","percent of total billed charges",""
"Tunneled Peritoneal Catheter Change","PX-76002684","CDM","49999","CPT","0761","RC","","","","both","","","4802.00","3601.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","1057.74","3817.59","other","OPPS APC"
"Tunneled Peritoneal Catheter Change","PX-76002684","CDM","49999","CPT","0761","RC","","","","both","","","4802.00","3601.50","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3817.59","other","OPPS APC"
"Tunneled Peritoneal Catheter Change","PX-76002684","CDM","49999","CPT","0761","RC","","","","both","","","4802.00","3601.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","1057.74","3817.59","other","OPPS APC"
"Tunneled Peritoneal Catheter Change","PX-76002684","CDM","49999","CPT","0761","RC","","","","outpatient","","","4802.00","3601.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2401.00","50","","14640.00","14640.00","14640.00","1 through 10","2401","8899.59","percent of total billed charges",""
"Tx Fx (M-P)(I-P) Jt W/Man Clsd","PX-76000509","CDM","26742","CPT","0761","RC","","","","both","","","2240.00","1680.00","MEDICARE [2001]","HB BWH MEDICARE","1900.39","","APC Price ($1,900.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1900.58","1900.58","1900.58","1 through 10","694.4","2375.49","other","OPPS APC"
"Tx Fx Acetabulum W/O Man Closed","PX-76000538","CDM","27220","CPT","0761","RC","","","","both","","","3616.00","2712.00","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","2874.72","other","OPPS APC"
"Tx Fx Acetabulum W/O Man Closed","PX-76000538","CDM","27220","CPT","0761","RC","","","","both","","","3616.00","2712.00","TRICARE [160005]","HB BWH TRICARE","270.63","","APC Price ($284.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","284.87","284.87","284.87","1 through 10","270.63","2874.72","other","Tricare OPPS"
"Tx Fx Ankle Bimalleolar Closed","PX-76000616","CDM","27808","CPT","0761","RC","","","","outpatient","","","2048.00","1536.00","AETNA [1001]","HB AMC AETNA HMO","1429.50","69.8","","1344.52","1344.52","1344.52","1 through 10","225.09","2384.07","percent of total billed charges",""
"Tx Fx Calcaneal Closed","PX-76000643","CDM","28400","CPT","0761","RC","","","","both","","","1590.00","1192.50","AETNA [1001]","HB AMC AETNA HMO","1109.82","69.8","","1202.76","1202.76","1202.76","1 through 10","270.63","1278.36","percent of total billed charges",""
"Tx Fx Calcaneal Closed","PX-76000643","CDM","28400","CPT","0761","RC","","","","both","","","1590.00","1192.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","580.35","36.5","","558.20","558.20","558.20","1 through 10","270.63","1278.36","percent of total billed charges",""
"Tx Fx Carpal W/O Manip Closed","PX-76000466","CDM","25630","CPT","0761","RC","","","","both","","","1335.00","1001.25","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","142.44","142.44","142.44","1 through 10","270.63","1061.33","other","OPPS APC"
"Tx Fx Carpal W/O Manip Closed","PX-76000466","CDM","25630","CPT","0761","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB AMC WELLPOINT","984.96","73.78","","964.13","964.13","964.13","1 through 10","270.63","1061.33","percent of total billed charges",""
"Tx Fx Carpal W/O Manip Closed","PX-76000466","CDM","25630","CPT","0761","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1090.96","81.72","","1035.23","1035.23","1035.23","1 through 10","225.09","1090.96","percent of total billed charges",""
"Tx Fx Clavicle W/O Manip Closed","PX-76000387","CDM","23500","CPT","0761","RC","","","","both","","","1025.00","768.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","293.39","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","293.13","293.13","293.13","1 through 10","270.63","814.88","other","OPPS APC"
"Tx Fx Clavicle W/O Manip Closed","PX-76000387","CDM","23500","CPT","0761","RC","","","","both","","","1025.00","768.75","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","814.88","other","OPPS APC"
"Tx Fx Clavicle W/O Manip Closed","PX-76000387","CDM","23500","CPT","0761","RC","","","","outpatient","","","1025.00","768.75","AETNA [1001]","HB AMC AETNA HMO","715.45","69.8","","672.94","475.13","672.94","1 through 10","225.09","2384.07","percent of total billed charges",""
"Tx Fx Clavicle W/O Manip Closed","PX-76000387","CDM","23500","CPT","0761","RC","","","","outpatient","","","1025.00","768.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","837.63","81.72","","794.60","794.60","794.60","1 through 10","225.09","2384.07","percent of total billed charges",""
"Tx Fx Coccygeal Closed","PX-76000532","CDM","27200","CPT","0761","RC","","","","outpatient","","","1236.00","927.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","257.40","","Case rate ($257.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","517.12","517.12","517.12","1 through 10","225.09","993.74","other","ASC"
"Tx Fx Coccygeal Closed","PX-76000532","CDM","27200","CPT","0761","RC","","","","outpatient","","","1236.00","927.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","257.40","","Case rate ($257.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","596.65","596.65","596.65","1 through 10","225.09","993.74","other","ASC "
"Tx Fx Femoral Trochan W/O Man Clsd","PX-76000547","CDM","27238","CPT","0761","RC","","","","both","","","3082.00","2311.50","MEDICARE [2001]","HB BWH MEDICARE","1900.39","","APC Price ($1,900.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1900.58","1900.58","1900.58","1 through 10","955.42","2450.19","other","OPPS APC"
"Tx Fx Fibula Distal W/O Man Closed","PX-76000613","CDM","27786","CPT","0761","RC","","","","both","","","1322.00","991.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","506.33","38.3","","501.26","501.26","501.26","1 through 10","270.63","1050.99","percent of total billed charges",""
"Tx Fx Fibula Distal W/O Man Closed","PX-76000613","CDM","27786","CPT","0761","RC","","","","both","","","1322.00","991.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","279.17","279.17","279.17","1 through 10","270.63","1050.99","other","OPPS APC"
"Tx Fx Fibula Shaft/Prox W/Oman Clsd","PX-76000610","CDM","27780","CPT","0761","RC","","","","both","","","1830.00","1372.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","139.88","139.88","139.88","1 through 10","270.63","1454.85","other","OPPS APC"
"Tx Fx Greater Trochan W/O Man Clsd","PX-76000551","CDM","27246","CPT","0761","RC","","","","both","","","2615.00","1961.25","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","2136.98","other","OPPS APC"
"Tx Fx Humer Epicondylar Closed","PX-76000420","CDM","24560","CPT","0761","RC","","","","both","","","1905.00","1428.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","279.38","279.38","279.38","1 through 10","270.63","1514.48","other","OPPS APC"
"Tx Fx Humer Shaft W/O Man Closed","PX-76000413","CDM","24500","CPT","0761","RC","","","","both","","","2106.00","1579.50","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1674.27","other","OPPS APC"
"Tx Fx Humerus Prox W/O Man Closed","PX-76000395","CDM","23600","CPT","0761","RC","","","","both","","","1387.00","1040.25","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1102.67","other","OPPS APC"
"Tx Fx Humerus Prox W/O Man Closed","PX-76000395","CDM","23600","CPT","0761","RC","","","","both","","","1387.00","1040.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","279.17","279.17","279.17","1 through 10","270.63","1102.67","other","OPPS APC"
"Tx Fx Humerus Tuberos W/O Man Clsd","PX-76000397","CDM","23620","CPT","0761","RC","","","","both","","","1192.00","894.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","279.17","279.17","279.17","1 through 10","270.63","947.64","other","OPPS APC"
"Tx Fx Metacarpal W/O Manip Closed","PX-76000498","CDM","26600","CPT","0761","RC","","","","both","","","1261.00","945.75","WELLPOINT [1015]","HB AMC WELLPOINT","930.37","73.78","","910.52","910.52","910.52","1 through 10","270.63","1002.5","percent of total billed charges",""
"Tx Fx Metacarpal W/O Manip Closed","PX-76000498","CDM","26600","CPT","0761","RC","","","","outpatient","","","1261.00","945.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","257.40","","Case rate ($257.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","517.12","517.12","517.12","1 through 10","225.09","1030.49","other","ASC"
"Tx Fx Metatarsal W/O Manip Closed","PX-76000651","CDM","28470","CPT","0761","RC","","","","both","","","906.00","679.50","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","720.27","other","OPPS APC"
"Tx Fx Metatarsal W/O Manip Closed","PX-76000651","CDM","28470","CPT","0761","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","347.00","38.3","","343.69","343.69","343.69","1 through 10","270.63","720.27","percent of total billed charges",""
"Tx Fx Metatarsal W/O Manip Closed","PX-76000651","CDM","28470","CPT","0761","RC","","","","outpatient","","","906.00","679.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","257.40","","Case rate ($257.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","517.12","517.12","517.12","1 through 10","225.09","740.38","other","ASC"
"Tx Fx Metatarsal W/O Manip Closed","PX-76000651","CDM","28470","CPT","0761","RC","","","","outpatient","","","906.00","679.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","257.40","","Case rate ($257.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","298.33","298.33","298.33","1 through 10","225.09","740.38","other","ASC "
"Tx Fx Navicular W/O Manip Closed","PX-76000464","CDM","25622","CPT","0761","RC","","","","both","","","1832.00","1374.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","976.46","53.3","","938.26","938.26","938.26","1 through 10","270.63","1497.11","percent of total billed charges",""
"Tx Fx Patellar W/O Manip Closed","PX-76000584","CDM","27520","CPT","0761","RC","","","","both","","","1348.00","1011.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","293.39","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","293.13","293.13","293.13","1 through 10","270.63","1101.59","other","OPPS APC"
"Tx Fx Patellar W/O Manip Closed","PX-76000584","CDM","27520","CPT","0761","RC","","","","both","","","1348.00","1011.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.23","252.23","252.23","1 through 10","270.63","1101.59","other","OPPS APC"
"Tx Fx Patellar W/O Manip Closed","PX-76000584","CDM","27520","CPT","0761","RC","","","","both","","","1348.00","1011.00","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1101.59","other","OPPS APC"
"Tx Fx Patellar W/O Manip Closed","PX-76000584","CDM","27520","CPT","0761","RC","","","","both","","","1348.00","1011.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1101.59","81.72","","1044.82","1044.82","1044.82","1 through 10","270.63","1101.59","percent of total billed charges",""
"Tx Fx Patellar W/O Manip Closed","PX-76000584","CDM","27520","CPT","0761","RC","","","","both","","","1348.00","1011.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","279.17","279.17","279.17","1 through 10","270.63","1101.59","other","OPPS APC"
"Tx Fx Patellar W/O Manip Closed","PX-76000584","CDM","27520","CPT","0761","RC","","","","both","","","1348.00","1011.00","WELLPOINT [1015]","HB AMC WELLPOINT","994.55","73.78","","973.06","973.06","973.06","1 through 10","270.63","1101.59","percent of total billed charges",""
"Tx Fx Phalanx Dist W/O Man Closed","PX-76000511","CDM","26750","CPT","0761","RC","","","","outpatient","","","860.00","645.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","257.40","","Case rate ($257.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","517.12","517.12","517.12","1 through 10","225.09","702.79","other","ASC"
"Tx Fx Radial Dist W/O Man Closed","PX-76000458","CDM","25600","CPT","0761","RC","","","","both","","","1223.00","917.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","293.39","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","132.42","132.42","132.42","1 through 10","270.63","972.29","other","OPPS APC"
"Tx Fx Radial Dist W/O Man Closed","PX-76000458","CDM","25600","CPT","0761","RC","","","","both","","","1223.00","917.25","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","142.44","284.87","1 through 10","270.63","972.29","other","OPPS APC"
"Tx Fx Radial Dist W/O Man Closed","PX-76000458","CDM","25600","CPT","0761","RC","","","","both","","","1223.00","917.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","468.41","38.3","","463.73","463.73","463.73","1 through 10","270.63","972.29","percent of total billed charges",""
"Tx Fx Radial Dist W/O Man Closed","PX-76000458","CDM","25600","CPT","0761","RC","","","","both","","","1223.00","917.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","127.66","127.66","127.66","1 through 10","270.63","972.29","other","OPPS APC"
"Tx Fx Radial Head/Neck W/Manip Clsd","PX-76000433","CDM","24655","CPT","0761","RC","","","","both","","","2565.00","1923.75","MEDICARE [2001]","HB BWH MEDICARE","1900.39","","APC Price ($1,900.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1900.58","1900.58","1900.58","1 through 10","795.15","2375.49","other","OPPS APC"
"Tx Fx Radial Head/Neck W/Manip Clsd","PX-76000433","CDM","24655","CPT","0761","RC","","","","outpatient","","","2565.00","1923.75","AETNA [1001]","HB AMC AETNA HMO","1790.37","69.8","","1683.70","1683.70","1683.70","1 through 10","1100.39","2384.07","percent of total billed charges",""
"Tx Fx Radial Head/Neck W/O Man Clsd","PX-76000432","CDM","24650","CPT","0761","RC","","","","both","","","1091.00","818.25","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","867.35","other","OPPS APC"
"Tx Fx Radial Head/Neck W/O Man Clsd","PX-76000432","CDM","24650","CPT","0761","RC","","","","both","","","1091.00","818.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","398.22","36.5","","394.63","394.63","394.63","1 through 10","270.63","867.35","percent of total billed charges",""
"Tx Fx Radial Head/Neck W/O Man Clsd","PX-76000432","CDM","24650","CPT","0761","RC","","","","both","","","1091.00","818.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","417.85","38.3","","413.68","413.68","413.68","1 through 10","270.63","867.35","percent of total billed charges",""
"Tx Fx Radial Head/Neck W/O Man Clsd","PX-76000432","CDM","24650","CPT","0761","RC","","","","outpatient","","","1091.00","818.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","225.09","","Case rate ($225.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","652.76","652.76","652.76","1 through 10","225.09","891.57","other","Multiple Surgery"
"Tx Fx Radial Head/Neck W/O Man Clsd","PX-76000432","CDM","24650","CPT","0761","RC","","","","outpatient","","","1091.00","818.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","891.57","81.72","","845.77","845.77","845.77","1 through 10","225.09","891.57","percent of total billed charges",""
"Tx Fx Radius/Ulna W/Man Closed","PX-76000459","CDM","25605","CPT","0761","RC","","","","both","","","3373.00","2529.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","1957.40","","APC Price ($1,900.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1956.50","1956.50","1956.50","1 through 10","1045.63","2681.54","other","OPPS APC"
"Tx Fx Radius/Ulna W/Man Closed","PX-76000459","CDM","25605","CPT","0761","RC","","","","both","","","3373.00","2529.75","MEDICARE [2001]","HB BWH MEDICARE","1900.39","","APC Price ($1,900.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1900.58","1900.58","1900.58","1 through 10","1045.63","2681.54","other","OPPS APC"
"Tx Fx Radius/Ulna W/Man Closed","PX-76000459","CDM","25605","CPT","0761","RC","","","","outpatient","","","3373.00","2529.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2756.42","81.72","","2614.84","2614.84","2614.84","1 through 10","1182.01","2756.42","percent of total billed charges",""
"Tx Fx Scapular W/O Manip Closed","PX-76000393","CDM","23570","CPT","0761","RC","","","","both","","","1613.00","1209.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","293.39","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","293.13","293.13","293.13","1 through 10","270.63","1282.34","other","OPPS APC"
"Tx Fx Scapular W/O Manip Closed","PX-76000393","CDM","23570","CPT","0761","RC","","","","both","","","1613.00","1209.75","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1282.34","other","OPPS APC"
"Tx Fx Scapular W/O Manip Closed","PX-76000393","CDM","23570","CPT","0761","RC","","","","both","","","1613.00","1209.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","279.17","279.17","279.17","1 through 10","270.63","1282.34","other","OPPS APC"
"Tx Fx Scapular W/O Manip Closed","PX-76000393","CDM","23570","CPT","0761","RC","","","","outpatient","","","1613.00","1209.75","AETNA [1001]","HB AMC AETNA HMO","1125.87","69.8","","747.59","747.59","747.59","1 through 10","225.09","2384.07","percent of total billed charges",""
"Tx Fx Tarsal W/O Manip Closed","PX-76000649","CDM","28450","CPT","0761","RC","","","","outpatient","","","1296.00","972.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","257.40","","Case rate ($257.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","602.57","596.65","602.57","1 through 10","225.09","1059.09","other","ASC "
"Tx Fx Tibia Prox W/O Man Closed","PX-76000585","CDM","27530","CPT","0761","RC","","","","both","","","1742.00","1306.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","293.39","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","293.13","293.13","293.13","1 through 10","270.63","1423.56","other","OPPS APC"
"Tx Fx Tibia Prox W/O Man Closed","PX-76000585","CDM","27530","CPT","0761","RC","","","","both","","","1742.00","1306.50","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","257.38","284.87","1 through 10","270.63","1423.56","other","OPPS APC"
"Tx Fx Tibia Prox W/O Man Closed","PX-76000585","CDM","27530","CPT","0761","RC","","","","both","","","1742.00","1306.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","667.19","38.3","","557.37","557.37","557.37","1 through 10","270.63","1423.56","percent of total billed charges",""
"Tx Fx Tibia Prox W/O Man Closed","PX-76000585","CDM","27530","CPT","0761","RC","","","","both","","","1742.00","1306.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1423.56","81.72","","742.65","742.65","742.65","1 through 10","270.63","1423.56","percent of total billed charges",""
"Tx Fx Tibia Prox W/O Man Closed","PX-76000585","CDM","27530","CPT","0761","RC","","","","both","","","1742.00","1306.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","279.75","279.75","279.75","1 through 10","270.63","1423.56","other","OPPS APC"
"Tx Fx Tibia Prox W/O Man Closed","PX-76000585","CDM","27530","CPT","0761","RC","","","","both","","","1742.00","1306.50","WELLPOINT [1015]","HB AMC WELLPOINT","1285.25","73.78","","2946.46","1723.51","2946.46","1 through 10","270.63","1423.56","percent of total billed charges",""
"Tx Fx Ulnar Styloid Closed","PX-76000469","CDM","25650","CPT","0761","RC","","","","both","","","2015.00","1511.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","1601.93","other","OPPS APC"
"Tx Fx Ulnar Styloid Closed","PX-76000469","CDM","25650","CPT","0761","RC","","","","both","","","2015.00","1511.25","WELLPOINT [1015]","HB AMC WELLPOINT","1486.67","73.78","","1454.75","1454.75","1454.75","1 through 10","270.63","1601.93","percent of total billed charges",""
"Tx Fx Vertebral Body W/O Man Clsd","PX-76000358","CDM","22310","CPT","0761","RC","","","","both","","","1831.00","1373.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","293.39","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","293.13","293.13","293.13","1 through 10","270.63","1455.65","other","OPPS APC"
"Tx Fx Vertebral Body W/O Man Clsd","PX-76000358","CDM","22310","CPT","0761","RC","","","","both","","","1831.00","1373.25","MEDICARE [2001]","HB BWH MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1455.65","other","OPPS APC"
"Tx Fx Vertebral Body W/O Man Clsd","PX-76000358","CDM","22310","CPT","0761","RC","","","","both","","","1831.00","1373.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","668.32","36.5","","662.45","662.45","662.45","1 through 10","270.63","1455.65","percent of total billed charges",""
"Tx Fx Vertebral Body W/O Man Clsd","PX-76000358","CDM","22310","CPT","0761","RC","","","","both","","","1831.00","1373.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","1455.65","other","OPPS APC"
"Tx Fx Vertebral Body W/O Man Clsd","PX-76000358","CDM","22310","CPT","0761","RC","","","","outpatient","","","1831.00","1373.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","257.40","","Case rate ($257.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","602.57","596.65","602.57","1 through 10","225.09","2384.07","other","ASC "
"Tx Swlng Dsyf &/ Oral Fnctn","PX-43000083","CDM","92526","CPT","0431","RC","","","","both","","","302.00","226.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","160.97","53.3","","154.70","154.70","154.70","1 through 10","90.27","286.9","percent of total billed charges",""
"Tx Swlng Dsyf &/ Oral Fnctn","PX-43000083","CDM","92526","CPT","0431","RC","","","","both","","","302.00","226.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","110.23","36.5","","109.29","92.88","109.29","1 through 10","90.27","286.9","percent of total billed charges",""
"Tx Swlng Dsyf &/ Oral Fnctn","PX-43000083","CDM","92526","CPT","0431","RC","","","","both","","","302.00","226.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","115.67","38.3","","114.56","114.56","114.56","29","90.27","286.9","percent of total billed charges",""
"Tx Swlng Dsyf &/ Oral Fnctn","PX-43000083","CDM","92526","CPT","0431","RC","","","","both","","","302.00","226.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","90.27","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($92.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($69.07). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","90.27","90.27","90.27","1 through 10","90.27","286.9","fee schedule",""
"Tx Swlng Dsyf &/ Oral Fnctn","PX-43000083","CDM","92526","CPT","0431","RC","","","","outpatient","","","302.00","226.50","AETNA [1001]","HB AMC AETNA HMO","210.80","69.8","","140.05","107.50","198.36","1 through 10","157.83","577.02","percent of total billed charges",""
"Typhoid Vaccine VI Capsular Polysaccharide Im","PX-63600480","CDM","90691","CPT","0636","RC","","","","both","","","228.40","171.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.37","36.5","","85.19","72.40","85.19","1 through 10","70.8","175.87","percent of total billed charges",""
"Typhoid Vaccine VI Capsular Polysaccharide Im","PX-63600480","CDM","90691","CPT","0636","RC","","","","both","","","228.40","171.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.48","38.3","","89.30","86.79","89.30","16","70.8","175.87","percent of total billed charges",""
"Typhoid Vaccine VI Capsular Polysaccharide Im","PX-63600480","CDM","90691","CPT","0636","RC","","","","outpatient","","","228.40","171.30","AETNA [1001]","HB AMC AETNA HMO","159.42","69.8","","178.15","154.63","178.15","1 through 10","107.12","186.65","percent of total billed charges",""
"Typhoid Vaccine VI Capsular Polysaccharide Im","PX-63600480","CDM","90691","CPT","0636","RC","","","","outpatient","","","228.40","171.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.65","69.9","","158.28","158.28","158.28","1 through 10","107.12","186.65","percent of total billed charges",""
"Typhoid Vaccine VI Capsular Polysaccharide Im","PX-63600480","CDM","90691","CPT","0636","RC","","","","outpatient","","","228.40","171.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","107.12","46.9","","105.98","105.98","105.98","1 through 10","107.12","186.65","percent of total billed charges",""
"Typhoid Vaccine VI Capsular Polysaccharide Im","PX-63600480","CDM","90691","CPT","0636","RC","","","","outpatient","","","228.40","171.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","186.65","81.72","","244.20","228.40","254.02","1 through 10","107.12","186.65","percent of total billed charges",""
"U Blastomyces Ag","PX-30002251","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","159.00","79.5","","102.43","102.43","102.43","1 through 10","11.74","190","percent of total billed charges",""
"U Blastomyces Ag","PX-30002251","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.00","36.5","","61.50","61.50","61.50","1 through 10","11.74","190","percent of total billed charges",""
"U Blastomyces Ag","PX-30002251","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","76.60","38.3","","75.85","75.85","75.86","1 through 10","11.74","190","percent of total billed charges",""
"U Blastomyces Ag","PX-30002251","CDM","87449","CPT","0306","RC","","","","both","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.80","42.9","","155.08","155.08","155.08","1 through 10","11.74","190","percent of total billed charges",""
"U Blastomyces Ag","PX-30002251","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","AETNA [1001]","HB AMC AETNA HMO","139.60","69.8","","131.34","92.73","185.46","17","11.81","163.44","percent of total billed charges",""
"U Blastomyces Ag","PX-30002251","CDM","87449","CPT","0306","RC","","","","outpatient","","","200.00","150.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","163.44","81.72","","155.08","60.38","194.00","1 through 10","11.81","163.44","percent of total billed charges",""
"U of Iowa, Fshd12 Fshd1 and Fshd2 Gene Mutations","PX-31001336","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"U/S Trtmt, Prostate, Not Leiomyomata, W Guidance","PX-76102089","CDM","55899","CPT","0761","RC","","","","both","","","30289.00","22716.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","11055.49","36.5","","16414.61","16414.61","16414.61","1 through 10","9389.59","24079.76","percent of total billed charges",""
"U/S Trtmt, Prostate, Not Leiomyomata, W Guidance","PX-76102089","CDM","55899","CPT","0761","RC","","","","outpatient","","","30289.00","22716.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","18339.99","60.55","","24192.00","270.73","32118.00","1 through 10","700.33","24988.43","percent of total billed charges",""
"U/S Trtmt, Prostate, Not Leiomyomata, W Guidance","PX-76102089","CDM","55899","CPT","0761","RC","","","","outpatient","","","30289.00","22716.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","15816.92","52.22","","24192.00","613.44","32118.00","1 through 10","700.33","24988.43","percent of total billed charges",""
"U/S Trtmt, Prostate, Not Leiomyomata, W Guidance","PX-76102089","CDM","55899","CPT","0761","RC","","","","outpatient","","","30289.00","22716.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15144.50","50","","18860.73","18860.73","18860.73","1 through 10","700.33","24988.43","percent of total billed charges",""
"U/S Trtmt, Prostate, Not Leiomyomata, W Guidance","PX-76102089","CDM","55899","CPT","0761","RC","","","","outpatient","","","30289.00","22716.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","24752.17","81.72","","28843.15","22507.11","28843.15","1 through 10","700.33","24988.43","percent of total billed charges",""
"Uag Schng Smarcb1, Nf2, Lztr1 Gene Mutations Del/Dup","PX-31001060","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Uag Schng Smarcb1, Nf2, Lztr1 Gene Mutations Del/Dup","PX-31001060","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Uag Schng Smarcb1, Nf2, Lztr1 Gene Mutations Del/Dup","PX-31001060","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Uag Schng Smarcb1, Nf2, Lztr1 Gene Mutations Del/Dup","PX-31001060","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Ucsf Cfs Pathogen Detection","PX-31001164","CDM","81479","CPT","0310","RC","","","","both","","","6702.00","5026.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5328.09","79.5","","0.65","0.65","0.65","1 through 10","2077.62","6366.9","percent of total billed charges",""
"Ucsf Cfs Pathogen Detection","PX-31001164","CDM","81479","CPT","0310","RC","","","","both","","","6702.00","5026.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3572.17","53.3","","0.79","0.79","0.79","1 through 10","2077.62","6366.9","percent of total billed charges",""
"Ucsf Cfs Pathogen Detection","PX-31001164","CDM","81479","CPT","0310","RC","","","","outpatient","","","6702.00","5026.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3351.00","50","","1.00","1.00","1.00","1 through 10","156.55","5529.15","percent of total billed charges",""
"Ucsf Cfs Pathogen Detection","PX-31001164","CDM","81479","CPT","0310","RC","","","","outpatient","","","6702.00","5026.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","3518.55","52.5","","1.00","0.53","1.00","1 through 10","156.55","5529.15","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6888.68","79.5","","1309.77","674.56","6049.93","26","2686.15","6888.68","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4618.45","53.3","","1901.83","1901.83","2962.25","1 through 10","2686.15","6888.68","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3162.73","36.5","","1620.31","1620.31","19908.88","1 through 10","2686.15","6888.68","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3318.70","38.3","","352.91","352.91","2046.30","1 through 10","2686.15","6888.68","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3717.29","42.9","","9668.75","9668.75","9668.75","1 through 10","2686.15","6888.68","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","WELLPOINT [1015]","HB AMC WELLPOINT","6393.04","73.78","","699.88","384.10","3443.31","33","2686.15","6888.68","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8665.00","6498.75","AETNA [1001]","HB AMC AETNA HMO","6048.17","69.8","","1421.24","264.50","4933.46","29","4528.33","7081.04","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8665.00","6498.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6966.66","80.4","","1022.97","1022.97","3607.50","1 through 10","4528.33","7081.04","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8665.00","6498.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7081.04","81.72","","3010.54","693.88","5019.88","35","4528.33","7081.04","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.33","2212.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2345.51","79.5","","800.18","480.96","1887.97","195","914.6","2345.51","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.33","2212.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1572.53","53.3","","813.12","216.42","1444.50","81","914.6","2345.51","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.33","2212.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","914.60","31","","432.60","432.60","432.60","1 through 10","914.6","2345.51","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.33","2212.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1076.87","36.5","","148.37","54.89","631.39","94","914.6","2345.51","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.33","2212.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1129.98","38.3","","279.30","91.72","1116.77","266","914.6","2345.51","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.33","2212.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1265.69","42.9","","731.00","63.70","731.00","1 through 10","914.6","2345.51","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.33","2212.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1265.69","42.9","","384.74","384.74","384.74","1 through 10","914.6","2345.51","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2950.33","2212.75","WELLPOINT [1015]","HB AMC WELLPOINT","2176.75","73.78","","286.63","119.22","1107.45","105","914.6","2345.51","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2950.33","2212.75","AETNA [1001]","HB AMC AETNA HMO","2059.33","69.8","","675.31","184.75","1721.50","286","1541.84","2411.01","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2950.33","2212.75","AETNA [1001]","HB AMC AETNA PPO","2372.07","80.4","","1261.44","103.12","1514.10","21","1541.84","2411.01","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2950.33","2212.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2372.07","80.4","","1365.00","1365.00","1365.00","1 through 10","1541.84","2411.01","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2950.33","2212.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2411.01","81.72","","5157.68","5157.68","5157.68","1 through 10","1541.84","2411.01","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2950.33","2212.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2411.01","81.72","","431.26","71.26","1459.57","88","1541.84","2411.01","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4528.33","52.26","","1113.10","1113.10","1113.10","1 through 10","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6888.68","79.5","","1293.60","1148.53","1603.80","1 through 10","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3162.73","36.5","","1023.42","771.29","2068.67","33","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3318.70","38.3","","850.52","759.78","1211.25","66","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3717.29","42.9","","2548.09","2548.09","2548.09","1 through 10","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3717.29","42.9","","956.46","956.46","956.46","1 through 10","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","WELLPOINT [1015]","HB AMC WELLPOINT","6393.04","73.78","","2344.73","1619.47","2530.35","16","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8665.00","6498.75","AETNA [1001]","HB AMC AETNA HMO","6048.17","69.8","","1523.63","988.41","4330.26","39","4528.33","7081.04","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8665.00","6498.75","AETNA [1001]","HB AMC AETNA PPO","6966.66","80.4","","1670.25","1670.25","1670.25","1 through 10","4528.33","7081.04","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8665.00","6498.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4528.33","52.26","","1113.10","1113.10","1113.10","1 through 10","4528.33","7081.04","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8665.00","6498.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7081.04","81.72","","1738.90","1484.65","2716.94","38","4528.33","7081.04","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4528.33","52.26","","1113.10","1113.10","1113.10","1 through 10","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6888.68","79.5","","1293.60","1148.53","1603.80","1 through 10","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3162.73","36.5","","1023.42","771.29","2068.67","33","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3318.70","38.3","","850.52","759.78","1211.25","66","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3717.29","42.9","","2548.09","2548.09","2548.09","1 through 10","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3717.29","42.9","","956.46","956.46","956.46","1 through 10","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","8665.00","6498.75","WELLPOINT [1015]","HB AMC WELLPOINT","6393.04","73.78","","2344.73","1619.47","2530.35","16","2686.15","6888.68","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8665.00","6498.75","AETNA [1001]","HB AMC AETNA HMO","6048.17","69.8","","1523.63","988.41","4330.26","39","4528.33","7081.04","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8665.00","6498.75","AETNA [1001]","HB AMC AETNA PPO","6966.66","80.4","","1670.25","1670.25","1670.25","1 through 10","4528.33","7081.04","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8665.00","6498.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4528.33","52.26","","1113.10","1113.10","1113.10","1 through 10","4528.33","7081.04","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8665.00","6498.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7081.04","81.72","","1738.90","1484.65","2716.94","38","4528.33","7081.04","percent of total billed charges",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC","279","MS-DRG","","","","","","","","inpatient","","","148925.91","111694.43","MEDICARE [2001]","HB BWH MEDICARE","33277.81","","Case rate ($33,277.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,982.50, add-ons for qualifying new technology services are included. If operating cost exceeds $85,626.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,342.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $29,996.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,602.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,901.92. The transfer capital threshold is the transfer adjustment factor * $2,901.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38055.44","38055.44","38100.04","1 through 10","32612.25","54424.1824","other","Inpatient Replacement Plans DRG"
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC","279","MS-DRG","","","","","","","","inpatient","","","148925.91","111694.43","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","32612.25","","Case rate ($33,277.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,982.50, add-ons for qualifying new technology services are included. If operating cost exceeds $85,626.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,342.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $29,996.04 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,602.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,901.92. The transfer capital threshold is the transfer adjustment factor * $2,901.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","28861.19","28861.19","28861.19","1 through 10","32612.25","54424.1824","other","Inpatient DRG"
"Ultrasound Guided IR Drain Injection of TPA.","PX-76002888","CDM","49999","CPT","0761","RC","","","","both","","","1741.00","1305.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","539.71","1391.62","other","OPPS APC"
"Ultrasound Guided IR Drain Injection of TPA.","PX-76002888","CDM","49999","CPT","0761","RC","","","","both","","","1741.00","1305.75","MEDICARE [2001]","HB BWH MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","539.71","1391.62","other","OPPS APC"
"Ultrasound Guided IR Drain Injection of TPA.","PX-76002888","CDM","49999","CPT","0761","RC","","","","both","","","1741.00","1305.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","1091.03","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3299.04","3299.04","3299.04","1 through 10","539.71","1391.62","other","OPPS APC"
"Ultrasound Guided IR Drain Injection of TPA.","PX-76002888","CDM","49999","CPT","0761","RC","","","","outpatient","","","1741.00","1305.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","870.50","50","","14640.00","14640.00","14640.00","1 through 10","870.5","8899.59","percent of total billed charges",""
"Ultrasound Trgt Dynamic Microbubble 1st Lesion","PX-40000152","CDM","76978","CPT","0402","RC","","","","both","","","2164.00","1623.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","217.73","","APC Price ($211.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","218.44","218.44","218.44","1 through 10","200.84","1720.38","other","OPPS APC"
"Ultrasound Trgt Dynamic Microbubble 1st Lesion","PX-40000152","CDM","76978","CPT","0402","RC","","","","both","","","2164.00","1623.00","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","1720.38","other","OPPS APC"
"Ultrasound Trgt Dynamic Microbubble 1st Lesion","PX-40000152","CDM","76978","CPT","0402","RC","","","","both","","","2164.00","1623.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","828.81","38.3","","820.71","820.71","820.71","1 through 10","200.84","1720.38","percent of total billed charges",""
"Ultrasound Trgt Dynamic Microbubble 1st Lesion","PX-40000152","CDM","76978","CPT","0402","RC","","","","both","","","2164.00","1623.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","196.52","196.52","196.52","1 through 10","200.84","1720.38","other","OPPS APC"
"Ultrasound Trgt Dynamic Microbubble 1st Lesion","PX-40000152","CDM","76978","CPT","0402","RC","","","","outpatient","","","2164.00","1623.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","415.26","","Case rate ($415.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","415.26","415.26","415.26","1 through 10","201.74","1768.42","other","Multiple Imaging"
"Ultrasound Trgt Dynamic Microbubble 1st Lesion","PX-40000152","CDM","76978","CPT","0402","RC","","","","outpatient","","","2164.00","1623.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","415.26","","Case rate ($415.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","415.26","415.26","415.26","1 through 10","201.74","1768.42","other","Multiple Imaging"
"Ultrasound Trgt Dynamic Microbubble 1st Lesion","PX-40000152","CDM","76978","CPT","0402","RC","","","","outpatient","","","2164.00","1623.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","548.73","548.73","548.73","1 through 10","201.74","1768.42","other","Multiple Radiology"
"Ultrasound Trgt Dynamic Microbubble 1st Lesion","PX-40000152","CDM","76978","CPT","0402","RC","","","","outpatient","","","2164.00","1623.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","905.81","905.81","905.81","1 through 10","201.74","1768.42","other","Multiple Radiology"
"Uncomplicated Peptic Ulcer Without McC","384","MS-DRG","","","","","","","","inpatient","","","44401.90","33301.42","MEDICARE [2001]","HB BWH MEDICARE","8177.42","","Case rate ($8,177.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,766.59, add-ons for qualifying new technology services are included. If operating cost exceeds $55,411.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,127.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,109.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,386.74 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $687.82. The transfer capital threshold is the transfer adjustment factor * $687.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10530.13","10530.13","10530.13","1 through 10","8013.87","13123.1336","other","Inpatient Replacement Plans DRG"
"Univ of Alabama Medical Disease Center, Multi Menningioma Pnl","PX-31001216","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Univ of Alabama Medical Disease Center, Multi Menningioma Pnl","PX-31001216","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Univ of Alabama Medical Disease Center, Multi Menningioma Pnl","PX-31001216","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Univ of Alabama Medical Disease Center, Multi Menningioma Pnl","PX-31001216","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Univ of Chicago, 4103 Single Gene Repeat Expansion 13 Genes Uc410","PX-31001201","CDM","81479","CPT","0310","RC","","","","both","","","1621.00","1215.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1288.70","79.5","","0.65","0.65","0.65","1 through 10","502.51","1539.95","percent of total billed charges",""
"Univ of Chicago, 4103 Single Gene Repeat Expansion 13 Genes Uc410","PX-31001201","CDM","81479","CPT","0310","RC","","","","both","","","1621.00","1215.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","863.99","53.3","","0.79","0.79","0.79","1 through 10","502.51","1539.95","percent of total billed charges",""
"Univ of Chicago, 4103 Single Gene Repeat Expansion 13 Genes Uc410","PX-31001201","CDM","81479","CPT","0310","RC","","","","outpatient","","","1621.00","1215.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","810.50","50","","1.00","1.00","1.00","1 through 10","156.55","1337.33","percent of total billed charges",""
"Univ of Chicago, 4103 Single Gene Repeat Expansion 13 Genes Uc410","PX-31001201","CDM","81479","CPT","0310","RC","","","","outpatient","","","1621.00","1215.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","851.03","52.5","","1.00","0.53","1.00","1 through 10","156.55","1337.33","percent of total billed charges",""
"Univ of Pennsylvania School of Medicine, Cdkn1c Sequencing","PX-31001232","CDM","81479","CPT","0310","RC","","","","both","","","1311.00","983.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1042.25","79.5","","0.65","0.65","0.65","1 through 10","406.41","1245.45","percent of total billed charges",""
"Univ of Pennsylvania School of Medicine, Cdkn1c Sequencing","PX-31001232","CDM","81479","CPT","0310","RC","","","","both","","","1311.00","983.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","698.76","53.3","","0.79","0.79","0.79","1 through 10","406.41","1245.45","percent of total billed charges",""
"Univ of Pennsylvania School of Medicine, Cdkn1c Sequencing","PX-31001232","CDM","81479","CPT","0310","RC","","","","outpatient","","","1311.00","983.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","655.50","50","","1.00","1.00","1.00","1 through 10","156.55","1081.58","percent of total billed charges",""
"Univ of Pennsylvania School of Medicine, Cdkn1c Sequencing","PX-31001232","CDM","81479","CPT","0310","RC","","","","outpatient","","","1311.00","983.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","688.28","52.5","","1.00","0.53","1.00","1 through 10","156.55","1081.58","percent of total billed charges",""
"Univ of Pennsylvania School of Medicine, Russell Silver Syndrome Rss Met","PX-31001233","CDM","81479","CPT","0310","RC","","","","both","","","627.00","470.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","498.47","79.5","","0.65","0.65","0.65","1 through 10","194.37","595.65","percent of total billed charges",""
"Univ of Pennsylvania School of Medicine, Russell Silver Syndrome Rss Met","PX-31001233","CDM","81479","CPT","0310","RC","","","","both","","","627.00","470.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","334.19","53.3","","0.79","0.79","0.79","1 through 10","194.37","595.65","percent of total billed charges",""
"Univ of Pennsylvania School of Medicine, Russell Silver Syndrome Rss Met","PX-31001233","CDM","81479","CPT","0310","RC","","","","outpatient","","","627.00","470.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","313.50","50","","1.00","1.00","1.00","1 through 10","156.55","517.28","percent of total billed charges",""
"Univ of Pennsylvania School of Medicine, Russell Silver Syndrome Rss Met","PX-31001233","CDM","81479","CPT","0310","RC","","","","outpatient","","","627.00","470.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","329.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","517.28","percent of total billed charges",""
"Upgrade Pacemaker Implanted","PX-48000050","CDM","33214","CPT","0361","RC","","","","both","","","13489.00","10116.75","MEDICARE [2001]","HB BWH MEDICARE","12426.95","","APC Price ($12,426.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","23309.00","23309.00","23309.00","1 through 10","4181.59","15533.69","other","OPPS APC"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","","","","inpatient","","","141859.10","106394.32","MEDICARE [2001]","HB BWH MEDICARE","20481.16","","Case rate ($20,481.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,024.85, add-ons for qualifying new technology services are included. If operating cost exceeds $64,669.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,806.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $18,735.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,645.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,366.23. The transfer capital threshold is the transfer adjustment factor * $1,366.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20245.58","20245.58","20275.44","1 through 10","15550.9","25559.6267","other","Inpatient DRG"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","","","","inpatient","","","141859.10","106394.32","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15550.90","","Case rate ($15,868.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,024.85, add-ons for qualifying new technology services are included. If operating cost exceeds $64,669.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,806.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $14,122.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,645.01 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,366.23. The transfer capital threshold is the transfer adjustment factor * $1,366.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15376.02","15376.02","15376.02","1 through 10","15550.9","25559.6267","other","Inpatient DRG"
"Upper Limb And Toe Amputation For Circulatory System Disorders With McC","255","MS-DRG","","","","","","","","inpatient","","","93396.61","70047.46","MEDICARE [2001]","HB BWH MEDICARE","32314.16","","Case rate ($32,314.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,000.58, add-ons for qualifying new technology services are included. If operating cost exceeds $75,645.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,610.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $29,763.83 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,620.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,170.49. The transfer capital threshold is the transfer adjustment factor * $2,170.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17930.23","17930.23","17930.23","1 through 10","24486.09","39485.6015","other","Inpatient DRG"
"Upper Limb And Toe Amputation For Circulatory System Disorders With McC","255","MS-DRG","","","","","","","","inpatient","","","93396.61","70047.46","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","24486.09","","Case rate ($24,985.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $30,000.58, add-ons for qualifying new technology services are included. If operating cost exceeds $75,645.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,610.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $22,435.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $29,620.73 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,170.49. The transfer capital threshold is the transfer adjustment factor * $2,170.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","79152.60","79152.60","79152.60","1 through 10","24486.09","39485.6015","other","Inpatient DRG"
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","both","","","58.00","43.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","38.05","65.6","","43.68","43.68","43.68","1 through 10","3.87","55.1","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","both","","","58.00","43.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","46.11","79.5","","44.07","29.57","44.07","46","3.87","55.1","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","both","","","58.00","43.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","30.91","53.3","","29.57","29.57","44.07","19","3.87","55.1","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","both","","","58.00","43.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","17.98","31","","17.30","17.30","17.30","1 through 10","3.87","55.1","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","both","","","58.00","43.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","21.17","36.5","","20.89","17.75","20.89","46","3.87","55.1","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","both","","","58.00","43.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","22.21","38.3","","21.90","21.28","65.70","101","3.87","55.1","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","both","","","58.00","43.50","TRICARE [160005]","HB BWH TRICARE","55.10","95","","4.76","4.76","4.76","1 through 10","3.87","55.1","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","both","","","58.00","43.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.88","42.9","","44.77","24.62","44.77","1 through 10","3.87","55.1","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","both","","","58.00","43.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.88","42.9","","24.62","24.62","24.62","1 through 10","3.87","55.1","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","outpatient","","","58.00","43.50","AETNA [1001]","HB AMC AETNA HMO","40.48","69.8","","37.91","26.77","43.68","52","4.07","47.4","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","outpatient","","","58.00","43.50","AETNA [1001]","HB AMC AETNA PPO","46.63","80.4","","43.68","26.77","43.68","1 through 10","4.07","47.4","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","outpatient","","","58.00","43.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","47.40","81.72","","44.77","44.77","44.77","1 through 10","4.07","47.4","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","outpatient","","","58.00","43.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","47.40","81.72","","44.77","44.77","44.77","1 through 10","4.07","47.4","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","outpatient","","","58.00","43.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","47.40","81.72","","44.77","24.62","44.77","39","4.07","47.4","percent of total billed charges",""
"Urea Nitrogen Urine","PX-30000723","CDM","84540","CPT","0301","RC","","","","both","","","85.00","63.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","67.58","79.5","","64.53","64.53","64.53","1 through 10","4.89","80.75","percent of total billed charges",""
"Urea Nitrogen Urine","PX-30000723","CDM","84540","CPT","0301","RC","","","","both","","","85.00","63.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","45.31","53.3","","41.41","41.41","41.41","1 through 10","4.89","80.75","percent of total billed charges",""
"Urea Nitrogen Urine","PX-30000723","CDM","84540","CPT","0301","RC","","","","both","","","85.00","63.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","31.03","36.5","","77.97","77.97","77.97","1 through 10","4.89","80.75","percent of total billed charges",""
"Urea Nitrogen Urine","PX-30000723","CDM","84540","CPT","0301","RC","","","","both","","","85.00","63.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","32.56","38.3","","32.06","27.06","32.06","1 through 10","4.89","80.75","percent of total billed charges",""
"Urea Nitrogen Urine","PX-30000723","CDM","84540","CPT","0301","RC","","","","outpatient","","","85.00","63.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","69.46","81.72","","65.55","36.06","65.55","1 through 10","4.89","69.46","percent of total billed charges",""
"Urethral And Transurethral Procedures,EXTREME","446","DRG","","","","","","","","inpatient","","","124269.00","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","98052.59","","Fee schedule rate ($98,052.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","98052.59","98052.59","98052.59","1 through 10","6055.68","145907.87","case rate",""
"Urethral And Transurethral Procedures,MAJOR","446","DRG","","","","","","","","inpatient","","","78443.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","50050.93","","Standard inlier is a Case rate ($50,050.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,570, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,105.03) for the length of stay and the standard reimbursement.","45623.24","45623.24","45623.24","1 through 10","6055.68","145907.87","case rate",""
"Urethral And Transurethral Procedures,MAJOR","446","DRG","","","","","","","","inpatient","","","78443.25","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","56270.74","","Standard inlier is a Case rate ($56,270.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,570, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,987.16) for the length of stay and the standard reimbursement.","51408.17","51408.17","51408.17","1 through 10","6055.68","145907.87","case rate",""
"Urethral And Transurethral Procedures,MINOR","446","DRG","","","","","","","","inpatient","","","62535.51","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6055.68","","Case rate ($6,695.60). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,125.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6693.95","6693.95","6693.95","1 through 10","6055.68","145907.87","case rate",""
"Urethral Procedures With Cc/McC","671","MS-DRG","","","","","","","","inpatient","","","144091.59","108068.69","FALLON HEALTH [1008]","HB BWH MEDICARE","16754.01","","Case rate ($16,754.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,091.12, add-ons for qualifying new technology services are included. If operating cost exceeds $65,735.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,884.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $14,929.82 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,711.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,444.36. The transfer capital threshold is the transfer adjustment factor * $1,444.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15923.75","15923.75","15923.75","1 through 10","16418.93","26012.3567","other","Inpatient Replacement Plans DRG"
"Urethral Procedures With Cc/McC","671","MS-DRG","","","","","","","","inpatient","","","144091.59","108068.69","MEDICARE [2001]","HB BWH MEDICARE","16754.01","","Case rate ($16,754.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,091.12, add-ons for qualifying new technology services are included. If operating cost exceeds $65,735.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,884.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $14,929.82 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,711.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,444.36. The transfer capital threshold is the transfer adjustment factor * $1,444.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7942.72","7942.72","7942.72","1 through 10","16418.93","26012.3567","other","Inpatient Replacement Plans DRG"
"Urethral Procedures With Cc/McC","671","MS-DRG","","","","","","","","inpatient","","","144091.59","108068.69","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16418.93","","Case rate ($16,754.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,091.12, add-ons for qualifying new technology services are included. If operating cost exceeds $65,735.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,884.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $14,929.82 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,711.28 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,444.36. The transfer capital threshold is the transfer adjustment factor * $1,444.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15629.83","15629.83","15629.83","1 through 10","16418.93","26012.3567","other","Inpatient DRG"
"Urethral Stricture","697","MS-DRG","","","","","","","","inpatient","","","22522.98","16892.23","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","10518.00","","Case rate ($10,211.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,215.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,859.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,307.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,964.54 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,835.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $867.26. The transfer capital threshold is the transfer adjustment factor * $867.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9671.82","9671.82","9671.82","1 through 10","10007.42","15118.1638","other","Inpatient DRG"
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","58.88","71.8","","57.44","57.44","57.44","1 through 10","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","53.79","65.6","","4.65","4.65","4.65","1 through 10","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","53.30","65","","52.00","52.00","52.00","1 through 10","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","57.40","70","","240.00","57.60","240.00","1 through 10","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","65.19","79.5","","62.96","42.24","62.96","195","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","43.71","53.3","","42.24","42.24","62.96","93","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","53.30","65","","52.00","52.00","52.00","1 through 10","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","25.42","31","","24.72","24.72","24.72","1 through 10","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29.93","36.5","","29.84","25.36","50.72","120","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31.41","38.3","","31.28","31.28","93.84","481","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","63.14","77","","62.40","62.40","62.40","1 through 10","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","TRICARE [160005]","HB BWH TRICARE","77.90","95","","5.45","5.18","80.00","1 through 10","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.18","42.9","","63.95","63.95","63.95","1 through 10","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","82.00","61.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.18","42.9","","35.18","35.18","35.18","1 through 10","4.43","77.9","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","82.00","61.50","AETNA [1001]","HB AMC AETNA HMO","57.24","69.8","","54.16","38.24","62.40","253","4.65","67.01","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","82.00","61.50","AETNA [1001]","HB AMC AETNA PPO","65.93","80.4","","62.40","38.24","125.76","29","4.65","67.01","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","82.00","61.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","42.85","52.26","","12.87","4.07","49.50","1 through 10","4.65","67.01","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","82.00","61.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","65.93","80.4","","62.40","62.40","62.40","1 through 10","4.65","67.01","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","67.01","81.72","","39.84","35.18","63.95","1 through 10","4.65","67.01","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","67.01","81.72","","63.95","35.18","63.95","169","4.65","67.01","percent of total billed charges",""
"Uric Acid Other Source","PX-30000726","CDM","84560","CPT","0301","RC","","","","both","","","81.00","60.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29.57","36.5","","29.47","29.47","29.47","1 through 10","4.89","76.95","percent of total billed charges",""
"Uric Acid Other Source","PX-30000726","CDM","84560","CPT","0301","RC","","","","both","","","81.00","60.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31.02","38.3","","30.89","26.07","30.89","1 through 10","4.89","76.95","percent of total billed charges",""
"Uric Acid Other Source","PX-30000726","CDM","84560","CPT","0301","RC","","","","outpatient","","","81.00","60.75","AETNA [1001]","HB AMC AETNA HMO","56.54","69.8","","53.48","51.09","53.48","1 through 10","4.89","66.19","percent of total billed charges",""
"Uric Acid Other Source","PX-30000726","CDM","84560","CPT","0301","RC","","","","outpatient","","","81.00","60.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","66.19","81.72","","63.15","63.15","63.15","1 through 10","4.89","66.19","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","35.18","71.8","","34.46","34.46","103.38","57","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","32.14","65.6","","32.50","32.50","37.44","1 through 10","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","31.85","65","","31.20","25.34","37.78","56","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","34.30","70","","38.37","20.64","61.92","36","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","CHAMPVA [160001]","HB BWH TRICARE","46.55","95","","3.82","3.82","3.82","1 through 10","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","38.96","79.5","","37.78","25.34","37.78","419","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","26.12","53.3","","25.34","25.34","76.02","238","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","37.73","77","","36.96","36.96","110.88","1 through 10","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","31.85","65","","31.20","30.55","31.20","1 through 10","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","38.96","79.5","","37.78","37.78","37.78","1 through 10","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","15.19","31","","14.83","14.83","44.49","24","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17.89","36.5","","17.90","15.22","17.90","503","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18.77","38.3","","18.77","18.24","36.48","1487","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","MOLINA [1014]","HB BWH MOLINA","17.15","35","","6.29","3.17","9.41","18","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","37.73","77","","37.44","3.96","420.14","1 through 10","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","TRICARE [160005]","HB BWH TRICARE","46.55","95","","3.82","3.63","48.00","29","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21.02","42.9","","38.37","21.11","38.37","24","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","49.00","36.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","21.02","42.9","","21.11","21.11","21.11","1 through 10","3.11","46.55","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","49.00","36.75","AETNA [1001]","HB AMC AETNA HMO","34.20","69.8","","32.50","22.94","37.44","705","3.27","40.04","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","49.00","36.75","AETNA [1001]","HB AMC AETNA PPO","39.40","80.4","","37.44","25.15","37.44","77","3.27","40.04","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","49.00","36.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","27.39","55.9","","25.15","25.15","25.15","1 through 10","3.27","40.04","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","49.00","36.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","25.61","52.26","","11.34","11.34","29.71","1 through 10","3.27","40.04","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","49.00","36.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","39.40","80.4","","37.44","24.00","37.44","12","3.27","40.04","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","49.00","36.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","40.04","81.72","","38.37","36.19","38.37","1 through 10","3.27","40.04","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","49.00","36.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","40.04","81.72","","21.11","19.97","38.37","25","3.27","40.04","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","49.00","36.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","40.04","81.72","","38.37","21.11","38.37","533","3.27","40.04","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","26.57","71.8","","25.85","1.98","77.55","1 through 10","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","24.27","65.6","","2.31","2.31","2.31","1 through 10","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","24.05","65","","23.40","19.01","23.40","1 through 10","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","25.90","70","","35.00","15.48","36.00","1 through 10","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","29.42","79.5","","28.33","19.01","28.33","299","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","19.72","53.3","","19.01","19.01","28.33","138","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","28.49","77","","27.72","27.72","27.72","1 through 10","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","24.05","65","","23.40","23.40","23.40","1 through 10","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","11.47","31","","11.12","11.12","11.12","1 through 10","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","13.51","36.5","","13.43","11.41","39.09","253","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","14.17","38.3","","14.08","13.68","42.24","755","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","MOLINA [1014]","HB BWH MOLINA","12.95","35","","4.46","2.25","4.46","1 through 10","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","28.49","77","","26.39","26.39","26.39","1 through 10","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","TRICARE [160005]","HB BWH TRICARE","35.15","95","","2.71","2.57","2.71","1 through 10","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.87","42.9","","28.78","15.83","28.78","11","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","37.00","27.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.87","42.9","","15.83","15.83","15.83","1 through 10","2.21","35.15","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","37.00","27.75","AETNA [1001]","HB AMC AETNA HMO","25.83","69.8","","24.37","17.21","28.08","385","2.31","30.24","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","37.00","27.75","AETNA [1001]","HB AMC AETNA PPO","29.75","80.4","","28.08","18.34","28.08","48","2.31","30.24","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","37.00","27.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","20.68","55.9","","18.86","18.86","18.86","1 through 10","2.31","30.24","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","37.00","27.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","19.34","52.26","","8.24","8.24","22.28","1 through 10","2.31","30.24","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","37.00","27.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","29.75","80.4","","28.08","18.00","28.08","1 through 10","2.31","30.24","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","37.00","27.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","30.24","81.72","","36.00","28.78","36.00","1 through 10","2.31","30.24","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","30.24","81.72","","28.78","15.83","28.78","14","2.31","30.24","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","30.24","81.72","","28.78","15.83","28.78","288","2.31","30.24","percent of total billed charges",""
"Urinalysis Micro Only","PX-30001379","CDM","81015","CPT","0307","RC","","","","both","","","47.00","35.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","25.05","53.3","","24.29","24.29","24.29","1 through 10","2.99","44.65","percent of total billed charges",""
"Urinalysis Micro Only","PX-30001379","CDM","81015","CPT","0307","RC","","","","both","","","47.00","35.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17.16","36.5","","14.58","14.58","14.58","1 through 10","2.99","44.65","percent of total billed charges",""
"Urinalysis Micro Only","PX-30001379","CDM","81015","CPT","0307","RC","","","","both","","","47.00","35.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18.00","38.3","","17.99","17.99","17.99","1 through 10","2.99","44.65","percent of total billed charges",""
"Urinalysis Micro Only","PX-30001379","CDM","81015","CPT","0307","RC","","","","outpatient","","","47.00","35.25","AETNA [1001]","HB AMC AETNA PPO","37.79","80.4","","35.88","35.88","35.88","1 through 10","3.14","38.41","percent of total billed charges",""
"Urinalysis Micro Only","PX-30001379","CDM","81015","CPT","0307","RC","","","","outpatient","","","47.00","35.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","38.41","81.72","","14.54","14.54","14.54","1 through 10","3.14","38.41","percent of total billed charges",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,EXTREME","465","DRG","","","","","","","","inpatient","","","70642.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","55206.09","","Standard inlier is a Case rate ($55,206.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,579, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,836.84) for the length of stay and the standard reimbursement.","55206.08","55206.08","55206.08","1 through 10","4095.38","88998.82","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,EXTREME","465","DRG","","","","","","","","inpatient","","","70642.44","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","62066.52","","Standard inlier is a Case rate ($62,066.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $54,579, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,809.83) for the length of stay and the standard reimbursement.","56703.12","56703.12","56703.12","1 through 10","4095.38","88998.82","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MAJOR","465","DRG","","","","","","","","inpatient","","","40736.75","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","31781.50","","Standard inlier is a Case rate ($31,781.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,362, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,511.58) for the length of stay and the standard reimbursement.","31781.50","31781.50","31781.50","1 through 10","4095.38","88998.82","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MAJOR","465","DRG","","","","","","","","inpatient","","","40736.75","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","35730.97","","Standard inlier is a Case rate ($35,730.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $36,362, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,071.71) for the length of stay and the standard reimbursement.","35730.97","35730.97","35730.97","1 through 10","4095.38","88998.82","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MAJOR","465","DRG","","","","","","","","inpatient","","","40736.75","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","24766.9791","","Fee schedule rate ($19,911.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24766.9791","19911.12","19911.12","1 through 10","4095.38","88998.82","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MAJOR","465","DRG","","","","","","","","inpatient","","","40736.75","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9651.3605","","Fee schedule rate ($19,911.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9651.3605","19911.12","19911.12","1 through 10","4095.38","88998.82","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MAJOR","465","DRG","","","","","","","","inpatient","","","40736.75","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","28141.69","","Fee schedule rate ($28,141.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28141.69","28141.69","28141.69","1 through 10","4095.38","88998.82","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MINOR","465","DRG","","","","","","","","inpatient","","","46807.90","","MASSHEALTH [3001]","HB BWH MEDICAID","4095.38","","Case rate ($4,528.15). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $46,958.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4527.03","4527.03","4527.03","1 through 10","4095.38","88998.82","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MODERATE","465","DRG","","","","","","","","inpatient","","","35834.81","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","21590.57","","Standard inlier is a Case rate ($21,590.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $26,581, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,064.60) for the length of stay and the standard reimbursement.","19724.84","19724.84","19724.84","1 through 10","4095.38","88998.82","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MODERATE","465","DRG","","","","","","","","inpatient","","","35834.81","","MASSHEALTH [3001]","HB BWH MEDICAID","4561.47","","Case rate ($5,043.49). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,473.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5246.55","5246.55","5246.55","1 through 10","4095.38","88998.82","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MODERATE","465","DRG","","","","","","","","inpatient","","","35834.81","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","4561.47","","Case rate ($5,043.49). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,473.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5042.25","5042.25","5042.25","1 through 10","4095.38","88998.82","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MODERATE","465","DRG","","","","","","","","inpatient","","","35834.81","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","4561.47","","Case rate ($5,043.49). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $47,473.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15297.45","15297.45","15297.45","1 through 10","4095.38","88998.82","case rate",""
"Urinary Stones With McC","693","MS-DRG","","","","","","","","inpatient","","","47899.51","35924.63","MEDICARE [2001]","HB BWH MEDICARE","16297.27","","Case rate ($16,297.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $15,144.08, add-ons for qualifying new technology services are included. If operating cost exceeds $60,788.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,522.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $14,835.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $14,764.25 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,081.86. The transfer capital threshold is the transfer adjustment factor * $1,081.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17613.05","17613.05","17613.05","1 through 10","12391.62","21060.25","other","Inpatient DRG"
"Urinary Stones Without McC","694","MS-DRG","","","","","","","","inpatient","","","47115.44","35336.58","MEDICARE [2001]","HB BWH MEDICARE","7510.59","","Case rate ($7,510.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,963.86, add-ons for qualifying new technology services are included. If operating cost exceeds $54,608.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,069.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,501.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,584.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.00. The transfer capital threshold is the transfer adjustment factor * $629.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1087.88","293.64","9504.09","1 through 10","7360.38","11792.1074","other","Inpatient Replacement Plans DRG"
"Urinary Stones Without McC","694","MS-DRG","","","","","","","","inpatient","","","47115.44","35336.58","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7360.38","","Case rate ($7,510.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,963.86, add-ons for qualifying new technology services are included. If operating cost exceeds $54,608.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,069.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,501.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,584.02 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $629.00. The transfer capital threshold is the transfer adjustment factor * $629.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7292.17","7292.17","7292.17","1 through 10","7360.38","11792.1074","other","Inpatient DRG"
"Urine Cath; Str Up W/WO Coat(Tfl, Sil, Hydro, Etc)","PX-27001136","CDM","A4351","HCPCS","0272","RC","","","","both","","","8.16","6.12","WELLPOINT [1015]","HB AMC WELLPOINT","6.02","73.78","","6.08","6.08","6.08","1 through 10","2.53","6.49","percent of total billed charges",""
"Urine Cath; Str Up W/WO Coat(Tfl, Sil, Hydro, Etc)","PX-27001136","CDM","A4351","HCPCS","0272","RC","","","","outpatient","","","8.16","6.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6.67","81.72","","3.59","3.59","3.59","1 through 10","4.26","6.67","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","AETNA [1001]","HB AMC AETNA HMO","73.29","69.8","","69.05","48.76","79.56","201","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","58.70","55.9","","53.45","53.45","53.45","1 through 10","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","75.39","71.8","","73.24","73.24","73.24","1 through 10","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","68.88","65.6","","79.56","69.05","79.56","1 through 10","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","68.25","65","","53.86","53.86","53.86","1 through 10","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","73.50","70","","81.60","43.86","102.00","1 through 10","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","83.48","79.5","","80.27","53.86","240.81","139","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","55.97","53.3","","80.27","53.86","206.04","86","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","80.85","77","","235.62","235.62","235.62","1 through 10","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","68.25","65","","66.30","64.35","66.30","1 through 10","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","83.48","79.5","","80.24","8.32","80.25","1 through 10","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","68.25","65","","1100.00","1100.00","1100.00","1 through 10","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","32.55","31","","94.56","31.52","94.56","13","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","38.33","36.5","","38.05","32.33","114.15","176","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","40.22","38.3","","39.88","38.76","119.64","478","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","80.85","77","","80.27","79.56","80.27","1 through 10","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","TRICARE [160005]","HB BWH TRICARE","99.75","95","","102.00","10.38","102.00","1 through 10","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.05","42.9","","81.54","44.85","102.00","1 through 10","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.05","42.9","","44.85","44.85","44.85","1 through 10","6.52","99.75","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","105.00","78.75","AETNA [1001]","HB AMC AETNA PPO","84.42","80.4","","53.45","48.76","106.90","33","6.52","85.81","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","105.00","78.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","54.87","52.26","","63.12","63.12","63.12","1 through 10","6.52","85.81","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","84.42","80.4","","79.56","51.00","79.56","1 through 10","6.52","85.81","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","85.81","81.72","","102.00","102.00","105.99","1 through 10","6.52","85.81","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","85.81","81.72","","44.85","44.85","81.54","1 through 10","6.52","85.81","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","85.81","81.72","","81.54","44.85","81.54","134","6.52","85.81","percent of total billed charges",""
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","both","","","717.00","537.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","570.02","79.5","","546.97","546.97","546.97","1 through 10","222.27","570.02","percent of total billed charges",""
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","both","","","717.00","537.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","382.16","53.3","","366.96","366.96","366.96","1 through 10","222.27","570.02","percent of total billed charges",""
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","both","","","717.00","537.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","466.05","65","","451.75","368.35","451.75","1 through 10","222.27","570.02","percent of total billed charges",""
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","both","","","717.00","537.75","MEDICARE [2001]","HB BWH MEDICARE","369.77","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","342.57","342.57","342.57","1 through 10","222.27","570.02","other","OPPS APC"
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","both","","","717.00","537.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","362.37","","APC Price ($369.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.41","362.41","362.41","1 through 10","222.27","570.02","other","OPPS APC"
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","both","","","717.00","537.75","WELLPOINT [1015]","HB AMC WELLPOINT","529.00","73.78","","517.43","517.43","517.43","1 through 10","222.27","570.02","percent of total billed charges",""
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","outpatient","","","717.00","537.75","AETNA [1001]","HB AMC AETNA HMO","500.47","69.8","","194.33","194.33","194.33","1 through 10","135.95","585.93","percent of total billed charges",""
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","outpatient","","","717.00","537.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","155.47","","Case rate ($155.47). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","156.17","156.17","159.05","13","135.95","585.93","other","ASC"
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","outpatient","","","717.00","537.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","155.47","","Case rate ($155.47). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","180.19","180.19","360.38","27","135.95","585.93","other","ASC "
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","outpatient","","","717.00","537.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","135.95","","Case rate ($135.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","174.02","174.02","174.02","1 through 10","135.95","585.93","other","Multiple Surgery"
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","outpatient","","","717.00","537.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","135.95","","Case rate ($135.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","157.70","151.59","315.40","1 through 10","135.95","585.93","other","Multiple Surgery"
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","outpatient","","","717.00","537.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","135.95","","Case rate ($135.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","165.86","159.74","165.86","1 through 10","135.95","585.93","other","Multiple Surgery"
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","outpatient","","","717.00","537.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","135.95","","Case rate ($135.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","197.13","197.13","197.13","1 through 10","135.95","585.93","other","Multiple Surgery"
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","outpatient","","","717.00","537.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","135.95","","Case rate ($135.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","348.03","174.02","348.03","1 through 10","135.95","585.93","other","Multiple Surgery"
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","outpatient","","","717.00","537.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","576.47","80.4","","347.50","347.50","542.10","1 through 10","135.95","585.93","percent of total billed charges",""
"Uroflowmetry/Ufr Cplx","PX-76001270","CDM","51741","CPT","0761","RC","","","","outpatient","","","717.00","537.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","585.93","81.72","","555.58","555.58","555.58","1 through 10","135.95","585.93","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","40","119.97","784.67","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","708.67","71.8","","687.13","687.13","687.13","1 through 10","119.97","784.67","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","641.55","65","","622.05","622.05","622.05","1 through 10","119.97","784.67","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","124.27","114.47","220.00","1 through 10","119.97","784.67","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","784.67","79.5","","753.16","505.30","753.16","38","119.97","784.67","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","526.07","53.3","","505.30","505.30","753.16","21","119.97","784.67","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.65","1 through 10","119.97","784.67","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","ELDER SERVICES [1037]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","784.67","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","784.67","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.80","124.77","126.12","1 through 10","119.97","784.67","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","784.67","79.5","","753.16","753.16","753.16","1 through 10","119.97","784.67","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","236","119.97","784.67","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","305.97","31","","295.71","295.71","295.71","1 through 10","119.97","784.67","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","360.26","36.5","","356.96","303.37","674.46","40","119.97","784.67","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","378.02","38.3","","374.19","363.66","374.19","93","119.97","784.67","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.26","119.09","125.26","14","119.97","784.67","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","63.15","126.29","1 through 10","119.97","784.67","other","Tricare OPPS"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","372.81","119.59","377.28","30","119.97","784.67","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","423.42","42.9","","765.03","336.40","765.03","1 through 10","119.97","784.67","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","987.00","740.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.37","119.99","126.29","106","119.97","784.67","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","987.00","740.25","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","647.89","522.28","647.89","1 through 10","112.51","806.58","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","987.00","740.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","87","112.51","806.58","other","Multiple Imaging"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","987.00","740.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","187","112.51","806.58","other","Multiple Imaging"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","987.00","740.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","382.53","336.40","382.53","1 through 10","112.51","806.58","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","987.00","740.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","52","112.51","806.58","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","987.00","740.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","924.84","19","112.51","806.58","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","987.00","740.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","505.17","505.17","505.17","1 through 10","112.51","806.58","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","987.00","740.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","382.53","382.53","1 through 10","112.51","806.58","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","987.00","740.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","185.02","336.40","15","112.51","806.58","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","987.00","740.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","806.58","81.72","","765.03","420.79","765.03","34","112.51","806.58","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","20","119.97","641.57","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","524.55","65","","413.42","413.42","413.42","1 through 10","119.97","641.57","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","564.90","70","","563.76","126.29","563.76","1 through 10","119.97","641.57","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","123.76","123.76","123.76","1 through 10","119.97","641.57","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","641.57","79.5","","616.22","413.42","616.22","23","119.97","641.57","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","430.13","53.3","","616.22","413.42","616.22","12","119.97","641.57","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","104.64","124.27","1 through 10","119.97","641.57","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","621.39","77","","602.91","602.91","602.91","1 through 10","119.97","641.57","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.96","125.96","125.96","1 through 10","119.97","641.57","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","641.57","79.5","","616.22","616.22","616.22","1 through 10","119.97","641.57","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","154","119.97","641.57","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","250.17","31","","241.95","241.95","241.95","1 through 10","119.97","641.57","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","294.56","36.5","","292.06","248.21","744.63","30","119.97","641.57","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","309.08","38.3","","306.15","297.54","306.15","66","119.97","641.57","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.26","119.09","357.27","14","119.97","641.57","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","621.39","77","","681.21","681.21","681.21","1 through 10","119.97","641.57","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","119.98","126.29","1 through 10","119.97","641.57","other","Tricare OPPS"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","123.76","375.56","15","119.97","641.57","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","180.09","180.09","180.09","1 through 10","119.97","641.57","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.20","42.9","","625.93","344.29","625.93","1 through 10","119.97","641.57","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","807.00","605.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.17","119.99","126.29","36","119.97","641.57","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","807.00","605.25","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","530.09","374.27","530.09","1 through 10","112.51","659.48","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","807.00","605.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","46","112.51","659.48","other","Multiple Imaging"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","807.00","605.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","199.42","231.59","125","112.51","659.48","other","Multiple Imaging"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","807.00","605.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","382.53","336.40","382.53","1 through 10","112.51","659.48","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","807.00","605.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","293.65","918.09","49","112.51","659.48","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","807.00","605.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","308.28","320.65","14","112.51","659.48","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","807.00","605.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","382.53","382.53","1 through 10","112.51","659.48","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","807.00","605.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","151.38","336.40","1 through 10","112.51","659.48","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","807.00","605.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","659.48","81.72","","625.93","625.93","625.93","1 through 10","112.51","659.48","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","807.00","605.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","659.48","81.72","","625.93","344.29","625.93","15","112.51","659.48","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","449.00","336.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","435.00","1 through 10","119.97","356.96","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","449.00","336.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","356.96","79.5","","342.35","342.35","342.35","1 through 10","119.97","356.96","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","449.00","336.75","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","118.31","123.76","1 through 10","119.97","356.96","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","449.00","336.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","38","119.97","356.96","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","449.00","336.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","163.89","36.5","","162.26","162.26","162.26","1 through 10","119.97","356.96","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","449.00","336.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","171.97","38.3","","170.09","165.30","170.09","1 through 10","119.97","356.96","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","449.00","336.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","117.59","123.76","1 through 10","119.97","356.96","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","449.00","336.75","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","435.00","435.00","435.00","1 through 10","119.97","356.96","other","Tricare OPPS"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","449.00","336.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","119.97","356.96","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","449.00","336.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","117.60","123.77","16","119.97","356.96","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","449.00","336.75","WELLPOINT [1015]","HB AMC WELLPOINT","331.27","73.78","","323.86","323.86","323.86","1 through 10","119.97","356.96","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","449.00","336.75","AETNA [1001]","HB AMC AETNA HMO","313.40","69.8","","207.93","207.93","207.93","1 through 10","112.51","513.1","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","449.00","336.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","1 through 10","112.51","513.1","other","Multiple Imaging"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","449.00","336.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","1 through 10","112.51","513.1","other","Multiple Imaging"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","449.00","336.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","1 through 10","112.51","513.1","other","Multiple Radiology"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","449.00","336.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","513.1","other","Multiple Radiology"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","449.00","336.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","336.40","336.40","1 through 10","112.51","513.1","other","Multiple Radiology"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","449.00","336.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","366.92","81.72","","347.74","191.27","347.74","1 through 10","112.51","513.1","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","20","37.51","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","78.65","65","","413.42","413.42","413.42","1 through 10","37.51","360.14","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","84.70","70","","563.76","126.29","563.76","1 through 10","37.51","360.14","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","123.76","123.76","123.76","1 through 10","37.51","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","96.20","79.5","","616.22","413.42","616.22","23","37.51","360.14","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","64.49","53.3","","616.22","413.42","616.22","12","37.51","360.14","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","104.64","124.27","1 through 10","37.51","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","93.17","77","","602.91","602.91","602.91","1 through 10","37.51","360.14","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.96","125.96","125.96","1 through 10","37.51","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","96.20","79.5","","616.22","616.22","616.22","1 through 10","37.51","360.14","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","154","37.51","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","37.51","31","","241.95","241.95","241.95","1 through 10","37.51","360.14","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","44.17","36.5","","292.06","248.21","744.63","30","37.51","360.14","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","46.34","38.3","","306.15","297.54","306.15","66","37.51","360.14","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.26","119.09","357.27","14","37.51","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","93.17","77","","681.21","681.21","681.21","1 through 10","37.51","360.14","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","119.98","126.29","1 through 10","37.51","360.14","other","Tricare OPPS"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","123.76","375.56","15","37.51","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","180.09","180.09","180.09","1 through 10","37.51","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","51.91","42.9","","625.93","344.29","625.93","1 through 10","37.51","360.14","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.17","119.99","126.29","36","37.51","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","530.09","374.27","530.09","1 through 10","98.88","513.1","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","46","98.88","513.1","other","Multiple Imaging"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","199.42","231.59","125","98.88","513.1","other","Multiple Imaging"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","382.53","336.40","382.53","1 through 10","98.88","513.1","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","293.65","918.09","49","98.88","513.1","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","308.28","320.65","14","98.88","513.1","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","382.53","382.53","1 through 10","98.88","513.1","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","151.38","336.40","1 through 10","98.88","513.1","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","98.88","81.72","","625.93","625.93","625.93","1 through 10","98.88","513.1","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","98.88","81.72","","625.93","344.29","625.93","15","98.88","513.1","percent of total billed charges",""
"US Breast Uni Real Time With Image Complete","PX-40000139","CDM","76641","CPT","0402","RC","","","","both","","","476.00","357.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","309.40","65","","600.60","600.60","600.60","1 through 10","119.97","436.4","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","364.00","273.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","289.38","79.5","","555.62","277.81","1201.75","1 through 10","99.34","289.38","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","364.00","273.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","194.01","53.3","","186.38","186.38","186.38","1 through 10","99.34","289.38","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","364.00","273.00","TRICARE [160005]","HB BWH TRICARE","99.34","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","104.56","104.56","104.56","1 through 10","99.34","289.38","other","Tricare OPPS"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.16","42.9","","279.42","279.42","279.42","1 through 10","99.34","289.38","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.20","102.67","79","99.34","289.38","other","OPPS APC"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","364.00","273.00","AETNA [1001]","HB AMC AETNA HMO","254.07","69.8","","238.98","168.73","477.96","20","62.3","333.74","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","364.00","273.00","AETNA [1001]","HB AMC AETNA PPO","292.66","80.4","","275.34","275.34","275.34","1 through 10","62.3","333.74","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","364.00","273.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","62.30","","Case rate ($62.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","317.73","317.73","317.73","1 through 10","62.3","333.74","other","Multiple Radiology"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","364.00","273.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","62.30","","Case rate ($62.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","169.46","169.46","169.46","1 through 10","62.3","333.74","other","Multiple Radiology"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","364.00","273.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","62.30","","Case rate ($62.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","256.05","177.56","569.75","11","62.3","333.74","other","Multiple Radiology"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","364.00","273.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","62.30","","Case rate ($62.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","355.12","177.56","355.12","1 through 10","62.3","333.74","other","Multiple Radiology"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","364.00","273.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","62.30","","Case rate ($62.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","186.28","179.42","372.56","35","62.3","333.74","other","Multiple Radiology"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","297.46","81.72","","310.42","310.42","310.42","1 through 10","62.3","333.74","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","297.46","81.72","","310.42","177.56","564.38","1 through 10","62.3","333.74","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited|BILATERAL PROCEDURE","PX-40000140","CDM","76642","CPT","0402","RC","","","50","both","","","364.00","273.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","90.15","114.99","other","OPPS APC"
"US Breast Uni Real Time With Image Limited|BILATERAL PROCEDURE","PX-40000140","CDM","76642","CPT","0402","RC","","","50","both","","","364.00","273.00","MEDICARE [2001]","HB BWH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","40","90.15","114.99","other","OPPS APC"
"US Breast Uni Real Time With Image Limited|BILATERAL PROCEDURE","PX-40000140","CDM","76642","CPT","0402","RC","","","50","both","","","364.00","273.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","90.15","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","104.47","99.18","311.29","1 through 10","90.15","114.99","other","OPPS APC"
"US Breast Uni Real Time With Image Limited|BILATERAL PROCEDURE","PX-40000140","CDM","76642","CPT","0402","RC","","","50","both","","","364.00","273.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","90.15","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","99.18","104.56","18","90.15","114.99","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","599.00","449.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","59.53","59.53","59.53","1 through 10","119.97","476.21","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","599.00","449.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","476.21","79.5","","457.25","457.25","457.25","1 through 10","119.97","476.21","percent of total billed charges",""
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","599.00","449.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","319.27","53.3","","306.77","306.77","306.77","1 through 10","119.97","476.21","percent of total billed charges",""
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","599.00","449.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","476.21","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","599.00","449.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","218.64","36.5","","216.71","216.71","216.71","1 through 10","119.97","476.21","percent of total billed charges",""
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","599.00","449.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","229.42","38.3","","227.17","220.78","681.51","1 through 10","119.97","476.21","percent of total billed charges",""
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","599.00","449.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","123.76","125.76","1 through 10","119.97","476.21","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","599.00","449.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","123.77","123.77","1 through 10","119.97","476.21","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","599.00","449.25","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","393.34","393.34","393.34","1 through 10","112.51","489.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","599.00","449.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","1 through 10","112.51","489.5","other","Multiple Imaging"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","599.00","449.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","115.80","231.59","1 through 10","112.51","489.5","other","Multiple Imaging"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","599.00","449.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","1 through 10","112.51","489.5","other","Multiple Radiology"
"US Chest|REDUCED SERVICES","PX-40000030","CDM","76604","CPT","0402","RC","","","52","both","","","599.00","449.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","59.04","59.04","59.04","1 through 10","119.97","157.84","other","OPPS APC"
"US Chest|REDUCED SERVICES","PX-40000030","CDM","76604","CPT","0402","RC","","","52","both","","","599.00","449.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","61.89","61.89","61.89","1 through 10","119.97","157.84","other","OPPS APC"
"US Chest|REDUCED SERVICES","PX-40000030","CDM","76604","CPT","0402","RC","","","52","both","","","599.00","449.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.14","60.00","63.14","1 through 10","119.97","157.84","other","OPPS APC"
"US Chest|REDUCED SERVICES","PX-40000030","CDM","76604","CPT","0402","RC","","","52","both","","","599.00","449.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","61.89","61.89","61.89","1 through 10","119.97","157.84","other","OPPS APC"
"US Chest|REDUCED SERVICES","PX-40000030","CDM","76604","CPT","0402","RC","","","52","both","","","599.00","449.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","58.80","58.80","58.80","1 through 10","119.97","157.84","other","OPPS APC"
"US Elastography Organ Parenchyma","PX-40000158","CDM","76981","CPT","0402","RC","","","","both","","","544.00","408.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","432.48","79.5","","415.54","415.54","415.54","1 through 10","119.97","432.48","percent of total billed charges",""
"US Elastography Organ Parenchyma","PX-40000158","CDM","76981","CPT","0402","RC","","","","both","","","544.00","408.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","289.95","53.3","","415.54","278.78","415.54","1 through 10","119.97","432.48","percent of total billed charges",""
"US Elastography Organ Parenchyma","PX-40000158","CDM","76981","CPT","0402","RC","","","","both","","","544.00","408.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","432.48","other","OPPS APC"
"US Elastography Organ Parenchyma","PX-40000158","CDM","76981","CPT","0402","RC","","","","both","","","544.00","408.00","WELLPOINT [1015]","HB AMC WELLPOINT","401.36","73.78","","393.10","393.10","393.10","1 through 10","119.97","432.48","percent of total billed charges",""
"US Elastography Organ Parenchyma","PX-40000158","CDM","76981","CPT","0402","RC","","","","outpatient","","","544.00","408.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","221.13","","Case rate ($221.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","221.13","221.13","221.13","1 through 10","112.51","444.56","other","Multiple Imaging"
"US Elastography Organ Parenchyma","PX-40000158","CDM","76981","CPT","0402","RC","","","","outpatient","","","544.00","408.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","444.56","other","Multiple Radiology"
"US Elastography Organ Parenchyma","PX-40000158","CDM","76981","CPT","0402","RC","","","","outpatient","","","544.00","408.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","444.56","81.72","","422.08","422.08","422.08","1 through 10","112.51","444.56","percent of total billed charges",""
"US Elastography Organ Parenchyma","PX-98302451","CDM","76981","CPT","0983","RC","","","","both","","","124.00","93.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","98.58","79.5","","415.54","415.54","415.54","1 through 10","38.44","157.84","percent of total billed charges",""
"US Elastography Organ Parenchyma","PX-98302451","CDM","76981","CPT","0983","RC","","","","both","","","124.00","93.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","66.09","53.3","","415.54","278.78","415.54","1 through 10","38.44","157.84","percent of total billed charges",""
"US Elastography Organ Parenchyma","PX-98302451","CDM","76981","CPT","0983","RC","","","","both","","","124.00","93.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","38.44","157.84","other","OPPS APC"
"US Elastography Organ Parenchyma","PX-98302451","CDM","76981","CPT","0983","RC","","","","both","","","124.00","93.00","WELLPOINT [1015]","HB AMC WELLPOINT","91.49","73.78","","393.10","393.10","393.10","1 through 10","38.44","157.84","percent of total billed charges",""
"US Elastography Organ Parenchyma","PX-98302451","CDM","76981","CPT","0983","RC","","","","outpatient","","","124.00","93.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","221.13","","Case rate ($221.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","221.13","221.13","221.13","1 through 10","69.32","252.37","other","Multiple Imaging"
"US Elastography Organ Parenchyma","PX-98302451","CDM","76981","CPT","0983","RC","","","","outpatient","","","124.00","93.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","69.32","252.37","other","Multiple Radiology"
"US Elastography Organ Parenchyma","PX-98302451","CDM","76981","CPT","0983","RC","","","","outpatient","","","124.00","93.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","101.33","81.72","","422.08","422.08","422.08","1 through 10","69.32","252.37","percent of total billed charges",""
"US Extremity Non Vascular Complete","PX-40000062","CDM","76881","CPT","0402","RC","","","","both","","","836.00","627.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","664.62","other","OPPS APC"
"US Extremity Non Vascular Complete","PX-40000062","CDM","76881","CPT","0402","RC","","","","both","","","836.00","627.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","664.62","other","OPPS APC"
"US Fetal Biophysical Profile W","PX-40000049","CDM","76818","CPT","0402","RC","","","","both","","","818.00","613.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","313.29","38.3","","310.06","310.06","310.06","1 through 10","119.97","650.31","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","609.00","456.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","484.16","79.5","","465.12","312.05","465.12","113","119.97","484.16","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","609.00","456.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","324.60","53.3","","465.12","312.05","465.12","61","119.97","484.16","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","609.00","456.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","102.65","124.27","1 through 10","119.97","484.16","other","OPPS APC"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","609.00","456.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","484.16","other","OPPS APC"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","609.00","456.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","188.79","31","","182.62","182.62","182.62","1 through 10","119.97","484.16","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","609.00","456.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","222.29","36.5","","220.44","187.35","220.44","55","119.97","484.16","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","609.00","456.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","233.25","38.3","","231.08","231.08","693.24","304","119.97","484.16","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","609.00","456.75","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","119.98","126.29","1 through 10","119.97","484.16","other","Tricare OPPS"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","609.00","456.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","261.26","42.9","","472.44","472.44","472.44","1 through 10","119.97","484.16","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","609.00","456.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","124.27","126.29","1 through 10","119.97","484.16","other","OPPS APC"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","609.00","456.75","AETNA [1001]","HB AMC AETNA HMO","425.08","69.8","","400.11","282.50","400.11","23","231.59","513.1","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","609.00","456.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","318.26","52.26","","365.71","365.71","365.71","1 through 10","231.59","513.1","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","609.00","456.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","497.67","81.72","","259.86","259.86","472.45","1 through 10","231.59","513.1","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","609.00","456.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","497.67","81.72","","472.45","259.86","472.45","133","231.59","513.1","percent of total billed charges",""
"US Fetal Doppler Velocimerty Cereb","PX-40000052","CDM","76821","CPT","0402","RC","","","","both","","","659.00","494.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","351.25","53.3","","337.39","337.39","337.39","24","119.97","523.91","percent of total billed charges",""
"US Fetal Doppler Velocimerty Cereb","PX-40000052","CDM","76821","CPT","0402","RC","","","","both","","","659.00","494.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","240.54","36.5","","238.35","238.35","238.35","1 through 10","119.97","523.91","percent of total billed charges",""
"US Fetal Doppler Velocimerty Cereb","PX-40000052","CDM","76821","CPT","0402","RC","","","","both","","","659.00","494.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","252.40","38.3","","242.82","242.82","249.85","1 through 10","119.97","523.91","percent of total billed charges",""
"US Fetal Doppler Velocimerty Cereb","PX-40000052","CDM","76821","CPT","0402","RC","","","","outpatient","","","659.00","494.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","538.53","81.72","","1021.63","510.82","1021.63","21","231.59","538.53","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","both","","","547.00","410.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","434.87","79.5","","417.11","279.84","417.11","34","119.97","434.87","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","both","","","547.00","410.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","291.55","53.3","","279.84","279.84","417.11","66","119.97","434.87","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","both","","","547.00","410.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","169.57","31","","163.77","163.77","163.77","1 through 10","119.97","434.87","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","both","","","547.00","410.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","199.66","36.5","","197.69","191.86","197.69","34","119.97","434.87","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","both","","","547.00","410.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","209.50","38.3","","207.23","201.40","604.20","233","119.97","434.87","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","both","","","547.00","410.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.66","42.9","","423.68","423.68","423.68","1 through 10","119.97","434.87","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","both","","","547.00","410.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.66","42.9","","233.04","233.04","233.04","1 through 10","119.97","434.87","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","547.00","410.25","AETNA [1001]","HB AMC AETNA HMO","381.81","69.8","","358.81","358.81","358.81","1 through 10","231.59","505.17","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","547.00","410.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","285.86","52.26","","327.96","327.96","327.96","1 through 10","231.59","505.17","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","547.00","410.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","447.01","81.72","","423.68","233.04","847.36","115","231.59","505.17","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0400","RC","","","","inpatient","","","663.00","497.25","AETNA [1001]","HB AMC AETNA PPO","527.09","79.5","","336.93","336.93","336.93","1 through 10","366.64","527.09","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","both","","","663.00","497.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","527.09","79.5","","506.04","339.50","1332.39","12","205.53","527.09","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","both","","","663.00","497.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","353.38","53.3","","1012.08","339.50","1518.12","1 through 10","205.53","527.09","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","both","","","663.00","497.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","242.00","36.5","","232.77","203.83","719.52","1 through 10","205.53","527.09","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","both","","","663.00","497.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","253.93","38.3","","754.23","251.41","754.23","31","205.53","527.09","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","both","","","663.00","497.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","284.43","42.9","","514.01","292.57","514.01","1 through 10","205.53","527.09","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","outpatient","","","663.00","497.25","AETNA [1001]","HB AMC AETNA HMO","462.77","69.8","","435.31","307.35","614.70","1 through 10","346.48","541.8","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","outpatient","","","663.00","497.25","AETNA [1001]","HB AMC AETNA PPO","533.05","80.4","","501.54","501.54","501.54","1 through 10","346.48","541.8","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","outpatient","","","663.00","497.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","541.80","81.72","","514.01","514.01","514.01","1 through 10","346.48","541.8","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","outpatient","","","663.00","497.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","541.80","81.72","","514.01","514.01","643.00","1 through 10","346.48","541.8","percent of total billed charges",""
"US Guidance Monitoring Tissue Ablat","PX-40000072","CDM","76940","CPT","0402","RC","","","","both","","","764.00","573.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","292.61","38.3","","563.16","547.88","563.16","1 through 10","236.84","607.38","percent of total billed charges",""
"US Guided Amniocentesis","PX-40000078","CDM","76946","CPT","0402","RC","","","","both","","","261.00","195.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","207.50","79.5","","1216.70","1216.70","1216.70","1 through 10","80.91","261.88","percent of total billed charges",""
"US Guided Amniocentesis","PX-40000078","CDM","76946","CPT","0402","RC","","","","both","","","261.00","195.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.11","53.3","","1201.75","133.58","1400.86","12","80.91","261.88","percent of total billed charges",""
"US Guided Amniocentesis","PX-40000078","CDM","76946","CPT","0402","RC","","","","both","","","261.00","195.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.27","36.5","","283.11","283.11","471.85","11","80.91","261.88","percent of total billed charges",""
"US Guided Amniocentesis","PX-40000078","CDM","76946","CPT","0402","RC","","","","both","","","261.00","195.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","99.96","38.3","","296.76","98.92","480.70","32","80.91","261.88","percent of total billed charges",""
"US Guided Amniocentesis","PX-40000078","CDM","76946","CPT","0402","RC","","","","both","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","111.97","42.9","","202.25","202.25","202.25","1 through 10","80.91","261.88","percent of total billed charges",""
"US Guided Amniocentesis","PX-40000078","CDM","76946","CPT","0402","RC","","","","outpatient","","","261.00","195.75","AETNA [1001]","HB AMC AETNA HMO","182.18","69.8","","171.28","171.28","171.28","1 through 10","136.4","213.29","percent of total billed charges",""
"US Guided Amniocentesis","PX-40000078","CDM","76946","CPT","0402","RC","","","","outpatient","","","261.00","195.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","209.84","80.4","","197.34","197.34","197.34","1 through 10","136.4","213.29","percent of total billed charges",""
"US Guided Amniocentesis","PX-40000078","CDM","76946","CPT","0402","RC","","","","outpatient","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","213.29","81.72","","248.65","189.44","248.65","1 through 10","136.4","213.29","percent of total billed charges",""
"US Guided Chorionic Villus Sampling","PX-40000077","CDM","76945","CPT","0402","RC","","","","both","","","983.00","737.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","781.49","79.5","","2517.61","750.01","2517.61","13","261.88","781.49","percent of total billed charges",""
"US Guided Chorionic Villus Sampling","PX-40000077","CDM","76945","CPT","0402","RC","","","","both","","","983.00","737.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","523.94","53.3","","2822.16","1334.22","2822.16","1 through 10","261.88","781.49","percent of total billed charges",""
"US Guided Chorionic Villus Sampling","PX-40000077","CDM","76945","CPT","0402","RC","","","","both","","","983.00","737.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","358.80","36.5","","906.30","355.47","1066.41","11","261.88","781.49","percent of total billed charges",""
"US Guided Chorionic Villus Sampling","PX-40000077","CDM","76945","CPT","0402","RC","","","","both","","","983.00","737.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","376.49","38.3","","1086.42","372.62","1117.86","23","261.88","781.49","percent of total billed charges",""
"US Guided Chorionic Villus Sampling","PX-40000077","CDM","76945","CPT","0402","RC","","","","outpatient","","","983.00","737.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","803.31","81.72","","761.83","761.83","1022.72","1 through 10","513.72","803.31","percent of total billed charges",""
"US Guided Interstitial Therapy","PX-40000081","CDM","76965","CPT","0402","RC","","","","both","","","802.00","601.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","637.59","79.5","","410.78","410.78","410.78","1 through 10","248.62","637.59","percent of total billed charges",""
"US Guided Interstitial Therapy","PX-40000081","CDM","76965","CPT","0402","RC","","","","both","","","802.00","601.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","427.47","53.3","","612.29","612.29","612.29","1 through 10","248.62","637.59","percent of total billed charges",""
"US Guided Interstitial Therapy","PX-40000081","CDM","76965","CPT","0402","RC","","","","both","","","802.00","601.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","344.06","42.9","","342.09","342.09","342.09","1 through 10","248.62","637.59","percent of total billed charges",""
"US Guided Interstitial Therapy","PX-40000081","CDM","76965","CPT","0402","RC","","","","outpatient","","","802.00","601.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","655.39","81.72","","342.09","342.09","342.09","1 through 10","419.13","655.39","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","1432.00","1074.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","939.39","65.6","","663.94","663.94","663.94","1 through 10","261.88","1138.44","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","1432.00","1074.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","930.80","65","","3087.50","902.85","3087.50","1 through 10","261.88","1138.44","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","1432.00","1074.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1002.40","70","","212.20","212.20","212.20","1 through 10","261.88","1138.44","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","1432.00","1074.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1138.44","79.5","","3465.15","1093.14","3588.71","94","261.88","1138.44","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","1432.00","1074.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","763.26","53.3","","1601.37","701.45","1648.33","17","261.88","1138.44","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","1432.00","1074.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","1102.64","77","","2139.06","2079.00","2139.06","1 through 10","261.88","1138.44","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","1432.00","1074.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","930.80","65","","902.85","92.95","902.85","1 through 10","261.88","1138.44","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","522.68","36.5","","1320.93","440.31","1554.30","37","261.88","1138.44","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","1432.00","1074.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","548.46","38.3","","1055.64","543.10","1629.30","72","261.88","1138.44","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","614.33","42.9","","1106.33","632.00","1106.33","1 through 10","261.88","1138.44","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","1432.00","1074.00","AETNA [1001]","HB AMC AETNA HMO","999.54","69.8","","940.35","663.94","940.35","1 through 10","748.36","1170.23","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","1432.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","748.36","52.26","","859.51","859.51","859.51","1 through 10","748.36","1170.23","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1170.23","81.72","","610.74","610.74","610.74","1 through 10","748.36","1170.23","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","1432.00","1074.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1170.23","81.72","","1110.37","610.74","1110.37","23","748.36","1170.23","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","297.00","222.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","194.83","65.6","","194.98","194.98","224.64","1 through 10","92.07","236.12","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","297.00","222.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","193.05","65","","226.66","152.06","226.66","1 through 10","92.07","236.12","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","297.00","222.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","207.90","70","","288.00","135.86","449.28","44","92.07","236.12","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","297.00","222.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","236.12","79.5","","226.66","152.06","226.66","32","92.07","236.12","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","297.00","222.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","158.30","53.3","","187.20","152.06","260.04","13","92.07","236.12","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","297.00","222.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","193.05","65","","187.20","178.10","187.20","1 through 10","92.07","236.12","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","92.07","31","","88.99","88.99","88.99","1 through 10","92.07","236.12","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","108.41","36.5","","107.42","91.30","107.42","18","92.07","236.12","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","297.00","222.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","113.75","38.3","","112.61","109.44","112.61","24","92.07","236.12","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","288.00","230.23","288.00","1 through 10","92.07","236.12","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","297.00","222.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","127.41","42.9","","230.23","230.23","230.23","1 through 10","92.07","236.12","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","297.00","222.75","WELLPOINT [1015]","HB AMC WELLPOINT","219.13","73.78","","214.42","201.55","214.42","28","92.07","236.12","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA HMO","207.31","69.8","","194.98","179.47","288.00","1 through 10","155.21","242.71","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","297.00","222.75","AETNA [1001]","HB AMC AETNA PPO","238.79","80.4","","224.64","224.64","224.64","1 through 10","155.21","242.71","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","297.00","222.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","155.21","52.26","","178.22","178.22","178.22","1 through 10","155.21","242.71","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","297.00","222.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","238.79","80.4","","224.64","224.64","224.64","1 through 10","155.21","242.71","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","242.71","81.72","","126.63","126.63","230.23","1 through 10","155.21","242.71","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","242.71","81.72","","230.23","126.63","230.23","31","155.21","242.71","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","879.00","659.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","698.81","79.5","","642.41","642.41","642.41","1 through 10","99.34","698.81","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","879.00","659.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","320.84","36.5","","308.42","308.42","308.42","1 through 10","99.34","698.81","percent of total billed charges",""
"US Intravascular Initial Vessel","PX-48000107","CDM","92978","CPT","0481","RC","","","","both","","","5068.00","3801.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3294.20","65","","3194.75","3194.75","3194.75","1 through 10","1571.08","4029.06","percent of total billed charges",""
"US Intravascular Initial Vessel","PX-48000107","CDM","92978","CPT","0481","RC","","","","outpatient","","","5068.00","3801.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4141.57","81.72","","3929.05","3929.05","3929.05","1 through 10","2648.54","4141.57","percent of total billed charges",""
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","both","","","1056.00","792.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","839.52","other","OPPS APC"
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","both","","","1056.00","792.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","758.21","71.8","","735.23","735.23","735.23","1 through 10","119.97","839.52","percent of total billed charges",""
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","both","","","1056.00","792.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","686.40","65","","540.67","540.67","540.67","1 through 10","119.97","839.52","percent of total billed charges",""
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","both","","","1056.00","792.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","739.20","70","","1320.96","1320.96","1320.96","1 through 10","119.97","839.52","percent of total billed charges",""
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","both","","","1056.00","792.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","839.52","79.5","","805.89","805.89","805.89","1 through 10","119.97","839.52","percent of total billed charges",""
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","both","","","1056.00","792.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","378.87","126.29","378.87","24","119.97","839.52","other","OPPS APC"
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","both","","","1056.00","792.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","385.44","36.5","","381.95","381.95","381.95","1 through 10","119.97","839.52","percent of total billed charges",""
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","both","","","1056.00","792.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","404.45","38.3","","400.38","389.12","400.38","1 through 10","119.97","839.52","percent of total billed charges",""
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","both","","","1056.00","792.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","839.52","other","OPPS APC"
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","outpatient","","","1056.00","792.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","1 through 10","112.51","862.96","other","Multiple Imaging"
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","outpatient","","","1056.00","792.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","1 through 10","112.51","862.96","other","Multiple Imaging"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","342.00","256.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","106.02","271.89","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","342.00","256.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","119.99","119.99","119.99","1 through 10","106.02","271.89","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","342.00","256.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","271.89","79.5","","261.28","261.28","261.28","1 through 10","106.02","271.89","percent of total billed charges",""
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","342.00","256.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","14","106.02","271.89","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","342.00","256.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","130.99","38.3","","129.81","129.81","129.81","1 through 10","106.02","271.89","percent of total billed charges",""
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","342.00","256.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","117.60","126.29","19","106.02","271.89","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","outpatient","","","342.00","256.50","AETNA [1001]","HB AMC AETNA HMO","238.72","69.8","","224.76","158.70","224.76","1 through 10","178.73","505.17","percent of total billed charges",""
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-98302041","CDM","76882","CPT","0983","RC","","","","both","","","142.00","106.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","44.02","231.74","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-98302041","CDM","76882","CPT","0983","RC","","","","both","","","142.00","106.50","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","119.99","119.99","119.99","1 through 10","44.02","231.74","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-98302041","CDM","76882","CPT","0983","RC","","","","both","","","142.00","106.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","112.89","79.5","","261.28","261.28","261.28","1 through 10","44.02","231.74","percent of total billed charges",""
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-98302041","CDM","76882","CPT","0983","RC","","","","both","","","142.00","106.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","14","44.02","231.74","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-98302041","CDM","76882","CPT","0983","RC","","","","both","","","142.00","106.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.39","38.3","","129.81","129.81","129.81","1 through 10","44.02","231.74","percent of total billed charges",""
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-98302041","CDM","76882","CPT","0983","RC","","","","both","","","142.00","106.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","117.60","126.29","19","44.02","231.74","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-98302041","CDM","76882","CPT","0983","RC","","","","outpatient","","","142.00","106.50","AETNA [1001]","HB AMC AETNA HMO","99.12","69.8","","224.76","158.70","224.76","1 through 10","79.38","505.17","percent of total billed charges",""
"US Nrv&Acc Strux 1 Xtr Compre W/Img PR Extremity","PX-40000175","CDM","76883","CPT","0402","RC","","","","both","","","388.00","291.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","130.06","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","65.08","65.08","129.95","1 through 10","119.97","308.46","other","OPPS APC"
"US Nrv&Acc Strux 1 Xtr Compre W/Img PR Extremity","PX-40000175","CDM","76883","CPT","0402","RC","","","","both","","","388.00","291.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.15","63.15","126.29","1 through 10","119.97","308.46","other","OPPS APC"
"US Nrv&Acc Strux 1 Xtr Compre W/Img PR Extremity","PX-40000175","CDM","76883","CPT","0402","RC","","","","both","","","388.00","291.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.88","62.14","62.88","1 through 10","119.97","308.46","other","OPPS APC"
"US Nrv&Acc Strux 1 Xtr Compre W/Img PR Extremity","PX-40000175","CDM","76883","CPT","0402","RC","","","","both","","","388.00","291.00","WELLPOINT [1015]","HB AMC WELLPOINT","286.27","73.78","","279.93","279.93","279.93","1 through 10","119.97","308.46","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","126.29","19","119.97","713.91","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","628.60","70","","627.12","627.12","627.12","1 through 10","119.97","713.91","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","CHAMPVA [160001]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","713.91","other","Tricare OPPS"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","713.91","79.5","","685.48","459.89","685.48","105","119.97","713.91","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","478.63","53.3","","459.89","459.89","685.48","65","119.97","713.91","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","1 through 10","119.97","713.91","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","FALLON HEALTH [1008]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","167.64","167.64","167.64","1 through 10","119.97","713.91","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","119.97","713.91","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","187","119.97","713.91","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","278.38","31","","538.28","269.14","538.28","1 through 10","119.97","713.91","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","327.77","36.5","","324.88","276.11","324.88","78","119.97","713.91","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","343.93","38.3","","340.56","340.56","340.56","257","119.97","713.91","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","125.26","1 through 10","119.97","713.91","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","119.98","133.03","1 through 10","119.97","713.91","other","Tricare OPPS"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.76","373.56","14","119.97","713.91","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.24","42.9","","382.98","168.20","696.28","1 through 10","119.97","713.91","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.24","118.20","126.29","60","119.97","713.91","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","898.00","673.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.24","42.9","","382.98","382.98","382.98","1 through 10","119.97","713.91","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","898.00","673.50","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","589.67","416.34","1179.34","19","112.51","733.85","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","898.00","673.50","AETNA [1001]","HB AMC AETNA PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 80.4% of billed. Procedures 2 - 9999, 40.2% of billed.","589.67","589.67","589.67","1 through 10","112.51","733.85","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","898.00","673.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","194","112.51","733.85","other","Multiple Imaging"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","898.00","673.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","469.29","52.26","","231.59","231.59","231.59","1 through 10","112.51","733.85","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","898.00","673.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","467","112.51","733.85","other","Multiple Imaging"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","898.00","673.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","382.53","191.27","382.53","20","112.51","733.85","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","898.00","673.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","153.01","153.01","306.03","37","112.51","733.85","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","898.00","673.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","160.32","462.42","13","112.51","733.85","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","898.00","673.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","367.91","382.53","1 through 10","112.51","733.85","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","898.00","673.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","733.85","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","898.00","673.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","168.20","168.20","336.40","39","112.51","733.85","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","898.00","673.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","733.85","81.72","","696.28","153.01","696.28","1 through 10","112.51","733.85","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","898.00","673.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","733.85","81.72","","696.28","382.98","696.28","65","112.51","733.85","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","126.29","1 through 10","119.97","604.2","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","498.56","65.6","","498.95","498.95","498.95","1 through 10","119.97","604.2","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","604.20","79.5","","580.02","389.14","580.02","131","119.97","604.2","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","405.08","53.3","","580.02","389.14","580.02","53","119.97","604.2","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","604.20","79.5","","580.02","580.02","580.02","1 through 10","119.97","604.2","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","20","119.97","604.2","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","235.60","31","","227.73","227.73","227.73","1 through 10","119.97","604.2","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","277.40","36.5","","266.79","233.63","1374.50","24","119.97","604.2","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","291.08","38.3","","288.17","280.06","288.17","117","119.97","604.2","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.26","125.26","125.26","1 through 10","119.97","604.2","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","119.97","604.2","other","Tricare OPPS"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","119.97","604.2","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.04","42.9","","589.16","589.15","589.16","1 through 10","119.97","604.2","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","118.07","126.29","1 through 10","119.97","604.2","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","760.00","570.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.04","42.9","","589.16","589.16","589.16","1 through 10","119.97","604.2","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","760.00","570.00","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","352.29","352.29","498.95","13","112.51","621.07","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","760.00","570.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","111","112.51","621.07","other","Multiple Imaging"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","760.00","570.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","458","112.51","621.07","other","Multiple Imaging"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","760.00","570.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","382.53","336.40","382.53","1 through 10","112.51","621.07","other","Multiple Radiology"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","760.00","570.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","293.65","597.42","69","112.51","621.07","other","Multiple Radiology"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","760.00","570.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","308.28","616.56","30","112.51","621.07","other","Multiple Radiology"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","760.00","570.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","505.17","505.17","505.17","1 through 10","112.51","621.07","other","Multiple Radiology"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","760.00","570.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","336.40","336.40","50","112.51","621.07","other","Multiple Radiology"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","760.00","570.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","621.07","81.72","","589.16","324.06","589.16","83","112.51","621.07","percent of total billed charges",""
"US Pregnancy <14 Weeks Ea Add","PX-40000039","CDM","76802","CPT","0402","RC","","","","both","","","458.00","343.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","364.11","79.5","","1048.29","234.43","1048.29","1 through 10","141.98","364.11","percent of total billed charges",""
"US Pregnancy <14 Weeks Ea Add","PX-40000039","CDM","76802","CPT","0402","RC","","","","both","","","458.00","343.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","244.11","53.3","","349.43","217.66","349.43","1 through 10","141.98","364.11","percent of total billed charges",""
"US Pregnancy <14 Weeks Ea Add","PX-40000039","CDM","76802","CPT","0402","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","167.17","36.5","","165.61","140.75","165.61","1 through 10","141.98","364.11","percent of total billed charges",""
"US Pregnancy <14 Weeks Ea Add","PX-40000039","CDM","76802","CPT","0402","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","175.41","38.3","","173.60","173.60","520.80","11","141.98","364.11","percent of total billed charges",""
"US Pregnancy <14 Weeks Ea Add","PX-40000039","CDM","76802","CPT","0402","RC","","","","outpatient","","","458.00","343.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","374.28","81.72","","354.93","195.23","354.93","1 through 10","239.35","374.28","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","698.81","79.5","","670.52","449.86","670.52","113","119.97","698.81","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","468.51","53.3","","449.86","449.86","1556.55","57","119.97","698.81","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","126.02","1 through 10","119.97","698.81","other","OPPS APC"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","676.83","77","","656.04","656.04","656.04","1 through 10","119.97","698.81","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","698.81","other","OPPS APC"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","272.49","31","","263.27","263.27","263.27","1 through 10","119.97","698.81","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","320.84","36.5","","317.80","270.08","810.24","83","119.97","698.81","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","336.66","38.3","","333.13","323.76","999.39","342","119.97","698.81","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","676.83","77","","670.52","670.52","670.52","1 through 10","119.97","698.81","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","126.29","16","119.97","698.81","other","Tricare OPPS"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","698.81","other","Tricare OPPS"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","195.96","195.96","195.96","1 through 10","119.97","698.81","other","OPPS APC"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","377.09","42.9","","681.09","374.62","1533.09","1 through 10","119.97","698.81","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","124.27","126.29","1 through 10","119.97","698.81","other","OPPS APC"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","879.00","659.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","377.09","42.9","","681.09","681.09","681.09","1 through 10","119.97","698.81","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","AETNA [1001]","HB AMC AETNA HMO","613.54","69.8","","576.80","407.26","576.80","19","112.51","718.32","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","AETNA [1001]","HB AMC AETNA PPO","706.72","80.4","","576.80","576.80","576.80","1 through 10","112.51","718.32","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","338","112.51","718.32","other","Multiple Imaging"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","459.37","52.26","","231.59","231.59","231.59","1 through 10","112.51","718.32","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","792","112.51","718.32","other","Multiple Imaging"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","CIGNA ALTERNATE [1018]","HB AMC TUFTS CIGNA CARELINK HYBRID","513.10","","Case rate ($513.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","430.26","408.76","430.26","1 through 10","112.51","718.32","other","Multiple Imaging Pregnancy Ultrasound"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","336.40","191.27","382.53","12","112.51","718.32","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","293.65","880.95","192","112.51","718.32","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","961.95","122","112.51","718.32","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","327.40","327.40","327.40","1 through 10","112.51","718.32","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","191.27","382.53","13","112.51","718.32","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","160.33","320.65","1 through 10","112.51","718.32","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","218.27","372.21","62","112.51","718.32","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","706.72","80.4","","664.56","664.56","664.56","1 through 10","112.51","718.32","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","718.32","81.72","","681.09","374.62","681.09","1 through 10","112.51","718.32","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","718.32","81.72","","681.09","374.62","681.09","127","112.51","718.32","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","879.00","659.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","367.91","183.96","367.91","1 through 10","112.51","718.32","other","Multiple Radiology"
"US Pregnancy >14 Weeks Ea Add","PX-40000041","CDM","76810","CPT","0402","RC","","","","both","","","686.00","514.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","545.37","79.5","","523.36","523.36","523.36","1 through 10","212.66","545.37","percent of total billed charges",""
"US Pregnancy >14 Weeks Ea Add","PX-40000041","CDM","76810","CPT","0402","RC","","","","both","","","686.00","514.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","262.74","38.3","","260.02","260.02","260.02","1 through 10","212.66","545.37","percent of total billed charges",""
"US Pregnancy >14 Weeks Ea Add","PX-40000041","CDM","76810","CPT","0402","RC","","","","outpatient","","","686.00","514.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","","","Case rate ($0). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","109.44","109.44","109.44","1 through 10","358.5","560.6","other","Multiple Radiology standard_charge|negotiated_dollar calculated as 0;"
"US Pregnancy >14 Weeks Ea Add","PX-40000041","CDM","76810","CPT","0402","RC","","","","outpatient","","","686.00","514.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","560.60","81.72","","531.60","531.60","531.60","1 through 10","358.5","560.6","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1012.00","759.00","CHAMPVA [160001]","HB BWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","804.54","other","Tricare OPPS"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1012.00","759.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","804.54","79.5","","772.05","517.97","772.05","32","119.97","804.54","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1012.00","759.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","539.40","53.3","","517.97","517.97","772.05","11","119.97","804.54","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1012.00","759.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","804.54","79.5","","1254.65","1254.65","1254.65","1 through 10","119.97","804.54","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1012.00","759.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","804.54","other","OPPS APC"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1012.00","759.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","313.72","31","","303.13","303.13","303.13","1 through 10","119.97","804.54","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1012.00","759.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","369.38","36.5","","365.91","310.98","1097.73","35","119.97","804.54","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1012.00","759.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","387.60","38.3","","383.57","383.57","383.57","81","119.97","804.54","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1012.00","759.00","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","126.29","1 through 10","119.97","804.54","other","Tricare OPPS"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1012.00","759.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.15","42.9","","1765.21","1765.21","1765.21","1 through 10","119.97","804.54","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1012.00","759.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","804.54","other","OPPS APC"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1012.00","759.00","AETNA [1001]","HB AMC AETNA HMO","706.38","69.8","","664.14","664.14","664.14","1 through 10","112.51","827.01","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1012.00","759.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","100","112.51","827.01","other","Multiple Imaging"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1012.00","759.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","202","112.51","827.01","other","Multiple Imaging"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1012.00","759.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","336.40","191.27","382.53","1 through 10","112.51","827.01","other","Multiple Radiology"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1012.00","759.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","49","112.51","827.01","other","Multiple Radiology"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1012.00","759.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","961.95","27","112.51","827.01","other","Multiple Radiology"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1012.00","759.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","382.53","382.53","1 through 10","112.51","827.01","other","Multiple Radiology"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1012.00","759.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","308.28","308.28","308.28","1 through 10","112.51","827.01","other","Multiple Radiology"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1012.00","759.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","208.14","336.40","21","112.51","827.01","other","Multiple Radiology"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1012.00","759.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","813.65","80.4","","765.18","765.18","765.18","1 through 10","112.51","827.01","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1012.00","759.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","324.03","324.03","324.03","1 through 10","112.51","827.01","other","Multiple Radiology"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1012.00","759.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","827.01","81.72","","784.21","431.35","784.21","29","112.51","827.01","percent of total billed charges",""
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","both","","","1039.00","779.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","826.01","79.5","","532.22","532.22","532.22","1 through 10","322.09","826.01","percent of total billed charges",""
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","both","","","1039.00","779.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","553.79","53.3","","509.04","509.04","793.30","1 through 10","322.09","826.01","percent of total billed charges",""
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","both","","","1039.00","779.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","322.09","31","","311.47","311.47","311.47","1 through 10","322.09","826.01","percent of total billed charges",""
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","both","","","1039.00","779.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","379.24","36.5","","375.98","375.98","375.98","1 through 10","322.09","826.01","percent of total billed charges",""
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","both","","","1039.00","779.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","397.94","38.3","","394.13","383.04","394.13","1 through 10","322.09","826.01","percent of total billed charges",""
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","both","","","1039.00","779.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","445.73","42.9","","443.22","443.22","443.22","1 through 10","322.09","826.01","percent of total billed charges",""
"US Pregnancy Detailed Ea Add","PX-40000043","CDM","76812","CPT","0402","RC","","","","outpatient","","","1039.00","779.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","849.07","81.72","","805.80","805.80","805.80","1 through 10","542.98","849.07","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","852.24","79.5","","818.48","549.12","818.48","55","272.7","852.24","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","571.38","53.3","","818.48","525.20","4465.44","42","272.7","852.24","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","852.24","other","OPPS APC"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","825.44","77","","2402.40","800.80","2402.40","1 through 10","272.7","852.24","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","852.24","79.5","","818.48","818.48","818.48","1 through 10","272.7","852.24","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","852.24","other","OPPS APC"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","332.32","31","","321.36","321.36","321.36","1 through 10","272.7","852.24","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","391.28","36.5","","387.92","329.68","1939.60","35","272.7","852.24","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","410.58","38.3","","406.64","395.20","1219.92","161","272.7","852.24","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","825.44","77","","811.20","811.20","811.20","1 through 10","272.7","852.24","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","287.06","272.71","287.06","1 through 10","272.7","852.24","other","Tricare OPPS"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","459.89","42.9","","831.38","457.29","831.38","1 through 10","272.7","852.24","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","263.16","287.06","1 through 10","272.7","852.24","other","OPPS APC"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","both","","","1072.00","804.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","459.89","42.9","","457.29","457.29","457.29","1 through 10","272.7","852.24","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","AETNA [1001]","HB AMC AETNA HMO","748.26","69.8","","704.08","497.12","1408.16","13","230.56","876.04","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","AETNA [1001]","HB AMC AETNA PPO","861.89","80.4","","704.08","704.08","704.08","1 through 10","230.56","876.04","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","474.59","","Case rate ($474.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","474.59","474.59","474.59","204","230.56","876.04","other","Multiple Imaging"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","474.59","","Case rate ($474.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","474.59","474.59","474.59","416","230.56","876.04","other","Multiple Imaging"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","783.90","689.37","783.90","1 through 10","230.56","876.04","other","Multiple Radiology"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","627.12","1881.36","110","230.56","876.04","other","Multiple Radiology"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","1971.30","58","230.56","876.04","other","Multiple Radiology"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","783.90","783.90","783.90","1 through 10","230.56","876.04","other","Multiple Radiology"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","230.56","876.04","other","Multiple Radiology"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","689.37","526.00","689.37","25","230.56","876.04","other","Multiple Radiology"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","861.89","80.4","","811.20","811.20","811.20","1 through 10","230.56","876.04","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","664.01","664.01","664.01","1 through 10","230.56","876.04","other","Multiple Radiology"
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","876.04","81.72","","831.38","457.29","831.38","1 through 10","230.56","876.04","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","876.04","81.72","","831.38","457.29","831.38","67","230.56","876.04","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1072.00","804.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","664.01","664.01","664.01","1 through 10","230.56","876.04","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","817.00","612.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","649.52","79.5","","623.30","418.18","623.30","225","119.97","649.52","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","817.00","612.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","435.46","53.3","","623.30","418.18","623.31","181","119.97","649.52","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","817.00","612.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","649.52","other","OPPS APC"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","817.00","612.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","649.52","79.5","","623.30","623.30","623.30","1 through 10","119.97","649.52","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","817.00","612.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","63.15","126.29","1 through 10","119.97","649.52","other","OPPS APC"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","817.00","612.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","253.27","31","","244.73","244.73","244.73","11","119.97","649.52","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","817.00","612.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","298.21","36.5","","295.42","251.06","886.26","174","119.97","649.52","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","817.00","612.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","312.91","38.3","","309.67","300.96","929.01","740","119.97","649.52","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","817.00","612.75","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","59.99","126.29","1 through 10","119.97","649.52","other","Tricare OPPS"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","817.00","612.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.16","182.16","182.16","1 through 10","119.97","649.52","other","OPPS APC"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","817.00","612.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","350.49","42.9","","633.12","348.24","1425.12","1 through 10","119.97","649.52","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","817.00","612.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","126.29","1 through 10","119.97","649.52","other","OPPS APC"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","817.00","612.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","350.49","42.9","","348.24","348.24","348.24","1 through 10","119.97","649.52","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","AETNA [1001]","HB AMC AETNA HMO","570.27","69.8","","536.18","378.58","757.15","52","112.51","667.65","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","426.96","52.26","","490.09","231.59","490.09","1 through 10","112.51","667.65","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","CIGNA ALTERNATE [1018]","HB AMC TUFTS CIGNA CARELINK HYBRID","333.74","","Case rate ($333.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","967.35","644.90","967.35","1 through 10","112.51","667.65","other","Multiple Imaging Pregnancy Ultrasound"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","367.91","324.03","382.53","41","112.51","667.65","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.02","918.09","524","112.51","667.65","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","308.28","961.95","267","112.51","667.65","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","505.17","505.17","505.17","1 through 10","112.51","667.65","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","367.91","505.17","24","112.51","667.65","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","160.33","320.65","1 through 10","112.51","667.65","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","238.95","672.81","109","112.51","667.65","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","324.03","324.03","324.03","1 through 10","112.51","667.65","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","667.65","81.72","","348.24","348.24","633.12","1 through 10","112.51","667.65","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","667.65","81.72","","633.12","348.24","633.13","265","112.51","667.65","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","367.91","367.91","367.91","1 through 10","112.51","667.65","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","308.28","308.28","308.28","1 through 10","112.51","667.65","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","817.00","612.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","324.03","324.03","324.03","1 through 10","112.51","667.65","other","Multiple Radiology"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","623.00","467.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","495.29","79.5","","475.35","318.91","1895.10","39","119.97","495.29","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","623.00","467.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","332.06","53.3","","318.91","305.02","475.35","15","119.97","495.29","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","623.00","467.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","227.40","36.5","","225.29","191.47","675.87","25","119.97","495.29","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","623.00","467.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","238.61","38.3","","236.16","236.16","708.48","105","119.97","495.29","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","623.00","467.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","267.27","42.9","","265.58","265.58","265.58","1 through 10","119.97","495.29","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","623.00","467.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","118.25","118.25","118.25","1 through 10","119.97","495.29","other","OPPS APC"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","623.00","467.25","AETNA [1001]","HB AMC AETNA HMO","434.85","69.8","","408.91","288.71","408.91","1 through 10","112.51","509.12","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","623.00","467.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","325.58","52.26","","231.59","231.59","231.59","1 through 10","112.51","509.12","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","623.00","467.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","382.53","324.03","382.53","1 through 10","112.51","509.12","other","Multiple Radiology"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","623.00","467.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","918.09","52","112.51","509.12","other","Multiple Radiology"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","623.00","467.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","308.28","1282.60","27","112.51","509.12","other","Multiple Radiology"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","623.00","467.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","191.27","484.92","1 through 10","112.51","509.12","other","Multiple Radiology"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","623.00","467.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","200.27","336.40","16","112.51","509.12","other","Multiple Radiology"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","623.00","467.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","500.89","80.4","","471.12","471.12","471.12","1 through 10","112.51","509.12","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","623.00","467.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","509.12","81.72","","482.84","265.58","482.84","26","112.51","509.12","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","623.00","467.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","484.92","484.92","484.92","1 through 10","112.51","509.12","other","Multiple Radiology"
"US Pregnancy Nuchal Meas Addl Gest","PX-40000045","CDM","76814","CPT","0402","RC","","","","both","","","534.00","400.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","424.53","79.5","","1223.01","273.50","1223.01","1 through 10","165.54","424.53","percent of total billed charges",""
"US Pregnancy Nuchal Meas Addl Gest","PX-40000045","CDM","76814","CPT","0402","RC","","","","both","","","534.00","400.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","284.62","53.3","","407.67","254.02","407.67","1 through 10","165.54","424.53","percent of total billed charges",""
"US Pregnancy Nuchal Meas Addl Gest","PX-40000045","CDM","76814","CPT","0402","RC","","","","both","","","534.00","400.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","194.91","36.5","","193.21","164.21","193.21","1 through 10","165.54","424.53","percent of total billed charges",""
"US Pregnancy Nuchal Meas Addl Gest","PX-40000045","CDM","76814","CPT","0402","RC","","","","both","","","534.00","400.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","204.52","38.3","","202.54","196.84","607.62","1 through 10","165.54","424.53","percent of total billed charges",""
"US Pregnancy Nuchal Meas Addl Gest","PX-40000045","CDM","76814","CPT","0402","RC","","","","outpatient","","","534.00","400.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","436.38","81.72","","414.09","414.09","414.09","1 through 10","279.07","436.38","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","842.00","631.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","669.39","79.5","","642.98","431.38","1928.94","72","119.97","669.39","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","842.00","631.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","448.79","53.3","","431.38","431.38","1920.35","34","119.97","669.39","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","842.00","631.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","669.39","other","OPPS APC"
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","842.00","631.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","261.02","31","","252.45","252.45","252.45","1 through 10","119.97","669.39","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","842.00","631.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","307.33","36.5","","304.74","258.99","914.22","62","119.97","669.39","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","842.00","631.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","322.49","38.3","","319.45","310.46","958.35","240","119.97","669.39","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","842.00","631.50","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","119.98","126.29","1 through 10","119.97","669.39","other","Tricare OPPS"
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","842.00","631.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.91","187.91","187.91","1 through 10","119.97","669.39","other","OPPS APC"
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","outpatient","","","842.00","631.50","AETNA [1001]","HB AMC AETNA HMO","587.72","69.8","","553.11","390.53","553.11","15","231.59","688.08","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","outpatient","","","842.00","631.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","440.03","52.26","","231.59","231.59","231.59","1 through 10","231.59","688.08","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","outpatient","","","842.00","631.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","676.97","80.4","","637.26","637.26","637.26","1 through 10","231.59","688.08","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","outpatient","","","842.00","631.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","361.22","42.9","","1470.11","1470.11","1470.11","1 through 10","231.59","688.08","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","outpatient","","","842.00","631.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","688.08","81.72","","359.23","359.23","359.23","1 through 10","231.59","688.08","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","outpatient","","","842.00","631.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","688.08","81.72","","653.11","359.23","653.11","80","231.59","688.08","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","704.00","528.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","559.68","79.5","","537.52","360.62","1612.56","52","119.97","559.68","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","704.00","528.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","375.23","53.3","","360.62","360.62","1612.56","27","119.97","559.68","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","704.00","528.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","542.08","77","","525.91","525.91","525.91","1 through 10","119.97","559.68","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","704.00","528.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","218.24","31","","211.05","211.05","211.05","1 through 10","119.97","559.68","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","704.00","528.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","256.96","36.5","","254.76","216.51","254.76","31","119.97","559.68","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","704.00","528.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","269.63","38.3","","267.05","267.05","801.15","140","119.97","559.68","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","704.00","528.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","542.08","77","","537.52","537.52","537.52","1 through 10","119.97","559.68","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","302.02","42.9","","545.99","545.99","545.99","1 through 10","119.97","559.68","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","AETNA [1001]","HB AMC AETNA HMO","491.39","69.8","","462.39","231.19","462.39","1 through 10","112.51","575.31","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","AETNA [1001]","HB AMC AETNA PPO","566.02","80.4","","462.39","462.39","462.39","1 through 10","112.51","575.31","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","115.80","115.80","231.59","161","112.51","575.31","other","Multiple Imaging"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","367.91","52.26","","115.80","115.80","231.59","1 through 10","112.51","575.31","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","115.80","115.80","231.59","401","112.51","575.31","other","Multiple Imaging"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","336.40","191.27","382.53","1 through 10","112.51","575.31","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","153.01","146.82","459.03","100","112.51","575.31","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","160.32","160.32","801.60","64","112.51","575.31","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","248.65","191.27","382.53","1 through 10","112.51","575.31","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","308.28","154.14","320.65","1 through 10","112.51","575.31","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","168.20","127.79","208.14","24","112.51","575.31","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","566.02","80.4","","532.74","532.74","532.74","1 through 10","112.51","575.31","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","324.03","324.03","324.03","1 through 10","112.51","575.31","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","575.31","81.72","","545.99","545.99","545.99","1 through 10","112.51","575.31","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","575.31","81.72","","545.99","300.32","545.99","63","112.51","575.31","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","704.00","528.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","367.91","183.96","367.91","1 through 10","112.51","575.31","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","62","119.97","749.69","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","660.10","70","","658.08","658.08","658.08","1 through 10","119.97","749.69","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","119.99","119.99","119.99","1 through 10","119.97","749.69","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","749.69","79.5","","719.32","482.59","719.32","43","119.97","749.69","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","502.62","53.3","","482.59","482.59","719.32","14","119.97","749.69","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","102.65","124.27","12","119.97","749.69","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","ELDER SERVICES [1037]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","749.69","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","118.43","118.43","118.43","1 through 10","119.97","749.69","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.76","124.52","126.29","1 through 10","119.97","749.69","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","749.69","79.5","","689.16","689.16","689.16","1 through 10","119.97","749.69","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","320","119.97","749.69","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","292.33","31","","282.43","282.43","282.43","1 through 10","119.97","749.69","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","344.20","36.5","","340.92","289.74","643.96","19","119.97","749.69","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","361.17","38.3","","357.37","347.32","357.37","98","119.97","749.69","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.26","123.76","375.78","23","119.97","749.69","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","MOLINA [1014]","HB BWH MOLINA","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","749.69","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","119.98","126.29","1 through 10","119.97","749.69","other","Tricare OPPS"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","123.76","371.28","22","119.97","749.69","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","943.00","707.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","126.29","87","119.97","749.69","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","943.00","707.25","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","618.78","436.89","618.78","1 through 10","112.51","770.62","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","943.00","707.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","76","112.51","770.62","other","Multiple Imaging"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","943.00","707.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","162","112.51","770.62","other","Multiple Imaging"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","943.00","707.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","382.53","336.40","382.53","1 through 10","112.51","770.62","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","943.00","707.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","55","112.51","770.62","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","943.00","707.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","18","112.51","770.62","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","943.00","707.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","382.53","382.53","1 through 10","112.51","770.62","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","943.00","707.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","770.62","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","943.00","707.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","283.91","336.40","14","112.51","770.62","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","943.00","707.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","770.62","81.72","","730.65","730.65","730.65","1 through 10","112.51","770.62","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","943.00","707.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","770.62","81.72","","730.65","730.65","730.65","1 through 10","112.51","770.62","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","943.00","707.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","770.62","81.72","","730.65","401.89","730.65","20","112.51","770.62","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","943.00","707.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","324.03","324.03","324.03","1 through 10","112.51","770.62","other","Multiple Radiology"
"US Retroperitioneal Ltd","PX-40000035","CDM","76775","CPT","0402","RC","","","","both","","","802.00","601.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","637.59","79.5","","410.78","410.78","410.78","1 through 10","119.97","637.59","percent of total billed charges",""
"US Retroperitioneal Ltd","PX-40000035","CDM","76775","CPT","0402","RC","","","","both","","","802.00","601.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","292.73","36.5","","290.19","290.19","290.19","1 through 10","119.97","637.59","percent of total billed charges",""
"US Retroperitioneal Ltd","PX-40000035","CDM","76775","CPT","0402","RC","","","","both","","","802.00","601.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","307.17","38.3","","295.64","295.64","295.64","1 through 10","119.97","637.59","percent of total billed charges",""
"US Retroperitioneal Ltd","PX-40000035","CDM","76775","CPT","0402","RC","","","","outpatient","","","802.00","601.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","160.32","160.32","160.32","1 through 10","112.51","655.39","other","Multiple Radiology"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","62","46.81","360.14","other","OPPS APC"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","105.70","70","","658.08","658.08","658.08","1 through 10","46.81","360.14","percent of total billed charges",""
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","119.99","119.99","119.99","1 through 10","46.81","360.14","other","OPPS APC"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","120.05","79.5","","719.32","482.59","719.32","43","46.81","360.14","percent of total billed charges",""
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","80.48","53.3","","482.59","482.59","719.32","14","46.81","360.14","percent of total billed charges",""
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","102.65","124.27","12","46.81","360.14","other","OPPS APC"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","ELDER SERVICES [1037]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","46.81","360.14","other","OPPS APC"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","118.43","118.43","118.43","1 through 10","46.81","360.14","other","OPPS APC"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.76","124.52","126.29","1 through 10","46.81","360.14","other","OPPS APC"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","120.05","79.5","","689.16","689.16","689.16","1 through 10","46.81","360.14","percent of total billed charges",""
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","320","46.81","360.14","other","OPPS APC"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","46.81","31","","282.43","282.43","282.43","1 through 10","46.81","360.14","percent of total billed charges",""
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","55.12","36.5","","340.92","289.74","643.96","19","46.81","360.14","percent of total billed charges",""
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.83","38.3","","357.37","347.32","357.37","98","46.81","360.14","percent of total billed charges",""
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.26","123.76","375.78","23","46.81","360.14","other","OPPS APC"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","MOLINA [1014]","HB BWH MOLINA","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","46.81","360.14","other","OPPS APC"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","119.98","126.29","1 through 10","46.81","360.14","other","Tricare OPPS"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","123.76","371.28","22","46.81","360.14","other","OPPS APC"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","both","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","126.29","87","46.81","360.14","other","OPPS APC"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","outpatient","","","151.00","113.25","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","618.78","436.89","618.78","1 through 10","112.51","513.1","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","outpatient","","","151.00","113.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","76","112.51","513.1","other","Multiple Imaging"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","outpatient","","","151.00","113.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","162","112.51","513.1","other","Multiple Imaging"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","outpatient","","","151.00","113.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","382.53","336.40","382.53","1 through 10","112.51","513.1","other","Multiple Radiology"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","outpatient","","","151.00","113.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","55","112.51","513.1","other","Multiple Radiology"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","outpatient","","","151.00","113.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","18","112.51","513.1","other","Multiple Radiology"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","outpatient","","","151.00","113.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","382.53","382.53","1 through 10","112.51","513.1","other","Multiple Radiology"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","outpatient","","","151.00","113.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","513.1","other","Multiple Radiology"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","outpatient","","","151.00","113.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","283.91","336.40","14","112.51","513.1","other","Multiple Radiology"
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","outpatient","","","151.00","113.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","123.40","81.72","","730.65","730.65","730.65","1 through 10","112.51","513.1","percent of total billed charges",""
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","123.40","81.72","","730.65","730.65","730.65","1 through 10","112.51","513.1","percent of total billed charges",""
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","123.40","81.72","","730.65","401.89","730.65","20","112.51","513.1","percent of total billed charges",""
"US Retroperitoneal Real Time W/Image Complete","PX-98302379","CDM","76770","CPT","0983","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","324.03","324.03","324.03","1 through 10","112.51","513.1","other","Multiple Radiology"
"US Retroperitoneal Real Time W/Image Limited","PX-98302099","CDM","76775","CPT","0983","RC","","","","both","","","142.00","106.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","112.89","79.5","","410.78","410.78","410.78","1 through 10","44.02","360.14","percent of total billed charges",""
"US Retroperitoneal Real Time W/Image Limited","PX-98302099","CDM","76775","CPT","0983","RC","","","","both","","","142.00","106.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.83","36.5","","290.19","290.19","290.19","1 through 10","44.02","360.14","percent of total billed charges",""
"US Retroperitoneal Real Time W/Image Limited","PX-98302099","CDM","76775","CPT","0983","RC","","","","both","","","142.00","106.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.39","38.3","","295.64","295.64","295.64","1 through 10","44.02","360.14","percent of total billed charges",""
"US Retroperitoneal Real Time W/Image Limited","PX-98302099","CDM","76775","CPT","0983","RC","","","","outpatient","","","142.00","106.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","160.32","160.32","160.32","1 through 10","112.51","513.1","other","Multiple Radiology"
"US Saline Infus Son Incl Color Flow","PX-40000054","CDM","76831","CPT","0402","RC","","","","both","","","905.00","678.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","719.48","other","OPPS APC"
"US Saline Infus Son Incl Color Flow","PX-40000054","CDM","76831","CPT","0402","RC","","","","both","","","905.00","678.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","280.55","31","","271.30","271.30","271.30","1 through 10","272.7","719.48","percent of total billed charges",""
"US Saline Infus Son Incl Color Flow","PX-40000054","CDM","76831","CPT","0402","RC","","","","both","","","905.00","678.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","330.33","36.5","","278.33","278.33","327.49","1 through 10","272.7","719.48","percent of total billed charges",""
"US Saline Infus Son Incl Color Flow","PX-40000054","CDM","76831","CPT","0402","RC","","","","both","","","905.00","678.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","346.62","38.3","","343.30","343.30","1029.90","23","272.7","719.48","percent of total billed charges",""
"US Saline Infus Son Incl Color Flow","PX-40000054","CDM","76831","CPT","0402","RC","","","","outpatient","","","905.00","678.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","594.41","594.41","594.41","1 through 10","230.56","801.22","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Saline Infus Son Incl Color Flow","PX-40000054","CDM","76831","CPT","0402","RC","","","","outpatient","","","905.00","678.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","474.59","","Case rate ($474.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","474.59","474.59","474.59","11","230.56","801.22","other","Multiple Imaging"
"US Saline Infus Son Incl Color Flow","PX-40000054","CDM","76831","CPT","0402","RC","","","","outpatient","","","905.00","678.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","472.95","52.26","","474.59","474.59","474.59","1 through 10","230.56","801.22","percent of total billed charges",""
"US Saline Infus Son Incl Color Flow","PX-40000054","CDM","76831","CPT","0402","RC","","","","outpatient","","","905.00","678.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","474.59","","Case rate ($474.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","474.59","474.59","474.59","33","230.56","801.22","other","Multiple Imaging"
"US Saline Infus Son Incl Color Flow","PX-40000054","CDM","76831","CPT","0402","RC","","","","outpatient","","","905.00","678.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","627.12","601.76","627.12","1 through 10","230.56","801.22","other","Multiple Radiology"
"US Saline Infus Son Incl Color Flow","PX-40000054","CDM","76831","CPT","0402","RC","","","","outpatient","","","905.00","678.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","230.56","801.22","other","Multiple Radiology"
"US Saline Infus Son Incl Color Flow","PX-40000054","CDM","76831","CPT","0402","RC","","","","outpatient","","","905.00","678.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","689.37","689.37","689.37","1 through 10","230.56","801.22","other","Multiple Radiology"
"US Saline Infus Son Incl Color Flow","PX-40000054","CDM","76831","CPT","0402","RC","","","","outpatient","","","905.00","678.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","739.57","81.72","","701.87","386.06","701.87","1 through 10","230.56","801.22","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","893.00","669.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","37.71","124.27","1 through 10","119.97","709.94","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","893.00","669.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","709.94","79.5","","681.54","457.25","681.54","14","119.97","709.94","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","893.00","669.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","475.97","53.3","","681.54","457.25","681.54","1 through 10","119.97","709.94","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","893.00","669.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","709.94","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","893.00","669.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","16","119.97","709.94","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","893.00","669.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","325.95","36.5","","323.02","274.52","323.02","13","119.97","709.94","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","893.00","669.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","342.02","38.3","","338.61","338.61","338.61","16","119.97","709.94","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","893.00","669.75","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","119.97","709.94","other","Tricare OPPS"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","893.00","669.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","125.76","1 through 10","119.97","709.94","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","893.00","669.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","709.94","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","893.00","669.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","586.28","586.28","586.28","1 through 10","112.51","729.76","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","893.00","669.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","26","112.51","729.76","other","Multiple Imaging"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","893.00","669.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","74","112.51","729.76","other","Multiple Imaging"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","893.00","669.75","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","382.53","336.40","382.53","1 through 10","112.51","729.76","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","893.00","669.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","293.65","551.30","16","112.51","729.76","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","893.00","669.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","308.28","320.65","1 through 10","112.51","729.76","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","893.00","669.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","382.53","382.53","1 through 10","112.51","729.76","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","893.00","669.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","729.76","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","893.00","669.75","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","336.40","336.40","1 through 10","112.51","729.76","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","893.00","669.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","729.76","81.72","","692.28","320.65","692.28","1 through 10","112.51","729.76","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","55","119.97","658.26","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","579.60","70","","678.92","678.92","678.92","1 through 10","119.97","658.26","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","126.29","126.29","126.29","1 through 10","119.97","658.26","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","658.26","79.5","","631.96","423.98","1659.78","157","119.97","658.26","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","441.32","53.3","","631.96","423.98","1113.54","70","119.97","658.26","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","126.29","1 through 10","119.97","658.26","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","ELDER SERVICES [1037]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","658.26","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","126.29","1 through 10","119.97","658.26","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","538.20","65","","521.95","521.95","521.95","1 through 10","119.97","658.26","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","358","119.97","658.26","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","256.68","31","","248.13","248.13","248.13","1 through 10","119.97","658.26","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","302.22","36.5","","299.52","254.55","898.56","76","119.97","658.26","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","317.12","38.3","","313.97","305.14","941.91","244","119.97","658.26","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.26","119.09","363.44","28","119.97","658.26","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","MOLINA [1014]","HB BWH MOLINA","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","250.56","126.29","250.56","1 through 10","119.97","658.26","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","637.56","77","","626.34","272.87","626.34","1 through 10","119.97","658.26","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","126.29","1 through 10","119.97","658.26","other","Tricare OPPS"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","658.26","other","Tricare OPPS"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","119.85","377.28","26","119.97","658.26","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","355.21","42.9","","641.92","353.08","641.92","1 through 10","119.97","658.26","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.97","119.99","126.29","123","119.97","658.26","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","828.00","621.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","355.21","42.9","","641.92","641.92","641.92","1 through 10","119.97","658.26","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","AETNA [1001]","HB AMC AETNA HMO","577.94","69.8","","543.63","543.63","1087.26","12","112.51","676.64","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","292","112.51","676.64","other","Multiple Imaging"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","432.71","52.26","","496.90","231.59","496.90","1 through 10","112.51","676.64","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","700","112.51","676.64","other","Multiple Imaging"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","382.53","336.40","382.53","15","112.51","676.64","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","587.30","250","112.51","676.64","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","308.28","961.95","118","112.51","676.64","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","505.17","505.17","505.17","1 through 10","112.51","676.64","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","382.53","367.91","382.53","1 through 10","112.51","676.64","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","676.64","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","336.40","336.40","50","112.51","676.64","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","665.71","80.4","","588.12","588.12","588.12","1 through 10","112.51","676.64","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","676.64","81.72","","641.92","641.92","641.92","1 through 10","112.51","676.64","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","676.64","81.72","","353.08","353.08","641.92","1 through 10","112.51","676.64","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","676.64","81.72","","641.92","353.08","641.92","113","112.51","676.64","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","828.00","621.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","324.03","324.03","336.40","1 through 10","112.51","676.64","other","Multiple Radiology"
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2621.00","1965.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","29.95","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2542.00","30.53","2542.00","1 through 10","27.63","2083.7","other","OPPS APC"
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2621.00","1965.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","1 through 10","27.63","2083.7","other","OPPS APC"
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2621.00","1965.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1396.99","53.3","","1342.18","1342.18","1342.18","1 through 10","27.63","2083.7","percent of total billed charges",""
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2621.00","1965.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.61","28.61","28.61","1 through 10","27.63","2083.7","other","OPPS APC"
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2621.00","1965.75","HUMANA [1012]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","1 through 10","27.63","2083.7","other","OPPS APC"
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2621.00","1965.75","MEDICARE [2001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","32.50","97","27.63","2083.7","other","OPPS APC"
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2621.00","1965.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.50","28.50","28.50","1 through 10","27.63","2083.7","other","OPPS APC"
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2621.00","1965.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.90","28.50","28.90","1 through 10","27.63","2083.7","other","OPPS APC"
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2621.00","1965.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","29.00","28.50","31.85","11","27.63","2083.7","other","OPPS APC"
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2621.00","1965.75","WELLPOINT [1015]","HB AMC WELLPOINT","1933.77","73.78","","1892.52","1892.52","1892.52","1 through 10","27.63","2083.7","percent of total billed charges",""
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","outpatient","","","2621.00","1965.75","AETNA [1001]","HB AMC AETNA HMO","1829.46","69.8","","1215.08","1135.70","1215.08","1 through 10","39.83","2141.88","percent of total billed charges",""
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","outpatient","","","2621.00","1965.75","AETNA [1001]","HB AMC AETNA PPO","2107.28","80.4","","30.04","30.04","30.04","1 through 10","39.83","2141.88","percent of total billed charges",""
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","outpatient","","","2621.00","1965.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1587.02","60.55","","39.44","39.44","39.44","1 through 10","39.83","2141.88","percent of total billed charges",""
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","outpatient","","","2621.00","1965.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1368.69","52.22","","45.95","45.50","45.95","1 through 10","39.83","2141.88","percent of total billed charges",""
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","outpatient","","","2621.00","1965.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2141.88","81.72","","1117.72","1117.72","1117.72","1 through 10","39.83","2141.88","percent of total billed charges",""
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","outpatient","","","2621.00","1965.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2141.88","81.72","","2032.07","1117.72","2032.08","1 through 10","39.83","2141.88","percent of total billed charges",""
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","1746.00","1309.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","29.95","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2542.00","30.53","2542.00","1 through 10","27.63","1388.07","other","OPPS APC"
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","1746.00","1309.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","1 through 10","27.63","1388.07","other","OPPS APC"
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","1746.00","1309.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","930.62","53.3","","1342.18","1342.18","1342.18","1 through 10","27.63","1388.07","percent of total billed charges",""
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","1746.00","1309.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.61","28.61","28.61","1 through 10","27.63","1388.07","other","OPPS APC"
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","1746.00","1309.50","HUMANA [1012]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","1 through 10","27.63","1388.07","other","OPPS APC"
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","1746.00","1309.50","MEDICARE [2001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","32.50","97","27.63","1388.07","other","OPPS APC"
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","1746.00","1309.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.50","28.50","28.50","1 through 10","27.63","1388.07","other","OPPS APC"
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","1746.00","1309.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.90","28.50","28.90","1 through 10","27.63","1388.07","other","OPPS APC"
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","1746.00","1309.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","29.00","28.50","31.85","11","27.63","1388.07","other","OPPS APC"
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","1746.00","1309.50","WELLPOINT [1015]","HB AMC WELLPOINT","1288.20","73.78","","1892.52","1892.52","1892.52","1 through 10","27.63","1388.07","percent of total billed charges",""
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","outpatient","","","1746.00","1309.50","AETNA [1001]","HB AMC AETNA HMO","1218.71","69.8","","1215.08","1135.70","1215.08","1 through 10","39.83","1426.83","percent of total billed charges",""
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","outpatient","","","1746.00","1309.50","AETNA [1001]","HB AMC AETNA PPO","1403.78","80.4","","30.04","30.04","30.04","1 through 10","39.83","1426.83","percent of total billed charges",""
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","outpatient","","","1746.00","1309.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1057.20","60.55","","39.44","39.44","39.44","1 through 10","39.83","1426.83","percent of total billed charges",""
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","outpatient","","","1746.00","1309.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","911.76","52.22","","45.95","45.50","45.95","1 through 10","39.83","1426.83","percent of total billed charges",""
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","outpatient","","","1746.00","1309.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1426.83","81.72","","1117.72","1117.72","1117.72","1 through 10","39.83","1426.83","percent of total billed charges",""
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","outpatient","","","1746.00","1309.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1426.83","81.72","","2032.07","1117.72","2032.08","1 through 10","39.83","1426.83","percent of total billed charges",""
"US Transrectal","PX-40000058","CDM","76872","CPT","0402","RC","","","","both","","","1092.00","819.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","868.14","other","OPPS APC"
"US Transrectal","PX-40000058","CDM","76872","CPT","0402","RC","","","","both","","","1092.00","819.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","582.04","53.3","","559.15","559.15","559.15","1 through 10","119.97","868.14","percent of total billed charges",""
"US Transrectal","PX-40000058","CDM","76872","CPT","0402","RC","","","","both","","","1092.00","819.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","868.14","other","OPPS APC"
"US Transrectal","PX-40000058","CDM","76872","CPT","0402","RC","","","","both","","","1092.00","819.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","12","119.97","868.14","other","OPPS APC"
"US Transrectal","PX-40000058","CDM","76872","CPT","0402","RC","","","","both","","","1092.00","819.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","418.24","38.3","","414.07","414.07","414.07","1 through 10","119.97","868.14","percent of total billed charges",""
"US Transrectal","PX-40000058","CDM","76872","CPT","0402","RC","","","","both","","","1092.00","819.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.76","124.27","1 through 10","119.97","868.14","other","OPPS APC"
"US Transrectal","PX-40000058","CDM","76872","CPT","0402","RC","","","","both","","","1092.00","819.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","868.14","other","OPPS APC"
"US Transrectal","PX-40000058","CDM","76872","CPT","0402","RC","","","","outpatient","","","1092.00","819.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","1 through 10","112.51","892.38","other","Multiple Imaging"
"US Transrectal","PX-40000058","CDM","76872","CPT","0402","RC","","","","outpatient","","","1092.00","819.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","1 through 10","112.51","892.38","other","Multiple Imaging"
"US Transrectal","PX-40000058","CDM","76872","CPT","0402","RC","","","","outpatient","","","1092.00","819.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","1 through 10","112.51","892.38","other","Multiple Radiology"
"US Transrectal","PX-40000058","CDM","76872","CPT","0402","RC","","","","outpatient","","","1092.00","819.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1379.65","320.65","1379.65","1 through 10","112.51","892.38","other","Multiple Radiology"
"US Transrectal","PX-40000058","CDM","76872","CPT","0402","RC","","","","outpatient","","","1092.00","819.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","168.20","168.20","168.20","1 through 10","112.51","892.38","other","Multiple Radiology"
"US Transrectal","PX-40000058","CDM","76872","CPT","0402","RC","","","","outpatient","","","1092.00","819.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","892.38","81.72","","846.56","846.56","846.56","1 through 10","112.51","892.38","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","126.29","20","119.97","702.78","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","579.90","65.6","","580.19","580.19","580.19","1 through 10","119.97","702.78","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","618.80","70","","617.04","617.04","617.04","1 through 10","119.97","702.78","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","CHAMPVA [160001]","HB BWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","702.78","other","Tricare OPPS"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","702.78","79.5","","674.46","452.50","674.46","138","119.97","702.78","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","471.17","53.3","","452.50","452.50","674.46","78","119.97","702.78","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","1 through 10","119.97","702.78","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","FALLON HEALTH [1008]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","197.08","126.29","197.08","1 through 10","119.97","702.78","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","119.97","702.78","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","179","119.97","702.78","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","274.04","31","","264.81","264.81","529.62","1 through 10","119.97","702.78","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","322.66","36.5","","319.66","271.67","620.46","84","119.97","702.78","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","338.57","38.3","","335.09","325.66","335.09","295","119.97","702.78","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.26","123.76","125.26","1 through 10","119.97","702.78","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","118.83","126.29","1 through 10","119.97","702.78","other","Tricare OPPS"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","124.27","375.56","14","119.97","702.78","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","379.24","42.9","","685.08","336.40","685.09","1 through 10","119.97","702.78","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.97","119.99","126.29","55","119.97","702.78","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","884.00","663.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","379.24","42.9","","376.82","376.82","376.82","1 through 10","119.97","702.78","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","AETNA [1001]","HB AMC AETNA HMO","617.03","69.8","","409.65","0.68","580.19","35","112.51","722.4","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","AETNA [1001]","HB AMC AETNA PPO","710.74","80.4","","580.19","580.19","580.19","1 through 10","112.51","722.4","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","115.80","115.80","231.59","221","112.51","722.4","other","Multiple Imaging"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","461.98","52.26","","115.80","115.80","115.80","1 through 10","112.51","722.4","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","115.80","115.80","231.59","569","112.51","722.4","other","Multiple Imaging"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","191.27","168.20","367.91","22","112.51","722.4","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","293.65","306.03","140","112.51","722.4","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","308.28","320.65","83","112.51","722.4","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 449%, 224.5 procedures at 0%.","505.17","505.17","505.17","1 through 10","112.51","722.4","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 340%, 170 procedures at 0%.","191.27","191.27","382.53","1 through 10","112.51","722.4","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","160.33","160.33","160.33","1 through 10","112.51","722.4","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 299%, 149.5 procedures at 0%.","336.40","168.20","336.40","50","112.51","722.4","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","710.74","80.4","","668.46","668.46","668.46","1 through 10","112.51","722.4","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1381.37","1381.37","1381.37","1 through 10","112.51","722.4","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","722.40","81.72","","685.09","306.03","685.09","1 through 10","112.51","722.4","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","884.00","663.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","722.40","81.72","","685.09","376.82","685.09","93","112.51","722.4","percent of total billed charges",""
"US, Chest, Real Time","PX-98302083","CDM","76604","CPT","0983","RC","","","","both","","","117.00","87.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","59.53","59.53","59.53","1 through 10","36.27","360.14","other","OPPS APC"
"US, Chest, Real Time","PX-98302083","CDM","76604","CPT","0983","RC","","","","both","","","117.00","87.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","93.02","79.5","","457.25","457.25","457.25","1 through 10","36.27","360.14","percent of total billed charges",""
"US, Chest, Real Time","PX-98302083","CDM","76604","CPT","0983","RC","","","","both","","","117.00","87.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","62.36","53.3","","306.77","306.77","306.77","1 through 10","36.27","360.14","percent of total billed charges",""
"US, Chest, Real Time","PX-98302083","CDM","76604","CPT","0983","RC","","","","both","","","117.00","87.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","36.27","360.14","other","OPPS APC"
"US, Chest, Real Time","PX-98302083","CDM","76604","CPT","0983","RC","","","","both","","","117.00","87.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","42.71","36.5","","216.71","216.71","216.71","1 through 10","36.27","360.14","percent of total billed charges",""
"US, Chest, Real Time","PX-98302083","CDM","76604","CPT","0983","RC","","","","both","","","117.00","87.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","44.81","38.3","","227.17","220.78","681.51","1 through 10","36.27","360.14","percent of total billed charges",""
"US, Chest, Real Time","PX-98302083","CDM","76604","CPT","0983","RC","","","","both","","","117.00","87.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","123.76","125.76","1 through 10","36.27","360.14","other","OPPS APC"
"US, Chest, Real Time","PX-98302083","CDM","76604","CPT","0983","RC","","","","both","","","117.00","87.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","123.77","123.77","1 through 10","36.27","360.14","other","OPPS APC"
"US, Chest, Real Time","PX-98302083","CDM","76604","CPT","0983","RC","","","","outpatient","","","117.00","87.75","AETNA [1001]","HB AMC AETNA HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","393.34","393.34","393.34","1 through 10","95.61","333.74","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US, Chest, Real Time","PX-98302083","CDM","76604","CPT","0983","RC","","","","outpatient","","","117.00","87.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","231.59","231.59","1 through 10","95.61","333.74","other","Multiple Imaging"
"US, Chest, Real Time","PX-98302083","CDM","76604","CPT","0983","RC","","","","outpatient","","","117.00","87.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","231.59","","Case rate ($231.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","231.59","115.80","231.59","1 through 10","95.61","333.74","other","Multiple Imaging"
"US, Chest, Real Time","PX-98302083","CDM","76604","CPT","0983","RC","","","","outpatient","","","117.00","87.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 272%, 136 procedures at 0%.","306.03","306.03","306.03","1 through 10","95.61","333.74","other","Multiple Radiology"
"US, Chest, Real Time|REDUCED SERVICES","PX-98302083","CDM","76604","CPT","0983","RC","","","52","both","","","117.00","87.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","59.04","59.04","59.04","1 through 10","119.97","157.84","other","OPPS APC"
"US, Chest, Real Time|REDUCED SERVICES","PX-98302083","CDM","76604","CPT","0983","RC","","","52","both","","","117.00","87.75","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","61.89","61.89","61.89","1 through 10","119.97","157.84","other","OPPS APC"
"US, Chest, Real Time|REDUCED SERVICES","PX-98302083","CDM","76604","CPT","0983","RC","","","52","both","","","117.00","87.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.14","60.00","63.14","1 through 10","119.97","157.84","other","OPPS APC"
"US, Chest, Real Time|REDUCED SERVICES","PX-98302083","CDM","76604","CPT","0983","RC","","","52","both","","","117.00","87.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","61.89","61.89","61.89","1 through 10","119.97","157.84","other","OPPS APC"
"US, Chest, Real Time|REDUCED SERVICES","PX-98302083","CDM","76604","CPT","0983","RC","","","52","both","","","117.00","87.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","58.80","58.80","58.80","1 through 10","119.97","157.84","other","OPPS APC"
"Usher Syndrome Panel (11 Genes) Test","PX-31000686","CDM","81479","CPT","0310","RC","","","","both","","","603.00","452.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","479.39","79.5","","0.65","0.65","0.65","1 through 10","186.93","572.85","percent of total billed charges",""
"Usher Syndrome Panel (11 Genes) Test","PX-31000686","CDM","81479","CPT","0310","RC","","","","both","","","603.00","452.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","321.40","53.3","","0.79","0.79","0.79","1 through 10","186.93","572.85","percent of total billed charges",""
"Usher Syndrome Panel (11 Genes) Test","PX-31000686","CDM","81479","CPT","0310","RC","","","","outpatient","","","603.00","452.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","301.50","50","","1.00","1.00","1.00","1 through 10","156.55","497.48","percent of total billed charges",""
"Usher Syndrome Panel (11 Genes) Test","PX-31000686","CDM","81479","CPT","0310","RC","","","","outpatient","","","603.00","452.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","316.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","497.48","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","both","","","316.00","237.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","251.22","79.5","","106.25","71.28","106.25","1 through 10","14.12","300.2","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","both","","","316.00","237.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","168.43","53.3","","106.25","71.28","106.25","1 through 10","14.12","300.2","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","both","","","316.00","237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","115.34","36.5","","50.36","42.80","92.50","13","14.12","300.2","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","both","","","316.00","237.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","121.03","38.3","","52.79","44.55","158.37","30","14.12","300.2","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","outpatient","","","316.00","237.00","AETNA [1001]","HB AMC AETNA HMO","220.57","69.8","","91.40","64.53","105.30","14","14.12","258.24","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","outpatient","","","316.00","237.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","254.06","80.4","","105.30","105.30","105.30","1 through 10","14.12","258.24","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","outpatient","","","316.00","237.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","258.24","81.72","","59.36","15.50","59.36","1 through 10","14.12","258.24","percent of total billed charges",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC","742","MS-DRG","","","","","","","","inpatient","","","95799.70","71849.77","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","22101.88","","Case rate ($22,101.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,528.17, add-ons for qualifying new technology services are included. If operating cost exceeds $66,172.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,916.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $20,245.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,148.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,476.39. The transfer capital threshold is the transfer adjustment factor * $1,476.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16676.39","16676.39","16676.39","1 through 10","16774.72","28740.31","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC","742","MS-DRG","","","","","","","","inpatient","","","95799.70","71849.77","HUMANA [1012]","HB BWH MEDICARE","22101.88","","Case rate ($22,101.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,528.17, add-ons for qualifying new technology services are included. If operating cost exceeds $66,172.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,916.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $20,245.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,148.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,476.39. The transfer capital threshold is the transfer adjustment factor * $1,476.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16591.38","16591.38","16591.38","1 through 10","16774.72","28740.31","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC","742","MS-DRG","","","","","","","","inpatient","","","95799.70","71849.77","MEDICARE [2001]","HB BWH MEDICARE","22101.88","","Case rate ($22,101.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,528.17, add-ons for qualifying new technology services are included. If operating cost exceeds $66,172.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,916.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $20,245.67 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,148.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,476.39. The transfer capital threshold is the transfer adjustment factor * $1,476.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21845.75","21813.53","21845.75","1 through 10","16774.72","28740.31","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC","742","MS-DRG","","","","","","","","inpatient","","","95799.70","71849.77","MOLINA [1014]","HB BWH MOLINA","16774.72","","Case rate ($17,117.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,528.17, add-ons for qualifying new technology services are included. If operating cost exceeds $66,172.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,916.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $15,260.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,148.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,476.39. The transfer capital threshold is the transfer adjustment factor * $1,476.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","33413.73","33413.73","33413.73","1 through 10","16774.72","28740.31","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC","742","MS-DRG","","","","","","","","inpatient","","","95799.70","71849.77","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16774.72","","Case rate ($17,117.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,528.17, add-ons for qualifying new technology services are included. If operating cost exceeds $66,172.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,916.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $15,260.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,148.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,476.39. The transfer capital threshold is the transfer adjustment factor * $1,476.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16554.99","16554.99","16554.99","1 through 10","16774.72","28740.31","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC","742","MS-DRG","","","","","","","","inpatient","","","95799.70","71849.77","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16774.72","","Case rate ($17,117.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,528.17, add-ons for qualifying new technology services are included. If operating cost exceeds $66,172.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,916.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $15,260.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,148.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,476.39. The transfer capital threshold is the transfer adjustment factor * $1,476.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16705.85","16568.76","32922.14","1 through 10","16774.72","28740.31","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC","743","MS-DRG","","","","","","","","inpatient","","","81973.99","61480.49","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","12048.57","","Case rate ($11,697.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,004.24, add-ons for qualifying new technology services are included. If operating cost exceeds $59,648.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,438.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,319.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,624.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $998.34. The transfer capital threshold is the transfer adjustment factor * $998.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11509.37","11509.37","11509.37","1 through 10","11463.69","18089.5817","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC","743","MS-DRG","","","","","","","","inpatient","","","81973.99","61480.49","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","11697.64","","Case rate ($11,697.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,004.24, add-ons for qualifying new technology services are included. If operating cost exceeds $59,648.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,438.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,319.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,624.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $998.34. The transfer capital threshold is the transfer adjustment factor * $998.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11047.68","11047.68","11047.68","1 through 10","11463.69","18089.5817","other","Inpatient Replacement Plans DRG"
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC","743","MS-DRG","","","","","","","","inpatient","","","81973.99","61480.49","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","11697.64","","Case rate ($11,697.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,004.24, add-ons for qualifying new technology services are included. If operating cost exceeds $59,648.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,438.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,319.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,624.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $998.34. The transfer capital threshold is the transfer adjustment factor * $998.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11002.61","11002.61","11002.61","1 through 10","11463.69","18089.5817","other","Inpatient Replacement Plans DRG"
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC","743","MS-DRG","","","","","","","","inpatient","","","81973.99","61480.49","MEDICARE [2001]","HB BWH MEDICARE","11697.64","","Case rate ($11,697.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,004.24, add-ons for qualifying new technology services are included. If operating cost exceeds $59,648.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,438.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,319.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,624.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $998.34. The transfer capital threshold is the transfer adjustment factor * $998.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14409.94","14409.94","14431.07","1 through 10","11463.69","18089.5817","other","Inpatient Replacement Plans DRG"
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC","743","MS-DRG","","","","","","","","inpatient","","","81973.99","61480.49","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","11463.69","","Case rate ($11,697.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $14,004.24, add-ons for qualifying new technology services are included. If operating cost exceeds $59,648.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,438.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,319.46 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $13,624.40 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $998.34. The transfer capital threshold is the transfer adjustment factor * $998.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10975.30","10975.30","10975.30","1 through 10","11463.69","18089.5817","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","","","","inpatient","","","118367.11","88775.33","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","21803.56","","Case rate ($21,803.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,251.45, add-ons for qualifying new technology services are included. If operating cost exceeds $65,895.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,896.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $19,967.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,871.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.11. The transfer capital threshold is the transfer adjustment factor * $1,456.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16600.99","16600.99","16600.99","1 through 10","16549.46","27439.9653","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","","","","inpatient","","","118367.11","88775.33","MEDICARE [2001]","HB BWH MEDICARE","21803.56","","Case rate ($21,803.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,251.45, add-ons for qualifying new technology services are included. If operating cost exceeds $65,895.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,896.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $19,967.61 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,871.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.11. The transfer capital threshold is the transfer adjustment factor * $1,456.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21714.50","12363.95","21746.56","1 through 10","16549.46","27439.9653","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","","","","inpatient","","","118367.11","88775.33","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","16549.46","","Case rate ($16,887.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,251.45, add-ons for qualifying new technology services are included. If operating cost exceeds $65,895.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,896.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $15,051.25 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,871.61 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,456.11. The transfer capital threshold is the transfer adjustment factor * $1,456.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16484.55","16484.55","16484.55","1 through 10","16549.46","27439.9653","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With McC","739","MS-DRG","","","","","","","","inpatient","","","205661.41","154246.06","MEDICARE [2001]","HB BWH MEDICARE","42796.34","","Case rate ($42,796.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,723.34, add-ons for qualifying new technology services are included. If operating cost exceeds $85,367.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,323.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $39,533.57 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,343.50 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,882.93. The transfer capital threshold is the transfer adjustment factor * $2,882.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.01","0.01","0.01","1 through 10","32401.27","56120.98","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/McC","741","MS-DRG","","","","","","","","inpatient","","","95828.06","71871.04","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","13388.89","","Case rate ($13,388.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,040.16, add-ons for qualifying new technology services are included. If operating cost exceeds $61,684.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,587.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $11,861.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,660.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,147.52. The transfer capital threshold is the transfer adjustment factor * $1,147.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12607.87","12607.87","12607.87","1 through 10","13121.11","20728.9976","other","Inpatient Replacement Plans DRG"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/McC","741","MS-DRG","","","","","","","","inpatient","","","95828.06","71871.04","MEDICARE [2001]","HB BWH MEDICARE","13388.89","","Case rate ($13,388.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,040.16, add-ons for qualifying new technology services are included. If operating cost exceeds $61,684.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,587.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $11,861.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,660.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,147.52. The transfer capital threshold is the transfer adjustment factor * $1,147.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16496.09","16496.09","16496.09","1 through 10","13121.11","20728.9976","other","Inpatient Replacement Plans DRG"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/McC","741","MS-DRG","","","","","","","","inpatient","","","95828.06","71871.04","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13121.11","","Case rate ($13,388.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,040.16, add-ons for qualifying new technology services are included. If operating cost exceeds $61,684.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,587.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $11,861.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $15,660.31 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,147.52. The transfer capital threshold is the transfer adjustment factor * $1,147.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12509.02","12509.02","12509.02","1 through 10","13121.11","20728.9976","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,MAJOR","512","DRG","","","","","","","","inpatient","","","150785.07","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","52154.78","","Standard inlier is a Case rate ($52,154.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,722, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,402.94) for the length of stay and the standard reimbursement.","74986.31","74986.31","74986.31","1 through 10","11075.24","219133.07","case rate",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,MAJOR","512","DRG","","","","","","","","inpatient","","","150785.07","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","23798.488","","Fee schedule rate ($57,203.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23798.488","57203.60","57203.60","1 through 10","11075.24","219133.07","case rate",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,MAJOR","512","DRG","","","","","","","","inpatient","","","150785.07","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","62924.73","","Fee schedule rate ($62,924.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","62924.73","62924.73","62924.73","1 through 10","11075.24","219133.07","case rate",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,MINOR","512","DRG","","","","","","","","inpatient","","","115844.48","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","42730.46","","Fee schedule rate ($42,730.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","42730.46","42730.46","42730.46","1 through 10","11075.24","219133.07","case rate",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,MODERATE","512","DRG","","","","","","","","inpatient","","","122917.68","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","46389.93","","Standard inlier is a Case rate ($46,389.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,722, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,585.33) for the length of stay and the standard reimbursement.","46389.93","46389.93","46389.93","1 through 10","11075.24","219133.07","case rate",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,MODERATE","512","DRG","","","","","","","","inpatient","","","122917.68","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","52154.78","","Standard inlier is a Case rate ($52,154.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $47,722, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,402.94) for the length of stay and the standard reimbursement.","52154.78","52154.78","74986.31","1 through 10","11075.24","219133.07","case rate",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,MODERATE","512","DRG","","","","","","","","inpatient","","","122917.68","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","23798.488","","Fee schedule rate ($29,446.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23798.488","29446.16","29446.16","1 through 10","11075.24","219133.07","case rate",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,MODERATE","512","DRG","","","","","","","","inpatient","","","122917.68","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","32391.17","","Fee schedule rate ($32,391.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32391.17","32391.17","32391.17","1 through 10","11075.24","219133.07","case rate",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy,MODERATE","512","DRG","","","","","","","","inpatient","","","122917.68","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","47430.05","","Fee schedule rate ($47,430.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","47430.05","47430.05","47430.05","1 through 10","11075.24","219133.07","case rate",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","","","","inpatient","","","152771.46","114578.59","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","19176.85","","Case rate ($19,176.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,007.73, add-ons for qualifying new technology services are included. If operating cost exceeds $68,652.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,098.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $17,138.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,627.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,658.08. The transfer capital threshold is the transfer adjustment factor * $1,658.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23515.01","23515.01","23515.01","1 through 10","18793.31","32277.24","other","Inpatient Replacement Plans DRG"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","","","","inpatient","","","152771.46","114578.59","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","19176.85","","Case rate ($19,176.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,007.73, add-ons for qualifying new technology services are included. If operating cost exceeds $68,652.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,098.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $17,138.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,627.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,658.08. The transfer capital threshold is the transfer adjustment factor * $1,658.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18081.18","18081.18","18081.18","1 through 10","18793.31","32277.24","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","","","","inpatient","","","152771.46","114578.59","HUMANA [1012]","HB BWH MEDICARE","19176.85","","Case rate ($19,176.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,007.73, add-ons for qualifying new technology services are included. If operating cost exceeds $68,652.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,098.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $17,138.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,627.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,658.08. The transfer capital threshold is the transfer adjustment factor * $1,658.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18246.60","18246.60","18246.60","1 through 10","18793.31","32277.24","other","Inpatient Replacement Plans DRG"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","","","","inpatient","","","152771.46","114578.59","MEDICARE [2001]","HB BWH MEDICARE","19176.85","","Case rate ($19,176.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,007.73, add-ons for qualifying new technology services are included. If operating cost exceeds $68,652.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,098.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $17,138.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,627.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,658.08. The transfer capital threshold is the transfer adjustment factor * $1,658.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23865.54","0.03","23872.96","35","18793.31","32277.24","other","Inpatient Replacement Plans DRG"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","","","","inpatient","","","152771.46","114578.59","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","19176.85","","Case rate ($19,176.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,007.73, add-ons for qualifying new technology services are included. If operating cost exceeds $68,652.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,098.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $17,138.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,627.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,658.08. The transfer capital threshold is the transfer adjustment factor * $1,658.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18073.36","18073.36","18073.36","1 through 10","18793.31","32277.24","other","Inpatient Replacement Plans DRG"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","","","","inpatient","","","152771.46","114578.59","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","18793.31","","Case rate ($19,176.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,007.73, add-ons for qualifying new technology services are included. If operating cost exceeds $68,652.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,098.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $17,138.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,627.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,658.08. The transfer capital threshold is the transfer adjustment factor * $1,658.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18088.18","18068.47","18119.56","1 through 10","18793.31","32277.24","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","","","","inpatient","","","152771.46","114578.59","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","18793.31","","Case rate ($19,176.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,007.73, add-ons for qualifying new technology services are included. If operating cost exceeds $68,652.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,098.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $17,138.93 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $22,627.89 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,658.08. The transfer capital threshold is the transfer adjustment factor * $1,658.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18104.55","18104.55","18104.55","1 through 10","18793.31","32277.24","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","","","","inpatient","","","152771.46","114578.59","WELLPOINT [1015]","HB AMC WELLPOINT","32277.24","","Fee schedule rate ($32,277.24).","392628.20","392628.20","392628.20","1 through 10","18793.31","32277.24","case rate",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With McC","736","MS-DRG","","","","","","","","inpatient","","","269278.66","201958.99","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","33976.40","","Case rate ($32,986.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,632.19, add-ons for qualifying new technology services are included. If operating cost exceeds $85,276.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,316.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $29,730.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,252.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,876.25. The transfer capital threshold is the transfer adjustment factor * $2,876.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","37161.50","37161.50","37161.50","1 through 10","32327.06","55990.97","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With McC","736","MS-DRG","","","","","","","","inpatient","","","269278.66","201958.99","MEDICARE [2001]","HB BWH MEDICARE","32986.80","","Case rate ($32,986.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,632.19, add-ons for qualifying new technology services are included. If operating cost exceeds $85,276.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,316.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $29,730.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,252.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,876.25. The transfer capital threshold is the transfer adjustment factor * $2,876.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","46768.70","46699.26","59773.03","1 through 10","32327.06","55990.97","other","Inpatient Replacement Plans DRG"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With McC","736","MS-DRG","","","","","","","","inpatient","","","269278.66","201958.99","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","32327.06","","Case rate ($32,986.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $39,632.19, add-ons for qualifying new technology services are included. If operating cost exceeds $85,276.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,316.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $29,730.71 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $39,252.36 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,876.25. The transfer capital threshold is the transfer adjustment factor * $2,876.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","35377.91","35377.91","35377.91","1 through 10","32327.06","55990.97","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/McC","738","MS-DRG","","","","","","","","inpatient","","","132572.98","99429.73","MEDICARE [2001]","HB BWH MEDICARE","13775.66","","Case rate ($13,775.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,505.76, add-ons for qualifying new technology services are included. If operating cost exceeds $62,150.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,621.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $12,214.17 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,125.92 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.64. The transfer capital threshold is the transfer adjustment factor * $1,181.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18161.25","18161.25","18161.25","1 through 10","13500.15","23002.58","other","Inpatient Replacement Plans DRG"
"Uwmc Molecular Diagnosis of Congenital Sucrase-Isomaltase Deficiency (Csid)","PX-31001068","CDM","81479","CPT","0310","RC","","","","both","","","1483.00","1112.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1178.99","79.5","","0.65","0.65","0.65","1 through 10","459.73","1408.85","percent of total billed charges",""
"Uwmc Molecular Diagnosis of Congenital Sucrase-Isomaltase Deficiency (Csid)","PX-31001068","CDM","81479","CPT","0310","RC","","","","both","","","1483.00","1112.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","790.44","53.3","","0.79","0.79","0.79","1 through 10","459.73","1408.85","percent of total billed charges",""
"Uwmc Molecular Diagnosis of Congenital Sucrase-Isomaltase Deficiency (Csid)","PX-31001068","CDM","81479","CPT","0310","RC","","","","outpatient","","","1483.00","1112.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","741.50","50","","1.00","1.00","1.00","1 through 10","156.55","1223.48","percent of total billed charges",""
"Uwmc Molecular Diagnosis of Congenital Sucrase-Isomaltase Deficiency (Csid)","PX-31001068","CDM","81479","CPT","0310","RC","","","","outpatient","","","1483.00","1112.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","778.58","52.5","","1.00","0.53","1.00","1 through 10","156.55","1223.48","percent of total billed charges",""
"Vad Drive Line Managment System T1","PX-27001171","CDM","Q0508","HCPCS","0274","RC","","","","both","","","707.00","530.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","459.55","65","","1092.00","1092.00","1092.00","1 through 10","219.17","671.65","percent of total billed charges",""
"Vad Drive Line Managment System T1","PX-27001171","CDM","Q0508","HCPCS","0274","RC","","","","both","","","707.00","530.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","494.90","70","","51.84","51.84","51.84","21","219.17","671.65","percent of total billed charges",""
"Vad Drive Line Managment System T1","PX-27001171","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","707.00","530.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","428.09","60.55","","48.41","48.41","48.41","1 through 10","282.8","583.28","percent of total billed charges",""
"Vad Drive Line Managment System T1","PX-27001171","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","707.00","530.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","369.20","52.22","","43.55","43.55","43.55","24","282.8","583.28","percent of total billed charges",""
"Vad Drive Line Managment System T1","PX-27001171","CDM","Q0508","HCPCS","0274","RC","","","","outpatient","","","707.00","530.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","353.50","50","","37.73","37.73","188.64","1 through 10","282.8","583.28","percent of total billed charges",""
"Vagina, Cervix And Vulva Procedures With Cc/McC","746","MS-DRG","","","","","","","","inpatient","","","92240.72","69180.54","MEDICARE [2001]","HB BWH MEDICARE","16225.85","","Case rate ($16,225.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $19,455.31, add-ons for qualifying new technology services are included. If operating cost exceeds $65,099.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,837.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,448.24 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $19,075.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,397.77. The transfer capital threshold is the transfer adjustment factor * $1,397.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20020.39","20020.39","80138.45","1 through 10","15901.33","25271.3886","other","Inpatient Replacement Plans DRG"
"Vagina, Cervix And Vulva Procedures Without Cc/McC","747","MS-DRG","","","","","","","","inpatient","","","63560.89","47670.67","MEDICARE [2001]","HB BWH MEDICARE","10557.76","","Case rate ($10,557.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,820.40, add-ons for qualifying new technology services are included. If operating cost exceeds $55,464.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,131.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $9,486.16 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,440.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.77. The transfer capital threshold is the transfer adjustment factor * $691.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11539.28","4657.20","11556.13","1 through 10","8057.67","13466.34","other","Inpatient DRG"
"Vagina, Cervix And Vulva Procedures Without Cc/McC","747","MS-DRG","","","","","","","","inpatient","","","63560.89","47670.67","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8057.67","","Case rate ($8,222.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,820.40, add-ons for qualifying new technology services are included. If operating cost exceeds $55,464.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,131.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.3. The base transfer operating payment is the transfer adjustment factor * $7,150.51 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,440.55 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $691.77. The transfer capital threshold is the transfer adjustment factor * $691.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8806.87","8806.87","8806.87","1 through 10","8057.67","13466.34","other","Inpatient DRG"
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,EXTREME","542","DRG","","","","","","","","inpatient","","","61233.61","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","59983.09","","Standard inlier is a Case rate ($59,983.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $53,137, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,514.10) for the length of stay and the standard reimbursement.","54806.21","54806.21","54806.21","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MAJOR","542","DRG","","","","","","","","inpatient","","","47226.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","23233.77","","Standard inlier is a Case rate ($23,233.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,298.17) for the length of stay and the standard reimbursement.","23233.77","23233.77","26325.98","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MAJOR","542","DRG","","","","","","","","inpatient","","","47226.98","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","26121.02","","Standard inlier is a Case rate ($26,121.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,707.66) for the length of stay and the standard reimbursement.","23863.81","23863.81","26121.02","11","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MAJOR","542","DRG","","","","","","","","inpatient","","","47226.98","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10575.1176","","Fee schedule rate ($27,551.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10575.1176","27551.68","27551.68","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MAJOR","542","DRG","","","","","","","","inpatient","","","47226.98","","MASSHEALTH [3001]","HB BWH MEDICAID","10843.34","","Case rate ($11,989.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,419.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11986.23","11986.23","12705.40","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MAJOR","542","DRG","","","","","","","","inpatient","","","47226.98","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19117.76","","Fee schedule rate ($19,117.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16250.10","16250.10","16250.10","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MAJOR","542","DRG","","","","","","","","inpatient","","","47226.98","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20073.96","","Fee schedule rate ($20,073.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20073.96","20073.96","20073.96","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MAJOR","542","DRG","","","","","","","","inpatient","","","47226.98","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10843.34","","Case rate ($11,989.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,419.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11986.23","597.76","12705.41","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MINOR","542","DRG","","","","","","","","inpatient","","","39174.79","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","15565.72","","Standard inlier is a Case rate ($15,565.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,415, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,209.42) for the length of stay and the standard reimbursement.","15565.71","15565.71","15565.71","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MINOR","542","DRG","","","","","","","","inpatient","","","39174.79","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11104.1808","","Fee schedule rate ($11,104.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11104.1808","11498.76","11498.76","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MINOR","542","DRG","","","","","","","","inpatient","","","39174.79","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11654.98","","Fee schedule rate ($11,654.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11654.98","11654.98","11654.98","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MINOR","542","DRG","","","","","","","","inpatient","","","39174.79","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7158.07","","Case rate ($7,914.47). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,344.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7912.53","7912.53","7912.53","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","39858.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","23233.77","","Standard inlier is a Case rate ($23,233.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,298.17) for the length of stay and the standard reimbursement.","15750.06","14356.76","15750.06","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","39858.65","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","26121.02","","Standard inlier is a Case rate ($26,121.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,707.66) for the length of stay and the standard reimbursement.","17707.32","16177.16","17707.32","36","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","39858.65","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10575.1176","","Fee schedule rate ($12,825.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10575.1176","12825.24","12825.24","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","39858.65","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11104.1808","","Fee schedule rate ($13,466.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11104.1808","13466.88","13466.88","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","39858.65","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","14107.93","","Fee schedule rate ($14,107.93). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14107.93","14107.93","14107.93","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","39858.65","","MASSHEALTH [3001]","HB BWH MEDICAID","10843.34","","Case rate ($11,989.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,419.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9030.08","9030.08","9030.08","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","39858.65","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","19117.76","","Fee schedule rate ($19,117.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12591.72","12591.72","12591.72","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","39858.65","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","20073.96","","Fee schedule rate ($20,073.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13221.51","13221.51","13221.51","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","39858.65","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","10843.34","","Case rate ($11,989.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,419.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9030.08","9030.08","9571.89","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedure Except Sterilization And/Or D&C,MODERATE","542","DRG","","","","","","","","inpatient","","","39858.65","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","10843.34","","Case rate ($11,989.17). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $54,419.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8779.22","8779.22","8779.22","1 through 10","7158.07","59983.09","case rate",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","","","","inpatient","","","40338.11","30253.58","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","9951.99","","Case rate ($10,155.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,147.30, add-ons for qualifying new technology services are included. If operating cost exceeds $57,791.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,302.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $8,912.98 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,767.47 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.27. The transfer capital threshold is the transfer adjustment factor * $862.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10118.24","10118.24","10118.24","1 through 10","9951.99","16785.54","other","Inpatient DRG"
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","TRIS-DRG","","","","","","","","inpatient","","","39485.36","","TRICARE [160005]","HB BWH TRICARE","4284.91","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($7,526.68). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $51,253.68 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($5,789.75), capped at $5,417.22. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $51,253.68 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","7987.66","7987.66","7987.66","1 through 10","4284.91","4284.91","other","Inpatient DRGs"
"Vaginal Delivery With Sterilization And/Or D&C,MAJOR","541","DRG","","","","","","","","inpatient","","","48571.16","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","27072.65","","Standard inlier is a Case rate ($27,072.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,701, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,843.13) for the length of stay and the standard reimbursement.","27072.65","27072.65","27072.65","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MAJOR","541","DRG","","","","","","","","inpatient","","","48571.16","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","30436.96","","Standard inlier is a Case rate ($30,436.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $32,701, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,320.27) for the length of stay and the standard reimbursement.","30436.95","30436.95","30436.96","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MAJOR","541","DRG","","","","","","","","inpatient","","","48571.16","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","15777.8948","","Fee schedule rate ($23,298.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15777.8948","24407.17","24407.17","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MAJOR","541","DRG","","","","","","","","inpatient","","","48571.16","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15026.1506","","Fee schedule rate ($22,188.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15026.1506","22188.08","22188.08","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MAJOR","541","DRG","","","","","","","","inpatient","","","48571.16","","MASSHEALTH [3001]","HB BWH MEDICAID","12031.40","","Case rate ($13,302.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,732.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","56911.67","56911.67","56911.67","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MAJOR","541","DRG","","","","","","","","inpatient","","","48571.16","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24390.60","","Fee schedule rate ($24,390.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24390.60","24390.60","24390.60","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MAJOR","541","DRG","","","","","","","","inpatient","","","48571.16","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","25610.53","","Fee schedule rate ($25,610.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25610.53","25610.53","25610.53","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MAJOR","541","DRG","","","","","","","","inpatient","","","48571.16","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","12031.40","","Case rate ($13,302.78). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $55,732.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13299.51","13299.51","13299.51","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MINOR","541","DRG","","","","","","","","inpatient","","","39608.33","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21102.50","","Standard inlier is a Case rate ($21,102.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,057, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,995.63) for the length of stay and the standard reimbursement.","21674.74","21674.74","21674.74","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MINOR","541","DRG","","","","","","","","inpatient","","","39608.33","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","15777.8948","","Fee schedule rate ($15,777.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15777.8948","16528.97","16528.97","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MINOR","541","DRG","","","","","","","","inpatient","","","39608.33","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","16528.97","","Fee schedule rate ($16,528.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16528.97","16528.97","16528.97","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MINOR","541","DRG","","","","","","","","inpatient","","","39608.33","","MASSHEALTH [3001]","HB BWH MEDICAID","7928.02","","Case rate ($8,765.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,195.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6806.34","6806.34","8763.63","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MINOR","541","DRG","","","","","","","","inpatient","","","39608.33","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18077.76","","Fee schedule rate ($18,077.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18077.76","18077.76","18077.76","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MINOR","541","DRG","","","","","","","","inpatient","","","39608.33","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","7928.02","","Case rate ($8,765.79). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $51,195.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8763.64","8763.64","8763.64","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","45323.37","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","21991.88","","Standard inlier is a Case rate ($21,991.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,750, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,121.88) for the length of stay and the standard reimbursement.","7546.88","7546.88","7546.88","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","45323.37","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","24724.80","","Standard inlier is a Case rate ($24,724.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $28,750, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,509.48) for the length of stay and the standard reimbursement.","22588.24","22588.24","24724.80","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","45323.37","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","15777.8948","","Fee schedule rate ($16,867.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15777.8948","20080.15","20080.15","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","45323.37","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","15026.1506","","Fee schedule rate ($16,063.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15026.1506","16063.96","16063.96","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","45323.37","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","15777.8948","","Fee schedule rate ($16,867.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15777.8948","16867.64","16867.64","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","45323.37","","MASSHEALTH [3001]","HB BWH MEDICAID","9475.93","","Case rate ($10,477.27). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,907.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7634.72","6806.34","10474.69","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","45323.37","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","17289.11","","Fee schedule rate ($17,289.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17289.11","17289.11","17289.11","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","45323.37","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","18153.84","","Fee schedule rate ($18,153.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18153.84","18153.84","18153.84","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C,MODERATE","541","DRG","","","","","","","","inpatient","","","45323.37","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9475.93","","Case rate ($10,477.27). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,907.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10474.69","10474.69","10474.69","1 through 10","7928.02","63046.12","case rate",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","38863.43","29147.57","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","7475.65","","Case rate ($7,257.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,659.68, add-ons for qualifying new technology services are included. If operating cost exceeds $54,304.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,046.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,271.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,279.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $606.71. The transfer capital threshold is the transfer adjustment factor * $606.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7077.75","7077.75","7077.75","1 through 10","7112.75","10919.8476","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","38863.43","29147.57","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","7257.91","","Case rate ($7,257.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,659.68, add-ons for qualifying new technology services are included. If operating cost exceeds $54,304.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,046.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,271.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,279.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $606.71. The transfer capital threshold is the transfer adjustment factor * $606.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6795.94","6795.94","6795.94","1 through 10","7112.75","10919.8476","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","38863.43","29147.57","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","9775.12","9775.12","9775.12","1 through 10","7112.75","10919.8476","case rate",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","38863.43","29147.57","MEDICARE [2001]","HB BWH MEDICARE","7257.91","","Case rate ($7,257.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,659.68, add-ons for qualifying new technology services are included. If operating cost exceeds $54,304.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,046.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,271.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,279.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $606.71. The transfer capital threshold is the transfer adjustment factor * $606.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8808.90","8808.90","8808.90","1 through 10","7112.75","10919.8476","other","Inpatient Replacement Plans DRG"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","38863.43","29147.57","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","7112.75","","Case rate ($7,257.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $8,659.68, add-ons for qualifying new technology services are included. If operating cost exceeds $54,304.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,046.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,271.36 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $8,279.84 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $606.71. The transfer capital threshold is the transfer adjustment factor * $606.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","94254.19","94254.19","94254.19","1 through 10","7112.75","10919.8476","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","TRIS-DRG","","","","","","","","inpatient","","","32858.13","","TRICARE [160005]","HB BWH TRICARE","3624.16","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($6,366.02). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $50,093.03 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($5,535.67), capped at $4,581.85. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $50,093.03 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","7408.14","7408.14","7408.14","1 through 10","3624.16","3624.16","other","Inpatient DRGs"
"Vaginal Delivery Without Sterilization Or D&C With McC","805","MS-DRG","","","","","","","","inpatient","","","41211.16","30908.37","MEDICARE [2001]","HB BWH MEDICARE","10224.41","","Case rate ($10,224.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,230.76, add-ons for qualifying new technology services are included. If operating cost exceeds $57,875.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,308.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,976.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,850.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $868.39. The transfer capital threshold is the transfer adjustment factor * $868.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12061.45","12061.45","12061.45","1 through 10","10019.92","15060.818","other","Inpatient Replacement Plans DRG"
"Vaginal Delivery Without Sterilization Or D&C With McC","805","MS-DRG","","","","","","","","inpatient","","","41211.16","30908.37","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10019.92","","Case rate ($10,224.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $12,230.76, add-ons for qualifying new technology services are included. If operating cost exceeds $57,875.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,308.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,976.19 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $11,850.93 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $868.39. The transfer capital threshold is the transfer adjustment factor * $868.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12787.84","12787.84","12787.84","1 through 10","10019.92","15060.818","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C With McC","805","TRIS-DRG","","","","","","","","inpatient","","","36750.43","","TRICARE [160005]","HB BWH TRICARE","4066.97","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($7,143.85). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $50,870.85 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($5,495.27), capped at $5,141.68. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $50,870.85 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","8915.68","8915.68","8915.68","1 through 10","4066.97","4066.97","other","Inpatient DRGs"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","37797.35","28348.01","FALLON HEALTH [1008]","HB BWH MEDICAID","","","Base payment rate plus any adjustments related to capital costs, transfers and outliers.","7634.72","7634.72","7634.72","1 through 10","6399.36","10560.67","case rate",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","37797.35","28348.01","MEDICARE [2001]","HB BWH MEDICARE","6529.96","","Case rate ($6,529.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,783.38, add-ons for qualifying new technology services are included. If operating cost exceeds $53,427.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,607.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,403.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.50. The transfer capital threshold is the transfer adjustment factor * $542.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7802.74","7802.74","7802.74","1 through 10","6399.36","10560.67","other","Inpatient Replacement Plans DRG"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","37797.35","28348.01","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","6399.36","","Case rate ($6,529.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,783.38, add-ons for qualifying new technology services are included. If operating cost exceeds $53,427.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,607.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,403.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.50. The transfer capital threshold is the transfer adjustment factor * $542.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9681.41","9681.41","9681.41","1 through 10","6399.36","10560.67","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","37797.35","28348.01","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6399.36","","Case rate ($6,529.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $7,783.38, add-ons for qualifying new technology services are included. If operating cost exceeds $53,427.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $2,982.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,607.62 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $7,403.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.50. The transfer capital threshold is the transfer adjustment factor * $542.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8468.44","8135.59","8907.48","1 through 10","6399.36","10560.67","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","TRIS-DRG","","","","","","","","inpatient","","","31231.74","","TRICARE [160005]","HB BWH TRICARE","3230.63","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($5,674.77). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $49,401.77 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($5,674.77), capped at $4,084.33. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.245 that exceeds an outlier threshold of $49,401.77 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","6266.01","5836.51","6480.77","13","3230.63","3230.63","other","Inpatient DRGs"
"Vaginal Delivery,EXTREME","560","DRG","","","","","","","","inpatient","","","48729.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","25148.36","","Standard inlier is a Case rate ($25,148.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,205, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,569.96) for the length of stay and the standard reimbursement.","25148.36","25148.36","25148.36","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,EXTREME","560","DRG","","","","","","","","inpatient","","","48729.46","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","28273.54","","Standard inlier is a Case rate ($28,273.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $31,205, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,013.19) for the length of stay and the standard reimbursement.","28273.53","25830.31","28273.53","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,EXTREME","560","DRG","","","","","","","","inpatient","","","48729.46","","MASSHEALTH [3001]","HB BWH MEDICAID","12315.85","","Case rate ($13,617.29). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $56,047.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13613.94","13613.94","13613.94","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,EXTREME","560","DRG","","","","","","","","inpatient","","","48729.46","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28922.62","","Fee schedule rate ($28,922.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28922.62","28922.62","28922.62","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","42063.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","17858.70","","Standard inlier is a Case rate ($17,858.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,536, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,535.15) for the length of stay and the standard reimbursement.","17858.70","17858.70","17858.70","43","6157.35","45471.88","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","42063.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","20077.99","","Standard inlier is a Case rate ($20,077.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,536, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,849.90) for the length of stay and the standard reimbursement.","18342.97","18342.97","18342.97","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","42063.43","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","20077.99","","Standard inlier is a Case rate ($20,077.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $25,536, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,849.90) for the length of stay and the standard reimbursement.","20077.99","18342.97","20077.99","90","6157.35","45471.88","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","42063.43","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10575.1176","","Fee schedule rate ($14,860.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10575.1176","14860.64","14860.64","22","6157.35","45471.88","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","42063.43","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11104.1808","","Fee schedule rate ($15,604.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11104.1808","15002.16","15604.08","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","42063.43","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","18334.12","","Fee schedule rate ($18,334.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18575.96","18575.96","18575.96","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","42063.43","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","15604.10","","Fee schedule rate ($15,604.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15604.10","15604.10","15604.10","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","42063.43","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","16346.90","","Fee schedule rate ($16,346.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16346.90","16346.90","16346.90","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","42063.43","","MASSHEALTH [3001]","HB BWH MEDICAID","8843.06","","Case rate ($9,777.52). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,207.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9775.11","9775.11","10361.63","23","6157.35","45471.88","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","42063.43","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","8843.06","","Case rate ($9,777.52). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,207.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","42063.43","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15000.09","","Fee schedule rate ($15,000.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14563.03","14563.03","15000.09","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","42063.43","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","15750.34","","Fee schedule rate ($15,750.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15750.34","15291.46","15750.34","13","6157.35","45471.88","case rate",""
"Vaginal Delivery,MAJOR","560","DRG","","","","","","","","inpatient","","","42063.43","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8843.06","","Case rate ($9,777.52). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,207.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9775.12","400.47","10361.63","27","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","12008.21","","Standard inlier is a Case rate ($12,008.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $20,987, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,704.64) for the length of stay and the standard reimbursement.","12008.21","10945.92","12008.21","139","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","13500.47","","Standard inlier is a Case rate ($13,500.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $20,987, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,916.28) for the length of stay and the standard reimbursement.","13500.46","12333.84","13500.46","365","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","11104.1808","","Fee schedule rate ($11,104.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11104.1808","11632.77","11632.77","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10575.1176","","Fee schedule rate ($10,575.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10575.1176","10575.12","10575.12","70","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11104.1808","","Fee schedule rate ($11,104.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11104.1808","10675.84","11104.20","45","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","13046.92","","Fee schedule rate ($13,046.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13219.02","13219.02","13219.02","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","11104.18","","Fee schedule rate ($11,104.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11104.18","11104.18","11104.18","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","11632.77","","Fee schedule rate ($11,632.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11632.77","11632.76","11632.77","33","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","MASSHEALTH [3001]","HB BWH MEDICAID","6157.35","","Case rate ($6,808.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,238.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6806.34","6806.34","6806.34","71","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","6157.35","","Case rate ($6,808.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,238.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2765.70","2765.70","2765.70","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9876.44","","Fee schedule rate ($9,876.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9876.44","8394.98","9876.44","19","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10370.43","","Fee schedule rate ($10,370.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10370.43","10068.29","10370.43","134","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","11104.1808","","Fee schedule rate ($11,104.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11104.1808","11184.56","11184.56","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MINOR","560","DRG","","","","","","","","inpatient","","","33329.72","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6157.35","","Case rate ($6,808.01). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,238.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6806.34","2.77","7634.72","94","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","13712.58","","Standard inlier is a Case rate ($13,712.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,312, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,946.58) for the length of stay and the standard reimbursement.","13712.58","12499.52","14084.43","165","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","15416.64","","Standard inlier is a Case rate ($15,416.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $22,312, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,188.26) for the length of stay and the standard reimbursement.","15416.64","14084.43","15416.64","387","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","11104.1808","","Fee schedule rate ($12,118.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11104.1808","12695.66","14426.84","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","10575.1176","","Fee schedule rate ($11,541.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10575.1176","11541.36","11541.36","88","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","11104.1808","","Fee schedule rate ($12,118.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11104.1808","12118.76","12118.76","54","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","14239.02","","Fee schedule rate ($14,239.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14426.84","14426.84","14426.84","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","12118.78","","Fee schedule rate ($12,118.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12118.78","12118.78","12118.78","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","12695.66","","Fee schedule rate ($12,695.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12695.68","12695.66","12695.68","36","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","HEALTH NEW ENGLAND [1034]","HB BWH MEDICAID","6906.74","","Case rate ($7,636.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,066.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7334.18","7334.18","7334.18","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","MASSHEALTH [3001]","HB BWH MEDICAID","6906.74","","Case rate ($7,636.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,066.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7634.72","4916.36","7634.72","76","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","MASSHEALTH ALTERNATE [3003]","HB BWH MEDICAID","6906.74","","Case rate ($7,636.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,066.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","MEDICAID NON MASSACHUSETTS [3002]","HB BWH MEDICAID","6906.74","","Case rate ($7,636.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,066.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3203.61","3203.61","3203.61","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","10647.97","","Fee schedule rate ($10,647.97). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10647.97","9050.78","10647.97","34","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","11180.55","","Fee schedule rate ($11,180.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11180.55","11180.55","11180.55","107","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","11632.7712","","Fee schedule rate ($12,695.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11632.7712","12206.50","12206.50","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6906.74","","Case rate ($7,636.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,066.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7634.72","3.37","8092.80","117","6157.35","45471.88","case rate",""
"Vaginal Delivery,MODERATE","560","DRG","","","","","","","","inpatient","","","38518.35","","WELLSENSE NH [1050]","HB BWH WELLSENSE MCO","6906.74","","Case rate ($7,636.59). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $50,066.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8664.62","8664.62","8664.62","1 through 10","6157.35","45471.88","case rate",""
"Vaginal Needle Core Biospy","PX-76002688","CDM","58999","CPT","0761","RC","","","","both","","","1020.00","765.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","255.84","","APC Price ($255.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2891.02","2891.02","2891.02","1 through 10","226.96","810.9","other","OPPS APC"
"Vaginal Needle Core Biospy","PX-76002688","CDM","58999","CPT","0761","RC","","","","outpatient","","","1020.00","765.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","617.61","60.55","","28155.00","28155.00","28155.00","1 through 10","510","841.5","percent of total billed charges",""
"Vaginal Needle Core Biospy","PX-76002688","CDM","58999","CPT","0761","RC","","","","outpatient","","","1020.00","765.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","532.64","52.22","","8340.00","222.09","8340.00","1 through 10","510","841.5","percent of total billed charges",""
"Vaginogram","PX-76001925","CDM","58999","CPT","0761","RC","","","","both","","","1007.00","755.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","255.84","","APC Price ($255.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2891.02","2891.02","2891.02","1 through 10","226.96","800.57","other","OPPS APC"
"Vaginogram","PX-76001925","CDM","58999","CPT","0761","RC","","","","outpatient","","","1007.00","755.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","609.74","60.55","","28155.00","28155.00","28155.00","1 through 10","503.5","830.78","percent of total billed charges",""
"Vaginogram","PX-76001925","CDM","58999","CPT","0761","RC","","","","outpatient","","","1007.00","755.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","525.86","52.22","","8340.00","222.09","8340.00","1 through 10","503.5","830.78","percent of total billed charges",""
"VALVE AORTIC 21MM EPIC PLUS","SUP-ITM-10308874","CDM","C1889","HCPCS","0278","RC","","","","both","","","10875.00","8156.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8645.63","79.5","","1309.77","674.56","6049.93","26","3371.25","8645.63","percent of total billed charges",""
"VALVE AORTIC 21MM EPIC PLUS","SUP-ITM-10308874","CDM","C1889","HCPCS","0278","RC","","","","both","","","10875.00","8156.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5796.38","53.3","","1901.83","1901.83","2962.25","1 through 10","3371.25","8645.63","percent of total billed charges",""
"VALVE AORTIC 21MM EPIC PLUS","SUP-ITM-10308874","CDM","C1889","HCPCS","0278","RC","","","","both","","","10875.00","8156.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3969.38","36.5","","1620.31","1620.31","19908.88","1 through 10","3371.25","8645.63","percent of total billed charges",""
"VALVE AORTIC 21MM EPIC PLUS","SUP-ITM-10308874","CDM","C1889","HCPCS","0278","RC","","","","both","","","10875.00","8156.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4165.13","38.3","","352.91","352.91","2046.30","1 through 10","3371.25","8645.63","percent of total billed charges",""
"VALVE AORTIC 21MM EPIC PLUS","SUP-ITM-10308874","CDM","C1889","HCPCS","0278","RC","","","","both","","","10875.00","8156.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4665.38","42.9","","9668.75","9668.75","9668.75","1 through 10","3371.25","8645.63","percent of total billed charges",""
"VALVE AORTIC 21MM EPIC PLUS","SUP-ITM-10308874","CDM","C1889","HCPCS","0278","RC","","","","both","","","10875.00","8156.25","WELLPOINT [1015]","HB AMC WELLPOINT","8023.58","73.78","","699.88","384.10","3443.31","33","3371.25","8645.63","percent of total billed charges",""
"VALVE AORTIC 21MM EPIC PLUS","SUP-ITM-10308874","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10875.00","8156.25","AETNA [1001]","HB AMC AETNA HMO","7590.75","69.8","","1421.24","264.50","4933.46","29","5683.28","8887.05","percent of total billed charges",""
"VALVE AORTIC 21MM EPIC PLUS","SUP-ITM-10308874","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10875.00","8156.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8743.50","80.4","","1022.97","1022.97","3607.50","1 through 10","5683.28","8887.05","percent of total billed charges",""
"VALVE AORTIC 21MM EPIC PLUS","SUP-ITM-10308874","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10875.00","8156.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8887.05","81.72","","3010.54","693.88","5019.88","35","5683.28","8887.05","percent of total billed charges",""
"VALVE AORTIC SZ 29MM TRANSCATHETER SAPIEN 3 IMPLANTABLE","SUP-ITM-10126465","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","64593.75","79.5","","1309.77","674.56","6049.93","26","25187.5","64593.75","percent of total billed charges",""
"VALVE AORTIC SZ 29MM TRANSCATHETER SAPIEN 3 IMPLANTABLE","SUP-ITM-10126465","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","43306.25","53.3","","1901.83","1901.83","2962.25","1 through 10","25187.5","64593.75","percent of total billed charges",""
"VALVE AORTIC SZ 29MM TRANSCATHETER SAPIEN 3 IMPLANTABLE","SUP-ITM-10126465","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29656.25","36.5","","1620.31","1620.31","19908.88","1 through 10","25187.5","64593.75","percent of total billed charges",""
"VALVE AORTIC SZ 29MM TRANSCATHETER SAPIEN 3 IMPLANTABLE","SUP-ITM-10126465","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31118.75","38.3","","352.91","352.91","2046.30","1 through 10","25187.5","64593.75","percent of total billed charges",""
"VALVE AORTIC SZ 29MM TRANSCATHETER SAPIEN 3 IMPLANTABLE","SUP-ITM-10126465","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34856.25","42.9","","9668.75","9668.75","9668.75","1 through 10","25187.5","64593.75","percent of total billed charges",""
"VALVE AORTIC SZ 29MM TRANSCATHETER SAPIEN 3 IMPLANTABLE","SUP-ITM-10126465","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","WELLPOINT [1015]","HB AMC WELLPOINT","59946.25","73.78","","699.88","384.10","3443.31","33","25187.5","64593.75","percent of total billed charges",""
"VALVE AORTIC SZ 29MM TRANSCATHETER SAPIEN 3 IMPLANTABLE","SUP-ITM-10126465","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","81250.00","60937.50","AETNA [1001]","HB AMC AETNA HMO","56712.50","69.8","","1421.24","264.50","4933.46","29","42461.25","66397.5","percent of total billed charges",""
"VALVE AORTIC SZ 29MM TRANSCATHETER SAPIEN 3 IMPLANTABLE","SUP-ITM-10126465","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","81250.00","60937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","65325.00","80.4","","1022.97","1022.97","3607.50","1 through 10","42461.25","66397.5","percent of total billed charges",""
"VALVE AORTIC SZ 29MM TRANSCATHETER SAPIEN 3 IMPLANTABLE","SUP-ITM-10126465","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","81250.00","60937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","66397.50","81.72","","3010.54","693.88","5019.88","35","42461.25","66397.5","percent of total billed charges",""
"VALVE CERTAS PLUS INLINE W/SIPHONGUARD ANTI-SIPHON DEVICE UNITIZED CATHETER AND ACCESSORIES","SUP-ITM-10158737","CDM","C1729","HCPCS","0272","RC","","","","both","","","9619.00","7214.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","6906.44","71.8","","162.24","51.52","162.24","1 through 10","2981.89","7647.11","percent of total billed charges",""
"VALVE CERTAS PLUS INLINE W/SIPHONGUARD ANTI-SIPHON DEVICE UNITIZED CATHETER AND ACCESSORIES","SUP-ITM-10158737","CDM","C1729","HCPCS","0272","RC","","","","both","","","9619.00","7214.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3510.94","36.5","","94.34","22.19","146.22","26","2981.89","7647.11","percent of total billed charges",""
"VALVE CERTAS PLUS INLINE W/SIPHONGUARD ANTI-SIPHON DEVICE UNITIZED CATHETER AND ACCESSORIES","SUP-ITM-10158737","CDM","C1729","HCPCS","0272","RC","","","","both","","","9619.00","7214.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3684.08","38.3","","51.52","27.37","51.52","26","2981.89","7647.11","percent of total billed charges",""
"VALVE CERTAS PLUS INLINE W/SIPHONGUARD ANTI-SIPHON DEVICE UNITIZED CATHETER AND ACCESSORIES","SUP-ITM-10158737","CDM","C1729","HCPCS","0272","RC","","","","both","","","9619.00","7214.25","WELLPOINT [1015]","HB AMC WELLPOINT","7096.90","73.78","","207.21","122.12","216.28","14","2981.89","7647.11","percent of total billed charges",""
"VALVE CERTAS PLUS INLINE W/SIPHONGUARD ANTI-SIPHON DEVICE UNITIZED CATHETER AND ACCESSORIES","SUP-ITM-10158737","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","9619.00","7214.25","AETNA [1001]","HB AMC AETNA HMO","6714.06","69.8","","155.96","47.39","155.96","1 through 10","5026.89","7860.65","percent of total billed charges",""
"VALVE CERTAS PLUS INLINE W/SIPHONGUARD ANTI-SIPHON DEVICE UNITIZED CATHETER AND ACCESSORIES","SUP-ITM-10158737","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","9619.00","7214.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7860.65","81.72","","57.36","51.76","232.23","35","5026.89","7860.65","percent of total billed charges",""
"VALVE DUAL 10CMX30 SYSTEM CSF LUMBOPERITONEAL WATER RECUMBENT PRESSURE STANDING TITANIUM PC/1EA","SUP-ITM-10073216","CDM","C1889","HCPCS","0278","RC","","","","both","","","4941.95","3706.46","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3928.85","79.5","","1309.77","674.56","6049.93","26","1532","3928.85","percent of total billed charges",""
"VALVE DUAL 10CMX30 SYSTEM CSF LUMBOPERITONEAL WATER RECUMBENT PRESSURE STANDING TITANIUM PC/1EA","SUP-ITM-10073216","CDM","C1889","HCPCS","0278","RC","","","","both","","","4941.95","3706.46","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2634.06","53.3","","1901.83","1901.83","2962.25","1 through 10","1532","3928.85","percent of total billed charges",""
"VALVE DUAL 10CMX30 SYSTEM CSF LUMBOPERITONEAL WATER RECUMBENT PRESSURE STANDING TITANIUM PC/1EA","SUP-ITM-10073216","CDM","C1889","HCPCS","0278","RC","","","","both","","","4941.95","3706.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1803.81","36.5","","1620.31","1620.31","19908.88","1 through 10","1532","3928.85","percent of total billed charges",""
"VALVE DUAL 10CMX30 SYSTEM CSF LUMBOPERITONEAL WATER RECUMBENT PRESSURE STANDING TITANIUM PC/1EA","SUP-ITM-10073216","CDM","C1889","HCPCS","0278","RC","","","","both","","","4941.95","3706.46","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1892.77","38.3","","352.91","352.91","2046.30","1 through 10","1532","3928.85","percent of total billed charges",""
"VALVE DUAL 10CMX30 SYSTEM CSF LUMBOPERITONEAL WATER RECUMBENT PRESSURE STANDING TITANIUM PC/1EA","SUP-ITM-10073216","CDM","C1889","HCPCS","0278","RC","","","","both","","","4941.95","3706.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2120.10","42.9","","9668.75","9668.75","9668.75","1 through 10","1532","3928.85","percent of total billed charges",""
"VALVE DUAL 10CMX30 SYSTEM CSF LUMBOPERITONEAL WATER RECUMBENT PRESSURE STANDING TITANIUM PC/1EA","SUP-ITM-10073216","CDM","C1889","HCPCS","0278","RC","","","","both","","","4941.95","3706.46","WELLPOINT [1015]","HB AMC WELLPOINT","3646.17","73.78","","699.88","384.10","3443.31","33","1532","3928.85","percent of total billed charges",""
"VALVE DUAL 10CMX30 SYSTEM CSF LUMBOPERITONEAL WATER RECUMBENT PRESSURE STANDING TITANIUM PC/1EA","SUP-ITM-10073216","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4941.95","3706.46","AETNA [1001]","HB AMC AETNA HMO","3449.48","69.8","","1421.24","264.50","4933.46","29","2582.66","4038.56","percent of total billed charges",""
"VALVE DUAL 10CMX30 SYSTEM CSF LUMBOPERITONEAL WATER RECUMBENT PRESSURE STANDING TITANIUM PC/1EA","SUP-ITM-10073216","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4941.95","3706.46","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3973.33","80.4","","1022.97","1022.97","3607.50","1 through 10","2582.66","4038.56","percent of total billed charges",""
"VALVE DUAL 10CMX30 SYSTEM CSF LUMBOPERITONEAL WATER RECUMBENT PRESSURE STANDING TITANIUM PC/1EA","SUP-ITM-10073216","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4941.95","3706.46","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4038.56","81.72","","3010.54","693.88","5019.88","35","2582.66","4038.56","percent of total billed charges",""
"VALVE ENDOBRONCHIAL 4.0 ZEPHYR","SUP-ITM-10232027","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","4929.00","79.5","","1309.77","674.56","6049.93","26","1922","4929","percent of total billed charges",""
"VALVE ENDOBRONCHIAL 4.0 ZEPHYR","SUP-ITM-10232027","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3304.60","53.3","","1901.83","1901.83","2962.25","1 through 10","1922","4929","percent of total billed charges",""
"VALVE ENDOBRONCHIAL 4.0 ZEPHYR","SUP-ITM-10232027","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2263.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1922","4929","percent of total billed charges",""
"VALVE ENDOBRONCHIAL 4.0 ZEPHYR","SUP-ITM-10232027","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2374.60","38.3","","352.91","352.91","2046.30","1 through 10","1922","4929","percent of total billed charges",""
"VALVE ENDOBRONCHIAL 4.0 ZEPHYR","SUP-ITM-10232027","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2659.80","42.9","","9668.75","9668.75","9668.75","1 through 10","1922","4929","percent of total billed charges",""
"VALVE ENDOBRONCHIAL 4.0 ZEPHYR","SUP-ITM-10232027","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","WELLPOINT [1015]","HB AMC WELLPOINT","4574.36","73.78","","699.88","384.10","3443.31","33","1922","4929","percent of total billed charges",""
"VALVE ENDOBRONCHIAL 4.0 ZEPHYR","SUP-ITM-10232027","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6200.00","4650.00","AETNA [1001]","HB AMC AETNA HMO","4327.60","69.8","","1421.24","264.50","4933.46","29","3240.12","5066.64","percent of total billed charges",""
"VALVE ENDOBRONCHIAL 4.0 ZEPHYR","SUP-ITM-10232027","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6200.00","4650.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4984.80","80.4","","1022.97","1022.97","3607.50","1 through 10","3240.12","5066.64","percent of total billed charges",""
"VALVE ENDOBRONCHIAL 4.0 ZEPHYR","SUP-ITM-10232027","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6200.00","4650.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5066.64","81.72","","3010.54","693.88","5019.88","35","3240.12","5066.64","percent of total billed charges",""
"VALVE EVOLUT R 34MM TRANSCATHETER AORTIC REPLACEMENT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10171882","CDM","C1889","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59625.00","79.5","","1309.77","674.56","6049.93","26","23250","59625","percent of total billed charges",""
"VALVE EVOLUT R 34MM TRANSCATHETER AORTIC REPLACEMENT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10171882","CDM","C1889","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39975.00","53.3","","1901.83","1901.83","2962.25","1 through 10","23250","59625","percent of total billed charges",""
"VALVE EVOLUT R 34MM TRANSCATHETER AORTIC REPLACEMENT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10171882","CDM","C1889","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27375.00","36.5","","1620.31","1620.31","19908.88","1 through 10","23250","59625","percent of total billed charges",""
"VALVE EVOLUT R 34MM TRANSCATHETER AORTIC REPLACEMENT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10171882","CDM","C1889","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28725.00","38.3","","352.91","352.91","2046.30","1 through 10","23250","59625","percent of total billed charges",""
"VALVE EVOLUT R 34MM TRANSCATHETER AORTIC REPLACEMENT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10171882","CDM","C1889","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32175.00","42.9","","9668.75","9668.75","9668.75","1 through 10","23250","59625","percent of total billed charges",""
"VALVE EVOLUT R 34MM TRANSCATHETER AORTIC REPLACEMENT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10171882","CDM","C1889","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","WELLPOINT [1015]","HB AMC WELLPOINT","55335.00","73.78","","699.88","384.10","3443.31","33","23250","59625","percent of total billed charges",""
"VALVE EVOLUT R 34MM TRANSCATHETER AORTIC REPLACEMENT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10171882","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","75000.00","56250.00","AETNA [1001]","HB AMC AETNA HMO","52350.00","69.8","","1421.24","264.50","4933.46","29","39195","61290","percent of total billed charges",""
"VALVE EVOLUT R 34MM TRANSCATHETER AORTIC REPLACEMENT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10171882","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","75000.00","56250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","60300.00","80.4","","1022.97","1022.97","3607.50","1 through 10","39195","61290","percent of total billed charges",""
"VALVE EVOLUT R 34MM TRANSCATHETER AORTIC REPLACEMENT - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10171882","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","75000.00","56250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","61290.00","81.72","","3010.54","693.88","5019.88","35","39195","61290","percent of total billed charges",""
"VALVE HEART 19MM FREESTYLE STENTLESS AORTIC BIOPROSTHESIS NON ALLOGRAFT PORCINE","SUP-ITM-10004830","CDM","C1889","HCPCS","0278","RC","","","","both","","","12787.50","9590.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10166.06","79.5","","1309.77","674.56","6049.93","26","3964.13","10166.06","percent of total billed charges",""
"VALVE HEART 19MM FREESTYLE STENTLESS AORTIC BIOPROSTHESIS NON ALLOGRAFT PORCINE","SUP-ITM-10004830","CDM","C1889","HCPCS","0278","RC","","","","both","","","12787.50","9590.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6815.74","53.3","","1901.83","1901.83","2962.25","1 through 10","3964.13","10166.06","percent of total billed charges",""
"VALVE HEART 19MM FREESTYLE STENTLESS AORTIC BIOPROSTHESIS NON ALLOGRAFT PORCINE","SUP-ITM-10004830","CDM","C1889","HCPCS","0278","RC","","","","both","","","12787.50","9590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4667.44","36.5","","1620.31","1620.31","19908.88","1 through 10","3964.13","10166.06","percent of total billed charges",""
"VALVE HEART 19MM FREESTYLE STENTLESS AORTIC BIOPROSTHESIS NON ALLOGRAFT PORCINE","SUP-ITM-10004830","CDM","C1889","HCPCS","0278","RC","","","","both","","","12787.50","9590.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4897.61","38.3","","352.91","352.91","2046.30","1 through 10","3964.13","10166.06","percent of total billed charges",""
"VALVE HEART 19MM FREESTYLE STENTLESS AORTIC BIOPROSTHESIS NON ALLOGRAFT PORCINE","SUP-ITM-10004830","CDM","C1889","HCPCS","0278","RC","","","","both","","","12787.50","9590.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5485.84","42.9","","9668.75","9668.75","9668.75","1 through 10","3964.13","10166.06","percent of total billed charges",""
"VALVE HEART 19MM FREESTYLE STENTLESS AORTIC BIOPROSTHESIS NON ALLOGRAFT PORCINE","SUP-ITM-10004830","CDM","C1889","HCPCS","0278","RC","","","","both","","","12787.50","9590.62","WELLPOINT [1015]","HB AMC WELLPOINT","9434.62","73.78","","699.88","384.10","3443.31","33","3964.13","10166.06","percent of total billed charges",""
"VALVE HEART 19MM FREESTYLE STENTLESS AORTIC BIOPROSTHESIS NON ALLOGRAFT PORCINE","SUP-ITM-10004830","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12787.50","9590.62","AETNA [1001]","HB AMC AETNA HMO","8925.68","69.8","","1421.24","264.50","4933.46","29","6682.75","10449.95","percent of total billed charges",""
"VALVE HEART 19MM FREESTYLE STENTLESS AORTIC BIOPROSTHESIS NON ALLOGRAFT PORCINE","SUP-ITM-10004830","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12787.50","9590.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10281.15","80.4","","1022.97","1022.97","3607.50","1 through 10","6682.75","10449.95","percent of total billed charges",""
"VALVE HEART 19MM FREESTYLE STENTLESS AORTIC BIOPROSTHESIS NON ALLOGRAFT PORCINE","SUP-ITM-10004830","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12787.50","9590.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10449.95","81.72","","3010.54","693.88","5019.88","35","6682.75","10449.95","percent of total billed charges",""
"VALVE HEART 25MM KONECT RESELIA AORTIC VALVED CONDUIT","SUP-ITM-10282824","CDM","C1889","HCPCS","0278","RC","","","","both","","","35000.00","26250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","27825.00","79.5","","1309.77","674.56","6049.93","26","10850","27825","percent of total billed charges",""
"VALVE HEART 25MM KONECT RESELIA AORTIC VALVED CONDUIT","SUP-ITM-10282824","CDM","C1889","HCPCS","0278","RC","","","","both","","","35000.00","26250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","18655.00","53.3","","1901.83","1901.83","2962.25","1 through 10","10850","27825","percent of total billed charges",""
"VALVE HEART 25MM KONECT RESELIA AORTIC VALVED CONDUIT","SUP-ITM-10282824","CDM","C1889","HCPCS","0278","RC","","","","both","","","35000.00","26250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12775.00","36.5","","1620.31","1620.31","19908.88","1 through 10","10850","27825","percent of total billed charges",""
"VALVE HEART 25MM KONECT RESELIA AORTIC VALVED CONDUIT","SUP-ITM-10282824","CDM","C1889","HCPCS","0278","RC","","","","both","","","35000.00","26250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","13405.00","38.3","","352.91","352.91","2046.30","1 through 10","10850","27825","percent of total billed charges",""
"VALVE HEART 25MM KONECT RESELIA AORTIC VALVED CONDUIT","SUP-ITM-10282824","CDM","C1889","HCPCS","0278","RC","","","","both","","","35000.00","26250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15015.00","42.9","","9668.75","9668.75","9668.75","1 through 10","10850","27825","percent of total billed charges",""
"VALVE HEART 25MM KONECT RESELIA AORTIC VALVED CONDUIT","SUP-ITM-10282824","CDM","C1889","HCPCS","0278","RC","","","","both","","","35000.00","26250.00","WELLPOINT [1015]","HB AMC WELLPOINT","25823.00","73.78","","699.88","384.10","3443.31","33","10850","27825","percent of total billed charges",""
"VALVE HEART 25MM KONECT RESELIA AORTIC VALVED CONDUIT","SUP-ITM-10282824","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","35000.00","26250.00","AETNA [1001]","HB AMC AETNA HMO","24430.00","69.8","","1421.24","264.50","4933.46","29","18291","28602","percent of total billed charges",""
"VALVE HEART 25MM KONECT RESELIA AORTIC VALVED CONDUIT","SUP-ITM-10282824","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","35000.00","26250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","28140.00","80.4","","1022.97","1022.97","3607.50","1 through 10","18291","28602","percent of total billed charges",""
"VALVE HEART 25MM KONECT RESELIA AORTIC VALVED CONDUIT","SUP-ITM-10282824","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","35000.00","26250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","28602.00","81.72","","3010.54","693.88","5019.88","35","18291","28602","percent of total billed charges",""
"VALVE HEART SAPIEN 3 29MM TRANSCATHETER WITH COMMANDER SYSTEM","SUP-ITM-10150618","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","64593.75","79.5","","1309.77","674.56","6049.93","26","25187.5","64593.75","percent of total billed charges",""
"VALVE HEART SAPIEN 3 29MM TRANSCATHETER WITH COMMANDER SYSTEM","SUP-ITM-10150618","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","43306.25","53.3","","1901.83","1901.83","2962.25","1 through 10","25187.5","64593.75","percent of total billed charges",""
"VALVE HEART SAPIEN 3 29MM TRANSCATHETER WITH COMMANDER SYSTEM","SUP-ITM-10150618","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","29656.25","36.5","","1620.31","1620.31","19908.88","1 through 10","25187.5","64593.75","percent of total billed charges",""
"VALVE HEART SAPIEN 3 29MM TRANSCATHETER WITH COMMANDER SYSTEM","SUP-ITM-10150618","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","31118.75","38.3","","352.91","352.91","2046.30","1 through 10","25187.5","64593.75","percent of total billed charges",""
"VALVE HEART SAPIEN 3 29MM TRANSCATHETER WITH COMMANDER SYSTEM","SUP-ITM-10150618","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34856.25","42.9","","9668.75","9668.75","9668.75","1 through 10","25187.5","64593.75","percent of total billed charges",""
"VALVE HEART SAPIEN 3 29MM TRANSCATHETER WITH COMMANDER SYSTEM","SUP-ITM-10150618","CDM","C1889","HCPCS","0278","RC","","","","both","","","81250.00","60937.50","WELLPOINT [1015]","HB AMC WELLPOINT","59946.25","73.78","","699.88","384.10","3443.31","33","25187.5","64593.75","percent of total billed charges",""
"VALVE HEART SAPIEN 3 29MM TRANSCATHETER WITH COMMANDER SYSTEM","SUP-ITM-10150618","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","81250.00","60937.50","AETNA [1001]","HB AMC AETNA HMO","56712.50","69.8","","1421.24","264.50","4933.46","29","42461.25","66397.5","percent of total billed charges",""
"VALVE HEART SAPIEN 3 29MM TRANSCATHETER WITH COMMANDER SYSTEM","SUP-ITM-10150618","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","81250.00","60937.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","65325.00","80.4","","1022.97","1022.97","3607.50","1 through 10","42461.25","66397.5","percent of total billed charges",""
"VALVE HEART SAPIEN 3 29MM TRANSCATHETER WITH COMMANDER SYSTEM","SUP-ITM-10150618","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","81250.00","60937.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","66397.50","81.72","","3010.54","693.88","5019.88","35","42461.25","66397.5","percent of total billed charges",""
"VALVE M.BLUE 0","SUP-ITM-10279963","CDM","C1729","HCPCS","0272","RC","","","","both","","","8273.65","6205.24","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","5940.48","71.8","","162.24","51.52","162.24","1 through 10","2564.83","6577.55","percent of total billed charges",""
"VALVE M.BLUE 0","SUP-ITM-10279963","CDM","C1729","HCPCS","0272","RC","","","","both","","","8273.65","6205.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3019.88","36.5","","94.34","22.19","146.22","26","2564.83","6577.55","percent of total billed charges",""
"VALVE M.BLUE 0","SUP-ITM-10279963","CDM","C1729","HCPCS","0272","RC","","","","both","","","8273.65","6205.24","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3168.81","38.3","","51.52","27.37","51.52","26","2564.83","6577.55","percent of total billed charges",""
"VALVE M.BLUE 0","SUP-ITM-10279963","CDM","C1729","HCPCS","0272","RC","","","","both","","","8273.65","6205.24","WELLPOINT [1015]","HB AMC WELLPOINT","6104.30","73.78","","207.21","122.12","216.28","14","2564.83","6577.55","percent of total billed charges",""
"VALVE M.BLUE 0","SUP-ITM-10279963","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","8273.65","6205.24","AETNA [1001]","HB AMC AETNA HMO","5775.01","69.8","","155.96","47.39","155.96","1 through 10","4323.81","6761.23","percent of total billed charges",""
"VALVE M.BLUE 0","SUP-ITM-10279963","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","8273.65","6205.24","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6761.23","81.72","","57.36","51.76","232.23","35","4323.81","6761.23","percent of total billed charges",""
"VALVE MITRAL 31MM MITRIS RESILIA","SUP-ITM-10318941","CDM","C1889","HCPCS","0278","RC","","","","both","","","18000.00","13500.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","14310.00","79.5","","1309.77","674.56","6049.93","26","5580","14310","percent of total billed charges",""
"VALVE MITRAL 31MM MITRIS RESILIA","SUP-ITM-10318941","CDM","C1889","HCPCS","0278","RC","","","","both","","","18000.00","13500.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","9594.00","53.3","","1901.83","1901.83","2962.25","1 through 10","5580","14310","percent of total billed charges",""
"VALVE MITRAL 31MM MITRIS RESILIA","SUP-ITM-10318941","CDM","C1889","HCPCS","0278","RC","","","","both","","","18000.00","13500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","6570.00","36.5","","1620.31","1620.31","19908.88","1 through 10","5580","14310","percent of total billed charges",""
"VALVE MITRAL 31MM MITRIS RESILIA","SUP-ITM-10318941","CDM","C1889","HCPCS","0278","RC","","","","both","","","18000.00","13500.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6894.00","38.3","","352.91","352.91","2046.30","1 through 10","5580","14310","percent of total billed charges",""
"VALVE MITRAL 31MM MITRIS RESILIA","SUP-ITM-10318941","CDM","C1889","HCPCS","0278","RC","","","","both","","","18000.00","13500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7722.00","42.9","","9668.75","9668.75","9668.75","1 through 10","5580","14310","percent of total billed charges",""
"VALVE MITRAL 31MM MITRIS RESILIA","SUP-ITM-10318941","CDM","C1889","HCPCS","0278","RC","","","","both","","","18000.00","13500.00","WELLPOINT [1015]","HB AMC WELLPOINT","13280.40","73.78","","699.88","384.10","3443.31","33","5580","14310","percent of total billed charges",""
"VALVE MITRAL 31MM MITRIS RESILIA","SUP-ITM-10318941","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18000.00","13500.00","AETNA [1001]","HB AMC AETNA HMO","12564.00","69.8","","1421.24","264.50","4933.46","29","9406.8","14709.6","percent of total billed charges",""
"VALVE MITRAL 31MM MITRIS RESILIA","SUP-ITM-10318941","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18000.00","13500.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","14472.00","80.4","","1022.97","1022.97","3607.50","1 through 10","9406.8","14709.6","percent of total billed charges",""
"VALVE MITRAL 31MM MITRIS RESILIA","SUP-ITM-10318941","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18000.00","13500.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","14709.60","81.72","","3010.54","693.88","5019.88","35","9406.8","14709.6","percent of total billed charges",""
"VALVE PRESSURE .5 8X16.5 13 40MM LEVEL 1 PS MEDICAL DELTA POLYPROPYLENE SILICONE","SUP-ITM-10000377","CDM","C1889","HCPCS","0278","RC","","","","both","","","2820.07","2115.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2241.96","79.5","","1309.77","674.56","6049.93","26","874.22","2241.96","percent of total billed charges",""
"VALVE PRESSURE .5 8X16.5 13 40MM LEVEL 1 PS MEDICAL DELTA POLYPROPYLENE SILICONE","SUP-ITM-10000377","CDM","C1889","HCPCS","0278","RC","","","","both","","","2820.07","2115.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1503.10","53.3","","1901.83","1901.83","2962.25","1 through 10","874.22","2241.96","percent of total billed charges",""
"VALVE PRESSURE .5 8X16.5 13 40MM LEVEL 1 PS MEDICAL DELTA POLYPROPYLENE SILICONE","SUP-ITM-10000377","CDM","C1889","HCPCS","0278","RC","","","","both","","","2820.07","2115.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1029.33","36.5","","1620.31","1620.31","19908.88","1 through 10","874.22","2241.96","percent of total billed charges",""
"VALVE PRESSURE .5 8X16.5 13 40MM LEVEL 1 PS MEDICAL DELTA POLYPROPYLENE SILICONE","SUP-ITM-10000377","CDM","C1889","HCPCS","0278","RC","","","","both","","","2820.07","2115.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1080.09","38.3","","352.91","352.91","2046.30","1 through 10","874.22","2241.96","percent of total billed charges",""
"VALVE PRESSURE .5 8X16.5 13 40MM LEVEL 1 PS MEDICAL DELTA POLYPROPYLENE SILICONE","SUP-ITM-10000377","CDM","C1889","HCPCS","0278","RC","","","","both","","","2820.07","2115.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1209.81","42.9","","9668.75","9668.75","9668.75","1 through 10","874.22","2241.96","percent of total billed charges",""
"VALVE PRESSURE .5 8X16.5 13 40MM LEVEL 1 PS MEDICAL DELTA POLYPROPYLENE SILICONE","SUP-ITM-10000377","CDM","C1889","HCPCS","0278","RC","","","","both","","","2820.07","2115.05","WELLPOINT [1015]","HB AMC WELLPOINT","2080.65","73.78","","699.88","384.10","3443.31","33","874.22","2241.96","percent of total billed charges",""
"VALVE PRESSURE .5 8X16.5 13 40MM LEVEL 1 PS MEDICAL DELTA POLYPROPYLENE SILICONE","SUP-ITM-10000377","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2820.07","2115.05","AETNA [1001]","HB AMC AETNA HMO","1968.41","69.8","","1421.24","264.50","4933.46","29","1473.77","2304.56","percent of total billed charges",""
"VALVE PRESSURE .5 8X16.5 13 40MM LEVEL 1 PS MEDICAL DELTA POLYPROPYLENE SILICONE","SUP-ITM-10000377","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2820.07","2115.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2267.34","80.4","","1022.97","1022.97","3607.50","1 through 10","1473.77","2304.56","percent of total billed charges",""
"VALVE PRESSURE .5 8X16.5 13 40MM LEVEL 1 PS MEDICAL DELTA POLYPROPYLENE SILICONE","SUP-ITM-10000377","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2820.07","2115.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2304.56","81.72","","3010.54","693.88","5019.88","35","1473.77","2304.56","percent of total billed charges",""
"VALVE PRESSURE 8X16.5 13MM LEVEL 2 PS MEDICAL DELTA POLYPROPYLENE SILICONE REGULAR","SUP-ITM-10100890","CDM","C1889","HCPCS","0278","RC","","","","both","","","2819.87","2114.90","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2241.80","79.5","","1309.77","674.56","6049.93","26","874.16","2241.8","percent of total billed charges",""
"VALVE PRESSURE 8X16.5 13MM LEVEL 2 PS MEDICAL DELTA POLYPROPYLENE SILICONE REGULAR","SUP-ITM-10100890","CDM","C1889","HCPCS","0278","RC","","","","both","","","2819.87","2114.90","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1502.99","53.3","","1901.83","1901.83","2962.25","1 through 10","874.16","2241.8","percent of total billed charges",""
"VALVE PRESSURE 8X16.5 13MM LEVEL 2 PS MEDICAL DELTA POLYPROPYLENE SILICONE REGULAR","SUP-ITM-10100890","CDM","C1889","HCPCS","0278","RC","","","","both","","","2819.87","2114.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1029.25","36.5","","1620.31","1620.31","19908.88","1 through 10","874.16","2241.8","percent of total billed charges",""
"VALVE PRESSURE 8X16.5 13MM LEVEL 2 PS MEDICAL DELTA POLYPROPYLENE SILICONE REGULAR","SUP-ITM-10100890","CDM","C1889","HCPCS","0278","RC","","","","both","","","2819.87","2114.90","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1080.01","38.3","","352.91","352.91","2046.30","1 through 10","874.16","2241.8","percent of total billed charges",""
"VALVE PRESSURE 8X16.5 13MM LEVEL 2 PS MEDICAL DELTA POLYPROPYLENE SILICONE REGULAR","SUP-ITM-10100890","CDM","C1889","HCPCS","0278","RC","","","","both","","","2819.87","2114.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1209.72","42.9","","9668.75","9668.75","9668.75","1 through 10","874.16","2241.8","percent of total billed charges",""
"VALVE PRESSURE 8X16.5 13MM LEVEL 2 PS MEDICAL DELTA POLYPROPYLENE SILICONE REGULAR","SUP-ITM-10100890","CDM","C1889","HCPCS","0278","RC","","","","both","","","2819.87","2114.90","WELLPOINT [1015]","HB AMC WELLPOINT","2080.50","73.78","","699.88","384.10","3443.31","33","874.16","2241.8","percent of total billed charges",""
"VALVE PRESSURE 8X16.5 13MM LEVEL 2 PS MEDICAL DELTA POLYPROPYLENE SILICONE REGULAR","SUP-ITM-10100890","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2819.87","2114.90","AETNA [1001]","HB AMC AETNA HMO","1968.27","69.8","","1421.24","264.50","4933.46","29","1473.66","2304.4","percent of total billed charges",""
"VALVE PRESSURE 8X16.5 13MM LEVEL 2 PS MEDICAL DELTA POLYPROPYLENE SILICONE REGULAR","SUP-ITM-10100890","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2819.87","2114.90","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2267.18","80.4","","1022.97","1022.97","3607.50","1 through 10","1473.66","2304.4","percent of total billed charges",""
"VALVE PRESSURE 8X16.5 13MM LEVEL 2 PS MEDICAL DELTA POLYPROPYLENE SILICONE REGULAR","SUP-ITM-10100890","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2819.87","2114.90","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2304.40","81.72","","3010.54","693.88","5019.88","35","1473.66","2304.4","percent of total billed charges",""
"VALVE PRESSURE HYDROCEPHALUS STRATA 2 SILICONE PLASTIC SIPHON CONTROL CEREBRAL SPINAL FLUID REGULAR","SUP-ITM-10030740","CDM","C1889","HCPCS","0278","RC","","","","both","","","4928.27","3696.20","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3917.97","79.5","","1309.77","674.56","6049.93","26","1527.76","3917.97","percent of total billed charges",""
"VALVE PRESSURE HYDROCEPHALUS STRATA 2 SILICONE PLASTIC SIPHON CONTROL CEREBRAL SPINAL FLUID REGULAR","SUP-ITM-10030740","CDM","C1889","HCPCS","0278","RC","","","","both","","","4928.27","3696.20","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2626.77","53.3","","1901.83","1901.83","2962.25","1 through 10","1527.76","3917.97","percent of total billed charges",""
"VALVE PRESSURE HYDROCEPHALUS STRATA 2 SILICONE PLASTIC SIPHON CONTROL CEREBRAL SPINAL FLUID REGULAR","SUP-ITM-10030740","CDM","C1889","HCPCS","0278","RC","","","","both","","","4928.27","3696.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1798.82","36.5","","1620.31","1620.31","19908.88","1 through 10","1527.76","3917.97","percent of total billed charges",""
"VALVE PRESSURE HYDROCEPHALUS STRATA 2 SILICONE PLASTIC SIPHON CONTROL CEREBRAL SPINAL FLUID REGULAR","SUP-ITM-10030740","CDM","C1889","HCPCS","0278","RC","","","","both","","","4928.27","3696.20","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1887.53","38.3","","352.91","352.91","2046.30","1 through 10","1527.76","3917.97","percent of total billed charges",""
"VALVE PRESSURE HYDROCEPHALUS STRATA 2 SILICONE PLASTIC SIPHON CONTROL CEREBRAL SPINAL FLUID REGULAR","SUP-ITM-10030740","CDM","C1889","HCPCS","0278","RC","","","","both","","","4928.27","3696.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2114.23","42.9","","9668.75","9668.75","9668.75","1 through 10","1527.76","3917.97","percent of total billed charges",""
"VALVE PRESSURE HYDROCEPHALUS STRATA 2 SILICONE PLASTIC SIPHON CONTROL CEREBRAL SPINAL FLUID REGULAR","SUP-ITM-10030740","CDM","C1889","HCPCS","0278","RC","","","","both","","","4928.27","3696.20","WELLPOINT [1015]","HB AMC WELLPOINT","3636.08","73.78","","699.88","384.10","3443.31","33","1527.76","3917.97","percent of total billed charges",""
"VALVE PRESSURE HYDROCEPHALUS STRATA 2 SILICONE PLASTIC SIPHON CONTROL CEREBRAL SPINAL FLUID REGULAR","SUP-ITM-10030740","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4928.27","3696.20","AETNA [1001]","HB AMC AETNA HMO","3439.93","69.8","","1421.24","264.50","4933.46","29","2575.51","4027.38","percent of total billed charges",""
"VALVE PRESSURE HYDROCEPHALUS STRATA 2 SILICONE PLASTIC SIPHON CONTROL CEREBRAL SPINAL FLUID REGULAR","SUP-ITM-10030740","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4928.27","3696.20","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3962.33","80.4","","1022.97","1022.97","3607.50","1 through 10","2575.51","4027.38","percent of total billed charges",""
"VALVE PRESSURE HYDROCEPHALUS STRATA 2 SILICONE PLASTIC SIPHON CONTROL CEREBRAL SPINAL FLUID REGULAR","SUP-ITM-10030740","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4928.27","3696.20","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4027.38","81.72","","3010.54","693.88","5019.88","35","2575.51","4027.38","percent of total billed charges",""
"VALVE SHUNT 100MM MED HIGH MICRO HAKIM RICKMAN RESERVOIR UNITIZED","SUP-ITM-10045282","CDM","C1889","HCPCS","0278","RC","","","","both","","","2213.40","1660.05","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1759.65","79.5","","1309.77","674.56","6049.93","26","686.15","1759.65","percent of total billed charges",""
"VALVE SHUNT 100MM MED HIGH MICRO HAKIM RICKMAN RESERVOIR UNITIZED","SUP-ITM-10045282","CDM","C1889","HCPCS","0278","RC","","","","both","","","2213.40","1660.05","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1179.74","53.3","","1901.83","1901.83","2962.25","1 through 10","686.15","1759.65","percent of total billed charges",""
"VALVE SHUNT 100MM MED HIGH MICRO HAKIM RICKMAN RESERVOIR UNITIZED","SUP-ITM-10045282","CDM","C1889","HCPCS","0278","RC","","","","both","","","2213.40","1660.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","807.89","36.5","","1620.31","1620.31","19908.88","1 through 10","686.15","1759.65","percent of total billed charges",""
"VALVE SHUNT 100MM MED HIGH MICRO HAKIM RICKMAN RESERVOIR UNITIZED","SUP-ITM-10045282","CDM","C1889","HCPCS","0278","RC","","","","both","","","2213.40","1660.05","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","847.73","38.3","","352.91","352.91","2046.30","1 through 10","686.15","1759.65","percent of total billed charges",""
"VALVE SHUNT 100MM MED HIGH MICRO HAKIM RICKMAN RESERVOIR UNITIZED","SUP-ITM-10045282","CDM","C1889","HCPCS","0278","RC","","","","both","","","2213.40","1660.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","949.55","42.9","","9668.75","9668.75","9668.75","1 through 10","686.15","1759.65","percent of total billed charges",""
"VALVE SHUNT 100MM MED HIGH MICRO HAKIM RICKMAN RESERVOIR UNITIZED","SUP-ITM-10045282","CDM","C1889","HCPCS","0278","RC","","","","both","","","2213.40","1660.05","WELLPOINT [1015]","HB AMC WELLPOINT","1633.05","73.78","","699.88","384.10","3443.31","33","686.15","1759.65","percent of total billed charges",""
"VALVE SHUNT 100MM MED HIGH MICRO HAKIM RICKMAN RESERVOIR UNITIZED","SUP-ITM-10045282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2213.40","1660.05","AETNA [1001]","HB AMC AETNA HMO","1544.95","69.8","","1421.24","264.50","4933.46","29","1156.72","1808.79","percent of total billed charges",""
"VALVE SHUNT 100MM MED HIGH MICRO HAKIM RICKMAN RESERVOIR UNITIZED","SUP-ITM-10045282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2213.40","1660.05","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1779.57","80.4","","1022.97","1022.97","3607.50","1 through 10","1156.72","1808.79","percent of total billed charges",""
"VALVE SHUNT 100MM MED HIGH MICRO HAKIM RICKMAN RESERVOIR UNITIZED","SUP-ITM-10045282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2213.40","1660.05","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1808.79","81.72","","3010.54","693.88","5019.88","35","1156.72","1808.79","percent of total billed charges",""
"VALVE SHUNT 10MM H20 HAKIM RICKMAN RESERVOIR VERY LOW PRECISION UNITIZED RANGE","SUP-ITM-10009814","CDM","C1889","HCPCS","0278","RC","","","","both","","","2508.52","1881.39","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1994.27","79.5","","1309.77","674.56","6049.93","26","777.64","1994.27","percent of total billed charges",""
"VALVE SHUNT 10MM H20 HAKIM RICKMAN RESERVOIR VERY LOW PRECISION UNITIZED RANGE","SUP-ITM-10009814","CDM","C1889","HCPCS","0278","RC","","","","both","","","2508.52","1881.39","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1337.04","53.3","","1901.83","1901.83","2962.25","1 through 10","777.64","1994.27","percent of total billed charges",""
"VALVE SHUNT 10MM H20 HAKIM RICKMAN RESERVOIR VERY LOW PRECISION UNITIZED RANGE","SUP-ITM-10009814","CDM","C1889","HCPCS","0278","RC","","","","both","","","2508.52","1881.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","915.61","36.5","","1620.31","1620.31","19908.88","1 through 10","777.64","1994.27","percent of total billed charges",""
"VALVE SHUNT 10MM H20 HAKIM RICKMAN RESERVOIR VERY LOW PRECISION UNITIZED RANGE","SUP-ITM-10009814","CDM","C1889","HCPCS","0278","RC","","","","both","","","2508.52","1881.39","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","960.76","38.3","","352.91","352.91","2046.30","1 through 10","777.64","1994.27","percent of total billed charges",""
"VALVE SHUNT 10MM H20 HAKIM RICKMAN RESERVOIR VERY LOW PRECISION UNITIZED RANGE","SUP-ITM-10009814","CDM","C1889","HCPCS","0278","RC","","","","both","","","2508.52","1881.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1076.16","42.9","","9668.75","9668.75","9668.75","1 through 10","777.64","1994.27","percent of total billed charges",""
"VALVE SHUNT 10MM H20 HAKIM RICKMAN RESERVOIR VERY LOW PRECISION UNITIZED RANGE","SUP-ITM-10009814","CDM","C1889","HCPCS","0278","RC","","","","both","","","2508.52","1881.39","WELLPOINT [1015]","HB AMC WELLPOINT","1850.79","73.78","","699.88","384.10","3443.31","33","777.64","1994.27","percent of total billed charges",""
"VALVE SHUNT 10MM H20 HAKIM RICKMAN RESERVOIR VERY LOW PRECISION UNITIZED RANGE","SUP-ITM-10009814","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2508.52","1881.39","AETNA [1001]","HB AMC AETNA HMO","1750.95","69.8","","1421.24","264.50","4933.46","29","1310.95","2049.96","percent of total billed charges",""
"VALVE SHUNT 10MM H20 HAKIM RICKMAN RESERVOIR VERY LOW PRECISION UNITIZED RANGE","SUP-ITM-10009814","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2508.52","1881.39","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2016.85","80.4","","1022.97","1022.97","3607.50","1 through 10","1310.95","2049.96","percent of total billed charges",""
"VALVE SHUNT 10MM H20 HAKIM RICKMAN RESERVOIR VERY LOW PRECISION UNITIZED RANGE","SUP-ITM-10009814","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2508.52","1881.39","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2049.96","81.72","","3010.54","693.88","5019.88","35","1310.95","2049.96","percent of total billed charges",""
"VALVE SHUNT 120CM HAKIM MICRO PROGRAMMABLE RICKHAM RESERVOIR UNITIZED","SUP-ITM-10005135","CDM","C1889","HCPCS","0278","RC","","","","both","","","7073.50","5305.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5623.43","79.5","","1309.77","674.56","6049.93","26","2192.79","5623.43","percent of total billed charges",""
"VALVE SHUNT 120CM HAKIM MICRO PROGRAMMABLE RICKHAM RESERVOIR UNITIZED","SUP-ITM-10005135","CDM","C1889","HCPCS","0278","RC","","","","both","","","7073.50","5305.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3770.18","53.3","","1901.83","1901.83","2962.25","1 through 10","2192.79","5623.43","percent of total billed charges",""
"VALVE SHUNT 120CM HAKIM MICRO PROGRAMMABLE RICKHAM RESERVOIR UNITIZED","SUP-ITM-10005135","CDM","C1889","HCPCS","0278","RC","","","","both","","","7073.50","5305.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2581.83","36.5","","1620.31","1620.31","19908.88","1 through 10","2192.79","5623.43","percent of total billed charges",""
"VALVE SHUNT 120CM HAKIM MICRO PROGRAMMABLE RICKHAM RESERVOIR UNITIZED","SUP-ITM-10005135","CDM","C1889","HCPCS","0278","RC","","","","both","","","7073.50","5305.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2709.15","38.3","","352.91","352.91","2046.30","1 through 10","2192.79","5623.43","percent of total billed charges",""
"VALVE SHUNT 120CM HAKIM MICRO PROGRAMMABLE RICKHAM RESERVOIR UNITIZED","SUP-ITM-10005135","CDM","C1889","HCPCS","0278","RC","","","","both","","","7073.50","5305.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3034.53","42.9","","9668.75","9668.75","9668.75","1 through 10","2192.79","5623.43","percent of total billed charges",""
"VALVE SHUNT 120CM HAKIM MICRO PROGRAMMABLE RICKHAM RESERVOIR UNITIZED","SUP-ITM-10005135","CDM","C1889","HCPCS","0278","RC","","","","both","","","7073.50","5305.12","WELLPOINT [1015]","HB AMC WELLPOINT","5218.83","73.78","","699.88","384.10","3443.31","33","2192.79","5623.43","percent of total billed charges",""
"VALVE SHUNT 120CM HAKIM MICRO PROGRAMMABLE RICKHAM RESERVOIR UNITIZED","SUP-ITM-10005135","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7073.50","5305.12","AETNA [1001]","HB AMC AETNA HMO","4937.30","69.8","","1421.24","264.50","4933.46","29","3696.61","5780.46","percent of total billed charges",""
"VALVE SHUNT 120CM HAKIM MICRO PROGRAMMABLE RICKHAM RESERVOIR UNITIZED","SUP-ITM-10005135","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7073.50","5305.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5687.09","80.4","","1022.97","1022.97","3607.50","1 through 10","3696.61","5780.46","percent of total billed charges",""
"VALVE SHUNT 120CM HAKIM MICRO PROGRAMMABLE RICKHAM RESERVOIR UNITIZED","SUP-ITM-10005135","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7073.50","5305.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5780.46","81.72","","3010.54","693.88","5019.88","35","3696.61","5780.46","percent of total billed charges",""
"VALVE SHUNT 40MM LOW CONTROL RESERVOIR PROGRAMABLE INLINE WATER","SUP-ITM-10011511","CDM","C1889","HCPCS","0278","RC","","","","both","","","2285.96","1714.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1817.34","79.5","","1309.77","674.56","6049.93","26","708.65","1817.34","percent of total billed charges",""
"VALVE SHUNT 40MM LOW CONTROL RESERVOIR PROGRAMABLE INLINE WATER","SUP-ITM-10011511","CDM","C1889","HCPCS","0278","RC","","","","both","","","2285.96","1714.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1218.42","53.3","","1901.83","1901.83","2962.25","1 through 10","708.65","1817.34","percent of total billed charges",""
"VALVE SHUNT 40MM LOW CONTROL RESERVOIR PROGRAMABLE INLINE WATER","SUP-ITM-10011511","CDM","C1889","HCPCS","0278","RC","","","","both","","","2285.96","1714.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","834.38","36.5","","1620.31","1620.31","19908.88","1 through 10","708.65","1817.34","percent of total billed charges",""
"VALVE SHUNT 40MM LOW CONTROL RESERVOIR PROGRAMABLE INLINE WATER","SUP-ITM-10011511","CDM","C1889","HCPCS","0278","RC","","","","both","","","2285.96","1714.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","875.52","38.3","","352.91","352.91","2046.30","1 through 10","708.65","1817.34","percent of total billed charges",""
"VALVE SHUNT 40MM LOW CONTROL RESERVOIR PROGRAMABLE INLINE WATER","SUP-ITM-10011511","CDM","C1889","HCPCS","0278","RC","","","","both","","","2285.96","1714.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","980.68","42.9","","9668.75","9668.75","9668.75","1 through 10","708.65","1817.34","percent of total billed charges",""
"VALVE SHUNT 40MM LOW CONTROL RESERVOIR PROGRAMABLE INLINE WATER","SUP-ITM-10011511","CDM","C1889","HCPCS","0278","RC","","","","both","","","2285.96","1714.47","WELLPOINT [1015]","HB AMC WELLPOINT","1686.58","73.78","","699.88","384.10","3443.31","33","708.65","1817.34","percent of total billed charges",""
"VALVE SHUNT 40MM LOW CONTROL RESERVOIR PROGRAMABLE INLINE WATER","SUP-ITM-10011511","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2285.96","1714.47","AETNA [1001]","HB AMC AETNA HMO","1595.60","69.8","","1421.24","264.50","4933.46","29","1194.64","1868.09","percent of total billed charges",""
"VALVE SHUNT 40MM LOW CONTROL RESERVOIR PROGRAMABLE INLINE WATER","SUP-ITM-10011511","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2285.96","1714.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1837.91","80.4","","1022.97","1022.97","3607.50","1 through 10","1194.64","1868.09","percent of total billed charges",""
"VALVE SHUNT 40MM LOW CONTROL RESERVOIR PROGRAMABLE INLINE WATER","SUP-ITM-10011511","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2285.96","1714.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1868.09","81.72","","3010.54","693.88","5019.88","35","1194.64","1868.09","percent of total billed charges",""
"VALVE SHUNT CEREBRAL SPINAL FLUID PROGRAMMABLE HAKIM SIPHONGUARD INLINE RESEVOIR EA","SUP-ITM-10022925","CDM","C1889","HCPCS","0278","RC","","","","both","","","9193.10","6894.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7308.51","79.5","","1309.77","674.56","6049.93","26","2849.86","7308.51","percent of total billed charges",""
"VALVE SHUNT CEREBRAL SPINAL FLUID PROGRAMMABLE HAKIM SIPHONGUARD INLINE RESEVOIR EA","SUP-ITM-10022925","CDM","C1889","HCPCS","0278","RC","","","","both","","","9193.10","6894.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4899.92","53.3","","1901.83","1901.83","2962.25","1 through 10","2849.86","7308.51","percent of total billed charges",""
"VALVE SHUNT CEREBRAL SPINAL FLUID PROGRAMMABLE HAKIM SIPHONGUARD INLINE RESEVOIR EA","SUP-ITM-10022925","CDM","C1889","HCPCS","0278","RC","","","","both","","","9193.10","6894.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3355.48","36.5","","1620.31","1620.31","19908.88","1 through 10","2849.86","7308.51","percent of total billed charges",""
"VALVE SHUNT CEREBRAL SPINAL FLUID PROGRAMMABLE HAKIM SIPHONGUARD INLINE RESEVOIR EA","SUP-ITM-10022925","CDM","C1889","HCPCS","0278","RC","","","","both","","","9193.10","6894.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3520.96","38.3","","352.91","352.91","2046.30","1 through 10","2849.86","7308.51","percent of total billed charges",""
"VALVE SHUNT CEREBRAL SPINAL FLUID PROGRAMMABLE HAKIM SIPHONGUARD INLINE RESEVOIR EA","SUP-ITM-10022925","CDM","C1889","HCPCS","0278","RC","","","","both","","","9193.10","6894.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3943.84","42.9","","9668.75","9668.75","9668.75","1 through 10","2849.86","7308.51","percent of total billed charges",""
"VALVE SHUNT CEREBRAL SPINAL FLUID PROGRAMMABLE HAKIM SIPHONGUARD INLINE RESEVOIR EA","SUP-ITM-10022925","CDM","C1889","HCPCS","0278","RC","","","","both","","","9193.10","6894.82","WELLPOINT [1015]","HB AMC WELLPOINT","6782.67","73.78","","699.88","384.10","3443.31","33","2849.86","7308.51","percent of total billed charges",""
"VALVE SHUNT CEREBRAL SPINAL FLUID PROGRAMMABLE HAKIM SIPHONGUARD INLINE RESEVOIR EA","SUP-ITM-10022925","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9193.10","6894.82","AETNA [1001]","HB AMC AETNA HMO","6416.78","69.8","","1421.24","264.50","4933.46","29","4804.31","7512.6","percent of total billed charges",""
"VALVE SHUNT CEREBRAL SPINAL FLUID PROGRAMMABLE HAKIM SIPHONGUARD INLINE RESEVOIR EA","SUP-ITM-10022925","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9193.10","6894.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7391.25","80.4","","1022.97","1022.97","3607.50","1 through 10","4804.31","7512.6","percent of total billed charges",""
"VALVE SHUNT CEREBRAL SPINAL FLUID PROGRAMMABLE HAKIM SIPHONGUARD INLINE RESEVOIR EA","SUP-ITM-10022925","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9193.10","6894.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7512.60","81.72","","3010.54","693.88","5019.88","35","4804.31","7512.6","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMABLE VALVE MICRO UNITIZED DISTAL CATHETER STYLET PRIMING ADAPTER INTRODUCER","SUP-ITM-10114902","CDM","C1889","HCPCS","0278","RC","","","","both","","","10815.40","8111.55","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8598.24","79.5","","1309.77","674.56","6049.93","26","3352.77","8598.24","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMABLE VALVE MICRO UNITIZED DISTAL CATHETER STYLET PRIMING ADAPTER INTRODUCER","SUP-ITM-10114902","CDM","C1889","HCPCS","0278","RC","","","","both","","","10815.40","8111.55","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5764.61","53.3","","1901.83","1901.83","2962.25","1 through 10","3352.77","8598.24","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMABLE VALVE MICRO UNITIZED DISTAL CATHETER STYLET PRIMING ADAPTER INTRODUCER","SUP-ITM-10114902","CDM","C1889","HCPCS","0278","RC","","","","both","","","10815.40","8111.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3947.62","36.5","","1620.31","1620.31","19908.88","1 through 10","3352.77","8598.24","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMABLE VALVE MICRO UNITIZED DISTAL CATHETER STYLET PRIMING ADAPTER INTRODUCER","SUP-ITM-10114902","CDM","C1889","HCPCS","0278","RC","","","","both","","","10815.40","8111.55","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4142.30","38.3","","352.91","352.91","2046.30","1 through 10","3352.77","8598.24","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMABLE VALVE MICRO UNITIZED DISTAL CATHETER STYLET PRIMING ADAPTER INTRODUCER","SUP-ITM-10114902","CDM","C1889","HCPCS","0278","RC","","","","both","","","10815.40","8111.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4639.81","42.9","","9668.75","9668.75","9668.75","1 through 10","3352.77","8598.24","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMABLE VALVE MICRO UNITIZED DISTAL CATHETER STYLET PRIMING ADAPTER INTRODUCER","SUP-ITM-10114902","CDM","C1889","HCPCS","0278","RC","","","","both","","","10815.40","8111.55","WELLPOINT [1015]","HB AMC WELLPOINT","7979.60","73.78","","699.88","384.10","3443.31","33","3352.77","8598.24","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMABLE VALVE MICRO UNITIZED DISTAL CATHETER STYLET PRIMING ADAPTER INTRODUCER","SUP-ITM-10114902","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10815.40","8111.55","AETNA [1001]","HB AMC AETNA HMO","7549.15","69.8","","1421.24","264.50","4933.46","29","5652.13","8838.34","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMABLE VALVE MICRO UNITIZED DISTAL CATHETER STYLET PRIMING ADAPTER INTRODUCER","SUP-ITM-10114902","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10815.40","8111.55","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8695.58","80.4","","1022.97","1022.97","3607.50","1 through 10","5652.13","8838.34","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMABLE VALVE MICRO UNITIZED DISTAL CATHETER STYLET PRIMING ADAPTER INTRODUCER","SUP-ITM-10114902","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10815.40","8111.55","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8838.34","81.72","","3010.54","693.88","5019.88","35","5652.13","8838.34","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE SIPHONGUARD UNITIZED DISTAL","SUP-ITM-10045307","CDM","C1889","HCPCS","0278","RC","","","","both","","","8377.73","6283.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6660.30","79.5","","1309.77","674.56","6049.93","26","2597.1","6660.3","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE SIPHONGUARD UNITIZED DISTAL","SUP-ITM-10045307","CDM","C1889","HCPCS","0278","RC","","","","both","","","8377.73","6283.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4465.33","53.3","","1901.83","1901.83","2962.25","1 through 10","2597.1","6660.3","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE SIPHONGUARD UNITIZED DISTAL","SUP-ITM-10045307","CDM","C1889","HCPCS","0278","RC","","","","both","","","8377.73","6283.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3057.87","36.5","","1620.31","1620.31","19908.88","1 through 10","2597.1","6660.3","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE SIPHONGUARD UNITIZED DISTAL","SUP-ITM-10045307","CDM","C1889","HCPCS","0278","RC","","","","both","","","8377.73","6283.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3208.67","38.3","","352.91","352.91","2046.30","1 through 10","2597.1","6660.3","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE SIPHONGUARD UNITIZED DISTAL","SUP-ITM-10045307","CDM","C1889","HCPCS","0278","RC","","","","both","","","8377.73","6283.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3594.05","42.9","","9668.75","9668.75","9668.75","1 through 10","2597.1","6660.3","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE SIPHONGUARD UNITIZED DISTAL","SUP-ITM-10045307","CDM","C1889","HCPCS","0278","RC","","","","both","","","8377.73","6283.30","WELLPOINT [1015]","HB AMC WELLPOINT","6181.09","73.78","","699.88","384.10","3443.31","33","2597.1","6660.3","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE SIPHONGUARD UNITIZED DISTAL","SUP-ITM-10045307","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8377.73","6283.30","AETNA [1001]","HB AMC AETNA HMO","5847.66","69.8","","1421.24","264.50","4933.46","29","4378.2","6846.28","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE SIPHONGUARD UNITIZED DISTAL","SUP-ITM-10045307","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8377.73","6283.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6735.69","80.4","","1022.97","1022.97","3607.50","1 through 10","4378.2","6846.28","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE SIPHONGUARD UNITIZED DISTAL","SUP-ITM-10045307","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8377.73","6283.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6846.28","81.72","","3010.54","693.88","5019.88","35","4378.2","6846.28","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE UNITIZED","SUP-ITM-10045308","CDM","C1889","HCPCS","0278","RC","","","","both","","","8188.50","6141.37","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6509.86","79.5","","1309.77","674.56","6049.93","26","2538.44","6509.86","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE UNITIZED","SUP-ITM-10045308","CDM","C1889","HCPCS","0278","RC","","","","both","","","8188.50","6141.37","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4364.47","53.3","","1901.83","1901.83","2962.25","1 through 10","2538.44","6509.86","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE UNITIZED","SUP-ITM-10045308","CDM","C1889","HCPCS","0278","RC","","","","both","","","8188.50","6141.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2988.80","36.5","","1620.31","1620.31","19908.88","1 through 10","2538.44","6509.86","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE UNITIZED","SUP-ITM-10045308","CDM","C1889","HCPCS","0278","RC","","","","both","","","8188.50","6141.37","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3136.20","38.3","","352.91","352.91","2046.30","1 through 10","2538.44","6509.86","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE UNITIZED","SUP-ITM-10045308","CDM","C1889","HCPCS","0278","RC","","","","both","","","8188.50","6141.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3512.87","42.9","","9668.75","9668.75","9668.75","1 through 10","2538.44","6509.86","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE UNITIZED","SUP-ITM-10045308","CDM","C1889","HCPCS","0278","RC","","","","both","","","8188.50","6141.37","WELLPOINT [1015]","HB AMC WELLPOINT","6041.48","73.78","","699.88","384.10","3443.31","33","2538.44","6509.86","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE UNITIZED","SUP-ITM-10045308","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8188.50","6141.37","AETNA [1001]","HB AMC AETNA HMO","5715.57","69.8","","1421.24","264.50","4933.46","29","4279.31","6691.64","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE UNITIZED","SUP-ITM-10045308","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8188.50","6141.37","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6583.55","80.4","","1022.97","1022.97","3607.50","1 through 10","4279.31","6691.64","percent of total billed charges",""
"VALVE SHUNT HAKIM PROGRAMMABLE RIGHT ANGLE UNITIZED","SUP-ITM-10045308","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8188.50","6141.37","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6691.64","81.72","","3010.54","693.88","5019.88","35","4279.31","6691.64","percent of total billed charges",""
"VALVE SHUNT MICRO PV RICKHAM MD HIGH PRESSURE","SUP-ITM-10045301","CDM","C1889","HCPCS","0278","RC","","","","both","","","2541.67","1906.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2020.63","79.5","","1309.77","674.56","6049.93","26","787.92","2020.63","percent of total billed charges",""
"VALVE SHUNT MICRO PV RICKHAM MD HIGH PRESSURE","SUP-ITM-10045301","CDM","C1889","HCPCS","0278","RC","","","","both","","","2541.67","1906.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1354.71","53.3","","1901.83","1901.83","2962.25","1 through 10","787.92","2020.63","percent of total billed charges",""
"VALVE SHUNT MICRO PV RICKHAM MD HIGH PRESSURE","SUP-ITM-10045301","CDM","C1889","HCPCS","0278","RC","","","","both","","","2541.67","1906.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","927.71","36.5","","1620.31","1620.31","19908.88","1 through 10","787.92","2020.63","percent of total billed charges",""
"VALVE SHUNT MICRO PV RICKHAM MD HIGH PRESSURE","SUP-ITM-10045301","CDM","C1889","HCPCS","0278","RC","","","","both","","","2541.67","1906.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","973.46","38.3","","352.91","352.91","2046.30","1 through 10","787.92","2020.63","percent of total billed charges",""
"VALVE SHUNT MICRO PV RICKHAM MD HIGH PRESSURE","SUP-ITM-10045301","CDM","C1889","HCPCS","0278","RC","","","","both","","","2541.67","1906.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1090.38","42.9","","9668.75","9668.75","9668.75","1 through 10","787.92","2020.63","percent of total billed charges",""
"VALVE SHUNT MICRO PV RICKHAM MD HIGH PRESSURE","SUP-ITM-10045301","CDM","C1889","HCPCS","0278","RC","","","","both","","","2541.67","1906.25","WELLPOINT [1015]","HB AMC WELLPOINT","1875.24","73.78","","699.88","384.10","3443.31","33","787.92","2020.63","percent of total billed charges",""
"VALVE SHUNT MICRO PV RICKHAM MD HIGH PRESSURE","SUP-ITM-10045301","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2541.67","1906.25","AETNA [1001]","HB AMC AETNA HMO","1774.09","69.8","","1421.24","264.50","4933.46","29","1328.28","2077.05","percent of total billed charges",""
"VALVE SHUNT MICRO PV RICKHAM MD HIGH PRESSURE","SUP-ITM-10045301","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2541.67","1906.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2043.50","80.4","","1022.97","1022.97","3607.50","1 through 10","1328.28","2077.05","percent of total billed charges",""
"VALVE SHUNT MICRO PV RICKHAM MD HIGH PRESSURE","SUP-ITM-10045301","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2541.67","1906.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2077.05","81.72","","3010.54","693.88","5019.88","35","1328.28","2077.05","percent of total billed charges",""
"VALVE SHUNT STRATAMR II REGULAR","SUP-ITM-10329239","CDM","C1729","HCPCS","0272","RC","","","","both","","","13747.50","10310.62","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","9870.71","71.8","","162.24","51.52","162.24","1 through 10","4261.73","10929.26","percent of total billed charges",""
"VALVE SHUNT STRATAMR II REGULAR","SUP-ITM-10329239","CDM","C1729","HCPCS","0272","RC","","","","both","","","13747.50","10310.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5017.84","36.5","","94.34","22.19","146.22","26","4261.73","10929.26","percent of total billed charges",""
"VALVE SHUNT STRATAMR II REGULAR","SUP-ITM-10329239","CDM","C1729","HCPCS","0272","RC","","","","both","","","13747.50","10310.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5265.29","38.3","","51.52","27.37","51.52","26","4261.73","10929.26","percent of total billed charges",""
"VALVE SHUNT STRATAMR II REGULAR","SUP-ITM-10329239","CDM","C1729","HCPCS","0272","RC","","","","both","","","13747.50","10310.62","WELLPOINT [1015]","HB AMC WELLPOINT","10142.91","73.78","","207.21","122.12","216.28","14","4261.73","10929.26","percent of total billed charges",""
"VALVE SHUNT STRATAMR II REGULAR","SUP-ITM-10329239","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","13747.50","10310.62","AETNA [1001]","HB AMC AETNA HMO","9595.76","69.8","","155.96","47.39","155.96","1 through 10","7184.44","11234.46","percent of total billed charges",""
"VALVE SHUNT STRATAMR II REGULAR","SUP-ITM-10329239","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","13747.50","10310.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","11234.46","81.72","","57.36","51.76","232.23","35","7184.44","11234.46","percent of total billed charges",""
"VALVE SHUNT SURGICAL CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10030605","CDM","C1889","HCPCS","0278","RC","","","","both","","","8850.08","6637.56","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7035.81","79.5","","1309.77","674.56","6049.93","26","2743.52","7035.81","percent of total billed charges",""
"VALVE SHUNT SURGICAL CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10030605","CDM","C1889","HCPCS","0278","RC","","","","both","","","8850.08","6637.56","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4717.09","53.3","","1901.83","1901.83","2962.25","1 through 10","2743.52","7035.81","percent of total billed charges",""
"VALVE SHUNT SURGICAL CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10030605","CDM","C1889","HCPCS","0278","RC","","","","both","","","8850.08","6637.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3230.28","36.5","","1620.31","1620.31","19908.88","1 through 10","2743.52","7035.81","percent of total billed charges",""
"VALVE SHUNT SURGICAL CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10030605","CDM","C1889","HCPCS","0278","RC","","","","both","","","8850.08","6637.56","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3389.58","38.3","","352.91","352.91","2046.30","1 through 10","2743.52","7035.81","percent of total billed charges",""
"VALVE SHUNT SURGICAL CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10030605","CDM","C1889","HCPCS","0278","RC","","","","both","","","8850.08","6637.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3796.68","42.9","","9668.75","9668.75","9668.75","1 through 10","2743.52","7035.81","percent of total billed charges",""
"VALVE SHUNT SURGICAL CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10030605","CDM","C1889","HCPCS","0278","RC","","","","both","","","8850.08","6637.56","WELLPOINT [1015]","HB AMC WELLPOINT","6529.59","73.78","","699.88","384.10","3443.31","33","2743.52","7035.81","percent of total billed charges",""
"VALVE SHUNT SURGICAL CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10030605","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8850.08","6637.56","AETNA [1001]","HB AMC AETNA HMO","6177.36","69.8","","1421.24","264.50","4933.46","29","4625.05","7232.29","percent of total billed charges",""
"VALVE SHUNT SURGICAL CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10030605","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8850.08","6637.56","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","7115.46","80.4","","1022.97","1022.97","3607.50","1 through 10","4625.05","7232.29","percent of total billed charges",""
"VALVE SHUNT SURGICAL CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10030605","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8850.08","6637.56","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","7232.29","81.72","","3010.54","693.88","5019.88","35","4625.05","7232.29","percent of total billed charges",""
"VALVE SPIRATION 5MM SVS ENDOBRONCHIAL PRELOADED CARTRIDGE","SUP-ITM-10283195","CDM","C1889","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5366.25","79.5","","1309.77","674.56","6049.93","26","2092.5","5366.25","percent of total billed charges",""
"VALVE SPIRATION 5MM SVS ENDOBRONCHIAL PRELOADED CARTRIDGE","SUP-ITM-10283195","CDM","C1889","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3597.75","53.3","","1901.83","1901.83","2962.25","1 through 10","2092.5","5366.25","percent of total billed charges",""
"VALVE SPIRATION 5MM SVS ENDOBRONCHIAL PRELOADED CARTRIDGE","SUP-ITM-10283195","CDM","C1889","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2463.75","36.5","","1620.31","1620.31","19908.88","1 through 10","2092.5","5366.25","percent of total billed charges",""
"VALVE SPIRATION 5MM SVS ENDOBRONCHIAL PRELOADED CARTRIDGE","SUP-ITM-10283195","CDM","C1889","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2585.25","38.3","","352.91","352.91","2046.30","1 through 10","2092.5","5366.25","percent of total billed charges",""
"VALVE SPIRATION 5MM SVS ENDOBRONCHIAL PRELOADED CARTRIDGE","SUP-ITM-10283195","CDM","C1889","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2895.75","42.9","","9668.75","9668.75","9668.75","1 through 10","2092.5","5366.25","percent of total billed charges",""
"VALVE SPIRATION 5MM SVS ENDOBRONCHIAL PRELOADED CARTRIDGE","SUP-ITM-10283195","CDM","C1889","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","WELLPOINT [1015]","HB AMC WELLPOINT","4980.15","73.78","","699.88","384.10","3443.31","33","2092.5","5366.25","percent of total billed charges",""
"VALVE SPIRATION 5MM SVS ENDOBRONCHIAL PRELOADED CARTRIDGE","SUP-ITM-10283195","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","AETNA [1001]","HB AMC AETNA HMO","4711.50","69.8","","1421.24","264.50","4933.46","29","3527.55","5516.1","percent of total billed charges",""
"VALVE SPIRATION 5MM SVS ENDOBRONCHIAL PRELOADED CARTRIDGE","SUP-ITM-10283195","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5427.00","80.4","","1022.97","1022.97","3607.50","1 through 10","3527.55","5516.1","percent of total billed charges",""
"VALVE SPIRATION 5MM SVS ENDOBRONCHIAL PRELOADED CARTRIDGE","SUP-ITM-10283195","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5516.10","81.72","","3010.54","693.88","5019.88","35","3527.55","5516.1","percent of total billed charges",""
"VALVE TRANSCATHETER 29MM AORTIC EVOLUTTM PRO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266580","CDM","C1889","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","59625.00","79.5","","1309.77","674.56","6049.93","26","23250","59625","percent of total billed charges",""
"VALVE TRANSCATHETER 29MM AORTIC EVOLUTTM PRO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266580","CDM","C1889","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39975.00","53.3","","1901.83","1901.83","2962.25","1 through 10","23250","59625","percent of total billed charges",""
"VALVE TRANSCATHETER 29MM AORTIC EVOLUTTM PRO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266580","CDM","C1889","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27375.00","36.5","","1620.31","1620.31","19908.88","1 through 10","23250","59625","percent of total billed charges",""
"VALVE TRANSCATHETER 29MM AORTIC EVOLUTTM PRO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266580","CDM","C1889","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28725.00","38.3","","352.91","352.91","2046.30","1 through 10","23250","59625","percent of total billed charges",""
"VALVE TRANSCATHETER 29MM AORTIC EVOLUTTM PRO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266580","CDM","C1889","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32175.00","42.9","","9668.75","9668.75","9668.75","1 through 10","23250","59625","percent of total billed charges",""
"VALVE TRANSCATHETER 29MM AORTIC EVOLUTTM PRO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266580","CDM","C1889","HCPCS","0278","RC","","","","both","","","75000.00","56250.00","WELLPOINT [1015]","HB AMC WELLPOINT","55335.00","73.78","","699.88","384.10","3443.31","33","23250","59625","percent of total billed charges",""
"VALVE TRANSCATHETER 29MM AORTIC EVOLUTTM PRO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266580","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","75000.00","56250.00","AETNA [1001]","HB AMC AETNA HMO","52350.00","69.8","","1421.24","264.50","4933.46","29","39195","61290","percent of total billed charges",""
"VALVE TRANSCATHETER 29MM AORTIC EVOLUTTM PRO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266580","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","75000.00","56250.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","60300.00","80.4","","1022.97","1022.97","3607.50","1 through 10","39195","61290","percent of total billed charges",""
"VALVE TRANSCATHETER 29MM AORTIC EVOLUTTM PRO - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10266580","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","75000.00","56250.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","61290.00","81.72","","3010.54","693.88","5019.88","35","39195","61290","percent of total billed charges",""
"VALVE TRIAL 19MM MITRAL HAART 300 AORTIC ANNULOPLASTY","SUP-ITM-10213048","CDM","C1889","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12918.75","79.5","","1309.77","674.56","6049.93","26","5037.5","12918.75","percent of total billed charges",""
"VALVE TRIAL 19MM MITRAL HAART 300 AORTIC ANNULOPLASTY","SUP-ITM-10213048","CDM","C1889","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8661.25","53.3","","1901.83","1901.83","2962.25","1 through 10","5037.5","12918.75","percent of total billed charges",""
"VALVE TRIAL 19MM MITRAL HAART 300 AORTIC ANNULOPLASTY","SUP-ITM-10213048","CDM","C1889","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5931.25","36.5","","1620.31","1620.31","19908.88","1 through 10","5037.5","12918.75","percent of total billed charges",""
"VALVE TRIAL 19MM MITRAL HAART 300 AORTIC ANNULOPLASTY","SUP-ITM-10213048","CDM","C1889","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6223.75","38.3","","352.91","352.91","2046.30","1 through 10","5037.5","12918.75","percent of total billed charges",""
"VALVE TRIAL 19MM MITRAL HAART 300 AORTIC ANNULOPLASTY","SUP-ITM-10213048","CDM","C1889","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6971.25","42.9","","9668.75","9668.75","9668.75","1 through 10","5037.5","12918.75","percent of total billed charges",""
"VALVE TRIAL 19MM MITRAL HAART 300 AORTIC ANNULOPLASTY","SUP-ITM-10213048","CDM","C1889","HCPCS","0278","RC","","","","both","","","16250.00","12187.50","WELLPOINT [1015]","HB AMC WELLPOINT","11989.25","73.78","","699.88","384.10","3443.31","33","5037.5","12918.75","percent of total billed charges",""
"VALVE TRIAL 19MM MITRAL HAART 300 AORTIC ANNULOPLASTY","SUP-ITM-10213048","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","16250.00","12187.50","AETNA [1001]","HB AMC AETNA HMO","11342.50","69.8","","1421.24","264.50","4933.46","29","8492.25","13279.5","percent of total billed charges",""
"VALVE TRIAL 19MM MITRAL HAART 300 AORTIC ANNULOPLASTY","SUP-ITM-10213048","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","16250.00","12187.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","13065.00","80.4","","1022.97","1022.97","3607.50","1 through 10","8492.25","13279.5","percent of total billed charges",""
"VALVE TRIAL 19MM MITRAL HAART 300 AORTIC ANNULOPLASTY","SUP-ITM-10213048","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","16250.00","12187.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13279.50","81.72","","3010.54","693.88","5019.88","35","8492.25","13279.5","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL MICRO W OUT RESERVOIR PROGRAMABLE","SUP-ITM-10018562","CDM","C1889","HCPCS","0278","RC","","","","both","","","8136.63","6102.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6468.62","79.5","","1309.77","674.56","6049.93","26","2522.36","6468.62","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL MICRO W OUT RESERVOIR PROGRAMABLE","SUP-ITM-10018562","CDM","C1889","HCPCS","0278","RC","","","","both","","","8136.63","6102.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4336.82","53.3","","1901.83","1901.83","2962.25","1 through 10","2522.36","6468.62","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL MICRO W OUT RESERVOIR PROGRAMABLE","SUP-ITM-10018562","CDM","C1889","HCPCS","0278","RC","","","","both","","","8136.63","6102.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2969.87","36.5","","1620.31","1620.31","19908.88","1 through 10","2522.36","6468.62","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL MICRO W OUT RESERVOIR PROGRAMABLE","SUP-ITM-10018562","CDM","C1889","HCPCS","0278","RC","","","","both","","","8136.63","6102.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3116.33","38.3","","352.91","352.91","2046.30","1 through 10","2522.36","6468.62","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL MICRO W OUT RESERVOIR PROGRAMABLE","SUP-ITM-10018562","CDM","C1889","HCPCS","0278","RC","","","","both","","","8136.63","6102.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3490.61","42.9","","9668.75","9668.75","9668.75","1 through 10","2522.36","6468.62","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL MICRO W OUT RESERVOIR PROGRAMABLE","SUP-ITM-10018562","CDM","C1889","HCPCS","0278","RC","","","","both","","","8136.63","6102.47","WELLPOINT [1015]","HB AMC WELLPOINT","6003.21","73.78","","699.88","384.10","3443.31","33","2522.36","6468.62","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL MICRO W OUT RESERVOIR PROGRAMABLE","SUP-ITM-10018562","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8136.63","6102.47","AETNA [1001]","HB AMC AETNA HMO","5679.37","69.8","","1421.24","264.50","4933.46","29","4252.2","6649.25","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL MICRO W OUT RESERVOIR PROGRAMABLE","SUP-ITM-10018562","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8136.63","6102.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","6541.85","80.4","","1022.97","1022.97","3607.50","1 through 10","4252.2","6649.25","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL MICRO W OUT RESERVOIR PROGRAMABLE","SUP-ITM-10018562","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8136.63","6102.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6649.25","81.72","","3010.54","693.88","5019.88","35","4252.2","6649.25","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL SM CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10045332","CDM","C1889","HCPCS","0278","RC","","","","both","","","7275.60","5456.70","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5784.10","79.5","","1309.77","674.56","6049.93","26","2255.44","5784.1","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL SM CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10045332","CDM","C1889","HCPCS","0278","RC","","","","both","","","7275.60","5456.70","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","3877.89","53.3","","1901.83","1901.83","2962.25","1 through 10","2255.44","5784.1","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL SM CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10045332","CDM","C1889","HCPCS","0278","RC","","","","both","","","7275.60","5456.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2655.59","36.5","","1620.31","1620.31","19908.88","1 through 10","2255.44","5784.1","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL SM CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10045332","CDM","C1889","HCPCS","0278","RC","","","","both","","","7275.60","5456.70","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2786.55","38.3","","352.91","352.91","2046.30","1 through 10","2255.44","5784.1","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL SM CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10045332","CDM","C1889","HCPCS","0278","RC","","","","both","","","7275.60","5456.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3121.23","42.9","","9668.75","9668.75","9668.75","1 through 10","2255.44","5784.1","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL SM CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10045332","CDM","C1889","HCPCS","0278","RC","","","","both","","","7275.60","5456.70","WELLPOINT [1015]","HB AMC WELLPOINT","5367.94","73.78","","699.88","384.10","3443.31","33","2255.44","5784.1","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL SM CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10045332","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7275.60","5456.70","AETNA [1001]","HB AMC AETNA HMO","5078.37","69.8","","1421.24","264.50","4933.46","29","3802.23","5945.62","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL SM CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10045332","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7275.60","5456.70","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","5849.58","80.4","","1022.97","1022.97","3607.50","1 through 10","3802.23","5945.62","percent of total billed charges",""
"VALVE VENTRICULOPERITONEAL SM CONTROL RESERVOIR PROGRAMABLE","SUP-ITM-10045332","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7275.60","5456.70","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","5945.62","81.72","","3010.54","693.88","5019.88","35","3802.23","5945.62","percent of total billed charges",""
"Valvuloplasty Mitral Valve","PX-48000110","CDM","92987","CPT","0481","RC","","","","both","","","36997.00","27747.75","MEDICARE [2001]","HB BWH MEDICARE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13467.61","13467.61","13467.61","1 through 10","11469.07","29412.62","other","OPPS APC"
"Vancomycin","PX-30000192","CDM","80202","CPT","0301","RC","","","","both","","","232.00","174.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","184.44","79.5","","177.08","177.08","177.08","1 through 10","13.27","220.4","percent of total billed charges",""
"Vancomycin","PX-30000192","CDM","80202","CPT","0301","RC","","","","both","","","232.00","174.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","123.66","53.3","","177.08","118.80","177.08","1 through 10","13.27","220.4","percent of total billed charges",""
"Vancomycin","PX-30000192","CDM","80202","CPT","0301","RC","","","","both","","","232.00","174.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","84.68","36.5","","83.93","83.93","83.93","1 through 10","13.27","220.4","percent of total billed charges",""
"Vancomycin","PX-30000192","CDM","80202","CPT","0301","RC","","","","both","","","232.00","174.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","88.86","38.3","","87.98","87.98","87.98","1 through 10","13.27","220.4","percent of total billed charges",""
"Vancomycin Hcl Injection","PX-63601082","CDM","J3370","HCPCS","0636","RC","","","","both","","","11.00","8.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4.02","36.5","","8.52","1.24","12.76","16","3.41","10.45","percent of total billed charges",""
"Vancomycin Hcl Injection","PX-63601082","CDM","J3370","HCPCS","0636","RC","","","","both","","","11.00","8.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4.21","38.3","","4.47","1.48","10.45","46","3.41","10.45","percent of total billed charges",""
"Vancomycin Hcl Injection","PX-63601082","CDM","J3370","HCPCS","0636","RC","","","","both","","","11.00","8.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4.72","42.9","","4.00","4.00","4.30","1 through 10","3.41","10.45","percent of total billed charges",""
"Vancomycin Hcl Injection","PX-63601082","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","11.00","8.25","AETNA [1001]","HB AMC AETNA HMO","7.68","69.8","","3.04","1.86","17.82","83","5.16","8.99","percent of total billed charges",""
"Vancomycin Hcl Injection","PX-63601082","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","11.00","8.25","AETNA [1001]","HB AMC AETNA PPO","8.84","80.4","","3.04","1.85","3.06","1 through 10","5.16","8.99","percent of total billed charges",""
"Vancomycin Hcl Injection","PX-63601082","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","11.00","8.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","7.69","69.9","","5.87","2.70","47.49","47","5.16","8.99","percent of total billed charges",""
"Vancomycin Hcl Injection","PX-63601082","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","11.00","8.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5.16","46.9","","10.72","1.81","23.07","42","5.16","8.99","percent of total billed charges",""
"Vancomycin Hcl Injection","PX-63601082","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","11.00","8.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","7.69","69.9","","20.13","20.13","20.13","1 through 10","5.16","8.99","percent of total billed charges",""
"Vancomycin Hcl Injection","PX-63601082","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","11.00","8.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8.99","81.72","","4.00","4.00","4.00","1 through 10","5.16","8.99","percent of total billed charges",""
"Vancomycin Hcl Injection","PX-63601082","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","11.00","8.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8.99","81.72","","4.00","4.00","8.60","19","5.16","8.99","percent of total billed charges",""
"Vancomycin Vl 500mg","PX-63600191","CDM","J3370","HCPCS","0636","RC","","","","both","","","15.81","11.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5.77","36.5","","8.52","1.24","12.76","16","4.9","15.02","percent of total billed charges",""
"Vancomycin Vl 500mg","PX-63600191","CDM","J3370","HCPCS","0636","RC","","","","both","","","15.81","11.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6.06","38.3","","4.47","1.48","10.45","46","4.9","15.02","percent of total billed charges",""
"Vancomycin Vl 500mg","PX-63600191","CDM","J3370","HCPCS","0636","RC","","","","both","","","15.81","11.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.78","42.9","","4.00","4.00","4.30","1 through 10","4.9","15.02","percent of total billed charges",""
"Vancomycin Vl 500mg","PX-63600191","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","15.81","11.86","AETNA [1001]","HB AMC AETNA HMO","11.04","69.8","","3.04","1.86","17.82","83","7.41","12.92","percent of total billed charges",""
"Vancomycin Vl 500mg","PX-63600191","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","15.81","11.86","AETNA [1001]","HB AMC AETNA PPO","12.71","80.4","","3.04","1.85","3.06","1 through 10","7.41","12.92","percent of total billed charges",""
"Vancomycin Vl 500mg","PX-63600191","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","15.81","11.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11.05","69.9","","5.87","2.70","47.49","47","7.41","12.92","percent of total billed charges",""
"Vancomycin Vl 500mg","PX-63600191","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","15.81","11.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7.41","46.9","","10.72","1.81","23.07","42","7.41","12.92","percent of total billed charges",""
"Vancomycin Vl 500mg","PX-63600191","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","15.81","11.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","11.05","69.9","","20.13","20.13","20.13","1 through 10","7.41","12.92","percent of total billed charges",""
"Vancomycin Vl 500mg","PX-63600191","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","15.81","11.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","12.92","81.72","","4.00","4.00","4.00","1 through 10","7.41","12.92","percent of total billed charges",""
"Vancomycin Vl 500mg","PX-63600191","CDM","J3370","HCPCS","0636","RC","","","","outpatient","","","15.81","11.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12.92","81.72","","4.00","4.00","8.60","19","7.41","12.92","percent of total billed charges",""
"Vanillylmandelic Acid (Vma) Urine","PX-30000731","CDM","84585","CPT","0301","RC","","","","both","","","191.00","143.25","TRICARE [160005]","HB BWH TRICARE","181.45","95","","17.75","17.75","17.75","1 through 10","15.19","181.45","percent of total billed charges",""
"Vanillylmandelic Acid (Vma) Urine","PX-30000731","CDM","84585","CPT","0301","RC","","","","outpatient","","","191.00","143.25","AETNA [1001]","HB AMC AETNA HMO","133.32","69.8","","88.43","88.43","88.43","1 through 10","15.99","156.09","percent of total billed charges",""
"Var Vaccine Live for Subcutaneous Use","PX-63600320","CDM","90716","CPT","0636","RC","","","","both","","","304.06","228.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","110.98","36.5","","113.41","113.41","113.41","1 through 10","94.26","288.86","percent of total billed charges",""
"Var Vaccine Live for Subcutaneous Use","PX-63600320","CDM","90716","CPT","0636","RC","","","","both","","","304.06","228.04","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","116.45","38.3","","118.89","115.54","118.89","1 through 10","94.26","288.86","percent of total billed charges",""
"Var Vaccine Live for Subcutaneous Use","PX-63600320","CDM","90716","CPT","0636","RC","","","","both","","","304.06","228.04","WELLPOINT [1015]","HB AMC WELLPOINT","224.34","73.78","","197.27","197.27","197.27","1 through 10","94.26","288.86","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","110.57","71.8","","320.94","106.98","320.94","15","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","100.10","65","","117.26","96.85","117.26","1 through 10","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","107.80","70","","149.00","107.28","149.00","1 through 10","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","122.43","79.5","","117.26","78.67","117.26","125","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","82.08","53.3","","117.26","78.67","117.27","55","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","100.10","65","","96.85","96.85","96.85","1 through 10","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","122.43","79.5","","117.26","117.26","117.26","1 through 10","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","47.74","31","","46.04","46.04","46.04","1 through 10","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56.21","36.5","","55.58","47.23","166.74","120","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","58.98","38.3","","58.26","56.62","169.86","457","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","118.58","77","","117.26","117.26","117.26","1 through 10","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","TRICARE [160005]","HB BWH TRICARE","146.30","95","","14.75","14.75","14.75","1 through 10","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.07","42.9","","119.11","65.52","119.11","1 through 10","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","154.00","115.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.07","42.9","","65.52","65.52","65.52","1 through 10","12.62","146.3","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","154.00","115.50","AETNA [1001]","HB AMC AETNA HMO","107.49","69.8","","100.87","71.22","116.22","197","13.29","125.85","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","154.00","115.50","AETNA [1001]","HB AMC AETNA PPO","123.82","80.4","","116.22","71.22","149.00","27","13.29","125.85","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","154.00","115.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","80.48","52.26","","45.36","45.36","45.36","1 through 10","13.29","125.85","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","154.00","115.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","123.82","80.4","","74.50","74.50","74.50","1 through 10","13.29","125.85","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","154.00","115.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","125.85","81.72","","65.52","65.52","65.52","1 through 10","13.29","125.85","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","154.00","115.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","125.85","81.72","","119.11","65.52","119.11","163","13.29","125.85","percent of total billed charges",""
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","both","","","34897.00","26172.75","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","21962.20","","APC Price ($21,322.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","21943.09","21943.09","21943.09","1 through 10","10818.07","27743.12","other","OPPS APC"
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","both","","","34897.00","26172.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","21322.53","","APC Price ($21,322.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20983.49","20983.49","20983.49","1 through 10","10818.07","27743.12","other","OPPS APC"
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","both","","","34897.00","26172.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","27743.12","79.5","","26632.87","26632.87","26632.87","1 through 10","10818.07","27743.12","percent of total billed charges",""
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","both","","","34897.00","26172.75","MEDICARE [2001]","HB BWH MEDICARE","21322.53","","APC Price ($21,322.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","21324.68","21324.68","63974.04","13","10818.07","27743.12","other","OPPS APC"
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","both","","","34897.00","26172.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12737.41","36.5","","12622.69","12622.69","12622.69","1 through 10","10818.07","27743.12","percent of total billed charges",""
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","both","","","34897.00","26172.75","TRICARE [160005]","HB BWH TRICARE","20258.45","","APC Price ($21,324.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","21324.68","21324.68","21324.68","1 through 10","10818.07","27743.12","other","Tricare OPPS"
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","both","","","34897.00","26172.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","20896.08","","APC Price ($21,322.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20906.09","20906.09","20906.09","1 through 10","10818.07","27743.12","other","OPPS APC"
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","outpatient","","","34897.00","26172.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","22622.83","22622.83","22622.83","1 through 10","8702.14","28517.83","other","ASC"
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","outpatient","","","34897.00","26172.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","25630.36","25630.36","25884.67","1 through 10","8702.14","28517.83","other","ASC "
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","outpatient","","","34897.00","26172.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8702.14","","Case rate ($8,702.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","38811.54","19405.77","38811.54","1 through 10","8702.14","28517.83","other","Multiple Surgery"
"Vasc Embolize/Occlude Bleed","PX-76001945","CDM","37244","CPT","0761","RC","","","","both","","","33704.00","25278.00","MEDICARE [2001]","HB BWH MEDICARE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13467.61","12006.91","13467.61","1 through 10","10448.24","26794.68","other","OPPS APC"
"Vasc Embolize/Occlude Bleed","PX-76001945","CDM","37244","CPT","0761","RC","","","","both","","","33704.00","25278.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12908.63","38.3","","12779.44","12779.44","12779.44","1 through 10","10448.24","26794.68","percent of total billed charges",""
"Vasc Embolize/Occlude Bleed","PX-76001945","CDM","37244","CPT","0761","RC","","","","both","","","33704.00","25278.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13196.92","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13206.16","13206.16","13206.16","1 through 10","10448.24","26794.68","other","OPPS APC"
"Vasc Embolize/Occlude Bleed","PX-76001945","CDM","37244","CPT","0761","RC","","","","outpatient","","","33704.00","25278.00","AETNA [1001]","HB AMC AETNA HMO","23525.39","69.8","","22127.07","22127.07","22127.07","1 through 10","8702.14","27542.91","percent of total billed charges",""
"Vasc Embolize/Occlude Bleed","PX-76001945","CDM","37244","CPT","0761","RC","","","","outpatient","","","33704.00","25278.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","25630.36","25630.36","25630.36","1 through 10","8702.14","27542.91","other","ASC "
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","34862.00","26146.50","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","13870.23","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","13914.73","13865.17","13914.73","1 through 10","10807.22","27715.29","other","OPPS APC"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","34862.00","26146.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13252.13","11814.80","13252.13","1 through 10","10807.22","27715.29","other","OPPS APC"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","34862.00","26146.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","24403.40","70","","33807.00","33807.00","33807.00","1 through 10","10807.22","27715.29","percent of total billed charges",""
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","34862.00","26146.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","27715.29","79.5","","26606.11","17850.10","26606.11","1 through 10","10807.22","27715.29","percent of total billed charges",""
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","34862.00","26146.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13252.13","13252.13","13252.13","1 through 10","10807.22","27715.29","other","OPPS APC"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","34862.00","26146.50","MEDICARE [2001]","HB BWH MEDICARE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","24013.82","12006.91","24013.82","85","10807.22","27715.29","other","OPPS APC"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","34862.00","26146.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12724.63","36.5","","10716.82","10716.82","12238.13","1 through 10","10807.22","27715.29","percent of total billed charges",""
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","34862.00","26146.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","13352.15","38.3","","47179.78","13218.54","47179.78","1 through 10","10807.22","27715.29","percent of total billed charges",""
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","34862.00","26146.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13198.26","11766.77","13198.26","1 through 10","10807.22","27715.29","other","OPPS APC"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","34862.00","26146.50","MOLINA [1014]","HB BWH MOLINA","13196.92","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","26719.74","26719.74","26719.74","1 through 10","10807.22","27715.29","other","OPPS APC"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","34862.00","26146.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","13196.92","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","39610.98","39594.78","39610.98","1 through 10","10807.22","27715.29","other","OPPS APC"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","34862.00","26146.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13196.92","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13207.16","11766.77","13209.04","1 through 10","10807.22","27715.29","other","OPPS APC"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","both","","","34862.00","26146.50","WELLPOINT [1015]","HB AMC WELLPOINT","25721.18","73.78","","24168.14","24168.14","25169.31","1 through 10","10807.22","27715.29","percent of total billed charges",""
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","outpatient","","","34862.00","26146.50","AETNA [1001]","HB AMC AETNA HMO","24333.68","69.8","","22887.34","22887.34","22887.34","1 through 10","8702.14","28489.23","percent of total billed charges",""
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","outpatient","","","34862.00","26146.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","22622.83","22213.71","25884.67","1 through 10","8702.14","28489.23","other","ASC"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","outpatient","","","34862.00","26146.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","25884.67","21138.91","25884.67","11","8702.14","28489.23","other","ASC "
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","outpatient","","","34862.00","26146.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8702.14","","Case rate ($8,702.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","20188.96","20188.96","60566.88","1 through 10","8702.14","28489.23","other","Multiple Surgery"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","outpatient","","","34862.00","26146.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","8702.14","","Case rate ($8,702.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","63699.66","63699.66","63699.66","1 through 10","8702.14","28489.23","other","Multiple Surgery"
"Vasc Embolize/Occlude Organ","PX-76001944","CDM","37243","CPT","0761","RC","","","","outpatient","","","34862.00","26146.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","28489.23","81.72","","27025.32","14864.94","57208.22","1 through 10","8702.14","28489.23","percent of total billed charges",""
"Vasc Embolize/Occlude Venous","PX-76001942","CDM","37241","CPT","0761","RC","","","","both","","","30868.00","23151.00","MARTIN'S POINT [160007]","HB BWH MEDICARE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11774.77","11774.77","11774.77","1 through 10","9569.08","24540.06","other","OPPS APC"
"Vasc Embolize/Occlude Venous","PX-76001942","CDM","37241","CPT","0761","RC","","","","both","","","30868.00","23151.00","WELLPOINT [1015]","HB AMC WELLPOINT","22774.41","73.78","","22285.86","22285.86","22285.86","1 through 10","9569.08","24540.06","percent of total billed charges",""
"Vasc Embolize/Occlude Venous","PX-76001942","CDM","37241","CPT","0761","RC","","","","outpatient","","","30868.00","23151.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","25630.36","25630.36","25884.67","1 through 10","5545.35","25225.33","other","ASC "
"Vasc Embolize/Occlude Venous","PX-76001942","CDM","37241","CPT","0761","RC","","","","outpatient","","","30868.00","23151.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","8702.14","","Case rate ($8,702.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","20188.96","20188.96","20188.96","1 through 10","5545.35","25225.33","other","Multiple Surgery"
"Vasc Embolize/Occlude Venous","PX-76001942","CDM","37241","CPT","0761","RC","","","","outpatient","","","30868.00","23151.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","25225.33","81.72","","23929.24","13161.98","23929.24","1 through 10","5545.35","25225.33","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Vasectomy Semen Exam Postop","PX-76001320","CDM","55250","CPT","0761","RC","","","","both","","","6045.00","4533.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","2315.24","38.3","","7909.54","7909.54","7909.54","1 through 10","1873.95","4805.78","percent of total billed charges",""
"Vasectomy Semen Exam Postop","PX-76001320","CDM","55250","CPT","0761","RC","","","","both","","","6045.00","4533.75","WELLPOINT [1015]","HB AMC WELLPOINT","4460.00","73.78","","6209.13","6209.13","6209.13","1 through 10","1873.95","4805.78","percent of total billed charges",""
"Vasectomy Semen Exam Postop","PX-76001320","CDM","55250","CPT","0761","RC","","","","outpatient","","","6045.00","4533.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","4070.52","3996.91","4070.52","1 through 10","1565.78","4939.97","other","ASC"
"Vasectomy Semen Exam Postop","PX-76001320","CDM","55250","CPT","0761","RC","","","","outpatient","","","6045.00","4533.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","2328.71","2328.71","4657.42","1 through 10","1565.78","4939.97","other","ASC "
"Vasectomy Semen Exam Postop","PX-76001320","CDM","55250","CPT","0761","RC","","","","outpatient","","","6045.00","4533.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","3820.50","3820.50","3820.50","1 through 10","1565.78","4939.97","other","Multiple Surgery"
"Vasectomy Semen Exam Postop","PX-76001320","CDM","55250","CPT","0761","RC","","","","outpatient","","","6045.00","4533.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4939.97","81.72","","4008.40","4008.40","4008.40","1 through 10","1565.78","4939.97","percent of total billed charges",""
"Vasoreactivity Study W/Tcd Icr Arteries Complete","PX-92000191","CDM","93896","CPT","0921","RC","","","","outpatient","","","865.00","648.75","AETNA [1001]","HB AMC AETNA HMO","603.77","69.8","","568.00","568.00","568.00","1 through 10","346","713.63","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","144.32","65.6","","166.14","166.14","166.14","1 through 10","13.35","209","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","174.90","79.5","","167.63","112.46","167.63","111","13.35","209","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","117.26","53.3","","112.46","112.46","167.63","44","13.35","209","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","169.40","77","","164.01","164.01","164.01","1 through 10","13.35","209","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","68.20","31","","65.82","65.82","65.82","1 through 10","13.35","209","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","80.30","36.5","","79.45","67.52","238.35","91","13.35","209","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","84.26","38.3","","83.28","80.94","242.82","207","13.35","209","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","TRICARE [160005]","HB BWH TRICARE","209.00","95","","19.77","19.77","20.81","12","13.35","209","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","170.27","93.66","249.84","1 through 10","13.35","209","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","both","","","220.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.38","42.9","","93.66","93.66","93.66","1 through 10","13.35","209","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA HMO","153.56","69.8","","144.20","101.81","166.14","90","13.35","179.78","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA PPO","176.88","80.4","","166.14","111.61","223.22","20","13.35","179.78","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","122.98","55.9","","111.61","111.61","111.61","1 through 10","13.35","179.78","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.97","52.26","","49.50","49.50","49.50","1 through 10","13.35","179.78","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","179.78","81.72","","170.27","93.66","170.27","1 through 10","13.35","179.78","percent of total billed charges",""
"Vedolizumab Abs","PX-31000868","CDM","83520","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","179.78","81.72","","170.27","93.66","170.27","133","13.35","179.78","percent of total billed charges",""
"Vedolizumab Level","PX-31000867","CDM","80299","CPT","0301","RC","","","","both","","","339.00","254.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","269.51","79.5","","106.25","71.28","106.25","1 through 10","14.12","322.05","percent of total billed charges",""
"Vedolizumab Level","PX-31000867","CDM","80299","CPT","0301","RC","","","","both","","","339.00","254.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","180.69","53.3","","106.25","71.28","106.25","1 through 10","14.12","322.05","percent of total billed charges",""
"Vedolizumab Level","PX-31000867","CDM","80299","CPT","0301","RC","","","","both","","","339.00","254.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.74","36.5","","50.36","42.80","92.50","13","14.12","322.05","percent of total billed charges",""
"Vedolizumab Level","PX-31000867","CDM","80299","CPT","0301","RC","","","","both","","","339.00","254.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","129.84","38.3","","52.79","44.55","158.37","30","14.12","322.05","percent of total billed charges",""
"Vedolizumab Level","PX-31000867","CDM","80299","CPT","0301","RC","","","","outpatient","","","339.00","254.25","AETNA [1001]","HB AMC AETNA HMO","236.62","69.8","","91.40","64.53","105.30","14","14.12","277.03","percent of total billed charges",""
"Vedolizumab Level","PX-31000867","CDM","80299","CPT","0301","RC","","","","outpatient","","","339.00","254.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","272.56","80.4","","105.30","105.30","105.30","1 through 10","14.12","277.03","percent of total billed charges",""
"Vedolizumab Level","PX-31000867","CDM","80299","CPT","0301","RC","","","","outpatient","","","339.00","254.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","277.03","81.72","","59.36","15.50","59.36","1 through 10","14.12","277.03","percent of total billed charges",""
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","5201.00","3900.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1898.37","36.5","","1598.95","1598.95","1598.95","1 through 10","598.61","4134.8","percent of total billed charges",""
"Vein Ligation And Stripping","263","MS-DRG","","","","","","","","inpatient","","","207520.11","155640.08","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","27704.37","","Case rate ($28,269.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $33,953.81, add-ons for qualifying new technology services are included. If operating cost exceeds $79,598.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,900.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $25,429.76 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $33,573.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,460.16. The transfer capital threshold is the transfer adjustment factor * $2,460.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","24232.12","24232.12","24232.12","1 through 10","27704.37","40475.5711","other","Inpatient DRG"
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","10.50","65.6","","9.35","9.35","10.83","1 through 10","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","10.40","65","","10.40","10.40","10.40","1 through 10","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","11.20","70","","16.00","11.52","54.80","153","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","CHAMPVA [160001]","HB BWH TRICARE","15.20","95","","8.83","8.83","8.83","1 through 10","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","12.72","79.5","","12.59","12.36","13.26","256","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","8.53","53.3","","8.45","8.45","42.58","56","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","12.32","77","","12.32","12.32","36.96","72","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","10.40","65","","10.40","10.40","10.40","52","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","12.72","79.5","","12.59","12.59","12.59","1 through 10","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","10.40","65","","986.44","163.80","3962.40","1 through 10","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC QHM INTERNATIONAL","11.52","72","","11.52","11.52","11.52","1 through 10","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4.96","31","","9.88","9.88","9.88","1 through 10","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5.84","36.5","","11.94","5.79","23.88","35","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","6.13","38.3","","12.52","6.26","25.04","173","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","MOLINA [1014]","HB BWH MOLINA","5.60","35","","18.03","17.66","35.18","65","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","12.32","77","","12.48","2.50","13.92","36","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","TRICARE [160005]","HB BWH TRICARE","15.20","95","","8.64","8.64","9.09","126","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","15.20","95","","9.09","9.09","9.09","1 through 10","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.86","42.9","","12.79","7.04","12.79","161","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.86","42.9","","7.04","7.04","12.79","34","4.96","15.2","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","inpatient","","","16.00","12.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12.58","78.61","","25.58","7.03","25.58","1 through 10","8.85","12.72","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","12.00","AETNA [1001]","HB AMC AETNA HMO","11.17","69.8","","10.83","7.65","12.48","664","8.94","18.46","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","12.00","AETNA [1001]","HB AMC AETNA PPO","12.86","80.4","","12.48","8.38","12.48","44","8.94","18.46","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","12.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","12.86","80.4","","12.48","8.00","12.48","46","8.94","18.46","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","12.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","13.08","81.72","","12.79","12.32","12.80","18","8.94","18.46","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","12.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","13.08","81.72","","12.79","7.04","12.79","134","8.94","18.46","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","12.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","13.08","81.72","","12.79","7.04","12.79","3332","8.94","18.46","percent of total billed charges",""
"Venipuncture > Age 3 by MD/Prof","PX-76001061","CDM","36410","CPT","0761","RC","","","","both","","","67.00","50.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","24.46","36.5","","24.25","24.25","24.25","1 through 10","20.77","53.27","percent of total billed charges",""
"Venipuncture > Age 3 by MD/Prof","PX-76001061","CDM","36410","CPT","0761","RC","","","","outpatient","","","67.00","50.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","54.75","81.72","","28.58","28.58","28.58","1 through 10","15.77","54.75","percent of total billed charges",""
"Vent Mngmnt Inpat/Obs Init Day","PX-41000001","CDM","94002","CPT","0410","RC","","","","both","","","2551.00","1913.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","785.02","","APC Price ($785.02). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","772.54","772.54","772.54","1 through 10","505.5","2028.05","other","OPPS APC"
"Vent Mngmnt Inpat/Obs Init Day","PX-41000001","CDM","94002","CPT","0410","RC","","","","both","","","2551.00","1913.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","785.02","","APC Price ($785.02). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","587.53","587.53","587.53","1 through 10","505.5","2028.05","other","OPPS APC"
"Vent Mngmnt Inpat/Obs Init Day","PX-41000001","CDM","94002","CPT","0410","RC","","","","both","","","2551.00","1913.25","MEDICARE [2001]","HB BWH MEDICARE","785.02","","APC Price ($785.02). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","785.10","683.96","785.10","1 through 10","505.5","2028.05","other","OPPS APC"
"Vent Mngmnt Inpat/Obs Subs Day","PX-41000002","CDM","94003","CPT","0410","RC","","","","both","","","1833.00","1374.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","785.02","","APC Price ($785.02). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","772.54","772.54","772.54","1 through 10","505.5","1457.24","other","OPPS APC"
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","","","","inpatient","","","89366.50","67024.87","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","19819.04","","Case rate ($19,819.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,780.80, add-ons for qualifying new technology services are included. If operating cost exceeds $69,425.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,154.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $17,724.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,400.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.73. The transfer capital threshold is the transfer adjustment factor * $1,714.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","82601.60","82601.60","82601.60","1 through 10","19422.66","32228.3396","other","Inpatient DRG"
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","","","","inpatient","","","89366.50","67024.87","MEDICARE [2001]","HB BWH MEDICARE","19819.04","","Case rate ($19,819.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,780.80, add-ons for qualifying new technology services are included. If operating cost exceeds $69,425.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,154.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $17,724.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,400.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.73. The transfer capital threshold is the transfer adjustment factor * $1,714.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25455.21","0.03","25492.87","25","19422.66","32228.3396","other","Inpatient Replacement Plans DRG"
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","","","","inpatient","","","89366.50","67024.87","MOLINA [1014]","HB BWH MOLINA","19422.66","","Case rate ($19,819.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,780.80, add-ons for qualifying new technology services are included. If operating cost exceeds $69,425.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,154.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $17,724.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,400.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.73. The transfer capital threshold is the transfer adjustment factor * $1,714.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","38965.49","38965.49","38965.49","1 through 10","19422.66","32228.3396","other","Inpatient DRG"
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","","","","inpatient","","","89366.50","67024.87","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","19422.66","","Case rate ($19,819.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,780.80, add-ons for qualifying new technology services are included. If operating cost exceeds $69,425.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,154.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $17,724.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,400.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.73. The transfer capital threshold is the transfer adjustment factor * $1,714.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19311.30","19311.30","19311.30","1 through 10","19422.66","32228.3396","other","Inpatient DRG"
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","","","","inpatient","","","89366.50","67024.87","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","19422.66","","Case rate ($19,819.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $23,780.80, add-ons for qualifying new technology services are included. If operating cost exceeds $69,425.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,154.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $17,724.48 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $23,400.97 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,714.73. The transfer capital threshold is the transfer adjustment factor * $1,714.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19326.89","19326.89","19381.76","1 through 10","19422.66","32228.3396","other","Inpatient DRG"
"Ventricular Shunt Procedures With McC","031","MS-DRG","","","","","","","","inpatient","","","144127.02","108095.26","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","42488.98","","Case rate ($41,251.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,581.18, add-ons for qualifying new technology services are included. If operating cost exceeds $95,225.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,045.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $37,266.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,201.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,605.27. The transfer capital threshold is the transfer adjustment factor * $3,605.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","39548.84","39548.84","39548.84","1 through 10","40426.41","63240.3446","other","Inpatient DRG"
"Ventricular Shunt Procedures With McC","031","MS-DRG","","","","","","","","inpatient","","","144127.02","108095.26","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","53424.15","","Case rate ($53,424.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,581.18, add-ons for qualifying new technology services are included. If operating cost exceeds $95,225.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,045.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $49,439.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,201.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,605.27. The transfer capital threshold is the transfer adjustment factor * $3,605.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","48995.99","48995.99","48995.99","1 through 10","40426.41","63240.3446","other","Inpatient DRG"
"Ventricular Shunt Procedures With McC","031","MS-DRG","","","","","","","","inpatient","","","144127.02","108095.26","MEDICARE [2001]","HB BWH MEDICARE","53424.15","","Case rate ($53,424.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,581.18, add-ons for qualifying new technology services are included. If operating cost exceeds $95,225.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,045.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $49,439.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,201.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,605.27. The transfer capital threshold is the transfer adjustment factor * $3,605.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","49681.91","21452.68","49755.81","17","40426.41","63240.3446","other","Inpatient DRG"
"Ventricular Shunt Procedures With McC","031","MS-DRG","","","","","","","","inpatient","","","144127.02","108095.26","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","40426.41","","Case rate ($41,251.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $49,581.18, add-ons for qualifying new technology services are included. If operating cost exceeds $95,225.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $6,045.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7. The base transfer operating payment is the transfer adjustment factor * $37,266.32 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $49,201.34 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,605.27. The transfer capital threshold is the transfer adjustment factor * $3,605.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","37857.99","37857.99","37857.99","1 through 10","40426.41","63240.3446","other","Inpatient DRG"
"Ventricular Shunt Procedures Without Cc/McC","033","MS-DRG","","","","","","","","inpatient","","","85710.39","64282.79","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","15548.98","","Case rate ($15,548.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,640.50, add-ons for qualifying new technology services are included. If operating cost exceeds $64,284.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,778.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $13,831.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,260.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.07. The transfer capital threshold is the transfer adjustment factor * $1,338.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","129254.10","129254.10","129254.10","1 through 10","15238","24077.6905","other","Inpatient DRG"
"Ventricular Shunt Procedures Without Cc/McC","033","MS-DRG","","","","","","","","inpatient","","","85710.39","64282.79","MEDICARE [2001]","HB BWH MEDICARE","15548.98","","Case rate ($15,548.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,640.50, add-ons for qualifying new technology services are included. If operating cost exceeds $64,284.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,778.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $13,831.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,260.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.07. The transfer capital threshold is the transfer adjustment factor * $1,338.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19087.88","0.03","19116.00","20","15238","24077.6905","other","Inpatient Replacement Plans DRG"
"Ventricular Shunt Procedures Without Cc/McC","033","MS-DRG","","","","","","","","inpatient","","","85710.39","64282.79","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","15238.00","","Case rate ($15,548.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,640.50, add-ons for qualifying new technology services are included. If operating cost exceeds $64,284.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,778.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $13,831.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,260.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.07. The transfer capital threshold is the transfer adjustment factor * $1,338.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","24.60","24.60","24.60","1 through 10","15238","24077.6905","other","Inpatient DRG"
"Ventricular Shunt Procedures Without Cc/McC","033","MS-DRG","","","","","","","","inpatient","","","85710.39","64282.79","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","15238.00","","Case rate ($15,548.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $18,640.50, add-ons for qualifying new technology services are included. If operating cost exceeds $64,284.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,778.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $13,831.08 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $18,260.66 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,338.07. The transfer capital threshold is the transfer adjustment factor * $1,338.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14604.55","14499.86","20947.83","1 through 10","15238","24077.6905","other","Inpatient DRG"
"Ventricular Shunt Procedures,EXTREME","022","DRG","","","","","","","","inpatient","","","182012.49","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","140505.47","","Standard inlier is a Case rate ($140,505.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $120,910, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($19,945.60) for the length of stay and the standard reimbursement.","140506.91","140506.91","140506.91","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,EXTREME","022","DRG","","","","","","","","inpatient","","","182012.49","","MASSHEALTH [3001]","HB BWH MEDICAID","60504.27","","Case rate ($66,897.88). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $109,327.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","76679.25","76679.25","76679.25","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,MAJOR","022","DRG","","","","","","","","inpatient","","","121822.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","69571.96","","Standard inlier is a Case rate ($69,571.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $65,750, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,876.16) for the length of stay and the standard reimbursement.","78217.63","78217.63","78217.63","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,MAJOR","022","DRG","","","","","","","","inpatient","","","121822.26","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","78217.63","","Standard inlier is a Case rate ($78,217.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $65,750, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($11,102.34) for the length of stay and the standard reimbursement.","78217.63","78217.63","78217.63","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,MAJOR","022","DRG","","","","","","","","inpatient","","","121822.26","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28041.5079","","Fee schedule rate ($104,004.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28041.5079","104004.32","104004.32","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,MAJOR","022","DRG","","","","","","","","inpatient","","","121822.26","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","27083.21","","Case rate ($29,945.15). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $72,375.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29937.80","29937.80","29937.80","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,MINOR","022","DRG","","","","","","","","inpatient","","","79575.78","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","42188.83","","Standard inlier is a Case rate ($42,188.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $44,456, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,988.96) for the length of stay and the standard reimbursement.","42188.83","42188.83","42188.83","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,MINOR","022","DRG","","","","","","","","inpatient","","","79575.78","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","47431.62","","Standard inlier is a Case rate ($47,431.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $44,456, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,732.52) for the length of stay and the standard reimbursement.","47431.62","43332.88","47431.62","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,MINOR","022","DRG","","","","","","","","inpatient","","","79575.78","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28041.5079","","Fee schedule rate ($28,041.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28041.5079","28041.52","28041.52","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,MINOR","022","DRG","","","","","","","","inpatient","","","79575.78","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43460.02","","Fee schedule rate ($43,460.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","43460.02","43460.02","43460.02","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,MODERATE","022","DRG","","","","","","","","inpatient","","","103119.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","50034.76","","Standard inlier is a Case rate ($50,034.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,556, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,102.74) for the length of stay and the standard reimbursement.","45608.50","45608.50","50034.76","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,MODERATE","022","DRG","","","","","","","","inpatient","","","103119.88","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","56252.56","","Standard inlier is a Case rate ($56,252.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $50,556, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,984.58) for the length of stay and the standard reimbursement.","56252.55","56252.55","56252.55","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,MODERATE","022","DRG","","","","","","","","inpatient","","","103119.88","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","28041.5079","","Fee schedule rate ($41,428.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28041.5079","39831.56","39831.56","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,MODERATE","022","DRG","","","","","","","","inpatient","","","103119.88","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","29444.3982","","Fee schedule rate ($43,500.77). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29444.3982","43500.76","43500.76","1 through 10","12786.5","288413.01","case rate",""
"Ventricular Shunt Procedures,MODERATE","022","DRG","","","","","","","","inpatient","","","103119.88","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","48082.13","","Fee schedule rate ($48,082.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","48082.13","48082.13","48082.13","1 through 10","12786.5","288413.01","case rate",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","both","","","4790.00","3592.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3808.05","79.5","","3655.62","2452.56","3655.62","1 through 10","1484.9","4719.38","percent of total billed charges",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","both","","","4790.00","3592.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2553.07","53.3","","10966.86","10966.86","10966.86","1 through 10","1484.9","4719.38","percent of total billed charges",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","both","","","4790.00","3592.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1748.35","36.5","","1732.59","1472.47","1732.59","1 through 10","1484.9","4719.38","percent of total billed charges",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","both","","","4790.00","3592.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1834.57","38.3","","1816.20","1816.20","5448.60","14","1484.9","4719.38","percent of total billed charges",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","both","","","4790.00","3592.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2054.91","42.9","","3713.21","3713.21","3713.21","1 through 10","1484.9","4719.38","percent of total billed charges",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4790.00","3592.50","AETNA [1001]","HB AMC AETNA HMO","3343.42","69.8","","3623.10","2220.31","3623.10","1 through 10","2125.14","10792.81","percent of total billed charges",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4790.00","3592.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 200.9%, 100.45 procedures at 0%.","5524.71","5424.80","5524.71","1 through 10","2125.14","10792.81","other","ASC"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4790.00","3592.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 231.8%, 115.9 procedures at 0%.","6259.18","6259.18","6321.29","13","2125.14","10792.81","other","ASC "
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4790.00","3592.50","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5440.36","5440.36","5440.36","1 through 10","2125.14","10792.81","other","Multiple Surgery"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4790.00","3592.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 232%, 116 procedures at 0%.","4930.32","4739.06","4930.32","1 through 10","2125.14","10792.81","other","Multiple Surgery"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4790.00","3592.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 244%, 122 procedures at 0%.","5185.34","5185.34","5185.34","1 through 10","2125.14","10792.81","other","Multiple Surgery"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4790.00","3592.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 290%, 145 procedures at 0%.","6162.91","6162.91","6162.91","1 through 10","2125.14","10792.81","other","Multiple Surgery"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4790.00","3592.50","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 246%, 123 procedures at 0%.","5303.58","4271.53","5303.58","1 through 10","2125.14","10792.81","other","Multiple Surgery"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","4790.00","3592.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3914.39","81.72","","3713.21","3713.21","3713.21","1 through 10","2125.14","10792.81","percent of total billed charges",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0761","RC","","","","inpatient","","","4790.00","3592.50","AETNA [1001]","HB AMC AETNA PPO","3808.05","79.5","","2433.98","2433.98","2433.98","1 through 10","2648.87","3808.05","percent of total billed charges",""
"Versiti Acgh","PX-31001245","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Versiti Acgh","PX-31001245","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Versiti Acgh","PX-31001245","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Versiti Acgh","PX-31001245","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Versiti Elane Genetic Analysis, Acgh","PX-31001200","CDM","81479","CPT","0310","RC","","","","both","","","2240.00","1680.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1780.80","79.5","","0.65","0.65","0.65","1 through 10","694.4","2128","percent of total billed charges",""
"Versiti Elane Genetic Analysis, Acgh","PX-31001200","CDM","81479","CPT","0310","RC","","","","both","","","2240.00","1680.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1193.92","53.3","","0.79","0.79","0.79","1 through 10","694.4","2128","percent of total billed charges",""
"Versiti Elane Genetic Analysis, Acgh","PX-31001200","CDM","81479","CPT","0310","RC","","","","outpatient","","","2240.00","1680.00","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1120.00","50","","1.00","1.00","1.00","1 through 10","156.55","1848","percent of total billed charges",""
"Versiti Elane Genetic Analysis, Acgh","PX-31001200","CDM","81479","CPT","0310","RC","","","","outpatient","","","2240.00","1680.00","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1176.00","52.5","","1.00","0.53","1.00","1 through 10","156.55","1848","percent of total billed charges",""
"Versiti Elane Genetic Analysis, Ngs","PX-31001199","CDM","81479","CPT","0310","RC","","","","both","","","1281.00","960.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1018.40","79.5","","0.65","0.65","0.65","1 through 10","397.11","1216.95","percent of total billed charges",""
"Versiti Elane Genetic Analysis, Ngs","PX-31001199","CDM","81479","CPT","0310","RC","","","","both","","","1281.00","960.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","682.77","53.3","","0.79","0.79","0.79","1 through 10","397.11","1216.95","percent of total billed charges",""
"Versiti Elane Genetic Analysis, Ngs","PX-31001199","CDM","81479","CPT","0310","RC","","","","outpatient","","","1281.00","960.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","640.50","50","","1.00","1.00","1.00","1 through 10","156.55","1056.83","percent of total billed charges",""
"Versiti Elane Genetic Analysis, Ngs","PX-31001199","CDM","81479","CPT","0310","RC","","","","outpatient","","","1281.00","960.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","672.53","52.5","","1.00","0.53","1.00","1 through 10","156.55","1056.83","percent of total billed charges",""
"Versiti Fibrnogen Disordr Pnl Bcw4885","PX-31001203","CDM","81479","CPT","0310","RC","","","","both","","","2747.00","2060.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2183.87","79.5","","0.65","0.65","0.65","1 through 10","851.57","2609.65","percent of total billed charges",""
"Versiti Fibrnogen Disordr Pnl Bcw4885","PX-31001203","CDM","81479","CPT","0310","RC","","","","both","","","2747.00","2060.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1464.15","53.3","","0.79","0.79","0.79","1 through 10","851.57","2609.65","percent of total billed charges",""
"Versiti Fibrnogen Disordr Pnl Bcw4885","PX-31001203","CDM","81479","CPT","0310","RC","","","","outpatient","","","2747.00","2060.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","1373.50","50","","1.00","1.00","1.00","1 through 10","156.55","2266.28","percent of total billed charges",""
"Versiti Fibrnogen Disordr Pnl Bcw4885","PX-31001203","CDM","81479","CPT","0310","RC","","","","outpatient","","","2747.00","2060.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","1442.18","52.5","","1.00","0.53","1.00","1 through 10","156.55","2266.28","percent of total billed charges",""
"Versiti, Inherited Thrombocytupenia Panel","PX-31001230","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","0.80","79.5","","0.65","0.65","0.65","1 through 10","0.31","0.95","percent of total billed charges",""
"Versiti, Inherited Thrombocytupenia Panel","PX-31001230","CDM","81479","CPT","0310","RC","","","","both","","","1.00","0.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.53","53.3","","0.79","0.79","0.79","1 through 10","0.31","0.95","percent of total billed charges",""
"Versiti, Inherited Thrombocytupenia Panel","PX-31001230","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","0.50","50","","1.00","1.00","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Versiti, Inherited Thrombocytupenia Panel","PX-31001230","CDM","81479","CPT","0310","RC","","","","outpatient","","","1.00","0.75","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","0.53","52.5","","1.00","0.53","1.00","1 through 10","0.48","156.55","percent of total billed charges",""
"Versiti, Platelet Function Disorder Panel","PX-31001252","CDM","81479","CPT","0310","RC","","","","both","","","7739.00","5804.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6152.51","79.5","","0.65","0.65","0.65","1 through 10","2399.09","7352.05","percent of total billed charges",""
"Versiti, Platelet Function Disorder Panel","PX-31001252","CDM","81479","CPT","0310","RC","","","","both","","","7739.00","5804.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","4124.89","53.3","","0.79","0.79","0.79","1 through 10","2399.09","7352.05","percent of total billed charges",""
"Versiti, Platelet Function Disorder Panel","PX-31001252","CDM","81479","CPT","0310","RC","","","","outpatient","","","7739.00","5804.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","3869.50","50","","1.00","1.00","1.00","1 through 10","156.55","6384.68","percent of total billed charges",""
"Versiti, Platelet Function Disorder Panel","PX-31001252","CDM","81479","CPT","0310","RC","","","","outpatient","","","7739.00","5804.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","4062.98","52.5","","1.00","0.53","1.00","1 through 10","156.55","6384.68","percent of total billed charges",""
"VERTEBRAE CAGE 10MM LG 0DEG BENGAL REPLACEMENT STACKABLE MID EA/1","SUP-ITM-10045519","CDM","C1889","HCPCS","0278","RC","","","","both","","","4035.00","3026.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3207.83","79.5","","1309.77","674.56","6049.93","26","1250.85","3207.83","percent of total billed charges",""
"VERTEBRAE CAGE 10MM LG 0DEG BENGAL REPLACEMENT STACKABLE MID EA/1","SUP-ITM-10045519","CDM","C1889","HCPCS","0278","RC","","","","both","","","4035.00","3026.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2150.66","53.3","","1901.83","1901.83","2962.25","1 through 10","1250.85","3207.83","percent of total billed charges",""
"VERTEBRAE CAGE 10MM LG 0DEG BENGAL REPLACEMENT STACKABLE MID EA/1","SUP-ITM-10045519","CDM","C1889","HCPCS","0278","RC","","","","both","","","4035.00","3026.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1472.78","36.5","","1620.31","1620.31","19908.88","1 through 10","1250.85","3207.83","percent of total billed charges",""
"VERTEBRAE CAGE 10MM LG 0DEG BENGAL REPLACEMENT STACKABLE MID EA/1","SUP-ITM-10045519","CDM","C1889","HCPCS","0278","RC","","","","both","","","4035.00","3026.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1545.41","38.3","","352.91","352.91","2046.30","1 through 10","1250.85","3207.83","percent of total billed charges",""
"VERTEBRAE CAGE 10MM LG 0DEG BENGAL REPLACEMENT STACKABLE MID EA/1","SUP-ITM-10045519","CDM","C1889","HCPCS","0278","RC","","","","both","","","4035.00","3026.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1731.02","42.9","","9668.75","9668.75","9668.75","1 through 10","1250.85","3207.83","percent of total billed charges",""
"VERTEBRAE CAGE 10MM LG 0DEG BENGAL REPLACEMENT STACKABLE MID EA/1","SUP-ITM-10045519","CDM","C1889","HCPCS","0278","RC","","","","both","","","4035.00","3026.25","WELLPOINT [1015]","HB AMC WELLPOINT","2977.02","73.78","","699.88","384.10","3443.31","33","1250.85","3207.83","percent of total billed charges",""
"VERTEBRAE CAGE 10MM LG 0DEG BENGAL REPLACEMENT STACKABLE MID EA/1","SUP-ITM-10045519","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4035.00","3026.25","AETNA [1001]","HB AMC AETNA HMO","2816.43","69.8","","1421.24","264.50","4933.46","29","2108.69","3297.4","percent of total billed charges",""
"VERTEBRAE CAGE 10MM LG 0DEG BENGAL REPLACEMENT STACKABLE MID EA/1","SUP-ITM-10045519","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4035.00","3026.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3244.14","80.4","","1022.97","1022.97","3607.50","1 through 10","2108.69","3297.4","percent of total billed charges",""
"VERTEBRAE CAGE 10MM LG 0DEG BENGAL REPLACEMENT STACKABLE MID EA/1","SUP-ITM-10045519","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4035.00","3026.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3297.40","81.72","","3010.54","693.88","5019.88","35","2108.69","3297.4","percent of total billed charges",""
"VERTEBRAE SPACER 10X30MM INTER 0DEG FUSION PEEK AVS","SUP-ITM-10026389","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3975.00","79.5","","1309.77","674.56","6049.93","26","1550","3975","percent of total billed charges",""
"VERTEBRAE SPACER 10X30MM INTER 0DEG FUSION PEEK AVS","SUP-ITM-10026389","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2665.00","53.3","","1901.83","1901.83","2962.25","1 through 10","1550","3975","percent of total billed charges",""
"VERTEBRAE SPACER 10X30MM INTER 0DEG FUSION PEEK AVS","SUP-ITM-10026389","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1825.00","36.5","","1620.31","1620.31","19908.88","1 through 10","1550","3975","percent of total billed charges",""
"VERTEBRAE SPACER 10X30MM INTER 0DEG FUSION PEEK AVS","SUP-ITM-10026389","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1915.00","38.3","","352.91","352.91","2046.30","1 through 10","1550","3975","percent of total billed charges",""
"VERTEBRAE SPACER 10X30MM INTER 0DEG FUSION PEEK AVS","SUP-ITM-10026389","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2145.00","42.9","","9668.75","9668.75","9668.75","1 through 10","1550","3975","percent of total billed charges",""
"VERTEBRAE SPACER 10X30MM INTER 0DEG FUSION PEEK AVS","SUP-ITM-10026389","CDM","C1889","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB AMC WELLPOINT","3689.00","73.78","","699.88","384.10","3443.31","33","1550","3975","percent of total billed charges",""
"VERTEBRAE SPACER 10X30MM INTER 0DEG FUSION PEEK AVS","SUP-ITM-10026389","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","AETNA [1001]","HB AMC AETNA HMO","3490.00","69.8","","1421.24","264.50","4933.46","29","2613","4086","percent of total billed charges",""
"VERTEBRAE SPACER 10X30MM INTER 0DEG FUSION PEEK AVS","SUP-ITM-10026389","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","4020.00","80.4","","1022.97","1022.97","3607.50","1 through 10","2613","4086","percent of total billed charges",""
"VERTEBRAE SPACER 10X30MM INTER 0DEG FUSION PEEK AVS","SUP-ITM-10026389","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","4086.00","81.72","","3010.54","693.88","5019.88","35","2613","4086","percent of total billed charges",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,EXTREME","310","DRG","","","","","","","","inpatient","","","262404.82","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","113814.45","","Standard inlier is a Case rate ($113,814.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $100,153, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,156.65) for the length of stay and the standard reimbursement.","167480.51","167480.51","167480.51","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,EXTREME","310","DRG","","","","","","","","inpatient","","","262404.82","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","127958.11","","Standard inlier is a Case rate ($127,958.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $100,153, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,162.59) for the length of stay and the standard reimbursement.","127958.11","127958.11","127958.11","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,EXTREME","310","DRG","","","","","","","","inpatient","","","262404.82","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","45239.98","","Case rate ($50,020.57). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $92,450.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","125460.59","125460.59","125460.59","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MAJOR","310","DRG","","","","","","","","inpatient","","","135273.34","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","66169.69","","Standard inlier is a Case rate ($66,169.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,103, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,393.19) for the length of stay and the standard reimbursement.","64626.64","64626.64","64626.64","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MAJOR","310","DRG","","","","","","","","inpatient","","","135273.34","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","74392.56","","Standard inlier is a Case rate ($74,392.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $63,103, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,559.41) for the length of stay and the standard reimbursement.","74392.56","74392.56","74392.56","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MAJOR","310","DRG","","","","","","","","inpatient","","","135273.34","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","21627.27","","Case rate ($23,912.67). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $66,342.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23906.80","23906.80","23906.80","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","68496.08","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","35070.58","","Standard inlier is a Case rate ($35,070.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,920, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,978.48) for the length of stay and the standard reimbursement.","35070.58","35070.58","35070.58","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","68496.08","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","39428.78","","Standard inlier is a Case rate ($39,428.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,920, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,596.59) for the length of stay and the standard reimbursement.","36021.59","36021.59","39428.78","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","68496.08","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","18969.4527","","Fee schedule rate ($18,969.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18969.4527","18969.44","18969.44","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","68496.08","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","19918.4766","","Fee schedule rate ($19,918.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19918.4766","19918.48","19918.48","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","68496.08","","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","20866.65","","Fee schedule rate ($20,866.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20866.65","20866.65","20866.65","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","68496.08","","MASSHEALTH [3001]","HB BWH MEDICAID","9727.25","","Case rate ($10,755.14). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,185.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8644.24","8644.24","8644.24","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","68496.08","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37968.21","","Fee schedule rate ($37,968.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","36862.03","36862.03","36862.03","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MODERATE","310","DRG","","","","","","","","inpatient","","","86202.07","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","39428.78","","Standard inlier is a Case rate ($39,428.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $38,920, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,596.59) for the length of stay and the standard reimbursement.","53158.32","53158.32","53158.32","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MODERATE","310","DRG","","","","","","","","inpatient","","","86202.07","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","19918.4766","","Fee schedule rate ($28,573.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19918.4766","28573.08","28573.08","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MODERATE","310","DRG","","","","","","","","inpatient","","","86202.07","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","37968.21","","Fee schedule rate ($37,968.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","45653.16","45653.16","45653.16","1 through 10","9727.25","231315.74","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MODERATE","310","DRG","","","","","","","","inpatient","","","86202.07","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","9727.25","","Case rate ($10,755.14). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $53,185.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15383.09","15383.09","15383.09","1 through 10","9727.25","231315.74","case rate",""
"Vertebroplasty Each Addl Cervicothor/Lumbosacral","PX-76002083","CDM","22512","CPT","0761","RC","","","","outpatient","","","6470.00","4852.50","AETNA [1001]","HB AMC AETNA HMO","4516.06","69.8","","3989.61","3989.61","3989.61","1 through 10","349.16","5287.28","percent of total billed charges",""
"Vertigo And Other Labyrinth Disorders,MAJOR","111","DRG","","","","","","","","inpatient","","","35724.52","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","9711.461","","Fee schedule rate ($17,269.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9711.461","17269.24","17269.24","1 through 10","3854.34","27136.98","case rate",""
"Vertigo And Other Labyrinth Disorders,MODERATE","111","DRG","","","","","","","","inpatient","","","38352.45","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","22285.04","","Standard inlier is a Case rate ($22,285.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $27,061, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,163.18) for the length of stay and the standard reimbursement.","22285.04","22285.04","22285.04","1 through 10","3854.34","27136.98","case rate",""
"Vfc Admin Hepatitis B Vaccine","PX-77100026","CDM","G0010","HCPCS","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","14","7.13","68.49","other","OPPS APC"
"Vfc Admin Hepatitis B Vaccine","PX-77100026","CDM","G0010","HCPCS","0771","RC","","","","both","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Hepatitis B Vaccine","PX-77100026","CDM","G0010","HCPCS","0771","RC","","","","both","","","23.00","17.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Hepatitis B Vaccine","PX-77100026","CDM","G0010","HCPCS","0771","RC","","","","both","","","23.00","17.25","HUMANA [1012]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Hepatitis B Vaccine","PX-77100026","CDM","G0010","HCPCS","0771","RC","","","","both","","","23.00","17.25","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","54.79","81","7.13","68.49","other","OPPS APC"
"Vfc Admin Hepatitis B Vaccine","PX-77100026","CDM","G0010","HCPCS","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.81","53.69","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Hepatitis B Vaccine","PX-77100026","CDM","G0010","HCPCS","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","53.69","161.07","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Hepatitis B Vaccine","PX-77100026","CDM","G0010","HCPCS","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","53.69","54.79","77","7.13","68.49","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","53.35","56.38","51","7.13","68.49","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.02","51.02","53.91","30","7.13","68.49","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","50.81","50.81","53.69","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","ELDER SERVICES [1037]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","54.79","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","50.81","50.81","50.81","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","HUMANA [1012]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","222.65","11.57","222.65","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","103.70","563","7.13","68.49","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","97.86","50.81","101.62","34","7.13","68.49","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","MOLINA [1014]","HB BWH MOLINA","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","103.70","102.66","154.51","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","53.69","161.07","21","7.13","68.49","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9.66","9.20","9.66","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","51.85","50.81","53.70","336","7.13","68.49","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","WELLPOINT [1015]","HB AMC WELLPOINT","16.97","73.78","","84.00","84.00","84.00","1 through 10","7.13","68.49","percent of total billed charges",""
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","56.43","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","48","7.13","68.49","other","OPPS APC"
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","31","7.13","68.49","other","OPPS APC"
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.81","53.69","11","7.13","68.49","other","OPPS APC"
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","161.07","161.07","161.07","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","HUMANA [1012]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","MEDICARE [2001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","51.85","54.79","516","7.13","68.49","other","OPPS APC"
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.81","155.31","26","7.13","68.49","other","OPPS APC"
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","50.81","53.69","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9.66","9.66","9.66","1 through 10","7.13","68.49","other","OPPS APC"
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","53.69","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","50.82","54.79","137","7.13","68.49","other","OPPS APC"
"Vfc Im Adm Thru 18yr Any Rte 1st/Only Compt Vac/Tox","PX-77100018","CDM","90460","CPT","0771","RC","","","","both","","","23.00","17.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18.29","79.5","","33.06","33.05","33.06","17","7.13","35.45","percent of total billed charges",""
"Vfc Im Adm Thru 18yr Any Rte 1st/Only Compt Vac/Tox","PX-77100018","CDM","90460","CPT","0771","RC","","","","both","","","23.00","17.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12.26","53.3","","22.18","21.21","33.05","1 through 10","7.13","35.45","percent of total billed charges",""
"Vfc Im Adm Thru 18yr Any Rte 1st/Only Compt Vac/Tox","PX-77100018","CDM","90460","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","7.13","31","","12.98","12.98","12.98","1 through 10","7.13","35.45","percent of total billed charges",""
"Vfc Im Adm Thru 18yr Any Rte 1st/Only Compt Vac/Tox","PX-77100018","CDM","90460","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.40","36.5","","15.67","15.21","15.67","27","7.13","35.45","percent of total billed charges",""
"Vfc Im Adm Thru 18yr Any Rte 1st/Only Compt Vac/Tox","PX-77100018","CDM","90460","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8.81","38.3","","16.42","15.96","49.27","69","7.13","35.45","percent of total billed charges",""
"Vfc Im Adm Thru 18yr Any Rte 1st/Only Compt Vac/Tox","PX-77100018","CDM","90460","CPT","0771","RC","","","","both","","","23.00","17.25","WELLPOINT [1015]","HB AMC WELLPOINT","16.97","73.78","","31.27","31.27","31.27","1 through 10","7.13","35.45","percent of total billed charges",""
"Vfc Im Adm Thru 18yr Any Rte 1st/Only Compt Vac/Tox","PX-77100018","CDM","90460","CPT","0771","RC","","","","outpatient","","","23.00","17.25","AETNA [1001]","HB AMC AETNA HMO","16.05","69.8","","28.44","20.08","28.44","1 through 10","12.02","228.84","percent of total billed charges",""
"Vfc Im Adm Thru 18yr Any Rte 1st/Only Compt Vac/Tox","PX-77100018","CDM","90460","CPT","0771","RC","","","","outpatient","","","23.00","17.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","18.80","81.72","","67.15","67.15","67.15","1 through 10","12.02","228.84","percent of total billed charges",""
"Vfc Im Adm Thru 18yr Any Rte 1st/Only Compt Vac/Tox","PX-77100018","CDM","90460","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18.80","81.72","","33.57","18.47","42.00","12","12.02","228.84","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","50.78","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","50.74","48.94","50.74","54","7.13","61.63","other","OPPS APC"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.52","46.80","48.52","30","7.13","61.63","other","OPPS APC"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","16.51","71.8","","53.85","53.85","53.85","1 through 10","7.13","61.63","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18.29","79.5","","59.03","39.60","177.09","35","7.13","61.63","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12.26","53.3","","59.03","37.88","96.97","20","7.13","61.63","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.32","40.69","48.32","1 through 10","7.13","61.63","other","OPPS APC"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","FALLON HEALTH [1008]","HB BWH MEDICARE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.93","147.93","147.93","1 through 10","7.13","61.63","other","OPPS APC"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","93.22","46.61","93.22","1 through 10","7.13","61.63","other","OPPS APC"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","17.71","77","","115.50","57.75","115.50","1 through 10","7.13","61.63","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","HUMANA [1012]","HB BWH MEDICARE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.32","46.61","48.32","1 through 10","7.13","61.63","other","OPPS APC"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","MEDICARE [2001]","HB BWH MEDICARE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","49.31","47.56","49.31","597","7.13","61.63","other","OPPS APC"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","7.13","31","","23.18","23.18","69.54","1 through 10","7.13","61.63","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.40","36.5","","27.98","23.78","54.30","95","7.13","61.63","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8.81","38.3","","29.33","28.50","57.00","310","7.13","61.63","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","49.30","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.32","46.61","93.22","36","7.13","61.63","other","OPPS APC"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","MOLINA [1014]","HB BWH MOLINA","48.32","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","97.63","95.12","97.63","1 through 10","7.13","61.63","other","OPPS APC"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","17.71","77","","294.29","35.85","294.29","1 through 10","7.13","61.63","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","TRICARE [160005]","HB BWH TRICARE","46.84","","APC Price ($49.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","46.84","45.18","49.31","1 through 10","7.13","61.63","other","Tricare OPPS"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","48.32","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","93.22","48.32","144.96","14","7.13","61.63","other","OPPS APC"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","48.32","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","17.25","17.25","17.25","1 through 10","7.13","61.63","other","OPPS APC"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.87","42.9","","59.95","59.95","59.95","1 through 10","7.13","61.63","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","48.32","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","48.32","46.61","48.52","277","7.13","61.63","other","OPPS APC"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.87","42.9","","32.98","32.98","32.98","1 through 10","7.13","61.63","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","WELLPOINT [1015]","HB AMC WELLPOINT","16.97","73.78","","55.84","55.84","130.84","37","7.13","61.63","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","AETNA [1001]","HB AMC AETNA HMO","16.05","69.8","","50.78","35.85","58.50","60","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","AETNA [1001]","HB AMC AETNA PPO","18.49","80.4","","58.50","39.30","58.50","1 through 10","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","12.86","55.9","","39.30","39.30","39.30","1 through 10","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","13.93","60.55","","45.88","45.88","45.88","267","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","12.02","52.26","","46.41","46.41","46.41","1 through 10","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","12.01","52.22","","45.88","45.88","45.88","418","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","HARVARD PILGRIM [120001]","HB AMC HPHC ALLIANCE PPO PREFERRED A","12.08","52.5","","49.13","43.20","49.13","1 through 10","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","11.50","50","","74.03","39.30","74.03","344","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","12.08","52.5","","77.78","39.68","77.78","119","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","14.38","62.5","","49.13","47.18","49.13","1 through 10","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED A","12.08","52.5","","41.25","39.68","75.00","1 through 10","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","12.65","55","","41.55","31.69","43.20","21","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC HPHC ALLIANCE PPO PREFERRED A","12.08","52.5","","47.18","47.18","47.18","1 through 10","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","18.80","81.72","","59.96","32.98","75.00","1 through 10","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18.80","81.72","","59.96","32.98","75.00","54","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","14.38","62.5","","47.18","47.18","47.18","1 through 10","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED A","12.08","52.5","","41.25","41.25","41.25","1 through 10","11.5","55.72","percent of total billed charges",""
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC HPHC ALLIANCE PPO PREFERRED B","12.65","55","","41.55","41.55","41.55","1 through 10","11.5","55.72","percent of total billed charges",""
"Vfc Imadm Intransl/Oral 1 Vaccine","PX-77100022","CDM","90473","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8.81","38.3","","16.42","16.42","16.42","1 through 10","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Intransl/Oral Ea Vaccine","PX-77100023","CDM","90474","CPT","0771","RC","","","","both","","","23.00","17.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18.29","79.5","","29.91","29.91","29.91","1 through 10","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Intransl/Oral Ea Vaccine","PX-77100023","CDM","90474","CPT","0771","RC","","","","both","","","23.00","17.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12.26","53.3","","29.91","20.06","29.91","1 through 10","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Intransl/Oral Ea Vaccine","PX-77100023","CDM","90474","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.40","36.5","","14.17","12.05","14.17","23","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Intransl/Oral Ea Vaccine","PX-77100023","CDM","90474","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8.81","38.3","","14.86","14.86","14.86","27","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Intransl/Oral Ea Vaccine","PX-77100023","CDM","90474","CPT","0771","RC","","","","both","","","23.00","17.25","WELLPOINT [1015]","HB AMC WELLPOINT","16.97","73.78","","28.29","28.29","28.29","1 through 10","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Intransl/Oral Ea Vaccine","PX-77100023","CDM","90474","CPT","0771","RC","","","","outpatient","","","23.00","17.25","AETNA [1001]","HB AMC AETNA HMO","16.05","69.8","","25.73","18.16","25.73","11","12.02","18.8","percent of total billed charges",""
"Vfc Imadm Intransl/Oral Ea Vaccine","PX-77100023","CDM","90474","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18.80","81.72","","16.71","16.71","16.71","1 through 10","12.02","18.8","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","83.17","83.17","83.17","1 through 10","7.13","105.64","other","OPPS APC"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","16.51","71.8","","90.48","30.16","90.48","1 through 10","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","14.95","65","","265.20","22.18","265.20","1 through 10","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","16.10","70","","18.06","18.06","18.06","1 through 10","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","105.64","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","10.29","10.29","10.29","1 through 10","7.13","105.64","other","OPPS APC"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18.29","79.5","","33.05","22.18","33.05","264","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12.26","53.3","","22.18","22.18","33.05","149","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","17.71","77","","32.34","32.34","32.34","1 through 10","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","18.29","79.5","","33.05","30.56","33.05","1 through 10","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","84.52","48","7.13","105.64","other","OPPS APC"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","7.13","31","","12.98","12.98","38.94","32","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.40","36.5","","15.67","13.31","15.67","517","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8.81","38.3","","16.42","15.96","31.92","1492","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.83","75.35","82.83","1 through 10","7.13","105.64","other","OPPS APC"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","17.71","77","","30.80","20.08","489.46","1 through 10","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","TRICARE [160005]","HB BWH TRICARE","80.29","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","42.00","42.00","84.52","1 through 10","7.13","105.64","other","Tricare OPPS"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","82.83","82.83","1 through 10","7.13","105.64","other","OPPS APC"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9.66","9.66","9.66","1 through 10","7.13","105.64","other","OPPS APC"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.87","42.9","","19.11","18.47","33.57","1 through 10","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","82.83","124.83","17","7.13","105.64","other","OPPS APC"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.87","42.9","","18.47","18.47","18.47","1 through 10","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","WELLPOINT [1015]","HB AMC WELLPOINT","16.97","73.78","","31.27","31.27","73.27","241","7.13","105.64","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","outpatient","","","23.00","17.25","AETNA [1001]","HB AMC AETNA HMO","16.05","69.8","","28.43","20.08","32.76","380","12.02","228.84","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","outpatient","","","23.00","17.25","AETNA [1001]","HB AMC AETNA PPO","18.49","80.4","","32.76","22.01","32.76","46","12.02","228.84","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","outpatient","","","23.00","17.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","12.86","55.9","","22.01","22.01","22.01","1 through 10","12.02","228.84","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","outpatient","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","12.02","52.26","","25.99","25.99","168.72","1 through 10","12.02","228.84","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","outpatient","","","23.00","17.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","18.80","81.72","","42.00","42.00","42.00","1 through 10","12.02","228.84","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","18.80","81.72","","33.57","18.47","42.00","17","12.02","228.84","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18.80","81.72","","33.57","18.47","42.00","300","12.02","228.84","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","16.51","71.8","","81.86","81.86","81.86","1 through 10","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","16.10","70","","16.34","16.34","16.34","1 through 10","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18.29","79.5","","29.91","20.06","29.91","33","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12.26","53.3","","20.06","20.06","29.91","41","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","18.29","79.5","","29.91","29.91","29.91","1 through 10","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","7.13","31","","35.22","11.74","35.22","1 through 10","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.40","36.5","","14.17","12.05","14.18","142","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8.81","38.3","","14.86","14.44","14.86","256","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.87","42.9","","30.38","30.38","30.38","1 through 10","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","both","","","23.00","17.25","WELLPOINT [1015]","HB AMC WELLPOINT","16.97","73.78","","28.29","28.29","66.29","35","7.13","18.29","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","outpatient","","","23.00","17.25","AETNA [1001]","HB AMC AETNA HMO","16.05","69.8","","25.73","18.16","29.64","70","12.02","18.8","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","outpatient","","","23.00","17.25","AETNA [1001]","HB AMC AETNA PPO","18.49","80.4","","29.64","29.64","29.64","1 through 10","12.02","18.8","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","outpatient","","","23.00","17.25","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","12.86","55.9","","19.91","19.91","19.91","1 through 10","12.02","18.8","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","18.80","81.72","","38.00","38.00","38.00","1 through 10","12.02","18.8","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs Ea Vaccine","PX-77100021","CDM","90472","CPT","0771","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18.80","81.72","","30.38","16.71","38.00","50","12.02","18.8","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","86.97","43.67","87.33","49","7.13","105.64","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.59","37.83","84.52","91","7.13","105.64","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","16.51","71.8","","191.71","191.71","191.71","1 through 10","7.13","105.64","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","15.09","65.6","","87.33","87.33","87.33","1 through 10","7.13","105.64","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","16.10","70","","192.24","114.81","207.77","13","7.13","105.64","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","105.64","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","84.52","59.94","84.52","1 through 10","7.13","105.64","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","18.29","79.5","","210.13","140.98","630.39","72","7.13","105.64","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","12.26","53.3","","210.13","140.98","210.13","34","7.13","105.64","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.59","20.79","83.17","41","7.13","105.64","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","ELDER SERVICES [1037]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","76.89","76.89","76.89","1 through 10","7.13","105.64","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.70","150.70","150.70","1 through 10","7.13","105.64","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","HUMANA [1012]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","83.34","82.83","84.52","1 through 10","7.13","105.64","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","14.95","65","","0.74","0.74","0.74","1 through 10","7.13","105.64","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","MEDICARE [2001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","38.45","84.52","1857","7.13","105.64","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","7.13","31","","82.51","82.51","82.51","1 through 10","7.13","105.64","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","8.40","36.5","","99.59","84.64","99.59","145","7.13","105.64","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","8.81","38.3","","104.40","104.40","208.79","403","7.13","105.64","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","84.51","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.83","75.35","248.49","30","7.13","105.64","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","TRICARE [160005]","HB BWH TRICARE","80.29","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","80.29","73.04","80.29","1 through 10","7.13","105.64","other","Tricare OPPS"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","41.42","20.71","151.32","73","7.13","105.64","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","184.23","61.41","184.23","1 through 10","7.13","105.64","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9.87","42.9","","117.40","117.40","213.44","19","7.13","105.64","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","82.82","","APC Price ($84.51). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","41.59","84.52","301","7.13","105.64","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","inpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18.08","78.61","","2744.02","2744.02","2744.02","1 through 10","12.72","18.29","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","outpatient","","","23.00","17.25","AETNA [1001]","HB AMC AETNA HMO","16.05","69.8","","180.76","127.63","208.26","140","12.02","315.07","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","outpatient","","","23.00","17.25","AETNA [1001]","HB AMC AETNA PPO","18.49","80.4","","208.26","86.97","208.26","1 through 10","12.02","315.07","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","outpatient","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","12.02","52.26","","159.96","158.39","165.22","1 through 10","12.02","315.07","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","outpatient","","","23.00","17.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","18.49","80.4","","208.26","208.26","208.26","1 through 10","12.02","315.07","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","18.80","81.72","","213.44","213.44","213.44","1 through 10","12.02","315.07","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","18.80","81.72","","213.44","117.40","267.00","74","12.02","315.07","percent of total billed charges",""
"Vhl Gene Sequencing","PX-31001347","CDM","81404","CPT","0310","RC","","","","both","","","1916.00","1437.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1523.22","79.5","","1462.25","1207.70","1462.25","1 through 10","269.33","1820.2","percent of total billed charges",""
"Viral Illness With McC","865","MS-DRG","","","","","","","","inpatient","","","69032.60","51774.45","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","18118.11","","Case rate ($18,118.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,833, add-ons for qualifying new technology services are included. If operating cost exceeds $62,477.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,645.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $16,532.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,453.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,205.62. The transfer capital threshold is the transfer adjustment factor * $1,205.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13566.86","13566.86","13566.86","1 through 10","13766.55","23469.37","other","Inpatient DRG"
"Viral Illness With McC","865","MS-DRG","","","","","","","","inpatient","","","69032.60","51774.45","MEDICARE [2001]","HB BWH MEDICARE","18118.11","","Case rate ($18,118.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,833, add-ons for qualifying new technology services are included. If operating cost exceeds $62,477.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,645.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $16,532.64 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,453.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,205.62. The transfer capital threshold is the transfer adjustment factor * $1,205.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17677.89","581.04","17703.92","19","13766.55","23469.37","other","Inpatient DRG"
"Viral Illness With McC","865","MS-DRG","","","","","","","","inpatient","","","69032.60","51774.45","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","13766.55","","Case rate ($14,047.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $16,833, add-ons for qualifying new technology services are included. If operating cost exceeds $62,477.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,645.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,462.03 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $16,453.16 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,205.62. The transfer capital threshold is the transfer adjustment factor * $1,205.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","27386.18","27386.18","27386.18","1 through 10","13766.55","23469.37","other","Inpatient DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","49856.62","37392.46","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","8561.80","","Case rate ($8,312.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,929.11, add-ons for qualifying new technology services are included. If operating cost exceeds $55,573.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,139.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,232.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,549.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $699.73. The transfer capital threshold is the transfer adjustment factor * $699.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8590.36","8590.36","8590.36","1 through 10","8146.18","13352.5168","other","Inpatient DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","49856.62","37392.46","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","8312.43","","Case rate ($8,312.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,929.11, add-ons for qualifying new technology services are included. If operating cost exceeds $55,573.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,139.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,232.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,549.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $699.73. The transfer capital threshold is the transfer adjustment factor * $699.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8309.33","8309.33","8309.33","1 through 10","8146.18","13352.5168","other","Inpatient Replacement Plans DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","49856.62","37392.46","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","8312.43","","Case rate ($8,312.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,929.11, add-ons for qualifying new technology services are included. If operating cost exceeds $55,573.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,139.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,232.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,549.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $699.73. The transfer capital threshold is the transfer adjustment factor * $699.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8176.69","8176.68","8186.79","1 through 10","8146.18","13352.5168","other","Inpatient DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","49856.62","37392.46","MEDICARE [2001]","HB BWH MEDICARE","8312.43","","Case rate ($8,312.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,929.11, add-ons for qualifying new technology services are included. If operating cost exceeds $55,573.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,139.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,232.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,549.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $699.73. The transfer capital threshold is the transfer adjustment factor * $699.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10709.33","10709.33","10724.94","13","8146.18","13352.5168","other","Inpatient Replacement Plans DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","49856.62","37392.46","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","8146.18","","Case rate ($8,312.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,929.11, add-ons for qualifying new technology services are included. If operating cost exceeds $55,573.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,139.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,232.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,549.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $699.73. The transfer capital threshold is the transfer adjustment factor * $699.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8169.63","8169.63","8169.63","1 through 10","8146.18","13352.5168","other","Inpatient DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","49856.62","37392.46","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","8146.18","","Case rate ($8,312.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $9,929.11, add-ons for qualifying new technology services are included. If operating cost exceeds $55,573.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,139.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,232.85 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $9,549.27 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $699.73. The transfer capital threshold is the transfer adjustment factor * $699.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8209.89","8209.89","8209.89","1 through 10","8146.18","13352.5168","other","Inpatient DRG"
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","63599.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","24517.71","","Standard inlier is a Case rate ($24,517.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,714, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,480.44) for the length of stay and the standard reimbursement.","24517.71","24517.71","27564.51","1 through 10","3794.94","121468.72","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","63599.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","27564.52","","Standard inlier is a Case rate ($27,564.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $30,714, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,912.55) for the length of stay and the standard reimbursement.","25182.56","25182.56","27564.51","1 through 10","3794.94","121468.72","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","63599.22","","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","","65","","39191.19","39191.19","39191.19","1 through 10","3794.94","121468.72","percent of total billed charges",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","63599.22","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9631.2302","","Fee schedule rate ($21,564.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9631.2302","27684.04","27684.04","1 through 10","3794.94","121468.72","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","63599.22","","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","10113.0716","","Fee schedule rate ($22,642.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10113.0716","21769.36","21769.36","1 through 10","3794.94","121468.72","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","63599.22","","MASSHEALTH [3001]","HB BWH MEDICAID","8685.41","","Case rate ($9,603.21). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,033.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10153.07","10153.07","10153.07","1 through 10","3794.94","121468.72","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","63599.22","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26509.11","","Fee schedule rate ($26,509.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26509.11","26509.11","26509.11","1 through 10","3794.94","121468.72","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","63599.22","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27835.00","","Fee schedule rate ($27,835.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27835.00","27835.00","27835.00","1 through 10","3794.94","121468.72","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","63599.22","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","8685.41","","Case rate ($9,603.21). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $52,033.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9600.86","9600.86","9600.86","1 through 10","3794.94","121468.72","case rate",""
"Viral Illness,MODERATE","723","DRG","","","","","","","","inpatient","","","47190.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","16338.67","","Standard inlier is a Case rate ($16,338.67). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,354, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,319.37) for the length of stay and the standard reimbursement.","16338.67","16338.67","16338.67","1 through 10","3794.94","121468.72","case rate",""
"Viral Illness,MODERATE","723","DRG","","","","","","","","inpatient","","","47190.22","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","18369.07","","Standard inlier is a Case rate ($18,369.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $24,354, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,607.34) for the length of stay and the standard reimbursement.","16781.73","16781.73","16781.73","1 through 10","3794.94","121468.72","case rate",""
"Viral Illness,MODERATE","723","DRG","","","","","","","","inpatient","","","47190.22","","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","9631.2302","","Fee schedule rate ($21,564.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.331), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($83,006), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9631.2302","11975.28","11975.28","1 through 10","3794.94","121468.72","case rate",""
"Viral Illness,MODERATE","723","DRG","","","","","","","","inpatient","","","47190.22","","HEALTH NEW ENGLAND [1034]","HB BWH MEDICAID","6031.69","","Case rate ($6,669.07). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,099.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6667.44","6667.44","6667.44","1 through 10","3794.94","121468.72","case rate",""
"Viral Illness,MODERATE","723","DRG","","","","","","","","inpatient","","","47190.22","","WELLSENSE [1003]","HB BWH WELLSENSE MCO","6031.69","","Case rate ($6,669.07). If cost, defined as total billed times cost-to-charge ratio (0.3017), exceeds outlier threshold $49,099.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6667.44","6667.44","6667.44","1 through 10","3794.94","121468.72","case rate",""
"Viral Meningitis With Cc/McC","075","MS-DRG","","","","","","","","inpatient","","","47148.73","35361.55","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","17514.05","","Case rate ($17,871.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,436.32, add-ons for qualifying new technology services are included. If operating cost exceeds $67,080.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,983.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,948.70 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,056.48 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,542.93. The transfer capital threshold is the transfer adjustment factor * $1,542.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","127751.62","127751.62","127751.62","1 through 10","17514.05","25992.7384","other","Inpatient DRG"
"Viral Meningitis,MODERATE","051","DRG","","","","","","","","inpatient","","","47148.73","","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","22499.63","","Standard inlier is a Case rate ($22,499.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2457, exceeds the outlier threshold of $29,143, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,193.96) for the length of stay and the standard reimbursement.","34084.77","34084.77","34084.77","1 through 10","7361.41","31200.33","case rate",""
"Viral Meningitis,MODERATE","051","DRG","","","","","","","","inpatient","","","47148.73","","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","21595.74","","Fee schedule rate ($21,595.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2353), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($79,294), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21595.74","21595.74","21595.74","1 through 10","7361.41","31200.33","case rate",""
"Virus Not Elsewhere Specified","PX-30001009","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","124.82","79.5","","119.62","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Virus Not Elsewhere Specified","PX-30001009","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.68","53.3","","80.26","80.26","119.62","1 through 10","9.6","149.15","percent of total billed charges",""
"Virus Not Elsewhere Specified","PX-30001009","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.31","36.5","","56.70","40.57","143.19","1 through 10","9.6","149.15","percent of total billed charges",""
"Virus Not Elsewhere Specified","PX-30001009","CDM","86790","CPT","0302","RC","","","","both","","","157.00","117.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.13","38.3","","59.43","57.76","178.29","54","9.6","149.15","percent of total billed charges",""
"Virus Not Elsewhere Specified","PX-30001009","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA HMO","109.59","69.8","","102.90","72.66","175.56","43","9.6","128.3","percent of total billed charges",""
"Virus Not Elsewhere Specified","PX-30001009","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","AETNA [1001]","HB AMC AETNA PPO","126.23","80.4","","72.66","72.66","118.56","1 through 10","9.6","128.3","percent of total billed charges",""
"Virus Not Elsewhere Specified","PX-30001009","CDM","86790","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.30","81.72","","121.51","66.83","121.51","11","9.6","128.3","percent of total billed charges",""
"Viscosity","PX-30001131","CDM","85810","CPT","0305","RC","","","","outpatient","","","170.00","127.50","AETNA [1001]","HB AMC AETNA HMO","118.66","69.8","","111.71","111.71","111.71","1 through 10","12.04","138.92","percent of total billed charges",""
"Visual Field Exam Exd","PX-51000017","CDM","92083","CPT","0510","RC","","","","both","","","624.00","468.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","115.44","480.48","other","OPPS APC"
"Visual Field Exam Exd","PX-51000017","CDM","92083","CPT","0510","RC","","","","both","","","624.00","468.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","191.33","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","83.63","83.63","83.63","1 through 10","115.44","480.48","other","OPPS APC"
"Visual Field Exam Exd","PX-51000017","CDM","92083","CPT","0510","RC","","","","both","","","624.00","468.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","115.44","480.48","other","OPPS APC"
"Visual Field Exam Exd","PX-51000017","CDM","92083","CPT","0510","RC","","","","both","","","624.00","468.00","MEDICARE [2001]","HB BWH MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","115.44","480.48","other","OPPS APC"
"Visual Field Exam Exd","PX-51000017","CDM","92083","CPT","0510","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","227.76","36.5","","191.79","191.79","225.67","1 through 10","115.44","480.48","percent of total billed charges",""
"Visual Field Exam Exd","PX-51000017","CDM","92083","CPT","0510","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","238.99","38.3","","236.56","236.56","459.80","37","115.44","480.48","percent of total billed charges",""
"Visual Field Exam Exd","PX-51000017","CDM","92083","CPT","0510","RC","","","","both","","","624.00","468.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","451.26","451.26","451.26","1 through 10","115.44","480.48","other","OPPS APC"
"Visual Field Exam Exd","PX-51000017","CDM","92083","CPT","0510","RC","","","","both","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","267.70","42.9","","266.02","266.02","483.64","1 through 10","115.44","480.48","percent of total billed charges",""
"Visual Field Exam Exd","PX-51000017","CDM","92083","CPT","0510","RC","","","","outpatient","","","624.00","468.00","AETNA [1001]","HB AMC AETNA HMO","435.55","69.8","","409.59","409.59","819.17","1 through 10","40.19","509.93","percent of total billed charges",""
"Visual Field Exam Exd","PX-51000017","CDM","92083","CPT","0510","RC","","","","outpatient","","","624.00","468.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","212.78","34.1","","476.14","319.44","476.14","14","40.19","509.93","percent of total billed charges",""
"Visual Field Exam Exd","PX-51000017","CDM","92083","CPT","0510","RC","","","","outpatient","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","509.93","81.72","","483.64","266.02","483.64","1 through 10","40.19","509.93","percent of total billed charges",""
"Visual Field Exam Exd","PX-51000017","CDM","92083","CPT","0510","RC","","","","outpatient","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","509.93","81.72","","483.64","266.02","483.64","16","40.19","509.93","percent of total billed charges",""
"Vit B1 (Thiamine)","PX-63600193","CDM","J3411","HCPCS","0636","RC","","","","both","","","27.80","20.85","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","10.65","38.3","","7.11","7.11","7.11","1 through 10","6.36","21.41","percent of total billed charges",""
"Vit B12 (Cyanocobalamin) Inj 1000mc","PX-63600194","CDM","J3420","HCPCS","0636","RC","","","","both","","","2.04","1.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.74","36.5","","1.35","1.20","1.42","27","0.63","3.25","percent of total billed charges",""
"Vit B12 (Cyanocobalamin) Inj 1000mc","PX-63600194","CDM","J3420","HCPCS","0636","RC","","","","both","","","2.04","1.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.78","38.3","","1.47","1.41","4.41","77","0.63","3.25","percent of total billed charges",""
"Vit B12 (Cyanocobalamin) Inj 1000mc","PX-63600194","CDM","J3420","HCPCS","0636","RC","","","","outpatient","","","2.04","1.53","AETNA [1001]","HB AMC AETNA HMO","1.42","69.8","","2.44","1.80","2.55","1 through 10","0.01","2.04","percent of total billed charges",""
"Vit B12 (Cyanocobalamin) Inj 1000mc","PX-63600194","CDM","J3420","HCPCS","0636","RC","","","","outpatient","","","2.04","1.53","AETNA [1001]","HB AMC AETNA PPO","1.64","80.4","","2.00","2.00","2.00","1 through 10","0.01","2.04","percent of total billed charges",""
"Vit B12 (Cyanocobalamin) Inj 1000mc","PX-63600194","CDM","J3420","HCPCS","0636","RC","","","","outpatient","","","2.04","1.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.43","69.9","","2.61","1.67","2.99","1 through 10","0.01","2.04","percent of total billed charges",""
"Vit B12 (Cyanocobalamin) Inj 1000mc","PX-63600194","CDM","J3420","HCPCS","0636","RC","","","","outpatient","","","2.04","1.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.96","46.9","","2.61","1.67","7.83","1 through 10","0.01","2.04","percent of total billed charges",""
"Vit B12(Cyanocobal) Vl 1ml","PX-63600332","CDM","J3420","HCPCS","0636","RC","","","","both","","","2.04","1.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.74","36.5","","1.35","1.20","1.42","27","0.63","3.25","percent of total billed charges",""
"Vit B12(Cyanocobal) Vl 1ml","PX-63600332","CDM","J3420","HCPCS","0636","RC","","","","both","","","2.04","1.53","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.78","38.3","","1.47","1.41","4.41","77","0.63","3.25","percent of total billed charges",""
"Vit B12(Cyanocobal) Vl 1ml","PX-63600332","CDM","J3420","HCPCS","0636","RC","","","","outpatient","","","2.04","1.53","AETNA [1001]","HB AMC AETNA HMO","1.42","69.8","","2.44","1.80","2.55","1 through 10","0.01","2.04","percent of total billed charges",""
"Vit B12(Cyanocobal) Vl 1ml","PX-63600332","CDM","J3420","HCPCS","0636","RC","","","","outpatient","","","2.04","1.53","AETNA [1001]","HB AMC AETNA PPO","1.64","80.4","","2.00","2.00","2.00","1 through 10","0.01","2.04","percent of total billed charges",""
"Vit B12(Cyanocobal) Vl 1ml","PX-63600332","CDM","J3420","HCPCS","0636","RC","","","","outpatient","","","2.04","1.53","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.43","69.9","","2.61","1.67","2.99","1 through 10","0.01","2.04","percent of total billed charges",""
"Vit B12(Cyanocobal) Vl 1ml","PX-63600332","CDM","J3420","HCPCS","0636","RC","","","","outpatient","","","2.04","1.53","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.96","46.9","","2.61","1.67","7.83","1 through 10","0.01","2.04","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","both","","","148.00","111.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","117.66","79.5","","113.33","76.03","113.33","29","11.38","140.6","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","both","","","148.00","111.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.88","53.3","","76.03","76.03","218.16","22","11.38","140.6","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","both","","","148.00","111.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.88","31","","44.50","44.50","44.50","1 through 10","11.38","140.6","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","both","","","148.00","111.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54.02","36.5","","53.71","45.65","53.71","59","11.38","140.6","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","both","","","148.00","111.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.68","38.3","","56.30","56.30","168.90","147","11.38","140.6","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","both","","","148.00","111.00","MOLINA [1014]","HB BWH MOLINA","51.80","35","","23.03","22.76","23.03","1 through 10","11.38","140.6","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","both","","","148.00","111.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.49","42.9","","115.11","115.11","115.11","1 through 10","11.38","140.6","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","both","","","148.00","111.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.49","42.9","","115.11","115.11","115.11","1 through 10","11.38","140.6","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","148.00","111.00","AETNA [1001]","HB AMC AETNA HMO","103.30","69.8","","97.49","68.83","112.32","52","11.97","120.95","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","148.00","111.00","AETNA [1001]","HB AMC AETNA PPO","118.99","80.4","","112.32","112.32","112.32","1 through 10","11.97","120.95","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","148.00","111.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","118.99","80.4","","112.32","72.00","112.32","1 through 10","11.97","120.95","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","148.00","111.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","120.95","81.72","","63.32","63.32","63.32","1 through 10","11.97","120.95","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","148.00","111.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","120.95","81.72","","115.11","63.32","115.11","44","11.97","120.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","129.96","71.8","","126.37","13.30","126.37","1 through 10","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","126.70","70","","104.92","14.81","126.72","1 through 10","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","143.90","79.5","","138.51","92.93","138.51","392","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","96.47","53.3","","92.93","92.93","278.79","239","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","139.37","77","","406.56","135.52","406.56","1 through 10","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","117.65","65","","114.40","114.40","141.37","1 through 10","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","143.90","79.5","","88.00","88.00","88.00","1 through 10","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","56.11","31","","54.38","54.38","163.14","20","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","66.07","36.5","","65.65","55.79","196.95","434","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","69.32","38.3","","68.82","68.82","206.46","1368","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","MOLINA [1014]","HB BWH MOLINA","63.35","35","","29.56","29.56","29.56","1 through 10","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","TRICARE [160005]","HB BWH TRICARE","171.95","95","","18.17","17.26","18.17","20","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.65","42.9","","140.69","77.39","140.70","27","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","181.00","135.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.65","42.9","","77.39","77.39","140.69","1 through 10","14.78","171.95","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","181.00","135.75","AETNA [1001]","HB AMC AETNA HMO","126.34","69.8","","119.15","84.13","137.28","568","15.43","147.91","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","181.00","135.75","AETNA [1001]","HB AMC AETNA PPO","145.52","80.4","","137.28","92.22","176.44","52","15.43","147.91","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","181.00","135.75","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","101.18","55.9","","92.22","92.22","92.22","1 through 10","15.43","147.91","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","181.00","135.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","94.59","52.26","","53.62","53.62","108.91","1 through 10","15.43","147.91","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","181.00","135.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","145.52","80.4","","137.28","88.00","137.28","1 through 10","15.43","147.91","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","181.00","135.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","147.91","81.72","","140.69","140.69","140.69","1 through 10","15.43","147.91","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","147.91","81.72","","140.69","77.39","140.69","22","15.43","147.91","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","147.91","81.72","","140.69","77.39","140.69","383","15.43","147.91","percent of total billed charges",""
"Vitamin B-2 (Riboflavin)","PX-30000668","CDM","84252","CPT","0301","RC","","","","both","","","254.00","190.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","201.93","79.5","","193.60","193.60","193.60","1 through 10","19.84","241.3","percent of total billed charges",""
"Vitamin B-2 (Riboflavin)","PX-30000668","CDM","84252","CPT","0301","RC","","","","both","","","254.00","190.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","135.38","53.3","","129.89","129.89","129.89","1 through 10","19.84","241.3","percent of total billed charges",""
"Vitamin B-2 (Riboflavin)","PX-30000668","CDM","84252","CPT","0301","RC","","","","both","","","254.00","190.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","92.71","36.5","","91.76","91.76","91.76","1 through 10","19.84","241.3","percent of total billed charges",""
"Vitamin B-2 (Riboflavin)","PX-30000668","CDM","84252","CPT","0301","RC","","","","both","","","254.00","190.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","97.28","38.3","","96.19","96.19","96.19","1 through 10","19.84","241.3","percent of total billed charges",""
"Vitamin B-2 (Riboflavin)","PX-30000668","CDM","84252","CPT","0301","RC","","","","outpatient","","","254.00","190.50","AETNA [1001]","HB AMC AETNA HMO","177.29","69.8","","166.54","117.59","166.54","1 through 10","20.87","207.57","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","both","","","337.00","252.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","241.97","71.8","","234.79","234.79","234.79","1 through 10","27.54","320.15","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","both","","","337.00","252.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","267.92","79.5","","257.35","172.66","257.35","13","27.54","320.15","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","both","","","337.00","252.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","179.62","53.3","","257.35","172.66","772.05","12","27.54","320.15","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","both","","","337.00","252.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","123.01","36.5","","121.97","103.66","121.97","14","27.54","320.15","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","both","","","337.00","252.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","129.07","38.3","","127.86","124.26","372.78","30","27.54","320.15","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","both","","","337.00","252.75","TRICARE [160005]","HB BWH TRICARE","320.15","95","","32.17","32.17","32.17","1 through 10","27.54","320.15","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","both","","","337.00","252.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","144.57","42.9","","261.40","261.40","261.40","1 through 10","27.54","320.15","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","337.00","252.75","AETNA [1001]","HB AMC AETNA HMO","235.23","69.8","","156.31","156.31","221.38","25","28.01","275.4","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","337.00","252.75","AETNA [1001]","HB AMC AETNA PPO","270.95","80.4","","255.06","255.06","255.06","1 through 10","28.01","275.4","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","337.00","252.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","270.95","80.4","","163.50","163.50","163.50","1 through 10","28.01","275.4","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","337.00","252.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","275.40","81.72","","143.78","143.78","143.78","1 through 10","28.01","275.4","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","337.00","252.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","275.40","81.72","","261.40","143.78","261.40","23","28.01","275.4","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","both","","","262.00","196.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","208.29","79.5","","199.90","134.11","199.90","36","20.81","248.9","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","both","","","262.00","196.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","139.65","53.3","","134.11","134.11","402.33","24","20.81","248.9","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","both","","","262.00","196.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","81.22","31","","78.49","78.49","78.49","1 through 10","20.81","248.9","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","both","","","262.00","196.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","95.63","36.5","","94.74","80.52","241.56","79","20.81","248.9","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","both","","","262.00","196.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","100.35","38.3","","99.31","99.31","289.56","172","20.81","248.9","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","both","","","262.00","196.50","MOLINA [1014]","HB BWH MOLINA","91.70","35","","41.62","41.62","41.62","1 through 10","20.81","248.9","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","both","","","262.00","196.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.40","42.9","","203.05","203.05","203.05","1 through 10","20.81","248.9","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","both","","","262.00","196.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.40","42.9","","203.05","203.05","203.05","1 through 10","20.81","248.9","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","262.00","196.50","AETNA [1001]","HB AMC AETNA HMO","182.88","69.8","","171.96","121.41","171.96","58","21.89","214.11","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","262.00","196.50","AETNA [1001]","HB AMC AETNA PPO","210.65","80.4","","198.12","198.12","396.24","1 through 10","21.89","214.11","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","262.00","196.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","210.65","80.4","","127.00","127.00","127.00","1 through 10","21.89","214.11","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","262.00","196.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","214.11","81.72","","111.68","111.68","111.68","1 through 10","21.89","214.11","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","262.00","196.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","214.11","81.72","","203.05","111.68","203.05","48","21.89","214.11","percent of total billed charges",""
"Vitamin B12 Injection","PX-63601030","CDM","J3420","HCPCS","0636","RC","","","","both","","","2.00","1.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","0.73","36.5","","1.35","1.20","1.42","27","0.62","3.25","percent of total billed charges",""
"Vitamin B12 Injection","PX-63601030","CDM","J3420","HCPCS","0636","RC","","","","both","","","2.00","1.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","0.77","38.3","","1.47","1.41","4.41","77","0.62","3.25","percent of total billed charges",""
"Vitamin B12 Injection","PX-63601030","CDM","J3420","HCPCS","0636","RC","","","","outpatient","","","2.00","1.50","AETNA [1001]","HB AMC AETNA HMO","1.40","69.8","","2.44","1.80","2.55","1 through 10","0.01","2.04","percent of total billed charges",""
"Vitamin B12 Injection","PX-63601030","CDM","J3420","HCPCS","0636","RC","","","","outpatient","","","2.00","1.50","AETNA [1001]","HB AMC AETNA PPO","1.61","80.4","","2.00","2.00","2.00","1 through 10","0.01","2.04","percent of total billed charges",""
"Vitamin B12 Injection","PX-63601030","CDM","J3420","HCPCS","0636","RC","","","","outpatient","","","2.00","1.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1.40","69.9","","2.61","1.67","2.99","1 through 10","0.01","2.04","percent of total billed charges",""
"Vitamin B12 Injection","PX-63601030","CDM","J3420","HCPCS","0636","RC","","","","outpatient","","","2.00","1.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","0.94","46.9","","2.61","1.67","7.83","1 through 10","0.01","2.04","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","both","","","146.00","109.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","116.07","79.5","","111.75","74.98","111.75","1 through 10","9.69","138.7","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","both","","","146.00","109.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","77.82","53.3","","74.98","74.98","74.98","1 through 10","9.69","138.7","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.29","36.5","","52.97","45.01","52.97","1 through 10","9.69","138.7","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","55.92","38.3","","55.52","55.52","55.52","1 through 10","9.69","138.7","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","both","","","146.00","109.50","TRICARE [160005]","HB BWH TRICARE","138.70","95","","11.32","11.32","11.32","1 through 10","9.69","138.7","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA HMO","101.91","69.8","","96.13","67.88","110.76","1 through 10","10.19","119.31","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","outpatient","","","146.00","109.50","AETNA [1001]","HB AMC AETNA PPO","117.38","80.4","","74.41","74.41","74.41","1 through 10","10.19","119.31","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","outpatient","","","146.00","109.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","117.38","80.4","","110.76","110.76","110.76","1 through 10","10.19","119.31","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","119.31","81.72","","113.52","62.44","113.52","1 through 10","10.19","119.31","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","255.61","71.8","","247.71","26.10","743.13","15","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","231.40","65","","224.25","182.16","224.25","1 through 10","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","249.20","70","","248.40","96.24","345.00","13","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","CHAMPVA [160001]","HB BWH TRICARE","338.20","95","","35.67","35.67","35.67","1 through 10","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","283.02","79.5","","271.52","182.16","351.36","460","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","189.75","53.3","","182.16","182.16","546.48","276","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","274.12","77","","265.65","265.65","265.65","1 through 10","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","231.40","65","","224.25","104.65","302.90","11","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","283.02","79.5","","46.00","46.00","46.00","1 through 10","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","110.36","31","","106.61","106.61","319.83","17","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","129.94","36.5","","128.69","109.37","386.07","490","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","136.35","38.3","","134.90","134.90","404.70","1638","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","MOLINA [1014]","HB BWH MOLINA","124.60","35","","58.73","58.02","59.20","1 through 10","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","274.12","77","","269.10","41.44","351.36","1 through 10","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","TRICARE [160005]","HB BWH TRICARE","338.20","95","","35.67","33.89","345.00","29","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","152.72","42.9","","156.98","151.70","275.80","30","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","356.00","267.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","152.72","42.9","","151.70","151.70","275.79","1 through 10","29.01","338.2","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","356.00","267.00","AETNA [1001]","HB AMC AETNA HMO","248.49","69.8","","233.57","164.91","269.10","698","30.54","290.92","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","356.00","267.00","AETNA [1001]","HB AMC AETNA PPO","286.22","80.4","","269.10","180.78","361.56","71","30.54","290.92","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","356.00","267.00","AETNA [1001]","HB AMC AETNA STUDENT HEALTH","199.00","55.9","","180.78","180.78","180.78","1 through 10","30.54","290.92","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","356.00","267.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","186.05","52.26","","213.49","104.15","345.00","19","30.54","290.92","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","356.00","267.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","286.22","80.4","","269.10","172.50","269.10","14","30.54","290.92","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","356.00","267.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC UNITED PPO / POS","290.92","81.72","","275.79","275.79","358.87","1 through 10","30.54","290.92","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","356.00","267.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","290.92","81.72","","151.70","151.70","275.79","20","30.54","290.92","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","356.00","267.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","290.92","81.72","","275.79","151.70","275.79","534","30.54","290.92","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","both","","","188.00","141.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","149.46","79.5","","429.69","96.10","429.69","1 through 10","13.9","178.6","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","both","","","188.00","141.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","100.20","53.3","","275.73","96.10","275.73","1 through 10","13.9","178.6","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","68.62","36.5","","67.89","57.69","67.89","1 through 10","13.9","178.6","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","both","","","188.00","141.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","72.00","38.3","","71.16","71.16","71.16","20","13.9","178.6","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","both","","","188.00","141.00","MOLINA [1014]","HB BWH MOLINA","65.80","35","","28.13","28.13","28.13","1 through 10","13.9","178.6","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","both","","","188.00","141.00","TRICARE [160005]","HB BWH TRICARE","178.60","95","","16.24","16.24","16.24","1 through 10","13.9","178.6","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","both","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.65","42.9","","145.49","145.49","145.49","1 through 10","13.9","178.6","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA HMO","131.22","69.8","","123.21","87.00","246.42","16","14.61","153.63","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","outpatient","","","188.00","141.00","AETNA [1001]","HB AMC AETNA PPO","151.15","80.4","","141.96","141.96","141.96","1 through 10","14.61","153.63","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","outpatient","","","188.00","141.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","151.15","80.4","","141.96","141.96","141.96","1 through 10","14.61","153.63","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","outpatient","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","153.63","81.72","","145.49","145.49","145.49","12","14.61","153.63","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","both","","","223.00","167.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","177.29","79.5","","169.99","169.99","169.99","1 through 10","13.45","211.85","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","both","","","223.00","167.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","118.86","53.3","","169.99","169.99","169.99","1 through 10","13.45","211.85","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","both","","","223.00","167.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","81.40","36.5","","80.57","80.57","80.57","1 through 10","13.45","211.85","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","both","","","223.00","167.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","85.41","38.3","","84.46","84.46","84.46","12","13.45","211.85","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","both","","","223.00","167.25","TRICARE [160005]","HB BWH TRICARE","211.85","95","","15.70","15.70","15.70","1 through 10","13.45","211.85","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","outpatient","","","223.00","167.25","AETNA [1001]","HB AMC AETNA HMO","155.65","69.8","","146.23","103.25","146.23","1 through 10","14.14","182.24","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","outpatient","","","223.00","167.25","AETNA [1001]","HB AMC AETNA PPO","179.29","80.4","","113.18","113.18","113.18","1 through 10","14.14","182.24","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","outpatient","","","223.00","167.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","182.24","81.72","","172.67","94.98","172.67","1 through 10","14.14","182.24","percent of total billed charges",""
"Vitamin Other","PX-30000735","CDM","84591","CPT","0301","RC","","","","both","","","139.00","104.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.51","79.5","","106.25","106.25","106.25","1 through 10","11.97","132.05","percent of total billed charges",""
"Vitamin Other","PX-30000735","CDM","84591","CPT","0301","RC","","","","both","","","139.00","104.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.74","36.5","","50.36","50.36","50.36","1 through 10","11.97","132.05","percent of total billed charges",""
"Voiding Press Study Intra-Abdominal Void","PX-98301690","CDM","51797","CPT","0983","RC","","","","both","","","290.00","217.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","230.55","79.5","","772.83","772.83","772.83","1 through 10","89.9","230.55","percent of total billed charges",""
"Voiding Press Study Intra-Abdominal Void","PX-98301690","CDM","51797","CPT","0983","RC","","","","both","","","290.00","217.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","154.57","53.3","","772.83","518.50","772.83","1 through 10","89.9","230.55","percent of total billed charges",""
"Voiding Press Study Intra-Abdominal Void","PX-98301690","CDM","51797","CPT","0983","RC","","","","both","","","290.00","217.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","188.50","65","","638.30","520.46","638.30","1 through 10","89.9","230.55","percent of total billed charges",""
"Voiding Press Study Intra-Abdominal Void","PX-98301690","CDM","51797","CPT","0983","RC","","","","both","","","290.00","217.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","105.85","36.5","","366.29","311.29","366.29","1 through 10","89.9","230.55","percent of total billed charges",""
"Voiding Press Study Intra-Abdominal Void","PX-98301690","CDM","51797","CPT","0983","RC","","","","both","","","290.00","217.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","111.07","38.3","","383.96","383.96","1151.88","1 through 10","89.9","230.55","percent of total billed charges",""
"Voiding Press Study Intra-Abdominal Void","PX-98301690","CDM","51797","CPT","0983","RC","","","","both","","","290.00","217.50","WELLPOINT [1015]","HB AMC WELLPOINT","213.96","73.78","","731.10","731.10","731.10","1 through 10","89.9","230.55","percent of total billed charges",""
"Voiding Press Study Intra-Abdominal Void","PX-98301690","CDM","51797","CPT","0983","RC","","","","outpatient","","","290.00","217.50","AETNA [1001]","HB AMC AETNA HMO","202.42","69.8","","704.49","704.49","704.49","1 through 10","162.11","236.99","percent of total billed charges",""
"Voiding Press Study Intra-Abdominal Void","PX-98301690","CDM","51797","CPT","0983","RC","","","","outpatient","","","290.00","217.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","233.16","80.4","","765.96","491.00","765.96","1 through 10","162.11","236.99","percent of total billed charges",""
"Voiding Press Study Intra-Abdominal Void","PX-98301690","CDM","51797","CPT","0983","RC","","","","outpatient","","","290.00","217.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","236.99","81.72","","785.01","785.01","785.01","1 through 10","162.11","236.99","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","both","","","219.00","164.25","WELLPOINT [1015]","HB AMC WELLPOINT","161.58","73.78","","157.83","157.83","212.00","1 through 10","11.81","208.05","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","outpatient","","","219.00","164.25","AETNA [1001]","HB AMC AETNA HMO","152.86","69.8","","165.36","165.36","165.36","1 through 10","53.91","180.68","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","outpatient","","","219.00","164.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","114.45","52.26","","46.42","46.42","46.42","1 through 10","53.91","180.68","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","outpatient","","","219.00","164.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","109.50","50","","111.09","106.64","111.09","1 through 10","53.91","180.68","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","outpatient","","","219.00","164.25","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","114.98","52.5","","116.60","116.60","116.60","1 through 10","53.91","180.68","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","outpatient","","","219.00","164.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO PREFERRED B","120.45","55","","117.45","117.45","117.45","1 through 10","53.91","180.68","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","outpatient","","","219.00","164.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","178.97","81.72","","169.47","169.47","169.47","1 through 10","53.91","180.68","percent of total billed charges",""
"WASHER BONE 18X10MM HUMERAL T2 SQUARE TITANIUM","SUP-ITM-10033745","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.26","730.69","CIGNA [1006]","HB AMC CIGNA HMO / PPO","774.54","79.5","","800.18","480.96","1887.97","195","302.02","774.54","percent of total billed charges",""
"WASHER BONE 18X10MM HUMERAL T2 SQUARE TITANIUM","SUP-ITM-10033745","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.26","730.69","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","519.28","53.3","","813.12","216.42","1444.50","81","302.02","774.54","percent of total billed charges",""
"WASHER BONE 18X10MM HUMERAL T2 SQUARE TITANIUM","SUP-ITM-10033745","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.26","730.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","302.02","31","","432.60","432.60","432.60","1 through 10","302.02","774.54","percent of total billed charges",""
"WASHER BONE 18X10MM HUMERAL T2 SQUARE TITANIUM","SUP-ITM-10033745","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.26","730.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","355.60","36.5","","148.37","54.89","631.39","94","302.02","774.54","percent of total billed charges",""
"WASHER BONE 18X10MM HUMERAL T2 SQUARE TITANIUM","SUP-ITM-10033745","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.26","730.69","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","373.14","38.3","","279.30","91.72","1116.77","266","302.02","774.54","percent of total billed charges",""
"WASHER BONE 18X10MM HUMERAL T2 SQUARE TITANIUM","SUP-ITM-10033745","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.26","730.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","417.96","42.9","","731.00","63.70","731.00","1 through 10","302.02","774.54","percent of total billed charges",""
"WASHER BONE 18X10MM HUMERAL T2 SQUARE TITANIUM","SUP-ITM-10033745","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.26","730.69","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","417.96","42.9","","384.74","384.74","384.74","1 through 10","302.02","774.54","percent of total billed charges",""
"WASHER BONE 18X10MM HUMERAL T2 SQUARE TITANIUM","SUP-ITM-10033745","CDM","C1713","HCPCS","0278","RC","","","","both","","","974.26","730.69","WELLPOINT [1015]","HB AMC WELLPOINT","718.81","73.78","","286.63","119.22","1107.45","105","302.02","774.54","percent of total billed charges",""
"WASHER BONE 18X10MM HUMERAL T2 SQUARE TITANIUM","SUP-ITM-10033745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","974.26","730.69","AETNA [1001]","HB AMC AETNA HMO","680.03","69.8","","675.31","184.75","1721.50","286","509.15","796.17","percent of total billed charges",""
"WASHER BONE 18X10MM HUMERAL T2 SQUARE TITANIUM","SUP-ITM-10033745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","974.26","730.69","AETNA [1001]","HB AMC AETNA PPO","783.31","80.4","","1261.44","103.12","1514.10","21","509.15","796.17","percent of total billed charges",""
"WASHER BONE 18X10MM HUMERAL T2 SQUARE TITANIUM","SUP-ITM-10033745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","974.26","730.69","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","783.31","80.4","","1365.00","1365.00","1365.00","1 through 10","509.15","796.17","percent of total billed charges",""
"WASHER BONE 18X10MM HUMERAL T2 SQUARE TITANIUM","SUP-ITM-10033745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","974.26","730.69","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","796.17","81.72","","5157.68","5157.68","5157.68","1 through 10","509.15","796.17","percent of total billed charges",""
"WASHER BONE 18X10MM HUMERAL T2 SQUARE TITANIUM","SUP-ITM-10033745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","974.26","730.69","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","796.17","81.72","","431.26","71.26","1459.57","88","509.15","796.17","percent of total billed charges",""
"WASHER BONE 3.5X4.5MM STAINLESS STEEL","SUP-ITM-10005740","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","CIGNA [1006]","HB AMC CIGNA HMO / PPO","117.37","79.5","","800.18","480.96","1887.97","195","45.77","117.37","percent of total billed charges",""
"WASHER BONE 3.5X4.5MM STAINLESS STEEL","SUP-ITM-10005740","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","78.69","53.3","","813.12","216.42","1444.50","81","45.77","117.37","percent of total billed charges",""
"WASHER BONE 3.5X4.5MM STAINLESS STEEL","SUP-ITM-10005740","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","45.77","31","","432.60","432.60","432.60","1 through 10","45.77","117.37","percent of total billed charges",""
"WASHER BONE 3.5X4.5MM STAINLESS STEEL","SUP-ITM-10005740","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","53.88","36.5","","148.37","54.89","631.39","94","45.77","117.37","percent of total billed charges",""
"WASHER BONE 3.5X4.5MM STAINLESS STEEL","SUP-ITM-10005740","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","56.54","38.3","","279.30","91.72","1116.77","266","45.77","117.37","percent of total billed charges",""
"WASHER BONE 3.5X4.5MM STAINLESS STEEL","SUP-ITM-10005740","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.33","42.9","","731.00","63.70","731.00","1 through 10","45.77","117.37","percent of total billed charges",""
"WASHER BONE 3.5X4.5MM STAINLESS STEEL","SUP-ITM-10005740","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.33","42.9","","384.74","384.74","384.74","1 through 10","45.77","117.37","percent of total billed charges",""
"WASHER BONE 3.5X4.5MM STAINLESS STEEL","SUP-ITM-10005740","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","WELLPOINT [1015]","HB AMC WELLPOINT","108.92","73.78","","286.63","119.22","1107.45","105","45.77","117.37","percent of total billed charges",""
"WASHER BONE 3.5X4.5MM STAINLESS STEEL","SUP-ITM-10005740","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","AETNA [1001]","HB AMC AETNA HMO","103.05","69.8","","675.31","184.75","1721.50","286","77.15","120.64","percent of total billed charges",""
"WASHER BONE 3.5X4.5MM STAINLESS STEEL","SUP-ITM-10005740","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","AETNA [1001]","HB AMC AETNA PPO","118.69","80.4","","1261.44","103.12","1514.10","21","77.15","120.64","percent of total billed charges",""
"WASHER BONE 3.5X4.5MM STAINLESS STEEL","SUP-ITM-10005740","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","118.69","80.4","","1365.00","1365.00","1365.00","1 through 10","77.15","120.64","percent of total billed charges",""
"WASHER BONE 3.5X4.5MM STAINLESS STEEL","SUP-ITM-10005740","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","120.64","81.72","","5157.68","5157.68","5157.68","1 through 10","77.15","120.64","percent of total billed charges",""
"WASHER BONE 3.5X4.5MM STAINLESS STEEL","SUP-ITM-10005740","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","120.64","81.72","","431.26","71.26","1459.57","88","77.15","120.64","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","308.00","231.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","244.86","79.5","","800.18","480.96","1887.97","195","95.48","244.86","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","308.00","231.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","164.16","53.3","","813.12","216.42","1444.50","81","95.48","244.86","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","308.00","231.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","95.48","31","","432.60","432.60","432.60","1 through 10","95.48","244.86","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","308.00","231.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","112.42","36.5","","148.37","54.89","631.39","94","95.48","244.86","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","308.00","231.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","117.96","38.3","","279.30","91.72","1116.77","266","95.48","244.86","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","308.00","231.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.13","42.9","","731.00","63.70","731.00","1 through 10","95.48","244.86","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","308.00","231.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.13","42.9","","384.74","384.74","384.74","1 through 10","95.48","244.86","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","308.00","231.00","WELLPOINT [1015]","HB AMC WELLPOINT","227.24","73.78","","286.63","119.22","1107.45","105","95.48","244.86","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","308.00","231.00","AETNA [1001]","HB AMC AETNA HMO","214.98","69.8","","675.31","184.75","1721.50","286","160.96","251.7","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","308.00","231.00","AETNA [1001]","HB AMC AETNA PPO","247.63","80.4","","1261.44","103.12","1514.10","21","160.96","251.7","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","308.00","231.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","247.63","80.4","","1365.00","1365.00","1365.00","1 through 10","160.96","251.7","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","308.00","231.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","251.70","81.72","","5157.68","5157.68","5157.68","1 through 10","160.96","251.7","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","308.00","231.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","251.70","81.72","","431.26","71.26","1459.57","88","160.96","251.7","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.23","53.42","CIGNA [1006]","HB AMC CIGNA HMO / PPO","56.63","79.5","","800.18","480.96","1887.97","195","22.08","56.63","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.23","53.42","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","37.97","53.3","","813.12","216.42","1444.50","81","22.08","56.63","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.23","53.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","22.08","31","","432.60","432.60","432.60","1 through 10","22.08","56.63","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.23","53.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.00","36.5","","148.37","54.89","631.39","94","22.08","56.63","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.23","53.42","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27.28","38.3","","279.30","91.72","1116.77","266","22.08","56.63","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.23","53.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.56","42.9","","731.00","63.70","731.00","1 through 10","22.08","56.63","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.23","53.42","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.56","42.9","","384.74","384.74","384.74","1 through 10","22.08","56.63","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.23","53.42","WELLPOINT [1015]","HB AMC WELLPOINT","52.55","73.78","","286.63","119.22","1107.45","105","22.08","56.63","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","71.23","53.42","AETNA [1001]","HB AMC AETNA HMO","49.72","69.8","","675.31","184.75","1721.50","286","37.22","58.21","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","71.23","53.42","AETNA [1001]","HB AMC AETNA PPO","57.27","80.4","","1261.44","103.12","1514.10","21","37.22","58.21","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","71.23","53.42","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","57.27","80.4","","1365.00","1365.00","1365.00","1 through 10","37.22","58.21","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","71.23","53.42","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","58.21","81.72","","5157.68","5157.68","5157.68","1 through 10","37.22","58.21","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","71.23","53.42","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","58.21","81.72","","431.26","71.26","1459.57","88","37.22","58.21","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","60.75","79.5","","800.18","480.96","1887.97","195","23.69","60.75","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","40.73","53.3","","813.12","216.42","1444.50","81","23.69","60.75","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","23.69","31","","432.60","432.60","432.60","1 through 10","23.69","60.75","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","27.89","36.5","","148.37","54.89","631.39","94","23.69","60.75","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","29.27","38.3","","279.30","91.72","1116.77","266","23.69","60.75","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.78","42.9","","731.00","63.70","731.00","1 through 10","23.69","60.75","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.78","42.9","","384.74","384.74","384.74","1 through 10","23.69","60.75","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","76.41","57.31","WELLPOINT [1015]","HB AMC WELLPOINT","56.38","73.78","","286.63","119.22","1107.45","105","23.69","60.75","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","76.41","57.31","AETNA [1001]","HB AMC AETNA HMO","53.33","69.8","","675.31","184.75","1721.50","286","39.93","62.44","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","76.41","57.31","AETNA [1001]","HB AMC AETNA PPO","61.43","80.4","","1261.44","103.12","1514.10","21","39.93","62.44","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","76.41","57.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","61.43","80.4","","1365.00","1365.00","1365.00","1 through 10","39.93","62.44","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","76.41","57.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","62.44","81.72","","5157.68","5157.68","5157.68","1 through 10","39.93","62.44","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","76.41","57.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","62.44","81.72","","431.26","71.26","1459.57","88","39.93","62.44","percent of total billed charges",""
"WASHER BONE 7MM SELF TAPPING FASTENER","SUP-ITM-10241200","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.50","55.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","58.43","79.5","","800.18","480.96","1887.97","195","22.79","58.43","percent of total billed charges",""
"WASHER BONE 7MM SELF TAPPING FASTENER","SUP-ITM-10241200","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.50","55.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","39.18","53.3","","813.12","216.42","1444.50","81","22.79","58.43","percent of total billed charges",""
"WASHER BONE 7MM SELF TAPPING FASTENER","SUP-ITM-10241200","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.50","55.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","22.79","31","","432.60","432.60","432.60","1 through 10","22.79","58.43","percent of total billed charges",""
"WASHER BONE 7MM SELF TAPPING FASTENER","SUP-ITM-10241200","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.50","55.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.83","36.5","","148.37","54.89","631.39","94","22.79","58.43","percent of total billed charges",""
"WASHER BONE 7MM SELF TAPPING FASTENER","SUP-ITM-10241200","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.50","55.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","28.15","38.3","","279.30","91.72","1116.77","266","22.79","58.43","percent of total billed charges",""
"WASHER BONE 7MM SELF TAPPING FASTENER","SUP-ITM-10241200","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.50","55.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.53","42.9","","731.00","63.70","731.00","1 through 10","22.79","58.43","percent of total billed charges",""
"WASHER BONE 7MM SELF TAPPING FASTENER","SUP-ITM-10241200","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.50","55.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.53","42.9","","384.74","384.74","384.74","1 through 10","22.79","58.43","percent of total billed charges",""
"WASHER BONE 7MM SELF TAPPING FASTENER","SUP-ITM-10241200","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.50","55.12","WELLPOINT [1015]","HB AMC WELLPOINT","54.23","73.78","","286.63","119.22","1107.45","105","22.79","58.43","percent of total billed charges",""
"WASHER BONE 7MM SELF TAPPING FASTENER","SUP-ITM-10241200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.50","55.12","AETNA [1001]","HB AMC AETNA HMO","51.30","69.8","","675.31","184.75","1721.50","286","38.41","60.06","percent of total billed charges",""
"WASHER BONE 7MM SELF TAPPING FASTENER","SUP-ITM-10241200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.50","55.12","AETNA [1001]","HB AMC AETNA PPO","59.09","80.4","","1261.44","103.12","1514.10","21","38.41","60.06","percent of total billed charges",""
"WASHER BONE 7MM SELF TAPPING FASTENER","SUP-ITM-10241200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.50","55.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","59.09","80.4","","1365.00","1365.00","1365.00","1 through 10","38.41","60.06","percent of total billed charges",""
"WASHER BONE 7MM SELF TAPPING FASTENER","SUP-ITM-10241200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.50","55.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","60.06","81.72","","5157.68","5157.68","5157.68","1 through 10","38.41","60.06","percent of total billed charges",""
"WASHER BONE 7MM SELF TAPPING FASTENER","SUP-ITM-10241200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.50","55.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","60.06","81.72","","431.26","71.26","1459.57","88","38.41","60.06","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.46","47.59","CIGNA [1006]","HB AMC CIGNA HMO / PPO","50.45","79.5","","800.18","480.96","1887.97","195","19.67","50.45","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.46","47.59","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","33.82","53.3","","813.12","216.42","1444.50","81","19.67","50.45","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.46","47.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","19.67","31","","432.60","432.60","432.60","1 through 10","19.67","50.45","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.46","47.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","23.16","36.5","","148.37","54.89","631.39","94","19.67","50.45","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.46","47.59","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","24.31","38.3","","279.30","91.72","1116.77","266","19.67","50.45","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.46","47.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.22","42.9","","731.00","63.70","731.00","1 through 10","19.67","50.45","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.46","47.59","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.22","42.9","","384.74","384.74","384.74","1 through 10","19.67","50.45","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.46","47.59","WELLPOINT [1015]","HB AMC WELLPOINT","46.82","73.78","","286.63","119.22","1107.45","105","19.67","50.45","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.46","47.59","AETNA [1001]","HB AMC AETNA HMO","44.30","69.8","","675.31","184.75","1721.50","286","33.16","51.86","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.46","47.59","AETNA [1001]","HB AMC AETNA PPO","51.02","80.4","","1261.44","103.12","1514.10","21","33.16","51.86","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.46","47.59","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","51.02","80.4","","1365.00","1365.00","1365.00","1 through 10","33.16","51.86","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.46","47.59","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","51.86","81.72","","5157.68","5157.68","5157.68","1 through 10","33.16","51.86","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.46","47.59","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","51.86","81.72","","431.26","71.26","1459.57","88","33.16","51.86","percent of total billed charges",""
"WASHER FOOT 4MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082980","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","411.81","79.5","","800.18","480.96","1887.97","195","160.58","411.81","percent of total billed charges",""
"WASHER FOOT 4MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082980","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","276.09","53.3","","813.12","216.42","1444.50","81","160.58","411.81","percent of total billed charges",""
"WASHER FOOT 4MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082980","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","160.58","31","","432.60","432.60","432.60","1 through 10","160.58","411.81","percent of total billed charges",""
"WASHER FOOT 4MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082980","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","189.07","36.5","","148.37","54.89","631.39","94","160.58","411.81","percent of total billed charges",""
"WASHER FOOT 4MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082980","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","198.39","38.3","","279.30","91.72","1116.77","266","160.58","411.81","percent of total billed charges",""
"WASHER FOOT 4MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082980","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.22","42.9","","731.00","63.70","731.00","1 through 10","160.58","411.81","percent of total billed charges",""
"WASHER FOOT 4MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082980","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.22","42.9","","384.74","384.74","384.74","1 through 10","160.58","411.81","percent of total billed charges",""
"WASHER FOOT 4MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082980","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.00","388.50","WELLPOINT [1015]","HB AMC WELLPOINT","382.18","73.78","","286.63","119.22","1107.45","105","160.58","411.81","percent of total billed charges",""
"WASHER FOOT 4MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","AETNA [1001]","HB AMC AETNA HMO","361.56","69.8","","675.31","184.75","1721.50","286","270.71","423.31","percent of total billed charges",""
"WASHER FOOT 4MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","AETNA [1001]","HB AMC AETNA PPO","416.47","80.4","","1261.44","103.12","1514.10","21","270.71","423.31","percent of total billed charges",""
"WASHER FOOT 4MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","416.47","80.4","","1365.00","1365.00","1365.00","1 through 10","270.71","423.31","percent of total billed charges",""
"WASHER FOOT 4MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","423.31","81.72","","5157.68","5157.68","5157.68","1 through 10","270.71","423.31","percent of total billed charges",""
"WASHER FOOT 4MM ANKLE MAXTORQUE DOMED","SUP-ITM-10082980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.00","388.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","423.31","81.72","","431.26","71.26","1459.57","88","270.71","423.31","percent of total billed charges",""
"WASHER LOCKING 5DEG LEFT S ATTACH NAIL FEMORAL RETROGRADE","SUP-ITM-10296659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2392.95","79.5","","800.18","480.96","1887.97","195","933.1","2392.95","percent of total billed charges",""
"WASHER LOCKING 5DEG LEFT S ATTACH NAIL FEMORAL RETROGRADE","SUP-ITM-10296659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1604.33","53.3","","813.12","216.42","1444.50","81","933.1","2392.95","percent of total billed charges",""
"WASHER LOCKING 5DEG LEFT S ATTACH NAIL FEMORAL RETROGRADE","SUP-ITM-10296659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","933.10","31","","432.60","432.60","432.60","1 through 10","933.1","2392.95","percent of total billed charges",""
"WASHER LOCKING 5DEG LEFT S ATTACH NAIL FEMORAL RETROGRADE","SUP-ITM-10296659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1098.65","36.5","","148.37","54.89","631.39","94","933.1","2392.95","percent of total billed charges",""
"WASHER LOCKING 5DEG LEFT S ATTACH NAIL FEMORAL RETROGRADE","SUP-ITM-10296659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1152.83","38.3","","279.30","91.72","1116.77","266","933.1","2392.95","percent of total billed charges",""
"WASHER LOCKING 5DEG LEFT S ATTACH NAIL FEMORAL RETROGRADE","SUP-ITM-10296659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1291.29","42.9","","731.00","63.70","731.00","1 through 10","933.1","2392.95","percent of total billed charges",""
"WASHER LOCKING 5DEG LEFT S ATTACH NAIL FEMORAL RETROGRADE","SUP-ITM-10296659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1291.29","42.9","","384.74","384.74","384.74","1 through 10","933.1","2392.95","percent of total billed charges",""
"WASHER LOCKING 5DEG LEFT S ATTACH NAIL FEMORAL RETROGRADE","SUP-ITM-10296659","CDM","C1713","HCPCS","0278","RC","","","","both","","","3010.00","2257.50","WELLPOINT [1015]","HB AMC WELLPOINT","2220.78","73.78","","286.63","119.22","1107.45","105","933.1","2392.95","percent of total billed charges",""
"WASHER LOCKING 5DEG LEFT S ATTACH NAIL FEMORAL RETROGRADE","SUP-ITM-10296659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","AETNA [1001]","HB AMC AETNA HMO","2100.98","69.8","","675.31","184.75","1721.50","286","1573.03","2459.77","percent of total billed charges",""
"WASHER LOCKING 5DEG LEFT S ATTACH NAIL FEMORAL RETROGRADE","SUP-ITM-10296659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","AETNA [1001]","HB AMC AETNA PPO","2420.04","80.4","","1261.44","103.12","1514.10","21","1573.03","2459.77","percent of total billed charges",""
"WASHER LOCKING 5DEG LEFT S ATTACH NAIL FEMORAL RETROGRADE","SUP-ITM-10296659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2420.04","80.4","","1365.00","1365.00","1365.00","1 through 10","1573.03","2459.77","percent of total billed charges",""
"WASHER LOCKING 5DEG LEFT S ATTACH NAIL FEMORAL RETROGRADE","SUP-ITM-10296659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2459.77","81.72","","5157.68","5157.68","5157.68","1 through 10","1573.03","2459.77","percent of total billed charges",""
"WASHER LOCKING 5DEG LEFT S ATTACH NAIL FEMORAL RETROGRADE","SUP-ITM-10296659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3010.00","2257.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2459.77","81.72","","431.26","71.26","1459.57","88","1573.03","2459.77","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","169.79","79.5","","800.18","480.96","1887.97","195","66.21","169.79","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","113.83","53.3","","813.12","216.42","1444.50","81","66.21","169.79","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","66.21","31","","432.60","432.60","432.60","1 through 10","66.21","169.79","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.95","36.5","","148.37","54.89","631.39","94","66.21","169.79","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.80","38.3","","279.30","91.72","1116.77","266","66.21","169.79","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.62","42.9","","731.00","63.70","731.00","1 through 10","66.21","169.79","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.62","42.9","","384.74","384.74","384.74","1 through 10","66.21","169.79","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","WELLPOINT [1015]","HB AMC WELLPOINT","157.57","73.78","","286.63","119.22","1107.45","105","66.21","169.79","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","AETNA [1001]","HB AMC AETNA HMO","149.07","69.8","","675.31","184.75","1721.50","286","111.61","174.53","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","AETNA [1001]","HB AMC AETNA PPO","171.71","80.4","","1261.44","103.12","1514.10","21","111.61","174.53","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","171.71","80.4","","1365.00","1365.00","1365.00","1 through 10","111.61","174.53","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","174.53","81.72","","5157.68","5157.68","5157.68","1 through 10","111.61","174.53","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.53","81.72","","431.26","71.26","1459.57","88","111.61","174.53","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.74","226.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","239.88","79.5","","800.18","480.96","1887.97","195","93.54","239.88","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.74","226.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","160.83","53.3","","813.12","216.42","1444.50","81","93.54","239.88","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.74","226.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","93.54","31","","432.60","432.60","432.60","1 through 10","93.54","239.88","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.74","226.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","110.14","36.5","","148.37","54.89","631.39","94","93.54","239.88","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.74","226.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","115.57","38.3","","279.30","91.72","1116.77","266","93.54","239.88","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.74","226.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.45","42.9","","731.00","63.70","731.00","1 through 10","93.54","239.88","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.74","226.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.45","42.9","","384.74","384.74","384.74","1 through 10","93.54","239.88","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","both","","","301.74","226.30","WELLPOINT [1015]","HB AMC WELLPOINT","222.62","73.78","","286.63","119.22","1107.45","105","93.54","239.88","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.74","226.30","AETNA [1001]","HB AMC AETNA HMO","210.61","69.8","","675.31","184.75","1721.50","286","157.69","246.58","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.74","226.30","AETNA [1001]","HB AMC AETNA PPO","242.60","80.4","","1261.44","103.12","1514.10","21","157.69","246.58","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.74","226.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","242.60","80.4","","1365.00","1365.00","1365.00","1 through 10","157.69","246.58","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.74","226.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","246.58","81.72","","5157.68","5157.68","5157.68","1 through 10","157.69","246.58","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","301.74","226.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","246.58","81.72","","431.26","71.26","1459.57","88","157.69","246.58","percent of total billed charges",""
"WASHER SCREW 2.3MM BONE","SUP-ITM-10307528","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","CIGNA [1006]","HB AMC CIGNA HMO / PPO","169.79","79.5","","800.18","480.96","1887.97","195","66.21","169.79","percent of total billed charges",""
"WASHER SCREW 2.3MM BONE","SUP-ITM-10307528","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","113.83","53.3","","813.12","216.42","1444.50","81","66.21","169.79","percent of total billed charges",""
"WASHER SCREW 2.3MM BONE","SUP-ITM-10307528","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","66.21","31","","432.60","432.60","432.60","1 through 10","66.21","169.79","percent of total billed charges",""
"WASHER SCREW 2.3MM BONE","SUP-ITM-10307528","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","77.95","36.5","","148.37","54.89","631.39","94","66.21","169.79","percent of total billed charges",""
"WASHER SCREW 2.3MM BONE","SUP-ITM-10307528","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","81.80","38.3","","279.30","91.72","1116.77","266","66.21","169.79","percent of total billed charges",""
"WASHER SCREW 2.3MM BONE","SUP-ITM-10307528","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.62","42.9","","731.00","63.70","731.00","1 through 10","66.21","169.79","percent of total billed charges",""
"WASHER SCREW 2.3MM BONE","SUP-ITM-10307528","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.62","42.9","","384.74","384.74","384.74","1 through 10","66.21","169.79","percent of total billed charges",""
"WASHER SCREW 2.3MM BONE","SUP-ITM-10307528","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.57","160.18","WELLPOINT [1015]","HB AMC WELLPOINT","157.57","73.78","","286.63","119.22","1107.45","105","66.21","169.79","percent of total billed charges",""
"WASHER SCREW 2.3MM BONE","SUP-ITM-10307528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","AETNA [1001]","HB AMC AETNA HMO","149.07","69.8","","675.31","184.75","1721.50","286","111.61","174.53","percent of total billed charges",""
"WASHER SCREW 2.3MM BONE","SUP-ITM-10307528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","AETNA [1001]","HB AMC AETNA PPO","171.71","80.4","","1261.44","103.12","1514.10","21","111.61","174.53","percent of total billed charges",""
"WASHER SCREW 2.3MM BONE","SUP-ITM-10307528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","171.71","80.4","","1365.00","1365.00","1365.00","1 through 10","111.61","174.53","percent of total billed charges",""
"WASHER SCREW 2.3MM BONE","SUP-ITM-10307528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","174.53","81.72","","5157.68","5157.68","5157.68","1 through 10","111.61","174.53","percent of total billed charges",""
"WASHER SCREW 2.3MM BONE","SUP-ITM-10307528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.57","160.18","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","174.53","81.72","","431.26","71.26","1459.57","88","111.61","174.53","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","CIGNA [1006]","HB AMC CIGNA HMO / PPO","57.32","79.5","","800.18","480.96","1887.97","195","22.35","57.32","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","38.43","53.3","","813.12","216.42","1444.50","81","22.35","57.32","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","22.35","31","","432.60","432.60","432.60","1 through 10","22.35","57.32","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","26.32","36.5","","148.37","54.89","631.39","94","22.35","57.32","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","27.61","38.3","","279.30","91.72","1116.77","266","22.35","57.32","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.93","42.9","","731.00","63.70","731.00","1 through 10","22.35","57.32","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.93","42.9","","384.74","384.74","384.74","1 through 10","22.35","57.32","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.10","54.07","WELLPOINT [1015]","HB AMC WELLPOINT","53.20","73.78","","286.63","119.22","1107.45","105","22.35","57.32","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.10","54.07","AETNA [1001]","HB AMC AETNA HMO","50.33","69.8","","675.31","184.75","1721.50","286","37.68","58.92","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.10","54.07","AETNA [1001]","HB AMC AETNA PPO","57.97","80.4","","1261.44","103.12","1514.10","21","37.68","58.92","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.10","54.07","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","57.97","80.4","","1365.00","1365.00","1365.00","1 through 10","37.68","58.92","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.10","54.07","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","58.92","81.72","","5157.68","5157.68","5157.68","1 through 10","37.68","58.92","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.10","54.07","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","58.92","81.72","","431.26","71.26","1459.57","88","37.68","58.92","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.86","137.89","CIGNA [1006]","HB AMC CIGNA HMO / PPO","146.17","79.5","","800.18","480.96","1887.97","195","57","146.17","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.86","137.89","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","98.00","53.3","","813.12","216.42","1444.50","81","57","146.17","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.86","137.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","57.00","31","","432.60","432.60","432.60","1 through 10","57","146.17","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.86","137.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","67.11","36.5","","148.37","54.89","631.39","94","57","146.17","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.86","137.89","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","70.42","38.3","","279.30","91.72","1116.77","266","57","146.17","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.86","137.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.88","42.9","","731.00","63.70","731.00","1 through 10","57","146.17","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.86","137.89","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.88","42.9","","384.74","384.74","384.74","1 through 10","57","146.17","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.86","137.89","WELLPOINT [1015]","HB AMC WELLPOINT","135.65","73.78","","286.63","119.22","1107.45","105","57","146.17","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.86","137.89","AETNA [1001]","HB AMC AETNA HMO","128.33","69.8","","675.31","184.75","1721.50","286","96.09","150.25","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.86","137.89","AETNA [1001]","HB AMC AETNA PPO","147.82","80.4","","1261.44","103.12","1514.10","21","96.09","150.25","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.86","137.89","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","147.82","80.4","","1365.00","1365.00","1365.00","1 through 10","96.09","150.25","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.86","137.89","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","150.25","81.72","","5157.68","5157.68","5157.68","1 through 10","96.09","150.25","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.86","137.89","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","150.25","81.72","","431.26","71.26","1459.57","88","96.09","150.25","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","139.13","79.5","","800.18","480.96","1887.97","195","54.25","139.13","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.28","53.3","","813.12","216.42","1444.50","81","54.25","139.13","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.25","31","","432.60","432.60","432.60","1 through 10","54.25","139.13","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.88","36.5","","148.37","54.89","631.39","94","54.25","139.13","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","67.03","38.3","","279.30","91.72","1116.77","266","54.25","139.13","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","731.00","63.70","731.00","1 through 10","54.25","139.13","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.08","42.9","","384.74","384.74","384.74","1 through 10","54.25","139.13","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.00","131.25","WELLPOINT [1015]","HB AMC WELLPOINT","129.12","73.78","","286.63","119.22","1107.45","105","54.25","139.13","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA HMO","122.15","69.8","","675.31","184.75","1721.50","286","91.46","143.01","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB AMC AETNA PPO","140.70","80.4","","1261.44","103.12","1514.10","21","91.46","143.01","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","140.70","80.4","","1365.00","1365.00","1365.00","1 through 10","91.46","143.01","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","143.01","81.72","","5157.68","5157.68","5157.68","1 through 10","91.46","143.01","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","143.01","81.72","","431.26","71.26","1459.57","88","91.46","143.01","percent of total billed charges",""
"WASHER SCREW 4.0MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10134029","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.63","126.47","CIGNA [1006]","HB AMC CIGNA HMO / PPO","134.06","79.5","","800.18","480.96","1887.97","195","52.28","134.06","percent of total billed charges",""
"WASHER SCREW 4.0MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10134029","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.63","126.47","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","89.88","53.3","","813.12","216.42","1444.50","81","52.28","134.06","percent of total billed charges",""
"WASHER SCREW 4.0MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10134029","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.63","126.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","52.28","31","","432.60","432.60","432.60","1 through 10","52.28","134.06","percent of total billed charges",""
"WASHER SCREW 4.0MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10134029","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.63","126.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","61.55","36.5","","148.37","54.89","631.39","94","52.28","134.06","percent of total billed charges",""
"WASHER SCREW 4.0MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10134029","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.63","126.47","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","64.59","38.3","","279.30","91.72","1116.77","266","52.28","134.06","percent of total billed charges",""
"WASHER SCREW 4.0MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10134029","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.63","126.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.34","42.9","","731.00","63.70","731.00","1 through 10","52.28","134.06","percent of total billed charges",""
"WASHER SCREW 4.0MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10134029","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.63","126.47","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.34","42.9","","384.74","384.74","384.74","1 through 10","52.28","134.06","percent of total billed charges",""
"WASHER SCREW 4.0MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10134029","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.63","126.47","WELLPOINT [1015]","HB AMC WELLPOINT","124.42","73.78","","286.63","119.22","1107.45","105","52.28","134.06","percent of total billed charges",""
"WASHER SCREW 4.0MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10134029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.63","126.47","AETNA [1001]","HB AMC AETNA HMO","117.70","69.8","","675.31","184.75","1721.50","286","88.13","137.8","percent of total billed charges",""
"WASHER SCREW 4.0MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10134029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.63","126.47","AETNA [1001]","HB AMC AETNA PPO","135.58","80.4","","1261.44","103.12","1514.10","21","88.13","137.8","percent of total billed charges",""
"WASHER SCREW 4.0MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10134029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.63","126.47","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","135.58","80.4","","1365.00","1365.00","1365.00","1 through 10","88.13","137.8","percent of total billed charges",""
"WASHER SCREW 4.0MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10134029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.63","126.47","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","137.80","81.72","","5157.68","5157.68","5157.68","1 through 10","88.13","137.8","percent of total billed charges",""
"WASHER SCREW 4.0MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10134029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.63","126.47","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","137.80","81.72","","431.26","71.26","1459.57","88","88.13","137.8","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.82","179.86","CIGNA [1006]","HB AMC CIGNA HMO / PPO","190.66","79.5","","800.18","480.96","1887.97","195","74.34","190.66","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.82","179.86","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","127.82","53.3","","813.12","216.42","1444.50","81","74.34","190.66","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.82","179.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","74.34","31","","432.60","432.60","432.60","1 through 10","74.34","190.66","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.82","179.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","87.53","36.5","","148.37","54.89","631.39","94","74.34","190.66","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.82","179.86","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","91.85","38.3","","279.30","91.72","1116.77","266","74.34","190.66","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.82","179.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.88","42.9","","731.00","63.70","731.00","1 through 10","74.34","190.66","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.82","179.86","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.88","42.9","","384.74","384.74","384.74","1 through 10","74.34","190.66","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","both","","","239.82","179.86","WELLPOINT [1015]","HB AMC WELLPOINT","176.94","73.78","","286.63","119.22","1107.45","105","74.34","190.66","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","239.82","179.86","AETNA [1001]","HB AMC AETNA HMO","167.39","69.8","","675.31","184.75","1721.50","286","125.33","195.98","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","239.82","179.86","AETNA [1001]","HB AMC AETNA PPO","192.82","80.4","","1261.44","103.12","1514.10","21","125.33","195.98","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","239.82","179.86","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","192.82","80.4","","1365.00","1365.00","1365.00","1 through 10","125.33","195.98","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","239.82","179.86","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","195.98","81.72","","5157.68","5157.68","5157.68","1 through 10","125.33","195.98","percent of total billed charges",""
"WASHER SCREW 4.5/6.5/ 8.0MM BONE ASNIS III CANNULATED SS","SUP-ITM-10091787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","239.82","179.86","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","195.98","81.72","","431.26","71.26","1459.57","88","125.33","195.98","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.48","45.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","48.08","79.5","","800.18","480.96","1887.97","195","18.75","48.08","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.48","45.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","32.24","53.3","","813.12","216.42","1444.50","81","18.75","48.08","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.48","45.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","18.75","31","","432.60","432.60","432.60","1 through 10","18.75","48.08","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.48","45.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","22.08","36.5","","148.37","54.89","631.39","94","18.75","48.08","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.48","45.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","23.16","38.3","","279.30","91.72","1116.77","266","18.75","48.08","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.48","45.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.95","42.9","","731.00","63.70","731.00","1 through 10","18.75","48.08","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.48","45.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.95","42.9","","384.74","384.74","384.74","1 through 10","18.75","48.08","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.48","45.36","WELLPOINT [1015]","HB AMC WELLPOINT","44.62","73.78","","286.63","119.22","1107.45","105","18.75","48.08","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.48","45.36","AETNA [1001]","HB AMC AETNA HMO","42.22","69.8","","675.31","184.75","1721.50","286","31.61","49.42","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.48","45.36","AETNA [1001]","HB AMC AETNA PPO","48.63","80.4","","1261.44","103.12","1514.10","21","31.61","49.42","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.48","45.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","48.63","80.4","","1365.00","1365.00","1365.00","1 through 10","31.61","49.42","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.48","45.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","49.42","81.72","","5157.68","5157.68","5157.68","1 through 10","31.61","49.42","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.48","45.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","49.42","81.72","","431.26","71.26","1459.57","88","31.61","49.42","percent of total billed charges",""
"WASHER SCREW 4X4MM FLAT GOLD","SUP-ITM-10082979","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","272.69","79.5","","800.18","480.96","1887.97","195","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 4X4MM FLAT GOLD","SUP-ITM-10082979","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","182.82","53.3","","813.12","216.42","1444.50","81","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 4X4MM FLAT GOLD","SUP-ITM-10082979","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","106.33","31","","432.60","432.60","432.60","1 through 10","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 4X4MM FLAT GOLD","SUP-ITM-10082979","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","125.20","36.5","","148.37","54.89","631.39","94","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 4X4MM FLAT GOLD","SUP-ITM-10082979","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","131.37","38.3","","279.30","91.72","1116.77","266","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 4X4MM FLAT GOLD","SUP-ITM-10082979","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.15","42.9","","731.00","63.70","731.00","1 through 10","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 4X4MM FLAT GOLD","SUP-ITM-10082979","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.15","42.9","","384.74","384.74","384.74","1 through 10","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 4X4MM FLAT GOLD","SUP-ITM-10082979","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","WELLPOINT [1015]","HB AMC WELLPOINT","253.07","73.78","","286.63","119.22","1107.45","105","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 4X4MM FLAT GOLD","SUP-ITM-10082979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","AETNA [1001]","HB AMC AETNA HMO","239.41","69.8","","675.31","184.75","1721.50","286","179.25","280.3","percent of total billed charges",""
"WASHER SCREW 4X4MM FLAT GOLD","SUP-ITM-10082979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","AETNA [1001]","HB AMC AETNA PPO","275.77","80.4","","1261.44","103.12","1514.10","21","179.25","280.3","percent of total billed charges",""
"WASHER SCREW 4X4MM FLAT GOLD","SUP-ITM-10082979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","275.77","80.4","","1365.00","1365.00","1365.00","1 through 10","179.25","280.3","percent of total billed charges",""
"WASHER SCREW 4X4MM FLAT GOLD","SUP-ITM-10082979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","280.30","81.72","","5157.68","5157.68","5157.68","1 through 10","179.25","280.3","percent of total billed charges",""
"WASHER SCREW 4X4MM FLAT GOLD","SUP-ITM-10082979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","280.30","81.72","","431.26","71.26","1459.57","88","179.25","280.3","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","272.69","79.5","","800.18","480.96","1887.97","195","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","182.82","53.3","","813.12","216.42","1444.50","81","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","106.33","31","","432.60","432.60","432.60","1 through 10","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","125.20","36.5","","148.37","54.89","631.39","94","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","131.37","38.3","","279.30","91.72","1116.77","266","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.15","42.9","","731.00","63.70","731.00","1 through 10","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","147.15","42.9","","384.74","384.74","384.74","1 through 10","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","both","","","343.00","257.25","WELLPOINT [1015]","HB AMC WELLPOINT","253.07","73.78","","286.63","119.22","1107.45","105","106.33","272.69","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","AETNA [1001]","HB AMC AETNA HMO","239.41","69.8","","675.31","184.75","1721.50","286","179.25","280.3","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","AETNA [1001]","HB AMC AETNA PPO","275.77","80.4","","1261.44","103.12","1514.10","21","179.25","280.3","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","275.77","80.4","","1365.00","1365.00","1365.00","1 through 10","179.25","280.3","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","280.30","81.72","","5157.68","5157.68","5157.68","1 through 10","179.25","280.3","percent of total billed charges",""
"WASHER SCREW 5.5MM FLAT GREEN","SUP-ITM-10082981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","343.00","257.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","280.30","81.72","","431.26","71.26","1459.57","88","179.25","280.3","percent of total billed charges",""
"WASHER SCREW 6.5X80MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10144535","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","CIGNA [1006]","HB AMC CIGNA HMO / PPO","181.73","79.5","","800.18","480.96","1887.97","195","70.86","181.73","percent of total billed charges",""
"WASHER SCREW 6.5X80MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10144535","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","121.84","53.3","","813.12","216.42","1444.50","81","70.86","181.73","percent of total billed charges",""
"WASHER SCREW 6.5X80MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10144535","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","70.86","31","","432.60","432.60","432.60","1 through 10","70.86","181.73","percent of total billed charges",""
"WASHER SCREW 6.5X80MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10144535","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","83.44","36.5","","148.37","54.89","631.39","94","70.86","181.73","percent of total billed charges",""
"WASHER SCREW 6.5X80MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10144535","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","87.55","38.3","","279.30","91.72","1116.77","266","70.86","181.73","percent of total billed charges",""
"WASHER SCREW 6.5X80MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10144535","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.07","42.9","","731.00","63.70","731.00","1 through 10","70.86","181.73","percent of total billed charges",""
"WASHER SCREW 6.5X80MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10144535","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.07","42.9","","384.74","384.74","384.74","1 through 10","70.86","181.73","percent of total billed charges",""
"WASHER SCREW 6.5X80MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10144535","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.59","171.44","WELLPOINT [1015]","HB AMC WELLPOINT","168.65","73.78","","286.63","119.22","1107.45","105","70.86","181.73","percent of total billed charges",""
"WASHER SCREW 6.5X80MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10144535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.59","171.44","AETNA [1001]","HB AMC AETNA HMO","159.56","69.8","","675.31","184.75","1721.50","286","119.46","186.8","percent of total billed charges",""
"WASHER SCREW 6.5X80MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10144535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.59","171.44","AETNA [1001]","HB AMC AETNA PPO","183.79","80.4","","1261.44","103.12","1514.10","21","119.46","186.8","percent of total billed charges",""
"WASHER SCREW 6.5X80MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10144535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.59","171.44","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","183.79","80.4","","1365.00","1365.00","1365.00","1 through 10","119.46","186.8","percent of total billed charges",""
"WASHER SCREW 6.5X80MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10144535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.59","171.44","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","186.80","81.72","","5157.68","5157.68","5157.68","1 through 10","119.46","186.8","percent of total billed charges",""
"WASHER SCREW 6.5X80MM BONE ASNIS III CANNULATED TITANIUM","SUP-ITM-10144535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.59","171.44","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","186.80","81.72","","431.26","71.26","1459.57","88","119.46","186.8","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","160.86","79.5","","800.18","480.96","1887.97","195","62.73","160.86","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","107.85","53.3","","813.12","216.42","1444.50","81","62.73","160.86","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","62.73","31","","432.60","432.60","432.60","1 through 10","62.73","160.86","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","73.85","36.5","","148.37","54.89","631.39","94","62.73","160.86","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","77.50","38.3","","279.30","91.72","1116.77","266","62.73","160.86","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.80","42.9","","731.00","63.70","731.00","1 through 10","62.73","160.86","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.80","42.9","","384.74","384.74","384.74","1 through 10","62.73","160.86","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.34","151.75","WELLPOINT [1015]","HB AMC WELLPOINT","149.29","73.78","","286.63","119.22","1107.45","105","62.73","160.86","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","AETNA [1001]","HB AMC AETNA HMO","141.23","69.8","","675.31","184.75","1721.50","286","105.74","165.35","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","AETNA [1001]","HB AMC AETNA PPO","162.68","80.4","","1261.44","103.12","1514.10","21","105.74","165.35","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","162.68","80.4","","1365.00","1365.00","1365.00","1 through 10","105.74","165.35","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","165.35","81.72","","5157.68","5157.68","5157.68","1 through 10","105.74","165.35","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.34","151.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","165.35","81.72","","431.26","71.26","1459.57","88","105.74","165.35","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.35","84.26","CIGNA [1006]","HB AMC CIGNA HMO / PPO","89.32","79.5","","800.18","480.96","1887.97","195","34.83","89.32","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.35","84.26","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","59.88","53.3","","813.12","216.42","1444.50","81","34.83","89.32","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.35","84.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","34.83","31","","432.60","432.60","432.60","1 through 10","34.83","89.32","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.35","84.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","41.01","36.5","","148.37","54.89","631.39","94","34.83","89.32","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.35","84.26","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","43.03","38.3","","279.30","91.72","1116.77","266","34.83","89.32","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.35","84.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.20","42.9","","731.00","63.70","731.00","1 through 10","34.83","89.32","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.35","84.26","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.20","42.9","","384.74","384.74","384.74","1 through 10","34.83","89.32","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","112.35","84.26","WELLPOINT [1015]","HB AMC WELLPOINT","82.89","73.78","","286.63","119.22","1107.45","105","34.83","89.32","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","112.35","84.26","AETNA [1001]","HB AMC AETNA HMO","78.42","69.8","","675.31","184.75","1721.50","286","58.71","91.81","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","112.35","84.26","AETNA [1001]","HB AMC AETNA PPO","90.33","80.4","","1261.44","103.12","1514.10","21","58.71","91.81","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","112.35","84.26","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","90.33","80.4","","1365.00","1365.00","1365.00","1 through 10","58.71","91.81","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","112.35","84.26","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","91.81","81.72","","5157.68","5157.68","5157.68","1 through 10","58.71","91.81","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","112.35","84.26","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","91.81","81.72","","431.26","71.26","1459.57","88","58.71","91.81","percent of total billed charges",""
"WASHER SCREW BONE SPINE XIA TITANIUM SS","SUP-ITM-10046858","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA [1006]","HB AMC CIGNA HMO / PPO","125.21","79.5","","800.18","480.96","1887.97","195","48.83","125.21","percent of total billed charges",""
"WASHER SCREW BONE SPINE XIA TITANIUM SS","SUP-ITM-10046858","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","83.95","53.3","","813.12","216.42","1444.50","81","48.83","125.21","percent of total billed charges",""
"WASHER SCREW BONE SPINE XIA TITANIUM SS","SUP-ITM-10046858","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","48.83","31","","432.60","432.60","432.60","1 through 10","48.83","125.21","percent of total billed charges",""
"WASHER SCREW BONE SPINE XIA TITANIUM SS","SUP-ITM-10046858","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","57.49","36.5","","148.37","54.89","631.39","94","48.83","125.21","percent of total billed charges",""
"WASHER SCREW BONE SPINE XIA TITANIUM SS","SUP-ITM-10046858","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","60.32","38.3","","279.30","91.72","1116.77","266","48.83","125.21","percent of total billed charges",""
"WASHER SCREW BONE SPINE XIA TITANIUM SS","SUP-ITM-10046858","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","731.00","63.70","731.00","1 through 10","48.83","125.21","percent of total billed charges",""
"WASHER SCREW BONE SPINE XIA TITANIUM SS","SUP-ITM-10046858","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.57","42.9","","384.74","384.74","384.74","1 through 10","48.83","125.21","percent of total billed charges",""
"WASHER SCREW BONE SPINE XIA TITANIUM SS","SUP-ITM-10046858","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB AMC WELLPOINT","116.20","73.78","","286.63","119.22","1107.45","105","48.83","125.21","percent of total billed charges",""
"WASHER SCREW BONE SPINE XIA TITANIUM SS","SUP-ITM-10046858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA HMO","109.94","69.8","","675.31","184.75","1721.50","286","82.31","128.71","percent of total billed charges",""
"WASHER SCREW BONE SPINE XIA TITANIUM SS","SUP-ITM-10046858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","AETNA [1001]","HB AMC AETNA PPO","126.63","80.4","","1261.44","103.12","1514.10","21","82.31","128.71","percent of total billed charges",""
"WASHER SCREW BONE SPINE XIA TITANIUM SS","SUP-ITM-10046858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","126.63","80.4","","1365.00","1365.00","1365.00","1 through 10","82.31","128.71","percent of total billed charges",""
"WASHER SCREW BONE SPINE XIA TITANIUM SS","SUP-ITM-10046858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","128.71","81.72","","5157.68","5157.68","5157.68","1 through 10","82.31","128.71","percent of total billed charges",""
"WASHER SCREW BONE SPINE XIA TITANIUM SS","SUP-ITM-10046858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","128.71","81.72","","431.26","71.26","1459.57","88","82.31","128.71","percent of total billed charges",""
"WASHER SPINE MOUNTAINEER LATERAL","SUP-ITM-10018220","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","1309.77","674.56","6049.93","26","162.75","417.38","percent of total billed charges",""
"WASHER SPINE MOUNTAINEER LATERAL","SUP-ITM-10018220","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","1901.83","1901.83","2962.25","1 through 10","162.75","417.38","percent of total billed charges",""
"WASHER SPINE MOUNTAINEER LATERAL","SUP-ITM-10018220","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","1620.31","1620.31","19908.88","1 through 10","162.75","417.38","percent of total billed charges",""
"WASHER SPINE MOUNTAINEER LATERAL","SUP-ITM-10018220","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","352.91","352.91","2046.30","1 through 10","162.75","417.38","percent of total billed charges",""
"WASHER SPINE MOUNTAINEER LATERAL","SUP-ITM-10018220","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","9668.75","9668.75","9668.75","1 through 10","162.75","417.38","percent of total billed charges",""
"WASHER SPINE MOUNTAINEER LATERAL","SUP-ITM-10018220","CDM","C1889","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","699.88","384.10","3443.31","33","162.75","417.38","percent of total billed charges",""
"WASHER SPINE MOUNTAINEER LATERAL","SUP-ITM-10018220","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","1421.24","264.50","4933.46","29","274.37","429.03","percent of total billed charges",""
"WASHER SPINE MOUNTAINEER LATERAL","SUP-ITM-10018220","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1022.97","1022.97","3607.50","1 through 10","274.37","429.03","percent of total billed charges",""
"WASHER SPINE MOUNTAINEER LATERAL","SUP-ITM-10018220","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","3010.54","693.88","5019.88","35","274.37","429.03","percent of total billed charges",""
"WATER PROSTHESIS 61 70CM URINARY PRESSURE AMS 800 ELASTOMER SPHINCTER SILICONE CUFF PUMP","SUP-ITM-10004823","CDM","C1815","HCPCS","0278","RC","","","","both","","","7059.00","5294.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","5611.91","79.5","","18938.70","18113.72","18938.70","1 through 10","2188.29","5611.91","percent of total billed charges",""
"WATER PROSTHESIS 61 70CM URINARY PRESSURE AMS 800 ELASTOMER SPHINCTER SILICONE CUFF PUMP","SUP-ITM-10004823","CDM","C1815","HCPCS","0278","RC","","","","both","","","7059.00","5294.25","WELLPOINT [1015]","HB AMC WELLPOINT","5208.13","73.78","","27772.46","27772.46","27772.46","1 through 10","2188.29","5611.91","percent of total billed charges",""
"WEIGHT MOLECULAR MEDIUM FOSSA BONE TMJ GLENOID ULTRA HIGH POLYETHYLENE LEFT","SUP-ITM-10126203","CDM","C1713","HCPCS","0278","RC","","","","both","","","13435.00","10076.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","10680.83","79.5","","800.18","480.96","1887.97","195","4164.85","10680.83","percent of total billed charges",""
"WEIGHT MOLECULAR MEDIUM FOSSA BONE TMJ GLENOID ULTRA HIGH POLYETHYLENE LEFT","SUP-ITM-10126203","CDM","C1713","HCPCS","0278","RC","","","","both","","","13435.00","10076.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","7160.86","53.3","","813.12","216.42","1444.50","81","4164.85","10680.83","percent of total billed charges",""
"WEIGHT MOLECULAR MEDIUM FOSSA BONE TMJ GLENOID ULTRA HIGH POLYETHYLENE LEFT","SUP-ITM-10126203","CDM","C1713","HCPCS","0278","RC","","","","both","","","13435.00","10076.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","4164.85","31","","432.60","432.60","432.60","1 through 10","4164.85","10680.83","percent of total billed charges",""
"WEIGHT MOLECULAR MEDIUM FOSSA BONE TMJ GLENOID ULTRA HIGH POLYETHYLENE LEFT","SUP-ITM-10126203","CDM","C1713","HCPCS","0278","RC","","","","both","","","13435.00","10076.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4903.78","36.5","","148.37","54.89","631.39","94","4164.85","10680.83","percent of total billed charges",""
"WEIGHT MOLECULAR MEDIUM FOSSA BONE TMJ GLENOID ULTRA HIGH POLYETHYLENE LEFT","SUP-ITM-10126203","CDM","C1713","HCPCS","0278","RC","","","","both","","","13435.00","10076.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5145.61","38.3","","279.30","91.72","1116.77","266","4164.85","10680.83","percent of total billed charges",""
"WEIGHT MOLECULAR MEDIUM FOSSA BONE TMJ GLENOID ULTRA HIGH POLYETHYLENE LEFT","SUP-ITM-10126203","CDM","C1713","HCPCS","0278","RC","","","","both","","","13435.00","10076.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5763.62","42.9","","731.00","63.70","731.00","1 through 10","4164.85","10680.83","percent of total billed charges",""
"WEIGHT MOLECULAR MEDIUM FOSSA BONE TMJ GLENOID ULTRA HIGH POLYETHYLENE LEFT","SUP-ITM-10126203","CDM","C1713","HCPCS","0278","RC","","","","both","","","13435.00","10076.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5763.62","42.9","","384.74","384.74","384.74","1 through 10","4164.85","10680.83","percent of total billed charges",""
"WEIGHT MOLECULAR MEDIUM FOSSA BONE TMJ GLENOID ULTRA HIGH POLYETHYLENE LEFT","SUP-ITM-10126203","CDM","C1713","HCPCS","0278","RC","","","","both","","","13435.00","10076.25","WELLPOINT [1015]","HB AMC WELLPOINT","9912.34","73.78","","286.63","119.22","1107.45","105","4164.85","10680.83","percent of total billed charges",""
"WEIGHT MOLECULAR MEDIUM FOSSA BONE TMJ GLENOID ULTRA HIGH POLYETHYLENE LEFT","SUP-ITM-10126203","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13435.00","10076.25","AETNA [1001]","HB AMC AETNA HMO","9377.63","69.8","","675.31","184.75","1721.50","286","7021.13","10979.08","percent of total billed charges",""
"WEIGHT MOLECULAR MEDIUM FOSSA BONE TMJ GLENOID ULTRA HIGH POLYETHYLENE LEFT","SUP-ITM-10126203","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13435.00","10076.25","AETNA [1001]","HB AMC AETNA PPO","10801.74","80.4","","1261.44","103.12","1514.10","21","7021.13","10979.08","percent of total billed charges",""
"WEIGHT MOLECULAR MEDIUM FOSSA BONE TMJ GLENOID ULTRA HIGH POLYETHYLENE LEFT","SUP-ITM-10126203","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13435.00","10076.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","10801.74","80.4","","1365.00","1365.00","1365.00","1 through 10","7021.13","10979.08","percent of total billed charges",""
"WEIGHT MOLECULAR MEDIUM FOSSA BONE TMJ GLENOID ULTRA HIGH POLYETHYLENE LEFT","SUP-ITM-10126203","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13435.00","10076.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","10979.08","81.72","","5157.68","5157.68","5157.68","1 through 10","7021.13","10979.08","percent of total billed charges",""
"WEIGHT MOLECULAR MEDIUM FOSSA BONE TMJ GLENOID ULTRA HIGH POLYETHYLENE LEFT","SUP-ITM-10126203","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13435.00","10076.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","10979.08","81.72","","431.26","71.26","1459.57","88","7021.13","10979.08","percent of total billed charges",""
"Wet Mount & Prep Vaginal/Cerv/Skin","PX-31000064","CDM","Q0111","HCPCS","0310","RC","","","","outpatient","","","76.00","57.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","62.11","81.72","","59.16","59.16","59.16","1 through 10","16.51","62.11","percent of total billed charges",""
"Whfo Wrist Brace T1","PX-27000505","CDM","L3931","HCPCS","0274","RC","","","","outpatient","","","84.28","63.21","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS HMO","51.03","60.55","","56.66","56.66","56.66","1 through 10","42.14","472.44","percent of total billed charges",""
"Whfo Wrist Brace T1","PX-27000505","CDM","L3931","HCPCS","0274","RC","","","","outpatient","","","84.28","63.21","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","42.14","50","","44.16","44.16","44.16","1 through 10","42.14","472.44","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","both","","","143.00","107.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","113.69","79.5","","75.50","75.50","112.54","1 through 10","44.33","565.16","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","both","","","143.00","107.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","76.22","53.3","","112.54","112.54","112.54","1 through 10","44.33","565.16","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","both","","","143.00","107.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","52.20","36.5","","53.34","53.34","53.34","1 through 10","44.33","565.16","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","both","","","143.00","107.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","54.77","38.3","","55.91","54.34","55.92","1 through 10","44.33","565.16","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","both","","","143.00","107.25","WELLPOINT [1015]","HB AMC WELLPOINT","105.51","73.78","","106.46","106.46","106.46","1 through 10","44.33","565.16","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","outpatient","","","143.00","107.25","AETNA [1001]","HB AMC AETNA HMO","99.81","69.8","","68.35","68.35","111.54","1 through 10","71.5","938.87","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","71.50","50","","74.93","74.93","74.93","1 through 10","71.5","938.87","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","outpatient","","","143.00","107.25","HARVARD PILGRIM ALTERNATE [120002]","HB AMC HPHC ALLIANCE PPO NON PREFERRED B","89.38","62.5","","92.95","92.95","92.95","1 through 10","71.5","938.87","percent of total billed charges",""
"WIRE CERCLAGE 1.25MMX25 COIL SS EYE","SUP-ITM-10038563","CDM","C1713","HCPCS","0278","RC","","","","both","","","181.30","135.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","144.13","79.5","","800.18","480.96","1887.97","195","56.2","144.13","percent of total billed charges",""
"WIRE CERCLAGE 1.25MMX25 COIL SS EYE","SUP-ITM-10038563","CDM","C1713","HCPCS","0278","RC","","","","both","","","181.30","135.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","96.63","53.3","","813.12","216.42","1444.50","81","56.2","144.13","percent of total billed charges",""
"WIRE CERCLAGE 1.25MMX25 COIL SS EYE","SUP-ITM-10038563","CDM","C1713","HCPCS","0278","RC","","","","both","","","181.30","135.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","56.20","31","","432.60","432.60","432.60","1 through 10","56.2","144.13","percent of total billed charges",""
"WIRE CERCLAGE 1.25MMX25 COIL SS EYE","SUP-ITM-10038563","CDM","C1713","HCPCS","0278","RC","","","","both","","","181.30","135.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","66.17","36.5","","148.37","54.89","631.39","94","56.2","144.13","percent of total billed charges",""
"WIRE CERCLAGE 1.25MMX25 COIL SS EYE","SUP-ITM-10038563","CDM","C1713","HCPCS","0278","RC","","","","both","","","181.30","135.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","69.44","38.3","","279.30","91.72","1116.77","266","56.2","144.13","percent of total billed charges",""
"WIRE CERCLAGE 1.25MMX25 COIL SS EYE","SUP-ITM-10038563","CDM","C1713","HCPCS","0278","RC","","","","both","","","181.30","135.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.78","42.9","","731.00","63.70","731.00","1 through 10","56.2","144.13","percent of total billed charges",""
"WIRE CERCLAGE 1.25MMX25 COIL SS EYE","SUP-ITM-10038563","CDM","C1713","HCPCS","0278","RC","","","","both","","","181.30","135.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.78","42.9","","384.74","384.74","384.74","1 through 10","56.2","144.13","percent of total billed charges",""
"WIRE CERCLAGE 1.25MMX25 COIL SS EYE","SUP-ITM-10038563","CDM","C1713","HCPCS","0278","RC","","","","both","","","181.30","135.97","WELLPOINT [1015]","HB AMC WELLPOINT","133.76","73.78","","286.63","119.22","1107.45","105","56.2","144.13","percent of total billed charges",""
"WIRE CERCLAGE 1.25MMX25 COIL SS EYE","SUP-ITM-10038563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","181.30","135.97","AETNA [1001]","HB AMC AETNA HMO","126.55","69.8","","675.31","184.75","1721.50","286","94.75","148.16","percent of total billed charges",""
"WIRE CERCLAGE 1.25MMX25 COIL SS EYE","SUP-ITM-10038563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","181.30","135.97","AETNA [1001]","HB AMC AETNA PPO","145.77","80.4","","1261.44","103.12","1514.10","21","94.75","148.16","percent of total billed charges",""
"WIRE CERCLAGE 1.25MMX25 COIL SS EYE","SUP-ITM-10038563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","181.30","135.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","145.77","80.4","","1365.00","1365.00","1365.00","1 through 10","94.75","148.16","percent of total billed charges",""
"WIRE CERCLAGE 1.25MMX25 COIL SS EYE","SUP-ITM-10038563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","181.30","135.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","148.16","81.72","","5157.68","5157.68","5157.68","1 through 10","94.75","148.16","percent of total billed charges",""
"WIRE CERCLAGE 1.25MMX25 COIL SS EYE","SUP-ITM-10038563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","181.30","135.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","148.16","81.72","","431.26","71.26","1459.57","88","94.75","148.16","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.58","130.93","CIGNA [1006]","HB AMC CIGNA HMO / PPO","138.79","79.5","","800.18","480.96","1887.97","195","54.12","138.79","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.58","130.93","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","93.05","53.3","","813.12","216.42","1444.50","81","54.12","138.79","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.58","130.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","54.12","31","","432.60","432.60","432.60","1 through 10","54.12","138.79","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.58","130.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","63.72","36.5","","148.37","54.89","631.39","94","54.12","138.79","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.58","130.93","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","66.86","38.3","","279.30","91.72","1116.77","266","54.12","138.79","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.58","130.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.89","42.9","","731.00","63.70","731.00","1 through 10","54.12","138.79","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.58","130.93","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.89","42.9","","384.74","384.74","384.74","1 through 10","54.12","138.79","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.58","130.93","WELLPOINT [1015]","HB AMC WELLPOINT","128.81","73.78","","286.63","119.22","1107.45","105","54.12","138.79","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.58","130.93","AETNA [1001]","HB AMC AETNA HMO","121.86","69.8","","675.31","184.75","1721.50","286","91.24","142.67","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.58","130.93","AETNA [1001]","HB AMC AETNA PPO","140.36","80.4","","1261.44","103.12","1514.10","21","91.24","142.67","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.58","130.93","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","140.36","80.4","","1365.00","1365.00","1365.00","1 through 10","91.24","142.67","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.58","130.93","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","142.67","81.72","","5157.68","5157.68","5157.68","1 through 10","91.24","142.67","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.58","130.93","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","142.67","81.72","","431.26","71.26","1459.57","88","91.24","142.67","percent of total billed charges",""
"WIRE COMPRESSION LONG","SUP-ITM-10126730","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.43","103.82","CIGNA [1006]","HB AMC CIGNA HMO / PPO","110.05","79.5","","800.18","480.96","1887.97","195","42.91","110.05","percent of total billed charges",""
"WIRE COMPRESSION LONG","SUP-ITM-10126730","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.43","103.82","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","73.78","53.3","","813.12","216.42","1444.50","81","42.91","110.05","percent of total billed charges",""
"WIRE COMPRESSION LONG","SUP-ITM-10126730","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.43","103.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","42.91","31","","432.60","432.60","432.60","1 through 10","42.91","110.05","percent of total billed charges",""
"WIRE COMPRESSION LONG","SUP-ITM-10126730","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.43","103.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","50.53","36.5","","148.37","54.89","631.39","94","42.91","110.05","percent of total billed charges",""
"WIRE COMPRESSION LONG","SUP-ITM-10126730","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.43","103.82","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.02","38.3","","279.30","91.72","1116.77","266","42.91","110.05","percent of total billed charges",""
"WIRE COMPRESSION LONG","SUP-ITM-10126730","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.43","103.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.39","42.9","","731.00","63.70","731.00","1 through 10","42.91","110.05","percent of total billed charges",""
"WIRE COMPRESSION LONG","SUP-ITM-10126730","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.43","103.82","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.39","42.9","","384.74","384.74","384.74","1 through 10","42.91","110.05","percent of total billed charges",""
"WIRE COMPRESSION LONG","SUP-ITM-10126730","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.43","103.82","WELLPOINT [1015]","HB AMC WELLPOINT","102.13","73.78","","286.63","119.22","1107.45","105","42.91","110.05","percent of total billed charges",""
"WIRE COMPRESSION LONG","SUP-ITM-10126730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.43","103.82","AETNA [1001]","HB AMC AETNA HMO","96.62","69.8","","675.31","184.75","1721.50","286","72.34","113.12","percent of total billed charges",""
"WIRE COMPRESSION LONG","SUP-ITM-10126730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.43","103.82","AETNA [1001]","HB AMC AETNA PPO","111.30","80.4","","1261.44","103.12","1514.10","21","72.34","113.12","percent of total billed charges",""
"WIRE COMPRESSION LONG","SUP-ITM-10126730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.43","103.82","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","111.30","80.4","","1365.00","1365.00","1365.00","1 through 10","72.34","113.12","percent of total billed charges",""
"WIRE COMPRESSION LONG","SUP-ITM-10126730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.43","103.82","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","113.12","81.72","","5157.68","5157.68","5157.68","1 through 10","72.34","113.12","percent of total billed charges",""
"WIRE COMPRESSION LONG","SUP-ITM-10126730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.43","103.82","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","113.12","81.72","","431.26","71.26","1459.57","88","72.34","113.12","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","both","","","385.00","288.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","201.20","52.26","","25.34","25.34","25.34","1 through 10","119.35","306.08","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","both","","","385.00","288.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","276.43","71.8","","105.81","105.81","366.90","1 through 10","119.35","306.08","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","both","","","385.00","288.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","269.50","70","","512.90","74.70","612.85","1 through 10","119.35","306.08","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","both","","","385.00","288.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","306.08","79.5","","200.27","182.80","200.27","1 through 10","119.35","306.08","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","both","","","385.00","288.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","205.21","53.3","","37.73","37.73","169.33","1 through 10","119.35","306.08","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","both","","","385.00","288.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","250.25","65","","100.27","8.48","494.52","1 through 10","119.35","306.08","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","both","","","385.00","288.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","250.25","65","","160.19","160.19","160.19","1 through 10","119.35","306.08","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","119.35","31","","28.12","28.12","28.12","1 through 10","119.35","306.08","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","140.53","36.5","","101.66","28.85","502.70","121","119.35","306.08","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","both","","","385.00","288.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","147.46","38.3","","61.58","25.32","328.44","138","119.35","306.08","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","both","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","165.17","42.9","","71.66","71.66","71.66","1 through 10","119.35","306.08","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","both","","","385.00","288.75","WELLPOINT [1015]","HB AMC WELLPOINT","284.05","73.78","","74.75","27.97","425.28","93","119.35","306.08","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","385.00","288.75","AETNA [1001]","HB AMC AETNA HMO","268.73","69.8","","52.67","14.36","414.90","1 through 10","201.2","314.62","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","385.00","288.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","201.20","52.26","","25.34","25.34","25.34","1 through 10","201.2","314.62","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","385.00","288.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","309.54","80.4","","478.02","107.84","478.02","1 through 10","201.2","314.62","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","314.62","81.72","","32.74","12.33","122.05","1 through 10","201.2","314.62","percent of total billed charges",""
"WIRE FINISHING SUPPORTRAK 90CM .017IN IS-1","SUP-ITM-10051706","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","385.00","288.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","314.62","81.72","","144.95","32.78","676.91","104","201.2","314.62","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM REDUCTION MR CONDITIONAL DRILL POINT","SUP-ITM-10039196","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.42","546.31","CIGNA [1006]","HB AMC CIGNA HMO / PPO","579.09","79.5","","800.18","480.96","1887.97","195","225.81","579.09","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM REDUCTION MR CONDITIONAL DRILL POINT","SUP-ITM-10039196","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.42","546.31","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","388.25","53.3","","813.12","216.42","1444.50","81","225.81","579.09","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM REDUCTION MR CONDITIONAL DRILL POINT","SUP-ITM-10039196","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.42","546.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","225.81","31","","432.60","432.60","432.60","1 through 10","225.81","579.09","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM REDUCTION MR CONDITIONAL DRILL POINT","SUP-ITM-10039196","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.42","546.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","265.87","36.5","","148.37","54.89","631.39","94","225.81","579.09","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM REDUCTION MR CONDITIONAL DRILL POINT","SUP-ITM-10039196","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.42","546.31","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","278.98","38.3","","279.30","91.72","1116.77","266","225.81","579.09","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM REDUCTION MR CONDITIONAL DRILL POINT","SUP-ITM-10039196","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.42","546.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.49","42.9","","731.00","63.70","731.00","1 through 10","225.81","579.09","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM REDUCTION MR CONDITIONAL DRILL POINT","SUP-ITM-10039196","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.42","546.31","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.49","42.9","","384.74","384.74","384.74","1 through 10","225.81","579.09","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM REDUCTION MR CONDITIONAL DRILL POINT","SUP-ITM-10039196","CDM","C1713","HCPCS","0278","RC","","","","both","","","728.42","546.31","WELLPOINT [1015]","HB AMC WELLPOINT","537.43","73.78","","286.63","119.22","1107.45","105","225.81","579.09","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM REDUCTION MR CONDITIONAL DRILL POINT","SUP-ITM-10039196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.42","546.31","AETNA [1001]","HB AMC AETNA HMO","508.44","69.8","","675.31","184.75","1721.50","286","380.67","595.26","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM REDUCTION MR CONDITIONAL DRILL POINT","SUP-ITM-10039196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.42","546.31","AETNA [1001]","HB AMC AETNA PPO","585.65","80.4","","1261.44","103.12","1514.10","21","380.67","595.26","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM REDUCTION MR CONDITIONAL DRILL POINT","SUP-ITM-10039196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.42","546.31","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","585.65","80.4","","1365.00","1365.00","1365.00","1 through 10","380.67","595.26","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM REDUCTION MR CONDITIONAL DRILL POINT","SUP-ITM-10039196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.42","546.31","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","595.26","81.72","","5157.68","5157.68","5157.68","1 through 10","380.67","595.26","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM REDUCTION MR CONDITIONAL DRILL POINT","SUP-ITM-10039196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","728.42","546.31","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","595.26","81.72","","431.26","71.26","1459.57","88","380.67","595.26","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.29","177.22","CIGNA [1006]","HB AMC CIGNA HMO / PPO","187.85","79.5","","800.18","480.96","1887.97","195","73.25","187.85","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.29","177.22","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","125.94","53.3","","813.12","216.42","1444.50","81","73.25","187.85","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.29","177.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","73.25","31","","432.60","432.60","432.60","1 through 10","73.25","187.85","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.29","177.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","86.25","36.5","","148.37","54.89","631.39","94","73.25","187.85","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.29","177.22","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","90.50","38.3","","279.30","91.72","1116.77","266","73.25","187.85","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.29","177.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.37","42.9","","731.00","63.70","731.00","1 through 10","73.25","187.85","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.29","177.22","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.37","42.9","","384.74","384.74","384.74","1 through 10","73.25","187.85","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","both","","","236.29","177.22","WELLPOINT [1015]","HB AMC WELLPOINT","174.33","73.78","","286.63","119.22","1107.45","105","73.25","187.85","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","236.29","177.22","AETNA [1001]","HB AMC AETNA HMO","164.93","69.8","","675.31","184.75","1721.50","286","123.49","193.1","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","236.29","177.22","AETNA [1001]","HB AMC AETNA PPO","189.98","80.4","","1261.44","103.12","1514.10","21","123.49","193.1","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","236.29","177.22","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","189.98","80.4","","1365.00","1365.00","1365.00","1 through 10","123.49","193.1","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","236.29","177.22","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","193.10","81.72","","5157.68","5157.68","5157.68","1 through 10","123.49","193.1","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","236.29","177.22","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","193.10","81.72","","431.26","71.26","1459.57","88","123.49","193.1","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","226.24","169.68","CIGNA [1006]","HB AMC CIGNA HMO / PPO","179.86","79.5","","800.18","480.96","1887.97","195","70.13","179.86","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","226.24","169.68","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","120.59","53.3","","813.12","216.42","1444.50","81","70.13","179.86","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","226.24","169.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","70.13","31","","432.60","432.60","432.60","1 through 10","70.13","179.86","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","226.24","169.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","82.58","36.5","","148.37","54.89","631.39","94","70.13","179.86","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","226.24","169.68","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","86.65","38.3","","279.30","91.72","1116.77","266","70.13","179.86","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","226.24","169.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.06","42.9","","731.00","63.70","731.00","1 through 10","70.13","179.86","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","226.24","169.68","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","97.06","42.9","","384.74","384.74","384.74","1 through 10","70.13","179.86","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","226.24","169.68","WELLPOINT [1015]","HB AMC WELLPOINT","166.92","73.78","","286.63","119.22","1107.45","105","70.13","179.86","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","226.24","169.68","AETNA [1001]","HB AMC AETNA HMO","157.92","69.8","","675.31","184.75","1721.50","286","118.23","184.88","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","226.24","169.68","AETNA [1001]","HB AMC AETNA PPO","181.90","80.4","","1261.44","103.12","1514.10","21","118.23","184.88","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","226.24","169.68","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","181.90","80.4","","1365.00","1365.00","1365.00","1 through 10","118.23","184.88","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","226.24","169.68","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","184.88","81.72","","5157.68","5157.68","5157.68","1 through 10","118.23","184.88","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","226.24","169.68","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","184.88","81.72","","431.26","71.26","1459.57","88","118.23","184.88","percent of total billed charges",""
"WIRE GUIDE 3.2X300MM ORTHOPEDIC SS TROCAR POINT THREADED","SUP-ITM-10004038","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","CIGNA [1006]","HB AMC CIGNA HMO / PPO","246.06","79.5","","800.18","480.96","1887.97","195","95.95","246.06","percent of total billed charges",""
"WIRE GUIDE 3.2X300MM ORTHOPEDIC SS TROCAR POINT THREADED","SUP-ITM-10004038","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","164.97","53.3","","813.12","216.42","1444.50","81","95.95","246.06","percent of total billed charges",""
"WIRE GUIDE 3.2X300MM ORTHOPEDIC SS TROCAR POINT THREADED","SUP-ITM-10004038","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","95.95","31","","432.60","432.60","432.60","1 through 10","95.95","246.06","percent of total billed charges",""
"WIRE GUIDE 3.2X300MM ORTHOPEDIC SS TROCAR POINT THREADED","SUP-ITM-10004038","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","112.97","36.5","","148.37","54.89","631.39","94","95.95","246.06","percent of total billed charges",""
"WIRE GUIDE 3.2X300MM ORTHOPEDIC SS TROCAR POINT THREADED","SUP-ITM-10004038","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","118.54","38.3","","279.30","91.72","1116.77","266","95.95","246.06","percent of total billed charges",""
"WIRE GUIDE 3.2X300MM ORTHOPEDIC SS TROCAR POINT THREADED","SUP-ITM-10004038","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.78","42.9","","731.00","63.70","731.00","1 through 10","95.95","246.06","percent of total billed charges",""
"WIRE GUIDE 3.2X300MM ORTHOPEDIC SS TROCAR POINT THREADED","SUP-ITM-10004038","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","132.78","42.9","","384.74","384.74","384.74","1 through 10","95.95","246.06","percent of total billed charges",""
"WIRE GUIDE 3.2X300MM ORTHOPEDIC SS TROCAR POINT THREADED","SUP-ITM-10004038","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.51","232.13","WELLPOINT [1015]","HB AMC WELLPOINT","228.36","73.78","","286.63","119.22","1107.45","105","95.95","246.06","percent of total billed charges",""
"WIRE GUIDE 3.2X300MM ORTHOPEDIC SS TROCAR POINT THREADED","SUP-ITM-10004038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","AETNA [1001]","HB AMC AETNA HMO","216.04","69.8","","675.31","184.75","1721.50","286","161.75","252.93","percent of total billed charges",""
"WIRE GUIDE 3.2X300MM ORTHOPEDIC SS TROCAR POINT THREADED","SUP-ITM-10004038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","AETNA [1001]","HB AMC AETNA PPO","248.85","80.4","","1261.44","103.12","1514.10","21","161.75","252.93","percent of total billed charges",""
"WIRE GUIDE 3.2X300MM ORTHOPEDIC SS TROCAR POINT THREADED","SUP-ITM-10004038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","248.85","80.4","","1365.00","1365.00","1365.00","1 through 10","161.75","252.93","percent of total billed charges",""
"WIRE GUIDE 3.2X300MM ORTHOPEDIC SS TROCAR POINT THREADED","SUP-ITM-10004038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","252.93","81.72","","5157.68","5157.68","5157.68","1 through 10","161.75","252.93","percent of total billed charges",""
"WIRE GUIDE 3.2X300MM ORTHOPEDIC SS TROCAR POINT THREADED","SUP-ITM-10004038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.51","232.13","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","252.93","81.72","","431.26","71.26","1459.57","88","161.75","252.93","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","both","","","42.81","32.11","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","22.37","52.26","","25.34","25.34","25.34","1 through 10","13.27","34.03","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","both","","","42.81","32.11","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","30.74","71.8","","105.81","105.81","366.90","1 through 10","13.27","34.03","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","both","","","42.81","32.11","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","29.97","70","","512.90","74.70","612.85","1 through 10","13.27","34.03","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","both","","","42.81","32.11","CIGNA [1006]","HB AMC CIGNA HMO / PPO","34.03","79.5","","200.27","182.80","200.27","1 through 10","13.27","34.03","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","both","","","42.81","32.11","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22.82","53.3","","37.73","37.73","169.33","1 through 10","13.27","34.03","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","both","","","42.81","32.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","27.83","65","","100.27","8.48","494.52","1 through 10","13.27","34.03","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","both","","","42.81","32.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","27.83","65","","160.19","160.19","160.19","1 through 10","13.27","34.03","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","both","","","42.81","32.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","13.27","31","","28.12","28.12","28.12","1 through 10","13.27","34.03","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","both","","","42.81","32.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15.63","36.5","","101.66","28.85","502.70","121","13.27","34.03","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","both","","","42.81","32.11","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.40","38.3","","61.58","25.32","328.44","138","13.27","34.03","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","both","","","42.81","32.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.37","42.9","","71.66","71.66","71.66","1 through 10","13.27","34.03","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","both","","","42.81","32.11","WELLPOINT [1015]","HB AMC WELLPOINT","31.59","73.78","","74.75","27.97","425.28","93","13.27","34.03","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","42.81","32.11","AETNA [1001]","HB AMC AETNA HMO","29.88","69.8","","52.67","14.36","414.90","1 through 10","22.37","34.98","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","42.81","32.11","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","22.37","52.26","","25.34","25.34","25.34","1 through 10","22.37","34.98","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","42.81","32.11","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","34.42","80.4","","478.02","107.84","478.02","1 through 10","22.37","34.98","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","42.81","32.11","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","34.98","81.72","","32.74","12.33","122.05","1 through 10","22.37","34.98","percent of total billed charges",""
"WIRE LIGATURE 22GA .64X160MM BLUNT TIP","SUP-ITM-10118295","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","42.81","32.11","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34.98","81.72","","144.95","32.78","676.91","104","22.37","34.98","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","both","","","19.56","14.67","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","10.22","52.26","","25.34","25.34","25.34","1 through 10","6.06","15.55","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","both","","","19.56","14.67","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","14.04","71.8","","105.81","105.81","366.90","1 through 10","6.06","15.55","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","both","","","19.56","14.67","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","13.69","70","","512.90","74.70","612.85","1 through 10","6.06","15.55","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","both","","","19.56","14.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","15.55","79.5","","200.27","182.80","200.27","1 through 10","6.06","15.55","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","both","","","19.56","14.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","10.43","53.3","","37.73","37.73","169.33","1 through 10","6.06","15.55","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","both","","","19.56","14.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","12.71","65","","100.27","8.48","494.52","1 through 10","6.06","15.55","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","both","","","19.56","14.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC GMMI INTERNATIONAL","12.71","65","","160.19","160.19","160.19","1 through 10","6.06","15.55","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","both","","","19.56","14.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","6.06","31","","28.12","28.12","28.12","1 through 10","6.06","15.55","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","both","","","19.56","14.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","7.14","36.5","","101.66","28.85","502.70","121","6.06","15.55","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","both","","","19.56","14.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","7.49","38.3","","61.58","25.32","328.44","138","6.06","15.55","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","both","","","19.56","14.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8.39","42.9","","71.66","71.66","71.66","1 through 10","6.06","15.55","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","both","","","19.56","14.67","WELLPOINT [1015]","HB AMC WELLPOINT","14.43","73.78","","74.75","27.97","425.28","93","6.06","15.55","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","19.56","14.67","AETNA [1001]","HB AMC AETNA HMO","13.65","69.8","","52.67","14.36","414.90","1 through 10","10.22","15.98","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","19.56","14.67","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","10.22","52.26","","25.34","25.34","25.34","1 through 10","10.22","15.98","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","19.56","14.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","15.73","80.4","","478.02","107.84","478.02","1 through 10","10.22","15.98","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","19.56","14.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","15.98","81.72","","32.74","12.33","122.05","1 through 10","10.22","15.98","percent of total billed charges",""
"WIRE LIGATURE 24GA .5X160MM BLUNT TIP","SUP-ITM-10118294","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","19.56","14.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","15.98","81.72","","144.95","32.78","676.91","104","10.22","15.98","percent of total billed charges",""
"Wire Loc Soft Tissue","PX-76002103","CDM","17999","CPT","0761","RC","","","","both","","","779.00","584.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","235.94","","APC Price ($235.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4490.63","3878.56","4490.63","1 through 10","224.17","619.31","other","OPPS APC"
"Wire Loc Soft Tissue","PX-76002103","CDM","17999","CPT","0761","RC","","","","outpatient","","","779.00","584.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS PPO","406.79","52.22","","467.73","465.00","467.73","1 through 10","389.5","700.33","percent of total billed charges",""
"WIRE PIN 1/8X9IN BONE STEINMANN SS THREADED TROCAR POINT SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10147980","CDM","C1713","HCPCS","0278","RC","","","","both","","","41.81","31.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","33.24","79.5","","800.18","480.96","1887.97","195","12.96","33.24","percent of total billed charges",""
"WIRE PIN 1/8X9IN BONE STEINMANN SS THREADED TROCAR POINT SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10147980","CDM","C1713","HCPCS","0278","RC","","","","both","","","41.81","31.36","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","22.28","53.3","","813.12","216.42","1444.50","81","12.96","33.24","percent of total billed charges",""
"WIRE PIN 1/8X9IN BONE STEINMANN SS THREADED TROCAR POINT SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10147980","CDM","C1713","HCPCS","0278","RC","","","","both","","","41.81","31.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","12.96","31","","432.60","432.60","432.60","1 through 10","12.96","33.24","percent of total billed charges",""
"WIRE PIN 1/8X9IN BONE STEINMANN SS THREADED TROCAR POINT SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10147980","CDM","C1713","HCPCS","0278","RC","","","","both","","","41.81","31.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15.26","36.5","","148.37","54.89","631.39","94","12.96","33.24","percent of total billed charges",""
"WIRE PIN 1/8X9IN BONE STEINMANN SS THREADED TROCAR POINT SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10147980","CDM","C1713","HCPCS","0278","RC","","","","both","","","41.81","31.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","16.01","38.3","","279.30","91.72","1116.77","266","12.96","33.24","percent of total billed charges",""
"WIRE PIN 1/8X9IN BONE STEINMANN SS THREADED TROCAR POINT SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10147980","CDM","C1713","HCPCS","0278","RC","","","","both","","","41.81","31.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17.94","42.9","","731.00","63.70","731.00","1 through 10","12.96","33.24","percent of total billed charges",""
"WIRE PIN 1/8X9IN BONE STEINMANN SS THREADED TROCAR POINT SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10147980","CDM","C1713","HCPCS","0278","RC","","","","both","","","41.81","31.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17.94","42.9","","384.74","384.74","384.74","1 through 10","12.96","33.24","percent of total billed charges",""
"WIRE PIN 1/8X9IN BONE STEINMANN SS THREADED TROCAR POINT SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10147980","CDM","C1713","HCPCS","0278","RC","","","","both","","","41.81","31.36","WELLPOINT [1015]","HB AMC WELLPOINT","30.85","73.78","","286.63","119.22","1107.45","105","12.96","33.24","percent of total billed charges",""
"WIRE PIN 1/8X9IN BONE STEINMANN SS THREADED TROCAR POINT SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10147980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","41.81","31.36","AETNA [1001]","HB AMC AETNA HMO","29.18","69.8","","675.31","184.75","1721.50","286","21.85","34.17","percent of total billed charges",""
"WIRE PIN 1/8X9IN BONE STEINMANN SS THREADED TROCAR POINT SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10147980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","41.81","31.36","AETNA [1001]","HB AMC AETNA PPO","33.62","80.4","","1261.44","103.12","1514.10","21","21.85","34.17","percent of total billed charges",""
"WIRE PIN 1/8X9IN BONE STEINMANN SS THREADED TROCAR POINT SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10147980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","41.81","31.36","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","33.62","80.4","","1365.00","1365.00","1365.00","1 through 10","21.85","34.17","percent of total billed charges",""
"WIRE PIN 1/8X9IN BONE STEINMANN SS THREADED TROCAR POINT SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10147980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","41.81","31.36","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","34.17","81.72","","5157.68","5157.68","5157.68","1 through 10","21.85","34.17","percent of total billed charges",""
"WIRE PIN 1/8X9IN BONE STEINMANN SS THREADED TROCAR POINT SIN - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10147980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","41.81","31.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","34.17","81.72","","431.26","71.26","1459.57","88","21.85","34.17","percent of total billed charges",""
"WIRE PIN 5/32X9IN BONE STEINMANN SS SMOOTH TROCAR POINT SING - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10004133","CDM","C1713","HCPCS","0278","RC","","","","both","","","25.27","18.95","CIGNA [1006]","HB AMC CIGNA HMO / PPO","20.09","79.5","","800.18","480.96","1887.97","195","7.83","20.09","percent of total billed charges",""
"WIRE PIN 5/32X9IN BONE STEINMANN SS SMOOTH TROCAR POINT SING - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10004133","CDM","C1713","HCPCS","0278","RC","","","","both","","","25.27","18.95","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","13.47","53.3","","813.12","216.42","1444.50","81","7.83","20.09","percent of total billed charges",""
"WIRE PIN 5/32X9IN BONE STEINMANN SS SMOOTH TROCAR POINT SING - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10004133","CDM","C1713","HCPCS","0278","RC","","","","both","","","25.27","18.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","7.83","31","","432.60","432.60","432.60","1 through 10","7.83","20.09","percent of total billed charges",""
"WIRE PIN 5/32X9IN BONE STEINMANN SS SMOOTH TROCAR POINT SING - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10004133","CDM","C1713","HCPCS","0278","RC","","","","both","","","25.27","18.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","9.22","36.5","","148.37","54.89","631.39","94","7.83","20.09","percent of total billed charges",""
"WIRE PIN 5/32X9IN BONE STEINMANN SS SMOOTH TROCAR POINT SING - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10004133","CDM","C1713","HCPCS","0278","RC","","","","both","","","25.27","18.95","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","9.68","38.3","","279.30","91.72","1116.77","266","7.83","20.09","percent of total billed charges",""
"WIRE PIN 5/32X9IN BONE STEINMANN SS SMOOTH TROCAR POINT SING - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10004133","CDM","C1713","HCPCS","0278","RC","","","","both","","","25.27","18.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.84","42.9","","731.00","63.70","731.00","1 through 10","7.83","20.09","percent of total billed charges",""
"WIRE PIN 5/32X9IN BONE STEINMANN SS SMOOTH TROCAR POINT SING - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10004133","CDM","C1713","HCPCS","0278","RC","","","","both","","","25.27","18.95","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.84","42.9","","384.74","384.74","384.74","1 through 10","7.83","20.09","percent of total billed charges",""
"WIRE PIN 5/32X9IN BONE STEINMANN SS SMOOTH TROCAR POINT SING - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10004133","CDM","C1713","HCPCS","0278","RC","","","","both","","","25.27","18.95","WELLPOINT [1015]","HB AMC WELLPOINT","18.64","73.78","","286.63","119.22","1107.45","105","7.83","20.09","percent of total billed charges",""
"WIRE PIN 5/32X9IN BONE STEINMANN SS SMOOTH TROCAR POINT SING - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10004133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25.27","18.95","AETNA [1001]","HB AMC AETNA HMO","17.64","69.8","","675.31","184.75","1721.50","286","13.21","20.65","percent of total billed charges",""
"WIRE PIN 5/32X9IN BONE STEINMANN SS SMOOTH TROCAR POINT SING - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10004133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25.27","18.95","AETNA [1001]","HB AMC AETNA PPO","20.32","80.4","","1261.44","103.12","1514.10","21","13.21","20.65","percent of total billed charges",""
"WIRE PIN 5/32X9IN BONE STEINMANN SS SMOOTH TROCAR POINT SING - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10004133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25.27","18.95","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","20.32","80.4","","1365.00","1365.00","1365.00","1 through 10","13.21","20.65","percent of total billed charges",""
"WIRE PIN 5/32X9IN BONE STEINMANN SS SMOOTH TROCAR POINT SING - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10004133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25.27","18.95","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","20.65","81.72","","5157.68","5157.68","5157.68","1 through 10","13.21","20.65","percent of total billed charges",""
"WIRE PIN 5/32X9IN BONE STEINMANN SS SMOOTH TROCAR POINT SING - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10004133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","25.27","18.95","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","20.65","81.72","","431.26","71.26","1459.57","88","13.21","20.65","percent of total billed charges",""
"WIRE SPINAL 18GA DOUBLE DEPUY ISOLA S/S IMPLANTABLE","SUP-ITM-10001697","CDM","C1889","HCPCS","0278","RC","","","","both","","","140.00","105.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","111.30","79.5","","1309.77","674.56","6049.93","26","43.4","111.3","percent of total billed charges",""
"WIRE SPINAL 18GA DOUBLE DEPUY ISOLA S/S IMPLANTABLE","SUP-ITM-10001697","CDM","C1889","HCPCS","0278","RC","","","","both","","","140.00","105.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","74.62","53.3","","1901.83","1901.83","2962.25","1 through 10","43.4","111.3","percent of total billed charges",""
"WIRE SPINAL 18GA DOUBLE DEPUY ISOLA S/S IMPLANTABLE","SUP-ITM-10001697","CDM","C1889","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","51.10","36.5","","1620.31","1620.31","19908.88","1 through 10","43.4","111.3","percent of total billed charges",""
"WIRE SPINAL 18GA DOUBLE DEPUY ISOLA S/S IMPLANTABLE","SUP-ITM-10001697","CDM","C1889","HCPCS","0278","RC","","","","both","","","140.00","105.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","53.62","38.3","","352.91","352.91","2046.30","1 through 10","43.4","111.3","percent of total billed charges",""
"WIRE SPINAL 18GA DOUBLE DEPUY ISOLA S/S IMPLANTABLE","SUP-ITM-10001697","CDM","C1889","HCPCS","0278","RC","","","","both","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.06","42.9","","9668.75","9668.75","9668.75","1 through 10","43.4","111.3","percent of total billed charges",""
"WIRE SPINAL 18GA DOUBLE DEPUY ISOLA S/S IMPLANTABLE","SUP-ITM-10001697","CDM","C1889","HCPCS","0278","RC","","","","both","","","140.00","105.00","WELLPOINT [1015]","HB AMC WELLPOINT","103.29","73.78","","699.88","384.10","3443.31","33","43.4","111.3","percent of total billed charges",""
"WIRE SPINAL 18GA DOUBLE DEPUY ISOLA S/S IMPLANTABLE","SUP-ITM-10001697","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","AETNA [1001]","HB AMC AETNA HMO","97.72","69.8","","1421.24","264.50","4933.46","29","73.16","114.41","percent of total billed charges",""
"WIRE SPINAL 18GA DOUBLE DEPUY ISOLA S/S IMPLANTABLE","SUP-ITM-10001697","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","112.56","80.4","","1022.97","1022.97","3607.50","1 through 10","73.16","114.41","percent of total billed charges",""
"WIRE SPINAL 18GA DOUBLE DEPUY ISOLA S/S IMPLANTABLE","SUP-ITM-10001697","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","140.00","105.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","114.41","81.72","","3010.54","693.88","5019.88","35","73.16","114.41","percent of total billed charges",""
"WIRE SUTURE 18X1MM 24IN 18GA BEADED END SS BX/6EA","SUP-ITM-10004543","CDM","C1713","HCPCS","0278","RC","","","","both","","","33.74","25.30","CIGNA [1006]","HB AMC CIGNA HMO / PPO","26.82","79.5","","800.18","480.96","1887.97","195","10.46","26.82","percent of total billed charges",""
"WIRE SUTURE 18X1MM 24IN 18GA BEADED END SS BX/6EA","SUP-ITM-10004543","CDM","C1713","HCPCS","0278","RC","","","","both","","","33.74","25.30","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","17.98","53.3","","813.12","216.42","1444.50","81","10.46","26.82","percent of total billed charges",""
"WIRE SUTURE 18X1MM 24IN 18GA BEADED END SS BX/6EA","SUP-ITM-10004543","CDM","C1713","HCPCS","0278","RC","","","","both","","","33.74","25.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","10.46","31","","432.60","432.60","432.60","1 through 10","10.46","26.82","percent of total billed charges",""
"WIRE SUTURE 18X1MM 24IN 18GA BEADED END SS BX/6EA","SUP-ITM-10004543","CDM","C1713","HCPCS","0278","RC","","","","both","","","33.74","25.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","12.32","36.5","","148.37","54.89","631.39","94","10.46","26.82","percent of total billed charges",""
"WIRE SUTURE 18X1MM 24IN 18GA BEADED END SS BX/6EA","SUP-ITM-10004543","CDM","C1713","HCPCS","0278","RC","","","","both","","","33.74","25.30","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","12.92","38.3","","279.30","91.72","1116.77","266","10.46","26.82","percent of total billed charges",""
"WIRE SUTURE 18X1MM 24IN 18GA BEADED END SS BX/6EA","SUP-ITM-10004543","CDM","C1713","HCPCS","0278","RC","","","","both","","","33.74","25.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.47","42.9","","731.00","63.70","731.00","1 through 10","10.46","26.82","percent of total billed charges",""
"WIRE SUTURE 18X1MM 24IN 18GA BEADED END SS BX/6EA","SUP-ITM-10004543","CDM","C1713","HCPCS","0278","RC","","","","both","","","33.74","25.30","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.47","42.9","","384.74","384.74","384.74","1 through 10","10.46","26.82","percent of total billed charges",""
"WIRE SUTURE 18X1MM 24IN 18GA BEADED END SS BX/6EA","SUP-ITM-10004543","CDM","C1713","HCPCS","0278","RC","","","","both","","","33.74","25.30","WELLPOINT [1015]","HB AMC WELLPOINT","24.89","73.78","","286.63","119.22","1107.45","105","10.46","26.82","percent of total billed charges",""
"WIRE SUTURE 18X1MM 24IN 18GA BEADED END SS BX/6EA","SUP-ITM-10004543","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","33.74","25.30","AETNA [1001]","HB AMC AETNA HMO","23.55","69.8","","675.31","184.75","1721.50","286","17.63","27.57","percent of total billed charges",""
"WIRE SUTURE 18X1MM 24IN 18GA BEADED END SS BX/6EA","SUP-ITM-10004543","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","33.74","25.30","AETNA [1001]","HB AMC AETNA PPO","27.13","80.4","","1261.44","103.12","1514.10","21","17.63","27.57","percent of total billed charges",""
"WIRE SUTURE 18X1MM 24IN 18GA BEADED END SS BX/6EA","SUP-ITM-10004543","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","33.74","25.30","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","27.13","80.4","","1365.00","1365.00","1365.00","1 through 10","17.63","27.57","percent of total billed charges",""
"WIRE SUTURE 18X1MM 24IN 18GA BEADED END SS BX/6EA","SUP-ITM-10004543","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","33.74","25.30","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","27.57","81.72","","5157.68","5157.68","5157.68","1 through 10","17.63","27.57","percent of total billed charges",""
"WIRE SUTURE 18X1MM 24IN 18GA BEADED END SS BX/6EA","SUP-ITM-10004543","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","33.74","25.30","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","27.57","81.72","","431.26","71.26","1459.57","88","17.63","27.57","percent of total billed charges",""
"Wireless Pressure Sensor W/Del Cath, All Cmpnts","PX-27001178","CDM","C2624","HCPCS","0278","RC","","","","both","","","43750.00","32812.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","15968.75","36.5","","43750.00","43750.00","43750.00","1 through 10","13562.5","34781.25","percent of total billed charges",""
"Wnd Prep Ped, Face/Nck/Hnd/Ft/Gen 1st 100 Cm","PX-98302355","CDM","15004","CPT","0983","RC","","","","both","","","1140.00","855.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","906.30","79.5","","7878.66","5539.50","7878.66","1 through 10","267.79","906.3","percent of total billed charges",""
"Wnd Prep Ped, Face/Nck/Hnd/Ft/Gen 1st 100 Cm","PX-98302355","CDM","15004","CPT","0983","RC","","","","both","","","1140.00","855.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","607.62","53.3","","7098.94","7098.94","7098.94","1 through 10","267.79","906.3","percent of total billed charges",""
"Wnd Prep Ped, Face/Nck/Hnd/Ft/Gen 1st 100 Cm","PX-98302355","CDM","15004","CPT","0983","RC","","","","both","","","1140.00","855.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","436.62","38.3","","8318.13","8318.13","8318.13","1 through 10","267.79","906.3","percent of total billed charges",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc","464","MS-DRG","","","","","","","","inpatient","","","171700.71","128775.53","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","29656.23","","Case rate ($28,792.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,583.03, add-ons for qualifying new technology services are included. If operating cost exceeds $80,227.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,946.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $25,906.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,203.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,506.27. The transfer capital threshold is the transfer adjustment factor * $2,506.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","27864.13","27864.13","27864.13","1 through 10","28216.61","44497.3226","other","Inpatient DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc","464","MS-DRG","","","","","","","","inpatient","","","171700.71","128775.53","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","28792.46","","Case rate ($28,792.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,583.03, add-ons for qualifying new technology services are included. If operating cost exceeds $80,227.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,946.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $25,906.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,203.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,506.27. The transfer capital threshold is the transfer adjustment factor * $2,506.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","108569.96","108569.96","108569.96","1 through 10","28216.61","44497.3226","other","Inpatient Replacement Plans DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc","464","MS-DRG","","","","","","","","inpatient","","","171700.71","128775.53","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","28792.46","","Case rate ($28,792.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,583.03, add-ons for qualifying new technology services are included. If operating cost exceeds $80,227.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,946.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $25,906.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,203.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,506.27. The transfer capital threshold is the transfer adjustment factor * $2,506.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","440501.65","440501.65","440501.65","1 through 10","28216.61","44497.3226","other","Inpatient Replacement Plans DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc","464","MS-DRG","","","","","","","","inpatient","","","171700.71","128775.53","MEDICARE [2001]","HB BWH MEDICARE","28792.46","","Case rate ($28,792.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,583.03, add-ons for qualifying new technology services are included. If operating cost exceeds $80,227.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,946.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $25,906.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,203.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,506.27. The transfer capital threshold is the transfer adjustment factor * $2,506.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35039.80","0.03","51191.57","20","28216.61","44497.3226","other","Inpatient Replacement Plans DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc","464","MS-DRG","","","","","","","","inpatient","","","171700.71","128775.53","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","28216.61","","Case rate ($28,792.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $34,583.03, add-ons for qualifying new technology services are included. If operating cost exceeds $80,227.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $4,946.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $25,906.35 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $34,203.19 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,506.27. The transfer capital threshold is the transfer adjustment factor * $2,506.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","26615.72","24213.62","383030.08","1 through 10","28216.61","44497.3226","other","Inpatient DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC","463","MS-DRG","","","","","","","","inpatient","","","272635.37","204476.53","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","53942.42","","Case rate ($52,371.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $62,967.28, add-ons for qualifying new technology services are included. If operating cost exceeds $108,611.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,026.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $47,405.29 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $62,587.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,586.15. The transfer capital threshold is the transfer adjustment factor * $4,586.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","60095.24","60095.24","60095.24","1 through 10","51323.85","81506.491","other","Inpatient DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC","463","MS-DRG","","","","","","","","inpatient","","","272635.37","204476.53","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","67855.79","","Case rate ($67,855.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $62,967.28, add-ons for qualifying new technology services are included. If operating cost exceeds $108,611.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,026.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $62,889.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $62,587.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,586.15. The transfer capital threshold is the transfer adjustment factor * $4,586.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22840.72","22840.72","22840.72","1 through 10","51323.85","81506.491","other","Inpatient DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC","463","MS-DRG","","","","","","","","inpatient","","","272635.37","204476.53","MEDICARE [2001]","HB BWH MEDICARE","67855.79","","Case rate ($67,855.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $62,967.28, add-ons for qualifying new technology services are included. If operating cost exceeds $108,611.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,026.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $62,889.80 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $62,587.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,586.15. The transfer capital threshold is the transfer adjustment factor * $4,586.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","63951.51","63951.51","64046.76","1 through 10","51323.85","81506.491","other","Inpatient DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC","463","MS-DRG","","","","","","","","inpatient","","","272635.37","204476.53","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","51323.85","","Case rate ($52,371.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $62,967.28, add-ons for qualifying new technology services are included. If operating cost exceeds $108,611.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $7,026.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.6. The base transfer operating payment is the transfer adjustment factor * $47,405.29 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $62,587.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,586.15. The transfer capital threshold is the transfer adjustment factor * $4,586.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","48353.47","48353.47","48353.47","1 through 10","51323.85","81506.491","other","Inpatient DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC","463","MS-DRG","","","","","","","","inpatient","","","272635.37","204476.53","WELLPOINT [1015]","HB AMC WELLPOINT","81506.491","","Fee schedule rate ($89,276.97).","81506.491","48415.45","48415.45","1 through 10","51323.85","81506.491","case rate",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC","465","MS-DRG","","","","","","","","inpatient","","","81493.90","61120.42","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","17526.29","","Case rate ($17,015.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,406.28, add-ons for qualifying new technology services are included. If operating cost exceeds $66,050.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,907.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $15,168.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,026.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,467.46. The transfer capital threshold is the transfer adjustment factor * $1,467.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","16573.29","16573.29","16573.29","1 through 10","16675.5","26199.4851","other","Inpatient DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC","465","MS-DRG","","","","","","","","inpatient","","","81493.90","61120.42","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","17015.82","","Case rate ($17,015.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,406.28, add-ons for qualifying new technology services are included. If operating cost exceeds $66,050.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,907.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $15,168.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,026.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,467.46. The transfer capital threshold is the transfer adjustment factor * $1,467.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","43144.50","43144.50","43144.50","1 through 10","16675.5","26199.4851","other","Inpatient Replacement Plans DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC","465","MS-DRG","","","","","","","","inpatient","","","81493.90","61120.42","MARTIN'S POINT [160007]","HB BWH MEDICARE","17015.82","","Case rate ($17,015.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,406.28, add-ons for qualifying new technology services are included. If operating cost exceeds $66,050.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,907.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $15,168.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,026.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,467.46. The transfer capital threshold is the transfer adjustment factor * $1,467.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15016.16","15016.16","15016.16","1 through 10","16675.5","26199.4851","other","Inpatient Replacement Plans DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC","465","MS-DRG","","","","","","","","inpatient","","","81493.90","61120.42","MEDICARE [2001]","HB BWH MEDICARE","17015.82","","Case rate ($17,015.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,406.28, add-ons for qualifying new technology services are included. If operating cost exceeds $66,050.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,907.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $15,168.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,026.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,467.46. The transfer capital threshold is the transfer adjustment factor * $1,467.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20769.59","20745.43","20776.05","1 through 10","16675.5","26199.4851","other","Inpatient Replacement Plans DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC","465","MS-DRG","","","","","","","","inpatient","","","81493.90","61120.42","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","16675.50","","Case rate ($17,015.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $20,406.28, add-ons for qualifying new technology services are included. If operating cost exceeds $66,050.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,907.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $15,168.53 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $20,026.44 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,467.46. The transfer capital threshold is the transfer adjustment factor * $1,467.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6.87","6.87","6.87","1 through 10","16675.5","26199.4851","other","Inpatient DRG"
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","","","","inpatient","","","134225.19","100668.89","MEDICARE [2001]","HB BWH MEDICARE","17844.11","","Case rate ($17,844.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,403.37, add-ons for qualifying new technology services are included. If operating cost exceeds $67,047.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,980.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $15,923.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,023.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.52. The transfer capital threshold is the transfer adjustment factor * $1,540.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22682.85","22682.85","22682.85","1 through 10","17487.23","28636.6816","other","Inpatient Replacement Plans DRG"
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","","","","inpatient","","","134225.19","100668.89","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","17487.23","","Case rate ($17,844.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $21,403.37, add-ons for qualifying new technology services are included. If operating cost exceeds $67,047.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,980.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $15,923.75 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $21,023.54 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.52. The transfer capital threshold is the transfer adjustment factor * $1,540.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17215.97","17215.97","17215.97","1 through 10","17487.23","28636.6816","other","Inpatient DRG"
"Wound Debridements For Injuries With McC","901","MS-DRG","","","","","","","","inpatient","","","112404.09","84303.07","MEDICARE [2001]","HB BWH MEDICARE","50063.08","","Case rate ($50,063.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $46,463.62, add-ons for qualifying new technology services are included. If operating cost exceeds $92,108.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $5,816.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $46,306.40 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $46,083.77 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,376.83. The transfer capital threshold is the transfer adjustment factor * $3,376.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","52588.26","52510.14","52588.26","1 through 10","37888.44","65735.54","other","Inpatient DRG"
"Wound Debridements For Injuries Without Cc/McC","903","MS-DRG","","","","","","","","inpatient","","","52573.85","39430.39","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","11380.52","","Case rate ($11,049.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,223.47, add-ons for qualifying new technology services are included. If operating cost exceeds $58,867.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,381.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,728.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,843.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.13. The transfer capital threshold is the transfer adjustment factor * $941.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11704.24","11704.24","11704.24","1 through 10","10828.07","18320.61","other","Inpatient DRG"
"Wound Debridements For Injuries Without Cc/McC","903","MS-DRG","","","","","","","","inpatient","","","52573.85","39430.39","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","10828.07","","Case rate ($11,049.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.243, exceeds $13,223.47, add-ons for qualifying new technology services are included. If operating cost exceeds $58,867.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.013, exceeds $3,381.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,728.09 + an uncompensated DSH payment of $379.84. The transfer operating threshold is the transfer adjustment factor * $12,843.63 + an uncompensated DSH payment of $379.84. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.13. The transfer capital threshold is the transfer adjustment factor * $941.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11131.79","11131.79","11131.79","1 through 10","10828.07","18320.61","other","Inpatient DRG"
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","4428.90","3321.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3520.98","79.5","","800.18","480.96","1887.97","195","1372.96","3520.98","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","4428.90","3321.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2360.60","53.3","","813.12","216.42","1444.50","81","1372.96","3520.98","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","4428.90","3321.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1372.96","31","","432.60","432.60","432.60","1 through 10","1372.96","3520.98","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","4428.90","3321.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1616.55","36.5","","148.37","54.89","631.39","94","1372.96","3520.98","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","4428.90","3321.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1696.27","38.3","","279.30","91.72","1116.77","266","1372.96","3520.98","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","4428.90","3321.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1900.00","42.9","","731.00","63.70","731.00","1 through 10","1372.96","3520.98","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","4428.90","3321.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1900.00","42.9","","384.74","384.74","384.74","1 through 10","1372.96","3520.98","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","4428.90","3321.67","WELLPOINT [1015]","HB AMC WELLPOINT","3267.64","73.78","","286.63","119.22","1107.45","105","1372.96","3520.98","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4428.90","3321.67","AETNA [1001]","HB AMC AETNA HMO","3091.37","69.8","","675.31","184.75","1721.50","286","2314.54","3619.3","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4428.90","3321.67","AETNA [1001]","HB AMC AETNA PPO","3560.84","80.4","","1261.44","103.12","1514.10","21","2314.54","3619.3","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4428.90","3321.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3560.84","80.4","","1365.00","1365.00","1365.00","1 through 10","2314.54","3619.3","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4428.90","3321.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3619.30","81.72","","5157.68","5157.68","5157.68","1 through 10","2314.54","3619.3","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4428.90","3321.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3619.30","81.72","","431.26","71.26","1459.57","88","2314.54","3619.3","percent of total billed charges",""
"WRIST PLATE 118MM SHORT LCP FUSION BEND STERILE","SUP-ITM-10073026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4174.71","3131.03","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3318.89","79.5","","800.18","480.96","1887.97","195","1294.16","3318.89","percent of total billed charges",""
"WRIST PLATE 118MM SHORT LCP FUSION BEND STERILE","SUP-ITM-10073026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4174.71","3131.03","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2225.12","53.3","","813.12","216.42","1444.50","81","1294.16","3318.89","percent of total billed charges",""
"WRIST PLATE 118MM SHORT LCP FUSION BEND STERILE","SUP-ITM-10073026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4174.71","3131.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1294.16","31","","432.60","432.60","432.60","1 through 10","1294.16","3318.89","percent of total billed charges",""
"WRIST PLATE 118MM SHORT LCP FUSION BEND STERILE","SUP-ITM-10073026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4174.71","3131.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1523.77","36.5","","148.37","54.89","631.39","94","1294.16","3318.89","percent of total billed charges",""
"WRIST PLATE 118MM SHORT LCP FUSION BEND STERILE","SUP-ITM-10073026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4174.71","3131.03","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1598.91","38.3","","279.30","91.72","1116.77","266","1294.16","3318.89","percent of total billed charges",""
"WRIST PLATE 118MM SHORT LCP FUSION BEND STERILE","SUP-ITM-10073026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4174.71","3131.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1790.95","42.9","","731.00","63.70","731.00","1 through 10","1294.16","3318.89","percent of total billed charges",""
"WRIST PLATE 118MM SHORT LCP FUSION BEND STERILE","SUP-ITM-10073026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4174.71","3131.03","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1790.95","42.9","","384.74","384.74","384.74","1 through 10","1294.16","3318.89","percent of total billed charges",""
"WRIST PLATE 118MM SHORT LCP FUSION BEND STERILE","SUP-ITM-10073026","CDM","C1713","HCPCS","0278","RC","","","","both","","","4174.71","3131.03","WELLPOINT [1015]","HB AMC WELLPOINT","3080.10","73.78","","286.63","119.22","1107.45","105","1294.16","3318.89","percent of total billed charges",""
"WRIST PLATE 118MM SHORT LCP FUSION BEND STERILE","SUP-ITM-10073026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4174.71","3131.03","AETNA [1001]","HB AMC AETNA HMO","2913.95","69.8","","675.31","184.75","1721.50","286","2181.7","3411.57","percent of total billed charges",""
"WRIST PLATE 118MM SHORT LCP FUSION BEND STERILE","SUP-ITM-10073026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4174.71","3131.03","AETNA [1001]","HB AMC AETNA PPO","3356.47","80.4","","1261.44","103.12","1514.10","21","2181.7","3411.57","percent of total billed charges",""
"WRIST PLATE 118MM SHORT LCP FUSION BEND STERILE","SUP-ITM-10073026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4174.71","3131.03","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3356.47","80.4","","1365.00","1365.00","1365.00","1 through 10","2181.7","3411.57","percent of total billed charges",""
"WRIST PLATE 118MM SHORT LCP FUSION BEND STERILE","SUP-ITM-10073026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4174.71","3131.03","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3411.57","81.72","","5157.68","5157.68","5157.68","1 through 10","2181.7","3411.57","percent of total billed charges",""
"WRIST PLATE 118MM SHORT LCP FUSION BEND STERILE","SUP-ITM-10073026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4174.71","3131.03","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3411.57","81.72","","431.26","71.26","1459.57","88","2181.7","3411.57","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","11870.00","8902.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","9436.65","79.5","","800.18","480.96","1887.97","195","3679.7","9436.65","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","11870.00","8902.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","6326.71","53.3","","813.12","216.42","1444.50","81","3679.7","9436.65","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","11870.00","8902.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3679.70","31","","432.60","432.60","432.60","1 through 10","3679.7","9436.65","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","11870.00","8902.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","4332.55","36.5","","148.37","54.89","631.39","94","3679.7","9436.65","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","11870.00","8902.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4546.21","38.3","","279.30","91.72","1116.77","266","3679.7","9436.65","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","11870.00","8902.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5092.23","42.9","","731.00","63.70","731.00","1 through 10","3679.7","9436.65","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","11870.00","8902.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5092.23","42.9","","384.74","384.74","384.74","1 through 10","3679.7","9436.65","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","11870.00","8902.50","WELLPOINT [1015]","HB AMC WELLPOINT","8757.69","73.78","","286.63","119.22","1107.45","105","3679.7","9436.65","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11870.00","8902.50","AETNA [1001]","HB AMC AETNA HMO","8285.26","69.8","","675.31","184.75","1721.50","286","6203.26","9700.16","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11870.00","8902.50","AETNA [1001]","HB AMC AETNA PPO","9543.48","80.4","","1261.44","103.12","1514.10","21","6203.26","9700.16","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11870.00","8902.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","9543.48","80.4","","1365.00","1365.00","1365.00","1 through 10","6203.26","9700.16","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11870.00","8902.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","9700.16","81.72","","5157.68","5157.68","5157.68","1 through 10","6203.26","9700.16","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11870.00","8902.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","9700.16","81.72","","431.26","71.26","1459.57","88","6203.26","9700.16","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3297.26","79.5","","800.18","480.96","1887.97","195","1285.73","3297.26","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","2210.62","53.3","","813.12","216.42","1444.50","81","1285.73","3297.26","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1285.73","31","","432.60","432.60","432.60","1 through 10","1285.73","3297.26","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1513.84","36.5","","148.37","54.89","631.39","94","1285.73","3297.26","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1588.49","38.3","","279.30","91.72","1116.77","266","1285.73","3297.26","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1779.28","42.9","","731.00","63.70","731.00","1 through 10","1285.73","3297.26","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1779.28","42.9","","384.74","384.74","384.74","1 through 10","1285.73","3297.26","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","both","","","4147.50","3110.62","WELLPOINT [1015]","HB AMC WELLPOINT","3060.03","73.78","","286.63","119.22","1107.45","105","1285.73","3297.26","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4147.50","3110.62","AETNA [1001]","HB AMC AETNA HMO","2894.96","69.8","","675.31","184.75","1721.50","286","2167.48","3389.34","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4147.50","3110.62","AETNA [1001]","HB AMC AETNA PPO","3334.59","80.4","","1261.44","103.12","1514.10","21","2167.48","3389.34","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4147.50","3110.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","3334.59","80.4","","1365.00","1365.00","1365.00","1 through 10","2167.48","3389.34","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4147.50","3110.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","3389.34","81.72","","5157.68","5157.68","5157.68","1 through 10","2167.48","3389.34","percent of total billed charges",""
"WRIST PLATE 5 HOLE SS BEARING VOLAR LT PEG","SUP-ITM-10019523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4147.50","3110.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3389.34","81.72","","431.26","71.26","1459.57","88","2167.48","3389.34","percent of total billed charges",""
"WRIST PLATE BONE DVR ANATOMIC TITANIUM DORSAL NAIL LT LIME","SUP-ITM-10072405","CDM","C1713","HCPCS","0278","RC","","","","both","","","2444.19","1833.14","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1943.13","79.5","","800.18","480.96","1887.97","195","757.7","1943.13","percent of total billed charges",""
"WRIST PLATE BONE DVR ANATOMIC TITANIUM DORSAL NAIL LT LIME","SUP-ITM-10072405","CDM","C1713","HCPCS","0278","RC","","","","both","","","2444.19","1833.14","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1302.75","53.3","","813.12","216.42","1444.50","81","757.7","1943.13","percent of total billed charges",""
"WRIST PLATE BONE DVR ANATOMIC TITANIUM DORSAL NAIL LT LIME","SUP-ITM-10072405","CDM","C1713","HCPCS","0278","RC","","","","both","","","2444.19","1833.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","757.70","31","","432.60","432.60","432.60","1 through 10","757.7","1943.13","percent of total billed charges",""
"WRIST PLATE BONE DVR ANATOMIC TITANIUM DORSAL NAIL LT LIME","SUP-ITM-10072405","CDM","C1713","HCPCS","0278","RC","","","","both","","","2444.19","1833.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","892.13","36.5","","148.37","54.89","631.39","94","757.7","1943.13","percent of total billed charges",""
"WRIST PLATE BONE DVR ANATOMIC TITANIUM DORSAL NAIL LT LIME","SUP-ITM-10072405","CDM","C1713","HCPCS","0278","RC","","","","both","","","2444.19","1833.14","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","936.12","38.3","","279.30","91.72","1116.77","266","757.7","1943.13","percent of total billed charges",""
"WRIST PLATE BONE DVR ANATOMIC TITANIUM DORSAL NAIL LT LIME","SUP-ITM-10072405","CDM","C1713","HCPCS","0278","RC","","","","both","","","2444.19","1833.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1048.56","42.9","","731.00","63.70","731.00","1 through 10","757.7","1943.13","percent of total billed charges",""
"WRIST PLATE BONE DVR ANATOMIC TITANIUM DORSAL NAIL LT LIME","SUP-ITM-10072405","CDM","C1713","HCPCS","0278","RC","","","","both","","","2444.19","1833.14","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1048.56","42.9","","384.74","384.74","384.74","1 through 10","757.7","1943.13","percent of total billed charges",""
"WRIST PLATE BONE DVR ANATOMIC TITANIUM DORSAL NAIL LT LIME","SUP-ITM-10072405","CDM","C1713","HCPCS","0278","RC","","","","both","","","2444.19","1833.14","WELLPOINT [1015]","HB AMC WELLPOINT","1803.32","73.78","","286.63","119.22","1107.45","105","757.7","1943.13","percent of total billed charges",""
"WRIST PLATE BONE DVR ANATOMIC TITANIUM DORSAL NAIL LT LIME","SUP-ITM-10072405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2444.19","1833.14","AETNA [1001]","HB AMC AETNA HMO","1706.04","69.8","","675.31","184.75","1721.50","286","1277.33","1997.39","percent of total billed charges",""
"WRIST PLATE BONE DVR ANATOMIC TITANIUM DORSAL NAIL LT LIME","SUP-ITM-10072405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2444.19","1833.14","AETNA [1001]","HB AMC AETNA PPO","1965.13","80.4","","1261.44","103.12","1514.10","21","1277.33","1997.39","percent of total billed charges",""
"WRIST PLATE BONE DVR ANATOMIC TITANIUM DORSAL NAIL LT LIME","SUP-ITM-10072405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2444.19","1833.14","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1965.13","80.4","","1365.00","1365.00","1365.00","1 through 10","1277.33","1997.39","percent of total billed charges",""
"WRIST PLATE BONE DVR ANATOMIC TITANIUM DORSAL NAIL LT LIME","SUP-ITM-10072405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2444.19","1833.14","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1997.39","81.72","","5157.68","5157.68","5157.68","1 through 10","1277.33","1997.39","percent of total billed charges",""
"WRIST PLATE BONE DVR ANATOMIC TITANIUM DORSAL NAIL LT LIME","SUP-ITM-10072405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2444.19","1833.14","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1997.39","81.72","","431.26","71.26","1459.57","88","1277.33","1997.39","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.90","2430.67","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2576.52","79.5","","800.18","480.96","1887.97","195","1004.68","2576.52","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.90","2430.67","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1727.40","53.3","","813.12","216.42","1444.50","81","1004.68","2576.52","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.90","2430.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","1004.68","31","","432.60","432.60","432.60","1 through 10","1004.68","2576.52","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.90","2430.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1182.93","36.5","","148.37","54.89","631.39","94","1004.68","2576.52","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.90","2430.67","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1241.26","38.3","","279.30","91.72","1116.77","266","1004.68","2576.52","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.90","2430.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1390.35","42.9","","731.00","63.70","731.00","1 through 10","1004.68","2576.52","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.90","2430.67","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1390.35","42.9","","384.74","384.74","384.74","1 through 10","1004.68","2576.52","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","3240.90","2430.67","WELLPOINT [1015]","HB AMC WELLPOINT","2391.14","73.78","","286.63","119.22","1107.45","105","1004.68","2576.52","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.90","2430.67","AETNA [1001]","HB AMC AETNA HMO","2262.15","69.8","","675.31","184.75","1721.50","286","1693.69","2648.46","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.90","2430.67","AETNA [1001]","HB AMC AETNA PPO","2605.68","80.4","","1261.44","103.12","1514.10","21","1693.69","2648.46","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.90","2430.67","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2605.68","80.4","","1365.00","1365.00","1365.00","1 through 10","1693.69","2648.46","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.90","2430.67","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2648.46","81.72","","5157.68","5157.68","5157.68","1 through 10","1693.69","2648.46","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3240.90","2430.67","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2648.46","81.72","","431.26","71.26","1459.57","88","1693.69","2648.46","percent of total billed charges",""
"WRIST PLATE MED JOINT CARPAL UNIVERSAL2","SUP-ITM-10018345","CDM","C1776","HCPCS","0278","RC","","","","both","","","8187.33","6140.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4278.70","52.26","","1113.10","1113.10","1113.10","1 through 10","2538.07","6508.93","percent of total billed charges",""
"WRIST PLATE MED JOINT CARPAL UNIVERSAL2","SUP-ITM-10018345","CDM","C1776","HCPCS","0278","RC","","","","both","","","8187.33","6140.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","6508.93","79.5","","1293.60","1148.53","1603.80","1 through 10","2538.07","6508.93","percent of total billed charges",""
"WRIST PLATE MED JOINT CARPAL UNIVERSAL2","SUP-ITM-10018345","CDM","C1776","HCPCS","0278","RC","","","","both","","","8187.33","6140.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2988.38","36.5","","1023.42","771.29","2068.67","33","2538.07","6508.93","percent of total billed charges",""
"WRIST PLATE MED JOINT CARPAL UNIVERSAL2","SUP-ITM-10018345","CDM","C1776","HCPCS","0278","RC","","","","both","","","8187.33","6140.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","3135.75","38.3","","850.52","759.78","1211.25","66","2538.07","6508.93","percent of total billed charges",""
"WRIST PLATE MED JOINT CARPAL UNIVERSAL2","SUP-ITM-10018345","CDM","C1776","HCPCS","0278","RC","","","","both","","","8187.33","6140.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3512.36","42.9","","2548.09","2548.09","2548.09","1 through 10","2538.07","6508.93","percent of total billed charges",""
"WRIST PLATE MED JOINT CARPAL UNIVERSAL2","SUP-ITM-10018345","CDM","C1776","HCPCS","0278","RC","","","","both","","","8187.33","6140.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3512.36","42.9","","956.46","956.46","956.46","1 through 10","2538.07","6508.93","percent of total billed charges",""
"WRIST PLATE MED JOINT CARPAL UNIVERSAL2","SUP-ITM-10018345","CDM","C1776","HCPCS","0278","RC","","","","both","","","8187.33","6140.50","WELLPOINT [1015]","HB AMC WELLPOINT","6040.61","73.78","","2344.73","1619.47","2530.35","16","2538.07","6508.93","percent of total billed charges",""
"WRIST PLATE MED JOINT CARPAL UNIVERSAL2","SUP-ITM-10018345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8187.33","6140.50","AETNA [1001]","HB AMC AETNA HMO","5714.76","69.8","","1523.63","988.41","4330.26","39","4278.7","6690.69","percent of total billed charges",""
"WRIST PLATE MED JOINT CARPAL UNIVERSAL2","SUP-ITM-10018345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8187.33","6140.50","AETNA [1001]","HB AMC AETNA PPO","6582.61","80.4","","1670.25","1670.25","1670.25","1 through 10","4278.7","6690.69","percent of total billed charges",""
"WRIST PLATE MED JOINT CARPAL UNIVERSAL2","SUP-ITM-10018345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8187.33","6140.50","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","4278.70","52.26","","1113.10","1113.10","1113.10","1 through 10","4278.7","6690.69","percent of total billed charges",""
"WRIST PLATE MED JOINT CARPAL UNIVERSAL2","SUP-ITM-10018345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8187.33","6140.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6690.69","81.72","","1738.90","1484.65","2716.94","38","4278.7","6690.69","percent of total billed charges",""
"WRIST PLATE MED JOINT STD CARPAL UNIVERSAL2 UHMWPE","SUP-ITM-10018346","CDM","C1776","HCPCS","0278","RC","","","","both","","","3445.82","2584.36","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1800.79","52.26","","1113.10","1113.10","1113.10","1 through 10","1068.2","2739.43","percent of total billed charges",""
"WRIST PLATE MED JOINT STD CARPAL UNIVERSAL2 UHMWPE","SUP-ITM-10018346","CDM","C1776","HCPCS","0278","RC","","","","both","","","3445.82","2584.36","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2739.43","79.5","","1293.60","1148.53","1603.80","1 through 10","1068.2","2739.43","percent of total billed charges",""
"WRIST PLATE MED JOINT STD CARPAL UNIVERSAL2 UHMWPE","SUP-ITM-10018346","CDM","C1776","HCPCS","0278","RC","","","","both","","","3445.82","2584.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1257.72","36.5","","1023.42","771.29","2068.67","33","1068.2","2739.43","percent of total billed charges",""
"WRIST PLATE MED JOINT STD CARPAL UNIVERSAL2 UHMWPE","SUP-ITM-10018346","CDM","C1776","HCPCS","0278","RC","","","","both","","","3445.82","2584.36","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1319.75","38.3","","850.52","759.78","1211.25","66","1068.2","2739.43","percent of total billed charges",""
"WRIST PLATE MED JOINT STD CARPAL UNIVERSAL2 UHMWPE","SUP-ITM-10018346","CDM","C1776","HCPCS","0278","RC","","","","both","","","3445.82","2584.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1478.26","42.9","","2548.09","2548.09","2548.09","1 through 10","1068.2","2739.43","percent of total billed charges",""
"WRIST PLATE MED JOINT STD CARPAL UNIVERSAL2 UHMWPE","SUP-ITM-10018346","CDM","C1776","HCPCS","0278","RC","","","","both","","","3445.82","2584.36","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1478.26","42.9","","956.46","956.46","956.46","1 through 10","1068.2","2739.43","percent of total billed charges",""
"WRIST PLATE MED JOINT STD CARPAL UNIVERSAL2 UHMWPE","SUP-ITM-10018346","CDM","C1776","HCPCS","0278","RC","","","","both","","","3445.82","2584.36","WELLPOINT [1015]","HB AMC WELLPOINT","2542.33","73.78","","2344.73","1619.47","2530.35","16","1068.2","2739.43","percent of total billed charges",""
"WRIST PLATE MED JOINT STD CARPAL UNIVERSAL2 UHMWPE","SUP-ITM-10018346","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3445.82","2584.36","AETNA [1001]","HB AMC AETNA HMO","2405.18","69.8","","1523.63","988.41","4330.26","39","1800.79","2815.92","percent of total billed charges",""
"WRIST PLATE MED JOINT STD CARPAL UNIVERSAL2 UHMWPE","SUP-ITM-10018346","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3445.82","2584.36","AETNA [1001]","HB AMC AETNA PPO","2770.44","80.4","","1670.25","1670.25","1670.25","1 through 10","1800.79","2815.92","percent of total billed charges",""
"WRIST PLATE MED JOINT STD CARPAL UNIVERSAL2 UHMWPE","SUP-ITM-10018346","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3445.82","2584.36","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","1800.79","52.26","","1113.10","1113.10","1113.10","1 through 10","1800.79","2815.92","percent of total billed charges",""
"WRIST PLATE MED JOINT STD CARPAL UNIVERSAL2 UHMWPE","SUP-ITM-10018346","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3445.82","2584.36","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2815.92","81.72","","1738.90","1484.65","2716.94","38","1800.79","2815.92","percent of total billed charges",""
"WRIST PLATE MED UNIVERSAL2 TITANIUM RADIAL LT UNIVERSAL","SUP-ITM-10018344","CDM","C1776","HCPCS","0278","RC","","","","both","","","14879.55","11159.66","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","7776.05","52.26","","1113.10","1113.10","1113.10","1 through 10","4612.66","11829.24","percent of total billed charges",""
"WRIST PLATE MED UNIVERSAL2 TITANIUM RADIAL LT UNIVERSAL","SUP-ITM-10018344","CDM","C1776","HCPCS","0278","RC","","","","both","","","14879.55","11159.66","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11829.24","79.5","","1293.60","1148.53","1603.80","1 through 10","4612.66","11829.24","percent of total billed charges",""
"WRIST PLATE MED UNIVERSAL2 TITANIUM RADIAL LT UNIVERSAL","SUP-ITM-10018344","CDM","C1776","HCPCS","0278","RC","","","","both","","","14879.55","11159.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5431.04","36.5","","1023.42","771.29","2068.67","33","4612.66","11829.24","percent of total billed charges",""
"WRIST PLATE MED UNIVERSAL2 TITANIUM RADIAL LT UNIVERSAL","SUP-ITM-10018344","CDM","C1776","HCPCS","0278","RC","","","","both","","","14879.55","11159.66","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","5698.87","38.3","","850.52","759.78","1211.25","66","4612.66","11829.24","percent of total billed charges",""
"WRIST PLATE MED UNIVERSAL2 TITANIUM RADIAL LT UNIVERSAL","SUP-ITM-10018344","CDM","C1776","HCPCS","0278","RC","","","","both","","","14879.55","11159.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6383.33","42.9","","2548.09","2548.09","2548.09","1 through 10","4612.66","11829.24","percent of total billed charges",""
"WRIST PLATE MED UNIVERSAL2 TITANIUM RADIAL LT UNIVERSAL","SUP-ITM-10018344","CDM","C1776","HCPCS","0278","RC","","","","both","","","14879.55","11159.66","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6383.33","42.9","","956.46","956.46","956.46","1 through 10","4612.66","11829.24","percent of total billed charges",""
"WRIST PLATE MED UNIVERSAL2 TITANIUM RADIAL LT UNIVERSAL","SUP-ITM-10018344","CDM","C1776","HCPCS","0278","RC","","","","both","","","14879.55","11159.66","WELLPOINT [1015]","HB AMC WELLPOINT","10978.13","73.78","","2344.73","1619.47","2530.35","16","4612.66","11829.24","percent of total billed charges",""
"WRIST PLATE MED UNIVERSAL2 TITANIUM RADIAL LT UNIVERSAL","SUP-ITM-10018344","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14879.55","11159.66","AETNA [1001]","HB AMC AETNA HMO","10385.93","69.8","","1523.63","988.41","4330.26","39","7776.05","12159.57","percent of total billed charges",""
"WRIST PLATE MED UNIVERSAL2 TITANIUM RADIAL LT UNIVERSAL","SUP-ITM-10018344","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14879.55","11159.66","AETNA [1001]","HB AMC AETNA PPO","11963.16","80.4","","1670.25","1670.25","1670.25","1 through 10","7776.05","12159.57","percent of total billed charges",""
"WRIST PLATE MED UNIVERSAL2 TITANIUM RADIAL LT UNIVERSAL","SUP-ITM-10018344","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14879.55","11159.66","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","7776.05","52.26","","1113.10","1113.10","1113.10","1 through 10","7776.05","12159.57","percent of total billed charges",""
"WRIST PLATE MED UNIVERSAL2 TITANIUM RADIAL LT UNIVERSAL","SUP-ITM-10018344","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14879.55","11159.66","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","12159.57","81.72","","1738.90","1484.65","2716.94","38","7776.05","12159.57","percent of total billed charges",""
"WRIST PLATE SM SZ 2 CARPAL NHPL PERI OP ORTHO JOINT","SUP-ITM-10146091","CDM","C1713","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","CIGNA [1006]","HB AMC CIGNA HMO / PPO","8530.85","79.5","","800.18","480.96","1887.97","195","3326.5","8530.85","percent of total billed charges",""
"WRIST PLATE SM SZ 2 CARPAL NHPL PERI OP ORTHO JOINT","SUP-ITM-10146091","CDM","C1713","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5719.43","53.3","","813.12","216.42","1444.50","81","3326.5","8530.85","percent of total billed charges",""
"WRIST PLATE SM SZ 2 CARPAL NHPL PERI OP ORTHO JOINT","SUP-ITM-10146091","CDM","C1713","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","3326.50","31","","432.60","432.60","432.60","1 through 10","3326.5","8530.85","percent of total billed charges",""
"WRIST PLATE SM SZ 2 CARPAL NHPL PERI OP ORTHO JOINT","SUP-ITM-10146091","CDM","C1713","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","3916.68","36.5","","148.37","54.89","631.39","94","3326.5","8530.85","percent of total billed charges",""
"WRIST PLATE SM SZ 2 CARPAL NHPL PERI OP ORTHO JOINT","SUP-ITM-10146091","CDM","C1713","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","4109.83","38.3","","279.30","91.72","1116.77","266","3326.5","8530.85","percent of total billed charges",""
"WRIST PLATE SM SZ 2 CARPAL NHPL PERI OP ORTHO JOINT","SUP-ITM-10146091","CDM","C1713","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4603.44","42.9","","731.00","63.70","731.00","1 through 10","3326.5","8530.85","percent of total billed charges",""
"WRIST PLATE SM SZ 2 CARPAL NHPL PERI OP ORTHO JOINT","SUP-ITM-10146091","CDM","C1713","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4603.44","42.9","","384.74","384.74","384.74","1 through 10","3326.5","8530.85","percent of total billed charges",""
"WRIST PLATE SM SZ 2 CARPAL NHPL PERI OP ORTHO JOINT","SUP-ITM-10146091","CDM","C1713","HCPCS","0278","RC","","","","both","","","10730.63","8047.97","WELLPOINT [1015]","HB AMC WELLPOINT","7917.06","73.78","","286.63","119.22","1107.45","105","3326.5","8530.85","percent of total billed charges",""
"WRIST PLATE SM SZ 2 CARPAL NHPL PERI OP ORTHO JOINT","SUP-ITM-10146091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10730.63","8047.97","AETNA [1001]","HB AMC AETNA HMO","7489.98","69.8","","675.31","184.75","1721.50","286","5607.83","8769.07","percent of total billed charges",""
"WRIST PLATE SM SZ 2 CARPAL NHPL PERI OP ORTHO JOINT","SUP-ITM-10146091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10730.63","8047.97","AETNA [1001]","HB AMC AETNA PPO","8627.43","80.4","","1261.44","103.12","1514.10","21","5607.83","8769.07","percent of total billed charges",""
"WRIST PLATE SM SZ 2 CARPAL NHPL PERI OP ORTHO JOINT","SUP-ITM-10146091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10730.63","8047.97","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","8627.43","80.4","","1365.00","1365.00","1365.00","1 through 10","5607.83","8769.07","percent of total billed charges",""
"WRIST PLATE SM SZ 2 CARPAL NHPL PERI OP ORTHO JOINT","SUP-ITM-10146091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10730.63","8047.97","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","8769.07","81.72","","5157.68","5157.68","5157.68","1 through 10","5607.83","8769.07","percent of total billed charges",""
"WRIST PLATE SM SZ 2 CARPAL NHPL PERI OP ORTHO JOINT","SUP-ITM-10146091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10730.63","8047.97","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","8769.07","81.72","","431.26","71.26","1459.57","88","5607.83","8769.07","percent of total billed charges",""
"X-PLATE","SUP-ITM-10317512","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2295.56","79.5","","800.18","480.96","1887.97","195","895.13","2295.56","percent of total billed charges",""
"X-PLATE","SUP-ITM-10317512","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1539.04","53.3","","813.12","216.42","1444.50","81","895.13","2295.56","percent of total billed charges",""
"X-PLATE","SUP-ITM-10317512","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","895.13","31","","432.60","432.60","432.60","1 through 10","895.13","2295.56","percent of total billed charges",""
"X-PLATE","SUP-ITM-10317512","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1053.94","36.5","","148.37","54.89","631.39","94","895.13","2295.56","percent of total billed charges",""
"X-PLATE","SUP-ITM-10317512","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1105.91","38.3","","279.30","91.72","1116.77","266","895.13","2295.56","percent of total billed charges",""
"X-PLATE","SUP-ITM-10317512","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1238.74","42.9","","731.00","63.70","731.00","1 through 10","895.13","2295.56","percent of total billed charges",""
"X-PLATE","SUP-ITM-10317512","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1238.74","42.9","","384.74","384.74","384.74","1 through 10","895.13","2295.56","percent of total billed charges",""
"X-PLATE","SUP-ITM-10317512","CDM","C1713","HCPCS","0278","RC","","","","both","","","2887.50","2165.62","WELLPOINT [1015]","HB AMC WELLPOINT","2130.40","73.78","","286.63","119.22","1107.45","105","895.13","2295.56","percent of total billed charges",""
"X-PLATE","SUP-ITM-10317512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2887.50","2165.62","AETNA [1001]","HB AMC AETNA HMO","2015.48","69.8","","675.31","184.75","1721.50","286","1509.01","2359.67","percent of total billed charges",""
"X-PLATE","SUP-ITM-10317512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2887.50","2165.62","AETNA [1001]","HB AMC AETNA PPO","2321.55","80.4","","1261.44","103.12","1514.10","21","1509.01","2359.67","percent of total billed charges",""
"X-PLATE","SUP-ITM-10317512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2887.50","2165.62","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2321.55","80.4","","1365.00","1365.00","1365.00","1 through 10","1509.01","2359.67","percent of total billed charges",""
"X-PLATE","SUP-ITM-10317512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2887.50","2165.62","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2359.67","81.72","","5157.68","5157.68","5157.68","1 through 10","1509.01","2359.67","percent of total billed charges",""
"X-PLATE","SUP-ITM-10317512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2887.50","2165.62","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2359.67","81.72","","431.26","71.26","1459.57","88","1509.01","2359.67","percent of total billed charges",""
"X-TACK ENDO HELIX TACK SYS GASTRIC","SUP-ITM-10340596","CDM","C1713","HCPCS","0278","RC","","","","both","","","2894.50","2170.87","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2301.13","79.5","","800.18","480.96","1887.97","195","897.3","2301.13","percent of total billed charges",""
"X-TACK ENDO HELIX TACK SYS GASTRIC","SUP-ITM-10340596","CDM","C1713","HCPCS","0278","RC","","","","both","","","2894.50","2170.87","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1542.77","53.3","","813.12","216.42","1444.50","81","897.3","2301.13","percent of total billed charges",""
"X-TACK ENDO HELIX TACK SYS GASTRIC","SUP-ITM-10340596","CDM","C1713","HCPCS","0278","RC","","","","both","","","2894.50","2170.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","897.30","31","","432.60","432.60","432.60","1 through 10","897.3","2301.13","percent of total billed charges",""
"X-TACK ENDO HELIX TACK SYS GASTRIC","SUP-ITM-10340596","CDM","C1713","HCPCS","0278","RC","","","","both","","","2894.50","2170.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1056.49","36.5","","148.37","54.89","631.39","94","897.3","2301.13","percent of total billed charges",""
"X-TACK ENDO HELIX TACK SYS GASTRIC","SUP-ITM-10340596","CDM","C1713","HCPCS","0278","RC","","","","both","","","2894.50","2170.87","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1108.59","38.3","","279.30","91.72","1116.77","266","897.3","2301.13","percent of total billed charges",""
"X-TACK ENDO HELIX TACK SYS GASTRIC","SUP-ITM-10340596","CDM","C1713","HCPCS","0278","RC","","","","both","","","2894.50","2170.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1241.74","42.9","","731.00","63.70","731.00","1 through 10","897.3","2301.13","percent of total billed charges",""
"X-TACK ENDO HELIX TACK SYS GASTRIC","SUP-ITM-10340596","CDM","C1713","HCPCS","0278","RC","","","","both","","","2894.50","2170.87","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1241.74","42.9","","384.74","384.74","384.74","1 through 10","897.3","2301.13","percent of total billed charges",""
"X-TACK ENDO HELIX TACK SYS GASTRIC","SUP-ITM-10340596","CDM","C1713","HCPCS","0278","RC","","","","both","","","2894.50","2170.87","WELLPOINT [1015]","HB AMC WELLPOINT","2135.56","73.78","","286.63","119.22","1107.45","105","897.3","2301.13","percent of total billed charges",""
"X-TACK ENDO HELIX TACK SYS GASTRIC","SUP-ITM-10340596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2894.50","2170.87","AETNA [1001]","HB AMC AETNA HMO","2020.36","69.8","","675.31","184.75","1721.50","286","1512.67","2365.39","percent of total billed charges",""
"X-TACK ENDO HELIX TACK SYS GASTRIC","SUP-ITM-10340596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2894.50","2170.87","AETNA [1001]","HB AMC AETNA PPO","2327.18","80.4","","1261.44","103.12","1514.10","21","1512.67","2365.39","percent of total billed charges",""
"X-TACK ENDO HELIX TACK SYS GASTRIC","SUP-ITM-10340596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2894.50","2170.87","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","2327.18","80.4","","1365.00","1365.00","1365.00","1 through 10","1512.67","2365.39","percent of total billed charges",""
"X-TACK ENDO HELIX TACK SYS GASTRIC","SUP-ITM-10340596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2894.50","2170.87","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","2365.39","81.72","","5157.68","5157.68","5157.68","1 through 10","1512.67","2365.39","percent of total billed charges",""
"X-TACK ENDO HELIX TACK SYS GASTRIC","SUP-ITM-10340596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2894.50","2170.87","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2365.39","81.72","","431.26","71.26","1459.57","88","1512.67","2365.39","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","941.00","705.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","748.10","79.5","","718.53","669.21","718.53","1 through 10","291.71","748.1","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","941.00","705.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","291.71","31","","564.24","282.12","564.24","1 through 10","291.71","748.1","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","941.00","705.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","343.47","36.5","","340.55","289.42","340.55","12","291.71","748.1","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","941.00","705.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","360.40","38.3","","356.98","356.98","356.98","106","291.71","748.1","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","941.00","705.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.69","42.9","","729.85","729.85","729.85","1 through 10","291.71","748.1","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","941.00","705.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.69","42.9","","401.45","401.45","401.45","1 through 10","291.71","748.1","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","941.00","705.75","WELLPOINT [1015]","HB AMC WELLPOINT","694.27","73.78","","679.73","679.73","1592.73","31","291.71","748.1","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","outpatient","","","941.00","705.75","AETNA [1001]","HB AMC AETNA HMO","656.82","69.8","","618.10","618.10","618.10","1 through 10","491.77","768.99","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","outpatient","","","941.00","705.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","756.56","80.4","","712.14","712.14","712.14","1 through 10","491.77","768.99","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","outpatient","","","941.00","705.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","768.99","81.72","","729.85","729.85","729.85","1 through 10","491.77","768.99","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","outpatient","","","941.00","705.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","768.99","81.72","","729.85","401.45","729.85","37","491.77","768.99","percent of total billed charges",""
"Xr 3d Rndr W/Postprocess","PX-32000255","CDM","76377","CPT","0320","RC","","","","both","","","1334.00","1000.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","486.91","36.5","","482.66","482.66","911.86","1 through 10","413.54","1060.53","percent of total billed charges",""
"Xr 3d Rndr W/Postprocess","PX-32000255","CDM","76377","CPT","0320","RC","","","","both","","","1334.00","1000.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","510.92","38.3","","505.95","505.95","505.95","12","413.54","1060.53","percent of total billed charges",""
"Xr 3d Rndr W/Postprocess","PX-32000255","CDM","76377","CPT","0320","RC","","","","both","","","1334.00","1000.50","WELLPOINT [1015]","HB AMC WELLPOINT","984.23","73.78","","963.38","923.91","963.38","1 through 10","413.54","1060.53","percent of total billed charges",""
"Xr 3d Rndr W/Postprocess","PX-32000255","CDM","76377","CPT","0320","RC","","","","outpatient","","","1334.00","1000.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1090.14","81.72","","1034.42","568.97","1034.42","1 through 10","697.15","1090.14","percent of total billed charges",""
"Xr 3d Rndr W/Postprocess","PX-32000255","CDM","76377","CPT","0320","RC","","","","outpatient","","","1334.00","1000.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1090.14","81.72","","1034.42","568.97","1034.42","16","697.15","1090.14","percent of total billed charges",""
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","both","","","1102.00","826.50","MEDICARE [2001]","HB BWH MEDICARE","651.07","","APC Price ($651.07). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","651.14","651.14","12","341.62","876.09","other","OPPS APC"
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","both","","","1102.00","826.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","402.23","36.5","","386.98","386.98","386.98","1 through 10","341.62","876.09","percent of total billed charges",""
"Xr Ac Joints Bilat W/W/O Weights","PX-32000094","CDM","73050","CPT","0320","RC","","","","both","","","562.00","421.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","99.34","451.85","other","OPPS APC"
"Xr Ac Joints Bilat W/W/O Weights","PX-32000094","CDM","73050","CPT","0320","RC","","","","both","","","562.00","421.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","446.79","79.5","","428.92","287.76","428.92","1 through 10","99.34","451.85","percent of total billed charges",""
"Xr Ac Joints Bilat W/W/O Weights","PX-32000094","CDM","73050","CPT","0320","RC","","","","both","","","562.00","421.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","299.55","53.3","","287.76","287.76","287.76","1 through 10","99.34","451.85","percent of total billed charges",""
"Xr Ac Joints Bilat W/W/O Weights","PX-32000094","CDM","73050","CPT","0320","RC","","","","both","","","562.00","421.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","215.25","38.3","","207.10","201.55","207.10","1 through 10","99.34","451.85","percent of total billed charges",""
"Xr Ac Joints Bilat W/W/O Weights","PX-32000094","CDM","73050","CPT","0320","RC","","","","both","","","562.00","421.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.87","102.87","102.87","1 through 10","99.34","451.85","other","OPPS APC"
"Xr Angio Ea Add Vessel","PX-32000346","CDM","75774","CPT","0323","RC","","","","both","","","3234.00","2425.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","2263.80","70","","3136.00","3136.00","3136.00","1 through 10","1002.54","2571.03","percent of total billed charges",""
"Xr Angio Ea Add Vessel","PX-32000346","CDM","75774","CPT","0323","RC","","","","both","","","3234.00","2425.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2571.03","79.5","","2468.03","2468.03","2468.03","1 through 10","1002.54","2571.03","percent of total billed charges",""
"Xr Angio Extremity Bilat","PX-32000333","CDM","75716","CPT","0323","RC","","","","both","","","9418.00","7063.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3678.04","3678.04","3678.04","1 through 10","2919.58","7487.31","other","OPPS APC"
"Xr Angio Extremity Bilat","PX-32000333","CDM","75716","CPT","0323","RC","","","","both","","","9418.00","7063.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","5019.79","53.3","","4822.22","4822.22","4822.22","1 through 10","2919.58","7487.31","percent of total billed charges",""
"Xr Angio Extremity Bilat","PX-32000333","CDM","75716","CPT","0323","RC","","","","both","","","9418.00","7063.50","MEDICARE [2001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","3737.85","1 through 10","2919.58","7487.31","other","OPPS APC"
"Xr Angio Extremity Bilat","PX-32000333","CDM","75716","CPT","0323","RC","","","","both","","","9418.00","7063.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3663.09","3663.09","3663.09","1 through 10","2919.58","7487.31","other","OPPS APC"
"Xr Angio Pelvic","PX-32000339","CDM","75736","CPT","0323","RC","","","","both","","","8650.00","6487.50","MEDICARE [2001]","HB BWH MEDICARE","6418.94","","APC Price ($6,418.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6419.59","6419.59","6419.59","1 through 10","2681.5","8023.68","other","OPPS APC"
"Xr Angio Spinal","PX-32000331","CDM","75705","CPT","0323","RC","","","","both","","","2298.00","1723.50","MEDICARE [2001]","HB BWH MEDICARE","6418.94","","APC Price ($6,418.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","299.89","299.89","534.97","32","712.38","8023.68","other","OPPS APC"
"Xr Angio Visceral W/W/O Flush","PX-32000336","CDM","75726","CPT","0323","RC","","","","both","","","14159.00","10619.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","6418.94","","APC Price ($6,418.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4530.62","4530.62","4530.62","1 through 10","4389.29","11256.41","other","OPPS APC"
"Xr Angio Visceral W/W/O Flush","PX-32000336","CDM","75726","CPT","0323","RC","","","","both","","","14159.00","10619.25","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","9911.30","70","","13731.00","13731.00","13731.00","1 through 10","4389.29","11256.41","percent of total billed charges",""
"Xr Angio Visceral W/W/O Flush","PX-32000336","CDM","75726","CPT","0323","RC","","","","both","","","14159.00","10619.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","11256.41","79.5","","10806.30","10806.30","10806.30","1 through 10","4389.29","11256.41","percent of total billed charges",""
"Xr Angio Visceral W/W/O Flush","PX-32000336","CDM","75726","CPT","0323","RC","","","","both","","","14159.00","10619.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","6418.94","","APC Price ($6,418.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4006.41","4006.41","4006.41","1 through 10","4389.29","11256.41","other","OPPS APC"
"Xr Angio Visceral W/W/O Flush","PX-32000336","CDM","75726","CPT","0323","RC","","","","both","","","14159.00","10619.25","MEDICARE [2001]","HB BWH MEDICARE","6418.94","","APC Price ($6,418.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3209.80","3209.80","3209.80","28","4389.29","11256.41","other","OPPS APC"
"Xr Angio Visceral W/W/O Flush","PX-32000336","CDM","75726","CPT","0323","RC","","","","both","","","14159.00","10619.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","5168.04","36.5","","5121.66","5121.66","5121.66","1 through 10","4389.29","11256.41","percent of total billed charges",""
"Xr Angio Visceral W/W/O Flush","PX-32000336","CDM","75726","CPT","0323","RC","","","","both","","","14159.00","10619.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","6418.94","","APC Price ($6,418.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4724.10","4724.10","4724.10","1 through 10","4389.29","11256.41","other","OPPS APC"
"Xr Angio Visceral W/W/O Flush","PX-32000336","CDM","75726","CPT","0323","RC","","","","both","","","14159.00","10619.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","6290.57","","APC Price ($6,418.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","18873.60","11323.41","18873.60","12","4389.29","11256.41","other","OPPS APC"
"Xr Angio Visceral W/W/O Flush","PX-32000336","CDM","75726","CPT","0323","RC","","","","both","","","14159.00","10619.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","6290.57","","APC Price ($6,418.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4840.81","4015.08","4840.81","1 through 10","4389.29","11256.41","other","OPPS APC"
"Xr Ankle 3+ Views","PX-32000177","CDM","73610","CPT","0320","RC","","","","both","","","590.00","442.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","469.05","79.5","","450.16","450.16","450.16","1 through 10","99.34","469.05","percent of total billed charges",""
"Xr Ankle 3+ Views","PX-32000177","CDM","73610","CPT","0320","RC","","","","both","","","590.00","442.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","43","99.34","469.05","other","OPPS APC"
"Xr Ankle 3+ Views","PX-32000177","CDM","73610","CPT","0320","RC","","","","outpatient","","","590.00","442.50","AETNA [1001]","HB AMC AETNA HMO","411.82","69.8","","387.24","387.24","774.49","1 through 10","128.23","482.15","percent of total billed charges",""
"Xr Ankle 3+ Views","PX-32000177","CDM","73610","CPT","0320","RC","","","","outpatient","","","590.00","442.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","482.15","81.72","","914.51","177.56","914.51","1 through 10","128.23","482.15","percent of total billed charges",""
"Xr Aortogram Abdomen W/Ser","PX-32000328","CDM","75625","CPT","0323","RC","","","","both","","","7776.00","5832.00","MEDICARE [2001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","3737.85","1 through 10","2410.56","6181.92","other","OPPS APC"
"Xr Aortogram Abdomen W/Ser","PX-32000328","CDM","75625","CPT","0323","RC","","","","both","","","7776.00","5832.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3663.39","3663.39","3663.39","1 through 10","2410.56","6181.92","other","OPPS APC"
"Xr Aortogram Abdomen W/Ser","PX-32000328","CDM","75625","CPT","0323","RC","","","","both","","","7776.00","5832.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","3662.72","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3666.10","3666.10","3666.10","1 through 10","2410.56","6181.92","other","OPPS APC"
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","both","","","349.00","261.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","277.46","79.5","","178.46","178.46","266.01","1 through 10","108.19","277.46","percent of total billed charges",""
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","both","","","349.00","261.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","186.02","53.3","","178.46","178.46","178.46","1 through 10","108.19","277.46","percent of total billed charges",""
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","both","","","349.00","261.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","127.39","36.5","","126.07","126.07","126.07","1 through 10","108.19","277.46","percent of total billed charges",""
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","both","","","349.00","261.75","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","108.19","277.46","other","Tricare OPPS"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","386.00","289.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","31","99.34","306.87","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","386.00","289.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","306.87","79.5","","294.34","294.34","294.34","1 through 10","99.34","306.87","percent of total billed charges",""
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","386.00","289.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","104.55","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.47","84.85","102.47","1 through 10","99.34","306.87","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","386.00","289.50","MEDICARE [2001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","515","99.34","306.87","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","386.00","289.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.47","97.20","307.41","19","99.34","306.87","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","386.00","289.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","204.94","1 through 10","99.34","306.87","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","386.00","289.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.20","104.56","88","99.34","306.87","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","outpatient","","","386.00","289.50","AETNA [1001]","HB AMC AETNA HMO","269.43","69.8","","253.20","253.20","253.20","1 through 10","128.23","315.44","percent of total billed charges",""
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","outpatient","","","386.00","289.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","315.44","81.72","","298.98","298.98","298.98","1 through 10","128.23","315.44","percent of total billed charges",""
"Xr Bone Density Appendicular|UNUSUAL SEPARATE SERVICE","PX-32000279","CDM","77081","CPT","0320","RC","","","XU","both","","","386.00","289.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","250.90","65","","243.10","243.10","243.10","1 through 10","250.9","270.2","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","AETNA [1001]","HB BWH AETNA MEDICARE REPLACEMENT","130.06","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","129.95","129.95","129.95","1 through 10","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","329","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","473.88","71.8","","459.52","459.52","459.52","1 through 10","119.97","524.7","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","429.00","65","","416.00","416.00","416.00","1 through 10","119.97","524.7","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","462.00","70","","512.00","511.62","640.00","1 through 10","119.97","524.7","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","230.85","119.99","230.85","1 through 10","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","524.70","79.5","","503.68","337.92","503.68","135","119.97","524.7","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","351.78","53.3","","337.92","337.92","503.68","70","119.97","524.7","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","102.65","123.76","17","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","ELDER SERVICES [1037]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","117.59","126.29","1 through 10","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","FALLON HEALTH [1008]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","371.28","1 through 10","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","352.77","123.76","352.77","1 through 10","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","508.20","77","","492.80","492.80","492.80","1 through 10","119.97","524.7","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.77","124.77","124.77","1 through 10","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","12","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC CIGNA HMO / PPO","524.70","79.5","","503.68","503.68","503.68","1 through 10","119.97","524.7","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","2004","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","204.60","31","","197.76","197.76","197.76","1 through 10","119.97","524.7","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","240.90","36.5","","238.72","202.88","463.36","85","119.97","524.7","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","252.78","38.3","","250.24","243.20","250.24","314","119.97","524.7","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","117.59","123.96","138","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","MOLINA [1014]","HB BWH MOLINA","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","250.05","239.98","250.05","1 through 10","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","508.20","77","","503.68","194.92","556.80","1 through 10","119.97","524.7","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","119.98","759.98","1 through 10","119.97","524.7","other","Tricare OPPS"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.99","119.99","126.29","1 through 10","119.97","524.7","other","Tricare OPPS"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","371.28","106","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","283.14","42.9","","511.62","281.41","511.62","1 through 10","119.97","524.7","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","117.60","126.29","503","119.97","524.7","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","660.00","495.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","283.14","42.9","","281.41","281.41","281.41","1 through 10","119.97","524.7","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","660.00","495.00","AETNA [1001]","HB AMC AETNA HMO","460.68","69.8","","433.28","433.28","433.28","22","231.59","539.35","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","660.00","495.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","344.92","52.26","","231.59","231.59","396.04","1 through 10","231.59","539.35","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","539.35","81.72","","511.62","511.62","511.62","1 through 10","231.59","539.35","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","539.35","81.72","","511.62","281.41","511.62","116","231.59","539.35","percent of total billed charges",""
"Xr Bone Density Hip/Pelvis/Spine Inc Verterbral Fx Assessment","PX-32000402","CDM","77085","CPT","0320","RC","","","","both","","","626.00","469.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.59","117.59","117.59","1 through 10","119.97","497.67","other","OPPS APC"
"Xr Bone Density Hip/Pelvis/Spine Inc Verterbral Fx Assessment","PX-32000402","CDM","77085","CPT","0320","RC","","","","both","","","626.00","469.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","17","119.97","497.67","other","OPPS APC"
"Xr Bone Density Hip/Pelvis/Spine Inc Verterbral Fx Assessment","PX-32000402","CDM","77085","CPT","0320","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","239.76","38.3","","237.34","237.34","237.34","1 through 10","119.97","497.67","percent of total billed charges",""
"Xr Bone Density Hip/Pelvis/Spine Inc Verterbral Fx Assessment","PX-32000402","CDM","77085","CPT","0320","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","119.97","497.67","other","OPPS APC"
"Xr Bone Density Hip/Pelvis/Spine Inc Verterbral Fx Assessment","PX-32000402","CDM","77085","CPT","0320","RC","","","","both","","","626.00","469.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.77","126.29","1 through 10","119.97","497.67","other","OPPS APC"
"Xr Bone Density Hip/Pelvis/Spine Inc Verterbral Fx Assessment","PX-32000402","CDM","77085","CPT","0320","RC","","","","both","","","626.00","469.50","WELLPOINT [1015]","HB AMC WELLPOINT","461.86","73.78","","451.91","451.91","451.91","1 through 10","119.97","497.67","percent of total billed charges",""
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","556.00","417.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","454.36","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","556.00","417.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","442.02","79.5","","424.19","284.59","424.19","1 through 10","119.97","454.36","percent of total billed charges",""
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","556.00","417.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","17","119.97","454.36","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","556.00","417.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","202.94","36.5","","201.05","201.05","201.05","1 through 10","119.97","454.36","percent of total billed charges",""
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","556.00","417.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","212.95","38.3","","210.75","204.82","210.75","1 through 10","119.97","454.36","percent of total billed charges",""
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","556.00","417.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.96","117.89","123.96","1 through 10","119.97","454.36","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","556.00","417.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","454.36","81.72","","430.88","267.89","430.88","1 through 10","119.97","454.36","percent of total billed charges",""
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","556.00","417.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","123.97","126.29","1 through 10","119.97","454.36","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","556.00","417.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","238.52","42.9","","237.00","237.00","237.00","1 through 10","119.97","454.36","percent of total billed charges",""
"Xr Bone Survey Cmpl","PX-32000275","CDM","77075","CPT","0320","RC","","","","both","","","1286.00","964.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","124.27","126.29","1 through 10","119.97","1022.37","other","OPPS APC"
"Xr Bone Survey Cmpl","PX-32000275","CDM","77075","CPT","0320","RC","","","","both","","","1286.00","964.50","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","843.62","65.6","","844.22","844.22","844.22","1 through 10","119.97","1022.37","percent of total billed charges",""
"Xr Bone Survey Cmpl","PX-32000275","CDM","77075","CPT","0320","RC","","","","both","","","1286.00","964.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1022.37","79.5","","658.42","658.42","658.42","1 through 10","119.97","1022.37","percent of total billed charges",""
"Xr Bone Survey Cmpl","PX-32000275","CDM","77075","CPT","0320","RC","","","","both","","","1286.00","964.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","1022.37","other","OPPS APC"
"Xr Bone Survey Cmpl","PX-32000275","CDM","77075","CPT","0320","RC","","","","both","","","1286.00","964.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","469.39","36.5","","395.30","395.30","395.30","1 through 10","119.97","1022.37","percent of total billed charges",""
"Xr Bone Survey Cmpl","PX-32000275","CDM","77075","CPT","0320","RC","","","","both","","","1286.00","964.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","123.76","124.16","1 through 10","119.97","1022.37","other","OPPS APC"
"Xr Bone Survey Cmpl","PX-32000275","CDM","77075","CPT","0320","RC","","","","both","","","1286.00","964.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","123.77","123.77","1 through 10","119.97","1022.37","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","104.56","25","99.34","452.36","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","408.54","71.8","","77.53","77.53","77.53","1 through 10","99.34","452.36","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","452.36","79.5","","434.42","291.46","437.64","41","99.34","452.36","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","303.28","53.3","","291.46","291.46","434.42","26","99.34","452.36","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","88.05","84.85","102.89","1 through 10","99.34","452.36","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","438.13","77","","425.04","425.04","425.04","1 through 10","99.34","452.36","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","HUMANA [1012]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","452.36","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","MEDICARE [2001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","58","99.34","452.36","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","176.39","31","","170.57","170.57","170.57","1 through 10","99.34","452.36","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","207.69","36.5","","205.90","174.98","617.70","30","99.34","452.36","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","217.93","38.3","","215.83","215.83","215.83","76","99.34","452.36","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.47","102.47","102.77","1 through 10","99.34","452.36","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","MOLINA [1014]","HB BWH MOLINA","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.45","207.45","207.45","1 through 10","99.34","452.36","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","TRICARE [160005]","HB BWH TRICARE","99.34","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","104.56","99.33","552.00","1 through 10","99.34","452.36","other","Tricare OPPS"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.60","103.07","1 through 10","99.34","452.36","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.96","126.96","126.96","1 through 10","99.34","452.36","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","569.00","426.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.40","102.97","32","99.34","452.36","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","569.00","426.75","AETNA [1001]","HB AMC AETNA HMO","397.16","69.8","","373.70","373.70","373.70","1 through 10","128.23","464.99","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","569.00","426.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","457.48","80.4","","430.56","430.56","430.56","1 through 10","128.23","464.99","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","569.00","426.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","464.99","81.72","","242.71","242.71","242.71","1 through 10","128.23","464.99","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","569.00","426.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","464.99","81.72","","441.27","242.71","441.27","18","128.23","464.99","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","795.00","596.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","118.07","126.29","1 through 10","119.97","632.03","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","795.00","596.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","632.03","79.5","","606.78","407.09","606.78","12","119.97","632.03","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","795.00","596.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","423.74","53.3","","407.09","407.09","606.78","1 through 10","119.97","632.03","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","795.00","596.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","632.03","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","795.00","596.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","22","119.97","632.03","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","246.45","31","","238.24","238.24","238.24","1 through 10","119.97","632.03","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","290.18","36.5","","287.58","279.10","287.58","1 through 10","119.97","632.03","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","304.49","38.3","","301.46","301.46","301.46","18","119.97","632.03","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.96","123.96","123.96","1 through 10","119.97","632.03","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","795.00","596.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","123.76","124.36","1 through 10","119.97","632.03","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","795.00","596.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","177.33","177.33","177.33","1 through 10","119.97","632.03","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","117.90","126.29","1 through 10","119.97","632.03","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","795.00","596.25","AETNA [1001]","HB AMC AETNA HMO","554.91","69.8","","521.97","521.97","521.97","1 through 10","231.59","649.67","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","795.00","596.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","415.47","52.26","","477.10","231.59","477.10","1 through 10","231.59","649.67","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","639.18","80.4","","601.38","601.38","601.38","1 through 10","231.59","649.67","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","649.67","81.72","","616.34","616.33","616.34","1 through 10","231.59","649.67","percent of total billed charges",""
"Xr C-Spine 6 or More Views","PX-32000058","CDM","72052","CPT","0320","RC","","","","both","","","1025.00","768.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","546.33","53.3","","782.28","782.28","782.28","1 through 10","119.97","814.88","percent of total billed charges",""
"Xr C-Spine 6 or More Views","PX-32000058","CDM","72052","CPT","0320","RC","","","","both","","","1025.00","768.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","124.07","124.07","1 through 10","119.97","814.88","other","OPPS APC"
"Xr Calcaneus 2+ Views","PX-32000189","CDM","73650","CPT","0320","RC","","","","both","","","420.00","315.00","ELDER SERVICES [1037]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","333.9","other","OPPS APC"
"Xr Calcaneus 2+ Views","PX-32000189","CDM","73650","CPT","0320","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.77","102.77","1 through 10","99.34","333.9","other","OPPS APC"
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","both","","","1345.00","1008.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","941.50","70","","938.87","938.87","938.87","1 through 10","416.95","1069.28","percent of total billed charges",""
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","both","","","1345.00","1008.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1069.28","79.5","","1026.25","1026.25","1026.25","1 through 10","416.95","1069.28","percent of total billed charges",""
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","both","","","1345.00","1008.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","716.89","53.3","","688.51","688.51","688.51","1 through 10","416.95","1069.28","percent of total billed charges",""
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","both","","","1345.00","1008.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","490.93","36.5","","472.05","472.05","472.05","1 through 10","416.95","1069.28","percent of total billed charges",""
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","both","","","1345.00","1008.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","515.14","38.3","","509.86","486.39","509.86","1 through 10","416.95","1069.28","percent of total billed charges",""
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","both","","","1345.00","1008.75","WELLPOINT [1015]","HB AMC WELLPOINT","992.34","73.78","","970.82","970.82","970.83","1 through 10","416.95","1069.28","percent of total billed charges",""
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","outpatient","","","1345.00","1008.75","AETNA [1001]","HB AMC AETNA HMO","938.81","69.8","","882.81","882.81","882.81","1 through 10","702.9","1099.13","percent of total billed charges",""
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","outpatient","","","1345.00","1008.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1099.13","81.72","","1042.42","573.37","1042.42","1 through 10","702.9","1099.13","percent of total billed charges",""
"Xr Change Tube/Drainage Catheter","PX-32000317","CDM","75984","CPT","0320","RC","","","","outpatient","","","1491.00","1118.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1218.45","81.72","","1155.93","1155.93","1155.93","1 through 10","779.2","1218.45","percent of total billed charges",""
"Xr Clavicle Cmpl","PX-32000084","CDM","73000","CPT","0320","RC","","","","both","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.97","102.77","102.97","1 through 10","99.34","338.67","other","OPPS APC"
"Xr Clavicle Cmpl","PX-32000084","CDM","73000","CPT","0320","RC","","","","outpatient","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","348.13","81.72","","186.28","186.28","186.28","1 through 10","128.23","348.13","percent of total billed charges",""
"Xr Cystogram 3+ Views","PX-32000229","CDM","74430","CPT","0320","RC","","","","both","","","1094.00","820.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","339.14","869.73","other","OPPS APC"
"Xr Cystogram 3+ Views","PX-32000229","CDM","74430","CPT","0320","RC","","","","both","","","1094.00","820.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","869.73","79.5","","835.01","835.01","835.01","1 through 10","339.14","869.73","percent of total billed charges",""
"Xr Cystogram 3+ Views","PX-32000229","CDM","74430","CPT","0320","RC","","","","both","","","1094.00","820.50","HEALTH NEW ENGLAND [1034]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.02","419.02","419.02","1 through 10","339.14","869.73","other","OPPS APC"
"Xr Cystogram 3+ Views","PX-32000229","CDM","74430","CPT","0320","RC","","","","both","","","1094.00","820.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","711.10","65","","689.65","689.65","689.65","1 through 10","339.14","869.73","percent of total billed charges",""
"Xr Cystogram 3+ Views","PX-32000229","CDM","74430","CPT","0320","RC","","","","both","","","1094.00","820.50","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","38","339.14","869.73","other","OPPS APC"
"Xr Cystogram 3+ Views","PX-32000229","CDM","74430","CPT","0320","RC","","","","both","","","1094.00","820.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","399.31","36.5","","395.75","395.75","395.75","1 through 10","339.14","869.73","percent of total billed charges",""
"Xr Cystogram 3+ Views","PX-32000229","CDM","74430","CPT","0320","RC","","","","both","","","1094.00","820.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","411.34","411.34","411.34","1 through 10","339.14","869.73","other","OPPS APC"
"Xr Cystogram 3+ Views","PX-32000229","CDM","74430","CPT","0320","RC","","","","both","","","1094.00","820.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","416.13","415.63","416.33","1 through 10","339.14","869.73","other","OPPS APC"
"Xr Cystourethrogram Retrograde","PX-32000231","CDM","74450","CPT","0320","RC","","","","both","","","1144.00","858.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","909.48","79.5","","872.78","585.55","872.78","1 through 10","272.7","909.48","percent of total billed charges",""
"Xr Cystourethrogram Retrograde","PX-32000231","CDM","74450","CPT","0320","RC","","","","both","","","1144.00","858.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","609.75","53.3","","585.55","585.55","585.55","1 through 10","272.7","909.48","percent of total billed charges",""
"Xr Cystourethrogram Retrograde","PX-32000231","CDM","74450","CPT","0320","RC","","","","both","","","1144.00","858.00","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","909.48","other","OPPS APC"
"Xr Elbow Cmpl 3+ Views","PX-32000103","CDM","73080","CPT","0320","RC","","","","both","","","542.00","406.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","430.89","79.5","","413.96","413.96","413.96","1 through 10","99.34","430.89","percent of total billed charges",""
"Xr Elbow Cmpl 3+ Views","PX-32000103","CDM","73080","CPT","0320","RC","","","","both","","","542.00","406.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","12","99.34","430.89","other","OPPS APC"
"Xr Elbow Cmpl 3+ Views","PX-32000103","CDM","73080","CPT","0320","RC","","","","outpatient","","","542.00","406.50","AETNA [1001]","HB AMC AETNA HMO","378.32","69.8","","356.10","356.10","356.10","1 through 10","128.23","442.92","percent of total billed charges",""
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","2555.00","1916.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","2031.23","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","2555.00","1916.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","2031.23","79.5","","1950.19","1308.38","1950.19","1 through 10","200.84","2031.23","percent of total billed charges",""
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","2555.00","1916.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1361.82","53.3","","1950.19","1308.38","1950.19","1 through 10","200.84","2031.23","percent of total billed charges",""
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","2555.00","1916.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","2031.23","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","2555.00","1916.25","FALLON HEALTH [1008]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","621.54","621.54","621.54","1 through 10","200.84","2031.23","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","2555.00","1916.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","1660.75","65","","1610.70","1610.70","1610.70","1 through 10","200.84","2031.23","percent of total billed charges",""
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","2555.00","1916.25","MARTIN'S POINT [160007]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","197.12","197.12","197.12","1 through 10","200.84","2031.23","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","2555.00","1916.25","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","27","200.84","2031.23","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","932.58","36.5","","924.29","785.53","924.29","1 through 10","200.84","2031.23","percent of total billed charges",""
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","978.57","38.3","","968.90","968.90","968.90","1 through 10","200.84","2031.23","percent of total billed charges",""
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","2555.00","1916.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.18","207.18","207.18","1 through 10","200.84","2031.23","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","2555.00","1916.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.58","207.58","207.78","1 through 10","200.84","2031.23","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","207.69","211.41","1 through 10","200.84","2031.23","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","outpatient","","","2555.00","1916.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","2087.95","81.72","","1980.91","1089.58","1980.91","1 through 10","415.26","2087.95","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1322.00","991.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","131.24","457.74","1 through 10","200.84","1050.99","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1322.00","991.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1050.99","79.5","","1008.93","676.90","1008.93","1 through 10","200.84","1050.99","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1322.00","991.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","1050.99","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1322.00","991.50","HUMANA [1012]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.87","208.87","208.87","1 through 10","200.84","1050.99","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1322.00","991.50","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","40","200.84","1050.99","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1322.00","991.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","409.82","31","","396.14","396.14","396.14","1 through 10","200.84","1050.99","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1322.00","991.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","482.53","36.5","","478.19","478.19","478.19","1 through 10","200.84","1050.99","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1322.00","991.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","506.33","38.3","","501.26","501.26","501.26","1 through 10","200.84","1050.99","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1322.00","991.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","622.34","207.18","622.34","1 through 10","200.84","1050.99","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1322.00","991.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.49","207.18","208.03","1 through 10","200.84","1050.99","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","outpatient","","","1322.00","991.50","AETNA [1001]","HB AMC AETNA HMO","922.76","69.8","","867.91","867.91","867.91","1 through 10","415.26","1080.34","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","outpatient","","","1322.00","991.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1080.34","81.72","","1024.83","1024.83","1024.83","1 through 10","415.26","1080.34","percent of total billed charges",""
"Xr Esophagus|REDUCED SERVICES","PX-32000198","CDM","74220","CPT","0320","RC","","","52","both","","","1322.00","991.50","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","105.70","105.70","105.70","1 through 10","200.84","264.24","other","OPPS APC"
"Xr Facial Bones 3+ Views","PX-32000012","CDM","70150","CPT","0320","RC","","","","both","","","650.00","487.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","516.75","79.5","","332.64","332.64","332.64","1 through 10","119.97","516.75","percent of total billed charges",""
"Xr Facial Bones 3+ Views","PX-32000012","CDM","70150","CPT","0320","RC","","","","both","","","650.00","487.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","516.75","other","OPPS APC"
"Xr Facial Bones 3+ Views","PX-32000012","CDM","70150","CPT","0320","RC","","","","both","","","650.00","487.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","248.95","38.3","","246.33","246.33","246.33","1 through 10","119.97","516.75","percent of total billed charges",""
"Xr Facial Bones 3+ Views","PX-32000012","CDM","70150","CPT","0320","RC","","","","both","","","650.00","487.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","119.97","516.75","other","OPPS APC"
"Xr Finger(S) 2+ Views","PX-32000131","CDM","73140","CPT","0320","RC","","","","both","","","473.00","354.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","376.04","79.5","","240.54","240.54","240.54","1 through 10","99.34","376.04","percent of total billed charges",""
"Xr Finger(S) 2+ Views","PX-32000131","CDM","73140","CPT","0320","RC","","","","both","","","473.00","354.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","13","99.34","376.04","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","287.06","1 through 10","272.7","1374.56","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1374.56","79.5","","1319.80","1319.80","1319.80","1 through 10","272.7","1374.56","percent of total billed charges",""
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","921.56","53.3","","885.46","885.46","885.46","1 through 10","272.7","1374.56","percent of total billed charges",""
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","1374.56","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","HUMANA [1012]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.04","283.04","283.04","1 through 10","272.7","1374.56","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","16","272.7","1374.56","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","631.09","36.5","","625.52","625.52","625.52","1 through 10","272.7","1374.56","percent of total billed charges",""
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","662.21","38.3","","1967.13","1967.13","1967.13","1 through 10","272.7","1374.56","percent of total billed charges",""
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","281.32","281.32","1 through 10","272.7","1374.56","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","1729.00","1296.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.82","281.62","281.82","1 through 10","272.7","1374.56","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","outpatient","","","1729.00","1296.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1412.94","81.72","","1340.59","1253.72","1340.59","1 through 10","474.59","1412.94","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","1529.00","1146.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","1003.02","65.6","","1003.99","1003.99","1156.74","1 through 10","473.99","1215.56","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","1529.00","1146.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","993.85","65","","1167.12","783.02","1167.12","1 through 10","473.99","1215.56","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","1529.00","1146.75","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","1070.30","70","","1186.40","610.40","2135.52","56","473.99","1215.56","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","1529.00","1146.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1215.56","79.5","","1167.12","783.02","1167.12","36","473.99","1215.56","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","1529.00","1146.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","814.96","53.3","","1167.12","783.02","1723.86","21","473.99","1215.56","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","1529.00","1146.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","993.85","65","","1149.85","963.95","1149.85","1 through 10","473.99","1215.56","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","1529.00","1146.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","473.99","31","","458.25","458.25","458.25","1 through 10","473.99","1215.56","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","1529.00","1146.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","558.09","36.5","","553.16","470.11","553.16","15","473.99","1215.56","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","1529.00","1146.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","585.61","38.3","","579.85","563.54","579.85","25","473.99","1215.56","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","1529.00","1146.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","655.94","42.9","","1483.00","1185.51","1483.00","1 through 10","473.99","1215.56","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","1529.00","1146.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","655.94","42.9","","1185.51","1185.51","1185.51","1 through 10","473.99","1215.56","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","1529.00","1146.75","WELLPOINT [1015]","HB AMC WELLPOINT","1128.10","73.78","","1104.09","1104.09","1104.09","25","473.99","1215.56","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1529.00","1146.75","AETNA [1001]","HB AMC AETNA HMO","1067.24","69.8","","1003.99","1003.99","1483.00","1 through 10","799.06","1249.5","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1529.00","1146.75","AETNA [1001]","HB AMC AETNA PPO","1229.32","80.4","","1156.74","1156.74","1156.74","1 through 10","799.06","1249.5","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1529.00","1146.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","799.06","52.26","","917.69","917.69","917.69","1 through 10","799.06","1249.5","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1529.00","1146.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","1229.32","80.4","","1156.74","1156.74","1156.74","1 through 10","799.06","1249.5","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1529.00","1146.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1249.50","81.72","","1185.51","652.08","1185.51","1 through 10","799.06","1249.5","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1529.00","1146.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1249.50","81.72","","1185.51","652.08","1185.51","41","799.06","1249.5","percent of total billed charges",""
"Xr Fluoro Needle Localization","PX-32000365","CDM","77003","CPT","0320","RC","","","","both","","","1055.00","791.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","838.73","79.5","","805.10","540.14","805.10","1 through 10","327.05","838.73","percent of total billed charges",""
"Xr Fluoro Needle Localization","PX-32000365","CDM","77003","CPT","0320","RC","","","","both","","","1055.00","791.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","562.32","53.3","","540.14","540.14","540.14","1 through 10","327.05","838.73","percent of total billed charges",""
"Xr Fluoro Needle Localization","PX-32000365","CDM","77003","CPT","0320","RC","","","","both","","","1055.00","791.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","385.08","36.5","","972.87","324.29","972.87","1 through 10","327.05","838.73","percent of total billed charges",""
"Xr Fluoro Needle Localization","PX-32000365","CDM","77003","CPT","0320","RC","","","","both","","","1055.00","791.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","404.07","38.3","","399.99","399.99","399.99","1 through 10","327.05","838.73","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","1060.00","795.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT AETNA","695.36","65.6","","801.84","801.84","801.84","1 through 10","328.6","842.7","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","1060.00","795.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","842.70","79.5","","809.04","542.78","809.04","32","328.6","842.7","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","1060.00","795.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","564.98","53.3","","542.78","542.78","809.04","23","328.6","842.7","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","1060.00","795.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","689.00","65","","668.20","668.20","668.20","1 through 10","328.6","842.7","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","1060.00","795.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","328.60","31","","317.65","317.65","317.65","1 through 10","328.6","842.7","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","1060.00","795.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","386.90","36.5","","372.14","325.88","383.44","23","328.6","842.7","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","1060.00","795.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","405.98","38.3","","401.95","390.64","401.95","98","328.6","842.7","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","1060.00","795.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","816.20","77","","801.83","801.83","801.83","1 through 10","328.6","842.7","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","1060.00","795.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","454.74","42.9","","821.79","452.01","821.79","1 through 10","328.6","842.7","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","1060.00","795.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","454.74","42.9","","452.01","452.01","452.01","1 through 10","328.6","842.7","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","1060.00","795.00","WELLPOINT [1015]","HB AMC WELLPOINT","782.07","73.78","","765.35","765.35","765.35","31","328.6","842.7","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","outpatient","","","1060.00","795.00","AETNA [1001]","HB AMC AETNA HMO","739.88","69.8","","695.96","695.96","695.96","1 through 10","553.96","866.23","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","outpatient","","","1060.00","795.00","AETNA [1001]","HB AMC AETNA PPO","852.24","80.4","","801.84","801.84","801.84","1 through 10","553.96","866.23","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","outpatient","","","1060.00","795.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","852.24","80.4","","695.96","695.96","695.96","1 through 10","553.96","866.23","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","outpatient","","","1060.00","795.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","866.23","81.72","","821.78","452.01","821.79","27","553.96","866.23","percent of total billed charges",""
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","both","","","487.00","365.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","374.99","77","","410.64","410.64","410.64","1 through 10","99.34","387.17","percent of total billed charges",""
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","both","","","487.00","365.25","TRICARE [160005]","HB BWH TRICARE","99.34","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","104.56","104.56","104.56","1 through 10","99.34","387.17","other","Tricare OPPS"
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","both","","","487.00","365.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.47","102.97","55","99.34","387.17","other","OPPS APC"
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","both","","","487.00","365.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","208.92","42.9","","207.54","207.54","207.54","1 through 10","99.34","387.17","percent of total billed charges",""
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","outpatient","","","487.00","365.25","AETNA [1001]","HB AMC AETNA HMO","339.93","69.8","","319.54","225.62","639.09","18","128.23","397.98","percent of total billed charges",""
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","outpatient","","","487.00","365.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","397.98","81.72","","754.64","754.64","754.64","1 through 10","128.23","397.98","percent of total billed charges",""
"Xr Forearm 2 Views","PX-32000109","CDM","73090","CPT","0320","RC","","","","both","","","410.00","307.50","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","22.87","22.87","22.87","1 through 10","99.34","325.95","other","OPPS APC"
"Xr Forearm 2 Views","PX-32000109","CDM","73090","CPT","0320","RC","","","","both","","","410.00","307.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.97","97.50","102.97","1 through 10","99.34","325.95","other","OPPS APC"
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","both","","","487.00","365.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","130.69","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","102.47","102.47","102.47","1 through 10","99.34","387.17","other","OPPS APC"
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","both","","","487.00","365.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","387.17","79.5","","371.46","371.46","371.46","1 through 10","99.34","387.17","percent of total billed charges",""
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","both","","","487.00","365.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","37","99.34","387.17","other","OPPS APC"
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","outpatient","","","487.00","365.25","AETNA [1001]","HB AMC AETNA HMO","339.93","69.8","","451.23","225.62","639.09","1 through 10","128.23","397.98","percent of total billed charges",""
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","outpatient","","","487.00","365.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","397.98","81.72","","754.64","415.08","754.64","25","128.23","397.98","percent of total billed charges",""
"Xr Humerus 2+ Views","PX-32000097","CDM","73060","CPT","0320","RC","","","","both","","","445.00","333.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","353.78","79.5","","339.98","339.98","339.98","1 through 10","99.34","353.78","percent of total billed charges",""
"Xr Humerus 2+ Views","PX-32000097","CDM","73060","CPT","0320","RC","","","","outpatient","","","445.00","333.75","AETNA [1001]","HB AMC AETNA HMO","310.61","69.8","","292.46","292.46","292.46","1 through 10","128.23","363.65","percent of total billed charges",""
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1262.00","946.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1003.29","79.5","","895.75","646.27","963.29","1 through 10","272.7","1003.29","percent of total billed charges",""
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1262.00","946.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","672.65","53.3","","646.27","646.27","646.27","1 through 10","272.7","1003.29","percent of total billed charges",""
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1262.00","946.50","MEDICARE [2001]","HB BWH MEDICARE","287.03","","APC Price ($287.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","267.44","267.44","267.44","1 through 10","272.7","1003.29","other","OPPS APC"
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1262.00","946.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","460.63","36.5","","456.55","388.01","1164.03","11","272.7","1003.29","percent of total billed charges",""
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1262.00","946.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","483.35","38.3","","478.58","465.12","478.58","26","272.7","1003.29","percent of total billed charges",""
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1262.00","946.50","TRICARE [160005]","HB BWH TRICARE","272.70","","APC Price ($287.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","287.06","287.06","287.06","1 through 10","272.7","1003.29","other","Tricare OPPS"
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1262.00","946.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","287.06","287.06","287.06","1 through 10","272.7","1003.29","other","OPPS APC"
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","outpatient","","","1262.00","946.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1031.31","81.72","","978.47","978.47","978.47","1 through 10","474.59","1325.45","percent of total billed charges",""
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","outpatient","","","1262.00","946.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1031.31","81.72","","978.46","538.19","978.47","11","474.59","1325.45","percent of total billed charges",""
"Xr Joint Survey 1 View","PX-32000277","CDM","77077","CPT","0320","RC","","","","both","","","582.00","436.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","462.69","other","OPPS APC"
"Xr Joint Survey 1 View","PX-32000277","CDM","77077","CPT","0320","RC","","","","both","","","582.00","436.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","462.69","79.5","","443.87","297.79","443.87","1 through 10","119.97","462.69","percent of total billed charges",""
"Xr Joint Survey 1 View","PX-32000277","CDM","77077","CPT","0320","RC","","","","both","","","582.00","436.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","310.21","53.3","","297.79","297.79","297.79","1 through 10","119.97","462.69","percent of total billed charges",""
"Xr Knee 1-2 Views","PX-32000154","CDM","73560","CPT","0320","RC","","","","both","","","436.00","327.00","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","283.40","65","","224.19","224.19","224.19","1 through 10","99.34","346.62","percent of total billed charges",""
"Xr Knee 1-2 Views","PX-32000154","CDM","73560","CPT","0320","RC","","","","both","","","436.00","327.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","13","99.34","346.62","other","OPPS APC"
"Xr Knee 1-2 Views","PX-32000154","CDM","73560","CPT","0320","RC","","","","outpatient","","","436.00","327.00","AETNA [1001]","HB AMC AETNA HMO","304.33","69.8","","286.37","286.37","286.37","1 through 10","128.23","356.3","percent of total billed charges",""
"Xr Knee 1-2 Views","PX-32000154","CDM","73560","CPT","0320","RC","","","","outpatient","","","436.00","327.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","356.30","81.72","","341.40","341.40","341.40","1 through 10","128.23","356.3","percent of total billed charges",""
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","both","","","539.00","404.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","130.69","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","153.04","153.04","153.04","1 through 10","99.34","428.51","other","OPPS APC"
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","both","","","539.00","404.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","428.51","79.5","","1323.20","411.60","1323.20","1 through 10","99.34","428.51","percent of total billed charges",""
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","both","","","539.00","404.25","ELDER SERVICES [1037]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","99.18","99.18","99.18","1 through 10","99.34","428.51","other","OPPS APC"
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","both","","","539.00","404.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.89","97.50","102.97","36","99.34","428.51","other","OPPS APC"
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","outpatient","","","539.00","404.25","AETNA [1001]","HB AMC AETNA HMO","376.22","69.8","","354.07","354.07","708.14","1 through 10","128.23","440.47","percent of total billed charges",""
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","both","","","647.00","485.25","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","157.84","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","298.28","298.28","298.28","1 through 10","119.97","514.37","other","OPPS APC"
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","both","","","647.00","485.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","514.37","79.5","","493.45","459.19","493.45","1 through 10","119.97","514.37","percent of total billed charges",""
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","both","","","647.00","485.25","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","127.20","10.93","127.20","1 through 10","119.97","514.37","other","OPPS APC"
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","both","","","647.00","485.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","420.55","65","","332.31","332.31","332.31","1 through 10","119.97","514.37","percent of total billed charges",""
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","both","","","647.00","485.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","514.37","other","OPPS APC"
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","both","","","647.00","485.25","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","514.37","other","Tricare OPPS"
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","both","","","647.00","485.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","117.90","124.27","87","119.97","514.37","other","OPPS APC"
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","outpatient","","","647.00","485.25","AETNA [1001]","HB AMC AETNA HMO","451.61","69.8","","424.48","424.48","424.48","1 through 10","231.59","528.73","percent of total billed charges",""
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","outpatient","","","647.00","485.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","528.73","81.72","","336.40","336.40","336.40","1 through 10","231.59","528.73","percent of total billed charges",""
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","both","","","483.00","362.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","99.34","383.99","other","OPPS APC"
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","both","","","483.00","362.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","383.99","79.5","","368.32","247.10","1479.57","1 through 10","99.34","383.99","percent of total billed charges",""
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","both","","","483.00","362.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","257.44","53.3","","368.32","247.10","368.32","1 through 10","99.34","383.99","percent of total billed charges",""
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","both","","","483.00","362.25","MEDICARE [2001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","383.99","other","OPPS APC"
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","both","","","483.00","362.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","149.73","31","","144.61","144.61","144.61","1 through 10","99.34","383.99","percent of total billed charges",""
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","both","","","483.00","362.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","176.30","36.5","","174.56","148.36","523.68","1 through 10","99.34","383.99","percent of total billed charges",""
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","both","","","483.00","362.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","184.99","38.3","","182.99","182.99","355.68","12","99.34","383.99","percent of total billed charges",""
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","both","","","483.00","362.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.80","102.97","1 through 10","99.34","383.99","other","OPPS APC"
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","outpatient","","","483.00","362.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","394.71","81.72","","374.12","374.12","374.12","1 through 10","128.23","394.71","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","48","119.97","477.8","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","431.52","71.8","","418.59","418.59","418.59","1 through 10","119.97","477.8","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","CHAMPVA [160001]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","119.99","126.29","1 through 10","119.97","477.8","other","Tricare OPPS"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","477.80","79.5","","458.82","307.82","458.82","67","119.97","477.8","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","320.33","53.3","","307.82","307.82","458.82","32","119.97","477.8","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","477.8","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","ELDER SERVICES [1037]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","477.8","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.96","123.96","123.96","1 through 10","119.97","477.8","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","HEALTH NEW ENGLAND [1034]","HB AMC CLARITEV (PRIMARY PPO)","462.77","77","","448.91","448.91","448.91","1 through 10","119.97","477.8","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","477.8","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","185","119.97","477.8","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","186.31","31","","180.15","180.15","180.15","1 through 10","119.97","477.8","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","219.37","36.5","","217.46","184.81","217.46","34","119.97","477.8","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","230.18","38.3","","227.95","221.54","683.85","112","119.97","477.8","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.96","117.89","124.06","11","119.97","477.8","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","MOLINA [1014]","HB BWH MOLINA","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","501.12","252.58","501.12","1 through 10","119.97","477.8","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","462.77","77","","402.80","402.80","402.80","1 through 10","119.97","477.8","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","119.98","583.00","1 through 10","119.97","477.8","other","Tricare OPPS"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","123.76","372.48","26","119.97","477.8","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","134.09","134.09","134.09","1 through 10","119.97","477.8","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","257.83","42.9","","466.05","260.80","466.05","1 through 10","119.97","477.8","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.97","117.90","124.27","77","119.97","477.8","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","601.00","450.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","257.83","42.9","","256.35","256.35","256.35","1 through 10","119.97","477.8","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","601.00","450.75","AETNA [1001]","HB AMC AETNA HMO","419.50","69.8","","394.69","278.67","394.69","1 through 10","231.59","505.17","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","601.00","450.75","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","314.08","52.26","","231.59","231.59","360.76","1 through 10","231.59","505.17","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","601.00","450.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","491.14","81.72","","256.35","199.14","256.35","1 through 10","231.59","505.17","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","601.00","450.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","491.14","81.72","","466.05","256.35","466.05","39","231.59","505.17","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","126.62","17","119.97","663.83","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","663.83","79.5","","637.47","427.68","637.47","26","119.97","663.83","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","445.06","53.3","","427.68","427.68","637.47","12","119.97","663.83","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","103.07","124.27","1 through 10","119.97","663.83","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","FALLON HEALTH [1008]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","119.97","663.83","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","56","119.97","663.83","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","304.78","36.5","","302.13","256.77","302.13","14","119.97","663.83","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","319.81","38.3","","316.71","307.80","316.71","47","119.97","663.83","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","124.06","1 through 10","119.97","663.83","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","MOLINA [1014]","HB BWH MOLINA","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","250.56","126.29","250.56","1 through 10","119.97","663.83","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","642.95","77","","236.44","236.44","236.44","1 through 10","119.97","663.83","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","TUFTS HEALTH PLAN [170001]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","663.83","other","Tricare OPPS"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.36","117.59","371.28","1 through 10","119.97","663.83","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","358.22","42.9","","647.51","647.51","647.51","1 through 10","119.97","663.83","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","835.00","626.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","123.76","124.27","21","119.97","663.83","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","835.00","626.25","AETNA [1001]","HB AMC AETNA HMO","582.83","69.8","","548.37","548.37","548.37","1 through 10","231.59","682.36","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","835.00","626.25","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","436.37","52.26","","231.59","231.59","231.59","1 through 10","231.59","682.36","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","835.00","626.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","682.36","81.72","","647.51","647.51","647.51","1 through 10","231.59","682.36","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","835.00","626.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","682.36","81.72","","647.51","356.16","647.51","16","231.59","682.36","percent of total billed charges",""
"Xr L-Spine Bending Only 2/3 Views","PX-32000068","CDM","72120","CPT","0320","RC","","","","both","","","762.00","571.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","605.79","other","OPPS APC"
"Xr L-Spine Bending Only 2/3 Views","PX-32000068","CDM","72120","CPT","0320","RC","","","","both","","","762.00","571.50","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","124.16","124.16","1 through 10","119.97","605.79","other","OPPS APC"
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","outpatient","","","1116.00","837.00","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","583.22","52.26","","231.59","231.59","231.59","1 through 10","231.59","897.26","percent of total billed charges",""
"Xr Mandible Cmpl 4+ Views","PX-32000005","CDM","70110","CPT","0320","RC","","","","outpatient","","","544.00","408.00","AETNA [1001]","HB AMC AETNA HMO","379.71","69.8","","252.38","252.38","252.38","1 through 10","231.59","505.17","percent of total billed charges",""
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","both","","","495.00","371.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","393.53","79.5","","377.76","377.76","377.76","1 through 10","99.34","393.53","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","both","","","419.00","314.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","99.34","333.11","other","OPPS APC"
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","both","","","419.00","314.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","333.11","79.5","","214.37","214.37","319.52","1 through 10","99.34","333.11","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","both","","","419.00","314.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","223.33","53.3","","214.37","214.37","214.37","1 through 10","99.34","333.11","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","both","","","419.00","314.25","HUMANA [1012]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.31","103.31","103.31","1 through 10","99.34","333.11","other","OPPS APC"
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","both","","","419.00","314.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","152.94","36.5","","151.44","151.44","151.44","1 through 10","99.34","333.11","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","both","","","419.00","314.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","160.48","38.3","","158.75","158.75","158.75","1 through 10","99.34","333.11","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","outpatient","","","419.00","314.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","342.41","81.72","","178.52","178.52","178.52","1 through 10","128.23","342.41","percent of total billed charges",""
"Xr Orbits Cmp 4+ Views|REDUCED SERVICES","PX-32000022","CDM","70200","CPT","0320","RC","","","52","both","","","658.00","493.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","60.00","38.61","60.00","1 through 10","119.97","157.84","other","OPPS APC"
"Xr Orbits Cmp 4+ Views|REDUCED SERVICES","PX-32000022","CDM","70200","CPT","0320","RC","","","52","both","","","658.00","493.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.14","63.14","63.14","1 through 10","119.97","157.84","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","64.93","335.00","13","106.95","274.28","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","CHAMPVA [160001]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","153.04","153.04","153.04","1 through 10","106.95","274.28","other","Tricare OPPS"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","274.28","79.5","","263.65","176.88","263.65","16","106.95","274.28","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","183.89","53.3","","176.88","176.88","263.65","1 through 10","106.95","274.28","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","103.07","124.27","1 through 10","106.95","274.28","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.75","126.75","126.75","1 through 10","106.95","274.28","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","MARTIN'S POINT [160007]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.04","124.04","124.04","1 through 10","106.95","274.28","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","252.58","45","106.95","274.28","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","125.93","36.5","","124.96","106.20","124.96","18","106.95","274.28","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","132.14","38.3","","130.99","127.30","130.99","32","106.95","274.28","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.06","123.96","124.06","1 through 10","106.95","274.28","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","MOLINA [1014]","HB BWH MOLINA","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","250.56","250.56","250.56","1 through 10","106.95","274.28","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","126.29","1 through 10","106.95","274.28","other","Tricare OPPS"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","248.72","123.76","371.28","1 through 10","106.95","274.28","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.01","42.9","","267.80","147.30","267.80","1 through 10","106.95","274.28","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","123.76","124.27","1 through 10","106.95","274.28","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","345.00","258.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.01","42.9","","147.30","147.30","147.30","1 through 10","106.95","274.28","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","outpatient","","","345.00","258.75","AETNA [1001]","HB AMC AETNA HMO","240.81","69.8","","226.80","226.80","226.80","1 through 10","180.3","505.17","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","outpatient","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","281.93","81.72","","267.80","147.30","267.80","16","180.3","505.17","percent of total billed charges",""
"Xr Pelvis Cmp 3+ Views","PX-32000070","CDM","72190","CPT","0320","RC","","","","both","","","411.00","308.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","326.75","other","OPPS APC"
"Xr Pelvis Cmp 3+ Views","PX-32000070","CDM","72190","CPT","0320","RC","","","","both","","","411.00","308.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","326.75","79.5","","314.01","314.01","314.01","1 through 10","119.97","326.75","percent of total billed charges",""
"Xr Pelvis Cmp 3+ Views","PX-32000070","CDM","72190","CPT","0320","RC","","","","both","","","411.00","308.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","219.06","53.3","","210.67","201.50","210.67","1 through 10","119.97","326.75","percent of total billed charges",""
"Xr Pelvis Cmp 3+ Views","PX-32000070","CDM","72190","CPT","0320","RC","","","","both","","","411.00","308.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","252.58","15","119.97","326.75","other","OPPS APC"
"Xr Pelvis Cmp 3+ Views","PX-32000070","CDM","72190","CPT","0320","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","150.02","36.5","","297.66","297.66","297.66","1 through 10","119.97","326.75","percent of total billed charges",""
"Xr Pelvis Cmp 3+ Views","PX-32000070","CDM","72190","CPT","0320","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","157.41","38.3","","156.01","156.01","156.01","1 through 10","119.97","326.75","percent of total billed charges",""
"Xr Pelvis Cmp 3+ Views","PX-32000070","CDM","72190","CPT","0320","RC","","","","both","","","411.00","308.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","124.16","124.16","1 through 10","119.97","326.75","other","OPPS APC"
"Xr Pelvis Cmp 3+ Views","PX-32000070","CDM","72190","CPT","0320","RC","","","","both","","","411.00","308.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","516.80","124.27","516.80","1 through 10","119.97","326.75","other","OPPS APC"
"Xr Pelvis Cmp 3+ Views","PX-32000070","CDM","72190","CPT","0320","RC","","","","outpatient","","","411.00","308.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","335.87","81.72","","318.96","318.96","318.96","1 through 10","214.79","505.17","percent of total billed charges",""
"Xr Ribs 2 Views Uni","PX-32000048","CDM","71100","CPT","0324","RC","","","","both","","","487.00","365.25","MEDICARE [2001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","387.17","other","OPPS APC"
"Xr Ribs 3 Views Bilat","PX-32000050","CDM","71110","CPT","0320","RC","","","","both","","","606.00","454.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","323.00","53.3","","310.46","310.46","310.46","1 through 10","119.97","481.77","percent of total billed charges",""
"Xr Ribs 3 Views Bilat","PX-32000050","CDM","71110","CPT","0320","RC","","","","both","","","606.00","454.50","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","481.77","other","OPPS APC"
"Xr Ribs 3 Views Bilat","PX-32000050","CDM","71110","CPT","0320","RC","","","","both","","","606.00","454.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","232.10","38.3","","229.91","229.91","229.91","1 through 10","119.97","481.77","percent of total billed charges",""
"Xr Ribs 3 Views Bilat","PX-32000050","CDM","71110","CPT","0320","RC","","","","both","","","606.00","454.50","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.06","124.06","124.06","1 through 10","119.97","481.77","other","OPPS APC"
"Xr Ribs 3 Views Bilat","PX-32000050","CDM","71110","CPT","0320","RC","","","","both","","","606.00","454.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.76","124.27","1 through 10","119.97","481.77","other","OPPS APC"
"Xr Ribs W/Cxr 3+ Views Uni","PX-32000049","CDM","71101","CPT","0324","RC","","","","both","","","596.00","447.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","117.60","124.27","1 through 10","119.97","473.82","other","OPPS APC"
"Xr Ribs W/Cxr 4+ Views Bilat","PX-32000051","CDM","71111","CPT","0324","RC","","","","both","","","804.00","603.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","639.18","79.5","","613.86","613.86","613.86","1 through 10","119.97","646.42","percent of total billed charges",""
"Xr Ribs W/Cxr 4+ Views Bilat","PX-32000051","CDM","71111","CPT","0324","RC","","","","both","","","804.00","603.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.95","125.95","125.95","1 through 10","119.97","646.42","other","OPPS APC"
"Xr Ribs W/Cxr 4+ Views Bilat","PX-32000051","CDM","71111","CPT","0324","RC","","","","both","","","804.00","603.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","117.59","117.59","117.59","1 through 10","119.97","646.42","other","OPPS APC"
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","311.00","233.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","96.41","247.25","other","OPPS APC"
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","311.00","233.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","247.25","79.5","","237.67","159.46","577.65","15","96.41","247.25","percent of total billed charges",""
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","311.00","233.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","165.76","53.3","","159.46","159.46","237.67","1 through 10","96.41","247.25","percent of total billed charges",""
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","311.00","233.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","96.41","247.25","other","OPPS APC"
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","311.00","233.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","96.41","247.25","other","OPPS APC"
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","311.00","233.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","96.41","31","","93.32","93.32","93.32","1 through 10","96.41","247.25","percent of total billed charges",""
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","311.00","233.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","113.52","36.5","","112.65","112.65","229.60","1 through 10","96.41","247.25","percent of total billed charges",""
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","311.00","233.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","119.11","38.3","","354.24","118.08","354.24","30","96.41","247.25","percent of total billed charges",""
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","311.00","233.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","96.41","247.25","other","OPPS APC"
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","311.00","233.25","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","96.41","247.25","other","Tricare OPPS"
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","311.00","233.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","374.16","374.16","374.16","1 through 10","96.41","247.25","other","OPPS APC"
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","311.00","233.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.07","124.27","1 through 10","96.41","247.25","other","OPPS APC"
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","outpatient","","","311.00","233.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","254.15","81.72","","241.42","132.79","241.42","1 through 10","162.53","505.17","percent of total billed charges",""
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","both","","","543.00","407.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","431.69","79.5","","414.75","414.75","414.75","1 through 10","119.97","431.69","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","438.00","328.50","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","99.34","348.21","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","438.00","328.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","348.21","79.5","","334.48","334.48","334.48","1 through 10","99.34","348.21","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","438.00","328.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","233.45","53.3","","334.48","334.48","334.48","1 through 10","99.34","348.21","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","438.00","328.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","99.34","348.21","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","438.00","328.50","MEDICARE [2001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","99.18","104.56","15","99.34","348.21","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","438.00","328.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","159.87","36.5","","158.53","134.73","158.53","1 through 10","99.34","348.21","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","438.00","328.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","167.75","38.3","","166.18","161.50","166.18","12","99.34","348.21","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","438.00","328.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","97.75","97.75","97.75","1 through 10","99.34","348.21","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","438.00","328.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.90","42.9","","339.75","339.74","339.75","1 through 10","99.34","348.21","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","438.00","328.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.50","103.37","1 through 10","99.34","348.21","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","outpatient","","","438.00","328.50","AETNA [1001]","HB AMC AETNA HMO","305.72","69.8","","203.15","203.15","203.15","1 through 10","128.23","357.93","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","outpatient","","","438.00","328.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","357.93","81.72","","339.74","186.87","339.75","1 through 10","128.23","357.93","percent of total billed charges",""
"Xr Shoulder 1 View","PX-32000087","CDM","73020","CPT","0320","RC","","","","outpatient","","","340.00","255.00","AETNA [1001]","HB AMC AETNA HMO","237.32","69.8","","216.81","216.81","216.81","1 through 10","128.23","279.73","percent of total billed charges",""
"Xr Shoulder Cmp 2+ Views","PX-32000090","CDM","73030","CPT","0320","RC","","","","both","","","452.00","339.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","316.40","70","","102.67","102.67","102.67","1 through 10","99.34","359.34","percent of total billed charges",""
"Xr Shoulder Cmp 2+ Views","PX-32000090","CDM","73030","CPT","0320","RC","","","","both","","","452.00","339.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","359.34","79.5","","660.50","344.71","660.50","1 through 10","99.34","359.34","percent of total billed charges",""
"Xr Shoulder Cmp 2+ Views","PX-32000090","CDM","73030","CPT","0320","RC","","","","both","","","452.00","339.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","103","99.34","359.34","other","OPPS APC"
"Xr Shoulder Cmp 2+ Views","PX-32000090","CDM","73030","CPT","0320","RC","","","","outpatient","","","452.00","339.00","AETNA [1001]","HB AMC AETNA HMO","315.50","69.8","","296.53","209.36","296.53","14","128.23","369.37","percent of total billed charges",""
"Xr Shoulder Cmp 2+ Views","PX-32000090","CDM","73030","CPT","0320","RC","","","","outpatient","","","452.00","339.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","369.37","81.72","","700.28","385.18","700.28","1 through 10","128.23","369.37","percent of total billed charges",""
"Xr Sinuses 3+ Views","PX-32000028","CDM","70220","CPT","0320","RC","","","","both","","","575.00","431.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.87","102.87","102.87","1 through 10","99.34","457.13","other","OPPS APC"
"Xr Skull Cmpl 4+ Views","PX-32000031","CDM","70260","CPT","0320","RC","","","","both","","","715.00","536.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","568.43","other","OPPS APC"
"Xr Skull Ltd <4 Views","PX-32000030","CDM","70250","CPT","0320","RC","","","","both","","","548.00","411.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","64.21","64.21","64.21","1 through 10","119.97","435.66","other","OPPS APC"
"Xr Skull Ltd <4 Views","PX-32000030","CDM","70250","CPT","0320","RC","","","","both","","","548.00","411.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","435.66","79.5","","417.90","417.90","417.90","1 through 10","119.97","435.66","percent of total billed charges",""
"Xr Skull Ltd <4 Views","PX-32000030","CDM","70250","CPT","0320","RC","","","","both","","","548.00","411.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","292.08","53.3","","280.37","280.37","280.37","1 through 10","119.97","435.66","percent of total billed charges",""
"Xr Skull Ltd <4 Views","PX-32000030","CDM","70250","CPT","0320","RC","","","","both","","","548.00","411.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","435.66","other","OPPS APC"
"Xr Skull Ltd <4 Views","PX-32000030","CDM","70250","CPT","0320","RC","","","","both","","","548.00","411.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","200.02","36.5","","504.99","168.33","504.99","1 through 10","119.97","435.66","percent of total billed charges",""
"Xr Skull Ltd <4 Views","PX-32000030","CDM","70250","CPT","0320","RC","","","","both","","","548.00","411.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","209.88","38.3","","207.62","207.62","207.62","1 through 10","119.97","435.66","percent of total billed charges",""
"Xr Skull Ltd <4 Views","PX-32000030","CDM","70250","CPT","0320","RC","","","","both","","","548.00","411.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","119.97","435.66","other","OPPS APC"
"Xr Small Intestine","PX-32000206","CDM","74250","CPT","0320","RC","","","","both","","","1324.00","993.00","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","200.53","200.53","211.41","1 through 10","200.84","1052.58","other","OPPS APC"
"Xr Small Intestine","PX-32000206","CDM","74250","CPT","0320","RC","","","","both","","","1324.00","993.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","507.09","38.3","","502.04","502.04","502.04","1 through 10","200.84","1052.58","percent of total billed charges",""
"Xr Small Intestine","PX-32000206","CDM","74250","CPT","0320","RC","","","","outpatient","","","1324.00","993.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","568.00","42.9","","564.57","564.57","564.57","1 through 10","231.59","1081.97","percent of total billed charges",""
"Xr Spine 1 View Any Level","PX-32000055","CDM","72020","CPT","0320","RC","","","","both","","","346.00","259.50","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.77","102.77","1 through 10","99.34","275.07","other","OPPS APC"
"Xr Sternum 2+ Views","PX-32000052","CDM","71120","CPT","0324","RC","","","","both","","","486.00","364.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","259.04","53.3","","248.69","248.69","370.68","1 through 10","99.34","386.37","percent of total billed charges",""
"Xr Sternum 2+ Views","PX-32000052","CDM","71120","CPT","0324","RC","","","","both","","","486.00","364.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","177.39","36.5","","149.31","149.31","149.31","1 through 10","99.34","386.37","percent of total billed charges",""
"Xr Sternum 2+ Views","PX-32000052","CDM","71120","CPT","0324","RC","","","","both","","","486.00","364.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","186.14","38.3","","184.16","184.16","184.16","1 through 10","99.34","386.37","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1162.00","871.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","923.79","79.5","","886.95","595.06","886.95","1 through 10","170.35","923.79","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1162.00","871.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","619.35","53.3","","886.95","569.14","1038.29","1 through 10","170.35","923.79","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1162.00","871.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","424.13","36.5","","420.37","420.37","420.37","1 through 10","170.35","923.79","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1162.00","871.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","445.05","38.3","","440.66","428.26","1321.98","1 through 10","170.35","923.79","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","1162.00","871.50","AETNA [1001]","HB AMC AETNA HMO","811.08","69.8","","1433.14","1077.41","1433.14","1 through 10","607.26","2233.73","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","1162.00","871.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","949.59","81.72","","900.92","495.54","900.93","19","607.26","2233.73","percent of total billed charges",""
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","1276.00","1 through 10","200.84","1046.22","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","855.40","65","","2021.19","2021.19","2021.19","1 through 10","200.84","1046.22","percent of total billed charges",""
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT OPTUM HEALTH","921.20","70","","1276.00","1276.00","1276.00","1 through 10","200.84","1046.22","percent of total billed charges",""
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","CENTERS OF EXCELLENCE [1026]","HB BWH TRANSPLANT OPTUM MEDICARE REPLACEMENT","264.24","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 125%.","280.68","280.68","280.68","1 through 10","200.84","1046.22","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1046.22","79.5","","673.73","673.73","1004.21","1 through 10","200.84","1046.22","percent of total billed charges",""
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","701.43","53.3","","673.73","673.73","673.73","1 through 10","200.84","1046.22","percent of total billed charges",""
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","1046.22","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.45","208.45","208.45","1 through 10","200.84","1046.22","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","601.59","102","200.84","1046.22","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","480.34","36.5","","404.49","404.49","404.49","1 through 10","200.84","1046.22","percent of total billed charges",""
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","504.03","38.3","","498.92","484.88","498.92","1 through 10","200.84","1046.22","percent of total billed charges",""
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","393.04","393.04","393.04","1 through 10","200.84","1046.22","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","622.74","207.18","622.74","1 through 10","200.84","1046.22","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","293.48","293.48","293.48","1 through 10","200.84","1046.22","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1316.00","987.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.19","207.18","207.59","11","200.84","1046.22","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","outpatient","","","1316.00","987.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1075.44","81.72","","1020.03","1020.03","1020.03","1 through 10","231.59","1075.44","percent of total billed charges",""
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","outpatient","","","1316.00","987.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1075.44","81.72","","1020.03","561.06","1020.03","1 through 10","231.59","1075.44","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","399.89","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","399.89","79.5","","384.06","257.66","1152.18","18","119.97","399.89","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","268.10","53.3","","257.66","257.66","384.06","1 through 10","119.97","399.89","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","ELDER SERVICES [1037]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","119.97","399.89","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","HUMANA [1012]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","119.97","399.89","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","35","119.97","399.89","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","155.93","31","","150.79","150.79","150.79","1 through 10","119.97","399.89","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","183.60","36.5","","176.66","176.66","176.66","1 through 10","119.97","399.89","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","192.65","38.3","","190.81","185.44","190.81","33","119.97","399.89","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.06","117.89","124.06","1 through 10","119.97","399.89","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","TRICARE [160005]","HB BWH TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","399.89","other","Tricare OPPS"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","124.36","1 through 10","119.97","399.89","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWH TUFTS MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","112.24","112.24","112.24","1 through 10","119.97","399.89","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","503.00","377.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.17","123.97","126.29","12","119.97","399.89","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","503.00","377.25","AETNA [1001]","HB AMC AETNA HMO","351.09","69.8","","330.38","330.38","330.38","1 through 10","231.59","505.17","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","503.00","377.25","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","404.41","80.4","","380.64","380.64","380.64","1 through 10","231.59","505.17","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","503.00","377.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","411.05","81.72","","214.57","214.57","214.57","1 through 10","231.59","505.17","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","503.00","377.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","411.05","81.72","","390.11","336.40","390.11","1 through 10","231.59","505.17","percent of total billed charges",""
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","576.00","432.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","457.92","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","576.00","432.00","CENTERS OF EXCELLENCE [1026]","HB AMC TRANSPLANT CIGNA","374.40","65","","363.35","363.35","363.35","1 through 10","119.97","457.92","percent of total billed charges",""
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","576.00","432.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","457.92","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","576.00","432.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","210.24","36.5","","208.51","208.51","208.51","1 through 10","119.97","457.92","percent of total billed charges",""
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","576.00","432.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","220.61","38.3","","218.57","218.57","218.57","1 through 10","119.97","457.92","percent of total billed charges",""
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","576.00","432.00","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.06","124.06","124.06","1 through 10","119.97","457.92","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","576.00","432.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","123.75","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.17","124.07","124.27","1 through 10","119.97","457.92","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","outpatient","","","576.00","432.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","470.71","81.72","","446.86","446.86","446.87","1 through 10","231.59","505.17","percent of total billed charges",""
"Xr Tibia/Fibula 2 Views","PX-32000167","CDM","73590","CPT","0320","RC","","","","both","","","404.00","303.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.89","102.47","102.97","1 through 10","99.34","321.18","other","OPPS APC"
"Xr Tibia/Fibula 2 Views","PX-32000167","CDM","73590","CPT","0320","RC","","","","outpatient","","","404.00","303.00","AETNA [1001]","HB AMC AETNA HMO","281.99","69.8","","265.38","265.38","265.38","1 through 10","128.23","330.15","percent of total billed charges",""
"Xr Tmj Open & Closed Bilat","PX-32000036","CDM","70330","CPT","0320","RC","","","","both","","","725.00","543.75","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","99.34","576.38","other","OPPS APC"
"Xr Tmj Open & Closed Bilat","PX-32000036","CDM","70330","CPT","0320","RC","","","","both","","","725.00","543.75","MEDICARE [2001]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","576.38","other","OPPS APC"
"Xr Tmj Open & Closed Bilat","PX-32000036","CDM","70330","CPT","0320","RC","","","","both","","","725.00","543.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","277.68","38.3","","274.87","274.87","274.87","1 through 10","99.34","576.38","percent of total billed charges",""
"Xr Tomogram Single Plane","PX-32000251","CDM","76100","CPT","0320","RC","","","","both","","","2588.00","1941.00","MEDICARE [2001]","HB BWH MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","2057.46","other","OPPS APC"
"Xr Transcath Angio Exist Catheter","PX-32000299","CDM","75898","CPT","0323","RC","","","","both","","","3188.00","2391.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1163.62","36.5","","980.17","980.17","980.17","1 through 10","409.67","4671.83","percent of total billed charges",""
"Xr Transcath Biopsy","PX-32000314","CDM","75970","CPT","0320","RC","","","","both","","","4922.00","3691.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3912.99","79.5","","3752.72","3752.72","3752.72","1 through 10","1490.18","3912.99","percent of total billed charges",""
"Xr Transcath Biopsy","PX-32000314","CDM","75970","CPT","0320","RC","","","","both","","","4922.00","3691.50","INTERNATIONAL COMMERCIAL [140001]","HB AMC / MEE / PCC / ONE TEAM HEALTH INTERNATIONAL","3199.30","65","","3102.45","3102.45","3102.45","1 through 10","1490.18","3912.99","percent of total billed charges",""
"Xr Transcath Biopsy","PX-32000314","CDM","75970","CPT","0320","RC","","","","outpatient","","","4922.00","3691.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","4022.26","81.72","","2098.69","2098.69","2098.69","1 through 10","2572.24","4022.26","percent of total billed charges",""
"Xr Transcath Embolization Any","PX-32000297","CDM","75894","CPT","0320","RC","","","","both","","","6266.00","4699.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2287.09","36.5","","1926.09","1926.09","1926.09","1 through 10","1157.15","4981.47","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","1970.00","1 through 10","200.84","1614.65","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","CHAMPVA [160001]","HB BWH TRICARE","200.84","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","211.41","211.41","211.41","1 through 10","200.84","1614.65","other","Tricare OPPS"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","CIGNA [1006]","HB AMC CIGNA HMO / PPO","1614.65","79.5","","1550.39","1550.39","1582.47","1 through 10","200.84","1614.65","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","1082.52","53.3","","1040.16","994.85","1550.39","1 through 10","200.84","1614.65","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","1614.65","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","HUMANA [1012]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","209.25","211.41","1 through 10","200.84","1614.65","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","211.41","66","200.84","1614.65","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","629.61","31","","608.73","608.73","608.73","1 through 10","200.84","1614.65","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","741.32","36.5","","734.81","624.49","2139.42","16","200.84","1614.65","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","777.87","38.3","","770.27","770.27","770.27","26","200.84","1614.65","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","MGB HEALTH PLAN [150001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.18","196.82","207.38","1 through 10","200.84","1614.65","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","208.03","208.03","1 through 10","200.84","1614.65","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","871.30","42.9","","1574.82","1574.82","1574.82","1 through 10","200.84","1614.65","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2031.00","1523.25","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.49","196.82","208.03","18","200.84","1614.65","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","outpatient","","","2031.00","1523.25","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1659.73","81.72","","866.21","866.21","866.21","1 through 10","415.26","1659.73","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","outpatient","","","2031.00","1523.25","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1659.73","81.72","","1574.82","840.57","1574.82","1 through 10","415.26","1659.73","percent of total billed charges",""
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","both","","","1664.00","1248.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","197.32","197.32","197.32","1 through 10","200.84","1322.88","other","OPPS APC"
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","both","","","1664.00","1248.00","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","886.91","53.3","","852.19","852.19","852.19","1 through 10","200.84","1322.88","percent of total billed charges",""
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","both","","","1664.00","1248.00","MEDICARE [2001]","HB BWH MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","422.82","1 through 10","200.84","1322.88","other","OPPS APC"
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","both","","","1664.00","1248.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","607.36","36.5","","1806.06","511.64","1806.06","1 through 10","200.84","1322.88","percent of total billed charges",""
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","both","","","1664.00","1248.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","637.31","38.3","","631.07","613.32","631.07","1 through 10","200.84","1322.88","percent of total billed charges",""
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","both","","","1664.00","1248.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.18","207.18","207.18","1 through 10","200.84","1322.88","other","OPPS APC"
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","both","","","1664.00","1248.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.49","207.18","208.03","1 through 10","200.84","1322.88","other","OPPS APC"
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","outpatient","","","1664.00","1248.00","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","1359.82","81.72","","709.68","709.68","709.68","1 through 10","415.26","1359.82","percent of total billed charges",""
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","outpatient","","","1664.00","1248.00","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","1359.82","81.72","","1290.23","1290.23","1290.23","1 through 10","415.26","1359.82","percent of total billed charges",""
"Xr Urogram Retrograde","PX-32000227","CDM","74420","CPT","0320","RC","","","","both","","","1364.00","1023.00","BLUE CROSS BLUE SHIELD [110001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1323.00","1323.00","1323.00","1 through 10","402.91","1084.38","other","OPPS APC"
"Xr Urogram Retrograde","PX-32000227","CDM","74420","CPT","0320","RC","","","","both","","","1364.00","1023.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWH COMMONWEALTH CARE ALLIANCE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","402.91","1084.38","other","OPPS APC"
"Xr Urogram Retrograde","PX-32000227","CDM","74420","CPT","0320","RC","","","","both","","","1364.00","1023.00","MEDICARE [2001]","HB BWH MEDICARE","424.07","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","419.73","424.11","1 through 10","402.91","1084.38","other","OPPS APC"
"Xr Urogram Retrograde","PX-32000227","CDM","74420","CPT","0320","RC","","","","both","","","1364.00","1023.00","TUFTS HEALTH PLAN [170001]","HB BWH TUFTS MEDICARE REPLACEMENT","415.59","","APC Price ($424.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","415.63","415.63","415.63","1 through 10","402.91","1084.38","other","OPPS APC"
"Xr Venacavagram Inferior S&I","PX-32000285","CDM","75825","CPT","0320","RC","","","","both","","","7534.00","5650.50","MEDICARE [2001]","HB BWH MEDICARE","3737.47","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","3737.85","1 through 10","1949.7","5989.53","other","OPPS APC"
"Xr Venacavagram Inferior S&I","PX-32000285","CDM","75825","CPT","0320","RC","","","","both","","","7534.00","5650.50","TRICARE [160005]","HB BWH TRICARE","3550.95","","APC Price ($3,737.85). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3550.96","3550.96","3550.96","1 through 10","1949.7","5989.53","other","Tricare OPPS"
"Xr Venogram Extremity Uni","PX-32000283","CDM","75820","CPT","0320","RC","","","","both","","","2117.00","1587.75","MEDICARE [2001]","HB BWH MEDICARE","1844.62","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1844.80","1844.80","1 through 10","656.27","2305.77","other","OPPS APC"
"Xr Venogram Extremity Uni","PX-32000283","CDM","75820","CPT","0320","RC","","","","both","","","2117.00","1587.75","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","1807.72","","APC Price ($1,844.62). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1844.80","1844.80","1844.80","1 through 10","656.27","2305.77","other","OPPS APC"
"Xr Venogram Sampling Catheter","PX-32000354","CDM","75893","CPT","0320","RC","","","","both","","","7937.00","5952.75","MEDICARE [2001]","HB BWH MEDICARE","6418.94","","APC Price ($6,418.94). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3209.80","3209.80","3209.80","1 through 10","1949.7","8023.68","other","OPPS APC"
"Xr Venogram Sampling Catheter","PX-32000354","CDM","75893","CPT","0320","RC","","","","both","","","7937.00","5952.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","2897.01","36.5","","2439.95","2439.95","2439.95","1 through 10","1949.7","8023.68","percent of total billed charges",""
"Xr Venogram Sampling Catheter","PX-32000354","CDM","75893","CPT","0320","RC","","","","outpatient","","","7937.00","5952.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","6486.12","81.72","","6152.98","6152.98","6152.98","1 through 10","4147.88","19650.57","percent of total billed charges",""
"Xr Wrist 2 Views","PX-32000116","CDM","73100","CPT","0320","RC","","","","outpatient","","","454.00","340.50","AETNA [1001]","HB AMC AETNA HMO","316.89","69.8","","297.88","297.88","297.88","1 through 10","128.23","371.01","percent of total billed charges",""
"Xr Wrist Cmpl 3+ Views","PX-32000119","CDM","73110","CPT","0320","RC","","","","both","","","544.00","408.00","CIGNA [1006]","HB AMC CIGNA HMO / PPO","432.48","79.5","","415.54","415.54","415.54","1 through 10","99.34","432.48","percent of total billed charges",""
"Xr Wrist Cmpl 3+ Views","PX-32000119","CDM","73110","CPT","0320","RC","","","","both","","","544.00","408.00","GENERIC COMMERCIAL [1009]","HB BWH MEDICARE","104.55","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.88","8.25","34.88","1 through 10","99.34","432.48","other","OPPS APC"
"Xr Wrist Cmpl 3+ Views","PX-32000119","CDM","73110","CPT","0320","RC","","","","both","","","544.00","408.00","PHCS MULTIPLAN [1022]","HB AMC CLARITEV (PRIMARY PPO)","418.88","77","","146.38","146.38","146.38","1 through 10","99.34","432.48","percent of total billed charges",""
"Xr Wrist Cmpl 3+ Views","PX-32000119","CDM","73110","CPT","0320","RC","","","","both","","","544.00","408.00","UNITED HEALTHCARE [1016]","HB BWH UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.208). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","29","99.34","432.48","other","OPPS APC"
"Xr Wrist Cmpl 3+ Views","PX-32000119","CDM","73110","CPT","0320","RC","","","","outpatient","","","544.00","408.00","AETNA [1001]","HB AMC AETNA HMO","379.71","69.8","","357.46","252.38","714.91","1 through 10","128.23","444.56","percent of total billed charges",""
"Yersinia Antibody","PX-30001011","CDM","86793","CPT","0302","RC","","","","both","","","156.00","117.00","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","56.94","36.5","","56.33","56.33","56.33","1 through 10","9.6","148.2","percent of total billed charges",""
"YOKE COBALT 93MM COMPONENT FEMORAL KNEE OSS REINFORCED","SUP-ITM-10036216","CDM","C1776","HCPCS","0278","RC","","","","both","","","3913.88","2935.41","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2045.39","52.26","","1113.10","1113.10","1113.10","1 through 10","1213.3","3111.53","percent of total billed charges",""
"YOKE COBALT 93MM COMPONENT FEMORAL KNEE OSS REINFORCED","SUP-ITM-10036216","CDM","C1776","HCPCS","0278","RC","","","","both","","","3913.88","2935.41","CIGNA [1006]","HB AMC CIGNA HMO / PPO","3111.53","79.5","","1293.60","1148.53","1603.80","1 through 10","1213.3","3111.53","percent of total billed charges",""
"YOKE COBALT 93MM COMPONENT FEMORAL KNEE OSS REINFORCED","SUP-ITM-10036216","CDM","C1776","HCPCS","0278","RC","","","","both","","","3913.88","2935.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","1428.57","36.5","","1023.42","771.29","2068.67","33","1213.3","3111.53","percent of total billed charges",""
"YOKE COBALT 93MM COMPONENT FEMORAL KNEE OSS REINFORCED","SUP-ITM-10036216","CDM","C1776","HCPCS","0278","RC","","","","both","","","3913.88","2935.41","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","1499.02","38.3","","850.52","759.78","1211.25","66","1213.3","3111.53","percent of total billed charges",""
"YOKE COBALT 93MM COMPONENT FEMORAL KNEE OSS REINFORCED","SUP-ITM-10036216","CDM","C1776","HCPCS","0278","RC","","","","both","","","3913.88","2935.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1679.05","42.9","","2548.09","2548.09","2548.09","1 through 10","1213.3","3111.53","percent of total billed charges",""
"YOKE COBALT 93MM COMPONENT FEMORAL KNEE OSS REINFORCED","SUP-ITM-10036216","CDM","C1776","HCPCS","0278","RC","","","","both","","","3913.88","2935.41","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1679.05","42.9","","956.46","956.46","956.46","1 through 10","1213.3","3111.53","percent of total billed charges",""
"YOKE COBALT 93MM COMPONENT FEMORAL KNEE OSS REINFORCED","SUP-ITM-10036216","CDM","C1776","HCPCS","0278","RC","","","","both","","","3913.88","2935.41","WELLPOINT [1015]","HB AMC WELLPOINT","2887.66","73.78","","2344.73","1619.47","2530.35","16","1213.3","3111.53","percent of total billed charges",""
"YOKE COBALT 93MM COMPONENT FEMORAL KNEE OSS REINFORCED","SUP-ITM-10036216","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3913.88","2935.41","AETNA [1001]","HB AMC AETNA HMO","2731.89","69.8","","1523.63","988.41","4330.26","39","2045.39","3198.42","percent of total billed charges",""
"YOKE COBALT 93MM COMPONENT FEMORAL KNEE OSS REINFORCED","SUP-ITM-10036216","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3913.88","2935.41","AETNA [1001]","HB AMC AETNA PPO","3146.76","80.4","","1670.25","1670.25","1670.25","1 through 10","2045.39","3198.42","percent of total billed charges",""
"YOKE COBALT 93MM COMPONENT FEMORAL KNEE OSS REINFORCED","SUP-ITM-10036216","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3913.88","2935.41","BLUE CROSS BLUE SHIELD [110001]","HB AMC BLUE CROSS INDEMNITY","2045.39","52.26","","1113.10","1113.10","1113.10","1 through 10","2045.39","3198.42","percent of total billed charges",""
"YOKE COBALT 93MM COMPONENT FEMORAL KNEE OSS REINFORCED","SUP-ITM-10036216","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3913.88","2935.41","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","3198.42","81.72","","1738.90","1484.65","2716.94","38","2045.39","3198.42","percent of total billed charges",""
"YUKON CONTOURED 3.5X65 MM TI","SUP-ITM-10255001","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","800.18","480.96","1887.97","195","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 3.5X65 MM TI","SUP-ITM-10255001","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","813.12","216.42","1444.50","81","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 3.5X65 MM TI","SUP-ITM-10255001","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.75","31","","432.60","432.60","432.60","1 through 10","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 3.5X65 MM TI","SUP-ITM-10255001","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","148.37","54.89","631.39","94","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 3.5X65 MM TI","SUP-ITM-10255001","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","279.30","91.72","1116.77","266","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 3.5X65 MM TI","SUP-ITM-10255001","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","731.00","63.70","731.00","1 through 10","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 3.5X65 MM TI","SUP-ITM-10255001","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","384.74","384.74","384.74","1 through 10","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 3.5X65 MM TI","SUP-ITM-10255001","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","286.63","119.22","1107.45","105","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 3.5X65 MM TI","SUP-ITM-10255001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","675.31","184.75","1721.50","286","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 3.5X65 MM TI","SUP-ITM-10255001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA PPO","422.10","80.4","","1261.44","103.12","1514.10","21","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 3.5X65 MM TI","SUP-ITM-10255001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1365.00","1365.00","1365.00","1 through 10","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 3.5X65 MM TI","SUP-ITM-10255001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","429.03","81.72","","5157.68","5157.68","5157.68","1 through 10","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 3.5X65 MM TI","SUP-ITM-10255001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","431.26","71.26","1459.57","88","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","800.18","480.96","1887.97","195","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","813.12","216.42","1444.50","81","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.75","31","","432.60","432.60","432.60","1 through 10","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","148.37","54.89","631.39","94","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","279.30","91.72","1116.77","266","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","731.00","63.70","731.00","1 through 10","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","384.74","384.74","384.74","1 through 10","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","286.63","119.22","1107.45","105","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","675.31","184.75","1721.50","286","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA PPO","422.10","80.4","","1261.44","103.12","1514.10","21","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1365.00","1365.00","1365.00","1 through 10","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","429.03","81.72","","5157.68","5157.68","5157.68","1 through 10","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 4.0X35 MM TI","SUP-ITM-10254995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","431.26","71.26","1459.57","88","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 4.0X55 MM TI","SUP-ITM-10254993","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA [1006]","HB AMC CIGNA HMO / PPO","417.38","79.5","","800.18","480.96","1887.97","195","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X55 MM TI","SUP-ITM-10254993","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","279.83","53.3","","813.12","216.42","1444.50","81","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X55 MM TI","SUP-ITM-10254993","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","162.75","31","","432.60","432.60","432.60","1 through 10","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X55 MM TI","SUP-ITM-10254993","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","191.63","36.5","","148.37","54.89","631.39","94","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X55 MM TI","SUP-ITM-10254993","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","201.08","38.3","","279.30","91.72","1116.77","266","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X55 MM TI","SUP-ITM-10254993","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","731.00","63.70","731.00","1 through 10","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X55 MM TI","SUP-ITM-10254993","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.23","42.9","","384.74","384.74","384.74","1 through 10","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X55 MM TI","SUP-ITM-10254993","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB AMC WELLPOINT","387.35","73.78","","286.63","119.22","1107.45","105","162.75","417.38","percent of total billed charges",""
"YUKON CONTOURED 4.0X55 MM TI","SUP-ITM-10254993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA HMO","366.45","69.8","","675.31","184.75","1721.50","286","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 4.0X55 MM TI","SUP-ITM-10254993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","AETNA [1001]","HB AMC AETNA PPO","422.10","80.4","","1261.44","103.12","1514.10","21","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 4.0X55 MM TI","SUP-ITM-10254993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB AMC AETNA PPO","422.10","80.4","","1365.00","1365.00","1365.00","1 through 10","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 4.0X55 MM TI","SUP-ITM-10254993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","429.03","81.72","","5157.68","5157.68","5157.68","1 through 10","274.37","429.03","percent of total billed charges",""
"YUKON CONTOURED 4.0X55 MM TI","SUP-ITM-10254993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","429.03","81.72","","431.26","71.26","1459.57","88","274.37","429.03","percent of total billed charges",""
"Zellweger Spectrum Disorders Ngs Panel","PX-31000735","CDM","81479","CPT","0310","RC","","","","both","","","410.00","307.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","325.95","79.5","","0.65","0.65","0.65","1 through 10","127.1","389.5","percent of total billed charges",""
"Zellweger Spectrum Disorders Ngs Panel","PX-31000735","CDM","81479","CPT","0310","RC","","","","both","","","410.00","307.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","218.53","53.3","","0.79","0.79","0.79","1 through 10","127.1","389.5","percent of total billed charges",""
"Zellweger Spectrum Disorders Ngs Panel","PX-31000735","CDM","81479","CPT","0310","RC","","","","outpatient","","","410.00","307.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","205.00","50","","1.00","1.00","1.00","1 through 10","156.55","338.25","percent of total billed charges",""
"Zellweger Spectrum Disorders Ngs Panel","PX-31000735","CDM","81479","CPT","0310","RC","","","","outpatient","","","410.00","307.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","215.25","52.5","","1.00","0.53","1.00","1 through 10","156.55","338.25","percent of total billed charges",""
"Zika Virus Igm Antibody","PX-30003474","CDM","86794","CPT","0302","RC","","","","outpatient","","","253.00","189.75","AETNA [1001]","HB AMC AETNA HMO","176.59","69.8","","282.98","117.11","282.98","1 through 10","59.8","206.75","percent of total billed charges",""
"Zika Virus Igm Antibody","PX-30003474","CDM","86794","CPT","0302","RC","","","","outpatient","","","253.00","189.75","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","206.75","81.72","","107.73","107.73","107.73","1 through 10","59.8","206.75","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","both","","","150.00","112.50","CENTERS OF EXCELLENCE [1026]","HB AMC MGBHP TRANSPLANT","107.70","71.8","","104.11","104.11","104.11","1 through 10","11.16","142.5","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","both","","","150.00","112.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","119.25","79.5","","114.12","76.56","342.36","23","11.16","142.5","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","both","","","150.00","112.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","79.95","53.3","","76.56","76.56","114.12","1 through 10","11.16","142.5","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL GIC","46.50","31","","44.81","44.81","44.81","1 through 10","11.16","142.5","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL HMO","54.75","36.5","","54.09","45.97","54.09","31","11.16","142.5","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB AMC MGBHP COMMERCIAL PPO","57.45","38.3","","56.70","56.70","56.70","94","11.16","142.5","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","both","","","150.00","112.50","TRICARE [160005]","HB BWH TRICARE","142.50","95","","13.03","13.03","13.72","1 through 10","11.16","142.5","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.35","42.9","","115.91","63.76","115.91","1 through 10","11.16","142.5","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","150.00","112.50","AETNA [1001]","HB AMC AETNA HMO","104.70","69.8","","98.17","69.31","113.10","39","11.75","122.58","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","150.00","112.50","AETNA [1001]","HB AMC AETNA PPO","120.60","80.4","","113.10","113.10","226.20","1 through 10","11.75","122.58","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC UNITED HMO / INDEMNITY","122.58","81.72","","63.76","63.76","63.76","1 through 10","11.75","122.58","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC UNITED PPO / POS","122.58","81.72","","115.91","63.76","115.91","28","11.75","122.58","percent of total billed charges",""
"Zmpste24-Related Disorders: Zmpste24 Gene Sequencing","PX-31000813","CDM","81479","CPT","0310","RC","","","","both","","","1166.00","874.50","CIGNA [1006]","HB AMC CIGNA HMO / PPO","926.97","79.5","","0.65","0.65","0.65","1 through 10","361.46","1107.7","percent of total billed charges",""
"Zmpste24-Related Disorders: Zmpste24 Gene Sequencing","PX-31000813","CDM","81479","CPT","0310","RC","","","","both","","","1166.00","874.50","CIGNA ALTERNATE [1018]","HB AMC CIGNA NEW BUSINESS DISCOUNT","621.48","53.3","","0.79","0.79","0.79","1 through 10","361.46","1107.7","percent of total billed charges",""
"Zmpste24-Related Disorders: Zmpste24 Gene Sequencing","PX-31000813","CDM","81479","CPT","0310","RC","","","","outpatient","","","1166.00","874.50","HARVARD PILGRIM [120001]","HB AMC HPHC HMO / POS","583.00","50","","1.00","1.00","1.00","1 through 10","156.55","961.95","percent of total billed charges",""
"Zmpste24-Related Disorders: Zmpste24 Gene Sequencing","PX-31000813","CDM","81479","CPT","0310","RC","","","","outpatient","","","1166.00","874.50","HARVARD PILGRIM [120001]","HB AMC HPHC PPO","612.15","52.5","","1.00","0.53","1.00","1 through 10","156.55","961.95","percent of total billed charges",""